Library

Student Yi: This also raised two doubts in my mind: First, the two compound prescriptions the patient took previously were quite consistent with the syndrome differentiation, so why did they show no obvious effect? Second, the patient clearly presented a set of heat signs, such as dry mouth, continuous drinking without relief of thirst, red tongue body with densely distributed small red spots on the edges and tip, white coating slightly yellow and thick/greasy, and wiry-slippery pulse slightly rapid. Why could Da Xin Da Re (greatly pungent and greatly hot) Wu Zhu Yu Tang be used?

Student Bing: There are many reports of Wu Zhu Yu Tang curing headaches. The pathogenesis of this headache is Liver-Stomach deficiency-cold with turbid yin counterflow. Wu Zhu Yu Tang warms the Liver and Stomach, raises clear yang and descends turbid yin, accurately targeting the pathogenesis, hence its good efficacy. However, as mentioned earlier, this case does not possess the systemic syndromes and tongue/pulse manifestations of Liver-Stomach deficiency-cold and turbid yin counterflow—such as cold limbs, fear of cold or cold pain in the epigastrium/abdomen, pale tongue with white slippery coating, wiry-deep or wiry-slow pulse. On the contrary, it presents a clear set of heat signs. It is indeed hard to understand why the teacher prescribed the original formula of Wu Zhu Yu Tang with a non-light dosage.

Teacher: I know you have many questions, so I will address the key points. Article 378 of *Shanghan Lun* states: "For dry retching, vomiting of saliva/froth, and headache, Wu Zhu Yu Tang governs." Since this article appears in the Jueyin chapter, the location of the headache should be at the vertex (the Jueyin Liver meridian meets the Du vessel at the vertex); furthermore, inferring the syndrome from the prescription, it undoubtedly belongs to cold. According to the principle that "what exists internally must manifest externally," the systemic syndromes and tongue/pulse should naturally present a set of cold signs. Clinical verification confirms this is a general rule. However, what deserves attention is that this rule cannot exhaust all possibilities. In recent years, I have treated some patients with headaches accompanied by nausea and vomiting of clear water or thin froth who do not necessarily possess the systemic syndromes and tongue/pulse of Liver-Stomach deficiency-cold and turbid yin counterflow; moreover, some present heat signs, and the headache location is not at the vertex. If one is constrained by general rules and limits oneself, one would dare not use Wu Zhu Yu Tang exclusively or heavily. This reminds us to prevent fixed thinking patterns during clinical practice.

Student Yi: Preventing fixed thinking patterns is certainly correct, but one cannot simply disregard the patient's set of heat signs! Can Wu Zhu Yu Tang be used for headache due to heat syndromes?

Teacher: If I disregarded that set of heat signs, I would not have probed into the patient's lifestyle history. The patient's lifestyle history of swimming in the river daily from March to October over the past few years, frequently eating fruits and ice foods, and drinking strong tea is quite enlightening. Based on the lifestyle history and drug efficacy, it is speculated that cold stagnation and cold binding remained for a long time, preventing the smooth distribution of internal Yang qi, which turned stagnant and generated heat, or the dark/cold qi forced Yang qi to float upward, thus presenting a set of floating heat rushing upward. The key to using Wu Zhu Yu Tang in this case lies in: first, grasping the characteristic syndrome—headache accompanied by vomiting of thin froth; second, conducting a comprehensive analysis combining lifestyle history and treatment history, exposing the essence of Yin-cold through the phenomenon of floating heat.

Student Jia: It seems the teacher uses the method of syndrome-prescription correspondence (Fang Zheng Xiang Dui). My understanding is: For the syndrome-prescription correspondence of Wu Zhu Yu Tang, it means that whenever one sees "dry retching, vomiting of saliva/froth, and headache," one can prioritize and use Wu Zhu Yu Tang exclusively, without obsessing over whether the systemic syndromes and tongue/pulse of Liver-Stomach deficiency-cold and turbid yin counterflow are present, nor discussing whether it belongs to external contraction or internal injury, meridians or zang-fu organs, or the duration of the disease. Is this correct?

Teacher: Yes. Because the characteristic syndrome described by Zhongjing—"dry retching, vomiting of saliva/froth, and headache"—has already sufficiently reflected the special essence of this disease. As Cheng Wuji said in *Zhu Jie Shanghan Lun*: "Dry retching and vomiting of saliva/froth indicate interior cold; headache indicates cold qi attacking upward. Give Wu Zhu Yu Tang to warm the interior and dissipate cold." In other words, Zhongjing's analysis of this syndrome was accurate and error-free, and he provided an highly effective prescription. Clinically, as long as the syndrome matches, one can apply it effortlessly, demonstrating the wonder of mastering simplicity to control complexity and handling things with ease. The main reason for the rapid effect in this headache case lies here. What deserves reflection is that there seems to be a tendency in recent years: emphasizing the flexibility of syndrome differentiation and treatment (which is appropriate), while neglecting the principled nature of syndrome-prescription correspondence. This is unfavorable to the inheritance and promotion of Zhongjing's theory.

Student Yi: Before taking the original formula of Wu Zhu Yu Tang, the patient had taken a large compound prescription containing Wu Zhu Yu Tang. Why was the efficacy poor?

Teacher: That large compound prescription was synthesized from four formulas: Cang Er San, Sheng Ma Ge Gen Tang, Xiao Chai Hu Tang, and Wu Zhu Yu Tang. It contained up to 19 herbs, and the dosages were light, which might have interfered with each other. As everyone knows, the prescriptions passed down after Zhongjing's "diligent study of ancient teachings and extensive collection of prescriptions" were mostly high-efficiency empirical formulas. For example, Wu Zhu Yu Tang contains only four herbs; although it seems plain, its depth is infinite. If one dislikes the small number of herbs or fears the patient won't believe it and arbitrarily adds them, it may sometimes affect efficacy. If syndrome-prescription correspondence is achieved and the original formula yields good results, why add superfluous elements? Of course, appropriate modification according to the condition is necessary. But if too many additions are made, overshadowing the main theme; or if modifications make the formula unrecognizable yet still called "modification of Jing Fang," it is not worthy of instruction. The modern sage Chen Xunzai said, "Jing Fang values non-modification," which is very thought-provoking.

Student Ding: When the teacher used the original formula of Wu Zhu Yu Tang to treat headache, what were the routine dosages of the four herbs in the formula?

Teacher: At initial intake, Wu Zhu Yu and Sheng Jiang should not be less than 15g, Dang Shen and Da Zao should not be less than 30g. Dosages can be reduced appropriately once the disease is addressed.

Cough and Asthma for 1 Month

Yu Guojun, Director of TCM Research Office, Leshan People's Hospital, Sichuan Province

Chang X, Male, 56 days old, First visit on Feb 6, 1986. The infant was born prematurely at 8 months gestation and developed pneumonia 20 days after birth; hospitalized for 14 days, improved and discharged, but cough and asthma recurred a few days later. Previously took several doses of Ma Xing Shi Gan Tang, symptoms decreased, but relapsed upon stopping medication, worsening day by day, without fever. After repeated injections, oral medications, IV fluids, and oxygen therapy, the condition did not improve, and critical conditions occurred multiple times. Western medical diagnosis: Wheezing pneumonia, Congenital heart disease (Atrial Septal Defect). Reluctantly transferred to TCM outpatient clinic. Examination revealed: Infant listless, pale complexion, emaciated skin/muscles; cough and asthma with tight breathing, rattling phlegm sound in throat, cyanotic lips; profuse cold sweat when crying; restless sleep at night, occasional irritability and convulsions, cold limbs; refusing milk/food, stool containing undigested milk/food residues; pale tongue body, white coating, pale red fingerprint. Considered as weak constitution contracting pathogen, prolonged struggle between righteous Qi and pathogenic factors, righteous Qi unable to overcome pathogen, resulting in damage to both Yin and Yang, Wind-Cold lingering in Lung, Lung losing diffusion and descending functions; plus Heart Yang weakness, Spleen transport dysfunction, righteous Qi declining daily, thus lingering and gradually becoming critical. Prescribed Gui Zhi Jia Hou Po Xing Zi Tang modified to transform Qi, regulate Yin/Yang, and descend Qi to stop asthma: Gui Zhi 3g, Bai Shao 6g, Gan Cao 3g, Da Zao 10g, Sheng Jiang 2 slices, Hou Po 10g, Xing Ren 6g, Su Zi 10g, Bai Jie Zi 5g, Chao Lai Fu Zi 6g, Ting Li Zi 6g, Huang Qi 15g, Bai Zhu 6g, Fu Ling 6g. After 1 dose, profuse sweating that night, asthma/cough/tight breathing/cold sweat greatly reduced, slept peacefully. After finishing 2 doses, appetite opened, stool normal; face/lips turned pale red. Still coughing, removed Lai Fu Zi from above formula, added Xuan Fu Hua 3g (wrapped decoction), Jie Geng 6g, Fa Xia 6g. After 3 doses, all symptoms cured, spirit bright, ruddy complexion, increased appetite, good sleep, normal urination/defecation. Later slight cough, excessive discharge in left eye, took Jin Fei Cao San plus Ju Hua, Lian Qiao, Sang Ye for 2 doses, thereafter cough/asthma did not recur. (This case has been recorded in the book *Research on Application of Gui Zhi Tang Category Formulas* -- Author)

Trainee Jia: In this case, the premature infant developed pneumonia 20 days after birth, hospitalized for 14 days, improved and discharged, but cough/asthma recurred a few days later. Despite repeated Western medicine rescue, condition did not improve, lingering for 1 month, with multiple critical episodes. Did the teacher have absolute confidence when receiving the patient?

Teacher: To be honest, there was indeed no confidence, let alone "absolute." Although I prescribed 2 doses, I felt uneasy, so I specifically agreed with the parents: come for follow-up after finishing 1 dose. The next day we waited in the clinic until 10 AM, very anxious. Suddenly seeing the parents arrive with joyful expressions, I urgently asked and learned the medicine hit the mark, then we breathed a sigh of relief, and instructed them to continue the second dose. Afterwards, it was smooth sailing, nothing worth mentioning.

Student Jia: This case of wheezing pneumonia has many symptoms, presenting critical signs, complex pathogenesis. A slight lack of caution could lead to errors. How did the teacher grasp the pathogenesis?

Teacher: Using induction, it becomes clear at a glance: First, the infant was premature, congenital insufficiency; cough/asthma lingered for 1 month, repeated Western medicines ineffective, symptoms showed listlessness, pale complexion, cyanotic lips, profuse cold sweat, irritability/convulsions, cold limbs, obviously indicating Heart Yang deficiency/exhaustion. Second, emaciated skin/muscles, refusing food, stool with undigested residues, obviously indicating Stomach deficiency failing to receive, Spleen deficiency failing to transport. Third, cough/asthma with tight breathing, rattling phlegm, obviously indicating Phlegm-Qi rushing upward attacking Lung. The first two points are Righteous Qi deficiency, the third is Pathogenic Excess.

Trainee Yi: Since the basic pathogenesis is Righteous Qi deficiency and Pathogenic excess, the basic treatment principle is naturally supporting Righteous Qi and expelling Pathogen. But based on this to create prescriptions and use drugs, how to proceed?

Teacher: Grasping the basic pathogenesis and treatment principle overall can avoid principled errors in creating prescriptions and using drugs, which is highly valued in clinical practice. However, in specific treatment, one must establish specific treatment principles based on specific pathogenesis to fit precisely. The specific pathogenesis of this case is Heart Yang exhaustion, Spleen/Stomach distress, Phlegm-Qi counterflow; the specific treatment method should be warming/strengthening Heart Yang, moving Spleen/harmonizing Stomach, dispelling Phlegm/descending counterflow. Because Heart Yang exhaustion appears urgent and severe, warming/strengthening Heart Yang is taken as the focus of rescue.

Trainee Bing: Since warming/strengthening Heart Yang is the focus of rescue, why choose Gui Zhi Jia Hou Po Xing Zi Tang modified? This formula only harmonizes Ying/Wei, dispels Phlegm/descends Qi; I've never heard of it having the effect of warming/strengthening Heart Yang.

Teacher: This is thanks to the influence and enlightenment of my mentor Jiang Erxun. Everyone knows, Master Jiang has recently devoted himself to the theoretical and clinical research of the basic syndrome-prescriptions of *Shanghan Lun*—specifically Gui Zhi Tang. He published many unique insights. Master Jiang firmly believes: The ancient sages' theoretical summary regarding Gui Zhi Tang—"for exterior syndromes, it resolves muscle layer and harmonizes Ying/Wei; for interior syndromes, it transforms Qi and regulates Yin/Yang"—is absolutely not empty talk. He considers that Gui Zhi Tang is synthesized from Gui Zhi Gan Cao Tang and Shao Yao Gan Cao Tang; the former is Pungent-Sweet transforming Yang, the latter is Sour-Sweet transforming Yin; combined, they can harmonize Yin/Yang of exterior and interior syndromes, being the best prescription for holistic regulation. *Shanghan Lun* says, "For asthmatics, make Gui Zhi Tang, adding Hou Po and Xing Zi is good." This refers to people whose Yin/Yang (including Ying/Wei, Qi/Blood) are deficient and disordered normally; if contracted by external pathogens triggering chronic asthma, one should use Gui Zhi Tang to harmonize Yin/Yang, adding Hou Po and Xing Ren to dispel Phlegm/descend Qi. Zhongjing's word "good" stands up to clinical verification. But honestly, when I followed Master Jiang's思路 to borrow this formula, it only matched the basic pathogenesis of this case (Righteous Qi deficiency, Pathogenic excess), not yet fitting the specific pathogenesis. So I consulted Master Jiang on the spot. After pondering for a moment, he added Bai Zhu, Fu Ling, Huang Qi, turning it into this formula combined with Ling Gui Zhu Gan Tang plus Huang Qi; this combination yielded the effect of warming/strengthening Heart Yang. After Master Jiang re-examined the infant, he added Su Zi, Bai Jie Zi, Lai Fu Zi, Ting Li Zi, i.e., further combining San Zi Yang Qin Tang and Ting Li Da Zao Xie Fei Tang; this combination not only yielded the effect of moving Spleen/harmonizing Stomach, but also greatly enhanced the effect of dispelling Phlegm/descending Qi. Thus, although this formula is named Gui Zhi Jia Hou Po Xing Zi Tang modified, it is actually a compound formula, containing within it Gui Zhi Jia Hou Po Xing Zi Tang, Ling Gui Zhu Gan Tang, San Zi Yang Qin Tang, and Ting Li Da Zao Xie Fei Tang, jointly exerting effects of warming/strengthening Heart Yang, moving Spleen/harmonizing Stomach, and dispelling Phlegm/descending Qi.

Trainee Yi: This compound formula was used well, achieving high efficiency, worth learning from. But is it like the saying "only this shop, no other branches"? According to medical records, this case took several doses of Ma Xing Shi Gan Tang initially, symptoms decreased, but relapsed upon stopping. Why didn't the teacher learn from the previous doctor's approach, especially since the infant's cough/asthma with tight breathing and cold sweat are indications for Ma Xing Shi Gan Tang!

Teacher: *Shanghan Lun* states, "After sweating, do not use Gui Zhi Tang again; if sweating occurs with asthma and no great heat, Ma Huang Xing Ren Gan Cao Shi Gao Tang can be given." Inferring syndrome from prescription, the asthma/wheezing is due to pathogen closing Lung, so Ma Huang paired with Xing Ren diffuses Lung/opens closure; the sweating is due to stagnant heat congesting Lung, so Ma Huang paired with Shi Gao diffuses Lung/drains heat. The whole formula is Pungent-Cool dispersing/venting,肃肺 (calming Lung) calming asthma, designed for Excess-Heat cough/asthma. When the infant took it effectively in the early stage of cough/asthma, it must have possessed these syndromes. But relapse upon stopping, worsening day by day; although still seeing cough/asthma/tight breathing, it is no longer just sweating cold sweat, but profuse cold sweat, accompanied by a set of Heart Yang exhaustion syndromes, indicating transformation from Excess asthma to Deficiency asthma. If one sees the previous formula effective and follows suit, using Ma Xing Shi Gan Tang again, one will definitely commit the taboo of "making deficiency more deficient." Currently, there seems to be a clinical tendency of "fitting into slots," e.g., seeing pneumonia cough/asthma, immediately considering Ma Xing Shi Gan Tang. This laziness in careful observation/differentiation when identifying diseases/syndromes, and preference for standard formulas/drugs when selecting prescriptions, violates the principle of syndrome differentiation and treatment. Note: After recovery, this infant was examined at Affiliated Hospital of West China University of Medical Sciences, where the diagnosis of "Congenital Heart Disease" was negated. Now 5 years old, healthy.

Hypochondriac Dull Pain, Epigastric Fullness, Lower Abdominal Burning Distension for Half a Year

Yu Guojun, Director of TCM Research Office, Leshan People's Hospital, Sichuan Province

Liu XX, Female, 56 years old, First visit on Mar 16, 1987. The patient suffered from acute icteric hepatitis 12 years ago, cured after treatment. Subsequently occasional dull pain in liver area, epigastric fullness, taking several doses of soothing Liver/harmonizing Stomach prescriptions could temporarily relieve. Only half a year ago, due to emotional depression plus overwork, causing hypochondriac dull pain, epigastric fullness, lower abdominal burning distension to worsen. Previously repeatedly used Xiao Chai Hu Tang, Dan Zhi Xiao Yao San, Ban Ling Tang, Zi Shui Qing Gan Yin etc. modified, taking over 60 doses, all with little effect. Patient assumed she had an incurable disease, living in constant fear. But after B-ultrasound, X-ray, gastroscopy etc., no lesions found. Current examination: Hypochondriac dull pain in afternoon, epigastric fullness, lower abdominal burning distension, frequent belching, worsening at night; accompanied by dry eyes, chaotic dreams at night, dry/bitter mouth, dry stool; pale red tongue, thin yellow coating lacking moisture, wiry-thin pulse. This is Liver-Kidney Yin deficiency combined with Liver Qi stagnation syndrome. Treatment should nourish Kidney, soothe Liver/move Qi. Prescribed Yi Guan Jian combined with Si Ni San modified: Dang Gui 10g, Sheng Di 12g, Gou Qi Zi 12g, Bei Sha Shen 12g, Mai Dong 15g, Jin Ling Zi Tan 6g, Chai Hu 10g, Bai Shao 12g, Zhi Ke 10g, Sheng Gan Cao 5g, Chao Zao Ren 10g, 3 doses. Also informed her the disease is curable, urgently needs to change emotions/nature, be optimistic/open-minded. Second visit: Hypochondriac dull pain, epigastric fullness, lower abdominal burning distension reduced; but chest dull pain unchanged, stool still dry. Added Bai He 30g, Jue Ming Zi 20g, Rou Cong Rong 20g to above formula, changed Zhi Ke to Zhi Shi, 3 doses. Third visit: Chest dull pain and all symptoms significantly reduced, stool smooth, pale red tongue, thin white coating, wiry-thin pulse. Removed Jin Ling Zi Tan from above formula, added Bai Ji Li 10g, continued until subjective symptoms disappeared. 3 months later, patient introduced relatives to consult, stating after continuing 8 doses of above formula, all subjective symptoms disappeared.

Student Jia: When treating Liver diseases belonging to Liver-Kidney Yin deficiency, the teacher always prioritizes Yi Guan Jian, adding several Kidney-nourishing/Essence-filling herbs, often achieving good results. But recently, the therapeutic experience of using Yi Guan Jian combined with Si Ni San is also considerable.

Student Yi: Efficacy is undeniable, but it easily invites criticism. Because the efficacy and indications of these two formulas are vastly different, using them together is theoretically hard to justify. Simply put, Yi Guan Jian uses a large group of Yin-nourishing herbs to nourish Liver/Kidney, with a small amount of Jin Ling Zi to soothe Liver/move Qi, making tonification without stagnation; Si Ni San belongs to Yang-gang agents, specializing in soothing Liver/moving Qi. Therefore, combining the two must have reservations: If the syndrome is mainly Liver-Kidney Yin deficiency, using Yi Guan Jian combined with Si Ni San may damage Qi and injure Yin; if the syndrome is mainly Liver Qi stagnation, using Si Ni San combined with Yi Guan Jian may cause cloying/stagnating Qi.