6．温为阳邪，火必克金，故先犯肺，火性炎上，难得下行，用下法，移其热由腑出，正是病的去路。
临证用药 重视调理脾胃
李老治病对脾胃十分重视。他说： “脾胃为后天之本，气血生化之源，灌溉五脏六腑。”又说脾胃健运与否，不仅关系到人体的健康，而且关系到生命的存亡。因此在临床用药方面重视脾胃对提高临床疗效有着重要意义。李老对脾胃的治疗，一般分为益气、养阴、升举、温中、清热、理气、祛湿、攻下、消导等治疗方法，每法均有主方和兼证用药。
如脾胃正气虚者，善用四君子汤为主方；脾胃阴虚者，善用养胃汤为主方；脾阳不足者，善用理中汤为主方；中气不足者，善用补中益气汤为主方；肝脾不和者，善用舒肝和胃丸为主方；脾胃实热者，善用大黄黄连泻心汤为主方；腑实证，热实者，善用三承气汤；腑实证，寒实者，善用温脾汤；攻补兼施善用增液承气汤；脾胃食滞证，轻者善用保和丸，重者善用木香槟榔丸等。
应用泻下之剂 贵在有胆有识
泻下之剂多由通导大便、泻下积滞及攻逐水饮等作用峻烈的药物所组成。泻下之法属“八法”中的“下法”，凡里实之证，包括气滞、瘀血、积饮、食滞、便秘、虫积诸多有形之邪所引起的一些危急重症，如外科的许多急腹症，妇产科的宫外孕等，如应用得当，常常有起死回生，救性命于顷刻之间，扶危难于既倒之时的奇效神功。但看证不准，用不得法，则又有伐伤正气，甚至危及患者性命之危险。因此，应用泻下特别是峻下之剂，应当慎重，即所谓要有胆有识。有胆即辨证明确，特别是一些里实较重，病势较急者，应果断决策，峻攻急下，且剂量不宜过小，大黄之类宜重用；有识即看证准确，同时要特别注意禁忌症的有无，以防误下。识是胆的前提，有识才能有胆。李老一生十分注重和善用泻下剂，现将其应用承气类方的临床经验总结为下述两条：
1．使用标准
临床上同时出现发热、大便秘结在2天以上，或虽有大便，但质硬而干燥，腹部灼热板滞，按之微有疼痛，舌苔干燥而黄，根部较厚，即可大胆使用。
2．用药关键
(1)剂量不宜过小。一般泻下药，用量不宜少于9克，其中大黄更宜重用。不必顾虑便泻不止，因邪热下泄之后，其泻必能自止。
(2)可以配合润下药。如李老常以朴硝、蒌仁同时应用，其效更佳。
(3)可与解毒药同用。如表邪未解或热毒在膈上如乳蛾、痄腮、烂喉丹痧等均可加用清热解毒之品，如公英、地丁、银花、连翘等。
(4)可与清热泄热药同用。如高热神昏谵语者，宜去厚朴之类温燥之弊，配用石膏、知母、生地、黄连、黄芩、黄柏等。
(5)可与滋阴生津药同用。如大热伤阴，津亏而燥者，应与生地、麦冬、元参、石斛等同用。
(6)泻下之后宜续服和胃之剂。使用泻下剂后，便下热臭者，为药已中病，可再服1一2剂，以防热结未清而复骤；如便下清稀而无热臭或热臭不重者，恐误下，即宜停用，并续服和胃之剂以顾护胃气。
(7)注意承气证之假象。虽有上述之证，但伴有腹胀，肠鸣音亢进者，为承气证之假象，宜慎用，不可不察。
组方用药 严密灵巧
李老认为，组方的好坏对临床疗效的影响很大，所以临症处方时一定要注意。他说：“每一个方都应该是一个有秩序的个体，不是一个乱杂烩。每处一个方都应该知道它的主治证，都应该知道里面药物的主治、性味、归经，哪个药物的特性最明显，哪些药物的特性不明显，哪些药物相互配合时可以产生什么新的作用，哪几个药物配合时是前人制定的什么方剂，其主治证是什么，哪几个药物的功用雷同，哪几个药物的功用大异，以及数个药物组成方剂时的寒或热、升降浮沉、补泻开合的总趋势，特别是药物的特殊影响。即如剂型的改变对整个治疗的影响也应加以考虑。”他认为，要想做到这一点必须在以下两个方面下功夫：一是熟读药物学，在读药物学时切忌死背，要多在比较中下功夫，找出众多的相同点和相异点。二是多读方书，把众医家主治相同、组成相同、主治相同而用药不同及药物相同而剂型不同的方剂进行纵横比较，找出它们的共性和特性，如此这般地努力数年就可达到心中有数。所以曾有人问道：李所长。你为什么开数钱之方即能取效?李老说： “我每开一方都要方求对证，药求对证，配伍求对证，剂型求对证，药量求对证耳。”同时，李老强调说：“要想做到处方精练有效，必须在处方时做到方中有方，方中有药，药中有方，药中有药。”
“方中有方” 李老认为，通常情况下，一方系由一味或多味药物组成，尤其是经方，每方组成殊为严密。例如大青龙汤一方中，实际包含有麻黄汤、麻杏石甘汤与桂枝甘草汤三方，但其主治却与三方均不同．，因此，经方中的药味不宜随意增减，否则就会导致原方主治的重大改变，甚至根本变成他方。
“方中有药” 李老举例说：“温经回阳救误的桂枝去芍药加附子汤(桂枝三两，附子一枚，甘草二两，生姜三两，大枣十二二枚)和散风寒补阳胜湿的桂枝附子汤(桂枝四两，附子三枚，甘草二两，生姜三两，大枣二枚)，二方从药的品种上看是相同的。从药的剂量上看却不相同，因此方名各异，作用自然也不同。”至于临床误用，李老认为：“若前方用于后证，绝不会有显著效果，因为桂、附用量减少。甘、枣补缓之性相对增加，而风湿相搏之证，宜于温散，不宜补缓也；若后方用于前证，反会发生害处，因为桂枝散性过甚，不利于阳虚恶寒之体。”
“药中有方” 李老曾说：“有寒热往来之症，不一定完全用柴胡，但用柴胡时必须以寒热往来为上症．如桃仁承气汤之用于热入血室，可以把桂枝改为柴胡效果很好。”还需注意的是，药味少并不意味着药力就弱。李老曾指出： “干姜附子汤去四逆汤之甘草，其力甚猛，比四逆汤为峻，回阳力强。如增加药味，反牵制其力，减低功效。”
“药小有药” 李老说：“真武汤是治疗心力衰竭、肺心病的有效方剂，但是用之能否有效，关键在于本病是否是水饮上凌心肺。具体应用此方时还须注意每味药所起的作用，如方中的生姜，由于它辛温入肺、胃，能助白术、茯苓化饮，但因辛温上浮，不纳肾气者绝非所宜，故应去生姜。又，本证脉多见细数、促，说明不但阳虚，而且阴竭，因此宜加人参以补气益阴， 巳人参、附子、白术、茯苓、白芍相配，名附子汤，具有治疗少阴病，身体痛，手足寒之功，亦与本证合拍。但加人参之补，又易壅滞水饮之邪，故宜加厚朴、杏仁，且厚朴、杏仁、人参相配，不但定喘，而且消胀助脾。”
由此可见， “方中有方，方中有药，药中有方，药中有药”是李老在方剂加减应用中对药味、药量、药效三者之间关系的高度概括。因此，在选方用药时应从临证出发，该守则守，该变则变。正如李老所说： “执成方而治病，如拆旧房盖新房，不经大匠之手经营如何得宜。所以，用方切忌依样画葫芦，古方并不能尽合今病……如有一方面不符，即须加减适宜才行，不论伤寒、杂证都一样。总之，用方必须对证，我每在临床上也常用古人原方，也常师古人用方的精神而化裁应用，都能收到同样的效果，即是这个道理。”
师古方重在师其法
执古方成方而治病，犹如拆旧房以盖新房，非经大匠之手经营如何得宜?李老认为，古方不能尽合今病，用古方、成方最忌依样绘葫芦。如用仲景之经方，从临证实践中品验，只要脉证病机完全符合，用之即有效验，此时加减不是治错就是画蛇填足，但方证只要有一方面不符，即须加减适宜才行，不论伤寒、杂病都是一样。学习古方须掌握其精神法则，不一定非用它的原药原量。如麻杏石甘汤是什么作用，什么情况下可用?临床遇有该证时，即可灵活应用。李老常用的石膏阿斯匹林汤即遵此方之意。又如需要辛温发汗，不一定非用麻黄汤，用柴姜汤、胡椒汤亦未尝不可。用古方治今病，要抓重点，领会方剂精神，师其意，随证加减，做到面面周到，方能用之有效。例如治腹胀，川朴为君，兼虚者加人参，兼呕者加姜夏，即师法厚姜半甘参之意也。如系实胀加枳实、大黄，即承气之意，寒者加干姜，寒热者加柴胡，腹痛者加芍药，寒热夹杂者，往往干姜、黄连寒热并用，仿泻心汤、黄连汤之意。只要掌握精神，随证加减，皆能取效。总之，用古方成方治病，贵在师其法而非拘泥其方药，不论固守原方，还是加减化裁，均应做到方由证定，药随法出，方能病药相符，效如桴鼓。
关于方义与加减法
方义指出了每个方剂的主要治疗方向，如果正确地掌握了这个方向，除对于主治范围内的病证能够收到良好的效果外，就是主治范围以外的疾病，往往触类引申也会取得一定疗效；如果离开了这个方向，治病就会张冠李戴，不但对于主治范围外的疾病不可想象，就是主治范围内的证候也是毫无把握。
加减法有两种用意。一种是为了帮助学者解决主治范围以外比较常见的病证。在初学临床的时候，一旦遇到主治范围以外的证候往往会无法下手．因为任何疾病都不是截然分开的，或多或少总有互相牵连的地力，所主治范围以外的证候经常见到。有了这一栏即可按图索骥，按证用药，相当便利。 一种是为了帮助学者解决许多不常见的证候，因为人的病变是无穷的，绝不可能把所有的都写出来，有了这一条的启发，可以触类引申或举一反三，得到适当的解决。
以上这一段关于“方义与加减法”的医话，写在“李翰卿资料50”的封皮上。该资料记载有26昔温病方剂，每首方剂按方义、主治．药品、加减法、制法或煎服法、禁忌、用药大意等项收载。其中方义居首，说明李翰卿先生有着清醒的方剂学治学思想，这一点在其手稿《伤寒论113方临床使用经验》一书中展现得最为淋漓尽至，学者可以从中细细体味。而对于加减法的重视是李老审查证候、尤重夹杂的中医诊病学学术思想的体现。由于是在主方对证的基础上重视夹杂，所以李老的学术思想才显得既有原则性又有灵活性。
四物汤的临床应用
四物汤源于宋代《太平惠民和剂局方》，功能补血调经，为治疗各种血虚证之基础方或主方。
[历史经验集要]
《局方》：治一切血虚、血热、血燥诸证。
柯韵伯：是方乃肝经调血之专剂，非心经生血之主方。此方能补有形之血于平时，不能生无形之血于仓卒。如遇血崩、血晕等证，四物不能骤补而反助其滑脱。
唐容川：四物为生血和血之通剂。调血者，食四物不能为功。 徐灵胎：此血病之主方。 陈修园：治一切血证。皆纯滞之品，不能治血之源头……必善得加减之法方效。
黄宫绣：营中之血，非此不能生。
《医宗金鉴》：妇人血病主四物。言本方是妇人经产一切血病通用之方。
[药品]
当归9—15克 熟地9—15克 川芎4．5—7．5克 白芍9—15克
[加减法]
血虚者，加人参、黄芪(名圣愈汤)。
血结血瘀者，宜去白芍加赤芍，去当归加归尾，或加桃仁、红花等。
血闭或血不行者，或再加大黄、芒硝。
血寒者，加肉桂、附于。
血热实者，去熟地，加生地或再加黄芩、黄连。
出血者，宜去川芎，或加三七，或加各种炭药。
血虚兼恶寒身热无汗者，宜合麻黄汤。
血虚兼恶风身热有汗者，宜合桂枝汤。
血虚兼少阳寒热往来者，宜合小柴胡汤。
血虚兼阳明里热证者．宜合用调胃承气汤。
血多无热者，加阿胶、艾叶。
血多有热者，加黄芩、白术。
血多有块，色紫稠粘者，乃内有瘀血也，加桃仁、红花．、
[作用]
补血调血。
[主治]
一切营血虚滞，妇人经水不凋，脐腹作痛，及崩中漏下血块硬等。
[禁忌证]
吐血、衄血家，咳喘家，呕恶家，凡是阴虚血热者，均忌归、芎，因归、芎性温故也。泄泻者，忌当归，因其性油润滑肠故也。血脱血晕忌用四物，恐其助滑脱也。平素脾胃阳虚，食少便溏者，忌用地黄、芍药，因二药俱属阴药，恐其碍阳也。
三泻心汤使用宜忌
半夏泻心汤、生姜泻心汤与甘草泻心汤，组成大致相同，或仅有一药之别，或只药量有异，虽辛开苦降，调治寒热，调和肠胃之旨不变，但主治确各有侧重，临证使用，不能不辨。使用生姜泻心汤时，临床BL症以心下痞硬．干噫食臭、胁下有水气、腹中雷鸣、下利为特征。且必须是以舌苔黄浊、二便清利、无下坠之征的上热下寒之证最为适宜。偏寒偏热者均不宜用。半夏、甘草两泻心汤，虽前者重在呕吐，后者重在下利，但亦同样必须具有上热下寒之证，才能应用无误。
丝丝入扣用“逍遥”
逍遥散出自《太平惠民和剂局方》，主治肝郁血虚证，证诸临床多有效验，历代医家也多有发挥。李老根据自己多年经验，反复揣摩，总结出逍遥散的使用方法，内容丰富，条理清晰，颇有临床指导意义。
[方义]
此系治因受不顺意的刺激，郁郁不乐，迁延日久，不能痊愈，且影响了消化和吸收的机能及血液循环的常度和充分供给，从而引起一切病变之方也。逍遥散证就是古人所谓“肝郁脾虚”或“肝火旺，肝血伤”的证候。
[主症]
6. Warm pathogenic factors belong to Yang pathogens; Fire pathogens inevitably overcome Metal (the Lung), so they first attack the Lung. The nature of Fire is flaming upward, making it difficult for heat to descend naturally. Using the purgative method guides the heat out through the Fu organs, which is precisely the pathway for the disease to exit.
Clinical Medication: Emphasis on Regulating the Spleen and Stomach
Old Li places great importance on regulating the Spleen and Stomach in treating diseases. He stated: "The Spleen and Stomach are the foundation of acquired constitution and the source of Qi and Blood generation, irrigating and nourishing the Five Zang and Six Fu organs." He further said that whether the Spleen and Stomach function vigorously or not relates not only to human health but also to life and death. Therefore, emphasizing the regulation of the Spleen and Stomach in clinical medication is of significant importance for improving clinical efficacy. Old Li's treatment of the Spleen and Stomach generally includes methods such as tonifying Qi, nourishing Yin, raising Yang, warming the Middle, clearing Heat, regulating Qi, dispelling Dampness, purging downward, and promoting digestion. Each method has a principal formula and medications for accompanying syndromes.
For example, for deficiency of righteous Qi in the Spleen and Stomach, he skillfully uses Si Jun Zi Tang (Four Gentlemen Decoction) as the principal formula; for Yin deficiency of the Spleen and Stomach, he skillfully uses Yang Wei Tang (Stomach-Nourishing Decoction); for insufficiency of Spleen Yang, he skillfully uses Li Zhong Tang (Regulate the Middle Decoction); for insufficiency of Middle Qi, he skillfully uses Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction); for disharmony between the Liver and Spleen/Stomach, he skillfully uses Shu Gan He Wei Wan (Soothe the Liver and Harmonize the Stomach Pill); for excess Heat in the Spleen and Stomach, he skillfully uses Da Huang Huang Lian Xie Xin Tang (Rhubarb and Coptis Decoction to Drain the Heart); for Fu organ excess syndrome with Heat excess, he skillfully uses San Cheng Qi Tang (Three Bowel-Regulating Decoctions); for Fu organ excess syndrome with Cold excess, he skillfully uses Wen Pi Tang (Warm the Spleen Decoction); for combined attacking and tonifying, he skillfully uses Zeng Ye Cheng Qi Tang (Increase Fluids Bowel-Regulating Decoction); for food stagnation in the Spleen and Stomach, for mild cases he skillfully uses Bao He Wan (Preserve Harmony Pill), and for severe cases, Mu Lan Bing Lang Wan (Aquilaria and Areca Nut Pill).
Application of Purgative Formulas: Courage and Insight are Precious
Purgative formulas are mostly composed of potent drugs that promote bowel movement, purge accumulation, and drive out fluid retention. The purgative method belongs to the "Purgative Method" among the "Eight Methods." For all interior excess syndromes, including those caused by Qi stagnation, blood stasis, fluid retention, food stagnation, constipation, and intestinal parasites—many tangible pathogens causing critical conditions, such as many acute abdominal surgeries in surgery and ectopic pregnancy in obstetrics—if applied appropriately, often yield miraculous effects of bringing the dead back to life, saving lives in an instant, and rescuing from perilous situations. However, if the syndrome is misdiagnosed or the method is misapplied, there is a danger of damaging righteous Qi and even endangering the patient's life. Therefore, applying purgatives, especially drastic purgatives, should be cautious, meaning one must have both courage and insight. "Courage" means clear differentiation of syndromes; especially for cases with heavy interior excess and rapid progression, decisive action to drastically purge urgently is required, and doses should not be too small, with Rhubarb being used in heavy doses. "Insight" means accurate diagnosis, while paying special attention to contraindications to prevent erroneous purging. Insight is the prerequisite for courage; only with insight can there be courage. Old Li attached great importance to and skillfully used purgatives throughout his life. His clinical experience in using Cheng Qi-type formulas is summarized below:
1. Criteria for Use
When fever and constipation for more than 2 days appear simultaneously in clinical practice, or although there is stool, it is hard and dry, the abdomen feels burning and stiff, pressing causes slight pain, the tongue coating is dry and yellow, thicker at the root, one can boldly use these formulas.
2. Key Points in Medication
(1) Dosage should not be too small. Generally, the dosage of purgative drugs should not be less than 9 grams, with Rhubarb preferably used in heavier doses. There is no need to worry about unceasing diarrhea, because after the pathogenic heat is discharged downward, the diarrhea will stop spontaneously.
(2) Can be combined with moistening laxatives. For example, Old Li often applies Xiao Ming Jian (Natrii Sulfas) and Trichosanthis Semen (Trichosanthes Seed) together, yielding better efficacy.
(3) Can be used with detoxifying drugs. If exterior pathogens are unresolved or heat-toxin is above the diaphragm, such as tonsillitis, mumps, or scarlet fever, heat-clearing and detoxifying herbs like Taraxaci Herba (Dandelion Herb), Viola Herba (Viola Herb), Lonicerae Japonicae Flos (Honeysuckle Flower), and Forsythiae Fructus (Forsythia Fruit) can be added.
(4) Can be used with heat-clearing and draining drugs. For patients with high fever, coma, and delirium, the warming and drying properties of drugs like Magnoliae Officinalis Cortex (Magnolia Bark) should be removed, and Gypsum Fibrosum (Gypsum), Anemarrhenae Rhizoma (Anemarrhena Rhizome), Rehmanniae Radix (Rehmannia Root), Coptidis Rhizoma (Coptis Rhizome), Scutellariae Radix (Scutellaria Root), and Phellodendri Cortex (Phellodendron Bark) should be paired.
(5) Can be used with Yin-nourishing and fluid-generating drugs. For severe heat injuring Yin, resulting in fluid deficiency and dryness, it should be used with Rehmanniae Radix, Ophiopogonis Radix (Ophiopogon Root), Scrophulariae Radix (Figwort Root), and Dendrobii Caulis (Dendrobium Stem).
(6) After purging, stomach-harmonizing agents should be continued. After using purgatives, if hot and foul-smelling stool is passed, it indicates the medicine has hit the target; 1-2 more doses can be taken to prevent residual heat結 from rebounding; if clear, watery stool without heat odor or with mild heat odor is passed, fearing erroneous purging, usage should be stopped immediately, and stomach-harmonizing agents should be continued to protect Stomach Qi.
(7) Note the false signs of Cheng Qi syndrome. Although the above symptoms exist, if accompanied by abdominal distension and hyperactive bowel sounds, it is a false sign of Cheng Qi syndrome; caution is advised, and this must not be overlooked.
Formula Composition and Medication: Rigorous and Agile
Old Li believes that the quality of formula composition greatly affects clinical efficacy, so attention must be paid when prescribing clinically. He said: "Every formula should be an ordered individual, not a messy mix. When prescribing every formula, one should know its indicated syndrome, the indications, nature, flavor, and meridian tropism of the drugs within it, which drug's characteristics are most obvious, which are not, what new effects arise from the cooperation of certain drugs, which combination corresponds to a formula formulated by predecessors and what its indication is, which drugs have similar functions, which have vastly different functions, and the overall trend of cold/heat, ascending/descending/floating/sinking, tonification/draining, opening/closing when several drugs form a formula, especially the special influence of drugs. Even the impact of changing dosage forms on the entire treatment should be considered." He believed that to achieve this, effort must be made in two aspects: First, study pharmacology thoroughly; avoid rote memorization, focus on comparison to find similarities and differences. Second, read many formula books, conducting vertical and horizontal comparisons of formulas with same indications but different compositions, same compositions but different indications, and same drugs but different dosage forms, to find their commonalities and specificities. Efforting in this way for several years leads to mastery. Someone once asked Director Li: Why do your prescriptions work effectively? Old Li replied: "For every formula I prescribe, I seek correspondence in the formula, the drugs, the compatibility, the dosage form, and the dosage." At the same time, Old Li emphasized: "To achieve concise and effective prescriptions, one must achieve 'formula within formula, drug within formula, formula within drug, drug within drug' during prescription."
"Formula within Formula" Old Li believed that usually, a formula consists of one or more drugs, especially Jing Fang (Classic Formulas), where each formula is extremely rigorous. For instance, Da Qing Long Tang (Major Green Dragon Decoction) actually contains three formulas: Ma Huang Tang (Ephedra Decoction), Ma Xing Shi Gan Tang (Ephedra, Apricot Kernel, Gypsum and Licorice Decoction), and Gui Zhi Gan Cao Tang (Cinnamon Twig and Licorice Decoction), but its indication differs from all three. Therefore, drug ingredients in Jing Fang should not be arbitrarily added or removed, otherwise leading to major changes in the original indication, or even transforming it into another formula entirely.
"Drug within Formula" Old Li gave examples: "Gui Zhi Qu Shao Yao Jia Fu Zi Tang (Cinnamon Twig Decoction minus Peony plus Aconite) for warming meridians, restoring Yang, and correcting errors (Cinnamon Twig 3 liang, Aconite 1 piece, Licorice 2 liang, Fresh Ginger 3 liang, Jujube 12 pieces) and Gui Zhi Fu Zi Tang (Cinnamon Twig and Aconite Decoction) for dispersing Wind-Cold, tonifying Yang, and overcoming Dampness (Cinnamon Twig 4 liang, Aconite 3 pieces, Licorice 2 liang, Fresh Ginger 3 liang, Jujube 2 pieces). From the variety of drugs, the two formulas are identical. From the dosage, they differ, hence different names and natural differences in effect." Regarding clinical misuse, Old Li believed: "If the former formula is used for the latter syndrome, there will definitely be no significant effect because the dosage of Cinnamon and Aconite is reduced. The tonifying and moderating nature of Licorice and Jujube relatively increases, whereas for Wind-Dampness bi syndrome, warming dispersion is suitable, not tonifying moderation; if the latter formula is used for the former syndrome, it may cause harm because the dispersing nature of Cinnamon Twig is too strong, unsuitable for bodies with Yang deficiency and aversion to cold."
"Formula within Drug" Old Li once said: "Symptoms of alternating chills and fever do not necessarily require complete reliance on Bupleurum, but when using Bupleurum, alternating chills and fever must be the primary symptom. For example, in Tao Ren Cheng Qi Tang (Peach Kernel Bowel-Regulating Decoction) used for Heat entering the Blood Chamber, replacing Cinnamon Twig with Bupleurum yields good results." It is also worth noting that fewer drug ingredients do not mean weaker potency. Old Li pointed out: "Gan Jiang Fu Zi Tang (Dried Ginger and Aconite Decoction) removes Licorice from Si Ni Tang (Reverse Cold Decoction); its power is very fierce, more drastic than Si Ni Tang, with strong Yang-restoring strength. Adding more drug ingredients would instead restrain its power and reduce efficacy."
"Drug within Drug" Old Li said: "Zhen Wu Tang (True Warrior Decoction) is an effective formula for treating heart failure and cor pulmonale, but its effectiveness depends on whether the disease involves Water-Fluid invading the Heart and Lungs. When specifically applying this formula, one must note the role of each drug. For example, Fresh Ginger in the formula, due to its acrid-warm nature entering the Lung and Stomach, helps Bai Zhu (Atractylodis Macrocephalae Rhizoma, Large-headed Atractylodes Rhizome) and Fu Ling (Poria, Poria Cocos) transform fluids, but because it is acrid-warm and floats upward, it is absolutely unsuitable for cases failing to grasp Kidney Qi, so Fresh Ginger should be removed. Furthermore, the pulse in this syndrome often appears fine-rapid or intermittent, indicating not only Yang deficiency but also Yin exhaustion; therefore, Ren Shen (Ginseng Radix, Ginseng Root) should be added to tonify Qi and benefit Yin. With Ren Shen, Fu Zi (Aconiti Lateralis Radix Praeparata, Prepared Lateral Root of Aconite), Bai Zhu, Fu Ling, and Bai Shao (Paeoniae Radix Alba, White Peony Root) combined, it is named Fu Zi Tang (Aconite Decoction), possessing the function of treating Shaoyin disease with body pain and cold hands/feet, which also fits this syndrome. However, the tonifying nature of Ren Shen easily obstructs Water-Fluid pathogens, so Hou Po (Magnoliae Officinalis Cortex, Magnolia Bark) and Xing Ren (Armeniacae Semen Amarum, Bitter Apricot Seed) should be added. Moreover, the combination of Hou Po, Xing Ren, and Ren Shen not only calms wheezing but also reduces distension and assists the Spleen."
Thus, "formula within formula, drug within formula, formula within drug, drug within drug" is Old Li's highly condensed summary of the relationship between drug ingredients, dosage, and efficacy in the application of formula modifications. Therefore, when selecting formulas and medications, one should start from clinical practice, adhering when necessary and changing when appropriate. As Old Li said: "Using fixed formulas to treat diseases is like demolishing an old house to build a new one; how can it be done properly without the management of a master craftsman? Therefore, using formulas must avoid copying mechanically; ancient formulas cannot fully fit modern diseases... If any aspect does not match, appropriate modification is required, whether for Shang Han (Cold Damage) or miscellaneous diseases. In short, using formulas must correspond to the syndrome. I often use the original formulas of ancients in clinical practice, and often learn the spirit of their formula usage to modify and apply them, achieving the same effect. This is the principle."
Learning Ancient Formulas: Emphasis on Learning Their Methods
Using ancient fixed formulas to treat diseases is like demolishing an old house to build a new one; how can it be done properly without the management of a master craftsman? Old Li believed that ancient formulas cannot fully fit modern diseases, and the greatest taboo in using ancient or fixed formulas is copying mechanically. For example, using Zhang Zhongjing's Jing Fang (Classic Formulas), verified through clinical practice, if the pulse, symptoms, and pathogenesis completely match, using them yields effective results; at this time, modification is either incorrect treatment or superfluous. But if any aspect of the formula-syndrome match does not align, appropriate modification is required, whether for Shang Han or miscellaneous diseases. Learning ancient formulas requires mastering their spiritual principles; it is not necessary to use exactly the original drugs and dosages. For instance, what is the function of Ma Xing Shi Gan Tang (Ephedra, Apricot Kernel, Gypsum and Licorice Decoction), and under what circumstances can it be used? When encountering this syndrome clinically, it can be applied flexibly. The Gypsum Aspirin Decoction commonly used by Old Li follows the intent of this formula. Similarly, if acrid-warm sweating is needed, it is not mandatory to use Ma Huang Tang (Ephedra Decoction); using Chai Jiang Tang (Bupleurum and Ginger Decoction) or Hu Jiao Tang (Pepper Decoction) is also acceptable. Using ancient formulas to treat modern diseases requires grasping key points, understanding the spirit of the formula, learning its intent, modifying according to the syndrome, ensuring comprehensiveness, and only then can it be effective. For example, treating abdominal distension, Chuan Bo (Magnoliae Officinalis Cortex, Magnolia Bark) serves as the sovereign drug; for accompanying deficiency, add Ren Shen (Ginseng Radix, Ginseng Root); for accompanying vomiting, add Sheng Jiang (Zingiberis Rhizoma, Fresh Ginger) and Ban Xia (Pinelliae Rhizoma, Pinellia Tuber), following the intent of Hou Po Huang Ji Ban Xia Gan Ren Tang (Magnolia Bark, Dried Ginger, Pinellia, Licorice and Ginseng Decoction). If it is excess distension, add Zhi Shi (Immaturus Fortunellea Fructus, Immature Kankun Orange Fruit) and Da Huang (Rhei Radix et Rhizoma, Rhubarb Root and Rhizome), following the intent of Cheng Qi formulas; for Cold, add Gan Jiang (Zingiberis Rhizoma, Dried Ginger); for mixed Cold and Heat, add Chai Hu (Bupleuri Radix, Bupleurum Root); for abdominal pain, add Bai Shao (Paeoniae Radix Alba, White Peony Root); for mixed Cold and Heat, often Gan Jiang (Zingiberis Rhizoma, Dried Ginger) and Huang Lian (Coptidis Rhizoma, Coptis Rhizome) are used together for Cold and Heat, imitating the intent of Xie Xin Tang (Drain the Epigastrium Decoction) and Huang Lian Tang (Coptis Decoction). As long as the spirit is mastered and modifications are made according to the syndrome, efficacy can be achieved. In short, using ancient fixed formulas to treat diseases values learning their methods rather than being bound by their drugs; whether adhering strictly to the original formula or modifying it, one must ensure the formula is determined by the syndrome and the drugs follow the method, so that the disease and medicine correspond, achieving efficacy as swift as a drumbeat.
On Formula Meaning and Modification Methods
Formula meaning points out the main therapeutic direction of each formula. If this direction is correctly grasped, besides achieving good results for syndromes within the indicated scope, diseases outside the indicated scope often yield certain efficacy through analogy; if this direction is abandoned, treating diseases becomes mismatched, not only making diseases outside the indicated scope unimaginable, but even syndromes within the indicated scope become uncertain.
Modification methods have two purposes. One is to help scholars solve relatively common syndromes outside the indicated scope. When initially learning clinical practice, encountering syndromes outside the indicated scope often leaves one unable to proceed, because no disease is completely separate; there are always interconnections, so syndromes outside the indicated scope are frequently seen. Having this section allows one to follow clues and medicate according to the syndrome, which is quite convenient. The other purpose is to help scholars solve many uncommon syndromes, because human pathological changes are infinite, and it is impossible to list them all. With the inspiration from this item, one can draw inferences or apply knowledge to new situations to obtain appropriate solutions.
The above medical commentary on "Formula Meaning and Modification Methods" was written on the cover of "Li Hanqing Materials 50". This material records 26 ancient Warm Disease formulas, each recorded according to formula meaning, indication, drugs, modification methods, preparation or decoction/administration methods, contraindications, and general medication guidelines. Among them, formula meaning is listed first, indicating Mr. Li Hanqing's clear scholarly thought in formula studies, which is most vividly demonstrated in his manuscript "Clinical Experience of Using 113 Formulas from Shang Han Lun", where scholars can savor it carefully. The emphasis on modification methods reflects Old Li's academic thought in TCM diagnostics, particularly his focus on complicated syndromes. Because he emphasized complications on the basis of the principal formula matching the syndrome, Old Li's academic thought appears both principled and flexible.
Clinical Application of Si Wu Tang
Si Wu Tang (Four Substances Decoction) originates from the Song Dynasty's "Tai Ping Hui Min He Ji Ju Fang", with functions of tonifying Blood and regulating menstruation, serving as a basic or principal formula for treating various Blood deficiency syndromes.
[Collection of Historical Experience]
"Ju Fang": Treats all Blood deficiency, Blood Heat, and Blood Dryness syndromes.
Ke Yunbo: This formula is a specialized agent for regulating Blood in the Liver Meridian, not the principal formula for generating Blood in the Heart Meridian. This formula can tonify substantial Blood in normal times but cannot generate insubstantial Blood in emergencies. In cases of uterine bleeding or Blood fainting, Si Wu Tang cannot rapidly tonify and may反而 assist slipping and loss.
Tang Rongchuan: Si Wu Tang is a universal agent for generating and harmonizing Blood. Those who regulate Blood cannot achieve success merely by eating Si Wu Tang.
Xu Lingtai: This is the principal formula for Blood diseases.
Chen Xiuyuan: Treats all Blood syndromes. All are purely cloying substances, unable to treat the source of Blood... Only by skillfully obtaining modification methods can it be effective.
Huang Gongxiu: Blood in the Ying (Nutritive) level cannot be generated without this.
"Yi Zong Jin Jian": Women's Blood diseases primarily use Si Wu Tang. It states this formula is a universal formula for all Blood diseases related to menstruation and childbirth in women.
[Drugs]
Dang Gui (Angelicae Sinensis Radix, Dong Quai Root) 9–15 g, Shu Di Huang (Rehmanniae Radix Preparata, Prepared Rehmannia Root) 9–15 g, Chuan Xiong (Chuanxiong Rhizoma, Szechwan Lovage Rhizome) 4.5–7.5 g, Bai Shao (Paeoniae Radix Alba, White Peony Root) 9–15 g.
[Modification Methods]
For Blood deficiency, add Ren Shen (Ginseng Radix, Ginseng Root) and Huang Qi (Astragali Radix, Astragalus Root) (named Sheng Yu Tang).
For Blood binding and Blood stasis, remove Bai Shao (Paeoniae Radix Alba, White Peony Root) and add Chi Shao (Paeoniae Radix Rubra, Red Peony Root); remove Dang Gui (Angelicae Sinensis Radix, Dong Quai Root) and add Gui Wei (Angelicae Sinensis Radix, Dong Quai Root Tail), or add Tao Ren (Persicae Semen, Peach Seed) and Hong Hua (Carthami Flos, Safflower Flower), etc.
For Blood closure or non-flowing Blood, additionally add Da Huang (Rhei Radix et Rhizoma, Rhubarb Root and Rhizome) and Mang Xiao (Natrii Sulfas, Mirabilite).
For Blood Cold, add Rou Gui (Cinnamomi Cortex, Cinnamon Bark) and Fu Zi (Aconiti Lateralis Radix Praeparata, Prepared Lateral Root of Aconite).
For Blood Heat excess, remove Shu Di Huang (Rehmanniae Radix Preparata, Prepared Rehmannia Root), add Sheng Di Huang (Rehmanniae Radix, Rehmannia Root), or additionally add Huang Qin (Scutellariae Radix, Scutellaria Root) and Huang Lian (Coptidis Rhizoma, Coptis Rhizome).
For bleeding, remove Chuan Xiong (Chuanxiong Rhizoma, Szechwan Lovage Rhizome), or add San Qi (Notoginseng Radix et Rhizoma, Notoginseng Root and Rhizome), or add various Charred Drugs.
For Blood deficiency accompanied by aversion to cold, body heat, and no sweat, combine with Ma Huang Tang (Ephedra Decoction).
For Blood deficiency accompanied by aversion to wind, body heat, and sweat, combine with Gui Zhi Tang (Cinnamon Twig Decoction).
For Blood deficiency accompanied by Shaoyang alternating chills and fever, combine with Xiao Chai Hu Tang (Minor Bupleurum Decoction).
For Blood deficiency accompanied by Yangming interior Heat syndrome, combine with Tiao Wei Cheng Qi Tang (Regulate the Stomach Bowel-Regulating Decoction).
For excessive Blood without Heat, add E Jiao (Colla Corii Asini, Donkey-Hide Gelatin) and Ai Ye (Artemisiae Argyi Folium, Mugwort Leaf).
For excessive Blood with Heat, add Huang Qin (Scutellariae Radix, Scutellaria Root) and Bai Zhu (Atractylodis Macrocephalae Rhizoma, Large-headed Atractylodes Rhizome).
For excessive Blood with clots, dark purple color, and thick sticky consistency, indicating internal Blood stasis, add Tao Ren (Persicae Semen, Peach Seed) and Hong Hua (Carthami Flos, Safflower Flower).
[Function]
Tonifies and regulates Blood.
[Indication]
All Ying-Blood deficiency and stagnation, irregular menstruation in women, umbilical and abdominal pain, and metrorrhagia with hard blood clots, etc.
[Contraindications]
For those with hematemesis, epistaxis, cough and asthma, or vomiting and nausea, and all those with Yin deficiency and Blood Heat, Gui (Angelicae Sinensis Radix, Dong Quai Root) and Xiong (Chuanxiong Rhizoma, Szechwan Lovage Rhizome) are contraindicated because they are warm in nature. For those with diarrhea, Dang Gui (Angelicae Sinensis Radix, Dong Quai Root) is contraindicated because its oily nature lubricates the intestines. For Blood collapse and Blood fainting, Si Wu Tang is contraindicated for fear of assisting slipping and loss. For those with chronic Spleen-Stomach Yang deficiency, poor appetite, and loose stools, Di Huang (Rehmanniae Radix, Rehmannia Root) and Shao Yao (Paeoniae Radix, Peony Root) are contraindicated because both are Yin drugs, feared to hinder Yang.
Precautions for Using the Three Xie Xin Decoctions
Ban Xia Xie Xin Tang (Pinellia Decoction to Drain the Epigastrium), Sheng Jiang Xie Xin Tang (Fresh Ginger Decoction to Drain the Epigastrium), and Gan Cao Xie Xin Tang (Licorice Decoction to Drain the Epigastrium) have roughly the same composition, differing by only one drug or only in dosage. Although the principle of acrid-opening and bitter-draining, regulating Cold and Heat, and harmonizing the Stomach and Intestines remains unchanged, their indications indeed have different focuses, and differentiation is essential in clinical use. When using Sheng Jiang Xie Xin Tang (Fresh Ginger Decoction to Drain the Epigastrium), clinical symptoms are characterized by fullness and hardness below the heart, dry belching with food odor, fluid Qi under the flanks, borborygmus in the abdomen, and diarrhea. It is most suitable for upper Heat and lower Cold syndromes with yellow turbid tongue coating, clear urination and defecation, and no sensation of bearing down. Cases leaning towards Cold or Heat are not suitable. For Ban Xia (Pinelliae Rhizoma, Pinellia Tuber) and Gan Cao (Glycyrrhizae Radix et Rhizoma, Licorice Root and Rhizome) Xie Xin Decoctions, although the former focuses on vomiting and the latter on diarrhea, they similarly must possess upper Heat and lower Cold syndromes to be applied correctly.
Meticulous Use of "Xiao Yao"
Xiao Yao San (Free and Easy Wanderer Powder) originates from "Tai Ping Hui Min He Ji Ju Fang", indicated for Liver Qi Stagnation and Blood Deficiency syndrome. Clinical evidence shows it is often effective, and physicians of past generations have elaborated on it. Based on his years of experience, Old Li repeatedly pondered and summarized the usage methods of Xiao Yao San (Free and Easy Wanderer Powder), with rich content and clear logic, having significant clinical guidance value.
[Formula Meaning]
This is a formula for treating lesions caused by unpleasant stimuli, leading to depression over a long period, inability to recover, and affecting digestive and absorptive functions as well as the normality and sufficient supply of blood circulation. Xiao Yao San (Free and Easy Wanderer Powder) syndrome is what the ancients called "Liver Qi Stagnation and Spleen Deficiency" or "Hyperactive Liver Fire and Injured Liver Blood."
[Principal Symptoms]