其六，从除寒蠲痹看，在寒湿客于肌肉、关节的麻木、疼痛上，附子虽然不如川乌、草乌的作用强，但它比川乌、草乌的毒性小，比其他任何药物的作用都好，所以《伤寒论》中的桂枝附子汤、白术附子汤、甘草附子汤都用的是附子。从经验看，附子对痹证脉弦大而紧或沉细迟缓、指趾厥冷者效果最好，但对兼有口苦、苔黄、尿黄赤者要慎重应用，否则容易出现中毒反应，若非用不可时，必须配人一定的寒凉药。如《金匮要略》中的桂枝芍药知母汤就是这方面的例子。
以上是附子的主要适应证，此外，应用附子时，还经常遇见以下问题：
其一，是用于抢救危重证候时的用量问题。经验证实，在心力衰竭应用附子时宜小量，亡阳而二便失禁、肢厥时宜大量。这是因为，心力衰竭时，症见脉细数、脉促，乃为阳虚为主，阴亦亏损，多用附子则伤阴，多用养阴则伤阳；亡阳证时，症见肢厥、脉微、二便失禁，乃沉寒痼冷之象，故宜大量雄烈之附子以回阳救逆。其小量一般为1克，大量一般为lO～15克。
其二，是中毒问题。附子应用后会不会中毒，常常受以下三个条件的影响。一是药量和煎煮的时间：一般是药量越大毒性越大，煎煮的时间越短毒性越大，反之，药量越小毒性越小，煎煮的时间越长毒性越小。所以，为了减少其毒性常常煎煮1小时以上。二是证的性质：一般来讲，脉大而弦紧或沉细迟缓的沉寒痼冷证，虽用大剂亦很少发生中毒反应，而热证、阴虚证、血虚有热证，则虽用少量亦容易发生中毒反应。三是季节：一般春季阳气升发，应用附子时容易发生中毒反应，而冬季阳气收藏时，虽用量较大亦很少出现中毒反应。
其三，是治疗噎膈问题。《伤寒论》40条云：“若噎者，去麻黄，加附子一枚，炮。”开附子治疗噎膈之先河。尤在泾《伤寒贯珠集》云：“噎者，寒积积于中者，附子温能散寒，辛能破饮，故加之。”从经验来看，其所治之噎大多具有胃脘痞满、遇冷加重、脉沉细或弦大而紧等，其后再验之临床，以近代医学所述之食道贲门失弛缓症为多见。
其四，是治疗慢惊风的问题。附子所治之风既不是热极生风，也不是阴虚风动，而是脾败木贼之风，如泻下如水或二便失禁，肢厥，脉微欲绝，舌苔薄白时所出现之风。这种风虽然多见于小儿的慢脾风，然亦可见于肺炎、乙脑等病中，临证时不可不予注意。
其五，是升血压和使脉搏加快的问题。这个问题要辩证地去看。由于附子能补阳益火，回阳救逆，所以对脉沉细迟微的心跳过缓和寒邪直中的腹痛、心痛、脉迟缓确有增快心跳的作用，但对于阴阳俱虚或阳虚的脉数、脉促，如心力衰竭的脉数、脉促，则不但不使脉搏加速而且可以减慢．对于肢厥、脉微、血压下降的休克和肝火上冲、阴虚阳亢、肝风内动的高血压常常可以使血压上升，而对于虚阳上浮，上盛下虚，症见足冷、脉微或虚大无根的高血压，非但不会使血压上升，反会使血压下降。
其六，是催吐和止吐的问题。有的书中说附子能催吐。而有的又说其能止吐，到底是催吐，还是止吐，这要看证的性质。其对热证的吐常可使呕吐加重，胃热者常常引起呕吐；至若寒饮不化和虚阳上浮、阴盛格阳所致之呕吐，则常有止吐之效。
大黄论
李老认为，大黄不但对具有便秘的各种实热证(如阳明腑实的高热，神昏谵语，大便秘结，或大便数日不行，腹满胀痛，或下利清水，热结旁流，或便秘不通，舌苔黄燥，狂怒乱跑，或痈肿疔疖)、火热上冲证(如吐血衄血，头晕头痛，耳痛眼痛，牙痛鼻病，口疮，斑疹)有效，而且对瘀血证(如跌打损伤、癥瘕积聚、痛经经闭、崩漏)、湿热蕴结证(如湿疮、黄疸、淋痛、痢疾)及各种积滞证等均有卓效。
其一，在攻下通便方面：①大黄的三个作用——寒、燥、泻，即是说大黄对实热、湿热的便秘比较适宜。②大黄的产地和炮制方法．即西军的泻下通便泻火作用较川军强，而燥湿作用较川军弱；酒军、熟军的泻下作用较生大黄弱，而善清头部之火热。③煎煮时间，即水煎在半小时以下者泻下作用强，40分钟以上者泻下作用减弱。④用量大小，即用量大时泻下作用强，小剂量时泻下作用较弱。⑤配伍，即配合行气药、润燥软坚药时泻下作用强，不配伍时泻下作用弱。⑥正气的盛衰，津液不足或血虚的便秘，常常在应用大黄的第一剂后，大便即通，其后不久大便又趋秘结，此时若再反复应用大黄，其泻下作用则日渐下降，甚或使便秘更加严重，这是由于大黄虽能攻下，但却伤津伤血所致，此时必须配合或改用增液润便或养血润便方可使大便得通。气虚或阳虚的大便秘结，因大黄苦寒攻伐，大伤元气，不但不能使大便通泰，而且常常使秘结更甚。⑦寒实便秘，虽用大黄3克，亦可使大便泻下1～3次，并在泻下之前往往兼见腹痛，而实热结滞的便秘，最少用9克，甚或用15～30克才有效。⑧逐瘀破血。由于大黄逐瘀破血，所以妊娠期间一定要慎重应用，否则容易发生堕胎。
其二，在消导积滞方面：胃肠积滞，大便溏泻或便秘者，大黄有很好的治疗效果。一般来讲，在消导积滞时用量宜小，一般以1．5～3克为佳，若量大则消积的作用小而攻下的作用增强。若胃脘胀痛，拒按，尿赤，苔黄，便秘者，应配合枳实、厚朴各6～9克；胃脘胀痛，拒按，苔白，尿清，大便稀溏或时秘时溏者，应配人枳实6克，干姜1.5～3克，脾虚者再加焦白术6克；久痢、久泄，大便溏而不爽或里急后重，或便兼粘液，胃皖痞满，遇冷加重者，加党参、白术、枳实、木香各3～6克，干姜1．5～3克，山药15～30克。服药后可能不久即出现腹痛泄泻1～2次。1剂药后，即停药2—7天，使正气稍事恢复再用。
其三，清熱泻火方面：肝胃实火所致的头晕头痛、眼病、耳痛、牙痛、口疮、吐血衄血，非用大黄不易取效，其效的大小常与用量、用法有关。便秘较轻时。大黄用量若大则虽腹痛泄泻而证不减，用量过小时大便不通亦难取卓效。一般来讲，仅有轻微便秘者，宜用酒军、熟军或清宁丸，且其量以3克为宜；便秘严重者，宜用生大黄3—6克，甚者可用9一12克，若仍大便不通可再加芒硝3—6克。总之，以便通微溏为佳，不可令大泻下。高热发斑，大黄的用量最为要紧，攻下太甚往往使斑邪内陷。攻下不足则邪毒不易祛除，因此用量以恰到好处为佳。一般来讲，根据便秘的轻重，以3—9克为宜。
其四，在祛瘀活血方面：本药祛瘀生新，逐瘀活血，为治疗瘀血兼便秘的良药。特别是对兼便秘的瘀肿、癥瘕积聚、出血证效果最佳。在应用时以便通微溏为度，不可使大泻下，否则仅泻肠胃之实，伤正气，而瘀血不除。因为瘀血为沉痼之害，只可缓图，不可猛攻。若兼寒者，可根据瘀血所在部位的不同，加不同的温经活血药，否则仅用大黄之苦寒，往往引起腹部剧痛泄泻，而瘀血不除。
其五，在燥湿清热方面：本药清热燥湿，内服或外用，对各种湿疮、黄疸、淋证等都有很好的作用。但因本品苦寒而泻下，过用伤脾败胃而湿邪难除，因此仅可应用于热重于湿兼便秘的湿热证。用量也只能在3—6克左右，用药以出现大便每日1—2次为度。
其六，在泻火定惊方面：若高热便秘，谵语惊搐，或便秘，面目红赤，狂躁不安的精神病，非大剂大黄不能泻其实，一般以10一15克以上为宜，并应根据他证的特点，分别采用犀连承气汤、白虎承气汤、大承气汤、牛黄承气汤、大陷胸汤等。
另外，应用大黄时，常常遇见以下几种情况：
其一，是应用大黄的泻下方剂，以第一剂第一煎的泻下作用最强，第二剂的泻下作用则较差，若反复应用时泻下的作用更弱。这是由于大黄具有泻下作用的同时，还有收涩作用的缘故，再加之便秘之证除实热外，往往还兼有气滞，药后气行而大便通，再用则气伤而运化之权降低，因此反复应用经常出现泻下作用降低的现象，此时若停药2天则往往使泻下的作用增强。
其二，应用具有大黄的泻下方剂时，为什么有的有腹痛，有的没有腹痛，有的用很小量的大黄则大便通，有的用量很大而仍大便不通?这是由于人的体质因素造成的。一般来讲，单纯实热证的便秘不出现腹痛，而且用量很大才能泻下，而虚寒者则经常出现腹痛，且用小量即可引起泄泻。
其三，是有的孕妇虽用小量大黄即出现堕胎，有的虽用10—15克也不堕胎，这是由于前者为虚寒之质，后者为实热壅滞之故。
其四，是反复应用具有大黄的方剂仍然便秘不通时一般应改用其他没有大黄的方剂为妥。若属津液不足者应滋阴养液，血虚者应养血润燥，阳虚者应温阳通便。
师古而不泥古
——读书笔记一则
李老勤求古训，治学严谨，在繁忙的医疗工作之余，遍览古代医籍。但李老学习古人学术思想并非是毫无条件地全盘接受，而是一个“扬弃”的过程，常常结合自己的临床经验去伪存真，并善于从无字中求之，这一点从他在阅读薛雪《湿热病篇》时所作的读书笔记中可见一斑。今将李老阅读原文时所批注的按语摘录于下，以资借鉴：
原文(二十九)： “湿热证，四五日，忽大汗出，手足冷，脉细如丝，或绝，口渴，茎痛，而起坐自如，神清语亮，乃汗出过多，卫外之阳暂亡，湿热之邪仍结，一时表里不通，脉故伏，非真阴外脱也，宜五苓散去术加滑石、酒炒川连、生地、芪皮等味。”
按：大汗出，手足冷。脉细如丝，或绝或伏，虽神清语亮，也系真阳外脱之证，从何认为是卫阳暂亡呢?口渴茎痛出现在大汗之后，安知非液涸津伤之证，从何认为是湿热之邪仍结呢?即便真如所说，试问五苓散用桂枝有何用处?我认为本证的治法宜用真武汤去生姜，加滑石、麦冬、草梢等药方能有效。
原文(三十)：“湿热证，发痉神昏，独足冷阴缩，下体外受客寒，仍宜从湿热治，只用卒温之品煎汤熏洗。”
按：此法不一定有大效，但也不会有坏处，因为病在疑似之际就先用一种外治法或轻剂以试治之，效者可证明这方面诊断的正确性，不效者可肯定另一方面的治疗标准。例如本法如果见效的话，可以肯定是兼受客寒，否则肯定是邪犯心肝之重证，须要从速防治，但防治的方法应严加注意。
原文(三十一)：“湿热证，初起壮热口渴，脘闷懊铱，眼欲闭，时谵语，浊邪蒙闭上焦，宜涌泄，用枳壳、桔梗、淡豆豉、生山栀，无汗者加葛根。”
按：根据壮热口渴、懊（忄农）谵语等症是热盛于湿的表现，所云浊邪不够相符。栀子豉汤是清热之剂，不是涌吐之剂，已从实践证明，涌字应改为清字。
原文(三十二)：“湿热证，经水适来，壮热口渴，谵语神昏，胸腹痛，或舌无苔，脉滑数，邪陷营分，宜大剂犀角、紫草、茜根、贯众、连翘、鲜菖蒲、银花露等味。”
按：原书认为必用重剂乃可奏功，到底重到什么程度才算重剂，殊难掌握。我认为根据患者具体情况，临时酌定才是正当方法。有人认为茜根不如丹皮、赤芍，我认为可作临时参考，不要把它固定起来。
原文(三十三)：“湿热证，上下失血或汗血，毒邪深入营分，走窜欲泄，宜大剂犀角、生地、赤芍、丹皮、连翘、紫草、茜根、银花等味。”
按：善后宜参芪补气，芍地养血，或更加牡蛎咸寒之品以清热止汗。此系暑热不夹湿证，因暑热之气极易伤营也。此证本系危证，因毒从汗泄，故能少缓其势。
原文(三十五)：“湿热证，口渴苔黄起刺，脉弦缓，囊缩舌硬，谵语，昏不知人，两手搐搦，津枯邪滞，宜鲜生地、芦根、生首乌、鲜稻根等味。若脉有力，大便不通，大黄亦可加入。”
按：这是增液承气汤证、加减白虎汤证之类，临床可棍据腹诊及脉象之有力无力斟酌用之，自能取效。
原文(三十六)：“湿热证，发痉撮空，神昏笑妄，舌苔干黄起刺或转黑色，大便不通者，热邪闭结胃腑，宜用承气汤下之。”
按：本证应以腹部拒按为主，否则宜重用白虎，不宜用承气也。曾治一证，舌苔干黄起刺，大便闭结，但腹不拒按，用白虎汤治愈。
原文(三十七)： “湿热证，壮热口渴，自汗身重，胸痞，脉洪大而长者，此太阴之湿与阳明之热相合，宜白虎加苍术汤。”
按：身热口渴自汗为热，身重胸痞为湿，此热多湿少之证。胸痞也可少加厚朴。
原文(三十九)：“暑月热伤元气，其证气短倦怠，口渴多汗，肺虚而咳者，宜人参、麦冬、五味子等味。”
按：此系伤暑后津液被伤之证，脉必虚弱，欲绝，热必有太盛，否则须防收住邪气，误人性命。
原文(四十)：“暑月乘凉饮冷，阳气为阴寒所遏，皮肤蒸热，凛凛畏寒，头痛头重，自汗烦渴或腹痛吐泻者，宜香薷、厚朴、扁豆等味。”
按：自汗应作无汗，否则不宜使用香薷发汗之品。腹痛吐泻系因饮冷所致，其病势也不宜太甚，否则服用此方会引起亡阳之患，注意!
原文(四十一)：“湿热内滞太阴，郁久成为滞下，其证胸痞腹痛，下坠窘迫，脓血稠粘，里结后重，脉软数者，宜厚朴、黄芩、神曲、广皮、木香、槟榔、柴胡、煨葛根、银花炭、荆芥炭等味。”
Sixth, from the perspective of dispelling cold and eliminating bi-syndrome (Bi syndrome), when cold-dampness invades the muscles and joints causing numbness and pain, although Fuzi (Aconiti Lateralis Radix Praeparata) is not as potent as Chuanwu (Aconiti Kusnezoffii Radix) and Caowu (Aconiti Kusnezoffii Radix), its toxicity is lower than that of Chuanwu and Caowu, and its efficacy is better than any other drug. Therefore, Guizhi Fuzi Tang (Cinnamon Twig and Prepared Aconite Decoction), Baizhu Fuzi Tang (Atractylodes Macrocephala and Prepared Aconite Decoction), and Gancao Fuzi Tang (Licorice and Prepared Aconite Decoction) in Shanghan Lun (Treatise on Cold Pathogenic Diseases) all use Fuzi. From clinical experience, Fuzi is most effective for Bi syndrome patients with a wiry, large, and tight pulse or a deep, fine, slow pulse, accompanied by cold extremities; however, it should be used cautiously in patients with bitter taste in the mouth, yellow tongue coating, and dark yellow urine, otherwise toxic reactions may easily occur. If it must be used, it must be combined with a certain proportion of cooling herbs. For example, Guizhi Shaoyao Zhimu Tang (Cinnamon Twig, Peony, and Anemarrhena Decoction) in Jin Gui Yao Lue (Essential Prescriptions from the Golden Cabinet) is an example of this.
The above are the main indications for Fuzi. In addition, the following problems are often encountered when applying Fuzi:
First, the issue of dosage when rescuing critical conditions. Experience has confirmed that when treating Heart Failure (Heart failure), small doses of Fuzi should be used, whereas large doses should be used in Yang Collapse (Yang collapse) presenting with incontinence of urine and feces and cold limbs. This is because in Heart Failure, symptoms such as a fine and rapid pulse or a hurried pulse indicate primarily Yang deficiency with concurrent Yin depletion; excessive use of Fuzi damages Yin, while excessive use of Yin-nourishing herbs damages Yang. In Yang Collapse, symptoms such as cold limbs, faint pulse, and incontinence indicate entrenched cold; therefore, large doses of the potent Fuzi are suitable to restore Yang and rescue from collapse. Small doses are generally 1 gram, and large doses are generally 10–15 grams.
Second, the issue of toxicity. Whether toxicity occurs after using Fuzi is often influenced by three conditions. First is the dosage and decoction time: generally, the larger the dosage, the greater the toxicity; the shorter the decoction time, the greater the toxicity. Conversely, smaller dosages have less toxicity, and longer decoction times reduce toxicity. Therefore, to reduce toxicity, it is often decocted for more than one hour. Second is the nature of the syndrome: generally, entrenched cold syndromes with wiry, large, tight, deep, fine, or slow pulses rarely cause toxic reactions even with large doses, whereas heat syndromes, Yin deficiency syndromes, and blood deficiency with heat syndromes are prone to toxic reactions even with small doses. Third is the season: in spring, when Yang Qi ascends, toxic reactions to Fuzi are likely; whereas in winter, when Yang Qi stores, toxic reactions are rare even with larger doses.
Third, the treatment of dysphagia (difficulty swallowing). Article 40 of Shanghan Lun states: "If there is a sensation of choking, remove Mahuang (Ephedrae Herba) and add one prepared Fuzi." This pioneered the use of Fuzi for treating dysphagia. You Zaijing in Shanghan Guan Zhu Ji (Commentary on Shanghan Lun) stated: "Choking is caused by cold accumulation in the middle jiao; Fuzi's warmth can dispel cold, and its pungency can break fluid retention, hence it is added." From experience, the dysphagia treated usually presents with epigastric fullness, worsening upon exposure to cold, and a deep, fine, or wiry, large, and tight pulse. Subsequent clinical verification showed that esophageal achalasia (achalasia of the esophagus) described in modern medicine is most common.
Fourth, the treatment of slow convulsions (slow infantile tetany). The wind syndrome treated by Fuzi is neither wind generated by extreme heat nor wind due to Yin deficiency, but rather wind due to Spleen failure and Liver overacting (Spleen deficiency with Liver wind), appearing when diarrhea is watery or there is incontinence, cold limbs, a pulse barely perceptible, and a thin white tongue coating. Although this type of wind is mostly seen in slow Spleen wind in children, it can also appear in diseases such as pneumonia and Japanese encephalitis, and must not be ignored during clinical practice.
Fifth, the issue of raising blood pressure and accelerating the pulse. This issue must be viewed dialectically. Since Fuzi can tonify Yang and benefit fire, restoring Yang and rescuing from collapse, it indeed has the effect of accelerating heart rate in cases of slow heartbeat due to a deep, fine, slow, or faint pulse, or abdominal/heart pain caused by direct invasion of cold pathogen with a slow pulse. However, for hurried or rapid pulses due to dual deficiency of Yin and Yang or Yang deficiency, such as the rapid/hurried pulse in Heart Failure, it not only does not accelerate the pulse but can slow it down. For shock with cold limbs, faint pulse, and decreased blood pressure, as well as hypertension due to Liver Fire rushing upward, Yin deficiency with Yang hyperactivity, or internal stirring of Liver Wind, Fuzi often raises blood pressure. However, for hypertension due to floating deficient Yang, excess above and deficiency below, presenting with cold feet and a faint or empty and rootless pulse, it not only fails to raise blood pressure but can lower it.
Sixth, the issue of inducing vomiting versus stopping vomiting. Some books state that Fuzi induces vomiting, while others say it stops vomiting. Whether it induces or stops vomiting depends on the nature of the syndrome. It often aggravates vomiting in heat syndromes, frequently causing vomiting in those with Stomach Heat; however, for vomiting caused by untransformed cold-fluid retention, floating deficient Yang, or Yin excess repelling Yang, it often has an anti-emetic effect.
Discussion on Dahuang (Rhei Radix et Rhizoma)
Old Li believes that Dahuang is not only effective for various excess-heat syndromes characterized by constipation (such as high fever, delirium, and severe constipation in Yangming Fu-shi [Yangming organ syndrome]; infrequent bowel movements with abdominal fullness and pain; purging of clear water with heat binding leading to flow [heat-binding with purging of clear water]; unrelieved constipation with dry yellow tongue coating; mania and running around; or carbuncles and sores), and syndromes of fire-heat rushing upward (such as hematemesis, epistaxis, dizziness, headache, earache, eye pain, toothache, nasal disease, mouth ulcers, macules and papules), but also has remarkable efficacy for blood stasis syndromes (such as traumatic injuries, masses and accumulations, dysmenorrhea, amenorrhea, metrorrhagia), damp-heat accumulation syndromes (such as eczema, jaundice, painful urinary dysfunction, dysentery), and various stagnation syndromes.
First, in terms of purging and promoting bowel movement: ① The three actions of Dahuang—cold, drying, and purging—mean that Dahuang is relatively suitable for constipation due to excess-heat and damp-heat. ② Origin and processing methods of Dahuang: Xi Jun (Dahuang from Western regions) has stronger purgative and fire-draining effects than Chuan Jun (Dahuang from Sichuan), but weaker drying-dampness effects; Jiu Jun (Wine-processed Dahuang) and Shu Jun (Steamed Dahuang) have weaker purgative effects than raw Dahuang but are good at clearing fire-heat from the head. ③ Decoction time: Water decoction for less than half an hour has strong purgative effects, while decoction for over 40 minutes weakens these effects. ④ Dosage: Larger dosages have stronger purgative effects, while smaller dosages have weaker effects. ⑤ Compatibility: Purgative effects are stronger when combined with Qi-moving drugs and softening-hardness/drying-moisture drugs, and weaker without them. ⑥ Strength of Zheng Qi (Upright Qi): For constipation due to insufficiency of body fluids or blood deficiency, bowel movement often occurs after the first dose of Dahuang, but constipation returns soon after. Repeated use of Dahuang then leads to diminishing purgative effects, or even worsened constipation, because although Dahuang can purge, it damages body fluids and blood. At this point, it is necessary to combine with or switch to formulas that increase fluids and moisten bowels or nourish blood and moisten dryness to achieve bowel movement. For constipation due to Qi deficiency or Yang deficiency, since Dahuang is bitter and cold and attacks vigorously, severely damaging Yuan Qi (Primordial Qi), it not only fails to promote smooth bowel movement but often makes constipation worse. ⑦ Constipation due to cold-excess: Even using only 3 grams of Dahuang can cause 1–3 bowel movements, often accompanied by abdominal pain before defecation; whereas for constipation due to excess-heat binding, a minimum of 9 grams, or even 15–30 grams, is required for efficacy. ⑧ Expelling blood stasis and breaking blood clots. Due to Dahuang's ability to expel blood stasis and break blood clots, it must be used with caution during pregnancy to avoid miscarriage.
Second, in terms of resolving stagnation: For gastrointestinal stagnation, whether presenting with loose stools or constipation, Dahuang has good therapeutic effects. Generally, the dosage for resolving stagnation should be small, ideally 1.5–3 grams; if the dose is large, the action of resolving accumulation becomes small while the purgative action strengthens. For epigastric distension and pain with refusal to press, red urine, yellow tongue coating, and constipation, combine with Zhishi (Immature Bitter Orange) and Houpo (Magnolia Bark) 6–9 grams each; for epigastric distension and pain with refusal to press, white tongue coating, clear urine, and loose or alternating constipation/loose stools, combine with Zhishi 6 grams and Ganjiang (Dried Ginger) 1.5–3 grams, adding Jiaobaizhu (Charred Atractylodes Macrocephala) 6 grams for Spleen deficiency; for chronic dysentery or diarrhea with loose but unsatisfactory stools, tenesmus, mucus in stool, epigastric fullness, and worsening upon cold exposure, add Dangshen (Codonopsis Root), Baizhu (Atractylodes Macrocephala Rhizome), Zhishi, and Muxiang (Aucklandia Root) 3–6 grams each, Ganjiang 1.5–3 grams, and Shanyao (Chinese Yam) 15–30 grams. Abdominal pain and diarrhea of 1–2 episodes may occur shortly after taking the medicine. After one dose, stop medication for 2–7 days to allow Zheng Qi to recover slightly before resuming.
Third, in terms of clearing heat and draining fire: For dizziness, headache, eye diseases, earache, toothache, mouth ulcers, hematemesis, and epistaxis caused by excess fire of the Liver and Stomach, it is difficult to achieve efficacy without Dahuang. The magnitude of its effect is often related to dosage and method of administration. When constipation is mild, if the dosage of Dahuang is large, the syndrome will not improve despite abdominal pain and diarrhea; if the dosage is too small, bowel movement will not occur and efficacy will be hard to achieve. Generally, for those with only slight constipation, Jiu Jun, Shu Jun, or Qingning Wan (Qingning Pill) are suitable, with a dosage of 3 grams being appropriate; for severe constipation, raw Dahuang 3–6 grams is suitable, or even 9–12 grams; if bowel movement still does not occur, Mangxiao (Natrii Sulfas) 3–6 grams can be added. In short, the goal is smooth bowel movement with slightly loose stools; massive purgation should be avoided. For high fever with macules, the dosage of Dahuang is crucial; excessive purgation often causes the macule pathogen to sink inward. Insufficient purgation makes it difficult to eliminate pathogenic toxins, so the dosage should be just right. Generally, based on the severity of constipation, 3–9 grams is appropriate.
Fourth, in terms of removing blood stasis and activating blood circulation: This herb removes blood stasis and generates new blood, expelling stasis and activating circulation, making it an excellent drug for treating blood stasis complicated by constipation. It is particularly effective for bruising/swelling, masses, and bleeding syndromes complicated by constipation. When applied, the goal is smooth bowel movement with slightly loose stools; massive purgation should be avoided, otherwise, only intestinal excess is purged, Zheng Qi is damaged, and blood stasis remains. Because blood stasis is a deep-seated harm, it can only be addressed gradually, not attacked violently. If cold is present, different warming meridians and activating blood herbs should be added according to the location of the blood stasis; otherwise, using only the bitter-cold Dahuang often causes severe abdominal pain and diarrhea without removing the blood stasis.
Fifth, in terms of drying dampness and clearing heat: This herb clears heat and dries dampness; taken internally or applied externally, it has good effects on various eczemas, jaundice, and strangury. However, because this product is bitter, cold, and purgative, overuse damages the Spleen and Stomach, making it difficult to eliminate dampness. Therefore, it is only applicable to damp-heat syndromes where heat predominates over dampness and is complicated by constipation. The dosage should be around 3–6 grams, and the medication should result in 1–2 bowel movements per day.
Sixth, in terms of draining fire and calming fright: For high fever with constipation, delirium and convulsions, or constipation with red face and eyes and manic restlessness in psychiatric disorders, only large doses of Dahuang can drain the excess, generally 10–15 grams or more. Depending on the characteristics of other syndromes, Xilian Chengqi Tang (Rhizoma Coptidis and Rhei Radix et Rhizoma Da-Cheng-Qi Decoction), Baihu Chengqi Tang (White Tiger Da-Cheng-Qi Decoction), Da Chengqi Tang (Major Da-Cheng-Qi Decoction), Niuhuang Chengqi Tang (Calculus Bovis Da-Cheng-Qi Decoction), or Da Xianxiong Tang (Major Great Chest-Binding Decoction) should be adopted respectively.
In addition, the following situations are often encountered when applying Dahuang:
First, in purgative formulas containing Dahuang, the purgative effect of the first decoction of the first dose is strongest, the effect of the second dose is poorer, and if applied repeatedly, the purgative effect becomes even weaker. This is because Dahuang has both purgative and astringent properties. Furthermore, besides excess-heat, constipation often involves Qi stagnation; after medication, Qi moves and bowel movement occurs, but repeated use damages Qi and reduces the power of transformation and transportation. Therefore, repeated application often results in diminished purgative effects; stopping medication for 2 days at this point often enhances the purgative effect.
Second, why do some patients experience abdominal pain when using purgative formulas with Dahuang, while others do not? Why do some pass stool with very small doses of Dahuang, while others do not pass stool even with large doses? This is due to individual constitutional factors. Generally, constipation due to pure excess-heat does not present with abdominal pain and requires large doses to induce purgation, whereas deficiency-cold types often experience abdominal pain and can induce diarrhea with small doses.
Third, why do some pregnant women miscarry with small doses of Dahuang, while others do not miscarry even with 10–15 grams? This is because the former have a deficiency-cold constitution, while the latter have excess-heat stagnation.
Fourth, when repeated application of formulas containing Dahuang still fails to relieve constipation, it is generally advisable to switch to other formulas without Dahuang. If due to insufficiency of body fluids, nourish Yin and generate fluids; if due to blood deficiency, nourish blood and moisten dryness; if due to Yang deficiency, warm Yang and promote bowel movement.
Following Antiquity Without Being Bound by It
—A Reading Note
Old Li diligently sought ancient teachings and was rigorous in his scholarship. Amidst busy medical work, he read extensively through ancient medical texts. However, Old Li did not accept ancient academic thoughts unconditionally; rather, it was a process of "sublation" (discarding the dross and selecting the essential), often combining his own clinical experience to distinguish truth from falsehood, and being skilled at seeking knowledge from the unwritten. This is evident in his reading notes on Xue Xue's (Xue Lanxi) Pian Yu Re Shi Bing Bian (Treatise on Warm-Damp Diseases). Below are excerpts from the annotations Old Li made while reading the original text, for reference:
Original Text (29): "In warm-damp syndrome, on the fourth or fifth day, sudden profuse sweating occurs, hands and feet are cold, pulse is fine like a thread or absent, thirst is present, and there is penile pain, yet the patient sits and moves freely, spirit is clear, and speech is bright. This is due to excessive sweating causing temporary loss of defensive Yang, while warm-damp pathogens remain bound, causing temporary blockage between interior and exterior, hence the pulse is hidden. This is not true Yin collapsing outward. It is suitable to use Wuling San (Five-Ingredient Powder with Poria) removing Baizhu, adding Huashi (Talcum), wine-fried Chuanlian (Coptidis Rhizoma), Shengdi (Rehmanniae Radix), and Qipi (Pericarpium Citri Reticulatae)."
Annotation: Profuse sweating, cold hands and feet, pulse fine like a thread or absent/hidden—even with clear spirit and bright speech, this is a syndrome of True Yang collapsing outward. How can it be considered temporary loss of Defensive Yang? Thirst and penile pain appearing after profuse sweating, how can we know it is not a syndrome of depleted fluids and injured Jin-Ye (Body Fluids)? How can it be considered that warm-damp pathogens remain bound? Even if truly as stated, what is the use of Guizhi (Cinnamomi Ramulus) in Wuling San? I believe the treatment method for this syndrome should be Zhenwu Tang (True Warrior Decoction) removing Shengjiang (Fresh Ginger), adding Huashi, Maidong (Ophiopogonis Radix), and Caochao (Scutellaria Barbata Caulis or similar, context implies a specific herb, likely referring to a clearing/drainage herb like Tongcao or similar, but literal translation keeps 'Caoshao' or interprets as specific part. Given context of clearing heat/fluids, likely refers to a specific herb. *Correction*: 'Caoshao' usually refers to Scutellaria barbata stem or sometimes interpreted as a typo for another herb. In TCM contexts regarding Zhenwu Tang modifications for fluid injury, Maidong and Huashi are common. I will translate literally as 'Caoshao' but note it might be a specific local term or typo for something like 'Tongcao'. Actually, looking at standard texts, 'Caoshao' isn't standard. It might be 'Gancao' (Licorice) or 'Maidong'. Let's stick to literal 'Caoshao' or interpret as 'Grass Tip'. *Self-Correction*: In many editions, this might be 'Maidong' or 'Shigujie'. However, strictly translating the provided text: 'Caoshao'.) etc., would be effective.
Original Text (30): "In warm-damp syndrome, spasms occur with confusion and coma, only the feet are cold and the genitals retract. The external lower body has been invaded by guest cold. Treatment should still follow warm-damp principles, using only hot-warming substances decocted for fumigation and washing."
Annotation: This method may not have great efficacy, but it will not cause harm. Because when the disease is ambiguous, using an external therapy or light formula to test treatment first allows efficacy to confirm the correctness of this diagnosis, and lack of efficacy to affirm the treatment standard of the other aspect. For example, if this method is effective, it can certainly be confirmed as concomitant guest cold; otherwise, it is certainly a severe syndrome of pathogen invading Heart and Liver, requiring urgent prevention and treatment, but the methods of prevention and treatment should be noted strictly.
Original Text (31): "In warm-damp syndrome, initially there is high fever, thirst, epigastric stuffiness and vexation, desire to close eyes, occasional delirium. Turbid pathogens obscure the Upper Jiao. It is suitable to induce vomiting and drainage, using Zhike (Citrus Aurantium Pericarpium Immaturum), Jiegeng (Platycodonis Radix), Danshichi (Fermented Soybean), and raw Zhizi (Gardeniae Fructus). Add Gegen (Puerariae Lobatae Radix) if there is no sweat."
Annotation: Based on symptoms such as high fever, thirst, vexation, and delirium, this is a manifestation of heat prevailing over dampness, which does not match the description of "turbid pathogens". Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) is a heat-clearing formula, not a vomiting-inducing formula. Practical evidence has shown that the character "Yong" (induce/vomit) should be changed to "Qing" (clear).
Original Text (32): "In warm-damp syndrome, menstruation arrives suddenly, with high fever, thirst, delirium, confusion, chest and abdominal pain, or no tongue coating, slippery and rapid pulse. Pathogen has sunk into Ying Level (Nutrient Level). It is suitable to use large doses of Xijiao (Rhinoceros Horn - *Note: Substitute with Buffalo Horn in modern practice*), Zicao (Arnebiae Radix et Rhizoma), Qianggen (Rubiae Radix), Guanzhong (Dryopteridis Crassirhizoma), Lianqiao (Forsythiae Fructus), fresh Changpu (Acori Tatarinowii Rhizoma), and Yinhua Lu (Silver Flower Dew)."
Annotation: The original book believes that heavy doses are necessary to achieve success, but it is difficult to grasp exactly how heavy constitutes a "heavy dose". I believe determining it temporarily based on the patient's specific condition is the proper method. Some people believe Qianggen is inferior to Danpi (Moutan Cortex) and Chishao (Paeoniae Radix Rubra); I consider this a temporary reference and advise against fixing it rigidly.
Original Text (33): "In warm-damp syndrome, bleeding from upper and lower orifices or sweating blood, toxic pathogens have deeply entered Ying Level, wandering and attempting to exit. It is suitable to use large doses of Xijiao, Shengdi, Chishao, Danpi, Lianqiao, Zicao, Qianggen, and Yinhua."
Annotation: For recovery, it is suitable to add Renshen (Ginseng Radix et Rhizoma) and Huangqi (Astragali Radix) to tonify Qi, Shaoyao (Paeoniae Radix) and Dihuang (Rehmanniae Radix) to nourish Blood, or further add Omu (Concha Ostreae) and other salty-cold products to clear heat and stop sweating. This is a summer-heat syndrome without dampness, because summer-heat Qi easily injures Ying. This syndrome is originally critical, but because toxins exit via sweat, the momentum can be slightly slowed.
Original Text (35): "In warm-damp syndrome, thirst, yellow tongue coating with prickles, string-taut and slow pulse, scrotal retraction, stiff tongue, delirium, unconsciousness, convulsions of both hands. Fluids are dried up and pathogens are stagnant. It is suitable to use fresh Shengdi, Lugeng (Phragmitis Rhizoma), Sheng Shouwu (Polygoni Multiflori Radix), and fresh Dao Gen (Oryza Sativa Root). If the pulse is forceful and bowel movement is blocked, Dahuang can also be added."
Annotation: This is similar to Zengye Chengqi Tang (Increase Fluids Da-Cheng-Qi Decoction) or Jiabai Hu Tang (Modified White Tiger Decoction) syndromes. Clinically, it can be used after deliberation based on abdominal palpation and whether the pulse is forceful or weak, and efficacy will naturally be achieved.
Original Text (36): "In warm-damp syndrome, spasms occur with grasping at empty air, confusion, inappropriate laughter, dry yellow tongue coating with prickles turning black, and bowel obstruction. Heat pathogens are closed and bound in the Stomach Fu. It is suitable to use Chengqi Tang to purge it."
Annotation: This syndrome should primarily feature abdominal refusal to press; otherwise, heavy use of Baihu Tang (White Tiger Decoction) is suitable, and Chengqi Tang is not. I once treated a case with dry yellow tongue coating with prickles and bowel obstruction, but no abdominal refusal to press, which was cured using Baihu Tang.
Original Text (37): "In warm-damp syndrome, high fever, thirst, spontaneous sweating, heaviness of body, chest stuffiness, large and long pulse. This is Taiyin Dampness combining with Yangming Heat. It is suitable to use Baihu Jia Cangzhu Tang (White Tiger Decoction plus Atractylodes Lancea)."
Annotation: Body heat, thirst, and spontaneous sweating indicate heat; body heaviness and chest stuffiness indicate dampness. This is a syndrome where heat is more than dampness. Chest stuffiness can also be treated by adding a little Houpo.
Original Text (39): "In summer months, heat injures Yuan Qi. Symptoms include shortness of breath, fatigue, thirst, and profuse sweating. With Lung deficiency and cough, it is suitable to use Renshen, Maidong, and Wuweizi (Schisandrae Fructus)."
Annotation: This is a syndrome where Jin-Ye (Body Fluids) are injured after summer-heat injury. The pulse must be weak, nearly absent. Heat must be excessively severe; otherwise, one must guard against retaining pathogens, which could be fatal.
Original Text (40): "In summer months, cooling off and drinking cold beverages suppresses Yang Qi with Yin-cold. Skin steams with heat, shivering chills are felt, headache and heaviness of head, spontaneous sweating, vexation and thirst, or abdominal pain and vomiting/diarrhea. It is suitable to use Xiangru (Elsholtziae Herba), Houpo, and Bidou (Euphorbiae Humifusae Herba)."
Annotation: "Spontaneous sweating" should be read as "no sweat"; otherwise, Xiangru, a diaphoretic, should not be used. Abdominal pain and vomiting/diarrhea are caused by drinking cold beverages. The disease progression should not be too severe; otherwise, taking this formula could lead to Yang Collapse. Note!
Original Text (41): "Warm-dampness stagnates internally in Taiyin, lingering for a long time becoming dysentery. Symptoms include chest stuffiness, abdominal pain, tenesmus, thick sticky pus and blood, feeling of incomplete evacuation, and soft, rapid pulse. It is suitable to use Houpo, Huangqin (Scutellariae Radix), Shenqu (Massa Medicata Fermentata), Guangpi (Tangerine Peel), Muxiang, Binglang (Arecae Semen), Chaihu (Bupleuri Radix), Wei Gegen (Roasted Puerariae Radix), Yinhua Tan (Charred Forsythiae Fructus), and Jingjie Tan (Charred Schizonepetae Spica)."