小女朱彦欣医生跟我说：“我跟您学习了多年，一直糊里糊涂，有的方剂我亲眼看到您用的疗效很好，可是我一用到临床却不好，有的甚至无效。这是为什么呢?是我用的脉证不对吗?不是。在这方面我反复问过您，也在临床上反复追问过他们出现的每一个症状，并仔细检查过他们的脉象和舌象。是我用药有加减，用量有改变吗?也不是。因为我用的方完全是学习您的，用的药味和用量及其用量比例完全与您一样，可就是效果不一样，这个问题我一直不清楚，及至我注意了您告诉患者的服药时间与节律时，才算解决了这个问题。例如：一陈姓患者。急性扁桃体炎，咽喉肿痛，且已化脓，高热一直不退。开始用青霉素治疗效果不好，改用升降散加减方后，虽然较青霉素为好，但7天以后才获得了痊愈。前几天，陈姓患者又患急性扁桃体炎，其症状比上次还严重，但这次采用了您向患者嘱咐的6小时1次，昼夜连进两剂的方法，结果次日即症状全部消失。又如用肾康灵胶囊治肾病，我见您用的效果很好，但我用起来则不如您的效果好，及至也采用了您所嘱咐的空腹服后，果然效果明显增加。”我说：“《素问·至真要大论》在阐述治疗问题时，除强调了谨守病机，各司其属，有者求之，无者求之，盛者责之，虚者责之，必先五胜，疏其血气，令其调达，而致和平，之外，还强调了①五味阴阳之用要辛甘发散为阳，酸苦涌泄为阴，咸味涌泄为阴，淡昧渗泄为阳。六者或收或散，或缓或急，或燥或润，或耍或坚，以所利而行之。，②有毒无毒，所治为主，适大小为制也。’③寒者热之，热者寒之，微者逆之，甚者从之，坚者削之，客者除之，劳者温之，结者散之，留者攻之，燥者濡之，急者缓之，散者收之，损者温之，逸者行之，惊者平之，上之下之，摩之浴之，薄之劫之，开之发之，适事为故。’《神农本草经》在指出疗寒以热药，疗热以寒药时，还强调指出病在胸膈以上者，先食后服药；病在心腹以下者，先服药而后食。病在四肢血脉者，宜空腹而在旦；病在骨髓者，宜饱满而在夜。’《伤寒论》在桂枝汤的服用方法上指出：眼已须臾，啜热稀粥一升余，以助药力。温覆令一时许，遍身染染微似有汗者益佳，不可令如水流离，病必不除。若一服汗出病差，停后服，不必尽剂。若不汗，更服依前法。又不汗，后服小促其间，半日许令三服尽。若病重者，一日一夜服，周时观之。服一剂尽，病证犹在者，更作服，若不汗出，乃服至二三剂。’在桂枝二麻黄一汤的服用方法上指出：温服一升，日再服。，在五苓散的服法上指出：捣为散，以白饮和服方寸匕，日三服。’在桃仁承气汤的服法上指出：先食温服五合，日三服。当微利。’在抵当汤的服法上指出：煮取三升，去滓，温服一升。不下，更服。’在抵当丸的服法上指出：以水一升煮一丸，取七合服之。啐时当下血，若不下者，更服。，在桂枝甘草汤的服法上指出：顿服。’在黄连汤的服法上指出：昼三，夜二。，在十枣汤的服法上指出：饮服十丸，日三服，渐加，以知为度。’在麻黄连轺赤小豆汤服法上指出：分温三服，半日服尽。’在黄芩汤的服法上指出：温服一升，日再，夜一服。，《金匮要略》在蜀漆散服法上指出：未发前以浆水服半钱。温疟加蜀漆半分，临发时服一钱匕。’在皂角丸方的服法上指出：以枣膏和汤服三丸，日三夜一服。’如此等等。总之，从原则上看，如果仅仅注意了治则，而不注意方法中细节问题，也往往不能取得优良的疗效，因此我们临床工作者不但要注意大，而且要注意小。”
中药的疗效是快，还是慢?
中药的疗效是快?还是慢?对于这个问题我曾与很多同道进行过交谈。在一次畅谈中，某个医生说：“有人说中药的疗效慢，副作用小，西药的疗效快，副作用大，所以治疗急性病、危重病时应尽量用西药，慢性病再用中药。”又说：“在我开始看到你们宝宝一贴灵的研究报告中有4小时即可见效的说明时，我非常怀疑。因为我认为中药不可能那么见效快，更何况它是一个外用药呢?及至临床一应用，却屡屡发现患者反映：有的贴后3—4分钟即腹痛泄泻消失，有的一贴上即腹痛缓解，有的一贴上即上车旅行而不晕车。才使我发现我的认识有偏见，有成见，有错误。通过这一事实的教育，使我不得不修正对中药疗效快慢的认识，不得不重新研究中药疗效发挥的时间问题。通过多年的研究逐步发现中药对某些证候不但作用快，而且副作用少。这个快，有的竟达到了不可想象的程度，我看古人说的覆杯而愈一点也不夸张，这完全是客观的，现实的描述。”我说：“你的观察是科学的，是实事求是的。对于中药疗效快、慢的认识，不但在中医界是件大事，而且在中、西医合作上也是件大事。因为：①对中药疗效快、慢的认识，不但关系到中医、中药能不能参加急性病、危重病的抢救，而且关系到中、西医合作抢救危急重病时能不能当主角。②对中药疗效快、慢的认识，不但直接关系到应用中药治疗过程中的疗效评价，而且关系到中、西医合作治疗疾病时中药作用有无的认识。③对中药疗效快、慢的认识，不但关系到对所用中药副作用的认识，而且关系到在中、西医合作治疗中，中药副作用的评价。④对中药疗效快，慢的认识，不但关系到中药配伍中的相反、相须、相畏、相使，而且关系到中、西医合作治疗疾病时的药物协同、拮抗作用的评价。⑤对中药疗效快、慢的认识，不但关系到对辨证论治中正确与错误的评价，而且关系到中、西医合作治疗中中药应用得正确与错误的认识。⑥对中药疗效快、慢的认识，不但关系到所用中药剂型正确与错误的评价，而且关系到中、西医合作治疗疾病时，应用中药剂型恰当与否的认识。⑦对中药疗效快、慢的认识，不但关系到对中药给药方法、给药时间正确与错误的认识，而且关系到中、西医合作治疗疾病时给药方法、给药时间正确与错误的评价。⑧对中药疗效快、慢的认识，不但关系到对所用中药给药途径正确与错误的认识，而且关系到中、西医合作治疗疾病时，对中药给药途径正确与错误的评价等等。
对于中医、中药能不能直接参加治疗急性病和抢救危重病的问题，早已通过中医药的数千年发展史得到了证明。对于中、西医合作治疗过程中中医药能不能当主角的问题，这在近目年来的医疗实践中也得到了证明：不但是可以的，而且很多是恰当的。
对于中医、中药疗效评价的问题，虽然已经通过历史画正了句号，但是由于中、西医的学术观点不同，某些西医对中药疗效的认识仍然存在着鸡叫天亮，鸡不叫天也亮的观点。这种观点固然与他们的学术观点和不以实践是检验真理的唯一标准的非科学态度有关，也与我们中医不够了解什么中药可以多长时间出现疗效，出现什么样的症状改善有关系。所以我们要想正确评价中药的疗效，必须深刻了解什么中药多长时间出现疗效，出现什么样的疗效。通过临床观察发现中药出现疗效大致有以下几种规律：①局部用药出现的作用快，内服药出现的作用慢。其中局部用药疗效快者可见用药后的一刹那间即症状缓解，而内服药则需15分钟至4个小时才能出现疗效。②辛散药用药后出现的作用快，苦降药次之，甘缓药作用最慢。其中卒散药内服大致在30分钟至1个小时即可症状缓解；苦降药则需30分钟至2个小时，甚至4个小时才出现效果；甘缓药常常1小时以上，甚至24小时后才出现效果。③表证用药后疗效出现的作用快，里证用药后疗效出现的作用缓。其中快者常常在2—8个小时，慢者则需8—48个小时。④虚证用药后疗效出现的作用慢，实证用药后疗效出现的作用快。其中实证快者15分钟至2个小时，虚证慢者约在4—48个小时，甚至以上。⑤寒证用药后药效出现的作用快，热证用药后疗效出现的作用慢。其中快者仅需几分钟，甚者1小时；慢者则需40分钟至48小时方才有效。⑥气分证用药后疗效出现得快，血分证用药后疗效出现得慢，其中快者十几分钟即可见效，而血分证则必须40分钟以上方可有效。⑦亡阳证用药后疗效出现得快，亡阴证用药后疗效出现得慢，其中快者约需十几分钟，甚者1个小时；慢者则需40分钟，甚者2个小时至4个小时。
对于中药有无毒副作用的问题，在当前来说有两种观点。一种观点认为中药没有什么毒副作用，即使有也只能说很小；另一种观点则认为中药不但有的有毒性，而且有的有严重副作用。我本人同意后一种观点。但如何评价每味中药的毒副作用，还应具体问题具体分析。通过临床观察，大多：①胃肠道的毒副反应出现于用药后的一瞬间至l—2小时左右。②心悸心慌的毒副反应出现于用药后30分钟至l小时左右。③头晕，四肢麻木的毒副反应出现于1个小时左右。④大汗不止的毒副反应出现于用药后1小时左右。⑤口干舌燥，咽喉肿痛的毒副反应出现于用药后l—2小时，甚至3—4小时以后。⑥烦躁狂乱的毒副反应出现于用药后1小时以后，甚至更长。⑦荨麻疹的毒副反应出现于用药后4—12小时，甚至48小时以后。⑧鼻衄、斑疹的毒副反应出现于用药后1—2小时，甚至48小时以后。反之，若不是在此时间内出现的毒副反应，则应考虑是不是中药引起的。
对于中、西药联合应用中的协同和拮抗的认识，更是一个极其复杂的问题，因为要想了解它们的联合作用，必须首先清楚的认识中药、西药单独应用时的疗效发挥时间，而单独应用时的疗效发挥时间我们常常是不清楚的，所以对联合应用后的药效发挥时间就很难分析清楚其是发生了拮抗或协同，但是只要我们善于观察，认真观察，还是可以知道的。
对于辨证论治的认识，绝大多数医家认为它是中医的精髓。但是怎么衡量辨证论治中的正确与错误，则有两种观点。一种观点认为反正是中药都疗效慢，因此不能在短期内说明其是有效，还是无效，只要继续服药就是了。另一种观点则认为不同的病，不同的证，不同的药，在用药出现的药效作用时间是不同的，如果在应该出现药效作用的时间内没有出现应有的疗效，那么就应该说明该种辨证的认识是错误的，在此情况下，我们就应该继续根据观其脉证，知犯何逆，随证治之的精神处理。
对于中药剂型与疗效快慢的认识，前人早有汤者，荡也；丸者，缓也的论述。对于用药途径的搐鼻催嚏的不同用药途径疗效的评价，前人也有一定的论述，这些问题均需在临床上认真地总结经验。
以上这些意见仅是我数十年经验的初步总结，正确与否，还需同道们在实践中加以验证。
是走科学的发展道路，还是走教条主义式的路
读了《三联生活周刊》1997年第20期记者朱彤先生访第一代中西医学家陈可冀院士的文章《中医要引进现代科学》，使我感触良多。
一、是走科学的发展之路，还是走两个凡是之路
纵观古今中外的发展史可以看出，凡是有突出成就的科学工作者，没有一个不是在吸收前人科学成就的同时，靠着自己的创新，靠着自己走自己的路才成功的。自然科学是如此，社会科学也是如此。在我国的革命中，早期依靠照搬苏联的经验没有成功，至我们党批判了教条主义，树立了毛泽东思想在我党的统治地位，才使革命走向了胜利。在我国的建设中，长期以来，由于坚持两个凡是，几乎使我们国家走到了破产的边缘，及至确立了走中国特色的社会主义，确立了邓小平理论在我党的统治地位，才使建设步人了健康的发展道路。
在我国的医学发展史中，由于坚持了自己独特的发展道路，使中国医药学影响了整个东方医学的发展。近百年来，由于余云岫先生的凡是符合当时西医理论、方法之中医理论、方法即是正确的，凡是不符合当时西医理论、方法之中医理论、方法即是不正确的教条主义思想影响，使近百年来的大量有关中医的著作、文章变成了对号入座的文章和著作，使中医的发展受到了严重的影响。近些年来，由于西医的理论和方法一个一个地被否定，使某些以对号入座为研究方法的教条主义思想感到站不住脚，于是又提出“中医要引进现代科学”作为新的口号以代替过去的中西医对号入座的教条主义，陈可冀先生引以为自豪的两个方面恰恰表现在这一点。
(一)中医发展迟缓的原因在哪儿
我的女儿朱彦欣医生告诉我：“我跟您学习多年，始终感到困惑。有些方剂我亲眼看到您使用疗效很好，但我一到临床使用却效果不佳，有的甚至完全无效。这是为什么呢？是我辨证的脉象和症状不对吗？不是。在这方面我反复向您请教，也在临床上对每位患者出现的每一个症状进行反复追问，并仔细检查他们的脉象和舌象。是我用药有加减变化，或者用量有改变吗？也不是。因为我使用的方剂完全是按照您的方法，药味、用量及其比例都与您完全一致，但效果就是不一样。这个问题我一直不清楚，直到我注意到您嘱咐患者的服药时间与节律时，才算解决了这个问题。
例如：有一位陈姓患者，患有急性扁桃体炎，咽喉肿痛且已化脓，高热一直不退。起初使用青霉素治疗效果不好，改用升降散（Shengjiang San, Ascending and Descending Powder）加减方后，虽然比青霉素效果好，但7天后才痊愈。前几天，这位陈姓患者又患急性扁桃体炎，症状比上次更严重，但这次采用了您向患者嘱咐的每6小时服药1次，昼夜连续服用两剂的方法，结果第二天症状全部消失。又如使用肾康灵胶囊（Shenkangling Capsule）治疗肾病，我看到您使用效果很好，但我用起来则不如您的效果好，直到我也采用了您所嘱咐的空腹服用方法，果然效果明显增加。”
我说：“《素问·至真要大论》（Suwen: Zhizhen Yao Dalun, Supreme Basic Questions: The Great Treatise on the Most Essential Truths）在阐述治疗问题时，除了强调‘谨守病机，各司其属，有者求之，无者求之，盛者责之，虚者责之，必先五胜，疏其血气，令其调达，而致和平’之外，还强调了三点：①五味阴阳之用要‘辛甘发散为阳，酸苦涌泄为阴，咸味涌泄为阴，淡味渗泄为阳。六者或收或散，或缓或急，或燥或润，或软或坚，以所利而行之’；②‘有毒无毒，所治为主，适大小为制也’；③‘寒者热之，热者寒之，微者逆之，甚者从之，坚者削之，客者除之，劳者温之，结者散之，留者攻之，燥者濡之，急者缓之，散者收之，损者温之，逸者行之，惊者平之，上之下之，摩之浴之，薄之劫之，开之发之，适事为故’。
《神农本草经》（Shennong Bencao Jing, Divine Farmer’s Materia Medica）在指出‘疗寒以热药，疗热以寒药’时，还强调指出：‘病在胸膈以上者，先食后服药；病在心腹以下者，先服药而后食。病在四肢血脉者，宜空腹而在旦；病在骨髓者，宜饱满而在夜’。
《伤寒论》（Shanghan Lun, Treatise on Cold Damage Disorders）在桂枝汤（Guizhi Tang, Cinnamon Twig Decoction）的服用方法上指出：‘服已须臾，啜热稀粥一升余，以助药力。温覆令一时许，遍身漐漐微似有汗者益佳，不可令如水流离，病必不除。若一服汗出病差，停后服，不必尽剂。若不汗，更服依前法。又不汗，后服小促其间，半日许令三服尽。若病重者，一日一夜服，周时观之。服一剂尽，病证犹在者，更作服，若不汗出，乃服至二三剂’。在桂枝二麻黄一汤（Guizhi Er Mahuang Yi Tang, Two Parts of Cinnamon Twig Decoction and One Part of Ephedra Decoction）的服用方法上指出：‘温服一升，日再服’。在五苓散（Wuling San, Five-Ingredient Powder with Poria）的服法上指出：‘捣为散，以白饮和服方寸匕，日三服’。在桃仁承气汤（Taoren Chengqi Tang, Peach Kernel Purging the Intestines Decoction）的服法上指出：‘先食温服五合，日三服。当微利’。在抵当汤（Didang Tang, Resolute Attack Decoction）的服法上指出：‘煮取三升，去滓，温服一升。不下，更服’。在抵当丸（Didang Wan, Resolute Attack Pill）的服法上指出：‘以水一升煮一丸，取七合服之。晬时当下血，若不下者，更服’。在桂枝甘草汤（Guizhi Gancao Tang, Cinnamon Twig and Licorice Decoction）的服法上指出：‘顿服’。在黄连汤（Huanglian Tang, Coptis Decoction）的服法上指出：‘昼三，夜二’。在十枣汤（Shizao Tang, Ten Jujube Decoction）的服法上指出：‘饮服十丸，日三服，渐加，以知为度’。在麻黄连轺赤小豆汤（Mahuang Lianqiao Chixiaodou Tang, Ephedra, Forsythia and Red Bean Decoction）服法上指出：‘分温三服，半日服尽’。在黄芩汤（Huangqin Tang, Scutellaria Decoction）的服法上指出：‘温服一升，日再，夜一服’。
《金匮要略》（Jingui Yaolue, Essential Prescriptions of the Golden Cabinet）在蜀漆散（Shuqi San, Vinca Powder）服法上指出：‘未发前以浆水服半钱。温疟加蜀漆半分，临发时服一钱匕’。在皂角丸（Zaojiao Wan, Gleditsia Sinensis Pill）方的服法上指出：‘以枣膏和汤服三丸，日三夜一服’。如此等等。总之，从原则上看，如果仅仅注意了治则，而不注意方法中细节问题，也往往不能取得优良的疗效，因此我们临床工作者不但要注意大，而且要注意小。”
中药的疗效是快，还是慢？
中药的疗效是快？还是慢？对于这个问题我曾与很多同道进行过交谈。在一次畅谈中，某个医生说：“有人说中药的疗效慢，副作用小，西药的疗效快，副作用大，所以治疗急性病、危重病时应尽量用西药，慢性病再用中药。”又说：“在我开始看到你们宝宝一贴灵的研究报告中有4小时即可见效的说明时，我非常怀疑。因为我认为中药不可能那么见效快，更何况它是一个外用药呢？及至临床一应用，却屡屡发现患者反映：有的贴后3—4分钟即腹痛泄泻消失，有的一贴上即腹痛缓解，有的一贴上即上车旅行而不晕车。才使我发现我的认识有偏见，有成见，有错误。通过这一事实的教育，使我不得不修正对中药疗效快慢的认识，不得不重新研究中药疗效发挥的时间问题。通过多年的研究逐步发现中药对某些证候不但作用快，而且副作用少。这个快，有的竟达到了不可想象的程度，我看古人说的‘覆杯而愈’一点也不夸张，这完全是客观的，现实的描述。”
我说：“你的观察是科学的，是实事求是的。对于中药疗效快、慢的认识，不但在中医界是件大事，而且在中、西医合作上也是件大事。因为：①对中药疗效快、慢的认识，不但关系到中医、中药能不能参加急性病、危重病的抢救，而且关系到中、西医合作抢救危急重病时能不能当主角。②对中药疗效快、慢的认识，不但直接关系到应用中药治疗过程中的疗效评价，而且关系到中、西医合作治疗疾病时中药作用有无的认识。③对中药疗效快、慢的认识，不但关系到对所用中药副作用的认识，而且关系到在中、西医合作治疗中，中药副作用的评价。④对中药疗效快，慢的认识，不但关系到中药配伍中的相反、相须、相畏、相使，而且关系到中、西医合作治疗疾病时的药物协同、拮抗作用的评价。⑤对中药疗效快、慢的认识，不但关系到对辨证论治中正确与错误的评价，而且关系到中、西医合作治疗中中药应用得正确与错误的认识。⑥对中药疗效快、慢的认识，不但关系到所用中药剂型正确与错误的评价，而且关系到中、西医合作治疗疾病时，应用中药剂型恰当与否的认识。⑦对中药疗效快、慢的认识，不但关系到对中药给药方法、给药时间正确与错误的认识，而且关系到中、西医合作治疗疾病时给药方法、给药时间正确与错误的评价。⑧对中药疗效快、慢的认识，不但关系到对所用中药给药途径正确与错误的认识，而且关系到中、西医合作治疗疾病时，对中药给药途径正确与错误的评价等等。
对于中医、中药能不能直接参加治疗急性病和抢救危重病的问题，早已通过中医药的数千年发展史得到了证明。对于中、西医合作治疗过程中中医药能不能当主角的问题，这在近年来的医疗实践中也得到了证明：不但是可以的，而且很多是恰当的。
对于中医、中药疗效评价的问题，虽然已经通过历史画上了句号，但是由于中、西医的学术观点不同，某些西医对中药疗效的认识仍然存在着‘鸡叫天亮，鸡不叫天也亮’的观点。这种观点固然与他们的学术观点和不以实践是检验真理的唯一标准的非科学态度有关，也与我们中医不够了解什么中药可以多长时间出现疗效，出现什么样的症状改善有关系。所以我们要想正确评价中药的疗效，必须深刻了解什么中药多长时间出现疗效，出现什么样的疗效。通过临床观察发现中药出现疗效大致有以下几种规律：①局部用药出现的作用快，内服药出现的作用慢。其中局部用药疗效快者可见用药后的一刹那间即症状缓解，而内服药则需15分钟至4个小时才能出现疗效。②辛散药用药后出现的作用快，苦降药次之，甘缓药作用最慢。其中辛散药内服大致在30分钟至1个小时即可症状缓解；苦降药则需30分钟至2个小时，甚至4个小时才出现效果；甘缓药常常1小时以上，甚至24小时后才出现效果。③表证（Exterior Syndrome）用药后疗效出现的作用快，里证（Interior Syndrome）用药后疗效出现的作用缓。其中快者常常在2—8个小时，慢者则需8—48个小时。④虚证（Deficiency Syndrome）用药后疗效出现的作用慢，实证（Excess Syndrome）用药后疗效出现的作用快。其中实证快者15分钟至2个小时，虚证慢者约在4—48个小时，甚至以上。⑤寒证（Cold Syndrome）用药后药效出现的作用快，热证（Heat Syndrome）用药后疗效出现的作用慢。其中快者仅需几分钟，甚者1小时；慢者则需40分钟至48小时方才有效。⑥气分证（Qi Level Syndrome）用药后疗效出现得快，血分证（Blood Level Syndrome）用药后疗效出现得慢，其中快者十几分钟即可见效，而血分证则必须40分钟以上方可有效。⑦亡阳证（Yang Collapse Syndrome）用药后疗效出现得快，亡阴证（Yin Collapse Syndrome）用药后疗效出现得慢，其中快者约需十几分钟，甚者1个小时；慢者则需40分钟，甚者2个小时至4个小时。
对于中药有无毒副作用的问题，在当前来说有两种观点。一种观点认为中药没有什么毒副作用，即使有也只能说很小；另一种观点则认为中药不但有的有毒性，而且有的有严重副作用。我本人同意后一种观点。但如何评价每味中药的毒副作用，还应具体问题具体分析。通过临床观察，大多：①胃肠道的毒副反应出现于用药后的一瞬间至1—2小时左右。②心悸心慌的毒副反应出现于用药后30分钟至1小时左右。③头晕，四肢麻木的毒副反应出现于1个小时左右。④大汗不止的毒副反应出现于用药后1小时左右。⑤口干舌燥，咽喉肿痛的毒副反应出现于用药后1—2小时，甚至3—4小时以后。⑥烦躁狂乱的毒副反应出现于用药后1小时以后，甚至更长。⑦荨麻疹的毒副反应出现于用药后4—12小时，甚至48小时以后。⑧鼻衄、斑疹的毒副反应出现于用药后1—2小时，甚至48小时以后。反之，若不是在此时间内出现的毒副反应，则应考虑是不是中药引起的。
对于中、西药联合应用中的协同和拮抗的认识，更是一个极其复杂的问题，因为要想了解它们的联合作用，必须首先清楚的认识中药、西药单独应用时的疗效发挥时间，而单独应用时的疗效发挥时间我们常常是不清楚的，所以对联合应用后的药效发挥时间就很难分析清楚其是发生了拮抗或协同，但是只要我们善于观察，认真观察，还是可以知道的。
对于辨证论治（Syndrome Differentiation and Treatment）的认识，绝大多数医家认为它是中医的精髓。但是怎么衡量辨证论治中的正确与错误，则有两种观点。一种观点认为反正是中药都疗效慢，因此不能在短期内说明其是有效，还是无效，只要继续服药就是了。另一种观点则认为不同的病，不同的证，不同的药，在用药出现的药效作用时间是不同的，如果在应该出现药效作用的时间内没有出现应有的疗效，那么就应该说明该种辨证的认识是错误的，在此情况下，我们就应该继续根据‘观其脉证，知犯何逆，随证治之’的精神处理。
对于中药剂型与疗效快慢的认识，前人早有‘汤者，荡也；丸者，缓也’的论述。对于用药途径的搐鼻催嚏的不同用药途径疗效的评价，前人也有一定的论述，这些问题均需在临床上认真地总结经验。
以上这些意见仅是我数十年经验的初步总结，正确与否，还需同道们在实践中加以验证。
是走科学的发展道路，还是走教条主义式的路
读了《三联生活周刊》1997年第20期记者朱彤先生访第一代中西医学家陈可冀院士的文章《中医要引进现代科学》，使我感触良多。
一、是走科学的发展之路，还是走两个凡是之路
纵观古今中外的发展史可以看出，凡是有突出成就的科学工作者，没有一个不是在吸收前人科学成就的同时，靠着自己的创新，靠着自己走自己的路才成功的。自然科学是如此，社会科学也是如此。在我国的革命中，早期依靠照搬苏联的经验没有成功，至我们党批判了教条主义，树立了毛泽东思想在我党的统治地位，才使革命走向了胜利。在我国的建设中，长期以来，由于坚持两个凡是，几乎使我们国家走到了破产的边缘，及至确立了走中国特色的社会主义，确立了邓小平理论在我党的统治地位，才使建设步入了健康的发展道路。
在我国的医学发展史中，由于坚持了自己独特的发展道路，使中国医药学影响了整个东方医学的发展。近百年来，由于余云岫先生的‘凡是符合当时西医理论、方法之中医理论、方法即是正确的，凡是不符合当时西医理论、方法之中医理论、方法即是不正确的’教条主义思想影响，使近百年来的大量有关中医的著作、文章变成了对号入座的文章和著作，使中医的发展受到了严重的影响。近些年来，由于西医的理论和方法一个一个地被否定，使某些以对号入座为研究方法的教条主义思想感到站不住脚，于是又提出‘中医要引进现代科学’作为新的口号以代替过去的中西医对号入座的教条主义，陈可冀先生引以为自豪的两个方面恰恰表现在这一点。
(一)中医发展迟缓的原因在哪儿
My daughter, Dr. Zhu Yanxin, told me: "I have studied under you for many years, yet I remain confused. There are prescriptions that I have seen you use with excellent efficacy, but when I apply them in clinical practice, they are ineffective or even completely useless. Why is this? Is it because my pulse and symptom differentiation are incorrect? No. In this regard, I have repeatedly consulted you, and in clinical practice, I have carefully questioned every symptom presented by each patient and meticulously examined their pulses and tongues. Is it because I modified the prescriptions or altered the dosages? Also no. Because the prescriptions I used were exactly as learned from you, including the herbal ingredients, dosages, and their proportions, which were identical to yours, yet the effects were different. I was unclear about this issue until I paid attention to the timing and rhythm of medication administration that you instructed patients to follow, at which point the problem was resolved.
For example: A patient surnamed Chen suffered from acute tonsillitis, with sore throat and swelling, and suppuration had already occurred. His high fever persisted. Initially, penicillin treatment was ineffective. After switching to a modified Shengjiang San (Ascending and Descending Powder), although the effect was better than penicillin, he did not recover until 7 days later. A few days ago, Mr. Chen contracted acute tonsillitis again, with symptoms more severe than before. However, this time he followed your instruction to take the medicine once every 6 hours, continuously taking two doses day and night. As a result, all symptoms disappeared the next day. Another example: When using Shenkangling Capsule to treat kidney disease, I observed that your results were excellent, but mine were inferior. Only after I adopted your instruction to take it on an empty stomach did the efficacy significantly increase."
I said: "In *Suwen: Zhizhen Yao Dalun* (Supreme Basic Questions: The Great Treatise on the Most Essential Truths), when discussing treatment principles, besides emphasizing 'strictly adhere to the pathogenesis, assign responsibilities accordingly, investigate what exists, investigate what does not exist, hold accountable what is excessive, hold accountable what is deficient, first address the five phases' dominance, unblock the blood and qi, ensure smooth flow, and achieve harmony,' it also emphasizes three points: ① The yin-yang properties of the five flavors: 'Pungent and sweet disperse and ascend are yang; sour and bitter induce vomiting and purgation are yin; salty induces vomiting and purgation is yin; bland promotes diuresis and leakage is yang. These six may astringe or disperse, slow or accelerate, dry or moisten, soften or harden, acting according to what is beneficial.' ② 'Whether toxic or non-toxic, the treatment target is primary; the dosage should be adjusted appropriately.' ③ 'Treat cold with heat, heat with cold; treat minor disorders oppositely, major disorders similarly; reduce hardness, eliminate pathogens, warm exhaustion, dissipate stagnation, attack retention, moisten dryness, relieve urgency, gather dispersion, warm deficiency, promote movement of lethargy, calm fright, elevate sinking, lower rebellion, massage, bathe, press, rob, open, and develop, adapting to the specific situation.'
*Shennong Bencao Jing* (Divine Farmer’s Materia Medica), while stating 'treat cold with hot herbs, treat heat with cold herbs,' further emphasizes: 'For diseases above the chest and diaphragm, take medicine after meals; for diseases below the heart and abdomen, take medicine before meals. For diseases in the limbs and blood vessels, take on an empty stomach in the morning; for diseases in the bone marrow, take when full in the evening.'
*Shanghan Lun* (Treatise on Cold Damage Disorders), regarding the administration of Guizhi Tang (Cinnamon Twig Decoction), states: 'Shortly after taking the medicine, drink more than one sheng of hot thin porridge to assist the medicinal power. Cover warmly for about an hour until a slight, uniform sweat appears over the body, which is optimal. Do not allow profuse sweating like flowing water, or the disease will certainly not be eliminated. If sweating occurs after the first dose and the illness improves, stop subsequent doses; there is no need to finish the entire decoction. If no sweat occurs, administer again following the previous method. If still no sweat, shorten the interval between doses slightly, allowing three doses to be completed within half a day. If the disease is severe, administer day and night, observing for a full cycle (24 hours). If one dose is finished and symptoms persist, prepare another dose. If no sweat occurs, continue up to two or three doses.' Regarding Guizhi Er Mahuang Yi Tang (Two Parts of Cinnamon Twig Decoction and One Part of Ephedra Decoction), it states: 'Take one sheng warm, twice daily.' Regarding Wuling San (Five-Ingredient Powder with Poria), it states: 'Grind into powder, mix with white rice water, take one cun-bi, three times daily.' Regarding Taoren Chengqi Tang (Peach Kernel Purging the Intestines Decoction), it states: 'Take five he warm before meals, three times daily. Mild diarrhea is expected.' Regarding Didang Tang (Resolute Attack Decoction), it states: 'Boil to obtain three sheng, remove dregs, take one sheng warm. If no evacuation occurs, take again.' Regarding Didang Wan (Resolute Attack Pill), it states: 'Boil one pill in one sheng of water, take seven he. Within a zhou period (24 hours), blood should be evacuated; if not, take again.' Regarding Guizhi Gancao Tang (Cinnamon Twig and Licorice Decoction), it states: 'Take in one dose.' Regarding Huanglian Tang (Coptis Decoction), it states: 'Three times during the day, twice at night.' Regarding Shizao Tang (Ten Jujube Decoction), it states: 'Take ten pills with water, three times daily, gradually increasing until effective.' Regarding Mahuang Lianqiao Chixiaodou Tang (Ephedra, Forsythia and Red Bean Decoction), it states: 'Divide into three warm doses, finish within half a day.' Regarding Huangqin Tang (Scutellaria Decoction), it states: 'Take one sheng warm, twice daily, once at night.'
*Jingui Yaolue* (Essential Prescriptions of the Golden Cabinet), regarding Shuqi San (Vinca Powder), states: 'Take half qian with grain vinegar water before onset. For warm malaria, add half fen of Shuqi, take one qian-bi at the time of onset.' Regarding Zaojiao Wan (Gleditsia Sinensis Pill), it states: 'Mix with jujube paste and decoction, take three pills, three times daily and once at night.' And so on. In principle, merely focusing on treatment principles while ignoring details in methods often fails to yield excellent efficacy. Therefore, clinicians must pay attention not only to the big picture but also to the details."
Is the efficacy of Chinese herbal medicine fast or slow?
Is the efficacy of Chinese herbal medicine fast or slow? I have discussed this question with many colleagues. During one conversation, a doctor said: "Some say Chinese herbal medicine acts slowly with fewer side effects, while Western medicine acts quickly with more side effects. Therefore, for acute and critical illnesses, Western medicine should be prioritized, reserving Chinese medicine for chronic conditions." He added: "When I first saw the research report on your 'Baobao Yitianling' indicating effectiveness within 4 hours, I was very skeptical. I believed Chinese medicine could not act that quickly, especially since it is an external application. However, upon clinical application, I repeatedly found patients reporting: some experienced relief from abdominal pain and diarrhea within 3-4 minutes of application; some felt abdominal pain relief immediately upon application; some could travel by car without motion sickness after application. This made me realize my understanding was biased, preconceived, and erroneous. Through this fact, I was forced to revise my view on the speed of Chinese medicine's efficacy and re-study the time course of its action. Through years of research, I gradually discovered that for certain syndromes, Chinese medicine acts not only quickly but also has fewer side effects. This speed can reach unimaginable levels; I believe the ancient description 'recovered before the cup is overturned' is not exaggerated, but an objective, realistic description."
I said: "Your observation is scientific and pragmatic. Understanding the speed of Chinese medicine's efficacy is crucial not only within TCM but also in Sino-Western medical cooperation. Because: ① It relates to whether TCM can participate in rescuing acute and critical illnesses, and whether it can play a leading role in joint rescue efforts. ② It directly affects the evaluation of efficacy during Chinese medicine treatment and the recognition of its role in joint treatments. ③ It relates to the understanding of side effects of Chinese medicine and their evaluation in joint treatments. ④ It concerns the compatibility principles (contrary, mutual enhancement, mutual fear, mutual promotion) in Chinese medicine and the evaluation of synergistic and antagonistic effects in joint treatments. ⑤ It relates to evaluating the correctness of syndrome differentiation and treatment, and understanding the correct application of Chinese medicine in joint treatments. ⑥ It concerns evaluating the correctness of dosage forms and the appropriateness of applying these forms in joint treatments. ⑦ It relates to evaluating the correctness of administration methods and timing in joint treatments. ⑧ It concerns evaluating the correctness of administration routes in joint treatments.
The question of whether TCM can directly participate in treating acute diseases and rescuing critical illnesses has long been proven by thousands of years of TCM history. The question of whether TCM can play a leading role in Sino-Western joint treatment has also been proven in recent medical practice: not only is it possible, but it is often appropriate.
Regarding the evaluation of TCM efficacy, although history has settled the matter, due to differing academic views, some Western doctors still hold the view that 'the sun rises whether the rooster crows or not.' This view is related to their academic stance and a non-scientific attitude that does not take practice as the sole criterion for testing truth. It is also related to our insufficient understanding of how long it takes for specific Chinese medicines to show efficacy and what kind of symptom improvement occurs. Therefore, to correctly evaluate efficacy, we must deeply understand the time course and nature of efficacy for different medicines. Clinical observations reveal general patterns: ① Local applications act faster than internal medications. Local applications may relieve symptoms instantly, while internal medications may take 15 minutes to 4 hours. ② Pungent-dispersing herbs act fastest, bitter-descending herbs next, and sweet-moderating herbs slowest. Pungent herbs may relieve symptoms in 30 minutes to 1 hour; bitter herbs may take 30 minutes to 2 hours, or even 4 hours; sweet herbs may take over 1 hour, or even 24 hours. ③ Exterior Syndromes respond faster than Interior Syndromes. Fast responses occur in 2-8 hours; slow responses take 8-48 hours. ④ Deficiency Syndromes respond slower than Excess Syndromes. Excess syndromes may respond in 15 minutes to 2 hours; deficiency syndromes may take 4-48 hours or more. ⑤ Cold Syndromes respond faster than Heat Syndromes. Fast responses take minutes to 1 hour; slow responses take 40 minutes to 48 hours. ⑥ Qi Level Syndromes respond faster than Blood Level Syndromes. Qi level responses may appear in tens of minutes; Blood level responses require over 40 minutes. ⑦ Yang Collapse Syndromes respond faster than Yin Collapse Syndromes. Yang collapse responses may appear in tens of minutes to 1 hour; Yin collapse responses may take 40 minutes to 2-4 hours.
Regarding the toxicity and side effects of Chinese medicine, there are two current views. One view holds that Chinese medicine has little to no toxicity or side effects; the other argues that some are toxic and have serious side effects. I agree with the latter. However, evaluating the toxicity of each herb requires case-by-case analysis. Clinical observations show: ① Gastrointestinal reactions occur instantly to 1-2 hours after administration. ② Palpitations occur 30 minutes to 1 hour after administration. ③ Dizziness and limb numbness occur around 1 hour after administration. ④ Profuse sweating occurs around 1 hour after administration. ⑤ Dry mouth, parched tongue, and sore throat occur 1-2 hours, or even 3-4 hours after administration. ⑥ Irritability and mania occur after 1 hour, or longer. ⑦ Urticaria occurs 4-12 hours, or even 48 hours after administration. ⑧ Epistaxis and maculopapular rashes occur 1-2 hours, or even 48 hours after administration. Conversely, if adverse reactions do not occur within these timeframes, they may not be caused by the Chinese medicine.
Understanding synergy and antagonism in combined Sino-Western medicine is extremely complex. To understand combined effects, one must first know the time course of individual effects, which is often unclear. Thus, analyzing combined efficacy to determine synergy or antagonism is difficult. However, careful observation can reveal these interactions.
Most physicians consider Syndrome Differentiation and Treatment the essence of TCM. However, there are two views on evaluating its correctness. One view assumes Chinese medicine always acts slowly, so short-term ineffectiveness doesn't prove failure; just continue medication. The other view holds that different diseases, syndromes, and medicines have different onset times. If expected efficacy does not appear within the appropriate timeframe, the differentiation is likely incorrect, and treatment should be adjusted according to the principle of 'observe pulse and symptoms, identify deviations, and treat according to the syndrome.'
Regarding dosage forms and efficacy speed, predecessors stated 'Decoctions are vigorous; pills are slow.' There are also discussions on the efficacy of different administration routes, such as nasal insufflation to induce sneezing. These issues require careful clinical summarization.
These opinions are merely a preliminary summary of my decades of experience. Their correctness needs verification by colleagues in practice.
Should we follow the path of science or dogmatism?
Reading Mr. Zhu Tong's interview with Academician Chen Keji, a pioneer in integrated Chinese and Western medicine, titled "TCM Must Introduce Modern Science" in the 20th issue of *Sanlian Life Weekly* (1997), left me with deep reflections.
I. Should we follow the path of science or the "Two Whatevers"?
Looking at the development history of China and abroad, any scientist with outstanding achievements succeeded not only by absorbing previous achievements but also through innovation and forging their own path. This applies to natural sciences and social sciences alike. In China's revolution, early reliance on copying Soviet experiences failed. Only after our Party criticized dogmatism and established Mao Zedong Thought as the guiding ideology did the revolution achieve victory. In China's construction, long-term adherence to the "Two Whatevers" nearly brought the country to bankruptcy. Only after establishing socialism with Chinese characteristics and Deng Xiaoping Theory as the guiding ideology did construction enter a healthy developmental path.
In China's medical history, adhering to a unique developmental path allowed Chinese medicine to influence the entire Eastern medical tradition. In the past century, influenced by Yu Yunxiu's dogmatic thought that "any TCM theory/method conforming to contemporary Western medicine is correct, and any divergent one is incorrect," many TCM works became mere exercises in matching terms, severely hindering TCM development. In recent years, as Western theories and methods have been progressively challenged, some dogmatic thinking based on term-matching has become untenable. Consequently, the slogan "TCM must introduce modern science" has been proposed to replace the old dogmatism. The two aspects Academician Chen Keji prides himself on precisely reflect this shift.
(1) Where lies the cause of TCM's sluggish development?