Stroke and Joint Pain: Diagnosis and Treatment, Chapter 5
San Huang Decoction
Treatment for stroke, rigidity of hands and feet, joint pain, irritability and heat in the heart, aversion to cold, and lack of appetite for days.
Introduction: The “Golden Chamber” is edited according to the classification method in Liu Duozhou’s commentary on the “Golden Chamber”. Annotations are primarily selected from the works of Qing Dynasty and modern physicians, and due to personal understanding, there may be biases. Readers are encouraged to extract the essence and discard the dross, combining it with clinical practice and focusing on self-understanding. Comments and contributions from readers are welcome!
Notes by Zi Heng
Wind-cold attacking the exterior leads to disharmony of Ying and Wei, causing stagnation of Qi and blood, resulting in aversion to cold, rigidity of hands and feet, and pain in the joints. The exterior is closed by wind-cold, and internal Yang Qi is constrained, generating heat, hence the irritability and lack of appetite.
The treatment is based on the formula San Huang Decoction, which uses Ma Huang (Ephedra) to disperse wind-cold, Xi Xin (Asarum) and Du Huo (Angelica pubescens) to penetrate the muscles and joints, dispelling wind, cold, and dampness, while Huang Qi (Astragalus) strengthens the exterior and boosts Qi to resist external pathogens, and Huang Qin (Scutellaria) clears internal heat.
Qing Dynasty – Shen Mingzong’s Commentary on Zhang Zhongjing’s Golden Chamber
The liver governs the tendons and joints; when the pathogen is on the surface, the joints respond with rigidity and pain. If liver wind invades the heart, it causes irritability and heat; however, if the heart is deficient, the heat is retained internally, leading to aversion to cold. The wood pathogen obstructs the stomach Qi, causing a lack of appetite. This pathogen is still in the three Yang meridians, hence Ma Huang is used to open the pores and promote Yang. If there is deficiency of Yang, Huang Qi is used to restrain it. Du Huo and Xi Xin harmonize the Qi of the heart and kidney, allowing the pathogen to exit. Huang Qin specifically clears the heat generated by wind.
Qing Dynasty – Chen Xiuyuan’s Commentary on the Golden Chamber
XU Zhongke states: This wind enters the Ying and Wei between the limbs and joints, disturbing for a long time, thus the pathogen attacks the kidney, causing rigidity of hands and feet, and Yang is not circulating; joint pain indicates Yin is not flowing; irritability and heat indicate heat is retained in the heart; aversion to cold for days indicates the kidney is affected by the pathogen, unable to communicate with the heart and stomach. Therefore, Ma Huang is used to open Yang and relieve obstruction, while Huang Qi is combined to move the muscles, and Huang Qin is used to clear the pathogenic heat. Du Huo and Xi Xin specifically target kidney pathogens, while symptoms of heart heat, abdominal fullness, Qi counterflow, palpitations, and thirst are treated according to the principles of treatment.
Liu Duozhou’s Commentary on the Golden Chamber
This formula discusses the treatment of stroke with deficiency and wind-cold penetrating deeply, leading to stagnation and transformation into heat. The patient has a deficiency of Ying and Wei, and is externally affected by wind-cold pathogens, hence the aversion to cold, rigidity of hands and feet, and joint pain. The exterior is closed by wind-cold, and internal Yang Qi is constrained and transforms into heat, leading to irritability and lack of appetite.
The treatment is with San Huang Decoction, which disperses cold, clears heat, and nourishes the Wei Qi. The formula includes Ma Huang, Du Huo, and Xi Xin to disperse the wind-cold-damp pathogens, warming the meridians and moving Ying and Wei, while Huang Qin clears heat and dries dampness, and Huang Qi supplements the Wei Qi to prevent wind pathogens. The formula also notes treatments for symptoms such as heart heat, abdominal fullness, Qi counterflow, palpitations, and thirst. Due to damp-heat stagnation, there may be abdominal fullness and constipation, or sticky and foul-smelling stools, hence Da Huang (Rhubarb) is added to purge excess heat and promote Qi to relieve fullness. If damp-heat is obstructing the stomach, Ren Shen (Ginseng) is added to tonify the spleen and stomach Qi to transform dampness and descend counterflow Qi. If there is heat transforming into irritability, Mu Li (Oyster Shell) is added to calm the spirit; if there is heat in the lungs and stomach damaging Yin, Gua Lou Gen (Trichosanthes Root) is added to nourish Yin and clear heat, and to clear lung Qi; if there is a history of Yang deficiency and inability to resist wind-cold, Fu Zi (Aconite) is added to warm the kidneys and promote Yang, adjusting the formula according to symptoms.
Hu Xishu’s Lecture on the Golden Chamber
San Huang Decoction in the “Golden Chamber” treats stroke, rigidity of hands and feet, joint pain, irritability and heat in the heart, aversion to cold, and lack of appetite for days. The main issue is joint pain, which is caused by wind pathogens. The patient may feel irritable and cold, and the heart is disturbed, leading to a lack of appetite. The formula includes Ma Huang, Du Huo, Xi Xin, Huang Qi, and Huang Qin. This formula was simpler during Sun Simiao’s time. This Huang Qi can be used for severe joint pain caused by wind, but it must be particularly sensitive to wind. If the exterior is not treated with Huang Qi, it cannot dispel the wind, and sweating will not work either. Xi Xin has a similar effect to Fu Zi for treating rigidity and pain in the joints, so these two herbs are effective for joint pain. Additionally, Ma Huang, Du Huo, and Huang Qin are used to release heat and resolve exterior symptoms; otherwise, it will not work.
However, the dosages of these herbs are light, measured in fractions. In ancient times, one tael was divided into four parts. For example, Ma Huang is just over one tael, which is about 3 grams in modern measurements. Du Huo does not have much power to induce sweating; it is somewhat similar to Ge Gen (Kudzu), being a moistening and cooling herb that can induce sweating but not strongly. Huang Qin also has a heat-clearing and irritability-relieving effect. This formula is for exterior symptoms, and if there is no sweating but severe aversion to wind and cold, along with joint pain, it can be used. This analysis is based on the herbs. It is not like the term ‘stroke’ is just placed at the beginning; it is still said to be a stroke caused by wind and dampness. However, this formula is quite straightforward.
Some modifications mentioned are somewhat confusing. For example, adding a small sweat or a large sweat, and adding Da Huang for heart heat, does not make much sense; heart heat should only be treated with Huang Lian (Coptis). Huang Lian and Huang Qin are also used in the heat-clearing formula, so adding Da Huang for heart heat is not appropriate. For abdominal fullness, adding Zhi Shi (Bitter Orange) is fine, as it helps to relieve stagnation and promote Qi. However, adding Ren Shen for Qi counterflow is incorrect; Qi counterflow should only be treated with herbs like Ban Xia (Pinellia) and Sheng Jiang (Ginger). Ren Shen is for tonifying deficiency, and deficiency does not necessarily mean Qi counterflow. If there is a history of fullness in the abdomen, it indicates a blockage. For palpitations, adding Mu Li is appropriate, as it can treat palpitations. For thirst, adding Gua Lou Gen is also acceptable; there are two types of thirst: one due to deficiency of body fluids, and the other due to heat in the Yangming, which requires Shi Gao (Gypsum). Therefore, adding Gua Lou Gen is not appropriate. The modifications should not be written casually. If there is a history of cold, adding Fu Zi is acceptable for treating joint pain, which is not a major issue. This is the San Huang Decoction, named for the three Huang herbs: Huang Qi, Huang Qin, and Ma Huang.
Other Physicians
“The Essentials of the Golden Chamber” states: “This is also a standard treatment for stroke, but it is less flexible. Using Du Huo instead of Gui Zhi (Cinnamon Twig) is for deeper wind invasion. Using Xi Xin instead of Gan Jiang (Dried Ginger) is for pathogens entering the meridians. Huang Qi is used to tonify deficiency and extinguish wind; Huang Qin is used instead of Shi Gao to clear heat, for dampness obstructing below and heat being excessive above; for heart heat, add Da Huang to drain heat; for abdominal fullness, add Zhi Shi to open stagnation and promote Qi; for Qi counterflow, add Ren Shen to tonify the middle and benefit the stomach; for palpitations, add Mu Li to prevent water pathogens; for thirst, add Gua Lou Gen to clear the lungs, generate fluids, and eliminate heat… If there is a history of cold, it indicates that there is no heat; even if there is heat, it is only true cold with false heat externally. If Fu Zi is added, then the Huang Qin in the formula should also be considered; this is only for those with deficiency and cold.
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Copyright Notice
Copyright Notice: Some content of this article is excerpted from “Liu Duozhou’s Commentary on the Golden Chamber”; author/Liu Duozhou; “Hu Xishu’s Lecture on the Golden Chamber”; lecturer/Hu Xishu. The purpose of reprinting is to disseminate knowledge of Traditional Chinese Medicine culture, and the copyright belongs to the relevant rights holders. If there are any improper uses, please feel free to contact us for negotiation. The section “Notes by Zi Heng” is original content; please indicate the source when reprinting.
Full Chapter Content
Article 1: If wind causes illness, it may result in hemiplegia or only paralysis of the arm; this is called Bi syndrome. The pulse is weak and rapid, caused by stroke.
Article 2: The pulse at the cun position is floating and tight; tightness indicates cold, floating indicates deficiency. Cold and deficiency are intertwined, and the pathogen is in the skin. Floating indicates blood deficiency, and the vessels are empty; the evil pathogen does not drain, either left or right; the evil Qi is counterflowing, while the righteous Qi is urgent, leading the evil to obstruct the flow. If the evil is in the vessels, the skin is numb; if the evil is in the meridians, it is heavy and unmanageable; if the evil enters the bowels, the person cannot recognize others; if the evil enters the organs, the tongue becomes difficult to speak, and saliva is drooling.
Hou’s Black Powder.Treats severe wind, heaviness in the limbs, and aversion to cold.
Article 3: The pulse at the cun position is slow and weak; slowness indicates cold, weakness indicates deficiency. If the Ying is slow, it indicates loss of blood, and if the Wei is slow, it indicates stroke. If the evil Qi enters the meridians, it causes itching and rashes; if the heart Qi is insufficient, the evil Qi enters the center, leading to fullness in the chest and shortness of breath.
Wind-Dispelling Decoction.Eliminates heat and treats epilepsy.
Fang Ji and Di Huang Decoction.Treats madness, wandering, and talking incessantly, without cold or heat, with a floating pulse.
Head Wind Ointment.
Article 4:The pulse at the cun position is deep and weak; deep indicates the bones, and weak indicates the tendons. Deep indicates the kidneys, and weak indicates the liver. Sweating occurs when entering water, as if water injures the heart, leading to joint sweat, hence it is called joint sweat.
Article 5: The pulse at the foot yang position is floating and slippery; slippery indicates fullness of Qi, and floating indicates spontaneous sweating.
Article 6: The Shaoyin pulse is floating and weak; weakness indicates blood deficiency, and floating indicates wind. When wind and blood interact, it causes pain like pulling.
Article 7: In robust individuals, the pulse is rough and small, with spontaneous sweating, joint pain, and inability to bend or stretch; all of these are caused by drinking alcohol and sweating in the wind.
Article 8: All limbs and joints are painful, the body is emaciated, the feet swell as if they are falling off, the head is dizzy, and there is shortness of breath, with a desire to vomit; Gui Zhi and Shao Yao Decoction is the main treatment.
Article 9: Sour flavors injure the tendons; if the tendons are injured, they become slack, which is called leakage. Salty flavors injure the bones; if the bones are injured, they become weak, which is called withering. Withering and leakage interact, which is called broken leakage. If the Ying Qi is not flowing, and the Wei Qi is not acting independently, both Ying and Wei are weak, and the three Jiao cannot defend, leading to emaciation, unilateral swelling of the feet, yellow sweat, and cold shins. If there is fever, it is called joint sweat.
Article 10: Joint pain that cannot bend or stretch is treated with Wu Tou Decoction. Wu Tou Decoction. Treats foot pain that cannot bend or stretch.
Alum Decoction.Treats foot pain affecting the heart.
Additional Formulas:
“Ancient and Modern Records of Efficacy” – Continuation of Life Decoction. Treats stroke with inability to self-recover, inability to speak, and not knowing the painful area, or rigidity and inability to turn.
San Huang Decoction from the “Golden Chamber”. Treats stroke, rigidity of hands and feet, joint pain, irritability and heat in the heart, aversion to cold, and lack of appetite for days.
“Recent Effective Formulas” – Shu Fu Zi Decoction. Treats wind deficiency, heavy head, dizziness, extreme bitterness, and lack of taste; warms the muscles, tonifies the middle, and benefits Qi.
Cui’s Eight Flavor Pill. Treats foot pain that ascends, with numbness in the lower abdomen.
“Golden Chamber Formula” – Yue Bi Jia Shu Decoction. Treats extreme heat in the flesh, leading to loss of body fluids, opening the pores, and excessive sweating, with severe wind Qi and weakness in the lower body.
Study and Recite
San Huang Decoction from the “Golden Chamber”. Treats stroke, rigidity of hands and feet, joint pain, aversion to cold, irritability and heat in the heart, lack of appetite for days.
