Source: China Traditional Chinese Medicine NewsDate: 2011-07-18Gao Jianzhong, Second Hospital of Shanxi University of Traditional Chinese MedicineExpanding the Application of Classical Formulas through the Treatment of Internal Injury DiseasesThe so-called “thinking of treating internal injury diseases” focuses on the understanding of the onset and treatment of diseases, emphasizing the importance of Zhengqi (正气, Vital Qi). According to the views of Li Dongyuan, a physician from the Jin-Yuan dynasty, it can be summarized as “injury to the spleen and stomach leads to the emergence of various diseases.”The longevity of classical formulas requires both a return to the source and an expansion of their application. In fact, scholars of classical formulas throughout history have been working on these two aspects, whether intentionally or unintentionally.There are at least two ways to expand the application of classical formulas: one is to broaden the range of diseases treated by classical formulas, and the other is to expand or supplement the theoretical system guiding the use of classical formulas. The former is commonly used by classical formula scholars, such as the use of Xiao Chai Hu Tang (小柴胡汤, Minor Bupleurum Decoction) from the “Shang Han Lun” (伤寒论, Treatise on Cold Damage) to treat Shaoyang disease, which later generations of physicians used to treat malaria, various febrile diseases, and colds in children and the elderly, as well as many immune system disorders in contemporary medicine. The latter method has also been used by some classical formula scholars, but few have explicitly proposed it.Zhang Zhongjing constructed the “external pathogen theory” based on the six meridian differentiation guided by the theory of Yin and Yang (阴阳学说), while Li Dongyuan constructed the “internal injury theory” based on the five elements theory (五行学说) and organ differentiation (脏腑辨证), which is distinctly different from the external pathogen theories of Shang Han and Wen Bing. Of course, the six meridian differentiation can be used to treat internal injury diseases, and organ differentiation can also be used to treat external pathogen diseases. Therefore, can classical formulas originating from the external pathogen theory be guided by the internal injury theory? Is it a development of classical formulas to use them under the guidance of organ differentiation, departing from the six meridian differentiation? The answer is certainly affirmative.Mr. Hu Xishu clearly stated: “The six meridians of the ‘Shang Han Lun’ come from the eight principles.” Teacher Feng Shilun, through detailed argumentation, pointed out: “The source of classical formulas and their patterns dates back to the Shennong era. The ‘Tang Ye Jing Fa’ marked the development of classical formulas, while the ‘Shang Han Lun’ marked the establishment of the theoretical system of classical formulas. The continuity from the ‘Shennong Bencao Jing’ to the ‘Tang Ye Jing Fa’ is not only in formulas and patterns but also in the eight principles differentiation theory, which is the theoretical system of classical formulas. The theory of treating diseases based on the six meridian differentiation of classical formulas is formed on the basis of the accumulation of ancient formulas and patterns, and its theory is based on the eight principles, as Zhang Zhongjing and his disciples recognized that there are diseases that are half exterior and half interior, thus transforming the eight principles differentiation into six meridian differentiation.” I believe this understanding is closer to the essence of the classical formula system itself.Many later classical formula scholars interpreted the six meridian differentiation through the five elements theory and used organ differentiation to interpret the patterns and applications of classical formulas, which can withstand clinical verification. Who is right and who is wrong has been debated for a long time.I believe that the six meridian differentiation and organ differentiation are two independent systems of differentiation and treatment. Using the thinking of treating external pathogen diseases to interpret the patterns of classical formulas and guide their application is consistent with Zhang Zhongjing’s establishment of the external pathogen theory system and restores the origin of classical formulas. Using the thinking of treating internal injury diseases to interpret the patterns of classical formulas and guide their application is more suitable for the internal injury theory system established by later generations, representing the development of classical formulas.The efficacy of classical formulas is reflected in their treatment of specific diseases. When classical formulas are used within the external pathogen theory system, they have their unique efficacy, while their corresponding efficacy will change when applied to the internal injury theory system. This objectively expands the clinical application range of classical formulas. For example, Ma Huang Tang (麻黄汤, Ephedra Decoction) treats external pathogen diseases with the effect of inducing sweating and releasing the exterior; when treating internal injury diseases, its effect is to warm and promote Yang Qi and disperse cold from the lungs. Gui Zhi Tang (桂枝汤, Cinnamon Twig Decoction) treats external pathogen diseases with the effect of releasing the muscle layer and inducing sweating; when treating internal injury diseases, its effect is to harmonize the spleen and stomach. Xiao Qing Long Tang (小青龙汤, Minor Bluegreen Dragon Decoction) treats external pathogen diseases with the effect of releasing the exterior and transforming phlegm; when treating internal injury diseases, its effect is to warm the lungs and transform phlegm. Xiao Chai Hu Tang treats external pathogen diseases with the effect of harmonizing the exterior and interior; when treating internal injury diseases, its effect is to harmonize the liver (gallbladder) and spleen (stomach). Da Cheng Qi Tang (大承气汤, Major Order the Qi Decoction) treats external pathogen diseases with the effect of purging and preserving Yin; when treating internal injury diseases, its effect is to purge and promote bowel movements. Bai Hu Tang (白虎汤, White Tiger Decoction) treats external pathogen diseases with the effect of clearing and dispersing internal heat; when treating internal injury diseases, its effect is to clear and drain stomach heat. Li Zhong Wan (理中丸, Regulate the Middle Pill) treats external pathogen diseases with the effect of dispelling cold and stopping diarrhea; when treating internal injury diseases, its effect is to warm and tonify the spleen and stomach. Ma Huang Fu Zi Xi Xin Tang (麻黄附子细辛汤, Ephedra, Aconite, and Asarum Decoction) treats external pathogen diseases with the effect of warming Yang and dispersing cold; when treating internal injury diseases, its effect is to warm and promote Yang Qi. Si Ni Tang (四逆汤, Four Reversals Decoction) treats external pathogen diseases with the effect of dispersing cold and returning Yang; when treating internal injury diseases, its effect is to invigorate Yang Qi. Si Ni San (四逆散, Four Reversals Powder) treats external pathogen diseases with the effect of smoothing and relieving Yang Qi stagnation; when treating internal injury diseases, its effect is to harmonize the liver and spleen (Qi and blood).Three Case Studies of Classical Formula Treatment for Internal Injury DiseasesCase 1: Modified Chai Hu Gui Zhi TangWu, female, 46 years old. Initial diagnosis on June 20, 2010. For the past week, she has felt unwell all over, fatigued, with poor sleep, itchy and dry eyes, dry and peeling lips, difficulty swallowing, dry skin, and swelling in both lower limbs. Her menstrual cycle is usually regular, but it has been delayed for 10 days this month. The tongue is red, the tongue coating is thin and white, and the pulse is thin, wiry, and slow. The diagnosis is stagnation in the San Jiao (三焦, Three Burners), disharmony of Qi and blood, and obstruction of Qi and water. The treatment is to regulate the San Jiao, transform Qi, and promote water metabolism. The formula used is modified Chai Hu Gui Zhi Tang. Prescription: Chai Hu (Bupleurum) 9g, Gui Zhi (Cinnamon Twig) 9g, Huang Qin (Scutellaria) 12g, Sheng Bai Shao (Raw White Peony) 12g, Jiang Ban Xia (Ginger Processed Pinellia) 9g, Fu Ling (Poria) 15g, Zhu Ling (Polyporus) 15g, Sheng Gan Cao (Raw Licorice) 3g. 5 doses, decocted in water, taken once daily, divided into morning and evening doses.June 27, second diagnosis: After taking one dose of the above formula, menstruation began, with the first two days being dark red coffee color, and on the third day, the color returned to normal, lasting for 5 days. With the onset of menstruation, all symptoms began to alleviate, sleep improved, energy increased, dryness of lips decreased, and skin became more hydrated. Currently, only a feeling of fatigue in both lower limbs remains, and there is no swelling. The above formula’s Sheng Gan Cao is changed to Zhi Gan Cao (Honey-Processed Licorice), and 5 more doses are taken before stopping the medication.Note: This case is related to the delayed menstruation, with no history of external pathogen diseases, and is classified as an internal injury disease. The various symptoms are complex and cannot be explained by a single organ or viscera pathology. Considering all symptoms, the delayed menstruation indicates Qi and blood stagnation, while the swelling in the lower limbs indicates obstruction of Qi and water. Qi and blood stagnation leads to general discomfort, fatigue, and poor sleep; obstruction of Qi and water leads to dry eyes, dry lips, difficulty swallowing, and dry skin. All symptoms are caused by the disharmony in the movement and distribution of Qi, blood, and water. The San Jiao and Ying Wei (营卫, Nutritive and Defensive Qi) are the pathways for the movement of Qi, blood, and water, hence the use of Chai Hu Gui Zhi Tang to harmonize Ying Wei and the San Jiao, adding Zhu Ling and Fu Ling to assist Gui Zhi in transforming Qi and promoting water metabolism. Considering the disease belongs to internal injury, the amounts of Chai Hu and Gui Zhi are less than Huang Qin and Bai Shao; since the Zhengqi is not prominent and the tongue is red, no warming tonics like Ren Shen (Ginseng), Sheng Jiang (Fresh Ginger), or Da Zao (Jujube) are used, and Sheng Gan Cao is used instead of Zhi Gan Cao.If treated with the time-honored formula, it would be easy to choose Xiao Yao San (逍遥散, Free and Easy Wanderer Powder) with modifications. In this case, the key advantage of Chai Hu Gui Zhi Tang over Xiao Yao San is the presence of Gui Zhi, which transforms Qi and regulates Ying.Case 2: Modified Si Ni TangZhang, female, 54 years old. Initial diagnosis on December 9, 2009. For the past year, she has felt mentally unwell, occasionally experiencing palpitations, poor sleep, and frequent nighttime urination (once every 1-2 hours). In the past month, she has had facial and lower limb swelling, and her head feels heavy. Her appetite is fair, with stools being sometimes dry and sometimes loose, and her mouth is not dry. She has a history of hypertension for over 20 years. A week ago, tests showed elevated blood lipids, normal fasting blood sugar, and elevated postprandial blood sugar, with normal urinalysis. The tongue is pale and dark, the tongue coating is white and moist, and the pulse is deep and thin. The diagnosis is deficiency of Yang Qi (阳气, Yang Vitality) and internal retention of cold fluids. The treatment is to warm and invigorate Yang Qi and transform cold fluids. The formula used is modified Si Ni Tang. Prescription (Chinese herbal granules): Zhi Fu Zi (Processed Aconite) 6g, Gan Jiang (Dried Ginger) 3g, Zhi Gan Cao (Honey-Processed Licorice) 3g, Fu Ling 10g, Zhu Ling 10g. 7 doses, taken with hot water.December 17, second diagnosis: After taking the medicine, facial and lower limb swelling gradually subsided, and both sleep and energy improved. The tongue is pale and dark, the tongue coating is white and moist, and the pulse is deep and thin. The above formula is supplemented with Shi Chang Pu (Acorus) 6g, and 7 doses are taken with hot water.December 24, third diagnosis: All symptoms have reduced, energy has further improved, and nighttime urination is down to 2 times. The tongue is pale and dark, the tongue coating is thin and white, and the pulse is deep and thin. The above formula is modified by removing Zhu Ling and Shi Chang Pu, and 7 doses are taken with hot water.December 31, fourth diagnosis: Symptoms have nearly resolved, energy and sleep are good, palpitations have ceased, nighttime urination is down to 1-2 times, and there is no swelling, appetite is good, and bowel movements are regular. The above formula is supplemented with Hong Ren Shen (Red Ginseng) 5g, and 7 doses are taken with hot water.After the medication, there are no discomforts, and the medication is stopped.Note: This case can be easily differentiated as Taiyin disease or Shaoyin disease using the six meridian differentiation, and “Si Ni Bei” or “Zhen Wu Tang” could be selected. Although Si Ni Tang is used in this case, it seems to be a conventional use of Si Ni Tang. However, two points need to be noted: first, the efficacy of Si Ni Tang used in this case is not to disperse cold and return Yang, but to warm and invigorate Yang Qi; second, the dosage of Si Ni Tang used is relatively small. The reason for this usage of Si Ni Tang is based on the consideration of internal injury diseases. If one believes that a small dosage is insufficient or that a small dosage will yield small effects, and arbitrarily uses a large amount, it would deviate from the above treatment philosophy and may not achieve satisfactory results.If treated with the time-honored formula, it would generally use warming tonics, which are less flexible than classical formulas.Case 3: Modified Si Ni Tang combined with Da Cheng Qi TangRuan, male, 86 years old. Initial diagnosis on March 8, 2009. For the past week, he has been unable to defecate, with abdominal distension, eating very little, feeling mentally unwell, and not wanting to drink water. The tongue is pale and dark, the tongue coating is thin and white, and the pulse is thin and slow. Two years ago, he suffered from a “cerebral infarction,” but now he can move his limbs freely. The diagnosis is deficiency of Yang Qi and stagnation of evil in the bowels. The treatment is to warm Yang, benefit Qi, and promote bowel movements. The formula used is modified Si Ni Tang combined with Da Cheng Qi Tang. Prescription (Chinese herbal granules): Zhi Fu Zi 6g, Gan Jiang 3g, Hong Ren Shen 5g, Sheng Bai Zhu (Raw White Atractylodes) 10g, Ji Nei Jin (Chicken Gizzard Lining) 10g, Sheng Da Huang (Raw Rhubarb) 6g, Mang Xiao (Mirabilite) 3g, Zhi Shi (Bitter Orange) 6g, Hou Po (Magnolia Bark) 6g, Zhi Gan Cao 3g. 3 doses, taken with hot water.March 12, second diagnosis: After taking one dose of the above formula, bowel movements became smooth, and after finishing 3 doses, appetite improved, abdominal distension resolved, and energy significantly improved. The tongue and pulse remain the same as before. To promote spleen function and appetite, the prescription is: Sheng Bai Zhu 30g, Ji Nei Jin 15g, Zhi Shi 9g. 7 doses, taken as a decoction.Note: This case is an internal injury disease, with inability to defecate and abdominal distension indicating stagnation of evil in the bowels. The advanced age, lack of appetite, and poor energy indicate deficiency of Zhengqi. During treatment, it is easier to tonify than to purge, and it is easier to harm the Zhengqi when purging. The prescription uses a small dose of Si Ni Tang to warm and invigorate Yang Qi, adding Ren Shen, Bai Zhu, and Ji Nei Jin to tonify Qi and promote spleen function, while also combining a small dose of Da Cheng Qi Tang to promote bowel movements. After the medication, the bowel Qi descended, the spleen Qi rose, and the recovery of spleen function and appetite is natural. The follow-up prescription uses the “Zhi Zhu Wan” method to strengthen the stomach Qi for recovery.If treated according to the six meridian differentiation, the patient does not present typical symptoms of Shaoyin disease for Si Ni Tang, nor typical symptoms of Yangming disease for Da Cheng Qi Tang. If forced to differentiate as Shaoyin disease, it would be impossible to combine it with Da Cheng Qi Tang. However, starting from the understanding of internal injury diseases, using Si Ni Tang combined with Da Cheng Qi Tang is reasonable and has achieved satisfactory results.Additionally, if treated according to the organ differentiation method, it would generally use Si Jun Zi Tang (四君子汤, Four Gentlemen Decoction), Bu Zhong Yi Qi Tang (补中益气汤, Tonify the Middle and Benefit Qi Decoction), etc., combined with purgative and stagnation-relieving herbs, which would be less effective than classical formulas.
