A Case Study on the Use of Si Ni Decoction for Exogenous Diseases

Chinese Medicine Book ClubIssue 3596

Daily updates to accompany the growth of TCM practitioners

IIntroduction: The use of Si Ni Decoction (四逆汤) for treating exogenous diseases is not a common practice, but it can be seen in the Shang Han Lun (《伤寒论》) in articles 29 and 92, where the diseases treated indeed resemble exogenous symptoms. If this case did not use Si Ni Decoction and instead used a different formula, what do you think could be used?—This article is approximately1700words, expected reading time5minutes—

Reflections on the Use of Si Ni Decoction for Exogenous Diseases by Master Zhang YingdongAuthor/Liu Ning

Recently, Master Zhang Yingdong used Si Ni Decoction to treat my exogenous disease, achieving rapid results. The analysis is as follows.

Case Report

Liu, female, 26 years old, student.The patient caught a cold after exposure to wind on February 25, 2023, presenting with symptoms ofchills, fatigue, significant sweating,nausea, accompanied by cough, white phlegm, wheezing; nasal congestion with clear discharge; dizziness and heaviness in the head; heat in the upper body, cold in the lower limbs.On February 26, 2023, the initial diagnosis showed that the symptoms from yesterday had worsened.The patient usually has frequent urination, sweats easily, is sensitive to cold, prefers warmth, dislikes winter, with a pale tongue and tooth marks.After pulse diagnosis by Professor Zhang and several students, they all agreed thatthe pulse was significantly deep, and it was not suitable to simply release the exterior. The treatment was to warm the middle and disperse cold, prescribing Si Ni Decoction:Fu Zi (Aconite) 15g, Gan Jiang (Dried Ginger) 15g, Sheng Gan Cao (Raw Licorice) 15g. The Chinese medicine was prepared as granules, 2 doses totaling 4 bags, instructed to take 3 times a day, 1 bag each time, aiming for the goal of feeling warm without sweating.After taking the first bag of Si Ni Decoction, the wheezing disappeared within half an hour, cough and phlegm, nasal congestion and clear discharge were alleviated, with no sweating, but the coldness in the lower limbs worsened.After 6 hours, the lower limbs felt cold, and the alternating cold and heat continued for half an hour, then a sudden warmth sensation moved down the calves, and there was even sweating, after which the lower limbs warmed up, and the symptoms of heat in the upper body and cold in the lower limbs disappeared. After taking the third bag, the nasal congestion disappeared, and the cough, phlegm, and runny nose were significantly reduced.On February 27, 2023, the second diagnosis.The original prescription of Si Ni Decoction remained unchanged, and 3 more doses (6 bags) were prescribed. The patient was instructed to use the “rest method” for taking medicine, aiming for a “slight warmth throughout the body”: take 1 bag in the morning, 2 bags at noon, and 3 bags in the evening.(“Rest method” for taking medicine: ① Set a target, ② If the target is not reached and there are no discomforts, increase the dose by one bag each time, ③ Once the target is reached, maintain that dosage and continue taking.)That evening, after taking 3 bags, the patient felt a slight warmth throughout the body, achieving the expected goal.On March 1, 2023, the third diagnosis. After waking up, the patient felt that all symptoms had disappeared. The teacher followed the principle from the Nei Jing (《内经》):“For major toxins, treat the disease, ten parts remove six; for common toxins, ten parts remove seven; for minor toxins, ten parts remove eight; for non-toxic treatments, ten parts remove nine; grains, meat, fruits, and vegetables, nourish completely.”(from Suwen: Discussion on the Five Constant Regulations), and instructed to stop the medication, waiting for the recovery of the qi.

Analysis

1. A deep pulse cannot be diagnosed as a Tai Yang disease

This case was the author’s own illness, and after discussion and analysis with the teacher and senior students, medication was decided. After inquiring about the medical history, the teacher pointed out: First,

“In Tai Yang disease,the pulse is floating, with stiffness and pain in the head and neck, and aversion to cold.”

The pulse pattern for Tai Yang disease should be “floating,” while my pulse was deep, which did not match the typical pulse pattern for Tai Yang disease.

2. Using exterior-releasing methods for interior deficiency can easily lead to transformation of the disease

Secondly, Gui Zhi Decoction is a representative formula for releasing the exterior. Articles 91, 164, and 372 of the Shang Han Lun all support the use of Gui Zhi Decoction for releasing the exterior.

However, considering my usual frequent urination, easy sweating, sensitivity to cold, preference for warmth, pale tongue, and tooth marks, these are clear symptoms of interior deficiency and cold.

As stated in Article 29 of the Shang Han Lun:

“In cases of cold damage with a floating pulse, spontaneous sweating, frequent urination, irritability, slight aversion to cold, and cramping of the feet, if Gui Zhi Decoction is taken, it will lead to cold limbs, dry throat, irritability, and nausea. In such cases, use Gan Cao and Gan Jiang Decoction to restore Yang… If excessive sweating occurs, Si Ni Decoction is the main treatment.”

The text indicates that if there are symptoms of interior deficiency and cold, Gui Zhi Decoction and similar exterior-releasing formulas should not be used.

Previously, my understanding of similar symptoms was limited to Tai Yang disease, neglecting the pulse pattern indications, and I usually treated with scallion white decoction, Huo Xiang Zheng Qi Water, Tong Xuan Li Fei Wan, and other exterior-releasing medications. However, symptoms would often only gradually improve after about two weeks of medication, leaving lingering cough and phlegm for months, making recovery difficult, and sweating would increase with treatment. This sufficiently illustrates thatinterior deficiency combined with exogenous symptoms, using only exterior-releasing methods is ineffective and can easily lead to transformation of the disease.

3. When rescuing the interior, one must restore Yang, use Si Ni Decoction

“If excessive sweating occurs, Si Ni Decoction is the main treatment.”

“For diseases with fever and headache, if the pulse is deep and not floating, and the body aches, one must rescue the interior, using Si Ni Decoction.”

These two articles provide the best explanation for this case. As Huang Yuan Yu stated in Shang Han Xuan Jie::

“Fever and headache are exterior symptoms, and the pulse should be floating. If the pulse is deep, it indicates that it has already entered the Tai Yin organ. If the pulse is deep and not floating, even if there is body pain, the exterior symptoms have not resolved, but one must first warm the interior, thus Si Ni Decoction is appropriate, with Gan Cao nourishing the earth, Gan Jiang warming the interior, and Fu Zi warming the lower.”

Therefore, when the body is affected by external pathogens, the sufficiency of internal Yang Qi cannot be overlooked,“one must rescue the interior and restore Yang.”If one disperses the pathogens at the cost of excessive Qi consumption, even if symptoms are alleviated temporarily, the disease will become increasingly difficult to treat.

Conclusion

Many colleagues believe that Si Ni Decoction can only treat critical conditions such as “cold limbs,” and rarely consider it for exogenous diseases. However, through my actual experience with the medication and prognosis observation, it is clear that: interior deficiency should not be treated with exterior-releasing methods; one must first replenish what is lacking. The approach of using Si Ni Decoction for treating interior deficiency and cold combined with exogenous symptoms is indeed worthy of consideration, as it emphasizes“one must rescue the interior and restore Yang.”

Learning classical formulas must return to the theoretical framework of the classics to be meaningful; one cannot reduce the study of classical formulas to scattered and superficial experiences. It is essential to draw from various sources while also returning to the classical formulas themselves, exploring the theoretical framework of classical formulas to truly use them correctly and effectively.

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