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Source｜China Traditional Chinese Medicine News
Written by｜Henan Provincial Hospital of Traditional Chinese Medicine Mao Dexi
• Zhao Xiw believes that the application of classical formulas requires a clear understanding of the relationship between disease differentiation and syndrome differentiation. The disease is the essence, the body; the syndrome is the superficial, the manifestation. The disease does not change, but the syndrome often changes; the disease is fixed, but the syndrome is not fixed, hence syndrome differentiation cannot be separated from the essence of the disease.
• The so-called syndrome differentiation and treatment means first identifying the disease, then differentiating its exterior, interior, cold, heat, deficiency, and excess, and then applying treatment. Its essence is to clearly distinguish the different causes of the disease, and then treat the same disease differently, or treat different diseases similarly, with the medicine changing according to the syndrome.
Zhao Xiw (1902—1980), from Xiayi County, Henan, served as the vice president of the China Academy of Traditional Chinese Medicine (now the China Academy of Chinese Medical Sciences) and has profound research on “Shang Han Lun” and “Jin Gui Yao Lue”. The book “Zhao Xiw’s Medical Experience”, compiled by the Xiyuan Hospital of the China Academy of Traditional Chinese Medicine, reflects Zhao Xiw’s understanding and experience of classical formulas.
Zhao Xiw believes that the application of classical formulas requires a clear understanding of the relationship between disease differentiation and syndrome differentiation. The “Shang Han Lun” lists “differentiating certain diseases and pulse syndromes and their treatment”; what is the relationship between disease and syndrome here? Zhao Xiw states: “The disease is the essence, the body; the syndrome is the superficial, the manifestation. The disease does not change, but the syndrome often changes. The disease is fixed, but the syndrome is not fixed. Hence, syndrome differentiation cannot be separated from the essence of the disease.” (“Zhao Xiw’s Medical Experience”) The so-called syndrome differentiation and treatment means first identifying the disease, then differentiating its exterior, interior, cold, heat, deficiency, and excess, and then applying treatment. Its essence is to clearly distinguish the ‘different causes of the disease’, and then ‘treat the same disease differently’, ‘treat different diseases similarly’, and ‘the medicine changes according to the syndrome’.” (“Zhao Xiw’s Medical Experience”) Although the symptoms are different, the treatment method is the same, which is called treating different diseases similarly; although the diseases are the same, the treatment methods are different, which is called treating the same disease differently.
Zhao Xiw points out, “Doctors must grasp principles while also being flexible to be able to differentiate syndromes and treat accordingly.” (“Zhao Xiw’s Medical Experience”) The so-called principle refers to the relative stability of the essence of the disease; while flexibility refers to the changing nature of the syndrome. “Observing the pulse and symptoms, knowing what is being violated, and treating according to the syndrome.” (“Shang Han Lun”) This is the guiding principle of syndrome differentiation and treatment.
Now, Zhao Xiw’s experience in treating heart disease with classical formulas is described below for the readers.
Clinical Experience
Coronary Heart Disease
For coronary heart disease, Zhao Xiw emphasizes the relationship between the heart, blood vessels, and stomach. The stomach governs the intake of grains, and the spleen governs transportation and transformation. The two work together to divide the essence of food and water into three pathways, which are Ying (Nutrient), Wei (Defensive), and Zong Qi (Ancestral Qi). Zong Qi accumulates in the chest, while Ying and Wei circulate in the vessels, and the heart resides in the vessels, hence the heartbeat and lung respiration. The “Suwen: Ping Ren Qi Xiang Lun” states: “The great collateral of the stomach is called Xu Li, which connects the diaphragm and lung, and emerges below the left breast; its movement corresponds to clothing, which is the pulse of Zong Qi.” The area below the left breast is precisely where the heart apex beats, thus the heart and stomach are closely related. Therefore, Zhao Xiw believes that the diagnosis and treatment of coronary heart disease should adopt a holistic view and not be limited to the heart while neglecting its relationship with other organs.
Zhao Xiw emphasizes the characteristics of coronary heart disease being “deficiency leading to excess” and “excess leading to deficiency”. The treatment principle is “to focus on tonifying, to tonify for unblocking, to unblock for tonifying, and to apply both tonifying and unblocking; to apply tonifying methods without causing stagnation, and to apply unblocking methods without harming the righteous Qi.” (“Zhao Xiw’s Medical Experience”) Based on this, six treatment methods for coronary heart disease are proposed.
Dispersing Phlegm and Unblocking Yang Method Use Guo Lou Xie Bai Ban Xia Tang (Trichosanthes, Allium, and Pinellia Decoction) as the main formula. Guo Lou disperses phlegm to unblock Yang, Xie Bai unblocks Yang to disperse phlegm, and Ban Xia harmonizes the stomach to descend counterflow. For chest and rib fullness and cold limbs, Zhi Shi Xie Bai Gui Zhi Tang (Bitter Orange, Allium, and Cinnamon Decoction) should be used; if there is also organ restlessness and lily disease, add Bai He Zhi Mu Tang (Lily and Anemarrhena Decoction) and Gan Mai Da Zao Tang (Licorice, Wheat, and Jujube Decoction).
Heart and Stomach Concurrent Treatment Method For chest obstruction with Qi stagnation and excess syndrome, use Ju Zhi Jiang Tang (Tangerine Peel, Bitter Orange, and Ginger Decoction) as the main formula; for deficiency syndrome, use Ren Shen Tang (Ginseng Decoction) as the main formula. If the disease also affects the lungs without gastrointestinal symptoms, treat with Fu Ling Xing Ren Gan Cao Tang (Poria, Apricot Kernel, and Licorice Decoction); for chest obstruction with post-meal abdominal distension, use Hou Po Sheng Jiang Ban Xia Gan Cao Ren Shen Tang (Magnolia Bark, Ginger, Pinellia, Licorice, and Ginseng Decoction) as the main formula; for diarrhea and vomiting, treat with Wu Zhu Yu Tang (Evodia Decoction).
Tonifying Qi and Nourishing Blood Method Commonly used is Dang Gui Bu Xue Tang (Angelica Blood-Tonifying Decoction), but if the pulse is intermittent, short of breath, and rapid, then Dang Gui Shao Yao San (Angelica and Peony Powder) is more appropriate; if there is a knotty pulse and palpitations, increase the dosage of Zhi Gan Cao Tang (Honey-Fried Licorice Decoction); for liver and kidney Yin deficiency type hypertension (or coronary heart disease), commonly use Qi Ju Di Huang Tang (Lycium and Chrysanthemum Decoction) with modifications.
Supporting Yang and Suppressing Yin Method For chest obstruction that is sometimes slow and sometimes rapid, use Yi Yi Fu Zi San (Coix and Aconite Powder) as appropriate, with Fu Zi supporting Yang and Yi Yi Ren alleviating urgency; for cold extremities, weak pulse, and diarrhea, increase the dosage of Si Ni Tang (Frigid Extremities Decoction); if cold is severe, add Xi Xin (Asarum) and Gui Zhi (Cinnamon Twig).
Activating Blood and Promoting Water Method Use Zhen Wu Tang (True Warrior Decoction) as the main formula, with blood stasis and edema adding Dang Gui Shao Yao San; if there is pulmonary blood stasis or liver enlargement, add Shen Su Yin (Ginseng and Sugi Decoction); if there is a knotty pulse, palpitations, and concurrent Yang deficiency edema, then use Guo Lou Xie Bai Ban Xia Tang and Zhen Wu Tang combined, adding blood-activating herbs.
Nourishing Kidney and Strengthening Tendons Method For chest obstruction with low back and knee soreness and weak pulse, use Guo Lou Xie Bai Ban Xia Tang with Shen Qi Wan (Kidney Qi Pill) for treatment, and may also add Lu Jiao Jiao (Deer Antler Glue), Ba JI Tian (Morinda Root), Yin Yang Huo (Epimedium), Dang Shen (Codonopsis), and Mai Dong (Ophiopogon); if there is a knotty pulse and palpitations (or atrial fibrillation), increase Zhi Gan Cao Tang; for insomnia, add Suan Zao Ren Tang (Sour Jujube Decoction).
Pulmonary Heart Disease
Zhao Xiw believes that pulmonary heart disease is “primarily due to kidney Yang deficiency, with phlegm and fluid retention as the secondary manifestation, leading to lung Qi obstruction. The treatment principle should clarify the primary and secondary, addressing both the root and the branch.” (“Zhao Xiw’s Medical Experience”) The book records Zhao Xiw’s complete experience in treating chronic pulmonary heart disease, primarily using Chinese medicine, with Western medicine added as necessary.
1. When lung Qi is obstructed and there are exterior symptoms, use Xiao Qing Long Tang (Minor Blue Dragon Decoction) to dispel cold and scatter evil; if there are heat symptoms, combine Xiao Qing Long Tang with Ma Xing Shi Gan Tang (Ephedra, Apricot Kernel, and Gypsum Decoction).
2. If kidney Yang deficiency is the main issue, with significant chest tightness and shortness of breath, and lower limb edema, the treatment should warm Yang, disperse lung Qi, and promote water, using Zhen Wu Tang combined with Yue Bi Tang (Yue Bi Decoction) with modifications; if edema is severe, use Xiao Shui Sheng Yu Tang (Chen Xiuyuan’s “Shifang Miaoyong”), which is Gui Zhi Tang combined with Ma Huang, Fu Zi, and Xi Xin, plus Zhi Mu.
3. If there is kidney Yang deficiency with insufficient heart and lung Qi and Yin, on the basis of warming Yang and transforming water, add Qi-invigorating and fluid-generating herbs, such as Zhen Wu Tang combined with Sheng Mai Yin (Generate Pulse Decoction); if edema is severe, add Che Qian Zi (Plantago Seed) 30g (wrapped for decoction), Bai Mao Gen (Imperata) 30g, or add blood-activating herbs to assist diuresis, such as Ou Jie (Lotus Rhizome), Su Mu (Sugi), and Tao Ren (Peach Kernel).
4. If there is a water-hen sound in the throat, with dry rales on auscultation, use She Gan Ma Huang Tang (Belamcanda and Ephedra Decoction). If there is mixed phlegm, with mixed rales on auscultation, use Hou Po Ma Huang Tang (Magnolia Bark and Ephedra Decoction). If there is foamy phlegm and rapid pulse with palpitations, then use Ma Xing Shi Gan Tang combined with Guo Lou Xie Bai Ban Xia Tang and Sheng Mai Yin.
Heart Failure
Zhao Xiw proposes three methods for treating water based on the “Suwen: Tang Ye Lao Li Lun”, namely opening the ghost gate, cleansing the residence, and removing the residual Chen Zhi, using Zhen Wu Tang as the main formula. This treatment is effective for congestive heart failure. Zhen Wu Tang is a heart-strengthening, Yang-warming, and water-controlling formula, clinically based on the pulmonary congestion, liver enlargement, and edema that appear in heart failure, respectively paired with the three methods of opening the ghost gate, cleansing the residence, and removing the residual Chen Zhi. The opening the ghost gate method disperses lung Qi and clears the exterior, allowing the Ying and Wei to harmonize. It is used for heart failure with exterior symptoms, treated primarily with Zhen Wu Tang, combined with Yue Bi Tang to disperse wind and clear the exterior, and to disperse lung Qi and promote water; for lung heat, combine with Ma Xing Shi Gan Tang for a pungent and cool dispersal, clearing the lung and calming wheezing. The cleansing the residence method refers to promoting water and diuresis, indicated for heart failure with significant edema, treated primarily with Zhen Wu Tang, combined with Wu Ling San (Five-Ingredient Powder with Poria) plus Che Qian Zi 15g (wrapped for decoction), Chen Xiang and Rou Gui each 9g, to transform Qi and promote water, acting on the kidneys. The removing the residual Chen Zhi method refers to dispersing masses and unblocking collaterals, acting on the vessels, addressing heart failure with significant blood stasis, treated primarily with Zhen Wu Tang, combined with Tao Hong Si Wu Tang (Peach Blossom and Four Substance Decoction) minus Sheng Di, adding Ou Jie and Su Mu to promote blood circulation and disperse water.
Heart failure often presents with arrhythmias, and Zhao Xiw advocates the use of Zhi Gan Cao Tang, Gui Zhi Gan Cao Long Gu Mu Li Tang, and Fu Ling Gan Cao Tang. The specific usage is: for Yin deficiency, use Zhi Gan Cao Tang combined with Sheng Mai Yin; for water Qi obstructing the heart and restlessness, use Gui Zhi Gan Cao Long Gu Mu Li Tang; for severe Yang deficiency, heavily use Zhen Wu Tang.
Myocarditis
Zhao Xiw points out based on years of clinical practice that myocarditis is a complication or sequela of warm diseases. When there are exterior symptoms with pathogenic warm diseases, or when the evil is strong and damages the body, or in the later stages of the disease with residual evil remaining in the body, it is caused by blood circulation damaging the myocardium (“Zhao Xiw’s Medical Experience”).
In diagnosing and treating myocarditis, it is essential to distinguish whether the toxic evil injures Yin or Yang, whether the evil is strong or the righteous Qi is deficient, so as to determine the treatment principles, either supporting the righteous Qi primarily while assisting in expelling the evil, or expelling the evil primarily while assisting in supporting the righteous Qi.
In the early stage, it is necessary to disperse and detoxify, nourish Yin and clear heat. For dispersing and detoxifying, use Zhu Ye Shi Gao Tang (Bamboo Leaf and Gypsum Decoction) with modifications, adding Ge Gen 18g, Lian Qiao 15g, Sheng Di Huang 30g, Zi Hua Di Ding 12g, Pu Gong Ying 30g, and Jin Yin Hua 15g. For nourishing Yin and clearing heat, use Sheng Mai Yin combined with Yi Guan Jian (Linking Decoction).
In the middle or later stages, if heart failure symptoms appear, use the method of supporting the righteous Qi and expelling the evil, with Si Jun Zi Tang (Four Gentlemen Decoction) with modifications. If there are tangible factors such as water, blood, stasis, or food affecting the condition, use the method of activating blood and promoting water, taking Dang Gui Shao Yao San and Guo Lou Xie Bai Decoction to treat.
If there is a low fever that does not subside, accompanied by unrelenting chills, use Chai Hu Gui Zhi Tang (Bupleurum and Cinnamon Decoction) to harmonize Ying and Wei. Harmonizing Ying and Wei is a major method for adjusting body temperature, using Gui Zhi Tang to assist Yang and nourish Yin, and Xiao Chai Hu Tang to harmonize the exterior and interior. Especially Xiao Chai Hu Tang can open the upper burner, allowing fluids to descend, harmonizing stomach Qi, and causing heat to retreat and tranquility to ensue.
Myocarditis can be divided into viral myocarditis and rheumatic myocarditis. The former often shows symptoms in the throat, and treatment should first clear the primary disease; the latter often presents with arthritis symptoms, and treatment should also use the Dispersing Phlegm Decoction (“Wen Bing Tiao Bian”), which is effective for arrhythmias.
Sick Sinus Syndrome
Zhao Xiw discusses in “Brief Discussion on Slow Pulse” that the slow pulse syndrome is similar to sick sinus syndrome. This type of slow pulse is neither due to cold, nor phlegm, nor masses, nor Yangming slow pulse with diarrhea, nor is there diarrhea or cold extremities, but is related to the five organs. The pulse of a person “originates from the kidneys”, “is generated in the stomach”, “is governed by the heart”, “meets in the lungs”, and “is regulated by the liver” (“Zhao Xiw’s Medical Experience”). The treatment method for palpitations and knotty pulse is to use Zhi Gan Cao Tang; for cold extremities, diarrhea, and weak pulse, use Si Ni Tang; if the patient also has impotence, use Shen Qi Wan combined with Zhi Gan Cao Tang. The Zhi Gan Cao Tang and Si Ni Tang must heavily use Gan Cao to utilize the Qi of the middle burner to assist in unblocking.
Typical Medical Cases
Pulmonary Heart Disease Case
A 48-year-old female patient has suffered from chronic cough for 8 years, presenting with significant signs of pulmonary heart disease (shortness of breath, cyanosis of lips, distended neck veins, enlarged left heart border, fine moist rales in both lungs, and a grade II blowing systolic murmur at the mitral valve, with severe lower limb edema). The TCM diagnosis is kidney Yang deficiency, with internal retention of water and phlegm obstructing, leading to lung Qi obstruction. The treatment should clear and disperse lung metal, descend Qi and transform phlegm, warm Yang and promote water. The prescription is a combination of Yue Bi Tang and Zhen Wu Tang with modifications: Sheng Shi Gao 12g, Ma Huang 3g, Gan Cao 9g, Fu Ling 12g, Bai Zhu 9g, Bai Shao 9g, Fu Zi 6g, Sheng Jiang 9g, Da Zao 5 pieces (split), Che Qian Zi 15g, Bai Mao Gen 30g, Xing Ren 9g. After taking 3 doses, urine output significantly increased, and lower limb edema markedly decreased; after 5 doses, liver enlargement receded, and cough lessened. Subsequently, treatment with Hou Po Ma Huang Tang with modifications led to significant improvement and stabilization of the condition. (“Zhao Xiw’s Medical Experience”)
Heart Failure Case
A 24-year-old male patient has experienced palpitations and shortness of breath for 3 years, worsening in the last 7 months. In 1960, he was diagnosed with rheumatic heart disease and had not received treatment, leading to gradual worsening with palpitations, shortness of breath, abdominal distension, and lower limb edema. Physical examination revealed cyanosis of lips, jaundice of sclera, conjunctival congestion, distended neck veins, enlarged heart borders, and a grade III blowing systolic murmur and grade IV rumbling diastolic murmur in the apex area. The heart rhythm was irregular with premature beats, and the heart rate was 69 beats/min. After ECG and X-ray examinations, he was diagnosed with rheumatic heart disease, mitral stenosis with insufficiency, atrial fibrillation, hepatic cirrhosis, and grade II heart failure. The TCM diagnosis is kidney Yang deficiency with blood stasis. Therefore, Zhen Wu Tang combined with the removing residual Chen Zhi method was used for treatment. The prescription included Fu Zi 9g, Hang Shao 30g, Bai Zhu 15g, Fu Ling 18g, Sheng Jiang 9g, Rou Gui 6g (added later), Chen Xiang 6g (added later), Dang Gui 12g, Hong Hua 12g, Bai Mao Gen 30g, and Ou Jie 10 pieces.
After taking 5 doses of Chinese medicine (without Western medicine), symptoms improved, urine output increased, and liver hardness softened. The heart rate occasionally increased. Heart failure significantly improved. Later, due to a shortage of Fu Zi, the condition fluctuated. After continuing with the original formula, the condition gradually improved. Heart failure was controlled, and the ECG indicated atrial fibrillation. The patient was discharged and continued treatment. (“Zhao Xiw’s Medical Experience”)
Myocarditis Case
A 37-year-old female patient experienced chest tightness and slight pain after a cold, with a heart rate of 110 beats/min and frequent premature contractions, indicating late-stage myocarditis. The pulse was deep, slow, and weak, with three movements and one arrival showing significant signs. The first dose was Gui Zhi Jia Shao Yao Tang combined with Dang Gui Shao Yao San and Pu Gong Ying, to activate Yang, invigorate blood, promote water, harmonize Ying and Wei, and clear heat and detoxify. The prescription included Fu Ling 12g, Bai Zhu 9g, Ze Xie 18g, Dang Gui 9g, Bai Shao 15g, Chuan Xiong 9g, Pu Gong Ying 30g, Gan Cao 9g, Gui Zhi 9g, Sheng Jiang 9g, and Da Zao 7 pieces. 10 doses were given.
Second diagnosis: After taking the medicine, various symptoms slightly reduced; the previous prescription was modified by removing Gui Zhi, ginger, and dates, adding Guo Lou Xie Bai Tang and Dang Shen 30g. After taking 10 more doses, the condition significantly improved. Continuing with the second diagnosis prescription for another 10 doses led to the resolution of symptoms and recovery from the disease. (“Zhao Xiw’s Medical Experience”)
“Pulse Not Present” Case
A 65-year-old male patient was confirmed by ECG to have insufficient coronary blood supply and atrial fibrillation. The TCM diagnosis was based on fear of cold, palpitations, and absent pulse at the wrist, with a tongue without thick coating, indicating Qi damage and Yang deficiency. Therefore, the treatment was based on Li Zhong Tang (Regulating the Middle Decoction). The prescription included Hong Shen and Bai Zhu each 15g, Gan Jiang and Zhi Gan Cao each 10g, and Huang Qi 45g. After one week of medication, the patient felt stable, palpitations lessened, and he could climb three flights of stairs without shortness of breath, with improved fear of cold. Due to slight abdominal distension, the previous prescription was modified by adding Chen Pi and Zhi Ke each 15g, and after taking for 2 weeks, the pulse was harmonious, and the inch, guan, and chi were even. Re-examination of the ECG showed significant improvement in chronic coronary blood supply insufficiency (secondary ST-T changes disappeared), and atrial fibrillation lasting 4 months surprisingly converted to sinus rhythm. (“Zhao Xiw on Supporting Yang and Suppressing Yin”, from “Chinese Medicine Journal”, 1980, Issue 8, pages 15-18, by Yu Tianxing et al.)
Hypertension and Coronary Heart Disease Case
A 67-year-old male patient suddenly fainted during dinner, with cold hands and sweating. After regaining consciousness, he went to a hospital where his blood pressure was 220/140 mmHg, diagnosed with hypertension and coronary heart disease. After using Western medicine, blood pressure decreased but remained unstable. He often experienced headaches and chest tightness, with right back pain occurring around 3 AM, feeling as if Qi was rising. The tongue was dark red with a white coating, and the pulse was wiry, thin, and rapid. Blood pressure was 210/105 mmHg. The diagnosis was liver Yang headache combined with chest obstruction. The treatment should nourish the kidneys, soften the liver, clear heat, and subdue Yang, combined with dispersing phlegm and opening the chest, dispersing masses and unblocking Yang. The prescription used Qi Ju Di Huang Tang combined with Zhen Gan Xi Feng Tang, Guo Lou Xie Bai Ban Xia Tang with modifications: Sheng Di 24g, Gou Qi 18g, Ju Hua 18g, Cao Jue Ming 30g, Huai Niu Xi 12g, Sheng Long Gu 24g, Mu Li 24g, Dai Zhe Shi 18g, whole Guo Lou 30g, Xie Bai 15g, Zhi Ban Xia 15g, and Xiang Fu 12g, Zhi Ke 12g. After taking 12 doses, blood pressure dropped to 180/100 mmHg, headaches lessened, and chest tightness and back pain disappeared. The previous prescription was modified by adding Mu Dan Pi 12g, and after taking 6 more doses, blood pressure returned to normal, and headaches disappeared.
(“Zhao Xiw’s Use of Nourishing Yin Method in Three Cases”, from “Chinese Medicine Journal”, 1988, Issue 8, by Wei Qingxing)
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