Constrained heat with acid regurgitation. Warm Gallbladder Decoction (wen dan tang) plus Gardeniae Fructus (zhï zî), Moutan Cortex (mû dän pí), Curcumae Radix (yù jïn), Zingiberis Rhizomatis Succus (jiäng zhï), and dry-fried Coptidis Rhizoma (châo huáng lián).

Commentary:

Warm Gallbladder Decoction (wen dan tang) contains Bambusae Caulis in taeniam (zhú rú), Aurantii Fructus immaturus (zhî shí), Pinelliae Rhizoma preparatum (zhì bàn xià), Citri reticulatae Pericarpium (chén pí), Poria (fú líng), Glycyrrhizae Radix (gän câo), Zingiberis Rhizoma recens (shëng jiäng), and Jujubae Fructus (dà zâo). From Material Medica III　(Ｅａｓｔｌａｎｄ　ｐｒｅｓｓ):

Ginger Juice (薑汁 jïang zhï) – pharmaceutical　name: Zingiberis Rhizomatis Succus:　Ginger juice is acrid and warm, stronger at dispersing and　in settling the Stomach than Zingiberis Rhizoma recens　(shëng jiäng). It is best for alleviating nausea and breaking　up phlegm to reduce coughing. Ginger juice is very commonly　used in herb preparation to increase the anti-nausea　effect, for example, when used to treat Bambusae Caulis　in　taeniam (zhú rú) or Pinelliae Rhizoma (bàn xià).”

Original Chinese: 某 郁热吞酸。温胆汤加山栀丹皮郁金姜汁炒黄连。

Case from: Dr. Liu Du Zhou

This patient was a 10-year-old girl who received a cold Qi in late autumn.  She developed fever and an aversion to cold and had episodes of this many times a day.  This went on for several months.  Her pulse was floating and without strength.  Her tongue body was red and the moss was thin and white.  Her food and drink intake and excretions were normal.  This was a case of wind cold stagnating on the outside chronically without resolution.  The cold had transformed to heat but was a light case.  I gave her two packages of Gui Zhi Er Yue Bi Yi Tang (modified).

Gui Zhi 5g
Bai Shao 5g
Chao Xing Ren 3g
Zhi Gan Cao 3g
Sheng Jiang 3g
Ma Huang 3g
Da Zao 4g
Zhu Ru 3g

There was slight sweating and this brought resolution.

Discussion:

In this case there was fever and an aversion to cold that came in frequent episodes every day.  This indicated unresolved Tai Yang evil.  These external evils have a tendency to enter the interior and transform into heat.  The pulse was floating but without strength.  This is an indication that the cold evil is wanting to journey out to the fleshy exterior.  The original text says, “The pulse is slightly weak and this means an absence of Yang”.  So treatment should not rashly use pungent and warm Ma Huang and Gui Zhi.  One should treat this patient by using Gui Zhi Er Yue Bi Yi Tang with the addition of Zhu Ru to resolve the exterior and clear the interior, generate fluids and nourish moisture.

Commentary:

In regard to the sentence “The pulse is slightly weak and this indicates an absence of Yang”, many scholars think that this means there is Yang depletion.  Because the clause has two parts, they connect the use of Gui Zhi Er Yue Bi Yi Tang to the part that says “fever is greater than cold”.  I do not agree with this.  In this case, the pulse being slightly weak is the opposite of being floating and tight.  This is a pulse that was floating and tight and it changed to be scattered and weak.  The exterior evil, though wanting to leave then has a tendency to enter the interior and transform into heat. This is not the expiring pulse of Yang depletion.  This “absence of Yang” is speaking about the evil wanting to leave the exterior.  This is exactly like that impartial saying “The absence of Yang that stagnates the exterior pattern”.  The evil qi moves into the interior from the exterior and therefore one should not use Ma Huang and Gui Zhi to promote sweating.  One should use Gui Zhi Er Yue Bi Yi Tang to resolve the exterior and clear the interior.

Gui Zhi Er Yue Bi Yi Tang

Gui Zhiu 4g
Sheng Jiang 3g
Bai Shao 3g
Zhi Gan Cao 3g
Ma Huang 3g
Da Zao 4pieces
Shi Gao 3g

This formula is indicated when there is external wind cold and internal stagnant heat.  This formula is differentiated from Xiao Qing Long Tang by the degree of seriousness.  In the Xiao Qing Long Tang pattern, in addition to the cold and heat with fever predominant, there is also lack of sweating, headache, mouth thirst and agitation.  This formula is used when one wants to create a mild sweat while clearing inner heat.

** Translated by: Sharon Weizenbaum

From doctor Huang Dao-fu[1], September 14, 1984:
Ms. Chen was age 17.  Seven days previously she had developed a cold with fever and fear of cold.  The heat was more than the cold.  Everyday she had fever 2-3 times.    Though she had dizziness, there was no vomiting and her two excretions were normal.  She did not sweat easily.  She had itching and an unpleasant body odor that did not go away with bathing.  The school doctor suspected malaria but blood tests were negative for the malaria organism.  She was then diagnosed with an endocrine disorder and treated with oryzanol but there was no improvement.  She then came to see me.  I saw that her tongue was pale with thin white moss and her pulse was minute and weak.  This was a case of long term wind cold damp and Ying and Wei disharmony.  It was appropriate to dispel wind and scatter cold while harmonizing the Ying and the Wei.  I thought to try Zhang Zhong-jing’s method and gave her two packages of Gui Zhi Ma Huang Ge Ban Tang with added flavors. 

Gui Zhi 5g
Bai Shao 3g
Chao Xing Ren 3g
Zhi Gan Cao 3g
Sheng Jiang 2 Slices
Ma Huang 3g
Da Zao 4g
Yi Yi Ren 15g

After one package the patient experienced a physiological sweat and the body itching stopped.  After 2 packages, she noticed that her body felt light and relaxed after bathing and that the unpleasant odor had gone.  After several days there was no recurrence.

Discussion: In terms of unpleasant body odor, Chao Yuan-fang says in the Zhu Bing Yuan Hou Lun (诸病源侯论),

That when the Qi is not harmonized, the fluids become mixed with dirtiness.  This causes unpleasant body odor.” 

In this case, the symptom followed the contraction of a cold.  This was Qi closure in which the remaining evil had not completely left and it mixed with damp turbidity.  This was contained and flowed out the surface with a bad odor.  It is said that,

When the body cannot slightly sweat, there will be body itching”

and therefore one should use pungent warm to resolve the exterior in order to induce a slight sweat with Gui Zhi Ma Huang Ge Ban Tang.  The added Yi Yi Ren increases the formula’s ability to transform and induce the dampness to seep out and makes the formula’s action very quick. 

Translated by: Sharon Weizenbaum

NOTE: For further reading on this case and formula, please see Sharon’s introduction, Guizhi mahuang ge ban tang & guizhi er mahuang yi tang

[1] From the Hu Nan Journal of Traditional Chinese Medicine, 1990 (5) :29

Original Chinese:  体臭 – 黄道富医案；陈某，女，17岁，1989年9月14日初诊。自述7天前曾患“感冒”，发热恶寒．热多寒少，一日二三发，头晕不呕，二便正常；汗出不畅，身痒体臭，浴后不减，校医疑为“疟疾”，建议至某院诊治。血液检验未找到疟原虫，诊断为内分泌功能紊乱．予谷维素等药治疗，症情依然，遂求治于余。证见舌质淡、苔薄白，脉微弱。此届风寒湿久稽，营卫不和。宜祛风散寒，调和营卫。仿张仲景小发汗例，试投桂麻各半汤加味：桂枝5克，白芍3克，麻黄(先煎)3克，杏仁3克，炙甘草3克，生姜2片，薏苡仁15克，2剂，水煎服。
服药1剂，汗出、身痒即止；2剂后自觉身如浴后轻松舒畅，体臭等症随之消失，至今未复发。
(湖南中医杂志1990，(5)：29)
按语：体臭一症，隋·巢元方《谙病源侯论》云：“体气不和，使津液杂秽，故令体臭。”本例发于感冒之后，当为余邪未尽与湿浊之气相搏，蕴蒸外溢作臭。所谓“以其不得小汗出，身必痒。”故采用辛温解表，小发其汗的桂枝麻黄各半汤，更加薏苡仁一味以增强其宣化渗湿之功，故取效甚捷。

3. Twitching of tendons and muscles:

Original case from: Xu Shu-Wei’s Case number 17

A townsperson named Jing made a living in the country village by twisting fibres into rope (”sheng”), and so was known as Jing Sheng Zi — “Roper Jing”.

Her son was almost thirty years old when he became ill, showing a slight sweat, weak pulse, and aversion to wind. The doctor mistakenly gave him Ma Huang Tang to bring on a sweat, and sweat he did — without stop! Fever, chest pain, intense palpitations, unable to sleep at night, and delirium all followed. Soon he did not recognise his mother, and began twitching convulsively, moving and shaking. The doctor then tried heavy sedators and wind extinguishing herbs as treatment.

I saw this and said: “Erroneous forcing of diaphoresis! Zhong-Jing said:

Patients with weak forceless pulse, sweating and aversion to wind cannot be given [Da] Qing Long Tang (Major Blue-Green Dragon Decoction). When they take it the result will be twitching of the tendons and convulsions of the muscles, and coldness of the limbs. “
[Clause 38 (38)]

I continued: “Only Zhen Wu Tang (True Warrior Decoction) can save him. Zhong-Jing says:

Tai Yang illness with sweating that does not stop, and the patient still has fever, palpitations, convulsive twitching that threatens to lift him off the ground: Zhen Wu Tang is the treatment.”
[Clause 82 (84)]

After giving him three doses of the worst was over; as a follow-up Qing Xin Wan (Pill to Clear the Heart) and Zhu Ye Tang (Bamboo Leaf Decoction) was given to relieve any further remaining toxic pathogen. After several days he was cured.

Steve’s comment: The above two cases [see previous Zhu Ling Tang case] are juxtaposed to illustrate Xu’s adroitness in the face of two cases, of exactly similar etiology, with yet differing consequences. Note that while each case suffered insomnia as a result of incorrect diaphoresis, in the second case this was overridden by the severity of the spasming. Each patient, too, varied in constitution and thus treatment necessarily varied.

What impresses me is Xu’s encyclopaedic familiarity with the Shang Han Lun, his appreciation that “These are no idle words!” and his ability to recognise in confusing cases the core symptoms which identify the applicable portion of the classic. Very inspiring! While it is true that we have relatively scant resources for studying the Shang Han Lun in English so far, we should remember that it could not have been easy in Song dynasty China, either.

Translated by Steven Clavey

Tai yin deficiency cold pattern with heat signs
Xu Shu-Wei’s Case

In the beginning, Mr. Cao had cold-damage that lasted for 6-7 days. There was abdominal fullness with vomiting, inability to get food down, a warm body, hot extremities, spontaneous diarrhea, pain in the abdomen, retching, and nausea. The first doctor said there was too much yang, because of the hot extremities. He feared there was an amassment of heat in the stomach leading to vomiting or because there was vomiting and diarrhea this was sudden turmoil disorder. At this point, I (Xu) was asked to give a diagnosis. The pulse was thin and submerged.  One can say that this was a tai yin pattern.

In the disease of the tai yin, there is abdominal fullness and vomiting, inability to get food down, severe spontaneous diarrhea, and periodic spontaneous abdominal pain. Therefore, to bring things to a halt, I gave him Regulate the Middle Pill (li zhong wan) the size, as Zhong Jing said, of  “large chicken egg yolks”. The patient took five or six pills during the day and night. This was followed up for several days by Five-Accumulation Powder (wu ji san) and there was resolution.

Translated by: Jason Blalack

Source: (《伤寒九十论•证二十三》)

Commentary: The “hot extremities” has the meaning of  extremities that are not cold and means “extremities that are spontaneously warm”. This specific sign can be understood that this  pattern has not yet reached the shao yin with yang debilitation and yin exuberance, where there is reversal cold of the four extremities. This is therefore only a pattern of tai yin deficiency cold, where Regulate the Middle Pill (li zhong wan) was used to regulate the yang of the middle burner and the patient was healed. Furthermore, the pulse is a classic Regulate the Middle Pill (li zhong wan) pulse, which would make much less sense with a heat amassment pattern.

Original Chinese: 许叔微医案:曹生初病伤寒，六七日，腹满而吐，食不下，身温，手足热，自利，腹中痛，呕，恶心。医者谓之阳多，尚疑其手足热, 恐热蓄于胃中吐呕，或见吐利而为霍乱，请予诊。其脉细而沉。质之日:太阴证也。太阴之为病，腹满而吐，食不下，自利益甚，时腹自痛。予止以理中丸，用仲景云”如鸡子黄大”。昼夜投五六枚。继以五积散，数日愈。

Dr. Liu Jingqi[1], July 20, 1982

Ms. Sun, age 45 had an aversion to cold and fever and all over her body she developed large round patches of wind rash.  She had had this for over 20 days.  Before the illness, she had been out sweating in the rain and after one day she developed the rash.  Every day she had 5-6 episodes with itching and heart vexation.  She had a calcium injection and oral chlor-trimeton and vitamin C all with no effect.  Her facial complexion was sallow and the skin scratch test was positive and her whole body had round patches though it was most profuse on her chest and thorax area.  Her tongue was pale with thin moss and her pulse was wiry.  This was a presentation of Wind Cold tied up on the exterior though it was inappropriate to drain.  The treatment principle was to use pungent warm to penetrate through to the exterior, dredge wind and stop itching.  I gave her 6 packages of the following formula:

Discussion: According to reports, this formula treats contraction of wind cold with itching, a cold and heat illness or a cold that lasts without resolution in which the evil is light with itching.  For this it is quite effective.

Translated by: Sharon Weizenbaum

NOTE: For further reading on this case and formula, please see Sharon’s introduction, Guizhi mahuang ge ban tang & guizhi er mahuang yi tang

Original Chinese: 五、风隐疹(荨麻疹)
刘景棋医案：孙某某，女，45岁，1982年7月20日初诊。恶寒发热，全身起大片风团已二十余日。发病前曾汗出冒雨，过一日后即发现全身起大片风团，每日发作五六次，痒甚，心烦。曾注射钙剂，口服扑尔敏、维生素丙等无效。面色苍白，皮肤划痕试验阳性全身敲在大片风团，胸部较多。舌淡苔白，脉弦。辨证：风寒束表不得宣泄。治则：辛温透表，疏风止痒。处方：桂枝5克，白芍3克，生姜3克，炙甘草3克，麻黄3克，大枣4个，炒杏仁3克。 服6剂，临床治愈，随访三个月末复发。
(《经方验肘987；13)
按语：据报道，本方治疗感受风寒所致荨麻疹，有寒热表证或日久不愈，邪微而痒者，有良效。

[1] From 经方验, experience with classical formulas, 1987, page 13

Treatment was to regulate the qi,  unlock the yang, moisten the intestines, and unblock the bowels. Frigid Extremities Powder (sì nì sân) with modifications was given:

Bupleuri Radix (chái hú) 12g
Aurantii Fructus immaturus (zhî shí) 9g
Paeoniae Radix alba (bái sháo) 9g
Allii macrostemi Bulbus (xiè bái) 9g
Cannabis Semen (huô má rén) 30g
Glycyrrhizae Radix (gän câo) 3g

Four packets were given whereby the stools were unblocked and normal.

Source: (陕西中医 1993;〈7〉 : 324 )

Translated by: Jason Blalack

Jason’s Commentary:
Since I came across this case years ago I have used this idea and base formula multiple times with success. “Qi constipation” is an ancient disease name that comes about from yang qi constraint and clumping, qi stagnation not outthrusting, and a sluggish Large Intestine. Cold limbs and a wiry pulse are the key signs/symptoms for diagnosing this pattern. In the book, Book to Safeguard Life Arranged According to Pattern (1108), it says, “cold extremities with constipation, urination that is reddish” is a “yang pattern resembling symptoms of yin.”  Use Frigid Extremities Powder (si ni san) to dredge and outthrust the constrained and trapped yang qi and free the qi dynamic.  Allii macrostemi Bulbus (xie bai) is added to aid in unblocking the stool whereas Cannabis Semen (huo ma ren) is added moisten the stool/dryness.

Original Chinese:

安少先医案 : 傅某 ,男 ,28 岁, 1986 年 3 月 10 日 就诊。大便干燥如羊矢, 2~3 日 1 行近 1年, 脘腹胀满疼痛, 两手发凉, 舌红、苔薄黄, 脉弦数。证属气秘, 治宜理气通阳, 润肠通便, 投四逆散加味 :柴胡 12g, 积实、白芍、薤白各 9g, 火麻仁 3Og, 甘草 3g。服 4 剂便通如常。

This is a case from Dr. Wang Zhan[1], January 5, 1976

Ms. Liu, age 26, had a cold for 4-5 days.  She still had a fever, fear of cold and a temperature of 38°C.  She was sweating slightly.  Although she had taken an instant tea for colds and anti-inflammatory analgesics, these had had no effect.  She had body pain, her excretions were normal, her tongue moss was thin and white and her pulse was floating and tight.  I gave her Gui Zhi Ma Huang Ge Ban Tang with added flavors.

Gui Zhi 8 gm
Bai Shao 5 gm
Xing Ren 5 gm
Gan Cao 5 gm
Sheng Jiang 5 gm
Ma Huang 8 gm
Da Zao 4 gm
Fu Ping 9gm

After the herbs, she had a slight sweat and after two more packages the illness was completely resolved.

Discussion: When someone has a cold for several days and it is not a Shao Yang and or Yang Ming presentation and yet there is a fever with an aversion to cold, sweating, a floating tight pulse, it is appropriate to lightly induce sweat using Gui Zhi Ma Huang Ge Ban Tang.

Translated by: Sharon Weizenbaum

[1] 伤寒论临床应用 The Clinical Application of the Shang Han Lun, 1990, pg 24

Original Chinese:

二、表部不解

王占玺医案：刘某，女，26岁，1976年1月5日初诊。感冒已四五日，仍发热恶寒，体温38℃，微汗出，虽经服感冒冲剂及解热镇痛剂不效，身酸 痛，二便正常，苔薄白，脉浮紧。随予桂枝麻黄各半汤加味：桂枝8克，白芍5克，生姜5克 甘草5克，大枣4枚，麻黄8克 杏仁5克,浮萍9克。
药后取微汗，2剂诸证悉平。(《伤寒论临床应用》1990：24)
按语：外感数日，无少阳、阳明见证，仍发热恶寒，汗出，脉浮紧，宜小发汗，与桂麻各半汤愈之。

NOTE: For further reading on this case and formula, please see Sharon’s introduction, Guizhi mahuang ge ban tang & guizhi er mahuang yi tang

Gui Zhi Ma Huang Ge Ban Tang

Gui Zhi (1 liang + 16 zhu) 4 grams
Sheng Jiang (1 liang) 3 grams
Bai Shao (1 liang) 3 grams
Zhi Gan Cao (1 liang) 3 grams
Ma Huang (1 liang) 3 grams
Da Zao 4 dates
Xing Ren (24 pieces) 3 grams

Gui Zhi Er Ma Huang Yi Tang

Gui Zhi (2 liang + 17 zhu) 4 grams
Sheng Jiang (1 liang +6 zhu) 3 grams
Bai Shao (1 liang + 6 zhu) 3 grams
Zhi Gan Cao (1 liang +2 zhu) 3 grams
Ma Huang (6 zhu) 1 grams
Da Zao 5 dates
Xing Ren (6 pieces) 2 grams

Original clauses from the Shan Han Lun

1.Tai Yang disease, for 8 or 9 days, malaria like symptoms, fever and aversion to cold, more fever, less cold, the person does not vomit, urine and stool are normal, episodes occurring 2-3 times each day.  2. Where the pulse is slightly moderate, there will be imminent recovery. 3. Where the pulse is faint with aversion to cold, this is deficiency of both Yin and Yang and one should not further promote sweating, purging or vomiting, 4. Where the complexion is like that of a hot color, there has been no imminent recovery.  This is because the patient cannot raise a mild sweat, the body will be itchy and Gui Zhi Ma Huang Ge Ban Tang is appropriate. (clause 23)”

Having taken Gui Zhi Tang, there is copious sweat; if the pulse is flooding and big, give Gui Zhi Tang as before.  If the disease resembles malaria, occurring again during the day, sweating will resolve it, Gui Zhi Er Ma Huang Yi Tang will resolve it. (clause 25)”

Explanation of Formulas:

Although there are symptoms of illness in this presentation, the cold and heat manifest together and these episodes occur two to three times a day and there is no vomiting.  This means that the illness has not entered the Shao Yang.  Although the heat is more than the cold, there is still clear urine and normal bowels.  This means that the illness has not entered the Yang Ming.  Since there is not a Yang Ming or a Shao Yang pattern, there has been no transmutation.  This means that the illness is still at the Tai Yang and that it has become mild and chronic.  The correct Qi attempts to push the evil out by sweating but the sweating is not effective to resolve the evil.  The result is that the illness becomes chronic and yet one cannot create a big sweat.  Gui Zhi Ma Huang Ge Ban Tang is appropriate because it will create a light sweat.

Gui Zhi Er Ma Huang Yi Tang is similar to the above formula in that it is also for a mild condition.  In order to resolve the muscles, the ingredients only slightly promote sweating.

Clinically, this illness presentation is most often seen in young people and elderly people as well as those who are weakened with chronic illness.  There is no discussion as to whether this is cold damage or wind strike.  What is important is only that this is chronic without resolution, that the presentation is relatively light, and that there is cold and heat like malaria.  For this, one can use the above two formulas.

Case examples:

1. A light presentation with stasis on the exterior
2. Unresolved stasis on the exterior
3. Urticaria
4. Unpleasant Body Oder 

This is a case from Dr. Yu Zhangrong[1], April 10, 1963

Mr. Li, age 49: Chills and fever.  After sweating from the fever his body would become cold.  This happened once a day and had continued for three days.  He also had headache, leg pain, and back pain, cough with slight amount of phlegm, poor appetite and normal excretions.  His pulse was floating and tight and his tongue moss was thick white and slippery.  For treatment it was appropriate to use pungent and warm to lightly resolve the exterior.  I used Gui Zhi Er Ma Huang Yi Tang.

After he took the herbs the fever and chills cleared and the other symptoms lessened.  He developed palpitations and shortness of breath and soreness in his back that responded favorably to pressure.  His bowels were normal.  His pulse had become wiry and moderate.  The outside evil was resolving and the insufficiency of the moistening blood and qi stasis were now apparent.  I gave him 1 package of Xiao Jian Zhong Tang and these symptoms quieted down.

Discussion: In this case the patient suffered from a daily episode of chills and fever, headache and limb pain.  This had gone on for three days and yet because there was no agitation or desire to vomit, his bowels were normal and he had no chest or rib-side fullness, this was not a Shao Yang pattern.  Additionally, because his excretions were normal so this was also not a Yang Ming pattern.  This was a weak evil in Tai Yang.  The floating and tight pulse was an indication to use Ma Huang to induce sweat yet the deficiency contraindicates the promotion of sweat.  It was inappropriate to use as strong diaphoretic formula and so I used Gui Zhi Er Ma Huang Yi Tang to lightly induce sweating and drain off and benefit the Lung Qi.

Translated by: Sharon Weizenbaum

NOTE: For further reading on this case and formula, please see Sharon’s introduction, Guizhi mahuang ge ban tang & guizhi er mahuang yi tang

 Original Chinese: 一、表部轻证

俞长荣医案：李某，男，49岁，1963年4月10日就诊。恶寒战栗，发热，热后汗出身凉，日发一次，连续三日。伴见头痛，肢楚，腰疼，咳嗽痰少，食欲不振，二便自调。脉浮紧，舌苔白厚而滑。治宜辛温解表轻剂，与桂枝二麻黄一汤。处方：桂枝9克，白芍9克，杏仁6克，炙甘草6克，生姜6克，麻黄4.5克，大枣3枚。服药后，寒热已除，诺症悉减。现惟心悸少气，昨起腹中微痛而喜按。大便正常，脉转弦缓。此因外邪初解，荣血不足，气滞使然，遂与小建中汤，1剂而安。、    (《伤寒论汇要分析b1964：70一71)
按语：恶寒发热，头痛肢楚，日发一次，连续三日，但无心烦喜呕，胸胁苦满，知未入少阳；又二便自调，知未传阳明。邪在太阳之表，其脉浮紧，本当麻黄取汗，但虑已出汗，不便峻剂发表，故取桂二麻一汤以小发其汗，宣利肺气。

[1] From the 伤寒论汇要分析， Shang Han Lun Hui Yao Fen Xi, 1964, pg 70-71