The Way of Medicine 醫道

或謂腎氣丸為補水之劑，以熟地大補精血故也。不知精血足則真陽自生，況山藥茱萸，皆能濇精固氣，氣者火也。水中之火，乃為真陽，此劑水火兼補，不寒不燥，至平淡，至神奇也。或曰腎氣丸實補肝藥也。腎為肝母，子虛則補母之義，古云：肝腎之病，同一治也。

Some people say Shènqì Wán is the prescription to tonify water, this is because shúdì is used in order to greatly tonify the jīng/essence and blood. But they are ignorant that if jīng and blood are sufficient then true yáng will naturally be generated, moreover shānyào and [shan] zhūyú, both have the function of astringing the jīng and securing the qì, the qì, this is fire. Fire within water, this is called true yáng, and this prescription tonifies both water and fire, it is neither cold nor drying, though it appears ordinary, its [effects] are miraculous. Some people say Shènqì Wán is actually a formula for tonify the liver. The kidney is the mother of the liver, this is the significance of if the child is deficient then tonify the mother. The ancients said: for disease of liver and kidney, use one treatment to treat [both]. (My note, this is a continuation of the theory that kidney and liver have the same source).

昂按：腎氣丸熟地溫而丹皮涼，山藥濇而茯苓滲，山茱收而澤瀉瀉，補腎而兼補脾，有補而必有瀉，相和相濟，以成平補之功，乃平淡之神奇，所以為古今不易之良方也。即有加減，不過一二味，極三四味而止，今人多揀本草補藥，任意加入，有補無瀉，且客倍於主，責成不專，而六味之功反退處於虛位，失製方之本旨矣。此後世庸師之誤也。

[Wang] Áng explains: Shúdì in Shènqì Wán warms and dānpí cools, shānyào astringes and fúlíng percolates, shānzhū constrains and zéxiè drains. [The formula] tonifies the kidney and additionally tonifies the spleen, for tonification there must be draining, mutually harmonising and mutually beneficial, to construct a formula] that is balanced and tonifiying, this is the miraculous [effect] of common [formula], therefore, this is an effective formula that has remained unchanged throughout history. In regards to modifying, do not exceed one or two herbs, at most three or four herbs and then stop. People now days select excessive amount of tonifiying herbs from the Běncǎo, arbitrability modify [the formula], add tonifying but ignore draining [herbs], causing guests [auxiliary herbs] to overshadow the primary [herbs], the intended task [of the formula] becomes unfocused [in its effect], causing the function of Liùwèi to be decreased to a lower position, losing the original intent in the design of this formula. These are the errors of later generations of mediocre physicians.

李士材曰：用此方者，有四失，地黃非懷慶則力薄，蒸曬非九次則不熟，或疑地黃之滯而減之，則君主弱，或惡澤瀉之瀉而減之，則使力薄，故歸咎於藥之無功，毋乃愚乎？

Lǐ Shìcái (1588～1655, also known as Li Zhongzi) said: in prescribing this formula, there are four common errors, dìhuáng is not of Huáiqìng region thus it’s strength is inferior. [Dìhuáng] that is not steamed and dried 9 times then it is not shú [prepared (this is because in the formula preparation it says to do this)]. Some suspect the cloying [nature] of dìhuáng [is problematic] and reduce it, thus causing the efficacy of the sovereign [herb] to be weakened. Some dislike the draining [nature] of zéxiè and then reduce it, this then decreases the strength [of the formula], then they blame the inefficacy of the herb, is that not foolish?

按：擇瀉本經云聰耳明目，為其能滲下焦之溼熱也。溼熱既除，則清氣上行，故能養五臟，起陰氣補虛損，止頭旋，有聰耳明目之功，是以古方用之，今人多以昏目疑之，蓋服之太多，則腎水過利而目昏，若古方配合，多寡適宜，未易增減也。

Áng explains: zéxiè in the classic states sharpens the hearing and brightens the eyes, yet it is used to percolate damp heat of the lower jiāo. Once damp-heat is eliminated, then clear qì is able to ascend, therefore it is capable of nourishing the five zàng, it rises the yīn qì, tonifies vacuity detriment, ceases sensations that the head is spinning, also has the effect of sharpening the hearing and brightening the eyes, thus the ancient formula use it. Now days people are confused and doubt it, then they take excessive amounts of [zéxiè], then the kidney-water is excessively disinhibited causing clouded vision. Comply with combinations in the ancient formulas, and [prescribe] the appropriate dosage, do not wilfully add or subtract!

Thanks to Leo Lok for his help on paragraphs 2 and 3, any errors that remain are my own.

【加減 Modifications】

錢氏加減法：

血虛陰衰，熟地為君；
精滑頭昏，山茱為君；
小便或多或少，或赤或白，茯苓為君；
小便淋瀝，澤瀉為君；
心虛火盛及有瘀血，丹皮為君；
脾胃虛弱，皮膚乾濇，山藥為君。
言為君者，其分用八兩，地黃只用臣分兩。

Doctor Qián’s methods of modifications
blood deficiency and yin debilitation, shúdì is sovereign;
essence efflux and dizziness, shānzhū is sovereign;
uriniation is copious or scant, or red or white, fúlíng is sovereign;
dribbling urination, zé xiè is sovereign;
heart deficiency with exuberant fire as to cause stasis of blood, dānpí is sovereign;
spleen and stomach deficient and weak, the skin is dry and rough, shānyào is sovereign.
For the herb that is sovereign, it is allocated 8 liǎng, while dìhuáng is allocated the dosage of minister.

【方義 Formula Explanation】

此足少陰厥陰藥也。熟地滋陰補腎，生血生精，山茱溫肝逐風，濇精祕氣，牡丹瀉君相之伏火，涼血退蒸(1)。山藥清虛熱于肺脾，補脾固腎(2)。茯苓滲脾中溼熱，而通腎交心，澤瀉瀉膀胱水邪，而聰耳明目(3)。六經備治，而功專腎肝，寒燥不偏，而補兼氣血，苟能常服，其功未易殫述也。

1. 李時珍曰：伏火即陰火也。陰火即相火也。世人專以黃蘗治相火，不知丹皮之功更勝也。丹者南方火色，牡而非牝，屬陽故能入腎，瀉陰火，退無汗之骨蒸。
2. 能濇精。
3. 解見後註。

These are foot shǎoyīn and juéyīnherbs. Shúdì nourishes the yīn and tonifies the kidneys, generates blood and jīng/essence,shānzhū warms the liver to expel wind, astringes jīng and secures the qì, mǔdāndrains the latent fire of imperial and ministerial, cools blood and reduces streaming (of heat in the body) (1). Shānyào clears deficiency heat in the lungand spleen, tonifies the spleen and secures the kidneys (2). Fúlíng percolates the damp-heat within the spleen, and allows communication between the kidney and heart, zéxiè drains the water-evil in the bladder, and improves hearing and brightens the eyes (3). [This formula] can treat all the six conformations, moreover have a specific function on the kidneys and liver, without an inclination tocooling or drying, in addition to tonifying both the qì and blood. If oneconsumes it daily, the benefits [which one can enjoy] cannot be exhaustively described.

1. Lǐ Shízhēn says: latent heat is yīn fire. Yīnfire is ministerial fire. The common people specifically use huángbò (huangbai) to treat ministerial fire, but are ignorant of the efficacy of dānpí toovercome it. Dān, it is the southern direction and colour of fire, it is maleand not female, it belongs to yáng and can enter the kidney, draining the yīn fire,reducing the steaming bones without sweating.
2. To astringe the jīng/essence.
3. See explanation below. [This will come nextweek!]

Thanks to Leo Lok forhelp with two difficult phrases.

Part 3 will follow next week discussing more information about the formula.

六味地黃丸 Liùwèi dìhuáng wán [Part 1] from with commentary from the Yīfāng jíjiě 《医方集解》 1689 CE.

補真陰，除百病。(1)

Tonify true yīn, eliminates the hundred diseases. (1)

1. 錢氏仲陽因仲景八味丸減去桂附，以治小兒，以小兒純陽，故減桂附，今用通治大小證。

1. Doctor Qián Zhòngyáng (1032-1113) in accordance with Sage Zhòngjǐng’s Bāwèi Wan, modified it to remove guìzhi fùzi, in order to treat children, this is because children are pure yáng, therefore remove guìzhi and fùzi, now it is used to treat symptoms in both young and old.

【Indications】

治肝腎不足，真陰虧損，精血枯竭，憔悴羸弱，腰痛足酸，自汗盜汗，水泛為痰(2)。發熱欬嗽(3)。頭暈目眩(4)。耳鳴耳聾，遺精便血，消渴淋瀝，失血失音，舌燥喉痛，虛火牙痛，足跟作痛，下部瘡瘍等證(5)。
Treats liver and kidney insufficiency, true yīn depletion, jīng and blood desiccated, sallow, emaciated and weak, back pain with aching feet, spontaneous sweating night sweating, flooding water-fluids becoming phlegm (2). Fever with cough (3). Dizzy head and vision (4). Tinnitus and deafness, seminal emission and bloody stool, dispersion-thirst and dribbling [urination], blood loss and aphonia, dry tongue and throat pain, deficiency fire and tooth ache, pain in the heel, different types of sores of the lower body (5).

【註 Annotations】

2. 仲景曰：氣虛有痰，宜腎氣丸補而逐之，丹溪曰：久病陰火上升，津液生痰不生血，宜補血以制相火，其痰自除。
3. 腎虛則移熱於肺而欬嗽，按之至骨，其熱烙手，骨困不任，為腎熱。
4. 直指方云：淫慾過度，腎氣不能歸元，此氣虛頭暈也。吐衄崩漏，脾不攝血，致血妄行，此血頭暈。
5. 諸證皆由腎水不足，虛火上炎所致，詳註分見各門。

2. Zhòngjǐng says: if there is qì deficient there is phlegm, it is appropriate to use Shènqì Wán to tonify and expel [phlegm], Dānxī says: if there is chronic illness then yīn fire will ascend, jīnyè-fluids generate phlegm and cannot generate blood, it is appropriate to tonify blood in order to control ministerial fire, then the phlegm will naturally be eliminated.
   3. If the kidneys are deficient then the heat will shift to the lungs causing cough. Pressing to feel the bone, it is burning to touch, the bones are extremely cumbersome, this is due to the kidney heat.
   4. 《Zhízhǐ Fāng》 (1264 CE Song Dynasty) states: if there is excessive desires, kidney qì cannot return to the source (yuan), this is qì deficiency dizziness. Vomiting of blood and spotting, this is spleen unable to contain the blood, causing frenetic blood movement, this is blood dizziness.
   5. All these various patterns originated in kidney water insufficiency, and as a result of deficiency fire flaming upwards, meticulously study each of these clauses.

【組成 Composition】

地黃  山茱肉 山藥  茯苓 拌乳  丹皮 澤瀉

dìhuáng, shānzhūròu, shānyào, fúlíng, dān pí, zé xiè

I would also like to thank Ivan for helping out last week with proofreading.

Commentary from the Yīfāng jíjiě 《医方集解》 1689 CE

補陽益氣 Tonifies yáng and supplements qì

【主治 Indications】

治一切陽虛氣弱，脾衰肺損，飲食少思，體瘦面黃，皮聚毛落，脈來細軟(1)。

Treats all kinds of yáng deficiency with weakness of qì, spleen debilitation and lung detriment, little thought of [eating] food and drink, thin body with yellow complexion, loss of skin and hair, pulse is fine and soft (1).

(1) 脾者萬物之母也。肺者氣之母也。脾胃一虛，肺氣先絕，脾不健運，故飲食少思，飲食減少，則營衛無所資養，脾主肌肉，故體瘦面黃，肺主皮毛，故皮聚毛落，脾肺皆虛，故脈來細軟也。

(1) The spleen, it is the mother of the 10,000 things. The lung, it is the mother of qì. Once the spleen and stomach become deficient, the lung qì will be the first to expire, then the spleen is unable to [perform] transportation and transformation, therefore there is little thought of [eating] food and drink, because the food and drink is reduced then the yíng and wèi have no means of being nourishment. The spleen governs the flesh, therefore the body is thin and there is yellow complexion. The lung governs the skin and body hair, therefore there is loss of skin and hair. If the spleen and lung are both deficient, then the pulse will be fine and soft.

【組成 Composition】

人參、白朮 茯苓 二錢  甘草 一錢  薑三片、棗二枚

2 qián of rénshēn, báizhú, and fúlíng, 1 qián of gāncǎo, with 3 slices of [sheng]jiāng, and 2 [da]zǎo

【方義 Explanation of Formula】

此手足太陰足陽明藥也。人參甘溫，大補元氣，為君，白朮苦溫，燥脾補氣，為臣，茯苓甘淡，滲溼瀉熱，為佐，甘草甘平，和中益土，為使也。氣足脾運，飲食倍進，則餘臟受蔭，而色澤身強矣。

These are foot and hand tàiyīn, and foot yángmíng herbs. Rénshēn, it is sweet and warm, it will greatly tonify the yuánqì, it is the emperor/sovereign [herb]. Báizhú, it is bitter and warm, it will dry the spleen and tonify qì, it is the minister [herb]. Fúlíng, it is sweet and bland, it will percolate dampness and drain heat, it is the assistant [herb]. Gāncǎo, it is sweet and even, it will harmonise the middle and supplement earth, it is the courier [herb]. If qì is sufficient then the spleen can [perform] transportation, if food intake is increased, then the zàng can receive nourishment, leading to the complexion having lustre and the body strengthening.

再加陳皮以理氣散逆，半夏以燥溼除痰，名曰六君，以其皆中和之品，故曰君子也。

To add chénpí in order to rectify the qì and disperse counterflow, and bànxià in order to dry dampness and eliminate phlegm, this is called liùjūn, this is because all of these are herbs that harmonising the middle, therefore they are called jūnzǐ.

Line 4 of the Wēnbìng tiáobiàn (Systematic Differentiation of Warm Diseases 溫病條辨) – Part 1 by  吴鞠通 Wú jū tōng

The bold text is the line, the unbolded text is his commentary.

太陰風溫、溫熱、溫疫、冬溫，初起惡風寒者，桂枝湯主之；但熱不惡寒而渴者，辛涼平劑銀翹散主之。溫毒、暑溫、濕溫、溫瘧，不在此例。

Tàiyīn wind warmth, warm heat, warm epidemic, winter warmth, [all] at the onset have aversion to wind, Guìzhī Tāng governs it; but if there is heat and absence of aversion to cold moreover with thirst, pungent cooling Yínqiào Sàn governs it. For warm toxin, summerheat warmth, damp warmth, warm malaria, do not follow this precedent.

按仲景《傷寒論》原文，太陽病（謂如太陽証，即上文頭痛身熱惡風自汗也），但惡熱不惡寒而渴者，名曰溫病，桂枝湯主之。蓋溫病忌汗，最喜解肌，桂枝本為解肌，且桂枝芳香化濁，芍藥收陰斂液，甘草敗毒和中、薑、棗調和營衛，溫病初起，原可用之。

According to the original text in Zhòngjǐng’s Shānghán Lùn”, Tàiyáng disease (this is tàiyáng pattern, headache, body heat, aversion to wind, spontaneous sweating), but there is aversion to heat and no aversion to cold with also with thirst, this is called warm disease (wēn bìng), Guìzhī Tāng governs it. Because in warm disease one should abstain from [causing] sweat, the favourable method is resolving the flesh, guìzhī fundamentally resolves the flesh, moreover it transforms turbidity with aroma[1], sháoyào contracts yīn and constrains yè-fluids, gāncǎo relieves toxins and harmonises the centre, [sheng] jiāng and [da] zǎo regulate and harmonise the yíng and wèi [qi], at the onset of warm disease, one can use it.

此處卻變易前法，惡風寒者主以桂枝，不惡風寒主以辛涼者，非敢擅違古訓也。仲景所云不惡風寒者，非全不惡風寒也，其先亦惡風寒，迨既熱之後，乃不惡風寒耳，古文簡、質，且對太陽中風熱時亦惡風寒言之，故不暇詳耳。

In this situation I alter the past methods, aversion to wind and cold is governed with guìzhī, if there is an absence of aversion to wind and cold it is governed by pungent cooling [herbs], I dare not violate the ancient teachings? Zhòngjǐng states absence of aversion to wind and cold, it is not all absence of wind and cold, it initially is aversion to wind and cold, after a short period of time it becomes hot, as a result there is no longer aversion to wind and cold, classic writing is succinct and unadorned, moreover it states in tàiyáng wind strike there is periodic fevers with aversion to wind and cold, therefore it is not necessary to go into more detail [here].

蓋寒水之病，冬氣也，非辛溫春夏之氣，不足以解之，雖曰溫病，既惡風寒，明是溫自內發，風寒從外搏，成內熱外寒之証，故仍舊用桂枝辛溫解肌法，俾得微汗，而寒熱之邪皆解矣。溫熱之邪，春夏氣也，不惡風寒，則不兼寒風可知，此非辛涼秋金之氣，不足以解之。桂枝辛溫，以之治溫，是以火濟火也，故改從內經“風淫於內、治以辛涼、佐以苦甘”法。

Because the disease of cold water, that is winter qì, that is not the qì of warm pungent spring and summer, if it is insufficient then one must resolve it, although it is called warmth disease, jì aversion to wind cold, clearly this is warmth originating in the interior and effusing [outwards], wind and cold from exterior struggle, then the pattern of internal heat and external cold is formed, therefore as before use the method of pungent warm of guìzhī to resolve the flesh, cause a slight sweat, and the evils of cold and heat will then both be resolved. The evil of warmth heat, it is the qì of spring and summer, there is absence of aversion to wind and cold, thus one knows there is not concurrent cold wind, this is not the qì of pungent cooling autumn metal, it is not enough to resolve the flesh. Guìzhī is pungent and warm, using it to treat warmth, that is akin to using fire to aid fire, therefore modify the method to follow the Nèijīng (Inner Classic) [which states] “wind excess in the interior, treat with pungent and cooling, assist with bitter and sweet [herbs]”.

胸膈悶者，加藿香三錢、鬱金三錢︰護膻中；渴甚者，加花粉；項腫咽痛者，加馬勃、元參，衄者，去芥穗、豆豉，加白茅根三錢、側柏炭三錢、梔子炭三錢；咳者，加杏仁利肺氣；二、三日病猶在肺，熱漸入裡，加細生地、麥冬保津液；再不解或小便短者，加知母、黃芩、梔子之苦寒，與麥、地之甘寒，合化陰氣，而治熱淫所勝。

Modifications [of Yinqiao San]

Oppression in the chest and diaphragm, add 3 qián of huòxiāng, 3 qián of yùjīn; to protect the dànzhōng, with extreme thirst, add huāfěn; swelling of the nape and pain in the throat, add mǎbó, yuán shēn; nose bloods, remove jièsuì, dòuchǐ, add 3 qián of bái máogēn, 3 qián of cèbó tàn, 3 qián of zhīzi tàn; cough, add xìngrén to disinhibit lung qì; if after 2-3 days the diseases is still in the lung, heat will gradually enter the interior, add xì shēngdì, mài dōng to protect jīnyè fluids; if again the [flesh] is not resolved or short voidings of urination, add  bitter cold [herbs] zhīmǔ, huángqín and zhīzǐ, together with sweet cold mài [mendong], [sheng] di, together transform yīn qì, and treat the heat excess that is prevalent.

[Author thanks Stephen Boyanton for his help]

[1] This is a herbal method

退熱調經《局方》

Abates heat and regulates menstruation, from the 《Júfang》 1151 CE.

治血虛肝燥，骨蒸勞熱，欬嗽潮熱，往來寒熱，口乾便澀，月經不調（骨蒸潮熱，肝血虛也。肝火乘肺故欬嗽，邪在少陽故往來寒熱，火盛爍金，不能生水，故口渴便秘，肝病故經水不調。）。

This treats blood deficiency and liver dryness, steaming bone taxation heat, cough with tidal fevers, alternating chills and fever, dry mouth with constipation, menstrual irregularities (steaming bone and tidal fevers, this is liver blood deficiency.  If the liver is hot then it will overwhelm the lung, therefore there is cough, the evil is located in shǎoyáng therefore there is alternating chills and fevers, if fire is exuberant then metal will be scorched, [metal] cannot generate water, therefore there is thirst and constipation, the liver is diseased therefore there is menstrual irregularities.).

此足少陽厥陰藥也。肝虛則血病，當歸芍藥養血而斂陰，木盛則土衰，甘草白朮和中而補土（補土生金，亦以平木）。柴胡升陽散熱，合芍藥以平肝，而使木得條達（木喜條達，故以瀉為補，取疏通之義）。茯苓清熱利溼，助甘朮以益土，而令心氣安寧（茯苓能通心腎。）。生薑暖胃祛痰，調中解鬱，薄荷搜肝瀉肺，理血消風，疏逆和中，諸證自已，所以有逍遙之名（ 有乾咳嗽者，丹溪曰：極為難治，此係火鬱之證，乃痰鬱其火邪在中，用逍遙散以開之，下用補陰之劑可愈，昂按：此即後條醫貫所言之旨也。）。

These are foot shǎoyáng and juéyīn medicinals. If the liver is deficient then there will be diseases of the blood, dāngguī and sháoyào nourish blood and constrain yīn, if wood is exuberant then earth will be debilitated, gāncǎo and báizhú harmonise the middle and tonify earth (tonify earth to generate metal, this will additionally help balance wood). Cháihú rises yang and disperses heat, combined with sháoyào it balances the liver, and this causes the liver to be orderly reaching (the liver prefers orderly reaching, therefore drain in order to tonify, this is the meaning of dredging (coursing and freeing)). Fúlíng clears heat and disinhibits dampness, assists gān[cǎo] and bái[zhú] in order to supplement earth, and orders the heart qì to be tranquil (fúlíng facilitates the communication of heart and kidney.). Shēng jiāng warms the stomach and dispels phlegm, regulates the middle and resolves depression, bòhé seeks the liver and drains the lung, regulates (rectifies) the blood and disperses wind, courses counterflow and harmonises the middle, all of these signs naturally cease, therefore it is given the name xiāoyáo (if dry cough is present, Dānxī says: this is extremely difficult to treat, this correlates to the pattern of depressed fire, also with phlegm depression and fire evil in the middle, use xiāoyáo sàn in order to open it, after use yīn tonifying formulas for the patient to recover, Wáng’àn says this statement is decreed in the 《Yīguàn》.).