"On Differentiating Lung Organ Disease Patterns and Corresponding Formulas", followed by Commentary

輔行訣臟腑用藥法要 梁華陽隱居 陶弘景 撰 EXTRANEOUS SECRETS: The Essential Method of Using Medicinal Substances for Differential Treatment of the Organ Networks Attributed to the Hermit of Huayang, Tao Hongjing (456-536), As Recorded and Transmitted by Zhang Dachang (1926-1995) and his Disciples 辨肺臟病證文併方 On Differentiating Lung Organ Disease Patterns and Corresponding Formulas Translated by Michael Dell'Orfano Edited and critically annotated by Heiner Fruehauf National University of Natural Medicine, College of Classical Chinese Medicine 肺虛則鼻息不利；實則喘咳，憑胸仰息。 肺病者，必咳喘逆氣，肩息背痛，汗出憎風；虛則胸中痛，少氣不能報息，耳聾，咽乾。 邪在肺，則皮膚痛，發寒熱，上氣喘，汗出，咳動肩背，取之膺中外腧，背第三椎旁，以手按之快然，乃刺之，取缺盆以越之。陶雲：肺德在收。 故經雲：“以酸補之，咸瀉之；肺苦氣上逆，食辛以散之，開腠理以通氣也。” If the Lung is deficient, breathing through the nose is inhibited. If it is in a state of excess, there will be coughing and asthmatic wheezing, and fullness in the chest accompanied by the need for breathing in an upright and supported position. All types of Lung disease manifest as coughing and wheezing due to counterflow of qi, accompanied by symptoms of shallow shoulder breathing, upper back pain, sweating, and an aversion to wind. If is deficient, there will be chest pain, shortness of breath with a feeling that the breath cannot be replenished, loss of hearing, and a dry throat. When external pathogens are present in the Lung, there will be pain in the skin layer, fever with alternating hot and cold sensations, qi counterflow with symptoms of wheezing, and a deep cough that vibrates the shoulders and upper back. For this condition, needle the acupuncture points on the lateral side of the area above the breasts (yingzhong waishu: LU 1 and LU 2), and the points alongside the third vertebra (BL 13). Prepare these points by rubbing them with your hand, then needle them. Afterwards, needle Quepen (ST 12) to disperse . Tao says: The virtue of the Lung is to contract. Therefore, the classic says: “Use sour flavors to tonify and salty flavors to purge . If the Lung suffers from counterflowing qi, quickly eat pungent flavors to disperse it, and to open the pores (couli) so that qi can flow through them freely again.” 小瀉肺湯 治咳喘上氣，胸中迫滿，不可臥者方：葶藶子（熬黑，搗如泥), 大黃, 芍藥（各三兩)。 上三味，以水三升，煮取二升，溫分再服，喘定止后服。 Minor Purge the Lung Decoction This prescription treats counterflow of qi manifesting as coughing and wheezing, oppressive fullness in the chest, and inability to lie down. Tinglizi (Semen Descurainiae seu Lepidii, heat until black, then pound until mashed)..........3 liang Dahuang (Radix et Rhizoma Rhei)..........3 liang Shaoyao (Radix Peaoniae Lactiflorae)..........3 liang Cook these 3 ingredients in 3 sheng of water until reduced to 2 sheng. Divide and drink 1 sheng warm, 2 times daily. Once the wheezing symptoms have been stabilized, stop taking additional doses. 大瀉肺湯 治胸中有痰涎，喘不得臥，大小便閟，身面腫，迫滿，欲得氣利者方：葶藶子（熬), 大黃, 芍藥（各三兩)。 甘草（炙), 黃芩, 乾姜（各一兩)。 上六味，以水五升，煮取二升，溫分再服，日二服。 Major Purge the Lung Decoction This prescription treats accumulation of phlegm and thinner fluids in the chest, accompanied by symptoms of wheezing and inability to lie down, obstructed urination and bowel movements, swelling in the face and torso, oppressive fullness , and the urgent desire to restore qi flow. Tinglizi (Semen Descurainiae seu Lepidii, heated)..........3 liang Dahuang (Radix et Rhizoma Rhei)..........3 liang Shaoyao (Radix Peaoniae Lactiflorae)..........3 liang Zhi Gancao (Radix Glycirrhizae Uralensis, honey-baked)..........1 liang Huangqin (Radix Scutellariae Baicalensis)..........1 liang Ganjiang (Rhizoma Zingiberis Officinalis, dried)..........1 liang Cook these 6 ingredients in 5 sheng of water until reduced to 2 sheng. Divide in half and serve each dose warm, 2 times during the day. 小補肺湯 治汗出口渴，少氣不足以息 ，胸中痛，脈虛者方：麥門冬, 五味子, 旋覆花 （各三兩），細辛（一兩)。 上四味，以水八升，煮取三升，每服一升，日三服。若胸中煩熱者，去細辛，加海蛤一两；若胸中滿痛者，還用細辛；咳不利，脈结者, 倍旋覆花；若眩冒者, 去細辛, 加澤瀉一两；咳而有血者，倍麥門冬；若煩渴者，去細辛，加粳米半升；涎多者，加半夏半升，洗。 Minor Tonify the Lung Decoction This prescription treats sweating with thirst, feeble voice with shortness of breath, chest pain, and a deficient pulse. Maimendong (Radix Ophiopogonis)..........3 liang Wuweizi (Fructus Schisandra Chinensis)..........3 liang Xuanfuhua (Flos Inulae)..........3 liang Xixin (Herba Asari)..........1 liang Cook these 4 ingredients in 8 sheng of water until reduced to 3 sheng. Divide into 3 servings, and drink 1 sheng 3 times a day. For restless heat sensations in the chest, remove Xixin and add 1 liang of Haige (Concha Cyclinae Sinensis); for fullness and pain in the chest, add the Xixin back in again. For unproductive cough accompanied by an irregular pulse, double the amount of Xuanfuhua. For dizziness, remove Xixin and add 1 liang of Zexie (Rhizoma Alismatis Orientalis). For coughing accompanied by the expectoration of blood, double the amount of Maimendong. For thirst accompanied by obvious restlessness, remove Xixin and add ½ sheng of Gengmi (Oryzae Sativae); for copious amounts of runny mucous, add ½ sheng of well-rinsed Banxia (Rhizoma Pinelliae Ternatae). 大補肺湯 治煩熱汗出，少氣不足以息，口乾，耳聾，脈虛而快者方：麥門冬, 五味子, 旋覆花（各三兩) ，細辛（一兩)，地黃, 竹葉, 甘草（各一兩)。 上七味，以水一斗，煮取四升，溫分四服，日三夜一服。 Major Tonify the Lung Decoction This formula treats restless heat accompanied by sweating, a feeble voice accompanied by shortness of breath, a dry mouth, hearing loss, and a deficient and rapid pulse. Maimendong (Radix Ophiopogonis)..........3 liang Wuweizi (Fructus Schisandrae Chinensis)..........3 liang Xuanfuhua (Flos Inulae)..........3 liang Xixin (Herba Asari)..........1 liang Dihuang (Radix Rehmanniae Glutinosae)..........1 liang Zhuye (Herba Lophatheri Gracilis)..........1 liang Gancao (Radix Glycirrhizae Uralensis)..........1 liang Cook these 7 ingredients in 1 dou of water until reduced to 4 sheng. Divide into 4 servings, and drink 1 serving 3 times during the day, and 1 time at night. Notes This passage represents a slight adaptation of a passage on Lung pathology in Huangdi neijing lingshu, chapter 8 “Benshen.” This passage represents an adaptation of a passage on Lung pathology in Huangdi neijing suwen, chapter 22 “Zangqi fashi lun.” This passage represents an adaptation of a passage on Lung function in Huangdi neijing lingshu, chapter 20 “Wuxie.” Yingzhong waishu literally means “the external point(s) in the area above the breasts.” The Tang dynasty Neijing commentator Yang Shanshang interprets this to refer to the point Feishu (BL 13) in the back, which is located next to the 3rd thorassic vertebrae. According to the Ming dynasty scholar physician Zhang Jingyue and contemporary commentators, yingzhong waishu refers to the acupuncture points Lung 1 and Lung 2. This passage reflects a defining line on Lung physiology in Huangdi neijing suwen chapter 22 “Zangqi fashi lun,” but also stands in partial contrast to it. The Neijing passage states: 肺欲收，急食酸以收之，用酸補之，辛寫之 (The Lung desires to contract. Urgently imbibe sour flavors to help it contract; use sour flavors to tonify the Lung, and pungent flavors to purge it). LDX, YZB and DQX add a note about Zhang Dachang’s personal clinical experience: “If Tinglizi is being replaced by Baijiezi (Semen Sinapis Albae) this formula will deliver even better results.” LDX, YZB, SBG, DQX and ZDC/YZB record 3 liang of Zhishi (Aurantium Pericarpium) instead of Shaoyao. ZDC records instead: “Cook these 3 ingredients in 3 sheng of water until reduced to 1 sheng.” ZDC records instead: 治痰飲喘不得臥，心下腹中脹滿而痛者方（This prescription treats accumulation of phlegm and thinner fluids accompanied by symptoms of wheezing and inability to lie down, as well as fullness and pain in the solar plexus and abdominal regions）. LDX, YZB, SBG, DQX also record: 心下痞而時腹中疼痛方 (This prescription also treats obstruction in the solar plexus region and episodic pain in the abdomen). LDX, YZB, SBG, DQX and ZDC/YZB record 3 liang of Zhishi instead of Shaoyao. LDX, YZB, SBG, and DQX record 1 ½ liang of (Zhi) Gancao. ZDC/YZB records 2 liang of (Zhi) Ganco. LDX, YZB, SBG, and DQX record 1 ½ liang of Huangqin. ZDC/YZB records 2 liang of Huangqin. LDX, YZB, SBG, and DQX record 1 ½ liang of Ganjiang. ZDC/YZB records 2 liang of Ganjiang. LDX, YZB, and DQX record: “Cook these 6 ingredients in 7 sheng of water until reduced to 3 sheng.” ZDC records instead: 治氣乏惙惙而短，汗出憎風，脈虛者方 (This prescription treats a general state of exhaustion accompanied by shortness of breath, sweating, aversion to wind, and a weak pulse). LDX also records: 另補文：治胸有積飲，咳而不利，喘不能息，鼻癃不能聞香臭，口舌乾燥者方 (Additional note：This prescription also treats accumulation of thin fluids in the chest, accompanied by unproductive coughing, wheezing with difficulty inhaling, stuffy nose with inability to differentiate smell, and a dry sensation in the mouth and tongue). ZDC records Danpi (Cortex Moutan Radicis) instead of Xuanfuhua. FZL and ZGZYYJY note that “another version of this formula contains Mudanpi ; that version should be followed.” ZDC records 3 liang of Xixin. ZDC, LDX, YZB, and DQX record: “Cook these 4 ingredients in 5 sheng of water until reduced to 2 sheng.” LDX, YZB, SBG, DQX and ZDC/YZB record: “For restless heat sensations in the chest, remove Xixin and add 1 fen of Haige.” LDX, YZB, SBG, DQX and ZDC/YZB record: “For fullness and pain in the chest, add an additional fen of Xixin.” LDX, YZB, SBG, DQX and ZDC/YZB record: “For dizziness, remove Xixin and add 1 liang of Zexie.” LDX, YZB, SBG, and DQX record: “For copious amounts of runny mucous, keep Xixin in the prescription.” LDX, YZB, SBG, and DQX add the notation: 補文：治肺癆喘咳不利，鼻癃，胸中煩熱，心下痞，時吐血出者，此為屍勞（Note: This prescription also treats wasting syndrome of the Lung accompanied by a wheezing and unproductive cough, stuffy nose, restlessness in the chest, a feeling of congestion in the solar plexus region, and episodic spitting of blood—this is called shilao, corpse wasting syndrome）. ZDC records Danpi (Cortex Moutan Radicis) instead of Xuanfuhua. FZL, ZGZYYJY and WZX note that “another version of this formula contains Mudanpi ; that version should be followed.” YZB and DQX record 1 ½ liang of Dihuang. YZB and DQX record 1 ½ liang of Zhuye. LDX records 1 liang each of Renshen (Radix Ginseng) and Huanglian (Rhizoma Coptidis) instead of Gancao. YZB, SBG and DQX record 1 ½ liang each of Renshen and Huanglian instead of Gancao. Download (PDF)COMMENTARY ON FORMULA DESIGN By Michael Dell'Orfano Minor Purge the Lung Decoction Analysis The Tangye jing states, “the virtue of the Lung is to contract.” The symptoms of cough, panting, qi rising up and fullness in the chest all represent a dysfunction of the Lung qi since the qi is moving up and out instead of gathering into the Lung. The Tangye jing states, “salty purges the Lung,” and since salty belongs to the Fire class according to Tangye jing theory, herbs from the Fire class are most appropriate for purging excess from the Metal Lung. Therefore, since both are categorized as Fire herbs with a salty flavor, the herbs Tinglizi and Dahuang are used as emperor and minister herbs respectively in Minor Purge the Lung Decoction. To alleviate the symptoms and cure the disease, Tinglizi and Dahuang transport their salty flavor into the Lung channel and organ to gather in the qi. The emperor herb, Tinglizi, can be viewed as an alternate, corollary herb to Houpo as the Metal herb of the Fire class, and thus is able to transport its salty flavor to the Lung. Tinglizi purges the excess phlegm and dampness in the Lung that blocks the qi from being delivered to its child, the Kidney. Excessive pathological fluids in the upper burner and the inability of qi to descend leads to rebellious qi symptoms and yin excess accumulation in the Lung; all of which can be corrected through the use of Tinglizi since it can break-up accumulations and descend the Lung qi. Dahuang is the minister herb in this formula and is classified as the Wood herb of the Fire class. From the Tangye jing perspective, it is classified as salty in flavor despite being classified in the Shen Nong bencao jing as bitter in flavor and cold in nature. Since it is also salty, Dahuang aids Tinglizi in descending the Lung qi and breaking up yin fluid accumulation in the Lung, and thus it is able to purge the Lung. Dahuang’s salty flavor is transported to the Liver to combat any excess Metal causing imbalance in the network. According to Five Phase theory, excess Metal tends to flow across the ke cycle and attack Wood. Shaoyao is the assistant herb in this formula. It is classified as the Earth herb of the Metal class. As a Metal/sour herb, it is capable of tonifying the Lung to help balance the formula in order to prevent excessive purgation of the Lung. It tonifies the qi and blood of the Spleen, and can aid the emperor and minister in breaking up the yin accumulations found in the Lung. Major Purge the Lung Decoction Analysis This formula uses Minor Purge the Lung Decoction as its base formula and adds Zhi Gancao, Huangqin and Ganjiang as assistant and servant herbs. Zhi Gancao is the second assistant in the formula and is classified in the Tangye jing as the Wood herb of the Earth class. The Shen Nong bencao jing says it is sweet in flavor and has a neutral nature. Its sweet flavor is able to tonify the Spleen qi, but it also transports its flavor to the Liver since it is a Wood herb. The sweet flavor of Gancao helps to relax the Liver. This prevents excess Metal from flowing across the ke cycle and “chopping down” the Liver Wood by moving the Liver qi across the ke cycle (in the reverse direction of its normal flow) out of the realm of Earth and back into the realm of Wood in order to concentrate the Liver qi and blood so it will be strong enough to withstand the attack from the excess Metal. Huangqin is the third assistant in this formula, and is classified in the Tangye jing as the Wood herb of the Water class. Huangqin tonifies Wood and Water with its bitter flavor since it has an affinity for both organ networks. The Liver and Kidney need be tonified because the Lung is in excess and unable to nourish its child organ network, the Kidney, which consequently is unable to nourish its child, The Liver. Additionally, the excess Metal coming across the ke cycle injures the Wood qi that is already present in the Liver. Huangqin assists in clearing heat symptoms that arise from the congestion of qi and phlegm in the upper burner. It can descend the qi in the chest, disperse Lung phlegm and treat the cough. Ganjiang is the Earth herb of the Wood class. It is pungent in flavor, and can tonify the Liver and purge the Spleen. The Tangye jing says, “eat pungent to disperse the qi and to open the couli so qi can flow through if one has pain due to stagnation.” The Shen Nong bencao jing states that Ganjiang is acrid in flavor and warm in nature, and that it mainly treats chest fullness, cough and counterflow qi (Yang Shou-zhong, trans., The Divine Farmer’s Materia Medica. Boulder: Blue Poppy Press, 2005. p. 50). Minor Tonify the Lung Decoction Analysis As the emperor herb, Maimendong treats several of the symptoms in this pattern including the shortness of breath, weak pulse and cough. Maimendong is a yin-nourishing herb that is used to treat Lung yin deficiency and heat symptoms. Since the Tangye jing states that the “virtue of the Lung is to contract,” and sour is the flavor of Metal, it would seem Wuweizi should be the emperor of this formula, however, it is listed as the second ingredient in the source text. This, perhaps, suggests that Maimendong is classified as the emperor herb in the formula originally, unless Wuweizi is mistakenly listed as the second ingredient instead of the first ingredient in this version of the text. Maimendong is the Metal herb of the Earth class and is considered to be sweet in flavor according to the Tangye jing. The Shen Nong bencao jing lists it as possessing a sweet flavor and a neutral nature. Maimendong transports the sweet flavor of Earth to the Lung. Since Earth is the mother of Metal, it promotes the generation of Lung qi via the sheng cycle from its mother, the Spleen. While Maimendong tonifies the Lung more indirectly, the minister herb, Wuweizi, tonifies the Lung more directly since it is the Metal herb of the Metal class, and thus is sour in flavor. The Shen Nong bencao jing classifies it as having a sour flavor and a warm nature. Additionally, the Shen Nong bencao jing says it tonifies deficient qi, treats cough, reverses counterflow qi ascent and nourishes yin (Yang Shou-zhong, trans., The Divine Farmer’s Materia Medica, Boulder 2005, p.42). Wuweizi transports its sour flavor to the Lung to help gather in the qi and moisten the Lung to tonify yin through its astringing action. Xuanfuhua is the assistant herb in the formula and is classified as the Fire herb of the Fire class. It is salty in flavor and warm in nature, and able to descend the qi, according to the Shen Nong bencao jing. This makes it useful for treating the cough. Xuanfuhua transports its salty flavor to the Heart to tonify any deficiency of the Heart since the upper jiao organs are intimately entwined. In addition, tonifying Fire will aid in producing Earth to promote the flow of qi along the sheng cycle so that Metal will be produced from the Earth. The servant herb for this formula is Xixin. It is classified as the Metal herb of the Wood class, and according to Tangye jing theory, it is pungent in flavor. The Tangye jing says, “eat pungent to disperse the qi and open up the couli so that qi can flow through if one has pain due to stagnation.” Thus, the pungent flavor of Xixin is transported to the Lung to treat the symptom of chest pain. It also serves to treat cough and counterflow qi symptoms. Major Tonify the Lung Decoction Analysis Major Tonify the Lung Decoction contains the same first four herbs as Minor Tonify the Lung Decoction with the addition of three herbs. In this formula, Xixin takes on an assistant role rather than a servant role. Dahuang is added as the third assistant in the formula. The cold qi of this herb will alleviate the heat symptoms caused by the Lung yin deficiency. Dahuang is classified in the Tangye jing as the Wood herb of the Fire class, and so is salty in flavor. However, the Shen Nong bencao jing classifies Dahuang as bitter in flavor and cold in nature. The fourth assistant in this formula is Zhuye. Zhuye is the Metal herb of the Water class, and thus its flavor is bitter. The Shen Nong bencao jing notes that Zhuye is bitter in flavor and balanced in nature, and is able to quench thirst, supplement deficiency, and alleviate vexation heat in the Heart (Yang Shou-zhong, trans., The Divine Farmer’s Materia Medica. Boulder: Blue Poppy Press, 2005. p. 97). Zhuye transports its bitter flavor to the Lung to help descend the Lung qi into the Kidney since Metal naturally generates Water when it is healthy and functioning correctly. The descending of the qi will aid in stopping counterflow qi ascent and the symptom of cough. The servant herb in this formula is Gancao. Gancao is classified as the Wood herb of the Earth class in the Tangye jing. It serves to help boost the qi, nourish yin and drain heat in the upper jiao. As an Earth herb, it transports its sweet flavor to the Liver to aid in relaxing the Liver from anxiousness resulting from the inability of Metal qi to travel across the ke cycle to keep Wood qi in check. Download (PDF)

“On Differentiating Lung Organ Disease Patterns and Corresponding Formulas”, followed by Commentary

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