is chinese medicine for real?

Naming them:

1. 苓桂甘枣汤
2. 苓桂术甘汤
3. 苓桂甘姜汤（aka 茯苓甘草汤）
4. 五苓散

Understanding the first two:

The first two are under 虚证 in the textbook. The former for 心阳虚, the latter for 脾虚.

“发汗后，其人脐下悸者，欲发奔豚，茯苓桂枝甘草大枣汤主之。” (line 65)

• Think of this decoction as 桂枝甘草汤 (4两:2两) with alot of 茯苓 (8两) added. And 大枣 too.
• Why add 茯苓? My take on this is to consider a verse in 《金匮要略》：“假令瘦人，脐下有悸 ，口吐沫涎而颠眩，为水也，五苓散主之。”
• 桂枝 is the key herb used to treat palpitations (心悸) that occured below the naval. The other herbs added in are mainly diuretics which get rid of water (“口吐沫涎” tells us there is water, which may be the cause of the problem).
• That said, I believe that 五苓散 is a fluid-replenisher. And “口吐沫涎” may be a symptom of vertigo, but it may also be a cause of fluid loss. So 五苓散 may not just treat vertigo, but also replenish fluids. And the 桂枝 inside may help calm the palpitations.

“伤寒若吐若下后，心下逆满，气上冲胸，起则头眩，脉沉紧，发汗则动经，身为振振摇者，茯苓桂枝白术甘草汤主之。”

• 伤寒 is to be treated by perspiration and I think that most times it works if done correctly. But no, we shouldn’t treat by vomiting or precipitation, which is what was done here. If say we precipitate and the diarrhea stops, we’ll usually end up with 痞块 or 结胸 (also 脉沉而紧), which is expressed here as “心下逆满”, a kind of vacuity in the system that causes dizziness (not unlike that in 栀子豉汤证)
• Please do not try to induce perspiration NOW (after having already wrongly induced vomiting or precipitation). The body will go into further hypovolemia and express as 动经，身为振振摇.
• 苓桂术甘汤 is indicated here, which is fine as a means to replenish fluids and building up the ’spleen system’ in general. If understood like this, and with an understanding that 五苓散 is also a fluid-replenisher, then the key herbs for fluid-replenishment and healthy water metabolism are the 苓-桂 pair

Understanding the next two:

The next two appear in the discussion on 蓄水证…

For 五苓散, there are three lines related to 蓄水证

1. Sweating causes dry stomach and vexation, need to drink water slowly and will be fine.
   1. “若脉浮，小便不利， 微热消渴者，五苓散主之。” See here for more.
2. “发汗已，脉浮数，烦渴者，五苓散主之。”
3. If after extended treatment using 发汗 but still unable to 解表, the patient will start feeling vexed (this is a sign of 里证, look also at 栀子豉汤证), he’ll feel thirsty but upon drinking, he vomits (水逆). Treat using 五苓散.

For 茯苓甘草汤：

Think of this decoction as very very similar to the above 苓桂甘枣汤 for “心下有悸，欲发奔豚” in that the proportion of 桂枝：甘草 is still the same. But it’s 2:1 instead of 4:2. And less 茯苓 is used: 2两 instead of 8两.

And instead of 大枣，we have alot (3两) of 生姜. The addition of ginger (生姜) tells us that this person can handle dryness, and hence he’s probably not thirsty. And we’re right, if you take a look bel0w:

“伤寒汗出而渴者，五苓散主之；不渴者，茯苓甘草汤主之。”

The takeaway is that 五苓散 is used when you’re thirsty after much sweating. If you’re not thirsty, then use 茯苓甘草汤.

Note: compare against what the textbook calls 水厥…

茯苓甘草汤 is quoted in line 74 of SHL, where a comparison is made between it and 五苓散. Use 五苓散 if there is thirst after the sweating; use 茯苓甘草汤 if there is no thirst.

Now, in line 356, we have another interpretation of 茯苓甘草汤:

“伤寒厥而心下悸，以先治水，当服茯苓甘草汤，却治其厥。

不爾，水渍(zi3)入胃，必作利也。” (line 356)

In this situation, a 伤寒 causes two things, (a) 厥，which is 厥逆 which is 四肢厥冷; (b) 心下悸.

Treatment:

First treat the 心下悸, which according to the writer is a water problem - so we use 茯苓甘草汤 as a diuretic (利小便) and hopefully the palpitations tame down. Only when the palpitations are taken care of do we deal with the 厥.

The writer also adds that if you don’t get rid of the water, the guy might starts having diarrhea due to too much fluids accumulating in the stomach. 渍(zi3) means 渍浸, which means ‘to steep in water.’ aka 利小便，从而防大便不实…

We can put together 5 uses of 五苓散…

ONE: 小便不利

Usually after over-perspiring, the person is dehydrated and thirsty. On top of that, he has a floating pulse and inhibited urination.

“…若脉浮，小便不利，微热消渴者，五苓散主之。”

“发汗已，脉浮数，烦渴者，五苓散主之。”

TWO: 水肿

More focused on using the diuretic properties of the herbs inside.

THREE: 眩晕

See here on how 五苓散 can help when an illness makes a person skinny, 脐下有悸 who exhibit vertigo-like symptoms (吐涎沫而颠倒). The original text says, “此水也” and prescribes 五苓散.
FOUR: 呕吐（水逆）

See here for that 水逆 verse: “渴欲饮水，水入则吐者，名曰水逆，五苓散主之。”

FIVE: 下利

When diarrhea doesn’t stop, use 五苓散 to 利小便，使大便. Refer to this for more.
To treat 霍乱 aka Sudden Turmoil (to me a certain immune response).

SIX: 斑秃

“阳明病，自汗出，若发汗，小便自利者，此为津液内竭，虽硬不能攻之，当须自欲大便，宜蜜煎导而通之。

若土瓜根及大猪胆汁，皆可为导。”  (line 233)

Yangming disease, sweat comes out on its own [due to interior heat]. If we try to treat a Yangming disease by sweating the bloke even further, AND if this guy’s urination is spontaneously uninhibited, then we’re in trouble, because fluids are being exhausted. The shit will be hard, BUT don’t you even think of propelling it down by attacking it [with prescriptions like 大小承气汤]. What’s most desirable is that the bloke WANT TO SHIT. How? Use cooked honey to guide the shit out. Cucumber gourd root and pig bile can also be used.

The idea of “津液内竭” is also repeated in lines 247, 245 and 246 - all talking about the 麻子仁丸 pattern. Basically explains that the shit is hard because you have urinated or sweated all the fluids out, leaving shit without fluids to soften it.

Point to make:

We notice that with Yangming  disease, there is heat and hence sweating. Sweating is not a solution. How about precipitation (aka attacking or 攻下)? Only use it if there is pain, but here he’s just dehydrated and weak, and don’t need further weakening. That’s why you consider a milder method.

Mild method. 麻子仁丸 or 导下? To me, both are fine, just that the former sounds like a more convenient solution, where herbs like 麻子仁、芍药、杏仁 can help lubricate the intestinal wall too.

That said, my teacher seems to emphasize that you use 导下 when you have the urge to defecate, but it just doesn’t happen. As for 麻子仁丸, use it to create that urge.

The verse:

“趺阳脉浮而涩，浮则胃气强，涩则小便数，浮涩相搏，大便则硬，其脾为约，麻子仁丸主之。” (line 247)

Here we get a glimpse of the unfettered logic of Zhang Ji and perhaps all his predecessors and post-decessors. He says that the fuyang pulse is floating and rough (literally: astringent). And then he explains why: floating means that the stomach qi is strong (from this we know that during exterior illnesses, your stomach qi is always strong enough for you to garner up some immune reaction), and rough means your pee comes out fast.

And he continues: Now, when floating and rough interact, your shit will be hard. The logic of this two-pronged:

1. when your stomach qi is strong, you won’t produce sloppy shit (便溏).
2. when your pee is coming out alot, the level of fluids in the shit is also compromised.

The concept of 脾约：

“When the shit is hard, your spleen must be hindered.” This is the what the last part of the line is trying to say. And we can then link the idea of strong stomach qi to weak spleen qi. A relative idea albeit, but it then gave birth to the idea of 胃强脾弱.

The next verse:

“脉阳微而汗出少者，为自和也，

汗出多者，为太过。” (line 245a)

“阳脉实，因发其汗，出多者，亦为太过。” (line 245b)

“太过者，为阳绝于里，亡津液，大便因硬也。” (line 245c)

The above three sections of line 245 are summarized as below:

1. When the surface pulse is weak and
   1. sweating is mild, the situation will resolve (harmonize) on its own.
   2. sweating is alot, it is considered in excess.
2. When the surface pulse is replete, if due to perspiration the sweat is alot, it is also considered in excess.
3. That which is in excess, is where yang is trapped inside, drying up all the fluids, thence will the shit be hard.

Okay, he explains that sweating in excess will cause yang to build up but be trapped inside. His rationale is not that fluids are lost via sweating - rather fluids are dried up inside, causing the interior to be lacking in fluids, hence the hard stool.

From here, we can recap that there are two ways to cause hard shit:

1. One is by having strong agni (stomach fire) while having your urine drain very quickly
2. The other is by sweating alot.

The next and last verse supports first patho-mechanism:

“脉浮而芤，浮为阳，芤为阴，浮芤相搏，胃气生热，其阳则绝。” (line 246)

Again, our dear Zhang Ji uses the pulse as a starting point to explain what happens in the organs. Two pulses interacts and cause the stomach qi to create fire. This fire then is trapped [inside].

Back to 麻子仁丸 - Something on how to prepare it:

“上六味，蜜和丸如梧桐子大，饮服十丸 ，日三服，渐加，以知为度。

The important point is to take the six herbs and roll it into huge balls (size of a 梧桐子) with honey. Then swallow down ten balls each time, three times daily, until not necessary.