Gong Tingxian's "Qingre Daotan Tang" for Treating Stroke

The Ming physician Gong Tingxian included a formula called Qingre Daotan Tang (Heat-Clearing Phlegm-Driving Decoction) in his Shoushi Baoyuan. Gong Tingxian described the composition and indications of the formula as follows:

Huanglian (Coptis) 8 fen; Huangqin (Scutellaria) 2 qian; Gualouren (Trichosanthes seed) 4 qian, shell removed; Zhishi (immature bitter orange) 2 qian, bran-fried; Jiegeng (Platycodon) 8 fen; Baizhu (Atractylodes) 1.5 qian, rhizome removed; Baifuling (white Poria) 3 qian, peel removed; Chenpi (tangerine peel) 2 qian; Banxia (Pinellia) 2 qian; Tiannanxing (Arisaema) 2 qian; Renshen (ginseng) 3 qian; Gancao (licorice) 8 fen.

Cut the above into a single dose; add 3 slices of ginger and 1 jujube; boil in water until done; take together with Zhuli (bamboo sap) and ginger juice.

One version adds Fangfeng (Saposhnikovia) and Baifuzi (Typhonium); it is especially effective.

It treats wind-stroke with clouded obtundation, loss of consciousness, deviated mouth and eye, hemiplegia, rattling in the throat, and phlegm and qi surging upward. Regardless of whether caused by external wind-cold or internal injury from joy and anger, and whether the six pulses are deep-hidden or forcefully floating under the fingers, it is appropriate to take. It also treats phlegm syncope and fluid-retention syncope, as well as qi-deficiency vertigo of a cold-deficiency type.

From Gong Tingxian's description of Qingre Daotan Tang's indications, he used this formula to treat what modern medicine calls stroke. The patient is comatose, with deviated mouth and eye and hemiplegia, and accompanied by symptoms of pulmonary infection, but not yet so severe as to cause sudden death. In ancient times such patients were very hard to rescue. The Qing physician Xu Lingtai once said that patients with this true wind-stroke could basically not be cured under Qing medical conditions, with an extremely high mortality rate.

Even today, whether such a patient can be rescued is uncertain. In better-equipped hospitals the rescue success rate may be a little higher; in poorer hospitals the mortality will be higher still. Of those rescued, most are left with sequelae.

If an integrated Chinese-Western regimen is adopted at the very onset of stroke, it can not only improve survival but also reduce the chance of sequelae. Even if sequelae occur, the symptoms will be milder.

In practice I often see stroke patients with severe sequelae; after discharge they require enormous care from their families, and the patients themselves have a poor quality of life and a low mood. At such moments I regret that modern hospitals dare not attempt integrated Chinese-Western treatment of stroke.

Gong Tingxian's Qingre Daotan Tang is a stroke formula of considerable research and practical value. It was developed by modifying Erchen Tang (Two-Aged Decoction), Jupi Zhuru Tang (Tangerine Peel and Bamboo Shavings Decoction), and Huanglian Huangqin Banxia Xiexin Tang (Coptis-Scutellaria-Pinellia Heart-Draining Decoction).

Used together, these three formulas expel phlegm, reduce fever, fight infection, and promote arousal, shortening the patient's coma and thereby lowering the probability and severity of stroke sequelae. The longer a stroke patient remains comatose and the longer the pulmonary infection persists, the higher the probability and complexity of later sequelae; resolving coma and pulmonary infection promptly creates favorable conditions for later rehabilitation.

Huanglian Huangqin Banxia Xiexin Tang comes from the Shanghan Lun and consists of Coptis, Scutellaria, Pinellia, ginseng, ginger, and jujube; it is the representative formula for intermingled cold and heat, nausea and vomiting, and epigastric glomus and abdominal distension, with good effect on these symptoms caused by digestive and respiratory infections. Erchen Tang consists of tangerine peel, Pinellia, Poria, and licorice, and is the representative TCM formula for expelling phlegm and stopping vomiting. Jupi Zhuru Tang consists of tangerine peel and bamboo shavings (here replaced by bamboo sap; fresh bamboo-sap oral liquid is available at pharmacies and may be used directly), and is likewise a representative phlegm-expelling, vomiting-stopping formula. The added Baifuzi, Jiegeng, and Tiannanxing all also expel phlegm and stop vomiting.

Why did Gong Tingxian combine three classic antiemetic formulas? Because stroke patients, with brain tissue compressed by cerebral edema, have typical nausea and vomiting, and most also have infections. For this kind of vomiting, weak medication is useless; combining the three formulas is forceful and gives good symptomatic treatment. Combining them is equivalent to modern medicine using mannitol together with antibiotics—both reducing cerebral edema and fighting infection.

Antiquity lacked today's advanced diagnostic tools, yet ancient physicians worked out rich symptomatic treatments in practice, which is remarkable. I have long advocated a "cocktail" approach to refractory diseases, treating them with large compound formulas. Gong Tingxian's composing approach is a typical cocktail therapy. If, as we learn, we carefully think through how these experienced clinicians compose formulas, over time we too will become adept in our own clinical practice.

To prescribe such complex and effective formulas, a physician's basic skills must be solid. These large prescriptions look complex at first glance, but if one is thoroughly familiar with TCM's foundational formulas, the composer's reasoning is plain at a glance. Many effective TCM formulas, like permutations and combinations in mathematics, are organic combinations of different elements according to definite rules—not reckless drug use.

This is the internal logic of TCM diagnosis and treatment, and it is perfectly clear. Once this logic is grasped, a clinician treating disease need not be overly idealistic, reasoning from theories like yin-yang and the five phases. With respect, if our diagnosis and treatment are too subjective and arbitrary, whether a patient improves becomes purely a matter of luck, which is very risky. But if we build diagnosis and treatment on distinguishing symptoms and then seeking objective medication indications, prescribing according to the actual experience of predecessors, we will not go too far astray.