Several Treatments for Shaoyin Sore-Throat Patterns in the Shanghan Lun

Sore throat is a very common clinical symptom. In the Shanghan Lun, the chapter "Differentiating and Treating the Pulse and Manifestations of Shaoyin Disease" contains several passages addressing sore throat, and later practitioners of throat disorders have long used their formulas.

The original text of the Shanghan Lun reads:

"In Shaoyin disease, with diarrhea, sore throat, chest fullness, and vexation, Pig-skin Decoction (Zhutu Tang) governs. Zhutu Tang: one jin of pig skin. The single ingredient is boiled in one dou of water down to five sheng, the dregs removed; add one sheng of white honey and five ge of fried rice powder, stir until well combined, and take warm in six divided doses."

"In Shaoyin disease on the second or third day with sore throat, Licorice Decoction (Gancao Tang) may be given; if not cured, give Jiegeng Tang. Gancao Tang: two liang of Gancao. The single ingredient is boiled in three sheng of water down to one and a half sheng, the dregs removed; take seven ge warm, twice daily. Jiegeng Tang: one liang of Jiegeng, two liang of Gancao. Boil the two ingredients in three sheng of water down to one sheng, remove dregs, and take warm in two divided doses."

"In Shaoyin disease with the throat injured and sores formed, inability to speak, and loss of voice, Bitter-wine Decoction (Kujiu Tang) governs. Kujiu Tang: Banxia (washed, broken into pieces the size of a jujube pit, fourteen pieces), one chicken egg (yolk removed; the bitter wine is placed in the eggshell). Put the Banxia and bitter wine in the eggshell, set it on the ring of a knife over the fire, and bring to three boils; remove dregs and swallow small amounts. If not cured, make three more doses."

"In Shaoyin disease with sore throat, Banxia Powder and Decoction (Banxia San Ji Tang) governs. Banxia San Ji Tang: Banxia (washed), Guizhi (bark removed), Gancao (processed), equal parts of each. Pound and sift the three ingredients separately, combine, and take with white rice water, a fangcunbi measure, three times daily. If unable to take as powder, boil one sheng of water for seven boils, add two fangcunbi of powder, boil three more times, remove from heat until slightly cool, and swallow small amounts."

These passages have rarely been analyzed in detail by scholars; these formulas are seldom used, there are few instructive case records, and the explanations of the herbs involved are rather forced.

Professor Liu Duzhou held that Zhutu Tang treats Shaoyin yin-deficiency sore throat; Gancao Tang and Jiegeng Tang treat sore throat from Shaoyin deficiency-fire flaring upward; Kujiu Tang treats the Shaoyin pattern of throat injury and sores; and Banxia San Ji Tang treats Shaoyin sore throat from guest cold.

Professor Hu Xishu held that the various Shaoyin sore-throat patterns mentioned by Zhongjing represent Shaoyin disease transitioning to Shaoyang with exuberant Shaoyang heat, and that these formulas therefore treat Shaoyang patterns.

From these passages of Zhang Zhongjing, Shaoyin sore throat must also be classified and treated according to pattern; it is just that Zhongjing's original text is itself very brief. He gives separate treatments for the various sore throats and loss of voice caused by Shaoyin disease, but does not explain their causes.

I will venture to analyze the Shaoyin pattern through the functions of the herbs Zhongjing used in its sore-throat patterns.

Zhutu is pig skin—the thin outermost layer of pork, now usually cut off when buying meat because it is hard to slice. This layer has little fat; its main component is collagen. The collagen in pig skin can be processed into gelatin, which has a network-like spatial structure that binds large amounts of water and enhances cellular physiological metabolism. If the body lacks this collagen—a biological macromolecular gel substance—the mechanism by which cells store water is disrupted. When the amount of water bound by cells drops markedly, the body undergoes "dehydration": at the mild end, dry, flaking skin that loses elasticity and wrinkles; at the severe end, it threatens life.

Traditional Chinese medicine holds that pig skin nourishes yin and supplements deficiency, and clears heat and soothes the throat—a view that coincides with modern pharmacology's understanding of pig skin. What TCM calls yin deficiency often leads to dryness and low-grade fever; from a modern medical standpoint, TCM's yin-deficiency dryness is a symptom of cellular water shortage.

Then it is not hard to understand why Zhang Zhongjing uses Zhutu Tang in this passage. Zhutu Tang addresses Shaoyin disease presenting with diarrhea, sore throat, chest oppression, and vexation. Diarrhea is loose bowels; too much of it leads to dehydration. Such a patient is prone to dehydration and weak as well, so Zhang Zhongjing's choice of Zhutu Tang could not be better.

I often use Zhutu Tang for diarrhea and sore throat arising after chemotherapy or targeted therapy in cancer patients. Chemotherapy and targeted drugs strongly irritate the gastrointestinal tract, so some patients develop very severe diarrhea; these patients also often have sore throat and generalized aching. Zhutu Tang works well for them.

Besides pig skin, Zhutu Tang also uses honey. Here the pig skin is half a jin—about 120 g in Han times—the honey one sheng—about 200 mL—and the white powder five ge—about 100 mL of rice powder. The "white powder" in Zhutu Tang is rice stir-fried then ground into powder. So this formula consists entirely of food. Honey has a laxative and ulcer-healing effect; rice powder has an astringent, intestine-stopping and spleen-fortifying effect.

Taken together, these three ingredients give us a rough idea of Zhutu Tang's indication: it treats the various sore throats caused by dehydration from any cause. The collagen in pig skin, made into gelatin, also has anti-aging and anticancer effects.

Zhutu Tang is not limited to the problems Zhang Zhongjing mentions; patients with withered hair, dry skin, and frequent nosebleeds can also be treated with it, because these are all caused by cellular water shortage.

Another food-medicine Zhang Zhongjing uses is jizi—chicken egg. He uses the egg white, removing the yolk. Egg white not only treats sore throat but also clears the voice; ancient Chinese opera singers knew this well. Actors in old China drank a little raw egg white every day to protect their voices. Nowadays some teachers, with occupational damage and frequent sore throats, I also treat with egg white.

What is egg white's main component? Water and protein: 87% of egg white is water, only 13% solids. Of the solids, ovalbumin is 75%, ovomucoid 15%, ovomucin 7%, and conalbumin 3%. Egg white begins as the cytoplasm of a single-cell ovum and nourishes the developing embryo, so it has a fine cell-repairing action.

Traditional Chinese medicine holds that egg white clears heat and resolves toxin, and moistens the lung and soothes the throat. Zhang Zhongjing often used egg white for sore throat, showing that the working people of ancient China had already discovered this effect in practice. In fact, many doctors who use Zhutu Tang also give egg white, the two combined strengthening the treatment of sore throat.

Egg white also has a detoxifying action: many poisonings from drugs or foods can be countered with egg white. There is a whole chapter on detoxification in TCM internal medicine, in which egg white is used often. When Zhang Zhongjing treated Shaoyin sore throat and used the violently toxic Banxia, he paired it with egg white: on one hand egg white treats sore throat, and on the other it antidotes Banxia, preventing Banxia poisoning.

Gancao (licorice) has an extremely broad range of effects; it is the single most prescribed herb in TCM formulas. Known as the "elder statesman" of Chinese herbs, it fortifies the spleen and boosts qi, clears heat and resolves toxin, dispels phlegm and stops cough, moderates urgency and stops pain, and harmonizes all the herbs. Using Gancao for sore throat draws on its phlegm-dispelling and pain-stopping merits, generally for sore throat from inflammation of the throat.

Jiegeng (Platycodi) is one of the dedicated herbs for throat disorders; it diffuses the lung, soothes the throat, dispels phlegm, and expels pus. TCM uses it for cough with abundant phlegm, chest oppression, sore throat, hoarseness, lung abscess with pus, and sores that have formed pus but not ruptured.

So Gancao Tang and Jiegeng Tang are generally used for sore throat with inflammation and redness/swelling of the throat, but not severe. In TCM terms, Gancao Tang and Jiegeng Tang clear heat and resolve toxin—what Professor Liu Duzhou called treating flaring deficiency fire. It should be noted that sore throat is not always caused by flaring deficiency fire; acute tonsillitis and epiglottitis and other emergencies are often unrelated to deficiency fire and are caused by external contraction, and these too can be treated with raw Gancao and Jiegeng.

Banxia has a strong phlegm-dispelling effect; Kujiu Tang uses Banxia and egg white mainly for Banxia's phlegm-expelling power. When sores form in the throat, abundant secretions are inevitably produced; what TCM calls dispelling phlegm is, in Western terms, the expulsion of inflammatory secretions. Banxia has this effect. The "bitter wine" in Kujiu Tang is what we today call vinegar, which also has anti-inflammatory and antibacterial effects; hence Kujiu Tang is not decocted in water but in vinegar, drawing on vinegar's medicinal value.

Generally, severe throat inflammation causes edema and ulcers; folk medicine calls this condition "milk moth." Shining a flashlight into the throat reveals severe edema. The patient cannot only speak but sometimes cannot even swallow water. This is treated with Kujiu Tang, taken by slowly swallowing small amounts—simply because the throat hurts too much to drink medicine in quantity.

But in my view Kujiu Tang is still a bit dangerous: Banxia is highly toxic and can kill. By my family's transmitted method, one squeezes a certain wild herb and drips the juice into the nose; it works very well. Unfortunately I have never known this herb's formal name; I have asked many experts and no one recognizes it, so it cannot be popularized.

Banxia Powder uses not only Banxia but also the pungent-warm Guizhi. Professor Liu Duzhou says Banxia Powder resolves Shaoyin sore throat from guest cold—a phrase not easy for most to understand. In fact it is a common symptom at the onset of a cold when a weak person is struck by wind-cold. Many people have had the experience: after catching cold, before any other symptom appears, the throat hurts first. At this point, using some Guizhi to scatter wind-cold, some Banxia to dispel phlegm, and some Gancao to stop pain solves the problem.

I personally also often cook a soup of scallion white and fresh ginger, adding some honey, to resolve this kind of sore throat. Scallion and ginger scatter wind-cold, and honey plays the same role as Gancao; these things are more convenient than decocting herbs, and all are foods with no side effects, safe to use.

With this analysis, we gain a fairly clear picture of the classified treatment of Shaoyin sore throat. Zhang Zhongjing is remarkable: he gathered the several methods for treating sore throat together. Because TCM holds that the Shaoyin channel circulates through the throat, he classified sore throat under the Shaoyin section. From ancient times to today, most commentators on the Shanghan Lun have been vague at this passage; because the rationale of the herbs is hard to explain by TCM theory, they cannot make it clear, which makes choosing a formula clinically very difficult.