An Experiential Formula for Cough and Wheezing: Xiao Chaihu Tang Plus Schisandra

Xiao Chaihu Tang (Minor Bupleurum Decoction) comes from the Shanghan Lun. Among the indications treated by Xiao Chaihu Tang is cough. But the causes of cough are very complex, and not all coughs are suitable for treatment with Xiao Chaihu Tang.

The Shanghan Lun has this passage: "In cold damage of five or six days, or wind-strike, with alternating chills and fever, fullness and discomfort in the chest and hypochondrium, silence and no desire to eat or drink, vexation in the heart and frequent nausea, perhaps vexation in the chest without nausea, or thirst, or abdominal pain, or hard fullness below the ribs, or palpitations below the heart with difficult urination, or no thirst with mild fever on the body, or cough—Xiao Chaihu Tang governs."

So the cough treated here by Xiao Chaihu Tang is mainly caused by shaoyang constraint-heat not being vented, and by disharmony of yin and yang. If a patient shows the main shaoyang signs of "bitter mouth, dry throat, dizziness, vexation in the heart and frequent nausea, and a wiry or deep-tight pulse," together with incessant cough, then using Xiao Chaihu Tang is exactly the right match.

The original Xiao Chaihu Tang is: half a jin of Chaihu (Bupleurum), three liang of Huangqin (Scutellaria), three liang of Renshen (ginseng), half a sheng of Banxia (Pinellia), three liang of Zhi Gancao (honey-fried licorice), three liang of Shengjiang (fresh ginger), and twelve Dazao (jujubes, broken apart).

Now commonly used: Chaihu 12-24g, Huangqin 6-9g, Renshen (or Dangshen, Codonopsis) 6-9g, Fabanxia (processed Pinellia) 6-9g, Zhi Gancao 6-9g, Shengjiang 6-9g, Dazao 3-7 pieces.

My own habitual dose is Chaihu 12-24g, Huangqin 9g, Dangshen 9g, Fabanxia 9g, Zhi Gancao 9g, Shengjiang 3-5 slices, Dazao 3-5 pieces. If used to treat intractable cough, add 12g of Wuweizi (Schisandra) on top of the above.

The sovereign herb of Xiao Chaihu Tang is Chaihu, so the dose of Chaihu must not be less than the other herbs. Ideally, the dose of Chaihu should be twice or even three times that of Renshen and the others.

The Shennong Bencao Jing records that Chaihu "is bitter and neutral; it governs bound qi in the heart, abdomen, and intestines-stomach, accumulations of food and drink, and cold-heat evil qi, pushing out the old and bringing forth the new." If, in Xiao Chaihu Tang, the dose of Renshen and the other herbs exceeds that of Chaihu, it will cancel out Chaihu's effect of dispersing bound qi.

The role of Chaihu and Huangqin in Xiao Chaihu Tang is mainly to diffuse the constrained heat of the liver and gallbladder and to smooth the qi mechanism of the liver and gallbladder. The role of Fabanxia and Shengjiang is to harmonize the stomach, downbear counterflow, and stop vomiting, while also helping Chaihu vent the shaoyang evil. The effect of Renshen, Zhi Gancao, and Dazao is to fortify the spleen and harmonize the center; they can both boost stomach qi to assist the pivoting of shaoyang and also have the preventive effect of, "seeing liver disease, knowing the liver transmits to the spleen, one must first fortify the spleen" (a saying from the Jingui Yaolue), preventing shaoyang liver-gallbladder disease from transmitting to the spleen. These three groups of herbs together embody the spirit of TCM's great harmonizing method; this is the formula-composition principle of this prescription.

Therefore, in Chen Xiuyuan's "Cough" poem in the Yixue Shizai Yi (Medicine That Is Truly Easy), Xiao Chaihu Tang is specifically listed as an excellent formula for treating difficult cough-and-wheezing diseases. Chen Xiuyuan said: "The source of cough is the branch-rheum in the chest; seek no wonder formula beyond this prescription; those who thoroughly read the Jingui will understand. There are also the Xiao Chaihu modifications, which free the fluids and treat the grievous."

Chen Xiuyuan believed that Xiao Chaihu Tang can unblock the sanjiao, so that the body's qi mechanism is regulated, the fluids descend, and the stomach qi harmonizes; then the wind-cold evil will not carry the fluids upward to gather in the diaphragm, turning to phlegm over time and causing incessant cough. This argument is also quite reasonable.

In the Xiao Chaihu Tang line of the Shanghan Lun it says: "For cough, remove Renshen and Shengjiang, add Ganjiang (dried ginger) and Wuweizi." Whether to remove Renshen here depends on whether the patient is thirsty; if thirsty, Renshen should still be used to generate fluids.

Zhang Lei treated a female patient with a 40-year chronic cough; the patient had coughed since age seven, flaring each autumn, worse in winter, and resolving on its own in summer. The phlegm was copious and thin, making it hard to sleep, and the throat was itchy. Seeking treatment everywhere to no avail, Zhang Lei treated her with modified Xiao Chaihu Tang plus Wuweizi.

Prescription: Chaihu 9g, Banxia 9g, Huangqin 9g, Dangshen 9g, Wuweizi 9g, Gancao 6g, Shengjiang 9g, Dazao 4 pieces, decocted in water. After one dose she could sleep peacefully; after four doses the cough was more than half gone; after several more doses the cough stopped. Zhang Lei was inspired by Chen Xiuyuan and treated according to Chen Xiuyuan's approach.

Liu Xi is an expert skilled in using Xiao Chaihu Tang to treat diseases that flare at fixed times. He treated a patient who, every night at the midnight (zi) hour, suffered wheezing and vexation; judging that the patient had a fine-wiry pulse and that the zi hour is when shaoyang qi rises, he used the original Xiao Chaihu Tang, which specifically treats shaoyang disease, and the patient was cured after three doses.

So if pattern differentiation shows some features of shaoyang disease, treating cough with Xiao Chaihu Tang as the main formula is quite effective. Adding Wuweizi to astringe the lung and stop cough adds the effect of matching the symptoms.

Finally, a reminder: Xiao Chaihu Tang, as the representative formula of the harmonizing method, is decocted differently from other formulas. Xiao Chaihu Tang requires adding 3-4 bowls of water; once decocted down to half, remove the dregs, then decoct the medicinal liquid again until only one quarter of the original water amount remains.

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