It is generally accepted that Liuwei Dihuang Pills first appeared in Pediatric Medicine Certificate by Qian Yi of the Song Dynasty, where it was simply called “Dihuang Pills.” Most scholars believe it was derived from Zhang Zhongjing’s Eight-Ingredient Pills.

The standard TCM textbook Prescriptionology describes it as follows:

Composition: Prepared Rehmannia Root 24 g, Asiatic Cornelian Cherry Fruit 12 g, Chinese Yam 12 g, Oriental Waterplantain Rhizome 9 g, Tree Peony Root Bark 9 g, Poria 9 g.

Method: Grind into powder, mix with refined honey to form pills the size of phoenix tree seeds. Take three pills dissolved in warm water on an empty stomach. (Modern usage: may also be taken as a decoction.)

Actions: Nourish the liver and kidney.

Indications: Liver and kidney yin deficiency syndrome — soreness and weakness in the lower back and knees, dizziness, tinnitus, nocturnal emissions, excessive thirst, bone-steaming tidal fever, heat sensation in the palms and soles, dry mouth and throat, loose teeth, heel pain, dribbling urination, and in children, failure of the fontanelle to close. The tongue is red with scanty coating; the pulse is deep, fine, and rapid.

Principles of Combination: The syndrome addressed by this formula has liver and kidney yin deficiency as its root, with concurrent interior harassment by deficient heat. Treatment should primarily nourish liver and kidney yin, supplemented by herbs that clear deficient heat and drain damp-turbidity. The formula is derived from “Cui’s Eight-Ingredient Pills” recorded in the Essentials from the Golden Cabinet (which Zhang Zhongjing renamed Kidney Qi Pills) by removing cinnamon twig and prepared aconite. Prepared Rehmannia is used in heavy dosage as the sovereign herb to nourish yin, supplement the kidney, and fill the essence and marrow. The deputy herbs are Asiatic Cornelian Cherry to nourish liver and kidney while astringing essence (reflecting the principle that “liver and kidney share the same source”), and Chinese Yam to supplement spleen yin while also consolidating the kidney. Together these three form the “Three Supplements.” Assisted by Oriental Waterplantain to drain dampness and purge kidney turbidity while reducing the greasiness of Prepared Rehmannia, Poria to percolate spleen dampness and support Chinese Yam’s transformation, and Tree Peony Root Bark to clear and drain deficient heat while restraining the warm-astringent nature of Cornelian Cherry. These three are called the “Three Drainers.” All six ingredients together supplement and drain, with supplementation as the primary aim; liver, spleen, and kidney yin are all nourished, with kidney yin as the principal focus.

Differentiation: Zhibo Dihuang Pills, Qiju Dihuang Pills, Maiwei Dihuang Pills, and Duqi Pills are all modifications of Liuwei Dihuang Pills, all possessing the ability to nourish yin and supplement the kidney. Among them, Zhibo Dihuang Pills lean toward nourishing yin and descending fire, suitable for yin deficiency with hyperactive fire, bone-steaming tidal fever, nocturnal emissions, and night sweats. Qiju Dihuang Pills emphasize nourishing the liver and brightening the eyes, suitable for liver and kidney yin deficiency with blurred vision. Maiwei Dihuang Pills focus on nourishing the kidney and astringing the lung, suitable for panting and coughing due to lung and kidney yin deficiency. Duqi Pills emphasize nourishing the kidney and grasping qi, suitable for panting and counterflow due to kidney deficiency.

However, when I consulted the original texts of Pediatric Medicine Certificate, Danxi’s Mastery of Medicine, He’s Transmission on Consumptive Disease, Collected Discourses of Wu Physicians, and Enlightenment on Deficiency and Damage, none of them mentioned tongue presentation. Most regarded Liuwei Dihuang Pills as a formula for nourishing kidney water. When modern textbooks were compiled, it was taken for granted that since the pills are a yin-nourishing formula, they must naturally treat yin deficiency patterns, and therefore the physical symptoms should uniformly present as yin deficiency — hence the description found in Prescriptionology.

In clinical practice, Liuwei Dihuang Pills are widely used with generally good results. Yet I have always felt that the description of yin deficiency — particularly the tongue sign of “red tongue with scanty coating” — is not very typical. Most of the time, when I observe a deep, fine chi (proximal) pulse, I can already consider using the principle of Dihuang Pills.

It wasn’t until this year, when Professor Shi Xinde was teaching our class, that he specifically pointed out the applicable tongue presentation for Liuwei Dihuang Pills: a tender, slightly red and somewhat enlarged tongue, with a thin and scanty coating. This directly inspired me — one cannot say this tongue picture is not yin deficiency, but it differs from the dry, red tongue with scanty coating seen in yin deficiency with hyperactive fire. The tongue in Liuwei Dihuang Pills does not need to be very red; as long as it is not pale white, it suffices. Furthermore, the tongue body should not be rough or old in texture, and the presence of teeth marks is an important sign — this is precisely the tongue of deficiency and damage, indicating insufficient kidney water rather than yin deficiency with blazing fire.

I had the opportunity to put this theory to a small clinical test. A patient had been experiencing frequent epigastric pain recently — mostly colicky and hard to bear, worsening with cold. Urinalysis had shown white blood cells for nearly half a year. She was losing one to two jin of body weight per month. Her mouth and nose were dry, while bowel movements and urination were normal. Her appetite was good, but sleep was poor with many dreams. Her tongue was tender-red, somewhat enlarged, with slight teeth marks and a white, dull coating. I differentiated this as dual deficiency of spleen and kidney, with cold pathogen lodging in the stomach, and prescribed the following:

Prepared Rehmannia 24 g, Chinese Yam 12 g, Asiatic Cornelian Cherry 12 g, Oriental Waterplantain 9 g, Tree Peony Root Bark 9 g, Poria 9 g, Dried Ginger 6 g, Pinellia 9 g, Evodia Fruit 3 g, Coptis 3 g, Scutellaria 6 g, Honey-fried Licorice 6 g.

A week later she returned for a follow-up visit. All signs and symptoms had greatly improved. Urinalysis was not repeated, and the guardian formula was continued.

The outcome of this case has had a profound impact on me. In the current system of TCM internal medicine, there is far too much taken for granted. When I was reviewing for my doctoral entrance exams, the formulas in the internal medicine sections contained far too many repetitions of Guipi Decoction and Dihuang Pills. Many identical patterns were separated out under different diseases. Although the Chinese language is powerful, no matter how the pattern description changes, the same formula is still used — this creates enormous confusion for students. You could call it “treating different diseases with the same method,” but it feels devoid of genuine character. I believe this is the result of infiltration by modern medical thinking. Its toxic influence is widespread and directly contributes to the decline in clinical efficacy.

目前公认六味地黄丸是宋代钱乙首先刊登在《小儿药证直诀》中，名为”地黄丸”，一般认为是从张仲景八味丸化裁而来。

中医统编教材《方剂学》认为：

【组成】 熟地黄八钱（24g） 山萸肉 干山药各四钱（各12g） 泽泻 牡丹皮 茯苓各三钱（各9g）

【用法】 上为末，炼蜜为丸，如梧桐子大。空心温水化下三丸（现代用法：亦可水煎服）。

【功用】 滋补肝肾。

【主治】 肝肾阴虚证。腰膝酸软，头晕目眩，耳鸣耳聋，盗汗，遗精，消渴，骨蒸潮热，手足心热，口燥咽干，牙齿动摇，足跟作痛，小便淋沥，以及小儿囟门不合，舌红少苔，脉沉细数。

【配伍意义】 本方证以肝肾阴虚为本，兼有虚热内扰。治宜滋补肝肾为主，适当配伍清虚热、泻湿浊之品。本方为《金匮要略》所载之”崔氏八味丸”（仲景易名日肾气丸）减去桂枝、附子而成。方中重用熟地黄滋阴补肾，填精益髓，为君药。臣以山茱萸补养肝肾，并能涩精，取”肝肾同源”之意；山药补益脾阴，亦能固肾。三药配合，是为”三补”。佐以泽泻利湿而泄肾浊，并能减熟地黄之滋腻；茯苓淡渗脾湿，并助山药之健运；丹皮清泄虚热，并制山萸肉之温涩。三药称为”三泻”。六味合用，三补三泻而以补为主；肝、脾、肾三阴并补而以补肾阴为主。

【鉴别】 知柏地黄丸、杞菊地黄丸、麦味地黄丸、都气丸四方均由六味地黄丸加味而成，皆具滋阴补肾之功。其中知柏地黄丸偏于滋阴降火，适用于阴虚火旺、骨蒸潮热、遗精盗汗之证；杞菊地黄丸偏于养肝明目，适用于肝肾阴虚、两目昏花、视物模糊之证；麦味地黄丸偏于滋肾敛肺，适用于肺肾阴虚之喘嗽；都气丸偏于滋肾纳气，适用于肾虚喘逆。大补阴丸（大补丸）

但是，我查阅《小儿药证直诀》、《丹溪心法》、《何氏虚劳心传》、《吴医汇讲》、《虚损启微》这几本书，原文中均未提及舌象，大多认为六味地黄丸为滋补肾水之方，现代编书时可以想当然地认为六味地黄丸是滋阴剂，自然是治疗阴虚证，那么身体的症状应该也是一派阴虚的症状，故在方剂学中有以上描述。

临床中，六味地黄丸的运用也很广泛，效果大多不错，可是，阴虚证的描述和舌红少苔这个舌象我认为并不是很典型，大多数时候，我从脉象看到尺脉沉细基本都可以用到地黄丸的意思。

直到今年，史欣德老师在给我们上课的时候特别讲到，六味地黄丸适用的舌象是舌嫩红偏胖大，舌苔薄少，这直接启发了我，这种舌象你不能说他不是阴虚，但又与阴虚火旺的干红少苔有所不同。六味地黄丸的舌象不一定非常红，只要不是淡白应该就可以，另外，舌质不宜老，有齿痕也是一个重要征象，这正是虚损的舌象，是肾水不足，而不是阴虚火旺。

在临床上我也小小地验证了一下理论，这位患者近期时常胃脘疼痛，多为绞痛，难以忍受，且遇凉加重，另查尿中有白细胞近半年，体重每月下降1-2斤，口干鼻干，二便可，纳佳，寐差，梦多，舌质嫩红胖大略有齿痕，苔白暗。辨为脾肾两虚，且有寒邪客胃，处方如下：

熟地黄24g，山药12g，山萸肉12g，泽泻9g，丹皮9g，茯苓9g，干姜6g，半夏9g，吴茱萸3g，黄连3g，黄芩6g，炙甘草6g。

一周后复诊，诸证皆大为好转，小便未查，守方续进。

此案的收效对我影响极大，在目前的中医内科学体系中，有太多的想当然，在我考博复习的时候，中内的方剂中重复了太多的归脾汤、地黄丸，病里分出很多一样证，虽然汉语很强大，但是无论证怎么变还是用相同的方，给学生的学习造成很大的困扰。你说这是异病同治吧，感觉很没有特色，我认为这还是现代医学思维的渗入所致，其毒害之广，直接造成临床疗效的下降。