Oral ulcers are a common and frequently encountered condition in clinical practice. The conventional approach is to clear heat and fire — patent remedies such as Niuhuang Shangqing Pill or Huanglian Shangqing Pill generally produce satisfactory results. Some cases, however, are more complex: when cold and heat are intermingled in the body and ulcers recur persistently, Licorice Xiexin Decoction often works remarkably well. Yet a subset of oral ulcers remains stubbornly refractory to treatment.
During a teaching and research session today, a colleague mentioned the method of thickening earth to restrain fire (厚土敛火). Upon closer examination, it proved to be an unusual and insightful approach.
This method likely originated in the Qing Dynasty. Zai Jin (尤在泾), in particular, was adept at using thickened earth to restrain fire when treating epistaxis (齿衄), reasoning that deficiency-cold of the spleen and stomach generates Yin Fire internally, which then ascends to disturb the clear orifices and forces blood to flow recklessly. Naturally, when Yin Fire is mentioned, one thinks of Li Dongyuan (李东垣), and many practitioners accordingly adopt Buzhong Yiqi Decoction (补中益气汤) as their principal means of thickening the earth.
The theoretical foundation of this approach ultimately rests on the premise that “spleen deficiency fails to restrain fire” (脾虚不能敛火) — a rather novel formulation. The primary manifestation of spleen deficiency should be Qi deficiency. After all, as Li Dongyuan wrote, “When the Qi of the spleen and stomach is deficient and cannot ascend and float, it is because Yin Fire injures the Qi of growth and development.” Yet according to Zhu Danxi (朱丹溪), insufficient Qi does not produce fire — so this fire must be a deficient fire, not a vigorous one. Restraining it by tonifying deficiency is therefore feasible. Otherwise, fire is the sort of thing that grows more fierce the more you tonify it.
Recently, I encountered a case of recurrent oral ulcers. An elderly man, robustly built, had suffered from recurring ulcers for nearly ten years — virtually every day, with new lesions appearing as soon as the old ones healed. He had been taking Niuhuang Jiedu Tablets year-round; they provided some relief, but without them the pain was unbearable. On examination, his tongue coating was thin with a slightly red body, the tongue surface was slippery, and his pulse was slippery and rapid — a picture of Qi and blood surging turbulently. I prescribed a modified combination of Licorice Xiexin Decoction and Longdan Xiegan Decoction. After three doses, the ulcers subsided, but five days later a new one appeared. He took the medicine again — it subsided, then recurred again. It seemed to have entered an infinite loop, and the patient did not return for follow-up.
I believe this presentation also reflects spleen deficiency with floating Qi (脾虚气浮). A large dose of spleen-strengthening herbs should be added on top of the fire-clearing base. I suspect that incorporating Buzhong Yiqi Decoction or Lizhong Decoction (理中汤) would be appropriate. It is certainly worth trying when similar cases arise in the future.
中文原文 / Chinese Original
口腔溃疡是临床的常见病多发病，常规治疗是清火法，服用成药牛黄上清丸或黄连上清丸一般都有良好的疗效。亦有些复杂的情况，例如身体寒热错杂，口腔溃疡反复发作的，用甘草泻心汤治疗往往收效甚佳，但是，仍有部分口腔溃疡难以治愈。今日教研活动，有老师提到了厚土敛火法，细细察看，果然不同寻常。
此法应出自清朝，尤在泾治齿衄善用厚土敛火，认为脾胃虚寒，阴火内生，上干清窍，迫血妄行而致齿衄。当然提到阴火，自然想到了李东垣，所以有许多一家选用补中益气汤作为厚土的主要方法。
这个治法归根结底，其理论基础是”脾虚不能敛火”，这是个很新奇的提法，脾虚主要表现还应该是气虚，毕竟”脾胃气虚不能升浮,为阴火伤其生发之气”，然而按照朱丹溪的说法，气不足不会有火，那么这个火自然是虚火，不是旺火，通过补虚进行收敛是可行的。否则，火这种东西是越补越旺。
近期我遇到了一例反复发作的口腔溃疡。一老年男性，体壮，溃疡反复发作近十年，基本上每天都会有，消下去马上就会长出新的，所以常年服用牛黄解毒片，吃上就会好一些，否则疼痛难忍。刻诊苔薄质略红，舌水滑，脉滑数，一派气血奔腾的样子，于是给了甘草泻心汤合龙胆泻肝汤加减。吃下三副后溃疡消退，但是5天之后又新发一个，再服药再消退再发，似乎又进入了死循环，此后患者不再复诊。我想，这种情况应该也是脾虚气浮的表象，应该在清火的基础上加用大量健脾药物。我猜想，加补中益气或者理中汤应该都是合适的，日后遇到此类情况值得一试。
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