Hypertension in Young and Middle-aged Adults - Master Guo Ziguang’s “San Huang Shi Gao Tang” (Three Yellows and Raw Gypsum Decoction)
17. Hypertension in Young and Middle-aged Adults - Master Guo Ziguang’s “San Huang Shi Gao Tang” (Three Yellows and Raw Gypsum Decoction)
I. Master Guo Ziguang, a National Master of Traditional Chinese Medicine. This formula is recorded in “A Hundred Years of Chinese Medicine: A Hundred Clinical Masters of Traditional Chinese Medicine - National Masters Volume: Guo Ziguang,” and is his representative empirical formula for treating hypertension in young and middle-aged adults accompanied by metabolic abnormalities.
II. Pathogenesis
The pathogenesis of hypertension in young and middle-aged adults mostly involves Liver Yang rising upward with concurrent Phlegm-Dampness and Blood Stasis. Patients in this age group, due to long-term imbalance between work and rest, overindulgence in rich and fatty foods, and immoderate smoking and drinking, develop Liver stagnation transforming into Fire that depletes Liver Yin; when Liver Yang rises excessively, blood pressure elevates. When Spleen transport and transformation are impaired, Phlegm-Dampness is internally generated; when Phlegm obstructs the collaterals, blood flow is impeded and gradually forms Blood Stasis. Fire, Phlegm, and Stasis intertwine, and clinically, elevated blood pressure is commonly accompanied by abnormal blood glucose, blood lipids, and blood viscosity - the so-called “five highs” coexisting. The disease nature is root deficiency with manifest excess: Liver Yin insufficiency is the root, while Fire, Phlegm, and Stasis are the manifest signs. In the acute phase, the priority should be on clearing and draining Liver Fire, resolving Phlegm, and dispelling Stasis.
Formula Composition
Composition: Coptis 10g, Scutellaria 10g, Phellodendron 10g, Raw Gypsum 30g, Salvia 20g, Pueraria 20g, Earthworm 10g, Cassia Seed 15g, Alisma 15g, Processed Pinellia 12g, Chinese Achyranthes 15g
Efficacy: Clears and drains Liver Fire, resolves Phlegm and dispels Stasis
Indications: Hypertension in young and middle-aged adults (Liver Yang rising with Phlegm-Dampness and Blood Stasis pattern), accompanied by abnormal blood glucose, blood lipids, and blood viscosity
In this formula, the Three Yellows (Coptis, Scutellaria, Phellodendron) combined with Raw Gypsum clear and drain Fire and Heat from the Three Jiao, Liver, and Gallbladder as the sovereign herbs. Scutellaria clears upper jiao Lung and Liver Fire; Coptis clears middle jiao Heart and Stomach Fire; Phellodendron clears lower jiao Kidney and Bladder Fire. The Three Yellows respectively target the three jiao levels; combined with Raw Gypsum, they greatly clear excessive heat from the Qi level, dispersing Liver Fire both from above and below. Salvia, Pueraria, and Earthworm invigorate blood, resolve stasis, and open the collaterals, targeting the pathological products of Phlegm-Stasis obstructing the collaterals. Cassia Seed clears the Liver, benefits the eyes, and moistens the intestines to promote bowel movement; Chinese Achyranthes guides blood downward to lower the rising Liver Yang. Alisma promotes water drainage, leaches out dampness, and discharges heat; Processed Pinellia dries dampness, transforms phlegm, and descends counterflow. Together they regulate the middle jiao Qi mechanism so that Phlegm-Dampness is resolved. The entire formula does not focus directly on lowering blood pressure but instead addresses the underlying pathogenesis: when Fire is cleared, Yang naturally settles; when Phlegm is resolved, the vessel pathways open; when Stasis is removed, blood flows freely, and blood pressure naturally descends. In the original case records, Guo Ziguang combined this formula with Qi Ju Di Huang Wan to nourish the Kidney and Liver; using the decoction and pill formula in parallel addressed both root and branch.
| Herb Group | Herb Dosage | Function |
|---|---|---|
| Clear Heat, Drain Fire | Coptis 10g, Scutellaria 10g, Phellodendron 10g, Raw Gypsum 30g | The Three Yellows respectively clear Fire and Heat from the Three Jiao; combined with Gypsum, they greatly clear excessive heat from the Qi level, directly quelling the intensity of Liver Fire; when Fire descends, Liver Yang naturally stabilizes |
| Invigorate Blood, Open Collaterals | Salvia 20g, Pueraria 20g, Earthworm 10g | Salvia invigorates blood and resolves stasis; Pueraria releases the muscles, relaxes the sinews, and raises the clear Yang; Earthworm opens the channels and activates the collaterals. The three herbs together improve microcirculation and reduce blood viscosity |
| Pacify Liver, Descend Counterflow | Cassia Seed 15g, Chinese Achyranthes 15g | Cassia Seed clears the Liver, benefits the eyes, and moistens the intestines; Chinese Achyranthes invigorates blood, opens the menstruation, and guides blood downward. The two herbs guide the rising Liver Yang downward |
| Resolve Phlegm, Promote Dampness | Alisma 15g, Processed Pinellia 12g | Alisma promotes water drainage, leaches out dampness, and discharges Kidney turbidity; Processed Pinellia dries dampness, transforms phlegm, and descends counterflowing Qi. Together they regulate the middle jiao so that Phlegm-Dampness is resolved and Spleen transport is restored |
In the original case, the dosages were somewhat larger than this formula (Scutellaria 20g, Phellodendron 15g, Gypsum 40g, Pueraria 30g, Earthworm 15g), as Guo Ziguang was treating a patient with all “five highs” present and a robust, strong physique. In clinical practice, the dosage of the Three Yellows and Gypsum can be reduced according to the degree of Fire and Heat; when Phlegm-Stasis is obvious, Salvia and Earthworm should not be reduced.
IV. Pattern-Based Modifications
| Coexisting Pattern | Modified Herbs | Therapeutic Rationale |
|---|---|---|
| Liver Yin insufficiency | Combine with Qi Ju Di Huang Wan orally | The decoction clears and drains Liver Fire to address the manifest signs; the pill formula nourishes Liver and Kidney to address the root; decoction and pill formula in parallel |
| Obvious Liver Yang rising | Add Uncaria 15g, Chrysanthemum 12g | Pacify the Liver, extinguish Wind, and strengthen the power of settling Yang |
| Phlegm-Heat prevailing | Add Processed Arisaema 10g, Bamboo Shavings 10g | Clear heat and transform phlegm; for patients with yellow greasy tongue coating, bitter taste, and excessive phlegm |
| Obvious blood stasis | Add Chuanxiong 10g, Safflower 6g | Strengthen invigorating blood and resolving stasis; for patients with a dark tongue showing stasis spots |
| Severe constipation | Add Rhubarb 3-5g | Open the bowels and drain heat; remove the fuel from beneath the cauldron, allowing Fire and Heat to exit from below |
| Excess body weight | Add Cornus 15g, Green Rice Sprout 30g | Digest food, resolve accumulation, and assist in lipid regulation and weight reduction |
Guo Ziguang emphasized that the key to the effectiveness of this formula lies in the patient’s cooperation with lifestyle modifications - quitting smoking and alcohol, avoiding rich and fatty foods, controlling salt intake, and persisting in exercise. In the original case, the patient took the formula for more than three months combined with lifestyle intervention; blood pressure, blood glucose, blood lipids, and blood viscosity all returned to normal, and body weight decreased by 14 kg. In the formula, Raw Gypsum and Earthworm may be removed, and Rhubarb, Cornus, etc. may be added according to the pattern changes.
V. Summary
San Huang Shi Gao Tang (Three Yellows and Raw Gypsum Decoction) centers on clearing and draining Liver Fire from the Three Jiao, with concurrent functions of resolving Phlegm and promoting dampness, invigorating blood and opening collaterals, and guiding blood downward. It simultaneously targets “Fire, Phlegm, and Stasis,” making it suitable for hypertension in young and middle-aged adults with metabolic abnormalities. The formula does not use a single heavy or anchoring herb to pacify the Liver; instead, it achieves the settling of Liver Yang through clearing Fire, resolving Phlegm, and dispelling Stasis. In clinical practice, it must be combined with lifestyle intervention. In the original case, the decoction was combined with Qi Ju Di Huang Wan, using both the decoction and pill formula in parallel to address both root and branch.
References:
[1] Liu Yang, Jiang Yong, eds. “A Hundred Years of Chinese Medicine: A Hundred Clinical Masters of Traditional Chinese Medicine - National Masters Volume: Guo Ziguang” [M]. Beijing: China Press of Traditional Chinese Medicine
[2] Professor Guo Ziguang’s Proven Cases of “Five Highs Syndrome” [J]. Sichuan Journal of TCM, 2006
17. 中青年高血壓 —國醫大師郭子光「三黃石膏湯」
一、郭子光， 國醫大師，本方載於《中國百年百名中醫臨床家叢書·國醫大師卷：郭子光》，是其治療中青年高血壓伴代謝異常的代表經驗方。
二、病機
中青年高血壓的病機多屬肝陽上亢夾痰濁瘀滯。此年齡段患者長期勞逸失度、肥甘厚味、菸酒不節，肝鬱化火耗傷肝陰，肝陽上亢則血壓升高；脾失健運則痰濁內生，痰阻脈絡則血行不暢，漸成血瘀。火、痰、瘀三者交織，臨床常見血壓升高同時伴血糖、血脂、血黏度異常，即所謂”五高”並存。病性屬本虛標實，肝陰不足為本，火、痰、瘀為標，急性期當以清瀉肝火、除痰化瘀為先。
方藥組成
組成：黃連 10g、黃芩 10g、黃柏 10g、生石膏 30g、丹參 20g、葛根 20g、地龍 10g、決明子 15g、澤瀉 15g、法半夏 12g、川牛膝 15g
功效：清瀉肝火，除痰化瘀
主治：中青年高血壓（肝陽上亢、痰濁瘀滯證），伴血糖、血脂、血黏度異常
方中以黃連、黃芩、黃柏三黃合生石膏，清瀉三焦肝膽火熱為君。黃芩清上焦肺肝之火，黃連清中焦心胃之火，黃柏清下焦腎膀之火，三黃分走三焦，合生石膏大清氣分實熱，使肝火從上下分消。丹參、葛根、地龍活血化瘀通絡，針對痰瘀阻絡之病理產物。決明子清肝明目、潤腸通便，川牛膝引血下行以降上亢之肝陽。澤瀉利水滲溼洩熱，法半夏燥溼化痰降逆，合而調暢中焦氣機，使痰濁得化。全方不著意降壓而治其病機，火清則陽自潛，痰化則脈道通，瘀去則血行暢，血壓自降。原案中郭子光以本方配合杞菊地黃丸滋腎養肝，湯丸並進，標本兼顧。
| 藥組 | 藥物劑量 | 功用 |
|---|---|---|
| 清熱瀉火 | 黃連 10g、黃芩 10g、黃柏 10g、生石膏 30g | 三黃分清三焦火熱，合石膏大清氣分實熱，直折肝火之熾，火降則肝陽自平 |
| 活血通絡 | 丹參 20g、葛根 20g、地龍 10g | 丹參活血化瘀，葛根解肌舒筋升清，地龍通經活絡，三藥合用改善微循環，降低血黏度 |
| 平肝降逆 | 決明子 15g、川牛膝 15g | 決明子清肝明目潤腸，川牛膝活血通經引血下行，二藥引上亢之肝陽下行 |
| 化痰利溼 | 澤瀉 15g、法半夏 12g | 澤瀉利水滲溼洩腎濁，法半夏燥溼化痰降逆氣，合而調暢中焦，使痰濁得化、脾運得復 |
原案劑量較本方偏大（黃芩20g、黃柏15g、石膏40g、葛根30g、地龍15g），郭子光治療的是”五高”齊備、形體壯實的患者。臨床運用時可根據火熱程度酌減三黃及石膏用量，痰瘀明顯者丹參、地龍不宜減。
四、隨證加減
| 兼證 | 加減藥物 | 立法用意 |
|---|---|---|
| 肝陰不足 | 配合杞菊地黃丸口服 | 湯劑清瀉肝火治標，丸劑滋養肝腎治本，湯丸並進 |
| 肝陽上亢明顯 | 加鉤藤 15g、菊花 12g | 平肝熄風，增強潛陽之力 |
| 痰熱較盛 | 加膽南星 10g、竹茹 10g | 清熱化痰，針對苔黃膩、口苦痰多者 |
| 血瘀明顯 | 加川芎 10g、紅花 6g | 增強活血化瘀之力，針對舌暗有瘀點者 |
| 大便秘結 | 加大黃 3~5g | 通腑洩熱，釜底抽薪，使火熱從下而出 |
| 體重超標 | 加山楂 15g、谷芽 30g | 消食化積，輔助調脂減重 |
郭子光強調，本方取效的關鍵在於患者配合生活方式調整——戒菸酒、遠肥甘、控制食鹽、堅持鍛鍊。原案患者服藥三月餘，配合生活方式干預，血壓、血糖、血脂、血黏度均恢復正常，體重下降14公斤。方中可去生石膏、地龍，加大黃、山楂等隨證出入。
五、小結
三黃石膏湯以清瀉三焦肝火為核心，兼以化痰利溼、活血通絡、引血下行，同步作用於”火、痰、瘀”，適用於中青年高血壓伴代謝異常者。方中不用一味重鎮平肝藥，而是通過清火、化痰、祛瘀使肝陽自降。臨床運用須配合生活方式干預，原案以湯劑合杞菊地黃丸湯丸並進，標本兼顧。
參考文獻：
[1] 劉楊,江泳編.《中國百年百名中醫臨床家叢書·國醫大師卷：郭子光》[M].北京：中國中醫藥出版社
[2] 郭子光教授”五高症”驗案[J].四川中醫，2006