Source 出处 · Shanghan Lun · Doses are not given here: they are set by a licensed practitioner for the individual.
Safety. Chai Hu Jia Long Gu Mu Li Tang is recorded in Shanghan Lun and is the heaviest formula in this batch, twelve ingredients: chai hu, huang qin, ban xia, ren shen, sheng jiang, da zao, long gu, mu li, gui zhi, fu ling, da huang and qian dan. It is the Xiao Chai Hu Tang base with the heavy and astringent drugs added and a purgative included, and the classical indication is specific and rather vivid: fullness in the chest, agitation and fright, difficult urination, delirious speech, and a body so heavy that the person cannot turn over. That is a description of someone who is quite unwell, and it is the reason this entry carries the largest safety obligation of the four.
The first obligation is a single sentence that has to come before everything else. Qian dan is red lead, lead tetroxide. Lead is a developmental neurotoxicant with no identified safe blood level; it accumulates in bone, and it is toxic to the nervous system, the kidney, the bone marrow and the cardiovascular system in adults as well as in children. Qian dan is not a substance that the contemporary Chinese Pharmacopoeia carries, and the honest statement is that lead tetroxide belongs to this formula's history rather than to current practice. Modern versions of this formula are generally made without it, or with a different mineral substituted, and this library makes no recommendation about what should replace it. Anyone holding a product that contains qian dan, or any traditional preparation of unknown composition, should treat the label as the question rather than the answer.
The remaining cautions are ones this library has stated elsewhere, and their accumulation is itself the point. Long gu is fossil bone and mu li is oyster shell; both carry the contamination question and both are substantial calcium sources. Da huang is rhubarb, whose anthraquinones are stimulant laxatives, and prolonged use is associated with dependence, with potassium loss and with the pigmentation seen on endoscopy; hypokalaemia is not a safe state in someone taking digoxin or a diuretic. Raw ban xia is an irritant poison, needle-shaped calcium oxalate crystals and a lectin that cause burning and swelling of the mouth and throat which can threaten the airway, so only the processed forms are used, and ban xia also appears among the classical incompatibilities with aconite. Ren shen and warfarin have a mixed evidence base, and this library writes mixed rather than safe. Zhi gan cao carries the licorice mineralocorticoid caution. Chai hu is Bupleurum, and one specific thing is worth recording precisely: Bupleurum-containing preparations have been reported in connection with liver injury, and the combination of the related formula Xiao Chai Hu Tang with interferon was reported in association with interstitial pneumonitis. That is an interaction rather than a property of the herb alone, which is exactly why the caution is worth stating in that form. Huang qin is Scutellaria root; sheng jiang and da zao complete the harmonising pair.
The last obligation is the largest, and it follows from the classical text itself. Delirious speech and agitation are the indications, and that presentation today is delirium, and delirium is a symptom with a cause that has to be found: hypoglycaemia, hypoxia, sepsis including urinary sepsis, meningitis and encephalitis, withdrawal from alcohol or benzodiazepines, anticholinergic medication, electrolyte disturbance, thyroid storm, intracranial events including stroke and haemorrhage, and drug toxicity. Difficult urination has its own list, and retention with back pain, saddle anaesthesia or new leg weakness is cauda equina syndrome, which is a surgical emergency. Fullness in the chest with breathlessness or chest pain is an emergency pathway first. And the practical rule this library repeats wherever an altered state is the indication: nothing should be given by mouth to a person whose consciousness or swallowing is impaired, because aspiration is not a theoretical risk. This library does not claim that Chai Hu Jia Long Gu Mu Li Tang calms the spirit, or treats anxiety, insomnia, epilepsy, delirium or any named disease.
柴胡加龙骨牡蛎汤著录于《伤寒论》，是本批最重的一首，十二味：**柴胡、黄芩、半夏（洗）、人参、生姜、大枣、龙骨、牡蛎、桂枝、茯苓、大黄、铅丹**。它是**小柴胡汤**的底子加上重涩之品、并纳入一味攻下之药，而古典指征写得具体而鲜活：**胸满、烦惊、小便不利、谵语、一身尽重不可转侧**。这是对一位病得不轻的人的描述，也正是本条的安全义务比其他各条更大的原因。
第一条义务只有一句话，且必须在其他一切之前说：**铅丹是四氧化三铅（红丹，铅的氧化物）**。**铅是明确的神经发育毒物，没有已确定的安全血铅阈值**；它在骨内蓄积，并且对成人同样具有神经、肾脏、骨髓与心血管系统的毒性。**铅丹不是现行《中国药典》收载的物质**；诚实的表述是：**四氧化三铅属于本方的历史组成，而不属于今天的做法** —— 现代配伍本方通常**不用铅丹，或以他味矿物药替代**，而**本库对应当以何物替代不作任何推荐**。手中有含铅丹的制品、或成分不明的传统制剂者，应当把标签当作**需要提出的问题**，而不是**已经给出的答案**。
其余提示是本库在别处已经说过的，而它们的堆叠本身就是要点。**龙骨是化石、牡蛎是贝壳**：两者都带污染问题，也同为相当大的钙来源。**大黄**属蒽醌类刺激性泻药，**久用与依赖、失钾以及内镜下所见的结肠黑变病相关**，而低钾对服用地高辛或利尿剂者不是安全状态。**半夏生品是刺激性毒物** —— **草酸钙针晶与凝集素**，入口即灼肿，咽部肿胀可威胁气道，故**实际只用炮制品**；且半夏在古典「反乌头」之列。**人参与华法林的证据是混杂的**，本库写混杂而不写安全。**炙甘草**带着甘草的类盐皮质激素提示。**柴胡是柴胡属（Bupleurum）**，这里值得记下的是一件具体的事：**含柴胡制剂曾有肝损伤报告**，而**相关的小柴胡汤与干扰素合用曾报告间质性肺炎** —— 那是**相互作用，不是单味药的属性**，这正是这条提示值得写准的原因。黄芩是黄芩（Scutellaria）之根，生姜与大枣成调和之对。
最后一条义务最大，而它来自古典原文本身。**谵语与烦惊正是指征，而今天这副表现就是谵妄**，谵妄是有原因可查的症状：**低血糖、缺氧、脓毒症（含尿路来源）、脑膜炎与脑炎、酒精或苯二氮䓬类戒断、抗胆碱能药物、电解质紊乱、甲状腺危象、包括卒中与出血在内的颅内事件，以及药物中毒**。**小便不利另有其清单**：伴背痛、鞍区麻木或新发下肢无力的尿潴留是**马尾综合征，属外科急症**。**胸满伴呼吸困难或胸痛，首先走的是急救路径**。还有一条本库凡遇意识状态为指征便重述的实用规则：**不向意识或吞咽受损者经口给予任何东西** —— 误吸不是理论上的风险。**本库不声称柴胡加龙骨牡蛎汤能安神，或治疗焦虑、失眠、癫痫、谵妄或任何具体疾病**。