In the vast theories of Traditional Chinese Medicine (TCM), treatment principles serve as guiding stars. Based on the urgency of onset, severity of the condition, duration of the illness, depth of the disease location, speed of transmission, prognosis, and the properties and compatibility of medicinal substances, we employ the wisdom of analogy to summarize a series of treatment principles for exogenous diseases, endogenous injuries, and pathologies of the upper, middle, and lower Sanjiao (Triple Burner). “Treat exogenous diseases like a general,” akin to a commander on the battlefield, who must make swift decisions and strike decisively to expel pathogens with great force; “Treat endogenous injuries like a chancellor,” who must think deeply and harmonize Yin and Yang, balancing the organs to address the root of internal injuries; “Treat the upper Sanjiao like feathers,” lightly and delicately adjusting the chaotic Qi of the upper body, akin to a feather gently brushing, soft yet powerful; “Treat the middle Sanjiao like a scale,” requiring precise balance to harmonize the spleen and stomach, ensuring the orderly rise and fall of Qi in the middle Sanjiao, like a stable weight that is neither biased nor unsteady; “Treat the lower Sanjiao like a strategist,” who must think carefully and skillfully use medicines to achieve the goal of unblocking water pathways and expelling turbid substances.
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These treatment principles not only highlight the wisdom and depth of TCM but also reveal the laws of disease treatment. Let us continue to explore the intricacies within, contributing more to the health of humanity.
1. Treatment principles for exogenous and endogenous diseases.
The six climatic factors intertwine, mutually causing and affecting each other, potentially combining into diseases, with their infinite variations being awe-inspiring. Pathogenic factors are not limited to the six excesses; therefore, in treatment, we should not be confined to the distinctions of Shanghan (Cold Damage) and Wenbing (Warm Disease), but should meticulously analyze the presence of any combinations and the nature of the accompanying pathogens. Only then can we swiftly take measures to effectively eliminate external pathogens, cutting off their path of spread and safeguarding the tranquility of the organs. The book Wenbing Tiaobian elaborates on the various manifestations of exogenous diseases, covering ten types of warm diseases such as fengwen (wind warmth), wenshu (warm heat), and wenyi (warm epidemic), as well as many miscellaneous syndromes. It mentions that “warm diseases enter through the mouth and nose,” with their rapid invasion akin to the nine orifices being attacked, instantly penetrating the organs and catching one off guard. Therefore, when treating exogenous diseases, it is like conducting military operations; one must be flexible and swift, accurately grasping the timing to annihilate the pathogens in one fell swoop. Subsequently, one must conduct detailed adjustments based on the Yin and Yang status of the organs and meridians, aiming to expel the evil Qi as soon as possible and alleviate the patient’s suffering.
In treating endogenous injuries, we follow the principles outlined in the classics such as the Neijing (Inner Canon) and Nanjing (Classic of Difficulties), opposing the indiscriminate use of bitter and cold medicines, advocating for a warming and nourishing approach. When treating endogenous injuries, it is essential to thoroughly understand the patient’s etiology, ensuring they are aware and do not repeat the offense. Additionally, one must carefully observe the patient’s constitution, work, age, etc. For instance, postpartum and elderly individuals often have insufficient Yin, while those engaged in mental labor, such as writing or legal work, tend to consume Yin; conversely, those who overexert themselves through recitation or singing may deplete Yang. Therefore, treatment must be tailored to the patient’s specific situation, weighing the excesses and deficiencies of Yin, Yang, Qi, and blood, and handled cautiously to avoid hasty actions that may lead to deviations. Although the effects may not always be immediately apparent, as long as Yin and Yang Qi and blood gradually move towards balance, the body will naturally restore health.
In the world of TCM, the intertwining of diseases always appears complex, especially when exogenous symptoms coexist with endogenous diseases, requiring thoughtful treatment strategies. As stated in the Yiyibing Shu (Book of Medical Diagnosis): “If there are symptoms of liver depression, hernia, emotional distress, and blood in the stool, the more symptoms coexist, the more complex the condition becomes.” The phrase “the more symptoms coexist” profoundly depicts the complexity of the condition. In treating such diseases, physicians must adhere to the basic principle of “treating new diseases first, and old diseases later.” However, this does not imply a rigid approach, as each patient’s condition is unique. In clinical practice, physicians must keenly perceive the urgency of the condition, like a general on the battlefield, flexibly adjusting tactics based on the situation. If the exterior symptoms are urgent, one must first address the exterior, like extinguishing a raging fire; if the interior symptoms are critical, one must first address the interior, like building a dam against a flood. If both exterior and interior are urgent, one must consider both, akin to fighting on two fronts, advancing on both lines without neglecting either. This treatment strategy reflects both the rigor and science of TCM, as well as its flexibility and wisdom. It is like a brilliant commander, possessing strategies for victory and the composure to remain unflustered in crisis. The physician is this commander, wielding great methods and harboring compassion, applying this wisdom in the treatment of each patient.
2. Treatment principles for Sanjiao diseases.
All warm diseases originate from the upper Sanjiao, primarily focusing on the Taiyin (Greater Yin) area. Just as a trickle of water from a high mountain begins small but can gather into a mighty river, warm diseases often start quietly. However, once the pathogenic factor invades the upper Sanjiao, it wreaks havoc like a storm. If lung disease reverses, it is like a flood breaking through a dam, reaching the pericardium. If the disease of the upper Sanjiao is not treated in time, it will inevitably spread downward, like a mountain flood rushing down, affecting the health of the middle Sanjiao and the stomach and spleen. If the middle Sanjiao is diseased and untreated, the pathogenic factor will continue to impact the lower Sanjiao, affecting the liver and kidneys. This process resembles the natural phenomenon of water flowing downward, gradually eroding everything in its path. The entire book of Wenbing Tiaobian serves as an encyclopedia of warm diseases, systematically discussing the principles of diagnosis and treatment of various warm diseases based on the Sanjiao. From top to bottom, from shallow to deep, it reveals the evolution of warm diseases. The treatment principles for Sanjiao diseases are not only a guideline for diagnosing and treating warm diseases but also the foundation for treating miscellaneous syndromes. The blood of the upper Sanjiao relates to lung and heart Qi, akin to clouds in the sky that must remain clear and ethereal. The blood of the middle Sanjiao is closely related to the Qi of the stomach and spleen, like the fertile soil of the earth that must remain rich and vibrant. The blood of the lower Sanjiao is closely connected to the Qi of the liver and kidneys, like the deep waters of the sea that must remain profound and tranquil. In treatment, nourishing the upper Sanjiao should be like a bright mirror hanging high, clear and transparent; nourishing the middle Sanjiao should be like a balanced scale, maintaining stability; nourishing the lower Sanjiao should be like flowing water, full of vitality. Whether treating blood syndromes, deficiency fatigue, or other conditions, it is essential to base treatment on the location of the Sanjiao and the functions of the five organs, thus grasping the condition to achieve optimal treatment results.
(1) Treat the upper Sanjiao like feathers, not lifting lightly.
The focus of upper Sanjiao pathologies is primarily on the heart, lungs, and pericardium. When pathogenic Qi invades the lung’s defensive Qi, the defensive Qi is suppressed, and lung Qi cannot normally disperse, leading to a series of symptoms: splitting headaches, fever like a tide, chills with shivering, profuse sweating, thirst with difficulty drinking, or thirst without drinking but accompanied by coughing, a thin white tongue coating, and a red tip of the tongue, with a rapid pulse, especially a prominent pulse at the two cun positions. At this time, the pathogenic Qi is still shallow, and the condition is mild; treatment must be light and clear, dispersing gently like a breeze. Commonly used herbs include Jin Yin Hua (Honeysuckle Flower), Lian Qiao (Forsythia Fruit), Sang Ye (Mulberry Leaf), Bo He (Peppermint), Niu Bang Zi (Burdock Seed), Dou Chi (Fermented Soybean), and Zhu Ye (Bamboo Leaf), which are light and mild, dancing within the body to promote Qi flow and harmonize the defensive and nutritive Qi, guiding the pathogenic Qi to quietly leak out. If the pathogenic Qi is not warm but rather damp-heat, a different strategy is required, using Pei Lan (Eupatorium), Huo Xiang (Agastache), Xiang Ru (Elsholtzia), Bai Zhi (Angelica Dahurica), Bian Dou Hua (Lima Bean Flower), and Zi Su (Perilla Leaf), which are warm and aromatic, dispersing dampness and clearing heat, guiding the pathogenic heat outward with slight sweating, akin to a gentle summer rain that lightly brushes away the heat. In cases of summer heat or autumn dryness, one may use Yin Qiao San (Silver and Golden Powder) with modifications for light dispersal, or Sang Xing Tang (Mulberry and Apricot Decoction) for cooling and moistening. These formulas utilize light and mild herbs that are easy to volatilize and disperse, as their lightness allows them to rise directly to the disease site. However, when the pathogenic Qi deeply invades the pericardium, the symptoms become particularly severe, such as a crimson tongue and delirium; at this point, the method of dispersing with pungent and cool herbs is no longer applicable, akin to a raging fire that cannot be extinguished by clear springs. Therefore, the symptoms of pathogenic Qi in the pericardium in upper Sanjiao pathologies do not fall within the realm of the “like feathers” treatment method. Furthermore, the preparation method of Yin Qiao San emphasizes “taking it when the fragrance is strong, do not over-boil,” which captures its light and clear essence, directly reaching the disease site, exemplifying the exquisite practice of the “like feathers” treatment method.
(2) Treat the middle Sanjiao like a scale, not stable without balance.
The middle Sanjiao serves as the hub of the body’s organs, with its pathologies centered on the spleen and stomach. When warm pathogens quietly invade the middle Sanjiao, they sweep in like a storm, primarily manifesting as an abnormal excess of heat, leading to a disruption of the spleen and stomach‘s ascending and descending functions. Yangming warm diseases resemble a raging fire, presenting a scene of internal heat and dryness. Patients experience high fever, profuse sweating, a red face and eyes, a heavy and hoarse voice, labored breathing, constipation, and difficulty urinating. The tongue coating resembles a withered tree, even appearing black with prickly protrusions, and the pulse is either surging or firm and forceful. At this time, one must use Bai Hu Tang (White Tiger Decoction) or Da Cheng Qi Tang (Major Order the Qi Decoction) to clear the invisible excess heat or tangible heat accumulation, ensuring the pathogenic heat retreats and the stomach and spleen‘s ascending and descending functions are orderly restored. However, Taiyin warm diseases resemble a shroud of gloom, manifesting as symptoms of warm turbidity and stickiness. Patients may feel warm but without significant heat, sweating without relief, a heavy body, abdominal distension, nausea, vomiting, loose stools, and turbid or difficult urination, with a white, slippery, and greasy tongue coating, and a pulse that is soft and rapid. At this time, one should use herbs such as Huang Lian (Coptis), Ban Xia (Pinellia), Sha Ren (Amomum), Hao Ren (Cardamom), and Chen Pi (Aged Tangerine Peel), which are pungent but not floating, heavy but not sinking, with properties that are either slightly cold or warm, akin to a gentle rain that moistens and clears dampness, harmonizing Qi and guiding the pathogenic heat outward, thus restoring the balance of the spleen and stomach‘s ascending and descending functions. Caution is essential in medication. Bai Hu has four prohibitions, Cheng Qi has three drawbacks, and Wenwen has three prohibitions, all of which must be remembered. The goal is to eliminate pathogens without harming the righteous Qi, stopping treatment when the condition improves. In this way, one can balance the coordination of the upper and lower Sanjiao and the relationship between pathogenic and righteous Qi, allowing the spleen and stomach to restore their harmonious and balanced Qi functions.
(3) Treat the lower Sanjiao like a weight, not heavy without sinking.
The lower Sanjiao is the residence of the liver and kidneys. Once pathogenic Qi invades, due to its deep location, the condition becomes particularly challenging. At this time, the Yin fluids of the liver and kidneys are depleted, like a river running dry, with internal wind rampaging, leading to numerous and complex symptoms. Patients may experience low fever, flushed cheeks, dry mouth and throat, as if a traveler in a desert yearning for water. They may feel fatigued, desiring sleep, restless, and even experience tremors. The tongue may appear crimson, with little dry coating, and the pulse may be weak and thin or have intermittent beats, resembling leaves in the autumn wind, precariously hanging on. In more severe cases, there may be slight movements of the hands and feet, convulsions, tremors of the mouth corners, and mental agitation, akin to the calm before a storm.
During treatment, one should use salty and cold medicines, such as A Jiao (Donkey-hide Gel), Gui Ban (Tortoise Shell), Mu Li (Oyster Shell), Bie Jia (Soft-shelled Turtle), and Ji Zi Huang (Egg Yolk), which are heavy and rich, sinking to the lower Sanjiao and directly addressing the disease, replenishing the Yin fluids of the liver and kidneys. The dosage should be large, and the cooking time should be long to fully manifest their effects. However, if damp-heat lingers in the lower Sanjiao, one must use more diuretic medicines to clear the damp-heat pathogens. If the fire is still strong, with a mix of deficiency and excess, one must open the orifices to search for pathogens, and after the pathogens are expelled, then consider heavy nourishment. This is the wisdom of treating the lower Sanjiao like a weight. For those with both Yin and Yang deficiencies, nourishing the lower Sanjiao requires distinguishing between Yin and Yang. As stated in the Treating Endogenous Injuries Must Distinguish Between Yin and Yang in the Sanjiao Theory: “When discussing nourishing the lower Sanjiao, there are three methods: using Zhu Yi Gao (Great Nourishing Paste) to nourish the Yin of the lower Sanjiao; using Qijing Wan (Miraculous Pill) to nourish the Yang of the lower Sanjiao; and using Tian Gen Yue Ku Gao (Heavenly Root and Moon Cave Paste) to nourish both Yin and Yang, allowing them to interconnect.” When using medicines, one must consider the stomach Qi, as those with weak stomach Qi may not be able to process heavy and turbid medicines. Therefore, the use of bitter and cold Huang Bai (Phellodendron) and Zhi Mu (Anemarrhena) is discouraged, while advocating for the use of Dai Cai (Seaweed), Hai Shen (Sea Cucumber), Abalone, Gui Ban (Tortoise Shell), and Wu Ji (Black Chicken), which are sweet and salty, belonging to the category of nourishing Yang, with a connection to blood and flesh, to harmonize Yin and Yang and nourish the liver and kidneys.
In the Yiyibing Shu (Book of Medical Diagnosis), the discussions on the use of medicines for the organs are exquisite. Taking the lungs as an example, Mai Dong (Ophiopogon), Sha Shen (Adenophora), nourish Yin and moisten the lungs; Wu Wei Zi (Schisandra) astringes lung Qi; Bai He (Lily Bulb) moistens the lungs and stops coughing; Ren Shen (Ginseng), Fu Ling (Poria), and Bai Zhu (White Atractylodes) tonify lung Qi; Bai Dou Kou (White Cardamom) can warm the lungs and disperse cold. The selection of these herbs reflects TCM’s profound understanding of lung function. Looking at the heart, Gui Ban nourishes Yin and subdues Yang, Bai Zi Ren (Biota Seed) nourishes the heart and calms the spirit, Dan Shen (Salvia) promotes blood circulation and unblocks the vessels, Ren Shen tonifies Qi and benefits the heart, Gui Zhi (Cinnamon Twig) warms and unblocks heart Yang, and Fu Ling calms the spirit and stabilizes the mind. The combination of these herbs not only reflects TCM’s detailed research on heart function but also showcases TCM’s precise grasp of medicinal effects. The use of medicines for the spleen emphasizes strengthening the spleen and benefiting Qi, with Long Yan (Longan), Da Zao (Jujube), and Gan Cao (Licorice) tonifying spleen Qi, Bai Zhu strengthening the spleen and drying dampness, Chen Pi regulating Qi and strengthening the spleen, and Yi Zhi Ren (Alpinia) and Bai Dou Kou aiding digestion and resolving accumulation. The selection of these herbs highlights TCM’s emphasis on the function of the spleen and its unique approach to treating spleen and stomach diseases. For the stomach, Fu Ling, Ren Shen strengthen the spleen and stomach, Ban Xia descends Qi and stops vomiting, Yi Ren (Job’s Tears), Sheng Di Huang (Rehmannia), Yu Zhu (Polygonatum), Li Zhi (Pear Juice), and Ou Zhi (Lotus Root Juice) moisten dryness and nourish the stomach. The combination of these herbs fully demonstrates TCM’s meticulous approach to treating stomach diseases. As for the liver, A Jiao, Yuan Rou (Goji Berries), Bie Jia, and Mu Li nourish Yin and benefit the liver, while Dang Gui (Angelica), Yu Jin (Curcuma), Xiang Fu (Cyperus), and Xiang Ru soothe the liver and relieve depression. The selection of these herbs not only reflects TCM’s unique insights into liver function but also showcases TCM’s profound expertise in treating liver diseases. The use of medicines for the kidneys emphasizes nourishing the kidneys and replenishing essence, with Abalone, Hai Shen (Sea Cucumber) benefiting the kidneys and essence, Di Huang (Rehmannia) and Xuan Shen (Scrophularia) nourishing Yin and replenishing the kidneys, Rou Gui (Cinnamon) and Fu Zi (Aconite) warming Yang and benefiting the kidneys, while Liuhuang (Sulfur) and Tu Si Zi (Cuscuta) can secure the kidneys and reduce urination. The combination of these herbs fully demonstrates TCM’s profound understanding of kidney function and unique treatment approach. Although these methods are designed for treating endogenous miscellaneous syndromes, a careful examination of the principles of herb selection reveals that the treatment philosophy embodies the essence of TCM’s “treating the upper Sanjiao (heart and lungs) like feathers, treating the middle Sanjiao (spleen and stomach) like a scale, and treating the lower Sanjiao (liver and kidneys) like a weight.” This treatment principle applies not only to endogenous diseases but also to exogenous diseases. Therefore, it can be said that the treatment principles for Sanjiao diseases represent TCM’s overall treatment principles, reflecting TCM’s profound understanding and comprehensive grasp of human life activities.