Hello students, it’s time for class. In our last lesson, we introduced the Shaoyin disease, which involves the Shaoyin heart and kidney and the kidney meridian. Since the Shaoyin heart governs fire and the kidney governs water, the Shaoyin kidney is the root of the body’s original Yang and Yin. Therefore, when the disease involves the heart and kidney, it often affects the fundamental Qi of the body. Thus, we say that Shaoyin disease, in general, is a group of syndromes characterized by both heart and kidney Yin and Yang deficiency, with a primary focus on kidney Yang deficiency, exhibiting systemic deficiency of Zheng Qi.
From the classification of Shaoyin disease, we discussed that the main symptoms of Shaoyin disease are related to the Shaoyin organ disease. When the constitution is characterized by Shaoyin Yang deficiency and Yin excess, the evil Qi transforms into cold from Yin, leading to the Shaoyin cold transformation syndrome. Conversely, when the constitution is characterized by Shaoyin Yin deficiency and Yang excess, the evil Qi transforms into heat from Yang, resulting in the Shaoyin heat transformation syndrome. Therefore, the symptoms of Shaoyin can be divided into two categories: cold transformation and heat transformation.
In our last class, we mentioned that Shaoyin disease is characterized by a “thin and weak pulse, desiring sleep.” A thin pulse indicates Yang deficiency, while a weak pulse indicates Yin deficiency. This pulse pattern reflects the essence of Shaoyin disease, which is characterized by both Yin and Yang deficiency, with a primary focus on kidney Yang deficiency. The term “desiring sleep” indicates a state of mental fatigue; in severe cases, the patient may appear lethargic, with a blurred consciousness and decreased responsiveness to the external environment, resembling a state between sleep and wakefulness. This mental state suggests a deficiency of both Yin essence and Yang Qi, indicating a lack of nourishment for the spirit, which is the key symptom of Shaoyin disease.
Next, we discussed the clinical features of Shaoyin cold transformation syndrome, primarily manifested as clear and frequent urination and thirst. We emphasized that the characteristic of this frequent urination is the passage of clear stools, indicating that the food is not digested. The pathogenesis involves kidney Yang deficiency, where the fire does not warm the earth, leading to improper digestion. The thirst indicates that the Shaoyin Yang deficiency has lost its ability to transform Qi, resulting in fluid retention. The clear and frequent urination indicates that the Shaoyin Yang cannot control water, leading to Yang not restraining Yin. This is a Shaoyin cold transformation syndrome primarily characterized by true Yang deficiency.
Is there a Shaoyin cold transformation syndrome primarily characterized by evil excess? Yes.
Next, let’s look at the original text from section 283. Please open your handout to page 163 and refer to section 283. “If the patient has a tight pulse in both Yin and Yang, and experiences sweating, it indicates loss of Yang, which belongs to Shaoyin. The treatment should address throat pain and subsequent diarrhea.” The pulse of Shaoyin disease is typically thin and weak, but why does it now show a tight pulse in both Yin and Yang? We say that for Shaoyin Yang deficiency and Yin excess, there can be a primary focus on Zheng deficiency. The Zheng deficiency symptoms should be a thin and weak pulse, desiring sleep, clear and frequent urination, and thirst. However, there is another situation characterized by cold excess, known as cold excess injuring Yang. Even if your body is relatively strong, if you go to an environment of -20, -30, or -40 degrees Celsius and encounter an avalanche that partially buries you, you may find that your Shaoyin Yang Qi is still strong, but the Yin cold evil Qi is too excessive, resulting in cold hands and feet and a stiff body. What syndrome is this? It is a syndrome of cold excess injuring Yang, primarily characterized by evil Qi excess. Therefore, the pulse is not thin and weak but tight in both Yin and Yang.
In the “Shang Han Lun,” the pulse of both Yin and Yang being tight is seen in both Taiyang disease and Shaoyin disease. When the cold evil injures the exterior, since cold is a Yin evil and primarily constricting, it easily causes the muscles and tendons to contract, resulting in a tight pulse in the cun, guan, and chi positions. Cold injures the Taiyang exterior, and the pulse of both Yin and Yang being tight indicates a floating tight pulse; cold injures the Shaoyin interior, and the pulse of both Yin and Yang being tight indicates a sinking tight pulse. Therefore, both Taiyang disease and Shaoyin disease can exhibit a tight pulse of both Yin and Yang. The floating tight pulse belongs to Taiyang, while the sinking tight pulse belongs to Shaoyin. Why is it not thin and weak? Because this is cold excess injuring Yang, not true Yang deficiency. Cold excess injuring Yang Qi would lead to the exterior being closed off by cold evil, preventing sweating. Now, with “反汗出” (reverse sweating), this indicates that the Yang is injured internally, and Yang cannot restrain Yin, leading to sweating. Here, it is determined that it is a loss of Yang, which is different from the concept of loss of Yang in later interpretations. The term “loss” here refers to injury, indicating that cold excess has harmed Yang Qi, rather than being primarily Zheng deficiency. “This belongs to Shaoyin” indicates that this is indeed a Shaoyin disease, as the cold evil has harmed the Yang Qi of Shaoyin. “The treatment should address throat pain and subsequent diarrhea,” indicating what symptoms should appear.
Throat pain indicates that the cold has injured the Shaoyin meridian, as the Shaoyin meridian runs through the throat and tongue. When the cold evil injures the Shaoyin meridian, the meridian contracts, leading to throat pain. Cold injures the Taiyang meridian, resulting in headache and neck stiffness; cold injures the Yangming meridian, resulting in forehead pain; cold injures the Shaoyang meridian, resulting in unilateral headache; and cold injures the Shaoyin meridian, resulting in throat pain. “And subsequent diarrhea” indicates that the cold has injured the Shaoyin organ, where the Shaoyin kidney Yang is harmed by cold evil, preventing it from warming the spleen and stomach, leading to a disruption of the spleen and stomach’s ascending and descending functions, resulting in vomiting due to cold evil rising and diarrhea due to cold evil descending. This cold excess injuring Yang, and the true Yang deficiency in Shaoyin disease, have essential differences. Cold excess injuring Yang is primarily characterized by evil excess, and once treated, Yang Qi can recover, expelling the cold evil, leading to a good prognosis. Just like when you are in an environment of -30 or -40 degrees Celsius and experience cold hands and feet, as long as your heart is still beating, if you are placed in a warm room and receive emergency treatment, you can recover well. Therefore, cold excess injuring Yang has a relatively good prognosis, while true Yang deficiency in Shaoyin disease is more serious, as the Yang Qi of the body is greatly diminished, and life is nearing extinction. Thus, we cannot take the true Yang deficiency syndrome lightly, while the prognosis for cold excess injuring Yang is relatively better.
When we discussed Taiyin disease, we mentioned, “Taiyin disease is characterized by abdominal fullness and vomiting, inability to eat, and frequent diarrhea.” This is primarily due to spleen Yang deficiency and spleen Qi deficiency, leading to disordered transportation and accumulation of cold dampness. In the case of Taiyang disease, we also mentioned, “If the pulse is floating and slow, and the hands and feet are warm, this indicates a connection to Taiyin. If the urine is frequent, it cannot indicate yellowing. After seven or eight days, dryness and diarrhea will stop on their own, as the spleen is full, and the filth must be expelled.” Why does Taiyin disease self-resolve? Because it is primarily characterized by evil excess rather than Zheng deficiency. The key symptom of Taiyin syndrome 273 is Taiyin organ deficiency and cold syndrome, which is primarily characterized by Zheng deficiency. If not treated, it can develop into both spleen and kidney deficiency, ultimately leading to true Shaoyin disease. Therefore, in the three Yin diseases of the “Shang Han Lun,” to determine the prognosis, we must assess whether it is primarily Zheng deficiency or evil excess. Zheng deficiency has a poorer prognosis, while evil excess has a better prognosis, and even evil excess can self-resolve.
Next, let’s look at the treatment contraindications for Shaoyin disease, sections 285 and 286, which are particularly important for our study. We can generally explain them: “In Shaoyin disease, the pulse is thin, sinking, and rapid, and the disease is located internally; sweating should not be induced.” Is this a cold transformation syndrome or a heat transformation syndrome? A thin pulse generally indicates Yin injury, a sinking pulse indicates an internal disease, and a rapid pulse indicates heat. This can be entirely viewed as a Shaoyin heat transformation syndrome due to Yin deficiency. In this case, it is certainly inappropriate to induce sweating, as sweating is for treating exterior syndromes. However, some scholars argue that a sinking pulse indicates Yang deficiency, where Yang Qi is weak and unable to circulate, resulting in a sinking pulse. A thin pulse indicates Yin deficiency, and both Yin and Yang are deficient. A rapid pulse is a compensatory response after Zheng deficiency. This rapid pulse does not indicate heat but rather a compensatory response after Zheng Qi has weakened, similar to what we learned in the Taiyang disease section, “In Taiyang disease, after purging, if the pulse is rapid and there is chest tightness, Gui Zhi Decoction minus Shao Yao should be used.” The rapid pulse indicates that the chest Yang is not strong, and heart Yang is insufficient, leading to a weak response to expel evil. If we interpret it this way, this disease can also be a Shaoyin cold transformation syndrome. However, the Shaoyin cold transformation syndrome is also an internal disease, so sweating should not be induced. I believe both viewpoints can coexist; whether it is heat transformation or cold transformation, sweating should be prohibited.
Section 286 states, “In Shaoyin disease, the pulse is thin,” which is indisputable; this is definitely true Yang deficiency, with weak and ineffective pulse. “Sweating should not be induced,” as Zhang Zhongjing himself stated, “due to loss of Yang.” The thin pulse indicates that the Yang Qi of the body has been harmed. “If the pulse is thin and rough, it indicates that on the basis of Yang deficiency, there is also Yin deficiency; weakness indicates Yang deficiency, and rough indicates insufficient Yin blood. Both Yin and Yang are deficient, and thus, purging should not be done.” Of course, if both Yin and Yang are deficient, purging would be inappropriate; the doctor should have their medical license revoked for such an action.
Well, the first five sections we studied can be seen as Zhang Zhongjing’s overview of Shaoyin disease. Next, we will specifically discuss the diagnosis and treatment of Shaoyin disease. As we mentioned earlier, the heart is a fire organ, and the kidney is a water organ. The kidney also houses the original Yin and Yang. When the patient has a constitution of Yang deficiency and Yin excess, the external evil transforms into cold from Yin, leading to the Shaoyin cold transformation syndrome. Therefore, we will first discuss the diagnosis and treatment of Shaoyin cold transformation syndrome.
The symptoms of Shaoyin cold transformation syndrome are quite numerous. First, we will discuss the Yang deficiency and Yin excess syndrome. The original text included in our handout regarding the Yang deficiency and Yin excess syndrome in Shaoyin is quite limited, so I will summarize all the symptoms related to this syndrome from the “Shang Han Lun” for everyone to review.
For the Yang deficiency and Yin excess syndrome in Shaoyin, the overall symptoms manifest as a fear of cold and curling up. When you enter the ward, you will see the patient curled up in bed, covered with many blankets, with hands and feet curled up. When you approach the bedside, you will notice cold sweat on their forehead, and they may be sweating profusely. Then, when you check their pulse and feel their hands and feet, they are cold and stiff. You might ask, “Why are your hands so cold?” They might respond, “Not only are my hands and feet cold, but my limbs also hurt.” This is a set of symptoms. What causes these symptoms? It is due to kidney Yang deficiency, where the skin and extremities lose warmth. Why is there cold sweat? It is because Yang cannot restrain Yin. Kidney Yang deficiency leads to the skin and extremities losing warmth, resulting in cold sweat. This is the first set of symptoms.
The second set of symptoms manifests in the digestive system, which we have mentioned multiple times: clear and frequent diarrhea, with undigested food. What is the pathogenesis? It is due to kidney Yang deficiency, where the fire does not warm the earth, leading to improper digestion. We will not elaborate further on this. From the urinary system’s perspective, clear and frequent urination indicates that Yang cannot restrain Yin, or there may be scanty urination. When kidney Yang is deficient, the Qi transformation is disordered. The body’s water metabolism relies on Yang Qi for warmth and propulsion. When kidney Yang is deficient, the warming and propelling functions are disordered, leading to water metabolism issues, where waste cannot be expelled in a timely manner, resulting in scanty urination. Both conditions of kidney Yang deficiency can manifest in opposite clinical symptoms: one is clear and frequent urination, while the other is scanty urination.
As for the mental symptoms, the desire for sleep indicates that we need not elaborate further, as we have discussed this previously. This is due to the deficiency of Yin essence and Yang Qi, leading to a lack of nourishment for the spirit. Is it not kidney Yang deficiency? How does it involve Yin essence? Because Yin and Yang are interdependent. When true Yang is greatly diminished, the body’s Yin essence cannot be generated. Therefore, we say that Shaoyin disease is characterized by both Yin and Yang deficiency, with a primary focus on kidney Yang deficiency. The Yin we refer to in the context of Yin and Yang deficiency is not the Yin cold evil Qi, but rather the true Yin of the body, the Yin essence. When Yang Qi is deficient, it cannot generate true Yin or Yin essence, leading to both Yin and Yang deficiency. With both Yin and Yang Qi deficient, the spirit is not nourished, resulting in mental fatigue and decreased responsiveness to the surrounding environment.
The pulse pattern for Shaoyin Yang deficiency is that the lightest is a sinking pulse, where Yang Qi cannot warm and circulate throughout the body, leading to a sinking pulse. The next is a thin and weak pulse, and the most severe is a pulse that is thin and nearly absent. The most severe is a sinking pulse that cannot be felt, indicating a lack of Yang Qi and ineffective circulation. Through the above symptoms, including systemic symptoms, digestive symptoms, urinary symptoms, mental symptoms, and pulse patterns, we classify this as the Yang deficiency and Yin excess syndrome in Shaoyin.
How should this syndrome be treated? The treatment is to use Si Ni Tang to revive Yang and rescue the reverse. Since Yang Qi is deficient, we use Si Ni Tang to restore Yang Qi. If the hands and feet are cold, we use Si Ni Tang, as cold hands and feet in the “Shang Han Lun” are referred to as Jue Ni. Therefore, we use Si Ni Tang to revive Yang, expel cold, and rescue the reverse. Si Ni Tang contains Gan Cao (Licorice), Gan Jiang (Dried Ginger), and Fu Zi (Aconite), which can treat cold extremities, hence the name Si Ni Tang.
This is what we discussed regarding the first syndrome of Shaoyin cold transformation, known as Yang deficiency and Yin excess syndrome.
The second syndrome is Yin excess obstructing Yang syndrome. The clinical manifestation of Yin excess obstructing Yang syndrome is based on the Yang deficiency and Yin excess syndrome, with the addition of body heat without aversion to cold. All the above symptoms are present, except for the fear of cold and curling up, which is absent because there is body heat without aversion to cold. Therefore, the fear of cold and curling up is absent, while the other symptoms such as cold sweat, cold extremities, clear and frequent diarrhea, or scanty urination, and the desire for sleep, with a pulse that is thin and nearly absent, are all present. This body heat indicates that Yin is excessive internally, obstructing Yang externally. What is Yang Qi? Yang Qi is a subtle substance that contains heat energy and can release heat. When Yin cold evil Qi is excessive internally and obstructs the body’s Yang Qi at the surface, the density of Yang Qi at the surface becomes relatively high, leading to the appearance of body heat, which may be measurable with a thermometer.
You may recall that when we discussed Taiyang disease, we mentioned, “If the body is very hot and desires clothing, the heat is in the skin, and the cold is in the marrow.” This statement illustrates Yin excess obstructing Yang syndrome. In treatment, we use Tong Mai Si Ni Tang to force Yin back to Yang and connect the internal and external. Since Yin cold is excessive, we need to break Yin, and since Yang Qi is deficient, we need to restore Yang. When Yin is excessive internally and obstructs Yang externally, Yin and Yang are not coordinated, and they are separated, so we need to connect the internal and external. The composition of Tong Mai Si Ni Tang is the same as that of Si Ni Tang, which includes Gan Jiang (Dried Ginger), Sheng Fu Zi (Raw Aconite), and Gan Cao (Licorice), but the amounts of Gan Jiang and Sheng Fu Zi are increased, hence the name Tong Mai Si Ni Tang.
The third syndrome of Shaoyin cold transformation is Yin excess with Yang deficiency syndrome. This syndrome is characterized by a red complexion. This is a manifestation of Yin excess internally and Yang deficiency externally. This red complexion primarily manifests as a flush on the cheekbones, resembling a person who is drunk, with a flushed face as if painted with makeup. It differs from the red face caused by Yangming meridian evil, which is uniformly red from inside to outside. The red face in Yin excess with Yang deficiency is a superficial redness. By combining the overall symptoms, it is easy to distinguish whether this is a Yangming meridian heat causing a uniformly red face or a Yin excess with Yang deficiency causing a red complexion. How should this syndrome be treated? We use Bai Tong Tang to force Yin back to Yang and connect the upper and lower.
Now we have discussed the three syndromes of Shaoyin cold transformation: Yang deficiency and Yin excess syndrome, Yin excess obstructing Yang syndrome, and Yin excess with Yang deficiency syndrome, along with their main clinical manifestations and treatment methods.
Let’s take a look at the original text of Shaoyin disease in the “Shang Han Lun,” section 323 on page 164 of the handout: “In Shaoyin disease, if the pulse is sinking, it should be urgently warmed, and Si Ni Tang is appropriate.” This Shaoyin disease mentions a sinking pulse, indicating a mild deficiency of Shaoyin kidney Yang, which has not yet developed into a thin and nearly absent pulse or a sinking pulse that cannot be felt. However, even so, Zhang Zhongjing still emphasizes the need to “urgently warm it,” indicating the importance of active treatment. This is a principle of recognizing the early signs and preventing future problems. Why? Because Shaoyin disease is a syndrome characterized by both heart and kidney Yin and Yang deficiency, primarily focusing on kidney Yang deficiency, which is a systemic deficiency of Zheng Qi. When the early signs are observed, active treatment is necessary. If we wait until all the symptoms of Shaoyin disease appear, the body’s Zheng Qi will have already weakened, making treatment much more difficult. Therefore, as soon as we see signs of Shaoyin kidney Yang deficiency, indicated by a sinking pulse, we must “urgently warm it.” This is why later practitioners summarized that for Shaoyin disease, one must urgently warm it, while for Yangming disease, one must urgently purge. There is a saying: “For Shaoyin disease, urgent warming is like rescuing someone from drowning; for Yangming disease, urgent purging is like extinguishing a fire.” When signs of Yang deficiency in Shaoyin disease are observed, we must actively and promptly use warming methods, just as one would rescue someone who has fallen into water and cannot swim. If you say, “Wait a moment, I will go get a swimming suit,” by the time you return, that person may have already drowned. Therefore, the ancients used this vivid analogy to illustrate that Yangming heat excess should be treated decisively and quickly, while Shaoyin Yang deficiency should also be treated actively and promptly.
Si Ni Tang consists of 15g of Gan Cao (Licorice), 12g of Gan Jiang (Dried Ginger), and one piece of Sheng Fu Zi (Raw Aconite), which is cut into eight pieces. Combine these three ingredients with 3 liters of water, boil down to 1.2 liters, strain, and take warm. This formula is for two doses. Each dose contains 15g of Gan Cao, 12g of Gan Jiang, and about 20g of Sheng Fu Zi, which is equivalent to 10g per dose, using raw Aconite. In the “Shang Han Lun,” whenever Gan Jiang is used together with Aconite, it is always raw Aconite. In what situations is raw Aconite used, and when is processed Aconite used? Raw Aconite is used for reviving Yang and rescuing the reverse, while processed Aconite is used for warming and dispersing cold. In terms of herbal compatibility, whenever Gan Jiang is used with Aconite, it must be raw Aconite; if there is Aconite without Gan Jiang, it is processed Aconite. For example, in the Taiyang disease section, we mentioned Zhen Wu Tang, which contains Shao Yao (Peony), Jiang (Ginger), Ling (Poria), Shu (Atractylodes), and Aconite, where the ginger is fresh ginger, not dried ginger, so Aconite is processed Aconite. However, there is one exception to remember: when we study the Jueyin section, we will learn about Wu Mei Wan, which contains both Gan Jiang and Aconite, but in this case, Aconite is processed Aconite. I want to emphasize again that in the “Shang Han Lun,” whenever Gan Jiang is used with Aconite, it is always raw Aconite, and only Wu Mei Wan is an exception where both Gan Jiang and Aconite are used, but it is processed Aconite.
Next, let’s look at section 324, which is another indication for Si Ni Tang: “In Shaoyin disease, if food enters and then vomits, with a warm sensation in the heart and an inability to vomit, this is due to a full chest, and purging should not be done; it should be vomited.” The syndrome described here is not true Shaoyin disease but rather a similar syndrome to Shaoyin disease. In the “Shang Han Lun,” certain similar syndromes are sometimes named after the disease itself. Why is this considered a similar syndrome to Shaoyin disease? It has cold hands and feet and a desire to vomit. You see, in the previous lesson, we learned about section 282, which states, “In Shaoyin disease, there is a desire to vomit but cannot; the heart is disturbed, and one desires sleep.” This also has a desire to vomit but cannot, along with cold hands and feet, indicating a similar syndrome to Shaoyin disease. Sometimes, Zhang Zhongjing uses the name of the disease to refer to a similar syndrome. Now, let’s analyze the original text: vomiting immediately after eating suggests two possibilities: one is stomach heat, as we mentioned before, where vomiting occurs with food intake, indicating heat; if vomiting occurs after eating in the morning and not after eating in the evening, it indicates cold. Now, if vomiting occurs immediately after eating, it may be due to stomach heat or an obstruction by tangible evil Qi, as something is blocking the stomach, preventing it from accepting food, leading to immediate vomiting. We conclude that this is due to an obstruction by tangible evil Qi, and Zhang Zhongjing himself states, “This indicates fullness in the chest.” This is the first set of symptoms. In normal circumstances, the sensation of warmth in the heart and an inability to vomit indicates that the chest is obstructed by tangible evil Qi. Due to the obstruction of Qi, the Zheng Qi wants to expel the evil, leading to a desire to vomit, but the tangible evil obstructs the Qi, preventing it from being expelled, resulting in an inability to vomit. This indicates a feeling of discomfort in the chest and a desire to vomit but being unable to do so. “At the beginning, hands and feet are cold,” indicating that at the onset, the hands and feet are cold. At this time, the cold hands and feet are not due to Yang deficiency but rather due to cold obstructing the chest Yang, preventing Yang Qi from reaching the surface. The pulse is wiry, indicating phlegm and fluid retention, while a slow pulse indicates Yang deficiency with cold. In the “Shang Han Lun,” a slow pulse can indicate either Yin blood deficiency or Yang deficiency with cold.
How does Zhang Zhongjing recognize this pathogenesis? “This indicates fullness in the chest.” In the discussion of Yangming stomach fullness, we mentioned the concept of fullness. We said that in the “Shang Han Lun,” whenever Zhang Zhongjing uses the term “fullness,” it indicates the presence of tangible pathological products. For example, in the case of heat entering the blood chamber, it mentions, “If you press on the Qimen point, follow the fullness and purge it,” etc. Here, the term “fullness” indicates that there is a tangible evil obstructing the chest. What kind of evil Qi? It is phlegm and turbid evil Qi, which obstructs the chest and diaphragm. In treatment, we should guide the treatment according to the situation, so purging should not be done. The obstruction in the chest and diaphragm should be treated by inducing vomiting, which is called guiding the treatment according to the situation. “It should be vomited, and Guati San is appropriate.” We discussed this in the section on similar syndromes of Taiyang disease, so we will not elaborate further. This section primarily aims to describe the following sentence, which discusses another indication for Si Ni Tang: “If there is cold fluid in the diaphragm,” as we mentioned earlier, Guati San is used to treat phlegm and turbid evil Qi, while the latter discusses cold fluid. Cold fluid invading the stomach can lead to dry heaving. This cold fluid differs from tangible phlegm and turbid evil Qi; it is fluid Qi, which is the water Qi. This is a manifestation of Shaoyin Yang deficiency, where Qi transformation is disordered, leading to cold fluid Qi rising. The lack of warming function leads to the internal generation of cold fluid, which rises and causes dry heaving. In this case, warming methods can be used. It should not be vomited. When warming, Si Ni Tang is appropriate. In cases where there is cold fluid in the diaphragm, Si Ni Tang can be used to warm, as well as Li Zhong Tang or Wu Zhu Yu Tang. We will discuss these later, and at that time, we will compare this section with section 324 regarding the indications for Si Ni Tang, which can warm and transform cold fluid in the chest.
Having learned these two sections, we know that one indication for Si Ni Tang is the Yang deficiency and Yin excess syndrome of Shaoyin cold transformation, and the second is to warm and transform cold fluid in the chest due to kidney Yang deficiency. However, for the overall manifestation of Shaoyin Yang deficiency and Yin excess, these two sections do not fully address it, so I summarized and organized it on the blackboard.
Next, let’s look at the Tong Mai Si Ni Tang syndrome, which is the Yin excess obstructing Yang syndrome. In the handout, section 165 states, “In Shaoyin disease, there is clear and frequent diarrhea, with internal cold and external heat.” This internal cold and external heat is the key to this section’s pathogenesis. Internally, there is true cold, while externally, there is false heat, indicating Yin excess obstructing Yang. The manifestation of true cold internally includes clear and frequent diarrhea, cold extremities, and a pulse that is thin and nearly absent, which are clinical manifestations of Yang deficiency and Yin excess syndrome. The pathogenesis does not need to be discussed further. “Body heat without aversion to cold” indicates that there is no heat; how can there be body heat? It is simply stated as “body heat without aversion to cold” because the internal cold and external heat combine to indicate that there is true cold internally and false heat externally, which is the manifestation of Yin excess obstructing Yang. “The person has a red complexion,” which is often seen in Yin excess obstructing Yang syndrome, indicating that there is also a red complexion. “There may be abdominal pain, dry heaving, or throat pain,” as the abdomen and throat are both areas traversed by the foot Shaoyin kidney meridian. The foot Shaoyin kidney meridian runs through the throat and tongue. Therefore, when kidney Yang is deficient, Yin cold stagnates in the meridian, leading to abdominal pain and throat pain. Kidney Yang deficiency, with cold evil rising, invades the stomach, leading to dry heaving. “If diarrhea stops and the pulse cannot be felt,” this indicates that in the case of clear and frequent diarrhea, if the diarrhea stops and the pulse cannot be felt, we know that Yang Qi has recovered, and the diarrhea has stopped. If the diarrhea has stopped and the pulse cannot be felt, what does this mean?
This indicates that the diarrhea has exhausted the Yin, and there is nothing left to expel. When the intestines are empty, there is nothing left to expel, so of course, there will be no more diarrhea. This indicates that the intestines have no content, and a dead person does not have diarrhea. “If diarrhea stops and the pulse cannot be felt, Tong Mai Si Ni Tang should be used.” Tong Mai Si Ni Tang is used to treat this condition, as it forces Yin back to Yang and connects the internal and external. You can see the composition of the formula: 15g of Gan Cao (Licorice, roasted), one piece of Sheng Fu Zi (Raw Aconite, peeled and cut into eight pieces), and 30g of Gan Jiang (Dried Ginger, strong individuals may use 40g). We just mentioned that the previous Si Ni Tang did not specify that Sheng Fu Zi should be a large piece. In Tong Mai Si Ni Tang, the amount of Gan Jiang and Sheng Fu Zi is increased, hence the name Tong Mai Si Ni Tang. The preparation method is the same: combine these three ingredients with 3 liters of water, boil down to 1.2 liters, strain, and take warm. This is also for two doses. After taking the medicine, if the pulse returns, the patient recovers.
“If the complexion is red, add 9 green onions.” This indicates that there is also a red complexion. I believe that green onions in the Han Dynasty were not like today’s Shandong green onions, which weigh two or three pounds each; they must have been thinner. Green onions are used to promote Yang Qi and connect the internal and external. “If there is abdominal pain, remove the green onions and add 30g of Shao Yao (Peony).” Abdominal pain indicates that cold has condensed in the kidney meridian, leading to meridian contraction, so Shao Yao is added to nourish blood, relax the tendons, and alleviate pain. “If there is dry heaving, add 30g of Sheng Jiang (Fresh Ginger).” This is clearly to warm the stomach, disperse cold, and stop the dry heaving. “If there is throat pain, remove Shao Yao and add 30g of Jie Geng (Platycodon).” We say that throat pain is due to cold injuring the Shaoyin meridian, as the Shaoyin meridian runs through the throat and tongue. Therefore, at this time, adding Jie Geng can open the throat and relieve pain. “If diarrhea stops and the pulse cannot be felt, remove Jie Geng and add 30g of Ren Shen (Ginseng).” The stopping of diarrhea and the pulse not being felt indicate true Yin exhaustion. We say that the ginseng in the Han Dynasty is different from modern ginseng; its nourishing effect on true Yin is very good. Since true Yin is exhausted, adding ginseng serves the same purpose as adding ginseng in Bai Hu Tang, which is to nourish true Yin. “The treatment should correspond to the symptoms and the formula,” indicating that the adjustments to the formula should correspond to the clinical symptoms for it to be effective.
In the “Shang Han Lun,” there are seven formulas that have accompanying adjustments: Xiao Qing Long Tang, Xiao Chai Hu Tang, Tong Mai Si Ni Tang, Si Ni San, Zhen Wu Tang, Li Zhong Tang, and Zhi Shi Zhi Zi Tang. Among these, the adjustments for the first six formulas are particularly important, as they reveal Zhang Zhongjing’s principles of herbal use. If time permits, we can study these formula adjustments ourselves. In this lesson, we discussed Yang deficiency syndrome, Yin excess obstructing Yang syndrome, and after a break, we will specifically discuss the original text of Yin excess with Yang deficiency syndrome.
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