Hello everyone, let’s begin our class. In the last lesson, we discussed the concept of dialectical differentiation, the principles of dialectical treatment, and the authenticity of “cold and heat” in diseases. Today, we will continue discussing certain syndromes, which have both exterior and interior conditions. We will focus on the principles and methods for handling exterior and interior conditions, as well as the timing of treatment based on urgency. This is what we will cover next: the treatment methods for exterior and interior conditions, and the principles of urgency and delay.
The first situation is when there are both exterior and interior conditions. Generally, in such cases, one should first resolve the exterior before addressing the interior. This has been emphasized previously. Why is this necessary? Because if you attack the interior first when both exterior and interior conditions are present, the body’s righteous qi will tend to move inward, while the pathogenic qi, although the dampness in the interior may be expelled, the exterior pathogenic factors will take the opportunity to invade the interior, complicating the condition. If you first resolve the exterior and then attack the interior, the exterior pathogenic factors will be eliminated, and during the process of resolving the exterior, the dampness in the interior will remain stationary. You cannot say that during the process of resolving the exterior, the interior pathogenic factors will move outward; that is impossible. The dampness in the interior will remain in place, and when you then attack the interior, there will be no concerns, and the condition will be completely resolved. Therefore, in cases of both exterior and interior conditions, the principle is to first resolve the exterior and then attack the interior. Of course, later physicians have developed formulas for simultaneous treatment of both exterior and interior conditions, which is a later development. In the Treatise on Cold Damage, exterior and interior conditions are treated separately.
Only in very special circumstances, when both exterior and interior conditions are present, and the interior condition is severe and urgent, can one consider attacking the interior first based on the principle of “treat the urgent first, and the less urgent later.” However, there is a prerequisite: the interior condition must be severe and urgent, while the exterior condition is relatively mild. In this case, one can consider attacking the interior first; this is the principle of treating the urgent first. However, such cases are relatively rare in the Treatise on Cold Damage. What is this principle called? It is referred to as “the damp person with cold damage sweats out.” We previously learned about the indications for the formula Peach Kernel Decoction, which states, “If the exterior is not resolved, it is not yet appropriate to attack; if the exterior is resolved, but there is a hard mass in the lower abdomen, then it is appropriate to attack with Peach Kernel Decoction.” Do you remember from our last class? That is, when there are both exterior and interior conditions, one should first resolve the exterior and then attack the interior, which is the principle of “the solid person with cold damage sweats out.” Only when the interior condition is severe and urgent, and the exterior condition is mild, can one consider attacking the interior first. Are there any examples of this? Now let’s turn to page 69 of the handout and look at item 124: “In the case of Taiyang disease lasting six or seven days, if the exterior condition still exists, the pulse is weak and deep, and there is no hard mass in the chest, but the person is delirious, it indicates heat in the lower jiao, and the lower abdomen should be hard and full. If urination is frequent, then bleeding will resolve the condition; this is treated with the formula Di Dang Decoction.” This item illustrates a severe interior condition with accumulated blood, where heat and stagnation are intertwined, and the condition is relatively urgent. Therefore, although the exterior condition still exists, it is not taken into account, and Di Dang Decoction is used for treatment. This is considered by later physicians to be an example of simultaneous treatment of both exterior and interior conditions, where the interior condition is severe and urgent, and Di Dang Decoction is used to break blood and eliminate stagnation. Since the exterior condition is relatively mild, it can be considered later. This is the only example that later physicians have recognized as attacking the interior first. Of course, some physicians believe that if the pulse is weak and deep, then the exterior condition no longer exists. Therefore, this situation is relatively rare in the Treatise on Cold Damage.
The second situation is when there are both exterior and interior deficiency conditions. In this case, one should first tonify the interior and then resolve the exterior. This is because the efficacy of Chinese medicine in inducing sweating relies on the body’s righteous qi to transport the medicine and expel the pathogenic factors. If the interior qi is deficient, it cannot transport the medicine or invigorate the body’s strength to expel the pathogenic factors. Therefore, even if you use exterior resolving herbs, it will not induce sweating. This is why in the twelfth item of the Treatise on Cold Damage, regarding the formula Gui Zhi Decoction, it states, “Do not allow it to flow away like water; the illness will not be resolved.” Therefore, for cases of both exterior and interior deficiency, Zhang Zhongjing requires that one first support the interior and then resolve the exterior. This principle has been summarized by later physicians as “the deficient person with cold damage builds up the interior.”
“The solid person with cold damage sweats out, the deficient person with cold damage builds up the interior,” is a concise summary of the treatment principles for “simultaneous exterior and interior conditions, urgency and delay.” For cases of both exterior and interior excess, one should first resolve the exterior and then attack the interior; for cases of both exterior and interior deficiency, one should first support the interior and then resolve the exterior. When the interior qi is sufficient, sometimes the body fluids will naturally “sweat out and resolve.” If the interior qi is sufficient and the exterior pathogenic factors have not yet been resolved, it is not too late to resolve the exterior afterward. Now, let’s pose a question: for cases of both exterior and interior excess, what formula should be used to first resolve the exterior? This exterior condition may have sweating or may not; the formula Gui Zhi Decoction can be used to resolve the exterior, even if there is no sweating, one should not use Ma Huang Decoction. This is because Ma Huang Decoction is a purely pungent and warm formula, which has a strong expelling power, easily injures body fluids, and can easily increase interior heat and excess.
Next, we need to address the second question: “The deficient person with cold damage builds up the interior.” After the interior qi has been supplemented, if the exterior pathogenic factors still exist, what formula should be used to resolve the exterior? Again, it should only be Gui Zhi Decoction, not Ma Huang Decoction. This is because the interior qi has just been restored; if you again use the pungent and warm Ma Huang Decoction, which has a strong expelling power, the righteous qi will not be able to support it. Therefore, Gui Zhi Decoction is used, which shows that the application of Gui Zhi Decoction is very broad. Now, the third situation is when both exterior and interior conditions are present, but the relationship between the pathogenesis of the exterior and interior conditions is closely related. If both conditions are not severe, then we can treat both simultaneously.
Think about it, which formulas we have discussed meet these two conditions and are also treated simultaneously? One is Da Qing Long Decoction. The indications for Da Qing Long Decoction are that there is exterior cold, the cold is trapped in the exterior, and the yang is constrained and transforms into heat, causing the heat to disturb the heart. This is also an interior condition, presenting as no sweating and irritability, with the exterior cold trapped. The irritability is a manifestation of interior heat disturbing the heart. Isn’t this a simultaneous exterior and interior condition? However, the pathogenesis of the exterior and interior conditions is very closely related, because the exterior cold obstructs the exterior, leading to the yang being constrained and transforming into heat. Does this interior condition require the use of purgative formulas or Da Huang? No, it only requires the treatment of interior heat, not a severe excess condition. Therefore, Da Qing Long Decoction disperses the exterior cold and clears the interior heat, treating both simultaneously.
Next, we think of the second formula: Xiao Qing Long Decoction. This is when there is exterior cold and interior water retention. During the onset of the disease, the exterior cold triggers the internal water, leading to water cold invading the lungs. Therefore, the relationship between the pathogenesis of the exterior and interior conditions is closely related, and this interior condition is not a severe excess or deficiency condition. Thus, Xiao Qing Long Decoction disperses the exterior cold and transforms the internal water, treating both simultaneously.
The formula Wu Ling San also illustrates that the exterior pathogenic factors follow the meridians into the interior, affecting the bladder’s qi transformation function. The relationship between the pathogenesis of the exterior and interior conditions is closely related, and this interior condition is not a deficiency condition. The water pathogenic factors are not stagnant enough to require purgation with Da Huang. Therefore, Wu Ling San disperses the exterior and promotes urination, resolving both simultaneously. These are three formulas we have already discussed.
We have not yet discussed some formulas, but I would like to give a hint. Of course, in teaching, it is generally avoided to discuss the connections between previous and later content, but for the students here, you have all previewed the later content before studying the Treatise on Cold Damage, so it is acceptable for me to give you a brief hint. For example, we will later discuss the indications for Ge Gen Chen Lian Decoction, which we have already covered in the study of formulas, so it is not something you have not learned. The indications for Ge Gen Chen Lian Decoction are that there is exterior pathogenic factors and interior heat causing diarrhea. The use of Ge Gen Chen Lian Decoction disperses the exterior pathogenic factors and clears the interior heat to treat diarrhea, which is a simultaneous exterior and interior condition, and the interior condition is not a severe excess or deficiency condition.
Another example is Gui Zhi Ren Shen Decoction, which has an exterior condition and an interior deficiency cold causing diarrhea. However, this interior deficiency cold is merely a deficiency of the interior yang, without involving the severe deficiency of the kidney yang. Therefore, this interior condition is not severe, and it is also treated simultaneously.
Let’s give another example, which we have learned in the study of formulas: Ma Huang Xi Xin Fu Zi Decoction. From the composition of the formula, Ma Huang disperses the exterior cold, while Fu Zi warms the interior yang of the Shaoyin and disperses the cold in the Shaoyin. Xi Xin can disperse both the exterior cold and the cold in the Shaoyin. Therefore, it is a formula that treats both the Taiyang and Shaoyin simultaneously from the perspective of the herbs. Its clinical indications actually involve a mild deficiency of the Shaoyin yang, which is only slight, and it is accompanied by a Taiyang exterior condition. This indicates that both the Taiyang and Shaoyin have simultaneously been affected by the cold pathogenic factors, and the relationship between the pathogenesis of the exterior and interior conditions is still very closely related. The interior condition is not a severe deficiency condition, as there are no symptoms of severe deficiency such as “diarrhea with clear grains, cold limbs, weak pulse, and desire to sleep.” Therefore, in this case, Ma Huang Xi Xin Fu Zi Decoction can be used to warm the meridians and induce sweating, which is an example of simultaneous treatment of both exterior and interior conditions.
In the Treatise on Cold Damage, the principles of “simultaneous exterior and interior conditions, urgency and delay” generally do not exceed these three aspects. The first two aspects can be summarized as “the solid person with cold damage sweats out, the deficient person with cold damage builds up the interior.” This is something that everyone needs to remember. However, the “building up the interior” does not limit itself to the yang and qi of the body; it refers broadly to the interior. For example, if there is kidney yang deficiency, accompanied by an exterior condition, diarrhea with clear grains, cold limbs, and weak pulse, along with a Taiyang exterior condition, one should first tonify the interior with Si Ni Decoction. Therefore, this “interior” is not limited to the middle jiao; it refers to the entire body.
Now let’s look at the original text of the Treatise on Cold Damage to see if our summarized content can be encapsulated. Open to page 44 of the handout and look at the original text of item 90: “If one originally should induce sweating, but then purges, this is a reversal; if one first induces sweating and treats, it is not a reversal. If one first purges and then induces sweating, this is a reversal; if one first purges, it is not a reversal.” This item discusses the treatment of both exterior and interior excess conditions, with two situations: “originally” means that one should have induced sweating, but instead purged, which is a reversal. The term “reversal” indicates a mistake. Why does it say “if one first induces sweating, it is not a reversal”? This is because if you first induce sweating, it is not considered wrong.
The next item discusses the treatment of both exterior and interior excess conditions, where the interior condition is severe and urgent, and the exterior condition is relatively mild. In this case, one should first purge. “Originally, one should have purged first,” which means that one should have purged first, “but instead induced sweating,” which is a reversal. “If one first purges, it is not a reversal.” If you first purge, it will not be wrong. Therefore, item 90 is precisely the first situation we summarized on the blackboard.
Item 91 states, “If a physician uses purgation for cold damage, and subsequently there is diarrhea that does not stop, this indicates that the purging has been excessive.” Here, “diarrhea” refers to loose stools, and “clear” refers to the clarity of the stools, indicating that the stools are not well-digested food. In the Treatise on Cold Damage, the term “clear” is used as a verb, meaning to expel undigested food. The term “谷” (gu) refers to undigested food. Therefore, “diarrhea with clear grains” indicates that the food consumed has not been digested properly. This situation arises when the middle jiao is likened to a pot, and the lower jiao is likened to fire. When the fire in the lower jiao is weak, it is like placing a pot on the fire without it being heated; when you return home at noon, you find that the rice is still uncooked. Therefore, when the kidney yang is weak, the fire does not warm the earth, and the food cannot be cooked. This is why the stools are still undigested. If one eats millet porridge, the stools will still contain undigested millet, which is the manifestation of “diarrhea with clear grains.”
Here, “diarrhea with clear grains that does not stop” indicates that the degree of interior deficiency is already quite severe. “Body aches” indicates the presence of an exterior condition. This is what we refer to as the second situation: both exterior and interior deficiency conditions. “Urgently rescue the interior” means to treat it. This type of exterior and interior deficiency should be treated based on the principle of “the deficient person with cold damage builds up the interior,” actively and decisively. “After the body aches,” once the interior yang has been restored, if there is still “body aches” as an exterior condition, “the clear stools return to normal” indicates that the stools have returned to normal. This means that the interior yang has been restored. At this point, one should urgently resolve the exterior. Why should one not wait and observe? Because the interior yang has just been restored; if you do not actively resolve the exterior, the exterior pathogenic factors may linger and potentially invade the interior, causing a recurrence of the interior condition. In this item, two instances of the word “clear” are used: one is “clear grains,” and the other is “clear stools.” Some texts mistakenly interpret “clear stools” as referring to urination, which is incorrect. The term “clear” here means to expel, and is used as a verb, meaning to defecate. “Clear grains” refers to undigested food, while “clear stools” refers to normal stools. The return to normal stools indicates that the interior yang has been restored. At this point, one should treat the exterior, and for rescuing the interior, one should use Si Ni Decoction, while for resolving the exterior, one should use Gui Zhi Decoction. Why not use Ma Huang Decoction? As we just mentioned, because the interior yang has just been restored, even if the exterior condition is without sweating, one should not rashly use the purely pungent and warm Ma Huang Decoction, as it may induce excessive sweating and further injure the yang qi.
Item 92 states, “If there is fever and headache, the pulse is instead deep; why use the term ‘instead’? Fever and headache indicate a Taiyang exterior condition, and the pulse should be floating. If the pulse is deep, this is an abnormal phenomenon, hence the use of ‘instead.’ “If it does not resolve,” the addition of the character for illness is actually redundant; the original text of the Treatise on Cold Damage does not include this character. The term “差” (cha) means to recover, and in the Treatise on Cold Damage, it is used to indicate recovery. The term “若不差” (ruo bu cha) means if the illness does not improve. In the Treatise on Cold Damage, there is a phrase, “若不间” (ruo bu jian), which means if the illness does not improve. This is very simple; however, in one translation of the Treatise on Cold Damage, the term “间” was translated as “intermittent,” meaning if the illness does not intermittently improve, which indicates a misunderstanding of the term. The term “知” (zhi) means to know, and in the context of taking Ma Zi Ren Wan, it refers to the amount taken, gradually increasing. Some translations interpret this as “if you feel it, then stop taking it,” but this is unclear. Therefore, the term “知” does not refer to feeling but to recovery. The terms “差,” “间,” and “知” all refer to recovery. Some physicians pronounce this character as “cuo” (搓). When I was in school, I also pronounced it as “cuo.” I remember one year, the Central People’s Broadcasting Station organized a lecture on Traditional Chinese Medicine, and when I was discussing the Treatise on Cold Damage, I pronounced it as “阴阳易[cuo]后病脉并治” (yin yang yi [cuo] hou bing mai bing zhi). The accompanying announcer turned off the microphone and said, “Teacher, how do you pronounce this character as ‘cuo’?” I said, “My teacher pronounced it as ‘cuo.'” He immediately took out the Xinhua Dictionary and said, “Look, this character, when referring to ‘病愈’ (bing yu), is pronounced ‘chai.’ You should reconsider how to pronounce it.” He said, “I dare not violate the dictionary,” so I changed my pronunciation to ‘cai’ because it is the standard pronunciation. Later, I asked my teacher why he pronounced it as ‘cuo.’ He said, “My teacher pronounced it as ‘cuo.'” I asked if he had ever asked his teacher why he pronounced it that way, and he said, “I asked him, and he said his teacher pronounced it as ‘cuo.'” So, in reality, Traditional Chinese Medicine is passed down from generation to generation, and many teachers still pronounce it as ‘cuo.’ Now, I am not sure if your teachers or other teachers also pronounce it as ‘cuo.’ There are some who do. Later, I changed my pronunciation to ‘cai’ according to the announcer’s request because that is the standard pronunciation.
Now, “若不差” (ruo bu cha) means if the illness does not improve. This “若不差” omits a part of the sentence. What is omitted? It is omitted that if after using Ma Huang Xi Xin Fu Zi Decoction and Ma Huang Xi Xin Gan Cao Decoction to warm the meridians and induce sweating, the illness still does not improve, then this part is omitted. The body aches indicate the presence of an exterior condition, but one should also “first rescue the interior.” What should be used here? “Use Si Ni Decoction.” This indicates that for cases of both exterior and interior deficiency, even if the interior deficiency is not severe, if you use the method of simultaneous treatment of both exterior and interior, and it does not improve, you should still tonify the interior. This emphasizes Zhang Zhongjing’s focus on the righteous qi, especially the importance of the body’s yang qi in his academic thought. Therefore, when treating cases of both exterior and interior deficiency, he is very cautious. In cases of mild interior deficiency, where only a deep pulse is observed, the first consideration is to use Ma Huang Xi Xin Fu Zi Decoction. If after using these two formulas, the condition does not improve, then these two formulas should not be used again, and one should directly use Si Ni Decoction to tonify the interior. Therefore, the treatment of mild exterior and interior deficiency is approached with great caution. If one observes severe interior deficiency, with symptoms such as “diarrhea with clear grains and cold limbs,” this is what we discussed in item 91, where it states, “Urgently rescue it, use Si Ni Decoction.” This is the treatment approach for severe cases of both exterior and interior deficiency.
Now, from the concept of Taiyang differentiation and the concept of Taiyang disease, we should say that this is a general discussion on the principles of dialectical treatment. For Taiyang differentiation or disease, whether it is cold or heat, deficiency or excess, or a mixture of cold and heat, or both deficiency and excess, whether it is in the zang or fu organs, the situation is complex and variable. The basic treatment principle is to “observe the pulse and symptoms, understand what is being reversed, and treat according to the symptoms.” Therefore, the following Zhang Zhongjing provides examples of “treating according to the symptoms.”
Now let’s look at the heat syndrome. The first formula for heat syndrome is Wei Zi Chi Decoction. Look at the original text of item 76: “After inducing sweating, vomiting, and purging, if there is irritability and inability to sleep, if severe, there will be restlessness and vexation in the heart; Wei Zi Chi Decoction is indicated. If there is shortness of breath, Wei Zi Gan Cao Chi Decoction is indicated. If there is vomiting, Wei Zi Sheng Jiang Chi Decoction is indicated.” First, this illness has undergone sweating, vomiting, and purging, and the exterior pathogenic factors have entered the interior and transformed into heat. From the clinical symptoms, it can be seen that the pathogenic heat is lingering and disturbing the chest, causing irritability and disturbing the heart, leading to “irritability and inability to sleep.” Why does Zhang Zhongjing call it “irritability”? This “irritability” does not refer to the deficiency of the righteous qi, but rather to the heat that has not yet combined with tangible pathological products. Tangible pathological products refer to phlegm, water, food accumulation, blood stasis, and parasitic accumulation, all of which can be called tangible pathological products. In the Treatise on Cold Damage, there is a habitual use of terms; whenever the pathogenic qi combines with tangible pathological products, Zhang Zhongjing habitually uses the term “excess.” For example, in the future, we will mention the heat evil combining with phlegm and water in the chest, which Zhang Zhongjing calls “excess heat in the chest.” You see, he uses the term “excess.” When heat evil combines with blood stasis in the uterus, heat enters the blood chamber, and when Zhang Zhongjing treats it, he says, “puncture its gate and take it according to its excess.” In the indications for the three purgative formulas in Yangming disease, “if there is tidal fever, this is excess,” he uses the term “excess” because that refers to the combination of heat evil and the remnants of Yangming.
In the case of Gua Di San, Zhang Zhongjing uses the term “this is excess in the chest” because Gua Di syndrome refers to the presence of tangible phlegm and fluid in the chest. Therefore, in the Treatise on Cold Damage, the term “excess” often refers to tangible pathological products and tangible pathogenic qi. However, for intangible pathological products and intangible pathogenic qi, such as here, the heat evil is intangible and has not yet combined with phlegm, fluid, food accumulation, or blood stasis, Zhang Zhongjing not only does not use the term “excess,” but instead uses the term “deficiency.” Therefore, here, “irritability” refers to the opposite of “excessive irritability.” For example, in the indications for Da Cheng Qi Decoction, there is irritability, which is excessive irritability. In the case of major chest obstruction, there is also irritability and vexation, which is also excessive irritability. It simply indicates that the pathogenic qi has not yet combined with tangible pathological products, rather than indicating that the righteous qi is deficient. Thus, when we describe its pathogenesis, we can say that the irritability syndrome is caused by the mismanagement of Taiyang disease, leading to intangible pathogenic heat accumulating in the chest, disturbing the heart, and causing irritability. The mild cases present as irritability and inability to sleep, as the person cannot close their eyes and rest. The term “sleep” here does not refer to sleeping; Zhang Zhongjing uses the term “寐” (mei) to refer to sleep. The term “眠” (mian) means to close the eyes. The idiom “死不瞑目” (si bu ming mu) means to die without closing one’s eyes. The term “瞑目” (ming mu) means to close the eyes. The term “眠” (mian) is a variation of the term “瞑” (ming). When one is irritable, they cannot close their eyes. If it is severe, they will be restless and unable to find peace, turning back and forth, unable to settle down, with a feeling of vexation in the heart.
In my school days, there was a classmate who was particularly diligent in his studies, always wanting to get to the bottom of things. When the teacher mentioned “restlessness and vexation,” the first director of the Cold Damage Research Office, Mr. Chen Shenwu, was chased down the hall by this classmate, who asked, “Teacher, what does ‘vexation in the heart’ mean?” We were in the large courtyard of Dongzhimen, and Mr. Chen’s office was in the sixth floor of the white building, while the classroom was in the teaching building. This classmate chased Mr. Chen all the way to his office. Mr. Chen had no choice but to say, “It feels like eating raw Aconite.” The classmate replied, “Teacher, can you find some raw Aconite for me to try?” The teacher was afraid to let him try raw Aconite, as it contains Aconitine, which could be fatal. The teacher had no choice but to say, “Well, if you really want to experience what ‘vexation in the heart’ feels like, prepare a head of purple garlic and eat it on an empty stomach to see how it feels.”
One day at noon, just as I was about to go eat, he stopped me and said, “Don’t go eat yet; I want to experience what ‘vexation in the heart’ feels like.” I asked, “How are you going to experience it?” He said, “Teacher Chen told me to eat a head of purple garlic.” He took a head of purple garlic out of his pocket and ate a couple of cloves. Soon, he was tearing up, his nose was running, and he was salivating. He was patting his chest, trying to get it out, but he couldn’t. Imagine that fiery feeling in his stomach. He said, “Do you have anything to eat?” I said, “I have nothing here, it’s empty.” He said, “Hurry to the cafeteria.” I asked, “Why don’t you finish the garlic?” He said, “I’ve already experienced what ‘vexation in the heart’ feels like.” This classmate is now doing very well in clinical practice, so he wanted to experience what it felt like. Therefore, this feeling of “vexation in the heart” is that kind of discomfort, a mix of heat and fullness, a feeling of pain that is neither clearly hot nor cold, neither clearly swollen nor painful. I have used so many words to describe it, but I still cannot clarify it. Our classmate experienced it clearly after eating a couple of cloves of garlic on an empty stomach. Therefore, this is the heat disturbing the heart, and Wei Zi Chi Decoction is used to clear it. Everyone knows that Wei Zi is a medicine that clears heat from the three jiaos, while Dou Chi is a dispersing medicine. The combination of these two herbs has a clearing and dispersing effect, which can clear the heat and relieve the vexation.
As we know, heat can easily damage the righteous qi. This is what the ancients referred to as “less fire generates qi, strong fire consumes qi.” Less fire refers to the body’s yang qi, which has a warming effect and a qi transformation effect, allowing the generation of the body’s righteous qi. Strong fire refers to the excess heat, which is the body’s pathogenic qi that consumes the righteous qi. Therefore, if there is shortness of breath, Wei Zi Gan Cao Chi Decoction is indicated. This indicates that the heat has damaged the qi, which is easily consumed by the pathogenic heat. This is not the same as shortness of breath due to obstruction of qi, which is a feeling of stagnation. Shortness of breath indicates a lack of qi. Wei Zi Gan Cao Chi Decoction is indicated to clear the heat and also tonify the qi. Gan Cao is used to tonify the qi; why not use Ren Shen? Because Ren Shen is for heat syndromes, and using it may exacerbate the heat. Therefore, Gan Cao is used to tonify the qi.
In cases of vomiting, Wei Zi Sheng Jiang Chi Decoction is indicated. This vomiting is due to heat disturbing the stomach, causing the stomach qi to rebel. Therefore, adding Sheng Jiang can harmonize the stomach and stop the vomiting. Now, let’s look back at Wei Zi Chi Decoction, Wei Zi Gan Cao Chi Decoction, and Wei Zi Sheng Jiang Chi Decoction. For Wei Zi Chi Decoction, we have discussed it before. In the study of herbal medicine, we have also covered it. Now we encounter it again. You see, “Take the first two ingredients, boil them in four sheng of water, first boil the Wei Zi to obtain two and a half sheng, then add the Dou Chi and boil to obtain one and a half sheng, strain, and divide into two doses.” Therefore, Wei Zi Chi Decoction uses fourteen Wei Zi and four sheng of Dou Chi, which is a treatment dose of eighty milliliters for two doses. “Warm and take one dose. If vomiting occurs, stop taking afterward.” This “if vomiting occurs, stop taking afterward” is actually the original text of the Treatise on Cold Damage and should not have a comma. The following Wei Zi Gan Cao Chi Decoction adds two liang of Gan Cao to Wei Zi Chi Decoction, also divided into two doses, so Gan Cao is also used in one liang, which is fifteen grams. Wei Zi Sheng Jiang Chi Decoction adds five liang of Sheng Jiang to Wei Zi Chi Decoction, which is a larger amount, also divided into two doses, so one dose is two and a half liang, which is over thirty milliliters. The formula also states, “If vomiting occurs, stop taking afterward.” Therefore, if we follow the logic of the sweating formula “if sweating occurs, stop taking afterward” and the purging formula “if purging occurs, stop taking afterward,” it is easy to misunderstand that Wei Zi Chi Decoction has an emetic effect. Would this be a misunderstanding? You see, “if sweating occurs, stop taking afterward” indicates that it is a sweating formula, and “if purging occurs, stop taking afterward” indicates that it is a purging formula. Following this logic, it is easy to deduce that “if vomiting occurs, stop taking afterward” means that Wei Zi Chi Decoction has an emetic effect. In fact, Wei Zi and Dou Chi do not have an emetic effect. Why does vomiting occur after taking this formula? This is mainly because when the heat is trapped in the chest, taking Wei Zi and Dou Chi can disperse the heat in the heart, allowing the righteous qi to expel the pathogenic factors. Often, this leads to a strong urge to vomit, expelling the pathogenic heat from the body. This is a manifestation of the body’s righteous qi, not the effect of the medicine.
Traditional Chinese Medicine is a very compassionate medicine. When the pathogenic qi is at the surface, we use the skin, which acts as a semi-permeable membrane, to expel the pathogenic factors and toxins from the body through sweating. What is a semi-permeable membrane? Our skin can breathe, expelling carbon dioxide and absorbing oxygen. Our skin can sweat and excrete metabolic waste. However, the nutrients and blood in our body do not pass through the skin. This is what is meant by a semi-permeable membrane. It retains useful substances in the body while excreting metabolic waste. Therefore, when the pathogenic qi is at the surface and toxins are at the surface, we take advantage of the situation and use sweating to expel the pathogenic factors from the body. Therefore, when the heat is trapped in the chest, after taking the medicine, the heat is released, and the righteous qi drives the pathogenic factors outward. This often leads to a strong urge to vomit, expelling the toxins and heat from the chest. So, what semi-permeable membrane can the pathogenic factors in the chest use to communicate with the outside world?
The mucous membranes of the esophagus and stomach are located in the upper part. Through the mucous membranes of the esophagus and stomach, metabolic products are secreted, and the trapped heat in the chest is expelled. When one vomits, does it not carry away some heat? For example, some young men tell me, “Teacher, why do I feel a chill all over after urinating?” I say, “Your urine carries away some heat, so your yang qi is temporarily insufficient, which causes a chill.” Therefore, when the heat is trapped in the chest, the only way to expel it is to vomit the contents of the stomach, thus expelling the heat, toxins, and pathogenic factors. This is why after taking Wei Zi Chi Decoction, one may experience vomiting, which is a reaction of the body to expel toxins. The vomiting before taking the medicine is a manifestation of heat disturbing the stomach.
Therefore, everyone should distinguish this point: Wei Zi Chi Decoction itself does not have an emetic effect; if there is vomiting, it is due to heat disturbing the stomach. This vomiting is pathological and cannot expel the toxins and heat from the body. After taking Wei Zi Sheng Jiang Chi Decoction, the vomiting is a manifestation of the righteous qi expelling the pathogenic factors. This is different from the original vomiting. Next, we look at item 77: “After inducing sweating, if purging leads to irritability and a feeling of fullness in the chest, Wei Zi Chi Decoction is indicated.” After using sweating and purging methods, if residual heat lingers and disturbs the chest, leading to irritability, the irritability is a manifestation of residual heat disturbing the heart. The fullness in the chest indicates that the heat is obstructing the qi mechanism, causing discomfort. In this case, Wei Zi Chi Decoction is still used to clear the heat and relieve the vexation, without adding any qi-regulating herbs. By dispersing the trapped heat, the qi mechanism will naturally become smooth.
Item 78 states, “If after five or six days of cold damage, there is a significant purging, and the body heat does not dissipate, with pain in the heart, this indicates that the condition has not resolved; Wei Zi Chi Decoction is indicated.” Here, it describes a specific case. In fact, the original text of the Treatise on Cold Damage consists of individual case studies. In the case of an external pathogen lasting five or six days, after significant purging, if the body heat does not dissipate, it indicates that the residual pathogenic factors are still present. The pain in the heart is due to the heat obstructing the qi mechanism, leading to discomfort. Therefore, in this case, Wei Zi Chi Decoction is used to clear the heat and relieve the vexation. In this case, neither qi-regulating herbs nor blood-activating herbs are needed; simply clearing the heat can resolve the pain in the heart.
Next, we look at item 79: “After cold damage and purging, if there is irritability, fullness in the abdomen, and difficulty in lying down or getting up, Wei Zi Hou Po Decoction is indicated.” The irritability is due to residual heat disturbing the chest, while the fullness in the abdomen is due to heat disturbing the lower part, causing discomfort. The combination of irritability and fullness leads to difficulty in lying down or getting up. In this case, Zhang Zhongjing uses Wei Zi Hou Po Decoction. Wei Zi is used to clear the heat in the heart, while Hou Po and Zhi Shi are used to regulate qi and relieve fullness. We notice that this formula does not include Dou Chi. Why not? Dou Chi is a dispersing herb that acts upward. Now that the heat has disturbed the lower part, causing discomfort, it is not appropriate to use the upward-dispersing Dou Chi. Instead, Wei Zi is used to clear the heat, while Hou Po and Zhi Shi are used to regulate qi and relieve fullness.
We have discussed part of the indications for Wei Zi Chi Decoction. Due to time constraints, we have not yet finished discussing the irritability syndrome. We will continue this in the next class. Thank you all for attending today’s class.
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