Essential Texts from the Treatise on Cold Damage: Recitation Class [Day 20 of Consistent Practice]

Original Text from the Treatise on Cold Damage

For those who have had a cold for five or six days, with vomiting and fever, the symptoms of Chai Hu Tang (Bupleurum Decoction) are present. If other medications are administered and the symptoms of Chai Hu (Bupleurum) persist, then Chai Hu Tang should be given again.

Even if other medications have been administered, it is not considered a reversal; the patient must experience a resurgence of symptoms, with fever and sweating leading to resolution.If there is fullness and hardness below the heart, this indicates Jie Xiong (Chest Binding), and Da Xian Xiong Tang (Major Decoction for Chest Binding) is indicated.However, if there is fullness without pain, this indicates Pi (Plum Pit Qi), and Chai Hu should not be used; instead, Ban Xia Xie Xin Tang (Pinellia Decoction to Drain the Heart) is appropriate. (149)

Clinical Case

“For those who have had a cold for five or six days, with vomiting and fever, the symptoms of Chai Hu Tang are present.” This statement discusses an external pathogen that, after five or six days, may lead to changes in the condition. What are the new symptoms that arise?“Vomiting and fever” indicates that vomiting is a manifestation of Dan Re (Gallbladder Heat) invading the stomach. We have previously mentioned that Shaoyang (Lesser Yang) diseases often involve issues of Dan Re and Qi stagnation. The Dan (Gallbladder) is associated with wood, while the spleen and stomach are associated with earth; wood diseases easily overcome earth. We will discuss this issue further later, so Dan Re easily invades the stomach, and when the stomach Qi rebels, vomiting occurs.Thus, in the Treatise on Cold Damage, the presence or absence of vomiting often indicates the existence of Shaoyang disease.Should we provide more examples? “If a cold occurs on the first day, and the Taiyang (Greater Yang) is affected, if the pulse is tranquil, it indicates no transmission; if there is a desire to vomit, but if there is agitation and the pulse is rapid, it indicates transmission.” The desire to vomit indicates that the pathogen has entered Shaoyang.In the 61st clause, “After purging, if sweating recurs, and during the day there is agitation and inability to sleep, but at night there is calmness,” a person with restless limbs may exhibit Shaoyang heart agitation. “If there is no vomiting, no thirst, no exterior symptoms, and the pulse is deep and weak, with no significant fever, Gan Jiang Fu Zi Tang (Dried Ginger and Aconite Decoction) is indicated; the absence of vomiting indicates no Shaoyang disease.Here, “vomiting and fever” indicates the presence of Shaoyang disease, which is a manifestation of Dan Re invading the stomach, causing the stomach Qi to rebel. What does the fever indicate? It is a manifestation of heat stagnating in the Dan (Gallbladder), which can lead to persistent fever.Thus, there are two types of heat patterns in Shaoyang disease. If a cold pathogen is present in the channel, there will be alternating chills and fever. During chills, there is always a problem of cold pathogens injuring Yang Qi, as Shaoyang is a small Yang, a weak Yang. Its ability to resist pathogens is limited, so when cold is present in the Shaoyang channel, the righteous and evil Qi contend, with alternating dominance. When the righteous Qi is dominant, there is fever; when the evil Qi is dominant, there is chills. Therefore, when the evil Qi is in the channel, there will be alternating chills and fever.However, when heat stagnates in the Dan, the evil Qi completely transforms into heat, leading to persistent fever. Therefore, we should not think that Shaoyang disease only presents with alternating chills and fever; Shaoyang also has a heat type characterized by vomiting and fever, which we will discuss in detail in the Shaoyang disease section.Thus, “vomiting and fever” is precisely a manifestation of heat stagnating in the Dan, indicating the presence of Shaoyang disease. Therefore, Zhang Zhongjing states, “The symptoms of Chai Hu Tang are present,” indicating that the indications for Xiao Chai Hu Tang (Minor Bupleurum Decoction) are met. “If other medications are administered,” Shaoyang disease is contraindicated for sweating, vomiting, or purging, as Shaoyang is a small Yang, a weak Yang. At the beginning, we mentioned that the amount of Yang Qi in Shaoyang is one part, while in Yangming it is two parts, and in Taiyang it is three parts.Thus, the amount of Yang Qi in Shaoyang is the smallest. Later generations of physicians referred to Shaoyang as small Yang, weak Yang, young Yang, tender Yang, and all terms describing youthfulness are used to describe the Yang Qi of Shaoyang. Therefore, the ability of Shaoyang to resist pathogens is insufficient; using sweating methods cannot resolve the evil Qi of Shaoyang, nor can purging methods eliminate the evil Qi of Shaoyang, and using vomiting methods cannot expel the evil Qi of Shaoyang. These aggressive treatment methods cannot eliminate the evil Qi of Shaoyang, but only deplete the righteous Qi of Shaoyang, worsening the condition. Therefore, Shaoyang disease must avoid sweating, vomiting, and purging.The Yizong Jinjian (Golden Mirror of Medicine) summarizes a verse based on the original text of the Treatise on Cold Damage: “The three prohibitions of Shaoyang must be clearly understood.” Shaoyang must avoid sweating, vomiting, and purging; “Sweating leads to delirium, vomiting and purging lead to agitation; if severe, vomiting and purging will not stop.” If misused, it can lead to continuous diarrhea, and not even water can be ingested, which poses a significant risk. Therefore, Shaoyang must avoid sweating, vomiting, and purging.However, this clause “If other medications are administered” violates the prohibitions of Shaoyang treatment. Fortunately, this person’s constitution is good, and the misuse of purging methods did not lead to a worsening condition.“If the symptoms of Chai Hu persist, then Chai Hu Tang should be given again.” The symptoms of Shaoyang still exist, and the indications for Chai Hu Tang remain. If there are symptoms, use the appropriate formula. If Chai Hu Tang is given again, “Even if other medications have been administered, it is not considered a reversal.” This is not a major error, as the condition did not worsen significantly. However, due to the misuse of purging, the righteous Qi was compromised, and after taking Xiao Chai Hu Tang, the patient exhibited a clinical manifestation of “battle sweat leading to resolution,” indicating a resurgence of symptoms with fever and sweating leading to resolution.“Battle sweat leading to resolution” is a term we previously mentioned when discussing the self-resolution of Taiyang disease. We mentioned that there are self-resolving methods for Taiyang disease, including spontaneous sweating, spontaneous bleeding, and battle sweat leading to resolution.The process of battle sweat leading to resolution begins with chills, which is a manifestation of the struggle between evil and righteous Qi. What does “蒸蒸而振” (zhengzheng er zhen) mean? It means to flourish, to be vigorous. What is flourishing depends on what it modifies. If “蒸蒸而振” modifies chills, then it indicates vigorous chills; if it modifies fever, then it indicates vigorous heat; if it describes our construction efforts, it indicates flourishing development. Therefore, it is a compound word.Compound words have no fixed characters; you can write them in various ways. You can remove the dots below or the grass radical above. So, do not immediately associate “蒸蒸” with a steamer. In many books, when they see “蒸蒸,” they think of a steamer, interpreting “蒸蒸而振” as internal heat steaming outward. Can we say that our construction efforts are like a steamer heating up?I think not. Therefore, do not associate “蒸蒸” with a steamer. If “蒸蒸发热” (zhengzheng fa re) is interpreted as steaming, it is acceptable, but interpreting it as internal heat surging outward is incorrect. “蒸蒸而振” does not refer to heat; what does it refer to? It refers to the flourishing state of chills. “蒸蒸” means to flourish.I have previously mentioned that compound words can be double-voiced, can be rhymed, or can be both double-voiced and rhymed. For example, the word “马虎” (mǎhǔ) in ancient pronunciation is a double-voiced word.We all know that “马虎” means to be careless, to be forgetful. If you try to explain the word “马虎” by breaking it down into “马” (horse) and “虎” (tiger), you cannot explain its meaning. Similarly, “玻璃” (glass) is also a compound word. If you try to explain it by breaking it down, you cannot explain its meaning.Therefore, when explaining compound words, we look at what they modify. If it modifies “蒸蒸而振” as chills, then “振” refers to chills; if it modifies “蒸蒸而热,” then it refers to the flourishing state of heat; if it describes our construction efforts, it indicates flourishing development. This is why I emphasize what “蒸蒸” refers to here; it indicates vigorous chills, intense chills.“However, fever and sweating lead to resolution”; what does “却” (que) mean? It means again. “When will we cut the candle at the west window together, and talk about the night rain in Bashan?” Here, “却” means again. The patient originally had fever, “vomiting and fever” indicates the presence of fever. Now, during chills, the fever temporarily disappears, but with the return of chills, fever reappears. Therefore, he says, “却发热” (que fa re), indicating that this fever is a manifestation of the struggle between righteous and evil Qi. When the righteous Qi attempts to expel the evil Qi, it is a sign of excitement, followed by sweating, indicating the victory of the righteous Qi over the evil Qi.Hao Wanshan discusses the three stages of battle sweat: chills, fever, and sweating. Chills indicate the struggle between righteous and evil Qi, where the evil Qi is dominant. After taking the medicine, the righteous Qi begins to gather strength to resist the evil Qi. Under the influence of the medicine, the evil Qi perceives that the righteous Qi is resisting it, and thus it mobilizes its forces to contend with the righteous Qi. At this point, the original fever symptoms temporarily disappear, and chills become prominent. When the righteous Qi, under the influence of the medicine, gathers strength to resist the evil, it leads to a noticeable fever.Following this fever, sweating occurs, which is a manifestation of the righteous Qi overcoming the evil Qi. Each stage of battle sweat is essential; if there are only chills without fever, it indicates that the righteous Qi is not resisting the evil. If there is only fever without sweating, it indicates that the righteous Qi is not expelling the evil. Only when all three stages are completed can the effects of sweating, fever reduction, and a tranquil pulse be achieved. This is called “battle sweat leading to resolution.”When Liu Duzhou was young, he practiced medicine in Yingkou, Liaoning. One summer, despite being in the northeast, it was quite hot. A family invited him to see a postpartum woman with a fever. Upon arrival, he found the windows tightly closed, and the woman was dressed in a cotton coat and pants, sitting on a heated kang (a traditional Chinese bed). Liu Duzhou thought, how could she not have a fever? Even a normal person would have a fever in such a hot room. He asked the woman if she felt hot, and she replied yes. He then asked why the windows were not opened, and the mother-in-law said it was to prevent the woman from catching a cold. The mother-in-law was very strict, unlike today’s young people who do as they please. Liu Duzhou insisted on opening the window, and the mother-in-law reluctantly agreed. He then asked the woman if she was thirsty, and she said she wanted to drink cold water, especially freshly drawn from the well. Liu Duzhou noticed her pulse was rapid and strong, with profuse sweating and great thirst, and her tongue was red. In the northeast, the houses are often dark, and he saw a water tank in the bright hall. Liu Duzhou, being young, scooped a ladle of cold water for the woman to drink, and she gulped it down.Afterward, he pondered what prescription to write and how to measure the dosage. At that moment, the woman began to shiver. The mother-in-law, seeing this, grabbed Liu Duzhou’s hand and said, “Doctor Liu, don’t leave yet!” Liu Duzhou, being young and inexperienced, wondered if the half ladle of cold water had harmed her. After about 20 minutes, she began to develop a fever. Liu Duzhou had to stay, and after about half an hour, she started sweating. After sweating, Liu Duzhou stayed for another hour, and her temperature gradually decreased. Thus, drinking cold water can also lead to battle sweat resolution, but this is in a very special situation.In the past, there was a famous qigong master in China, whose photo appeared on many qigong magazines. One year, he went to Singapore and Malaysia to give lectures, and he developed a high fever. The local treatments were ineffective, so he was quickly sent back to Beijing and admitted to a military hospital.In the hospital, various tests were conducted, but no diagnosis was made. They suspected he had contracted a disease not found in China, so they isolated his ward. After a long time in the hospital, he still had a high fever. Many reporters visited him, and he told them, “In the field of Chinese medicine, I only know Hao Wanshan. Can you find out where he is and ask him to come see me?” A reporter from Xinhua News Agency, who had previously worked with me, said he knew where I was and called me to come see him. When I arrived, I saw that his tongue was covered with a thick white coating, and I asked him to lift his tongue. The underside was red, indicating cold dampness and stagnation, with internal heat and Yang Qi stagnation, leading to the persistent high fever.I prescribed a very simple formula, San Ren Tang (Three Nut Decoction) with modifications. I told him to prepare it in the afternoon and take it that night. At around 11 PM, his wife called me and said, “Dr. Hao, the situation is not good; he is now shivering all over, and several young men cannot hold him down. What should we do?” I told her to call me back in 20 minutes. After 20 minutes, she called back and said he was no longer shivering and was now developing a fever. I asked if he was sweating, and she said no. I told her to call me back in another 20 minutes. After another 20 minutes, she called again and said he was sweating. I said that meant the fever was starting to subside. After just one treatment with San Ren Tang, the Qi was unblocked, the dampness was transformed, and the fever gradually subsided. By the next afternoon, his temperature returned to normal.Thus, battle sweat resolution does not necessarily require Xiao Chai Hu Tang to occur; it often happens during the course of an external heat illness due to various reasons, where the righteous Qi is compromised. Using formulas that promote Qi flow, transform dampness, harmonize the mechanisms, and resolve Shaoyang can even be triggered by drinking a ladle of cold water. In such situations, we should not panic.Once, after discussing battle sweat, students went to Dongzhimen Hospital for clinical practice. In the emergency room, a child had dysentery and a high fever. After receiving IV fluids, the child began to shiver. The child’s grandmother, accompanying him, said, “Doctor, what is happening?” One of the students said, “It’s okay, it’s battle sweat resolution; don’t worry.” Soon, the child would have a fever and then sweat, just as I had explained in class. However, the grandmother was not reassured. At that time, there were no regular nurses or doctors in the room, just a group of interns. She quickly called the head nurse, saying, “Nurse, come see what’s wrong with this child!” The head nurse looked and exclaimed, “Oh no, this is an IV reaction! Quickly stop the IV and handle it urgently!” The initial chills were followed by fever, but the subsequent sweating could lead to collapse, shock, and a drop in blood pressure, potentially resulting in death if not addressed. Therefore, this is a condition that requires urgent treatment. We must clearly distinguish between battle sweat resolution and IV reactions.Thus, whenever I discuss battle sweat resolution, I always use this example to help everyone differentiate between the two, ensuring that similar mistakes do not occur.“If there is fullness and hardness below the heart, this indicates Jie Xiong (Chest Binding), and Da Xian Xiong Tang is indicated.” If “vomiting and fever” occur, and the Shaoyang disease is mistakenly treated with other medications, leading to the disappearance of Chai Hu symptoms, and the patient presents with fullness and hardness below the heart, this indicates the binding of Shaoyang evil and water evil, forming Jie Xiong.The symptoms of Jie Xiong include fullness and hardness below the heart. In previous lessons, we discussed the three types of Da Jie Xiong symptoms, stating, “If there is pain below the heart, and it feels hard like a stone, Da Xian Xiong Tang is indicated.” Here, fullness and hardness below the heart refer to this condition. In previous lessons, we summarized the causes of Jie Xiong symptoms, which can arise from either the Taiyang exterior evil entering and transforming into heat, or from the Shaoyang disease being mistreated, allowing the evil Qi to enter and transform into heat, binding with water. Do you remember this summary?In this summary, we mentioned that after mistreatment of Shaoyang disease, the evil Qi enters and transforms into heat, binding with water. The basis for this is this clause, which indicates that after mistreatment of Shaoyang disease, the evil Qi enters and transforms into heat, binding with water. Since it is Jie Xiong, we should use Da Xian Xiong Tang for treatment.Now, the last part: “If there is only fullness without pain, this indicates Pi (Plum Pit Qi).” If there is only fullness below the heart without pain, this indicates Pi, which refers to a feeling of obstruction without significant tenderness. Of course, Pi below the heart is soft and does not have significant tenderness. “This indicates Pi“; thus, Chai Hu should not be used again. It is not appropriate to use Xiao Chai Hu Tang again; instead, Ban Xia Xie Xin Tang is recommended for treatment.Here, we differentiate between the symptoms of Ban Xia Xie Xin Tang and Da Jie Xiong symptoms, as well as Shaoyang disease. Why do we need to differentiate from Da Jie Xiong symptoms? Because Da Jie Xiong symptoms involve pain below the heart, with hardness upon palpation, while Pi symptoms also occur below the heart. Therefore, differentiation is necessary.Why do we need to differentiate from Xiao Chai Hu Tang symptoms? Because Ban Xia Xie Xin Tang symptoms involve dysfunction of the middle burner, while Xiao Chai Hu Tang symptoms involve dysfunction of the Shaoyang half-exterior, half-interior. Both involve dysfunction of the mechanism, so it is essential to differentiate which is the dysfunction of Shaoyang and which is the dysfunction of the middle burner.Thus, Zhang Zhongjing emphasizes that this is no longer the dysfunction of the Shaoyang half-exterior, half-interior mechanism, so Chai Hu should not be used. Instead, what should be used? Ban Xia Xie Xin Tang should be used to harmonize the middle burner, which is half above and half below.Regarding the indications for Ban Xia Xie Xin Tang, this clause provides little information. In our lecture notes, we referenced a statement from the Jin Kui Yao Lue (Essential Prescriptions of the Golden Chamber) regarding “vomiting and rumbling in the intestines, with fullness below the heart, Ban Xia Xie Xin Tang is indicated.” The main symptom is fullness below the heart, with the cause being stomach deficiency. We diagnose based on the formula, which uses Ban Xia (Pinellia) as the monarch herb. Ban Xia is also a phlegm-transforming herb, so it is disturbed by phlegm, leading to dysfunction of the middle burner, resulting in fullness below the heart.When Qi is obstructed in the middle burner, there will be heat in the stomach Qi rebelling. Why do we add the word heat? Because the heart is above, and the Yang Qi in the upper burner is abundant, while the Yin Qi in the lower burner is abundant. The middle burner coordinates the cold and heat of the body. When the middle burner is obstructed, the upper heat cannot descend, and the lower cold cannot ascend, leading to the manifestation of rebellious stomach heat, which results in vomiting. The cold Qi of the spleen sinks, leading to diarrhea. This is the clinical characteristics and pathogenesis of Ban Xia Xie Xin Tang symptoms.How do you determine if there is phlegm turbidity? Generally, the tongue coating is thick and greasy. Therefore, we call this condition Phlegm Qi Pi, which is caused by Qi stagnation leading to fullness below the heart, accompanied by interference from phlegm evil.Ban Xia Xie Xin Tang is a representative formula of Ban Xia, Sheng Jiang (Fresh Ginger), and Gan Cao (Licorice), or the leading formula. Its composition is very interesting; it uses Ban Xia and Gan Jiang (Dried Ginger), both of which are pungent herbs that have dispersing effects. When we eat chili, we sweat; when we drink white liquor, we also sweat. This is the dispersing effect of pungent herbs. Pungent herbs disperse the obstruction. Is there not Qi stagnation in the middle burner? Is there not Qi obstruction in the middle burner? Pungent herbs disperse the obstruction. Then, two bitter herbs are used: Huang Lian (Coptis) and Huang Qin (Scutellaria), which have a draining effect. Pungent herbs disperse the obstruction, and bitter herbs drain the fullness. This alleviates the fullness below the heart caused by Qi obstruction in the middle burner.Since it is a deficiency of stomach Qi, Ren Shen (Ginseng), Gan Cao, and Da Zao (Jujube) are used to tonify the deficiency of the middle burner and restore its function. These three herbs are all sweet and tonify the middle Qi. You could say it is half a Li Zhong Tang (Regulate the Middle Decoction) or half a Si Jun Zi Tang (Four Gentlemen Decoction). Of course, the Treatise on Cold Damage does not mention Si Jun Zi Tang; it is a later formula. However, Ren Shen, Gan Cao, and Da Zao can be considered half of Li Zhong Tang or half of Si Jun Zi Tang, as they tonify the deficiency of the middle burner.From the perspective of flavor and properties, this formula combines pungent dispersing, bitter draining, and sweet tonifying. The combination of pungent dispersing, bitter draining, and sweet tonifying is precisely to harmonize the middle burner, restore its function, and resolve the dysfunction of the half above and half below mechanism.Additionally, Ban Xia has a phlegm-transforming effect, while Huang Qin and Huang Lian clear the upper heat. Gan Jiang and Gan Cao are also part of Gan Cao Gan Jiang Tang (Licorice and Dried Ginger Decoction), which has a warming effect on the cold below. This is effective for the vomiting caused by upper heat and the diarrhea caused by the cold Qi of the spleen.Ban Xia Xie Xin Tang is widely used in clinical practice for chronic gastroenteritis, where there is fullness in the middle burner, diarrhea below, and occasional vomiting above. It is not often used for acute gastroenteritis, as chronic gastroenteritis often presents with a mix of cold and heat, with both deficiency and excess. This formula harmonizes cold and heat, combining both attacking and tonifying effects, making it very effective for the complex pathogenesis of chronic gastroenteritis.Regarding its administration, “Take the seven ingredients, add one dou of water, boil to obtain six sheng, remove the dregs, and then boil again to obtain three sheng. Warmly take one sheng, three times a day.” In the process of preparing this medicine, the term “boil” is used, and the term “decoct” is also used. Are the meanings of “boil” and “decoct” the same? They should be considered different.Today, we may not distinguish between boiling and decocting, but in the Han Dynasty, the distinction was very strict. What does boiling mean? It refers to the process of heating the herbs in water over fire. What does decocting mean? We refer to the words of Yang Xiong from the Western Han Dynasty in his Fang Yan (Dialect of Prescriptions): “Anything with juice that is dried is called decocting.” This means the process of heating and concentrating liquid substances. Therefore, the meanings of “boil” and “decoct” in the Treatise on Cold Damage are different.More than ten years ago, when we were writing the Treatise on Cold Damage annotations, led by Liu Duzhou, we aimed to create a contemporary, widely recognized base text for the Treatise on Cold Damage. In the annotation section of the Treatise on Cold Damage, I wrote the annotations for the meanings of words. When annotating the word “decoct,” I referenced the words from Fang Yan, stating, “Anything with juice that is dried is called decocting.” During the review process of our book, an elder in the field of Cold Damage thought that the explanation of decocting was incorrect and wrote a comment saying, “If it is all boiled dry, what is there to drink?” He misunderstood the meaning. Decocting refers to the process of heating and concentrating liquid substances; it does not mean to boil it dry. The instructions say to boil to obtain six sheng, then decoct to obtain three sheng, indicating that you should leave three sheng, so there is still something to drink.In the Treatise on Cold Damage, the terms “boil” and “decoct” are used correctly. There is a formula called Mi Jian Fang (Honey Decoction), which everyone knows. What does Mi Jian Fang mean? Honey is originally in liquid form, and when placed in a copper pot over low heat, it is slowly heated to evaporate the water. This process does not involve adding herbs; it is the process of drying the liquid, which is why it is called Mi Jian Fang. Honey cannot be picked up with chopsticks; it is gradually heated and stirred until it reaches a consistency like syrup. At what point? It is concentrated to the point where it can be picked up with chopsticks, resembling a small sugar lump. In Taiwan, almost every village has a place that makes syrup.When you go there, the first thing they do is take a pair of chopsticks and roll it in the syrup pot, and you get a small sugar lump to eat. This is what it means to be concentrated to a syrup-like consistency.In the Treatise on Cold Damage, there are seven formulas that require boiling, removing the dregs, and then decocting. Which seven formulas are they? The four formulas we are discussing now: Ban Xia Xie Xin Tang, Sheng Jiang Xie Xin Tang (Fresh Ginger Decoction to Drain the Heart), Gan Cao Xie Xin Tang (Licorice Decoction to Drain the Heart), and Xuan Fu Dai Zhe Tang (Inula and Hematite Decoction). These four formulas are clearly aimed at harmonizing the middle burner, which is half above and half below. There are also three formulas that require boiling, removing the dregs, and then decocting: Xiao Chai Hu Tang, Da Chai Hu Tang (Major Bupleurum Decoction), and Chai Hu Gui Zhi Gan Jiang Tang (Bupleurum, Cinnamon, and Dried Ginger Decoction). These three formulas harmonize the Shaoyang half-exterior, half-interior mechanism.It is evident that in the Treatise on Cold Damage, all harmonizing formulas require boiling, removing the dregs, and then decocting. Harmonizing formulas share a common characteristic in their composition: they combine cold and heat, attacking and tonifying, and have the effect of harmonizing mechanisms and resolving stagnation.Thus, later generations of physicians believed that the reason these seven formulas in the Treatise on Cold Damage require boiling, removing the dregs, and then decocting is to ensure that the herbs in the formula can work together in harmony, effectively achieving the harmonizing effect.