Shang Han Za Bing Lun (Treatise on Cold Damage and Miscellaneous Diseases) is the earliest clinical diagnosis and treatment book in China that connects theory with practice. It systematically analyzes the causes, symptoms, stages of development, and treatment methods of cold damage, creatively establishing the principle of differentiation and treatment based on the “Six Meridians Classification” for cold damage diseases, laying the theoretical foundation for the principles, methods, formulas, and medicines.Shang Han Za Bing Lun is a classic work that later generations of practitioners must study, highly esteemed by physicians throughout history, and is still one of the main foundational courses offered in Chinese medicine colleges today, remaining a source of learning in TCM.
Presented by Hao WanshanHao Wanshan, male, born in November 1944, professor, chief physician, doctoral supervisor in clinical Chinese medicine, and head of the Department of Clinical Chinese Medicine at Beijing University of Chinese Medicine. He is the vice chairman of the Marginal Science Professional Committee of the Chinese Association of Old Professors, vice president of the Chinese Academy of Traditional Chinese Medicine, executive director of the Chinese Music Therapy Association, and a member of the National Zhongjing Theory Professional Committee.Lecture 44: Discussion on Fluid Deficiency and Constipation Syndrome, Differentiation of Treatment Methods, and ContraindicationsHello everyone, let’s start class.In our last class, we discussed the Yangming syndrome related to the solid organ and the part concerning the spleen deficiency syndrome. We have reviewed and summarized the Yangming solid organ syndrome multiple times. Regarding the spleen deficiency syndrome, it is primarily due to excessive stomach yang and deficient spleen yin.The spleen has the function of transporting and distributing fluids to the stomach. This function involves absorbing the essence of food and fluids from the gastrointestinal tract and distributing them throughout the body.On the other hand, it also returns fluids to the gastrointestinal tract to moisten the waste for downward movement. However, when the stomach yang is excessive and the spleen yin is deficient, the spleen can only absorb fluids but cannot return them to the gastrointestinal tract. This means that the spleen’s function of transporting fluids to the stomach is somewhat restricted, leading to an accumulation of fluids in the bladder, resulting in frequent urination and dry stools.This symptom is referred to as “the spleen is deficient” in Shang Han Lun, and later generations of physicians have termed it spleen deficiency syndrome, treated with Ma Zi Ren Wan (Hemp Seed Pill) to moisten the intestines and relieve constipation. This is what we refer to as the “moistening method” in later discussions.This concludes the content we discussed in the last class.Now, regarding the third syndrome of Yangming solid organ syndrome, called fluid deficiency and constipation syndrome, which is the new topic we will discuss below.Everyone, please open your handouts to page 118. Look at the original text in section 233, “In Yangming disease, if there is spontaneous sweating, and if sweating is induced, and urination is frequent, this indicates that the internal fluids are depleted. Even if the stools are hard, they should not be forcibly purged. The patient must have the desire to defecate, and honey decoction should be used to guide and unblock the bowels. Both Tu Guo Gen (Earthmelon Root) and pig bile can be used as guides.”Yangming disease itself has spontaneous sweating. If you induce sweating again, and the patient has frequent urination, then the fluids are being lost through sweat and urine, leading to fluid depletion. Therefore, we call it fluid deficiency. After fluid depletion, the stools will become dry and hard, hence the term fluid deficiency and constipation syndrome.This syndrome does not exhibit systemic toxic heat symptoms; it is merely due to insufficient fluids that the stools become dry. Therefore, Zhang Zhongjing stated that although the stools are hard, there are no systemic toxic heat symptoms, and one should not use harsh purgatives to treat it. What should be done?When the patient has the urge to defecate, which means they must desire to defecate, honey decoction should be used, and “guide and unblock” refers to a parallel action, using honey decoction to guide the stools to unblock them. Therefore, this guiding method is not a formula name but a treatment method called the guiding method to unblock the bowels.It is called “guide and unblock.” What is the formula called? The formula is called “honey decoction,” and it can also be referred to as honey guiding decoction. Some people confuse the guiding method with the formula name, and I think this should remind everyone to pay attention. “If using Tu Guo Gen,” or using Tu Guo Gen, “and pig bile,” or using pig bile, “both can be used as guides,” all can serve as means and methods to guide the stools. The guiding method mentioned here is essentially an anal suppository.Let’s look at the honey decoction: “7 parts of honey,” where honey refers to bee honey, and “7 parts” means 140 milliliters of honey. “Place it in a copper vessel and simmer on low heat,” meaning to put it in a copper container and simmer on low heat. What does simmer mean? We mentioned it when discussing Ban Xia Xie Xin Tang, Sheng Jiang Xie Xin Tang, and Gan Cao Xie Xin Tang:“Any liquid that is dried is called simmering.” Honey itself is a liquid substance, and when placed on the fire, it is heated and concentrated, which is called simmering. Therefore, this formula is called honey decoction and not honey boiling, so it is important to note that in Shang Han Lun, the meanings of simmering and boiling are different. To what extent should it be concentrated?“It should be thick like syrup,” meaning maltose syrup, which we mentioned in the previous discussion of Xiao Jian Zhong Tang’s ingredients. Maltose syrup has a high viscosity, and you can pick it up with chopsticks. Fresh honey, however, cannot be picked up with chopsticks. When honey is heated to the point where it can be picked up with chopsticks and forms a round lump on the chopsticks, that is sufficient.“Stir it to prevent burning,” meaning while heating and concentrating, stir it with chopsticks to prevent it from burning. Here, a period should be placed after “stir it to prevent burning.” Stir it to prevent burning, and place a period there. “It should be suitable for forming into pills,” meaning it should be heated to a suitable consistency for forming into pills. When it can be formed into a lump, “and roll it into a stick,” meaning to roll it into a stick shape with both hands, “making one end sharp, about the size of a finger, and about two inches long.” The end should be a bit pointed, and how big should the stick be? It should be about the size of a finger.Of course, when we use it clinically, it can be about the size of a pinky finger, not too thick like a thumb, as that would be too thick, about the size of a pinky finger. “About two inches long,” where one inch is 2.3 centimeters, two inches is about 4.6 centimeters, which is about 4-5 centimeters, actually 4 centimeters is sufficient. Of course, you should consider whether it is for children or adults; if it is for children, you can make the honey suppository or honey stick smaller.For adults, it should be like Zhang Zhongjing described, about the size of a pinky finger, with a length of about 4-5 centimeters, and one end should be sharper.“It should be made urgently while hot; if it cools, it will harden,” and a period should be placed after this. If it cools, it will harden, and you cannot form it into this stick shape, so it should be made while hot. In fact, if you do not hurry while making it hot, it will burn your hands, so people apply a little oil to their hands and quickly roll it back and forth. If you do not hurry, it will be very hot. You can imagine that the freshly made honey is at a high temperature.I have made this kind of thing, and I can understand that what is written in Shang Han Lun is indeed to be made while hot; if it cools, it will harden, and if you do not act quickly, it can burn your hands.Why is it stated that “if it cools, it will harden”? The following discusses its usage, “to be inserted into the anal canal,” which refers to its usage. Some students see this and put a comma, saying, “Teacher, should it be inserted while hot?” I said, when rolling it, it is still very hot; if you insert it while hot, wouldn’t that burn the patient? So I changed it to a period here.“Insert it into the anal canal, and hold it tightly with your hand,” meaning when using it, after it cools, it should be inserted into the anal canal. However, when using it, it is still relatively hard after cooling, so we generally dip it in a little warm water before inserting it, to slightly dissolve the surface of the honey, making it smoother and easier to insert into the anal canal. “Hold it tightly with your hand,” this does not require holding tightly; it just tells the patient to hold it for a while, “when you want to defecate, you can remove it.” In fact, you do not need to pull it out again; when they defecate, this suppository will have mostly dissolved, and any undissolved part will be expelled with the stool.In our clinical practice, we often use glycerin suppositories for children and the elderly with constipation, which can indeed help soften the stool. For fluid deficiency and constipation syndrome, when the stool is obstructed at the anal area and cannot be expelled, glycerin suppositories are effective.However, I have noticed a problem: glycerin suppositories need to be used almost every time for defecation. After switching to honey suppositories, in addition to softening the stool, they also have a good effect on adjusting colon function. After using honey suppositories a few times, the patient can defecate well on their own without needing them anymore.Last summer, a well-known university professor’s elderly mother, nearly 90 years old, had been bedridden for a long time, and her intestinal peristalsis was slow, leading to dry stools. Her children and siblings would use glycerin suppositories every time she needed to defecate, and sometimes they even had to use their fingers to assist, which was painful for the elderly woman and distressing for her children.Later, I instructed the children to use the honey suppository method from Shang Han Lun. They made many, but actually only used three or four, and afterward, the elderly woman said, “You don’t need to give me honey suppositories anymore; I can defecate on my own now.” Indeed, she was able to defecate on her own.For half a year, she had to use glycerin suppositories every time, but after using three or four honey suppositories, she could defecate on her own, so this method, compared to glycerin suppositories, has a better long-term effect on the elderly and children with fluid deficiency and constipation syndrome.I think it is a pity that no one in the market has developed this preparation yet. If developed, packaged well, and made available for direct purchase, it would be a great thing.The formula for Tu Guo Gen has been lost, and we do not know what it is. The pig bile formula consists of one pig bile. “To extract the juice” means to squeeze out the pig bile. Pig bile is alkaline and has a certain stimulating effect on the anal mucosa and colonic mucosa.The anal mucosa has relatively rich nerve endings, so when we eat too much chili, we may feel a burning pain during defecation. Now, using a strong alkaline pig bile directly injected into the anal canal will cause stimulation and discomfort. Therefore, in Shang Han Lun, “with a little vinegar,” where vinegar refers to the vinegar we consume, in Shang Han Lun, vinegar is also called bitter wine. Mixing vinegar with bile neutralizes its alkalinity, “and then inject it into the anal canal,” which is the earliest record of an enema method, as it is a fluid.I previously mentioned that I am still unclear about what method Zhang Zhongjing used for enemas, whether it was bamboo tubes or something else, because at that time, there could not have been the modern rubber tubes we have today. After the enema, “like the time it takes to eat a meal,” “the stool will expel the retained food and waste, with great effect.”Today, in large cities, fresh pig bile is not easy to find, but using pig bile for enemas should be said to be the earliest recorded enema therapy in the history of world medicine. This method may seem very simple today, but at that time, using this enema technique was quite remarkable.We now often use soap water for cleansing enemas. In medicine, we should use what is appropriate; we cannot casually find substitutes. There was a hospital where a doctor ordered a nurse to give an enema to a patient who had not defecated for several days, as enemas are a good method for relieving constipation.The nurse saw that the soap water for the enema was gone, and there was no soap either. She thought that soap can wash clothes, and laundry detergent can wash clothes, and since there was a pile of laundry detergent nearby, she thought, “Soap can be used for enemas, and laundry detergent can also be used for enemas,” so she invented a method and mixed laundry detergent with water to give the patient an enema.Unexpectedly, the patient developed intestinal mucosal damage and intestinal bleeding. This was classified as a medical accident. When asked, she explained that soap can be used for enemas, and laundry detergent can wash clothes, so laundry detergent can also be used for enemas. Therefore, medicine and daily life are not the same, and we should not casually assume when using medical methods.The content of Yangming solid organ syndrome we discussed earlier, including Yangming solid organ syndrome, spleen deficiency syndrome, and fluid deficiency and constipation syndrome, all belong to the Qi aspect of Yangming solid organ syndrome. There are also blood aspect syndromes in Yangming solid organ syndrome, which is called Yangming blood accumulation syndrome.Let’s open the handout to page 128 and look at section 237, “In Yangming disease, if the person is forgetful, there must be blood accumulation. The reason is that there is a long-standing blood stasis, which causes forgetfulness. Although the stools are hard, defecation is relatively easy, and the color must be black; it is advisable to use Di Dang Tang (Di Dang Decoction) to treat it.”Yangming blood accumulation syndrome is formed by the combination of Yangming heat and long-standing blood stasis. Due to the long-standing blood stasis, new blood does not form. This leads to insufficient nourishment of the heart and spirit, resulting in forgetfulness. The term “forgetfulness” here does not mean liking to forget.Later, when we discuss the symptoms of Shaoyang disease, such as irritability and preference for vomiting, some people say that Shaoyang is a Qi stagnation syndrome. If Qi stagnation wants to vomit, it will feel that the stagnant Qi is relieved, so they like to vomit. This explanation is incorrect; the term “like” does not mean preference. Vomiting is a painful symptom; who would like to vomit? Therefore, both “liking to vomit” and “forgetfulness” refer to the same thing. Shaoyang disease is characterized by frequent vomiting and a tendency to vomit; Yangming blood accumulation syndrome is characterized by insufficient nourishment of the spirit, leading to forgetfulness, which is what we today refer to as amnesia.Stasis heat intermingling leads to dry stools; although the stools are hard, they are relatively easy to pass. This is because stasis blood is a yin substance that has a moistening effect, so even though it is dry, it is easier to pass.Because there is stasis blood, the stools are black. From this perspective, the patient originally had chronic upper gastrointestinal bleeding and chronic seepage. Why do we say it is not acute? Acute cases may have more complications, and in acute cases, the amount of bleeding is larger, leading to tarry stools, which are relatively loose. It would not present with hard stools. Therefore, it is a small amount of chronic seepage, with blood accumulating in the intestines, combined with heat, and the heat and blood intermingling cause the stools to harden.A person with chronic upper gastrointestinal bleeding may also have anemia; insufficient nourishment of the spirit leads to symptoms of insufficient blood supply to the brain and insufficient oxygen supply—forgetfulness. This syndrome is referred to by Zhang Zhongjing as Yangming blood accumulation, and he used Di Dang Tang to treat it.In clinical practice, can we use Di Dang Tang to treat this condition? This mainly depends on whether the bleeding has stopped. If the bleeding continues, and the hemoglobin level is still decreasing, we should prioritize stopping the bleeding. For example, we usually use a mixture of San Qi powder and Ren Shen powder, combining San Qi, Bai Ji, and a small amount of Ren Shen powder, which has a good effect on gastric bleeding.If the bleeding has stopped, and the hemoglobin level is no longer decreasing but is on the rise, and the accumulated blood in the intestines, due to Yangming heat, stasis heat intermingling, has not been expelled in time, in this case, we can consider using blood-activating and stasis-resolving medicines, but we do not necessarily have to use Di Dang Tang. In Shang Han Lun, the use of Di Dang Tang should be based on the situation; if it is a heat syndrome, we can appropriately use Tao Ren Cheng Qi Tang (Peach Kernel Decoction), and if the stasis blood is particularly obvious but the heat is not particularly severe, we should reduce the dosage of Di Dang Tang. Therefore, for Yangming blood accumulation syndrome, the real opportunity to use blood-breaking and stasis-resolving methods is not particularly frequent; it mainly depends on the situation of upper gastrointestinal bleeding.Thus, we have completed the discussion on Yangming solid organ syndrome.Next, let’s turn back to page 119 and look at the differentiation of treatment methods.The differentiation of treatment methods has a total of four original texts, which actually discuss two issues: one is how to distinguish between large and small Cheng Qi, and the other is the relationship between defecation and urination.First, let’s look at section 208, “In Yangming disease, if the pulse is slow, although there is sweating, there is no aversion to cold; the body must be heavy, with shortness of breath and abdominal fullness with wheezing.” This describes a syndrome of Yangming heat obstruction. This slow pulse does not indicate Yang deficiency or insufficient yin blood, but rather indicates heat obstruction, so the pulse should be slow yet strong.Sweating is a manifestation of heat forcing fluids outward; no aversion to cold indicates that there is no exterior wind-cold syndrome; body heaviness is due to the obstruction of Qi by the pathogenic heat, causing the Qi to be unbeneficial. The shortness of breath is due to Yangming solid organ Qi not being able to descend; Yangming turbid heat forces the lungs, leading to not only shortness of breath but also wheezing; abdominal fullness is due to the obstruction of Qi in the abdomen by pathogenic heat. The above symptoms indicate a syndrome of internal excess heat in Yangming, “If there is tidal fever, it can be attacked internally.”These symptoms of Yangming internal heat are all present; can we attack internally? Tidal fever is a key point in differentiation. Therefore, as long as there is tidal fever, it indicates that the exterior pathogen has been resolved, and you can attack internally. The next sentence has a different meaning: “If there is profuse sweating from the hands and feet, this indicates that the stools have already hardened; Da Cheng Qi Tang (Major Order the Qi Decoction) is the main treatment for it.”If there are symptoms of internal heat obstruction, does that mean the stools have already hardened, and we should use Da Cheng Qi Tang to purge? If there is profuse sweating from the hands and feet, it indicates a special form of dryness-heat forcing fluids outward, which allows us to use Da Cheng Qi Tang.The profuse sweating from the hands and feet described by Zhang Zhongjing, I encountered once in clinical practice over twenty years ago. There was an elderly lady with jaundice, weight loss, and high fever, hospitalized in a certain hospital in Beijing. At that time, we had not yet introduced B ultrasound or CT scans, and the hospital diagnosed her with stubborn jaundice and severe weight loss, suspecting she had pancreatic head cancer. Additionally, the patient was not very clear-headed, and the doctors said there was basically no hope; they asked if the family wanted to keep her in the hospital or take her home. Her children came to me, hoping I could take a look at her mother.I asked what illnesses her mother had in the past. They said she often had colds. I asked how often she had colds, and they said every week for the past few months. I found it strange that someone could catch a cold every week, so I asked them which day of the week she usually caught a cold. They said it was usually on Friday nights. I asked if it was regular, and they said it generally was.I asked what symptoms she had when she caught a cold, and they said she would first feel cold and shiver, then develop a high fever. We often gave her a fever-reducing medicine, and the fever would subside. Sometimes, if she did not take the medicine, the fever would subside by itself in the middle of the night.I asked what happened the next day, and they said when they brought her urine to the bedpan, it was particularly yellow. I asked if they noticed her eyes or face turning yellow, and they said they had not paid attention because they were not doctors and did not understand. I asked if she had abdominal pain when she had a cold and fever, and they said yes, she definitely had abdominal pain.Upon hearing this description of symptoms, I thought this was a case of periodic chills and high fever, accompanied by upper abdominal pain and yellow urine, which likely indicated mild jaundice. I suspected she had a mild case of jaundice, and this pattern matched the clinical features of Charcot’s triad.This is a typical case of periodic chills and high fever, accompanied by upper abdominal pain and jaundice, which is a clinical feature of gallbladder stones. Therefore, when she presented with obstructive jaundice and persistent high fever, I thought she resembled a case of obstructive stones rather than pancreatic head cancer, and there was still hope for treatment. So I decided to take a look. When I arrived at the ward, I saw another daughter sitting next to her mother, who was confused and had a high fever, constantly wiping the sweat from her hands.When I looked, I was shocked; her hands were extremely thin, and the sweat pores on the back of her hands were open like holes in a sieve, with crystal-clear sweat continuously seeping out. The daughter was constantly wiping it. Seeing this, I thought of the “profuse sweating from the hands and feet” mentioned in Shang Han Lun; this was indeed the case of profuse sweating from the hands and feet.This must be Yangming internal excess, but I also thought of her medical history. Therefore, we certainly could not use Da Cheng Qi Tang alone to treat her. I used Da Chai Hu Tang (Major Bupleurum Decoction) for treatment, adding Hai Jin Sha and Jin Qian Cao. I prescribed only one dose of medicine, saying, “We can only treat this as a dead horse being used as a live horse. The hospital said she has pancreatic head cancer; you can give her whatever she wants to eat, as you are preparing for her funeral. I will prescribe one dose of medicine, and if it works, it works; if not, don’t look for me again.”Unexpectedly, after taking the medicine, there was no response in the afternoon, but by the evening, her consciousness became clearer, and during the night, she began to defecate. As a result, she defecated, and her consciousness became clear. Then her daughter called me, saying, “My mother has defecated.” I said, “Now check the stool; if the stool can expel stones, we can determine that she has obstructive stones rather than pancreatic head cancer, and your mother will not have any major issues in the future.”The first stool did not expel any stones, and the second stool also did not. By the second day in the evening, the third stool expelled stones the size of corn kernels and soybeans, and about twenty pieces came out. From then on, the elderly lady’s fever subsided, and her jaundice gradually disappeared. That dose of medicine was only prescribed for her to take once; the residue of the medicine was not continued, and she recovered.The elderly lady said, “What if I have another episode in the future?” I said, “If you have another episode, I will prescribe another formula for you; keep it, and if it happens again, go get the medicine.”Therefore, in cases of gallbladder stones, if they do not flare up, using purgative methods may not necessarily be effective. However, if the gallbladder stones flare up acutely, using purgative methods can often yield good results.This elderly lady is still alive today, over 80 years old. Last year, I visited her home, and when she saw me, she cried, saying, “Dr. Hao, you saved my life over twenty years ago.” I thought about it; if she had died back then, I would not have so many sad things now.This patient had profuse sweating from the hands and feet, which is very obvious. Therefore, in clinical practice, when we see hands and feet sweating profusely, it generally indicates the presence of Yangming solid organ syndrome. Zhang Zhongjing used this as a differentiation indicator, which he derived from clinical experience.“If there is excessive sweating,” this excessive sweating indicates Yangming internal heat, “and slight fever with aversion to cold indicates that the exterior has not been resolved.” This slight fever with aversion to cold is clearly not the same as the previously mentioned tidal fever.Because there is tidal fever, you can attack internally; now there is no tidal fever but slight fever with aversion to cold, indicating that the exterior has not been resolved. Therefore, it is particularly emphasized that “if the heat is not tidal, it is not appropriate to use Cheng Qi Tang.” If this fever is not tidal, then do not give them Da Cheng Qi Tang. “If there is abdominal fullness and no passage, you can use Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to harmonize the stomach Qi, but do not allow for excessive purging.” This indicates that there is no tidal heat, but there are clear clinical signs of abdominal fullness and no passage. What should be done at this time?Do not use Da Cheng Qi; use Xiao Cheng Qi Tang to unblock the bowels. Therefore, the presence of tidal heat indicates that there is excessive heat, while abdominal fullness and no passage indicate that the obstruction of the bowel Qi is more pronounced. If there is tidal heat, use Da Cheng Qi, as it both purges heat and unblocks the bowels. If there is no tidal heat, but only abdominal fullness and no passage, use Xiao Cheng Qi Tang, focusing on unblocking the bowels rather than purging heat. In this way, the distinction between Da Cheng Qi Tang and Xiao Cheng Qi Tang becomes very clear.In section 209, “In Yangming disease, if there is tidal heat and the stools are slightly hard, you can use Da Cheng Qi Tang.” The word “slightly” in “slightly hard” has been considered by many later physicians to be an extraneous word. It should be that the stools are hard to use Da Cheng Qi Tang; why can slightly hard stools be treated with Da Cheng Qi Tang?Therefore, this “slightly” may be an extraneous word, and we can interpret it this way. “If the stools are not hard, it is not appropriate to use it.” If the stools are not hard, even if there is tidal heat, it is still not appropriate to use it.We will mention in the Shaoyang disease section that although it is emphasized that there must be tidal heat to use Da Cheng Qi Tang, this is under the premise that the stools are hard and there are signs of abdominal excess. If there is tidal heat, then use Da Cheng Qi Tang with more confidence. If there is only tidal heat and no hard stools, then it is still not appropriate to use Da Cheng Qi Tang.Next, let’s look at section 203, “In Yangming disease, if there is spontaneous sweating, and the physician further induces sweating.” Yangming disease has excessive sweating; originally, it is spontaneous sweating. The physician, “further” means “again,” has used methods to induce sweating. Of course, the fever has already subsided, so it is said that “the disease has improved,” and the fever has subsided. “If there is still slight irritability and discomfort, this must be due to hard stools.”At this time, there is still some discomfort and slight irritability, which must be due to dry stools. He has no fever; why are the stools dry? “Because of the loss of fluids, the stomach is dry, which causes the stools to harden.” This is because there was already sweating, and you used methods to induce sweating again. Although the fever has subsided, the fluids have been depleted, leading to dryness in the gastrointestinal tract, which is why the stools are hard.At this time, should you use purgatives or wait for the body’s self-recovery mechanism to restore and allow the stools to be expelled naturally?“You should ask how many times the patient has urinated in a day.” At this time, you should observe how many times they urinate. “If originally the patient urinated three to four times a day,” and today they only urinate twice, “it indicates that the stools will not be long in coming out.” Therefore, you should not use purgatives; the stools will soon be expelled naturally.“If today there is frequent urination and less urine, although there is no food intake, but the stools are initially hard, they will eventually become soft; it is not yet determined that they are hard, and purging will lead to them becoming soft.” This indicates that if there are five to six days without defecation, and the urine is not abundant but rather scant, it indicates that the transportation is impaired, and the fluids are not being separated. If the urine is scant, where is the water? It must be in the intestines. Since it is in the intestines, why are the stools not soft but rather hard? This is because they are initially hard and will eventually become soft. Therefore, in this situation, do not blindly use purgatives.“You should use small amounts to facilitate defecation; if the stools are hard, then you can attack it, and it is advisable to use Da Cheng Qi.” Therefore, as long as you see that the urine is frequent, this indicates that the fluids are being forced out, and the fluids cannot return to the gastrointestinal tract. Additionally, if there are systemic toxic heat symptoms and abdominal signs of excess, then you can use purgative methods.We previously mentioned that profuse sweating from the hands and feet can use Da Cheng Qi. Here, it mentions that frequent urination can also use Da Cheng Qi. Both indicate that Yangming solid organ syndrome is forcing fluids outward or causing them to be lost.Next, let’s look at section 204, “In cold damage, if there is excessive vomiting, although there are Yangming symptoms, it is not appropriate to attack it.” This is a very important point. From the perspective of the annotators, if there are Yangming disease symptoms and excessive vomiting, what could this indicate? Some say this is heat in the chest and diaphragm. Yangming disease, with heat in the chest and diaphragm, can use Zhi Zi Shi Tang (Gardenia and Licorice Decoction) to clear and disperse the stagnant heat. If the heat in the chest and diaphragm disturbs the stomach, it can lead to vomiting, and we can use Zhi Zi Sheng Jiang Guo Tang (Gardenia and Ginger Decoction) to treat it.If you treat this disease as Yangming internal excess and use purgatives, it will further damage the internal Qi and worsen the condition, so this Yangming disease should not be purged. This is one explanation. The second explanation is that excessive vomiting is a feature of Shaoyang. Shaoyang disease has irritability and a tendency to vomit; Shaoyang is a gallbladder heat and Qi stagnation syndrome. Internal gallbladder fire is most likely to disturb the stomach, so Shaoyang disease often presents with a tendency to vomit, frequent vomiting, and a preference for vomiting.In Shang Han Lun, the presence or absence of shivering is often used to indicate the presence or absence of Shaoyang disease. Here, the Yangming disease has excessive vomiting, indicating that Yangming disease is combined with Shaoyang disease. Shaoyang disease itself should be treated with caution regarding vomiting, sweating, and purging. Shaoyang is a lesser Yang, with insufficient ability to resist pathogens; methods of sweating, vomiting, and purging do not effectively eliminate Shaoyang pathogens. They can only damage the righteous Qi of Shaoyang.Therefore, Shang Han Lun particularly emphasizes the need to avoid sweating, vomiting, and purging. In the course of treating exterior heat diseases, whenever Shaoyang disease is observed, treatment should prioritize Shaoyang. If both Shaoyang and Yangming are present, then you can primarily focus on harmonizing, or on the basis of harmonizing, you can also use purgative methods, but you must not use purgative methods alone.This is our second explanation.Yangming disease is a Yangming internal heat excess syndrome, and excessive vomiting is a feature of Shaoyang disease. In treatment, the focus should be on harmonizing, and on the basis of harmonizing, purgative methods can be used, but purgative methods alone are not appropriate.Whether in TCM or Western medicine, the subjects of study are patients, and the subjects of study are clinical diseases. If we look at this point clinically, what kind of patients would exhibit both Yangming disease characteristics and excessive vomiting? I have observed that strangulated intestinal obstruction is rarely seen in cities, as treatment is usually timely, but it can occasionally be seen in rural areas.Therefore, strangulated intestinal obstruction is intestinal obstruction accompanied by blood circulation disorders in the intestinal wall, and even intestinal wall necrosis. When the condition develops to this extent, the clinical manifestations of intestinal Qi obstruction, such as no defecation and no gas expulsion, are inevitable, and symptoms of abdominal pain, fullness, and distension are also inevitable. When the condition develops to this extent, systemic toxic heat symptoms also appear, with tidal fever, delirium, and even manifestations of severe heat and confusion. Therefore, this Yangming disease is present, but we must not forget that this is an intestinal obstruction. One of the characteristics of intestinal obstruction is vomiting.If the obstruction is high, vomiting appears early; if the obstruction is low, vomiting appears late. However, the most prominent symptom is vomiting. Therefore, I suspect that Zhang Zhongjing encountered a patient with strangulated intestinal obstruction. From the perspective of systemic toxic heat symptoms and abdominal signs of excess, it can be diagnosed as Yangming disease.However, if there is excessive vomiting, using Cheng Qi Tang to purge will lead to intestinal perforation, causing infection and toxic shock, resulting in death. This is why he wrote this point. This serves as a special reminder for us in clinical practice when encountering a patient with strangulated intestinal obstruction. Even if they exhibit all the symptoms of Yangming solid organ syndrome, if they have excessive vomiting, purging is absolutely prohibited; otherwise, the patient will surely die.Next, let’s look at section 205: “In Yangming disease, if there is hardness and fullness in the heart area, it is not appropriate to attack. If you attack, and the diarrhea does not stop, the patient will die; if the diarrhea stops, the patient will recover.” It should be noted that the heart area, because the Yangming meridian runs from the chest to the abdomen, includes the upper, middle, and lower jiao, all belonging to Yangming. The hardness and fullness in the heart area actually refer to the stomach, which is governed by Yangming solid organ syndrome.Yangming solid organ syndrome refers to the abdominal signs of excess. It is characterized by abdominal pain around the navel, abdominal fullness, and no passage. It does not refer to hardness and fullness in the heart area. Therefore, this Yangming disease indicates that the pathogenic Qi has not yet entered the intestines; the location of the obstruction is too high. In TCM treatment, it should be guided by the situation. Now, the location of the obstruction is high and has not fully entered the intestines; premature purging may worsen the condition. Therefore, hardness and fullness in the heart area should not be purged.Another possibility is that hardness and fullness in the heart area may indicate a heart area distension syndrome, which is caused by stomach deficiency being disturbed by pathogenic Qi. If you treat a heart area distension syndrome as a Yangming internal excess and purge it, it will inevitably further damage the stomach Qi, leading to adverse outcomes.Therefore, regarding section 205, there are two understandings. One understanding is that the Yangming pathogenic Qi is obstructed at a high location and has not fully entered the intestines, so do not purge prematurely. The other understanding is that it is a heart area distension syndrome, which is caused by stomach deficiency being disturbed by pathogenic Qi. If purged mistakenly, it will further damage the stomach Qi, leading to continuous diarrhea. If diarrhea does not stop, the prognosis is poor; if diarrhea can stop, the prognosis can be good.In particular, this section reminds us that the location of Yangming solid organ syndrome is not in the heart area but rather in abdominal fullness, pain around the navel, and abdominal distension with no passage.206 “In Yangming disease, if the face is red and the complexion is yellow, it is not appropriate to attack. This indicates that there is heat, and the color yellow indicates that there is difficulty in urination.” The Yangming meridian runs through the head and face. “Face red” indicates that the Yangming meridian has a pathogen; the Yangming meridian’s Yang Qi is obstructed, which is a manifestation of the Yangming meridian being obstructed. This is also what we previously quoted from the “Shang Han Heart Method Essentials,” which states that “Ge Gen (Kudzu Root) floating on the Yangming meridian, causing a red face, headache, fever, aversion to cold, no sweating, eye pain, and dry nose, leading to restlessness.”This indicates a red face, and although it is Yangming disease, the pathogen is in the meridian and has not entered the intestines, so it should not be purged. If purged, it will damage the stomach and spleen Qi. If the stomach and spleen Qi are damaged, the transportation will be impaired, leading to internal dampness, and if dampness and heat combine, it may lead to jaundice. Therefore, section 206 indicates that the pathogen is in the Yangming meridian and should not be purged.Section 189 is more complex, and the interpretations of the annotators are not entirely the same. “Yangming wind” should refer to the Yangming meridian being harmed by wind pathogens. “Bitter mouth and dry throat” are believed by annotators to indicate Shaoyang disharmony. “Abdominal fullness and slight wheezing” are believed to indicate that the Yangming meridian’s Qi is not smooth. “Fever and aversion to cold, with a floating and tight pulse” are believed to indicate that there is an exterior pathogen in the Taiyang meridian.Therefore, this syndrome is viewed as a simultaneous attack of three Yang pathogens, with the pathogens biased towards the meridians. Since the pathogens are in the meridians, “if you purge, there will be abdominal fullness and difficulty in urination.” If there is internal excess, mistakenly using purgative methods will inevitably damage the stomach and spleen Qi, leading to impaired transportation, and the water and dampness cannot be expelled, resulting in difficulty in urination. The external pathogen in the meridian should not be purged. This is similar to the meaning of section 206.Next, let’s look at section 194: “In Yangming disease, if the patient cannot eat, attacking the heat will lead to hiccups. The reason is that the stomach is deficient and cold.” The “Yangming disease, if the patient cannot eat” indicates that the stomach is deficient and cold, and the ability to receive is impaired. This is not the same as the internal excess of Yangming solid organ syndrome, which obstructs the ability to receive. Therefore, this inability to eat, if mistakenly interpreted as internal excess obstructing the ability to receive, and using Cheng Qi Tang to attack heat and purge excess, will further damage the internal Qi, leading to persistent hiccups. Zhang Zhongjing himself explains the pathogenesis: “The reason for this is that the stomach is deficient and cold, and since the person is originally deficient, attacking the heat will lead to persistent hiccups.”The above-mentioned contraindications for purging in Yangming can be summarized as follows: pathogens in the meridian should not be purged, hardness and fullness in the heart area should not be purged, excessive vomiting should not be purged, and stomach deficiency and cold should not be purged.This is what we should pay attention to when using Cheng Qi Tang in clinical practice. Today’s class ends here.Okay, class dismissed.
