Introduction: Professor Hao Wanshan from Beijing University of Chinese Medicine, male, born in November 1944, professor, chief physician, doctoral supervisor in the field of clinical TCM, and a member of the Basic Medical College of Beijing University of Chinese Medicine.
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Lecture 44: Syndrome of Fluid Deficiency and Constipation, Differentiation of Treatment Methods and Contraindications
Hello everyone, we are starting class. In our last lesson, we discussed the Yangming excess syndrome and the part related to the spleen deficiency syndrome. We have reviewed and summarized the Yangming excess syndrome multiple times. Regarding the spleen deficiency syndrome, it is mainly due to the excess of stomach yang and deficiency of spleen yin. The spleen has the function of transporting fluids to the stomach. This function involves distributing the refined essence of food and fluids absorbed from the gastrointestinal tract throughout the body, while also returning 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 fluid retention in the bladder, resulting in frequent urination and dry stools. This symptom is referred to in the “Shang Han Lun” as “the spleen is deficient,” and later physicians termed it the 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, we will talk about the third syndrome of Yangming excess, known as the syndrome of fluid deficiency and constipation, which is the new topic we will cover 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. Although 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 relieve constipation. Both the root of the earth melon 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 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 simply due to insufficient fluids causing dry stools. 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, honey decoction should be used to guide the stool. Honey decoction is a formula name, and “to guide and relieve” is a compound verb, meaning to use honey decoction to guide the stool. Therefore, “to guide” is not a formula name but a treatment method called the guiding method for stool relief. The formula is called “honey decoction,” and some people confuse the guiding method with the formula name. I think this should remind everyone to pay attention. “If using the root of the earth melon or pig bile, both can be used as guiding methods for stool relief.” The guiding method mentioned here actually refers to rectal suppositories.
Now let’s look at the honey decoction: “7 parts of honey” means honey, and “7 parts” refers to 140 milliliters of honey. “Put it in a copper vessel and simmer over low heat.” Simmering means heating it gently. We mentioned in the discussions of Ban Xia Xie Xin Tang, Sheng Jiang Xie Xin Tang, and Gan Cao Xie Xin Tang that “any liquid that is dried is called simmering.” Honey is a liquid substance, and when placed over heat, it is heated and concentrated, which is called simmering. Therefore, this formula is called honey decoction and not honey boiling. It is important to note that in the “Shang Han Lun,” the meanings of simmering and boiling are different. To what extent should it be concentrated? “It should be thick like syrup.” Syrup is maltose, which we mentioned in the previous discussion of Xiao Jian Zhong Tang. Maltose has a high viscosity, and you can pick it up with chopsticks. Fresh honey 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, it is ready. “Stir it to prevent burning.” While heating and concentrating, stir it with chopsticks to prevent it from burning. Here, we should put a period after “stir it to prevent burning.” “It should be suitable for making into pills.” To what extent should it be heated? It should be suitable, meaning it should be heated to the point where it can be formed into pills. “Roll it into a stick shape.” Use both hands to roll it into a stick shape, “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 thickness of a finger. Of course, in clinical practice, it can be about the thickness of a pinky finger, not too thick like a thumb. It should be about two inches long, which is about 4-5 centimeters. In fact, 4 centimeters is sufficient. Of course, if it is for children, it should be made smaller. For adults, it should be about the thickness of a pinky finger, around 4-5 centimeters long, with one end being sharper. “It should be made quickly while hot; if it cools, it will harden.” This should be followed by a period. If it cools, it will harden, and you will not be able to form it into a stick shape. Therefore, it should be made while hot. In fact, if you do not hurry while making it hot, it will burn your hands, so people should apply a little oil to their hands and quickly roll it. If you do not hurry, it will be very hot. You see, freshly made honey is very hot.
I have made this before, and I truly understand that what is written in the “Shang Han Lun” must be done while hot; if it cools, it will harden. If you do not act quickly, it can burn your hands. Why does it say “if it cools, it will harden”? The following discusses its usage: “Insert it into the anal canal.” This refers to its usage. Some students see this and ask, “Teacher, should it be inserted while hot?” I say, when you are rolling it, it is still very hot. If you insert it while hot, wouldn’t that burn the patient? So I change this to a period. “Insert it into the anal canal, and use your hand to hold it tightly.” This means that when using it, it should be cooled first. However, when using it, it is still relatively hard, so we generally dip it in a little warm water before inserting it into the anal canal to make it smoother and easier to insert. “Hold it tightly with your hand.” This does not mean to hold it tightly with your hand; it just tells the patient to hold it for a while. “When you have the urge to defecate, you can remove it.” In fact, you do not need to remove it; when the patient defecates, the suppository will mostly dissolve, and any undissolved part will be expelled with the stool.
In clinical practice, we often use glycerin suppositories for children and the elderly with constipation. They can indeed soften the stool and are effective for the syndrome of fluid deficiency and constipation when the stool is obstructed at the anal area. 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 regulating colon function. After using honey suppositories a few times, the patient can defecate well on their own without needing them again.
Last summer, a well-known university professor had an elderly mother who was nearly 90 years old and bedridden for a long time, leading to slow intestinal peristalsis and dry stools. His children and siblings would use glycerin suppositories for her every time she needed to defecate, sometimes even needing to use their fingers to assist. The elderly woman suffered, and her children felt that defecation was a real problem for their mother. Later, I instructed the children to use honey suppositories according to the method in the “Shang Han Lun.” They used many, but actually only three or four were needed. After that, the elderly woman said, “You don’t need to give me honey suppositories anymore; I can defecate on my own.” Indeed, she was able to defecate on her own. For six months, she had to use glycerin suppositories every time, but after using three or four honey suppositories, she could defecate on her own. Therefore, this method, compared to glycerin suppositories, has a better long-term effect on the syndrome of fluid deficiency and constipation in children and the elderly.
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 using the root of the earth melon has been lost, and we do not know what it is. The pig bile formula consists of one pig bile. “To extract the bile” means to squeeze out the pig bile. Pig bile is alkaline and has a certain stimulating effect on the mucosa of the anal canal and colon. The nerve endings in the anal mucosa are relatively rich, and they have sensation. Therefore, when we eat too much chili, we may feel a burning pain when defecating. Now, using a strong alkaline pig bile directly injected into the anal canal will cause stimulation and discomfort. Therefore, in the “Shang Han Lun,” it is stated, “Mix with a little vinegar.” Vinegar is what we consume, and in the “Shang Han Lun,” vinegar is also called bitter wine. Mixing vinegar with bile neutralizes its alkalinity, “and then inject it into the anal canal.” This 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 were no artificial tubes like we have today. After the enema, “within a meal’s time,” the patient should defecate out the food and waste, which is very effective.
Today, in large cities, fresh pig bile is not easy to find, but using pig bile for enemas should be said to be one of the earliest recorded enema therapies in the history of world medicine. This method may seem very simple to us today, but at that time, using such enema techniques was quite remarkable.
We often use soap water for cleansing enemas. In medicine, we should use what is appropriate; we cannot casually find substitutes. There was a case in 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 there was no soap water available, and no soap either. She thought that since soap can wash clothes, washing powder can wash clothes too, and there was a large pile of washing powder nearby. She thought that soap can be used for enemas, and washing powder can also be used for enemas, so she invented a method of mixing washing powder with water and gave it to the patient. Unexpectedly, the patient suffered damage to the intestinal mucosa and intestinal bleeding. This was treated as a medical accident. When asked, she explained that soap can be used for enemas, soap can wash clothes, and washing powder can wash clothes, so washing powder can also be used for enemas. Therefore, medicine and daily life are not the same, and we should not make assumptions when using medical methods.
The content of Yangming excess syndrome we discussed earlier, including Yangming excess syndrome, spleen deficiency syndrome, and fluid deficiency and constipation syndrome, all belong to the Qi aspect of Yangming excess syndrome. There are also blood aspect syndromes in Yangming excess syndrome, which is known as 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 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 heat of Yangming and the long-standing blood stasis. Due to the long-standing blood stasis, new blood does not form. This leads to the heart and spirit being deprived of nourishment, resulting in forgetfulness. Forgetfulness here does not mean liking to forget; it means being prone to forgetfulness. 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 feels that the stagnation is relieved, so they like to vomit. This explanation is incorrect; the preference for vomiting is a painful symptom. Who would like to vomit? Therefore, both “preference for vomiting” and “forgetfulness” refer to the same thing, which is to be prone to it. Shaoyang disease is characterized by frequent vomiting and a tendency to vomit; Yangming blood accumulation syndrome is characterized by mental deprivation, leading to forgetfulness, which is what we refer to as forgetfulness today.
Stasis and heat intermingling lead to dry stools. Although the stools are hard, they are easy to pass because stasis is a yin substance that has a moistening effect. Therefore, although they are dry, they are easier to pass. Because there is stasis, the stools are black. From this perspective, the patient originally had chronic upper gastrointestinal bleeding or 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, and the stools are tarry and more liquid. It would not present with hard stools. Therefore, it is a small amount of chronic seepage. Blood accumulates in the intestines, and combined with heat, the heat and blood intermingling leads to hard stools. For this syndrome, Zhang Zhongjing 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 is still decreasing, we think it is better to focus on 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, and let the patient swallow it, which has a good effect on gastric bleeding. If the bleeding has stopped, and the hemoglobin is no longer decreasing but is on the rise, and the accumulation of blood in the intestines is due to Yangming heat, with stasis and heat intermingling, and it has not been expelled in time, in this case, we can consider using blood-activating and stasis-resolving herbs, but we do not necessarily have to use Di Dang Tang. The Di Dang Tang mentioned in the “Shang Han Lun” should be used according to the situation. If it is a heat syndrome, we can appropriately use Tao Ren Cheng Qi Tang (Peach Kernel Decoction). If the stasis is particularly obvious and the heat is not particularly severe, then we should reduce the dosage of Di Dang Tang. Therefore, for Yangming blood accumulation syndrome, the opportunity to use blood-breaking and stasis-resolving methods is not particularly high; it mainly depends on the situation of upper gastrointestinal bleeding.
In this way, we have finished discussing the content of Yangming excess 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. These four original texts 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 excess heat obstruction. This slow pulse does not indicate Yang deficiency or insufficient yin blood, but rather indicates excess heat obstruction, so the slow pulse should be slow yet strong. Sweating is a manifestation of heat forcing fluids outward, and no aversion to cold indicates that there is no exterior wind-cold syndrome. A heavy body indicates that the excess heat evil obstructs the Qi mechanism, and the Qi is not flowing smoothly, leading to a heavy sensation. We mentioned this in section 6 regarding fire evil injuring yin and internal heat syndrome; shortness of breath indicates that Yangming excess heat obstructs the lungs, leading to not only shortness of breath but also wheezing; abdominal fullness indicates that excess heat obstructs the Qi mechanism in the abdomen. The above symptoms indicate a syndrome of Yangming excess heat internally. “If there is tidal fever, and the patient wants to defecate, it can be purged.” The symptoms of Yangming excess heat are all present; can we purge? Tidal fever is a key point for differentiation. As long as there is tidal fever, it indicates that the exterior evil has been resolved, and you can purge the interior. The next sentence has a different meaning: “If there is profuse sweating from the hands and feet, this indicates that the stools are already hard; Da Cheng Qi Tang (Major Order the Qi Decoction) is the main treatment.” If there are symptoms of excess heat obstruction, does that mean the stools are already hard? If there is profuse sweating from the hands and feet, it indicates a special form of dryness-heat evil forcing fluids outward, which allows the use of Da Cheng Qi Tang.
The profuse sweating from the hands and feet described by Zhang Zhongjing is something I encountered clinically once. This was over 20 years ago when an elderly lady with jaundice, weight loss, and high fever was 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 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 she had in the past. They said she often had colds. I asked how often she had colds, and they said every week. I found it strange that someone could catch a cold every week. I asked them which day of the week she usually caught a cold, and they said it was usually Friday night. I asked if it was regular, and they said it was generally like that. I asked what symptoms she had when she caught a cold, and they said she would first feel cold and shiver, then have 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 checked her urine, it was very yellow. I asked if they noticed her eyes or face turning yellow, and they said they did not pay 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. Based on this description of symptoms, this is called periodic chills and fever, accompanied by upper abdominal pain, and the yellow urine they mentioned indicates mild jaundice. This means that the patient likely has the clinical features of Charcot’s triad. Typical periodic chills and fever, accompanied by upper abdominal pain and jaundice, is a clinical feature of biliary stones. Therefore, this time she presented with obstructive jaundice and persistent high fever. I thought she resembled a case of obstructive stones, and if it was not diagnosed as pancreatic head cancer, there would still be 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. I was shocked to see that 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 kept wiping, and seeing this made me think of the “Shang Han Lun” where it says “profuse sweating from the hands and feet.” This is exactly the appearance of hands and feet sweating profusely. This indicates that there is Yangming excess internally, but I also thought about her medical history. Therefore, we cannot simply use Da Cheng Qi Tang to treat her. I decided to use Da Chai Hu Tang (Major Bupleurum Decoction), of course, adding Hai Jin Sha and Jin Qian Cao. I prescribed only one dose of medicine, saying that we could only treat her as a last resort. The hospital had already said she had pancreatic head cancer, and they could eat whatever they wanted, as they were preparing for the worst. I said I would prescribe one dose, and if it worked, it worked; if not, do not look for me again.
Unexpectedly, after taking the medicine, there was no response in the afternoon, but by evening, her consciousness became clearer, and she started to defecate. After defecating, she became clear-headed, and her daughter called me to say, “My mother has defecated.” I said, “Now check the stool. If the stool can expel the stones, we can determine that she has obstructive stones rather than pancreatic head cancer. Then there will be no major issues for her.” The first stool did not expel the 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. After that, the elderly woman’s fever subsided, and the jaundice gradually disappeared. That dose of medicine was only prescribed for her to take once, and she did not continue taking it.
The elderly woman 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, sometimes for biliary stones, if they do not flare up, using purgative methods may not necessarily be effective. As long as biliary stones flare up, using purgative methods can often yield good results, which is called treating according to the situation.
This patient’s profuse sweating from the hands and feet is very obvious. Therefore, in clinical practice, when we see hands and feet sweating profusely, it generally indicates the presence of Yangming excess 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. “If there is slight fever and aversion to cold, it indicates that the exterior has not been resolved.” The slight fever and aversion to cold clearly indicate that it is not the tidal fever mentioned earlier. Because there is tidal fever, you can purge the interior; now there is no tidal fever, but slight fever and 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 slight fever is not tidal, then do not give Da Cheng Qi Tang. “If there is abdominal fullness and no passage, you can use Xiao Cheng Qi Tang to harmonize the stomach Qi, but do not allow it to leak excessively.” If there are no tidal fever symptoms but there is abdominal fullness and no passage, what should be done? Do not use Da Cheng Qi Tang; instead, use Xiao Cheng Qi Tang to relieve constipation. Therefore, the distinction between Da Cheng Qi Tang and Xiao Cheng Qi Tang is very clear.
In section 209, “In Yangming disease, if there is tidal fever and the stools are slightly hard, you can use Da Cheng Qi Tang.” The word “slightly” in “slightly hard” is 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” be used for Da Cheng Qi Tang? Therefore, this “slightly” may be an extraneous word. “If it is not hard, it cannot be used.” If the stools are not hard, even if there is tidal fever, it cannot be used.
We will mention in the Shaoyang disease section that although it is emphasized that there must be tidal fever to use Da Cheng Qi Tang, this is under the premise that the stools are hard and there are abdominal fullness symptoms. If there is tidal fever but the stools are not hard, then Da Cheng Qi Tang should not be used. We will mention in the Shaoyang disease section that “In Yangming disease, if there is tidal fever and the stools are loose, and urination is normal, but there is fullness in the chest and hypochondrium that does not go away, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is the main treatment.” Why is this Yangming disease? Because there is tidal fever. If we look at the stools, they are loose; there are no hard stools, and there are no signs of Yangming dryness and obstruction. If we look at urination, it is normal, and there is no frequent urination, but there is fullness in the chest and hypochondrium, which is a characteristic of Shaoyang disease. Therefore, this tidal fever is at most Yangming stagnant heat, and our handout places it in the Shaoyang disease section, using Xiao Chai Hu Tang to harmonize Shaoyang and smooth the Qi mechanism to relieve the stagnant heat caused by Yangming.
“If you want to drink water, give water, and it will lead to hiccups (yǔe).” Only in cases of paralytic intestinal obstruction, when the Qi is not flowing smoothly, if you give them water, due to the stimulation of the water, it can lead to diaphragm spasms. Many patients with paralytic intestinal obstruction have hiccups. In the “Shang Han Lun,” the character “哕 (yǔe)” refers to hiccups, which in TCM literature is also called “呃忒 (te),” which we refer to today as diaphragm spasms. This character “哕 (yǔe)” has changed meaning since the Song Dynasty; after the Song Dynasty, it refers to dry vomiting.
Therefore, these two sections are actually discussing the differentiation and application of Da Cheng Qi Tang and Xiao Cheng Qi Tang. After this, everyone should take a good look at these two original texts and the explanations of the annotators. I always feel that there are some places where the explanations are not particularly ideal, and I feel regretful about some of the explanations.
Next, let’s look at sections 251 and 203, which discuss the relationship between defecation and urination.
First, let’s look at section 251, “If the disease lasts for two or three days, the pulse is weak,” indicating deficiency, “and there is no Taiyang Chai Hu syndrome,” meaning there is no Taiyang exterior syndrome or Shaoyang half-exterior half-interior syndrome. “If there is restlessness and hardness under the heart,” this is a manifestation of internal heat, but it is not a typical Yangming excess syndrome location. Because the location of Yangming excess syndrome is around the navel, with abdominal fullness and pain, the hardness under the heart is not a typical Yangming excess syndrome location. “If after four or five days, although able to eat,” the indication for Da Cheng Qi is that one cannot eat; here, they can eat, so it is not a Da Cheng Qi indication. “Use a small amount of Xiao Cheng Qi Tang to harmonize it and make the patient feel comfortable.” He has restlessness and a manifestation of internal heat, but the symptoms are not typical, so do not rashly use Da Cheng Qi Tang; instead, use a small dose of Xiao Cheng Qi Tang to see how it goes. “If after six days, use one sheng of Cheng Qi Tang.” If after using Xiao Cheng Qi Tang, the condition does not worsen or change significantly, but the stools have not passed, then on the sixth day, increase the amount of Xiao Cheng Qi Tang to one sheng, as the previous “small amount” refers to a small dose.
Next, we discuss the relationship between urination and defecation. “If there has been no defecation for six or seven days, and urination is scant, even if there is no food intake, but the stools are initially hard, they will eventually be loose, and they are not yet determined to be hard, purging will lead to looseness.” This indicates that if there has been no defecation for five or six days and the urination is not abundant but scant, it indicates that the transportation is not functioning properly, and the fluids are not being separated. If the urination is scant, where is the water? It must be in the intestines. Since it is in the intestines, why are the stools not loose but rather hard? This is because they are initially hard but will eventually be loose. Therefore, in this situation, if the urination is scant and there is no defecation, do not rashly purge.
“It is necessary to have a small amount of urination, and if the stools are determined to be hard, then it can be purged, and Da Cheng Qi Tang is appropriate.” Therefore, as long as you see that the urination is frequent, this indicates that the fluids are being forced outward, and the fluids cannot return to the gastrointestinal tract. Additionally, if there are systemic toxic heat symptoms and abdominal fullness symptoms, then purging methods can be used.
Earlier, we mentioned that profuse sweating from the hands and feet can use Da Cheng Qi Tang. Here, it mentions that frequent urination can also use Da Cheng Qi Tang. Both indicate that Yangming excess syndrome is forcing fluids outward or causing them to be forced outward or retained.
Next, let’s look at section 203, “In Yangming disease, if there is spontaneous sweating, and the physician further induces sweating,” Yangming disease has spontaneous sweating. The physician, “further” means “again,” has used sweating methods again. Of course, the fever has subsided, so it is said that “the disease has improved.” The fever has subsided, “but there is still slight restlessness,” which is a symptom characteristic. This must be due to hard stools. Although the fever has subsided, why are the stools hard? “Due to the loss of fluids, the stomach is dry, causing hard stools.” This is because there was already sweating, and you used sweating methods again. Although the fever has subsided, the fluids have been depleted, leading to dryness in the gastrointestinal tract, which causes hard stools. At this point, should you use purgative methods or wait for the body’s self-recovery mechanisms to restore normal defecation? “You should ask how many times the patient has urinated in a day.” At this point, you should observe the frequency of urination. “If the patient originally urinated three to four times a day, and today only twice,” this indicates that the stools will not be long in coming out. “If today there is less urination, it indicates that the fluids are returning to the gastrointestinal tract, so it is known that the stools will soon be expelled.” Therefore, you should not use purgative methods. “If the urination is frequent and scant, it indicates that the fluids are returning to the gastrointestinal tract, so it is known that the stools will soon be expelled.” This indicates that there is no abdominal fullness or pain, no tidal fever, and no abdominal fullness symptoms. If the urination frequency decreases, it indicates that the fluids are returning to the gastrointestinal tract, so the stools will soon be expelled. In this case, you should not use purgative methods.
Therefore, the classic summary of “Frequent urination indicates hard stools; no pain and scant urination indicates fluid return” is very classic and summarizes the two situations in sections 251 and 203. This has certain reference significance for us in clinical practice to differentiate whether Yangming dryness and heat can be purged.
Next, let’s look at the contraindications for purgative methods. Section 204 states, “In cases of cold damage, if there is excessive vomiting, even if there are Yangming symptoms, it cannot be purged.” This section is very important. According to the explanations of the annotators, if a patient has Yangming disease and excessive vomiting, what could this indicate? Some say this is heat in the chest and diaphragm. In Yangming disease, heat in the chest and diaphragm can be treated with Zhi Zi Shi Tang (Gardenia and Perilla Decoction) to clear and disperse the stagnant heat. If the heat in the chest and diaphragm disturbs the stomach, it can lead to vomiting. If you treat this condition as Yangming excess syndrome and purge it, it will further damage the internal Qi and worsen the condition. Therefore, Yangming disease cannot be purged; this is one explanation. The second explanation is that excessive vomiting is a characteristic of Shaoyang. Shaoyang disease has irritability and preference for vomiting. Shaoyang is a weak Yang, and its ability to resist evil is insufficient. Sweating, vomiting, and purging methods do not effectively eliminate Shaoyang evil. They can only damage the righteous Qi of Shaoyang. Therefore, the “Shang Han Lun” emphasizes the need to avoid sweating, vomiting, and purging. In the course of treating externally contracted febrile diseases, as soon as Shaoyang disease is observed, treatment should prioritize Shaoyang. If both Shaoyang and Yangming are present, you can only harmonize as the main treatment, or use purgative methods in conjunction with harmonization, but you cannot use purgative methods alone. This is our second explanation.
Yangming disease is a Yangming internal heat excess syndrome, and excessive vomiting is a characteristic of Shaoyang disease. In treatment, the focus should be on harmonization, and purgative methods can be used in conjunction with harmonization, but Da Cheng Qi Tang should not be used alone.
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 section clinically, what kind of patients will exhibit both Yangming disease characteristics and excessive vomiting? I have observed that strangulated intestinal obstruction is rarely seen in cities because treatment is timely. However, 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 necrosis of the intestinal wall. When the condition develops to this extent, the clinical manifestations of obstructed Qi will be present, with no defecation and no gas passing, and symptoms of abdominal pain, fullness, and obstruction will also be present. When the condition develops to this extent, systemic toxic heat symptoms will also appear, with tidal fever, delirium, and even symptoms of heat causing confusion. Therefore, this Yangming disease is present, but do not forget that this is intestinal obstruction. One of the characteristics of intestinal obstruction is vomiting. If the obstruction is high, vomiting occurs early; if the obstruction is low, vomiting occurs later. However, the most prominent symptom is vomiting. Therefore, I think Zhang Zhongjing encountered a patient with strangulated intestinal obstruction. From the perspective of systemic toxic heat symptoms and abdominal fullness, it can be diagnosed as Yangming disease. However, if there is excessive vomiting, using purgative methods will lead to intestinal perforation and cause infection and toxic shock, resulting in death. This is why he wrote this section. This reminds us that when encountering a patient with strangulated intestinal obstruction in clinical practice, even if they exhibit all the symptoms of Yangming excess syndrome, if they have excessive vomiting, purging is absolutely contraindicated, as it will lead to the patient’s death.
Next, let’s look at section 205: “In Yangming disease, if there is hardness and fullness under the heart, it cannot be purged. If purged, it will lead to continuous diarrhea and death; if it stops, it will recover.” It should be noted that the area under the heart is governed by the stomach, and the Yangming meridian runs from the chest to the abdomen, covering the upper, middle, and lower jiao. Hardness and fullness under the heart actually refer to the stomach. Yangming excess syndrome refers to abdominal fullness symptoms. There should be symptoms of abdominal pain, fullness, and obstruction. It is not hardness and fullness under the heart. Therefore, this Yangming disease indicates that the evil has not yet entered the intestines, and the evil is too high. If purged too early, it may worsen the condition. Therefore, hardness and fullness under the heart cannot be purged. Another possibility is that hardness and fullness under the heart may indicate a stomach Qi deficiency with interference from evil Qi. If you treat a stomach Qi deficiency as Yangming excess and purge it, it will further damage the stomach Qi, leading to adverse outcomes. Therefore, for section 205, it is important to recognize two understandings: one is that the Yangming evil is too high and has not yet fully entered the intestines, so do not purge too early; the other is that it may be a stomach Qi deficiency with interference from evil Qi. If purged incorrectly, 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 is better. This section particularly emphasizes that the location of Yangming excess syndrome is not under the heart but rather in abdominal fullness, pain around the navel, and abdominal fullness and obstruction.
Section 206 states, “In Yangming disease, if the face is red and the complexion is yellow, it cannot be purged, as it must lead to fever and yellow color, indicating that urination is not smooth.” The Yangming meridian runs through the head and face. “Face red” indicates that the Yangming meridian has evil, and the Yangming meridian’s Yang Qi is obstructed. This is also the exterior syndrome of Yangming meridian we mentioned earlier. It is not the case that “Ge Gen floats and the Yangming meridian is red, with fever, aversion to cold, no sweating, and pain in the eyes and dryness of the nose, and restlessness.” This indicates that the face is red, but it is Yangming disease, and the evil is in the meridian, not yet in the intestines, so it cannot be purged. If purged, it will damage the stomach and spleen Qi. If the stomach and spleen Qi are damaged, the transportation will fail, and the damp evil will remain inside, leading to possible jaundice. Therefore, section 206 indicates that the evil is in the Yangming meridian and cannot be purged.
Section 189 is more complex, and the annotators have different understandings. “Yangming wind” should refer to the Yangming meridian being harmed by wind evil. “Bitter taste in the mouth and dry throat” indicates that there is Shaoyang disharmony. “Abdominal fullness and slight wheezing” indicates that the Yangming meridian’s Qi is not smooth. “Fever and aversion to cold, with a floating and tight pulse” indicates that there is exterior evil in the Taiyang. Therefore, this syndrome is viewed as a simultaneous attack of the three Yangs, with the evil Qi biased towards the meridians. Since the evil Qi is in the meridians, “if purged, it will lead to abdominal fullness and difficulty urinating.” If there is internal evil, using purgative methods will inevitably damage the stomach and spleen Qi, leading to failure of transportation and Qi stagnation, resulting in difficulty urinating. The exterior evil in the meridians cannot be purged. This is similar to the meaning of section 206.
Next, let’s look at section 194: “In Yangming disease, if one cannot eat, purging the heat will lead to hiccups (yǔe).” The “Yangming disease, if one cannot eat” indicates that the stomach is deficient and cold, leading to an inability to receive food. This is not the same as the obstruction of Yangming excess syndrome. Therefore, if you mistakenly think it is due to internal obstruction and use Cheng Qi Tang to purge heat, it will further damage the internal Qi, leading to persistent hiccups. Zhang Zhongjing himself explains the pathogenesis: “The reason is that the stomach is deficient and cold.” This indicates that Yangming stomach is deficient and cold. “Since the person is originally deficient, purging the heat will lead to hiccups.” This means that if you use bitter cold herbs, it will lead to persistent hiccups.
In summary, the contraindications for purgative methods in Yangming disease are: 1 evil in the meridians cannot be purged; 2 hardness and fullness under the heart cannot be purged; 3 excessive vomiting cannot be purged; 4 stomach deficiency and cold cannot be purged. These are issues we should pay attention to when using Cheng Qi Tang in clinical practice. Today’s class ends here.
Okay, class dismissed.
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