Pathogenesis of Taiyang Disease
Taiyang governs the exterior and controls the Ying and Wei (nutritive and defensive qi), serving as the “barrier of the body”. When external pathogens invade through the skin, they obstruct the Wei Yang, causing stagnation of Ying Yin and excess of pathogenic heat at the exterior, hence it is termed Taiyang disease. The “Shang Han Lun” states in its fourth section: “In the case of febrile disease, Taiyang is affected on the first day,” thus Taiyang disease also signifies the early stage of illness.
The fundamental pathogenesis of Taiyang disease is: invasion of wind-cold from the exterior, causing the Ying and Wei to be affected and lose their harmony. The heart governs blood and belongs to Ying, while the organs govern qi and belong to Wei, both residing in the chest. Qing, Ke Yunbo in “Shang Han Lun Yi: Explanation of Taiyang Disease” states: “Ying and Wei circulate at the exterior, originating from the heart and lungs.” Therefore, Taiyang disease is essentially a disease of Ying and Wei, and when Ying and Wei are affected, it leads to heart and lung issues. It is believed that “the heart and lungs are the interior of Taiyang.” Thus, although Taiyang disease is caused by the invasion of wind-cold at the skin, it is actually due to the invasion of the heart’s Ying and the lung’s Wei, hence the pathogenesis often involves changes in the chest.
From the perspective of meridian connections, although the small intestine and bladder belong to Taiyang and often have pathogenesis changes due to meridian evil entering the organs, these are results of the evil affecting the heart’s Ying and the lung’s Wei not resolving.
1. Disharmony of Ying and Wei
Ying is Yin, and Wei is Yang. Yin is characterized by sinking and stillness, while Yang is characterized by rising and movement. Both fill the exterior of the body, one rising and one sinking, one moving and one still, maintaining the normal physiological function of solidifying the exterior and regulating opening and closing. The so-called Ying and Wei being affected and losing their harmony means that one side, either Ying or Wei, is enhanced by external factors, causing a state of imbalance in the rising and sinking of Yin and Yang at the skin. Wind injures Wei, and cold injures Ying. Wind is Yang in nature, while cold is Yin in nature. When the Yang (wind) external evil is felt, it naturally enhances the rising and dispersing nature of Yang (Wei), leading to a pathogenesis of strong Wei and weak Ying. Conversely, when the Yin (cold) external evil is felt, it enhances the sinking and still nature of Yin (Ying), leading to a pathogenesis of strong Ying and weak Wei. When both wind and cold are present, it forms a pathogenesis of both Ying and Wei being solid. This is the reasoning behind Cheng Wujis saying “wind combines with Wei” and “cold combines with Ying” (“Annotated Shang Han Lun”).
When Wei is strong and Ying is weak, the rising and dispersing nature of Wei Yang dominates, leading to fever; the weak Ying Yin lacks the ability to contain, hence leads to spontaneous sweating, with a floating and relaxed pulse; after spontaneous sweating, part of the Wei Yang is lost, and the skin slightly loses warmth, hence aversion to wind, which is termed the “deficiency of Taiyang exterior syndrome.” When Ying is strong and Wei is weak, the sinking and still nature of Ying Yin exceeds the rising and dispersing nature of Wei Yang, causing Wei Yang to be trapped within the skin and unable to disperse outward to warm the skin, hence aversion to cold; the Yang Qi trapped internally rises, leading to fever. The dominant sinking nature of Ying Yin causes absence of sweating, a floating and tight pulse, and leads to pain in the head and body joints, which is termed the “excess of Taiyang exterior syndrome.” If both wind and cold are present, with cold combining with Ying, the sinking nature of Ying Yin is enhanced, leading to severe aversion to cold and absence of sweating; if wind combines with Wei, the rising and dispersing nature of Wei Yang is enhanced, but due to absence of sweating, Yang heat cannot disperse outward and becomes trapped internally, leading to high fever and restlessness, forming a syndrome of both exterior and interior being solid, also known as the “exterior cold and interior heat syndrome.” All these are termed Taiyang meridian syndromes.
The deficiency of Taiyang exterior syndrome is treated with Gui Zhi (Cinnamon Twig) Decoction, the excess syndrome is treated with Ma Huang (Ephedra) Decoction, and the syndrome of both exterior and interior being solid is treated with Da Qing Long (Major Blue Dragon) Decoction.
2. Exterior Cold and Interior Fluid
This often occurs in individuals with pre-existing fluid retention who are then attacked by cold evil from the exterior, leading to a binding at the skin. The exterior cold and interior fluid clash with each other, obstructing the lung’s Wei, causing the lung to lose its ability to diffuse and descend, resulting in illness. The lung Qi fails to diffuse, hence the exterior is solid with absence of sweating; the lung fails to descend, hence cough and wheezing occur. Additionally, the fluid disperses irregularly, obstructing the airways, leading to wheezing and coughing; if it obstructs the stomach, it leads to dry retching; if it stagnates below and does not disperse, it leads to difficulty in urination and fullness in the lower abdomen; if the fluid congeals and does not dissolve, it leads to thirst due to lack of fluids. If the fluid stagnates for too long and tends to transform into heat, once the fluid combines with heat, the heat resides within the fluid, making it most difficult to separate, leading to a recurrent illness.
The exterior cold and interior fluid, although both are diseases of the exterior and interior, both caused by the binding of cold evil from the exterior, this one has tangible water fluid stagnating internally, even if it transforms into heat after prolonged stagnation, it must still involve fluid; the other has intangible heat evil stagnating internally, with high heat, thus the nature of the pathogenesis of the two is entirely different. The exterior cold and interior fluid is treated with Xiao Qing Long (Minor Blue Dragon) Decoction, and if the fluid evil transforms into heat, it is treated with Xiao Qing Long (Minor Blue Dragon) Decoction plus Shi Gao (Gypsum) Decoction.
3. Evil Entering the Meridian
The Taiyang meridian begins at the inner canthus of the eye, ascends to the forehead, intersects at the vertex, connects to the brain, and descends along the spine to the waist. The exterior evil of Taiyang enters the meridian, causing the meridian Qi to be obstructed, and the sinews to lose nourishment, leading to symptoms such as stiffness in the neck and back, which is the pathogenesis of evil entering the meridian.
If wind evil enters the meridian, it leads to exterior deficiency and spontaneous sweating; if cold evil enters the meridian, it leads to exterior excess and absence of sweating. Evil entering the meridian with exterior deficiency and spontaneous sweating is treated with Gui Zhi (Cinnamon Twig) plus Ge Gen (Kudzu) Decoction; with exterior excess and absence of sweating, it is treated with Ge Gen (Kudzu) Decoction.
4. Evil Trapped in the Chest
Ke Yunbo states: “Taiyang takes the chest as the interior… Yangming takes the chest as the exterior” (“Shang Han Lun Yi”), and the chest is indeed where the heart and lungs reside. Therefore, if Taiyang disease does not resolve, the evil Qi transmits internally, often first involving the chest, leading to symptoms of the heart and lungs. The pathogenesis of evil trapped in the chest often varies depending on the individual’s organ conditions, the nature of the evil, and the presence or absence of pre-existing diseases. Generally speaking, when the exterior evil penetrates inward, it affects the lungs, leading to the basic pathogenesis of the lung losing its ability to diffuse and descend, manifesting as wheezing, coughing, and phlegm production. However, there are variations such as cold transformation, heat transformation, and the presence of fluid or phlegm.
When the exterior evil enters the interior, it leads to symptoms such as “sweating and wheezing” or “no sweating and restlessness,” which are pathogenesis changes due to the heat transformation of the evil Qi, causing the lung to lose its ability to clear and descend. If there is a pre-existing condition of wheezing or if there is water retention in the heart area, the pathogenesis changes lead to cold Qi combined with fluid, causing the lung Qi to be obstructed, manifesting as coughing and wheezing.
If the exterior evil is mismanaged, or if sweating is excessive, or if fire attack is misused, it can damage the heart Yang, leading to symptoms such as rapid pulse, fullness in the chest, restlessness, palpitations, and chaotic thoughts. If the heart Yang is damaged, it can lead to cold Qi in the lower burner rising, causing chaotic movements; or if fluid stagnates below, it can lead to palpitations and chaotic movements.
5. Solid Evil in the Chest
The chest cavity often has pre-existing phlegm and fluid accumulation, and when the exterior evil penetrates the chest cavity, it combines with tangible phlegm and fluid solid evil, occupying the chest cavity, forming the so-called pathogenesis of solid chest. If it is exterior heat penetrating inward, the heat resides in the fluid, while the fluid resides outside the heat, obstructing the Qi mechanism of rising and descending, leading to illness, this is termed heat solid in the chest. If it is cold phlegm accumulation, it is termed cold solid in the chest. Generally, solid chest manifests as fullness and pain in the chest, and even from the heart down to the lower abdomen, leading to fullness and pain.
6. Evil Trapped Below the Heart
The exterior evil trapped below the heart often arises from mismanagement of downward treatment, and its pathogenesis changes are also diverse, primarily forming fullness syndrome, manifesting as fullness below the heart, tenderness upon pressure, or inability to expel gas. If it is heat evil obstructing below the heart, it leads to heat fullness. If it is due to stomach deficiency and Qi stagnation, it leads to deficiency fullness or Qi fullness.
If the exterior syndrome is mismanaged, or if vomiting and purging are excessive, it can damage the spleen Yang, leading to weakness of Yang Qi, which cannot transform fluids, resulting in the pathogenesis changes of fluid retention below the heart. Fluid retention below the heart primarily manifests as fullness below the heart, but due to the fluid’s movement, there can be different pathogenesis evolutions and clinical manifestations. If the water Qi rises, it leads to Qi rushing up to the chest; if it obscures the clear Yang, the Yang Qi cannot rise, leading to dizziness; if it rises to the heart, it leads to palpitations; if it obstructs the stomach, it leads to vomiting of clear phlegm; if it rises to the lungs, it leads to coughing and wheezing. The formation of water Qi originates from Yang deficiency, and insufficient Yang Qi can also lead to the sinews and meridians losing warmth, manifesting as tremors and shaking of the body.
7. Evil Heat Leading to Diarrhea
The Taiyang exterior syndrome mismanaged with downward treatment leads to the interior heat of the intestines, termed evil heat leading to diarrhea, which has several pathogenesis changes. One is that the exterior heat penetrates inward, the exterior evil is completely resolved, and it is purely interior heat leading to diarrhea, with symptoms of “diarrhea that does not stop… wheezing and sweating,” and the pulse is not rapid, treated with Ge Gen (Kudzu) Huang Qin (Scutellaria) Huang Lian (Coptis) Decoction. If the pulse is rapid, it indicates that the exterior is not resolved, and treatment should continue to resolve the exterior, allowing the interior to harmonize. The second is that the exterior evil transmits to Yangming, and the interior heat is not solid, forming “Taiyang and Yangming co-disease, which must lead to diarrhea,” with the exterior not resolved, still having fever, aversion to cold, headache, and absence of sweating, along with Yangming’s diarrhea, indicating that the Taiyang evil is strong, affecting Yangming, and the Yangming interior syndrome is caused by the exterior syndrome. Treatment should resolve the exterior, allowing the interior to harmonize, using Ge Gen (Kudzu) Decoction. The third is that Taiyang and Shaoyang co-disease, “leading to diarrhea, treated with Huang Qin (Scutellaria) Decoction,” is caused by evil heat pressing down on the intestines. The fourth is that Taiyang disease “the exterior syndrome is not resolved, yet there is frequent diarrhea, leading to heat and diarrhea that does not stop.”
The so-called “cooperation” means “to combine”. Due to repeated mismanagement of downward treatment, it weakens the spleen and stomach, leading to exterior heat, while internally it is deficient cold, with deficient cold combined with exterior heat leading to diarrhea, termed “cooperation heat leading to diarrhea.” In fact, this cooperation heat leading to diarrhea is the Taiyang affecting the Taiyin, which can be termed Taiyang and Taiyin co-disease, namely the Gui Zhi (Cinnamon Twig) Ren Shen (Ginseng) Decoction syndrome. The fifth is that the exterior evil penetrates below the heart, leading to fullness syndrome, and repeated mismanagement of downward treatment, leading to diarrhea that does not stop, resulting in the pathogenesis changes of the lower burner slipping away, such as the Chi Shi Zhi (Red Stone) Yu Yu Liang (Yuyuliang) Pill syndrome.
8. Meridian Evil Entering the Organs
This refers to the unresolved Taiyang meridian evil, transmitting along the meridian to the Taiyang organs’ pathogenesis changes. One is that the evil enters the bladder Qi aspect, combining with water, leading to water retention and difficulty in urination. The second is that evil heat enters the bladder blood aspect, combining with blood stasis, leading to urgent fullness in the lower abdomen and self-relieving urination, with symptoms resembling madness due to blood retention. The lower abdomen is the chamber of the bladder, and the so-called bladder blood retention syndrome actually refers to blood stasis in the lower abdomen, with some cases showing symptoms of blood in the stool.
9. Injury to the Yang of the Organs
This often arises from improper sweating and purging in Taiyang disease. All five organs have Yang Qi, and the injuries differ, with pathogenesis changes also varying. For example, excessive sweating injures the lung’s Wei Yang, manifesting as aversion to cold, sweating without fever. Excessive sweating injures the heart Yang, with pathogenesis changes manifesting as anxiety in the upper burner, leading to fullness in the chest, restlessness, chaotic thoughts, fullness in the lower burner, and palpitations. If the lower burner is cold Qi rising, it leads to chaotic movements, or if fluid stagnates, it leads to palpitations and chaotic movements, as previously mentioned. If vomiting and purging damage the spleen Yang, it often leads to fluid stagnation, Qi stagnation, and diarrhea, as previously mentioned. If excessive sweating injures the kidney Yang, the disease transmits from Taiyang to Shaoyin, leading to symptoms such as “sweating, leading to continuous leakage, aversion to wind, difficulty in urination, and slight urgency in the limbs, making it difficult to bend and stretch,” which is the Gui Zhi (Cinnamon Twig) Fu Zi (Aconite) Decoction syndrome. If Yang deficiency is too severe, it can transform into Shaoyin disease.
10. Injury to the Yin of the Organs
The pathogenesis changes of Yang injury in disease primarily manifest as loss of body fluids, with the disease tendency shifting towards Yangming. The so-called “Taiyang disease, if sweating, purging, or frequent urination, this leads to loss of body fluids, dryness in the stomach, hence shifting to Yangming.” This indicates that the disease changes often arise from Yangming heat transformation.
Pathogenesis of Yangming Disease
The Yangming meridian includes the hand Yangming large intestine and foot Yangming stomach. Yang represents heat, and ming means prominent. The excessive Yang heat occurring in the Yangming area forms a pathological response, termed Yangming disease. Therefore, Yangming disease often arises from heat transformation, with interior heat and stomach fullness as the basic pathogenesis.
The transmission of Yangming disease has three origins: one is improper treatment of Taiyang disease leading to loss of body fluids, causing dryness in the stomach, transforming into heat and solidifying, thus shifting to Yangming, termed Taiyang to Yangming; the second is improper use of sweating, vomiting, purging, and diarrhea in Shaoyang disease, leading to stomach dryness and solidification, thus shifting to Yangming, termed Shaoyang to Yangming; the third is not due to improper treatment, but rather the evil heat solidifying directly, invading Yangming, termed Zheng Yang to Yangming. Regardless of the source, it is fundamentally characterized by excessive Yang Qi and rampant evil heat as the basic pathological change.
When the evil heat first enters the Yangming area, it becomes trapped between the chest and diaphragm, unable to disperse, leading to the pathological change of heat stagnation in the chest; if the evil heat transmits into the Yangming meridian, it leads to the pathological change of Yangming meridian heat excess; if the evil heat enters the organs along the meridian, it leads to the pathological change of Yangming organ heat excess.
Yangming and Taiyin are mutually exterior and interior, their meridians are interconnected, and their Qi is communicated. In disease, they can transmit changes to each other. Yangming disease with unresolved evil heat, if combined with Taiyin spleen dampness, can lead to pathological changes of jaundice. Yangming disease mismanaged or excessively purged can often damage spleen Yang, transforming into Taiyin disease. The “Shang Han Lun” states in section 214: “If the Qi does not turn, this is merely the initial stage, later it must lead to diarrhea, and it cannot be purged, as purging will lead to fullness and inability to eat,” indicating that mismanagement can lead to transformation into Taiyin disease. When Taiyin disease is at its peak, it can also often transform into Yangming disease. Yangming disease belongs to heat excess syndrome, while Taiyin disease belongs to deficiency syndrome and cold syndrome, thus there exists a mechanism of mutual transformation between the two, hence the saying “Yangming deficiency is Taiyin, Taiyin excess is Yangming.” Not only that, but all three Yin diseases can transform into Yangming, indicating a favorable prognosis.
1. Heat Stagnation in the Chest
The chest cavity is the exterior of Yangming, or due to residual heat after sweating, vomiting, or purging, while the righteous Qi is damaged, residual heat takes advantage of the void to stagnate in the chest cavity; or due to evil heat transmitting through the meridian initially entering Yangming, not yet entering the organs, disturbing the chest cavity, both belong to the pathogenesis of heat stagnation in the chest. The characteristic manifestation is insomnia and restlessness. If the stagnation of heat is too severe, Yang Qi is disturbed, leading to symptoms such as vexation and restlessness.
The nature of the pathogenesis is evil excess and righteous deficiency, with the excess being dominant. This is similar to the Wei Zi Guo (Hawthorn) Decoction syndrome.
2. Yangming Meridian Heat
The intangible evil heat solely dominates the Yin and Yang meridians, not yet entering the organs to transform into dryness: one is that the evil heat is excessive externally, forming both exterior and interior heat, manifesting as high fever, profuse sweating, and extreme thirst; the second is that the heat evil is deeply hidden internally, Yang Qi cannot extend and distribute outward, leading to a false cold phenomenon in the extremities, which is termed heat collapse syndrome, meaning “the deeper the collapse, the deeper the heat; the milder the collapse, the milder the heat.” Due to the high heat, filling both internally and externally, it is most likely to injure body fluids, consume Qi, and transform into dryness in the organs. This is similar to the Bai Hu (White Tiger) Decoction syndrome.
3. Yangming Organ Excess
The evil heat enters the organs, steaming and scorching body fluids, transforming into dryness and solidifying, leading to obstruction of the organ Qi, causing stagnation and rapid consumption of body fluids, resulting in various pathogenesis changes. One is that dry heat and waste combine, accumulating in the stomach and intestines, obstructing the organ Qi from descending, leading to abdominal distension and pain; the second is that if the organ Qi does not flow, the lung Qi does not descend, leading to symptoms such as wheezing and shortness of breath; the third is that dry stool becomes hard and dry, with body fluids flowing down, leading to self-relieving diarrhea with pure blue color; the fourth is that if the internal heat is excessive, it disperses outward, leading to tidal fever and sweating; if it accumulates above, disturbing the heart spirit, it leads to restlessness, vexation, delirium, and incoherence, which are symptoms of stomach heat affecting the heart. The fifth is that if the heat evil is deeply hidden, it scorches body fluids, leading to symptoms such as unclear vision, eye discomfort, and even rapid descent into fainting and other severe conditions. Yangming organ excess is similar to the Cheng Qi (Purge Qi) Decoction syndrome.
4. Yangming Jaundice
The “Shang Han Lun” states: “In Yangming disease, if there is fever and sweating, this is due to heat excess, and it cannot lead to jaundice.” “If there is self-relieving urination, it cannot lead to jaundice.” This indicates that Yangming disease is primarily characterized by excessive sweating and self-relieving urination, as Yangming belongs to heat, and the nature of heat evil is dispersive and outwardly penetrating, hence merely having heat evil will not lead to jaundice. The cause of Yangming jaundice is primarily due to “stagnation of heat internally.” The so-called “stagnation of heat” refers to damp-heat stagnation, which is due to absence of sweating and difficulty in urination, leading to dampness, which is sticky, combining with heat, thus heat obstructs dampness, and dampness steams heat, leading to jaundice.
Pathogenesis of Shaoyang Disease
The pathogenesis changes of Shaoyang are primarily based on the gallbladder and Sanjiao. Shaoyang and Jueyin are mutually exterior and interior, with their meridians running along the sides of the body, representing a pathological response layer that is half exterior and half interior. It is externally adjacent to Taiyang and Yangming, and internally close to the three Yin, representing the pivot of the evil entering from the exterior to the interior, or from the interior to the exterior, or the transmission of Yin to Yang.
The term “Shaoyang” implies a lesser degree, meaning that the Yang heat is not as excessive as that of Taiyang or Yangming, hence it is termed Shaoyang disease. The evil Qi and righteous Qi contest between the interior and exterior, leading to the basic pathogenesis of Shaoyang disease. The transmission of Shaoyang disease has two origins: one is the evil entering from the exterior, as stated in section 267 of the “Shang Han Lun”: “Originally a Taiyang disease, if unresolved, it transforms into Shaoyang”; the other is originating from Shaoyang itself, as stated in section 266: “In febrile disease, if the pulse is wiry and thin, with headache and fever, it belongs to Shaoyang.”
If Shaoyang disease is improperly treated or mismanaged, the key to its transmission lies in the deficiency or excess of the spleen and stomach. The “Shang Han Lun” states in section 270: “In febrile disease, after three days, the three Yangs are exhausted, and the three Yins will receive the evil; if the person can still eat without vomiting, this indicates that the three Yins are not receiving the evil.” The ability to eat without vomiting indicates that the spleen and stomach are not deficient, hence it does not transmit to the three Yins. Generally speaking, if the spleen and stomach Yin is excessive, it is easy to enter the three Yin organs; if the stomach is excessive and Yang is strong, it is easy to transmit to the Yangming organs. If the righteous Qi is too deficient and the evil Qi is too excessive, the disease can reverse from Shaoyang to Jueyin; if the Jueyin Yang recovers and the heat is excessive, it can also transform into Shaoyang, indicating a favorable prognosis. Since Shaoyang and Jueyin are mutually exterior and interior, there is the saying “Shaoyang deficiency is Jueyin, Jueyin excess is Shaoyang.”
Shaoyang disease belongs to the category of the three Yangs, and it also has pathological evolutions of meridian and organ syndromes. When the evil Qi invades the Shaoyang area, gallbladder fire rises, gallbladder Qi does not descend, leading to the stomach Qi rising, as stated in the “Ling Shu”: “If the evil is in the gallbladder, it will reverse in the stomach,” and the pivot is not favorable, leading to the contest between the righteous and evil Qi. This is the pathogenesis change of Shaoyang meridian syndrome. The Shaoyang organ syndrome must involve the gallbladder. The “Shang Han Lun” states in section 106: “… if there is persistent vomiting, fullness below the heart, vexation, and slight restlessness, this indicates that it is unresolved; if treated with Da Chai Hu (Major Bupleurum) Decoction, it will recover.” Section 170 states: “… if there is fullness below the heart, vomiting, and diarrhea, it is treated with Da Chai Hu (Major Bupleurum) Decoction.” This indicates the pathogenesis change of heat stagnation in the gallbladder. Since the Shaoyang gallbladder meridian runs down the chest, penetrating the diaphragm, and connecting to the liver, the gallbladder is located below the heart. The so-called “fullness below the heart” and “fullness below the heart” are evidently related to the stagnation of gallbladder Qi, which is essentially the Shaoyang organ syndrome. In the past, some believed that Da Chai Hu (Major Bupleurum) Decoction syndrome belonged to the co-disease of Shaoyang and Yangming, but the three symptoms (106, 140, 170) do not include symptoms of dryness and obstruction in the stomach and intestines, indicating that the disease does not involve Yangming. The treatment of Da Chai Hu (Major Bupleurum) Decoction without the involvement of Yangming is to relieve the diarrhea and release the heat in the gallbladder. Shaoyang meridian syndrome is prohibited from purging, while organ syndrome is not prohibited from purging.
1. Pivot Not Favorable
Shaoyang resides between the exterior and interior, serving as the pivot for the three Yangs and three Yins to enter and exit. Once the evil enters Shaoyang, causing the pivot to be unfavorable, it leads to various pathogenesis changes. One is that the evil resides in Shaoyang, half exterior and half interior, with the righteous and evil Qi contesting, leading to alternating cold and heat. The evil Qi stagnates in the Shaoyang meridian, causing fullness in the chest and flanks. The stagnation of Shaoyang wood invades the earth, leading to symptoms such as loss of appetite and vexation. These are all due to the stagnation of cold and heat in the Shaoyang area, leading to changes in the Qi mechanism. This is similar to the Xiao Chai Hu (Minor Bupleurum) Decoction syndrome.
The second is that the Taiyang exterior evil has not yet been resolved, and the disease has already involved Shaoyang, forming a co-disease of Taiyang and Shaoyang, leading to symptoms such as fever, slight aversion to cold, joint pain, slight vomiting, and fullness below the heart, which is the Chai Hu Gui Zhi (Bupleurum and Cinnamon Twig) syndrome.
The third is that if Shaoyang disease is unresolved, the evil heat transmits into the Yangming organs, forming a co-disease of Shaoyang and Yangming, which is the Chai Hu plus Mang Xiao (Bupleurum and Glauber’s Salt) Decoction syndrome.
The fourth is that if the Shaoyang pivot is unfavorable, the heat stagnation in the upper burner has not yet been resolved, while the Sanjiao water pathway is obstructed, leading to difficulty in urination, fluid retention, and the pathogenesis changes of mixed water and heat evil in the Sanjiao area, which is the Chai Hu Gui Zhi Gan Jiang (Bupleurum, Cinnamon Twig, and Ginger) Decoction syndrome.
2. Heat Stagnation in the Gallbladder
The heat of Shaoyang stagnates in the gallbladder, causing gallbladder Qi to fail to descend, leading to symptoms such as persistent vomiting, fullness below the heart, vexation, and slight restlessness. The gallbladder is located below the heart, hence even if there is persistent vomiting, it can still be purged using Da Chai Hu (Major Bupleurum) Decoction, resolving the Shaoyang externally and releasing the internal heat. This differs from the pathogenesis stated in section 209 of the “Shang Han Lun”: “In febrile disease with excessive vomiting, although there are Yangming symptoms, it cannot be purged,” because in Yangming, the evil heat is above the diaphragm and has not yet entered the organs, hence it cannot be purged.
3. Heat Entering the Blood Chamber
Heat entering the blood chamber is a unique pathogenesis change that occurs in women during the physiological period before and after menstruation when they contract febrile diseases. For details, refer to the section on blood pathogenesis in the chapter on Wei Qi Ying Blood pathogenesis.
Pathogenesis of Taiyin Disease
Taiyin governs the spleen, and its diseases arise from the interior, with deficiency and cold initially prevailing in the interior, leading to the onset of the three Yin, hence it is termed Taiyin disease. The deficiency and cold of the spleen and stomach are the basic pathogenesis of Taiyin disease.
The transmission of Taiyin disease has three origins: one is that “the organs have cold,” and the evil Qi directly enters Taiyin; the second is that Taiyang disease is mismanaged, leading to damage to the spleen Yang, as stated in section 279 of the “Shang Han Lun”: “Originally a Taiyang disease, if the physician purges it, leading to abdominal fullness and pain, it belongs to Taiyin.” The third is that excessive purging of Yangming can damage the spleen Yang, leading to transformation into Taiyin. Furthermore, excessive use of warming and drying methods can also transform into Yangming, as Taiyin spleen and Yangming stomach are mutually exterior and interior. The “Shang Han Lun” states in section 192: “In febrile disease, if the pulse is floating and relaxed, and the hands and feet are warm, this indicates that it is in Taiyin… After seven or eight days, if there is diarrhea, it indicates Yangming disease.” This indicates the mutual transformation of Taiyin and Yangming pathogenesis. Hence, there is the saying that deficiency indicates Taiyin, while excess indicates Yangming.
If Taiyin is not treated, and vomiting and diarrhea do not stop, leading to loss of Yang fluids, the disease can transmit to Shaoyang and Jueyin, making the condition more severe.
1. Taiyin Deficiency and Cold
The pathogenesis changes of Taiyin deficiency and cold primarily arise from weakness of spleen Yang, leading to failure in warming and transporting, causing the clear Yang to fail to rise, leading to cold and dampness prevailing in the stomach, with failure in transformation and movement, causing Qi stagnation and reversal, leading to symptoms such as vomiting, diarrhea, fullness, pain, and inability to eat. This purely belongs to the interior cold excess syndrome, similar to the Li Zhong (Regulate the Middle) Decoction syndrome.
2. Slippery and Uncontrolled
The severe development of Taiyin Yang deficiency and internal cold leads to an inability to raise body fluids and control blood, causing intestinal fluids and blood to slip down, leading to persistent diarrhea, with symptoms such as pus and blood in the stool, and continuous abdominal pain, similar to the Tao Hua (Peach Blossom) Decoction syndrome.
3. Cold Dampness Leading to Jaundice
Taiyin dampness is prone to deficiency, with internal cold prevailing, leading to water dampness stagnating and not transforming, resulting in jaundice, termed cold dampness jaundice. Cold dampness jaundice can transform into heat jaundice through Yangming heat transformation, while Yang jaundice can also transform into cold dampness jaundice through Taiyin cold transformation.
Pathogenesis of Shaoyin Disease
Shaoyin pertains to the heart and kidneys, governing the two Qi of water and fire, serving as the foundation of the human body. When the disease enters Shaoyin, the heart and kidneys become weak, Yang Qi is not vigorous, and Yin blood is insufficient, leading to a significant decrease in the body’s righteous Qi, representing a critical pathogenesis change. When Yang Qi is not vigorous, the pulse is weak; when Yin blood is deficient, the pulse is thin; when both Yin and Yang Qi and blood are insufficient, the spirit loses nourishment, leading to fatigue and a state of indifference, termed “only wanting to sleep.” Therefore, “weak pulse and thin, only wanting to sleep” is a common clinical feature of Shaoyin disease.
Shaoyin governs water and fire, being primarily Yin while representing Yang. If the body is Yang deficient, the disease evil transforms into cold, leading to internal cold excess, manifesting as absence of heat and aversion to cold, with diarrhea and vomiting, weak pulse, and a desire to collapse. If the internal cold is extremely severe, the remaining Yang Qi often floats outward, termed “Ge Yang”; if it floats upward, it is termed “Dai Yang,” leading to symptoms such as facial redness, body heat, and restlessness, representing true cold and false heat pathogenesis.
If the body is primarily Yin deficient, the disease evil transforms into heat, leading to Yang excess, resulting in symptoms such as vexation, insomnia, sore throat, red tongue, and thin rapid pulse, representing heat transformation pathogenesis. Although Shaoyin disease has both cold transformation and heat transformation pathogenesis, it is primarily characterized by Yang deficiency, with cold transformation being more common, hence cold transformation syndrome is the main aspect of Shaoyin, while heat transformation syndrome is the secondary aspect.
Therefore, Shaoyin disease is fundamentally characterized by deficiency of heart and kidney Yang, with internal cold excess.
The prognosis of Shaoyin disease depends on the recovery of Yin and Yang. If Yang recovers, there is life; if Yang is lost, there is death; if Yin is exhausted, there is also death. For example, if the hands and feet transition from cold to warm, aversion to cold and desire to lie down transforms into restlessness and desire to remove clothing, and diarrhea of clear fluids gradually stops, with the pulse transitioning from Yin to Yang, this indicates recovery of Yang Qi and a favorable prognosis. If the hands and feet remain cold, diarrhea does not stop, aversion to cold increases, and the pulse is weak and nearly absent, this indicates impending loss of Yang Qi; if diarrhea stops but the condition does not improve, the pulse remains absent, and dizziness occurs, this indicates true exhaustion of Yin and a severe prognosis.
The pathogenesis and transmission of Shaoyin disease have three origins: one is the pre-existing Yang deficiency, with the disease evil directly entering Shaoyin; the second is the mismanagement of other meridians leading to transmission; the third is the heat transformation of Shaoyin leading to Yangming acute diarrhea, or cold transformation leading to Jueyin.
1. Yang Deficiency and Exterior Cold
The “Shang Han Lun” states in section 301: “In Shaoyin disease, if it begins with fever, and the pulse is deep, it is treated with Ma Huang (Ephedra) Fu Zi (Aconite) Xi Xin (Asarum) Decoction.” This indicates that the evil is externally binding, while the Yang Qi is internally deficient, leading to the co-influence of Taiyang and Shaoyin, representing the pathogenesis of Yang deficiency and exterior cold. The root of Taiyang is indeed Shaoyin. Ke Yunbo states: “If Taiyang Yang is deficient, it cannot govern the exterior, leading to internal injury of true Yin Qi, revealing the foundation of Shaoyin. If Shaoyin is Yin deficient, it cannot govern the interior, leading to external injury of Taiyang Qi, hence the Taiyang disease presents with a deep pulse… while the Shaoyin disease presents with a fever at the exterior.” (“Shang Han Lun Yi: Explanation of Taiyang Disease”) This illustrates the mechanism of mutual transformation between Taiyang and Shaoyin.
2. Yin Excess and Yang Deficiency
Yin excess and Yang deficiency is the basic pathogenesis of Shaoyin cold transformation, with both being interdependent. When Yang Qi is deficient, Yin cold prevails; when Yin cold prevails, Yang Qi becomes increasingly deficient, but Yang Qi deficiency is the primary cause. If Yang Qi is not deficient, even if Yin cold is excessive, it will not transform into Shaoyin. Shaoyin Yang Qi is weak, and Yin cold is excessively strong, representing a systemic deficiency cold transformation, which includes various pathogenesis changes. One is that excessive cold leads to Yang deficiency, causing cold extremities and diarrhea. Since the extremities are the foundation of all Yang, when Yang is weak, it fails to warm, leading to cold extremities. When Yin cold prevails internally, it cannot digest food, leading to undigested food and diarrhea. Shaoyin diarrhea often presents with thirst, indicating that Yang Qi is weak and cannot generate fluids, combined with diarrhea leading to fluid loss. This differs from Taiyin, which presents with diarrhea without thirst, as Taiyin merely has spleen Yang deficiency while kidney Yang is not deficient, and kidney Yang can still generate fluids.
The second is that Yang deficiency and Yin excess lead to water Qi not transforming. Since the foot Shaoyin kidney is the organ of cold water, when kidney Yang is weak, cold water loses its warming and transforming ability, leading to stagnation and infiltration, causing illness. Cold water stagnating in the sinews and joints leads to body pain, joint pain, and cold hands and feet. Yang deficiency and cold excess fail to warm the sinews and joints, leading to tremors and shaking of the body. Yang Qi is weak, and bladder Qi transformation fails, leading to difficulty in urination. Water Qi not transforming leads to upward infiltration, causing palpitations; if it infiltrates the extremities, it leads to heaviness and pain in the limbs, even swelling; if water cold stagnates, clear Yang cannot rise, leading to dizziness.
3. Yin Excess Resisting Yang
Due to extreme Yang deficiency, the internal organs become excessively Yin cold, and the remaining Yang Qi cannot hide, being resisted externally, termed “Ge Yang,” leading to symptoms such as body heat and absence of aversion to cold; if resisted above, it leads to facial redness and restlessness, termed “Dai Yang.” The two manifest differently, but essentially they are the same. Both represent the pathogenesis of true cold and false heat. This pathogenesis change indicates a tendency for Yin and Yang to separate, and the condition is very serious, indicating a poor prognosis. This is similar to the Tong Mai Si Ni (Open the Pulse and Four Reversals) and Bai Tong (White Passage) Decoction syndrome.
4. Heat Transformation Injuring Yin
The evil enters Shaoyin, transforming from Yang into heat, leading to injury of Yin fluids. Hence, Shaoyin heat transformation injures Yin, with Yin deficiency and Yang excess as the basic pathogenesis. Among these, there are several different evolutions. One is that kidney Yin deficiency cannot nourish heart fire, leading to excessive heart fire, with Yang excess not entering Yin, and Yin deficiency failing to restrain Yang, leading to symptoms such as vexation and inability to sleep, treated with nourishing Yin and clearing heat, using Huang Lian (Coptis) and E Jiao (Donkey-hide Gelatin) Decoction and similar formulas. The second is that Yin deficiency with heat combined with water Qi leads to a clash between water and heat, with body fluids leaking into the large intestine, leading to diarrhea and difficulty in urination, vexation, inability to sleep, and thirst. The source of water Qi primarily arises from Yin deficiency leading to bladder Qi transformation failure, treated with nourishing Yin and promoting water, using Zhu Ling (Polyporus) Decoction and similar formulas. The third is that Yin deficiency and Yang excess lead to floating fire, leading to symptoms such as diarrhea, sore throat, fullness in the chest, and vexation, with diarrhea arising from spleen Qi deficiency, rather than excess water Qi. Hence, although Yin deficiency leads to floating fire, there is no evil heat present.
5. Heat Transformation into Solid
Refer to the section on “Pathogenesis of Yangming Disease”.
6. Qi Stagnation Leading to Collapse
Qi stagnation leading to collapse arises from liver Qi stagnation, which cannot rise, causing Yang to stagnate internally, leading to a lack of warmth in the extremities, representing a different essence from Shaoyin Yang deficiency and Yin excess. Historically, this pathogenesis change has been included in the discussion of Shaoyin disease. In fact, Qi stagnation leading to collapse is a manifestation of liver wood invading earth, often accompanied by symptoms such as abdominal pain, diarrhea, and heaviness, while cold extremities are relatively mild, which is similar to the Si Ni San (Four Reversal Powder) syndrome.
Pathogenesis of Jueyin Disease
Jueyin includes the pericardium and liver, representing the final pathological response layer among the six meridians, and also the final stage of the contest between evil and righteous Qi. The origins of its transmission include: one is that cold evil directly enters Jueyin, but this is rare; the second is that the conditions of Taiyin and Shaoyang worsen, transmitting to Jueyin; the third is that Shaoyang disease transforms into Jueyin due to deficiency.
There have been various interpretations regarding the essence of Jueyin disease. Some believe that Jueyin represents the extreme of Yin, essentially being cold collapse; others argue that Jueyin is governed by wind Qi, with the presence of Shaoyang fire transformation, essentially being heat collapse, while the loss of Yang cold collapse is primarily discussed in Shaoyin disease; others believe that Jueyin represents the end of Yin and the beginning of Yang, with Yang Qi returning, leading to excessive or insufficient Qi, hence the pathogenesis can be mixed with cold and heat, with Yin and Yang being excessive or deficient. In fact, within Jueyin disease, there are heat extremes such as Bai Hu (White Tiger) Decoction, Cheng Qi (Purge Qi) Decoction, and Bai Tou Weng (White Headed Weng) Decoction; there are cold extremes such as Wu Zhu Yu (Evodia) Decoction and Si Ni (Four Reversal) syndrome; and there are mixed cold and heat conditions such as Gan Jiang (Dried Ginger) Huang Qin (Scutellaria) Huang Lian (Coptis) Ren Shen (Ginseng) Decoction and Wu Mei (Mume) Pill syndrome. This is due to Jueyin being the intersection of two extremes of Yin, immediately followed by the initial emergence of Yang, being Yin in essence while representing heat, hence it can transform from extreme cold to heat, or from extreme heat to cold, as the saying goes, “extreme leads to reversal,” thus both extremes represent the characteristics of Jueyin.
Therefore, it can be concluded that when the disease reaches Jueyin, the two extremes of Yin intersect, and the initial emergence of Yang occurs, leading to extreme imbalances of Yin and Yang, with the two Qi not harmonizing, hence leading to the basic pathogenesis of heat excess and mixed cold and heat.
Heat collapse is the pathological change of excessive Yang heat, rejecting Yin externally. Collapse refers to the coldness of the hands and feet, while heat refers to the overall body heat. Heat collapse often begins with fever followed by collapse, with the heat being true heat and the collapse being false collapse, but it can transform into cold collapse leading to death. Cold collapse is the pathological change of extreme Yin cold, with true Yang exhaustion, leading to the absence of Yang to warm the extremities. Cold collapse often presents without heat, or with collapse followed by heat, such as Yin excess resisting Yang, with residual Yang floating outward, leading to symptoms such as facial redness and body heat, but the heat is false heat while the cold is true cold. Zang collapse falls under the category of cold collapse.
Mixed cold and heat leading to collapse is also a unique aspect of Jueyin disease. Generally speaking, the formation of transmission is often due to extreme heat leading to cold; when the heat has not yet subsided, the righteous Qi is exhausted, leading to internal cold; when the cold is extreme, Yang can re-emerge, leading to the emergence of cold and heat mixed pathogenesis. For example, the Wu Mei (Mume) Pill syndrome for collapse due to phlegm, the Gua Ti (Melon Seed) San syndrome for collapse due to phlegm, and the Ma Huang (Ephedra) Sheng Ma (Cimicifuga) Decoction syndrome for upper heat and lower cold are all examples.
The victory of heat collapse represents the changes in the contest between evil and righteous Qi, with the observation of the balance of collapse and heat serving as an indicator for judging the prognosis of all collapse syndromes. The so-called “collapse” refers to the coldness of the extremities, indicating Yin excess; “heat” refers to fever, indicating Yang excess. In the “Shang Han Lun,” the number of days of heat and collapse is compared, indicating the relationship between the amount of collapse and heat.
In the early stages of heat collapse, the fever represents heat rising, while the collapse represents heat stagnation; the deeper the heat, the deeper the collapse; the milder the heat, the milder the collapse, termed the “alternation of collapse and heat.” At this time, the amount of heat and collapse should not be used to judge the progress of the disease, nor should the equal duration of heat and collapse be used to determine that it will “certainly recover.” However, in the later stages, if there is a gradual appearance of more cold than heat, the victory of collapse over heat indicates that heat collapse is transforming into cold collapse. The collapse of cold indicates Yin excess, while the emergence of heat indicates Yang recovery. If the amount of collapse exceeds the amount of heat, it indicates insufficient Yang recovery, with the evil Qi prevailing over the righteous Qi, indicating a worsening condition. If the amount of collapse and heat is equal, it indicates appropriate Yang recovery, and the disease is expected to recover. If the amount of collapse is less than the amount of heat, it indicates excessive Yang recovery, still belonging to the righteous Qi prevailing over the evil Qi, indicating a favorable prognosis. However, if there is collapse without heat, it indicates that Yin is long and Yang is exhausted, with the evil Qi prevailing over the righteous Qi, indicating a severe prognosis, falling within the range of “collapse that does not stop leads to death.”
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