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Shang Han Lun · Treatise on Cold Damage
8. Yangming Illness · Pulses, Signs and Treatment
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179. Question: What are Taiyang-Yangming, Zhengyang-Yangming and Shaoyang-Yangming illness?
Answer: Taiyang-Yangming is Spleen constraint. Zhengyang-Yangming is repletion in the Stomach domain. Shaoyang-Yangming is dryness, agitation and repletion in the Stomach with difficult defecation after sweating and promotion of urination.
180. Yangming illness is repletion in the Stomach domain.
181. Question: How does Yangming illness arise?
Answer: In Taiyang illness, sweating, purging or promotion of urination causes loss of fluids and dryness within the Stomach, and the illness turns to Yangming. No bowel movement, internal repletion and difficult defecation are called Yangming.
182. Question: What are the outward signs of Yangming illness?
Answer: Bodily heat, spontaneous sweating, no aversion to cold and instead aversion to heat.
183. Question: Why may someone on the first day of illness have aversion to cold without fever?
Answer: Although it is only the first day, the aversion to cold is about to cease by itself, followed by spontaneous sweating and aversion to heat.
184. Question: Why does aversion to cold cease by itself?
Answer: Yangming occupies the center and governs Earth, to which all things return, leaving nowhere further for transmission. Although aversion to cold appears initially, it stops by itself on the second day. This is Yangming illness.
185. The illness was originally Taiyang. At its beginning, sweating was induced but did not come through completely, so the illness turned to Yangming. In cold damage with fever, no sweat, vomiting and inability to eat, the unexpected appearance of continuous moist sweating means it has turned to Yangming.
186. On the third day of cold damage, the Yangming pulse is large.
187. In cold damage, a floating, relaxed pulse and naturally warm hands and feet mean the illness is tied to Taiyin. In Taiyin, the body should turn yellow. If urination is naturally free, yellowing cannot develop. If stool becomes hard by the seventh or eighth day, this is Yangming illness.
188. When cold damage turns and becomes tied to Yangming, the person has slight, continuous moist sweating.
189. Yangming wind-strike has bitter mouth, dry throat, abdominal fullness, slight panting, fever, aversion to cold and a floating, tight pulse. Purging then produces abdominal fullness and difficult urination.
190. In Yangming illness, an ability to eat is called wind-strike; inability to eat is called cold-strike.
191. In Yangming cold-strike, inability to eat, difficult urination and moist sweating of the hands and feet indicate that a fixed jia disorder is about to form. Stool must be hard at first and loose afterward. This occurs because cold in the Stomach prevents separation of water and grain.
192. In Yangming illness, the person initially wishes to eat, but urination is unexpectedly difficult while stool regulates itself. There is aching of the bones and joints, a gently rising sensation as if feverish, then sudden mania. Continuous moist sweating brings resolution. Water cannot overcome grain qi and joins with the sweat. The passage states that a tight pulse brings recovery.
193. The time when Yangming illness tends to resolve runs from the shen period through the beginning of xu.
194. In Yangming illness with inability to eat, attacking the heat must cause hiccups, because the Stomach is deficient and cold. Since the person was originally deficient, attacking the heat must cause hiccups.
195. In Yangming illness with a slow pulse, it is difficult to eat to fullness. Fullness produces slight agitation and dizziness, and urination must become difficult. Grain jaundice is about to arise. Even after purging, abdominal fullness remains, because the pulse is slow.
196. Yangming illness normally has much sweating. If there is instead no sweat and a sensation like insects crawling within the skin, longstanding deficiency is responsible.
197. In Yangming illness with unexpectedly absent sweating and free urination, vomiting and cough after two or three days, together with reversal cold of the hands and feet, must cause distressing headache. Without cough, vomiting or reversal of the hands and feet, there is no headache.
198. In Yangming illness with dizziness alone and no aversion to cold, an ability to eat together with cough means the throat must be painful. Without cough, the throat is not painful.
199. Yangming illness with no sweat, difficult urination and distressing vexation in the Heart region must cause yellowing of the body.
200. If fire is applied in Yangming illness and slight sweating on the forehead accompanies difficult urination, yellowing must occur.
201. A floating, tight pulse in Yangming illness means tidal fever must arise in timed attacks. A pulse that is only floating means night sweating must occur.
202. In Yangming illness, a dry mouth with a wish only to rinse with water, without wishing to swallow it, means nosebleeding must occur.
203. In Yangming illness with spontaneous sweating, the physician may induce further heavy sweating. Although the illness improves, slight agitation and incomplete resolution remain because stool must be hard. Loss of fluids dries the Stomach and makes stool hard. Ask how many times the person urinates each day. If formerly three or four times but only twice today, stool will soon pass. Urination is now less frequent because fluids should return to the Stomach; this tells us that a bowel movement must soon occur.
204. In cold damage with much vomiting, attacking treatment is forbidden even if a Yangming presentation is present.
205. In Yangming illness with hardness and fullness below the Heart, attacking treatment is forbidden. If attacking produces unceasing diarrhea, the person dies; if diarrhea stops, recovery follows.
206. In Yangming illness with a uniformly red face, attacking treatment is forbidden. Fever must develop; a yellow complexion indicates difficult urination.
207. In Yangming illness, if vomiting and purging have not been applied but there is vexation, Tiaowei Chengqi Tang may be given.
208. In Yangming illness with a slow pulse, even though there is sweating without aversion to cold, the body must be heavy, with shortness of qi, abdominal fullness and panting. Tidal fever means the exterior is approaching resolution and the interior may be attacked. Moist sweating of the hands and feet means stool is already hard. Da Chengqi Tang governs.
If sweating is profuse with slight fever and aversion to cold, the exterior remains unresolved. If the heat is not tidal, Chengqi Tang must not yet be given. If the abdomen is greatly full and passage obstructed, Xiao Chengqi Tang may be given to harmonize Stomach qi slightly; do not produce drastic diarrhea.
Da Chengqi Tang formula:
Dahuang, four liang, washed with wine; Houpo, half a jin, roasted and outer covering removed; Zhishi, five fruits, roasted; Mangxiao, three he.
For these four ingredients, first boil Houpo and Zhishi in one dou of water until five sheng remain and remove the dregs. Add Dahuang and boil again until two sheng remain, then remove the dregs. Add Mangxiao, return to a low fire for one or two boils, divide, and take warm in two doses. Once downward passage occurs, do not take the remainder.
Xiao Chengqi Tang formula:
Dahuang, four liang, washed with wine; Houpo, two liang, roasted and outer covering removed; Zhishi, three large fruits, roasted.
Boil these three ingredients in four sheng of water until one sheng and two he remain. Remove the dregs, divide, and take warm in two doses. The first dose should produce a bowel movement. If not, drink the rest; if a bowel movement occurs, do not take it.
209. In Yangming illness with tidal fever and slightly hard stool, Da Chengqi Tang may be given. If stool is not hard, it must not be given. If there has been no bowel movement for six or seven days and dry stool is suspected, test by giving a small amount of Xiao Chengqi Tang. If qi turns and flatus passes after it enters the abdomen, dry stool is present and attacking treatment is permissible. If no flatus passes, only the initial portion of stool is hard and the later portion must be loose. Do not attack: doing so must cause distention and inability to eat. If the person wishes to drink, giving water causes hiccups. If fever appears afterward, stool must again be hard and scant; harmonize with Xiao Chengqi Tang. If flatus does not pass, take care never to attack.
210. Repletion produces delirious speech; deficiency produces zhengsheng, meaning repetitive speech. Fixed staring, delirious speech, panting and fullness mean death; diarrhea also means death.
211. Much sweating or repeated sweat induction causes loss of yang. With delirious speech, a short pulse means death; a naturally harmonious pulse means the person does not die.
212. After vomiting or purging in cold damage, the illness remains unresolved, with no bowel movement for five or six days or as long as more than ten days. Tidal fever appears toward late afternoon, without aversion to cold, and the person talks alone as if seeing spirits. In severe attacks, the person fails to recognize others, picks over clothing and feels over the bed, is alarmed and restless, pants slightly and stares fixedly. A wiry pulse means life; a rough pulse death. In a mild case with only fever and delirious speech, Da Chengqi Tang governs. If one dose produces diarrhea, stop the remaining dose.
213. In Yangming illness, profuse sweating carries fluids outward and dries the Stomach. Stool must become hard, and hardness produces delirious speech. Xiao Chengqi Tang governs. If one dose stops the delirious speech, do not take it again.
214. Yangming illness with delirious speech, tidal fever and a slippery, swift pulse is governed by Xiao Chengqi Tang. Give one sheng of Chengqi Tang; if qi turns in the abdomen, give another sheng. If qi does not turn, do not give more. If there is again no bowel movement the next day and the pulse is instead faint and rough, the interior is deficient and treatment difficult. Chengqi Tang must not be given again.
215. In Yangming illness with delirious speech and tidal fever, unexpected inability to eat means there must be five or six pieces of dry stool in the Stomach. If eating is possible, the stool is merely hard. Purging with Da Chengqi Tang is appropriate.
216. In Yangming illness, downward bleeding and delirious speech mean heat has entered the blood chamber. If only the head sweats, needle Qimen and drain according to the repletion present. Continuous moist sweating brings recovery.
217. Sweating and delirious speech are due to dry stool in the Stomach; this is called wind. If purging is required, wait until the channel course has passed. Purging too early must disorder speech, because the exterior is deficient and interior replete. Purging brings recovery; Da Chengqi Tang is appropriate.
218. On the fourth or fifth day of cold damage, a deep pulse with panting and fullness indicates the interior. If sweating is induced instead, fluids escape outward and defecation becomes difficult. Exterior deficiency and interior repletion develop, eventually producing delirious speech.
219. Combined illness of the three yang divisions has abdominal fullness, bodily heaviness and difficulty turning from side to side, numbness of the mouth, a grimy face, delirious speech and urinary incontinence. Inducing sweat produces delirious speech; purging produces sweat on the forehead and reversal cold of the hands and feet. If sweating occurs spontaneously, Baihu Tang governs.
220. In merged illness of the two yang divisions, if Taiyang signs have ceased and only tidal fever, moist sweating of the hands and feet, difficult defecation and delirious speech remain, purging brings recovery. Da Chengqi Tang is appropriate.
221. Yangming illness has a floating, tight pulse, dry throat, bitter mouth, abdominal fullness and panting, fever and sweating, no aversion to cold but instead aversion to heat, and bodily heaviness. Induced sweating causes restlessness, mental confusion and delirious speech. Added warm-needling must cause alarm, agitation, restlessness and inability to sleep. Purging empties and weakens the Stomach; guest qi disturbs the diaphragm, causing distressing vexation in the Heart region. If there is a tongue coating, Zhizi Chi Tang governs.
222. With thirst and a wish to drink, dry mouth and dry tongue, Baihu Jia Renshen Tang governs.
223. With a floating pulse, fever, thirst and a wish to drink, and difficult urination, Zhuling Tang governs.
Zhuling Tang formula:
Zhuling with outer covering removed, Fuling, Zexie, Ejiao, and Huashi crushed, one liang each.
For these five ingredients, first boil the four other ingredients in four sheng of water until two sheng remain. Remove the dregs, add Ejiao and melt it. Take seven he warm, three times daily.
224. In Yangming illness with profuse sweating and thirst, Zhuling Tang must not be given. Sweating has dried the Stomach, and Zhuling Tang would further promote urination.
225. A floating, slow pulse, exterior heat, interior cold and diarrhea with undigested grain are governed by Sini Tang.
226. If the Stomach is deficient and cold and eating is impossible, drinking water produces hiccups.
227. With a floating pulse, fever, dry mouth and dry nose, an ability to eat means nosebleeding will occur.
228. After purging Yangming illness, if heat remains externally, the hands and feet are warm, chest binding is absent, but there is distressing vexation in the Heart region, hunger without ability to eat, and sweating only on the head, Zhizi Chi Tang governs.
229. In Yangming illness with tidal fever, loose stool, naturally normal urination and persistent fullness of the chest and flanks, give Xiao Chaihu Tang.
230. In Yangming illness with hardness and fullness below the flanks, no bowel movement, vomiting and a white tongue coating, Xiao Chaihu Tang may be given. Once the upper burner communicates and fluids descend, Stomach qi harmonizes; continuous moist sweating over the body brings resolution.
231. Yangming wind-strike has a wiry, floating, large pulse, shortness of qi, fullness of the entire abdomen, pain below the flanks and in the Heart region, and failure of qi to pass despite prolonged pressure. There are a dry nose, inability to sweat, a desire to lie down, yellowing of the entire body and eyes, difficult urination, tidal fever, intermittent hiccups and swelling in front of and behind the ears. Needling brings slight improvement, but the exterior remains unresolved. If illness has passed ten days and the pulse continues floating, give Xiao Chaihu Tang.
232. If the pulse is only floating and there are no other signs, give Mahuang Tang. If there is no urination and abdominal fullness is joined by hiccups, the condition is untreatable.
233. In Yangming illness with spontaneous or induced sweating and free urination, fluids are exhausted internally. Even if stool is hard, attacking treatment is forbidden. Wait until the person has an urge to defecate, then use a honey preparation as a rectal guide to open passage. Tuguagen or the liquid from a large pig gallbladder may also be used as guides.
Honey Guide formula:
Edible honey, seven he.
Cook this single ingredient over a low fire in a copper vessel until it thickens like malt sugar. Stir so that it does not scorch or stick. When it can be shaped, quickly roll it between both hands into a rod with a pointed tip, about a finger in thickness and two cun long. Shape it while hot, since it hardens when cold. Insert it into the anal passage and hold it firmly in place by hand; remove it when the urge to defecate comes.
Tuguagen formula: the supplementary formula is lost. No ingredients or preparation instructions are supplied here.
Pig Gall Liquid Method:
Take one large pig gallbladder, pour out its liquid and mix with a small amount of prepared vinegar. Introduce it into the anal passage. In about the time needed to eat a meal, stool should carry out retained food and foul matter. The source calls this very effective.
234. In Yangming illness with a slow pulse, much sweating and slight aversion to cold, the exterior is unresolved. Sweating may be induced; Guizhi Tang is appropriate.
235. In Yangming illness with a floating pulse, no sweating and panting, induced sweating brings recovery. Mahuang Tang is appropriate.
236. Fever and sweating in Yangming illness mean heat is escaping, so yellowing cannot occur. If sweat appears only on the head, stopping at the neck, while the body is dry, urination difficult and thirst draws the person to water and gruel, congealed heat is within and the body must turn yellow. Yinchenhao Tang governs.
Yinchenhao Tang formula:
Yinchenhao, six liang; Zhizi, fourteen fruits, split; Dahuang, two liang, outer covering removed.
For these three ingredients, first boil Yinchen in one dou and two sheng of water until the volume has decreased by six sheng. Add the other two ingredients and boil until three sheng remain. Remove the dregs and divide into three doses. Urination should become free, with urine resembling Zaojia liquid and distinctly red in color. After one night the abdomen diminishes, and yellowing leaves through the urine.
237. In a Yangming presentation, marked forgetfulness means retained blood must be present. Longstanding static blood was originally present and causes the forgetfulness. Although the stool is hard, it passes unexpectedly easily and must be black. Purging with Didang Tang is appropriate.
238. After purging Yangming illness, with distressing vexation and agitation in the Heart region, attacking treatment is permissible if dry stool is in the Stomach. With slight abdominal fullness, an initial hard portion of stool must be followed by loose stool; do not attack. If dry stool is present, Da Chengqi Tang is appropriate.
239. No bowel movement for five or six days, pain around the navel, agitation and restlessness with periodic attacks indicate dry stool, which is preventing defecation.
240. Agitated heat that resolves with sweating, or a nüe-like condition with fever toward late afternoon, belongs to Yangming. A replete pulse calls for purging; a floating, deficient pulse calls for sweating. For purging, give Da Chengqi Tang; for sweating, Guizhi Tang is appropriate.
241. After drastic purging, no bowel movement for six or seven days, unresolved agitation and painful abdominal fullness indicate dry stool. Retained food was originally present. Da Chengqi Tang is appropriate.
242. Difficult urination, defecation that is now difficult and now easy, occasional slight fever, panting and clouded oppression preventing lying down indicate dry stool. Da Chengqi Tang is appropriate.
243. An inclination to vomit after eating grain belongs to Yangming. Wu Zhuyu Tang governs. If the decoction instead aggravates the condition, it belongs to the upper burner.
Wu Zhuyu Tang formula:
Wu Zhuyu, one sheng, washed; Renshen, three liang; Shengjiang, six liang, sliced; Dazao, twelve fruits, split.
Boil these four ingredients in seven sheng of water until two sheng remain. Remove the dregs and take seven he warm, three times daily.
244. In Taiyang illness with a relaxed cun pulse, floating guan pulse and weak chi pulse, fever and sweating, renewed aversion to cold, no vomiting and only focal obstruction below the Heart are due to the physician's purging. If purging has not been applied, but the patient is not averse to cold and is thirsty, the illness has turned to Yangming. Frequent urination means stool must be hard; even without a bowel movement for ten days, there need be no distress. For thirst and a wish to drink, give water in small amounts and use the appropriate rescuing method. For thirst, Wuling San is appropriate.
245. A faint yang pulse with scant sweating indicates spontaneous harmony. Profuse sweating is excess, and the yang pulse is replete. Inducing sweat until it flows profusely is likewise excessive. Excess means yang is cut off within and fluids are lost, making stool hard.
246. A floating, hollow pulse: floating signifies yang and hollowness yin. Floating and hollowness strike together, Stomach qi generates heat, and its yang expires.
247. A floating, rough Fuyang pulse: floating means strong Stomach qi, roughness frequent urination. Floating and roughness strike together, making stool hard and constraining the Spleen. Mazi Ren Wan governs.
Mazi Ren Wan formula:
Mazi Ren, two sheng; Shaoyao, half a jin; Zhishi, half a jin, roasted; Dahuang, one jin, outer covering removed; Houpo, one chi, roasted and outer covering removed; Xingren, one sheng, skins and tips removed, heated and separately made into a paste.
Combine these six ingredients with honey to make pills the size of wutong seeds. Take ten pills with a drink, three times daily. Increase gradually until a response is perceived. The Houpo quantity is a length of one chi, as supplied.
248. On the third day of Taiyang illness, failure of sweating to resolve the illness, with steaming fever, means it belongs to the Stomach. Tiaowei Chengqi Tang governs.
249. For abdominal distention and fullness after vomiting in cold damage, give Tiaowei Chengqi Tang.
250. In Taiyang illness after vomiting, purging or sweating, slight agitation, frequent urination and consequently hard stool are harmonized with Xiao Chengqi Tang, bringing recovery.
251. On the second or third day of illness, with a weak pulse, no Taiyang or Chaihu presentation, agitation, restlessness and hardness below the Heart, give Xiao Chengqi Tang little by little on the fourth or fifth day, even if eating is possible. Harmonize slightly to bring a little ease. On the sixth day, give one sheng of Chengqi Tang.
If there has been no bowel movement for six or seven days and urination is scant, even inability to take food does not establish hard stool throughout: the initial portion is hard, but the later portion must be loose. Purging must produce loose stool. Wait until urination becomes free and the stool is definitely hard before attacking. Da Chengqi Tang is appropriate then.
252. On the sixth or seventh day of cold damage, indistinct vision and disharmony of the eyes, no exterior or interior presentation, difficult defecation and slight bodily heat indicate repletion. Purge urgently; Da Chengqi Tang is appropriate.
253. In Yangming illness with fever and profuse sweating, purge urgently. Da Chengqi Tang is appropriate.
254. If sweating does not resolve the illness and there is painful abdominal fullness, purge urgently. Da Chengqi Tang is appropriate.
255. If abdominal fullness does not diminish, or diminishes too little to count, purging is required. Da Chengqi Tang is appropriate.
256. Combined Yangming and Shaoyang illness must have diarrhea. A pulse that is not overcome is favorable. Overcome means loss: mutual overcoming and injuring are called being overcome. A slippery, rapid pulse indicates retained food. Purging is required; Da Chengqi Tang is appropriate.
257. If a patient has no exterior or interior presentation but has had fever for seven or eight days, purging is permissible even with a floating, rapid pulse. If purging has already occurred but rapidity remains, its combination with heat should digest grain and produce easy hunger. If there is still no bowel movement by the sixth or seventh day, static blood is present. Didang Tang is appropriate.
258. If pulse rapidity persists and diarrhea does not stop, heat must accompany the passage of pus and blood.
259. Yellowing of the body and eyes after sweating in cold damage occurs because internal cold-dampness remains unresolved. Purging is considered unsuitable; seek the cause within cold-dampness.
260. On the seventh or eighth day of cold damage, with an orange-colored yellow body, difficult urination and slight abdominal fullness, Yinchenhao Tang governs.
261. In cold damage with a yellow body and fever, Zhizi Baipi Tang governs.
Zhizi Bopi Tang formula:
Plump Zhizi, fifteen fruits, split; Gancao, one liang, roasted; Huangbo, two liang.
Boil these three ingredients in four sheng of water until one and a half sheng remain. Remove the dregs, divide, and take warm in two doses. The supplied formula heading uses Bopi, while the preceding clause uses Baipi.
262. In cold damage with congealed heat within, the body must turn yellow. Mahuang Lianyao Chixiaodou Tang governs.
Mahuang Lianyao Chixiaodou Tang formula:
Mahuang, two liang, nodes removed; Lianyao, two liang—the note identifies this as Lianqiao root; Xingren, forty kernels, skins and tips removed; Chixiaodou, one sheng; Dazao, twelve fruits, split; fresh Zi white bark, one sheng, cut; Shengjiang, two liang, sliced; Gancao, two liang, roasted.
For these eight ingredients, first boil Mahuang in one dou of rain runoff water, bring to a boil twice and skim off the foam. Add the other ingredients and boil until three sheng remain. Remove the dregs, divide, and take warm in three doses, finishing them within half a day.
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