Library

[Background Information]
Book: Yi Shu (Records of Medicine)
Author: Cheng Xingxuan
Dynasty: Yuan
Chapter: Shanghan (Cold Damage) (2/11)
Category: Medical Discourse

If yellow eyes, scanty and difficult urination, thirst, and aversion to heat are observed, it belongs to damp-heat syndrome; treatment should involve separating and draining (promoting diuresis to remove dampness). If urination is free, stool is black, and the lower abdomen is hard, full, painful, and tender, it belongs to blood stasis syndrome. In spasm disease (a disease characterized by stiffness of the neck and back, trismus, and opisthotonos), if the eyes are red, epistaxis occurs, the patient closes their eyes and refuses to open them, and the complexion is slightly yellow, the disease is about to heal. Eyes open and able to see people belong to Yang syndromes; eyes closed and unwilling to see people belong to Yin syndromes. If the gaze is clear and the patient can recognize people, it is treatable. If the vision is dim and the patient cannot recognize people, or if the eyes roll upward, the eyelids are small with staring eyes, fixed gaze, oblique gaze, round and fixed eyeballs, Daiyan (upward deviation of the eyes without ability to move) accompanied by body opisthotonos, or sunken eye sockets, all are signs of death. "Muddled vision" refers to unclear eyesight, described as seeing half clearly and half unclearly; this is caused by pathogenic heat solidifying internally and steaming upwards to the eyes. Once the bowel movement becomes unobstructed, the eyes will naturally become clear. (*Quansheng Ji*)

**Differentiating the Tongue**
Generally, a moist tongue coating is auspicious, while a dry and rough coating is inauspicious. A white and slippery tongue coating indicates that the pathogen has not yet entered the Fu organs; treatment should employ sweating methods. A yellow coating with dryness and thirst indicates that the pathogen has entered the Fu organs; treatment should employ purgative methods. A black coating with prickles, extreme dryness, and thirst is difficult to treat but may still require purgation. If there is no dryness or thirst, and the body is not hot, with a black tongue and slippery coating, it belongs to Yin-cold syndrome; treatment should employ warming methods. If the tongue is curled, scorched-black, and dry, it belongs to Yang-toxin syndrome; treatment should also employ purgation. A blue-green tongue with a slippery coating, no heat, and no thirst belongs to Yin-toxin syndrome; treatment should employ warming methods. Generally, a red tongue is auspicious, while a blue-green or black tongue is inauspicious. Black mixed with purple indicates Yin-cold; red mixed with purple indicates Yang-heat. The tongue is the sprout of the Heart; red corresponds to the Fire of the South and represents the true color, hence it is auspicious; black corresponds to the Ren-Gui Water of the North, where Kidney Water overcomes Heart Fire, hence it is inauspicious. A stiff, curled, short, or rigid tongue are all difficult to treat. A short tongue with slurred speech, coma, and pulse exhaustion indicates death. In Yin-Yang exchange disease (recurrence of illness after recovery due to sexual activity), a tongue extending several inches indicates death. In febrile diseases, a black coating with dryness and thirst indicates internal blazing of pathogenic fire, leading to easy formation of prickles on the tongue; this does not fall under fatal cases. (*Quansheng Ji*)

**Palpating Chest and Abdomen**
The chest belongs to the Half-Exterior and Half-Interior. First observe the patient's eyes and tongue, then ask if there is pain or fullness in the chest. If there is no pain or fullness, the pathogen remains in the Exterior; if there is pain/fullness and no prior purgation, it is a Half-Exterior/Half-Interior syndrome; if purgation has already been used, it is a Chest Binding syndrome. Since the pathogen is in the Exterior, how could there be chest pain and distension? Thus, asking about the chest reveals whether the pathogen has transmitted. ○ The abdomen belongs to Yin and the Interior. After asking about the chest, palpate the abdomen. If there is no pain or distension, the pathogen has not entered the Interior; if it enters the Interior, the abdomen will surely be painful and distended. If abdominal fullness does not decrease and pain is severe and unremitting, this is an Interior Excess syndrome, and attack (purgation) is permissible. If abdominal fullness decreases at times and pain is lingering, the Interior is not yet excess, and urgent attack is forbidden. Thus, palpating the abdomen reveals whether the pathogen is excess or not. (Chen Yanghui)

**Observing the Body Form**
In examining patients, if the body is light and capable of turning freely, it is easy to treat; if the body is heavy and immobile, it is difficult to treat. If the body is hot with thirst, clothes/quilts are thrown off, hands and feet are flailing, and the pulse is surging, rapid, and forceful, this is a Yang syndrome; treatment should employ purgation. If the body is not hot, the patient desires covering with quilts, curls up lying down without thirst, and the pulse is deep, fine, and weak, this is a Yin syndrome; treatment should employ warming. If the jaw is locked making speech difficult, and limbs are pulling/twitching, it is called Wind syndrome; if hands cross over the heart, this is due to excessive sweating and is called Deficiency syndrome. If hands grasp at clothing and bedrails, it is called "grasping at empty air," indicating Liver Heat attacking Lung Metal, Yuan Qi unable to control itself, and Spirit departing with Hun chaotic. If the body feels like being beaten with a staff, pain is heavy as mountains, and turning is impossible, this is Yin-Toxin; if the body is heavy and painful, limbs are hard to move, and urination is scanty/difficult, this is named Damp-Wind; if sweat is like oil, panting is ceaseless, form is numb/unresponsive, alternating between quiet and chaotic, and pulse is floating and surging, this is Life Exhaustion. (*Quansheng Ji*)

**Examining Urine and Stool**
To know the cold/heat and deficiency/excess of the Zang-Fu organs, one must inquire about excretions from within; thus, all diseases require examination of urine and stool. Difficult urination and red urine verify Internal Heat; free urination and clear/white urine verify absence of Internal Heat. Constipation and hard stool verify Internal Heat; spontaneous diarrhea with undigested food verifies Internal Cold. Treatment determines cold/heat, dryness/dampness, deficiency/excess via urine/stool, avoiding errors. For example, dry stool indicates Heat, but diarrhea of clear water can also indicate Heat, which people often overlook. Yellow/red urine indicates Heat, but white turbid urine can also indicate Heat, which people often overlook. Again, dry stool indicates Heat, but blood depletion and fluid exhaustion contraindicate bitter-cold herbs. Yellow/red urine indicates Heat, but food stagnation in the Middle Jiao causing yellow turbid urine requires warm-acrid herbs for clearing/drainage rather than cold-cool ones. (*Shanghan Dabai*)

The Large Intestine and Small Intestine both belong to the Stomach. To know the deficiency/excess of the Stomach, one must verify via urine/stool. Free urination means stool is definitely hard; difficult urination means stool is hard initially then loose. People today know that hard stool, difficult stool, and no stool are Yangming diseases, but do they know that difficult urination, urinary difficulty, frequent urination, or anuria are also Yangming diseases? (Ke Yunbo)

**Yang Meridians: Differentiating Jing and Fu**
Diseases of the Three Yang meridians located in the Jing (Meridian) can be resolved by sweating. "Jing" implies pathogen lodging in the skin. However, meridians run inside the skin and within muscles; pathogens residing in the Jing include Taiyang Jing, Yangming Jing, and Shaoyang Jing, so they can be released, resolved, or harmonized. Zhang Zhongjing said: Diseases of the Three Yang in the Jing cannot be purged; purging leads to Pi-fullness (stagnant fullness) or Jie-Xiong (Chest Binding). ○ Diseases of the Three Yang entering the Fu (Organ) can be resolved by purging. "Fu" implies pathogen residing in the intestines/stomach. Fu organs store water/grain and transmit waste; pathogens entering the Fu come from Taiyang, Yangming, or Shaoyang, so they can be purged, cleared, or attacked. Zhang Zhongjing said: Diseases of the Three Yang in the Fu cannot be sweated; sweating leads to delirium or Jue-Jie (extremity cold exhaustion). Clear distinction between Jing and Fu prevents confusion between sweating and purging methods. (*Shanghan Wufa*)

**Yin Meridians: Transmission vs. Direct Invasion**
Pathogen entering Yin meridians from Yang meridians is called "Transmission" (Chuan-Jing); it can be attacked/purged. "Transmission" means pathogen moves from exterior to interior, constituting Excess-Heat; warming herbs are contraindicated as they disturb Yin blood, making Excess more Excess. ○ Pathogen entering Yin meridians directly without passing through Yang meridians is called "Direct Invasion" (Zhi-Zhong); it can be warmed. "Direct Invasion" means pathogen does not come from Yang meridians, constituting Deficiency-Cold; cold herbs are contraindicated as they kill, making Deficiency more Deficient. Understanding Transmission and Direct Invasion allows proper use of Lizhong Tang and Chengqi Tang. (*Shanghan Wufa*)

**Taiyang Jing and Fu Diseases**
Taiyang refers to the Bladder. Taiyang is in the Exterior; if pathogen has not entered the Fu, urination is normal, mouth is not thirsty, only headache, fever, aversion to cold, and stiff neck/back with no sweat occur. This is pathogen in Taiyang Jing; treatment should release the Exterior. If pathogen transmits to the Fu, with exterior symptoms plus red urine and thirst, it is named Fu disease; thus, Wuling San is used, with Guizhi (Cinnamon Twig) resolving Jing pathogen, and Zhuling (Polyporus) & Fuling (Poria) removing heat from the Fu organ. (*Shanghan Wufa*)

**Yangming Jing and Fu Diseases**
Yangming Jing disease is Exterior disease with Interior harmony; Fu disease is Interior disease with Exterior harmony; simultaneous Jing/Fu disease is simultaneous Exterior/Interior disease. Jing disease presents with eye pain, dry nose, without constipation, delirium, or aversion to heat; in Jing, purging is forbidden. Fu disease presents with aversion to heat, spontaneous sweating, constipation, without headache, aversion to wind/cold; in Fu, sweating is forbidden. Sweating releases Yangming Jing pathogen, not Fu pathogen; purging attacks Yangming Fu pathogen, not Jing pathogen. Thus, treatments differ; do not mistake Jing for Fu or vice versa. (*Shanghan Wufa*)

**Three Yin Febrile Diseases**
Three Yang meridians have only Yang syndromes, no Yin syndromes. Three Yin meridians have Yin and Deficiency syndromes, which people know; however, Three Yin meridians can have Yang syndromes, which people do not know. Once heat pathogen transmits to Yin meridians, deeper heat causes deeper Jue (cold extremities); the body may feel not hot, pulse deep/fine. One must know that Yang Jue, though cold extremities, allows movement, unlike Yin Jue where extremities are cold and immobile. Yang syndromes, though body not hot, have dry mouth, unlike Yin syndromes with neutral mouth. Yang syndromes, though pulse deep/fine, are fine/rapid upon deep pressure, unlike Yin syndromes which are deep/fine/slow. Major difference: Three Yin Cold diseases have clear spirit/mind; Three Yin Heat diseases have confused spirit/mind. Three Yin Cold: dry mouth but inability to drink; Three Yin Heat: dry mouth with desire to drink. Three Yin Cold: clear urine/stool; Three Yin Heat: red/scanty urine/stool. Yin and Yang are worlds apart. (*Shanghan Dabai*)

**Exterior/Interior, Deficiency/Excess**
Spontaneous sweating is Exterior Deficiency; no sweat is Exterior Excess. Diarrhea is Interior Deficiency; constipation is Interior Excess. This is fixed theory. But Deficiency containing Excess, or Excess containing Deficiency, cannot be judged by common rules. Why? Wind injury with spontaneous sweating is Exterior Deficiency; if heat pathogen enters Fu, steaming pores causing sweating, it is Excess. This is Excess within Exterior Deficiency. Cold damage with no sweat is Exterior Excess; if person is inherently deficient and cannot sweat, it is Deficiency. This is Deficiency within Exterior Excess. Diarrhea is Interior Deficiency; if transmission to Fu causes diarrhea with intestinal mucus, it is Excess. This is Excess within Interior Deficiency. Constipation is Interior Excess; if fluid exhaustion or old/weak chronic illness causes constipation, it is Deficiency. This is Deficiency within Interior Excess. Accurate syndrome differentiation ensures safety and avoids Deficiency/Excess inversion. Analyzing further: Mahuang (Ephedra) is purgative but only purges Exterior Excess, not Interior Excess; Guizhi (Cinnamon Twig) is tonifying but only tonifies Exterior Deficiency, not Interior Deficiency; Chengqi Tang is purgative but only purges Interior Excess, not Exterior Excess; Jiang (Ginger) & Fu Zi (Aconite) are tonifying but only tonify Interior Deficiency, not Exterior Deficiency; Tiaowei Chengqi Tang is purgative but only purges Middle Jiao Excess, not Upper/Lower Jiao Excess; Jianzhong Tang is tonifying but only tonifies Middle Jiao Deficiency, not Upper/Lower Jiao Deficiency. These are differences in herb usage for Deficiency/Excess. (*Shanghan Wufa*)

**Differentiating Treatment by Exterior/Interior**
Shanghan must distinguish Exterior/Interior; failing to do so leads to erroneous sweating/purging, unfit for superior physicians. For instance, both are fevers: body heat without thirst is Exterior Heat, treated with Xiaochaihu Tang plus Guizhi (Cinnamon Twig); Jue with slippery pulse is Interior Heat, treated with Baihu Tang plus Renshen (Ginseng). Both are Water-Qi: dry retching, mild diarrhea, fever with cough is Exterior Water, treated with Xiao Qinglong Tang; cool body, exterior symptoms resolved, cough with hypochondriac pain is Interior Water, treated with Shizao Tang. Both are aversion to cold: fever with aversion to cold originates in Yang, treated with Mahuang Tang, Guizhi Tang, or Xiaochaihu Tang; no fever with aversion to cold originates in Yin, treated with Fuzi Tang or Sini Tang. Both are body pain: floating pulse, fever, headache/body pain indicates unresolved Exterior, treated with Mahuang Tang; deep pulse, spontaneous diarrhea, body pain indicates unresolved Interior, treated with Sini Tang. (Wang Haogu)

**Interior within Interior**
Pathogen in Shanghan: Three Yang are Exterior, Three Yin are Interior; everyone knows this, but "Interior within Interior" is unknown. What is it? It is the Yangming Stomach Fu. Once pathogen from Three Yang/Yin enters Stomach Fu, it stops transmitting, hence "Interior within Interior." Some argue Yin Zang organs are deeper than Yang Fu organs? Answer: Yangming resides in Central Earth, gathering all things, stopping transmission, like grain attracting water. Comparing Yang/Yin meridians, Yin is deeper; comparing Yin meridians/Stomach Fu, Stomach Fu is deepest. All Three Yang/Yin meridians surround the Stomach Fu, entering from anywhere. From Taiyang, Yangming, Shaoyang, Taiyin, Shaoyin, Jueyin—all enter Stomach Fu and stop transmitting. Treating Shanghan requires understanding Transmission/Direct Invasion, distinguishing Exterior/Interior within Transmission, and "Interior within Interior" within Exterior/Interior. This ensures precise treatment. (*Yixue Xinwu*)

**Yang Syndrome Resembling Yin**
Yang syndrome is Heat syndrome. If Yang syndrome shows Heat signs, it is easy to know; if Yang disease shows Cold signs, it confuses people. For example, Taiyin disease diarrhea occurring >10 times/day will self-resolve because Spleen Qi recovers and foul matter is expelled. Or Shaoyin disease Jue (cold extremities) with cough/palpitations, treated with Sini San; Shaoyin disease spontaneous diarrhea of pure green water, treated with Dachengqi Tang; Jueyin disease cold extremities treated with emesis; Jueyin fever first then Jue, treated with Sini San. All these are Yang syndrome resembling Yin. (*Shanghan Dabai*)

**Yin Syndrome Resembling Yang**
Yin syndrome refers to cold pathogen directly invading Three Yin meridians without transmission from Yang. Yin syndrome showing Yin signs is known; Yin syndrome showing Yang signs confuses people. For example, Shaoyin disease diarrhea of undigested food, Interior Cold/Exterior Heat, cold extremities, pulse faint/almost absent, body not averse to cold, face red, or sore throat; or Jueyin cold damage, days 6-7 no diarrhea, suddenly fever with diarrhea, or profuse sweating with persistent heat, body stiffness, limb pain; or extreme Yin causing restlessness, wanting to sit in mud/water. All are Extreme Yin resembling Yang. However, substance differs greatly. Analysis: Diarrhea of undigested food, cold extremities, faint pulse confirms Yin syndrome. Here, no aversion to cold and red face indicate True Yang escaping outward; sore throat indicates Floating Deficient Yang. Further analysis: In Yang syndrome, profuse sweating removes heat, body relaxes, limbs don't hurt. Here, profuse sweating persists with heat, body stiffens, limbs hurt. Thus, this sweat is not Exterior pathogen sweat but Yang-loss sweat; this heat is not Yang pathogen heat but Deficient Yang escaping heat; stiffness/pain are not Exterior signs but Yang-loss signs. (*Shanghan Dabai*)

**Relying on Pulse, Not Symptoms**
As per Classics: Chest Binding syndrome should be purged; if pulse is floating, purging is forbidden. This is not the case of fever for 7-8 days with floating/rapid pulse, which *can* be purged. Or delirium, tidal fever, slippery/rapid pulse, treated with Xiao Chengqi Tang; if given 1 sheng, next day no stool, pulse becomes micro/rough, Chengqi Tang is forbidden. This is not the case of passing gas after decoction, which *can* be attacked. Or fever/aversion to cold, weak pulse, slow Chi position, sweating is forbidden. This is not an Exterior syndrome suitable for sweating. This is treating by pulse, ignoring symptoms. (*Shanghan Leizheng*)

Body cold/Jue with slippery/rapid pulse, beating against fingers upon pressure, is not True Cold, but Yang Excess repelling Yin. Body hot with rapid pulse, not beating against fingers upon pressure, is not True Heat, but Yin Excess repelling Yang. This is taking pulse, not symptoms. (Tao Jie'an)

**Relying on Symptoms, Not Pulse**
Shanghan requires syndrome-based treatment. Matching pulse/symptom is easy; mismatching requires judging urgency. There are cases relying only on symptoms, not pulse. As per Classics: Floating/large pulse, hard epigastrium, Heat belonging to Zang, should be attacked, not sweated. This is not "floating means Exterior." Or Cuo (hurried) pulse indicates Yang Excess; if diarrhea, wheezing, sweating, use Gegen Huangqin Huanglian Tang; if Jue, Cuo pulse, indicates collapse, requiring moxa/warming. This is not "Yang Excess with Cuo pulse." Or Yangming disease, slow pulse, no aversion to cold, continuous hand/foot sweating, use Dachengqi Tang. This is not "all slow pulses mean Cold." Or Shaoyin disease, initial fever, deep pulse, use Mahuang Fuzi Xixin Tang. This is not "deep pulse means Interior." This is treating by symptoms, not pulse. (*Shanghan Leizheng*)

Deep pulse suggests purging, floating pulse suggests sweating, generally correct. But floating pulse can allow purging if heat pathogen enters Fu causing difficult stool. If stool not difficult, purging is forbidden. Deep pulse can allow sweating if Shaoyin disease has body heat. If no heat, sweating is forbidden. This is taking symptoms, not pulse. (Tao Jie'an)

**Different Pulse/Syndrome Combinations**
Shaoyin pulse deep, initial fever, resembles Taiyang. Difference: heat is not "Xi Xi Ran" (warmth), no headache. ○ Shaoyin abdominal pain/diarrhea resembles Taiyin. Difference: Taiyin no thirst, Shaoyin thirst; limbs vary between warm/Jue. ○ Warm disease and Spasm disease resemble Taiyang. Difference: Spasm pulse deep/fine, Warm disease no aversion to cold but thirst. ○ Wind injury and Stroke resemble each other. Difference: Wind injury no thirst, Stroke thirst. ○ Cold damage and Winter-Warmth resemble each other. Difference: Cold damage floating-tight pulse, Winter-Warmth non-floating pulse. ○ Epidemic contagion resembles Cold damage. Difference: Epidemic non-floating pulse, Cold damage floating pulse. ○ Dampness and Spasm both have deep/fine pulses, but symptoms differ: Spasm no body pain, Dampness body pain. ○ Summer-heat pulse is empty/fine, or weak, or string-thin/thin/hollow/slow, similar to Spasm/Damp pulses, but symptoms differ: Summer-heat spontaneous sweating/thirst, Dampness no thirst/body pain, Spasm no body pain. ○ Taiyang Wind Injury with Cold pulse uses Da Qinglong Tang, resembling Taiyang Cold Damage. Difference: Wind Injury with Cold pulse has irritability; Taiyang Cold Damage has no irritability. ○ Taiyang Cold Damage with Wind pulse uses Da Qinglong Tang, resembling Cold-Damp invasion. Difference: Cold Damage with Wind pulse is floating-slow, Cold-Damp is deep/fine. (Huang Zhongli)

**Debate on No Tonification in Shanghan**
In Shanghan, only Yuan Qi deficiency is most critical. Without tonification, how to recover? Why do modern doctors say Shanghan has no tonification method? Ancient texts lack this saying; only Tao Jie'an stated: After sweating/vomiting/purging in Shanghan, do not immediately use Renshen (Ginseng) & Huangqi (Astragalus), lest pathogen gain support and heat worsen. This derives from Sun Simiao: After gaining relief from Chengqi Tang, strictly avoid tonics. His intent was that recovery via attack implies Excess pathogen, so tonics should not aid pathogen. It was never said that Deficiency syndromes should not be tonified. Today, 70-80% of Shanghan cases are fatigue/internal injury or emotional deficiency. Yet 80-90% recite "Shanghan has no tonification," which is unsustainable.