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Exterior Excess Syndrome of Cold Damage to the Taiyang Channel

Patient Wang, male, 42 years old, a cadre at a certain factory.
The patient developed fever last night with a body temperature of 38.9°C. Upon consultation this morning, he still had fever, accompanied by headache, stiffness and discomfort in the neck and nape, soreness and pain in the limbs, runny clear nasal discharge, nausea with desire to vomit, decreased appetite without thirst, floating-tight pulse, and thin white tongue coating. This is caused by wind-cold pathogenic factors damaging the exterior surface of the Taiyang channel. As stated in the *Huangdi Neijing* (Yellow Emperor's Inner Canon): "When the pathogen is in the skin, use sweating methods to expel it." Following Zhang Zhongjing's method, acrid-warm dispersing agents should be used to resolve the exterior pathogen. The modified Mahuang Tang (Ephedra Decoction) was prescribed as the main formula.
Mahuang (Ephedrae Herba) 6g, Guizhi (Cinnamomi Ramulus) 10g, Xingren (Armeniacae Semen Amarum) 10g, Fa Banxia (Pinelliae Rhizoma Preparatum) 6g, Fangfeng (Saposhnikoviae Radix) 6g, Gancao (Glycyrrhizae Radix et Rhizoma) 6g, Shengjiang (Zingiberis Rhizoma Recens) 3 slices.
Instructed to take warm and lie down to induce slight sweating for self-healing. Unexpectedly, the patient's family members feared the warming nature of Mahuang, worrying that dryness-heat would damage body fluids, and arbitrarily removed Mahuang from the prescription. After taking one bowl, no sweating occurred.
Observing restlessness, the heat intensified, with body temperature rising to 39.7°C. After taking the second bowl, severe splitting headache and body pain as if beaten by sticks occurred, with worsening aversion to cold compared to yesterday. Suspecting the prescription was incorrect, they invited me to examine urgently. The pulse was floating, urgent, and rapid; the tongue coating was white and greasy; he cried out in pain. Although treatment was delayed, fortunately, the exterior cold syndrome pattern remained unchanged. I explained the rationale and instructed to continue with the original prescription, absolutely not removing Mahuang again. After taking the medicine twice according to the prescription, covered with blankets and lying down, sweating occurred shortly thereafter, followed by subsidence of fever. The exterior pathogen was resolved, leading to a calm pulse, cool body, and recovery.
Commentary: There are people in the world who fear Mahuang and Guizhi like snakes and scorpions, believing their warming nature easily damages fluids and causes dryness. They do not realize that for exterior excess cold syndromes, without the acrid dispersal of Mahuang, how can the couli (pores) be opened to drive pathogens out? Without the warming unblocking action of Guizhi, how can Yang energy be assisted to warm the channels and dispel cold? Fearing the warming nature of herbs rather than the harm of pathogens is indeed a fault of indulging evil. Medication depends not on the physician's preferences but on accurate differentiation. With the correct syndrome, use the correct herb; when used appropriately, the disease is cured. Inappropriate use leads to unpredictable changes. For those with excess Yang-heat, acrid-warm herbs are unsuitable; for deficiency of Ying-Blood or interior deficiency with internal injury, sweating is also unsuitable. If it is indeed a syndrome of cold binding the exterior, failing to use appropriate treatment and instead using cooling bitter-cold herbs to suppress heat will likely aid the pathogen and damage healthy Qi, leaving the exterior cold unresolved and heat more rampant. At this time, formulas like Mahuang Tang or Guizhi Tang should be used to guide the pathogen out顺势利导. Do not miss the opportunity for the exterior pathogen to transmit inward, causing disaster. This is the method of eliminating pathogens to support healthy Qi.
Mahuang opens the xuanku (spiritual gates/pores) and unblocks the couli. Guizhi is acrid and warm, unblocking Yang and aiding dispersion. Xingren benefits Lung Qi, directs rebellious Qi downward, and calms wheezing. Gancao protects Middle Qi and generates fluids. The combination of herbs specifically induces sweating from the Taiyang exterior cold syndrome, with efficacy as immediate as striking a drum. However, after taking one or two bowls, covering and lying down to induce sweating is sufficient; there is no need to finish the entire dose, nor should profuse sweating occur, which would damage fluids and deplete Qi. As the saying goes, "Formulas are fixed, but methods are flexible." To achieve efficacy, one must study the principles deeply, which is no easy task.

Pediatric Acute Convulsive Disease (I)

Eldest son of Mr. Ke, aged one and a half years, residing at the former Railway Branch Bureau in Kunming City, Yunnan Province.
On the morning of the sixth day of the ninth lunar month in 1922, after waking from sleep and being carried outside, the child was exposed to wind and frightened. Symptoms included fever, spontaneous sweating, lethargy, opisthotonos (arching of the back), convulsions of hands and feet, upward deviation of eyes, red and superficial finger vein, red lips, pale tongue body, and floating-slow pulse. This was due to wind-cold obstructing the circulation of Qi in the Taiyang channel, combined with the child's insufficient Ying-Blood and Wei-Qi, tender Zang-Fu organs, and intolerance to wind-cold, resulting in sudden convulsions constituting acute pediatric convulsive disease. This is a Taiyang muscle-surface syndrome. Zhang Zhongjing's Guizhi Tang (Cinnamon Twig Decoction) was used as the main formula to resolve the pathogen invading the Taiyang muscle-couli through slight sweating.
Guizhi (Cinnamomi Ramulus) 10g, Hang Shaoyao (Paeoniae Radix Alba) 10g, Gancao (Glycyrrhizae Radix et Rhizoma) 6g, Shengjiang (Zingiberis Rhizoma Recens) 10g, Xiaozao (Jujubae Fructus) 7 pieces.
Added a pinch of Jingmi (Oryzae Fructus Glutinosus) for decoction. Instructed to cover and lie down after ingestion to induce slight sweating.
After one dose, the child fell into deep sleep, sweated, fever subsided, and recovered completely the next day.
Commentary: This syndrome requires urgent treatment. If delayed, complications may arise unpredictably. The full Guizhi Tang formula in this case has sufficient potency, hence its immediate efficacy.

Pediatric Acute Convulsive Disease (II)
(Mishandled Wind-Cold Rescue)

Zhu Xiaodi, born only two months ago, with weak constitution. One day, illness began due to wind-cold exposure. Symptoms included fever, cough, refusal to nurse, and loud crying. The doctor used clearing-heat and resolving-exterior agents, but fever persisted, leading to fright. Subsequent treatments with wind-chasing, heat-clearing, and calming-fright methods resulted in lethargy, refusal to nurse, body hot as burning charcoal, spontaneous sweating, cold limbs, incessant coughing and panting, rattling phlegm sounds, intermittent opisthotonos and convulsions, and critical breathing. Later, I examined him. The finger vein was blue-black penetrating the three joints; face and lips showed bluish hue; tongue coating was white and greasy. This was wind-cold mishandled, drawing pathogen into the Yin aspect, where Yang could not overcome Yin, causing deficient Yang to float outward. The treatment method should be to support Yang and dispel cold.
Fupian (Aconiti Lateralis Radix Praeparata) 20g, Paojiang (Zingiberis Rhizoma Preparatum) 6g, Jingxia (Pinelliae Rhizoma) 6g, Beixin (Asari Radix et Rhizoma) 2g, Sheng Mahuang (Ephedrae Herba) 2g, Fuling (Poria) 10g, Gancao (Glycyrrhizae Radix et Rhizoma) 3g.
Fed frequently. After one dose, sweating occurred, fever reduced by half, fright and convulsions ceased, coughing and panting decreased, and nursing resumed. After another two doses, symptoms improved by 70-80%. Mahuang and Xin were removed, and two more doses were taken until all symptoms disappeared.

Pediatric Chronic Convulsive Disease

Second son of Mr. Zhang, aged one year, residing in Luchang Street, Huili County, Sichuan Province.
In March 1914, he suffered from pediatric convulsive disease, which was very critical, with continuous convulsions for three days.
Upon examination, the finger vein was blue-black penetrating the three joints; pulse was deep, fine, and weak; tongue coating was white and slippery; face and lips were dark bluish; eyes closed, lethargic, and unconscious; occasional limb spasms and convulsions; refusal of milk and food; night fever; green watery diarrhea. Inquiry revealed the mother stated the illness started with cold exposure and respiratory infection, initially presenting with fever, cough, and loose stools. A doctor prescribed two doses of clearing-heat and resolving-exterior medicines. Daytime fever subsided slightly, but night fever returned, and cough/diarrhea persisted. Then, two doses of digestion-promoting and heat-clearing medicines were given, but the condition did not improve, suddenly developing wind-movement and convulsions.
The doctor attributed this to Liver channel wind-heat and prescribed two doses of liver-calming, wind-dispelling, and fright-calming medicines, causing the condition to worsen further. By then, the illness had lasted over ten days. Based on pulse and symptoms, I reasoned that children have unfulfilled Qi and Blood and tender Zang-Fu, intolerant to harsh purgatives. Early wind-cold should be treated with mild exterior-releasing methods for cure. However, mistaken use of heat-clearing agents, followed by digestion-promoting, liver-calming, and wind-dispelling methods, damaged Yuan-Yang (Primordial Yang). Healthy Qi could not overcome the pathogen, leading to internal accumulation of cold-phlegm and constituting the chronic convulsive disease of Three-Yin deficiency-cold. The condition was critical. Refusing treatment would violate my duty as a physician. I strongly advocated using Zhuhan Dangjing Tang (Cold-Expelling and Fright-Shaking Decoction) to save the patient.
Rougui (Cinnamomi Cortex) 6g (powdered, mixed with water), Gongding (Syzygii Flos) 3g, Paojiang (Zingiberis Rhizoma Preparatum) 10g, Baihujiao (Piperis Longi Fructus) 3g (crushed), Zaoxintu (Caulis Argillae Ustus) 130g (heated red, quenched with water, clarified, and used to decoct herbs).
After two feedings, a small cup of salivary phlegm was vomited, wind signs slightly reduced, convulsions lighter, eyes opened, and eyeballs could move and track. After another feeding, another cup of salivary phlegm was vomited, wind signs stabilized, convulsions stopped, cough ceased, and night fever ended. The parents were relieved but noticed the child's emaciated constitution and believed spleen-stomach tonification was needed. They self-prescribed Lizhong Dihuang Tang (Regulate Middle and Rehmannia Decoction) for one dose. Unexpectedly, after some time, wind-movement and convulsions recurred. Upon examination, I learned that although the major illness had turned, cold-phlegm and evil Yin were not fully expelled. Premature tonification increased pathogenic factors and hindered the expulsion of Yin evil and internal cold-phlegm, causing recurrence of slow wind. The family then realized the dangers of inappropriate tonification. I continued with Zhuhan Dangjing Tang plus Fupian (Aconiti Lateralis Radix Praeparata) 15g. After feeding, another cup of salivary phlegm was vomited, followed by two passages of dark brown watery stool. Convulsions ceased, nursing resumed, and crying was heard. The original formula was modified by removing Baihujiao and Gongding, adding Renshen (Codonopsis Radix) 6g and Gancao (Glycyrrhizae Radix et Rhizoma) 6g, increasing Fupian to 30g, decocted and fed frequently. After two doses, all symptoms resolved.

Taiyang and Shaoin Simultaneous Cold Damage Syndrome
(Severe Common Cold)

Mr. Zhang, aged 42, residing at Nanlian Sheng Alley, Wumiao Xia, Kunming City, Yunnan Province. He had always deficient Kidney Qi. On September 2, 1929, during his return home in rainy weather, he contracted wind-cold. Initial symptoms included fever, aversion to cold, headache, body pain, lethargy and desire to sleep (similar to Shaoyin disease's "desire to sleep"), slight thirst preferring hot drinks, deep-fine-tight pulse.
Tongue coating was white and slippery; tongue body had bluish-purple tints. Due to inherent Kidney Qi deficiency and weak Kan-Yang (Kidney Yang), unable to defend the exterior against external pathogens, cold wind entered the Shaoyin directly through the deficiency, blocking the circulation of True Yang, resulting in this state. Zhang Zhongjing's Maxing Fuzi Tang (Ephedra, Asarum, and Prepared Aconite Decoction) was used to warm the channels, resolve the exterior, support healthy Qi, and eliminate pathogens.
Hei Fupian (Prepared Black Aconite Root) 36g, Mahuang (Ephedrae Herba) 10g (boiled first to remove foam), Beixin (Asari Radix et Rhizoma) 6g, Guizhi (Cinnamomi Ramulus) 13g.
On the 3rd day, after one dose, sweating occurred, and fever subsided. Only dizziness, cough, and mental timidity remained. Although the exterior pathogen was resolved, Lung cold was not cleared, and Yang Qi was still deficient. Sini Tang (Four Reversal Decoction) combined with Erchen Tang (Two Aged Things Decoction) plus Beixin and Wuweizi (Schisandrae Fructus) was used to support Yang and warm cold.
Hei Fupian 50g, Ganjiang (Zingiberis Rhizoma) 26g, Gancao 10g, Guangpi (Citri Reticulatae Pericarpium) 10g, Faxia (Pinelliae Rhizoma Preparatum) 13g, Fuling 13g, Beixin 4g, Wuweizi 2g.
After one dose, cough stopped immediately, appetite increased, spirit recovered, and the illness was cured.

Plague Disease Syndrome of Dry-Heat Internal Binding

Wife of Mr. Xie, surnamed Che, aged 18, residing in South Street, Huili County, Sichuan Province.
In March 1920, she contracted plague pathogenic factors. Two days into the illness, initial symptoms included fever with thirst, aversion to heat without aversion to cold, headache, body pain, floating-string-numerous pulse, red lips, dirty complexion, and white tongue coating like accumulated powder. Although early stage, the pathogen was not in the meridians. Sweating would damage exterior Qi and consume fluids, likely intensifying heat. This was plague pathogen lodging in the Mu Yuan (semi-interior/semi-exterior region), trending inward to transform into dryness and damage fluids. The strategy was to transport the Mu Yuan pathogen to the exterior for resolution, using Da Yuan Yin (Reach the Origin Drink) plus Shigao (Gypsum Fibrosum) as the main formula.
Bolang (Arecae Semen) 10g, Houpo (Magnoliae Officinalis Cortex) 10g, Caoguo (Tsaoko Fructus) 10g, Zhimu (Anemarrhenae Rhizoma) 12g, Hangshaoyao (Paeoniae Radix Alba) 12g, Huangqin (Scutellariae Radix) 10g, Gancao 6g, Sheng Shigao (Gypsum Fibrosum) 15g (crushed, cloth-wrapped).
After one dose, symptoms slightly decreased, but constipation for three days persisted. Therefore, Dahuang (Rhei Radix et Rhizoma) 12g was added to the previous formula, instructed to take immediately. The patient's father, knowing some medicine, believed the girl was constitutionally weak and feared intolerance to cold-purgative agents. He privately removed Dahuang and Shigao. Two days later, upon re-examination, the tongue coating turned yellow and dry, epigastric fullness and chest distension with tenderness and pain on pressure, irritability, thirst for cold drinks, short dark urine, persistent constipation, high fever unresolved, and occasional delirium. This indicated the pathogen had entered the Fu organs, with dry-heat binding. Only clearing-heat and purging could save the critical situation. Immediately, Baihu Jia Chengqi Tang (White Tiger Plus Chengqi Decoction) was prescribed. The father hesitated and refused administration. Suddenly, the patient suffered continuous epistaxis, bright red and heavy. Shortly after, the blood clotted. The family panicked and sought another TCM practitioner, Peng, who diagnosed Yang deficiency with blood loss, arguing that heat-induced epistaxis would not clot, and prescribed Sini Tang. The family doubted and hesitated, refusing to take it. They consulted me again. I explained firmly: This is a syndrome of extreme pathogenic heat scorching Yin. Urgent large-dose cooling purgation is needed to save True Yin; delay will lead to exhaustion of True Yin and critical danger. I also stated that even I, skilled in using Jiang (Zingiberis Rhizoma) and Fu (Aconiti Radix), dare not recklessly use warming agents here. With this syndrome, bitter-cold purgation might even be insufficient; mistakenly using warming agents would be like pouring oil on fire, leading to immediate death. Persuaded by my insistence, the family agreed, and a cooling purgative formula was prescribed.
Sheng Shigao 60g (crushed, cloth-wrapped), Sheng Dahuang 30g (soaked, mixed in), Zhishi (Aurantii Fructus Immaturus) 20g (crushed), Houpo 20g, Mangxiao (Natrii Sulfas) 13g, Zhimu 20g, Shengdi (Rehmanniae Radix) 16g, Gancao 6g.
After continuous day-and-night intake, epistaxis stopped, consciousness cleared, and fever reduced by 60-70%. The next day, another dose of the original formula was taken, resulting in free urination and defecation, calm pulse, cool body, but still craving cold drinks due to residual heat and unrecovered fluids. Shengmai San (Generate Pulse Powder) plus modifications was taken for three doses, stopping thirst and restoring oral moisture. Subsequently, Shigao and Dahuang were removed, and three more doses were taken for complete recovery.
Shashen (Glehniae Radix) 30g, Maidong (Ophiopogonis Radix) 13g, Wuweizi 6g, Danggui (Angelicae Sinensis Radix) 16g, Shengdi 16g, Hangshaoyao 16g, Shigao 16g, Dahuang 6g.

Plague Disease Yangming Dry-Heat Excess Syndrome

Mr. Li, male, aged 25, farmer in Southern Township, Huili County, Sichuan Province. Contracted seasonal epidemic in March 1921. Fever persisted for twelve days without relief. Pulse was surging-numerous; tongue coating was yellow-black with prickles; lips were cracked, teeth dry, breath hot to touch; fever intensified in the afternoon with continuous sweating; delirium, irritability, inability to lie still. Urine was short and dark. No bowel movement for over ten days since onset. Abdominal distension and fullness from epigastrium to lower abdomen, groaning in pain, tenderness on pressure, difficulty turning while supine, refusal of food, only irritability and thirst for cold drinks. At this point, pathogenic heat was extreme, Yin fluids exhausted, dry feces bound internally, and all Yangming purgation indications were present. Urgent purgation was needed to save Yin; delay meant critical danger. Considering prolonged high heat and hard dry feces without Yin fluid lubrication, like a boat lacking water, pathogenic heat and dryness had no outlet. Urgent purgation combined with Yin-nourishing and fluid-generating agents was required. Modified Huanglong Tang (Yellow Dragon Decoction) was prescribed.
Turenshen (Codonopsis Radix / Panax Ginseng substitute) 30g, Danggui 26g, Shengdi 16g, Dahuang 16g (soaked, mixed in).
Mangxiao 10g (added later), Zhishi 16g, Houpo 16g, Sheng Shigao 26g (crushed, cloth-wrapped).
That night, after ingestion, the patient desired defecation but struggled significantly. Straining produced a segment of dry feces slowly, about one chi long, hard and unbroken, sauce-black in color.
I personally examined it; truly hard as a whip. Next morning, pulse was more harmonious, fever reduced by half, tongue prickles softened, oral moisture slightly returned, abdominal distension and pain greatly reduced, still craving cold drinks. Instructed to take another dose of the original formula. On the third day, bowel movements were smooth, stool turned yellow and soft. Pulse was calm, body cool, able to eat rice porridge. Tongue coating had receded by half, fluids regenerated, but still preferred cold drinks, indicating initial heat subsidence and incomplete Yin fluid recovery. Shengmai San plus modifications was prescribed to nourish Yin, generate fluids, and clear residual heat.
Shashen 26g, Cundong (Ophiopogonis Radix) 16g, Wuweizi 3g, Gancao 6g, Shengdi 16g.
Xuanshen (Scrophulariae Radix) 13g, Huanglian (Coptidis Rhizoma) 5g.
After two doses, Liuwei Dihuang Tang (Six-Ingredient Rehmannia Pill) was used to regulate the Yin aspect, recovering after one or two doses.
Shengdi 26g, Fudanpi (Moutan Cortex) 10g, Zaopi (Corni Fructus) 10g, Huaiyao (Dioscoreae Rhizoma) 13g, Fuling 13g, Zexie (Alismatis Rhizoma) 10g.

Plague Disease Yangming Urgent Purgation Syndrome

Father of Mr. Chen, farmer in Niushangkhan, Luchang, Huili County, Sichuan Province. Although sixty years old, constitution was generally robust. In early April 1916, visiting a neighboring village during an epidemic outbreak, he became infected. Returning home, after a few days, he suddenly felt chest oppression, poor appetite, dizziness, body fatigue, dry mouth desiring drink, initiating illness. Initially felt chilling aversion to cold, followed by fever, thirst for cold drinks, head and body pain, scanty tea-colored urine. Bedridden for seven to eight days, self-administered two doses of exterior-releasing and digestion-promoting medicines with no effect, then sought my consultation. Pulse was surging-numerous; lips cracked, mouth dry; tongue coating thick and greasy, white edges, yellow center with prickles. Sweating only on the head, no sweat elsewhere; high fever, irritability, thirst for cold drinks, occasional delirium; scanty difficult urination with involuntary dribbling. No bowel movement for six to seven days; abdominal fullness preventing eating. This was plague mishandled by exterior-releasing methods, severely damaging True Yin. Epidemic toxin transmitted to the Yangming Fu organs, with internal steaming of pathogenic heat. Urgent cooling purgation was needed to save True Yin. Zhang Zhongjing's Dachengqi Tang (Major Order the Qi Decoction) plus Shigao and Cundong was prescribed for urgent purgation to save Yin, akin to removing firewood from under the pot, aiming to purge all pathogenic heat and epidemic toxin from the stomach and intestines.
Dahuang 16g (soaked, mixed in), Mangxiao 3g (added later), Zhishi 13g (stir-fried, crushed).
Houpo 13g (stir-fried), Sheng Shigao 30g (crushed, cloth-wrapped), Cundong 26g.
After three decoctions and administrations, profuse passage of black sauce-like stool amounting to half a small bucket, extremely foul-smelling. Fever reduced by 70-80%, oral moisture gradually returned, tongue prickles softened, delirium ceased, urination no longer dribbled, becoming slightly clear and long, though still yellow, still craving cold drinks. Immediately provided a bowl of ice-cold water from a stone jar. After drinking, the patient reported feeling refreshed internally. After a second bowl, whole-body coolness ensued, allowing peaceful sleep. Residual heat remaining, Xiao Chengqi Tang (Minor Order the Qi Decoction) plus clearing-heat, nourishing-Yin, and generating-fluid agents was prescribed subsequently.