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[Background Information]
Book: Waike Xuanyao (Selected Essentials of Surgery)
Author: Xu Zhixiong
Dynasty: Qing
Chapter: Lower / Thirst (Ke)
Category: Surgery

During the swelling stage of sores and ulcers, if "Five Excesses" (Wu Shi - characterized by surging pulse, hot skin, abdominal distension, obstruction of urination and defecation, and mental confusion) are observed, it indicates that pathogenic factors are deep within the body. It is appropriate to use cold-natured herbs to purge and promote drainage, such as Neishu Huanglian Tang (Internal Draining Coptis Decoction). Subsequently, tonifying herbs for supporting the healthy qi and expelling pus should be used. In the ulcerative stage, although symptoms such as dry mouth and constipation may persist, these are caused by the depletion of body fluids internally. The pulse will necessarily be fine and rapid, the mouth feels normal but dry, appetite is poor, and there is a preference for hot foods; this constitutes deficient fire. Only by tonifying qi and blood, nourishing body fluids, and strengthening the spleen and stomach can bowel movements and urination naturally become harmonious, thereby preventing complications. For instance, in cases of urinary retention, even during the swelling stage, one should not use Zhu Ling (Polyporus) or Ze Xie (Alisma) to promote diuresis. Instead, using Ren Shen (Ginseng), Dang Gui (Angelica Sinensis), Bai Shao (White Peony Root), along with Tuoli Xiaodu San (Supporting Interior and Detoxifying Powder), adjusted according to the condition, will yield effective results. A red face in patients with sores and ulcers indicates constrained fire; it should be treated with dispersing methods. If wind pulses and wind symptoms are present, disperse the wind. If stools are dry and urgent, moisten and purge. If yu mao (syncope or coma) occurs, sweating methods are also suitable. For the above symptoms, purgative methods must be strictly avoided. Therefore, the principle in treating sores and ulcers lies in keeping the meridians closed without stagnation and unobstructed without excessive discharge.

Thirst caused by sores and ulcers applies regardless of whether it is the swelling or ulcerative stage. If the pulse is rapid, accompanied by fever and thirst, use Zhuye Huangqi Tang (Bamboo Leaf and Astragalus Decoction). If the pulse is not rapid, without fever, or if the pulse is rapid but forceless with thirst, or merely dry mouth, use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction). If the pulse is rapid with constipation, use Qingliang Yin (Cooling Drink). If the chi position pulse is large and forceful at the surface but forceless upon pressure, with thirst, use Jiaban Bawei Wan (Modified Eight-Ingredient Pill). This pill is particularly excellent for treating dry mouth, yellow tongue coating, and incessant drinking. (From *Da Fa*)

For thirst caused by sores and ulcers, if accompanied by pain, fever, and harmonious bowel and bladder functions, it indicates heat in the upper jiao; use Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction). If there is swelling, pain, fever, and dry, difficult defecation, it indicates heat within the five zang organs; use Sishun Qingliang Yin (Four-Obedience Cooling Drink). If swelling and pain are severe, it indicates accumulation and binding of toxic heat; use Xianfang Huoming Yin (Immortal Life Preserving Decoction). If there is diffuse swelling with slight pain, it indicates deficiency and stagnation of qi and blood; use Buzhong Yiqi Tang. If caused by stomach fire consuming fluids, leading to shortness of body fluids, use Zhuye Huangqi Tang. If caused by deficiency of stomach qi failing to generate fluids, use Buzhong Yiqi Tang. If caused by injury to stomach qi leading to internal loss of fluids, use Qiwei Baizhu San (Seven-Ingredient Atractylodes Macrocephala Powder). If caused by dryness of kidney water leading to thirst or dry mouth and tongue, use Jiaban Bawei Wan. If dry mouth and thirst precede frequent urination, followed by the development of carbuncles, or if thirst and drinking occur after the healing of carbuncles, or if the tongue is yellow, dry, and hard with frequent urination and emergence of carbuncles, these are extremely ominous signs. If the cause can be anticipated in advance, preemptive administration of Jiaban Bawei Wan and Buzhong Yiqi Tang to nourish the source of transformation can prevent subsequent complications. (From Xue's Medical Cases)

Thirst occurring during the onset of carbuncles and sores is due to dual deficiency of qi and blood. Use Ren Shen (Ginseng) to tonify qi, and Dang Gui (Angelica Sinensis) and Bai Shao (White Peony Root) to nourish blood. Alternatively, Rendong Wan (Honeysuckle Pill) or Huangqi Liuyi Tang (Astragalus Six-to-One Decoction) may be used. (From Danxi) If thirst associated with sore onset is very urgent, administer Shenxian Zhuidu Wan (Immortal Poison-Chasing Pill). To expel evil toxins, options include Qingtan Tang (Clear Chest Decoction), Qianjin Lulu Tang (Thousand-Gold Rhinacanthus Decoction), Wuxiang Lianqiao Tang (Five-Aromatic Forsythia Decoction), Liuwei Ch'ao San (Six-Ingredient Ark Shell Powder), and Wanjinsan (Ten-Thousand Gold Powder). If thirst persists after purgation, switch to herbs that generate fluids and tonify qi. Once fluids are generated and qi and blood are restored, thirst will cease naturally. (From Wu's Commentary) However, administering purgatives for extreme thirst without clearly indicating pulse and symptom patterns raises questions about the rationale. Later stating that post-purgation thirst requires tonification, yet again without clear pulse/symptom indications, suggests a simplistic approach: assume purgation for any extreme thirst, and only tonify if thirst persists. Is this how ancients practiced preventive treatment? Such medication usage is questionable. Moreover, thirst belongs to the upper jiao; purgatives might be applicable during the swelling stage. But for post-ulceration thirst, it is mostly due to qi and blood deficiency; why wait until after purgation to discuss deficiency? (From Danxi's Viewpoint)

Dry mouth differs from thirst. It is inappropriate to use Danxi’s method of suppressing and descending fire; doing so brings disaster swiftly. Instead, use Sang Zhi Jian (Mulberry Twig Decoction) or Wuweizi Tang (Schisandra Decoction) to rescue yin fluids. (From *Jingyao*) Danxi stated this was an excellent formula but failed to account for fire arising from dietary tastes, anger, or sexual exhaustion; thus, he feared thirst would not be easily resolved.

Thirst appearing after the healing of carbuncles often leads to untreatable conditions; only Jiaban Bawei Wan (Modified Eight-Ingredient Pill) is most effective. Since carbuncles and sores often arise from deficiency, if a patient has healed from a carbuncle but still experiences thirst, taking this pill stops the thirst. If stable and not thirsty, taking this pill prevents future thirst. Even if thirst precedes the carbuncle, taking this pill stops thirst and prevents the carbuncle from developing. (From Li's Commentary)

The aforementioned syndromes belong to dryness and depletion of kidney water with deficient fire flaming upward, causing dry mouth and thirst with excessive drinking, or yellow cracked tongue coating, frequent urination, or phlegm-qi obstructing upward causing restlessness, or two-to-three-year history of thirst and drinking, or mouth/tongue ulcers, hot feet, phlegm-qi obstruction, or three-to-four years post-healing with dry mouth/thirst and frequent urination. Urgent application of the aforementioned medicines often leads to recovery. Who can anticipate the cause? Preemptive use of the aforementioned pills can avoid this affliction. If accompanied by cold limbs, it indicates true yang deficiency; Bawei Wan (Eight-Ingredient Pill) is suitable. Generally, for post-sore conditions assessing insufficient kidney water, use Jiaban Bawei Wan. For weak middle qi, use Buzhong Yiqi Tang. For weak qi and blood, use Shiquan Dabu Tang (Perfect Ten Great Tonifying Decoction). For yang deficiency and cold, add Sheng Jiang (Fresh Ginger) and Rou Gui (Cinnamon Bark). If ineffective, use Bawei Wan. (From Xue's Commentary)

Modifications of Tuoli Xiaodu San (Supporting Interior and Detoxifying Powder):
Thirst induced by drinking cold liquids indicates toxic heat; add Chi Xiao Dou (Adzuki Bean) and Zhi Mu (Anemarrhena Rhizome). If ineffective, temporarily use Zhuye Huangqi Tang. Increased appetite with thirst indicates stomach fire; add Shi Gao (Gypsum), Shan Zhi (Gardenia Fruit), and Tian Hua Fen (Trichosanthes Root). If ineffective, temporarily use Zhuye Shigao Tang. Poor appetite, fatigue, and thirst indicate deficiency of stomach qi; remove Lian Qiao (Forsythia Fruit) and Jin Yin Hua (Honeysuckle Flower), add Ren Shen (Ginseng) and Bai Zhu (Atractylodes Macrocephala Rhizome). If ineffective, temporarily use Buzhong Yiqi Tang. Profuse pus with thirst indicates qi and blood deficiency; remove the previous three herbs, add Shu Di Huang (Prepared Rehmannia Root) and Wu Wei Zi (Schisandra Berry). If ineffective, temporarily use Shiquan Dabu Tang, adding Wu Wei Zi and Mai Men Dong (Ophiopogon Tuber). Dry mouth and tongue indicate deficiency of kidney qi; remove the previous three herbs, add Shu Di Huang, Shan Zhu Yu (Cornus Fruit), and Shan Yao (Dioscorea Rhizome). If ineffective, combine with Liuwei Wan (Six-Ingredient Pill). If still ineffective, assist with Buzhong Yiqi Tang. Spontaneous sweating, internal heat, and dry mouth indicate deficiency of stomach qi; remove the previous three herbs, add Ren Shen, Dang Gui, and Bai Zhu. If ineffective, temporarily use Liujunzi Tang (Six-Gentleman Decoction). Night sweats, internal heat, and dry mouth indicate deficiency of yin blood; remove the previous three herbs, add Shu Di Huang, Mai Dong, and Wu Wei Zi. If ineffective, temporarily use Danggui Liuhuang Tang (Angelica and Rheum Decoction).

Zhuye Huangqi Tang (Bamboo Leaf and Astragalus Decoction): Treats extreme thirst in carbuncles/sores, fever, diarrhea, or dysuria resembling dripping. Xue stated: Thirst is one of the Seven Evil signs. This formula treats it with swift efficacy. If the left hand pulse is floating, large, and hot, or with thirst, disperse exterior pathogens. If the right hand pulse is deep, solid, and hot, or with thirst, drain interior pathogens. If post-ulceration thirst, dysuria, or large forceless pulse indicates qi and blood deficiency, greatly tonify qi and blood. Some mistake persistent post-ulceration heat/thirst as a fatal decline. However, if the patient has inherent stomach fire or unresolved stomach meridian toxic heat, and the stomach pulse remains rapid, continue using the former decoction. If the pulse becomes larger and heat/thirst worsens after administration, this confirms a fatal decline due to deficiency of true qi and excess of pathogenic factors. Modern physicians fear the cold nature of Shi Gao (Gypsum) and Huang Qin (Scutellaria Root) and refuse them. If the stomach pulse is unsettled, no other herb can treat it. Delaying treatment allows prolonged consumption of qi and blood; more pus/blood means greater deficiency, leading to fatal decline. Physicians should prioritize pulse over symptoms. Generally, seeing one or two of the Seven Evils in sore/ulcer conditions is terrifying. Fatal decline with evil signs in deficiency patterns is untreatable; excess patterns without evil signs heal spontaneously.

Tuoli Huangqi Tang (Supporting Interior Astragalus Decoction):
Xue stated: I use this formula effectively for qi deficiency-induced thirst. For dual qi and blood deficiency, or profuse pus/blood loss with thirst, or accompanied by fever, use Tuoli Yangrong Tang (Supporting Interior and Nourishing Prosperity Decoction).

Tuoli Yangrong Tang (Supporting Interior and Nourishing Prosperity Decoction):

Huangqi Liuyi Tang (Astragalus Six-to-One Decoction): Regular lifelong consumption can prevent carbuncles/sores; it is a key agent for treating thirst and tonifying deficiency.

Qiwei Baizhu San (Seven-Ingredient Atractylodes Macrocephala Powder): Treats deficiency of stomach qi, or damage from harsh purgatives, or vomiting/diarrhea, causing dry mouth/thirst and poor appetite.

Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction): Treats carbuncles/sores with盛 stomach fire, swelling, pain, and thirst.

Yuanshen San (Scrophularia Powder): Treats carbuncles/sores with suppurating fluid, inability to eat, mental distress, dry mouth, extreme thirst, and emaciated limbs.

Gegen San (Kudzu Root Powder): Treats swollen sores with intense heat, dry mouth/extreme thirst, or occasional dry heaving.

Gan Ge Yin (Dried Kudzu Drink): Treats back carbuncles with thirst.

Rendong Wan (Honeysuckle Pill): Prevents carbuncles after thirst illness resolves. Place fresh Honeysuckle Vine in a jar, add non-ash wine, simmer gently overnight, take out, dry, mix with small amount of Gan Cao (Licorice Root), grind to powder. Use remaining wine to make pills sized like paulownia seeds. Take 60-70 pills with warm wine. Also treats five hemorrhoids and various goiters.

Sang Zhi Fang (Mulberry Twig Formula): Highly effective for thirst. Take one sheng of finely cut tender mulberry twigs (stir-fried), boil in three sheng of water until reduced to one sheng. Take 5-7 doses daily; more is better. Baopuzi stated: Treats wind-bi dryness, arm pain, beriberi, limb spasms, rising qi, dizziness. Long-term use tonifies lungs, aids digestion, promotes urination, lightens the body, sharpens hearing/vision, enhances complexion. Effects are too numerous to list.

Xue stated: Mulberry twig tonifies qi and blood, generates fluids, lightens the body, brightens eyes; it is an excellent agent for tonifying lungs and kidneys.

Wuweizi Tang (Schisandra Decoction): Treats dryness/depletion of kidney water, dry mouth/tongue.

Xue stated: This formula is a compound of Liuyi Tang and Shengmai San; it is an excellent agent for nourishing the source. If kidney water is depleted with deficient fire flaming upward causing dry mouth/thirst, it must be assisted with Jiaban Bawei Wan.

Jiaban Bawei Dihuang Wan (Modified Eight-Ingredient Rehmannia Pill):
Li stated: A nobleman suffered from a carbuncle; before healing, severe thirst developed, drinking several sheng daily. I prescribed the former formula. Other doctors laughed, saying: If this medicine stops thirst, we shall quit medicine! They continued using Mugua (Chaenomeles), Wumei (Mume Fruit), Baiyaojian (Betel Nut Infusion), etc., worsening the thirst. Reluctantly, they used this pill. Thirst stopped in three days. Long-term use strengthened qi and blood, doubling food intake.