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[Background Information]
Book: Zabing Guangyao (Comprehensive Requirements for Miscellaneous Diseases)
Author: Danbo Yuanjian (Japanese)
Dynasty: Qing
Chapter: Hongxiangjiao (1/4)
Category: Comprehensive

The "Hongxiangjiao" mentioned before the Tang Dynasty is the same as the modern "Hongxiangjiao"; however, the "Hongxiangjiao" mentioned since the Song Dynasty probably refers only to ordinary foot numbness and foot pain. Treating it as "Hongxiangjiao" is hardly the modern "Jiaqi" (Beriberi). Could it be that changes in customs and climates have led to differences in the disease? This compilation takes the *Qianjin Fang* (Prescriptions Worth a Thousand Gold) and the *Waitai Miyao* (Essential Prescriptions from the Imperial Library) as its main sources, extracting only the key points from later medical works. Nevertheless, how can we know that future "Hongxiangjiao" will not differ from today's? Physicians should adapt their treatments according to the times.

**Nomenclature**
In the Jiangdong and Lingnan regions, the land is low and damp, an environment prone to wind-dampness that easily injures people. When first contracting this disease, it often progresses upward from the lower body; thus, the feet initially become weak and difficult to flex. Subsequently, toxic qi travels along the meridians and gradually enters the zang-fu organs. Once the zang-fu are affected by pathogenic qi, symptoms such as panting and chest fullness occur. Because the disease originates from the feet, it is named "Hongxiangjiao" (Cantonese Foot / Beriberi). (*Zhubing Yuanhou Lun* [Treatise on the Pathogenesis and Symptoms of All Diseases])

When this disease manifests, it usually starts in the feet, followed by swelling of the shins. People at the time called it "Hongxiangjiao." Shenshi stated that "foot weakness" refers to this meaning. (*Qianjin Fang*)

Before the Jin and Song dynasties, it was called "Huanfeng" (Slow Wind); there was no name "Hongxiangjiao" in ancient times. Later, because the disease started in the feet and initially presented with swelling, it was named "Hongxiangjiao." There were also cases without swelling but with weakness, where walking suddenly caused falling, progressing to insensitivity (numbness). If toxic qi attacked the heart upwards, death would ensue rapidly, without time to turn around; if delayed, survival might extend for months. Thus, "Huanfeng" and "toxic qi" can be collectively termed this disease. (*Waitai Miyao*, citing *Lun by Director Su*) (Note: *Qianjin Fang* states: The Yellow Emperor considered this to be slow wind-damp bi.)

**Etiology**
Question: Why does wind-toxin affect people everywhere yet specifically target the feet? Answer: Humans have five zang organs. The meridians of the Heart and Lung originate in the ten fingers of the hands; the meridians of the Liver, Kidney, and Spleen originate in the ten toes of the feet. Wind-toxin arises from the ground; the cold, heat, wind, and dampness of the earth all transform into vapors. Since the feet are always covered by shoes and contact the ground, when wind-toxin attacks the human body, it must first strike the feet. If untreated over time, it spreads to the four limbs, abdomen, back, head, and neck. Initially imperceptible, it becomes known only when it becomes entrenched. As the classics state, this is "sequential transmission" or "intermittent transmission." (*Qianjin Fang*) (Note: *Sanyin Fang* states: Contracting wind, cold, summer-heat, and dampness results in sudden and shallow illness; Hongxiangjiao develops gradually and deeply. *Jisheng Fang* states: Cold, summer-heat, wind, and dampness can all cause this, not just wind-toxin. Inferring the true intent, cold, summer-heat, wind, and dampness stifling and injuring humans are all named wind-toxin; there is no separate wind-toxin. Chen's and Er's theories may contradict each other. *Jifeng Fang* states: Hongxiangjiao toxin has much dampness and little wind.)

Throughout the four seasons, one should not stand or sit for long periods in cold, damp places, nor should one remove clothing, boots, or socks while drunk and sweating to cool off in the wind; these actions all lead to Hongxiangjiao. If standing or sitting on wet ground for a long time during summer, hot-damp qi steams into the meridians; upon onset, fever, soreness, and irritability in the four limbs occur. If standing or sitting on cold, damp ground in winter, cold-damp qi enters the meridians; upon onset, the four limbs become extremely cold with muscle cramps. If contracted by cooling off in the wind, the skin and flesh become numb and insensitive, with twitching in various areas gradually moving toward the head. On days of sudden extreme heat, which people find unbearable, one must not immediately seek cold relief for pleasure. Similarly, one should not endure sudden extreme cold; both cause illness. Scholars who study diligently, focusing entirely on their work, often sit or stand on wet ground for long periods without moving frequently. When cold wind strikes and enters the meridians, they unknowingly contract the disease. Thus, wind-toxin may first strike the ten fingers of the hands and feet due to open pores and loose cou-li (skin texture), with wind striking like arrows; or it may first strike the sole of the foot, the dorsum of the foot, or the interior and exterior of the lower legs below the knees. To prevent illness, upon initial sensation of discomfort, moxibustion should be applied to the affected area for 30-20 burns, leading to immediate cure and no recurrence. The Yellow Emperor said: Cooling off in the wind and engaging in sexual activity after drinking can cause this disease. (Ibid.)

*Lun by Director Su* states: Hongxiangjiao originates from Kidney deficiency and mostly affects those with obesity and abundant flesh, regardless of gender. However, thin individuals who labor and have tight, dense skin may suffer without fatal consequences. After recovery, one must avoid standing in humid places or consuming excessive alcohol and wheat products, and avoid sorrow and anger, as these can trigger relapse. (*Waitai Miyao*) (Note: Post-prescription note in *Qianjin Fang*'s Neibu Shihu Qinjiao San states: Wind diseases originate from Kidney deficiency.)

*Lun by Su* further states: Hongxiangjiao typically manifests in late spring and early summer due to heat steaming and mental distress. Spring onset is mild; summer onset is severe; autumn brings slight relief; winter sees natural remission, generally speaking, though variations exist. Since entering the capital, I have seen unmarried women, married women, and young scholars contracting this disease outside the Jiang-Ling region. Unqualified physicians, failing to recognize it, misdiagnose and mistreat them, causing many deaths. Wind-toxin spreads throughout the world, not just in Jiang-Ling. Since women also suffer, and it is not solely due to Kidney deficiency, it is particularly prevalent in low, damp areas. Failure to treat this leads to many unjust deaths, causing deep sorrow and helplessness. (Ibid.)

*Argument by Tang Shizhong* states: Hongxiangjiao is caused by the accumulation of summer-heat and dampness internally, combined with toxic qi pressing externally. (*Yixin Fang*)

*Argument by Xu Sigong* states: This disease often affects leisurely individuals, also resulting from prolonged standing on cold, damp ground. It often occurs after walking in heat and soaking feet in cold water, excessive sexual activity, sleeping without covering the feet, feeling distressed, or living in hot, steaming environments. These are the origins of Hongxiangjiao. (Ibid.)

Xu Renze states: There are several types of this disease: one type involves descending fluid qi forming Hongxiangjiao, where fluid qi is the gradual progression of water qi; another type involves pre-existing Kidney deficiency, exposure to summer heat, washing feet with cold water, and retained dampness forming Hongxiangjiao; another type involves Kidney deficiency, lack of moderation in activities, residence in low, damp areas, and rising dampness forming Hongxiangjiao. (*Waitai Miyao*) (*Zhengyao Fang* cited in *Yixin Fang*)

**Internal vs. External Causes (North-South Differences)**
*Waitai Miyao Zonglu* also mentions that Jiangdong and Lingnan predominantly suffer from this disease. This is because clear-dampness invades deficiency at the lower part, injuring skin, flesh, sinews, and bones as stated in the classics. Therefore, prescriptions and theories are detailed based on local conditions. Observing the current region (North), which is dry and lacks low, damp lands, and where cou-li is dense making external pathogens hard to invade, why does this disease still occur? It is likely due to excessive consumption of milk, cheese, and strong wine, which are water-damp substances. Coupled with excessive nourishment, this generates dampness that sinks downward. Qi fails to control it, so it deposits in the feet, accumulating over time to cause swelling, fullness, and pain. This results from the downward flow of fluids. How can it be treated the same as southern regions? One must examine terrain elevation and analyze diet and lifestyle, establishing two methods: one treating terrestrial dampness, the other treating the downward flow of fluids. Adapting medication to the specific qi allows for treatment free of suffering, hopefully aligning with the principles of Huangdi and Qibo. (*Yixue Faming*) (Note: *Yuji Weiyi* cites *Yixue Faming*)

There are two causes of Hongxiangjiao: external contraction and internal generation. External causes involve yin-cold, water-damp, rain, and dew, or sitting/lying on wet ground, allowing damp-pathogens to invade skin, flesh, sinews, and vessels. Clear-dampness invading deficiency starts at the lower part, causing leg and foot diseases. Internal causes involve excessive rich and sweet foods, unregulated wine consumption, or eating too much milk, cheese, and damp-heat substances, causing heat to stagnate in the lower jiao, flowing to the calves, causing progressive swelling and pain, or extending to hand joints. Ancient texts suggested southern dampness caused external factors, while northern wine/cheese habits caused internal factors. This is one view; however, the north also has cold-damp, and the south has wine-damp. Thus, dividing by North/South is unnecessary. (*Jingyue Quanshu*) (Note: *Bencao Gangmu* and *Yixue Zhunsheng* argue judging by person rather than geography for cold/heat, which Zhang Jiebin based his views on.)

**Women's Hongxiangjiao due to Blood Deficiency**
Hongxiangjiao arises from Kidney deficiency; however, women also suffer from it, necessarily due to emptiness of the Sea of Blood, compounded by chronic resentment and grief. Many women suffer from this now, indicating women contract it due to Sea of Blood deficiency, similar to men's Kidney deficiency. Treatment for women uses the same medicines as men but adds herbs for treating sorrow and anger, yielding excellent results. (*Jisheng Fang*)

**Pulse Diagnosis**
*Duanju Fang* states: Floating and large pulses indicate exterior disease; sinking and fine pulses indicate interior disease. Floating, large, tight, and rapid pulses are the worst among the three categories. (*Yixin Fang*)

When the disease enters the zang organs (referred to as wind-toxin entering the body in *Qianjin Fang*), there are three pulse categories. Exterior and interior symptoms are similar, differing only in pulse. If the patient's pulse is floating, large, and slow, administer Xuming Decoction for two doses. If wind is predominant, use Yeshi Decoction with four liang of Atractylodes. If the pulse becomes rapid and tight, use Bamboo Sap Decoction. If the pulse is faint and weak, use Fengyin Decoction for 2-3 doses (*Tai Ping Hui Min He Ji Ju Fang* states: Faint and weak pulses indicate spontaneous recovery according to classics—note: this likely derives from Su Shi). These are mostly due to deficiency. For severe deficiency with shortness of breath, tonifying decoctions can be given intermittently, adjusted for cold/heat patterns. If unresolved, prepare Bamboo Sap Decoction again. If the pulse is floating, large, tight, and rapid, it is the worst category. Sinking, fine, and rapid pulses are equally ominous. Floating/large indicates exterior; sinking/fine indicates interior; treatment principles remain similar, requiring careful judgment. If the physical form is acceptable but limbs are not yet weak, upper-jiao qi ascent can cause death within days. For such pulses (often fatal, per *Qianjin Fang*), urgently administer Bamboo Sap Decoction daily, ensuring continuous administration without gaps exceeding half a day. (*Zhubing Yuanhou Lun*) (Note: This theory belongs in treatment examples, but is placed here for pulse discussion.)

According to *Duanju* and *Jiyan*, there are three Hongxiangjiao pulses: slow is mild, sinking-tight is moderate, flooding-numerate is severe. In thirty years, observing hundreds of cases, sinking-tight pulses often resulted in death, flooding-numerate pulses survived, and slow pulses healed spontaneously without treatment. (*Waitai Miyao*, citing Director Su)

Although Hongxiangjiao diagnosis is complex, pulses in the three positions must not contradict the four seasons to be auspicious; contrary pulses should not be treated. Others follow *Mai Jing*. (*Qianjin Fang*)

**Symptoms**
Hongxiangjiao originated in Lingnan, spread to Jiangdong. Onset may be abrupt, with slight pain/numbness, mild shin fullness, sudden leg weakness, abdominal insensitivity, alternating cold/heat, urinary difficulty, panting with qi rushing to the throat, suffocation, vomiting inability to eat, and rebellious qi—all are signs. Without timely treatment, it moves upward into the abdomen, causing qi eruption, which is fatal. (*Zhouhou Beiji Fang*) (Note: Five sentences from urinary difficulty onwards are absent in original text, added later from *Qianjin Fang*. Also, "small fullness" in *Qianjin Fang* is "swelling/fullness".)

All Hongxiangjiao is caused by wind-toxin. Onset is often unnoticed, occurring suddenly without prior illness or after other diseases. Initially subtle, with normal appetite, playfulness, and strength, careful observation is needed. Signs include insensitivity from knee to foot, numbness, crawling sensations, trembling in toes/shins/knees, leg weakness preventing walking, slight swelling, extreme cold, pain, flaccidity, spasms, varying dietary tolerance, vomiting at sight/smell of food, objects rising from intestines to heart, whole-body cramps, high fever/headache, chest palpitations, aversion to light, abdominal pain with diarrhea, confusion/memory loss, cloudy eyes/dull spirit—all are symptoms. Delayed treatment allows upward movement into the abdomen, causing swelling or fullness, chest/hypochondriac distension, and fatal qi ascent. Acute cases die within a day; chronic cases last 1-3 months. Early treatment is crucial, unlike common diseases. (*Zhubing Yuanhou Lun*)

All Hongxiangjiao is caused by wind-toxin. Often unnoticed until triggered by another illness, presenting as sudden severe oppression, unable to rise for 2-3 days. Incompetent physicians misdiagnose and kill patients. Thus, it is unrecognized. Initial signs are subtle, with normal strength, except for sudden leg weakness preventing movement. (*Qianjin Fang*)

Some feel no foot abnormality but suffer in head/neck/arms; others feel no external issues but suffer internally. Wind-toxin may cause vomiting/aversion to food smell, abdominal pain/diarrhea, constipation, chest palpitations, aversion to light, dull spirit, forgetfulness/confusion, high fever/headache, extreme cold/pain, cramps, swelling/non-swelling, leg numbness, flaccidity, joint spasms, abdominal insensitivity—all are Hongxiangjiao manifestations, also called wind-toxin Hongxiangjiao signs. Signs are hard to detect, requiring careful observation. Otherwise, critical timing is missed, and once established, difficult to manage. Women are similar; postpartum women cooling off in spring/summer often contract this toxin, requiring caution. Heat/oppression/twitching, palpitations/irritability, vomiting/rebellious qi are signs. Cold/pain below navel, discomfort, and dribbling urination different from usual are also Hongxiangjiao signs. Flaccidity is called Huanfeng; pain is Shibi. (Ibid.)

Treating wind-toxin disease: Initially resembling epidemic toxin disease, with floating-slow pulse remaining unchanged. Untreated, death occurs in days or weeks, or patient loses consciousness, jaundice, macules, red eyes, or genital ulceration. This is most urgent. Upon onset, administer Xuming Decoction, followed by Gegen Decoction and Mahuang Decoction to purge. If ineffective, give Xuming Decoction 2-3 more doses for cure. This disease is extremely urgent; decoctions must be continuous, never missing half a day, or death ensues. (Ibid.) (Note: Mahuang Decoction is a variation of Xuming Decoction; Gegen Decoction may not be from Zhang Zhongjing.)

These Hongxiangjiao cases cause enlarged calves, swollen/heavy dorsum of foot, oppressive qi rushing to heart/abdomen, fullness, and shortness of breath. There are Dry and Wet types: Wet presents with foot swelling; Dry presents without swelling, with gradual dryness and rough skin ("fish scale" appearance). Careful observation is needed. If preceded by stabbing pain in heart/abdomen/hypochondrium, chest/back fullness worsening after eating, frequent shortness of breath, heavy limbs, bone marrow pain, sighing, and aggravation after eating sticky/stale/odorous foods, this is Hongxiangjiao caused by descending fluid qi. (*Waitai Miyao*, citing Xu Renze)

Dry Hongxiangjiao presents with headache, waist/leg soreness, mental restlessness/thirst, immediate vomiting of food/medicine, generalized sweating, and panting. (*Jifeng Puji Fang*)

**Swelling vs. Non-Swelling**
People often suffer from Hongxiangjiao unknowingly for years, only manifesting when triggered by other illnesses. After treatment resolves other issues, persistent vomiting and leg weakness reveal the true diagnosis. Patients deny ever having swollen feet, refusing treatment, suspecting stone toxicity. Hesitation leads to death within ten days. Thus, Hongxiangjiao cannot always be identified by swelling; some swell, some do not. Abdominal insensitivity usually accompanies non-swollen feet. If abdominal insensitivity is followed by vomiting within 3-5 days, it is called "Hongxiangjiao entering the Heart," fatal within days. Treatment is difficult when reaching the Heart because Kidney Water overcomes Heart Fire. (*Qianjin Fang*)

**Cold, Heat, and Five Types**
Question: Why do cases present as cold or heat? Answer: The feet have three Yin and three Yang meridians. Cold attacking Yang meridians causes cold pathology; Summer-heat attacking Yin meridians causes heat pathology. Thus, there are exterior/interior cold/heat distinctions. Treatments differ: heat with cold herbs, cold with hot herbs, adjusted by judgment. Spleen affected by Yang toxin causes heat-numbness; Kidney affected by Yin dampness causes cold-bi. (*Qianjin Fang*)

There are five types: Cold Hongxiangjiao, Heat Hongxiangjiao, Neutral Hongxiangjiao, Severe Deficiency Hongxiangjiao, Severe Excess Hongxiangjiao. (*Waitai Miyao*, citing Su)

**Obesity/Emaciation and Difficulty**
Thin, dark-skinned individuals are easier to treat; fat, fleshy, pale/red-skinned individuals are harder to cure. Dark-skinned people tolerate wind-damp; pale/red-skinned do not tolerate wind. Thin people have firm flesh; fat people have soft flesh. Soft flesh allows deeper disease penetration, making it harder to cure. (*Qianjin Fang*)

**Hongxiangjiao Similar to Shanghan**
Headache, fever, joint pain, constipation, or vomiting with leg weakness is named Hongxiangjiao. Shanghan transmits only through Foot meridians, not Hand meridians. Earth's cold/heat/wind/damp transform into vapors; feet constantly tread on them, forming Hongxiangjiao. Thus, symptoms resemble Shanghan. (*Leizheng Huoren Shu*) (Note: Based on Tongzhenzi's *Shanghan Kuoyao*)

**Dominance of Four Qi**
Exterior signs: Spontaneous sweating/spreading indicates Wind dominance; No sweat/pain/spasms indicates Cold dominance; Swelling/heaviness indicates Damp dominance; Irritability/thirst/heat-numbness indicates Summer-heat dominance. When four qi coexist, identify the dominant one. (*Sanyin Fang*)

**Other Symptom Discussions**
Men and women initially suffering Hongxiangjiao with chills/fever, headache, sudden leg weakness, and a painful tendon running from shin to buttock/waist are caused by interaction of wind/cold/summer-heat/dampness. (*Degong Fang*)

*Neijing* states: All dampness, swelling, and fullness belong to Spleen Earth. Also: Those injured by dampness are affected from below first. Spleen governs four limbs; feet are lowest and receive most dampness. Dampness stagnates into heat; damp-heat conflict causes disease. It often starts with pain at Qichong acupoint, red/swollen shins, chills/fever resembling Shanghan, tendon spasms/pain. Recurring every 10-15 days, eventually causing calf swelling like a gourd, common in Southeast low-damp areas, rare in Northwest high-dry areas. Origins vary, including external contraction and internal injury. Though causes differ internally/externally, the result is damp-heat pathology. (*Yixue Zhengchuan*)