Library

Cold pathogen latent in the Shaoyin (Lesser Yin) channel, transforms into heat upon stimulation by Yang Qi. If Kidney Qi is not deficient, the pathogen cannot reside and will reach outward. The most favorable scenario is that the pathogen does not linger in the Yin aspect but directly emerges through the Three Yang channels, presenting as syndromes of the Three Yang meridians. Involvement of the Taiyang (Greater Yang) channel manifests as aversion to cold and fever, headache and stiffness of the head and neck, and stiffness of the lower back and spine; treatment should employ fermented soybean (Douchi) and Scutellaria root (Huangqin), combined with Yangdan Decoction. Involvement of the Yangming (Yang Brightness) channel manifests as high fever, dry nose, and inability to lie down; treatment should employ fermented soybean (Douchi) and Scutellaria root (Huangqin), combined with Pueraria root (Gegen) and Anemarrhena rhizome (Zhimu). Involvement of the Shaoyang (Lesser Yang) channel manifests as alternating chills and fever, bitter taste in the mouth, and hypochondriac pain; treatment should employ Scutellaria root (Huangqin) and fermented soybean (Douchi), combined with Bupleurum root (Chaihu) and Gardenia fruit (Shanzhi). When the pathogen first emerges from the Three Yang channels, or when accompanied by a new external contraction manifesting as aversion to cold and absence of sweating on the exterior, Cinnamon twig (Guizhi), Pueraria root (Gegen), and Bupleurum root (Chaihu) should be used in combination. However, if interior heat is severe, Cinnamon twig (Guizhi) is contraindicated; if there is high fever with profuse sweating, Pueraria root (Gegen) is contraindicated; if internal wind tends to stir easily, Bupleurum root (Chaihu) is contraindicated. These require flexible adjustment based on the clinical presentation. The *Nan Jing* states: "Warm pathogen travels through various meridians, it is unknown which meridian is affected." Therefore, its onset has no fixed location, generally occurring when meridian Qi is deficient, or accompanying other pathogens. For instance, if Taiyang is deficient, it manifests in the Taiyang channel; if Yin Qi is deficient, it lingers in the Yin aspect. There are cases where warm pathogen has transformed into heat and emerged through the Three Yang channels, yet residual pathogen remains latent in the Shaoyin without transforming (this indicates insufficient Kidney Qi, requiring concurrent warming and supporting methods); even if fully transformed into heat, the heat may be half in the Yang and half lingering in the Yin (this indicates insufficient Yin Qi unable to push out the pathogen, requiring concurrent nourishing of Yin). Medication must always be adjusted flexibly according to symptoms, acting with agility, to achieve immediate efficacy.

When latent warmth transforms into heat and reaches outward, with syndromes emerging from Shaoyin to the Three Yang channels, this is considered a favorable progression in treatment principles. Only formless heat can reach outward via meridian Qi. If the Middle Jiao is complicated by tangible food stagnation or turbid phlegm, the pathogenic heat will accumulate and steam, often taking the opportunity to enter the Stomach, binding in the center and forming a syndrome amenable to purgation. The Stomach is the sea of the five Zang and six Fu organs, located in the central Earth element, and is most capable of accommodation. Once pathogenic heat enters the Stomach, it ceases to transmit elsewhere. Thus, in warm-heat diseases, cases of heat binding in the Stomach resolved by purgation account for six out of ten. Predecessors such as Wu Keyou discussed these, although naming them pestilence, they are essentially latent pathogens. Among the treatments listed, purgation was used in seven or eight out of ten cases. Generally, Shanghan (Cold Damage) emphasizes avoiding erroneous purgation, while Wenbing (Warm Diseases) emphasizes avoiding erroneous sweating; early use of purgation in warm diseases does not constitute major harm, a view held by former sages. Wu Shi indeed observed many cases suitable for purgation, hence speaking boldly, unaware of the bias in his statements. Lu Jiuzhi argued that warm disease pathogenic heat burns from within, with the most critical cases involving only Yangming channel and fu-organ syndromes. Channel syndromes are treated with White Tiger Decoction (Baihu Tang), and fu-organ syndromes with Chengqi Decoction. With these two methods, no warm disease is untreatable. His focus is exclusively on Yangming, implying warm diseases never involve other meridians, which is somewhat biased. In summary, warm disease pathogenic heat steaming and郁 (stagnating) mostly enters Yangming. Heat in the channel remains formless. Symptoms include irritability, thirst, profuse sweating, mania, delirium, and a surging pulse, constituting a Baihu Tang syndrome. If heat binds in the fu-organ, symptoms include dental plaque, scorched lips, afternoon fever exacerbation, scorched yellow tongue coating, coma, delirium, and a deep, solid pulse, constituting a Chengqi Tang syndrome. As long as differentiation is clear and heat is confirmed in the Stomach, administering Baihu Tang or Chengqi Tang according to protocol yields rapid results. Do not let hesitation breed timidity, causing delay and worsening the condition.

Former physicians used Rhubarb (Dahuang) for purgation for various reasons: some to drain heat (e.g., Sanhuang Xiexin Decoction); some to detoxify (e.g., Sanhuang Jiedu Decoction); some to resolve stasis and transform phlegm (e.g., Dahuang Zhechong Wan, Guntan Wan); some to vent stagnant Qi (e.g., Dahuang Huanglian Xiexin Decoction). It was not originally designed solely for stagnation. Unfortunately, those unfamiliar with medical theory see Rhubarb in a formula and call it Chengqi Decoction or purgation for accumulation; thus generating numerous doubts, failing to use it when necessary, leading to much延误 (delay/neglect).

In Shanghan, heat binding in the Stomach typically presents with black, hard, and dry stools. In warm diseases, heat binding in the Stomach typically presents with sauce-colored, loose stools. Commoners (with coarse diets) with heat binding have chestnut-like dry stools. Nobles (consuming rich foods) may have heat scorching but stools do not immediately dry; often, with prolonged heat accumulation, stools resemble mud without forming hard pellets. This must be known. Some patients have loose stools at onset, but after two to three days, as heat intensifies, it binds in the Stomach causing constipation; these still require purgation according to protocol. Others have severe heat, frequent thirst, or use cooling-draining agents resulting in watery diarrhea while hard stool remains unpassed; this is "heat binding with peripheral flow" (Rejie Pangliu). Ancient methods used Da Chengqi Tang for purgation; Wujutong modified it to Tiaowei Chengqi Tang, which is highly appropriate.

When heat binding forms dry feces, one or two bowel movements complete the expulsion of dry feces, clearing the pathogenic heat. If stools are like moldy paste, or alternating between dry and loose, the retained filth is hardest to clear, and pathogenic heat is hardest to eradicate. Bowel movements may stop for one or two days before resuming, or occur five to ten times. One must assess the patient's condition to decide whether to continue purgation. Do not be intimidated by the false notion that purgation causes deficiency, thinking purgation cannot be repeated, thereby retaining pathogen and causing complications, suffering the real disaster of nurturing an abscess.

In the winter of the second month of the Guangxu era, Mr. Xu Shengzhi wished to take tonics and asked me to prescribe. I palpated his pulse: both Chi positions were floating, rapid, wiry, and restless. I told him, based on this pulse and syndrome, Winter Warmth would likely erupt, and tonics should be delayed. I prescribed Huangqin Tang plus Rehmannia root (Shengdi), advising him to take several doses. At that time, he ate and drank normally, feeling no illness. He reluctantly took three doses then stopped. On December 17th, he suddenly experienced chills and fever. Two days later, he felt mental confusion and fatigue, with heat steaming and unable to reach the exterior, mental dullness, deafness, and dirty complexion. This was Shaoyin latent pathogen transforming into heat and reaching outward. The pathogen had reached the Stomach externally, but internally emanating from Yin had not yet left the Shaoyin boundary, showing signs of invading Jueyin. The condition was deep, severe, and urgent. Being close relatives, I could not decline treatment. Initially, I gave Gardenia (Zhizi) and Fermented Soybean (Chichi) with Scutellaria (Huangqin) for two doses, followed by Qingxin Liangge method for two doses, with little effect. Spasms, convulsions, coma, delirium, dry tongue, and scorched lips worsened the urgency. I then used Tiaowei Chengqi Tang added with American Ginseng (Yangshen), Rehmannia (Shengdi), Rhinoceros horn (Xijiao - *note: modern substitutes used*), Antelope horn (Lingyang), and Scrophularia (Yuanshen) for nourishing Yin and clearing heat. After two doses, he passed moldy-paste-like loose stools twice. Intermittently, I administered formulas with Rhinoceros/Antelope horn, Rehmannia, Peony (Shaoyao), Fermented Soybean, Gardenia, Moutan (Danpi), Scutellaria, and Scrophularia to nourish Yin, extinguish heat, and clear/vent Shaoyin, but heat persisted. I then used Tiaowei Chengqi Tang combined with Zengye method, passing another batch of filthy stools. Thereafter, I alternated this method with nourishing-Yin-and-clearing-heat methods. From December 23rd to January 10th, he took Chengqi Decoction eight times, passing over ten batches of dark, loose retained filth, allowing interior heat to gradually relax and mental clarity to return. He recovered after two months of Yin-nourishing regulation. Commentary: This case had heavy Shaoyin latent pathogen. If heat had gathered entirely in the Stomach, even if extremely congested, purgative drugs could have been used decisively for a chance of success. However, middle-jiao heat was severe, and latent heat invading Yin burned fiercely between Shaoyin and Jueyin, risking clouding the mind and convulsions. Forced to use methods to assist Yin and support the pathogen outward, clearing from the Yin aspect to allow gradual exteriorization. For what reached the Stomach, gentle purgation was used to drain it. Combining offense and defense, adapting to changes. This lasted nearly twenty days until heat cleared. If purgation had been stopped after one or two times due to fear of deficiency, the danger would have been unimaginable. Yet, those who save lives become honored guests today, which is fortunate.

Eldest daughter-in-law Xu, in July of Wuxu year, suffered from cold complicated by Liver Qi stagnation and fever, epigastric pain, vomiting, and inability to eat for five to six days. On August 1st, she had a smooth bowel movement. I said once bowels moved, the illness would ease. Unexpectedly, that night, severe chills and fever erupted, with nausea and dry retching all night. Zuojin Pill, Pingwei San, Wendan Tang, and Xiexin Tang yielded no effect. By the 5th day, irritability, thirst, dry prickly tongue. Considering her weak constitution and Yin deficiency, fearing intolerance to high fever, I urgently sought to repel it early to avoid lingering. I used Liangge San combined with Xiexin method, aided by American Ginseng (Yangshen) and Dendrobium (Shihu). After two doses, two bowel movements occurred, vomiting stopped, but interior heat remained. Intermittent Yin-nourishing and heat-draining herbs failed to move bowels; tongue coating turned gray and hot. I switched to Tiaowei Chengqi Tang combined with Zengye method, given every other day. Each dose resulted in one bowel movement, stool color varying from yellow to black, loose to hard. After three more doses, on the 15th, Rhubarb (Dahuang) dosage increased to five qian, causing severe abdominal pain and passage of retained filth. Cold sweat and cold limbs ensued, nearly collapsing. Emergency Ren Shen (Ginseng) restored Qi stability. Since this smooth passage, interior heat relaxed; treatment focused on nourishing Yin and supporting Stomach. Every three to four days of constipation, Ginseng decoction delivered Dahuang pills or Xieye soup moved bowels, though stool remained black-purple like sauce. By early September, she could slowly consume rice gruel. However, every few days of constipation caused stomach heat oppression, requiring clearing/draining until bowel movement resumed. On September 19th, after Xieye soup, massive passage of retained filth occurred, expelling half a bucket of black stool: finally, accumulated and turbid heat were cleared, with no residual heat steaming. Total usage: Rhubarb >3 liang, Mang Xiao (Yuanmingfen) >1 liang, Ginseng rootlets 2-3 liang, American Ginseng and Ophiopogon (Maidong) >10 liang each, Fresh Rehmannia and Dendrobium 1 jin each. Rhinoceros/Antelope horn and Pearl powder amounts negligible. This case involved a weak, Yin-deficient body suffering severe illness, abstaining from liquids for a month, yet surviving because treatment consistently prioritized supporting Zheng Qi and nourishing Yin. Thus, despite critical moments, life was preserved. Retained filth took over a month to clear, exceeding initial expectations. This shows that residual heat in seasonal diseases stems from uncleared filth; one must not fear deficiency and retain pathogen. Most confusing about this case was the pulse remaining fine and weak throughout, lacking excess signs. Careful examination revealed deficiency of body but excess of pathogen. Only using American Ginseng, Fresh Rehmannia, Dendrobium, and Rhubarb to nourish Yin and drain heat was the correct principle. Adherence to this saved her from death, which is fortunate.