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Chapter 14 of 29
伤寒杂病论
Overall Paraphrase
This chapter is the middle portion of the Taiyang (Greater Yang) disease section in the Treatise on Cold Damage and Miscellaneous Diseases. Its content is exceptionally rich. It no longer merely discusses "whether or not Taiyang disease should induce sweating," but further addresses: what to do when Taiyang exterior syndrome is complicated by neck and back stiffness, diarrhea, vomiting, cough and wheezing, agitation, or retained fluid; what transformational syndromes arise when sweating, purging, emetic, or fire methods are used incorrectly; and how to "rescue against adverse treatment." The ancients repeatedly emphasize one principle here: First distinguish exterior from interior, then examine deficiency from excess. If there is exterior syndrome, resolve the exterior first; if there is interior deficiency, rescue the interior first. Fluids, yang qi, and defensive qi must not be recklessly harmed.
Below, the meaning of the original text is explained clearly in several sections.
When Taiyang disease presents with stiffness and tightness of the nape and back, no sweating, and aversion to wind, the ancients use Gegen Tang (Pueraria Decoction). The "stiffness of the neck and back" here is a manifestation of the Taiyang channels being invaded by pathogenic factors, with fluids unable to nourish the sinews and vessels. Gegen Tang consists of Gegen (Pueraria), Mahuang (Ephedra), Guizhi (Cinnamon Twig), Shaoyao (White Peony), Gancao (Licorice), Shengjiang (Fresh Ginger), and Dazao (Jujube). Its principle is to induce sweating and resolve the exterior while simultaneously raising fluids and relaxing the sinews.
If Taiyang and Yangming are simultaneously affected, and the exterior pathogen affects the stomach and intestines, resulting in diarrhea, Gegen Tang is still used; if there is no diarrhea but only vomiting, Gegen Jia Banxia Tang (Pueraria plus Pinellia Decoction) is used, adding Banxia (Pinellia) to direct rebellious qi downward and stop vomiting.
If the original syndrome warranted Guizhi Tang but the physician erroneously used purging, resulting in incessant diarrhea, rapid pulse, wheezing, and sweating, this indicates that the exterior heat has sunk inward. In this case, Gegen Huangqin Huanglian Tang (Pueraria, Scutellaria, and Coptis Decoction) is used, consisting of Gegen, Huangqin (Scutellaria), Huanglian (Coptis), and Gancao. The ancients considered that Gegen raises the clear qi and stops diarrhea, Huangqin and Huanglian clear interior heat, and Gancao harmonizes the middle.
The typical Mahuang Tang syndrome is: Taiyang disease with headache, fever, body pain, low back pain, bone and joint pain, aversion to wind, no sweating, and wheezing. This is the most classic description of wind-cold constraining the exterior and the wei (defensive) qi becoming blocked. Mahuang Tang consists of Mahuang, Guizhi, Gancao, and Xingren (Apricot Kernel) , with the functions of inducing sweating to resolve the exterior, and diffusing the lungs to calm wheezing.
When Taiyang and Yangming have combined disease, if there is wheezing with chest fullness, this indicates that exterior pathogen obstruction is primary, and purging must not be used; Mahuang Tang is still appropriate.
When Taiyang disease has persisted for over ten days, if the pulse is floating and fine and the patient prefers lying down, this indicates the exterior pathogen has already resolved; if there is still chest fullness and hypochondriac pain, Xiao Chaihu Tang (Minor Bupleurum Decoction) is used; if the pulse is still floating, Mahuang Tang is still used.
Da Qinglong Tang is used for conditions where exterior cold is severely constrained and concurrently there is interior heat: floating and tight pulse, fever with aversion to cold, body pain, no sweating, and agitation. In the formula, Mahuang and Guizhi induce sweating and resolve the exterior; Shigao (Gypsum) clears interior heat; Shengjiang, Dazao, and Gancao harmonize the middle. However, if the pulse is faint and weak, with sweating and aversion to wind, this indicates deficiency syndrome, and the decoction must absolutely not be taken; after taking it, "adverse syndromes" such as cold extremities and muscle twitching will appear.
Xiao Qinglong Tang is used when exterior cold has not resolved and there is retained fluid below the heart: dry retching, fever, cough, or complicated by thirst, diarrhea, choking sensation, difficulty urinating, lower abdominal fullness, and wheezing. Its composition is Mahuang, Shaoyao, Xixin (Asarum), Guizhi, Ganjiang (Dried Ginger), Gancao, Wuweizi (Schisandra), and Banxia. The ancients considered that Mahuang and Guizhi resolve the exterior; Ganjiang, Xixin, and Banxia warm and transform retained fluid; Wuweizi and Shaoyao astringe and restrain the lung qi. Following the main formula, there are also symptom-based modifications, reflecting the flexibility of "treating according to the manifest syndrome."
This section repeatedly explains a therapeutic sequencing issue.
When the exterior syndrome of Taiyang disease has not resolved, purging must not be used; purging constitutes "adverse treatment." As long as the exterior syndrome remains, formulas like Guizhi Tang should be used to resolve the exterior. Even if sweating was first induced without complete resolution, and then erroneous purging occurred but the pulse remains floating, this also indicates the pathogen is still at the exterior level, and the exterior should still be resolved.
If Taiyang disease presents with floating and tight pulse, no sweating, fever, and body pain that does not resolve after eight or nine days, with the exterior syndrome still present, sweating should be induced. After taking the medicine, if symptoms diminish slightly but heart vexation, blurred vision, or even epistaxis appear, the ancients believed that after nosebleed the heat may be resolved along with the blood; this is called "resolution through epistaxis." However, this is not a justification in modern times for allowing bleeding, but rather represents the ancients' observation of the phenomenon of nasal bleeding during certain exogenous febrile disease processes.
Concordant disease of the two yangs (二阳并病) refers to a situation where Taiyang disease at onset was not adequately resolved through sweating, and the pathogen turned into Yangming, manifesting with slight sweating and no longer fearing cold. However, if Taiyang syndrome is still present, purging is still not permitted; only mild sweating should be induced. If the face is flushed red, this indicates yang qi constrained at the surface, and the exterior should be resolved, perhaps through steaming and fumigation methods. If sweating was insufficient, the patient will experience agitation, pain without fixed location, or shortness of breath with inability to lie flat, and resolution can only occur through additional sweating.
Simultaneously, the original text specifically points out: although a floating and tight pulse indicates the need for sweating, if there is body heaviness with palpitations, or the chi (proximal) pulse is faint or slow, this indicates interior deficiency and insufficient nutritive blood. In such cases, strong sweating must not be induced; one must wait until the interior qi recovers and fluids are naturally harmonized before sweating.
This is the largest section of the chapter, reflecting the ancient physicians' systematic management of transformational syndromes resulting from "mistreatment."
The original text enumerates multiple situations in which strong sweating must not be induced: dryness of the throat, those with habitual urinary issues (linjia), those with sores (chuangjia), those prone to epistaxis (nüjia), those with blood loss disorders (wangxuejia), and those with excessive sweating (hanjia) . These patients already have insufficiency of yin blood and fluids; further sweating may easily lead to bloody stools, convulsive disease, chills and shivering, mental confusion, and post-urination genital pain. Yuyuliang Wan (Limonite Pill) is mentioned as an ancient recuperative formula after erroneous sweating in sweating-prone individuals, but in modern practice it is not a routine medication.
Xiao Chaihu Tang is another core formula in this chapter. Its typical manifestations are: alternating chills and fever, fullness and discomfort in the chest and hypochondria, a withdrawn demeanor with no desire to eat or speak, heart vexation with tendency to vomit, sometimes complicated by thirst, abdominal pain, stuffiness and hardness below the ribs, palpitations below the heart, difficult urination, cough, etc. In the formula, Chaihu (Bupleurum) and Huangqin (Scutellaria) clear and resolve Shaoyang; Banxia and Shengjiang harmonize the stomach and stop vomiting; Renshen, Gancao, and Dazao support the upright (healthy) qi.
The original text states, "Seeing just one syndrome is sufficient; it is not necessary to have all syndromes present," which is an important principle in identifying Xiao Chaihu Tang syndrome. If after erroneous purging the Chaihu syndrome is still present, Xiao Chaihu Tang can still be used, and the patient may first experience shivering (cold stage) followed by fever with sweating, through which resolution occurs.
Xiao Jianzhong Tang (Minor Decoction for Strengthening the Middle) is used for acute cramping abdominal pain, as well as palpitations with vexation. It consists of Guizhi Tang with doubled Shaoyao, plus Yitang (Maltose), and warms the middle, supplements deficiency, and relaxes urgency to relieve pain. Da Chaihu Tang (Major Bupleurum Decoction) is used for Chaihu syndrome complicated by incessant vomiting, urgency below the heart, and a feeling of oppression with slight vexation, indicating Shaoyang combined with interior excess. It uses Chaihu, Huangqin, Shaoyao, Banxia, Shengjiang, Zhishi (Immature Bitter Orange), Dazao, and Dahuang (Rhubarb), harmonizing while simultaneously conducting downward. Chaihu Jia Mangxiao Tang (Bupleurum Decoction plus Mirabilite) is used when there is still tidal fever after erroneous purging—first resolve the exterior, then unblock the interior.
Chaihu Jia Longgu Muli Tang (Bupleurum Decoction plus Dragon Bone and Oyster Shell) is used for chest fullness, fright, agitation, difficult urination, delirious speech, and heaviness of the entire body with inability to turn over. In addition to Chaihu, Huangqin, Banxia, Renshen, Guizhi, Fuling, Dahuang, Longgu (Dragon Bone), Muli (Oyster Shell), Shengjiang, and Dazao, the formula also contains Qiandan (Minium/Red Lead) . Qiandan contains lead; modern understanding has recognized its toxicity, and it must absolutely not be used by individuals on their own.
When Taiyang disease does not resolve, and pathogenic heat settles in the lower burner, there may be "manic-like" behavior and acute binding below the lesser abdomen. If blood is passed spontaneously, the ancients believed heat may be resolved along with the blood. If the lower abdomen remains acutely bound after the exterior has resolved, Taoren Chengqi Tang (Peach Kernel Qi-Conducting Decoction) is used, consisting of Taoren (Peach Kernel), Dahuang, Guizhi, Gancao, and Mangxiao (Mirabilite), to invigorate blood, transform stasis, and conduct and clear stagnant heat.
If the pulse is faint and deep, with mania, hard and full lower abdomen, and normal urination, this indicates blood stasis in the lower burner rather than fluid accumulation, and Didang Tang (Resistance Decoction) is used. Its composition includes Shuizhi (Leech), Mangchong (Gadfly), Taoren, and Dahuang—a potent formula for breaking blood stasis and expelling stasis. When the condition is slightly less severe, Didang Wan (Resistance Pill) is used. These insect-based medicinals are used with extreme caution in modern clinical practice, and would only be considered under strict pattern differentiation by a professional licensed Chinese medicine practitioner; they are absolutely not for self-administration by the general public.
The original text contains extensive material on "fire reversal" (fire-induced adverse treatment), criticizing the use of fire fumigation, fire moxibustion, warm needling, and other methods that forcefully induce sweating. It is believed that fire pathogens injure fluids and stir blood, potentially resulting in jaundice, epistaxis, bloody stools, dry throat with blood-spitting, agitation, fright mania, and even "charred bones and injured sinews." Rescue formulas include:
Additionally, there are methods such as needling Qimen (Liv 14) and formulations like Renshen Dihuang Longgu Muli Fuling Tang (Ginseng, Rehmannia, Dragon Bone, Oyster Shell, and Poria Decoction), each addressing different fire-adverse transformational patterns.
The core ideas of this chapter can be summarized as follows:
First, exterior syndromes have two major approaches: Mahuang and Guizhi. With sweating, use Guizhi Tang; without sweating, use Mahuang Tang; with neck and back stiffness, use Gegen Tang; with interior heat and agitation, use Da Qinglong Tang; with retained fluid, cough, and wheezing, use Xiao Qinglong Tang. This shows that even though Taiyang disease is at the exterior, there is absolutely no single formula that applies to all cases.
Second, there is a strict order of priority between exterior and interior. When the exterior syndrome has not resolved, purging cannot be used; when interior deficiency is present, strong sweating cannot be used; when both exterior and interior are diseased, urgency must first be distinguished: when there is interior deficiency with diarrhea of undigested food, rescue the interior first; when the interior is harmonized but the exterior remains unresolved, then rescue the exterior.
Third, after mistreatment, one must "observe the pulse and syndromes, recognize what reversal has occurred, and treat according to the syndrome." After erroneous sweating, vomiting, purging, or fire methods, various transformational patterns appear—yang deficiency, fluid injury, water retention, qi rebellion, vexation with heat, blood stasis, etc.—and the ancients corrected these with warming yang, nourishing fluids, transforming qi, promoting diuresis, clearing and diffusing, and activating blood respectively. This is precisely the concentrated embodiment of the spirit of "pattern differentiation and treatment."
Fourth, the protection of fluids and yang qi runs throughout. The contraindications to sweating, the warnings against fire methods, and the dictum that after yang collapse and fluid depletion "if yin and yang naturally harmonize, recovery will occur spontaneously" all emphasize that drastic methods must not be recklessly used.
This chapter demonstrates extremely meticulous observation of acute exogenous febrile illnesses, and many formula-syndrome correspondences remain practical approaches in modern Chinese medicine to this day. For example, Gegen Tang, Mahuang Tang, Xiao Qinglong Tang, Xiao Chaihu Tang, and Wuling San, when used by modern practitioners after careful syndrome differentiation, still play effective roles for specific syndromes. Principles such as "exterior before interior" and "protect stomach qi and fluids" resonate with modern medicine's emphasis on rest, fluid replacement, and avoiding excessive intervention during early infection.
However, it must also be recognized that these contents represent empirical medicine of antiquity, and many descriptions should not be directly equated with modern disease names. For example, "blood stasis with manic behavior" cannot be directly equated with mental illness; "yang collapse with reversed cold extremities" cannot be simplistically equated with shock; and "running piglet" cannot be equated with cardiac or gastrointestinal disease. Therapies such as fire moxibustion, warm needling, and Qiandan (minium) are rarely used or prohibited in modern times. Statements in the original text such as "resolution through epistaxis" and "those with spontaneous bleeding will recover" also cannot be interpreted as justification in modern times for allowing bleeding or refusing medical treatment.
This content is based on classic ancient Chinese medical texts and is provided solely for traditional cultural study and reading. It does not constitute any form of medical diagnosis, medication recommendation, or treatment advice. If you experience discomfort, please seek medical attention promptly.