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Chapter 16 of 29
伤寒杂病论
Holistic Paraphrase
"Distinguishing Yangming Disease Pulse, Syndrome, and Treatment" is the chapter in the Treatise on Cold Damage and Miscellaneous Diseases devoted to the Yangming disease. The general outline of Yangming disease is "Stomach and Intestines Excess" (Wei Jia Shi), meaning that the stomach and large intestine manifest excess pathological states such as heat pathogen, dry bound accumulation, and stagnation. The ancients classified the pathways into Yangming into three categories: Taiyang-Yangming is "Spleen Constraint" (Pi Yue), in which the body's fluids are inherently insufficient and the spleen's transport function is constrained, leading to dry, bound stool that is difficult to pass; Proper Yangming is "Stomach and Intestines Excess," where the gastrointestinal tract directly becomes dry-heat excess; Shaoyang-Yangming results from excessive sweating or profuse urination caused by medical treatment, damaging fluids, drying the stomach, and producing difficult stool. Many Yangming diseases develop from Taiyang disease after erroneous sweating, purging, or diuresis, which causes fluid loss and gastrointestinal dryness, leading to the disease shifting into the Yangming channel.
The typical external manifestations of Yangming disease are: fever, spontaneous sweating, no aversion to cold, and instead aversion to heat. Although short-lived aversion to cold may appear in the first day or two of onset, it soon resolves on its own, giving way to sweating and aversion to heat. The ancients explained this by saying that Yangming occupies the center and belongs to Earth, just as all things return to the earth; once the pathogen enters Yangming, it no longer transmits to other channels. Determining whether the disease has shifted into Yangming often involves observing the appearance of "continuous slight sweating," fever without sweating turning into sweating, a large pulse, and other signs. At the same time, the patency of urination is emphasized: if urine flows freely, dampness has an outlet and jaundice is less likely; if urination is inhibited and there is no sweating, damp-heat may stagnate and brew into jaundice.
The core elements of differentiation throughout the chapter are "heat, dryness, excess, and fluid damage." The ability to eat suggests stomach heat; inability to eat suggests stomach cold or internal binding of dry stool. Excessive sweating and frequent urination worsen fluid depletion and harden the stool. In treatment, the ancients established levels based on the degree of dryness and excess: for mild cases with restlessness and neither vomiting nor diarrhea, use Tiao Wei Cheng Qi Tang (Stomach-Regulating Qi-Coordinating Decoction); for predominant abdominal fullness and hard stool, use Xiao Cheng Qi Tang (Minor Qi-Coordinating Decoction) to gently harmonize stomach qi; when dry stool has formed, presenting with tidal fever, delirium, abdominal fullness with wheezing, and continuous slight sweating of the hands and feet, use Da Cheng Qi Tang (Major Qi-Coordinating Decoction) to vigorously purge heat and excess. However, purgative therapy has strict contraindications: when the exterior syndrome has not resolved, when there is excessive vomiting, when there is hard and full oppression below the heart, or when there is deficient pulse with faint and choppy signs, purging must not be used rashly. When heat is exuberant but excess has not yet formed, use Bai Hu Tang (White Tiger Decoction) to clear heat; when both qi and fluids are damaged, use Bai Hu Jia Ren Shen Tang (White Tiger Decoction plus Ginseng); when heat harasses the chest and diaphragm causing vexation and agitation, use Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction); when water and heat bind with inhibited urination, use Zhu Ling Tang (Polyporus Decoction).
The chapter also devotes considerable space to jaundice. For damp-heat jaundice with a bright yellow color like that of an orange, Yin Chen Hao Tang, Zhi Zi Bai Pi Tang, Ma Huang Lian Qiao Chi Xiao Dou Tang, and similar formulas are commonly used; for jaundice due to damage by alcohol and food, use Zhi Zi Da Huang Tang; for jaundice due to stagnant heat or retained blood, use Di Dang Tang and others. Cold-damp jaundice, however, must not be treated with heat-clearing or purgative methods but rather with warming transformation of cold-damp. For deficiency-cold abdominal pain, vomiting, and diarrhea, warming methods such as Wu Zhu Yu Tang, Li Zhong Tang, Si Ni Tang, and Da Jian Zhong Tang are used. In addition, for retained food, spleen constraint, and fluid-deficient constipation, treatments include the Cheng Qi Tang formulas, Ma Zi Ren Wan, Honey Enema Suppository, and Pig Bile Enema, embodying the diagnostic principle of "where there is this syndrome, use this method."
I. "Stomach and Intestines Excess" as the Guideline, but Not Confined to Excess Heat Alone
"That Yangming disease is Stomach and Intestines Excess" serves as the outline. Yet the entire chapter is not only about purging heat—it also covers cold in the middle, deficiency cold, fluid depletion, retained blood, jaundice, and other conditions. This demonstrates that while Yangming disease is typically characterized by interior excess heat, clinical practice requires careful differentiation of cold, heat, deficiency, and excess; one cannot simply purge upon seeing Yangming. For example, "inability to eat" may indicate cold in the stomach, and "desire to vomit upon eating grains" is the syndrome of Wu Zhu Yu Tang, both showing that deficiency cold can also appear in the Yangming stage.
II. The Preservation or Loss of Fluids is the Thread Running Through the Entire Chapter
Yangming disease places special emphasis on the relationship between sweating, urination, defecation, and fluids. Excessive sweating, profuse urination, or aggressive purging all deplete fluids, drying the stomach and binding the stool. The chapter repeatedly states "fluid loss, stomach dryness," "internal exhaustion of fluids," and "excessive sweating causing stomach dryness," using these to determine whether purging is appropriate and to prognosticate outcomes.
III. Purging Must Be Timed and Conditioned with Care
The chapter repeatedly emphasizes: "when the exterior syndrome has not resolved, do not attack the interior," "when vomiting is excessive, do not attack," "when there is hard and full oppression below the heart, do not attack," "when the pulse is faint and choppy, do not use Cheng Qi Tang again."