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Chapter 26 of 29
伤寒杂病论
Overall Paraphrase
This chapter focuses on the pulse manifestations, clinical presentations, and treatment approaches for cough, water-retention, water-qi diseases (including yellow sweat), and painful joint disease (arthralgia). The central theme throughout is: the same symptom may originate from different viscera and different pathogenic qi, and one must seek the root cause through combined pulse and symptom assessment, then apply methods such as sweating, promoting urination, attacking and expelling water-retention, and harmonizing nutritive and defensive qi — providing an outlet for pathogenic qi — based on the location of the disease and the trend of the pathological state.
The teacher said: Although cough is emitted from the lung, it is not exclusively a lung disease. When the five viscera and six bowels are affected by external pathogens, all can cause cough. The reason is that when pathogenic qi rebels upward, it inevitably disturbs lung qi; when lung qi is agitated, a cough sound is produced. To trace the root of the cough, one must examine the pulse.
If cough of the five viscera persists without resolution, it transmits to the corresponding bowel (interior-exterior relationship): Lung cough transmits to the large intestine, manifesting as cough with fecal incontinence; heart cough transmits to the small intestine, manifesting as cough with passing gas; liver cough transmits to the gallbladder, manifesting as vomiting of bitter water; spleen cough transmits to the stomach, manifesting as vomiting, and in severe cases, vomiting of roundworms; kidney cough transmits to the urinary bladder, manifesting as cough with urinary incontinence. Prolonged unresolved cough may also involve the triple burner, presenting with abdominal fullness and loss of appetite.
When cough is complicated by water-retention, the patient cannot lie flat — lying down immediately triggers gasp-like breathing—this is excess-type cough; inability to speak, with shortness of breath upon speaking, is deficiency-type cough. The pathological changes are manifold, and treatment methods differ accordingly.
The original text lists formulas according to different cough presentations: for cough with water-retention and a stringlike pulse, use Ten Jujube Decoction (Shizao Tang) to attack and expel water-retention; for cough with a croaking sound in the throat (like a water chicken), use Belamcanda and Ephedra Decoction (Shegan Mahuang Tang) to disperse cold, resolve fluid-retention, direct qi downward, and calm panting; for cough with rebellious qi, vomiting turbid phlegm, and being able only to sit but not to sleep, use Gleditsia Pill (Zaojia Wan) to eliminate phlegm and open the orifices; for cough with a floating pulse, use Magnolia Bark and Ephedra Decoction (Houpo Mahuang Tang) to diffuse the lung and resolve fluid-retention; for cough with a deep pulse, use Zeqi (Euphorbia) Decoction (Zeqi Tang) to expel water and activate yang; for cough with up-rushing qi, throat discomfort, and a rapid pulse, use Ophiopogon Decoction (Maimendong Tang) to moisten the lung, nourish the stomach, direct rebellious qi downward; for cough with rebellious breathing, inability to lie flat, and floating-stringlike pulse, use Minor Green Dragon Decoction (Xiao Qinglong Tang) to release the exterior, disperse cold, and resolve fluid-retention; for cough with chest fullness, chills, rapid pulse, dry throat without thirst, vomiting turbid and foul-smelling phlegm, and prolonged vomiting of pus resembling rice gruel, the ancients regarded this as lung abscess, treated with Platycodon Decoction (Jiegeng Tang) to expel pus; for cough with panting, eyes feeling as if protruding outward, and a floating-large pulse, this was considered lung distension, treated with Yuebi (Maidenhair Tree) plus Pinellia Decoction (Yuebi Jia Banxia Tang) or Minor Green Dragon plus Gypsum Decoction (Xiao Qinglong Jia Shigao Tang) to diffuse the lung and drain heat; for lung distension presenting with chest fullness, swelling of the entire body, face, and eyes, clear nasal discharge, and loss of smell, use Tingli (Lepidium) and Jujube Lung-Draining Decoction (Tingli Dazao Xiefei Tang) to drain the lung and expel water; for a condition resembling cough but not truly cough, with copious drooling of thin saliva and absence of thirst, this was considered lung cold, treated with Licorice and Dried Ginger Decoction (Gancao Ganjiang Tang) to warm the lung; for cough with incessant drooling of thin saliva, dry throat with thirst, and a floating-thin-rapid pulse, this was considered lung wilting (consumption), treated with Honey-Fried Licorice Decoction (Zhi Gancao Tang) to nourish yin and supplement qi.
Question: What is water-retention disease? The teacher said: Water-retention disease has four types, namely phlegm-rheum, suspending (hypochondriac) rheum, spillage rheum, and supportive (thoracic) rheum.
When water pathogen affects different organs, the manifestations differ: water in the heart causes pulsating sensations below the heart, shortness of breath, aversion to water, and no desire to drink; water in the lung causes vomiting of drool and desire to drink water; water in the spleen causes lack of qi and heaviness of the body; water in the liver causes distending fullness beneath the flanks, and sneezing causes flank pain; water in the kidney causes palpitations below the heart.
When there is retained fluid below the heart, there will be a cold area on the back about the size of a palm; coughing causes flank pain that pulls toward the supraclavicular fossa. When there is retained fluid in the chest, there is shortness of breath with thirst and pain in the four limb joints.
When one customarily eats little but drinks much water, water stagnates below the heart, and over time it becomes disease. In severe cases, palpitations occur; in mild cases, shortness of breath. If both pulse positions are stringlike, it indicates cold; if one side is stringlike, it indicates fluid-retention. Shortness of breath with mild fluid-retention should be treated by promoting urination.
The formulas listed in the text: Gansui and Pinellia Decoction (Gansui Banxia Tang) treats retained fluid with hardness and fullness below the heart; Poria, Cinnamon Twig, Atractylodes, and Licorice Decoction (Fuling Guizhi Baizhu Gancao Tang) treats phlegm-rheum below the heart with fullness in the chest and hypochondrium, and dizziness; Ten Jujube Decoction (Shizao Tang) treats suspending rheum with internal pain; Major Green Dragon Decoction (Da Qinglong Tang) and Minor Green Dragon Decoction (Xiao Qinglong Tang) induce sweating to treat spillage rheum; Mufangji (Aristolochia) Decoction (Mu Fangji Tang) and its modified versions treat supportive rheum in the diaphragmatic region; Alisma Decoction (Zexie Tang) treats supportive rheum with dizziness and blurred vision; Magnolia Bark and Rhubarb Decoction (Houpo Dahuang Tang) treats supportive rheum with chest fullness; Tingli and Jujube Lung-Draining Decoction (Tingli Dazao Xiefei Tang) treats supportive rheum with inability to lie flat and breathe; Minor Pinellia Decoction (Xiao Banxia Tang) treats supportive rheum with vomiting; Prickly Pear, Belamcanda, Lepidium, and Rhubarb Pill (Jijiao Lihuang Wan) treats water-qi in the intestines; Minor Pinellia plus Poria Decoction (Xiao Banxia Jia Fuling Tang) treats vomiting, dizziness, and palpitations due to water-qi in the diaphragmatic region; Five-Ingredient Powder with Poria (Wuling San) treats palpitations below the navel, vomiting of drool, and dizziness.
The teacher divided water-qi disease into five types:
Differentiation between wind edema and yellow sweat: Aversion to wind indicates wind edema; no aversion to wind, free urination, cold above the diaphragm, and copious saliva in the mouth indicate yellow sweat. When the cunkou pulse is deep and slippery, indicating water-qi within, with facial and eye swelling and fever, this is also called wind edema. Slight eyelid swelling, pulsating neck vessels, frequent coughing, and pitting edema of hands and feet on pressure also belong to wind edema.
Water in the five viscera also presents differently: water in the heart causes heavy body, shortness of breath, inability to lie flat, restlessness, and swelling of the genitals; water in the liver causes a large abdomen, inability to turn sides, and pain beneath the flanks; water in the lung causes body swelling, difficult urination, and loose stool resembling duck droppings; water in the spleen causes a large abdomen, heaviness of the four limbs, shortness of breath, and difficult urination; water in the kidney causes a large abdomen, umbilical swelling, lumbar pain, urinary obstruction, moist genitals, cold feet, and counter-flush emaciation of the face.
The general treatment principle is: For swelling below the waist, promote urination; for swelling above the waist, promote sweating.
Additionally, a distinction is made between water type (Shuifen) and blood type (Xuefen): When water disease occurs first followed by amenorrhea, this is called water type, which is easier to treat; when amenorrhea occurs first followed by water disease, this is called blood type, which is more difficult to treat.
Formulas from the text: Ephedra, Aconite, and Licorice Decoction (Mahuang Fuzi Gancao Tang) and Ephedra plus Atractylodes Decoction (Mahuang Jia Zhu Tang) treat water-qi disease with deep or floating pulses; Fangji (Aristolochia) and Astragalus Decoction (Fangji Huangqi Tang) treats wind edema with heavy body, sweating, and aversion to wind; Yuebi Decoction (Yuebi Tang) treats wind edema with generalized swelling; Fangji and Poria Decoction (Fangji Fuling Tang) treats skin edema with swelling and twitching of the four limbs; Licorice and Ephedra Decoction (Gancao Mahuang Tang) and Yuebi plus Atractylodes Decoction (Yuebi Jia Zhu Tang) treat internal water with generalized jaundice-like swelling of the body, face, and eyes.
Yellow sweat disease manifests as body swelling and heaviness, fever and thirst after sweating, sweat that stains clothing and is positively yellow like a phellodendron bark infusion. The teacher said: This is caused by entering water to bathe while sweating, allowing dampness to invade through the sweat pores. One may use Astragalus, Peony, and Cinnamon Twig Decoction (Huangqi Shaoyao Guizhi Tang) to harmonize nutritive and defensive qi, secure the exterior, and dispel dampness. If yellow sweat persists with heavy body, lightening after sweating, sweating above the waist only with no sweating below the waist, and slack pain in the lumbosacral region, use Cinnamon Twig plus Astragalus Decoction (Guizhi Jia Huangqi Tang).
Painful joint disease is characterized by joint pain. When the cunkou pulse is deep and weak, depth pertains to bone and weakness to sinews; depth pertains to the kidney and weakness to the liver. When one sweats and enters water, water pathogen injures the heart, causing joint pain and yellow sweat — this is called painful joint disease (Lijie).
Excessive consumption of sour flavors injures the sinews; when sinews are injured, they become slack and atonic — this is called "discharge (Xie)". Excessive consumption of salty flavors injures the bones; when bones are injured, they become frail and flaccid — this is called "withered (Ku)". When the two combine, it is called "severance and exhaustion (Duanxie)". When nutritive qi is blocked and defensive qi cannot act alone, both nutritive and defensive qi become deficient, the triple burner loses its governing function, the four limbs lose nourishment, the body becomes emaciated, but the feet become swollen, yellow sweat appears, and the two shins feel hot — this is painful joint disease.
When the Shaoyin pulse at the ankle is floating and weak, weakness indicates blood insufficiency and floating indicates wind; when wind and blood contend, pain arises as if twitching and pulling. In obese individuals with a choppy and small pulse, shortness of breath, spontaneous sweating, and joint pain with inability to flex or extend, this is mostly caused by sweating after drinking alcohol and then being exposed to wind.
Formulas from the text: Cinnamon Twig, Peony, Anemarrhena, and Licorice Decoction (Guizhi Shaoyao Zhimu Gancao Tang) treats limb and joint pain, emaciated body, swollen feet as if about to fall off, dizziness, and shortness of breath; Aconite, Ephedra, Astragalus, Peony, and Licorice Decoction (Wutou Mahuang Huangqi Shaoyao Gancao Tang) treats painful joint disease with severe pain and inability to flex or extend; Licorice and Ephedra Decoction (Gancao Mahuang Tang) and Yuebi plus Atractylodes Decoction (Yuebi Jia Zhu Tang) are selected according to pulse and symptoms.
When the cunkou pulse is slow and choppy, slowness indicates cold and choppiness indicates blood insufficiency; when the fuyang pulse is faint and slow, faintness indicates qi insufficiency and slowness indicates cold. Insufficiency of stomach qi causes cold hands and feet; disharmony of nutritive and defensive qi causes abdominal fullness and borborygmus. When yang qi fails to circulate, the body becomes cold; when yin qi fails to circulate, the bones ache. When yin and yang qi coordinate with each other, qi movement is able to operate — once the body's "great qi revolves," cold qi can be dispersed. This state is called qi-division (Qifen).
When qi-division presents with hardness below the heart, plate-like, with edges resembling a rotated cup, use Cinnamon Twig, Licorice, Ephedra, Fresh Ginger, Jujube, Asarum (Xixin), and Aconite Decoction (Guizhi Gancao Mahuang Shengjiang Dazao Xixin Fuzi Tang) to warm yang, disperse cold, promote sweating, and move qi; for hardness below the heart, plate-like, due to water-retention, use Immature Bitter Orange and Atractylodes Decoction (Zhishi Baizhu Tang) to move qi and disperse fluid-retention.
When there is difficulty in urination with water-qi and thirst, use Trichosanthes Root, Fritillaria (Qumai), and Dioscorea (Shuyu) Pill (Gualou Qumai Shuyu Wan); when water-qi is in the blood aspect, use Talc, Hair (Renshou), and Whitefish Bone Powder (Huashi Rengfa Baiji Yu San) or Poria, Atractylodes, and Salt Decoction (Fuling Baizhu Rongyan Tang).
All formulas above are recorded in the original text, reflecting the ancients' judgment of pathogenesis and treatment principles. They are provided for study purposes only and do not constitute medication guidance.
Cough "Is Not Exclusively a Lung Condition"
This is the most important holistic view of this chapter. The lung is the "canopy cover," vulnerable to pathogenic attack, but cough is merely an outlet. When pathogenic qi of the five viscera and six bowels rebels upward and attacks the lung, cough can result. Therefore, the ancients did not simply treat cough by suppressing it but determined which viscus was affected and by which pathogen through pulse and accompanying symptoms.
Identifying Pathogen and Location through Pulse Diagnosis
The text repeatedly employs the method of "base pulse plus accompanying pulse." For example, the lung cough base pulse is "short and choppy"; on this basis, floating indicates wind, tight indicates cold, rapid indicates heat, urgent indicates dryness, and soft indicates dampness. The heart cough base pulse is "large and scattered," the liver cough is "stringlike and choppy," and so forth. Although this pulse-based localization has a speculative character, it embodies the diagnostic spirit of combining pulse and symptoms.
Classification of Fluid-Retention Syndromes and "Guiding According to the Trend"
Phlegm-rheum, suspending rheum, spillage rheum, and supportive rheum are classified according to the different locations where water-retention stagnates. Treatment provides an outlet for pathogens: spillage rheum at the exterior is treated by sweating, suspending rheum internally stagnating is attacked and expelled, slight fluid-retention with shortness of breath is treated by promoting urination, and supportive rheum in the diaphragm is treated by expelling water and directing qi downward. This is consistent with the Inner Classic principle: "For what is on the exterior, sweat and dispel it; for what is below, guide and drain it."
Water-Qi Disease Relies on "Sweating and Diuresis" as Two Great Approaches
Edema above the waist calls for sweating; edema below the waist calls for promoting urination — these are the overall guidelines for water-qi disease. The essence is to follow the physiological trend of water metabolism: the upper region is close to the surface and can utilize the sweat pores; the lower region is close to the interior and can utilize the urinary bladder.
Yellow Sweat and Painful Joints Emphasize "Nutritive-Defensive Qi" and "Triggers"
Yellow sweat is attributed to entering water while perspiring, allowing water to enter through the sweat pores; painful joint disease is associated with entering water while sweating, exposure to wind after drinking alcohol with sweating, and injury to sinews and bones from sour and salty flavors. This highlights the ancient view that disease develops when nutritive-defensive deficiency combines with invasion of external pathogens.
Associated Concepts
Further Reading
Bu Gua invites you to approach the classics from a scholarly perspective: This content is based on classical Chinese medicine texts and is provided solely for the study and research of traditional culture. It does not constitute any medical diagnosis, medication, or treatment advice; if you feel unwell, please seek medical attention promptly.