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Chapter 4 of 27
金匮要略
Chapter 2: Pulse, Syndromes, and Treatment of Rigidity, Dampness, and Heatstroke
Overall Paraphrase
This chapter discusses the pulse manifestations, clinical presentations, and treatment principles for three categories of disorders: rigidity disease, dampness disease, and heatstroke disease (summer-heat affliction).
In Taiyang disease, if there is fever, no sweating, and instead pronounced aversion to cold, it is called rigid rigidity. In Taiyang disease, if there is fever, sweating, and no aversion to cold, it is called soft rigidity. In Taiyang disease, if there is fever with a deep and thin pulse, it is also designated as rigidity disease and is considered a difficult-to-treat condition. If sweating is induced excessively in Taiyang disease, causing damage to body fluids, rigidity disease may also develop. If wind disease is erroneously treated with purging, rigidity will ensue; if sweating is then further induced, muscular tension and contraction of the limbs will inevitably appear. In persons with chronic sores and ulcers, even though the body is painful, sweating should not be induced; if sweating occurs, qi and blood are further damaged, readily triggering rigidity disease.
When the patient presents with generalized heat, cold feet, stiff and taut neck, aversion to cold, intermittent heat in the head, flushed face and red eyes, the head shaking alone, sudden trismus with clenched jaws, and opisthotonos with the back arching backward, these are manifestations of rigidity disease. If sweating is erroneously induced, cold and dampness combine, further depleting the superficial defensive qi, and aversion to cold will worsen. After sweating, the pulse may be tortuous and impeded like the movement of a snake. If the abdomen suddenly becomes distended, it is a sign that the disease is about to resolve. If the pulse remains unchanged—instead becoming deep, hidden, taut, and tense—rigidity disease persists. The pulse of rigidity disease is tight upon palpation, like a drawn bowstring, running straight upward and downward. If a patient with rigidity disease also has moxibustion sores, qi and blood have already been injured, making the condition more difficult to treat.
When the full complex of Taiyang disease symptoms is present, with the body stiff and uncomfortable, and the pulse instead deep and slow, this is rigidity disease. Ancient texts record the use of Gualou Guizhi Tang (Trichosanthes and Cinnamon Twig Decoction) as the primary treatment. This formula consists of Trichosanthes root, cinnamon twig, peony, licorice, fresh ginger, and jujube. After decoction, it is taken warm in three divided doses to induce slight sweating. If sweating does not occur, within the time of one meal, warm congee is drunk to assist sweating. This exemplifies the approach of generating fluids, resolving the muscle layer, and harmonizing nutritive and defensive qi to relax muscular tension.
In Taiyang disease with no sweating and conversely scanty urine, qi rushing upward to the chest, and trismus with inability to speak, rigidity rigidity is about to occur. Ancient texts record Gegen Tang (Pueraria Decoction) as the primary treatment. The formula consists of Pueraria, ephedra, cinnamon twig, peony, licorice, fresh ginger, and jujube. Ephedra and Pueraria are decocted first, the foam is skimmed off, then the remaining ingredients are added. After taking warm, the patient covers themselves to induce a slight sweat; consuming congee is not necessary. This formula embodies the therapeutic approach of opening the exterior, promoting sweating, ascending fluids, and relaxing the sinews.
For rigidity disease presenting with chest fullness, trismus, the back unable to touch the mat when lying supine, calf muscle cramps and contracture, and the upper and lower teeth grinding together, ancient physicians considered the use of Da Chengqi Tang (Major Purgative Decoction). The formula consists of rhubarb, houpo (magnolia bark), zhishi (bitter orange), and mirabilite. Houpo and zhishi are decocted first, then rhubarb is added, and mirabilite is added last. The decoction is taken warm in two divided doses and discontinued once bowel movements become free. This exemplifies the therapeutic concept of urgently purging to preserve yin, unblocking the bowels, and draining heat to arrest rigidity.
In Taiyang disease, with joint pain and vexatious restlessness, and a deep and thin pulse, this is called dampness bi (damp impediment). The characteristic features of dampness bi are scanty urine and conversely loose stools; the treatment principle should be to promote urination. Dampness as a pathogenic factor commonly manifests as generalized pain, fever, and a yellow complexion like that of smoke staining. In dampness disease, the patient manifests sweating only on the head, a stiff and taut back, and a desire to cover oneself and face the fire for warmth. If purging is prematurely employed, hiccups may occur, or chest fullness, scanty urine, and a greasy, turbid tongue coating may develop. This is because there is heat in the lower burner and cold in the upper burner—the patient is thirsty and wishes to drink but cannot, with dry mouth and vexatious distress.
After erroneous purging in dampness disease, if sweating appears on the forehead, slight wheezing occurs, and urination is free-flowing, the prognosis is poor. If diarrhea becomes unabating, this also constitutes a critical condition.
When wind and dampness combine and attack, generalized body pain ensues, which should normally be resolved through sweating. If heavy continuous rain occurs and the physician states that sweating may be induced, yet the disease does not improve after sweating, the reason is that vigorous sweating only eliminates the wind pathogen while the dampness remains; hence the condition does not resolve. In treating wind-dampness through sweating, one should cause the body to have a slight, delicate sweat, so that both wind and dampness may be eliminated together.
If a dampness patient manifests body pain with fever, yellow facial complexion, wheezing, headache with nasal congestion, vexation, a large pulse, normal appetite, and no disorder in the abdomen, this is cold-dampness affecting the head; hence the nasal congestion. Ancient methods prescribed the insertion of medicinals into the nose to effect a cure.
For dampness disease with generalized vexatious pain, ancient physicians considered Mahuang Jia Zhu Tang (Ephedra plus Atractylodes Decoction) to induce slight sweating, with a specific warning against the use of fire therapy. The formula consists of ephedra, cinnamon twig, licorice, apricot kernel, and atractylodes. Ephedra is decocted first with foam removed, then the other ingredients are added; the decoction is taken warm to induce a slight sweat.
When a patient manifests generalized pain with fever that intensifies in the afternoon and toward evening, this is termed wind-dampness. This condition typically arises from sweating while exposed to wind, or from prolonged exposure to cold and dampness. Ancient physicians considered Mahuang Xingren Yiyi Gancao Tang (Ephedra, Apricot Kernel, Coix, and Licorice Decoction) as the appropriate treatment. The formula consists of ephedra, licorice, coix seed, and apricot kernel. After taking, a slight sweat should be induced, with avoidance of wind.
For wind-dampness with floating pulse, heavy and cumbersome body, sweating, and aversion to wind, ancient texts record Fangji Huangqi Tang (Stephania and Astragalus Decoction) as the primary treatment. The formula consists of fangji (Stephania tetrandra), licorice, atractylodes, and astragalus, with fresh ginger and jujube added in decoction. The original formula's modifications mention adding ephedra for wheezing, peony for stomach disharmony, cinnamon twig for qi rushing upward, and asarum for lingering cold in the lower burner. After taking, there may be a sensation akin to worms crawling beneath the skin—signifying the herbs dispersing water-dampness through the exterior; if coldness is felt below the waist as if against ice, one should cover warmly to induce a slight sweat. This reflects the approach of harmonizing the defensive exterior and simultaneously draining dampness while securing the surface.
In cold damage of eight to nine days' duration with wind-dampness combining, causing painful vexation in the body such that the patient cannot turn around by themselves, no vomiting, no thirst, and a floating, vacuous, and choppy pulse, ancient texts record Guizhi Fuzi Tang (Cinnamon Twig and Aconite Decoction) as the primary treatment. If the stools are hard and urination is spontaneous, Qu Gui Jia Baizhu Tang (Atractylodes and Aconite Decoction, also known as Baizhu Fuzi Tang) is used as the primary treatment. The former formula consists of cinnamon twig, fresh ginger, aconite, licorice, and jujube; the latter consists of atractylodes, aconite, licorice, fresh ginger, and jujube. If after taking the decoction there is numbness of the body or dizziness and blurred vision, this reflects the action of atractylodes and aconite dispersing water-dampness through the skin; one need not be alarmed.
When wind-dampness combines, causing severe bone and joint pain with pulling and traction sensations, inability to flex or extend, severe pain on touch, sweating, shortness of breath, scanty urine, aversion to wind with reluctance to remove clothing, or slight swelling of the body, ancient texts record Gancao Fuzi Tang (Licorice and Aconite Decoction) as the primary treatment. The formula consists of licorice, atractylodes, aconite, and cinnamon twig, taken warm to induce a slight sweat.
In Taiyang summer-heat stroke, there is fever with aversion to cold, heavy and painful body, and a pulse that is thin, wiry, and faint. After urination, there is chills with goosebumps, cold extremities of hands and feet, and with the slightest exertion the body becomes feverish, with mouth open for breathing and dryness of the incisor teeth. If sweating is erroneously induced, aversion to cold worsens. If warm needling is used, fever worsens. If purging is repeatedly applied, urinary dribbling becomes more severe.
When the Taiyang channel is affected by summer-heat, this is "ye" (heatstroke). With sweating, aversion to cold, generalized heat, and thirst, ancient texts record Baihu Jia Renshen Tang (White Tiger plus Ginseng Decoction) as the primary treatment. The formula consists of anemarrhena, gypsum, licorice, japonica rice, and ginseng, decocted until the rice is cooked into a finished decoction, taken warm in three divided doses. This embodies the therapeutic approach of clearing summer-heat, replenishing qi, and generating fluids.
In Taiyang summer-heat stroke with generalized heat, pain, heaviness, and a faint pulse, this arises from excessive indulgence in cold water during summer months, with water-dampness retained in the skin. Ancient texts record Yiwu Guadi Tang (Single Melon Stalk Decoction) as the treatment. The formula consists of only one ingredient—melon stalk (Cucumis melo stalk)—decocted and taken in a single dose. This is an ancient method, not used as routine treatment in modern times, and is provided for scholarly study only.
The above ancient formulas, compositions, and decoction and administration methods are all as recorded in the original classical texts and are provided solely for the study of traditional culture. They do not constitute medication guidance.
The core of rigidity disease lies in failure of sinews and vessels to be nourished, with wind pathogen damaging fluids. The distinction between rigid rigidity and soft rigidity lies in the presence or absence of sweating, reflecting differences between exterior excess and exterior deficiency. In treating rigidity disease, special emphasis is placed on "preserving body fluids": sweating should not be excessive, and erroneous sweating or purging will severely damage fluids, causing the sinews to lose nourishment and become taut. In terms of pharmacotherapy, soft rigidity is treated with Gualou Guizhi Tang to generate fluids and resolve the muscle layer; rigid rigidity with Gegen Tang to open the exterior and generate fluids; and rigidity due to exuberant Yangming heat with Da Chengqi Tang to drain heat and preserve yin—all embodying the principle of "preserving fluids and softening the sinews."
The key aspect of dampness disease is that dampness is heavy, turbid, and viscous-adherent in nature, easily damaging yang qi and obstructing qi movement. When dampness is in the exterior, slight sweating should be induced and vigorous sweating avoided; otherwise wind departs while dampness remains. When dampness is in the interior, presenting with scanty urine and loose stools, one should promote urination. Fire therapy is strictly prohibited in treating dampness, because fire methods readily damage fluids and augment heat, causing the dampness to become more congealed and fixed. In terms of pharmacotherapy, Mahuang Jia Zhu Tang and Ma Xing Yi Gan Tang are used for exterior dampness; Fangji Huangqi Tang for exterior deficiency with exuberant dampness; and Guizhi Fuzi Tang, Baizhu Fuzi Tang, and Gancao Fuzi Tang for yang deficiency with wind-dampness combative attack.
The core of heatstroke disease is summer-heat consuming qi and damaging fluids, often with concurrent dampness. In treating summer-heat disease, sweating, warm needling, and purging are all contraindicated, as all three further damage qi and yin. Baihu Jia Renshen Tang clears summer-heat, supplements qi, and generates fluids, representing the typical approach to heatstroke with fluid damage.
The stiff neck, opisthotonos, trismus, and other manifestations described in rigidity disease bear resemblance to certain central nervous system disorders, febrile convulsions, and tetanus in modern medicine, although ancient disease names cannot be simply equated with modern conditions. Regarding the notion that "excessive sweating induces rigidity," this can be understood in modern terms as dehydration and electrolyte disturbance after profuse sweating triggering muscle spasms—the ancient explanation of "body fluid depletion" has a certain degree of rationality.
The joint pain, heaviness, and limited mobility described in dampness disease overlap in symptoms with rheumatic and autoimmune diseases, chronic pain conditions, and edema. The ancient emphasis on slight sweating and promoting urination bears conceptual similarity to the modern rehabilitation principles of moderate exercise, promoting metabolism, and avoiding excessive expenditure. However, "dampness" as an etiological theory belongs to a traditional explanatory model that has not yet been directly confirmed by modern medicine.
Heatstroke disease has comparability with modern heatstroke and heat exhaustion. The heat-clearing, qi-supplementing, and fluid-generating approach of Baihu Jia Renshen Tang suggests the need to attend to both cooling and fluid replacement in heatstroke. However, severe heatstroke is an emergency condition requiring prompt medical attention and cannot rely on ancient formulas.
Drugs in these formulas such as aconite, ephedra, and melon stalk have relatively potent actions; dosage and processing methods differ between ancient and modern times, and melon stalk has notable toxicity—these must never be adopted without modification.
Bu Gua Reminder: This content is based on classical texts of traditional Chinese medicine and is provided solely for the study and reading of traditional culture. It does not constitute any medical diagnosis, medication, or treatment advice. If you are unwell, please seek medical attention promptly.