Loading...
Chapter 9 of 27
金匮要略
This chapter focuses on the pulse presentations, patterns, and treatment methods for three categories of lung-system diseases—Lung Atrophy, Lung Abscess, and Coughing with Reversed Qi Flow—and constitutes the core chapter on lung disease differentiation and treatment in the Synopsis of the Golden Chamber.
Someone asked: "When pathogenic heat lodges in the Upper Burner (the region above the diaphragm and chest, where the heart and lungs reside), it causes coughing that leads to Lung Atrophy. How does this Lung Atrophy disease come about?" The physician replied: "Some cases arise from excessive sweating, some from frequent vomiting, some from wasting-thirst (a condition of excessive drinking and urination) causing frequent urination and loss of fluids, and some from constipation where fluids are already depleted and then attacked with harsh purgatives, severely exhausting the body fluids—hence Lung Atrophy develops."
Question: "When the Cunkou pulse (the radial artery at the wrist) is rapid, the patient coughs, and the mouth conversely has turbid drool and thin sputum—what disease is this?" The physician replied: "This is Lung Atrophy. If the mouth is extremely dry, coughing is accompanied by dull chest pain, and the pulse is nevertheless slippery and rapid, this is Lung Abscess, which will discharge pus and blood. A rapid but deficient pulse indicates Lung Atrophy; a rapid but excess pulse indicates Lung Abscess."
Core differentiation point: Lung Atrophy belongs to deficiency, with exhaustion of fluids; Lung Abscess belongs to excess, with heat toxin stagnating to form pus. Although both present with coughing and a rapid pulse, their deficiency and excess patterns are fundamentally distinct.
Question: "When a patient coughs with reversed qi flow, how does one know through pulse diagnosis that it is Lung Abscess? Should there be pus and blood, and will the patient die if it is vomited out? To which category does this pulse belong?"
The physician replied: "The Cunkou pulse is faint and rapid. Faintness indicates wind pathogen; rapidity indicates heat pathogen. When the pulse is faint, there is a tendency to sweat easily; when rapid, there is aversion to cold. When wind pathogen injures the Defensive Qi (the protective qi at the body surface), expiration does not enter inward; when heat pathogen injures the Nutritive Blood (the refined substances moving within the vessels), inspiration does not exit outward. Wind pathogen injures the skin and body hair; heat pathogen injures the blood vessels. When wind pathogen lodges in the lung, the person coughs, has a dry mouth, wheezing, and a full chest. The throat is dry but without thirst, and the person frequently vomits turbid foam, with intermittent bouts of chills and shivering. Where heat pathogen passes, blood congeals and accumulates, forming pus abscess. The person vomits material like rice gruel. In the early stages, treatment can save the patient; once pus has fully formed, the prognosis is poor."
Reversed Qi Flow (qi rebelling upward with wheezing), facial edema, shoulder breathing (elevation of the shoulders during respiration, indicating labored breathing), a floating, large, but rootless pulse—this is difficult to treat. If accompanied by diarrhea, the condition becomes even more severe.
Reversed qi flow with wheezing and irritability belongs to Lung Distension and is about to develop into Wind-Edema (a type of edema disease). It can be cured by promoting sweating.
When Lung Atrophy presents with spitting of thin drool but without coughing, the patient does not thirst and will definitely have enuresis and frequent urination. This is because the Upper Burner is vacuous and cold, unable to control the Lower Burner. This is Cold in the Lung, and the patient will certainly experience dizziness, blurred vision, and copious drooling. Use Gancao Ganjiang Tang (Licorice and Dried Ginger Decoction) to warm the lung. If, after taking the medicine, the patient instead becomes thirsty, this belongs to wasting-thirst disease.
The following formula contents are provided for academic study of the principles and methods only, and do not constitute any medication guidance. The prescribing approaches of the ancients reflect the pattern-differentiation and treatment concepts of their time; in modern clinical practice, the original formulas and dosages are rarely used directly.
Composition: Honey-fried licorice (4 liang), blast-dried ginger (2 liang).
Principle and Method Explanation: Uses the method of pungent-sweet transformation of yang to warm and restore the yang qi of the lung. Dried ginger warms the middle and disperses cold; licorice supplements the middle and boosts qi. The two herbs combined are warming yet not drying, suited for upper burner yang vacuity with vacuity-cold in the lung. The ancients believed this formula could restore the lung's governing and regulating function, allowing fluids to be distributed properly rather than overflowing upward as drool or leaking downward as enuresis.
Composition: Shegan (belamcanda), Mahuang (ephedra), Shengjiang (fresh ginger), Xixin (asarum), Ziwan (aster root), Kuandonghua (coltsfoot flower), Wuweizi (schisandra), Dazao (jujube), Banxia (pinellia).
Principle and Method Explanation: Targets the pattern of "water-frog sound in the throat" (phlegm rumbling in the throat like a frog's croak) caused by cold-rheum congesting the lung with inhibited lung qi. Mahuang diffuses the lung and disperses cold; Shegan eliminates phlegm and benefits the throat; Xixin, Banxia, and Shengjiang warm and transform cold-rheum; Ziwan and Kuandonghua stop coughing and direct qi downward; Wuweizi astringes the lung to prevent over-disruption from the pungent dispersing herbs; Dazao protects the spleen and stomach. This formula embodies the principle that "rheum and phlegm diseases should be harmonized with warming medicinals."
Composition: Gleditsia (sincere-fried), made into honey pills, taken with jujube paste dissolved in water.
Principle and Method Explanation: Targets the severe pattern of stubborn phlegm congesting the lung with incessant coughing and reversed qi, where the patient "can only sit but cannot lie down to sleep." Gleditsia is pungent and salty, able to open obstructions, flush phlegm, and free the airways. However, its medicinal force is fierce, so honey pills moderate its nature and jujube paste protects the stomach. The ancients held that "once phlegm is eliminated, qi flows smoothly." This is a drastic formula for treating the branch, employed only for stubborn phlegm causing block and obstruction.
Composition: Houpo (magnolia bark), Mahuang (ephedra), Shigao (gypsum), Xingren (apricot kernel), Banxia (pinellia), Ganjiang (dried ginger), Xixin (asarum), Xiaomai (wheat), Wuweizi (schisandra).
Principle and Method Explanation: Targets the pattern of "coughing with a floating pulse," with the mechanism being external cold pathogen with internal rheum and heat. Mahuang diffuses the lung and releases the exterior; Houpo and Xingren direct qi downward and calm wheezing; Ganjiang, Xixin, and Banxia warm and transform cold-rheum; Shigao clears constrained heat; Xiaomai nourishes the heart and protects correct qi; Wuweizi astringes the lung. This formula combines cold and warm medicinals, and simultaneously diffuses and downbears—demonstrating channel-based treatment of complex mechanisms.
Composition: Banxia (pinellia), Zishen (or Ziwan/aster root), Zeqi (euphorbia), Shengjiang (fresh ginger), Baiqian (cynanchum), Gancao (licorice), Huangqin (scutellaria), Renshen (ginseng), Guizhi (cinnamon twig).
Principle and Method Explanation: Targets the condition of "a sunken pulse," indicating a deeper disease location with internal collection of water-rheum. Zeqi (also known as cat's-eye weed) disinhibits water and disperses phlegm as the sovereign herb; Baiqian directs qi downward and stops coughing; Zishen clears heat and dissipates masses; Huangqin clears lung heat; Banxia and Shengjiang transform phlegm and direct rebellious qi downward; Guizhi unblocks yang and transforms qi; Renshen and Gancao support rectification. This formula exemplifies the treatment principle of "supporting the correct and dispelling the pathogenic, combining attack and supplementation."
Composition: Maimendong (ophiopogon root, 7 sheng), Banxia (pinellia, 1 sheng), Renshen (ginseng), Gancao (licorice), Jingmi (rice), Dazao (jujube).
Principle and Method Explanation: Targets the pattern of "fire rebelling upward with qi, causing throat discomfort," with the mechanism being yin damage to the lung and stomach with vacuity-fire flaming upward. This formula uses large amounts of Maidong to moisten the lung and stomach, nourish yin, and clear heat as the sovereign, combined with Renshen, Gancao, Jingmi, and Dazao for sweet-moist supplementation of the middle; small amounts of Banxia direct rebellion downward, transform phlegm, without being drying. This formula is the representative prescription of the "cultivate earth to generate metal" method, embodying the Synopsis treatment principle of "when vacuous, supplement its mother."
Composition: Tinglizi (lepidium seed, stir-fried yellow and pounded into pills), Dazao (jujube, 12 pieces).
Principle and Method Explanation: Targets the excess pattern of water-rheum congesting the lung in "Lung Abscess with wheezing and inability to lie down." Tinglizi is bitter and cold, draining water-rheum and phlegm-heat from the lung with fierce force; Dazao protects the spleen and stomach, moderating its medicinal nature. This formula aims at treating the branch in acute presentations, restoring the lung's downbearing and depurating function by draining the lung and expelling water. Modern study should note: such attacking and expelling formulas were also not commonly or prolonged-use methods even in ancient times.
Composition: Jiegeng (platycodon root, 1 liang), Gancao (licorice, 2 liang).
Principle and Method Explanation: This is the representative formula for treating Lung Abscess "when pus has already formed." Jiegeng is pungent to open and bitter to discharge, able to expel pus and soothe the throat, carrying medicinals upward; raw licorice clears heat and resolves toxin. The two herbs combine to promote discharge of the abscess pus. The annotation after the formula states "take in divided warm doses, and pus and blood will be vomited, " indicating that the ancients considered drug-assisted expulsion of pus the key to treatment. This formula also became the ancestral formula of the later Paiyuan San and Paiyuan Tang (Pus Expelling Powders and Decoctions).
Composition: Mahuang (ephedra), Shigao (gypsum), Shengjiang (fresh ginger), Dazao (jujube), Gancao (licorice), Banxia (pinellia).
Principle and Method Explanation: Targets the severe pattern of Lung Distension with "eyes protruding as if about to pop out" (bulging eyeballs, describing extreme wheezing and shortness of breath). The Yuebi decoction was originally a formula for effusing and dispelling water qi; adding Banxia transforms phlegm and directs rebellious qi downward. Shigao clears lung heat; Mahuang diffuses the lung—one cold and one warm mutually restraining each other, together achieving the function of diffusing the lung, discharging heat, disinhibiting water, and calming wheezing. "Eyes protruding as if about to pop out" suggests intense water qi congestion with elevated ocular pressure; the ancients used the sweating method to resolve water qi from the exterior.
Composition: Mahuang (ephedra), Shaoyao (peony), Guizhi (cinnamon twig), Xixin (asarum), Gancao (licorice), Ganjiang (dried ginger), Wuweizi (schisandra), Banxia (pinellia), Shigao (gypsum).
Principle and Method Explanation: Targets Lung Distension with "water below the heart," with the mechanism being external cold with internal rheum complicated by constrained heat. Xiao Qinglong Tang disperses cold, transforms rheum, releases the exterior, and eliminates rheum; adding Shigao clears heat and eliminates vexation. This formula and Houpo Mahuang Tang are both cold-warm combined agents, yet Xiao Qinglong Jia Shigao Tang is more inclined toward releasing the exterior and transforming rheum, while Houpo Mahuang Tang is more inclined toward directing qi downward and calming wheezing.
Treats Lung Atrophy with copious drooling and a warm, fluidish sensation in the chest. This formula uses honey-fried licorice as the sovereign, combined with Renshen (ginseng), Dihuang (rehmannia), Ejiao (donkey-hide gelatin), Maidong (ophiopogon), Maren (hemp seed), Guizhi (cinnamon twig), Shengjiang (fresh ginger), and Dazao (jujube)—supplementing qi and nourishing blood, enriching yin and restoring the pulse. For Lung Atrophy with dual deficiency of qi and blood where the heart vessels are undernourished, the ancients employed this formula for regulation and supplementation.
Uses licorice alone as the sole ingredient, treating mild patterns of Lung Atrophy, deriving meaning from its sweet moistening to supplement the middle and relax urgency.
Treats Lung Atrophy with incessant coughing and spitting of drool, dry throat, and thirst. Uses Shengjiang (fresh ginger), Renshen (ginseng), Gancao (licorice), and Dazao (jujube) to warm the middle, supplement qi, transform rheum, and engender fluids—suited for Lung Atrophy with middle burner vacuity weakness and failure to distribute fluids.
Treats Lung Atrophy with spitting of drool. Removes the sour astringent Shaoyao (peony) from Guizhi Tang and adds the pungent warm Gleditsia to flush phlegm. The ancients believed Lung Atrophy is primarily vacuity, but if phlegm and drool are copious and congested, the obstruction must also be opened—hence removing Shaoyao's astringency and adding Gleditsia's unblocking action.
Treats Lung Abscess with formed pus in excess patterns. Composition: Jiegeng (platycodon root), Beimu (fritillaria), Badou (croton seed). Badou drastically purges cold accumulation, Jiegeng expels pus, Beimu transforms phlegm and disperses masses. This is a fierce attacking and expelling formula; after administration, the patient may vomit or purge, allowing pus toxin to drain from above and below. The annotation states "if excessive purging does not stop, drinking one cup of cold water will settle it, " demonstrating the ancients already recognized croton's violent nature and established countermeasures.
Treats Lung Abscess with "coughing with slight fever, vexation and fullness, and a scaly, crusted chest." Composition: Weijing (phragmites stem), Yiyiren (coix seed), Taoren (peach kernel), Guaban (melon seed—generally considered to be winter melon seed). This formula clears heat, transforms phlegm, dispels stasis, and expels pus—a classic formula for treating Lung Abscess. Weijing clears lung heat; Yiyiren disinhibits dampness and expels pus; Taoren quickens the blood and transforms stasis; Guaban moistens the lung and transforms phlegm. "Scaly, crusted chest" refers to rough, fish-scale-like skin on the chest, which the ancients considered a somatic manifestation of internal blood stasis.
Treats Lung Abscess with a full, distended chest, facial and facial edema, nasal congestion with nasal discharge, inability to distinguish fragrances, coughing with reversed qi flow upward, wheezing, and a sensation of urgency and blockage. This entry supplements the indications of Tingli Dazao Xiepai Tang and annotates the administration method: first use Xiao Qinglong Tang to disperse the exterior cold, then use this formula to drain the interior water—embodying the treatment principle of "exterior first, interior second. "
1. The "Deficiency vs. Excess Differentiation" Between Lung Atrophy and Lung Abscess is the Guiding Framework
This chapter establishes from the outset the core framework of Lung Atrophy belonging to deficiency and Lung Abscess belonging to excess (or deficiency-excess complex). Lung Atrophy arises from "severe loss of fluids," with its essence being exhaustion of lung yin and withering of the lung lobes—hence the pulse is rapid yet deficient. Lung Abscess arises from "wind-heat congesting the lung, blood congealing to form pus, " with its essence being heat toxin and stasis binding, flesh putrefying into pus—hence the pulse is rapid yet excess (or slippery and rapid). This deficiency-excess differentiation directly determines the treatment direction: for deficiency, warm, nourish, moisten, and supplement; for excess, attack, expel, and drain pus.
2. The "Treatability" vs. "Incurability" of Reversed Qi Flow Depends on the Survival or Demise of Correct Qi
"Reversed qi flow, facial edema, shoulder breathing, floating and large pulse—incurable"—a floating, large pulse may appear forceful, but if it is vacuous and rootless, it indicates true yang flaming outward and the kidney's failure to secure and absorb qi—a critical pattern. "Reversed qi flow with wheezing and irritability, belonging to Lung Distension, about to develop into Wind-Edema" still shows an opportunity for correct qi to struggle against the pathogen, and is resolvable through sweating. The ancient criterion for assessing prognosis was fundamentally an evaluation of whether correct qi can still hold its ground amid the struggle between pathogen and correct qi.
3. The Unique Recognition of "Cold in the Lung"
Lung Atrophy is not necessarily always yin vacuity with dry heat. This chapter explicitly identifies the pattern of "cold in the lung": due to yang vacuity of the upper burner with failure to control the lower, it presents with absence of thirst, enuresis, frequent urination, and copious drool. The treatment method is not to nourish yin and moisten dryness, but to warm the lung and restore yang. This exemplifies the core spirit of pattern-based treatment—same disease, different treatments; adapting to the pattern as it changes.
4. The "Staging" Concept in Lung Abscess Treatment
This chapter's discussion of Lung Abscess implies a timeline of disease evolution: wind-heat initially attacking the skin and body hair (faintly rapid pulse, aversion to cold, sweating) → pathogen entering the lung (cough, dry mouth, dry throat) → heat damaging the blood vessels, blood congealing to form pus (chills with shivering, rapid pulse, spitting of turbid, foul-smelling drool) → pus fully formed (vomiting like rice gruel). This evolutionary process indicates that "in the beginning, treatment can save; once pus is formed, death follows, " emphasizing early intervention.
5. The Essentials of Treating the Lung: Appropriate Diffusion and Downbearing, Fitting Attack and Supplementation
Surveying all the formulas throughout this chapter, treatment methods for lung-system diseases consistently revolve around the two concepts of "diffusion" and "downbearing. " Mahuang and Xixin diffuse and disperse externally; Xingren, Houpo, and Baiqian direct qi downward and calm wheezing; Wuweizi and Shaoyao astringe the lung to guard against over-dispersal; Shigao and Huangqin clear lung heat; Banxia and Shengjiang transform phlegm and direct rebellious qi downward; Renshen, Gancao, Dazao, and Jingmi protect and support the spleen and stomach. Attacking pathogens should not harm correct qi; supplementing vacuity should not constrain pathogens.
1. Correlation with Modern Respiratory Diseases
Certain manifestations of "Lung Atrophy" described in this chapter bear some comparability to modern pulmonary fibrosis, chronic wasting lung diseases: progressively worsening dyspnea, coughing, constitutional wasting, and states of fluid depletion. The ancients understood its causes from the angle of "fluid loss" (sweating, vomiting, purging, wasting-thirst)—which resonates to some degree with modern medical attention to chronic dehydration, nutritional disorders, and immune dysregulation—yet the ancients lacked direct recognition of pulmonary histopathological changes, and their description of "lung lobes withering" was more of a theoretical extrapolation.
2. Similarities Between "Lung Abscess" and Modern Lung Abscess
The description of "Lung Abscess"—coughing, chest pain, chills with shivering, vomiting of pus and blood like rice gruel—is highly consistent with the clinical manifestations of bacterial lung abscess, bronchiectasis with infection, and suppurative pneumonia. The description of "vomiting pus like rice gruel" is remarkably vivid. Without imaging or microbiology, the ancients could accurately determine "pus within the lung" through symptoms and pulse alone—a testament to meticulous clinical observation. The core pus-expelling herbs in formulas such as Jiegeng Tang and Weijing Tang (Jiegeng/platycodon, Weijing/phragmites, Yiyiren/coix) indeed demonstrate some anti-inflammatory, phlegm-transforming, and expectorant-promoting effects in laboratory studies; however, the ancients' therapeutic expectation of "vomiting pus and blood leads to recovery" should not be over-interpreted within the framework of modern medicine. Modern treatment of lung abscess is based on antimicrobial therapy, with drainage or surgery required in severe cases.
3. The Rational Core of "Treating Reversed Qi Flow with Sweating"
"Reversed qi flow with wheezing and irritability belongs to Lung Distension, about to develop into Wind-Edema; sweating will cure it"—in modern medicine, patients with cardiogenic asthma often present with fluid retention and a tendency toward edema. Loop diuretics alleviate dyspnea by eliminating water and reducing cardiac preload—a therapeutic logic that shares an underlying resonance with the ancient approach of "dispelling water through sweating to calm wheezing" at the level of removing the burden of fluid overload. However, "sweating" as a therapeutic method is rarely used in modern treatment of acute dyspnea, and its actual pharmacological mechanism also differs fundamentally from the ancients' understanding of "opening the ghost gate (pores)."
4. Historical Limitations
The following are general principles of daily care and do not target any specific disease:
This content is based on classical Chinese medicine texts and is provided solely for traditional culture study and research. It does not constitute any medical diagnosis, medication, or treatment advice. Please seek medical attention promptly if you feel unwell.