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Chapter 12 of 27
金匮要略
Overall Paraphrase
This chapter specifically discusses the pulse manifestations, treatment principles, and formulas for three categories of diseases: abdominal fullness, cold hernia, and retained food.
Examination of the Fuyang pulse (dorsalis pedis artery, assessing the qi of the spleen and stomach) revealing a slightly wiry pulse indicates abdominal fullness as the expected presentation; if the abdomen is not distended, then there will certainly be difficult defecation and pain in both flanks, which results from deficiency-cold rebelling upward from below, and should be treated with warming medicinals. In a patient with abdominal fullness, if pressing does not cause pain, it pertains to deficiency pattern; if pressing causes pain, it pertains to excess pattern. Excess patterns can be treated with purgation. In cases where the tongue coating is yellow and purgation has not yet been administered, the yellow coating will recede spontaneously after purgation.
Abdominal fullness that is intermittent—relieved and then returning to its former state—pertains to cold pattern and should be treated with warming medicinals.
A patient with a sallow complexion, irritability without thirst, cold excess in the chest, and incessant diarrhea has an unfavorable prognosis.
If the Cunkou pulse (radial artery at the wrist) is wiry, then there will be cramping pain beneath the flanks, accompanied by aversion to cold.
People with a constitutionally cold middle burner (spleen and stomach deficiency-cold) frequently yawn and have clear nasal discharge; if they have fever but normal complexion, they are prone to sneezing—this indicates that righteous qi is still capable of resisting pathogens.
In cold-middle-burner patients with diarrhea, it is due to internal deficiency; if they want to sneeze but cannot, it indicates that cold pathogen in the abdomen is relatively deep.
In thin individuals with pain around the navel, there must be invasion by wind-cold (wind-cold pathogen) and failure of grain qi to transport. If purgation is mistakenly applied at this point, righteous qi will necessarily rush upward causing distension; if it does not rush upward, then a glomus (stuffiness and obstruction) will form beneath the heart.
For disease of abdominal fullness with fever for ten days, a floating and rapid pulse, and the patient still being able to eat normally, Houpu Qiwu Tang governs.
Houpu Qiwu Tang formula: Banxia (Magnolia officinalis) eight liang, Gancao (Licorice) three liang, Dahuang (Rhubarb) three liang, Dazao (Jujube) ten pieces, Zhishi (Immature bitter orange) five pieces, Guizhi (Cinnamon twig) two liang, Shengjiang (Fresh ginger) five liang. Boil in one dou of water to obtain four sheng; take eight ge warm, three times daily. If vomiting, add Banxia (Pinellia) five ge; if diarrhea, remove Dahuang; if cold is pronounced, increase Shengjiang to half a jin.
For cold qi in the abdomen with intestinal rumbling like thunder, severe pain, rebellious fullness in the chest and flanks, and vomiting, Fuzi Jingmi Tang governs.
Fuzi Jingmi Tang formula: Fuzi (Prepared aconite) one piece (processed), Banxia (Pinellia) half sheng, Gancao (Licorice) one liang, Dazao (Jujube) ten pieces, Jingmi (Polished round-grained rice) half sheng. Boil in eight sheng of water until the rice is cooked and the decoction is complete; remove the dregs and take one sheng warm, three times daily.
For abdominal fullness and pain with constipation, Houpu Sanwu Tang governs.
Houpu Sanwu Tang formula: Houpu eight liang, Dahuang four liang, Zhishi five pieces. Boil in one dou and two sheng of water; first boil Houpu and Zhishi to obtain five sheng, then add Dahuang and boil down to three sheng. Take one sheng warm, discontinued once the bowels move freely.
For pressure-induced fullness and pain beneath the heart, this pertains to excess pattern, and purgation should be applied, with Da Chaihu Tang being appropriate.
Da Chaihu Tang formula: Chaihu (Bupleurum) half jin, Huangqin (Scutellaria) three liang, Shaoyao (Peony) three liang, Banxia (Pinellia) half sheng (washed), Zhishi four pieces (honey-fried), Dahuang two liang, Dazao twelve pieces, Shengjiang five liang. Boil in one dou and two sheng of water to obtain six sheng; remove dregs and decoct again; take one sheng warm, three times daily.
For abdominal fullness that does not decrease persistently, or decreases only insignificantly, purgation is necessary, with Da Chengqi Tang being appropriate.
Da Chengqi Tang formula: Dahuang four liang (washed with wine), Houpu half jin (peeled, honey-fried), Zhishi five pieces (honey-fried), Mangxiao (Mirabilite) three ge. Boil in one dou of water; first boil Houpu and Zhishi to obtain five sheng; remove dregs, add Dahuang and boil to obtain two sheng; then add Mangxiao and bring to a brief boil over gentle fire. Divide into two warm doses; discontinue once purgation occurs.
For severe cold pain in the chest and heart region, vomiting with inability to eat or drink, cold qi rushing upward from the abdomen with the abdominal wall rising like a head or foot shape, and pain attacking upward and downward that cannot be touched, Da Jianzhong Tang governs.
Da Jianzhong Tang formula: Shujiao (Zanthoxylum) two ge (dehydrated), Gangjiang (Dried ginger) four liang, Renshen (Ginseng) two liang. Boil in four sheng of water to obtain two sheng; remove dregs, add Jiaoyi (Maltose) one sheng, and simmer over gentle fire to obtain one and a half sheng. Divide into two warm doses; approximately one meal-time later, one may drink congee two sheng, then take the next dose. On that day, one should eat thin congee and keep warmly covered.
For pain on one side beneath the flank, with fever and a tight, wiry pulse, this pertains to cold pattern, and warming medicinals combined with purgation should be applied, with Dahuang Fuzi Tang being appropriate.
Dahuang Fuzi Tang formula: Dahuang three liang, Fuzi three pieces (processed), Xixin (Asarum) two liang. Boil in five sheng of water to obtain two sheng; divide into three warm doses. For robust individuals, boil to obtain two and a half sheng and take in three doses. After taking, wait the time it takes to walk four or five li, then take the next dose.
For cold qi rebelling upward with cold extremities, Chi Wan governs.
Chi Wan formula: Fuling (Poria) four liang, Wutou (Aconite root) two liang (processed), Banxia (Pinellia) four liang (washed) (one version uses Gui/Gui Zhi), Xixin one liang (in 《Qianjin》 Renshen is used instead). Grind all into fine powder, color with cinnabar, and make into pills with honey the size of sesame seeds. Take three pills with wine before food, two times daily and once at night; if no effect, increase the dose slightly, stopping only when effect is achieved.
Abdominal pain with a wiry and tight pulse: wiry indicates wei qi (yang qi circulating at the body surface) failing to circulate, hence aversion to cold; tight indicates cold congealing with loss of desire for food and drink. When righteous and pathogenic qi contend, cold hernia develops.
For cold hernia with pain around the navel, cold sweat during attacks, cold hands and feet, and a deep, wiry pulse, Da Wutou Jian governs.
Da Wutou Jian formula: Large Wutou five pieces (boiled, peeled, not cut into pieces). Boil in three sheng of water to obtain one sheng; remove dregs, add honey two sheng, and decoct until the water content is exhausted to obtain two sheng. Robust individuals take seven ge; weaker individuals take five ge. If not cured, take again the next day; one must not take twice in the same day.
For cold hernia with abdominal pain, flank pain, and abdominal cramping, Danggui Shengjiang Yangrou Tang governs.
Danggui Shengjiang Yangrou Tang formula: Danggui (Chinese angelica) three liang, Shengjiang five liang, Yangrou (Mutton) one jin. Boil in eight sheng of water to obtain three sheng; take seven ge warm, three times daily. If cold is pronounced, increase Shengjiang to one jin; if pain is severe with vomiting, add Jupi (Tangerine peel) two liang and Baizhu (Atractylodes) one liang.
For cold hernia with abdominal pain, cold extremities, numbness and loss of sensation in hands and feet, accompanied by generalized body pain, where moxibustion, acupuncture, and various medicinals have all failed, Dizhuang Wutou Guizhi Tang governs.
Wutou Guizhi Tang formula: Single-ingredient Wutou, decocted in two jin of honey until reduced by half; remove dregs, and mix with five ge of Guizhi Tang to obtain one sheng of medicinal liquid. Initially take two ge; if no effect, take three ge; if still no effect, increase to five ge. When effective, the patient feels like being inebriated; if vomiting occurs, it indicates the medicinals have hit the disease.
Guizhi Tang formula: Guizhi three liang (peeled), Shaoyao three liang, Gancao two liang (honey-fried), Shengjiang three liang, Dazao twelve pieces. Boil in seven sheng of water over gentle fire to obtain three sheng; remove dregs.
A rapid and tight pulse is equivalent to a wiry pulse, shaped like a bowstring, hard and immovable upon palpation. A rapid and wiry pulse: one should warm and purge the cold; a tight, large, and slow pulse: there will certainly be hardness beneath the heart; a large and tight pulse indicates yang within yin, and it can be purged.
Attached Formulas:
Waitai Wutou Tang: Treats cold hernia with acute twisting pain in the abdomen, thieves's wind attacking the five viscera, cramping with inability to turn over, attacks occurring at set times, causing contraction of the genitals and reversal cold of the hands and feet (formula seen previously).
Waitai Chaihu Guizhi Tang formula: Treats sudden pain in the heart and abdomen.
Chaihu four liang, Huangqin, Renshen, Shaoyao, Guizhi, Shengjiang each one and a half liang, Gancao one liang, Banxia two and a half ge, Dazao six pieces. Boil in six sheng of water to obtain three sheng; take one sheng warm, three times daily.
Waitai Zouma Tang: Treats sudden visitation by evil qi, heart pain with abdominal distension, and constipation.
Xingren (Apricot kernel) two pieces, Badou (Croton seed) two pieces (peeled and cored, boiled). Wrap both together in cotton and pound into fragments; add two ge of hot water, squeeze to extract the white juice and drink. This will produce purgation. Reduce the dose for the elderly and children. It universally treats feishi and guiji diseases.
Someone asks: When a patient has retained food, how does one distinguish it? The master answers: The Cunkou pulse is floating and large; upon firm pressing it is conversely hesitant, and the Chi pulse is also faint and hesitant. Therefore, one knows there is retained food. Da Chengqi Tang governs.
A rapid and slippery pulse pertains to excess; this indicates retained food. Purgation will cure it, and Da Chengqi Tang is appropriate.
Diarrhea with lack of desire for food and drink indicates retained food, and purgation should be applied, with Da Chengqi Tang being appropriate.
Da Chengqi Tang formula (see previously in the chapter on convulsions)
For retained food in the upper burner (upper portion of the stomach), the emetic method should be used, with Guadi San being appropriate.
Guadi San formula: Guadi (Muskmelon pedicel) one fen (dry-fried yellow), Chixiaodou (Red adzuki bean) one fen (boiled). Pound both together into a powder. Boil seven ge of Xiangchi (Fermented soybean) to obtain the juice, mix with one qianchi of the powder, and take warm. If vomiting does not occur, increase the dose slightly, stopping only when a free and thorough vomiting is achieved. (Those with blood loss and deficient constitutions should not use it.)
A tight pulse that turns like a twisting rope without constancy indicates retained food.
A tight pulse with headache, wind-cold, and undigested retained food in the abdomen.
The core academic thought of this chapter lies in using deficiency-excess and cold-heat as the guiding principle to govern the pattern differentiation and treatment of the three major conditions: abdominal fullness, cold hernia, and retained food, centrally embodying Zhang Zhongjing's diagnostic spirit of "observing the pulse and pattern, knowing where the violation lies, and treating according to the pattern."
I. Distinguishing Deficiency and Excess in Abdominal Fullness—"Absence of pain on pressure is deficiency; pain on pressure is excess"
This is the guiding principle of pattern differentiation for the entire chapter. The ancients used abdominal palpation to determine the nature of disease: if pressing does not cause pain, it indicates that there is no accumulation of substantive pathogen in the abdomen, and it pertains to deficiency-cold, which should be treated with warming and supplementation; if pressing causes pain with guarding, it indicates stagnation of substantive pathogen (retained food, dry feces, qi stagnation), which can be purged. This "deficiency-excess" dichotomy runs throughout the chapter: Houpu Qiwu Tang treats abdominal fullness with simultaneous exterior-interior involvement; Houpu Sanwu Tang treats abdominal fullness due to qi stagnation and constipation; Da Chaihu Tang treats fullness and pain beneath the heart due to combined shaoyang-yangming disease; Da Chengqi Tang treats abdominal fullness that does not decrease due to excess-heat with dry bound feces—these four formulas progress layer by layer, from treating both exterior and interior to purely purging interior excess, embodying the layered approach of "same disease, different treatments." Meanwhile, Fuzi Jingmi Tang and Da Jianzhong Tang are representative warming methods for deficiency-cold abdominal fullness.
II. Distinguishing Cold Congealing in Cold Hernia—"Wiry and tight contending with each other, that is cold hernia"
The essence of cold hernia is cold pathogen congealing and stagnating, with yang qi failing to circulate. A wiry pulse indicates pain and cold; a tight pulse indicates cold congealing and contraction; the simultaneous presence of wiry and tight indicates cold congelation with qi stagnation and cramping of the channels and vessels, hence the presentation of severe pain around the navel, cold hands and feet, and profuse cold sweat. The highlight of treatment is "purging with warming medicinals"—Dahuang Fuzi Tang uses Dahuang paired with Fuzi and Xixin, combining warming yang with purgation, pioneering the method of warming purgation; Da Wutou Jian uses Wutou, which is greatly acrid and greatly hot, paired with honey for its sweet and slowing properties, administering a potent medicine gradually; Danggui Shengjiang Yangrou Tang, as a dietary therapy, warms and nourishes qi and blood and disperses cold to relieve pain, embodying the treatment principle of "warming the insubstantial with qi, supplementing the deficient with flavors."
III. Distinguishing Retained Food by Pulse—"Hesitant and slippery"
In distinguishing retained food, Zhang Zhongjing does not rely purely on asking "what did the patient eat," but rather infers from the pulse: when retained food stagnates, the qi and blood circulation is impeded, and the pulse becomes hesitant; if retained food transforms into heat and the pathogen is exuberant with excess, the pulse becomes rapid and slippery. Treatment methods are divided by upper and lower: for retained food in the upper burner, Guadi San is used to induce vomiting; for retained food in the lower part, Da Chengqi Tang is used to attack downward, completely following the principle from the Suwen·Yinyang Yingxiang Da Lun of "that which is high, expel it upward; that which is low, drain it downward."
IV. The Holistic View Centered on the Spleen and Stomach
Although the chapter discusses three diseases, the disease location never departs from the spleen and stomach. Abdominal fullness is obstruction of spleen-stomach qi movement; cold hernia is spleen-stomach yang qi being trapped by cold pathogen; retained food results from insufficient spleen-stomach transportation and transformation. In all the formulas for abdominal fullness, whether warming and purging or cold purging, the ultimate goal is to restore the ascending and descending mechanism of the spleen and stomach. Da Jianzhong Tang uses Renshen and Jiaoyi (maltose) to fortify the central qi; Fuzi Jingmi Tang uses Jingmi, Dazao, and Gancao to protect stomach qi; even Da Chengqi Tang, a potent purgative, emphasizes "once purgation occurs, do not take the remainder"—stop once effect is achieved, without harming stomach qi. This thought of "preserving stomach qi" is a consistent main line throughout the Zhang-Zhongjing tradition.
Aspects that can be corroborated from the modern perspective:
Objectivity of abdominal palpation: Pressing the abdomen to determine deficiency and excess has common ground with modern clinical abdominal palpation. Abdominal muscle tension, tenderness, and rebound tenderness are indeed important signs of acute abdomen; "pressure-induced fullness and pain beneath the heart" suggests the possibility of organic disease in the upper abdomen. The ancients' empirical observations still hold clinical reference value today.
The wisdom of warming purgation: The combination approach of Dahuang Fuzi Tang—Dahuang paired with Fuzi—is still used in contemporary TCM clinical practice for cold-accumulation constipation and certain acute abdominal conditions. From a pharmacological perspective, the anthraquinone components in Dahuang stimulate intestinal motility, while the aconitine components in Fuzi have analgesic, cardiotonic, and circulation-improving effects; processed and combined rationally, they achieve the effect of "unblocking without harming righteousness."
The soundness of dietary therapy formulas: Danggui Shengjiang Yangrou Tang, as a warming and nourishing dietary therapy formula, has a rationale in its high protein, high caloric, iron, and vitamin content for replenishing nutrition in deficiency-cold constitutions. Modern nutritional science also recognizes mutton's warming and nourishing effects and danggui's blood-circulation-promoting action.
Historical positioning of emetic methods: Guadi San uses guadi (muskmelon pedicel) to induce vomiting and expel gastric contents, a principle similar to the "gastric emptying" concept of modern emergency gastric lavage. However, the cucurbitacins in guadi are quite toxic, and the toxic dose is close to the effective dose—it is now essentially no longer used. Badou (croton seed) is likewise a highly toxic purgative, and the use of Zouma Tang would be completely unacceptable today.
Limitations that require honest acknowledgment:
Among the formulas in this chapter, Wutou, Fuzi, Badou, and Guadi are all relatively toxic medicinal substances. The lethal dose of aconitine is extremely low (approximately 2–3 mg). Although the ancients' processing and decocting methods had some toxin-reducing effect, the safety profile is far below modern standards. Da Wutou Jian uses five pieces of Wutou boiled down to one sheng—without strict processing and decoction control, the risk of poisoning is extremely high. These formulas cannot be self-administered in modern times.
The descriptions of "feishi" (flying corpse) and "guiji" (ghost attack) clearly carry the disease concept coloring of ancient shamanic medicine, attributing sudden severe cardiothoracic pain and fainting to ghosts and spirits. This is a historical limitation and should be viewed rationally. Modern medicine understands that such symptoms may correspond to life-threatening diseases such as acute myocardial infarction, aortic dissection, and acute abdomen.
Descriptions of "pulse images" such as "tight pulse like a twisting rope without constancy" carry an individualized and experiential hue; the subjectivity of pulse diagnosis makes it difficult to obtain objective verification within the framework of modern medicine.
From the etiologies of cold hernia and cold abdominal fullness in this chapter, general principles of daily care can be extracted:
Avoid cold and keep warm: The direct triggers of cold hernia and deficiency-cold abdominal fullness are invasion by cold pathogen. In daily life, one should pay attention to keeping the abdomen, lower back, and back warm, avoid indulgence in cold food and drink, and especially in cold seasons, those with weak constitutions should protect the navel area and feet. 🌿
Eat and drink with moderation: The root cause of retained food disease is exactly dietary intemperance and binge eating. One should keep regular timing, adequate quantities, and chew thoroughly, with moderate activity after meals, neither over-hungered nor over-full. The ancient warning of "when retained food is in the upper burner, induce vomiting" reminds us: when discomfort occurs from overeating, letting the stomach naturally empty itself is far safer than toughing it out or blindly using purgatives. 🍚
The medication philosophy of stopping once effective: This chapter repeatedly emphasizes "stopping once the bowels are facilitated," "once purgation occurs, do not take the remainder," and "stopping when improvement is achieved." This cautious attitude is worth emulating for modern readers—any conditioning or treatment method should be applied in appropriate measure; going too far is as bad as not going far enough.
The deficient should be warmed and nourished: Those with deficiency-cold constitutions may appropriately select warming food ingredients (such as mutton, ginger, and jujube) in their daily diet, but it should be noted: this is self-care at the dietary level, targeted at no specific condition, and by no means a substitute for formal medical treatment. ⚠️
Related concepts:
Further Reading:
This content is based on classical traditional Chinese medicine texts and is provided solely for traditional cultural learning and study. It does not constitute any medical diagnosis, medication, or treatment advice; please consult a healthcare professional promptly if you experience any discomfort.