Huáng Yuán-Yù (黄元御) on the importance of center earth in physiological regulation

The following is a collection of notes gathered for research on a course I am developing on center earth physiology and pathology. This is a large subject, and therefore the following information is far from complete, but is merely presented here to provide a glimpse into this important concept of proper physiological movement and dynamics. 

In the majority of Huáng’s books, great importance is laid on proper physiological movement throughout the body. Huáng’s interpretations of formulas and disease mechanisms are usually described through the lens of the proper or faulty movement and breakdown of this dynamic. The basic tenet of this medicine is based on proper movement and interaction of yin and yang, and when describing physiology or pathology, the terms Shùn (顺) translated as ‘normal’, ‘favourable’ or ‘to follow the course of’, and Nì (逆), typically translated as ‘counterflow’ are used. In very simple terms, when the body is running in ‘Shùn’, all physical processes are in harmony, running along their proper course, resulting in a state of health. When ‘Nì’ occurs and the natural movement or order of things are running against their proper course, physiological processes start to break down, resulting in dis-ease. 

As can be seen from the image below, proper healthy movement in the entire human organism is dependant on this specific circular dynamic. Elucidation on this concept is not mentioned in many literary works, with the exception of Qing Dynasty scholar/physician Péng Zǐ-Yì’s (彭子益), Circular Movements in Ancient Chinese Medicine (圆运动的古中医学), a text primarily focused on these circular movements. 

Physiological Implications

The following commentary is essentially a translation of Huáng’s original chart, with a few extra tidbits added from some of his other works. 

“When ascending and descending are balanced, and yin and yang interact, this is referred to as center qi.”

Center Qi debilitation results in an obstruction to ascent and descent. 

Foot Taiyin Spleen governs ascent on the left – Foot Yangming Stomach governs descent on the right. 

When Kidney water is too cold, this results in diseases of the Essence. 

When the stomach fails to descend, the heart is unable to descend as well leading to excessive cold of kidney water due to lack of fire. 

Heart fire flaring results in diseases of the Shen. 

When the spleen fails to ascend, both the liver and kidneys are unable to ascend. When water fails to ascend, fire flares. 

** Proper movement of center qi ensures a good balance between water and fire. 

When liver wood is depressed, this results in blood diseases. 

When the spleen fails to ascend, wood is depressed. Because the liver stores blood, when wood is depressed, this results in blood disease. 

When the lungs are obstructed on the right, this results in qi diseases. 

When the stomach fails to descend, the lungs are also unable to descend. Because the lungs store the qi, obstructed metal leads to qi disease. 

Spleen dampness is the result of center qi non-transformation resulting in a failure to ascend or descend. This leads to the improper movement of both the clear yang and turbid yin. Another possibility is a yang deficiency in the body which leads to the earth being unable to descend. As a result dampness forms.

[Upper] – Lung-Metal and Heart-Fire —> descend through stomach-earth —> When stomach earth fails to descend, this leads to counterflow ascent of both metal and fire. 

[Lower] – Liver-Wood and Kidney-Water —> ascend through spleen-earth —> When the earth is weak or center earth yang is deficient this leads to earth dampness with a failure to ascend, and thus both wood and water sink. 

Musings on Bēn Tún Tāng

A formula I’ve been quite intrigued with for many years, and use quite often in clinic, is Bēn Tún Tāng from the Jīn Guì Yào Lüè. The following is a short translation from one of my favourite Qīng dynasty scholar/physicians Huáng Yuán-Yù, followed by some brief clinical musings written by myself. 

Huáng Yuán-Yù on Bēn Tún Tāng

Translated from the Cháng Shā Yào Jiě (长沙药解)

The Golden Cabinet’s Bēn Tún Tāng

Gān Cǎo  2 liǎng

Bàn Xià 4 liǎng

Shēng Jiāng 4 liǎng

Shēng Gé (Gēn) 5 liǎng

Huáng Qín 2 liǎng

Xiōng Qióng 2 liǎng

Dāng Guī 2 liǎng

Sháo Yào 2 liǎng

Gān Lǐ Gēn Bái Pí 1 jīn 

This formula treats Bēn Tún qi, with surging into the chest, abdominal pain, and alternating heat and cold. When yang collapses, and the spleen is vanquished, (this causes) sinking and obstruction in Liver-wood, wood qi depressed effusion, and surging from the umbilicus, abdomen, chest and diaphragm, (resulting in) pain and concurrent heat and cold. Because Liver-wood surges upwards, both the stomach and gall-bladder run counterflow, and the Shaoyang is depressed and distressed, this results in a struggle between the interior and the yin, and this ongoing battle manifests with alternating cold and heat. The qi of Jué Yīn is wind-wood. When wind stirs it consumes the blood, and when warmth is depressed, it results in heat. Gān Cǎo supplements the earth and moderates the center; Shēng Jiāng and Bàn Xià descend stomach and gall-bladder counterflow; Huáng Qín and Shēng Gé (Gēn) clear depressed heat in the stomach and gall-bladder; Xiōng Qióng and Sháo Yào course wood and moisten wood dryness; Gān Lǐ Gēn Bái Pí clears the liver and descends surging qi. 

Gān Lǐ Gēn Bái Pí is sweet, cold, collecting and astringent. It is excellent at descending the surging qi of Jué Yīn, which can therefore treat bēn tùn. It is mainly indicated for alleviating thirst, eliminating vexing counterflow, arresting dysentery, and stopping vaginal discharge. 

Notes:

In my experience, Bēn Tùn (running piglet) can be both objective and subjective. Subjective in that the patient will feel some sort of rush that starts in the lower body, and rises either to the chest, throat, or face. It’s pretty hard to get a patient to tell you that they feel a surging sensation from their lower abdomen to their chest. Some do, but it’s not something I hear very often. Anxiety can manifest this way for some people, while some will tell you that they get facial redness, slightly dizzy or a bit of a rush when they are nervous. Another possibility for some is that this sensation, or ‘rush’ can cause patients to become anxious. I would interpret these manifestations as a form of running piglet. 

However, running piglet is also objective, manifesting in several ways such as; sudden sweating, facial redness, epigastric pain, chest tightness, shortness of breath, dizziness, headaches/migraines, premenstrual acne, etc.

This is due to a wood-earth pathology, where wood is abundant, which damages the earth, hence we see the abdominal pain. Since we have a Shào Yáng element here, there is alternating heat and cold (往来寒热), which can be interpreted the way Huáng Huáng (黄煌) does in that this alternating heat and cold can refer to anything that alternates, or occurs cyclically. This is a major feature of the Shào Yáng, and so having someone that breaks out into sweats, gets cyclical acne, cyclical migraines, anxiety attacks, etc., that is due to a wood-earth pathology, Bēn Tùn Tāng is a great choice. 

In addition, we have an element of a Jué Yīn pathology as well just to complicate things. Here, blood was affected which left a slight blood deficiency and when there is not enough blood and wood-qi tries to move, this can get stuck and lead to heat (which is the flaring of ministerial fire). 

Sāng Bái Pí is the most common substitute for the Gān Lǐ Gēn Bái Pí. Some doctors like Hu Xi-Shu used Chái Hú as they saw this pattern as a Shào Yáng-Tài Yīn concurrent pattern, and added Chái Hú to clear Shào Yáng heat from the chest. I personally use Sāng Bái Pí, as I feel that due to the flaring of ministerial fire, there is a bit of heat in the lungs and adding Sāng Bái Pí ensures that it gets cleared but also that metal descends. With the Spleen-earth affected, ascent and descent in the entire body is affected and we always need to make sure that the proper physiological wheel keeps turning. 

Huáng Yuán-Yù on Wú Zhū Yú Tāng

Wú Zhū Yú (吳茱萸): Acrid and bitter flavor, warm nature; enters the foot Yángmíng stomach, foot Tàiyīn spleen, and foot Juéyīn liver channels. Warms the centre, drains dampness, opens depression, breaks congealment, descends turbid yin to stop vomiting, and ascends clear yang to stop diarrhea. 

Cold Damage’s Wú Zhū Yú Tāng

Wú Zhū Yú (吳茱萸) 1 shēng

Rén Shēn (人蔘) 3 liǎng

Shēng Jiāng (生薑) 6 liǎng

Dà Zǎo (大棗) 12 pieces

Treats Yángmíng cold damage with a desire to vomit after eating. Normally, stomach qi descends, [which results] in the absence of vomiting on the intake [of food]. [When] stomach qi adversely ascends, this results in vomiting and reduced [food] intake. Rén Shēn and Dà Zǎo bank the earth and supplement the center; Wú Zhū Yú and Shēng Jiāng warm the stomach and descend counterflow. [This] treats Juéyīn disease with dry retching, vomiting of foamy drool, and headaches. 

Due to deficiency of the earth, wood becomes stagnant, centre qi is harmed, the stomach ascends as opposed to descending, and turbid qi is upthrusted, resulting in headaches and dry retching. 

When damp qi is congealed and stagnant, this results in vomiting of foamy drool. Rén Shēn and Dà Zǎo bank the earth and supplement the center; Wú Zhū Yú and Shēng Jiāng descend counterflow and course wood. [This] treats Shàoyīn disease with vomiting, diarrhea, reversal cold of the extremities, vexation, agitation and a desire to die. 

When cold water rebels against the earth, the spleen sinks and the stomach [runs] counterflow, which leads to both vomiting and diarrhea. [When] center qi is depleted, the four limbs lack warmth, resulting in reversal cold of the extremities. [When] yang departs from its root, it disperses and strays without returning, resulting in vexation, agitation and a desire to die. Rén Shēn and Dà Zǎo bank the earth and supplement the center; Wú Zhū Yú and Shēng Jiāng descend counterflow and ascend that which is sinking. 

In the Jīn Guì [this formula] treats vomiting and chest fullness. [When] the center is deficient and the stomach runs counterflow, turbid qi becomes congested in the chōng vessel, resulting in vomiting and chest fullness. Rén Shēn and Dà Zǎo bank the earth and supplement the center; Wú Zhū Yú and Shēng Jiāng descend counterflow and drain fullness. 

Huáng Huáng – A Bàn Xià Hòu Pò Tāng Case

Huang, 65-year-old male, 171cm/75kg. 

Initial consultation on January 29, 2019.

History: Superficial gastritis with ulceration for over 10 years. Patient reported that he often experienced abdominal pain after taking western medications as well as abdominal discomfort after eating fruit. He felt a sticky sensation in his umbilicus, and also experienced abdominal distention, belching, poor appetite, difficulty falling asleep, and had no issues with his bowel movements. He was worried that his digestive disease will develop into cancer, and therefore, his mood was quite poor. 

Signs: Robust build, double eyelids, frowning eyebrows, lively facial expressions, a red face, and dusky red lips. In addition, he procrastinated when he spoke. His abdomen was soft, there were purple stasis marks below his tongue, his throat was red, tongue coating slightly greasy, and his pulse was slippery. 

Prescription: jiangbanxia 15g, houpo 15g, fuling 15g, sugeng 15g, zhike 15g, zhizi 15g, lianqiao 30g, huangqin 10g; 9 packets; 3 days on, 2 days off. 

Second consultation on February 26, 2019: After taking the formula, his symptoms had improved. However, once stopping them, the symptoms returned, yet this time there was no abdominal pain, and only a feeling of discomfort, plus the location of the pain had now changed. He was also belching, had subcostal distention, and his sleep was reduced. 9 packets of the same formula with chenpi 20g was given; 3 days on, 2 days off. 

Selected Clinical Case Histories of Liú Dù-Zhōu – Gé Gēn Tāng

 

Li X, a 38-year-old male. He had suffered with stubborn migraines for 2 years, which had not resolved despite being treated for a long time. He was introduced to Doctor Liu by a good friend and brought in for a consultation. 

Chief complaint: right sided headaches, which commonly extended to the forehead and supraorbital ridge. This was accompanied by an absence of sweating, chills, a runny nose with clear mucus, irritability, a red complexion, dizziness, and poor sleep. During examination, the patients’ range of motion in his back was inhibited, and on inquiry, the patient reported that his neck and occiput usually felt tight, more severely so during his headaches. His tongue was pale with a white coat, and his pulse was floating and slightly rapid. 

This was differentiated as cold pathogens being lodged in the taiyang channels, resulting in symptoms of inhibited flow of channel qi. 

Treatment required the promotion of sweat to expel pathogens, and unblock taiyang qi, so Kudzu Decoction (gé gēn tāng) was given: 

Ephedrae Herba (má huáng) 4g
Puerariae Radix (gé gēn) 18g
Cinnamomi Ramulus (guì zhī) 12g
Paeoniae Radix alba (bái sháo) 12g
Glycyrrhizae Radix praeparata (zhì gān cǎo) 6g
Zingiberis Rhizoma recens (shēng jiāng) 12g
Jujubae Fructus (dà zǎo) 12 pieces

Ephedrae Herba (má huáng) and Puerariae Radix (gé gēn) were to be decocted first with the froth removed before adding the other ingredients. 

After taking the decoction, the patient was covered up so a slight sweat could be obtained. He was instructed to avoid cold drafts. 

After taking 3 packets, his back felt warm, which was followed by a mild sweat throughout the body, and a reduction in his headache and neck tension. 15 packets of the same formula was
prescribed again, which completely resolved his headaches and neck tension. 

Selected Clinical Case Histories of Liu Du-Zhou (Liú Dù-Zhōu lín zhèng yàn àn jīng xuǎn)

Spring Dawn by Mèng Hào Rán (春曉, 孟浩然)

 

 

 
孟浩然

 

 

春眠不覺曉,

處處聞啼鳥。

夜來風雨聲,

花落知多少。

Spring Dawn

Mèng Hào Rán

In spring sleep, dawn arrives unknowingly,

I hear crying birds everywhere.

From the sound of the wind and rain last night,

I wonder how many flowers fell?

Mèng Hào Rán  (689-740) was a famous Tang dynasty poet. In his later years preferring the life of a recluse, when Mèng was not visiting friends at their posts along the Cháng Jiāng river (Yangtze), including his close compadre Wáng Wéi (for which he wrote several poems), he  would be writing poetry while immersed in nature, primarily at his family seat in South mountain (南山) or in his hermitage on Lù Mén mountain (鹿門山) where he briefly lived in retreat. Mèng is often referred to as a ‘landscape poet’, for his beautiful reflections and writings on the landscapes around him, especially the ones around his hometown, modern day Hú Běi province.

Another five character quatrain poem, this and my previous poetry post (Wáng Wéi’s Deer Fence), are a couple of the most popular poems in modern day China, which can be recited by memory by many Chinese folk. Archie Barnes in his Chinese through Poetry describes this simple poem eloquently, “It describes the process of waking up in four successive stages: first, unconsciousness; second, the awakening of sensory perception; third, the awakening of memory; and fourth, the awakening of rational thought, giving full daytime consciousness.”

 

 

Lù Zhái (The Deer Fence) by Wáng Wéi (鹿柴, 王维)

 

鹿柴

王维[1]

空山不見人

但聞人語響

返景[2]深林

復照青苔上

 

Lù Zhái (The Deer Fence) [3]

Wáng Wéi

In (this) empty mountain[4], no one is seen,

But only the sounds of others are heard.

On return, (sun)light enters the deep forest,

And once again, it shines atop the green moss.

 

Notes:

This poem was written in the classic five-syllable quatrain form, which is the shortest of forms in Chinese poetry. How fitting that Wáng Wéi in his simple Buddhist, reflective tone would use this minimalistic style, requiring the reader to meditate on the characters, and visualize and conjure up their own ideas as to what the poet meant. Here, every character counts, and has the potential to hold a deeper meaning.


[1] Wang Wei (701-761) a Tang Dynasty poet was a devout Buddhist, having spent many years studying with his master Dao Guang. Wang’s poetry conveys beautiful imagery and his deep love of nature often using only a few characters, which were tinged with Buddhist themes throughout, showing the interconnections and relationships of all phenomenon in nature.

[2] Many commentators have said that ‘’ here is an alternate for ‘’ (reflection, shadow), however, I believe since 景 alludes to daylight and its resulting brightness this character makes more sense in the poem.  

[3] Lu Zhai is a place name, thought to be the location near Wáng Wéi’s cottage. This is in current Lán Tián county in Shǎn Xī province.

[4] Empty mountain (空山): The idea here is not simply of an ‘empty mountain’ or one devoid of any other humans or objects, as we know this is not the case, given that there is mention of a deep forest on this mountain. Although this may be what Wáng Wéi was alluding to, we can assume based on his Buddhist lens on the world, that the ‘empty ’ here was speaking to more of an ‘empty’ quality from the Buddhist perspective, the idea of a false or illusory nature of existence, and that all phenomenon have no reality.  As Lù Zhái was one of Wáng\’s retirement cottages, solitude may have been exactly what he was looking for and therefore the first definition also makes sense. This is the beauty of this style of poetry, as since we\’ll never know exactly what the poet meant, we can conjure up our own ideas and thoughts. 

The Classic Formulas (Jīng Fāng) System of Treatment Based on Pattern Identification By Féng Shì Lún

 
 
1.     What is Treatment Based on Pattern Identification
Pattern identification is a method in which (one) gathers disease responses and symptoms through the four diagnostic methods, and also uses Chinese medical theory to summarize and analyze (these responses) in order to distinguish the disease nature and location (and to have) a clear understanding of the disease signs. This is another step in elucidating the pattern involved, and this process is referred to as pattern identification. Determining treatment is essentially the use of medicinals in accordance with the pattern. The characteristic (of this process) is that both the patient and the doctor work together in gathering the symptoms (to obtain information), and the doctor, in accordance with Chinese medical theory, will summarize and analyze (these) to have a clear understanding of where these signs belong (information classification), in order to clearly define the pattern (treating the specific information), and use medicinals according to the pattern (information processing). This is the entire process involved in treating disease.
The pattern identification methods commonly used in Chinese medicine are: eight principles pattern identification, bowel and viscera pattern identification, qì, blood, liquids, and humors pattern identification, defensive qì and nutritive blood pattern identification, triple warmer pattern identification, channels and collaterals pattern identification, six conformation pattern identification, and so on. The Shāng hán lùn (傷寒論 Discussion of Cold Damage) specifically uses the six conformations pattern identification method.
2.    The Evolution of the Shāng hán lùn’s Treatment Based on Pattern Identification
Treatment based on pattern identification is also referred to as treatment based on pattern differentiation. The Chinese medicine use of formulas and medicinals to treat disease is a particularly traditional method, which has been put into practice for extensive periods of time by our ancestors through the ages to combat disease, and is summed up as a major extraordinary accomplishment. The earliest recording, which established and summarized these methods is found in the Decoction classic ().
  
3.     Discussion on the Six Conformations and Eight Principles
The Shāng hán lùn (傷寒論 Discussion of Cold Damage) used the six conformations as a method of division. Later commentators have stated that with the six conformations, one would only be confined to cold damage methods. In fact, the six conformations come from the eight principles (and are the) general principles behind (the treatment) of numerous diseases. In order to explain further, the following discussion will begin from the eight principles.
(1) Eight Principles [ ]
The eight principles refer to the exterior, interior, yīn, yáng, cold, heat, vacuity, and repletion. In actual fact, within the exterior and interior, there is also the half-exterior and half-interior, so really, they should be called the nine principles. However, the half-exterior, half-interior portion is usually discussed with the interior, so it is customary to simply refer to them as the eight principles.  I will now explain them in order.
The Exterior, Interior, and Half-Exterior Half-Interior: 
The exterior, interior, and half-exterior half-interior are essentially the location of a disease response.  The exterior refers to the exterior of the body, namely the skin, muscles, flesh, tendons, and bones, and anything, which constitutes the outer part of the body can be called the exterior.  If pathogenic factors accumulate and cause a reaction in this part of the body, we can call this an exterior pattern.  The interior refers to the inner aspect of the body, namely the esophagus, stomach, large intestine, and small intestine, and anything, which constitutes the digestive tract, is referred to as the interior. If pathogenic factors accumulate and elicit a response in this part of the body, this can be called an interior pattern.  The half-exterior half-interior portion refers to the exterior of the interior, and the interior of the exterior, which is namely the large space between the chest and abdomen. This is the location of all the organs and bowels, and is considered to be the half-exterior half-interior portion of the body. If pathogenic factors accumulate here and cause a reaction, this is called a half-exterior half-interior pattern.  It needs to be explained here that the exterior, interior, and half-exterior half-interior disease location responses are fixed, and regardless of what the disease is, (one needs to look at) the location of the disease response, whether it be in the exterior, interior, or half-exterior half-interior. In addition, two or even all three of these may sometimes appear simultaneously. It must also be emphasized that here when discussing disease location, it refers to the location of the response to the disease pathogens, and not to be mistakenly believed to be the location of the disease changes. That is to say, if there are pathological changes in the interior, but pathogenic factors have accumulated and caused a response in the exterior, this is referred to as an exterior pattern, and is also referred to as pathogens in the exterior or an exterior disease. For the same reason, even if a condition manifests with exterior symptoms, yet there is an accumulation of pathogenic factors with a response in the interior of the body, this is referred to as an interior pattern, for which it can also be said that pathogens are in the interior, or simply called an interior disease.
Yīn and Yáng: Yīn and Yáng refer to the nature of the pathological changes. Yīn has namely a yīn nature, and yáng a yáng nature. When a person contracts a disease, there will be a struggle between right (qì) and the pathogen. This will have not yet influenced any changes of bodily functions, and will particularly first make changes to metabolic functions. If this change is relatively abnormal, than it is called excessive, and if relatively normal, it is considered deficient. With excess, the body will correspond with and reflect hyperactivity, rising, and excited types of disease characteristics, which are referred to as a yáng pattern. With deficiency, the body will reflect decline, hypo-function, and inhibition types of deficient disease characteristics, which are referred to as a yīn pattern. 
Cold and Heat: 
Cold refers to a cold type of pattern, while heat refers to a hot type of pattern. If a patient reflects cold natured symptoms, then this is ultimately considered a cold pattern; if a patient reflects heat type symptoms, then this is referred to as a heat pattern. As was mentioned above in the explanation of yīn and yáng, cold is a reflection of deficiency, which belongs to yīn, therefore cold is also yīn, and heat is a reflection of excess, which belongs to yáng, so therefore heat must also be yáng.  However, cold and heat have characteristics of yīn and yáng, and if we generally say yīn, then indefinitely there must be cold, and if we say yáng, then there will indefinitely be heat. In instances of an absence of cold or heat in disease, this by no means indicates an absence of yīn or yáng.)
Vacuity and Repletion: 
Vacuity refers to a vacuous patient, while repletion refers to repletion of disease (factors). If a disease has not yet been resolved, and a patients’ energy is failing to sustain to some extent, the reflection of the body manifests a type of vacuous, debilitated state, which is typically referred to as a vacuity pattern. If the dynamics of the disease are advanced, and the patients’ energy is not vacuous, the body will manifest with disease characteristics of fullness and repletion, which would be referred to as a repletion pattern. From the aforementioned explanation, we are able to see that vacuity, repletion, cold and heat are similar, containing both yīn and yáng characteristics within them. When vacuity, repletion and cold intertwine with one another, there is still (either) yīn or yáng. For example, vacuity and cold are definitely yīn, but vacuity and heat is on the contrary yáng. Repletion and heat are most certainly yáng, however, repletion and cold would be considered yīn. In a yáng pattern it is possible to have heat, or repletion, or heat with repletion, no heat or no repletion, or even heat and vacuity. In a yīn pattern, we can have either cold, or vacuity, or vacuity with cold, no cold or no vacuity, or cold with repletion. This can be seen in the following chart.
 
 
(1) Six Conformations ()
The six conformations refers to the three yáng conformations of Tài Yáng, Yáng Míng, and Shào Yáng, and the three yīn conformations of Tài Yīn, Shào Yīn, and Jué Yīn. Although the Shāng hán lùn (傷寒論 Discussion of Cold Damage) refers to these as diseases, they are actually patterns, which come from the eight principles. I will now explain the relationships between them.
The so-called exterior, interior, and half exterior half interior, all reflect disease location, while yīn, yáng, cold, heat, vacuity, and repletion reflect the nature of the disease.  However, the manifestation of the disease nature must reflect the disease location, and the location of the disease will inevitably reflect the nature of the disease, therefore, without the nature of the disease, there is no location, and vice versa. Exterior, interior, or half exterior half interior patterns will always be accompanied by signs of either yīn, yáng, cold, heat, vacuity or repletion.  At the same time, yīn, yáng, cold, heat, vacuity, and repletion patterns will be accompanied by exterior, interior, or half exterior half interior signs. Therefore, regardless of whether it’s an exterior, interior, or a half exterior half interior pattern they will all be accompanied by various yīn and yáng signs and responses.  
Disease location and nature of the six conformations
Eight Principles
Disease nature
Six conformations
Disease location
Exterior
Yáng
Tài Yáng disease
Interior
Yáng
Yáng Míng disease
Half exterior half interior
Yáng
Shào Yáng disease
Interior
Yīn
Tài Yīn disease
Exterior
Yīn
Shào Yīn disease
Half exterior half interior
Yīn
Jué Yīn disease
The following are the representative lines from the Shāng hán lùn (傷寒論 Discussion of Cold Damage) for each of the six conformations with a small commentary.
“In Tài Yáng disease, the pulse is floating, the head and nape are stiff and painful, and there is aversion to cold” [line 1]
Commentary: Tài Yáng disease is an exterior yáng pattern. The characteristics signs of a Tài Yáng disease are a floating pulse, stiff and painful head and nape, and aversion to cold. With that being said, in any disease, whenever a floating pulse, a stiff and painful head and nape, and aversion to cold are seen, one can most certainly diagnose it as a Tài Yáng disease, thereby avoiding any errors.
“In Yáng Míng disease, the stomach domain is replete” [line 180]
Commentary:  Yáng Míng disease is an interior yáng pattern. The term ‘stomach domain is replete’ means that pathogens are full and replete in the stomach and intestines, and with palpation is hard with resistance and possibly painful on pressure. The general idea here is that any disease with a replete stomach domain, can definitely be considered a Yáng Míng disease.
“What are the external signs of Yáng Míng disease? Answer: generalized heat effusion, spontaneous sweating, and no aversion to cold, but aversion to heat” [line 182]
Commentary: The stomach domain being replete, is a Yáng Míng disease abdominal finding, and in addition there is also a Yáng Míng disease exterior pattern. Symptoms of generalized heat effusion, spontaneous sweating, and no aversion to cold, but aversion to heat exemplify the exterior pattern.  Any disease with these external signs can be diagnosed as a Yáng Míng disease.
“In Shào Yáng disease, there is a bitter taste in the mouth, dry throat, and dizzy vision” [line 263]
Commentary: Shào Yáng disease is a half exterior half interior yáng pattern. The characteristic symptoms for a Shào Yáng pattern are a bitter taste in the mouth, dry throat, and dizzy vision. Any disease with these characteristic signs could be diagnosed as a Shào Yáng disease.
 
“In Tài Yīn disease, there is abdominal fullness and vomiting, inability to get food down, severe spontaneous diarrhea, and periodic spontaneous abdominal pain. If purgation is used, there will be a hard bind below the chest” [line 273]
Commentary: Tài Yīn disease is an interior yīn disease. The characteristic symptoms of a Tài Yīn disease are abdominal fullness and vomiting, inability to get food down, severe spontaneous diarrhea, and periodic spontaneous abdominal pain. Any disease manifesting these characteristics can be diagnosed as a Tài Yīn disease. The abdominal fullness in a Tài Yīn disease is a vacuity type of fullness, which is quite different than the repletion fullness seen in a Yáng Míng repletion of the stomach domain disease. If one erroneously mistakes this for a repletion type of fullness and purges it, this will further increase the vacuity and cause a hard bind below the chest.
“In Shào Yīn disease, the pulse is faint and fine, and there is a desire only to sleep” [line 281]
Commentary: Shào Yīn disease is an exterior yīn pattern, which needs to be compared to a Tài Yáng pattern. Basically, if there is a Tài Yáng pattern with a faint and fine pulse, accompanied by a desire only to sleep, this can be diagnosed as a Shào Yīn disease.
Commentary: Jué Yīn disease is a half exterior half interior yīn disease. The symptoms which typically reflect a Jué Yīn disease are wasting thirst, qi surging upward to the heart, pain and heat in the heart, hunger with no desire to eat, and vomiting of roundworms after eating. Any disease seen with these symptoms can be considered a Jué Yīn disease. Half exterior half interior pattern cannot be purged, and it is especially strictly prohibited when they are yīn patterns. If one is not careful and erroneously uses purgation, then this will cause a calamity of incessant diarrhea.
1.     Summary of Treatment Principles
The so-called treatment principles are essentially the principle of determination of treatment based on six conformation and eight principles pattern identification.  I will now differentiate and give an account of these principles.
Tài Yáng disease: Because this is an exterior pattern, it is appropriate to effuse sweat, and not to purge nor cause vomiting. Formulas such as guì zhī tāng (Cinnamon Twig Decoction), má huáng tāng (Ephedra Decoction), and gé gēn tāng (Kudzu Decoction) are specific sweat effusing Tài Yáng disease formulas.
Shào Yīn disease: This is a type of Tài Yáng disease, and although they both belong to the exterior, for which sweating should resolve it, here sweat effusion must be combined with warm natured, stimulating medicinals such as fù zǐ (Aconiti Radix lateralis preparata), and xì xǐn (Asari Herba) in formulas such as guì zhī jiā fù zî tāng (Cinnamon Twig Decoction plus Aconite), má huáng fù zǐ gān cǎo tāng (Ephedra, Aconite Accessory Root Tuber and Licorice Decoction), and má huáng fù zǐ xì xīn tāng (Ephedra, Aconite Accessory Root Tuber and Asarum Decoction). These are specific Shào Yīn sweat effusing formulas.
Yáng Míng disease: When heat has bound in the interior and the stomach domain is replete, it is appropriate to purge it. However, when there is (simply) heat and no repletion (in the stomach domain), it is appropriate to simply clear heat. A typical purging formula would be one of the chéng qì tāng (Order the Qi Decoction) formulas, and bái hǔ tāng (White Tiger Decoction) to clear heat. If there is repletion in the chest, it is appropriate here to cause vomiting and not to purge using a formula such as guā dì sǎn (Melon Stalk Powder).
Tài Yīn disease: With interior vacuity and cold obstruction, only warming and supplementation is warranted. The promotion of sweat, vomiting and purgation are all contraindicated. Formulas such as lǐ zhōng tāng (Regulate the Middle Decoction), and sì nì tāng (Frigid Extremities Decoction) are typical Tài Yīn warming and supplementing formulas.
Shào Yáng disease: In half exterior half interior patterns, the appropriate method of treatment is to harmonize and resolve. Promoting sweating, vomiting and purgation are all unnecessary. xiǎo chái hú tāng (Minor Bupleurum Decoction) and huáng qín tāng (Scutellariae Decoction) are prototypical Shào Yáng harmonizing and heat resolving formulas.
Jué Yīn disease: Although this is also a half exterior half interior pattern, for which harmonizing and resolving are appropriate, this must be combined with warm, strengthening medicinals. Chái hú guì zhī gān jiāng tāng (Bupleurum, Cinnamon Twig, and Ginger Decoction) and wū méi wán (Mume Pill) are typical formulas for this pattern.
Cold and Heat: In cold patterns, warming medicinals should be used to expel cold such as gān jiāng (Zingiberis Rhizoma), fù zǐ (Aconiti Radix lateralis preparata), and wū tóu (Aconiti Kusnezoffi Radix) in combination with specific formulas. In heat patterns, cool and cold medicinals are used in order to eliminate heat such as huáng qín (Scutellariae Radix), zhī zǐ (Gardeniae Fructus), huáng lián (Coptidis Rhizoma), and shí gāo (Gypsum fibrosum) in combination with specific formulas.
Vacuity and Repletion: In vacuity patterns it is appropriate to use strengthening medicinals in order to supplement insufficiency. Sweat promoting, vomiting, and purgative medicinals are all contraindicated. Formulas such as zhì gān cǎo tāng (Honey-Fried Licorice Decoction), lǐ zhōng tāng (Regulate the Middle Decoction), and shèn qì wán (Kidney Qì Pill) are all used to supplement vacuity. In repletion patterns, sweat promoting, vomiting inducing, and purgation are all methods, which are utilized to thoroughly attack and eliminate pathogenic factors. Examples of attacking repletion formulas would be má huáng tāng (Ephedra Decoction) and dà chéng qì tāng (Major Order the Qi Decoction).
Case Example:
 
Guì Zhī Jiā Gé Gēn Tāng (Cinnamon Twig Decoction plus Kudzu)
On December 10, 1965 a twenty one-year-old female presented at the clinic. Yesterday she had contracted a common cold manifesting with symptoms of headache, dizziness, sweating, aversion to cold, weak pain in her shoulders and back, and a tight obstructive pain in the left side of her neck on rotation towards the left. She had a thin white tongue coating, and her pulse was floating and slightly rapid.
A floating, slightly rapid pulse, thin-white tongue coat, aversion to cold, sweating, and headaches signify a Tài Yáng wind strike pattern. Shoulder and back pain, and neck pain on left rotation of the head signify a gé gēn tāng (Kudzu Decoction) pattern. The dizziness indicates that the exterior has not yet been resolved, with upward surging of qì.
Comprehensive analysis: This is a Tài Yáng wind strike pattern with simultaneous stretched stiff nape and back, seen in a guì zhī jiā gé gēn tāng (Cinnamon Twig Decoction plus Kudzu) formula presentation.
Formula:
guì zhī (Cinnamomi Ramulus) 10g
bái sháo (Paeoniae Radix alba) 10g
shēng jiāng (Zingiberis Rhizoma recens) 10g
dà zǎo (Jujubae Fructus) 4 pieces
zhì gān cǎo (Glycyrrhizae Radix preparata) 6g
gé gēn (Kudzu Radix) 12g
Results:  After taking 1 package of the formula, her symptoms decreased, and after 2 more, her symptoms had completely resolved.
 

Kē Qín on Xuán Fù Dài Zhě Shí Tāng from the Collected Writings on Renewal of the Discussion of Cold Damage (伤寒来苏集)

 

“In Cold Damage which has resolved following sweating, purging or vomiting, [but there is now] a hard glomus below the heart and belching which will not resolve, Xuán Fù Dài Zhě Shí Tāng (Inula and Hematite Decoction) governs.”

(Shāng Hán Lùn clause 161) 

 

 

In cold damage, cold damages the heart. Now if sweat is effused, or one is purged or made to vomit, heart qi will become majorly deficient, and exterior cold will exploit this deficiency and bind below the heart. Heart qi will be unable to descend and instead ascend upwards resulting in noise [belching]. The sovereign [medicinal] governs the manifestation of this fleeing. Belching is the sound of pain. It cannot be referred to as sound, but should be named qi. Qi follows the sound and is seen on the outside.  

Xuán Fù Huā 3 liǎng

Gān Cǎo 3 liǎng

Rén Shēn 2 liǎng

Bàn Xià half a shēng

Dài Zhě Shí 1 liǎng

Shēng Jiāng 5 liǎng

Dà Zǎo 12 pieces

Use one dou of water for the above 7 ingredients, and boil until 6 shēng remain. Remove the dregs, and simmer again until 3 shēng remain. Take 1 shēng warm, three times daily.

This formula is shēng jiāng xiè xīn tang with huáng qín, huáng lián, and gān jiāng removed, and xuán fù huā and dài zhě shí added. In a heart qi deficiency a xiè xīn tang [formula] should not be taken, and can therefore be controlled with this formula. The heart governs the summer, and xuán fù huā reaches its end stage in the summer. Its salty flavor can supplement the heart, soften hardness, and disperse bound qi. Bàn xià grows at the beginning of summer, and its acrid flavor can scatter pathogens, disperse glomus, and move bound qi. Dài zhě shí is endowed with the fire of the south, which enters and frees the heart, scatters hard glomus, and settles the deficient counterflow. The sweetness of rén shēn, gān cǎo, and dà zǎo assist xuán fù huā in draining deficient fire, while acrid shēng jiāng assists bàn xià in scattering bound water. This will result in the dispersal of the hard glomus, and the elimination of belching. If huáng qín and huáng lián are used to drain the heart, how can one protect subtle yang from not being extinguished?

Kē Qín (柯琴), courtesy name Yùn Bó (韵伯) (1662 – 1735) was a Qīng Dynasty Shāng Hán Lùn (傷寒論 Discussion of Cold Damage) scholar, from Cí Xī county in Zhè Jiāng province. A prolific writer, Kē authored several books in his time and was a large proponent of the ‘school of formula types’ (方类证派), famously saying,  “Patterns are differentiated from the conformations, therefore the pattern is named after the formula (证从经分,以方名证).”

Zé Xiè from Zhāng Zhì-Cōng’s Běn Cǎo Chóng Yuán (本草崇原)

Zé Xiè from Zhāng Zhì-Cōng’s Běn Cǎo Chóng Yuán (本草崇原)
The Qi and flavor of Zé Xiè are sweet, cold and non-toxic. It treats wind, cold, damp impediment, difficult lactation; [it] nourishes the five viscera and boosts qi and strength, makes one plump and healthy, and disperses water. Taken for extended periods of time, the ears and eyes will become sharp and bright. It reduces hunger, extends the years [life], lightens the body, brightens the complexion, and [gives one] the ability to walk on water. [1]
Zexie is a water medicinal, which is sweet and cold. It is able to ascend the qi of water-yin upwards and nourish center earth. It governs the treatment of wind, cold, damp impediment, by initiating the water-fluids in the lower body, which then from center earth irrigate the muscles, interstices and skin. Breast milk is the fluid of the middle burner, so by the nourishment of water-fluids in center earth, it is able to treat difficult lactation. The five viscera receive the essence of food and grains, and since zexie flows and pools in center earth, it can therefore nourish the five viscera. The kidneys are the unyielding official, whose water essence supports the upper, and therefore boosts qi and strength. By irrigating the muscles and interstices from center earth, [zexie] is able to make one plump and healthy. Water qi first ascends then descends, therefore [zexie] disperses water. The sharpening and brightening of the ears and eyes after being taken over an extended period of time are the result of water assisting fire. Decreasing hunger and extending the years is due to water nourishing the earth. Lightening the body and brightening the complexion is due to the outward flow of water. With [giving one] the ability to walk on water, it can be said that [when one’s] ears and eyes are sharp and bright, and hunger is reduced, the years are extended, the body is lightened, and the complexion is bright, [they feel as if] they can walk on water!

[1] This last line is very interesting and can be translated and interpreted a couple different ways. The first translation, which is the most common interpretation and the one that makes sense according to later commentaries, is “the ability to walk on water.” Based on Zhāng’s reasoning it makes the most sense. However when first reading the line from the Běn Cǎo, I read it as “[zexie] is able to move water upwards.” This is a common function of the plant and the justification used for many of the positive effects experienced from taking this medicinal, therefore it would make sense. As there is no actual commentary found after the original entry, it’s impossible to know for sure what Shén Nóng meant with this string of characters.