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Shāng Hán Lùn, greater yáng (tài yáng) disease: The pathology, clinical manifestation, and treatment of the greater yáng wind strike pattern.

(#) 太阳中风， 阳浮而阴弱， 阳浮者， 热自发， 阴弱者， 汗自出。 (#) 啬啬恶寒，淅淅恶风， 翕翕发热， 鼻鸣干呕者， 桂枝汤主之。

(#) Tài yáng zhòng fēng, yáng fú ér yīn ruò, yáng fú zhě, rè zì fā, yīn ruò zhě, hàn zì chū. (#) Sè sè wù hán, xī xī wù fēng, xì xì fā rè, bí míng gān ǒu zhě, guì zhī tāng zhǔ zhī.

(#) In greater yáng wind strike with floating yáng and weak yīn,^# floating yáng is spontaneous heat effusion,^# and weak yīn is spontaneous issue of sweat.^# (#) If [there is] huddled aversion to cold,^# wetted aversion to wind,^# feather-warm heat effusion,^# noisy nose,^# and dry retching, Cinnamon Twig Decoction (guì zhī tāng) governs.

Text Notes

1. Floating yáng and weak yīn, 阳浮阴弱 yáng fú yīn ruò: There are two interpretations of this phrase, one from the perspective of the pulse and the other considering the pathomechanism. The interpretation relative to the pathomechanism provides greater insight into these patterns, and consequently may be given precedence.

The superficial pulse felt by applying light pressure is yáng, the deep pulse felt by applying heavy pressure is yīn. “Floating yáng and weak yīn” means a floating moderate pulse. This pulse is forceful when light pressure is applied and forceless when heavy pressure is applied. Chéng Yìng-Máo writes, “`Yīn [and] yáng' describe floating and deep [qualities of the pulse]; [they] do not describe the cubit and inch [positions].”

A pathomechanism in which wind-cold fetters the exterior and exuberant defensive yáng floats up to contend with an evil. The defensive exterior becomes insecure and the provisioning cannot be contained. This phrase is the same as strength in the defense and weakness in the provisioning. Chéng Wú-Jǐ writes, “Yáng is an indicator of defense; yīn is an indicator of provisioning. When the yáng pulse is floating, [there is] wind in the defensive [exterior]. When the yīn pulse is weak, the provisioning qì is weak. Wind merges with the defense so [there is] strength in the defense and weakness in the provisioning. Thus, [there is] heat effusion and spontaneous sweating.”

2. Floating yáng is spontaneous heat effusion, 阳浮者, 热自发 yáng fú zhě, rè zì fā: Describes the pathomechanism of greater yáng wind strike and the production of heat effusion. When wind evil fetters the exterior, exuberant defensive yáng floats to the exterior and contends with the evil. This struggle produces heat which effuses from the surface of the body.
3. Weak yīn is spontaneous issue of sweat, 阴弱者, 汗自出 yīn ruò zhě, hàn zì chū: Describes the pathomechanism of greater yáng wind strike involving the production of sweat. When the defensive yáng is striving to contend with the evil, its normal function of securing the exterior and regulating the opening and closing of the interstices is compromised. Consequently, the provisioning-yīn is not contained in the interior and sweat issues. Here weak yīn refers to weak provisioning, 营弱 yíng ruò.
4. Huddled aversion to cold, 啬啬恶寒 sè sè wù hán: Severe aversion to cold. The Chinese 啬 sè, usually meaning stingy, is here used to describe how the patient huddles up to preserve his own bodily warmth. Fāng Yǒu-Zhí writes, “`Huddled' means aversion to cold that stems from dispirited qì, which is insufficient to delay [inward] percolation [of the exterior evil], and so the aversion is severe.”
5. Wetted aversion to wind, 淅淅恶风 xī xī wù fēng: Acute aversion to wind. 淅 xī, which usually means to wash or soak rice, is taken in this context to mean to spray or to splash. When the surface of the body is splashed with water, it is more sensitive to wind. Fāng Yǒu-Zhí writes, “`Wetted' refers to aversion to wind owing to looseness of the external body, as if there is fear and hatred of rain-water suddenly splashing the body, and means the feeling of aversion.”
6. Feather-warm heat effusion, 翕翕发热 xì xì fā rè: Gentle heat effusion, felt in the skin and fleshy exterior, as if the body were wrapped in feathers. It does not mean a great sweltering heat effusion. Fāng Yǒu-Zhí writes, “… [this means] warm heat and not a great steaming heat.”
7. Noisy nose, 鼻鸣 bí míng: Nasal congestion which results in audible breathing.

Formula
Cinnamon Twig Decoction (桂枝汤 guì zhī tāng)

Resolve the flesh and dispel wind; harmonize provisioning and defense.

桂枝三两（去皮）  芍药三两  甘草二两（炙）  生姜三两（切）  大枣十二枚（擘）

(#) 右五味， 呋夫咀三味， 以水七升， 微火煮取三升， 去滓， 适寒温， 服一升。 (#) 服已须臾， 歠热稀粥一升余， 以助药力。 (#) 温覆令一时许，直 遍身漐漐，微似有汗者益佳， 不可令如水流漓， 病必不除。 (#) 若一服汗病差， 停后服， 不必尽剂。 (#) 若不汗， 更服依前法。 (#) 又不汗， 后服小促其间， 半日许令三服尽。 (#) 若病重者， 一日一夜服， 周时观之。 (#) 服一剂尽， 病证犹在者， 更作服。 (#) 若汗不出， 乃服至二、三剂。 (#) 禁生冷、粘滑、肉面、五辛、酒酪， 臭恶等物。

Guì zhī sān liǎng (qù pí)  sháo yào sān liǎng  gān cǎo èr liǎng (zhì)  shēng jiāng sān liǎng (qiè)  dà zǎo shí èr méi (bò)

(#) Yòu wǔ wèi, fǔ jǔ sān wèi, yǐ shuǐ qī shēng, wēi huǒ zhǔ qǔ sān shēng, qū zǐ, shì hán wēn, fú yī shēng. (#) Fú yǐ xū yú, chuò rè xī zhōu yī shēng yú, yǐ zhù yào lì. (#) Wēn fù lìng yī shí xǔ, piān shēn zhí zhí, wēi sì yǒu hàn zhě yì jiā, bù kě lìng rú shuǐ liú lí, bìng bì bù chú. (#) Ruò yī fú hàn bìng chài, tíng hòu fú, bù bì jìn jì. (#) Ruò bù hàn, gèng fú yī qián fǎ. (#) Yòu bù hàn, hòu fú xiǎo cù qí jiān, bàn rì xǔ lìng sān fú jìn. (#) Ruò bìng zhòng zhě, yī rì yī yè fú, zhōu shí guān zhī. (#) Fú yī jì jìn, bìng zhèng yóu zài zhě, gèng zuò fú. (#) Ruò hàn bù chū, nǎi fú zhì èr、sān jì. (#) Jìn shēng lěng、 nián huá、 ròu miàn、wǔ xīn、jiǔ luò、 chòu è děng wù.

cinnamon twig (桂枝 guì zhī, Cinnamomi Ramulus) 3 liǎng (remove bark)^#

peony (芍药 sháo yào, Paeoniae Radix)^# 3 liǎng

mix-fried^# licorice (甘草 gān cǎo, Glycyrrhizae Radix) 2 liǎng

fresh ginger (生姜 shēng jiāng, Zingiberis Rhizoma Recens) 3 liǎng (cut)

jujube (大枣 dà zǎo, Jujubae Fructus) 12 pieces (broken)

(#) [For] the preceding five ingredients, break the [first] three ingredients into small pieces and use seven shēng of water. Boil over a mild flame to get three shēng and remove the dregs. Take one shēng at moderate temperature. (#) Shortly after taking [the first dose] drink approximately one shēng of hot, thin gruel to reinforce the strength of the medicinals. (#) Warm [the body] by covering [with a blanket] for a short period, ideally until the whole body is moist, as if sweating very lightly. One cannot allow [the sweat] to flow like water, since the disease will not be eliminated [in this way]. (#) If one dose [causes] sweating and the disease is diminished, cease taking further [doses]. One need not finish the whole packet. (#) If sweating is absent, take another dose according to the previous method. (#) If sweating is again absent, reduce the time between doses, finishing three doses in half a day. (#) If the disease is severe, take [doses] throughout the whole day, and observe [the patient] the whole time. (#) After finishing one packet, [if] the disease signs are still evident, take again. (#) If sweating is absent, one can take up to two or three packets. (#) Foods contraindicated [while taking the formula] include raw and cold foods, sticky and slimy foods, meat and noodles, the five acrids,^# liquor, milk products, and foods with a peculiar or spoiled flavor or odor.

Formula Notes

1. Remove bark, 去皮 qù pí: Because the flavor (and hence the medicinal strength) cinnamon twig (guì zhī, Cinnamomi Ramulus) is contained in the bark, the instruction to remove the bark has led to different interpretations. According to Kē Qín, “removing the bark” refers to the removal of the rough outer bark of Cinnamon twig (guì zhī, Cinnamomi Ramulus). According to Zhāng Zhì-Cōng, it means using tender twigs without skin. Both interpretations are considered acceptable.
2. Peony, 芍药 sháo yào: Peony (sháo yào, Paeoniae Radix) is taken to mean white peony (bái sháo yào, Paeoniae Radix Alba).
3. Mix-fried, 炙 zhì: In modern terms, this refers to stir-frying with liquid adjuvants, but it is unclear what it means in this text. It may simply mean that the medicinal agent is roasted, not necessarily stir-fried with honey, vinegar, or wine, as is common today.
4. Five acrids, 五辛 wǔ xīn: This term refers generally to foods with a penetrating and stimulating odor or flavor, but it has been the subject of much disagreement among authors. Below are some of the main lists as recorded in the Shāng Hán Lùn Yán Jiū Dà Cí Diǎn (伤寒论研究大辞典 "Shāng Hán Lùn Studies Dictionary").

According to the authors of the dictionary: scallion (cōng, Allium Fistulosum), Chinese chive (xiè, Allium spp.), garlic chives (jiǔ, Allium Tuberosum), garlic (suàn, Allium Sativum), and asafetida (qú, Asafoetida).

Lǐ Shí-Zhēn (李时珍, sobriquet 滨湖 Bīn Hú), in the Běn Cǎo Gāng Mù (本草纲目 "The Comprehensive Herbal Foundation") writes, “The five strong-smelling vegetables are the five acrid; those that are acrid, malodorous, and cloud the spirit with an attacking nature. [According to] those who cultivate their bodies, the five strong-smelling vegetables are sand garlic (xiǎo suàn, Allium Scorodoprasum), garlic (dà suàn, Allium Sativum), oil rape (yún tái, Brassica Oleifera), and coriander (hú suī, Coriandrum). [According to] Taoist [teaching], the five strong-smelling vegetables are Garlic chives (jiǔ, Allium Tuberosum), Chinese chive (xiè, Allium spp.), garlic (suàn, Allium Sativum), oil rape (yún tái, Brassica Oleifera), and coriander (hú suī, Coriandrum). [According to] Buddhist [teaching], the five strong-smelling vegetables are garlic (dà suàn, Allium Sativum), sand garlic (xiǎo suàn, Allium Scorodoprasum), asafetida (xīng qú, Asafoetida), scallion (cí cōng, Allium Fistulosum), Garlic chives (jiǔ, Allium Tuberosum), and victorialis (gè cōng, Allium Victorialis).

According to Gāo Děng Cóng Shū, the significance of the contraindication is that one must avoid foods that have a penetrating fragrance and a stimulating or irritating taste.

Synopsis

The pathology, clinical manifestation, and treatment of the greater yáng wind strike pattern.

Commentary

The signs of greater yáng wind strike include heat effusion, aversion to wind and cold, sweating, stiffness and pain of the head and nape, noisy nose, dry retching, and a pulse that is floating and moderate. The pulse is not only moderate, but also floating since this quality is common to greater yáng disease. In this pattern, wind-cold fetters the exterior and defensive yáng floats to the exterior to resist the evil. Because of existing yáng qì (defense qì) vacuity, the exterior becomes insecure and provisioning-yīn is not contained. This pathomechanism is described in the text as “floating yáng and weak yīn.” The struggle between defense qì and the exterior evil produces heat effusion. The presence of an evil in the exterior and vacuity of defense qì gives rise to wetted aversion to wind and huddled aversion to cold. The provisioning-yīn issues outward in the form of sweat and the nourishment normally provided by the provisioning-yīn is lost or diminished. This loss of nourishment results in stiffness and pain. The evil may also interfere with the lung and/or stomach. If it attacks the lung, inhibiting lung qì, the patient will have a noisy nose. If it attacks the stomach, causing counterflow ascent of qì, retching will be observed.

Cinnamon Twig Decoction (guì zhī tāng) is the formula of choice for greater yáng wind strike. Cinnamon twig (guì zhī, Cinnamomi Ramulus) is acrid and warm. Because acrid-flavored medicinals disperse and warm-natured medicinals dispel cold and free yáng, cinnamon twig (guì zhī, Cinnamomi Ramulus) resolves exterior wind and cold from the fleshy exterior and interstices. Peony (sháo yào, Paeoniae Radix) is sour and cold. Because sour-flavored medicinals contract and cold-natured medicinals penetrate the provisioning-yīn, peony (sháo yào, Paeoniae Radix) contracts yīn and harmonizes provisioning. These two medicinals used together harmonize provisioning and defense, which is the basic action of Cinnamon Twig Decoction (guì zhī tāng). Acrid and warm, fresh ginger (shēng jiāng, Zingiberis Rhizoma Recens) not only assists cinnamon twig (guì zhī, Cinnamomi Ramulus) in resolving the exterior, but also downbears counterflow and checks retching. This last action is particularly useful when the exterior evil impairs the function of the stomach. Sweet jujube (dà zǎo, Jujubae Fructus) boosts the center and assists peony (sháo yào, Paeoniae Radix) in boosting yīn and harmonizing provisioning. Sweet, balanced, mix-fried licorice (gān cǎo, Glycyrrhizae Radix) harmonizes all the ingredients in the formula and promotes interaction between the provisioning and defense. This formula can be used for any disharmony of the provisioning and defense, not just greater yáng wind strike.

After taking the decoction, the patient should drink a bowl of thin, warm gruel. Eating rice gruel provides fluid nourishment and stomach qì, which supports right qì; hence sweating occurs easily. If after the first dose sweat issues, no more doses should be taken. If sweating is absent, another dose may be taken, up to three times in a roughly twelve hour period. Zhāng Jī cautions against the excessive promotion of sweating. Generally, the sweat should issue very lightly, and as soon as it does, the patient is not allowed to take the decoction again. If the illness is severe, doses may be given continuously and two to three whole packets may be used in one day. When Cinnamon Twig Decoction (guì zhī tāng) is prepared, it is divided into three doses. A dose is one-third of the whole decoction prepared from one packet. The terms used in the Hàn Dynasty to denote weights and measures are largely the same as those used in modern texts, but the amounts are different. For example, in the Hàn Dynasty, a liǎng was equivalent to 15.625 grams, whereas today a liǎng is equivalent to 31.25 grams. Many authors have written commentaries on this issue and after researching historical commentaries and modern clinical ingredient dosages, Kē Xuě-Fán (柯雪帆) suggests the following equivalents:

one jīn = 250 grams

one liǎng = 15.625 grams

one zhū = 1/24 of a liǎng

one gě = 20 milliliters

one shēng = 200 milliliters = 6.76 fluid ounces

one dǒu = 10 shēng

Note: Shēng is a unit of volume used for any liquid as well as for solid materials, such as pinellia (bàn xià, Pinelliae Rhizoma) or schisandra (wǔ wèi zǐ, Schisandrae Fructus), which can be conveniently measured with a scoop.

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