Annotations to Yangke Xinde Ji (2)
General Treatise on External Ulcers (2)
Original text: Then how is one to treat them? It is simply to examine the pulse and distinguish the pattern. Generally, before an ulcer has ruptured, the pulse should be exuberant; after it has ruptured, the pulse should be deficient. Exuberance means the toxin is strong; deficiency means the original qi is vacuous. If, before rupture, a deficient pulse appears, it means fire-toxin is exuberant while original qi is vacuous; if, after rupture, an exuberant pulse appears, it means fire-toxin is exuberant while original qi is stagnant. Having fixed on the six pulse positions and carefully examined deficiency and excess, the choice—cold or heat, dispersing or astringing, attacking or supplementing, contrary or obedient—all depends simply on suiting the matter; one must not treat rashly.
Annotation: This passage discusses the treatment principles for sores and ulcers. The overall treatment principle is to support upright qi and expel evil; this must be based on examining the patient’s pulse and identifying the pattern, then taking corresponding measures according to the condition. The general situation is that before the ulcer ruptures the pulse should be exuberant, and after it has ruptured the pulse should be deficient.
The pair of concepts “exuberance” and “deficiency” comes from Laozi, who wrote that “the Way of heaven reduces the excessive and supplements the insufficient.” Chinese medicine is closely bound up with ancient philosophy and has borrowed many concepts and theories from it; the overall treatment principle of Chinese medicine is exactly what Laozi called “reducing the excessive and supplementing the insufficient.”
In Chinese medical theory, the pair “exuberance” and “deficiency” appears often, and their reference point is always the normal state: exuberance is above the normal, deficiency below it. Pulses are divided into normal, exuberant, and deficient: the normal pulse is that of a healthy person; the exuberant pulse is stronger than normal; the deficient pulse is weaker than normal. Broadly, slow, vacuous, fine, and weak pulses all belong to deficient pulses; rapid, excess, slippery, and surging pulses all belong to exuberant pulses.
Before an ulcer ruptures, though the evil is strong, upright qi has not declined, so the pulse is exuberant; after it ruptures, the evil is strong and upright qi has declined, so the pulse should be deficient. This is a reasonable pulse—pattern and pulse agree; this is called a “favorable pattern,” with good prognosis. If, before rupture, the pulse is already deficient, it means the evil is very strong and upright qi very vacuous; if, after rupture, the pulse is still exuberant, it means not only is the evil strong but upright qi is also stagnant; Chinese medicine calls this an “adverse pattern,” usually with poor prognosis.
Chinese pulse diagnosis stresses “three positions and nine indicators.” The three positions are cun, guan, and chi; the practitioner feels the pulse with three fingers, corresponding respectively to cun, guan, and chi. The guan pulse lies at the radius, where the middle of the three fingers rests; the cun is on the wrist side of the radius, and the chi on the forearm side.
Each hand has three positions, making six pulses in total. The “nine indicators” means, for each of cun, guan, and chi, applying a light, medium, and heavy pressure. Slight pressure is light pressure, to detect the floating pulse; slightly heavier is medium pressure; heavier still, until the doctor’s fingertip feels the patient’s sinew and bone, is heavy pressure, to detect the deep and hidden pulses. So a normal pulse diagnosis takes at least two minutes.
Ancient Chinese medicine lacked modern examination means and could only rely on pulse diagnosis to determine the exterior/interior, deficiency/excess, and cold/heat of the patient, so it greatly prized taking the pulse. But in fact the reliability of pulse diagnosis is not high; hence the ancients also said “clear in the mind, hard to make out under the fingers,” and they especially stressed combining the four examinations (inspection, auscultation-olfaction, inquiry, and palpation). Sometimes one must “set aside the pulse and follow the pattern,” and sometimes “set aside the pattern and follow the pulse”—all because diagnosing disease is a very complex matter, hard to diagnose accurately by any single method. Modern medicine’s examination means are highly developed and can make up for the shortcomings of the four examinations; Chinese medicine practitioners should keep pace with the times and be broadly learned in order to achieve more precise diagnosis.
Although this passage speaks only of the pulse, it must not be understood as relying on pulse-taking alone; in fact it requires combining the four examinations. After the doctor identifies, from the patient’s pulse and signs, which pattern the patient has, he can decide which treatment principle to apply.
“Cold or heat, dispersing or astringing, attacking or supplementing, contrary or obedient” are treatment principles. Chinese medicine stresses yin-yang balance, so the overall treatment principle is to adjust the patient’s body to a balanced state. If the patient has a heat pattern, then according to the principle “treat heat with cold,” use cooling herbs to cool and moisten the body; if a cold pattern, according to “treat cold with heat,” use warming herbs to warm the body; supplement the deficient with tonics, and attack the exuberant evil with expelling and purging herbs; dissipate what is knotted, astringe what leaks; treat favorable patterns by the normal obedient method, and adverse patterns by the contrary method.
This yin-yang-balancing idea pervades the whole of Chinese medical theory, so Chinese medicine often says that in treating disease one must seek the root, and the root lies in yin and yang. By such theory, indeed almost no disease under heaven is untreatable, but in clinical practice many diseases cannot be solved by such simple theory; the student should be aware of this.
“All depends on suiting the matter; one must not treat rashly” emphasizes that the physician must treat disease according to the above principles, cautiously, neither treating without principles and at random nor overtreating. One must stop when enough is enough: treat cold with heat, but if warming herbs are used to excess, they produce a heat pattern; if poison-to-attack-poison herbs are used too much, they poison the patient. So in treating disease one must grasp the measure and not over-treat, lest new problems arise for the patient. The “suit” in “suited to the matter” carries the meaning of “stopping when enough is enough.”
Original text: Moreover, as to the location of sores and ulcers, the circulation of their channel qi and blood is the same as in cold damage. Cold damage has no fixed shape, so if mismanaged it transforms. External patterns, though they have a fixed shape, yet the roaming of the poison has no fixed location. Thus poison entering the heart causes coma; entering the liver, convulsion and syncope; entering the spleen, abdominal pain and distention; entering the lung, panting and cough; entering the kidney, dim vision and cold hands and feet. Entering the six fu organs, each also shows its own transformations, with many accompanying patterns and the seven evils appearing one after another.
Annotation: This passage discusses the six-channel and zang-fu differentiation principles for sores and ulcers. The author wrote an article a few days agoThe Three Main Steps of Pattern Differentiation and Treatment in Chinese Medicine (click the title link for details), in which he said that the first step of Chinese pattern differentiation is eight-principle differentiation, and the second step is six-channel, zang-fu, triple-burner, and defense-qi-nutrient-blood differentiation. Eight-principle differentiation distinguishes the nature of disease; the six-channel, zang-fu, triple-burner, and defense-qi-nutrient-blood differentiation distinguish the disease’s location—that is, which part of the body the disease involves.
For sores, ulcers, and cold damage, the rules of channel qi and blood circulation are the same. If cold damage is not treated in time or correctly, transformed patterns arise. Although sores and ulcers have special manifestations on the body surface, their poison, like that of cold damage, can transmit and roam within the body; without timely or proper treatment, transformed patterns will also arise.
When the poison of a sore enters the heart channel, the patient becomes comatose; entering the liver channel, there are spasms and convulsions; entering the spleen channel, there is abdominal distending pain; entering the lung channel, panting and cough; entering the kidney channel, dim eyesight and cold hands and feet. Entering the six fu organs also has corresponding transformations, with many accompanying patterns, and sometimes the seven evils appear. Note that the five zang and six fu organs of Chinese medicine are not the same as those of modern anatomy.
The “seven evils” is a technical term in Chinese external medicine. External surgery has some basic rules for judging a patient’s prognosis, summed up as the five good signs and seven evils. The five good signs are: 1. normal eating and drinking; 2. normal urination and defecation; 3. red, lustrous, firm lesion color; 4. calm pulse and cool body with warm hands and feet; 5. a loud voice and peaceful movement. The seven evils are: 1. agitation, vexation, clouded mind, delirium, and trance; 2. vomiting, hiccup, diarrhea, inability to eat; 3. withered, dark, sunken lesions, itchy collapse, and putrefaction; 4. cyanotic swelling of the head and face, blocked nose, closed eyes, cracked lips, dry tongue; 5. shivering chattering teeth, hoarse voice, sallow complexion; 6. ulcerated throat and tongue, vomiting on eating, choking on drinking; 7. abdominal distention and panting, with cold extremities. For patients with sores and ulcers, the five good signs are auspicious, the seven evils inauspicious.
Original text: The Classic says: in treating disease one must seek the root. What is the root? It is the zang and fu, yin and yang, deficiency and excess, exterior and interior, cold and heat. Having grasped the root, then whether to cool, warm, attack, or supplement, the medicinal treatment will be free of error; if the root is not grasped, a hair’s breadth of error leads to a thousand-li mistake—can one be too cautious?
Annotation: Here “the Classic” refers to Huangdi Neijing, which set forth the principle that in treating disease one must seek the root. What then is the root? The root may be understood as the so-called root of the disease—its fundamental cause or source. Chinese medicine holds that people fall ill because of disharmony of the zang-fu and imbalance of yin and yang, with clinical symptoms mainly manifesting in deficiency/excess, exterior/interior, and cold/heat. Thus treating sores and ulcers also stays within these basic frameworks of Chinese medicine: one must perform eight-principle differentiation and six-channel, zang-fu, triple-burner, and defense-qi-nutrient-blood differentiation; only with correct differentiation can one choose the right treatment principle and method. If differentiation is wrong, a hair’s breadth of error leads to a thousand-li mistake.
This “General Treatise on External Ulcers” is the master outline of Gao Bingjun’s Yangke Xinde Ji, highly condensed in expounding the causes and pathology of sores and ulcers. Chinese medicine speaks of “principle, method, formula, and herb”; this master outline corresponds to the “principle” among the four.
This general treatise embodies both the strengths and the shortcomings of Chinese medicine. Its most distinctive features are holism and pattern differentiation, and both are reflected in this treatise.
Chinese medicine’s greatest shortcoming is that all its treatment principles and methods are derived step by step from theory, like solving a math problem, relying on logical thinking to complete diagnosis and treatment. As to whether this derivation is reasonable, what its accuracy rate is, or whether there are other more reasonable explanations for the cause of disease—it cares for none of these. Thus it lacks the complete evaluation, re-evaluation, and self-correction mechanisms of modern evidence-based medicine, making Chinese medicine hard to progress; over the centuries it has accumulated a great deal of both essence and dross.
Over time, certain literati who love grand talk and belittle empirical evidence conflate Chinese medical practice with theory, speaking of Chinese medicine as utterly mysterious and exaggerating its efficacy. Such practitioners deeply harm the cause of Chinese medicine; the fundamental reason many people resent Chinese medicine is precisely that they resent this grandstanding ethos.