Medication Strategy for Treating Yellow Sweat Disease in the Jingui Yaolüe
Yellow sweat disease is a very rare condition in which the patient's sweat is yellow and can stain clothing yellow. Why do people produce yellow sweat? Medicine cannot yet explain it clearly; some yellow-sweat patients are checked for bilirubin, and the level is not elevated, so it is not caused by jaundice. Modern medicine has so far had no reasonable explanation and can only classify it as a difficult, complicated disease. I have encountered three cases in clinic: one breast cancer patient with lung metastasis had yellow sweat, one gastric cancer patient with liver metastasis had yellow sweat, and one late-stage kidney cancer patient had yellow sweat.
Zhang Zhongjing's Jingui Yaolüe (Essential Prescriptions of the Golden Cabinet) records the disease of “yellow sweat,” in the chapter “On Pulse, Syndrome, and Treatment of Water-Qi Diseases, Number 14.” The chapter opens: “The Master said: diseases include wind-water, skin-water, ordinary-water, stone-water, and yellow sweat.” This divides water-qi diseases into five types, one of which is yellow sweat.
It specifies the series of symptoms of “yellow sweat”: “Yellow sweat: the pulse is deep and slow, the body is feverish, the chest is full, the four limbs, head, and face are swollen; if prolonged without cure, it must lead to abscess and pus.” That is, the disease also has a deep-slow pulse, bodily fever, chest and abdominal fullness, and edema of the limbs, head, and face; if long uncured, it leads to carbuncles and pus.
Professor Hu Xishu said he once saw a yellow-sweat patient who was a liver cirrhosis patient. The three cases I saw were all cancer patients. Why is this disease more common in tumor patients? Perhaps it relates to some endocrine dysfunction within the patient's body, but this is only my personal guess, lacking scientific evidence.
How is this disease treated? The Jingui Yaolüe also records this. There are two formulas that can treat yellow sweat: one is called “Qi Shao Gu Ku Jiu Tang” (Astragalus-Peony-Cinnamon Bitter-Wine Decoction), and the other is called “Guizhi Jia Huangqi Tang Fang.”
Qi Shao Gu Ku Jiu Tang: Huang Qi (Astragali Radix) 5 liang, Shaoyao (Paeoniae Radix) 3 liang, Guizhi (Cinnamomi Ramus) 3 liang. One liang here can be converted to 3 grams today, or to 5 grams. How is this formula used? The Jingui Yaolüe says: “Someone asked: Yellow sweat is a disease in which the body is swollen (one version says heavy), feverish and sweating with thirst; it resembles wind-water; the sweat soaks the clothing, the color truly yellow like the juice of phellodendron; the pulse is naturally deep. How does one contract it? The Master said: It is obtained by bathing in water after sweating, with water entering through the sweat pores; Qi Shao Gu Jiu Tang governs it. Take the three herbs, with one sheng of bitter wine and seven sheng of water, mix, boil down to three sheng, and take one sheng warm. There will be vexation; it resolves after six or seven days of taking it. If the vexation does not cease, it is because the bitter wine obstructs it.” This explains the indications of Qi Shao Gu Ku Jiu Tang in the form of teacher-disciple Q and A: the patient not only sweats yellow sweat but also has a swollen, heavy body, with fever and thirst; the sweat soaks the clothing, which turns as yellow as if dyed by phellodendron juice; the pulse is deep.
Guizhi Jia Huangqi Tang Fang: Guizhi 3 liang, Shaoyao 3 liang, Gancao (Glycyrrhizae Radix) 2 liang, Sheng Jiang (Zingiberis Rhizoma) 3 liang, Da Zao (Jujubae Fructus) 12 pieces, Huang Qi (Astragali Radix) 2 liang. How is Guizhi Jia Huangqi Tang used? The Jingui Yaolüe explains: “In the disease of yellow sweat, the two lower legs are naturally cold; suppose they are feverish, this belongs to li-jie (joint wind). If sweating occurs after eating, and the body often has night sweating while lying in the evening, this is lao-qi (fatigue qi). If, after sweating, the body is instead feverish, over time the skin must become like scaled armour; if the fever does not cease, malignant sores must arise. If the body is heavy and becomes light as soon as sweating occurs, over time the body must twitch, and the twitching means pain in the chest; moreover, above the waist there must be sweating, while below there is no sweat; the lower back and hips are limp and painful, as if there were something within the skin; in severe cases one cannot eat, the body is painful and heavy, one is irritable, and urination is difficult. This is yellow sweat; Guizhi Jia Huangqi Tang governs it. Take the six herbs, with eight sheng of water, boil down to three sheng, and take one sheng warm. After a moment, drink a little over one sheng of thin porridge to help the medicine's force; take warm to induce slight sweating. If there is no sweat, take again.”
The meaning of this passage is that the patient not only sweats yellow sweat but also has cold lower legs; if the two lower legs are not cold but feverish, then it is not yellow sweat but another disease called “li-jie.” Yellow-sweat patients sweat as soon as they eat; in fact, many patients I have seen not only sweat when eating but also when drinking water, when nervous, and have night sweats while sleeping.
TCM considers this condition “la-qi” (consumed qi). Sweat is the body's fluids; normal sweating is fine, but too much sweating, TCM holds, consumes the person's essence-qi. Many patients in oncology departments with spontaneous deficiency-sweating are like this: after sweating too much, the person is spiritless and listless.
Generally speaking, sweating is an effective measure for regulating body temperature; as soon as sweat comes out, the body cools. But yellow-sweat patients, after sweating, are not cool but feverish; over time, the symptom of “skin like scaled armour” appears—a TCM term meaning dry, cracked skin. TCM holds this is due to ’tatic blood” in the body; the indications of Da Huang Zhe Chong Wan and Bie Jia Jian Wan both include “skin like scaled armour,” and TCM “static blood” patterns are often modern late-stage tumors or liver cirrhosis. So sweating with aversion to heat must produce “evil sores,” many of which are also malignant tumors.
This yellow-sweat patient's body is also heavy, and there is also the symptom of muscular twitching, a common symptom recorded in TCM in which the patient feels as if something is crawling under the skin. Sometimes chest pain also appears, with a feeling of difficult-to-cough-up phlegm. Such patients have a characteristic sweating pattern: sweating above the waist, no sweating below, and the lower half is not only without sweat but very cold. The lower back and hips are weak and painful, with discomfort; in severe cases appetite is affected, urination is very scant, and the person is restless.
I have seen many similar symptoms in clinic, especially in female patients, but they are not all yellow sweat. Many doctors treat it as female menopausal syndrome, but why does it concentrate in tumor patients? We can hardly get a reasonable explanation. When these patients are examined, some have inflammatory shadows in the lungs, and some do not. This resembles cancer fever somewhat, but although patients sweat and feel hot, their temperature is normal when measured—some patients' temperature is even low—so doctors do not diagnose it as cancer fever. I think this may be a series of symptoms caused by the tumor body continuously releasing histamine.
The two formulas Zhang Zhongjing used are actually very similar; both are modifications of Guizhi Tang. Guizhi Tang treats spontaneous sweating from discordance between the ying and wei; yellow sweat disease is also a disease of spontaneous sweating, so Guizhi Tang is taken as the base formula. Huangqi Guizhi Tang is Guizhi Tang plus astragalus; in the past everyone thought astragalus mainly supplements qi and secures the exterior. In clinic I have found astragalus has a good diuretic effect and a bidirectional regulatory effect on white blood cells in the blood: when WBC is too high, astragalus lowers it; when too low, it raises it. Modern pharmacology has proven that astragalus has anti-inflammatory and antioxidant effects.
Qi Shao Gu Ku Jiu Tang is actually Huangqi Guizhi Tang minus Gancao, Sheng Jiang, and Da Zao, plus bitter wine, i.e., vinegar. Professor Hu Xishu held that the pattern-differentiation key to these two formulas is whether there is thirst: if thirsty, only Qi Shao Gu Ku Jiu Tang can be used; if not thirsty, use Huangqi Guizhi Tang. Vinegar has the effect of quenching thirst and generating fluids; ginger and jujube are warming-tonifying herbs, and if used when one is thirsty, they worsen the thirst.
But why must the dose of astragalus be larger in Qi Shao Gu Ku Jiu Tang? I think it is mainly to strengthen the diuretic force: the patient's fluids cannot be excreted through urine, so they come out as yellow sweat and edema, and there is great thirst. Thirst is very common in edematous patients; most late-stage ascites patients are thirsty. I lean toward using this formula for yellow sweat with the astragalus dose calculated by Han Dynasty weights and measures: one Han liang is about 15 grams, so five liang is 75 grams; when astragalus is used at 75 grams, the diuretic effect is excellent.
However, using these formulas to address yellow sweat in tumor patients has only the merit of treating the manifestation, not the root. I have used this approach to treat yellow sweat; it is effective in resolving the patient's yellow sweat but ineffective in controlling the tumor. Controlling the tumor still requires combining it with other herbs.