Dilema

How to treat all three Yang Conformations?

I came across this line when studying and working out the xiao chai hu tang lines from the Shang Han Lun. It got me thinking about how I would treat all three Yang Conformations with an herbal formula. There are none, so I would have to figure it out.

When all three Yang Conformations are diseased, and the surface is closed, there is only one solution. Treat the pivot of Shao yang. I will explain why there is no formula that treats all three Conformations.

231 In yang ming wind strike, the pulse is string like, floating, and large, and there is shortness of breath, fullness of the entire abdomen, and pain under the rib-side and in the heart, which gives rise to qi blockage when pressed for a long time, dry nose, inability to sweat, somnolence, yellowing of the entire body including the eyes, difficult urination, tidal heat effusion, frequent hiccup, and swelling in front of and behind the ear. When needling brings slight recovery, but the exterior has not yet resolved, and the disease has lasted more than three days and the pulse is still floating, one should give xiao chai hu tang.

The Pulse

The pulse is string like, floating, and large.

Qian Huang comments, A string like pulse indicates Shao yang, a floating pulse indicates Tai yang, and a large pulse indicates Yang ming disease.

Indicating disease in all three Yang Conformations.

Tai yang

A floating pulse and absence of sweating.

Shao yang

Pain under the rib-side and below the Heart, difficult urination, and swelling around the ears.

Yang ming

Shortness of breath, abdominal fullness, dry nose, generalized yellowing, tidal heat effusion, somnolence, and hiccup.

In Yang ming disease there is normally profuse sweating, but the surface is closed due to Tai yang disease.

Generalized yellowing

Generalized yellowing is a sign that there is heat in the central burner.

This heat ascends and cause somnolence, which is tiredness. The heat also causes Counter Flow Qi that is seen as hiccups.

Ears

The area around the ears belongs to Shao yang. Heat causes the congestion and swelling of the ears.

Difficult urination

The Shao yang disease inhibits the waterways of all three burners causing inhibited urination.

Treatment

In line 231 needling is used. The reason is that in disease of all three Yang Conformations caution is advised. No points are suggested?

Qian Huang comments, When the evil passes to the Shao yang, promotion of sweating, vomiting, and precipitation, are all contradicted.

This reflects the core Shao Yang principle:

• Sweating would damage fluids and the exterior
• Vomiting would disturb the Stomach Qi
• Purging would pull the pathogen inward

The text itself gives a very clear directive:

“When needling brings slight recovery, but the exterior has not yet resolved, and the disease has lasted more than three days and the pulse is still floating, one should give Xiao Chai Hu Tang.”

This is Zhang Zhongjing telling us: Restore the pivot of Shao yang first.

Zhang Zhongjing usually prefers:

• One clear method at a time
• Especially: “harmonize first, attack later”

Now the dilemma!

Huang Di: Question, Is there a formula that treats a Tai yang closed surface, harmonizes Shao yang and clears heat in Yang ming without purging?

Qi Bo: Answer, xiao chai hu tang will restore the pivot.

But if forced to make a formula, this is what I would do?

Chai Hu Gui Zhi + Ge Gen + Ma Huang + extra Bai Shao

ge gen 12 ma huang 9 chai hu 24 huang qin 9 ban xia 12 ren shen 9 gui zhi 9 bai shao 12 sheng jiang 9 da zao 9 zhi gan cao 9

This formula is very “Jin-Yuan style clinical creativity.”

It is a balance of :

• releasing
• harmonizing
• protecting fluids

In defence of my choice.

I am using the structure found in ge gen tang, which treats a half open, half closed surface. The gui zhi tang base combined with the xiao chai hu tang treats the Tai yang and Shao yang. The extra bai shao cools the internal heat and the ge gen balances out the effect of the bai shao.

Promoting sweating but not too much, harmonizing Shao yang and cooling Yang ming. 

The Heart of the Matter

In the end, “just xiao chai hu tang will suffice”.

And this is really the genius of Zhang Ji.

He constantly teaches us:

When the pattern is complicated and tangled:

• Don’t panic
• Don’t over-treat
• Don’t try to fix every symptom

Instead:

Stabilize the pivot first.

Once Shao Yang is harmonized:

• The exterior may open by itself
• Yang Ming heat may descend naturally
• The whole picture can transform

It’s a humbling lesson

Our modern clinical minds want to build:

• multi-layered
• super customized
• “perfectly matched” formulas

But the Shang Han Lun keeps reminding us:

The simplest method, applied at the correct level, often works better than the most brilliant modification.