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Module 5   Lesson 14   Liu Jing

The Six Stages: Cold moving from the outside in

How do you follow an invasion of Cold layer by layer, and which finding tells you it has moved one layer deeper?

After this lesson you know, for each stage, the signs, tongue, pulse, principle and classical formula, the ways in which a disease moves on, and you see where the stages touch the core patterns of module 1. Formulas by name, without dosages.

OUTSIDE FORMULA AND PRINCIPLE PARTNER direct invasion (zhi zhong) usual sequence Greater Yang 太阳 aversion to cold, stiff neck, pulse floating Gui Zhi Tang, Ma Huang Tang release the Exterior Lesser Yin Bright Yang 阳明 four greats; or afternoon fever, constipation Bai Hu Tang, Da Cheng Qi Tang clear Heat or purge Greater Yin Lesser Yang 少阳 alternating chills and fever, bitter, wiry Xiao Chai Hu Tang harmonise Terminal Yin Greater Yin 太阴 full abdomen, vomiting, diarrhoea, no thirst Li Zhong Wan warm the Middle Bright Yang Lesser Yin 少阴 wants only to sleep, pulse minute and thin Si Ni Tang; Huang Lian E Jiao Tang rescue Yang; or nourish Yin Greater Yang Terminal Yin 厥阴 Heat above, Cold below, hungry, no appetite Wu Mei Wan warm and clear at once Lesser Yang INSIDE
Schematic. Red: Yang stages, usually Excess; blue: Yin stages, usually Deficiency. Lesser Yang with a dashed border: the hinge, half outside and half inside. Sequence as in the Shang Han Lun; by depth, Lesser Yang lies between Greater Yang and Bright Yang (textbook knowledge). Partner: the interior-exterior pair through which a disease can jump across.

Know by heart

  • Greater Yang (Taiyang). Aversion to cold, fever, stiff neck and headache, pulse floating. No sweating and pulse tight: Attack of Cold, Ma Huang Tang. Slight sweating and pulse relaxed: Attack of Wind, Gui Zhi Tang. Principle: release the Exterior. mnemonic: Ma Huang opens a closed door, Gui Zhi closes a leaking one.
  • Bright Yang (Yangming). Channel: the four greats (fever, sweating, thirst, pulse overflowing), no more chills; Bai Hu Tang; clear Heat. Organ: afternoon fever, constipation, full painful abdomen, thick dry yellow coating, pulse deep and full; Da Cheng Qi Tang; purge via the bowels.
  • Lesser Yang (Shaoyang). Alternating chills and fever, fullness under the ribs, bitter taste, dry throat, dizziness, nausea, no appetite; pulse wiry; Xiao Chai Hu Tang; harmonise, do not induce sweating and do not purge. mnemonic: the hinge swings back and forth, so cold and hot take turns.
  • Greater Yin (Taiyin). Full abdomen, vomiting, no appetite, diarrhoea, no thirst, abdominal pain that is better for warmth and pressure; tongue pale with a white coating; pulse deep, slow, weak; Li Zhong Wan; warm the Middle.
  • Lesser Yin (Shaoyin). Cold: cold, lies curled up, wants only to sleep, cold limbs, pulse minute and thin; Si Ni Tang; rescue the Yang. Heat: restlessness, insomnia, dry throat, tongue red with little coating, pulse thin and rapid; Huang Lian E Jiao Tang; nourish Yin, clear Heat.
  • Terminal Yin (Jueyin). Heat above and Cold below: unquenchable thirst, Qi rushing up to the chest, hunger without wanting to eat, vomiting, cold limbs; Wu Mei Wan; warm and clear at the same time.
  • Progression. Along the sequence, skipping a stage, via the partner (Greater Yang and Lesser Yin, Bright Yang and Greater Yin, Lesser Yang and Terminal Yin), direct invasion in weakness (zhi zhong), two stages at once (he bing) or overlapping (bing bing). mnemonic: a staircase with a lift, a slide and a side door.

The rest of this lesson is reference.

Six Stages: How do you follow an invasion of Cold layer by layer, and which finding tells you it has moved one layer deeper?
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Three practice questions from this lesson

Case. Woman, 29. Since this morning shivery, 37.9 °C, headache, stiff neck, pain in all her muscles, no sweating. Tongue thin white. Pulse floating and tight. No neck stiffness on bending forward.
  1. Ma Huang Tang
  2. Gui Zhi Tang
  3. Xiao Chai Hu Tang

Answer: Ma Huang Tang. Greater Yang, Attack of Cold: no sweating and a tight pulse. Gui Zhi Tang is for the leaking variant with sweating; Xiao Chai Hu Tang is for Lesser Yang, with chills and fever taking turns.

Case. Man, 55, tires easily. Since yesterday slightly feverish, sensitive to draughts, sneezing, slightly sweaty, headache. Tongue thin white. Pulse floating and relaxed.
  1. Wind-Heat: Yin Qiao San
  2. Greater Yang Attack of Wind: Gui Zhi Tang
  3. Greater Yang Attack of Cold: Ma Huang Tang

Answer: Greater Yang Attack of Wind: Gui Zhi Tang. Aversion to wind, slight sweating and a relaxed floating pulse: the leaking door. The sweat is leakage, not Heat; no sore throat or thirst. Attack of Cold does not sweat and has a tight pulse.

Case. Day 3 of flu. No more shivering, 39.6 °C, he feels too hot, sweats heavily, great thirst for iced water, red face. Tongue red with a dry yellow coating. Pulse big and rapid. Alert, breathing calm.
  1. Bright Yang channel
  2. Greater Yang Attack of Cold
  3. Bright Yang organ

Answer: Bright Yang channel. The four greats without chills: Bright Yang channel pattern, Bai Hu Tang. No more shivering: not Greater Yang. No full hard abdomen and no constipation: not the organ pattern. At 40 °C or with confusion, refer first.

The rest of this lesson

In the course you get the step-by-step explanation, 16 case-based practice questions, 23 spaced-repetition flashcards, the pitfalls and the bridge to physiology with evidence grades. This lesson belongs to module 5: Patterns.

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