A Translation of the Differential Diagnosis of 10 Conditions from Gōng Xìn's 1576CE Enduring Medical Observations
By Chad Ryan
The following are English translations of ten excerpts from the 1576 Míng dynasty work entitled Enduring Medical Observations (古今一鑑). The original editor of this work, Gōng Xìn (龔信) was born in Jīnxī (金谿) of Jiāngxī province, and spent twenty years collecting and collating the content of this book, a product formed by a conglomerate of influences ranging from as far back as the Yellow Emperor's Classic of Internal Medicine and the Classic of Difficulties, and to noted physicians including Yī Hé (醫和), Yī Huǎn (醫緩), Chún Yúyì (淳于意), Liú Wánsù (劉完素), Zhāng Cóngzhèng (張從正) and Zhū Zhènxiǎng (朱震享), right up to Dài Yuánlǐ (戴元禮) from the present era at the time of its writing. Gōng Xìn's son, Gōng Tíngxián (龔廷賢) continued to revise his father's work up until 1589.
Enduring Medical Observations discusses in depth the factors of pulse, pathology, herbal nature, and environmental influences. Specifically, the sections relating to differential diagnosis of the following ten conditions are herein transcribed: 1, diarrhoea; 2, nausea; 3, fever: 4, seizures; 5, headache; 6, insomnia; 7, coughing; 8, spontaneous sweating; 9, forgetfulness; and 10, fatigue in females. Gynecological conditions can require their own separate discussion, and the tenth condition detailed in here relates specifically to women.
1
Diarrhoea is the pathology of pouring downward. While the spleen and stomach are the sea of fluid and grain, the large intestine is an organ of delivery. It may be due to food and fluid types that induce cold, or due to external environmental factors of summer heat, damp, wind or cold, that cause the spleen and stomach to stagnate, and the ileocecal valve to fail to separate the clear from the turbid, which in turn lead to pouring downward and diarrhoea.
It is said in the Classic of Internal Medicine that when damp prevails, diarrhoea results. It is also said that when there is injury due to wind in spring, summer will bring with it diarrhoea with undigested food. Explosive diarrhoea forcing its way downward is always due to heat. All watery fluid type illnesses, those clear, translucent and cool in nature, are on the other hand all due to cold pathogen.
Shúhé, author of the Pulse Classic, says that when damp is abundant that it brings about the five types of diarrhoea, and you have the runs that move as fast as lightning. By the five types of diarrhoea, he is referring to spleen diarrhoea, stomach diarrhoea, large intestine diarrhoea, small intestine diarrhoea and great obstruction of the intestine diarrhoea types. There is also diarrhoea with undigested food, kidney diarrhoea, internal cold due to yīn exuberance (dòng, 洞) diarrhoea, soggy diarrhoea and duck stool diarrhoea, all of which are distinguishable from each other.
Zhū Dānxī states that there is diarrhoea due damp, qì deficiency, fire, phlegm and food stagnation. Regular watery diarrhoea without abdominal pain is due to damp. Food and drink not absorbed by the spleen and stomach, with grains thus not metabolised, is due to qì deficiency. Abdominal pain with watery diarrhoea like hot soup, alternating between hurting and running, is the fire type. Diarrhoea that presents with irregularity in its occurence and quantity is due to phlegm. Deep abdominal pain that accompanies diarrhoea and is reduce after the bowel is passed successfully is due to food stagnation. Diarrhoea that smells like the colon is harbouring rotten eggs or is accompanied by a sour taste in the throat is also due to injury by food.
2
Nausea is always related to appetite, and may be due to deficiency, heat, cold, food or phlegm.
3
A person with a fever will namely experience an intense discomfort beneath the skin. There are similarities and differences between this and hot flushes as well alternating chills and fever. Hot flushes come at rhythmic intervals, and alternating chills and fever features chills and fever, following each other in a continuous fashion. When comes to fever though, it's occurrence is not related to time. Between all the types of fever within society, many involve cold damage. The treatment of each is different, while understanding the relationship between exterior cause and internal damage is key to the comprehension of this disorder.
Zhāng Zhòngjīng discusses damage due to cold and damage due to wind, which are both exterior pathogens. Since wind-cold virulent pathogen is felt exteriorly, yet will spontaneously move interiorly, and the response is to disperse and scatter using Ephedra sinica and ramulus Cinnamomi. As this sensation comes about between winter and spring, during the the cold months, it is called cold damage, and acrid, warming herbs are used to overcome the cold. If occurring at a time when there is no coldness, the herbs used should be appropriately altered. Spring being characterised by months of warmness rightly sees an adjustment to acrid and cooling medicinals, and in summer as the period characterised by heat, there is an appropriate adjustment to sweet, bitter and cold herbs. That is to say that treatment must change according to time.
There is also such a thing as winter warmth damage, that is just like regular warmth damage, though out of sync with its regular timing. Winter is the time of coldness, and yet in this instance there is infection consequent of irregularity in the weather, and subsequent pervasion of yàng qì into the environment. The use of warming medicinals is in such instances is forbidden. There are by the same token cold epidemics which can crop up during warmer times of the year, once again as a result of irregularity in seasonal weather featuring the presence of yīn qì contrary to expectations, and in such circumstances cooling medicinals are forbidden. Then there are warm epidemics that occur in accord with seasonal weather patterns, those of warm diseases occurring most often as it would be either side of the time in which spring becomes summer, and the nature of this energy is severe. The appropriate treatment is to allow movement of the source energy, while following Liú Héjiān's method of using acrid, cool, sweet and bitter medicinals to clear heat and resolve toxicity.
These aforementioned syndromes are all due to external pathogenic influences. Should food, drink or work injure the source energy internally, it would follow that the upright energy will sink, giving birth to deficient heat. This is why Dōngyuán came up with the 'tonifying the centre to benefit qì' formula (補中益氣湯), using sweet warm medicinals of Ginseng and Astragalus to greatly tonify qì, thus lifting what has sunken. This is using qì medicinals to tonify qì deficiency. In instances of mental overexertion or lasciviousness, there is injury to the true yīn, injuring both yīn and blood, causing yáng qì to predominate, that in turn leads to the formation of fire, thence giving way to the syndrome of tuberculosis due to yīn deficiency and fire blazing. In accordance with Dānxī's theorem of expansion of yáng due to insufficiency of yīn, use four substance decoction plus Phellodendron and Anemarrhena to tonify yīn and allow fire to spontaneously descend, while prescribing the use of blood medicinals to tonify blood. The bolstering of qì and tonifying of yīn are both principles for syndromes of internal damage. When yáng qì sinks, tonify qì to lift it back up again, and when yáng fire flares upwards, tonify yīn to subdue it once more. One cause is due to ascent and the other descent, and thus both are different.
Then there is the syndrome of summerheat damage, and notwithstanding its external origin, it is a type of pathogen that causes internal damage comparable in extent to the cold pathogen. The nature of cold damage is for the cold pathogen to settle in the exterior of the body. It is a syndrome of excess, and thus it is appropriate to induce sweating. Summerheat damages qì. As source qì is consumed due to damage by heat, this is a deficiency condition, and it is appropriate to tonify accordingly with Dōngyuán's 'clear summerheat and bolster qì decoction' (清暑益氣湯).
Then there is summerheat damage in summer with preexisting internal damage due to intake of cold food or preexisting external damage due exposure to wind cold, and the principle of treatment is not that which is used for a person with damage simply due to summerheat. Although it is the summerheat which sets off this illness, it should be treated according to principles of cold damage, and acrid warming ingredients to release the exterior or acrid warming ingredients to regulate the interior are appropriate.
These syndromes occur commonly, and while they seem comparable, in reality they are not the same; the treatments are many, and should not be confused. Thus one must investigate whether the outcome is due to cold damage, wind damage or cold epidemic, in which case it is advised to use Zhòngjīng's methods; or whether the outcome is due to warm disease, hot disease or warm epidemic, in which case use Héjiān's methods; or whether the outcome is due to qì deficiency, in which case use Dōngyuán's method; or whether the outcome is due to yīn deficiency, in which case use Dānxī's method. It should be that these rules are followed without mistake that could otherwise endanger people's lives.
Allowing someone to simply look at the pathology of fever, they will invariably consider it due to external cold pathogen, and they will resolve to use herbs that induce sweating to release the exterior. When the condition does not resolve after sweating, they will they will then use exterior releasing herbs to cool the flesh. If the condition was due to deficiency, it is hard to imagine this approach not leading to ruin! Even if the healer knows that the fever is due to deficiency, and so uses tonic herbs, they may not understand whether the cause of the fever belongs to that of qì or blood deficiency, and those who mistakenly tonify blood when there is qì deficiency or vice versa are many. Between external influence and internal damage, cold disease and hot disease, qì deficiency and blood deficiency, the difference is as great as ice and carbon, and if the treatment is poor, a mild illness will become servere, and a serious illness will become fatal. Is that not frightening?
4
Of the Chinese characters that merge to form the word for seizure, 眩暈, the first indicates seeing blackness, and the second indicates convulsions. It this condition, the eyelids shut and the eyes see darkness, and the body convulses while the ears are deaf, the movements resembling those as if lying in a cart or on a boat, rising and falling. All forms of this phenomenon relate to the liver, with attack of wind pathogen being the cause.
To qualify, people with deficient constitutions, who are subject to the six intemperances, and injured by the seven emotions, can all suffer from seizures, and the type of seizure that they suffer should be distinguished according to their pulse. When there is wind the pulse is floating, and the person will also experience sweating and tension of the neck; when there is cold the pulse is tight, and the person will be without sweating, while the muscle contractions will be painful; when there is summerheat the pulse will be deficient, and the person will be vexed; and when there is damp, the pulse will be deep and thin, and there be vomiting.
As for the seven emotions, they will enforce disharmony upon the qì of the internal organs. The knotting and stagnation due to fluids will give rise to drooling that has followed the qì upwards that caused the person to have the seizure. There will be pain of the superior orbital margin, the eyes will be unable to open, and in the majority of cases the pulse will be deep, but only as a result of the change in condition. Those who are overly weary, or have deficiency below and excess above, as well as women who experience nosebleed or vomiting of blood before or during their period, or who experience postpartum bleeding, or others who experience an excessive loss of blood, can all experience seizures, and the treatment must respond to the nature of the cause.
It is said that seizure syndromes are always the result of excess above and deficiency below, although their cause is not always clearly stated. It could generally be stated that deficiency would refer to blood and qì, and so-called excess: phlegm fluids, and wind and fire.
Examining the origin of the deficiency forms of the illness: where due to qì deficiency, it is a case of clear qì being unable to rise, or profuse sweating extinguishing yáng as a cause, and it is appropriate to raise yáng and tonify qì; and where due to blood deficiency, it is because of the loss of too much blood and yáng being unable to attach itself to any substance, and it is appropriate to bolster yīn and tonify blood.
Considering excessive factors: where there is stagnation due to phlegm fluids, it is appropriate to clear phlegm and disinhibit stagnation, whereby inducing vomiting and purging are important principles; and where wind fire is flaring, it is appropriate to clear the upper region and descend fire. Where seizures are due to external pathogenic influence, the first question is to differentiate between the four climatic factors, and in each case it is appropriate to disperse the pathogenic influence.
There is such a thing as so-called qì not returning to the source, and by the use of minerals to settle and descend, one can employ the Aquilaria qì-descending (沉香降氣) method. Usually, fragrant (香) medicinals would scatter qì, and the minerals used in elixirs would fan the internal flames, which is not returning source qì, so how can this response be applied? In the Classic of Internal Medicine it is said that to treat an illness, you must find its origin. Should qì not return to the source, find its origin, and using herbs is a good way of doing so.
5
Dōngyuán said: The east wind is born is spring, at which time illness resides in the liver, and is transferred to the neck and nape. Illness affects the head as a result of spring qì. Additionally, all yáng channels meet on the head and face. This includes the foot greater yáng bladder channel, which originates at the inner canthus of the eye, then crosses the forehead and crown of the head, before entering the brain and exiting at the nape, so when illness attacks it a headache that is produced. The foot lesser yáng gallbladder channel, which originates at the outer canthus, and crosses the depression at the base of the skull, when struck by illness presents as pain of the forehead and corner of the forehead.
With regard to wind exposure from above, when wind-cold exterior pathogen is implicated and enters the channels and collaterals, it will cause a person to shiver and experience a headache, while they have a strong aversion to cold. The treatment rests with acupoints GB20 (風池) and GV16 (風府) to regulate yīn and yáng. Tonify that which is deficient and drain that which is in excess, while inducing sweating for a recovery. This is a cold damage type headache.
Headache with tinnitus, where the nine orifices are not freeflowing, is a pattern brought about by the stomach and intestines, and represents a qì deficiency type headache.
In headache accompanied by irritability, the pathogen is residing in the ears. Having traversed the hand greater yáng and hand lesser yīn, it is a damp heat type headache.
When qì has risen and will not descend, there is headache and mental derangement, deficiency below and excess above, the pathology having traversed the foot lesser yīn and foot greater yáng, and even into the kidneys. This is a damp cold type headache.
If there is a cold-type pain affecting half the head, it is a temporal headache. Enquire first as to the hand lesser yáng and hand yáng brightness channels, and then to the foot lesser yáng and foot yáng brightness channels.
There is a true headache in which even the entire brain hurts, indicative of cold to the joints of the hands and the feet, for which the prognosis is poor and no treatment is recommended.
There is a final rebellion type headache that always results from great coldness penetrating the bones and marrow, and the brain being the sea of marrow revolts and in doing so brings about pain that extends to the teeth. It is a standard type of headache, that is invariably taken to be due to wind. Healers tend to fear that wind is able to reach the vertex of the head.
There exists the principle that light medicinals, those embodying of yáng with yīn, will naturally bring the earth to the heaven.
Differentiation may furthermore proceed in accordance with the three yīn and three yáng types of headache.
6
Insomnia has two types: the infirmity in the aftermath of illness, or decline of yáng in those of great age, type insomnia; and phlegm in the gall bladder channel, due to which the spirit cannot return to its abode, as the second cause.
7
Those with cough due to injury by wind have a floating pulse, a high fever and aversion to cold, spontaneous sweating, an intolerance of wind, a dry mouth, irritability, a runny nose with clear nasal discharge and coughing mid sentence.
Those with cough due to injury by summerheat have a tight pulse, a fever, an intolerance to cold, irritability, no sweating, no thirst and a cough on exposure to cold.
Those with cough due to injury by cold have a rapid pulse, irritability and a fever with desire for fluids, a dry mouth or regurgitation of froth, hoarseness and hemoptysis.
Those with cough due to injury by damp have a thin pulse, stiff and painful joints, heaviness of the four limbs, or perhaps spontaneous sweating, and hesitant and painful micturition.
8
Man's sweat is the fluid of the heart. When the heartbeat becomes cautious, sweat will exude. Spontaneous sweating exudes without a cause for its dispersal; while thief sweating, which is night sweating, comes out without us realising it.
The pathology of spontaneous sweating is without instances that do not include dual deficiency of the heart and kidneys. In yīn deficiency, yáng will necessarily accumulate, resulting in fever and night sweats. In yáng deficiency, yīn loses its ride, and in its final stand will be exudation as spontaneous sweat. It is this relative predominance of either yīn or yáng that always induces these sweating conditions.
Dānxī said: spontaneous sweating may belong to qì deficiency, or may belong to phlegm and damp; while thief sweating may belong to yīn deficiency, or may be due to mutual flaring of liver and kidney fires brought on by anger and desire (相火).
There is spontaneous sweating due to cold damage, summerheat damage, wind damage, damp damage, and phlegm cough, all of which lodge within the pores.
When spontaneous sweating exudes without illness, and then after illness becomes profuse, this is a case of external deficiency and defensive qì insecurity, and it is the flourishing of blood that seeps out. The appropriate response is to use 'Astragalus establish the centre decoction' (黃耆建中湯) plus 'fructus Tritici levis sautué decoction' (福麥煎), 'Astragalus six-to-one powder' (黃耆六一散) or 'jade windscreen powder' (玉屏風散).
If the body temperature is warm, yet there is frequent exudation of cold sweat, or if the body is cool and the sweat is also cool, there is no associated illness, and the sweating itself is the root of the syndrome.
Regular exudation of damp sweat is one condition that cannot be treated; exudation of oily sweat is a second; and condensed sweat like pearls is a third.
9
People with forgetfulness suddenly forget things, whereby despite exercising their upmost capacity, their thought cannot be recalled. They may have begun doing something and be unable to finish it, or while talking they may not know how to start or finish their sentence, and this all relates to the heart and spleen channels. This may come about due to too many thoughts and concerns injuring the heart and causing depletion and dispersion of blood, such that the spirit does not maintain its residence; or by injury to the spleen leading to severe expenditure of stomach qì, where there has been deep apprehension. These two circumstances both cause people to suddenly forget things. The reasons are that the heart produces blood, and due to blood deficiency it is unable to nourish its own self; or when fluids settle and the qì becomes stagnant, phlegm forms, and qì already being stagnant the spleen is unable to find relief, and that is how this forgetfulness comes to be.
10
While the great majority of instances of fatigue in males find their origin in injury of the essence, fatigue in females begins with amenorrhea. Amenorrhea brings about fatigue, usually because accrued thoughts and worry inhibit the heart, and when the heart is injured, blood revolts entirely, and the fluid of the menses immediately stops. With the organ of fire having become diseased, it is not able to nourish its son [the earth, or spleen], and thus the individual is unable to indulge in food. Spleen deficiency in turn imparts debility on to the metal [lung], and subsequently gives rise to coughing. When kidney water is exhausted, there ceases to be satiety of wood qì, leading to great anger and rage, and emaciation of the four limbs. Passing on through all five organs like this, the condition is most difficult to treat.
Then there is the instance of [the physician] reckoning there to be blood heat, and thus using cooling medicinals to rectify it, or reckoning there to be cold blood, and hence using hot medicinals to move it. Especially when not cognisant that the menstrual blood is already reduced, this response can gradually cause a loss of freeflow, leading the flesh and bones of the hands and feet to become irritable and sore, bit by bit ensuring the advancement of emaciation, and occurrence of tidal fever. The pulse is felt as minute and rapid, because yīn and blood are insufficient, while yáng is able to establish superiority, so water cannot overcome fire, resulting in fire scorching and water dripping. It is appropriate to nourish yīn and blood for the above, being cautious not to use medicinals to induce movement.
Reference
Gōng X. Enduring Medical Observations. Beijing: China Chinese Medicine and Herb Publishing House; 1997.