②痞：本是一種疾狀名稱，不是獨立的病名。但也有以痞為主證，而進行治療的，如諸瀉心湯證。
鄭論：按脈浮而緊，是寒傷的候，理應解表，醫者不知解表，而複下之，緊反入裏，明明引邪深入而成痞滿之象，但按之濡，是無形之熱邪結於心下。至於關上浮大，足見中州之實有熱助之，而原文之大黃黃連瀉心湯，是的確之法。若心下痞，而見惡寒汗出者，則又陽虛之征，因誤下所致，原文以附子瀉心湯主之，附子可用，而芩連必不可用，何也？惡寒者，陽衰之驗，汗出者，亡陽之機，心下痞者，陰邪上逆之據，法宜大劑扶陽宣散為是，學者宜細察之。
【闡釋】本條係《傷寒論》151、154、155三條合併而成。“脈浮而緊”至“氣痞耳”為一節，說明痞的成因與證狀；“心下痞”至“大黃黃連瀉心湯主之”為第二節，此熱痞的證治；“心下痞”至“附子瀉心湯主之”為第三節，此痞證而兼陽虛的證治。鄭氏對第三節所按：“附子可用，芩、連必不可用。”發人深省。筆者認為可用附子理中湯扶陽抑陰，加半夏、砂仁健脾降逆為當。
大黃黃連瀉心湯（校補）
大黃二兩黃連一兩上二味，以麻沸湯①二升漬之，須臾絞去滓，分溫再服。
大黃二兩黃連一兩黃芩一兩附子一枚（炮，去皮，破，別煮取汁）上四味，切三味，以麻沸湯二升漬之，須臾絞去滓，內附子汁，分溫再服。
①麻沸湯：即沸水。汪苓友曰：麻沸湯者，熟湯也，湯將熟時，其面沸泡如麻，以故雲麻。漬之：用沸水泡藥，而不用煎熬。
【方解及其應用範圍】大黃黃連瀉心湯為瀉火泄熱之劑。大黃苦寒，急瀉上炎之火；黃連瀉中焦邪火，清熱消痞。二藥僅用沸湯漬泡，取汁飲服，重在清中焦之熱邪而不主瀉下。
故凡不惡寒，但惡熱，心下痞悶不舒，按之膨滿而微有抵抗，自覺煩熱，熱氣上沖，頭痛，面赤等，都可治之。《金匱》用治“心氣不足，吐血、衄血。”此氣盛火旺，逼血妄行也。近人推廣治療炎性的胃腸病，和一般突發的充血性疾病，如高血壓等，更廣泛用於熱盛之吐血，療效可靠。附子瀉心湯即上方加黃芩、附子，為寒熱並用，溫清兼施，正邪兩顧之和劑。三黃泄熱消痞，僅用沸水漬泡取汁，附子久煮，取濃汁。合和與服，取寒熱異其氣，生熟異其性藥雖同行，而功則各奏。故凡證屬實熱而體屬陽虛之胃病或吐血鼻衄等病，都可適用。
三十一、傷寒五六日，嘔而發熱者，柴胡湯證具，而以他藥下之②，柴胡證仍在者，複與柴胡湯，此雖已下之，不為逆，必（兼之）〔蒸蒸而振〕③，卻發熱汗出而解。若心下滿而鞭〔痛〕者，此為結胸也，大陷胸湯主之（可也）。但滿而不（病）〔痛者〕，此為痞，柴胡湯不中與之，宜半夏瀉心湯。原文149
②他藥：即承氣之類，非有別藥也。
③蒸蒸而振：蒸蒸，身熱汗欲出之狀也；振者，振振然動搖之貌，即寒戰也。
鄭論：按柴胡湯症具，而以他藥下之，柴胡症仍在者，是下之而邪未深入，尚在少陽，故不為逆，若下之而轉變別症，少陽症全無者，則是下之過，咎無可辭。若心下滿而鞕，雖名結胸，究竟務要察其虛實，果係有邪熱結於心下者，可與大陷胸湯。若係下之失宜，而陰寒水濕上逆而作者，猶宜溫中降逆，化氣行水方是。所雲滿而不（病）〔痛〕則為痞，原非柴胡湯所宜。原文以半夏瀉心湯，確乎有理，至於方中芩連，似覺不當，學者察之。
【闡釋】此條乃柴胡湯證具，誤下後的三種病變。其一是雖誤下而證未變，所以仍用原方治療。其二是病轉結胸的證治，又有兩種情況，果係有邪熱結於心下者，可與大陷胸湯；若陰寒水濕上逆而作者，則宜溫中降逆，化氣行水，可用附子理中湯加肉桂、砂仁、半夏、茯苓治之。其三是轉痞滿的證治，亦即是心下滿而不痛的痞證，則宜用半夏瀉心湯治療。鄭氏提出方中芩連，似覺不當，應用時宜詳加審察，示人以慎重之意。
半夏半升（洗）黃芩、乾薑、人參、甘草（炙）各三兩、黃連一兩大棗十二枚（擘）上七味，以水一鬥，煮取六升，去渣，再煎取三升，溫服一升，日三服。須大陷胸湯者，方用前第二法。原注雲：“一方用半夏一升”
【方解及其應用範圍】柯韻伯雲：“即小柴胡湯去柴胡加黃連乾薑也。不往來寒熱，是無半表證，故不用柴胡，痞因寒熱之氣互結而成，用黃連乾薑之大寒大熱者，為之兩解也。”但下後中虛，所以用參草大棗以補正。近代推廣應用治療胃腸道疾病，如急慢性胃腸炎、消化不良、食欲不振，髒寒腸熱之泄瀉等，都有一定療效。
三十二、本以下之，故心下痞，與瀉心湯①，痞不解，其人渴而口（煩燥）〔燥煩〕②，小便不利者，五苓散主之。原文156
鄭論：痞由誤下而致，服瀉心湯而不解，又複見（煩燥）〔燥煩〕口渴，小便不利，原文以五苓散主之，可見初非下症，實太陽之症。因下而引入太陽之腑也。可見醫家不可妄下，總要斟酌妥貼為妙。
【闡釋】痞由誤下而成，本條痞證是水飲內停，津液不行所致，故有渴而口燥心煩，小便不利等。如鄭氏所說：“實太陽之症，因誤下而引入太陽之腑，”故五苓散為對症之良方。
三十三、傷寒服（瀉）〔湯〕藥，下利不止，心下痞鞭，服瀉心湯已，（後）〔複〕以他藥下之，利不止，醫以理中與之，利益甚，理中者，理中焦①，此利在下焦②，赤石脂禹餘糧湯主之。複（利）不止者，當利其小便。原文159
②下焦：是指病在下部。
鄭論：據所稱傷寒，服（瀉）〔湯〕藥下利不止，而至心下痞，明是下傷胸中之陽，遂使濁陰僭居高位而成痞，雖服瀉心湯而病未解，又複下之，一誤再誤，所失愈多，醫㈠〔以〕理中湯治之，下利益甚。非下利甚之可怪，實由中州轉運，而積陰下泄，雖泄甚一時，而收功已在旦夕，昧者不察，以為病在下焦，非理中可了，又複以赤石脂禹餘糧湯治之，仍不效，而曰當利小便，不知下利，有小便尚利者，有小便不利者，不利者可利，而小便利者決不可利。以余所見，全是誤下所致，理中是不易良法，理中內加桂、芩、砂、半是絕妙法，原文所論之方，皆在似是而非之例，學者詳細辨之。
【闡釋】本條指出，下後再次誤下，有各種不同病情，應根據辯證論治的精神來處方治療。如下後痞鞕下利，而胃脘部痞鞭偏甚的，宜用瀉心湯；如中焦虛寒的，宜用理中湯。如下利不止，下虛滑脫的，可用赤石脂禹餘糧湯；如屬清濁不分，小便不利的，可用五苓散，小便一利，便可減少大便中水分，有利於下利不止的治療。鄭氏認為全是誤下所致，理中是不易良法，理中內加桂、苓、砂、半是絕妙法，亦可遵從。
赤石脂禹餘糧方（校補）
赤石脂一斤（碎）太一禹餘糧一斤〔碎）上二味，、以水六升，煮取二升，去渣，分溫三服。
【方解及其應用範圍】柯韻伯雲：“大腸之不固，仍責在胃，關門之不緊，仍責在脾，此二味皆土之精氣所結，能實胃而澀腸，凡下焦虛脫者，以二物為末，參湯調服，最效”。
三十四、傷寒發熱，汗出不解，心中痞鞭，嘔吐而下利者，大柴胡湯主之。原文165
鄭論：按傷寒發熱，有風傷衛之發熱，寒傷營之發熱。出汗，有風傷衛之出汗，有陽明熱甚之出汗，有少陰亡陽症之出汗。而此只雲：發熱汗出不解，是用桂枝解表之劑而出汗不解乎？是用麻黃解表而發熱汗出不解乎？此中全無實據。言陽越於外發熱也可，言汗出亡陽也可。又雲：心中痞鞭，嘔吐下利，全是太陰病情，則於太陽症不合，至於大柴胡湯，則更屬不合也，學者盍察之。
【闡釋】此條鄭氏提出種種疑問，以及心中痞鞭，嘔吐下利，證屬太陰，皆值得學者辨證時深思，大柴胡湯為和表清裏之劑，與病症不合，不可用矣。舒馳遠更說：“大柴胡湯不可用，仲景必無此法”。方見“過經不解”一條。
三十五、傷寒發汗，若吐若下，解後①，心下痞〔鞭〕，噫氣不除者②，旋複代赭石湯主之。原文161
①解：謂大邪已散去。
②噫氣：即飽食息也。俗曰打飽呃。
鄭論：按傷寒病，至用汗、吐、下三法，外病已解，而見心下痞，噫氣不除者，由或汗、或吐、或下，傷及胸中之陽，以致濁陰上幹，逆於心下，阻其升降之氣機而為噫。原文以旋複代赭石湯主之，實屬至當之法。
【闡釋】本條為傷寒大邪解後，虛氣作痞的治法。鄭氏釋“噫氣不除者，傷及胸中之陽，以致濁陰上幹，逆於心下，阻其升降之氣機而為噫”。實屬至當，主以旋複代赭石湯，為確切不易之方矣。
旋複代赭石湯方（校補）
旋複花三兩人參二兩生薑五兩代赭一兩甘草三兩（炙）半夏半升（洗）大棗十二枚（擘）上七味，以水一鬥，煮取六升，去渣，再煎取三升，溫服一升，曰三服。
【方解及其應用範圍】本方以人參、甘草養正補虛，薑、棗和脾養胃，半夏以蠲飲降濁，更以代赭石之重，使之斂浮鎮逆，旋複花之辛，用以宣氣滌飲。濁降則痞鞕可消，清升則噫氣可除。現多用於慢性胃腸病，胃氣上逆，眩暈嘔吐，胸痞，痰多而粘，食不下，大便秘結，噎膈反胃等。
三十六、病脅下素有痞，連在臍旁，痛引少腹，入陰筋者①，此名髒結②，死。髒結無陽症③，不往來寒熱，其人反靜，（則）舌上苔滑者，（而）不可攻也。原文167、130
①入陰筋：指睾丸而言，此指陰莖縮入。
②髒結：髒氣結塞不通的意思。
③陽症：指發熱、頭痛、身疼、口渴等陽性證狀。
鄭論：兩脅屬肝地面，素有痞連在臍旁，是陰寒久聚于厥陰而未解，陰邪甚則痛直入陰筋，故決其死。而曰髒結者，肝為陰髒故也。無陽症，不往來寒熱，其人安靜，舌滑苔，則是陰症之實據，言不可攻，是教人不可妄用藥以攻其結也。
【闡釋】此條《傷寒論》原書分作兩條：“病脅下素有痞，……此名髒結，死”。為第一節，此言髒結的痞屬極危候。痞症之結深結久，惟陰無陽，陰氣過極，陽氣竭絕，故死。第二節為“髒結無陽症……不可攻也。”繼續說明髒結證的屬性，是純陰無陽，雖有如結胸的鞕滿證狀，慎不可攻，若誤攻之，則犯虛虛之戒。此條有論無方，前節言死，後節言不可攻。筆者認為可用大劑四逆湯、白通湯以回陽，或當於十百中挽救一二，亦是盡治病之道而已。
三十七、問曰：病有結胸④，有（結髒）〔髒結〕⑤，其狀何如？
答曰：按（則病）〔之痛〕，寸脈浮，關脈沉，名曰結胸也。何為（結髒）〔髒結〕？答曰：如結胸狀，飲食如故，時時下利，寸脈浮，關脈小、細、沉、緊，名日髒結，舌上白苔滑者⑥，難治。原文128、129
⑤髒結：證候名，證狀與結胸相似，而性質不同，為髒氣虛寒而結。
⑥舌上白苔滑：就是舌上有白色的滑苔。
鄭論：按結胸、髒結兩症，答曰寸浮、關沉緊；寸浮、關細沉緊，皆非確論。若寸浮、關沉而不結胸；寸浮、關細沉緊而不髒結，則又當何說？以餘鄙見，當時胸高突起，結於胸之上部者，可名結胸。如物盤狀，結於少腹兩側，或在臍旁，可名髒結。然後以脈象參之，庶為近理。若僅以脈象而論，恐未必盡如是說也，學者須知。
【闡釋】本條《傷寒論》原書分為兩條。“問曰……名曰結胸也”為一條；“何為髒結……難治”又為一條。鄭氏說：不能只憑脈辨結胸與髒結，而應結合證狀參之。如胸高突起，結於胸之上部者可名結胸；如物盤狀，結於少腹兩側，或在臍旁，可名髒結。必這樣辨結胸與髒結，方為恰當。亦即對證候的診斷，四診缺一不可。
三十八、傷寒六七日，結胸熱實①，脈沉〔而〕緊，心下痛，按之石鞕者，大陷胸湯主之。原文135
鄭論：此條明言熱邪盤聚胸中，以致心下痛，按之如石鞕，故取大陷胸湯以治之，急欲逐去熱邪之意也。前太陽上篇三十七條內雲：脈浮者必結胸，此何不見脈浮也？脈沉緊者，必欲嘔，此何不見嘔也？總之，專以脈定病，決乎〔不〕可，況氣機變化莫測，焉能以二十八脈象，以定億萬病象乎？學者切不可為脈所囿，則得矣。
【闡釋】此節乃未經誤下而成結胸之證也。傷寒六七日，寒不外解，而反化熱入裏，故曰結胸熱實。提出熱實二字，恐人以沉緊之脈而誤認為寒實結胸也。
此證寒化為熱，而與有形之水，搏結於心下，故按之石鞕而痛也。治以大陷胸湯，瀉熱逐水，得快利，則病自愈矣。鄭氏曰：“專以脈定病，決乎不可。”必需四診合參，乃能探得病原，辨證處方，斯為得矣（此條舒本列為38條，鄭書列為58條，按理應列為38條，故從舒本將此條移前。鄭書38條移為39條，以下依次順移）。
[Background Information]
Book Title: Shanghan Heng Lun (Constant Commentary on Cold Damage)
Chapter: Main Text (10/33)
Category: Shanghan (Cold Damage)
② Pi (Fullness and obstruction): Originally a term for a symptom, not an independent disease name. However, there are cases where Pi is the primary syndrome treated with formulas such as the various Xiexin Tang (Heart-Draining Decoctions).
Commentary by Zheng: A pulse that is floating and tight indicates cold pathogen injuring the exterior; the appropriate treatment should be to release the exterior. If the physician fails to do so and instead uses purgation, the tight pulse enters the interior, clearly indicating that the pathogen has been drawn deep into the body, resulting in fullness and obstruction (Pi). However, if palpation reveals softness, it indicates that formless heat pathogen is knotted at the epigastrium. The presence of a floating and large pulse at the Guan position confirms that there is excess heat in the Middle Jiao (Middle Burner). Therefore, the Dahuang Huanglian Xiexin Tang (Rhubarb and Coptis Heart-Draining Decoction) mentioned in the original text is indeed the correct method. If Pi at the epigastrium is accompanied by aversion to cold and sweating, this is a sign of Yang deficiency caused by erroneous purgation. In such cases, Fuzi Xiexin Tang (Aconite Heart-Draining Decoction) is indicated. While Fuzi (Prepared Aconite Root) can be used, Huangqin (Scutellaria Root) and Huanglian (Coptis Rhizome) must absolutely not be used. Why? Aversion to cold is evidence of declining Yang; sweating is a mechanism of Yang collapse; Pi at the epigastrium is evidence of Yin pathogen counterflow upward. The treatment principle should be to use a large dose of herbs to support Yang and disperse stagnation. Students should examine this carefully.
[Explanation] This section is compiled from Articles 151, 154, and 155 of the *Shanghan Lun* (Treatise on Cold Damage). From "floating and tight pulse" to "Qi Pi (Qi-type fullness)" constitutes the first section, explaining the etiology and symptoms of Pi. From "Pi at the epigastrium" to "Dahuang Huanglian Xiexin Tang is prescribed" constitutes the second section, addressing the syndrome differentiation and treatment of Heat Pi. From "Pi at the epigastrium" to "Fuzi Xiexin Tang is prescribed" constitutes the third section, addressing Pi complicated by Yang deficiency. Zheng's comment on the third section—"Fuzi can be used, but Huangqin and Huanglian must not be used"—is thought-provoking. I believe that using Fuzi Lizhong Tang (Aconite and Poria Decoction for the Middle Jiao) to support Yang and suppress Yin, added with Banxia (Pinellia Tuber) and Sharen (Amomum Fruit) to strengthen the Spleen and direct rebellious Qi downward, is appropriate.
Dahuang Huanglian Xiexin Tang (Corrected and Supplemented)
Dahuang (Rhei Radix et Rhizoma) 2 liang, Huanglian (Coptidis Rhizoma) 1 liang. Take these two ingredients, steep them in 2 sheng of Mafei Tang (boiling water), wait briefly, strain off the dregs, and divide into two warm doses.
Fuzi Xiexin Tang Formula (Corrected and Supplemented)
Dahuang (Rhei Radix et Rhizoma) 2 liang, Huanglian (Coptidis Rhizoma) 1 liang, Huangqin (Scutellariae Radix) 1 liang, Fuzi (Aconiti Lateralis Radix Praeparata) 1 piece (processed, skin removed, broken, boiled separately to extract juice). Take the above four ingredients, chop the first three, steep them in 2 sheng of Mafei Tang, wait briefly, strain off the dregs, add the Fuzi juice, and divide into two warm doses.
① Mafei Tang: Refers to boiling water. Wang Lingyou stated: "Mafei Tang means cooked water; when the water is nearly boiling, bubbles like hemp seeds appear on the surface, hence the name." Zhi zhi: Soaking herbs in boiling water without decocting.
[Formula Analysis and Scope of Application] Dahuang Huanglian Xiexin Tang is a formula for draining fire and clearing heat. Dahuang is bitter and cold, rapidly draining flaming-upward fire; Huanglian drains evil fire in the Middle Jiao and clears heat to resolve fullness. These two herbs are only soaked in boiling water to extract the juice for drinking; the emphasis is on clearing heat pathogen in the Middle Jiao rather than promoting purgation.
Therefore, it can treat conditions where there is no aversion to cold, but only aversion to heat, fullness and discomfort at the epigastrium, distension upon palpation with slight resistance, subjective feeling of irritability and heat, rising sensation of heat qi, headache, and red face. In the *Jinkui Yaolue*, it is used to treat "deficiency of Heart Qi, hematemesis, and epistaxis," caused by excessive Qi and flourishing fire forcing blood to move recklessly. Modern practitioners have expanded its use to treat inflammatory gastrointestinal diseases and general sudden congestive diseases, such as hypertension, and it is widely used for hematemesis due to excess heat, with reliable efficacy. Fuzi Xiexin Tang adds Huangqin and Fuzi to the above formula, combining cold and hot properties, warming and clearing simultaneously, and attending to both healthy Qi and pathogenic factors. The three yellow herbs (Dahuang, Huanglian, Huangqin) drain heat and resolve fullness, soaked only in boiling water to extract juice, while Fuzi is boiled for a long time to extract concentrated juice. Mixed and taken together, they utilize the different natures of cold and hot and the different properties of raw and cooked processing; although the herbs act together, their functions achieve separate effects. Thus, it is applicable to stomach diseases or hematemesis and epistaxis characterized by excess heat syndromes but underlying Yang deficiency.
Article 31: In Cold Damage, after five or six days, if vomiting and fever occur, the Chaihu Tang (Bupleurum Decoction) syndrome is complete. If purged with other medicines erroneously, and the Chaihu syndrome remains, administer Chaihu Tang again. Although purgation has been performed, this is not adverse; there will inevitably be a sensation of intense heat and trembling, followed by fever, sweating, and resolution. If there is fullness and hardness-pain below the heart, this is Jie Xiong (Chest Binding), treated with Daxianxiong Tang (Major Expulsion from the Chest Decoction). If there is fullness without pain, this is Pi, Chaihu Tang is not suitable, and Banxia Xiexin Tang (Pinellia Heart-Draining Decoction) is appropriate. Original Text 149.
② Other medicines: Refers to formulas like Chengqi Tang (Gastrointestinal Draining Decoctions), not distinct medicines.
③ Zhengzheng er zhen: "Zhengzheng" describes the state of body heat with sweat欲 emerging; "zhen" refers to trembling and shaking, i.e., chills.
Commentary by Zheng: When the Chaihu Tang syndrome is present and purgation is erroneously applied, if the Chaihu syndrome remains, it means the pathogen has not penetrated deeply and remains in the Shaoyang (Lesser Yang) stage, so it is not adverse. If purgation leads to transformation into other syndromes with no remaining Shaoyang signs, the fault lies entirely with the purgation. If there is fullness and hardness below the heart, although named Jie Xiong, one must ascertain whether it is excess or deficiency. If it is truly evil heat knotted at the epigastrium, Daxianxiong Tang may be given. If it results from inappropriate purgation causing Yin-cold, water, and dampness to counterflow upward, warming the Middle Jiao, directing rebellious Qi downward, transforming Qi, and promoting water metabolism is the correct approach. Fullness without pain constitutes Pi, which is originally not suitable for Chaihu Tang. The original text's prescription of Banxia Xiexin Tang is reasonable; however, the inclusion of Huangqin and Huanglian seems inappropriate. Students should observe this.
[Explanation] This article describes three pathological changes following erroneous purgation when the Chaihu Tang syndrome is present. First, although purgation was erroneous, the syndrome did not change, so the original formula is still used. Second, the condition transforms into Jie Xiong, with two scenarios: if evil heat is knotted at the epigastrium, Daxianxiong Tang may be given; if Yin-cold, water, and dampness counterflow upward due to improper purgation, warming the Middle Jiao, directing rebellious Qi downward, transforming Qi, and promoting water metabolism should be employed, possibly using Fuzi Lizhong Tang added with Rougui (Cinnamon Bark), Sharen, Banxia, and Fuling (Poria). Third, the condition transforms into Pi-fullness, specifically Pi at the epigastrium with fullness but no pain, treated with Banxia Xiexin Tang. Zheng points out that Huangqin and Huanglian in the formula seem inappropriate, urging careful examination during application to demonstrate caution.
Banxia Xiexin Tang Formula (Corrected and Supplemented)
Banxia (Pinelliae Tuber) half sheng (washed), Huangqin (Scutellariae Radix), Ganjiang (Zingiberis Rhizoma), Renshen (Ginseng Radix et Rhizoma), Gancao (Glycyrrhizae Radix et Rhizoma, honey-fried) each 3 liang, Huanglian (Coptidis Rhizoma) 1 liang, Dazao (Ziziphus Jujubae Fructus) 12 pieces (broken). Take these seven ingredients, boil in 1 dou of water to obtain 6 sheng, remove the dregs, decoct again to obtain 3 sheng, take 1 sheng warm, three times daily. For Daxianxiong Tang, use the second method described previously. Original note: "One version uses Banxia 1 sheng."
[Formula Analysis and Scope of Application] Ke Yunbo stated: "This is Xiaochaihu Tang (Minor Bupleurum Decoction) minus Chaihu (Bupleuri Radix) plus Huanglian and Ganjiang. There is no alternating chills and fever, meaning there is no half-exterior syndrome, so Chaihu is not used. Pi is formed by the mutual knotting of cold and hot Qi; using the great cold of Huanglian and the great heat of Ganjiang resolves both." However, since purgation causes deficiency in the Middle Jiao, Renshen, Gancao, and Dazao are used to tonify healthy Qi. In modern times, it has been widely applied to treat gastrointestinal diseases such as acute and chronic gastroenteritis, indigestion, loss of appetite, and diarrhea due to cold intestines and heat bowels, showing certain efficacy.
Article 32: Originally, because of erroneous purgation, there is Pi at the epigastrium. Given Xiexin Tang, the Pi does not resolve. The patient becomes thirsty with dry mouth and irritability, and urination is difficult. Wuling San (Five-Ingredient Powder with Poria) is prescribed. Original Text 156.
① Xiexin Tang: Refers to Dahuang Huanglian Xiexin Tang.
② Zaofan: Refers to dry mouth and mental irritability.
Commentary by Zheng: Pi is caused by erroneous purgation. If taking Xiexin Tang does not resolve it, and dry mouth/thirst and irritability reappear with difficulty in urination, the original text prescribes Wuling San. This shows that initially it was not a purgation syndrome, but actually a Taiyang (Greater Yang) syndrome. Erroneous purgation drew the pathogen into the Taiyang Fu organs. Physicians must not use purgation recklessly; careful consideration is essential.
[Explanation] Pi results from erroneous purgation. In this case, the Pi syndrome is caused by internal retention of fluid-dampness and failure of Jin-Ye (Body Fluids) to circulate, leading to thirst, dry mouth, irritability, and difficulty in urination. As Zheng stated: "It is actually a Taiyang syndrome, drawn into the Taiyang Fu organs by erroneous purgation." Therefore, Wuling San is an excellent symptomatic prescription.
Article 33: In Cold Damage, after taking herbal medicine, diarrhea persists incessantly, with Pi-hardness at the epigastrium. After taking Xiexin Tang, the patient is purged again with other medicines, and diarrhea persists. The physician administers Lizhong Tang (Middle-Jiao Regulating Decoction), but the diarrhea worsens. Lizhong Tang regulates the Middle Jiao, but this diarrhea originates in the Lower Jiao. Chishizhi Yuyuliang Tang (Red Halloysite and Hematite Decoction) is prescribed. If diarrhea persists despite this, promote diuresis. Original Text 159.
① Lizhong Tang regulates the Middle Jiao: Explains that the function of Lizhong Tang is to regulate the Spleen and Stomach of the Middle Jiao.
② Lower Jiao: Refers to pathology located in the lower part of the body.
Commentary by Zheng: Regarding the described Cold Damage, taking herbal medicine leads to incessant diarrhea and Pi at the epigastrium. Clearly, purgation injured the Yang of the chest, allowing turbid Yin to usurp the high position and form Pi. Although Xiexin Tang was taken, the disease did not resolve. Purging again compounds the error. Administering Lizhong Tang makes the diarrhea worse. It is not strange that the diarrhea worsens; rather, it is due to the failure of the Middle Jiao's transportation, causing accumulated Yin to leak downward. Although the leakage is severe temporarily, recovery should come soon. Ignorant physicians fail to see this, assuming the disease is in the Lower Jiao and cannot be resolved by Lizhong Tang. They then administer Chishizhi Yuyuliang Tang, which remains ineffective, and suggest promoting diuresis. They do not know that in diarrhea, some patients have normal urination, while others have difficulty urinating. Those with difficulty can be treated with diuretics, but those with normal urination must absolutely not be given diuretics. In my experience, this is entirely caused by erroneous purgation. Lizhong Tang is an unchangeable good method; adding Guizhi (Cinnamon Twig), Huangqin, Sharen, and Banxia to Lizhong Tang is an exquisite method. The formulas discussed in the original text fall into examples of being plausible yet incorrect. Students must distinguish them carefully.
[Explanation] This article points out that after purgation, repeated erroneous purgation leads to various different conditions. Prescription should follow the spirit of syndrome differentiation and treatment. If Pi-hardness and diarrhea occur after purgation, with severe epigastric Pi-hardness, Xiexin Tang is appropriate. If there is Middle Jiao deficiency-cold, Lizhong Tang is appropriate. If diarrhea persists with lower deficiency and slipping-depletion, Chishizhi Yuyuliang Tang may be used. If clear and turbid substances are mixed with difficulty in urination, Wuling San may be used; once urination improves, water content in stool decreases, aiding the treatment of persistent diarrhea. Zheng believes this is entirely caused by erroneous purgation, and Lizhong Tang is an excellent method. Adding Guizhi, Fuling, Sharen, and Banxia to Lizhong Tang is also an exquisite method and can be followed.
Chishizhi Yuyuliang Tang Formula (Corrected and Supplemented)
Chishizhi (Halloysitum Rubrum) 1 jin (crushed), Taiyi Yuyuliang (Hematitum) 1 jin (crushed). Take these two ingredients, boil in 6 sheng of water to obtain 2 sheng, remove the dregs, and divide into three warm doses.
[Formula Analysis and Scope of Application] Ke Yunbo stated: "The insecurity of the Large Intestine is still attributed to the Stomach; the looseness of the gate is still attributed to the Spleen. These two ingredients are結 (condensed) from the essence of Earth, capable of solidifying the Stomach and astringing the intestines. For any case of Lower Jiao deficiency and collapse, grinding these two into powder and mixing with Ginseng decoction is most effective."
This formula can also be used for Large Intestine cough, where coughing leads to involuntary defecation. Li Dongyuan called it "astringing to stop cough."
Article 34: In Cold Damage, fever persists despite sweating, with fullness-hardness in the heart region, vomiting, and diarrhea. Da Chaihu Tang (Major Bupleurum Decoction) is prescribed. Original Text 165.
Commentary by Zheng: In Cold Damage, fever can result from Wind injuring Wei (Defensive) Qi or Cold injuring Ying (Nutritive) Qi. Sweating can result from Wind injuring Wei Qi, extreme heat in Yangming, or Yang collapse in Shaoyin. Here, it only says "fever and sweating do not resolve." Was this due to Guizhi Tang (Cinnamon Twig Decoction) failing to release the exterior? Or Ma Huang Tang (Ephedra Decoction) failing to induce sweating and resolve fever? There is no substantial evidence here. One could say Yang floats outward causing fever, or sweating causes Yang collapse. Furthermore, fullness-hardness in the heart region, vomiting, and diarrhea are all symptoms of Taiyin (Too-Yin) syndrome, inconsistent with Taiyang syndrome. Da Chaihu Tang is even more inappropriate. Students should examine this.
[Explanation] Zheng raises various doubts in this article. The symptoms of fullness-hardness in the heart region, vomiting, and diarrhea belong to Taiyin syndrome, warranting deep reflection during syndrome differentiation. Da Chaihu Tang harmonizes the exterior and clears the interior, which is inconsistent with the syndrome and should not be used. Shu Chiyan further stated: "Da Chaihu Tang cannot be used; Zhang Zhongjing certainly did not prescribe this method." See the formula under "Unresolved Syndrome After Passing Through Channels."
Article 35: In Cold Damage, after sweating, vomiting, or purgation, once the major pathogen has dispersed, Pi-hardness at the epigastrium and persistent belching occur. Xuanfu Daizhe Shi Tang (Inula and Hematite Decoction) is prescribed. Original Text 161.
① Resolve: Means the major pathogen has dispersed.
② Yi Qi: Belching after eating. Colloquially known as hiccuping/belching.
Commentary by Zheng: In Cold Damage, after using sweating, vomiting, or purgation methods, if the exterior disease has resolved but Pi at the epigastrium and persistent belching remain, it is because sweating, vomiting, or purgation injured the Yang of the chest, causing turbid Yin to attack upward, counterflow at the epigastrium, obstructing the ascending and descending Qi mechanism, resulting in belching. Prescribing Xuanfu Daizhe Shi Tang in the original text is indeed the most appropriate method.
[Explanation] This article addresses the treatment of Pi caused by deficient Qi after the major pathogen of Cold Damage has resolved. Zheng explains "persistent belching" as injury to the Yang of the chest, causing turbid Yin to attack upward, counterflow at the epigastrium, and obstructing the Qi mechanism, resulting in belching. This is highly appropriate. Prescribing Xuanfu Daizhe Shi Tang is a precise and unchangeable formula.
Xuanfu Daizhe Shi Tang Formula (Corrected and Supplemented)
Xuanfuhua (Inulae Flos) 3 liang, Renshen (Ginseng Radix et Rhizoma) 2 liang, Shengjiang (Zingiberis Rhizoma Recens) 5 liang, Daizheshi (Hematitum) 1 liang, Gancao (Glycyrrhizae Radix et Rhizoma, honey-fried) 3 liang, Banxia (Pinelliae Tuber) half sheng (washed), Dazao (Ziziphus Jujubae Fructus) 12 pieces (broken). Take these seven ingredients, boil in 1 dou of water to obtain 6 sheng, remove the dregs, decoct again to obtain 3 sheng, take 1 sheng warm, three times daily.
[Formula Analysis and Scope of Application] This formula uses Renshen and Gancao to nourish healthy Qi and tonify deficiency; Jiang (Ginger) and Zao (Jujube) harmonize the Spleen and nourish the Stomach; Banxia eliminates fluid-retention and directs turbidity downward; Daizheshi, being heavy, gathers floating Qi and suppresses counterflow; Xuanfuhua, being acrid, promotes Qi circulation and washes away fluid-dampness. When turbidity descends, Pi-hardness can dissipate; when clear Qi ascends, belching can cease. It is now mostly used for chronic gastrointestinal diseases, rebellious Stomach Qi, vertigo and vomiting, chest fullness, sticky phlegm, inability to eat, constipation, dysphagia, and regurgitation.
Article 36: If there has long been Pi under the hypochondrium, connected to the side of the umbilicus, pain radiating to the lower abdomen and entering the Yin sinews, this is named Zang Jie (Organ Binding), and is fatal. Zang Jie presents with no Yang syndromes, no alternating chills and fever, the person is quiet, and if the tongue has a slippery coating, it cannot be attacked. Original Texts 167, 130.
① Entering Yin sinews: Refers to the testicles; here referring to retraction of the penis.
② Zang Jie: Means organ Qi is knotted and blocked.
③ Yang syndromes: Refers to positive symptoms such as fever, headache, body ache, and thirst.
Commentary by Zheng: The hypochondrium belongs to the Liver territory. Long-standing Pi connected to the umbilicus indicates Yin-cold has gathered in Jueyin (Terminal Yin) for a long time without resolving. When Yin pathogen is severe, pain penetrates directly into the Yin sinews, thus determining fatality. It is called Zang Jie because the Liver is a Yin Zang. No Yang syndromes, no alternating chills and fever, quietness of the person, and slippery tongue coating are solid evidence of Yin syndromes. Saying "cannot be attacked" teaches people not to recklessly use attacking medications to break the binding.
[Explanation] This article divides the original *Shanghan Lun* into two sections. The first, "Long-standing Pi under the hypochondrium... this is named Zang Jie, fatal," states that Pi in Zang Jie is an extremely critical condition. The binding is deep and long-standing, possessing only Yin without Yang; when Yin Qi reaches extremity, Yang Qi is exhausted, hence death. The second section, "Zang Jie has no Yang syndromes... cannot be attacked," continues to explain the nature of Zang Jie syndrome: pure Yin without Yang. Although there are hard-fullness symptoms similar to Jie Xiong, one must be cautious not to attack. If erroneously attacked, it violates the prohibition against treating deficiency as excess. This article contains discussion but no formula; the first section mentions death, the second mentions cannot be attacked. I believe using large doses of Sini Tang (Frigid Extremities Decoction) and Baitong Tang (White Aconite Decoction) to restore Yang might save one or two in a hundred, fulfilling the way of treating disease.
Article 37: Question: Some diseases have Jie Xiong, some have Zang Jie. What are their manifestations?
Answer: Pain upon palpation, Cun pulse floating, Guan pulse sinking, is named Jie Xiong. What is Zang Jie? Answer: Similar to Jie Xiong, food intake is normal, frequent loose stools, Cun pulse floating, Guan pulse small, fine, sinking, and tight, is named Zang Jie. If the tongue has a white slippery coating, it is difficult to treat. Original Texts 128, 129.
④ Jie Xiong: Syndrome name, main symptom is hard-pain at the epigastrium (stomach region).
⑤ Zang Jie: Syndrome name, symptoms similar to Jie Xiong but different in nature, caused by deficiency-cold of organ Qi.
⑥ White slippery coating on tongue: Refers to a white slippery coating on the tongue.
Commentary by Zheng: Regarding Jie Xiong and Zang Jie, answering with "Cun floating, Guan tight" or "Cun floating, Guan small/fine/sinking/tight" is not definitive. If Cun is floating and Guan is sinking without Jie Xiong; if Cun is floating and Guan is small/fine/sinking/tight without Zang Jie, what then? In my humble opinion, if the chest protrudes high and knots in the upper chest, it can be named Jie Xiong. If it is plate-like, knotting in the sides of the lower abdomen or beside the umbilicus, it can be named Zang Jie. Then, consulting the pulse image would be closer to reason. If relying solely on pulse images, it is unlikely to be exactly as stated. Students must know this.
[Explanation] The original *Shanghan Lun* divides this into two articles. "Question... named Jie Xiong" is one article; "What is Zang Jie... difficult to treat" is another. Zheng states: One cannot distinguish Jie Xiong from Zang Jie based solely on pulse; symptoms must be consulted. If the chest protrudes high and knots in the upper chest, it can be named Jie Xiong; if plate-like, knotting in the sides of the lower abdomen or beside the umbilicus, it can be named Zang Jiong. Only by distinguishing Jie Xiong and Zang Jie in this way is it appropriate. This implies that for syndrome diagnosis, the Four Diagnostic Methods are indispensable.
Article 38: In Cold Damage, after six or seven days, Jie Xiong is heat-excess, pulse is sinking and tight, pain at the epigastrium, hardness upon palpation like stone. Daxianxiong Tang is prescribed. Original Text 135.
① Jie Xiong heat-excess: Indicates Jie Xiong syndrome belongs to heat and excess, contrasting with cold-excess Jie Xiong.
Commentary by Zheng: This article explicitly states that heat pathogen gathers in the chest, causing pain at the epigastrium, hardness upon palpation like stone. Thus, Daxianxiong Tang is taken to treat it, urgently desiring to expel the heat pathogen. In the previous Taiyang Upper Chapter, Article 37, it says: "If the pulse is floating, there must be Jie Xiong." Why is there no floating pulse here? It says: "If the pulse is sinking and tight, there must be vomiting." Why is there no vomiting here? In short, determining disease solely by pulse is definitely impossible. Moreover, Qi mechanism changes unpredictably; how can twenty-eight pulse images determine billions of disease manifestations? Students must absolutely not be confined by pulse alone, and this will suffice.
[Explanation] This section describes Jie Xiong syndrome occurring without prior erroneous purgation. In Cold Damage, after six or seven days, cold does not resolve externally but transforms into heat and enters the interior, hence "Jie Xiong heat-excess." The terms "heat-excess" are emphasized to prevent mistaking the sinking-tight pulse for cold-excess Jie Xiong.
In this syndrome, cold transforms into heat and knots with tangible water at the epigastrium, causing hardness and pain upon palpation. Treatment with Daxianxiong Tang drains heat and expels water; obtaining rapid purgation leads to self-healing. Zheng said: "Determining disease solely by pulse is definitely impossible." The Four Diagnostic Methods must be combined to discover the pathogen, differentiate syndromes, and prescribe formulas, which is the correct approach. (This article is listed as Article 38 in Shu Ben and Article 58 in Zheng Shu. Logically it should be Article 38, so it is moved forward according to Shu Ben. Zheng Shu Article 38 is moved to 39, and subsequent articles are shifted accordingly.)