四十七、傷寒五六日，大下之後，身熱不去，心中結痛者①，未欲解也，梔子豉湯主之，發汗若下之，而煩熱胸中窒者②，梔子豉湯主之。發汗吐下後，虛煩不得眠，若劇者，必反復顛倒，心中懊儂③，梔子豉湯主之。若少氣者①，梔子甘草豉湯主之。若嘔者，梔子生薑豉湯主之。凡用梔子湯，病人舊微溏者②，不可與服之。原文78、77、76後段、81
①結痛：是一種支結而痛，由胸中窒塞不通進一步發展而成。
③懊濃：虛煩之劇，自覺心中煩亂不寧。
①少氣：呼吸時若不能接續的意思。
②舊微溏：指病人平素大便溏薄。
鄭論：按傷寒（病）四十七條內，用汗、吐、下三法，所用方，總以梔子豆豉湯、梔子甘草豉湯、梔子生薑豉湯。以餘所見，務要果有熱象足征，方可酌用。設若下後發熱，而有陽從外越者，因發汗而有陽外出者，因吐後氣機因而上浮者，此中大有經權，學者切勿以梔豉等湯，定為可恃也，汗下定要下細探求。
【闡釋】鄭氏將《傷寒論》原書76條後段及77條78條81條合成47條，其所述皆是汗吐下後餘熱留擾胸隔的證狀與治法，最後一節為用梔豉湯的禁例。
以上諸方之應用，務要果有熱象足征，否則不要輕投。若下後發熱，有陽從外越者；因發汗而有陽外出者，因吐後氣機上浮者。必須細心探求辨證，故鄭氏告誡切勿以梔豉等湯，定為可恃也。
梔子豉湯方（校補）
梔子十四個（擘）香豉四合（綿裹）上二味，以水四升，先煮梔子，得二升半，內豉，煮取一升半，去渣，分為二服，溫先一服（得吐者，止後服）。
梔子甘草豉湯方（校補）
梔子十四個（擘）甘草二兩（炙）香豉二兩（綿裹）上三味，以水四升，先煮梔子甘草，取二升半，內豉，煮取一升半，去渣，分二服，溫進一服，得吐者，止後服。
梔子生薑豉湯方（校補）
梔子十四個（擘）生薑五兩香豉四合（綿裹）上三味，以水四升，先煮梔子生薑，取二升半，內豉，煮取一升半，去渣，分二服，溫進一服，得吐者，止後服。
【方解及其應用範圍】按梔豉湯一方，乃坎離交濟之方，非湧吐之方也。夫梔子色赤、味苦、性寒，能瀉心中邪熱，又能導火熱之氣下交於腎，而腎臟溫。豆形象腎，製造為豉輕浮，能引水液之氣上交於心，而心臟涼。一升一降，往來不乖，則心腎相交矣。仲景以此方治汗、吐、下後虛煩不得眠，心中懊儂者，是取其有既濟之功。由於方後注雲；“得吐者，止後服”，故許多注家據此說本方為湧吐之劑，名醫家如柯韻伯、汪昂亦因襲其說，以訛傳訛，越錯越遠。獨不思仲景既列此方於汗、吐、下後虛煩之證，猶有複吐之理哉！梔子生薑豉湯即梔子豉湯加生薑一味，由於在梔子豉湯證的基礎上有嘔的兼證，所以加生薑以降逆止嘔，如梔豉湯有催吐作用，仲景又為何選用梔子生薑豉湯來止嘔耶？如果少氣無力則梔子豉湯中加甘草以補中益氣。上三方後皆雲：“得吐者止後服”，皆已刪去。
四十八、下之後，複發汗，必振寒①，脈微細，所以然者，以內外俱虛故也。原文60。
①振寒：振栗惡寒的意思。
鄭論：按汗、下兩法，皆在要有可汗、可下之（列）〔例〕，當汗而不汗不可，當下而不下亦不可，汗、下均是祛邪之良法，若汗、下而不去，則正必虧，汗則傷陽，下則傷陰，陰陽兩傷，豈有脈不細而不振寒者乎？原文故稱內外俱虛，此刻只宜大固元氣，不可疏忽。
【闡釋】下之虛其裏，汗之虛其表，是陰陽俱虛。振寒、脈微是陽氣虛，脈細是陰血不足。汗下後見此脈證，為內外俱虛之危候，當以陽虛為主。鄭氏謂此刻只宜大固元氣，不可疏忽。筆者認為應以四逆加人參湯主之，四逆以回陽，人參益陰。
四十九、下之後，複發汗，晝日煩（燥）〔躁〕，不得眠，夜而安靜，不（吐）〔嘔〕不渴，無表證，脈沉微，身無大熱者，乾薑附子湯主之。原文61
鄭論：按汗下太過，足以損傷元氣，至晝而煩（燥）〔躁〕，不得眠，其表陽之虛也明甚。但陰陽之道，晝宜不眠，從陽也，夜而安靜，從陰也。今病晝煩（燥）〔躁〕，是傷在陽分一面，夜而安靜，是未傷在陰分一面。不眠者，是煩（燥）〔躁〕已極，不能仰臥片時之意也。原文以附子乾薑湯主之，實屬妥切。
【闡釋】下後又汗，內外陽氣大虛，陰邪獨盛，晝日煩躁不得眠，夜而安靜，正是陽虛陰盛的表現。繼提出不嘔不渴，無表證，脈沉微，充分證明不是陽經熱證的煩躁，而是陽氣大虛，陰寒獨盛的煩躁。用乾薑附子湯大辛大熱以回陽，單刀直入為不易之法也。
乾薑附子湯方（校補）
乾薑一兩附子一枚生用（去皮切八片）上二味，以水三升，煮取一升，去渣，頓服①
①頓服：猶言一次服
【方解及其應用範圍】本方是四逆湯去甘草而成，乾薑、附子是辛熱回陽藥味，由於陰寒特盛，陽氣大虛，故不用甘草，以免牽制薑、附回陽祛寒之功，方比四逆湯為峻。凡有少陰病見證、其中煩躁一證晝甚夜較安靜為特出者，適用本方。
五十、傷寒若吐若下後，心下逆滿，氣上沖胸，起則頭眩，脈（浮）〔沉〕緊，發汗則動〔經〕，身為振振搖（搖）者，茯苓桂枝白朮甘草湯主之。原文67
鄭論：按此由吐、下，傷及胸中之陽，以致濁陰上幹，逆於心下，氣逆上沖太甚，故頭眩，發汗傷陰，筋脈失養，故見筋惕肉瞤之狀，此刻只宜大劑扶陽，若原文之茯苓桂枝白朮甘草湯，恐力不足以當此任。
【闡釋】傷寒吐、下後傷及胸中之陽，而水飲上逆，身為振振搖者，此說明不可汗，發汗則犯虛虛之禁。鄭氏謂只宜大劑扶陽，若原文之茯苓桂枝白朮甘草湯，恐力不足以當此任。筆者認為可原方加附片，或用茯苓四逆湯亦可。
茯苓四兩桂枝三兩（去皮）白朮、甘草各二兩（炙）上四味，以水六升，煮取三升，去滓，分溫三服。
【方解及其應用範圍】按苓桂朮甘湯一方，乃化氣行水之方也。夫桂枝辛溫，能化膀胱之氣，茯苓、白朮健脾除濕。化者從皮膚而運行於外，除者從內行以消滅於中，甘草補土又能制水。除用以治本條陽虛水停之心下滿頭眩等證外，筆者用治一切脾虛水腫及痰飲咳嗽、哮喘，皆取得滿意療效.現代有人用以治高血壓、腦震盪、帶下、潰瘍、風濕性關節炎及心力衰竭諸病，均取得較好效果。
五十一、傷寒，吐下後，發汗，虛煩，脈甚微，八九日心下痞鞭，脅下痛，氣上沖咽喉，眩冒，經脈動（搖）〔惕〕者，久而成痿①。原文160
①痿：是一種證候的名稱，主要證狀是兩足軟弱不能行動。
鄭論：按汗、吐、下以致虛煩，脈微，元氣之衰可知，至八九日，心下痞鞭，經脈動，原文以為久而成痿，此全是虧損太過，寒水彌漫，陰逆上沖，故見脅下痛，與咽喉眩冒，經脈動者，皆汗、下、吐傷及血液，以致筋脈失養，成痿者，言氣衰而不振也。
【闡釋】吐下後又複發汗，陰陽氣血俱虛，不能濡養筋脈，久而成痿。鄭氏曰：“此全是虧損太過。”但此處所指之痿，與雜病中的濕痿、寒痿、熱痿是不完全相同的，故治法亦不相同。仲景對此條雖未出方治，但根據從證測藥的法則，以及與上條之苓桂朮甘湯證頗有相同之處。筆者認為即可用上方重加附子合當歸補血湯治之，庶幾合拍。
五十二、傷寒有熱，少腹滿，應小便不利，今反利者，為有血也，當下之，不可餘藥②，宜抵當丸。原文126
②不可餘藥：不可用其他的藥。
鄭論：（具）〔據〕喻嘉言先生雲：傷寒蓄血，較中風蓄血，更為〔凝〕滯，故變湯為丸，而連渣服之，所以求功于必勝也。
【闡釋】此節乃蓄血之輕證也。傷寒有熱，少腹滿是邪在下焦，應小便不利，今反利者知為有瘀血之候也，宜抵當丸緩下之。
抵當丸方（校補）
水蛭二十個（熬）虻蟲二十個（去翅足熬）桃仁二十個（去皮尖）大黃三兩上四味，搗分四丸，以水一升，煮一丸，取七合服之。晬時當下血③，若不下者更服。
③晬時：周時也，從今旦至明旦。
【方解及其應用範圍】本方藥物完全和抵當湯相同，其方解可參閱抵當湯條。但因改為丸藥劑型，藥物吸收緩慢，故其下血破瘀的作用，比抵當湯為和緩，但較之桃仁承氣湯的藥力，則仍為猛烈。
五十三、傷寒八九日，風濕相（持）〔搏〕①，身體煩疼，不能自轉側，不嘔不渴，脈浮虛而澀者，桂枝附子湯主之。若其人大〔便〕鞕，小便自利者，去桂（枝）加白朮湯主之。原文174
①風濕相搏：猶言風濕並至，風濕交作的意思。
鄭論：按身體煩疼，乃風濕之的候，不能轉側，乃濕邪流入關節，阻滯之征，不嘔不渴，脈虛浮者，濕邪之驗，原文以桂枝附子湯，溫經散寒除濕之意。若其人大便鞕，小便自利，由中宮氣弱，不能輸津液於大腸，故大便鞕，小便自利，加白朮者，培中土之意，實為妥貼。
【闡釋】所謂風濕病，就是風邪與濕邪合併為病。風為陽邪，風淫所勝，則周身疼煩，濕為陰邪，濕淫所勝，則肢體重，難於轉側。治以桂枝附子湯，乃溫經散寒除濕之意也。若小便自利，是濕邪能從下泄，所以大便變鞕，濕邪既欲下泄，即當因勢利導，所以去解表之桂枝，加燥濕健脾之白朮。濕去則津液自還，而大便之鞕結者自調。
桂枝四兩（去皮）附子三枚（炮、去皮、破）生薑三兩（切）大棗十二枚（擘）甘草二兩（炙）上五味，以水六升，煮取二升，去渣，分溫三服。
去桂加白朮湯（校補）
附子三枚（炮、去皮、破）白朮四兩生薑三兩（切）甘草二兩（炙）大棗十二枚（擘）上五味，以水六升，煮取二升，去渣，分溫三服，初一服，其人身如痹，半日許複服之，三服都盡，其人如冒狀，勿怪。此以附子、朮，並走皮內，逐水氣未得除，故使之耳。法當加桂四兩。此本一方二法，以大便鞭，小便自利，去桂也，以大便不鞭，小便不利，當加桂。
附子三枚恐多也，虛弱家及產婦，宜減服之。
【方解及其應用範圍】桂枝辛溫，驅在表之風邪，附子辛熱，逐在經之濕邪，甘草、大棗、生薑，辛甘化陽，相互配合以和營衛，五味成方，具有祛風溫經，助陽散濕作用，為風濕盛於肌表之主方。本方治風濕相搏的身體疼煩，桂枝與附子用量特重。附子小量，則溫經回陽，大量則力能鎮痛。本方用附子三枚，而桂枝去芍藥加附子湯，只用附子一枚，所以主治完全不同。本方減去桂枝之走表，加上白朮之燥濕健脾，用以治風濕病，見有大便鞕，小便自利者，主要作用是使濕邪從小便而出。筆者常用此二方治風濕痹證（即風濕關節炎），但劑量重，有時附子用量達250克，白朮100克，取得滿意效果。
五十四、風濕相（持）〔搏〕，骨節疼（痛）〔煩〕掣痛（而）不得屈伸①，近之則痛劇，汗出〔短〕氣，小便不利，惡風不欲去衣，或身微腫者，甘草附子湯主之。原文175
①掣痛：痛有牽引的感覺。
鄭論：按風濕相〔持）〔搏〕，明風與濕阻滯經脈，以致疼痛不能屈伸。近之則痛劇者，風濕之邪甚也。汗出〔短〕氣，小便不利者，太陽為風所擾，氣機不得下降，以致汗出而小便不利，惡風者，太陽風傷衛之驗也，不欲去衣者，濕氣滯內之驗也。或身微腫者，風邪之實據也。原文以甘草附子湯主之，實屬恰切。余意方中再加防風、雲苓，更覺功速。
【闡釋】本條是風濕留注關節的證狀與治法。其證狀比上條更重篤，上條疼痛僅不能轉側，這條更不得屈伸，近之則劇痛；上條小便自利，這條小便不利”；上條不嘔不渴，這條汗出短氣。短氣、身微腫、小便不利、惡風不欲去衣，都是心陽衰弱的徵象，亦即真陽之氣化不行，則當以甘草附子湯主之。鄭氏認為方中再加防風、雲苓，更覺功速。蓋前者以祛風，後者以除濕矣。
甘草二兩（炙）附子二枚（炮去皮破）白朮二兩桂枝四兩（去皮）上四味，以水六升，煮取三升，去渣，溫服一升，日三服。初服得微汗則解，能食汗止複煩者，將服五合，恐一升多者，宜服六七合為始。
【方解及其應用範圍】本方附子辛熱，用以溫經扶陽，除濕，白朮苦溫，燥脾化濕，桂枝辛溫合附子白朮同用，能溫表陽而固衛氣，甘草甘溫，甘能緩和諸藥，使猛烈的藥物，緩緩發揮其作用。風濕之邪，留注在關節之內，若徒恃猛力驅散，風邪易去，而濕邪不易盡除，故用甘草為君藥以名方，豈能忽視甘草之作用哉！筆者常用此方加味治療風寒濕邪留著關節之痹證。患者大多惡風、特別怕冷，骨節抽掣疼痛，不得屈伸，短氣，小便不利，舌苔白滑，脈沉細。此表裏陽氣皆虛，致邪凝滯關節不解，用大劑甘草附子湯治療，甘、附用量有時各至250克，如鄭氏所言，有時加茯苓、防風，雖十數年之頑疾，亦獲滿意效果。
五十五、傷寒發汗已，身目為黃，所以然者，以寒濕在裏，不解故也，以為不可下〔也〕，於寒濕中求之。原文259
47. In a cold damage disease, after five or six days, following severe purgation, if the body heat does not subside and there is a knotted pain in the heart region①, the pathogen has not yet resolved; Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should be administered. If, after sweating or purgation, vexation-heat and a sensation of obstruction in the chest occur②, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should also be administered. After sweating, emesis, or purgation, if empty vexation prevents sleep, and in severe cases, the patient tosses and turns restlessly with deep inner embarrassment③, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should be administered. If there is shortness of breath①, Zhi Zi Gan Cao Chi Tang (Gardenia, Licorice, and Fermented Soybean Decoction) should be administered. If vomiting occurs, Zhi Zi Sheng Jiang Chi Tang (Gardenia, Ginger, and Fermented Soybean Decoction) should be administered. Whenever using Zhi Zi Tang (Gardenia Decoction), if the patient has a history of loose stools②, it must not be given. Original texts 78, 77, latter part of 76, 81.
① Knotted pain: A type of pain characterized by blockage and knotting, developing from the progression of chest obstruction and lack of free flow.
② Vexation-heat: The sensation of chest vexation accompanied by heat. Chest obstruction: The sensation of chest stuffiness and discomfort.
③ Inner embarrassment: Severe empty vexation, feeling restless and disturbed in the heart region.
① Shortness of breath: Breathing that seems unable to continue smoothly.
② History of loose stools: Refers to the patient's usual loose bowel movements.
Zheng's Commentary: Regarding Article 47 of Shang Han Lun (Treatise on Cold Damage Diseases), which employs sweating, emesis, and purgation methods, the formulas used are primarily Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction), Zhi Zi Gan Cao Chi Tang (Gardenia, Licorice, and Fermented Soybean Decoction), and Zhi Zi Sheng Jiang Chi Tang (Gardenia, Ginger, and Fermented Soybean Decoction). Based on my observations, one must ensure there is conclusive evidence of heat signs before cautiously applying these formulas. If fever persists after purgation due to Yang Qi escaping outward; if Yang Qi goes out due to sweating; or if Qi mechanism floats upward after emesis, there are significant principles of standard treatment versus flexible adaptation involved. Practitioners must not rely solely on Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) as infallible; careful investigation of sweating and purgation methods is essential.
[Interpretation] Zheng combined the latter part of original text 76 and texts 77, 78, and 81 into Article 47. These describe the symptoms and treatments for residual heat disturbing the chest and diaphragm after sweating, emesis, or purgation. The final section outlines contraindications for using Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction).
The application of these formulas requires conclusive evidence of heat signs; otherwise, they should not be administered lightly. If fever follows purgation with Yang Qi escaping outward; if Yang Qi goes out due to sweating; or if Qi mechanism floats upward after emesis, careful differentiation is necessary. Thus, Zheng warns against relying absolutely on Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction).
Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) Formula (Revised and Supplemented)
Zhi Zi (Gardeniae Fructus) 14 pods (broken open)
Xiang Chi (Sojae Preparata) 4 he (wrapped in cotton cloth)
Take the above two ingredients, add four sheng (approx. 800ml) of water. First decoct Zhi Zi (Gardeniae Fructus) until two and a half sheng (approx. 500ml) remains. Add Xiang Chi (Sojae Preparata), decoct until one and a half sheng (approx. 300ml) remains. Remove dregs. Divide into two doses. Take the first dose warm. If vomiting occurs, stop taking the second dose.
Zhi Zi Gan Cao Chi Tang (Gardenia, Licorice, and Fermented Soybean Decoction) Formula (Revised and Supplemented)
Zhi Zi (Gardeniae Fructus) 14 pods (broken open)
Gan Cao (Glycyrrhizae Radix et Rhizoma) 2 liang (roasted)
Xiang Chi (Sojae Preparata) 2 liang (wrapped in cotton cloth)
Take the above three ingredients, add four sheng (approx. 800ml) of water. First decoct Zhi Zi (Gardeniae Fructus) and Gan Cao (Glycyrrhizae Radix et Rhizoma) until two and a half sheng (approx. 500ml) remains. Add Xiang Chi (Sojae Preparata), decoct until one and a half sheng (approx. 300ml) remains. Remove dregs. Divide into two doses. Take one dose warm. If vomiting occurs, stop taking.
Zhi Zi Sheng Jiang Chi Tang (Gardenia, Ginger, and Fermented Soybean Decoction) Formula (Revised and Supplemented)
Zhi Zi (Gardeniae Fructus) 14 pods (broken open)
Sheng Jiang (Zingiberis Rhizoma Recens) 5 liang
Xiang Chi (Sojae Preparata) 4 he (wrapped in cotton cloth)
Take the above three ingredients, add four sheng (approx. 800ml) of water. First decoct Zhi Zi (Gardeniae Fructus) and Sheng Jiang (Zingiberis Rhizoma Recens) until two and a half sheng (approx. 500ml) remains. Add Xiang Chi (Sojae Preparata), decoct until one and a half sheng (approx. 300ml) remains. Remove dregs. Divide into two doses. Take one dose warm. If vomiting occurs, stop taking.
[Formula Analysis and Scope of Application] Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is a formula for the mutual interaction of Heart and Kidney, not an emetic formula. Zhi Zi (Gardeniae Fructus) is red, bitter, and cold; it clears evil heat from the Heart and guides fire-qi downward to interact with the Kidney, warming it. Beans resemble the Kidney; when processed into Chi (fermented soybeans), they become light and floating, guiding water-qi upward to interact with the Heart, cooling it. One ascends, one descends, moving in harmony, thus achieving Heart-Kidney interaction. Zhang Zhongjing uses this formula for empty vexation, insomnia, and inner embarrassment after sweating, emesis, or purgation, leveraging its ability to facilitate mutual completion. Because the post-formula note states "if vomiting occurs, stop taking the subsequent dose," many commentators have mistakenly classified this as an emetic formula. Famous physicians like Ke Yunbo and Wang Ang followed this error, propagating the mistake. Did Zhang Zhongjing place this formula for post-sweating/emesis/purgation empty vexation only to induce further vomiting? Zhi Zi Sheng Jiang Chi Tang (Gardenia, Ginger, and Fermented Soybean Decoction) is Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) plus Sheng Jiang (Zingiberis Rhizoma Recens). Since vomiting is a concurrent symptom on the basis of Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) syndrome, Sheng Jiang (Zingiberis Rhizoma Recens) is added to direct rebellious Qi downward and stop vomiting. If Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) were emetic, why would Zhang Zhongjing use Zhi Zi Sheng Jiang Chi Tang (Gardenia, Ginger, and Fermented Soybean Decoction) to stop vomiting? For shortness of breath and weakness, Gan Cao (Glycyrrhizae Radix et Rhizoma) is added to Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) to tonify the Middle and benefit Qi. The notes "if vomiting occurs, stop taking" in all three formulas have been deleted.
48. After purgation, followed by sweating, chills and trembling① will definitely occur, with a faint and fine pulse. This happens because both interior and exterior are deficient. Original text 60.
① Chills and trembling: Trembling with aversion to cold.
Zheng's Commentary: Both sweating and purgation methods require specific indications. Failure to sweat when indicated is incorrect; failure to purge when indicated is also incorrect. Sweating and purgation are excellent methods for expelling pathogens. If pathogens remain after sweating and purgation, healthy Qi will inevitably be depleted. Sweating damages Yang, purgation damages Yin. With both Yin and Yang damaged, how could the pulse not be fine and chills not occur? The original text calls this interior-exterior deficiency. At this moment, only vigorous consolidation of Yuan Qi (Primal Qi) is appropriate; negligence is unacceptable.
[Interpretation] Purgation empties the interior; sweating empties the exterior. This is a deficiency of both Yin and Yang. Chills and trembling, along with a faint pulse, indicate Yang deficiency; a fine pulse indicates Yin-blood insufficiency. Seeing these pulses and symptoms after sweating and purgation signifies a critical state of interior-exterior deficiency, primarily Yang deficiency. Zheng states that only vigorous consolidation of Yuan Qi (Primal Qi) is appropriate at this moment. I believe Si Ni Jia Ren Shen Tang (Counterflow Decoction with Added Ginseng) should be used: Si Ni Tang (Counterflow Decoction) returns Yang, while Ren Shen (Panacis Ginseng Radix) benefits Yin.
49. After purgation, followed by sweating, daytime irritability and insomnia, but quietness at night, no vomiting, no thirst, no exterior syndrome, a deep and faint pulse, and no significant body heat indicate that Gan Jiang Fu Zi Tang (Dried Ginger and Aconite Decoction) should be administered. Original text 61.
Zheng's Commentary: Excessive sweating and purgation sufficiently damage Yuan Qi (Primal Qi). Daytime irritability and insomnia clearly indicate superficial Yang deficiency. However, according to the Dao of Yin and Yang, daytime non-sleep aligns with Yang, and nighttime quietness aligns with Yin. Now, daytime irritability indicates injury to the Yang aspect; nighttime quietness indicates the Yin aspect is uninjured. Insomnia here means extreme irritability preventing even a moment of supine rest. Using Fu Zi Gan Jiang Tang (Aconite and Dried Ginger Decoction) as stated in the original text is indeed appropriate.
[Interpretation] Purgation followed by sweating causes severe deficiency of interior and exterior Yang Qi, allowing Yin pathogens to dominate alone. Daytime irritability and insomnia, with quietness at night, manifest Yang deficiency and Yin excess. The absence of vomiting and thirst, lack of exterior syndrome, deep and faint pulse, and absence of significant heat fully prove this is not irritability from Yang meridian heat, but rather irritability from severe Yang deficiency and dominant Yin-cold. Gan Jiang Fu Zi Tang (Dried Ginger and Aconite Decoction), being extremely acrid and hot, returns Yang directly and effectively.
Gan Jiang Fu Zi Tang (Dried Ginger and Aconite Decoction) Formula (Revised and Supplemented)
Gan Jiang (Zingiberis Rhizoma) 1 liang
Fu Zi (Aconiti Lateralis Radix Praeparata) 1 piece, raw (skin removed, cut into eight slices)
Take the above two ingredients, add three sheng (approx. 600ml) of water. Decoct until one sheng (approx. 200ml) remains. Remove dregs. Administer all at once (one dose)①.
① Dun fu: Administering all at once in a single dose.
[Formula Analysis and Scope of Application] This formula is Si Ni Tang (Counterflow Decoction) minus Gan Cao (Glycyrrhizae Radix et Rhizoma). Gan Jiang (Zingiberis Rhizoma) and Fu Zi (Aconiti Lateralis Radix Praeparata) are acrid-hot herbs that return Yang. Due to extreme Yin-cold and severe Yang deficiency, Gan Cao (Glycyrrhizae Radix et Rhizoma) is omitted to avoid restraining the Yang-returning and cold-dispelling effects of Ginger and Aconite. This formula is more potent than Si Ni Tang (Counterflow Decoction). It is suitable for Shaoyin disease manifestations where irritability is prominent during the day and relatively quiet at night.
50. In cold damage, after emesis or purgation, followed by sweating, if there is fullness and rebellion below the heart, Qi rushing up to the chest, dizziness upon standing, a deep and tight pulse (originally stated as floating), and if sweating disturbs the meridians causing the body to tremble and shake, Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala, and Licorice Decoction) should be administered. Original text 67.
Zheng's Commentary: This results from emesis and purgation damaging Yang Qi in the chest, allowing turbid Yin to rise and rebel below the heart. Severe Qi rebellion causes dizziness. Sweating damages Yin, leading to loss of nourishment in sinews and vessels, resulting in twitching muscles. At this moment, large-dose Yang-supporting therapy is required. Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala, and Licorice Decoction) may be insufficient for this task.
[Interpretation] Cold damage after emesis and purgation damages Yang Qi in the chest, causing water-fluids to rebel upward. Body trembling indicates that sweating is contraindicated; sweating would violate the prohibition against treating deficiency as excess. Zheng states only large-dose Yang support is appropriate, suggesting Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala, and Licorice Decoction) might be too weak. I believe adding Fu Pian (Prepared Aconite Lateralis Radix) to the original formula, or using Fu Ling Si Ni Tang (Poria Counterflow Decoction), would be appropriate.
Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala, and Licorice Decoction) Formula (Revised and Supplemented)
Fu Ling (Poria) 4 liang
Gui Zhi (Cinnamomi Ramulus) 3 liang (skin removed)
Bai Zhu (Atractylodis Macrocephalae Rhizoma) 2 liang
Gan Cao (Glycyrrhizae Radix et Rhizoma) 2 liang (roasted)
Take the above four ingredients, add six sheng (approx. 1200ml) of water. Decoct until three sheng (approx. 600ml) remains. Remove dregs. Divide into three warm doses.
[Formula Analysis and Scope of Application] Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala, and Licorice Decoction) transforms Qi and promotes fluid metabolism. Gui Zhi (Cinnamomi Ramulus) is acrid-warm, transforming Bladder Qi. Fu Ling (Poria) and Bai Zhu (Atractylodis Macrocephalae Rhizoma) strengthen the Spleen and remove dampness. Transformation moves outward through the skin; removal eliminates internally. Gan Cao (Glycyrrhizae Radix et Rhizoma) tonifies Earth and controls Water. Besides treating chest fullness and dizziness from Yang deficiency and water retention described in this article, I have used it successfully for all types of Spleen-deficiency edema, phlegm-fluid cough, and asthma. Modern practitioners have used it for hypertension, concussion, leukorrhea, ulcers, rheumatoid arthritis, and heart failure with good results.
51. In cold damage, after emesis and purgation, followed by sweating, empty vexation, and a very faint pulse, after eight or nine days, if there is epigastric fullness and hardness, hypochondriac pain, Qi rushing up to the throat, dizziness, and meridian twitching/trembling, prolonged deficiency will lead to flaccidity syndrome①. Original text 160.
① Flaccidity: A syndrome name, mainly characterized by weakness of the lower limbs preventing movement.
Zheng's Commentary: Sweating, emesis, and purgation cause empty vexation and faint pulse, indicating depletion of Yuan Qi (Primal Qi). By day eight or nine, epigastric fullness and hardness, and meridian twitching suggest the original text's view that prolonged deficiency leads to flaccidity. This is entirely due to excessive depletion, flooding of cold-water, and counter-flow of Yin Qi upward, causing hypochondriac pain, throat dizziness, and meridian twitching. All result from sweating, purgation, and emesis damaging Blood, leading to loss of nourishment in sinews and vessels, forming flaccidity. "Flaccidity" here means Qi depletion failing to振奋 (invigorate).
[Interpretation] Emesis and purgation followed by sweating deplete Yin, Yang, Qi, and Blood, failing to nourish sinews and vessels, leading to flaccidity over time. Zheng says: "This is entirely excessive depletion." However, the flaccidity here differs partially from damp-flaccidity, cold-flaccidity, and heat-flaccidity in miscellaneous diseases, so treatments differ. Although Zhang Zhongjing provides no formula for this article, based on deducing herbs from symptoms and similarity to the previous Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala, and Licorice Decoction) syndrome, I believe using the aforementioned formula with heavy Fu Zi (Aconiti Lateralis Radix Praeparata) combined with Dang Gui Bu Xue Tang (Angelica Sinensis and Astragalus Decoction) would be appropriate.
52. In cold damage with heat, lower abdominal fullness, urination should be difficult; if it is actually free, there is blood stasis. It should be purged, not with other medicines②, but with Di Dang Wan (Di Dang Pill). Original text 126.
② Bu ke yu yao: Do not use other medicines.
Zheng's Commentary: According to Mr. Yu Jiayan: Cold damage blood accumulation is more stagnant than wind-stroke blood accumulation, hence changing the decoction to a pill and taking it with dregs to ensure victory.
[Interpretation] This section describes mild blood accumulation. Cold damage with heat and lower abdominal fullness indicates pathogen in the Lower Jiao. Urination should be difficult; since it is free, it indicates blood stasis. Di Dang Wan (Di Dang Pill) should be used for gentle purgation.
Di Dang Wan (Di Dang Pill) Formula (Revised and Supplemented)
Shui Zhi (Hirudo) 20 pieces (fried)
Meng Chong (Ophrya) 20 pieces (wings and feet removed, fried)
Tao Ren (Persicae Semen) 20 pieces (skin and tips removed)
Da Huang (Rhei Radix et Rhizoma) 3 liang
Grind the above four ingredients, divide into four pills. Boil one pill in one sheng (approx. 200ml) of water until seven he (approx. 140ml) remains. Take orally. Within a zui shi (24 hours) blood should pass. If not, take another dose.
③ Zui shi: A full day, from this morning to next morning.
[Formula Analysis and Scope of Application] The ingredients are identical to Di Dang Tang (Di Dang Decoction); see its analysis. However, as a pill, absorption is slower, making its blood-purging and stasis-breaking action milder than Di Dang Tang (Di Dang Decoction), yet still more potent than Tao Ren Cheng Qi Tang (Peach Kernel and Major Order the Qi Decoction).
53. In cold damage after eight or nine days, if Wind and Dampness contend①, causing painful body agitation, inability to turn independently, no vomiting, no thirst, and a floating, deficient, and choppy pulse, Gui Zhi Fu Zi Tang (Cinnamon Twig and Aconite Decoction) should be administered. If the person has hard stool and free urination, Gui Zhi Fu Zi Tang (Cinnamon Twig and Aconite Decoction) minus Gui Zhi (Cinnamomi Ramulus) plus Bai Zhu (Atractylodis Macrocephalae Rhizoma) should be administered. Original text 174.
① Wind-Damp contention: Means Wind and Damp arriving together, alternating.
Zheng's Commentary: Painful body agitation is the definitive sign of Wind-Damp. Inability to turn indicates Dampness entering joints and causing obstruction. No vomiting/thirst, floating/deficient pulse verify Dampness. Gui Zhi Fu Zi Tang (Cinnamon Twig and Aconite Decoction) warms meridians, dispels cold, and removes Dampness. Hard stool and free urination indicate weak Middle Jiao Qi failing to transport fluids to the Large Intestine, causing hard stool and free urination. Adding Bai Zhu (Atractylodis Macrocephalae Rhizoma) strengthens the Middle Earth, which is appropriate.
[Interpretation] Rheumatism is the combination of Wind and Damp pathogens. Wind is Yang; excessive Wind causes whole-body pain and agitation. Damp is Yin; excessive Damp causes limb heaviness and difficulty turning. Gui Zhi Fu Zi Tang (Cinnamon Twig and Aconite Decoction) warms meridians, dispels cold, and removes Dampness. Free urination indicates Dampness draining downward, causing hard stool. Since Dampness seeks to drain downward, guide it accordingly: remove exterior-releasing Gui Zhi (Cinnamomi Ramulus) and add drying/Damp-removing Spleen-strengthening Bai Zhu (Atractylodis Macrocephalae Rhizoma). When Dampness leaves, fluids return, and hard stool regulates naturally.
Gui Zhi Fu Zi Tang (Cinnamon Twig and Aconite Decoction) Formula (Revised and Supplemented)
Gui Zhi (Cinnamomi Ramulus) 4 liang (skin removed)
Fu Zi (Aconiti Lateralis Radix Praeparata) 3 pieces (processed, skin removed, broken)
Sheng Jiang (Zingiberis Rhizoma Recens) 3 liang (sliced)
Da Zao (Jujubae Fructus) 12 pieces (broken open)
Gan Cao (Glycyrrhizae Radix et Rhizoma) 2 liang (roasted)
Take the above five ingredients, add six sheng (approx. 1200ml) of water. Decoct until two sheng (approx. 400ml) remains. Remove dregs. Divide into three warm doses.
Qu Gui Jia Bai Zhu Tang (Remove Cinnamon Twig, Add Atractylodes Macrocephala Decoction) Formula (Revised and Supplemented)
Fu Zi (Aconiti Lateralis Radix Praeparata) 3 pieces (processed, skin removed, broken)
Bai Zhu (Atractylodis Macrocephalae Rhizoma) 4 liang
Sheng Jiang (Zingiberis Rhizoma Recens) 3 liang (sliced)
Gan Cao (Glycyrrhizae Radix et Rhizoma) 2 liang (roasted)
Da Zao (Jujubae Fructus) 12 pieces (broken open)
Take the above five ingredients, add six sheng (approx. 1200ml) of water. Decoct until two sheng (approx. 400ml) remains. Remove dregs. Divide into three warm doses. After the first dose, the body feels numb; take the second dose after about half a day. After all three doses, the patient may feel dizzy; do not be alarmed. This is because Fu Zi (Aconiti Lateralis Radix Praeparata) and Bai Zhu (Atractylodis Macrocephalae Rhizoma) move into the skin to drive out water-qi, which has not yet been eliminated. Standard practice adds Gui Zhi (Cinnamomi Ramulus) 4 liang. This is originally one formula with two methods: remove Gui Zhi (Cinnamomi Ramulus) for hard stool/free urination; add Gui Zhi (Cinnamomi Ramulus) for soft stool/difficult urination.
Three pieces of Fu Zi (Aconiti Lateralis Radix Praeparata) may be too much; reduce dosage for weak individuals and postpartum women.
[Formula Analysis and Scope of Application] Gui Zhi (Cinnamomi Ramulus) is acrid-warm, driving Wind from the exterior. Fu Zi (Aconiti Lateralis Radix Praeparata) is acrid-hot, driving Damp from the meridians. Gan Cao (Glycyrrhizae Radix et Rhizoma), Da Zao (Jujubae Fructus), and Sheng Jiang (Zingiberis Rhizoma Recens) transform Yang via acrid-sweet synergy, harmonizing Ying and Wei. The five ingredients form a formula that expels Wind, warms meridians, assists Yang, and disperses Damp, serving as the primary formula for Wind-Damp abundant in muscle layers. Treating Wind-Damp contention with body pain/agitation, Gui Zhi (Cinnamomi Ramulus) and Fu Zi (Aconiti Lateralis Radix Praeparata) dosages are heavy. Small doses of Fu Zi (Aconiti Lateralis Radix Praeparata) warm meridians and return Yang; large doses relieve pain. This formula uses three pieces of Fu Zi (Aconiti Lateralis Radix Praeparata), whereas Gui Zhi Qu Shao Yao Jia Fu Zi Tang (Cinnamon Twig Decoction Removing Peony, Adding Aconite) uses only one piece, hence different indications. Removing Gui Zhi (Cinnamomi Ramulus)'s exterior action and adding Bai Zhu (Atractylodis Macrocephalae Rhizoma)'s drying/Spleen-strengthening action treats Wind-Damp with hard stool/free urination, primarily driving Damp out via urine. I often use these two formulas for Bi Syndrome (Rheumatoid Arthritis) with heavy dosages, sometimes up to 250g Fu Zi (Aconiti Lateralis Radix Praeparata) and 100g Bai Zhu (Atractylodis Macrocephalae Rhizoma), achieving satisfactory results.
54. Wind and Dampness contend, causing joint pain, pulling pain, inability to flex or extend①, severe pain upon touch, sweating, shortness of breath, difficult urination, aversion to wind with desire to keep clothes on, or slight body swelling; Gan Cao Fu Zi Tang (Licorice and Aconite Decoction) should be administered. Original text 175.
① Pulling pain: Pain with a pulling sensation.
Zheng's Commentary: Wind and Dampness contending blocks meridians, causing pain and immobility. Severe pain upon touch indicates strong Wind-Damp pathogens. Sweating and shortness of breath, difficult urination indicate Taiyang disturbed by Wind, blocking Qi descent, causing sweating and difficult urination. Aversion to wind verifies Taiyang Wind damaging Wei Qi. Desire to keep clothes on verifies internal Damp stagnation. Slight swelling confirms Wind pathogen. Gan Cao Fu Zi Tang (Licorice and Aconite Decoction) is appropriate. I suggest adding Fang Feng (Saposhnikoviae Radix) and Fu Ling (Poria) for faster efficacy.
[Interpretation] This article describes symptoms and treatment for Wind-Damp lodging in joints. Symptoms are more severe than the previous article: inability to flex/extend vs. inability to turn; severe pain on touch; difficult urination vs. free urination; sweating/shortness of breath vs. no vomiting/thirst. Shortness of breath, slight swelling, difficult urination, aversion to wind with desire to keep clothes on are signs of Heart Yang decline, i.e., failure of True Yang Qi transformation. Gan Cao Fu Zi Tang (Licorice and Aconite Decoction) should be used. Zheng suggests adding Fang Feng (Saposhnikoviae Radix) to expel Wind and Fu Ling (Poria) to remove Damp for faster results.
Gan Cao Fu Zi Tang (Licorice and Aconite Decoction) Formula (Revised and Supplemented)
Gan Cao (Glycyrrhizae Radix et Rhizoma) 2 liang (roasted)
Fu Zi (Aconiti Lateralis Radix Praeparata) 2 pieces (processed, skin removed, broken)
Bai Zhu (Atractylodis Macrocephalae Rhizoma) 2 liang
Gui Zhi (Cinnamomi Ramulus) 4 liang (skin removed)
Take the above four ingredients, add six sheng (approx. 1200ml) of water. Decoct until three sheng (approx. 600ml) remains. Remove dregs. Take one sheng (approx. 200ml) warm, three times daily. Initial dose inducing slight sweat resolves the condition. If appetite returns but vexation recurs after sweat stops, take five he (approx. 100ml). If one sheng (approx. 200ml) is too much, start with six or seven he (approx. 120-140ml).
[Formula Analysis and Scope of Application] Fu Zi (Aconiti Lateralis Radix Praeparata) is acrid-hot, warming meridians, supporting Yang, and removing Damp. Bai Zhu (Atractylodis Macrocephalae Rhizoma) is bitter-warm, drying Spleen and transforming Damp. Gui Zhi (Cinnamomi Ramulus) is acrid-warm; combined with Fu Zi (Aconiti Lateralis Radix Praeparata) and Bai Zhu (Atractylodis Macrocephalae Rhizoma), it warms exterior Yang and secures Wei Qi. Gan Cao (Glycyrrhizae Radix et Rhizoma) is sweet-warm, moderating harsh drugs for slow action. Wind-Damp lodging in joints cannot be dispersed by force alone; Wind leaves easily, but Damp lingers. Hence, Gan Cao (Glycyrrhizae Radix et Rhizoma) is the sovereign herb, naming the formula. Its role must not be ignored. I often use this modified formula for Bi Syndrome caused by Wind-Cold-Damp lodging in joints. Patients mostly have aversion to wind, extreme cold fear, pulling joint pain, immobility, shortness of breath, difficult urination, white slippery tongue coating, and deep fine pulse. Interior-exterior Yang deficiency causes pathogen stagnation in joints. Using large doses of Gan Cao Fu Zi Tang (Licorice and Aconite Decoction), Gan Cao (Glycyrrhizae Radix et Rhizoma) and Fu Zi (Aconiti Lateralis Radix Praeparata) dosages sometimes reach 250g each. As Zheng noted, adding Fu Ling (Poria) and Fang Feng (Saposhnikoviae Radix) can yield satisfactory results even for decade-long stubborn diseases.
55. After sweating in cold damage, if the body and eyes turn yellow, it is because Cold-Damp in the interior has not resolved. It should not be purged; seek treatment within the context of Cold-Damp. Original text 259.