鄭論：此條既服桂枝湯，大汗出，而病豈有不解之理乎？既已大汗而脈見洪大，若再用桂枝湯，能不慮其亡陽乎？條中大字，定有錯誤，想是服桂枝湯而汗不出，故可以用桂枝湯，方為合理。至形如瘧狀，是表裏之寒熱尚未盡解，故仍以桂枝〔二〕麻黃一湯主之，俾邪外出無遺，故決之曰：汗出必解，方為合式。
㈠或者汗出而邪未盡解，脈見洪大，邪仍欲出表之意，理亦不錯，但大字不能無疑（頂批）。
【闡釋】鄭注文“既以大汗而脈見洪大，若再用桂枝湯；能不慮其亡陽乎？
條中大字，定有錯誤。”其頂批亦雲：“或者汗出而邪未盡解，脈見洪大，邪仍欲出表之意，理亦不錯，但大字不能無疑？＂曹穎甫對本條訂正為“脈不洪大，故仍宜桂枝，傳寫者脫去不字耳。”若如此訂正，則可釋鄭書之疑。
桂枝二麻黃一湯方（校補）
桂枝一兩十七銖（去皮）芍藥一兩六銖麻黃十六銖（去節）杏仁十六個（去皮尖）甘草一兩二銖（炙）大棗五枚（擘）生薑一兩六銖（切）上七味，以水五升，先煮麻黃一、二沸，去上沫，內諸藥，煮取二升，去渣，溫服一升，日再服，本雲桂枝湯兩分，麻黃湯一分，合為二升，分再服，今合為一方，將息如前法。
【方解及其應用範圍】本方與桂枝麻黃各半湯藥同而量異，麻、杏兩味再減輕，則名桂枝二麻黃一湯，為辛溫、微發汗之輕劑。其方解可參看桂枝湯、麻黃湯。現今用治風寒感冒之輕者，但風重於寒，用此方和其營衛，略佐疏表，大多汗出而愈。
九、傷寒不大便六七日，（若）頭痛有熱者，與承氣湯。其小便清者，知不在裏，仍在表也，當須發汗。若頭痛一者，必衄，宜桂枝湯。原文56
鄭論：按傷寒六七日不大便，有熱結寒結之分，務要察其果係熱結，方可以大承氣湯施之；頭痛亦必審其腦後，方是太陽的候，有熱而必兼見惡寒者為確，有不惡寒而獨發熱者為非。又曰其小便清者，知不在裏而在表也，理宜解表。頭痛而衄者，是邪從外解，仍以桂枝湯治之，是隨機斡旋之意，真立法之妙也。
【闡釋】傷寒六七日不大便，頭痛有熱者，此因大便不通，由濁陰之氣與裏熱上犯，用大承氣下之，熱清濁降，大便通暢，頭痛發熱，隨之而愈。如果頭痛身熱，而小便清利如常的，雖然不大便六七日，是邪不在裏而仍在表；既然在表，就是桂枝湯證仍未罷，用桂枝湯解表，表解則頭痛發熱自愈。若頭痛而衄者，此久不大便，其熱較一般表證頭痛之熱為重，傷及陽絡而衄血，則邪亦從外解也。至鄭氏所言不大便有熱結寒結之分，臨證時，必須細心分辨，若係寒結，則當用四味回陽飲加安桂治之。
十、服桂枝湯，或下之，仍頭痛、項強、翕翕發熱，無汗，心下滿，微痛，小便不利者，桂枝湯去桂加茯苓白朮湯主之。原文28
鄭論：按此條雖雲服桂枝湯，或下之，而仍頭痛、項強、翕翕發熱、無汗，是邪尚在表而未解，仍宜發表為是。至於心下滿而痛，小便不利，是太陽之氣，不從小便而下趨，逆從於上而為心下滿痛，何也？太陽之氣，是由下而上至胸腹也，今既心下痛而小便不利，理應以五苓散方施之，化太陽之氣，俾邪從下解，此方去桂枝加白朮、茯苓，亦是五苓之意。以予拙見，桂枝似不宜去。
【闡釋】歷代注家對於本條的注釋，各有見解，去桂去芍，尤為爭辨的焦點。鄭氏認為邪尚在表而未解，仍宜發表為是。又雲：太陽之氣，是由下而上至胸腹也，今既心下痛而小便不利，理應以五苓散方施之，化太陽之氣，俾邪從下解，……以予拙見，桂枝似不宜去，這是鄭氏獨特的見解。筆者認為去桂去芍皆非，用桂枝湯以解表，加苓、朮以利水，豈五苓散方中，用桂枝以化氣行水，桂枝豈能去耶？鄭氏之說為妥。
芍藥三兩甘草二兩（炙）生薑（切）白朮、茯苓各三兩大棗十二枚（擘）上六味，以水八升，煮取三升，去渣，溫服一升，小便利則愈。本雲桂枝湯，今去桂枝加茯苓白朮。
【方解及其應用範圍】本方即桂枝湯原方去桂加苓、朮而成。此方末雲，小便利則愈，重在利水，故去桂枝。加白朮、茯苓健脾除水而利小便，使內停之水飲，盡從下去，則心下滿頭項強痛發熱諸證，皆可隨之而解。此和裏而表自解之法也。
十一、傷寒脈浮，醫以火迫劫之①，亡陽②，必驚狂，起臥不安者，桂枝去芍藥加蜀（膝）〔漆〕牡蠣龍骨救逆湯主之。原文112
①火迫劫之：以火法強迫其發汗。凡燒針、火熏、炙法，皆屬火法。
②亡陽：此處的陽，指心陽而言。亡陽即心陽外亡，神氣浮越之謂。
鄭論：按傷寒脈浮，而醫以火迫劫之，浮為陽，邪火亦陽，兩陽相會，邪火內攻，擾亂心君，故驚狂不安之象所由來。致于亡陽二字，所論不切，當是亡陰，庶于此條方為合法，主以救逆湯，亦是斂陰、祛邪、安神之意也。
【闡釋】鄭氏所雲“亡陽二字，所論不切，當是亡陰，庶于此條方為合法。”上篇以火劫而致變者，皆為亡陰，但頭汗出頸項而還，其不得汗顯然矣，觀本條之去芍藥，其為無汗之故，更顯然矣。篇首誤服大青龍湯而亡陽者，乃為汗多所致，以皆為無汗而致也，豈有無汗而亡陽之理哉？
桂枝三兩（去皮）甘草二兩（炙）生薑三兩（切）大棗十二枚（擘）牡蠣五兩（熬）蜀漆三兩（洗去腥）龍骨四兩上七味，以水一鬥二升，先煮蜀漆二升，內諸藥，煮取三升，去渣，溫服一升。本雲桂枝湯，今去芍藥，加蜀漆、龍骨、牡蠣。
【方解及其應用範圍】用桂枝湯去芍藥之陰柔以助心陽，以治其本；蜀漆辛苦微寒，可滌痰消飲，重用牡蠣助蜀漆消痰飲，配龍骨鎮納浮陽安神而止驚狂，臥起不安。全方共奏溫補心陽，滌痰鎮驚之功，而收調和陰陽之效。用以治療各種原因引起的心陽驟傷，兼痰濁阻竅，神志不寧，甚至驚狂等為主的症候。
十二、火逆下之，因燒針煩（燥）〔躁〕者，（當用）桂枝甘草龍〔骨〕牡蠣湯主之。原文118
鄭論：按火逆則傷陰，未見下症而下之，則傷陰，複又燒針而陰又傷，此煩（燥）〔躁〕之症所由生，而陰虛之象所由見，主以桂枝〔甘草〕龍骨牡蠣者，是取其調中而交心腎也。
【闡釋】此先火後下，又加燒針，是經過三誤。故鄭氏說：“此煩躁之症所由生，而陰虛之象所由見。”亦即心陽受傷，而見煩躁不安之狀。故用桂枝甘草以助心陽，龍、牡以止煩躁。
桂枝一兩（去皮）甘草二兩（炙）牡蠣二兩（熬）龍骨二兩上四味，以水五升，煮取二升半，去渣，溫服八合，日三服。
【方解及其應用範圍】本方以桂枝入心助陽，甘草以補養心氣，龍骨牡蠣以收斂浮越之正氣，安神鎮驚，全方有調和陰陽，潛鎮心神之功。陳修園說；此為火逆煩躁者，立交通心腎之法也。”用以治療某些心悸、怔忡、自汗、盜汗、遺精、滑精等證。近人推廣用於治療某些心血管系統和神經系統疾病，都有很好療效。
十三、傷寒脈浮，自汗出，小便數，心煩，微惡寒，腳攣急①，反與桂枝（湯）欲攻其表，此誤也，得之便厥①，咽中幹，煩（燥）〔躁〕吐逆者，作甘草乾薑湯與之，以複其陽；若厥愈足溫者，更作芍藥〔甘草〕湯與之，其腳即伸；（者）〔若〕胃氣不和、譫語者②，少與〔調胃〕承氣湯；若重發汗，複加燒針者，四逆湯主之。原文29
①腳攣急：就是腳伸展不利之意。
①厥：手足發冷。
②譫語：神昏妄言，也就是說胡話。
鄭論：據脈浮自汗至（拘）〔腳〕攣急，症中並無發熱、惡寒、身疼，而獨見自汗出者，衛外之陽不足也，小便數者，氣化失機也，心煩、微惡寒者，陽衰之征也，拘攣急者，由血液外亡，不能滋潤筋脈也。本非桂枝湯症，而曰欲攻其表，此誤也，實為有理。至於得之便厥，咽中幹，煩（燥）〔躁〕吐逆者，大抵此症先因吐逆太過，中宮轉輸之機，卒然錯亂，不能輸精氣於心腎，故煩（燥）〔躁〕，吐則亡陽，故四肢厥也。咽中幹者，腎陽衰不能升騰津液於上也。原文以甘草乾薑湯與之，此是守中複陽之法也，何愁腳之不伸也？原文又以芍藥甘草湯，此湯本為火盛灼筋者宜，而用之於此症，殊非正論。若胃氣不和，譫語者，少與承氣湯，此說覺得支離，又並無胃實足征，何得有譫語之說？即果譫語，務必探其虛實真偽方可。若重發汗，複加燒針者，主以四逆湯，此是何病情？而重汗，而又燒針耶？一條之中，東一若，西一若，吾甚不解。
㈠厥症原有熱厥寒厥之分，原文主甘草乾薑，是定非熱厥也。總之㈠〔醫〕家臨症時，務宜下細探求陰陽實據方可。此論是就原文主方說法也（頂批）。
【闡釋】本節“傷寒脈浮……腳攣急”，為未治以前的證狀，類似桂枝湯證，但小便數，心煩，腳攣急則不是桂枝湯證所應有，與太陽上篇22條的太陽病，發汗，遂漏不止，其人惡風，小便難，四肢微急，難以屈伸等證，基本是一致的。此為表陽虛，腠理不固所致，法當溫經複陽，用桂枝加附子湯治療。但辨證不明，反與桂枝湯攻其表，耗散真陽，得之便厥，咽中幹，煩躁、吐逆者，此又重傷其陽，原文主以甘草乾薑湯，以守中複陽，其腳即伸，是為正治。至原文所列之芍藥甘草湯、調胃承氣湯、四逆湯等，有如鄭氏所說：“一條之中，東一若，西一若，吾甚不解。”可見條文有誤，姑存之。
甘草乾薑湯方（校補）
甘草四兩（炙）乾薑二兩（炮）上二味，以水三升，煮取一升五合，去渣，分溫再服。
【方解及其應用範圍】甘草乾薑湯一方，乃辛甘化陽之方，亦苦甘化陰之方也。夫乾薑辛溫，辛與甘合則從陽化，乾薑炮黑，其味即苦，苦與甘合則從陰化。此方應用範圍極廣，仲景以此方治誤吐逆煩躁而厥者，取大甘以化熱，守中而複陽也。又治吐血，治中寒，取辛甘以化陽，陽氣也，氣能統血，陽能勝寒，陽能溫中也。又用以治拘急，治筋攣，治肺痿，治腸燥，取苦甘以化陰，陰血也，血能勝熱，血能潤燥，血能養筋也。筆者對治多種肺、胃虛寒病症，常用甘草乾薑湯加味而獲效。對治血症，無論其為血熱妄行，或陰虛火動，或陽不統血，皆先選用甘草乾薑湯加血餘炭，以止其血，然後才對症下藥，屢屢獲效。
芍藥甘草湯（校補）
白芍藥、甘草各四兩（炙）上二味，以水三升，煮取一升五合，去渣，分溫再服。
【方解及其應用範圍】芍藥甘草湯一方，乃苦甘化陰之方也。夫芍藥苦平入肝，肝者陰也。甘草味甘入脾，脾者土也。苦與甘合，足以調周身之血，周身之血既調，則周身之筋骨得養，筋得血養而燥氣平，燥氣平則筋舒而自伸矣。本方不僅治兩足拘攣急，治兩足劇痛，治濕熱腳氣、腳弱無力皆有效。近人推廣用於陰血不足致筋脈攣急疼痛各症，如頸項強痛、頭痛、胃脘痛、脅痛、腹痛等，皆有療效。
十四、發汗，若下之，病仍不解，煩（燥）〔躁〕者，茯苓四逆湯主之。原文69
鄭論：按病有當發汗者，有當下者，但要有發汗之實據，可下之病情，此統以發汗、下後，病仍不解，不解是何病情不解，以致煩（燥）〔躁〕，殊令人難以猜詳。
【闡釋】據歷代注家之注釋：發汗，若下，病宜解也，若病仍不解，則發汗是外虛陽氣，下之內虛陰液，陰陽俱虛，水火不濟，故出現煩躁。又從治方上看，茯苓四逆湯是用四逆湯以回陽，加人參茯苓以複陰。《名醫別錄》上說：“茯苓能益陰氣，補神氣。”從這裏亦可看出茯苓滋陰生津的作用，並不只是利水一端。本條在證狀上的敍述比較簡略，故鄭氏說：“此統以發汗下後，病仍不解，不解是何病情不解，以致煩躁，殊令人難以猜詳。”提出質疑，可以啟發後學之多加思考。
茯苓四逆湯方（校補）
茯苓四兩人參一兩附子一枚（生用去皮破八片）甘草二兩（炙）乾薑一兩半上五味，以水五升，煮取三升，去渣，溫服七合，日二服。
【方解及其應用範圍】本方主要以薑、附回陽救逆，人參茯苓益氣生陰，並有治煩躁，止驚悸作用；炙甘草補中益氣。此方效力較四逆湯、四逆加人參湯、乾薑附子湯三方為緩，但應用範圍較三方為廣，並有利水去濕之功。凡四肢厥逆，面容晦黯無神，脈沉微欲絕，舌質淡，苔白滑或白膩，口中津液多等，表現為腎寒、脾濕、正虛、陰弱證候，均可使用。
十五、傷寒，胸中有熱，胃中有邪氣，腹中痛，欲嘔吐者，黃連湯主之。原文173
鄭論：按太陽之氣，由下而上至胸腹，今因寒邪拂郁於內而熱生，以致胃中不和，腹痛欲嘔吐者，此是上熱下寒之征也。原文以黃連湯主之，是用黃連以清上焦之熱，乾薑、桂枝、半夏以祛中下之寒邪，用參、（附）〔棗〕以和中，是調和上下之妙劑也。
【闡釋】本條是上熱下寒，陰陽升降失其常度，陽在上不能下交于陰，故下寒者自寒；陰在下不能上交于陽，故上熱者自熱。鄭氏指稱：“黃連湯乃調和上下之妙劑。”信而有征。
黃連湯方（校補）
[Background Information]
Book Title: Shanghan Heng Lun (Constant Commentary on Cold Damage) Chapter: Main Text (14/33) Category: Shanghan (Cold Damage)
[Original Text Processing]
Zheng’s Commentary: This clause states that after taking Guizhi Tang (Cinnamon Twig Decoction), profuse sweating occurred; how could the disease not be resolved? Since there has been profuse sweating and the pulse is now surging and large (Hong Da), if Guizhi Tang is used again, can one not worry about the loss of Yang Qi (Yang Energy)? The character "large" (Da) in this clause must be an error. It is likely that after taking Guizhi Tang, no sweat was produced, which would make the use of Guizhi Tang reasonable. As for the symptoms resembling malaria (alternating chills and fever), it indicates that the cold and heat at the exterior and interior have not yet fully resolved. Therefore, Guizhi Er Mahuang Yi Tang (Guizhi Two-part, Ephedra One-part Decoction) should still be used as the principal formula, allowing the pathogenic factors to exit without remainder. Thus, it is concluded: sweating will lead to resolution, which conforms to the correct method.
㈠ Alternatively, if sweating occurs but the pathogenic factors are not fully resolved, and the pulse appears surging and large, this may indicate that the pathogen still intends to exit via the exterior. This reasoning is also correct, but the character "large" cannot help but be doubted (Top Annotation).
[Explanation] Zheng’s annotation says: "Since there has been profuse sweating and the pulse is surging and large, if Guizhi Tang is used again; can one not worry about the loss of Yang?" The top annotation also states: "Alternatively, if sweating occurs but the pathogenic factors are not fully resolved, and the pulse appears surging and large, this may indicate that the pathogen still intends to exit via the exterior. This reasoning is also correct, but the character 'large' cannot help but be doubted?" Cao Yingfu corrected this clause to read "the pulse is NOT surging and large, therefore Guizhi is still appropriate; the copyist omitted the character 'not'." If corrected in this way, the doubt in Zheng’s book can be explained.
Formula: Guizhi Er Mahuang Yi Tang (Corrected and Supplemented)
Guizhi (Cinnamomi Ramulus) 1 liang 17 zhu (peeled); Shaoyao (Paeoniae Radix Alba) 1 liang 6 zhu; Mahuang (Ephedrae Herba) 16 zhu (nodes removed); Xingren (Armeniacae Semen Amarum) 16 pieces (skin and tips removed); Gancao (Glycyrrhizae Radix et Rhizoma) 1 liang 2 zhu (honey-fried); Dazao (Ziziphi Fructus) 5 pieces (split open); Shengjiang (Zingiberis Rhizoma Recens) 1 liang 6 zhu (sliced). These seven ingredients are decocted with 5 sheng of water. First, boil Mahuang for one or two boils, remove the foam on the surface, then add the remaining herbs. Boil until 2 sheng remain, remove the dregs, and take 1 sheng warm. Take twice a day. Originally, it was said to be two parts of Guizhi Tang and one part of Mahuang Tang, combined into 2 sheng, taken in two doses. Now combined into one formula, the administration follows the previous method.
[Formula Analysis and Scope of Application] This formula contains the same herbs as Guizhi Mahuang Banban Tang (Half-and-Half Guizhi and Ephedra Decoction) but differs in dosage. The amounts of Mahuang and Xingren are further reduced, hence the name Guizhi Er Mahuang Yi Tang. It is a mild agent for acrid-warm release of the exterior and slight diaphoresis. Its analysis can be referred to under Guizhi Tang and Mahuang Tang. Currently, it is used for mild cases of wind-cold common cold, where wind predominates over cold. This formula harmonizes Ying and Wei (Nutritive and Defensive levels) and slightly disperses the exterior. Most patients recover after sweating.
Nine. In Shanghan (Cold Damage), if there is constipation for six or seven days, and if headache with fever is present, administer Chengqi Tang (Bowel-Regulating Decoction). If the urine is clear, it is known that the disease is not in the Interior but remains in the Exterior; thus, diaphoresis should be employed. If there is headache accompanied by epistaxis (nosebleed), Guizhi Tang is suitable. Original Clause 56
Zheng’s Commentary: According to Shanghan, constipation for six or seven days can be divided into heat accumulation and cold accumulation. One must carefully examine whether it is truly heat accumulation before administering Da Chengqi Tang (Major Bowel-Regulating Decoction). Headache must also be examined to see if it is located at the back of the head, which is the sign of the Taiyang (Greater Yang) channel. Fever accompanied by aversion to cold is accurate; fever alone without aversion to cold is incorrect. Furthermore, clear urine indicates the disease is not in the Interior but in the Exterior, so resolving the Exterior is the correct principle. Headache with epistaxis indicates the pathogen is resolving from the exterior; treating with Guizhi Tang is appropriate. This represents flexible adaptation, truly a wonderful aspect of legislative principles.
[Explanation] In Shanghan, constipation for six or seven days with headache and fever is caused by turbid Yin qi and interior heat attacking upward. Using Da Chengqi Tang to purge downward clears the heat and descends the turbidity, unblocking the bowels. Consequently, headache and fever resolve spontaneously. If there is headache and body heat, but urination is clear and normal, although there is constipation for six or seven days, the pathogen is not in the Interior but remains in the Exterior. Since it is in the Exterior, the Guizhi Tang syndrome has not yet ceased; using Guizhi Tang to resolve the Exterior will allow headache and fever to heal spontaneously. If there is headache with epistaxis, prolonged constipation causes heat heavier than typical exterior headache syndromes, damaging the Yang collaterals and causing bleeding, thus the pathogen also resolves from the exterior. Regarding Zheng’s distinction between heat and cold accumulation in constipation, careful differentiation is required during clinical practice. If it is cold accumulation, Siwei Huiyang Yin (Four-Ingredient Return-Yang Decoction) plus Angui (An Gui) should be used.
Ten. After taking Guizhi Tang, or after purgation, if headache, neck stiffness, low-grade fever (Xi Xi Fa Re), absence of sweat, fullness in the epigastrium, slight pain, and dysuria persist, Guizhi Tang Qu Guizi Jia Fuling Baizhu Tang (Guizhi Decoction minus Cinnamon Twig plus Poria and Atractylodes Macrocephala Decoction) should be used as the principal formula. Original Clause 28
Zheng’s Commentary: Although this clause mentions taking Guizhi Tang or undergoing purgation, the persistence of headache, neck stiffness, low-grade fever, and absence of sweat indicates that the pathogen remains in the Exterior and has not resolved. Thus, releasing the Exterior is correct. As for fullness and pain in the epigastrium and dysuria, this is because the Qi of Taiyang does not flow downward through the bladder but rebels upward, causing epigastric fullness and pain. Why? The Qi of Taiyang rises from below to the chest and abdomen. Now, since there is epigastric pain and dysuria, Wuling San (Five-Ingredient Powder with Poria) should theoretically be used to transform Taiyang Qi, allowing the pathogen to exit from below. This formula removes Guizhi and adds Baizhu and Fuling, which aligns with the intent of Wuling San. From my humble opinion, Guizhi should not be removed.
[Explanation] Commentators throughout history have had various interpretations of this clause, with the removal of Guizhi and Shaoyao being the focal point of debate. Zheng believes that since the pathogen remains in the Exterior and has not resolved, releasing the Exterior is correct. He also states: "The Qi of Taiyang rises from below to the chest and abdomen. Now, since there is epigastric pain and dysuria, Wuling San should theoretically be used to transform Taiyang Qi, allowing the pathogen to exit from below... From my humble opinion, Guizhi should not be removed." This is Zheng’s unique viewpoint. I believe removing both Guizhi and Shaoyao is incorrect. Using Guizhi Tang to resolve the Exterior, while adding Fuling and Baizhu to promote urination, aligns with the use of Guizhi in Wuling San to transform Qi and move water. How could Guizhi be removed? Zheng’s theory is appropriate.
Formula: Guizhi Tang Qu Guizi Jia Fuling Baizhu Tang (Corrected and Supplemented)
Shaoyao (Paeoniae Radix Alba) 3 liang; Gancao (Glycyrrhizae Radix et Rhizoma) 2 liang (honey-fried); Shengjiang (Zingiberis Rhizoma Recens) (sliced); Baizhu (Atractylodis Macrocephalae Rhizoma) and Fuling (Poria) each 3 liang; Dazao (Ziziphi Fructus) 12 pieces (split open). These six ingredients are decocted with 8 sheng of water until 3 sheng remain. Remove the dregs and take 1 sheng warm. Recovery occurs when urination becomes smooth. Originally, it was Guizhi Tang, now Guizhi is removed and Fuling and Baizhu are added.
[Formula Analysis and Scope of Application] This formula is derived from the original Guizhi Tang by removing Guizhi and adding Fuling and Baizhu. The end of the formula notes that recovery occurs when urination becomes smooth, emphasizing the promotion of urination; hence, Guizhi is removed. Adding Baizhu and Fuling strengthens the Spleen, eliminates dampness, and promotes urination, allowing retained fluid retention to exit downward. Consequently, symptoms such as epigastric fullness, neck stiffness, headache, and fever resolve. This is a method of harmonizing the Interior so that the Exterior resolves spontaneously.
Eleven. In Shanghan, if the pulse is floating, and the physician uses fire methods to force sweating①, leading to loss of Yang②, resulting in fright, mania, restlessness, and inability to lie still, Guizhi Qu Shaoyao Jia Shuqi Muli Longgu Jiuni Tang (Guizhi Decoction minus Peony plus Vitreous Pyrite, Oyster Shell, and Dragon Bone Rescue-the-Reversed Decoction) should be used as the principal formula. Original Clause 112
① Fire forcing sweating: Forcing sweating using fire methods. All methods involving moxibustion, fire fumigation, and burning needles belong to fire methods.
② Loss of Yang: Here, "Yang" refers to Heart Yang. Loss of Yang means the external departure of Heart Yang and the floating of Shen (Spirit).
Zheng’s Commentary: In Shanghan, if the pulse is floating, and the physician uses fire methods to force sweating, floating indicates Yang, and the pathogenic fire is also Yang. When two Yangs meet, the pathogenic fire attacks internally, disturbing the Heart Sovereign, which explains the symptoms of fright, mania, and restlessness. Regarding the term "loss of Yang," the discussion is inaccurate; it should be "loss of Yin" to conform to this clause. Using Jiuni Tang (Rescue-the-Reversed Decoction) reflects the intent to astringe Yin, expel pathogens, and calm the Spirit.
[Explanation] Zheng stated that "loss of Yang" is inaccurate and should be "loss of Yin" to fit this clause. In the previous section, changes caused by fire coercion were all due to loss of Yin. However, sweating only on the head and returning at the neck clearly indicates no sweating elsewhere. Observing the removal of Shaoyao in this clause further confirms the cause is absence of sweat. At the beginning of the chapter, loss of Yang caused by mistakenly taking Da Qinglong Tang (Major Blue Green Dragon Decoction) was due to excessive sweating. Since all these cases resulted from absence of sweat, how could there be loss of Yang without sweating?
Formula: Guizhi Qu Shaoyao Jia Shuqi Longgu Muli Jiuni Tang (Corrected and Supplemented)
Guizhi (Cinnamomi Ramulus) 3 liang (peeled); Gancao (Glycyrrhizae Radix et Rhizoma) 2 liang (honey-fried); Shengjiang (Zingiberis Rhizoma Recens) 3 liang (sliced); Dazao (Ziziphi Fructus) 12 pieces (split open); Muli (Ostreae Concha) 5 liang (calcined); Shuqi (Vitrei Pyritis) 3 liang (washed to remove fishy odor); Longgu (Dinosaur Bone) 4 liang. These seven ingredients are decocted with 12 dou of water. First, boil Shuqi in 2 sheng of water, then add the other herbs. Boil until 3 sheng remain, remove the dregs, and take 1 sheng warm. Originally, it was Guizhi Tang, now Shaoyao is removed and Shuqi, Longgu, and Muli are added.
[Formula Analysis and Scope of Application] This formula uses Guizhi Tang minus Shaoyao to remove its yin-nourishing softness, thereby assisting Heart Yang to treat the root cause. Shuqi is acrid, bitter, and slightly cold, capable of washing away phlegm and eliminating fluid retention. Heavy use of Muli assists Shuqi in eliminating phlegm-fluid. Paired with Longgu to anchor floating Yang, calm the Spirit, and stop fright and mania/restlessness, the entire formula jointly warms and tonifies Heart Yang, washes away phlegm, and calms fright, achieving the effect of harmonizing Yin and Yang. It is used to treat conditions primarily characterized by sudden injury to Heart Yang due to various causes, accompanied by phlegm-turbidity obstructing the orifices, mental unrest, and even fright and mania.
Twelve. After fire reversal and purgation, followed by burning needle therapy, if irritability (Zao) occurs, Guizhi Gancao Longgu Muli Tang (Guizhi and Licorice with Dragon Bone and Oyster Shell Decoction) should be used as the principal formula. Original Clause 118
Zheng’s Commentary: Fire reversal injures Yin. If purgation is performed without indications for purgation, Yin is injured again. Subsequently, burning needle therapy injures Yin once more. This generates the symptom of irritability (Zao) and reveals signs of Yin deficiency. Using Guizhi [Gancao] Longgu Muli takes advantage of regulating the Middle Jiao and connecting Heart and Kidney.
[Explanation] This case involves fire first, then purgation, and finally burning needles, representing three errors. Hence Zheng says: "This is how the symptom of irritability arises and why signs of Yin deficiency appear." This means Heart Yang is injured, leading to irritability and restlessness. Therefore, Guizhi and Gancao are used to assist Heart Yang, while Longgu and Muli stop irritability.
Formula: Guizhi Gancao Longgu Muli Tang (Corrected and Supplemented)
Guizhi (Cinnamomi Ramulus) 1 liang (peeled); Gancao (Glycyrrhizae Radix et Rhizoma) 2 liang (honey-fried); Muli (Ostreae Concha) 2 liang (calcined); Longgu (Dinosaur Bone) 2 liang. These four ingredients are decocted with 5 sheng of water until 2.5 sheng remain. Remove the dregs and take 0.8 sheng warm, three times a day.
[Formula Analysis and Scope of Application] This formula uses Guizhi to enter the Heart and assist Yang, Gancao to tonify Heart Qi, and Longgu and Muli to astringe floating righteous Qi, calm the Spirit, and suppress fright. The entire formula harmonizes Yin and Yang and subdues the Heart Spirit. Chen Xiuyuan said: "This establishes a method of connecting Heart and Kidney for those with fire reversal and irritability." It is used to treat certain cases of palpitations, panic, spontaneous sweating, night sweats, seminal emission, and spermatorrhea. Modern practitioners have expanded its use to treat certain cardiovascular and nervous system diseases with good efficacy.
Thirteen. In Shanghan, if the pulse is floating, there is spontaneous sweating, frequent urination, heart vexation, slight aversion to cold, and cramped/tight legs①, and instead Guizhi (Tang) is given to attack the Exterior, this is an error. Upon receiving this treatment, cold extremities① develop, dryness in the throat, irritability (Zao), vomiting, and reversing occur. Prepare Gancao Ganjiang Tang (Licorice and Dried Ginger Decoction) to restore Yang; if cold extremities resolve and feet become warm, prepare Shaoyao [Gancao] Tang (Peony and Licorice Decoction) to extend the legs; [if] stomach Qi is disharmonious and delirium occurs②, give a small amount of [Tiaowei] Chengqi Tang (Harmonizing the Stomach Bowel-Regulating Decoction); if heavy sweating is repeated and burning needles are added, Sini Tang (Counterflow Extremity Decoction) should be used as the principal formula. Original Clause 29
① Cramped/Tight Legs: Refers to difficulty extending the legs.
① Cold Extremities (Jue): Cold hands and feet.
② Delirium (Chan Yu): Confusion and nonsensical speech, i.e., talking nonsense.
Zheng’s Commentary: Based on floating pulse, spontaneous sweating, up to leg cramps, the symptoms lack fever, aversion to cold, and body ache, showing only spontaneous sweating. This indicates insufficiency of Defensive Yang protecting the exterior. Frequent urination indicates failure of Qi transformation. Heart vexation and slight aversion to cold are signs of Yang decline. Leg cramps result from blood loss externally, failing to nourish sinews and vessels. This is fundamentally not a Guizhi Tang syndrome, yet it says "to attack the Exterior," which is an error; this is indeed reasonable. As for developing cold extremities, dry throat, irritability, vomiting, and reversing after this error, generally this condition first suffered from excessive vomiting/reversing, causing the mechanism of transport in the Middle Palace to suddenly disorder, unable to transmit essence and Qi to Heart and Kidney, hence irritability. Vomiting leads to loss of Yang, hence cold extremities. Dry throat indicates Kidney Yang decline failing to ascend fluids to the upper body. The original text gives Gancao Ganjiang Tang, which is a method of guarding the Center and restoring Yang; how could one worry about legs not extending? The original text also uses Shaoyao Gancao Tang, which is originally suitable for fire excess scorching sinews, but using it here is not the correct argument. If stomach Qi is disharmonious and delirium occurs, giving a small amount of Chengqi Tang seems fragmented, and there are no sufficient signs of stomach excess, so where does delirium come from? Even if there is delirium, one must probe for true/false and deficiency/excess. If heavy sweating is repeated and burning needles are added, using Sini Tang—what kind of condition is this? To sweat heavily and then burn needles? Within one clause, east this, west that, I do not understand at all.
㈠ Jue syndromes originally have divisions of heat Jue and cold Jue. The original text prioritizing Gancao Ganjiang indicates it is definitely not heat Jue. In summary, physicians during clinical practice must carefully investigate substantial evidence of Yin and Yang. This commentary discusses based on the principal formulas in the original text (Top Annotation).
[Explanation] This section "Shanghan floating pulse... leg cramps" describes symptoms before treatment, similar to Guizhi Tang syndrome, but frequent urination, heart vexation, and leg cramps are not present in Guizhi Tang syndrome. It is basically consistent with Clause 22 of the Upper Taiyang chapter: Taiyang disease, after sweating, leakage continues unabated, the person fears wind, difficult urination, slight tightness of four limbs, difficulty bending and stretching. This is caused by deficiency of Exterior Yang and insecure pores. The method should be warming meridians and restoring Yang, using Guizhi Jia Fuzi Tang (Guizhi plus Aconite Decoction). However, due to unclear differentiation, instead Guizhi Tang was used to attack the Exterior, dissipating True Yang. Upon receiving this, cold extremities developed, dry throat, irritability, vomiting, and reversing occurred. This further severely injured Yang. The original text prioritized Gancao Ganjiang Tang to guard the Center and restore Yang, and the legs extended, which is the correct treatment. Regarding the Shaoyao Gancao Tang, Tiaowei Chengqi Tang, and Sini Tang listed in the original text, as Zheng said: "Within one clause, east this, west that, I do not understand." This shows the clause has errors; we tentatively preserve it.
Formula: Gancao Ganjiang Tang (Corrected and Supplemented)
Gancao (Glycyrrhizae Radix et Rhizoma) 4 liang (honey-fried); Ganjiang (Zingiberis Rhizoma) 2 liang (roasted). These two ingredients are decocted with 3 sheng of water until 1.5 sheng remain. Remove the dregs and take warm in two doses.
[Formula Analysis and Scope of Application] Gancao Ganjiang Tang is a formula where acrid and sweet transform Yang, and also bitter and sweet transform Yin. Ganjiang is acrid and warm; combining acrid with sweet transforms toward Yang. When roasted black, Ganjiang becomes bitter; combining bitter with sweet transforms toward Yin. This formula has a wide scope of application. Zhongjing used this formula to treat vomiting, reversals, irritability, and cold extremities caused by mistaken emesis, taking great sweetness to transform heat, guarding the Center to restore Yang. It also treats hematemesis and middle-jiao cold, taking acrid-sweet to transform Yang; Yang Qi controls blood, Yang overcomes cold, and Yang warms the Middle. It is also used to treat spasms, sinew cramps, lung flaccidity, and intestinal dryness, taking bitter-sweet to transform Yin; Yin Blood overcomes heat, moistens dryness, and nourishes sinews. I often use Gancao Ganjiang Tang with modifications to treat various Lung and Stomach deficiency-cold conditions with success. For treating blood disorders, whether due to blood heat acting recklessly, Yin deficiency with fire movement, or Yang failing to control blood, I first select Gancao Ganjiang Tang plus Xuyutan (Hair Charcoal) to stop bleeding, then prescribe according to symptoms, repeatedly achieving success.
Formula: Shaoyao Gancao Tang (Corrected and Supplemented)
Baishaoyao (Paeoniae Radix Alba) and Gancao (Glycyrrhizae Radix et Rhizoma) each 4 liang (honey-fried). These two ingredients are decocted with 3 sheng of water until 1.5 sheng remain. Remove the dregs and take warm in two doses.
[Formula Analysis and Scope of Application] Shaoyao Gancao Tang is a formula where bitter and sweet transform Yin. Shaoyao is bitter and neutral, entering the Liver, which is Yin. Gancao is sweet, entering the Spleen, which is Earth. Combining bitter and sweet is sufficient to regulate blood throughout the body. Once blood is regulated, sinews and bones throughout the body are nourished. Sinews nourished by blood flatten dryness Qi; flattened dryness Qi allows sinews to relax and extend naturally. This formula is effective not only for bilateral leg cramps and severe pain but also for damp-heat gout and weak legs. Modern practitioners have expanded its use to treat various conditions of sinew and vessel cramping and pain caused by Yin-blood deficiency, such as neck stiffness, headache, epigastric pain, hypochondriac pain, and abdominal pain, all with efficacy.
Fourteen. After sweating, or if purgation is used, and the disease still does not resolve, with irritability (Zao), Fuling Sini Tang (Poria and Counterflow Extremity Decoction) should be used as the principal formula. Original Clause 69
Zheng’s Commentary: Some diseases require sweating, some require purgation, but there must be substantial evidence for sweating and indications for purgation. Here, generally after sweating and purgation, the disease still does not resolve. What condition fails to resolve, leading to irritability, is truly hard to speculate.
[Explanation] According to commentators throughout history: Sweating or purgation should resolve the disease. If the disease still does not resolve, then sweating externally deficient Yang Qi, and purgation internally deficient Yin Fluid. Both Yin and Yang are deficient, Water and Fire do not interact, hence irritability appears. Looking at the treatment formula, Fuling Sini Tang uses Sini Tang to return Yang, adding Renshen and Fuling to restore Yin. *Mingyi Bie Lu* (Separate Records of Famous Physicians) states: "Fuling can benefit Yin Qi and supplement Shen Qi." From this, we can also see Fuling’s role in nourishing Yin and generating fluids, not just promoting urination. The description of symptoms in this clause is relatively brief, so Zheng said: "Generally after sweating and purgation, the disease still does not resolve. What condition fails to resolve, leading to irritability, is truly hard to speculate." This raises questions and inspires future students to think more.
Formula: Fuling Sini Tang (Corrected and Supplemented)
Fuling (Poria) 4 liang; Renshen (Ginseng Radix) 1 liang; Fuzi (Aconiti Lateralis Radix Praeparata) 1 piece (raw, peeled, broken into eight pieces); Gancao (Glycyrrhizae Radix et Rhizoma) 2 liang (honey-fried); Ganjiang (Zingiberis Rhizoma) 1.5 liang. These five ingredients are decocted with 5 sheng of water until 3 sheng remain. Remove the dregs and take 0.7 sheng warm, twice a day.
[Formula Analysis and Scope of Application] This formula mainly uses Jiang (Ginger) and Fu (Aconite) to return Yang and rescue from collapse, Renshen and Fuling to boost Qi and generate Yin, and has effects on treating irritability and stopping palpitations; honey-fried Gancao tonifies the Middle and boosts Qi. The efficacy of this formula is milder than Sini Tang, Sini Jia Renshen Tang (Counterflow Extremity plus Ginseng Decoction), and Ganjiang Fuzi Tang (Dried Ginger and Aconite Decoction), but its scope of application is broader than these three formulas, and it also has the function of promoting urination and removing dampness. It can be used for any manifestations of Kidney cold, Spleen dampness, righteous deficiency, and Yin weakness, such as cold extremities, dull complexion without spirit, sinking and minute pulse nearly imperceptible, pale tongue body, white slippery or white greasy coating, and excessive saliva in the mouth.
Fifteen. In Shanghan, if there is heat in the Chest, pathogenic qi in the Stomach, abdominal pain, and desire to vomit, Huanglian Tang (Coptis Decoction) should be used as the principal formula. Original Clause 173
Zheng’s Commentary: The Qi of Taiyang rises from below to the chest and abdomen. Now, due to cold pathogen stagnating internally generating heat, causing Stomach disharmony, abdominal pain, and desire to vomit, this is a sign of Upper Heat and Lower Cold. The original text uses Huanglian Tang, employing Huanglian to clear Upper Jiao heat, Ganjiang, Guizhi, and Banxia to dispel Middle and Lower Jiao cold pathogens, and Renshen and [Fu] [Zao] to harmonize the Middle. This is a wonderful agent for harmonizing Upper and Lower.
[Explanation] This clause presents Upper Heat and Lower Cold, where the ascent and descent of Yin and Yang lose their normal rhythm. Yang above cannot descend to communicate with Yin, so Lower Cold remains cold; Yin below cannot ascend to communicate with Yang, so Upper Heat remains heat. Zheng pointed out: "Huanglian Tang is a wonderful agent for harmonizing Upper and Lower." This is credible and evidenced.
Formula: Huanglian Tang (Corrected and Supplemented)