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The formulas such as Xuanxiong Tang (Chest-Trap Decoction) and Xiexin Tang (Drain the Epigastrium Decoction) generally treat excess syndromes of external contraction. However, there are cases where the syndrome belongs to external contraction, yet the patient suffers from severe internal deficiency; this is the syndrome governed by Zhigancao Tang (Rehmannia Root and Licorice Decoction) in the *Shanghan Lun* (Treatise on Cold Pathogenic Diseases).

Original text of *Shanghan Lun*: In cold damage, if the pulse is Jie-Dai (knotted and intermittent), and there is palpitation of the heart, Zhigancao Tang (Rehmannia Root and Licorice Decoction) should be administered.

When the pulse beats, it occasionally stops. If the stoppage has no fixed number, it is called "Jie" (Knotted), meaning the pulse is knotted and does not flow smoothly, thus stopping midway; if the stoppage has a fixed number, it is called "Dai" (Intermittent), meaning that when the pulse reaches this point, one beat is missing, and another pulse must substitute for it. Although both pulses are special pathological pulses, there is indeed a distinction in severity. Generally, Jie pulse stops without a fixed number; it is merely that the pulse occasionally obstructs at places where Qi and Blood are stagnant, stopping once in a while, so the disease is still mild. As for Dai pulse, the stoppage has a fixed number, indicating that the Qi of one Zang organ within the viscera is internally deficient and cannot reach outward to the pulse site, so the disease is very severe. The palpitation of the heart is precisely the origin of the Jie and Dai pulses.

[Zhigancao Tang Formula] Zhi Gancao (Honey-fried Licorice Root) 4 liang, Shengjiang (Fresh Ginger) 3 liang sliced, Guizhi (Cinnamon Twig) 3 liang peeled, Renshen (Ginseng Root) 2 liang, Sheng Dihuang (Raw Rehmannia Root) 1 jin, Ejiao (Donkey-hide Gelatin) 2 liang, Maimendong (Ophiopogon Tuber) half sheng, Maziren (Hemp Seed) half sheng, Dazao (Jujube Fruit) 30 pieces split open.

These nine ingredients are boiled with 7 sheng of clear wine and 8 sheng of water. First, boil the first eight ingredients to obtain 3 sheng of liquid, remove the dregs, add the gelatin, melt it completely until dissolved, and take 1 sheng warm each time, three times a day. This formula is also named Fumai Tang (Restore the Pulse Decoction).

The intention behind Zhigancao Tang is profound, but commentators claim that the formula uses many drugs rich in juice. They argue that because Heart Blood is deficient, causing palpitations and leading to Jie-Dai pulses, heavy use of juicy drugs is intended to nourish Heart Blood, which they consider the main purpose of this formula. However, discussing the formula in this way superficializes its true value. Observe the drugs in the formula: only Sheng Dihuang (i.e., Gan Dihuang/Dried Rehmannia Root) is used in a heavy dose of 1 jin. Dihuang is originally a Kidney-nourishing drug. Since Shu Dihuang (Prepared Rehmannia Root) was unavailable at that time, and using too much raw Dihuang might be too cooling, it was boiled with 7 sheng of wine and 8 sheng of water. With a total of 15 sheng of wine and water, the volume reduced by 12 sheng after boiling. Since wine nature is hot, and prolonged boiling aims to transform the cool nature of raw Dihuang into a warm nature, the intent is to warm-tonify the Kidneys. The heartbeat originates in the Heart, but the strength of the pulse relies on Kidney Qi rising to assist Heart Qi. Therefore, in Shaoyin cold damage, when the Kidney is injured and suppresses Kidney Qi transformation, preventing it from ascending to interact with the Heart, regardless of whether the disease is cold or hot, the pulse becomes weak and powerless. This is clear evidence. Thus, the intention of Zhigancao Tang is primarily to assist Kidney Qi transformation, making it vigorous and ascending, to mutually assist Heart Qi transformation as the key measure. Nourishing Heart Blood is merely a secondary effect treated concurrently in the formula, something slowly addressed.

Renshen (Ginseng Root) in the formula can originally assist Heart pulse beating and is an essential drug, but only 2 liang are used, equivalent to 6 qian today. Taking one-third of this amount leaves only 2 qian of Renshen in the dose. This may be an error in dosage; I propose doubling it to 4 qian for faster efficacy. However, Dangshen (Codonopsis Root) must be used instead of Liaoshen (Korean Ginseng), as Liaoshen has a hot nature.

If the pulse presents Jie-Dai combined with Yangming Excess Heat, treating solely with Zhigancao Tang may fail. It is advisable to borrow Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction), replacing Zhimu (Anemarrhena Rhizome) in that formula with Sheng Dihuang (Raw Rehmannia Root) from Zhigancao Tang, and replacing Jingmi (Rice Grain) with Huai Shanyao (Chinese Yam Rhizome). I once treated an elderly man near sixty years old who contracted cold damage. Within four to five days, he had severe heat in both exterior and interior. His pulse was Hong (Surging) but not solid, showing signs of Dai pulse. His tongue coating was white with slight yellow, and he had not had a bowel movement for several days. I prescribed: Sheng Shigao (Raw Gypsum) 3 liang, Da Shengdi (Large Raw Rehmannia) 1 liang, Ye Taishen (Wild Codonopsis) 4 qian, Sheng Huai Shanyao (Fresh Chinese Yam) 6 qian, Gancao (Licorice Root) 3 qian. Boiled to make 3 zhong of decoction, taken warm in three doses. After finishing all three doses, the Dai pulse disappeared, heat subsided by more than half, but the bowels remained unopened. I then modified the original formula by reducing Shigao by 5 qian and adding Tiandong (Asparagus Tuber) 8 qian, brewing and administering as before. The illness was completely cured.

Although Zhigancao Tang treats both Jie and Dai pulses, since Jie is mild and Dai is severe, the formula formulation focuses on Dai, using purely tonifying drugs. However, Jie pulse often does not suit pure tonification; it is better to add a small amount of opening/unblocking drugs to suit the condition. Recently, I treated a young adult surnamed Qian in Tianjin for cold damage. He sought my consultation after three to four days. His pulse was Hong (Surging) and Hua (Slippery) and very solid, stopping every seven or eight beats, or every ten-plus beats. All stoppages were on the left side. Asking about the cause, I learned that before falling ill, he had angered his Liver Fire, followed by exposure to cold outdoors. Thus, I knew the Jie pulse on the left was due to constrained Liver Qi. I prescribed a modification of Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction): Sheng Shigao (Raw Gypsum) fine powder 4 liang, Zhimu (Anemarrhena Rhizome) 8 qian, Sheng Shanyao (Chinese Yam) replacing Jingmi (Rice) 6 qian, Ye Taishen (Wild Codonopsis) 4 qian, Gancao (Licorice Root) 3 qian, plus Sheng Laifuzi (Raw Radish Seed) 4 qian crushed. Boiled to 3 zhong of decoction, taken warm in three doses. The Jie pulse was eliminated, but residual heat remained in the pulse. I then reduced Shigao in the original formula by 1 liang, and reduced Renshen and Laifuzi by 1 qian each, brewing and administering as before. His bowels, which had been unopened for four days, moved after completing the three doses, and the illness was cured. In this prescription, I did not replace Zhimu with Sheng Dihuang because Dihuang's nature is incompatible with Laifuzi.

In my treatment of cold and warm diseases, I rarely use purgative/descending agents. Even if heat enters the Fu organs of Yangming, if there are no signs of dry, hard stool or the desire to purge but inability to do so, I often administer large doses of Baihu Tang (White Tiger Decoction) to clear heat. Once the heat clears, the bowels usually move spontaneously. Therefore, in my daily clinical practice, Baihu Tang is indeed a commonly used formula, while Chengqi Tang (Order the Qi Decoction) is hardly used throughout the year.

I treated an elderly man over sixty years old suffering from bloody stools. After thirty-plus days of medical treatment, his condition worsened, with more than ten episodes of bloody stool daily, containing many blood clots, and mental confusion. Upon examination, his pulse was extremely Hong (Surging) and Shi (Solid), with a normal rate, but stoppages occurred only on the right side. These stoppages had no fixed number, identifying it as a Jie (Knotted) pulse. His tongue coating was entirely black, indicating a severe external contraction with excess syndrome. It was strange that previous doctors only treated the bloody stool, ignoring the external excess heat. I administered Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction), heavily dosing Sheng Shigao (Raw Gypsum) at 4 liang. Because of the prolonged bleeding, I added Sheng Shanyao (Chinese Yam) 1 liang to replace Jingmi (Rice), utilizing its ability to nourish Yin, tonify the Kidneys, and secure Yuan Qi. Boiled to 3 zhong of decoction, taken warm in three doses. Each dose was accompanied by 1 qian of Guang Sanqi (Notoginseng Root Powder). Administered once daily, bleeding stopped after two days. Bowel movements continued several times daily, the pulse's Hong-Shi quality decreased significantly, but the Jie pulse became more severe, accompanied by abdominal distension. Inquiry revealed the cause was anger. I switched to Sheng Laifuzi (Raw Radish Seed) 5 qian, assisted by Baishao (White Peony Root), Huashi (Talcum), Tianhua Fen (Trichosanthes Root), and Gancao (Licorice Root). Additionally, fresh Baixiaogen (Imperata Rhizome) 4 liang chopped was boiled for three to four boils, and the resulting water was used to decoct the herbs. After one dose, distension resolved, the pulse rate became regular, the Jie phenomenon disappeared while remaining forceful, and loose diarrhea halved. I then administered my own formulated Ziyin Qingzao Tang (Nourish Yin and Clear Dryness Decoction), consisting of Sheng Huai Shanyao (Chinese Yam) and Huashi (Talcum) each 1 liang, Sheng Hangshaoyao (Hangzhou White Peony Root) 6 qian, and Gancao (Licorice Root) 3 qian. After one dose, diarrhea stopped, and the pulse became peaceful. Observing the two cases recorded above, one can see that Jie pulse phenomena do not necessarily belong to internal deficiency; often, they result from constrained Qi, and regulating Qi can lead to recovery.

There are also cases where the pulse is neither Jie nor Dai, but presents a Quezhao (Sparrow Pecking) image. This is also due to obstruction in the Qi level. I once treated a young woman who was chronically ill. In mid-Mengchun (early spring), she contracted cold damage. Within four to five days, she had high fever in both exterior and interior. Her tongue coating was white with slight yellow in the center, lacking fluids. Her pulse was near six beats per breath, strong upon deep pressure. After every ten-plus or twenty-plus beats, a Quezhao (Sparrow Pecking) image often appeared, resembling a sparrow pecking millet, often pecking two or three times consecutively. When exhaling, her breathing seemed obstructed and unable to flow smoothly. Detailed inquiry into the cause revealed that she managed household accounts, and her mother-in-law checked them strictly. Before falling ill, she was reprimanded for accounting errors. Thus, her irregular breathing and Quezhao pulse were caused by this emotional trauma. She reported no bowel movement since the onset of illness. I treated her with the same formula used for Mr. Qian, reducing Sheng Shigao (Raw Gypsum) by 1 liang. Due to fluid depletion, I added Tianhua Fen (Trichosanthes Root) 8 qian. Brewed to 3 zhong of decoction, taken warm in three doses. The pulse approached peace, the rate became regular, and breathing smoothed out. Only the bowels remained unopened. I switched to drugs that nourish Yin, moisten dryness, and clear fire. After two doses, the bowels moved, and she recovered completely.