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Mahuang (Ephedrae Herba, 麻黄) [devoid of nodes] liang (Chinese ounce), Fuzi (Aconiti Lateralis Radix Praeparata, 附子) [prepared, skin removed, broken into eight pieces] one piece, Gancao (Glycyrrhizae Radix et Rhizoma Praeparata cum Melle, 甘草) [roasted with honey] liang.
The above three ingredients are decocted in seven sheng (Chinese liquid measure) of water. First, boil Mahuang until it boils once, remove the foam on the surface, then add the remaining herbs. Decoct until three sheng remain, filter out the dregs, and take one sheng warm. Administer three times a day.
[Collected Commentary]
Ke Qin stated: In Taiyang disease (Taiyang syndrome), if the pulse is unexpectedly deep, Si Ni Tang (Counterflow Decoction) is used to urgently rescue the interior, indicating an excess of Yin-cold in the interior. In this case of Shaoyin disease (Shaoyin syndrome), where the pulse suggests Shaoyin but there is superficial heat, Fuzi is added to exterior-resolving formulas to preemptively secure Yang Qi, indicating deficient Yang with superficial heat. Fever without sweating corresponds to the deep pulse of Taiyang exterior; lethargy corresponds to Shaoyin interior. If Mahuang were used alone to open the pores and Xixin (Asari Radix, 细辛) to scatter floating heat, without Fuzi to secure the Primordial Yang, the slight Yang of Taiyang would escape outward. Only when Fuzi and Mahuang are used together can cold pathogens be dispersed without losing Yang. This represents interior pathology affecting the exterior, where a deep pulse indicates the need for diaphoresis, which is fundamentally different from exterior pathology with a floating pulse requiring diaphoresis. If there is slight superficial heat, the cold pathogen is light; thus, Gancao replaces Xixin to induce mild diaphoresis. The sweet flavor moderates the action, making it milder than the dispersing action of acrid flavors.
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In Shaoyin disease, if the pulse is faint, diaphoresis is contraindicated because it may lead to the loss of Yang. If Yang is already deficient and the Chi (cun-guan-chi pulse position corresponding to the lower jiao/kidneys) pulse is weak and choppy, purgation is also contraindicated.
[Annotation]
In Shaoyin disease, a faint pulse, even with fever, indicates interior cold with exterior heat (deficient Yang floating outward), which cannot be compared to the fever of Taiyang disease; therefore, diaphoresis is contraindicated as it leads to the loss of Yang. However, if Yang is already deficient and body fluids are exhausted, even if symptoms suitable for purgation such as dry mouth and throat appear, if the Chi pulse is weak and choppy, purgation is still contraindicated to avoid the loss of Yin.
[Collected Commentary]
Fang Youzhi stated: A faint pulse indicates insufficient Yang Qi, hence "no Yang." Without Yang, transformation and movement do not occur, so diaphoresis is impossible. The Chi position reflects Yin; a weak and choppy pulse indicates deficiency of Yin-blood. Thus, purgation is contraindicated, and urgent warming and tonification should be employed.
Cheng Yingmao stated: Shaoyin disease often presents with spontaneous diarrhea, so people generally do not lightly use purgatives. However, by highlighting the "weak and choppy Chi pulse," it implies that in Shaoyin cases requiring Da Cheng Qi Tang (Great Order the Qi Decoction), the Chi pulse must be forceful and slippery, a condition foreshadowed here.
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If a patient's pulse is tight at all positions (Yin and Yang) but they sweat profusely, this indicates the loss of Yang and belongs to Shaoyin disease. According to standard patterns, this should present with sore throat, vomiting, and diarrhea.
[Annotation]
Tight pulses at all positions with fever and no sweating indicate Taiyang Cold Damage syndrome. Fever with continuous sweating indicates Taiyang loss of Yang. Now, a tight pulse without fever but with sweating indicates Shaoyin disease. In Shaoyin disease, the standard presentation includes sore throat, vomiting, and diarrhea. In the previous clause, the faint pulse without sweating made diaphoresis contraindicated based primarily on the pulse. In this clause, the presence of sweating with a tight pulse makes diaphoresis contraindicated based primarily on the symptoms. One must carefully distinguish between relying on the pulse versus the symptoms.
[Collected Commentary]
Cheng Zhi stated: Tightness in all pulse positions is characteristic of Cold Damage, where sweating should not occur. Profuse sweating indicates the external loss of Taiyang Yang. Mistaking Shaoyin loss of Yang for Taiyang Wind Strike would be an error. When Shaoyin cold forces upward, it causes sore throat and vomiting; when it forces downward, it causes diarrhea.
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In Shaoyin disease, after one or two days, if the mouth feels normal and comfortable, but there is aversion to cold in the back, moxibustion should be applied, and Fu Zi Tang (Aconite Decoction) should be administered as the primary treatment.
[Annotation]
Aversion to cold in the back can occur in both Yin and Yang diseases. For example, in Yangming disease, if there is no high fever but dry mouth, thirst, irritability, and slight aversion to cold in the back, it is a Bai Hu Jia Ren Shen Tang (White Tiger Plus Ginseng Decoction) pattern. Here, in Shaoyin disease, with lethargy, occurring after two or three days, if the mouth is not dry but comfortable, and there is aversion to cold in the back, it is aversion to cold due to Shaoyin Yang deficiency, not the aversion to cold caused by Yangming heat steaming. Therefore, moxibustion should be applied, and Fu Zi Tang should be given to assist Yang and dissipate Yin. Dry mouth versus a comfortable mouth are definitive signs distinguishing these conditions.
[Collected Commentary]
Cheng Zhi stated: This describes the initial stage where the mouth is comfortable, not thirsty or dry, indicating no interior heat. The *Neijing* states: "The back is Yang." Aversion to cold in the back indicates Yang deficiency and Yin-cold excess, revealing deep cold. If aversion to cold were due to wind-cold in the exterior, the whole body would feel cold. Moxibustion assists Yang to dissipate Yin, and Fu Zi Tang warms the meridians and scatters cold. The text mentions that in cases of Cold Damage with no high fever, dry mouth, thirst, irritability, and slight aversion to cold in the back, Bai Hu Tang plus Ginseng is used. That is aversion to cold caused by Yang-heat sinking into Yin due to Yin deficiency, which differs from the current case of severe Yin-cold. When Yang enters Yin, there is dry mouth and irritability; when Yin-cold is excessive, it cannot consume body fluids, so the mouth remains comfortable.
Zhang Lu stated: When Taiyang exterior Qi is severely deficient, pathogens enter and attack Shaoyin. Thus, within one or two days, there is aversion to cold in the back without fever. This represents a deficiency of both Yin and Yang, differing significantly from Liang Gan (simultaneous involvement of Taiyang and Shaoyin). In Liang Gan, both exterior and interior involve heat pathogens, allowing for exterior-releasing and interior-purging treatments. Here, both interior and exterior are deficient-cold, with no heat pathogens to attack. Treatment should focus on warming the meridians and tonifying Yang to supplement insufficiency, supplemented by moxibustion at Guan Yuan (CV4). Although the condition seems less acute than fever with a deep pulse, it is more critical.
Wang Hu stated: This clause does not specify which acupoints Zhongjing intended for moxibustion. Chang Qizhi said: Moxi Ge Shu (BL17) and Guan Yuan (CV4). Guo Yong noted a textual error, suggesting it should be Ge Shu (BL17) and Guan Yuan (CV4). Ge Shu is in the second row of Back-Shu points. However, Chang Qizhi's mention of the "third row" likely refers to Ge Guan (BL47), not Ge Shu. The *Tu Jing* states: Ge Guan points are located below the seventh thoracic vertebra, three cun lateral to the midline, in depressions. They are accessed in a sitting position, are exit points of the Foot-Taiyang channel, and specifically treat aversion to cold in the back, stiff spine, and difficulty bending/straightening. Five moxa cones can be applied. Since Shaoyin cold invasion typically enters via Taiyang, these points are appropriate. Guan Yuan is located three cun below the umbilicus on the anterior midline, meeting the Foot-Yin channels and Ren Mai. One hundred moxa cones can be applied. Moxibustion on Ge Guan warms the exterior to scatter external pathogens, while moxibustion on Guan Yuan warms the interior to boost Yuan Qi.
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In Shaoyin disease, with body pain, cold hands and feet, bone and joint pain, and a deep pulse, Fu Zi Tang is the primary treatment.
[Annotation]
This elaborates on the previous clause to clarify the symptoms and treatment. Body pain can occur in both exterior and interior conditions. In Taiyang disease, floating pulse, fever, aversion to cold, body pain, warm hands/feet, and joint pain indicate exterior cold, treated with Ma Huang Tang (Ephedra Decoction) to release the exterior and disperse cold. In Shaoyin disease, however, a deep pulse, absence of fever, aversion to cold, body pain, cold hands/feet, and joint pain indicate interior cold, treated with Fu Zi Tang to warm the interior and disperse cold.
[Collected Commentary]
Fang Youzhi stated: Shaoyin corresponds to the Kidney. The Kidney governs the bones. Excess cold causes pain.
Cheng Yingmao stated: Body pain, cold hands/feet, and joint pain are also seen in Taiyang Cold Damage. Differentiation relies on the deep pulse. Deepness indicates heavy Yin-cold. There is excess Yin in the interior and deficiency of Yang in the exterior; thus, Fu Zi Tang is indicated.