Library

[Collected Commentaries] Fang Youzhi said: After sweating, if there is no aversion to cold, it indicates that the person's exterior qi is strong. The presence of fever alone, with depletion of body fluids leading to dryness in the stomach, is termed "excess" (Shi). One should harmonize the stomach qi because the pathogen is stagnant in the stomach presenting as an excess pattern. Thus, administering Tiaowei Chengqi Tang (Stomach-Harmonizing Purging Decoction) aims to purge excess, while Licorice Root (Gancao) serves to harmonize within the purgative action.

Cheng Zhi said: If aversion to cold occurs after sweating, it signifies deficiency of both Ying (Nutritive) and Wei (Defensive) qi; if only fever occurs without aversion to cold after sweating, it indicates dried-up body fluids and gastric excess. Hence, there is a method to harmonize the stomach and promote fluid generation. However, the use of terms "should" (Dang) and "give" (Yu) suggests careful deliberation rather than reckless purging, which would further deplete fluids.

Tiaowei Chengqi Tang Formula (See Yangming Chapter)

When the pulse is floating and tight, according to the principles, there should be body pain, and sweating therapy is appropriate. If, however, the cunian position at the chi level is slow, sweating must not be induced. How do we know this? It is due to insufficient Ying qi and blood deficiency.

[Annotation] A floating and tight pulse is the pulse of cold injuring the Ying level; body pain is the manifestation of cold injuring the Ying level. Since both pulse and symptoms indicate exterior excess pathogens, sweating is indicated, preferably using Mahuang Tang (Ephedra Decoction). Suppose the cun and guan positions show floating and tight pulses, but only the chi position is slow; then sweating is contraindicated. Why? Because the person has a chronic deficiency of Ying qi and blood. From this, we can infer that if the yin and yang aspects of the pulse are not both tight, one should not lightly induce sweating.

[Collected Commentaries] Fang Youzhi said: The chi pulse reflects the yin aspect; a slow pulse indicates insufficiency. Ying governs blood, and sweat is the fluid of blood. A slow chi pulse makes sweating inadvisable to avoid depleting blood.

Zhang Lu said: With a slow pulse at the chi position, Mahuang should not be used for sweating. Instead, Xiao Jianzhong Tang (Minor Construct the Middle Decoction) should be administered frequently to harmonize. If harmonization resolves the pathogen, no sweating is needed; if unresolved, continued administration followed by covering to induce sweating is acceptable.

After sweating, if body pain persists and the pulse is deep and slow, Guizhi Jia Shaoyao Shengjiang Ge Yi Liang Renshen Sanli Xinjia Tang (Guizhi Decoction with Added Peony and Ginger, One Tael Each, and Ginseng, Three Taels, Newly Modified Decoction) is the primary treatment.

[Annotation] After sweating, if body pain is accompanied by a floating-tight or floating-rapid pulse, it indicates incomplete sweating and residual exterior pathogens; sweating should still be employed, preferably using Guizhi Tang (Cinnamon Twig Decoction). Now, although body pain persists after sweating, the pulse is deep and slow, indicating deficiency-cold of Ying and Wei qi. Therefore, Guizhi Xinjia Tang is suitable to warm and tonify Ying and Wei.

[Collected Commentaries] Cheng Wuji said: Exuberant exterior pathogens cause body ache; blood deficiency also causes body ache. A floating-tight pulse indicates pathogen exuberance; a deep-slow pulse indicates blood deficiency. For exuberance, reduction brings peace; for deficiency, tonification brings recovery.

Yu Chang said: A deep-slow pulse applies to all six positions, which is vastly different from a slow chi pulse. A slow chi pulse implies constitutional deficiency, whereas this case represents new deficiency caused by sweating. Thus, Peony (Shaoyao) and Fresh Ginger (Shengjiang) are doubled by one tael each in the Guizhi formula to dispel pathogens, and Ginseng (Renshen) three taels are added to tonify upright qi. Named "Newly Modified Decoction," it clearly differs from the old methods of Guizhi Tang.

Wang Hu said: Body pain with a deep-slow pulse—how do we know it is not Cold Strike (Zhong Han)? One must understand that this condition arises from persistent body pain after sweating for Taiyang Shanghan, with the pulse changing to deep and slow; it is not comparable to Cold Strike.

Guizhi Xinjia Tang Formula
Guizhi (Cinnamon Twig, 1 tael), Shaoyao (Peony Root, 4 taels), Gancao (Licorice Root, 2 taels), Renshen (Ginseng Root, 3 taels), Shengjiang (Fresh Ginger, sliced, 4 taels), Dazao (Jujube, broken open, 12 pieces).
These six ingredients are decocted in 12 sheng of water over low heat until 3 sheng remain. Strain and take warm in divided doses, following the administration method of Guizhi Tang.

[Formula Analysis] This formula is essentially Guizhi Tang with doubled Shaoyao and Shengjiang, plus Renshen. Post-sweating body pain indicates Ying-Wei deficiency and disharmony; thus, Guizhi Tang is used to harmonize Ying and Wei. Doubling Shengjiang addresses the deep-slow pulse and cold in the Ying level; doubling Shaoyao addresses Ying insufficiency and blood deficiency; adding Renshen tonifies various deficiencies. Guizhi combined with Renshen allows Great Qi to circulate freely, enriching blood and qi to regulate the limbs. Renshen combined with Guizhi connects interior and exterior, nourishing Ying Yin and benefiting Wei Yang. Exterior deficiency with body pain will surely resolve.

If a patient presents with fever, headache, and a pulse that is surprisingly deep, and if symptoms do not improve, accompanied by body pain, the interior should be warmed using Sini Tang (Four Reversal Decoction).

[Note] Under "body pain," the phrase "diarrhea with undigested food" (Xiali Qinggu) should likely exist to align with the text "warm the interior." In the Taiyang Chapter, it states: If a Shanghan patient is mistakenly purged, leading to incessant diarrhea with undigested food and body pain, urgent rescue of the interior with Sini Tang is required. Although here there was no purging, the surprising deep pulse indicates interior cold, suggesting a textual omission.

[Annotation] Fever and headache are typical Taiyang exterior patterns. The pulse should be floating; a surprising deep pulse indicates a Taiyang exterior pattern presenting with Shaoyin interior pulse. For diseases where both Taiyang and Shaoyin present with exterior-interior cold and no sweat, Mahuang Fuzi Xixin Tang (Ephedra, Prepared Aconite, and Asarum Decoction) is suitable for inducing sweating. If unresolved without diarrhea, Mahuang Fuzi Gancao Tang (Ephedra, Prepared Aconite, and Licorice Decoction) is used to harmonize; if diarrhea with undigested food occurs, even with unresolved exterior body pain, sweating is contraindicated. The interior must be warmed using Sini Tang to prevent Yang transformation into Yin, avoiding complications like Jue (cold extremities), fright, and Yang collapse. One must never argue that since the disease is in Taiyang, warming is inappropriate.

Sini Tang Formula (See Shaoyin Chapter)

In Shanghan, if after vomiting or purging, the disease remains unresolved after seven to eight days, with heat consolidated in the interior, causing fever in both exterior and interior, occasional aversion to wind, extreme thirst, dryness and烦躁 (restlessness) on the tongue, and a desire to drink several sheng of water, Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) is the primary treatment.

[Note] Under "Shanghan," the phrase "if sweating" (Ruo Han) should likely exist, as sweating damages body fluids more severely than vomiting or purging. "Occasional aversion to wind" should probably read "occasional sweating and aversion to wind." Without "sweating," occasional aversion to wind implies unresolved exterior, making Baihu Tang contraindicated. The Treatise states: For fever without sweat and unresolved exterior, Baihu Tang is forbidden; for thirst wanting water without exterior signs, Baihu Jia Renshen Tang is indicated. Readers should study the original text carefully.

[Annotation] After Shanghan treated with sweating, vomiting, or purging, if unresolved after seven to eight days, leading to heat consolidation in the exterior and interior, with occasional sweating and aversion to wind, the consolidated heat in the exterior remains unresolved. Extreme thirst, dry tongue, restlessness, and desire to drink several sheng of water indicate consolidated heat in the interior is manifest. Thus, it is described as exterior-interior heat, treated with Baihu Jia Renshen Tang. Baihu Tang releases muscle heat externally and clears interior heat internally. Renshen is added because sweating, vomiting, and purging have depleted fluids and weakened Qi; it helps generate Qi and fluids.

[Note] Da Qinglong Tang treats Taiyang exterior-interior heat, where exterior heat predominates, hence no thirst. Baihu Tang treats Yangming exterior-interior heat, where interior heat predominates, hence extreme thirst. Current symptoms of extreme thirst, dryness, restlessness, occasional sweating, and aversion to wind indicate heat in Yangming combined with Taiyang. Baihu Tang is used because Yangming interior heat patterns are predominant over Taiyang exterior heat patterns. If there were no sweat and slight thirst, Taiyang exterior patterns would predominate, and Da Qinglong Tang would be indicated even for severe exterior-interior heat.

[Collected Commentaries] Yu Chang said: Examining this clause, heat consolidated in the interior with exterior-interior heat requires careful consideration. Only because heat is consolidated in the interior does the exterior heat persist. Given extreme thirst and drinking, clearing heat must be urgent!

Cheng Zhi said: Exterior heat refers to body fever; interior heat refers to internal heat. Unresolved after sweating, vomiting, or purging allows pathogens to exploit deficiency and consolidate as interior heat. Because heat consolidates in the interior, exterior heat persists, causing aversion to wind. Extreme thirst indicates blazing interior heat; thus, Baihu Tang is urgently needed to resolve it. Gypsum (Shigao) is acrid and cold, clearing interior heat and dispersing exterior heat. Because this follows sweating, vomiting, or purging, Renshen is essential to protect upright Qi.

Wang Hu said: Baihu Jia Renshen Tang supports upright Qi to resolve interior and exterior pathogenic heat. This decoction is suitable only when upright Qi is deficient and pathogens are mild; for severe pathogens, Renshen should not be lightly added.

Baihu Jia Renshen Tang Formula (See Yangming Chapter)

After sweating, if the pulse is floating and rapid, with irritability and thirst, Wuling San (Five-Ingredient Powder with Poria) is the primary treatment.

[Note] Under "floating and rapid pulse," the phrase "difficulty urinating" (Xiaobian Buli) should likely exist. Without this, irritability and thirst would stem from Yangming interior heat and dry mouth, indicating Baihu Tang syndrome. With difficulty urinating and irritability/thirst, it indicates Taiyang water-heat stasis, indicating Wuling San syndrome. Using Wuling San without difficulty urinating violates the prohibition against doubly depleting fluids. Several similar cases appear in the Upper Taiyang chapter; only one involving vomiting immediately after drinking water lacks mention of difficulty urinating. This clause should include "difficulty urinating."

[Annotation] "Sweating completed" means Taiyang disease has undergone sweating. A floating-rapid pulse indicates pathogens remain in the exterior. If urination is free with irritability/thirst, it indicates entry into Yangming stomach heat (Baihu Tang syndrome). Now, with difficulty urinating and irritability/thirst, it is a Taiyang Fu organ disease, bladder water retention (Wuling San syndrome). Thus, Wuling San is used; taken correctly, it disperses outward and drains inward, resolving both exterior and interior.

[Collected Commentaries] Fang Youzhi said: "Completed" means sweating is finished, not that the exterior disease has ceased. Irritability and thirst result from bladder water retention failing to transform fluids; thus, Si Ling (Four-Ingredient Powder) components are used to drain water. Floating-rapid pulse indicates unremoved exterior; thus, Cinnamon Twig (Guizhi) harmonizes the exterior. Hence, Wuling San is said to resolve both exterior and interior.

In Shanghan, if sweating occurs with thirst, Wuling San is indicated; if without thirst, Fuling Gancao Tang (Poria and Licorice Decoction) is indicated.

[Annotation] This elaborates on the previous clause regarding irritability with or without thirst to distinguish treatments. After Shanghan sweating, if pulse is floating-rapid, sweating occurs with irritability/thirst and difficulty urinating, Wuling San is indicated. Here, only sweating is mentioned as an ellipsis. Thirst without irritability indicates water abundance over heat; thus, Wuling San is used to drain water and transform fluids. If neither irritability nor thirst exists, there is no interior heat. Only floating-rapid pulse, sweating, and difficulty urinating indicate Ying-Wei disharmony; thus, Fuling Gancao Tang is used to harmonize the exterior and drain water.

[Collected Commentaries] Zheng Zhongguang said: Shanghan originally has no sweat; sweat results from inducing it. The previous clause had irritability and thirst; this clause has thirst without irritability, indicating milder interior signs and similar treatment. If even less thirsty, there is no interior dryness, fewer interior signs, and more exterior signs. Thus, three parts Guizhi Tang and one part Wuling San are used, indicating three exterior to one interior ratio. Renamed Fuling Gancao Tang, it is a modification of Guizhi and Wuling formulas.

Fuling Gancao Tang Formula
Fuling (Poria, 2 taels), Guizhi (Cinnamon Twig, 2 taels), Shengjiang (Fresh Ginger, sliced, 3 taels), Gancao (Licorice Root, roasted, 1 tael).
These four ingredients are decocted in 4 sheng of water until 3 sheng remain. Strain and take warm in three divided doses.

[Formula Analysis] This formula imitates the principles of Guizhi Tang and Wuling San but in a smaller dosage. It addresses the exterior sign of floating-rapid pulse and sweating using Guizhi. Dazao and Shaoyao are removed because of interior difficulty urinating, to avoid astringency hindering urination. Wuling San's Baizhu, Zexie, and Zhuling are removed because lack of thirst/irritability indicates minimal interior fluid retention; only promoting urination is needed, avoiding excessive drying that damages Yin.

[Collected Commentary] Wang Hu said: Both Wuling San and Fuling Gancao Tang treat simultaneous Biaobing (Exterior Syndrome) and Benbing (Interior Syndrome) of Taiyang, addressing both exterior and interior. What is Biaobing? The Taiyang Meridian. What is Benbing? The Bladder Fu organ. The Meridian is exterior; the Fu organ is interior. In Wuling San, pathogens have entered the Fu organ, and exterior signs are minor; thus, only Guizhi addresses the exterior, while the other four ingredients address the interior. In Fuling Gancao Tang, pathogens remain in the Meridian, and interior signs are few; thus, only Fuling addresses the interior, while the other three ingredients address the exterior.

If the pulse is floating and rapid, sweating should normally lead to recovery. If purging is mistakenly applied, resulting in heavy body and palpitations, sweating is contraindicated. Recovery comes through spontaneous sweating. Why? Because the chi pulse is weak, indicating interior deficiency. The exterior and interior must become solid, body fluids must harmonize naturally, and spontaneous sweating will occur for recovery.

[Annotation] Before fever onset in Shanghan, pulses are often floating-tight due to cold excess. After fever onset, pulses are often floating-rapid due to heat excess. Both are suitable for Mahuang Tang to induce sweating for recovery. If sweating is not induced and purging is mistakenly applied, preventing adverse transformations, the person must have constitutionally solid interior Qi. Thus, seeing only exterior heaviness from missed sweating and interior palpitations from mistaken purging, re-inducing sweating is forbidden. One must wait for natural exterior-interior harmony and spontaneous sweating. This occurs because missed sweating causes exterior excess, mistaken purging causes interior deficiency, and a weak chi pulse shows exterior-interior disharmony. Recovery requires the interior to become solid and balance the exterior. Balance leads to harmony, allowing Yang fluids and Yin fluids to harmonize spontaneously, resulting in recovery. The method to solidify the interior is using Xiao Jianzhong Tang, as described in the next clause.

[Collected Commentaries] Yu Chang said: This is another variation of constructing the Middle before sweating. Zhang Zhongjing stated: Weak chi pulse contraindicates sweating. Also: Weak chi pulse contraindicates purging. These explore the profound essence of human fluids. Even if the pulse remains floating-rapid after mistaken purging requiring urgent sweating, the chi pulse must be examined carefully; one cannot act arbitrarily.

Zhang Lu said: Mistaken purging causing heaviness and palpitations contraindicates further sweating, even if the pulse remains floating-rapid. If the chi pulse is weak, indicating chronic interior Yin deficiency, caution is especially warranted. Floating-rapid pulse indicates severe heat about to sweat; mistaken purging causes heaviness and palpitations. Xiao Jianzhong Tang should be given to harmonize fluids, leading to recovery via sweating.

On the second or third day of Shanghan, if there is palpitation and irritability in the heart, Xiao Jianzhong Tang (Minor Construct the Middle Decoction) is the primary treatment.

[Annotation] On the second or third day of Shanghan, without prior sweating or purging, if palpitation and irritability occur, the person must have constitutionally deficient Middle Qi. Despite exterior signs, sweating is contraindicated. Palpitation indicates diminished Yang; irritability indicates weakened Yin. Thus, Xiao Jianzhong Tang is used first to establish the Middle Qi and harmonize Ying and Wei.

[Collected Commentaries] Wang Kentang said: On the second or third day of Shanghan, with palpitation and irritability, Xiao Jianzhong Tang is indicated. A string-thin pulse in Shanghan belongs to Shaoyang and contraindicates sweating; sweating causes delirium. Stomach disharmony causes irritability and palpitation. Generally, irritability preceding palpitation indicates Heat; palpitation preceding irritability indicates Deficiency. Seeking the root in treatment is key.

Cheng Yingmao said: This shows that Yang departing into Yin has precursors. Skilled practitioners prevent this before it arises. Heart palpitation and irritability indicate deficient interior Qi and Yang invaded by Yin. Jianzhong Tang tonifies deficiency, harmonizes the interior, stabilizes the Middle State, and generates Qi and Blood. Although palpitation and irritability are seen in Xiaochaihu Tang, on the second or third day, interior signs may not yet be complete, making Xiaochaihu Tang unsuitable.

Wei Litong said: Establishing the Middle treats the root. After establishing the Middle, if the pathogen remains in the exterior, sweating can still be safely performed without Yang collapse. If it transmits to the interior, purging can be safely performed without Yang sinking. This illustrates treating the branch in emergencies and the root in stable conditions.

Xiao Jianzhong Tang Formula
Guizhi (Cinnamon Twig, 3 taels), Shaoyao (Peony Root, 6 taels), Gancao (Licorice Root, 2 taels), Shengjiang (Fresh Ginger, sliced, 3 taels), Jiaoyi (Malt Sugar, 1 sheng), Dazao (Jujube, broken open, 12 pieces).
These six ingredients are decocted in 7 sheng of water until 3 sheng remain. Strain, add Jiaoyi, and dissolve over low heat. Take 1 sheng warm, three times daily. Patients with vomiting should not use Jianzhong Tang due to its sweetness.

[Formula Analysis] This formula is Guizhi Tang with doubled Shaoyao and added Jiaoyi. Named "Minor Construct the Middle," it implies gently establishing Middle Qi. Although Middle Qi is deficient, the exterior is not yet harmonized, so strong tonification is avoided. Guizhi harmonizes Ying and Wei; doubled Shaoyao and Jiaoyi build the Middle State. Unlike standard Guizhi Tang protocols involving porridge and covering for sweat, the focus here is on heart palpitation and Middle deficiency, not the Shanghan exterior. Establishing the Middle harmonizes Ying and Wei, generates fluids, induces sweat, resolves palpitation and irritability. Vomiting patients should avoid it as sweetness may aggravate vomiting.

In Shanghan, if the pulse is knotted (Jie) or intermittent (Dai), with palpitation, Zhigancao Tang (Prepared Licorice Decoction) is the primary treatment.

[Annotation] "Palpitation" describes a throbbing sensation in the chest, restless and uneasy. Palpitation after sweating/purging is usually deficiency; without these, it is usually heat. Thirst with difficulty urinating indicates Fluid Retention; cold extremities with diarrhea indicate Cold. Here, in Shanghan without sweating/purging, and lacking Fluid, Heat, Cold, or Deficiency signs, but presenting with a deficient knotted/intermittent Yin pulse, Zhigancao Tang is indicated. This is because the person chronically suffers from blood and Qi weakness, unable to withstand cold pathogens, causing the pulse to fail to continue smoothly. Although the Shanghan exterior may persist, it is secondary; the priority is tonifying the Middle, generating blood, restoring the pulse, and circulating Ying and Wei.

[Collected Commentaries] Cheng Wuji said: When the pulse beats and stops, returning on its own, it is called Jie (Knotted); if it does not return on its own, it is called Dai (Intermittent). This results from blood and Qi deficiency failing to sustain continuity.

Cheng Zhi said: This establishes a variation for tonification. "Shanghan" implies unresolved pathogens. The Heart governs Blood; knotted/intermittent pulse and palpitation indicate blood deficiency and discontinuity of True Qi. Thus, Yin is vigorously tonified to generate blood, and Yang is unblocked to disperse cold. Without Yang, micro-Yin cannot be retained. Hence, Guizhi Tang minus Shaoyao is soaked in clear wine to salvage True Qi at the brink of collapse and avoid interior cold during weak pulses. Observing Xiao Jianzhong Tang reveals Shanghan has Yang-tonifying formulas; observing Zhigancao Tang reveals Shanghan has Yin-tonifying methods.

Cheng Yingmao said: This diagnosis relies on the pulse. Pathogen stagnation is Jie; upright Qi deficiency is Dai. Seeing this in Shanghan with palpitation indicates internal deficiency of True Qi. Zhigancao Tonifies Yin, calms Blood, and harmonizes Ying and Wei. Furthermore, Taiyang transformations often involve Yang loss; Shaoyin transformations involve Yin loss due to their interior-exterior relationship and Ying Yin injury. Zhigancao Harmonizes Ying to nourish Yin Qi.

Zhigancao Tang Formula
Gancao (Licorice Root, roasted, 4 taels), Shengjiang (Fresh Ginger, sliced, 3 taels), Guizhi (Cinnamon Twig, 3 taels), Maimendong (Ophiopogon Tuber, half sheng), Maziren (Hemp Seed, half jin), Dazao (Jujube, broken open, 12 pieces), Renshen (Ginseng Root, 2 taels), Ejiao (Donkey-hide Gelatin, 2 taels), Shengdihuang (Rehmannia Root, fresh, 1 jin).
These nine ingredients are decocted in 7 sheng of clear wine and 8 sheng of water. First boil eight ingredients until 3 sheng remain. Strain, add Ejiao, melt completely, and take 1 sheng warm, three times daily. Also known as Fumai Tang (Pulse-Recovering Decoction).

[Collected Commentary] Zhang Lu said: For those with withered fluids, prevention of constipation is necessary. Maimendong and Shengdihuang nourish the source of Bladder transformation; Maziren and Ejiao specifically address Large Intestine dryness. This prevents Yin deficiency, spring exhaustion, fire dryness, and blood withering—a brilliant method of saving Yin and retreating Yang by Zhang Zhongjing.

Ke Qin said: Zhang Zhongjing typically uses Shaoyao for deficient Yin pulses to benefit Yin, and Guizhi for Yang deficiency pulses to unblock Yang, sometimes adding Renshen to generate pulse. He rarely used Maimendong. Does Shanghan methodology prioritize supporting Yang? Or is there no sudden method for tonifying Yin? In this case of Middle deficiency with knotted/intermittent pulse, Shengdihuang is used as Sovereign and Maimendong as Minister to vigorously tonify True Yin, opening the path for later scholars to tonify Yin. However, Dihuang and Maimendong are sweet but cold, not suitable for sprouting and flourishing. They require Renshen and Guizhi to unblock Yang pulses, Shengjiang and Dazao to harmonize Ying and Wei, Ejiao to tonify blood, Suanzaoren to calm spirit, Gancao to slow descent, and strong clear wine to accelerate upward movement. Interior and exterior harmonize, palpitations calm, and...