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Leech (fried, 30 pieces) Tabanid fly (fried, heads and feet removed, 30 pieces) Rhubarb (peeled, broken into six pieces, 3 liang) Peach Kernel (peeled and tips removed, 20 pieces)

The above four herbs are boiled in five sheng of water to obtain three sheng of decoction. Strain the dregs, and take one sheng warm. If the blood stasis is not expelled, administer again.

In Taiyang disease (disease of the Taiyang channel), if there is yellowing of the body, a deep and knotted pulse, hardness and fullness in the lower abdomen, and difficulty in urination, it indicates damp-heat affecting the Qi level rather than blood stasis; however, if urination is normal and the patient exhibits symptoms resembling mania, this confirms blood stasis, which falls under the indication for Didang Tang (Cockroach Decoction).

[Annotation] This section elaborates on the pulse and symptoms from the previous clause, mutually elucidating their meanings. In Taiyang disease, whether Wind Strike or Cold Damage, if there is yellowing of the body, a large pulse, abdominal fullness, difficulty in urination, and sweating only on the head, it is jaundice caused by damp-heat, not blood stasis. Now, with yellowing of the body, a deep and knotted pulse, hardness in the lower abdomen, normal urination, and symptoms resembling mania, it is blood stasis, not damp-heat; therefore, Didang Tang should be used to attack the blood stasis.

[Collected Annotations] Fang Youzhi said: "Di" means examination. It implies that judging it as blood stasis is thoroughly verified and beyond doubt; using Didang Tang is mandatory, encouraging physicians not to hesitate.

Cheng Zhi said: Yellowing of the body, deep and knotted pulse, and hardness in the lower abdomen are all signs of blood accumulation in the lower Jiao. However, these are similar to the syndrome of jaundice due to stomach heat, so differentiation must rely on urination. If the lower abdomen is full but urination is difficult, it is a functional Qi disorder, belonging to Yinchen Tang (Artemisia Capillaris Decoction); if the lower abdomen is hard and urination is normal, it is an organic Blood stasis disorder, undoubtedly belonging to Didang Tang.

Wang Hu said: According to the original text, below "difficulty in urination," Zhongjing does not mention treatment methods. Cheng Wuji's annotation says: One may use Yinchen Tang. The "Bu Wang Lun" says: Use Wuling San (Five-Ingredient Powder with Poria). The "Hou Tiaobian" says: It belongs to Yinchen Wuling San. These three formulas can be selected and used.

In Cold Damage with fever, lower abdominal fullness, urination should be difficult; now that it is surprisingly normal, it indicates blood stasis, which should be purged. Didang Wan (Cockroach Pill) is appropriate.

[Annotation] This section continues from the previous one to discuss milder cases, mutually elucidating principles and斟酌 (considering) treatment methods. In Cold Damage affecting the Ying (Nutritive) level, if fever persists, stagnating within the Ying level, and the blood does not follow the channels to cause epistaxis, it will likely descend along the channels and accumulate in the Bladder. The lower abdomen is the chamber of the Bladder, hence the lower abdominal fullness. If urination is difficult, the disease is in the Wei (Defensive) level with retained water; now that urination is surprisingly normal, the disease is in the Ying level with blood stasis. The method requires purging, and Didang Tang is appropriate. Reducing the dosage to form pills allows for a slow purgative action; excessive use of Didang Tang should be avoided.

[Collected Annotations] Fang Youzhi said: The formula in the previous clause was changed from a decoction to a pill. Although named a pill, it is still boiled as a decoction. A decoction acts vigorously (dang); a pill acts slowly (huan). Changing from decoction to pill while retaining the decoction method aims for a balance between slowness and vigor, achieving a purgative effect without being overly drastic.

Cheng Yingmao said: Fullness arises when heat enters the Qi level and affects fluids, leading to difficult urination; now that urination is normal, we know what accumulates is not fluid but blood. Blood becomes full and knotted due to heat, so Didang Tang is used, altered into pills, boiled and taken with dregs, to reach the site of blood directly, purge old heat, and sweep away new stasis, thereby eliminating the root cause!

Didang Wan Formula
Leech (fried, 20 pieces) Tabanid fly (fried, wings and feet removed, 20 pieces) Peach Kernel (peeled and tips removed, 25 pieces) Rhubarb (3 liang)

The above four herbs are crushed, sifted, and divided into four pills. Boil one pill in one sheng of water to obtain seven he of liquid, and take it. Blood should be discharged at this time; if not, administer again.

[Ji Jie - Collected Exegesis] Ke Qin said: The Bladder is the residence of water, where blood has no place to accumulate. The lower abdomen is the chamber of the Bladder. Heat knotting causes hardness and fullness, which should lead to difficult urination; the fact that urination is normal indicates the disease is not inside the Bladder but within the lower abdomen. The Ying blood descending along the channels, due to heat-stasis knotting in the interior of the lower abdomen, is not in the interior of the Bladder. Thus, although urination is normal, the hardness, fullness, urgency, and knotted sensation remain unchanged, indicating blood stasis accumulating in the lower abdomen. Heat rampant internally disturbs the soul and spirit, causing mania; blood stasis impedes circulation, so Ying blood cannot move, resulting in a faint and deep pulse; Ying blood not moving leads to Qi obstruction, resulting in a deep and knotted pulse; Ying Qi not circulating throughout the body causes yellowing of the skin. Eating well and feeling hungry quickly indicates blazing Stomach fire; stool being surprisingly easy to pass indicates blood moistening the intestines; black color indicates transformation of accumulated blood; forgetfulness indicates blood failing to nourish the mind, leading to unclear intellect. All these are signs of blood stasis. Only the most potent agents can penetrate its nest and bear this heavy responsibility; thus, Didang Tang was established. Leeches are good at drinking blood and thrive in water; Tabanid flies are good at sucking blood and are fierce on land. Using both aquatic and terrestrial blood-sucking creatures attacks via sympathetic resonance (tong qi xiang qiu). Assisted by the bitter-warm Peach Kernel to push out the old and generate the new, and the bitter-cold Rhubarb to scour evil heat, it is named Didang. If heat is severe but without mania, and the lower abdomen is full but not hard, it is appropriate to reduce the dosage into pills for slow treatment. If exterior symptoms have resolved, but there is urgency and knotted sensation in the lower abdomen, and the patient resembles mania, this is a syndrome transferring to Yangming. Use Tiaowei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction) added with Peach Kernel and Cinnamon Twig for blood-moving properties, to mildly promote evacuation, so that the Stomach harmonizes and health returns. This is why Taohe Chengqi Tang (Peach Pit and Magnolia Bark Decoction) serves as a slow treatment method.

After severe purgation in Cold Damage, followed by sweating, if there is epigastric stuffiness (pi) and aversion to cold, the exterior is unresolved. One must not attack the pi; first resolve the exterior. Only after the exterior is resolved can one attack the pi. To resolve the exterior, Guizhi Tang (Cinnamon Twig Decoction) is appropriate; to attack the pi, Dahuang Huanglian Xiexin Tang (Rhubarb and Coptis Heart-Purging Decoction) is appropriate.

[Annotation] After severe purgation in Cold Damage, followed by sweating, the sequence of treatment (purgation then sweating) was incorrect. Evil heat sank inward, causing epigastric stuffiness; the method should be to attack the interior. However, if there is aversion to cold, the exterior is not yet cleared. Since the exterior is not cleared, one must not attack the pi; first resolve the exterior. Only after the exterior is resolved can one attack the pi. Guizhi Tang is appropriate for resolving the exterior because it is an exterior condition following sweating and purgation; Dahuang Huanglian Xiexin Tang is appropriate for attacking the pi because it is a pi condition caused by interior heat after the exterior has resolved.

[Collected Annotations] "Huoren Shu" says: Generally, Jie Xiong (Constraint in the Chest) and Pi (Stuffiness) should be treated with purgation, but if the exterior is unresolved, one must not attack.

Fang Youzhi said: The "exterior" here is not the initial exterior of the disease, but the exterior loosened by subsequent sweating after purgation. "Resolve" (jie) is like relieving, such as relieving thirst or urgency. Resolving the exterior differs from releasing the exterior. For the initial exterior of Cold Damage, one should release it, hence Ma Huang Tang (Ephedra Decoction); for the exterior after sweating, one should resolve it, hence Guizhi Tang is indicated.

Zhang Lu said: Severe purgation followed by sweating reverses the order of treating interior then exterior, which is an error. Ultimately, the sinking evil knots in the epigastrium, accompanied by aversion to cold, shows that the exterior evil is not diminished by sweating. One must not attack the pi again; instead, one should first employ the method of releasing the muscle layer to treat the exterior. After the exterior resolves, then use Dahuang Huanglian to attack the heat-knotting pi, which is the correct method.

Dahuang Huanglian Xiexin Tang Formula
Rhubarb (2 liang) Coptis (1 liang)

The above two herbs are soaked in two sheng of boiling water ("Ma Fei Tang"). After a moment, strain the dregs, and divide into two warm doses.

[Fang Jie - Formula Explanation] Stuffiness and hardness due to empty evil, yet using Rhubarb and Coptis—can this not raise doubts among later generations? However, the places where Zhongjing raises doubts are precisely where understanding lies. Probably because later generations failed to study carefully and did not grasp the method, actually boiling and taking it, greatly violating its intent. Observe that using boiling water to soak Rhubarb and Coptis, straining after a moment, extracts only the formless Qi/Flavor, not the solid taste. This takes advantage of their thin flavor and Qi, avoiding strong purgation. Although it attacks pi, the subtlety of this attacking method is inconceivable.

If the pulse is floating and tight, and purgation is mistakenly applied, the tight pulse moves inward, forming pi. Palpation reveals softness; it is merely Qi pi.

[Annotation] In Cold Damage, a floating-tight pulse, if not released by sweating but purged, changes from floating-tight to deep-tight; this is the diagnostic sign of cold evil sinking inward to form pi. "Soft upon palpation" means neither hard nor painful, merely uncomfortable Qi pi. This is a Ganycao Xiexin Tang (Licorice Heart-Purging Decoction) syndrome.

[Collected Annotations] Cheng Yingmao said: Mistaken purgation leading to pi is erroneous in both syndrome and pulse. Therefore, the rescue method must determine treatment based on both pulse and syndrome. The tight pulse moving inward changes floating-tight to deep-tight; the exterior evil sinks and does not disperse, merely stagnating in the epigastrium, thus forming pi.

Epigastric stuffiness, soft upon palpation, with a floating pulse at the Guan position, is primarily treated with Dahuang Huanglian Xiexin Tang.

[Commentary] There should be a "not" before "soft." If soft upon palpation, it is empty pi; supplementation would barely suffice, let alone using Rhubarb to purge!

[Annotation] This continues the previous clause to clarify. Soft upon palpation is merely Qi pi! If epigastric stuffiness is not soft upon palpation, it is hot pi suitable for attack. However, since the pulse at the Guan position is floating rather than deep-tight, the accumulated heat is shallow, and harsh purgation is not warranted. Thus, Dahuang Huanglian Xiexin Tang is used.

Epigastric stuffiness, accompanied by aversion to cold and sweating, is primarily treated with Fuzi Xiexin Tang (Aconite Heart-Purging Decoction).

[Annotation] Hard and painful epigastrium is Jie Xiong. Hard but painless epigastrium is Pi. Epigastric stuffiness with aversion to cold and sweating is not unresolved exterior, but deficiency of Exterior Yang. Therefore, Rhubarb, Coptis, and Scutellaria are used to purge the heat of pi, and Aconite is used to warm the Exterior Yang, treating both external cold and internal heat simultaneously. Its brilliance lies especially in soaking the three yellows (San Huang) in Ma Fei Tang, straining after a moment, and adding separately boiled Aconite juice. The intent is light on purging pi and heavy on supporting Yang.

[Collected Annotations] Fang Youzhi said: Pi is originally Yin evil lurking internally with deficient heat condensing upward. Accompanied by aversion to cold and sweating, it indicates exterior deficiency and Yang failing to protect. Xiexin Tang is indeed for clearing heat and pouring out pi; adding Aconite aims to stop sweating and consolidate Yang. With Scutellaria and Aconite together, the dual resolution of exterior and interior is fully manifested.

Li Zhongzi said: Using the bitter-cold of the Three Yellows to clear the middle and assist Yin, and the acrid-hot of Aconite to warm the channels and consolidate Yang. Cold and heat used mutually, attack and tonification applied together without contradiction—this is Zhongjing's divine妙用 (wonderful application).

Cheng Yingmao said: This clause should be read together with "Severe purgation in Cold Damage, followed by sweating, epigastric pi, aversion to cold, exterior unresolved...". In that clause, Guizhi Tang is used because sweating failed to produce sweat, and initial aversion to cold persists, indicating unharmonized exterior; in this clause, Aconite is added because sweating occurred, initial aversion to cold ceased, but aversion to cold and sweating returned, indicating deficiency of Exterior Yang. Carefully examine the similarities and differences.

Fuzi Xiexin Tang Formula
Rhubarb (2 liang) Coptis (1 liang) Scutellaria (1 liang) Aconite (processed, peeled, broken, separately boiled to extract juice, one piece)

The above four herbs: Cut the first three. Soak them in two sheng of Ma Fei Tang. After a moment, strain the dregs. Add the Aconite juice. Divide into two warm doses.

In Cold Damage or Wind Strike, if the physician mistakenly applies purgation, the patient suffers diarrhea dozens of times a day, undigested food, borborygmus in the abdomen, epigastric hardness and fullness, dry retching, irritability, and inability to rest. Seeing epigastric pi, the physician thinks the disease is not exhausted and purges again, making the pi worse. This is not heat knotting, but simply deficiency in the Stomach with rebellious Qi ascending, causing hardness. Ganycao Xiexin Tang is appropriate.

[Annotation] Regardless of Cold Damage or Wind Strike, if the exterior is unresolved, purgation is contraindicated. The physician mistakenly purged, resulting in either pi or diarrhea. Now, due to mistaken purgation, the patient has diarrhea dozens of times daily with undigested food and borborygmus; this is evil exploiting interior deficiency to cause diarrhea. Epigastric hardness/fullness, dry retching, irritability, and unrest indicate evil sinking into the chest deficiency and rebelling upward. In such pi and diarrhea involving both interior and exterior, the method should use Guizhi Jia Renshen Tang (Guizhi Decoction plus Ginseng) to resolve both. The physician, seeing only epigastric pi and thinking the disease remains, purged again, worsening the pi. This shows the pi is neither heat knotting nor cold knotting, but pi formed by evil rebelling upward and Yang sinking/Yin condensing due to middle deficiency caused by mistaken purgation. Thus, Ganycao Xiexin Tang is used to relieve urgency and harmonize the middle.

[Collected Annotations] Shen Liangchen said: Banxia Xiexin Tang and Ganycao Xiexin Tang are errors of damaging Qi after purgation. Shengjiang Xiexin Tang is due to diet; Dahuang Xiexin Tang is due to internal heat; Fuzi Xiexin Tang is due to external cold. Since syndromes differ, medicines vary.

Yu Chang said: Diarrhea with undigested food, borborygmus, vomiting, and irritability are all due to mistaken purgation leaving the Stomach empty. If one fails to understand this and assumes heat knotting to purge again, the pi will worsen. Thus, pointing out Stomach deficiency and rebellious guest Qi clarifies the etiology.

Cheng Yingmao said: Zhongjing clarified the difficulty of heat knotting, specifically highlighting Stomach emptiness and rebellious guest Qi to refute misconceptions. Therefore, acrid-warm herbs regulate Yang to restrain guest Qi from rebelling; bitter-cold herbs clear and肃 (purify) to remove guest heat, preventing obstruction. Thus, neither interferes with the other, Yin and Yang harmonize, and adversity turns to prosperity.

Wang Hu said: Diarrhea dozens of times a day means Stomach contents are exhausted, how could it not be deficient? Moreover, the physician purged again, worsening the pi, further proving it is not an excess syndrome. If it were excess, it would surely be described as hard and painful, not just hard and full. This single character "full" makes the distinction between excess and deficiency clear.

Wei Litong said: In the previous clause, due to aversion to cold and sweating, Yang follows sweat to the exterior, fearing Yang collapse externally, so Aconite is used to restore Yang; in this clause, the focus is Stomach deficiency, with weak Yang in the middle, so Licorice and Dried Ginger are used to benefit Yang; this is also an urgent matter of treating interior and exterior separately. Yet, consolidating Yang as the foundation for expelling evil shares the same intent.

Ganycao Xiexin Tang Formula
Licorice (roasted, 4 liang) Scutellaria (3 liang) Coptis (1 liang) Dried Ginger (3 liang) Pinellia (washed, 8 liang) Jujube (broken open, 12 pieces)

The above six herbs are boiled in ten sheng of water to obtain six sheng. Strain the dregs, and decoct again to obtain three sheng. Take one sheng warm, three times daily.

[Fang Jie - Formula Explanation] Named after Licorice, taking the meaning of gentleness and moderation. Licorice and Jujube's sweetness tonifies middle deficiency and relieves middle urgency; Pinellia's acridity descends rebellion and stops vomiting; Scutellaria and Coptis' coldness purges the heat of pi sinking from Yang; Dried Ginger's heat disperses the cold of pi condensing from Yin. Relieving the middle, descending rebellion, purging pi, removing irritability—cold and heat used together.

After Cold Damage sweating and exterior resolution, if there is Stomach disharmony, epigastric hardness/fullness, dry belching with food odor, water-Qi under the flanks, borborygmus, and diarrhea, Shengjiang Xiexin Tang (Fresh Ginger Heart-Purging Decoction) is appropriate.

[Annotation] After Cold Damage sweating and exterior resolution, if residual evil transfers to Yangming, causing epigastric pi, fullness, hardness, pain, and constipation, it usually indicates inherent Stomach dryness-heat becoming excess, suitable for purgation. Now, the patient inherently has Stomach deficiency, combined with water-Qi under the flanks. Even without mistaken purgation, residual heat would enter the interior exploiting deficiency, causing Stomach disharmony and failure to transform grain, leading to epigastric hardness/fullness and dry belching with food odor. Water-Qi failing to circulate causes borborygmus and diarrhea. Using Shengjiang Xiexin Tang focuses on dispersing water-Qi-related empty pi.

[Collected Annotations] Yu Chang said: The chapter discusses the roots of Jie Xiong and Pi, stating Stomach emptiness. Here it says Stomach disharmony, because it was not caused by mistaken purgation leading to emptiness. Hence, only "disharmony" is stated. Yet, disharmony is sufficient to form pi; the importance of Stomach Qi is indeed this great!

Cheng Zhi said: This establishes a treatment method for post-sweating, unmistaken purgation, with epigastric pi/hardness and gathered water-fluids. Although exterior evil resolves, Stomach Qi must be harmonious to ensure recovery. Post-sweating resolution, Stomach disharmony, food gathering/knotting, causes epigastric pi/hardness. Middle Jiao cannot digest grain, causing dry belching with food odor. Earth weakness fails to control Water, causing water-Qi under flanks to flow sideways. Borborygmus results from gathering/striking sounds, diarrhea with mixed clear/turbid. Thus, in Xiexin Tang, Fresh Ginger is the sovereign herb to disperse it; the method uses double decoction to achieve ripeness and harmonize the Stomach.

Cheng Yingmao said: Profuse sweating causing Yang collapse is known. However, Yang in the body has specific dominions. There is Defensive Yang governing Ying-Wei throughout the body; deficiency causes leaking sweat, aversion to cold, and body pain. There is Kidney Yang governing Lower Jiao true Yuan; deficiency causes fever, vertigo, palpitations, tremors, and desire to fall to the ground. There is Pericardium Yang governing Upper Jiao Heart Qi; deficiency causes hands covering the heart, deafness, and running piglet syndrome. There is Stomach Yang governing Middle Jiao grain transformation; deficiency causes abdominal fullness, Stomach disharmony, and epigastric pi. Although all arise post-sweating, those correcting errors must observe pulse and syndrome, identify the deviation, and treat accordingly, not conflating everything under "profuse sweating causes Yang collapse."

Shengjiang Xiexin Tang Formula
Licorice (roasted, 3 liang) Ginseng (3 liang) Dried Ginger (1 liang) Pinellia (washed, 0.5 sheng) Scutellaria (3 liang) Coptis (1 liang) Fresh Ginger (sliced, 4 liang) Jujube (broken open, 12 pieces)

The above eight herbs are boiled in ten sheng of water to obtain six sheng. Strain dregs and decoct again to obtain three sheng. Take one sheng warm, three times daily.

[Fang Jie - Formula Explanation] Named Shengjiang Xiexin Tang, the meaning focuses on dispersing water-Qi pi. Fresh Ginger and Pinellia disperse water-Qi under the flanks; Ginseng and Jujube tonify Middle Jiao Earth deficiency; Dried Ginger and Licorice warm interior cold; Scutellaria and Coptis purge pi heat. Covering treatments for deficiency, water, cold, and heat, how could Stomach disharmony, diarrhea, and pi not heal?

In Cold Damage on the fifth or sixth day, with vomiting and fever, Chaihu Tang syndrome is complete. If mistakenly purged with other drugs, and Chaihu syndrome remains, administer Chaihu Tang again. Although purged, this is not adverse; the patient will likely experience trembling chills, followed by fever and sweating, leading to resolution. If the epigastrium is full, hard, and painful, this is Jie Xiong, primarily treated with Da Xianxiong Tang (Major Gallbladder-Breaking Decoction). If merely full but not painful, this is Pi; Chaihu Tang is not applicable; Banxia Xiexin Tang (Pinellia Heart-Purging Decoction) is appropriate.

[Annotation] Jie Xiong combined with Yangming interior excess is Da Xianxiong Tang syndrome; combined with Yangming non-excess is Xiao Xianxiong Tang (Minor Gallbladder-Breaking Decoction) syndrome. Pi/hardness combined with Shaoyang interior excess is Da Chaihu Tang (Major Bupleurum Decoction) syndrome; combined with Shaoyang non-excess is Banxia Xiexin Tang syndrome. Now, Cold Damage on day five or six, with vomiting and fever, indicates evil transmitting to Shaoyang. Since Chaihu syndrome is complete, failing to harmonize with Chaihu but mistakenly purging is wrong. If Chaihu syndrome remains, although purged, it is not yet adverse; one should re-administer Chaihu Tang. The patient will likely experience trembling chills, then fever and sweating to resolve. This is because post-purgation middle deficiency and the state of resolution manifest thus. If post-purgation epigastrium is full, hard, and painful, this is Jie Xiong, and Da Xianxiong Tang is appropriate; if merely full but not painful, this is empty heat and rebellious Qi pi. Even with Shaoyang symptoms of vomiting and fever, Chaihu Tang is not applicable. The method should treat pi; Banxia Xiexin Tang is appropriate.

[Collected Annotations] Cheng Wuji said: If post-purgation Yang evil transmits to the interior, it knots in the chest as Jie Xiong, because the chest is the division where Yang receives Qi.