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Gancao (Zhi, two liang) Ganjiang (three liang, strong individuals may use four liang) Fuzi (Shengyong, peeled, broken into eight pieces, one large tuber)
The above three ingredients are boiled in three sheng of water to obtain one sheng and two he. The dregs are removed, and the liquid is divided into two doses and taken warm. If the pulse reappears, the patient will recover.
If the face is red, add nine stems of Congbai. If there is abdominal pain, remove Congbai and add Shaoyao (two liang). If there is vomiting, add Shengjiang (two liang). If there is a sore throat, remove Shaoyao and add Jiegeng (one liang). If diarrhea stops but the pulse does not emerge, remove Jiegeng and add Renshen (two liang). Only administer this formula when the symptoms correspond to the indications of the prescription.
[Formula Analysis] Among the formulas in the Treatise on Cold Damage that support Yang and suppress Yin: for middle-cold with weak Yang unable to reach the exterior, SiNi Tang (Cinnamon Twig, Aconite, and Licorice Decoction) is indicated; for cold inside and out with extremely deficient Yang, Fuzi Tang (Aconite Decoction) is indicated; for Yin excess below with Yang repelled above, Baitong Tang (White Scallion Decoction) is indicated; for Yin excess inside with Yang repelled outside, Tongmai Sini Tang (Pulse-Resuscitating Cinnamon Twig, Aconite, and Licorice Decoction) is indicated. Thus, it can be known that SiNi Tang circulates and operates Yang; Fuzi Tang warms and tonifies Yang; Baitong Tang unblocks Yang above and below; Tongmai Sini Tang unblocks Yang inside and outside. Now, with a pulse that is faint and about to vanish, interior cold with exterior heat, this indicates Yin excess in the Kidney repelling Yang to the exterior. Therefore, Tongmai Sini Tang is indicated. By doubling the dosage of Ganjiang and adding Gancao to assist Fuzi, and renaming it Tongmai Sini Tang, it is because this formula greatly strengthens the Primordial Yang, governs both interior and exterior, and collectively attracts the external heat back into the interior. At this time, the vital Qi has already departed, and death is imminent. If soft and slow Gancao were used as the sovereign herb, how could it swiftly call back the external Yang? Hence, Ganjiang is substituted. However, Gancao must be added in equal proportion to Ganjiang, lest the fierce nature of Ganjiang and Fuzi fail to nourish the Yuan Qi amidst the dispersion of the remaining vitality. This is what is meant by "a disciplined army." If the face is red, add Congbai to unblock the Yang repelled at the upper level. If there is abdominal pain, add Shaoyao to harmonize the Yin within. If there is vomiting and counterflow qi, add Shengjiang to stop vomiting. If there is a sore throat, add Jiegeng to benefit the throat. If diarrhea stops but the pulse does not emerge and Qi is deficient, double the dosage of Renshen to generate Yuan Qi and restore the pulse.
In Shaoyin disease, with vomiting and diarrhea, if the hands and feet are not cold and there is fever instead, death will not occur. If the pulse cannot be felt, moxa should be applied to the Shaoyin channel seven times (seven moxa cones).
[Annotation] In Shaoyin disease with vomiting and diarrhea, the hands and feet should naturally be cold. The fact that they are not cold and there is fever indicates that Yang has not declined, hence it is said that death will not occur. If the pulse cannot be felt, although there is external heat, it may be false heat. One must guard against Yang collapse. It is appropriate to urgently moxa the Shaoyin channel to rapidly unblock Yang, so that the pulse can be restored.
[Collected Annotations] Cheng Zhi said: The previous clause regarding Tongmai Sini Tang involves interior cold with exterior heat, cold hands and feet, and an absent pulse. This clause involving moxibustion involves interior cold with exterior heat, non-cold hands and feet, and an absent pulse. The Shaoyin artery is located at the medial malleolus of the foot.
Yu Chang said: In the previous clause regarding chills on the back, after moxibustion, Fuzi Tang was used because internal Yin-cold coagulation cannot be overcome by a single application of moxibustion. In this clause, the reverse heat in the hands and feet indicates only Yin inside and Yang outside, so only the primary channel needs to be moxaed to guide the Qi inward, without the need for further warming herbs.
Wang Hu said: The Classic states: The Yuan source of the Kidney emerges at Taixi (KI3). Moxa applied to the Shaoyin channel seven times should be applied to Taixi (KI3). This acupoint is located in the depression behind the medial malleolus where the posterior tibial artery beats.
In Shaoyin disease, with vomiting and diarrhea, cold hands and feet, and extreme restlessness bordering on death, Wuzhuyu Tang (Evodia Decoction) is indicated.
[Annotation] Although named Shaoyin disease, the indication of a Jueyin formula is because Shaoyin and Jueyin often present as combined diseases. The symptoms are similar but the pathogenesis differs, leading to different treatments. Shaoyin disease features vomiting and diarrhea; Jueyin disease also features vomiting and diarrhea. Shaoyin disease features Jue (cold extremities); Jueyin disease also features Jue. Shaoyin disease features Fan/Zao (restlessness/agitation); Jueyin disease also features Fan/Zao. This is a combined disease with identical symptoms. However, Shaoyin Jue varies in severity, while Jueyin Jue varies in cold and heat. Shaoyin Fan/Zao is mostly Zao (agitation/restlessness), whereas Jueyin Fan/Zao is mostly Fan (mental restlessness/irritability). Generally, Shaoyin disease involves Yin excess repelling Yang, so SiNi Tang (containing Ganjiang and Fuzi) is used to drive out Yin and restore Yang. Jueyin disease involves Yin excess stifling Yang, so Wuzhuyu's pungent and fierce nature is used to rapidly disperse and unblock Yang. This illustrates different pathogenesis requiring different treatments. Since there is vomiting without vomiting roundworms, and cold hands and feet, it is named Shaoyin disease. Generally, Jue limited to the elbows and knees, with much Fan and Zao bordering on death, belongs to the treatment scope of Jueyin disease. Therefore, SiNi Tang is not used, but Wuzhuyu Tang is used.
[Collected Annotations] Cheng Zhi said: Vomiting and diarrhea indicate Yin pathogen in the interior affecting the Spleen and Stomach upward. Cold extremities indicate Yang failing to warm the four limbs. Fan and Zao indicate extreme Yin excess causing exposed Yang to become disturbed and unsettled. The condition is nearly critical. Without the pungent warmth of Wuzhuyu, the counterflow of Yin Qi cannot be descended. Without the sweet warmth of Renshen, Ganjiang, and Dazao, the Middle Earth cannot be cultivated to control the Kidney pathogen. There is a distinction between Zao/Fan and Fan/Zao. Zao is Yin agitation; Fan is Yang restlessness. Zao/Fan means progressing from Zao to Fan, indicating Yin pathogen forcing outward. Fan/Zao means progressing from Fan to Zao, indicating Yang still struggling internally. Students should carefully examine these differences in severity and depth.
Cheng Yingmao said: The warming method is originally designed for Yin-cold. True cold patterns often mimic false heat. All cases of Yin excess repelling Yang, or Yin patterns resembling Yang, are deceptive aspects of Shaoyin disease. One must discern the truth from the falsehood to avoid being constrained. For example, vomiting and diarrhea with cold extremities indicate Stomach Yang decline and Kidney Yin merging. Everyone knows this is cold, yet seeing Fan/Zao bordering on death deceives people. This occurs because Yang is rejected by Yin and has nowhere to reside. Wuzhuyu Tang utilizes the power of Wood to augment Fire, warming the Earth and dispelling Water-cold.
Wuzhuyu Tang Formula
Wuzhuyu (one sheng) Renshen (three liang) Shengjiang (one liang) Dazao (twelve fruits)
The above four ingredients are boiled in seven sheng of water to obtain two sheng. Take seven he warm, three times daily.
[Collected Exegesis] Luo Tianyi said: Zhang Zhongjing's methodology emphasizes securing Primordial Yang in Shaoyin disease and securing Vital Qi in Jueyin disease. Although Jueyin Liver Wood represents the convergence of two Yins, the true Qi of one Yang actually arises within it. If this Vital Qi becomes deficient, the turbid Qi of the Three Yin channels directly attacks the Middle and Upper Jiao. Not only do all symptoms of the primary channel manifest, but the healthy transport function of Yangming fails, causing the True Yang of Shaoyin to float and expose itself. Consequently, vomiting, diarrhea, cold extremities, extreme restlessness, and nausea upon eating arise. Wuzhuyu possesses the Qi of the Eastern Zhen trigram; it is pungent, bitter, and very hot. It can reach Wood stagnation, enter Jueyin directly, and descend its Yin-excess turbid Qi, serving as the Sovereign herb. Renshen embodies balanced and righteous Qi; it is sweet, warm, and strongly tonifying. It can connect with Heavenly Truth, salvage life, and elevate declining Vital Qi, serving as the Minister herb. Ginger and Jujube assist the Stomach and circulate to the four extremities as Assistants. Thus, Zhen and Kun harmonize, Wood and Earth do not harm each other, the subtle function of one Yang is achieved, and the Three Yin channels are filled with generative Qi. How could any symptoms remain unresolved?
Fang Youzhi said: Vomiting injures Yang; diarrhea damages Yin. Cold extremities indicate Yin damage and counterflow. Restlessness indicates Yang injury and chaos. Evodia is pungent and warm, dispersing cold, warming the Stomach, and stopping vomiting. Ginseng is sweet and warm, benefiting Yang, securing the root, and tonifying the Middle. Jujube assists the Stomach and benefits the Spleen. Fresh Ginger is the sacred medicine for vomiting. Therefore, these four substances are necessary for warming the Middle and descending counterflow.
In Shaoyin disease, with vomiting, diarrhea, agitation, irritability, and cold extremities, death ensues.
[Annotation] This continues the previous clause to clarify the meaning, distinguishing between treatable and untreatable conditions. This clause presents vomiting, diarrhea, irritability, and cold extremities, identical to the previous clause. One is treated with Wuzhuyu Tang, while the other is declared a fatal, untreatable condition. Why? Generally, Shaoyin irritability is mostly agitation (Zao), which belongs to Yin. Jueyin irritability is mostly mental restlessness (Fan), which belongs to Yang. In Jueyin, cold extremities do not exceed the elbows and knees, and slight Yang remains unextinguished, so it is treatable. In Shaoyin, cold extremities cannot return to warmth, and solitary Yin cannot transform, so it is declared fatal.
[Collected Annotations] Cheng Yingmao said: Agitation and irritability arising from vomiting and diarrhea indicate separation and depletion of Yin and Yang with disturbance. Coupled with cold extremities, Yang is extinguished. Is there anything but death to await? Had warming the Middle been practiced early, would such a situation have occurred?
Zhang Lu said: This clause is no different from the previous one. Why is the former treatable and the latter not? It must be that warming the Middle was attempted without success, followed by worsening agitation and irritability, hence prognosis is fatal.
In Shaoyin disease, with aversion to cold, curled-up body posture, and diarrhea, if the hands and feet are cold, it is untreatable.
[Annotation] This elaborates on the reason why cold extremities in the previous clause are untreatable. Aversion to cold and a curled-up posture, though Shaoyin symptoms, do not necessarily lead to death. However, if diarrhea persists and cold extremities do not return, it indicates Yin without Yang. Even without vomiting, diarrhea, agitation, or irritability, it is untreatable.
[Collected Annotations] Yu Chang said: With Yin excess and absence of Yang, even using methods like SiNi Tang to restore Yang from nothingness often fails to succeed, hence it is called untreatable.
In Shaoyin disease, with cold extremities, aversion to cold, curled-up body posture, absent pulse, no mental restlessness but only agitation, death ensues.
[Annotation] This summarizes the previous three clauses to explain fatal, untreatable signs. "Si Ni" refers to cold extremities extending beyond the elbows and knees without returning. Exterior Yang deficiency causes aversion to cold. Yin governs flexion, hence the curled posture. An absent pulse indicates the extinction of Vital Qi. If there were restlessness without agitation, there might still be recoverable Yang. Now, with no restlessness but only agitation, it indicates Yin without Yang, hence death.
[Collected Annotations] Cheng Yingmao said: All Yin pathogens are present, and the pulse is absent; Yang has perished first. No restlessness but only agitation means solitary Yin has no attachment and will perish. The Classic states: Yin Qi, when quiet, stores the Spirit; when agitated, it dissipates. Agitation implies the Spirit of the Yin organs escapes externally. Escape means death. Had pulse restoration and Yang unblocking been practiced early, would such a situation have occurred?
In Shaoyin disease, with diarrhea, faint and choppy pulse, vomiting, and sweating, frequent trips to the toilet with scant output are expected. The upper region should be warmed with moxibustion.
[Annotation] A faint pulse indicates Yang deficiency. A choppy pulse indicates blood deficiency. Frequent trips to the toilet indicate persistent diarrhea. Scant output indicates tenesmus. This corresponds to current Yang deficiency and blood deficiency with tenesmus and diarrhea. Vomiting and sweating indicate Yin excess internally causing counterflow vomiting. Yang deficiency fails to secure the exterior, causing sweating. The upper region should be warmed with moxibustion.
[Collected Annotations] Cheng Yingmao said: In Shaoyin disease with diarrhea, Yang deficiency is evident. With a faint and choppy pulse, not only is Yang weak, but Yin is also exhausted. Weak Yang allows Yin pathogen to counterflow upward causing vomiting. Exhausted Yin causes sweating and straining. Within the method of straining, one wishes to assist Yang and protect Yin simultaneously. Thus, SiNi Tang and Fuzi are difficult to use. Only moxaing Baihui (GV20) at the vertex to warm it can substitute for the Yang-assisting action of Ginger and Aconite while avoiding their pungent dispersion and lower drying effects. Thus, diarrhea can stop without injuring Yin blood. This shows that in Shaoyin disease, one should not abandon warming just because it is difficult to apply.
Wang Hu said: According to this clause, Zhang Zhongjing did not specify which acupoint to moxa. *Mai Jing* says: Moxa Jueyin Shu. Chang Qizhi says: Moxa Taichong (LR3). Both are errors. Guo Yong says: Moxa Taixi (KI3). Although it is a Shaoyin acupoint, it is also an error. Zhang Zhongjing says: Warm the upper region. Fang Youzhi says: "Upper" refers to the vertex, Baihui (GV20). *Tu Jing* states: Also known as San Yang Wu Hui, located one inch five fen posterior to Qian Ding (GV21) at the center of the vertex. Originally indicated for pediatric rectal prolapse that does not heal, seven moxa cones can be applied. Moxaing this point in this clause lifts Yang to regulate Yin.
In Shaoyin disease, if diarrhea stops but there is dizziness and frequent sensations of blackout, death ensues.
[Annotation] In Shaoyin disease, if diarrhea stops and the Stomach Qi harmonizes allowing food intake, with clear spirit and refreshing mind, recovery is anticipated. Now, if diarrhea stops but there is dizziness and frequent blackouts/unconsciousness, it indicates Qi depletion and Spirit departure. Thus, despite the cessation of diarrhea, death is predicted.
[Collected Annotations] Fang Youzhi said: Dizziness is commonly called vertigo or faintness. All Yang gathers in the head. If diarrhea stops but dizziness occurs, Yang has no foundation and floats outward, causing Spirit and Qi to scatter. Frequent blackouts ensue, and death is certain.
Zhang Xiju said: The fatal sign in this clause is entirely seen in the dizziness and blackouts. If diarrhea stops without dizziness or blackouts, the interior is harmonized, how could it be fatal?
Zhang Lu said: Yin and Yang in the human body rely on each other. If Yin perishes below, the Yang gathering in the head moves chaotically, causing dizziness and frequent blackouts. Yang escaping from above leads to death. It can be seen that if Yang returns and diarrhea stops, life is preserved; if Yin exhausts and diarrhea stops, death occurs.
Wang Hu said: Diarrhea stopping usually indicates recovery. Now it is a sign of death. This is not Yang returning and diarrhea stopping, but Yang escaping and fluids exhausting.
In Shaoyin disease, after six or seven days, if breathing is high (shallow and rapid), death ensues.
[Annotation] In Shaoyin disease, lethargy with calm and regular breathing is favorable. Now, high and rapid breathing is unfavorable. Generally, patients lying down with high and rapid breathing often die.
[Collected Annotations] Yu Chang said: The phrase "six or seven days" reflects meticulous differentiation. Transmission to Shaoyin with high breathing is distinctly different from the exterior syndrome of panting appearing on the second or third day of Taiyang disease.
Cheng Zhi said: The Kidney is the source of Vital Qi. High breathing indicates True Qi scattering in the chest, unable to return to the Sea of Qi. Hence, death ensues.
Cheng Yingmao said: The Lungs govern Qi, and the Kidney is the source of Vital Qi, acting as the gate of respiration, crucially relating to life and death. High breathing indicates that Vital Qi has perished below and is no longer grasped. Thus, respiration is merely exhalation above without inhalation. Although death manifests after six or seven days, the mechanism appears before. Given Shaoyin disease, why was protection not prepared in advance to prevent the dispersion of True Yang making it irretrievable? The repeated warnings against sweating and urgent emphasis on warming in various clauses aim precisely at this!
Wei Litong said: After seven days, high and rebellious breathing is the same as frequent blackouts: both represent upper depletion. One involves dizziness/blackout with Yang rising and not returning; the other involves high breathing with the root of Qi destroyed. They share the same principle but present differently. Hence, Zhang Zhongjing predicts death for both.
In Shaoyin disease, with a fine, deep, and rapid pulse, the disease is in the interior. Sweating should not be induced.
[Annotation] In Shaoyin disease, lethargy with a fine, deep, and faint pulse indicates pathogen transforming along the Cold pathway. Now, a fine, deep, and rapid pulse indicates pathogen transforming along the Heat pathway. Even if there is fever, it is likely transitioning to Yangming. It cannot be compared to the initial Shaoyin disease with reverse fever, deep but not rapid pulse, where Mahuang Fuzi Xixin Tang is indicated to induce sweating. Hence, it is said: The disease is in the interior; sweating should not be induced.
[Collected Annotations] Cheng Zhi said: This indicates a prohibition against sweating when Heat pathogen is in the interior. The normal Shaoyin pulse is faint and fine. A deep and rapid addition is precisely a sign of Heat pathogen in the interior. Inducing sweating disturbs the channels and increases dryness-heat, risking blood loss.
Zheng Zhongguang said: A fine, deep, and rapid pulse indicates hidden Yang in the interior; hence, the disease is in the interior. This is a Heat pathogen transmitting to the interior. Sweating must absolutely be avoided. Inducing sweating disturbs Channel Qi and risks blood loss. In Shaoyin fever with a deep pulse, the disease is in the exterior; since there are no interior signs, sweating can be induced. If the pulse is floating and slow, with exterior heat and interior cold, and diarrhea with undigested food, slowness indicates absence of Yang and disease in the interior. One must not mistake floating for exterior and induce sweating. One must know that within Yin there is Yang, so deep pulses can sometimes be sweated; within Yang there is Yin, so floating pulses may require warming. In this clause, the pulse is fine, deep, and rapid. Rapid indicates Heat; deep indicates Interior. This is Yang pathogen entering the interior, hence the warning against sweating.
In Shaoyin disease, with cold extremities but no sweat, forcibly inducing sweating will inevitably disturb Blood. It is unknown from which orifice it will exit; whether from the mouth and nose or the eyes, this is called Lower Jue and Upper Exhaustion, and is difficult to treat.
[Annotation] This clause clarifies that forcibly inducing sweating in Shaoyin Heat pathogen leads to blood disturbance. Shaoyin disease with a fine, deep, and rapid pulse plus cold extremities is also Heat Jue. Yin normally does not sweat. Even without sweat, sweating should not be induced. Forcibly inducing sweating constitutes forcing sweat in Shaoyin Heat pathogen. When sweating is inappropriate but forced, it exacerbates Shaoyin Heat. Boiling fiercely, it inevitably disturbs the Blood of the primary channel. Whether exiting from the mouth/nose or eyes, this is called Lower Jue and Upper Exhaustion. Lower Jue refers to Shaoyin Heat Jue below; Upper Exhaustion refers to Shaoyin Blood exhaustion above. Hence, it is difficult to treat.
[Collected Annotations] Zhang Lu said: Forcing Shaoyin sweat and disturbing Blood inevitably causes counterflow upward, exiting through Yang orifices, because sweating agents are Yang herbs.
Cheng Yingmao said: The Five Fluids are governed by the Kidney. Forcibly inducing Shaoyin sweat reverses Qi throughout the body. Blood follows the rushing Qi and appears, hence the unknown exit route.
Shen Mingzong said: In Shaoyin disease with cold extremities and no sweat, the disease is in the interior. SiNi San (Four Counterflow Powder) should be used to harmonize Yin and disperse pathogen. The disease will recede, and Jue will heal naturally. How can sweating be forced?
Wei Litong said: Jue with sweat is a sign of internal cold forcing Yang outward, indicating Cold transformation. Yin pathogen without sweat and with Jue indicates Heat pathogen hiding in the interior without venting outward, consuming Heat internally. This is undoubtedly Heat transformation and Yang pathogen.
In Shaoyin disease, with cough and diarrhea, if delirium occurs, it is due to coercion by Fire Qi. Urination will certainly be difficult, caused by forcibly demanding sweat from Shaoyin.
[Annotation] Shaoyin belongs to the Kidney and governs Water. When Shaoyin is invaded by pathogen, it cannot govern Water. Attacking upward causes cough; attacking downward causes diarrhea. Pathogen transforming along Cold indicates Zhenwu Tang syndrome; pathogen transforming along Heat indicates Zhu Ling Tang syndrome. Now, coerced by Fire Qi to sweat, it transforms along Heat and transfers to the Stomach, causing delirium. Internal exhaustion of Body Fluids causes difficult urination. All these result from forcibly demanding sweat from Shaoyin. To rescue Yin, either Baihu Tang (White Tiger Decoction) or Zhu Ling Tang (Polyporus Decoction) should be selected and used.
[Collected Annotations] Fang Youzhi said: "Qiang Ze" means excessive seeking. Urine and sweat are both Blood. Shaoyin has little Blood. Coercing sweat and seizing Blood causes urine to dry up, hence difficulty.
In Shaoyin disease, after six or seven days of diarrhea, if there is cough, vomiting, thirst, mental restlessness, and inability to sleep, Zhu Ling Tang (Polyporus Decoction) is indicated.
[Annotation] Generally, in Shaoyin diarrhea with undigested food, cough, vomiting, and no thirst, it belongs to Cold-Fluid retention. Now, in Shaoyin disease after six or seven days, sticky and foul diarrhea, cough, vomiting, thirst, irritability, and insomnia indicate Shaoyin Heat-Fluid pathology. Fluid and Heat contend: attacking upward causes cough; attacking middle causes vomiting; attacking downward causes diarrhea. Heat consumes Body Fluids, causing thirst. Heat disturbs the Heart, causing irritability and insomnia. Zhu Ling Tang should be used to promote urination and moisten dryness. Heat-Fluid syndromes can all be cured.
[Collected Annotations] Zhao Sizhen said: Shaoyin cough with diarrhea, vomiting, thirst, irritability, and insomnia, as well as Jueyin diarrhea with desire to drink water, are all transmitted Heat pathogens. The pulse must be deep, fine, and rapid. Hence, Huanglian and Shihui are used to clear and drain. In contrast, Shaoyin spontaneous diarrhea with thirst, desire to vomit but unable to, mental irritability, lethargy, and white urine belong to Cold Yin pathogen of the primary channel. The pulse must be deep and faint. Hence, Fuzi and Ganjiang are used to warm.
Wang Hu said: Diarrhea, cough, vomiting, thirst, irritability, and insomnia—how do we know this is not Shaoyang or Yangming disease? However, if Shaoyang or Yangming presented with these signs, it would be Interior Excess, and the pulse would be wiry, large, and long. Here, the pulse is faint and fine, confirming undoubtedly Shaoyin disease.
Lin Lan said: Diarrhea means pathogen converges below. Why vomiting and cough? By the sixth or seventh day, thirst, irritability, and insomnia indicate transmitted pathogen attacking upward is vigorous. Thirst leads to excessive drinking; excessive drinking leads to water retention. Thus, Heat pathogen cannot resolve, and water accumulation syndrome recurs. Diarrhea from Heat pathogen sinking is incomparable to simultaneous Yin-Cold vomiting and diarrhea. Vomiting and