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[Background Information]
Book: Zhengzhi Zhunsheng · Shanghan (Standardized Treatment of Cold Damage)
Author: Wang Kentang
Dynasty: Ming
Chapter: Heart Pain, Epigastric Pain / Agitation (Fan)
Category: Shanghan (Cold Damage)

[English Translation]

After five or six days of a Shanghan (Cold Damage) disease, following severe purgation, if body heat persists and there is a sensation of painful constriction in the chest/epigastrium, the pathogen has not yet resolved. Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should be administered as the primary treatment. (Cheng Wuji's commentary: When Shanghan reaches the fifth or sixth day, the pathogen is in the interior. If after severe purgation the body heat subsides and the chest/epigastrium feels empty and comfortable, the disease is about to resolve. However, if after severe purgation the body heat subsides but pain and constriction remain in the chest/epigastrium, this is Jie Xiong (Chest Binding). If body heat persists with painful constriction in the chest/epigastrium, this is Xu Fan (Deficiency Heat Agitation). Jie Xiong involves heat binding in the chest, constituting an excess syndrome; thus, external heat subsides as heat converges internally. Xu Fan involves heat lodging in the chest without forming excess, scattering to cause agitation; thus, body heat persists. The fifth to seventh day is typically when resolution occurs, but because the heat manifests as Xu Fan, it is stated as "not yet resolving." Zhi Zi Chi Tang is given to induce vomiting and expel the pathogen. The phrase "body heat persists" requires careful consideration. In Jie Xiong where body heat is absent, knowing the heat is not in the exterior, Da Xianxiong Tang (Great Inward-Draining Decoction) or Xiao Xianxiong Tang (Small Inward-Draining Decoction) can be used to purge downward. Since heat remains in the exterior here, inducing vomiting to disperse it is appropriate. Cheng Wuji's annotation is not thorough enough.)

In Yangming Disease (Yangming Channel Disease) complicated by Wind Strike, with a wiry, floating, and large pulse, shortness of breath, abdominal fullness, pain under the ribs and in the heart region, dry nose, absence of sweating, lethargy, jaundice, difficult urination, tidal fever (Chao Re), and occasional hiccups, Xiao Chaihu Tang (Minor Bupleurum Decoction) should be used. (See chapter on Stomach Excess Syndrome.)

In Shaoyin Disease (Shaoyin Channel Disease), spontaneous diarrhea of clear water with pure green color, accompanied by inevitable pain in the epigastrium and dry mouth/throat, requires urgent purgation. Da Chengqi Tang (Major Order the Qi Decoction) is indicated. (Cheng Wuji's commentary: Shaoyin corresponds to Kidney Water, and green corresponds to Liver Color. Green diarrhea indicates Liver pathogen attacking Kidney. The *Nanjing* states: "Coming from the preceding organ constitutes an Excess Pathogen." Because the Kidney harbors excess pathogen, epigastric pain and dry mouth/throat occur. Da Chengqi Tang is given to purge the excess pathogen.)

Jueyin Disease (Jueyin Channel Disease) presents with Xiao Ke (Wasting-Thirst), qi rushing up to the heart, painful heat in the heart, hunger without desire to eat, and vomiting roundworms upon eating. If purged, diarrhea will persist uncontrollably. (Note: The text lists Guizhi Fuling Baizhu Tang here, which may be an error or specific context).

Appendix: Moxibustion. For Shanghan caused by excessive water intake leading to abdominal distension, wheezing, and unbearable epigastric pain, moxibustion should be applied to Zhongwan (CV12) and Qihai (CV6). If qi rushes upward from the lower abdomen, apply moxibustion to Tianshu (ST25), Qichong (ST30), Zusanli (ST36), and Sanyinjiao (SP6). (If these symptoms are absent, only use the first two acupoints.)

(Old texts included "painful agitation" here. Upon detailed analysis, "painful agitation" refers to body and limb pain with mental distress, distinct from mental agitation, so it has been removed.)

Agitation (Fan) is essentially heat. "Fan" denotes restlessness and disturbance. It resembles fever but differs: Fan-heat is agitation caused by heat without cessation, unlike fever which comes and goes. Classics mention various forms such as Fan, Wei Fan (Mild Agitation), Fan Re (Agitating Heat), Fu Fan (Recurring Agitation), Fan Man (Agitating Fullness), Fan Tong (Agitating Pain), Fan Ke (Agitating Thirst), Xiong Zhong Fan (Chest Agitation), Xin Zhong Fan (Heart Agitation), Nei Fan (Internal Agitation), Xu Fan (Deficiency Agitation), and Da Fan Yu Jie (Severe Agitation before Resolution), all attributing Fan to heat. However, agitation due to Yin-Cold is also common.
If agitation is in the Exterior, symptoms include floating pulse, aversion to wind/cold, and stiff body pain.
If in the Interior, symptoms include tidal fever, delirium, constipation, abdominal fullness, and dark/scanty urine.
If at Half-Exterior/Half-Interior, symptoms include alternating chills and fever, and hypochondriac pain.
If pathogen is above the chest/diaphragm, symptoms include chest fullness and Ao Nao (Oppressive Discomfort), treatable by vomiting.
If due to Yin-Cold, symptoms include aversion to cold, curling up, diarrhea, cold reversal, faint pulse, or vomiting roundworms.
When Severe Agitation precedes resolution, the pulse must be harmonious; if the pulse does not match, it is difficult to treat. If feet are cold with a deep, fine, and faint pulse, this is Yin-pattern agitation, requiring urgent warming with Ren Shen Fu Zi (Ginseng and Aconite) hot decoctions.
If due to internal injury from overwork, Yin deficiency with fire hyperactivity, presenting with fatigue, spontaneous sweating, and floating/deficient radial pulse, Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) added with fried Huang Lian (Coptis), Sheng Di Huang (Rehmannia), Mai Men Dong (Ophiopogon), Huang Bo (Phellodendron), and Zhi Mu (Anemarrhena) is suitable.
For insomnia with mental agitation, Zhu Sha An Shen Wan (Cinnabar Calm-the-Spirit Pill) can be taken adjunctively to anchor floating fire and calm the spirit. This is a general overview. Practitioners should cross-reference various syndromes.

Xu Fan (Deficiency Agitation), Xiong Zhong Fan (Chest Agitation), and Xin Zhong Fan (Heart Agitation) that arise without prior sweating, vomiting, or purging indicate transmitted pathogenic factors, not diaphragmatic excess. They are treated with harmonizing methods, e.g., Xiao Chaihu Tang, Huang Lian E Jiao Tang (Coptis and Donkey-Hide Gelatin Decoction), or Zhu Fu Tang (Pig Skin Decoction).
If agitation arises after sweating, vomiting, or purging, it indicates pathogenic heat sinking inward to become Xu Fan, characterized by Ao Nao and helpless urge to vomit. These are treated by inducing vomiting, e.g., Zhi Zi Chi Tang, Zhi Zi Gan Jiang Tang (Gardenia and Dried Ginger Decoction), or Zhi Zi Hou Po Tang (Gardenia and Magnolia Bark Decoction).
Generally, if pathogen binds in the chest without prior sweating/vomiting/purging, it becomes Diaphragmatic Excess, treated with Gua Di San (Melon Seed Powder). Yangming mental agitation is treated with Tiao Wei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction); these are Excess patterns of agitation.
In Shanghan, palpitations with agitation after 2-3 days indicate Deficiency, treated with Xiao Jian Zhong Tang (Minor Construct the Middle Decoction). Shaoyang pathogen entering the Fu organs causing agitation with palpitations indicates Heat. Generally, agitation followed by palpitations is Heat; palpitations followed by agitation is Deficiency. Treating disease requires addressing the root.

In Taiyang Disease (Taiyang Channel Disease) Shanghan, if after sweating resolves, agitation returns after half a day with a floating, rapid pulse, another sweating method is appropriate using Guizhi Tang (Cinnamon Twig Decoction). (Sweating leads to coolness/resolution; return of heat after half a day indicates incomplete pathogen expulsion, necessitating further sweating.)

In Taiyang Disease, if initial administration of Guizhi Tang causes increased agitation without resolution, needle Fengchi (GB20) and Fengfu (GV16) first, then administer Guizhi Tang for cure. (Fengchi is the intersection of Shaoyang and Yang Linking Vessel. Needling Fengchi instead of Tianzhu is because Yang Linking Vessel links all Yang vessels, and Greater Yang governs Yang qi.)
After sweating, if pulse is floating/rapid with agitation and thirst, use Wu Ling San (Five-Ingredient Powder with Poria).
For Wind Strike fever unresolved after 6-7 days with agitation, exterior/interior signs, thirst for water, and vomiting upon drinking (Water Reversal), use Wu Ling San.
If Yang-pattern disease is incorrectly treated with cold water washing instead of sweating, heat cannot escape, worsening agitation, causing gooseflesh, desire to drink but no actual thirst. Use Wen Ge San (Clam Shell Powder); if ineffective, use Wu Ling San. (Formula see Thirst chapter).
After vomiting/purging in Shanghan, if 7-8 days pass with unresolved heat binding in interior, exterior/interior heat, occasional aversion to wind, severe thirst, dry tongue, and agitation, use Bai Hu Jia Ren Shen Tang (White Tiger Decoction plus Ginseng).
After heavy sweating from Guizhi Tang, if severe agitation/thirst persists with a flooding pulse, Bai Hu Jia Ren Shen Tang is indicated.

Yuan treated Yin-deficiency fever with agitation, thirst, hunger-heat, and night exacerbation. Pulse is flooding but empty on pressure, indicating Blood deficiency causing restlessness. Treat with Dang Gui Bu Xue Tang (Angelica Sinensis Decoction to Tonify Blood). Using Bai Hu Tang would be an error. If pulse is floating/large lightly but empty deeply (Scattered Pulse), it indicates extreme deficiency and impending Yuan Qi collapse. Do not use exterior-releasing or heat-clearing methods; use large doses of Ren Shen Sheng Mai Tang (Ginseng Generate the Pulse Decoction) to save life. (Dang Gui Bu Xue Tang formula see Miscellaneous Diseases Fever chapter).

In Taiyang Disease, after sweating or purging, if heat-agitation and chest oppression occur, use Zhi Zi Chi Tang.
After severe purging in Shanghan (5-6 days), if body heat persists with painful chest constriction, disease is unresolved; use Zhi Zi Chi Tang.
After sweating/vomiting/purging, if patient has mental agitation and insomnia, or severe restlessness with Ao Nao, use Zhi Zi Chi Tang.
If short of qi, use Zhi Zi Gan Cao Chi Tang (Gardenia, Licorice and Fermented Soybean Decoction).
If vomiting, use Zhi Zi Sheng Jiang Chi Tang (Gardenia, Ginger and Fermented Soybean Decoction).

Zhi Zi Chi Tang Formula: Zhi Zi (14 pods, broken), Xiang Chi (4 he, wrapped in silk). Boil Zhi Zi in 4 sheng water to 2.5 sheng, add Chi, boil to 1.5 sheng, strain. Divide into two warm doses. Stop subsequent dose if vomiting occurs.

The Classics state: High pathogen, induce vomiting; Low pathogen, drain thoroughly; Middle fullness, purge internally; Pathogen in form, soak to sweat; Pathogen in skin, release via sweating. Shanghan treatment varies but adheres to these principles. Pathogen moving from exterior to interior, lodging in chest (high area), can be vomited.
If pathogen condenses in diaphragm without prior sweating/vomiting/purging, it is Excess; use Gua Di San to purge chest excess.
If pathogen lodges in chest due to deficiency after sweating/vomiting/purging, it is Xu Fan; use Zhi Zi Chi Tang to purge chest Xu Fan.
Zhi Zi is bitter and cold. *Neijing* states: "Sour and bitter induce vomiting and drainage (Yin)." Vomiting Xu Fan requires bitter taste; thus Zhi Zi is Sovereign. Fan is due to heat excess; bitter clears heat, cold cools. Xiang Chi is bitter/cold, assisting Zhi Zi, thus Minister. *Neijing*: Qi has high/low, disease has far/near, syndrome has exterior/interior, treatment has light/heavy. Apply appropriately.

Zhi Zi Gan Cao Chi Tang: Add 1 liang Gan Cao to Zhi Zi Chi Tang. Follow previous method. Stop if vomiting.

Zhi Zi Sheng Jiang Chi Tang: Add 2 liang Sheng Jiang to Zhi Zi Chi Tang. Follow previous method. Stop if vomiting.

After purging in Shanghan, if agitation, abdominal fullness, and restlessness (lying down/sitting up) occur, use Zhi Zi Hou Po Tang. (Cheng Wuji: Post-purgation abdominal fullness without agitation is Interior Excess. Agitation without fullness is Chest Xu Fan. Both indicate pathogen stagnating between heart and abdomen. Fullness prevents sitting, agitation prevents lying. Zhi Zi Hou Po Tang purges agitation and relieves fullness.)

Zhi Zi Hou Po Tang Formula: Zhi Zi (14 pods, broken), Hou Po (4 liang, ginger-fried), Zhi Shi (4 pieces, soaked, de-rinded, fried). Boil in 3.5 sheng water to 1.5 sheng, strain. Divide into two warm doses. Stop if vomiting.

If doctor uses pill-based strong purgatives in Shanghan, resulting in persistent mild heat and slight agitation, use Zhi Zi Gan Jiang Tang. (Cheng Wuji: Pills do not clear heat but damage righteous qi. Pathogen lodges in chest without deep invasion, causing mild heat and slight agitation. Zhi Zi Gan Jiang Tang purges agitation. Pills referred to as Shen Dan Gan Sui or sometimes Ba Dou/Ephedrae Herba contextually misattributed here as purgative pills).

Zhi Zi Gan Jiang Tang Formula: Zhi Zi (14 pods, broken), Gan Jiang (2 liang). Boil in 3.5 sheng water to 1.5 sheng, strain. Divide into two warm doses. Stop if vomiting.
Contraindication: Do not use Zhi Zi Tang in patients with chronic loose stools (Interior Deficiency-Cold). Even if agitated, it is not heat accumulation. *Neijing*: If diarrhea precedes other diseases, treat the root (diarrhea) first.

In Taiyang Disease, if vomiting/purging/sweating leads to mild agitation, frequent urination, and consequent hard stool, give Xiao Chengqi Tang (Minor Order the Qi Decoction) to harmonize.
Post-sweating/vomiting/purging, if Ao Nao and agitation occur:
- No dry stool, soft stool: Zhi Zi category formulas.
- Dry stool, constipation: Xiao Chengqi Tang.

Pi (Stagnation), Jie Xiong, Xin Fan (See Chapter 2); Xin Fan with Thirst (See Thirst chapter).

In Shanghan, if 2-3 days bring palpitations and agitation, use Xiao Jian Zhong Tang. (Cheng Wuji: Pathogen is still in exterior. Palpitations indicate Qi deficiency; agitation indicates Blood deficiency. Internal deficiency of Qi/Blood requires Xiao Jian Zhong Tang to build the Interior first.)
In Taiyang Disease, if pulse is floating/tight, no sweat, fever, body pain for 8-9 days, exterior signs persist, sweating is indicated. After medication, if symptoms slightly improve but agitation and eye closure occur, severe cases will resolve via nasal hemorrhage (Ni Xue). Resolution requires agitation followed by sweating.
If Taiyang disease exceeds meridian cycle (>10 days), with epigastric hardness, urge to vomit, chest pain, loose stool, slight fullness, and slight depression/agitation (See Chest Disease).
Shanghan with floating pulse, spontaneous sweat, frequent urination, agitation, slight aversion to cold, and leg cramps. Incorrectly giving Guizhi Tang to attack exterior causes error: leading to cold limbs, dry throat, irritability, vomiting. Treat with Gan Cao Gan Jiang Tang (Licorice and Dried Ginger Decoction) (See Cold Reversal).
If Taiyang disease is treated with vomiting, aversion to cold should cease but clothing rejection occurs due to internal agitation from vomiting. With slight rapid pulse, avoid moxibustion; fire pathogen causes agitation/reversal, chasing deficiency, pursuing excess, scattering blood, damaging bones/tendons.
After vomiting/diarrhea/sweating, if pulse is平和 (peaceful) with mild agitation, it is due to Stomach deficiency unable to process grain qi.

In Yangming Disease, after purging, if exterior heat exists, hands/feet are warm, no Jie Xiong, Ao Nao in chest, hunger but inability to eat, and only head sweats, use Zhi Zi Chi Tang.
If Yangming pulse is floating/tight and purged, stomach becomes empty, guest qi moves diaphragm, Ao Nao in chest, white tongue coating, use Zhi Zi Chi Tang. (See Spontaneous Sweat chapter).
After diarrhea, if agitation occurs and epigastrium is soft on pressure, it is Xu Fan; use Zhi Zi Chi Tang.
Yangming pulse slow, difficulty eating to fullness, slight agitation/head dizziness upon fullness, difficult urination, indicates impending Gu Dan (Grain Jaundice) (See Dizziness).
Yangming post-purging, Ao Nao/agitation, dry stool in stomach allows purging; slight fullness with hard start/loose end prohibits purging. If dry stool exists, use Da Chengqi Tang.
After major purging, if 6-7 days pass without stool, unresolved agitation, abdominal fullness/pain, due to old food retention, use Da Chengqi Tang.
Yangming without vomiting/purging but with agitation, use Tiao Wei Chengqi Tang. (Cheng Wuji: Post-vomit agitation is Internal Agitation; post-purge is Xu Fan. Here, no vomit/purge but agitation indicates Stomach stagnant heat; Tiao Wei Chengqi Tang purges stagnant heat.)
Yangming with spontaneous sweat, aggravated sweating, residual mild agitation, due to fluid loss and dry stomach causing hard stool. If urine is low, fluids return to stomach, stool will resolve soon.
Patient with heat-agitation resolving with sweat, or malarial-like afternoon fever belongs to Yangming.

Regarding Stomach Excess constipation with agitation:
- Post-vomit/purge: Da/Xiao Chengqi Tang.
- Pre-vomit/purge: Tiao Wei Chengqi Tang.

Xu treated a Shanghan case of 8-9 days: fever, no sweat, delirium, constipation for 3 days post-purge. Not dry, not agitated, not cold, not painful, but sleepless all night with indescribable discomfort and sighing sounds. Diagnosed as combined Ao Nao and Fu Yu (Depression). Stomach had dry stool. Given Chengqi Tang, passed >20 dry stools, resolved.
Jing Fang said: Yangming post-purge, Ao Nao/mild agitation, dry stool allows purging. Also: No urine difficulty, irregular stool, slight heat, Fu Yu insomnia indicates dry stool, treat with Chengqi Tang. *Suwen*: "Stomach disharmony leads to restless sleep." Jing Fang: "Dry stomach/hard stool causes delirium." Hence delirium and sighing (external Qi Fu Yu). Removing dry stool harmonizes stomach, curing disease.

Shaoyang Shanghan with wiry/fine pulse, headache, fever belongs to Shaoyang. Do not sweat; sweating causes delirium (Stomach issue). Stomach harmony cures; disharmony causes agitation/palpitations (*Huoren* uses Tiao Wei Chengqi Tang).
Chest fullness/agitation without mild sweating/purging or alternating chills/fever: Xiao Chaihu Tang.
Post-sweating/purging alternating chills/fever: Chaihu Guizhi Gan Jiang Tang.
With fright, difficult urination, delirium, heavy body: Chaihu Guizhi Longgu Muli Tang.
Vomiting with slight depression/agitation: If Xiao Chaihu Tang fails to stop vomiting, use Da Chaihu Tang (Major Bupleurum Decoction).
Post-extreme vomiting/purging, chest fullness, loose stool, abdominal pain: Tiao Wei Chengqi Tang.

Taiyin Shanghan with floating/slow pulse, warm hands/feet belongs to Taiyin, likely jaundice unless urine is free. By day 7-8, sudden agitation with >10 diarrheal episodes will self-resolve because Pi Jia Shi (Spleen Righteousness) expels foul rot. (Cheng Wuji: Day 7-8 hard stool is Taiyin transmitting to Yangming. Here, sudden agitation/diarrhea is Spleen expelling pathogens. Diarrhea with restlessness is fatal; here, Spleen harmony expels pathogen, so diarrhea stops. Use Zhi Zi Bai Pi Tang (Gardenia and Phellodendron Bark Decoction) or Ping Wei San (Peaceful Stomach Powder) + Shan Jian Jia (Pangolin Scale)).

Shaoyin Disease with somnolence and agitation. If diarrhea/thirst with white urine, *Huoren* uses Si Ni Tang (Counterflow Decoction). (See Somnolence).
If post-Bai Tong Tang (Bai Tong Decoction), diarrhea persists, cold reversal, no pulse, dry heaves/agitation, use Bai Tong Tang plus Pig Bile. (Known Yin pattern warmed by Aconite; dry heaves/agitation indicate rejection; adding human urine/pig bile facilitates entry, "Heat treating with Cold").
Shaoyin 2-3 days, agitation/insomnia: Huang Lian E Jiao Tang.
Diarrhea 6-7 days, cough/vomit, agitation/insomnia: Zhu Ling Tang (Polyporus Decoction).
Diarrhea, sore throat, chest fullness, agitation: Zhu Fu Tang.
Aversion to cold, curling up, spontaneous agitation, wanting to remove clothes: Treatable.
Tight pulse, day 7-8 spontaneous diarrhea, pulse suddenly faint, hands/feet warm, tight pulse gone: Resolving. Agitation/diarrhea will self-resolve.

Jueyin cold limbs with agitation. Pulse knotted/tight, chest full, hunger/no desire to eat: Use Gua Di San to vomit.
Hui Jue (Roundworm Cold Reversal) quiet then periodic agitation (See Vomiting Roundworms).
Day 6-7, pulses present in three positions, severe agitation/jaw lock, restlessness: Resolving.
Pulse harmonious, severe agitation, yellow inner canthus: Resolving.