三十九、小結胸（症）〔病〕，〔正〕在心下，（若）按之則痛，脈浮滑者，（小者）小陷胸湯主之。原文138
鄭論：既名結胸，何分大小，要知有熱結於胸者，有寒結於胸者，有痰結於胸者，有食結於胸者，總要分辨的確，庶無差錯。若小陷胸湯，與熱結者宜，而非寒、痰、食所宜，即以原文脈之浮滑而論，浮主風，而滑主痰，宜是內痰，若小陷胸湯，則未必妥切。
【闡釋】小結胸症，有熱結於胸者？小陷胸湯為正治之方。若寒結、痰結、食結於胸者，則非小陷胸湯所宜。筆者在臨症中，對寒結於胸者，用大黃附子細辛湯；因痰結於胸者，則用苓桂朮甘湯加附子以溫化之；若食積結胸者，選用加味平胃散。此皆屢用屢效之方也。
小陷胸湯方（校補）
黃連一兩半夏半升（洗）栝蔞實大者一枚上三味，以水六升，先煮栝蔞，取三升，去渣，內諸藥，煮取二升，去渣，分溫三服。
【方解及其應用範圍】本方用黃連苦寒以清熱，半夏辛燥而祛痰，栝蔞實甘寒滑潤，既可助黃連以清熱，又可助半夏以化痰，藥力較大陷胸湯為緩，故稱為小陷胸湯。因本方有清熱、開結、化痰之作用，推廣應用於呼吸系統及消化系統疾病，如急慢性胃炎炎、支氣管炎、肺炎、胸膜炎等呈痰熱結於胸脘之證者。
四十、傷寒十（條）〔餘〕日，熱結在裏，複往來寒熱者，〔與〕大柴胡湯（主之）。但結胸（而）無大熱者①，此為水結在胸脅也，但（欲）〔頭〕微汗出者，大陷胸湯主之。原文136
鄭論：據所稱熱結在裏，是見小便短赤乎？是見大便閉塞乎？
是見舌苔幹黃、大渴飲冷乎？務要有一定實據，原文籠統言之，學者當于病情處探求，果見大便不利，複往來寒熱者，大柴胡湯可用。又雲：結胸而無大熱者，此為水結在胸脅，但（欲）〔頭〕微汗，原文以大陷胸主之，既以無大熱，而為水結胸脅明是中宮不宣，水逆不行；法宜溫中、健脾、行水為是，若大陷胸湯，斷乎不可。
【闡釋】熱結在裏，必要有裏熱之實據，複往來寒熱，則大柴胡湯可用。若水結在胸脅，明是中宮之陽不能傳運，水流入脅而結聚，應如鄭氏所說：“當溫中、健脾、行水，大陷胸湯斷乎不可”。此證可用理中湯加砂、半、茯苓治之。
四十一、傷寒六七日，發熱微惡寒，肢節煩疼②，微嘔，心下支結③，外證未去者，柴胡桂枝湯主之。原文146
①無大熱：指邪熱傳裏，表無大熱。
②肢節煩疼：四肢關節疼痛之甚。
鄭論：按傷寒至六七日，所現仍是太陽表證病情，但有微嘔，則柴胡桂枝湯可用。至於心下支結，是太陽寒水之氣上逆所致也，當于方中加茯苓、砂、半，庶為恰切。
【闡釋】發熱微惡寒，肢節煩疼，此是太陽表證未除的現象；同時又現輕微嘔吐，並感覺心下支撐悶結，此即少陽證之輕者。兩經證狀都比較輕微，所以用桂枝湯、柴胡湯各取原方之半，雙解兩經之邪。
桂枝一兩半（去皮）黃芩一兩半人參一兩半甘草一兩（炙）半夏二合半（洗）芍藥一兩半大棗六枚（擘）生薑一兩半（切）柴胡四兩上九味，以水七升，煮取三升，去渣，溫服一升。本雲：人參湯作如桂枝法，加半夏柴胡黃芩，複如柴胡法，今用人參，作半劑。
【方解及其應用範圍】此小柴胡與桂枝湯兩方各半合劑而成。桂枝湯疏通營衛，解太陽之邪，則發熱、微惡寒、支節煩疼除；以柴胡湯和少陽半表半裏之邪，則微嘔、心下支結自愈。現推廣應用以治感冒，瘧疾、在表之風濕性關節炎，凡與本方病機相符者，均可使用。
四十二、傷寒八九日，下之，胸滿煩驚，小便不利，譫語，一身盡重，不可轉側者，柴胡加龍骨牡蠣湯主之。原文107
鄭論：按此條果係下證，下則病去無遺，何至有胸滿煩驚，小便不利，譫語，一身盡重不能轉側者？明是下傷胸中之陽，以致濁陰上泛，而為胸滿煩驚者，心腎之陽為下所傷也。小便不利者，下焦之陽衰，不能化下焦之陰也。譫語者，濁陰上閉神明昏亂也。一身盡重不能轉側者，少陰之陰寒甚，而無陽以化也。法非四逆、白通不能了。若原文之方，決不妥當
【闡釋】鄭氏對此條，其見解獨特，與歷代注家不同。果係下證，下之則病去無遺，何致有胸滿煩驚，小便不利等證狀，明是傷及中下焦之陽，柴胡加龍骨牡蠣湯則非對症之方。而又當用四逆、白通以扶中下焦之陽，則諸證自愈。筆者信之而不疑。
柴胡加龍骨牡蠣湯方（校補）
柴胡四兩龍骨、黃芩、生薑（切）鉛丹、人參、桂枝（去皮）茯苓各一兩半半夏二合半（洗）大黃二兩牡蠣一兩半（熬）大棗六枚（擘）上十二味，以水八升，煮取四升，內大黃切如碁子，更煮一兩沸，去渣，溫服一升。本雲柴胡湯，今加龍骨等。
【方解及其應用範圍】本方係柴胡桂枝二湯合方，去芩、芍、甘草，加龍骨、牡蠣、茯苓、大黃、鉛丹。柴胡、桂枝解外而除身重，龍、牡、鉛丹鎮內而止煩驚，大黃和胃氣止譫語，茯苓利小便，人參、薑、棗益氣養營，扶正驅邪。如是則錯雜之邪，庶可內外盡解。本方有和解少陽，疏肝和胃，清熱鎮驚之作用。多用於治療神經系統方面的病證；或肝膽氣鬱、驚痰，與治癲癇多效。
四十三、傷寒脈結代①，心動悸（者）②，炙甘草湯主之。（一名複脈湯）〔脈〕按之來緩，（而）時一止複來者，名曰結。又脈來動而中止，更來小數，中有還者反動，名日結，陰也。脈來動而中止，不能自還，因而複動〔者〕，名曰代，陰也，得此脈者，（為）〔必〕難治。原文177、178
①脈結代：是結脈和代脈的並稱。景嶽說：“脈來忽止，止而複起，總謂之結。”代者更代之意，于平脈中忽見軟弱，或乍疏乍數，或斷而複起，均名為代。
鄭論：據脈而論，結促之止，止無常數，代脈之止，止有常數。結促之脈，病尚可治者多，而代脈之見者，十難九痊，仲景以複脈湯主之，亦是盡治病之道而已。
【闡釋】心血不足，心陽不振，則脈見結代。兩脈的特徵，都是脈的搏動間有歇止。結脈之止無常數，或三五至一止，旋又八九至一止，旋二三十至一止，前後參差，無一定之止也。代脈止有定規，如十五至處歇止，其第二候亦在十五至歇止，第三候仍在十五歇止，謂之止有定數。這兩種脈都為氣血虛憊，而脈之搏動正常，都是陰陽營衛調協之功。倘陰陽失調，氣血因虛不能正常運行，皆屬難治。筆者在臨症中，脈見結者，除用炙甘草湯外，並用大劑回陽飲扶陽驅陰治之而愈。至代脈者，甚屬罕見，雖用大劑四逆、炙甘草湯之類，收效甚微。誠如鄭氏所說：“結促之脈，病尚可治者多，而代脈之見者，十難九痊”。非虛語矣。
炙甘草湯方（校補）
甘草四兩（炙）生薑三兩（切）人參二兩生地黃一斤桂枝三兩（去皮）阿膠二兩麥門冬半升（去心）麻仁半升大棗三十枚（擘）上九味，以清酒七升，水八升，先煮八味，取三升，去渣，內膠烊消盡。溫服一升，日三服。一名複脈湯。
【方解及其應用範圍】本方以炙甘草為君，養胃益氣，人參補氣，桂枝通陽，生地、麥冬、麻仁、阿膠養陰補血，薑、棗調和營衛，又加清酒通經隧，則脈複而悸自寧矣。據現代藥物之研究，甘草有強心的作用，故以為主藥。其方具有滋陰生血，補氣複脈之功。後世滋補方劑，多從此方化裁而出。本方氣血雙補，陰陽兩調，為治心動悸、脈結代首選方。現推廣用來治心血管疾病，如各種原因引起的心律失常，凡心肌炎、冠心病、風心病，肺心肺、以及冠狀動脈硬化、主動脈硬化等，只須見脈結代、心動悸者，均可採用。而在應用時，當根據病證偏陽虛或偏陰虛進行加減，如偏于陽虛者，可加附片、黃芪、肉桂；偏于陰虛者，可加枸杞、山藥。
四十四、傷寒，醫下之，續得下利，清穀①不止，身疼痛者，急當救裏；（複）〔後〕身疼痛，清便②自調者，急當救表。救裏宜四逆湯，救表宜桂枝湯。原文91
①清穀：清古與“圊”通，清穀就是腹瀉而食物不化的意思。
②清便：就是解大便。
鄭論：救表救裏兩法，頗與病符，不再贅。
【闡釋】表證誤下後，裏氣大虛，此指腸胃虛寒，竟至完穀不化，其嚴重程度可知，此時雖有身疼痛之表證，亦不暇顧及。因裏氣虛寒，如再行解表，必將造成虛脫之危候，故急當用四逆湯以救裏。俟大便正常，尚有身疼痛等表證，再用桂枝湯以解表。
四逆湯方（校補）
甘草二兩（炙）乾薑一兩半附子一枚（生用，去皮，破八片）上三味，以水三升，煮取一升二合，去渣，分溫再服，強人可大附子一枚，乾薑三兩
【方解及其應用範圍】四逆湯一方，乃回陽救逆之主方。乾薑、附子為純陽大熱藥，附子是一團烈火也。凡人一身，全賴一團真火，真火欲絕，故病見純陰。仲景用之以補先天欲絕之火種，故用之以為君。乾薑辛烈溫散，能蕩盡陰邪之阻塞，使附子能直入根蒂，火種復興，而性命立複，故曰回陽。陽氣既回，若無土覆之，光焰易熄，雖生不永，故繼以甘草之甘，以緩其正氣，緩者即伏之之意也。真火伏藏，命根永固，故得重生也。《傷寒論》原文治下利清谷，三陰厥逆，惡寒，脈沉而微者。
前哲謂：寒病多為陽虛，而四逆湯亦不獨為少陰立法。凡太陽病脈沉與寒入三陰及一切陽虛之證，俱能治之。鄭氏在《醫法圓通》中說：“少陰為水火交會之地，元氣之根。四逆湯不專為少陰立法，而上、中、下三部之法俱備”。隨即舉出其圓通應用法：（l）治頭腦冷，（2）治氣喘痰鳴，（3）治耳腫皮色如常，（4）治舌黑唇焦，不渴少神，（5）治喉痛、畏寒、腳冷，（6）治喉痛、身大熱、面赤、目瞑、舌冷，（7）治吐血困倦，（8）治齒縫流血，（9）治朝食暮吐，完穀不化，（lO）治足心夜發熱如焚，不渴尿多，（11）治面赤發熱，汗出抽掣，（l2）治大便下血，氣短少神，（13）治頭搖，面白少神，（14）治背冷目瞑，（15）治舌腫鞕而青，（16）治唇腫而赤，不渴，（17）治鼻涕如注，面白少神，（18）治尿多，（19）治周身發起包塊，皮色如常，（20）治周身忽現紅片如雲，不熱不渴，（21）治發熱、譫語、無神、不渴，（22）治兩目白睛青色，（23）治兩目赤霧縷縷，微脹不痛。最後鄭氏說：“此方功用頗多，得其要者，一方可治數百種病，因病加減，其功用更為無窮。余每用此方，救好多人，人咸目余為姜、附先生。”的確，對於四逆湯能起死回生作用的重現，與善用之而活人無算，直可說是前無古人。筆者在臨床中，細思此方既能回陽，則凡世之一切陽虛陰盛為病者，皆可服也，何必定要見四肢厥逆，腹痛下利，脈微欲絕等症而始用之，一見是陽虛症，而即以此方在分兩輕重上斟酌，效如桴鼓，從未發生任何副作用，實由鄭氏三書之教導也。
四十五、傷寒下後，心煩腹滿，（起臥）〔臥起〕不安者，梔子厚朴湯主之，原文79
鄭論：按下後，至心煩腹滿，起臥不安，總緣下傷中宮之陽，遂至濁陰上壅，而為腹滿，脾胃之精氣，不能上輸於心，故心煩，此病理應溫中扶陽，何得更行清熱破滯之品，庶覺不合。若果係熱邪，下後而仍舊彌漫，有熱象可憑，則原文定不可少，學者須知。
【闡釋】下後至心煩腹滿，起臥不安，誠如鄭氏所說，有兩種不同情況。下傷中宮之陽者，應溫中扶陽，理中湯是也。下後熱邪彌漫，有熱象可憑，方可用梔子厚朴湯梔子厚朴湯方（校補）
梔子十四個（擘）厚樸四兩（炙，去皮）枳實四枚（水浸，炙令黃）上三味，以水三升半，煮取一升半，去渣，分二服，溫進一服，得吐者，止後服。
【方解及其應用範圍】張隱菴雲：“梔子之苦寒，能泄心中之煩熱，厚朴之苦溫，能消脾家之腹滿，枳實之苦寒，能解胃中之熱結。”合之則清熱除煩，氣行則滿自解。
四十六、傷寒，醫以丸藥大下之，身熱不去，微煩者，梔子乾薑湯主之。原文80
鄭論：按大下非微下可比，既稱大下，豈有邪下而不去之理乎？尚見身熱微煩，吾恐陽從外脫，已在幾希，若更吐之，能不速其亡乎？
【闡釋】大下之後，損及脾胃之陽，形成中焦有寒。從條文中看，身熱不去，微煩，此上焦有熱。治以梔子清上熱，即所以除煩，乾薑溫中散寒。筆者不知鄭氏所指“若更吐之，能不速其亡乎”之意也!
梔子乾薑湯方（校補）
梔子十四個（擘）乾薑二兩上二味，以水三升半，煮取一升半，去渣，分二服，溫進一服（得吐者止後服）。
【方解及其應用範圍】梔子苦寒，清熱除煩；乾薑辛熱，溫中散寒。寒熱異性，功用不同，有是病即用是藥，有何不可。此為寒熱並用之方劑，亦即溫清兩行的治法。至方後所雲：“得吐者止後服”。此不通之論，宜刪去。
三十九、小结胸病，病位正当在心下（胃脘部），如果按压时才会疼痛，脉象浮滑的，用小陷胸汤主治。原文138
郑氏按语：既然名为结胸，为何还要区分大小？要知道，有热邪结聚在胸部的，有寒邪结聚在胸部的，有痰浊结聚在胸部的，有食积结聚在胸部的，总归要分辨清楚，才不会有差错。如果是小陷胸汤，适用于热邪结聚的情况，而不适合寒、痰、食积所致者。仅从原文提到的“脉浮滑”来看，浮脉主风，滑脉主痰，这应该是内有痰浊，那么用小陷胸汤，恐怕未必恰当。
【阐释】小结胸证，若是热邪结聚在胸，小陷胸汤是正治之方。若是寒结、痰结、食积结聚在胸，则不是小陷胸汤所适宜的。笔者在临证中，对于寒邪结聚于胸者，使用大黄附子细辛汤；因痰浊结聚于胸者，则用苓桂术甘汤加附子以温化之；若是食积结胸者，选用加味平胃散。这些都是屡试屡效的方剂。
小陷胸汤方（校补）
黄连一两 半夏半升（洗） 栝楼实大者一枚 以上三味药，用水六升，先煮栝楼，取汁三升，去渣，加入其余药物，煮取二升，去渣，分三次温服。
【方解及其应用范围】本方用黄连苦寒以清热，半夏辛燥而祛痰，栝楼实甘寒滑润，既可助黄连以清热，又可助半夏以化痰，药力较之大陷胸汤为缓，故称为小陷胸汤。因为本方具有清热、开结、化痰的作用，推广应用于呼吸系统及消化系统疾病，如急慢性胃炎、支气管炎、肺炎、胸膜炎等呈现痰热结于胸脘之证者。
四十、伤寒十余日，热邪结聚在里，又出现往来寒热的，给予大柴胡汤主治。若是结胸而没有大热的，这是水饮结聚在胸胁，只是头部微微出汗的，用大陷胸汤主治。原文136
郑氏按语：据所称的热邪结聚在里，是见到小便短赤吗？是见到大便闭塞吗？是见到舌苔干黄、大渴喜冷饮吗？务必要有确实的依据。原文笼统地说，学者应当在病情处探求，果然见到不便秘，又出现往来寒热的，大柴胡汤可用。又说：结胸而没有大热的，这是水饮结聚在胸胁，只是头部微汗出，原文主张用大陷胸汤主治。既然没有大热，而为水饮结聚胸胁，明是中焦脾胃阳气不宣，水气逆乱不行；治法应当温中、健脾、行水才是正确的，若用大陷胸汤，绝对不可。
【阐释】热邪结聚在里，必须有里热的实证依据，又出现往来寒热，则大柴胡汤可用。若是水饮结聚在胸胁，明是中焦脾阳不能运化，水流入胁肋而结聚，应当像郑氏所说：“当温中、健脾、行水，大陷胸汤绝对不可”。此证可用理中汤加砂仁、半夏、茯苓治疗。
四十一、伤寒六七日，发热轻微恶寒，肢节烦痛，轻微呕吐，心下支撑闷结，表证未去的，用柴胡桂枝汤主治。原文146
①无大热：指邪热传里，体表没有大热。
②肢节烦疼：四肢关节疼痛剧烈。
③心下支结：心下感觉支撑闷结。
郑氏按语：按伤寒至六七日，所现仍然是太阳表证的病情，但有轻微呕吐，则柴胡桂枝汤可用。至于心下支结，是太阳寒水之气上逆所致，应当在方中加入茯苓、砂仁、半夏，才算恰当。
【阐释】发热轻微恶寒，肢节烦痛，这是太阳表证未除的现象；同时又出现轻微呕吐，并感觉心下支撑闷结，这就是少阳证的轻症。两经症状都比较轻微，所以用桂枝汤、柴胡汤各取原方的一半，双解两经之邪。
柴胡桂枝汤方（校补）
桂枝一两半（去皮） 黄芩一两半 人参一两半 甘草一两（炙） 半夏二合半（洗） 芍药一两半 大枣六枚（擘） 生姜一两半（切） 柴胡四两 以上九味药，用水七升，煮取三升，去渣，温服一升。原本说：人参汤作如桂枝法，加半夏、柴胡、黄芩，复如柴胡法，今用人参，作半剂。
【方解及其应用范围】此方是小柴胡汤与桂枝汤两方各半合剂而成。桂枝汤疏通营卫，解除太阳之邪，则发热、轻微恶寒、肢节烦痛消除；以柴胡汤和解少阳半表半里之邪，则轻微呕吐、心下支结自愈。现在推广用于治疗感冒、疟疾、在表之风湿性关节炎，凡与本方病机相符者，均可使用。
四十二、伤寒八九日，误用攻下法后，出现胸满、烦躁惊悸、小便不利、谵语、全身沉重、不能转侧的，用柴胡加龙骨牡蛎汤主治。原文107
郑氏按语：按此条果若是下证（可下之证），攻下则病邪去除无余，何至于还有胸满、烦躁惊悸、小便不利、谵语、全身沉重不能转侧等症状？明是攻下损伤了胸中之阳，以致浊阴上泛，而出现胸满、烦躁惊悸，这是心肾之阳被下法所伤。小便不利，是下焦阳气衰微，不能化生下焦之阴液。谵语，是浊阴上闭，神明昏乱。全身沉重不能转侧，是少阴之阴寒甚盛，而无阳气以化生。治法非四逆汤、白通汤不能解决。若用原文之方，决不妥当。
【阐释】郑氏对此条见解独特，与历代注家不同。果若是下证，攻下则病邪去除无余，何至于有胸满、烦躁惊悸、小便不利等症状，明是伤及中下焦之阳，柴胡加龙骨牡蛎汤则不是对症之方。而又应当用四逆汤、白通汤以扶持中下焦之阳，则诸证自愈。笔者深信不疑。
柴胡加龙骨牡蛎汤方（校补）
柴胡四两 龙骨、黄芩、生姜（切）、铅丹、人参、桂枝（去皮）、茯苓各一两半 半夏二合半（洗） 大黄二两 牡蛎一两半（熬） 大枣六枚（擘） 以上十二味药，用水八升，煮取四升，纳入大黄切成棋子状，再煮一两个沸，去渣，温服一升。原本说：柴胡汤，今加龙骨等。
【方解及其应用范围】本方是柴胡桂枝二汤合方，去掉黄芩、芍药、甘草，加上龙骨、牡蛎、茯苓、大黄、铅丹。柴胡、桂枝解外而除身重，龙、牡、铅丹镇内而止烦躁惊悸，大黄和胃气止谵语，茯苓利小便，人参、姜、枣益气养营，扶正驱邪。如此则错杂之邪，庶可内外尽解。本方有和解少阳，疏肝和胃，清热镇惊的作用。多用于治疗神经系统方面的病证；或肝胆气郁、惊痰，治疗癫痫多有效。
四十三、伤寒脉结代，心动悸的，用炙甘草汤主治。（一名复脉汤）〔脉〕按之来势缓慢，时而一次停止后又来的，名叫结脉。又脉来跳动而中止，再次来时稍快，中间有回还之象反而跳动，名叫结，属阴。脉来跳动而中止，不能自还，因而再次跳动的，名叫代脉，属阴，得到这种脉象的，必定难治。原文177、178
①脉结代：是结脉和代脉的并称。景岳说：“脉来忽止，止而复起，总谓之结。”代者是更代之意，于平脉中忽见软弱，或乍疏乍数，或断而复起，均名为代。
②心动悸：心脏筑然悸动。
郑氏按语：据脉而论，结促之止，止无常数，代脉之止，止有常数。结促之脉，病尚可治者多，而代脉之见的，十难九痊，仲景以复脉汤主治，也是尽力治病之道而已。
【阐释】心血不足，心阳不振，则脉见结代。两脉的特征，都是脉搏搏动间有歇止。结脉之止无常数，或三五至一止，旋又八九至一止，旋二三十至一止，前后参差，无一定之止也。代脉止有定规，如十五至处歇止，其第二候亦在十五至歇止，第三候仍在十五歇止，谓之止有定数。这两种脉都为气血虚惫，而脉之搏动正常，都是阴阳营卫调协之功。倘若阴阳失调，气血因虚不能正常运行，皆属难治。笔者在临证中，脉见结者，除用炙甘草汤外，并用大剂回阳饮扶阳驱阴治之而愈。至代脉者，甚属罕见，虽用大剂四逆汤、炙甘草汤之类，收效甚微。诚如郑氏所说：“结促之脉，病尚可治者多，而代脉之见的，十难九痊”。并非虚语。
炙甘草汤方（校补）
甘草四两（炙） 生姜三两（切） 人参二两 生地黄一斤 桂枝三两（去皮） 阿胶二两 麦门冬半升（去心） 麻仁半升 大枣三十枚（擘） 以上九味药，用清水酒七升，水八升，先煮八味，取汁三升，去渣，纳入胶烊化消尽。温服一升，日服三次。一名复脉汤。
【方解及其应用范围】本方以炙甘草为君药，养胃益气，人参补气，桂枝通阳，生地、麦冬、麻仁、阿胶养阴补血，姜、枣调和营卫，又加清酒通经隧，则脉复而悸自宁矣。据现代药物之研究，甘草有强心的作用，故以为主药。其方具有滋阴生血，补气复脉之功。后世滋补方剂，多从此方化裁而出。本方气血双补，阴阳两调，为治心动悸、脉结代首选方。现在推广用来治心血管疾病，如各种原因引起的心律失常，凡心肌炎、冠心病、风心病、肺心病、以及冠状动脉硬化、主动脉硬化等，只要见脉结代、心动悸者，均可采用。而在应用时，当根据病证偏阳虚或偏阴虚进行加减，如偏于阳虚者，可加附片、黄芪、肉桂；偏于阴虚者，可加枸杞、山药。
四十四、伤寒，医生误用攻下法，随后出现下利，完谷不化不止，身体疼痛的，急当救里；（后）身体疼痛，大便正常的，急当救表。救里宜用四逆汤，救表宜用桂枝汤。原文91
①清谷：清古与“圊”通，清谷就是腹泻而食物不化的意思。
②清便：就是解大便。
郑氏按语：救表救里两法，颇与病情相符，不再赘述。
【阐释】表证误下后，里气大虚，此指肠胃虚寒，竟至完谷不化，其严重程度可知，此时虽有身体疼痛之表证，亦无暇顾及。因为里气虚寒，如果再行解表，必将造成虚脱之危候，故急当用四逆汤以救里。俟大便正常，尚有身体疼痛等表证，再用桂枝汤以解表。
四逆汤方（校补）
甘草二两（炙） 干姜一两半 附子一枚（生用，去皮，破八片） 以上三味药，用水三升，煮取一升二合，去渣，分两次温服，体壮者可加大附子一枚，干姜三两。
【方解及其应用范围】四逆汤一方，乃回阳救逆之主方。干姜、附子为纯阳大热药，附子是一团烈火也。凡人一身，全赖一团真火，真火欲绝，故病见纯阴。仲景用之以补先天欲绝之火种，故用之以作为君药。干姜辛烈温散，能荡尽阴邪之阻塞，使附子能直入根蒂，火种复兴，而性命立复，故曰回阳。阳气既回，若无土覆之，光焰易熄，虽生不永，故继以甘草之甘，以缓其正气，缓者即伏藏之意也。真火伏藏，命根永固，故得重生也。《伤寒论》原文治下利清谷，三阴厥逆，恶寒，脉沉而微者。
前哲谓：寒病多为阳虚，而四逆汤亦不独为少阴立法。凡太阳病脉沉与寒入三阴及一切阳虚之证，俱能治之。郑氏在《医法圆通》中说：“少阴为水火交会之地，元气之根。四逆汤不专为少阴立法，而上、中、下三部之法俱备”。随即举出其圆通应用法：（1）治头脑冷，（2）治气喘痰鸣，（3）治耳肿皮色如常，（4）治舌黑唇焦，不渴少神，（5）治喉痛、畏寒、脚冷，（6）治喉痛、身大热、面赤、目瞑、舌冷，（7）治吐血困倦，（8）治齿缝流血，（9）治朝食暮吐，完谷不化，（10）治足心夜发热如焚，不渴尿多，（11）治面赤发热，汗出抽掣，（12）治大便下血，气短少神，（13）治头摇，面白少神，（14）治背冷目瞑，（15）治舌肿硬而青，（16）治唇肿而赤，不渴，（17）治鼻涕如注，面白少神，（18）治尿多，（19）治周身发起包块，皮色如常，（20）治周身忽现红片如云，不热不渴，（21）治发热、谵语、无神、不渴，（22）治两目白睛青色，（23）治两目赤雾缕缕，微胀不痛。最后郑氏说：“此方功用颇多，得其要者，一方可治数百种病，因病加减，其功用更为无穷。余每用此方，救好多人，人咸目余为姜、附先生。”的确，对于四逆汤能起死回生作用的显现，与善用之而活人无数，直可说是前无古人。笔者在临床中，细思此方既能回阳，则凡世之一切阳虚阴盛为病者，皆可服也，何必定要见四肢厥逆，腹痛下利，脉微欲绝等症而始用之，一见是阳虚症，而即以此方在分量轻重上斟酌，效如桴鼓，从未发生任何副作用，实由郑氏三书之教导也。
四十五、伤寒下后，心烦腹满，（卧起）不安的，用栀子厚朴汤主治，原文79
郑氏按语：按下后，至心烦腹满，卧起不安，总缘下法损伤中宫之阳，遂至浊阴上壅，而为腹满，脾胃之精气，不能上输于心，故心烦，此病理应温中扶阳，何得更行清热破滞之品，庶觉不合。若果系热邪，下后而仍旧弥漫，有热象可凭，则原文定不可少，学者须知。
【阐释】下后至心烦腹满，卧起不安，诚如郑氏所说，有两种不同情况。下伤中宫之阳者，应温中扶阳，理中汤是也。下后热邪弥漫，有热象可凭，方可用栀子厚朴汤。
栀子厚朴汤方（校补）
栀子十四个（擘） 厚朴四两（炙，去皮） 枳实四枚（水浸，炙令黄） 以上三味药，用水三升半，煮取一升半，去渣，分二次服，温进一服，得吐者，止后服。
【方解及其应用范围】张隐庵云：“栀子之苦寒，能泄心中之烦热，厚朴之苦温，能消脾家之腹满，枳实之苦寒，能解胃中之热结。”合之则清热除烦，气行则满自解。
四十六、伤寒，医生用丸药大下之，身热不去，微烦的，用栀子干姜汤主治。原文80
郑氏按语：按大下非微下可比，既称大下，岂有邪下而不去之理乎？尚见身热微烦，吾恐阳从外脱，已在几希，若更吐之，能不速其亡乎？
【阐释】大下之后，损及脾胃之阳，形成中焦有寒。从条文中看，身热不去，微烦，此上焦有热。治以栀子清上热，即所以除烦，干姜温中散寒。笔者不知郑氏所指“若更吐之，能不速其亡乎”之意也！
栀子干姜汤方（校补）
栀子十四个（擘） 干姜二两 以上二味药，用水三升半，煮取一升半，去渣，分二次服，温进一服（得吐者止后服）。
【方解及其应用范围】栀子苦寒，清热除烦；干姜辛热，温中散寒。寒热异性，功用不同，有是病即用是药，有何不可。此为寒热并用之方剂，亦即温清两行的治法。至方后所云：“得吐者止后服”。此不通之论，宜删去。
39. Minor Jie Xiong (Chest Binding) syndrome, with the pathology located precisely at Xin Xia (epigastrium), if pain occurs only upon palpation, and the pulse is floating and slippery, Xiao Xian Xiong Tang (Minor Intrapleural Decoction) should be administered as the primary treatment. Original Text 138
Zheng's Commentary: Since it is named Jie Xiong (Chest Binding), why distinguish between major and minor? One must understand that there are cases where heat binds in the chest, cold binds in the chest, phlegm binds in the chest, and food retention binds in the chest. It is essential to differentiate accurately to avoid errors. If Xiao Xian Xiong Tang (Minor Intrapleural Decoction) is indicated for heat binding, it is not suitable for cold, phlegm, or food retention. Judging solely from the original text's mention of a "floating and slippery" pulse, floating indicates wind, and slippery indicates phlegm; this suggests internal phlegm. Therefore, using Xiao Xian Xiong Tang (Minor Intrapleural Decoction) may not be entirely appropriate.
[Elucidation]: For Minor Jie Xiong (Chest Binding) syndrome caused by heat binding in the chest, Xiao Xian Xiong Tang (Minor Intrapleural Decoction) is the correct treatment. However, for cases of cold binding, phlegm binding, or food retention binding in the chest, Xiao Xian Xiong Tang (Minor Intrapleural Decoction) is not suitable. In clinical practice, for cold binding in the chest, I use Da Huang Fu Zi Xi Xin Tang (Rhubarb, Aconite, and Asarum Decoction); for phlegm binding in the chest, I use Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala, and Licorice Decoction) added with Fu Zi (Aconiti Lateralis Radix Preparata) to warm and transform; for food retention Jie Xiong (Chest Binding), I select Jia Wei Ping Wei San (Modified Powder to Maintain Stability). These are formulas that have proven effective repeatedly.
Xiao Xian Xiong Tang (Minor Intrapleural Decoction) Formula (Textual Correction and Supplement)
Huang Lian (Coptidis Rhizoma) 1 liang, Ban Xia (Pinelliae Tuber) half sheng (washed), Gua Lou Shi (Trichosanthis Fructus) one large fruit. The above three ingredients are boiled in six sheng of water. First, boil Gua Lou Shi (Trichosanthis Fructus) until reduced to three sheng, then remove the dregs. Add the remaining herbs, boil until reduced to two sheng, remove the dregs, and divide into three warm doses.
[Formula Analysis and Scope of Application]: This formula uses Huang Lian (Coptidis Rhizoma) which is bitter and cold to clear heat, Ban Xia (Pinelliae Tuber) which is acrid and dry to dispel phlegm, and Gua Lou Shi (Trichosanthis Fructus) which is sweet, cold, slippery, and moistening. It assists Huang Lian (Coptidis Rhizoma) in clearing heat and assists Ban Xia (Pinelliae Tuber) in resolving phlegm. Its medicinal power is milder than that of Da Xian Xiong Tang (Major Intrapleural Decoction), hence it is called Xiao Xian Xiong Tang (Minor Intrapleural Decoction). Because this formula has the effects of clearing heat, unbinding knots, and resolving phlegm, it is extended to respiratory and digestive system diseases, such as acute and chronic gastritis, bronchitis, pneumonia, and pleurisy, presenting with symptoms of phlegm-heat binding in the chest and epigastrium.
40. After ten-plus days of Shang Han (Cold Damage), if heat binds internally and there is alternating chills and fever, give Da Chai Hu Tang (Major Bupleurum Decoction). If there is Jie Xiong (Chest Binding) without significant fever, this indicates water binding in the chest and hypochondrium; if there is only slight sweating on the head, Da Xian Xiong Tang (Major Intrapleural Decoction) should be administered. Original Text 136
Zheng's Commentary: Regarding the so-called heat binding internally, does this present with short, dark urine? Or constipation? Or a dry, yellow tongue coating with intense thirst for cold drinks? There must be definite evidence. The original text speaks generally; students should investigate the specific condition. If indeed there is constipation accompanied by alternating chills and fever, Da Chai Hu Tang (Major Bupleurum Decoction) can be used. It also states: "Jie Xiong (Chest Binding) without significant fever indicates water binding in the chest and hypochondrium; with only slight head sweating." The original text prescribes Da Xian Xiong Tang (Major Intrapleural Decoction). Since there is no significant fever, indicating water binding in the chest and hypochondrium, it clearly shows that the middle jiao (middle burner) yang qi is not disseminating, and water qi is reversing and failing to move. The treatment method should be warming the middle, strengthening the spleen, and promoting water metabolism. Using Da Xian Xiong Tang (Major Intrapleural Decoction) is absolutely contraindicated.
[Elucidation]: Heat binding internally requires concrete evidence of interior heat. With alternating chills and fever, Da Chai Hu Tang (Major Bupleurum Decoction) is applicable. If water binds in the chest and hypochondrium, it clearly indicates that the spleen yang of the middle jiao cannot transport, causing water to flow into the hypochondrium and bind. As Zheng stated: "One should warm the middle, strengthen the spleen, and promote water metabolism; Da Xian Xiong Tang (Major Intrapleural Decoction) is absolutely contraindicated." This pattern can be treated with Li Zhong Tang (Regulate the Middle Decoction) added with Sha Ren (Amomi Fructus Rotundus), Ban Xia (Pinelliae Tuber), and Fu Ling (Poria).
41. After six or seven days of Shang Han (Cold Damage), presenting with mild fever and aversion to cold, severe pain in the limbs and joints, mild vomiting, a sensation of support and binding under the heart (epigastrium), and exterior signs persisting, Chai Hu Gui Zhi Tang (Bupleurum and Cinnamon Twig Decoction) should be administered. Original Text 146
① No significant fever: Refers to pathogenic heat transmitting inward, with no significant fever on the exterior.
② Severe limb and joint pain: Intense pain in the four limbs and joints.
③ Xin Xia Zhi Jie (Support and binding under the heart): A sensation of support and stifling binding in the epigastrium.
Zheng's Commentary: At six or seven days of Shang Han (Cold Damage), the presentation remains largely Tai Yang (Greater Yang) exterior syndrome. However, with mild vomiting, Chai Hu Gui Zhi Tang (Bupleurum and Cinnamon Twig Decoction) can be used. As for Xin Xia Zhi Jie (support and binding under the heart), this is caused by the counterflow of Tai Yang (Greater Yang) cold-water qi.茯苓 (Poria), Sha Ren (Amomi Fructus Rotundus), and Ban Xia (Pinelliae Tuber) should be added to the formula for appropriateness.
[Elucidation]: Mild fever and aversion to cold, along with severe limb and joint pain, indicate that the Tai Yang (Greater Yang) exterior syndrome has not been resolved. Simultaneously, mild vomiting and a sensation of support and binding under the heart appear, representing a mild Shaoyang (Lesser Yang) syndrome. Since the symptoms of both meridians are relatively mild, half doses of Gui Zhi Tang (Cinnamon Twig Decoction) and Chai Hu Tang (Bupleurum Decoction) are combined to resolve pathogens in both meridians simultaneously.
Chai Hu Gui Zhi Tang (Bupleurum and Cinnamon Twig Decoction) Formula (Textual Correction and Supplement)
Gui Zhi (Cinnamomi Ramulus) 1.5 liang (peeled), Huang Qin (Scutellariae Radix) 1.5 liang, Ren Shen (Ginseng Radix) 1.5 liang, Gan Cao (Glycyrrhizae Radix et Rhizoma) 1 liang (honey-fried), Ban Xia (Pinelliae Tuber) 2.5 he (washed), Bai Shao (Paeoniae Radix Alba) 1.5 liang, Da Zao (Ziziphi Jujubae Fructus) 6 pieces (split), Sheng Jiang (Zingiberis Rhizoma Recens) 1.5 liang (sliced), Chai Hu (Bupleuri Radix) 4 liang. The above nine ingredients are boiled in seven sheng of water until reduced to three sheng. Remove the dregs and take one sheng warm. Originally stated: Ren Shen Tang is prepared like Gui Zhi Tang (Cinnamon Twig Decoction), adding Ban Xia (Pinelliae Tuber), Chai Hu (Bupleuri Radix), and Huang Qin (Scutellariae Radix), then following Chai Hu Tang (Bupleurum Decoction) method. Now using Ren Shen (Ginseng Radix), prepare as half dose.
[Formula Analysis and Scope of Application]: This formula is a combination of half doses of Xiao Chai Hu Tang (Minor Bupleurum Decoction) and Gui Zhi Tang (Cinnamon Twig Decoction). Gui Zhi Tang (Cinnamon Twig Decoction) unblocks Ying (Nutrient) and Wei (Defensive) qi, resolving Tai Yang (Greater Yang) pathogens, thereby eliminating fever, mild aversion to cold, and limb/joint pain. Chai Hu Tang (Bupleurum Decoction) harmonizes Shaoyang (Lesser Yang) pathogens at the half-exterior/half-interior level, thereby curing mild vomiting and Xin Xia Zhi Jie (support and binding under the heart). It is now extended to treat common cold, malaria, and rheumatoid arthritis at the exterior level, applicable whenever the pathogenesis matches this formula.
42. After eight or nine days of Shang Han (Cold Damage), if purgatives were mistakenly used, resulting in chest fullness, irritability, fright, difficulty urinating, delirious speech, heaviness of the entire body, and inability to turn over, Chai Hu Jia Long Gu Mu Li Tang (Bupleurum Decoction plus Dragon Bone and Oyster Shell) should be administered. Original Text 107
Zheng's Commentary: If this clause truly represents a purgative indication, purging would eliminate the disease completely. Why would chest fullness, irritability, fright, difficulty urinating, delirious speech, and body heaviness with inability to turn over remain? Clearly, purging has damaged the Yang qi of the chest, causing turbid yin to ascend, leading to chest fullness and irritability/fright; this indicates injury to Heart and Kidney Yang by the purgative. Difficulty urinating indicates decline of Lower Jiao (Lower Burner) Yang qi, unable to transform Lower Jiao Yin fluids. Delirious speech indicates turbid yin closing up and confusing the Spirit. Heaviness of the entire body with inability to turn over indicates severe Shaoyin (Lesser Yin) cold-yin with insufficient Yang qi to transform it. The treatment must involve Si Ni Tang (Counterflow Decoction) or Bai Tong Tang (White Pass Decoction). The formula in the original text is definitely inappropriate.
[Elucidation]: Zheng's interpretation of this clause is unique, differing from commentators throughout history. If it were truly a purgative indication, purging would eliminate the disease. Why would symptoms like chest fullness, irritability, fright, and difficulty urinating occur? Clearly, the Middle and Lower Jiao (Middle and Lower Burners) Yang qi have been injured. Chai Hu Jia Long Gu Mu Li Tang (Bupleurum Decoction plus Dragon Bone and Oyster Shell) is not the correct formula. Instead, Si Ni Tang (Counterflow Decoction) and Bai Tong Tang (White Pass Decoction) should be used to support the Yang qi of the Middle and Lower Jiao, after which all symptoms will resolve. I believe this without doubt.
Chai Hu Jia Long Gu Mu Li Tang (Bupleurum Decoction plus Dragon Bone and Oyster Shell) Formula (Textual Correction and Supplement)
Chai Hu (Bupleuri Radix) 4 liang, Long Gu (Fossilia Ossis Mastodi), Huang Qin (Scutellariae Radix), Sheng Jiang (Zingiberis Rhizoma Recens) (sliced), Qian Dan (Minium), Ren Shen (Ginseng Radix), Gui Zhi (Cinnamomi Ramulus) (peeled), Fu Ling (Poria) each 1.5 liang, Ban Xia (Pinelliae Tuber) 2.5 he (washed), Da Huang (Rhei Radix et Rhizoma) 2 liang, Mu Li (Ostreae Concha) 1.5 liang (calcined), Da Zao (Ziziphi Jujubae Fructus) 6 pieces (split). The above twelve ingredients are boiled in eight sheng of water until reduced to four sheng. Add Da Huang (Rhei Radix et Rhizoma) cut into chess-piece shapes, boil for one or two more boils, remove the dregs, and take one sheng warm. Originally stated: Chai Hu Tang (Bupleurum Decoction), now adding Long Gu (Fossilia Ossis Mastodi) etc.
[Formula Analysis and Scope of Application]: This formula combines Er Chai Hu Gui Zhi Tang (Two Bupleurum-Cinnamon Twig Formulas), removing Huang Qin (Scutellariae Radix), Bai Shao (Paeoniae Radix Alba), and Gan Cao (Glycyrrhizae Radix et Rhizoma), and adding Long Gu (Fossilia Ossis Mastodi), Mu Li (Ostreae Concha), Fu Ling (Poria), Da Huang (Rhei Radix et Rhizoma), and Qian Dan (Minium). Chai Hu (Bupleuri Radix) and Gui Zhi (Cinnamomi Ramulus) release the exterior and relieve body heaviness; Long Gu (Fossilia Ossis Mastodi), Mu Li (Ostreae Concha), and Qian Dan (Minium) calm the interior and stop irritability/fright; Da Huang (Rhei Radix et Rhizoma) harmonizes Stomach Qi and stops delirium; Fu Ling (Poria) promotes urination; Ren Shen (Ginseng Radix), Ginger, and Jujube tonify Qi and nourish Ying (Nutrient) blood, supporting healthy Qi to expel pathogens. Thus, complex pathogens can be resolved both internally and externally. This formula harmonizes Shaoyang (Lesser Yang), soothes the Liver and harmonizes the Stomach, clears heat, and calms fright. It is mostly used for nervous system disorders, Liver-Gallbladder Qi stagnation, fright-phlegm, and is effective for epilepsy.
43. In Shang Han (Cold Damage), with a Jie Dai Mai (Knotted and Intermitting Pulse) and Xin Dong Ji (Palpitations), Zhi Gan Cao Tang (Honey-Fried Licorice Decoction) should be administered. (Also known as Fu Mai Tang (Restore the Pulse Decoction)). [The] pulse feels slow upon pressure, stopping occasionally before resuming, is named Jie Mai (Knotted Pulse). Also, if the pulse beats and stops, resumes slightly faster, with a returning movement, it is named Jie (Knotted), belonging to Yin. If the pulse beats and stops, cannot return spontaneously, and then beats again, it is named Dai Mai (Intermitting Pulse), belonging to Yin. Obtaining this pulse indicates a difficult-to-treat condition. Original Text 177, 178
① Jie Dai Mai (Knotted and Intermitting Pulse): A collective term for Jie Mai (Knotted Pulse) and Dai Mai (Intermitting Pulse). Jingyue said: "The pulse suddenly stops, stops and then rises again, collectively called Jie (Knotted)." Dai means replacement. Suddenly appearing weak in a normal pulse, or irregularly rapid and slow, or broken and then rising again, are all named Dai (Intermitting).
② Xin Dong Ji (Palpitations): The heart throbs palpably.
Zheng's Commentary: Based on the pulse, the stopping of Jie and Cu (Rapid) pulses has no fixed number, while the stopping of Dai Mai (Intermitting Pulse) has a fixed number. For Jie and Cu pulses, many diseases are still treatable; however, when Dai Mai (Intermitting Pulse) appears, nine out of ten cases are difficult to cure. Zhang Zhongjing prescribed Fu Mai Tang (Restore the Pulse Decoction), which is merely doing his best in treating disease.
[Elucidation]: Insufficiency of Heart Blood and decline of Heart Yang result in Jie Dai Mai (Knotted and Intermitting Pulse). Both pulses are characterized by intermittent pauses in heartbeat. The pause of Jie Mai (Knotted Pulse) has no fixed number; it may stop every three to five beats, then every eight to nine beats, then every twenty to thirty beats, varying irregularly without a fixed interval. Dai Mai (Intermitting Pulse) has a fixed rule; for example, if it pauses at the fifteenth beat, it pauses at the fifteenth beat in the second observation, and the fifteenth beat in the third observation, meaning the pause has a fixed number. Both pulses indicate exhaustion of Qi and Blood, yet the pulse beat is normal, reflecting the coordination of Yin-Yang, Ying (Nutrient), and Wei (Defensive) Qi. If Yin-Yang is disordered and Qi-Blood cannot circulate normally due to deficiency, it is considered difficult to treat. In clinical practice, for Jie Mai (Knotted Pulse), besides using Zhi Gan Cao Tang (Honey-Fried Licorice Decoction), I use large doses of Hui Yang Yin (Decoction to Restore Yang) to support Yang and驱散 Yin Cold, achieving cure. Dai Mai (Intermitting Pulse) is very rare; even with large doses of Si Ni Tang (Counterflow Decoction) or Zhi Gan Cao Tang (Honey-Fried Licorice Decoction), efficacy is minimal. As Zheng stated: "For Jie and Cu pulses, many diseases are treatable; but when Dai Mai (Intermitting Pulse) appears, nine out of ten are difficult to cure." This is not empty talk.
Zhi Gan Cao Tang (Honey-Fried Licorice Decoction) Formula (Textual Correction and Supplement)
Zhi Gan Cao (Glycyrrhizae Radix et Rhizoma Preparata) 4 liang, Sheng Jiang (Zingiberis Rhizoma Recens) 3 liang (sliced), Ren Shen (Ginseng Radix) 2 liang, Sheng Di Huang (Rehmanniae Radix) 1 jin, Gui Zhi (Cinnamomi Ramulus) 3 liang (peeled), E Jiao (Colla Corii Asini) 2 liang, Mai Men Dong (Ophiopogonis Radix) half sheng (core removed), Ma Ren (Cannabis Semen) half sheng, Da Zao (Ziziphi Jujubae Fructus) 30 pieces (split). The above nine ingredients are boiled in seven sheng of clear wine and eight sheng of water. First, boil the eight ingredients until reduced to three sheng, remove the dregs, add E Jiao (Colla Corii Asini) and melt it completely. Take one sheng warm, three times daily. Also known as Fu Mai Tang (Restore the Pulse Decoction).
[Formula Analysis and Scope of Application]: This formula takes Zhi Gan Cao (Glycyrrhizae Radix et Rhizoma Preparata) as the sovereign herb to nourish the Stomach and tonify Qi; Ren Shen (Ginseng Radix) tonifies Qi; Gui Zhi (Cinnamomi Ramulus) unblocks Yang; Sheng Di Huang (Rehmanniae Radix), Mai Men Dong (Ophiopogonis Radix), Ma Ren (Cannabis Semen), and E Jiao (Colla Corii Asini) nourish Yin and tonify Blood; Ginger and Jujube harmonize Ying (Nutrient) and Wei (Defensive) Qi; clear wine is added to unblock collaterals, allowing the pulse to restore and palpitations to settle. Modern pharmacological research shows that Licorice has a cardiotonic effect, justifying its role as the principal drug. The formula has the functions of nourishing Yin, generating Blood, tonifying Qi, and restoring the pulse. Later tonic formulas are mostly derived from this formula. This formula tonifies both Qi and Blood and harmonizes both Yin and Yang, making it the first-choice formula for treating palpitations and Jie Dai Mai (Knotted and Intermitting Pulse). It is now extended to cardiovascular diseases, such as arrhythmias of various causes, myocarditis, coronary heart disease, rheumatic heart disease, pulmonary heart disease, coronary atherosclerosis, and aortic sclerosis, provided there are Jie Dai Mai (Knotted and Intermitting Pulse) and palpitations. When applying, adjustments should be made based on whether the condition leans towards Yang deficiency or Yin deficiency. For Yang deficiency, add Fu Pian (Prepared Aconite Root), Huang Qi (Astragali Radix), and Rou Gui (Cinnamomi Cortex); for Yin deficiency, add Gou Qi (Lycii Fructus) and Shan Yao (Dioscoreae Rhizoma).
44. In Shang Han (Cold Damage), if the physician mistakenly used purgatives, leading to persistent diarrhea with undigested food and body pain, urgent rescue of the Interior is required. (Later,) if body pain persists but bowel movements are normal, urgent rescue of the Exterior is required. To rescue the Interior, Si Ni Tang (Counterflow Decoction) is suitable; to rescue the Exterior, Gui Zhi Tang (Cinnamon Twig Decoction) is suitable. Original Text 91
① Qing Gu (Clear Grain): "Qing" is anciently interchangeable with "Qing" (toilet). Qing Gu means diarrhea with undigested food.
② Qing Bian: Means defecation.
Zheng's Commentary: The methods of rescuing the Exterior and Interior are quite consistent with the pathology; no further elaboration is needed.
[Elucidation]: After mistaken purging of an Exterior syndrome, Interior Qi is severely deficient, referring here to Spleen-Stomach deficiency-cold, severe enough to cause undigested food in stool. The severity is evident. Although there are exterior signs like body pain, they cannot be attended to. Because the Interior is deficient and cold, attempting to release the Exterior again would likely cause collapse. Therefore, Si Ni Tang (Counterflow Decoction) must be used urgently to rescue the Interior. Once bowel movements normalize, if exterior signs like body pain remain, Gui Zhi Tang (Cinnamon Twig Decoction) is then used to release the Exterior.
Si Ni Tang (Counterflow Decocoction) Formula (Textual Correction and Supplement)
Zhi Gan Cao (Glycyrrhizae Radix et Rhizoma Preparata) 2 liang, Gan Jiang (Zingiberis Rhizoma) 1.5 liang, Fu Zi (Aconiti Lateralis Radix Preparata) one piece (raw, peeled, broken into eight pieces). The above three ingredients are boiled in three sheng of water until reduced to one sheng and two he. Remove the dregs and divide into two warm doses. Strong individuals may use one large Fu Zi (Aconiti Lateralis Radix Preparata) and three liang of Gan Jiang (Zingiberis Rhizoma).
[Formula Analysis and Scope of Application]: Si Ni Tang (Counterflow Decoction) is the main formula for restoring Yang and rescuing from collapse. Gan Jiang (Zingiberis Rhizoma) and Fu Zi (Aconiti Lateralis Radix Preparata) are pure Yang and intensely hot herbs; Fu Zi (Aconiti Lateralis Radix Preparata) is like a ball of fierce fire. The human body relies entirely on a ball of True Fire. If True Fire is about to extinguish, the disease manifests as Pure Yin. Zhongjing used it to replenish the dying spark of congenital Fire, thus using it as the sovereign herb. Gan Jiang (Zingiberis Rhizoma) is acrid, fierce, warm, and dispersing, capable of sweeping away obstructions by Yin pathogens, allowing Fu Zi (Aconiti Lateralis Radix Preparata) to penetrate directly to the root. With the revival of the Fire spark, life is immediately restored, hence it is called "Restoring Yang". Once Yang Qi returns, if not covered by Earth, the flame easily extinguishes, and longevity is not ensured. Therefore, the sweetness of Gan Cao (Glycyrrhizae Radix et Rhizoma) follows to moderate the vigorous Qi; moderation implies subduing/anchoring. With True Fire anchored, the root of life is secure, allowing rebirth. The original text of *Shang Han Lun* treats diarrhea with undigested food, Jue Ni (Cold Reversal) of the Three Yin meridians, aversion to cold, and deep, faint pulse.
Ancient sages stated: Cold diseases are mostly due to Yang deficiency, and Si Ni Tang (Counterflow Decoction) is not exclusively legislated for Shaoyin (Lesser Yin). It can treat Tai Yang (Greater Yang) disease with deep pulse, cold entering the Three Yin meridians, and all conditions of Yang deficiency. Zheng stated in *Yi Fa Yuan Tong*: "Shaoyin (Lesser Yin) is the place where Water and Fire intersect, the root of Primordial Qi. Si Ni Tang (Counterflow Decoction) is not exclusively for Shaoyin (Lesser Yin); it contains methods for the Upper, Middle, and Lower parts." He subsequently listed its versatile applications: (1) Treating cold head, (2) Treating asthma and rattling phlegm, (3) Treating swollen ears with normal skin color, (4) Treating black tongue and scorched lips without thirst and low spirit, (5) Treating sore throat, aversion to cold, and cold feet, (6) Treating sore throat, high fever, red face, closed eyes, and cold tongue, (7) Treating hematemesis and fatigue, (8) Treating bleeding from gum crevices, (9) Treating morning eating and evening vomiting with undigested food, (10) Treating burning heat in soles at night without thirst and frequent urination, (11) Treating red face and fever with sweating and spasms, (12) Treating hematochezia, shortness of breath, and low spirit, (13) Treating head tremors, pale face, and low spirit, (14) Treating cold back and closed eyes, (15) Treating swollen, stiff, and blue tongue, (16) Treating swollen and red lips without thirst, (17) Treating running nasal discharge, pale face, and low spirit, (18) Treating frequent urination, (19) Treating generalized lumps with normal skin color, (20) Treating sudden appearance of red patches like clouds, without heat or thirst, (21) Treating fever, delirium, lack of spirit, and no thirst, (22) Treating blue sclera, (23) Treating red misty lines in eyes with slight swelling but no pain. Finally, Zheng said: "This formula has many functions. Those who grasp its essence can use one formula to treat hundreds of diseases, with infinite utility through modifications. I have saved many people with this formula, and they call me Mr. Ginger and Aconite." Indeed, the reappearance of Si Ni Tang (Counterflow Decoction)'s life-saving power, and the countless lives saved by its skilled use, can be said to be unprecedented. In my clinical practice, reflecting on this formula's ability to restore Yang, I believe any disease caused by Yang deficiency and Yin excess in the world can be treated with it. Why wait for signs like cold extremities, abdominal pain, diarrhea, and faint pulse? Upon seeing any Yang deficiency pattern, adjusting the dosage appropriately yields immediate results without side effects, thanks to the teaching of Zheng's three books.
45. After Shang Han (Cold Damage) and purging, if there is irritability, abdominal fullness, and restlessness (unable to lie down or sit up), Zhi Zi Hou Po Tang (Gardenia and Magnolia Bark Decoction) should be administered. Original Text 79
Zheng's Commentary: After purging, leading to irritability, abdominal fullness, and restlessness, it is generally due to purging injuring the Yang of the Middle Palace (Spleen/Stomach), causing turbid Yin to obstruct upward, resulting in abdominal fullness. The essence and Qi of the Spleen and Stomach cannot transport upward to the Heart, causing irritability. Pathologically, this should be treated by warming the Middle and supporting Yang. Why use heat-clearing and stagnation-breaking agents? This seems inappropriate. If it were truly Heat Pathogen, lingering diffusely after purging with visible heat signs, then the original text's prescription is indispensable. Students must know this.
[Elucidation]: Post-purging irritability, abdominal fullness, and restlessness, as Zheng stated, involve two different situations. If purging injured the Yang of the Middle Palace, one should warm the Middle and support Yang, using Li Zhong Tang (Regulate the Middle Decoction). If Heat Pathogen lingers diffusely after purging with visible heat signs, Zhi Zi Hou Po Tang (Gardenia and Magnolia Bark Decoction) can be used.
Zhi Zi Hou Po Tang (Gardenia and Magnolia Bark Decoction) Formula (Textual Correction and Supplement)
Zhi Zi (Gardeniae Fructus) 14 pieces (split), Hou Po (Magnoliae Officinalis Cortex) 4 liang (honey-fried, peeled), Zhi Shi (Aurantii Fructus Immaturus) 4 pieces (soaked in water, honey-fried until yellow). The above three ingredients are boiled in three and a half sheng of water until reduced to one and a half sheng. Remove the dregs and divide into two doses. Take one dose warm. If vomiting occurs, stop subsequent doses.
[Formula Analysis and Scope of Application]: Zhang Yin'an said: "The bitterness and cold of Zhi Zi (Gardeniae Fructus) can drain heat and irritability from the Heart; the bitterness and warmth of Hou Po (Magnoliae Officinalis Cortex) can dissipate abdominal fullness in the Spleen; the bitterness and cold of Zhi Shi (Aurantii Fructus Immaturus) can resolve heat binding in the Stomach." Combined, they clear heat and relieve irritability; as Qi moves, fullness resolves naturally.
46. In Shang Han (Cold Damage), if the physician used pill purgatives for strong purging, leaving body heat unresolved and slight irritability, Zhi Zi Gan Jiang Tang (Gardenia and Dried Ginger Decoction) should be administered. Original Text 80
Zheng's Commentary: Strong purging is not comparable to mild purging. If it is called strong purging, how could pathogens be expelled yet remain? With persistent body heat and slight irritability, I fear Yang is escaping from the exterior, being nearly exhausted. If vomiting is induced further, will it not hasten death?
[Elucidation]: After strong purging, the Yang of the Spleen and Stomach is damaged, forming Cold in the Middle Jiao (Middle Burner). From the clause, persistent body heat and slight irritability indicate Heat in the Upper Jiao (Upper Burner). Treatment involves Zhi Zi (Gardeniae Fructus) clearing Upper Jiao Heat to relieve irritability, and Gan Jiang (Zingiberis Rhizoma) warming the Middle and dispersing Cold. I do not understand Zheng's meaning behind "If vomiting is induced further, will it not hasten death!"
Zhi Zi Gan Jiang Tang (Gardenia and Dried Ginger Decoction) Formula (Textual Correction and Supplement)
Zhi Zi (Gardeniae Fructus) 14 pieces (split), Gan Jiang (Zingiberis Rhizoma) 2 liang. The above two ingredients are boiled in three and a half sheng of water until reduced to one and a half sheng. Remove the dregs and divide into two doses. Take one dose warm (if vomiting occurs, stop subsequent doses).
[Formula Analysis and Scope of Application]: Zhi Zi (Gardeniae Fructus) is bitter and cold, clearing heat and relieving irritability; Gan Jiang (Zingiberis Rhizoma) is acrid and hot, warming the Middle and dispersing Cold. Cold and Hot have different natures and functions. Use the appropriate medicine for the disease; what is wrong with that? This is a formula combining Cold and Hot, employing both Warming and Clearing methods. The post-formula statement "If vomiting occurs, stop subsequent doses" is illogical and should be deleted.