[Background Information]
Book: Shanghan Zhengzhi Zhunsheng (Standard for Diagnosis and Treatment of Cold Damage)
Author: Wang Kentang
Dynasty: Ming
Chapter: Heart Pain, Epigastric Pain / Irritability (Fan)
Category: Cold Damage (Shanghan)

[English Translation]

After five or six days of contracting a cold damage disease, following a severe purgative treatment, if the body heat persists and there is a sensation of painful constriction in the heart region, indicating that the pathogen has not yet resolved, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should be administered. (Cheng Wuji's commentary: When five or six days have passed since contracting cold damage, the pathogen is in the interior. If after severe purgation, the body heat subsides and the chest and heart feel empty and comfortable, it indicates the disease is about to resolve. If after severe purgation, the body heat subsides but there is painful constriction in the heart, this is Jie Xiong (Chest Binding). If the body heat does not subside and there is painful constriction in the heart, this is Xu Fan (Empty Irritability). Jie Xiong involves heat binding in the chest, which is an excess condition; the heat has converged internally, so external body heat subsides. Xu Fan involves heat lodging in the chest without forming excess, scattering to cause irritability, hence body heat persists. The sixth and seventh days are typically when the disease should resolve, but because the heat manifests as empty irritability, it is said "not yet resolved." Administer Zhi Zi Chi Tang to eliminate the pathogen via emesis. The phrase "body heat persists" warrants careful consideration. In Jie Xiong, the body is not hot, indicating the heat is not in the exterior, so Da Xian Xiong Tang (Major Yinward-Draining Chest Decoction) or Wan can be used to purge downwards. Now that the heat remains in the exterior, it is appropriate to use emesis to disperse it. Cheng Wuji's commentary is not thorough enough.)

Yangming Wind Strike presents with a wiry, floating, and large pulse, shortness of breath, abdominal fullness, pain in the hypochondrium and epigastrium, dry nose, absence of sweating, lethargy, jaundice, difficult urination, tidal fever, and occasional hiccups. Xiao Chai Hu Tang (Minor Bupleurum Decoction) should be administered (see Stomach Excess Syndrome).

Shaoyin Disease presents with spontaneous diarrhea of clear water, purely green in color, inevitable pain in the epigastrium, and dry mouth. Urgent purgation is required, and Da Cheng Qi Tang (Major Order the Qi Decoction) is indicated. (Cheng Wuji's commentary: Shaoyin belongs to Kidney Water, and green corresponds to Liver Color. Diarrhea of green water indicates Liver Pathogen attacking the Kidney. The Nan Jing states: "Coming from the preceding element is an Excess Pathogen." Because the Kidney harbors excess pathogen, it inevitably causes epigastric pain and dry mouth. Da Cheng Qi Tang is given to purge the excess pathogen.)

Jueyin Disease manifests as excessive thirst (Xiao Ke), qi rushing up to strike the heart, painful heat in the heart, hunger without desire to eat, and vomiting of roundworms upon eating. If purgation is used, it will lead to continuous diarrhea (Gui Zhi Fu Ling Bai Zhu Tang may be used).

Appendix: Moxibustion. For cold damage caused by excessive drinking of water, resulting in abdominal distension, panting, and unbearable pain in the epigastrium, moxibustion on Zhongwan (CV12) and Qihai (CV6) is suitable. If there is qi rushing up from the lower abdomen, Tian Shu (ST25), Qichong (ST30), Zusanli (ST36), and Sanyinjiao (SP6) should be moxed (if these symptoms are absent, only the first two acupoints are needed).

(Old editions included "irritating pain" here. Upon detailed examination, "irritating pain" refers to body and limb pain accompanied by a sense of grievance and irritation, which differs from mental irritability (Fan Xin) and should not be indiscriminately included; thus, it has been removed.)

"Irritability" (Fan) is a manifestation of heat, referring to a state of restlessness and disturbance. It appears similar to fever but is distinct. Irritable heat is being disturbed by heat pathogens without interval, unlike fever which comes and goes intermittently. The classics mention Fan (Irritability), Wei Fan (Mild Irritability), Fan Re (Irritable Heat), Fu Fan (Recurring Irritability), Fan Fan (Reverse Irritability), Fan Man (Irritable Fullness), Fan Tong (Irritating Pain), Fan Ke (Irritating Thirst), Xiong Zhong Fan (Chest Irritability), Xin Zhong Fan (Heart Irritability), Nei Fan (Internal Irritability), Xu Fan (Empty Irritability), and Da Fan Yu Jie (Severe Irritability Resolving), all using "Fan" as a marker of heat. However, cases of irritability due to yin-cold are also numerous. If irritability occurs in the exterior, there are signs such as floating pulse, aversion to wind and cold, and body stiffness/pain. If in the interior, there are tidal fever, delirium, constipation, abdominal fullness, and dark/scanty urine. If at half-exterior/half-interior, there are alternating chills and fever, and hypochondriac pain. If the pathogen is above the chest and diaphragm causing irritability, there is chest fullness and Ao Nao (regretful discomfort), treatable by emesis. If due to yin-cold, there is aversion to cold, curling up, diarrhea, cold limbs, faint pulse, and vomiting of worms. When severe irritability resolves, the pulse must be harmonious; if the pulse does not correspond, it is difficult to treat. If feet are cold and the pulse is deep, fine, and faint, this is irritability of a yin syndrome, requiring urgent warming with hot formulas like Ren Shen Fu Zi Tang (Ginseng and Aconite Decoction). If irritability arises from internal injury, overwork, yin deficiency, and fire hyperactivity, the patient is fatigued, weak, sweats spontaneously, and has a floating/deficient chi pulse. Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) added with stir-fried Huang Lian (Coptis Rhizome), Sheng Di Huang (Rehmannia Root), Mai Men Dong (Ophiopogon Tuber), Huang Bo (Phellodendron Bark), and Zhi Mu (Anemarrhena Rhizome) is suitable. If insomnia accompanies irritability, Zhu Sha An Shen Wan (Cinnabar Calming the Spirit Pill) can be taken to anchor floating fire and calm the spirit. This is merely a general overview. Skilled physicians should cross-reference various syndromes.

Xu Fan (Empty Irritability), Xiong Zhong Fan (Chest Irritability), and Xin Zhong Fan (Heart Irritability) that do not arise from sweating, emesis, or purgation are due to transmitted pathogenic factors, not phlegm-fluid retention in the diaphragm, and are mostly treated with harmonizing methods, such as Xiao Chai Hu Tang, Huang Lian E Jiao Tang (Coptis and Donkey-Hide Gelatin Decoction), or Zhu Fu Tang (Pig Skin Decoction). If irritability arises after sweating, emesis, or purgation, it is due to pathogenic heat sinking inward becoming Xu Fan, characterized by Ao Nao in the heart and a helpless urge to vomit. These are mostly treated with emesis, such as 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 not induced by sweating/emesis/purgation, and pathogen binds in the chest becoming Phlegm-Fluid Retention in the Diaphragm, Gua Di San (Melon Sepal Powder) is used. For Yangming irritability, Tiao Wei Cheng Qi Tang (Regulate the Stomach and Order the Qi Decoction) is used; these are excess forms of irritability. In cold damage, if palpitations and irritability occur on the second or third day, it is a deficiency syndrome, treated with Jian Zhong Tang (Establish the Middle Decoction). If Shaoyang pathogen enters the fu organs causing irritability and palpitations, it is heat. Generally, irritability followed by palpitations indicates heat; palpitations followed by irritability indicates deficiency. Treating disease requires seeking the root, which is what this refers to.

In Taiyang Cold Damage, after sweating resolves the condition, if irritability returns after half a day with a floating and rapid pulse, another sweating method is appropriate, using Gui Zhi Tang (Cinnamon Twig Decoction) (Sweating leading to cool body indicates resolution; return of heat after half a day means pathogen remains, so re-sweating is needed).

In Taiyang Disease, if after initially taking Gui Zhi Tang, irritability worsens and does not resolve, first needle Fengchi (GB20) and Fengfu (GV16), then administer Gui Zhi Tang for cure (Fengchi is the intersection of the Gallbladder Meridian and Yang Linking Vessel. Needling Fengchi instead of Tianzhu (BL10) is because the Yang Linking Vessel connects all yang meridians, and the Greater Yang governs qi for all yang). After sweating, if the pulse is floating and rapid with irritability and thirst, Wu Ling San (Five-Ingredient Powder with Poria) is used. For Wind Strike fever persisting for six or seven days without resolution, accompanied by irritability and exterior-interior signs, thirst, desire to drink, and vomiting immediately after drinking (Water Reverse), Wu Ling San is used. For a disease in the yang aspect that should be treated by sweating but was instead cooled with cold water washing/spraying, causing heat to remain, increasing irritability, and goosebumps on the skin, with desire to drink but no actual thirst, Wen Li San (Clam Shell Powder) is administered; if ineffective, Wu Ling San is given (formula see Thirst section). After vomiting and purgation in cold damage, if unresolved after seven or eight days, with heat binding in the interior, exterior and interior both hot, occasional aversion to wind, extreme thirst, dry tongue, and irritability, Bai Hu Jia Ren Shen Tang (White Tiger Decoction plus Ginseng) is used. After heavy sweating from Gui Zhi Tang, if severe irritability and thirst persist without resolution and the pulse is flooding and large, Bai Hu Jia Ren Shen Tang is indicated.

Yuan (Li Dongyuan) treats yin-deficiency fever with irritability, thirst, craving food, heat, and agitation, worse at night, with a flooding pulse that is empty upon pressure. This is blood deficiency causing agitation, treated with Dang Gui Bu Xue Tang (Angelica Tonifying Blood Decoction). Using Bai Hu Tang would be a mistake. If the pulse is floating and large lightly but disappears upon pressure, it is a scattered pulse without root, indicating extreme deficiency and impending collapse of yuan qi. Exterior-releasing or heat-purging methods must not be used; mis-treatment leads to death. Large doses of Ren Shen Sheng Mai Tang (Ginseng Generating Pulse Decoction) are required to save the patient (Dang Gui Bu Xue Tang formula see Miscellaneous Diseases Fever Section).

After sweating or purgation in Taiyang Disease, if irritability and chest oppression occur, Zhi Zi Chi Tang is used. After severe purgation in cold damage (5-6 days), if body heat persists and there is painful constriction in the heart, indicating unresolved disease, Zhi Zi Chi Tang is used. After sweating, emesis, or purgation, if the patient has irritability and insomnia, or severe restlessness and Ao Nao, Zhi Zi Chi Tang is used. If there is shortness of breath, Zhi Zi Gan Cao Chi Tang (Gardenia, Licorice, and Fermented Soybean Decoction) is used. If there is vomiting, Zhi Zi Sheng Jiang Chi Tang (Gardenia, Ginger, and Fermented Soybean Decoction) is used.

Zhi Zi Chi Tang Formula:
Zhi Zi (Gardeniae Fructus, 14 pods, broken) and Xiang Chi (Fermented Soybeans, 4 he measured units, wrapped in silk). Boil these two ingredients in four sheng of water. First boil Zhi Zi until two and a half sheng remain, then add Xiang Chi and boil until one and a half sheng remain. Strain and divide into two warm doses. Stop subsequent doses if vomiting occurs.

The Classics state: For high pathogenic factors, use emesis to raise them out; for low ones, use draining to exhaust them; for middle fullness, purge from within; for exterior pathogens, soak the form to sweat; for skin-level pathogens, release via sweating. The subtleties of treating cold damage involve variation but ultimately adhere to these methods. Cold damage pathogens transmit from exterior to interior, remaining in the chest (high position), allowing for emesis. Types of emesis vary. If not preceded by sweating/emesis/purgation, pathogen stagnates in the diaphragm as "Excess," treated with Gua Di San to purge chest excess. If after sweating/emesis/purgation, pathogen lodges in the chest due to deficiency, it is "Xu Fan," treated with Zhi Zi Chi Tang to purge chest empty irritability. Zhi Zi is bitter and cold. The Nei Jing states: "Sour and bitter induce vomiting and purging, belonging to Yin." Yong (surge) means vomiting. To surge empty irritability, bitterness is primary, so Zhi Zi is the Sovereign herb. Irritability is due to heat excess; to surge heat, bitterness overcomes heat, and cold clears heat. Xiang Chi is bitter and cold, assisting Zhi Zi to surge empty irritability, serving as the Minister herb. The Nei Jing states: Qi has high and low positions; diseases have distant and near origins; syndromes have exterior and interior locations; treatments have light and heavy degrees. Adapt to each situation. Following these principles makes one a good physician.

Zhi Zi Gan Cao Chi Tang: Add one liang of Gan Cao (Licorice Root) to Zhi Zi Chi Tang. Follow previous method. Stop if vomiting occurs.

Zhi Zi Sheng Jiang Chi Tang: Add two liang of Sheng Jiang (Fresh Ginger) to Zhi Zi Chi Tang. Follow previous method. Stop if vomiting occurs.

After purgation in cold damage, if irritability, abdominal fullness, and restlessness (unable to lie or sit comfortably) occur, Zhi Zi Hou Po Tang (Gardenia and Magnolia Bark Decoction) is indicated. (Cheng Wuji's commentary: Post-purgation abdominal fullness without irritability indicates interior excess from pathogen entering interior. Irritability without fullness indicates empty irritability from pathogen in chest. Both irritability and fullness indicate pathogen congestion between heart and abdomen. Fullness prevents sitting; irritability prevents lying, causing restlessness. Zhi Zi Hou Po Tang purges irritability and drains fullness.)

Zhi Zi Hou Po Tang Formula (Sour/Bitter Surge/Purge: Zhi Zi's bitterness surges empty irritability; Hou Po and Zhi Shi's bitterness drains abdominal fullness):
Zhi Zi (14 pods, broken), Hou Po (Magnoliae Officinalis Cortex, 4 liang, ginger-fried), Zhi Shi (Immature Bitter Orange, 4 pieces, water-soaked, de-veined, stir-fried). Boil three ingredients in three and a half sheng of water until one and a half sheng remain. Strain and divide into two warm doses. Stop if vomiting occurs.

If a physician uses pill-based purgatives heavily in cold damage, resulting in persistent body heat and mild irritability, Zhi Zi Gan Jiang Tang (Gardenia and Dried Ginger Decoction) is indicated. (Cheng Wuji's commentary: Pill purgatives fail to clear heat and only damage righteous qi. Pathogen lodges in the chest due to deficiency without going deep, causing persistent heat and mild irritability. Zhi Zi Gan Jiang Tang purges irritability and supports righteous qi. Pill purgatives referred to as Shen Dan Gan Sui, sometimes containing Ba Dou (Croton Seed).)

Zhi Zi Gan Jiang Tang Formula (Bitter to Surge: Zhi Zi's bitterness purges irritability; Acrid to Moisten/Nourish: Gan Jiang's acridity supports qi):
Zhi Zi (14 pods, broken), Gan Jiang (Dried Ginger, 2 liang). Boil two ingredients in three and a half sheng of water until one and a half sheng remain. Strain and divide into two warm doses. Stop if vomiting occurs. For all Zhi Zi Tang usage, if the patient has a history of loose stools, it is contraindicated (History of loose stools indicates interior deficiency-cold below. Even if irritable, it is not heat stagnation, so Zhi Zi Tang for dispersing is forbidden. Nei Jing states: If diarrhea precedes other diseases, treat the root; regulate first, then treat other diseases). In Taiyang Disease, after vomiting, purgation, or sweating, if there is mild irritability, frequent urination, and consequent hard stool, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is given to harmonize for cure. After upper jiao sweating/vomiting/purgation, if Ao Nao and irritability occur without dry feces and with soft stool, it falls under Zhi Zi decoctions. If dry feces and constipation exist, it falls under Xiao Cheng Qi Tang.

Pi (Stagnation), Jie Xiong (Chest Binding), Xin Fan (Heart Irritability) (See Section II). Xin Fan Er Ke (Heart Irritability with Thirst) (See Thirst Section).

In cold damage, if on the second or third day, palpitations and irritability occur, Xiao Jian Zhong Tang (Minor Establish the Middle Decoction) is indicated. (Cheng Wuji's commentary: On day 2-3, pathogen is in exterior, not yet transmitting. Palpitations and irritability here are not due to pathogen conflict. Palpitations indicate qi deficiency; irritability indicates blood deficiency. Due to interior deficiency of qi and blood, Xiao Jian Zhong Tang is given to first establish the interior.) In Taiyang Disease, with floating-tight pulse, no sweat, fever, and body ache for eight or nine days, with exterior signs still present, sweating is indicated. After medication, if symptoms slightly decrease but irritability and eye closure occur, and severely, nasal bleeding (Bi Xi) resolves the disease. Resolution requires prior irritability followed by sweating. If Taiyang Disease passes its stage for over ten days, with epigastric stuffiness, desire to vomit, chest pain, loose stool, slight fullness, and slight depression/irritability (See Chest Disease Section). In cold damage with floating pulse, spontaneous sweat, frequent urination, irritability, slight aversion to cold, and leg cramps, giving Gui Zhi Tang to attack the exterior is an error. This leads to cold limbs, dry throat, irritability, and vomiting/reversal, treated with Gan Jiang Gan Cao Tang (Ginger and Licorice Decoction) (See Cold Limbs Section). After vomiting in Taiyang Disease, aversion to cold should persist; if absent and patient dislikes clothing, it is internal irritability from vomiting. With a slightly rapid pulse, moxibustion is strictly forbidden, as fire becomes pathogen, causing reverse irritability, chasing deficiency, pursuing excess, scattering blood, and damaging bones/tendons despite mild fire energy. After vomiting/diarrhea/sweating, if pulse is平和 (peaceful) but slight irritability persists, it is due to stomach deficiency unable to handle grain qi.

In Yangming Disease, after purgation, if exterior heat exists, hands/feet are warm, no chest binding, Ao Nao in heart, hunger but inability to eat, and only head sweating, Zhi Zi Chi Tang is indicated. In Yangming Disease, if floating-tight pulse is purged, stomach becomes empty, guest qi disturbs diaphragm, Ao Nao in heart, white coating on tongue, Zhi Zi Chi Tang is suitable (Discussion see Spontaneous Sweat Section). After diarrhea, if irritability and soft epigastrium upon pressure indicate empty irritability, Zhi Zi Chi Tang is suitable. In Yangming Disease, if slow pulse, difficulty eating to fullness, slight irritability after fullness, dizziness, and difficult urination occur, it suggests impending Gu Dan (Grass Jaundice) (See Dizziness Section). In Yangming Disease, after purgation, if Ao Nao and irritability occur, and dry feces exist in stomach, attack is possible. If slight abdominal fullness with hard head and loose tail, attack is impossible. If dry feces exist, Da Cheng Qi Tang is suitable. After major purgation, if six-seven days pass without bowel movement, unresolved irritability, and abdominal fullness/pain, it is due to existing food retention, so Da Cheng Qi Tang is used. In Yangming Disease, if irritability occurs without vomiting or purgation, Tiao Wei Cheng Qi Tang is given. (Cheng Wuji's commentary: Post-vomit irritability is Internal Irritability; post-purge irritability is Empty Irritability. Here, no vomit/purge but irritability indicates stomach stagnant heat, treated with Tiao Wei Cheng Qi Tang to purge stagnant heat.) In Yangming Disease with spontaneous sweat, if heavy sweating occurs, disease resolves but slight irritability remains due to fluid loss and dry stomach causing hard stool. Ask about urine frequency; if low, fluids return to stomach, predicting eventual normal stool. Patient with irritability/heat resolving with sweat, resembling malaria with afternoon fever, belongs to Yangming.

Regarding stomach excess with constipation and irritability: if post-vomit/purge, it is Da/Xiao Cheng Qi Tang syndrome; if pre-vomit/purge, it is Tiao Wei Cheng Qi Tang syndrome.

Xu (Xu Shuwei) treated a case of cold damage for eight-nine days with body heat, no sweat, occasional delirium, and constipation for three days post-purgation. Not dry, not irritable, not cold, not painful, but unable to sleep all night, feeling vaguely uncomfortable, occasionally sighing. Physicians did not know the syndrome. I diagnosed it as simultaneous Ao Nao and Fu Yu (depressed qi). There were dry feces in the stomach. Given Cheng Qi Tang to purge dry feces twenty-plus times, relief came upon defecation. Zhang Zhongjing stated: In Yangming Disease post-purgation, Ao Nao and mild irritability with dry feces in stomach can be attacked. Also: Urinary difficulty, alternating hard/loose stool, slight heat, Fu Yu, insomnia indicate dry feces, treated with Cheng Qi Tang. Su Wen states: "Stomach disharmony leads to restless sleep," explaining insomnia. Zhang Zhongjing stated: "Dry stomach and hard stool cause delirium," explaining occasional delirium. Non-irritability/non-dryness/non-cold/non-pain causes Ao Nao. Sighing indicates exterior qi depression. Removal of dry feces and restoration of stomach harmony cures the disease.

In Shaoyang Cold Damage, wiry-thin pulse, headache, and fever belong to Shaoyang. Sweating is forbidden; it causes delirium, relating to Stomach. Stomach harmony brings cure; disharmony causes irritability and palpitations (Huo Ren Shu uses Tiao Wei Cheng Qi Tang). Chest fullness and irritability without mild sweating/purgation or alternating chills/fever are treated with Xiao Chai Hu Tang (See Alternating Chills/Fever Section). If alternating chills/fever occur post-sweat/purge, Chai Hu Gui Zhi Gan Jiang Tang is used (See Alternating Chills/Fever Section). With palpitations, urinary difficulty, delirium, and body heaviness preventing turning, Chai Hu Gui Zhi Long Gu Mu Li Tang is used (See Palpitations Section). Vomiting with slight depression/irritability: if Xiao Chai Hu Tang fails to stop vomiting, Da Chai Hu Tang is indicated. If severe vomiting/purgation leads to chest fullness, loose stool, and abdominal pain, Tiao Wei Cheng Qi Tang is indicated.

In Taiyin Cold Damage, floating-slow pulse and warm extremities relate to Taiyin, likely leading to jaundice. If urine is free, no jaundice. By day 7-8, sudden irritability and diarrhea (>10 times) will self-resolve because Pi Jia Shi (Spleen Righteous Qi is sufficient) expels rotting filth. (Cheng Wuji's commentary: Taiyin day 7-8 with hard stool indicates transmission to Yangming. Here, sudden irritability/diarrhea indicates Spleen Righteous Qi expelling filth. Diarrhea with restlessness is fatal. Here, spleen qi harmonizes, expelling pathogen downward, so despite severe diarrhea, it stops. Use Zhi Zi Bai Pi Tang or Ping Wei San plus Shan Zha/Jia (Pangolin Scale)).

In Shaoyin Disease, if lethargy and irritability occur, and spontaneous diarrhea with thirst and white urine, Huo Ren Shu uses Si Ni Tang (Discussion see Lethargy Section). If after Bai Tong Tang, diarrhea continues, cold limbs, no pulse, dry vomiting, and irritability occur, Bai Tong Tang plus Pig Bile is used (Some say knowing it is yin syndrome, use Aconite to warm; dry vomiting/irritability indicates rejection; adding human urine/pig bile works via "hot treating cold"). In Shaoyin Disease, day 2-3, irritability and insomnia require Huang Lian E Jiao Tang. If diarrhea for 6-7 days with cough, vomiting, irritability, and insomnia, Zhu Ling Tang is used. Diarrhea with sore throat, chest fullness, and irritability requires Zhu Fu Tang. If aversion to cold, curling up, and spontaneous irritability with desire to remove clothes indicate treatability. Tight pulse to day 7-8 with spontaneous diarrhea, sudden weak pulse, warm extremities, and disappearance of tight pulse indicate resolution; despite irritability/diarrhea, it will stop.

In Jueyin Disease, cold limbs and irritability, with intermittent knotted/tight pulse, chest fullness, hunger without desire to eat, require Gua Di San for emesis. Hui Jue (Roundworm Convulsion) is quiet but periodically irritable (See Vomiting Roundworms Section). After 6-7 days, if pulses at hand/foot are present, severe irritability, jaw lock, inability to speak, and restlessness indicate resolution. If pulse is harmonious, severe irritability, and yellow inner canthus indicate resolution.