[Background Information]
Book: Shanghan Zhengzhi Zhunsheng (Standard for Diagnosis and Treatment of Cold Damage)
Author: Wang Kentang
Dynasty: Ming
Chapter: Unresolved after Sweating, Vomiting, or Purging / Asthma
Category: Cold Damage

[English Translation]

(Line 1) On the fifth or sixth day, after sweating has been applied and purging has been repeated, the pathogenic factor remains unresolved. Symptoms include fullness and slight binding in the chest and hypochondrium, dysuria, thirst without vomiting, sweating only on the head, alternating chills and fever, and irritability. This indicates that the disease is not yet resolved; treat with Chaihu Guijin Tang (Bupleurum and Cinnamon Twig Decoction).

(Line 2) After Taiyang disease has been treated with sweating, vomiting, or purging, if there is epigastric stiffness and distension accompanied by persistent belching that does not subside, treat with Xuanfuzhe Shi Tang (Inula and Hematite Decoction).

(Line 3) In Taiyang disease, if sweating was administered first but failed to resolve the condition, followed by erroneous purging, and the pulse remains floating, it indicates the pathogen is still in the exterior. It should be resolved from the exterior using Guizhi Tang (Cinnamon Twig Decoction).

(Line 4) If sweating or purging fails to resolve the condition, resulting in restlessness and insomnia, treat with Fuling Sini Tang (Poria and Four Reversal Decoction).

(Line 5) Following severe sweating or profuse diarrhea, if cold extremities occur, treat with Sini Tang (Four Reversal Decoction).

(Line 6) After purging followed by sweating, if the patient experiences daytime irritability and inability to sleep, but remains quiet at night, without vomiting or thirst, lacking exterior signs, with a deep and faint pulse, and no significant body heat, treat with Ganjiang Fuzi Tang (Dried Ginger and Aconite Decoction).

(Line 7) After purging followed by sweating, the patient inevitably shivers and feels cold, with a faint and thin pulse; this indicates deficiency in both the interior and exterior.

(Line 8) Cold damage initially involves cold pathogens, but subsequent vomiting or purging causes food to be vomited immediately upon entry. Treat with Ganjiang Huanglian Huangqin Renshen Tang (Dried Ginger, Coptis, Scutellaria, and Ginseng Decoction).

(Line 9) After sweating, vomiting, or purging, if empty irritability and insomnia occur, with severe cases involving tossing and turning and inner vexation, treat with Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction).

(Line 10) After sweating or purging, if irritability and heat sensation with chest oppression occur, treat with Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction).

(Line 11) After vomiting or purging, if constipation persists from the fifth day to over ten days, with evening tidal fever, aversion to cold absent, muttering as if seeing ghosts, picking at clothes and bedrails, a wiry pulse indicates survival, while a choppy pulse indicates death. If there is only fever and delirium, treat with Dachengqi Tang (Major Order the Qi Decoction).

(Line 12) After vomiting or purging, if abdominal fullness occurs due to pathogenic heat entering the stomach, treat with Xiaochengqi Tang (Minor Order the Qi Decoction).

(Line 13) After Taiyang disease is treated with vomiting or purging, if slight irritability, frequent urination, and hard stool occur, treat with Xiaochengqi Tang (Minor Order the Qi Decoction).

(Line 14) After vomiting or purging, if the condition remains unresolved after seven or eight days, with heat binding in the interior, simultaneous exterior and interior heat, occasional aversion to wind, extreme thirst, dry tongue coating, and irritability desiring water, treat with Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction).

(Line 15) After vomiting or purging, if epigastric rebellion and fullness, qi rushing to the chest, dizziness, and a deep, tight pulse occur, further sweating will disturb the collaterals, causing body tremors. Treat with Fuling Guizhi Baizhu Gancao Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala, and Licorice Decoction).

Cheng Wuji's Commentary: The Lung governs Qi. External cold or cold drinks injure the Lung, causing Qi to reverse upward. This manifests as rushing Qi,急促 breathing, gasping, opening the mouth, raising shoulders, shaking the body, and rolling the abdomen—this is asthma (chuan). When pathogenic factors are in the exterior causing Qi obstruction leading to asthma, use Mahuang Tang (Ephedra Decoction) or Guizhi Jia Houpo Xingren Tang (Cinnamon Twig Plus Magnolia Bark and Apricot Kernel Decoction). When fluid retention attacks the Lung causing asthma, use Xiao Qinglong Tang (Minor Green Dragon Decoction). After sweating, drinking too much water will cause asthma; bathing with cold water also causes asthma. For Cold Damage with fluid retention in the epigastrium, presenting with dry heaves, fever, cough, or asthma, use Xiao Qinglong Tang.

Asthma patients (those with chronic asthma) who have sweating should use Guizhi Tang plus Houpo (Magnolia Bark) and Xingren (Apricot Kernel), which is preferable (Taiyang disease governs Yang Qi; excessive Wind causes Qi stagnation leading to asthma. Guizhi Tang disperses Wind, while Houpo and Xingren direct Qi downward).

If Taiyang disease is erroneously purged, resulting in slight asthma because the exterior is not resolved, Guizhi Jia Houpo Xingren Tang is indicated. (Severe asthma after purging indicates severe interior deficiency and transmission of pathogen; slight asthma indicates interior Qi rebellion with pathogen remaining in the exterior. Guizhi Tang resolves the exterior, while Houpo and Xingren direct rebellious Qi downward.)

Guizhi Jia Houpo Xingren Tang Formula: Guizhi (Cortex Cinnamomi, peeled), Shaoyao (Radix Paeoniae Rubra), Shengjiang (Rhizoma Zingiberis Recens, sliced, each 3 liang), Houpo (Cortex Magnoliae Officinalis, processed, peeled), Gancao (Radix Glycyrrhizae Uralensis, processed, each 2 liang), Xingren (Semen Pruni Armeniacae, peeled and dehydrated, 50 pieces), Dazao (Fructus Jujubae, 12 pieces, split). Seven ingredients. Boil in 7 sheng of water to obtain 3 sheng. Remove dregs. Warm take 1 sheng.

After sweating, do not use Guizhi Tang again. If sweating occurs with asthma and no significant high fever, Ma Huang Xing Ren Gan Cao Shi Gao Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction) may be used. (Cheng Wuji notes: Post-sweating asthma should typically be treated with Guizhi Jia Houpo Xingren Tang. Sweating usually relieves asthma; if sweating accompanies asthma, it indicates severe pathogenic congestion, which Guizhi Tang cannot disperse. High fever indicates intense internal heat; lack of significant fever indicates severe exterior pathogen. Use Ma Huang Xing Ren Gan Cao Shi Gao Tang to disperse the pathogen. Zhang Jingyue notes: Zhongjing often states that after sweating, the exterior pathogen is completely resolved, leaving only one symptom. Thus, Guizhi Tang is contraindicated. Here, sweating with asthma and no high fever indicates residual upper Jiao pathogen. Using Guizhi Jia Houpo Xingren Tang is for cases where all Guizhi symptoms are present plus asthma. The note claiming severe congestion makes Guizhi ineffective is an error. Furthermore, without high fever or other signs, claiming severe exterior pathogen is illogical. Later comments clarify that sweating and purging differ but should not damage righteous Qi. This highlights an inconsistency in the original commentary.)

After purging, do not use Guizhi Tang again. If sweating occurs with asthma and no significant high fever, Ma Huang Xing Ren Gan Cao Shi Gao Tang may be used. (Cheng Wuji notes: This matches the previous clause regarding post-sweating treatment. Although sweating and purging differ, neither should damage righteous Qi. Since the transmitted pathogen is the same, the treatment is identical, as stated in the Classic: "After sweating, purging, or vomiting.")

Ma Huang Xing Ren Gan Cao Shi Gao Tang Formula: Ma Huang (Herba Ephedrae, 4 liang, nodes removed), Xingren (Semen Pruni Armeniacae, 50 pieces, peeled and dehydrated), Gancao (Radix Glycyrrhizae Uralensis, processed, 2 liang), Shi Gao (Mineral Gypsum, 0.5 jin, crushed, wrapped in silk). Four ingredients. Boil in 7 sheng of water. First boil Ma Huang, reduce by 2 sheng, remove foam. Add other herbs. Boil to obtain 2 sheng. Remove dregs. Warm take 1 sheng. (The Liver dislikes tension and seeks sweetness to relax it. Wind Qi connects to the Liver. When Wind pathogen is excessive externally, sweet agents are used to release it.)

Taiyang Disease (Harmonizing Method): If a Guizhi pattern is erroneously purged, leading to persistent diarrhea and a rapid pulse indicating unresolved exterior, or if asthma with sweating occurs, use Gegen Qinlian Tang (Kudzu Root, Scutellaria, Coptis, and Licorice Decoction).

Yangming Disease Wind Strike (Sweating Method): Bitter taste in mouth, dry throat, abdominal fullness, slight asthma, fever, aversion to cold, floating and tight pulse. Erroneous purging leads to abdominal fullness and dysuria; use Mahuang Tang. If Yangming disease presents with floating pulse, no sweating, and asthma, sweating will resolve it; use Mahuang Tang.

Yangming Disease (Harmonizing Method): Floating and tight pulse, dry throat, bitter taste, abdominal fullness, asthma, fever, sweating, aversion to heat rather than cold, heavy body. Use Baihu Tang (White Tiger Decoction). Wuling San (Five-Ingredient Powder with Poria).

Cold Damage on the fourth or fifth day, with deep pulse and asthma/fullness. Deep indicates interior; erroneous sweating causes fluid loss, making defecation difficult. Exterior deficiency and interior excess lead to delirium over time. (When pathogen enters interior, deep pulse and asthma/fullness indicate interior syndrome requiring purging. Erroneous sweating dries the Stomach, causing hard stool and delirium. Dachengqi Tang is indicated.)

Yangming disease with slow pulse, sweating without aversion to cold, heavy body, shortness of breath, abdominal fullness, and asthma, with tidal fever, indicates the exterior is resolving and interior can be attacked. Continuous sweating on hands and feet indicates hardened stool; Dachengqi Tang is indicated. If the patient has dysuria, intermittent difficulty in defecation, slight fever, asthma, vertigo, and inability to lie down, dried feces are present; Dachengqi Tang is indicated.

Diagnosis: After Cold Damage vomiting/purging, if constipation, tidal fever, unconsciousness, picking at clothes, slight asthma, fixed gaze, wiry pulse (survival) or choppy pulse (death) occur. Wet-type patients purged with forehead sweating, slight asthma, and normal bowel/bladder function face death. Shaoyin disease with high respiration faces death. Cold extremities, absence of pulse, failure to recover after moxibustion, with slight asthma facing death. Fixed gaze, delirium, asthma/fullness facing death. Floating and洪 (surging) pulse, oily sweating, moist hair, unceasing asthma indicates life extinction.

Appendix:
Huoren Shu: Yin-pattern asthma with urgency is treated with Fanyin Dan (Return to Yin Pill). Cold extremities with asthma improve upon ingestion. Patients with slight thirst who drink excessively, causing fluid retention and epigastric binding, often die of asthma; treat with Wuling San or Xianxiong Wan.

Dai Yuanli: Asthma and cough have Yin and Yang patterns. Shaoyang has cough but no asthma; presence of asthma excludes Shaoyang. If Shaoyang signs accompany asthma, use Xiaochaihu Tang (Minor Bupleurum Decoction) plus Bei Wuweizi (Schisandra) and Ganjiang (Dried Ginger). Yangming has asthma but no cough; if Yangming signs accompany asthma with tidal fever, use Dachengqi Tang. Yin-pattern asthma is exclusive to Shaoyin. Heavy limbs, pain, normal urine, loose stool with cough: Zhenwu Tang minus Shaoyao, plus Bei Wuweizi, Ganjiang, and Xixin (Asarum)—this is Yin within Yin. Cold extremities, abdominal pain, diarrhea with heavy sensation and cough: Sini Tang plus Bei Wuweizi and Ganjiang. Diarrhea, vomiting, thirst, irritability, insomnia with cough: Zhu Ling Tang (Polyporus Decoction)—this is Yang within Yin. All Yin-pattern asthmas are critical; use Fanyin Dan.

Wu Qiu: Exterior cold causing asthma (floating/tight pulse, aversion to cold, body pain, no sweating) requires Mahuang Tang to sweat. Exterior wind causing asthma (floating/relaxed pulse, aversion to wind, spontaneous sweating) requires Guizhi Tang plus Houpo and Xingren. Yangming interior excess with constipation, abdominal fullness, shortness of breath, tidal fever, and asthma requires Da Chaihu Tang plus Houpo and Xingren, or Xiaochengqi Tang. Yin-pattern cold extremities, deep/faint pulse, shortness of breath, asthma, no sweating: Sini Tang plus Wuweizi and Xingren. Deficiency pulse, cold extremities, asthma: Wuweizi Tang. Sudden exposure to wind/cold, floating pulse, no sweating, asthma: Su Shen Jiu Bao Tang. Excessive heat with phlegm, wiry/rapid pulse, asthma (no sweating/purging allowed): Xiaochaihu Tang plus Zhimu, Beimu, Gualou Ren. Chest fullness adds Zhike and Jiegeng. Epigastric fullness adds Zhishi and Huanglian. Dry tongue/thirst adds Zhimu and Shigao. Ancient texts state asthma is serious. Hua Tuo said: "Excess leads to asthma," meaning excess of pathogenic fire in the Lung, not Lung Qi itself. Xiebai San clears Lung fire, not the Lung organ itself. Xiexin Tang clears epigastric fullness. Weisheng Baojian states: Treat apparent excess as deficiency, as the constitution is deficient while pathogen is excess.

Wuweizi Tang (See Jue Section).

Su Shen Jiu Bao Tang: Sangbaipi (Morus Cortex), Gancao (Licorice), Dafupi (Areca Peel), Guanzi (Cinnamon Twig), Mahuang (Ephedra), Bohe (Mint), Chenpi (Citrus Peel), Zisu (Perilla Leaf), Xingren (Apricot Kernel), Shengjiang (Ginger), Wumei (Mume Fruit). Boil in 2 zhong water to 0.8 zhong. Strain and drink.

Jiajian Xiebai San: Treats irritability, chest discomfort, upper asthma, dry mouth, or cough. Sangbaipi, Zhimu, Juhong (Tangerine Peel), Gualou Ren (Trichosanthes Seed), Huangqin (Scutellaria), Beimu (Fritillaria), Jiegeng (Platycodon), Gancao (each 1.5 qian), Digupi (Lycium Cortex, 1 qian). Prepare as before.