If sweating or purgation is performed, and the illness still does not resolve, with dysphoria present, Poria Cold-Extremities Decoction should be used.

bubble_chart Note

• This follows from the previous passage.
• First, sweating should be induced, and then decoction should be administered later. This method is not contrary to the principles, and the illness should resolve. However, if it still does not resolve and dysphoria persists, it indicates a different treatment approach. This is because both sweating and purgation have been overused, leading to deficiency in both the exterior and interior, with exuberant yin repelling yang, resulting in disturbances seen day and night. In such cases, Cold-Extremities Decoction should be used to tonify yang and overcome yin, with the addition of Poria to suppress yin pathogens and Ginseng to support healthy qi. This way, yang will grow while yin diminishes, the right qi will return, and the pathogenic factors will retreat, leading to the resolution of the illness and the alleviation of dysphoria.
• In the case of Dyers Woad syndrome, dysphoria without sweating is due to the absence of sweating and purgation, and it is considered a substantial condition. In this passage, the dysphoria that persists after sweating and purgation is considered a deficiency condition.
• However, the floating and tight pulse versus the deep and faint pulse should be distinguished to avoid misdiagnosis. Therefore, this is emphasized repeatedly.

bubble_chart Collected Commentary

• Wang Hu said: "In cold-damage disease, sweating and purgation should stop dysphoria and resolve the illness. However, in cases of dysphoria due to yin exuberance, forcibly inducing sweating will lead to exterior laxity and yang exhaustion; repeated purgation will lead to interior deficiency and yin exhaustion. When defensive yang loses its protection and nutritive yin becomes empty internally, the pathogenic factors remain unresolved, and dysphoria worsens. This is also a case of false heat due to deficiency. Only warming and tonifying should be used, and dispersing pathogenic factors should be avoided. Therefore, Poria Cold-Extremities Decoction is the appropriate treatment."

bubble_chart Formula

Poria Cold-Extremities Decoction Formula
Poria 6 liang, Ginseng 1 liang, Liquorice Root 2 liang (roasted), Dried Ginger 1.5 liang, Aconite Lateral Root 1 piece (used raw, peel removed, broken into 8 pieces)
The above five ingredients are boiled in 5 sheng of water until 3 sheng remain. The dregs are removed, and the decoction is taken warm, 7 ge at a time, three times a day.

bubble_chart Formula Explanation

When the internal and external diseases are not treated properly, such as excessive sweating followed by excessive purging, or purging followed by sweating, repeated mistakes lead to a deteriorated disease. If the person has yang exuberance and transforms into heat, it shifts to the three yang channels; if yang declines and transforms into cold, it is related to the three yin channels. These two types of dysphoria are both deteriorated diseases. Although dysphoria can occur in all six channels, it is most commonly seen in the taiyang and shaoyin channels, as the taiyang is the manifestation of true yin, and the shaoyin is the root of true yang. Dysphoria without prior sweating or purging is mostly yang-related, with a strong and large pulse, and symptoms of heat and thirst, indicating yang exuberance with yin deficiency. Dysphoria after sweating or purging is mostly yin-related, with a deep and faint pulse, and symptoms of sweating and cold extremities, indicating yang deficiency with yin exuberance. Purging followed by sweating is against the treatment principles. If there is no significant external heat, no internal vomiting or thirst, it may seem like a spontaneous harmonization of yin and yang, but it is actually a deficiency of yang with exuberance of yin. This causes yin to disturb the yang aspect, leading to daytime dysphoria and insomnia; while exuberant yin dominates the yin aspect, resulting in nighttime calmness. A deep and faint pulse indicates that true yang is about to collapse, causing dysphoria. Use Dried Ginger Aconite Lateral Root to tonify yang and balance yin. Ginger and Aconite are yang within yang; using them first increases their potency. Without Liquorice Root, their effect is even stronger, making this formula more intense than the Four Rebellions formula, as it urgently rescues the separation of yin and yang. Sweating first, followed by decoction, is in line with treatment principles. If the disease persists and dysphoria worsens day and night, it is also due to exuberant yin repelling yang. Use Poria with the Four Rebellions formula to suppress yin and restore yang. Poria, influenced by the harmonious qi transformation, eliminates water pathogens without damaging yang, making it the primary herb. Ginseng generates qi in a barren state and revives the pulse at the brink of collapse, serving as an assistant. Ginseng combined with Ginger and Aconite tonifies qi and enhances fire; Ginger and Aconite combined with Poria tonify yang and purge yin. Adding Liquorice Root makes the formula milder than the Four Rebellions formula, suitable for resolving the conflict between yin and yang. Removing Liquorice Root and adding Ginseng and Poria creates a distinct balance between urgency and moderation, showcasing the brilliance of Zhang Zhongjing's prescriptions.