【纲】仲景曰。太阳病。发热恶寒。热多寒少。脉微弱者。此无阳也。不可发汗。宜桂枝二越
婢一汤。
【目】朱肱曰。春不可大发汗。以阳气尚弱。不可急夺。使阴气胜。于时天寒初解。营卫腠理
俱缓。可用小柴胡汤之类治之。冬不可汗者。以阳气伏藏。不可妄扰。不论伤寒中风。以轻药解利
之。伤寒无汗者。只与桂枝麻黄合半汤。伤风
有汗。只与柴胡桂枝汤。或得少汗而解。或无汗而解。势甚者不拘。此夏月天气大热。玄府开。脉
洪大。宜正发汗。但不可用麻黄桂枝热性药。须麻黄桂枝汤加黄芩、石膏、知母、升麻也。夏月有
麻桂症。不加黄芩辈。转助热气。便发斑黄也。白虎汤虽可用。然治中暑。与汗后。一解表药耳。
白虎未能驱逐表解。况夏月阴气在内。或患热病。气虚人妄投白虎。往往有成结胸者。以白虎性寒。
非治伤寒药也。其人当汗而衄血下血者。不可表也。桂枝汤。坏病者。不可表也。知犯何逆。临
症治之。妇人经水适来。不可表也。表则郁冒不知人。此为表里俱虚。故令郁冒也。风温者。不可
表也。葳蕤汤。湿温者。不可表也。苍术白虎汤。虚烦者。不可表也。竹叶汤。以诸虚烦热。与伤
寒相似。然不恶寒。身不疼。故知非伤寒。不可汗也。头不疼。脉不紧。故知里不实。不可下也。
病患腹间左右上下。有筑然动气者。不可汗也。方治。详在动气本条。以此见古人慎用表药也。
张云岐曰。太阳症。非头疼项强。不可发汗。非身热恶寒。不可发汗。非脉浮。不可发汗。
【纲】仲景曰。桂枝本为解肌。若其人脉浮紧。发热汗不出者。不可与也。当须识此。勿令误
也。
【目】李中梓曰。无表症。不可汗。脉沉。不可汗。尺脉迟。不可汗。脉微弱。虽恶寒。不可
汗。汗家。不可重汗。太阳少阳并病。头项强痛。或眩冒心下痞。不可汗。脉弦细。头痛而热。属
少阳。不可汗。
【纲】仲景曰。疮家身虽疼。不可发汗。汗出则痉。
【目】汪昂曰。疮家虽伤寒身痛。不可发汗。发汗则痉。表虚热聚。故生疮。汗之则表愈虚。
热愈甚而生风。故变痉也。衄家亡血家。不可发汗。发汗则阴阳俱虚也。淋家。不可发汗。发汗必
便血。亡耗津液。反增客热也。尺脉迟。不可发汗。以营弱血少故也。脉沉迟为在里。反发其汗。
则津液越出。大便难。表虚里实。必谵语也。咽燥喉干。不可发汗。津液不足也。咳而小便利。若
失小便者。不可发汗。发汗则四肢厥冷。肺肾虚寒也。下利虽有表症。不可发汗。汗出必胀满。
走津
液而胃虚也。汗家重发汗。必恍惚心乱。汗者心之液。心亡血液故乱也。
【纲】仲景曰。脉浮数者。法当汗出而愈。若身重心悸者。不可发汗。当自汗出乃解。所以然
者。尺中脉微。此里虚。须表里实。津液自和。使汗出愈。
【目】闵芝庆曰。可汗者。脉症全在表也。若太早太过。津液竭而变生焉。有不可汗者。诸虚
百损。咽干口燥咽痛。疮疡淋沥。经水适至。诸失血。吐沫咳嗽。坏病。脉迟微涩。或厥而脉紧。
俱宜和解。不宜汗。若强发之。病微者难瘥。剧者言乱目眩而死。
鳌按。本条曰里虚。只重在里。表里实。表字带言耳。盖表者。身也。里者。心也。表里字。
即顶上身重心悸身心二字言。若心悸由于水气者。亦须发汗。但曰尺脉微。则明言心液虚矣。如何
与悸由水气者同用汗法。
【纲】仲景曰。脉浮紧者。法当身疼痛。宜以汗解之。假令尺中迟者。不可发汗。以营气不足。
血少故也。
【目】鳌按。此与上条。单论脉法本当发汗者。然上以尺中微为里虚。而不可汗。此以尺中迟
为营气不足。亦不可汗。盖此二者。虽发其汗。而一则心液虚。一则营气虚。俱不能作汗。徒使正
气益耗耳。
【纲】仲景曰。脉微而恶寒者。此阴阳俱虚。不可更发汗。更下。更吐也。
【目】张介宾曰。脉有忌汗者。如论曰。脉微而恶寒者。此阴阳俱虚。不可更汗吐下。太阳
病。发热恶寒。热多寒少。脉微弱。为无阳。不可发汗。弦为阳运。微为阴寒。上实下虚。意欲得
温。微弦为虚。不可发汗。汗则寒栗不能自还。伤寒四五日。脉沉而喘满。沉为里。不可汗。汗亡
津液。必大便难而谵语。少阴病脉微。不可发汗。以亡阳故。尺脉弱而无力。切不可汗下。尺中迟。
不可汗。以荣气不足血少故。按以上忌汗诸脉。可见仲景大意。故凡治伤寒。但见脉息微弱。及
沉细无力者。皆不可任意发汗。然欲去外邪。又非汗不可。而仲景云。脉微弱者。不可发汗。夫脉
弱非阳。既不可用寒凉。而
寒邪在表。又不可用攻下。然则舍汗又将何法以治此表邪乎。不知温中即所以散寒。强主即可以逐
寇。此仲景之意。岂不尽露于言表乎。且凡病外感而脉见微弱者。其汗最不易出。其邪最不易解。何
也。以元气不能托送。即发亦无汗。邪不能解。则愈发愈虚。而危亡立至。夫汗即血。由于营也。
营本乎气。由乎中也。未有中气虚而营能盛者。未有营气虚而汗能达者。脉即营之外候。脉既微弱。
元气可知。元气愈虚。邪愈不解。所以阳症最嫌阴脉也。凡治表邪之法。如果邪实无汗。则发散为宜。有汗而热不除。
则和解为宜。元虚而邪不能退。
则急培其根本。以待其自解自汗。此逐邪三昧。万全之法也。若但见其外。不见其内。不论症之阴
阳。脉之虚实。但知寒凉可以退热。但知发散可以解表。不知元阳一败。危立至矣。凡发汗太过。
一时将致亡阳。或身寒而栗。或气脱昏沉。惟煎独参汤饮之。甚者或以四味回阳汤。庶可保全。又
有邪本不盛。或挟虚年衰感邪等症。医不能察。但知表症宜解。而发散太过。或误散无效。或屡散
不已。遂被其害者有之。或邪气虽去。竟至胃气大伤。不能饮食。渐至羸惫不振者有之。皆过汗之戒
也。
柯琴曰。脉微而无和缓之意。此太阴虚矣。但恶寒而不恶热。是二阳虚矣。阴阳俱虚。当调其
阴阳。
【纲】仲景曰。发汗后。不可更行桂枝汤。无汗而喘。大热者。可与麻黄杏仁甘草石膏汤。下
后。不可更行桂枝汤。若无汗而喘。大热者。可与麻黄杏仁甘草石膏汤。
【目】李时珍曰。仲景每于汗下后表不解者。用桂枝更汗。而不用麻黄。此则内外皆热而不恶
寒。必其用麻黄汤后。寒解而热反甚。与发汗解半日许复烦。下后而微喘者。不同。发而不得汗。
或下之而仍不汗。喘不止。其阳气重也。若与桂枝加浓朴杏仁汤。下咽即毙。此汤使温解之方。转
为凉散之剂也。
【纲】仲景曰。酒客病。不可与桂枝汤。得汤则呕。以酒客不喜甘故也。
【目】危亦林曰。酒客不喜甘。平日蓄有湿热也。病虽中风。应与桂枝。以不喜甘而不与。正
以善桂枝汤之用也。言外
当知有葛根芩连之法。
鳌按。危氏补出葛根芩连之法。若魏伯乡柯韵伯辈俱宗之。凡遇酒客病。使人知所以用药。
[General Principle] Zhang Zhongjing stated: In Taiyang disease (a syndrome caused by pathogenic factors affecting the Taiyang meridian), if there is fever and aversion to cold, with more heat than cold, and the pulse is faint and weak, this indicates "absence of Yang" (deficiency of Yang qi failing to propel the blood vessels). Sweating therapy should not be used. Guizhi Er Yuebi Yi Tang (Cinnamon Twig Twice and Minor Bi Decoction Once) is appropriate.
[Commentary] Zhu Gong stated: In spring, vigorous sweating should not be induced because the body's Yang qi is still weak and should not be abruptly depleted, which would cause Yin qi to prevail. At this time, as the weather transitions from cold to warm, Ying (Nutritive) and Wei (Defensive) qi, along with the couli (pores), are relaxed. Formulas such as Xiaochaihu Tang (Minor Bupleurum Decoction) can be used. In winter, sweating should not be induced because Yang qi is hidden and stored internally and should not be disturbed recklessly. Regardless of whether it is Shanghan (Cold Damage) or Fengshang (Wind Strike), light and clearing herbs should be used to resolve the exterior. For Shanghan with no sweat, only Guizhi Mahuang Ban Tang (Half Cinnamon Twig and Ephedra Decoction) should be used; for Fengshang with sweat, only Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) should be used. Recovery may occur through slight sweating or without sweating, depending on severity. This refers to summer when the weather is hot, xuanku (sweat pores) are open, and the pulse is surging; normal sweating is indicated, but hot-natured herbs like Mahuang (Ephedrae Herba) and Guizhi (Cinnamomi Ramulus) should not be used alone. Huangqin (Scutellariae Radix), Shigao (Gypsum Fibrosum), Zhimu (Anemarrhenae Rhizoma), and Shengma (Cimicifugae Rhizoma) must be added to Mahuang Guizhi Tang. If summer patterns resembling Mahuang Tang or Guizhi Tang are treated without Huangqin and similar herbs, heat will be exacerbated, leading to macules and jaundice. While Baihu Tang (White Tiger Decoction) can be used, it primarily treats Zhongshu (Heatstroke). For post-sweating exterior syndromes, it acts merely as an exterior-resolving agent. Baihu Tang fails to drive out exterior pathogens. Moreover, in summer, Yin qi resides internally. If a patient with Qi deficiency mistakenly takes Baihu Tang for a heat disease, Jie Xiong (Chest Binding Syndrome) often results because Baihu Tang is cold in nature and not suitable for Shanghan. Patients who should have sweated but instead experienced nosebleeds or lower bleeding should not undergo exterior therapy. Patients with Guizhi Tang patterns that have become Huai Bing (complicated diseases due to mismanagement) should not undergo exterior therapy. One must determine the error and treat based on specific symptoms. When a woman's menstruation is just beginning, exterior therapy is contraindicated; otherwise, Yu Mao (depression and dizziness with loss of consciousness) may occur due to deficiency of both interior and exterior. Fengwen (Wind-Warmth) should not be treated with exterior therapy; Weiyu Tang (Polygonatum Decoction) is indicated. Shiwen (Damp-Warmth) should not be treated with exterior therapy; Cangzhu Baihu Tang (Atractylodes and White Tiger Decoction) is indicated. Xu Fan (Deficiency Irritability) should not be treated with exterior therapy; Zhuye Tang (Bamboo Leaf Decoction) is indicated. Various deficiency-heat irritabilities resemble Shanghan but lack aversion to cold and body pain, indicating they are not Shanghan and should not be sweated. Lack of headache and tight pulse indicates interior excess is absent, so purgation is contraindicated. If patients have pulsating movements (Dongqi) in the abdomen, sweating is contraindicated. See the Dongqi section for treatment details. This illustrates the ancients' caution with exterior-resolving herbs. Zhang Yunqi stated: For Taiyang patterns, if there is no headache and stiff neck, do not sweat; if there is no fever and aversion to cold, do not sweat; if there is no floating pulse, do not sweat.
[General Principle] Zhang Zhongjing stated: Guizhi Tang is originally for resolving the muscle layer. If the pulse is floating and tight, with fever and no sweat, Guizhi Tang should not be given. This must be recognized to avoid errors.
[Commentary] Li Zhongzi stated: If there is no exterior syndrome, do not sweat. If the pulse is deep, do not sweat. If the Chi (cun-guan-chi position, distal part) pulse is slow, do not sweat. If the pulse is faint and weak, even with aversion to cold, do not sweat. Hanjia (habitual sweaters) should not be subjected to heavy sweating. In concurrent Taiyang and Shaoyang disease with headache, stiff neck, dizziness, or epigastric fullness, do not sweat. If the pulse is string-taut and fine, with headache and fever, it belongs to Shaoyang and should not be sweated.
[General Principle] Zhang Zhongjing stated: Patients with chronic sores (Chuangjia), even if they have body pain, should not be sweated. Sweating will lead to Jing (spasm).
[Commentary] Wang Ang stated: Chuangjia with Shanghan body pain should not be sweated. Sweating leads to spasm. Exterior deficiency with heat accumulation causes sores. Sweating increases exterior deficiency and heat, generating wind and causing spasm. Nujia (frequent nosebleeders) and Wangxuejia (blood losers) should not be sweated, as this causes dual deficiency of Yin and Yang. Linjia (patients with strangury) should not be sweated, as this leads to hematuria. Sweating depletes fluids and increases exogenous heat. A slow Chi pulse indicates deficient Ying and blood, so sweating is contraindicated. A deep and slow pulse indicates interior pathology; forcing sweat causes fluid loss, difficult defecation, interior excess, and delirium. Dry throat and mouth indicate insufficient fluids, so sweating is contraindicated. Cough with free urination or urinary incontinence indicates lung and kidney Yang deficiency; sweating causes cold limbs and is contraindicated. Diarrhea with exterior signs should not be sweated, as sweating causes abdominal fullness due to fluid loss and stomach Qi deficiency. Heavy sweating in habitual sweaters causes mental confusion because sweat is the fluid of the Heart, and blood loss disrupts the Heart spirit.
[General Principle] Zhang Zhongjing stated: A floating and rapid pulse usually resolves with sweating. However, if the patient has heavy body sensation and palpitations, sweating is contraindicated. Recovery occurs through spontaneous sweating. The Chi pulse is faint, indicating interior deficiency. Interior and exterior must be strengthened, fluids harmonized, and then sweating leads to recovery.
[Commentary] Min Zhiqing stated: Sweating is indicated when pulse and symptoms are entirely exterior. Premature or excessive sweating depletes fluids and causes complications. Contraindications include various deficiencies, dry mouth/throat/pain, sores, strangury, menstruation, blood loss, coughing foam, complicated diseases, slow/faint/ choppy pulses, or cold extremities with tight pulses. Harmonization is preferred over sweating. Forced sweating in mild cases delays recovery; in severe cases, it causes delirium, dizziness, and death.
Shen Jin'ao noted: The term "interior deficiency" emphasizes the interior. "Exterior and interior solid" mentions the exterior incidentally. Exterior refers to the body, interior to the Heart. Regarding palpitations due to water qi, sweating might be used, but a faint Chi pulse explicitly indicates Heart fluid deficiency, distinguishing it from water qi-induced palpitations.
[General Principle] Zhang Zhongjing stated: A floating and tight pulse usually presents with body pain and should be resolved by sweating. However, if the Chi pulse is slow, sweating is contraindicated due to insufficient Ying qi and blood.
[Commentary] Shen Jin'ao noted: Both this and the previous paragraph discuss pulses that typically require sweating. The previous one cites a faint Chi pulse (interior deficiency) as a contraindication; this one cites a slow Chi pulse (Ying qi deficiency) as a contraindication. Although sweating might be attempted, one case involves Heart fluid deficiency and the other Ying qi deficiency; neither can produce sweat effectively, leading only to further depletion of healthy Qi.
[General Principle] Zhang Zhongjing stated: A faint pulse with aversion to cold indicates dual deficiency of Yin and Yang. Sweating, purging, or vomiting are all contraindicated.
[Commentary] Zhang Jiebín stated: Certain pulses contraindicate sweating. As stated: "Faint pulse with aversion to cold indicates dual deficiency; do not use sweating, vomiting, or purging." "Taiyang disease with fever, aversion to cold, more heat than cold, and faint pulse indicates absence of Yang; do not sweat." "String-taut indicates Yang movement, faint indicates Yin cold... faint and string-taut indicates deficiency; do not sweat. Sweating causes chills." "Shanghan after 4-5 days with deep pulse and wheezing/fullness: deep indicates interior; do not sweat. Sweating loses fluids, causing constipation and delirium." "Shaoyin disease with faint pulse: do not sweat due to Yang loss." "Weak and powerless Chi pulse: absolutely contraindicated for sweating and purging." "Slow Chi pulse: do not sweat due to Ying deficiency and blood shortage." These contraindications reveal Zhang Zhongjing's intent. In treating Shanghan, if the pulse is faint, deep, thin, or powerless, arbitrary sweating is forbidden. Yet, to expel exterior pathogens, sweating is necessary. How to treat exterior pathogens with a faint pulse? Warming the middle dissipates cold; strengthening the host expels invaders. For external pathogens with faint pulses, sweat is hard to produce, and pathogens are hard to resolve because Yuan Qi cannot push them. Forcing sweat without result worsens deficiency. Sweat comes from Ying, which depends on Qi and the Middle Jiao. Weak pulse indicates weak Yuan Qi. Treatment principles: If exterior excess with no sweat, disperse; if sweat persists with fever, harmonize; if Yuan deficiency prevents pathogen expulsion, tonify the root to allow spontaneous resolution. This is the complete method. Ignoring internal condition and using only cooling or dispersing methods risks Yang collapse. Excessive sweating causes Yang collapse, cold shivering, or coma. Treat with Dushen Tang (Single Ginseng Decoction) or Siwei Huiyang Tang (Four-Ingredient Decoction to Restore Yang). Physicians who fail to detect deficiency in elderly or weak patients may over-disperse, damaging Stomach Qi and leading to emaciation. This warns against excessive sweating. Ke Qin stated: Faint pulse without moderation indicates Taiyin deficiency. Aversion to cold without aversion to heat indicates Yang deficiency. Dual deficiency requires regulating Yin and Yang.
[General Principle] Zhang Zhongjing stated: After sweating, Guizhi Tang should not be used again. If there is no sweat and wheezing with high fever, Mahuang Xingren Gancao Shigao Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction) may be given. After purging, Guizhi Tang should not be used again. If there is no sweat and wheezing with high fever, Mahuang Xingren Gancao Shigao Tang may be given.
[Commentary] Li Shizhen stated: Zhang Zhongjing often used Guizhi Tang for residual exterior syndrome after sweating or purging, avoiding Mahuang Tang. However, in cases of internal and external heat without aversion to cold, where heat intensified after initial Mahuang Tang use, or persistent wheezing after failed sweating/purging due to heavy Yang qi, Guizhi Tang with Naren and Xingren would be fatal. This formula transforms a warming resolution into a cooling dispersion.
[General Principle] Zhang Zhongjing stated: Wine drinkers suffering from illness should not be given Guizhi Tang, as it causes vomiting due to their dislike of sweet flavors.
[Commentary] Wei Yilin stated: Wine drinkers dislike sweet flavors due to accumulated damp-heat. Even if Wind Strike is present, Guizhi Tang is withheld. This implies the use of Gegen Qinlian Tang (Kudzu, Scutellaria, Coptis, and Licorice Decoction).
Shen Jin'ao noted: Wei supplemented the Gegen Qinlian Tang method, followed by scholars like Wei Boxiang and Ke Yunbo, guiding medication choices for wine drinkers.