【纲】仲景曰。阳明病。下血。谵语者。此为热入血室。但头汗出者。刺期门。随其实而泻之。
然汗出则愈。
【目】朱肱曰。汗出谵语者。有燥屎也。过经乃可下也。下之早。语言必乱。以表实里虚故也。
病患表实里虚。元府不开。则阳气上出。汗见于头。凡头汗出者。五内干枯。胞中空虚。津液少
也。慎不可下。下之者。谓之重虚。然头汗出者。有数症。伤寒五六日头汗出。微恶寒。手足冷。
心下满。口不欲食。大便硬脉细者。此为阳微结。必有表复有里也。脉沉。亦有里也。汗出为阳微。
假令纯阴结。不得复有外症。悉入在里。此为半在里半在外也。脉虽沉紧。不得为少阴病。所以
然者。阴不得有汗。今头汗出。故知非少阴也。小柴胡汤主之。
伤寒五六日。已汗下。胸胁满。微结。小便不利。渴而不呕。但头汗出。往来寒热。心烦者。此
表未解。柴胡桂枝干姜汤。心下紧满。无大热。汗出者。茯苓汤。
刘完素曰。热入血室。或阳明被火。及水结胸。皆但头汗出。俱是热郁于内。而不得越者也。
此数者。或吐或下。皆欲除其热也。
朱震亨曰。血室。肝也。肝之热者。必移其热于心。遂令心气受伤。既不能主血。亦不能作汗。
故但头有汗而不能遍及于身也。
【纲】仲景曰。阳明病。下之。其外有热。手足温。不结胸。心中懊 。饥不能食。但头汗者。
栀子豉汤主之。
【目】朱肱曰。病患表实里虚。元府不开。则阳上出而头有汗也。
张介宾曰。头汗之症有二。一为热邪上壅。一为阳气内脱。盖头乃诸阳之会。凡伤寒遍身得汗。
谓之热越。若身无汗。则热不得越而上蒸阳分。故但头汗出也。治热蒸者。可清可散。甚者可下。
在去其热而病自愈。至气脱一症。则多以
妄下伤阴。或克伐太过。或泄泻不止。以致阴竭于下。则阳脱于上。小水不通。而止见头汗。则大
危矣。
头汗脉紧数。有表邪当散者。小柴胡汤。或柴胡桂枝干姜汤。若有火邪。脉洪滑。内多烦热。
头汗。当清者。人参白虎汤、益元散。若水结胸。心下满。头汗出者。大陷胸汤、小半夏茯苓汤。
若便结腹胀疼痛。头汗者。承气汤。若诸虚泄泻。阳脱头汗者。速用独参汤、大补元煎。急救之。
庶可保全。
鳌按。此是下后变症。但头汗出者。心火上炎也。
【纲】仲景曰。阳明病。发热汗出。此为热越。不能发黄也。但头汗出者。身无汗。齐颈而还。
腹满。小便不利。渴饮水浆。此为瘀热在里。身必发黄。茵陈蒿汤主之。
【目】许叔微曰。亦可用五苓散。
刘完素曰。头者。诸阳之会。邪搏诸阳。津液上凑。则汗见于头。邪热内蓄。蒸发腠理。遍身
汗者。为热越。身无汗。则热不得越。热蒸于阳。故但头汗出也。何者。以三阴经皆上至胸颈而还。
不循于头。独诸阳脉上循于头耳。故为热不得越而上达者也。
王好古曰。头汗出齐颈而还。血症也。额上遍多者。属心部。为血症也。独益中州脾土。以血
药治之。其法无以加矣。
王肯堂曰。头乃诸阳之会。热蒸于阳。故但头汗出也。三阴无头汗。其经不上头故也。遍身有汗
为热越。但头汗出。热上达也。如瘀热在里。身必发黄。及热入血室。与其虚烦。或阳明被火。及
水结胸数者。皆但头汗出。俱是热不得越。故或吐或下以除其热也。且邪但在表。则无头汗之症。
必也寒湿相搏。与邪在半表里。乃有头汗也。如伤寒五六日。已发汗而复下之。胸胁满。微结。小
便不利。渴而不呕。但头汗出。往来寒热。心烦。及伤寒五六日。头汗。微恶寒。手足冷。心下满。
口不欲食。大便硬。脉细者。此皆邪在表里两间。令头汗出也。湿家但头汗出。欲得被覆向火者。
寒湿相搏。故头
汗也。此皆不得谓之逆。然小便不利而成关格。若头汗者。阳脱也。经云。关格不通。不得尿。头
无汗者生。有汗者死。又湿家下后。头额汗出而微喘者。亦阳脱也。经曰。湿家下之。额上汗出。
小便不利者死。下利不止者亦死。二者乃头汗之逆。
陶华曰。诸阳经络循于头。头汗者。邪搏诸阳也。里虚则不可下。内涸则不宜汗。头汗症。不可再
汗也。谵语头汗。是为血热。属阳明。用承气汤。心中懊 而头汗。栀豉汤。
[General Principle] Zhang Zhongjing stated: In Yangming disease, if there is bleeding from the lower orifice and delirium, this indicates that heat has entered the Blood Chamber (a concept related to the uterus and liver meridian in gynecological and general pathology). If only the head sweats, puncture the Qimen (LR14) acupoint. Follow its excess condition and apply the reducing method. Once sweating occurs, the disease will be cured.
[Detailed Discussion] Zhu Gong stated: When sweating is accompanied by delirium, it indicates the presence of dry stool accumulation. Purging can only be performed after the pathogen has passed through a meridian stage (i.e., when the exterior syndrome has resolved). If purging is done too early, speech will become chaotic because the exterior is excess while the interior is deficient.
When patients have an excess exterior and deficient interior, and the Yuan Fu (pores) are not open, Yang Qi ascends and exits outward, resulting in sweat on the head. In cases of head sweating alone, the five Zang organs are dried up, the Bao Palace (uterus/womb area) is empty, and body fluids are scant. One must absolutely avoid purging; doing so is called "double deficiency" (aggravating the deficiency of the deficient). However, head sweating arises from several conditions: In cold damage occurring on the fifth or sixth day, with head sweating, slight aversion to cold, cold hands and feet, fullness in the epigastrium, lack of desire to eat, hard stools, and a fine pulse, this is termed "Yang Wei Jie" (slight Yang binding). There is both an exterior and an interior component. A deep pulse also indicates an interior condition. Sweating indicates weak Yang. If it were a pure Yin binding, there would be no exterior symptoms, and all signs would be interior. This represents a condition half in the interior and half in the exterior. Although the pulse may be deep and tight, it cannot be diagnosed as Shaoyin disease. The reason is that Yin syndromes typically do not present with sweating; since there is head sweating, we know it is not Shaoyin. Xiao Chai Hu Tang (Minor Bupleurum Decoction) should be used.
In cold damage on the fifth or sixth day, after already having been treated with sweating or purging methods, if there is fullness in the chest and hypochondrium, slight binding, difficulty in urination, thirst without vomiting, only head sweating, alternating chills and fever, and irritability, this indicates the exterior syndrome has not yet resolved. Chai Hu Gui Zhi Gan Jiang Tang (Bupleurum, Cinnamon Twig, and Dried Ginger Decoction) should be used. If there is tight fullness in the epigastrium, no significant heat, and sweating, Fu Ling Tang (Poria Decoction) should be used.
Liu Wansu stated: Heat entering the Blood Chamber, Yangming disease treated with fire therapy, and water retention in the chest all present with only head sweating. These are all cases where heat is constrained internally and cannot vent outward. For these conditions, either emesis or purging is used to eliminate the heat.
Zhu Zhenheng stated: The Blood Chamber refers to the Liver. Heat in the Liver inevitably transfers to the Heart, injuring Heart Qi. Since the Heart governs blood and transforms sweat, once injured, it cannot govern blood nor produce sweat throughout the body, resulting in sweat only on the head and not covering the whole body.
[General Principle] Zhang Zhongjing stated: In Yangming disease, after purging, if there is heat on the exterior, warm hands and feet, no formation of Jie Xiong (Chest Binding), mental restlessness (Ao Nu), hunger but inability to eat, and only head sweating, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should be be used.
[Detailed Discussion] Zhu Gong stated: When patients have an excess exterior and deficient interior, and the Yuan Fu (pores) are not open, Yang Qi ascends outward, resulting in sweat on the head.
Zhang Jingyue stated: There are two types of head sweating: one is caused by heat evil obstructing upwards, and the other is due to internal collapse of Yang Qi. The head is the meeting point of all Yang meridians. In cold damage, if the whole body sweats, it is called "Re Yue" (Heat Venting), meaning heat dissipates with sweat. If the body does not sweat, heat cannot vent and steams upward into the Yang regions, causing only head sweating. For heat steaming upward, treatment involves clearing or dispersing heat; for severe cases, purging may be used. Once the heat is removed, the disease resolves spontaneously. Regarding Qi collapse, it is often caused by reckless purging damaging Yin, excessive attacking tonification, or persistent diarrhea, leading to exhaustion of Yin below and collapse of Yang above. With obstruction of urination and only head sweating present, the condition is critical.
If head sweating is accompanied by a tight and rapid pulse, indicating exterior pathogens that should be dispersed, use Xiao Chai Hu Tang or Chai Hu Gui Zhi Gan Jiang Tang. If there is Fire Evil, with a surging and slippery pulse, internal irritability and heat, and head sweating, use Ren Shen Bai Hu Tang (Ginseng and White Tiger Decoction) or Yi Yuan San (Benefit Origin Powder) to clear heat. If water retention in the chest causes epigastric fullness and head sweating, use Da Xian Xiong Tang (Major Sinking into the Chest Decoction) or Xiao Ban Xia Fu Ling Tang (Minor Pinellia and Poria Decoction). If constipation, abdominal distension, and pain accompany head sweating, use Cheng Qi Tang (Order the Qi Decoction). If various deficiencies cause diarrhea and Yang collapse leads to head sweating, urgently use Du Shen Tang (Single Ginseng Decoction) or Da Bu Yuan Jian (Great Tonify Origin Decoction) for emergency rescue to preserve life.
Shen Jin'ao commented: This is a complication after purging. Head sweating alone indicates Heart Fire flaming upward.
[General Principle] Zhang Zhongjing stated: In Yangming disease, fever with sweating indicates "Re Yue" (Heat Venting), so jaundice will not develop. If only the head sweats, the body has no sweat, the sweat stops at the neck, there is abdominal fullness, difficulty in urination, and thirst for drinking fluids, this indicates Stagnant Heat in the interior. Jaundice will definitely develop. Yin Chen Hao Tang (Artemisia Capillaris Decoction) should be used.
[Detailed Discussion] Xu Shumi stated: Wu Ling San (Five Ingredient Powder with Poria) can also be used.
Liu Wansu stated: The head is the meeting point of all Yang meridians. When pathogens contend with the Yang meridians, body fluids gather upward, resulting in head sweating. When pathogenic heat accumulates internally and evaporates the Cou Li (skin and muscle interstices), causing whole-body sweating, it is called "Re Yue." If the body does not sweat, heat cannot vent. Heat steams into the Yang, causing only head sweating. Why? Because the Three Yin meridians ascend only to the chest and neck and return, not circulating to the head. Only the Yang meridians ascend to the head. Thus, this is heat unable to vent, reaching upward instead.
Wang Haogu stated: Head sweating stopping at the neck indicates a Blood disorder. Sweating profusely on the forehead belongs to the Heart region and is also a Blood disorder. One should solely benefit the Middle Jiao Spleen Earth and treat with blood-invigorating herbs; there is no better method.
Wang Kentang stated: The head is the meeting point of all Yang meridians; heat steams into the Yang, causing only head sweating. The Three Yin meridians do not cause head sweating because their channels do not ascend to the head. Whole-body sweating is "Re Yue"; head-only sweating indicates heat ascending. Examples include stagnant heat in the interior leading to jaundice, heat entering the Blood Chamber, mental restlessness, Yangming disease treated with fire, and water retention in the chest. All these present with only head sweating because heat cannot vent. Therefore, emesis or purging is used to remove heat. If the pathogen is only in the exterior, there is no head sweating. Head sweating occurs only when Cold-Dampness contends with each other or when the pathogen is at the Half-Exterior/Half-Interior level. For instance, in cold damage on the fifth or sixth day, after sweating and purging, with chest/hypochondriac fullness, slight binding, urinary difficulty, thirst without vomiting, head sweating, alternating chills/fever, and irritability; or on the fifth/sixth day, with head sweating, slight aversion to cold, cold extremities, epigastric fullness, lack of desire to eat, hard stools, and fine pulse—these are all pathogens between the exterior and interior causing head sweating. Patients with Dampness who only sweat on the head and desire warmth/covering are experiencing Cold-Damp contention, hence head sweating. These are not considered adverse reversals. However, if urinary difficulty progresses to Guan Ge (Obstruction and Reversal), and head sweating occurs, it indicates Yang collapse. The Classics state: In Guan Ge with no urine and no head sweat, survival is possible; with head sweat, death ensues. Furthermore, after purging a Dampness patient, if forehead sweating occurs with slight wheezing, it is also Yang collapse. The Classics state: Purging a Dampness patient leading to forehead sweating and urinary difficulty results in death; persistent diarrhea also results in death. These two scenarios are adverse reversals of head sweating.
Tao Hua stated: Yang meridians circulate to the head; head sweating indicates pathogens contending with Yang meridians. Interior deficiency precludes purging; internal depletion precludes sweating. Head sweating syndromes should not be treated with further sweating methods. Delirium with head sweating indicates Blood Heat in Yangming, treated with Cheng Qi Tang. Mental restlessness with head sweating is treated with Zhi Zi Chi Tang.