【纲】仲景曰。病发于阳。而反下之。热入。因作结胸。若不结胸。但头汗出。余无汗。至颈
而还。小便不利。身必发黄也。
【目】苏颂曰。小便不利有数种。有因被下者。津液耗于内也。有因汗者。津液亡于外也。有
因发黄与痞及热病者。热郁所致。风湿相搏。与夫阳明中风。其小便不利。寒邪所乘。其小便难者。
亦多由汗下而然。宜详辨之。
鳌按。湿郁发热。能下行则便利。即内亦解。若小便不利。则湿热内蒸于脏腑者。因黄色外见
于皮肤。而发黄矣。
【纲】仲景曰。伤寒表不解。心下有水气。干呕发热而咳。或渴。或利。或噎。或小便不利少
腹满。或喘者。小青龙汤主之。
【目】陶华曰。小便不利者。邪气聚于下焦。结而不散。甚则小腹硬满而痛。此小便所以不通
也。大抵有所不利者。行之有所渗泄也。若饮水过多。下焦蓄热。或中湿发黄。水饮停留。皆以利
小便为先。惟汗后亡津液。胃汁干。与阳明汗多者。则以利小便为戒。设或小便不利。而见头汗出
者。乃为阳脱关格之疾矣。
鳌按。水气留而不行。故小便不利。小便不利。故少腹满。此条言小便不利。正欲明少腹满之
故也。
【纲】仲景曰。太阳病。发汗后。若脉浮。小便不利。微热消渴者。五苓散主之。太阳病。饮
水多。小便利者。必心下悸。小便少者。必苦里急也。
【目】柯琴曰。发汗后。脉仍浮。而微热犹在表。未尽除也。虽不烦而渴特甚。饮多即消。小
便不利。水气未散也。便利便少。双顶饮水多。火用不宣。致水停心下而悸。水用不宣。致水结膀
胱而里急也。
【纲】仲景曰。本以下之。故心下痞。与泻心汤。痞不解。其人渴而口躁烦。小便不利者。五
苓散主之。大下之后。复发汗。小便不利者。亡津液故也。勿治之。得小便利。必自愈。
【目】鳌按。与泻心汤而痞仍不解。小便仍不利。心下之水气。停结甚矣。
【纲】仲景曰。太阳病。身黄。脉沉结。少腹硬。小便不利者。为无血也。小便自利。其人如
狂者。血结症也。抵当汤主之。
【目】吴绶曰。凡伤寒小便不利。当分六经治之。固已。若阴虚火动。小便赤涩不利者。加知、
柏、木通、生地。凡内热盛。大便不通。小便赤涩不利者。八正散治之。凡不渴。小便不利者。
热在血分也。宜知、柏、生地之类。夫膀胱为津液之府。气化而能出也。若汗多者。津液外泄。小
便因少。不可利之。恐重亡津液。待汗止。小便自行。又小便自利。亦不可妄利之。恐引热入膀胱。
则变蓄血。又为害也。
【纲】仲景曰。风湿为病。脉阴阳俱浮。自汗出。身重。多眠睡。鼻息必鼾。语言难出。若被
下者。小便不利。直视失溲。若被火
者。微发黄色。剧则如惊痫。时螈 。
风湿相搏。骨节烦疼。掣痛。不得屈伸。近之则痛剧。汗出短气。小便不利。恶风不欲去衣。
或身微肿者。甘草附子汤主之。
【目】鳌按。下则大便利。故小便反不利。何者。以肺家之化源不清。胃家之关门不启也。
【纲】仲景曰。太阳病。发汗。遂漏不止。其人恶风。小便难。四肢拘急。难以屈伸者。桂枝
加附子汤主之。
【目】朱肱曰。伤寒发汗后。汗出多。亡津液。胃中干。故小便不利。医见不利。往往利之。
误矣。伤寒有不利者。行之。取其渗泄也。有渴而停饮者。有躁而烦渴。有病气去而水气不得行者。
其表里得见。烦躁口燥。欲饮水。水入即吐。病名水逆。及霍乱头痛发热。身疼痛。欲饮水者。有
发热汗出。复恶寒。不呕。但心下痞者。并宜五苓散。
问。小便难。何也。曰。阴虚故也。阴虚者。阳必凑之。为阳所凑也。故小便黄者。中有热也。
宜滑石、瞿麦辈泻之。
赵嗣真曰。伤寒小便难。仲景论有发汗漏不止。桂枝加附子汤者。有阳明中风。或脉浮弦大而
潮热哕者。或脉浮而紧。误下而成腹满者。又有阳明脉浮迟。饱则微烦头眩者。活人问中。当以传
经邪热。与漏风亡阳。分作两条。其桂枝加附子汤。乃亡阳经虚所致。岂得均谓之阴虚阳凑。为有
热耶。要当以阳明小柴胡症。及误下症。谷疸症。次于阳凑传邪之下。却别出一条云。外有汗多亡
阳。津液不足。亦有小便难者。还以桂枝加附子症属之。若太阳中风。以火劫发汗。则邪风被火热。
血气流溢。身黄。阳盛阴虚。欲衄。小便难也。若少阴以火劫汗者。则咳而下利。谵语。小便难也。
若下后小便难有二。一、脉浮迟弱。恶风寒。下之者。则胁满身黄项强。小便难。一、阳明胃实。
发热恶寒。脉浮紧。下之者。则腹满。小便难。
[Outline] Zhang Zhongjing stated: When a disease originates from a Yang syndrome (exterior-heat syndrome) but is erroneously treated with purgation, the pathogenic heat enters inward, resulting in Jie Xiong (chest binding). If Jie Xiong does not form, but there is only sweating on the head and no sweating elsewhere, stopping at the neck, accompanied by difficulty in urination, the body will inevitably develop jaundice.
[Commentary] Su Song stated: There are several types of difficulty in urination. Some result from erroneous purgation, depleting fluids internally; some from excessive sweating, losing fluids externally; some from jaundice, Pi (fullness obstructing), or febrile diseases, caused by heat stagnation; some from wind-dampness battling each other, or Yangming wind-stroke, where cold pathogens invade causing difficulty in urination; others arise from sweating or purgation leading to difficult urination. These must be carefully differentiated.
Shen Jin'ao's note: Damp-heat stagnation causing fever can resolve downward through free passage of stool and urine, thereby resolving internal stagnation. If urination is difficult, damp-heat steams internally within the zang-fu organs, manifesting externally as yellow skin, resulting in jaundice.
[Outline] Zhang Zhongjing stated: In Taiyang disease (Taiyang syndrome), if the exterior pattern is unresolved and there is fluid retention in the epigastrium (water qi), presenting with dry heaving, fever, and cough, or thirst, or diarrhea, or dysphagia, or difficulty in urination with lower abdominal fullness, or wheezing, Xiao Qing Long Tang (Minor Blue Dragon Decoction) is indicated.
[Commentary] Tao Hua stated: Difficulty in urination occurs when pathogenic factors gather in the Lower Jiao (Lower Burner), knotting without dispersing. Severe cases present with hardness, fullness, and pain in the lower abdomen, which is why urination is blocked. Generally, for any obstruction, one should promote its flow and excretion via diuresis. However, if excessive water intake leads to heat accumulation in the Lower Jiao, or if dampness causes jaundice with fluid retention, promoting urination is the priority. Conversely, after sweating that depletes fluids, leaving stomach juices dry, or in Yangming syndrome with excessive sweating, diuretics are contraindicated. If difficulty in urination is accompanied by head sweating alone, it indicates Yang collapse and Gan Ge (rebellion and blockage) syndrome.
Shen Jin'ao's note: Fluid retention prevents movement, causing difficulty in urination; difficulty in urination leads to lower abdominal fullness. This section discusses difficulty in urination specifically to explain the cause of lower abdominal fullness.
[Outline] Zhang Zhongjing stated: In Taiyang disease, after sweating, if the pulse remains floating, there is difficulty in urination, slight fever, and Xiao Ke (wasting-thirst/excessive thirst), Wu Ling San (Five-Ingredient Powder with Poria) is indicated. In Taiyang disease, if one drinks excessively and urination is normal, palpitations in the epigastrium will occur; if urination is scanty, there will be distressing urgency in the interior.
[Commentary] Ke Qin stated: After sweating, if the pulse remains floating and slight fever persists at the exterior, the pathogen is not fully resolved. Although there is no irritability, thirst is severe, and ingested water is quickly consumed. Difficulty in urination indicates that water qi has not dispersed. Whether urination is frequent or scanty relates to excessive water intake. If Fire (Yang heat) function fails to disseminate, water stops in the epigastrium causing palpitations; if Water (Yin fluid) function fails to disseminate, water knots in the Bladder causing interior urgency.
[Outline] Zhang Zhongjing stated: Originally due to erroneous purgation, Pi (epigastric fullness) resulted. After administering Xie Xin Tang (Drain the Epigastrium Decoctions), if Pi persists, and the patient presents with thirst, dry mouth, irritability, and difficulty in urination, Wu Ling San (Five-Ingredient Powder with Poria) is indicated. After severe purgation followed by sweating, if difficulty in urination occurs, it is due to fluid depletion. Do not treat it directly; once urination becomes free, the condition will heal spontaneously.
[Commentary] Shen Jin'ao's note: If Pi persists after taking Xie Xin Tang and urination remains difficult, it indicates severe stagnation and knotting of water qi in the epigastrium.
[Outline] Zhang Zhongjing stated: In Taiyang disease, if the body is yellow, the pulse is deep and choppy, the lower abdomen is hard, and urination is difficult, this indicates no blood stasis (it is damp-heat jaundice). If urination is spontaneous and the patient behaves like a maniac, this is blood stasis syndrome, treated with Di Dang Tang (Di Dang Decoction).
[Commentary] Wu Shou stated: In all cases of Taiyang disease with difficulty in urination, treatment should be differentiated by the Six Channels. For Yin deficiency with fire hyperactivity causing red, scanty, and difficult urination, add Zhi Mu (Anemarrhenae Rhizoma), Huang Bo (Phellodendri Cortex), Mu Tong (Akebiae Caulis), and Sheng Di Huang (Rehmanniae Radix). For excess internal heat with constipation and red, scanty, difficult urination, Ba Zheng San (Eight-Herb Powder for Rectification) is used. For those without thirst and with difficulty in urination, the heat is in the Blood level; use Zhi Mu, Huang Bo, Sheng Di Huang, etc. The Bladder is the mansion of fluids, relying on Qi transformation to excrete them. If sweating is excessive, fluids leak outward, reducing urination; do not use diuretics, lest fluids be further depleted. Wait for sweating to stop, and urination will normalize. Also, if urination is spontaneous, do not recklessly use diuretics, lest heat be drawn into the Bladder, transforming into blood stasis, which is harmful.
[Outline] Zhang Zhongjing stated: In Wind-Damp disease, the pulse is floating at the Cun, Guan, and Chi positions bilaterally, with spontaneous sweating, heaviness of the body, somnolence, snoring during respiration, and difficulty speaking. If erroneously purged, it leads to difficulty in urination, fixed staring, and incontinence of urine and feces. If erroneously treated with fire therapy, mild cases present with yellowish discoloration; severe cases resemble convulsive epilepsy with occasional spasms.
When wind and dampness battle each other, causing painful joints, pulling pain, inability to flex or extend, exacerbated by touch, with sweating, shortness of breath, difficulty in urination, aversion to wind, reluctance to remove clothing, or slight edema, Gan Cao Fu Zi Tang (Licorice and Aconite Decoction) is indicated.
[Commentary] Shen Jin'ao's note: Purging usually promotes bowel movement, so urination may paradoxically become difficult. Why? Because the source of transformation in the Lung is unclear, and the gate of the Stomach fails to open.
[Outline] Zhang Zhongjing stated: In Taiyang disease, after sweating, if sweating continues unceasingly (leaking), the patient feels aversion to wind, has difficulty in urination, spasm and stiffness of the four limbs, and difficulty in flexion and extension, Gui Zhi Jia Fu Zi Tang (Cinnamon Twig Decoction plus Aconite) is indicated.
[Commentary] Zhu Gong stated: After sweating in Taiyang disease, if sweating is excessive and fluids are depleted, the Stomach becomes dry, causing difficulty in urination. Physicians often see difficulty in urination and prescribe diuretics, which is an error. In Taiyang disease, difficulty in urination may require promoting flow for excretion. Cases include thirst with fluid retention, restlessness with irritability and thirst, or pathogen departure with retained water qi. Manifestations include irritability, dry mouth, desire to drink, vomiting immediately after drinking (Water Reversal syndrome); Huoluan with headache, fever, body pain, desire to drink; fever with sweating, recurrence of chills, no vomiting, but epigastric fullness. All these are suitable for Wu Ling San (Five-Ingredient Powder with Poria).
Question: What is difficult urination? Answer: It is due to Yin deficiency. Yin deficiency allows Yang to crowd in. Affected by Yang, the urine becomes yellow, indicating internal heat. Use Shi Gao (Gypsum Fibrosum), Qu Mai (Dianthi Herba), etc., to drain heat.
Zhao Sizhen stated: Regarding difficult urination in Taiyang disease, Zhang Zhongjing mentions cases of leaking sweat after sweating, treated with Gui Zhi Jia Fu Zi Tang (Cinnamon Twig Decoction plus Aconite); Yangming wind-stroke with floating, wiry, large pulse, tidal fever, and hiccups; or floating, tight pulse with abdominal fullness after erroneous purgation; and Yangming with floating, slow pulse, slight irritability, and dizziness after fullness. The *Huo Ren Shu* questions should distinguish between transmitted pathogenic heat and Yang collapse from leaking sweat. Gui Zhi Jia Fu Zi Tang results from Yang collapse and channel deficiency, not merely Yin deficiency with Yang crowding and heat. One should list Yangming Xiao Chai Hu Tang patterns, erroneous purgation patterns, and Grain Jaundice patterns under Yang crowding and transmitted pathogen, then separately state: External excessive sweating causing Yang collapse and fluid insufficiency also leads to difficult urination, attributing this to Gui Zhi Jia Fu Zi Tang patterns. If Taiyang wind-stroke is treated with fire coercion to sweat, pathogenic wind combines with fire, blood and qi overflow, causing yellow body, excess Yang and deficient Yin, desire for nosebleed, and difficult urination. If Shaoyin is treated with fire coercion to sweat, it causes cough, diarrhea, delirium, and difficult urination. There are two types of difficult urination after purgation: 1. Floating, slow, weak pulse with aversion to wind and cold; erroneous purgation leads to hypochondriac fullness, yellow body, stiff neck, and difficult urination. 2. Yangming Stomach excess with fever, aversion to cold, floating, tight pulse; erroneous purgation leads to abdominal fullness and difficult urination.