上五味。以水九升。先煮四味。取五升。纳桂。更煮取三升。去滓。温服一升。日再。夜一服。（五升下。
玉函。有去滓二字。成本。三升下。脱去滓二字。方氏。圈白术之白。吴本。删。）
〔喻〕此方。即理中加桂枝。而易其名。亦治虚痞下利之圣法也。〔吴〕桂枝辛香。经火久煎。则气散而
力有不及矣。故须迟入。凡用桂枝诸方。俱当根据此为例。用肉桂。亦当临用去粗皮。切碎。俟群药煎好。方入。
煎二三沸。即服。伤寒类方曰。桂独后煮。欲其于治里症药中。越出于表。以散其邪也。
伤寒大下后。复发汗。心下痞恶寒者。表未解也。不可攻痞。当先解表。表解乃可攻痞。解表宜桂枝汤。
攻痞宜大黄黄连泻心汤。（玉函。脉经。发下。有其字。）
〔柯〕心下痞。是误下后里症。恶寒。是汗后未解症。里实表虚。内外俱病。皆因汗下倒施所致。表里交持。
仍当遵先表后里。先汗后下正法。盖恶寒之表。甚于身疼。心下之
痞。轻于清谷。与救急之法不同。〔钱〕心下已痞。而仍恶寒者。犹有表邪未解也。前条同是痞证而恶寒。以
附子泻心者。因恶寒汗出。所以知其为阳虚之恶寒也。此则恶寒而不汗出。是以知其为表未解也。〔方〕伤寒病
初之表当发。故用麻黄汤。此以汗后之表当解。故曰宜桂枝汤。
活人书曰。大抵结胸痞。皆应下。然表未解者不可攻也。总病论曰。前加附子。是汗出多而恶寒。表汗
解。而里结未除故也。此症。是发后无汗恶寒故也。先须解表也。
伤寒发热。汗出不解。心中痞硬。呕吐而下利者。大柴胡汤主之。（中。玉函。正脉。作下。方本。汪本同。）
〔程〕心中痞硬。呕吐而下利。较之心腹濡软。呕吐而下利。为里虚者不同。发热汗出不解。较之呕吐下利。
表解者乃可攻之。竟用十枣汤者又不同。况其痞不因下后而成。并非阳邪陷入之痞。而里气内拒之痞。痞气填入
心中。以致上下不交。故呕吐而下利也。大柴胡汤。虽属攻剂。然实管领表里上中之邪。总从下焦为出路。则
攻中自寓和解之义。主之是为合法。
案金鉴云。下利之下字。当是不字。若是下字。岂有上吐下利。而以大柴胡汤。下之之理乎。此说似是。
而实非也。所谓下利。乃是热利。若改作不利。则与小便何别。可谓失考矣。
病如桂枝证。头不痛。项不强。寸脉微浮。胸中痞硬。气上冲喉咽。不得息者。此为胸有寒也。当吐之。
宜瓜蒂散。（头上。项上。脉经。有其字。千金翼。作头项不强痛。喉咽。玉函。成本。作咽喉此为胸有寒。
千金。作此以内有久痰。）
〔成〕病如桂枝证。为发热汗出恶风也。〔方〕头不痛。项不强。言太阳经中无外入之风邪。以明非中风
也。寸候身半
以上。微浮。邪自内出也。胸中痞硬。痰涎塞膈也。气上冲咽喉者。痰涌上逆。或谓喉中声如曳锯。是也。寒。
以痰言。〔喻〕寒者。痰也。痰饮内动。身必有汗。加以发热恶寒。全似中风。但头不痛。项不强。此非外入
之风。乃内蕴之痰。窒塞胸间。宜用瓜蒂散。以涌出其痰也。〔周〕寒饮停蓄。阻遏胸中之阳。使卫气不能外
固。故发热恶寒汗出也。〔程〕邪气蕴蓄于膈间。此为胸有寒也。痞硬一证。因吐下者为虚。不因吐下者为实。
实邪填塞心胸。中下二焦。为之阻绝。自不得不从上焦为出路。所谓在上者因而越之。是也。
案方氏诸家。以寒为痰。盖瓜蒂能吐膈间之顽痰。故有此说。而不可以寒直斥为痰。程氏则为邪字看。极
稳当矣。如钱氏单为风寒之寒。亦恐不尔。厥阴篇。瓜蒂散条云。邪结在胸中。又云。病在胸中。程说有所据。
瓜蒂散方
瓜蒂（一分熬黄） 赤小豆（一分○玉函作各六铢）
上二味。各别捣筛为散。已合治之。取一钱匕。以香豉一合。用热汤七合。煮作稀糜。去滓。取汁和散。
温顿服之。不吐者。少少加。得快吐乃止。诸亡血虚家。不可与瓜蒂散。（一钱匕。千金翼。作半钱匕。）
〔鉴〕胸中者。清阳之府。诸邪入胸府。阻遏阳气。不得宣达。以致胸满痞硬。热气上冲。燥渴心烦。
欲吐。脉数促者此热郁结也。胸满痞硬。气上冲咽喉不得息。手足寒冷。欲吐不能吐。脉迟紧者。此寒郁结也。
凡胸中寒热。与气与饮。郁结为病。谅非汗下之法所能治。必得酸苦涌泄之品。因而越之。上焦得通。阳气得
复。痞硬可消。胸中可和也。瓜蒂极苦。赤豆味酸。相须相益。能疏胸中实邪。为吐剂中第一品也。而佐香豉
汁合服者。藉谷气以保胃气也。服
之不吐。少少加服。得快吐即止者。恐伤胸中元气也。此方奏功之捷。胜于汗下。所谓汗吐下三大法也。今人
不知仲景子和之精义。置之不用。可胜惜哉。然诸亡血虚家。胸中气液已亏。不可轻与。特为申禁。〔汪〕伤
寒一病。吐法不可不讲。华元化云。伤寒至四日在胸。宜吐之。巢元方云。伤寒病三日以上。气浮在上部。胸
心填塞满闷。当吐之则愈。仲景以此条论。特出之太阳下编者。以吐不宜迟。与太阳汗证相等。当于两三日间。
审其证而用其法也。条辨。以胸有寒为痰。亦通。盖胸有风寒。则其人平素饮食之积。必郁而成热。变而为痰。
所以瓜蒂散。亦涌痰热之药也。尚论篇以此条证。竟列入痰病中。误矣。煮作稀糜。言以汤七合。煮香豉如糜
粥之烂也。方氏以稀糜。为另是稀粥。大谬之极。
古方选注曰。瓜蒂散。乃酸苦涌泄重剂。以吐胸寒者。邪结于胸。不涉太阳表实。只以三物为散。煮作
稀糜。留恋中焦。以吐之。能事毕矣。瓜蒂性升。味苦而涌。豆性酸敛。味苦而泄。恐其未必即能宣越。故复
以香豉汤。陈腐之性。开发实邪。定当越上而吐矣。
外台秘要。张文仲瓜蒂散。主伤寒胸中痞塞。瓜蒂。赤小豆。各一两。上二味。捣散。白汤服一钱匕。
又范汪。疗伤寒及天行。瓜蒂散方。同上二味。捣作散。温汤二合。服一钱匕。药下便卧。若吐便且急忍也。
候食顷不吐者。取钱五七散。二合汤和服之。便吐矣。不吐复稍增。以吐为度。吐出青黄如菜汁者。五升以上
为佳。若吐少病不除者。明日如前法。复服之。可至再三。不令人虚也。药力过时不吐。服汤一升。助药力也。
吐出便可食。无复余毒。若服药过多者。益饮冷水解之。（和服之下。活人书。有以手指 之五字。）
东垣试效方曰。若有宿食而烦者。仲景以栀子大黄汤主
之。气口三盛。则食伤太阴。填塞闷乱。极则心胃大疼。兀兀欲吐。得吐则已。俗呼食迷风。是也。经云。上
部有脉。下部无脉。其人当吐。不吐者死。宜瓜蒂散之类吐之。经云。高者因而越之。此之谓也。
医方集解曰。治卒中痰迷。涎潮壅盛。癫狂烦乱。人事昏沉。五痫痰壅上膈。及火气上冲。喉不得息。食
填中脘。欲吐不出。量人虚实服之。吐时须令闭目紧束肚皮。吐不止者。葱白汤解之。良久不出者。含砂糖一
块。即吐。○案张子和不用豆豉。加人参甘草。齑汁调下。吐不止者。用煎麝香汤。瓜苗闻麝香即死。所以立解。
活人指掌辨疑曰。瓜蒂。即丝瓜蒂。俗名藤罗。○案此说。本草所不载。录以俟试验。舒氏亦云。如无甜瓜。
丝瓜蒂可代。
病胁下素有痞。连在脐旁。痛引少腹。入阴筋者。此名脏结。死。（玉函。脉经。病下。有者若二字。入
阴筋。作入阴挟阴筋。）
〔程〕其人胁下素有痞积。阴邪之伏里者。根柢深且固也。今因新得伤寒。未察其阴经之痞。误行攻下。致
邪气入里。与宿积相互。使脏之真气。结而不通。因连在脐旁。痛引少腹入阴筋。故名脏结。盖痞为阴邪。而
脐旁。阴分也。在脏为阴。以阴邪结于阴经之脏。阳气难开。至此而结势已成。于法为死。〔钱〕其痛下引少腹。
入厥阴而控引睾丸之阴筋者。此等脏结。以阴气过极。阳气竭绝。故曰死。〔锡〕上文论脏结。曰难治。曰不
可攻。此复论脏结之死症。以见脏结可生。而亦可死也。
伤寒若吐若下后。七八日不解。热结在里。表里俱热。时时恶风。大渴。舌上干燥而烦。欲饮水数升者。
白虎加人参汤主之。（白虎加人参汤。脉经。千金。千金翼作白虎汤。伤寒下。成本。有病字。）
〔成〕若吐若下后七八日。则当解。复不解而热结在里。表热者。身热也。里热者。内热也。本因吐下后。
邪气乘虚内陷为结热。若无表热。而纯为里热。则邪热结而为实。此以表热未罢。时时恶风。若邪气纯在表。
则恶风无时。若邪气纯在里。则更不恶风。以时时恶风。知表里俱有热也。邪热结而为实者。则无大渴。邪热
散漫则渴。今虽热结在里。表里俱热。未为结实。邪气散漫。熏蒸焦膈。故大渴。舌上干燥而烦。欲饮水数升。
与白虎加人参汤。散热生津。〔钱〕大渴舌上干燥而烦。欲饮水数升。则里热甚于表热矣。谓之表热者。乃热
邪已结于里。非尚有表邪也。因里热太甚。其气腾达于外。故表间亦热。即阳明篇所谓蒸蒸发热。自内达外之
热也。〔汪〕时时恶风者。乃热极汗多。不能收摄。腠理疏。以故时时恶风也。里热。则胃腑中燥热。以故大
渴。舌上干燥而烦。欲饮水数升。此因吐下之后。胃气虚。内亡津液。以故燥渴甚极也。〔周〕口至干。舌至
燥。无津液极矣。能生津液。而神速者。莫若人参。故加之。
案金鉴云。伤寒二字之下。当有若汗二字。盖发汗较吐下。更伤津液为多也。时时恶风。当是时汗恶风。
若非汗字。则时时恶风。是表不解。白虎汤在所禁也。论中谓发热无汗。表不解者。不可与白虎汤。渴欲饮水。
无表证者。白虎加人参汤主之。读者细玩经文自知。此说难从。柯氏云。当汗不汗。反行吐下。是治之逆也。
吐则津液亡于上。下得津液亡于下。是也。
伤寒类方曰。胃液已尽。不在经。不在腑。亦非若承气症之有实邪。因胃口津液枯竭。内火如焚。欲引水
自救。故其证如此。与热邪在腑者迥别。
外台秘要。仲景伤寒论。疗伤寒汗出。恶寒身热。大渴
不止。欲饮水一二斗者。白虎加人参汤主之。○此条。本经不载。姑附存于此。
白虎加人参汤方
知母（六两） 石膏（一斤碎） 人参（二两○上编。玉函。作三两） 甘草（二两炙） 粳米（六两）
上五味。以水一斗。煮米熟。汤成去滓。温服一升。日三服。此方。立夏后立秋前乃可服。立秋后不可服。
正月二月三月尚凛冷。亦不可与服之。与之则呕利而腹痛。诸亡血虚家。亦不可与。得之则腹痛利者。但可温
之当愈。（玉函。作春三月病常苦里冷。案此方。已见太阳上编。而无此方立夏以下六十二字。故再举于斯。
此六十二字。疑是后人所添。而玉函。千金。及翼方。外台秘要。并有之。故不可妄删。姑存其旧耳。）
内台方议。问曰。活人书云。白虎汤。惟夏至发可用。何耶。答曰。非也。古人一方对一证。若严冬之
时。果有白虎汤证。安得不用石膏。盛夏之时。果有真武汤证。安得不用附子。若老人可下。岂得不用硝黄。
壮人可温。岂得不用姜附。此乃合用者必需之。若是不合用者。强而用之。不问四时。皆能为害也。
汪氏引徐春沂云。立夏后云云。疑是后人所加。
张氏伤寒百问经络图曰。白虎加人参。名化斑汤。出异书。
伤寒无大热。口燥渴。心烦背微恶寒者。白虎加人参汤主之。（玉函。心。作而。千金。及翼。外台。作白虎汤。）
〔鉴〕伤寒身无大热。不烦不渴。口中和。背恶寒。附子汤主之者。属少阴病也。今伤寒身无大热。知
热渐去表入里也。口燥渴心烦。知热已入阳明也。虽有背微恶寒一证。似乎少阴。但少阴证口中和。今口燥渴。
是口中不和也。背恶
寒。非阳虚。恶寒乃阳明内热。熏蒸于背。汗出肌疏。故微恶之也。主白虎汤。以直走阳明。大清其热。加人
参者。盖有意以顾肌疏也。〔钱〕此条之背恶寒。口燥渴而心烦者。乃内热生外寒也。非口中和之背恶寒。可
比拟而论也。〔汪〕内蒸热而表必多汗。以故恶寒。与上条恶风之义相同。
案背恶寒。成氏以为表邪未尽。程氏以为阳虚。并非也。伤寒类方曰。此亦虚燥之症。微恶寒。谓虽恶寒
而甚微。又周身不寒。寒独在背。知外邪已解若大恶寒。则不得用此汤矣。
伤寒脉浮。发热无汗。其表不解。不可与白虎汤。渴欲饮水。无表证者。白虎加人参汤主之。（解下。成
本。玉函。外台。有者字。千金。及翼。外台。作白虎汤。）
〔魏〕脉浮而不至于滑。则热未变而深入。正发热无汗。表证显然如此。不可与白虎汤。徒伤胃气。言当
于麻黄汤。大青龙。桂枝二越婢一之间。求治法也。如其人渴欲饮水。与之水。果能饮者。是表邪变热。已深
入矣。再诊脉无浮缓浮紧之表脉。审证无头身疼痛。发热无汗之表证。即用白虎加人参。补中益气。止其燥渴。
〔钱〕若渴欲饮水。则知邪热已入阳明之里。胃中之津液枯燥矣。然犹必审其无表证者。方以白虎汤。解其烦热。
The above five herbs, with nine sheng of water, first decoct the first four herbs, obtain five sheng of liquid, add Guizhi (Cinnamon Twig), and further decoct to obtain three sheng. Strain the dregs. Take one sheng warm, twice a day and once at night. (Under "five sheng", *Yufang* has the characters "strain the dregs". Under "three sheng", the Cheng edition omits "strain the dregs". Fang Shi circled the character 'Bai' in Baizhu. Wu Ben deleted this part.)
[Yu Jia Yan] This formula is Lizhong Tang (Regulate the Middle Decoction) plus Guizhi (Cinnamon Twig), but with a changed name. It is also a sacred method for treating deficiency-type epigastric fullness and diarrhea. [Wu Qian] Guizhi (Cinnamon Twig) is pungent and aromatic; after prolonged boiling over fire, its qi dissipates and its efficacy diminishes. Therefore, it must be added later. For all formulas using Guizhi (Cinnamon Twig), this principle should be followed. If Rougui (Cinnamon Bark) is used, the rough bark should be removed and chopped just before use. Add it after the other herbs have finished decocting. Boil for two or three boils, then take. *Shanghan Leifang* states: Guizhi (Cinnamon Twig) is boiled separately at the end so that, amidst the drugs treating interior syndromes, it can emerge to the exterior to disperse pathogenic factors.
After severe purgation in Shanghan (Cold Damage), followed by sweating, if there is epigastric fullness and aversion to cold, the exterior syndrome remains unresolved. One must not attack the fullness; instead, one should first resolve the exterior. Only after the exterior is resolved can the fullness be attacked. To resolve the exterior, Guizhi Tang (Cinnamon Twig Decoction) is suitable. To attack the fullness, Dahuang Huanglian Xiexin Tang (Rhubarb and Coptis Heart-Draining Decoction) is suitable. (*Yufang*, *Maijing* have the character "qi" after "fa xia".)
[Ke Qin] Epigastric fullness is an interior syndrome resulting from erroneous purgation. Aversion to cold is a syndrome remaining unresolved after sweating. Interior excess and exterior deficiency, with both interior and exterior diseased, are caused by the inverted application of sweating and purging methods. With exterior and interior conflicting, one must still adhere to the correct method of treating the exterior first and the interior second, sweating first and purging second. Moreover, aversion to cold here is more severe than body ache, and epigastric fullness is milder than undigested food in stool. This differs from emergency rescue methods. [Qian Huang] The epigastrium is already full, yet aversion to cold persists, indicating that exterior pathogens remain unresolved. In the previous clause, although there was also fullness and aversion to cold, Fuzi Xiexin Tang (Aconite Heart-Draining Decoction) was used because aversion to cold accompanied sweating indicates yang deficiency. Here, aversion to cold without sweating indicates that the exterior is unresolved. [Fang Youzhi] At the initial stage of Shanghan (Cold Damage), the exterior syndrome should be released via sweating, hence Ma Huang Tang (Ephedra Decoction) is used. Here, since it is the exterior syndrome after sweating that needs resolving, Guizhi Tang (Cinnamon Twig Decoction) is indicated.
*Huo Ren Shu* states: Generally, Jie Xiong (Chest Binding) and Pi (Fullness) syndromes should be treated with purging. However, if the exterior is unresolved, one must not purge. *Zong Bing Lun* states: Adding Fuzi (Aconite Root) previously was because excessive sweating led to aversion to cold; the exterior sweat had resolved, but the interior binding remained. This symptom arises from no sweating and aversion to cold after sweating, so one must first resolve the exterior.
In Shanghan (Cold Damage), fever persists despite sweating, the illness does not resolve, there is epigastric hardness, vomiting, and diarrhea. Da Chai Hu Tang (Major Bupleurum Decoction) is the primary treatment. (*Zhongcangjing*, *Yufang*, *Zhengmai* read "xia" [downward]. Fang Ben, Wang Ben agree.)
[Cheng Zhi] Epigastric hardness with vomiting and diarrhea differs from soft epigastrium/abdomen with vomiting and diarrhea, which belongs to interior deficiency. Fever and sweating without resolution differ from cases where vomiting and diarrhea occur after the exterior resolves, leading to the use of Shizao Tang (Ten Jujube Decoction). Furthermore, this fullness did not form after purgation, nor is it a fullness caused by yang pathogens sinking inward. It is a fullness due to interior qi resisting internally. Fullness qi fills the heart/middle, causing obstruction between upper and lower, leading to vomiting and diarrhea. Although Da Chai Hu Tang (Major Bupleurum Decoction) is a purgative, it actually manages pathogens in the exterior, interior, upper, middle, and lower aspects, directing them out through the lower jiao. Thus, within purging lies the meaning of harmonizing. Using it as the main treatment is appropriate.
Note: *Yizong Jinjian* states that the character "xia" (downward/diarrhea) in "xiali" should be "bu" (not). If it were "xia", how could one use Da Chai Hu Tang (Major Bupleurum Decoction) to purge when there is vomiting and diarrhea? This view seems plausible but is incorrect. The so-called diarrhea here refers to heat-induced diarrhea. Changing it to "no diarrhea" would make it indistinguishable from urinary issues, showing a lack of textual research.
The condition resembles Guizhi Tang (Cinnamon Twig Decoction) syndrome, but the head does not hurt, the nape is not stiff, the cun pulse is slightly floating, there is epigastric hardness, qi rushes up to the throat causing difficulty breathing. This is called "cold in the chest" (phlegm-fluid retention). Emetic therapy should be used. Gouti San (Melon Stamen Powder) is suitable. (*Maijing* adds "qi" after "tou shang", "xiang shang", "mai". *Qianjin Yi* reads "head and nape not stiff/painful". *Yufang*, Cheng Edition read "hou yan". *Qianjin* reads "this is due to long-standing phlegm in the interior".)
[Cheng Wuji] Resembling Guizhi Tang (Cinnamon Twig Decoction) syndrome means fever, sweating, and aversion to wind. [Fang Youzhi] Head painlessness and nape stiffness absence indicate no external wind pathogen in the Taiyang channel, clarifying this is not Wind Strike. Cun position reflects the upper half of the body; slight floating indicates pathogen emerging from within. Epigastric hardness is phlegm-saliva blocking the diaphragm. Qi rushing to the throat is phlegm surging upward. Some describe the sound in the throat as like drawing a saw. "Han" (Cold) refers to phlegm. [Yu Jia Yan] "Han" (Cold) is phlegm. Internal movement of phlegm-fluid causes sweating, combined with fever and aversion to cold, resembling Wind Strike. But without head pain and nape stiffness, this is not external wind, but internal accumulated phlegm obstructing the chest. Gouti San (Melon Stamen Powder) should be used to induce vomiting of the phlegm. [Zhou Yangjun] Cold-fluid retention obstructs yang qi in the chest, preventing Wei Qi from securing the exterior, causing fever, aversion to cold, and sweating. [Cheng Zhi] Pathogenic factors accumulate in the diaphragm, termed "cold in the chest." Fullness-hardness caused by emesis/purgation is deficiency; that not caused by them is excess. Excess pathogens filling the heart/chest block the middle and lower jiao, necessitating an exit via the upper jiao. This is "those above should be evacuated upwards."
Note: Fang Shi and others interpret "cold" as phlegm because Gouti (Melon Stamen) expels stubborn phlegm from the diaphragm. However, "cold" cannot be directly equated with phlegm. Cheng Shi interpreting it as "pathogen" is very appropriate. Qian Shi interpreting it solely as wind-cold "cold" is likely incorrect. In the Jueyin chapter regarding Gouti San, it says "pathogen binds in the chest" and "disease is in the chest," supporting Cheng's view.
Gouti San Formula
Gouti (Melon Stamen) - 1 fen, roasted until yellow
Chixiaodou (Red Adzuki Bean) - 1 fen (*Yufang* says each 6 zhu)
The above two herbs are separately pounded and sifted into powder, then mixed. Take one qianbi (square-inch spoonful) of the powder. Use Xiangchi (Fragrant Fermented Soybean) 1 he, and hot water 7 he. Boil until a thin porridge consistency is reached. Strain the dregs. Mix the juice with the powder. Take warm in one dose. If vomiting does not occur, gradually increase the dose until near-vomiting, then stop. Do not give to patients with blood loss or deficiency constitutions. (*Qianjin Yi* says half qianbi.)
[Wu Qian] The chest is the mansion of clear yang. When various pathogens enter the chest mansion, they obstruct yang qi, preventing its dissemination, leading to chest fullness and hardness, rising hot qi, dryness/thirst, irritability, desire to vomit, and rapid/irregular pulse—this is heat binding. Chest fullness/hardness, qi rushing to throat causing breathing difficulty, cold hands/feet, desire to vomit but unable to, slow/tight pulse—this is cold binding. For diseases caused by binding of cold/heat, qi, or fluids in the chest, sweating and purging methods are ineffective. One must use sour and bitter agents that induce vomiting (upward evacuation). Once the upper jiao is unblocked and yang qi restored, fullness/hardness disappears and the chest harmonizes. Gouti (Melon Stamen) is extremely bitter; Chidou (Adzuki Bean) is sour. They complement each other to vent solid pathogens in the chest, being the premier emetic. Mixing with Xiangchi (Fragrant Fermented Soybean) juice utilizes grain qi to protect stomach qi. Taking small amounts repeatedly until near-vomiting prevents damage to yuan qi in the chest. This formula acts faster than sweating or purging, representing the three major methods: sweating, vomiting, purging. Modern people ignore the essence of Zhang Zhongjing and He Jianhe, discarding this formula—a great pity! However, for those with blood loss or deficiency, chest qi/fluids are depleted; do not administer lightly. This prohibition is emphasized. [Wang Ang] Emesis therapy must be studied in Shanghan (Cold Damage). Hua Yuanhua said: Shanghan reaching the fourth day affects the chest; emesis is suitable. Chao Yuanfang said: After three days of Shanghan, qi floats upward, causing chest/heart fullness; emesis cures it. Zhang Zhongjing placed this clause in the Lower Taiyang section because emesis should not be delayed, comparable to Taiyang sweating protocols. Assess symptoms within two to three days and apply the method. *Tiaobian* interprets "cold in chest" as phlegm, which is also valid. Wind-cold in the chest causes dietary accumulation to transform into heat and then phlegm. Thus, Gouti San (Melon Stamen Powder) also vents phlegm-heat. *Shanglun Pian* incorrectly classifies this syndrome under Phlegm Disease. "Boil into thin porridge" means boiling Xiangchi (Fragrant Fermented Soybean) in seven he of water until soft like porridge. Fang Shi interpreting "thin porridge" as separate congee is extremely wrong.
*Gu Fang Xuan Zhu* states: Gouti San (Melon Stamen Powder) is a heavy sour-bitter emetic for venting chest cold. Pathogen binds in the chest, not involving Taiyang exterior excess. Using only three herbs as powder, boiled into thin porridge, lingers in the middle jiao to induce vomiting, accomplishing the task. Gouti (Melon Stamen) rises, bitter and inducing vomiting; Dou (Bean) is sour/astringent, bitter and draining. To ensure upward evacuation, Xiangchi (Fragrant Fermented Soybean) tea uses its stale nature to develop solid pathogens, ensuring upward vomiting.
*Waitai Miyao* (Zhang Wenzhong's Gouti San) treats Shanghan (Cold Damage) with chest oppression. Gouti (Melon Stamen) and Chixiaodou (Red Adzuki Bean), each 1 liang. Pound these two into powder. Take one qianbi with plain water.
Fan Wang's Gouti San for Shanghan and epidemic fevers: Same two herbs, pounded into powder. Take one qianbi with two he of warm water. Lie down after taking. If vomiting occurs, endure it briefly. If no vomiting after eating time, take five-seven qian of powder mixed with two he of soup; vomiting will occur. If not, increase slightly until vomiting. Vomiting green/yellow fluid like vegetable juice, over five sheng, is ideal. If little vomited and disease remains, repeat next day as before, up to three times, without causing deficiency. If drug power passes without vomiting, take one sheng of soup to assist. Eat after vomiting; no residual toxicity. If overdosed, drink cold water to relieve. (*Huo Ren Shu* adds "probe with finger" after "mix and take".)
*Dongyuan Shixiao Fang* states: For food stagnation with irritability, Zhang Zhongjing uses Zhizi Dahuang Tang (Gardenia and Rhubarb Decoction). If the Qi Kou pulse is three times stronger than the Chi pulse, food injures the Taiyin, causing fullness/oppression/confusion, eventually severe heart/stomach pain, nausea, relieved by vomiting. Commonly called "food confusion wind." Classics state: Pulse present at upper body, absent at lower body, patient should vomit; if not, death ensues. Use Gouti San (Melon Stamen Powder) type to vomit. Classics state: "High pathogens should be evacuated upwards." This is what is meant.
*Yifang Jijie* states: Treats sudden phlegm confusion, flooding saliva, mania/restlessness, unconsciousness, five types of epilepsy with phlegm blocking upper diaphragm, fire/qi rushing up blocking throat, food filling middle jiao unable to vomit. Dosage based on deficiency/excess. During vomiting, close eyes and bind abdomen tightly. If vomiting continues, solve with Congbai Tang (Scallion White Decoction). If no vomiting after a while, hold a piece of rock sugar in mouth to induce vomiting. ○ Note: Zhang Hezi did not use Douchi (Fermented Soybean), adding Renshen (Ginseng Root) and Gancao (Licorice Root), mixed with pickle juice. If vomiting continues, use decocted Musk Soup. Melon seedlings die upon smelling musk, thus instantly stopping vomiting.
*Huo Ren Zhizhang Bianyi* states: Gouti (Melon Stamen) is Si Gua Di (Luffa Fruit Stalk). Commonly named Teng Luo. ○ Note: Not recorded in *Bencao*. Recorded for experimental verification. Shu Shi also said: If sweet melon stalk is unavailable, Luffa stalk can substitute.
If a patient has chronic masses under the hypochondrium connected to beside the umbilicus, pain radiating to the lower abdomen and entering the yin sinews, this is called Zang Jie (Organ Binding), a fatal syndrome. (*Yufang*, *Maijing* add "zhe ruo" after "bing". "Ru yin jin" reads "ru yin xie yin jin".)
[Cheng Zhi] Chronic masses under the hypochondrium indicate deep-rooted yin pathogens lurking in the interior. Now, newly contracting Shanghan (Cold Damage), failing to observe Yin channel fullness, erroneously applying purgation causes pathogens to enter the interior, interacting with chronic accumulations. This blocks true qi in the organs, causing binding and obstruction. Connected to beside the umbilicus, pain radiates to lower abdomen and yin sinews, hence named Zang Jie (Organ Binding). Fullness is yin pathogen; beside umbilicus is yin division. In organs is yin. Yin pathogen binding in yin-channel organs makes yang qi hard to open. Binding formation is complete; legally fatal. [Qian Huang] Pain radiating to lower abdomen, entering Jueyin and pulling testicular yin sinews indicates extreme yin qi and exhausted yang qi, hence fatal. [Xi Chun] Previous discussions on Zang Jie (Organ Binding) said difficult to treat,不可攻 (cannot purge). This discusses fatal Zang Jie (Organ Binding) to show it can be curable or fatal.
If Shanghan (Cold Damage) has no significant fever, dry mouth/thirst, irritability, and slight aversion to cold on the back, Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) is the primary treatment. (*Yufang* "xin" reads "er". *Qianjin*, *Yi*, *Waitai* read "Baihu Tang".)
[Wu Qian] Shanghan (Cold Damage) with no significant fever, no irritability/thirst, neutral mouth feel, and back aversion to cold treated with Fuzi Tang (Aconite Decoction) belongs to Shaoyin disease. Current Shanghan (Cold Damage) with no significant fever indicates heat gradually moving from exterior to interior. Dry mouth/thirst and irritability indicate heat has entered Yangming. Although slight back aversion to cold seems like Shaoyin, Shaoyin has neutral mouth feel; current dry mouth/thirst means mouth is not neutral. Back aversion to cold is not yang deficiency; it is Yangming interior heat steaming the back, sweating causing porous skin, hence slight aversion. Primary Baihu Tang (White Tiger Decoction) goes straight to Yangming to clear heat greatly. Adding Renshen (Ginseng Root) protects porous skin. [Qian Huang] Back aversion to cold, dry mouth/thirst, and irritability here result from interior heat generating exterior cold. It cannot be compared to back aversion to cold with neutral mouth feel. [Wang Ang] Interior steaming heat causes exterior sweating, hence aversion to cold, same meaning as previous clause's aversion to wind. Interior heat causes stomach dryness/heat, hence great thirst, dry tongue, irritability, desire to drink several sheng of water. After emesis/purgation, stomach qi is deficient, internal fluids lost, hence extreme dryness/thirst.
Note: *Yizong Jinjian* suggests "ruo han" (if sweating) should follow "shanghan" (Shanghan). Sweating damages fluids more than emesis/purgation. "Shishi eweng" (frequent aversion to wind) should be "shi han eweng" (frequent sweating and aversion to wind). Without "sweating", frequent aversion to wind implies unresolved exterior, contraindicating Baihu Tang (White Tiger Decoction). The text says fever without sweating, unresolved exterior, cannot use Baihu Tang (White Tiger Decoction); thirst for water, no exterior syndrome, Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) is used. Readers should study carefully. This view is hard to accept. Ke Shi said: Failure to sweat, instead using emesis/purgation is inverted treatment. Emesis loses fluids above; purging loses fluids below. Correct.
*Shanghan Leifang* states: Stomach fluids are exhausted, neither in channels nor fu organs, nor like Chengqi syndrome with solid pathogens. Due to exhaustion of stomach opening fluids, internal fire burns like furnace, seeking water to save itself. Thus the syndrome appears so. It is distinctly different from heat pathogens in fu organs.
*Waitai Miyao* (Zhang Zhongjing's Shanghan Lun) treats Shanghan (Cold Damage) with sweating, aversion to cold, body heat, endless great thirst, desire to drink one or two dou of water. Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) is the primary treatment. ○ This clause is not in the original text, attached here for reference.
Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) Formula
Zhimu (Anemarrhena Rhizome) - 6 liang
Shigao (Gypsum Fibrosum) - 1 jin, crushed
Renshen (Ginseng Root) - 2 liang (*Shangbian*, *Yufang* say 3 liang)
Gancao (Licorice Root), roasted - 2 liang
Jingmi (Glutinous Rice) - 6 liang
The above five herbs, with one斗 (dou) of water, boil until rice is cooked and liquid is ready. Strain dregs. Take one sheng warm, three times a day. This formula can be taken from Start of Summer to Start of Autumn. Cannot be taken after Start of Autumn. January, February, March are still cold; also cannot be taken. Taking it causes vomiting, diarrhea, and abdominal pain. Those with blood loss or deficiency constitutions also cannot take it. Taking it causes abdominal pain and diarrhea; warming will cure. (*Yufang* says "Spring three months often suffer interior cold." Note: This formula appeared in Taiyang Upper Section without these 62 characters, so repeated here. These 62 characters are suspected additions by later scholars, but appear in *Yufang*, *Qianjin*, *Yifang*, *Waitai Miyao*, so cannot be arbitrarily deleted. Preserving old text.)
*Neitai Fangyi* asks: *Huo Ren Shu* says Baihu Tang (White Tiger Decoction) can only be used at Summer Solstice. Why? Answer: Incorrect. Ancients matched one formula to one syndrome. If genuine Baihu Tang (White Tiger Decoction) syndrome exists in severe winter, why not use Shigao (Gypsum)? If genuine Zhenwu Tang (True Warrior Decoction) syndrome exists in midsummer, why not use Fuzi (Aconite Root)? If elderly need purging, why not use Xiaoshi (Sodium Sulfate) and Dahuang (Rhubarb)? If robust need warming, why not use Jiang (Ginger) and Fu (Aconite)? These are necessary for applicable cases. For inapplicable cases, forcing usage harms regardless of season.
Wang Shi cites Xu Chunyi: Suspects "Start of Summer..." addition is by later scholars.
Zhang Shi's *Shanghan Baiwen Jingluo Tu* states: Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) is named Huaban Tang (Transform Spot Decoction), appearing in heterodox books.
If Shanghan (Cold Damage) has no significant fever, dry mouth/thirst, irritability, and slight aversion to cold on the back, Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) is the primary treatment. (*Yufang* "xin" reads "er". *Qianjin*, *Yi*, *Waitai* read "Baihu Tang".)
[Wu Qian] Shanghan (Cold Damage) with no significant fever, no irritability/thirst, neutral mouth feel, back aversion to cold, treated with Fuzi Tang (Aconite Decoction) belongs to Shaoyin. Current Shanghan (Cold Damage) with no significant fever indicates heat moving from exterior to interior. Dry mouth/thirst and irritability indicate heat entered Yangming. Although slight back aversion to cold seems like Shaoyin, Shaoyin has neutral mouth feel; current dry mouth/thirst means mouth is not neutral. Back aversion to cold is not yang deficiency; it is Yangming interior heat steaming the back, sweating causing porous skin, hence slight aversion. Primary Baihu Tang (White Tiger Decoction) goes straight to Yangming to clear heat greatly. Adding Renshen (Ginseng Root) protects porous skin. [Qian Huang] Back aversion to cold, dry mouth/thirst, and irritability here result from interior heat generating exterior cold. Cannot be compared to back aversion to cold with neutral mouth feel. [Wang Ang] Interior steaming heat causes exterior sweating, hence aversion to cold, same meaning as previous clause's aversion to wind.
Note: Back aversion to cold, Cheng Shi thought unresolved exterior pathogen, Cheng Shi thought yang deficiency, both incorrect. *Shanghan Leifang* states: This is also deficiency-dryness syndrome. Slight aversion to cold means mild aversion, whole body not cold, cold only on back, indicating exterior pathogens resolved. If severe aversion to cold, this decoction cannot be used.
If Shanghan (Cold Damage) pulse is floating, fever without sweating, exterior unresolved, Baihu Tang (White Tiger Decoction) cannot be given. Thirst for drinking water, no exterior syndrome, Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) is the primary treatment. (*Xie* down, Cheng Edition, *Yufang*, *Waitai* have "zhe". *Qianjin*, *Yi*, *Waitai* read "Baihu Tang".)
[Wei Litong] Floating pulse not slippery indicates heat has not transformed but penetrated deeply. Currently fever without sweating, exterior syndrome obvious. Baihu Tang (White Tiger Decoction) cannot be given, merely damaging stomach qi. Treatment should be sought among Ma Huang Tang (Ephedra Decoction), Da Qing Long Tang (Major Green Dragon Decoction), Guizhi Er Yuebi Yi Tang (Cinnamon Twig Twice Yuebi One Decoction). If person desires water and can drink, it indicates exterior pathogen transformed to heat, penetrating deeply. Re-examining pulse shows no floating-slow or floating-tight exterior pulses. Examining symptoms shows no head/body pain, fever without sweating exterior signs. Immediately use Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) to tonify middle, benefit qi, stop dryness/thirst. [Qian Huang] Desire to drink water indicates pathogen heat entered Yangming interior, stomach fluids dried. Must still verify no exterior syndrome before using Baihu Tang (White Tiger Decoction) to resolve vexing heat.