此一卷论表里。治伤寒。须辨表里。表里不分。汗下差误。古人所以云桂枝下咽。阳盛即毙。承
气入胃。阴盛以亡。伤寒有表证。有里证。有半在表半在里。有表里两证俱见。有无表里证。在表宜
汗。在里宜下。半在里半在表宜和解。表里俱见。随证渗泄。无表里证。用大柴胡汤下之。（正方三
十）又四逆汤（正七十五）证。有先温里乃发表。桂枝汤（正方一）证。有先解表乃攻里。仲景云。下
利清谷。身体疼痛。急当救里。身体疼痛。清便自调。急当救表。如附应桴。间不容栉。非特此也。
均是发热。身热不渴为表有热。小柴胡加桂主之。（正二十九）厥而脉滑为里有热。白虎加人参主之。
（正六十五）（黄帝所谓发表不远热。攻里不远寒也）均是水气干呕。微利发热而咳为表有水。小
青龙加荛花主之。（正三十六）身体凉。表证罢。咳而胁下痛为里有水。十枣汤主之。（正八十九）
均是恶寒发热而恶寒者。发于阳也。麻黄桂枝小柴胡主之。（无麻黄桂枝小柴胡汤。只有柴胡桂枝汤。见正方三十一）
无热而恶寒者发于阴也。附子四逆汤主之。（正七十五）均是身体痛。脉浮发热头疼身体痛者为表未解。麻黄汤主
之。（正二十）脉沉自利身体痛者为里不和。四逆汤主之（正七十五）。以此观之。仲景之于表里亦详矣。学人宜深究之。
虽
然。伤寒六七日。目中不了了。无表里证。脉虽浮亦有下之者。少阴病二三日无阳证。亦有发汗者。
非表里之所能拘。又不可不知也。
（十三）问表证
发热恶寒。身体痛而脉浮者。表证也。（浮。表阳也。其脉按之不足。举之有余。素问云。寸
口脉浮而盛。曰病在外。寸口脉沉而紧。曰病在中。仲景云。脉浮者病在表。可发汗。又曰表
有病者。脉当浮。又曰。结胸证脉浮者不可下。则知脉浮者表证也）表证者。恶寒是也。恶
寒者。表之虚。此属太阳。宜汗之。然伤寒发表。须当随病轻重而汗之。故仲景有发汗者。有
和解之者。兼四时发汗。亦自不同。○春不可大发汗。以阳气尚弱。不可亟夺。使阴气胜于时。
天寒初解。营卫腠理缓。可用小柴胡汤（正二十九）之类。○冬不可汗者。以阳气伏藏。不可妄扰。不问伤
寒中风。以轻药解利之。伤寒无汗者。只与桂枝麻黄各半汤。（正方二）伤风有汗。只与柴胡桂枝汤。（正三十一）
或得少汗而解。或无汗自解。（病势甚者不拘此）○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。须是桂枝麻黄汤加黄芩石膏知母升麻也。（加减法在第十二卷
药方中）夏月有桂枝麻黄证。不加黄芩辈服之。转助热气。便发黄斑出也。白虎汤虽可用。然
治中暑与汗后一解表药耳。一白虎未能驱逐表邪。况夏月阴气在内。或患热病而气虚人。妄投白
虎。往往有成结胸者。以白虎性寒。非治伤寒药也。○凡发汗欲令手足俱周。 然一时许为佳。
不欲如水淋漓。服汤中病即止。不必尽剂。然发汗。须如常覆腰以上。浓衣覆腰以下。盖腰以上
流漓。而腰以下至足心微润。病终不解。凡发汗病证仍在者。三日内可二三汗之。令腰脚周遍为
度。○又问三阴有可汗者乎。阴病不当发汗。发汗即动经。然太阴脉浮。少阴发热。亦须微微取
汗。但不正发汗耳。大抵风寒中人与营卫俱薄而发热。又未曾行诸汗药。虽无阳证。须少汗解逐
之。王叔和云。表中风寒。入里则不消。故知初病脉沉细数。虽里不消。本表中风寒。须宜温覆
少汗而解。仲景太阴证脉浮可汗。宜桂枝汤。（正方一）少阴病发热脉沉。宜麻黄细辛附子汤。（正二十三）少
阴二三日。常见少阴证。无阳证者。宜麻黄附子甘草汤（正二十二）微发汗。皆阴证表药也。要知脉沉细数。
病在里不可发汗。此大略之言耳。脉应里而发热在表。宜以小辛之药取微汗而温散也。○大抵伤寒
太阳证发热恶寒。宜发其汗。然热多寒少。其脉微弱。或尺脉迟者。不可表也。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。（正方四）尺脉迟者。血少也。先以小建中
加黄 汤。（正三十七）以养其血。 时用小柴胡桂枝二越婢一汤。小分剂以和解之其人当汗而衄血下血者。
不可表也。（太阳病脉浮而紧。发热身无汗。自衄者愈。不可汗。汗出必额上陷脉紧急。直视不得
瞬。又云。太阳病不解。热结膀胱。其人如狂。血自下。下者愈。不愈宜桂枝汤。正方一）坏病者。不可
表也。太阳病三日。已发汗。若吐若下若温针仍不解者。为坏病。桂枝不中与也。当犯何逆。随
证治之。又云太阳病不解。传入少阳者。胁下硬满。干呕不能食。往来寒热。尚未吐下。脉沉紧者。
与小柴胡汤。（正二十九）若已吐下发汗。柴胡证罢。此为坏病。知犯何逆。以法治之。妇人经水适来者。不
可表也。（妇人病经水适下而发其汗。则郁冒不知人。此病为表里俱虚。故令郁冒也）风温者。
不可表也。脉尺寸俱浮。头疼身热常自汗。体重。其息必喘。其形不仁。嘿嘿但欲眠者。风温证
也。复发其汗者死。宜葳蕤汤。（杂四十五）湿温者。不可表也。两胫逆冷。胸腹满。头目痛苦妄言。必
多汗者。湿温证也。不可发汗。发汗者。名曰重 。如此死者医杀之耳。宜桂附汤（正十七）、白虎加苍术
汤。（杂一百十七）虚烦者。不可表也。诸虚烦热与伤寒相似。然不恶寒。身不疼。故知非伤寒也。不可发
汗。头不痛。脉不紧。故知非里实也。不可下。宜服竹叶汤。（正九十五）病患腹间左右上下有筑触动气者。
不可表也。动气在左。不可发汗。发汗则头眩。汗不止。筋惕肉 。此为逆难治。先服防风白
术牡蛎汤。（杂方二）汗止。次当服建中汤。（正三十七）动气在右。不可发汗。发汗则衄而渴。心苦烦。饮则吐水。先
服五苓散一二服。（正六十六）次服竹叶汤。动气在下不可发汗。发汗则气上冲。正在心端。宜服李根汤。（杂方三）动
气在下。不可发汗。发汗则无汗。心中大烦（杂方四）。骨节疼烦。目晕恶寒。食即反吐。谷不得化。先服大橘皮汤。（杂
方四）吐止后。服小建中汤（正三十七）以此见古人慎用表
药如此。
（十四）问里证
不恶寒。反恶热。手掌心并腋下 汗出。胃中干涸。燥粪结聚。潮热。大便硬。小便如常。
腹满而喘。或谵语。脉沉而滑者。里证也。（仲景云。手足 然汗出者。此大便已硬也。伤寒欲下
而小便少。手足心并腋下不滋润者。不可攻也）里证者。（内热是也。内热者。里之弱）此
属阳明也。宜
下之。○伤寒始发热恶寒。今汗后不恶寒。但倍发热而躁。始脉浮大。今脉洪实。或沉细数。始惺静。
今狂语。此为胃实阳盛。再汗即死。须下之即愈。○亦有始得病。便变阳盛之证。须便下之。不可
拘以日数。○更有心胸连脐腹大段疰闷。腹中疼。坐卧不安。冒闷喘急极者。亦不候他证。便下之。
凡大便秘。妨闷恐尚有表证者。亦须少少饮小承气汤（正四十二）微解之。不可过多。令大泄也失下则气
血不通。四肢便厥。医人不知。反疑是阴厥。复进热药。祸如反掌。不可不察也。○又问三阴有可
下者乎。三阴大约可温。然须有积证方可也。何谓积证。太阴腹满时痛。桂枝加芍药汤（正十二）痛甚者桂枝
加大黄汤。（正十三）少阴口燥咽干。或腹满不大便。或下利清水。心下痛。皆积证也。仲景云。少阴病
得之二三日口燥咽干者。急下之。宜大承气汤（正四十一）。少阴病自利清水。心下痛。口干者。宜大承气汤。
少阴病六七日腹满不大便者。宜大承气汤也。下证悉具。服汤已。更衣者。止后服。不尔尽剂服
之。（更衣谓病患服承气汤后得下利。故勿与也）下后慎不中服补药。孙真人云。服大承气汤。
得利瘥。慎不中服补药也。热气得补复成。更复下之。是重困也。宜消息安养之。○大抵伤寒最慎
于下。若表证未罢。不可乱投汤剂。虚其胃气。（仲景云。表解而内不消。非大满。犹生寒热。则
病不除也。表已解而内不消。大满大实。坚有燥屎。乃可下之。虽四五日不能为祸。若不宜下而便
攻之。内虚热入。协热遂利。烦躁诸变。不可胜数。轻者困笃。重者必死矣。古人所以伤寒有承气
之戒）脉浮者。不可下。（仲景云。脉浮者。病在表。可发其汗。应汗而下。为懊 。为痞。为
结胸）脉虚细者。不可下。（王叔和云。脉微不可吐。虚细不可下）恶寒者不可下。（恶寒者。
表之虚。虽是阳明证。尚恶寒。即与太阳合病。属表。可发其汗。少阴恶寒。当温之）呕吐者。不
可下。仲景云。呕多虽有阳明证。不可下。阳明病胁下硬满。不大便而呕。舌上白苔者。宜与小
柴胡汤。（正二十九）上焦得通。津液得下。胃气因和。身 然汗出。得屎而解。不转失气者。不可下。转
失气。今人所谓下泄也。伤寒论云。阳明病。不大便六七日。恐有燥屎。欲知之法。少与小承气汤。
腹中转失气者。此有燥屎也。乃可攻之。若不转失气者。此但头硬后必溏。不可攻之。攻之必胀满
不能食也。又云。阳明病谵语。发潮热。脉滑而疾者。小承气汤主之。（正四十二）因与小承气汤一升。腹中转失
气者。更服一升。若不转失气者。勿更与之。仲景无治法。今详。宜与小柴胡汤。（正二十九）明日又不大便。
脉反微涩者。里虚也。为难治。仲景亦无治法。宜与黄 建中汤。大便坚。小便数。不可用承气
汤攻之。趺阳脉浮而涩。浮则胃气强。涩则小便
数。浮涩相搏。大便则硬。其脾为约。麻子仁丸主之（正九十二）。千金云。脾约者。大便坚。小便利。宜枳实
丸。太阳阳明者。脾约乃是也。小便清者不可下。（仲景云。伤寒不大便。六七日头疼有热。与
承气汤。小便清者。知不在里）大便硬。小便少者。未可攻。（恐津液还入胃。必先硬后溏也。
小便自如。乃可攻之。当问其小便日几行。若本小便日三四行。今日再行。故知大便不久出。今为
小便数少。以津液当还入胃中。故知不久必大便也）阳明病。自汗出若发汗。小便自利者。不可下。
此为津液内竭。虽硬不可攻之。当须自大便蜜导之。若土瓜根、大猪胆汁。皆可导之。（正一百十一）以此知
古人慎用转药如此。
（十五）问表里两证俱见
伤寒表证当汗。里证当下。不易之法也。发表攻里。本自不同。甘遂神丹不可以合饮。桂枝承气
安可以并进。○然而假令病患脉浮而大。是表证当汗。其人发热烦渴。小便赤。却当下。此是表里证
俱见。五苓散主之。（正六十六）（仲景云。中风发热。六七日不解而烦。有表里证。渴欲饮水者。水入则吐。
名曰水逆。五苓散主之）○假令伤寒不大便六七日。头痛有热者。是里证当下。其人小便清者。
知不在里。仍在表。当须发汗。此是两证俱见。即未可下。宜与桂枝汤。（正方一）○假令病患心下满。口不
欲食。大便硬。脉沉细。是里证当下。其人头汗出。微恶寒。手足冷。却当汗。此两证俱见者。仲景
所谓半在里半在表也。小柴胡汤主之。（正二十九）○假令太阳病表证未除。而医数下之。遂协热而利。利不止。
心下痞硬。仲景谓之表里不解。桂枝人参汤主之。（正十六）○本太阳病。医反下之。因尔腹痛。是有表。复有
里。仲景用桂枝加芍药汤。（正十二）痛甚者。桂枝加大黄汤。（正十三）此皆仲景治伤寒有表复有里之法。学人当以意
推
之也。
（十六）问无表里证
伤寒四五日后。以至过经。（十三日为过经）无表证。又于里证未可下者。但非汗证。亦非下
证者。皆可用小柴胡。（正二十九）随证加减用之。（加减法在第十二卷药方中也）以至十余日者。亦可用。
十余日外用小柴胡汤不愈者。若大便硬。看证可下。则用大柴胡下之。（正三十）以过经。其人气稍虚当下者。
用大柴胡汤则稳。盖恐承气汤太紧。病患不禁也。○仲景云。六七日目中不了了。睛不和。无表里证。
大便难。身微热。此为实也。当下之。宜大承气汤。（正四十一）○又云。病患无表里证。发热七八日。脉虽浮
数。可大柴胡下之。（正三十）假令已下。脉数不解。至六七日不大便者。有瘀血也。属抵当汤。（正九十一）
（十七）问病患有身大热。反欲得衣。有身大寒。反不欲近衣者。
此名表热里寒。表寒里热也。病患身大热。反欲得衣。热在皮肤。寒在骨髓也。仲景无治法。宜
先与阴旦汤。（杂方六）寒已。次以小柴胡加桂（杂三十九）以温其表。病患身大寒。反不欲近衣。寒在皮肤。热在骨髓
也。
仲景亦无治法。宜先与白虎加人参汤。（正六十五）热除。次以桂枝麻黄各半汤（正方二）以解其外。大抵病有标本。治
有先
后。表热里寒者。脉须沉而迟。手或微厥。下利清谷也。所以阴证亦有发热者。四逆汤（正七十五）、通脉四逆
This volume discusses exterior and interior syndromes. In treating Shanghan (Cold Damage), one must differentiate between exterior and interior. If exterior and interior are not distinguished, the errors of sweating and purging will occur. Hence the ancients said: "When Guizhi Tang (Cinnamon Twig Decoction) is swallowed, if Yang is excessive, death ensues; when Chengqi Tang (Gastro-Draining Decoction) enters the stomach, if Yin is excessive, death follows." Shanghan may present with an exterior syndrome, an interior syndrome, a half-exterior half-interior syndrome, simultaneous exterior and interior syndromes, or neither exterior nor interior syndromes. For diseases in the exterior, sweating is indicated; for diseases in the interior, purging is indicated; for half-exterior half-interior conditions, harmonization is indicated; for simultaneous exterior and interior syndromes, treatment should follow the symptoms to promote fluid drainage; for cases with neither exterior nor interior syndromes, Dachaihu Tang (Greater Bupleurum Decoction) should be used to purge it. (Zheng 30) There are also indications for Sini Tang (Frigid Extremities Decoction) (Zheng 75), where one should first warm the interior before releasing the exterior, and indications for Guizhi Tang (Cinnamon Twig Decoction) (Zheng 1), where one should first release the exterior before attacking the interior. Zhang Zhongjing stated: "In cases of diarrhea with undigested food and body pain, urgent rescue of the interior is required; in cases of body pain with normal bowel and bladder function, urgent rescue of the exterior is required." This precision allows no room for error, like an arrow hitting the target without a hair's breadth of deviation. It is not just this case. Similarly, regarding fever: body heat without thirst indicates heat in the exterior, treated with Xiaochaihu Tang plus Guizhi (Bupleurum Decoction plus Cinnamon Twig) (Zheng 29). Cold extremities with a slippery pulse indicate heat in the interior, treated with Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) (Zheng 65). (As Huangdi stated: "Releasing the exterior does not avoid heat; attacking the interior does not avoid cold.") Similarly, regarding water retention causing dry retching: mild diarrhea, fever, and cough indicate water in the exterior, treated with Xiaoqinglong Tang plus Wanghua (Minor Green Dragon Decoction plus Euphorbia fischeriana) (Zheng 36). Cool body, resolved exterior syndrome, cough with hypochondriac pain indicate water in the interior, treated with Shizao Tang (Ten Jujube Decoction) (Zheng 89). Similarly, regarding aversion to cold and fever where aversion to cold predominates: this originates from Yang, treated with Mahuang Tang (Ephedra Decoction), Guizhi Tang, or Xiaochaihu Tang. (Note: The original text lacks Mahuang Tang, Guizhi Tang, and Xiaochaihu Tang here, only having Chaihu Guizhi Tang, see Zheng 31). Absence of fever with only aversion to cold originates from Yin, treated with Fuzi Sini Tang (Aconite Frigid Extremities Decoction) (Zheng 75). Similarly, regarding body pain: floating pulse, fever, headache, and body pain indicate unresolved exterior, treated with Mahuang Tang (Zheng 20). Deep pulse, spontaneous diarrhea, and body pain indicate interior disharmony, treated with Sini Tang (Zheng 75). From this, we see that Zhang Zhongjing's differentiation of exterior and interior was detailed. Students should investigate this deeply.
Nevertheless, in Shanghan after six or seven days, if vision is unclear ("mubuliao liao"), with no exterior or interior syndromes, and although the pulse is floating, purging may be used. In Shaoyin disease after two or three days, without Yang syndromes, sweating may also be used. These are not constrained by exterior or interior classifications, which is something one must know.
(13) Question on Exterior Syndromes
Fever, aversion to cold, body pain, and a floating pulse constitute an exterior syndrome. (Floating pulse belongs to Exterior Yang. Pressing reveals insufficiency, lifting reveals excess. Suwen states: "Floating and full cunkou pulse indicates disease outside; deep and tight cunkou pulse indicates disease inside." Zhang Zhongjing says: "Floating pulse indicates disease in the exterior, sweating is appropriate." Also: "Disease in the exterior implies a floating pulse." Also: "Jie Xiong syndrome with floating pulse cannot be purged." Thus, floating pulse indicates an exterior syndrome.) An exterior syndrome is characterized by aversion to cold. Aversion to cold is deficiency of the exterior, belonging to the Taiyang channel, and sweating is indicated. However, releasing the exterior in Shanghan must be adjusted according to the severity of the illness. Therefore, Zhang Zhongjing has formulas for sweating and for harmonizing. Combined with the four seasons, methods of sweating differ. ○ In spring, heavy sweating should be avoided because Yang Qi is still weak and should not be abruptly depleted, allowing Yin Qi to dominate the season. As the weather warms, Ying and Wei Qi and the pores are relaxed; formulas like Xiaochaihu Tang (Zheng 29) may be used. ○ In winter, sweating should be avoided because Yang Qi is hidden and stored, and should not be disturbed recklessly. Regardless of whether it is Shanghan or Shangfeng, light herbs should be used to resolve it. For Shanghan without sweat, only Guizhi Mahuang Ban Tang (Half Cinnamon Twig and Ephedra Decoction) is given (Zheng 2). For Shangfeng with sweat, only Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) is given (Zheng 31). Sometimes slight sweating leads to resolution, or absence of sweat resolves spontaneously. (Severe cases do not adhere to this.) ○ In summer, when the weather is very hot and pores are open, with a洪大 (surging-large) pulse, proper sweating is indicated. However, hot-natured drugs like Mahuang and Guizhi should not be used alone. One must use Guizhi Mahuang Tang added with Huangqin (Scutellaria Root), Shigao (Gypsum), Zhimu (Anemarrhena Rhizome), and Shengma (Cimicifuga Rhizome). (Modification methods are in Volume 12 prescriptions.) In summer, if there are Guizhi Mahuang indications but Huangqin etc. are not added, it will further assist heat, leading to jaundice and macules. Although Baihu Tang (White Tiger Decoction) can be used, it is merely a herb for treating Zhongshu (Heatstroke) and resolving the exterior after sweating. Baihu alone cannot expel exterior pathogens. Moreover, in summer, Yin Qi is internal; for those with heat disease and Qi deficiency, mistakenly administering Baihu often results in Jie Xiong (Chest Binding) syndrome because Baihu is cold-natured and not a drug for treating Shanghan. ○ When sweating, it is desired that sweat covers the whole body evenly, ideally within one shichen (two hours). Profuse sweating like dripping water is undesirable. Stop medication once the disease is addressed; there is no need to finish the entire dose. However, during sweating, cover the upper waist as usual, and cover the lower waist with thick clothing. If only the upper waist sweats profusely while the lower waist to soles remain slightly moist, the disease will not resolve. If symptoms persist after sweating, up to two or three sweat-inducing treatments may be given within three days, aiming for sweat covering the waist and legs. ○ Another question: Are there cases in the Three Yin channels suitable for sweating? Yin diseases generally should not be sweated, as sweating disturbs the meridians. However, if Taiyang pulse is floating or Shaoyin presents with fever, slight sweating is necessary, though not formal heavy sweating. Generally, when Wind-Cold invades, affecting both Ying and Wei with fever, and no sweating drugs have been used yet, even without Yang syndromes, slight sweating is needed to expel it. Wang Shuhe said: "Wind-Cold in the exterior, if entering the interior, will not dissipate." Thus, knowing that initial deep, fine, rapid pulse with unresolving interior signs actually stems from exterior Wind-Cold, one should use warming covers and slight sweating to resolve it. Zhang Zhongjing states Taiyin syndrome with floating pulse can be sweated, using Guizhi Tang (Zheng 1). Shaoyin disease with fever and deep pulse uses Mahuang Xixin Fuzi Tang (Ephedra, Asarum, and Aconite Decoction) (Zheng 23). Shaoyin disease after two or three days, showing Shaoyin signs without Yang signs, uses Mahuang Fuzi Gancao Tang (Ephedra, Aconite, and Licorice Decoction) (Zheng 22) for slight sweating; these are all exterior-resolving drugs for Yin syndromes. Know that deep, fine, rapid pulse indicates interior disease where sweating is contraindicated; this is a general statement. Pulse reflecting interior with exterior fever requires slight sweating with acrid-warm drugs. ○ Generally, Taiyang syndrome in Shanghan with fever and aversion to cold requires sweating. However, if heat predominates over cold, pulse is weak, or chi pulse is slow, exterior release is contraindicated. Taiyang disease with fever, aversion to cold, heat > cold, and weak pulse indicates "No Yang," and sweating is contraindicated; Guizhi Er Yuebi Yi Tang (Two Parts Cinnamon Twig, One Part Minor White Tiger Decoction) is indicated (Zheng 4). Slow chi pulse indicates blood deficiency; first use Xiao Jianzhong Tang plus Huangqi (Minor Construct the Middle Decoction plus Astragalus) (Zheng 37) to nourish blood. Occasionally use Xiaochaihu Guizhi Er Yuebi Yi Tang in small doses to harmonize. If the patient should sweat but instead has epistaxis or hematochezia, exterior release is contraindicated. (Taiyang disease with floating-tight pulse, fever, no sweat, self-epistaxis heals; do not sweat, as sweating causes sunken temples, urgent pulse, staring eyes. Also: Unresolved Taiyang, heat binding Bladder, mania-like state, spontaneous bleeding heals; if not, use Guizhi Tang, Zheng 1.) Huai Bing (Ruined Disease) cannot be released via exterior. Taiyang disease after three days, already sweated, or vomited, purged, or treated with moxibustion without resolution, is called Huai Bing. Guizhi Tang is no longer applicable. Determine what reversal occurred and treat accordingly. Also: Unresolved Taiyang transmitting to Shaoyang, with hypochondriac fullness, dry retching, inability to eat, alternating chills and fever, without prior vomiting/purging, deep-tight pulse: give Xiaochaihu Tang (Zheng 29). If vomiting/purging/sweating already occurred and Chaihu signs ceased, this is Huai Bing; determine the reversal and treat legally. Menstruation onset in women: exterior release is contraindicated. (Sweating menstruating women causes Yu Mao [depression/dizziness] and unconsciousness due to exterior-interior deficiency.) Fengwen (Wind-Warmth) cannot be released via exterior. Floating pulses at cun and chi, headache, body heat, spontaneous sweating, heaviness, panting, numbness, silence, desire to sleep: these are Fengwen signs. Sweating again causes death; use Weihui Tang (Polygonatum Decoction) (Za 45). Shiwen (Damp-Warmth) cannot be released via exterior. Reverse cold in calves, chest/abdominal fullness, head/eye pain, delirium, profuse sweating: these are Shiwen signs. Sweating is contraindicated; doing so is called "Chong Re" (Heavy Heat). Death from this is physician-induced. Use Guifu Tang (Cinnamon and Aconite Decoction) (Zheng 17) or Baihu Jia Cangzhu Tang (White Tiger Plus Atractylodes Macrocephala Decoction) (Za 117). Xu Fan (Deficiency Irritability) cannot be released via exterior. Deficiency irritability/heat resembles Shanghan but lacks aversion to cold and body pain, so it is not Shanghan; sweating is contraindicated. No headache, tight pulse means not interior excess; purging is contraindicated. Use Zhuye Tang (Bamboo Leaf Decoction) (Zheng 95). Patients with pulsating Qi in abdomen left/right/up/down: exterior release is contraindicated. Qi movement on left: do not sweat; sweating causes dizziness, continuous sweating, muscle twitching. This is adverse and hard to treat. First use Fangfeng Baizhu Muli Tang (Saposhnikovia, Atractylodes Macrocephala, and Oyster Shell Decoction) (Za Fang 2). After sweating stops, use Jianzhong Tang (Zheng 37). Qi movement on right: do not sweat; sweating causes epistaxis, thirst, heart vexation, vomiting water after drinking. First use Wuling San (Five-Ingredient Powder with Poria) (Zheng 66), then Zhuye Tang. Qi movement below: do not sweat; sweating causes Qi rushing upward to the heart, use Ligeng Tang (Li Root Decoction) (Za Fang 3). Qi movement below: do not sweat; sweating causes no sweat, severe heart vexation (Za Fang 4), joint pain, dizziness, aversion to cold, vomiting upon eating, undigested food. First use Daju Pi Tang (Large Tangerine Peel Decoction) (Za Fang 4). After vomiting stops, use Xiao Jianzhong Tang (Zheng 37). This shows how cautiously ancients used exterior-releasing drugs.
(14) Question on Interior Syndromes
Absence of aversion to cold, preference for heat, sweating in palms and axillae, dry stomach, accumulated dry feces, tidal fever, hard stool, normal urination, abdominal fullness with wheezing, or delirium, deep-slippery pulse: these are interior syndromes. (Zhang Zhongjing said: "Sweating from hands and feet indicates hard stool." In Shanghan, if purging is considered but urine is scant and palms/axillae are not moist, purging is contraindicated.) Interior syndrome refers to internal heat (weakness of the interior). This belongs to Yangming, and purging is indicated. ○ Shanghan starts with fever/aversion to cold; after sweating, no longer aversive to cold, but increased fever/agitation; pulse changes from floating-large to surging-solid or deep-fine-rapid; consciousness changes from calm to delirious: this is Stomach Excess and Yang Prosperity. Further sweating causes death; purging leads to recovery. ○ Some cases immediately transform into Yang Excess signs upon onset; immediate purging is required, ignoring day counts. ○ More cases involve severe stuffiness from chest to umbilicus/abdomen, abdominal pain, restlessness, suffocation, extreme wheezing: do not wait for other signs, purge immediately. For constipation with stuffiness fearing residual exterior syndrome, give small amounts of Xiao Chengqi Tang (Minor Gastro-Draining Decoction) (Zheng 42) to mildly resolve it; do not overdose to cause severe diarrhea. Failure to purge leads to Qi/Blood blockage and cold extremities. Physicians unaware may mistake this for Yin Cold and administer hot drugs, causing disaster instantly; this must be observed carefully. ○ Question: Can Three Yin channels be purged? Three Yin generally requires warming, unless there are accumulation signs. What are accumulation signs? Taiyang abdominal fullness and intermittent pain: Guizhi Jia Shaoyao Tang (Cinnamon Twig Plus Peony Decoction) (Zheng 12); severe pain: Guizhi Jia Dahuang Tang (Cinnamon Twig Plus Rhubarb Decoction) (Zheng 13). Shaoyin dry mouth/throat, or abdominal fullness with constipation, or clear-water diarrhea with epigastric pain: all are accumulation signs. Zhang Zhongjing said: Shaoyin disease after 2-3 days with dry mouth/throat requires urgent purging; use Dachengqi Tang (Greater Gastro-Draining Decoction) (Zheng 41). Shaoyin spontaneous clear-water diarrhea, epigastric pain, dry mouth: use Dachengqi Tang. Shaoyin disease after 6-7 days with abdominal fullness and constipation: use Dachengqi Tang. When all purging signs are present, take decoction; if bowel movement occurs, stop subsequent doses; otherwise, finish the dose. After purging, strictly avoid tonics. Sun Simiao said: After Dachengqi Tang brings relief, avoid tonics. Heat reaccumulates with tonics, requiring repeated purging, causing severe distress. Monitor and nourish gently. ○ Generally, Shanghan requires utmost caution with purging. If exterior syndrome is unresolved, do not indiscriminately prescribe decoctions to weaken Stomach Qi. (Zhang Zhongjing: "If exterior resolves but interior remains un-dissipated, unless large fullness exists, chills/fever persist, disease not cured." "If exterior resolved, interior un-dissipated, large fullness/excess, hard dry stool exists, then purge." "Even after 4-5 days, this is not harmful." "If inappropriate purging occurs, interior deficiency, heat enters,協熱遂利 (coordinated heat diarrhea),烦躁 (vexation/restlessness) changes are countless. Mild cases worsen, severe cases die." Hence the warning against Chengqi Tang.) Floating pulse: do not purge. (Zhang Zhongjing: "Floating pulse indicates exterior, sweating appropriate. Purging when sweating is indicated causes Ao Nao (restlessness), Pi (stuffiness), Jie Xiong.") Empty-fine pulse: do not purge. (Wang Shuhe: "Micro pulse cannot be emetic; empty-fine cannot be purged.") Aversion to cold: do not purge. (Aversion to cold is exterior deficiency. Even if Yangming, if aversion to cold persists, it combines with Taiyang, belongs to exterior, sweating appropriate. Shaoyin aversion to cold requires warming.) Vomiting: do not purge. Zhang Zhongjing: "Many vomits, even with Yangming signs, do not purge." Yangming disease with hypochondriac fullness, constipation, vomiting, white tongue coating: use Xiaochaihu Tang (Zheng 29). Upper Jiao opens, fluids descend, Stomach Qi harmonizes, sweating occurs, stool passes. No passing of flatus: do not purge. Passing flatus (modern term: lower discharge): Shanghan Lun says: Yangming disease, constipation 6-7 days, fear of dry stool. Test with small Xiao Chengqi Tang. If flatus passes, dry stool exists, purge. If no flatus, head is hard, later stool will be loose, do not purge. Purging causes fullness and inability to eat. Also: Yangming delirium, tidal fever, slippery-rapid pulse: Xiao Chengqi Tang (Zheng 42). Give 1 liter; if flatus passes, give another liter. If no flatus, do not give more. Zhang Zhongjing has no further method; currently detailed, use Xiaochaihu Tang (Zheng 29). Next day still constipated, pulse micro-slippery: interior deficiency, difficult to treat. Zhang Zhongjing has no method; use Huangqi Jianzhong Tang (Astragalus Construct the Middle Decoction). Hard stool, frequent urination: do not use Chengqi Tang to purge. Duyang pulse floating-slippy: floating indicates strong Stomach Qi, slippy indicates frequent urination. Floating-slippy interaction causes hard stool, Spleu Constraint (Pi Yue). Maziren Wan (Hemp Seed Pill) is indicated (Zheng 92). Qianjin says: Pi Yue, hard stool, free urination, use Zhishi Wan (Immature Bitter Orange Pill). Taiyang-Yangming is Pi Yue. Clear urine: do not purge. (Zhang Zhongjing: Shanghan constipation 6-7 days, headache, fever. Give Chengqi Tang. If urine clear, know disease is not interior.) Hard stool, scant urine: do not purge yet. (Fear fluids returning to Stomach, stool may become loose. Free urination allows purging. Ask daily urine frequency. If normally 3-4 times/day, now 2 times, know stool will exit soon. Scant urine means fluids return to Stomach, stool will soon exit.) Yangming disease, spontaneous sweating or induced sweating, free urination: do not purge. This is internal exhaustion of fluids. Though hard, do not purge. Use honey suppository for self-expulsion. Fig root or large pig bile can also guide expulsion (Zheng 111). This shows how cautiously ancients used purgatives.
(15) Question on Simultaneous Exterior and Interior Syndromes
Shanghan exterior syndrome requires sweating, interior syndrome requires purging; this is an unchangeable law. Releasing exterior and attacking interior are fundamentally different. Ganshen Shendan cannot be mixed; Guizhi and Chengqi cannot be advanced together. ○ However, suppose patient has floating-large pulse (exterior, needs sweating). Patient has fever, vexation, thirst, red urine (interior, needs purging). This is simultaneous exterior-interior syndrome; Wuling San (Zheng 66) is indicated. (Zhang Zhongjing: Windstroke fever, unresolved 6-7 days with vexation, exterior-interior signs, thirst for water, vomiting after drinking: named Shui Ni (Water Counterflow), Wuling San indicated.) ○ Suppose Shanghan constipation 6-7 days, headache, fever (interior, needs purging). Urine is clear (know not interior, still exterior, needs sweating). This is simultaneous signs, do not purge yet; use Guizhi Tang (Zheng 1). ○ Suppose patient has epigastric fullness, no desire to eat, hard stool, deep-fine pulse (interior, needs purging). Head sweating, slight aversion to cold, cold extremities (needs sweating). This simultaneous presentation is what Zhang Zhongjing calls half-exterior half-interior; Xiaochaihu Tang (Zheng 29) is indicated. ○ Suppose Taiyang exterior unresolved, but physician purges repeatedly, leading to coordinated heat diarrhea, unceasing diarrhea, epigastric hardness. Zhang Zhongjing calls this exterior-interior unresolved; Guizhi Renshen Tang (Cinnamon Twig and Ginseng Decoction) (Zheng 16) is indicated. ○ Original Taiyang disease, physician wrongly purges, resulting in abdominal pain. This has exterior and interior; Zhang Zhongjing uses Guizhi Jia Shaoyao Tang (Zheng 12). Severe pain: Guizhi Jia Dahuang Tang (Zheng 13). These are Zhang Zhongjing's methods for Shanghan with both exterior and interior; students should deduce by intent.
(16) Question on No Exterior or Interior Syndromes
After 4-5 days of Shanghan, or beyond the meridian cycle (13 days is beyond meridian), with no exterior syndrome, and interior not ready for purging, but not a sweating indication nor purging indication: Xiaochaihu Tang (Zheng 29) can be used. Modify according to symptoms. (Modifications in Vol 12). Up to 10+ days can also use it. If Xiaochaihu Tang fails after 10+ days, and stool is hard, symptoms allow purging, use Dachaihu Tang to purge (Zheng 30). Because beyond meridian, Qi is slightly deficient; if purging is needed, Dachaihu Tang is safer, fearing Chengqi Tang is too harsh for the patient to tolerate. ○ Zhang Zhongjing: 6-7 days, unclear vision, eye dysfunction, no exterior-interior signs, difficult stool, slight body heat: this is Excess, purge with Dachengqi Tang (Zheng 41). ○ Also: Patient with no exterior-interior signs, fever 7-8 days, pulse floating-rapid: Dachaihu Tang can purge (Zheng 30). Suppose purged, rapid pulse unresolved, 6-7 days later constipation: Blood Stasis exists, belong to Didang Tang (Zheng 91).
(17) Question on Patient with Great Heat Desiring Clothes, or Great Cold Rejecting Clothes
This is named Exterior Heat Interior Cold, or Exterior Cold Interior Heat. Patient with great heat desiring clothes: heat in skin, cold in bone marrow. Zhang Zhongjing has no method; first use Yindan Tang (Za Fang 6). After cold resolves, use Xiaochaihu Jia Gui (Minor Bupleurum Plus Cinnamon) (Za 39) to warm exterior. Patient with great cold rejecting clothes: cold in skin, heat in bone marrow. Zhang Zhongjing has no method; first use Baihu Jia Renshen Tang (Zheng 65). After heat removes, use Guizhi Mahuang Ban Tang (Zheng 2) to resolve exterior. Generally, disease has root and branch, treatment has priority. Exterior Heat Interior Cold: pulse deep-slow, hands slightly cold, diarrhea with undigested food. Hence Yin syndromes also have fever; Sini Tang (Zheng 75), Tongmai Sini...