半夏辛而散痞。滑能利膈。故以之为君。半夏之滑。见小陷胸汤方论中。干姜温中。除阴气而蠲痞。
人参炙甘草。大补中气。以益误下之虚。三者补则气旺。热则流通。故以之为臣。黄芩黄连。即前甘
草泻心汤中之热因寒用。苦以开之之义。故黄连亦仅用三倍之一。以为之反佐。大枣和中濡润。以为倾
痞之助云。
伤寒汗出解之后。胃中不和。心下痞硬。干噫食臭。胁下有水气。腹中雷鸣下利者。生姜泻心汤主之。
伤寒汗出解之后。言表邪俱从汗出而悉解也。胃中不和以下。皆言里症未除也。此条非误下所致。乃
邪传太阴也。然但曰胃中不和而不言太阴脾土者。太阴阳明论云。脾胃以膜相连。足太阴之脉。贯胃属脾络嗌。
与足阳明相为表里也。胃阳衰弱。气不流行。阴寒闭塞。故心下痞硬。胃寒不能腐化。脾弱不能健运。故
干噫食臭也。噫者。嗳食气也。胃寒不化。宿食停留而嗳食酸臭也。灵枢口问篇云。寒气客于胃。厥逆从下上。
散复出于胃。故为噫。素问脉解篇云。太阴所谓病胀。上走心为噫者。阴盛而上走阳明也。中焦痞塞。脾不
能为胃行其津液。传化失常。津液不流。故水气旁聚于胁下。气滞不得流行。所以腹中雷鸣。中气不守。清阳
不升。脾气下陷。水谷不分而下利。故以生姜泻心汤主之。
生姜泻心汤方
生姜（四两切） 甘草（三两炙） 人参（三两） 干姜（一两） 半夏（半升洗） 黄芩（三两） 黄连
（一两） 大枣（十二枚擘）
上八味。以水一斗。煮取六升。去滓。再煎取三升。温服一升。日三服。
生姜泻心汤。即半夏泻心汤而增入生姜也。半夏泻心。本所以治但满不痛之虚痞者也。此则汗后外邪已解。虽非
误下之变。而中气虚寒。阳和不布。三焦不能宣化。津液不得流行。尤甚于但满不痛。故加生姜以宣之。徐之才曰。宣
可去壅。生姜橘皮之属是也。李东垣云。外感六淫之邪。欲传入里。三阴实而不受。逆于胸中天分气分。窒塞不通。或
哕或呕。所谓壅也。三阴者。脾也。故必以破气药泻其壅塞。李时珍曰。壅者。塞也。宣者。布也。散也。郁塞之病。
不升不降。传化失常。必药以宣布敷散之。如承流宣化之意也。盖生姜辛而能散。温而能走。故以为宣扬开发之主。流
通其郁滞阴浊之气。鼓动其传化转运之机。或曰胁下有水气。何以不用十枣乎。曰十枣汤证乃太阳中风之邪入里。下利
呕逆。头痛心下痞硬。满引胁下痛。干呕短气。至汗出不恶寒。表邪已解。里邪已实。故用之以逐饮和里。此条乃脾胃
虚寒。太阴经之虚痞也。故以干姜半夏温中蠲饮足矣。减用干姜至一两者。以生姜四两故也。又以人参炙甘草补助正气。
使气盛流行。然后能宣通布散也。黄芩黄连大枣之用。一如半夏泻心汤之制而已。观仲景五等泻心汤之法。其攻补进退。
阴阳虚实。无不各尽其制。其所以裁成辅相者。为何如哉。
伤寒发热。汗出不解。心下痞硬。呕吐而下利者。大柴胡汤主之。
此条亦不由误下。乃自表传里之痞也。以寒伤营而头痛发热恶寒无汗之证。汗之则当解矣。乃汗之而不解。非汗之
不彻。即邪气深重也。遂至传入于里而心下痞硬。以客邪在里。不得发越。故上吐下泄。此为变逆已甚。势所必攻。
然其未尽入里之邪。犹在半表。若但下之。恐其邪亦并陷入。故以小柴胡汤入承气之半。名之曰大柴胡汤以双解
之。庶几外邪可解。里邪得泄。而成先否后喜之功也小柴胡去人参甘草者。邪在里也。加芍药者。汗后下利。敛阴气
也。下利而用大黄者。邪实则通因通用也。此与结胸条中之大柴胡互相发明。可见痞症之邪从外入者。与热入之
结胸。名虽异而实同。其感受与治法。不甚相悬也。
伤寒发汗。若吐若下解后。心下痞硬。噫气不除者。旋复代赭石汤主之。
言伤寒头痛发热恶寒无汗之证。已发其汗。又或吐或下。表里已解之后。而心下痞硬。噫气不除者。因邪气虽去。而
胃中阳气虚损。阴寒痞塞。阳气不得流行。脾弱不能健运。故气上逆而嗳食气也。此条比前生姜泻心汤同一伤寒
汗出邪解之后。而少胃中不和。胁下水气。腹中雷鸣下利诸证。为较轻矣。故增减生姜泻心汤之制。而以旋复代赭
石汤主之也。
辨误 前注皆曰伏饮为逆。而以旋复半夏蠲饮。不知阴邪痞塞。胃气不行。凡水饮入胃。皆可停蓄。聚为痰饮。何
必
执泥其说。若能使胃气通行。则精液无不流贯矣。注谓胃气上逆。全不下行。有升无降。而以素问之弦绝者声嘶。土
败者声哕二句证之。误矣。按素问宝命全角论。黄帝问云。君王众庶。尽欲全角。形之疾病。莫知其情。留淫日深。着
于
骨髓。心私虑之。余欲针除其病。岐伯对曰。夫盐之味咸者。其气令器津泄。弦绝者。其音嘶败。木敷者其叶发。（溯
洄集云太素作木陈者其叶落）病深者其声哕。人有此三者。是为坏腑。毒药无治。短针无取。此皆绝皮伤肉。血气争黑。
盖此篇帝欲尽愈天下最深之病。而伯对以病之深而将败者。岂能悉愈。若留淫日深。着于骨髓者。如盐之味咸。其气味
深入
浸润。虽以磁器之坚。亦能渗透而津泄其卤液。以譬邪气之浸淫于筋骨脏腑之中。而难于洗拔。且肾为润下咸
水之脏。若下泄不固。则肾之元阳精气败绝矣。又如丝弦之将绝。则其音声必破碎而嘶败。以譬脉之弦绝急者。为
肝气将绝。岂若木之敷荣者。能生发其枝叶乎。所以病之深而难治者。胃气败而脾绝。声必哕逆也。谓之坏腑者。人
身之躯壳。所以藏五脏六腑如藏器之府。灵枢胀论曰。脏腑之在胸胁腹里也。若匮匣之藏禁器也。若人而有此三
脏之败。是谓坏腑。虽毒药无能治。短针不能取。若徒用之。适足以绝皮伤肉而无益也。何也。病情至此。气乖血死。血
气争黑而不可治也。奈何注家引必死不治之经文。以证仲景论中。邪气已解。极轻不死之痞症。致经论之旨并失。
且此篇经义。自唐王太仆以来。俱未之能解。岂可引之以作证邪。嗟乎。素问虽上古典坟。义深难解。其旨岂终晦乎。
易曰。书不尽言。言不尽意。然则圣人之意。其终不可见乎。倘后之人。或有能解之者。则如之何。
旋复代赭石汤方
旋复花（三两） 人参（二两） 生姜（五两切） 半夏（半升） 代赭石（一两） 大枣（十二枚擘） 甘草（三
两炙）
上七味。以水一斗。煮取六升。去滓。再煎取三升。温服一升。日三服。
金匮所谓七物旋复代赭石汤者。即生姜泻心汤之意而增减之也。以证有轻重。故方亦因之而为损益也。夫生姜
泻心之症。水气聚于胁下。腹中雷鸣而下利。以阴气过盛。故以生姜之宣散。同干姜之辛热。以开其阴痞。又恐寒邪拒
格。
入而不受。故用芩连之反佐以导引之。此条不过心下虚痞。噫气不除耳。因减去干姜。故不须寒凉之反佐。但多加生姜
一两
以代干姜。增益其辛温宣散之用。助参甘而成温补开豁之功而已。旋复花。神农本经言其能治结
气胁满。除水下气。故用之以为君。李时珍云。代赭石乃手足厥阴之药。取其镇重。故能除上走之噫。
此方较之五泻心汤。为和平之正治。无用出奇。不须霸术。所谓无党无偏。王道平平者乎。
伤寒服汤药。下利不止。心下痞硬。服泻心汤已。复以他药下之。利不止。医以理中与之。利益甚。
理中者理中焦。此利在下焦。赤石脂禹余粮汤主之。复利不止者。当利其小便。
汤药。荡涤之药也。他药。亦下药也。此条自伤寒服汤药至利不止。皆承前误下成痞之义。不必重看医
以理中与之一段。盖示人以病无一定之情。治有变通之法。当审察机宜。随时应变。未可专守一法。概治诸症也。
前五泻心汤诸症。无论寒热攻补之法。皆以邪在中焦为治。而不知更有气虚下陷。利在下焦者。故曰理中者。
但能理中焦之虚寒而已。与下焦毫不相涉。病药相悬。故其利益甚也。谓之益甚者。言药不中病。不能止而
益甚。非理中有所妨害而使之益甚也。尚论以邻国为壑譬之。亦过情之论也。病既在下。大肠滑泄。非重不
足以达下。非涩不足以固其脱。故以赤石脂禹余粮汤主之。然此方此法。犹是过文语气。非仲景着意处。
其所重者。全在复利不止。当利其小便句。言元气未尽虚脱。不过大肠滑泄。则以石脂余粮涩之。亦足以
取效。若已下再下。真气已虚。下焦无火。真阳不能司其蒸腾气化之功。则清浊不能升降。水谷不得分消。
故利复不止。岂涩药所能治哉。必使下焦有火。气化流行。而后可以言治也。其但言当利小便而不立方者。以三
焦膀胱气化之说繁多。非一言可蔽。故不具载也。若后之以道自任者。学力优深。经义精熟。胸中自能了然。
何必多赘。所以仲景自叙中云。观今之医。不念思求经旨。以演其所知。各承家技。终始顺旧。省疾问病。
务在口给。而欲视死别生。实为难矣。膀胱气化说。见五苓散方论中。
赤石脂禹余粮汤方
赤石脂（一斤研碎） 禹余粮（一斤研碎）
以上二味。以水六升。煮取二升。去滓。分三服。
徐之才曰。涩可去脱。牡蛎龙骨之属是也。李时珍云。牡蛎龙骨海螵蛸五倍五味乌梅榴皮诃子粟壳莲房棕
灰石脂皆涩药也。而石脂禹余粮。皆手足阳明经药。石脂气温体重性涩。涩而重。故能收湿固下。甘而温。
故能益气调中。中者。肠胃肌肉也。下者。肠 泄痢也。禹余粮性涩。故主下焦。李先知诗曰。下焦有病患难会。
须用余粮赤石脂是也。时珍又云。脱有气脱血脱精脱神脱。脱则散而不收。故用酸涩温平之药。以敛其耗散。
然气者。血之帅也。故气脱当兼以气药。血脱当兼以血药及兼气药。所以桃花汤之立治。又不同也。
本以下之故。心下痞。与泻心汤。痞不解。其人渴而口燥烦。小便不利者。五苓散主之。
言本以误下之故。以致邪气入里而心下痞硬。则当与泻心汤矣。然泻心之用不一。有误下寒邪外入之痞。
即紧反入里也。有下后胃虚内作之痞。有汗解以后阴邪内结之痞。所以有攻下热实之法。又有攻下而兼温经复
阳之法。有温中散痞之法。有温补宣开之法。大抵皆因证而施。故治法各异。此所谓痞者。盖太阳表邪入里之痞也。
因膀胱为太阳之腑。痞虽结于心下。而邪已入里。内犯膀胱。虽用泻心之法。非惟痞不得解。且其人渴而口燥烦。
小便不利矣。夫足太阳膀胱者。津液之府也。必藉三焦之气化而后行焉。所谓气化者。下焦之气上腾。然后上焦之气
下降。气上腾则津液上行而为涕唾。气下降则津液下走而为便泻。邪犯膀胱。则下焦之气不上升而气液不腾。故口渴而
燥烦。下气既不上升。则上焦无以下降而小便不利。故以五苓散主之。说见五苓散方论中。然渴而口燥烦。
与伤寒误汗首条之脉浮数烦渴同义。虽有误汗误下之殊。而下焦虚寒无火。则无异也。但认定经络。审清脉理。
有何疑惮。而至逡巡畏缩哉。要之临证狐疑。处方犹豫。皆平日信道不笃。工夫未尽耳。岂古人有所隐秘乎。
太阳中风。下利呕逆。表解者。乃可攻之。其人 汗出。发作有时。头痛心下痞硬。满引胁下痛。
干呕短气。汗出不恶寒者。此表解里未和也。十枣汤主之。
旧说以风伤卫而误下之。则为结胸。寒伤营而误下之。则作痞。以此释仲景发于阳发于阴之义。前已
有伤寒六七日之结胸热实。及伤寒十余日之结胸无大热矣。又半夏泻心汤条内。以伤寒而且结且痞矣。此条又
以太阳中风而为心下痞硬。则仲景之发于阳发于阴之意。在乎阴经阳经。而不在于中风伤寒也明矣。此节不
叙表证。即曰下利呕逆者。邪热已犯肠胃。里已受邪。似可攻下。然邪虽入里。必表邪已解者。乃可攻之。
若表证未除者。未可攻也。 。热汗微出也。其人 然身热汗出而发作有时者。即邪入阳明。自汗潮热之
类是也。头痛非必表症而后有也。邪结于里。阳邪怫郁于上而头痛也。心下痞硬而满牵。引胁下痛者。乃邪
已入里。痞塞于中焦胃脘之间。故心下痞硬也。若但属气痞。则不至硬满而引及胁下作痛矣。因邪既入里。
胃不能行其津液。以致水饮停蓄。故心下硬满。气不得伸。其痛牵引胁下也。即生姜泻心汤条下所云。心下
痞硬。胁下有水气。又所谓水结在胸胁者是也。邪在胃中。故气逆而干呕。中焦痞塞。故中满而短气。皆必
攻之症也。然必汗出而不恶寒者。乃为表邪尽解。已入阳明。止里邪未和耳。里未和者。胃困于邪。不能使
津液流贯。停蓄于胸胁之间。非结胸热实。心下痛。按之石硬者比也。结胸有热
实。故主之以大陷胸汤。而以大黄芒硝为君。此虽痞症之实者。然终不若结胸之有实热者也。所以当蠲其水湿痰
饮之邪。则胃和而气自流通矣。故以十枣汤主之。
十枣汤方
芫花（熬） 甘遂 大戟 大枣（十枚擘）
半夏味辛，能消散痞结。滑利之性，能通利膈间气机。因此将其作为君药。半夏的滑利特性，在小陷胸汤的方论中已有论述。干姜性温，能温暖中焦，驱除阴寒之气而消除痞满。人参、炙甘草，大补中气，以弥补因误用下法导致的虚弱。这三味药（指人参、炙甘草及前文隐含的补气之意，此处原文逻辑为三者共为臣，实指人参、甘草配合干姜等，但依原文“三者”指代需结合语境，通常指人参、甘草及干姜或泛指补益组，此处直译原文结构），补益则正气旺盛，温热则气机流通，因此将它们作为臣药。黄芩、黄连，即前文甘草泻心汤中“热因寒用”、“苦以开之”的含义。因此黄连仅使用三分之一的用量，作为反佐药。大枣能调和脾胃、濡润中焦，以辅助消除痞满。
伤寒病经过发汗后表证已解，但胃气不和，心下（胃脘部）感觉痞塞且硬满，嗳气带有食物腐败的气味，胁下有停饮（水气），肠鸣音亢进并伴有腹泻的，用生姜泻心汤主治。
“伤寒汗出解之后”，是说表邪全部随着汗出而解除。“胃中不和”以下的内容，都是说里证尚未清除。这一条并非由误用下法所致，而是邪气传入太阴经。然而只说“胃中不和”而不提太阴脾土，是因为《素问·太阴阳明论》中说：“脾胃通过膜相连。足太阴脾经，贯穿胃部，属于脾脏，联络咽喉，与足阳明胃经互为表里。”胃阳衰弱，气机不能正常运行，阴寒闭塞，所以心下痞硬。胃寒不能腐熟水谷，脾弱不能健运运化，所以出现嗳气且有食物臭味。所谓“噫”，就是嗳出食物的气味。胃寒不消化，宿食停留而嗳出酸臭之气。《灵枢·口问篇》说：“寒气客居于胃，厥逆之气从下向上，散而复出于胃，所以发生嗳气。”《素问·脉解篇》说：“太阴经所说的病胀，向上走到心脏引起嗳气的，是阴气盛而上走阳明经。”中焦痞塞，脾不能为胃传输津液，传化功能失常，津液不流动，所以水气旁聚于胁下。气机阻滞不能流行，所以腹中雷鸣。中气不守，清阳不升，脾气下陷，水谷不分而致腹泻。因此用生姜泻心汤主治。
生姜泻心汤方
生姜（四两，切片） 甘草（三两，炙） 人参（三两） 干姜（一两） 半夏（半升，洗） 黄芩（三两） 黄连（一两） 大枣（十二枚，掰开）
以上八味药，用水一斗，煮取六升，去渣滓，再煎取三升。每次温服一升，每日三次。
生姜泻心汤，就是在半夏泻心汤的基础上增加生姜而成。半夏泻心汤原本是用来治疗只有痞满而没有疼痛的虚痞证的。此条是发汗后外邪已解，虽然并非误下引起的变证，但中气虚寒，阳气不和不能布散，三焦不能宣通化源，津液不得流行，比单纯的痞满不痛更为严重，所以加入生姜来宣散。徐之才说：“宣散可以去除壅滞，如生姜、橘皮这类药物。”李东垣说：“外感六淫之邪，想要传入体内，三阴经充实而不受邪，邪气逆于胸中天分和氣分，窒塞不通，或者呃逆或者呕吐，这就是所谓的‘壅’。三阴经指的是脾脏。所以必须用破气药来泻其壅塞。”李时珍说：“壅，就是堵塞；宣，就是布散、发散。郁塞的病，不升不降，传化失常，必须用药来宣布敷散，如同承流宣化的意思一样。”大概生姜味辛能散，性温能行，所以作为宣扬开发的主要药物，流通郁滞的阴浊之气，鼓动传化转运的机能。有人问：胁下有水气，为什么不用十枣汤？回答说：十枣汤证是太阳中风之邪入里，表现为下利、呕逆、头痛、心下痞硬、满痛牵引至胁下、干呕、短气，直到汗出且不恶寒，表邪已解，里邪已实，所以用它来逐饮和里。这一条是脾胃虚寒，太阴经的虚痞证。所以用干姜、半夏温中蠲饮就足够了。减少干姜用量至一两，是因为用了四两生姜的缘故。又用人参、炙甘草补助正气，使气盛流行，然后才能宣通布散。黄芩、黄连、大枣的作用，完全像半夏泻心汤的制方原则一样。看张仲景五种泻心汤的方法，其攻补进退、阴阳虚实，无不各尽其制，它们之所以能裁成辅相，是何等精妙啊。
伤寒发热，汗出后病不解，心下痞硬，呕吐并伴有腹泻的，用大柴胡汤主治。
这一条也不是由误下所致，而是邪气自表传里的痞证。因为寒邪伤营，出现头痛、发热、恶寒、无汗的症状，发汗后应当解除。现在发汗后却不解除，不是发汗不彻底，就是邪气深重。于是传入体内导致心下痞硬。由于客邪在里，不得发越，所以上吐下泄。这是变逆已经很严重，势必要攻下。然而那些尚未完全入里的邪气，还在半表半里之间。如果只用下法，恐怕邪气也会一并陷入。所以用小柴胡汤合入承气汤的一半，命名为大柴胡汤，以双解表里。这样外邪可解，里邪得泄，从而达成先否后喜的功效。小柴胡汤去掉人参、甘草，是因为邪在里。加入芍药，是因为汗后下利，需要敛阴气。下利却用大黄，是因为邪实则采用“通因通用”的方法。这与结胸条中的大柴胡汤互相发明，可见痞症的邪气从外入内，与热入血室之结胸，名称虽异而实质相同，其感受病因与治疗方法，并没有太大差别。
伤寒发汗，或用吐法，或用下法，表里证已解之后，心下痞硬，嗳气不止的，用旋复代赭石汤主治。
这里说的是伤寒头痛、发热、恶寒、无汗的症状，已经发了汗，或者又用了吐法或下法，表里已解之后，仍然心下痞硬，嗳气不止。这是因为邪气虽然去了，但胃中阳气虚损，阴寒痞塞，阳气不能流行，脾弱不能健运，所以气上逆而嗳出食物气味。这一条与前文的生姜泻心汤同属伤寒汗出邪解之后，但少了胃中不和、胁下水气、腹中雷鸣下利等症状，病情较轻。所以增减生姜泻心汤的制方，而用旋复代赭石汤主治。
辨误 前面的注解说都是伏饮为逆，而用旋复花、半夏蠲饮。不知道阴邪痞塞，胃气不行，凡是水饮进入胃中，都可以停蓄，聚为痰饮，何必拘泥于这种说法。如果能使胃气通行，那么精液没有不流动的。注家认为胃气上逆，全不下行，有升无降，并用《素问》中“弦绝者声嘶，土败者声哕”两句来证明，这是错误的。按《素问·宝命全形论》，黄帝问道：“君王众庶，都想保全形体。形体的疾病，没有人知道其情状，留连浸淫日益加深，附着于骨髓。我心里私下忧虑，我想用针除治病痛。”岐伯回答说：“盐的味道咸，它的气味会使容器渗出津液。琴弦将断，声音嘶哑破碎。树木茂盛，枝叶繁发。（《溯洄集》说《太素》作‘木陈者其叶落’）病深入的人，声音会呃逆。人有这三种情况，称为坏腑。毒药无法治疗，短针无法取效。这都是损伤皮毛肌肉，血气争黑不可治的情况。”大概这篇经文是皇帝想尽愈天下最深的病，而岐伯回答病深将败者，岂能全部治愈。如果留连浸淫日益加深，附着于骨髓，就像盐的味道咸，气味深入浸润，即使是坚硬的磁器，也能渗透而流出卤液，以此比喻邪气浸淫于筋骨脏腑之中，难以拔除。而且肾是润下咸水之脏，如果下泄不固，那么肾的元阳精气就会败绝。又如丝弦将断，声音必然破碎嘶哑，以此比喻脉象弦急将绝，是肝气将绝，难道像树木茂盛那样能生发枝叶吗？所以病深难治的，是胃气败而脾绝，声音必然呃逆。称为坏腑的，人身躯壳，用来藏五脏六腑，就像藏器的府库。《灵枢·胀论》说：“脏腑在胸胁腹里，就像柜匣藏着禁器。”如果人有这三脏的败坏，称为坏腑。即使毒药也无法治疗，短针也无法取效。如果徒然使用，只会损伤皮毛肌肉而无益。为什么呢？病情到了这一步，气乖血死，血气争黑不可治。奈何注家引用必死不治的经文，来证明张仲景论中邪气已解、极轻不死的痞症，致使经论的宗旨都失去了。况且这篇经义，自从唐代王冰以来，都不能解释，怎么能引用它来作证呢？唉！《素问》虽然是上古经典，义理深奥难解，其宗旨难道最终晦暗吗？《易经》说：“书不尽言，言不尽意。”那么圣人的意图，难道最终不可见吗？倘若后人中有能解释它的，那该怎么办呢？
旋复代赭石汤方
旋复花（三两） 人参（二两） 生姜（五两，切片） 半夏（半升） 代赭石（一两） 大枣（十二枚，掰开） 甘草（三两，炙）
以上七味药，用水一斗，煮取六升，去渣滓，再煎取三升。每次温服一升，每日三次。
《金匮要略》所说的七物旋复代赭石汤，就是生姜泻心汤的意思而增减而成的。因为病症有轻重，所以方剂也相应损益。生姜泻心汤的病症，水气聚于胁下，腹中雷鸣而下利，因为阴气过盛，所以用生姜的宣散，配合干姜的辛热，来开其阴痞。又担心寒邪拒格，入而不受，所以用芩、连的反佐来引导。这一条不过是心下虚痞，嗳气不止罢了。因为减去了干姜，所以不需要寒凉的反佐，只是多加生姜一两来代替干姜，增益其辛温宣散的作用，帮助人参、甘草完成温补开豁的功效而已。旋复花，《神农本草经》说它能治结气胁满，除水下气，所以用它作为君药。李时珍说：代赭石是手足厥阴经的药物，取其镇重的性质，所以能消除上走的嗳气。
这个方子比起五种泻心汤，是和平的正治之法，没有出奇之处，不需要霸道的手段，可以说是无党无偏，王道平平的方子。
伤寒服用汤药后，腹泻不止，心下痞硬。服用泻心汤后，又用其他药物攻下，腹泻仍不止。医生用理中丸给他治疗，腹泻反而更严重。理中丸是调理中焦的，此处的腹泻在下焦，应用赤石脂禹余粮汤主治。如果再次腹泻不止，应当利小便。
汤药，是荡涤的药。他药，也是下药。这一条从伤寒服汤药到利不止，都承接前文误下成痞的意义，不必过分看重“医以理中之”这一段。大概是告诉人们病没有一定的情状，治疗有变通的方法，应当审察机宜，随时应变，不可以专守一种方法，概括治疗所有症状。前五首泻心汤诸症，无论寒热攻补之法，都是以邪在中焦为治疗重点，而不知道还有气虚下陷、利在下焦的情况。所以说理中丸，只能调理中焦的虚寒，与下焦毫不相涉。病与药不相符，所以腹泻更加严重。所谓“益甚”，是说药不对症，不能止住反而加重，并不是理中丸有什么妨害使之加重。尚论用邻国为壑来比喻，也是过分的言论。病既在下焦，大肠滑泄，非重用不足以达下，非涩味不足以固脱，所以用赤石脂禹余粮汤主治。然而此方此法，还是文章的过场语气，不是张仲景着意强调的地方。他所重视的，全在“复利不止者，当利其小便”这句话。意思是元气未尽虚脱，不过是大肠滑泄，就用石脂、余粮涩之，也足以取效。如果已经下后再下，真气已虚，下焦无火，真阳不能司其职进行蒸腾气化，那么清浊不能升降，水谷不得分消，所以腹泻再次不止。这难道是涩药能治疗的吗？必须使下焦有火，气化流行，然后才可以谈治疗。他只说“当利小便”而不立方，是因为三焦膀胱气化的学说繁多，非一言可概括，所以不具体记载。如果后世以道自任的人，学力优深，经义精熟，胸中自然了然，何必多赘述。所以张仲景在自叙中说：“看现在的医生，不想思考探究经旨，以推演他们的知识，各自继承家技，始终沿袭旧法。诊视疾病询问病情，务在口才敏捷，而想区分生死，实在很难了。”膀胱气化说，见五苓散方论中。
赤石脂禹余粮汤方
赤石脂（一斤，研碎） 禹余粮（一斤，研碎）
以上两味药，用水六升，煮取二升，去渣滓，分三次服用。
徐之才说：“涩可以去除滑脱，如牡蛎、龙骨这类药物。”李时珍说：“牡蛎、龙骨、海螵蛸、五倍子、五味子、乌梅、榴皮、诃子、粟壳、莲房、棕灰、石脂都是涩药。而石脂、禹余粮，都是手足阳明经的药物。石脂气温、体重、性涩，涩而重，所以能收湿固下；甘而温，所以能益气调中。中，指肠胃肌肉；下，指肠泄痢疾。禹余粮性涩，所以主下焦。李先知诗曰：‘下焦有病患难会，须用余粮赤石脂。’”时珍又说：“脱证有气脱、血脱、精脱、神脱，脱则散而不收，所以用酸涩温平的药物，来收敛其耗散。然而气是血的统帅，所以气脱应当兼用气药，血脱应当兼用血药及气药。所以桃花汤的设立治疗，又有所不同。”
本来是因为误下，导致心下痞。给予泻心汤，痞满未解。其人口渴、口燥、心烦、小便不利的，用五苓散主治。
这里说是因为误下的缘故，导致邪气入里而心下痞硬，则应当给予泻心汤。然而泻心汤的运用不一，有误下寒邪外入的痞，即紧反入里；有下后胃虚内作的痞；有汗解以后阴邪内结的痞。所以有攻下热实的方法，又有攻下而兼温经复阳的方法，有温中散痞的方法，有温补宣开的方法。大体上都因证施治，所以治法各异。这个所谓的痞，是太阳表邪入里的痞。因为膀胱是太阳之腑，痞虽然结于心下，但邪已入里，内犯膀胱。虽然用泻心之法，不仅痞不得解，而且其人会出现口渴、口燥、烦、小便不利。足太阳膀胱，是津液之府，必须借助三焦的气化才能运行。所谓气化，是下焦之气上腾，然后上焦之气下降。气上腾则津液上行而为涕唾，气下降则津液下走而为便泻。邪犯膀胱，则下焦之气不上升而气液不腾，所以口渴而燥烦。下气既不上升，则上焦无以下降而小便不利。所以用五苓散主治。说详见五苓散方论中。然而渴而口燥烦，与伤寒误汗首条的脉浮数烦渴意义相同，虽然有误汗误下的不同，但下焦虚寒无火，则没有区别。只要认定经络，审清脉理，有什么疑虑，以至于犹豫畏缩呢？总之临证狐疑，处方犹豫，都是平日信道不笃，工夫未尽罢了。难道古人有所隐秘吗？
太阳中风，下利呕逆，表证已解的，才可以攻下。其人濈然汗出，发作有时，头痛，心下痞硬，满痛牵引胁下，干呕，短气，汗出不恶寒的，这是表解里未和，用十枣汤主治。
旧说认为风伤卫而误下，则为结胸；寒伤营而误下，则作痞。以此来解释张仲景发于阳发于阴的意义，前面已经有伤寒六日之结胸热实，及伤寒十余日之结胸无大热了。又在半夏泻心汤条内，提到伤寒而且结且痞。此条又以太阳中风而为心下痞硬，那么张仲景发于阳发于阴的意思，在于阴经阳经，而不在于中风伤寒，这是很明显的。这一节不叙述表证，就说下利呕逆，是邪热已犯肠胃，里已受邪，似乎可以攻下。然而邪虽入里，必须表邪已解，才可以攻下。如果表证未除，不可攻下。濈然，是微出汗的样子。其人濈然身热汗出而发作有时，就是邪入阳明，自汗潮热之类。头痛不一定非要有表证才有。邪结于里，阳邪怫郁于上而头痛。心下痞硬而满，牵引胁下痛，是邪已入里，痞塞于中焦胃脘之间，所以心下痞硬。如果仅是气痞，不至于硬满而牵引胁下作痛。因为邪既入里，胃不能行其津液，以致水饮停蓄，所以心下硬满，气不得伸，其痛牵引胁下。即生姜泻心汤条下所说：“心下痞硬，胁下有水气。”又所谓“水结在胸胁”的就是。邪在胃中，所以气逆而干呕。中焦痞塞，所以中满而短气，都是必须攻下的症状。然而必须汗出而不恶寒，才是表邪尽解，已入阳明，只是里邪未和。里未和，是胃困于邪，不能使津液流贯，停蓄于胸胁之间，不像结胸热实，心下痛，按之石硬那样。结胸有热实，所以主之以大陷胸汤，而以大黄、芒硝为君。这虽是痞症之实者，然而终究不如结胸之有实热。所以当蠲除其水湿痰饮之邪，则胃和而气自流通。所以用十枣汤主治。
十枣汤方
芫花（熬） 甘遂 大戟 大枣（十枚，掰开）
Banxia (Pinelliae Rhizoma) is acrid and can dissipate stagnation. Its slippery nature can unblock the diaphragm. Therefore, it is used as the sovereign drug. The slippery property of Banxia is discussed in the commentary on Xiaoxianxiong Tang (Minor Inward-Draining Decoction). Ganjiang (Dried Zingiberis Rhizoma) is warm, warms the middle jiao, eliminates yin-cold, and removes stagnation. Renshen (Ginseng Radix et Rhizoma) and Zhigancao (Prepared Glycyrrhizae Radix et Rhizoma) greatly tonify middle qi to benefit the deficiency caused by erroneous purgation. These three ingredients, when tonifying, make qi vigorous; when warm, they promote circulation. Thus, they are used as minister drugs. Huangqin (Scutellariae Radix) and Huanglian (Coptidis Rhizoma) follow the principle of "using cold for heat" and "bitterness to open," as seen in the previous Gancao Xiexin Tang (Licorice Heart-Draining Decoction). Therefore, Huanglian is used only in one-third of the dosage as a counter-agent (antidote). Dazao (Ziziphi Jujubae Fructus) harmonizes the middle and moistens, assisting in resolving the stagnation.
After a taiyang disease (disease of the taiyang channel) has been resolved by sweating, if there is disharmony in the stomach, fullness and hardness in the epigastrium (xin xia), belching with the smell of food, fluid retention under the flanks, borborygmus, and diarrhea, Shengjiang Xiexin Tang (Ginger Heart-Draining Decoction) should be administered.
"After taiyang disease is resolved by sweating" means that all exterior pathogens have been expelled through sweat. The phrase "disharmony in the stomach" onwards describes the persistence of interior syndromes. This case is not caused by erroneous purgation but by the transmission of pathogenic factors to the taiyin (taiyin spleen-stomach system). However, it mentions "disharmony in the stomach" without explicitly referring to the taiyin spleen earth, because the *Suwen* (Basic Questions) chapter on Taiyin and Yangming states: "The spleen and stomach are connected by membranes. The foot-taiyin meridian passes through the stomach, belongs to the spleen, and connects to the throat, forming an exterior-interior relationship with the foot-yangming meridian." When stomach yang is weak and qi fails to circulate, yin-cold blocks the pathway, resulting in epigastric fullness and hardness. Cold in the stomach prevents the rotting and ripening of food, and weakness of the spleen impairs its transportation function, leading to belching with a food odor. "Yi" (belching) refers to the emission of food odors. Due to stomach cold and failure to digest, retained food ferments, causing sour and foul belching. The *Lingshu* (Spiritual Pivot) chapter on Kouwen states: "When cold qi lodges in the stomach, rebellious qi rises from below, disperses, and re-emerges from the stomach, causing belching." The *Suwen* chapter on Maijie states: "What taiyin calls 'distension' moving upward to the heart causes belching; this is due to excess yin moving upward to yangming." Stagnation in the middle jiao prevents the spleen from transporting fluids for the stomach, disrupting transformation and transportation. Fluids fail to flow, gathering as water qi under the flanks. Qi stagnation prevents normal circulation, causing borborygmus. Middle qi fails to maintain control, clear yang fails to ascend, spleen qi sinks, and water and grain are not separated, leading to diarrhea. Hence, Shengjiang Xiexin Tang is indicated.
Shengjiang Xiexin Tang Formula
Shengjiang (Fresh Zingiberis Rhizoma, 4 liang, sliced) Zhigancao (Prepared Glycyrrhizae Radix et Rhizoma, 3 liang) Renshen (Ginseng Radix et Rhizoma, 3 liang) Ganjiang (Dried Zingiberis Rhizoma, 1 liang) Banxia (Pinelliae Rhizoma, half sheng, washed) Huangqin (Scutellariae Radix, 3 liang) Huanglian (Coptidis Rhizoma, 1 liang) Dazao (Ziziphi Jujubae Fructus, 12 pieces, split)
Take these eight ingredients, add ten dou of water, decoct to obtain six sheng, remove the dregs, and decoct again to obtain three sheng. Take one sheng warm, three times daily.
Shengjiang Xiexin Tang is derived from Banxia Xiexin Tang (Pinellia Heart-Draining Decoction) by adding Shengjiang. Banxia Xiexin Tang is originally used to treat deficiency-type stagnation characterized by fullness without pain. In this case, after sweating, the exterior pathogen is resolved. Although not caused by erroneous purgation, the middle qi is deficient and cold, yang harmony is not distributed, the three jiao cannot disseminate and transform, and fluids do not circulate. This condition is more severe than simple fullness without pain, so Shengjiang is added to disseminate. Xu Zhicai stated: "Dispersing can remove obstruction, such as with Shengjiang and Jupe (Citri Reticulatae Pericarpium)." Li Dongyuan said: "When external six-excess pathogens attempt to transmit inward, the san-yin channels are solid and reject them. The pathogens rebel in the chest, affecting both qi and blood levels, causing blockage. This may manifest as hiccups or vomiting, which is termed 'obstruction.' San-yin refers to the spleen. Therefore, qi-breaking herbs must be used to drain the obstruction." Li Shizhen said: "Obstruction means blockage; dispersing means spreading and scattering. Diseases of stagnation, neither ascending nor descending, with disrupted transformation, require herbs that spread and scatter, akin to the concept of conveying flow and disseminating transformation." Generally, Shengjiang is acrid and dispersing, warm and moving, serving as the primary agent for dissemination and development. It circulates stagnant yin-turbid qi and stimulates the mechanism of transformation and transport. One might ask: Since there is water qi under the flanks, why not use Shizao Tang (Ten Date Decoction)? The answer is: Shizao Tang syndrome occurs when shaoyang wind-pathogens enter the interior, presenting with diarrhea, vomiting, headache, epigastric fullness and hardness, pain radiating to the flanks, dry retching, shortness of breath, until sweating occurs without aversion to cold. At this point, the exterior pathogen is resolved, and the interior pathogen is excess, so it is used to drain fluid and harmonize the interior. This case involves spleen-stomach deficiency-cold and deficiency-stagnation of the taiyin channel. Therefore, Ganjiang and Banxia to warm the middle and drain fluid suffice. The dosage of Ganjiang is reduced to one liang because four liang of Shengjiang are used. Renshen and Zhigancao are added to support righteous qi, making qi vigorous and circulating, thereby enabling dissemination. The uses of Huangqin, Huanglian, and Dazao are identical to those in Banxia Xiexin Tang. Observing Zhang Zhongjing's five Heart-Draining Decoctions, their advances and retreats in attack and tonification, yin and yang, excess and deficiency, fully embody their principles. How profound is their supportive and coordinating role!
If taiyang disease presents with fever, and sweating does not resolve the condition, accompanied by epigastric fullness and hardness, vomiting, and diarrhea, Da Chaihu Tang (Greater Bupleurum Decoction) should be administered.
This case is also not caused by erroneous purgation but is a stagnation syndrome transmitted from the exterior to the interior. When cold injures the ying (nutritive) level, symptoms include headache, fever, aversion to cold, and anhidrosis. Sweating should resolve these. If sweating fails to resolve them, it is either due to insufficient sweating or heavy pathogens. The pathogens then transmit inward, causing epigastric fullness and hardness. Because the invading pathogen is trapped in the interior and cannot vent outward, it causes upper vomiting and lower diarrhea. This represents severe reversal, necessitating attack. However, some pathogens remain at the semi-exterior/semi-interior level. If only purgation is used, there is a risk of pathogens sinking deeper. Therefore, Da Chaihu Tang combines half of Xiao Chaihu Tang (Lesser Bupleurum Decoction) with Chengqi (Purgative) principles to resolve both exterior and interior. This allows exterior pathogens to be resolved and interior pathogens to be drained, achieving the effect of initial obstruction followed by relief. Xiao Chaihu Tang omits Renshen and Zhigancao because the pathogen is in the interior. Shaoyao (Paeoniae Radix Alba) is added to astringe yin qi due to diarrhea after sweating. Dahuang (Rhei Radix et Rhizoma) is used despite diarrhea because "treating obstruction with unblocking methods" applies when there is excess. This clarifies the Da Chaihu Tang section on Jie Xiong (Chest Binding), showing that stagnation entering from the exterior is essentially similar to heat-entering Jie Xiong, differing only in name, with comparable etiologies and treatments.
After taiyang disease is treated with sweating, emesis, or purgation, and the exterior and interior are resolved, if epigastric fullness and hardness persist along with incessant belching, Xuanfu Daizhe Shi Tang (Inula and Hematite Decoction) should be administered.
This refers to cases where taiyang symptoms (headache, fever, aversion to cold, anhidrosis) have been treated with sweating, or further with emesis or purgation. After the exterior and interior are resolved, if epigastric fullness and hardness and incessant belching remain, it is because although pathogens are gone, stomach yang is deficient, yin-cold causes stagnation, and yang qi cannot circulate. Spleen weakness impairs transportation, causing rebellious qi and belching. Compared to the previous Shengjiang Xiexin Tang case (post-sweating resolution), this lacks stomach disharmony, fluid retention under flanks, borborygmus, and diarrhea, indicating a milder condition. Thus, the formula is modified from Shengjiang Xiexin Tang to Xuanfu Daizhe Shi Tang.
Correction of Misinterpretations Previous commentaries attributed the rebellion to latent fluid retention, using Xuanfu and Banxia to drain fluid. They failed to recognize that when yin-pathogens cause stagnation and stomach qi fails to move, any fluid entering the stomach can accumulate into phlegm-fluid. Why cling to such rigid views? If stomach qi moves freely, essential fluids will circulate everywhere. Commentators argued that stomach qi rebels upward, never descending, having ascent without descent, citing Suwen: "When strings break, the sound is hoarse; when earth fails, the sound is hiccup." This is erroneous. According to *Suwen: Baoming Quanxing Lun*, the Yellow Emperor asked: "Kings and commoners alike wish to preserve their bodies. Yet diseases of the form are unknown in their details, lingering and deepening, attaching to the marrow. I worry privately. I wish to cure these diseases with needles." Qibo replied: "Salt tastes salty; its vapor causes moisture to seep from vessels. When a string breaks, its sound becomes hoarse and broken. When trees flourish, leaves sprout (*Suhui Ji* notes *Tai Su* reads 'when trees decay, leaves fall'). When disease is deep, the voice hiccups. Having these three signs indicates damaged fu organs. Poisonous drugs cannot treat them, and short needles cannot access them. This damages skin and flesh, causing blood and qi to contend and turn black." This passage discusses the emperor's desire to cure the deepest diseases, while Qibo explains that deeply failing diseases cannot be fully cured. If pathogens linger and attach to the marrow, like salt penetrating even hard ceramic vessels to exude brine, it illustrates pathogens infiltrating sinews, bones, zang, and fu organs, making them difficult to eradicate. The kidney is the organ of descending, salty water. If lower leakage is uncontrolled, kidney yuan-yang essence fails. Like a breaking string producing broken sounds, it illustrates liver qi failing when the pulse is taut and about to snap. Unlike flourishing trees that sprout leaves, deep diseases involve stomach qi failure and spleen extinction, manifesting as hiccups. "Damaged fu organs" refers to the body shell housing the zang-fu like containers. *Lingshu: Zhang Lun* states: "Zang-fu in the chest and abdomen are like boxes containing precious items." Damage to three zang organs constitutes damaged fu organs. Even poisonous drugs cannot treat them, and short needles cannot reach them. Using them merely damages skin and flesh without benefit. Why? At this stage, qi is disordered, blood dies, and blood-qii contention turns black, rendering it incurable. How can commentators cite scriptures of inevitable death to prove the mild, non-lethal stagnation in Zhang Zhongjing's text, distorting the meaning of both classics? Moreover, since Wang Bing (Wang Taipu) in the Tang dynasty, no one has successfully interpreted this scripture. How can it be cited as proof? Alas! Although *Suwen* is an ancient classic with profound meanings, its intent need not remain obscure. The *I Ching* says: "Books cannot fully express words, and words cannot fully express intent." Can the sages' intent remain forever hidden? If future generations can interpret it, what then?
Xuanfu Daizhe Shi Tang Formula
Xuanfuhua (Inulae Flos, 3 liang) Renshen (Ginseng Radix et Rhizoma, 2 liang) Shengjiang (Fresh Zingiberis Rhizoma, 5 liang, sliced) Banxia (Pinelliae Rhizoma, half sheng) Daizhe Shi (Hematitum, 1 liang) Dazao (Ziziphi Jujubae Fructus, 12 pieces, split) Zhigancao (Prepared Glycyrrhizae Radix et Rhizoma, 3 liang)
Take these seven ingredients, add ten dou of water, decoct to obtain six sheng, remove dregs, and decoct again to obtain three sheng. Take one sheng warm, three times daily.
The Seven-Ingredient Xuanfu Daizhe Shi Tang mentioned in *Jinkui Yaolue* is derived from Shengjiang Xiexin Tang by modification. Due to differences in severity, the formula is adjusted. Shengjiang Xiexin Tang treats fluid retention under flanks, borborygmus, and diarrhea due to excessive yin qi. Shengjiang's dispersing action combined with Ganjiang's acrid-warmth opens yin stagnation. To prevent cold rejection, Huangqin and Huanglian are used as counter-agents. This case involves only deficiency-stagnation in the epigastrium and incessant belching. Ganjiang is removed, eliminating the need for cold counter-agents. Instead, one extra liang of Shengjiang replaces Ganjiang to enhance acrid-warmth and dispersing power, aiding Renshen and Gancao in warming, tonifying, and opening. Xuanfuhua, according to *Shennong Bencao Jing*, treats qi-knots and flank fullness, draining fluid and directing qi downward, thus serving as the sovereign drug. Li Shizhen noted: Daizhe Shi acts on the jueyin channels. Its heavy nature suppresses upward-rebellious belching. Compared to the five Heart-Draining Decoctions, this formula is a gentle, orthodox treatment, lacking extraordinary measures or harsh tactics, representing a balanced, impartial approach.
If taiyang disease patients take herbal medicine and suffer continuous diarrhea with epigastric fullness and hardness, and after taking Xiexin Tang, another purgative is administered causing persistent diarrhea, and the physician prescribes Lizhong Wan (Middle-Regulating Pill), worsening the diarrhea: Lizhong Wan regulates the middle jiao, but this diarrhea originates in the lower jiao. Chishizhi Yuyuliang Tang (Red Halloysite and Metastone Decoction) should be used. If diarrhea persists, promote urination.
"Tangyao" refers to cleansing herbs. "Ta Yao" refers to other purgatives. This section, from taking medicine to persistent diarrhea, follows the theme of stagnation caused by erroneous purgation. The part about the physician using Lizhong Wan serves to illustrate that diseases vary and treatments must adapt. One must assess the situation and change strategies accordingly, not adhere rigidly to one method for all conditions. The previous five Xiexin Tang formulas address pathogens in the middle jiao via various methods (cold, heat, attack, tonification). However, they do not account for qi-sinking diarrhea originating in the lower jiao. Lizhong Wan only treats middle-jiao deficiency-cold and has no effect on the lower jiao. Mismatched pathology and treatment worsen the diarrhea. "Worsening" means the medicine is inappropriate, not that Lizhong Wan harms. Comparing it to "flooding a neighbor's state" is an exaggeration. Since the pathology is in the lower jiao with intestinal sliding and prolapse, heavy and astringent herbs are needed to reach the lower jiao and secure closure. Hence, Chishizhi Yuyuliang Tang is used. However, this is rhetorical elaboration, not the core emphasis. The crucial point is "if diarrhea persists, promote urination." If primordial qi is not exhausted and it is merely intestinal sliding, astringents suffice. But if repeated purgation depletes true qi, leaving lower jiao fireless and true yang unable to perform steaming and transforming functions, clear and turbid fail to separate, and water/grain are not differentiated. Diarrhea persists beyond the reach of astringents. Treatment requires restoring lower jiao fire and promoting qi transformation. The reason no formula is provided for "promoting urination" is that theories on three-jiao and bladder qi transformation are complex and cannot be summarized briefly. Scholars confident in their understanding need not add赘述. As Zhang Zhongjing wrote in his preface: "Modern physicians do not study classics to expand knowledge, relying instead on family techniques and old methods. In diagnosing, they rely on eloquence rather than insight, making it difficult to distinguish life from death." Bladder qi transformation theory is detailed in the Wuling San commentary.
Chishizhi Yuyuliang Tang Formula
Chishizhi (Halloysitum Rubrum, 1 jin, ground) Yuyuliang (Metastone, 1 jin, ground)
Take these two ingredients, add six sheng of water, decoct to obtain two sheng, remove dregs, and divide into three doses.
Xu Zhicai stated: "Astringency removes slipping/prolapse, such as with Muli (Ostreae Concha) and Longgu (Fossilia Ossis Mastodi)." Li Shizhen listed Muli, Longgu, Haopiaoxiao (Sepiae Endoconcha), Wubeizi (Terminalia Chebulae Fructus), Wuweizi (Schisandrae Chinensis Fructus), Wumei (Mume Fructus), Liupi (Granati Cortex), Hezi (Chebulae Fructus), Shuke (Arecae Semen), Lianfang (Nelumbinis Plumula), Zonghui (Ziziphus Spinosae Ramulus Cinis), and Shizhi as astringents. Chishizhi and Yuyuliang act on the hand-foot yangming channels. Chishizhi is warm, heavy, and astringent; its heaviness and astringency stop dampness and secure the lower jiao. Its sweetness and warmth tonify qi and regulate the middle (intestines/stomach/muscles). Yuyuliang is astringent and targets the lower jiao. Li Xianzhi's poem states: "Lower jiao ailments are hard to comprehend, requiring Yuliang and Chishizhi." Li Shizhen added: "Slipping syndromes include qi, blood, essence, and spirit slipping. Slipping implies scattering without retention, requiring sour-astringent, warm, and neutral herbs to gather dispersion. Since qi commands blood, qi-slipping requires qi-tonics, and blood-slipping requires blood-tonics and qi-tonics. Thus, Taohua Tang (Peach Kernel Decoction) differs in its application."
Originally, due to erroneous purgation, epigastric stagnation occurred. Xiexin Tang was given, but stagnation did not resolve. The patient presents with thirst, dry mouth, irritability, and dysuria. Wuling San (Five-Ling Powder) should be administered.
This refers to stagnation in the epigastrium caused by erroneous purgation driving pathogens inward, initially warranting Xiexin Tang. However, Xiexin Tang applications vary: there is stagnation from cold pathogens entering after purgation (tight pulse entering interior); stagnation from stomach deficiency after purgation; and stagnation from yin pathogens knotting internally after sweating resolution. Treatments range from purging heat-excess to warming meridians, dispelling stagnation, and tonifying/opening. Treatments differ based on syndrome. This specific stagnation is taiyang exterior pathogens transmitting inward. The bladder is the fu organ of taiyang. Although stagnation is in the epigastrium, the pathogen has entered the interior, affecting the bladder. Using Xiexin Tang alone will not resolve the stagnation and may exacerbate thirst, dry mouth, irritability, and dysuria. The foot-taiyang bladder is the repository of fluids, dependent on three-jiao qi transformation for movement. Qi transformation involves lower jiao qi ascending, allowing upper jiao qi to descend. Ascending qi transforms fluids into saliva/nasal discharge; descending qi directs fluids to urine/feces. Pathogens invading the bladder prevent lower jiao qi from ascending, stopping fluid ascent. This causes thirst and dryness/irritability. With lower qi failing to ascend, upper qi cannot descend, causing dysuria. Hence, Wuling San is indicated (see Wuling San commentary). Thirst, dry mouth, and irritability here share the same meaning as floating-pulse, rapid-pulse, irritability, and thirst in the first taiyang mis-sweating clause. Despite different causes (mis-sweating vs. mis-purgation), the underlying lower-jiao deficiency-cold and lack of fire are identical. By identifying meridians and analyzing pulses clearly, hesitation is unnecessary. Clinical doubt and hesitant prescribing stem from weak faith in the dao and insufficient practice, not from ancient secrecy.
In taiyang wind-stroke, with diarrhea and vomiting, if the exterior is resolved, attack may proceed. If the patient has continuous sweating occurring at intervals, headache, epigastric fullness and hardness, fullness radiating pain to the flanks, dry retching, shortness of breath, sweating without aversion to cold, this indicates resolved exterior and unresolved interior. Shizao Tang (Ten Date Decoction) should be administered.
Old interpretations claimed wind injuring wei (defensive) layer with erroneous purgation leads to Jie Xiong, while cold injuring ying (nutritive) layer leads to Pi (Stagnation). This explains Zhang Zhongjing's "manifesting on yang" vs. "manifesting on yin." Previously, we saw Jie Xiong Heat-Excess after six days and Jie Xiong without significant heat after ten days. In the Banxia Xiexin Tang section, taiyang presented with both Jie Xiong and Pi. Here, taiyang wind-stroke presents with epigastric fullness and hardness. Thus, Zhang Zhongjing's distinction lies in yin/yang channels, not wind/cold patterns. This section omits exterior symptoms, stating diarrhea and vomiting indicate heat pathogens attacking intestines/stomach, suggesting interior excess suitable for purgation. However, even if pathogens enter the interior, attack is only permissible if the exterior is fully resolved. If exterior signs persist, attack is contraindicated. "Jiran" refers to slight sweating. Intermittent sweating and fever suggest yangming transmission with spontaneous sweating and tidal fever. Headache is not exclusive to exterior syndromes; it can result from interior pathogen knotting and yang-pathogen oppression upward. Epigastric fullness/hardness radiating to flanks indicates interior pathogen blocking middle jiao. Pure qi-stagnation would not cause hardness or radiating pain. Interior pathogens impair stomach fluid transport, causing fluid retention, epigastric hardness, qi restriction, and flank pain. This aligns with Shengjiang Xiexin Tang's "fluid retention under flanks" and "water knotting in chest/flanks." Pathogens in the stomach cause rebellious qi (dry retching). Middle jiao blockage causes fullness and shortness of breath. These are indications for attack. Sweating without aversion to cold confirms complete exterior resolution and yangming entry, leaving only interior disharmony. Interior disharmony means stomach is constrained by pathogens, failing to circulate fluids, accumulating in chest/flanks. This differs from Jie Xiong Heat-Excess (painful epigastrium, stone-hard on pressure). Jie Xiong Heat-Excess uses Daxiexiong Tang (Major Inward-Draining Decoction) with Dahuang and Mangxiao as sovereigns. This is a solid stagnation case but less severe than Jie Xiong Heat-Excess. Therefore, draining water-dampness-phlegm-fluid is required to harmonize the stomach and restore qi flow. Shizao Tang is indicated.
Shizao Tang Formula
Yuanhua (Genkwa Flos, processed) Gansui (Euphorbiae Kansui Radix) Daji (Euphorbiae Pekinensis Radix) Dazao (Ziziphi Jujubae Fructus, 10 pieces, split)