病如桂枝证，头不痛，项不强，寸脉微浮，胸中痞硬，气上冲咽喉，不得息者，此为胸有寒也，当吐之，宜
瓜蒂散。
病如桂枝，是见发热、汗出、恶风、鼻鸣、干呕等证。头不痛，项不强，则非太阳中风。未经汗下而胸中痞硬，
其气上冲，便非桂枝证矣。病机在胸中痞硬，盒饭究痞硬之病，因思胸中痞硬之治法矣。胸中者，阳明之表也。
邪中于面，则入阳明，中于膺，亦入阳明。则鼻鸣、发热、
汗出、恶风者，是邪中于面，在表之表也。胸中痞硬，气上冲不得息者，邪中膺，在里之表也。寒邪结而不散，
胃阳抑而不升，故成此痞象耳。胃者土也，土生万物，不吐者死，必用酸苦涌泄之味，因而越之，胃阳得升，胸
寒自散。里之表和，表之表亦解矣。此瓜蒂散为阳明之表剂。
病患手足厥冷，脉乍紧者，邪结在胸中；心下满而烦，饥不能食者，病在胸中。当吐之，宜瓜蒂散。
手足为诸阳之本，厥冷则胃阳不达于四肢。紧则为寒，乍紧者，不厥时不紧，言紧与厥相应也。此寒结胸
中之脉证。心下者，胃口也。满者胃气逆，烦者胃火盛。火能消物，故饥；寒结胸中，故不能食。此阴并于上，
阳并于下，故寒伤形，热伤气也。非汗下温补之法所能治，必瓜蒂散吐之。此塞因通用法，又寒因寒用法。
上条是阳明中风脉证，此条是阳明伤寒脉证。上条是阳明小结胸，此条是阳明大结胸。太阳结胸因热入，硬
满而痛为有形，故制大陷胸下之。阳明结胸因寒塞，硬满不痛为无形，故制瓜蒂散吐之。
少阴证，饮食入口则吐。心中温温欲吐，复不能吐，始得之，手足寒，脉弦迟者，此胸中实，不可下也，当
吐之。若膈上有寒饮，干呕者，不可吐也，当温之，宜四逆汤。
欲吐而不吐者，少阴虚证。此饮食入口即吐，非胃寒矣。心下温即欲吐，温止则不欲吐矣。复不能吐者，
寒气在胸中，似有形而实无形，非若饮食有形而可直拒之也。此病升而不降，宜从“高者抑之”之法，下之则愈
矣。而不敢者，以始得病时手足寒，脉弦迟，疑其为寒。今以心下温证之，此为热实，然实不在胃而在胸中，则
不可下也。当因其势而利导之，不出“高者越之”之法。然病在少阴，呕吐多属于虚寒，最宜细究。若膈上有寒
饮，与心下温者不同；而反干呕者，与饮食即吐者不同矣。瓜蒂散不中与也。气上冲、满而烦、心下温，皆是
瓜蒂散着眼处。
手足寒，脉弦迟，有心温、膈寒二证，须着眼。
瓜蒂散∶
赤小豆 瓜蒂（熬黄，各一分）
二味，各别捣筛为散，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。
不吐，少少加，得快吐乃止。诸亡血虚家，不可与之。
瓜为甘果，而熟于长夏，清胃热者也。其蒂，瓜之生气所系也。色青味苦，象东方甲木之化，得春升生发
之机。故能提胃中之气，除胸中实邪，为吐剂中第一品药。故必用谷气以和之。赤小豆甘酸下行而止吐，取为反
佐，制其太过也。香豉本性沉重，糜熟而使轻浮，苦甘相济，引阳气以上升，驱阴邪而外出，作为稀糜，调二散，
虽快吐而不伤神。仲景制方之精义∶赤豆为心谷而主降，香豉为肾谷而反升，既济之理也。
太阳病，当恶寒发热。今自汗出，不恶寒发热，关上脉细数者，以医吐之过也，此为小逆。一二日吐之者，
腹中饥，口不能食。三四日吐之者，不喜糜粥，欲食冷食，朝食暮吐，以医吐之所致也。
言太阳病，头项强痛可知。今自汗出而不恶寒发热，疑非桂枝证。以脉辨之，关上者，阳明脉位也，细数而
不洪大。虽自汗而不恶热，则不是与阳明并病。不口干烦满而自汗出，是不与少阴两感。原其故，乃庸医妄吐
之所致也。吐后恶寒发热之表虽除，而头项强痛仍在，则自汗为表虚，脉细数为里热也。此其人胃气未伤，犹未
至不能食，尚为小逆。其误吐而伤及胃气者，更当计日以辨之。若一二日间，热正在表，当汗解而反吐之，寒邪
乘虚入胃，故饥不能食。三四日间，热发于里，当清解而反吐之，胃阳已亡，故不喜谷食，而反喜瓜果，是除中
也。邪热不化物，故朝食暮吐，生意尽矣，此为大逆。
按∶三阳皆受气于胸中。在阳明以胸为表，吐之阳气得宣，故吐中便寓发散之意。太阳以胸为里，故有干呕、
呕逆之证，而不可吐，吐之则伤胃而为逆。少阳得胸中之表，故亦有喜呕证，吐之则悸而惊矣。
太阳病吐之，但太阳病当恶寒，今反不恶寒，不欲近衣，此为吐之内烦也。
上条因吐而亡胃脘之阳，此因吐而伤膻中之阴。前条见其人之胃虚，此条见其人之阳盛。前条寒入太阴而
伤脾精，此条热入阳明而成胃实。皆太阳妄吐之变证，是瓜蒂散所禁，不特亡血虚家也。
病证表现类似桂枝汤证，但头部不痛，项部不强硬，寸脉微浮，胸中痞塞坚硬，气向上冲至咽喉，导致呼吸不畅，这是胸中有寒邪所致，应当采用涌吐法治疗，适宜使用瓜蒂散。
所谓“病如桂枝”，是指出现发热、汗出、恶风、鼻鸣、干呕等症状。既然头不痛、项不强，那就不是太阳中风证。未经过发汗或攻下治疗，却出现胸中痞塞坚硬，且气机上冲，这就不是桂枝汤证了。病机关键在于胸中痞塞坚硬，必须探究痞硬的病因，进而思考胸中痞硬的治疗方法。胸中部位，属于阳明的表位。邪气侵犯面部，则进入阳明经；侵犯胸部膺部，也进入阳明经。因此，鼻鸣、发热、汗出、恶风，是邪气侵犯面部，处于表中之表（浅层）的表现；而胸中痞塞坚硬，气上冲导致呼吸不畅，是邪气侵犯膺部，处于里中之表（较深层但仍属表）的表现。寒邪凝结不散，胃阳被抑制不能升发，所以形成这种痞塞的现象。胃属土，土能生养万物，如果不通过涌吐祛除邪气就会死亡，必须使用酸苦性质的涌泄药物，顺势使邪气从上而出，胃阳得以升发，胸中的寒邪自然消散。里之表和调，表中之表也随之解除。这就是瓜蒂散作为阳明经表剂的作用原理。
患者手足厥冷，脉搏突然变得紧束，这是邪气结聚在胸中；心下部胀满且心烦，饥饿却无法进食，这是病位在胸中。应当采用涌吐法治疗，适宜使用瓜蒂散。
手足是诸阳经的根本，手足厥冷说明胃阳不能通达四肢。脉紧主寒，脉搏突然变紧，意味着在不厥冷的时候脉不紧，说明脉紧与手足厥冷是相应的。这是寒邪结聚于胸中的脉证表现。心下部即胃口所在。胀满是胃气上逆，心烦是胃火旺盛。火能消化食物，所以感到饥饿；但寒邪结聚在胸中，阻碍受纳，所以不能进食。这是阴寒之气并聚于上部，阳气并聚于下部，导致寒邪损伤形体，热邪损伤气机。这不是发汗、攻下或温补的方法所能治疗的，必须用瓜蒂散进行涌吐。这属于“塞因通用”的治疗法则，也是“寒因寒用”的用法。
上一条条文讲述的是阳明中风证的脉象和症状，这一条讲述的是阳明伤寒证的脉象和症状。上一条属于阳明小结胸证，这一条属于阳明大结胸证。太阳病的结胸是因为热邪内陷，表现为硬满且疼痛，是有形实邪，所以制定大陷胸汤来攻下。阳明病的结胸是因为寒邪阻塞，表现为硬满但不疼痛，是无形邪气，所以制定瓜蒂散来涌吐。
少阴病证，饮食入口就呕吐。心中感觉温热想吐，却又吐不出来，刚发病时，手足寒冷，脉象弦迟，这是胸中有实邪，不可使用攻下法，应当采用涌吐法。如果是膈上有寒饮，出现干呕，则不可涌吐，应当温阳散寒，适宜使用四逆汤。
想吐又吐不出来的，属于少阴虚证。这里是饮食入口即吐，并非胃寒所致。心下部感觉温热就想吐，温热感停止就不想吐了。却又吐不出来，是因为寒气在胸中，看似有形实则无形，不像饮食那样是有形的实物可以直接拒绝排出。这种病势是上升而不下降，适宜遵循“高者抑之”的原则，但此处不敢轻易攻下，因为刚发病时手足寒冷、脉象弦迟，让人怀疑是寒证。现在根据心下部温热的症状来辨证，这是热实邪气，然而实邪不在胃而在胸中，所以不可攻下。应当顺应病势加以引导，不出“高者越之”（即涌吐）的范围。然而病在少阴，呕吐多属于虚寒，需要仔细研究。如果膈上有寒饮，与心下部温热不同；反而出现干呕，与饮食入口即吐也不同。此时不宜使用瓜蒂散。气上冲、胀满且心烦、心下部温热，这些都是使用瓜蒂散的关键着眼点。
手足寒冷，脉象弦迟，有心下部温热和膈部寒饮两种证候，必须仔细辨别。
瓜蒂散的配方：
赤小豆、瓜蒂（炒至黄色，各一分）。
将这两味药分别捣碎筛成粉末，混合均匀。取一方寸匕的药粉，用香豉一合，加入热水七合，煮成稀粥状，滤去渣滓取汁液，将药粉混入药汁中，温服一次顿服。如果不吐，可少量增加剂量，直到迅速吐出为止。凡是失血患者及体质虚弱者，禁止服用。
瓜是甘甜的果实，成熟于长夏季节，能清泻胃热。瓜蒂是瓜生气机系连之处，颜色青、味道苦，象征东方甲木的化生，具备春季升发生发的机理。因此它能提起胃中之气，清除胸中的实邪，是涌吐剂中的第一品药物。所以必须用谷气（米食之气）来调和它。赤小豆味甘酸，性下行而止吐，取其作为反佐，以制约瓜蒂涌吐太过。香豉本性沉重，煮熟糜烂后变得轻浮，苦甘相济，引导阳气以上升，驱除阴邪而外出，制成稀糜调和两味药粉，虽然能迅速催吐却不伤神气。张仲景制方的精妙义理在于：赤小豆为心之谷，主降；香豉为肾之谷，主升，体现了水火既济的道理。
太阳病，应当恶寒发热。现在患者自汗出，且不恶寒发热，关上脉象细数，这是因为医生误用涌吐法造成的过失，这属于较小的逆证。如果在发病一二日时就误用涌吐，患者会感到腹中饥饿，但口不能进食。如果在三四日时误用涌吐，患者不喜欢喝稀粥，想吃冷食，早晨吃晚上吐，这都是因为医生误用涌吐法导致的。
说太阳病，应该伴有头项强痛。现在自汗出且不恶寒发热，让人怀疑不是桂枝汤证。通过脉象来辨析，关脉对应阳明脉位，脉象细数而不洪大。虽然有自汗出但不恶热，说明不是与阳明经并病。没有口干、烦满而只有自汗出，说明不是与少阴经两感。推究其原因，乃是庸医妄用涌吐法所致。涌吐后，恶寒发热的表证虽然解除，但头项强痛仍在，那么自汗出就是表虚，脉细数则是里有热。这种人胃气尚未受伤，还没有到不能进食的地步，尚且算作小逆。那些误吐伤及胃气的，更应当根据发病天数来辨别。如果在发病一两天间，热邪还在体表，应当发汗解表却反而涌吐，寒邪乘虚侵入胃中，所以感到饥饿但不能进食。如果在三四日间，热邪发于体内，应当清热解表却反而涌吐，胃阳已经亡失，所以不喜欢谷物食物，反而喜欢瓜果，这就是“除中”（胃气败绝的假象）。邪热不能腐熟水谷，所以早晨吃晚上吐，生机已尽，这属于大的逆证。
按语：三阳经的气血都来源于胸中。在阳明经，以胸为表，涌吐可以使阳气宣通，所以涌吐中便蕴含发散的意思。在太阳经，以胸为里，所以有干呕、呕逆的症状，不可涌吐，涌吐则会损伤胃气而导致逆证。少阳经得到胸中之表气，所以也有喜呕的症状，涌吐会导致心悸和惊恐。
太阳病误用涌吐法，仅见太阳病应当恶寒，现在反而不恶寒，不想穿衣，这是因为涌吐导致内部烦热。
上一条条文是因为涌吐而亡失胃脘之阳，这一条是因为涌吐而损伤膻中之阴。前一条见到的是人的胃气虚弱，这一条见到的是人的阳气盛实。前一条寒邪进入太阴损伤脾精，这一条热邪进入阳明形成胃实。都是太阳病误用涌吐产生的变证，这些情况都是瓜蒂散的禁忌症，不仅仅是失血和体质虚弱的人不能使用。
The disease presentation resembles the *Guizhi Tang* (Cinnamon Twig Decoction) syndrome, yet there is no headache or stiffness in the neck. The cun (inch) pulse is slightly floating, there is a sensation of fullness and hardness in the chest, qi rushes upward to the throat causing dyspnea. This indicates cold pathogen accumulation in the chest; emesis should be induced, and *Gua Di San* (Melon Stalk Powder) is indicated.
"Disease resembling *Guizhi*" refers to symptoms such as fever, sweating, aversion to wind, nasal congestion with roaring sound (*biming*), and dry retching. Since there is no headache or neck stiffness, it is not *Taiyang* Wind-Strike (*Zhongfeng*). Without prior sweating or purging therapies, the presence of chest fullness/hardness and upward rushing of qi distinguishes it from *Guizhi* syndrome. The pathological mechanism centers on chest fullness and hardness; one must investigate the cause of this fullness to determine the treatment for the chest. The chest region is the exterior aspect of the Yangming channel. Pathogens invading the face enter the Yangming channel; those invading the pectoral region also enter the Yangming channel. Thus, nasal roaring, fever, sweating, and aversion to wind indicate pathogens invading the face, located at the "exterior of the exterior" (superficial layer). Chest fullness/hardness with upward rushing qi causing dyspnea indicates pathogens invading the pectoral region, located at the "interior of the exterior" (deeper but still exterior level). Cold pathogens condense and do not disperse, suppressing Stomach Yang from ascending, resulting in this pattern of fullness. The Stomach corresponds to Earth, which generates all things. If emesis is not performed, death ensues. One must use sour and bitter draining flavors to induce vomiting via the upper route, allowing Stomach Yang to ascend and chest cold to dissipate. When the interior-exterior harmony is restored, the superficial exterior resolves. Thus, *Gua Di San* serves as an exterior-releasing agent for the Yangming channel.
Patients presenting with cold extremities and a pulse that suddenly becomes tight have pathogenic accumulation in the chest. Those with epigastric fullness, irritability, hunger but inability to eat have pathology located in the chest. Emesis should be induced, and *Gua Di San* is indicated.
The hands and feet are the root of the Yang channels; cold extremities indicate Stomach Yang failing to reach the limbs. A tight pulse indicates cold. Sudden tightness implies that the pulse is not tight when extremities are warm, showing correspondence between tightness and coldness. These are the pulse and symptom manifestations of cold binding in the chest. The epigastrium corresponds to the stomach opening. Fullness indicates rebellious Stomach Qi; irritability indicates abundant Stomach Fire. Fire digests food, hence hunger; however, cold binding in the chest prevents ingestion, hence inability to eat. This represents Yin accumulating above and Yang accumulating below, where cold damages the form and heat damages the Qi. This cannot be treated with sweating, purging, or warming tonification methods; only *Gua Di San* for emesis will work. This applies the principle of "treating obstruction with unblocking" (*sai yin tong yong*) and "treating cold with cold" (*han yin han yong*).
The previous clause describes the pulse and symptoms of Yangming Wind-Strike; this clause describes Yangming Cold Damage. The previous clause represents a minor Yangming Jie Xiong (chest binding); this clause represents major Yangming Jie Xiong. Taiyang Jie Xiong results from heat entering, presenting with hardness, fullness, and pain (有形 solid pathogen), thus requiring *Da Xian Xiong Tang* (Major Blue-Green Pill) for purging. Yangming Jie Xiong results from cold blocking, presenting with hardness and fullness without pain (无形 non-solid pathogen), thus requiring *Gua Di San* for emesis.
Shaoyin syndrome involves vomiting immediately after food enters the mouth. A feeling of warmth in the heart with desire to vomit but inability to do so, accompanied by cold hands/feet and a string-tight, slow pulse at onset, indicates real pathogen in the chest. Purging is contraindicated; emesis should be induced. However, if there is cold fluid above the diaphragm causing dry retching, emesis is contraindicated; warming is required, and *Si Ni Tang* (Frigid Extremities Decoction) is indicated.
Desire to vomit but inability to do so characterizes Shaoyin deficiency. Here, vomiting upon food entry is not due to Stomach cold. Warmth in the epigastrium triggers the urge to vomit; when warmth subsides, the urge ceases. Inability to vomit suggests cold in the chest, appearing solid but actually empty, unlike tangible food that can be directly rejected. The disease trend is ascending rather than descending. While the principle "high paths should be suppressed" applies, purging is avoided because initial cold extremities and string-tight/slow pulses suggest cold. Based on epigastric warmth, this is heat-real pathogen, but since the excess is in the chest not the Stomach, purging is contraindicated. One must guide the pathogen according to its trend, adhering to "high paths should be vented" (emesis). Given Shaoyin vomiting often relates to deficiency-cold, careful differentiation is needed. Cold fluid above the diaphragm differs from epigastric warmth; dry retching differs from immediate vomiting. *Gua Di San* is inappropriate here. Upward rushing qi, fullness with irritability, and epigastric warmth are key indicators for using *Gua Di San*.
Cold extremities with string-tight/slow pulses require distinguishing between epigastric warmth and diaphragmatic cold.
**Gua Di San Formula:**
Chi Xiao Dou (Adzuki Bean) and Gua Di (Melon Stalk), roasted until yellow, each 1 fen.
Pulverize each separately, mix. Take 1 qian bi (measure), boil Xiang Chi (Prepared Soybean Fermented) 1 he with 7 he of hot water into a thin porridge, strain, take the liquid, mix with powder, and drink warm in one dose. If no vomiting occurs, increase dosage slightly until rapid vomiting occurs. Contraindicated in patients with blood loss or deficiency constitutions.
Melon is a sweet fruit ripening in late summer, clearing Stomach heat. The stalk connects the vital energy of the melon. Green color and bitter taste correspond to East Wood (Jia Mu), possessing spring-like ascending and generating mechanisms. It lifts Stomach Qi and expels chest real pathogens, being the premier emetic herb. Grain Qi harmonizes it. Adzuki bean is sweet-sour and descending, acting as a counter-agent to prevent excessive vomiting. Xiang Chi is heavy by nature but becomes light when cooked into porridge; bitter and sweet together guide Yang Qi upward and expel Yin pathogens externally. The porridge texture allows rapid emesis without damaging Shen (Spirit). Zhang Zhongjing's formula wisdom: Adzuki bean (Heart grain) descends; Xiang Chi (Kidney grain) ascends, achieving Water-Fire intersection (*Ji Ji*).
Taiyang syndrome typically presents with aversion to cold and fever. Now, spontaneous sweating occurs without aversion to cold or fever, and the Guan (bar) pulse is fine and rapid. This is iatrogenic error from improper emesis, considered a minor adverse reaction. If emesis is used on days 1-2, the patient feels hungry but cannot eat. If used on days 3-4, the patient dislikes congee, desires cold food, and vomits what was eaten in the morning by evening. This results from physician-induced emesis.
Taiyang syndrome implies headache and neck stiffness. Spontaneous sweating without aversion to cold/fever might suggest non-*Guizhi* syndrome. Pulse analysis: Guan position corresponds to Yangming; fine/rapid pulse is not surging/large. Spontaneous sweating without heat aversion rules out Yangming concurrent disease. No dry mouth or irritability rules out Shaoyin dual infection. The cause is quack emesis. Although exterior symptoms (aversion to cold/fever) resolve, head/neck stiffness remains; spontaneous sweating indicates exterior deficiency, while fine/rapid pulse indicates interior heat. Stomach Qi is intact, appetite remains, hence "minor adverse reaction." For severe Stomach Qi damage, differentiate by day count. Days 1-2: Heat at exterior requires sweating; emesis allows cold to enter Stomach, causing hunger without intake. Days 3-4: Heat in interior requires clearing; emesis destroys Stomach Yang, leading to dislike of grains and preference for fruits/melons, indicating "Chu Zhong" (elimination of central Qi/death omen). Heat fails to digest food, causing morning-eating/evening-vomiting, signaling end of life—this is "major adverse reaction."
Note: Three Yang channels derive Qi from the chest. In Yangming, chest is exterior; emesis disseminates Yang Qi, containing dispersing intent. In Taiyang, chest is interior; dry retching/vomiting occur, emesis is contraindicated as it damages Stomach Qi. Shaoyang receives chest exterior Qi, causing frequent vomiting; emesis causes palpitations and fright.
Taiyang syndrome treated with emesis: Typically aversion to cold exists; now absence of aversion to cold and reluctance to wear clothes indicates internal irritability caused by emesis.
Previous clause: Emesis destroyed Stomach Yang. This clause: Emesis damaged Pericardium Yin. Previous: Stomach deficiency. This: Yang excess. Previous: Cold entered Taiyin, damaging Spleen essence. This: Heat entered Yangming, forming Stomach excess. All are adverse changes from improper Taiyang emesis. These are contraindications for *Gua Di San*, extending beyond just blood-loss or deficient patients.