【纲】仲景曰。太阳病。头痛发热。身疼腰痛。骨节疼痛。恶风。无汗而喘者。麻黄汤主之。
【目】刘完素曰。肺主气。形寒饮冷则伤肺。故其气逆而上行。冲冲而气急。喝喝而息数。抬肩张口。掀肚摇身是
也。伤寒之喘。有由邪气在表。气不利而喘者。有由寒水之气。射肺而喘者。各不同也。伤寒止于邪气在表而喘者。心
腹必濡而不坚。设或腹满而喘。则又为可下之症。
鳌按。本症重在发热身疼无汗而喘。其喘者。因风寒外束。阳气不伸而郁于内也。太阳为开。本症又宜开。故仲景
立麻黄法以开之。
【纲】仲景曰。太阳病。桂枝症。医反下之。利遂不止。脉促者。表未解也。喘而汗出者。葛
根黄连黄芩汤主之。太阳病。下之。微喘者。表未解故也。桂枝加浓朴杏仁汤主之。喘家作桂枝汤。
加浓朴、杏仁佳。
【目】鳌按。来苏集谓桂枝症上复冠太阳字。见诸经皆有桂枝症。是桂枝不独为太阳设。固已。
愚窃谓太阳病下。复接桂枝症字。亦可见太阳治方。不独一桂枝汤。而此则为桂枝汤之症。非别
方之症。且可见喘而汗出者。以邪束于外阳扰于内也。总之。此条为微热在表。而大热入里之症。
故仲景制此轻清苦寒之剂。喘本为麻黄症。既制葛根芩连方治之。又以桂枝加朴杏为治。皆不用麻黄。何也。盖因妄下
后。表虽不解。毕竟腠理已疏。故不用麻黄而用桂枝。且桂枝方中有芍药。若单加杏仁。喘虽微。恐
不胜任。故必佐以浓朴。斯喘随汗解也。杏仁。治喘胜品。
【纲】仲景曰。太阳与阳明合病。喘而胸满者。不可下。麻黄汤主之。阳明症。脉浮。无汗而
喘者。发汗则愈。宜麻黄汤。
【目】朱肱曰。伤寒喘。只有太阳阳明两症。
柯琴曰。三阳俱受气于胸中。而部位则属阳明。若喘属太阳。呕属阳明。故胸满而喘者。尚未
离乎太阳。虽有阳明可下之症。而不可下也。
鳌按。病虽已入阳明。脉浮无汗而喘。故为未离太阳也。故仍用麻黄汤。
【纲】仲景曰。发汗后。不可更行桂枝汤。无汗。而喘。大热者。可与麻黄杏子甘草石膏汤。
下后。不可更行桂枝汤。若无汗而喘。大热者。可与麻黄杏子甘草石膏汤。
【目】陶华曰。伤寒发喘。有邪在表者。有邪在里者。有水气在表者。心腹濡而不坚。外症无
汗。法当汗之。在里者。心腹胀满。外症有汗。法当下之。其由水气者。心下怔忡。小青龙去麻黄
加杏仁汤。经云。喘而汗出。宜利之。汗不出而喘。宜
发之。其或直视谵语。汗出如油。喘而不休。死症也。水气喘咳。乃太阳汗后。饮水多而水停心下也。既用小青龙去麻
黄加杏仁矣。其或兼小腹痛者。则小青龙去麻黄加茯苓。阴病喘促。返阴丹。
喻昌曰。误用桂枝固卫。寒不得泄。气逆变喘。本当用大青龙。乃于汤中除去桂枝、姜、枣者。
一误不堪再误也。然治之终不出麻杏甘石之外。见内饮水多。外行水灌。皆足以敛邪闭汗。不独
误行桂枝汤为然也。太阳中风。与太阳伤寒。一从桂枝。一从麻黄。分途异治。由中风之误下而喘者。用浓朴、杏
仁加入桂枝汤中观之。则伤寒之误下而喘者。用石膏加入麻黄汤中。乃天造地设。两不移易之定法。
仲师所以谆谆告戒者。正恐人以伤寒已得汗之证。认为伤风有汗而误用桂枝。故特出误汗误下两
条。示以同归麻黄一治之要。益见荣卫分途。而成法不可混施也。
鳌按。喻注饮水过多。水气上逆。其说甚是。而以水灌为沃其皮肤。则谬。
此二条无字。旧本俱讹在大热字上。柯氏韵伯始改正之。
【纲】仲景曰。发汗后。饮水多者。必喘。以水灌之。亦喘。
【目】柯琴曰。未发汗。因风寒而喘者。是麻黄症。下后微喘者。桂枝加朴杏症。喘而汗出者。
葛根芩连症。此汗后津液不足。饮水多而喘者。五苓散症。水灌亦喘者。形寒饮凉。皆能伤肺。
气迫上行。是以喘。
鳌按。汉时治病。服药而外。有水治火治之法。以水灌之。料即是水治。但不知如何用法。若
喻以为沃其皮肤。恐未尽然。
【纲】仲景曰。伤寒表不解。心下有水气。干呕发热而咳。或渴。或利。或噎。或小便不利少
腹满。或喘者。小青龙汤主之。加减法。若喘者。去麻黄加杏仁去皮尖。
伤寒心下有水气。咳而微喘。发热不渴。小青龙汤主之。服汤已渴者。此寒去欲解也。
【目】朱肱曰。麻黄主喘。何故去之。答曰。此治心下有水而喘。不当汗也。故去之。
鳌按。此二条之喘。皆因心下有水气。小青龙与小柴胡俱为枢机之剂。故皆设或然症。各立加
减法。咳与喘。皆水气射肺也。
【纲】仲景曰。直视谵语。喘满者死。汗出发润。喘不休者。此为肺绝。身汗如油。喘而不休
者。此为命绝。
【目】成无己曰。此皆邪气内盛。正气欲脱。气壅上逆也。皆不治之症。
【纲】张仲景说：太阳病，出现头痛、发热、身体疼痛、腰痛、骨节疼痛、怕风、无汗且伴有气喘的症状，应当用麻黄汤主治。
【目】刘完素说：肺主司气机，形体受寒或饮食生冷会损伤肺脏，因此肺气上逆而上行，表现为气息急促冲撞，呼吸声粗重，耸肩张口，腹部起伏摇动身体，这就是喘的表现。伤寒引起的气喘，有的是因为邪气在体表，气机不利而致喘；有的是因为寒水之气射入肺部而致喘，情况各不相同。如果伤寒仅因邪气在表而致喘，心腹部必然柔软而不坚硬；假如出现腹部胀满且气喘，则又属于可以使用攻下法的证候。
沈金鳌按语：本证的重点在于发热、身疼、无汗且气喘。其气喘的原因，是由于风寒束缚于外，阳气不能舒展而郁结于内。太阳经主“开”，本证也适宜用“开”法治疗，所以张仲景创立了麻黄法来开通腠理。
【纲】张仲景说：太阳病，具备桂枝汤证的特征，医生反而使用攻下法，导致腹泻不止，脉象急促的，说明表证仍未解除；若伴有气喘且出汗，应用葛根黄连黄芩汤主治。太阳病，经过攻下后，出现轻微气喘的，是因为表证未解的缘故，应用桂枝加厚朴杏子汤主治。素有气喘病的患者，发作时服用桂枝汤，再加入厚朴和杏仁效果更佳。
【目】沈金鳌按语：《来苏集》认为，在桂枝汤证前冠以“太阳病”三字，表明各经都有桂枝汤证，可见桂枝汤并非专为太阳病设立，这已经明确了。我私下认为，太阳病之下接着写桂枝汤证，也可以看出太阳病的治疗方剂不仅仅只有桂枝汤，而此处指的是符合桂枝汤适应症的证候，而非其他方剂的适应症。并且可以看出，“喘而汗出”是因为邪气束缚于外，阳气扰动于内。总之，这一条是微热在表、大热入里的证候，所以张仲景制定了这种轻清苦寒的方剂。气喘本来是麻黄汤的主治症，既然制定了葛根芩连汤来治疗它，又用桂枝加厚朴杏仁汤来治疗，都不使用麻黄，为什么呢？大概是因为误用攻下后，虽然表证未解，但腠理已经疏松，所以不用麻黄而用桂枝。而且桂枝汤中有芍药，如果只加杏仁，即使气喘轻微，恐怕也难以胜任，所以必须佐以厚朴，这样气喘就能随着汗液排出而解除。杏仁是治疗气喘的佳品。
【纲】张仲景说：太阳病与阳明病合病，出现气喘且胸部胀满的，不可使用攻下法，应用麻黄汤主治。阳明病，脉浮，无汗且气喘的，发汗即可痊愈，宜用麻黄汤。
柯琴说：三阳经的气都汇聚于胸中，而部位归属于阳明。如果气喘属于太阳病，呕吐属于阳明病，所以胸部胀满且气喘的，尚未脱离太阳病的范畴，虽然有阳明病可下的证候，但不可攻下。
沈金鳌按语：病虽然已传入阳明，但脉浮、无汗且气喘，所以为尚未脱离太阳病。因此仍然使用麻黄汤。
【纲】张仲景说：发汗后，不可再使用桂枝汤。若无汗且气喘，有大热的症状，可与麻黄杏仁甘草石膏汤。攻下后，不可再使用桂枝汤。若无汗且气喘，有大热的症状，可与麻黄杏仁甘草石膏汤。
【目】陶华说：伤寒引起的气喘，有邪气在表的，有邪气在里的，有水气在表的。水气在表者，心腹部柔软而不坚硬，外在症状无汗，治法应当发汗。邪气在里者，心腹胀满，外在症状有汗，治法应当攻下。由水气引起的，心下悸动不安，用小青龙汤去掉麻黄加入杏仁。经文说：“气喘且出汗的，适宜利小便；不出汗而气喘的，适宜发汗。”如果有的人出现两眼直视、胡言乱语，出汗如油，气喘不停，这是死证。水气引起的喘咳，是太阳病发汗后，饮水过多导致水停于心下所致。既然已经用了小青龙汤去麻黄加杏仁，如果兼有小腹疼痛的，则用小青龙汤去麻黄加茯苓。阴病引起的气喘急促，用返阴丹。
喻昌说：误用桂枝汤固护卫气，寒气不得宣泄，气机逆变而致喘，本当使用大青龙汤，却在汤剂中去除了桂枝、生姜、大枣，这是一误不能再误。然而治疗终究离不开麻黄杏仁甘草石膏汤的范围。见体内饮水多，体外用水浇灌，都足以收敛邪气、闭塞汗孔，不仅仅是误用桂枝汤如此。太阳中风证与太阳伤寒证，一个从桂枝汤治疗，一个从麻黄汤治疗，分途异治。从中风证误下后致喘，用厚朴、杏仁加入桂枝汤中观察，可知伤寒证误下后致喘，用石膏加入麻黄汤中，乃是天造地设、两不移易的定法。张仲师之所以谆谆告诫，正是担心人们将伤寒已得汗的证候，误认为是伤风有汗而误用桂枝汤，所以特意列出误汗、误下两条，示人以同归于麻黄汤治疗的要点，更可见营气和卫气分途，而成法不可混淆施用。
沈金鳌按语：喻嘉言注释饮水过多，水气上逆，这种说法是正确的；但他将“水灌”解释为用水浇灌皮肤，则是错误的。
这两条原文没有文字，旧版本都错误地脱漏了“大热”二字，柯韵伯（柯琴）才将其改正。
【纲】张仲景说：发汗后，饮水过多的，必定气喘；用水浇灌身体，也会气喘。
【目】柯琴说：未发汗前，因风寒而气喘的，是麻黄汤证；攻下后轻微气喘的，是桂枝加厚朴杏子汤证；气喘且出汗的，是葛根芩连汤证。此条是发汗后津液不足，饮水过多而致气喘的，属于五苓散证。用水浇灌身体也致气喘的，形体受寒和饮用凉水，都能损伤肺脏，气迫上行，所以气喘。
沈金鳌按语：汉代治病，除了服药之外，还有水治、火治的方法。“用水浇灌身体”，料想即是水治法，只是不知道具体如何用法。如果像喻嘉言所说的是浇灌皮肤，恐怕不完全正确。
【纲】张仲景说：伤寒表证未解，心下有停饮（水气），干呕、发热且咳嗽，或者口渴，或者腹泻，或者噎塞，或者小便不利、少腹满，或者气喘的，应用小青龙汤主治。加减法：如果出现气喘，去掉麻黄，加入杏仁，去皮尖。
伤寒心下有停饮，咳嗽且轻微气喘，发热但不口渴，应用小青龙汤主治。服用汤药后感到口渴的，这是寒气去除、病情欲愈的表现。
【目】朱肱说：麻黄主要治疗气喘，为什么这里要去掉它？回答说：这是治疗心下有停饮而导致的气喘，不应当发汗，所以去掉麻黄。
沈金鳌按语：这两条所述的气喘，都是因为心下有停饮。小青龙汤与小柴胡汤都是枢机之剂，所以都设有或然证（可能出现的症状），并分别设立加减法。咳嗽与气喘，都是水气射入肺部所致。
【纲】张仲景说：两眼直视、胡言乱语、气喘且胸部胀满的，预后不良（死证）；出汗后头发湿润、气喘不停的，这是肺气衰竭；身体出汗如油、气喘不停的，这是命门之火衰竭。
[General Principle] Zhang Zhongjing stated: In Taiyang disease, presenting with headache, fever, body pain, lower back pain, joint pain, aversion to wind, anhidrosis (absence of sweating), and wheezing, Mahuang Tang (Ephedra Decoction) is the primary treatment.
[Commentary] Liu Wansu stated: The Lung governs Qi. When the body is exposed to cold or when cold food and drink are ingested, the Lung is injured, causing Lung Qi to rebel and ascend. This manifests as rushing and急促 breath, heavy respiration, raising shoulders and opening mouth, and abdominal heaving with body shaking; this is defined as wheezing. Wheezing caused by Cold Damage (Shanghan) may result from pathogenic factors remaining in the exterior, leading to obstructed Qi dynamics; or it may result from Cold-Water Qi invading the Lung. These situations differ. If wheezing is solely due to pathogenic factors in the exterior, the heart and abdomen will be soft and not hard. However, if abdominal fullness accompanies wheezing, it becomes a syndrome suitable for purgation.
Shen Jin'ao's Note: The focus of this syndrome lies in fever, body pain, anhidrosis, and wheezing. The wheezing arises because Wind-Cold binds the exterior, preventing Yang Qi from extending, causing it to stagnate internally. The Taiyang channel governs "opening"; thus, this syndrome also requires an "opening" method. Therefore, Zhang Zhongjing established the Mahuang method to open the pores.
[General Principle] Zhang Zhongjing stated: In Taiyang disease, if symptoms characteristic of Guizhi Tang syndrome are present, but the physician erroneously applies purgation, resulting in persistent diarrhea and a rapid pulse, indicating that the exterior syndrome remains unresolved; if accompanied by wheezing and sweating, Gegen Huanglian Huangqin Tang (Pueraria, Coptis, and Scutellaria Decoction) should be used. If Taiyang disease is treated with purgation and results in mild wheezing, it is because the exterior syndrome has not resolved; Guizhi Jia Houpo Xingren Tang (Guizhi Decoction plus Magnolia Bark and Apricot Kernel) should be used. For patients with a chronic history of wheezing, administering Guizhi Tang supplemented with Houpo (Magnolia Bark) and Xingren (Apricot Kernel) is optimal.
[Commentary] Shen Jin'ao's Note: *Laisu Ji* argues that prefixing "Taiyang disease" before "Guizhi syndrome" indicates that Guizhi syndrome appears in various channels, implying Guizhi Tang is not exclusive to Taiyang. I personally believe that placing "Guizhi syndrome" after "Taiyang disease" shows that while Taiyang treatments are not limited to Guizhi Tang, this specific instance refers to the Guizhi Tang syndrome, not another formula's indication. Furthermore, "wheezing with sweating" occurs because pathogens bind the exterior and disturb Yang internally. In summary, this clause describes a syndrome with slight heat in the exterior and significant heat entering the interior. Thus, Zhang Zhongjing formulated this light, clear, bitter, and cold preparation. Although wheezing is typically indicated for Mahuang Tang, here neither Mahuang Tang nor simple modifications are used exclusively for Mahuang. Why? Because erroneous purgation, even if the exterior remains unresolved, has loosened the interstices (cou li). Therefore, Mahuang is avoided in favor of Guizhi. Moreover, since Guizhi Tang contains Shaoyao (Peony Root), adding only Xingren might be insufficient even for mild wheezing; thus, Houpo is added as an assistant to ensure wheezing resolves through sweating. Xingren is a premier herb for treating wheezing.
[General Principle] Zhang Zhongjing stated: In combined Taiyang and Yangming disease, presenting with wheezing and chest fullness, purgation is contraindicated; Mahuang Tang should be used. In Yangming disease, if the pulse is floating, there is no sweat, and wheezing is present, inducing sweating will lead to recovery; Mahuang Tang is appropriate.
[Commentary] Zhu Gong stated: Wheezing in Cold Damage involves only two syndromes: Taiyang and Yangming.
Ke Qin stated: The Qi of the Three Yang channels converges in the chest, anatomically belonging to Yangming. If wheezing belongs to Taiyang and vomiting to Yangming, then chest fullness with wheezing indicates the condition has not yet left the Taiyang stage. Even if Yangming purgation indications exist, purgation must not be performed.
Shen Jin'ao's Note: Although the disease has entered Yangming, the floating pulse, anhidrosis, and wheezing indicate it has not departed from Taiyang. Therefore, Mahuang Tang is still used.
[General Principle] Zhang Zhongjing stated: After inducing sweating, Guizhi Tang should not be administered again. If there is anhidrosis and wheezing with high fever, Mahuang Xingren Gancao Shigao Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction) may be given. After purgation, Guizhi Tang should not be administered again. If there is anhidrosis and wheezing with high fever, Mahuang Xingren Gancao Shigao Tang may be given.
[Commentary] Tao Hua stated: Wheezing in Cold Damage can stem from pathogens in the exterior, pathogens in the interior, or Water-Qi in the exterior. With Water-Qi in the exterior, the heart and abdomen are soft and not hard, and externally there is no sweat; the treatment method is diaphoresis (sweating). With pathogens in the interior, there is abdominal distension and fullness, and externally there is sweat; the treatment method is purgation. For cases caused by Water-Qi, presenting with palpitations beneath the heart, Xiao Qinglong Tang (Minor Blue Dragon Decoction) with Mahuang removed and Xingren added is used. The Classic states: "For wheezing with sweating, benefit via urination; for wheezing without sweating, induce sweating." If a patient presents with fixed staring, delirious speech, oily sweat, and ceaseless wheezing, it is a death syndrome. Wheezing and coughing due to Water-Qi occur when excessive water intake after Taiyang sweating leads to water retention in the epigastrium. Having used Xiao Qinglong Tang minus Mahuang plus Xingren, if accompanied by lower abdominal pain, use Xiao Qinglong Tang minus Mahuang plus Fuling (Poria). For wheezing and urgency due to Yin diseases, Fanyin Dan (Return to Yin Pill) is used.
Yu Chang stated: Erroneously using Guizhi Tang to secure the Wei (Defensive) Qi prevents the release of Cold, causing Qi rebellion and wheezing. Da Qinglong Tang (Major Blue Dragon Decoction) should have been used. Removing Guizhi, Shengjiang (Fresh Ginger), and Dazao (Jujube) from the decoction constitutes one error that cannot be compounded. However, treatment ultimately revolves around Mahuang Xingren Gancao Shigao Tang. Excessive internal water intake and external water pouring both suffice to trap pathogens and close sweat pores, not merely the erroneous use of Guizhi Tang. Taiyang Wind Strike and Taiyang Cold Damage are treated differently via Guizhi Tang and Mahuang Tang respectively, following separate paths. Observing that wheezing after erroneous purgation in Wind Strike uses Houpo and Xingren added to Guizhi Tang, it follows that wheezing after erroneous purgation in Cold Damage uses Shigao (Gypsum) added to Mahuang Tang. This is a heaven-sent, unchangeable standard method. Master Zhang's earnest warnings aim to prevent confusing Cold Damage post-sweating with Wind Strike with sweat, leading to the erroneous use of Guizhi Tang. By highlighting these two clauses on erroneous sweating and purgation, he demonstrates their convergence on Mahuang-based treatments, emphasizing that Ying (Nutritive) and Wei (Defensive) channels are distinct, and established methods must not be mixed.
Shen Jin'ao's Note: Yu Chang's annotation that excessive water intake causes Water-Qi to rebel upward is correct; however, interpreting "water pouring" as washing the skin is erroneous.
These two clauses lacked text in old editions, which erroneously omitted the characters "Da Re" (High Fever). Ke Yunbo (Ke Qin) corrected this.
[General Principle] Zhang Zhongjing stated: After inducing sweating, excessive water intake will inevitably cause wheezing; bathing/pouring water on the body will also cause wheezing.
[Commentary] Ke Qin stated: Wheezing due to Wind-Cold before sweating is a Mahuang Tang syndrome. Mild wheezing after purgation is a Guizhi Jia Houpo Xingren Tang syndrome. Wheezing with sweating is a Gegen Huanglian Tang syndrome. This clause describes wheezing due to fluid deficiency after sweating and excessive water intake, which is a Wuling San (Five-Ingredient Powder with Poria) syndrome. Wheezing from water pouring occurs because bodily cold exposure and cold drinks injure the Lung, forcing Qi upward, thus causing wheezing.
Shen Jin'ao's Note: In Han Dynasty medicine, besides herbal medication, water therapy and fire therapy were employed. "Pouring water on the body" is likely water therapy, though the specific method is unknown. Interpreting it as washing the skin, as Yu Chang suggested, is likely incomplete.
[General Principle] Zhang Zhongjing stated: In Cold Damage, if the exterior is unresolved and there is Water-Qi in the epigastrium, presenting with dry retching, fever, and cough, or thirst, or diarrhea, or choking sensation, or dysuria with hypogastric fullness, or wheezing, Xiao Qinglong Tang (Minor Blue Dragon Decoction) is the primary treatment. Modification rules: If wheezing is present, remove Mahuang and add Xingren (Apricot Kernel), removing the peel and tip.
In Cold Damage with Water-Qi in the epigastrium, presenting with cough and mild wheezing, fever, and absence of thirst, Xiao Qinglong Tang is the primary treatment. If thirst occurs after taking the decoction, it indicates the Cold is departing and the condition is resolving.
[Commentary] Zhu Gong stated: Mahuang primarily treats wheezing; why is it removed here? The answer is: This treats wheezing caused by Water-Qi in the epigastrium, where diaphoresis is inappropriate. Hence, Mahuang is removed.
Shen Jin'ao's Note: The wheezing in these two clauses is all due to Water-Qi in the epigastrium. Both Xiao Qinglong Tang and Xiao Chaihu Tang are pivot-regulating agents; thus, they both list optional symptoms (Huo Ran Zheng) and establish modification rules. Cough and wheezing are both caused by Water-Qi射 (shooting/invading) the Lung.
[General Principle] Zhang Zhongjing stated: Fixed staring, delirious speech, wheezing, and chest fullness indicate a fatal prognosis. Sweating with wet hair and ceaseless wheezing indicates Lung Qi exhaustion. Body sweat like oil and ceaseless wheezing indicates Life Fire exhaustion.
[Commentary] Cheng Wuji stated: These are all conditions where pathogenic factors are abundant internally, Righteous Qi is about to collapse, and Qi is congested and rebelling upward. They are all untreatable syndromes.