【纲】仲景曰。阳明病。下血。谵语者。此为热入血室。但头汗出者。刺期门。随其实而泻之。
然汗出则愈。
【目】朱肱曰。汗出谵语者。有燥屎也。过经乃可下也。下之早。语言必乱。以表实里虚故也。
病患表实里虚。元府不开。则阳气上出。汗见于头。凡头汗出者。五内干枯。胞中空虚。津液少
也。慎不可下。下之者。谓之重虚。然头汗出者。有数症。伤寒五六日头汗出。微恶寒。手足冷。
心下满。口不欲食。大便硬脉细者。此为阳微结。必有表复有里也。脉沉。亦有里也。汗出为阳微。
假令纯阴结。不得复有外症。悉入在里。此为半在里半在外也。脉虽沉紧。不得为少阴病。所以
然者。阴不得有汗。今头汗出。故知非少阴也。小柴胡汤主之。
伤寒五六日。已汗下。胸胁满。微结。小便不利。渴而不呕。但头汗出。往来寒热。心烦者。此
表未解。柴胡桂枝干姜汤。心下紧满。无大热。汗出者。茯苓汤。
刘完素曰。热入血室。或阳明被火。及水结胸。皆但头汗出。俱是热郁于内。而不得越者也。
此数者。或吐或下。皆欲除其热也。
朱震亨曰。血室。肝也。肝之热者。必移其热于心。遂令心气受伤。既不能主血。亦不能作汗。
故但头有汗而不能遍及于身也。
【纲】仲景曰。阳明病。下之。其外有热。手足温。不结胸。心中懊 。饥不能食。但头汗者。
栀子豉汤主之。
【目】朱肱曰。病患表实里虚。元府不开。则阳上出而头有汗也。
张介宾曰。头汗之症有二。一为热邪上壅。一为阳气内脱。盖头乃诸阳之会。凡伤寒遍身得汗。
谓之热越。若身无汗。则热不得越而上蒸阳分。故但头汗出也。治热蒸者。可清可散。甚者可下。
在去其热而病自愈。至气脱一症。则多以
妄下伤阴。或克伐太过。或泄泻不止。以致阴竭于下。则阳脱于上。小水不通。而止见头汗。则大
危矣。
头汗脉紧数。有表邪当散者。小柴胡汤。或柴胡桂枝干姜汤。若有火邪。脉洪滑。内多烦热。
头汗。当清者。人参白虎汤、益元散。若水结胸。心下满。头汗出者。大陷胸汤、小半夏茯苓汤。
若便结腹胀疼痛。头汗者。承气汤。若诸虚泄泻。阳脱头汗者。速用独参汤、大补元煎。急救之。
庶可保全。
鳌按。此是下后变症。但头汗出者。心火上炎也。
【纲】仲景曰。阳明病。发热汗出。此为热越。不能发黄也。但头汗出者。身无汗。齐颈而还。
腹满。小便不利。渴饮水浆。此为瘀热在里。身必发黄。茵陈蒿汤主之。
【目】许叔微曰。亦可用五苓散。
刘完素曰。头者。诸阳之会。邪搏诸阳。津液上凑。则汗见于头。邪热内蓄。蒸发腠理。遍身
汗者。为热越。身无汗。则热不得越。热蒸于阳。故但头汗出也。何者。以三阴经皆上至胸颈而还。
不循于头。独诸阳脉上循于头耳。故为热不得越而上达者也。
王好古曰。头汗出齐颈而还。血症也。额上遍多者。属心部。为血症也。独益中州脾土。以血
药治之。其法无以加矣。
王肯堂曰。头乃诸阳之会。热蒸于阳。故但头汗出也。三阴无头汗。其经不上头故也。遍身有汗
为热越。但头汗出。热上达也。如瘀热在里。身必发黄。及热入血室。与其虚烦。或阳明被火。及
水结胸数者。皆但头汗出。俱是热不得越。故或吐或下以除其热也。且邪但在表。则无头汗之症。
必也寒湿相搏。与邪在半表里。乃有头汗也。如伤寒五六日。已发汗而复下之。胸胁满。微结。小
便不利。渴而不呕。但头汗出。往来寒热。心烦。及伤寒五六日。头汗。微恶寒。手足冷。心下满。
口不欲食。大便硬。脉细者。此皆邪在表里两间。令头汗出也。湿家但头汗出。欲得被覆向火者。
寒湿相搏。故头
汗也。此皆不得谓之逆。然小便不利而成关格。若头汗者。阳脱也。经云。关格不通。不得尿。头
无汗者生。有汗者死。又湿家下后。头额汗出而微喘者。亦阳脱也。经曰。湿家下之。额上汗出。
小便不利者死。下利不止者亦死。二者乃头汗之逆。
陶华曰。诸阳经络循于头。头汗者。邪搏诸阳也。里虚则不可下。内涸则不宜汗。头汗症。不可再
汗也。谵语头汗。是为血热。属阳明。用承气汤。心中懊 而头汗。栀豉汤。
【纲】张仲景说：阳明病，出现下血、谵语的症状，这是热邪侵入血室。如果仅头部出汗，应针刺期门穴，根据其实证情况采用泻法。汗出之后，病即可痊愈。
【目】朱肱说：出汗且伴有谵语的，是有燥屎内结。必须等到经过一经（表证已解）之后才可攻下。如果攻下过早，语言必然错乱，这是因为表实里虚的缘故。
患者表实里虚，玄府（汗孔）不开，则阳气上逆外出，汗见于头部。凡是头部出汗的，都是五脏阴液干枯，胞宫空虚，津液不足。千万不可攻下，若强行攻下，称为“重虚”（使虚者更虚）。然而头部出汗的原因有多种：伤寒发病五六天，头部出汗，轻微恶寒，手足发冷，心下部胀满，口中不想进食，大便干硬，脉象细弱的，这叫做“阳微结”。必定既有表证又有里证。脉沉，说明也有里证。出汗是因为阳气微弱。假如是纯阴结，就不会再有外症，症状全部入里。这属于半在里半在表的情况。脉虽然沉紧，但不能诊断为少阴病。之所以这样，是因为阴证通常不出汗，现在头部出汗，所以知道不是少阴病。用小柴胡汤主治。
伤寒五六天，已经发汗或攻下后，胸胁部胀满，轻微痞结，小便不利，口渴但不呕吐，仅头部出汗，往来寒热，心烦的，这是表证未解，用柴胡桂枝干姜汤治疗。心下部拘急胀满，没有大热，有汗出的，用茯苓汤治疗。
刘完素说：热入血室，或者阳明病被误用火疗，以及水饮结于胸中，都表现为仅头部出汗。这些都是热邪郁结在内，而不能向外发散所致。这几类病症，或用吐法，或用下法，都是为了清除热邪。
朱震亨说：血室就是肝。肝有热邪，必然将热移传于心，导致心气受伤。心既不能主血，也不能化生汗液，所以只有头部出汗，而不能遍及全身。
【纲】张仲景说：阳明病，经过攻下治疗后，体表仍有发热，手足温暖，没有形成结胸，心中懊恼烦闷，饥饿却不想吃东西，仅头部出汗的，用栀子豉汤主治。
【目】朱肱说：患者表实里虚，玄府不开，则阳气上逆而出，导致头部出汗。
张介宾说：头部出汗的症状有两种原因：一是热邪上壅，二是阳气内脱。头是诸阳经汇聚的地方。凡伤寒病遍身出汗的，叫做“热越”（热邪随汗而散）。如果身体无汗，则热邪不得发散而上蒸于阳分，所以仅头部出汗。治疗热邪上蒸的，可以清热或疏散，严重的可以攻下，只要去除热邪，病自然痊愈。至于气脱这一症候，多因妄用攻下损伤阴液，或克伐太过，或泄泻不止，导致阴竭于下，则阳脱于上。小便不通，仅见头部出汗，这就非常危险了。
头部出汗且脉紧数，有表邪应当疏散的，用小柴胡汤，或柴胡桂枝干姜汤。如果有火邪，脉洪滑，体内多有烦热，头部出汗，应当清热的，用人参白虎汤、益元散。如果是水饮结于胸中，心下部胀满，头部出汗的，用大陷胸汤、小半夏茯苓汤。如果大便干结、腹胀疼痛，头部出汗的，用承气汤。如果是各种虚证导致的泄泻，阳气外脱引起的头部出汗，应迅速使用独参汤、大补元煎急救，才可以保全生命。
沈金鳌按：这是攻下后出现的变证。仅头部出汗，是心火上炎所致。
【纲】张仲景说：阳明病，发热出汗，这叫“热越”，不会发黄。如果仅头部出汗，身体无汗，汗止于颈部，腹部胀满，小便不利，口渴想喝水浆，这是瘀热在里，身体一定会发黄，用茵陈蒿汤主治。
【目】许叔微说：也可以用五苓散。
刘完素说：头是诸阳经汇聚的地方。邪气搏结于诸阳经，津液向上凑集，则汗见于头部。邪热内蓄，蒸发腠理，遍身出汗的，叫作“热越”。如果身体无汗，则热邪不得发散。热邪蒸腾于阳分，所以仅头部出汗。为什么呢？因为三阴经都上行至胸颈而回，不循行于头部，只有诸阳脉上行循行于头部。所以这是热邪不得发散而上达头部所致。
王好古说：头部出汗止于颈部，是血症。额头普遍多汗的，属于心部，也是血症。只需补益中焦脾土，用治血的药物治疗，这种方法就没有更好的了。
王肯堂说：头是诸阳经汇聚的地方，热邪蒸腾于阳分，所以仅头部出汗。三阴经没有头部出汗的症状，因为其经脉不上头。遍身出汗叫作“热越”，仅头部出汗，是热邪上达。如瘀热在里，身体必发黄；以及热入血室，与虚烦，或者阳明病被误用火疗，以及水饮结于胸中等几种情况，都表现为仅头部出汗，都是热邪不得发散，所以或用吐法或用下法以清除热邪。况且邪气仅在表，则不会有头部出汗的症状。必须是寒湿相搏，或邪气在半表半里，才会有头部出汗。如伤寒五六天，已经发汗又攻下，胸胁胀满，轻微痞结，小便不利，口渴但不呕吐，仅头部出汗，往来寒热，心烦；以及伤寒五六天，头部出汗，轻微恶寒，手足冷，心下部胀满，口中不想进食，大便干硬，脉细的，这都是邪气在表里之间，导致头部出汗。患湿病的人仅头部出汗，想要盖被子靠近火的，是寒湿相搏，所以头部出汗。这些都不能称为逆证。然而如果小便不利发展成关格，若头部出汗，则是阳气外脱。经书说：关格不通，不能排尿，头部无汗的能生，有汗的会死。另外，湿病患者攻下后，额头出汗且轻微喘息的，也是阳气外脱。经书说：湿病患者攻下后，额头出汗，小便不利的会死，腹泻不止的也会死。这两种情况是头部出汗的逆证。
陶华说：诸阳经络循行于头部，头部出汗，是邪气搏结于诸阳经。里虚则不可攻下，内部枯竭则不宜发汗。头部出汗的病症，不可再发汗。谵语且头部出汗，是血热，属阳明病，用承气汤。心中懊恼且头部出汗，用栀子豉汤。
[General Principle] Zhang Zhongjing stated: In Yangming disease, if there is bleeding from the lower orifice and delirium, this indicates that heat has entered the Blood Chamber (a concept related to the uterus and liver meridian in gynecological and general pathology). If only the head sweats, puncture the Qimen (LR14) acupoint. Follow its excess condition and apply the reducing method. Once sweating occurs, the disease will be cured.
[Detailed Discussion] Zhu Gong stated: When sweating is accompanied by delirium, it indicates the presence of dry stool accumulation. Purging can only be performed after the pathogen has passed through a meridian stage (i.e., when the exterior syndrome has resolved). If purging is done too early, speech will become chaotic because the exterior is excess while the interior is deficient.
When patients have an excess exterior and deficient interior, and the Yuan Fu (pores) are not open, Yang Qi ascends and exits outward, resulting in sweat on the head. In cases of head sweating alone, the five Zang organs are dried up, the Bao Palace (uterus/womb area) is empty, and body fluids are scant. One must absolutely avoid purging; doing so is called "double deficiency" (aggravating the deficiency of the deficient). However, head sweating arises from several conditions: In cold damage occurring on the fifth or sixth day, with head sweating, slight aversion to cold, cold hands and feet, fullness in the epigastrium, lack of desire to eat, hard stools, and a fine pulse, this is termed "Yang Wei Jie" (slight Yang binding). There is both an exterior and an interior component. A deep pulse also indicates an interior condition. Sweating indicates weak Yang. If it were a pure Yin binding, there would be no exterior symptoms, and all signs would be interior. This represents a condition half in the interior and half in the exterior. Although the pulse may be deep and tight, it cannot be diagnosed as Shaoyin disease. The reason is that Yin syndromes typically do not present with sweating; since there is head sweating, we know it is not Shaoyin. Xiao Chai Hu Tang (Minor Bupleurum Decoction) should be used.
In cold damage on the fifth or sixth day, after already having been treated with sweating or purging methods, if there is fullness in the chest and hypochondrium, slight binding, difficulty in urination, thirst without vomiting, only head sweating, alternating chills and fever, and irritability, this indicates the exterior syndrome has not yet resolved. Chai Hu Gui Zhi Gan Jiang Tang (Bupleurum, Cinnamon Twig, and Dried Ginger Decoction) should be used. If there is tight fullness in the epigastrium, no significant heat, and sweating, Fu Ling Tang (Poria Decoction) should be used.
Liu Wansu stated: Heat entering the Blood Chamber, Yangming disease treated with fire therapy, and water retention in the chest all present with only head sweating. These are all cases where heat is constrained internally and cannot vent outward. For these conditions, either emesis or purging is used to eliminate the heat.
Zhu Zhenheng stated: The Blood Chamber refers to the Liver. Heat in the Liver inevitably transfers to the Heart, injuring Heart Qi. Since the Heart governs blood and transforms sweat, once injured, it cannot govern blood nor produce sweat throughout the body, resulting in sweat only on the head and not covering the whole body.
[General Principle] Zhang Zhongjing stated: In Yangming disease, after purging, if there is heat on the exterior, warm hands and feet, no formation of Jie Xiong (Chest Binding), mental restlessness (Ao Nu), hunger but inability to eat, and only head sweating, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should be be used.
[Detailed Discussion] Zhu Gong stated: When patients have an excess exterior and deficient interior, and the Yuan Fu (pores) are not open, Yang Qi ascends outward, resulting in sweat on the head.
Zhang Jingyue stated: There are two types of head sweating: one is caused by heat evil obstructing upwards, and the other is due to internal collapse of Yang Qi. The head is the meeting point of all Yang meridians. In cold damage, if the whole body sweats, it is called "Re Yue" (Heat Venting), meaning heat dissipates with sweat. If the body does not sweat, heat cannot vent and steams upward into the Yang regions, causing only head sweating. For heat steaming upward, treatment involves clearing or dispersing heat; for severe cases, purging may be used. Once the heat is removed, the disease resolves spontaneously. Regarding Qi collapse, it is often caused by reckless purging damaging Yin, excessive attacking tonification, or persistent diarrhea, leading to exhaustion of Yin below and collapse of Yang above. With obstruction of urination and only head sweating present, the condition is critical.
If head sweating is accompanied by a tight and rapid pulse, indicating exterior pathogens that should be dispersed, use Xiao Chai Hu Tang or Chai Hu Gui Zhi Gan Jiang Tang. If there is Fire Evil, with a surging and slippery pulse, internal irritability and heat, and head sweating, use Ren Shen Bai Hu Tang (Ginseng and White Tiger Decoction) or Yi Yuan San (Benefit Origin Powder) to clear heat. If water retention in the chest causes epigastric fullness and head sweating, use Da Xian Xiong Tang (Major Sinking into the Chest Decoction) or Xiao Ban Xia Fu Ling Tang (Minor Pinellia and Poria Decoction). If constipation, abdominal distension, and pain accompany head sweating, use Cheng Qi Tang (Order the Qi Decoction). If various deficiencies cause diarrhea and Yang collapse leads to head sweating, urgently use Du Shen Tang (Single Ginseng Decoction) or Da Bu Yuan Jian (Great Tonify Origin Decoction) for emergency rescue to preserve life.
Shen Jin'ao commented: This is a complication after purging. Head sweating alone indicates Heart Fire flaming upward.
[General Principle] Zhang Zhongjing stated: In Yangming disease, fever with sweating indicates "Re Yue" (Heat Venting), so jaundice will not develop. If only the head sweats, the body has no sweat, the sweat stops at the neck, there is abdominal fullness, difficulty in urination, and thirst for drinking fluids, this indicates Stagnant Heat in the interior. Jaundice will definitely develop. Yin Chen Hao Tang (Artemisia Capillaris Decoction) should be used.
[Detailed Discussion] Xu Shumi stated: Wu Ling San (Five Ingredient Powder with Poria) can also be used.
Liu Wansu stated: The head is the meeting point of all Yang meridians. When pathogens contend with the Yang meridians, body fluids gather upward, resulting in head sweating. When pathogenic heat accumulates internally and evaporates the Cou Li (skin and muscle interstices), causing whole-body sweating, it is called "Re Yue." If the body does not sweat, heat cannot vent. Heat steams into the Yang, causing only head sweating. Why? Because the Three Yin meridians ascend only to the chest and neck and return, not circulating to the head. Only the Yang meridians ascend to the head. Thus, this is heat unable to vent, reaching upward instead.
Wang Haogu stated: Head sweating stopping at the neck indicates a Blood disorder. Sweating profusely on the forehead belongs to the Heart region and is also a Blood disorder. One should solely benefit the Middle Jiao Spleen Earth and treat with blood-invigorating herbs; there is no better method.
Wang Kentang stated: The head is the meeting point of all Yang meridians; heat steams into the Yang, causing only head sweating. The Three Yin meridians do not cause head sweating because their channels do not ascend to the head. Whole-body sweating is "Re Yue"; head-only sweating indicates heat ascending. Examples include stagnant heat in the interior leading to jaundice, heat entering the Blood Chamber, mental restlessness, Yangming disease treated with fire, and water retention in the chest. All these present with only head sweating because heat cannot vent. Therefore, emesis or purging is used to remove heat. If the pathogen is only in the exterior, there is no head sweating. Head sweating occurs only when Cold-Dampness contends with each other or when the pathogen is at the Half-Exterior/Half-Interior level. For instance, in cold damage on the fifth or sixth day, after sweating and purging, with chest/hypochondriac fullness, slight binding, urinary difficulty, thirst without vomiting, head sweating, alternating chills/fever, and irritability; or on the fifth/sixth day, with head sweating, slight aversion to cold, cold extremities, epigastric fullness, lack of desire to eat, hard stools, and fine pulse—these are all pathogens between the exterior and interior causing head sweating. Patients with Dampness who only sweat on the head and desire warmth/covering are experiencing Cold-Damp contention, hence head sweating. These are not considered adverse reversals. However, if urinary difficulty progresses to Guan Ge (Obstruction and Reversal), and head sweating occurs, it indicates Yang collapse. The Classics state: In Guan Ge with no urine and no head sweat, survival is possible; with head sweat, death ensues. Furthermore, after purging a Dampness patient, if forehead sweating occurs with slight wheezing, it is also Yang collapse. The Classics state: Purging a Dampness patient leading to forehead sweating and urinary difficulty results in death; persistent diarrhea also results in death. These two scenarios are adverse reversals of head sweating.
Tao Hua stated: Yang meridians circulate to the head; head sweating indicates pathogens contending with Yang meridians. Interior deficiency precludes purging; internal depletion precludes sweating. Head sweating syndromes should not be treated with further sweating methods. Delirium with head sweating indicates Blood Heat in Yangming, treated with Cheng Qi Tang. Mental restlessness with head sweating is treated with Zhi Zi Chi Tang.