【纲】仲景曰。病发于阳。而反下之。热入。因作结胸。若不结胸。但头汗出。余无汗。至颈
而还。小便不利。身必发黄也。
【目】苏颂曰。小便不利有数种。有因被下者。津液耗于内也。有因汗者。津液亡于外也。有
因发黄与痞及热病者。热郁所致。风湿相搏。与夫阳明中风。其小便不利。寒邪所乘。其小便难者。
亦多由汗下而然。宜详辨之。
鳌按。湿郁发热。能下行则便利。即内亦解。若小便不利。则湿热内蒸于脏腑者。因黄色外见
于皮肤。而发黄矣。
【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。
【目】陶华曰。小便不利者。邪气聚于下焦。结而不散。甚则小腹硬满而痛。此小便所以不通
也。大抵有所不利者。行之有所渗泄也。若饮水过多。下焦蓄热。或中湿发黄。水饮停留。皆以利
小便为先。惟汗后亡津液。胃汁干。与阳明汗多者。则以利小便为戒。设或小便不利。而见头汗出
者。乃为阳脱关格之疾矣。
鳌按。水气留而不行。故小便不利。小便不利。故少腹满。此条言小便不利。正欲明少腹满之
故也。
【纲】仲景曰。太阳病。发汗后。若脉浮。小便不利。微热消渴者。五苓散主之。太阳病。饮
水多。小便利者。必心下悸。小便少者。必苦里急也。
【目】柯琴曰。发汗后。脉仍浮。而微热犹在表。未尽除也。虽不烦而渴特甚。饮多即消。小
便不利。水气未散也。便利便少。双顶饮水多。火用不宣。致水停心下而悸。水用不宣。致水结膀
胱而里急也。
【纲】仲景曰。本以下之。故心下痞。与泻心汤。痞不解。其人渴而口躁烦。小便不利者。五
苓散主之。大下之后。复发汗。小便不利者。亡津液故也。勿治之。得小便利。必自愈。
【目】鳌按。与泻心汤而痞仍不解。小便仍不利。心下之水气。停结甚矣。
【纲】仲景曰。太阳病。身黄。脉沉结。少腹硬。小便不利者。为无血也。小便自利。其人如
狂者。血结症也。抵当汤主之。
【目】吴绶曰。凡伤寒小便不利。当分六经治之。固已。若阴虚火动。小便赤涩不利者。加知、
柏、木通、生地。凡内热盛。大便不通。小便赤涩不利者。八正散治之。凡不渴。小便不利者。
热在血分也。宜知、柏、生地之类。夫膀胱为津液之府。气化而能出也。若汗多者。津液外泄。小
便因少。不可利之。恐重亡津液。待汗止。小便自行。又小便自利。亦不可妄利之。恐引热入膀胱。
则变蓄血。又为害也。
【纲】仲景曰。风湿为病。脉阴阳俱浮。自汗出。身重。多眠睡。鼻息必鼾。语言难出。若被
下者。小便不利。直视失溲。若被火
者。微发黄色。剧则如惊痫。时螈 。
风湿相搏。骨节烦疼。掣痛。不得屈伸。近之则痛剧。汗出短气。小便不利。恶风不欲去衣。
或身微肿者。甘草附子汤主之。
【目】鳌按。下则大便利。故小便反不利。何者。以肺家之化源不清。胃家之关门不启也。
【纲】仲景曰。太阳病。发汗。遂漏不止。其人恶风。小便难。四肢拘急。难以屈伸者。桂枝
加附子汤主之。
【目】朱肱曰。伤寒发汗后。汗出多。亡津液。胃中干。故小便不利。医见不利。往往利之。
误矣。伤寒有不利者。行之。取其渗泄也。有渴而停饮者。有躁而烦渴。有病气去而水气不得行者。
其表里得见。烦躁口燥。欲饮水。水入即吐。病名水逆。及霍乱头痛发热。身疼痛。欲饮水者。有
发热汗出。复恶寒。不呕。但心下痞者。并宜五苓散。
问。小便难。何也。曰。阴虚故也。阴虚者。阳必凑之。为阳所凑也。故小便黄者。中有热也。
宜滑石、瞿麦辈泻之。
赵嗣真曰。伤寒小便难。仲景论有发汗漏不止。桂枝加附子汤者。有阳明中风。或脉浮弦大而
潮热哕者。或脉浮而紧。误下而成腹满者。又有阳明脉浮迟。饱则微烦头眩者。活人问中。当以传
经邪热。与漏风亡阳。分作两条。其桂枝加附子汤。乃亡阳经虚所致。岂得均谓之阴虚阳凑。为有
热耶。要当以阳明小柴胡症。及误下症。谷疸症。次于阳凑传邪之下。却别出一条云。外有汗多亡
阳。津液不足。亦有小便难者。还以桂枝加附子症属之。若太阳中风。以火劫发汗。则邪风被火热。
血气流溢。身黄。阳盛阴虚。欲衄。小便难也。若少阴以火劫汗者。则咳而下利。谵语。小便难也。
若下后小便难有二。一、脉浮迟弱。恶风寒。下之者。则胁满身黄项强。小便难。一、阳明胃实。
发热恶寒。脉浮紧。下之者。则腹满。小便难。
【纲】张仲景说：疾病起始于阳证（指表热证），却错误地使用了攻下法，导致邪热内陷，从而形成结胸证。如果不形成结胸，仅见头部出汗，身体其他部位无汗，汗液止于颈部，小便不通畅，身体必然会出现发黄的症状。
【目】苏颂说：小便不通畅有多种情况。有的是因为误用攻下法，导致体内津液耗损；有的是因为过度发汗，导致体表津液亡失；有的是因为发黄病、痞证或热病，由热邪郁结所致；有的是风湿相互搏结，以及阳明中风，因寒邪侵袭所致的小便不利；还有因发汗或攻下导致的小便困难。这些情况应当仔细辨别。
沈金鳌按语：湿热郁滞发热，如果湿热能向下排泄则二便通畅，体内的郁结自然解除。如果小便不通畅，湿热在脏腑内部蒸腾，就会表现为皮肤发黄，即出现黄疸。
【纲】张仲景说：伤寒表证未解，心下有停饮（水气），出现干呕、发热且咳嗽，或者口渴，或者腹泻，或者咽喉噎塞感，或者小便不通畅伴小腹胀满，或者气喘的，用小青龙汤主治。
【目】陶华说：小便不通畅，是邪气聚集在下焦，凝结而不散，严重时小腹部硬满且疼痛，这就是小便不通的原因。大抵来说，凡是小便不利的，需要通过通利的方法使其渗泄排出。如果饮水过多，导致下焦蓄积热邪，或者中湿发黄，水饮停留，都应当以通利小便为先。只有在发汗后津液亡失、胃中津液干枯，以及阳明病发汗过多的情况下，才禁止使用利小便的方法。假如小便不通畅，却出现头部出汗，这是阳气外脱、阴阳格拒的重症。
沈金鳌按语：水气停留而不能运行，所以小便不通畅；小便不通畅，所以小腹胀满。这一条论述小便不通畅，正是为了阐明小腹胀满的原因。
【纲】张仲景说：太阳病，发汗之后，如果脉象仍浮，小便不通畅，微热且消渴（口渴多饮），用五苓散主治。太阳病，如果饮水过多，小便通畅的，必定会出现心下悸动；如果小便量少，必定会感到小腹急迫难受。
【目】柯琴说：发汗后，脉象仍然浮，微热仍在体表，说明表邪未尽除。虽然心中不烦躁，但口渴特别严重，喝水后立即消耗，小便不通畅，说明水气尚未消散。如果小便通畅或量少，都是针对饮水过多的情况。火（阳热）功能不能宣通，导致水停聚在心下而引起心悸；水（阴液）功能不能宣通，导致水结聚在膀胱而引起小腹急迫。
【纲】张仲景说：本来是因为误用攻下法，导致心下痞满，给予泻心汤治疗后，痞满仍未解除，病人出现口渴、口燥心烦、小便不通畅的，用五苓散主治。经过剧烈攻下之后，又再次发汗，导致小便不通畅的，是因为津液亡失的缘故。不要强行治疗，待小便自然通畅，病必自愈。
【目】沈金鳌按语：给予泻心汤而痞满仍不解除，小便仍不通畅，说明心下的水气停聚结滞非常严重。
【纲】张仲景说：太阳病，身体发黄，脉象沉涩，小腹部硬满，小便不通畅的，属于无瘀血（为湿热发黄）；如果小便自通，病人神志如狂的，属于瘀血结聚的证候，用抵当汤主治。
【目】吴绶说：凡是伤寒病中出现小便不通畅，应当分六经进行治疗，这已经是定论。如果是阴虚火旺，小便赤涩不通畅的，加用知母、黄柏、木通、生地黄。凡是体内热盛，大便不通，小便赤涩不通畅的，用八正散治疗。凡是口不渴，小便不通畅的，说明热在血分，宜用知母、黄柏、生地黄之类。膀胱是津液之府，依靠气化作用才能排出尿液。如果发汗过多，津液从体表外泄，小便因此减少，不可使用利小便的药物，恐怕进一步亡失津液，等待汗止，小便自然会恢复。另外，如果小便自通，也不可妄用利小便药，恐怕引热进入膀胱，从而变为蓄血证，这也是危害。
【纲】张仲景说：风湿致病，脉象寸关尺俱浮，自汗出，身体沉重，嗜睡，呼吸必有鼾声，语言困难。如果误用攻下法，会导致小便不通畅，两眼直视，大小便失禁。如果误用火疗，轻微的发黄色，严重的如同惊痫发作，时时抽搐。
风湿相互搏结，骨节烦痛，牵引作痛，不能屈伸，触碰则疼痛加剧，汗出短气，小便不通畅，怕风不想穿衣，或者身体轻微浮肿的，用甘草附子汤主治。
【目】沈金鳌按语：误用攻下法通常导致大便通畅，所以反而出现小便不通畅。为什么呢？因为肺的化源不清，胃的关门不开启所致。
【纲】张仲景说：太阳病，发汗后，汗漏出不止，病人怕风，小便困难，四肢拘挛紧急，难以屈伸的，用桂枝加附子汤主治。
【目】朱肱说：伤寒发汗后，汗出过多，亡失津液，胃中干燥，所以小便不通畅。医生见到小便不利，往往使用利小便药，这是错误的。伤寒中有小便不利的，是通过通利方法取其渗泄作用。有的因口渴而停饮，有的因躁动烦渴，有的因病邪已去而水气不能运行。其表里症状显现，烦躁口燥，想喝水，水入即吐，病名水逆。以及霍乱头痛发热，身体疼痛，想喝水的，有发热汗出，又恶寒，不呕吐，只是心下痞满的，都适宜用五苓散。
问：什么是小便难？答：是阴虚的缘故。阴虚则阳必凑集于内，被阳热所凑集，所以小便黄的，说明内有热。宜用滑石、瞿麦等药泻热。
赵嗣真说：伤寒小便难，张仲景的论述中有发汗漏不止，用桂枝加附子汤的情况；有阳明中风，或脉浮弦大而潮热哕逆的；或脉浮紧，误下而成腹满的；又有阳明脉浮迟，饱食后微烦头眩的。《活人书》问答中，应当将传经邪热与漏汗亡阳分为两条。桂枝加附子汤，乃是亡阳、经虚所致，怎么能都称为阴虚阳凑而有热呢？应当将阳明小柴胡证及误下证、谷疸证，列在阳凑传邪之下，另外单独列出一条说：外有汗多亡阳，津液不足，也有小便难的，仍将桂枝加附子汤证归属于此类。如果是太阳中风，用火劫法发汗，则邪风被火热逼迫，血气流溢，身体发黄，阳盛阴虚，想要鼻衄，小便难。如果是少阴病用火劫汗法，则咳嗽而下利，谵语，小便难。如果是攻下后小便难有两种情况：一是脉浮迟弱，恶风寒，误用攻下法，则胁满、身黄、项强、小便难；二是阳明胃实，发热恶寒，脉浮紧，误用攻下法，则腹满、小便难。
[Outline] Zhang Zhongjing stated: When a disease originates from a Yang syndrome (exterior-heat syndrome) but is erroneously treated with purgation, the pathogenic heat enters inward, resulting in Jie Xiong (chest binding). If Jie Xiong does not form, but there is only sweating on the head and no sweating elsewhere, stopping at the neck, accompanied by difficulty in urination, the body will inevitably develop jaundice.
[Commentary] Su Song stated: There are several types of difficulty in urination. Some result from erroneous purgation, depleting fluids internally; some from excessive sweating, losing fluids externally; some from jaundice, Pi (fullness obstructing), or febrile diseases, caused by heat stagnation; some from wind-dampness battling each other, or Yangming wind-stroke, where cold pathogens invade causing difficulty in urination; others arise from sweating or purgation leading to difficult urination. These must be carefully differentiated.
Shen Jin'ao's note: Damp-heat stagnation causing fever can resolve downward through free passage of stool and urine, thereby resolving internal stagnation. If urination is difficult, damp-heat steams internally within the zang-fu organs, manifesting externally as yellow skin, resulting in jaundice.
[Outline] Zhang Zhongjing stated: In Taiyang disease (Taiyang syndrome), if the exterior pattern is unresolved and there is fluid retention in the epigastrium (water qi), presenting with dry heaving, fever, and cough, or thirst, or diarrhea, or dysphagia, or difficulty in urination with lower abdominal fullness, or wheezing, Xiao Qing Long Tang (Minor Blue Dragon Decoction) is indicated.
[Commentary] Tao Hua stated: Difficulty in urination occurs when pathogenic factors gather in the Lower Jiao (Lower Burner), knotting without dispersing. Severe cases present with hardness, fullness, and pain in the lower abdomen, which is why urination is blocked. Generally, for any obstruction, one should promote its flow and excretion via diuresis. However, if excessive water intake leads to heat accumulation in the Lower Jiao, or if dampness causes jaundice with fluid retention, promoting urination is the priority. Conversely, after sweating that depletes fluids, leaving stomach juices dry, or in Yangming syndrome with excessive sweating, diuretics are contraindicated. If difficulty in urination is accompanied by head sweating alone, it indicates Yang collapse and Gan Ge (rebellion and blockage) syndrome.
Shen Jin'ao's note: Fluid retention prevents movement, causing difficulty in urination; difficulty in urination leads to lower abdominal fullness. This section discusses difficulty in urination specifically to explain the cause of lower abdominal fullness.
[Outline] Zhang Zhongjing stated: In Taiyang disease, after sweating, if the pulse remains floating, there is difficulty in urination, slight fever, and Xiao Ke (wasting-thirst/excessive thirst), Wu Ling San (Five-Ingredient Powder with Poria) is indicated. In Taiyang disease, if one drinks excessively and urination is normal, palpitations in the epigastrium will occur; if urination is scanty, there will be distressing urgency in the interior.
[Commentary] Ke Qin stated: After sweating, if the pulse remains floating and slight fever persists at the exterior, the pathogen is not fully resolved. Although there is no irritability, thirst is severe, and ingested water is quickly consumed. Difficulty in urination indicates that water qi has not dispersed. Whether urination is frequent or scanty relates to excessive water intake. If Fire (Yang heat) function fails to disseminate, water stops in the epigastrium causing palpitations; if Water (Yin fluid) function fails to disseminate, water knots in the Bladder causing interior urgency.
[Outline] Zhang Zhongjing stated: Originally due to erroneous purgation, Pi (epigastric fullness) resulted. After administering Xie Xin Tang (Drain the Epigastrium Decoctions), if Pi persists, and the patient presents with thirst, dry mouth, irritability, and difficulty in urination, Wu Ling San (Five-Ingredient Powder with Poria) is indicated. After severe purgation followed by sweating, if difficulty in urination occurs, it is due to fluid depletion. Do not treat it directly; once urination becomes free, the condition will heal spontaneously.
[Commentary] Shen Jin'ao's note: If Pi persists after taking Xie Xin Tang and urination remains difficult, it indicates severe stagnation and knotting of water qi in the epigastrium.
[Outline] Zhang Zhongjing stated: In Taiyang disease, if the body is yellow, the pulse is deep and choppy, the lower abdomen is hard, and urination is difficult, this indicates no blood stasis (it is damp-heat jaundice). If urination is spontaneous and the patient behaves like a maniac, this is blood stasis syndrome, treated with Di Dang Tang (Di Dang Decoction).
[Commentary] Wu Shou stated: In all cases of Taiyang disease with difficulty in urination, treatment should be differentiated by the Six Channels. For Yin deficiency with fire hyperactivity causing red, scanty, and difficult urination, add Zhi Mu (Anemarrhenae Rhizoma), Huang Bo (Phellodendri Cortex), Mu Tong (Akebiae Caulis), and Sheng Di Huang (Rehmanniae Radix). For excess internal heat with constipation and red, scanty, difficult urination, Ba Zheng San (Eight-Herb Powder for Rectification) is used. For those without thirst and with difficulty in urination, the heat is in the Blood level; use Zhi Mu, Huang Bo, Sheng Di Huang, etc. The Bladder is the mansion of fluids, relying on Qi transformation to excrete them. If sweating is excessive, fluids leak outward, reducing urination; do not use diuretics, lest fluids be further depleted. Wait for sweating to stop, and urination will normalize. Also, if urination is spontaneous, do not recklessly use diuretics, lest heat be drawn into the Bladder, transforming into blood stasis, which is harmful.
[Outline] Zhang Zhongjing stated: In Wind-Damp disease, the pulse is floating at the Cun, Guan, and Chi positions bilaterally, with spontaneous sweating, heaviness of the body, somnolence, snoring during respiration, and difficulty speaking. If erroneously purged, it leads to difficulty in urination, fixed staring, and incontinence of urine and feces. If erroneously treated with fire therapy, mild cases present with yellowish discoloration; severe cases resemble convulsive epilepsy with occasional spasms.
When wind and dampness battle each other, causing painful joints, pulling pain, inability to flex or extend, exacerbated by touch, with sweating, shortness of breath, difficulty in urination, aversion to wind, reluctance to remove clothing, or slight edema, Gan Cao Fu Zi Tang (Licorice and Aconite Decoction) is indicated.
[Commentary] Shen Jin'ao's note: Purging usually promotes bowel movement, so urination may paradoxically become difficult. Why? Because the source of transformation in the Lung is unclear, and the gate of the Stomach fails to open.
[Outline] Zhang Zhongjing stated: In Taiyang disease, after sweating, if sweating continues unceasingly (leaking), the patient feels aversion to wind, has difficulty in urination, spasm and stiffness of the four limbs, and difficulty in flexion and extension, Gui Zhi Jia Fu Zi Tang (Cinnamon Twig Decoction plus Aconite) is indicated.
[Commentary] Zhu Gong stated: After sweating in Taiyang disease, if sweating is excessive and fluids are depleted, the Stomach becomes dry, causing difficulty in urination. Physicians often see difficulty in urination and prescribe diuretics, which is an error. In Taiyang disease, difficulty in urination may require promoting flow for excretion. Cases include thirst with fluid retention, restlessness with irritability and thirst, or pathogen departure with retained water qi. Manifestations include irritability, dry mouth, desire to drink, vomiting immediately after drinking (Water Reversal syndrome); Huoluan with headache, fever, body pain, desire to drink; fever with sweating, recurrence of chills, no vomiting, but epigastric fullness. All these are suitable for Wu Ling San (Five-Ingredient Powder with Poria).
Question: What is difficult urination? Answer: It is due to Yin deficiency. Yin deficiency allows Yang to crowd in. Affected by Yang, the urine becomes yellow, indicating internal heat. Use Shi Gao (Gypsum Fibrosum), Qu Mai (Dianthi Herba), etc., to drain heat.
Zhao Sizhen stated: Regarding difficult urination in Taiyang disease, Zhang Zhongjing mentions cases of leaking sweat after sweating, treated with Gui Zhi Jia Fu Zi Tang (Cinnamon Twig Decoction plus Aconite); Yangming wind-stroke with floating, wiry, large pulse, tidal fever, and hiccups; or floating, tight pulse with abdominal fullness after erroneous purgation; and Yangming with floating, slow pulse, slight irritability, and dizziness after fullness. The *Huo Ren Shu* questions should distinguish between transmitted pathogenic heat and Yang collapse from leaking sweat. Gui Zhi Jia Fu Zi Tang results from Yang collapse and channel deficiency, not merely Yin deficiency with Yang crowding and heat. One should list Yangming Xiao Chai Hu Tang patterns, erroneous purgation patterns, and Grain Jaundice patterns under Yang crowding and transmitted pathogen, then separately state: External excessive sweating causing Yang collapse and fluid insufficiency also leads to difficult urination, attributing this to Gui Zhi Jia Fu Zi Tang patterns. If Taiyang wind-stroke is treated with fire coercion to sweat, pathogenic wind combines with fire, blood and qi overflow, causing yellow body, excess Yang and deficient Yin, desire for nosebleed, and difficult urination. If Shaoyin is treated with fire coercion to sweat, it causes cough, diarrhea, delirium, and difficult urination. There are two types of difficult urination after purgation: 1. Floating, slow, weak pulse with aversion to wind and cold; erroneous purgation leads to hypochondriac fullness, yellow body, stiff neck, and difficult urination. 2. Yangming Stomach excess with fever, aversion to cold, floating, tight pulse; erroneous purgation leads to abdominal fullness and difficult urination.