〔成〕外台云。里和表病。汗之则愈。
案此条。方氏以降诸家。并为中风证。似非经旨。只柯琴志聪锡驹注。与程意同。
伤寒脉浮紧。不发汗因致衄者。麻黄汤主之。
〔鉴〕伤寒脉浮紧。法当发汗。若不发汗。是失汗也。失汗则热郁于营。因而致衄者。宜麻黄汤主之。若
能于未衄之先。早用麻黄汤汗之。汗出则解。必不致衄。其或如前条之自衄而解。亦无须乎药也。〔程〕大抵
伤寒见衄者。由其人营分素热。一被寒闭。营不堪遏。从而上升矣。〔王〕夺血者无汗。既致衄。不可轻用麻
黄汤。须审之又审。点滴不成流者。可也。
活人书云。衄家不可发汗。汗出额上陷。脉紧急直视不能瞬。不能眠。然而无汗而衄。脉尚浮紧者。须
与麻黄汤。脉已微者。不可发汗。黄芩芍药汤。犀角地黄汤。
江 名医类案云。陶尚文治一人伤寒四五日。吐血不止。医以犀角地黄汤等治。而反剧。陶切其脉。浮
紧而数。若不汗出。邪何由解。遂用麻黄汤。一服汗出而愈。或问。仲景
言衄家不可汗。亡血家不可发汗。而此用麻黄汤。何也。 曰。久衄之家。亡血已多。故不可汗。今缘当汗不
汗。热毒蕴结。而成吐血。当分其津液乃愈。故仲景又曰。伤寒脉浮紧。不发汗。因致衄血者。麻黄汤主之。
盖发其汗。则热越而出。血自止也。
案柯本。此条。作伤寒脉浮紧者。麻黄汤主之。不发汗。因致衄。注云。不发汗。阳气内扰。阳络伤则
衄血。是夺血者无汗也。若用麻黄汤再汗。液脱则毙矣。言不发汗因致衄。岂有因致衄。更发汗之理乎。愚故
亟为校正。恐误人者多耳。此执泥之说。难从矣。
伤寒不大便六七日。头痛有热者。与承气汤。其小便清者。（【原注】一云。大便青。）知不在里。仍
在表也。当须发汗。若头痛者必衄。宜桂枝汤。（玉函。作未可与承气汤。是。其小便清者。玉函。外台。并
作小便反清。脉经。千金翼。作大便反青。柯本。大便圊。知。玉函。脉经。千金翼。作此为二字。王肯堂校
本千金翼。有热。作身热。热下。有小便赤三字。其小便清。作若小便利。）
〔成〕不大便六七日。头痛有热者。故宜当下。若小便清者。知里无热。则不可下。经曰。小便数者。大
便必硬。不更衣十日无所苦也。况此不大便六七日。小便清者。不可责邪在里。是仍在表也。与桂枝汤以解外。
若头疼不已。为表不罢。郁甚于经。迫血妄行。上为衄也。〔程〕欲攻里。则有头痛之表证可疑。欲解表。则
有不大便之里证可疑。表里之间。何从辨之。以热辨之而已。热之有无。何从辨之。以小便辨之而已。有热者。
小便必短赤。热已入里。头痛只属热壅。可以攻里。其小便清者。无热可知。热未入里。不大便只属风秘。仍
须发汗。〔汪〕若头痛不已者。为风寒之邪上壅。热甚于经。势必致衄。须乘其未衄之时。宜用桂枝汤。以汗
解之。〔周〕此因发汗之后。不得再用麻黄也。〔魏〕此条之衄。意料之辞。非已见之证。用桂枝汤则可不衄而
解。与用麻黄汤一条亦有别。
伤寒选录云。丹溪曰。谨案外证未解不可下。下为逆。今头痛有热。宜解表。反与承气。正是责其妄下之
过也。故下文又言小便清者。知其无里邪。不当行承气。又继之曰。当须发汗。曰头痛必衄血。宜桂枝汤。反
复告戒。论意甚明。而注反直曰。故当宜下。想因六七日不大便尔。虽不大便。他无所苦。候表解然后攻之。
正仲景法也。注意似未莹。○案此说。与玉函符矣。
伤寒类方云。伤寒不大便六七日。宜下之候。头痛有热者。未可与承气汤。太阳症仍在。不得以日久不便
而下也。案未可二字。从金匮增入。伤寒论失此二字。○案徐氏注解近是。故表而出焉。又案张志聪。发汗用
麻黄汤。柯氏改小便清。作大便圊。并非也。
伤寒发汗已解。半日许复烦。脉浮数者。可更发汗。宜桂枝汤。（玉函。脉经。千金翼。脉上。有其字。
可更发汗。玉函。作与复发汗。脉经。千金翼。作可复发其汗。成本。无已字。汤下。有主之二字。）
〔成〕烦者。热也。发汗身凉为已解。至半日许。身复热。脉浮数者。邪不尽也。可更发汗。与桂枝汤。
〔鉴〕伤寒服麻黄汤发汗。汗出已热退。身凉解。半日许。复烦热而脉浮数者。是表邪未尽。退而复集也。
可更发汗。其不用麻黄汤者。以其津液。前已为发汗所伤。不堪再任麻黄。故宜桂枝更汗可也。
案方氏喻氏辈。并云伤寒已解。复伤风邪。且以更为改之义。非是。更。再也。玉函作复。其意可见耳。
凡病若发汗。若吐。若下。若亡血。亡津液。阴阳自和
者。必自愈。（成本。无亡血二字。玉函。脉经。亡津液。作无津液。液下。有而字。）
〔锡〕此论汗吐下三法。不可误用也。盖汗吐下三法。皆所以亡血亡津液者也。用之不当。不惟亡血亡津
液。而亡阴亡阳也。用之得宜。虽亡血亡津液。而亦能和阴和阳也。故曰阴阳自和者。必自愈。〔鉴〕凡病。
谓不论中风伤寒。一切病也。其邪正皆衰。可不必施治。惟当静以俟之。
案程氏柯氏汪氏。并谓用生津益血之剂。则阴阳自和。而病自愈。此不必矣。今审察原文语意。自和自愈
两自字。分明不假药力。可以见耳。方氏志聪金鉴。以阴阳。为脉之阴阳。此必不然。盖亡血则亡阴。亡津液
则亡阳。阴阳。即指气血而言也。
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。（玉函。脉经。千金翼。汗下。
有其人二字。得。作其。）
〔成〕因亡津液。而小便不利者。不可以药利之。俟津液足小便利。必自愈也。〔汪〕先汗后下。治伤寒
之正法也。今病未曾发汗。而先大下之。既下之后。复发其汗。是为汗下相反。津液重亡。案此条论。必病患
表里证悉具。以故汗下相反。但小便不利。无他变也。设使无里证而先下。无表证而复汗。则病患变证蜂起。
岂但小便之不利哉。〔喻〕言下后复发汗。有俟津液自回之法若强责其小便。则膀胱之气化不行。有增硬满喘
胀者矣。故宜以不治治之。〔程〕得小便利。得字宜着眼。
下之后复发汗。必振寒脉微细。所以然者。以内外俱虚故也。（玉函。脉经。千金翼。汗上。有其字。）
〔程〕下后复发汗。则卫外之阳必虚。故振寒。而守内之阳亦弱。故脉微细。能明其所以然。则虽有一应
热证。相兼而来。只补虚为主。良工于汗下之际。稍失治于其初。辄不
可不慎持于其后。脉证之间。各有本标。万不可因标误本也。〔柯〕内阳虚。故脉微细。外阳虚。故振栗恶寒。
即干姜附子汤证。
案汪氏引补亡论。常器之云。素无热人。可与芍药附子汤。有热人。可与黄 建中汤。魏氏云。四逆汤之
属。学人宜从其轻重。而择用耳。
下之后。复发汗。昼日烦躁不得眠。夜而安静。不呕不渴。无表证。脉沉微。身无大热者。干姜附子汤主
之。（玉函。脉经。千金翼。汗上。有其字。渴下。有而字。脉上。有其字。）
〔成〕下之虚其里。汗之虚其表。既下又汗。则表里俱虚。阳王于昼。阳欲复。虚不胜邪。正邪交争。
故昼日烦躁不得眠。夜阴为主。阳虚不能与之争。是夜则安静。不呕不渴者。里无热也。身无大热者。表无热
也。又无表证。而脉沉微。知阳气大虚。阴寒气胜。与干姜附子汤。退阴复阳。〔程〕昼日烦躁不得眠。虚阳
扰乱。外见假热也。夜而安静。不呕不渴。无表证。脉沉微。身无大热。阴气独治。内系真寒也。宜干姜附子
汤。直从阴中回阳。不当于昼日烦躁一假证狐疑也。〔柯〕身无大热。表阳将去矣。幸此微热未除。烦躁不宁
之际。独任干姜生附。以急回其阳。此四逆之变剂也。〔魏〕身无大热。非太阳发热。并非阳明大热也。洵是
阳虚于内。露假乱真耳。案昼间虽烦躁。亦不呕不渴。更明呕亦有寒逆。而渴不容假。渴亦有阴逼阳浮。面赤
口燥之渴。但与水不能饮。则真寒立见矣。
案无大热。又出麻黄杏仁甘草石膏汤。大陷胸汤。白虎加人参汤条。并谓身微热。无翕翕蒸蒸之势也。此
条烦躁。与茯苓四逆汤。吴茱萸汤。大青龙汤方后。汗多亡阳遂虚。恶风烦躁不得眠者。同属亡阳。但不过有
少异耳。案楼氏纲
目。作日夜烦躁。不得安眠。时安静。不知何据。
干姜附子汤方
干姜（一两） 附子（一枚生用去皮切八片○成本。切。作破。）
上二味。以水三升。煮取一升。去滓顿服。
〔徐〕脉微无大热。是外无袭邪。而更烦躁。非阳虚发躁之渐乎。故以生附干姜。急温其经。比四逆。不用
甘草者。彼重在厥。故以甘草。先调其中。而壮四肢之本。此重在虚阳上泛。寒极发躁。故用直捣之师。而无
取扶中为治耳。
柯氏曰。茯苓四逆。固阴以收阳。干姜附子。固阳以配阴。二方皆从四逆加减。而有救阳救阴之异。茯苓
四逆。比四逆为缓。固里宜缓也。姜附者。阳中之阳也。用生附。而去甘草。则势力更猛。比四逆为峻。回阳
当急也。一去甘草。一加茯苓。而缓急自别。加减之妙。见用方之神乎。
卢祖常续易简方曰。干姜一两。附子一枚。生去皮脐。然附子。纵重一两。去皮脐。已不等分。况有不重
一两者乎。兼其方。载干姜。既为主治之君。在附子之上。已知其不责附子之等分也。又曰。仲景一百十三方。
用附子者二十一。熟用者十有三。必佐麻黄桂枝大黄黄连黄芩细辛辈。生用者八。姜附汤。四逆汤。白通汤。
白通猪胆汤。通脉四逆汤。通脉四逆加猪胆汤。四逆人参汤。茯苓四逆汤。是也。必方方皆用干姜为正。未闻
用熟附佐干姜也。千金翼。姜附汤。主痰冷 气方。
于本方。以生姜。代干姜。
和剂局方。姜附汤。又治暴中风冷。久积痰水。心腹冷痛。霍乱转筋。一切虚寒。并皆治之。（即本方）
三因方。干姜附子汤。治中寒卒然晕倒。或吐逆涎沫。状如暗风。手脚挛搐。口噤。四足厥冷。或复燥热。
（即本方）
卫生宝鉴曰。身冷脉沉数。烦躁不饮水。此名阴盛格阳。干姜附子汤。加人参半两治之。
张氏医通曰。腰痛属寒者。其腰如冰。其脉必紧。得热则减。得寒则增。本方。加肉桂杜仲。外用摩腰膏。
发汗后。身疼痛。脉沉迟者。桂枝加芍药生姜各一两人参三两新加汤主之。（玉函。脉经。千金翼。身下。
有体字。脉上。有其字。作桂枝加芍药生姜人参汤。）
〔钱〕此本中风。而以麻黄汤。误发其汗。遂使阳气虚损。阴液耗竭。不能充灌滋养。故身疼痛。而脉沉
迟。非伤寒脉浮紧。而身疼痛之可比也。仍以桂枝汤。和解卫阳。因误汗之后。多加芍药之酸收。以敛营阴之
汗液。生姜以宣通其衰微之阳气。人参以扶补其耗散之元真。故名之曰桂枝新加汤。然身疼痛而脉沉迟。皆无
阳之证。而不加附子以温经复阳者。以未如肉 筋惕。汗漏不止之甚。故不必真武汤。及桂枝加附子汤。救急
之法也。若服而未除者。恐亦必当加入也。
伤寒准绳。张兼善曰。仲景凡言发汗后。以外无表证。里无热症。止余身疼一事而已。若脉稍浮盛。则为
表邪未尽解。今言脉沉迟。此血虚而致然也。故加人参生姜芍药以益血。
桂枝加芍药生姜各一两人参三两新加汤方
桂枝（三两去皮） 芍药（四两） 甘草（二两炙） 人参（三两） 大枣（十二枚擘） 生姜（四两○
千金翼。有切字。）
上六味。以水一斗二升。煮取三升。去滓。温服一升。本云桂枝汤。今加芍药生姜人参。（成本。不载本
方。第十卷云。于第二卷桂枝汤方内。更加芍药。生姜。各一两。人参。三两。余根据桂枝汤法服。玉函。味下。
有咀四味四字。云。作方。方本。煮上。有微火二字。注云。微火。皆当仿效首方。此盖后人之赘耳。）
〔志〕曰新加汤者。谓集用上古诸方。治疗表里之证。述而不作。如此汤方。则其新加者也。亦仲祖自谦之意。
古方选注曰。新加者。申明新得其分两之理。而加之也。伤寒类方曰。素体虚。而过汗者。方可用。
案柯氏作桂枝去芍药生姜新加人参汤。云。坊本作加芍药生姜者误。未知何据。恐是僭妄也。
案钱氏霍乱篇吐刹止而身痛不休云云注。如发汗后身疼痛脉沉迟者。此乃汗后亡阳。阳虚里寒。无阳气以
嘘培和暖其筋骨。营血凝涩而痛。此桂枝加芍药生姜人参新加汤证也。
发汗后。不可更行桂枝汤。汗出而喘。无大热者。可与麻黄杏仁甘草石膏汤。（杏仁。玉函。脉经。作杏
子。成本。汤下。有主之二字。）
〔方〕更行。犹言再用。不可再用桂枝汤。则是已经用过。所以禁止也。〔鉴〕太阳病下之后。微喘者。
表未解也。当以桂枝加浓朴杏仁汤。解太阳肌表。而治其喘也。太阳病桂枝证。医反下之。下利脉促。汗出而
喘。表未解者。当以葛根黄连黄芩汤。解阳明之肌热。而治其喘也。今发汗后。汗出而喘。身无大热。而不恶
【成无己注】《外台秘要》记载：里气平和而表邪未解，发汗即可痊愈。
【按语】这一条，从方有执以来的各家注解，都将其归为中风证，似乎不符合《伤寒论》的原意。只有柯琴、志聪、锡驹的注释，与程知的意思相同。
伤寒脉象浮紧，本应发汗却未发汗，导致鼻出血的，用麻黄汤主治。
【尤在泾注】伤寒脉象浮紧，依法应当发汗。如果不发汗，就是误失了发汗的机会。失于发汗则热邪郁结在营分，进而导致鼻出血，适宜用麻黄汤主治。如果能在尚未鼻出血之前，及早使用麻黄汤发汗，汗出后病邪自解，必定不会导致鼻出血。或者像前一条所说，通过自然鼻出血而病愈，也不需要用药。
【程知注】大抵伤寒出现鼻出血，是因为患者营分素有内热，一旦受到寒邪闭阻，营血不堪遏制，从而向上冲逆而出血。
【王肯堂注】“夺血者无汗”，既然已经导致鼻出血，不可轻易使用麻黄汤。必须仔细审察，只有当鼻出血点滴不成流时，才可以考虑使用。
《活人书》记载：经常鼻出血的人（衄家）不可发汗。若强行发汗，会导致额头汗出如珠、脉搏紧急、两眼直视不能眨眼、无法入睡等危候。然而，如果没有汗且鼻出血，脉象仍然浮紧的，必须给予麻黄汤。如果脉象已经微弱，则不可发汗，应用黄芩芍药汤或犀角地黄汤。
江瓘《名医类案》记载：陶尚文治疗一人，患伤寒四五日，吐血不止。医生用犀角地黄汤等药物治疗，病情反而加重。陶尚文切其脉象，浮紧而数。认为若不通过发汗使邪气外出，病邪如何能解？于是使用麻黄汤，服用一次后汗出而痊愈。有人问：仲景说“衄家不可汗”、“亡血家不可发汗”，而这里却用麻黄汤，为什么呢？回答说：长期鼻出血的人，失血已多，所以不可发汗。如今是因为该发汗而未发汗，热毒蕴结，导致吐血。应当分清津液与邪气的关系才能痊愈。所以仲景又说：“伤寒脉浮紧，不发汗，因致衄血者，麻黄汤主之。”大概是通过发汗，使热邪随汗外越，血自然停止。
【按语】柯韵伯版本中，这一条写作“伤寒脉浮紧者，麻黄汤主之。不发汗，因致衄。”并注释说：不发汗，阳气内扰，阳络受伤则鼻出血，这就是“夺血者无汗”。如果使用麻黄汤再次发汗，津液枯竭就会死亡。说不发汗导致鼻出血，哪有因为鼻出血还要再发汗的道理呢？我因此急于校正此说，担心误导人的地方太多。这种拘泥固执的说法，难以采纳。
伤寒不大便六七天，头痛且有发热的，给予承气汤。如果小便清长的，（【原注】一说大便色青。）可知病不在里，仍在表，应当需要发汗。如果头痛剧烈，必然会导致鼻出血，适宜用桂枝汤。（《玉函经》作“未可与承气汤”，这是正确的。“其小便清者”，《玉函经》、《外台秘要》并作“小便反清”，《脉经》、《千金翼方》作“大便反青”，柯本作“大便圊”。知，《玉函经》、《脉经》、《千金翼方》作“此为”二字。王肯堂校订的《千金翼方》，将“有热”改为“身热”，热字下有小便赤三字，“其小便清”作“若小便利”。）
【成无己注】不大便六七天，头痛且有发热，所以适宜攻下。如果小便清长，可知里没有热邪，则不可攻下。经文说：小便频数的，大便必然干硬，即使十天不排便也没有痛苦。何况这不大便六七天，小便清长的，不可指责邪气在里，说明邪气仍在表。给予桂枝汤以解除表邪。如果头痛不止，是因为表邪未解，郁滞严重于经脉，逼迫血液妄行，向上导致鼻出血。
【程知注】想要攻里，则有头痛的表证令人怀疑；想要解表，则有大便不通的里证令人怀疑。在表里之间，如何辨别呢？通过热邪来辨别罢了。热邪的有无，如何辨别呢？通过小便来辨别罢了。有热邪的，小便必然短赤，热邪已入里，头痛只属于热邪壅盛，可以攻里。小便清长的，没有热邪可知，热邪未入里，不大便只属于风邪秘结，仍须发汗。
【汪琥注】如果头痛不止，是因为风寒邪气上壅，经脉中热势严重，势必导致鼻出血。必须趁着尚未鼻出血的时候，适宜用桂枝汤，通过发汗来解除病邪。
【魏荔彤注】这一条所说的鼻出血，是推测性的言辞，并非已经出现的症状。使用桂枝汤就可以在不鼻出血的情况下病愈。这与使用麻黄汤的那一条也有区别。
《伤寒选录》记载：朱丹溪说：谨慎地考察，外证未解不可攻下，攻下为逆治。如今头痛且有发热，应当解表，反而给予承气汤，这正是责备其妄自攻下的过错。所以下面又说小便清长，知道没有里邪，不应当使用承气汤。接着又说：应当需要发汗。说头痛必然鼻出血，适宜桂枝汤。反复告诫，论意非常明确，而注释却直接说“故当宜下”，想必是因为六七天不大便的缘故。虽然不大便，但其他方面没有痛苦，等候表证解除后再攻里，这才是仲景的法度。注释似乎不够明晰。○按语：这种说法，与《玉函经》相符。
《伤寒类方》记载：伤寒不大便六七天，是适宜攻下的征候。如果有头痛且发热，暂时不可给予承气汤。太阳症仍在，不能因为日子久了不便秘就攻下。按语：“未可”二字，是从《金匮要略》增补进去的，《伤寒论》原本缺失这两个字。○按语：徐氏的注解接近正确，所以将其列出。又按语：张志聪认为，发汗用麻黄汤，柯氏将“小便清”改为“大便圊”，并不正确。
伤寒发汗后病已解除，半天左右又出现烦热，脉象浮数的，可以再次发汗，适宜桂枝汤。（《玉函经》、《脉经》、《千金翼方》在“脉”字上有“其”字。“可更发汗”，《玉函经》作“与复发汗”，《脉经》、《千金翼方》作“可复发其汗”，成本本作无“已”字，汤字下有“主之”二字。）
【成无己注】烦，就是热。发汗后身体凉爽为已解除。到了半天左右，身体又发热，脉象浮数，说明邪气未尽。可以再次发汗，给予桂枝汤。
【尤在泾注】伤寒服用麻黄汤发汗，汗出后热退，身体凉爽病解。半天左右，又出现烦热且脉象浮数，这是表邪未尽，退去后又聚集。可以再次发汗。之所以不用麻黄汤，是因为津液先前已被发汗所伤，不能再承受麻黄汤的药力，所以适宜用桂枝汤再次发汗。
【按语】方有执、喻嘉言等人，都说伤寒已解，又伤风邪，并且把“更”解释为改变的意思，这是不对的。“更”是再的意思。《玉函经》作“复”，意思可见一斑。
凡是疾病，如果经过发汗、催吐、泻下，或者失血、津液耗损，只要阴阳能够自行调和，必定会自愈。（成本本无“亡血”二字。《玉函经》、《脉经》中“亡津液”作“无津液”，液字下有“而”字。）
【李中梓注】这是论述汗、吐、下三法不可误用。汗、吐、下三法，都是会导致亡血、亡津液的治法。使用不当，不仅亡血亡津液，还会亡阴亡阳。使用得当，即使亡血亡津液，也能调和阴阳。所以说“阴阳自和者，必自愈”。
【尤在泾注】“凡病”，指不论中风还是伤寒，一切疾病。此时邪气和正气都已衰弱，可以不必施治，只需安静等待。
【按语】程知、柯琴、汪琥都认为，使用生津益血的药剂，就能使阴阳自和，病必自愈。这没有必要。现在审视原文语意，“自和”、“自愈”两个“自”字，分明是不假借药力的，由此可以看出。方有执、志聪、《医宗金鉴》将“阴阳”解释为脉的阴阳，这必然不正确。因为亡血则亡阴，亡津液则亡阳，这里的“阴阳”即指气血而言。
经过猛烈泻下之后，又再次发汗，小便不利的，是因为津液耗损的缘故。不要强行治疗，等到小便通利，必定会自愈。（《玉函经》、《脉经》、《千金翼方》在“汗下”之间有“其人”二字。“得”字作“其”。）
【成无己注】因为津液耗损而导致小便不利，不可以用药来利小便。等待津液充足，小便通利，必定会自愈。
【汪琥注】先汗后下，是治疗伤寒的正法。如今病未曾发汗，却先猛烈泻下，既泻下之后，又再次发汗，这是汗下相反，津液重度耗损。按语：这一条的论述，必然是病患表里证候齐全，所以才汗下相反。只是小便不利，没有其他变证。假设没有里证却先攻下，没有表证却再次发汗，那么病患变证蜂起，岂止是小便不利而已。
【喻昌注】说的是泻下后再次发汗，有等待津液自行恢复的方法。如果强行责求其小便通利，则膀胱的气化功能不行，会出现腹部硬满、气喘胀满等情况。所以适宜以不治之法来治疗。
【程知注】“得小便利”，“得”字值得注意。
泻下之后再次发汗，必然出现畏寒战栗、脉象微细。之所以这样，是因为内外俱虚的缘故。（《玉函经》、《脉经》、《千金翼方》在“汗”字上有“其”字。）
【程知注】泻下之后再次发汗，则卫护体外的阳气必然虚弱，所以畏寒战栗；守持体内的阳气也衰弱，所以脉象微细。能明白其中的原因，那么即使伴有热证，也只以补虚为主。良医在汗下之际，如果在初期稍有失误，在后继治疗中不得不谨慎持重。脉证之间，各有本标，万不可因标误本。
【柯琴注】内阳虚，所以脉象微细；外阳虚，所以畏寒战栗恶寒。这就是干姜附子汤证。
【按语】汪琥引用《补亡论》，常器之说：素来没有热象的人，可以给芍药附子汤；有热象的人，可以给黄芪建中汤。魏氏说：四逆汤之类的方剂。学习者应该根据病情的轻重来选择使用。
泻下之后再次发汗，白天烦躁不能入睡，夜间安静，不呕吐、不口渴、无表证，脉象沉微，身体没有明显发热的，用干姜附子汤主治。（《玉函经》、《脉经》、《千金翼方》在“汗”字上有“其”字，“渴”字下有“而”字，“脉”字上有“其”字。）
【成无己注】泻下损伤了里气，发汗损伤了表气。既泻下又发汗，则表里俱虚。阳气旺于白天，阳气欲恢复，但因虚不胜邪，正邪交争，所以白天烦躁不能入睡。夜间阴气主事，阳虚不能与之抗争，所以夜间安静。不呕吐、不口渴，说明里没有热邪。身体没有明显发热，说明表里没有热邪。又没有表证，且脉象沉微，可知阳气大虚，阴寒气盛。给予干姜附子汤，以退阴复阳。
【程知注】白天烦躁不能入睡，是虚阳扰乱，外现假热。夜间安静，不呕吐、不口渴，无表证，脉象沉微，身体无大热，是阴气独治，内属真寒。适宜干姜附子汤，直接从阴中回阳，不应在白天烦躁这一假证上犹豫不决。
【柯琴注】身体没有明显发热，说明表阳即将离去。幸好这点微热未除，在烦躁不宁之际，独任干姜、生附子，以急回其阳。这是四逆汤的变方。
【魏荔彤注】身体没有明显发热，不是太阳病的发热，也不是阳明病的大热。确实是阳虚于内，显露假象迷惑真象。按语：白天虽然烦躁，也不呕吐、不口渴，更明确说明呕吐也有寒逆，而口渴不容许假冒。口渴也有阴逼阳浮、面赤口燥的渴，但给水不能饮，则真寒立刻显现。
【按语】“无大热”，又出现在麻黄杏仁甘草石膏汤、大陷胸汤、白虎加人参汤条文中，都说是身微热，没有翕翕蒸蒸的热势。这一条的烦躁，与茯苓四逆汤、吴茱萸汤、大青龙汤方后所述“汗多亡阳遂虚，恶风烦躁不得眠者”，同属亡阳，只不过略有差异。按语：楼氏《纲目》作“日夜烦躁，不得安眠，时安静”，不知依据是什么。
干姜附子汤方
干姜（一两） 附子（一枚，生用，去皮，切成八片○成本本，“切”作“破”。）
以上两味药，用水三升，煮取一升，去渣，一次性服用。
【徐灵胎注】脉微且无大热，是外无袭邪，却更加烦躁，这不是阳虚发躁的征兆吗？所以用生附子、干姜，急温其经脉。相比四逆汤，不用甘草的原因，四逆汤重在厥逆，所以用甘草先调和中焦，以壮四肢之本。此方重在虚阳上泛，寒极发躁，所以用直捣之师，而不取扶中为治。
柯氏说：茯苓四逆汤，固阴以收阳；干姜附子汤，固阳以配阴。两方都从四逆汤加减而来，但有救阳救阴的区别。茯苓四逆汤比四逆汤缓和，固里宜缓。姜附者，是阳中之阳。用生附子而去甘草，则势力更猛，比四逆汤峻烈，回阳当急。一去甘草，一加茯苓，而缓急自然有别。加减的妙处，见用方的神妙。
卢祖常《续易简方》说：干姜一两，附子一枚，生用，去皮脐。然而附子，纵然重一两，去皮脐后，已不等分了，何况有不重一两的呢？况且这个方子，记载干姜在主治君药的位置，且在附子之上，已知其不要求附子等分。又说：仲景一百十三方中，用附子的二十一首，熟用的有十三首，必定佐使麻黄、桂枝、大黄、黄连、黄芩、细辛之类。生用的有八首，就是姜附汤、四逆汤、白通汤、白通猪胆汤、通脉四逆汤、通脉四逆加猪胆汤、四逆人参汤、茯苓四逆汤。这些方子必定都用干姜为正，没听说用熟附子佐干姜的。《千金翼方》中的姜附汤，主治痰冷气方。
《和剂局方》姜附汤，又治疗暴中风冷，久积痰水，心腹冷痛，霍乱转筋，一切虚寒，都治疗。（即本方）
《三因方》干姜附子汤，治疗中寒突然晕倒，或吐逆涎沫，状如暗风，手脚挛搐，口噤，四肢厥冷，或又燥热。（即本方）
《卫生宝鉴》说：身体冷，脉沉数，烦躁不饮水，这名叫阴盛格阳。干姜附子汤，加人参半两治疗。
《张氏医通》说：腰痛属寒的，腰部如冰，脉必紧，得热则减，得寒则增。本方加肉桂、杜仲，外用摩腰膏。
发汗后，身体疼痛，脉象沉迟的，用桂枝加芍药生姜各一两人参三两新加汤主治。（《玉函经》、《脉经》、《千金翼方》在“身”字下有“体”字，“脉”字上有“其”字，作“桂枝加芍药生姜人参汤”。）
【钱潢注】这原本是中风，却误用麻黄汤发汗，致使阳气虚损，阴液耗竭，不能充灌滋养，所以身体疼痛，脉象沉迟。这不是伤寒脉浮紧而身体疼痛可比拟的。仍以桂枝汤和解卫阳，因为误汗之后，多加芍药的酸收，以收敛营阴之汗液；生姜以宣通衰微之阳气；人参以扶补耗散之元气。所以命名为桂枝新加汤。然而身体疼痛且脉沉迟，都是无阳之证，而不加附子以温经复阳的，是因为还没有到肌肉跳动、汗漏不止那么严重的程度，所以不必用真武汤及桂枝加附子汤这种急救之法。如果服药后未除去的，恐怕也应当加入附子。
《伤寒准绳》张兼善说：仲景凡是说发汗后，外无表证，里无热症，只剩下身体疼痛一事而已。如果脉稍浮盛，则是表邪未尽解。如今说脉沉迟，这是血虚导致的。所以加人参、生姜、芍药以益血。
桂枝加芍药生姜各一两人参三两新加汤方
桂枝（三两，去皮） 芍药（四两） 甘草（二两，炙） 人参（三两） 大枣（十二枚，掰开） 生姜（四两○《千金翼方》有“切”字。）
以上六味药，用水一斗二升，煮取三升，去渣，温服一升。原本说是桂枝汤，现在加芍药、生姜、人参。（成本本不载本方，第十卷说：在第二卷桂枝汤方内，再加芍药、生姜各一两，人参三两，其余根据桂枝汤法服用。《玉函经》在“味”字下有“咀四味”四字。云：作方。方本，煮字上有“微火”二字。注云：微火，都应当仿效首方。这大概是后人的赘笔。）
【志】曰：所谓新加汤，是说集合运用上古诸方，治疗表里之证，述而不作。像这个汤方，就是新加的。也是仲景自谦的意思。
《古方选注》说：新加，申明是新得到分量比例的道理而加上去的。
《伤寒类方》说：素体虚弱，而过汗的人，才可以使用。
【按语】柯氏作“桂枝去芍药生姜新加人参汤”，说坊间本作“加芍药生姜”是错误的，不知依据是什么，恐怕是僭妄。
【按语】钱氏《霍乱篇》吐止而身痛不休云云注：如发汗后身疼痛脉沉迟者，这是汗后亡阳，阳虚里寒，无阳气以嘘培和暖其筋骨，营血凝涩而痛。这是桂枝加芍药生姜人参新加汤证。
发汗后，不可再用桂枝汤。汗出且喘，身体没有明显发热的，可以给予麻黄杏仁甘草石膏汤。（杏仁，《玉函经》、《脉经》作“杏子”，成本本在“汤”字下有“主之”二字。）
【方有执注】更行，犹言再用。不可再用桂枝汤，则是已经用过，所以禁止。
【尤在泾注】太阳病攻下之后，微喘的，表未解。应当用桂枝加厚朴杏子汤，解太阳肌表，而治其喘。太阳病桂枝证，医生反用攻下法，下利脉促，汗出而喘，表未解的，应当用葛根黄连黄芩汤，解阳明之肌热，而治其喘。如今发汗后，汗出而喘，身无大热，且不恶……
[Cheng Wuji's Commentary] The *Waitai Miyao* (Essential Prescriptions from the Imperial Library) records: When the interior is harmonious but the exterior pathogen remains, sweating will lead to recovery.
[Note] This clause has been interpreted by various scholars since Fang Youzhi as a Wind Strike syndrome, which seems inconsistent with the original intent of the *Shanghan Lun*. Only the commentaries by Ke Qin, Zhi Cong, and Xi Ju align with Cheng Zhi's interpretation.
In cold damage (Shanghan), if the pulse is floating and tight, and failure to induce sweating results in epistaxis (nosebleed), Mahuang Tang (Ephedra Decoction) should be primarily used.
[You Yuyuan's Commentary] In cold damage, a floating and tight pulse indicates that sweating is the appropriate treatment according to law. If sweating is not induced, it constitutes a missed opportunity. Failure to sweat causes heat to stagnate within the Ying (Nutritive) level, leading to epistaxis. In such cases, Mahuang Tang (Ephedra Decoction) is suitable. However, if Mahuang Tang (Ephedra Decoction) had been administered early enough before the onset of epistaxis, inducing sweat would have resolved the condition, preventing nosebleeds. Alternatively, as mentioned in the previous clause, if the disease resolves spontaneously through epistaxis, medication is unnecessary.
[Cheng Zhi's Commentary] Generally, epistaxis in cold damage occurs because the patient’s Ying level already harbors internal heat. Once constrained by cold pathogens, the Ying blood cannot withstand the pressure and surges upward, causing bleeding.
[Wang Kentang's Commentary] "Those who have lost blood do not sweat." Since epistaxis has occurred, Mahuang Tang (Ephedra Decoction) should not be used lightly. Careful examination is required; it may only be considered if the nosebleed is scanty, dripping rather than flowing.
The *Heren Shu* (Book of Living People) records: Patients prone to epistaxis (Nujia) should not undergo sweating therapy. Forced sweating can lead to critical signs such as beads of sweat on the forehead, urgent pulse, fixed gaze unable to blink, and insomnia. However, if there is no sweat and epistaxis occurs, yet the pulse remains floating and tight, Mahuang Tang (Ephedra Decoction) must be given. If the pulse has become faint, sweating is contraindicated; instead, Huangqin Shaoyao Tang (Scutellaria and Peony Decoction) or Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) should be used.
Jian Guan's *Mingyi Leian* (Collected Cases of Famous Physicians) records: Tao Shangwen treated a patient with cold damage for four to five days who suffered from continuous hematemesis (vomiting blood). Physicians treated him with Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) and other formulas, but his condition worsened. Tao palpated the pulse, finding it floating, tight, and rapid. He reasoned that without sweating to expel the pathogen, how could the illness resolve? Thus, he prescribed Mahuang Tang (Ephedra Decoction). After one dose, sweating occurred, and the patient recovered. Someone asked: Zhang Zhongjing stated that "patients prone to epistaxis should not sweat" and "those who have lost blood should not undergo sweating," yet here Mahuang Tang (Ephedra Decoction) is used. Why? The answer is: For those with chronic epistaxis, blood loss is already significant, so sweating is contraindicated. In this case, however, the failure to sweat when indicated led to the accumulation of heat toxins, resulting in hematemesis. One must distinguish the relationship between fluids and pathogens to achieve recovery. Therefore, Zhang Zhongjing also said: "In cold damage, if the pulse is floating and tight, and failure to induce sweating leads to epistaxis, Mahuang Tang (Ephedra Decoction) should be primarily used." Essentially, inducing sweating allows the heat to escape outward, stopping the bleeding naturally.
[Note] In Ke Yunbo's version, this clause reads: "In cold damage, if the pulse is floating and tight, Mahuang Tang (Ephedra Decoction) should be primarily used. Failure to induce sweating leads to epistaxis." The commentary states: Failure to sweat causes internal disturbance of Yang Qi; injury to the Yang collaterals leads to epistaxis, which is the principle that "those who lose blood do not sweat." Using Mahuang Tang (Ephedra Decoction) to induce further sweating would deplete fluids and cause death. It argues that if failure to sweat leads to epistaxis, how could one induce sweating after epistaxis has occurred? I urgently correct this view to prevent misleading others. Such rigid interpretations are difficult to accept.
If cold damage presents with constipation for six to seven days, accompanied by headache and fever, Chengqi Tang (Purgative Decoction) may be given. However, if urination is clear, [Original Note: Some versions say stool is green], it indicates the pathology is not in the interior but remains in the exterior, requiring sweating therapy. If the headache is severe, epistaxis is likely, and Guizhi Tang (Cinnamon Twig Decoction) is appropriate. (*Yuhan Jing* reads "Chengqi Tang should not yet be given," which is correct. Regarding "urination is clear," *Yuhan Jing* and *Waitai Miyao* read "urination is surprisingly clear"; *Maijing* and *Qianjin Yi* read "stool is surprisingly green"; Ke Ben reads "defecation." The character *Zhi* is read as *Ci Wei* in *Yuhan Jing*, *Maijing*, and *Qianjin Yi*. Wang Kentang's edited *Qianjin Yi* changes "fever" to "body heat," adding three characters "urine is red" below "heat," and changes "urination is clear" to "if urination is free."*)
[Cheng Wuji's Commentary] Constipation for six to seven days with headache and fever suggests the need for purgation. If urination is clear, it indicates no heat in the interior, so purgation is contraindandicated. The classic states: Frequent urination leads to hard stool; even ten days without defecation causes no distress. Moreover, with six to seven days of constipation and clear urination, one should not blame the pathogen for being in the interior; it remains in the exterior. Guizhi Tang (Cinnamon Twig Decoction) should be given to release the exterior. If the headache persists, it means the exterior pathogen has not resolved; severe stagnation in the meridians forces blood to move recklessly, causing epistaxis.
[Cheng Zhi's Commentary] To attack the interior, the headache (an exterior sign) raises doubts; to release the exterior, the constipation (an interior sign) raises doubts. How to distinguish between exterior and interior? By distinguishing heat. How to distinguish heat? By examining urination. With heat, urination is short and red, indicating heat has entered the interior; headache is due to heat congestion, and purgation is possible. With clear urination, there is no heat; heat has not entered the interior, and constipation is due to wind-induced constipation, requiring sweating.
[Wang Hu's Commentary] Persistent headache indicates stagnation of wind-cold pathogens upward, with severe heat in the meridians, inevitably leading to epistaxis. Before epistaxis occurs, Guizhi Tang (Cinnamon Twig Decoction) should be used to resolve the pathogen via sweating.
[Zhou Yangjun's Commentary] This is because sweating has already been performed, so Mahuang Tang (Ephedra Decoction) cannot be used again.
[Wei Litong's Commentary] The mention of epistaxis in this clause is speculative, not an observed symptom. Using Guizhi Tang (Cinnamon Twig Decoction) allows resolution without epistaxis. This differs from the clause using Mahuang Tang (Ephedra Decoction).
*Shanghan Xuanlu* records: Zhu Danxi said: Carefully examined, when exterior symptoms are unresolved, purgation is contraindicated as it is contrary to treatment. Now, with headache and fever, the exterior should be released; giving Chengqi Tang (Purgative Decoction) instead is precisely blaming the error of premature purgation. Hence, the text later states that clear urination indicates no interior pathogen, making Chengqi Tang (Purgative Decoction) inappropriate. It continues: Sweating is necessary. It says headache will lead to epistaxis, recommending Guizhi Tang (Cinnamon Twig Decoction). The repeated warnings make the meaning clear, whereas the commentary directly states "therefore purgation is appropriate," likely due to the six-to-seven-day constipation. Although constipated, with no other distress, waiting for exterior resolution before purging is Zhang Zhongjing's method. The commentary seems unclear. ○ Note: This view aligns with *Yuhan Jing*.
*Shanghan Leifang* records: Cold damage with constipation for six to seven days presents indications for purgation. However, with headache and fever, Chengqi Tang (Purgative Decoction) should not yet be given. The Taiyang syndrome persists; one should not purge simply due to prolonged constipation. Note: The phrase "should not yet" was added from *Jingui Yaolue*; it is missing in the original *Shanghan Lun*. ○ Note: Xu's annotation is close to correct, hence listed. Another note: Zhang Zhicong argued that for sweating, Mahuang Tang (Ephedra Decoction) is used, and Ke's change of "clear urination" to "defecation" is incorrect.
After cold damage is resolved by sweating, if restlessness returns after about half a day with a floating and rapid pulse, sweating may be induced again, preferably with Guizhi Tang (Cinnamon Twig Decoction). (*Yuhan Jing*, *Maijing*, *Qianjin Yi* add "its" before "pulse." *Yuhan Jing* reads "induce sweating again" for "can induce sweating again"; *Maijing* and *Qianjin Yi* read "can induce its sweat again." Cost edition lacks "already"; "mainly uses" follows "Tang.")
[Cheng Wuji's Commentary] Restlessness implies heat. Body cooling after sweating indicates resolution. Return of fever and floating/rapid pulse after half a day indicates incomplete expulsion of pathogens. Sweating may be induced again with Guizhi Tang (Cinnamon Twig Decoction).
[You Yuyuan's Commentary] After taking Mahuang Tang (Ephedra Decoction) for cold damage, sweating occurs, heat subsides, and the body cools, indicating resolution. If restlessness and fever return after half a day with a floating and rapid pulse, it means exterior pathogens remain, having retreated and then re-collected. Sweating may be induced again. Mahuang Tang (Ephedra Decoction) is not used because fluids were previously damaged by sweating and cannot withstand its strength again. Thus, Guizhi Tang (Cinnamon Twig Decoction) is preferred for secondary sweating.
[Note] Fang Youzhi and Yu Juyan claimed that after cold damage resolves, wind pathogens invade again, interpreting "Geng" as changing. This is incorrect. "Geng" means "again." *Yuhan Jing* uses "Fu," clarifying the meaning.
For any disease, whether subjected to sweating, vomiting, purgation, or suffering from blood loss or fluid depletion, if Yin and Yang self-harmonize, recovery will surely occur. (Cost edition lacks "blood loss." *Yuhan Jing* and *Maijing* read "no fluids" for "fluid depletion," adding "and" after "fluid.")
[Li Zhongzi's Commentary] This discusses the danger of misusing sweating, vomiting, and purgation. These methods all deplete blood and fluids. Improper use not only depletes blood and fluids but also Yin and Yang. Proper use, even if depleting blood and fluids, can harmonize Yin and Yang. Hence, "When Yin and Yang self-harmonize, recovery occurs."
[You Yuyuan's Commentary] "Any disease" refers to all conditions, regardless of Wind Strike or Cold Damage. When both pathogen and healthy Qi are depleted, treatment may be unnecessary; one should wait quietly.
[Note] Cheng Zhi, Ke Qin, and Wang Hu believed that using fluids-nourishing and blood-tonifying herbs achieves self-harmony and recovery. This is unnecessary. Examining the original text, the two "self" characters in "self-harmonize" and "self-recover" clearly indicate no reliance on medicinal force. Fang Youzhi, Zhi Cong, and *Yizong Jinjian* interpreted "Yin and Yang" as pulse Yin and Yang, which is unlikely. Blood loss depletes Yin; fluid depletion depletes Yang. Here, "Yin and Yang" refers to Qi and Blood.
After severe purgation followed by sweating, if urination is inadequate, it is due to fluid depletion. Do not treat it forcibly; once urination becomes normal, recovery will occur. (*Yuhan Jing*, *Maijing*, *Qianjin Yi* add "this person" before "sweating/purging." "Obtains" is read as "its".)
[Cheng Wuji's Commentary] Urinary difficulty due to fluid depletion should not be treated with diuretics. Wait for fluids to replenish and urination to normalize; recovery will occur.
[Wang Hu's Commentary] Sweating first, then purging, is the standard method for treating cold damage. Here, purging was done first without prior sweating, followed by sweating. This contradictory approach severely depletes fluids. Note: This clause assumes the patient presented with both exterior and interior signs, justifying the contradictory treatment. Only urinary difficulty is present, with no other complications. If purging were done without interior signs, or sweating repeated without exterior signs, numerous complications would arise, far beyond mere urinary difficulty.
[Yu Chang's Commentary] This describes a method of waiting for fluids to recover after purging and sweating. Forcing urination impairs Bladder Qi transformation, potentially causing abdominal hardness, fullness, wheezing, and distension. Thus, non-treatment is the appropriate approach.
[Cheng Zhi's Commentary] Emphasis should be placed on the word "obtains" in "obtains normal urination."
After purging and subsequent sweating, chills and fine, faint pulses will certainly occur. This is because both interior and exterior are deficient. (*Yuhan Jing*, *Maijing*, *Qianjin Yi* add "its" before "sweating.")
[Cheng Zhi's Commentary] Purging followed by sweating weakens the defensive Yang protecting the exterior, causing chills; it also weakens the guarding Yang within, causing faint and fine pulses. Understanding the cause ensures that even if heat symptoms accompany, tonification of deficiency remains primary. Skilled physicians must be cautious after initial errors in sweating or purging. Pulse and symptoms have root and branch aspects; never mistake the branch for the root.
[Ke Qin's Commentary] Interior Yang deficiency causes faint and fine pulses; exterior Yang deficiency causes chills and aversion to cold. This is the Ganjiang Fuzi Tang (Dried Ginger and Aconite Decoction) syndrome.
[Note] Wang Hu cites *Buwang Lun*: Chang Qizhi said: For patients without inherent heat, Shaoyao Fuzi Tang (Peony and Aconite Decoction) may be given; for those with heat, Huangqi Jianzhong Tang (Astragalus and Middle-Warming Decoction) is suitable. Wei suggested Si Ni Tang (Frigid Extremities Decoction) and similar formulas. Learners should choose based on severity.
After purging and subsequent sweating, if the patient experiences daytime irritability and insomnia but quietness at night, without vomiting, thirst, or exterior signs, with a deep, faint pulse and no significant body heat, Ganjiang Fuzi Tang (Dried Ginger and Aconite Decoction) should be primarily used. (*Yuhan Jing*, *Maijing*, *Qianjin Yi* add "its" before "sweating," "and" after "thirst," and "its" before "pulse.")
[Cheng Wuji's Commentary] Purging empties the interior; sweating empties the exterior. Both procedures leave interior and exterior deficient. Yang dominates the day; attempting restoration, the deficiency cannot resist the pathogen, leading to Zheng-Xie conflict and daytime irritability/insomnia. Night belongs to Yin; Yang deficiency prevents resistance, resulting in nighttime quietness. No vomiting/thirst indicates no interior heat; no significant heat indicates no exterior heat. With no exterior signs and a deep/faint pulse, severe Yang deficiency and excess Yin-Cold are confirmed. Ganjiang Fuzi Tang (Dried Ginger and Aconite Decoction) is given to dispel Yin and restore Yang.
[Cheng Zhi's Commentary] Daytime irritability/insomnia reflects chaotic deficient Yang manifesting as false heat. Nighttime quietness, no vomiting/thirst, no exterior signs, deep/faint pulse, and no significant heat indicate exclusive dominance of Yin and true cold internally. Ganjiang Fuzi Tang (Dried Ginger and Aconite Decoction) should be used to directly restore Yang from Yin. Hesitation over the false symptom of daytime irritability is inappropriate.
[Ke Qin's Commentary] No significant heat indicates exterior Yang is departing. Fortunately, slight heat remains. During irritability, relying solely on Dried Ginger and Raw Aconite rapidly restores Yang. This is a modification of Si Ni Tang (Frigid Extremities Decoction).
[Wei Litong's Commentary] No significant heat is neither Taiyang fever nor Yangming high fever. It is truly Yang deficiency internally, revealing false signs to confuse the true state. Note: Although irritable during the day, the absence of vomiting/thirst clarifies that vomiting can stem from cold reversal, while thirst cannot be feigned. Thirst can also result from Yin forcing Yang float, with red face and dry mouth, but inability to drink reveals true cold immediately.
[Note] "No significant heat" appears in clauses for Mahuang Xingren Gancao Shigao Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction), Da Xianxiong Tang (Major Chest-Trap Decoction), and Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction), all describing slight heat without steaming intensity. This clause's irritability shares the "Yang collapse" nature with Fuling Sini Tang (Poria Frigid Extremities Decoction), Wuzhuyu Tang (Evodia Decoction), and Dahqinglong Tang (Major Green Dragon Decoction) post-sweating descriptions ("profuse sweating collapses Yang, leading to deficiency, aversion to wind, irritability, and insomnia"), differing only slightly. Note: Lou's *Gangmu* reads "irritable day and night, unable to sleep, occasionally quiet," but the basis is unknown.
**Ganjiang Fuzi Tang (Dried Ginger and Aconite Decoction) Formula**
Ganjiang (Dried Ginger) (1 liang) Fuzi (Aconite Root, prepared) (1 piece, raw, peeled, cut into 8 slices○Cost edition reads "break" for "cut.")
These two ingredients are boiled in 3 sheng of water to yield 1 sheng. Strain and take in one dose.
[Xu Lingtai's Commentary] Faint pulse and no significant heat indicate no external invading pathogen, yet irritability persists, signaling impending Yang deficiency agitation. Thus, Raw Aconite and Dried Ginger are used to urgently warm the meridians. Unlike Si Ni Tang (Frigid Extremities Decoction), Glycyrrhiza (Licorice) is omitted because Si Ni Tang focuses on cold extremities, using Licorice to harmonize the middle and strengthen the limbs' root. This formula focuses on floating deficient Yang and extreme cold causing agitation, employing a direct assault strategy rather than supporting the middle.
Ke stated: Fuling Sini Tang (Poria Frigid Extremities Decoction) secures Yin to gather Yang; Ganjiang Fuzi Tang (Dried Ginger and Aconite Decoction) secures Yang to coordinate Yin. Both are modifications of Si Ni Tang (Frigid Extremities Decoction), differing in saving Yang vs. saving Yin. Fuling Sini Tang is milder than Si Ni Tang, suitable for gradual interior consolidation. Ginger and Aconite represent Yang within Yang. Using raw Aconite and omitting Licorice increases potency, making it more峻 (pungent/strong) than Si Ni Tang, necessitating urgent Yang restoration. Omitting Licorice and adding Poria distinguishes mild from urgent application. The subtlety of modifications reveals the divine skill in prescription.
Lu Zuchang's *Xu Yijian Fang* states: Ganjiang (Dried Ginger) 1 liang, Fuzi (Aconite Root, prepared) 1 piece, raw, peeled, umbilicus removed. However, even if Aconite weighs 1 liang, peeling removes weight, making equal parts impossible, especially if underweight. Since Ganjiang is the sovereign herb above Aconite, equal weighting of Aconite is not required. Furthermore, among Zhang Zhongjing's 113 formulas, 21 use Aconite; 13 are cooked, always assisted by Ephedra, Cinnamon Twig, Rhubarb, Scutellaria, Scutellaria, Asarum, etc. 8 are raw: Jiangfu Tang (Ginger-Aconite Decoction), Si Ni Tang (Frigid Extremities Decoction), Baitong Tang (White Through Decoction), Baitong Zhudansheng Tang (White Through Pig Gall Decoction), Tongmai Sini Tang (Pulse-Unblocking Frigid Extremities Decoction), Tongmai Sini Jia Zhudansheng Tang (Pulse-Unblocking Frigid Extremities Plus Pig Gall Decoction), Sini Renshen Tang (Frigid Extremities Plus Ginseng Decoction), Fuling Sini Tang (Poria Frigid Extremities Decoction). All these correctly use Dried Ginger. It is unheard of to use cooked Aconite assisting Dried Ginger. *Qianjin Yi*'s Jiangfu Tang treats Phlegm-Cold Qi.
Substituting Shengjiang (Fresh Ginger) for Ganjiang (Dried Ginger) in this formula.
Heji Jufang's Jiangfu Tang also treats sudden wind-cold, chronic phlegm-water accumulation, cold pain in heart/abdomen, cholera with cramps, and all deficiency-cold conditions (i.e., this formula).
Sanyin Fang's Ganjiang Fuzi Tang treats sudden cold collapse, vomiting saliva/phlegm, resembling silent stroke, limb spasms, locked jaw, cold extremities, or subsequent dry heat (i.e., this formula).
Weisheng Baojian states: Cold body, deep/rapid pulse, irritability without desire to drink indicates Yin excess repelling Yang. Ganjiang Fuzi Tang (Dried Ginger and Aconite Decoction) plus 0.5 liang of Renshen (Ginseng) treats this.
Zhangshi Yitong states: Cold-type lower back pain feels like ice, pulse is tight, relieved by heat, aggravated by cold. Add Rougui (Cinnamon Bark) and Duzhong (Eucommia) to this formula; apply external Yao Gao (Waist Paste) externally.
After sweating, if body aches persist with a deep, slow pulse, Guizhi Ji Shaoyao Shengjiang Ge Yi Ren San Liang Xinjia Tang (Guizhi Decoction Plus One Liang Each of Peony and Fresh Ginger, Three Liang of Ginseng, Newly Added Decoction) should be primarily used. (*Yuhan Jing*, *Maijing*, *Qianjin Yi* add "body" after "body," "its" before "pulse," reading "Guizhi Plus Peony, Fresh Ginger, Ginseng Decoction.")
[Qian Huang's Commentary] This was originally Wind Strike, mistakenly sweated with Mahuang Tang (Ephedra Decoction), damaging Yang Qi and depleting Yin fluids, failing to nourish tissues, causing body aches and deep/slow pulse. This differs from cold damage with floating/tight pulse and body aches. Guizhi Tang (Cinnamon Twig Decoction) harmonizes Defensive Yang. Due to erroneous sweating, extra Shaoyao (Peony) is added for its sour astringency to conserve Ying fluids; Shengjiang (Fresh Ginger) promotes circulation of weakened Yang; Renshen (Ginseng) supports scattered Yuan Qi. Hence named Guizhi Xinjia Tang (Guizhi Newly Added Decoction). Although body aches and deep/slow pulse indicate Yang deficiency, Fuzi (Aconite) is not added to warm meridians and restore Yang because symptoms are not as severe as muscle twitching or unceasing sweating requiring Zhenwu Tang (True Warrior Decoction) or Guizhi Jia Fuzi Tang (Guizhi Plus Aconite Decoction). If ineffective, adding Fuzi might be necessary.
Zhang Jianshan in *Shanghan Zhunsheng* stated: Whenever Zhang Zhongjing mentions post-sweating with no exterior signs or interior heat, leaving only body ache, a slightly floating/full pulse indicates unresolved exterior pathogens. A deep/slow pulse here indicates blood deficiency. Thus, Renshen (Ginseng), Shengjiang (Fresh Ginger), and Shaoyao (Peony) are added to nourish blood.
**Guizhi Ji Shaoyao Shengjiang Ge Yi Ren San Liang Xinjia Tang (Guizhi Decoction Plus One Liang Each of Peony and Fresh Ginger, Three Liang of Ginseng, Newly Added Decoction) Formula**
Guizhi (Cinnamon Twig) (3 liang, peeled) Shaoyao (Peony Root) (4 liang) Gancao (Licorice Root) (2 liang, honey-fried) Renshen (Ginseng Root) (3 liang) Dazao (Jujube) (12 pieces, split) Shengjiang (Fresh Ginger) (4 liang○*Qianjin Yi* adds "cut.")
These six ingredients are boiled in 12 sheng of water to yield 3 sheng. Strain and take 1 sheng warm. Originally called Guizhi Tang (Cinnamon Twig Decoction); now Peony, Fresh Ginger, and Ginseng are added. (Cost edition does not list this formula; Vol 10 states: Add Peony and Fresh Ginger 1 liang each, Ginseng 3 liang to the Vol 2 Guizhi Tang formula, following Guizhi Tang preparation methods. *Yuhan Jing* adds "chew four ingredients" after "ingredients." Says: Make formula. Original text adds "slight fire" before "boil." Note: "Slight fire" should follow the first formula. This is likely later interpolation.)
[Zhi] stated: "Newly Added" implies collecting ancient formulas to treat interior/exterior syndromes, narrating without creating. This formula represents the "new addition." It also reflects Zhang Zhongjing's humility.
*Gufang Xuanzhu* stated: "Newly Added" explains the rationale for new dosage ratios added.
*Shanghan Leifang* stated: Suitable only for patients with inherent weakness who have undergone excessive sweating.
[Note] Ke wrote "Guizhi Qu Shaoyao Shengjiang Xinjia Renshen Tang" (Guizhi Decoction Minus Peony and Fresh Ginger, Newly Adding Ginseng Decoction), claiming坊间 editions adding Peony/Ginger are wrong, without basis, likely presumptuous.
[Note] Qian's *Huoluan Pian* commentary on "vomiting stops but body pain persists": Post-sweating body ache with deep/slow pulse indicates Yang collapse after sweating, interior cold from Yang deficiency, lacking Qi to warm sinews/bones, causing stagnant Ying/Blood pain. This is the Guizhi Ji Shaoyao Shengjiang Renshen Xinjia Tang (Guizhi Plus Peony, Fresh Ginger, Ginseng Newly Added Decoction) syndrome.
After sweating, Guizhi Tang (Cinnamon Twig Decoction) should not be used again. If sweating is accompanied by wheezing without significant body heat, Mahuang Xingren Gancao Shigao Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction) may be given. (Xingren, *Yuhan Jing* and *Maijing* read "Xingzi"; Cost edition adds "mainly uses" after "Tang.")
[Fang Youzhi's Commentary] "Geng Xing" means using again. Guizhi Tang (Cinnamon Twig Decoction) should not be used again because it has already been administered, hence the prohibition.
[You Yuyuan's Commentary] After purging Taiyang disease with slight wheezing, the exterior is unresolved. Guizhi Houpo Xingzi Tang (Guizhi Plus Magnolia Bark and Apricot Kernel Decoction) should be used to release Taiyang muscle-surface and treat wheezing. In Taiyang Guizhi syndrome, mistaken purging causing diarrhea with urgent pulse, sweating, and wheezing (exterior unresolved) requires Gegen Huanglian Huangqin Tang (Kudzu, Coptis, and Scutellaria Decoction) to release Yangming muscle-heat and treat wheezing. Now, post-sweating, sweating with wheezing and no significant heat, and no aversion...