尚有留于表者。微觉烦闷。乃下后之虚邪陷膈。将结未结之征也。
案金鉴。改栀子豉汤。为注解。不可从也。
肘后方。卒客忤死。张仲景诸要方。桂一两。生姜三两。栀子十四枚。豉五合。捣。以酒三升搅。微煮之。
沫出去滓。顿服取瘥。
栀子干姜汤方
栀子（十四个擘） 干姜（一两○成本。玉函。千金翼。作二两。）
上二味。以水三升半。煮取一升半。去滓。分二服。温进一服。得吐者止后服。（三升半。一升半。玉函。
并无半字。吐上。有快字。）
〔柯〕或以丸药下之。心中微烦。外热不去。是知寒气留中。而上焦留热。故任栀子以除烦。用干姜逐内
寒。此甘草泻心之化方也。
圣惠。治赤白痢。无问日数老少。干姜散方。
即本方。入薤白七茎。豉半合。煎服。
杨氏家藏方。二气散。治阴阳痞结。咽膈噎塞。状若梅核。妨碍饮食。久而不愈。即成翻胃。
即本方。用炒栀子。
凡用栀子汤。病患旧微溏者。不可与服之。（玉函。作证其二字。无旧字。）
〔成〕病患旧微溏者。里虚而寒在下也。虽烦则非蕴热。故不可与栀子汤。内经曰。先泄而后生他病者。
治其本。必且调之。后乃治其他病。〔程〕凡治上焦之病者。辄当顾中下。栀子为苦寒之品。病患今受燥邪。不
必其溏否。但旧微溏者。便知中禀素寒。三焦不足。栀子之苦。虽去得上焦之邪。而寒气攻动脏腑。坐生他变。
困辄难支。凡用栀子汤者。俱不可不守此禁。非独虚烦一证也。
太阳病发汗。汗出不解。其人仍发热。心下悸。头眩。身 动。振振欲擗（【原注】一作僻。）地者。
真武汤主之。（玉函。作发其汗而不解。 下。有而字。医学纲目。擗。作 。真武。脉经。千金。千金翼。作
玄武。真武汤方。见少阴篇。）
〔鉴〕大汗出。仍热不解者。阳亡于外也。心下悸筑筑然动。阳虚不能内守也。头眩者。头晕眼黑。阳
微气不能升也。身 动者。蠕蠕然 动。阳虚液涸。失养于经也。振。耸动也。振振欲擗地者。耸动不已。
不能兴起。欲堕于地。阳虚气力不能支也。〔钱〕汗出不解。仍发热者。非仍前表邪发热。乃汗后亡阳。虚阳浮
散于外也。心下悸者。非心悸也。盖心之下。胃脘之上。鸠尾之间。气海之中。灵枢谓膻中为气之海也。误汗
亡阳。则膻中之阳气不充。所以筑筑然跳动也。振振欲擗地。前注不解。而方氏引毛诗注云。擗。拊心也。
喻氏谓无可置身。欲辟地而避处其内。并非也。愚谓振振欲擗地者。即所谓发汗则动经。身为振振摇之意。言
头眩而身体 动。振振然身不能自持。而欲仆地。因卫分之真阳。丧亡于外。周身经脉。总无定主也。方用真
武汤者。非行水导湿。乃补其虚。而复其阳也。
案仍发热者。成氏方氏魏氏锡驹志聪张璐。并以为表邪不解。非是也。又方喻二氏张璐魏氏。以此条证。
为误服大青龙之逆变。钱氏汪氏。驳其执泥。为得矣。
案擗字。与 通。倒也。见唐慧琳藏经音义。可以确钱氏及金鉴之说也。
医学纲目。孙兆治太乙宫道士周德真。患伤寒。发汗出多。惊悸目眩。身战掉欲倒地。众医有欲发汗者。
有作风治者。有用冷药解者。病皆不除。召孙至。曰。太阳经病。得汗早。欲解不解者。因太阳经欲解。复作
汗。肾气不足。汗不来。所以心悸目眩身转。遂作真武汤服之。三服微汗自出遂解。盖真武汤。附子白术。和
其肾气。肾气得行。故汗得来也。若但责太阳者。惟能干涸血液尔。仲景云。尺脉不足。营气不足。不可以汗。
以此知肾气怯。则难得汗也矣。
咽喉干燥者。不可发汗。（脉经。无喉字。玉函。汗上。有其字。）
〔钱〕咽喉干燥者。上焦无津液也。上焦之津液。即下焦升腾之气也。下焦之气液不腾。则咽喉干燥矣。
少阴之脉。循喉咙。挟舌本。热论篇云。少阴脉贯肾络于肺。系舌本。故口燥舌干而渴也。邪在少阴。故气液
不得上腾。即上文尺中微迟之类变也。故曰不可发汗。〔程〕凡遇可汗之证。必当顾虑夫上焦之津液。有如此者。
〔方〕末后无发汗之变。疑有漏落。〔汪〕补亡论。常器之云。可与小柴胡汤。其言于义未合。张璐云。宜小建
中汤。其言犹近乎理。
淋家不可发汗。发汗必便血。（玉函。下汗上。有其字。）
〔程〕淋家热蓄膀胱。肾水必乏。更发汗以竭其津。水腑告匮。徒逼血从小便出耳。凡遇可汗之证。必
当顾虑夫下焦之津液。有如此者。〔汪〕常云。宜猪苓汤。然用于汗后小便血者。亦嫌其过于渗利也。张璐云。
未汗。宜黄 建中汤。盖此汤。用于疮家身疼痛者甚妙。若淋家犹未尽善。
疮家虽身疼痛。不可发汗。汗出则 。（玉函。发汗。作攻其表。 作痉。）
〔锡〕疮家久失脓血。则充肤热肉之血虚矣。虽身疼痛而得太阳之表病。亦不可发汗。汗出必更内伤其筋
脉。血无营筋。强急而为 矣。亡血则 。是以产后及跌扑损伤。多病 。〔钱〕疮家。非谓疥癣之疾也。盖
指大脓大血。痈疽溃疡。杨梅结毒。 疮痘疹马刀侠瘿之属也。身疼痛。伤寒之表证也。言疮家气虚血少。营
卫衰薄。虽或有伤寒身体疼痛等表证。亦慎不可轻发其汗。若误发其汗。则阳气鼓动。阴液外泄。阳亡则不能
柔养。血虚则无以滋灌。所以筋脉劲急而成 也。故仲景于痉病中有云。太阳病。发汗太多。因致 也。岂有
所谓重感寒湿。外风袭虚之说哉。〔汪〕常云。误汗成 。桂枝加葛根汤。其言虽为可取。要不若王日休云。
小建中汤。加归 更妙。
案成氏云。疮家。虽身疼痛如伤寒。不可发汗。柯氏注意亦同。并似失经旨矣。
衄家不可发汗。汗出必额上陷。脉急紧。直视不能 。（【原注】音唤。又胡绢切。下同。一作瞬。）
不得眠。（玉函。发汗。作攻其表。作必额上促急而紧。病源同。促。作菹。外台。引病源。促。作脉。志本。
锡本。 。作 。非。脉经。作必额陷脉上促急而紧。）
〔成〕衄者。上焦亡血也。若发汗则上焦津液枯竭。经络
干涩。故额上陷。脉急紧。诸脉者。皆属于目。筋脉紧急。则牵引其目。故直视不能 也。针经曰。阴气虚则
目不眩。亡血为阴虚。是以不得眠也。〔钱〕脉急紧者。言目系急紧也。 。本作旬。音绚。目摇动也。血虚则
系目之筋脉急紧而直视。所以睛不能转侧而摇动也。〔汪〕常云。可与犀角地黄汤。此不过治衄之常剂。许叔微
云。黄 建中汤夺汗动血。加犀角。夫衄家系阳明经热。上汤恐非阳明药也。吕沧州云。小建中汤加葱豉。误
汗直视者。不可治。大抵衄家具汗证。葱豉专豁阳明经郁热。为对证之的药。
金匮心典曰。血与汗。皆阴也。衄家复汗。则阴重伤矣。脉者血之府。额上陷者。额上两旁之动脉。因血
脱于上。而陷下不起也。脉紧急者。寸口之脉。血不荣而失其柔。如木无液而枝乃劲也。直视不 不眠者。阴
气亡则阳独胜也。经曰。夺血者无汗。此之谓矣。
全书。韩氏曰。此人素有衄血证。非伤寒后如前条之衄也。故不可发汗。
案额上陷。谓额上肉脱。而陷下也。钱氏云。额上。非即额也。额骨坚硬。岂得即陷。盖额以上之囟门也。
魏氏云。额上气虚。陷入脑内。金鉴云。额角上陷中之脉。紧且急也。又案 。说文云。目摇也。而成氏喻氏
云。 瞬。合目也。金鉴亦同。并与经义畔。
亡血家。不可发汗。发汗则寒栗而振。（玉函。脉经。作不可攻其表汗出则。）
〔成〕针经曰。夺血者无汗。夺汗者无血。亡血发汗。则阴阳俱虚。故寒栗而振摇。〔鉴〕凡失血之后。血
气未复。为亡血虚家。皆不可发汗也。盖失血之初。固属阳热。然亡血之后。热随血去。热固消矣。而气随血
亡。阳亦危矣。若再
发汗。则阳气衰微。力不能支。故身寒噤栗。振振耸动。所必然也。〔程〕亡血而更发汗。身内只剩一空壳子。
阳于何有。寒自内生。故栗而振。〔汪〕常云。可与芍药地黄汤。夫亡血家。亦有阴虚发热者。上汤固宜用也。
石顽云。黄 建中汤。误汗振栗。苓桂术甘汤。加当归。据成注云。亡血发汗。则阴阳俱虚。愚以上二汤。皆
亡血家汗后之剂。
案汗后寒栗而振。非余药可议。宜芍药甘草附子汤。人参四逆汤之属。
汗家重发汗。心恍惚心乱。小便已阴疼。与禹余粮丸。（【原注】方本阙。）
〔成〕汗者心之液。汗家重发汗。则心虚。恍惚心乱。夺汗则无水。故小便已阴中疼。〔钱〕恍惚者心神
摇荡。而不能自持。心乱者。神虚意乱。而不能自主也。阴疼者。气弱不利。而茎中涩痛也。〔程〕心主血。
汗者心之液。平素多汗之家。心虚血少可知重发其汗。遂至心失所主。神恍惚而多忡憧之象。此之谓乱。小肠
与心为表里。心液虚。而小肠之水亦竭。自致小便已阴疼。与禹余粮丸。其为养心血。和津液。不急于利小便。
可意及也。
案禹余粮丸。原方阙。仍有数说。未知孰是。今备录下。金鉴云。案禹余粮丸。为涩痢之药。与此证不合。
与禹余粮丸五字。衍文也。汪氏云。补亡论。常器之云。禹余粮一味。火 。散服。亦可。郭白云云。用禹余
粮。不用石。石乃壳也。愚以其言未必尽合仲景原方之义。今姑存之。魏氏云。愚臆度之。即赤石脂禹余粮汤
耳。意在收涩小便。以养心气。镇安心神之义。如理中汤。可以制丸也。周氏载王日休补禹余粮丸方。用禹余
粮赤石脂生梓白皮。各三两。赤小豆半升。捣筛。蜜丸如弹丸大。以水二升。煮取一升。早暮各一服。
张氏亦引王氏。四味。各等分。丸如弹子大。水煮。日二服。蔡正言苏生的镜。补足禹余粮丸。禹余粮一两。
龙骨八钱。牡蛎五钱。铅丹六钱。茯苓六钱。人参五钱。上六味为末。粳米为丸。朱砂为衣。如绿豆大。空心
麻沸汤送下。朱砂所收敛而镇惊。茯苓行水以利小便。加人参以养心血。
病患有寒。复发汗。胃中冷必吐蛔。（【原注】一作逆。）
〔柯〕有寒。是未病时原有寒也。内寒则不能化物。饮食停滞而成蛔。以内寒之人。复感外邪。当温中以逐
寒。若复发其汗。汗生于谷。谷气外散。胃脘阳虚。无谷气以养其蛔。故蛔动而上从口出也。蛔多不止者死。
吐蛔不能食者亦死。〔方〕复。反也。言误也。〔汪〕补亡论。常器之云。可服乌梅丸。郭白云云。宜理中汤。
愚以乌梅丸。乃治吐蛔之药。若于未发汗以前。还宜服理中汤也。
案活人书曰。先服理中丸。次用乌梅丸。金鉴云。宜理中汤。送乌梅丸。张氏云。后人以理中丸。加乌梅
治之。仍不出仲景之成则耳。并此吐蛔以后之方。
本发汗。而复下之。此为逆也。若先发汗。治不为逆。本先下之。而反汗之。为逆。若先下之。治不为逆。
（玉函。无若字。先发汗。先下之下。并有者字。）
〔成〕病在表者。汗之为宜。下之为逆。病在里者。下之为宜。汗之为逆。〔方〕复。与覆同。古字通用。
复亦反也。犹言误也。〔鉴〕若表急于里。本应先汗。而反下之。此为逆也。若先汗而后下。治不为逆也。若里
急于表。本应先下。而反汗之。此为逆也。若先下而后汗。治不为逆也。〔汪〕太约治伤寒之法。表证急者。
即宜汗。里证急者。即宜下。不可拘拘于先汗而后下也。汗下得宜。治不为逆。
伤寒医下之。续得下利。清谷不止。身疼痛者。急当救
里。后身疼痛。清便自调者。急当救表。救里宜四逆汤。救表宜桂枝汤。（上身字下。玉函。有体字。）
〔锡〕此响应上文先下而后汗之之意。以见下之而表里俱虚。又当救里救表。不必拘于先下而复汗之说也。
言伤寒下之而正气内陷。续得里虚之症。下利清谷不止者。虽身疼痛。表症仍在。急当救里。救里之后。身疼
痛而清便自调者。知不在里。仍在表也。急当救表。救里宜四逆汤。以复其阳。救表宜桂枝汤。以解其肌。生
阳复而肌腠解。表里和矣。本经凡曰急者。急不容待。缓则无及矣。〔柯〕身疼本麻黄症。而下利清谷。其腠
理之疏可知。必桂枝汤和营卫。而痛自解。故不曰攻。而仍曰救。救表仍合和中也。〔程〕急救其表。而用桂
枝汤。壮阳以和营卫。诚恐表阳不壮。不但身疼痛不止。并里所新复之阳。顷刻间重为阴。寒所袭。故救之宜
急〔喻〕救里与攻里天渊。若攻里必须先表后里。必无倒行逆施之法。惟在里之阴寒极盛。恐阳气暴脱。不得不
急救其里。俟里症少定。仍救其表。初不敢以一时之权宜。更一定之正法也。厥阴篇。下利腹胀。身体疼痛者。
先温其里。乃攻其表。温里四逆汤。攻表桂枝汤。曰先温。曰乃攻。形容不得已之次第。足互此意。〔宸〕此
大关键。不可不知。若两感者。亦可类推矣。
案清便。方氏喻氏钱氏为小便。非也。详义见于桂枝麻黄各半汤条。
案钱氏汪氏以此条病。为阴阳两证并举。非一证分表里。而用二汤。辨前注之误。却非也。案金匮脏腑经
还有邪气停留在体表。患者微微感到烦闷，这是攻下之后虚邪陷入膈间，即将结聚但尚未完全结聚的征象。
按：《医宗金鉴》将栀子豉汤改为注解，这种观点不可采纳。
《肘后备急方》记载治疗突然客忤致死的情况，张仲景的重要方剂中：桂枝一两，生姜三两，栀子十四个，香豉五合。捣碎后，用酒三升搅拌，微煮。去除浮沫，滤去药渣，一次性服用以治愈。
栀子干姜汤方
栀子（十四个掰开） 干姜（一两○成本、玉函、千金翼作二两。）
以上两味药，用水三升半，煮取一升半，滤去药渣，分两次温服。如果服药后出现呕吐，则停止后续服用。（三升半、一升半，玉函本没有“半”字。“吐”字上，有“快”字。）
〔柯琴〕有的人误用丸药攻下，心中微微烦热，体表发热不退，这说明寒气留滞于中焦，而上焦留有热邪。因此用栀子来清除烦热，用干姜驱逐内寒。这是甘草泻心汤的变方。
《太平圣惠方》治疗赤白痢疾，不论天数多少、年龄老少，使用干姜散方。
即本方加入薤白七茎，香豉半合，煎服。
杨氏家藏方中的二气散，治疗阴阳痞结，咽喉膈部噎塞，感觉像梅核一样，妨碍饮食，久治不愈就会变成翻胃。
即本方，使用炒栀子。
凡是使用栀子汤，如果病人平时大便稀溏，不可以服用。（玉函本作“证其”，无“旧”字。）
〔成无己〕病人平时大便稀溏，说明里虚且寒在下焦。虽然烦热但不是蕴积之热，所以不可以服用栀子汤。《内经》说：先泄泻而后发生其他疾病的，治疗其根本，必须先调理好，然后再治疗其他疾病。〔程应旄〕凡是治疗上焦的疾病，应当顾护中下焦。栀子属于苦寒的药物，病人现在感受燥邪，不一定是否有便溏，但只要平时大便微溏，就知道其中气素来虚寒，三焦不足。栀子的苦味，虽然能去除上焦的邪气，但寒气会攻动脏腑，导致产生其他病变，困顿难以支撑。凡是使用栀子汤的人，都必须遵守这一禁忌，不仅仅是虚烦这一证候。
太阳病发汗后，汗出后病不解，病人仍然发热，心下悸动，头晕目眩，身体震颤动摇，站立不稳想要倒地。真武汤主治。（玉函本作“发其汗而不解”，“身”字下有“而”字。《医学纲目》中，“擗”写作“僻”。真武，《脉经》、《千金》、《千金翼》作“玄武”。真武汤方，见少阴篇。）
〔吴谦〕大汗出后，仍然发热不解，是阳气亡失于外。心下悸动，筑筑然跳动，是阳虚不能内守。头晕目眩，是头晕眼黑，阳气微弱，气不能上升。身体震颤动摇，是蠕蠕然颤动，阳虚液枯，经脉失去滋养。振，耸动。振振欲擗地，是耸动不已，不能起身，想要堕落于地，是阳虚气力不能支撑。〔钱潢〕汗出不解，仍然发热，不是之前的表邪发热，而是汗后亡阳，虚阳浮散于外。心下悸，不是心悸，是在心之下，胃脘之上，鸠尾之间，气海之中。《灵枢》说膻中是气之海。误汗亡阳，则膻中的阳气不充，所以筑筑然跳动。振振欲擗地，前注解释不清，方有执引用《毛诗》注云：“擗，拊心也。”喻嘉言认为无处安身，想要辟地而避处其中，都不对。我认为振振欲擗地，就是所谓“发汗则动经，身为振振摇”的意思，是说头晕而身体震颤，振振然身体不能自持，想要仆倒在地，因为卫分的真阳丧亡于外，周身经脉总无定主。方用真武汤，不是为了行水导湿，而是补其虚，恢复其阳气。
按：关于“仍发热”，成无己、方有执、魏荔彤、张璐都认为是表邪不解，这是不对的。另外方有执、喻嘉言、张璐、魏荔彤，将此条证候认为是误服大青龙汤的逆变，钱潢、汪琥驳斥他们的固执见解，是正确的。
按：“擗”字与“僻”通，意为倒。见于唐慧琳《一切经音义》，可以确证钱氏及《金鉴》的说法。
《医学纲目》记载：孙兆治疗太乙宫道士周德真，患伤寒，发汗过多，惊悸目眩，身体战栗摇晃想要倒地。众医有的想再发汗，有的按风证治疗，有的用冷药解表，病都不除。召孙兆来诊治，说：这是太阳经病，得汗过早，欲解而未解，是因为太阳经欲解时又作汗，肾气不足，汗出不来，所以心悸目眩身体转动。于是制作真武汤让他服用。服三剂后微汗自出，病遂解。盖真武汤中附子、白术，调和肾气，肾气得行，所以汗得来。如果只责求太阳经，只会使血液枯竭。仲景说：尺脉不足，营气不足，不可以发汗。由此可知肾气怯弱，就难得汗了。
咽喉干燥者，不可发汗。（《脉经》无“喉”字。玉函本在“汗”字上有“其”字。）
〔钱潢〕咽喉干燥者，是上焦没有津液。上焦的津液，就是下焦升腾之气。下焦的气液不升腾，则咽喉干燥。少阴的经脉，循行喉咙，挟舌根。《热论篇》说：少阴脉贯肾络于肺，系舌根。所以口燥舌干而渴。邪在少阴，所以气液不得上腾，就是上文尺中微迟之类的变证。所以说不可发汗。〔程应旄〕凡是遇到可汗的证候，必须顾虑到上焦的津液，就像这样。〔方有执〕最后没有发汗的变证，怀疑有漏落。〔汪琥〕《补亡论》常器之说：可与小柴胡汤，这话于理不合。张璐说：宜用小建中汤，这话还近乎合理。
淋家不可发汗，发汗必然导致便血。（玉函本在“汗”字上有“其”字。）
〔程应旄〕淋家热蓄膀胱，肾水必乏，再发汗以竭其津液，水腑告匮，只能逼迫血液从小便出罢了。凡是遇到可汗的证候，必须顾虑到下焦的津液，就像这样。〔汪琥〕常器之说：宜用猪苓汤，然而用于汗后小便血者，也嫌其过于渗利。张璐说：未汗之前，宜用黄芪建中汤。这个汤用于疮家身疼痛者甚妙，若用于淋家还不够完善。
疮家虽身疼痛，不可发汗，汗出则痉。（玉函本“发汗”作“攻其表”，“痉”作“痓”。）
〔魏荔彤〕疮家久失脓血，则充肤热肉的血虚了。虽然身疼痛而得了太阳的表病，也不可发汗。汗出必然更内伤其筋脉，血无营养筋脉，强急而为痉。亡血则致痉。所以产后及跌扑损伤，多病痉。〔钱潢〕疮家，不是说疥癣之疾。是指大脓大血，痈疽溃疡，杨梅结毒，疳疮痘疹马刀侠瘿之类。身疼痛，是伤寒的表证。说疮家气虚血少，营卫衰薄，虽然或有伤寒身体疼痛等表证，也慎不可轻发其汗。若误发其汗，则阳气鼓动，阴液外泄，阳亡则不能柔养，血虚则无以滋灌，所以筋脉劲急而成痉。所以仲景在痉病中说：太阳病，发汗太多，因致痉也。哪里有所谓重感寒湿、外风袭虚的说法呢？〔汪琥〕常器之说：误汗成痉，桂枝加葛根汤，这话虽为可取，不如王日休说的小建中汤加当归更妙。
按：成无己说：疮家，虽身疼痛如伤寒，不可发汗。柯琴注意也相同，都似乎失去了经旨。
衄家不可发汗，汗出必额上陷，脉急紧，直视不能眴，不得眠。（【原注】音唤。又胡绢切，下同。一作瞬。）
〔成无己〕衄，是上焦亡血。若发汗则上焦津液枯竭，经络干涩，所以额上陷，脉急紧。诸脉者，皆属于目。筋脉紧急，则牵引其目，所以直视不能眴。《针经》说：阴气虚则目不眩。亡血为阴虚，所以不得眠。〔钱潢〕脉急紧，是说目系急紧。眴，本作旬，音绚，目摇动也。血虚则系目之筋脉急紧而直视，所以睛不能转侧而摇动。〔汪琥〕常器之说：可与犀角地黄汤，这不过是治衄的常剂。许叔微说：黄芪建中汤夺汗动血，加犀角。夫衄家是阳明经热，上汤恐非阳明药。吕沧州说：小建中汤加葱豉。误汗直视者，不可治。大抵衄家具汗证，葱豉专豁阳明经郁热，为对证之的药。
《金匮心典》说：血与汗，都是阴。衄家复汗，则阴重伤了。脉是血之府。额上陷者，是额上两旁的动脉，因血脱于上，而陷下不起。脉紧急者，寸口之脉，血不荣而失其柔，如木无液而枝乃劲。直视不眴不眠者，阴气亡则阳独胜。经说：夺血者无汗，说的就是这个。
全书韩氏说：此人素有衄血证，不是伤寒后如前条之衄。所以不可发汗。
按：额上陷，谓额上肉脱而陷下。钱氏说：额上，非即额也。额骨坚硬，岂得即陷。盖额以上的囟门。魏氏说：额上气虚，陷入脑内。金鉴说：额角上陷中之脉，紧且急也。又案：眴，《说文》云：目摇也。而成氏、喻氏说：眴瞬，合目也。金鉴也同。都与经义违背。
亡血家，不可发汗，发汗则寒栗而振。（玉函本、《脉经》作“不可攻其表，汗出则”。）
〔成无己〕《针经》说：夺血者无汗，夺汗者无血。亡血发汗，则阴阳俱虚，所以寒栗而振摇。〔吴谦〕凡失血之后，血气未复，为亡血虚家，皆不可发汗。盖失血之初，固属阳热，然亡血之后，热随血去，热固消矣，而气随血亡，阳亦危矣。若再发汗，则阳气衰微，力不能支，故身寒噤栗，振振耸动，所必然也。〔程应旄〕亡血而更发汗，身内只剩一空壳子，阳于何有？寒自内生，故栗而振。〔汪琥〕常器之说：可与芍药地黄汤。夫亡血家，亦有阴虚发热者，上汤固宜用。石顽说：黄芪建中汤。误汗振栗，苓桂术甘汤加当归。据成注云：亡血发汗，则阴阳俱虚。愚以上二汤，皆亡血家汗后之剂。
按：汗后寒栗而振，非余药可议，宜芍药甘草附子汤、人参四逆汤之类。
汗家重发汗，心恍惚心乱，小便已阴疼，与禹余粮丸。（【原注】方本阙。）
〔成无己〕汗者心之液。汗家重发汗，则心虚，恍惚心乱。夺汗则无水，故小便已阴中疼。〔钱潢〕恍惚者心神摇荡而不能自持。心乱者神虚意乱而不能自主。阴疼者气弱不利而茎中涩痛。〔程应旄〕心主血，汗者心之液。平素多汗之家，心虚血少可知。重发其汗，遂至心失所主，神恍惚而多忡憧之象，此之谓乱。小肠与心为表里，心液虚而小肠之水亦竭，自致小便已阴疼。与禹余粮丸，其为养心血，和津液，不急于利小便，可意及也。
按：禹余粮丸，原方缺。仍有数说，未知孰是。今备录如下。金鉴说：案禹余粮丸，为涩痢之药，与此证不合。与禹余粮丸五字，衍文也。汪氏说：《补亡论》常器之说：禹余粮一味，火煅，散服，亦可。郭白云说：用禹余粮，不用石。石乃壳也。愚以其言未必尽合仲景原方之义，今姑存之。魏氏说：愚臆度之，即赤石脂禹余粮汤耳。意在收涩小便，以养心气，镇安心神之义。如理中汤，可以制丸。周氏载王日休补禹余粮丸方，用禹余粮、赤石脂、生梓白皮各三两，赤小豆半升，捣筛，蜜丸如弹丸大，以水二升，煮取一升，早暮各一服。张氏亦引王氏，四味各等分，丸如弹子大，水煮，日二服。蔡正言苏生的镜补足禹余粮丸，禹余粮一两，龙骨八钱，牡蛎五钱，铅丹六钱，茯苓六钱，人参五钱，上六味为末，粳米为丸，朱砂为衣，如绿豆大，空心麻沸汤送下。朱砂所收敛而镇惊，茯苓行水以利小便，加人参以养心血。
病患有寒，复发汗，胃中冷必吐蛔。（【原注】一作逆。）
〔柯琴〕有寒，是未病时原有寒。内寒则不能化物，饮食停滞而成蛔。以内寒之人，复感外邪，当温中以逐寒。若复发其汗，汗生于谷，谷气外散，胃脘阳虚，无谷气以养其蛔，故蛔动而上从口出。蛔多不止者死，吐蛔不能食者亦死。〔方有执〕复，反也。言误也。〔汪琥〕《补亡论》常器之说：可服乌梅丸。郭白云说：宜理中汤。愚以为乌梅丸，乃治吐蛔之药。若于未发汗以前，还宜服理中汤。
按：《活人书》说：先服理中丸，次用乌梅丸。金鉴说：宜理中汤送乌梅丸。张氏说：后人以理中丸加乌梅治之，仍不出仲景之成则耳。并此吐蛔以后之方。
本发汗，而复下之，此为逆也。若先发汗，治不为逆。本先下之，而反汗之，为逆。若先下之，治不为逆。（玉函本无“若”字。先发汗、先下之的下，并有“者”字。）
〔成无己〕病在表者，汗之为宜，下之为逆。病在里者，下之为宜，汗之为逆。〔方有执〕复，与覆同。古字通用。复亦反也。犹言误也。〔吴谦〕若表急于里，本应先汗，而反下之，此为逆也。若先汗而后下，治不为逆也。若里急于表，本应先下，而反汗之，此为逆也。若先下而后汗，治不为逆也。〔汪琥〕大率治伤寒之法，表证急者，即宜汗；里证急者，即宜下。不可拘拘于先汗而后下也。汗下得宜，治不为逆。
伤寒医下之，续得下利，清谷不止，身疼痛者，急当救里。后身疼痛，清便自调者，急当救表。救里宜四逆汤，救表宜桂枝汤。（上身字下，玉函本有“体”字。）
〔魏荔彤〕此响应上文先下而后汗之意，以见下之而表里俱虚，又当救里救表，不必拘于先下而复汗之说。言伤寒下之而正气内陷，续得里虚之症，下利清谷不止者，虽身疼痛，表症仍在，急当救里。救里之后，身疼痛而清便自调者，知不在里，仍在表也，急当救表。救里宜四逆汤，以复其阳。救表宜桂枝汤，以解其肌。生阳复而肌腠解，表里和矣。本经凡曰急者，急不容待，缓则无及。〔柯琴〕身疼本麻黄症，而下利清谷，其腠理之疏可知。必桂枝汤和营卫，而痛自解。故不曰攻，而仍曰救。救表仍合和中。〔程应旄〕急救其表，而用桂枝汤，壮阳以和营卫，诚恐表阳不壮，不但身疼痛不止，并里所新复之阳，顷刻间重为阴寒所袭，故救之宜急。〔喻嘉言〕救里与攻里天渊之别。若攻里必须先表后里，必无倒行逆施之法。惟在里之阴寒极盛，恐阳气暴脱，不得不急救其里，俟里症少定，仍救其表。初不敢以一时之权宜，更一定之正法。厥阴篇：下利腹胀，身体疼痛者，先温其里，乃攻其表。温里四逆汤，攻表桂枝汤。曰先温，曰乃攻，形容不得已之次第，足互此意。〔宸〕此大关键，不可不知。若两感者，亦可类推。
按：清便，方氏、喻氏、钱氏认为是小便，不对。详细义理见于桂枝麻黄各半汤条。
按：钱氏、汪氏以此条病，为阴阳两证并举，非一证分表里而用二汤，辨前注之误，却非。案金匮脏腑经
There remains pathogenic factor lingering in the exterior. The patient feels slightly vexed and stifled; this is a sign that after purgation, deficient pathogenic factor has sunk into the diaphragm region, about to bind but not yet fully bound.
Comment: *Yizong Jinjian* (Medical Standard Golden Mirror) changes Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) to an annotation; this view should not be followed.
*Zhouhou Beiji Fang* (Emergency Prescriptions Kept Up the Sleeve) records treatment for sudden death due to Ke Wu (sudden shock/evil influence). In Zhang Zhongjing's essential prescriptions: Guizhi (Cinnamon Twig) 1 liang, Shengjiang (Fresh Ginger) 3 liang, Zhizi (Gardenia Fruit) 14 pieces, Chichi (Fermented Soybean) 5 he. Pound them, stir with 3 sheng of wine, and simmer slightly. Remove the foam, filter out the dregs, and take all at once to achieve recovery.
**Zhi Zi Gan Jiang Tang (Gardenia and Dried Ginger Decoction) Formula**
Zhizi (Gardenia Fruit) (14 pieces, split open) Ganjiang (Dried Ginger) (1 liang; Cheng Ben, Yuhan, Qianjin Yi versions make it 2 liang.)
Take the above two ingredients, add 3.5 sheng of water, boil to obtain 1.5 sheng, filter out the dregs, divide into two doses, and take warm. If vomiting occurs, stop taking the subsequent dose. (3.5 sheng, 1.5 sheng: Yuhan version lacks the character "half". Above "tu" [vomit], there is the character "kuai" [rapid/comfortable].)
[Ke Qin] Some patients were mistakenly purged with pill medicines, resulting in slight vexation in the heart and persistent heat in the exterior. This indicates that cold pathogen remains in the middle jiao while heat lingers in the upper jiao. Therefore, Zhizi is used to clear vexation, and Ganjiang is used to expel internal cold. This is a modification of Gancao Xiexin Tang (Licorice and Pinellia Decoction to Drain the Epigastrium).
*Tai Ping Sheng Hui Fang* (Holy惠民 Formulas of the Taiping Era) treats red and white dysentery, regardless of duration or age, using Ganjiang San (Dried Ginger Powder).
This is the same formula as above, adding Xiebai (Allium Macrostemon Bulb) 7 stalks and Chichi (Fermented Soybean) half he, decocted and taken orally.
Yang Shi Jia Cang Fang (Yang Family’s Hidden Formulas) contains Er Qi San (Two Qi Powder), treating Yin-Yang obstruction and binding, with choking and blockage in the throat and diaphragm, feeling like a plum pit, hindering eating and drinking. If untreated for a long time, it becomes Fan Wei (Reversal Stomach/Vomiting).
This is the same formula, using fried Zhizi.
Whenever using Zhi Zi Tang (Gardenia Decoction), if the patient has a history of loose stools, it must not be administered. (Yuhan version reads "zheng qi", lacking the character "jiu" [old/past].)
[Cheng Wuji] A patient with a history of loose stools indicates interior deficiency and cold in the lower jiao. Although there is vexation, it is not accumulated heat; therefore, Zhi Zi Tang cannot be used. *Neijing* states: When diarrhea occurs first followed by other diseases, treat the root cause; one must regulate it first before treating other diseases. [Cheng Yingmao] Whenever treating diseases of the upper jiao, one must attend to the middle and lower jiao. Zhizi is a bitter-cold substance. Although the patient currently suffers from dry pathogen, regardless of whether they have loose stools now, if they historically had slight loose stools, it indicates inherent cold in the middle jiao and insufficiency of the three jiao. The bitterness of Zhizi may remove pathogen from the upper jiao, but the cold pathogen will attack the zang-fu organs, causing other complications, leading to exhaustion and inability to withstand. Anyone using Zhi Zi Tang must observe this contraindication, not only for the syndrome of empty vexation.
In Taiyang disease, after inducing sweating, the disease does not resolve. The patient still has fever, palpitations in the epigastrium, dizziness, body tremors and swaying, feeling unstable and wanting to fall to the ground. Zhen Wu Tang (True Warrior Decoction) is the primary treatment. (Yuhan version reads "fa qi han er bu jie"; below "shen" [body], there is the character "er" [and]. *Yixue Gangmu* writes "pi" instead of "bi". *Zhenwu*, *Mai Jing*, *Qianjin*, *Qianjin Yi* write "Xuanwu". Zhenwu Tang formula is seen in Shaoyin chapter.)
[Wu Qian] Profuse sweating with persistent unresolved heat indicates Yang collapse on the exterior. Palpitations in the epigastrium, beating violently, indicate Yang deficiency failing to hold inwardly. Dizziness and vertigo indicate head spinning and blacking out, where Yang is weak and Qi cannot ascend. Body trembling and swaying indicates wriggling movement, where Yang deficiency leads to fluid depletion and loss of nourishment to the meridians. "Zhen" means shaking/trembling. "Zhenzhen yu bi di" means shaking incessantly, unable to rise, wanting to fall to the ground, indicating Yang deficiency and lack of strength to support. [Qian Huang] Sweating without resolution and persistent fever is not the previous exterior pathogen fever, but post-sweating Yang collapse, with deficient Yang floating and scattering outward. "Heart under palpitation" is not heart palpitation itself, but located below the heart, above the stomach, between Jiutui and Qihai. *Ling Shu* states Danzhong is the Sea of Qi. Mistaken sweating causes Yang collapse, so Yang in Danzhong is insufficient, hence the violent beating. "Zhenzhen yu bi di": previous annotations are unclear. Fang Youzhi cites *Mao Shi* commentary: "Bi, strike the heart." Yu Jiayan argues it means having nowhere to place oneself, wanting to open the ground to hide inside; both are incorrect. I believe "Zhenzhen yu bi di" refers to "sweating moves the meridians, body shakes and sways," meaning dizziness and body tremors, unable to control oneself, wanting to collapse, because True Yang of the Wei division has collapsed outward, and the whole body's meridians lack a master. The formula uses Zhen Wu Tang not to move water and drain dampness, but to tonify deficiency and restore Yang.
Note: Regarding "still fever," Cheng Wuji, Fang Youzhi, Wei Litong, and Zhang Lu all consider it unresolved exterior pathogen, which is incorrect. Additionally, Fang Youzhi, Yu Jiayan, Zhang Lu, and Wei Litong regard this clause as a reverse reaction from mistakenly taking Da Qing Long Tang. Qian Huang and Wang Hu refute their rigid views, which is correct.
Note: The character "Bi" is interchangeable with "Pi," meaning to fall/collapse. Seen in Tang Hui Lin's *Yiqie Jing Yinyi*; this confirms the views of Qian and *Jin Jian*.
*Yixue Gangmu* records: Sun Zhao treated Daoist Zhou Dezhen of Taiyi Palace who suffered from Shang Han. After profuse sweating, he experienced palpitations, dizziness, body tremors, and wanted to fall. Other doctors tried sweating again, wind-treatment, or cold herbs, but the illness persisted. Sun Zhao was summoned and said: This is Taiyang channel disease. Sweating too early prevents resolution. Because Taiyang channel wants to resolve, it tries to sweat again, but Kidney Qi is insufficient, so sweat does not come, causing palpitations, dizziness, and body turning. He prescribed Zhen Wu Tang. After three doses, slight sweat came out naturally, and the disease resolved. Zhen Wu Tang contains Fuzi and Baizhu to harmonize Kidney Qi; when Kidney Qi moves, sweat comes. If one only blames Taiyang, it will only dry up blood. Zhongjing says: If Chi pulse is insufficient and Ying Qi is deficient, do not sweat. Thus, we know that if Kidney Qi is timid, sweat is hard to obtain.
If the throat is dry, do not induce sweating. (*Mai Jing* lacks the character "Hou". Yuhan version adds "Qi" above "Han".)
[Qian Huang] Dry throat indicates no fluids in the upper jiao. Fluids in the upper jiao are the ascending Qi from the lower jiao. If Qi and fluids of the lower jiao do not ascend, the throat becomes dry. The Shaoyin channel runs along the throat and flanks the tongue root. *Re Lun Pian* states: Shaoyin channel pierces Kidney, connects to Lung, and ties to tongue root. Hence dry mouth, tongue, and thirst. Pathogen in Shaoyin prevents Qi and fluids from ascending; this is a variation of the Chi pulse being slightly slow mentioned earlier. Hence, do not induce sweating. [Cheng Yingmao] Whenever encountering a syndrome suitable for sweating, one must consider the fluids of the upper jiao, as shown here. [Fang Youzhi] There is no variation regarding sweating at the end; suspect missing text. [Wang Hu] *Bu Wang Lun* Chang Qizhi says: Xiao Chai Hu Tang (Minor Bupleurum Decoction) can be given; this statement does not fit the principle. Zhang Lu says: Xiao Jian Zhong Tang (Minor Construct the Middle Decoction) is suitable; this statement is closer to reason.
Patients with chronic strangury (Lin) must not be sweated; sweating will inevitably cause blood in urine. (Yuhan version adds "Qi" above "Han".)
[Cheng Yingmao] Patients with chronic strangury have heat accumulating in the Bladder and必定 lack of Kidney Water. Further sweating exhausts their fluids; the Water Fu organ reports shortage, forcing blood out through the small intestine. Whenever encountering a syndrome suitable for sweating, one must consider the fluids of the lower jiao, as shown here. [Wang Hu] Chang says: Zhu Ling Tang (Polyporus Decoction) is suitable. However, using it for hematuria after sweating is considered too draining. Zhang Lu says: Before sweating, Huangqi Jian Zhong Tang (Astragalus Construct the Middle Decoction) is suitable. This formula is excellent for body pain in Chuang Jia (sores/ulcers patients), but not perfect for Lin Jia.
Patients with chronic sores (Chuang Jia), even if they have body pain, must not be sweated; sweating will cause Jing (spasm/stiffness). (Yuhan version reads "Gong Qi Biao" [attack the exterior] for "Fa Han" [induce sweat], and "Zhi" [stiffness] for "Jing" [spasm].)
[Wei Litong] Chronic sore patients have lost pus and blood for a long time, leading to deficiency of blood that nourishes skin and muscles. Even if they have Taiyang exterior symptoms with body pain, do not induce sweating. Sweating will further damage tendons and vessels internally; without blood to nourish tendons, they become stiff and spastic. Blood loss leads to spasm. Hence, postpartum women and those with falls/injuries often suffer from spasm. [Qian Huang] "Chuang Jia" does not refer to scabies or tinea. It refers to large abscesses, ulcers, syphilis chancres, herpes zoster, smallpox, scrofula, etc. Body pain is an exterior symptom of Shang Han. It means that Chuang Jia patients have Qi deficiency and blood scarcity, with weakened Ying and Wei. Even if they have exterior symptoms like body pain from Shang Han, one must be cautious not to lightly induce sweating. If mistakenly induced, Yang Qi agitates, Yin fluids leak outward. Yang collapse cannot soften/nourish; blood deficiency cannot moisten/nourish. Hence tendons and vessels become tense and spasm results. Zhongjing stated in Jing Bing: Taiyang disease, excessive sweating leads to spasm. Where is the talk of re-contracting cold-damp or external wind attacking deficiency? [Wang Hu] Chang says: Mistaken sweating causing spasm, Guizhi Jia Gegen Tang (Cinnamon Twig plus Kudzu Decoction) is acceptable, but not as good as Wang Riyou’s suggestion of Xiao Jian Zhong Tang plus Danggui.
Note: Cheng Wuji says: Chuang Jia, even if body pain resembles Shang Han, do not induce sweating. Ke Qin’s attention is the same; both seem to miss the original intent of the classic.
Patients with chronic nosebleeds (Nu Jia) must not be sweated; sweating will cause depression of the arteries above the forehead, tight and urgent pulse, fixed staring gaze unable to blink, and insomnia. (Original note: Pronounced huan. Also hu juan qie, same below. One version says Shun [blink].)
[Cheng Wuji] Nu is loss of blood in the upper jiao. If sweating is induced, upper jiao fluids dry up, meridians become dry and rough, causing depression of forehead arteries and tight pulse. All meridians belong to the eyes. Tense tendons and vessels pull the eyes, causing fixed staring and inability to blink. *Zhen Jing* states: Deficiency of Yin Qi causes eye dizziness. Loss of blood is Yin deficiency, hence insomnia. [Qian Huang] Tight pulse refers to tension in the eye connections. "Shun" originally written as "Xun", pronounced xuan, means eye trembling. Blood deficiency makes tendons connecting to eyes tense and fixed, so eyes cannot turn or tremble. [Wang Hu] Chang says: Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction) can be given; this is merely a standard formula for nosebleeds. Xu Shuaiwei says: Huangqi Jian Zhong Tang causes sweating and moving blood, add Xijiao. Nu Jia is Yangming channel heat; the above formula is likely not a Yangming medicine. Lv Cangzhou says: Xiao Jian Zhong Tang plus Congchi. If mistaken sweating causes fixed stare, it is untreatable. Generally, Nu Jia presents with sweating syndrome; Congchi specifically clears Yangming channel stagnant heat, acting as the specific remedy.
*Jingui Xin Dian* states: Blood and sweat are both Yin. Nu Jia sweating again injures Yin severely. Pulse is the mansion of blood. Depression of forehead arteries refers to the temporal arteries on both sides of the forehead sinking due to blood loss above. Tight pulse means the Cun Kou pulse loses softness due to lack of blood nourishment, like wood without sap becoming stiff. Fixed stare, inability to blink, and insomnia mean Yin collapse leaves Yang alone victorious. Classic states: Those who lose blood should not sweat; this is what is meant.
Quan Shu Han Shi says: This person has a chronic history of nosebleeds, not nosebleeds after Shang Han as in the previous clause. Hence, do not induce sweating.
Note: "Forehead depression" means flesh of the forehead wastes away and sinks. Qian Shi says: Forehead is not just the forehead bone. Forehead bone is hard, how can it sink? It refers to the fontanelle above the forehead. Wei Shi says: Qi deficiency in forehead sinks into brain. *Jin Jian* says: The artery in the depression of the forehead corner is tight and urgent. Another note: "Shun", *Shuo Wen* says: Eye trembling. But Cheng Wuji and Yu Jiayan say: Shun Shun means closing eyes. *Jin Jian* agrees. Both contradict the classic meaning.
Patients with chronic blood loss (Wang Xue Jia) must not be sweated; sweating will cause chills and tremors. (Yuhan version, *Mai Jing* read: "Do not attack the exterior; if sweat comes out...")
[Cheng Wuji] *Zhen Jing* states: Those who lose blood have no sweat; those who lose sweat have no blood. Sweating in blood-loss patients causes dual deficiency of Yin and Yang, hence chills and tremors. [Wu Qian] After any blood loss, before Qi and Blood recover, they are blood-loss deficient patients; none should be sweated. Initially, blood loss belongs to Yang Heat, but after blood loss, heat goes with blood, so heat dissipates. However, Qi follows blood loss, so Yang is also endangered. If sweating is induced again, Yang Qi becomes weak and unable to support, hence body cold, teeth chattering, and trembling, which is inevitable. [Cheng Yingmao] Sweating in blood-loss patients leaves only an empty shell inside; where is Yang? Cold generates internally, hence chills and tremors. [Wang Hu] Chang says: Shaoyao Dihuang Tang (Peony and Rehmannia Decoction) can be given. Blood-loss patients may also have Yin deficiency fever; the above formula is indeed suitable. Shiweng says: Huangqi Jian Zhong Tang. For trembling/chills after mistaken sweating, Linggui Zhugan Tang plus Danggui. According to Cheng’s annotation: Sweating in blood-loss causes dual deficiency of Yin and Yang. I believe these two formulas are post-sweating treatments for blood-loss patients.
Note: Chills and tremors after sweating cannot be discussed with other medicines;适宜 Shaoyao Gancao Fuzi Tang (Peony, Licorice, and Aconite Decoction) or Renshen Sini Tang (Ginseng and Four Reversal Decoction) types.
Patients prone to sweating (Han Jia) subjected to heavy sweating experience vague mind and mental confusion, and pain in the genitalia after urination. Give Yuyuliang Wan (Hematite Pill). (Original note: Formula originally missing.)
[Cheng Wuji] Sweat is the fluid of the Heart. Heavy sweating in patients prone to sweating causes Heart deficiency, vagueness, and mental confusion. Depletion of sweat leads to lack of water, hence pain in the urethra after urination. [Qian Huang] Vagueness means heart spirit oscillates and cannot hold itself. Mental confusion means spirit is weak and thoughts chaotic, unable to control itself. Genital pain means Qi is weak and unsmooth, causing涩 pain in the penis. [Cheng Yingmao] Heart governs Blood; sweat is Heart fluid. Patients prone to sweating clearly have Heart deficiency and blood scarcity. Heavy sweating causes Heart to lose its mastery, spirit becomes vague with many palpitations; this is called confusion. Small Intestine and Heart are exterior-interior partners. Heart fluid deficiency leads to Small Intestine water exhaustion, causing genital pain after urination. Giving Yuyuliang Wan aims to nourish Heart blood and harmonize fluids, not urgently promoting urination, which can be understood.
Note: Yuyuliang Wan original formula is missing. There are several theories; unknown which is correct. Recorded below for reference. *Jin Jian* says: Yuyuliang Wan is astringent for dysentery, incompatible with this syndrome. The five characters "Give Yuyuliang Wan" are superfluous. Wang Shi says: *Bu Wang Lun* Chang Qizhi says: Single herb Yuyuliang, calcined, taken as powder, is also acceptable. Guo Baiyun says: Use Yuyuliang, not Shi (stone). Shi is the shell. I think his words may not fully match Zhongjing’s original intent; kept for now. Wei Shi says: By conjecture, it is Chishizhi Yuyuliang Tang (Red Stone and Hematite Decoction). Intent is to astringe urine to nourish Heart Qi and calm Heart Spirit. Like Lizhong Tang, it can be made into pills. Zhou Shi records Wang Riyou’s supplemented Yuyuliang Wan formula: Yuyuliang, Chishizhi, Shengzipipi each 3 liang, Chixiaodou half sheng, pound and sift, honey pills like bullet size, boil in 2 sheng water to get 1 sheng, take morning and evening. Zhang Shi also cites Wang Shi: Four ingredients equal parts, pill like egg size, boil water, twice daily. Cai Zhengyan’s *Susheng de Jing* supplements Yuyuliang Wan: Yuyuliang 1 liang, Longgu 8 qian, Muli 5 qian, Qiandan 6 qian, Fuling 6 qian, Renshen 5 qian. Six ingredients powdered, rice paste pills, Cinnabar coating, size of mung bean, taken with boiling rice water on empty stomach. Cinnabar astringes and calms fright; Fuling moves water to benefit urination; added Renshen to nourish Heart blood.
Patient suffering from cold, if sweating is induced again, stomach becomes cold and必定 vomits roundworms. (Original note: One version reads "Ni" [reverse/regurgitate].)
[Ke Qin] "Having cold" means pre-existing cold before illness. Internal cold cannot transform food; diet stagnates and forms roundworms. In a person with internal cold contracting external pathogen, one should warm middle and expel cold. If sweating is induced again, sweat is born from grain; grain Qi scatters outward, Stomach Yang becomes deficient, lacking grain Qi to nourish roundworms, hence roundworms move upward and exit from mouth. Many roundworms not stopping leads to death; vomiting roundworms and inability to eat also leads to death. [Fang Youzhi] "Fu" means "Fan" [reverse/opposite]. Means error. [Wang Hu] *Bu Wang Lun* Chang Qizhi says: Wumei Wan (Mume Pill) can be taken. Guo Baiyun says: Lizhong Tang is suitable. I believe Wumei Wan treats vomiting roundworms. But before sweating, Lizhong Tang should be taken.
Note: *Huo Ren Shu* says: Take Lizhong Wan first, then use Wumei Wan. *Jin Jian* says: Lizhong Tang sending Wumei Wan. Zhang Shi says: Later generations treat with Lizhong Wan plus Wumei; this still does not exceed Zhongjing’s established rules. And this formula after vomiting roundworms.
Originally intended to sweat, but subsequently purged; this is a mistake (Ni). If sweating is done first, treatment is not a mistake. Originally intended to purge, but mistakenly sweated; this is a mistake. If purging is done first, treatment is not a mistake. (Yuhan version lacks "Ruo" [if]. Below "Xian Fa Han" and "Xian Xia Zhi", there is the character "Zhe" [particle].)
[Cheng Wuji] Disease in exterior, sweating is appropriate, purging is mistake. Disease in interior, purging is appropriate, sweating is mistake. [Fang Youzhi] "Fu" is same as "Fu" [cover/reverse]. Ancient characters interchangeable. "Fu" also means "Fan" [reverse]. Means error. [Wu Qian] If exterior urgency exceeds interior, originally should sweat first, but mistakenly purged; this is a mistake. If sweat first then purge, treatment is not a mistake. If interior urgency exceeds exterior, originally should purge first, but mistakenly sweated; this is a mistake. If purge first then sweat, treatment is not a mistake. [Wang Hu] Generally, treating Shang Han: if exterior syndrome is urgent, sweat immediately; if interior syndrome is urgent, purge immediately. Do not rigidly adhere to sweat first then purge. If sweating and purging are appropriate, treatment is not a mistake.
Shang Han, doctor purges, subsequently develops diarrhea with undigested food continuing endlessly. If body pain exists, urgently save the interior. Later, if body pain persists but stool/urine normalizes, urgently save the exterior. Saving interior suits Sini Tang (Four Reversal Decoction); saving exterior suits Guizhi Tang (Cinnamon Twig Decoction). (Below "Shang Shen" character, Yuhan version has "Ti" [body] character.)
[Wei Litong] This response echoes the meaning of "purge first then sweat" above, showing that purging causes both exterior and interior deficiency, requiring saving interior and exterior, not rigidly adhering to "purge then sweat" theory. Shang Han purged causes righteous Qi to sink inward, subsequently developing interior deficiency symptoms. Endless diarrhea with undigested food: although body pain exists, exterior syndrome remains; urgently save interior. After saving interior, if body pain persists but stool/urine normalizes, know it is not in interior, but still in exterior; urgently save exterior. Saving interior uses Sini Tang to restore Yang. Saving exterior uses Guizhi Tang to release muscle layer. Restored Yang and released muscle layers bring harmony to exterior and interior. Whenever the classic says "urgent," it means waiting is impossible; delaying is futile. [Ke Qin] Body pain is originally Mahuang syndrome, but with diarrhea and undigested food, pore openness is known. Must use Guizhi Tang to harmonize Ying and Wei, and pain resolves naturally. Hence not called "attack," but "save." Saving exterior still involves harmonizing middle. [Cheng Yingmao] Urgently save exterior using Guizhi Tang, strengthen Yang to harmonize Ying and Wei, fearing that if exterior Yang is not strong, not only will body pain persist, but newly restored interior Yang will instantly be attacked by Yin cold again; hence saving must be urgent. [Yu Jiayan] Saving interior is vastly different from attacking interior. If attacking interior requires exterior first, there is no method of acting backwards. Only when interior Yin cold is extremely severe, fearing sudden Yang collapse, must one urgently save interior, wait for interior symptoms to stabilize, then save exterior. Dare not use temporary expediency to change fixed orthodox law. Jueyin chapter: Diarrhea with abdominal distension and body pain, first warm interior, then attack exterior. Warm interior Sini Tang, attack exterior Guizhi Tang. Saying "first warm," "then attack" describes unavoidable sequence, sufficient to complement this meaning. [Chen] This is a major key point, must know. If Liang Gan (double contraction) cases exist, can be inferred analogously.
Note: "Qing Bian" (clear stool/urine), Fang Shi, Yu Shi, Qian Shi interpret as urine, which is incorrect. Detailed meaning is seen in Guizhi Mahuang Ge Ban Tang clause.
Note: Qian Shi and Wang Shi regard this clause’s disease as simultaneous presentation of Yin and Yang syndromes, not one syndrome divided into exterior/interior using two formulas, refuting previous annotations’ errors; this is incorrect. Note Jingui Zangfu Jing...