太阳病。桂枝证。医反下之。利遂不止。脉促者。表未解也。喘而汗出者。葛根黄连黄芩汤主
之。
太阳中风发热。本当桂枝解表。而反下之。里虚邪入。利遂不止。其脉则促。其证则喘而汗出。
夫促为阳盛。脉促者。知表未解也。无汗而喘。为寒在表。喘而汗出。为热在里也。是其邪陷于
里者十之七。而留于表者十之三。其病为表里并受之病。故其法亦宜表里两解之法。葛根黄连黄
芩汤。葛根解肌于表。芩、连清热于里。甘草则合表里而并和之耳。盖风邪国中。病为在表。一入
于里。则变为热矣。故治表者。必
以葛根之辛凉。治里者。必以芩、连之苦寒也。而古法汗者不以偶。下者不以奇。故葛根之表。
则数多而独行。芩、连之里。则数少而并须。仲景矩 。秩然不紊如此。
葛根黄连黄芩汤方
葛根（半斤） 甘草（二两炙） 黄芩（二两） 黄连（三两）
上四味。以水八升。先煮葛根。减二升。纳诸药。煮取二升。去滓。分温再服。
太阳病。外证未除。而数下之。遂协热而利。利下不止。心下痞硬。表里不解者。桂枝人参汤主
之。
太阳误下自利。而又表里不解。与上条同。然曰数下。则气屡伤矣。曰利下不止。则虚复甚矣。
虽心下痞硬。亦是正虚失运之故。是宜桂枝之辛。以解其表。参、术、姜、草之甘温。以安其里
。而不可以葛根攻表。亦不得以芩、连清里。治如上条之例矣。
桂枝人参汤方
桂枝（四两） 干姜（三两） 白术（三两） 人参（三两） 炙甘草（四两）
上五味。以水九升。先煮四味。取五升。纳桂。更煮取三升。温服一升。日再。夜一服。
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。
伤寒下后。邪气变热。乘虚入里者。则为挟热下利。其邪未入里而脏虚生寒者。则为下利清
谷。各因其
人邪气之寒热。与脏气之阴阳而为病也。身疼痛者。邪在表也。然脏气不充。则无以为发汗散邪
之地。故必以温药。舍其表而救其里。服后清便自调。里气已固。而身痛不除。则又以甘辛发散
为急。不然。表之邪又将入里而增患矣。而救里用四逆。救表用桂枝。与厥阴篇下利腹胀满身疼痛
条略同。彼为寒邪中阴。此为寒药伤里。而其温中散邪、先表后里之法。则一也。
太阳病。二三日。不能卧。但欲起。心下必结。脉微弱者。此本有寒分也。反下之。若利止。
必作结胸。未止者。四日复下之。此作协热利也。
太阳病。二三日。为病未久也。不能卧。但欲起者。心下结满。卧则气愈壅而不安也。脉微
弱。阳气衰少也。夫二三日。为病未久。则寒未变热。而脉又微弱。知其结于心下者。为寒分而非
热分矣。寒分者。病属于寒。故谓寒分。犹金匮所谓血分气分水分也。寒则不可下。而医反下之
里虚寒入。必为下利不止。若利止。必作结胸者。寒邪从阳之化。而上结于阳位也。若未止。四
日复下之者。寒已变热。转为协热下利。故须复下。以尽其邪。所谓在下者。引而竭之也。总之。
寒邪中人。久必变热。而邪不上结。势必下注。仲景反复详论。所以诏示后人者深矣。
伤寒服汤药。下利不止。心下痞硬。服泻心汤已。复以他药下之。利不止。医以理中与之。
利益甚。理中者。理中焦。此利在下焦。赤石脂禹余粮汤主之。复利不止者。当利其小便。
汤药亦下药也。下后下利痞硬。泻心汤是已。而复以他药下之。以虚益虚。邪气虽去。下焦
不约。利无止
期。故不宜参、术、姜、草之安中。而宜赤脂、禹粮之固下也。乃服之而利犹不止。则是下焦分
注之所清浊不别故也。故当利其小便。
赤石脂禹余粮汤方
赤石脂（一斤碎） 禹余粮（一斤碎）
上二味。以水六升。煮取二升。去滓。分温三服。
太阳病，具备桂枝汤证的表现，医生反而使用攻下法，导致腹泻不止。若脉象急促，说明表邪尚未解除；若伴有气喘且出汗，应使用葛根黄芩黄连汤主治。
太阳中风发热，本应当用桂枝汤解表，却反而使用攻下法，导致里气虚弱、邪气内陷，腹泻不止。此时脉象急促，症状表现为气喘且出汗。急促的脉象代表阳气偏盛，脉促说明表邪未解。无汗而气喘，是寒邪在表；气喘且出汗，是热邪在里。因此，邪气陷入体内的占十分之七，留在体表的占十分之三。这是表里同病的证候，所以治疗法则也应当采用表里双解的方法。葛根黄芩黄连汤中，葛根在表解除肌邪，黄芩、黄连在里清除热邪，甘草则调和表里。风邪郁于肌表，病位在表，一旦进入体内，就会转化为热邪。所以治疗表证，必须用葛根的辛凉之性；治疗里证，必须用黄芩、黄连的苦寒之性。古代方剂配伍原则中，发汗药不以偶数配伍，攻下药不以奇数配伍。因此，葛根治表，用量多且单独重用；黄芩、黄连治里，用量少且共同使用。张仲景的法度严谨，井然有序如此。
葛根黄芩黄连汤方
葛根（半斤） 甘草（二两，炙） 黄芩（二两） 黄连（三两）
以上四味药，用水八升，先煮葛根，减少二升水，再加入其他药物，煮取二升药液，去渣，分两次温服。
太阳病，表证未除，却多次使用攻下法，导致协热利，腹泻不止，胃脘部痞塞坚硬，表里均未能解除，应使用桂枝人参汤主治。
太阳病误用攻下法导致自利，且表里证均未解除，与上一条相同。但提到“多次攻下”，说明正气屡受损伤；提到“腹泻不止”，说明虚损更加严重。虽然出现胃脘痞塞坚硬，这也是正气虚弱、运化失职的缘故。适宜用桂枝的辛散以解表，用人参、白术、干姜、甘草的甘温以安里。不能用葛根来攻表，也不能用黄芩、黄连来清里，治疗方法参照上一条的例程。
桂枝人参汤方
桂枝（四两） 干姜（三两） 白术（三两） 人参（三两） 炙甘草（四两）
以上五味药，用水九升，先煮前四味药，取五升药液，加入桂枝，再煮取三升药液，每次温服一升，每日两次，夜间一次。
伤寒，医生使用攻下法后，接着出现腹泻，完谷不化且不止，身体疼痛的，应当紧急救治里证；后来身体疼痛，大小便正常的，应当紧急救治表证。救治里证适宜用四逆汤，救治表证适宜用桂枝汤。
伤寒攻下后，邪气化热，乘虚入里，则为挟热下利；邪气未入里而脏腑虚寒内生，则为下利清谷。这取决于患者邪气的寒热性质以及脏腑阴阳的状态而发病。身体疼痛，说明邪气在表。然而如果脏腑之气不充盛，就没有作为发汗散邪的基础。所以必须用温药，舍弃表证而急救里证。服药后大小便正常，说明里气已固，如果身体疼痛仍未消除，则又以甘辛发散之法为急务。否则，表邪又将入里增加病患。救里用四逆汤，救表用桂枝汤，这与《厥阴篇》中关于下利、腹胀满、身体疼痛的条文大致相同。彼处是寒邪中于阴经，此处是寒凉药物损伤里气，但其温中散邪、先救里后解表的原则是一致的。
太阳病，经过两三天，不能躺卧，只想坐起，心下部必然痞结，脉象微弱的，这是因为原本就有寒饮停聚。医生反而使用攻下法，如果腹泻停止，必然会形成结胸证；如果腹泻未止，第四天再次使用攻下法，这会形成协热利。
太阳病，经过两三天，病程尚短。不能躺卧，只想坐起，是因为心下部痞结胀满，躺下则气机更加壅滞而不安。脉象微弱，说明阳气衰少。病程尚短，说明寒邪尚未化热，而脉又微弱，可知心下痞结属于寒饮而非热邪。所谓“寒分”，即病属寒邪，故称寒分，如同《金匮要略》中所说的血分、气分、水分一样。寒邪不可攻下，医生反而攻下，导致里虚寒邪内陷，必然导致腹泻不止。如果腹泻停止，必然形成结胸，这是寒邪从阳化热，向上结聚于阳位所致。如果腹泻未止，第四天再次攻下，是因为寒邪已化为热邪，转为协热下利，所以需要再次攻下以祛除尽邪气，这就是所谓的“其在下者，引而竭之”。总之，寒邪侵入人体，久留必会化热，邪气如果不向上结聚，势必向下注泄。张仲景反复详细论述，以此来教导后人，用意深远。
伤寒服用汤药后，腹泻不止，胃脘痞塞坚硬，服用泻心汤后，医生又用其他药物攻下，导致腹泻不止。医生用理中汤治疗，腹泻反而加重。理中汤是调理中焦的，此处的腹泻病位在下焦，应使用赤石脂禹余粮汤主治。如果再次服用仍腹泻不止，应当通利小便。
汤药也是下药的一种。攻下后出现腹泻和痞硬，服用泻心汤是正确的。但又用其他药物攻下，使虚者更虚，虽然邪气已去，但下焦约束无力，腹泻没有止期。所以不宜用人参、白术、干姜、甘草来安定中焦，而宜用赤石脂、禹余粮来固涩止泻。如果服用后腹泻仍然不止，则是下焦分清泌浊功能失常所致。所以应当通利小便。
Taiyang disease (Disease of the Taiyang/Bladder channel) presenting with Guizhi Tang (Cinnamon Twig Decoction) syndrome, yet the physician erroneously applied purgation. Consequently, diarrhea persisted unceasingly. If the pulse is rapid and surging (Cu Mai), it indicates that the exterior pathogen has not yet been resolved. If accompanied by wheezing and sweating, Gegen Huanglian Huangqin Tang (Kudzu Root, Coptis, and Scutellaria Decoction) should be administered.
In Taiyang wind-stroke (Zhongfeng) with fever, the proper treatment is to release the exterior with Guizhi Tang. However, erroneous purgation leads to interior deficiency and invasion of pathogens, resulting in persistent diarrhea. The pulse becomes rapid and surging, and symptoms include wheezing and sweating. A rapid and surging pulse signifies excess Yang; thus, it confirms the exterior pathogen remains unresolved. Wheezing without sweating indicates cold in the exterior, whereas wheezing with sweating indicates heat in the interior. Therefore, seven-tenths of the pathogen has sunk into the interior, while three-tenths remain in the exterior. This constitutes a disease affecting both the exterior and interior simultaneously; hence, the therapeutic method should address both. In Gegen Huanglian Huangqin Tang, Gegen (Puerariae Radix) releases muscle-layer tension from the exterior, while Huangqin (Scutellariae Radix) and Huanglian (Coptidis Rhizoma) clear heat from the interior. Gancao (Glycyrrhizae Radix et Rhizoma) harmonizes both the exterior and interior. Wind pathogen stagnating in the muscle layer implies the disease is in the exterior; once entering the interior, it transforms into heat. Thus, treating the exterior requires the acrid-cool nature of Gegen, while treating the interior requires the bitter-cold nature of Huangqin and Huanglian. According to ancient prescription principles, diaphoretic formulas do not use even-numbered ingredient pairings, while purgative formulas do not use odd-numbered ones. Therefore, for the exterior, Gegen is used in larger quantities and acts independently; for the interior, Huangqin and Huanglian are used in smaller quantities and act jointly. Zhang Zhongjing’s methodology is rigorous and orderly.
**Gegen Huanglian Huangqin Tang Formula**
Gegen (Puerariae Radix) - 8 liang
Gancao (Glycyrrhizae Radix et Rhizoma Praeparata cum Melle) - 2 liang, honey-fried
Huangqin (Scutellariae Radix) - 2 liang
Huanglian (Coptidis Rhizoma) - 3 liang
Take these four ingredients, add eight sheng of water. First decoct Gegen until the volume reduces by two sheng. Then add the remaining herbs. Decoct until two sheng remain. Strain. Divide into two warm doses.
In Taiyang disease, if the exterior syndrome persists but purgation is applied repeatedly, it leads to "xie re" (collateral heat) diarrhea, which is unceasing, accompanied by epigastric fullness and hardness, indicating that neither the exterior nor the interior is resolved. Guizhi Renshen Tang (Cinnamon Twig and Ginseng Decoction) should be administered.
Erroneous purgation in Taiyang disease causing spontaneous diarrhea, with both exterior and interior syndromes unresolved, is similar to the previous clause. However, "repeated purgation" implies frequent injury to Qi; "unceasing diarrhea" indicates severe deficiency. Although epigastric fullness and hardness are present, this is due to deficiency of righteous Qi and failure of transportation. It is appropriate to use the acrid property of Guizhi to release the exterior, and the sweet-warm properties of Renshen (Ginseng Radix et Rhizoma), Baizhu (Atractylodis Macrocephalae Rhizoma), Ganjiang (Zingiberis Rhizoma), and Gancao to stabilize the interior. One must not use Gegen to attack the exterior, nor Huangqin and Huanglian to clear the interior. The treatment follows the precedent of the previous clause.
**Guizhi Renshen Tang Formula**
Guizhi (Cinnamomi Ramulus) - 4 liang
Ganjiang (Zingiberis Rhizoma) - 3 liang
Baizhu (Atractylodis Macrocephalae Rhizoma) - 3 liang
Renshen (Ginseng Radix et Rhizoma) - 3 liang
Zhi Gancao (Glycyrrhizae Radix et Rhizoma Praeparata cum Melle) - 4 liang
Take these five ingredients, add nine sheng of water. First decoct the first four ingredients until five sheng remain. Add Guizhi. Decoct again until three sheng remain. Take one sheng warm, twice daily and once at night.
In Shanghan (Cold Damage), after the physician applies purgation, if diarrhea ensues with undigested food (qing gu) persisting, and body pain is present, urgent rescue of the interior is required. Later, if body pain persists but defecation and urination normalize, urgent rescue of the exterior is required. To rescue the interior, Sini Tang (Frigid Extremities Decoction) is suitable; to rescue the exterior, Guizhi Tang is suitable.
After purgation in Shanghan, if pathogens transform into heat and invade the interior due to deficiency, it results in diarrhea with collateral heat. If pathogens do not enter the interior but organ deficiency generates cold, it results in diarrhea with undigested food. The pathology depends on the cold-heat nature of the pathogen and the Yin-Yang status of the organs. Body pain indicates the pathogen is in the exterior. However, if organ Qi is insufficient, there is no basis for inducing sweating to scatter pathogens. Therefore, warm medicines must be used to abandon the exterior and urgently rescue the interior. After administration, if defecation and urination normalize, the interior Qi is secured. If body pain remains, acrid-sweet dispersing methods become urgent. Otherwise, exterior pathogens may enter the interior and worsen the condition. Using Sini Tang to rescue the interior and Guizhi Tang to rescue the exterior is similar to the clause in the Jueyin chapter regarding diarrhea, abdominal distension, and body pain. That case involves cold pathogens invading the Yin channels; this case involves cold medicines injuring the interior. However, the principle of warming the middle and scattering pathogens, addressing the interior before the exterior, remains the same.
In Taiyang disease, after two or three days, if the patient cannot lie down but desires to sit up, there must be binding/stagnation in the epigastrium. If the pulse is faint and weak, this indicates pre-existing cold-fluid retention. Erroneous purgation is applied. If the diarrhea stops, Jie Xiong (Chest Binding) will likely develop. If the diarrhea does not stop, and purgation is repeated on the fourth day, this will result in xie re li (collateral heat diarrhea).
In Taiyang disease, two or three days indicate a short duration. Inability to lie down and desire to sit up suggest epigastric fullness and binding; lying down causes further Qi stagnation and discomfort. A faint and weak pulse indicates deficient Yang Qi. Since the disease duration is short, cold has not yet transformed into heat. Given the weak pulse, the binding in the epigastrium is determined to be cold-fluid rather than heat. "Cold portion" refers to diseases belonging to cold, analogous to blood, Qi, and water portions mentioned in Jin Gui Yao Lue. Cold pathogens should not be treated with purgation. Erroneous purgation leads to interior deficiency and cold invasion, causing unceasing diarrhea. If the diarrhea stops, Jie Xiong develops because the cold pathogen transforms via Yang into heat and binds upward in Yang positions. If the diarrhea does not stop, and purgation is repeated on the fourth day, it is because the cold has transformed into heat, turning into collateral heat diarrhea. Thus, repeated purgation is needed to exhaust the pathogen, following the principle: "For those below, draw them out and exhaust them." In summary, cold pathogens invading the human body eventually transform into heat. If the pathogen does not bind upward, it inevitably flows downward. Zhang Zhongjing’s detailed discussion serves as profound instruction for future generations.
After taking herbal decoctions for Shanghan, if diarrhea persists unceasingly with epigastric fullness and hardness, and after taking Xiexin Tang (Heart-Purgating Decoction), the physician applies other purgatives, leading to unceasing diarrhea. The physician administers Lizhong Tang (Middle-Regulating Decoction), but the diarrhea worsens. Lizhong Tang regulates the Middle Jiao (Middle Burner); however, this diarrhea originates in the Lower Jiao (Lower Burner). Chishizhi Yuyuliang Tang (Red Halloysite and Hematitum Decoction) should be administered. If diarrhea persists despite this, promoting urination is indicated.
Herbal decoctions are also forms of downward-draining agents. Post-purgation diarrhea and epigastric hardness were correctly treated with Xiexin Tang. However, subsequent purgation exacerbated deficiency. Although pathogens are expelled, the Lower Jiao fails to secure, leading to indefinite diarrhea. Therefore, tonifying the middle with Renshen, Baizhu, Ganjiang, and Gancao is inappropriate; instead, securing the lower with Chishizhi (Halloysitum Rubrum) and Yuyuliang (Hematitum) is required. If diarrhea persists after taking this, it indicates a failure of the Lower Jiao to separate the clear from the turbid. Therefore, promoting urination is necessary.
**Chishizhi Yuyuliang Tang Formula**
Chishizhi (Halloysitum Rubrum) - 1 jin, crushed
Yuyuliang (Hematitum) - 1 jin, crushed
Take these two ingredients, add six sheng of water. Decoct until two sheng remain. Strain. Divide into three warm doses.