乃为虚邪之诊，即有无汗热多之实邪，亦不可用大青龙汤更汗也。盖以脉微弱，是无太
阳表脉也，故不可更大汗也。然既有无汗、热多、寒少之表证，麻黄、桂枝、石膏之药，终
不可无，故只宜桂枝二越婢一汤之轻剂，令微微似汗，以解肌表而和荣卫也。
【集注】喻昌曰∶此亦风多寒少之证。“无阳”二字，仲景言之不一。无阳乃无表、
无津液之通称也，故以不可更汗为戒。然非汗则风寒终不能解，惟取桂枝之二以治风，越
婢之一以治寒，乃为合法耳。
汪琥曰∶“不可更汗”四字，当是不可更大发汗意，因其人脉微弱无阳也。此方比上小发汗之方更轻。
吴人驹曰∶微乃微甚之微，非微细之微，但不过强耳。既曰热多，脉安得微？无阳者，
谓表之阳邪微，故不可更大汗。热多者，谓肌之热邪其，故佐以石膏。越婢者，发越之力如
婢子之职，狭小其制，不似大青龙之张大也。
桂枝二越婢一汤方
桂枝（十八铢） 芍药（十八铢） 甘草（炙，十八铢） 石膏（碎，绵裹，二十四铢） 麻黄（去节，
十八铢） 大枣（擘，四枚） 生姜（一两二铢）
上七味，以水五升，煮麻黄一二沸，去上沫，纳诸药，煮取二升，去滓，温服一升。
本方当裁为越婢汤、桂枝汤合之，饮一升。今合为一方，乃桂枝汤二分，越婢汤一分。
【方解】此方即大青龙汤以芍药易杏仁也，名虽越婢辅桂枝，实则大青龙汤之变制
也。去杏仁，恶其从阳而辛散；用芍药，以其走阴而酸收。以此易彼，裁而用之，则主
治不同矣。以桂枝二主之，则不发汗，可知越婢一者，乃麻黄石膏二物，不过取其辛凉
之性，佐桂枝二以和表而清肌热，则是寓微汗于不发之中，亦可识也。非若大青龙汤以
石膏佐麻黄，而为发汗驱肌热之重剂也。
【按】桂枝二麻黄一汤，治形如疟，日再发者，汗出必解，而无热多寒少，故不用石
膏之凉也。桂枝麻黄各半汤，治如疟状，热多寒少，而不用石膏，更倍麻黄者，以其面
有怫郁热色，身有皮肤作痒，是知热不向里而向表，令得小汗，以顺其势，故亦不用石
膏之凉里也。桂枝二越婢一汤，治发热恶寒，热多寒少。而用石膏者，以其表邪寒少，肌
里热多，故用石膏之凉，佐麻桂以和荣卫，非发荣卫也。今人一见麻、桂，不问轻重，亦
不问温覆与不温覆，取汗与不取汗，总不敢用，皆因未究仲景之旨。麻黄、桂枝只是荣
卫之药，若重剂温覆取汗，则为发荣卫之药，轻剂不温覆取汗，则为和荣卫之方也。
【集解】吴人驹曰∶发散表邪，皆以石膏同用者，盖石膏其性寒，寒能胜热，其味薄，
薄能走表；非苦芩、连之辈，性寒味苦而浓，不能升达也。
伤寒，无大热，口燥渴，心烦，背微恶寒者，白虎加人参汤主之。
【注】伤寒身无大热，不烦不渴，口中和，背恶寒，附子汤主之者，属少阴病也。今伤
寒身无大热，知热渐去表入里也。口燥渴心烦，知热已入阳明也。虽有背微恶寒一证，似
乎少阴，但少阴证，口中和，今口燥渴，是口中不和也。背恶寒，非阳虚恶寒，乃阳明
内热熏蒸于背，汗出肌疏，故微恶之也。主白虎汤，以直走阳明，大清其热；加人参者，
盖有意以顾肌疏也。
【集注】喻昌曰∶此条辨证最细。脉必滑而带浮，浑身无大热，又不恶寒，但背间微
觉恶寒，是表邪已将罢。其人口燥渴心烦，是里热已大炽；更不可姑待，而当急为清解，恐
迟则热深津竭，无济于事矣。
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。
【注】伤寒表不解，谓脉浮紧、头痛、身痛、发热、无汗、恶寒之证仍在也。心下有
水气，谓干呕而咳也。然水之为病不一，故曰或渴、或利、或噎、或小便不利，少腹满，
或喘者，皆有水气之证，故均以小青龙汤，如法加减主之也。《经》曰∶三焦者，决渎之官，
水道出焉；膀胱者，州都之官，津液藏焉，气化则能出矣。太阳受邪，若无水气，病自在
经；若有水气，病必犯腑。病腑，则膀胱之气化不行，三焦之水气失道；停上焦则或咳、
或喘、或噎；停中焦则或渴、或干呕、或满；停下焦则或小便不利，少腹满，或下利。凡
水所行之处，皆得而病之也。小青龙汤外发太阳之表实，内散三焦之寒饮，亦汗法中之
峻剂，与大青龙汤并得其名。一以治太阳表实之热躁，一以治太阳表实之寒饮也。
【集注】程知曰∶此明伤寒表证未解，水积心下，散寒涤饮法也。
汪琥曰∶《明理论》云∶青龙主风寒两伤之疾固已。伤寒表不解，则麻黄可以发；中
风表不解，则桂枝可以散。惟其表不解，而又加之心下有水气，则非二汤所能发散，必
以小青龙汤，始可祛除表里之邪气尔。
小青龙汤方
麻黄（去节，三两） 芍药（三两） 五味子（半升） 干姜（二两） 甘草（炙，三两） 半夏（洗，半升）
桂枝（三两） 细辛（三两）
上八味，以水一斗，先煮麻黄，减二升，去上沫，纳诸药，煮取三升，去滓，温服一升。
加减法∶若渴，去半夏加栝蒌根三两。若噎者，去麻黄加附子一枚（炮）。若小便不利，
少腹满，去麻黄加茯苓四两。若喘，去麻黄加杏仁半升，去皮尖。若微利，去麻黄加荛
花如一鸡子，熬令赤色。
【按】加荛花如鸡子大，熬令赤色，此必传写之误。盖《本草》荛花，即芫花类也。用
之攻水，其力甚峻，五分可令人下行数十次，岂有治停饮之微利，而用鸡子大之荛花者乎？
似当改加茯苓四两。
【方解】太阳停饮有二∶一中风有汗为表虚，五苓散证也；一伤寒无汗为表实，小青
龙汤证也。表实无汗，故合麻、桂二方以解外。去大枣者，以其性滞也；去杏仁者，以
其无喘也，有喘者，仍加之；去生姜者，以有干姜也，若呕者，仍用之。佐干姜、细辛，
极温极散，使寒与水俱得从汗而解；佐半夏逐痰饮，以清不尽之饮；佐五味收肺气，以
敛耗伤之气。若渴者，去半夏加花粉，避燥以生津也；若微利与噎，小便不利，少腹满，
俱去麻黄，远表而就里也。加附子以散寒，则噎可止；加茯苓以利水，则微利止，少腹满
可除矣。此方与越婢汤同治水饮溢于表，而为腹胀水肿，宜发汗外解者，无不随手而消。
越婢治有热者，故方中君以石膏，以散阳水也；小青龙治有寒者，故方中佐以姜、桂以散阴水也。
【集解】柯琴曰∶两青龙俱治有表里证，皆用两解法。大青龙是里热，小青龙是里寒，
故发表之药相同，而治里之药则殊也。此与五苓同为治表不解，而心下有水气。然五苓
治水之蓄而不行，故专渗泻以利水，而微发其汗，使水从下而去也；此方治水之动而不
居，故备举辛温以散水，而大发其汗，使水从外而出也。仲景发表利水诸法，精义入神矣。
赵良曰∶溢饮之证，《金匮》云∶当发其汗，小青龙汤治之。盖水饮溢出于表，荣卫
尽为之不利，必仿伤寒荣卫两伤之法，发汗以散其水，而后荣卫行，经脉通，则周身之
水可消，必以小青龙汤为第一义，于此可类推矣。
伤寒，心中有水气，咳而微喘，发热不渴，服汤已，渴者，此寒去欲解也，小青龙汤主之。
【按】“小青龙汤主之”六字，当在发热不渴之下，始与“服汤已，渴者”之文义相
属。岂有寒去欲解，而更服小青龙汤之理乎？
【注】伤寒，心下有水气，咳而微喘，发热不渴，此为外伤寒邪，内停寒饮，宜以小
青龙汤两解之。服汤汗解已后渴者，乃已汗寒去内燥之渴，非未汗饮停不化之渴，故曰∶
寒去欲解也。当少少与水饮之，以滋其燥，令胃和自可愈也。
【集注】成无己曰∶咳而微喘者，水寒射肺也。发热不渴者，表证未罢也。与小青龙
汤发表散水，服汤已渴者，里气温，水气散，为欲解也。
方有执曰∶发热不渴，寒胜也，故以服汤已而渴，为寒去欲解，大意与上条相仿，故治亦同。
程知曰∶此明水寒未解，治宜小青龙也。心下有水气，寒在膈上也。故喘咳，发热不
渴，服汤已而渴，则水寒解矣。此解水气之法，当用小青龙，非谓解后仍用小青龙也。
张璐曰∶风寒挟水饮，为病在表者，故
不渴。服汤后而渴者，是为寒去津伤欲解之征，所以虽渴而不必服药，但当静俟津回可
也。咳而微喘，为水饮上逆。今水去而渴，与水逆而渴不同。世本“小青龙汤主之”在
“寒去欲解”也之下，错简也。
汪琥曰∶上条云渴，是未服汤而渴，乃水停津液不化而渴。此条云渴，是服汤已而
渴，乃汗后津液既亡而渴。渴既不同，岂可仍用上药小青龙主之？当在“服汤已”之上可知。
下之后，复发汗，必振寒，脉微细，所以然者，以内外俱虚故也。
【注】发汗当于未下之先，今下之后，复发汗，必振寒。脉微细者，表里皆虚也。所
以然者，以下之失宜，则内守之阳虚，故脉微细也。以汗之失宜，则外固之阳衰，故振寒也。
【集注】郑重光曰∶治伤寒先汗后下，此定法也。若下后外邪不尽，不得已而复汗之，
邪虽去而内外俱虚，是以脉细振寒，所伤滋大矣。
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。
【注】此承上条互详脉证，以出其治也。既下之以虚其里，复发汗以虚其表，阴阳两
虚，阳无所附。夜而安静，不呕不渴，是内无阳证也；无表证，身无大热，脉沉微，是
外无阳证也。表里无阳，内外俱阴，惟有昼日烦躁不得眠，一假阳证，则是独阴自治于
阴分，孤阳自扰于阳分，非相胜乃相离也，故以干姜附子汤，助阳以配阴。盖以阴虽盛而
未相格，阳气微而自不根据附也。
【集注】喻昌曰∶上条但言振寒及微细之脉，未定所主之病，以虚证不一也。然振寒
脉微细，阳虚已见一班。设昼日烦躁不得眠，其为虚阳扰乱可知；夜反安静，不呕不渴，则
虚阳扰乱不兼外邪可知。脉沉微，身无大热，则烦躁，为亡阳之诊，干姜附子在所必需。由
此而推，日中安静，夜而烦躁，则为阴病而阳不病，又可知矣。
程应旄曰∶下之后，复发汗，昼日烦躁不得眠，虚阳扰乱，外见假热也。夜安静，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，一假热证狐疑也。
干姜附子汤方
干姜（一两） 附子（去皮，生用，破八片，一枚）
上二味，以水三升，煮取一升，去滓，顿服。
发汗若下之，病仍不解，烦躁者，茯苓四逆汤主之。
【注】此又承上条言。先汗后下，于法不逆，病应解而仍不解，反烦躁者，以别其治
也。盖汗、下俱过，表里两虚，阴盛格阳，故昼夜见此扰乱之象也。当以四逆汤，壮阳胜
阴，更加茯苓以抑阴邪，佐人参以扶正气，庶阳长阴消，正回邪退，病自解而烦躁安矣。大
青龙证，不汗出之烦躁，乃未经汗下之烦躁，属实；此条病不解之烦躁，乃汗下后之烦躁，
属虚。然脉之浮紧沉微，自当别之，恐其误人，故谆谆言之也。
【集注】汪琥曰∶伤寒汗下，则烦躁止而病解矣。若阴盛之烦躁，强发其汗，则表疏
亡阳；复下之，则里虚亡阴。卫阳失护，营阴内空，邪仍不解，更生烦躁，此亦虚烦虚
躁，乃假热之象也。只宜温补，不当散邪，故以茯苓四逆汤主之。
茯苓四逆汤方
茯苓（六两） 人参（一两） 甘草（炙，二两） 干姜（一两半） 附子（生用，去皮，破八片，一枚）
上五味，以水五升，煮取三升，去滓，温服七合，日三服。
【方解】表里之病，治不如法，先过汗后复过下，或下后复汗，误而又误，变成坏病。
若其人阳盛而从热化，则转属三阳，阳衰而从寒化，则系在三阴，此二条烦躁皆坏病也。
烦躁，虽六经俱有，而多见于太阳、少阴者，太阳为真阴之标，少阴为真阳之本也。未经
汗下而烦躁，多属阳，其脉实大，其证热渴，是烦为阳盛，躁为阴虚。已经汗下而烦躁，多
属阴，其脉沉微，其证汗厥，是烦为阳虚，躁为阴盛也。夫先下后汗，于法为逆，外无大
热，内不呕渴，似乎阴阳自和，而实阳虚阴盛。所以虚阳扰乱于阳分，故昼日烦躁不得
眠；盛阴独治于阴分，故夜而安静；脉沉微，是真阳将脱而烦躁也。用干姜、附子，壮阳
以配阴。姜、附者，阳中阳也，生用则力更锐，不加甘草，则势更猛，比之四逆为更峻，
救其相离故当急也。先汗后下，于法为顺，病仍不解，遽增昼夜烦躁，亦是阴盛格阳之烦
躁也，用茯苓四逆，抑阴以回阳。茯苓感太和之气化，伐水邪而不伤阳，故以为君；人
参生气于乌有之乡，通血脉于欲绝之际，故以为佐；人参得姜、附，补气兼以益火；姜、
附得茯苓，补阳兼以泻阴；调以甘草，比之四逆为稍缓和，其相格故宜缓也。一去甘草，
一加参苓，而缓急自别，仲景用方之妙如此。
这是虚证的脉象诊断。即使存在无汗、热多等实邪表现，也不可使用大青龙汤再次发汗。因为脉象微弱，说明已不是太阳经表的典型脉象，所以不可再行强烈发汗。然而既然已有无汗、热多、寒少的表证，麻黄、桂枝、石膏这些药物终究不能不用，因此只适宜使用桂枝二越婢一汤这种轻剂，令患者微微出汗，以解除肌表之邪并调和营卫。
【集注】喻昌说：这也是风邪重而寒邪轻的病证。“无阳”二字，张仲景在不同地方多次提及。所谓“无阳”，是泛指没有表邪或津液不足，因此用不可再次发汗作为警戒。然而如果不发汗，风寒终究无法解除，只有取桂枝汤二分来治风，越婢汤一分来治寒，这才是合法的治疗。
汪琥说：“不可更汗”四个字，应当是不可再大力发汗的意思，因为其人脉象微弱且无阳。此方比上一条提到的轻微发汗的方子还要轻。
吴人驹说：这里的“微”是指程度轻微，并非指脉象微细。只是不过于猛烈罢了。既然说是热多，脉象怎么会微呢？所谓无阳，是指体表的阳邪轻微，所以不可再大力发汗。所谓热多，是指肌肉层面的热邪盛，所以佐以石膏。越婢的意思是发散的力量如同婢女做工那样，制方狭小，不像大青龙汤那样宏大。
桂枝二越婢一汤方
桂枝（十八铢） 芍药（十八铢） 甘草（炙，十八铢） 石膏（碎，绵裹，二十四铢） 麻黄（去节，十八铢） 大枣（掰开，四枚） 生姜（一两二铢）
以上七味药，用水五升，先煮麻黄一二沸，去掉上面的浮沫，加入其他药物，煮取二升，去渣，温服一升。
本方应当裁减为越婢汤和桂枝汤合用，每次饮一升。现在合为一方的比例，是桂枝汤二分，越婢汤一分。
【方解】此方即是大青龙汤用芍药替换杏仁而成，名字虽然叫越婢辅桂枝，实际上是大青龙汤的变制方。去掉杏仁，是厌恶其从阳分辛散；使用芍药，是因为它走阴分而酸收。以此替换彼药，裁减后使用，主治功效就不同了。以桂枝二为主，则不发汗，可知越婢一部分，不过是麻黄和石膏两味药，不过是取其辛凉的性质，佐助桂枝二来调和表邪并清除肌肉之热，这就是寓微汗于不发汗之中，也可以由此认识。不像大青龙汤用石膏佐助麻黄，作为发汗驱除肌肉之热的重剂。
【按】桂枝二麻黄一汤，治疗症状像疟疾，一天发作两次的情况，出汗后必解，但没有热多寒少的表现，所以不用石膏的凉性。桂枝麻黄各半汤，治疗像疟疾的症状，热多寒少，但不用石膏，反而加倍麻黄，这是因为患者面部有郁热之色，身体皮肤作痒，可知热势不向里而向表，令其得小汗，以顺应病势，所以也不用石膏的清里凉性。桂枝二越婢一汤，治疗发热恶寒，热多寒少。而使用石膏，是因为体表邪气寒少，肌肉内部热多，所以用石膏的凉性，佐助麻黄、桂枝来调和营卫，而不是发越营卫。现在的人一见麻黄、桂枝，不问轻重，也不问是否温覆取汗，总不敢使用，都是因为未探究张仲景的本意。麻黄、桂枝只是调和营卫的药物，如果重剂并温覆取汗，就成为发越营卫的药物；轻剂且不温覆取汗，就成为调和营卫的方子。
【集解】吴人驹说：发散表邪，都用石膏同用，大概是因为石膏性寒，寒能胜热，其味淡薄，薄能走表；不像苦芩、黄连之类，性寒味苦而浓，不能升达。
伤寒，身无大热，口燥渴，心烦，背部微微恶寒者，用白虎加人参汤主治。
【注】伤寒身无大热，不烦不渴，口中平和，背部恶寒，用附子汤主治的，属于少阴病。如今伤寒身无大热，可知热势逐渐由表入里。口燥渴心烦，可知热已入阳明。虽然有背部微微恶寒这一证候，似乎像少阴病，但少阴病口中平和，如今口燥渴，说明口中不和。背部恶寒，不是阳虚导致的恶寒，而是阳明内热熏蒸于背部，汗出肌肤疏松，所以微微觉得恶寒。主用白虎汤，以直走阳明，大清其热；加人参，是有意在顾护肌肤疏松。
【集注】喻昌说：这条辨证最细致。脉象必定滑而带浮，浑身无大热，又不恶寒，只是背部间微微觉得恶寒，说明表邪即将罢休。其人口燥渴心烦，说明里热已经大炽；更不可姑且等待，而应当紧急清解，恐怕迟了则热深津竭，无济于事。
伤寒表证未解，心下有水气，干呕发热而咳，或者口渴、或者腹泻、或者噎塞、或者小便不利，少腹胀满，或者气喘者，用小青龙汤主治。
【注】伤寒表不解，是指脉浮紧、头痛、身痛、发热、无汗、恶寒的证候仍在。心下有水气，是指干呕而咳。然而水之为病不一，所以说或者口渴、或者腹泻、或者噎塞、或者小便不利，少腹胀满，或者气喘，都是有水气的证候，所以均用小青龙汤，依法加减主治。《内经》说：三焦，是决渎之官，水道由此而出；膀胱，是州都之官，津液藏于此，气化则能排出。太阳受邪，若无水气，病自在经脉；若有水气，病必侵犯腑脏。病在腑，则膀胱的气化不行，三焦的水气失道；停在上焦则或者咳、或者喘、或者噎；停在中焦则或者渴、或者干呕、或者胀满；停在下焦则或者小便不利，少腹胀满，或者下利。凡水所行的地方，都能致病。小青龙汤外发太阳之表实，内散三焦之寒饮，也是汗法中的峻剂，与大青龙汤并得其名。一个用于治疗太阳表实的热躁，一个用于治疗太阳表实的寒饮。
【集注】程知说：这说明伤寒表证未解，水积心下，是散寒涤饮的方法。
汪琥说：《明理论》说：青龙主治风寒两伤的疾病固然正确。伤寒表不解，则麻黄可以发汗；中风表不解，则桂枝可以解散。正因为表不解，而又加上心下有水气，则非这两个汤所能发散，必须用小青龙汤，才能祛除表里之邪气。
小青龙汤方
麻黄（去节，三两） 芍药（三两） 五味子（半升） 干姜（二两） 甘草（炙，三两） 半夏（洗，半升）
桂枝（三两） 细辛（三两）
以上八味药，用水一斗，先煮麻黄，减少二升，去掉上面的浮沫，加入其他药物，煮取三升，去渣，温服一升。
加减法：如果口渴，去掉半夏，加栝蒌根三两。如果噎塞，去掉麻黄，加附子一枚（炮制）。如果小便不利，少腹胀满，去掉麻黄，加茯苓四两。如果气喘，去掉麻黄，加杏仁半升，去皮尖。如果轻微腹泻，去掉麻黄，加荛花如鸡子大小，熬至红色。
【按】加荛花如鸡子大小，熬至红色，这一定是传写错误。因为《本草》中荛花，就是芫花一类。用它攻逐水饮，力量非常峻猛，五分即可让人下行数十次，哪有治疗停饮引起的轻微腹泻，而用鸡子大小的荛花的道理？似乎应当改为加茯苓四两。
【方解】太阳停饮有两种：一中风有汗为表虚，是五苓散证；一伤寒无汗为表实，是小青龙汤证。表实无汗，所以合用麻黄、桂枝两个方子来解外。去掉大枣，是因为其性质滞涩；去掉杏仁，是因为没有气喘，如果有气喘，仍然加上；去掉生姜，是因为有干姜，如果有呕吐，仍然使用。佐以干姜、细辛，极温极散，使寒与水都能从汗而解；佐以半夏逐痰饮，以清除未尽之饮；佐以五味子收敛肺气，以敛耗伤之气。如果口渴，去掉半夏加花粉，避开燥性以生津；如果轻微腹泻与噎塞，小便不利，少腹胀满，都去掉麻黄，远离表证而治里。加附子以散寒，则噎可止；加茯苓以利水，则轻微腹泻止，少腹胀满可除。此方与越婢汤同治水饮溢于表，导致腹胀水肿，宜发汗外解的，无不随手而消。越婢汤治疗有热的，所以方中以石膏为君，以散阳水；小青龙汤治疗有寒的，所以方中佐以姜、桂以散阴水。
【集解】柯琴说：两个青龙汤都治疗有表里证，都用两解法。大青龙是里热，小青龙是里寒，所以发表的药物相同，而治里的药物则不同。这与五苓散同为治疗表不解，而心下有水气。然而五苓散治疗水的蓄积而不行，所以专事渗泻以利水，而轻微发汗，使水从下而去；此方治疗水的动而不居，所以备举辛温以散水，而大发其汗，使水从外而出。张仲景发表利水诸法，精义入神。
赵良说：溢饮的证候，《金匮要略》说：当发其汗，小青龙汤治疗它。大概水饮溢出于表，营卫全都不利，必须仿照伤寒营卫两伤的方法，发汗以散其水，然后营卫行，经脉通，则周身之水可消，必须以小青龙汤为第一要义，于此可类推。
伤寒，心中有水气，咳而微喘，发热不渴，服药后，感到口渴的，这是寒去欲解的表现，用小青龙汤主治。
【按】“小青龙汤主之”六个字，应当在“发热不渴”之下，才与“服药后，感到口渴”的文义相属。哪有寒去欲解，而更服小青龙汤的道理呢？
【注】伤寒，心下有水气，咳而微喘，发热不渴，此为外伤寒邪，内停寒饮，宜用小青龙汤两解之。服药汗解之后感到口渴，乃是已汗寒去内燥之渴，不是未汗饮停不化之渴，所以说：寒去欲解也。应当少量给水饮用，以滋润其燥，令胃气和顺自然痊愈。
【集注】成无己说：咳而微喘，是水寒射肺。发热不渴，是表证未罢。与小青龙汤发表散水，服药后感到口渴，是里气温，水气散，为欲解。
方有执说：发热不渴，是寒胜，所以以服药后而渴，为寒去欲解，大意与上条相似，所以治疗也相同。
程知说：这说明水寒未解，治疗宜用小青龙。心下有水气，寒在膈上。所以喘咳，发热不渴，服药后而渴，则水寒解矣。此解水气之法，当用小青龙，不是说解后仍用小青龙。
张璐说：风寒挟水饮，为病在表者，所以不渴。服药后而渴，是为寒去津伤欲解之征，所以虽渴而不必服药，但当静待津液回复即可。咳而微喘，为水饮上逆。如今水去而渴，与水逆而渴不同。世本“小青龙汤主之”在“寒去欲解”之下，是错简。
汪琥说：上条说渴，是未服汤而渴，乃水停津液不化而渴。此条说渴，是服药后而渴，乃汗后津液既亡而渴。渴既不同，岂可仍用上药小青龙主治？应当在“服药后”之上可知。
下法之后，又复发汗，必然振栗恶寒，脉微细，之所以这样，是因为内外俱虚的缘故。
【注】发汗应当在未下之前，如今下之后，又复发汗，必然振栗恶寒。脉微细，是表里皆虚。之所以这样，因为下法失宜，则内守之阳虚，所以脉微细。因为汗法失宜，则外固之阳衰，所以振栗恶寒。
【集注】郑重光说：治伤寒先汗后下，这是定法。若下后外邪不尽，不得已而复汗之，邪虽去而内外俱虚，是以脉细振寒，所伤滋大。
下法之后，又复发汗，白天烦躁不得眠，夜间安静，不呕不渴，无表证，脉沉微，身无大热者，用干姜附子汤主治。
【注】这是承接上条互详脉证，以出其治也。既下之以虚其里，复发汗以虚其表，阴阳两虚，阳无所附。夜间安静，不呕不渴，是内无阳证；无表证，身无大热，脉沉微，是外无阳证。表里无阳，内外俱阴，惟有白天烦躁不得眠，是一假阳证，则是独阴自治于阴分，孤阳自扰于阳分，非相胜乃相离也，故以干姜附子汤，助阳以配阴。盖因阴虽盛而未相格，阳气微而自不根据附。
【集注】喻昌说：上条只说振寒及微细之脉，未定所主之病，因为虚证不一。然而振寒脉微细，阳虚已见一斑。设若白天烦躁不得眠，其为虚阳扰乱可知；夜间反安静，不呕不渴，则虚阳扰乱不兼外邪可知。脉沉微，身无大热，则烦躁，为亡阳之诊，干姜附子在所必需。由此而推，日中安静，夜间烦躁，则为阴病而阳不病，又可知矣。
程应旄说：下之后，复发汗，白天烦躁不得眠，虚阳扰乱，外见假热。夜间安静，不呕不渴，无表证，脉沉微，身无大热，阴气独治，内系真寒。宜干姜附子汤，直从阴中回阳，不当于白天烦躁，一假热证狐疑。
干姜附子汤方
干姜（一两） 附子（去皮，生用，破八片，一枚）
以上两味药，用水三升，煮取一升，去渣，顿服。
【注】这是又承接上条言。先汗后下，于法不逆，病应解而仍不解，反烦躁者，以别其治也。盖汗、下俱过，表里两虚，阴盛格阳，故昼夜见此扰乱之象。当以四逆汤，壮阳胜阴，更加茯苓以抑阴邪，佐人参以扶正气，庶阳长阴消，正回邪退，病自解而烦躁安矣。大青龙证，不汗出之烦躁，乃未经汗下之烦躁，属实；此条病不解之烦躁，乃汗下后之烦躁，属虚。然脉之浮紧沉微，自当别之，恐其误人，故谆谆言之。
【集注】汪琥说：伤寒汗下，则烦躁止而病解。若阴盛之烦躁，强发其汗，则表疏亡阳；复下之，则里虚亡阴。卫阳失护，营阴内空，邪仍不解，更生烦躁，此亦虚烦虚躁，乃假热之象。只宜温补，不当散邪，故以茯苓四逆汤主治。
茯苓四逆汤方
茯苓（六两） 人参（一两） 甘草（炙，二两） 干姜（一两半） 附子（生用，去皮，破八片，一枚）
以上五味药，用水五升，煮取三升，去渣，温服七合，每日三次。
【方解】表里之病，治不如法，先过汗后复过下，或下后复汗，误而又误，变成坏病。若其人阳盛而从热化，则转属三阳，阳衰而从寒化，则系在三阴，此二条烦躁皆坏病。烦躁，虽六经俱有，而多见于太阳、少阴者，太阳为真阴之标，少阴为真阳之本。未经汗下而烦躁，多属阳，其脉实大，其证热渴，是烦为阳盛，躁为阴虚。已经汗下而烦躁，多属阴，其脉沉微，其证汗厥，是烦为阳虚，躁为阴盛。夫先下后汗，于法为逆，外无大热，内不呕渴，似乎阴阳自和，而实阳虚阴盛。所以虚阳扰乱于阳分，故白天烦躁不得眠；盛阴独治于阴分，故夜间安静；脉沉微，是真阳将脱而烦躁。用干姜、附子，壮阳以配阴。姜、附者，阳中阳也，生用则力更锐，不加甘草，则势更猛，比之四逆为更峻，救其相离故当急。先汗后下，于法为顺，病仍不解，遽增昼夜烦躁，亦是阴盛格阳之烦躁，用茯苓四逆，抑阴以回阳。茯苓感太和之气化，伐水邪而不伤阳，故以为君；人参生气于乌有之乡，通血脉于欲绝之际，故以为佐；人参得姜、附，补气兼以益火；姜、附得茯苓，补阳兼以泻阴；调以甘草，比之四逆为稍缓和，其相格故宜缓。一去甘草，一加参苓，而缓急自别，仲景用方之妙如此。
This is a diagnostic pulse pattern for deficiency syndromes. Even if there are excess pathogenic factors manifesting as absence of sweating and abundant heat, Da Qing Long Tang (Major Blue Dragon Decoction) must not be used to induce sweating again. This is because the pulse is weak and faint, indicating that it is no longer the typical exterior pulse of Taiyang disease (diseases affecting the bladder and small intestine meridians), so vigorous sweating should not be induced. However, since there are exterior signs such as absence of sweating, abundant heat, and slight cold, herbs like Ephedrae Herba (Mahuang, 麻黄), Cinnamon Twig (Guizhi, 桂枝), and Gypsum Fibrosum (Shigao, 石膏) cannot be entirely omitted. Therefore, only the mild formula Guizhi Er Yuebi Yi Tang (Cinnamon Twig Twice and Yuebi One Decoction) is suitable, to induce slight sweating, thereby releasing the muscle layer and harmonizing Ying and Wei (nutritive and defensive qi).
[Collected Annotations] Yu Chang stated: This is also a syndrome where wind pathogen is heavy and cold pathogen is light. The term "absence of Yang" appears multiple times in Zhang Zhongjing's writings. "Absence of Yang" generally refers to the lack of exterior pathogen or insufficient body fluids; thus, the warning against inducing sweating again is given. However, without sweating, wind-cold cannot be resolved. Only by using two parts of Guizhi Tang (Cinnamon Twig Decoction) to treat wind and one part of Yuebi Tang (Yuebi Decoction) to treat cold is this a lawful treatment.
Wang Hu stated: The phrase "cannot induce sweating again" implies that vigorous sweating should not be induced, due to the patient's weak and faint pulse and absence of Yang. This formula is milder than the previous formula mentioned for slight sweating.
Wu Renju stated: The "wei" (slight/weak) here refers to degree being slight, not the pulse being micro-fine. It simply means not too forceful. If it is said to have abundant heat, how can the pulse be weak? "Absence of Yang" means the exterior Yang pathogen is slight, so vigorous sweating should not be induced. "Abundant heat" means the heat pathogen in the muscles is strong, hence Gypsum Fibrosum is added as an assistant. "Yuebi" means the dispersing power is like the work of a maid; the prescription is narrow and small, unlike the grandeur of Da Qing Long Tang.
Formula: Guizhi Er Yuebi Yi Tang (Cinnamon Twig Twice and Yuebi One Decoction)
Guizhi (Cinnamon Twig, 18 zhu), Shaoyao (Peony Root, 18 zhu), Gancao (Licorice Root, prepared, 18 zhu), Shigao (Gypsum Fibrosum, crushed, wrapped in silk, 24 zhu), Mahuang (Ephedra Herb, nodes removed, 18 zhu), Dazao (Jujube Fruit, split, 4 pieces), Shengjiang (Fresh Ginger, 1 liang 2 zhu).
The above seven ingredients are boiled with five sheng of water. First boil Mahuang for one or two boils, remove the foam on top, then add the other herbs. Boil until two sheng remain, strain, and take one sheng warm.
This formula should ideally be calculated as a combination of Yuebi Tang and Guizhi Tang, taking one sheng per dose. Now combined into one formula, the ratio is two parts Guizhi Tang to one part Yuebi Tang.
[Formula Analysis] This formula is essentially Da Qing Long Tang (Major Blue Dragon Decoction) with Xingren (Apricot Seed) replaced by Shaoyao (Peony Root). Although named Yuebi assisting Guizhi, it is actually a modified version of Da Qing Long Tang. Xingren is removed because its acrid-dispersing nature acts on Yang; Shaoyao is used because its sour-astringent nature acts on Yin. By substituting one for the other and adjusting the dosage, the therapeutic indication changes. With Guizhi as the main component (two parts), it does not induce sweating. Thus, the Yuebi part (one part) consists merely of Mahuang and Shigao, utilizing their acrid-cool properties to assist Guizhi in harmonizing the exterior and clearing muscle heat. This embodies slight sweating within non-sweating, which can be understood. It is not like Da Qing Long Tang, where Shigao assists Mahuang as a heavy agent for inducing sweating and driving out muscle heat.
[Note] Guizhi Er Mahuang Yi Tang (Cinnamon Twig Twice and Ephedra One Decoction) treats symptoms resembling malaria, occurring twice a day, resolving with sweating, but lacks the sign of abundant heat and slight cold, hence Gypsum Fibrosum is not used. Guizhi Mahuang Ge Ban Tang (Cinnamon Twig and Ephedra Half-Half Decoction) treats symptoms resembling malaria with abundant heat and slight cold, but does not use Gypsum Fibrosum and instead doubles Mahuang. This is because the patient has a flushed face with trapped heat and itchy skin, indicating heat is moving outward rather than inward, allowing for slight sweating to follow the pathogenic trend; thus, Gypsum Fibrosum for clearing interior heat is not used. Guizhi Er Yuebi Yi Tang treats fever and aversion to cold with abundant heat and slight cold. Gypsum Fibrosum is used because the exterior pathogen has little cold but abundant heat in the muscles; thus, Gypsum Fibrosum's coolness assists Mahuang and Guizhi to harmonize Ying and Wei, rather than violently expelling them. Modern practitioners often fear using Mahuang and Guizhi regardless of dosage or whether to cover with blankets to induce sweat, because they have not investigated Zhang Zhongjing's intent. Mahuang and Guizhi are herbs for harmonizing Ying and Wei; in heavy doses with covering to induce sweat, they become agents for violent expulsion; in light doses without covering, they become formulas for harmonizing Ying and Wei.
[Collected Explanations] Wu Renju stated: For dispersing exterior pathogens, Gypsum Fibrosum is always used together. This is because Gypsum Fibrosum is cold in nature, and cold overcomes heat; its taste is thin, and thinness allows it to reach the exterior. Unlike Huangqin (Scutellaria Root) and Huanglian (Coptis Rhizome), which are cold in nature but bitter and thick in taste, preventing ascending action.
In Shanghan (Cold Damage) with no significant fever, dry mouth and thirst, mental restlessness, and slight aversion to cold on the back, Bai Hu Jia Ren Shen Tang (White Tiger Plus Ginseng Decoction) is indicated.
[Annotation] In Shanghan, if there is no significant fever, no irritability or thirst, a normal mouth sensation, and aversion to cold on the back, Fuzi Tang (Aconite Decoction) is used, belonging to Shaoyin disease (diseases affecting the heart and kidney meridians). Now, in Shanghan with no significant fever, it indicates heat is gradually moving from the exterior to the interior. Dry mouth, thirst, and mental restlessness indicate heat has entered the Yangming stage (stomach and large intestine meridians). Although there is slight aversion to cold on the back, resembling Shaoyin, Shaoyin syndromes present with a normal mouth sensation; here, dry mouth and thirst indicate the mouth is not normal. Aversion to cold on the back is not due to Yang deficiency, but rather Yangming interior heat steaming upwards to the back, causing sweating and loose pores, leading to slight aversion. Bai Hu Tang (White Tiger Decoction) is used to directly target Yangming and clear heat significantly; Ren Shen (Ginseng Root) is added to protect the loose pores.
[Collected Annotations] Yu Chang stated: This clause demonstrates very detailed differentiation. The pulse will likely be slippery and floating. There is no significant fever on the whole body, nor aversion to cold, only slight aversion to cold in the back, indicating the exterior pathogen is about to resolve. The patient's dry mouth, thirst, and mental restlessness indicate interior heat is blazing; waiting is not an option, and urgent clearing and resolving are required. Delay may lead to deep heat and exhaustion of fluids, rendering treatment useless.
In Shanghan, if the exterior is not resolved, and there is fluid retention in the epigastrium, presenting with dry retching, fever, and cough, or alternatively thirst, diarrhea, dysphagia, difficulty urinating with lower abdominal fullness, or wheezing, Xiao Qing Long Tang (Minor Blue Dragon Decoction) is indicated.
[Annotation] "Exterior not resolved" in Shanghan refers to the persistence of symptoms such as floating-tight pulse, headache, body pain, fever, absence of sweating, and aversion to cold. "Fluid retention in the epigastrium" refers to dry retching and cough. Since water diseases vary, it states "alternatively thirst, diarrhea..." etc., all indicating water retention syndromes. Therefore, Xiao Qing Long Tang is used with appropriate modifications. The Classic says: The Sanjiao (Triple Burner) is the official of irrigation, through which water passages flow; the Bladder is the official of the capital, storing fluids, which are excreted through Qi transformation. When Taiyang is affected by pathogens, without water retention, the disease remains in the meridians; with water retention, the disease invades the fu organs. Disease in the fu organs leads to failure of Bladder Qi transformation and loss of pathway for Sanjiao water. Stagnation in the Upper Jiao causes cough, wheezing, or dysphagia; stagnation in the Middle Jiao causes thirst, dry retching, or fullness; stagnation in the Lower Jiao causes difficulty urinating, lower abdominal fullness, or diarrhea. Wherever water travels, disease can occur. Xiao Qing Long Tang releases Taiyang exterior excess internally and scatters cold-fluid in the Sanjiao externally; it is a potent sweating method, sharing fame with Da Qing Long Tang. One treats heat-agitation of Taiyang exterior excess, the other treats cold-fluid of Taiyang exterior excess.
[Collected Annotations] Cheng Zhi stated: This clarifies that when Shanghan exterior signs are unresolved and water accumulates in the epigastrium, the method is to scatter cold and purge fluid.
Wang Hu stated: Ming Lilun states: Qing Long (Blue Dragon) treats diseases caused by both wind and cold. If Shanghan exterior is unresolved, Mahuang can induce sweating; if Fengzhong (Wind Strike) exterior is unresolved, Guizhi can disperse. Because the exterior is unresolved and compounded by fluid retention in the epigastrium, neither of the previous two decoctions can disperse it; only Xiao Qing Long Tang can eliminate exterior and interior pathogens.
Formula: Xiao Qing Long Tang (Minor Blue Dragon Decoction)
Mahuang (Ephedra Herb, nodes removed, 3 liang), Shaoyao (Peony Root, 3 liang), Wuweizi (Schisandra Fruit, half sheng), Ganjiang (Dried Ginger, 2 liang), Gancao (Licorice Root, prepared, 3 liang), Banxia (Pinellia Tuber, washed, half sheng), Guizhi (Cinnamon Twig, 3 liang), Xixin (Asarum Root, 3 liang).
The above eight ingredients are boiled with ten sheng of water. First boil Mahuang, reducing by two sheng, remove foam, add other herbs, boil until three sheng remain, strain, and take one sheng warm.
Modifications: If thirsty, remove Banxia, add Gualougen (Trichosanthes Root, 3 liang). If dysphagic, remove Mahuang, add one Fuzi (Prepared Aconite Root, processed). If difficult urination with lower abdominal fullness, remove Mahuang, add Fuling (Poria, 4 liang). If wheezing, remove Mahuang, add Xingren (Apricot Seed, half sheng, peeled and tip removed). If slight diarrhea, remove Mahuang, add Raohua (Edelweiss Flower, amount equal to a chicken egg, roasted until red).
[Note] Adding Raohua amount equal to a chicken egg, roasted until red, is likely a transcription error. Raohua belongs to the Yuanhua (Genkwa Flower) category. Used to attack water retention, its power is extremely harsh; five fen can cause dozens of bowel movements. How could one use a chicken-egg-sized dose of Raohua for treating mild diarrhea due to retained fluid? It seems it should be changed to adding Fuling (Poria, 4 liang).
[Formula Analysis] There are two types of fluid retention in Taiyang: one is Wind Strike with sweating, representing exterior deficiency, treated by Wuling San (Five-Ingredient Powder with Poria); the other is Shanghan without sweating, representing exterior excess, treated by Xiao Qing Long Tang. Due to exterior excess and absence of sweating, Mahuang and Guizhi formulas are combined to release the exterior. Dazao (Jujube) is removed because its nature is cloying; Xingren is removed because there is no wheezing (if wheezing exists, add it back); Shengjiang is removed because Ganjiang is present (if vomiting exists, add it back). Ganjiang and Xixin are assistants, extremely warm and dispersing, enabling cold and water to resolve via sweating. Banxia is an assistant to drive out phlegm-fluid and clear remaining fluid. Wuweizi is an assistant to astringe Lung Qi and conserve depleted Qi. If thirsty, remove Banxia and add Huafen (Trichosanthes Root) to avoid dryness and generate fluids. If slight diarrhea, dysphagia, difficulty urinating, or lower abdominal fullness, remove Mahuang to move from exterior to interior. Add Fuzi to scatter cold, stopping dysphagia; add Fuling to promote urination, stopping slight diarrhea and removing lower abdominal fullness. This formula, along with Yuebi Tang, treats water-fluid overflowing to the exterior causing abdominal distension and edema, requiring sweating to resolve externally, achieving success readily. Yuebi Tang treats cases with heat, using Shigao as the sovereign herb to disperse Yang-water; Xiao Qing Long Tang treats cases with cold, using Jiang (Ginger) and Gui (Cinnamon) as assistants to disperse Yin-water.
[Collected Explanations] Ke Qin stated: Both Qing Long decoctions treat syndromes involving both exterior and interior, using a dual-resolution method. Da Qing Long Tang treats interior heat, while Xiao Qing Long Tang treats interior cold. Thus, exterior-releasing herbs are the same, but interior-treating herbs differ. Like Wuling San, this treats unresolved exterior with fluid retention in the epigastrium. However, Wuling San treats stagnant water that does not move, focusing on leaching and draining to promote urination and slightly inducing sweating to send water downward; this formula treats dynamic water that does not stay, employing acrid-warm herbs to scatter water and vigorously inducing sweating to send water outward. Zhang Zhongjing's methods for releasing exterior and promoting urination are profound and divine.
Zhao Liang stated: For Yi Yin (Overflowing Drink) syndrome, Jin Gui Yao Lue says: "It should be treated by inducing sweating," using Xiao Qing Long Tang. Water-fluid overflowing to the exterior makes Ying and Wei completely unfavorable. One must imitate the method for Shanghan affecting both Ying and Wei, inducing sweating to scatter water. Only then will Ying and Wei circulate, meridians unblock, and water throughout the body dissipate. Xiao Qing Long Tang is the primary choice, from which others can be inferred.
In Shanghan, if there is fluid retention in the heart region, presenting with cough and slight wheezing, fever but no thirst, and after taking medicine, the patient feels thirsty, this indicates cold is departing and resolution is desired; Xiao Qing Long Tang is indicated.
[Note] The six characters "Xiao Qing Long Tang is indicated" should appear below "fever but no thirst" to align with the meaning of "after taking medicine, feels thirsty." How could one administer Xiao Qing Long Tang after cold has departed and resolution is desired?
[Annotation] In Shanghan, fluid retention in the epigastrium, cough, slight wheezing, fever without thirst, indicates external cold pathogen and internal cold-fluid retention. Xiao Qing Long Tang should be used to resolve both. After taking the medicine and resolving via sweating, if the patient feels thirsty, it is thirst due to interior dryness after cold departure, not thirst due to untransformed retained fluid before sweating. Hence it is said: "Cold is departing, resolution is desired." One should give small amounts of water to moisten dryness, allowing the Stomach to harmonize and heal naturally.
[Collected Annotations] Cheng Wuji stated: Cough and slight wheezing indicate cold-water attacking the Lung. Fever without thirst indicates the exterior syndrome is not yet resolved. Giving Xiao Qing Long Tang releases the exterior and scatters water. Feeling thirsty after taking the medicine indicates interior warmth returning and water dispersion, signaling resolution.
Fang Youzhi stated: Fever without thirst indicates cold dominance. Thus, feeling thirsty after taking medicine signifies cold departure and desired resolution. The general idea is similar to the previous clause, so the treatment is the same.
Cheng Zhi stated: This clarifies that when cold-water is unresolved, Xiao Qing Long Tang is appropriate. Fluid retention in the epigastrium, cold in the diaphragm above, causes wheezing and cough. Fever without thirst, followed by thirst after taking medicine, indicates cold-water has resolved. This method for resolving fluid retention uses Xiao Qing Long Tang; it does not mean continuing Xiao Qing Long Tang after resolution.
Zhang Lu stated: Wind-cold carrying fluid retention, with disease in the exterior, results in no thirst. Thirst after taking medicine is a sign of cold departure, fluid injury, and desired resolution. Thus, even with thirst, medication is not necessary; one should wait quietly for fluid recovery. Cough and slight wheezing indicate upward reversal of fluid retention. Now that water is gone and thirst exists, it differs from thirst caused by water reversal. In modern editions, "Xiao Qing Long Tang is indicated" appearing below "cold is departing, resolution is desired" is a misplaced text error.
Wang Hu stated: The previous clause mentions thirst before taking medicine, due to water stagnation preventing fluid transformation. This clause mentions thirst after taking medicine, due to fluid loss after sweating. Since the thirst is different, how can the same medicine, Xiao Qing Long Tang, be used? It should be placed above "after taking medicine," which is evident.
After purgation and subsequent sweating, chills and trembling occur, with a micro-fine pulse. This is because both interior and exterior are deficient.
[Annotation] Sweating should precede purgation. Now, purgation was performed first, followed by sweating, resulting in chills and trembling. A micro-fine pulse indicates deficiency in both exterior and interior. This occurs because improper purgation damages interior guarding Yang, causing a micro-fine pulse; improper sweating damages exterior securing Yang, causing chills and trembling.
[Collected Annotations] Zheng Zhongguang stated: Treating Shanghan with sweating first and purgation second is the standard method. If exterior pathogens remain after purgation, and sweating is reluctantly induced again, although pathogens leave, both interior and exterior become deficient, leading to fine pulse and chills, causing greater damage.
After purgation and subsequent sweating, if the patient experiences irritability and insomnia during the day but quietness at night, without vomiting or thirst, no exterior syndrome, a sunken-micro pulse, and no significant fever, Gan Jiang Fu Zi Tang (Dried Ginger and Aconite Decoction) is indicated.
[Annotation] This elaborates on the pulse and signs from the previous clause to determine treatment. Purgation weakened the interior, and subsequent sweating weakened the exterior, leading to dual deficiency of Yin and Yang, with Yang having no anchor. Quietness at night, no vomiting or thirst, indicates no interior Yang syndrome. No exterior syndrome, no significant fever, and sunken-micro pulse indicate no exterior Yang syndrome. With no Yang in exterior and interior, and pure Yin inside and out, the only symptom is daytime irritability and insomnia, a false Yang syndrome. This represents solitary Yin governing itself in the Yin division and lone Yang disturbing itself in the Yang division, not overcoming each other but separating. Thus, Gan Jiang Fu Zi Tang is used to assist Yang to match Yin. Although Yin is abundant, it does not repel Yang; Yang is weak and lacks anchorage.
[Collected Annotations] Yu Chang stated: The previous clause only mentioned chills and micro-fine pulse, not specifying the disease, as deficiency syndromes vary. However, chills with micro-fine pulse reveal Yang deficiency. If daytime irritability and insomnia occur, it indicates disturbance by deficient Yang. Nighttime quietness, no vomiting or thirst, shows deficient Yang disturbance is not accompanied by exterior pathogens. Sunken-micro pulse and no significant fever indicate irritability is a sign of Yang collapse; Gan Jiang and Fu Zi are essential. From this, one can infer that quietness during the day and irritability at night indicates Yin disease without Yang involvement.
Cheng Yingmao stated: After purgation and sweating, daytime irritability and insomnia represent disturbance by deficient Yang, showing false heat externally. Nighttime quietness, no vomiting or thirst, no exterior syndrome, sunken-micro pulse, and no significant fever indicate Yin Qi governs alone, revealing true cold internally. Gan Jiang Fu Zi Tang should be used to return Yang directly from Yin. One should not hesitate due to the false heat of daytime irritability.
Formula: Gan Jiang Fu Zi Tang (Dried Ginger and Aconite Decoction)
Ganjiang (Dried Ginger, 1 liang), Fuzi (Prepared Aconite Root, peeled, raw, broken into eight pieces, 1 piece).
The above two ingredients are boiled with three sheng of water, reduced to one sheng, strained, and taken in one dose.
If sweating or purgation fails to resolve the disease, and irritability persists, Fuling Sini Tang (Poria Four-Reverse Decoction) is indicated.
[Annotation] This continues from the previous clause. Sweating followed by purgation is not contrary to method; if the disease should resolve but does not, and irritability arises, the treatment must be distinguished. Both sweating and purgation were excessive, causing dual deficiency of exterior and interior, with Yin abundance repelling Yang, leading to disturbance day and night. Sini Tang (Four-Reverse Decoction) should be used to strengthen Yang and overcome Yin, adding Fuling to suppress Yin pathogens and Ren Shen to support healthy Qi. Thus, Yang grows, Yin diminishes, healthy Qi returns, pathogens retreat, the disease resolves, and irritability calms. In Da Qing Long Tang syndrome, irritability without sweating is due to unrest before sweating/purgation, belonging to excess; in this clause, irritability due to unresolved disease after sweating/purgation belongs to deficiency. The difference between floating-tight and sunken-micro pulses should distinguish them to prevent misguidance, hence the earnest explanation.
[Collected Annotations] Wang Hu stated: In Shanghan, sweating and purgation should stop irritability and resolve the disease. If irritability is due to Yin abundance, forcing sweating leads to exterior looseness and Yang collapse; subsequent purgation leads to interior deficiency and Yin collapse. Defensive Yang loses protection, Nutritive Yin becomes empty internally, pathogens remain unresolved, generating new irritability. This is false irritability and restlessness, a sign of false heat. Only warming and tonifying are appropriate, not dispersing pathogens; thus, Fuling Sini Tang is indicated.
Formula: Fuling Sini Tang (Poria Four-Reverse Decoction)
Fuling (Poria, 6 liang), Renshen (Ginseng Root, 1 liang), Gancao (Licorice Root, prepared, 2 liang), Ganjiang (Dried Ginger, 1.5 liang), Fuzi (Prepared Aconite Root, raw, peeled, broken into eight pieces, 1 piece).
The above five ingredients are boiled with five sheng of water, reduced to three sheng, strained, and taken 0.7 sheng warm, three times daily.
[Formula Analysis] Exterior and interior diseases, if treated improperly—first excessive sweating then excessive purgation, or purgation followed by sweating—mistakes compound mistakes, transforming into complicated diseases (Huai Bing). If the person has abundant Yang and transforms toward heat, it shifts to the Three Yang stages; if Yang is deficient and transforms toward cold, it attaches to the Three Yin stages. These two clauses regarding irritability are both complicated diseases. Irritability occurs in all Six Meridians but is common in Taiyang and Shaoyin. Taiyang is the mark of True Yin, and Shaoyin is the root of True Yang. Irritability before sweating/purgation mostly belongs to Yang, with solid-large pulse and heat-thirst symptoms; irritability is Yang abundance, restlessness is Yin deficiency. Irritability after sweating/purgation mostly belongs to Yin, with sunken-micro pulse and sweating/cold limbs symptoms; irritability is Yang deficiency, restlessness is Yin abundance. Purging then sweating is contrary to method. No significant exterior heat, no interior vomiting/thirst, seemingly Yin-Yang self-harmonizing, but actually Yang deficiency and Yin abundance. Thus, deficient Yang disturbs the Yang division, causing daytime irritability and insomnia; abundant Yin governs the Yin division alone, causing nighttime quietness. Sunken-micro pulse indicates True Yang about to collapse with irritability. Gan Jiang and Fu Zi are used to strengthen Yang to match Yin. Ginger and Aconite are Yang within Yang; raw usage increases potency, omitting Gan Cao increases momentum, making it more potent than Sini Tang. Urgent rescue is needed for separation. Sweating then purgation follows proper method; if disease remains unresolved and irritability increases day and night, it is also Yin abundance repelling Yang. Fuling Sini Tang is used to suppress Yin and return Yang. Fuling absorbs Taihe Qi transformation, attacks water pathogens without damaging Yang, serving as the sovereign herb. Ren Shen generates Qi from nothing, connects blood vessels at the verge of collapse, serving as an assistant. Ren Shen benefits Qi and augments Fire when combined with Jiang and Fu; Jiang and Fu benefit Yang and drain Yin when combined with Fuling. Harmonized with Gan Cao, it is milder than Sini Tang, suitable for repulsion. Removing Gan Cao and adding Renshen and Fuling distinguishes urgency and slackness. Such is the subtlety of Zhang Zhongjing's formula usage.