水蛭（熬，三十个） 虻虫（熬，去头足，三十个） 大黄（去皮，破六片，三两） 核桃（去皮尖，
二十个）
上四味，以水五升，煮取三升，去滓，温服一升。不下者更服。
太阳病，身黄，脉沉结，少腹硬满，小便不利者，为无血也；小便自利，其人如狂
者，血证谛，属抵当汤。
【注】此承上条详其脉证，互发其义也。太阳病，无论中风、伤寒，但身黄脉大，腹
满小便不利兼头汗出者，乃湿热之黄，非瘀血也。今身黄，脉沉结，少腹硬，小便自利，
其人如狂者，则是血证，非湿热也，故宜抵当汤以攻其血。
【集注】方有执曰∶谛，审也。言如此为血证审实，无复可疑，必须抵当汤，勉人勿二之意。
程知曰∶身黄，脉沉结，少腹硬，三者皆下焦蓄血之证。然尚与胃热发黄证相近，故
当以小便辨之。其少腹满而小便不利者，则为无形之气病，属茵陈证也；其少腹硬而小
便自利者，则为有形之血证，属抵当无可疑矣。
汪琥曰∶按本文云“小便不利者”之下，仲景不言治法。成注云∶可与茵陈汤。《补亡
论》云∶与五苓散。《后条辨》云∶属茵陈五苓散。此三方可选而用之。
伤寒有热，少腹满，应小便不利，今反利者，为有血也，当下之，宜抵当丸。
【注】此承上条而言证之轻者，以互发其义而酌其治也。伤寒荣病，有热不已，伏于
荣中，其血不随经妄行致衄，则必随经下蓄膀胱。少腹者，膀胱之室也，故少腹满。若
小便不利，则为病在卫分，有停水也；今小便反利，则为病在荣分，有瘀血也，法当下
之，宜以抵当汤。小其制为丸，缓缓下之，不可过用抵当汤也。
【集注】方有执曰∶上条之方，变汤而为丸。名虽丸也，而犹煮汤焉。汤者，荡也。丸
者，缓也。变汤为丸，而犹不离乎汤，盖取欲缓不缓，不荡而荡之意也。
程应旄曰∶夫满因热入气分，而蓄及津液者，应小便不利，今反利者，则知其所蓄
非津液也，乃血也。血因热而满结，故用抵当汤，变易为丸，煮而连滓服之，使之直达
血所，以下旧热，荡尽新瘀，乃除根耳！
抵当丸方
水蛭（熬，二十个） 虻虫（熬，去翅足，二十个） 桃核（去皮尖，二十五个） 大黄（三两）
上四味，捣筛为四丸，以水一升，煮一丸，取七合，服之。 时当下血，若不下者更服。
【集解】柯琴曰∶膀胱为水府，血本无所容蓄者也。少腹者，膀胱之室也。热结硬满，
当小便不利，而反利者，是病不在膀胱之内，而在少腹之内也。其随经之荣血，因瘀热结
于少腹之里，而非膀胱之里也。所以小便虽利，而硬满急结如故，是蓄血瘀于少腹也。热
淫于内，神魂不安，故发狂；血瘀不行，则荣不运，故脉微而沉；荣不运则气不宣，故
脉沉而结也；荣气不周于身，则身黄。消谷善饥者，胃火炽盛也；大便反易者，血之濡
也；色黑者，蓄血之化也；善忘者，血不荣智不明也。此皆瘀血之征，非至峻之剂，不
足以抵其巢穴，而当此重任，故立抵当汤。蛭虫之善饮血者，而利于水，虻虫之善吮血者，
而猛于陆，并取水陆之善取血者以攻之，同气相求；更佐以桃核之苦温，推陈致新，大
黄之苦寒，荡涤邪热，故名抵当也。若热虽盛而未狂，少腹满而未硬，则宜小其制为丸，
以缓治之。若外证已解，少腹急结，其人如狂者，是又为转属阳明之证，用调胃承气加
桃核、桂枝之行血者于其中，以微利之，使胃和则愈矣。此桃核承气所以为治之缓也。
伤寒大下后，复发汗，心下痞，恶寒者，表未解也。不可攻痞，当先解表，表解乃可
攻痞。解表宜桂枝汤，攻痞宜大黄黄连泻心汤。
【注】伤寒大下后，复发汗，先下后汗，治失其序矣。邪热陷入，心下痞结，法当攻
里。若恶寒者，为表未尽也。表既未尽，则不可攻痞，当先解表，表解乃可攻痞。解表
宜桂枝汤者，以其为已汗已下之表也；攻痞以大黄黄连泻心汤者，以其为表解里热之痞也。
【集注】《活人书》云∶大抵结胸、痞皆应下，然表未解者，不可攻也。
方有执曰∶表非初病之表，乃下后复汗，疏缓其表之表也。解犹救也，如解渴、解急
之类是也。解表与发表不同，伤寒初病之表当发，故用麻黄汤；此以汗后之表当解，故曰宜桂枝汤。
张璐曰∶大下之后复发汗，先里后表，颠倒差误。究竟已陷之邪痞结心下，证兼恶寒，
表邪不为汗衰，即不可更攻其痞，当先行解肌之法以治外，外解已后，乃用大黄黄连攻
其邪热凝聚之痞，方为合法。
大黄黄连泻心汤方
大黄（二两） 黄连（一两）
上二味，以麻沸汤二升渍之，须臾绞去滓，分温再服。
【方解】痞硬虚邪，而用大黄、黄连，能不起后人之疑耶？然仲景使人疑处，正是使
人解处。盖因后人未能细玩，不得其法，竟煎而服之，大悖其指矣。观其以滚沸如麻之
汤，渍大黄、黄连，须臾绞去滓，仅得其无形之气，不重其有形之味，是取其气味俱薄，
不大泻下。虽曰攻痞，而用攻之妙，不可思议也。
脉浮而紧，而复下之，紧反入里，则作痞，按之自濡，但气痞耳。
【注】伤寒脉浮紧，不汗而下之，浮紧之脉，变为沉紧；是为寒邪内陷作痞之诊也。按
之自濡者，谓不硬不痛，但气痞不快耳。此甘草泻心汤证也。
【集注】程应旄曰∶误下成痞，既误在证，尤误在脉，则救之之法，仍当兼凭夫脉与证
而定治矣。紧反入里，则浮紧变为沉紧，表邪陷入而不散，徒怫郁于心下，故作痞。
心下痞，按之濡，其脉关上浮者，大黄黄连泻心汤主之。
【按】濡字上当有“不”字，若按之濡，乃虚痞也，补之不暇，岂有用大黄泻之之理乎？
【注】此承上条以互明之也。按之自濡者，但气痞耳！若心下痞，按之不濡，此为可攻
之热痞也。然其脉，关上不沉紧而浮，则是所结之热亦浅，未可峻攻也，故以大黄黄连泻心汤主之。
心下痞，而复恶寒汗出者，附子泻心汤主之。
【注】心下硬痛，结胸也。硬而不痛，心下痞也。心下痞而复恶寒汗出者，非表不解，
乃表阳虚也。故以大黄、黄连、黄芩泻痞之热，附子温表之阳，合外寒内热而兼治之。其
妙尤在以麻沸汤渍三黄，须臾绞去滓，纳附子别煮汁。义在泻痞之意轻，扶阳之意重也。
【集注】方有执曰∶痞本阴邪内伏而虚热上凝，复恶寒汗出，则表虚而阳不为护卫可
知矣。泻心汤固所以为清热倾痞之用，加附子者，盖欲敛其汗，而固其阳也。黄芩因附
子而更加表里两解具见矣。
李中梓曰∶以三黄之苦寒，清中济阴，以附子之辛热，温经固阳。寒热互用，攻补并
施而不悖，此仲景之妙用入神也。
程应旄曰∶此条宜与伤寒大下后，复发汗，心下痞，恶寒者，表未解也，不可攻痞，
当先解表，表解乃可攻痞，解表宜桂枝汤，攻痞宜大黄黄连泻心汤合看。彼条用桂枝者，缘
发汗汗未出，而初时之恶寒不罢，故属表未和；此条加附子者，缘汗已出，恶寒已罢，而
复恶寒汗出，故属之表阳虚，须于异同处细细参看。
附子泻心汤方
大黄（二两） 黄连（一两） 黄芩（一两） 附子（炮，去皮，破，别煮取汁，一枚）
上四味，切三味，以麻沸汤二升渍之，须臾绞去滓，纳附子汁，分温再服。
伤寒中风，医反下之，其人下利，日数十行，谷不化，腹中雷鸣，心中痞硬而满，干
呕，心烦不得安。医见心下痞，谓病不尽，复下之，其痞益甚。此非结热，但以胃中虚，客
气上逆，故使硬也，甘草泻心汤主之。
【注】毋论伤寒中风，表未解总不当下。医反下之，或成痞，或作利。今其人以误下
之故，下利日数十行，水谷不化，腹中雷鸣，是邪乘里虚而利也。心下痞硬而满，干呕，心
烦不得安，是邪陷胸虚而上逆也。似此痞利，表里兼病，法当用桂枝加人参汤两解之。医
惟以心下痞，谓病不尽，复下之，其痞益甚，可见此痞非热结，亦非寒结，乃乘误下中虚，
而邪气上逆、阳陷阴凝之痞也，故以甘草泻心汤以缓其急，而和其中也。
【集注】沈亮宸曰∶半夏泻心、甘草泻心，皆下后伤气之过也。生姜泻心，因于饮食；大
黄泻心，因于内热；附子泻心，因于外寒。证既不同，药亦各异也。
喻昌曰∶下利完谷，腹鸣呕烦，皆误下而胃中空虚之故也。设不知此义，以为结热
而复下之，其痞必益甚，故复以胃中虚，客气上逆，昭揭病因。
程应旄曰∶仲景结热之疑难明，故特揭出胃中空虚，客气上逆之故，以明其非。所
以用辛温以调其阳，制住客气，使不得上逆；用苦寒清肃，彻去客热，使无阻留。庶两勿
羁縻，阴阳相和，否转为泰矣。
汪琥曰∶其人下利，日数十行，则胃中之物已尽，何得而不虚？况医复下之，而痞
益甚，愈可知其非实证矣。若是实证，当必曰硬而痛，不曰硬而满矣。只此“满”字，而
虚实之证了然。
魏荔彤曰∶前条因恶寒汗出，阳随汗而在表，恐亡阳于外，故用附子以回阳；此条
重在胃虚，阳微于中，故用甘草干姜以益阳；亦表里分治之急务也。而其固阳以为泻邪之本，则一意耳。
甘草泻心汤方
甘草（炙，四两） 黄芩（三两） 黄连（一两） 干姜（三两） 半夏（洗，半斤） 大枣（擘，十二枚）
上六味，以水一斗，煮取六升，去滓，再煎取三升，温服一升，日三服。
【方解】方以甘草命名者，取和缓之意也。用甘草、大枣之甘，补中之虚，缓中之急；半
夏之辛，降逆止呕；芩、连之寒，泻阳陷之痞热；干姜之热，散阴凝之痞寒。缓中降逆，
泻痞除烦，寒热并用也。
伤寒汗出，解之后，胃中不和，心下痞硬，干噫食臭，胁下有水气，腹中雷鸣下利
者，生姜泻心汤主之。
【注】伤寒汗出表解之后，余邪转属阳明心下痞满硬痛不大便者，必其人胃素燥热，因
而成实，攻之可也。今其人平素胃虚，兼胁下有水气，即不误下，而余热亦乘虚入里，以
致胃中不和，谷气不化，故心下痞硬，干噫食臭也。水气不行，故腹中雷鸣下利也。主
之以生姜泻心汤者，其意重在散水气之虚痞耳。
【集注】喻昌曰∶篇中论结胸及痞之根源，云胃中空虚。此云胃中不和，以其未经误下
而致空虚耳。故但言不和也，然不和已足成痞，胃气所关之巨，固若此哉！
程知曰∶此为汗后，未经误下，心中痞硬，水饮抟聚者，立治法也。外邪虽解，然
必胃气通和，始得脱然无恙。汗出解后，胃中不和，饮食抟结，故心中痞硬。中焦不能
消谷，故干噫食臭。土弱不能制水，故胁下有水气旁流。腹中雷鸣者，抟击有声，下利
而清浊不分也。故于泻心汤内，君生姜以散
之，法用再煮，取其熟而和胃也。
程应旄曰∶汗多亡阳，人皆知之矣。然人身之阳，部分各有所主。有卫外之阳，为
周身营卫之主，此阳虚，遂有汗漏不止，恶寒身疼痛之证；有肾中之阳，为下焦真元之
主，此阳虚，遂有发热眩悸，身 动，欲擗地之证；有膻中之阳，为上焦心气之主，此
阳虚，遂有叉手冒心、耳聋及奔豚之证；有胃中之阳，为中焦水谷化生之主，此阳虚，遂
有腹胀满，胃中不和，而成心下痞之证。虽皆从发汗后所得，然救误者，须观其脉证，知
犯何逆，以法治之，不得以汗多亡阳一语，混同漫及之也。
生姜泻心汤方
甘草（炙，三两） 人参（三两） 干姜（一两） 半夏（洗，半升） 黄芩（三两） 黄连（一两） 生姜
（切，四两） 大枣（擘，十二枚）
上八味，以水一斗，煮取六升，去滓再煎，取三升，温服一升，日三服。
【方解】名生姜泻心汤者，其义重在散水气之痞也。生姜、半夏散胁下之水气，人参、
大枣补中州之土虚，干姜、甘草以温里寒，黄芩、黄连以泻痞热，备乎虚水寒热之治，胃
中不和下利之痞，焉有不愈者乎？
伤寒五六日，呕而发热者，柴胡汤证具，而以他药下之，柴胡证仍在者，复与柴胡汤。
此虽已下之不为逆，必蒸蒸而振，却发热汗出而解。若心下满而硬痛者，此为结胸也，大
陷胸汤主之。但满而不痛者，此为痞，柴胡不中与之，宜半夏泻心汤。
【注】结胸兼阳明里实者，大陷胸汤证也；兼阳明不成实者，小陷胸汤证也。痞硬兼少
阳里实证者，大柴胡汤证也；兼少阳里不成实者，半夏泻心汤证也。今伤寒五六日，呕
而发热者，是邪传少阳之病也。既柴胡证具，乃不以柴胡和之，而以他药下之，误矣。若
柴胡证仍在者，此虽已下，尚未成逆，则当复与柴胡汤，必蒸蒸而振战，然后发热汗出
而解矣。盖以下后虚中、作解之状皆如是也。若下后心下满而硬痛者，此为结胸，大陷胸
汤固所宜也；若但满而不痛，此为虚热气逆之痞，即有呕而发热之少阳证，柴胡汤亦不
中与之。法当治痞也，宜半夏泻心汤主之。
【集注】成无己曰∶若下后阳邪传里者，则结于胸中为结胸，以胸中为阳受气之分也。
水蛭（熬制，三十个） 虻虫（熬制，去掉头和足，三十个） 大黄（去皮，破成六片，三两） 桃仁（去皮和尖，二十个）
以上四味药，用水五升，煮取三升药液，滤去药渣，温服一升。若服药后瘀血未下，可再服一次。
太阳病，身体发黄，脉象沉结，少腹部硬满，小便不利的，是气分湿热证，而非蓄血证；若小便自利，其人出现如狂症状的，则是蓄血证确凿无疑，属于抵当汤证。
【注】此段承接上一条详细论述脉证，互相阐发其义理。太阳病，无论是中风还是伤寒，只要身体发黄、脉大、腹满、小便不利且兼有头汗出的，乃是湿热引起的黄疸，并非瘀血所致。如今身体发黄，脉象沉结，少腹部硬，小便自利，其人如狂的，则是蓄血证，不是湿热，所以适宜用抵当汤来攻逐瘀血。
【集注】方有执说：谛，是审察的意思。意思是如此判断为蓄血证确实无误，不再可疑，必须使用抵当汤，这是勉励医者不要犹豫不决的意思。
程知说：身体发黄，脉象沉结，少腹部硬，这三者都是下焦蓄血的证候。然而这与胃热发黄的证候相近，所以应当通过小便情况来辨别。如果少腹胀满而小便不利的，就是无形之气机阻滞，属于茵陈汤证；如果少腹部硬而小便自利的，就是有形的血瘀证，属于抵当汤证，无可怀疑了。
汪琥说：按原文在“小便不利者”之下，仲景没有提及治法。成无己注解说：可与茵陈汤。《补亡论》说：与五苓散。《后条辨》说：属茵陈五苓散。这三个方剂可以酌情选用。
伤寒伴有发热，少腹胀满，本应小便不利，现在反而小便通利，是有瘀血，应当攻下，适宜用抵当丸。
【注】此段承接上一条而言病情较轻的情况，以互相阐发义理并斟酌治疗方法。伤寒营分受邪，发热不退，伏于营分之中，血液不随经脉妄行导致鼻衄，就必定随经脉下行蓄积在膀胱。少腹部，是膀胱所在的部位，所以少腹胀满。如果小便不利，就是病在卫分，有水湿停聚；现在小便反而通利，就是病在营分，有瘀血，治法应当攻下，适宜用抵当汤。减小剂量制成丸剂，缓缓攻下，不可过度使用抵当汤。
【集注】方有执说：上一条的方剂，由汤剂改为丸剂。名义上是丸剂，但还是要煮成汤服用。汤剂，作用是涤荡；丸剂，作用是缓和。将汤剂改为丸剂，但仍然不离乎汤剂的作用，大概是取想要缓和却不彻底缓和，不涤荡却起到涤荡作用的意思。
程应旄说：胀满是因热入气分，波及津液，应当小便不利，现在反而通利，就知道所蓄积的不是津液，而是血。血因热而满结，所以用抵当汤，改变剂型为丸，煮后连同药渣一起服用，使其直达血分所在，以下除旧热，荡尽新瘀，才能根除！
抵当丸方
水蛭（熬制，二十个） 虻虫（熬制，去掉翅足，二十个） 桃仁（去皮尖，二十五个） 大黄（三两）
以上四味药，捣碎筛细分为四丸，用水一升，煮一丸，取七合药液，服用。此时应当排出瘀血，若未排出，可再服。
【集解】柯琴说：膀胱是水腑，血液本来没有地方蓄积。少腹部，是膀胱所在的部位。热结导致硬满，应当小便不利，而反而通利的，说明病不在膀胱之内，而在少腹之内。那随经脉下行的营血，因瘀热结于少腹内部，而不是膀胱的内部。所以小便虽然通利，但硬满急结依旧，这是蓄血瘀积在少腹。热邪淫溢于内，神魂不安，所以发狂；血瘀不行，则营血不能运行，所以脉微而沉；营血不能运行则气机不畅，所以脉沉而结；营气不能周流全身，则身体发黄。消谷善饥，是胃火炽盛；大便反而容易排出，是血液濡润肠道；颜色黑，是蓄血化腐的表现；健忘，是血不养神导致智力不明。这些都是瘀血的征象，非至峻猛的药剂，不足以抵挡其巢穴，承担此重任，所以设立抵当汤。水蛭善于吸血且利于水中活动，虻虫善于吮血且猛烈于陆地，同时选取水陆两种善于取血的动物来攻逐瘀血，同气相求；更佐以桃仁的苦温，推陈致新，大黄苦寒，荡涤邪热，所以名叫抵当。如果热势虽盛但未发狂，少腹胀满但未变硬，就适宜减小剂量制成丸剂，以缓和方法治疗。如果外证已解，少腹急结，其人如狂的，这又是转属阳明的证候，用调胃承气汤加入桃仁、桂枝等行血药物在其中，轻微通利，使胃气和顺就好了。这就是桃核承气汤作为缓治方法的原因。
伤寒经过剧烈泻下后，又发汗，心下痞塞，恶寒的，是表证未解。不可攻逐痞结，应当先解表，表解之后才可攻痞。解表适宜用桂枝汤，攻痞适宜用大黄黄连泻心汤。
【注】伤寒经过剧烈泻下后，又发汗，先下后汗，治疗失去了次序。邪热陷入，心下痞结，治法应当攻里。如果恶寒，说明表邪未尽。表邪既然未尽，就不可攻痞，应当先解表，表解之后才可攻痞。解表适宜用桂枝汤，是因为这是已经发汗、已经泻下后的表证；攻痞用大黄黄连泻心汤，是因为这是表解后里热形成的痞证。
【集注】《活人书》说：大致结胸、痞证都应当用下法，然而表证未解的，不可攻下。
方有执说：这里的表证不是初病的表证，而是泻下后又发汗，疏缓其表的表证。“解”如同解救，如解渴、解急之类。解表与发表不同，伤寒初病的表证应当发散，所以用麻黄汤；这里因为是汗后的表证应当解除，所以说适宜桂枝汤。
张璐说：剧烈泻下后又发汗，先治里后治表，颠倒错误。最终已陷入的邪气痞结于心下，证候兼有恶寒，表邪不因发汗而衰减，就不可再次攻其痞结，应当先行解肌的方法治疗外部，外部解除了，再用大黄黄连攻逐其邪热凝聚的痞结，这才是合法的治疗。
以上两味药，用滚沸的水二升浸泡它们，片刻后绞去药渣，分两次温服。
【方解】痞硬虚邪，却用大黄、黄连，能不引起后人的疑惑吗？然而仲景让人疑惑的地方，正是让人理解的地方。大概因为后人未能仔细研读，不得其法，竟然煎煮后服用，大大违背了其旨意。看他用滚沸如麻的水，浸泡大黄、黄连，片刻后绞去药渣，仅取其无形的气味，不重用其有形的味道，这是取其气味俱薄，不大泻下。虽然说攻痞，但用攻的妙处，不可思议啊。
脉浮而紧，却又误用下法，紧脉反而入里，则形成痞证，按之柔软，只是气痞而已。
【注】伤寒脉浮紧，不发汗而误用下法，浮紧之脉变为沉紧；这是寒邪内陷形成痞证的诊察依据。按之柔软的，指不硬不痛，只是气机痞塞不适罢了。这是甘草泻心汤证。
【集注】程应旄说：误用下法导致成痞，既误在证候，更误在脉象，那么救治的方法，仍应当兼凭脉象与证候来决定治疗。紧脉反而入里，则浮紧变为沉紧，表邪陷入而不散，郁结于心下，所以形成痞证。
【按】“濡”字上面应当有“不”字，如果按之柔软，那是虚痞，补益尚且来不及，岂有用大黄泻下的道理呢？
【注】此段承接上一条以互相阐明。按之柔软的，只是气痞罢了！如果心下痞，按之不柔软，这是可攻的热痞。然而其脉象，关部不沉紧而浮，说明所结聚的热邪也浅，不可峻猛攻下，所以用大黄黄连泻心汤主治。
【注】心下硬痛，是结胸。硬而不痛，是心下痞。心下痞又兼恶寒汗出的，不是表证未解，而是表阳虚。所以用大黄、黄连、黄芩泻除痞热，附子温补表阳，合治外寒内热。其妙处尤其在于用麻沸汤浸泡三黄，片刻后绞去药渣，将附子另煮取汁。用意在于泻痞之意轻，扶阳之意重。
【集注】方有执说：痞本是阴邪内伏而虚热上凝，又兼恶寒汗出，则表虚而阳气不能护卫可知。泻心汤固然是为了清热倾泻痞结之用，加附子，是想收敛其汗，稳固其阳气。黄芩因附子而更加体现了表里两解的功效。
李中梓说：用三黄之苦寒，清中济阴；用附子之辛热，温经固阳。寒热互用，攻补并施而不悖，这是仲景妙用入神的体现。
程应旄说：此条宜与“伤寒大下后，复发汗，心下痞，恶寒者，表未解也，不可攻痞，当先解表，表解乃可攻痞，解表宜桂枝汤，攻痞宜大黄黄连泻心汤”合看。那条用桂枝，是因为发汗后汗未出，初时的恶寒未罢，所以属表未和；这条加附子，是因为汗已出，恶寒已罢，而复见恶寒汗出，所以属表阳虚，须在异同之处细细参看。
附子泻心汤方
大黄（二两） 黄连（一两） 黄芩（一两） 附子（炮制，去皮，破开，另煮取汁，一枚）
以上四味药，切前三味，用麻沸汤二升浸泡，片刻后绞去药渣，纳入附子汁，分两次温服。
伤寒中风，医生反而用下法，其人腹泻，一天数十次，完谷不化，腹中雷鸣，心下痞硬而满，干呕，心烦不得安宁。医生见心下痞，认为病邪未尽，再次用下法，其痞结更加严重。这不是结热，只是因为胃中虚，客气上逆，所以使心下硬，用甘草泻心汤主治。
【注】无论伤寒还是中风，表证未解总不应下。医生反而用下法，或成痞，或作利。如今其人因误用下法，腹泻一天数十次，水谷不化，腹中雷鸣，是邪气乘里虚而下利。心下痞硬而满，干呕，心烦不得安，是邪气陷入胸膈虚处而上逆。像这样的痞利，表里兼病，治法应当用桂枝加人参汤两解。医生只看到心下痞，认为病邪未尽，再次用下法，其痞结更加严重，可见此痞非热结，亦非寒结，乃是乘误下中气虚弱，而邪气上逆、阳陷阴凝的痞证，所以用甘草泻心汤以缓解其急迫，调和其中气。
【集注】沈亮宸说：半夏泻心汤、甘草泻心汤，都是下后伤气的过错。生姜泻心汤，是因为饮食；大黄泻心汤，是因为内热；附子泻心汤，是因为外寒。证候既然不同，药物也各异。
喻昌说：下利完谷，腹鸣呕烦，都是误下导致胃中空虚的缘故。假如不知此义，认为是结热而再次用下法，其痞结必然更加严重，所以再次指出胃中虚，客气上逆，昭示病因。
程应旄说：仲景明确了解热结的疑难，所以特意提出胃中空虚，客气上逆的原因，以明其非。所以用辛温以调其阳，制约住客气，使其不得上逆；用苦寒清肃，彻去客热，使其无阻留。这样两不相羁縻，阴阳相和，否极泰来。
汪琥说：其人腹泻，一天数十次，则胃中之物已尽，怎么会不虚呢？何况医生再次用下法，而痞结更加严重，愈可知其非实证了。如果是实证，应当一定说硬而痛，不说硬而满了。只此“满”字，虚实之证一目了然。
魏荔彤说：前条因恶寒汗出，阳随汗而在表，恐亡阳于外，所以用附子以回阳；此条重在胃虚，阳微于中，所以用甘草干姜以益阳；也是表里分治的急务。而其固阳以为泻邪之本，则心意一致。
甘草泻心汤方
甘草（炙，四两） 黄芩（三两） 黄连（一两） 干姜（三两） 半夏（洗，半斤） 大枣（掰开，十二枚）
以上六味药，用水一斗，煮取六升，滤去药渣，再煎取三升，温服一升，每日三次。
【方解】方名以甘草命名，取和缓之意。用甘草、大枣之甘，补中之虚，缓中之急；半夏之辛，降逆止呕；芩、连之寒，泻阳陷之痞热；干姜之热，散阴凝之痞寒。缓中降逆，泻痞除烦，寒热并用。
伤寒汗出，表解之后，胃中不和，心下痞硬，干噫食臭，胁下有水气，腹中雷鸣下利的，用生姜泻心汤主治。
【注】伤寒汗出表解之后，余邪转属阳明，心下痞满硬痛不大便的，必定其人胃素燥热，因而成实，攻之可也。如今其人平素胃虚，兼胁下有水气，即使不误用下法，余热也会乘虚入里，导致胃中不和，谷气不化，所以心下痞硬，干噫食臭。水气不行，所以腹中雷鸣下利。主用生姜泻心汤，其意重在散水气之虚痞。
【集注】喻昌说：篇中论结胸及痞的根源，说胃中空虚。这里说胃中不和，是因为未经误下而导致空虚。所以只说不和。然而不和已足以成痞，胃气关系之大，竟至于此啊！
程知说：这是汗后，未经误下，心中痞硬，水饮抟聚者，设立治法。外邪虽解，然而必须胃气通和，始得脱然无恙。汗出解后，胃中不和，饮食抟结，所以心中痞硬。中焦不能消谷，所以干噫食臭。土弱不能制水，所以胁下有水气旁流。腹中雷鸣者，抟击有声，下利而清浊不分。所以在泻心汤内，君以生姜以散之，法用再煮，取其熟而和胃。
程应旄说：汗多亡阳，人们都知道。然而人身之阳，部分各有所主。有卫外之阳，为周身营卫之主，此阳虚，遂有汗漏不止，恶寒身疼痛之证；有肾中之阳，为下焦真元之主，此阳虚，遂有发热眩悸，身动，欲擗地之证；有膻中之阳，为上焦心气之主，此阳虚，遂有叉手冒心、耳聋及奔豚之证；有胃中之阳，为中焦水谷化生之主，此阳虚，遂有腹胀满，胃中不和，而成心下痞之证。虽然都从发汗后所得，然而救误者，须观其脉证，知犯何逆，以法治之，不得以汗多亡阳一语，混同漫及之也。
生姜泻心汤方
甘草（炙，三两） 人参（三两） 干姜（一两） 半夏（洗，半升） 黄芩（三两） 黄连（一两） 生姜（切，四两） 大枣（掰开，十二枚）
以上八味药，用水一斗，煮取六升，滤去药渣再煎，取三升，温服一升，每日三次。
【方解】名生姜泻心汤，其义重在散水气之痞。生姜、半夏散胁下之水气，人参、大枣补中州之土虚，干姜、甘草以温里寒，黄芩、黄连以泻痞热，备乎虚水寒热之治，胃中不和下利之痞，焉有不愈者乎？
伤寒五六日，呕而发热者，柴胡汤证具备，却用其他药误下，柴胡证仍在的，再次给予柴胡汤。这虽然已误下但不为逆，必蒸蒸而振战，随后发热汗出而解。如果心下满而硬痛的，这是结胸，用大陷胸汤主治。但满而不痛的，这是痞，柴胡汤不适用，宜用半夏泻心汤。
【注】结胸兼阳明里实者，是大陷胸汤证；兼阳明不成实者，是小陷胸汤证。痞硬兼少阳里实证者，是大柴胡汤证；兼少阳里不成实者，是半夏泻心汤证。如今伤寒五六日，呕而发热者，是邪传少阳的病。既然柴胡证具备，却不以柴胡和解，而以其他药误下，是错误的。如果柴胡证仍在，这虽然已误下，尚未成逆，则应当再次给予柴胡汤，必蒸蒸而振战，然后发热汗出而解。因为下后虚中、作解之状皆如是。如果下后心下满而硬痛，这是结胸，大陷胸汤固所适宜；如果但满而不痛，这是虚热气逆之痞，即有呕而发热之少阳证，柴胡汤也不适用。治法应当治痞，宜半夏泻心汤主治。
Leech (fried, 30 pieces) Tabanid fly (fried, heads and feet removed, 30 pieces) Rhubarb (peeled, broken into six pieces, 3 liang) Peach Kernel (peeled and tips removed, 20 pieces)
The above four herbs are boiled in five sheng of water to obtain three sheng of decoction. Strain the dregs, and take one sheng warm. If the blood stasis is not expelled, administer again.
In Taiyang disease (disease of the Taiyang channel), if there is yellowing of the body, a deep and knotted pulse, hardness and fullness in the lower abdomen, and difficulty in urination, it indicates damp-heat affecting the Qi level rather than blood stasis; however, if urination is normal and the patient exhibits symptoms resembling mania, this confirms blood stasis, which falls under the indication for Didang Tang (Cockroach Decoction).
[Annotation] This section elaborates on the pulse and symptoms from the previous clause, mutually elucidating their meanings. In Taiyang disease, whether Wind Strike or Cold Damage, if there is yellowing of the body, a large pulse, abdominal fullness, difficulty in urination, and sweating only on the head, it is jaundice caused by damp-heat, not blood stasis. Now, with yellowing of the body, a deep and knotted pulse, hardness in the lower abdomen, normal urination, and symptoms resembling mania, it is blood stasis, not damp-heat; therefore, Didang Tang should be used to attack the blood stasis.
[Collected Annotations] Fang Youzhi said: "Di" means examination. It implies that judging it as blood stasis is thoroughly verified and beyond doubt; using Didang Tang is mandatory, encouraging physicians not to hesitate.
Cheng Zhi said: Yellowing of the body, deep and knotted pulse, and hardness in the lower abdomen are all signs of blood accumulation in the lower Jiao. However, these are similar to the syndrome of jaundice due to stomach heat, so differentiation must rely on urination. If the lower abdomen is full but urination is difficult, it is a functional Qi disorder, belonging to Yinchen Tang (Artemisia Capillaris Decoction); if the lower abdomen is hard and urination is normal, it is an organic Blood stasis disorder, undoubtedly belonging to Didang Tang.
Wang Hu said: According to the original text, below "difficulty in urination," Zhongjing does not mention treatment methods. Cheng Wuji's annotation says: One may use Yinchen Tang. The "Bu Wang Lun" says: Use Wuling San (Five-Ingredient Powder with Poria). The "Hou Tiaobian" says: It belongs to Yinchen Wuling San. These three formulas can be selected and used.
In Cold Damage with fever, lower abdominal fullness, urination should be difficult; now that it is surprisingly normal, it indicates blood stasis, which should be purged. Didang Wan (Cockroach Pill) is appropriate.
[Annotation] This section continues from the previous one to discuss milder cases, mutually elucidating principles and斟酌 (considering) treatment methods. In Cold Damage affecting the Ying (Nutritive) level, if fever persists, stagnating within the Ying level, and the blood does not follow the channels to cause epistaxis, it will likely descend along the channels and accumulate in the Bladder. The lower abdomen is the chamber of the Bladder, hence the lower abdominal fullness. If urination is difficult, the disease is in the Wei (Defensive) level with retained water; now that urination is surprisingly normal, the disease is in the Ying level with blood stasis. The method requires purging, and Didang Tang is appropriate. Reducing the dosage to form pills allows for a slow purgative action; excessive use of Didang Tang should be avoided.
[Collected Annotations] Fang Youzhi said: The formula in the previous clause was changed from a decoction to a pill. Although named a pill, it is still boiled as a decoction. A decoction acts vigorously (dang); a pill acts slowly (huan). Changing from decoction to pill while retaining the decoction method aims for a balance between slowness and vigor, achieving a purgative effect without being overly drastic.
Cheng Yingmao said: Fullness arises when heat enters the Qi level and affects fluids, leading to difficult urination; now that urination is normal, we know what accumulates is not fluid but blood. Blood becomes full and knotted due to heat, so Didang Tang is used, altered into pills, boiled and taken with dregs, to reach the site of blood directly, purge old heat, and sweep away new stasis, thereby eliminating the root cause!
Didang Wan Formula
Leech (fried, 20 pieces) Tabanid fly (fried, wings and feet removed, 20 pieces) Peach Kernel (peeled and tips removed, 25 pieces) Rhubarb (3 liang)
The above four herbs are crushed, sifted, and divided into four pills. Boil one pill in one sheng of water to obtain seven he of liquid, and take it. Blood should be discharged at this time; if not, administer again.
[Ji Jie - Collected Exegesis] Ke Qin said: The Bladder is the residence of water, where blood has no place to accumulate. The lower abdomen is the chamber of the Bladder. Heat knotting causes hardness and fullness, which should lead to difficult urination; the fact that urination is normal indicates the disease is not inside the Bladder but within the lower abdomen. The Ying blood descending along the channels, due to heat-stasis knotting in the interior of the lower abdomen, is not in the interior of the Bladder. Thus, although urination is normal, the hardness, fullness, urgency, and knotted sensation remain unchanged, indicating blood stasis accumulating in the lower abdomen. Heat rampant internally disturbs the soul and spirit, causing mania; blood stasis impedes circulation, so Ying blood cannot move, resulting in a faint and deep pulse; Ying blood not moving leads to Qi obstruction, resulting in a deep and knotted pulse; Ying Qi not circulating throughout the body causes yellowing of the skin. Eating well and feeling hungry quickly indicates blazing Stomach fire; stool being surprisingly easy to pass indicates blood moistening the intestines; black color indicates transformation of accumulated blood; forgetfulness indicates blood failing to nourish the mind, leading to unclear intellect. All these are signs of blood stasis. Only the most potent agents can penetrate its nest and bear this heavy responsibility; thus, Didang Tang was established. Leeches are good at drinking blood and thrive in water; Tabanid flies are good at sucking blood and are fierce on land. Using both aquatic and terrestrial blood-sucking creatures attacks via sympathetic resonance (tong qi xiang qiu). Assisted by the bitter-warm Peach Kernel to push out the old and generate the new, and the bitter-cold Rhubarb to scour evil heat, it is named Didang. If heat is severe but without mania, and the lower abdomen is full but not hard, it is appropriate to reduce the dosage into pills for slow treatment. If exterior symptoms have resolved, but there is urgency and knotted sensation in the lower abdomen, and the patient resembles mania, this is a syndrome transferring to Yangming. Use Tiaowei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction) added with Peach Kernel and Cinnamon Twig for blood-moving properties, to mildly promote evacuation, so that the Stomach harmonizes and health returns. This is why Taohe Chengqi Tang (Peach Pit and Magnolia Bark Decoction) serves as a slow treatment method.
After severe purgation in Cold Damage, followed by sweating, if there is epigastric stuffiness (pi) and aversion to cold, the exterior is unresolved. One must not attack the pi; first resolve the exterior. Only after the exterior is resolved can one attack the pi. To resolve the exterior, Guizhi Tang (Cinnamon Twig Decoction) is appropriate; to attack the pi, Dahuang Huanglian Xiexin Tang (Rhubarb and Coptis Heart-Purging Decoction) is appropriate.
[Annotation] After severe purgation in Cold Damage, followed by sweating, the sequence of treatment (purgation then sweating) was incorrect. Evil heat sank inward, causing epigastric stuffiness; the method should be to attack the interior. However, if there is aversion to cold, the exterior is not yet cleared. Since the exterior is not cleared, one must not attack the pi; first resolve the exterior. Only after the exterior is resolved can one attack the pi. Guizhi Tang is appropriate for resolving the exterior because it is an exterior condition following sweating and purgation; Dahuang Huanglian Xiexin Tang is appropriate for attacking the pi because it is a pi condition caused by interior heat after the exterior has resolved.
[Collected Annotations] "Huoren Shu" says: Generally, Jie Xiong (Constraint in the Chest) and Pi (Stuffiness) should be treated with purgation, but if the exterior is unresolved, one must not attack.
Fang Youzhi said: The "exterior" here is not the initial exterior of the disease, but the exterior loosened by subsequent sweating after purgation. "Resolve" (jie) is like relieving, such as relieving thirst or urgency. Resolving the exterior differs from releasing the exterior. For the initial exterior of Cold Damage, one should release it, hence Ma Huang Tang (Ephedra Decoction); for the exterior after sweating, one should resolve it, hence Guizhi Tang is indicated.
Zhang Lu said: Severe purgation followed by sweating reverses the order of treating interior then exterior, which is an error. Ultimately, the sinking evil knots in the epigastrium, accompanied by aversion to cold, shows that the exterior evil is not diminished by sweating. One must not attack the pi again; instead, one should first employ the method of releasing the muscle layer to treat the exterior. After the exterior resolves, then use Dahuang Huanglian to attack the heat-knotting pi, which is the correct method.
Dahuang Huanglian Xiexin Tang Formula
Rhubarb (2 liang) Coptis (1 liang)
The above two herbs are soaked in two sheng of boiling water ("Ma Fei Tang"). After a moment, strain the dregs, and divide into two warm doses.
[Fang Jie - Formula Explanation] Stuffiness and hardness due to empty evil, yet using Rhubarb and Coptis—can this not raise doubts among later generations? However, the places where Zhongjing raises doubts are precisely where understanding lies. Probably because later generations failed to study carefully and did not grasp the method, actually boiling and taking it, greatly violating its intent. Observe that using boiling water to soak Rhubarb and Coptis, straining after a moment, extracts only the formless Qi/Flavor, not the solid taste. This takes advantage of their thin flavor and Qi, avoiding strong purgation. Although it attacks pi, the subtlety of this attacking method is inconceivable.
If the pulse is floating and tight, and purgation is mistakenly applied, the tight pulse moves inward, forming pi. Palpation reveals softness; it is merely Qi pi.
[Annotation] In Cold Damage, a floating-tight pulse, if not released by sweating but purged, changes from floating-tight to deep-tight; this is the diagnostic sign of cold evil sinking inward to form pi. "Soft upon palpation" means neither hard nor painful, merely uncomfortable Qi pi. This is a Ganycao Xiexin Tang (Licorice Heart-Purging Decoction) syndrome.
[Collected Annotations] Cheng Yingmao said: Mistaken purgation leading to pi is erroneous in both syndrome and pulse. Therefore, the rescue method must determine treatment based on both pulse and syndrome. The tight pulse moving inward changes floating-tight to deep-tight; the exterior evil sinks and does not disperse, merely stagnating in the epigastrium, thus forming pi.
Epigastric stuffiness, soft upon palpation, with a floating pulse at the Guan position, is primarily treated with Dahuang Huanglian Xiexin Tang.
[Commentary] There should be a "not" before "soft." If soft upon palpation, it is empty pi; supplementation would barely suffice, let alone using Rhubarb to purge!
[Annotation] This continues the previous clause to clarify. Soft upon palpation is merely Qi pi! If epigastric stuffiness is not soft upon palpation, it is hot pi suitable for attack. However, since the pulse at the Guan position is floating rather than deep-tight, the accumulated heat is shallow, and harsh purgation is not warranted. Thus, Dahuang Huanglian Xiexin Tang is used.
Epigastric stuffiness, accompanied by aversion to cold and sweating, is primarily treated with Fuzi Xiexin Tang (Aconite Heart-Purging Decoction).
[Annotation] Hard and painful epigastrium is Jie Xiong. Hard but painless epigastrium is Pi. Epigastric stuffiness with aversion to cold and sweating is not unresolved exterior, but deficiency of Exterior Yang. Therefore, Rhubarb, Coptis, and Scutellaria are used to purge the heat of pi, and Aconite is used to warm the Exterior Yang, treating both external cold and internal heat simultaneously. Its brilliance lies especially in soaking the three yellows (San Huang) in Ma Fei Tang, straining after a moment, and adding separately boiled Aconite juice. The intent is light on purging pi and heavy on supporting Yang.
[Collected Annotations] Fang Youzhi said: Pi is originally Yin evil lurking internally with deficient heat condensing upward. Accompanied by aversion to cold and sweating, it indicates exterior deficiency and Yang failing to protect. Xiexin Tang is indeed for clearing heat and pouring out pi; adding Aconite aims to stop sweating and consolidate Yang. With Scutellaria and Aconite together, the dual resolution of exterior and interior is fully manifested.
Li Zhongzi said: Using the bitter-cold of the Three Yellows to clear the middle and assist Yin, and the acrid-hot of Aconite to warm the channels and consolidate Yang. Cold and heat used mutually, attack and tonification applied together without contradiction—this is Zhongjing's divine妙用 (wonderful application).
Cheng Yingmao said: This clause should be read together with "Severe purgation in Cold Damage, followed by sweating, epigastric pi, aversion to cold, exterior unresolved...". In that clause, Guizhi Tang is used because sweating failed to produce sweat, and initial aversion to cold persists, indicating unharmonized exterior; in this clause, Aconite is added because sweating occurred, initial aversion to cold ceased, but aversion to cold and sweating returned, indicating deficiency of Exterior Yang. Carefully examine the similarities and differences.
Fuzi Xiexin Tang Formula
Rhubarb (2 liang) Coptis (1 liang) Scutellaria (1 liang) Aconite (processed, peeled, broken, separately boiled to extract juice, one piece)
The above four herbs: Cut the first three. Soak them in two sheng of Ma Fei Tang. After a moment, strain the dregs. Add the Aconite juice. Divide into two warm doses.
In Cold Damage or Wind Strike, if the physician mistakenly applies purgation, the patient suffers diarrhea dozens of times a day, undigested food, borborygmus in the abdomen, epigastric hardness and fullness, dry retching, irritability, and inability to rest. Seeing epigastric pi, the physician thinks the disease is not exhausted and purges again, making the pi worse. This is not heat knotting, but simply deficiency in the Stomach with rebellious Qi ascending, causing hardness. Ganycao Xiexin Tang is appropriate.
[Annotation] Regardless of Cold Damage or Wind Strike, if the exterior is unresolved, purgation is contraindicated. The physician mistakenly purged, resulting in either pi or diarrhea. Now, due to mistaken purgation, the patient has diarrhea dozens of times daily with undigested food and borborygmus; this is evil exploiting interior deficiency to cause diarrhea. Epigastric hardness/fullness, dry retching, irritability, and unrest indicate evil sinking into the chest deficiency and rebelling upward. In such pi and diarrhea involving both interior and exterior, the method should use Guizhi Jia Renshen Tang (Guizhi Decoction plus Ginseng) to resolve both. The physician, seeing only epigastric pi and thinking the disease remains, purged again, worsening the pi. This shows the pi is neither heat knotting nor cold knotting, but pi formed by evil rebelling upward and Yang sinking/Yin condensing due to middle deficiency caused by mistaken purgation. Thus, Ganycao Xiexin Tang is used to relieve urgency and harmonize the middle.
[Collected Annotations] Shen Liangchen said: Banxia Xiexin Tang and Ganycao Xiexin Tang are errors of damaging Qi after purgation. Shengjiang Xiexin Tang is due to diet; Dahuang Xiexin Tang is due to internal heat; Fuzi Xiexin Tang is due to external cold. Since syndromes differ, medicines vary.
Yu Chang said: Diarrhea with undigested food, borborygmus, vomiting, and irritability are all due to mistaken purgation leaving the Stomach empty. If one fails to understand this and assumes heat knotting to purge again, the pi will worsen. Thus, pointing out Stomach deficiency and rebellious guest Qi clarifies the etiology.
Cheng Yingmao said: Zhongjing clarified the difficulty of heat knotting, specifically highlighting Stomach emptiness and rebellious guest Qi to refute misconceptions. Therefore, acrid-warm herbs regulate Yang to restrain guest Qi from rebelling; bitter-cold herbs clear and肃 (purify) to remove guest heat, preventing obstruction. Thus, neither interferes with the other, Yin and Yang harmonize, and adversity turns to prosperity.
Wang Hu said: Diarrhea dozens of times a day means Stomach contents are exhausted, how could it not be deficient? Moreover, the physician purged again, worsening the pi, further proving it is not an excess syndrome. If it were excess, it would surely be described as hard and painful, not just hard and full. This single character "full" makes the distinction between excess and deficiency clear.
Wei Litong said: In the previous clause, due to aversion to cold and sweating, Yang follows sweat to the exterior, fearing Yang collapse externally, so Aconite is used to restore Yang; in this clause, the focus is Stomach deficiency, with weak Yang in the middle, so Licorice and Dried Ginger are used to benefit Yang; this is also an urgent matter of treating interior and exterior separately. Yet, consolidating Yang as the foundation for expelling evil shares the same intent.
Ganycao Xiexin Tang Formula
Licorice (roasted, 4 liang) Scutellaria (3 liang) Coptis (1 liang) Dried Ginger (3 liang) Pinellia (washed, 8 liang) Jujube (broken open, 12 pieces)
The above six herbs are boiled in ten sheng of water to obtain six sheng. Strain the dregs, and decoct again to obtain three sheng. Take one sheng warm, three times daily.
[Fang Jie - Formula Explanation] Named after Licorice, taking the meaning of gentleness and moderation. Licorice and Jujube's sweetness tonifies middle deficiency and relieves middle urgency; Pinellia's acridity descends rebellion and stops vomiting; Scutellaria and Coptis' coldness purges the heat of pi sinking from Yang; Dried Ginger's heat disperses the cold of pi condensing from Yin. Relieving the middle, descending rebellion, purging pi, removing irritability—cold and heat used together.
After Cold Damage sweating and exterior resolution, if there is Stomach disharmony, epigastric hardness/fullness, dry belching with food odor, water-Qi under the flanks, borborygmus, and diarrhea, Shengjiang Xiexin Tang (Fresh Ginger Heart-Purging Decoction) is appropriate.
[Annotation] After Cold Damage sweating and exterior resolution, if residual evil transfers to Yangming, causing epigastric pi, fullness, hardness, pain, and constipation, it usually indicates inherent Stomach dryness-heat becoming excess, suitable for purgation. Now, the patient inherently has Stomach deficiency, combined with water-Qi under the flanks. Even without mistaken purgation, residual heat would enter the interior exploiting deficiency, causing Stomach disharmony and failure to transform grain, leading to epigastric hardness/fullness and dry belching with food odor. Water-Qi failing to circulate causes borborygmus and diarrhea. Using Shengjiang Xiexin Tang focuses on dispersing water-Qi-related empty pi.
[Collected Annotations] Yu Chang said: The chapter discusses the roots of Jie Xiong and Pi, stating Stomach emptiness. Here it says Stomach disharmony, because it was not caused by mistaken purgation leading to emptiness. Hence, only "disharmony" is stated. Yet, disharmony is sufficient to form pi; the importance of Stomach Qi is indeed this great!
Cheng Zhi said: This establishes a treatment method for post-sweating, unmistaken purgation, with epigastric pi/hardness and gathered water-fluids. Although exterior evil resolves, Stomach Qi must be harmonious to ensure recovery. Post-sweating resolution, Stomach disharmony, food gathering/knotting, causes epigastric pi/hardness. Middle Jiao cannot digest grain, causing dry belching with food odor. Earth weakness fails to control Water, causing water-Qi under flanks to flow sideways. Borborygmus results from gathering/striking sounds, diarrhea with mixed clear/turbid. Thus, in Xiexin Tang, Fresh Ginger is the sovereign herb to disperse it; the method uses double decoction to achieve ripeness and harmonize the Stomach.
Cheng Yingmao said: Profuse sweating causing Yang collapse is known. However, Yang in the body has specific dominions. There is Defensive Yang governing Ying-Wei throughout the body; deficiency causes leaking sweat, aversion to cold, and body pain. There is Kidney Yang governing Lower Jiao true Yuan; deficiency causes fever, vertigo, palpitations, tremors, and desire to fall to the ground. There is Pericardium Yang governing Upper Jiao Heart Qi; deficiency causes hands covering the heart, deafness, and running piglet syndrome. There is Stomach Yang governing Middle Jiao grain transformation; deficiency causes abdominal fullness, Stomach disharmony, and epigastric pi. Although all arise post-sweating, those correcting errors must observe pulse and syndrome, identify the deviation, and treat accordingly, not conflating everything under "profuse sweating causes Yang collapse."
Shengjiang Xiexin Tang Formula
Licorice (roasted, 3 liang) Ginseng (3 liang) Dried Ginger (1 liang) Pinellia (washed, 0.5 sheng) Scutellaria (3 liang) Coptis (1 liang) Fresh Ginger (sliced, 4 liang) Jujube (broken open, 12 pieces)
The above eight herbs are boiled in ten sheng of water to obtain six sheng. Strain dregs and decoct again to obtain three sheng. Take one sheng warm, three times daily.
[Fang Jie - Formula Explanation] Named Shengjiang Xiexin Tang, the meaning focuses on dispersing water-Qi pi. Fresh Ginger and Pinellia disperse water-Qi under the flanks; Ginseng and Jujube tonify Middle Jiao Earth deficiency; Dried Ginger and Licorice warm interior cold; Scutellaria and Coptis purge pi heat. Covering treatments for deficiency, water, cold, and heat, how could Stomach disharmony, diarrhea, and pi not heal?
In Cold Damage on the fifth or sixth day, with vomiting and fever, Chaihu Tang syndrome is complete. If mistakenly purged with other drugs, and Chaihu syndrome remains, administer Chaihu Tang again. Although purged, this is not adverse; the patient will likely experience trembling chills, followed by fever and sweating, leading to resolution. If the epigastrium is full, hard, and painful, this is Jie Xiong, primarily treated with Da Xianxiong Tang (Major Gallbladder-Breaking Decoction). If merely full but not painful, this is Pi; Chaihu Tang is not applicable; Banxia Xiexin Tang (Pinellia Heart-Purging Decoction) is appropriate.
[Annotation] Jie Xiong combined with Yangming interior excess is Da Xianxiong Tang syndrome; combined with Yangming non-excess is Xiao Xianxiong Tang (Minor Gallbladder-Breaking Decoction) syndrome. Pi/hardness combined with Shaoyang interior excess is Da Chaihu Tang (Major Bupleurum Decoction) syndrome; combined with Shaoyang non-excess is Banxia Xiexin Tang syndrome. Now, Cold Damage on day five or six, with vomiting and fever, indicates evil transmitting to Shaoyang. Since Chaihu syndrome is complete, failing to harmonize with Chaihu but mistakenly purging is wrong. If Chaihu syndrome remains, although purged, it is not yet adverse; one should re-administer Chaihu Tang. The patient will likely experience trembling chills, then fever and sweating to resolve. This is because post-purgation middle deficiency and the state of resolution manifest thus. If post-purgation epigastrium is full, hard, and painful, this is Jie Xiong, and Da Xianxiong Tang is appropriate; if merely full but not painful, this is empty heat and rebellious Qi pi. Even with Shaoyang symptoms of vomiting and fever, Chaihu Tang is not applicable. The method should treat pi; Banxia Xiexin Tang is appropriate.
[Collected Annotations] Cheng Wuji said: If post-purgation Yang evil transmits to the interior, it knots in the chest as Jie Xiong, because the chest is the division where Yang receives Qi.