脉沉为在里而反发其汗则津液越出大便难表虚里实久则谵语也（论见谵语）脉浮紧者法当身疼痛宜以汗解之假令尺
中迟者不可发汗何以知之以荣气不足血少故也（活人云先以小建中汤加黄 如尺脉尚迟再作一剂却服桂枝柴胡二越婢一
汤其汤分小剂和解之愈）
许 一乡人邱生者病伤寒发热头疼烦渴脉虽浮数而无力尺以下迟而弱予曰此虽麻黄证而尺迟弱仲景云尺中迟者
荣气不足血气微少未可发汗予于建中汤加当归黄 令饮翌日脉尚尔其家煎迫日夜督发汗药几不逊矣余忍之但用建中调荣
而已至五日尺部方应遂投麻黄汤啜二服发狂须臾稍定略睡已中汗矣信知此事诚难仲景虽云不避晨夜即宜便治医者亦须
顾其表里虚实待其时日若不循次第临时得安损亏五脏以促寿限亦何足贵哉南史载范云病伤寒恐不得预武帝九锡之庆召
徐文伯诊视以实恳之曰可便得愈乎文伯曰便瘥甚易但恐二年后不复起耳云曰朝闻道夕死犹可况二年乎文伯以火烧地布
桃叶设席置云于其上顷刻汗解扑以温粉翼日果愈云甚喜文伯曰不足喜也后二年果卒夫取汗先期尚促寿限况罔顾表里不
待时日便欲速效乎每见病家不耐病未三四日昼夜促汗医者随情顺意鲜有不败事者予故书此以为戒
少阴病脉细沉数病为在里不可发汗少阴病脉微不可发汗亡阳故也脉濡而弱弱反在关濡反在巅微反在上涩反在下微
则阳气不足涩则无血阳气反微中风汗出而反躁烦涩则无血厥而且寒阳微发汗躁不得眠动气在右不可发汗发汗则衄而渴
心苦烦饮即吐水动气在左不可发汗发汗则头眩汗不止筋惕肉 动气在上不可发汗发汗则气上冲正在心端动气在下不可
发汗发汗则无汗心中大烦骨节苦疼目连恶寒食则反吐谷不得前咽中闭塞不可发汗发汗则吐血气微绝手足厥冷欲得倦卧
不能自温诸脉得数动微弱者不可发汗发汗则大便难腹中干（一云小便难胞中干）胃躁而烦其形相象根本异源脉濡而弱弱
反在关濡反在巅弦反在上微反在下弦为阳运微为阴寒上实下虚意欲得温微弦为虚不可发汗发汗则寒栗不能自还咳者则
剧数吐涎沫咽中必干小便不利心中饥烦 时而发其形似疟有寒无热虚而寒栗咳而发汗蜷而苦满腹中复坚厥脉紧不可发
汗发汗则声乱咽嘶舌萎声不得前诸逆发汗病微者难瘥剧者言乱目眩者死（一云谵言目眩睛乱者死）命将难全太阳病得之
八九日如疟状发热恶寒热多寒少其人不呕清便续自可一日二三度发脉微而恶寒者此阴阳俱虚不可更发汗也太阳病发热
恶寒热多寒少脉微弱者无阳也不可发汗咽喉干燥者不可发汗亡血不可发汗发汗则寒栗而振衄家不可发汗汗出必额上陷
脉急紧直视不能 不得眠汗家不可发汗发汗必恍惚心乱小便已阴疼宜禹余粮丸（方本阙）淋家不可发汗发汗必便血疮家
虽身疼痛不可发汗汗出则痉下利不可发汗汗出必胀满咳而小便利若失小便者不可发汗汗出则四肢厥逆冷伤寒一二日至
四五日厥者必发热前厥者后必热厥深者热亦深厥微者热亦微厥应下之而反发汗者必口伤烂赤伤寒脉弦细头痛发热者属
少阳少阳不可发汗伤寒头痛翕翕发热形象中风常微汗出自呕者下之益烦心懊 如饥发汗则致痉身强难以伸屈熏之则发
黄不得小便久则发咳唾太阳与少阳并病头项强痛或眩冒时如结胸心下痞硬者不可发汗太阳病发汗因致痉少阴病咳而下
利谵语者此被火气劫故也小便必难以强责少阴汗也少阴病但厥无汗而强发之必动其血未知从何道出或从口鼻或从目出
者是名下厥上竭最为难治
永类钤方云伤寒发汗有四难凡发热头疼有汗而非无汗恶风而非恶寒例发其汗汗不止为漏风间有发而为痉者此分外
证发汗之一难也至于发热头痛尺脉迟者为荣虚血少不可发汗发热头痛脉弦细属少阳不可汗汗则谵语此分脉发汗之二难
也动气在左不可汗汗则头眩汗不止则筋惕肉 动气在右不可汗汗则衄而渴心烦饮则吐水动气在上不可汗汗则气冲心动
气在下不可汗汗则无汗心烦骨节疼此分内证发汗之三难也春宜汗不可大发以阳气尚微冬不大汗以阳气伏藏汗之必吐利
口烂生疮此知时发汗之四难也
云 太阳证非头痛项强不可发汗非身热恶寒不可发汗非脉浮不可发汗
活 其脉微弱或尺脉迟者不可表其人当汗而衄血下血者不可表坏病者不可表妇人经水适来者不可表风温者不可
表湿温者不可表虚烦者不可表病患腹间左右上下有筑触动气者不可表
太阳咽干鼻衄淋漓小便不利皆不当汗已经发汗不得
重发如无以上忌证虽经发汗邪气未尽亦当重发之当汗不汗则生黄其证为风寒所伤阳气下陷入内而与寒水上行于经络之
间本当发汗以彻其邪医失汗之故生黄也脾主肌肉四肢寒湿与内热相合故生黄也不当汗而汗为蓄血之证燥火也当益津液
为上而反汗以亡之其毒扰阳之极则侵阴也故燥血蓄于胸中也当汗而发汗过多腠理开泄汗漏不止故四肢急难以屈伸也
脉象沉，说明病邪在里，如果反而使用发汗法，会导致津液外泄，引起大便干结难解；表气虚弱而里气实，时间久了会出现谵语（神志不清，胡言乱语）的情况。（相关论述见“谵语”篇）脉象浮紧的，按照常规应当出现身体疼痛，适宜用发汗法解除。假如尺部脉象迟缓的，不可发汗。为什么知道这一点呢？因为营气不足，血液亏少。（《活人书》说：先给予小建中汤，加入黄芪；如果尺脉仍然迟缓，再服一剂，然后服用桂枝汤、柴胡汤或越婢汤中的一种，这些方剂用量要小，以和解的方法治疗，病就好了。）
许叔微记载：同乡邱先生患伤寒，发热、头痛、烦躁口渴。脉象虽然浮数但无力，尺部以下脉迟且弱。我说：这虽然是麻黄汤证，但尺脉迟弱，张仲景说过：“尺中迟者，荣气不足，血气微少，未可发汗。”我在建中汤中加入当归、黄芪让他服用。第二天脉象依然如此。他的家人煎药催促，日夜督促我发汗药，几乎不给我退路。我忍耐住，只用建中汤调和营气罢了。到了第五天，尺部脉象才应指有力，于是投予麻黄汤，喝了两服后，病人发狂，片刻后稍微安定，略睡一觉后全身出汗了。确实知道这件事很难处理。张仲景虽然说“不避晨夜，即宜便治”，但医者也必须顾及其表里虚实，等待适宜的时日。如果不遵循次第，临时求得安逸，损伤亏损五脏，缩短寿命，又有什么值得珍贵的呢？《南史》记载范云患伤寒，担心不能赶上武帝加九锡的庆典，召徐文伯诊治，诚恳地问他：“可以立刻痊愈吗？”徐文伯说：“立刻痊愈很容易，但恐怕两年后不能再起来（死亡）。”范云说：“朝闻道，夕死可矣，何况是两年呢？”徐文伯烧红地面铺上桃叶，设席让范云躺在上面，顷刻间汗出病解，扑上温粉。第二天果然痊愈，范云很高兴。徐文伯说：“不值得高兴，两年后果然去世。”这种取汗法提前尚且缩短寿命，何况不顾表里虚实，不等待时日，就想求速效呢？我常见病患家属不耐受病痛，不到三四日就昼夜催促发汗，医者顺从情欲意愿，很少有不出败事的。所以我写下此文作为警戒。
少阴病，脉细沉数，病邪在里，不可发汗。少阴病，脉微，不可发汗，因为会亡阳。脉濡而弱，弱脉反见于关部，濡脉反见于巅部（寸部），微脉反见于上部，涩脉反见于下部。微则阳气不足，涩则无血。阳气微弱，中风后汗出反而躁烦，涩则无血，四肢厥冷而且寒。阳气微弱，发汗后躁动不得睡眠。动气在右，不可发汗，发汗则鼻衄且口渴，心中苦烦，饮水即吐水。动气在左，不可发汗，发汗则头晕目眩，汗出不止，筋惕肉瞤（肌肉跳动）。动气在上，不可发汗，发汗则气上冲，正在心端。动气在下，不可发汗，发汗则无汗，心中大烦，骨节苦痛，眼睛连合恶寒，进食则反吐，谷气不得下行，咽中闭塞。不可发汗，发汗则吐血，气微绝，手足厥冷，想疲倦卧倒，不能自温。诸脉得数动微弱者，不可发汗，发汗则大便难，腹中干（一说小便难，胞中干），胃燥而烦。其形相象，根本异源。脉濡而弱，弱反在关，濡反在巅，弦反在上，微反在下。弦为阳运，微为阴寒，上实下虚，意欲得温。微弦为虚，不可发汗，发汗则寒栗不能自还。咳者则剧，数吐涎沫，咽中必干，小便不利，心中饥烦，时而发作，其形似疟，有寒无热，虚而寒栗。咳而发汗，蜷卧而苦满，腹中复坚。厥脉紧，不可发汗，发汗则声乱，咽嘶，舌萎，声不得前。诸逆发汗，病微者难瘥，剧者言乱目眩者死（一说谵言目眩睛乱者死），命将难全。
太阳病得之八九日，如疟状，发热恶寒，热多寒少，其人如果不呕，清便续自可（大小便正常），一日二三度发。脉微而恶寒者，此阴阳俱虚，不可更发汗也。太阳病发热恶寒，热多寒少，脉微弱者，无阳也，不可发汗。咽喉干燥者，不可发汗。亡血者，不可发汗，发汗则寒栗而振。衄家（经常鼻出血的人），不可发汗，汗出必额上陷，脉急紧，直视不能眴（眼球转动），不得眠。汗家（平素多汗的人），不可发汗，发汗必恍惚心乱，小便已阴疼，宜禹余粮丸（方本阙）。淋家（患淋病的人），不可发汗，发汗必便血。疮家（久患疮疡的人），虽身疼痛，不可发汗，汗出则痉。下利（腹泻），不可发汗，汗出必胀满。咳而小便利，若失小便者，不可发汗，汗出则四肢厥逆冷。伤寒一二日至四五日，厥者必发热，前厥者后必热。厥深者热亦深，厥微者热亦微。厥应下之而反发汗者，必口伤烂赤。伤寒脉弦细，头痛发热者，属少阳。少阳不可发汗。伤寒头痛，翕翕发热，形象中风，常微汗出，自呕者，下之益烦，心懊憹如饥。发汗则致痉，身强难以伸屈。熏之则发黄，不得小便，久则发咳唾。太阳与少阳并病，头项强痛，或眩冒，时如结胸，心下痞硬者，不可发汗。太阳病发汗，因致痉。少阴病咳而下利，谵语者，此被火气劫故也。小便必难，以强责少阴汗也。少阴病但厥无汗，而强发之，必动其血，未知从何道出，或从口鼻，或从目出，者是名下厥上竭，最为难治。
《永类钤方》说：伤寒发汗有四难。凡发热头疼，有汗而非无汗，恶风而非恶寒，例发其汗，汗不止为漏风，间有发而为痉者，此分外证发汗之一难也。至于发热头痛，尺脉迟者为荣虚血少，不可发汗；发热头痛，脉弦细属少阳，不可汗，汗则谵语，此分脉发汗之二难也。动气在左不可汗，汗则头眩，汗不止则筋惕肉瞤；动气在右不可汗，汗则衄而渴，心烦饮则吐水；动气在上不可汗，汗则气冲心动；动气在下不可汗，汗则无汗，心烦骨节疼，此分内证发汗之三难也。春宜汗，不可大发，以阳气尚微；冬不大汗，以阳气伏藏，汗之必吐利，口烂生疮，此知时发汗之四难也。
云岐子说：太阳证非头痛项强不可发汗，非身热恶寒不可发汗，非脉浮不可发汗。
活人书说：其脉微弱或尺脉迟者，不可表。其人当汗而衄血、下血者，不可表。坏病者，不可表。妇人经水适来者，不可表。风温者，不可表。湿温者，不可表。虚烦者，不可表。病患腹间左右上下有筑触动气者，不可表。
太阳病，咽干、鼻衄淋漓、小便不利，皆不当汗。已经发汗，不得重发。如无以上忌证，虽经发汗，邪气未尽，亦当重发之。当汗不汗，则生黄。其证为风寒所伤，阳气下陷入内，而与寒水上行于经络之间，本当发汗以彻其邪，医失汗之，故生黄也。脾主肌肉四肢，寒湿与内热相合，故生黄也。不当汗而汗，为蓄血之证，燥火也。当益津液为上，而反汗以亡之，其毒扰阳之极，则侵阴也，故燥血蓄于胸中也。当汗而发汗过多，腠理开泄，汗漏不止，故四肢急难以屈伸也。
Pulse is deep, indicating the pathogen is in the interior. If sweating method is used in error, body fluids will escape, leading to difficult defecation; exterior deficiency and interior excess, over time, will result in delirium (incoherent speech due to mental disturbance). (Discussion found under "Delirium"). Pulse is floating and tight, which typically presents with body pain and should be resolved by sweating. However, if the cun-guan-chi pulse at the chi position is slow, sweating must not be induced. How do we know this? Because Ying Qi (Nutritive Qi) is insufficient and blood is scant. (The *Liu Ren Shu* states: First administer Xiao Jian Zhong Tang (Minor Construct the Middle Decoction) added with Huangqi (Astragali Radix); if the chi pulse remains slow, take another dose, then take one of Guizhi Tang (Cinnamon Twig Decoction), Chaihu Tang (Bupleurum Decoction), or Yuebi Tang (Ephedra Decoction), using small doses to harmonize the condition until recovery.)
Xu Shimiao recorded: A fellow townsman, Mr. Qiu, suffered from Shanghan (Cold Damage) with fever, headache, restlessness, and thirst. The pulse was floating and rapid but forceless, while the lower chi position was slow and weak. I said: Although this resembles a Mahuang Tang (Ephedra Decoction) pattern, the slow chi pulse indicates, as Zhang Zhongjing stated, "If the chi pulse is slow, Ying Qi is insufficient, Qi and Blood are slightly deficient, and sweating should not be induced." I administered Jianzhong Tang (Construct the Middle Decoction) added with Danggui (Angelicae Sinensis Radix) and Huangqi (Astragali Radix) for him to drink. The next day, the pulse remained unchanged. His family prepared the medicine urgently, urging me day and night to induce sweating, leaving me little room to refuse. I endured it, using only Jianzhong Tang to harmonize Ying Qi. By the fifth day, the chi pulse became distinct and responsive, so I administered Mahuang Tang (Ephedra Decoction). After two doses, the patient went into a frenzy, then gradually settled, slept briefly, and finally sweated profusely. Indeed, this matter is difficult. Although Zhang Zhongjing said "do not avoid morning or night, treat immediately," physicians must also consider exterior-interior deficiency-excess and wait for the appropriate timing. If one does not follow the sequence and seeks temporary relief, damaging the Zang-Fu organs and shortening life, what value is there? The *History of the Southern Dynasties* records that Fan Yun suffered from Shanghan and feared he would miss Emperor Wu's celebration of receiving the Nine Bestowals. He summoned Xu Wenbo for diagnosis and asked earnestly, "Can I recover immediately?" Wenbo replied, "Recovery is easy, but I fear you will not rise again after two years." Yun said, "If I hear the Dao in the morning, I can die content in the evening, let alone two years." Wenbo heated the ground, spread peach leaves, set up a mat, and placed Yun upon it. In an instant, sweat flowed and the illness resolved; warm powder was applied. The next day, he indeed recovered, and Yun was very pleased. Wenbo said, "There is no need to be pleased; two years later, you will indeed pass away." This method of inducing sweating prematurely still shortens life, let alone disregarding exterior-interior conditions and timing, seeking quick results? I often see patients' families unable to endure the illness, urging sweating within three or four days, day and night. Physicians who follow their wishes rarely avoid failure. Therefore, I write this as a warning.
Shaoyin disease with fine, deep, rapid pulse indicates the pathogen is in the interior; sweating is contraindicated. Shaoyin disease with a faint pulse is contraindicated for sweating because it leads to Yang collapse. Pulse is soft and weak; weakness appears at the Guan position, softness at the Dian (Cun) position, faintness at the upper part, and choppy at the lower part. Faintness indicates insufficient Yang Qi; choppy indicates lack of Blood. With deficient Yang Qi, after wind-stroke induces sweating, restlessness occurs instead. Choppy pulse indicates lack of Blood, leading to cold limbs and cold sensation. With deficient Yang Qi, sweating causes restlessness and inability to sleep. Moving Qi on the right side is contraindicated for sweating; sweating causes epistaxis and thirst, heart vexation, and vomiting water after drinking. Moving Qi on the left side is contraindicated for sweating; sweating causes dizziness, continuous sweating, tremors of muscles and sinews. Moving Qi above is contraindicated for sweating; sweating causes Qi rushing upward, centered at the heart. Moving Qi below is contraindicated for sweating; sweating causes absence of sweat, severe heart vexation, bone joint pain, aversion to cold with eyes closed, vomiting food after eating, obstruction of grain flow, and throat blockage. Sweating is contraindicated; it causes hematemesis, faint Qi, cold extremities, desire to lie down exhausted, and inability to self-warm. Pulses that are rapid, moving, and weak are contraindicated for sweating; sweating causes difficult defecation and dry abdomen (or difficult urination and dry bladder), stomach dryness, and vexation. The forms appear similar, but origins differ. Pulse is soft and weak; weakness at Guan, softness at Dian, wiry at upper, faint at lower. Wiry indicates Yang movement, faint indicates Yin cold, upper excess and lower deficiency, desiring warmth. Faint and wiry indicates deficiency; sweating is contraindicated, causing chills and inability to recover. Cough becomes severe, frequent spitting of saliva, dry throat, difficult urination, hunger-vexation in the heart, intermittent attacks resembling malaria with cold but no heat, deficiency with chills. Sweating for cough leads to curling up, abdominal fullness, and hardness. Tight Jue pulse is contraindicated for sweating; sweating causes disordered voice, hoarse throat, flaccid tongue, and inability to speak. For all adverse conditions, sweating makes mild cases hard to cure and severe cases result in disordered speech, dizziness, and death (or delirium, dizziness, and chaotic vision), making survival unlikely.
Taiyang disease lasting eight or nine days resembles malaria, with fever and aversion to cold, more heat than cold. If the patient does not vomit and bowel/bladder functions remain normal, occurring two or three times a day, and the pulse is faint with aversion to cold, this indicates both Yin and Yang deficiency; further sweating is contraindicated. Taiyang disease with fever, aversion to cold, more heat than cold, and faint pulse indicates absence of Yang; sweating is contraindicated. Dry throat is contraindicated for sweating. Blood loss is contraindicated for sweating; sweating causes chills and trembling. Patients prone to epistaxis are contraindicated for sweating; sweating causes depression of the forehead, tight pulse, staring gaze without eye movement, and insomnia. Patients prone to sweating are contraindicated for sweating; sweating causes mental confusion and vagueness, pain in the genitalia after urination; Yuyuliang Wan (Hematite Pill) is suitable (formula missing). Patients with Lin syndrome are contraindicated for sweating; sweating causes blood in urine. Patients with chronic sores, even with body pain, are contraindicated for sweating; sweating causes spasms. Diarrhea is contraindicated for sweating; sweating causes abdominal distension. Cough with clear urination or urinary incontinence is contraindicated for sweating; sweating causes cold reversal of four limbs. Cold damage from one to two days to four to five days: if there is cold reversal, fever must follow; previous cold reversal means subsequent fever. Deeper cold reversal implies deeper heat; milder cold reversal implies milder heat. Cold reversal should be treated with purgation, but if sweating is used in error, mouth ulcers and redness occur. Cold damage with wiry-fine pulse, headache, and fever belongs to Shaoyang. Shaoyang is contraindicated for sweating. Cold damage with headache, mild fever resembling wind-stroke, constant slight sweating, and spontaneous vomiting: purgation increases vexation and heart discomfort like hunger. Sweating causes spasms and stiff body difficult to flex/extend. Moxibustion causes jaundice, inability to urinate, and eventually cough with sputum. Concurrent Taiyang and Shaoyang disease with stiff neck/headache, dizziness, occasional chest binding, and epigastric hardness is contraindicated for sweating. Taiyang disease treated with sweating leading to spasms. Shaoyin disease with cough, diarrhea, and delirium results from fire therapy coercion; urination will be difficult due to forced sweating of Shaoyin. Shaoyin disease with cold reversal and no sweat, forcibly induced sweating moves Blood; unknown exit route, possibly from mouth/nose or eyes, called Lower Cold and Upper Exhaustion, most difficult to treat.
*Yong Lei Ling Fang* states: There are four difficulties in sweating for Shanghan. Fever, headache, sweating present but not anhidrosis, aversion to wind but not aversion to cold: inducing sweating leads to non-stop sweating (Leak Wind) or occasionally spasms; this is the first difficulty regarding exterior patterns. Fever, headache, slow chi pulse indicates Ying deficiency and blood scarcity, contraindicated for sweating; fever, headache, wiry-fine pulse belongs to Shaoyang, contraindicated for sweating, sweating causes delirium; this is the second difficulty regarding pulse patterns. Moving Qi on left: contraindicated for sweating, causes dizziness, continuous sweating, muscle tremors. Moving Qi on right: contraindicated for sweating, causes epistaxis, thirst, heart vexation, vomiting water. Moving Qi above: contraindicated for sweating, causes Qi rushing and heart palpitations. Moving Qi below: contraindicated for sweating, causes anhidrosis, heart vexation, bone pain; this is the third difficulty regarding interior patterns. Spring allows sweating but not heavy sweating as Yang Qi is still slight; Winter avoids heavy sweating as Yang Qi is hidden; sweating causes vomiting, diarrhea, mouth ulcers, and sores; this is the fourth difficulty regarding seasonal timing.
Yun Qizi says: Taiyang pattern requires headache and stiff neck for sweating; requires fever and aversion to cold for sweating; requires floating pulse for sweating.
*Liu Ren Shu* says: Faint pulse or slow chi pulse is contraindicated for releasing the exterior. Patients who should sweat but have epistaxis or hematochezia are contraindicated for releasing the exterior. Complicated diseases are contraindicated for releasing the exterior. Women with menstruation onset are contraindicated for releasing the exterior. Fengwen (Wind-Warmth) is contraindicated for releasing the exterior. Shiwen (Damp-Warmth) is contraindicated for releasing the exterior. Deficiency vexation is contraindicated for releasing the exterior. Patients with pulsating Qi in the abdomen (left/right/up/down) are contraindicated for releasing the exterior.
Taiyang disease with dry throat, dripping epistaxis, or difficult urination should not be sweated. If already sweated, do not re-sweat. Unless the above contraindications exist, even if previously sweated, if pathogens remain, re-sweating may be necessary. Failure to sweat when indicated leads to Jaundice. This condition arises from Wind-Cold injury, where Yang Qi sinks inward and combines with Cold-Fluid rising through meridians. Sweating should have been used to expel pathogens; physician's omission causes Jaundice. Spleen governs muscles and four limbs; Cold-Damp combined with internal Heat causes Jaundice. Sweating when inappropriate leads to Blood Stasis and Dry Fire. Nourishing fluids is superior, but sweating destroys them; toxin harasses extreme Yang, invading Yin, causing dry Blood stasis in the chest. Excessive sweating when indicated opens pores, causing continuous leakage, leading to stiff limbs difficult to flex/extend.