夫时汗出而不愈，是邪不以汗解，其邪必非可汗解矣。乃曰先其时发汗则愈，何也?按
原文
云∶此卫气不和也。桂枝汤是从荣通卫，卫为风邪所扰，不能内和于荣，发其汗者，是助荣
之力以出而和于卫，荣卫之气相合，邪无地自客矣。其自汗不愈者，卫与荣乖，正气不能固
护于外，津液泄于其隙，而不与邪相值也。发其汗则 蒸遍，真气充周矣。风邪鼓卫气于
外，今更从邪气之后，壮荣气以逐风邪也。
荣行脉中，卫行脉外，俱日夜五十度周于身，若或迟速互有参差，即病矣。卫伤于风，
则卫
行速，而荣不能应之；荣不能应则卫力亦有不继，而腠理豁疏矣，故时汗出也。桂枝汤是鼓
荣之液，以润卫之燥，俾开合利而机关密也。荣伤寒脉紧无汗之麻黄证，是荣卫俱伤于寒也
，前人谓寒伤荣不伤卫者，误矣。其专荣伤于寒者，是寒湿下受，不从皮毛，而直窜经脉，
内入筋骨，血液凝聚，其行渐迟，不与卫应，而寒热病作矣。近时寒疟，多是寒湿下受，治
宜仿九味羌活汤法，重温下焦，开通少阴、太阳之表里经气，非桂枝、柴胡所能胜任也。桂
枝汤止汗之力胜于发汗，故欲发汗者，必啜热粥温覆以助之。
《千金方》曰∶凡服止痢药，初服皆剧，愚人不解，即止其药不服，此特不可。但使药
与病
源的相主对，虽剧但服，不过再三服，渐渐自知，惟非其主对者，本勿服也。《慎柔五书》
谓∶久服寒凉，阳气郁陷者，改用四君、保元，温脾理肺，阳气升举，邪气渐渐退出于表。
退至阳明，则有呕吐、便溏、水泄之事矣；退至少阳，则有头痛、寒热往来之事矣；退至太
阳，则有发热，恶风寒、项脊强痛之事矣。此时正宜加力辅正，随证施治，以收全功，不得
疑为新受外感，更不得疑为药误，改用他法，再误即难治矣。窃谓∶今人最虑肝阳，每于伤
风头痛，即曰肝阳上升，即以清凉浇灌，及至真火下陷，阴霾弥漫，头重颅胀，仍曰肝阳太
亢。明者用宣阳逐阴之剂以挽之，稍见阳气上达，口干微渴，即斥为药误，助动肝阳，必求
灭阳而死。可慨也!
如治外感，外证虽减，而内证转剧，此即邪气之内陷也。外邪内陷，治之能使渐透于表
，表
证日增，而内证日减，此即正气之充而渐复也。先见恶寒、发热，治之但使寒热稍轻，而增
见胸满、呕吐、不食，是风寒内陷矣；先见胸腹膨胀，治之但使膨胀不见，而转见大便滑泄
不禁，是正气下脱矣。故有外证见增，而实为医之功；外证见减，而转为医之过者。医家、
病家于此，皆须有定识定力，不为摇惑，方能临变不改，亦能临变知改矣。
周慎斋曰∶脾气虚而脉弦者，服补中益气汤后，必发疟；脾气虚而湿胜者，服补中益气
汤后，必患痢。此邪寻出路也，仍服前汤，自愈。(此与《慎柔五书》意同。)
朱丹溪治一虚人患痢，先用六君，多服久服，病证日增，略不为动，正气既充，以治痢
药一
剂迅扫之，而病除矣。此绝顶识力也。又凡寒湿内伏，必先用温药，使化湿热。其化热时，
痞满昏倦，反不如初时之神气清爽也。
更有猝然变证可骇者，尤须有定识以镇之。如许叔微治李信道，伏阳肢冷，与破阴丹，不半
时，烦躁狂扰。曰∶此换阳也。超时，果汗出而定。此即仲景所谓其人大烦、口噤、躁扰，
为欲解也。又赵晴初谓治某伤寒，日久失下，与四物承气加减，片晌腹中刺痛欲死，口噤目
瞪，不省人事；至天明，下黑粪累累而解。
当患者出现定时出汗但病情未愈的情况，说明病邪并未通过汗法解除，其病邪必然不是可以通过单纯发汗来驱除的。那么为什么说在发作之前进行发汗治疗就能痊愈呢？这是因为原文指出：这是卫气功能失调所致。桂枝汤的作用在于调和营卫，使营气通达于卫分。由于卫气受到风邪干扰，无法与营气内部和谐，此时使用发汗法，实际上是借助营气的力量向外发散，从而与卫气相协调。当营气和卫气重新融合，病邪就无处藏身了。那些表现为自汗且久治不愈的患者，是因为卫气与营气乖离，正气不能在外固护体表，导致津液从腠理间隙泄漏，但这部分津液流失并不伴随病邪的直接对抗。通过发汗治疗，可以使全身蒸腾温暖，真气充盈周流。风邪鼓动卫气浮越于外，此时医者顺势从风邪之后方入手，壮大营气以驱逐风邪。
营气运行于脉管之中，卫气运行于脉管之外，它们日夜各循环五十周于全身。如果两者节奏稍有快慢参差，就会发生疾病。卫气被风邪所伤，则卫气运行加速，而营气无法与之同步；营气若不能响应，卫气的力量也会后继乏力，导致腠理疏松，因此出现定时出汗的现象。桂枝汤的作用是鼓舞营阴之液，以滋润卫气的燥热，使得毛孔开合功能正常，肌表致密。对于营气受寒、脉象紧束且无汗的麻黄汤证，这是营卫二气都受到寒邪侵袭的结果。前人认为“寒邪只伤营而不伤卫”，这种观点是错误的。如果是专门由寒邪损伤营气的情况，通常是寒湿之气从下部侵入，不经过皮毛，而是直接窜入经脉，内达筋骨，导致血液凝滞，运行逐渐变慢，无法与卫气相应，从而引发寒热交替的疾病。近来的寒疟病症，大多属于寒湿从下部受邪，治疗应当效仿九味羌活汤的方法，温补下焦，开通少阴经和太阳经的表里经气，这不是单用桂枝或柴胡所能胜任的。桂枝汤止汗的功效强于发汗，所以想要通过它发汗时，必须喝热粥并覆盖衣被以辅助药力。
《千金方》说：凡是服用止痢药物，刚开始服用时症状往往会加重，愚昧的人不理解这一点，就立即停药不服，这是非常错误的。只要确保药物与病因相对症，即使症状暂时加重也要坚持服用，不过反复服用几次后，身体自然会慢慢适应好转。只有当药物不对症时，才根本不需要服用。《慎柔五书》中提到：长期服用寒凉药物导致阳气郁陷的患者，改用四君子汤、保元汤，以温脾理肺，提升阳气，邪气会逐渐退散到体表。当邪气退至阳明经时，会出现呕吐、大便稀溏、水样腹泻等症状；退至少阳经时，会出现头痛、寒热往来的症状；退至太阳经时，会出现发热、怕冷怕风、项部和脊背僵硬疼痛的症状。这个时候正是应该加强扶助正气的力度，根据具体证候施治，以取得彻底治愈的效果，绝不能怀疑是新的外感病，更不能怀疑是药物误治而改用其他方法，一旦再次误治就很难治愈了。我认为，现在的人最担心肝阳上亢，每当遇到伤风引起的头痛，就说是肝阳上升，立刻使用清凉药物浇灌压制。等到真火（肾阳）下陷，阴霾（寒湿/阴邪）弥漫，出现头重颅胀时，仍然说是肝阳太亢。明智的医生会使用宣通阳气、驱逐阴邪的方剂来挽救局面，稍微见到阳气上行，患者出现口干微渴，就被斥责为药物误治，助长了肝阳，结果必定追求熄灭阳气直至死亡，真是令人感慨！
在治疗外感病时，如果外部症状虽然减轻，但内部症状反而加重，这就是邪气内陷的表现。外邪内陷，经过治疗如果能逐渐透达于体表，表证日益增加，而内证日益减少，这就是正气充盛并逐渐恢复的表现。起初表现为恶寒、发热，治疗后虽然寒热稍轻，却增加了胸满、呕吐、食欲不振的症状，这是风寒邪气内陷了；起初表现为胸腹膨胀，治疗后虽然膨胀消失，却转而出现大便滑泄不禁的症状，这是正气下脱了。所以，有外部症状看似增加，实则是医生治疗有功；外部症状看似减轻，实则转为医生治疗失误的情况。医生和患者在面对这些情况时，都必须具备坚定的见识和定力，不被表象迷惑，才能在病情变化时不改变正确的治疗方向，也能在发现错误时及时调整。
周慎斋说：脾气虚弱且脉象弦细的患者，服用补中益气汤后，必然会诱发疟疾；脾气虚弱且湿气偏盛的患者，服用补中益气汤后，必然会患上痢疾。这是病邪寻找出路的表现，继续服用前面的汤药，疾病会自愈。（这与《慎柔五书》的观点相同。）
朱丹溪治疗一位体虚患痢疾的患者，先用六君子汤，多服久服，病症每天增加，但身体反应不大不为所动，待正气充足后，再用治痢疾的药物一剂迅速清除病邪，疾病随即痊愈。这是极高的见识和决断力。另外，凡是寒湿潜伏体内，必须先使用温热药物，使其转化为湿热。在转化热的过程中，患者可能会出现痞闷、腹胀、昏沉疲倦，这反而不如初诊时精神清爽。
更有突然发生的变证令人惊恐，尤其需要坚定的见识来镇定处理。例如许叔微治疗李信道，患者伏阳在内导致四肢冰冷，给予破阴丹，不到半小时，患者出现烦躁狂乱。许叔微说：这是阳气转换的过程。过了一个时辰，果然出汗后病情安定。这就是张仲景所说的“病人感到极度烦扰、牙关紧闭、躁动不安”，这是疾病将要解除的征兆。又比如赵晴初说治疗某伤寒患者，病程日久未能及时攻下，给予加减后的四物承气汤，片刻间患者腹中刺痛难忍，牙关紧闭，双目圆睁，不省人事；直到天亮，排出大量黑色粪便后病情得以缓解。
When a patient experiences periodic sweating without recovery, it indicates that the pathogenic factor has not been resolved through sweating, and thus the pathogen is certainly not one that can be expelled merely by inducing sweat. Then why does it say that inducing sweat before the onset of symptoms leads to cure? According to the original text: This is due to disharmony of Wei Qi (Defensive Qi). Guizhi Tang (Cinnamon Twig Decoction) functions to connect Ying Qi (Nutritive Qi) with Wei Qi. Since Wei Qi is disturbed by Wind Pathogen and cannot harmonize internally with Ying Qi, inducing sweat here actually assists the power of Ying Qi to move outward and harmonize with Wei Qi. When Ying Qi and Wei Qi merge, the pathogen has no place to lodge. In cases where spontaneous sweating persists without cure, it is because Wei Qi and Ying Qi are discordant; Zheng Qi (Upright Qi) fails to secure the exterior, causing Body Fluids to leak through the interstices, but this leakage does not involve direct confrontation with the pathogen. Inducing sweat causes full-body steaming, replenishing Zheng Qi throughout the body. Wind Pathogen drums Wei Qi outward; now, following the pathogen, we strengthen Ying Qi to drive out the Wind Pathogen.
Ying Qi circulates within the vessels, while Wei Qi circulates outside the vessels. Both complete fifty cycles around the body day and night. If there is any discrepancy in their speed or timing, disease occurs. When Wei Qi is injured by Wind, its movement accelerates, but Ying Qi cannot respond; if Ying Qi cannot respond, Wei Qi’s strength also becomes insufficient, leading to laxity of the Cou Li (pores and skin texture), hence the periodic sweating. Guizhi Tang stimulates the fluids of Ying Qi to moisten the dryness of Wei Qi, ensuring smooth opening and closing mechanisms and a tight exterior. For the Mahuang Tang (Ephedra Decoction) syndrome characterized by Ying Qi injury from Cold, tight pulse, and absence of sweat, this represents simultaneous injury of both Ying and Wei Qi by Cold. The previous assertion that "Cold injures Ying but not Wei" is erroneous. Cases specifically involving Ying Qi injury by Cold usually stem from Cold-Dampness entering from below, bypassing the skin and hair, and directly penetrating the meridians to enter the sinews and bones. This causes blood coagulation and gradual slowing of circulation, failing to correspond with Wei Qi, thereby triggering alternating chills and fever. Recent cases of Cold Malaria are mostly due to Cold-Dampness entering from below; treatment should emulate the method of Jiuwei Qianghuo Tang (Nine-Ingredient Notopterygium Decoction), warming the Lower Jiao (Lower Burner) and unblocking the interior-exterior meridian qi of Shaoyin (Lesser Yin) and Taiyang (Greater Yang). This cannot be accomplished solely by Guizhi or Chai Hu (Bupleurum). Guizhi Tang’s ability to stop sweating exceeds its ability to induce sweating; therefore, when aiming to induce sweat with it, one must drink hot porridge and cover warmly to assist the action.
The *Qianjin Fang* (Essential Prescriptions Worth a Thousand Gold) states: Whenever taking anti-dysentery medicine, symptoms initially worsen. Fools do not understand this and immediately stop taking the medicine, which is inadvisable. As long as the medicine corresponds to the root cause of the disease, even if symptoms worsen temporarily, continue taking it. After repeated doses, improvement will gradually become apparent. Only if the medicine is mismatched should it not be taken at all. The *Shenrou Wushu* (Five Books of Shenrou) notes: For patients whose Yang Qi is depressed and sunken due to long-term use of cold-cooling medicines, switching to Sijunzi Tang (Four Gentlemen Decoction) and Baoyuan Tang (Preserve Origin Decoction) warms the Spleen and regulates the Lungs, raising Yang Qi so that pathogenic factors gradually retreat to the exterior. When retreating to the Yangming (Yang Brightness) stage, vomiting, loose stools, or watery diarrhea may occur; when retreating to the Shaoyang (Lesser Yang) stage, headache and alternating chills and fever may appear; when retreating to the Taiyang stage, fever, aversion to wind and cold, and stiffness/pain in the neck and spine may manifest. At this time, it is crucial to intensify efforts to support Zheng Qi and treat according to the specific pattern to achieve complete recovery. One must not suspect this as a new external contraction, nor doubt it as a medication error requiring a change in method. Further misdiagnosis would make treatment difficult. I believe that modern physicians are overly concerned with Liver Yang rising. Upon encountering headache from wind-cold, they immediately diagnose "Liver Yang Rising" and apply cooling agents to douse it. Later, when True Fire (Kidney Yang) sinks and Yin pathogens (Cold-Damp/Yin Evil) fill the body, causing heavy head and distending skull, they still claim "Liver Yang is too hyperactive." Wise physicians use formulas to promote Yang and expel Yin to reverse the condition. Once slight signs of Yang ascending appear, such as dry mouth and slight thirst, these are dismissed as medication errors aggravating Liver Yang, inevitably leading to a pursuit of extinguishing Yang until death. This is truly lamentable!
In treating external contractions, if external symptoms decrease but internal symptoms worsen, this indicates the inward sinking of pathogenic factors. If treatment allows inward-sunk pathogens to gradually emerge to the exterior, with exterior symptoms increasing daily and interior symptoms decreasing daily, this indicates the restoration of Zheng Qi. Initially presenting with aversion to cold and fever, if treatment slightly alleviates chills and fever but increases chest fullness, vomiting, and anorexia, this is Wind-Cold sinking inward. Initially presenting with abdominal distension, if treatment resolves the distension but leads to uncontrollable loose stools, this is the collapse of Zheng Qi downward. Thus, there are cases where increased external symptoms actually reflect medical merit, while decreased external symptoms reflect medical fault. Physicians and patients must possess firm insight and resolve, remaining unswayed by appearances, to maintain correct treatment during changes and to adjust correctly when errors occur.
Zhou Shenzhai stated: Patients with Spleen Qi deficiency and a wiry pulse will inevitably develop Malaria after taking Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction); patients with Spleen Qi deficiency and excessive Dampness will inevitably develop Dysentery after taking Buzhong Yiqi Tang. This is the pathogen seeking an exit; continuing the previous decoction will lead to self-healing. (This aligns with the view in *Shenrou Wushu*.)
Zhu Danxi treated a deficient patient suffering from dysentery. He first administered Liu Junzi Tang (Six Gentlemen Decoction), taken in large amounts over a long period. Although symptoms appeared to increase daily, the patient showed little reaction. Once Zheng Qi was sufficient, a single dose of anti-dysentery medicine rapidly cleared the disease. This demonstrates supreme insight and decisiveness. Furthermore, whenever Cold-Dampness lies latent internally, warm medicines must be used first to transform it into Damp-Heat. During this transformation phase, patients may experience epigastric stuffiness, fullness, drowsiness, and fatigue, appearing less energetic than at the initial diagnosis.
There are sudden transformations that are particularly alarming, requiring firm insight to manage. For example, Xu Shuwu treated Li Xindao, who had hidden Yang causing cold limbs. He prescribed Poyin Dan (Break Yin Pill). Within half an hour, the patient became irritable and restless. Xu said: "This is the transformation of Yang." After an hour, the patient indeed sweated and stabilized. This corresponds to Zhang Zhongjing’s statement that "extreme restlessness, locked jaw, and agitation" indicate the resolution of disease. Similarly, Zhao Qingchu described treating a Taiyang disease patient whose prolonged course failed to utilize purgation. He prescribed modified Siwu Chengqi Tang (Four Substances and Da Huang Decoction). Moments later, the patient suffered severe abdominal stabbing pain, locked jaw, wide eyes, and unconsciousness. By dawn, the passage of abundant black stool led to recovery.