柯氏伤寒论翼云。六气为病。皆能发热。然寒与热相因。暑与湿相从。独燥与湿相反。湿病多得之地气。
燥病多得之内因。此病因之殊也。病机十九条。燥症独无。若诸痉项强。皆属于湿。愚窃疑之。今本论
有痉湿之分。又曰。太阳病。发汗太多。因致 。则 之属燥无疑也。夫 以状命名。因
血虚而筋急耳。六气为患。皆足以致 。然不热则不燥。不燥则不成 矣。又云。治风寒。不惜津液。所以
发汗太多。因致 者多矣。夫 本有由来。一经妄治。即奇形毕现。项背强KT KT 。是 之征兆。故用
葛根。身体强。是 之已着。故用栝蒌根。卧不着席。脚挛急。口噤齿 。是 之剧甚。
故用大黄芒硝。无非取多津液之品。以滋养阴血。不得与当汗不汗者同例也。
大承气汤方
大黄（四两酒洗） 浓朴（半斤炙去皮） 枳实（五枚炙） 芒硝（三合）
上四味。以水一斗。先煮二物。取五升。去滓。纳大黄。
煮取二升。去滓。纳芒硝。更上火微一二沸。分温再服。得下止服。（火微。宋版伤寒论。作微火。）
三因。大承气汤。治刚 云云。以阳明养宗筋。阳明者
胃也∶风湿寒入于胃。则热甚。宗筋无以养故急。直利阳明。以治其能养也。
案甲乙经云。刚痉。太阳中风。感于寒湿者也。其脉往来进退。以沉迟细。异于伤寒热病。巢源千金并
云。风邪伤于太阳经。复遇寒湿。则发痉也。于是成无己以降。皆宗其说。无复异论焉。特至张介宾则云。病
在筋脉。筋脉拘急。所以反张。其病在血液。血液枯燥。所以筋挛也。柯氏因而以燥证断之。其说固确矣。
故徐沈诸家。凡以寒湿注之者。皆不可凭也。
徐氏兰台轨范云。 病乃伤寒坏证。小儿得之。犹有愈者。其余则百难疗一。其实者。或有因下而得
生。虚者竟无治法。金匮诸方。见效绝少。
案千金方云。病发身软时醒者。谓之痫也。身强直。反张如弓。不时醒者。谓之痉也。此痫痉之辨也。
所谓痫。即圣惠方以降。称惊风。（急惊。即阳痫。慢惊。即阴痫。）二证自判然矣。
沈云。方中行伤寒条辨。谓小儿角弓反张。手足抽搦。后世儿科。总名惊风误治。谓非惊风。亦为痉病。余
详此乃少阴少阳。客热所至。为惊为螈。感冒热邪所致。实非惊风。并非痉。故详及之。沈此说极是。惜似
不知惊风即是古之痫焉。
太阳病。关节疼痛而烦。脉沉而细（〔原注〕一作缓）者。此名湿痹。（〔原注〕玉函云。中湿。）湿痹
之候。小便不利。大便反快。但当利其小便。
〔尤〕湿为六淫之一。故其感人。亦如风寒之先在太阳。但风寒伤于肌腠。而湿则流入关节。风脉浮。
寒脉紧。而湿脉则沉而细。湿性濡滞。而气重着。故亦名痹。痹者。闭也。其人平日土德不及。而湿动于中。
由是气化不速。而湿侵于外。外内合邪。为关节疼痛。为小便不利。大便反快。治之者。必先逐内湿。而后
可以除外湿。故曰。当利其小便。东垣亦云。治湿。不利小便。非其治也。然此为脉沉而小便不
利者设耳。若风寒在表。与湿相搏。脉浮恶风。身重疼痛者。则必以麻黄白术。薏苡杏仁。桂枝附子等。
发其汗为宜矣。
溯源集云。夫湿者。六气之一也。然一气之中。犹有别焉。雾露之气。为升于地之轻清而上腾者。故
为湿中之清。伤人皆中于上。雨雪泥水之湿。为着于地之重浊而在下者。为湿中之浊。伤人皆中于下。经云。
清邪中上。浊邪中下。所以金匮要略云。湿伤于下。雾伤于上。雾伤皮腠。湿流关节也。亦称太阳病者。以风
寒暑湿之邪。皆由卫气不密。其气得从皮毛而入。以营卫皆属太阳故也。关节。筋骨肢节之间也。以雨露
水湿之气。因卫阳不能外固。由太阳。而流入于关节筋骨之间。致肢节疼痛。而烦扰不宁。其脉沉而细者。
寒湿流于皮肉筋脉之间。血凝气滞。营卫不快于流行也。寒湿内淫。则三焦不能施化。气化不得流行。其人小
便不利。是以水谷不能泌别。湿气流溢于大肠。故大便不得燥结。而反快也。若此者。不必以燥湿为治。其
湿气淫溢。非燥湿之所能胜。故但当利其小便。小便利。则谷水分而湿淫去矣。此条盖论雨雪泥水。地气之
湿。乃湿中之浊者。故曰。但当利其小便。若雾露之清邪。即当以微似汗解之矣。然利小便
句。当察其脉证机宜。未可泛然以淡渗为治也。脉既沉细。
关节已疼。而小便不利。则阴寒可知。自当以寒湿为治。责
之下焦无火。膀胱之气化不行。则五苓散。及甘草附子汤之类。当意在言表。
活人书云。若小便不利。大便反快。当利其小便。宜甘
草附子汤。五苓散。至真要论云。治湿之法。不利小便。非其治也。
医说引信效方云。春夏之交。人病如伤寒。其人汗自出。肢体重痛。转仄难。小便不利。此名风湿。非
伤寒也。阴雨之后卑湿。或引饮过多。多有此证。但多服五苓散。小便通利。湿去则愈。切忌转泻发汗。小
误必不可救。初虞世云。医者不识。作伤风治之。发汗下之必死。案此盖与本条之证同。附以备考。
湿家之为病。一身尽疼。（〔原注〕一云疼烦。）发热。身色如熏黄也。（玉函。作一身疼烦。）
〔程〕脾主身之肌肉。湿为寒邪。郁于肌中不得散。则一
身尽疼发热也。阳明瘀热。则黄色鲜明如橘子。太阴寒湿。则黄色黧暗如烟熏。
成无己云。身黄如橘子色者。阳明瘀热也。此身色如似熏黄。即非阳明瘀热。身黄发热者。栀子柏皮汤
主之。为表里有热。则身不疼痛。此一身尽疼。非伤寒客热也。知湿邪在经。而使之。脾恶湿。湿伤则脾
病而色见。是以身发黄者。为其黄如烟熏。非正黄色也。张卿子云。湿热。即栀子柏皮
汤证也。此白术附子汤症。溯源集云。湿邪充塞。浸灌于表里肌肉肢节之间。所以一身尽疼。而身色如熏黄
也。熏黄者。如烟熏之状。黄中带黑。而不明润也。盖黄家有阴阳之别。阳黄则明润。阴黄则黑暗。而无光
泽。身如橘子色者。湿热停蓄所致。属阳黄。此一身尽疼。已属寒湿之邪。流于关节。
而身色如似熏黄。即阴黄之属也。当于寒湿中求之。
湿家其人但头汗出。背强。欲得被覆向火。若下之早则哕。或胸满。小便不利。（〔原注〕一云利。）
舌上如胎者。以丹田有热。胸上有寒。渴欲得饮。而不能饮。则口燥烦也。（不利。玉
函。作利。脉经。无烦字。似是。庞氏总病论。烦作故。神巧万全方。胎。作苔。胸上。作胸中。）
〔程〕湿为阴邪。阴邪客于阴。则阳上越。而不行于腠理肌肉。故但头汗出。背为阳。寒湿胜则阳
虚。故背强。欲得被覆向火也。若当表邪未解之时。误以阳明内湿之热。上越之头汗。而早下之。则虚其胃。
湿干于胃。则哕。寒客于上。则胸满。亡其津液。则小便不利。以寒湿在上。故舌上如苔
而实非苔也。丹田有热者。以下后里虚。上焦阳气。因虚而陷于下焦。为丹田有热。表中寒气。乘虚而客于
胸上。为胸上有寒。唯其丹田有热。则渴欲饮水。胸上有寒。不能散水。虽得水。而不能饮。故口燥烦也。
〔魏〕口但燥。而心发烦。
溯源集云。舌上如苔者。若热邪入胃。则舌上或黄或黑。或芒刺。或干硬。或燥裂。皆苔也。此云
如苔。乃湿滑而色白。似苔非苔也。此因寒湿之邪。陷入于里。而在胸膈。命门之真阳。不得上升。而在下
焦。上下不通。故曰丹田有热。胸中有寒。下焦之真火。既不得上达。即所谓清阳不升。是下焦无蒸腾之用。
气液不得上腾。而为涕唾。故渴。又以寒湿在胸。道路阻绝。故虽欲得水。而不能饮。则口燥而烦渴
也。仲景虽不立治法。然以理推之。下文之桂枝附子汤。甘草附子汤。即其治也。前人拟小陷胸汤。恐非其治。
即五苓散理中汤虽近于理。犹未尽善。（案以上三方。见张卿子注。）何也。以
但能温中而不能解外。故必以用桂枝者为妥也。
案胸上有寒。丹田有热。诸注欠详。第程钱二氏。义似
稍通。然犹未清晰。因考此寒热互误。黄连汤条云。胸中有
热。胃中有邪气。邪气。即寒也。方中用干姜桂枝。其义可见耳。他诸泻心汤。乌梅丸之类。悉为上热下冷
设。巢源有冷热不调之候云。阳并于上。则上热。阴并于下。则下冷。而无上冷下热之证。其故何也。盖火性
炎上。水性就下。病冷热不调。则热必浮于上。寒必沉于下。是所以无下热上冷之候也。凡误下之证。下焦之
阳骤虚。气必上逆。则上焦之阳。反因下而成实。以火气不下行。故为上热下冷之证。此
条证亦然。舌上如苔而口燥者。上热之征。渴欲得饮。而不能饮者。下冷之验。与厥阴病。心中疼热。饥
而不能食。虽有饮食之别。其理则一也。故如此证。亦必非寒热错杂之剂。则难奏效。学人宜致思焉。
湿家下之。额上汗出。微喘。小便利（〔原注〕一云。不利。）者死。若下利不止者亦死。
〔尤〕湿病在表者宜汗。在里者宜利小便。苟非湿热蕴积成实。未可遽用下法。额汗出微喘。阳已离而上
行。小便利。下利不止。阴复决而下走。阴阳离决。故死。一作小便不利者死。谓阳上游。而阴不下济也。
亦通。
〔鉴〕李玮西云。湿家当利小便。以湿气内瘀。小便原自不利。宜用药利之。此
下后里虚。小便自利。液脱而死。不可一例概也。
风湿相搏。一身尽疼痛。法当汗出而解。值天阴雨不止。医云。此可发汗。汗之病不愈者何也。盖发
其汗。汗大出者。但风气去湿气在。是故不愈也。若治风湿者。发其汗。但微微似欲出汗者。风湿俱去也。（
伤寒论。玉函。脉经。冒问曰二字。盖。作答曰二字。玉函。雨下。有溜字。湿气在。作湿气仍在。脉经。
作湿气续在。玉函。脉经。医。作师。成本。作似欲汗出。）
〔徐〕此言风湿当汗解。而不可过也。谓风湿相搏疼痛。
原当汗解。值天阴雨。则湿更甚。可汗无疑。而不愈何故。
盖风性急。可骤驱。湿性滞。当渐解。汗大出则骤风去。而湿不去。故不愈。若发之微。则出之缓。缓则风湿
俱去矣。然则湿在人身。粘滞难去。骤汗且不可。而况骤下乎。故前
章曰。下之死。此但云不愈。见用法不当。而非误下比也。
〔程〕兹条为治湿汗之严律。
王宇泰云。风湿宜汗。桂枝加白术黄 防己汤。张卿子
云。风湿相搏。法当汗出而解。如麻黄加术汤。使微微蒸发。表里气和。风湿俱去。
湿家病。身疼发热。面黄而喘。头痛鼻塞而烦。其脉大。自能饮食。腹中和无病。病在头中寒湿。故
鼻塞。纳药鼻中则愈。（〔原注〕脉经云。病患喘。而无湿家病以下。至而喘十三字。○案十三字。当
作十一字。伤寒论。作湿家病。身上疼痛。）
〔沈〕此湿淫于上。与湿从下受不同也。湿邪感于太阳。与肺气相合。气郁于表。故身疼发热。面黄
而喘。头痛鼻塞而烦也。邪居于表。故脉大。自能饮食者。腹中和而无病。当责病在头中寒湿。寒湿者。以湿
属阴故也。盖鼻为肺窍。肺气受湿。则鼻塞。故当纳药鼻中。搐去黄水。俾肺气通调。大气一转。肌腠开
而湿痹解矣。
〔魏〕瓜蒂散方。瓜蒂上一味。为末吹鼻中。
溯源集云。病浅不必深求。毋庸制剂。但当以辛香开发
之药。纳之鼻中。以宣泄头中之寒湿则愈。朱奉议及王氏准绳。俱用瓜蒂散。
湿家身烦疼。可与麻黄加术汤。发其汗为宜。慎不可以火攻之。
〔鉴〕赵良曰。湿与寒合。令人身疼。大法表实成热。则可发汗。无热是阳气尚微。汗之恐虚其表。
是证虽不云热。而烦以生。烦由热也。所以服药。不敢大发其汗。且湿亦非
暴汗可散。用麻黄汤治寒。加术去湿。使其微汗耳。不可火攻。火攻则增其热。必有他变。所以戒人慎之。
喻昌曰。麻黄加术。则虽发汗。不至多汗。而术得麻黄。并可以行表里之湿。
〔程〕若以火攻之。则湿热相
搏。血气流溢。迫而为衄。郁而为黄。非其治法。
麻黄加术汤方
麻黄（三两去节） 桂枝（二两去皮） 甘草（二两炙○案据麻黄汤本方当一两） 杏
仁（七十个去皮尖） 白术（四两○案术分苍白始出于名医别录此白字后人所加宜删）
上五味。以水九升先煮麻黄。减二升。去上沫。纳诸药。煮取二升半。去滓。温服八合。覆取微似汗。
三因。麻黄白术汤。治寒湿身体烦疼。无汗恶寒发热者。（即本方。）
千金翼 治多睡。欲合眼。则先服以止睡方。
麻黄（去节） 白术（各五两） 甘草（一两炙）
上三味。以日中时。南向捣筛为散。食后以汤服方寸匕。日三服。
病者一身尽疼。发热日晡所剧者。名风湿。此病伤于汗
出当风。或久伤取冷所致也。可与麻黄杏仁薏苡甘草汤。（玉函。脉经。作日晡即剧。非。）
〔鉴〕病者。谓一身尽痛之病患也。湿家一身尽痛。风湿亦一身尽痛。然湿家痛。则重。着不能转侧。
柯氏在《伤寒论翼》中说：六气致病，都能引起发热。然而寒与热相互关联，暑与湿相互伴随，唯独燥与湿性质相反。湿病多因感受地气所致；燥病多因内因而成。这是病因的不同之处。《素问·至真要大论》中的“病机十九条”，唯独没有关于燥症的论述。如果说各种痉病、项背强直都归属于湿，我私下对此表示怀疑。现在本论中有痉病与湿病的区分，又说：“太阳病，发汗过多，因此导致痉病。”那么痉病属于燥证是毫无疑问的。痉病是以症状命名的，是因为血虚导致筋脉拘急。六气为患，都能导致痉病，然而如果不热就不会燥，不燥就不会形成痉病了。又说：治疗风寒，不惜耗伤津液，所以发汗过多导致痉病的情况很多。痉病本来有它的由来，一经误治，就会表现出奇特的症状。项背部强直拘急（KT KT 形容僵硬之状），这是痉病的征兆，所以用葛根。身体强直，说明痉病已经明显，所以用栝蒌根（天花粉）。卧时背部不能着席，脚部挛急，牙关紧闭、磨牙（齿），这是痉病非常严重的表现，所以用大黄、芒硝。这些药物无非是取用能生津液的药材，来滋养阴血，不能与应当发汗而未发汗的情况混为一谈。
大承气汤方
大黄（四两，酒洗） 浓朴（半斤，炙后去皮） 枳实（五枚，炙） 芒硝（三合）
以上四味药，用水一斗，先煮浓朴和枳实，取五升药液，去渣，加入大黄，
再煮取二升药液，去渣，加入芒硝，再次上火微沸一两滚，分两次温服。如果大便通下就停止服用。（“火微”二字，宋版《伤寒论》作“微火”。）
三因方认为，大承气汤治疗刚痉等症。因为阳明经滋养宗筋，阳明经就是胃；风湿寒邪侵入胃中，则热势炽盛，宗筋得不到滋养所以拘急，直接通利阳明经，以恢复其滋养功能。
按语：《甲乙经》说，刚痉是太阳中风，又感受了寒湿之邪。其脉象往来进退，呈现沉迟细的特点，不同于伤寒热病。巢元方《诸病源候论》和《千金方》都说，风邪伤害太阳经，又遇到寒湿，就会引发痉病。从此以后，成无己等人皆尊崇这一说法，不再有异论。直到张介宾才说：病在筋脉，筋脉拘急，所以身体反张。病在血液，血液枯燥，所以筋脉挛缩。柯氏据此将痉病断定为燥证，这种说法确实正确。所以徐灵胎、沈金鳌等各家，凡是将其归注为寒湿的，都不可凭信。
徐灵胎在《兰台轨范》中说：痉病是伤寒的坏证，小儿得了它，还有治愈的可能，其他人则百难救一。实证者，或许通过攻下法还能生还；虚证者竟然没有治疗方法。《金匮要略》中的各方，见效极少。
按语：《千金方》说：发病时身体柔软，时而清醒的，称为痫病；身体强直，角弓反张，不时清醒的，称为痉病。这就是痫病与痉病的区别。所谓痫病，即从《太平圣惠方》以来所称的惊风（急惊风即阳痫，慢惊风即阴痫）。这两种病症自然是截然不同的。
沈金鳌说：方中行在《伤寒条辨》中认为，小儿角弓反张、手足抽搐，后世儿科总名为惊风，这是误治。认为不是惊风，也是痉病。我详细考察，这乃是少阴、少阳客热所致，表现为惊厥抽搐，是由感冒热邪引起的，实际上并非惊风，也并非痉病。所以详细说明这一点。沈氏此说极是，可惜似乎不知道惊风就是古代的痫病。
太阳病，关节疼痛且烦躁，脉象沉而细（〔原注〕一作缓）的，这名叫湿痹。（〔原注〕玉函经云：中湿。）湿痹的症状，是小便不利，大便反而通畅。治疗时只应当利小便。
〔尤在泾〕湿是六淫之一，所以它伤人，也像风寒一样先在太阳经。但风寒伤害肌腠，而湿则流入关节。风脉浮，寒脉紧，而湿脉则沉而细。湿性濡滞，气机重着，所以也叫痹。痹，就是闭的意思。此人平日土德不足（脾虚），湿气动于中焦，由此气化不速，湿气侵于外，内外合邪，导致关节疼痛、小便不利、大便反而通畅。治疗者，必须先祛除内湿，然后才可以除外湿。所以说：只应当利小便。李东垣也说：治湿，不利小便，不是正确的治法。然而这是针对脉沉而小便不利者设立的。如果风寒在表，与湿相搏，脉浮、恶风、身重疼痛的，则必须用麻黄、白术、薏苡仁、杏仁、桂枝、附子等药，发汗为宜。
溯源集说：夫湿，是六气之一。然而在一气之中，还有区别。雾露之气，是升于地面的轻清之气而上腾的，所以称为湿中之清，伤人皆中于上部。雨雪泥水之湿，是附着于地面的重浊之气而在下的，称为湿中之浊，伤人皆中于下部。经文说：清邪中上，浊邪中下。所以《金匮要略》说：湿伤于下，雾伤于上。雾伤皮腠，湿流关节。也称为太阳病，是因为风寒暑湿之邪，皆由卫气不密，其气得以从皮毛而入，因为营卫皆属太阳故也。关节，是指筋骨肢节之间。因为雨露水湿之气，因卫阳不能外固，由太阳经流入关节筋骨之间，导致肢节疼痛而烦扰不宁。其脉沉而细，是寒湿流于皮肉筋脉之间，血凝气滞，营卫运行不畅。寒湿内淫，则三焦不能施化，气化不得流行，其人小便不利，是以水谷不能泌别，湿气流溢于大肠，故大便不得燥结，反而通畅。像这种情况，不必用燥湿法治之，其湿气淫溢，非燥湿所能胜，所以只当利其小便。小便利，则谷水分流而湿淫去除。此条大概论述的是雨雪泥水、地气之湿，乃湿中之浊者，所以说：只当利其小便。如果是雾露之清邪，就应当用微似汗的方法解之。然而利小便一句，应当察其脉证机宜，不可泛然以淡渗之法治疗。脉既沉细，关节已疼，而小便不利，则可知为阴寒，自当以寒湿为治，责之下焦无火，膀胱之气化不行，则五苓散及甘草附子汤之类，意在言表。
《活人书》说：若小便不利，大便反快，当利其小便，宜用甘草附子汤、五苓散。《素问·至真要大论》说：治湿之法，不利小便，非其治也。
《医说》引《信效方》说：春夏之交，人病如伤寒，其人汗自出，肢体重痛，转侧困难，小便不利，这名叫风湿，不是伤寒。阴雨之后卑湿之地，或饮水过多，多有此证。只要多服五苓散，小便通利，湿去则愈。切忌转泻发汗，小误必不可救。初虞世说：医者不识，作伤风治之，发汗下之必死。按：此大概与本条之证相同，附以备考。
湿病患者，一身尽疼（〔原注〕一云疼烦），发热，身色如熏黄也（玉函经作：一身疼烦）。
〔程〕脾主身之肌肉，湿为寒邪，郁于肌中不得散，则一身尽疼发热。阳明瘀热，则黄色鲜明如橘子；太阴寒湿，则黄色黧暗如烟熏。
成无己说：身黄如橘子色者，是阳明瘀热。此身色如似熏黄，即非阳明瘀热。身黄发热者，栀子柏皮汤主之。为表里有热，则身不疼痛。此一身尽疼，非伤寒客热也。知湿邪在经，使之然。脾恶湿，湿伤则脾病而色见，是以身发黄者，为其黄如烟熏，非正黄色也。张卿子说：湿热，即栀子柏皮汤证也。此白术附子汤症。溯源集说：湿邪充塞，浸灌于表里肌肉肢节之间，所以一身尽疼，而身色如熏黄也。熏黄者，如烟熏之状，黄中带黑，而不明润也。盖黄家有阴阳之别，阳黄则明润，阴黄则黑暗，而无光泽。身如橘子色者，湿热停蓄所致，属阳黄。此一身尽疼，已属寒湿之邪，流于关节，而身色如似熏黄，即阴黄之属也。当于寒湿中求之。
湿家其人但头汗出，背强，欲得被覆向火。若下之早则哕，或胸满，小便不利（〔原注〕一云利）。舌上如胎者，以丹田有热，胸上有寒，渴欲得饮，而不能饮，则口燥烦也（不利，玉函经作利。脉经无烦字，似是。庞氏总病论烦作故。神巧万全方胎作苔。胸上作胸中）。
〔程〕湿为阴邪，阴邪客于阴，则阳上越，而不行于腠理肌肉，故但头汗出。背为阳，寒湿胜则阳虚，故背强，欲得被覆向火也。若当表邪未解之时，误以阳明内湿之热，上越之头汗，而早下之，则虚其胃，湿干于胃，则哕。寒客于上，则胸满。亡其津液，则小便不利。以寒湿在上，故舌上如苔而实非苔也。丹田有热者，以下后里虚，上焦阳气，因虚而陷于下焦，为丹田有热。表中寒气，乘虚而客于胸上，为胸上有寒。唯其丹田有热，则渴欲饮水；胸上有寒，不能散水，虽得水，而不能饮，故口燥烦也。
溯源集说：舌上如苔者，若热邪入胃，则舌上或黄或黑，或芒刺，或干硬，或燥裂，皆苔也。此云如苔，乃湿滑而色白，似苔非苔也。此因寒湿之邪，陷入于里，而在胸膈，命门之真阳，不得上升，而在下焦，上下不通，故曰丹田有热，胸中有寒。下焦之真火，既不得上达，即所谓清阳不升，是下焦无蒸腾之用，气液不得上腾，而为涕唾，故渴。又以寒湿在胸，道路阻绝，故虽欲得水，而不能饮，则口燥而烦渴也。仲景虽不立治法，然以理推之，下文之桂枝附子汤、甘草附子汤，即其治也。前人拟小陷胸汤，恐非其治。即五苓散、理中汤虽近于理，犹未尽善（案以上三方，见张卿子注）。何也？以但能温中而不能解外，故必以用桂枝者为妥也。
按语：胸上有寒，丹田有热，诸注欠详。第程、钱二氏，义似稍通，然犹未清晰。因考此寒热互误，黄连汤条云：胸中有热，胃中有邪气，邪气即寒也。方中用干姜、桂枝，其义可见耳。他诸泻心汤、乌梅丸之类，悉为上热下冷设。巢元方有冷热不调之候云：阳并于上，则上热；阴并于下，则下冷。而无上冷下热之证，其故何也？盖火性炎上，水性就下，病冷热不调，则热必浮于上，寒必沉于下，是所以无下热上冷之候也。凡误下之证，下焦之阳骤虚，气必上逆，则上焦之阳，反因下而成实，以火气不下行，故为上热下冷之证。此条证亦然。舌上如苔而口燥者，上热之征；渴欲得饮，而不能饮者，下冷之验。与厥阴病心中疼热、饥而不能食，虽有饮食之别，其理则一也。故如此证，亦必非寒热错杂之剂，则难奏效。学人宜致思焉。
湿家下之，额上汗出，微喘，小便利（〔原注〕一云：不利）者死。若下利不止者亦死。
〔尤〕湿病在表者宜汗，在里者宜利小便。苟非湿热蕴积成实，未可遽用下法。额汗出微喘，阳已离而上行；小便利，下利不止，阴复决而下走。阴阳离决，故死。一作小便不利者死，谓阳上游，而阴不下济也，亦通。
〔鉴〕李玮西说：湿家当利小便，以湿气内瘀，小便原自不利，宜用药利之。此下后里虚，小便自利，液脱而死，不可一例概也。
风湿相搏，一身尽疼痛，法当汗出而解。值天阴雨不止，医云：此可发汗。汗之病不愈者何也？盖发其汗，汗大出者，但风气去湿气在，是故不愈也。若治风湿者，发其汗，但微微似欲出汗者，风湿俱去也（伤寒论、玉函经、脉经冒问曰二字，盖作答曰二字。玉函经雨下有溜字。湿气在，作湿气仍在。脉经作湿气续在。玉函经、脉经医作师。成本作似欲汗出）。
〔徐〕此言风湿当汗解，而不可过也。谓风湿相搏疼痛，原当汗解。值天阴雨，则湿更甚，可汗无疑。而不愈何故？盖风性急，可骤驱；湿性滞，当渐解。汗大出则骤风去，而湿不去，故不愈。若发之微，则出之缓，缓则风湿俱去矣。然则湿在人身，粘滞难去，骤汗且不可，而况骤下乎？故前章曰：下之死。此但云不愈，见用法不当，而非误下比也。
〔程〕兹条为治湿汗之严律。
王宇泰说：风湿宜汗，桂枝加白术、黄芪、防己汤。张卿子说：风湿相搏，法当汗出而解，如麻黄加术汤，使微微蒸发，表里气和，风湿俱去。
湿家病，身疼发热，面黄而喘，头痛鼻塞而烦，其脉大，自能饮食，腹中和无病，病在头中寒湿，故鼻塞，纳药鼻中则愈（〔原注〕脉经云：病患喘，而无湿家病以下，至而喘十三字。○案十三字，当作十一字。伤寒论作湿家病身上疼痛）。
〔沈〕此湿淫于上，与湿从下受不同也。湿邪感于太阳，与肺气相合，气郁于表，故身疼发热，面黄而喘，头痛鼻塞而烦也。邪居于表，故脉大。自能饮食者，腹中和而无病，当责病在头中寒湿。寒湿者，以湿属阴故也。盖鼻为肺窍，肺气受湿，则鼻塞，故当纳药鼻中，搐去黄水，俾肺气通调，大气一转，肌腠开而湿痹解矣。
溯源集说：病浅不必深求，毋庸制剂，但当以辛香开发之药，纳之鼻中，以宣泄头中之寒湿则愈。朱奉议及王氏准绳，俱用瓜蒂散。
〔鉴〕赵良说：湿与寒合，令人身疼。大法表实成热，则可发汗；无热是阳气尚微，汗之恐虚其表。是证虽不云热，而烦以生，烦由热也。所以服药，不敢大发其汗。且湿亦非暴汗可散，用麻黄汤治寒，加术去湿，使其微汗耳。不可火攻，火攻则增其热，必有他变，所以戒人慎之。
喻昌说：麻黄加术，则虽发汗，不至多汗，而术得麻黄，并可以行表里之湿。
〔程〕若以火攻之，则湿热相搏，血气流溢，迫而为衄，郁而为黄，非其治法。
麻黄加术汤方
麻黄（三两，去节） 桂枝（二两，去皮） 甘草（二两，炙○案据麻黄汤本方当一两） 杏仁（七十个，去皮尖） 白术（四两○案术分苍白，始出于名医别录，此白字后人所加，宜删）
以上五味药，用水九升，先煮麻黄，减二升，去上沫，纳诸药，煮取二升半，去滓，温服八合，覆取微似汗。
三因方称麻黄白术汤，治寒湿身体烦疼，无汗恶寒发热者（即本方）。
千金翼方治多睡，欲合眼，则先服以止睡方：
麻黄（去节） 白术（各五两） 甘草（一两，炙）
以上三味药，以日中时，南向捣筛为散，食后以汤服方寸匕，日三服。
病者一身尽疼，发热日晡所剧者，名风湿。此病伤于汗出当风，或久伤取冷所致也。可与麻黄杏仁薏苡甘草汤（玉函经、脉经作日晡即剧，非）。
〔鉴〕病者，谓一身尽痛之病患也。湿家一身尽痛，风湿亦一身尽痛。然湿家痛，则重着不能转侧。
Ke (Shi) stated in *Wings to the Treatise on Cold Damage* (*Shanghan Lun Yi*): All diseases caused by the Six Qi can manifest with fever. However, cold and heat are interrelated, while summerheat and dampness accompany each other. Only dryness and dampness are contrary in nature. Damp diseases mostly arise from pathogenic factors originating from the earth (external environment), whereas dryness diseases mostly stem from internal causes. This constitutes the difference in etiology. In the "Nineteen Pathogenesis Formulas" of the *Suwen*, there is no specific mention of dryness syndromes. If one claims that all spasms and neck stiffness belong to dampness, I privately harbor doubts about this view. The current treatise distinguishes between spasm (*Jing*) and dampness. It also states: "In Taiyang disease, excessive sweating leads to spasm." Therefore, it is beyond doubt that spasm belongs to dryness. Spasm is named after its symptoms; it occurs due to blood deficiency causing tendon tension. Although all six qi can cause spasm, without heat there is no dryness, and without dryness, spasm cannot form. Furthermore, it is said that when treating wind-cold, one should not disregard the preservation of body fluids; thus, cases of spasm resulting from excessive sweating are common. Spasm has its own origins; a single instance of mismanagement can lead to peculiar manifestations. Neck and back stiffness (described as rigid) is a sign of impending spasm, hence *Ge Gen* (Puerariae Radix) is used. Generalized body rigidity indicates that spasm is already established, hence *Gua Lou Gen* (Trichosanthis Radix) is used. Inability to lie flat with the back touching the bed, leg cramps, trismus, and teeth grinding indicate severe spasm, hence *Da Huang* (Rhei Radix et Rhizoma) and *Mang Xiao* (Natrii Sulfas) are used. These herbs are chosen for their ability to generate fluids and nourish yin-blood. They should not be treated similarly to cases where sweating was indicated but not performed.
**Da Cheng Qi Tang Formula**
*Da Huang* (4 liang, washed with wine), *Nong Po* (Bai Zhu Pi / Magnolia Bark, 8 liang, roasted and peeled), *Zhi Shi* (Immature Bitter Orange, 5 pieces, roasted), *Mang Xiao* (Mirabilite, 3 he).
Take the above four ingredients, add ten dou of water, first decoct *Nong Po* and *Zhi Shi*, reduce to five sheng, remove dregs, add *Da Huang*, and decoct to obtain two sheng. Remove dregs again, add *Mang Xiao*, heat briefly until boiling once or twice more, divide into two warm doses. Stop taking if bowel movement occurs. ("Light fire" in Song edition of *Shanghan Lun* reads "slight fire".)
The *San Yin Fang* states that *Da Cheng Qi Tang* treats Gang Jing (Stiff Spasm). This is because the Yangming channel nourishes the tendons (Zong Jin); Yangming corresponds to the Stomach. When wind-damp-cold enters the stomach, heat becomes intense, and the tendons lack nourishment, leading to tension. Directly purging Yangming restores its nourishing function.
**Commentary:** The *Jia Yi Jing* states that Gang Jing is Taiyang Wind Strike complicated by cold-damp. The pulse is progressive and regressive, appearing deep, slow, and fine, differing from typical cold damage febrile diseases. Chao Yuanfang's *Zhu Bing Yuan Hou Lun* and *Qian Jin Fang* both state that wind pathogen damaging the Taiyang channel, combined with cold-damp, triggers spasm. From Cheng Wuji onwards, this view was universally accepted without dissent. However, Zhang Jiebin later argued: The disease lies in the tendons and vessels; tendon tension causes opisthotonos. The disease lies in the blood; blood dryness causes tendon contraction. Ke followed this to classify spasm as a dryness syndrome, which is indeed accurate. Therefore, assertions by Xu Lintai, Shen Jin'ao, and others attributing it to cold-damp are unreliable.
Xu Lintai in *Lantai Gui Fan* notes: Spasm is a deteriorated stage of cold damage. Even in children, there is a chance of recovery, but in adults, one in a hundred survives. Excess-type cases might survive with purgation, but deficiency-type cases have no treatment. The formulas in *Jin Gui Yao Lue* rarely show efficacy.
**Commentary:** *Qian Jin Fang* distinguishes epilepsy (*Xian*) from spasm (*Jing*): If the body is soft and consciousness returns intermittently, it is epilepsy; if the body is rigid, opisthotonic, and consciousness does not return, it is spasm. Epilepsy is later referred to as "Startled Wind" (Jing Feng) in texts like *Tai Ping Sheng Hui Fang* (Acute Startled Wind is Yang Epilepsy, Chronic is Yin Epilepsy). These two conditions are distinct.
Shen Jin'ao argues: Fang Zhongxing in *Shanghan Tiao Bian* suggests that pediatric opisthotonos and convulsions were misdiagnosed as Startled Wind. Shen asserts these are actually caused by guest-heat in Shaoyin and Shaoyang channels, manifesting as convulsions due to febrile pathogens, not Startled Wind or Spasm. While Shen's view is largely correct, he seems unaware that "Startled Wind" is the ancient term for epilepsy.
In Taiyang disease, joint pain accompanied by vexation, with a deep and fine pulse (original note: alternatively slow), is named **Shi Bi** (Damp Bi). Manifestations of Shi Bi include difficulty urinating and loose stools. Treatment should focus solely on promoting diuresis.
**You Zaijing:** Dampness is one of the Six Evils. Like wind and cold, it initially affects Taiyang. However, while wind-cold damages muscle layers, dampness flows into joints. Wind pulses float, cold pulses tight, but dampness pulses deep and fine. Dampness is sticky and heavy, causing obstruction (Bi). Bi means closure. If the patient has inherent Spleen deficiency (Earth virtue insufficient), dampness arises internally. Combined with external dampness, this causes joint pain, urinary difficulty, and loose stools. One must first eliminate internal dampness before addressing external dampness. Hence, promote diuresis. Li Dongyuan also stated: Treating dampness without promoting diuresis is incorrect. However, this applies to deep/fine pulses and urinary difficulty. If wind-cold is on the exterior interacting with dampness, presenting with floating pulse, aversion to wind, heaviness, and pain, then sweating with *Ma Huang* (Ephedrae Herba), *Bai Zhu* (Atractylodis Macrocephalae Rhizoma), *Yi Yi Ren* (Coicis Semen), *Xing Ren* (Armeniacae Semen Amarum), *Gui Zhi* (Cinnamomi Ramulus), and *Fu Zi* (Aconiti Lateralis Radix Praeparata) is appropriate.
**Su Yuan Ji:** Dampness is one of the Six Qi, but varies. Mist and dew are light, clear, ascending vapors (Clear Damp), affecting the upper body. Rain, snow, and mud are heavy, turbid, descending waters (Turbid Damp), affecting the lower body. Classics state: Clear evil attacks above, turbid evil attacks below. Thus, *Jin Gui Yao Lue* says: Dampness injures below, mist injures above. Mist damages skin and pores; dampness flows into joints. It is called Taiyang disease because wind, cold, summerheat, and dampness enter through open pores due to deficient Wei Qi, and Ying-Wei belong to Taiyang. Joints refer to bone-tendon junctions. Due to deficient Wei-Yang, rain/mud dampness enters via Taiyang into joints/tendons, causing pain and restlessness. Deep/fine pulses indicate cold-damp stagnating in flesh/tendons, blocking Ying-Wei flow. Internal cold-damp impairs San Jiao transformation, leading to urinary difficulty and loose stools (damp flooding Large Intestine). Dryness-resolving methods are ineffective here; only diuresis works. If diuresis succeeds, grain water separates and dampness clears. This clause discusses Turbid Damp (rain/mud), so diuresis is key. For Clear Damp (mist), mild sweating is appropriate. However, diuresis must be tailored to pulse/symptoms; bland leeching alone is insufficient. Deep/fine pulse + joint pain + urinary difficulty indicates Yin-Cold and Lower Jiao Fire deficiency. Wuling San or Gan Cao Fu Zi Tang are implied.
*Huo Ren Shu*: For urinary difficulty and loose stools, use Gan Cao Fu Zi Tang or Wuling San. *Suwen Zhi Yao Da Lun* confirms: Treating dampness without diuresis is wrong.
*Yi Shuo* cites *Xin Xiao Fang*: In spring/summer transitions, patients present with cold-damage-like symptoms, spontaneous sweating, heavy limb pain, difficulty turning, and urinary difficulty. This is Wind-Damp, not cold damage. Common after rainy weather or overdrinking. Multiple doses of Wuling San resolve it. Avoid purgatives or strong sweating; minor errors can be fatal. Chu Yushi warns that misdiagnosing as Wind Strike and using sweating/purgation is fatal. This matches the current clause.
For **Shi Jia** (Damp Patient) disease: Generalized body pain, fever, and sallow complexion resembling smoke-staining (Yun Huang).
**Cheng:** Spleen governs muscles. Cold-damp stagnating in muscles causes generalized pain and fever. Yangming stasis-heat causes bright orange-yellow jaundice; Taiyin cold-damp causes dark, smoke-stained jaundice.
Cheng Wuji: Bright orange-yellow is Yangming stasis-heat. Smoke-stained yellow is not Yangming heat. Fever with jaundice is treated with *Zhi Zi Bai Pi Tang* (Gardeniae Cortex Phellodendri Decoction). Table-interior heat usually lacks body pain. Here, generalized pain indicates dampness in channels, not cold damage heat. Dampness damages Spleen, revealing color. Smoke-stained yellow is Yin Jaundice.
**Su Yuan Ji:** Dampness filling muscles/joints causes pain and smoke-stained yellow (dark yellow-black, dull). This is Yin Jaundice (cold-damp), unlike Yangming heat jaundice (bright orange). Seek treatment within cold-damp patterns.
For **Shi Jia**: Sweating only on the head, stiff back, desire to cover up and face fire. Premature purgation leads to hiccups, chest fullness, or urinary difficulty. Tongue coating resembles mold. This is due to Heat in Dantian (Lower Jiao) and Cold in Chest (Upper Jiao). Thirst with inability to drink causes dry mouth and vexation.
**Cheng:** Dampness is Yin Evil. Yin invading Yin causes Yang to float upward, failing to circulate in muscles, causing only head sweating. Back is Yang; cold-damp excess causes Yang deficiency, leading to back stiffness and desire for warmth. Premature purgation damages Stomach Qi, causing hiccups. Cold lodging in Upper Jiao causes chest fullness. Fluid loss causes urinary difficulty. The tongue coating is not true moss but damp-slippery white. Purging empties interior, causing Upper Jiao Yang to sink to Lower Jiao (Heat in Dantian), while Cold lodges in Chest. Lower Jiao Heat causes thirst; Upper Jiao Cold prevents fluid distribution, causing inability to drink and dry mouth/vexation.
**Wei:** Dry mouth and heart vexation.
**Su Yuan Ji:** True heat coatings are yellow/black/thorny/dry/cracked. This "resembles coating" is wet, slippery, and white. Cold-damp sinking to Middle Jiao blocks Ming Men True Yang from rising. Lower Jiao Fire cannot ascend (Clear Yang fails to rise), preventing fluid vaporization into saliva, causing thirst. Upper Jiao Cold blocks pathways, preventing drinking despite thirst. Zhang Zhongjing did not provide a formula, but logically, *Gui Zhi Fu Zi Tang* or *Gan Cao Fu Zi Tang* (from later text) would be suitable. *Xiao Xian Xiong Tang* is likely inappropriate. *Wuling San* or *Li Zhong Tang* are close but incomplete as they warm middle but do not release exterior. *Gui Zhi*-based formulas are better.
**Commentary:** "Cold in Chest, Heat in Dantian" needs clarification. Cheng and Qian offer some insight but remain unclear. Comparing with *Huang Lian Tang* clause ("Heat in Chest, Evil/Cold in Stomach"), using *Gan Jiang* and *Gui Zhi* clarifies the mechanism. Other Heart-Purging Decoctions and *Wu Mei Wan* treat Upper Heat/Lower Cold. Chao Yuanfang notes Yang aggregating above causes Upper Heat, Yin below causes Lower Cold, but never Upper Cold/Lower Heat. Why? Fire flares up, Water sinks down. In mismanaged cases, Lower Jiao Yang collapses, Qi rebels upward, making Upper Jiao relatively solid (Upper Heat/Lower Cold). This case mirrors that: Tongue coating/dry mouth = Upper Heat; Thirst/inability to drink = Lower Cold. Similar to Jueyin disease (heart pain/hunger/no appetite). Complex cold-heat formulas may fail here. Scholars should ponder this.
If a **Shi Jia** is purged prematurely, leading to sweating on the forehead, slight wheezing, and free urination (or alternatively, urinary difficulty), death ensues. Uncontrollable diarrhea also leads to death.
**You:** Exterior dampness requires sweating; interior dampness requires diuresis. Unless damp-heat accumulates into excess, purgation is contraindicated. Forehead sweating/wheezing indicates Yang separating and rising; free urination/diarrhea indicates Yin collapsing and falling. Separation of Yin and Yang leads to death. Alternatively, urinary difficulty implies Yang rising without Yin supporting.
**Jian:** Li Weixi notes: Shi Jia should use diuresis because dampness obstructs urination. Here, post-purgation deficiency causes free urination and fluid exhaustion, leading to death. Do not generalize.
When **Wind-Damp** combines, causing generalized pain, sweating is the method of resolution. If raining continuously, a physician advises sweating, but the patient does not improve. Why? Profuse sweating expels Wind but leaves Damp behind. To treat Wind-Damp, induce only slight, continuous perspiration so both Wind and Damp are expelled.
**Xu:** Wind is swift and easily expelled; Damp is sticky and slowly resolved. Profuse sweating removes Wind but not Damp. Mild sweating resolves both. Damp is sticky; violent sweating is contraindicated, let alone purgation. Previous chapter warned against purgation (death); here, failure to cure indicates improper method, not necessarily fatal error.
**Cheng:** This clause sets strict rules for sweating in dampness treatment.
Wang Yutai recommends *Gui Zhi Jia Bai Zhu Huang Qi Fang Ji Tang*. Zhang Qingzi recommends *Ma Huang Jia Shu Tang* for mild evaporation, harmonizing table-interior to expel both.
For **Shi Jia** disease: Body pain, fever, yellow face, wheezing, headache, nasal congestion, and vexation. Pulse is large. Appetite is normal, abdomen is comfortable. Disease is Cold-Damp in the Head, causing nasal congestion. Inserting medicine into the nose cures it.
**Shen:** Dampness attacking the Upper Jiao differs from Lower Jiao dampness. Dampness affects Taiyang and Lung Qi, stagnating in exterior, causing pain, fever, yellow face, wheezing, headache, nasal congestion, and vexation. Exterior pathogen causes large pulse. Normal digestion indicates interior is healthy. Disease is localized Cold-Damp in Head. Nose is Lung orifice; Lung Qi blocked by dampness causes congestion. Nasal medication clears yellow discharge, unblocks Lung Qi, rotates Grand Qi, opens pores, and resolves Bi.
**Wei:** *Gua Di San* (Melon Seed Powder): Grind *Gua Di* (Momordicae Fructus) into powder and insufflate into nose.
**Su Yuan Ji:** For superficial disease, complex preparation is unnecessary. Use pungent-aromatic herbs insufflated into nose to vent Cold-Damp from Head. Zhu Fengyi and Wang Haoxu also use *Gua Di San*.
For **Shi Jia** with body pain and vexation, administer **Ma Huang Jia Shu Tang** (Ephedra Plus Atractylodes Decoction) to induce sweating. Strictly avoid fire therapy.
**Jian:** Zhao Liang notes: Cold-Damp causes pain. If exterior excess turns to heat, sweating is allowed. Here, no heat indicates weak Yang; sweating risks further deficiency. Vexation implies latent heat. Do not sweat heavily. Damp cannot be dispersed by violent sweating. *Ma Huang Tang* treats cold; adding *Bai Zhu* removes damp, inducing mild sweating. Fire therapy increases heat, causing bleeding or jaundice.
Yu Chang: *Ma Huang Jia Shu* induces sweating without excess; *Bai Zhu* helps *Ma Huang* resolve table-interior dampness.
**Cheng:** Fire therapy causes damp-heat interaction, forcing blood/qi flow, leading to epistaxis or jaundice.
**Ma Huang Jia Shu Tang Formula**
*Ma Huang* (3 liang, remove nodes), *Gui Zhi* (2 liang, remove bark), *Gan Cao* (2 liang, roasted - note: original Ma Huang Tang uses 1 liang), *Xing Ren* (70 seeds, remove skins/shells), *Bai Zhu* (4 liang - note: "Bai" character added later by editors, originally just *Shu*).
Decoct five ingredients in nine sheng water. First boil *Ma Huang*, reduce by two sheng, remove foam. Add remaining herbs, decoct to 2.5 sheng. Remove dregs. Warm dose of 8 ge. Cover to induce slight perspiration.
*San Yin Fang* calls this *Ma Huang Bai Zhu Tang*, treating cold-damp body pain, anhidrosis, aversion to cold, and fever.
**Qian Jin Yi Fang** for excessive sleepiness:
*Ma Huang* (remove nodes), *Bai Zhu* (each 5 liang), *Gan Cao* (1 liang, roasted).
Grind at noon facing south into powder. Take one fang-cun spoon with warm water after meals, three times daily.
Patient with generalized pain, fever worsening at dusk (You period), is named **Feng Shi** (Wind-Damp). Caused by sweating exposed to wind or prolonged exposure to cold. Administer **Ma Huang Xing Ren Yi Yi Gan Cao Tang** (Ephedra, Apricot Seed, Coix, Licorice Decoction).
**Jian:** "Patient" refers to those with generalized pain. Both Shi Jia and Feng Shi have generalized pain. However, Shi Jia pain is heavy and immovable...