〔鉴〕数主疮。主热。今外无身热。而内有疮热。疮之热在于阴。故默默但欲卧也。热在于阳。故微
烦汗出也。然其病初得之三四日。目赤如鸠眼者。是热蕴于血。故 络赤也。七八日。四 皆黑者。是热瘀血
腐。故 络黑也。若不能食。其毒尚伏诸里。若已能食。其毒已化成脓也。
〔程〕能食者。邪气散漫。不在脏腑。而在阴肛。烂肉腐肌。而成脓矣。
〔尤〕按此一条。注家有目为狐惑病者。有目为阴阳毒
者。要之亦是湿热蕴毒之病。其不腐而为虫者。积而为痈。不发于身面者。则发于肠脏。亦病机自然之
势也。仲景意谓与狐惑阴阳毒。同源而异流者。故特论列于此欤。
赤小豆当归散方
赤小豆（三升浸令芽出曝干） 当归（十两○案原本缺两数今根据宋本及俞本补之千
金作三两徐熔附遗引庞安时当归一两）
上二味。杵为散。浆水服方寸匕。日三服。
〔程〕当归。主恶疮疡。赤小豆。主排痈肿。浆水。能调理脏腑。三味为治痈脓已成之剂。此方蚀于
肛门者。当用之。按后先血后便。此近血也。亦用此汤。以大肠肛门。本是一源。病虽不同。其解脏毒则
一也。（浆。酢也。炊粟米热。投冷水中。浸五六日。生白花。色类浆者。案浆水法。出本草蒙筌。）
张氏医通云。此方治肠痈便毒。及下部恶血诸疾。
阳毒之为病。面赤斑斑如锦纹。咽喉痛。唾脓血。五日可治。七日不可治。升麻鳖甲汤
主之。（脉经。无鳖甲二字。）
阴毒之为病。面目青。身痛如被杖。咽喉痛。五日可治。七日不可治。升麻鳖甲汤。去雄黄蜀椒主之。
（肘后。七日不可治。作过此死三字。脉经千金。升麻以下十字。作甘草汤三字。）
〔尤〕毒者。邪气蕴蓄不解之谓。阳毒非必极热。阴毒非必极寒。邪在阳者。为阳毒。邪在阴者。为
阴毒也。而此所谓阴阳者。亦非脏腑气血之谓。但以面赤斑斑如锦纹。咽喉痛唾脓血。其邪着而在表者。谓之
阳。面目青。身痛如被杖。咽喉痛。不唾脓血。其邪隐而在表之里者。谓之阴耳。故皆得辛温升散之品。
以发其蕴蓄不解之邪。而亦并用甘润咸寒之味。以安其邪气。经扰之阴。五日邪气尚浅。发之犹易。
故可治。七日邪气已深。发之则难。故不可治。其蜀椒雄黄二物。阳毒用之者。以阳从阳。欲其速散也。
阴毒去之者。
恐阴邪不可劫。而阴气反受损也。
〔沈〕阴毒者。非阴寒之阴。即阴血受寒为阴。而血凝不散。故成阴毒。
后人不解其义。视为阴寒直中。变为阴毒。拟用霹雳散正阳丹。（案徐程注意。并如
是。）皆是未入仲景藩篱耳。惟元时王安道。辨非阴寒直中。（案出
溯洄集。）可谓言直理正。惜其又云天地恶毒异气。混淆未明。使后人无所措手。（案金鉴本于王氏之言。
遂云阴毒阳毒。即今世俗所称痧证。阴毒反去雄黄蜀椒。必传写之讹。故治是证者。不必问其阴阳。但刺其
尺泽委中。手中十指脉络。暴出之处出血。轻则用刮痧法。随即服紫金锭。此说亦叵从。）
升麻鳖甲汤方
升麻（二两） 当归（一两） 蜀椒（炒去汗一两） 甘草（二两） 鳖甲（手指大一
片炙） 雄黄（半两研）
上六味。以水四升。煮取一升。顿服之。老小再服汗。
〔原注〕肘后千金方。阳毒用升麻汤。无鳖甲有桂。阴毒用甘草汤。无雄黄。○案四升。肘
后。作五升。一升玉函。肘后。作二升。似是。
兰台轨范云。蜀椒辛热之品。阳毒用。而阴毒反去之。疑误。活人书。加犀角等四味。颇切当。
董氏医级云。此汤兼治阳毒阴毒二症。阳毒用此方治疗。阴毒亦以此方。去雄黄倍川椒为治。以阴毒不
吐脓血。故去雄黄。阴盛则阳衰。故倍川椒也。大抵亢阳之岁多阳毒。流衍之纪多阴毒也。但每遇此症。按法
施治。曾无一验。凡遇此证。多以不治之证视之。百岁老人袁云龙曰。细详此二证。俱有咽喉痛三字。窃论
疡科书。有锁喉风。缠喉风。铁蛾缠三证。其状相似。有面色赤如斑者。有面色凄惨而青黑者。
有吐脓血者。有身痛如杖。有气喘息促。谵语烦躁者。总以咽喉痹痛为苦。一发之间。三五日不减。即无
生理。岂非阳毒阴毒之类乎。再详其脉。缓大者生。细促者死。予见此二
症。先用咽喉科利痰方治之。全活甚众。
案巢源云。夫欲辨阴阳毒病者。始得病时。可看手足指。冷者是阴。不冷者是阳。又云。阳毒者。
面目赤。或便脓血。阴毒者。面目青而体冷。若发赤斑。十生一死。若发黑斑。十死一生。千金亦云。阳毒。
狂言或走。或见鬼。或吐血下利。其脉浮大数。阴毒。短气不得息。呕逆。唇青面黑。四肢厥冷。其脉沉
细紧数。由此观之。阳毒乃不得不用活人阳毒升麻汤。及化斑汤之属。即后世所谓阳斑也。阴毒乃不得
不用庞氏附子饮霹雳散正阳丹之类。即后世所谓阴斑也。而以升麻鳖甲汤一方主之者。可疑。董氏无一验
之说。觉不诬矣。
【尤在泾评注】“数”脉主疮疡，主热证。如今患者体表无发热症状，但体内有疮疡之热。若热邪蕴结于阴分，则表现为神情沉默、只想睡觉；若热邪蕴结于阳分，则表现为轻微烦躁、出汗。然而此病初起三四日时，若出现眼睛发红如同斑鸠眼睛的样子，这是热邪蕴结在血分，导致目络充血发红；到了七八日时，若眼周四周发黑，这是热邪瘀滞血液、血肉腐败所致，故目络呈现黑色。如果此时患者不能进食，说明毒邪仍潜伏在体内深处；如果患者已经能够进食，说明毒邪已化脓。
【程知评注】能够进食的人，是因为邪气散漫，不在脏腑内部，而是在阴部肛门处，导致烂肉腐肌，从而形成脓液。
【尤在泾评注】按：这一条原文，有的注家将其归为狐惑病，有的归为阴阳毒。总之，这也是湿热蕴结毒邪的疾病。如果不腐烂化为虫蚀，就会积聚成为痈肿。若不发生在身体面部，就会发生在肠脏。这也是病机发展的自然趋势。张仲景的本意是认为此病与狐惑病、阴阳毒同源而异流，所以特意论述列于此篇吧。
赤小豆当归散方
赤小豆（三升，浸泡令其发芽，晒干） 当归（十两○按：原本缺失重量，今根据宋本及俞氏本补入千金方作三两，徐熔《附遗》引庞安时记载当归一两）
以上两味药，捣碎研成散剂。用浆水送服一方寸匕，每日三次服用。
【程知评注】当归主治恶疮疡，赤小豆主治排解痈肿，浆水能调理脏腑。这三味药（注：此处指代方中药物组合之意，实为两味药加浆水）是治疗痈脓已成之剂。此方适用于侵蚀肛门的情况。按后文所述先出血后大便，这是近血证，也使用此汤。因为大肠和肛门本源相同，虽然病症不同，但解除脏毒的原理是一致的。（浆水即醋类酸水。做法是将粟米煮熟趁热投入冷水中，浸泡五六天，生出白花，颜色像浆汁一样。案：浆水的制作方法出自《本草蒙筌》。）张氏《医通》说，此方治疗肠痈、便毒以及下部恶血等各种疾病。
阳毒这种病，面色红赤，斑纹如锦缎花纹，咽喉疼痛，咳唾脓血。发病五天内可治，七天后不可治。用升麻鳖甲汤主治。（《脉经》中没有“鳖甲”二字。）
阴毒这种病，面目青紫，身体疼痛如同被棍棒打过，咽喉疼痛。发病五天内可治，七天后不可治。用升麻鳖甲汤，去掉雄黄、蜀椒来主治。（《肘后备急方》中，“七日不可治”写作“过此死”三个字；《脉经》《千金方》中，从“升麻”以下的十个字，写作“甘草汤”三个字。）
【尤在泾评注】所谓“毒”，是指邪气蕴蓄不解的状态。阳毒不一定就是极热，阴毒也不一定就是极寒。邪气在阳分，称为阳毒；邪气在阴分，称为阴毒。而这里所说的阴阳，也不是指脏腑气血的阴阳，而是以面赤斑斑如锦纹、咽喉痛、咳唾脓血，这些邪气附着且在表浅部位的，称为阳；面目青紫、身体疼痛如被杖打、咽喉痛、不咳唾脓血，这些邪气隐蔽且在表之里的，称为阴罢了。所以两者都可用辛温升散的药材，来发散那蕴蓄不解的邪气；同时也并用甘润咸寒的药材，来安抚受邪气扰乱阴分。发病五日，邪气尚浅，发散它比较容易，所以说可治；发病七日，邪气已深，发散它就难了，所以说不可治。其中蜀椒、雄黄这两味药，阳毒方中使用它们，是以阳助阳，想要邪气迅速消散；阴毒方中去掉它们，是担心阴邪不可强行攻劫，反而损伤阴气。
【沈金鳌评注】阴毒，并非阴寒之阴，而是阴血受寒凝滞不散，所以形成阴毒。后世人不理解其含义，将其视为阴寒直中脏腑变为阴毒，拟用霹雳散、正阳丹等方。（按：徐灵胎、程知等人的注释，也都是如此看法。）这都是没有进入张仲景学术体系门径的表现。只有元代的王安道，辨析指出这不是阴寒直中。（出处见《溯洄集》），可以说是言辞直率、道理正确，可惜他又说天地间的恶毒异气混淆不清，使得后人无所适从。（按：《金鉴》基于王氏之言，于是说阴毒、阳毒就是当今世俗所称的痧证。阴毒反而去掉雄黄、蜀椒，必然是传写之误。所以治疗此证者，不必问其阴阳，只需刺尺泽、委中穴以及手中十指脉络暴起之处出血，轻症用刮痧法，随即服用紫金锭。这种说法也不可取。）
升麻鳖甲汤方
升麻（二两） 当归（一两） 蜀椒（炒去汗，一两） 甘草（二两） 鳖甲（手指大一片，炙） 雄黄（半两，研细）
以上六味药，用水四升，煮取一升，一次性服用。老人小孩再服一次以出汗。
【原注】《肘后备急方》《千金方》中，阳毒用升麻汤，无鳖甲而有桂枝；阴毒用甘草汤，无雄黄。○按：四升，《肘后》作五升；一升，《玉函》作二升，似乎更合理。
《兰台轨范》说：蜀椒是辛热之品，阳毒方中使用，而阴毒方中反而去掉它，怀疑有误。《活人书》加入犀角等四味药，颇为恰当。
董氏《医级》说：此汤兼治阳毒、阴毒两种病症。阳毒用此方治疗，阴毒也用此方，去掉雄黄并加倍川椒来治疗。因为阴毒不吐脓血，所以去掉雄黄；阴盛则阳衰，所以加倍川椒。大抵亢阳之年多阳毒，流衍之纪多阴毒。但是每当遇到此类病症，按照方法施治，从未有过一次见效。凡是遇到此证，大多将其视为不治之症。百岁老人袁云龙说：仔细详查这两个病症，都有“咽喉痛”这三个字。我私下议论疡科书籍，有锁喉风、缠喉风、铁蛾缠这三种证候，它们的症状相似，有面色红赤如斑点的，有面色凄惨而青黑的，有吐脓血的，有身体疼痛如被杖打的，有气喘急促、谵语烦躁的。总之以咽喉痹痛为痛苦所在，一旦发作之间，三五天不减轻，就没有生机了。这难道不是阳毒、阴毒之类的吗？再详细查看其脉象，缓大的预后良好，细促的预后不良。我见到这两种症候，先用咽喉科的利痰方治疗，保全了很多性命。
按：巢元方《诸病源候论》说：要想辨别阴阳毒病，刚得病时，可以看手足指头，发冷的属于阴毒，不发冷的属于阳毒。又说：阳毒，面目红赤，或者大便脓血；阴毒，面目青紫且身体寒冷。如果发出赤斑，十人中生一人死；如果发出黑斑，十人中死九生一。《千金方》也说：阳毒，胡言乱语或奔跑，或看见鬼怪，或吐血下利，脉象浮大数；阴毒，短气呼吸困难，呕逆，嘴唇青紫面色黑，四肢厥冷，脉象沉细紧数。由此看来，阳毒乃不得不使用《活人书》中的阳毒升麻汤，以及化斑汤之类，即后世所谓的阳斑。阴毒乃不得不使用庞氏的附子饮、霹雳散、正阳丹之类，即后世所谓的阴斑。而只用升麻鳖甲汤一方来主治，令人可疑。董氏说无一验的说法，觉得并不虚假。
[Commentary by You Zaijing] The "Shu" pulse (rapid pulse) indicates sores and heat syndromes. Currently, the patient has no fever on the exterior, but there is heat from sores within. If the heat resides in the Yin aspect, it manifests as silence and a desire to sleep; if the heat resides in the Yang aspect, it manifests as slight irritability and sweating. However, when this disease first begins, after three or four days, if the eyes become red like those of a turtledove, this indicates heat accumulating in the blood vessels, causing the collaterals to turn red. After seven or eight days, if the area around the eyes turns black, this indicates heat stagnating in the blood and rotting flesh, causing the collaterals to turn black. If the patient cannot eat, the toxin remains latent in the interior; if the patient can already eat, the toxin has transformed into pus.
[Commentary by Cheng Zhi] Those who can eat indicate that the pathogenic factor is diffuse, not residing in the Zang-Fu organs, but in the Yin region of the anus, where flesh rots and muscles decay, forming pus.
[Commentary by You Zaijing] Note: Regarding this passage, some commentators classify it as Hu-Huo Disease (Fox-Sorcery Disease), while others classify it as Yin-Yang Toxicity. In essence, it is also a disease caused by damp-heat accumulating into toxicity. If it does not rot into worms, it accumulates into an abscess. If it does not appear on the body or face, it appears in the intestines and viscera. This is also the natural trend of pathological mechanisms. Zhang Zhongjing's intent seems to be that this disease shares the same origin but different manifestations with Hu-Huo Disease and Yin-Yang Toxicity, hence it is specifically discussed here.
Chixiaodou Danggui San Formula
Chixiaodou (Red Bean Seed) [3 Sheng, soaked until sprouted, then dried] Danggui [Angelicae Radix Sinensis] (10 Liang ○ Note: The original text lacks the weight; supplemented here according to the Song edition and Yu's edition. Qianjin Fang uses 3 Liang; Xu Rong's *Fuyi* cites Pang Anshi using 1 Liang.)
The above two ingredients are pounded into a powder. Take one Fangcun Bi (a square-inch measure) with Jiangshui (fermented grain water), three times daily.
[Commentary by Cheng Zhi] Danggui treats malignant sores and ulcers; Chixiaodou expels abscess swelling; Jiangshui regulates the Zang-Fu organs. These ingredients constitute a formula for treating formed pus. This formula should be used for lesions eroding the anus. According to the later text describing bleeding before stool, this is "Jin Xue" (proximal blood), which also uses this decoction. Since the large intestine and anus share the same source, although the diseases differ, the principle of resolving visceral toxicity remains the same. (Jiangshui refers to acidic water made by cooking millet rice hot, throwing it into cold water, soaking for five to six days until white flowers grow, resembling the color of gruel. Note: The method for making Jiangshui comes from *Bencao Mengqian*.) Zhang Shi's *Yitong* states this formula treats intestinal abscesses, groin swellings, and various evils of lower body blood stasis.
Yang Du (Yang Toxicity) presents with a red face with patterns like brocade, sore throat, and spitting of pus and blood. It is treatable within five days; after seven days, it is untreatable. It is primarily treated with Shengma Biejia Tang (Cinnamon Twig and Turtle Shell Decoction). (*Mai Jing* omits the characters "Biejia".)
Yin Du (Yin Toxicity) presents with a blue-green complexion, body pain as if beaten with a club, and sore throat. It is treatable within five days; after seven days, it is untreatable. It is primarily treated with Shengma Biejia Tang, removing Xionghuang (Realgar) and Shujiao (Sichuan Pepper). (*Zhou Hou Bei Ji Fang* writes "passing this leads to death" instead of "seven days untreatable"; *Mai Jing* and *Qianjin Fang* write "Gancao Tang" instead of the ten characters starting from "Shengma".)
[Commentary by You Zaijing] "Toxicity" refers to pathogenic factors accumulating and failing to resolve. Yang Du is not necessarily extreme heat, nor is Yin Du necessarily extreme cold. Pathogens in the Yang aspect are called Yang Du; pathogens in the Yin aspect are called Yin Du. The Yin and Yang mentioned here do not refer to Zang-Fu or Qi-Blood, but rather: symptoms such as a red face with brocade-like patterns, sore throat, and spitting pus/blood, where the pathogen attaches to the exterior, are called Yang; symptoms such as a blue-green complexion, body pain like being beaten, sore throat, and no spitting of pus/blood, where the pathogen is hidden in the interior relative to the exterior, are called Yin. Therefore, both can use acrid-warm ascending-dispersing herbs to vent the accumulated pathogens, and simultaneously use sweet-moist salty-cold flavors to pacify the Yin disturbed by pathogens. Within five days, the pathogen is shallow, making dispersion easier, hence treatable. After seven days, the pathogen is deep, making dispersion difficult, hence untreatable. Shujiao and Xionghuang are used in Yang Du to assist Yang with Yang, aiming for rapid dispersion. They are removed in Yin Du to avoid forcibly attacking Yin pathogens and damaging Yin Qi.
[Commentary by Shen Jin'ao] Yin Du is not Yin-Cold, but rather Yin Blood congealing due to cold, thus forming Yin Du. Later generations misunderstood its meaning, viewing it as direct invasion of Yin-Cold transforming into Yin Du, and proposed formulas like Pilei San and Zhengyang Dan. (Note: Commentaries by Xu Lingtai and Cheng Zhi hold similar views.) These individuals have not entered the gate of Zhang Zhongjing's scholarship. Only Wang Andao of the Yuan Dynasty correctly辨析 (analyzed) that it is not direct Yin-Cold invasion (*Suhui Ji*). His words were straightforward and principles correct, though he mistakenly claimed that heaven and earth's evil toxic qi were confused, leaving later generations at a loss. (Note: *Jin Jian* based on Wang's statement claims Yin/Yang Du are what modern people call Sha Syndrome. Removing Realgar and Sichuan Pepper for Yin Du must be a transcription error. Thus, treatment should ignore Yin/Yang distinctions, focusing on bleeding from acupoints Chize, Weizhong, and finger veins. Mild cases use scraping therapy followed by Zijin Ding. This view is unacceptable.)
Shengma Biejia Tang Formula
Shengma (Cimicifugae Rhizoma) (2 Liang) Danggui (Angelicae Radix Sinensis) (1 Liang) Shujiao (Sichuan Pepper, stir-fried to remove sweat, 1 Liang) Gancao (Licorice Root) (2 Liang) Biejia (Trionycis Carapax) (one piece the size of a finger, roasted) Xionghuang (Realgar) (0.5 Liang, ground)
The above six ingredients are boiled in 4 Sheng of water to obtain 1 Sheng. Take all at once. Elderly and children take another dose to induce sweating.
[Original Note] *Zhou Hou Bei Ji Fang* and *Qianjin Fang*: Yang Du uses Shengma Tang without Biejia but with Guizhi; Yin Du uses Gancao Tang without Xionghuang. ○ Note: 4 Sheng in *Zhou Hou* is 5 Sheng; 1 Sheng in *Yu Han* is 2 Sheng, which seems more plausible.
*Lantai Gui Fan* notes: Shujiao is acrid-hot; used in Yang Du but removed in Yin Du, suggesting an error. *Huo Ren Shu* adds Xijiao (Rhinoceros Horn - now substituted with Buffalo Horn) and four other ingredients, which is quite appropriate.
Dong Shi's *Yiji* states: This decoction treats both Yang and Yin Du. Yang Du uses this formula; Yin Du uses this formula minus Xionghuang and doubled Chuanjiao (Sichuan Pepper). Since Yin Du does not spit pus/blood, Xionghuang is removed; since Yin excess leads to Yang deficiency, Chuanjiao is doubled. Generally, years of excessive Yang feature more Yang Du; years of flowing abundance feature more Yin Du. However, whenever encountering these conditions, applying standard treatments yields no success. Most regard them as incurable. Yuan Yunlong, a centenarian, stated: Carefully examining these two conditions, both feature "sore throat." In surgical texts, Lock-Throat Wind, Entangling-Throat Wind, and Iron Moth Entanglement present similarly: red faces like spots, grimacing blue-black faces, spitting pus/blood, body pain like beatings, shortness of breath, delirium, and irritability. The suffering centers on throat obstruction. Once developed, if not improving within 3-5 days, there is no hope. Are these not akin to Yang/Yin Du? Examining pulses: slow and large indicates survival; fine and rapid indicates death. I treated these two conditions using phlegm-resolving formulas for throat diseases, saving many lives.
Note: Chao Yuanfang's *Zhubing Yuanhou Lun* states: To distinguish Yin/Yang Du, check fingers/toes upon onset. Cold indicates Yin; warm indicates Yang. Also: Yang Du features red face or bloody/purulent stool; Yin Du features blue face and cold body. Red macules: 1 survives out of 10; Black macules: 9 die out of 10. *Qianjin Fang* also states: Yang Du involves delirium, running, hallucinations, hematemesis, diarrhea, with floating-large-rapid pulses. Yin Du involves shortness of breath, vomiting, cyanotic lips/black face, cold limbs, with sinking-fine-tight-rapid pulses. Thus, Yang Du requires *Huo Ren Shu*'s Yang Du Shengma Tang or Huaban Tang (later known as Yang Ban). Yin Du requires Pang Shi's Fuzi Yin, Pilei San, or Zhengyang Dan (later known as Yin Ban). Using only Shengma Biejia Tang for both is questionable. Dong Shi's claim of zero efficacy seems valid.