上上三味。等分各别捣为散。以水一升半。先煮大枣肥者十枚。取八合。去滓。内药末。强人服一钱匕。羸
人服半钱。温服之。平旦服。若下少病不除者。明日更服。加半钱得快下利后。糜粥自养。
李时珍云。仲景治伤寒。盖以小青龙治未发散之表邪。使水气自毛窍而出。乃内经所谓开鬼门法也。十枣汤驱逐
里邪。使水气自大小便而泄。乃内经所谓洁净府。去陈 法也。五饮之中。水湿之流于肠胃者为痰饮。令人腹鸣吐
水。胸胁支满。或作泄泻。芫花大戟甘遂之性。逐水泄湿。能直达水饮窠囊隐僻之处。可徐徐用之。取效甚捷。余参考
方书。如控涎丹小胃丹舟车神 丸等法。虽后贤变通之法。然皆本之于此。夫芫花辛温而有小毒。能治水饮痰
胁下痛。大戟苦寒而有小毒。能泄脏腑之水湿。甘遂苦寒有毒。而能行经隧之水湿。盖因三者性未驯良。气质峻悍。
用之可泄真气。故以大枣之甘和滞缓。以柔其性气。裹其锋芒。然亦强者不过服一钱匕。羸者减至半钱而已。又以
肥枣十枚。煮汁八合和之。若服之而下少病未除者。又必至明日。方可更服。仲景制方之妙。可谓临深履薄。惴惴焉
矣。而近世医师。犹绝不用之。即遇其证。及见此方。读之未终。无不惶骇却走。啮指吐舌而已。其所长者。不过隐忍
姑
息。以示慎重。唯坐观成败。听其自为进退。以图侥幸。成则妄自居功。败则委之命数而已。岂知佳兵虽不祥之器。然
禁暴除乱。非此不可。苟欲戡祸乱而致太平者。其可少乎哉。仲景处方。以柔制刚。以宽济猛。其控御之法。
如无抚绥之众。纪律之兵。以之治实。又何虞焉。况大枣之用。其韬锋敛锷。不啻虎皮包倒载之戈。笏冕脱虎
贲之剑矣。易曰。以此毒天下而民从之。其斯之谓欤。
太阳病。外症未除而数下之。遂协热而利。利下不止。心下痞硬。表里不解者。桂枝人参汤主之。
解见上编误下条中。因是心下痞硬。故附录于此。以便简阅。
太阳病。医发汗。遂发热恶寒。因复下之。心下痞。表里俱虚。阴阳气并竭。无阳则阴独。复加烧针。
因胸烦面色青黄。肤 者难治。今色微黄。手足温者易愈。
太阳中风。已自头项强痛。发热恶寒而汗出矣。医不知而发其汗。发汗者。非误用麻黄汤。即犯如水流漓之戒。
病遂不除而发热恶寒。医又以为邪气不解而复下之。致邪气乘虚入里而痞塞于心下。因汗下两误。而表里俱虚矣。误
汗则卫外之真阳已亡。误下则内守之真阴亦竭。故曰阴阳气并竭。既曰阴阳气并竭。而又曰无阳则阴独者。何也。
前所谓并竭之阴阳。乃人身之真气也。此所谓无阳者。指胃中之阳气空虚也。阴独者。谓唯有阴邪痞塞于中也。言
误下之后。胃中阳气空虚。独有阴气痞塞也。医又不知而复烧针以逼其汗。火气外入而内攻。虚阳浮散而欲绝。故
胸烦也。阳气既无。阴邪独盛。所以青黄之色现于面也。肤 。肌肤跳动也。即前误汗亡阳身 动。振振欲擗地之
也。肤肉 动。青黄之色并见。阳气败竭。死之象也。素问五脏生成篇云。色见青如草兹者死。黄如枳黄者死。故曰难
治。色微黄者。不见阴寒败死之青色。但有微黄之色也。生成篇又云。黄如蟹腹者生也。灵枢终始篇云。阴受气于五
脏。阳受气于四末。素问阳明脉解云。四肢者。诸阳之本也。阳盛则四肢实。今手足温。则知阳气犹未败亡。
温经复阳之治。尚可施也。故曰易治。
太阳与少阳并病。头项强痛。或眩冒。时如结胸。心下痞硬者。当刺大椎第一间。肺俞肝俞。慎不可发汗。
发汗则谵语。脉弦五六日。谵语不止。当刺期门。
太阳少阳并病。心下硬。颈项强而眩者。当刺大椎肺俞肝俞。慎勿下之。
以上二条。解见并病条下。因属心下痞硬。故亦重附于此。
阳明病。心下硬满者。不可攻之。攻之利遂不止者死。利止者愈。
太阳病。寸缓关浮尺弱。其人发热汗出。复恶寒不呕。但心下痞者。此以医下之也。其不下者。病患不恶
寒而渴者。此转属阳明也。小便数者。大便必硬。不更衣十日无所苦也。渴欲饮水。少少与之。但以法救
之。渴者宜五苓散。
解见阳明篇中。因亦属心下痞硬。附此以便寻览。
伤寒吐下后发汗。虚烦。脉甚微。八九日心下痞硬。胁下痛。气上冲咽喉。眩冒。经脉动惕者。久而成痿。
此条当在少阳篇中。因属心下痞硬。故亦附入此篇。言伤寒既吐且下而后发其汗。是汗下颠倒。邪气已陷。内外俱
虚。元阳乏竭。虚火上炎。故作虚烦而脉甚微细也。至八九日不治。阴邪得以乘胃中阳气之虚。而痞硬于心下。气滞
不得流行。故旁引胁下而痛也。气上冲咽喉而眩冒者。阳虚而阴气上逆也。灵枢经脉篇云。足少阳之脉。起于目锐
。其支者别锐 。下大迎。合于少阳。下颈合缺盆以下胸中。贯膈络肝属胆。循胁里。出气街。故病者咽干目眩。胸
胁
苦满。胁下痞硬。足厥阴之脉。交出太阴之后。过阴器。抵少腹。挟胃属肝络胆。上贯膈。布胁肋。循喉咙之后。
肝胆受邪。阴气上逆。故气冲咽喉。汗吐下后。虚阳上浮。所以目眩昏冒也。素问生气通天论云。阳气者。精则养神。
柔则养
筋。开阖不得。寒气从之。乃生大偻。陷脉为 。此以阳气散亡。无以嘘养经脉。故惕然 动。如此阴盛阳虚之证。
虽或侥幸而不至危殆。若经久不愈。必至阳虚不治。筋弛骨痿而成废疾矣。
病如桂枝证。头不痛。项不强。寸脉微浮。胸中痞硬。气上冲咽喉不得息者。此为胸有寒也。当吐之。宜瓜蒂散。
此条既非中风。亦非伤寒。当在风寒并感。及风温例中。因胸中痞硬。故亦附此。桂枝证者。乃风邪在卫。发热汗
出恶
风头项强痛者是也。以如桂枝证之发热汗出恶风。而头不痛。项不强。则知非中风证矣。然但寸脉微浮。寸脉者。气口
脉也。
即脉要精微论之上附上。右外以候肺。内以候胸中。亦即灵枢禁服篇所云。寸口主中。人迎主外之义也。谓之上附上者。
古人论脉。自下而上。犹易卦之从下而上也。盖以天地之阳气。自下而上故也。自尺以上曰附上。附上者。关脉也。寸
在关
上。故曰上附上也。言寸口之外半以候肺。内半以候胸中也。浮主风邪在表。浮脉虽微。亦发热汗出恶风也。浮主上焦。
故邪
在胸中也。然既非中风之邪入里。而胸中痞硬。上冲咽喉不得息者。以胸中有寒邪故也。胸有寒邪。则阳气不得宣通。
津液不
能流贯。致成痞硬。其气不得下达。所以逆冲咽喉而不得息也。邪在上焦。因势利导。应从上越。当用内经高者因而越
之之法。
故以瓜蒂散吐之。使邪从上越。则胸中气自和平矣。然论中吐证不
一。其吐法亦自不同。如太阳中 。神热疼重而脉微弱。此夏月伤冷水。水行皮中也。宜吐之。此亦吐胸
中之寒邪水气。使阳气通行也。又如少阳病头痛发寒热。脉紧不大。是膈上有痰也。宜吐之。此胸膈有
痰而吐之也。宿食在上脘者当吐之。此以宿食填塞而吐之也。懊 烦躁不得眠。未经汗下者。谓之实烦。
当吐之。此外邪郁闷于胸中而吐之也。病胸上诸实郁。郁而痛不能食。欲人按之而反有涎唾。下利日十余
行。寸口脉微弦者。当吐之。此胸中或痰或食。或寒积。或郁热。诸实邪在上。浊气痞塞。则下焦清阳不升。
故日下利十余行。按之而有涎唾。寸口脉弦。尤知其实在上焦矣。阴阳应象论云。清气在下。则生飧泄。
所以即从上而越之。实邪既去。清阳得以升越。所以利止也。故李东垣曰。难经云。上部有脉。下部无脉。
其人当吐。不吐者死。此饮食内伤。填塞胸中。食伤太阴。风木生发之气伏于下。宜瓜蒂散吐之。则木得
舒畅。天地交而万物通矣。至于时行疫疠。 疹温邪。初感而恶心欲呕。尤当探吐。则邪气上越而发泄矣。
但尺脉绝者。及诸亡血家不宜用耳。明理论云。栀子豉汤吐胸中虚烦客热者也。瓜蒂散吐胸中痰食宿寒者也。
由此观之。则凡诸有形无形之实邪在上而填郁胸膈者。皆可吐。非独痰饮为然也。此条寒邪在膈。阳气郁塞。
津液不流。精微不运。痰饮在所必有。奈仲景止曰寒而不曰痰。注家偏曰痰而不曰寒。不知何所证据。岂寒邪
在胸。不须吐邪。又忽另立痰病一门。我恐以虚灵变化之圆机。改而为胶柱鼓瑟之死法矣。惜哉。
瓜蒂散方
瓜蒂（一分熬黄） 赤小豆（一分）
上二味。各别捣筛。为散已。合治之。取一钱匕。以香豉一合。用热汤七合。煮作稀糜。去滓。取汁和散。温顿
服之。不吐者少少加。得快吐乃止。诸亡血虚家不可与。
取瓜蒂、赤小豆、香豉这三味药，分别单独捣碎过筛成散剂。用一升半水，先煮十枚肥大饱满的大枣，煮取八合药汁，滤去药渣。将药末加入药汁中。体质强壮的人服用一钱匕的药量，体弱的人服用半钱匕的药量。温服。早晨空腹时服用。如果服药后腹泻轻微而病邪未除，第二天再服用，增加半钱匕的剂量，直到出现顺畅的腹泻为止。之后喝稀粥来调养身体。
李时珍说：张仲景治疗伤寒，大概是用小青龙汤来发散尚未外解的表邪，使水气从毛孔排出，这正是《内经》所说的“开鬼门”（发汗）的方法。十枣汤驱逐体内的邪气，使水气从小便和大便排出，这正是《内经》所说的“洁净府”（利小便）、“去陈莝”（通大便）的方法。在五饮之中，水湿流注于肠胃之间的称为痰饮，会导致肠鸣、吐清水、胸胁支撑胀满，或者发生泄泻。芫花、大戟、甘遂的药性，能够逐水泄湿，能直达水饮积聚的隐蔽角落，可以缓慢使用，取得疗效非常迅速。我参考其他医书，如控涎丹、小胃丹、舟车神丸等方法，虽然是后世医家的变通之法，但都基于此方原理。芫花辛温而有小毒，能治疗水饮痰癖引起的胁下疼痛；大戟苦寒而有小毒，能排泄脏腑间的水湿；甘遂苦寒有毒，能通行经络隧道中的水湿。因为这三者的药性未曾驯良，气质峻猛强悍，使用它们会损伤真气，所以要用大枣的甘缓之性来调和制约，以柔化其猛烈之气，包裹住它的锋芒。然而，即使是强壮的人也不过服用一钱匕，体弱者减至半钱而已。又用十枚肥大的大枣煮出八合汁液来调和药散。如果服药后腹泻轻微而病未除，必须等到第二天，才可以再次服用。张仲景制方的精妙之处，可以说是如临深渊、如履薄冰，小心翼翼啊。而近世的医生，竟然完全不用这个方子。即使遇到相应的证候，看到这张方子，还没读完，无不惊恐害怕、退避三舍，只是咬手指、吐舌头罢了。他们所谓的谨慎，不过是隐忍姑息，以示慎重，只是坐观成败，听任病情自行进退，企图侥幸成功。成功了就妄自居功，失败了就推卸给命运。哪里知道兵器虽然是不祥之物，但要制止暴乱，非用它不可。如果想要平定祸乱达到太平，怎么能缺少它呢？张仲景处方，以柔和克制刚猛，以宽缓救济猛烈，这种控制驾驭的方法，就像安抚民众、纪律严明的军队一样，用来治疗实证，又有什么可担忧的呢？何况大枣的作用，收敛锋芒，不啻于用虎皮包裹倒置的戈矛，用礼帽遮挡持剑的卫士。《易经》说：“用这有毒的东西治理天下，百姓却顺从。”说的就是这种情况吧。
太阳病，外部症状还未解除，却多次使用攻下法，导致协热利，下利不止，心下部痞塞坚硬，表里同病不解的，用桂枝人参汤主治。（解释见上编误下条中。因为涉及心下痞硬，所以附录在此，以便简要阅读。）
太阳病，医生发汗，于是出现发热恶寒，接着又用攻下法，导致心下痞塞，表里俱虚，阴阳之气都衰竭。无阳则阴独盛。如果再加上烧针疗法，导致胸中烦闷，面色青黄，肌肤跳动的，难以治愈。现在面色微黄，手足温暖的，容易痊愈。
太阳中风证，已经出现头项强痛、发热恶寒且出汗的症状。医生不知道这些情况而再次发汗。发汗如果不是误用麻黄汤，就是犯了让汗出如水流漓的禁忌。病因此未愈而继续发热恶寒。医生又认为邪气未解而再次攻下，致使邪气乘虚入里，痞塞于心下。因为汗法和下法都误用了，导致表里俱虚。误用汗法，卫护体外的真阳已亡失；误用下法，内守的真阴也枯竭了。所以说阴阳之气都衰竭。既然说阴阳之气都衰竭，又说“无阳则阴独”，为什么呢？前面所说的并竭的阴阳，是指人身上的真气。这里所说的“无阳”，指的是胃中的阳气空虚。“阴独”，是指只有阴邪痞塞在中间。意思是误用下法之后，胃中阳气空虚，独有阴气痞塞。医生又不知道，反而用烧针逼迫出汗，火气从外侵入并向内攻伐，虚阳浮散欲绝，所以胸中烦闷。阳气既已无存，阴邪独盛，所以青色和黄色出现在面上。肤 动，即肌肤跳动，也就是前面提到的误汗亡阳导致的身体 动，振振欲倒地的那种状态。肌肤跳动，青黄之色并见，是阳气败竭的死象。《素问·五脏生成篇》说：面色青得像死草一样的死，黄得像枳实皮一样的死。所以说难治。面色微黄的，没有见到阴寒败死的青色，只有微黄的颜色。《五脏生成篇》又说：黄得像蟹腹一样的生。《灵枢·终始篇》说：阴气受于五脏，阳气受于四肢末端。《素问·阳明脉解》说：四肢是诸阳之本。阳气旺盛则四肢充实。现在手足温暖，就知道阳气还没有败亡，采用温经复阳的治疗方法还可以施行。所以说易治。
太阳与少阳并病，头项强痛，有时眩晕昏冒，有时像结胸证，心下部痞塞坚硬的，应当针刺大椎穴的第一间隙，以及肺俞、肝俞穴。千万不要发汗。发汗会导致谵语。脉弦，经过五六天，谵语不止的，应当刺期门穴。
太阳少阳并病，心下部硬满，颈项强直且眩晕的，应当针刺大椎、肺俞、肝俞穴。千万不要攻下。
以上两条，解释见并病条下。因为属于心下痞硬，所以也重新附录在此。
阳明病，心下部硬满的，不可攻下。攻下后如果下利不止的会死亡，下利停止的就会痊愈。
太阳病，寸脉缓、关脉浮、尺脉弱，其人发热出汗，又恶寒，不呕吐，只是心下痞塞的，这是医生误用攻下法造成的。如果不曾攻下，病人不恶寒而口渴的，这是转属阳明病。小便频数的，大便必定硬，即使十天不大便也没有痛苦。想喝水，少量给予，只按法治之。口渴者适宜用五苓散。（解释见阳明篇中。因为也属于心下痞硬，附在此处以便查找。）
伤寒经过吐、下、发汗治疗后，出现虚烦，脉象非常微弱。到了第八九天，心下痞塞坚硬，胁下疼痛，气向上冲咽喉，眩晕昏冒，经脉跳动不安的，时间久了会发展成痿证。
这一条应当在少阳篇中，因为属于心下痞硬，所以也附录入本篇。意思是伤寒既用了吐法又用了下法，然后再发汗，这是汗下颠倒，邪气已经陷入，内外俱虚，元阳乏竭，虚火上炎，所以产生虚烦而脉象非常微细。到了第八九天如果不治疗，阴邪得以乘胃中阳气之虚，而痞硬于心下。气机阻滞不能流行，所以牵引胁下疼痛。气向上冲咽喉而眩晕昏冒的，是阳虚而阴气上逆。《灵枢·经脉篇》说：足少阳胆经，起于目外眦，其支脉从目外眦分出，下行至大迎穴，与手少阳经会合，下行颈部，通过缺盆，进入胸中，贯穿膈肌，联络肝脏，归属胆腑，沿胁肋内部外出至气街。所以病人咽干目眩，胸胁苦满，胁下痞硬。足厥阴肝经，交出于足太阴脾经之后，过阴器，抵少腹，挟胃，归属肝脏，联络胆腑，上行贯穿膈肌，散布于胁肋，沿喉咙后方。肝胆受邪，阴气上逆，所以气冲咽喉。汗、吐、下之后，虚阳上浮，所以目眩昏冒。《素问·生气通天论》说：阳气，精微则养神，柔和则养筋。开阖失常，寒气随之而入，就会产生严重的驼背。寒气陷于脉络形成 肉。这是因为阳气散亡，无法嘘养经脉，所以惕然跳动。像这样阴盛阳虚的证候，虽然或许侥幸不至危殆，但如果经久不愈，必然导致阳虚不治，筋弛骨痿而成废疾。
病症类似桂枝汤证，但头不痛，项不强，寸脉微浮，胸中痞塞坚硬，气向上冲咽喉导致呼吸不畅的，这是胸中有寒邪。应当用吐法。适宜用瓜蒂散。
这一条既不是中风，也不是伤寒，应当在风寒并感及风温的例子中。因为胸中痞硬，所以也附在此处。桂枝证，是指风邪在卫分，发热、出汗、恶风、头项强痛的情况。以类似桂枝证的发热、出汗、恶风，但头不痛、项不强，就知道这不是中风证了。然而仅仅寸脉微浮。寸脉，即气口脉，也就是《脉要精微论》所说的“上附上”。右手外侧候肺，内侧候胸中。这也符合《灵枢·禁服篇》所说的“寸口主中，人迎主外”的意义。所谓“上附上”，古人论述脉位，自下而上，如同易经卦象从下往上一样。因为天地阳气自下而上。自尺部以上称为“附上”，“附上”指的是关脉。寸脉在关脉之上，所以叫“上附上”。意思是寸口的外侧一半候肺，内侧一半候胸中。浮脉主风邪在表，浮脉虽微，也有发热、出汗、恶风的表现。浮脉主上焦，所以邪气在胸中。但这既然不是中风之邪入里，而是胸中痞硬，气上冲咽喉不得呼吸，是因为胸中有寒邪。胸中有寒邪，阳气就不能宣通，津液不能流通，导致痞硬。气不能下达，所以逆冲咽喉而不能呼吸。邪气在上焦，因势利导，应当从上越出。应当用《内经》“高者因而越之”的方法。所以用瓜蒂散吐之，使邪气从上越出，胸中气机自然平和。然而论中吐证不一，其吐法也各不相同。如太阳中暍，身热疼重而脉微弱，这是夏季伤冷水，水行皮中也，适宜吐之。这也是吐胸中之寒邪水气，使阳气通行。又如少阳病头痛发寒热，脉紧不大，是膈上有痰，适宜吐之。这是胸膈有痰而吐之。宿食在上脘的应当吐之。这是以宿食填塞而吐之。懊恼烦躁不得眠，未经汗下的，谓之实烦，应当吐之。这是外邪郁闷于胸中而吐之。病在胸上的各种实邪郁结，郁而痛不能食，想让人按压反而有涎唾，下利每天十几次，寸口脉微弦的，应当吐之。这是胸中或痰或食，或寒积，或郁热，诸实邪在上，浊气痞塞，则下焦清阳不升，所以每天下利十几次。按压而有涎唾，寸口脉弦，尤其知道实在上焦。《阴阳应象大论》说：清气在下，则生飧泄。所以即从上而越之。实邪既去，清阳得以升越，所以利止。所以李东垣说：《难经》说，上部有脉，下部无脉，其人当吐，不吐者死。这是饮食内伤，填塞胸中，食伤太阴，风木生发之气伏于下，适宜瓜蒂散吐之，则木得舒畅，天地交而万物通矣。至于时行疫疠，疹温邪，初感而恶心欲呕，尤当探吐，则邪气上越而发泄矣。但尺脉绝者，及诸亡血家不宜用。《明理论》说：栀子豉汤吐的是胸中虚烦客热。瓜蒂散吐的是胸中痰食宿寒。由此看来，那么凡是有形无形的实邪在上而填郁胸膈的，都可以吐，不仅仅是痰饮如此。这一条寒邪在膈，阳气郁塞，津液不流，精微不运，痰饮在所必有。无奈仲景只说寒而不说痰，注家偏说痰而不说寒，不知有什么证据。难道寒邪在胸，不需要吐邪，又忽然另立痰病一门？我恐怕是以虚灵变化之圆机，改而为胶柱鼓瑟之死法了。可惜啊。
以上两味药，分别单独捣碎过筛。混合在一起制成散剂。取一钱匕药散，用香豉一合，热汤七合，煮成稀糜，滤去药渣，取汁液调和药散。温顿服。不吐的，逐渐增加剂量，直到快吐出来才停止。凡是失血者和虚损之人不可服用。
Take three ingredients: Gengti (Thladiantrae Fructus), Chixiaodou (Adzuki Bean), and Xiangchi (Prepared Soybean). Process each separately by pounding and sieving into a powder. Use one sheng and half of water. First, decoct ten large and plump Dazao (Jujube) fruits until reduced to eight ge. Strain the liquid. Add the medicinal powder to the liquid. For robust individuals, administer one qianbi (a measure roughly equivalent to 1-2 grams) orally. For frail individuals, administer half a qianbi. Take warm on an empty stomach in the morning. If the diarrhea is slight and the disease persists, take again the next day, increasing the dose by half a qianbi, until a smooth and effective purgation occurs. Afterwards, nourish the body with millet porridge.
Li Shizhen stated: Zhang Zhongjing's treatment of Shanghan (Cold Damage) generally employs Xiao Qinglong Tang (Minor Blue Dragon Decoction) to disperse exterior pathogens that have not yet been resolved externally, allowing fluid retention to exit through the hair pores. This corresponds to the Neijing's method of "opening the ghost gate" (diaphoresis). The Shizao Tang (Ten Jujube Decoction) drives out interior pathogens, allowing fluid retention to be excreted via urination and defecation. This corresponds to the Neijing's methods of "cleansing the bladder" (promoting diuresis) and "removing old accumulation" (promoting bowel movement). Among the five types of fluid retention, when water-dampness flows into the intestines and stomach, it is called Tanyin (Phlegm-fluid). It causes borborygmus, vomiting of clear fluids, distension and fullness in the chest and hypochondrium, or diarrhea. The properties of Yuanhua (Genkwa Flos), Daji (Euphorbiae Pekinensis Radix), and Gansui (Kansui Radix) are to purge water and drain dampness, reaching the hidden pockets where fluid retention accumulates. They can be used gradually for rapid efficacy. I have consulted other medical texts regarding formulas such as Kongxian Dan (Control Phlegm Pill), Xiaowei Dan (Small Stomach Pill), and Zhouche Shenwan (Boat Divine Pill). Although these represent flexible adaptations by later physicians, they are all based on this principle. Yuanhua is acrid and warm with slight toxicity; it treats pain under the ribs caused by fluid retention and phlegm-pi. Daji is bitter and cold with slight toxicity; it drains water-dampness from the zang-fu organs. Gansui is bitter, cold, and toxic; it promotes the flow of water-dampness through the meridians and collaterals. Because the nature of these three herbs is untamed and their temperament is harsh and fierce, using them can damage true qi. Therefore, the sweetness of Dazao (Jujube) is used to harmonize and slow down the process, softening their harsh nature and sheathing their sharp edges. However, even for robust individuals, the dose does not exceed one qianbi, and for frail individuals, it is reduced to half a qianbi. Furthermore, ten large jujubes are decocted to yield eight ge of juice to mix with the powder. If the purgation is slight and the disease remains after administration, one must wait until the next day before administering again. The subtlety of Zhang Zhongjing's prescription formulation can be described as treading on thin ice and standing at the edge of an abyss, acting with extreme caution. Yet, modern physicians almost never use this formula. Even when encountering the corresponding syndrome and seeing this prescription, upon reading it incompletely, they are filled with panic and fear, retreating in alarm, biting their fingers and sticking out their tongues. Their so-called prudence is merely forbearance and indulgence, displayed to appear cautious. They simply sit and watch success or failure, letting the condition advance or retreat on its own, hoping for luck. If successful, they claim credit falsely; if failed, they blame fate. How could they know that although weapons are instruments of ill omen, they are indispensable for stopping violence and disorder. If one wishes to quell chaos and achieve peace, how can one do without them? Zhang Zhongjing's prescriptions use gentleness to control rigidity, and leniency to supplement ferocity. This method of control is like managing unruly masses or disciplining troops. When treating excess syndromes, what is there to fear? Moreover, the function of Dazao (Jujube) in sheathing its锋芒 (sharpness) is no different than wrapping a reversed halberd in tiger skin or hiding a sword carried by a tiger-guard behind a ceremonial hat. The I Ching says, "Using this poisonous substance to govern the world, the people follow." This is precisely what is meant.
In Taiyang disease, if external symptoms persist but multiple purgations are performed, it leads to Xiere Li (Diarrhea with accompanying heat), with unceasing diarrhea, Piying (fullness and hardness) in the epigastrium, and unresolved exterior and interior conditions. Guizhi Renshen Tang (Cinnamon Twig and Ginseng Decoction) is the primary treatment. (Explanation found in the section on erroneous purgation in the previous volume. Included here due to the presence of epigastric fullness and hardness for easy reference.)
In Taiyang disease, if the physician induces sweating, followed by fever and aversion to cold, and then subsequently performs purgation, it results in Pi (fullness/stuffiness) in the epigastrium. Both the exterior and interior become deficient, and both Yin and Yang Qi are exhausted. "No Yang implies Yin stands alone." If moxibustion (burning needle) is added, causing chest irritability, greenish-yellow complexion, and muscle twitching, the condition is difficult to treat. If the complexion is slightly yellow and the hands and feet are warm, recovery is easy.
In Taiyang Wind Strike syndrome, if there is already stiffness and pain in the head and neck, fever, aversion to cold, and sweating, and the physician, unaware of this, induces sweating again. Inducing sweating either involves the erroneous use of Mahuang Tang (Ephedra Decoction) or violates the prohibition against profuse sweating like flowing water. The disease persists with fever and aversion to cold. The physician, believing the pathogen remains, performs purgation again. This allows the pathogen to enter the interior due to deficiency, causing Pi (stuffiness) in the epigastrium. Due to the double error of sweating and purging, both exterior and interior are deficient. Erroneous sweating destroys the True Yang that guards the exterior; erroneous purging exhausts the True Yin that resides within. Thus, it is said that both Yin and Yang Qi are exhausted. Since it is stated that both Yin and Yang Qi are exhausted, why is it also said that "No Yang implies Yin stands alone"? The Yin and Yang mentioned as exhausted earlier refer to the True Qi of the human body. Here, "No Yang" refers to the emptiness of Yang Qi in the Stomach. "Yin stands alone" means only Yin pathogen is obstructing the center. It indicates that after erroneous purging, the Stomach's Yang Qi is empty, leaving only Yin Qi to cause obstruction. If the physician, ignorant of this, uses burning needles to force sweating, the fire energy enters from outside and attacks inward. The deficient Yang floats and scatters, nearing extinction, causing chest irritability. With Yang absent and Yin pathogen dominant, greenish-yellow colors appear on the face. "Skin twitching" refers to muscle tremors, similar to the body tremors and desire to fall seen in previous cases of Yang loss due to erroneous sweating. Muscle twitching combined with greenish-yellow complexion indicates the exhaustion of Yang Qi, a sign of death. Suwen Chapter on the Generation of the Five Zang Organs states: "Complexion blue like dead grass indicates death; yellow like dried orange peel indicates death." Hence, it is difficult to treat. A slightly yellow complexion shows no signs of Yin-cold death, only mild yellow. The same chapter states: "Yellow like crab belly indicates life." Lingnu Chapter on End and Beginning states: "Yin receives Qi from the Five Zang organs; Yang receives Qi from the four extremities." Suwen Chapter on Resolving Shaoyang Meridian Pathology states: "The four limbs are the root of all Yang." When Yang is abundant, the limbs are solid. Now, with warm hands and feet, we know Yang has not yet perished. Treatment to warm the meridians and restore Yang can still be applied. Hence, it is easy to treat.
When Taiyang and Shaoyang diseases occur simultaneously (Bingbing), with stiffness and pain in the head and neck, occasional dizziness or vertigo, sometimes resembling Jiechest (Chest Binding) syndrome, and fullness/hardness in the epigastrium, one should puncture the first interspace of the Dazhui (GV14) point, along with Feishu (BL13) and Ganshu (BL18). Sweating must be strictly avoided. Sweating will lead to delirious speech (Shanyu). If the pulse is wiry and, after five to six days, delirium persists, puncture Qimen (LR14).
In Taiyang-Shaoyang Bingbing, with epigastric hardness, stiff neck, and dizziness, puncture Dazhui (GV14), Feishu (BL13), and Ganshu (BL18). Purging must be strictly avoided.
(The explanations for the above two clauses are found in the section on Bingbing. Included here again because they involve epigastric fullness and hardness.)
In Yangming disease, if there is fullness and hardness in the epigastrium, purging is contraindicated. If purging is performed and diarrhea becomes unceasing, death ensues. If diarrhea stops, recovery occurs.
In Taiyang disease, if the Cun (inch) pulse is slack, Guan (bar) pulse is floating, and Chi (cubit) pulse is weak, and the patient has fever, sweating, aversion to cold, no vomiting, but only epigastric stuffiness, this is caused by the physician's erroneous purging. If purging was not performed, and the patient is not averse to cold but feels thirsty, this indicates transformation into Yangming disease. Frequent urination implies hard stool. Even if no bowel movement occurs for ten days, there is no discomfort. If thirst arises and the patient desires water, give small amounts frequently. Treat according to the principles. For thirst, Wuling San (Five-Ling Powder) is appropriate. (Explanation found in the Yangming chapter. Included here as it also relates to epigastric fullness and hardness for ease of reference.)
After Shanghan is treated with vomiting, purging, and sweating, leading to deficiency-heat irritability and a very faint pulse, by the eighth or ninth day, if there is epigastric fullness and hardness, hypochondriac pain, Qi rushing up to the throat, dizziness/vertigo, and meridian twitching/trembling, prolonged illness may result in Wei syndrome (flaccidity/atrophy).
This clause belongs in the Shaoyang chapter but is included here due to epigastric fullness and hardness. It describes how Shanghan treated with vomiting, purging, and then sweating represents an inversion of treatment methods. The pathogen has sunk, and both interior and exterior are deficient, with depleted Yuan Yang and flaming deficiency fire, causing deficiency-irritability and a very fine/faint pulse. By the eighth or ninth day, if untreated, Yin pathogen takes advantage of the deficiency of Stomach Yang to cause epigastric fullness and hardness. Qi stagnation fails to circulate, radiating to the hypochondrium causing pain. Qi rushing to the throat with dizziness/vertigo indicates Yang deficiency with counterflow of Yin Qi. Lingnu Chapter on Meridians states: The Foot-Shaoyang Gallbladder Meridian originates at the outer canthus, branches to the Da Ying point, meets the Hand-Shaoyang, descends the neck, passes through Que Pen, enters the chest, pierces the diaphragm, connects with the Liver, and belongs to the Gallbladder, following the hypochondrium to the Qi Street. Hence, patients suffer from dry throat, dizzy eyes, chest/hypochondriac fullness, and epigastric/hypochondriac hardness. The Foot-Jueyin Liver Meridian crosses behind the Foot-Taiyin Spleen, passes the genitalia, reaches the lower abdomen, flanks the Stomach, connects with the Liver, links to the Gallbladder, ascends through the diaphragm, spreads over the hypochondrium, and follows the posterior throat. With Liver and Gallbladder affected by pathogen, Yin Qi counterflows, causing Qi rush to the throat. After sweating, vomiting, and purging, deficient Yang floats upward, causing dizziness/vertigo. Suwen Chapter on Living Heaven and Human Connection states: "Yang Qi, when refined, nourishes the Spirit; when gentle, nourishes the sinews." If opening and closing fail, Cold Qi enters, causing severe curvature. If sinking into vessels, it causes muscle twitching. Here, due to the dissipation and loss of Yang Qi, unable to nourish the meridians, trembling occurs. In such Yin-excess and Yang-deficient conditions, although survival might be lucky, if prolonged and untreated, Yang deficiency will become incurable, leading to flaccid sinews and skeletal atrophy, resulting in disability.
If the symptoms resemble Guizhi Tang syndrome, but there is no headache or neck stiffness, and the Cun pulse is slightly floating, with epigastric fullness/hardness and Qi rushing to the throat causing breathing difficulty, this indicates Han (cold/pathogenic factor) in the Chest. Vomiting therapy should be employed. Gudi San (Melon Seed Powder) is suitable.
This clause is neither Wind Strike nor Cold Damage; it belongs to cases of simultaneous Wind-Cold or Wind-Warmth. Included here due to epigastric fullness. Guizhi syndrome refers to Wind pathogen in the Wei (Defensive) level, characterized by fever, sweating, aversion to wind, and head/neck stiffness. Given the fever, sweating, and aversion to wind resembling Guizhi syndrome, but without headache or neck stiffness, it is known not to be Wind Strike. However, only the Cun pulse is slightly floating. The Cun pulse, also known as the Qi Kou pulse, corresponds to the "Upper Attachment" in Ma Yao Jing Wei Lun. On the right side, the exterior reflects the Lung, and the interior reflects the Chest. This aligns with Lingnu Chapter on Forbidden Service: "Cun Kou governs the interior; Ren Ying governs the exterior." The term "Upper Attachment" refers to the ancient pulse diagnosis method from bottom to top, akin to I Ching hexagrams rising from below, reflecting celestial Yang Qi rising. From Chi upwards is called "Fu Shang" (Attached Above), referring to the Guan (Bar) pulse. Cun is above Guan, hence "Upper Attachment." The lateral half of Cun Hou reflects the Lung; the medial half reflects the Chest. Floating pulse indicates exterior Wind pathogen. Even if slightly floating, there is fever, sweating, and aversion to wind. Floating pulse governs the Upper Jiao, indicating pathogen in the Chest. Since this is not interior invasion by Wind Strike pathogen, but rather epigastric fullness and Qi rushing to the throat causing dyspnea, it is due to Cold pathogen in the Chest. Cold in the Chest prevents Yang Qi from circulating freely and Jin Ye (Body Fluids) from flowing, causing fullness and hardness. Qi cannot descend, thus counter-rushing the throat and causing dyspnea. Pathogen in the Upper Jiao should be guided by its tendency to rise. One should apply the Neijing principle: "For those high up, induce emesis." Therefore, Gudi San (Melon Seed Powder) is used to vomit, allowing pathogen to exit from above, restoring harmony in the Chest Qi. However, vomiting indications vary, and methods differ. For example, in Taiyang Zhongshu (Heat Stroke), with body heat, pain, heaviness, and faint pulse, caused by summer cold water injury, vomiting is indicated to expel Cold/Water Qi from the Chest and restore Yang circulation. For Shaoyang disease with headache, chills, fever, and tight/small pulse, indicating Phlegm above the Diaphragm, vomiting is indicated to expel Phlegm from the Chest/Diaphragm. For retained food in the Upper Wan, vomiting is indicated to expel blockage. For Ao Nan (regretful irritability) and insomnia without prior sweating/purging, termed Excess Irritability, vomiting is indicated to expel depressed exterior pathogen from the Chest. For various excesses in the upper Chest causing pain, inability to eat, desire for pressure but yielding saliva/phlegm, and frequent diarrhea (>10 times/day) with faint/wiry Cun pulse, vomiting is indicated. This suggests Phlegm, food, Cold accumulation, or Heat depression in the Chest, causing turbid Qi obstruction and preventing Clear Yang from ascending, leading to diarrhea. Pressure revealing saliva and wiry Cun pulse confirm excess in the Upper Jiao. Yinyang Yingxiang Lun states: "Clear Qi sinking generates undigested diarrhea." Thus, expelling from above restores Clear Yang ascent, stopping diarrhea. Li Dongyuan stated: Nanjing says, "Pulse present at upper, absent at lower, patient should vomit; if not, death." This applies to dietary injury blocking the Chest, damaging Taiyin, trapping Wood Qi generation below. Gudi San induces vomiting, allowing Wood Qi to flourish, facilitating Heaven-Earth interaction and universal communication. For epidemic fevers, rashes, or Warm pathogens, initial nausea/vomiting warrants induced vomiting to release pathogen upward. However, it is contraindicated if Chi pulse is absent or in patients with blood loss. Ming Lilun states: Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) vomits deficiency-heat/visitor-heat in the Chest. Gudi San vomits Phlegm, retained food, and Cold in the Chest. Thus, any有形 (material) or无形 (immaterial) excess pathogen blocking the Chest/Diaphragm can be vomited, not just Phlegm-Fluid. In this case, Cold pathogen in the Diaphragm blocks Yang, stagnates fluids, and impairs transport, inevitably producing Phlegm-Fluid. Yet Zhang Zhongjing mentions only "Cold," not "Phlegm." Commentators emphasize "Phlegm" over "Cold." What is the evidence? Does Cold in the Chest not require expelling the pathogen? Or did they suddenly establish a separate category for Phlegm disease? I fear turning the flexible wisdom of Zhang Zhongjing into rigid dogma. Regrettably.
**Gudi San Formula**
Gengti (Thladiantrae Fructus): 1 fen, roasted until yellow.
Chixiaodou (Adzuki Bean): 1 fen.
Process the two ingredients separately by pounding and sieving. Mix thoroughly to make a powder. Take one qianbi of the powder. Use Xiangchi (Prepared Soybean) 1 he, boiled in 7 ge of hot water until forming a thin paste. Strain the liquid. Mix the powder with the liquid. Take warm in one dose. If no vomiting occurs, increase the dose slightly. Stop once vigorous vomiting begins. Contraindicated for patients with blood loss or deficiency.