病患脉已解。而日暮微烦。以病新瘥。人强与谷。脾胃气尚弱。不能消谷。故令微烦。损谷则愈。
病患脉已解。是邪气衰去矣。而日暮犹微觉烦闷者。何也。以邪气初解。为病之新瘥。脾胃气尚虚弱。
则胃未能消。脾不能运。人强与谷。谷不能消。故至申酉阳明旺时。胃中之谷气郁蒸而烦也。若日将暮
时而发热。则是胃中停谷不化。已成日晡潮热。乃阳明胃实之证。即当以下法解之矣。此不过病后新虚。
胃不胜谷。谷气稍重耳。故其烦亦微也。
不须药物。但节损其谷。则自愈矣。
伤寒瘥以后。更发热者。小柴胡汤主之。脉浮者。以汗解之。脉沉实者。以下解之。
伤寒既瘥以后更发热者。若病后余气作虚热。固当以柴胡黄芩清解余热。以人参补其病后之虚。而以
姜枣和之。若复感外邪而发热。亦属病后新虚。理宜和解。但察其脉证之有类于半表半里之少阳者。以小
柴胡汤主之。若脉浮则邪盛于表。必有可汗之表证。仍当以汗解之。但病后新虚。不宜用麻黄过汗。使伤卫亡阳。
若脉沉实者。沉为在里。实则胃实。仍当用下法解之。但卫气已虚。不宜用承气峻下。宜消息其虚实。或
小承气。或调胃。或如博棋子之法。
随其轻重以为进止可也。
大病瘥后。从腰以下有水气者。牡蛎泽泻散主之。
大病后。若气虚则头面皆浮。脾虚则胸腹胀满。此因大病之后。下焦之气化失常。湿热壅滞。膀胱不泻。
水性下流。故但从腰以下水气壅积。膝胫足跗皆肿重也。以未犯中上二焦。中气未虚。为有余之邪。
脉必沉数有力。故但用排决之法。而以牡蛎泽泻散主之。
牡蛎泽泻散方
牡蛎 泽泻 栝蒌根 蜀漆（洗去腥） 苦葶苈 商陆根 海藻（洗去咸以上各等分）
上七味。异捣下。筛为散。更入臼中治之。白饮和服方寸匕。小便利。止后服。日三服。
牡蛎咸而走肾。得柴胡方能去胁下硬。同渗利则下走水道。泽泻利水入肾。泻膀胱之火。为渗湿之要
药。栝蒌根。解烦渴而行津液。导肿气。蜀漆乃常山苗也。二者功用相同。水在上焦。则能吐水。在胁下。
则能破其 。为驱痰逐水必用之药。苦葶苈泄气导肿。十剂云。泄可去闭。葶苈大黄之属。故能去十种水气。
下膀胱水。去通身肿胀。疗肺壅喘咳。但有甜苦二种。苦者能导肿泄水。甜者但能清泻肺邪而已。丹溪谓其杀
人甚健。李时珍云。肺中水气 满喘急者。非此不除。肺平水去则止。何至久服杀人。此千古之明辨也。
商陆苦寒。沉而降。其性下行。专于行水。治肿满小便不
利。赤者同麝香捣烂贴脐。白者入药无毒。海藻咸能润下。寒能泄热引水。故能消瘿瘤结核。除浮肿香港脚。
留饮湿热。使邪气自小便出也。立方之义。盖以肾为主水之脏。肺为水之化源。故内经水热穴论云。其本
在肾。其末在肺。皆积水也。又曰。肾者。胃之关也。关门不利。故聚水而从其类。上下溢于皮肤。故
为肿。聚水而生病也。
辨误 成注引金匮腰以下肿。当利小便。与牡蛎泽泻散。不知金匮原云诸有水者。腰以下肿。当利小
便。腰以上肿。当发汗乃愈。此仲景活法也。金匮治水气利小便之法。如五苓散。猪苓汤。栝蒌瞿麦丸。
蒲灰散。滑石白鱼散。肾气丸。种种各异。盖以寒热不同也。尚论遂以此方为定法。乃谓大病后脾土告困。
不能摄水。致水气泛溢。而用牡蛎泽泻散峻攻。何反罔顾其虚。可见活人之事。迂疏辈必不能动中机宜。
庸工遇大病后。悉行温补。自以为善。熟知其卤莽灭裂哉。愚窃谓水气在腰以下。乃水性下流。未为泛溢。
腹未胀满。脾胃亦未损伤。仲景但用牡蛎泽泻散以决水者。盖湿热下流。有余之证耳。非脾胃虚衰。土崩水
泛也。原文中虽有证无脉。似无从考其证之寒热。然据方论证。当自晓然其为湿热在下矣。倘必概以温补
为庸工卤莽之治。设遇病后虚寒。土不制水。下焦无火。气化不行。水湿肿胀者。然则仲景之五苓散。
肾气丸等方。岂亦为卤莽灭裂哉。不然。下文大病瘥后喜唾。胃中有寒者。以理中丸温之。则如之何。恐一
言之蔽。贻误后人。所以不得不辨也。
患者脉象已平和，但傍晚时分出现轻微烦闷。这是因为病刚痊愈，人们强行给病人进食，而脾胃之气尚虚弱，不能消化食物，所以导致轻微烦闷。只要减少饮食量，病就会好。
患者脉象已平和，说明邪气已经衰退。但傍晚时仍觉得轻微烦闷，为什么呢？因为邪气刚刚解除，是疾病初愈的状态，脾胃之气依然虚弱。那么胃不能消化，脾不能运化，人们强行给予谷物，谷物无法消化。因此到了申时、酉时（阳明经旺盛的时段），胃中的谷气郁结蒸腾而产生烦闷。如果临近傍晚时出现发热，那就是胃中停滞的谷物不消化，已经形成了日晡潮热，这是阳明胃实证的证候，就应当用下法来解除它。这不过是病后新虚，胃不胜任谷物，谷气稍重罢了。所以他的烦闷也是轻微的。
不需要药物，只要节制减少饮食，病就会自愈。
伤寒病痊愈后，再次发热的，用小柴胡汤主治。脉浮的，用发汗法解除；脉沉实的，用泻下法解除。
伤寒既已痊愈后又再次发热的，如果是病后余气导致的虚热，固然应当用柴胡、黄芩清解余热，用人参补益病后的虚弱，并用生姜、大枣调和。如果是又感受外邪而发热，也属于病后新虚，按理应当和解。但只要观察其脉证有类似半表半里少阳病的，就用小柴胡汤主治。如果脉浮，则邪气盛于体表，一定有可发汗的表证，仍然应当用发汗法解除。但病后新虚，不宜用麻黄过度发汗，以免损伤卫气、亡失阳气。如果脉沉实，沉主在里，实则胃实，仍然应当用下法解除。但卫气已经虚弱，不宜用承气汤类峻猛攻下，应当斟酌虚实情况，或者用小承气汤，或者用调胃承气汤，或者像博戏棋子那样，根据病情的轻重来决定用药的进退。
大病之后，如果气虚，则头面部都会浮肿；脾虚，则胸腹胀满。这是因为大病之后，下焦的气化功能失常，湿热壅滞，膀胱排泄不利，水性向下流动，所以仅从腰部以下水气壅积，膝盖、小腿和足背都肿胀沉重。因为未侵犯中上二焦，中气未虚，属于有余之邪，脉象必定沉数有力，所以只用排决水湿的方法，以牡蛎泽泻散主治。
牡蛎泽泻散方
牡蛎、泽泻、栝蒌根、蜀漆（洗去腥味）、苦葶苈、商陆根、海藻（洗去咸味，以上各等分）
以上七味药，分别捣碎过筛成散剂，再放入臼中研磨均匀。用白米汤送服一方寸匕，小便通利后，停服后面的药。每日服用三次。
牡蛎味咸，走肾经，得到柴胡才能去除胁下的硬结，配合渗利药则下行水道。泽泻利水入肾，泻膀胱之火，是渗湿的重要药物。栝蒌根，能解烦渴并运行津液，引导肿气消散。蜀漆是常山的苗，这两者功效相同。水在上焦，则能催吐出水；在胁下，则能破除痰结，是驱除痰饮、逐水的必用药物。苦葶苈泄气导肿，《十剂》说：泄可去闭，葶苈、大黄之类，所以能去除十种水气，下膀胱之水，去除全身肿胀，治疗肺壅喘咳。但有甜、苦两种，苦者能导肿泄水，甜者只能清泻肺邪而已。朱丹溪说它杀人很厉害，李时珍说：肺中水气胀满喘急的，不用此药不能消除，肺气平复、水气去除后就停药，怎么会久服杀人呢？这是千古以来的明辨。商陆苦寒，沉降下行，其性下行，专门行水，治疗肿胀满闷、小便不利。红色的同麝香捣烂贴脐部，白色的入药无毒。海藻味咸能润下，寒能泄热引水，所以能消瘿瘤结核，去除浮肿、脚气，留饮湿热，使邪气从小便排出。立方的意义，大概以肾为主水之脏，肺为水之化源，所以《内经·水热穴论》说：其本在肾，其末在肺，都是积水。又说：肾是胃的关口，关门不利，所以聚水而从其同类，上下溢于皮肤，所以成为肿胀，聚水而生病。
辨误 成无己注解说引用《金匮要略》腰以下肿，当利小便，与牡蛎泽泻散。不知道《金匮要略》原文说诸有水者，腰以下肿，当利小便；腰以上肿，当发汗乃愈。这是张仲景的活法。《金匮要略》治水气利小便的方法，如五苓散、猪苓汤、栝蒌瞿麦丸、蒲灰散、滑石白鱼散、肾气丸等，种种各异，是因为寒热不同。尚论派遂以此方为定法，却说大病后脾土困乏，不能摄水，致水气泛溢，而用牡蛎泽泻散峻猛攻下，为何反而不顾病人的虚弱？可见救人的事，迂腐疏漏之辈一定不能动中机宜。庸医遇到大病后，全部使用温补，自以为善，哪里知道他们的鲁莽灭裂呢？我私下认为水气在腰以下，是水性的向下流动，并未泛溢，腹部没有胀满，脾胃也没有损伤，张仲景只用牡蛎泽泻散来决水，大概是湿热下流，属于有余之证罢了。并非脾胃虚衰，土崩水泛。原文中虽然有证候描述但没有脉象，似乎无从考证证候的寒热，然而根据方剂论证，自然明白其为湿热在下。如果一定要一概以温补作为庸医鲁莽的治疗，假设遇到病后虚寒，土不制水，下焦无火，气化不行，水湿肿胀的情况，那么张仲景的五苓散、肾气丸等方，难道也是鲁莽灭裂吗？不然，下文大病痊愈后喜欢唾沫，胃中有寒的，用理中丸温补，那又怎么说呢？恐怕一句话的蔽障，贻误后人，所以不得不辨析清楚。
The patient's pulse has resolved (become normal), yet there is slight vexation in the evening. This is because the disease has just healed, and people force-feed them; the Qi of the Spleen and Stomach is still weak and cannot digest food, thus causing slight vexation. Reducing food intake will lead to recovery.
The fact that the patient's pulse has resolved indicates that the pathogenic factors have declined. Why is there still a feeling of slight vexation in the evening? Because the pathogenic factors have just resolved, marking the state of recent convalescence from illness; the Qi of the Spleen and Stomach remains weak. Consequently, the Stomach fails to digest, and the Spleen fails to transport. When people force-feed grains, the grains cannot be digested. Therefore, during the hours of Shen and You (when the Yangming channel is prosperous), the grain Qi in the Stomach becomes stagnant and steaming, generating vexation. If fever occurs as evening approaches, this indicates that the stagnant grain in the Stomach has not transformed, having already formed tidal fever at dusk (Ribang Chaore), which is a syndrome of Yangming Stomach excess. In such cases, purgative methods should be used to resolve it. This situation merely reflects new deficiency after illness, where the Stomach cannot handle the grain load, and the grain Qi is slightly heavy. Hence, the vexation is also slight.
Medication is unnecessary; simply regulating and reducing food intake will result in spontaneous recovery.
For fever recurring after the resolution of Cold Damage (Shanghan), Xiao Chai Hu Tang (Minor Bupleurum Decoction) is the primary treatment. If the pulse is floating, resolve it with sweating methods; if the pulse is deep and solid, resolve it with purgative methods.
When fever recurs after the resolution of Cold Damage, if it is deficient heat caused by residual pathogenic Qi post-illness, one should naturally use Chai Hu (Bupleuri Radix) and Huang Qin (Scutellariae Radix) to clear residual heat, Ren Shen (Ginseng Radix) to tonify post-illness deficiency, and Jiang (Zingiberis Rhizoma) and Zao (Jujubae Fructus) to harmonize. If the fever is due to re-contracting external pathogens, it also belongs to new deficiency post-illness, and harmonizing is theoretically appropriate. However, if the pulse and symptoms resemble those of Shaoyang (Lesser Yang) at the half-exterior and half-interior level, Xiao Chai Hu Tang (Minor Bupleurum Decoction) should be administered. If the pulse is floating, the pathogen is abundant at the exterior, and there must be exterior signs amenable to sweating; thus, sweating methods should still be employed. Yet, due to new deficiency post-illness, Ma Huang (Ephedrae Herba) should not be used for excessive sweating, to avoid damaging Wei Qi (Defensive Qi) and losing Yang Qi. If the pulse is deep and solid, deep indicates interior involvement, and solid indicates Stomach excess; thus, purgative methods should still be used. However, since Wei Qi (Defensive Qi) is already deficient, harsh purgatives like Cheng Qi Tangs (Pulse-Tonifying Decoctions) are inappropriate. One must weigh the deficiency and excess, possibly using Xiao Cheng Qi Tang (Minor Pulse-Tonifying Decoction), Tiao Wei Cheng Qi Tang (Regulate the Stomach Pulse-Tonifying Decoction), or adjusting dosage incrementally based on severity, much like playing chess.
For edema (water qi) below the waist after a major illness has resolved, Mu Li Ze Xie San (Oyster and Alisma Powder) is the primary treatment.
After a major illness, if Qi is deficient, the head and face will all swell; if the Spleen is deficient, the chest and abdomen will feel full and distended. This occurs because after a major illness, the Qi transformation in the Lower Jiao (Lower Burner) becomes abnormal, leading to stagnation of damp-heat and failure of the Bladder to excrete. Since water flows downward, water qi accumulates only below the waist, causing swelling and heaviness in the knees, shins, and dorsum of the feet. Because the Middle and Upper Jiaos are not involved and Zhong Qi (Middle Qi) is not deficient, this is an excess pathogen. The pulse must be deep, rapid, and forceful. Therefore, only draining and resolving methods are used, with Mu Li Ze Xie San (Oyster and Alisma Powder) as the primary treatment.
Formula: Mu Li Ze Xie San (Oyster and Alisma Powder)
Mu Li (Ostreae Concha), Ze Xie (Alismatis Rhizoma), Gua Lou Gen (Trichosanthis Radix), Shu Qi (Perillae Caulis, washed to remove fishy odor), Ku Ting Li (Semen Lepidii et Descurainiae), Shang Lu Gen (Phytolaccae Radix), Hai Zao (Sargassum, washed to remove saltiness). All ingredients are in equal proportions.
Crush the seven ingredients separately, sieve into powder, then grind further in a mortar. Mix with white rice decoction and administer one cun bi (square-inch measure) per dose. Stop subsequent doses once urination becomes smooth. Administer three times daily.
Mu Li (Ostreae Concha) is salty and enters the Kidney channel. Combined with Chai Hu (Bupleuri Radix), it removes hardness in the hypochondrium; combined with diuretics, it directs flow downward through the water passages. Ze Xie (Alismatis Rhizoma) promotes urination entering the Kidney and drains fire from the Bladder, serving as a key herb for leaching out dampness. Gua Lou Gen (Trichosanthis Radix) relieves vexation and thirst while promoting fluid circulation and guiding away swelling qi. Shu Qi (Perillae Caulis) is the sprout of Chang Shan (Dichroae Radix); both have similar functions. If water is in the Upper Jiao, it induces vomiting of water; if in the hypochondrium, it breaks phlegm accumulation. It is an essential herb for expelling phlegm and driving out water. Ku Ting Li (Semen Lepidii et Descurainiae) drains Qi and guides away swelling. The *Ten Categories* states: "Draining can remove closure," referring to herbs like Ting Li (Semen Lepidii et Descurainiae) and Da Huang (Rhei Radix et Rhizoma), thus capable of removing ten types of water qi, draining water from the Bladder, eliminating whole-body swelling, and treating Lung congestion with wheezing and cough. There are sweet and bitter varieties; the bitter type guides swelling and drains water, while the sweet type only clears Lung pathogens. Zhu Danxi claimed it kills people vigorously. Li Shizhen stated: For wheezing and urgency caused by water qi filling the Lungs, nothing else removes it except this herb. Once Lung Qi calms and water qi leaves, discontinue use. How could long-term administration kill? This is a clear distinction throughout history. Shang Lu (Phytolaccae Radix) is bitter and cold, sinking and descending, with a downward nature, specifically for moving water, treating swelling, fullness, and difficult urination. The red variety is crushed with She Xiang (Moschus) and applied to the navel; the white variety is non-toxic when taken internally. Hai Zao (Sargassum) is salty, moistening and descending, and cold, clearing heat and drawing out water; thus, it eliminates goiter, scrofula, edema, and beriberi, retaining damp-heat drinking fluids, allowing pathogens to exit via urine. The rationale of this formula focuses on the Kidney as the organ governing water and the Lung as the source of water transformation. Thus, the *Neijing · Shui Re Xue Lun* states: "Its root is in the Kidney, its branch is in the Lung; both involve accumulated water." It also says: "The Kidney is the gate of the Stomach." If the gate is not open, water gathers following its kind, overflowing above and below onto the skin, resulting in swelling and disease caused by accumulated water.
Correction of Misunderstandings: Cheng Wuji’s commentary cites *Jin Gui Yao Lue* stating that swelling below the waist requires promoting urination, linking it to Mu Li Ze Xie San (Oyster and Alisma Powder). He fails to realize that the original text of *Jin Gui Yao Lue* states: "For all cases with water retention, swelling below the waist requires promoting urination; swelling above the waist requires inducing sweating for cure." This is Zhang Zhongjing’s flexible method. Methods for promoting urination to treat water qi in *Jin Gui Yao Lue*, such as Wu Ling San (Five-Ling Powder), Zhu Ling Tang (Polyporus Decoction), Gua Lou Qu Mai Wan (Trichosanthes and Mahonia Pill), Pu Hui San (Cattail Seed Powder), Hua Shi Bai Yu San (Talc and White Fish Powder), and Shen Qi Wan (Kidney Qi Pill), vary greatly due to differences in cold and heat patterns. The Shanglun school treated this formula as a fixed rule, claiming that after a major illness, Spleen Earth is exhausted and cannot control water, causing water qi to overflow, and thus using Mu Li Ze Xie San (Oyster and Alisma Powder) for harsh attack. How could they disregard the deficiency? Clearly, those who are pedantic and negligent cannot grasp the opportune moment in saving lives. Quacks, encountering post-major illness conditions, uniformly apply warming and tonifying methods, considering themselves virtuous, unaware of their own recklessness and destruction. I privately believe that water qi below the waist represents water flowing downward, not overflowing; the abdomen is not full, and the Spleen and Stomach are not damaged. Zhang Zhongjing uses Mu Li Ze Xie San (Oyster and Alisma Powder) to drain water because it is likely damp-heat flowing downward, an excess pattern, not Spleen-Stomach deficiency collapse with water flooding. Although the original text describes symptoms without pulses, seemingly making it impossible to verify cold/heat, analyzing the formula against the symptoms clearly reveals damp-heat in the lower part. If one insists on uniformly applying warming and tonifying as the quackish reckless treatment, suppose one encounters post-illness deficiency-cold, where Earth fails to control Water, Lower Jiao lacks fire, Qi transformation fails, and water-dampness causes swelling. Would Zhang Zhongjing’s Wu Ling San (Five-Ling Powder) and Shen Qi Wan (Kidney Qi Pill) also be considered reckless? Otherwise, regarding the next section: after a major illness resolves, if the patient loves to spit saliva due to Cold in the Stomach, Li Zhong Wan (Center-Regulating Pill) is used to warm. What then? A single statement might obscure the truth and mislead future generations, so clarification is necessary.