【纲】仲景曰。伤寒表不解。心下有水气。干呕发热而咳。或渴。或利。或噎。或小便不利少
腹满。或喘者。小青龙汤主之。伤寒心下有水气。咳而微喘。发热不渴。小青龙汤主之。服汤已渴
者。此病去欲解也。少阴病。腹痛小便不利。四肢沉重疼痛。自下利者。此为有水气。其人或咳者。真武汤加五味
子细辛干姜主之。
【目】朱震亨曰。伤寒太阳症咳嗽。小青龙、小柴胡也。大抵热在上焦。其人必饮水。水停心
下。则肺为之浮。肺主于咳。水气乘之。故咳而微喘。少阳少阴。俱有咳症。
韩祗和曰。前二条。是由停饮而咳者也。虽皆为停饮所作。而小青龙所主。为水饮与表寒相合
而咳者。真武汤所主。为水饮与里寒相合而咳者。不可不知也。夫或表寒。或里寒。协水饮则必动
肺。以形寒寒饮则伤肺故也。
肺主气。形寒饮冷则伤肺。使气上而不下。逆而不收。冲击膈咽。令喉中淫淫如痒。习习如梗。
是令咳也。甚者续而不已。连连不止。坐卧不安。语言不竟。动引百骸。声闻四近矣。
龚信曰。水气太阳寒水之气也。咳者。水气射肺也。皮毛者肺之合。表寒不解。寒水已留其合
矣。心下之水气。又上至于肺。则肺寒。内外合邪。故咳也。水气在心下。则咳为必然。喘为或然。
亦如柴胡汤症但见一症即是。不必悉具。
【纲】仲景曰。伤寒五六日。中风。往来寒热。胸胁苦满。默默不欲饮食。心烦喜呕。或胸中
烦而不呕。或渴。或腹中痛。或胁下痞硬。或心下悸。小便不利。或不渴。身有微热。或咳者。小
柴胡汤主之。少阴病。四逆。泄利下重。其人或咳。或悸。或小便不利。或腹中痛者。四逆散主之。
【目】赵嗣真曰。此二条。是邪气自表传里而咳者也。虽皆为邪气传里。而小柴胡所主。为阳
邪传里动肺而咳。四逆散所主。为阴邪传里动肺而咳。又不可不识也。夫或阳邪。或阴邪。自表传
里。则必动肺。以脏真高于肺故也。停饮而咳。表邪传里而咳。固已。又有肺寒而咳者。内经曰。肺之令人咳。何也。
皮毛者。肺
之合也。皮毛先受寒气。寒气以从其合也。其寒饮食入胃。从肺脉上至于肺则肺寒。肺寒则外内合
邪。因而客之。则为咳嗽者。是肺寒而咳也。
陶华曰。咳者。謦咳。俗谓之嗽。肺主气。肺为邪所乘。气逆而不下。故令咳也。有肺寒而咳
者。有停饮而咳者。有邪在半表半里而咳者。治各不同。其水咳三症。不可不辨。小青龙治太阳之
表水也。十枣汤治太阳之里水也。真武汤治水症之水气也。盖水与表寒合。用小青龙汗之。水与里
寒合。用真武汤温之。里癖合水动肺而咳。用十枣汤下之。太阳病。身热咳嗽干呕。喘而利。小青
龙汤。恶寒身痛。只根据本方。身凉咳嗽。干呕微利。心下痞满。引胁下痛。十枣汤。四肢沉重。腹
痛下利。咳嗽或呕。真武汤。
【纲】仲景曰。咳而小便利者。不可发汗。发汗。则四肢厥逆冷。
【目】成无己曰。咳为肺疾。治之必发散方可。然必不可发汗。如本条是也。
吴绶曰。凡表寒咳嗽。脉浮恶寒。身疼拘急而无汗也。麻黄汤。或三拗汤汗之。痰唾如胶者。
金沸草散汗之。若有热者。参苏饮去木香、人参。加麻黄、桑皮、杏仁汗之。若虚弱人感冒风寒而
咳嗽有痰。或恶风头疼干呕者。人参杏仁汤。伤寒二三日传少阳经。脉弦口苦。发热而咳嗽者。小
柴胡汤去人参、姜、枣。加五味、干姜。若发热胸中烦满而咳。加炒栝蒌。若胸胁痞满发热而咳。加枳壳、桔梗。凡阴
症手足冷。脉沉细而咳嗽。四逆汤加五味。大抵伤寒咳嗽。非比杂症。按仲景治例有嗽者。不分阴阳二症。俱用五味、
干姜也。若五味收肺气而止嗽。干姜入肺经而散逆气也。凡初秋豪雨冷。及天行暴寒。其热喜伏于内。咳嗽。曲折不可
得气息。喉哑失声。干嗽。喉中如梗者。射干汤。
李中梓曰。有声无痰曰咳。有声有痰曰嗽。
朱 曰。夫咳嗽之疾一也。或曰。咳者有声而无痰。嗽者有痰而无声。又曰。咳为阳。嗽为阴。皆无考据。咳嗽非
独寒也。六气皆能为嗽焉。风嗽者。头目眩晕。痰涎不利。宜通圣散汗之。搜风丸清之。火嗽者。口燥舌干。喘逆唾血。
宜凉膈散加当归、桔梗治之。大金花丸解之。暑嗽者。面赤手冷。头有自汗。宜白虎汤除之。湿嗽者。面肿上喘。宜大
橘皮汤止之。甚者三花神 丸下之。燥嗽者。往来寒热。涕唾稠粘。宜柴胡饮子治之。寒嗽者。手足厥逆。宜宁肺散收
之。彼谬医不分六气。执以为寒。骤用枯矾、粟壳。虽老亦无悟矣。
鳌按。朱氏六气为嗽之论。乃统杂病言之。而伤寒咳嗽。其原亦有由六气者。治法固可参考。
【纲要】张仲景说：伤寒表证未解，心下有水饮停聚。出现干呕、发热且咳嗽，或口渴，或腹泻，或咽喉噎塞感，或小便不利伴少腹胀满，或气喘的，用小青龙汤主治。伤寒心下有水饮停聚，咳嗽且轻微气喘，发热但不口渴的，用小青龙汤主治。服用小青龙汤后感到口渴的，这是病邪将去、病情欲愈的表现。少阴病，腹痛、小便不利、四肢沉重疼痛、自发性腹泻的，这是体内有水气。若患者兼有咳嗽的，用真武汤加五味子、细辛、干姜主治。
【注释】朱震亨说：伤寒太阳经病症引起的咳嗽，可用小青龙汤或小柴胡汤治疗。大抵上焦有热的人必然想喝水。水饮停聚在心下，导致肺气上浮。肺主咳嗽，水气侵犯肺部，所以出现咳嗽和轻微气喘。少阳经和少阴经的病证中，都有咳嗽的症状。
韩祗和说：前两条（指小青龙汤证），是由水饮停聚引起的咳嗽。虽然都是因停饮所致，但小青龙汤主治的是水饮与表寒相结合引起的咳嗽；真武汤主治的是水饮与里寒相结合引起的咳嗽。这一点不可不知道。无论是表寒还是里寒，与水饮相合必然会扰动肺脏，因为形体受寒、饮用冷食会损伤肺脏。
肺主气，形体受寒、饮食生冷会损伤肺脏，使肺气上逆而不能下行，气机逆乱而不收敛，冲击膈膜和咽喉，导致喉咙中感觉瘙痒不适，如有异物梗塞感，这就是引起咳嗽的原因。严重的则咳嗽连续不断，连连不止，坐卧不安，说话未完，动作牵动全身，声音传到四周。
龚信说：水气即太阳寒水之气。咳嗽是水气射入肺脏所致。皮毛是肺的外合，表寒不解，寒水之气已留滞于皮毛之合。心下的水气又上达于肺，导致肺寒，内外邪气相合，所以发生咳嗽。水气在心下，咳嗽就是必然的，气喘则是可能的。这也像小柴胡汤证那样，只要见到一个相关症状即可诊断，不必所有症状都具备。
【纲要】张仲景说：伤寒五六天，或中风，出现往来寒热、胸胁部苦闷胀满、沉默不欲饮食、心烦喜呕，或者胸中烦闷但不呕吐，或者口渴，或者腹中疼痛，或者胁下痞硬，或者心悸、小便不利，或者不渴、身体微热，或者咳嗽的，用小柴胡汤主治。少阴病，四肢厥冷、泄利伴有肛门重坠感，若患者兼有咳嗽、或心悸、或小便不利、或腹中疼痛的，用四逆散主治。
【注释】赵嗣真说：这两条条文，是邪气从体表传入体内而引起的咳嗽。虽然都是邪气传里，但小柴胡汤主治的是阳邪传里扰动肺脏引起的咳嗽；四逆散主治的是阴邪传里扰动肺脏引起的咳嗽。这一点也不可不知。无论是阳邪还是阴邪，从表传里，必然会扰动肺脏，因为五脏的真气高于肺脏的缘故。
水饮停聚引起的咳嗽，表邪传里引起的咳嗽，这已经清楚了。又有因肺寒引起的咳嗽，《内经》说：肺让人咳嗽，为什么呢？皮毛是肺的外合。皮毛先受到寒气侵袭，寒气便随着其外合进入体内。如果寒冷饮食入胃，寒气沿肺脉上行至肺，则导致肺寒。肺寒则内外邪气相合，进而客居肺中，从而形成咳嗽，这就是肺寒引起的咳嗽。
陶华说：咳嗽，即清嗓子发声，俗称嗽。肺主气，肺被邪气乘袭，气机上逆不能下行，所以引起咳嗽。有因肺寒而咳的，有因停饮而咳的，有因邪在半表半里而咳的，治疗方法各不相同。其中关于水饮致咳的三种情况，不可不辨别。小青龙汤治疗太阳经表面的水气；十枣汤治疗太阳经内部的水气；真武汤治疗水气病症中的水气。大概水与表寒相合，用小青龙汤发汗解表；水与里寒相合，用真武汤温里散寒；里有癖积结合水饮扰动肺脏而咳嗽，用十枣汤攻下。太阳病，身热、咳嗽、干呕、气喘且腹泻，用小青龙汤；恶寒身痛，只依据本方（小青龙汤）；身凉、咳嗽、干呕、轻微腹泻、心下痞满、牵引胁下疼痛，用十枣汤；四肢沉重、腹痛、腹泻、咳嗽或呕吐，用真武汤。
【纲要】张仲景说：咳嗽且小便通利的，不可发汗。如果发汗，会导致四肢厥冷逆乱。
【注释】成无己说：咳嗽是肺部的疾病，治疗时必须用发散的方法才可以。然而绝对不可以发汗，就像本条所说的那样。
吴绶说：凡是表寒咳嗽，脉浮、恶寒、身疼拘急且无汗的，用麻黄汤，或者三拗汤发汗。痰唾如胶黏状的，用金沸草散发汗。若有热的，参苏饮去掉木香、人参，加入麻黄、桑白皮、杏仁发汗。若是虚弱之人感冒风寒而咳嗽有痰，或者恶风、头疼、干呕的，用人参杏仁汤。伤寒二三天传入少阳经，脉弦、口苦、发热且咳嗽的，用小柴胡汤去掉人参、生姜、大枣，加入五味子、干姜。若发热、胸中烦满且咳嗽，加入炒瓜蒌。若胸胁痞满、发热且咳嗽，加入枳壳、桔梗。凡是阴证手足冷、脉沉细且咳嗽的，用四逆汤加五味子。大抵伤寒咳嗽，不同于杂病。按照张仲景的治疗法则，有咳嗽症状的，不分阴阳两种证型，都使用五味子和干姜。因为五味子能收敛肺气而止咳，干姜入肺经而散除逆气。凡初秋豪雨寒冷，以及时行暴寒，热气喜欢伏藏于体内，出现咳嗽，气息曲折难以顺畅，喉哑失声，干咳，喉咙中有梗塞感的，用射干汤。
朱丹溪说：咳嗽这个疾病是一个整体。有人说，咳是有声而无痰，嗽是有痰而无声音。又说，咳属阳，嗽属阴，这些说法都没有确凿的依据。咳嗽不仅仅由寒引起，六气都能导致咳嗽。风嗽，表现为头目眩晕、痰涎不利，宜用通圣散发汗，搜风丸清热祛风。火嗽，表现为口燥舌干、喘逆唾血，宜用凉膈散加当归、桔梗治疗，大金花丸解毒。暑嗽，表现为面赤手冷、头部自汗，宜用白虎汤清除。湿嗽，表现为面肿上喘，宜用大橘皮汤止嗽，严重的用三花神丸攻下。燥嗽，表现为往来寒热、涕唾稠粘，宜用柴胡饮子治疗。寒嗽，表现为手足厥冷，宜用宁肺散收敛。那些错误的医生不分六气，固执地认为是寒，骤然使用枯矾、罂粟壳，即使到老也不会醒悟。
[Outline] Zhang Zhongjing stated: In Taiyang disease (Taiyang syndrome), if the exterior pattern is not resolved and there is fluid retention in the epigastrium, presenting with dry retching, fever, and cough, or thirst, or diarrhea, or a sensation of choking in the throat, or difficulty in urination with fullness in the lower abdomen, or wheezing, Xiao Qing Long Tang (Minor Blue Dragon Decoction) is indicated. If fluid retention exists in the epigastrium due to cold damage, presenting with cough and slight wheezing, fever but no thirst, Xiao Qing Long Tang (Minor Blue Dragon Decoction) is indicated. If thirst occurs after taking the decoction, it indicates that the pathogenic factor is departing and the condition is about to resolve. In Shaoyin disease (Shaoyin syndrome), if there is abdominal pain, difficulty in urination, heaviness and pain in the four limbs, and spontaneous diarrhea, this indicates the presence of fluid retention. If the patient also has a cough, Zhen Wu Tang (True Warrior Decoction) added with Wu Wei Zi (Schisandra Fruit), Xi Xin (Asarum Root), and Gan Jiang (Dried Ginger) is indicated.
[Commentary] Zhu Zhenheng stated: Cough associated with Taiyang disease patterns can be treated with Xiao Qing Long Tang (Minor Blue Dragon Decoction) or Xiao Chai Hu Tang (Minor Bupleurum Decoction). Generally, if heat is located in the Upper Jiao (Upper Burner), the person will desire to drink water. When water stagnates in the epigastrium, it causes the Lung Qi to float upward. Since the Lung governs coughing, when fluid qi invades it, cough and slight wheezing result. Both Shaoyang (Lesser Yang) and Shaoyin (Lesser Yin) diseases can present with cough symptoms.
Han Zhihe stated: The previous two clauses refer to cough caused by retained fluid. Although both are caused by fluid retention, Xiao Qing Long Tang (Minor Blue Dragon Decoction) treats cough resulting from the combination of fluid retention and exterior cold, whereas Zhen Wu Tang (True Warrior Decoction) treats cough resulting from the combination of fluid retention and interior cold. This distinction must be understood. Whether it is exterior cold or interior cold, when combined with fluid retention, it inevitably disturbs the Lung, because external cold and cold drinks injure the Lung.
The Lung governs Qi. External cold and cold dietary intake injure the Lung, causing Qi to ascend rather than descend, becoming rebellious and failing to gather. This impacts the diaphragm and pharynx, causing a itching sensation in the throat as if blocked. This induces coughing. Severe cases involve continuous, unceasing coughing, restlessness in sitting and lying, inability to finish speaking, movement affecting the whole body, and audible sounds reaching nearby areas.
Gong Xin stated: Fluid qi refers to the Cold Water Qi of the Taiyang channel. Coughing occurs because fluid qi shoots into the Lung. The skin and hair are the exterior correspondence of the Lung. If the exterior cold is not resolved, cold water remains in its correspondence. Fluid qi in the epigastrium ascends to the Lung, causing Lung cold. The combination of internal and external pathogens results in cough. With fluid qi in the epigastrium, cough is inevitable, while wheezing is possible. This is similar to the criteria for Xiao Chai Hu Tang (Minor Bupleurum Decoction) syndrome, where observing one symptom is sufficient for diagnosis, without needing all symptoms to be present.
[Outline] Zhang Zhongjing stated: After five or six days of cold damage, or wind strike, presenting with alternating chills and fever, bitter distension and fullness in the chest and hypochondrium, silence with lack of appetite, irritability and frequent vomiting, or irritability in the chest without vomiting, or thirst, or abdominal pain, or hardness and fullness under the ribs, or palpitations, or difficulty in urination, or no thirst with slight fever on the body, or cough, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is indicated. In Shaoyin disease (Shaoyin syndrome), presenting with cold extremities, diarrhea with a sensation of rectal heaviness, and if the patient also has cough, palpitations, difficulty in urination, or abdominal pain, Si Ni San (Frigid Extremities Powder) is indicated.
[Commentary] Zhao Sizhen stated: These two clauses describe cough caused by pathogenic factors transmitting from the exterior to the interior. Although both involve transmission to the interior, Xiao Chai Hu Tang (Minor Bupleurum Decoction) treats cough caused by Yang pathogens disturbing the Lung upon transmission, whereas Si Ni San (Frigid Extremities Powder) treats cough caused by Yin pathogens disturbing the Lung upon transmission. This distinction must also be recognized. Whether Yang or Yin pathogens transmit from the exterior to the interior, they inevitably disturb the Lung, because the Zhen Qi (True Qi) of the organs is superior to the Lung.
Cough due to retained fluid and cough due to exterior pathogens transmitting to the interior are already understood. There is also cough due to Lung cold. The Nei Jing states: "Why does the Lung cause cough?" The skin and hair are the exterior correspondence of the Lung. If the skin and hair first receive cold qi, the cold enters through its correspondence. If cold food and drink enter the stomach, the cold travels up via the Lung meridian to the Lung, causing Lung cold. Lung cold leads to the combination of external and internal pathogens, which then lodge in the Lung, resulting in cough. This is cough due to Lung cold.
Tao Hua stated: Cough involves clearing the throat; commonly called 'sou'. The Lung governs Qi. When the Lung is invaded by pathogens, Qi rebels and fails to descend, causing cough. There is cough due to Lung cold, cough due to retained fluid, and cough due to pathogens in the Half-Exterior Half-Interior. Treatments differ. The three types of water-induced cough must be distinguished. Xiao Qing Long Tang (Minor Blue Dragon Decoction) treats surface water of the Taiyang channel; Shi Zao Tang (Ten Date Pill) treats interior water of the Taiyang channel; Zhen Wu Tang (True Warrior Decoction) treats fluid qi in water-patterns. Generally, when water combines with exterior cold, use Xiao Qing Long Tang (Minor Blue Dragon Decoction) to induce sweating; when water combines with interior cold, use Zhen Wu Tang (True Warrior Decoction) to warm; when interior accumulation combines with water to disturb the Lung causing cough, use Shi Zao Tang (Ten Date Pill) to purge. For Taiyang disease with fever, cough, dry retching, wheezing, and diarrhea, use Xiao Qing Long Tang (Minor Blue Dragon Decoction); for aversion to cold and body pain, follow the base formula; for cool body, cough, dry retching, mild diarrhea, epigastric fullness, and pain radiating to the hypochondrium, use Shi Zao Tang (Ten Date Pill); for heavy limbs, abdominal pain, diarrhea, cough, or vomiting, use Zhen Wu Tang (True Warrior Decoction).
[Outline] Zhang Zhongjing stated: If coughing is accompanied by free urination, sweating therapy should not be used. If sweating is induced, it will lead to cold reversal in the four limbs.
[Commentary] Cheng Wuji stated: Cough is a disease of the Lung, and treatment requires dispersing methods. However, sweating therapy must absolutely be avoided, as stated in this clause.
Wu Shou stated: For exterior cold cough with floating pulse, aversion to cold, body ache, stiffness, and absence of sweat, use Ma Huang Tang (Ephedra Decoction) or San Ao Tang (Three Unbinding Decoction) to induce sweating. If sputum is like glue, use Jin Fei Cao San (Golden Whorlwort Powder) to induce sweating. If there is heat, use Shen Su Yin (Ginseng and Perilla Drink) removing Mu Xiang (Aucklandia Root) and Ren Shen (Ginseng Root), adding Ma Huang (Ephedra Stem), Sang Bai Pi (Mulberry Root Bark), and Xing Ren (Apricot Seed) to induce sweating. For weak individuals suffering from cold damage with cough and phlegm, or aversion to wind, headache, and dry retching, use Ren Shen Xing Ren Tang (Ginseng and Apricot Seed Decoction). If cold damage transmits to the Shaoyang channel within two to three days, presenting with wiry pulse, bitter taste, fever, and cough, use Xiao Chai Hu Tang (Minor Bupleurum Decoction) removing Ren Shen (Ginseng Root), Sheng Jiang (Fresh Ginger), and Da Zao (Jujube Fruit), adding Wu Wei Zi (Schisandra Fruit) and Gan Jiang (Dried Ginger). If there is fever, chest irritability, and cough, add fried Gua Lou (Trichosanthes Fruit). If there is chest and hypochondriac fullness, fever, and cough, add Zhi Ke (Bitter Orange) and Jie Geng (Platycodon Root). For any Yin pattern with cold extremities, deep and fine pulse, and cough, use Si Ni Tang (Frigid Extremities Decoction) added with Wu Wei Zi (Schisandra Fruit). Generally, cough in cold damage differs from miscellaneous diseases. According to Zhang Zhongjing's principles, for cough regardless of Yin or Yang patterns, Wu Wei Zi (Schisandra Fruit) and Gan Jiang (Dried Ginger) are always used. Wu Wei Zi (Schisandra Fruit) astringes Lung Qi to stop cough, while Gan Jiang (Dried Ginger) enters the Lung meridian to disperse rebellious Qi. In early autumn, following heavy rain and cold, or during epidemic severe cold, heat tends to hide internally. Symptoms include cough, difficult breathing, hoarseness, loss of voice, dry cough, and a sensation of blockage in the throat; She Gan Tang (Belamcanda Decoction) is indicated.
Li Zhongzi stated: Cough with sound but no phlegm is called 'Ke'; cough with sound and phlegm is called 'Sou'.
Zhu Danxi stated: Cough and Sou are essentially one disease. Some say Ke has sound but no phlegm, while Sou has phlegm but no sound. Others say Ke is Yang and Sou is Yin. These claims lack evidence. Cough is not solely caused by cold; the Six Qi (Six Excesses) can all cause cough. Wind cough presents with dizziness and vertigo, and difficult expectoration; treat with Tong Sheng San (Universal Salvation Powder) to induce sweating, and Sou Feng Wan (Wind-Searching Pill) to clear. Fire cough presents with dry mouth and tongue, wheezing, and hemoptysis; treat with Liang Ge San (Cool the Diaphragm Powder) added with Dang Gui (Angelica Sinensis Root) and Jie Geng (Platycodon Root), and Jie Du with Da Jin Hua Wan (Great Golden Flower Pill). Summerheat cough presents with red face, cold hands, and spontaneous sweating on the head; treat with Bai Hu Tang (White Tiger Decoction) to eliminate. Dampness cough presents with facial edema and upper wheezing; treat with Da Ju Pi Tang (Large Tangerine Peel Decoction) to stop cough; severe cases use San Hua Shen Wan (Three Flowers Divine Pill) to purge. Dryness cough presents with alternating chills and fever, and thick sticky nasal discharge and sputum; treat with Chai Hu Yin Zi (Bupleurum Drink). Cold cough presents with cold extremities; treat with Ning Fei San (Lung-Calming Powder) to astringe. Erroneous physicians fail to distinguish the Six Qi, stubbornly treating everything as cold, and abruptly using Kun Fan (Alum) and Su Qiao (Poppy Shell); even in old age, they remain unaware of their error.
Shen Jin'ao noted: Zhu's theory on the Six Qi causing cough applies generally to miscellaneous diseases. However, the etiology of cough in cold damage also includes causes related to the Six Qi, so the treatment methods can certainly be referenced.