地气蒸郁。令人骤病头疼壮热呕逆。有举家皆病者。谓之风湿气。不知服药。渐成温疫。宜用五苓散半帖。入
姜钱三片。大枣一枚。同煎。服一碗。立效。
未持脉时。病患手叉自冒心。师因教试令咳。而不咳者。此必两耳聋无闻也所以然者以重发汗虚故如此。
（脉经。手叉。作叉手。玉函。脉经。千金翼。不咳间。有即字。作以重发其汗虚故也。）
〔张〕此示人推测阳虚之一端也。阳虚耳聋。与少阳传经耳聋迥别。亟宜固阳为要也。叉手冒心。加之耳
聋。阳虚极矣。尝见汗后阳虚耳聋。诸医施治。不出小柴胡加减。屡服愈甚。必大剂参附。庶可挽回也。〔钱〕
误汗亡阳。则肾家之真阳败泄。所以肾窍之两耳无闻。犹老年肾惫阳衰。亦两耳无闻。其义一也。治法宜固其
阳。〔魏〕盖阳虚之甚。两耳无闻。则阳浮于上。根离于下。待时而脱。昏蒙之状。神明已乱矣。
案汪氏引补亡论曰。素无热人。可与芍药附子汤。素有热人。可与黄 建中汤。魏氏曰。轻则桂枝甘草。
重则加参附。程氏亦用以桂枝甘草汤。然桂枝甘草汤症。虚特在膻中。今加之以耳聋。精气将脱。危险殊甚。
张氏用大剂麦附。固为得矣。
发汗后。饮水多必喘。以水灌之亦喘。（玉函。脉经。千金翼。多下。有者字。）
〔成〕喘。肺疾。饮水多喘者。饮冷伤肺也。以冷水灌洗而喘者。形寒伤肺也。〔钱〕中风发汗后。欲得
饮水者。少少与之可也。若饮水过多。则胃虚不运。水冷难消。必至停蓄不渗。水寒侵肺。呼吸不利。故肺胀
胸满。气逆而喘急也。若以冷水灌濯。则营卫先已空疏。使寒邪入腠。水气侵肤。
内通于肺。而亦为喘也。〔柯〕汉时治病。有火攻水攻之法。故仲景言及之。
案水攻。论中无所考。唯玉函脉经。有可水篇。其中一条云。寸口脉洪而大。数而滑。云云。针药所不
能制。与水灌枯槁。阳气微散。身寒温衣覆汗出。表里通利。其病即除。正其义也。（文蛤散条。反以冷水
之。若灌之。）
案此条。喻氏张氏魏氏。并以麻黄杏仁甘草石膏汤为主。盖本于郭雍补亡论。水寒伤肺。恐非所宜也。柯
氏主以五苓散。汪氏则用茯苓桂枝生姜甘草汤。加浓朴杏仁。钱氏云。去麻黄加葶苈之小青龙汤。或可酌用。
盖钱所处。似切当矣。
发汗后。水药不得入口为逆。若更发汗。必吐下不止。（脉经。下发字下。有其字。玉函。若字以下九
字。无。）
〔成〕发汗后。水药不得入口。为之吐逆。发汗亡阳。胃中虚冷也。若更发汗。则愈损阳气。胃气大虚。
故吐下不止。
〔程〕发汗后见此者。由未汗之先。其人已是中虚而寒。故一误不堪再误。〔钱〕误汗则胃中阳气虚损。
胃本司纳。因胃中虚冷。气上逆而不受。故水药俱不得入口。以主纳者不得纳。故谓之逆。然与水逆证之水入
则吐不同也。〔汪〕汗多亡阳。胃中元气虚。不得消水。此治之之逆。谓治不以理也。补亡论。常器之云。可
与半夏茯苓汤。
案活人书曰。发汗后。水药不得入口。为逆。若更发汗。必吐下不止。小半夏加茯苓汤。大半夏加橘皮汤。
喻氏魏氏
周氏张氏。皆以为水逆。以五苓散为主。柯氏曰。此热在胃口。须用栀子汤。瓜蒂散。因其势而吐之。亦通因
通用法也。并于本条义难叶。盖此条证。其人素有痰饮。清阳之气久虚者。误汗则风药挟饮。结聚上焦。以致水
药拒格不入也。故主以小半夏加茯苓汤等。下逆驱饮者。为允当。若寒多者。理中去术加生姜汤之属。须酌用也。
案为逆。成氏喻氏辈。为吐逆之义。不可从也。金鉴以吐下之下为衍文。亦非也。
发汗吐下后。虚烦不得眠。若剧者。必反复颠倒。心中懊 。栀子豉汤主之。若少气者。栀子甘草豉汤主
之。若呕者栀子生姜豉汤主之。（发汗上。脉经。有伤寒二字。玉函。脉经。千金翼。无若剧之若。及必字。
外台。者必二字。作则一字。心中懊 作心内苦痛懊 。）
〔汪〕发汗吐下后者。谓虽经汗吐且下。而伤寒之邪热。犹未解也。邪热未解。必乘其人之虚。而客于胸
中。胸中郁热。因生烦躁。阳气扰乱。不得眠也。剧者。烦极也。烦极则知其人郁热愈甚。故不惟不眠。而且
反复颠倒而不安。心中懊 。郁郁然不舒畅而愦闷也。虚烦证。虚也。正气之虚。烦者。邪气之实。乃不可作
真虚看。作汗吐下后暴虚看。少气者。乃热伤气而气促急。非真气虚也。
案懊 。成氏曰。心中懊 而愦闷。懊 者。俗为鹘突。是也。伤寒直格曰。懊 者。烦心热燥。闷乱不
宁也。甚者。似中巴豆草乌头之类毒药之状也。王氏曰。 。即恼字。古通用。杨雄方言曰。愁恚愦愦。毒而
不发。谓之氐惆。郭璞注云。氐惆。懊 也。（孙奕示儿编云糊涂。读鹘突。或曰不分明也。鹘。隼也。突起
卤莽之状。）又案此似后世所谓嘈杂。医学统旨曰。 者。似饥而甚。似躁而轻。有懊 不自宁之况。皆因心
下有痰火而动。或食郁而有热故作。是也。
准绳曰。少气者。气少不足以言也。
栀子豉汤方（○脉经。千金翼。无豉字。）
栀子（十四个擘○成本。玉函。个。作枚。下并同。） 香豉（四合绵裹）
上二味。以水四升。先煮栀子。得二升半。纳豉。煮取一升半。去滓。分为二服。温进一服。得吐者。止
后服。（外台。二升半下。有去滓二字。取上。有更字。玉函。千金。并翼。吐上。有快字。）
〔锡〕栀子性寒。导心中之烦热以下行。豆豉。HT 熟而轻浮。引水液之上升也。阴阳和而水火济。烦自解
矣。案栀子豉汤。旧说指为吐药。即王好古之高明。亦云本草并不言栀子能吐。奚仲景用为吐药。此皆不能思
维经旨。以讹传讹者也。如瓜蒂散二条。本经必曰吐之。栀子豉汤六节。并不言一吐字。且吐下后虚烦。岂有
复吐之理乎。此因瓜蒂散内。用香豉二合。而误传之也。〔志〕旧本。有一服得吐止后服七字。此因瓜蒂散中
有香豉。而误传于此也。今为删正。盖栀子苦能下泄。以清在内之郁热。香豉甘能发散。启阴液为微汗。以散
在外之身热。案葛翁肘后方。用淡豆豉。治伤寒。主能发汗。
伤寒直格曰。或吐者。止后服。凡诸栀子汤。皆非吐人之药。以其燥热郁结之甚。而药顿攻之。不能开通。
则郁发而吐。因其呕吐。发开郁结。则气通津液宽行而已。故不须再服也。
伤寒蕴要曰。香豉味苦甘平。发汗必用之。又能佐栀子。治懊 之药也。伤寒明条曰。得汗止后服。
案本方。成氏而降诸家。率以为吐剂。特志聪锡驹。断为非吐剂。可谓卓见矣。汪氏曰。余曾调此汤。
与病患服之。未必能吐。何也。盖栀子之性苦寒。能清胃火。润燥。豉性苦寒微甘。能泻热。而兼下气调中。
所以其苦未必能使人吐
也。医工必欲升散火郁。当于病患喉中。探之使吐可耳。又用豉法。须陈腐极臭者。能使人吐。方中云香豉。
恐医工用豉。反取新制而气不臭者。无怪乎其不能使人吐也。今验之。极臭者能使人吐。然以为吐剂者。竟似
乖乎本条之旨焉。
汪氏曰。栀子十四枚。当是四十枚。否则香豉四合。分两多寡。不相称矣。案此说不必矣。
名医类案曰。江应宿治都事靳相主。患伤寒十余日。身热无汗。怫郁不得卧。非燥非烦。非寒非痛。时
发一声。如叹息之状。医者不知何证。迎予诊视曰。懊 怫郁证也。投以栀子豉汤一剂。十减二三。再以大柴
胡汤。下燥屎。怫郁除而安卧。调理数日而起。
小儿药证直诀。栀子饮子。治小儿蓄热在中。身热狂躁。昏迷不食。大栀子仁（七个槌破）豆豉（半两）
上共享水三盏。煎至二钱。看多少服之。无时。或吐或不吐。立效。
栀子甘草豉汤方（○千金翼。无豉字。）
栀子（十四个擘） 甘草（二两炙） 香豉（四合绵裹）
上三味。以水四升。先煮栀子甘草。取二升半。纳豉。煮取一升半。去滓。分二服。温进一服。得吐者
止后服。（得下。玉函。有快字。成本。不载本方。第十卷云。栀子汤方内。入甘草二两。余根据前法。得吐止后服。）
〔锡〕少气者。中气虚。而不能交通上下。加甘草以补之。
古方选注曰。栀子豉汤。吐胸中热郁之剂。加甘草一味。能治少气。而诸家注释。皆谓益中。非理也。
盖少气者。一如饮家之短气也。热蕴至高之分。乃加甘草。载栀豉于上。须臾即吐。越出至高之热。○案此说。
以甘草为涌吐之品。今验能吐胸中痰饮。然此方所用。不必在此。
案志聪本。锡驹本。本方及栀子生姜豉汤。栀子浓朴汤。
栀子干姜汤。方后。删得吐者止后服六字。似是。
栀子生姜豉汤方
栀子（十四个擘） 生姜（五两） 香豉（四合绵裹）
上三味。以水四升。先煮栀子生姜。取二升半。纳豉。煮取一升半。去滓。分二服。温进一服。得吐者止
后服。（二升半下。外台。有去滓二字。吐上。玉函。有快字。外台。引千金翼。得吐者三字。作安即二字。
成本。不载本方。第十卷云。栀子汤方内。加生虿五两。余根据前法。得吐止后服。）
〔锡〕呕者。中气逆。而不得上交。加生姜以宣通之。〔鉴〕呕者。是热迫其饮也。加生姜以散之。
发汗若下之。而烦热胸中窒者。栀子豉汤主之。（脉经。窒。作塞。千金。窒下。有气逆抢心四字。）
〔锡〕窒。窒碍而不通也。热不为汗下而解。故烦热。热不解而留于胸中。故窒塞而不通也。亦宜栀子豉
汤。升降上下。而胸中自通矣。〔方〕窒者。邪热壅滞而窒塞。未至于痛。而比痛较轻也。〔程〕烦热二字互
言。烦在内。热在外也。或虑汗吐下后。津液已亡。何堪更用吐剂。须知此汤以宣郁为主。火郁于胸。乘其虚
而客之。凡氤氲布气于胸中者。皆火为之。而无复津液为之。枯液不得布。遂有窒痛等证。宣去其火气。清液
自回也。
明理论曰。烦热与发热。若同而异也。发热者。怫怫然发于肌表。有时而已者。是也。烦者为烦而热。
无时而歇者。是也。二者均是表热。而烦热为热所烦。非若发热而时发时止也。
伤寒五六日。大下之后。身热不去。心中结痛者。未欲解也。栀子豉汤主之。（玉函。作此为不解。）
〔柯〕病发于阳。而反下之。外热未除。心中结痛。虽轻于结胸。而甚于懊 矣。结胸是水结胸胁。用陷胸汤。水
郁
则折之也。此乃热结心中。用栀豉汤。火郁则发之也。〔程〕所结者。客热烦蒸所致。而势之散漫者。尚连及
表。故云未欲解也。
伤寒类方曰。案胸中窒结痛。何以不用小陷胸。盖小陷胸症。乃心下痛。胸中在心之上。故不得用陷胸。
何以不用泻心诸法。盖泻心症。乃心下痞。痞为无形。痛为有象。故不得用泻心。古人治病。非但内外不失厘
毫。即上下亦不窬分寸也。
伤寒下后。心烦腹满。卧起不安者。栀子浓朴汤主之。（玉函。脉经。千金翼。心烦。作烦而。）
〔鉴〕论中下后满而不烦者有二。一热气入胃之实满。以承气汤下之。一寒气上逆之虚满。以浓朴生姜甘
草半夏人参汤温之。其烦而不满者。亦有二。一热邪入胸之虚烦。以竹叶石膏汤清之。一懊 欲吐之心烦。以
栀子豉汤吐之。今既烦且满。故卧起不安也。然既无三阳之实证。又非三阴之虚证。惟热与气结。壅于胸腹之
间。故用栀子枳朴。胸腹和。而烦自去。满自消矣。
栀子浓朴汤方
栀子（十四个擘） 枳实（四枚水浸炙令黄○玉函。无水浸二字。成本。玉函。炙令黄。作去穣炒。）
浓朴（四两炙去皮○成本。作四两。姜炙。）
上三味。以水三升半。煮取一升半。去滓。分二服。温进一服。得吐者止后服。（上字。成本。全书。作
已上二字。三升半。玉函。无半字。千金翼。吐上。有快字。）
〔志〕栀子之苦寒。能泄心下之热烦。浓朴之苦温。能消脾家之腹满。枳实之苦寒。能解胃中之热结。
集注。高世 曰。枳实。案神农本经。主除寒热结气。长肌肉。利五脏。益气轻身。盖枳实臭香色黄。
味辛形圆。
宣达中胃之品也。炙香而配补剂。则有长肌益气之功。生用而配泄剂。则有除邪破结之力。元人谓枳实泻痰。
能冲墙倒壁。而后人即为破泄之品。不可轻用。且实。乃结实之通称。无分大小。宋开窑以小者为实。大者为
壳。而后人即谓壳缓而实速。壳高而实下。此皆不明经旨。以讹传讹耳。
伤寒直格曰。枳实不去穣。为效甚速。
柯氏曰。栀子干姜汤。去豉用姜。取其横散。栀子浓朴汤。以枳朴易豉。是取其下泄。皆不欲上越之义。
旧本二方后。俱云。得吐止后服。岂不谬哉。
伤寒。医以丸药大下之。身热不去微烦者。栀子干姜汤主之。（玉函。脉经。丸。作圆。）
〔王〕案丸药。所谓神丹甘遂也。或作巴豆。〔喻〕丸药大下。徒伤其中。而不能荡涤其邪。故栀子合
干姜用之。亦温中散邪之法也。〔钱〕以峻厉丸药大下之。宜乎陷入而为痞结矣。而身热不去。是邪未全陷。
地气蒸腾郁结，使人突然患病，出现头痛、高热、呕吐逆气等症状，甚至全家都生病，这被称为“风湿气”。如果不知道服药，病情会逐渐演变成温疫。适宜使用五苓散半帖，加入生姜三片、大枣一枚，共同煎煮，服用一碗，立刻见效。
在切脉之前，病人双手交叉按在心口部位。医生因此教他试着咳嗽，但他不咳嗽，这说明他的两耳肯定已经听不见了。之所以这样，是因为过度发汗导致正气虚损的缘故。（《脉经》中，“手叉”写作“叉手”。《玉函》、《脉经》、《千金翼方》在“不咳”之间多出一个“即”字，表述为“因为过度发汗导致正气虚损”。）
〔张〕这是向人们展示推测阳气虚损的一个方面。阳气虚导致的耳聋，与少阳病传经引起的耳聋截然不同，急需以固护阳气为要务。双手交叉按在心口，加上耳聋，说明阳气虚损到了极点。我曾见过发汗后阳气虚损导致耳聋的病例，各位医生施治，不出小柴胡汤加减的范围，结果屡服后病情加重，必须用大剂量的参附汤，才可能挽回生机。〔钱〕误用发汗法导致亡阳，那么肾中的真阳就会败坏泄脱，所以肾窍（两耳）听不见声音，就像老年人肾气疲惫、阳气衰微一样，也是两耳听不见，其中的道理是一样的。治疗方法应当以固护阳气为主。〔魏〕阳气虚损到极点，两耳听不见，说明阳气浮越于上，根基脱离于下，等待时机脱失，出现昏蒙的症状，神明已经混乱了。
案：汪氏引用《补亡论》说，素来没有热象的人，可以给予芍药附子汤；素来有热象的人，可以给予黄耆建中汤。魏氏说，轻症用桂枝甘草汤，重症加人参、附子。程氏也主张用桂枝甘草汤。然而桂枝甘草汤证，虚损仅在膻中，现在又加上耳聋，精气即将脱失，情况非常危险。张氏使用大剂量的麦冬、附子，确实得当。
发汗之后，饮水过多必然导致气喘，如果用冷水浇洗身体也会导致气喘。（《玉函》、《脉经》、《千金翼方》在“多”字下多一个“者”字。）
〔成〕气喘是肺部的疾病。饮水过多导致气喘，是因为饮冷损伤了肺气。用冷水灌洗导致气喘，是因为形体受寒损伤了肺气。〔钱〕中风病发汗后，想要喝水，应该少量多次给予。如果饮水过多，则胃气虚弱不能运化，水冷难以消除，必然导致水液停蓄不能渗透。水寒之气侵袭肺部，呼吸不利，所以肺胀胸满，气逆而喘急。如果用冷水浇灌，那么营卫之气原本就已经空疏，使寒邪侵入腠理，水气侵犯皮肤，内通于肺，也会引起气喘。〔柯〕汉代治病，有火攻和水攻的方法，所以仲景提到了这一点。
案：水攻之法，在《伤寒论》正文中无法考证，只有《玉函》、《脉经》中有“可水篇”，其中一条说：“寸口脉洪大而数且滑……针药所不能控制，用水浇灌使其干枯，阳气微微发散，身体寒冷需穿衣覆盖出汗，表里通利，病即除去。”这正是其含义。（文蛤散条中提到：“反用冷水浇之，若灌之。”）
案：此条经文，喻嘉言、张路玉、魏荔彤等人，都以麻黄杏仁甘草石膏汤为主方。大概本源于郭雍的《补亡论》。水寒伤肺，恐怕不适合用此方。柯琴主张用五苓散，汪昂则用茯苓桂枝生姜甘草汤，加厚朴、杏仁。钱潢说，去掉麻黄加葶苈子的小青龙汤，或许可以斟酌使用。看来钱氏的观点，似乎更为恰当。
发汗之后，水药无法入口，这是逆证。如果再次发汗，必定呕吐腹泻不止。（《脉经》在“下发”字下有“其”字。《玉函》从“若”字以下的九个字没有。）
〔成〕发汗之后，水药无法入口，称为吐逆。发汗导致亡阳，胃中虚冷。如果再次发汗，则进一步损耗阳气，胃气大虚，所以呕吐腹泻不止。
〔程〕发汗后出现这种情况，是因为在发汗之前，此人已经是中焦虚寒，所以一次失误不堪再误。〔钱〕误用发汗导致胃中阳气虚损。胃本来主管受纳，因为胃中虚冷，气机上逆而不接受，所以水药都不能入口。因为主管受纳的器官不能受纳，所以称为逆。但这与水逆证的水入则吐是不同的。〔汪〕汗多导致亡阳，胃中元气虚弱，不能消化水液，这是治疗上的逆乱，指治疗不合情理。《补亡论》常器之说，可以给予半夏茯苓汤。
案：《活人书》说：发汗后，水药无法入口，称为逆。如果再次发汗，必定呕吐腹泻不止。用小半夏加茯苓汤，或大半夏加橘皮汤。喻嘉言、魏荔彤、周扬俊、张路玉等人都认为是水逆证，以五苓散为主方。柯琴说：这是热在胃口，须用栀子汤、瓜蒂散，顺应病势而催吐，这也是通因通用的方法。但这与本条的含义难以契合。因为此条证候，其人素来有痰饮，清阳之气久已虚损，误用发汗则风药挟带痰饮，结聚在上焦，导致水药拒格不入。所以主治用小半夏加茯苓汤等降逆逐饮的方法，才是恰当的。如果寒多者，理中汤去术加生姜汤之类，需要斟酌使用。
案：对于“为逆”，成无己、喻嘉言等人解释为吐逆的意思，不可采纳。《医宗金鉴》认为“吐下”的“下”字是衍文，也不对。
发汗、吐、下之后，出现虚烦、不得入睡，如果严重的，一定翻来覆去、心中懊恼烦闷，栀子豉汤主治。如果有气短症状的，栀子甘草豉汤主治。如果有呕吐症状的，栀子生姜豉汤主治。（“发汗”之上，《脉经》有“伤寒”二字。《玉函》、《脉经》、《千金翼方》没有“若剧”的“若”字及“必”字。《外台秘要》中“者必”二字作“则”一字。“心中懊憹”作“心内苦痛懊憹”。）
〔汪〕发汗、吐、下之后，是指虽然经过汗、吐、下治疗，但伤寒的邪热仍然没有解除。邪热未解，必然乘人体正气虚弱，客居于胸中。胸中郁热，因而产生烦躁，阳气扰乱，导致不得睡眠。严重的，是烦闷到了极点。烦闷到极点就知道此人郁热更甚，所以不仅不眠，而且翻来覆去不安稳，心中懊恼烦闷，郁郁然不舒畅而感到昏闷。虚烦证的“虚”，是指正气的虚；“烦”，是指邪气的实，不可以看作真正的虚证，也不要看作是汗吐下后暴发的虚证。“少气”，是热伤气而导致气促急，并非真气虚。
案：关于“懊憹”，成无己说：心中懊憹而昏闷。“懊憹”俗称为“鹘突”，是正确的。《伤寒直格》说：“懊憹”是心烦热燥，闷乱不宁。严重的，像中了巴豆、草乌头之类毒药的样子。王氏说：“憹”即“恼”字，古时通用。杨雄《方言》说：“愁恚愦愦，毒而不发，谓之氐惆。”郭璞注云：“氐惆，就是懊憹。”（孙奕《示儿编》说糊涂，读作“鹘突”。有人说是不分明。鹘，是隼鸟。突起卤莽的样子。）又案：这类似于后世所说的“嘈杂”。《医学统旨》说：“嘈”是似饥而严重，似躁而轻微，有懊憹不自安的情况，都是因为心下有痰火而动，或食积而有热所致，这是正确的。
《准绳》说：“少气”，是气少不足以说话。
栀子豉汤方（○《脉经》、《千金翼方》没有“豉”字。）
栀子（十四个掰开○成本、《玉函》，个作枚，以下相同。） 香豉（四合绵裹）
以上二味，用水四升，先煮栀子，得到二升半，纳入豉，煮取一升半，去渣，分为二服，温服一服，得吐的，停止后服。（《外台秘要》，二升半下有“去滓”二字。取上有“更”字。《玉函》、《千金》、《翼方》，吐上有“快”字。）
〔锡〕栀子的性味寒凉，引导心中的烦热下行。豆豉，经过发酵而性质轻浮，引水液上升。阴阳调和而水火既济，烦热自然解除。案：栀子豉汤，旧说认为是吐药，即使是王好古那样高明的人，也说本草并不说栀子能吐，为什么仲景用它作为吐药？这都是不能思考经典原意，以讹传讹的人。如瓜蒂散两条，本经一定说“吐之”，栀子豉汤六节，并没有说一个“吐”字。况且汗吐下后出现虚烦，哪有再用吐法的道理？这是因为瓜蒂散内用了香豉二合，而误传于此。〔志〕旧本中，有“一服得吐止后服”七字，这是因为瓜蒂散中有香豉，而误传于此。现在予以删正。大概栀子苦能下泄，以清除在内的郁热；香豉甘能发散，启阴液为微汗，以散在外的身热。案：葛洪《肘后方》，用淡豆豉治伤寒，主要能发汗。
《伤寒直格》说：或者吐的，停止后服。凡是各种栀子汤，都不是让人吐的药。因为燥热郁结得很厉害，药物顿然攻之，不能开通，则郁结发泄而吐。因为呕吐，发开了郁结，则气通津液宽行而已，所以不需要再服。
《伤寒蕴要》说：香豉味苦甘平，发汗时必须用，又能佐助栀子，治疗懊憹的药物。《伤寒明理论》说：得汗停止后服。
案：本方，成无己及以下各家，都认为它是吐剂，只有志聪、锡驹断定它不是吐剂，可以说是卓见。汪氏说：我曾调配此汤给病人服用，未必能吐。为什么呢？大概栀子的性味苦寒，能清胃火，润燥；豉性苦寒微甘，能泻热，兼下气调中。所以它的苦味未必能使人吐。医工一定要升散火郁，应当在病患喉中探之使其吐即可。又用豉的方法，必须陈腐极臭的，才能使人吐。方中说香豉，恐怕医工用豉，反而取新制的而气味不臭的，难怪他们不能使人吐。现在验证，极臭的能使人吐，但把它作为吐剂，竟然似乎违背了本条的宗旨。
汪氏说：栀子十四枚，应当是四十枚，否则香豉四合，分量多少不相称。案：这种说法不必采纳。
《名医类案》说：江应宿治疗都事靳相主，患伤寒十多天，身热无汗，怫郁不得卧，非燥非烦，非寒非痛，时常发出一声，像叹息的样子。医生不知道是什么证，请我去诊视，说：这是懊憹怫郁证。投以栀子豉汤一剂，减去二三成，再用大柴胡汤，下燥屎，怫郁除而安卧，调理数日而起。
《小儿药证直诀》栀子饮子，治疗小儿蓄热在中，身热狂躁，昏迷不食。大栀子仁（七个捣破）豆豉（半两）
以上共用清水三盏，煎至二钱，看多少服用，不拘时候，或者吐或者不吐，立刻见效。
栀子甘草豉汤方（○《千金翼方》没有“豉”字。）
栀子（十四个掰开） 甘草（二两炙） 香豉（四合绵裹）
以上三味，用水四升，先煮栀子甘草，取二升半，纳入豉，煮取一升半，去渣，分二服，温服一服，得吐的停止后服。（“得”下，《玉函》有“快”字。成本不载本方，第十卷说：栀子汤方内，入甘草二两，其余根据前法，得吐停止后服。）
《古方选注》说：栀子豉汤，是吐胸中热郁的药剂。加甘草一味，能治少气，而诸家注释，都说补益中气，不符合道理。大概少气，就像饮家之短气一样。热蕴藏在至高之分，乃加甘草，载栀豉于上，片刻即吐，越出至高之热。○案：这种说法，把甘草当作涌吐之品，现在验证能吐胸中痰饮，然而此方所用，不必在于此。
案：志聪本、锡驹本，本方及栀子生姜豉汤、栀子厚朴汤、栀子干姜汤，方后，删去了“得吐者止后服”六字，似乎是正确的。
栀子生姜豉汤方
栀子（十四个掰开） 生姜（五两） 香豉（四合绵裹）
以上三味，用水四升，先煮栀子生姜，取二升半，纳入豉，煮取一升半，去渣，分二服，温服一服，得吐的停止后服。（“二升半”下，《外台》有“去滓”二字。吐上，《玉函》有“快”字。《外台》引《千金翼》，得吐者三字，作“安即”二字。成本不载本方，第十卷说：栀子汤方内，加生虿五两，其余根据前法，得吐停止后服。）
〔锡〕呕，是中气逆，而不能上交，加生姜来宣通它。〔鉴〕呕，是热迫使其饮，加生姜来消散它。
发汗或下之后，出现烦热、胸中窒塞感的，栀子豉汤主治。（《脉经》，“窒”作“塞”。《千金》，窒下有“气逆抢心”四字。）
〔锡〕窒，是窒碍而不通。热不为汗下而解，所以烦热。热不解而留于胸中，所以窒塞而不通。也宜用栀子豉汤，升降上下，而胸中自然通畅。〔方〕窒，是邪热壅滞而窒塞，还没有到疼痛的程度，比痛较轻。〔程〕“烦热”二字互文见义，烦在内，热在外。有人担心汗吐下后，津液已亡，怎能再用吐剂？须知此汤以宣郁为主，火郁于胸，乘其虚而客居之。凡是在胸中布散气机的，都是火为之，而没有津液为之，枯液不得布散，遂有窒痛等证。宣散其火气，清液自然回复。
《明理论》说：烦热与发热，看似相同而实际不同。发热，是怫怫然发于肌表，有时停止的，就是这个。烦，是烦而热，没有时而歇息的，就是这个。二者都是表热，而烦热是被热所烦，不像发热那样时发时止。
伤寒五六天，大下之后，身热不去，心中结痛的，病未欲解，栀子豉汤主治。（《玉函》，作“此为不解”。）
〔柯〕病发于阳，而反下之，外热未除，心中结痛，虽然轻于结胸，但重于懊憹。结胸是水结胸胁，用陷胸汤，水郁则折之。这是热结心中，用栀豉汤，火郁则发之。〔程〕所结的，是客热烦蒸所致，而气势散漫的，尚连及表，所以说未欲解。
《伤寒类方》说：案胸中窒结痛，为什么不用小陷胸汤？大概小陷胸症，是心下痛。胸中在心之上，所以不能用陷胸。为什么不用泻心诸法？大概泻心症，是心下痞。痞为无形，痛为有象，所以不能用泻心。古人治病，不仅内外不失毫厘，即上下也不逾分寸。
伤寒下后，心烦腹满，卧起不安的，栀子厚朴汤主治。（《玉函》、《脉经》、《千金翼方》，心烦，作“烦而”。）
〔鉴〕《论》中下后满而不烦的有二种：一是热气入胃的实满，用承气汤下之；一是寒气上逆的虚满，用厚朴生姜甘草半夏人参汤温之。烦而不满的，也有二种：一是热邪入胸的虚烦，用竹叶石膏汤清之；一是懊憹欲吐的心烦，用栀子豉汤吐之。现在既烦且满，所以卧起不安。然而既然没有三阳的实证，又不是三阴的虚证，只是热与气结，壅于胸腹之间，所以用栀子枳朴，胸腹和，而烦自去，满自消矣。
栀子厚朴汤方
栀子（十四个掰开） 枳实（四枚水浸炙令黄○《玉函》，无水浸二字。成本、《玉函》，炙令黄，作去穣炒。）
厚朴（四两炙去皮○成本，作四两，姜炙。）
以上三味，用水三升半，煮取一升半，去渣，分二服，温服一服，得吐的停止后服。（“上”字，成本、全书，作“已上”二字。三升半，《玉函》，无半字。《千金翼》，吐上，有“快”字。）
〔志〕栀子的苦寒，能泄心下之热烦；厚朴的苦温，能消脾家之腹满；枳实的苦寒，能解胃中之热结。
《集注》高世栻曰：枳实，据《神农本经》，主除寒热结气，长肌肉，利五脏，益气轻身。大概枳实臭香色黄，味辛形圆，是宣达中胃的药品。炙香而配补剂，则有长肌益气之功；生用而配泄剂，则有除邪破结之力。元人谓枳实泻痰，能冲墙倒壁，而后人即为破泄之品，不可轻用。且“实”，乃是结实之通称，无分大小。宋开窑以小者为实，大者为壳，而后人即谓壳缓而实速，壳高而实下，这都是不明经旨，以讹传讹罢了。
柯氏说：栀子干姜汤，去豉用姜，取其横散；栀子厚朴汤，以枳朴易豉，是取其下泄，都不欲上越的意思。旧本二方后，俱云“得吐止后服”，难道不谬吗？
伤寒，医生用丸药大下之，身热不去微烦的，栀子干姜汤主治。（《玉函》、《脉经》，丸，作“圆”。）
〔王〕案丸药，所谓神丹甘遂也。或作巴豆。〔喻〕丸药大下，徒伤其中，而不能荡涤其邪，所以栀子合干姜用之，也是温中散邪的方法。〔钱〕用峻厉丸药大下之，理应陷入而为痞结。而身热不去，是邪未全陷。
The earthy qi steams and stagnates, causing sudden illness with headache, high fever, vomiting, and regurgitation. It is possible for the entire household to fall ill, which is called "wind-damp qi" (Fengshi Qi). If medication is not taken, it gradually develops into a warm epidemic (Wenyi). It is appropriate to use Banxia Houpo Tang (Pinellia and Magnolia Decoction) half a dose, adding three slices of fresh ginger (Shengjiang) and one jujube (Dazao), decocting them together, and drinking one bowl, which will produce immediate effect.
Before taking the pulse, the patient crosses their hands over the heart area. The physician then instructs them to try to cough, but they do not cough; this indicates that both ears are definitely deaf and unable to hear. The reason for this is that excessive sweating has caused deficiency (Xu). (*Mai Jing*: "crosses hands" is written as "cha shou". *Yu Han*, *Mai Jing*, and *Qianjin Yi Fang* have an additional character "ji" between "bu ke" [do not cough], phrasing it as "because of excessive sweating leading to deficiency".)
[Zhang] This demonstrates one aspect of inferring yang deficiency (Yang Xu). Deafness due to yang deficiency is distinctly different from deafness caused by the transmission of disease to the Shaoyang channel. It is urgent to prioritize securing the yang (Gu Yang). Crossing hands over the heart, combined with deafness, indicates extreme yang deficiency. I have seen cases of deafness after sweating due to yang deficiency where physicians treated it only with modifications of Xiaochaihu Tang (Minor Bupleurum Decoction), resulting in worsening conditions upon repeated administration. Only large doses of Renshen (Ginseng) and Fuzi (Aconite) can potentially reverse the situation. [Qian] Mistaken sweating leads to loss of yang (Wang Yang), causing the true yang (Zhen Yang) of the Kidney to fail and leak. Therefore, the kidney orifice (the two ears) cannot hear, similar to how elderly people with exhausted kidney qi and declining yang also lose hearing; the principle is the same. The treatment method should focus on securing the yang. [Wei] When yang deficiency is severe and hearing is lost, yang floats upward, detaching from its root below, waiting for the moment of collapse. The state is confused and dull, and the spirit (Shen) is already chaotic.
Note: Wang cites *Bu Wang Lun* saying: For those without prior heat, Shaoyao Fuzi Tang (Peony and Aconite Decoction) can be given; for those with prior heat, Huangqi Jianzhong Tang (Astragalus Middle-Nourishing Decoction) can be given. Wei says: For mild cases, Guizhi Gancao Tang (Cinnamon Twig and Licorice Decoction); for severe cases, add Renshen and Fuzi. Cheng also advocates using Guizhi Gancao Tang. However, in Guizhi Gancao Tang syndrome, the deficiency is merely at Danzhong (Conception Vessel 17). Now, with the addition of deafness, essence and qi are about to collapse, making the condition extremely dangerous. Zhang's use of large doses of Maidong (Ophiopogon) and Fuzi is indeed appropriate.
After sweating, drinking too much water will inevitably cause wheezing (Chuan). Washing the body with cold water will also cause wheezing. (*Yu Han*, *Mai Jing*, *Qianjin Yi Fang* have an additional character "zhe" after "duo" [much].)
[Cheng] Wheezing is a lung disease. Wheezing caused by excessive drinking results from cold beverages injuring the lung qi. Wheezing caused by washing with cold water results from external cold injuring the lung qi. [Qian] After sweating for wind-stroke, if the patient desires water, it should be given in small amounts. If too much water is drunk, the stomach qi becomes weak and fails to transport; the cold water is difficult to transform, leading to accumulation and failure to permeate. Cold-water qi invades the lungs, causing breathing difficulty, lung distension, chest fullness, rebellious qi, and urgent wheezing. If washed with cold water, the Ying (Nutritive) and Wei (Defensive) qi are already sparse, allowing cold pathogens to enter the interstices (Couli) and water qi to invade the skin, internally connecting to the lungs, thus also causing wheezing. [Ke] In the Han dynasty, there were methods of fire attack and water attack for treating diseases, so Zhongjing mentioned them.
Note: The water attack method cannot be verified in the main text of *Shanghan Lun*. Only *Yu Han* and *Mai Jing* have a chapter "Ke Shui Pian" (On Water Treatment). One entry states: "If the cun position pulse is surging, large, rapid, and slippery... acupuncture and herbs cannot control it. Pour water to dry it out, allowing slight dispersion of yang qi. The body feels cold, requiring clothing and covering to induce sweating. When interior and exterior are unobstructed, the disease is cured." This aligns with its meaning. (In the Wenli San clause: "Instead, cold water was poured on him, if washed.")
Note: Regarding this clause, Yu Jia Yan, Zhang Lu Yu, and Wei Li Tong all prioritize Mahuang Xingren Gancao Shigao Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction), likely based on Guo Yong's *Bu Wang Lun*. Using this for cold-water injuring the lung seems inappropriate. Ke Qin advocates Wuling San (Five-Ingredient Poria Powder), while Wang Ang uses Fuling Guizhi Shengjiang Gancao Tang (Poria, Cinnamon Twig, Fresh Ginger, and Licorice Decoction) with Houpo (Magnolia Bark) and Xingren (Apricot Kernel). Qian Huang suggests Xiao Qinglong Tang (Minor Blue Dragon Decoction) with Mahuang removed and Tingli (Lepidium Seed) added, which might be considered. It seems Qian's approach is quite fitting.
After sweating, if water and medicine cannot enter the mouth, it is a reversal (Ni). If sweating is induced again, vomiting and diarrhea will certainly not stop. (*Mai Jing* has the character "qi" after "xia fa". *Yu Han* lacks the nine characters starting from "ruo" [if].)
[Cheng] After sweating, if water and medicine cannot enter the mouth, it is called vomiting and regurgitation. Sweating leads to loss of yang, causing cold deficiency in the stomach. If sweating is induced again, it further damages yang qi, causing great stomach qi deficiency, hence continuous vomiting and diarrhea.
[Cheng] Seeing this after sweating means that before sweating, the person already had middle-jiao deficiency and cold. Thus, one mistake cannot bear a second. [Qian] Mistaken sweating damages stomach yang qi. The stomach governs reception; due to stomach cold deficiency, qi rebels upward and refuses intake, so neither water nor medicine can enter. Because the organ responsible for reception cannot receive, it is called reversal. However, this differs from the water-reversal syndrome where drinking causes immediate vomiting. [Wang] Excessive sweating leads to loss of yang, leaving yuan qi in the stomach weak and unable to transform water. This is a therapeutic reversal, meaning treatment was improper. *Bu Wang Lun* states Chang Qizhi said: Banxia Fuling Tang (Pinellia and Poria Decoction) can be given.
Note: *Huo Ren Shu* says: After sweating, if water and medicine cannot enter the mouth, it is reversal. If sweating is induced again, vomiting and diarrhea will certainly not stop. Use Xiaobanxia Ji Fuling Tang (Minor Pinellia and Poria Decoction) or Dabanxia Ji JuPi Tang (Major Pinellia and Tangerine Peel Decoction). Yu Jia Yan, Wei Li Tong, Zhou Yang Jun, and Zhang Lu Yu all consider it water-reversal syndrome, prioritizing Wuling San. Ke Qin says: This is heat in the stomach opening; Zhi Zi Tang (Gardenia Decoction) or Gouti San (Melon Spicule Powder) should be used to induce vomiting according to the pathogen's tendency, which is also the method of treating obstruction by promoting discharge. However, this is difficult to reconcile with the meaning of this clause. The syndrome here involves pre-existing phlegm-fluid retention and long-term deficiency of clear yang. Mistaken sweating causes wind-medicines to carry fluid retention, knotting in the upper jiao, causing rejection of water and medicine. Therefore, using Xiaobanxia Ji Fuling Tang to descend rebellion and drive out fluids is appropriate. For cases with more cold, Lizhong Tang removing Baizhu and adding Shengjiang should be considered.
Note: Regarding "wei ni" (is reversal), Cheng Wuji and Yu Jia Yan interpret it as vomiting/rebellion, which should not be followed. *Yizong Jinjian* considers the character "xia" (down/diarrhea) in "tu xia" (vomit and down) as a superfluous character, which is also incorrect.
After sweating, vomiting, or purging, deficiency vexation (Xu Fan) and insomnia occur. If severe, there will be tossing and turning and inner restlessness (Ao Nao). Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) governs. If there is shortness of breath (Shao Qi), Zhi Zi Gancao Chi Tang (Gardenia, Licorice, and Fermented Soybean Decoction) governs. If there is vomiting, Zhi Zi Shengjiang Chi Tang (Gardenia, Fresh Ginger, and Fermented Soybean Decoction) governs. (*Mai Jing* adds "Shanghan" before "fasihan". *Yu Han*, *Mai Jing*, *Qianjin Yi Fang* lack "ruo ju" [if severe] and "bi" [must]. *Waitai Mi Yao* changes "zhe bi" to "ze" [then]. "Xin zhong ao nao" is written as "xin nei ku tong ao nao".)
[Wang] "After sweating, vomiting, or purging" means that although these treatments were applied, the pathogenic heat of Shanghan has not yet resolved. Unresolved pathogenic heat takes advantage of the person's deficiency to lodge in the chest. Chest郁热 (depressed heat) generates vexation. Disordered yang qi causes insomnia. Severe cases mean extreme vexation. Extreme vexation indicates deeper depressed heat, causing not only insomnia but also tossing and turning, with inner restlessness (Ao Nao), feeling郁郁然 (depressed/uncomfortable) and confused/heavy. The "xu" (deficiency) in deficiency vexation refers to the deficiency of righteous qi; the "fan" (vexation) refers to the excess of pathogenic qi. It should not be viewed as true deficiency, nor as sudden deficiency after sweating/vomiting/purging. "Shao qi" (shortness of breath) is due to heat damaging qi causing急促 (urgency/shortness), not true qi deficiency.
Note: Regarding "ao nao", Cheng Wuji says: Inner restlessness and confusion. "Ao nao" is colloquially called "hu tu" (confused/muddled), which is correct. *Shanghan Zhi Ge* says: "Ao nao" is heart vexation, heat, dryness, confusion, and restlessness. Severe cases resemble poisoning by Radix Codonopsis, Rhizoma Aconiti, etc. Wang says: "Nao" is the character "nao" (annoyance), interchangeable in ancient texts. Yang Xiong's *Fangyan* says: "Sorrow, anger, confusion, poison not released, is called di chou." Guo Pu notes: "Di chou" is "ao nao". (Sun Yi's *Shi Er Bian* says muddled, read as "hu tu". Some say unclear. Hu is a falcon. Sudden, rash appearance.) Also, this resembles later generations' concept of "za cho" (clanging hunger/discomfort). *Yixue Tongzhi* says: "Cao" is like hunger but worse, like irritability but lighter, with a state of restless discomfort, all caused by phlegm-fire moving under the heart, or food stagnation generating heat. This is correct.
*Zhun Sheng* says: "Shao qi" means insufficient qi to speak.
Zhi Zi Chi Tang Formula (○ *Mai Jing*, *Qianjin Yi Fang* lack the character "chi".)
Zhi Zi (14 pods, split ○ *Cheng Ben*, *Yu Han*: "ge" [piece] is written as "mei" [unit], same below.) Xiang Chi (4 he, wrapped in silk)
These two ingredients, with 4 sheng of water, first decoct Zhi Zi until 2.5 sheng remains, add Chi, decoct until 1.5 sheng remains, remove dregs, divide into two doses. Take one dose warm. If vomiting occurs, stop subsequent doses. (*Waitai Mi Yao*: after "2.5 sheng" has "remove dregs". Before "qu" [take] has "geng" [more]. *Yu Han*, *Qianjin*, *Yi Fang*: before "tu" [vomit] has "kuai" [quickly].)
[Xi] Zhi Zi is cold in nature, guiding heart vexation-heat downward. Dou Chi, fermented and light/floating, draws fluid upward. Yin and Yang harmonize, water and fire assist each other, vexation resolves. Note: Old theories claim Zhi Zi Chi Tang is an emetic. Even the insightful Wang Haogu stated that Materia Medica does not say Zhi Zi induces vomiting. Why did Zhongjing use it as an emetic? These are those who fail to think through the classic intent, spreading errors. For example, in the two Gouti San clauses, the Classic explicitly says "induce vomiting". In the six Zhi Zi Chi Tang clauses, not a single word "vomit" appears. Moreover, after sweating/vomiting/purging, why induce vomiting again for deficiency vexation? This error arose because Gouti San uses 2 he of Xiang Chi, mistakenly transmitted here. [Zhi] Old editions have seven characters "yi fu de tu zhi hou fu" (one dose, if vomit, stop subsequent doses). This is a mistaken transmission due to Xiang Chi in Gouti San. Corrected now. Zhi Zi is bitter and descending, clearing internal depressed heat. Xiang Chi is sweet and dispersing, initiating yin fluid into slight sweat to dissipate external body heat. Note: Ge Hong's *Zhouhou Beiji Fang* uses Dan Dou Chi to treat Shanghan, primarily inducing sweating.
*Shanghan Zhi Ge* says: Or if vomiting occurs, stop subsequent doses. All Zhi Zi decoctions are not medicines to induce vomiting. Because燥热郁结 (dry-heat depression/knotting) is severe, sudden drug attack cannot open it, so depression releases and causes vomiting. Because vomiting opens the depression, qi flows and fluids move freely, so no need to take again.
*Shanghan Yun Yao* says: Xiang Chi is bitter, sweet, and neutral. Essential for inducing sweating. It also assists Zhi Zi in treating Ao Nao. *Shanghan Ming Tiao* says: Stop subsequent doses after sweating.
Note: This formula, Cheng Wuji and subsequent families, generally regarded it as an emetic. Only Zhi Cong and Xi Ju斷 (judged) it as non-emetic, which is a brilliant insight. Wang says: I once prepared this decoction for patients; it did not necessarily induce vomiting. Why? Zhi Zi is bitter-cold, clearing stomach fire, moistening dryness. Chi is bitter-cold with slight sweetness, draining heat, directing qi downward, regulating middle. So its bitterness does not necessarily induce vomiting. Physicians wishing to ascend and disperse fire-depression should probe the throat to induce vomiting. Also, regarding the use of Chi, it must be old, rotten, and extremely smelly to induce vomiting. The formula says "Xiang Chi" (fragrant Chi), perhaps physicians used newly made Chi without odor, hence failing to induce vomiting. Verification shows extremely smelly ones induce vomiting, but classifying it as an emetic seems contrary to the intent of this clause.
Wang says: 14 Zhi Zi pods should be 40 pods; otherwise, the weight of 4 he of Chi is disproportionate. Note: This view is unnecessary.
*Ming Yi Lei An* says: Jiang Yingsu treated Official Jin Xiangzhu, suffering from Shanghan for over ten days, body heat, no sweat, fuyu (depressed/stagnant) inability to lie down, neither dry nor vexed, neither cold nor painful, occasionally emitting a sound like sighing. Physicians did not know the syndrome. Invited me to diagnose: "This is Ao Nao and Fuyu syndrome." Administered one dose of Zhi Zi Chi Tang, reduced by 20-30%. Then used Dachaihu Tang to purge dry feces. Fuyu resolved, slept peacefully, recovered after days of conditioning.
*Xiao'er Yao Zheng Zhi Jue* Zhi Zi Yin Zi treats children with accumulated heat in the center, body heat, mania/restlessness, coma, refusal to eat. Da Zhi Zi Ren (7 pods, crushed) Dou Chi (0.5 liang)
Boil these three in 3 cups of water until 2 qian remains. Dosage depends on amount. Anytime. Vomiting or not, immediate effect.
Zhi Zi Gancao Chi Tang Formula (○ *Qianjin Yi Fang* lacks "chi".)
Zhi Zi (14 pods, split) Gancao (2 liang, honey-fried) Xiang Chi (4 he, wrapped in silk)
These three ingredients, with 4 sheng of water, first decoct Zhi Zi and Gancao until 2.5 sheng remains, add Chi, decoct until 1.5 sheng remains, remove dregs, divide into two doses. Take one dose warm. If vomiting occurs, stop subsequent doses. ("De" down, *Yu Han* has "kuai". *Cheng Ben* does not record this formula, Vol 10 says: In Zhi Zi Tang formula, add 2 liang Gancao, rest according to previous method, stop subsequent doses if vomiting occurs.)
[Xi] "Shao qi" (shortness of breath) is middle-jiao deficiency, unable to communicate upper and lower. Add Gancao to tonify it.
*Gu Fang Xuan Zhu* says: Zhi Zi Chi Tang is a formula to vomit chest heat-depression. Adding Gancao treats shortness of breath, but commentators say it benefits the middle, which is incorrect. "Shao qi" is like shortness of breath in fluid-retention cases. Heat accumulates in the highest region, so Gancao is added to carry Zhi and Chi upward, vomiting shortly after, expelling heat from the highest region. ○ Note: This view treats Gancao as an emetic. Currently verified to vomit chest phlegm-fluid, but this formula's use need not be for this purpose.
Note: Zhi Cong Ben, Xi Ju Ben, this formula, Zhi Zi Shengjiang Chi Tang, Zhi Zi Houpo Tang, Zhi Zi Ganjiang Tang, after the formulas, deleted the six characters "de tu zhe zhi hou fu" (if vomit, stop subsequent doses), which seems correct.
Zhi Zi Shengjiang Chi Tang Formula
Zhi Zi (14 pods, split) Shengjiang (5 liang) Xiang Chi (4 he, wrapped in silk)
These three ingredients, with 4 sheng of water, first decoct Zhi Zi and Shengjiang until 2.5 sheng remains, add Chi, decoct until 1.5 sheng remains, remove dregs, divide into two doses. Take one dose warm. If vomiting occurs, stop subsequent doses. ("2.5 sheng" down, *Waitai* has "remove dregs". Before "tu", *Yu Han* has "kuai". *Waitai* citing *Qianjin Yi Fang*: "de tu zhe" [if vomit] is written as "an ji" [peacefully then]. *Cheng Ben* does not record this formula, Vol 10 says: In Zhi Zi Tang formula, add 5 liang raw Chai [note: likely error in source text, usually Shengjiang], rest according to previous method, stop subsequent doses if vomiting occurs.)
[Xi] "Ou" (vomiting) is middle-jiao rebellion, unable to connect upward. Add Shengjiang to disseminate and unblock. [Jian] "Ou" is heat forcing fluid retention. Add Shengjiang to scatter it.
After sweating or purging, if there is vexation-heat and chest tightness/oppression (Zhi), Zhi Zi Chi Tang governs. (*Mai Jing*: "Zhi" is written as "sai" [block]. *Qianjin*: after "Zhi" has "qi ni qiang xin" [qi rebels seizing heart].)
[Xi] "Zhi" means obstruction and blockage. Heat is not resolved by sweating or purging, hence vexation-heat. Unresolved heat remains in the chest, causing obstruction and blockage. Zhi Zi Chi Tang is also suitable to regulate ascending and descending, allowing the chest to naturally unblock. [Fang] "Zhi" is pathogenic heat congestion and blockage, not yet reaching pain, lighter than pain. [Cheng] "Fan re" (vexation-heat) uses mutual wording: Fan is internal, Re is external. One might worry that after sweating/vomiting/purging, fluids are depleted, how can an emetic be used? Know that this formula focuses on dispersing depression. Fire depressed in the chest, taking advantage of deficiency to lodge. What distributes qi in the chest is fire, without fluid support. Withered fluid cannot distribute, leading to Zhi and pain syndromes. Dispersing the fire qi allows clear fluids to return.
*Ming Li Lun* says: Fan re (vexation-heat) and Fa re (fever) seem similar but differ. Fa re erupts on the muscle surface with a feeling of oppression, stopping intermittently. Fan is vexation with heat, without intermittent cessation. Both are exterior heat, but Fan re is heat causing vexation, unlike Fa re which comes and goes.
After five or six days of Shanghan, following severe purging, if body heat persists and there is knotting pain in the heart (Xin Zhong Jie Tong), the disease is not resolving. Zhi Zi Chi Tang governs. (*Yu Han*: writes "ci wei bu jie" [this is unresolved].)
[Ke] Disease originating in Yang, but mistakenly purged. Exterior heat remains, knotting pain in the heart. Although lighter than Jie Xiong (Knotting Chest), it is heavier than Ao Nao. Jie Xiong is water knotting in chest/hypochondrium, treated with Xian Xiong Tang (Depressing the Chest Decoction); water depression is broken. This is heat knotting in the heart, treated with Zhi Chi Tang; fire depression is dispersed. [Cheng] What knots is caused by guest heat and steaming, with a diffuse momentum still connecting to the exterior, hence "not resolving".
*Shanghan Lei Fang* says: Note chest Zhi and knotting pain, why not use Xiao Xian Xiong Tang? Xiao Xian Xiong syndrome is pain in Xin Xia (below heart/epigastrium). Chest Zhong is above the heart, hence Xian Xiong cannot be used. Why not use Xie Xin (Drain the Epigastrium) methods? Xie Xin syndrome is Pi (fullness/blockage) in Xin Xia. Pi is formless, pain has form, hence Xie Xin cannot be used. Ancient physicians treated diseases with precision inside/outside and up/down.
After Shanghan purging, if there is heart vexation, abdominal fullness, and restlessness lying down or sitting up, Zhi Zi Houpo Tang (Gardenia and Magnolia Decoction) governs. (*Yu Han*, *Mai Jing*, *Qianjin Yi Fang*: "Xin fan" is written as "fan er" [vexation and].)
[Jian] In the Treatise, post-purging fullness without vexation has two types: one is excess fullness of heat entering the stomach, treated with Chengqi Tang to purge; one is deficiency fullness of cold qi rebelling upward, treated with Houpo Shengjiang Gancao Banxia Renshen Tang to warm. Vexation without fullness has two types: one is deficiency vexation of heat entering the chest, treated with Zhuye Shigao Tang to clear; one is heart vexation with desire to vomit due to Ao Nao, treated with Zhi Zi Chi Tang to induce vomiting. Now, both vexation and fullness exist, causing restlessness. Since there is no Taiyang/Yangming/Taiyin excess syndrome, nor any Yin deficiency syndrome, it is merely heat and qi knotting, congested between chest and abdomen. Hence, using Zhi Zi, Zhishi (Immature Bitter Orange), and Houpo harmonizes chest/abdomen, vexation disappears, fullness消 (dissipates).
Zhi Zi Houpo Tang Formula
Zhi Zi (14 pods, split) Zhishi (4 pieces, soaked in water, fried until yellow ○ *Yu Han*: lacks "soaked in water". *Cheng Ben*, *Yu Han*: "fried until yellow" is written as "remove pith and stir-fry".)
Houpo (4 liang, peeled, fried ○ *Cheng Ben*: writes 4 liang, ginger-fried.)
These three ingredients, with 3.5 sheng of water, decoct until 1.5 sheng remains, remove dregs, divide into two doses. Take one dose warm. If vomiting occurs, stop subsequent doses. ("Shang" character, *Cheng Ben*, whole book: written as "yi shang" [above]. 3.5 sheng, *Yu Han*: lacks "ban" [half]. *Qianjin Yi Fang*: before "tu" [vomit] has "kuai" [quickly].)
[Zhi] Zhi Zi's bitter-cold drains heart-lower heat-vexation. Houpo's bitter-warm eliminates spleen-abdominal fullness. Zhishi's bitter-cold resolves stomach-internal heat-knotting.
*Ji Zhu* Gao Shishi says: Zhishi, according to *Shennong Ben Cao Jing*, treats cold-heat knotting qi, grows muscle, benefits five zang organs, enriches qi, lightens the body. Zhishi is fragrant, yellow-colored, pungent taste, round shape. It is a product that disseminates and reaches the middle stomach. Fried and paired with tonics, it grows muscle and enriches qi. Raw and paired with draining agents, it removes evil and breaks knotting. Yuan dynasty people said Zhishi drains phlegm, capable of toppling walls, leading later generations to view it as a breaking/draining agent to be used lightly. "Shi" (solid) is a general term for knotting,不分大小 (regardless of size). Song kilns classified small as Shi, large as Qiao (shell), leading later generations to believe shell is slow and solid is fast, shell is high and solid is low. These are misunderstandings of classic intent, spreading errors.
*Shanghan Zhi Ge* says: Zhishi without removing pith acts very quickly.
Ke says: Zhi Zi Ganjiang Tang removes Chi and uses Jiang, seeking horizontal dispersion. Zhi Zi Houpo Tang replaces Chi with Zhishi and Houpo, seeking downward drainage. Neither seeks upward emergence. Old editions of both formulas end with "stop subsequent doses if vomiting occurs," which is absurd.
Shanghan, physician used pill medicine for severe purging. Body heat persists, slight vexation. Zhi Zi Ganjiang Tang (Gardenia and Dried Ginger Decoction) governs. (*Yu Han*, *Mai Jing*: "wan" [pill] is written as "yuan" [round].)
[Wang] Note "pill medicine" refers to Shendan Gansui (Divine Pill Kansui) or possibly Radix Euphorbiae Pekingensis. [Yu] Severe purging with pills only injures the middle and fails to cleanse the pathogen. Hence, combining Zhi Zi with Ganjiang is a method of warming the middle and scattering pathogen. [Qian] Severe purging with harsh pills should lead to sinking and knotting. But body heat persists, indicating the pathogen has not fully sunk.