芫花（熬） 甘遂 大戟 大枣（擘）十枚
右三味，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。
【方解】
仲景治水之方，种种不同，此其最峻者也。凡水气为患，或喘、或咳、或悸、或噎、
或吐、或利，病在一处而止。此则水邪留于中，心腹□下痞满□痛，三焦升降之气阻
隔难通。此时表邪已罢，非汗散之法所宜，里饮实盛，又非淡渗之品所能胜，非选逐
水至峻之品，以直折之，则中气不支，束手待毙矣。甘遂、芫花、大戟三味，皆辛苦
气寒而禀性最毒，并举而用之，气味相济相须，故可直攻水邪之巢穴，决其渎而大下
之，一举而患可平也。然邪之所凑，其气必虚，以毒药攻邪，必伤及脾胃，使无冲和
甘缓之品为主宰，则邪气尽而大命亦随之矣。然此药最毒至峻，参术所不能君，甘草
又与之反，故选十枣之大而肥者以君之。一以顾其脾胃，一以缓其峻毒，得快利后，
糜粥自养，一以使谷气内充；一以使邪不复作，此仲景用毒攻病之法，尽美又尽善也
。昧者惑于甘能中满之说而不敢用，岂知承制之理乎！
太阳病，外证未解不可下也，下之为逆，欲解外者，宜桂枝汤。
【注】
太阳病外证未解者，谓桂枝汤之表证未解也。凡表证未解，无论已汗未汗，虽有可下
之证，而非在急下之例者，均不可下。下之为逆也。欲解外者，仍宜桂枝汤主之。
【集注】
王肯堂曰：但有一毫头痛恶寒 ，即为表证未解，不可下也。
程应旄曰：若下后外证未解者，仍当解外，有的证用是药，不可以既下而遂谓桂枝汤
不中与也。
汪琥曰：下之为逆；逆者，为病在外而反攻其内，于治法为不顺也。
太阳病，先发汗不解，而复下之，脉浮者不愈。浮为在外，而反下之，故令不愈。今
脉浮，故知在外，当须解外则愈，宜桂枝汤。
【注】
太阳病，先发汗表未解，仍宜汗之，而复下之，治失其宜矣。脉浮者不愈，盖以脉浮
，邪在外而反下之，故令不愈也。今误下未成逆，脉仍浮，故知邪尚在外，仍宜桂枝
汤解外则愈也。
【集注】
程应旄曰：愈不愈辨之于脉。其愈者，必其脉不浮而离于表也。若脉浮者，知尚在表
，则前此之下，自是误下，故令不愈。从前之误，不必计较，只据目前。目前之证，
不必计较，只据其脉。脉若浮，知尚在外，虽日久尚须解外则愈。有是脉，用是药，
亦不以既下，而遂以桂枝汤为不中与也。
本发汗而复下之，此为逆也；若先发汗，治不为逆。本先下之，而反汗之，为逆；若
先下之，治不为逆。
【注】
立治逆之法，不外乎表里；而表里之治，不外乎汗下。病有表里证者，当审其汗、下
何先，先后得宜为顺，失宜为逆。若表急于里，本应先汗而反下之，此为逆也；若先
汗而后下，治不为逆也。若里急于表，本应先下，而反汗之，此为逆也；若先下而后
汗，治不为逆也。
【集注】
程知曰：言汗下有先后缓急，不得倒行逆施。汪琥曰：治伤寒之法，表证急者即宜汗
，里证急者即宜下，不可拘拘于先汗而后下也。汗下得宜，治不为逆。
太阳病，下之，其脉促不结胸者，此为欲解也。脉浮者必结胸，脉紧者必咽痛，脉弦
者必两□拘急，脉细数者头痛未止，脉沈紧者必呕，脉沉滑者协热利，脉浮滑者，必
下血。
【按】
脉促当是「脉浮」，始与不结胸为欲解之文义相属。脉浮当是「脉促」，始与论中结
胸、胸满同义。脉紧当是「脉细数」，脉细数当是「脉紧」，始合论中二经本脉。脉
浮滑当是「脉数滑」，浮滑是论中白虎汤证之脉，数滑是论中下脓血之脉。细玩诸篇
自知。
【注】
病在太阳，误下，为变不同者，皆因人之藏气不一，各从所入而化，故不同也。误下
邪陷，当作结胸，反不结胸，其脉浮，此里和而不受邪，邪仍在表为欲解也。若脉促
者，为阳结实邪之脉，故必结胸也。脉细数，少阴邪热之脉，咽痛，少阴邪热之证；
误下邪陷少阴，法当从少阴治也。脉弦少阳之脉，两□拘急，少阳之证；误下邪陷少
阳，法当从少阳治也。脉紧太阳脉，头痛太阳证；误下邪仍在表，法当从太阳治也。
脉沉紧，寒邪入里之脉，欲呕，胃阳格拒之证；有表误下，邪陷在胃，法当从阳明治
也。脉沉滑，宿食脉，有表误下，协热入里下利，法当从协热下利治也。脉数滑，积
热脉，有表误下邪陷入阴，伤荣下血，法当从下脓血治也。
【按】
脉促固阳脉也，若促而有力为实，则为结胸实邪之证；若促而无力为虚，则为胸满虚
邪之证。故论中有脉促结胸，头汗小潮热者，用陷胸汤攻之；脉促胸满，汗出微恶寒
者，用桂枝去芍药加附子汤温之。观此促脉虚实治法，则可以类推矣。
【按】
咽痛，少阴寒热俱有之证也。咽干肿痛者为热，不干不肿而痛者为寒，故少阴论中有
甘桔汤、通脉四逆汤二治法也。
【集注】
方有执曰：凡在太阳皆表证也。误下则变证杂出，而不可以一途拘之。
程知曰：不宜下而下之，诸变不可胜数，此之谓也。今咽痛□急欲呕，是寒邪入里之
变。头痛热利下血，是风邪入里之变。所以然者，脉浮滑数为阳，沉弦紧细为阴也。
程应旄曰：据脉见证，各着一必字，见势所必然。考其源头，总在太阳病下之而来，
故虽有已成坏病、未成坏病之分，但宜以活法治之，不得据脉治脉、据证治证也。
太阳病，二、三日，不能卧，但欲起，心下必结，脉微弱者，此本有寒分也，反下之
，若利止，必作结胸，未止者，四日复下之，此作协热利也。
【按】
四日复下之「之」字，当是「利」字。上文利未止，岂有复下之理乎！细玩自知，是
必传写之误。
【注】
太阳病，谓头项强痛而恶寒也。二、二日见不得卧但欲起之证，谓已传阳明也。心下
，胃之分也；必结，谓胃分必有结也。若脉实大乃胃分有热而结也，则当下之。今脉
微弱，是胃分有寒而结也，法不当下，不当下而下之，谓之反下。二、三日，正常解
太阳、阳明之表，反下之，表热乘虚入里，必自利。设利自止，是其人胃实而同燥化
，必作结胸矣。今利未止，四日仍复下利，是其人胃虚而同湿化，故必作协热利也。
【集注】
程知曰：此表证误下，有结胸热利之变，不可不慎也。脉既微弱，则是寒结心下，法
当温散。医见心下结，而下之使利，是治之反也。
汪琥曰：太阳病，二、三日，不卧欲起，心下热结，似乎可下；然脉微弱，其人本有
寒分，岂可下乎？
太阳病，外证未除，而数下之，遂协热而利；利下不止，心下痞□，表里不解者，桂
枝人参汤主之。
【注】
此承上条脉微弱，协热利，互详其证，以明其治也。外证未除，谓太阳病未除，而数
下之，是下非一次也。里因数下而虚，遂协表热而利，利下不止，里虚不固也。心下
痞□，里虚而邪结也，外证既未除，是表不解也，故用桂枝以解表。利下痞□，里因
下虚而从寒化也，其脉必如上文之微弱，故用参、术、姜、草以温里，此温补中两解
表里法也。若其脉有力者，又当从甘草泻心汤之法矣。
【集注】
喻昌曰：误下而致里虚，外热乘之，变而为利不止者，里虚不守也，痞□者，正虚邪
实，中成滞碍，痞寒而不通也。以表未除，故用桂枝以解之。以里适虚，故用理中以
和之。此方即理中加桂枝而易其名，乃治虚痞下利之法也。
李中梓曰：经云：桂枝证医反下之，利遂不止，与葛根黄芩黄连汤。此则又与桂枝人
参汤。何用药有温凉之异邪？盖彼证但曰「下之」，此则曰「数下之」；彼证但曰「
利下」，此则曰「利不止」。合两论味之，自有虚实之分矣。
程知曰：表证误下，下利不止，喘而汗出者，治以葛根芩连。心下痞□者，治以桂枝
、参、术。一救其表邪入里之实热，一救其表邪入里之虚寒，皆表里两解法也。
程应旄曰：协热而利，向来俱作阳邪陷于下焦，果尔，安得用理中耶？盖不知利有寒
热二证也。
芫花（经熬制） 甘遂 大戟 大枣（掰开）十枚
以上三味药，分量相等，分别捣碎过筛成散剂。用一升半水，先煮肥大之十枚大枣，取八合药汁，滤去药渣，加入药末。体质强壮者服一钱匕，体质虚弱者服半钱，温服，于清晨空腹服用。若泻下量少、病邪未除者，次日继续服药，增加半钱剂量，待大便通畅泻下后，食用稀粥以调养身体。
【方解】
张仲景治疗水饮的方剂，种类繁多，此方是最为峻猛的。凡是水气为患，或出现喘、或咳、或心悸、或噎塞、或呕吐、或腹泻，病位局限在一处而止。此处则是水邪停留于体内，心腹部及胁下痞满疼痛，三焦升降之气阻隔难通。此时表邪已罢，非发汗解表之法所宜，里饮实盛，又非淡渗利湿之品所能胜任，若不选用逐水至峻猛之品，以直接折损水势，则中气不支，束手待毙。甘遂、芫花、大戟三味药，皆辛苦气寒且禀性最毒，联合使用，气味相济相须，故可直攻水邪之巢穴，决其水道而大下之，一举而患可平也。然而邪气聚集之处，正气必虚，以毒药攻邪，必伤及脾胃，若无冲和甘缓之品为主宰，则邪气尽而大命亦随之矣。然此药最毒至峻，人参、白术所不能君（主导），甘草又与之相反，故选十枚大而肥之大枣以君之。一来顾护脾胃，二来缓和其峻毒，待得快利之后，糜粥自养，一来使谷气内充；二来使邪气不复作，这是张仲景用毒攻病之法，尽美又尽善也。愚昧之人惑于“甘能中满”之说而不敢用，岂知承制之理乎！
太阳病，外证未解不可下也，下之为逆，欲解外者，宜桂枝汤。
【注】
太阳病外证未解者，谓桂枝汤之表证未解也。凡表证未解，无论已汗未汗，虽有可下之证，而非在急下之例者，均不可下。下之为逆也。欲解外者，仍宜桂枝汤主之。
【集注】
王肯堂曰：但有一毫头痛恶寒 ，即为表证未解，不可下也。
程应旄曰：若下后外证未解者，仍当解外，有的证用是药，不可以既下而遂谓桂枝汤不中与也。
汪琥曰：下之为逆；逆者，为病在外而反攻其内，于治法为不顺也。
太阳病，先发汗不解，而复下之，脉浮者不愈。浮为在外，而反下之，故令不愈。今脉浮，故知在外，当须解外则愈，宜桂枝汤。
【注】
太阳病，先发汗表未解，仍宜汗之，而复下之，治失其宜矣。脉浮者不愈，盖以脉浮，邪在外而反下之，故令不愈也。今误下未成逆，脉仍浮，故知邪尚在外，仍宜桂枝汤解外则愈也。
【集注】
程应旄曰：愈不愈辨之于脉。其愈者，必其脉不浮而离于表也。若脉浮者，知尚在表，则前此之下，自是误下，故令不愈。从前之误，不必计较，只据目前。目前之证，不必计较，只据其脉。脉若浮，知尚在外，虽日久尚须解外则愈。有是脉，用是药，亦不以既下，而遂以桂枝汤为不中与也。
本发汗而复下之，此为逆也；若先发汗，治不为逆。本先下之，而反汗之，为逆；若先下之，治不为逆。
【注】
立治逆之法，不外乎表里；而表里之治，不外乎汗下。病有表里证者，当审其汗、下何先，先后得宜为顺，失宜为逆。若表急于里，本应先汗而反下之，此为逆也；若先汗而后下，治不为逆也。若里急于表，本应先下，而反汗之，此为逆也；若先下而后汗，治不为逆也。
【集注】
程知曰：言汗下有先后缓急，不得倒行逆施。汪琥曰：治伤寒之法，表证急者即宜汗，里证急者即宜下，不可拘拘于先汗而后下也。汗下得宜，治不为逆。
太阳病，下之，其脉促不结胸者，此为欲解也。脉浮者必结胸，脉紧者必咽痛，脉弦者必两□拘急，脉细数者头痛未止，脉沈紧者必呕，脉沉滑者协热利，脉浮滑者，必下血。
【按】
脉促当是「脉浮」，始与不结胸为欲解之文义相属。脉浮当是「脉促」，始与论中结胸、胸满同义。脉紧当是「脉细数」，脉细数当是「脉紧」，始合论中二经本脉。脉浮滑当是「脉数滑」，浮滑是论中白虎汤证之脉，数滑是论中下脓血之脉。细玩诸篇自知。
【注】
病在太阳，误下，为变不同者，皆因人之藏气不一，各从所入而化，故不同也。误下邪陷，当作结胸，反不结胸，其脉浮，此里和而不受邪，邪仍在表为欲解也。若脉促者，为阳结实邪之脉，故必结胸也。脉细数，少阴邪热之脉，咽痛，少阴邪热之证；误下邪陷少阴，法当从少阴治也。脉弦少阳之脉，两□拘急，少阳之证；误下邪陷少阳，法当从少阳治也。脉紧太阳脉，头痛太阳证；误下邪仍在表，法当从太阳治也。脉沉紧，寒邪入里之脉，欲呕，胃阳格拒之证；有表误下，邪陷在胃，法当从阳明治也。脉沉滑，宿食脉，有表误下，协热入里下利，法当从协热下利治也。脉数滑，积热脉，有表误下邪陷入阴，伤荣下血，法当从下脓血治也。
【按】
脉促固阳脉也，若促而有力为实，则为结胸实邪之证；若促而无力为虚，则为胸满虚邪之证。故论中有脉促结胸，头汗小潮热者，用陷胸汤攻之；脉促胸满，汗出微恶寒者，用桂枝去芍药加附子汤温之。观此促脉虚实治法，则可以类推矣。
【按】
咽痛，少阴寒热俱有之证也。咽干肿痛者为热，不干不肿而痛者为寒，故少阴论中有甘桔汤、通脉四逆汤二治法也。
【集注】
方有执曰：凡在太阳皆表证也。误下则变证杂出，而不可以一途拘之。
程知曰：不宜下而下之，诸变不可胜数，此之谓也。今咽痛□急欲呕，是寒邪入里之变。头痛热利下血，是风邪入里之变。所以然者，脉浮滑数为阳，沉弦紧细为阴也。
程应旄曰：据脉见证，各着一必字，见势所必然。考其源头，总在太阳病下之而来，故虽有已成坏病、未成坏病之分，但宜以活法治之，不得据脉治脉、据证治证也。
太阳病，二、三日，不能卧，但欲起，心下必结，脉微弱者，此本有寒分也，反下之，若利止，必作结胸，未止者，四日复下之，此作协热利也。
【按】
四日复下之「之」字，当是「利」字。上文利未止，岂有复下之理乎！细玩自知，是必传写之误。
【注】
太阳病，谓头项强痛而恶寒也。二、二日见不得卧但欲起之证，谓已传阳明也。心下，胃之分也；必结，谓胃分必有结也。若脉实大乃胃分有热而结也，则当下之。今脉微弱，是胃分有寒而结也，法不当下，不当下而下之，谓之反下。二、三日，正常解太阳、阳明之表，反下之，表热乘虚入里，必自利。设利自止，是其人胃实而同燥化，必作结胸矣。今利未止，四日仍复下利，是其人胃虚而同湿化，故必作协热利也。
【集注】
程知曰：此表证误下，有结胸热利之变，不可不慎也。脉既微弱，则是寒结心下，法当温散。医见心下结，而下之使利，是治之反也。
汪琥曰：太阳病，二、三日，不卧欲起，心下热结，似乎可下；然脉微弱，其人本有寒分，岂可下乎？
太阳病，外证未除，而数下之，遂协热而利；利下不止，心下痞□，表里不解者，桂枝人参汤主之。
【注】
此承上条脉微弱，协热利，互详其证，以明其治也。外证未除，谓太阳病未除，而数下之，是下非一次也。里因数下而虚，遂协表热而利，利下不止，里虚不固也。心下痞□，里虚而邪结也，外证既未除，是表不解也，故用桂枝以解表。利下痞□，里因下虚而从寒化也，其脉必如上文之微弱，故用参、术、姜、草以温里，此温补中两解表里法也。若其脉有力者，又当从甘草泻心汤之法矣。
【集注】
喻昌曰：误下而致里虚，外热乘之，变而为利不止者，里虚不守也，痞□者，正虚邪实，中成滞碍，痞寒而不通也。以表未除，故用桂枝以解之。以里适虚，故用理中以和之。此方即理中加桂枝而易其名，乃治虚痞下利之法也。
李中梓曰：经云：桂枝证医反下之，利遂不止，与葛根黄芩黄连汤。此则又与桂枝人参汤。何用药有温凉之异邪？盖彼证但曰「下之」，此则曰「数下之」；彼证但曰「利下」，此则曰「利不止」。合两论味之，自有虚实之分矣。
程知曰：表证误下，下利不止，喘而汗出者，治以葛根芩连。心下痞□者，治以桂枝、参、术。一救其表邪入里之实热，一救其表邪入里之虚寒，皆表里两解法也。
程应旄曰：协热而利，向来俱作阳邪陷于下焦，果尔，安得用理中耶？盖不知利有寒热二证也。
Yuanhua (processed by roasting) [Genkwa Flos], Gansui [Radix Kansui], Daji [Radix Euphorbiae Pekinensis], Dazao (broken open) [Fructus Jujubae] ten pieces.
The above three ingredients are of equal parts, each separately pounded into powder. Using one sheng and half of water, first decoct the ten plump Dazao, obtain eight ge of liquid, remove the dregs, add the medicinal powder. Strong individuals take one qianbi, weak individuals take half a qianbi, take warm, administer on an empty stomach in the early morning. If the purgation is slight and the disease is not eliminated, continue to take medicine the next day, increase by half a qianbi. After obtaining thorough purgation, nourish oneself with millet porridge.
[Formula Analysis]
Zhang Zhongjing's formulas for treating fluid retention vary greatly; this is the most峻猛 (potent/aggressive) among them. Whenever fluid qi causes pathology, whether presenting as panting, cough, palpitations, dysphagia, vomiting, or diarrhea, the pathology is localized to one area and stops there. Here, however, pathogenic water remains within the interior, causing fullness, distension, and pain in the heart and abdomen as well as the hypochondrium, obstructing the ascending and descending qi of the Sanjiao (Triple Burner), making it difficult to unblock. At this time, exterior pathogens have ceased, so diaphoretic methods are inappropriate; interior fluid retention is substantial and robust, so bland and permeating diuretic agents cannot overcome it. Without selecting extremely potent phlegm-draining herbs to directly subdue the pathogen, the Middle Qi will collapse, leaving one helpless awaiting death. Gansui, Yuanhua, and Daji are all acrid, bitter, and cold in nature, possessing the most toxic properties. Used together, their flavors complement and enhance each other, thus allowing them to directly attack the nest of pathogenic water, drain its channels, and induce severe purgation, thereby resolving the affliction in one stroke. However, where pathogenic factors gather, vital Qi must be deficient. Using toxic substances to attack pathogens inevitably damages the Spleen and Stomach. Without harmonious and sweet-soothing substances to act as masters, once the pathogens are exhausted, life itself will also perish. Since these medicines are extremely toxic and potent, Renshen (Ginseng) and Baizhu (Atractylodes Macrocephala Rhizome) cannot serve as sovereigns, and Gancao (Licorice Root) is incompatible with them. Therefore, ten large and plump Dazao are selected as the sovereign herb. One purpose is to protect the Spleen and Stomach, another is to moderate their harsh toxicity. After obtaining thorough purgation, nourishing oneself with millet porridge serves to replenish internal grain Qi internally and prevent the recurrence of pathogens. This is Zhang Zhongjing's method of using toxicity to attack disease, perfect in both beauty and goodness. Ignorant people, confused by the theory that "sweetness can cause fullness in the center," dare not use it, failing to understand the principle of mutual restraint!
In Taiyang disease, if exterior symptoms are unresolved, purgation should not be used; using purgation is contrary to treatment principles. To resolve the exterior, Guizhi Tang (Cinnamon Twig Decoction) is appropriate.
[Annotation]
"Taiyang disease with unresolved exterior symptoms" refers to the unresolved exterior syndrome suitable for Guizhi Tang. Whenever exterior symptoms are unresolved, regardless of whether sweating has been induced previously, even if there are indications for purgation, unless it falls under the category of urgent purgation, purgation must not be used. Using purgation is contrary to treatment principles. To resolve the exterior, Guizhi Tang should still be administered as the primary treatment.
[Collected Notes]
Wang Kentang stated: Even the slightest headache and aversion to cold indicate unresolved exterior symptoms, and purgation should not be used.
Cheng Yingmao stated: If exterior symptoms remain unresolved after purgation, the exterior should still be resolved. If specific indications match the medication, one should not assume that because purgation was already performed, Guizhi Tang is no longer applicable.
Wang Hu stated: Using purgation is contrary; "contrary" means attacking the interior when the disease is in the exterior, which is inconsistent with treatment principles.
In Taiyang disease, if initial diaphoresis fails to resolve the condition, followed by purgation, and the pulse remains floating, recovery will not occur. Floating indicates the pathogen is in the exterior, but purgation was incorrectly applied, hence failure to recover. Now that the pulse is floating, we know the pathogen is still in the exterior; resolving the exterior is necessary for recovery, so Guizhi Tang is appropriate.
[Annotation]
In Taiyang disease, if initial diaphoresis fails to resolve the exterior, diaphoresis should still be indicated, but subsequent purgation represents an inappropriate treatment. The failure to recover with a floating pulse is because the pathogen is in the exterior, yet purgation was incorrectly applied. Although the incorrect purgation has not yet led to a fully adverse state, the pulse remains floating, indicating the pathogen is still in the exterior; therefore, Guizhi Tang should still be used to resolve the exterior for recovery.
[Collected Notes]
Cheng Yingmao stated: Recovery or non-recovery is distinguished by the pulse. Those who recover will have a pulse that is no longer floating and has left the exterior. If the pulse is floating, it indicates the pathogen is still in the exterior, meaning the previous purgation was incorrect, leading to non-recovery. Do not dwell on past errors; focus only on the present. Regarding current symptoms, do not dwell on them; focus only on the pulse. If the pulse is floating, knowing the pathogen is still in the exterior, even if many days have passed, resolving the exterior is still required for recovery. With such a pulse, use such a medication; do not assume that because purgation was performed, Guizhi Tang is no longer applicable.
Originally, diaphoresis should have been used, but purgation was applied instead; this is contrary. If diaphoresis is used first, the treatment is not contrary. Originally, purgation should have been used first, but diaphoresis was applied instead; this is contrary. If purgation is used first, the treatment is not contrary.
[Annotation]
The principles for managing contraindicated treatments revolve around the Exterior and Interior; treatment of the Exterior and Interior revolves around diaphoresis and purgation. For diseases presenting with both exterior and interior syndromes, one must determine whether diaphoresis or purgation should come first. Proper sequencing is compliant; improper sequencing is contrary. If the exterior urgency exceeds the interior, diaphoresis should be used first, but purgation was incorrectly applied; this is contrary. If diaphoresis is used first, followed by purgation, the treatment is not contrary. If the interior urgency exceeds the exterior, purgation should be used first, but diaphoresis was incorrectly applied; this is contrary. If purgation is used first, followed by diaphoresis, the treatment is not contrary.
[Collected Notes]
Cheng Zhi stated: This discusses the sequence and urgency of diaphoresis and purgation; one must not act backwards or against the natural order. Wang Hu stated: In treating Cold Damage, if exterior symptoms are urgent, diaphoresis is appropriate; if interior symptoms are urgent, purgation is appropriate. One should not rigidly adhere to "diaphoresis first, then purgation." Proper application of diaphoresis and purgation ensures the treatment is not contrary.
In Taiyang disease, after incorrect purgation, if the pulse is rapid-intermittent (Cu) and there is no Chest Binding (Jie Xiong), this indicates impending resolution. If the pulse is floating, Chest Binding will definitely occur; if tight, throat pain will definitely occur; if wiry, bilateral stiffness and spasm will definitely occur; if fine and rapid, headache will persist; if deep and tight, vomiting will definitely occur; if deep and slippery, heat-collateral diarrhea will occur; if floating and slippery, bleeding from below will definitely occur.
[Commentary]
"Cu" (rapid-intermittent) should likely be "floating"; only then does it align semantically with "no Chest Binding" indicating impending resolution. "Floating" should likely be "Cu"; only then does it align with the discussion of Chest Binding and chest fullness in the treatise. "Tight" should likely be "fine and rapid"; "fine and rapid" should likely be "tight"; only then does it conform to the fundamental pulses of the two meridians discussed. "Floating and slippery" should likely be "rapid and slippery"; floating-slippery is the pulse for Baihu Tang syndrome in the treatise, while rapid-slippery is the pulse for passing pus and blood. Careful study of various chapters will reveal this.
[Annotation]
When the disease is in Taiyang, incorrect purgation leads to different transformations due to individual differences in organ Qi, transforming according to where the pathogen enters. Incorrect purgation causing pathogen sinking should result in Chest Binding; conversely, if Chest Binding does not occur and the pulse is floating, this indicates interior harmony rejecting the pathogen, with the pathogen remaining in the exterior, signifying impending resolution. If the pulse is Cu, it is the pulse of Yang solidifying with excess pathogens, so Chest Binding will definitely occur. Fine and rapid is the pulse of Shaoyin pathogenic heat; throat pain is a Shaoyin pathogenic heat symptom; incorrect purgation causing pathogen sinking into Shaoyin requires treatment according to Shaoyin principles. Wiry is the pulse of Shaoyang; bilateral stiffness and spasm are Shaoyang symptoms; incorrect purgation causing pathogen sinking into Shaoyang requires treatment according to Shaoyang principles. Tight is the pulse of Taiyang; headache is a Taiyang symptom; incorrect purgation leaving the pathogen in the exterior requires treatment according to Taiyang principles. Deep and tight is the pulse of cold pathogens entering the interior; desire to vomit is a symptom of Stomach Yang repelling; having an exterior condition, incorrect purgation causes pathogen sinking into the Stomach, requiring treatment according to Yangming principles. Deep and slippery is the pulse of retained food; having an exterior condition, incorrect purgation causes heat-collateral entry into the interior leading to diarrhea, requiring treatment for heat-collateral diarrhea. Rapid and slippery is the pulse of accumulated heat; having an exterior condition, incorrect purgation causes pathogen sinking into Yin, damaging Ying (Nutritive Qi) and leading to lower bleeding, requiring treatment for passing pus and blood.
[Commentary]
Cu is indeed a Yang pulse. If Cu is forceful, it indicates excess, representing the syndrome of real pathogens in Chest Binding; if Cu is weak, it indicates deficiency, representing the syndrome of deficient pathogens in chest fullness. Thus, in the treatise, cases with Cu pulse, Chest Binding, head sweat, and minor tidal fever use Xiantong Tang to attack; cases with Cu pulse, chest fullness, sweating, and slight aversion to cold use Guizhi Qu Shaoyao Jia Fuzi Tang to warm. Observing the treatment methods for deficiency and excess in Cu pulses allows for analogy.
[Commentary]
Throat pain is a symptom present in both cold and heat conditions of Shaoyin. Dry, swollen, and painful throat indicates heat; non-dry, non-swollen but painful throat indicates cold. Thus, in the Shaoyin chapter, there are two treatment methods: Ganjie Tang and Tongmai Sini Tang.
[Collected Notes]
Fang Youzhi stated: All conditions in Taiyang are exterior syndromes. Incorrect purgation leads to mixed transformational symptoms, which cannot be restricted to a single approach.
Cheng Zhi stated: Improper purgation leads to countless transformations, which is what this refers to. Now, throat pain, abdominal urgency, and desire to vomit are transformations of cold pathogens entering the interior. Headache, hot diarrhea, and lower bleeding are transformations of wind pathogens entering the interior. The reason is that floating, slippery, and rapid pulses are Yang, while deep, wiry, tight, and fine pulses are Yin.
Cheng Yingmao stated: Based on pulse and symptoms, each uses the word "definitely," showing inevitability. Tracing the source, it always stems from Taiyang disease treated with incorrect purgation. Thus, although there is a distinction between formed and unformed damaged diseases, living methods should be used; one must not treat merely based on pulse or symptom alone.
In Taiyang disease, on the second or third day, inability to lie down, only desiring to rise, with必定 (must) knotting in the epigastrium, and a weak and faint pulse indicates pre-existing cold accumulation. Applying purgation contrary to this, if diarrhea stops, Chest Binding will definitely develop; if it does not stop, and on the fourth day purgation is repeated, this results in heat-collateral diarrhea.
[Commentary]
The character "zhi" (of/it) in "repeat purgation on the fourth day" should be "li" (diarrhea). Given the previous statement that diarrhea had not stopped, how could purgation be repeated? Careful study reveals this must be a transcription error.
[Annotation]
Taiyang disease refers to stiffness and pain in the head and neck with aversion to cold. On the second or third day, seeing symptoms of inability to lie down and only desiring to rise indicates transmission to Yangming. "Epigastrium" refers to the Stomach region; "must knot" means there must be knotting in the Stomach region. If the pulse is substantial and large, it indicates heat knotting in the Stomach region, warranting purgation. Now, the pulse is weak and faint, indicating cold knotting in the Stomach region; purgation is not indicated. Applying purgation when not indicated is called "contrary purgation." On the second or third day, normally resolving Taiyang and Yangming exterior, applying contrary purgation allows exterior heat to enter the interior via deficiency,必定 (must) causing spontaneous diarrhea. If diarrhea stops spontaneously, it indicates the person has Stomach excess transforming with dryness,必定 (must) developing Chest Binding. Now, since diarrhea has not stopped, and on the fourth day diarrhea recurs, it indicates the person has Stomach deficiency transforming with dampness, thus必定 (must) developing heat-collateral diarrhea.
[Collected Notes]
Cheng Zhi stated: This shows that incorrect purgation of exterior symptoms can lead to transformations of Chest Binding and hot diarrhea; caution is essential. Since the pulse is weak and faint, it indicates cold knotting in the epigastrium, requiring warming and dispersing. The physician sees epigastric knotting and applies purgation to induce diarrhea, which is contrary to proper treatment.
Wang Hu stated: In Taiyang disease, on the second or third day, inability to lie down, desiring to rise, and heat knotting in the epigastrium seem amenable to purgation; however, with a weak and faint pulse, the person inherently has cold accumulation; how can purgation be used?
In Taiyang disease, if exterior symptoms remain unresolved, and multiple purgations are applied, resulting in heat-collateral diarrhea; if diarrhea continues incessantly, with epigastric fullness and obstruction, and both exterior and interior remain unresolved, Guizhi Renshen Tang (Cinnamon Twig and Ginseng Decoction) is the primary treatment.
[Annotation]
This follows the previous clause regarding weak/faint pulse and heat-collateral diarrhea, detailing the symptoms to clarify the treatment. "Exterior symptoms unresolved" means Taiyang disease persists, and "multiple purgations" implies purgation was not a one-time event. The interior becomes deficient due to repeated purgation, subsequently collaborating with exterior heat to cause diarrhea; incessant diarrhea indicates interior deficiency failing to secure. Epigastric fullness and obstruction indicate interior deficiency with pathogenic knotting. Since exterior symptoms are unresolved, the exterior is not cleared; thus, Guizhi is used to resolve the exterior. Diarrhea with epigastric fullness and obstruction indicates the interior, due to deficiency from purgation, transforms into cold; the pulse will undoubtedly be weak and faint as described earlier; thus, Renshen, Baizhu, Shengjiang (Fresh Ginger), and Gancao are used to warm the interior. This is a method of warming and tonifying while simultaneously resolving the exterior and interior. If the pulse is forceful, one should follow the method of Ganxiao Xiexin Tang (Licorice and Pinellia Decoction).
[Collected Notes]
Yu Chang stated: Incorrect purgation leads to interior deficiency, allowing external heat to invade, transforming into incessant diarrhea due to interior deficiency failing to guard. Fullness and obstruction indicate righteous deficiency and pathogenic excess, creating stagnation in the middle, resulting in cold fullness without unblocking. Because the exterior is unresolved, Guizhi is used to resolve it. Because the interior is appropriately deficient, Lizhong Tang is used to harmonize it. This formula is essentially Lizhong Tang plus Guizhi with a changed name, serving as a method for treating deficient fullness and diarrhea.
Li Zhongzi stated: The Classics state: If a Guizhi syndrome patient is incorrectly purged, leading to incessant diarrhea, Gegen Huangqin Huanglian Tang (Kudzu, Scutellaria, and Coptis Decoction) is given. Here, Guizhi Renshen Tang is given instead. Why the difference in warming and cooling medications? That case merely says "purged," whereas this case says "repeatedly purged"; that case says "diarrhea," whereas this case says "incessant diarrhea." Comparing the two discussions reveals the distinction between deficiency and excess.
Cheng Zhi stated: For exterior symptoms incorrectly purged, leading to incessant diarrhea, panting, and sweating, Gegen Qinlian Tang is used. For epigastric fullness and obstruction, Guizhi, Renshen, and Baizhu are used. One rescues real heat entering the interior from exterior pathogens; the other rescues deficient cold entering the interior from exterior pathogens. Both are methods of simultaneously resolving the exterior and interior.
Cheng Yingmao stated: Heat-collateral diarrhea has traditionally been viewed as Yang pathogens sinking into the Lower Jiao. If so, how could Lizhong Tang be used? This is because one does not know that diarrhea has both cold and heat syndromes.