柴胡四两 半夏（洗）二合 龙骨一两半 人参一两半 大黄二两 牡蛎一两半 茯
苓一两半 铅丹一两半 桂枝一两半 生姜一两半 大枣（擘）二枚
右十一味，以水八升，煮取四升，内大黄切如碁子，更煮一、二沸，去滓，温服一升
。
【方解】
是证也，为阴阳错杂之邪；是方也，亦攻补错杂之药。柴、桂解未尽之表邪，大黄攻
已陷之里热，人参、姜、枣补虚而和胃，茯苓、半夏利水而降逆，龙骨、牡蛎、铅丹
之涩重，镇惊收心而安神明，斯为以错杂之药，而治错杂之病也。
@@@
汗家重发汗，必恍惚心乱，小便已阴痛，与禹余粮丸。
【按】
禹余粮丸为涩痢之药，与此证不合。「与禹余粮丸」五字，衍文也。
【注】
汗家，谓平素好出汗之人也。重发汗，谓大发汗也。心主血，汗乃心之液，重发其汗
，血液大伤，心失所恃，故神情恍惚，心志不宁也。液竭于下，宗筋失养，故小便已
，阴茎疼也。
【集注】
方有执曰：心主血而藏神，汗多则血虚而舍空，恍惚心乱者，以舍空神纷散也。阴，
宗筋也。痛者，液竭而失其所荣养也。
程应旄曰：心主血，汗者心之液，平素多汗之家，心虚血少可知。重发其汗，遂至心
失所养，神恍惚而多忡憧之象，此之谓乱。小肠与心为表里，心液虚而小肠之水亦竭
，故小便已而阴疼也。
@@@
衄家不可发汗，汗出必额上陷，脉紧急，目直视，不能眴，不得眠。
【注】
衄家者，该吐血而言也。谓凡衄血、吐血之人，阴气暴亡，若再发其汗，汗出液竭，
诸脉失养，则额角上陷，中之脉，为热所灼，故紧且急也。目直视，目瞪不转睛也。
不能眴，目睫不合也。亦皆由热灼其脉，引缩使然。不得眠者，阳气不能行于阴也。
凡此所见之病，皆阳盛阴微之危证，谁谓衄家可轻发其汗耶！
【集注】
喻昌曰：目得血而能视，汗为血液，衄血之人清阳之气素伤，更发其汗，则额上必陷
，乃上焦枯竭之应也。诸脉皆属于目筋，脉紧急，则目上瞪而不能合，目不合，则不
得眠也。伤寒发烦目瞑者，必衄，宜麻黄汤发其汗。此言素常失血之人，戒发其汗，
以重虚其虚故也。
@@@
亡血家不可发汗，发汗则寒栗而振。
【注】
凡失血之后，血气未复，为亡血虚家，皆不可发汗也。盖失血之初，固属阳热，然亡
血之后，热随血去，热固消矣，而气随血亡，阳亦危矣。若再发汗，则阳气衰微，力
不能支，故身寒噤栗，振振耸动，所必然也。盖发阴虚之汗，汗出则亡阴，即发暴吐
衄血之汗也，故见不能眴、不得眠亡阴等病也。发阳虚之汗，汗出则亡阳，即发亡血
虚家之汗也，故见寒栗而振，亡阳等病也。
【集注】
方有执曰：亡血阴已虚矣，发汗复亡其阳，故寒栗而振也。
程应旄曰：亡血阴虚，阳已失根据，若发其汗，阳从外脱，故寒栗而振，是为阴阳两竭
。凡遇当汗证，盒饭顾虑阴经之荣血，有如此者。
魏荔彤曰：与其汗出亡阳方救阳，何如汗未出先救阴以维阳，不令汗出亡阳之为愈也
。
@@@
咽喉干燥者，不可发汗。
【注】
咽喉干燥，津液不足也，更发其汗，则津液益枯，故戒。人虽有可汗之证，亦不可发
汗也。
【集注】
方有执曰：咽喉干燥，津液素亏，本于肾水不足，盖少阴之脉循喉咙也，发汗则津液
愈亡。
程应旄曰：凡遇可汗之证，必当顾虑上焦之津液，又有如此者。
张璐曰：此条与咽中闭塞，似同实异。此戒发汗以夺阳明之津，彼戒发汗以夺少阴之
血也。
@@@
淋家不可发汗，发汗则便血。
【注】
淋家者，湿热蓄于膀胱，水道涩痛之病也。若发其汗，湿随汗去，热必独留，水府告
匮，迫其本经之血，从小便而出矣。
【集注】
程知曰：膀胱里热则淋，更发其汗则膀胱愈燥，而小便血矣。
@@@
疮家虽身疼痛，不可发汗，发汗则痉。
【注】
疮家初起毒热未成，法当汗散。已经溃后，血气被伤，虽有身痛应汗表证，亦不可发
汗。恐汗出荣卫俞虚，外风乘袭，即不受外风，筋失液养，亦必致项强反张，而成痉
病也。
【集注】
喻昌曰：身疼痛为寒伤荣之证，本当发汗，疮疡之人，肌表素虚，荣血暗耗，更发其
汗，则外风袭虚，内血不荣，必致颈项强，身反张而成痉。痉亦膀胱之病也。
@@@
太阳伤寒者，加温针必惊也。烧针令其汗，针处被寒，核起而赤者，必发奔豚，气从
少腹上冲心者，先灸核上各一壮，与桂枝加桂汤，更加桂。
【注】
太阳伤寒，加温针必惊者，谓病伤寒之人，卒然加以温针，其心畏而必惊也，非温针
之后，必生惊病也。烧针即温针也，烧针取汗，亦是汗法，但针处宜当避寒，若不谨
慎，外被寒袭，火郁脉中，血不流行，必结肿核赤起矣。且温针之火，发为赤核，又
被寒侵，故不但不解，反召阴邪。盖加针之时，心既被惊，所以肾阴乘心之虚，上凌
心阳而发奔豚也。奔豚者，肾阴邪也，其状气从少腹上冲于心也。先灸核上各一壮者
，外去寒邪，继与桂枝加桂汤。更加桂者，内伐肾邪也。
【方解】
此证属于阴阳错杂之邪气；此方也是攻邪与补虚混杂的药物。柴胡、桂枝解除尚未完全解散的表邪，大黄攻逐已经陷入体内的里热，人参、生姜、大枣补益虚弱并调和胃气，茯苓、半夏通利水湿并降逆气，龙骨、牡蛎、铅丹具有收敛固涩和质重下沉的特性，能够镇惊安神、收敛心神以安定神明，这就是用混杂的药性来治疗混杂的病证。
@@@
平素多汗的人，如果再大发其汗，必然会出现心神恍惚、心中烦乱的症状，小便结束后阴茎疼痛，应当给予禹余粮丸。
【按语】
禹余粮丸是用于涩肠止痢的药物，与此证候不相符合。“给予禹余粮丸”这五个字，是衍文（多余的文字）。
【注释】
“汗家”，指平时容易出汗的人。“重发汗”，指大发其汗。心主血，汗是心的津液，如果大发其汗，血液大量受损，心失去所依靠的物质基础，所以神情恍惚，心志不宁。津液在下部枯竭，宗筋失去滋养，所以小便结束后，阴茎会疼痛。
【集注】
方有执说：心主血而藏神，汗出过多则血虚而心舍空虚，出现心神恍惚、心中烦乱，是因为心舍空虚导致神志纷散。阴，指宗筋。疼痛，是因为津液枯竭而失去荣养。
程应旄说：心主血，汗是心的津液，平时多汗的人，可知其心虚血少。如果再次大发其汗，致使心失所养，神志恍惚且多有惊恐不安的现象，这就叫做“乱”。小肠与心互为表里，心液虚亏则小肠之水也枯竭，所以小便结束后阴部疼痛。
@@@
经常鼻出血的人，不可发汗，如果发汗导致出汗，必然出现额角凹陷，脉象紧急，眼睛直视不能转动，无法眨眼，不能入睡。
【注释】
“衄家”，包括吐血在内而言。凡是患有鼻衄、吐血的人，阴气突然亡失，如果再发其汗，汗出则津液枯竭，所有经脉失去滋养，就会导致额角上陷下，其中的脉道被热邪灼伤，所以脉象紧且急。目直视，是指眼睛瞪大不转动。不能眴（xuàn），是指眼睑不能开合。这些都是由于热邪灼伤脉道，牵引收缩所致。不能入睡，是因为阳气不能行入于阴分。凡此所见到的病证，都是阳盛阴微的危险证候，谁说鼻衄之人可以轻易发其汗呢！
【集注】
喻昌说：眼睛得到血的滋养才能视物，汗也是血液的一种，鼻衄之人清阳之气素来受伤，再发其汗，则额上必然凹陷，这是上焦枯竭的表现。诸脉都连属于目筋，脉象紧急，则眼睛向上瞪而不能闭合，眼睛不闭合，就不能入睡。伤寒出现心烦、眼睛昏花者，必然会鼻衄，适宜用麻黄汤发其汗。这里说的是平时经常失血的人，告诫不可发汗，以免使虚者更虚。
@@@
失血的人不可发汗，如果发汗，则会出现身体寒冷战栗、颤抖。
【注释】
凡是失血之后，气血尚未恢复，属于亡血虚家，都不可发汗。大概失血之初，固然属于阳热证，然而亡血之后，热随血而去，热邪固然消退了，但气随血亡，阳气也危险了。如果再发汗，则阳气衰微，力量不能支撑，所以身体寒冷战栗，颤抖耸动，这是必然的结果。大概发阴虚之汗，汗出则亡阴，即发暴吐、鼻衄之汗，所以出现无法眨眼、不能入睡等亡阴的病证。发阳虚之汗，汗出则亡阳，即发亡血虚家之汗，所以出现寒战颤抖等亡阳的病证。
【集注】
方有执说：亡血则阴已虚，再发汗又亡其阳，所以出现寒战颤抖。
程应旄说：亡血导致阴虚，阳气已经失去依托，如果发其汗，阳气从体表脱失，所以寒战颤抖，这是阴阳两竭。凡是遇到应当发汗的证候，必须顾虑阴经的营血，情况如此。
魏荔彤说：与其在汗出后亡阳再去救阳，何如在汗未出时先救阴以维系阳气，不让汗出亡阳更好呢？
@@@
咽喉干燥的人，不可发汗。
【注释】
咽喉干燥，是津液不足的表现，如果再发其汗，则津液更加枯槁，所以告诫不可发汗。人即使有可发汗的证候，也不可以发汗。
【集注】
方有执说：咽喉干燥，是津液素来亏损，根本在于肾水不足，因为少阴经脉循行经过喉咙，发汗则津液更加亡失。
程应旄说：凡是遇到可发汗的证候，必须顾虑上焦的津液，情况如此。
张璐说：这一条与咽中闭塞，看似相同实则不同。这条是告诫发汗会夺取阳明之津，那条是告诫发汗会夺取少阴之血。
@@@
淋证患者不可发汗，如果发汗，则会导致尿血。
【注释】
“淋家”，是指湿热蓄积在膀胱，水道涩滞疼痛的病证。如果发其汗，湿气随汗而去，热邪必定独自留存，水府告急匮乏，逼迫本经之血，从小便排出。
【集注】
程知说：膀胱里有热则患淋证，再发其汗则膀胱更加燥热，从而出现尿血。
@@@
疮疡患者虽然身体疼痛，不可发汗，如果发汗，则会导致痉病。
【注释】
疮疡初起，毒热未成脓时，法当用汗法消散。如果已经溃破之后，气血受到损伤，即使有身体疼痛这种应当发汗解表的证候，也不可发汗。恐怕汗出导致营卫俞穴虚弱，外风乘虚侵袭，即使不受外风侵袭，筋脉失去津液滋养，也必然导致项强反张，而成痉病。
【集注】
喻昌说：身体疼痛是寒邪伤及营血的证候，本当发汗，但疮疡之人，肌表素来虚弱，营血暗中耗损，再发其汗，则外风袭虚，内血不荣，必然导致颈项强直，身体反张而成痉病。痉病也是膀胱的病。
@@@
太阳伤寒证，如果加用温针，必然会引起惊恐。烧针令其出汗，如果针孔处受寒，出现红肿结块且发红的，必然会发生奔豚病，气从少腹上冲至心脏的，先在红肿结块上各灸一壮，然后给予桂枝加桂汤，增加桂枝用量。
【注释】
太阳伤寒证，加用温针必然引起惊恐，是说患伤寒病的人，突然加上温针，心里畏惧而必然惊恐，并不是说温针之后必然产生惊病。烧针就是温针，烧针取汗，也是汗法，但针孔处应当避寒，如果不谨慎，外受寒邪侵袭，火郁结在脉中，血液运行不畅，必然结成红肿的硬块。而且温针之火，引发赤色硬块，又被寒邪侵扰，所以不仅病不解，反而招引阴邪。大概施针之时，心既被惊吓，所以肾阴乘心之虚，上凌心阳而发奔豚。奔豚，是肾的阴邪，其症状是气从少腹上冲于心。先在红肿结块上各灸一壮，是为了外去寒邪，继而又给予桂枝加桂汤。增加桂枝用量，是为了内伐肾邪。
[Analysis of the Formula]
This syndrome involves pathogens that are a mixture of Yin and Yang; this formula consists of herbs that mix purgative (attacking) and tonifying properties. Chai Hu (Bupleuri Radix) and Gui Zhi (Cinnamomi Ramulus) resolve the exterior pathogens that have not yet been fully dispersed; Da Huang (Rhei Radix et Rhizoma) attacks the interior heat that has already sunk inward; Ren Shen (Ginseng Radix), Sheng Jiang (Zingiberis Rhizoma Recens), and Da Zao (Jujubae Fructus) tonify deficiency and harmonize the Stomach; Fu Ling (Poria) and Ban Xia (Pinelliae Rhizoma) promote water metabolism and direct rebellious Qi downward; Long Gu (Fossilia Ossis Mastodi), Mu Li (Ostreae Concha), and Qian Dan (Plumbi Oxidum) possess astringent and heavy-sinking properties, calming fright, consolidating the Heart, and stabilizing the Spirit (Shen). Thus, this is using a mixed formula to treat a mixed disease.
@@@
In individuals who habitually sweat profusely (Han Jia), inducing severe sweating again will inevitably lead to mental confusion and restlessness (Huang Hu Xin Luan), and pain in the genitalia after urination. One should administer Yu Yu Liang Wan (Halloysitum Pill).
[Commentary]
Yu Yu Liang Wan is an astringent formula for dysentery, which does not match this syndrome. The five characters "administer Yu Yu Liang Wan" are likely interpolations (erroneous additions).
[Annotation]
"Han Jia" refers to individuals who habitually sweat. "Chong Fa Han" means inducing severe sweating. The Heart governs Blood, and sweat is the fluid of the Heart. Severe sweating causes significant damage to Blood, causing the Heart to lose its support; thus, there is mental confusion and restlessness. When fluids are exhausted below, the Zong Jin (tendons/genitals) lose nourishment, resulting in penile pain after urination.
[Collected Notes]
Fang Youzhi stated: The Heart governs Blood and houses the Spirit. Excessive sweating leads to Blood deficiency and an empty Heart chamber. Mental confusion arises because the Spirit scatters due to the emptiness of the chamber. The Yin refers to the Zong Jin. Pain results from fluid exhaustion and lack of nourishment.
Cheng Yingmao stated: The Heart governs Blood, and sweat is the Heart's fluid. In those who sweat excessively, Heart deficiency and Blood scarcity are evident. Inducing severe sweating further deprives the Heart of nourishment, leading to a scattered Spirit and palpitations, termed "confusion." The Small Intestine and Heart are exterior-interior pairs. If Heart fluids are deficient, Small Intestine fluids also dry up, causing genital pain after urination.
@@@
Individuals with a history of epistaxis (Nu Jia) must not be induced to sweat. If sweating occurs, it will inevitably lead to depression of the supraorbital region, urgent/tight pulse, staring eyes that cannot move, inability to blink, and insomnia.
[Annotation]
"Nu Jia" includes hematemesis. For those suffering from epistaxis or hematemesis, Yin Qi is suddenly depleted. If sweating is induced again, fluid exhaustion occurs, and all vessels lose nourishment. This leads to depression of the forehead corners, where the vessels are scorched by heat, becoming tight and urgent. "Staring eyes" means the eyes are fixed and unblinking. "Inability to blink" refers to the eyelids failing to close. These are caused by heat scorching the vessels, causing contraction. Insomnia occurs because Yang Qi cannot enter Yin. All these conditions represent critical syndromes of excess Yang and deficient Yin; who would say that individuals with a history of bleeding can be lightly induced to sweat?
[Collected Notes]
Yu Chang stated: The eyes see only when nourished by Blood; sweat is a form of blood fluid. In those with epistaxis, Clear Yang Qi is already injured. Further sweating causes the forehead to depress, reflecting depletion of the Upper Jiao. All vessels connect to the eye tendons; a tight pulse causes the eyes to stare upward and remain open. Open eyes prevent sleep. In Taiyang Shang Han, if irritability and eye dizziness occur, epistaxis is likely, and Ma Huang Tang (Ephedra Decoction) should be used to induce sweating. Here, however, it warns against sweating in those with chronic blood loss to avoid exacerbating deficiency.
@@@
Individuals who have suffered blood loss (Wang Xue Jia) must not be induced to sweat. If sweating is induced, they will experience chills and tremors (Han Li Er Zhen).
[Annotation]
After any blood loss, before Qi and Blood recover, one must not induce sweating in these "Wang Xue Xu Jia" (deficient individuals due to blood loss). Initially, blood loss may involve Yang-Heat, but after blood loss, Heat leaves with the Blood, so Heat subsides. However, Qi follows Blood into loss, so Yang becomes precarious. If sweating is induced again, Yang Qi becomes severely deficient and unable to sustain itself, inevitably causing cold chills, trembling, and shaking. Inducing sweat in Yin-deficiency leads to Yin collapse (manifesting as inability to blink and insomnia); inducing sweat in Yang-deficiency leads to Yang collapse (manifesting as chills and tremors).
[Collected Notes]
Fang Youzhi stated: Blood loss implies prior Yin deficiency; inducing sweat further depletes Yang, causing chills and tremors.
Cheng Yingmao stated: Blood loss causes Yin deficiency, leaving Yang without support. Sweating causes Yang to escape outward, resulting in chills and tremors, indicating exhaustion of both Yin and Yang. When encountering indications for sweating, one must consider the Ying Blood of the Yin channels.
Wei Litong stated: Rather than rescuing Yang after sweat-induced Yang collapse, it is better to tonify Yin beforehand to secure Yang, preventing Yang collapse through sweating.
@@@
Individuals with dry throat (Yan Hou Gan Zao) must not be induced to sweat.
[Annotation]
Dry throat indicates insufficient Body Fluids (Jin Ye). Inducing sweating would further desiccate fluids; hence, it is prohibited. Even if other indications for sweating exist, sweating must not be induced.
[Collected Notes]
Fang Youzhi stated: Dry throat indicates chronic fluid deficiency rooted in Kidney Water insufficiency, as the Sha Yin (Lesser Yin) meridian circulates around the throat. Sweating causes further fluid loss.
Cheng Yingmao stated: In cases suitable for sweating, one must always consider the fluids of the Upper Jiao.
Zhang Lu stated: This clause differs from "obstruction in the throat." This warns against taking Yang Ming fluids via sweating; the other warns against taking Shao Yin Blood via sweating.
@@@
Individuals with strangury (Lin Jia) must not be induced to sweat. If sweating is induced, hematuria (blood in urine) will result.
[Annotation]
"Lin Jia" refers to diseases characterized by damp-heat accumulation in the Bladder, causing painful and difficult urination. If sweating is induced, dampness leaves with the sweat, but Heat remains alone. The Water House (Bladder) becomes depleted, forcing Blood from the meridian to exit via urination.
[Collected Notes]
Cheng Zhi stated: Heat in the Bladder causes strangury; further sweating dries the Bladder, leading to hematuria.
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Individuals with sores and ulcers (Chuang Jia) who suffer body pain must not be induced to sweat. If sweating is induced, Jing Disease (spasm/convulsion) will develop.
[Annotation]
When sores first appear and toxic heat has not yet formed pus, sweating may be used to disperse. However, after ulceration, Qi and Blood are damaged. Even if body pain suggests an exterior syndrome requiring sweating, it must not be induced. Fearful that sweating depletes Ying and Wei Qi at the acupoints, allowing external Wind to invade. Even without external Wind, the tendons lose fluid nourishment, inevitably leading to neck stiffness and opisthotonos, forming Jing Disease.
[Collected Notes]
Yu Chang stated: Body pain indicates Cold injuring Ying Blood, typically treated with sweating. However, those with sores have weak exterior and hidden Ying Blood consumption. Sweating invites external Wind and fails to nourish internal Blood, leading to neck stiffness and opisthotonos. Jing Disease is also a Bladder disorder.
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In Taiyang Shang Han (Cold Damage), applying warm needle therapy (Wen Zhen) will inevitably cause fright. If burning needles (Shao Zhen) are used to induce sweating, and the needle site is exposed to Cold, resulting in red nodules, Ben Tun (Running Piglet) syndrome will occur, characterized by Qi rushing from the lower abdomen to the Heart. First, moxa each nodule once (one Zhu), then administer Gui Zhi Jia Gui Tang (Cinnamon Twig Plus Cinnamon Decoction), increasing the amount of Gui Zhi.
[Annotation]
Applying warm needles to Taiyang Shang Han causes fright because the patient fears the sudden application of heat; it does not mean that warm needles invariably cause a fright pathology. Burning needles is a method to induce sweating. The needle site must be protected from Cold. If neglected, external Cold invades, Fire stagnates in the vessels, and Blood flow obstructs, forming red nodules. The fire from the warm needle creates red nodules, which are then invaded by Cold. Instead of resolving the pathogen, this attracts Yin pathogens. Since the Heart was frightened during needling, Kidney Yin takes advantage of Heart deficiency to overwhelm Heart Yang, triggering Ben Tun. Ben Tun is a Kidney Yin pathogen, manifesting as Qi rushing from the lower abdomen to the Heart. Moxa on the nodules expels external Cold externally; Gui Zhi Jia Gui Tang treats internally. Increasing Gui Zhi dosage attacks the Kidney pathogen internally.