栀子（擘）十四枚 干姜二两
右二味，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。
【按】
此方干姜当是香豉。余义详前经文下正误文内。
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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。
【按】
此方香豉当是干姜。余义亦详前经文下正误文内。
【注】
伤寒五六日，邪气在里之时也。大下之后，若身热去，心胸和，是为欲解矣。今身热
不去，邪仍在表也。心中结痛过下里寒也，故曰未欲解也。但此表热里寒之证，欲温
其里，既碍表热，欲解其表，又碍里寒，故惟以栀子之寒，干姜之热，并举而涌之，
则解表温里两得之矣。岂尚有身热结痛而不尽除者哉！此仲景立两难治法，其妙如此
，余可类推矣。
【集注】
王肯堂曰：「身热不去」四字宜玩。结胸身不热，知热不在表也，今身热不去，惟宜
越之而已。
程应旄曰：痛而云结，殊类结胸，但结胸身无大热，知热已尽归于里为实邪。此则身
热不去，则所结者，因下而结，客邪仍在于表，故云未欲解也。
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凡用栀子汤，病人旧微溏者，不可与服之。
【注】
若汗、吐、下后，懊□少气，呕逆烦满，心中结痛者，皆宜以栀子等汤吐之。以其邪
留连于胸胃之间，或与热、与虚、与饮、与气、与寒相结而不实，则病势向上，即经
所谓在上者因而越之意也。若未经汗、吐、下，而有是证，则为实邪，非栀子汤轻剂
所能治矣。又当以瓜蒂散重剂主之也。若病人旧微溏者，虽有是证，但里既久虚，不
可与服，若与之，即使客邪尽去，亦必正困难支，盖病势向下，涌之必生他变也。本
草不言栀子为吐剂，仲景用之以为吐者，何也？栀子本非吐药，以其味苦能吐，故用
之以涌其热也。
【按】
吐药不止栀子也，诸药皆可为之，惟要确审胸胃之邪，是寒、是热、是食、是水、是
痰、是气，因何阻滞，使胸胃阳气不伸，遂以当用之药而吐涌之，自可愈也。如欲吐
寒则以干姜桂皮之类，吐热则以栀子苦茶之类，吐食平胃食盐之类，吐水五苓生姜之
类，吐痰稀涎橘皮之类，吐气流气枳朴之类。但形气弱者，药宜少，仍当佐以补中益
气等升药为妥；形气壮者药宜多，更佐以瓜蒂、藜芦等猛药更效。凡煎吐药汤及调散
，或用酸米汤，或用白汤，或用稀米粥，须备十余钟，令病者顿服一钟，即用指探吐
药出，再服一钟，亦随用指探吐药出，再服再吐，以顺溜快吐为度，则头额身上自有
微汗，所有病证轻减，即为中病，不必尽服余药。若过吐之，即使病尽除，恐损胸中
阳气也，近世之医，以吐为古法不可用，久矣。皆因仲景之道不彰，其法失传，无怪
乎其不敢用也。夫不知其妙，而不敢用，犹之可也，若竟委之曰古法不可用，则不可
也。盖邪之在上者，非吐不愈。若如俗工所云，使病者畏不敢服，因循生变，致轻者
重，重者死，夫谁之咎与抑、知汗、吐、下三法，用之诚当，其证无不立时取效，后
之业医者，又安可只言汗下两法，而置吐法于不用，致使古法沦亡也耶！
【集注】
程知曰：此言服栀子亦有禁忌也。病人旧微溏，里虚也，又服苦寒，则不能上涌，而
反下泄，故禁之。
张志聪曰：此言栀子而不言豉者，申明栀子之苦，能下泄，故病人旧微溏，不可与服
之也。
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太阳病，脉浮紧，无汗，发热，身疼痛，八、九日不解，表证仍在，此当发其汗，服
药已，微除，其人发烦目瞑；剧者，必□，□乃解。所以然者，阳气重故也，麻黄汤
主之。
【按】
张兼善曰：「麻黄汤主之」五字，不当在阳气重之下，岂有□乃解之后，而用麻黄汤
之理乎？其说甚是。况服药已之上，并无所服何药之文，宣将此五字移于其上始合。
【注】
太阳病，脉浮紧，无汗发热身疼痛，八九日不解，谓伤寒表证仍在，当以麻黄汤发其
汗也。服药已，微除者，谓已发汗，邪虽微除，犹未尽除也，仍当汗之，若因循失汗
，则阳邪久郁荣中，不得宣泄，致热并于阳而发烦，热郁于阴而目瞑。剧者，谓热极
也。热极于荣，势必逼脉中之血妄行为□，□则热随血去而解矣。所以然者，阳气重
故也。
【集注】
程知曰：脉见浮紧，表证仍在，虽八九日，仍当以麻黄汗解，服汤已其病微除，至于
烦瞑剧□，乃热郁于荣，阳气重盛，表散之药，与之相搏而然。然至于逼血上□，则
热随血解矣。此言发汗当主以麻黄汤，非□解之后，仍用麻黄汤也。
张璐曰：服药已微除，复发烦者，余邪未尽也。目瞑烦剧者，热盛于轻也，故迫血妄
行而为□，□则余热随血而解也。以汗后复□，故为阳气重也。或言汗后复□，而热
邪仍未尽，重以麻黄汤散其未尽之邪，非也。若果邪热不尽，则「□乃解」三字从何
着落？
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太阳病，脉浮紧，发热身无汗，自□者愈。
【注】
太阳病脉浮紧，发热无汗，此伤寒脉证也，当发其汗。若当汗不汗，则为失汗，失汗
则寒闭于卫，热郁于荣，初若不从卫分汗出而解，久则必从荣分□血而愈也。故太阳
病凡从外解者，惟汗与□二者而已。今既失汗于荣，则荣中血热妄行，自□，热随□
解，必自愈矣。
【集注】
方有执曰：此承上条复以其证之较轻者言，以见亦有不治而自愈者，所以晓人勿妄治
，以致误之意。太阳病脉浮紧，发热身无汗，与上条同，而无疼痛，则比之上条较轻
可知矣。所以不待攻治，得□自愈也。汗本血之液，北人谓□为红汗，即此说耳。
程知曰：言得□虽无汗，必自愈也。人之伤于寒而为热者，得□发越故愈。
张璐曰：□血成流，则邪热随血而散，夺血则无汗也。设不自□，当以麻黄汤发之，
发之而邪解，则不□矣。发之而余邪未尽，必仍□而解。
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伤寒脉浮紧，不发汗，因致□者，麻黄汤主之。
【注】
此承上条以出其治也。伤寒脉浮紧，法当发汗，若不发汗，是失汗也。失汗则热郁于
荣，因而致□者，宜麻黄汤主之。若能于未□之先，早用麻黄汤汗之，汗出则解，必
不致□，其或如上条之自□而解，亦无须乎药也。
【按】
凡伤寒初起，但不甚恶寒，便知夹热后多得□。其热多寒少者，则热随□去，继而汗
出，表与热均解也。其热少寒多者，纵热随□去，继必不汗出，表仍不解。诚能用青
龙、麻黄汤于未□之先发之，则汗□两解矣。若已经□后而汗不出，表不解，即用麻
桂之药，以和荣卫，亦须少兼芩、连、犀、地清阴凉血之品佐之，以护及阴血可也。
然大□之后，麻黄、青龙不可轻用，若用之不当，则犯□家不可汗之戒矣。
【集注】
『活人书』云：□后脉浮者，宜麻黄汤，□后脉微者、不可行麻黄汤，宜黄芩芍药汤
。盖□后脉浮，表未解也；脉微，表已解也，于此见仲景用麻黄汤于□后之大旨。
方有执曰：伤寒脉浮紧者，寒多风少之谓也。上二条皆风多寒少，前条以服药已微除
，汗发不透而致□，上条以较轻得自□，此以寒多不发汗而致□，三条之所以辨差分
也。盖寒多，则于法当发汗，而不发汗，热郁血乱，所以□也。□则阳邪之风散，麻
黄汤者，发其尚未散之寒也。
程知曰：此言寒邪不发之□，仍宜温散也。不发汗而致□，是入荣之寒，不得泄越而
然也。寒不尽则□不止，故仍用麻黄，不必待其□也。此与上条有寒热之别。
程应旄曰：大抵伤寒见□者，由其荣分素热，一被寒闭，荣不受遏，从而上升矣。
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伤寒不大便六、七日，头痛有热者，与承气汤，其小便清者，知不在里，仍在表也，
当须发汗，若头痛者，必□，宜桂枝汤。
【按】
若头痛之「若」字，当是「苦」字，苦头痛，方为必□之证，若是「若」字，则凡头
痛皆能致□矣。
【注】
伤寒不大便六、七日，里已实，似可下也。头痛热未已，表未罢，可汗也。然欲下则
有头痛发热之表，欲汗则有不大便之里，值此两难之时，惟当以小便辨之。其小便浑
赤，是热已在里，即有头痛发热之表，亦属里热，与承气汤下之可也；若小便清白，
是热尚在表也，即有不大便之里，仍属表邪，宜以桂枝汤解之。然伤寒头痛不论表里
，若苦头痛者，是热剧于荣，故必作□，□则荣热解矣。方其未□之时，无汗宜麻黄
汤，有汗宜桂枝汤汗之，则不□而解矣。
【集注】
汪琥曰：头痛不已者，为风寒之邪上壅，热甚于经，势必致□，须乘其未□之时，酌
用麻黄汤或桂枝汤以汗解之，而验小便，实为仲景妙法。
魏荔彤曰：此条之□，乃意料之辞，非已见之证也。
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太阳病不解，热结膀胱，其人如狂，血自下，下者愈，其外不解者，尚未可攻，当先
解其外，外解已，但少腹急结者，乃可攻之，宜桃核承气汤。
【注】
太阳病不解，当传阳明，若不传阳明而邪热随经，瘀于膀胱荣分，则其人必如狂。如
狂者、瘀热内结，心为所扰，有似于狂也。当此之时，血若自下，下者自愈，若不自
下，或下而未尽，则热与瘀血，下蓄膀胱，必少腹急结也。设外证不解者，尚未可攻
，当先以麻黄汤解外；外解已，但少腹急结痛者，乃可攻之，宜桃核承气汤；即调胃
承气加桃核，所以攻热逐血也。盖邪随太阳经来，故又加桂枝以解外而通荣也。先食
服者，谓空腹则药力下行捷也。
【按】
太阳病不解，不传阳明，邪热随经入里，谓之犯本，犯本者，谓犯膀胱之府也。膀胱
府之卫为气分，膀胱府之荣为血分，热入而犯气分，气化不行，热与水结者，谓之犯
卫分之里，五苓散证也；热入而犯血分，血蓄不行，热与血结者，谓之犯荣分之里，
桃核承气汤证也。二者虽皆为犯本之证，二方虽皆治犯本之药，而一从前利，一从后
攻，水与血，主治各不同也。
【集注】
喻昌曰：桃核承气汤用桂枝解外，与大柴胡汤解外相似，益见太阳随经之热，非桂枝
不解也。
程知曰：太阳病不解，随经入府，故热结膀胱。其人如狂者，瘀热内结，心不安宁，
有似于狂也，若血自下，下则热随瘀解矣。然必外证已解，乃可直攻少腹急结之邪，
于谓胃承气中加桃核者，欲其直达血所也；加桂枝以通血脉，兼以解太阳随经之邪耳
！
汪琥曰：膀胱乃小腹中之物，膀胱热结，在卫则尿不利，在荣则血不流，故作急结之
形，为下焦畜血之证谛也。所以用桃核承气汤，乃攻下焦畜血，治少腹急结之药，实
非通膀胱热结之药也。
栀子（掰开）十四枚，干姜二两。
以上两味药，用水三升半，煮取一升半，滤去药渣，分两次服用，温服一次，如果服药后出现呕吐现象，就停止后续服用。
【按语】
此方中的干姜应当是香豉。其余义理详见前文经文下的正误考证文章内。
@@@
伤寒病经过五六天，经过猛烈攻下之后，身体发热不退，心中郁结疼痛的，这是病邪尚未解除，应当用栀子豉汤主治。
【按语】
此方中的香豉应当是干姜。其余义理也详见前文经文下的正误考证文章内。
【注解】
伤寒病经过五六天，是邪气在里的时期。经过猛烈攻下之后，如果身体热退，心胸调和，这就是病欲解除的表现。现在身体发热不退，说明邪气仍在表。心中郁结疼痛是由于过度攻下导致里寒，所以说病未欲解。但是这种表热里寒的证候，想要温补里寒，就会妨碍表热的解除；想要解除表热，又会妨碍里寒的治疗。所以只用栀子的寒性、干姜的热性，同时使用以涌吐邪气，就能兼顾解表和温里。难道还有身热结痛不能尽除的吗！这是张仲景设立的两种难以治疗的治法，其精妙之处如此，其他情况可以类推。
【集注】
王肯堂说：“身热不去”这四个字值得玩味。结胸证身体不发热，可知热不在表；现在身热不退，只宜用涌吐法发散而已。
程应旄说：疼痛称为“结”，很像结胸证，但结胸证身体没有大热，可知热已经完全归于里成为实邪。这里则是身热不退，所结之症是因为攻下而形成的，客邪仍然在表，所以说病未欲解。
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凡是使用栀子汤的病人，如果平时大便稀溏的，不可服用。
【注解】
如果在发汗、涌吐、攻下之后，出现心中烦闷懊恼、少气、呕吐逆气、烦满、心中郁结疼痛等症状，都适宜用栀子等汤剂涌吐。因为邪气留连在胸胃之间，或与热、或虚、或饮、或气、或寒相结而不实，则病势向上，即经书所说的“病位在上者，因势利导而越之”的意思。如果没有经过发汗、涌吐、攻下，而有这些症状，就是实邪，不是栀子汤这种轻剂所能治疗的。应当用瓜蒂散这种重剂来主治。如果病人平时大便稀溏，虽然有上述症状，但因为里气久虚，不可服用。如果服用它，即使客邪全部去除，正气也难以支撑，因为病势向下，强行涌吐必然产生其他变证。本草书中不说栀子有催吐作用，张仲景用它作为催吐药，为什么呢？栀子本来不是催吐药，因为它味苦能引起呕吐，所以用它来涌泄热邪。
【按语】
催吐药不止栀子一种，各种药物都可以用来催吐，关键在于确切审察胸胃中的邪气，是寒、是热、是食积、是水饮、是痰浊、是气滞，因什么阻滞使胸胃阳气不能伸展，于是用相应的药物来涌吐，自然可以痊愈。如果想吐寒邪，就用干姜、桂皮之类；想吐热邪，就用栀子、苦茶之类；想吐食积，就用平胃散加食盐之类；想吐水饮，就用五苓散加生姜之类；想吐痰浊，就用稀涎散加橘皮之类；想吐气滞，就用行气药加枳实、厚朴之类。但是形体气力虚弱的人，药量宜少，仍当辅助以补中益气等升提药物为妥；形体气力壮实的人，药量宜多，更辅助以瓜蒂、藜芦等猛药效果更好。凡是煎煮催吐药汤及调配散剂，或用酸米汤，或用白开水，或用稀米粥，必须准备十余钟，让病人顿服一钟，随即用手指探喉催吐药出，再服一钟，也随即用手指探喉催吐药出，再服再吐，以顺畅快速地吐出为限度，那么头额身上自然会有微汗，所有病症减轻，就是中病，不必服完剩余的药物。如果过度催吐，即使病邪全部清除，恐怕会损伤胸中阳气。近世的医生，认为催吐是古法不可用，已经很久了。都是因为张仲景的道理不显扬，其方法失传，难怪他们不敢用。那些不知道其妙处而不敢用的，还可以原谅；如果竟然推托说古法不可用，那就不对了。大概邪气在上的，不用催吐法不能痊愈。如果像庸医所说，让病人畏惧不敢服用，因而拖延产生变证，致使轻病转重，重病致死，这又是谁的过错呢？抑或是知道汗、吐、下三法，使用得当，病症无不立即见效，后来的行医者，又怎么能只说汗、下两法，而将吐法弃置不用，致使古法沦亡呢！
【集注】
程知说：这说明服用栀子也有禁忌。病人平时大便稀溏，说明里虚，又服用苦寒药物，则不能上涌，反而会导致下泄，所以禁止服用。
张志聪说：这里只说栀子而不说香豉，是为了申明栀子的苦味，能导致下泄，所以病人平时大便稀溏的，不可服用。
@@@
太阳病，脉象浮紧，无汗，发热，身体疼痛，经过八、九天病仍未解除，表证仍然存在，这应当发汗。服药后，症状轻微缓解，其人感到心烦、眼睛闭合昏花；病情严重的，必定会出现鼻出血，鼻血流出后病才解除。之所以这样，是因为阳气郁闭太重的缘故，应当用麻黄汤主治。
【按语】
张兼善说：“麻黄汤主之”五个字，不应当放在“阳气重”之下，哪有鼻血流出病解之后，再用麻黄汤的道理呢？他的说法很正确。况且在“服药已”之上，并没有说明服用的是什么药的记载，应当将这五个字移到“服药已”之上才符合逻辑。
【注解】
太阳病，脉象浮紧，无汗，发热，身体疼痛，经过八、九天病仍未解除，是说伤寒表证仍然存在，应当用麻黄汤发汗。服药后，症状轻微缓解，是说已经发汗，邪气虽然轻微缓解，但并未完全清除，仍然应当发汗。如果因循延误未能发汗，则阳邪长久郁闭在营分中，不得宣泄，导致热并聚于阳分而发烦，热郁闭于阴分而目瞑（眼睛闭合昏花）。病情严重，是指热极。热极在营分，势必逼迫脉中的血液妄行而为衄血（鼻出血），衄血则热随血去而病解了。之所以这样，是因为阳气郁闭太重的缘故。
【集注】
程知说：脉象见浮紧，表证仍在，虽然经过八、九天，仍应当用麻黄汤发汗解表。服药后病情轻微缓解，至于出现烦闷、目瞑、剧烈衄血，乃是热郁于营分，阳气重盛，与表散药物相互搏结所致。然而到了逼迫血液上溢而出，则热随血解了。这说明发汗应当以麻黄汤为主，并非衄血病解之后，仍用麻黄汤。
张璐说：服药后症状轻微缓解，又复发烦的，是余邪未尽。目瞑烦剧的，是热盛于轻清之分，所以逼迫血液妄行而为衄血，衄血则余热随血而解。因为发汗后又衄血，所以称为阳气重。有人说发汗后又衄血，而热邪仍未尽，重用麻黄汤发散未尽之邪，这是不对的。如果果真是邪热不尽，那么“衄乃解”这三个字从何落实？
@@@
太阳病，脉象浮紧，发热，身体无汗，自行鼻出血的就会痊愈。
【注解】
太阳病，脉象浮紧，发热无汗，这是伤寒的脉证，应当发汗。如果应当发汗而未发汗，就是失汗。失汗则寒邪闭塞卫分，热邪郁闭营分。起初如果不从卫分发汗而解，时间久了必定会从营分通过衄血而痊愈。所以太阳病凡是向外解除的，只有发汗和衄血这两种途径。现在既然失汗于营分，则营中血热妄行，自行衄血，热随血解，必定自愈。
【集注】
方有执说：这是承接上一条，又以病情较轻的情况来说明，以此显示也有不治疗而自愈的情况，以此告诫人们不要妄加治疗，以致出错的意思。太阳病脉浮紧，发热身体无汗，与上一条相同，但没有疼痛，则比上一条较轻可知。所以不需要攻治，得衄血即可自愈。汗本是血的液体，北方人谓衄血为红汗，就是这个说法。
程知说：说明得到衄血，即使无汗，也必定自愈。人受寒邪侵袭而发热，得到衄血发越故愈。
张璐说：衄血成流，则邪热随血而散，夺血则无汗。假如不自衄血，应当用麻黄汤发汗。发汗后邪气解除，就不衄血了。发汗后余邪未尽，必定仍要衄血而解。
@@@
伤寒脉象浮紧，不发汗，因而导致鼻出血的，用麻黄汤主治。
【注解】
这是承接上一条以提出治疗方法。伤寒脉象浮紧，依法应当发汗，如果不发汗，就是失汗。失汗则热郁于营分，因而导致衄血的，适宜用麻黄汤主治。如果能于未衄血之前，早用麻黄汤发汗，汗出则病解，必定不会致衄血。或者像上一条那样自衄血而解，也不需要用药。
【按语】
凡是伤寒初起，只要不是特别恶寒，就知道夹热，后来大多会衄血。其热多寒少的，则热随衄血而去，继而汗出，表邪与热邪均解除。其热少寒多的，纵然热随衄血而去，继必不出汗，表邪仍不解。诚然能用青龙汤、麻黄汤在未衄血之前先发汗，则汗与衄两解。如果已经衄血后而汗不出，表不解，即用麻黄汤、桂枝汤调和营卫，也必须稍微兼用黄芩、黄连、犀角、地黄等清热凉血的药物辅助，以保护阴血。但是大衄血之后，麻黄汤、青龙汤不可轻率使用，如果使用不当，就犯了衄血家不可发汗的戒律。
【集注】
《活人书》说：衄血后脉浮的，适宜用麻黄汤；衄血后脉微的，不可行麻黄汤，适宜用黄芩芍药汤。大概衄血后脉浮，表邪未解；脉微，表邪已解，从这里可以看出张仲景在衄血后用麻黄汤的大旨。
方有执说：伤寒脉浮紧，是寒多风少的意思。上面两条都是风多寒少，前一条因为服药后症状轻微缓解，汗发不透而导致衄血，上一条因为病情较轻得自衄血，这一条因为寒多不发汗而导致衄血，三条之所以辨别区分在于此。大概寒多，则依法应当发汗，而不发汗，热郁血乱，所以衄血。衄血则阳邪之风散，麻黄汤是发散其尚未散的寒邪。
程知说：这说明寒邪不发汗而致衄血，仍适宜温散。不发汗而致衄血，是入营分的寒邪，不得泄越所致。寒不尽则衄血不止，所以仍用麻黄，不必等到衄血。这与上一条有寒热之别。
程应旄说：大体伤寒见到衄血的，是由其营分素来有热，一旦被寒邪闭塞，营分承受不了遏制，从而上升所致。
@@@
伤寒不大便六、七天，头痛且有发热的，给予承气汤；如果小便清长的，知道病不在里，仍在表，应当须发汗；如果头痛剧烈的，必定会鼻出血，适宜用桂枝汤。
【按语】
如果头痛的“若”字，应当是“苦”字，“苦头痛”才是必衄血的证候，如果是“若”字，则凡头痛皆能致衄血了。
【注解】
伤寒不大便六、七天，里已实证，似乎可下。但头痛热未已，表证未罢，可汗。然而欲下则有头痛发热的表证，欲汗则有不大便的里证，值此两难之时，只当以小便来辨别。如果小便浑赤，是热已在里，即使有头痛发热的表证，也属里热，给予承气汤攻下即可；如果小便清白，是热尚在表，即使有不大便的里证，仍属表邪，适宜用桂枝汤解表。然而伤寒头痛不论表里，如果剧烈头痛的，是热邪剧烈于营分，所以必定发生衄血，衄血则营热解了。在其未衄血之时，无汗适宜用麻黄汤，有汗适宜用桂枝汤发汗，则不衄血而解。
【集注】
汪琥说：头痛不已的，是风寒之邪上壅，热甚于经络，势必致衄，须乘其未衄血之时，酌情用麻黄汤或桂枝汤发汗解表，而验小便，实为张仲景的妙法。
魏荔彤说：这一条的衄血，是预料之辞，非已见到的证候。
@@@
太阳病不解，热结膀胱，其人如狂，血自下，下者愈；其外证不解者，尚未可攻，当先解其外；外证已解，只是少腹急结的，才可攻之，适宜用桃核承气汤。
【注解】
太阳病不解，应当传入阳明，如果不传阳明而邪热随经脉深入，瘀滞在膀胱营分，则其人必定如狂。如狂，是瘀热内结，心神被扰乱，有似于狂的状态。当此之时，如果血自下，下者自愈；如果不自下，或下而未尽，则热与瘀血下蓄膀胱，必定少腹急结。假设外证不解，尚不可攻里，应当先用麻黄汤解表；外证已解，只是少腹急结痛的，才可攻里，适宜用桃核承气汤；即调胃承气汤加桃仁，所以能攻热逐血。大概邪气随太阳经而来，所以又加桂枝以解外而通营。空腹服用，是说空腹则药力下行迅速。
【按语】
太阳病不解，不传阳明，邪热随经入里，称为犯本。犯本，是指侵犯膀胱之腑。膀胱腑的卫分为气分，膀胱腑的营分为血分。热入而犯气分，气化不行，热与水结的，称为犯卫分之里，是五苓散证；热入而犯血分，血蓄不行，热与血结的，称为犯营分之里，是桃核承气汤证。这两者虽都为犯本之证，两方虽都治犯本之药，但一方从前阴利水，一方从后阴攻下，水与血，主治各不相同。
【集注】
喻昌说：桃核承气汤用桂枝解外，与大柴胡汤解外相似，更加可见太阳随经之热，非桂枝不能解。
程知说：太阳病不解，随经入腑，故热结膀胱。其人如狂，是瘀热内结，心神不安宁，有似于狂，如果血自下，下则热随瘀解了。然而必须外证已解，才可直攻少腹急结之邪，于调胃承气中加桃仁，欲其直达血所；加桂枝以通血脉，兼以解太阳随经之邪耳！
汪琥说：膀胱是小腹中之物，膀胱热结，在卫分则尿不利，在营分则血不流，故作急结之形，为下焦蓄血之证的确实证据。所以用桃核承气汤，是攻下焦蓄血、治少腹急结的药，实在不是通膀胱热结的药。
Crispae Fructus Gardeniae (Zizhi, 栀子) [split open] fourteen pieces; Dried Ginger (Ganjiang, 干姜) two liang.
The above two ingredients are boiled in three and a half sheng of water to obtain one and a half sheng. The dregs are removed, and the decoction is divided into two doses. One dose is taken warm. If vomiting occurs after taking the dose, subsequent doses should be stopped.
[Commentary]
In this formula, Ganjiang (Dried Ginger) should be Chidou Chi (Fermented Soybean). The remaining rationale is detailed in the textual correction section under the preceding scripture text.
@@@
In Shaoyang disease (Taiyang disease), after five or six days, following vigorous purgation, if body heat persists and there is a knotted pain in the heart region, the condition has not yet resolved. Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) should be administered as the primary treatment.
[Commentary]
In this formula, Chidou Chi (Fermented Soybean) should be Ganjiang (Dried Ginger). The remaining rationale is also detailed in the textual correction section under the preceding scripture text.
[Annotation]
Five or six days into Shaoyang disease (Taiyang disease) marks the time when pathogenic factors are in the interior. Following vigorous purgation, if body heat subsides and the chest and heart become harmonious, this indicates that the disease is about to resolve. Now, since body heat persists, the pathogen remains in the exterior. The knotted pain in the heart region results from excessive purgation causing interior cold; hence it is said that the disease is not about to resolve. However, in this syndrome of exterior heat and interior cold, warming the interior would hinder the resolution of exterior heat, while resolving exterior heat would hinder the treatment of interior cold. Therefore, by using the cold nature of Zizhi (Crispae Fructus Gardeniae) and the hot nature of Ganjiang (Dried Ginger) together to induce vomiting (emesis), both resolving the exterior and warming the interior can be achieved simultaneously. Would there still be persistent body heat and knotted pain? This represents Zhang Zhongjing’s establishment of difficult dual treatments, whose subtlety is such that other cases can be inferred by analogy.
[Collected Notes]
Wang Kentang stated: "Body heat persists" – these four words deserve careful consideration. In Jie Xiong (Chest Binding) syndrome, the body is not feverish, indicating the heat is not in the exterior. Now, with persistent body heat, only the method of inducing vomiting (emesis) to disperse is suitable.
Cheng Yingmao stated: Pain described as "knotted" resembles Jie Xiong (Chest Binding), but Jie Xiong presents with no significant fever, indicating heat has fully entered the interior as excess pathogen. Here, persistent body heat indicates that the knotting resulted from purgation, and the external pathogen remains in the exterior; thus, it is said the disease is not about to resolve.
@@@
Whenever Zhizi Tang (Gardenia Decoction) is used, if the patient has a history of loose stools, it must not be administered.
[Annotation]
After sweating, vomiting (emesis), or purging, if symptoms include mental restlessness and oppression (Ao Nu), shortness of breath, vomiting and rebellious Qi, irritability and fullness, and knotted pain in the heart region, Zhizi Tang (Gardenia Decoction) or similar formulas should be used to induce vomiting (emesis). This is because the pathogen lingers between the chest and stomach, binding with heat, deficiency, fluid retention, Qi stagnation, or cold without forming solid excess. Consequently, the pathological trend moves upward, consistent with the classic principle: "For pathogens located above, use the method of dispersing them upwards." If these symptoms occur without prior sweating, vomiting (emesis), or purging, it constitutes an excess pathogen, which cannot be treated by the mild action of Zhizi Tang (Gardenia Decoction). Instead, a heavy agent like Gouti San (Melon Tendril Powder) should be used. If the patient has a history of loose stools, even if these symptoms are present, due to chronic interior deficiency, it must not be administered. Administering it would prevent the body's righteous Qi from sustaining itself, even if the external pathogen is cleared, because the pathological trend is downward; forcing upward dispersion would likely cause further complications. The Materia Medica does not list Zizhi (Crispae Fructus Gardeniae) as an emetic. Why did Zhang Zhongjing use it for this purpose? Zizhi (Crispae Fructus Gardeniae) is inherently not an emetic, but its bitter taste can induce vomiting; thus, it is used to dispel heat via upward expulsion.
[Commentary]
Emetics are not limited to Zizhi (Crispae Fructus Gardeniae); various herbs can serve this function. The key is to accurately diagnose the pathogen in the chest and stomach—whether it is cold, heat, food stagnation, water retention, phlegm, or Qi stagnation—and identify what obstructs the free flow of Yang Qi in the chest and stomach. Then, administer the appropriate herb to induce vomiting (emesis), and recovery will naturally follow. To expel cold, use Ganjiang (Dried Ginger) and Rougui (Cinnamon Bark); to expel heat, use Zizhi (Crispae Fructus Gardeniae) and Kucha (Bitter Tea); to expel food stagnation, use Pingwei San (Regular Stomach Powder) with salt; to expel water retention, use Wuling San (Five-Ingredient Powder with Poria) with fresh ginger; to expel phlegm, use Xixian San (Thin Saliva Powder) with Chenpi (Tangerine Peel); to expel Qi stagnation, use Qi-moving herbs with Zhishi (Immature Bitter Orange) and Houpo (Magnolia Bark). For patients with weak constitution, the dosage should be small, supplemented with tonifying and ascending herbs like Buzhong Yiqi Tang (Decoction for Boosting the Middle and Replenishing Qi). For those with strong constitution, the dosage may be larger, supplemented with potent emetics like Gouti (Melon Tendril) and Lilu (Veratrum). When preparing emetic decoctions or powders, use sour rice soup, plain water, or thin rice gruel. Prepare more than ten cups. Have the patient drink one cup rapidly, then stimulate vomiting with a finger. Drink another cup and repeat until vomiting is smooth and rapid. Mild sweating on the head, forehead, and body will naturally occur. As symptoms alleviate, the treatment is effective; there is no need to consume the remaining liquid. Over-vomiting may damage Yang Qi in the chest. Modern physicians have long dismissed emesis as an obsolete ancient method. This is because Zhang Zhongjing’s principles are not widely understood, and his methods have been lost. It is no wonder they dare not use it. Those who do not understand its efficacy and thus refrain from using it may be excused; however, dismissing it outright as "useless ancient practice" is unacceptable. Pathogens located above cannot be cured without emesis. If patients are made fearful by quacks and delay treatment, minor illnesses worsen, and major illnesses lead to death—who bears the blame? Indeed, when sweating, vomiting (emesis), and purging are applied correctly, all syndromes respond immediately. How can future practitioners speak only of sweating and purging, neglecting emesis, and allowing ancient methods to perish!
[Collected Notes]
Cheng Zhi stated: This passage highlights contraindications for Zhizi (Crispae Fructus Gardeniae). Patients with a history of loose stools have interior deficiency. Administering bitter-cold herbs prevents upward expulsion and causes downward discharge; therefore, it is prohibited.
Zhang Zhicong stated: Mentioning only Zizhi (Crispae Fructus Gardeniae) and not Chidou Chi (Fermented Soybean) clarifies that Zizhi’s bitter nature causes downward discharge. Thus, it is contraindicated for patients with a history of loose stools.
@@@
In Taiyang disease, with a floating-tight pulse, absence of sweating, fever, and body ache persisting for eight or nine days without resolution, if exterior signs remain, sweating should be induced. After medication, if symptoms slightly improve but the patient experiences irritability and closed eyes/dizziness; in severe cases, epistaxis (nosebleed) will occur, and the disease resolves upon bleeding. This occurs because Yang Qi is heavily constrained. Mahuang Tang (Ephedra Decoction) should be administered.
[Commentary]
Zhang Jianshan stated: The phrase "Mahuang Tang (Ephedra Decoction) should be administered" should not follow "Yang Qi is heavily constrained." How could Mahuang Tang (Ephedra Decoction) be used after epistaxis has already resolved the disease? His view is correct. Moreover, the text preceding "after medication" does not specify which medicine was taken. These five characters should be moved before "after medication" to make logical sense.
[Annotation]
Taiyang disease characterized by a floating-tight pulse, absence of sweating, fever, and body ache, persisting for eight or nine days without resolution, indicates that exterior signs of Cold Damage remain. Mahuang Tang (Ephedra Decoction) should be used to induce sweating. "Slightly improved after medication" means sweating has occurred, and although pathogens are slightly reduced, they are not fully eliminated; sweating should continue. If sweating is delayed, Yang pathogens remain stagnant in the Ying (Nutritive) level, unable to vent. Heat merges with Yang causing irritability, and heat stagnates in Yin causing closed eyes/dizziness. "Severe cases" refer to extreme heat. Extreme heat in the Ying level forces blood in the vessels to move recklessly, causing epistaxis (nosebleed). Epistaxis allows heat to exit with the blood, resolving the disease. This happens because Yang Qi is heavily constrained.
[Collected Notes]
Cheng Zhi stated: A floating-tight pulse with persistent exterior signs indicates that even after eight or nine days, Mahuang Tang (Ephedra Decoction) should be used to induce sweating and resolve the exterior. After taking the decoction, symptoms slightly improve. Irritability, closed eyes/dizziness, and severe epistaxis result from heat stagnating in the Ying level and abundant Yang Qi interacting with exterior-dispersing herbs. However, once blood is forced upward and epistaxis occurs, heat resolves with the blood. This passage emphasizes that Mahuang Tang (Ephedra Decoction) is the primary choice for inducing sweating, not that it should be used again after epistaxis resolves the disease.
Zhang Lu stated: Symptoms slightly improving after medication, followed by renewed irritability, indicates residual pathogens are not fully cleared. Severe irritability and closed eyes/dizziness indicate intense heat affecting light/clear aspects, forcing blood to move recklessly and causing epistaxis. Epistaxis allows residual heat to resolve with the blood. Because sweating was followed by epistaxis, this is termed "heavy Yang Qi." Some argue that after sweating and epistaxis, if heat pathogens remain, heavy use of Mahuang Tang (Ephedra Decoction) disperses residual pathogens. This is incorrect. If heat pathogens were truly not cleared, how would the phrase "resolves upon epistaxis" apply?
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In Taiyang disease, with a floating-tight pulse, fever, and absence of sweating, spontaneous epistaxis (nosebleed) leads to recovery.
[Annotation]
Taiyang disease with a floating-tight pulse, fever, and absence of sweating constitutes the pulse and signs of Cold Damage, requiring induction of sweating. If sweating is indicated but not performed, it is a missed opportunity. Missed sweating causes Cold to close the Wei (Defensive) level and Heat to stagnate in the Ying (Nutritive) level. Initially, if resolution does not occur through Wei-level sweating, over time, it must resolve through Ying-level epistaxis (nosebleed). Therefore, in Taiyang disease, external resolution occurs only through sweating or epistaxis (nosebleed). Now, having missed sweating at the Ying level, Ying-level blood heat moves recklessly, causing spontaneous epistaxis (nosebleed). Heat resolves with the blood, leading to natural recovery.
[Collected Notes]
Fang Youzhi stated: This continues from the previous clause, discussing milder syndromes to show that some conditions resolve spontaneously without treatment, warning against improper intervention. Taiyang disease with a floating-tight pulse, fever, and absence of sweating is identical to the previous clause but lacks body ache, indicating a milder condition. Thus, treatment is unnecessary; spontaneous epistaxis (nosebleed) leads to recovery. Sweat is the fluid of blood; northerners call epistaxis (nosebleed) "red sweat," reflecting this concept.
Cheng Zhi stated: Spontaneous epistaxis (nosebleed) ensures recovery even without sweating. Humans contracting Cold develop heat; epistaxis (nosebleed) allows heat to vent, leading to recovery.
Zhang Lu stated: Flowing epistaxis (nosebleed) disperses pathogenic heat; loss of blood precludes sweating. If spontaneous epistaxis (nosebleed) does not occur, Mahuang Tang (Ephedra Decoction) should be used to induce sweating. If pathogens resolve after sweating, epistaxis (nosebleed) ceases. If residual pathogens remain after sweating, epistaxis (nosebleed) will inevitably occur for resolution.
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In Cold Damage, with a floating-tight pulse, failure to induce sweating leads to epistaxis (nosebleed). Mahuang Tang (Ephedra Decoction) should be administered.
[Annotation]
This follows the previous clause to propose treatment. In Cold Damage, a floating-tight pulse legally requires induction of sweating. Failure to do so is a missed opportunity. Missed sweating causes heat to stagnate in the Ying (Nutritive) level, leading to epistaxis (nosebleed). Mahuang Tang (Ephedra Decoction) should be administered. If Mahuang Tang (Ephedra Decoction) had been used early before epistaxis (nosebleed) occurred, sweating would have resolved the disease, preventing epistaxis (nosebleed). Alternatively, if the patient resolves via spontaneous epistaxis (nosebleed) as in the previous clause, medication is unnecessary.
[Commentary]
In early Cold Damage, unless chills are severe, heat involvement is suspected, often leading to epistaxis (nosebleed). In cases where heat predominates over cold, heat exits with epistaxis (nosebleed), followed by sweating, resolving both exterior and heat. In cases where cold predominates over heat, even if heat exits with epistaxis (nosebleed), sweating will not follow, and the exterior remains unresolved. Using Qinglong Tang (Green Dragon Decoction) or Mahuang Tang (Ephedra Decoction) before epistaxis (nosebleed) induces sweating, resolving both pathways. If epistaxis (nosebleed) has already occurred and sweating fails to resolve the exterior, Mahuang Tang (Ephedra Decoction) or Guizhi Tang (Cinnamon Twig Decoction) should be used to harmonize Ying and Wei, supplemented slightly with Huangqin (Scutellaria Root), Huanglian (Coptis Rhizome), Xijiao (Rhinoceros Horn - substitute with Niuxi or other cooling agents in modern practice), and Dihuang (Rehmannia Root) to clear heat and cool blood, protecting Yin and blood. However, after massive epistaxis (nosebleed), Mahuang Tang (Ephedra Decoction) and Qinglong Tang (Green Dragon Decoction) must not be used lightly. Improper use violates the prohibition against sweating in patients with blood loss.
[Collected Notes]
"Huo Ren Shu" (Book of Saving Lives) states: After epistaxis (nosebleed), if the pulse is floating, Mahuang Tang (Ephedra Decoction) is suitable; if the pulse is thready/weak, Mahuang Tang (Ephedra Decoction) is contraindicated; Huangqin Shaoyao Tang (Scutellaria and Peony Decoction) is suitable. Floating pulse after epistaxis (nosebleed) indicates unresolved exterior; thready/weak pulse indicates resolved exterior. This reveals Zhang Zhongjing’s main principle regarding Mahuang Tang (Ephedra Decoction) use after epistaxis (nosebleed).
Fang Youzhi stated: Floating-tight pulse in Cold Damage indicates more Cold than Wind. The previous two clauses involved more Wind than Cold: the first caused epistaxis (nosebleed) due to incomplete sweating after medication; the second resolved via spontaneous epistaxis (nosebleed) due to mildness. This clause involves epistaxis (nosebleed) due to insufficient sweating from predominant Cold. The distinction lies here. Predominant Cold requires sweating; failure to sweat causes heat stagnation and blood disorder, leading to epistaxis (nosebleed). Epistaxis (nosebleed) disperses Yang/Wind pathogens; Mahuang Tang (Ephedra Decoction) disperses remaining Cold.
Cheng Zhi stated: Cold pathogens causing epistaxis (nosebleed) without sweating still require warm dispersion. Failure to sweat causes Cold entering the Ying level to fail to vent. Uncleared Cold leads to persistent epistaxis (nosebleed); thus, Mahuang is still used, without waiting for epistaxis (nosebleed). This differs from the previous clause in terms of Cold vs. Heat.
Cheng Yingmao stated: Generally, epistaxis (nosebleed) in Cold Damage occurs because the Ying level has inherent heat. Once blocked by Cold, the Ying level cannot withstand suppression and rises upward.
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In Cold Damage, constipation for six or seven days with headache and fever suggests administering Chengqi Tang (Cathartic Decoction). If urine is clear, the pathogen is not in the interior but remains in the exterior, requiring sweating. If the headache is severe, epistaxis (nosebleed) will likely occur; Guizhi Tang (Cinnamon Twig Decoction) is suitable.
[Commentary]
The character "ruo" (if) in "if headache" should likely be "ku" (suffering/severe). "Severe headache" is the sign for impending epistaxis (nosebleed). If read as "if," it implies any headache causes epistaxis (nosebleed), which is incorrect.
[Annotation]
Constipation for six or seven days in Cold Damage suggests interior excess, potentially requiring purging. However, persistent headache and fever indicate unresolved exterior, requiring sweating. Yet, purging is complicated by exterior signs, and sweating is complicated by interior constipation. In this dilemma, urine color determines the approach. Turbid yellow urine indicates heat in the interior; even with exterior signs, it is interior heat, and Chengqi Tang (Cathartic Decoction) should be used for purging. Clear white urine indicates heat remains in the exterior; even with constipation, it is exterior pathogen, and Guizhi Tang (Cinnamon Twig Decoction) should be used to resolve the exterior. Regarding headache in Cold Damage, regardless of interior/exterior status, severe headache indicates intense heat in the Ying level, leading to epistaxis (nosebleed), which resolves Ying heat. Before epistaxis (nosebleed) occurs, absence of sweating requires Mahuang Tang (Ephedra Decoction); presence of sweating requires Guizhi Tang (Cinnamon Twig Decoction) to induce sweating, resolving the disease without epistaxis (nosebleed).
[Collected Notes]
Wang Hu stated: Persistent headache indicates Wind-Cold pathogens congesting upward, with intense heat in the meridians, inevitably leading to epistaxis (nosebleed). Before epistaxis (nosebleed) occurs, appropriately using Mahuang Tang (Ephedra Decoction) or Guizhi Tang (Cinnamon Twig Decoction) to induce sweating, combined with testing urine, is Zhang Zhongjing’s brilliant method.
Wei Litong stated: The mention of epistaxis (nosebleed) in this clause is predictive, not describing an existing symptom.
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If Taiyang disease does not resolve, heat binds to the Bladder. The patient exhibits manic-like behavior. If blood passes spontaneously, the patient recovers. If exterior signs remain unresolved, attack is premature; resolve the exterior first. Once the exterior is resolved, if only lower abdominal urgency and knotted sensation persist, attack may proceed with Taohe Chengqi Tang (Peach Kernel Cathartic Decoction).
[Annotation]
Unresolved Taiyang disease typically transmits to Yangming. If it does not transmit to Yangming but pathogenic heat follows the meridians and stasis forms in the Bladder’s Ying (Nutritive) level, the patient becomes manic-like. Manic-like state indicates internal binding of stasis-heat disturbing the Heart, resembling mania. At this stage, if blood passes spontaneously, the patient recovers. If not, or if passage is incomplete, heat and stasis accumulate in the Bladder, causing lower abdominal urgency and knotted sensation. If exterior signs remain, interior attack is premature; resolve the exterior first with Mahuang Tang (Ephedra Decoction). Once the exterior is resolved, if only lower abdominal urgency and knotted pain persist, interior attack is permissible with Taohe Chengqi Tang (Peach Kernel Cathartic Decoction)—essentially Tiaowei Chengqi Tang (Regulating the Stomach Cathartic Decoction) plus Tao Ren (Peach Kernel) to purge heat and drive out blood stasis. Since the pathogen arrived via the Taiyang meridian, Guizhi (Cinnamon Twig) is added to resolve the exterior and unblock the Ying level. Taking the medicine on an empty stomach ensures rapid downward action of the drug’s potency.
[Commentary]
When Taiyang disease does not transmit to Yangming but pathogenic heat enters the interior via the meridians, it is called "invading the root." Invading the root refers to invading the Bladder Fu organ. The Wei (Defensive) level of the Bladder Fu corresponds to the Qi level; the Ying (Nutritive) level corresponds to the Blood level. Heat invading and affecting the Qi level impedes Qi transformation, binding heat with water, termed "invading the interior of the Wei level," corresponding to Wuling San (Five-Ingredient Powder with Poria) syndrome. Heat invading and affecting the Blood level causes blood stasis, binding heat with blood, termed "invading the interior of the Ying level," corresponding to Taohe Chengqi Tang (Peach Kernel Cathartic Decoction) syndrome. Although both are "invading the root" syndromes and both formulas treat such invasions, one promotes urination (anterior), and the other promotes purging (posterior); water and blood have different therapeutic targets.
[Collected Notes]
Yu Chang stated: Taohe Chengqi Tang (Peach Kernel Cathartic Decoction) uses Guizhi (Cinnamon Twig) to resolve the exterior, similar to Da Chaihu Tang (Major Bupleurum Decoction). This further confirms that heat following the Taiyang meridian cannot be resolved without Guizhi (Cinnamon Twig).
Cheng Zhi stated: Unresolved Taiyang disease follows the meridian into the Fu organ, causing heat binding to the Bladder. Manic-like behavior results from internal binding of stasis-heat disturbing the Heart. If blood passes spontaneously, heat resolves with the stasis. However, exterior signs must be resolved before directly attacking the lower abdominal knotted pathology. Adding Tao Ren (Peach Kernel) to Tiaowei Chengqi Tang (Regulating the Stomach Cathartic Decoction) directs the action to the blood; adding Guizhi (Cinnamon Twig) unblocks blood vessels and simultaneously resolves heat following the Taiyang meridian.
Wang Hu stated: The Bladder is located in the lower abdomen. Heat binding in the Bladder affects the Wei level by impeding urination and the Ying level by impeding blood flow, creating the sensation of urgency. This confirms the syndrome of Lower Jiao Blood Stasis. Taohe Chengqi Tang (Peach Kernel Cathartic Decoction) attacks Lower Jiao Blood Stasis and treats lower abdominal urgency; it is not merely a drug for clearing Bladder heat binding.