麻黄（去节）四两 杏仁（去皮尖）五十枚 甘草（炙）二两 石膏（绵裹，碎）半
筋
右四味以水七升，先煮麻黄减二升，去白沫，内诸药，煮取三升，去滓，温服一升。
【集注】
柯琴曰：石膏为清火之重剂，青龙、白虎皆赖以建功，然用之不当，适足以召祸。故
青龙以无汗烦燥，得姜桂以宣卫外之阳，白虎以有汗烦渴，须粳米以存胃中之液。今
但内热而无外寒，故不用姜桂。喘不在胃而在肺，故不需粳米，其意重在存阴，不虑
其亡阳也。故于麻黄汤法桂枝之监制，取麻黄之专开，杏仁之降，甘草之和，倍石膏
之寒，除内蕴之实热，斯溱溱之汗出，而内外之烦热与喘悉除矣。
下后不可更行桂枝汤，若汗出而喘，无大热者，可与麻黄杏仁甘草石膏汤。
【注】
此详上条，受病两途，同乎一治之法也。又有下后身无大热，汗出而喘者，知邪亦不
在表而在肺，故亦不可更行桂枝汤，可与麻黄杏仁甘草石膏汤以治肺也。彼之汗后喘
，此之下后喘，虽其致病之因不同，而其所见之证不异，所以从其证，不从其因，均
用此汤，亦喘家急则治其标之法也。
【集注】
方有执曰：汗与下虽殊，其为反误致变之喘则一，惟其喘一，故同归一治也。
太阳中风，（下）利呕逆，表解者，乃可攻之。其人□□汗出，发（作）有时，头痛
，心下痞□满，引□下痛，干呕短气，汗出不恶寒者，此表解里未和也，十枣汤主之
。
【按】
下利之「下」字，当是「不」字。若是「下」字，岂有上呕下利而用十枣汤峻剂攻之
之理乎？惟其大便不利，痞□满痛，始属里病；小便不利，呕逆短气，始属饮病，乃
可攻也。发作之「作」字，当是「热」字。若无热汗出，乃少阴阴邪寒饮，真武汤证
也。且「作」字与上下句文义皆不相属。
【注】
太阳中风，表邪也。不利呕逆，里饮也。表邪解者，乃可攻饮也。审其人微汗□□不
辍，发热有时，头痛，若仍恶寒，是表未解，尚不可攻。若不恶寒，则为表已解矣。
而更见里未和之心下痞□满，引□下痛，干呕短气，水蓄无所从出之急证，故迳以十
枣汤峻剂，直攻水之巢穴而不疑也。
【按】
伤寒表未解，水停心下，呕逆者，是寒束于外，水气不得宣越也，宜小青龙汤汗而散
之；中风表未解，水停心下而吐者，是饮格于中，水气不得输泄也，宜五苓散散而利
之。此皆表未解，不可攻里之饮证也。至如十枣汤与下篇之桂枝去芍药加白术茯苓汤
二方，皆治饮家有表里证者。十枣汤治头痛、发热、汗出、不恶寒之表已解，而有痞
□满痛之里未和，故专主攻里也。桂枝去芍药加白术茯苓汤，治头痛、发热、无汗之
表未解，而兼有心下满微痛之里不和，故不主攻里，当先解表也。然其心下□满痛之
微甚，亦有别矣。
【集注】
杜任曰：十枣汤惟壮实者宜之 ，不宜轻用。
方有执曰：乃可攻之，以上喻人勿妄下早之意。□□汗出至短气，言证虽有里，犹未
可下。直至汗出不恶寒，方是承上起下，言当下以出其治也。
喻昌曰：此证与结胸颇同，但结胸者，邪结于胸，其位高；此在心下及□，其位卑，
然必表解乃可攻之，亦与攻结胸之戒不殊也。药用十枣，亦与陷胸汤相仿，因伤寒下
法，多为胃实而设，胃实者邪热内盛，不得不用消黄以荡涤之。今证在胸□而不在胃
，则荡涤之药无所用，故取蠲热逐饮于胸□之间，以为下法。
张志聪曰：头痛，表证也。然亦有在里者，如伤寒不大便五六日，头痛有热者，与承
气汤。与此节之汗出不恶寒而头痛，为表解里有饮，用十棘汤。则凡遇风寒头痛，表
未解之证，当审别矣。
程应旄曰：所可惑者，头痛外惟身汗一证，表里难辨。汗出发热恶寒，则微有表；若
汗出发热不恶寒，则祗从不恶寒处认证，知表已解，里气为饮邪搏结不和，虽头痛亦
属里邪上攻，非关表也。
魏荔彤曰：太阳之邪既入里，宜下矣。又有不下胸膈，不下肠胃，而下心与□下者，
较下结胸部位稍卑，较下胃实部位又稍高，此下中之又一法也。须认明同一下也，证
不同而法自别。盖太阳、阳明之交，必辨表里而施汗下，彼之在里应下，乃邪热挟食
物为胃实；此之在里应下，乃邪热挟水饮为饮实，二者俱必待表解而后下，此大同也
。
麻黄（去节）四两 杏仁（去皮尖）五十枚 甘草（炙）二两 石膏（绵裹，碎）半斤
以上四味药，用水七升，先煮麻黄，水量减少二升，撇去水面上的白色浮沫，加入其余药物，煎煮至取药液三升，滤去药渣，每次温服一升。
【集注】
柯琴说：石膏是清泻火热的重要药物，大青龙汤、白虎汤都依赖它来建功，但如果使用不当，反而足以招致祸患。所以大青龙汤针对无汗烦躁的情况，需要生姜、桂枝来宣发卫外的阳气；白虎汤针对有汗烦渴的情况，需要粳米来保存胃中的津液。现在只有内热而没有外寒，所以不用生姜、桂枝。气喘的病位不在胃而在肺，所以不需要粳米，其用意重在保存阴液，而不必担心亡阳。所以在麻黄汤的基础上去掉桂枝的监制作用，取麻黄专门开泄肺气，杏仁降气，甘草调和，加倍使用石膏的寒性，以清除体内蕴积的实热，这样就能使汗出津津，内外的烦热和气喘全部消除。
经过攻下治疗后，不可再用桂枝汤，如果出现汗出且气喘，身体没有明显高热的，可以给予麻黄杏仁甘草石膏汤。
【注】
这一条详细解释了上一条的内容，指出致病途径虽有两条，但治疗方法相同。又有经过攻下治疗后，身体没有明显高热，出现汗出且气喘的情况，可知邪气也不在表而在肺，所以也不可再用桂枝汤，可以用麻黄杏仁甘草石膏汤来治疗肺病。之前的情况是发汗后出现气喘，这里是攻下后出现气喘，虽然导致疾病的起因不同，但所表现出的症状却一致，所以顺从症状的表现，不追究起因，都使用这个方剂，这也是对于素有气喘的人，在急症时治标的方法。
【集注】
方有执说：发汗和攻下虽然方法不同，但它们因误治而导致变证出现气喘是一样的，正因为都是气喘，所以归于同一种治疗方法。
太阳中风证，如果伴有腹泻、呕吐逆气，必须表证解除后，才可以攻里。其人微微汗出，发作有定时，头痛，心下部痞塞胀满，牵引胁下疼痛，干呕，呼吸短促，出汗且不恶寒的，这是表证已解而里气未和，用十枣汤主治。
【按语】
“下利”的“下”字，应当是“不”字。如果是“下”字，哪有上吐下泻却用十枣汤这种峻猛之剂攻下的道理呢？只有大便不通畅，痞塞胀满疼痛，才属于里病；小便不利，呕吐逆气，呼吸短促，才属于水饮病，这时才可以攻逐。发作的“作”字，应当是“热”字。如果没有发热而汗出，那是少阴病的阴寒邪气和水饮，是真武汤的适应证。而且“作”字与上下句的文义都不相属。
【注】
太阳中风，是表邪。不利呕逆，是里有水饮。表邪解除后，才可以攻逐水饮。仔细审视其人微汗不止，发热有时，头痛，如果仍然恶寒，说明表证未解，尚且不可攻逐。如果不恶寒，就是表证已经解除了。进而又见到里气未和的心下部痞塞胀满，牵引胁下疼痛，干呕，呼吸短促，这是水饮蓄积无处排出的急证，所以直接用十枣汤这种峻猛之剂，直捣水饮的老巢而毫不迟疑。
【按语】
伤寒表证未解，水饮停聚在心下，出现呕吐逆气的，是因为寒邪束缚于外，水气不得宣散，宜用小青龙汤通过发汗来解散它；中风表证未解，水饮停聚在心下而出现呕吐的，是因为水饮格拒于中，水气不得输布排泄，宜用五苓散通过发散和利小便来治疗它们。这些都是表证未解，不可攻逐里部水饮的情况。至于像十枣汤和下篇的桂枝去芍药加白术茯苓汤这两个方子，都是治疗既有表证又有里证的水饮病患者。十枣汤治疗头痛、发热、汗出、不恶寒的表证已解，而有痞塞胀满疼痛的里气未和，所以专门主攻里证。桂枝去芍药加白术茯苓汤，治疗头痛、发热、无汗的表证未解，而兼有心下满微痛的里气不和，所以不主攻里证，应当先解表。然而他们心下痞满疼痛的程度，也有轻重之别。
【集注】
杜任说：十枣汤只适合体质壮实的人服用，不宜轻易使用。
方有执说：“乃可攻之”，是承接上文比喻人不要妄自过早攻下的意思。从微汗出到短气，是说虽然有里证，但仍然不可以攻下。直到出汗且不恶寒，才是承上启下，说明应当攻下以给出治疗方案。
喻昌说：这个证候与结胸证很相似，但结胸证是邪气结聚在胸部，位置较高；这个证候在心下及胁下，位置较低，但也必须表证解除后才能攻里，这也与攻逐结胸证的禁忌没有不同。药用十枚大枣，也与陷胸汤相仿，因为伤寒的攻下法，多为胃腑实证而设，胃腑实证是邪热内盛，不得不使用大黄等药来荡涤清理。现在病证在胸胁而不在胃，那么荡涤肠胃的药物就没有用处，所以选取能清除热邪、驱逐水饮的药物在胸胁之间，作为攻下的方法。
张志聪说：头痛，通常是表证。但也有属于里的，比如伤寒不大便五六天，头痛且有发热的，给予承气汤。与此节所述的汗出不恶寒而头痛，属于表解里有水饮，用十枣汤。那么凡是遇到风寒引起的头痛，表证未解的情况，应当仔细辨别。
程应旄说：让人困惑的是，除了头痛之外只有身汗一个症状，表里难以分辨。如果出汗、发热、恶寒，则微有表证；如果出汗、发热、不恶寒，则只根据不恶寒这一点来认定，知道表证已解，里气被水饮邪气搏结而不和，即使头痛也属于里邪上攻，与表证无关。
魏荔彤说：太阳经的邪气既然入里，应当攻下。但又不是下在胸膈，也不是下在肠胃，而是下心与胁下，比结胸的部位稍低，比胃实的部位又稍高，这是攻下法中的另一种方法。必须认清同样是攻下，但证候不同，治疗方法自然有别。大概太阳、阳明经交界之处，必须辨别表里而施行汗法或下法，彼处的在里应下，是邪热挟带食物形成胃实；此处的在里应下，是邪热挟带水饮形成饮实，两者都必须等待表证解除后才攻下，这是它们的共同点。
Ephedrae Herba (Mahuang, 麻黄) [devoid of nodes] four liang, Armeniacae Semen Amarum (Xingren, 苦杏仁) [devoid of skin and tips] fifty seeds, Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) [roasted] two liang, Gypsum Fibrosum (Shigao, 石膏) [wrapped in silk, crushed] half a jin.
The above four ingredients are boiled with seven sheng of water. First, boil Ephedrae Herba until the liquid reduces by two sheng, remove the white foam from the surface, then add the remaining herbs. Boil until three sheng of decoction remains, strain off the dregs, and take one sheng warm.
[Collected Annotations]
Ke Qin stated: Gypsum Fibrosum is a heavy agent for clearing fire. Both Da Qing Long Tang (Major Blue Green Dragon Decoction) and Bai Hu Tang (White Tiger Decoction) rely on it to achieve their effects. However, if used improperly, it may only invite disaster. Therefore, Da Qing Long Tang addresses non-sweating irritability by employing Zingiberis Rhizoma (Shengjiang, 生姜) and Cinnamomi Ramulus (Guizhi, 桂枝) to disseminate the Yang qi of the Wei (Defensive) layer externally. Bai Hu Tang addresses sweating with irritability and thirst by employing Oryza Sativa (Jingmi, 粳米) to preserve the fluids of the Stomach. In this case, there is internal heat but no external cold, so Zingiberis Rhizoma and Cinnamomi Ramulus are not used. The wheezing lies not in the Stomach but in the Lung, so Oryza Sativa is unnecessary. The intent focuses on preserving Yin fluid, without worrying about the loss of Yang. Thus, based on the method of Ma Huang Tang (Ephedra Decoction), the restraining effect of Cinnamomi Ramulus is removed, taking advantage of Ephedrae Herba's specific ability to open the Lung, Armeniacae Semen Amarum's descending action, Glycyrrhizae Radix et Rhizoma's harmonizing property, and doubling the cold nature of Gypsum Fibrosum to eliminate the solid heat accumulated internally. This results in profuse sweating, thereby eliminating the internal and external irritability, heat, and wheezing completely.
After purgation, Gui Zhi Tang (Cinnamon Twig Decoction) should not be administered again. If there is sweating and wheezing without significant high fever, Ma Huang Xing Gan Shi Gao Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction) may be given.
[Annotation]
This detail elaborates on the previous clause, explaining that although the pathogenesis involves two different routes, the treatment method is the same. There is also a condition where, after purgation, there is no significant high fever, yet sweating and wheezing occur. This indicates that the pathogen is not in the Exterior but in the Lung. Therefore, Gui Zhi Tang should not be used again; instead, Ma Huang Xing Gan Shi Gao Tang can be used to treat the Lung. In the former case, wheezing occurred after sweating; in this case, wheezing occurred after purgation. Although the causes of disease differ, the observed symptoms are identical. Therefore, we follow the symptoms rather than the cause, using this decoction for both. This is also the method of treating the branch (symptoms) urgently in patients prone to wheezing.
[Collected Annotations]
Fang Youzhi said: Sweating and purgation are different methods, but the wheezing resulting from mismanagement is the same. Because the wheezing is the same, they return to a single treatment approach.
In Taiyang Wind Strike (Sunwind Syndrome), if accompanied by diarrhea and vomiting/retrograde flow, once the Exterior syndrome is resolved, one may proceed to attack the Interior. If the patient has slight sweating, occurring at specific times, headache, epigastric fullness and obstruction, pain radiating to the hypochondrium, dry retching, shortness of breath, sweating without aversion to cold, this indicates the Exterior is resolved but the Interior is not harmonized. Shi Zao Tang (Ten Jujube Decoction) is the primary treatment.
[Commentary]
The character "Xia" (Down/Lower) in "Xia Li" (Lower Diarrhea/Diarrhea) should likely be "Bu" (Not). If it were "Xia," how could one use the harsh agent Shi Zao Tang for simultaneous upper vomiting and lower diarrhea? Only when there is difficulty in defecation, epigastric fullness, obstruction, and pain, does it belong to an Interior disease; only when there is difficulty in urination, vomiting/retrograde flow, and shortness of breath, does it belong to a Fluid Retention disease, at which point attacking is appropriate. The character "Zuo" (Act/Make) in "Fa Zuo" (Attack/Onset) should likely be "Re" (Heat). If there is sweating without heat, it is a Shaoyin Yin-cold pathogen and fluid retention, which is a Zhen Wu Tang (True Warrior Decoction) syndrome. Moreover, the character "Zuo" does not fit the context of the surrounding sentences.
[Annotation]
Taiyang Wind Strike represents Exterior pathogens. Difficulty in defecation and vomiting/retrograde flow represent Interior Fluid Retention. Once the Exterior pathogens are resolved, one may proceed to attack the Fluid Retention. Carefully examine if the patient has continuous slight sweating, intermittent fever, and headache. If aversion to cold persists, the Exterior is not yet resolved, and attacking is still contraindicated. If there is no aversion to cold, the Exterior is resolved. Furthermore, if there is epigastric fullness and obstruction, pain radiating to the hypochondrium, dry retching, and shortness of breath due to fluid accumulation with no outlet, this is an urgent condition. Therefore, one directly uses the harsh agent Shi Zao Tang to attack the nest of the fluid retention without hesitation.
[Commentary]
In Shanghan (Cold Damage) with unresolved Exterior, fluid retention in the Epigastrium causing vomiting/retrograde flow, the cold binds externally, preventing the dissemination of Qi and fluids. Xiao Qing Long Tang (Minor Blue Green Dragon Decoction) should be used to disperse via sweating. In Fengzhong (Wind Strike) with unresolved Exterior, fluid retention in the Epigastrium causing vomiting, the fluid obstructs the Middle, preventing the transport and excretion of fluids. Wu Ling San (Five-Ling Powder) should be used to disperse and promote diuresis. These are all cases of unresolved Exterior where attacking Interior Fluid Retention is contraindicated. Regarding Shi Zao Tang and Gui Zhi Qu Shao Yao Jia Bai Zhu Fu Ling Tang (Cinnamon Twig Decoction minus Peony plus Atractylodes Macrocephala and Poria Decoction) from the next section, both treat fluid retention patients with Exterior and Interior syndromes. Shi Zao Tang treats headache, fever, sweating, and lack of aversion to cold (Exterior resolved) combined with epigastric fullness, obstruction, and pain (Interior not harmonized), thus focusing solely on attacking the Interior. Gui Zhi Qu Shao Yao Jia Bai Zhu Fu Ling Tang treats headache, fever, and absence of sweating (Exterior unresolved) combined with mild epigastric fullness and pain (Interior not harmonized), thus not focusing on attacking the Interior, but rather resolving the Exterior first. However, the severity of the epigastric fullness and pain differs between them.
[Collected Annotations]
Du Ren said: Shi Zao Tang is suitable only for robust individuals and should not be used lightly.
Fang Youzhi said: "One may proceed to attack" serves as a metaphor warning against premature purgation. From slight sweating to shortness of breath, it indicates that although there are Interior signs, purgation is still not indicated. Only until sweating occurs without aversion to cold does it transition from the preceding text to the following, indicating that purgation is now required.
Yu Chang said: This syndrome resembles Jie Xiong (Chest Binding), but in Jie Xiong, the pathogen binds in the Chest, which is a higher position; here, it is in the Epigastrium and Hypochondrium, a lower position. However, one must wait for the Exterior to resolve before attacking, which is similar to the warnings against attacking Jie Xiong. The use of ten Jujubes is similar to Xian Xiong Tang (Sinking Chest Decoction). The purgative method for Shanghan is mostly designed for Stomach Excess, where internal heat is abundant, requiring Da Huang (Rhei Radix et Rhizoma) to purge. Here, the syndrome is in the Chest/Hypochondrium, not the Stomach, so purging agents are useless. Instead, herbs that eliminate heat and drive out fluid retention in the Chest/Hypochondrium are chosen as the purgative method.
Zhang Zhicong said: Headache is typically an Exterior sign. However, it can also be Interior. For example, in Shanghan with constipation for five to six days, headache, and fever, Cheng Qi Tang (Order the Qi Decoction) is given. In contrast, the sweating without aversion to cold and headache described in this clause indicate that the Exterior is resolved but there is Interior Fluid Retention, treated with Shi Zao Tang. Therefore, whenever encountering headache caused by Wind-Cold with unresolved Exterior, careful differentiation is necessary.
Cheng Yingmao said: The confusing aspect is that besides headache, the only other symptom is sweating, making it difficult to distinguish between Exterior and Interior. If there is sweating, fever, and aversion to cold, there is a slight Exterior syndrome. If there is sweating, fever, and no aversion to cold, one identifies the syndrome based on the lack of aversion to cold, knowing the Exterior is resolved. The Interior Qi is bound and unharmonious due to fluid retention pathogens. Even the headache belongs to Interior pathogens attacking upward and is unrelated to the Exterior.
Wei Litong said: When Taiyang pathogens enter the Interior, purgation is usually indicated. However, this is not purgation in the Chest/Pharynx or the Intestines/Stomach, but rather in the Heart region and Hypochondrium. This position is slightly lower than Jie Xiong and slightly higher than Stomach Excess. This is another method within purgation. One must recognize that while the method is purgation, the differing syndromes dictate different approaches. Generally, at the junction of Taiyang and Yangming, one must differentiate Exterior and Interior to apply sweating or purgation. In the latter case, the Interior syndrome requiring purgation is due to pathogenic heat combining with food to form Stomach Excess; in this case, the Interior syndrome requiring purgation is due to pathogenic heat combining with water/fluid retention to form Fluid Excess. Both require waiting for the Exterior to resolve before purging, which is their commonality.