猪苓（去皮味甘平） 茯苓（味甘平） 阿胶（味甘平） 滑石（碎味甘寒） 泽
泻（味甘咸寒各一两）
上五味。以水四升。先煮四味。取二升。去滓。内下阿胶。烊消。温服七合。日三
服。
甘甚而反淡。淡味渗泄为阳。猪苓茯苓之甘。以行小便。咸味涌泄为阴。泽泻之咸。
以泄伏水。滑利窍。阿胶滑石之滑。以利水道。
阳明病。汗出多而渴者。不可与猪苓汤。以汗多。胃中燥。猪苓汤复利其小便故也。
针经曰。水谷入于口。输于肠胃。其液别为五。天寒衣薄则为溺。天热衣浓则为汗。
是汗溺一液也。汗多为津液外泄。胃中干燥。故不可与猪苓汤利小便也。
脉浮而迟。表
热里寒。下利清谷者。四逆汤主之。
浮为表热。迟为里寒。下利清谷者。里寒甚也。与四逆汤。温里散寒。
若胃中虚冷。不能食者。饮水则哕。
哕者、咳逆是也。千金曰。咳逆者。哕逆之名。胃中虚冷。得水。则水寒相搏。胃
气逆而哕。
脉浮发热。口干鼻燥。能食者。则衄。
脉浮发热。口干鼻燥者。热在经也。能食者。里和也。热甚于经。迫血为衄。胃中
虚冷。阴胜也。水入于经其血乃成。饮水者。助阴气。逆为哕。发热口干。阳胜也。食
入于阴。长气于阳。能食者。助阳。血妄为衄。三者。偏阴偏阳之疾也。
王三阳云。上二条。另是中阴腑之疾。此条以下。又是阳经传来之疾也。
阳明病。下之。其外有热。手足温。不结胸。心中懊 。饥不能食。但头汗出者。
栀子豉汤主之。
表未罢而下者。应邪热内陷也。热内陷者。则外热而无手足温。今外有热而手足温
者。热虽内陷。然而不深。故不作结胸也。心中懊 。饥不能食者。热客胸中。为虚烦
也。热自胸中薰蒸于上。故但头汗出而身无汗。与栀子豉汤。以吐胸中之虚烦。
阳明病。发潮热。大便溏。小便自可。胸胁满不去者。小柴胡汤主之。
阳明病。潮热。为胃实。大便硬而小便数。今大便溏。小便自可。则胃热未实而水
谷不别也。大便溏者。应气降而胸胁满去。今反不去者。邪气犹在半表半里之间。与小
柴胡汤。以去表里之邪。
吴氏云。邪在半表半里。虽潮热。不得为里大实。故仍以半表半里治之。何也。便
溏胁满故也。
阳明病。胁下硬满。不大便而呕。舌上白苔者。可与小柴胡汤。上焦得通。津液得
下。
胃气因和。身 然而汗出解也。
阳明病。腹满。不大便。舌上苔黄者。为邪热入腑。可下。若胁下硬满。虽不大便
而呕。舌上白苔者。为邪未入腑。在表里之间。与小柴胡汤。以和解之。上焦得通。则
呕止。津液得下。则胃气因和。汗出而解。
吴氏云。且有胁下硬满在。柴胡证犹未除也。
阳明中风。脉弦、浮、大、而短气。腹都满。胁下及心痛。又按之气不通。鼻干、不得
汗。嗜卧。一身及面目悉黄。小便难。有潮热。时时哕。耳前后肿。刺之小瘥。外不解。
病过十日。脉续浮者。与小柴胡汤。脉但浮无余证者。与麻黄汤。若不尿。腹满加哕者。
不治。
浮大为阳。风在表也。弦则为阴。风在里也。短气腹满。胁下及心痛。风热壅于腹
中而不通也。若寒客于内而痛者。按之则寒气散而痛止。此以风热内壅。故虽久按而气亦
不通。阳明病。鼻干。不得卧。自汗出者。邪在表也。此鼻干。不得汗。而嗜卧者。风
热内攻不干表也。一身面目悉黄。小便难。有潮热。时时哕者。风热攻于胃也。阳明之脉。
出大迎。循颊车。上耳前过客主人。热胜则肿。此风热在经。故耳前后肿。刺之经气通肿则
小瘥。如此者。外证罢。则可攻。若外证不解。虽过十
日。脉续浮者。邪气犹在半表半里。与小柴胡汤。以和解之。若其脉但浮而不弦大。无
诸里证者。是邪但在表也。可与麻黄汤。以发其汗。若不尿。腹满。加哕者。关格之疾
也。故云不治。难经曰。关格者。不得尽其命而死。
阳明病。自汗出。若发汗。小便自利者。此为津液内竭。虽硬。不可攻之。当须自
欲大便。宜蜜煎导而通之。若土瓜根。及与大猪胆汁。皆可为导。
津液内竭。肠胃干燥。大便因硬。此非结热。故不可攻。宜以药外治而导引之。
【猪苓汤方第七十五】
猪苓（去皮，味甘、性平） 茯苓（味甘、性平） 阿胶（味甘、性平） 滑石（捣碎，味甘、性寒） 泽泻（味甘、咸、性寒，各一两）
以上五味药。用水四升。先煮前四味药。取汁二升。去渣。加入阿胶。使其烊化溶解。每次温服七合。每日三次服用。
甘味极甚反而显得淡。淡味具有渗泄作用，属于阳。猪苓、茯苓的甘味，用来通利小便。咸味具有涌泄作用，属于阴。泽泻的咸味，用来排泄潜伏的水湿。滑石、阿胶的滑利之性，用来通畅水道。
阳明病。汗出多且口渴的。不可给予猪苓汤。因为汗出多导致胃中干燥。猪苓汤又会进一步利其小便的缘故。
《针经》说：水谷进入口中。输送到肠胃。其中的津液分别化为五种。天气寒冷衣服单薄时就化为尿。天气炎热衣服厚重时就化为汗。这说明汗和尿是同一种津液转化而来的。汗出多则是津液向外泄越。导致胃中干燥。所以不可用猪苓汤来利小便。
脉象浮而迟。表热里寒。下利清谷（大便中有未消化的食物）的。用四逆汤主治。
浮脉主表热。迟脉主里寒。下利清谷说明里寒严重。给予四逆汤。以温补里气、驱散寒邪。
呃逆，就是咳逆的意思。《千金方》说：咳逆，是呃逆的名称。胃中虚冷。遇到水。则水与寒气相互搏结。胃气上逆而发生呃逆。
脉象浮、发热。口干鼻燥。说明热在经脉中。能进食说明胃气调和。热邪盛于经脉。逼迫血液妄行导致鼻衄。胃中虚冷。是阴气胜。水进入经脉后转化为血。喝水会助长阴气。气逆则发生呃逆。发热口干。是阳气胜。食物进入体内滋养阴分。进而助长阳气。能进食说明助长了阳气。血液妄行导致鼻衄。这三种情况。分别是偏阴和偏阳的疾病。
王三阳说：上面两条。另外属于中阴腑的疾病。这一条以下。又是阳经传变而来的疾病。
阳明病。经过攻下治疗后。体表仍有热。手足温暖。没有形成结胸。心中烦闷懊恼。感觉饥饿但不能进食。只有头部出汗的。用栀子豉汤主治。
表证未解却进行攻下。应该是邪热内陷。热邪内陷的话。那么体表有热但手足应该发凉。现在体表有热且手足温暖。说明热邪虽然内陷。但并不深重。所以不会形成结胸。心中烦闷懊恼。感觉饥饿但不能进食。是热邪客居胸中。造成虚烦。热邪从胸中熏蒸向上。所以只有头部出汗而身体无汗。给予栀子豉汤。以吐出胸中的虚烦。
阳明病。出现定时发热（潮热）。大便稀溏。小便正常。胸胁部胀满不消退的。用小柴胡汤主治。
阳明病。出现潮热。通常是因为胃实。大便硬且小便频数。现在大便稀溏。小便正常。说明胃热尚未结实且水谷不分。大便稀溏。按理说气机下降后胸胁满闷应消除。现在反而不消除。说明邪气仍在半表半里之间。给予小柴胡汤。以祛除表里之间的邪气。
吴氏说：邪气在半表半里。虽然有潮热。不能认为是里大实证。所以仍然按半表半里证治疗。为什么呢？因为大便稀溏且胁肋胀满的缘故。
阳明病。胁下坚硬胀满。不大便且呕吐。舌上有白苔的。可以给予小柴胡汤。上焦气机通畅。津液得以向下输布。胃气因此调和。身体微微汗出而病愈。
阳明病。腹部胀满。不大便。舌上有黄苔的。是邪热入腑。可以攻下。如果胁下坚硬胀满。虽然不大便且呕吐。舌上有白苔的。是邪气未入腑。在表里之间。给予小柴胡汤。以和解表里。上焦通畅。则呕吐停止。津液下行。则胃气调和。汗出而病解。
吴氏说：况且还有胁下坚硬胀满存在。柴胡证仍未解除。
阳明中风。脉象弦、浮、大。且短气。腹部全面胀满。胁下及心口疼痛。按压时气机不通畅。鼻干。无汗。嗜睡。全身及面目都发黄。小便困难。有潮热。时时呃逆。耳前后肿胀。针刺后稍微好转。但表证未解。病过十天。脉象持续浮的。给予小柴胡汤。脉象仅浮而无其他症状的。给予麻黄汤。如果不排尿。腹部胀满加重并出现呃逆的。属不治之症。
浮大脉为阳。风邪在表。弦脉则为阴。风邪在里。短气腹满。胁下及心口疼痛。是风热壅塞于腹中而不通畅。如果是寒气客居体内导致的疼痛。按压则寒气散开而疼痛停止。这是因为风热内壅。所以即使久按气机也不通畅。阳明病。鼻干。不能卧。自汗出的。是邪气在表。这里鼻干。无汗。且嗜睡。是风热内攻而非干犯表证。全身面目都发黄。小便困难。有潮热。时时呃逆。是风热攻冲于胃。阳明经脉。出于大迎穴。沿颊车穴。上行至耳前经过客主人穴。热盛则肿胀。这是风热在经脉中。所以耳前后肿胀。针刺后经脉气通肿胀则稍好。像这样的情况。表证罢除后。才可以攻下。如果表证未解。即使过了十天。脉象持续浮的。邪气仍在半表半里。给予小柴胡汤。以和解表里。如果脉象仅浮而不弦大。无各种里证的。是邪气仅在表。可以给予麻黄汤。以发汗解表。如果不排尿。腹部胀满。加上呃逆的。是关格病。所以说是不治之症。《难经》说：关格病。不能尽其天年而死。
阳明病。自汗出。如果又发汗。小便自利的。这是津液内部枯竭。虽然大便硬。不可攻下。应当等待患者自然想排便。适宜用蜜煎导法通便。如果用土瓜根。以及给予大猪胆汁。都可以作为导引剂。
[Formula 75: Zhu Ling Tang (Polyporus Decoction)]
Zhu Ling (Polyporus, *Poria cocos* sclerotium, skin removed, sweet flavor, neutral nature) Fu Ling (Poria, *Poria cocos* sclerotium, sweet flavor, neutral nature) E Jiao (Donkey-hide Gelatin, *Colla Corii Asini*, sweet flavor, neutral nature) Hua Shi (Talcum, *Talcum*, crushed, sweet flavor, cold nature) Ze Xie (Alisma Rhizome, *Alismatis Rhizoma*, sweet and salty flavor, cold nature, each one tael).
The above five herbs. Use four sheng of water. First decoct the first four herbs. Obtain two sheng of liquid. Remove the dregs. Add E Jiao. Melt it completely. Take seven ge warm per dose. Three times a day.
When the sweet flavor is extreme, it appears bland. The bland flavor has a seeping and draining action, which belongs to Yang. The sweet flavor of Zhu Ling and Fu Ling promotes urination. The salty flavor has a surging and draining action, which belongs to Yin. The salty flavor of Ze Xie drains latent water. The slippery nature of Hua Shi and E Jiao facilitates the flow of the water passages.
In Yangming disease, if there is excessive sweating and thirst, Zhu Ling Tang should not be administered. This is because excessive sweating causes dryness in the stomach, and Zhu Ling Tang further promotes urination.
The *Zhen Jing* (Needle Classic) states: Food and drink enter the mouth, are transported by the stomach and intestines, and their fluids are transformed into five types. When it is cold and clothing is thin, they transform into urine; when it is hot and clothing is thick, they transform into sweat. Thus, sweat and urine are derived from the same fluid. Excessive sweating leads to the external leakage of body fluids and dryness in the stomach. Therefore, Zhu Ling Tang should not be used to promote urination.
If the pulse is floating and slow, indicating exterior heat and interior cold, with diarrhea containing undigested food, Si Ni Tang (Frigid Four Decoction) is indicated.
Floating indicates exterior heat; slow indicates interior cold. Diarrhea with undigested food signifies severe interior cold. Si Ni Tang is given to warm the interior and dispel cold.
If the stomach is deficient and cold, unable to accept food, drinking water will induce hiccups (yue). Hiccups refer to coughing against the reverse flow. The *Qian Jin Fang* states that "coughing against the reverse flow" is another name for hiccups. With a deficient and cold stomach, water interacts with cold, causing stomach qi to rebel and inducing hiccups.
If the pulse is floating, accompanied by fever, dry mouth, dry nose, and the ability to eat, epistaxis (nosebleed) will occur.
Floating pulse and fever indicate heat in the meridians. The ability to eat indicates harmony in the stomach. Heat prevailing in the meridians forces blood to bleed, causing epistaxis. A deficient and cold stomach represents excess yin. Water entering the meridians forms blood; drinking water aids yin qi, leading to rebellion and hiccups. Fever and dry mouth represent excess yang. Food enters the yin and nourishes the yang. The ability to eat aids yang, causing blood to move recklessly and resulting in epistaxis. These three conditions are diseases of yin or yang bias.
Wang Sanyang said: The previous two clauses describe diseases of the middle yin fu organs. The following clauses describe diseases transmitted from the yang meridians.
In Yangming disease, after purgation, if there is exterior heat, warm hands and feet, no chest binding, mental restlessness (ao nu), hunger but inability to eat, and only sweating on the head, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is indicated.
Exterior syndrome unresolving followed by purgation suggests internal collapse of pathogenic heat. If heat collapses internally, there would be exterior heat but cold hands and feet. Since there is exterior heat and warm hands and feet, although heat has collapsed internally, it is not deep, so chest binding does not form. Mental restlessness, hunger, and inability to eat indicate heat lodging in the chest, causing deficiency vexation. Heat steaming upward from the chest causes sweating only on the head and no sweat on the body. Zhi Zi Chi Tang is given to induce vomiting of the deficiency vexation in the chest.
In Yangming disease, with tidal fever, loose stools, normal urination, and persistent fullness in the chest and hypochondrium, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is indicated.
Tidal fever in Yangming disease usually indicates stomach excess, hard stools, and frequent urination. Here, loose stools and normal urination indicate that stomach heat is not yet solidified and water and grain are not separated. Loose stools should allow qi to descend and relieve chest and hypochondriac fullness. Since fullness persists, pathogenic factors remain between the exterior and interior. Xiao Chai Hu Tang is given to eliminate pathogenic factors between the exterior and interior.
Wu said: Pathogenic factors between the exterior and interior, even with tidal fever, cannot be considered major interior excess. Therefore, it is still treated as a half-exterior, half-interior condition. Why? Because of loose stools and hypochondriac fullness.
In Yangming disease, with hardness and fullness below the hypochondrium, constipation, vomiting, and a white coating on the tongue, Xiao Chai Hu Tang may be given. Once the upper jiao becomes unobstructed, body fluids can descend, stomach qi harmonizes, and the patient sweats slightly and recovers.
In Yangming disease, abdominal fullness, constipation, and a yellow coating on the tongue indicate pathogenic heat entering the fu organs; purgation is applicable. If there is hardness and fullness below the hypochondrium, constipation, vomiting, and a white coating on the tongue, pathogenic factors have not entered the fu organs but remain between the exterior and interior. Xiao Chai Hu Tang is given to harmonize. Unobstruction of the upper jiao stops vomiting; descent of body fluids harmonizes stomach qi; sweating leads to recovery.
Wu said: Moreover, since hardness and fullness below the hypochondrium persist, the Chai Hu syndrome remains unresolved.
Yangming wind-strike presents with wiry, floating, and large pulses, shortness of breath, generalized abdominal fullness, pain in the hypochondrium and heart region, obstruction of qi upon palpation, dry nose, inability to sweat, lethargy, jaundice of the whole body and face, difficulty in urination, tidal fever, occasional hiccups, and swelling around the ears. Acupuncture provides slight relief. If the exterior syndrome remains unresolved and the disease lasts over ten days, if the pulse continues to float, give Xiao Chai Hu Tang. If the pulse is merely floating without other symptoms, give Ma Huang Tang (Ephedra Decoction). If there is no urination, increased abdominal fullness, and added hiccups, it is incurable.
Floating and large pulses indicate yang; wind is at the exterior. Wiry pulse indicates yin; wind is at the interior. Shortness of breath, abdominal fullness, and pain in the hypochondrium and heart region indicate wind-heat congesting the abdomen and obstructing qi flow. If pain were caused by cold invading internally, pressing would disperse the cold and stop the pain. Here, due to internal congestion of wind-heat, pressing does not relieve the obstruction. In Yangming disease, dry nose, inability to lie down, and spontaneous sweating indicate pathogenic factors at the exterior. Here, dry nose, inability to sweat, and lethargy indicate internal attack by wind-heat rather than involvement of the exterior. Generalized jaundice, difficulty in urination, tidal fever, and occasional hiccups indicate wind-heat attacking the stomach. The Yangming meridian emerges at Daying, follows Jiache, and ascends to Erqianzhong passing through Guest Master. Excess heat causes swelling. This is wind-heat in the meridian, causing swelling around the ears. Acupuncture unblocks meridian qi, reducing swelling. If such cases resolve externally, purgation may proceed. If the exterior syndrome remains unresolved, even after ten days, if the pulse continues to float, pathogenic factors remain between the exterior and interior; give Xiao Chai Hu Tang to harmonize. If the pulse is merely floating, not wiry or large, without interior symptoms, pathogenic factors are solely at the exterior; give Ma Huang Tang to induce sweating. If there is no urination, abdominal fullness, and added hiccups, this is Guan Ge (Gate and Grid) disease, hence incurable. The *Nan Jing* states: Guan Ge disease leads to death before the natural lifespan is exhausted.
In Yangming disease, with spontaneous sweating, if sweating is induced again and urination is free, this indicates internal exhaustion of body fluids. Although stools are hard, purgation is contraindicated. One must wait for the natural desire to defecate. Honey suppositories are suitable to guide passage. Radix Trichosanthis (Tu Gua Gen) or large pig bile can also be used as guiding agents.
Internal exhaustion of body fluids leads to dryness of the intestines and stomach, causing hard stools. This is not accumulated heat; therefore, purgation is contraindicated. External medication and guiding methods are appropriate.