夫以为疾病至急,仓卒寻按,要者难得,故重集诸可与不可方治,比之三阴三阳篇中,此易见也。又时有
不止是三阴三阳,出在诸可与不可中也。
【注】夫以疾病至急,仓卒寻求,治法难得,其要者,汗、吐、下也,故重集汗、吐、下诸可与、不可与
之法,比之三阴三阳篇中,则易见也。又时有不止是三阴三阳篇中者,亦出在诸可与、不可与中也。
大法∶春夏宜发汗。
【注】春夏阳气舒畅,故宜发汗,医治常道,此大法也。
【集注】程应旄曰∶春夏宜发汗者,发汗有助宣阳气之功,等于春夏发生长育之义。今人多以麻、桂二汤,
作春夏之禁药,其轻于畔经者,由其未明天道也。
凡发汗,欲令手足俱周时出,以 然,一时间许,亦佳,不可令如水淋漓。若病不解,当重发汗。汗多
者必亡阳,阳虚不得重发汗也。
【注】凡发汗,令手足俱周时出,是欲汗缓出周遍,则邪气悉丢,正气不伤也。以 然,不得令如水淋
漓为度,不欲汗急出过多也。若急出过多,则邪气不尽,正气反伤矣。倘若病不解,当重发汗,但前汗已多,
更汗必亡其阳,阳虚即病不解,故不敢再发其汗也。
【集注】成无己曰∶汗缓缓出,则表里之邪悉去。汗大出,则邪气不除,但亡阳也。阳虚为无津液,故
不可重发汗。
方有执曰∶此叮咛发汗之节度也。
张锡驹曰∶汗乃津液,汗多则亡津液,何以又谓亡阳也?经云∶上焦开发腠理,熏肤、充身、泽毛,若雾
露之溉。盖汗虽津液,必借阳气之熏蒸宣发而后出,故汗多亡津液,而阳亦随之俱亡也。
凡服汤发汗,中病即止,不必尽剂也。
【注】服汤发汗,汗出病解,便可止再服,不必定然尽剂。
【集注】程应旄曰∶中病即止,亦麻黄、桂枝互举之词,示撙节于“中”字,所以严不中之禁也。
凡云可发汗,无汤者,丸散亦可用,要以汗出为解。然不如汤,随证良验。
【注】凡云可发汗无汤者,一时仓卒无汤,以丸散代之亦可,要不过以汗出为解耳。然丸散乃定剂,不如
汤可随证而进,其验甚准,故曰良也。
【集注】程应旄曰∶丸散仅可从权,随证则不如汤。
夫病脉浮大,问病者,言但便硬耳。设利者为大逆,硬为实,汗出而解,何以故?脉浮当以汗解。
【注】脉浮大,属表未解,虽有便硬里实,亦不可利下,何以故?因脉浮也。当先解其外,表解热除,内
外和谐,而大便自通矣。设用利药,是为大逆也。
【集注】成无己曰∶结胸虽急,脉浮大尤不可下,下之即死,况此便硬乎?论中有云∶
本发汗而复下之,此为逆;若先发汗,治不为逆,此之谓也。
认为疾病发生得非常急迫,仓促之间想要查阅相关脉证和治法,关键要点很难找到,所以重新汇编了各种“可用”与“不可用”的方治方法,相比于三阴三阳篇中的内容,这里更容易查阅。另外,有时情况不仅仅局限于三阴三阳篇中记载的内容,也会出现在这些“可用”与“不可用”的章节里。
【注】因为疾病极其紧急,仓促间寻求治疗方法很难得到要领,其中关键的治法是发汗、催吐、泻下,所以重新汇编了关于发汗、催吐、泻下等“可用”与“不可用”的方法,相比于三阴三阳篇,这样更容易看清。另外,有时情况不仅仅局限于三阴三阳篇中记载的内容,也出现在这些“可用”与“不可用”的章节里。
治疗的大原则:春夏季节适宜使用发汗法。
【注】春夏季节阳气舒畅,所以适宜发汗,这是医生治疗的常规法则,属于大原则。
【集注】程应旄说:春夏适宜发汗,是因为发汗有助于宣通阳气,这等同于春夏万物生长繁育的意义。现在很多人把麻黄汤(Mahuang Tang, Ephedra Decoction)和桂枝汤(Guizhi Tang, Cinnamon Twig Decoction)当作春夏季节的禁忌药物,这种轻视经典的行为,是因为他们不明白自然天道规律。
凡是进行发汗治疗,希望让手足周身均匀出汗,微微持续一段时间,大约一顿饭的时间也可以,不可以让汗水像水一样淋漓流出。如果病邪没有解除,应当再次发汗。但是,如果出汗过多,必然会导致亡阳(Yang Qi depletion),阳气虚弱时不得再次发汗。
【注】凡是发汗,要让手足周身均匀出汗,这是希望汗液缓慢排出且遍及全身,这样邪气就能全部去除,正气也不会受伤。以微微湿润为度,不要让它像水一样淋漓流出,这是不希望汗出太急且过多。如果汗出太急且过多,那么邪气不能完全去除,正气反而会受到损伤。倘若病邪没有解除,应当再次发汗,但如果之前的汗已经很多,再发汗必然会耗损阳气,阳气虚弱即使病邪未解,也不敢再发汗了。
【集注】成无己说:汗液缓缓流出,表里之邪都能去除。汗液大量流出,则邪气不能清除,只会导致亡阳。阳气虚弱意味着津液枯竭,所以不可再次发汗。
张锡驹说:汗就是津液,出汗多就会损耗津液,为什么又说亡阳呢?《内经》说:上焦开发腠理,熏蒸皮肤,充实身体,润泽毫毛,就像雾露滋润一样。大概汗虽然是津液,但必须借助阳气的熏蒸宣发才能排出,所以出汗多损耗津液,阳气也随之一起耗损。
凡是服用汤药发汗,只要病症缓解就停止服药,不必喝完一整剂药。
【注】服用汤药发汗,如果汗出后病愈,就可以停止再服,不必一定要喝完整剂药。
【集注】程应旄说:“中病即止”,也是举麻黄汤和桂枝汤为例,在“中”字上示以节制,以此来严格禁止用药不当的禁忌。
凡是说可以发汗,如果没有现成的汤药,丸剂或散剂也可以使用,关键在于通过出汗来使病情缓解。然而,不如汤药那样能随证候变化而灵活调整,疗效很好。
【注】凡是说可以发汗但没有汤药的情况,一时仓促间没有汤药,用丸剂或散剂替代也可以,不过主要是为了通过出汗来缓解病情。然而丸剂和散剂是固定剂量,不如汤药可以根据证候随时调整,其疗效非常准确,所以说疗效好。
【集注】程应旄说:丸剂和散剂只能权宜使用,随证调整则不如汤药。
如果病人的脉象浮大,询问病人,他说只是大便干硬而已。假设此时使用泻下法是大逆不道,大便干硬属于实证,应该通过发汗使病邪从表解,为什么呢?因为脉浮应当用发汗法解除。
【注】脉象浮大,属于表证未解,虽然有大便干硬的里实证,也不可以使用泻下法,为什么呢?因为脉象浮。应当先解除表邪,表解热除,内外和谐,大便自然会通畅。假如使用泻下药,这就是大逆不道。
【集注】成无己说:结胸证虽然急迫,脉象浮大尤其不可用下法,用了就会死亡,何况这只是大便干硬呢?论中有云:本来应该先发汗却反而用下法,这是逆治;如果先发汗,治疗就不算逆治,说的就是这个道理。
It is believed that diseases often arise with urgency, and in a hurried search for relevant pulse signs and treatments, key points are difficult to find. Therefore, the various "indicated" (Ke) and "contraindicated" (Bu Ke) prescriptions and treatments have been recompiled. Compared with the chapters on the Three Yin and Three Yang meridians, these are easier to consult. Furthermore, sometimes situations extend beyond what is recorded in the Three Yin and Three Yang chapters, appearing also within these sections on indicated and contraindicated treatments.
[Annotation] Because diseases can be extremely urgent, seeking treatment methods in haste makes it difficult to grasp the essentials. The crucial treatment methods are sweating (Han), vomiting (Tu), and purging (Xia). Thus, the methods regarding which sweating, vomiting, and purging techniques are "indicated" or "contraindicated" have been recompiled, making them easier to discern compared to the Three Yin and Three Yang chapters. Additionally, sometimes cases do not strictly fall within the scope of the Three Yin and Three Yang chapters but appear in these sections on indicated and contraindicated treatments.
General Principle: In spring and summer, sweating therapy is appropriate.
[Annotation] In spring and summer, Yang Qi flows freely; therefore, sweating is appropriate. This is the standard practice for physicians and constitutes a general principle.
[Collected Annotations] Cheng Yingmao stated: Sweating is appropriate in spring and summer because it aids in disseminating Yang Qi, analogous to the generative and nurturing processes of spring and summer. Many people today regard Mahuang Tang (Ephedra Decoction) and Guizhi Tang (Cinnamon Twig Decoction) as contraindicated medicines for spring and summer. Such disregard for the classics stems from a failure to understand the laws of nature.
When inducing sweating, one should aim for perspiration to spread evenly over the hands and feet, maintaining a slight moisture for about the time it takes to cook a meal. It is acceptable, but one must avoid profuse sweating like dripping water. If the disease persists, sweating may be repeated. However, excessive sweating will inevitably lead to the loss of Yang Qi (depletion of vital energy); when Yang Qi is deficient, further sweating is prohibited.
[Annotation] When inducing sweating, ensuring even perspiration over the hands and feet aims for a slow, thorough release of sweat, thereby eliminating pathogenic factors without damaging healthy Qi. The goal is slight moistening, avoiding profuse dripping, to prevent rapid and excessive loss. Rapid and excessive sweating fails to eliminate pathogens completely and damages healthy Qi. If the disease remains unresolved, sweating should be repeated; however, if previous sweating was excessive, repeating it will deplete Yang Qi. Since Yang deficiency prevents resolution, further sweating is contraindicated.
[Collected Annotations] Cheng Wuji stated: Slow sweating eliminates both exterior and interior pathogens. Profuse sweating fails to remove pathogens and only causes the loss of Yang Qi. Yang deficiency implies a lack of body fluids (Jin Ye), so repeated sweating is contraindicated.
Fang Youzhi stated: This passage emphasizes the proper degree and moderation of sweating therapy.
Zhang Xiju asked: Sweat is body fluid; excessive sweating depletes body fluids, so why speak of losing Yang Qi? The Classic states: The Upper Jiao opens the interstices, steaming the skin, filling the body, and moistening the hair, like mist and dew. Although sweat is body fluid, it requires the steaming and dissemination of Yang Qi to emerge. Therefore, excessive sweating depletes body fluids, and Yang Qi is lost along with it.
When administering decoctions to induce sweating, stop medication once the disease is addressed; there is no need to consume the entire dose.
[Annotation] After taking decoctions to induce sweating, if perspiration occurs and the disease resolves, administration should cease. There is no requirement to finish the entire prescription.
[Collected Annotations] Cheng Yingmao stated: "Stop when the disease is addressed" applies generally to formulas like Mahuang Tang and Guizhi Tang, emphasizing moderation at the point of efficacy to strictly prohibit improper dosing.
Whenever sweating is indicated but no decoction is available, pills or powders may be used, provided they achieve resolution through sweating. However, these are inferior to decoctions, which offer better efficacy due to their ability to be adjusted according to specific syndromes.
[Annotation] When sweating is indicated but decoctions are unavailable, pills or powders may serve as substitutes in an emergency, primarily to induce sweating for relief. However, pills and powders have fixed dosages, whereas decoctions can be tailored to the syndrome, offering more accurate and reliable results, hence described as having superior efficacy.
[Collected Annotations] Cheng Yingmao stated: Pills and powders are only for temporary use; they cannot match the adaptability of decoctions for syndrome differentiation.
If the patient's pulse is floating and large, and upon inquiry, the patient reports only hard stools, using purgatives would be a major error. Hard stools indicate excess, yet the condition should resolve through sweating. Why? Because a floating pulse indicates that the exterior should be resolved via sweating.
[Annotation] A floating and large pulse suggests the exterior pathogen has not yet resolved. Even if there is internal excess manifesting as hard stools, purgation is contraindicated. Why? Because the pulse is floating. One must first resolve the exterior; once the exterior is cleared and heat removed, internal harmony is restored, and bowel movements will normalize naturally. Using purgatives in this context constitutes a major therapeutic error.
[Collected Annotations] Cheng Wuji stated: Even in acute chest binding (Jie Xiong), a floating and large pulse absolutely contraindicates purgation; purging leads to death, let alone simple hard stools. The Treatise states: "Originally, sweating should have been performed first, but purgation was applied instead; this is incorrect. If sweating had been performed first, the treatment would not have been incorrect." This refers to such cases.