证皆小便不利，故均得而主之。若小便自利者，不可用，恐重伤津液，以其属阳明之里，
故不可用也。由此可知五苓散非治水热之专剂，乃治水热小便不利之主方也。君泽泻之
咸寒，咸走水府，寒胜热邪；佐二苓之淡渗，通调水道，下输膀胱，则水热并泻也；用白
术之燥湿，健脾助土，为之堤防以制水也；用桂之辛温，宣通阳气，蒸化三焦以行水也。泽
泻得二苓下降，利水之功倍，则小便利，而水不蓄矣。白术藉桂上升，通阳之效捷，则
气腾津化，渴自止也。若发热不解，以桂易桂枝，服后多服暖水，令汗出愈。是知此方
不止治停水小便不利之里，而犹解停水发热之表也。加人参名春泽汤，其意专在助气化
以生津。加茵陈名茵陈五苓散，治湿热发黄，表里不实，小便不利者，无不效也。
【集解】程应旄曰∶太阳为标，膀胱为本。中风发热，标受邪也。六七日不解，标邪转
入膀胱矣。是谓犯本。五苓散与麻黄、桂枝二汤，虽同为太阳经之药，一则解肌而治表，
一则利小便而治里，表与本所主各有别矣。
【按】此条谓有表里证者，非发热有汗，口干烦渴，水入则消，小便自利，太阳、阳明之表
里证也。乃发热无汗，口润烦渴，水入则吐，小便不利，太阳、膀胱之表里证也。此病虽未发
明无汗小便不利之证，若汗出小便利，则渴饮之水得从外越下出，必无水逆之证。仲景用五
苓散，多服暖水令汗出愈，其意在利水发汗，故知必有无汗小便不利之证也。
太阳病，小便利者，以饮水多，必心下悸；小便少者，必苦里急也。
【注】太阳初病，不欲饮水，将传阳明，则欲饮水，此其常也。今太阳初病，即饮水
多，必其人平素胃燥可知。设胃阳不衰，则所饮之水，亦可以敷布于外，作汗而解。今
饮水多，而胃阳不充，即使小便利，亦必停中焦，而为心下悸。若更小便少，则水停下
焦，必苦里急矣。
【集注】方有执曰∶饮水多而心下悸者，心为火脏，水多则受制也。小便少则水停，所以里急也。
汪琥曰∶太阳病，小便利者，是膀胱之腑无邪热也。若其人饮水多，此热在上焦，心
火亢甚，小便虽利，而渴饮水多，则水停犯火，必心下悸。若其人饮水多而小便少，此
热在下焦，为太阳邪热，随经入腑，水积不行，膀胱之里，必苦急也。
发汗后，饮水多必喘，以水灌之亦喘。
【注】上条未发汗饮水多，胃热津少也。此条发汗后饮水多，津亡胃干也。而不病心
下悸、苦里急者，盖以水不停于中焦、下焦，而停于上焦，所以攻肺必作喘也。水灌者，以
水浇洗也。饮水多者必喘，是饮冷，冷伤于内也。以水灌之亦喘者，是形寒，寒伤于外
也，均伤肺，故俱喘。
【集注】魏荔彤曰∶此申明本条喘急一证，有因水而成者。盖渴而饮水多之喘，与不渴
而灌之亦喘，其由虽不同，而致病则一也。
发汗后，不可更行桂枝汤。汗出而喘，无大热者，可与麻黄杏仁甘草石膏汤。
【注】太阳病，下之后微喘者，表未解也，当以桂枝加浓朴杏仁汤，解太阳肌表，而治
其喘也。太阳病桂枝证，医反下之，下利脉促，汗出而喘，表未解得，当以葛根黄连黄
芩汤，解阳明之肌热，而治其喘也。今太阳病发汗后，汗出而喘，身无大热而不恶寒者，
知邪已不在太阳之表；且汗出而不恶热，知邪亦不在阳明之里。其所以汗出而喘，既无大热，
又不恶寒，是邪独在太阴肺经，故不可更行桂枝汤，可与麻黄杏子甘草石膏汤，发散肺邪，而汗、喘自止矣。
麻黄杏仁甘草石膏汤方
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）
上四味以水七升，先煮麻黄减二升，去白沫，纳诸药，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。故青龙以无汗烦躁，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。故于麻黄汤去桂枝之监制，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
痞硬满，引胁下痛，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，痞硬满痛，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，乃可攻里饮也。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硬满，引胁下痛，干呕短气，水蓄无所从出之急证，故径以十
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。至如十枣汤与下编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，而有痞硬满
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。然其心下硬满痛之微甚，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∶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；此在心下及胁，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，不得不用硝黄以荡涤之。今证在胸胁而不在胃，则荡涤
之药无所用，故取蠲热逐饮于胸胁之间，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，用十枣汤。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，则只从不恶寒处认证，知表已解，里气为饮邪抟结不和，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，而下心与胁下者，较
下结胸博位稍卑，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。
十枣汤方
芫花（熬） 甘遂 大戟 大枣（擘，十枚）
上三味等分，各别捣为散。以水一升半，
先煮大枣肥者十枚，取八合，去滓，纳药末。强人服一钱匕，羸人服半钱，温服之，平旦
服。若下少病不除者，明日更服，加半钱，得快下利后，糜粥自养。
【方解】仲景治水之方，种种不同，此其最峻者也。凡水气为患，或喘、或咳、或悸、
或噎、或吐、或利，病在一处而止。此则水邪留结于中，心腹胁下痞满硬痛，三焦升降
之气阻隔难通。此时表邪已罢，非汗散之法所宜；里饮实盛，又非淡渗之品所能胜；非
选逐水至峻之品，以直折之，则中气不支，束手待毙矣。甘遂、芫花、大戟三味，皆辛苦
气寒而禀性最毒，并举而用之，气味相济相须，故可直攻水邪之巢穴，决其渎而大下之，
一举而患可平也。然邪之所凑，其气必虚，以毒药攻邪，必伤及脾胃，使无冲和甘缓之品
为主宰，则邪气尽而大命亦随之矣。然此药最毒至峻，参术所不能君，甘草又与之反，故
选十枣之大而肥者以君之。一以顾其脾胃，一以缓其峻毒。得快利后，糜粥自养。一以使
谷气内充；一以使邪不复作。此仲景用毒攻病之法，尽美又尽善也。昧者惑于甘能中满
之说而不敢用，岂知承制之理乎！
太阳病，外证未解不可下也，下之为逆。欲解外者，宜桂枝汤。
【注】太阳病外证未解者，谓桂枝汤之表证未解也。凡表证未解，无论已汗未汗，虽
有可下之证，而非在急下之例者，均不可下。下之为逆也。欲解外者，仍宜桂枝汤主之。
【集注】王肯堂曰∶但有一毫头痛恶寒，即为表证未解，不可下也。
程应旄曰∶若下后外证未解者，仍当解外，有是证用是药，不可以既下而遂谓桂枝汤不中与也。
汪琥曰∶下之为逆，逆者，为病在外而反攻其内，于治法为不顺也。
太阳病，先发汗不解，而复下之，脉浮者不愈。浮为在外，而反下之，故令不愈。今
脉浮，故知在外，当须解外则愈，宜桂枝汤。
【注】太阳病，先发汗表未解，仍宜汗之，而复下之，治失其宜矣。脉浮者不愈，盖以
脉浮，邪在外而反下之，故令不愈也。今误下未成逆，脉仍浮，故知邪尚在外，仍宜桂枝汤解外则愈也。
【集注】程应旄曰∶愈不愈辨之于脉。其愈者，必其脉不浮而离于表也。若脉浮者，知
尚在表，则前此之下，自是误下，故令不愈。从前之误，不必计较，只据目前。目前之证，
不必计较，只据其脉。脉若浮，知尚在外，虽日久尚须解外则愈。有是脉，用是药，亦不
以既下而遂以桂枝汤为不中与也。
本发汗而复下之，此为逆也；若先发汗，治不为逆。本先下之，而反汗之，为逆；若先下之，治不为逆。
【注】立治逆之法，不外乎表里；而表里之治，不外乎汗下。病有表里证者，当审其
汗、下何先，先后得宜为顺，失宜为逆。若表急于里，本应先汗而反下之，此为逆也；若
先汗而后下，治不为逆也。若里急于表，本应先下，而反汗之，此为逆也；若先下而后汗，治不为逆也。
【集注】程知曰∶言汗下有先后缓急，不得倒行逆施。
汪琥曰∶治伤寒之法，表证急者即宜汗，里证急者即宜下，不可拘拘于先汗而后下也。
汗下得宜，治不为逆。
太阳病，下之，其脉促不结胸者，此为欲解也。脉浮者必结胸，脉紧者必咽痛，脉
弦者必两胁拘急，脉细数者头痛未止，脉沉紧者必欲呕，脉沉滑者协热利，脉浮滑者必下血。
【按】脉促当是“脉浮”，始与不结胸为欲解之文义相属。脉浮当是“脉促”，始与论
中结胸、胸满同义。脉紧当是“脉细数”，脉
细数当是“脉紧”，始合论中二经本脉。脉浮滑当是“脉数滑”，浮滑是论中白虎汤证之脉，
数滑是论中下脓血之脉。细玩诸篇自知。
【注】病在太阳，误下，为变不同者，皆因人之脏气不一，各从所入而化，故不同也。误
下邪陷，当作结胸，反不结胸，其脉浮，此里和而不受邪，邪仍在表为欲解也。若脉促者，为
阳结实邪之脉，故必结胸也。脉细数，少阴邪热之脉；咽痛，少阴邪热之证。误下邪陷少阴，
法当从少阴治也。脉弦，少阳之脉；两胁拘急，少阳之证。误下邪陷少阳，法当从少阳治也。
脉紧，太阳脉；头痛，太阳证。误下邪仍在表，法当从太阳治也。脉沉紧，寒邪入里之脉；欲
呕，胃阳格拒之证。有表误下，邪陷在胃，法当从阳明治也。脉沉滑，宿食脉。有表误下，协
热入里下利，法当从协热下利治也。脉数滑，积热脉。有表误下，邪陷入阴，伤营下血，法当
从下脓血治也。
【按】脉促固阳脉也。若促而有力为实，则为结胸实邪之诊；若促而无力为虚，则为
胸满虚邪之诊。故论中有脉促结胸，头汗小潮热者，用陷胸汤攻之；脉促胸满，汗出微
恶寒者，用桂枝去芍药加附子汤温之。观此促脉虚实治法，则可以类推矣。
【按】咽痛，少阴寒热俱有之证也。咽干肿痛者为热，不干不肿而痛者为寒，故少阴
论中有甘桔汤、通脉四逆汤二治法也。
所有症状都表现为小便不利，因此都可以用五苓散来主治。如果小便通畅，则不可使用，因为担心会进一步损伤津液，这是由于病证属于阳明经的里证，所以不能使用。由此可知，五苓散并非专门治疗水热互结的方剂，而是治疗因水热互结导致小便不利的代表方。方中以泽泻为君药，其味咸性寒，咸味入肾（水府），寒性能清热邪；佐以茯苓、猪苓的淡渗之性，通调水道，使水液下输膀胱，从而水热并除；用白术的燥湿作用，健脾助土，像堤防一样制约水湿泛滥；用桂枝的辛温之性，宣通阳气，蒸腾气化三焦以运行水液。泽泻配合茯苓、猪苓下降，利水功效倍增，从而使小便通畅，水液不再蓄积。白术借助桂枝上升，通阳效果迅速，使得气机升腾、津液化生，口渴自然停止。如果出现发热不退的情况，将桂枝改为肉桂，服药后多喝热水，令其出汗即可痊愈。这说明此方不仅治疗停水导致的小便不利的里证，还能解除停水导致的发热的表证。加入人参称为春泽汤，其用意专在辅助气化以生津液。加入茵陈称为茵陈五苓散，治疗湿热发黄、表里俱不实、小便不利的患者，无不有效。
【集解】程应旄说：太阳经以体表为标，膀胱为本。中风发热，是标部受邪。经过六七天未愈，标部的邪气转入膀胱了。这叫做侵犯本脏。五苓散与麻黄汤、桂枝汤这两张方子，虽然都是治疗太阳经的药物，但一张是解肌发表以治表，一张是利小便以治里，表与本的主治各有区别。
【按语】这一条说的是既有表证又有里证的情况，并不是指发热有汗、口干烦渴、喝水即消、小便自利的太阳、阳明表里证。而是指发热无汗、口润烦渴、喝水即吐、小便不利的太阳、膀胱表里证。这个病虽然没有明确说明无汗和小便不利的症状，但如果汗出且小便通畅，那么喝进去的水就能从体外发散或向下排出，必然不会出现水逆的症状。仲景使用五苓散，要求服药后多喝热水令其出汗而愈，其意图在于利水发汗，所以推断必然存在无汗和小便不利的症状。
太阳病，小便通畅的，因为饮水过多，必然出现心下悸动；小便少的，必然感到小腹急迫难受。
【注】太阳病初起时，不想喝水，将要传入阳明经时，才会想喝水，这是正常情况。现在太阳病初起，就大量饮水，必定是因为此人平素胃中干燥。假设胃阳不衰，那么所饮用的水，也可以敷布于体表，化作汗液而病解。现在饮水多，而胃阳不足，即使小便通畅，水也必然停滞在中焦，从而导致心下悸动。如果再加上小便少，那么水就会停滞在下焦，必然感到小腹急迫难受。
【集注】方有执说：饮水多而心下悸动的，因为心属火脏，水多则克制心火。小便少则水液停滞，所以感到小腹急迫。
汪琥说：太阳病，小便通畅，说明膀胱腑中没有邪热。如果此人饮水多，这是热在上焦，心火亢盛，虽然小便通畅，但因口渴饮水多，水液停滞侵犯心火，必然导致心下悸动。如果此人饮水多而小便少，这是热在下焦，为太阳邪热随经脉传入腑中，水液积聚不行，膀胱内部必然感到急迫难受。
发汗后，饮水过多必然导致气喘，用水浇洗身体也会导致气喘。
【注】上一条讲的是未发汗前饮水过多，原因是胃热津液少。这一条讲的是发汗后饮水过多，原因是津液耗亡、胃干。而没有出现心下悸动、小腹急迫的症状，是因为水没有停滞在中焦、下焦，而是停滞在上焦，所以水气攻肺必然导致气喘。“水灌”是指用水浇洗。饮水过多必然气喘，是因为喝了冷水，寒气伤及体内。用水浇洗身体也导致气喘，是因为形体受寒，寒气伤及体表。两者都伤了肺，所以都会气喘。
【集注】魏荔彤说：这里申明了本条气喘一证，有因水饮引起的。口渴而饮水多引起的气喘，与不口渴而浇水也引起的气喘，虽然成因不同，但致病结果是一样的。
发汗后，不可再用桂枝汤。如果汗出且气喘，身上没有大热的，可以给予麻黄杏仁甘草石膏汤。
【注】太阳病，误用下法后出现轻微气喘的，是表证未解，应当用桂枝加厚朴杏子汤，解除太阳肌表之邪，同时治疗气喘。太阳病桂枝证，医生反而误用下法，导致下利、脉促、汗出且气喘，表证未解，应当用葛根黄连黄芩汤，解除阳明肌表之热，同时治疗气喘。现在太阳病发汗后，出现汗出且气喘，身上没有大热且不恶寒，知道邪气已经不在太阳之表；且汗出而不恶热，知道邪气也不在阳明之里。之所以汗出且气喘，既没有大热，又不恶寒，说明邪气独在太阴肺经，所以不可再用桂枝汤，可以给予麻黄杏子甘草石膏汤，发散肺经邪气，那么汗出和气喘自然会停止。
麻黄杏仁甘草石膏汤方
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，减少二升水量，去掉水面上的浮沫，加入其他药物，煮取三升药液，去掉药渣，温服一升。
【集注】柯琴说：石膏是清火的重剂，青龙汤、白虎汤都依靠它建功，但如果使用不当，足以招致祸患。所以青龙汤用于无汗烦躁，配合生姜、桂枝以宣发卫外之阳气；白虎汤用于有汗烦渴，需要粳米以保存胃中之津液。现在只有内热而无外寒，所以不用姜、桂。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，不必担心阳气亡失。所以在麻黄汤中去掉桂枝的监制作用，取麻黄的专于开泄，杏仁的降气，甘草的和缓，加倍使用石膏的寒性，清除内蕴的实热，这样汗出溱溱，内外的烦热与气喘全部消除。
误用下法后，不可再用桂枝汤。如果汗出且气喘，身上没有大热的，可以给予麻黄杏仁甘草石膏汤。
【注】这是对上一条的详细解释，说明病因虽有两条途径（汗后、下后），但治疗方法相同。又有误用下法后身无大热、汗出且气喘的，知道邪气也不在表而在肺，所以也不可再用桂枝汤，可以给予麻黄杏仁甘草石膏汤来治疗肺疾。那一条是发汗后气喘，这一条是误下后气喘，虽然致病原因不同，但所见症状无异，所以顺从其症状，不从其原因，均使用此汤，这也是治疗喘证“急则治其标”的方法。
【集注】方有执说：发汗与误下虽然不同，但它们作为误治导致的变证——气喘，是一致的。正因为气喘这一症状相同，所以归于同一种治法。
太阳中风，如果不拉肚子而是呕吐逆气，表证已解的，才可以攻里。其人汗出，发作有时，头痛，心下痞塞硬满，牵引胁下疼痛，干呕短气，汗出且不恶寒的，这是表已解而里未和，用十枣汤主治。
【按语】下利中的“下”字，应当是“不”字。如果是“下”字，哪有上吐下利却用十枣汤峻猛之剂攻下的道理呢？只有大便不通，痞塞硬满疼痛，才属于里病；小便不利，呕吐逆气短气，才属于饮病，才可以攻逐。发作的“作”字，应当是“热”字。如果没有热而汗出，那是少阴阴邪寒饮，是真武汤的证候。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，是里饮。表邪已解，才可以攻逐里饮。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，尚不可攻。如果不恶寒，则为表已解。而又见里未和的心下痞塞硬满，牵引胁下疼痛，干呕短气，水液蓄积无处排出的急证，所以直接用十枣汤峻猛之剂，直攻水邪巢穴而毫不犹豫。
【按语】伤寒表证未解，水停心下，呕吐逆气的，是寒邪束于外，水气不得宣发，宜用小青龙汤发汗解散；中风表证未解，水停心下而呕吐的，是水饮格拒于中，水气不得输泄，宜用五苓散散发并利水。这些都是表证未解，不可攻逐里饮的情况。至于十枣汤与下编的桂枝去芍药加白术茯苓汤两张方子，都是治疗素有水饮之人兼有表里证的。十枣汤治疗头痛、发热、汗出、不恶寒的表已解，而有痞塞硬满痛的里未和，所以专主攻里。桂枝去芍药加白术茯苓汤，治疗头痛、发热、无汗的表未解，而兼有心下满微痛的里不和，所以不主攻里，应当先解表。然而其心下硬满痛的轻重，也有区别。
【集注】杜任说：十枣汤只适合体质壮实的人，不宜轻易使用。
方有执说：“乃可攻之”，以上是比喻告诉人们不要妄自过早攻下的意思。从“汗出”到“短气”，是说虽然有里证，但还不可以攻下。直到“汗出不恶寒”，才是承接上文开启下文，说要攻下以给出治疗方案。
喻昌说：此证与结胸颇相似。但结胸是邪气结于胸，位置高；此证在心下及胁，位置低。但也必须表解之后才可攻下，这与攻结胸的禁忌没有不同。药用十枣，也与陷胸汤相似，因为伤寒的下法，多为胃实而设。胃实是邪热内盛，不得不使用硝石、大黄来荡涤。现在病位在胸胁而不在胃，那么荡涤的药就没有用处，所以选取能蠲除热邪、驱逐水饮于胸胁之间的药物，作为下法。
张志聪说：头痛，是表证。但也有在里的，如伤寒不大便五六日，头痛有热的，给予承气汤。与此节中汗出不恶寒而头痛，是表解里有饮，用十枣汤。那么凡遇到风寒头痛，表未解的证候，应当仔细辨别。
程应旄说：令人困惑的是，除了头痛之外只有身汗一证，表里难辨。汗出发热恶寒，则微有表证；若汗出发热不恶寒，则只从不恶寒处辨证，知道表已解，里气被饮邪搏结而不和，虽然头痛也属于里邪上攻，与表无关。
魏荔彤说：太阳的邪气既然入里，应当攻下。又有不下胸膈，不下肠胃，而下心与胁下的，比下结胸的位置稍低，比下胃实的位置又稍高，这是下法中的另一种方法。必须认清同样是下法，但证候不同而治法自然有别。大概在太阳、阳明之交，必须辨别表里而施以汗下。彼处的在里应下，是邪热挟食物形成胃实；此处的在里应下，是邪热挟水饮形成饮实。两者都必须等待表解而后攻下，这是大同点。
十枣汤方
芫花（熬） 甘遂 大戟 大枣（擘开，十枚）
以上三味药等分，分别捣碎过筛成散剂。用水一升半，先煮肥大的大枣十枚，取八合药汁，去掉药渣，纳入药末。强壮的人服一钱匕，瘦弱的人服半钱，温服，清晨空腹服用。如果泻下少而病未除，第二天再服，增加半钱，得到快速腹泻后，喝糜粥自行调养。
【方解】仲景治疗水饮的方子，种种不同，这是其中最峻猛的。凡是水气为患，或者气喘、或者咳嗽、或者心悸、或者噎塞、或者呕吐、或者下利，病在一处而止。这里则是水邪留结于中焦，心腹胁下痞满硬痛，三焦升降之气阻隔难通。此时表邪已罢，不是发汗解散的方法适宜；里饮实盛，也不是淡渗利湿的药物所能胜任；不选用逐水最峻猛的药物来直接折服它，那么中气就不支，束手待毙了。甘遂、芫花、大戟三味药，都是辛苦气寒而禀性最毒，并举而用之，气味相辅相成，所以可以直接攻治水邪的巢穴，决其堤防而大下之，一举而病患可平。然而邪气聚集的地方，正气必然虚弱，用毒药攻邪，必然会损伤脾胃，如果没有冲和甘缓的药物为主宰，那么邪气尽除而性命也随之丧失了。然而此药最毒至峻，人参、白术不能为之君药，甘草又与之相反，所以选十枚大而肥的大枣作为君药。一来顾护脾胃，二来缓和其峻猛毒性。得到快速腹泻后，喝糜粥自行调养。一来使谷气内充，二来使邪气不再复发。这是仲景用毒药攻治病邪的方法，尽善尽美。愚昧者被“甘能中满”的说法迷惑而不敢使用，哪里懂得承制之理呢！
太阳病，外证未解不可攻下，攻下就是逆治。想要解除外证，宜用桂枝汤。
【注】太阳病外证未解，指的是桂枝汤的表证未解。凡是表证未解，无论是否已经发汗，即使有可下的证候，如果不是急下之例，都不可攻下。攻下就是逆治。想要解除外证，仍宜用桂枝汤主治。
【集注】王肯堂说：只要有一毫头痛恶寒，就是表证未解，不可攻下。
程应旄说：如果下后外证未解，仍当解外，有是证用是药，不可以因为已经攻下就说桂枝汤不适用。
汪琥说：下之为逆，逆者，是指病在外而反攻其内，对于治法来说是不顺的。
太阳病，先发汗未愈，而复用下法，脉浮的未愈。浮脉表示病邪在外，反而用下法，所以导致未愈。现在脉浮，所以知道病邪仍在表，应当须解外则愈，宜用桂枝汤。
【注】太阳病，先发汗表未解，仍宜发汗，却反而用下法，治疗失去了适宜。脉浮者未愈，大概是因为脉浮，邪气在外而反用下法，所以导致未愈。现在误下未成逆证，脉仍浮，所以知道邪气尚在外，仍宜用桂枝汤解外则愈。
【集注】程应旄说：愈与不愈通过脉象来辨别。痊愈的，必定是其脉不浮而离于表。如果脉浮，知道尚在表，那么之前的下法自然是误下，所以导致未愈。以前的错误，不必计较，只看目前。目前的证候，不必计较，只看其脉。脉若浮，知道尚在外，即使日久也须解外则愈。有是脉，用是药，也不因为已经攻下就说桂枝汤不适用。
本来应当发汗却反而用下法，这是逆治；如果先发汗，治疗就不是逆治。本来应当先攻下却反而发汗，这是逆治；如果先攻下，治疗就不是逆治。
【注】确立治疗逆乱的方法，不外乎表里；而表里的治疗，不外乎汗下。病有表里证的，应当审察汗、下何者为先，先后得宜为顺，失宜为逆。如果表急于里，本来应先发汗而反而攻下，这是逆治；如果先发汗而后攻下，治疗就不是逆治。如果里急于表，本来应先攻下，而反而发汗，这是逆治；如果先攻下而后发汗，治疗就不是逆治。
【集注】程知说：意思是汗下有先后缓急，不得倒行逆施。
汪琥说：治疗伤寒的方法，表证急者即宜发汗，里证急者即宜攻下，不可拘泥于先汗而后下。汗下得宜，治疗就不是逆治。
太阳病，误用下法，其脉促而不结胸的，这是欲解的表现。脉浮的必结胸，脉紧的必咽痛，脉弦的必两胁拘急，脉细数的头痛未止，脉沉紧的必欲呕，脉沉滑的协热下利，脉浮滑的必下血。
【按语】脉促应当是“脉浮”，才与不结胸为欲解的文义相属。脉浮应当是“脉促”，才与论中结胸、胸满同义。脉紧应当是“脉细数”，脉细数应当是“脉紧”，才符合论中二经的本脉。脉浮滑应当是“脉数滑”，浮滑是论中白虎汤证的脉象，数滑是论中下脓血的脉象。仔细玩味诸篇自然知晓。
【注】病在太阳，误用下法，变证不同的，都是因为人的脏气不一，各随所入而化，所以不同。误下邪气内陷，当作结胸，反而不结胸，其脉浮，这是里气和而不受邪，邪气仍在表，为欲解。如果脉促，是阳结实邪的脉象，所以必结胸。脉细数，是少阴邪热的脉象；咽痛，是少阴邪热的证候。误下邪陷少阴，法当从少阴治疗。脉弦，是少阳的脉象；两胁拘急，是少阳的证候。误下邪陷少阳，法当从少阳治疗。脉紧，是太阳的脉象；头痛，是太阳的证候。误下邪仍在表，法当从太阳治疗。脉沉紧，是寒邪入里的脉象；欲呕，是胃阳格拒的证候。有表误下，邪陷在胃，法当从阳明治疗。脉沉滑，是宿食的脉象。有表误下，协热入里下利，法当从协热下利治疗。脉数滑，是积热的脉象。有表误下，邪陷入阴，伤营下血，法当从下脓血治疗。
【按语】脉促固然是阳脉。如果促而有力为实，则是结胸实邪的诊断；如果促而无力为虚，则是胸满虚邪的诊断。所以论中有脉促结胸，头汗小潮热的，用陷胸汤攻之；脉促胸满，汗出微恶寒的，用桂枝去芍药加附子汤温之。观此促脉虚实治法，则可以类推了。
【按语】咽痛，是少阴寒热都有的证候。咽干肿痛者为热，不干不肿而痛者为寒，所以少阴论中有甘桔汤、通脉四逆汤两种治法。
All symptoms manifest as difficulty in urination, therefore all can be primarily treated with Wuling San (Five-Ling Powder). If urination is normal, it must not be used, for fear of further damaging the body fluids, as this condition belongs to the interior syndrome of the Yangming channel; hence, it cannot be used. From this, we can understand that Wuling San (Five-Ling Powder) is not a specific agent solely for treating water-heat interaction, but rather the principal formula for treating difficulty in urination caused by water-heat retention. The sovereign herb is Xie (Alisma Rhizome), which is salty and cold; saltiness enters the Water Mansion (Kidney/Bladder), and coldness overcomes heat pathogens. The assistant herbs are Ling (Poria) and Fu Ling (Poria with Wood), which have a light and permeating nature, unblocking and regulating the water passages, directing water downward to the Bladder, thereby draining both water and heat together. Bai Zhu (Atractylodis Macrocephalae Rhizoma) is used for its drying-dampness property to strengthen the Spleen and assist Earth, acting as a dike to control water overflow. Gui Zhi (Cinnamon Twig) is used for its acrid and warm nature to disseminate and unblock Yang Qi, steaming and transforming the San Jiao (Triple Burner) to facilitate water movement. With the descending action of Ling (Poria) and Fu Ling (Poria with Wood), Ze Xie (Alisma Rhizome) doubles its water-draining efficacy, resulting in free urination and preventing water accumulation. Bai Zhu (Atractylodis Macrocephalae Rhizoma) relies on Gui Zhi (Cinnamon Twig) to ascend, rapidly enhancing the effect of unblocking Yang, causing Qi to rise and fluids to transform, thus stopping thirst. If fever persists, replace Gui Zhi (Cinnamon Twig) with Rou Gui (Cinnamon Bark); after taking the medicine, drink plenty of warm water to induce sweating for cure. This indicates that this formula not only treats the interior syndrome of water retention causing difficulty in urination but also resolves the exterior syndrome of fever caused by water retention. Adding Ren Shen (Ginseng Radix et Rhizoma) creates Chunze Tang (Spring Marsh Decoction), whose intent is specifically to assist Qi transformation to generate fluids. Adding Yin Chen (Artemisiae Scopariae Herba) creates Yinchin Wuling San (Yinchen Five-Ling Powder), which is effective for treating damp-heat jaundice in patients with neither exterior nor interior excess and difficulty in urination.
[Collected Commentaries] Cheng Yingmao stated: The Taiyang (Greater Yang) channel has the exterior as its marked aspect (Biao) and the Bladder as its root (Ben). Wind-stroke with fever indicates pathogenic invasion of the marked aspect. After six or seven days without resolution, the pathogen from the marked aspect transfers into the Bladder. This is called invading the root. Although Wuling San (Five-Ling Powder) and the two formulas Mahuang Tang (Ephedra Decoction) and Guizhi Tang (Cinnamon Twig Decoction) are all medicines for the Taiyang channel, one releases the muscle layer to treat the exterior, while the other promotes urination to treat the interior; their respective domains of treatment for the exterior and root are distinct.
[Annotation] This clause refers to cases with both exterior and interior syndromes, not to the Taiyang-Yangming exterior-interior syndromes characterized by fever with sweating, dry mouth with vexatious thirst, immediate consumption of ingested water, and spontaneous urination. Rather, it refers to the Taiyang-Bladder exterior-interior syndromes characterized by fever without sweating, moist mouth with vexatious thirst, vomiting immediately after drinking, and difficulty in urination. Although this disease does not explicitly mention the symptoms of no sweating and difficulty in urination, if there were sweating and free urination, the ingested water would escape via the exterior or exit downward, and certainly no "Water Rebellion" (Shuini) syndrome would occur. Zhang Zhongjing's use of Wuling San (Five-Ling Powder), requiring patients to drink warm water to induce sweating for cure, intends to promote urination and sweating; thus, it is known that symptoms of no sweating and difficulty in urination must exist.
In Taiyang disease, if urination is free, due to excessive water intake, palpitations in the epigastrium will inevitably occur; if urination is scanty, severe urgency in the lower abdomen will inevitably occur.
[Note] In the initial stage of Taiyang disease, there is no desire for water; when it is about to transmit to Yangming, there is a desire for water; this is the norm. Now, in the initial stage of Taiyang disease, there is excessive water intake, indicating that the person’s Stomach was dry in their usual state. Assuming Stomach Yang is not deficient, the ingested water could be distributed to the exterior and transformed into sweat for resolution. Now, with excessive water intake and insufficient Stomach Yang, even if urination is free, water will inevitably stagnate in the Middle Jiao, causing palpitations in the epigastrium. If urination is additionally scanty, water will stagnate in the Lower Jiao, causing severe lower abdominal urgency.
[Collected Notes] Fang Youzhi said: Excessive water intake leading to palpitations in the epigastrium occurs because the Heart is a Fire organ; excessive water suppresses it. Scanty urination leads to water stagnation, hence the lower abdominal urgency.
Wang Hu said: In Taiyang disease, free urination indicates no pathogenic heat in the Bladder fu-organ. If the person drinks excessively, this heat is in the Upper Jiao, with hyperactive Heart Fire. Although urination is free, excessive drinking due to thirst causes water stagnation attacking Fire, inevitably leading to palpitations in the epigastrium. If the person drinks excessively but urinates scantily, this heat is in the Lower Jiao, where Taiyang pathogenic heat follows the channel into the fu-organ. Water accumulates and fails to move, causing severe urgency in the interior of the Bladder.
After sweating, excessive water intake will inevitably cause wheezing; bathing with water will also cause wheezing.
[Note] The previous clause discussed excessive water intake before sweating, caused by Stomach heat and fluid deficiency. This clause discusses excessive water intake after sweating, caused by fluid loss and Stomach dryness. The absence of palpitations in the epigastrium and lower abdominal urgency is because the water did not stagnate in the Middle or Lower Jiao, but in the Upper Jiao; thus, water attacking the Lung inevitably causes wheezing. "Water irrigation" refers to washing the body with water. Wheezing from excessive water intake is due to drinking cold water, injuring the interior with cold. Wheezing from water irrigation is due to external cold injury to the form. Both injure the Lung, hence both cause wheezing.
[Collected Notes] Wei Litong said: This clarifies that the wheezing in this clause can be caused by water. Although the wheezing from drinking excessively due to thirst and the wheezing from irrigation without thirst have different origins, the resulting pathology is the same.
After sweating, Guizhi Tang (Cinnamon Twig Decoction) must not be administered again. If there is sweating and wheezing without significant heat, Mahuang Xingren Gancao Shigao Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction) may be given.
[Note] In Taiyang disease, if mild wheezing occurs after mistaken purgation, the exterior is unresolved; Guizhi Jia Houpo Xingren Tang (Cinnamon Twig Decoction plus Magnolia Bark and Apricot Kernel) should be used to release the Taiyang muscle-layer and treat wheezing. In Taiyang disease with Guizhi Tang (Cinnamon Twig Decoction) syndrome, if the physician mistakenly uses purgation, resulting in diarrhea, rapid pulse, sweating, and wheezing with unresolved exterior, Gegen Huanglian Huangqin Tang (Kudzu, Coptis, and Scutellaria Decoction) should be used to release Yangming muscle-layer heat and treat wheezing. Now, after sweating in Taiyang disease, if there is sweating and wheezing without significant heat and aversion to cold, it is known that the pathogen is no longer in the Taiyang exterior; and since there is sweating without aversion to heat, the pathogen is not in the Yangming interior. The reason for sweating and wheezing, without significant heat or aversion to cold, is that the pathogen resides exclusively in the Taiyin Lung channel. Therefore, Guizhi Tang (Cinnamon Twig Decoction) must not be used again; instead, Mahuang Xingren Gancao Shigao Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction) should be given to disperse Lung pathogens, after which sweating and wheezing will cease spontaneously.
Mahuang Xingren Gancao Shigao Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction) Formula
Mahuang (Ephedrae Herba, removed nodes, 4 liang)
Xingren (Prunus Armeniaca Semen, skin and tips removed, 50 pieces)
Gancao (Glycyrrhizae Radix et Rhizoma, honey-fried, 2 liang)
Shigao (Gypsum Fibrosum, wrapped in silk, crushed, 0.5 jin)
Take these four ingredients, add 7 sheng of water, first boil Mahuang (Ephedrae Herba) until reduced by 2 sheng, remove white foam, add the remaining herbs, boil to obtain 3 sheng, remove dregs, and take 1 sheng warm.
[Collected Notes] Ke Qin said: Shigao (Gypsum Fibrosum) is a heavy agent for clearing fire; Qinglong Tang (Green Dragon Decoction) and Baihu Tang (White Tiger Decoction) both rely on it for success. However, improper use can invite disaster. Qinglong Tang is used for no-sweat irritability, utilizing Jiang (Zingiberis Rhizoma) and Gui (Cinnamomi Ramulus) to disseminate defensive Yang; Baihu Tang (White Tiger Decoction) is used for sweating with vexatious thirst, requiring Jingmi (Oryza Sativa Germen) to preserve Stomach fluids. Here, there is internal heat but no external cold, so Jiang and Gui are not used. The wheezing is in the Lung, not the Stomach, so Jingmi (Oryza Sativa Germen) is not needed. The intent focuses on preserving Yin, not worrying about Yang collapse. Thus, Gui Zhi (Cinnamon Twig) is removed from Mahuang Tang (Ephedra Decoction) to avoid its restraining effect, taking Mahuang (Ephedrae Herba) for exclusive opening, Xingren (Prunus Armeniaca Semen) for descending, Gancao (Glycyrrhizae Radix et Rhizoma) for harmonizing, and doubling Shigao (Gypsum Fibrosum) for coldness to clear internal excess heat. This results in profuse sweating, eliminating internal and external vexatious heat and wheezing.
After purgation, Guizhi Tang (Cinnamon Twig Decoction) must not be administered again. If there is sweating and wheezing without significant heat, Mahuang Xingren Gancao Shigao Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction) may be given.
[Note] This elaborates on the previous clause, explaining that although the disease acquisition routes differ (post-sweating vs. post-purgation), the treatment method is the same. In cases of post-purgation with no significant heat, sweating, and wheezing, it is known that the pathogen is not in the exterior but in the Lung; thus, Guizhi Tang (Cinnamon Twig Decoction) must not be used again, and Mahuang Xingren Gancao Shigao Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction) should be used to treat the Lung. The wheezing after sweating in the former case and wheezing after purgation in the latter case have different etiologies but identical manifestations; therefore, treatment follows the manifestation rather than the etiology, using this decoction for both, which is also the principle of "treating the acute symptom first" in wheezing disorders.
[Collected Notes] Fang Youzhi said: Although sweating and purgation differ, the resulting wheezing from mismanagement is the same. Because the wheezing is identical, they share the same treatment.
In Taiyang wind-stroke, if there is no diarrhea but vomiting and reverse qi flow, once the exterior is resolved, the interior can be attacked. If the patient has sweating occurring at intervals, headache, epigastric fullness and hardness radiating to the hypochondrium, dry retching, shortness of breath, sweating without aversion to cold, this indicates the exterior is resolved but the interior is disharmonious; Shizao Tang (Ten-Date Decoction) is the primary treatment.
[Annotation] The character "xia" (down/diarrhea) in "xiali" should be "bu" (not). If it were "xia," how could one use the harsh Shizao Tang (Ten-Date Decoction) for simultaneous vomiting and diarrhea? Only constipation with epigastric fullness, hardness, and pain constitutes an interior disease; difficulty in urination, vomiting, reverse qi, and shortness of breath constitute a fluid-retention disease, which can then be attacked. The character "zuo" (act/happen) in "fazuo" should be "re" (heat). If there is sweating without heat, it is Shaoyin yin-cold fluid retention, the Zhengwu Tang (True Warrior Decoction) syndrome. Moreover, "zuo" does not fit the context of the surrounding sentences.
[Note] Taiyang wind-stroke involves exterior pathogens. No diarrhea but vomiting and reverse qi involve interior fluid retention. Once the exterior pathogen is resolved, interior fluid retention can be attacked. Examining the patient: continuous slight sweating, intermittent fever, headache. If aversion to cold persists, the exterior is unresolved and cannot be attacked. If there is no aversion to cold, the exterior is resolved. Seeing additionally the interior disharmony of epigastric fullness and hardness radiating to the hypochondrium, dry retching, shortness of breath, and urgent fluid retention with no outlet, Shizao Tang (Ten-Date Decoction) is directly used as a harsh agent to attack the nest of water pathogens without hesitation.
[Annotation] In Shanghan (Cold Damage) with unresolved exterior and water stagnation in the epigastrium causing vomiting and reverse qi, cold binds the exterior, preventing water qi from dispersing; Xiao Qinglong Tang (Minor Green Dragon Decoction) should be used to sweat and dissipate it. In Fengzhong (Wind Strike) with unresolved exterior and water stagnation in the epigastrium causing vomiting, fluid blocks the middle, preventing water qi from transmitting and excreting; Wuling San (Five-Ling Powder) should be used to dissipate and promote urination. These are all cases of unresolved exterior where interior fluid cannot be attacked. Regarding Shizao Tang (Ten-Date Decoction) and Guizhi Qushaoyao Ji Baizhu Fuling Tang (Cinnamon Twig Decoction minus Peony plus Atractylodes and Poria) from the lower section, both treat patients with chronic fluid retention having exterior-interior syndromes. Shizao Tang (Ten-Date Decoction) treats headache, fever, sweating, no aversion to cold (exterior resolved) with epigastric fullness, hardness, and pain (interior disharmony), focusing solely on attacking the interior. Guizhi Qushaoyao Ji Baizhu Fuling Tang (Cinnamon Twig Decoction minus Peony plus Atractylodes and Poria) treats headache, fever, no sweating (exterior unresolved) with mild epigastric fullness and pain (interior disharmony), focusing on resolving the exterior first. However, the severity of epigastric hardness, fullness, and pain differs.
[Collected Notes] Du Ren said: Shizao Tang (Ten-Date Decoction) is suitable only for robust individuals and should not be used lightly.
Fang Youzhi: "Then the interior can be attacked" implies advising against premature purgation. From "sweating" to "shortness of breath," it indicates that although there are interior signs, purgation is not yet indicated. Only when "sweating without aversion to cold" appears does it connect the preceding and following text, indicating that purgation is now indicated.
Yu Chang said: This syndrome is similar to Jie Xiong (Chest Binding). However, Jie Xiong involves pathogen binding in the chest, which is high; this involves the epigastrium and hypochondrium, which is low. Yet, exterior must be resolved before attacking, similar to the warning for attacking Jie Xiong. Using Shizao (Jujube Dates) is similar to Xian Xiong Tang (Trap Chest Decoction) because Shanghan purgative methods are mostly set for Wei Shi (Stomach Excess). Wei Shi involves intense internal pathogenic heat, requiring Xiaoshi (Natrii Sulfas) and Dahuang (Rhei Radix et Rhizoma) to purge. Here, the pathology is in the chest and hypochondrium, not the Stomach, so purging agents are useless; thus, herbs that eliminate heat and drive out fluid from the chest and hypochondrium are chosen as the purgative method.
Zhang Zhicong said: Headache is an exterior sign. But it can also be interior, e.g., Shanghan with constipation for five to six days, headache with fever, treated with Chengqi Tang (Descending Qi Decoction). This contrasts with the current clause: sweating, no aversion to cold, headache, indicating exterior resolved with interior fluid retention, treated with Shizao Tang (Ten-Date Decoction). Thus, whenever encountering wind-cold headache with unresolved exterior, differentiation is required.
Cheng Yingmao said: The confusing point is that besides headache, only sweating exists, making exterior-interior differentiation difficult. Sweating with fever and aversion to cold indicates slight exterior involvement; sweating with fever and no aversion to cold indicates only interior involvement. Knowing the exterior is resolved, the interior Qi is bound by fluid pathogens and disharmonious; even headache belongs to interior pathogen attacking upward, unrelated to the exterior.
Wei Litong said: Since Taiyang pathogen has entered the interior, purgation is indicated. However, it does not go down to the chest-diaphragm or intestines-stomach, but to the heart and hypochondrium. This position is slightly lower than purging Jie Xiong (Chest Binding) and slightly higher than purging Wei Shi (Stomach Excess); this is another method of purgation. One must recognize that although the method is purgation, different syndromes require different approaches. At the junction of Taiyang and Yangming, exterior and interior must be differentiated to apply sweating or purgation. The interior purgation there is for pathogenic heat combining with food to form Stomach Excess; the interior purgation here is for pathogenic heat combining with fluid retention to form Fluid Excess. Both require exterior resolution before purgation; this is the commonality.
Shizao Tang (Ten-Date Decoction) Formula
Yuan Hua (Genkwa Flos, processed)
Gan Sui (Kansui Radix)
Da Ji (Euphorbiae Pekinensis Radix)
Da Zao (Jujubae Fructus, torn open, 10 pieces)
Grind the three herbs equally into separate powders. Add 1.5 sheng of water, first boil ten fat Da Zao (Jujubae Fructus), obtain 0.8 sheng, remove dregs, add the herbal powders. Robust adults take one qianbi (coin-sized measure), frail adults take half a qianbi, take warm on an empty stomach at dawn. If stool is scanty and disease remains, take more the next day, increasing by half a qianbi. After obtaining rapid loose stools, nourish oneself with millet porridge.
[Formula Explanation] Zhang Zhongjing’s formulas for treating water vary greatly; this is the most harsh. Generally, water-pathogen diseases manifest as wheezing, cough, palpitations, choking, vomiting, or diarrhea, affecting only one area. Here, water pathogens remain bound in the middle, causing epigastric, abdominal, and hypochondriac fullness, hardness, and pain, blocking the ascending and descending Qi of the San Jiao (Triple Burner). With exterior pathogens resolved, sweating is inappropriate; with interior fluid retention excess, light diuretics are insufficient. Without selecting the harshest water-draining agents to directly subdue it, the Middle Qi will fail, leaving us helpless. Gan Sui (Kansui Radix), Yuan Hua (Genkwa Flos), and Da Ji (Euphorbiae Pekinensis Radix) are all acrid, bitter, cold, and extremely toxic. Used together, their flavors complement each other, allowing direct attack on the water-nest, breaking the dikes, and causing massive purgation to resolve the illness in one stroke. However, where pathogens gather, Qi is deficient; using toxic drugs to attack pathogens will damage the Spleen and Stomach. Without mild, sweet, and緩 (soothing) agents as masters, the pathogens may be eliminated, but life will perish too. Since these drugs are extremely toxic and harsh, Renshen (Ginseng Radix et Rhizoma) and Baizhu (Atractylodis Macrocephalae Rhizoma) cannot serve as sovereigns, and Gancao (Glycyrrhizae Radix et Rhizoma) is incompatible; thus, ten large, fat Da Zao (Jujubae Fructus) are chosen as sovereigns. To protect the Spleen and Stomach and to moderate the harsh toxicity. After rapid purgation, nourish with millet porridge: to replenish grain Qi internally and prevent pathogen recurrence. This is Zhang Zhongjing’s method of using toxic drugs to attack disease, perfect in both beauty and goodness. Ignorant people, confused by the theory that "sweet causes fullness," dare not use it, failing to understand the principle of mutual restraint.
In Taiyang disease, if exterior signs are unresolved, purgation must not be performed; purgation is contrary to treatment. To resolve the exterior, Guizhi Tang (Cinnamon Twig Decoction) is appropriate.
[Note] "Exterior signs unresolved in Taiyang disease" refers to unresolved exterior signs suitable for Guizhi Tang (Cinnamon Twig Decoction). Whenever exterior signs are unresolved, regardless of whether sweating has been induced, even if there are indications for purgation, unless it is an emergency purgation case, purgation must not be performed. Purgation is contrary to treatment. To resolve the exterior, Guizhi Tang (Cinnamon Twig Decoction) should still be used.
[Collected Notes] Wang Kentang said: Even a trace of headache and aversion to cold indicates unresolved exterior; purgation must not be performed.
Cheng Yingmao said: If exterior signs remain unresolved after purgation, the exterior must still be resolved. Use the appropriate medicine for the existing signs; do not assume Guizhi Tang (Cinnamon Twig Decoction) is unsuitable just because purgation was performed.
Wang Hu said: Purgation is contrary because it attacks the interior when the disease is in the exterior, which is inconsistent with proper treatment principles.
In Taiyang disease, if initial sweating fails to resolve the condition, followed by mistaken purgation, and the pulse is floating, the disease is not cured. Floating indicates the pathogen is in the exterior; mistaken purgation causes failure to cure. Now, with a floating pulse, it is known the pathogen is still in the exterior; the exterior must be resolved for cure, preferably with Guizhi Tang (Cinnamon Twig Decoction).
[Note] In Taiyang disease, if initial sweating fails to resolve the exterior, sweating should be repeated; mistaken purgation is inappropriate. Failure to cure with a floating pulse is because the pathogen is in the exterior, and purgation was mistakenly used. Now, after mistaken purgation without becoming contrary, the pulse remains floating, indicating the pathogen is still in the exterior; Guizhi Tang (Cinnamon Twig Decoction) should still be used to resolve the exterior for cure.
[Collected Notes] Cheng Yingmao said: Cure or non-cure is distinguished by the pulse. If cured, the pulse will no longer be floating and will leave the exterior. If the pulse is floating, it indicates the pathogen is still in the exterior; the previous purgation was erroneous, causing non-cure. Do not dwell on past errors; focus on the present. Focus not on past symptoms, but on the current pulse. If the pulse is floating, the pathogen is still in the exterior; even if time has passed, the exterior must be resolved for cure. Use the medicine corresponding to the pulse; do not assume Guizhi Tang (Cinnamon Twig Decoction) is unsuitable just because purgation was performed.
If sweating was originally indicated but purgation was used instead, this is contrary treatment; if sweating was performed first, the treatment is not contrary. If purgation was originally indicated but sweating was used instead, this is contrary treatment; if purgation was performed first, the treatment is not contrary.
[Note] Establishing rules for contrary treatment revolves around exterior and interior; treatment of exterior and interior revolves around sweating and purgation. For diseases with exterior and interior signs, one must determine whether to sweat or purge first. Proper sequence is compliant; improper sequence is contrary. If the exterior is urgent and purgation is used instead of sweating, this is contrary; if sweating is performed first followed by purgation, the treatment is not contrary. If the interior is urgent and sweating is used instead of purgation, this is contrary; if purgation is performed first followed by sweating, the treatment is not contrary.
[Collected Notes] Cheng Zhi said: This means sweating and purgation have priorities and urgency; one must not act backwards.
Wang Hu said: In treating Shanghan, if exterior signs are urgent, sweat immediately; if interior signs are urgent, purge immediately. Do not rigidly adhere to sweating first then purging. Proper sweating and purgation result in non-contrary treatment.
In Taiyang disease, after mistaken purgation, if the pulse is Cu (rapid and intermittent) without Jie Xiong (Chest Binding), this indicates impending resolution. If the pulse is Fu (floating), Jie Xiong (Chest Binding) will definitely occur; if the pulse is Jin (tight), throat pain will definitely occur; if the pulse is Xian (wiry), bilateral hypochondriac stiffness will definitely occur; if the pulse is Xi Shu (fine and rapid), headache will persist; if the pulse is Chen Jin (deep and tight), vomiting will definitely occur; if the pulse is Chen Hua (deep and slippery),xie Re Li (Heat-Collateral Diarrhea) will occur; if the pulse is Fu Hua (floating and slippery), bleeding from below will definitely occur.
[Annotation] "Cu" (rapid and intermittent) should be "Fu" (floating) to align with the text stating non-Jie Xiong (Chest Binding) indicates impending resolution. "Fu" (floating) should be "Cu" (rapid and intermittent) to align with Jie Xiong (Chest Binding) and chest fullness in the Treatise. "Jin" (tight) should be "Xi Shu" (fine and rapid), and "Xi Shu" (fine and rapid) should be "Jin" (tight) to match the original pulses of the two channels in the Treatise. "Fu Hua" (floating and slippery) should be "Shu Hua" (rapid and slippery); Fu Hua (floating and slippery) is the pulse for Baihu Tang (White Tiger Decoction) syndrome in the Treatise, while Shu Hua (rapid and slippery) is the pulse for pus and blood discharge. Careful study of various chapters will reveal this.
[Note] In Taiyang disease, mistaken purgation leads to different variations because each person’s Zang-Qi differs, transforming according to the invaded channel. Mistaken purgation sinking pathogens usually causes Jie Xiong (Chest Binding); if Jie Xiong (Chest Binding) does not occur and the pulse is Fu (floating), the interior is harmonious and rejects the pathogen, which remains in the exterior, indicating impending resolution. If the pulse is Cu (rapid and intermittent), it is the pulse of Yang-excess solid pathogens, so Jie Xiong (Chest Binding) will definitely occur. Xi Shu (fine and rapid) is the pulse of Shaoyin pathogenic heat; throat pain is the sign of Shaoyin pathogenic heat. Mistaken purgation sinking pathogens into Shaoyin requires treatment according to Shaoyin. Xian (wiry) is the Shaoyang pulse; bilateral hypochondriac stiffness is the Shaoyang sign. Mistaken purgation sinking pathogens into Shaoyang requires treatment according to Shaoyang. Jin (tight) is the Taiyang pulse; headache is the Taiyang sign. Mistaken purgation with pathogens remaining in the exterior requires treatment according to Taiyang. Chen Jin (deep and tight) is the pulse of cold pathogens entering the interior; vomiting is the sign of Stomach Yang rejection. Mistaken purgation of exterior pathogens sinking into the Stomach requires treatment according to Yangming. Chen Hua (deep and slippery) is the pulse of retained food. Mistaken purgation of exterior pathogens combining with heat entering the interior causing diarrhea requires treatment according to Xie Re Li (Heat-Collateral Diarrhea). Shu Hua (rapid and slippery) is the pulse of accumulated heat. Mistaken purgation of exterior pathogens sinking into Yin, damaging Ying and causing bleeding, requires treatment according to pus and blood discharge.
[Annotation] Cu (rapid and intermittent) is indeed a Yang pulse. If Cu (rapid and intermittent) is forceful, it is excess, diagnosing Jie Xiong (Chest Binding) solid pathogens; if Cu (rapid and intermittent) is weak, it is deficiency, diagnosing chest fullness deficiency pathogens. Thus, in the Treatise, Cu (rapid and intermittent) pulse with Jie Xiong (Chest Binding), head sweating, and slight tidal heat is treated with Xian Xiong Tang (Trap Chest Decoction) to purge; Cu (rapid and intermittent) pulse with chest fullness, sweating, and slight aversion to cold is treated with Guizhi Qushaoyao Jia Fuzi Tang (Cinnamon Twig Decoction minus Peony plus Aconite) to warm. Observing these treatments for deficiency and excess of the Cu (rapid and intermittent) pulse allows for analogy.
[Annotation] Throat pain is a sign present in both cold and heat Shaoyin syndromes. Dry, swollen, and painful throat indicates heat; non-dry, non-swollen, but painful throat indicates cold. Thus, in the Shaoyin chapter, there are two treatment methods: Ganjie Tang (Licorice and Platycodon Decoction) and Tongmai Sini Tang (Unbind the Pulse and Reverse Cold Decoction).