【集注】方有执曰∶凡在太阳皆表证也。误下则变证杂出，而不可以一途拘之。
程知曰∶不宜下而下之，诸变不可胜数，此之谓也。今咽痛胁急欲呕，是寒邪入里之
变。头痛热利下血，是风邪入里之变。所以然者，脉浮滑数为阳，沉弦紧细为阴也。
程应旄曰∶据脉见证，各着一必字，见势所必然。考其源头，总在太阳病下之而来，
故虽有已成坏病、未成坏病之分，但宜以活法治之，不得据脉治脉、据证治证也。
太阳病，二三日，不能卧，但欲起，心下必结。脉微弱者，此本有寒分也。反下之，
若利止，必作结胸；未止者，四日复下之，此作协热利也。
【按】四日复下之，“之”字，当是“利”字。上文利未止，岂有复下之理乎？细
玩自知，是必传写之误。
【注】太阳病，谓头项强痛而恶寒也。二三日见不得卧，但欲起之证，谓已传阳明也。
心下，胃之分也。必结，谓胃分必有结也。若脉实大乃胃分有热而结也，则当下之。今脉
微弱，是胃分有寒而结也，法不当下，不当下而下之，谓之反下。二三日正当解太阳、阳
明之表，反下之，表热乘虚入里，必自利。设利自止，是其入胃实而同燥化，必作结胸矣。
今利未止，四日仍复下利，是其人胃虚而同湿化，故必作协热利也。
【集注】程知曰∶此表证误下，有结胸、热利之变，不可不慎也。脉既微弱，则是寒
结心下，法当温散。医见心下结，而下之使利，是治之反也。
汪琥曰∶太阳病，二三日，不卧欲起，心下热结，似乎可下，然脉微弱，其人本有寒分，岂可下乎？
太阳病，外证未除，而数下之，遂协热而利；利下不止，心下痞硬，表里不解者，桂
枝人参汤主之。
【注】此承上条脉微弱，协热利，互详其证，以明其治也。外证未除，谓太阳病未除。
而数下之，是下非一次也。里因数下而虚，遂协表热而利，利下不止，里虚不固也。心下
痞硬，里虚而邪结也。外证既未除，是表不解也，故用桂枝以解表。利下痞硬，里因下
虚而从寒化也，其脉必如上文之微弱，故用参、术、姜、草以温里，此温补中两解表里
法也。若其脉有力者，又当从甘草泻心汤之法矣。
【集注】喻昌曰∶误下而致里虚，外热乘之，变而为利不止者，里虚不守也。痞硬者，
正虚邪实，中成滞碍，痞塞而不通也。以表未除，故用桂枝以解之。以里适虚，故用理
中以和之。此方即理中加桂枝而易其名，乃治虚痞下利之法也。
李中梓曰∶经云，桂枝证医反下之，利遂不止，与葛根黄芩黄连汤。此则又与桂枝
人参汤，何用药有温凉之异耶？盖彼证但曰“下之”，此则曰“数下之”；彼证但曰“利
下”，此则曰“利不止”。合两论味之，自有虚实之分矣。
程知曰∶表证误下，下利不止，喘而汗出者，治以葛根、芩、连。心下痞硬者，治
以桂枝、参、术。一救其表邪入里之实热，一救其表邪入里之虚寒，皆表里两解法也。
程应旄曰∶协热而利，向来俱作阳邪陷于下焦，果尔，安得用理中耶？盖不知利有寒热二证也。
桂枝人参汤方
桂枝（四两） 甘草（炙，四两） 白术（三两） 人参（三两） 干姜（三两）
上五味，以水九升，先煮四味，取五升，纳桂更煮，取三升去滓，温服一升，日再服，夜一服。
太阳病，桂枝证，医反下之，利遂不止。脉促者，表未解也。喘而汗出者，葛根黄芩黄连汤主之。
【注】此承上条又言协热利之脉促者，以别其治也。太阳病桂枝证，宜以桂枝解肌，而
医反下之，利遂不止者，是误下，遂协表热陷入而利不止也。若表未解，而脉缓无力，即
有下利而喘之里证，法当从桂枝人参汤以治利，或从桂枝加杏子浓朴汤，以治喘矣。今
下利不止，脉促有力，汗出而喘，表虽未解，而不恶寒，是热已陷阳明，即有桂枝之表，亦
当从葛根黄芩黄连汤主治也。方中四倍葛根以为君，芩、连、甘草为之佐，其意专解阳
明之肌表，兼清胃中之里热，此清解中兼解表里法也。若脉沉迟，或脉微弱，则为里寒
且虚，又当用理中汤加桂枝矣。于此可见上条之协热利，利不止，心下痞硬，表里不解
者，脉不微弱必沉迟也。
【按】协热利二证，以脉之阴阳分虚实，主治固当矣。然不可不辨其下利之粘秽、鸭
溏，小便或白或赤，脉之有力无力也。
【集注】成无己曰∶病有汗出而喘者，谓自汗出而喘也，是邪气外甚所致。若喘而汗
出者，谓因喘而汗出也，是里热气逆所致，故与葛根黄芩黄连汤，散表邪除里热也。
方有执曰∶利与上条同。而上条用理中者，以痞硬、脉弱属寒也。此用芩、连者，以
喘汗、脉促属热也。
喻昌曰∶太阳病，原无下法，当用桂枝解外，医反下之，则邪热之在太阳者，未传
阳明之表，已入阳明之里。所以其脉促急，其汗外越，其热上奔则喘，下奔则泄，故舍桂
枝而用葛根，以专主阳明之表，加芩、连以清里热，则不治喘而喘止，不治利而利止。此
又太阳、阳明两解表里之变法也。
汪琥曰∶误下虚其肠胃，为热所乘，遂利不止，此非肠胃真虚证，乃胃有邪热，下
通于肠而作泄也。脉促者，脉来数时一止复来也，此为阳独盛之脉也。脉促见阳，知表
未解，此表乃阳明经病，非犹太阳桂枝之表证也。喘而汗出者，亦阳明胃腑里热气逆所
致，非太阳风邪气壅之喘，亦非桂枝汤汗出之证也。故当解阳明表邪，清胃腑里热也。
葛根黄芩黄连汤方
葛根（半斤） 黄芩（三两） 黄连（三两） 甘草（炙，二两）
上四味，以水八升，先煮葛根，减二升，纳诸药，煮取二升，去滓，分温再服。
【集解】柯琴曰∶外热不除，是表不解；下利不止，是里未和。误下致利，病因则同。
一则脉微弱，心下痞硬，是脉不足而证有余也；一则脉促而喘，反汗自出，是脉有余而
证不足也。表里、虚实，当从脉辨，况弱脉见于数下后，则痞硬为虚，更可知也。故用
理中之辛甘温补，止下利化痞硬，又加桂枝以解表。先煮四味，后内桂枝，和中之力饶，
而解肌之气锐，是于两解中寓权宜法也。桂枝证本脉缓，误下后而反促，阳气内盛，邪
蒸于外，故汗出也；热暴于内，火逆上冲，故为喘也；暴注下迫，故为利也。故君清轻升
发之葛根，以解肌而止利；佐苦寒清肃之芩、连，以止汗而定喘；又加甘草以和中。先煮
葛根，后内诸药，解肌之力纯，而清中之气锐，又与补中逐邪者殊法矣。
太阳病，下之后，脉促胸满者，桂枝去芍药汤主之。若微恶寒者，去芍药，方中加附子汤主之。
【按】若微恶寒者，当是汗出微恶寒方合。若无“汗出”二字，乃表未解，无取乎加附子也。
【注】太阳病，表未解而下之，胸实邪陷，则为胸满，气上冲咽喉不得息，瓜蒂散证也。
胸虚邪陷，则为气上冲，桂枝汤证也。今下之后，邪陷胸中，胸满脉促，似乎胸实而无
冲喉不得息之证，似乎胸虚又见胸满之证，故不用瓜蒂散以治实，亦不用桂枝汤以治虚，惟
用桂枝之甘辛，以和太阳之表，去芍药之酸收，以避胸中之满。若汗出微恶寒，去芍药，
方中加附子主之者，以防亡阳之变也。
【按】上条脉促，喘而汗出不恶寒，下利不止，云属实热。此条脉促胸满，汗出微恶
寒，不喘不下利，反属虚寒者何也？上条是里热蒸越之汗，故汗出不恶寒，阳实也，喘
而下利，皆为热也。此条乃表阳不固之汗，故汗出微恶寒，阳虚也，即不喘利亦为寒也。要
知仲景立法，每在极微处设辨，恐人微处易忽也。今以微恶寒发其义，却不在汗出上辨
寒热，而在汗出恶寒、不恶寒上辨寒热；不在脉促上辨寒热，而在脉促之有力、无力辨
寒热。于此又可知不惟在胸满上辨虚实，而当在胸满之时满、时不满、常常满而不减上辨虚实矣。
【集注】喻昌曰∶此条之微恶寒，合上条观之，则脉促、胸满、喘而汗出之内，原伏
有虚阳欲脱之机。故仲景于此条，特以“微恶寒”三字发其义。可见阳虚则恶寒矣；又
可见汗不出之恶寒，即非阳虚矣。
程应旄曰∶有阳盛而见促脉，亦有阳虚而见促脉者，当辨之于有力无力，仍须辨之于外证也。
沈明宗曰∶误下扰乱阴阳之气则脉促，邪入胸膈几成结胸，但结满而未痛耳！故以桂
枝汤单提胸膈之邪，使从表解。去芍药者，恶其酸收，引邪内入故也。若脉促胸满而微恶
寒，乃虚而 ，阳气欲脱，又非阳实之比，所以加附子固护真阳也。然伤风下后之恶寒，
与未下之恶寒，迥然用别。而汗后之恶寒，与未汗之恶寒亦殊。
桂枝去芍药汤方
于桂枝汤内去芍药，余根据前法。
桂枝去芍药加附子汤方
于桂枝汤方内去芍药，加附子一枚，炮去皮，破八片，余根据前法。
太阳病下之，微喘者，表未解故也，桂枝加浓朴杏子汤主之。喘家作，桂枝汤加浓朴杏子佳。
【注】太阳病当汗，而反下之，下利脉促，喘而汗出不恶寒者，乃邪陷于里，热在阳明，
葛根黄芩黄连汤证也。今太阳病当汗而反下之，不下利而微喘，是邪陷于胸，未入于胃，
表仍未解也。故仍用桂枝汤以解肌表，加浓朴、杏子以降逆定喘也。喘家，谓素有喘病
之人。遇中风而喘者，桂枝汤皆宜用之，加浓朴杏子为佳也。
【集注】方有执曰∶喘者，气逆于上，故呼吸不顺而声息不利也。微者，声息缓，不
似大喘之气急也。以表尚在，不解其表，则喘不可定，故用桂枝解表，加浓朴利气，杏
仁下气，所以为定喘之要药。
喻昌曰∶此风邪误下作喘，治法之大要。其寒邪误下作喘，当用麻黄、杏仁、石膏、甘
草，即此可推。又曰∶微喘表未解，则是表邪因误下上逆，与虚证不同。
程应旄曰∶喘之一证，有表有里，不可不辨。下后汗出而喘，其喘必盛，属里热壅
逆火炎故也。下后微喘，汗必不大出，属表邪闭遏气逆故也；仍用桂枝汤解表，内加朴、杏以下逆气。
魏荔彤曰∶凡病患素有喘证，每感外邪，势必作喘，故谓之喘家。
桂枝加浓朴杏仁汤方
于桂枝汤方内，加浓朴二两，杏仁五十个，余根据桂枝汤方。
【按】戴原礼曰∶太阳病有喘咳，无汗喘者，宜麻杏石甘汤；有汗喘者，宜桂枝加浓
朴杏仁汤；无汗咳者，宜小青龙汤。少阳病无喘有咳，咳者，宜小柴胡汤加五味干姜。阳
明病无咳有喘，内实喘者，宜大承气汤；下利者，宜葛根黄芩黄连汤。三阴惟少阴有喘
咳，喘者宜四逆汤加五味、干姜；咳者阴邪下利，宜真武汤加五味、干姜；阳邪下利，宜
猪苓汤。然喘皆危候也。
太阳病，下之后，其气上冲者，可与桂枝汤，方用前法。若不上冲者，不可与之。
【注】太阳病，表未解而下之，里实者，邪陷则为结胸，大陷胸汤证也；里虚者，邪
陷则为下利，桂枝人参汤证也。胸实者，邪陷则为胸中痞硬，气上冲咽喉不得息，瓜蒂
散证也。今胸虚邪陷于胸，故但为气上冲，是表尚未罢，然无壅满不得息痞硬之证，故不
可吐下，仍当解表，可与桂枝汤，如法汗之。使陷胸之邪，不受外束，胸中之气，得以四
达，自不致内壅而上冲矣。若不上冲者不可与也。
【集注】方有执曰∶气上冲者，阳主气而上升，风属阳邪，下后入里乘虚而上冲也。若
不上冲，则非阳邪可知，故不可与。
病如桂枝证，头不痛，项不强，寸脉微浮，胸中痞硬，气上冲咽喉不得息者，此为
胸有寒也，当吐之，宜瓜蒂散。
【注】病如桂枝证，乃头项强痛，发热汗出，恶风脉浮缓也。今头不痛，项不强，是
桂枝证不悉具也。寸脉微浮，是邪去表未远，已离其表也。胸中痞硬，气上冲喉不得息，是
邪入里未深而在胸中，必胸中素有寒饮之所致也。寒饮在胸，不在肌腠，解肌之法，无
可用也。痞硬在胸，而不在心下，攻里之法，亦无所施。惟有高者越之一法，使胸中寒饮
一涌而出，故宜吐之以瓜蒂散也。
【集注】程应旄曰∶痞硬一证，因吐下者为虚，不因吐下者为实。实邪痰饮填塞心胸，
中、下二焦为之阻绝，自不得不从上焦为出路。所谓“在上者因而越之”是也。
汪琥曰∶伤寒一病，吐法不可不讲，所以仲景以此条特出之太阳上编者，以吐不宜
迟，与太阳汗证之法相等，当于二三日间，审其证而用此法也。
沈明宗曰∶素有痰饮内积，稍涉风寒，引动其痰，即外如桂枝汤证，但无头痛项强，知
非风邪中表矣。
张锡驹曰∶气上冲咽喉不得息者，邪挟寒饮从太阳之气而上越也。
瓜蒂散方
瓜蒂（熬黄，一分） 赤小豆（一分）
上二味，各别捣筛，为散已，合治之，取一钱匕，以香鼓一合，用热汤七合，煮作稀
糜，去滓，取汁和散，温顿服之。不吐者，少少加服，得快吐乃止。诸亡血虚家，不可与
瓜蒂散。
【方解】胸中者，清阳之府。诸邪入胸府，阻遏阳气，不得宣达，以致胸满痞硬，热气
上冲，燥渴心烦， 欲吐。脉数促者，此热郁结也；胸满痞硬，气上冲咽喉不得息，手
【集注】方有执说：凡是属于太阳病的，都是表证。误用下法会导致各种变证出现，不能拘泥于一种治法。
程知说：本不该用下法却用了下法，产生的各种变证数不胜数，说的就是这种情况。现在出现的咽痛、胁肋拘急、想呕吐，是寒邪入里产生的变证。头痛、发热、腹泻且便血，是风邪入里产生的变证。之所以这样，是因为脉象浮、滑、数属于阳，沉、弦、紧、细属于阴。
程应旄说：根据脉象和症状，各用一个“必”字，表明病情发展的必然趋势。考察其源头，总归是太阳病误用下法导致的，所以虽然有已成坏病和未成坏病的区别，但应当用灵活的方法治疗，不能仅凭脉象治脉象、仅凭症状治症状。
太阳病，经过两三天，病人无法躺卧，只想坐起，胃脘部必定痞结。如果脉象微弱，这是病人原本体内有寒饮。此时反而使用下法，如果腹泻停止，必定形成结胸；如果腹泻没有停止，到了第四天又再次出现下利，这就是协热利。
【按语】原文中“四日复下之”的“之”字，应当是“利”字。上文说腹泻没有停止，怎么会有再次使用下法的道理呢？仔细玩味自会明白，这一定是传抄时的错误。
【注解】太阳病，是指头项强痛且恶寒。在两三天内出现不能卧、只想起的症状，说明病邪已经传入阳明经。心下，指胃的部位。“必结”，指胃的部位必定有痞结。如果脉象实大，那是胃中有热而痞结，应当用下法。现在脉象微弱，是胃中有寒而痞结，按照法则不应当用下法，不应当用下法却用了，称为“反下”。发病两三天正当解除太阳、阳明表邪的时候，反而用下法，导致表热乘虚入里，必定引起自发性腹泻。假设腹泻自行停止，说明邪气入胃与燥屎相结而同化燥热，必定形成结胸。现在腹泻没有停止，到了第四天仍然反复下利，说明病人胃气虚弱而与湿邪同化，所以必定形成协热利。
【集注】程知说：这是表证误用下法，产生了结胸、热利的变证，不可不谨慎。脉象既然微弱，则是寒邪结于心下，按照法则应当温散。医生见心下痞结，就用下法使其腹泻，这是治疗上的相反做法。
汪琥说：太阳病，两三天，不能卧、想坐起，心下热结，似乎可以用下法，然而脉象微弱，病人原本就有寒邪，怎么能用下法呢？
太阳病，表证尚未解除，却多次使用下法，于是导致协热利；腹泻不止，胃脘部痞塞坚硬，表里同病不解的，用桂枝人参汤主治。
【注解】这是承接上一条脉象微弱、协热利的内容，详细阐述其症状，以明确治疗方法。外证未除，指太阳病未除。多次使用下法，不是只下了一次。因为多次误下导致里虚，于是协同表热而下利，腹泻不止，是里气虚弱不能固摄。胃脘部痞塞坚硬，是里虚而邪气结聚。外证既然未除，说明表邪未解，所以用桂枝来解表。腹泻且痞硬，说明里因误下而虚，从寒而化，其脉象必定像上一条所说的微弱，所以用人参、白术、干姜、甘草来温补里气，这是温补中同时兼顾解表里的方法。如果脉象有力，又应当遵循甘草泻心汤的治法了。
【集注】喻昌说：误用下法导致里虚，外热乘虚而入，变为腹泻不止，是里气虚弱不能守持。痞硬，是正气虚弱邪气盛实，中焦形成滞碍，痞塞不通。因为表证未除，所以用桂枝来解表。因为里气正虚，所以用理中汤来调和。这个方子就是在理中汤基础上加桂枝并改变名称，是治疗虚痞下利的方法。
李中梓说：经文说，桂枝证医生反而用下法，腹泻不停止，给予葛根黄芩黄连汤。这里却给予桂枝人参汤，为什么用药有温凉的区别呢？那个条文只说“下之”，这个条文说“数下之”；那个条文只说“利下”，这个条文说“利不止”。综合两个条文的味道，自然有虚实之分。
程知说：表证误用下法，腹泻不止，气喘且出汗的，用葛根、黄芩、黄连治疗。胃脘部痞塞坚硬的，用桂枝、人参、白术治疗。一个是救治表邪入里的实热，一个是救治表邪入里的虚寒，都是表里双解的方法。
程应旄说：协热利，向来都被认为是阳邪陷入下焦，果真如此，怎么能用理中汤呢？大概是不了解腹泻有寒热两种证型。
桂枝人参汤方
桂枝（四两） 甘草（炙，四两） 白术（三两） 人参（三两） 干姜（三两）
以上五味药，用水九升，先煮前四味药，取五升药液，加入桂枝再煮，取三升药液，去渣，温服一升，每日两次，夜间一次。
太阳病，具备桂枝证，医生反而用下法，腹泻随即不停止。脉象急促的，说明表邪未解。气喘且出汗的，用葛根黄芩黄连汤主治。
【注解】这是承接上一条，又说协热利中脉象急促的情况，以区别其治疗方法。太阳病桂枝证，应当用桂枝汤解肌发表，而医生反而用下法，导致腹泻不停止，这是误用下法，致使表热陷入而导致腹泻不止。如果表邪未解，而脉象缓弱无力，即使有下利伴喘的里证，按照法则应当用桂枝人参汤治疗下利，或者用桂枝加厚朴杏子汤治疗喘。现在下利不止，脉象急促有力，出汗且喘，虽然表邪未解，但不恶寒，说明热邪已陷入阳明，即使有桂枝证的表证，也应当用葛根黄芩黄连汤主治。方中重用四倍葛根作为君药，黄芩、黄连、甘草作为佐药，其意图专门解除阳明肌表之邪，兼清胃中之里热，这是清解中兼解表里的方法。如果脉象沉迟，或脉象微弱，则是里寒且虚，又应当用理中汤加桂枝了。从这里可以看出上一条所说的协热利，腹泻不止，胃脘痞硬，表里不解的情况，脉象如果不微弱，必定是沉迟。
【按语】协热利的两个证候，以脉象的阴阳来区分虚实，主治固然正确。然而不可不辨别腹泻的大便粘秽还是鸭溏，小便颜色白还是赤，脉象有力还是无力。
【集注】成无己说：有病汗出且喘的，指自汗出而喘，这是邪气在体表较盛所致。如果是喘而汗出，指因为喘而汗出，这是里热气逆所致，所以给予葛根黄芩黄连汤，疏散表邪清除里热。
方有执说：下利与上一条相同。但上一条用理中汤，是因为痞硬、脉弱属于寒证。这一条用黄芩、黄连，是因为喘、汗、脉促属于热证。
喻昌说：太阳病，本来没有下法，应当用桂枝汤解外，医生反而用下法，那么邪热在太阳经的，还没传到阳明之表，就已经进入阳明之里。所以脉象急促，汗液外越，热气上奔则喘，下奔则泄，所以舍弃桂枝而用葛根，专门主司阳明之表，加黄芩、黄连以清里热，则不治喘而喘止，不治利而利止。这又是太阳、阳明两解表里的变法。
汪琥说：误用下法使肠胃虚弱，被热邪所乘，于是腹泻不止，这不是肠胃真正的虚证，而是胃中有邪热，下通于肠而作泄。脉促，指脉来快速时偶尔停顿一下又继续跳动，这是阳气独盛的脉象。脉促见于阳证，知道表邪未解，此处的表乃阳明经病，不再是像太阳桂枝证那样的表证。喘而汗出，也是阳明胃腑里热气逆所致，不是太阳风邪气壅导致的喘，也不是桂枝汤证的汗出。所以应当解阳明表邪，清胃腑里热。
葛根黄芩黄连汤方
葛根（半斤） 黄芩（三两） 黄连（三两） 甘草（炙，二两）
以上四味药，用水八升，先煮葛根，减少二升水，加入其他药物，煮取二升药液，去渣，分两次温服。
【集解】柯琴说：外热不除，是表邪未解；下利不止，是里气未和。误用下法导致下利，病因相同。一种是脉微弱，心下痞硬，是脉象不足而症状有余；一种是脉促而喘，反而汗出，是脉象有余而症状不足。表里、虚实，应当从脉象辨别，何况弱脉出现在多次误下之后，那么痞硬为虚，就更可以知道了。所以用理中汤的辛甘温补，止住下利化解痞硬，又加桂枝以解表。先煮前四味药，后加入桂枝，和中之力雄厚，而解肌之气锐利，这是在两解中寓含权宜之法。桂枝证本来脉缓，误下后反而脉促，阳气内盛，邪气蒸腾于外，所以汗出；热势暴烈于内，火气上冲，所以为喘；暴注下迫，所以为利。所以用清轻升发的葛根作为君药，以解肌止利；用苦寒清肃的黄芩、黄连作为佐药，以止汗定喘；又加甘草以和中。先煮葛根，后加入其他药物，解肌之力纯粹，而清中之气锐利，又与补中逐邪的方法不同。
太阳病，用下法之后，脉象急促且胸部胀满的，用桂枝去芍药汤主治。如果有轻微恶寒的，去掉芍药，在原方中加入附子，用桂枝去芍药加附子汤主治。
【按语】“如果有轻微恶寒的”，应当是“汗出微恶寒”才符合。如果没有“汗出”二字，乃是表邪未解，不需要加附子。
【注解】太阳病，表邪未解而用下法，如果胸中实邪陷入，则成为胸满，气上冲咽喉不得呼吸，这是瓜蒂散的适应证。如果胸中虚邪陷入，则成为气上冲，这是桂枝汤的适应证。现在用下法之后，邪气陷入胸中，胸满脉促，似乎胸实却没有气冲咽喉不得呼吸的症状，似乎胸虚却又见胸满的症状，所以不用瓜蒂散治疗实证，也不用桂枝汤治疗虚证，只用桂枝汤的甘辛，来调和太阳之表，去掉芍药的酸收，以避免加重胸中之满。如果汗出且轻微恶寒，去掉芍药，在原方中加入附子主治，是为了防止亡阳的变证。
【按语】上一条脉促，喘而汗出不恶寒，下利不止，属于实热。这一条脉促胸满，汗出微恶寒，不喘不下利，反而属于虚寒，为什么呢？上一条是里热蒸腾外越的汗，所以汗出不恶寒，阳气实，喘和下利，都是热证。这一条是表阳不固的汗，所以汗出微恶寒，阳气虚，即使不喘利也是寒证。要知道张仲景立法，往往在极细微之处进行辨别，恐怕人们在细微处容易忽视。现在以“微恶寒”揭示其义，不在“汗出”上辨别寒热，而在“汗出是否恶寒、不恶寒”上辨别寒热；不在“脉促”上辨别寒热，而在“脉促有力、无力”上辨别寒热。从这里又可以知道，不仅要在胸满上辨别虚实，而且应当在胸满是时时满、还是时满时不满、常常满而不减上来辨别虚实。
【集注】喻昌说：这条的“微恶寒”，结合上一条来看，则在脉促、胸满、喘而汗出的内在机理中，原本潜伏着虚阳欲脱的机转。所以张仲景在这条文中，特意用“微恶寒”三个字来揭示其义。可见阳虚就会恶寒；又可见不出汗的恶寒，就不是阳虚。
程应旄说：有阳盛而出现促脉的，也有阳虚而出现促脉的，应当在有力无力上辨别，仍需结合外在症状辨别。
沈明宗说：误用下法扰乱阴阳之气则脉促，邪气进入胸膈几乎形成结胸，只是结满而没有疼痛！所以用桂枝汤单独提举胸膈之邪，使其从表而解。去掉芍药，是厌恶其酸收之性，引邪气内入。如果脉促胸满而微恶寒，是虚而阳气欲脱，又不是阳实可比，所以加附子以固护真阳。然而伤风误下后的恶寒，与未误下的恶寒，截然不同。而发汗后的恶寒，与未发汗的恶寒也不同。
桂枝去芍药加附子汤方
在桂枝汤方中去掉芍药，加附子一枚，炮制去皮，破成八片，其余依照前面的方法。
太阳病用下法后，微微气喘的，是表邪未解的缘故，用桂枝加厚朴杏子汤主治。素有喘病的人发作，用桂枝汤加厚朴杏子较好。
【注解】太阳病应当发汗，反而用下法，如果下利脉促，喘而汗出不恶寒，那是邪气陷入里，热在阳明，是葛根黄芩黄连汤的适应证。现在太阳病应当发汗反而用下法，不下利而微喘，是邪气陷入胸中，未进入胃中，表邪仍未解。所以仍用桂枝汤解肌表，加厚朴、杏子以降逆定喘。喘家，指平素患有喘病的人。遇到中风而喘的，桂枝汤都适宜使用，加厚朴杏子为佳。
【集注】方有执说：喘，是气逆于上，所以呼吸不顺且声音气息不利。微，指声音气息缓慢，不像大喘那样气急。因为表邪尚在，不解其表，则喘不可平息，所以用桂枝解表，加厚朴利气，杏仁下气，所以是定喘的要药。
喻昌说：这是风邪误下导致喘，治疗方法的要领。如果是寒邪误下导致喘，应当用麻黄、杏仁、石膏、甘草，即麻杏石甘汤，由此可以推断。又说：微喘表未解，则是表邪因误而上逆，与虚证不同。
程应旄说：喘这一症状，有表证有里证，不可不辨别。下法后汗出而喘，其喘一定严重，属于里热壅逆火炎所致。下法后微喘，汗一定不多出，属于表邪闭遏气逆所致；仍用桂枝汤解表，内加厚朴、杏仁以下降逆气。
魏荔彤说：凡是病人平素有喘证，每次感受外邪，势必引发喘，所以称为喘家。
桂枝加厚朴杏子汤方
在桂枝汤方内，加厚朴二两，杏仁五十个，其余依照桂枝汤方。
【按语】戴原礼说：太阳病有喘咳，无汗而喘的，宜用麻杏石甘汤；有汗而喘的，宜用桂枝加厚朴杏子汤；无汗而咳的，宜用小青龙汤。少阳病无喘有咳，咳的，宜用小柴胡汤加五味子、干姜。阳明病无咳有喘，里实而喘的，宜用大承气汤；下利的，宜用葛根黄芩黄连汤。三阴病只有少阴病有喘咳，喘的宜用四逆汤加五味子、干姜；咳的若是阴邪下利，宜用真武汤加五味子、干姜；若是阳邪下利，宜用猪苓汤。然而喘都是危重证候。
太阳病用下法之后，气机上冲的，可以给予桂枝汤，用法如前所述。如果不上冲的，不可以给予。
【注解】太阳病，表邪未解而用下法，里实的，邪气陷入则成为结胸，是大陷胸汤的适应证；里虚的，邪气陷入则成为下利，是桂枝人参汤的适应证。胸实的，邪气陷入则成为胸中痞硬，气上冲咽喉不得呼吸，是瓜蒂散的适应证。现在胸虚邪气陷入胸中，所以只是气上冲，这是表邪尚未罢除，然而没有壅满不得呼吸痞硬的症状，所以不可用吐下法，仍当解表，可以给予桂枝汤，依法发汗。使陷入胸中的邪气，不受外束，胸中之气，得以通达，自然不会致内壅而上冲。如果不上冲的，就不可以给予。
【集注】方有执说：气上冲，是阳气主气而上升，风属阳邪，下法后入里乘虚而上冲。如果不上冲，则可知非阳邪，所以不可给予。
病症类似桂枝证，但头不痛，项不强，寸脉微浮，胸中痞塞坚硬，气上冲咽喉不得呼吸的，这是胸中有寒饮，应当用吐法，宜用瓜蒂散。
【注解】病症类似桂枝证，是指头项强痛、发热、汗出、恶风、脉浮缓。现在头不痛，项不强，说明桂枝证不完全具备。寸脉微浮，说明邪气离开体表不远，已脱离表位。胸中痞塞坚硬，气上冲喉不得呼吸，说明邪气入里未深而在胸中，必定是胸中素有寒饮所致。寒饮在胸中，不在肌腠，解肌的方法无可施用。痞硬在胸中，而不在心下，攻里的方法也无从施展。唯有“高者越之”一法，使胸中寒饮一举涌出，所以宜用吐法，用瓜蒂散。
【集注】程应旄说：痞硬这一症状，因吐下法导致的为虚，不因吐下法导致的为实。实邪痰饮填塞心胸，中、下二焦为之阻绝，自然不得不从上焦为出路。所谓“在上者因而越之”就是这个意思。
汪琥说：伤寒一病，吐法不可不讲，所以张仲景特别将这一条列在太阳上编，是因为吐法不宜迟，与太阳汗证的方法同等重要，应当在两三天间，审察其证而使用此法。
沈明宗说：平素有痰饮内积，稍微涉及风寒，引动其痰，即使外表像桂枝汤证，但没有头痛项强，就知道不是风邪中表。
张锡驹说：气上冲咽喉不得呼吸，是邪气挟带寒饮从太阳之气而上越。
瓜蒂散方
瓜蒂（炒黄，一分） 赤小豆（一分）
以上两味药，分别捣碎筛成粉末，混合均匀，取一钱匕药粉，用香豉一合，用热水七合，煮成稀粥状，去渣，取汁调和药粉，温顿服。不吐的，少量增加服用，得快吐为止。所有失血及虚损的病人，不可给予瓜蒂散。
【方解】胸中，是清阳汇聚之所。各种邪气进入胸府，阻遏阳气，不得宣达，以致胸满痞硬，热气上冲，燥渴心烦，想要呕吐。脉数促的，这是热郁结；胸满痞硬，气上冲咽喉不得呼吸，手……
[Collected Commentaries] Fang Youzhi stated: All conditions in the Taiyang (Greater Yang) stage are exterior syndromes. If purgation is mistakenly applied, various transformation syndromes will emerge and cannot be restricted to a single treatment approach.
Cheng Zhi stated: When purgation is used inappropriately, the number of resulting transformations is countless; this is what is meant. The current symptoms of sore throat, hypochondriac stiffness, and desire to vomit are transformations caused by cold pathogen entering the interior. Headache, fever, diarrhea, and bloody stool are transformations caused by wind pathogen entering the interior. The reason for this is that floating (Fu), slippery (Hua), and rapid (Shuo) pulses belong to Yang, while deep (Chen), wiry (Xian), tight (Jin), and fine (Xi) pulses belong to Yin.
Cheng Yingmao stated: Based on the pulse and symptoms, the use of the word "must" (Bi) indicates the inevitability of the condition's progression. Tracing back to the source, it all stems from the Taiyang disease being treated with purgation. Therefore, although there is a distinction between established and unestablished Huai Bing (complicated diseases), one should employ flexible treatment methods and not treat merely based on the pulse or symptoms alone.
In Taiyang disease, after two or three days, if the patient cannot lie down but desires to sit up, there must be stagnation in the epigastrium (Xin Xia). If the pulse is weak and faint (Wei Ruo), this indicates the patient originally had cold-fluid retention. If purgation is mistakenly applied, and the diarrhea stops, Jie Xiong (Chest Binding) will inevitably develop; if the diarrhea does not stop, and upon the fourth day the diarrhea recurs, this is called Xie Re Li (Collaborating Heat Diarrhea).
[Note] In the phrase "on the fourth day, purge again," the character "Zhi" (之) should be "Li" (利/Diarrhea). Since the text previously stated that the diarrhea had not stopped, how could there be a rationale for purging again? Careful study will reveal this is likely a transcription error.
[Annotation] Taiyang disease refers to headache, stiff neck, and aversion to cold. The appearance of inability to lie down and desire to sit up within two or three days indicates transmission to the Yangming (Bright Yang) stage. "Xin Xia" refers to the stomach region. "Must stagnate" means there must be obstruction in the stomach region. If the pulse is solid and large, it indicates heat causing stagnation in the stomach, which requires purgation. Now, since the pulse is weak and faint, it indicates cold causing stagnation in the stomach; according to principles, purgation is contraindicated. Applying purgation when it is contraindicated is termed "reverse purgation." At two or three days, the proper course is to resolve the exterior of Taiyang and Yangming. Mistakenly applying purgation allows exterior heat to enter the interior due to deficiency, inevitably causing spontaneous diarrhea. If the diarrhea stops spontaneously, it implies the pathogen has entered the stomach and combined with dryness to transform into heat, leading to Jie Xiong. Now, since the diarrhea has not stopped, and recurs on the fourth day, it indicates stomach deficiency combining with dampness to transform, thus inevitably leading to Xie Re Li.
[Collected Commentaries] Cheng Zhi stated: This illustrates that mistaken purgation of an exterior syndrome can lead to transformations such as Jie Xiong and Heat Diarrhea; caution is essential. Since the pulse is weak and faint, it is cold stagnation in the epigastrium, and the method should be warming and dispersing. The physician, seeing epigastric stagnation, used purgation to induce diarrhea, which is contrary to the correct treatment.
Wang Hu stated: In Taiyang disease, after two or three days, inability to lie down and desire to sit up, with epigastric heat stagnation, seems amenable to purgation. However, the pulse is weak and faint, indicating the patient originally harbored cold; how can purgation be used?
In Taiyang disease, if the exterior syndrome remains unresolved and purgation is applied repeatedly, it leads to Xie Re Li (Collaborating Heat Diarrhea); if diarrhea persists incessantly, accompanied by epigastric fullness and hardness, with both exterior and interior unresolved, Gui Zhi Ren Shen Tang (Cinnamon Twig and Ginseng Decoction) is indicated.
[Annotation] This elaborates on the previous case of weak pulse and Xie Re Li to clarify the treatment. "Exterior syndrome unresolved" means Taiyang disease is not resolved. "Repeated purgation" implies more than one instance. Due to repeated purgation, the interior becomes deficient, collaborating with exterior heat to cause diarrhea; incessant diarrhea indicates interior deficiency failing to secure. Epigastric fullness and hardness indicate interior deficiency with pathogenic binding. Since the exterior syndrome is unresolved, the exterior is not released; therefore, Gui Zhi (Cinnamon Twig) is used to release the exterior. The diarrhea and epigastric hardness indicate the interior, due to deficiency from purgation, transforms toward cold; the pulse would be weak and faint as described earlier. Thus, Ren Shen (Ginseng), Bai Zhu (Atractylodes Macrocephala Rhizome), Gan Jiang (Dried Ginger), and Gan Cao (Licorice Root) are used to warm the interior. This is a method of warming and tonifying while simultaneously resolving the exterior and interior. If the pulse were forceful, the method of Gan Cao Xie Xin Tang (Licorice Decoction to Drain the Epigastrium) would be appropriate.
[Collected Commentaries] Yu Chang stated: Mistaken purgation causes interior deficiency, allowing exterior heat to invade, resulting in incessant diarrhea due to interior failure to maintain. Fullness and hardness result from righteous Qi deficiency and pathogenic excess, creating obstruction in the middle Jiao (Middle Burner), leading to blockage. Because the exterior is unresolved, Gui Zhi is used to release it. Because the interior is recently deficient, Li Zhong Tang (Regulate the Middle Decoction) is used to harmonize. This formula is essentially Li Zhong Tang plus Gui Zhi with a changed name, serving as a method for treating deficiency-type epigastric fullness and diarrhea.
Li Zhongzi stated: The classic states that if a Gui Zhi Tang syndrome is mistakenly purged, leading to incessant diarrhea, Ge Gen Huang Qin Huang Lian Tang (Kudzu Root, Scutellaria, and Coptis Decoction) is given. Here, Gui Zhi Ren Shen Tang is given instead. Why the difference in warming versus cooling herbs? The former case only says "purged," whereas this case says "repeatedly purged"; the former says "diarrhea," whereas this says "incessant diarrhea." Comparing the two contexts reveals the distinction between deficiency and excess.
Cheng Zhi stated: For exterior syndrome mistakenly purged, if diarrhea is incessant with wheezing and sweating, Ge Gen, Huang Qin, and Huang Lian are used. If epigastric fullness and hardness occur, Gui Zhi, Ren Shen, and Bai Zhu are used. One rescues excess heat from exterior pathogen entering the interior; the other rescues deficiency-cold from exterior pathogen entering the interior. Both are methods of simultaneous exterior-interior resolution.
Cheng Yingmao stated: Xie Re Li has traditionally been interpreted as Yang pathogen sinking into the Lower Jiao. If true, how could Li Zhong Tang be used? This arises from not understanding that diarrhea has both cold and heat patterns.
Gui Zhi Ren Shen Tang Formula
Gui Zhi (Cinnamon Twig) - 4 liang
Zhi Gan Cao (Honey-fried Licorice Root) - 4 liang
Bai Zhu (Atractylodes Macrocephala Rhizome) - 3 liang
Ren Shen (Ginseng Root) - 3 liang
Gan Jiang (Dried Ginger) - 3 liang
These five ingredients are decocted in 9 sheng of water. First, boil the first four ingredients to obtain 5 sheng. Add Gui Zhi and boil further to obtain 3 sheng. Strain. Take 1 sheng warm. Administer twice daily and once at night.
In Taiyang disease presenting with Gui Zhi Tang syndrome, if the physician mistakenly applies purgation, leading to incessant diarrhea: if the pulse is Cun Cu (Rapid/Agitated), the exterior is unresolved. If there is wheezing and sweating, Ge Gen Huang Qin Huang Lian Tang (Kudzu Root, Scutellaria, and Coptis Decoction) is indicated.
[Annotation] This continues the discussion on Xie Re Li, specifically addressing the Cun Cu pulse to differentiate treatment. In Taiyang disease with Gui Zhi Tang syndrome, Gui Zhi Tang should be used to release the muscle layer. Mistaken purgation leads to incessant diarrhea because the exterior heat sinks into the interior due to the error. If the exterior is unresolved and the pulse is slow and weak, even with diarrhea and wheezing (interior signs), the method should follow Gui Zhi Ren Shen Tang for diarrhea, or Gui Zhi Jia Hou Po Xing Zi Tang (Cinnamon Twig Decoction Augmented with Magnolia Bark and Apricot Kernel) for wheezing. Now, with incessant diarrhea, a forceful Cun Cu pulse, sweating, and wheezing, although the exterior is unresolved, the absence of aversion to cold indicates heat has sunk into Yangming. Even if Gui Zhi Tang signs exist, Ge Gen Huang Qin Huang Lian Tang is the primary indication. The formula uses Ge Gen (Kudzu Root) in quadruple dose as the sovereign herb, with Huang Qin (Scutellaria Root), Huang Lian (Coptis Rhizome), and Gan Cao as ministers. Its intent is to specifically resolve the Yangming muscle layer and clear interior stomach heat. This is a method of clearing and resolving while simultaneously addressing exterior and interior. If the pulse were deep-slow or weak/faint, indicating interior cold and deficiency, Li Zhong Tang plus Gui Zhi would be used. From this, we understand that in the previous case of Xie Re Li with incessant diarrhea, epigastric fullness/hardness, and unresolved exterior-interior, if the pulse were not weak/faint, it would necessarily be deep-slow.
[Note] The two cases of Xie Re Li are distinguished by the yin/yang nature of the pulse to determine deficiency/excess, making the treatment correct. However, one must distinguish whether the diarrhea involves sticky/foul stool or duck-like loose stool, whether urine is white or red, and whether the pulse is forceful or weak.
[Collected Commentaries] Cheng Wuji stated: "Sweating and wheezing" refers to spontaneous sweating followed by wheezing, caused by strong pathogenic qi on the exterior. "Wheezing with sweating" refers to sweating resulting from wheezing, caused by interior heat qi rebelling upward. Therefore, Ge Gen Huang Qin Huang Lian Tang is given to scatter exterior pathogen and remove interior heat.
Fang Youzhi stated: The diarrhea is the same as the previous case. The previous case used Li Zhong Tang because fullness/hardness and weak pulse indicated cold. This case uses Huang Qin and Huang Lian because wheezing, sweating, and Cun Cu pulse indicated heat.
Yu Chang stated: Taiyang disease originally has no indication for purgation; Gui Zhi Tang should be used to release the exterior. Mistaken purgation causes heat pathogen in Taiyang to enter the interior of Yangming before reaching its exterior. Hence, the pulse is rapid/agitated, sweat escapes outward, heat rushes upward causing wheezing, and downward causing diarrhea. Thus, Gui Zhi is abandoned for Ge Gen to focus on Yangming exterior, and Huang Qin/Huang Lian are added to clear interior heat. Wheezing and diarrhea cease without direct treatment. This is another variable method for simultaneous resolution of Taiyang and Yangming exterior-interior.
Wang Hu stated: Mistaken purgation empties the intestines and stomach, allowing heat pathogen to invade, causing incessant diarrhea. This is not true gastrointestinal deficiency, but rather stomach heat flowing downward into the intestines to cause diarrhea. Cun Cu pulse means the pulse is rapid with occasional pauses; this is a pulse of exclusive Yang excess. A Cun Cu pulse in a Yang context indicates the exterior is unresolved; here, the "exterior" refers to Yangming channel disease, not the Taiyang Gui Zhi exterior syndrome. Wheezing and sweating are caused by interior heat qi rebelling in the Yangming stomach organ, not by Taiyang wind pathogen congestion nor the sweating of Gui Zhi Tang syndrome. Therefore, one must resolve Yangming exterior pathogen and clear Yangming stomach interior heat.
Ge Gen Huang Qin Huang Lian Tang Formula
Ge Gen (Kudzu Root) - 8 liang
Huang Qin (Scutellaria Root) - 3 liang
Huang Lian (Coptis Rhizome) - 3 liang
Zhi Gan Cao (Honey-fried Licorice Root) - 2 liang
These four ingredients are decocted in 8 sheng of water. First, boil Ge Gen until reduced by 2 sheng. Add the remaining herbs and boil to obtain 2 sheng. Strain. Divide into two warm doses.
[Collected Explanations] Ke Qin stated: Exterior heat unresolved means exterior is not released; incessant diarrhea means interior is not harmonized. Mistaken purgation causing diarrhea shares the same etiology. One case has weak pulse and epigastric fullness/hardness, indicating insufficient pulse but excessive symptoms; the other has Cun Cu pulse with wheezing and spontaneous sweating, indicating excessive pulse but insufficient symptoms. Exterior-interior and deficiency-excess must be differentiated by the pulse. Especially since a weak pulse appears after repeated purgation, epigastric fullness/hardness is clearly deficiency. Therefore, Li Zhong Tang's acrid-sweet-warm tonification is used to stop diarrhea and resolve fullness/hardness, plus Gui Zhi to release the exterior. Boiling the first four ingredients first, then adding Gui Zhi, provides rich harmonizing power and sharp muscle-releasing energy, embodying a flexible method within dual resolution. Gui Zhi syndrome normally has a slow pulse; after mistaken purgation, the pulse becomes Cun Cu, indicating internal Yang excess and pathogen steaming outward, causing sweating. Violent heat internally and fire rebelling upward causes wheezing. Violent rushing downward causes diarrhea. Thus, Ge Gen, light and ascending, is used as sovereign to release muscle and stop diarrhea; Huang Qin and Huang Lian, bitter-cold and purifying, are used as ministers to stop sweating and calm wheezing; Gan Cao is added to harmonize the middle. Boiling Ge Gen first, then adding other herbs, ensures pure muscle-releasing power and sharp interior-clearing energy, differing from methods that tonify the middle to expel pathogen.
After Taiyang disease is treated with purgation, if the pulse is Cun Cu and there is chest fullness, Gui Zhi Qu Shao Yao Tang (Cinnamon Twig Decoction without Paeonia) is indicated. If there is slight aversion to cold, remove Shao Yao and add Fu Zi to the formula, using Gui Zhi Qu Shao Yao Jia Fu Zi Tang (Cinnamon Twig Decoction without Paeonia plus Aconite).
[Note] "If there is slight aversion to cold" should ideally include "sweating." Without "sweating," it indicates unresolved exterior, and adding Fu Zi is unnecessary.
[Annotation] In Taiyang disease, if the exterior is unresolved and purgation is applied, excess in the chest leads to pathogen sinking, causing chest fullness and Qi rushing to the throat preventing breathing; this is Gua Di San (Melon Spore Powder) syndrome. Deficiency in the chest leads to pathogen sinking, causing Qi rushing upward; this is Gui Zhi Tang syndrome. Now, after purgation, pathogen sinks into the chest, causing fullness and Cun Cu pulse. It seems like chest excess but lacks throat-rushing/breathing-prevention symptoms; it seems like chest deficiency yet presents chest fullness. Therefore, Gua Di San is not used for excess, nor Gui Zhi Tang for deficiency. Instead, the sweet-acrid nature of Gui Zhi is used to harmonize the Taiyang exterior, and Shao Yao (Paeonia Root) is removed to avoid its sour-astringent property aggravating chest fullness. If there is sweating with slight aversion to cold, removing Shao Yao and adding Fu Zi prevents the transformation of Yang collapse.
[Note] The previous case had Cun Cu pulse, wheezing, sweating, no aversion to cold, and incessant diarrhea, classified as excess-heat. This case has Cun Cu pulse, chest fullness, sweating, slight aversion to cold, no wheezing, no diarrhea, yet is classified as deficiency-cold. Why? The previous case involved sweat from interior heat steaming outward, hence no aversion to cold, representing Yang excess; wheezing and diarrhea were heat. This case involves sweat from exterior Yang insecurity, hence slight aversion to cold, representing Yang deficiency; even without wheezing/diarrhea, it is cold. One must know that Zhang Zhongjing’s laws often distinguish at minute levels to prevent oversight. Here, "slight aversion to cold" reveals the principle. Differentiation of cold/heat is not based on "sweating" alone, but on "sweating with/without aversion to cold"; not on "Cun Cu pulse" alone, but on "forceful/weak Cun Cu pulse." Furthermore, differentiation of deficiency/excess in chest fullness depends on whether it is constant/full-unrelenting versus intermittent.
[Collected Commentaries] Yu Chang stated: Observing "slight aversion to cold" in this case alongside the previous one reveals that within the mechanisms of Cun Cu pulse, chest fullness, wheezing, and sweating, there lies a latent tendency for deficient Yang to collapse. Thus, Zhang Zhongjing specifically uses "slight aversion to cold" to highlight this. It shows that Yang deficiency causes aversion to cold; conversely, aversion to cold without sweating is not Yang deficiency.
Cheng Yingmao stated: There are Cun Cu pulses caused by Yang excess and those caused by Yang deficiency. They must be differentiated by forcefulness/weakness and correlated with external symptoms.
Shen Mingzong stated: Mistaken purgation disturbs Yin-Yang Qi, causing Cun Cu pulse. Pathogen enters the chest-diaphragm, nearly forming Jie Xiong, but only fullness exists without pain. Thus, Gui Zhi Tang is used to lift pathogen from the chest-diaphragm for exterior resolution. Shao Yao is removed because its sour-astringency might draw pathogen inward. If Cun Cu pulse, chest fullness, and slight aversion to cold coexist, it indicates deficiency with Yang about to collapse, distinct from Yang excess. Hence, Fu Zi is added to secure True Yang. Note that aversion to cold after mistaken purgation for wind-stroke differs significantly from aversion to cold before purgation. Similarly, aversion to cold after sweating differs from that before sweating.
Gui Zhi Qu Shao Yao Tang Formula
Take Gui Zhi Tang and remove Shao Yao. Follow the previous method for preparation and administration.
Gui Zhi Qu Shao Yao Jia Fu Zi Tang Formula
Take Gui Zhi Tang, remove Shao Yao, add one Fu Zi (Aconite Lateralis Radix Praeparata), prepared, peeled, broken into eight pieces. Follow the previous method.
After Taiyang disease is treated with purgation, if there is slight wheezing, it is because the exterior is unresolved; Gui Zhi Jia Hou Po Xing Zi Tang (Cinnamon Twig Decoction Augmented with Magnolia Bark and Apricot Kernel) is indicated. For patients with chronic asthma who develop symptoms, Gui Zhi Tang augmented with Hou Po and Xing Zi is preferable.
[Annotation] Taiyang disease requires sweating; mistaken purgation leading to diarrhea, Cun Cu pulse, wheezing, sweating, and no aversion to cold indicates pathogen sinking into the interior, heat in Yangming, which is Ge Gen Huang Qin Huang Lian Tang syndrome. Now, Taiyang disease requiring sweating is mistakenly purged, resulting in no diarrhea but slight wheezing. This indicates pathogen sinking into the chest, not reaching the stomach, with the exterior still unresolved. Therefore, Gui Zhi Tang is used to release the muscle-exterior, augmented with Hou Po (Magnolia Bark) and Xing Zi (Apricot Kernel) to descend rebellious Qi and calm wheezing. "Chuan Jia" (Asthma Family) refers to individuals with a history of asthma. For those with wind-stroke triggering asthma, Gui Zhi Tang is suitable, especially when augmented with Hou Po and Xing Zi.
[Collected Commentaries] Fang Youzhi stated: Wheezing is Qi rebelling upward, causing difficult respiration and abnormal breath sounds. "Slight" means breath sounds are slow, unlike the urgency of severe wheezing. Since the exterior remains, failing to resolve the exterior means wheezing cannot settle. Thus, Gui Zhi releases the exterior, Hou Po moves Qi, and Xing Zi descends Qi; these are key herbs for calming wheezing.
Yu Chang stated: This outlines the major treatment principle for wind-pathogen mistaken purgation causing wheezing. For cold-pathogen mistaken purgation causing wheezing, Ma Huang, Xing Zi, Shi Gao, and Gan Cao (Ma Xing Shi Gan Tang) should be used; this can be inferred. Also, slight wheezing with unresolved exterior indicates exterior pathogen rebelling upward due to mistaken purgation, distinct from deficiency syndromes.
Cheng Yingmao stated: Wheezing has both exterior and interior aspects; differentiation is crucial. Post-purgation sweating and wheezing with severe wheezing belongs to interior heat congestion and fire rebellion. Post-purgation slight wheezing with minimal sweating belongs to exterior pathogen constriction and Qi rebellion; Gui Zhi Tang is still used to release the exterior, augmented with Hou Po and Xing Zi to descend rebellious Qi.
Wei Litong stated: Patients with pre-existing asthma will inevitably wheeze upon contracting external pathogens, hence the term "Chuan Jia."
Gui Zhi Jia Hou Po Xing Zi Tang Formula
To Gui Zhi Tang, add Hou Po (2 liang) and Xing Zi (50 seeds). Follow the Gui Zhi Tang method.
[Note] Dai Yuanli stated: Taiyang disease may present with wheezing/cough. For non-sweating wheezing, Ma Xing Shi Gan Tang is appropriate; for sweating wheezing, Gui Zhi Jia Hou Po Xing Zi Tang is appropriate; for non-sweating cough, Xiao Qing Long Tang is appropriate. Shaoyang disease has cough but no wheezing; for cough, Xiao Chai Hu Tang plus Wu Wei Zi and Gan Jiang is appropriate. Yangming disease has wheezing but no cough; for interior excess wheezing, Da Cheng Qi Tang is appropriate; for diarrhea, Ge Gen Huang Qin Huang Lian Tang is appropriate. Among the Three Yin stages, only Shaoyin presents with wheezing/cough. For wheezing, Si Ni Tang plus Wu Wei Zi and Gan Jiang is appropriate; for cough due to Yin pathogen diarrhea, Zhen Wu Tang plus Wu Wei Zi and Gan Jiang is appropriate; for Yang pathogen diarrhea, Zhu Ling Tang is appropriate. However, wheezing is always a critical sign.
After Taiyang disease is treated with purgation, if Qi rushes upward, Gui Zhi Tang may be administered following the previous method. If Qi does not rush upward, it should not be given.
[Annotation] In Taiyang disease, if the exterior is unresolved and purgation is applied, interior excess leads to pathogen sinking forming Jie Xiong (Da Xian Xiong Tang syndrome); interior deficiency leads to pathogen sinking causing diarrhea (Gui Zhi Ren Shen Tang syndrome). Chest excess leads to pathogen sinking causing epigastric fullness/hardness and Qi rushing to the throat preventing breathing (Gua Di San syndrome). Now, with chest deficiency, pathogen sinks into the chest, causing only Qi rushing upward. The exterior is not yet resolved, but there are no signs of congestion/prevented breathing or hardness. Therefore, emetic and purgative methods are contraindicated; the exterior must still be resolved. Gui Zhi Tang may be given to induce sweating according to protocol. This allows the sunken chest pathogen to be unbound externally, enabling chest Qi to circulate freely, preventing internal congestion and upward rushing. If Qi does not rush upward, do not administer it.
[Collected Commentaries] Fang Youzhi stated: Qi rushing upward occurs because Yang governs Qi rising; wind is a Yang pathogen. After purgation, it enters the interior and rushes upward due to deficiency. If it does not rush upward, it is known not to be a Yang pathogen, so it should not be given.
When symptoms resemble Gui Zhi Tang syndrome, but there is no headache or stiff neck, the Cun pulse is slightly floating, there is epigastric/chest fullness and hardness, and Qi rushes to the throat preventing breathing, this is Cold-Fluid (Han) in the chest. Emesis should be induced using Gua Di San (Melon Spore Powder).
[Annotation] "Symptoms resembling Gui Zhi Tang syndrome" refers to headache, stiff neck, fever, sweating, aversion to wind, and floating-slow pulse. Now, absence of headache and stiff neck means Gui Zhi syndrome signs are incomplete. Slightly floating Cun pulse indicates the pathogen has left the exterior but remains close. Epigastric/chest fullness/hardness and Qi rushing to the throat preventing breathing indicate the pathogen has entered the interior but not deeply, residing in the chest, likely due to pre-existing cold-fluid in the chest. Cold-fluid in the chest, not in the muscle layers, makes muscle-releasing methods ineffective. Fullness/hardness in the chest, not the epigastrium, makes interior-purging methods inapplicable. Only the method of "vomiting what is high" can expel the chest cold-fluid suddenly. Therefore, emesis with Gua Di San is indicated.
[Collected Commentaries] Cheng Yingmao stated: Fullness/hardness caused by emesis/purgation is deficiency; fullness/hardness not caused by them is excess. Excess pathogenic phlegm-fluid filling the heart-chest blocks the Middle and Lower Jiao, necessitating an exit via the Upper Jiao. This is the principle of "Those above should be expelled upwards."
Wang Hu stated: In Shang Han (Cold Damage) disease, the emetic method must be studied. Zhang Zhongjing placed this case in the Upper Taiyang section because emesis should not be delayed; it is equal in importance to Taiyang sweating methods. It should be applied within two to three days after assessing the syndrome.
Shen Mingzong stated: Pre-existing internal phlegm-fluid accumulation, triggered by slight wind-cold, can manifest externally like Gui Zhi Tang syndrome. However, the absence of headache/stiff neck indicates it is not wind-pathogen attacking the exterior.
Zhang Xiqiu stated: Qi rushing to the throat preventing breathing indicates pathogen carrying cold-fluid surging upward via Taiyang Qi.
Gua Di San Formula
Gua Di (Melon Spore) - roasted yellow, 1 fen
Chi Xiao Dou (Red Adzuki Bean) - 1 fen
These two ingredients are separately pounded and sifted into powder, then mixed. Take one qian-bi (measure) of the powder. Use Xiang Chi (Prepared Soybean) 1 he, boiled in 7 he of hot water to make a thin gruel. Strain, mix the juice with the powder, and take warm in one dose. If vomiting does not occur, increase the dose slightly. Stop when vigorous vomiting occurs. Do not administer to patients with blood loss or constitutional deficiency.
[Formula Explanation] The chest is the residence of Clear Yang. Various pathogens entering the chest obstruct Yang Qi, preventing dissemination, leading to chest fullness, hardness, upward rushing of heat, dry mouth/thirst, irritability, and desire to vomit. A rapid/agitated pulse indicates heat constraint. Chest fullness/hardness, Qi rushing to the throat preventing breathing...