【集注】方有执曰∶发汗后不恶寒，其人表气强也。但热、亡津液而胃中干，故曰实
也。当和胃气，以干在胃而实也。故曰与调胃承气汤所以泻实，而甘草则有泻中调和之义。
程知曰∶汗后恶寒，则为荣卫俱虚；汗后不恶寒但发热，则为津干胃实，故有调胃
通津之法。然曰当、曰与，则似深有酌量而不肯妄下，以重虚其津者。
调胃承气汤方（见阳明篇）
脉浮紧者，法当身疼痛，宜以汗解之。假令尺中迟者，不可发汗。何以知之然？以荣气不足血少故也。
【注】脉浮紧者，寒伤荣之脉也；身痛者，寒伤荣之证也。脉证皆表实邪，则当发汗，宜
麻黄汤。设若寸关脉浮紧，惟尺中迟者，则又不可发汗。何也？以其人平素荣气不足血
少故也。由此可知，脉阴阳不俱紧，不可轻汗也。
【集注】方有执曰∶尺以候阴，迟为不足，荣主血，汗者血之液，尺迟不宜汗者，嫌夺血也。
张璐曰∶尺中脉迟，不可用麻黄发汗，当频与小建中汤和之。和之而邪解，不须发汗；
设不解，不妨多与之，覆而汗之可也。
发汗后，身疼痛，脉沉迟者，桂枝加芍药生姜各一两、人参三两新加汤主之。
【注】发汗后，身疼痛脉浮紧或浮数，乃发汗未彻，表邪未尽也，仍当汗之，宜桂枝
汤。今发汗后身虽疼痛，脉见沉迟，是荣卫虚寒，故宜桂枝新加汤，以温补其荣卫也。
【集注】成无己曰∶表邪盛则身疼，血虚亦身疼。其脉浮紧者邪盛也，脉沉迟者血虚
也。盛者损之则安，虚者益之则愈。
喻昌曰∶脉沉迟者，六部皆然，与尺迟大异。尺迟乃素虚，此为发汗新虚，故于桂
枝方中，倍加芍药生姜各一两以去邪，加人参三两以补正。名曰新加汤者，明非桂枝汤中之旧法也。
汪琥曰∶身疼痛脉沉迟，焉知非中寒证？要知此证，乃太阳伤寒发汗后身疼不止，脉
变沉迟，非中寒比也。
桂枝新加汤方
桂枝（一两） 芍药（四两） 甘草（二两） 人参（三两） 生姜（切，四两） 大枣（擘，十二枚）
上六味，以水一斗二升，微火煮取三升，去滓，分温服，如桂枝法。
【方解】是方即桂枝汤倍芍药、生姜，加人参也。汗后身疼痛，是荣卫虚而不和也，故
以桂枝汤调和其荣卫。倍生姜者，以脉沉迟荣中寒也；倍芍药者，以荣不足血少故也；加
人参者，补诸虚也。桂枝得人参，大气周流，气血足而百骸理；人参得桂枝，通内联外，补
荣阴而益卫阳，表虚身疼未有不愈者也。
病发热头痛，脉反沉，若不瘥，身体疼痛，当温其里，宜四逆汤。
【按】身体疼痛之下，当有“下利清谷”四字，方合当温其里之文。观太阴篇云∶伤
寒医下之，续得下利清谷不止，身痛者，急当救里，宜四逆汤。此虽未下，但脉反沉，可知里寒，必是脱简。
【注】病发热头疼，凡太阳表证也。脉当浮，今反沉，是太阳表证而得少阴里脉也。凡
太阳、少阴表里皆寒无汗之病，均宜以麻黄附子细辛汤发之。若不瘥，不下利者，更以
麻黄附子甘草汤和之；若下利清谷，即有身体疼痛之表未解，不可更汗，当温其里，宜
四逆汤。防其阳从阴化，变厥惕亡阳之逆，断不可谓病在太阳，无可温之理也。
四逆汤方（见少阴篇）
伤寒，若吐若下后，七八日不解，热结在里，表里俱热，时时恶风，大渴，舌上干
燥而烦，欲饮水数升者，白虎加人参汤主之。
【按】“伤寒”二字之下，当有“若汗”二字，盖发汗较吐下更伤津液为多也。时时恶
风，当是时汗恶风，若非汗字，则时时恶风，是表不解，白虎汤在所禁也。论中谓发热无
汗，表不解者，不可与白虎汤；渴欲饮水，无表证者，白虎加人参汤主之。读者细玩经文自知。
【注】伤寒，若汗、若吐、若下后，七八日不解，以致热结表里，时汗恶风者，结热
在表未解也；大渴舌上干燥而烦，欲饮水数升者，结热在里已彰也。故曰表里俱热，宜
白虎加人参汤主之。以白虎能外解肌热，内清里热也。加人参者，因汗、吐、下后，津
亡气弱，藉此以益气生津也。
【按】大青龙汤治太阳表里俱热，表多里少，故不渴也。白虎汤治阳明表里俱热，里
多表少，故大渴也。今大渴燥烦，时汗恶风，是热在阳明又兼太阳也。而用白虎汤者，以
阳明里热证多，太阳表热证少也。若无汗微渴，则为太阳表证多，即表里大热，又当用大青龙汤矣。
【集注】喻昌曰∶玩此条本文，热结在里，表里俱热，已自酌量，惟热结在里，所以表
热不除，况加大渴饮水，安得不以清热为急耶！
程知曰∶表热者，身热也；里热者，内热也。以汗、吐、下后不解，故邪气乘虚结
为里热；惟结热在里，所以表热不除，有恶风证也。大渴引饮，里热炽盛，安得不以白
虎急解之。石膏辛寒，能清里热，兼散表热也；惟其在汗、吐、下后，故必加人参以顾其正气也。
汪琥曰∶与白虎汤加人参扶正气，以分解内外之邪热。要之，此汤惟正气虚而邪气
微者宜之；若邪气甚者，不敢轻加人参也。
白虎加人参汤方（见阳明篇）
发汗已，脉浮数，烦渴者，五苓散主之。
【按】脉浮数之下当有“小便不利”四字，若无此四字，则为阳明内热口燥之烦渴，白
虎汤证也。以其有小便不利烦渴，则为太阳水热瘀结之烦渴，五苓散证也。况无小便不
利证而用五苓散，则犯重竭津液之禁矣。太阳上编，类此证者数条，唯一条水入即吐，水
不下行，故无小便不利之文，此条应有“小便不利”四字。
【注】发汗已，为太阳病已发过汗也。脉浮数，知邪仍在表也。若小便利而烦渴者，是
初入阳明胃热，白虎汤证也。今小便不利而烦渴，是太阳腑病，膀胱水蓄，五苓证也。故
用五苓散，如法服之，外疏内利，表里均得解矣。
【集注】方有执曰∶已者言发汗毕，非谓表病罢也。烦渴者，膀胱水蓄，不化津液，故
用四苓以利之；浮数者，外表未除，故凭一桂以和之，所以谓五苓能两解表里也。
伤寒汗出而渴者，五苓散主之；不渴者，茯苓甘草汤主之。
【注】此申上条或渴而不烦，或烦而不渴者，以别其治也。伤寒发汗后，脉浮数，汗
出烦渴，小便不利者，五苓散主之，今惟曰汗出者，省文也。渴而不烦，是饮盛于热，故
亦以五苓散主之，利水以化津也。若不烦且不渴者，是里无热也。惟脉浮数汗出，小便
不利，是荣卫不和也，故主以茯苓甘草汤和表以利水也。
【集注】郑重光曰∶伤寒本无汗，汗因发而出也。上条烦而渴，此条但渴不烦，里证
较轻，治亦不殊；若更不渴，则内无燥，里病少而表证犹多也。故用桂枝汤之三，五苓
散之一，示三表一里之意，易名曰茯苓甘草汤者，乃桂枝五苓之变制也。
茯苓甘草汤方
茯苓（二两） 桂枝（二两） 生姜（切，三两） 甘草（炙，一两）
上四味，以水四升，煮取三升，去滓，分温三服。
【方解】是方乃仿桂枝、五苓二方之义，小制其法也。有脉浮数汗出之表，故主以桂
枝。去大枣、芍药者，因有小便不利之里，恐滞敛而有碍于癃闭也。五苓去术、泽、猪苓
者，因不渴不烦，里饮无多，惟小便一利可愈，恐过于燥渗伤阴也。
【集解】汪琥曰∶五苓散、茯苓甘草汤二方，皆太阳标本齐病，表里兼主之剂。何谓
标？太阳之经是也。何谓本？膀胱之腑是也。经在表，本在里。五苓散，邪已入腑表证已
微，故方中只用桂枝一味以主表，其余四味
皆主里之药也。茯苓甘草证，邪犹在经，里证尚少，故方中只用茯苓一味以主里，其余
三味皆主表之药也。
脉浮数者，法当汗出而愈，若下之，身重心悸者，不可发汗，当自汗出乃解。所以
然者，尺中脉微，此里虚，须表里实，津液自和，便自汗出愈。
【注】伤寒未发热，脉多浮紧，寒盛也。已发热，脉多浮数，热盛也。均宜麻黄汤发
汗则愈。若不发汗而误下之，不成逆坏者，必其人里气素实也。故惟见失汗身重之表，误
下心悸之里，则不可复发其汗；当待其表里自和，自然汗出而解。所以然者、因失汗表
实，误下里虚，尺中脉微，表里未谐，故不即解也。须待其里亦实而与表平，平则和，和
则阳津阴液自相和谐，所以便自汗出而愈也。使里实之法，即下条用小建中汤法也。
【集注】喻昌曰∶此亦先建中而后发汗之变法。要知仲景云∶尺脉微者，不可发汗。又
云∶尺微者，不可下。无非相人津液之奥旨，所以误下之，脉虽浮数不改，亟宜发汗者，亦
必当谛其尺脉，不可率意径情有如此者。
张璐曰∶误下体重心悸，纵脉仍浮数，亦不可复发其汗。设尺脉微，为里阴素虚，尤
宜戒也。脉浮而数，热邪已甚，将欲作汗，今误下之，故身重心悸，当与小建中和其津液，汗出而愈。
伤寒二三日，心中悸而烦者，小建中汤主之。
【注】伤寒二三日，未经汗下，即心悸而烦，必其人中气素虚，虽有表证，亦不可汗
之。盖心悸阳已微，心烦阴已弱，故以小建中汤先建其中，兼调荣卫也。
【集注】王肯堂曰∶伤寒二三日，心中悸而烦者，小建中汤主之。伤寒脉弦细，属少
阳，不可汗，汗之则谵语，胃不和则烦而悸。大抵先烦而后悸者是热，先悸而后烦者是虚，
治病必求其本者此也。
程应旄曰∶可见阳去入阴，必有其先兆，善治者，急宜杜之于未萌。心中悸而烦，则
里气虚而阳为阴袭，建中汤补虚和里，保定中州，以资气血为主。虽悸与烦，皆小柴胡
汤中兼见之证，而得之二三日，里证未必即具，小柴胡汤非所宜也。
魏荔彤曰∶建中者治其本也。与建中后，徐审其在表，则仍当发汗，以中州既建，虽
发汗阳亦不致亡矣。审其传里，则应下之，以中州既建，虽下阳亦不致陷矣。所谓急则从
标，而缓则从本也。
小建中汤方
桂枝（三两） 芍药（六两） 甘草（二两） 生姜（切，三两） 胶饴（一升） 大枣（擘，十二枚）
上六味，以水七升，煮取三升，去滓，纳胶饴，更上微火消解，温服一升，日三服。呕
家不可用建中汤，以甜故也。
【方解】是方也，即桂枝汤倍芍药加胶饴也。名曰小建中者，谓小小创建中气也。盖
中气虽虚，表尚未和，不敢大补，故仍以桂枝和营卫，倍芍药加胶饴，调建中州，而不
啜稀粥温覆令汗者，其意重在心悸中虚，而不在伤寒之表也。中州创建，营卫自和，津
液可生，汗出乃解，悸烦可除矣。呕家不可用，谓凡病呕者不可用，恐甜助呕也。
伤寒脉结代，心动悸，炙甘草汤主之。
【注】心动悸者，谓心下筑筑，惕惕然动而不自安也。若因汗下者多虚，不因汗下者
多热，欲饮水小便不利者属饮，厥而下利者属寒，今病伤寒，不因汗下而心动悸，又无
饮热寒虚之证，但据结代不足之阴脉，即主以炙甘草汤者，以其人平日血气衰微，不任
寒邪，故脉不能续行也。此时虽有伤寒之表未罢，亦在所罔顾，总以补中生血复脉为急，
通行营卫为主也。
【集注】成无己曰∶脉之动而中止，能自
还者，名曰结；不能自还者，名曰代，由血气虚衰，不能相续也。
程知曰∶此又为议补者，立变法也。曰伤寒，则有邪气未解也。心主血；曰脉结代，
心动悸，则是血虚而真气不相续也。故峻补其阴以生血，更通其阳以散寒，无阳则无以
绾摄微阴，故方中用桂枝汤去芍药，而渍以清酒，所以挽真气于将绝之候，而避中寒于
脉弱之时也。观小建中汤，而后知伤寒有补阳之方；观炙甘草汤，而后知伤寒有补阴之法也。
程应旄曰∶此又以脉论，邪气留结曰结，正气虚衰曰代。伤寒见此，而加以心动悸，乃
真气内虚，故用炙甘草汤，益阴宁血和荣卫以为主。又曰∶太阳变证，多属亡阳，少阳
变证，兼属亡阴，以少阳与厥阴为表里，荣阴被伤故也。用炙甘草汤，和荣以养阴气为治也。
炙甘草汤方
甘草（炙，四两） 生姜（切，三两） 桂枝（三两） 麦门冬（半升） 麻子仁（半斤） 大枣（擘，
十二枚） 人参（二两） 阿胶（二两） 生地黄（一斤）
上九味，以清酒七升，水八升，先煮八味，取三升，去滓，纳阿胶，烊消尽，温服
一升，日三服。一名复脉汤。
【集解】张璐曰∶津液枯槁之人，宜预防二便秘涩之虞。麦冬、生地溥滋膀胱之化源；
麻仁、阿胶专主大肠之枯约。免致阴虚泉竭，火燥血枯，此仲景救阴退阳之妙法也。
柯琴曰∶仲景凡于不足之脉，阴弱者用芍药以益阴，阳虚者用桂枝以通阳，甚则加
人参以生脉，未有用麦冬者，岂以伤寒之法，义重扶阳乎？抑阴无骤补之法，与此以中虚
脉结代，用生地黄为君，麦冬为臣，峻补真阴者，是已开后学滋阴之路矣。然地黄、麦
冬味虽甘而气则寒，非发陈蕃秀之品，必得人参、桂枝以通阳脉，生姜、大枣以和营卫，
阿胶补血，酸枣安神，甘草之缓，不使速下，清酒之猛，捷于上行，内外调和，悸可宁而
【集注】方有执说：发汗之后如果不恶寒，说明这个人的表气强盛。只是发热、津液耗亡导致胃中干燥，所以称为“实”。应当调和胃气，因为病邪结实在胃中而呈实证。所以说给予调胃承气汤是为了泻除实邪，而甘草则有在泻下中起到调和作用的意义。
程知说：发汗后如果恶寒，就是营卫都虚弱；发汗后不恶寒只发热，就是津液干枯、胃中实证，所以有调和胃气以通生津液的方法。然而文中用词是“当”、“与”，似乎经过深思熟虑而不肯轻易攻下，以免进一步损伤津液。
调胃承气汤方（见阳明篇）
脉象浮紧的，按照法度应当身体疼痛，适宜用发汗法解除。假如尺部脉搏迟缓，不可发汗。为什么知道是这样呢？因为营气不足、血少的原因。
【注】脉象浮紧，是寒邪伤及营分的脉象；身体疼痛，是寒邪伤及营分的证候。脉象和证候都属于表实邪气，则应当发汗，适宜用麻黄汤。假设寸关脉浮紧，只有尺部脉迟缓，那么又不可以发汗。为什么呢？因为这个人平素营气不足、血少。由此可知，脉象阴阳两部不俱紧，不可轻易发汗。
【集注】方有执说：尺脉用来候察阴分，迟脉代表不足，营主血，汗是血的津液，尺脉迟不宜发汗，是担心夺血。
张璐说：尺中脉迟，不可用麻黄发汗，应当频繁给予小建中汤来调和它。调和之后邪气解除，就不需要发汗；假使邪气不解，不妨多服用它，覆盖衣被使其出汗即可。
发汗之后，身体疼痛，脉象沉迟的，用桂枝加芍药生姜各一两、人参三两新加汤主治。
【注】发汗之后，身体疼痛且脉象浮紧或浮数，这是发汗不彻底，表邪未尽，仍然应当发汗，适宜用桂枝汤。现在发汗后身体虽然疼痛，脉象却呈现沉迟，这是营卫虚寒，所以适宜用桂枝新加汤，来温补其营卫。
【集注】成无己说：表邪盛则身体疼，血虚也会身体疼。脉象浮紧的是邪气盛，脉象沉迟的是血虚。邪盛的要损减它才能安宁，血虚的要补益它才能痊愈。
喻昌说：脉象沉迟，是六部脉都如此，这与尺脉迟大不相同。尺脉迟是素体虚弱，这是发汗后新近导致的虚弱，所以在桂枝方中，加倍加入芍药、生姜各一两以祛除邪气，加入人参三两以补益正气。名叫新加汤，表明这不是桂枝汤中的旧法。
汪琥说：身体疼痛且脉象沉迟，怎么知道不是中寒证？要知道此证，是太阳伤寒发汗后身体疼痛不止，脉象变为沉迟，不是中寒可比拟的。
桂枝新加汤方
桂枝（一两） 芍药（四两） 甘草（二两） 人参（三两） 生姜（切，四两） 大枣（掰开，十二枚）
以上六味药，用水一斗二升，用微火煮取三升，去掉药渣，分三次温服，服用方法同桂枝汤。
【方解】这个方子就是桂枝汤加倍芍药、生姜，加入人参。发汗后身体疼痛，是营卫虚弱而不调和，所以用桂枝汤调和其营卫。加倍生姜，是因为脉沉迟、营中有寒；加倍芍药，是因为营不足、血少；加入人参，是为了补益各种虚损。桂枝得人参，大气周流全身，气血充足而肢体得以调理；人参得桂枝，贯通内外，补益营阴而增益卫阳，表虚身体疼痛没有不痊愈的。
生病发热头痛，脉象反而沉，如果不好转，身体疼痛，应当温补里虚，适宜用四逆汤。
【按语】在“身体疼痛”之下，应当有“下利清谷”这四个字，才符合“当温其里”的文意。看太阴篇说：伤寒医生误用下法，接着出现下利清谷不止，身体痛的，急当救里，适宜用四逆汤。这里虽然没有误下，但脉象反而沉，可知是里寒，必定是脱简（文字脱落）。
【注】生病发热头疼，凡是太阳表证。脉象应当浮，现在反而沉，这是太阳表证却得了少阴里脉。凡是太阳、少阴表里皆寒无汗的病，均适宜用麻黄附子细辛汤发汗。如果不好转，不下利的，再用麻黄附子甘草汤调和；如果下利清谷，即使有身体疼痛的表证未解，也不可以再发汗，应当温补里虚，适宜用四逆汤。防止阳气从阴化，变成厥逆、惊惕、亡阳的变证，绝对不可以说病在太阳，就没有可温补的道理。
四逆汤方（见少阴篇）
伤寒，如果用吐法或用下法之后，七八天病邪不解，热邪结聚在里，表里都发热，时常恶风，极度口渴，舌上干燥而烦躁，想要喝几升水，用白虎加人参汤主治。
【按语】在“伤寒”二字之下，应当有“若汗”二字，大概发汗比吐下更伤津液。时时恶风，应当是时汗恶风，如果不是“汗”字，那么时时恶风就是表不解，白虎汤就在禁忌之列了。论中说发热无汗、表不解者，不可与白虎汤；渴欲饮水、无表证者，白虎加人参汤主治。读者仔细玩味经文自然明白。
【注】伤寒，如果经过汗、吐、下法之后，七八天病邪不解，导致热邪结聚于表里，时常出汗恶风的，是结热在表未解；极度口渴、舌上干燥而烦躁，想要喝几升水的，是结热在里已经明显。所以说表里俱热，适宜用白虎加人参汤主治。因为白虎能外解肌热，内清里热。加入人参，是因为汗、吐、下之后，津液亡失、气弱，借此来益气生津。
【按语】大青龙汤治疗太阳表里俱热，表多里少，所以不渴。白虎汤治疗阳明表里俱热，里多表少，所以大渴。现在大渴燥烦，时常出汗恶风，是热在阳明又兼太阳。而用白虎汤，是因为阳明里热证多，太阳表热证少。如果没有汗微渴，则为太阳表证多，即表里大热，又应当用大青龙汤了。
【集注】喻昌说：玩味此条本文，热结在里，表里俱热，已经自行斟酌，只有热结在里，所以表热不除，况且加大渴饮水，怎么能不以清热为急务呢！
程知说：表热，是身体发热；里热，是体内发热。因为汗、吐、下后病邪不解，所以邪气乘虚结聚为里热；只有结热在里，所以表热不除，有恶风证。大渴引饮，里热炽盛，怎么能不用白虎汤紧急解除它。石膏辛寒，能清里热，兼散表热；正因为是在汗、吐、下之后，所以必须加人参以顾护正气。
汪琥说：给予白虎汤加人参扶正祛邪，以分解内外的邪热。总之，此汤只适宜正气虚而邪气微的人；如果邪气盛的，不敢轻易加人参。
白虎加人参汤方（见阳明篇）
【按语】在“脉浮数”之下应当有“小便不利”四个字，如果没有这四个字，就是阳明内热口燥的烦渴，属于白虎汤证。因为它有小便不利和烦渴，就是太阳水热瘀结的烦渴，属于五苓散证。况且没有小便不利证而用五苓散，就犯了重竭津液的禁忌了。太阳上编，类似这样的证候有好几条，只有一条是水入即吐，水不下行，所以没有小便不利的文句，这一条应当有“小便不利”四个字。
【注】发汗已，是指太阳病已经发过汗了。脉象浮数，知道邪气仍在表。如果小便利而烦渴，是初入阳明胃热，属于白虎汤证。现在小便不利而烦渴，是太阳腑病，膀胱水蓄积，属于五苓证。所以用五苓散，依法服用，外疏内利，表里都能解除。
【集注】方有执说：“已”是说发汗完毕，不是说表病罢休。烦渴，是膀胱水蓄积，不能化生津液，所以用四苓以利水；脉浮数，外表未除，所以凭藉一味桂枝来调和，所以说五苓能两解表里。
伤寒出汗而口渴的，用五苓散主治；不口渴的，用茯苓甘草汤主治。
【注】这是申述上一条或渴而不烦，或烦而不渴的情况，以区别治疗方法。伤寒发汗后，脉浮数，出汗烦渴，小便不利的，用五苓散主治，现在只说出汗，是省略文字。渴而不烦，是水饮盛于热，所以也用五苓散主治，利水以化生津液。如果不烦且不渴，就是里没有热。只有脉浮数出汗，小便不利，是营卫不和，所以主治用茯苓甘草汤调和表气以利水。
【集注】郑重光说：伤寒本来无汗，汗是因发汗而出。上一条烦而渴，这一条但渴不烦，里证较轻，治法也不殊异；如果更不渴，则内无燥热，里病少而表证还多。所以用桂枝汤的三份，五苓散的一份，表示三表一里的意思，改名叫做茯苓甘草汤，乃是桂枝汤和五苓散的变制。
茯苓甘草汤方
茯苓（二两） 桂枝（二两） 生姜（切，三两） 甘草（炙，一两）
以上四味药，用水四升，煮取三升，去掉药渣，分三次温服。
【方解】这个方子是仿效桂枝汤、五苓散两方的意义，稍微缩小其法度。有脉浮数出汗的表证，所以主治用桂枝。去掉大枣、芍药，是因为有小便不利的里证，恐怕滞敛而有碍于小便不通。五苓散去白术、泽泻、猪苓，是因为不渴不烦，里饮不多，只要小便一通利就可以痊愈，恐怕过于燥渗伤阴。
【集解】汪琥说：五苓散、茯苓甘草汤两方，都是太阳标本齐病，表里兼主的药剂。什么叫标？太阳之经就是标。什么叫本？膀胱之腑就是本。经在表，本在里。五苓散，邪气已入腑，表证已微，所以方中只用桂枝一味来主表，其余四味都是主里的药。茯苓甘草证，邪气还在经，里证尚少，所以方中只用茯苓一味来主里，其余三味都是主表的药。
脉象浮数的，按照法度应当出汗而愈，如果误用下法，身体沉重、心悸的，不可发汗，应当等待自汗出才解。之所以这样，是因为尺中脉微，这是里虚，必须表里充实，津液自然调和，就会自汗出而痊愈。
【注】伤寒未发热，脉多浮紧，是寒盛。已发热，脉多浮数，是热盛。均适宜用麻黄汤发汗则愈。如果不发汗而误用下法，不成逆坏证的，一定是其人里气素实。所以只见失汗身重的表证，误下心悸的里证，则不可再发其汗；应当等待其表里自和，自然汗出而解。之所以这样，是因为失汗表实，误下里虚，尺中脉微，表里未谐，所以不立即解除。须等待其里也实而与表平衡，平衡则和，和则阳津阴液自然和谐，所以便自汗出而愈。使里实的方法，就是下一条用小建中汤的方法。
【集注】喻昌说：这也是先建中而后发汗的变法。要知道仲景说：尺脉微者，不可发汗。又说：尺微者，不可下。无非是探究人体津液的深奥旨意，所以误下之后，脉虽浮数不改，亟宜发汗的，也必须审慎其尺脉，不可随意径情有如此严重。
张璐说：误下体重心悸，纵然脉仍浮数，也不可再发其汗。假设尺脉微，为里阴素虚，尤其应当戒慎。脉浮而数，热邪已甚，将欲作汗，现在误下之，所以身重心悸，应当与小建中汤调和其津液，汗出而愈。
【注】伤寒二三日，未经汗下，就心悸而烦，必是其人中气素虚，虽然有表证，也不可发汗。盖心悸说明阳气已微，心烦说明阴气已弱，所以用小建中汤先建立其中气，兼调营卫。
【集注】王肯堂说：伤寒二三日，心中悸而烦的，用小建中汤主治。伤寒脉弦细，属少阳，不可汗，汗之则谵语，胃不和则烦而悸。大抵先烦而后悸的是热，先悸而后烦的是虚，治病必求其本就是这个道理。
程应旄说：可见阳去入阴，必有其先兆，善于治疗的，急宜杜绝于未萌之时。心中悸而烦，则是里气虚而阳为阴袭，建中汤补虚和里，保定中州，以资气血为主。虽然悸与烦，都是小柴胡汤中兼见的证候，而得之二三日，里证未必即具，小柴胡汤不适宜。
魏荔彤说：建中是治其本。与建中后，慢慢审察其在表，则仍当发汗，以中州既建，虽发汗阳气亦不至于亡失。审察其传里，则应下之，以中州既建，虽下阳气亦不至于陷落。所谓急则从标，而缓则从本。
小建中汤方
桂枝（三两） 芍药（六两） 甘草（二两） 生姜（切，三两） 胶饴（一升） 大枣（掰开，十二枚）
以上六味药，用水七升，煮取三升，去掉药渣，纳入胶饴，再次放在微火上消解，温服一升，每日三次。呕吐的人不可用建中汤，因为甜的缘故。
【方解】这个方子，就是桂枝汤倍芍药加胶饴。名叫小建中，是说小小创建中气。盖中气虽虚，表尚未和，不敢大补，所以仍以桂枝调和营卫，倍芍药加胶饴，调建中州，而不喝稀粥温覆令出汗的，其意重在心悸中虚，而不在伤寒之表。中州创建，营卫自然调和，津液可生，汗出乃解，悸烦可除矣。呕吐的人不可用，是说凡病呕者不可用，恐怕甜味助长呕吐。
【注】心动悸，是说心下筑筑跳动，惕惕然动而不自安。如果因汗下的多虚，不因汗下的多热，想喝水小便不利的属饮，四肢厥冷而下利的属寒，现在病伤寒，不因汗下而心动悸，又没有饮、热、寒、虚的证候，只根据结代不足的阴脉，就主治用炙甘草汤的，因为这个人平日血气衰微，不耐受寒邪，所以脉不能续行。此时虽然有伤寒之表未罢，也在所不顾，总以补中生血复脉为急，通行营卫为主。
【集注】成无己说：脉跳动而中止，能自己回来的，名叫结；不能自己回来的，名叫代，由血气虚衰，不能相续。
程知说：这又是为议补者，设立变法。说伤寒，则有邪气未解。心主血；说脉结代，心动悸，则是血虚而真气不相续。所以峻补其阴以生血，更通其阳以散寒，无阳则无以绾摄微阴，所以方中用桂枝汤去芍药，而渍以清酒，所以挽真气于将绝之候，而避中寒于脉弱之时。看小建中汤，而后知道伤寒有补阳的方子；看炙甘草汤，而后知道伤寒有补阴的方法。
程应旄说：这又是以脉论，邪气留结叫结，正气虚衰叫代。伤寒见此，而加以心动悸，乃真气内虚，所以用炙甘草汤，益阴宁血和荣卫以为主。又说：太阳变证，多属亡阳，少阳变证，兼属亡阴，以少阳与厥阴为表里，荣阴被伤故也。用炙甘草汤，和荣以养阴气为治。
炙甘草汤方
甘草（炙，四两） 生姜（切，三两） 桂枝（三两） 麦门冬（半升） 麻子仁（半斤） 大枣（掰开，十二枚） 人参（二两） 阿胶（二两） 生地黄（一斤）
以上九味药，用清酒七升，水八升，先煮八味，取三升，去掉药渣，纳入阿胶，烊化消尽，温服一升，每日三次。一名复脉汤。
【集解】张璐说：津液枯槁之人，宜预防二便秘涩的忧虑。麦冬、生地广泛滋助膀胱的化源；麻仁、阿胶专主大肠的枯约。免致阴虚泉竭，火燥血枯，这是仲景救阴退阳的妙法。
柯琴说：仲景凡是对于不足的脉，阴弱者用芍药以益阴，阳虚者用桂枝以通阳，甚至加人参以生脉，从未有用麦冬的，难道以伤寒之法，义重扶阳吗？还是阴无骤补之法，与此以中虚脉结代，用生地黄为君，麦冬为臣，峻补真阴的，是已开后学滋阴之路了。然而地黄、麦冬味虽甘而气则寒，非发陈蕃秀之品，必得人参、桂枝以通阳脉，生姜、大枣以和营卫，阿胶补血，酸枣安神，甘草之缓，不使速下，清酒之猛，捷于上行，内外调和，悸可宁而
[Collected Commentaries] Fang Youzhi said: After sweating, if there is no aversion to cold, it indicates that the person's exterior qi is strong. The presence of fever alone, with depletion of body fluids leading to dryness in the stomach, is termed "excess" (Shi). One should harmonize the stomach qi because the pathogen is stagnant in the stomach presenting as an excess pattern. Thus, administering Tiaowei Chengqi Tang (Stomach-Harmonizing Purging Decoction) aims to purge excess, while Licorice Root (Gancao) serves to harmonize within the purgative action.
Cheng Zhi said: If aversion to cold occurs after sweating, it signifies deficiency of both Ying (Nutritive) and Wei (Defensive) qi; if only fever occurs without aversion to cold after sweating, it indicates dried-up body fluids and gastric excess. Hence, there is a method to harmonize the stomach and promote fluid generation. However, the use of terms "should" (Dang) and "give" (Yu) suggests careful deliberation rather than reckless purging, which would further deplete fluids.
Tiaowei Chengqi Tang Formula (See Yangming Chapter)
When the pulse is floating and tight, according to the principles, there should be body pain, and sweating therapy is appropriate. If, however, the cunian position at the chi level is slow, sweating must not be induced. How do we know this? It is due to insufficient Ying qi and blood deficiency.
[Annotation] A floating and tight pulse is the pulse of cold injuring the Ying level; body pain is the manifestation of cold injuring the Ying level. Since both pulse and symptoms indicate exterior excess pathogens, sweating is indicated, preferably using Mahuang Tang (Ephedra Decoction). Suppose the cun and guan positions show floating and tight pulses, but only the chi position is slow; then sweating is contraindicated. Why? Because the person has a chronic deficiency of Ying qi and blood. From this, we can infer that if the yin and yang aspects of the pulse are not both tight, one should not lightly induce sweating.
[Collected Commentaries] Fang Youzhi said: The chi pulse reflects the yin aspect; a slow pulse indicates insufficiency. Ying governs blood, and sweat is the fluid of blood. A slow chi pulse makes sweating inadvisable to avoid depleting blood.
Zhang Lu said: With a slow pulse at the chi position, Mahuang should not be used for sweating. Instead, Xiao Jianzhong Tang (Minor Construct the Middle Decoction) should be administered frequently to harmonize. If harmonization resolves the pathogen, no sweating is needed; if unresolved, continued administration followed by covering to induce sweating is acceptable.
After sweating, if body pain persists and the pulse is deep and slow, Guizhi Jia Shaoyao Shengjiang Ge Yi Liang Renshen Sanli Xinjia Tang (Guizhi Decoction with Added Peony and Ginger, One Tael Each, and Ginseng, Three Taels, Newly Modified Decoction) is the primary treatment.
[Annotation] After sweating, if body pain is accompanied by a floating-tight or floating-rapid pulse, it indicates incomplete sweating and residual exterior pathogens; sweating should still be employed, preferably using Guizhi Tang (Cinnamon Twig Decoction). Now, although body pain persists after sweating, the pulse is deep and slow, indicating deficiency-cold of Ying and Wei qi. Therefore, Guizhi Xinjia Tang is suitable to warm and tonify Ying and Wei.
[Collected Commentaries] Cheng Wuji said: Exuberant exterior pathogens cause body ache; blood deficiency also causes body ache. A floating-tight pulse indicates pathogen exuberance; a deep-slow pulse indicates blood deficiency. For exuberance, reduction brings peace; for deficiency, tonification brings recovery.
Yu Chang said: A deep-slow pulse applies to all six positions, which is vastly different from a slow chi pulse. A slow chi pulse implies constitutional deficiency, whereas this case represents new deficiency caused by sweating. Thus, Peony (Shaoyao) and Fresh Ginger (Shengjiang) are doubled by one tael each in the Guizhi formula to dispel pathogens, and Ginseng (Renshen) three taels are added to tonify upright qi. Named "Newly Modified Decoction," it clearly differs from the old methods of Guizhi Tang.
Wang Hu said: Body pain with a deep-slow pulse—how do we know it is not Cold Strike (Zhong Han)? One must understand that this condition arises from persistent body pain after sweating for Taiyang Shanghan, with the pulse changing to deep and slow; it is not comparable to Cold Strike.
Guizhi Xinjia Tang Formula
Guizhi (Cinnamon Twig, 1 tael), Shaoyao (Peony Root, 4 taels), Gancao (Licorice Root, 2 taels), Renshen (Ginseng Root, 3 taels), Shengjiang (Fresh Ginger, sliced, 4 taels), Dazao (Jujube, broken open, 12 pieces).
These six ingredients are decocted in 12 sheng of water over low heat until 3 sheng remain. Strain and take warm in divided doses, following the administration method of Guizhi Tang.
[Formula Analysis] This formula is essentially Guizhi Tang with doubled Shaoyao and Shengjiang, plus Renshen. Post-sweating body pain indicates Ying-Wei deficiency and disharmony; thus, Guizhi Tang is used to harmonize Ying and Wei. Doubling Shengjiang addresses the deep-slow pulse and cold in the Ying level; doubling Shaoyao addresses Ying insufficiency and blood deficiency; adding Renshen tonifies various deficiencies. Guizhi combined with Renshen allows Great Qi to circulate freely, enriching blood and qi to regulate the limbs. Renshen combined with Guizhi connects interior and exterior, nourishing Ying Yin and benefiting Wei Yang. Exterior deficiency with body pain will surely resolve.
If a patient presents with fever, headache, and a pulse that is surprisingly deep, and if symptoms do not improve, accompanied by body pain, the interior should be warmed using Sini Tang (Four Reversal Decoction).
[Note] Under "body pain," the phrase "diarrhea with undigested food" (Xiali Qinggu) should likely exist to align with the text "warm the interior." In the Taiyang Chapter, it states: If a Shanghan patient is mistakenly purged, leading to incessant diarrhea with undigested food and body pain, urgent rescue of the interior with Sini Tang is required. Although here there was no purging, the surprising deep pulse indicates interior cold, suggesting a textual omission.
[Annotation] Fever and headache are typical Taiyang exterior patterns. The pulse should be floating; a surprising deep pulse indicates a Taiyang exterior pattern presenting with Shaoyin interior pulse. For diseases where both Taiyang and Shaoyin present with exterior-interior cold and no sweat, Mahuang Fuzi Xixin Tang (Ephedra, Prepared Aconite, and Asarum Decoction) is suitable for inducing sweating. If unresolved without diarrhea, Mahuang Fuzi Gancao Tang (Ephedra, Prepared Aconite, and Licorice Decoction) is used to harmonize; if diarrhea with undigested food occurs, even with unresolved exterior body pain, sweating is contraindicated. The interior must be warmed using Sini Tang to prevent Yang transformation into Yin, avoiding complications like Jue (cold extremities), fright, and Yang collapse. One must never argue that since the disease is in Taiyang, warming is inappropriate.
Sini Tang Formula (See Shaoyin Chapter)
In Shanghan, if after vomiting or purging, the disease remains unresolved after seven to eight days, with heat consolidated in the interior, causing fever in both exterior and interior, occasional aversion to wind, extreme thirst, dryness and烦躁 (restlessness) on the tongue, and a desire to drink several sheng of water, Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) is the primary treatment.
[Note] Under "Shanghan," the phrase "if sweating" (Ruo Han) should likely exist, as sweating damages body fluids more severely than vomiting or purging. "Occasional aversion to wind" should probably read "occasional sweating and aversion to wind." Without "sweating," occasional aversion to wind implies unresolved exterior, making Baihu Tang contraindicated. The Treatise states: For fever without sweat and unresolved exterior, Baihu Tang is forbidden; for thirst wanting water without exterior signs, Baihu Jia Renshen Tang is indicated. Readers should study the original text carefully.
[Annotation] After Shanghan treated with sweating, vomiting, or purging, if unresolved after seven to eight days, leading to heat consolidation in the exterior and interior, with occasional sweating and aversion to wind, the consolidated heat in the exterior remains unresolved. Extreme thirst, dry tongue, restlessness, and desire to drink several sheng of water indicate consolidated heat in the interior is manifest. Thus, it is described as exterior-interior heat, treated with Baihu Jia Renshen Tang. Baihu Tang releases muscle heat externally and clears interior heat internally. Renshen is added because sweating, vomiting, and purging have depleted fluids and weakened Qi; it helps generate Qi and fluids.
[Note] Da Qinglong Tang treats Taiyang exterior-interior heat, where exterior heat predominates, hence no thirst. Baihu Tang treats Yangming exterior-interior heat, where interior heat predominates, hence extreme thirst. Current symptoms of extreme thirst, dryness, restlessness, occasional sweating, and aversion to wind indicate heat in Yangming combined with Taiyang. Baihu Tang is used because Yangming interior heat patterns are predominant over Taiyang exterior heat patterns. If there were no sweat and slight thirst, Taiyang exterior patterns would predominate, and Da Qinglong Tang would be indicated even for severe exterior-interior heat.
[Collected Commentaries] Yu Chang said: Examining this clause, heat consolidated in the interior with exterior-interior heat requires careful consideration. Only because heat is consolidated in the interior does the exterior heat persist. Given extreme thirst and drinking, clearing heat must be urgent!
Cheng Zhi said: Exterior heat refers to body fever; interior heat refers to internal heat. Unresolved after sweating, vomiting, or purging allows pathogens to exploit deficiency and consolidate as interior heat. Because heat consolidates in the interior, exterior heat persists, causing aversion to wind. Extreme thirst indicates blazing interior heat; thus, Baihu Tang is urgently needed to resolve it. Gypsum (Shigao) is acrid and cold, clearing interior heat and dispersing exterior heat. Because this follows sweating, vomiting, or purging, Renshen is essential to protect upright Qi.
Wang Hu said: Baihu Jia Renshen Tang supports upright Qi to resolve interior and exterior pathogenic heat. This decoction is suitable only when upright Qi is deficient and pathogens are mild; for severe pathogens, Renshen should not be lightly added.
Baihu Jia Renshen Tang Formula (See Yangming Chapter)
After sweating, if the pulse is floating and rapid, with irritability and thirst, Wuling San (Five-Ingredient Powder with Poria) is the primary treatment.
[Note] Under "floating and rapid pulse," the phrase "difficulty urinating" (Xiaobian Buli) should likely exist. Without this, irritability and thirst would stem from Yangming interior heat and dry mouth, indicating Baihu Tang syndrome. With difficulty urinating and irritability/thirst, it indicates Taiyang water-heat stasis, indicating Wuling San syndrome. Using Wuling San without difficulty urinating violates the prohibition against doubly depleting fluids. Several similar cases appear in the Upper Taiyang chapter; only one involving vomiting immediately after drinking water lacks mention of difficulty urinating. This clause should include "difficulty urinating."
[Annotation] "Sweating completed" means Taiyang disease has undergone sweating. A floating-rapid pulse indicates pathogens remain in the exterior. If urination is free with irritability/thirst, it indicates entry into Yangming stomach heat (Baihu Tang syndrome). Now, with difficulty urinating and irritability/thirst, it is a Taiyang Fu organ disease, bladder water retention (Wuling San syndrome). Thus, Wuling San is used; taken correctly, it disperses outward and drains inward, resolving both exterior and interior.
[Collected Commentaries] Fang Youzhi said: "Completed" means sweating is finished, not that the exterior disease has ceased. Irritability and thirst result from bladder water retention failing to transform fluids; thus, Si Ling (Four-Ingredient Powder) components are used to drain water. Floating-rapid pulse indicates unremoved exterior; thus, Cinnamon Twig (Guizhi) harmonizes the exterior. Hence, Wuling San is said to resolve both exterior and interior.
In Shanghan, if sweating occurs with thirst, Wuling San is indicated; if without thirst, Fuling Gancao Tang (Poria and Licorice Decoction) is indicated.
[Annotation] This elaborates on the previous clause regarding irritability with or without thirst to distinguish treatments. After Shanghan sweating, if pulse is floating-rapid, sweating occurs with irritability/thirst and difficulty urinating, Wuling San is indicated. Here, only sweating is mentioned as an ellipsis. Thirst without irritability indicates water abundance over heat; thus, Wuling San is used to drain water and transform fluids. If neither irritability nor thirst exists, there is no interior heat. Only floating-rapid pulse, sweating, and difficulty urinating indicate Ying-Wei disharmony; thus, Fuling Gancao Tang is used to harmonize the exterior and drain water.
[Collected Commentaries] Zheng Zhongguang said: Shanghan originally has no sweat; sweat results from inducing it. The previous clause had irritability and thirst; this clause has thirst without irritability, indicating milder interior signs and similar treatment. If even less thirsty, there is no interior dryness, fewer interior signs, and more exterior signs. Thus, three parts Guizhi Tang and one part Wuling San are used, indicating three exterior to one interior ratio. Renamed Fuling Gancao Tang, it is a modification of Guizhi and Wuling formulas.
Fuling Gancao Tang Formula
Fuling (Poria, 2 taels), Guizhi (Cinnamon Twig, 2 taels), Shengjiang (Fresh Ginger, sliced, 3 taels), Gancao (Licorice Root, roasted, 1 tael).
These four ingredients are decocted in 4 sheng of water until 3 sheng remain. Strain and take warm in three divided doses.
[Formula Analysis] This formula imitates the principles of Guizhi Tang and Wuling San but in a smaller dosage. It addresses the exterior sign of floating-rapid pulse and sweating using Guizhi. Dazao and Shaoyao are removed because of interior difficulty urinating, to avoid astringency hindering urination. Wuling San's Baizhu, Zexie, and Zhuling are removed because lack of thirst/irritability indicates minimal interior fluid retention; only promoting urination is needed, avoiding excessive drying that damages Yin.
[Collected Commentary] Wang Hu said: Both Wuling San and Fuling Gancao Tang treat simultaneous Biaobing (Exterior Syndrome) and Benbing (Interior Syndrome) of Taiyang, addressing both exterior and interior. What is Biaobing? The Taiyang Meridian. What is Benbing? The Bladder Fu organ. The Meridian is exterior; the Fu organ is interior. In Wuling San, pathogens have entered the Fu organ, and exterior signs are minor; thus, only Guizhi addresses the exterior, while the other four ingredients address the interior. In Fuling Gancao Tang, pathogens remain in the Meridian, and interior signs are few; thus, only Fuling addresses the interior, while the other three ingredients address the exterior.
If the pulse is floating and rapid, sweating should normally lead to recovery. If purging is mistakenly applied, resulting in heavy body and palpitations, sweating is contraindicated. Recovery comes through spontaneous sweating. Why? Because the chi pulse is weak, indicating interior deficiency. The exterior and interior must become solid, body fluids must harmonize naturally, and spontaneous sweating will occur for recovery.
[Annotation] Before fever onset in Shanghan, pulses are often floating-tight due to cold excess. After fever onset, pulses are often floating-rapid due to heat excess. Both are suitable for Mahuang Tang to induce sweating for recovery. If sweating is not induced and purging is mistakenly applied, preventing adverse transformations, the person must have constitutionally solid interior Qi. Thus, seeing only exterior heaviness from missed sweating and interior palpitations from mistaken purging, re-inducing sweating is forbidden. One must wait for natural exterior-interior harmony and spontaneous sweating. This occurs because missed sweating causes exterior excess, mistaken purging causes interior deficiency, and a weak chi pulse shows exterior-interior disharmony. Recovery requires the interior to become solid and balance the exterior. Balance leads to harmony, allowing Yang fluids and Yin fluids to harmonize spontaneously, resulting in recovery. The method to solidify the interior is using Xiao Jianzhong Tang, as described in the next clause.
[Collected Commentaries] Yu Chang said: This is another variation of constructing the Middle before sweating. Zhang Zhongjing stated: Weak chi pulse contraindicates sweating. Also: Weak chi pulse contraindicates purging. These explore the profound essence of human fluids. Even if the pulse remains floating-rapid after mistaken purging requiring urgent sweating, the chi pulse must be examined carefully; one cannot act arbitrarily.
Zhang Lu said: Mistaken purging causing heaviness and palpitations contraindicates further sweating, even if the pulse remains floating-rapid. If the chi pulse is weak, indicating chronic interior Yin deficiency, caution is especially warranted. Floating-rapid pulse indicates severe heat about to sweat; mistaken purging causes heaviness and palpitations. Xiao Jianzhong Tang should be given to harmonize fluids, leading to recovery via sweating.
On the second or third day of Shanghan, if there is palpitation and irritability in the heart, Xiao Jianzhong Tang (Minor Construct the Middle Decoction) is the primary treatment.
[Annotation] On the second or third day of Shanghan, without prior sweating or purging, if palpitation and irritability occur, the person must have constitutionally deficient Middle Qi. Despite exterior signs, sweating is contraindicated. Palpitation indicates diminished Yang; irritability indicates weakened Yin. Thus, Xiao Jianzhong Tang is used first to establish the Middle Qi and harmonize Ying and Wei.
[Collected Commentaries] Wang Kentang said: On the second or third day of Shanghan, with palpitation and irritability, Xiao Jianzhong Tang is indicated. A string-thin pulse in Shanghan belongs to Shaoyang and contraindicates sweating; sweating causes delirium. Stomach disharmony causes irritability and palpitation. Generally, irritability preceding palpitation indicates Heat; palpitation preceding irritability indicates Deficiency. Seeking the root in treatment is key.
Cheng Yingmao said: This shows that Yang departing into Yin has precursors. Skilled practitioners prevent this before it arises. Heart palpitation and irritability indicate deficient interior Qi and Yang invaded by Yin. Jianzhong Tang tonifies deficiency, harmonizes the interior, stabilizes the Middle State, and generates Qi and Blood. Although palpitation and irritability are seen in Xiaochaihu Tang, on the second or third day, interior signs may not yet be complete, making Xiaochaihu Tang unsuitable.
Wei Litong said: Establishing the Middle treats the root. After establishing the Middle, if the pathogen remains in the exterior, sweating can still be safely performed without Yang collapse. If it transmits to the interior, purging can be safely performed without Yang sinking. This illustrates treating the branch in emergencies and the root in stable conditions.
Xiao Jianzhong Tang Formula
Guizhi (Cinnamon Twig, 3 taels), Shaoyao (Peony Root, 6 taels), Gancao (Licorice Root, 2 taels), Shengjiang (Fresh Ginger, sliced, 3 taels), Jiaoyi (Malt Sugar, 1 sheng), Dazao (Jujube, broken open, 12 pieces).
These six ingredients are decocted in 7 sheng of water until 3 sheng remain. Strain, add Jiaoyi, and dissolve over low heat. Take 1 sheng warm, three times daily. Patients with vomiting should not use Jianzhong Tang due to its sweetness.
[Formula Analysis] This formula is Guizhi Tang with doubled Shaoyao and added Jiaoyi. Named "Minor Construct the Middle," it implies gently establishing Middle Qi. Although Middle Qi is deficient, the exterior is not yet harmonized, so strong tonification is avoided. Guizhi harmonizes Ying and Wei; doubled Shaoyao and Jiaoyi build the Middle State. Unlike standard Guizhi Tang protocols involving porridge and covering for sweat, the focus here is on heart palpitation and Middle deficiency, not the Shanghan exterior. Establishing the Middle harmonizes Ying and Wei, generates fluids, induces sweat, resolves palpitation and irritability. Vomiting patients should avoid it as sweetness may aggravate vomiting.
In Shanghan, if the pulse is knotted (Jie) or intermittent (Dai), with palpitation, Zhigancao Tang (Prepared Licorice Decoction) is the primary treatment.
[Annotation] "Palpitation" describes a throbbing sensation in the chest, restless and uneasy. Palpitation after sweating/purging is usually deficiency; without these, it is usually heat. Thirst with difficulty urinating indicates Fluid Retention; cold extremities with diarrhea indicate Cold. Here, in Shanghan without sweating/purging, and lacking Fluid, Heat, Cold, or Deficiency signs, but presenting with a deficient knotted/intermittent Yin pulse, Zhigancao Tang is indicated. This is because the person chronically suffers from blood and Qi weakness, unable to withstand cold pathogens, causing the pulse to fail to continue smoothly. Although the Shanghan exterior may persist, it is secondary; the priority is tonifying the Middle, generating blood, restoring the pulse, and circulating Ying and Wei.
[Collected Commentaries] Cheng Wuji said: When the pulse beats and stops, returning on its own, it is called Jie (Knotted); if it does not return on its own, it is called Dai (Intermittent). This results from blood and Qi deficiency failing to sustain continuity.
Cheng Zhi said: This establishes a variation for tonification. "Shanghan" implies unresolved pathogens. The Heart governs Blood; knotted/intermittent pulse and palpitation indicate blood deficiency and discontinuity of True Qi. Thus, Yin is vigorously tonified to generate blood, and Yang is unblocked to disperse cold. Without Yang, micro-Yin cannot be retained. Hence, Guizhi Tang minus Shaoyao is soaked in clear wine to salvage True Qi at the brink of collapse and avoid interior cold during weak pulses. Observing Xiao Jianzhong Tang reveals Shanghan has Yang-tonifying formulas; observing Zhigancao Tang reveals Shanghan has Yin-tonifying methods.
Cheng Yingmao said: This diagnosis relies on the pulse. Pathogen stagnation is Jie; upright Qi deficiency is Dai. Seeing this in Shanghan with palpitation indicates internal deficiency of True Qi. Zhigancao Tonifies Yin, calms Blood, and harmonizes Ying and Wei. Furthermore, Taiyang transformations often involve Yang loss; Shaoyin transformations involve Yin loss due to their interior-exterior relationship and Ying Yin injury. Zhigancao Harmonizes Ying to nourish Yin Qi.
Zhigancao Tang Formula
Gancao (Licorice Root, roasted, 4 taels), Shengjiang (Fresh Ginger, sliced, 3 taels), Guizhi (Cinnamon Twig, 3 taels), Maimendong (Ophiopogon Tuber, half sheng), Maziren (Hemp Seed, half jin), Dazao (Jujube, broken open, 12 pieces), Renshen (Ginseng Root, 2 taels), Ejiao (Donkey-hide Gelatin, 2 taels), Shengdihuang (Rehmannia Root, fresh, 1 jin).
These nine ingredients are decocted in 7 sheng of clear wine and 8 sheng of water. First boil eight ingredients until 3 sheng remain. Strain, add Ejiao, melt completely, and take 1 sheng warm, three times daily. Also known as Fumai Tang (Pulse-Recovering Decoction).
[Collected Commentary] Zhang Lu said: For those with withered fluids, prevention of constipation is necessary. Maimendong and Shengdihuang nourish the source of Bladder transformation; Maziren and Ejiao specifically address Large Intestine dryness. This prevents Yin deficiency, spring exhaustion, fire dryness, and blood withering—a brilliant method of saving Yin and retreating Yang by Zhang Zhongjing.
Ke Qin said: Zhang Zhongjing typically uses Shaoyao for deficient Yin pulses to benefit Yin, and Guizhi for Yang deficiency pulses to unblock Yang, sometimes adding Renshen to generate pulse. He rarely used Maimendong. Does Shanghan methodology prioritize supporting Yang? Or is there no sudden method for tonifying Yin? In this case of Middle deficiency with knotted/intermittent pulse, Shengdihuang is used as Sovereign and Maimendong as Minister to vigorously tonify True Yin, opening the path for later scholars to tonify Yin. However, Dihuang and Maimendong are sweet but cold, not suitable for sprouting and flourishing. They require Renshen and Guizhi to unblock Yang pulses, Shengjiang and Dazao to harmonize Ying and Wei, Ejiao to tonify blood, Suanzaoren to calm spirit, Gancao to slow descent, and strong clear wine to accelerate upward movement. Interior and exterior harmonize, palpitations calm, and...