则心烦；邪入腹中，在下则腹满；两邪逼凑胸腹，所以心烦腹满。用此一涌一泻，亦表
里两解法也。
栀子浓朴汤方
栀子（擘，十四枚） 浓朴（姜炙，四两） 枳实（去穣，炒，四两）
以上三味，以水三升半，煮取一升半，去滓，分三服，温进一服，得吐，止后服。
伤寒，医以丸药大下之，身热不去，微烦者，栀子干姜汤主之。
【按】栀子干姜汤当是栀子豉汤，栀子豉汤当是栀子干姜汤，断无烦热用干姜，结痛用香豉之理。
【注】伤寒表邪未解，医以丸药大下之，不至结胸痞硬，犹未成逆也。然身热不去，表
仍未罢也；微烦者，热陷于胸也。表热之在胸者，既轻且微，故不可下，亦不可清，惟
宜以栀子豉汤，微涌其热，则微烦可除，而吐中有发散之意，身热亦可解矣。
【集注】汪琥曰∶丸药误下，邪热不除，所以身热不去，邪气乘虚客于胸中，故令微烦也。
栀子干姜汤方
栀子（擘，十四枚） 干姜（二两）
上二味，以水三升半，煮取一升半，去滓，分二服，温进一服，得吐者，止后服。
【按】此方干姜当是香豉。余义详前经文下正误文内。
伤寒五六日，大下之后，身热不去，心中结痛者，未欲解也，栀子豉汤主之。
【按】此方香豉当是干姜。余义亦详前经文下正误文内。
【注】伤寒五六日，邪气在里之时也。大下之后，若身热去，心胸和，是为欲解矣。今
身热不去，邪仍在表也。心中结痛过下里寒也，故曰未欲解也。但此表热里寒之证，欲
温其里，既碍表热，欲解其表，又碍里寒，故惟以栀子之寒，干姜之热，并举而涌之，则
解表温里两得之矣。岂尚有身热结痛而不尽除者哉！此仲景立两难治法，其妙如此，余可类推矣。
【集注】王肯堂曰∶“身热不去”四字宜玩。结胸身不热，知热不在表也，今身热不
去，惟宜越之而已。
程应旄曰∶痛而云结，殊类结胸，但结胸身无大热，知热已尽归于里为实邪。此则
身热不去，则所结者，因下而结，客邪仍在于表，故云未欲解也。
凡用栀子汤，病患旧微溏者，不可与服之。
【注】若汗、吐、下后，懊 少气，呕逆烦满，心中结痛者，皆宜以栀子等汤吐之。以
其邪留连于胸胃之间，或与热、与虚、与饮、与气、与寒相结而不实，则病势向上，即经
所谓“在上者因而越之”之意也。若未经汗、吐、下，而有是证，则为实邪，非栀子汤轻
剂所能治矣，又当以瓜蒂散重剂主之也。若病患旧微溏者，虽有是证，但里既久虚，不
可与服；若与之，即使客邪尽去，亦必正困难支，盖病势向下，涌之必生他变也。本草
不言栀子为吐剂，仲景用之以为吐者，何也？栀子本非吐药，以其味苦能吐，故用之以涌其热也。
【按】吐药不止栀子也，诸药皆可为之，惟要确审胸胃之邪，是寒是热？是食是水？是
痰是气？因何阻滞，使胸胃阳气不伸？遂以当用之药而吐涌之，自可愈也。如欲吐寒，则
以干姜桂皮之类；吐热，则以栀子苦茶之类；吐食，平胃食盐之类；吐水，五苓生姜之类；
吐痰稀涎，橘皮之类；吐气流气，枳朴之类。但形气弱者，药宜少，仍当佐以补中益气等
升药为妥；形气壮者药宜多，更佐以瓜蒂、藜芦等猛药更效。凡煎吐药汤及调散，或用酸
米汤，或用白汤，或用稀米粥，须备十余盅，令病者顿服一盅，即用指探吐药出，再服一
盅，亦随用指探吐药出，再服再叶，以顺溜快吐为度，则头额身上自有微汗，所有病证
轻减，即为中病，不必尽服余药。若过吐之，即使病尽除，恐损胸中阳气也。近世之医，以
吐为古法不可用，久矣。皆因仲景之道不彰，其法失传，无怪乎其不敢用也。夫不知其妙，
而不敢用，犹之可也；若竟委之曰古法不可用，则不可也。盖邪之在上者，非吐不愈。若
如俗工所云，使病者畏不敢服，因循生变，致轻者重，重者死，夫谁之咎与？抑知汗、吐、
下三法，用之诚当，其证无不立时取效。后之业医者，又安可只言汗下两法，而置吐法
于不用，致使古法沦亡也耶！
【集注】程知曰∶此言服栀子亦有禁忌也。病患旧微溏，里虚也，又服苦寒，则不能上
涌，而反下泄，故禁之。
张志聪曰∶此言栀子而不言豉者，申明栀子之苦能下泄，故病患旧微溏，不可与服之也。
太阳病，脉浮紧，无汗，发热，身疼痛，八九日不解，表证仍在，此当发其汗。服药
已，微除，其人发烦目瞑；剧者，必衄，衄乃解。所以然者，阳气重故也。麻黄汤主之。
【按】张兼善曰∶“麻黄汤主之”五字，不当在阳气重之下，岂有衄乃解之后，而用麻
黄汤之理乎？其说甚是。况服药已之上，并无所服何药之文，宜将此五字移于其上始合。
【注】太阳病，脉浮紧无汗，发热身疼痛，八九日不解，谓伤寒表证仍在，当以麻黄汤
发其汗也。服药已，微除者，谓已发汗，邪虽微除，犹未尽除也，仍当汗之，若因循失
汗，则阳邪久郁营中，不得宣泄，致热并于阳而发烦，热郁于阴而目瞑。剧者，谓热极
也。热极于营，势必逼脉中之血妄行为衄，衄则热随血去而解矣。所以然者，阳气重故也。
【集注】程知曰∶脉见浮紧，表证仍在，虽八九日，仍当以麻黄汗解，服汤已，其病
微除，至于烦瞑剧衄，乃热郁于营，阳气重盛，表散之药，与之相抟而然。然至于逼血
上衄，则热随血解矣。此言发汗当主以麻黄汤，非衄解之后，仍用麻黄汤也。
张璐曰∶服药已微除，复发烦者，余邪未尽也。目瞑烦剧者，热盛于经也，故迫血
妄行而为衄，衄则余热随血而解也。以汗后复衄，故为阳气重也。或言汗后复衄，而热
邪仍未尽，重以麻黄汤散其未尽之邪，非也。若果邪热不尽，则“衄乃解”三字从何着落？
太阳病，脉浮紧，发热身无汗，自衄者愈。
【注】太阳病脉浮紧，发热无汗，此伤寒脉证也，当发其汗。若当汗不汗，则为失汗。
失汗则寒闭于卫，热郁于营，初若不从卫分汗出而解，久则必从营分衄血而愈也。故太
阳病凡从外解者，惟汗与衄二者而已。今既失汗于营，则营中血热妄行，自衄，热随衄
解，必自愈矣。
【集注】方有执曰∶此承上条复以其证之较轻者言，以见亦有不治而自愈者，所以晓
人勿妄治，以致误之意。太阳病脉浮紧，发热身无汗，与上条同，而无疼痛，则比之上
条较轻可知矣。所以不待攻治，得衄自愈也。汗本血之液，北人谓衄为“红汗”，即此说耳。
程知曰∶言得衄虽无汗必自愈也。人之伤于寒而为热者，得衄发越故愈。
张璐曰∶衄血成流，则邪热随血而散。夺血则无汗也。设不自衄，当以麻黄汤发之。发
之而邪解，则不衄矣；发之而余邪未尽，必仍衄而解。
伤寒脉浮紧，不发汗，因致衄者，麻黄汤主之。
【注】此承上条以出其治也。伤寒脉浮紧，法当发汗，若不发汗，是失汗也。失汗则热
郁于营，因而致衄者，宜麻黄汤主之。若能于未衄之先，早用麻黄汤汗之，汗出则解，必
不致衄。其或如上条之自衄而解，亦无须乎药也。
【按】凡伤寒初起，但不甚恶寒，便知夹热后多得衄。其热多寒少者，则热随衄去，继
而汗出，表与热均解也。其热少寒多者，纵热随衄去，继必不汗出，表仍不解。诚能用
青龙、麻黄汤于未衄之先发之，则汗衄两解矣。若已经衄后而汗不出，表不解，即用麻
桂之药，以和荣卫，亦须少兼芩、连、犀、地清阴凉血之品佐之，以护及阴血可也。然大
衄之后，麻黄、青龙不可轻用，若用之不当，则犯衄家不可汗之戒矣。
【集注】《活人书》云∶衄后脉浮者，宜麻黄汤；衄后脉微者，不可行麻黄汤，宜黄
芩芍药汤。盖衄后脉浮，表未解也；脉微，表已解也。于此见仲景用麻黄汤于衄后之大旨。
方有执曰∶伤寒脉浮紧者，寒多风少之谓也。上二条皆风多寒少，前条以服药已微
除，汗发不透而致衄，上条以较轻得自衄，此以寒多不发汗而致衄，三条之所以辨差分也。
盖寒多，则于法当发汗，而不发汗，热郁血乱，所以衄也。衄则阳邪之风散。麻黄汤者，
发其尚未散之寒也。
程知曰∶此言寒邪不发之衄，仍宜温散也。不发汗而致衄，是入荣之寒，不得泄越
而然也。寒不尽则衄不止，故仍用麻黄，不必待其衄也。此与上条有寒热之别。
程应旄曰∶大抵伤寒见衄者，由其荣分素热，一被寒闭，荣不受遏，从而上升矣。
伤寒不大便六七日，头痛有热者，与承气汤。其小便清者，知不在里，仍在表也，当
须发汗。若头痛者，必衄，宜桂枝汤。
【按】若头痛之“若”字，当是“苦”字。苦头痛，方为必衄之证。若是“若”字，则凡头痛皆能致衄矣。
【注】伤寒不大便六七日，里已实，似可下也。头痛热未已，表未罢，可汗也。然欲
下则有头痛发热之表，欲汗则有不大便之里，值此两难之时，惟当以小便辨之。其小便浑
赤，是热已在里，即有头痛发热之表，亦属里热，与承气汤下之可也；若小便清白，是
热尚在表也，即有不大便之里，仍属表邪，宜以桂枝汤解之。然伤寒头痛不论表里，若苦
头痛者，是热剧于荣，故必作衄，衄则荣热解矣。方其未衄之时，无汗宜麻黄汤，有汗
宜桂枝汤汗之，则不衄而解矣。
【集注】汪琥曰∶头痛不已者，为风寒之邪上壅，热甚于经，势必致衄，须乘其未衄
之时，酌用麻黄汤或桂枝汤以汗解之，而验小便，实为仲景妙法。
魏荔彤曰∶此条之衄，乃意料之辞，非已见之证也。
太阳病不解，热结膀胱，其人如狂，血自下，下者愈。其外不解者，尚未可攻，当
先解其外∶外解已，但少腹急结者，乃可攻之，宜桃核承气汤。
【注】太阳病不解，当传阳明，若不传阳明而邪热随经，瘀于膀胱荣分，则其人必如
狂。如狂者，瘀热内结，心为所扰，有似于狂也。当此之时，血若自下，下者自愈；若
不自下，或下而未尽，则热与瘀血，下蓄膀胱，必少腹急结也。设外证不解者，尚未可
攻，当先以麻黄汤解外；外解已，但少腹急结痛者，乃可攻之，宜桃核承气汤，即调胃
承气加桃核，所以攻热逐血也。盖邪随太阳经来，故又加桂枝以解外而通荣也。先食服
者，谓空腹则药力下行捷也。
【按】太阳病不解，不传阳明，邪热随经入里，谓之犯本。犯本者，谓犯膀胱之腑也。
膀胱腑之卫为气分，膀胱腑之荣为血分。热入而犯气分，气化不行，热与水结者，谓之
犯卫分之里，五苓散证也；热入而犯血分，血蓄不行，热与血结者，谓之犯荣分之里，核
核承气汤证也。二者虽皆为犯本之证，二方虽皆治犯本之药，而一从前利，一从后攻，水
与血，主治各不同也。
【集注】喻昌曰∶桃核承气汤用桂枝解外，与大柴胡汤解外相似，益见太阳随经之热，非桂枝不解也。
程知曰∶太阳病不解，随经入腑，故热结膀胱。其人如狂者，瘀热内结，心不安宁，
有似于狂也。若血自下，下则热随瘀解矣。然必外证已解，乃可直攻少腹急结之邪，于调
胃承气中加桃核者，欲其直达血所也；加桂枝以通血脉，兼以解太阳随经之邪耳！
汪琥曰∶膀胱乃小腹中之物。膀胱热结，在卫则尿不利，在荣则血不流，故作急结之
形，为下焦蓄血之证谛也。所以用桃核承气汤，乃攻下焦蓄血，治少腹急结之药，实非
通膀胱热结之药也。
桃核承气汤方
桃核（去皮尖，五十个） 桂枝（三两） 大黄（四两） 芒硝（二两） 甘草（炙，二两）
上五味，以水七升，煮取二升半，去滓，纳芒硝，更上火微沸，下火，先食温服五合，日三服，当微利。
太阳病六七日，表证仍在，脉微而沉，反不结胸，其人发狂者，以热在下焦，少腹当
硬满。而小便自利者，下血乃愈。所以然者，以太阳随经瘀热在里故也，宜下之以抵当汤。
【注】太阳病六七日，表证仍在者，脉当浮大。若脉微而沉，则是外有太阳之表而内
见少阴之脉，乃麻黄附子细辛汤证也。或邪入里，则为结胸、脏结之证。今既无太阳、少
阴兼病之证，而又不作结胸、脏结之病，但其人发狂，是知太阳随经瘀热，不结于上焦
之卫分，而结于下焦之营分也，故少腹当硬满。而小便自利者，是血蓄于下焦也。下血
乃愈者，言不自下者，须当下之，非抵当汤不足以逐血下瘀，乃至当不易之法也。
【集注】喻昌曰∶蓄血而至于发狂，则热势攻心，桃核承气不足以动其血，桂枝不足
以散其邪，非用单刀直入之将，必不能斩关取胜也，故名其汤为抵当。抵者，至也。乃
至当不易之良法也。
张璐曰∶邪结于胸，则用陷胸以涤饮；邪结少腹，则用抵当以逐血。
程知曰∶脉微而沉，邪结于里也。表证仍在，而反不结胸，太阳随经之邪，不结上
焦，而结下焦。小便自利，血病而气不病也。
程应旄曰∶热结于气分，则为尿涩；热结于血分，则为蓄血。血既蓄而不行，自非大下其血不愈。
抵当汤方
于是出现心烦；邪气侵入腹中，在下部则导致腹部胀满；两种邪气逼迫聚集在胸腹部，所以出现心烦和腹部胀满。使用这一种涌吐、一种泻下的方法，也是表里双解的治法。
栀子厚朴汤方
栀子（掰开，十四枚） 厚朴（姜制，四两） 枳实（去掉瓤，炒，四两）
以上三味药，用水三升半，煮取一升半，去渣，分三次服用，温服一次，如果引起呕吐，就停止后面的服药。
伤寒病，医生用丸药猛烈攻下，身体发热不退，轻微心烦的，用栀子干姜汤主治。
【按语】栀子干姜汤应当是栀子豉汤，栀子豉汤应当是栀子干姜汤，绝没有烦热用干姜、结痛用香豉的道理。
【注释】伤寒表邪未解，医生用丸药猛烈攻下，不至于形成结胸痞硬，还算没有变成坏证。然而身体发热不退，说明表邪仍未解除；轻微心烦，是热邪陷入胸中。表热停留在胸中的，既轻又微，所以不可用下法，也不可用清法，只适宜用栀子豉汤，微微涌吐其热，那么微烦就可以消除，而吐法中有发散的意思，身体发热也可以解除。
【集注】汪琥说：误用丸药攻下，邪热不除，所以身体发热不退，邪气乘虚客居在胸中，所以导致轻微心烦。
栀子干姜汤方
栀子（掰开，十四枚） 干姜（二两）
上两味药，用水三升半，煮取一升半，去渣，分两次服用，温服一次，如果引起呕吐，就停止后面的服药。
【按语】此方中的干姜应当是香豉。其余义理详见前文经文下的正误文字内。
伤寒五六天，经过猛烈攻下之后，身体发热不退，心中感觉郁结疼痛的，病势尚未解除，用栀子豉汤主治。
【按语】此方中的香豉应当是干姜。其余义理也详见前文经文下的正误文字内。
【注释】伤寒五六天，是邪气在里的时期。猛烈攻下之后，如果身体发热退去，心胸调和，这是将要解除的表现。现在身体发热不退，说明邪气仍在表。心中郁结疼痛是因为过度攻下导致里寒，所以说病势未解。但这种表热里寒的证候，想要温补里寒，又会妨碍表热的解除；想要解除表热，又会妨碍里寒的治疗，所以只用栀子的寒性、干姜的热性，同时使用并涌吐之，那么解表和温里两方面都兼顾到了。难道还有身体发热、郁结疼痛不能完全消除的吗！这是张仲景设立的两难治法，其精妙之处如此，其余的可以类推。
【集注】王肯堂说：“身体发热不退”这四个字值得玩味。结胸证身体不发热，知道热不在表；现在身体发热不退，只适宜用涌吐法而已。
程应旄说：疼痛称为“结”，很像结胸，但结胸证身体没有大热，知道热已经完全归于里成为实邪。这里则是身体发热不退，所结的是因为攻下而结，客邪仍然在表，所以说病势未解。
凡是使用栀子汤，病人平时大便稀溏的，不可以服用。
【注释】如果在汗、吐、下之后，出现懊恼、少气、呕逆、烦满、心中郁结疼痛等症状，都适宜用栀子等汤剂涌吐。因为邪气留恋在胸胃之间，或与热、或与虚、或与饮、或与气、或与寒相结而不结实，那么病势向上，即经书所说的“在上者因而越之”的意思。如果没有经过汗、吐、下，而有这些症状，就是实邪，不是栀子汤这种轻剂所能治疗的，又应当用瓜蒂散这种重剂主治。如果病人平时大便稀溏的，虽然有这些症状，但因为里气久虚，不可以服用；如果服用它，即使客邪全部去除，正气也难以支撑，因为病势向下，涌吐必然产生其他变证。本草书不说栀子为吐药，张仲景用它作为吐药，为什么呢？栀子本来不是吐药，因为它味苦能引起呕吐，所以用它来涌吐热邪。
【按语】吐药不止栀子一种，各种药物都可以用来催吐，只要确切审察胸胃的邪气，是寒还是热？是食积还是水饮？是痰还是气？因什么阻滞，使胸胃阳气不能伸展？于是用适当的药物来涌吐，自然可以痊愈。如果想吐寒邪，就用干姜、桂皮之类；想吐热邪，就用栀子、苦茶之类；想吐食积，就用平胃散加食盐之类；想吐水饮，就用五苓散加生姜之类；想吐痰涎，就用橘皮之类；想吐气流滞气，就用枳实、厚朴之类。但是形体气虚弱的，药量宜少，仍当佐以补中益气等升提药物为妥；形体气壮的，药量宜多，更佐以瓜蒂、藜芦等猛药效果更好。凡是煎煮吐药汤剂及调服散剂，或用酸米汤，或用白开水，或用稀米粥，须准备十余盅，让病人顿服一盅，立即用手指探喉催吐，再服一盅，也随即用手指探喉催吐，再服再吐，以顺畅快速呕吐为标准，那么头额身上自然会有微汗，所有病症减轻，就是中病，不必服完剩余的药物。如果过度催吐，即使病邪全部清除，恐怕会损伤胸中阳气。近世的医生，认为吐法是古法不可用，已经很久了。都是因为仲景之道不显扬，其法失传，难怪他们不敢用。不知道它的妙处而不敢用，还可以原谅；竟然推委说古法不可用，就不行了。大概邪气在上部的，不用吐法不能痊愈。如果像庸医所说，使病人畏惧不敢服用，因循拖延产生变故，致使轻病转重，重病致死，这怪谁呢？况且汗、吐、下三法，用得恰当，病症无不立即见效。后世的行医者，怎么可以只说汗、下两法，而把吐法放在一边不用，致使古法沦亡呢！
【集注】程知说：这是说服用栀子也有禁忌。病人平时大便稀溏，是里虚，又服用苦寒药，就不能向上涌吐，反而向下泄利，所以禁止服用。
张志聪说：这里说栀子而不说豉，是申明栀子的苦味能向下泄利，所以病人平时大便稀溏的，不可以服用。
太阳病，脉浮紧，无汗，发热，身体疼痛，过了八九天病不解，表证仍在，这应当发汗。服药后，症状稍微减轻，这个人感到心烦、眼睛昏花；严重的，一定会流鼻血，流鼻血后病才解除。之所以这样，是因为阳气郁闭太重的缘故。用麻黄汤主治。
【按语】张兼善说：“麻黄汤主之”五个字，不应当在“阳气重故也”之下，哪有流鼻血病解之后，还用麻黄汤的道理呢？他的说法很正确。况且在“服药已”之上，并没有说服了什么药的记载，应该将这五个字移到上面才符合逻辑。
【注释】太阳病，脉浮紧无汗，发热身体疼痛，过了八九天病不解，是说伤寒表证仍在，应当用麻黄汤发汗。服药后，症状稍微减轻，是说已经发汗，邪气虽然稍微减轻，但没有完全解除，仍然应当发汗，如果因循延误没有发汗，那么阳邪长久郁闭在营分中，不得宣泄，导致热并入阳分而发烦，热郁于阴分而眼睛昏花。严重的，是说热极。热极在营分，势必逼迫脉中的血液妄行而流鼻血，流鼻血则热随血去而解除。之所以这样，是因为阳气郁闭太重的缘故。
【集注】程知说：脉象见浮紧，表证仍在，虽然过了八九天，仍应当用麻黄汤发汗解表，服药后，病情稍微减轻，至于烦闷昏花严重到流鼻血，乃是热郁于营分，阳气重盛，表散的药物，与之相搏结所致。然而到了逼迫血液上溢流鼻血，热就随血而解了。这是说发汗应当以麻黄汤为主，不是在流鼻血病解之后，再用麻黄汤。
张璐说：服药后症状稍微减轻，又复发烦的，是余邪未尽。眼睛昏花、烦躁严重的，是热盛于经脉，所以逼迫血液妄行而流鼻血，流鼻血则余热随血而解。因为发汗后又流鼻血，所以称为阳气重。有人说发汗后又流鼻血，而热邪仍未完全清除，再用麻黄汤发散未尽的邪气，这是不对的。如果果真是邪热不尽，那么“流鼻血后病解”这三个字从何落实？
太阳病，脉浮紧，发热身体无汗，自己流鼻血的就会痊愈。
【注释】太阳病脉浮紧，发热无汗，这是伤寒的脉证，应当发汗。如果该发汗而不发汗，就是失治。失治则寒邪闭塞卫分，热邪郁闭营分，起初如果不从卫分发汗而解，久了必定会从营分流鼻血而痊愈。所以太阳病凡是从外解除的，只有汗法和衄血法这两种而已。现在既然在营分失治，那么营中血热妄行，自己流鼻血，热随衄血而解，必定自愈。
【集注】方有执说：这是承接上一条，用较轻的证候来说明，以此显示也有不治而自愈的情况，以此告诫人们不要乱治，以致误人。太阳病脉浮紧，发热身体无汗，与上一条相同，但没有疼痛，则比上一条较轻可知。所以不需要攻治，得衄血即可自愈。汗本是血的津液，北方人称流鼻血为“红汗”，就是这个说法。
程知说：意思是即使没有汗，只要流鼻血必定自愈。人受寒邪侵袭而发热，得衄血发散就能痊愈。
张璐说：流鼻血成血流，则邪热随血而散。夺血则无汗。假如自己不流鼻血，应当用麻黄汤发汗。发汗后邪气解除，就不流鼻血了；发汗后余邪未尽，必定仍要流鼻血才能解除。
伤寒脉浮紧，不发汗，因此导致流鼻血的，用麻黄汤主治。
【注释】这是承接上一条来说明治疗方法。伤寒脉浮紧，依法应当发汗，如果不发汗，就是失治。失治则热邪郁闭在营分，因而导致流鼻血的，适宜用麻黄汤主治。如果能在不流鼻血之前，早用麻黄汤发汗，汗出则病解，必定不会导致流鼻血。或者像上一条那样自己流鼻血而病解，也不需要用药。
【按语】凡是伤寒初起，只要不是很怕冷，就知道夹有热邪，后来大多会流鼻血。热多寒少的，热随鼻血而去，继而出汗，表邪与热邪均解除。热少寒多的，纵然热随鼻血而去，继而必定不出汗，表邪仍不解。诚然能在不流鼻血之前用青龙汤、麻黄汤发散，那么汗法和衄血法两解。如果已经流鼻血后而不出汗，表邪不解，即用麻黄、桂枝的药物，来调和营卫，也必须少量兼用黄芩、黄连、犀角、地黄等清热凉血的药物辅助，以保护阴血。但是大量流鼻血之后，麻黄汤、青龙汤不可轻率使用，如果使用不当，就犯了“衄家不可发汗”的戒律。
【集注】《活人书》说：流鼻血后脉浮的，适宜用麻黄汤；流鼻血后脉微的，不可用麻黄汤，适宜用黄芩芍药汤。大概流鼻血后脉浮，说明表邪未解；脉微，说明表邪已解。从这里可以看出张仲景在流鼻血后用麻黄汤的大旨。
方有执说：伤寒脉浮紧，是说寒多风少。上两条都是风多寒少，前一条因为服药后症状稍微减轻，汗发不透而导致流鼻血，上一条因为证候较轻而自衄，这一条因为寒多不发汗而导致流鼻血，三条之所以辨别区分在于此。大概寒多，依法应当发汗，而不发汗，热郁血乱，所以流鼻血。流鼻血则阳邪之风散。麻黄汤，是发散那尚未散的寒邪。
程知说：这是说寒邪不发汗导致的流鼻血，仍适宜用温散法。不发汗而致流鼻血，是入营分的寒邪，不得泄越所致。寒邪不尽则流鼻血不止，所以仍用麻黄，不必等到流鼻血。这与上一条有寒热之别。
程应旄说：大致伤寒见到流鼻血的，是由其营分素来有热，一旦被寒邪闭塞，营分承受不住遏制，从而上升所致。
伤寒不大便六七天，头痛且有发热的，给承气汤。如果小便清长的，知道病不在里，仍在表，应当须发汗。如果头痛剧烈的，一定会流鼻血，适宜用桂枝汤。
【按语】如果头痛的“若”字，应当是“苦”字。剧烈头痛，才是必流鼻血的证候。如果是“若”字，那么凡是头痛都能导致流鼻血了。
【注释】伤寒不大便六七天，里气已实，似乎可以用下法。头痛热未止，表邪未罢，可以用汗法。然而想用下法则有头痛发热的表证，想用汗法又有不大便的里证，值此两难之时，只应当以小便利否来辨别。如果小便浑浊赤色，是热已在里，即使有头痛发热的表证，也属于里热，给承气汤下之即可；如果小便清白，是热尚在表，即使有不大便的里证，仍属表邪，适宜用桂枝汤解之。然而伤寒头痛不论表里，如果剧烈头痛的，是热邪剧烈于营分，所以必定流鼻血，流鼻血则营热解除。在其未流鼻血之时，无汗适宜用麻黄汤，有汗适宜用桂枝汤发汗，那么不流鼻血也能解除。
【集注】汪琥说：头痛不已的，是风寒邪气上壅，热甚于经脉，势必导致流鼻血，须趁其未流鼻血之时，斟酌用麻黄汤或桂枝汤发汗解表，而验小便，确实是张仲景的妙法。
魏荔彤说：这一条的流鼻血，是推测之辞，不是已见的证候。
太阳病不解，热邪结聚在膀胱，病人神志如狂，血液自行排出，排出的就痊愈。如果外部表证未解，还不可以攻里，应当先解表；表证解除后，只是小腹部急迫结痛的，才可以攻里，适宜用桃核承气汤。
【注释】太阳病不解，应当传入阳明，如果不传入阳明而邪热随经脉深入，瘀滞在膀胱营分，那么病人必定神志如狂。如狂，是瘀热内结，心神被扰乱，有点像发狂的样子。在这个时候，如果血液自行排出，排出的就自愈；如果不自行排出，或者排出但不彻底，那么热与瘀血下蓄在膀胱，必定小腹部急迫结痛。假设外部证候未解，还不可以攻里，应当先用麻黄汤解表；表证解除后，只是小腹部急迫结痛的，才可以攻里，适宜用桃核承气汤，即调胃承气汤加桃仁，所以能攻热逐血。大概邪气随太阳经而来，所以又加桂枝以解表通营。饭前服用，是说空腹时药力下行迅速。
【按语】太阳病不解，不传入阳明，邪热随经入里，称为犯本。犯本，是指侵犯膀胱之腑。膀胱腑的卫分为气分，膀胱腑的营分为血分。热邪侵入侵犯气分，气化不行，热与水结，称为犯卫分之里，是五苓散证；热邪侵入侵犯血分，血蓄不行，热与血结，称为犯营分之里，是桃核承气汤证。这两者虽然都是犯本的证候，两个方子虽然都是治犯本的药物，但一个从前阴利水，一个从后阴攻下，水和血，主治各不相同。
【集注】喻昌说：桃核承气汤用桂枝解表，与大柴胡汤解表相似，更加可见太阳随经的热邪，非桂枝不能解除。
程知说：太阳病不解，随经入腑，所以热结膀胱。病人神志如狂，是瘀热内结，心神不安宁，有点像发狂。如果血液自行排出，排出则热随瘀解。然而必须表证已解，才可直攻少腹急结之邪，在调胃承气汤中加入桃仁，是想让它直达血所；加入桂枝以通血脉，兼以解除太阳随经之邪。
汪琥说：膀胱是小腹中的脏器。膀胱热结，在卫分则尿不利，在营分则血不流，所以呈现急结的形状，是下焦蓄血的证候确凿无疑。所以用桃核承气汤，是攻下焦蓄血、治疗少腹急结的药，实在不是通利膀胱热结的药。
桃核承气汤方
桃仁（去皮尖，五十个） 桂枝（三两） 大黄（四两） 芒硝（二两） 甘草（炙，二两）
上五味药，用水七升，煮取二升半，去渣，纳入芒硝，再次上火微沸，熄火，饭前温服五合，每日三次，应当轻微通利。
太阳病六七天，表证仍在，脉象微而沉，反而没有形成结胸，病人发狂的，是因为热邪在下焦，小腹部应当硬满。如果小便自利的，下血才能痊愈。之所以这样，是因为太阳随经的瘀热在里的缘故，适宜用下法，用抵当汤。
【注释】太阳病六七天，表证仍在，脉应当浮大。如果脉微而沉，则是外有太阳之表而内见少阴之脉，是麻黄附子细辛汤证。或者邪气入里，则为结胸、脏结之证。现在既没有太阳、少阴兼病的证候，又不形成结胸、脏结的病，只是病人发狂，是知道太阳随经的瘀热，不结于上焦的卫分，而结于下焦的营分，所以小腹部应当硬满。如果小便自利的，是血蓄在下焦。下血才能痊愈，是说如果不自行排出，必须用下法，不是抵当汤不足以逐血下瘀，这是最恰当不变的方法。
【集注】喻昌说：蓄血到了发狂的程度，则热势攻心，桃核承气汤不足以动其血，桂枝不足以散其邪，非用单刀直入的将领，一定不能斩关取胜，所以命名这个汤为抵当。抵，是至的意思。是最恰当不变的良法。
张璐说：邪结于胸，则用陷胸汤涤荡水饮；邪结少腹，则用抵当汤逐血。
程知说：脉微而沉，邪结于里。表证仍在，反而不结胸，太阳随经的邪气，不结上焦，而结下焦。小便自利，是血病而气不病。
程应旄说：热结于气分，则小便涩滞；热结于血分，则蓄血。血既蓄积而不行，自然非大力攻下其血不能痊愈。
抵当汤方
Then, mental restlessness (Fanzao) occurs; when the pathogenic factor enters the abdomen, fullness in the lower abdomen (Fuman) results from its presence in the lower part. With both pathogens pressing upon and gathering in the chest and abdomen, mental restlessness and abdominal fullness occur. Employing one method of inducing vomiting and one of purging constitutes a simultaneous release of both exterior and interior syndromes.
Formula for Gardenia and Magnolia Bark Decoction (Zhizi Houpo Tang)
Gardeniae Fructus (broken open, 14 pieces), Magnoliae Officinalis Cortex (processed with ginger juice, 4 liang), Immature Bitter Orange (pulp removed, stir-fried, 4 liang).
The above three herbs are boiled in 3.5 sheng of water to obtain 1.5 sheng. The dregs are removed, and the decoction is divided into three doses. Take one dose warm. If vomiting occurs, stop taking subsequent doses.
In cold damage (Shanghan), if a physician uses pill medicines to cause severe purging, and body heat persists with slight mental restlessness, Gardenia and Dried Ginger Decoction (Zhizi Ganjiang Tang) is indicated.
[Commentary] "Gardenia and Dried Ginger Decoction" should be Gardenia and Fermented Soybean Decoction (Zhizi Chi Tang), and "Gardenia and Fermented Soybean Decoction" should be Gardenia and Dried Ginger Decoction. It is inconceivable that dried ginger would be used for irritability and heat, or fermented soybeans for knotted pain.
[Annotation] In cold damage, if the exterior pathogen is unresolved, and a physician causes severe purging with pill medicines, without leading to chest oppression-hardness (Jie Xiong) or epigastric fullness-stiffness (Pi Ying), it has not yet become an adverse condition. However, persistent body heat indicates the exterior syndrome remains unrelieved. Slight mental restlessness signifies heat sinking into the chest. For exterior heat lingering in the chest, which is mild and slight, neither purging nor clearing is appropriate. Instead, Gardenia and Fermented Soybean Decoction should be used to slightly induce vomiting to vent the heat, thereby resolving the slight mental restlessness. Since the vomiting method contains the intent of dispersal, body heat can also be resolved.
[Collected Notes] Wang Hu said: Mistaken purging with pills fails to eliminate pathogenic heat, hence body heat persists. Pathogenic qi takes advantage of deficiency to lodge in the chest, causing slight mental restlessness.
Formula for Gardenia and Dried Ginger Decoction (Zhizi Ganjiang Tang)
Gardeniae Fructus (broken open, 14 pieces), Zingiberis Rhizoma (Dried Ginger, 2 liang).
The above two herbs are boiled in 3.5 sheng of water to obtain 1.5 sheng. The dregs are removed, and the decoction is divided into two doses. Take one dose warm. If vomiting occurs, stop taking subsequent doses.
[Commentary] The dried ginger in this formula should be Fermented Soybean (Xiangchi). The rationale is detailed in the correction text below the previous scripture passage.
After five or six days of cold damage, following severe purging, if body heat persists and there is a knotted pain in the heart region, the disease is not yet resolving. Gardenia and Fermented Soybean Decoction (Zhizi Chi Tang) is indicated.
[Commentary] The fermented soybean in this formula should be dried ginger. The rationale is also detailed in the correction text below the previous scripture passage.
[Annotation] Five or six days into cold damage is when the pathogen is in the interior. After severe purging, if body heat subsides and the heart and chest feel harmonious, this indicates impending resolution. Now, since body heat persists, the pathogen remains at the exterior. Knotted pain in the heart region results from excessive purging causing interior cold; thus, it is said the disease is not yet resolving. In this pattern of exterior heat and interior cold, warming the interior would hinder resolving the exterior heat, while resolving the exterior would hinder treating the interior cold. Therefore, using the cold nature of gardenia and the hot nature of dried ginger together to induce vomiting allows for both resolving the exterior and warming the interior. Would body heat and knotted pain not then be completely resolved? This illustrates Zhang Zhongjing's clever method for treating difficult dual patterns; other cases can be inferred similarly.
[Collected Notes] Wang Kentang said: The phrase "body heat persists" warrants careful consideration. In chest oppression-hardness, there is no fever, indicating heat is not at the exterior. Here, since body heat persists, only the vomiting method is suitable.
Cheng Yingmao said: Pain described as "knotted" resembles chest oppression-hardness, but chest oppression-hardness lacks significant fever, indicating heat has fully entered the interior as excess pathogen. Here, persistent body heat means the knotting resulted from purging, and the external pathogen still resides at the exterior; thus, it is said the disease is not yet resolving.
Whenever using Gardenia Decoctions, patients with a history of loose stools should not be given them.
[Annotation] After sweating, vomiting, or purging, if symptoms such as vexation, shortness of breath, retching, irritability, fullness, and knotted pain in the heart region occur, they are all suitable for treatment with gardenia-type decoctions to induce vomiting. This is because the pathogen lingers between the chest and stomach, binding with heat, deficiency, fluid retention, qi stagnation, or cold without forming solid accumulation. The pathological trend is upward, consistent with the classic principle: "For pathogens located above, use the method of evacuating upwards." If these symptoms exist without prior sweating, vomiting, or purging, it indicates an excess pathogen, which cannot be treated by the mild action of gardenia decoctions; instead, heavy agents like Melon Twig Powder (Gua Di San) should be used. If a patient has a history of chronic loose stools, even if these symptoms are present, they should not be administered due to long-standing interior deficiency. Administering them might expel the pathogenic factors but would severely impair healthy qi, as the pathological trend is downward, and inducing vomiting would likely cause further complications. Although Materia Medica does not list gardenia as an emetic, Zhang Zhongjing used it as such. Why? Gardenia is not inherently an emetic, but its bitter taste can induce vomiting; thus, it is used to vent heat.
[Commentary] Emetics are not limited to gardenia; various herbs can serve this purpose. One must accurately diagnose whether the pathogen in the chest and stomach is cold or heat, food stagnation or fluid retention, phlegm or qi stagnation, and identify the cause of obstruction preventing the extension of chest-stomach yang qi. Then, using the appropriate herb to induce vomiting will lead to recovery. To vomit cold, use dried ginger and cinnamon bark; to vomit heat, use gardenia and bitter tea; to vomit food stagnation, use Pingwei San with salt; to vomit fluid retention, use Wuling San with fresh ginger; to vomit phlegm and thin saliva, use tangerine peel; to vomit qi stagnation, use immaturity bitter orange and magnolia bark. For patients with weak constitution, the dosage should be small, supplemented with uplifting herbs like those in Buzhong Yiqi Tang. For those with strong constitution, the dosage may be larger, supplemented with potent emetics like melon twig or veratrum for better effect. When preparing emetic decoctions or powders, use sour rice soup, plain water, or thin rice gruel. Prepare over ten cups. Have the patient drink one cup rapidly, then stimulate the throat with a finger to induce vomiting. Drink another cup and repeat until vomiting is smooth and rapid. Mild sweating on the head, forehead, and body will naturally follow. As symptoms alleviate, the treatment is effective; there is no need to consume the remaining medicine. Over-vomiting may damage chest yang qi even if the pathogen is eliminated. Modern physicians have long dismissed vomiting as an obsolete ancient method. This is because Zhang Zhongjing's principles have faded and his methods lost, explaining their reluctance to use them. Not knowing its efficacy and hesitating to use it is forgivable; but dismissing it as unusable is unacceptable. Pathogens located above cannot be cured without vomiting. If lay practitioners discourage patients from taking emetics due to fear, leading to delays and complications, turning mild cases severe and severe cases fatal, who bears the blame? Moreover, when sweating, vomiting, and purging methods are applied correctly, effects are immediate. How can future physicians discuss only sweating and purging while neglecting vomiting, allowing ancient methods to perish!
[Collected Notes] Cheng Zhi said: This states contraindications for gardenia. Patients with chronic loose stools have interior deficiency; administering bitter-cold herbs prevents upward vomiting and causes downward purgation, hence it is prohibited.
Zhang Zhicong said: Mentioning gardenia but not fermented soybean clarifies that gardenia's bitterness causes downward purgation; thus, it is contraindicated for patients with chronic loose stools.
In Taiyang disease, with floating-tight pulse, absence of sweating, fever, and body ache persisting for eight or nine days without resolution, if the exterior syndrome remains, sweating should be induced. After taking medicine, symptoms may slightly subside. The patient may experience mental restlessness and eye closure/dizziness; in severe cases, nasal bleeding (Xu) will occur, after which the disease resolves. This is due to excessive yang qi constraint. Ephedra Decoction (Mahuang Tang) is indicated.
[Commentary] Zhang Jianshan stated: The five characters "Ephedra Decoction is indicated" should not appear after "due to excessive yang qi constraint." How could Ephedra Decoction be used after resolution via nasal bleeding? His view is correct. Furthermore, preceding "after taking medicine," there is no mention of what medicine was taken. These five characters should be moved earlier to fit logically.
[Annotation] In Taiyang disease, with floating-tight pulse, no sweating, fever, and body ache persisting for eight or nine days without resolution, the exterior syndrome of cold damage remains, and Ephedra Decoction (Mahuang Tang) should be used to induce sweating. "Slightly subsiding after taking medicine" means sweating has occurred, pathogenic factors have slightly decreased, but not completely. Sweating should still be attempted. If delayed, yang pathogen remains constrained in the Ying level, unable to vent. Heat merges with Yang causing mental restlessness; heat constrains in Yin causing eye closure/dizziness. "Severe" means extreme heat. Extreme heat in the Ying level forces blood in vessels to flow recklessly, causing nasal bleeding. Nasal bleeding allows heat to exit with blood, resolving the disease. This occurs due to excessive yang constraint.
[Collected Notes] Cheng Zhi said: Floating-tight pulse indicates remaining exterior syndrome. Even after eight or nine days, Ephedra Decoction should be used for sweating. After administration, symptoms slightly subside. Vexation, dizziness, and severe nasal bleeding result from heat constrained in Ying and excessive yang qi interacting with dispersing herbs. However, once nasal bleeding occurs, heat resolves with blood. This emphasizes using Ephedra Decoction primarily for inducing sweating, not for use after resolution via nasal bleeding.
Zhang Lu said: Symptoms slightly subsiding after medication, followed by renewed vexation, indicates residual pathogen remains. Severe dizziness and vexation indicate heat abundant in meridians, forcing blood recklessly to cause nasal bleeding. Residual heat resolves with blood. Because nasal bleeding follows sweating, it is termed "excessive yang qi." Some argue that if heat remains after sweating and nasal bleeding, Ephedra Decoction should disperse remaining pathogen. This is incorrect. If heat were truly incomplete, how would the phrase "resolves after nasal bleeding" apply?
In Taiyang disease, with floating-tight pulse, fever, and absence of sweating, spontaneous nasal bleeding leads to recovery.
[Annotation] Floating-tight pulse, fever, and no sweating in Taiyang disease constitute cold damage signs, requiring sweating. Failure to sweat when indicated is a missed opportunity. Missed sweating causes cold to close the Wei level and heat to constrain in the Ying level. Initially, if resolution does not occur via Wei-level sweating, prolonged constraint will eventually lead to resolution via Ying-level nasal bleeding. Thus, in Taiyang disease, external resolution occurs only through sweating or nasal bleeding. Having missed sweating in the Ying level, blood heat in the Ying flows recklessly, causing spontaneous nasal bleeding. Heat resolves with nasal bleeding, leading to self-recovery.
[Collected Notes] Fang Youzhi said: This continues from the previous clause, discussing milder symptoms to show cases of spontaneous recovery without treatment, warning against erroneous interventions. Taiyang disease with floating-tight pulse, fever, and no sweating matches the previous clause but lacks body ache, indicating milder severity. Thus, treatment is unnecessary; spontaneous nasal bleeding leads to recovery. Sweat is the fluid of blood; northerners call nasal bleeding "red sweat," reflecting this concept.
Cheng Zhi said: Spontaneous nasal bleeding ensures recovery even without sweating. Humans contracting cold develop heat; nasal bleeding allows venting and recovery.
Zhang Lu said: Flowing nasal bleeding disperses pathogenic heat with blood. Blood loss precludes sweating. If spontaneous nasal bleeding does not occur, Ephedra Decoction should induce sweating. Successful sweating resolves pathogen without nasal bleeding; if residual pathogen remains, nasal bleeding will still occur for resolution.
In cold damage, with floating-tight pulse, failure to induce sweating leads to nasal bleeding. Ephedra Decoction (Mahuang Tang) is indicated.
[Annotation] This follows the previous clause to provide treatment guidance. Cold damage with floating-tight pulse requires sweating by law. Failure to sweat is a missed opportunity. Missed sweating causes heat constraint in the Ying level, leading to nasal bleeding. Ephedra Decoction is indicated. If Ephedra Decoction had been used early before nasal bleeding, sweating would resolve the disease, preventing nasal bleeding. Or, if it resolves spontaneously via nasal bleeding as in the previous clause, medication is unnecessary.
[Commentary] In early cold damage, if aversion to cold is not severe, heat involvement is suspected, often leading to nasal bleeding. In heat-dominant/cold-minor cases, heat exits with nasal bleeding, followed by sweating, resolving both exterior and heat. In heat-minor/cold-dominant cases, even if heat exits with nasal bleeding, sweating may not follow, leaving the exterior unresolved. Using Qinglong Decoction or Mahuang Tang before nasal bleeding achieves dual resolution via sweating and bleeding. If nasal bleeding has already occurred and sweating fails, exterior remains unresolved, Ma Huang Tang or Gui Zhi Tang can harmonize Ying and Wei, but should be supplemented with minor amounts of Scutellaria, Coptis, rhinoceros horn, or rehmannia to clear heat and cool blood, protecting yin blood. However, after significant nasal bleeding, Mahuang Tang or Qinglong Decoction should not be used lightly; improper use violates the prohibition against sweating patients with nasal bleeding history.
[Collected Notes] *Ren Shu* states: Post-nasal-bleeding floating pulse indicates suitability for Mahuang Tang; post-nasal-bleeding faint pulse contraindicates Mahuang Tang, favoring Scutellaria and Paeonia Decoction. Floating pulse post-bleeding indicates unresolved exterior; faint pulse indicates resolved exterior. This reveals Zhang Zhongjing's principle for using Mahuang Tang post-bleeding.
Fang Youzhi said: Cold damage with floating-tight pulse implies more cold than wind. The previous two clauses involved more wind than cold: the first caused nasal bleeding due to incomplete sweating after medication; the second resolved spontaneously due to mildness. This clause involves nasal bleeding due to lack of sweating from dominant cold. The distinction lies here. Dominant cold requires sweating; failure to sweat causes heat constraint and blood disorder, leading to nasal bleeding. Nasal bleeding disperses yang wind pathogen. Mahuang Tang disperses the remaining cold.
Cheng Zhi said: This addresses nasal bleeding caused by unconstrained cold pathogen, requiring warm dispersal. Nasal bleeding without sweating results from cold entering Ying failing to vent. Unresolved cold causes persistent bleeding; thus, Mahuang is used again, not waiting for bleeding. This differs from the previous clause regarding heat/cold.
Cheng Yingmao said: Generally, nasal bleeding in cold damage arises from inherent Ying heat. Once constrained by cold, Ying cannot withstand suppression and rises.
In cold damage, constipation for six to seven days with headache and fever indicates excess in the interior, suggesting Ba Xia Xie Xin Tang or Da Cheng Qi Tang (Chengqi Tang). However, if urine is clear, the pathogen is not in the interior but remains at the exterior, requiring sweating. If headache is severe, nasal bleeding will likely occur; Gui Zhi Tang is indicated.
[Commentary] The character "ruo" (if) in "if headache" should be "ku" (severe). Severe headache is the sign for inevitable nasal bleeding. If interpreted as "if," any headache could cause nasal bleeding.
[Annotation] Constipation for six to seven days in cold damage suggests interior excess, potentially requiring purging. Persistent headache and fever indicate unresolved exterior, potentially requiring sweating. Facing this dilemma, urine clarity distinguishes the location. Turbid red urine indicates interior heat; even with exterior signs, treat interior heat with Chengqi Tang. Clear white urine indicates heat remains at the exterior; even with constipation, treat exterior pathogen with Gui Zhi Tang. Regardless of interior/exterior status, severe headache indicates intense heat in Ying, inevitably causing nasal bleeding, which resolves Ying heat. Before nasal bleeding, absence of sweating requires Mahuang Tang; presence of sweating requires Gui Zhi Tang to induce sweating and resolve without bleeding.
[Collected Notes] Wang Hu said: Persistent headache stems from wind-cold obstructing upwards, heat abundant in meridians, inevitably leading to nasal bleeding. Treating before bleeding with Mahuang or Gui Zhi Tang, verified by urine testing, is Zhang Zhongjing's brilliant method.
Wei Litong said: The mention of nasal bleeding in this clause is predictive, not an observed symptom.
If Taiyang disease remains unresolved, heat binds in the Bladder. The patient exhibits manic behavior. If blood passes spontaneously, recovery ensues. If exterior symptoms remain unresolved, internal attack is premature; resolve the exterior first. Once the exterior is resolved, if only lower abdominal urgency and knotted sensation persist, internal attack is permissible. Taohe Chengqi Tang is indicated.
[Annotation] Unresolved Taiyang disease typically transmits to Yangming. If it does not transmit to Yangming but pathogenic heat follows the meridian, stasis forms in the Bladder Ying level, causing manic-like behavior. Manic-like state results from internal binding of stasis-heat disturbing the Heart. At this stage, spontaneous blood passage leads to self-recovery. If blood does not pass spontaneously, or passage is incomplete, heat and stasis accumulate in the lower Bladder, causing lower abdominal urgency and knotted sensation. If exterior symptoms persist, internal attack is contraindicated; resolve exterior first with Mahuang Tang. Once exterior resolves, if only lower abdominal urgency/pain remains, internal attack is permitted using Taohe Chengqi Tang (Tiao Wei Cheng Qi Tang plus Peach Kernel), which clears heat and drives out blood stasis. Since pathogen follows the Taiyang meridian, Cinnamon Twig is added to resolve exterior and unblock Ying. Taking medicine before meals ensures rapid downward action of the drug force.
[Commentary] Unresolved Taiyang disease not transmitting to Yangming, but heat following the meridian into the interior, is called "invading the root." Invading the root refers to invading the Bladder Fu organ. The Wei level of the Bladder Fu corresponds to the Qi level; the Ying level of the Bladder Fu corresponds to the Blood level. Heat invading the Qi level impedes Qi transformation, binding heat with water, constituting invasion of the Wei-level interior, presenting as Wu Ling San syndrome. Heat invading the Blood level impedes blood circulation, binding heat with blood, constituting invasion of the Ying-level interior, presenting as Taohe Chengqi Tang syndrome. Both are root-invading patterns, and both formulas treat root invasion, but one promotes urination (water) and the other purges from below (blood); their treatments differ.
[Collected Notes] Yu Chang said: Taohe Chengqi Tang uses Cinnamon Twig to resolve the exterior, similar to Da Chaihu Tang. This confirms that heat following the Taiyang meridian cannot be resolved without Cinnamon Twig.
Cheng Zhi said: Unresolved Taiyang disease follows the meridian into the Fu, causing heat binding in the Bladder. Manic-like behavior results from internal stasis-heat disturbing the Heart. Spontaneous blood passage allows heat to resolve with stasis. However, exterior symptoms must resolve before directly attacking lower abdominal knotted pathogen. Adding Peach Kernel to Tiao Wei Cheng Qi Tang targets the blood site; adding Cinnamon Twig unblocks blood vessels and resolves Taiyang meridian-following pathogen.
Wang Hu said: The Bladder is an organ in the lower abdomen. Bladder heat binding affects the Wei level (urinary difficulty) or Ying level (blood stasis), creating urgency/knotted sensations, confirming lower jiao blood stasis syndrome. Taohe Chengqi Tang attacks lower jiao blood stasis and treats lower abdominal urgency; it is not merely for clearing Bladder heat binding.
Formula for Peach Kernel and Rheum Decoction (Taohe Chengqi Tang)
Peach Kernel (skin and tip removed, 50 pieces), Cinnamomi Ramulus (3 liang), Rhei Radix et Rhizoma (4 liang), Natrii Sulfas (2 liang), Glycyrrhizae Radix et Rhizoma (roasted, 2 liang).
The above five herbs are boiled in 7 sheng of water to obtain 2.5 sheng. The dregs are removed, Natrii Sulfas is added, and the mixture is heated briefly until boiling, then removed from fire. Take 5 he of the warm decoction before meals, three times daily. Mild purgation is expected.
In Taiyang disease lasting six to seven days, if exterior symptoms persist, but the pulse is faint and deep, and contrary to expectation, chest oppression-hardness does not form, yet the patient becomes manic, it is because heat is in the lower jiao, and the lower abdomen should be hard and full. If urination is normal, blood letting is required for recovery. This is due to Taiyang pathogen following the meridian, causing stasis-heat in the interior. Purging with Didang Tang is indicated.
[Annotation] In Taiyang disease lasting six to seven days with persistent exterior symptoms, the pulse should be floating and large. A faint and deep pulse indicates exterior Taiyang syndrome combined with interior Shaoyin pulse, corresponding to Mahuang Fuzi Xixin Tang syndrome. Alternatively, pathogen entering the interior causes chest oppression-hardness or zang-jie. Here, lacking Taiyang-Shaoyin combined symptoms, and not forming chest oppression-hardness or zang-jie, but exhibiting mania, indicates Taiyang meridian-following stasis-heat binds not in the upper jiao Wei level, but in the lower jiao Ying level, causing lower abdominal hardness/fullness. Normal urination confirms blood stasis in the lower jiao. Recovery requires blood evacuation; if spontaneous passage does not occur, purging is necessary. Only Didang Tang is sufficient to drive out blood stasis; this is the definitive method.
[Collected Notes] Yu Chang said: When blood stasis progresses to mania, heat attacks the Heart. Taohe Chengqi Tang is insufficient to move blood, and Cinnamon Twig insufficient to scatter pathogen. Only a general striking straight in can win the battle, hence named Didang Tang. "Di" means arriving/reaching. It is the most appropriate and unchangeable excellent method.
Zhang Lu said: Pathogen binding in the chest uses Xianxiong Tang to purge fluids; pathogen binding in the lower abdomen uses Didang Tang to drive out blood.
Cheng Zhi said: Faint-deep pulse indicates pathogen binding in the interior. Persistent exterior symptoms without chest oppression-hardness show Taiyang meridian pathogen binds in the lower jiao, not upper. Normal urination indicates blood pathology without qi pathology.
Cheng Yingmao said: Heat binding in the Qi level causes urinary difficulty; heat binding in the Blood level causes blood stasis. Once blood stasis accumulates and stagnates, only powerful purging of blood can achieve recovery.
Formula for Didang Tang