逆也。夫呕家必渴。而其所饮之水。又因膈气虚寒而不能下运。则膈间之有水可必矣。眩者。晕眩。水抬气浮
之应。悸者。惊悸。水凌心火之应。与六条心下悸同。非虚悸也。姜、半温膈降逆。故能成止呕开痞之功。茯苓渗
水去饮。故能收伏气安神之效。与前二十八条相为发明。盖呕而不渴。是因先有寒饮而致呕者。卒呕而痞。
是因先见寒呕而致水者。症虽颠倒不同。而其能成支饮则一。故皆主此汤。而特为加减焉耳。
三十一条 假令瘦人。脐下有悸。吐涎沫而癫眩。此水也。五苓散主之。
五苓散方 茯苓（三分） 猪苓（三分去皮） 泽泻（一两一分） 白术（三分） 桂枝（二分去皮）
上五味。为末。白饮服方寸匕。日三服。多饮暖水。汗出愈。
脐下悸。与上文之惊悸。及他处之虚悸。俱不同。殆指脐下之左右。如弹指跳动之状。盖因胸膈之气上虚。而
少腹之气。将奔迫赴之。故其动机如此。与奔豚同候。癫。当作巅。巅眩。言巅顶上眩也。盖谓瘦人阳常有余。阴
常不足者。理也。阳有余。则脐下不应动悸。巅顶不应上眩矣。阴不足。则津液不应上泛而吐涎沫矣。今其人
脐下有悸。则知其气虚于胸膈。而有以招之上逆者。吐涎沫而巅眩。则知其邪实于肠间。而有以抬之上浮
者。夫上虚而致脐下动悸。其不能运饮可知。下实而致涎上泛。且致巅眩。其已经积饮又可知。故曰此水也。
五苓散方意。详伤寒本汤。以之主此条之症。另有奥义。盖去水固其本治。至去水以泻膀胱。而少腹不得以
有余者上乘胸膈。其治脐下之悸者。一也。水去而无饮气上射。则涎沫下摄者。二也。水去而浮鼓之气下伏。
则巅眩可除者。三也。且苓术桂枝。又能填在天之清气。以御脐下之上乘。四也。多服暖水以取汗。既恐肠间
之水。溢于经络。复恐浮鼓之气。未得尽平。而以微汗散之者。五也。长沙之诊法方意。入微入妙。大率如斯。
三十二条 咳家。其脉弦。为有水。十枣汤主之。
此言悬饮之未及逼肺。而但以饮气上射而咳者。其脉症治例如此也。弦脉为阳虚外削之诊。阳虚外削。则
不能运饮。故弦为水脉。久咳成家者而见此。则知其咳为悬饮在胁下。而水气上射之应。故曰为有水。十枣
汤治悬饮。已详二十二条。并伤寒注。其主之也宜矣。
三十三条 夫有支饮家。咳烦。胸中痛者。不卒死。至一百日。或一岁。宜十枣汤。
此言支饮日久。必从中脘而旁渗为悬饮。故其治同悬饮之例也。支饮从肠而积满至胃。从胃而积满至脘。
以致从脘外渗而至胸。支架撑鼓。故谓之支饮。支饮留久成家。其气上射于肺。则咳。且水饮化热。则烦。又胸
中孙络。灌满胀满者。多致饮高气绝而卒死。若不卒死。延至百日。或一岁。是其中路之支饮旁渗。于胁下而
为悬饮。故支饮之势中衰、而不死也。因其机而治从悬饮之例。则主十枣汤为的对矣。
三十四条 久咳数岁。其脉弱者可治。实大数者死。其脉虚者。必苦冒。其人本有支饮在胸中故也。治属饮家。
咳者百脉振动。故劳咳、热咳、寒咳等症。久则多死。必无至数岁者。惟寒饮之气上射。因而致咳者有之。盖胸
中之阳气有起伏。而火土之月日有平持故也。脉。指右寸而言。脉弱者。是肺与胸中之阳气虽微。而饮尚不
高。故其气犹得宽展。如囊 中贮物少。而有软和之象。其主苓桂术甘等剂。去饮填胸。犹为易易。故曰可治。
若夫脉体内坚而实。脉形外鼓而大。脉至迫促而数。三者见一即死。况全见乎。盖水饮上抬。气界逼窄。自塞
脏中阴精之奥府。则实。穷走气宇既尽之极边。则大。地界匾短。气机之往来俱促。则数。譬之赵宋。北兵势大。
畏避临安。聚臣民于弹丸。播宗社于南鄙。地促费繁。民贫赋重。此国脉实大而数之象。彼张、韩、刘、岳诸公。其
医国者。未尝非卢扁之妙手。然亦不过苟延数主。终归不振。而自亡于海。即长沙所谓死不治之义也。脉虚
以下。承上文而详言脉弱之可治者。盖自其鼓微而言曰弱。自其中空而言曰虚。以弱脉多虚故也。冒见二
十五条注。复言其脉症者。见水饮自有确据。而不必眩惑之意。曰治属饮家。以悬饮支饮。各有治例。且见不
必治咳。饮去而咳将自愈矣。
三十五条 咳逆。倚息。不得卧。小青龙汤主之。小青龙汤下已。多唾口燥。寸脉沉。尺脉微。手足厥逆。气
从
小腹上冲胸咽。手足痹。其面翕热如醉状。因复下流阴股。小便难。时复冒者。与茯苓桂枝五味甘草汤。治其冲气。冲
气即低。而反更咳。胸满者。用桂苓五味甘草汤去桂。加干姜细辛以治其咳满。咳满即止而更复渴。冲气复发
者。以细辛干姜为热药故也。服之当遂渴。而渴反止者。为支饮也。支饮者。法当冒。冒者必呕。呕者复内半夏
以去其水。茯苓桂枝五味甘草汤。去甘草。去桂。加细辛干姜半夏汤主之。水去呕止。其人形肿者。加杏仁主
之。其症应内麻黄。以其人遂痹。故不内之。若逆而内之者。必厥。所以然者。以其人血虚。麻黄发其阳故也。若
面热如醉。此为胃热。上冲。熏其面。加大黄以利之。
小青龙汤方
麻黄（三两去节） 白芍（三两） 五味子（半升） 干姜（三两一本作二两） 甘草（三两炙一本作二两）
桂枝（三两去皮） 半夏（半升一本作三两） 细辛（三两）
上八味。以水一斗。先煮麻黄减二升。去上沫。内诸药。煮取三升。去滓。温服一升。若微利者。去麻黄加芫花
如鸡子大。熬令赤色。若渴者。去半夏加栝蒌根三两。若噎者。去麻黄加附子一枚炮。若小便不利、少腹满。
去麻黄加茯苓四两。若喘者。去麻黄加杏仁半升。去皮尖。
桂苓五味甘草汤方 桂枝（四两去皮） 茯苓（四两） 五味子（半升） 甘草（一两炙）
上四味。以水八升。煮取三升。去滓。分温三服。
桂苓五味甘草汤去桂加干姜细辛方 茯苓（四两） 五味子（半升） 甘草 干姜 细辛（各三两）
上五味。以水八升。煮取三升。去滓。温服半升。日三服。
桂苓五味甘草汤去甘草去桂加干姜细辛半夏方
茯苓（四两） 五味子（半升） 干姜 细辛（各三两） 半夏（半升）
上五味。以水八升。煮取三升。去滓。温服半升。日三服。
苓甘五味姜辛半夏汤加杏仁方
茯苓（四两） 甘草（三两） 五味子（半升） 干姜（三两） 细辛（三两） 半夏（半升）
杏仁（半升去皮尖）
上七味。以水一斗。煮取三升。去滓。温服半升。日三服。
苓甘五味姜辛半杏汤加大黄方
茯苓（四两） 甘草（三两） 五味子（半升） 干姜（三两） 细辛（三两） 半夏（半升） 杏仁（半升） 大
黄（三两）
上八味。以水一斗。煮取三升。去滓。温服半升。日三服。
咳逆倚息不得卧。详已见。此症为饮支胸膈。气满肺管之候。小青龙为发汗利水。两解水饮之剂。故主之。方
论见伤寒论本汤下。下已犹言小青龙下后。而咳逆诸症俱已之谓。盖微发其汗。则饮从汗去。而肺气上平。
复下利其水。则饮从溺去。而胸阳下展。故其症俱已也。多唾至时复冒。凡十二句。又言支饮之咳逆等候虽
已。而其错杂之变症。所不能免。屈指计之。大概不越乎四者。各因其变而分治之。斯皆已而全愈矣。夫小青
龙半为发汗之剂。汗去而膈气上空。则在下之气上凑。而发为冲气者。一也。故气从小腹上冲胸咽。且唾随
冲气而上泛。以致多唾者是其候也。又痰饮之人。阳气自虚。今虚阳分驰于发汗利水。而其气益虚。则肾中
阴翳。乘肺而咳。乘胸而满。因变为咳满者。二也。故寸沉尺微。因阳气不贯于四末。而手足厥逆或痹者。是其
候也。或病饮之时。胃中素有积滞。及从汗以去饮。汗乃心液。汗出而上空。则胃中热实之气上熏者。三也。故
口燥、面翕热、如醉状者。是其候也。又饮之大势虽去。而其余波未净。因上焦汗空。而不能运布。多致渐积而
复成支饮者。四也。故余饮下流阴股。小便难而复冒者。是其候也。仲景于小青龙后。错综叙其脉症。而针线
一毫不乱。读金匮者。于此十二句中之错综处。理会清楚。则后文方治。丝丝入扣矣。四者单见。则单治之。如
其兼见。当先治冲气。以冲气为上虚下实之候。久则复能聚饮故也。主桂苓五味甘草汤者。以辛甘生阳之
桂枝。填上焦之空。而以甘浮之甘草。佐而托之。则其性益浮。然后以酸敛下摄之五味。抑其冲气。而佐以淡
渗之茯苓下泄之。其冲气之即低也宜矣。冲气下伏。则激其虚寒之气于上。寒气为肺性喜温之所忌。故咳。
虚寒之气。非胸中阳位之所宜。故满也。于本方去桂。加姜辛而益以甘草两倍。其方意另一世界。盖冲气系
下焦之本气。因膈虚而招之上冲者。其意在填高以御下。故用甘浮之桂甘为主。而后下压以泄之耳。若咳
满所乘者。为虚寒不足之气。其病在下。而其意因在温下以化上。故以五味之下渗下敛者为主。而以辛温
之干姜、细辛。趁势送至下焦。附以甘草者。欲其领辛温之气。从下而中浮。而使咳满之虚寒上化也。咳满即
止四句。为变症中之变。以仍主苓桂五味甘草汤。加归麦等味治之。则渴复止。冲气复低。而自愈故也。若服
此而当渴不渴。或先渴而服药反止者。是热药蒸于下。而浮其饮气于上之理。故知其复有支饮也。支饮者。
必冒且呕。以支饮于下。而气高于上故也。半夏去饮降逆。为饮家冒而且呕之圣药。故重加之。去桂及甘草
者。欲其专于下行。而不使留恋胸膈之意。至干姜细辛之用于本方者。较之前方。又是一番生面。盖前方是
借甘草之中浮。而上温咳满。本方又借淡渗降敛之品。下温去饮之阳气故也。仲景之方药。其游刃之妙。直
有才认梨花却是雪之幻耶。水去呕止。而形肿者。虚气薄于分肉而未行之候。杏仁利肺。故加之。痹。兼脉之
沉微。并手足厥逆而言。其症应内麻黄者。以杏仁利肺。麻黄泄气。肺利气泄。则虚气之薄于分肉者自散。故
二者为消肿之要药。今其人脉沉微而手足痹。况曾经厥逆乎。故单加杏仁。而不内麻黄者此也。若逆其法
而内之。则阳气益虚。故厥。盖阳附于阴。气根于血。阴血既虚。不任麻黄之泄其阳气也。面热如醉。兼口燥而
言。此为胃热上冲。加大黄以利之。乌容已哉。此条似当日之医案。更为引而伸之。而即存以为法者也。
三十六条 先渴后呕。为水停心下。此属饮家。小半夏茯苓汤主之。
先渴、则所饮既多。后呕、则逆而不运。故知为水停心下。曰此属饮家。言不必治呕。饮去而呕将自止矣。半夏
去饮。而且能降逆。以止呕。加茯苓以渗之。舍此其谁任乎。
这是逆证。凡是呕吐的人必定会口渴，但如果他喝水后，因为膈间气虚寒凉而不能运化下行，那么膈间有水饮就可以确定了。眩，是指晕眩，是水饮抬举、气机浮越的反应；悸，是指惊悸，是水饮凌犯心火的反应，这与第六条的心下悸相同，但不是虚性的惊悸。干姜、半夏能温通膈间、降逆止呕，所以能成就止呕、开痞的功效；茯苓能渗利水湿、去除饮邪，所以能收摄伏匿之气、安定神志的作用。这与前文第二十八条相互发明阐发。大概呕吐而不渴，是因为先有寒饮导致呕吐；突然呕吐且伴有痞满，是因为先见寒性呕吐而导致水饮停聚。症状虽然颠倒不同，但最终形成支饮是一样的，所以都主治此汤方，只是特别进行了加减罢了。
第三十一条 假如身体消瘦的人，脐下有跳动感，吐涎沫并且发生癫眩（头顶眩晕），这是水饮为患，用五苓散主治。
五苓散方：茯苓（三分）、猪苓（三分，去皮）、泽泻（一两一分）、白术（三分）、桂枝（二分，去皮）。
以上五味药，研成粉末，用米汤送服一方寸匕，每日三次服药。多喝暖水，出汗即愈。
脐下悸动，与上文所说的惊悸，以及其他地方的虚悸都不同。大概是指脐下左右两侧，像弹指跳动一样的状态。这是因为胸膈之气上部虚弱，而少腹之气奔迫向上应之，所以出现这种跳动的征象，与奔豚病的证候相似。“癫”字应当作“巅”，巅眩，是说头顶上的眩晕。大概认为瘦人通常阳气有余、阴气不足，这是常理。如果阳气有余，脐下就不应该动悸，头顶也不应该上眩；如果阴气不足，津液就不应该上泛而吐出涎沫。现在这个人脐下有悸动，就知道他胸膈气虚，有招引气机上逆的因素；吐涎沫并且巅顶眩晕，就知道他肠间邪气实盛，有抬举气机上浮的因素。上部虚导致脐下动悸，说明不能运化水饮是显而易见的；下部实导致涎沫上泛，并且导致巅顶眩晕，说明已经积聚了水饮也是显而易见的。所以说这是水饮为患。
五苓散的方义，详见《伤寒论》本方。用它来主治这一条的症状，另有深奥的含义。大概去除水饮是治本之法。通过泻膀胱去水，使少腹不至于以有余之势上乘胸膈，这是治疗脐下悸动的第一层意思。水饮去除了，没有饮气上射，那么涎沫就会向下收敛，这是第二层意思。水饮去除了，浮鼓之气下沉潜伏，那么巅眩就可以消除，这是第三层意思。而且茯苓、白术、桂枝又能填补在天的清气，以抵御脐下之气之上乘，这是第四层意思。多服暖水以取汗，既担心肠间的水溢入经络，又担心浮鼓之气未能完全平复，所以用微汗来发散它，这是第五层意思。长沙（张仲景）的诊法方意，入微入妙，大体如此。
这是说悬饮尚未逼迫肺脏，仅仅因为饮气上射而咳嗽的情况，其脉症治例就是这样。弦脉是阳虚外削的诊象，阳虚外削，就不能运化水饮，所以弦脉主水。久咳成疾的人出现这种脉象，就知道他的咳嗽是由于悬饮在胁下，水气上射的反应，所以说“是有水”。十枣汤治疗悬饮，已在第二十二条及《伤寒论》注中详细说明，用它来主治是适宜的。
第三十三条 凡是患有支饮的人，咳嗽、心烦、胸中痛，如果没有猝死，经过一百天或一年，适宜用十枣汤。
这是说支饮日久，必然从中脘旁渗成为悬饮，所以治疗方法同悬饮的条例一样。支饮从肠道积满至胃，从胃积满至脘，以致从脘外渗至胸，支架撑鼓，所以称为支饮。支饮停留久了成为宿疾，其气上射于肺，则咳嗽；且水饮化热，则心烦。另外胸中的孙络灌满胀满，多会导致饮气高绝而猝死。如果没有猝死，拖延到一百天或一年，这是其中的支饮旁渗于胁下成为悬饮，所以支饮的势头中途衰减，人就不会死。顺着这个病机治疗，遵循悬饮的条例，那么主治十枣汤就是对症的了。
第三十四条 久咳数年，脉象弱的可以治愈，脉象实大数的会死亡。脉象虚的，一定苦于头目昏冒。这是因为其人胸中本来就有支饮的缘故。治疗归属于治饮家。
咳嗽会使百脉振动，所以劳嗽、热嗽、寒嗽等症状，久了大多致死，必定没有持续数年的。只有寒饮之气上射因而致咳的才有这种情况。大概是因为胸中的阳气有起伏，而火土之月日有平持的缘故。这里的脉，指右寸脉。脉弱，是肺与胸中的阳气虽然微弱，但饮邪尚不高，所以气还能宽展，就像囊中贮物少，而有软和的样子。主治苓桂术甘等剂，去除水饮、填实胸中，还是比较容易的，所以说可治。如果脉体内部坚实，脉形外部鼓大而有力，脉至迫促而数，三者见到一个就会死，何况全见到呢？大概水饮上抬，气界逼窄，自然闭塞脏中阴精的深处，这就是“实”；穷尽走气宇既尽的极边，这就是“大”；地界短小，气机往来俱促，这就是“数”。譬如赵宋王朝，北兵势大，畏避临安，聚集臣民于弹丸之地，播迁宗社于南鄙，地促费繁，民贫赋重，这是国脉实大而数的景象。那些张、韩、刘、岳各位公卿，他们治理国家，未尝不是卢扁那样的妙手，但也只不过苟延数代君主，最终归于不振，而自亡于海。这就是长沙（张仲景）所谓死不治的意思。脉虚以下，承接上文详细论述脉弱可治的情况。大概从其鼓动微弱来说叫“弱”，从其中空来说叫“虚”，因为弱脉多虚的缘故。“冒”见第二十五条注，这里再次提及脉症，是表明水饮自有确据，而不必被眩晕迷惑的意思。说“治疗归属于饮家”，是因为悬饮、支饮各有治例，并且表明不必专门治咳，饮去而咳将自愈。
第三十五条 咳嗽气逆，倚靠呼吸，不能平卧，用小青龙汤主治。服完小青龙汤后，如果出现多唾、口燥、寸脉沉、尺脉微、手足厥逆、气从小腹上冲胸咽、手足麻木、面色红赤如醉状、随后又流注于阴股、小便困难、时常昏冒的情况，用茯苓桂枝五味甘草汤治疗其冲气。冲气降低后，反而更咳嗽、胸满的，用桂苓五味甘草汤去掉桂枝，加干姜、细辛以治疗其咳满。咳满停止后又再次口渴、冲气复发的，是因为细辛、干姜是热药的原因。服用后应当随即口渴，如果口渴反而停止的，是因为有支饮。支饮的人，按法应当昏冒，昏冒的人必定呕吐，呕吐者再加入半夏以去除水饮。茯苓桂枝五味甘草汤，去掉甘草、桂枝，加干姜、细辛、半夏汤主治。水饮去、呕吐止，如果病人形体浮肿的，加杏仁主治。其症状应当加入麻黄，但因为其人已有麻木，所以不加入。如果逆着病情加入，必定导致厥逆。之所以这样，是因为其人血虚，麻黄会发散其阳气。如果面热如醉，这是胃热上冲，熏蒸面部，加大黄以利之。
小青龙汤方：麻黄（三两，去节）、白芍（三两）、五味子（半升）、干姜（三两，一本作二两）、甘草（三两，炙，一本作二两）、桂枝（三两，去皮）、半夏（半升，一本作三两）、细辛（三两）。
以上八味药，用水一斗，先煮麻黄减少二升，去掉上面的泡沫，加入其他药物，煮取三升，去渣，温服一升。如果有轻微腹泻的，去掉麻黄，加芫花如鸡蛋大小，炒至赤色。如果口渴的，去掉半夏，加栝蒌根三两。如果有噎感的，去掉麻黄，加附子一枚（炮）。如果小便不利、少腹满，去掉麻黄，加茯苓四两。如果喘的，去掉麻黄，加杏仁半升，去皮尖。
桂苓五味甘草汤方：桂枝（四两，去皮）、茯苓（四两）、五味子（半升）、甘草（一两，炙）。
以上四味药，用水八升，煮取三升，去渣，分三次温服。
桂苓五味甘草汤去桂加干姜细辛方：茯苓（四两）、五味子（半升）、甘草、干姜、细辛（各三两）。
以上五味药，用水八升，煮取三升，去渣，温服半升，每日三次。
桂苓五味甘草汤去甘草去桂加干姜细辛半夏方：茯苓（四两）、五味子（半升）、干姜、细辛（各三两）、半夏（半升）。
以上五味药，用水八升，煮取三升，去渣，温服半升，每日三次。
苓甘五味姜辛半夏汤加杏仁方：茯苓（四两）、甘草（三两）、五味子（半升）、干姜（三两）、细辛（三两）、半夏（半升）、杏仁（半升，去皮尖）。
以上七味药，用水一斗，煮取三升，去渣，温服半升，每日三次。
苓甘五味姜辛半杏汤加大黄方：茯苓（四两）、甘草（三两）、五味子（半升）、干姜（三两）、细辛（三两）、半夏（半升）、杏仁（半升）、大黄（三两）。
以上八味药，用水一斗，煮取三升，去渣，温服半升，每日三次。
咳嗽气逆、倚息、不得卧，详情已见。此症为饮邪支结胸膈，气满肺管的证候。小青龙汤是发汗利水、两解水饮的方剂，所以主治它。方论见《伤寒论》本方下。下已，犹言小青龙汤服后，咳嗽气逆等症状都停止了。大概微微发汗，则饮邪从汗而去，肺气上平；再下利其水，则饮邪从小便而去，胸阳下展，所以症状都停止了。从“多唾”到“时复冒”，凡十二句，又说支饮的咳嗽气逆等候虽然已止，但其错杂的变症在所难免。屈指计算，大概不出四种情况，各因其变而分别治疗，这样就能全部痊愈。夫小青龙汤半为发汗之剂，汗出后膈气上空，则在下的气上凑，发为冲气，这是一。所以气从小腹上冲胸咽，且唾随冲气而上泛，以致多唾，是其证候。又痰饮之人，阳气自虚，今虚阳分驰于发汗利水，而其气益虚，则肾中阴翳，乘肺而咳，乘胸而满，因变为咳满，这是二。所以寸沉尺微，因阳气不贯于四末，而手足厥逆或麻木，是其证候。或在病饮之时，胃中素有积滞，及从汗以去饮，汗乃心液，汗出而上空，则胃中热实之气上熏，这是三。所以口燥、面翕热、如醉状，是其证候。又饮的大势虽去，而其余波未净，因上焦汗空，而不能运布，多致渐积而复成支饮，这是四。所以余饮下流阴股，小便难而复冒，是其证候。仲景在小青龙汤后，错综叙述其脉症，而针线一毫不乱。读《金匮要略》的人，在这十二句中的错综处，理会清楚，则后文的方治，丝丝入扣了。四者单见，则单治之。如其兼见，当先治冲气，以冲气为上虚下实的证候，久了又能聚饮。主治桂苓五味甘草汤，是以辛甘生阳的桂枝，填补上焦之空，而以甘浮的甘草，佐而托之，则其性益浮，然后用酸敛下摄的五味，抑制其冲气，而佐以淡渗的茯苓下泄之，其冲气的立即降低是理所当然的。冲气下伏，则激其虚寒之气于上。寒气为肺性喜温之所忌，故咳；虚寒之气，非胸中阳位之所宜，故满。在本方中去桂枝，加干姜、细辛而加倍甘草，其方意另有一番境界。盖冲气系下焦之本气，因膈虚而招之上冲者，其意在填高以御下，故用甘浮的桂枝、甘草为主，而后下压以泄之耳。若咳满所乘者，为虚寒不足之气，其病在下，而其意因在温下以化上，故以五味子的下渗下敛为主，而以辛温的干姜、细辛，趁势送至下焦，附以甘草者，欲其领辛温之气，从下而中浮，而使咳满的虚寒上化也。咳满即止四句，为变症中之变，以仍主苓桂五味甘草汤，加归麦等味治之，则渴复止，冲气复低，而自愈故也。若服此而当渴不渴，或先渴而服药反止者，是热药蒸于下，而浮其饮气于上之理，故知其复有支饮也。支饮者，必冒且呕，以支饮于下，而气高于上故也。半夏去饮降逆，为饮家冒而且呕的圣药，故重加之。去桂枝及甘草者，欲其专于下行，而不使留恋胸膈之意。至干姜、细辛之用于本方者，较之前方，又是一番生面。盖前方是借甘草之中浮，而上温咳满；本方又借淡渗降敛之品，下温去饮之阳气故也。仲景的方药，其游刃之妙，简直有才认梨花却是雪的幻象耶。水去呕止，而形肿者，是虚气薄于分肉而未行之候。杏仁利肺，故加之。痹，兼脉之沉微，并手足厥逆而言。其症应内麻黄者，以杏仁利肺，麻黄泄气，肺利气泄，则虚气之薄于分肉者自散，故二者为消肿的要药。今其人脉沉微而手足痹，况曾经厥逆乎？故单加杏仁，而不内麻黄者此也。若逆其法而内之，则阳气益虚，故厥。盖阳附于阴，气根于血，阴血既虚，不任麻黄之泄其阳气也。面热如醉，兼口燥而言，此为胃热上冲，加大黄以利之。乌容已哉。此条似当日之医案，更为引而伸之，而即存以为法者也。
第三十六条 先渴后呕，为水停心下，此属饮家，用小半夏茯苓汤主治。
先渴，则所饮既多；后呕，则逆而不运，故知为水停心下。曰此属饮家，言不必治呕，饮去而呕将自止矣。半夏去饮，而且能降逆以止呕，加茯苓以渗之，舍此其谁任乎？
This is a counter-flow syndrome. Individuals who vomit will inevitably feel thirsty. However, if the water they drink cannot be transported and descend due to deficiency-cold in the diaphragm, it can be confirmed that there is fluid retention in the diaphragm. "Xuan" (dizziness) refers to vertigo, which is a response to fluid lifting and Qi floating. "Ji" (palpitations) refers to startled palpitations, which is a response to fluid invading Heart Fire; this is the same as the subcardiac palpitations mentioned in Clause 6, but it is not deficiency-type palpitations. Shengjiang (Dried Ginger) and Banxia (Pinellia Rhizome) warm the diaphragm and direct rebellious Qi downward, thus achieving the effect of stopping vomiting and opening痞 (stagnation). Fuling (Poria) promotes diuresis to remove fluid, thus achieving the effect of settling latent Qi and calming the Spirit. This elucidates the previous Clause 28. Generally, vomiting without thirst is caused by pre-existing cold-fluid leading to vomiting; sudden vomiting accompanied by stagnation is caused by pre-existing cold-vomiting leading to fluid accumulation. Although the symptoms are inverted and different, both ultimately result in Zhi Yin (Branching Fluid), so both are primarily treated with this decoction, with specific modifications.
Clause 31: Suppose a thin person experiences palpitations below the umbilicus, spits saliva and foam, and suffers from dian xuan (vertigo of the vertex). This is due to fluid. Wuling San (Five-Ingredient Powder with Poria) is the primary treatment.
Wuling San Formula: Fuling (Poria), Zhuling (Polyporus), Zexie (Alisma), Baizhu (Atractylodes Macrocephala Rhizome), Guizhi (Cinnamon Twig).
The above five herbs are powdered. Take one cun-bi (a measure of volume) mixed with rice water, three times daily. Drink plenty of warm water; recovery occurs with sweating.
Palpitations below the umbilicus differ from the startled palpitations mentioned above and other deficiency-type palpitations elsewhere. It likely refers to a jumping sensation on either side of the umbilicus, like a finger snapping. This is because Qi in the chest and diaphragm is deficient above, causing Qi in the lower abdomen to rush upward to respond, resulting in this movement. The presentation is similar to Ben Tun (Running Piglet). "Dian" should be read as "Dian" (vertex). Dian xuan refers to vertigo at the vertex. It is generally understood that thin people often have excess Yang and insufficient Yin. If Yang were in excess, there would be no palpitations below the umbilicus or vertigo at the vertex. If Yin were insufficient, fluids would not float upward to produce saliva and foam. Now, since there are palpitations below the umbilicus, we know there is Qi deficiency in the chest and diaphragm attracting upward reversal. Since there is spitting of saliva/foam and vertex vertigo, we know there is pathogenic excess in the intestines lifting Qi upward. Upper deficiency leading to lower palpitations indicates an inability to transport fluid; lower excess leading to foaming and vertigo indicates accumulated fluid. Thus, it is said to be fluid pathology.
The rationale of Wuling San is detailed in the *Shanghan Lun*. Using it for this clause has profound implications. Removing fluid is treating the root. By draining the Bladder to remove fluid, the lower abdomen does not attack the chest and diaphragm with its excess; this addresses the first aspect of treating umbilical palpitations. With fluid removed and no fluid Qi shooting upward, saliva and foam will descend; this is the second aspect. With fluid removed and floating/distending Qi settling downward, vertex vertigo can be eliminated; this is the third aspect. Furthermore, Fuling, Baizhu, and Guizhi can replenish the clear Qi in the upper jiao to resist the upward attack from below; this is the fourth aspect. Drinking warm water to induce sweat prevents intestinal fluid from overflowing into collaterals and helps dissipate unsettled floating Qi; this is the fifth aspect. Zhang Zhongjing's diagnostic methods and formula principles are subtle and exquisite, generally as described.
Clause 32: In chronic cough, a wiry pulse indicates the presence of fluid. Shizao Tang (Ten-Date Decoction) is the primary treatment.
This describes Xuan Yin (Hanging Fluid) that has not yet forced the Lung, but causes cough due to fluid Qi shooting upward. Its pulse, symptoms, and treatment are as follows. A wiry pulse indicates Yang deficiency and external contraction. Yang deficiency leads to an inability to transport fluid, so a wiry pulse governs fluid. In chronic cough, seeing this pulse indicates the cough is due to Xuan Yin in the hypochondrium with water Qi shooting upward, hence "presence of fluid." Shizao Tang treats Xuan Yin, as detailed in Clause 22 and *Shanghan Lun* notes; thus, using it here is appropriate.
Clause 33: For patients with Zhi Yin (Branching Fluid) suffering from cough, irritability, and chest pain, if they do not die suddenly, after one hundred days or one year, Shizao Tang is suitable.
This states that long-standing Zhi Yin must seep laterally from the Middle Jiao to become Xuan Yin, so the treatment follows the Xuan Yin protocol. Zhi Yin accumulates from the intestines to the Stomach, then to the epigastrium, and finally seeps outward to the chest, forming a supportive structure, hence called Zhi Yin. When Zhi Yin lingers and becomes a chronic condition, its Qi shoots upward to the Lung, causing cough; if fluid transforms into heat, it causes irritability. Additionally, fullness in the collateral vessels of the chest often leads to sudden death due to high-rising fluid Qi cutting off vital energy. If they do not die suddenly and survive for a hundred days or a year, it means the Zhi Yin has seeped laterally into the hypochondrium to become Xuan Yin. Thus, the momentum of Zhi Yin wanes mid-course, preventing death. Treating according to this mechanism following the Xuan Yin protocol makes Shizao Tang the precise remedy.
Clause 34: Chronic cough lasting several years: a weak pulse is treatable; a solid, large, and rapid pulse indicates death. A deficient pulse implies severe dizziness (Mao). This is because the patient originally had Zhi Yin in the chest. Treatment belongs to the category of treating fluid retention.
Cough vibrates all meridians. Therefore, labor cough, heat cough, and cold cough often lead to death if prolonged, rarely lasting several years. Only cough caused by cold-fluid Qi shooting upward may persist. This is due to fluctuations in Yang Qi in the chest and the balancing influence of Fire/Earth months/days. Here, "pulse" refers to the Right Cun position. A weak pulse means although Lung and Chest Yang Qi are slight, the fluid is not high, allowing Qi to expand freely, like a bag with little content appearing soft. Treating with Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes, and Licorice Decoction) to remove fluid and fill the chest is relatively easy, hence "treatable." If the pulse body is internally hard and solid, externally bulging and large, and rapid and urgent, seeing any one indicates death, let alone all three. Fluid lifting narrows the Qi boundary, blocking the inner chambers of Yin Essence (Solid); exhausting the Qi to the extreme edge (Large); and shortening the Earth boundary making Qi movement urgent (Rapid). This is likened to the Song Dynasty fleeing south, crowding people into a small area, increasing taxes, and becoming poor—a state of solid, large, and rapid national pulse. Generals like Zhang, Han, Liu, and Yue tried to save the nation but could only prolong the dynasty briefly before collapse, akin to Zhang Zhongjing's meaning of "death, untreatable." Below "deficient pulse," elaborating on the treatability of a weak pulse: "Weak" refers to faint pulsation; "Deficient" refers to emptiness within, as weak pulses are often deficient. See Clause 25 note for "Mao" (dizziness). Reiterating pulse/symptoms confirms fluid evidence without confusion. "Treatment belongs to fluid family" means Xuan Yin and Zhi Yin have specific protocols; one need not treat cough directly, as removing fluid will stop the cough.
Clause 35: Cough with rebellious Qi, leaning on support to breathe, unable to lie flat. Xiao Qing Long Tang (Minor Green Dragon Decoction) is the primary treatment. After taking Xiao Qing Long Tang, if symptoms include excessive salivation, dry mouth, deep Cun pulse, shallow Chi pulse, cold limbs, Qi rushing from the lower abdomen to the chest and throat, numbness in hands/feet, facial flushing like drunkenness, subsequent flow to the inner thighs, difficult urination, and intermittent dizziness, use Fuling Guizhi Wuwei Gancao Tang (Poria, Cinnamon Twig, Schisandra, and Licorice Decoction) to treat the Chong Qi (Rushing Qi). Once Chong Qi subsides, if cough and chest fullness worsen, use Guiling Wuwei Gancao Tang minus Guizhi, plus Ganjiang (Dried Ginger) and Xixin (Asarum) to treat cough and fullness. If cough/fullness stops but thirst recurs and Chong Qi relapses, it is due to the heating nature of Xixin and Ganjiang. Normally, taking these should cause thirst; if thirst stops instead, it indicates Zhi Yin. Zhi Yin typically causes dizziness and vomiting. Add Banxia to remove fluid. Use Fuling Guizhi Wuwei Gancao Tang minus Gancao and Guizhi, plus Ganjiang, Xixin, and Banxia. If fluid is removed and vomiting stops but edema appears, add Xingren (Apricot Kernel). Although Mahuang (Ephedra) should be added for edema, it is omitted due to existing numbness. Adding it against indications would cause Jue (cold extremities/reversal) because the patient has Blood deficiency, and Mahuang disperses Yang. If facial flushing like drunkenness is due to Stomach Heat rushing up, add Dahuang (Rhubarb) to drain it.
Xiao Qing Long Tang Formula: Mahuang (Ephedra), Baishao (White Peony Root), Wuweizi (Schisandra Berry), Ganjiang (Dried Ginger), Gancao (Licorice Root), Guizhi (Cinnamon Twig), Banxia (Pinellia Rhizome), Xixin (Asarum).
Boil the eight ingredients in ten dou of water. First boil Mahuang to reduce by two sheng, skim the foam. Add remaining herbs, boil to three sheng, strain. Warm take one sheng. Modifications: If mild diarrhea, remove Mahuang, add Yuanhua (Genkwa Flower). If thirsty, remove Banxia, add Gualougen (Trichosanthes Root). If choking, remove Mahuang, add Fu Zi (Aconite). If difficult urination/lower abdominal fullness, remove Mahuang, add Fuling. If wheezing, remove Mahuang, add Xingren.
Fuling Guizhi Wuwei Gancao Tang Formula: Guizhi, Fuling, Wuweizi, Gancao.
Boil four ingredients in eight sheng of water to three sheng, strain. Divide into three warm doses.
Guiling Wuwei Gancao Tang minus Guizhi plus Ganjiang Xixin Formula: Fuling, Wuweizi, Gancao, Ganjiang, Xixin.
Boil five ingredients in eight sheng of water to three sheng, strain. Warm take half sheng, three times daily.
Guiling Wuwei Gancao Tang minus Gancao minus Guizhi plus Ganjiang Xixin Banxia Formula: Fuling, Wuweizi, Ganjiang, Xixin, Banxia.
Boil five ingredients in eight sheng of water to three sheng, strain. Warm take half sheng, three times daily.
Lingan Wuwei Jiangxin Banxia Tang plus Xingren Formula: Fuling, Gancao, Wuweizi, Ganjiang, Xixin, Banxia, Xingren.
Boil seven ingredients in ten dou of water to three sheng, strain. Warm take half sheng, three times daily.
Lingan Wuwei Jiangxin Banxia Xingren Tang plus Dahuang Formula: Fuling, Gancao, Wuweizi, Ganjiang, Xixin, Banxia, Xingren, Dahuang.
Boil eight ingredients in ten dou of water to three sheng, strain. Warm take half sheng, three times daily.
Cough with rebellious Qi, leaning to breathe, unable to lie flat is detailed previously. This symptom indicates fluid branching in the chest and diaphragm, filling the lung tubes. Xiao Qing Long Tang releases the exterior and promotes diuresis to resolve fluid, hence it is used. After taking it, symptoms cease. Mild sweating removes fluid via sweat, calming Lung Qi; diuresis removes fluid via urine, expanding Chest Yang. From "excessive salivation" to "intermittent dizziness" (twelve sentences), it describes complex variations after the main symptoms cease. There are roughly four types of variations:
1. Sweating empties the Diaphragm, causing lower Qi to rush up as Chong Qi, leading to upward surging and excessive salivation.
2. Phlegm-fluid patients have deficient Yang. Sweating/diuresis further depletes Yang, allowing Kidney Yin turbidity to invade Lung/Chest, causing cough and fullness. Deep Cun/Shallow Chi pulse and cold/numb limbs reflect this.
3. Pre-existing Stomach stagnation combined with sweating (Heart fluid) emptying the upper Jiao allows Stomach Heat to flare, causing dry mouth and flushed face.
4. Residual fluid remains, accumulating again as Zhi Yin due to upper Jiao emptiness, flowing to inner thighs, causing difficult urination and dizziness.
Zhang Zhongjing arranges these complexities meticulously. If variations appear singly, treat singly. If combined, treat Chong Qi first, as it represents upper deficiency and lower excess, potentially gathering more fluid. Fuling Guizhi Wuwei Gancao Tang uses Guizhi and Gancao to fill the upper emptiness and lift/support, while Wuweizi astringes and Fuling drains downward to suppress Chong Qi. Once Chong Qi settles, latent cold Qi rises, causing cough and fullness (Cold opposes Lung's warmth; Cold is unsuitable for Chest Yang). Remove Guizhi, add Ganjiang and Xixin, double Gancao. This shifts focus to warming the lower Jiao to transform upper cold. Wuweizi anchors downward, while Ganjiang/Xixin send warm Qi down to meet it, assisted by Gancao to float warm Qi upward to resolve cough/fullness. If thirst recurs after stopping cough/fullness, it indicates Zhi Yin returning due to heat drugs floating fluid. Zhi Yin causes dizziness and vomiting; add Banxia to descend and remove fluid. Remove Gancao/Guizhi to ensure downward action without lingering in the chest. This formula uses draining/astringent herbs to warm the lower Jiao and remove fluid, differing from the previous formula's use of Gancao to warm the middle. Zhang Zhongjing's mastery is miraculous. If edema persists after vomiting stops, add Xingren to benefit the Lung. Numbness with deep/shallow pulses and cold limbs contraindicates Mahuang due to Blood deficiency; using it would cause Jue. Facial flushing with dry mouth indicates Stomach Heat; add Dahuang to drain. This clause resembles a clinical case record preserved as a method.
Clause 36: Thirst followed by vomiting indicates water retention under the Heart (Stomach). This belongs to the fluid family. Xiaobanxia Fuling Tang (Minor Pinellia and Poria Decoction) is the primary treatment.
Thirst implies drinking much; vomiting implies rebellion and failure to transport. Thus, water is retained under the Heart. Saying "belongs to fluid family" means one need not treat vomiting directly; removing fluid will stop vomiting. Banxia removes fluid and directs rebellious Qi downward to stop vomiting; adding Fuling promotes diuresis. Who else but this combination could handle it?