伤寒脉浮此表有热里有寒白虎汤主之
少阴病下利清谷里寒外热手足厥逆脉微欲绝身反不恶寒其人面赤色或腹痛或干呕或咽痛或利止脉不出者通脉四逆
汤(方见下利)既吐且利小便复利大汗出下利清谷内寒外热脉微欲绝者四逆汤主之(成 吐利无津液则小盒饭少小便复
利而大汗出津液不禁阳气大虚也脉微为止阳若无外热但内寒下利清谷为纯阴此以外热为阳未绝犹可与通脉四逆汤救
之)下利清谷里寒外热汗出而厥者通脉四逆汤(成 下利清谷为里寒身热不解为外热汗出阳气通行于外则未当厥其汗出
而厥者阳气太虚也与通脉四逆汤以固阳气)脉浮而迟表热里寒下利清谷者通脉四主之(成 浮为表热迟为里寒下利清谷
者里寒甚也与四逆汤温里散寒)
表热里寒者脉虽沉而迟手足微厥下利清谷此里寒也所以阴证亦有发热者此表热也(四逆汤通脉四逆汤)表寒里热者
脉必滑身厥舌干也所以少阴恶寒而蜷此表寒也时时自烦不欲近衣此里热也(大柴胡汤)
太阳病发热恶寒热多寒少脉微弱者此无阳也不可发汗宜桂枝二越婢一汤(刘氏云脉迟者小建中加黄 或温中)
太阳病八九日如疟状发热恶寒热多寒少其人不呕清便欲自可一日二三度发脉微缓者为欲愈脉微恶寒者此阴阳俱虚
不可更发汗更下更吐也面色反有热色者未欲解也以其不得小汗出身必痒宜桂枝麻黄各半汤主之
赵 愚详仲景论中热多
寒少止有二证如上文一证仲景之意盖以得病七八日如疟状发热恶寒热多寒少十六字为自初至今之证以下文乃是以后拟
病防变之辞当分作三截看若其人不呕清便欲自可一日二三度发脉微缓为欲愈此一节乃里和无病而脉微缓微者邪气微缓
者阴阳同等脉证皆向安之兆可不待汗而欲自愈也若脉微而恶寒者此阴阳俱虚不可发汗更下更吐也此一节宜温之若面色
反有热者未欲解也以其不能得小汗出其身必痒宜各半汤此一节必待汗而后愈也活人书不详文意却将其人不呕清便欲自
可九字本是欲愈之证反以他证各半汤汗之又将不可汗吐下及各半汤证语句并脱略而不言反将其中欲愈之证而用彼药汗
其所不当汗何也其第二证仲景云太阳病发热恶寒热多寒少脉微弱者亡阳也不可发汗宜桂枝二越婢一汤活人书于脉微弱
上添都大二字岂以仲景论脉为未足而加之乎其第三证尺脉迟者仲景论中无热多寒少语句但云脉浮紧法当身疼痛宜以汗
解之假令尺中迟者不可发汗以荣气不足血少故也活人书但举尺中迟血少之语自添寒少热多四字加于其上因而编入此问
中何邪如一证尺迟者止当收入不可汗门中
刘 仲景一书只有热多寒少之条无寒多热少之证又云不烦躁手足厥逆为伤寒
脉反浮缓为伤风大青龙汤或云各半汤
少阴病,出现下利且排泄物中有未消化的食物(完谷不化),这是里有寒而外有假热,手足冰冷厥逆,脉搏微弱几乎摸不到,身体反而不觉得怕冷,病人面部呈现红色;或者伴有腹痛,或者干呕,或者咽喉痛,或者腹泻停止但脉搏仍摸不到的情况,用通脉四逆汤主治。(成无己注:呕吐和腹泻导致津液枯竭,小便应当减少,如果反而小便通利且大汗出,说明津液无法固摄,阳气极度虚弱。脉微是阳气将绝之象。如果没有外热的假象,只有内寒的下利清谷,这就是纯阴证。因为这里有外热的假象,说明阳气尚未完全断绝,还可以用通脉四逆汤来救治。)
既呕吐又腹泻,小便反而通利,大汗出,下利且排泄物中有未消化的食物,内有寒邪而外有假热,脉搏微弱几乎摸不到的情况,用四逆汤主治。(成无己注:下利清谷是因为里有寒,身体发热不退是外有假热。汗出说明阳气向外通行,按理说此时不应发生四肢厥冷。但如果汗出同时出现四肢厥冷,说明阳气极度虚弱,应用通脉四逆汤来固护阳气。)
脉象浮而迟,表有热、里有寒,且伴有下利且排泄物中有未消化的食物,用通脉四逆汤主治。(成无己注:脉浮表示表有热,脉迟表示里有寒。下利清谷说明里寒严重,应用四逆汤温补里阳、驱散寒邪。)
表热里寒的情况,脉象虽然沉而迟,手足轻微厥冷,下利且排泄物中有未消化的食物,这是里有寒。所以阴证也会出现发热的现象,这就是表热。(可用四逆汤或通脉四逆汤治疗)
表寒里热的情况,脉象必定滑数,身体厥冷,舌干。所以少阴病恶寒且身体蜷缩,这是表寒;时常自觉心中烦闷,不喜欢穿厚衣服,这是里热。(可用大柴胡汤治疗)
太阳病,发热、怕冷,热多寒少,脉象微弱,这是“无阳”(阳气虚衰),不可以发汗,适宜用桂枝二越婢一汤。(刘氏认为:如果是脉迟,可用小建中汤加黄芪,或者采用温中的方法)
太阳病经过八九天,症状像疟疾一样,发热、怕冷,热多寒少,病人没有呕吐,大小便基本正常,一天发作两三次,脉象微缓的,这是病情将要痊愈的迹象。如果脉微且怕冷,这是阴阳俱虚,不可以再使用发汗、攻下或催吐的方法。如果面色反常地发红,说明病还没有解除,这是因为不能通过微微出汗来排出邪气,身体一定会发痒,适宜用桂枝麻黄各半汤主治。
赵以德详细考证张仲景的论述中,“热多寒少”只有两个证候。如上文所述的一个证候,张仲景的意思大概是以“得病七八日,像疟疾一样,发热、怕冷,热多寒少”这十六个字作为从发病至今的症状描述,而下文则是针对后续可能出现的病情变化进行的预防性论述,应当分作三部分来看待。如果病人没有呕吐,大小便基本正常,一天发作两三次,脉象微缓,这是欲愈之兆,这一节说的是里气平和无病,脉微表示邪气微弱,脉缓表示阴阳平衡,脉证都趋向安宁,可以不等待发汗而自行痊愈。如果脉微且怕冷,这是阴阳俱虚,不可发汗、攻下或催吐,这一节适宜用温法。如果面色反常发红,说明病未解除,因为不能得到微微汗出,身体必然发痒,适宜用桂枝麻黄各半汤,这一节必须等待发汗后才能痊愈。《活人书》没有详察文意,却把“其人不呕,清便欲自可”这九个字——这本是欲愈的证候——当作其他证候,用桂枝麻黄各半汤发汗。又将不可发汗、催吐、攻下以及桂枝麻黄各半汤的禁忌语句省略不谈,反而对其中欲愈的证候使用了发汗的药物,这是为什么呢?第二个证候,张仲景说:“太阳病,发热、怕冷,热多寒少,脉微弱者,亡阳也,不可发汗,宜桂枝二越婢一汤。”《活人书》在“脉微弱”上加了“都大”二字,难道认为张仲景论述脉象不足而擅自添加吗?第三个证候,“尺脉迟者”,张仲景原文中没有“热多寒少”的字句,只说“脉浮紧,法当身疼痛,宜以汗解之。假令尺中迟者,不可发汗,以荣气不足,血少故也。”《活人书》只列举了“尺中迟,血少”的话语,擅自添加了“寒少热多”四个字加在上面,因而编入这个问题中,这是为什么呢?对于尺脉迟的证候,本应收入不可发汗的门类中。
刘氏指出:张仲景的书中只有“热多寒少”的条文,没有“寒多热少”的证候。又说:如果不烦躁、手足不厥冷,却是脉象反见浮缓,这是伤风,可用大青龙汤,或者说用桂枝麻黄各半汤。
In Taiyang disease (Taiyang syndrome), with a floating pulse, this indicates heat at the exterior and cold at the interior; Baihu Tang (White Tiger Decoction) is the primary treatment.
In Shaoyin disease (Shaoyin syndrome), with diarrhea containing undigested food (clearing of uncooked grains), this indicates cold in the interior and false heat at the exterior, accompanied by cold extremities (Jue Ni), a faint pulse nearly imperceptible, yet the body does not feel aversion to cold, and the person's face appears red. Alternatively, there may be abdominal pain, dry retching, sore throat, or cessation of diarrhea with an unpalpable pulse. Tongmai Sini Tang (Pulse-Returning Four Reversals Decoction) is indicated. (Cheng Wuji notes: Vomiting and diarrhea deplete fluids, so urination should decrease. If urination becomes frequent and profuse sweating occurs, it indicates that fluids are uncontrolled and Yang Qi is severely deficient. A faint pulse signifies the impending extinction of Yang. Without the false heat at the exterior, only the internal cold of clearing uncooked grains would constitute a pure Yin syndrome. Because there is false heat at the exterior, it indicates that Yang has not completely perished, and Tongmai Sini Tang can still be used to rescue it.)
When there is simultaneous vomiting and diarrhea, frequent urination, profuse sweating, diarrhea with undigested food, internal cold with external false heat, and a faint pulse nearly imperceptible, Sini Tang (Four Reversals Decoction) is the primary treatment. (Cheng Wuji notes: Diarrhea with undigested food is due to internal cold; persistent body heat is false heat at the exterior. Sweating allows Yang Qi to circulate outward, so cold extremities should not occur. However, if sweating is accompanied by cold extremities, it indicates severe deficiency of Yang Qi, and Tongmai Sini Tang should be used to consolidate Yang Qi.)
With a floating and slow pulse, indicating heat at the exterior and cold at the interior, accompanied by diarrhea with undigested food, Tongmai Sini Tang (Pulse-Returning Four Reversals Decoction) is the primary treatment. (Cheng Wuji notes: A floating pulse indicates external heat; a slow pulse indicates internal cold. Diarrhea with undigested food indicates severe internal cold, so Sini Tang (Four Reversals Decoction) should be used to warm the interior and dispel cold.)
In cases of external heat and internal cold, although the pulse is deep and slow, with slightly cold extremities and diarrhea with undigested food, this is internal cold. Therefore, Yin syndromes can also present with fever; this is external heat. (Sini Tang (Four Reversals Decoction) or Tongmai Sini Tang (Pulse-Returning Four Reversals Decoction) may be used.)
In cases of external cold and internal heat, the pulse must be slippery, accompanied by cold extremities and a dry tongue. Therefore, in Shaoyin disease (Shaoyin syndrome), aversion to cold and curling up indicate external cold; frequent spontaneous irritability and dislike for heavy clothing indicate internal heat. (Da Chaihu Tang (Major Bupleurum Decoction) is indicated.)
In Taiyang disease (Taiyang syndrome), with fever and aversion to cold, where heat predominates over cold, and the pulse is weak, this indicates "Wu Yang" (absence/deficiency of Yang). Sweating methods are contraindicated; Guizhi Er Yuebi Yi Tang (Cinnamon Twig Twice, Pueraria and Gypsum Decoction One Part) is appropriate. (Liu Shi states: If the pulse is slow, Xiaojianzhong Tang (Minor Construct the Middle Decoction) with Huangqi (Astragalus Root) or warming methods should be used.)
After eight or nine days of Taiyang disease (Taiyang syndrome), resembling malaria with fever and aversion to cold, where heat predominates over cold, if the patient does not vomit, bowel movements and urination are relatively normal, and episodes occur two or three times a day with a slightly rapid pulse, this indicates the disease is about to resolve. If the pulse is faint and there is aversion to cold, this indicates deficiency of both Yin and Yang; sweating, purging, or emetic methods are contraindicated. If the face abnormally appears flushed, the disease has not yet resolved because slight sweating has not occurred to expel pathogens, leading to itching of the skin; Guizhi Mahuang Ge Ban Tang (Half Cinnamon Twig and Half Ephedra Decoction) is the primary treatment.
Zhao Yide carefully analyzed Zhang Zhongjing's treatise, noting that "heat predominates over cold" appears in only two patterns. In the aforementioned pattern, Zhang Zhongjing's intent was likely to use the sixteen characters "onset seven or eight days, resembling malaria, fever, aversion to cold, heat predominates over cold" as the description of symptoms from onset to the present, while the following text describes preventive measures for potential future changes. It should be divided into three sections. If the patient does not vomit, bowel movements and urination are normal, episodes occur two or three times a day, and the pulse is slightly rapid, this is a sign of impending resolution. This section describes a harmonious interior without pathology; a faint pulse indicates weak pathogens, and a rapid pulse indicates balanced Yin and Yang, signaling recovery without the need for sweating. If the pulse is faint and there is aversion to cold, this indicates deficiency of both Yin and Yang; sweating, purging, or emetic methods are contraindicated, and warming methods are appropriate. If the face abnormally appears flushed, the disease has not resolved because slight sweating has not occurred, causing itching; Guizhi Mahuang Ge Ban Tang (Half Cinnamon Twig and Half Ephedra Decoction) is required, and resolution depends on sweating. *Huo Ren Shu* (Book of Vitality) failed to understand the textual context, treating the nine characters "the patient does not vomit, bowel movements and urination are normal"—which belong to the resolving pattern—as another condition, and incorrectly applied Guizhi Mahuang Ge Ban Tang (Half Cinnamon Twig and Half Ephedra Decoction) to induce sweating. It omitted statements regarding contraindications for sweating, purging, and emesis, and the use of Guizhi Mahuang Ge Ban Tang (Half Cinnamon Twig and Half Ephedra Decoction), instead using diaphoretic drugs on a resolving pattern, which is erroneous. Regarding the second pattern, Zhang Zhongjing stated: "Taiyang disease, fever, aversion to cold, heat predominates over cold, weak pulse, loss of Yang, sweating is contraindicated, Guizhi Er Yuebi Yi Tang (Cinnamon Twig Twice, Pueraria and Gypsum Decoction One Part) is appropriate." *Huo Ren Shu* added the characters "du da" (very/severely) to "weak pulse," questioning whether Zhang Zhongjing's pulse description was deemed insufficient. Regarding the third pattern, "slow chi pulse," Zhang Zhongjing's original text did not mention "heat predominates over cold," but rather: "Floating-tight pulse suggests body pain, suitable for sweating. If the chi pulse is slow, sweating is contraindicated due to insufficient Ying Qi and blood deficiency." *Huo Ren Shu* merely cited "slow chi pulse, blood deficiency," arbitrarily added "cold less, heat more," and incorporated it into this discussion, which is incorrect. The case of a slow chi pulse should have been included in the chapter on contraindications for sweating.
Liu Shi pointed out that Zhang Zhongjing's work contains only the clause "heat predominates over cold," with no syndrome of "cold predominates over heat." Furthermore, if there is no irritability and no cold extremities, but the pulse is surprisingly floating and relaxed, this is Wind Injury (Shang Feng); Da Qinglong Tang (Major Green Dragon Decoction) or Guizhi Mahuang Ge Ban Tang (Half Cinnamon Twig and Half Ephedra Decoction) may be used.