陶节庵曰凡证有头疼恶寒皆是伤寒无则皆否也何则盖伤寒则恶寒伤食则恶食理固然也但
在冬
时恶寒为甚盖冬时为正伤寒天气严凝风寒猛烈触冒之者恶寒殊甚其余时月虽恶寒亦微未若冬
时之恶寒为甚也冬时气寒腠理微密非辛甘温不可故以桂枝等药以治之然风与寒常相因寒则伤
荣恶寒头痛脉浮紧而无汗则用麻黄汤开发腠理以散邪得汗即愈风则伤卫头痛恶风脉浮缓而
自
汗则用桂枝汤充塞腠理以散邪汗止即愈经云甘辛发散为阳者是也若夫荣卫俱伤又非此二汤所
能治也须大青龙汤然此汤太峻亦有可代之者其非冬时有恶寒头痛之证皆宜辛凉之剂通表里以
和之则愈矣若以冬时所用桂枝辛温之药而通治之则杀人矣曰辛凉者何羌活冲和汤是也兼能代
大青龙汤为至稳呜呼一汤可代三方危险之药如坦夷其神乎哉过此则少阳阳明二经在乎半表半
里肌肉之间脉亦不浮不沉外证在阳明则有目疼鼻干不得眠之证脉似洪而长以葛根解肌汤升麻
汤治之在少阳则胸胁痛而耳聋脉见弦数以小柴胡汤加减而和之本方有加减法此二经不从标本
从乎中也余常以小柴胡汤加葛根芍药治少阳阳明俱病如拾芥过此不已则传阳明之本为入里矣
便作实热治之其外证悉罢谓无头痛恶寒脉见沉实不浮诂妄恶热六七日不大便口燥咽干而渴轻
则大柴胡汤重则三承气汤选用或曰邪既入里而作实无非大黄苦寒之药除下之何则用方之杂□
也余曰传来非一治之乃殊耳病有三焦俱伤者则痞满燥实全具则宜大承气汤浓朴苦温以去痞积
实苦寒以泄满芒硝咸寒以润燥软坚大黄苦寒以泄实去热病斯愈矣邪在中焦则有燥实坚三证故
用
调胃承气以甘草和中芒硝软坚润燥大黄泄实不用枳实浓朴以伤上焦氤氲轻清之元气调胃之
名于此立矣上焦受伤则痞而实用小承气汤枳实浓朴能除痞大黄之泄实去芒硝则不伤血分之真
阴谓不伐其根也若夫大柴胡汤则表邪尚有里证又急不得不下只得以此汤通表里而缓治之犹有
老弱及气血两虚之人不宜用此三阳之邪在里为患三时谓春夏秋也不头痛恶寒而反渴者此则温
病也暑病亦然比之温病则尤加热也治宜小柴胡汤盖此汤春可治温夏宜治暑秋能润燥又宜葛根
汤升麻汤解肌汤败毒散中暑而渴者柴胡石膏汤人参白虎汤看渴微甚而用无不效者经曰发热不
恶寒而渴者温病也若夫阴证则别有法不在此例矣
陶节庵说：凡是出现头痛、恶寒的症状，都是伤寒；如果没有这些症状，就都不是伤寒。为什么呢？因为伤寒会使人恶寒，伤食则使人厌恶食物，这是理所当然的。但是在冬季，恶寒的症状尤为严重。这是因为冬季是真正的伤寒高发期，天气严寒凝滞，风寒猛烈，触犯冒犯的人，恶寒非常严重。在其他季节，虽然也有恶寒，但程度轻微，不如冬季那样严重。
冬季气候寒冷，腠理（皮肤毛孔及肌肉间隙）致密，非辛甘温性的药物不可治疗，所以用桂枝汤等药物来治疗。然而，风邪与寒邪常相互关联。寒邪伤害营气，表现为头痛、恶寒、脉浮紧且无汗，此时应用麻黄汤开发腠理以驱散邪气，出汗后即刻痊愈；风邪伤害卫气，表现为头痛、恶风、脉浮缓且有自汗，此时应用桂枝汤充实腠理以驱散邪气，汗止后即刻痊愈。《内经》说：“甘辛发散为阳”，说的就是这种情况。
至于营卫俱伤的情况，就不是这两张方剂所能治疗的了，必须使用大青龙汤。然而此方药力过于峻猛，也有可以替代它的方剂。如果不是在冬季，但有恶寒、头痛的症状，都适宜用辛凉性质的药剂，疏通表里以调和身体，即可痊愈。如果用冬季所用的桂枝汤这类辛温药物通治所有情况，就会致人死亡。问：什么是辛凉之剂？答：羌活冲和汤就是，它兼能替代大青龙汤，最为稳妥。唉！一张汤剂可以替代三方危险的药物，如同将险途变为坦途，真是神妙啊！
除此之外，少阳经和阳明经的病证位于半表半里的肌肉之间，脉象既不浮也不沉。外证方面，若属阳明经，则有眼睛疼痛、鼻干、不能安睡等症状，脉象似洪大而长，用葛根解肌汤或升麻汤治疗；若属少阳经，则有胸胁疼痛、耳聋，脉象弦数，用小柴胡汤加减调和。小柴胡汤本方有加减法。这两条经络的病证不从标本论治，而从“中”论治。我常用小柴胡汤加葛根、芍药来治疗少阳和阳明同时发病的病症，就像从地上捡起草芥一样容易。
如果病情继续发展而不愈，则会传入阳明之本，成为入里的病证，便作为实热证来治疗。其外部症状全部消失，即没有头痛、恶寒，脉象沉实而不浮，谵语妄言，怕热，六七天不大便，口燥咽干而口渴。轻症用大柴胡汤，重症选用三承气汤之一。有人问：邪气既然已经入里形成实热，无非是用大黄这种苦寒药物通过泻下来清除，为什么用药如此复杂呢？我说：传变来源不一，治疗方法自然不同。
如果病邪导致上、中、下三焦都受伤，痞满燥实四证俱全，则宜用大承气汤。其中厚朴苦温以消除痞积，枳实苦寒以泄除胀满，芒硝咸寒以润燥软坚，大黄苦寒以泄实清热，病才能痊愈。如果邪气在中焦，则有燥、实、坚三种证候，故用调胃承气汤。其中甘草和中，芒硝软坚润燥，大黄泄实，不用枳实、厚朴以免损伤上焦氤氲轻清的元气，“调胃”之名由此确立。如果上焦受伤，则痞而实用，用小承气汤。枳实、厚朴能消除痞块，大黄泄实，去掉芒硝则不损伤血分的真阴，称为不伐其根本。
至于大柴胡汤，则是表邪尚存又有里证，又急需攻下，只得用此汤疏通表里而缓急治之。还有年老体弱及气血两虚的人，不宜使用这三张承气汤。如果是三阳经的邪气在里为患，在三时（春、夏、秋），如果不头痛恶寒反而口渴，这就是温病。暑病也是如此，比温病更加发热。治疗适宜用小柴胡汤，盖因该汤春季可治温病，夏季宜治暑病，秋季能润燥。又适宜用葛根汤、升麻汤、解肌汤、败毒散。中暑而口渴者，用柴胡石膏汤或人参白虎汤，根据口渴的轻重程度选用，无不有效。《内经》说：“发热不恶寒而口渴者，是温病。”至于阴证，则有另外的治疗方法，不在此例之中。
Tao Jie'an said: Whenever there are symptoms of headache and aversion to cold, it is Taiyang Cold Damage (Shanghan); if these symptoms are absent, it is not. Why? Because Cold Damage causes aversion to cold, while food stagnation causes aversion to food; this is the natural principle. However, in winter, aversion to cold is particularly severe. This is because winter is the time for true Cold Damage; the weather is freezing and condensed, wind-cold is fierce, and those who are exposed will experience severe aversion to cold. In other seasons, although there may be some aversion to cold, it is mild and not as severe as in winter.
In winter, the climate is cold, and the Couli (pores and interstitial spaces) are tight and dense; therefore, acrid-sweet-warm herbs are indispensable. Thus, Guizhi Tang (Cinnamon Twig Decoction) and similar formulas are used for treatment. However, Wind pathogen and Cold pathogen often accompany each other. When Cold damages Ying (Nutritive Qi), symptoms include headache, aversion to cold, floating-tight pulse, and absence of sweating; in this case, Mahuang Tang (Ephedra Decoction) should be used to open the Couli and disperse the pathogen. Recovery occurs once sweating ensues. When Wind damages Wei (Defensive Qi), symptoms include headache, aversion to wind, floating-slow pulse, and spontaneous sweating; in this case, Guizhi Tang (Cinnamon Twig Decoction) should be used to fill the Couli and disperse the pathogen. Recovery occurs once sweating stops. The Classic states: "Acrid and sweet substances that disperse belong to Yang." This refers to the aforementioned scenarios.
However, when both Ying and Wei are damaged, neither of these two formulas is sufficient; Da Qinglong Tang (Major Blue Green Dragon Decoction) must be used. Yet, this formula is too harsh, so there are alternatives. If the season is not winter, but there are symptoms of aversion to cold and headache, acrid-cool agents should be used to unblock the exterior and interior and harmonize the body, leading to recovery. Using acrid-warm medicines like Guizhi Tang indiscriminately would be fatal. Question: What are acrid-cool agents? Answer: Qianghuo Chonghe Tang (Notopterygium Harmonizing Decoction) is one such agent, which can also substitute for Da Qinglong Tang, making it very safe. Alas! One decoction can replace three dangerous formulas, turning peril into safety, truly miraculous.
Beyond this, Shaoyang (Lesser Yang) and Yangming (Yang Brightness) disorders lie between the exterior and interior, within the muscle layer. The pulse is neither floating nor sunken. Externally, Yangming manifestations include eye pain, nasal dryness, and insomnia; the pulse resembles a flooding-long pulse. These are treated with Gegen Jiemo Tang (Kudzu Muscle-Releasing Decoction) or Shengma Tang (Cimicifuga Decoction). Shaoyang manifestations include hypochondriac pain and deafness, with a wiry-rapid pulse; these are harmonized using Xiaochaihu Tang (Minor Bupleurum Decoction) with modifications. The base formula has specific modification rules. Disorders of these two meridians are treated according to the "Middle" principle rather than the Root or Branch. I often use Xiaochaihu Tang (Minor Bupleurum Decoction) added with Gegen (Kudzu Root) and Shaoyao (Peony Root) to treat simultaneous Shaoyang and Yangming diseases, which is as easy as picking up grass from the ground.
If the condition persists without improvement, it transmits to the root of Yangming, entering the interior, and becomes an Interior Excess-Heat syndrome. All external symptoms disappear, meaning no headache or aversion to cold; the pulse is deep, solid, and not floating; there is delirious speech, aversion to heat, constipation for six to seven days, dry mouth and throat with thirst. Mild cases are treated with Daxiehu Tang (Major Bupleurum Decoction); severe cases select among the Three Chengqi Decoctions. One might ask: Since the pathogen has entered the interior forming excess, why not simply use Kuhan (bitter-cold) drugs like Dahuang (Rhubarb) to purge downwards? Why is the prescription complex? I reply: The transmission sources vary, so treatments differ.
If the pathogen injures all three Jiao (Upper, Middle, Lower), presenting with fullness (Pi), distension (Man), dryness (Zao), and solidity (Shi), Dachengqi Tang (Major Order the Qi Decoction) is appropriate. Houpo (Magnolia Bark) is bitter-warm to remove Pi accumulation; Zhishi (Immature Bitter Orange) is bitter-cold to drain Man distension; Mangxiao (Mirabilite) is salty-cold to moisten Zao dryness and soften hardness; Dahuang (Rhubarb) is bitter-cold to drain Shi solidity and clear heat. Only then does the disease resolve. If the pathogen is in the Middle Jiao, presenting with dryness, solidity, and hardness, Tiaowei Chengqi Tang (Regulate the Stomach Order the Qi Decoction) is used. Gancao (Licorice) harmonizes the middle; Mangxiao softens hardness and moistens dryness; Dahuang drains solidity. Zhishi and Houpo are omitted to avoid damaging the ethereal, light, and clear Yuanqi (Original Qi) of the Upper Jiao. Hence the name "Regulate the Stomach." If the Upper Jiao is injured, resulting in Pi and Shi, Xiao Chengqi Tang (Minor Order the Qi Decoction) is used. Zhishi and Houpo remove Pi; Dahuang drains Shi; Mangxiao is omitted to avoid injuring the True Yin of the Blood aspect, preserving the root.
As for Daxiehu Tang (Major Bupleurum Decoction), it is used when exterior pathogens remain alongside interior syndromes requiring urgent purgation, thereby unblocking the exterior and interior while treating gently. It is contraindicated for the elderly and those with dual deficiency of Qi and Blood. Regarding San Yang (Three Yang) pathogens residing in the interior during the three seasons (Spring, Summer, Autumn): if there is no headache or aversion to cold, but instead thirst, this is Wenbing (Warm Disease). Shubing (Summerheat Disease) is similar but more febrile. Treatment favors Xiaochaihu Tang (Minor Bupleurum Decoction), as it treats Warm Disease in Spring, Summerheat in Summer, and moistens dryness in Autumn. Additionally, Gegen Tang (Kudzu Decoction), Shengma Tang (Cimicifuga Decoction), Jiemo Tang (Muscle-Releasing Decoction), and Baidu San (Detoxify Poison Powder) are suitable. For summerheat with thirst, Chaihu Shigao Tang (Bupleurum and Gypsum Decoction) or Renshen Baibu Tang (Ginseng White Tiger Decoction) are selected based on the severity of thirst, proving effective. The Classic states: "Fever without aversion to cold accompanied by thirst indicates Warm Disease." Yin syndromes have separate methods and are not covered here.