仲景云太阳病发热无汗而反恶寒名曰刚 太阳病发热汗出而不恶寒名曰柔 病身热足寒
颈项
强急恶寒时头热面赤独头动摇卒口噤背反张者 病也若发其汗寒湿相得其表益虚即恶寒甚
按活人云太阳经先因伤风又感寒湿而致然也古人谓之 又作痉痉者强直也古人以强直为 外
证与伤寒相似但其脉沉迟弦细而项背反张强硬如发痫状为异耳察其有汗无汗以分刚柔二 无
汗葛根汤主之有汗桂枝加栝蒌汤主之刚 胸满口噤脚挛急咬齿当行大承气汤愚谓刚 柔 并
属太阳至于项强口噤一证例太阳兼阳明也因有阳明故不宜发汗而有用大承气汤法者难知云伤
寒证五种皆属太阳余经不言圣人之大意也若头低视下手足牵引肘膝相构阳明 也若一目或
左或右邪视并一手一足搐搦者少阳 也汗之止之和之下之各随其经可使必已盖谓此也
仲景云太阳病发汗太多因致 风病下之则 复
发汗必拘急 疮家虽身疼痛不可发汗汗出则
按此谓发汗下之而致 则不专于风寒湿之外传矣是又因坏证而成也发汗下之太过皆亡津
液损血之所由也
脉经云太阳病发热脉沉而细者名曰 为难治 夫 脉按之紧如弦直上下行 家其脉伏
坚直上下 腹暴胀大为欲解脉反伏弦者 病发其汗已其脉 如蛇
按 证属风寒湿所伤有汗者脉必浮缓无汗者脉必浮紧若其脉沉细者湿所伤也坚直上下行
皆紧之象也发汗已如蛇亡津液而无胃气之象也
张仲景说:太阳病,发热、无汗,反而恶寒的,称为刚痉;太阳病,发热、汗出,不恶寒的,称为柔痉。
患痉病的人,身体发热,脚部发冷,颈项强直紧急,恶寒,有时头部发热,面色发红,只有头部动摇,突然牙关紧闭,角弓反张(背部向后反折如弓状),这就是痉病。如果对此误用发汗法,寒湿之邪相合,导致表气更加虚弱,就会使恶寒症状加剧。
按《活人书》所说,太阳经先因伤风,又感受寒湿而致病,这就是古人所说的“痓”(zhì)。又写作“痉”,“痉”的意思是强直。古人将强直作为外证,其表现与伤寒相似,但脉象沉迟、弦细,且出现项背反张、强硬,如同癫痫发作的样子,这是不同的地方。通过观察患者有汗还是无汗,来区分刚痉和柔痉两种类型。无汗的,用葛根汤主治;有汗的,用桂枝加栝蒌汤主治。
如果是刚痉,出现胸满、牙关紧闭、脚部拘挛抽搐、咬紧牙齿等症状,应当使用大承气汤。我认为,刚痉和柔痉都属于太阳病范畴。至于项强、口噤这一证候,通常属于太阳病兼夹阳明病的情况。因为有阳明病的存在,所以不宜单纯发汗,而有使用大承气汤的方法,这一点很难理解。云岐子说:伤寒证候有五种,都归属于太阳,其他经络没有单独提及,这是圣人的深意所在。
如果头低垂、视物向下,手足牵引,肘膝相互靠拢,这是阳明痉病。如果一只眼睛向左或向右斜视,并且一只手或一条腿抽搐痉挛,这是少阳痉病。对于这三种情况,根据病情分别采用发汗、和解、攻下的方法,随其所属经络治疗,可以使疾病痊愈。大概说的就是这个意思。
张仲景说:太阳病,发汗过多,因而导致痉病;如果误用泻下法,则再次发汗,必然会导致肢体拘急挛缩。疮疡患者,虽然身体疼痛,也不可以发汗,如果发汗出汗,就会导致痉病。
按照此处的论述,这是由于发汗和泻下过度而导致的痉病,就不单单是风寒湿邪从外部侵袭所致了,这也是因为误治导致坏证而形成的。发汗和泻下太过,都是耗亡津液、损伤血液的原因。
夫痉病的脉象,按之紧如弦,直上下行。痉病患者的脉象伏坚,直上下行。腹部突然胀大,是病情欲解的表现;如果脉象反而伏弦,则是痉病发作。经过发汗治疗后,脉象像蛇行一样蜿蜒,这是津液亡失、没有胃气的征象。
痉病证候属于风寒湿邪所伤,有汗的患者脉象必定浮缓,无汗的患者脉象必定浮紧。如果脉象沉细,则是湿邪所伤。脉象坚直上下行,都是紧脉的象义。发汗之后,脉象像蛇行一样,是津液亡失且没有胃气的表现。
Zhang Zhongjing stated: In Taiyang disease (Taiyang syndrome), if there is fever, anhidrosis (absence of sweating), and aversion to cold, it is called Gang Jing (Rigid Spasm); if there is fever, diaphoresis (sweating), and no aversion to cold, it is called Rou Jing (Flaccid Spasm).
Patients suffering from Jing disease (Spasm) exhibit fever in the body but coldness in the feet, stiffness and tension in the neck and nape, aversion to cold, sometimes with heat in the head, redness of the face, isolated trembling of the head, sudden lockjaw (trismus), and opisthotonos (arching of the back like a bow). This constitutes Jing disease. If sweat-inducing methods are mistakenly applied, the pathogenic factors of cold and dampness combine, further weakening the exterior qi, thereby exacerbating the aversion to cold.
According to *Huo Ren Shu* (The Book That Saves Lives), the Taiyang channel is first injured by wind-pathogen and subsequently affected by cold-dampness. This was referred to by ancient physicians as "Zhi" (痓). It is also written as "Jing" (痉), which means rigidity. The ancients regarded rigidity as an external manifestation; although its presentation resembles Shanghan (Cold Damage), the pulse is deep, slow, wiry, and thin, accompanied by opisthotonos and rigidity of the neck and back resembling epilepsy, which distinguishes it. By observing whether the patient has sweat or not, one can differentiate between Gang Jing (Rigid Spasm) and Rou Jing (Flaccid Spasm). For cases without sweat, Gegen Tang (Kudzu Decoction) is the primary treatment; for cases with sweat, Guizhi Jia Gualou Tang (Cinnamon Twig Decoction plus Trichosanthes Root) is indicated.
In cases of Gang Jing presenting with chest fullness, lockjaw, spasmodic contraction of the legs, and teeth grinding, Dachengqi Tang (Major Order the Qi Decoction) should be administered. I contend that both Gang Jing and Rou Jing belong to the category of Taiyang disease. Regarding the symptoms of neck stiffness and lockjaw, they generally indicate a combination of Taiyang and Yangming diseases. Due to the involvement of Yangming, simple sweat-inducing therapy is contraindicated, and the use of Dachengqi Tang is appropriate, though this principle can be difficult to comprehend. Yun Qizi stated: Among the five types of Shanghan syndromes, all are attributed to Taiyang; other channels are not mentioned separately, reflecting the profound intent of the Sages.
If the head droops, vision is directed downward, limbs are pulled inward, and elbows and knees touch each other, this is Yangming Jing disease. If one eye deviates to the left or right, and one hand or foot exhibits tremors or spasms, this is Shaoyang Jing disease. For these three conditions, treatments such as inducing sweat, harmonizing, or purging should be applied according to the affected channel, ensuring recovery. This is likely what is meant here.
Zhang Zhongjing stated: In Taiyang disease, excessive sweating may lead to Jing disease; if purgation is mistakenly used, followed by subsequent sweating, it will inevitably result in limb contracture and spasms. Patients with sores and ulcers, even if experiencing body pain, must not undergo sweat-inducing therapy; if sweating occurs, it will induce Jing disease.
This passage indicates that Jing disease caused by excessive sweating and purgation is not solely due to the external invasion of wind, cold, and dampness, but also results from mismanagement leading to complex disorders (Bian Zheng). Excessive sweating and purgation are the causes of fluid exhaustion and blood damage.
*Mai Jing* (Pulse Classic) states: In Taiyang disease, if there is fever and the pulse is deep and thin, it is termed difficult to treat.
The pulse in Jing disease feels tight and wiry when pressed, extending straight up and down. The pulse of Jing patients is deep, firm, and extends straight up and down. Sudden abdominal distension indicates impending resolution; however, if the pulse becomes deep and wiry, it signifies the onset of Jing disease. After inducing sweat, if the pulse moves sinuously like a snake, it indicates the loss of fluids and the absence of Stomach Qi.
Jing disease syndromes are caused by wind-cold-dampness injury. Patients with sweat typically present with a floating and moderate pulse, while those without sweat present with a floating and tight pulse. A deep and thin pulse suggests dampness injury. A pulse that is firm and extends straight up and down reflects the image of a tight pulse. After sweating, a pulse moving like a snake indicates fluid exhaustion and lack of Stomach Qi.