病机云破伤风者同伤寒证治通于表里分别阴阳有在表有在里有在半表半里者在里宜下在
表
宜汗在表里之间宜和解不可过其治也故表脉浮而无力者太阳也脉长而有力者阳明也脉浮而弦
小者少阳也若明此三法而施治不中病者鲜矣
原病式云夫破伤中风之由者因疮热甚郁结而荣卫不得宣通怫热因之遍体故多白痂是时疮
口闭
塞气难通泄热甚则生风也不已则表传于里亦犹触冒伤寒怫热郁甚不解则表传于里者也但有风
热微甚兼化故殊异矣大法破伤中风风热燥甚怫郁在表而里气尚平者善伸数欠筋脉拘急或时恶
寒或筋惕而搐脉浮数而弦也宜以辛热治风之药开冲结滞而愈犹伤寒表热怫郁而以麻黄汤辛热
发散者也凡用辛热开冲风热结滞宜以寒药佐之则良免致药中病而风热转甚也如治伤寒发热用
麻黄桂枝加黄芩石膏知母之类是也若世以甘草滑石葱豉寒药发散甚妙若表不已渐伤入里里又
未太甚而脉在肌肉者宜以退风热开结滞之寒药调之或微加治风辛热亦得犹伤寒在半表半里而
以小柴胡和解之也若里热已甚而舌强口噤项背反张惊搐惕搦涎唾稠粘胸腹满塞而或便溺闭结
或时汗出脉洪数而弦也然汗出者由风热郁甚于里而表热稍罢则腠理疏泄而心火热甚故汗出也
法宜除风散结寒药下之后以退风热开结滞之寒药调之而热退结散则风自愈矣凡治此亦宜按摩
导引及以药斡开牙关勿令口噤使粥药得下也
按此论表里中脉病证治至为详尽前人所未论也
《病机》中说：破伤风病的证治，与伤寒病相通，需根据表、里、半表半里进行区分。病在表的宜用汗法，病在里的宜用下法，病在半表半里的宜用和解法，治疗不可过度。因此，脉象浮而无力的是太阳病（太阳经受邪所致的病证）；脉象长而有力的是阳明病（阳明经受邪所致的病证）；脉象浮而弦小的是少阳病（少阳经受邪所致的病证）。如果明了这三种治法并加以施治，不中病的情况就很少了。
《原病式》中说：破伤中风的原因，是因为疮口热毒郁结，导致营卫之气不能宣通，郁热遍布全身，所以常出现白色痂皮。此时疮口闭塞，气机难以通畅排泄，热盛则生风。若不及时控制，病邪由表传入于里，这也如同触犯伤寒，郁热深重不解，从而由表传里的道理一样。只是由于风热的轻重及兼夹转化的不同，所以表现有所差异。
大凡治疗破伤中风，若风热燥盛，郁结在表而里气尚且平和，表现为喜欢伸展、频繁打哈欠、筋脉拘急，有时恶寒，或肌肉跳动抽搐，脉象浮数而弦的，宜用辛热性质的祛风药来开通冲散结滞，即可痊愈。这就像伤寒表热郁结，使用麻黄汤辛温发散的治法一样。凡是使用辛热药物开通冲散风热结滞时，宜配合寒性药物作为佐使，这样较好，以免药力虽中病但风热反而加重。例如治疗伤寒发热，在使用麻黄、桂枝时加入黄芩、石膏、知母等寒凉药物就是这种用法。如果世医使用甘草、滑石、葱白、豆豉等寒性药物发散，也非常巧妙。
如果表证未解，逐渐伤及入里，但里证尚未太严重，脉象出现在肌肉层（提示病位较深但未至脏腑），宜用退风热、开结滞的寒性药物调理，或者稍微加入一些治风的辛热药物也可以。这就像伤寒病在半表半里，用小柴胡汤进行和解的治法一样。
如果里热已经非常严重，表现为舌体僵硬、牙关紧闭、项背强直反张、惊悸抽搐、唾液稠粘、胸腹满塞，或者大小便闭结，有时出汗，脉象洪数而弦的。其中出汗的原因，是由于风热郁结在里，而表热稍减，导致腠理疏松泄越，加上心火亢盛，所以出汗。治疗方法宜先用除风散结的寒性药物攻下，之后再用退风热、开结滞的寒性药物调理，待热退结散，风证自然痊愈。
凡是治疗此病，也适宜进行按摩导引，并用药物撬开牙关，不要让牙关紧闭，以便能让粥药服下。
按语：这篇论述关于表、里、中的脉象、病证和治疗，详尽无遗，是前人未曾论及的。
The *Bingji* states: The pathogenesis and treatment of tetanus (Po Shang Feng) are consistent with those of cold damage diseases, requiring differentiation into exterior, interior, and half-exterior half-interior stages. For pathogens in the exterior, sweating methods should be used; for pathogens in the interior, purgative methods should be used; for pathogens in the half-exterior half-interior stage, harmonizing methods should be used. Treatment must not be excessive. Therefore, a floating but weak pulse indicates Taiyang disease (disease of the Taiyang channel); a long and forceful pulse indicates Yangming disease (disease of the Yangming channel); a floating, wiry, and small pulse indicates Shaoyang disease (disease of the Shaoyang channel). If these three methods are understood and applied correctly, cases of ineffective treatment will be rare.
The *Yuanbing Shi* states: The cause of tetanus following trauma is due to intense heat and toxin accumulation at the wound site, obstructing the circulation of Ying (Nutrient) and Wei (Defensive) Qi. This stagnation generates internal heat spreading throughout the body, often resulting in white scabs. At this time, the wound closes, preventing the smooth flow and discharge of Qi. Excessive heat generates wind. If unchecked, the pathogen transmits from the exterior to the interior. This is similar to contracting cold damage, where severe stagnation and heat fail to resolve, leading to transmission from the exterior to the interior. However, differences arise due to variations in the severity of wind-heat and their transformations.
Generally, for treating tetanus, if wind-heat and dryness are severe and stagnant in the exterior while the interior Qi remains peaceful, symptoms may include frequent stretching and yawning, tendon and vessel stiffness, occasional aversion to cold, or muscle twitching and convulsions, with a floating, rapid, and wiry pulse. In such cases, acrid-hot herbs that dispel wind should be used to open and disperse the stagnation, leading to recovery. This is analogous to using Mahuang Tang (Ephedra Decoction) for acrid-warm diaphoresis in cold damage with exterior heat stagnation. When using acrid-hot herbs to disperse wind-heat stagnation, it is advisable to combine them with cold-natured herbs as adjuncts to prevent the wind-heat from intensifying despite the medication targeting the pathology. For example, when treating fever from cold damage, adding cold herbs like Huangqin (Scutellaria Root), Shigao (Gypsum Fibrosum), and Zhimu (Anemarrhenae Rhizoma) to Mahuang (Ephedrae Herba) and Guizhi (Cinnamomi Ramulus) exemplifies this approach. Alternatively, using cold herbs for dispersal such as Gancao (Licorice Root), Huashi (Talcum), Congbai (Allii Fistulosi Bulbus), and Chidouchi (Fermented Soybean) is also highly effective.
If the exterior syndrome persists and gradually penetrates inward, but the interior condition is not yet severe, and the pulse is felt at the muscle level (indicating a deeper location but not yet involving the zang-fu organs), cold-natured herbs that clear wind-heat and resolve stagnation should be used for regulation. Slightly adding acrid-hot herbs for wind disorders is also acceptable. This corresponds to the use of Xiaochaihu Tang (Minor Bupleurum Decoction) for harmonization in cold damage located in the half-exterior half-interior stage.
If interior heat is already severe, presenting with a stiff tongue, locked jaw, opisthotonos (backward arching of the neck and back),惊搐 (startle and convulsions), thick and sticky saliva, chest and abdominal fullness and obstruction, constipation or urinary retention, and occasional sweating, with a surging, rapid, and wiry pulse, the sweating occurs because wind-heat is severely stagnant in the interior while exterior heat has slightly subsided, causing the pores to open and leak, combined with excessive heart fire. The treatment method should first employ cold-natured herbs to dispel wind and resolve stagnation via purgation, followed by regulation with cold-natured herbs that clear wind-heat and open stagnation. Once the heat recedes and stagnation dissipates, the wind disorder will naturally heal.
In all treatments for this condition, massage and Dao Yin (guiding and pulling exercises) are appropriate. Medications should also be used to pry open the jaw to prevent lockjaw, ensuring that gruel and medicine can be administered.
Commentary: This discussion on the pulses, pathologies, and treatments concerning the exterior, interior, and middle aspects is extremely comprehensive and detailed, representing insights not previously discussed by earlier authorities.