太阳统摄之营卫，乃风寒始入之两途，风则伤卫，寒则伤营。卫气剽疾，统气而行脉
外，其用疏泄而属阳，邪之犯也易，故其犯之也则有汗，为虚邪。营气专精，统血而行
脉中，其体固密而属阴，邪之犯也难，故其犯之也则无汗，为实邪。夫冬固寒令也，然
春月余寒，秋末早寒，皆能致病，但有无汗，实邪证候显然，即可谓之伤寒，不必尽属隆
冬也。然太阳经也，膀胱腑也，由经视腑，则经为表，而腑为里矣。上编用桂枝汤解肌，所
以治风伤卫之表也，而未及卫分之里，故又立五苓散一方，佐桂枝以和卫分之里焉。此
篇用麻黄汤发汗，所以治寒伤营之表也，而未及营分之里，故又立桃核抵当方，佐麻黄
以攻营分之里焉。至于汗下失宜，过之则伤正而虚其阳，不及则热炽而伤其阴。虚其阳，
则从少阴阴化之证多，以太阳少阴为表里也。伤其阴，则从阳明阳化之证多，以太阳、阳
明递相传也，此篇中所以又有四逆、承气之治也。凡风伤卫之虚邪已列上编，兹以寒伤
营之实邪疏为中篇，使读者先会大意于胸中，斯临证处方，自不致误矣。
太阳病，或已发热，或未发热，必恶寒，体痛，呕逆，脉阴阳俱紧者，名曰伤寒。
【注】太阳病，即上编首条脉浮，头项强痛，恶寒之谓也。营，表阴也。寒，阴邪也。
寒邪伤人则营受之，从其类也。已发热者，寒邪束于皮毛，元府闭密，阳气郁而为热也。未
发热者，寒邪初入，尚未郁而为热，顷之即发热也。恶寒者，为寒所伤，故恶之也。必
恶寒者，谓不论已热未热，而必恶寒也。寒入其经，故体痛也。胃中之气被寒外束不能
发越，故呕逆也。寒性劲急，故脉阴阳俱紧也。此承上编首条言太阳病，又兼此脉此证
者，名曰伤寒。以为伤寒病之提纲。后凡称伤寒者，皆指此脉证而言也。
【集注】方有执曰∶或者，未定之辞；必者，定然之谓。曰或曰必者，言发热早晚不
一，而恶寒则定然即见也。
喻昌曰∶仲景虑恶寒、体痛、呕逆、又未发热，恐误认为阴经之证，故早于篇首揭
明此语以辨之。
程应旄曰∶伤寒阴阳俱紧之脉，大不同于中风阳浮而阴弱之缓脉矣。证与脉兼得其
实，然后乃得正其名曰，此太阳伤寒之病，而非中风所能混也。
魏荔彤曰∶伤寒、中风同一浮脉，而彼为浮缓，此为浮紧，阳邪舒散故缓，阴邪劲
急故紧。同为在表之浮，而一缓一紧，风寒迥异矣。
太阳病，头痛发热，身疼腰痛，骨节疼痛，恶风无汗而喘者，麻黄汤主之。
【注】此承上条而详言其证，以出其治也。太阳经脉起于目内 ，上额交巅，入络脑还
出，别下项，循肩膊内，挟脊抵腰中，至足小指出其端。寒邪客于其经，则营血凝涩，所
伤之处，无不痛也。营病者恶寒，卫病者恶风，今营病而恶风者，盖以风动则寒生，恶
则皆恶，未有恶寒而不恶风，恶风而不恶寒者。所以仲景于中风、伤寒证中，每互言之，
以是知中风、伤寒，不在恶寒、恶风上辨，而在微甚中别之也。无汗者，伤寒实邪，腠理
闭密，虽发热而汗不出，不似中风虚邪，发热而汗自出也。阳气被寒邪所遏，故逆而为
喘。主之以麻黄汤者，解表发汗，逐邪安正也。
【集注】成无己曰∶寒则伤营，头痛身疼腰痛，以致牵连骨节疼痛者，太阳经营血不利也。
程应旄曰∶头痛发热，太阳病皆然，而身疼腰痛，骨节疼痛，是寒伤营室，若风伤
卫，则无是也。恶风，太阳病皆然，而无汗而喘，是阳被壅遏，若风伤卫，则无是也。得
其所同，因以别其所异也。
沈明宗曰∶太阳之邪从皮毛而入，郁逆肺气，以故作喘。且寒主收敛，伤营则腠理
闭密，故用麻黄汤发之。
麻黄汤方
麻黄（去节，三两） 桂枝（二两） 甘草（炙，一两） 杏仁（汤浸，去皮尖，七十个）
上四味，以水九升，先煮麻黄，减二升，去上沫，纳诸药，煮取二升半，去渣，温
服八合，覆取微似汗，不须啜粥，余如桂枝法将息。
【方解】名曰麻黄汤者，君以麻黄也。麻黄性温，味辛而苦，其用在迅升；桂枝性温，
味辛而甘，其能在固表。证属有余，故主以麻黄必胜之算也；监以桂枝，制节之师也。杏
仁之苦温，佐麻黄逐邪而降逆；甘草之甘平，佐桂枝和内而拒外。饮入于胃，行气于元府，
输精于皮毛，斯毛脉合精，溱溱汗出，在表之邪，必尽去而不留；痛止喘平，寒热顿解，
不须啜粥而藉汗于谷也。必须煮掠去上沫者，恐令人烦，以其轻浮之气，过于引气上逆也。
其不用姜、枣者，以生姜之性横散于肌，碍麻黄之迅升；大枣之性泥滞于膈，碍杏仁之
速降，此欲急于直达，少缓则不迅，横散则不升矣。然此为纯阳之剂，过于发汗，如单
刀直入之将，用之若当，一战成功；不当，则不戢而召祸。故可一而不可再。如汗后不解，
盒饭以桂枝代之。此方为仲景开表逐邪发汗第一峻药也。庸工不知其制在温覆取汗，若
不温覆取汗，则不峻也，遂谓麻黄专能发表不治他病。孰知此汤合桂枝汤，名麻桂各半
汤，用以和太阳留连未尽之寒热。去杏仁、加石膏，合桂枝汤。名桂枝二越婢一汤，用以
解太阳热多寒少之寒热，若阳盛于内，无汗而喘者，又有麻黄杏仁甘草石膏汤，以解散
太阴肺家之邪；若阴盛于内而无汗者，又有麻黄附子细辛甘草汤，以温散少阴肾家之寒。
《金匮要略》以此方去桂枝，《千金方》以此方桂枝易桂，皆名还魂汤，用以治邪在太阴，
卒中暴厥，口噤气绝，下咽奏效，而皆不温覆取汗。因是而知麻黄汤之峻与不峻，在温
覆与不温覆也。此仲景用方之心法，岂常人之所得而窥耶！
【集解】王肯堂曰∶此方为元气不虚者设也。如挟时气者，宜十神汤；挟暑湿者，宜
正气汤；挟寒者，宜五积散；挟热者，宜通圣散；挟食者，宜养胃汤；挟痰者，宜芎苏
散。按∶肯堂之议诚当矣。然必证兼表里，邪因错杂，似伤寒而非伤寒者，乃可于诸方中
斟酌选用。若脉证与麻黄、桂枝吻合，自当遵仲景之法治之。即元气素虚，或平素有热，
不宜麻桂者，亦必如刘完素、张洁古法，缓缓消息治之，庶不误人。临病之工，宜详审焉。
吴绶曰∶凡伤寒，寒邪在表，闭其腠理，身痛拘急，恶寒无汗，须用麻黄辛苦之药，开
发腠理，逐寒邪，使汗出而解。惟夏月炎暑之时，虽有是证，宜加凉药方可用，如防风
通圣散、三黄石膏汤是也。
伤寒一日，太阳受之，脉若静者，为不传；颇欲吐，若躁烦，脉数急者，为传也。
【注】伤寒一日，太阳受之，当脉浮紧，或汗或未汗，若脉静如常，此人病脉不病，为
不传也。初病或呕未止颇欲吐，若躁烦脉数急者，此外邪不解，内热已成，病势欲传也。
宜以大青龙汤发表解热，以杀其势；或表里有热证者，则当以双解汤两解之也。
【集注】沈明宗曰∶此凭脉辨证，知邪传与不传也。脉浮而紧，为太阳正脉，乃静是
不传他经矣。若颇欲吐，或躁烦而脉数急，则邪机向里已着，势必传经为病也。
伤寒二三日，阳明、少阳证不见者，为不传也。
【注】伤寒二日，阳明受之，三日少阳受之，此其常也。若二三日，阳明证之不恶寒、
反恶热、身热心烦、口渴不眠等证，与少阳证之寒热往来、胸胁满、喜呕、口苦、耳聋
等证不见者，此为太阳邪轻热微，不传阳明、少阳也。
【集注】程知曰∶伤寒一二日太阳，二三日阳明，三四日少阳，四五日太阴，五六日
少阴，六七日厥阴，此第言其常耳！其中变证不一，有专经不传者，有越经传者，有传
一二经而即止者，有发于阳即入少阴者，有直中三阴者，有足经冤热而传手经者，有误
药而传变者。大抵热邪乘经之虚即传，若经实即不受邪而不传；阳邪胜则传，阴邪胜多
不传；故经谓脉静为不传，脉数急为欲传也。又曰∶足经自足上行胸腹头背，主一身之大
纲，故寒邪入之，即见于其经，若手经第行于胸手，不能主一身之大纲也。邪既入足经，
必传入手经，故感风寒之重者，头项痛、肩、背、肘节亦痛也。圣人言足不言手，足可该
手，手不可该足也，非不传手也。夫五脏六腑十二经，气相输，络相通，岂有传足而不
传手者哉！亦岂有伤足而不伤手者哉！虞天民谓∶热先手，寒先足。义亦可互通也。
程应旄曰∶伤寒之有六经，无非从浅深而定部署。以皮肤为太阳所辖，故署之太阳；
肌肉为阳明所辖，故署之阳明；筋膜为少阳所辖，故署之少阳云耳！所以华佗曰∶伤寒
一日在皮，二日在肤，三日在肌，四日在胸，五日在腹，六日入胃，只就躯壳间约略其浅
深，而并不署太阳、阳明等名。然则仲景之分太阳、阳明等，亦是画限之意，用以辖病也。
脉浮者，病在表，可发汗，宜麻黄汤。脉浮而数者，可发汗，宜麻黄汤。
【注】伤寒脉浮紧者，麻黄汤诚为主剂矣。今脉浮与浮数，似不在发汗之列，然视其病
皆伤寒无汗之表实，则不妨略脉而从证，亦可用麻黄汤汗之。观其不曰以麻黄汤发之、主
之，而皆曰可发汗，则有商量斟酌之意焉。
【集注】方有执曰∶伤寒脉本紧，不紧而浮，则邪见还表而欲散可知矣。发者，拓而
出之也；麻黄汤者，乘其欲散而拓出之也。或脉浮而数，伤寒之欲传也，而亦宜麻黄汤发
汗者，言乘寒邪有向表之浮，当散其数，而不令其至于传也。
程应旄曰∶麻黄汤为寒伤营之主剂，然亦当于脉与证之间互参酌之，不必泥定
“紧”之一字，始为合法也。脉浮无紧，似不在发汗之列，然视其证，一一寒伤营之表病，
则不妨略脉而详证，无汗，可发汗，定麻黄汤。若脉浮数，邪势欲传于里，亦不妨略证
而详脉，无汗，可发汗，亦宜麻黄汤。就此二者之脉与证互参之，其有脉见浮紧，证具
伤寒，二者俱符，又何麻黄汤之必在禁例哉！
刘宏璧曰∶但脉浮不紧，何以知其表寒实也？必然无汗始可发也。脉数何以知其未
入里也？以脉兼浮故可汗也。
太阳病，外证未解，脉浮弱者，当以汗解，宜桂枝汤。
【注】太阳病外证未解，谓太阳病表证未解也。若脉浮紧，是为伤寒外证未解。今脉
浮弱，是为中风外证未解也，故当以桂枝汤汗解之。
【集注】方有执曰∶外证未解，谓头痛、
项强、恶寒等证犹在也。浮弱即阳浮而阴弱。此言太阳证凡在未传变者，仍当从于解表，盖
严戒不得早下之意。
程知曰∶外证未解，脉见浮弱，即日久犹当以汗解。然只宜桂枝解肌之法，不宜误
行大汗之剂。至于不可误下，更不待言矣。
伤寒发汗已解，半日许复烦，脉浮数者，可更发汗，宜桂枝汤。
【注】伤寒服麻黄汤发汗，汗出已，热退身凉解，半日许复烦热而脉浮数者，是表邪
未尽退而复集也，可更发汗。其不用麻黄汤者，以其津液前已为发汗所伤，不堪再任麻
黄，故宜桂枝更汗可也。
【集注】方有执曰∶伤寒发汗者，服麻黄汤以发之之谓也。解，散也；复，重复也。既
解半日许，何事而复哉？言发汗或不如法，或汗后不谨风寒，而复烦热，脉转浮数也，故
曰可更发汗。更，改也。言当改前法，故曰宜桂枝汤。
喻昌曰∶用桂枝汤者，一以邪重犯卫，一以营虚不能复任麻黄也。
程应旄曰∶改前发汗之法为解肌，则虽主桂枝，不为犯伤寒之禁也。
汪琥曰∶仲景法脉浮而数者，可发汗，宜麻黄汤。然此条已曾用过麻黄汤矣，故当更
方以发其汗，宜桂枝汤。
发汗病不解，反恶寒者，虚故也，芍药甘草附子汤主之。
【按】发汗病不解之“不”字，当是衍文。盖发汗病不解，则当恶寒，今曰反恶寒者，正
所谓病解之义也。病解恶寒，始谓之虚。
【注】伤寒，发汗病不解，则当恶寒，非表虚也，是表邪犹在不解，仍当汗也。今发
汗汗出，病已解，不当恶寒矣。反恶寒者，非表邪也，乃阳虚不能卫外所致，故以芍药甘
草附子汤主之。盖用附子以扶阳，芍药以补阴，甘草佐附、芍补阴阳而调营卫也。
【集注】方有执曰∶未汗而恶寒，邪盛而表实；已汗而恶寒，邪退而表虚。汗出之后，
大邪退散，荣气衰微，卫气疏慢，而但恶寒，故曰虚。
芍药甘草附子汤方
芍药（三两） 甘草（炙，二两） 附子（炮去皮，破八片，一枚）
以上三味，以水五升，煮取一升五合，去滓，分温服。
【集解】程应旄曰∶伤寒发汗一法，原为去寒而设，若表已解，较前反恶寒者，非复
表邪可知。缘汗外泄而表遂虚，故主之以芍药甘草附子汤。芍药得桂枝则发表，得附子
则补表，甘草和中从阴分，敛戢其阳，阳回而虚者不虚矣。
发汗后恶寒者，虚故也；不恶寒但热者，实也，当和胃气，与调胃承气汤。
【注】伤寒发汗，汗出病解，必不恶寒，亦不恶热，始可为愈。若发汗后恶寒者，是
阳虚也，宜用芍药甘草附子汤主之。今发汗后不恶寒，但恶热，则是胃实也，故与调胃
承气汤泻热以和胃也。
【背景信息】
书名：订正仲景全书伤寒论注 作者：吴谦 朝代：清 章节：辨太阳病脉证并治中篇(1/6) 类别：伤寒
太阳经统摄的营气（营养之气）和卫气（防御之气），是风寒之邪初次入侵的两条途径。风邪容易损伤卫气，寒邪容易损伤营气。卫气剽悍滑疾，统帅气运行于脉管之外，其功能主疏泄而归属于阳，因此外邪侵犯它比较容易，所以受邪后会有汗出，属于虚邪。营气精纯专一，统帅血运行于脉管之内，其体质固密而归属于阴，因此外邪侵犯它比较困难，所以受邪后无汗，属于实邪。冬天确实是寒冷的季节，然而春末残留的寒气、秋末早来的寒气，都能导致疾病，只要出现无汗这一实邪证候明显，就可以称之为伤寒，不一定非要等到隆冬时节。然而太阳经与膀胱腑相表里，从经络角度看脏腑，则经络为表，腑脏为里。上编使用桂枝汤（Cinnamon Twig Decoction）来解除肌表之邪，这是治疗风邪伤及卫气的表证，但尚未涉及卫分里的层面，所以又设立五苓散（Poria Decoction）一方，辅助桂枝汤以调和卫分之里。本篇使用麻黄汤（Ephedra Decoction）来发汗，这是治疗寒邪伤及营气的表证，但尚未涉及营分里的层面，所以又设立桃核承气汤（Taohe Chengqi Decoction，原文作桃核抵当方，此处依语境指代攻逐瘀血之剂，通常对应桃核承气或抵当汤类，鉴于前文对比桂枝-五苓，此处多指桃核承气或抵当汤，原文写“桃核抵当方”，暂译为桃核抵当方 Taohe Didang Formula）一方，辅助麻黄汤以攻逐营分之里。至于发汗和攻下不当，过度则会损伤正气而使其阳气虚弱，不足则会导致热势炽盛而损伤阴液。阳气虚弱，则多表现为少阴病（Shaoyin Disease）阴寒化的证候，因为太阳与少阴互为表里。阴液受损，则多表现为阳明病（Yangming Disease）阳热化的证候，因为太阳与阳明依次相传，本篇中因此又有四逆汤（Sini Decoction）和承气汤（Chengqi Decoction）的治疗法度。凡是风伤卫气的虚邪已在上编列出，现在将寒伤营气的实邪梳理为中篇，使读者先在胸中领会大意，这样在临证处方时，自然就不会出错。
太阳病（Taiyang Disease），或者已经发热，或者尚未发热，必定恶寒（aversion to cold），身体疼痛，呕吐逆气，脉象寸关尺三部都紧的，名叫伤寒。
【注】太阳病，即上编首条所说的脉浮（floating pulse）、头项强痛（stiffness and pain in the head and nape）、恶寒的症状。营气，属于表层的阴气。寒邪，属于阴邪。寒邪伤人则营气受之，这是同类相感。已经发热的，是因为寒邪束缚皮毛，玄府（毛孔）闭密，阳气郁结而化为热。尚未发热的，是因为寒邪刚侵入，尚未郁结化为热，不久就会发热。恶寒，是因为被寒邪所伤，所以厌恶寒冷。必定恶寒，是说无论是否已经发热，都必然恶寒。寒邪侵入经脉，所以身体疼痛。胃中的气被寒邪外束不能发散，所以呕吐逆气。寒性劲急，所以脉象寸关尺三部都紧。这是承接上编首条论述太阳病，又兼有这些脉象和症状的，名叫伤寒。作为伤寒病的提纲。后来凡是称伤寒的，都是指这些脉证而言。
【集注】方有执说：所谓“或”，是不确定的说法；所谓“必”，是肯定的说法。说“或”说“必”，是说发热的时间早晚不一，而恶寒则是必然立即出现的。
喻昌说：张仲景担心患者恶寒、体痛、呕逆，且尚未发热，恐怕误认为是阴经的病证，所以在篇首明确揭示这些话来加以辨别。
程应旄说：伤寒脉象阴阳俱紧，与大不同于中风脉象阳浮而阴弱的缓脉不同。证候与脉象兼得其实质，然后才能正名，这是太阳伤寒的病，而不是中风所能混淆的。
魏荔彤说：伤寒和中风脉象都是浮脉，但中风是浮缓，伤寒是浮紧，阳邪舒散故脉缓，阴邪劲急故脉紧。同样是在表的浮脉，一缓一紧，风寒截然不同。
太阳病，头痛发热，身疼腰痛，骨节疼痛，恶风无汗而喘的，用麻黄汤主治。
【注】这是承接上一条详细阐述其证候，从而提出治疗方法。太阳经脉起于目内眦，上行至额部交于巅顶，入络于脑，复出分别下行项后，沿肩膊内侧，夹脊柱到达腰部，至足小趾端。寒邪客居在经脉中，则营血凝涩，受伤的地方，没有不痛的。营气生病则恶寒，卫气生病则恶风，现在营气生病却恶风，大概是因为风动则寒生，恶寒和恶风往往同时存在，没有只恶寒而不恶风的，也没有只恶风而不恶寒的。所以张仲景在中风和伤寒的证候中，常常互相提及，由此可知中风和伤寒的区别，不在于恶寒还是恶风，而在于程度的轻重。无汗，是因为伤寒实邪，腠理闭密，虽然发热但汗不出，不像中风虚邪，发热而汗自出。阳气被寒邪遏制，所以逆乱而为喘。用麻黄汤主治，是为了解表发汗，驱逐邪气安护正气。
【集注】成无己说：寒邪伤营，头痛、身疼、腰痛，以至于牵连骨节疼痛，是太阳经营血运行不利所致。
程应旄说：头痛发热，太阳病都是如此，但身疼、腰痛、骨节疼痛，是寒邪伤了营气，如果是风邪伤卫，就没有这些症状。恶风，太阳病都是如此，但无汗而喘，是阳气被壅遏，如果是风邪伤卫，就没有这些症状。找到它们的共同点，从而区别它们的不同之处。
沈明宗说：太阳的邪气从皮毛而入，郁逆肺气，所以故作喘。而且寒主收敛，伤营则腠理闭密，所以用麻黄汤发汗。
麻黄汤方
麻黄（去节，三两） 桂枝（二两） 甘草（炙，一两） 杏仁（汤浸，去皮尖，七十个）
以上四味药，用水九升，先煮麻黄，减少二升，去掉上面的浮沫，加入其他药物，煮取二升半，去渣，温服八合，覆盖衣被使微微出汗，不需要喝热粥，其余调养方法如同桂枝汤法。
【方解】名叫麻黄汤，是以麻黄为君药。麻黄性温，味辛而苦，作用在于迅速升散；桂枝性温，味辛而甘，能力在于固护肌表。证候属于有余（实证），所以主以麻黄是必胜的策略；辅以桂枝，是节制约束的军队。杏仁的苦温，佐助麻黄驱逐邪气而降逆；甘草的甘平，佐助桂枝调和内部而抵御外部。药液进入胃中，行气于玄府，输布精气于皮毛，这样毛脉合精，溱溱然汗出，在表的邪气，必定全部去除而不留；疼痛停止喘息平息，寒热顿时解除，不需要喝粥而借助谷气来发汗。必须煮掠去掉上面的浮沫，是恐怕引起心烦，因为那是轻浮之气，过于引导气机上逆。不用生姜、大枣的原因，是因为生姜的性质横散于肌肉，妨碍麻黄的迅速升散；大枣的性质黏滞于膈膜，妨碍杏仁的快速下降，这是想要急于直达病所，稍微迟缓就不迅速，横散就不能升散了。然而这是纯阳的药剂，发汗力量过猛，像单刀直入的将领，使用得当，一战成功；使用不当，则不收敛而招致祸患。所以可以一次使用而不可再次使用。如果发汗后病不解，应当用桂枝汤代替。此方是张仲景开表逐邪发汗的第一峻烈药物。庸医不知道它的制伏在于温覆取汗，如果不温覆取汗，就不峻烈了，于是认为麻黄专门能发表而不能治其他病。哪里知道此汤合桂枝汤，名叫麻桂各半汤（Mahuang Guizhi Banxia Baicao Decoction? No, Mahuang Guizhi Half-Decoction），用来调和太阳经留恋未尽的寒热。去掉杏仁、加石膏，合桂枝汤，名叫桂枝二越婢一汤（Guizhi Er Yuebi Yi Decoction），用来解太阳热多寒少的寒热，如果阳盛于内，无汗而喘的，又有麻黄杏仁甘草石膏汤（Mahuang Xingren Gancao Shigao Decoction），来解散太阴肺家的邪气；如果阴盛于内而无汗的，又有麻黄附子细辛甘草汤（Mahuang Fuzi Xixin Gancao Decoction），来温散少阴肾家的寒邪。《金匮要略》以此方去掉桂枝，《千金方》以此方桂枝换肉桂，都名叫还魂汤（Huanhun Decoction），用来治疗邪在太阴，卒中暴厥，口噤气绝，下咽奏效，而且都不需要温覆取汗。由此可知麻黄汤的峻烈与否，在于是否温覆取汗。这是张仲景用药的心法，难道是常人所能窥探的吗！
【集解】王肯堂说：此方是为元气不虚的人设立的。如果挟带时气者，宜用十神汤（Shishen Decoction）；挟带暑湿者，宜用正气汤（Zhengqi Decoction）；挟带寒者，宜用五积散（Wuji San）；挟带热者，宜用通圣散（Tongsheng San）；挟带食积者，宜用养胃汤（Yangwei Decoction）；挟带痰者，宜用芎苏散（Xiong Su San）。按：王肯堂的议论确实恰当。但是必须证候兼有表里，邪气错杂，似伤寒而非伤寒的，才可以在诸方中斟酌选用。如果脉证与麻黄汤、桂枝汤吻合，自然应当遵循张仲景的法度治疗。即使元气素来虚弱，或者平时有热，不宜用麻黄、桂枝的，也必须像刘完素、张洁古的方法，缓缓调治，才不会误人。临证的医生，应该详细审察。
吴绶说：凡是伤寒，寒邪在表，闭塞腠理，身体疼痛拘急，恶寒无汗，必须用麻黄辛苦的药物，开发腠理，驱逐寒邪，使汗出而解。只有夏月炎暑之时，虽然有这些证候，宜加凉药方可使用，如防风通圣散（Fangfeng Tongsheng San）、三黄石膏汤（Sanhuang Shigao Decoction）等。
伤寒第一天，太阳经受邪，脉象如果平静的，为不传变；很想吐，或者烦躁，脉数急的，为传变。
【注】伤寒第一天，太阳经受邪，应当脉浮紧，或者已发汗或未发汗，如果脉象平静如常，这是病人病脉不病，为不传变。初病或者呕吐未止很想吐，如果烦躁脉数急，这是外邪不解，内热已成，病势欲传变。宜用大青龙汤（Daqinglong Decoction）发表解热，以遏制病势；或者表里有热证的，则当用双解汤（Shuangjie Decoction）表里双解。
【集注】沈明宗说：这是凭脉辨证，知道邪气传变还是不传变。脉浮而紧，是太阳的正脉，脉静就是不传他经了。如果很想吐，或者烦躁而脉数急，则邪机向里已显著，势必传经为病。
伤寒二三日，阳明病、少阳病的证候不见的，为不传变。
【注】伤寒第二天，阳明经受邪，第三天少阳经受邪，这是常规情况。如果二三日，阳明病的不恶寒、反恶热、身热心烦、口渴不眠等证候，与少阳病的寒热往来、胸胁满闷、喜呕、口苦、耳聋等证候不见的，这是太阳邪轻热微，不传阳明、少阳。
【集注】程知说：伤寒一二日太阳，二三日阳明，三四日少阳，四五日太阴，五六日少阴，六七日厥阴，这只是说常规情况！其中变证不一，有专经不传的，有越经传的，有传一二经就停止的，有发于阳即入少阴的，有直中三阴的，有足经受热而传手经的，有误药而传变的。大抵热邪乘经之虚即传，如果经气实则不受邪而不传；阳邪胜则传，阴邪胜多不传；所以说脉静为不传，脉数急为欲传。又说：足经自足上行胸腹头背，主一身之大纲，所以寒邪入之，即见于其经，如果手经只行于胸手，不能主一身之大纲。邪既入足经，必传入手经，所以感受风寒重的，头项痛、肩、背、肘节也痛。圣人言足不言手，足可概手，手不可概足，不是不传手经。五脏六腑十二经，气相输注，络脉相通，岂有传足而不传手的呢？岂有伤足而不伤手的呢？虞天民说：热先手，寒先足。义理也可以互通。
程应旄说：伤寒的六经，无非是从浅深来确定部署。以皮肤为太阳所辖，所以署名为太阳；肌肉为阳明所辖，所以署名为阳明；筋膜为少阳所辖，所以署名为少阳罢了！所以华佗说：伤寒一日在皮，二日在肤，三日在肌，四日在胸，五日在腹，六日入胃，只是就躯壳间粗略划分浅深，并不署太阳、阳明等名。那么张仲景区分太阳、阳明等，也是画限的意思，用来管辖病位。
脉浮的，病在表，可发汗，宜用麻黄汤。脉浮而数的，可发汗，宜用麻黄汤。
【注】伤寒脉浮紧的，麻黄汤诚然是主剂。现在脉浮与浮数，似乎不在发汗之列，然而看其病皆属伤寒无汗的表实证，则不妨略脉而从证，也可以用麻黄汤发汗。看他不说用麻黄汤发之、主之，而都说可发汗，则有商量斟酌的意思。
【集注】方有执说：伤寒脉本紧，不紧而浮，则邪气见还表而欲散可知矣。发，是拓而出之；麻黄汤，是乘其欲散而拓出之。或者脉浮而数，是伤寒欲传变，但也宜用麻黄汤发汗的，是说乘寒邪有向表的浮脉，当散其数，而不令其至于传变。
程应旄说：麻黄汤是寒伤营的主剂，但也应当在脉与证之间互参酌，不必死守“紧”之一字，始为合法。脉浮无紧，似乎不在发汗之列，然而看其证，一一符合寒伤营的表病，则不妨略脉而详证，无汗，可发汗，定用麻黄汤。如果脉浮数，邪势欲传于里，也不妨略证而详脉，无汗，可发汗，也宜用麻黄汤。就此二者之脉与证互参，如果有脉见浮紧，证具伤寒，二者俱符，又有什么麻黄汤的禁忌呢！
刘宏璧说：但脉浮不紧，怎么知道是表寒实呢？必然无汗才可发汗。脉数怎么知道未入里呢？因为脉兼浮所以可汗。
太阳病，外证未解，脉浮弱的，当以汗解，宜用桂枝汤。
【注】太阳病外证未解，是说太阳病表证未解。如果脉浮紧，是为伤寒外证未解。现在脉浮弱，是为中风外证未解，所以当用桂枝汤汗解。
【集注】方有执说：外证未解，是说头痛、项强、恶寒等证还在。浮弱即阳浮而阴弱。这里说太阳证凡在未传变的，仍应当从解表，大概是严厉告诫不得早下的意思。
程知说：外证未解，脉见浮弱，即使日久也应当以汗解。然而只宜桂枝解肌的方法，不宜误行大汗的药剂。至于不可误下，更不用说。
伤寒发汗已解，半天左右又烦，脉浮数的，可再发汗，宜用桂枝汤。
【注】伤寒服麻黄汤发汗，汗出已，热退身凉解，半天左右又烦热而脉浮数的，是表邪未尽退而复聚，可以再发汗。不用麻黄汤的原因，是因为津液前已被发汗所伤，不堪再承受麻黄，所以宜用桂枝汤更汗。
【集注】方有执说：伤寒发汗，是服麻黄汤以发之的意思。解，散也；复，重复也。既解半天左右，什么事又重复了呢？是说发汗不如法，或者汗后不谨风寒，而复烦热，脉转浮数，所以说可再发汗。更，改也。是说应当改前法，所以说宜桂枝汤。
喻昌说：用桂枝汤的原因，一是邪重犯卫，一是营虚不能复任麻黄。
程应旄说：改前发汗之法为解肌，则虽主桂枝，不为犯伤寒之禁。
汪琥说：张仲景法脉浮而数者，可发汗，宜麻黄汤。然而此条已曾用过麻黄汤了，故当更方以发其汗，宜桂枝汤。
发汗病不解，反恶寒的，是虚证，芍药甘草附子汤（Shaoyao Gancao Fuzi Decoction）主治。
【按】发汗病不解的“不”字，可能是衍文。盖发汗病不解，则当恶寒，现在说反恶寒的，正是所谓病解之义。病解恶寒，始谓之虚。
【注】伤寒，发汗病不解，则当恶寒，非表虚，是表邪犹在不解，仍当汗。现在发汗汗出，病已解，不当恶寒。反恶寒的，非表邪，乃阳虚不能卫外所致，所以用芍药甘草附子汤主治。盖用附子以扶阳，芍药以补阴，甘草佐附子、芍药补阴阳而调营卫。
【集注】方有执说：未汗而恶寒，邪盛而表实；已汗而恶寒，邪退而表虚。汗出之后，大邪退散，荣气衰微，卫气疏慢，而但恶寒，所以说虚。
芍药甘草附子汤方
芍药（三两） 甘草（炙，二两） 附子（炮去皮，破八片，一枚）
以上三味药，用水五升，煮取一升五合，去滓，分温服。
【集解】程应旄说：伤寒发汗一法，原为去寒而设，如果表已解，较前反恶寒的，非复表邪可知。缘汗外泄而表遂虚，所以主之以芍药甘草附子汤。芍药得桂枝则发表，得附子则补表，甘草和中从阴分，敛戢其阳，阳回而虚者不虚矣。
发汗后恶寒的，是虚证；不恶寒但热的，是实证，当和胃气，与调胃承气汤（Tiaowei Chengqi Decoction）。
【注】伤寒发汗，汗出病解，必不恶寒，亦不恶热，始可为愈。如果发汗后恶寒的，是阳虚，宜用芍药甘草附子汤主治。现在发汗后不恶寒，但恶热，则是胃实，所以给调胃承气汤泻热以和胃。
Background Information:
Book Title: Dingzheng Zhongjing Quanshanghan Lun Zhu (Corrected Annotations on the Complete Works of Zhang Zhongjing: Treatise on Cold Damage)
Author: Wu Qian
Dynasty: Qing
Chapter: Differentiating Pulse, Syndrome and Treatment of Taiyang Disease (Part 1/6)
Category: Shanghan (Cold Damage)
The Ying (Nutritive Qi) and Wei (Defensive Qi) governed by the Taiyang (Greater Yang) meridian are the two pathways through which Wind-Cold pathogens first enter the body. Wind pathogen injures the Wei Qi, while Cold pathogen injures the Ying Qi. The Wei Qi is swift and vigorous, governing Qi and circulating outside the vessels; its function is dispersion and excretion, belonging to Yang. Therefore, it is easily invaded by pathogens, resulting in sweating upon invasion, which constitutes a Deficient Pathogen (Xu Xie). The Ying Qi is pure and concentrated, governing Blood and circulating inside the vessels; its structure is solid and dense, belonging to Yin. Therefore, it is difficult for pathogens to invade, resulting in an absence of sweating upon invasion, which constitutes an Excess Pathogen (Shi Xie). Although Winter is the season of Cold, residual Cold in Spring and early Cold in late Autumn can also cause disease. As long as the symptom of anhidrosis (absence of sweating) appears, indicating an Excess Pathogen syndrome, it can be called Shanghan (Cold Damage), not necessarily limited to the depth of Winter. However, the Taiyang Meridian corresponds to the Bladder Organ. Viewing from the meridian to the organ, the meridian is Exterior and the organ is Interior. In the previous section, Guizhi Tang (Cinnamon Twig Decoction) was used to resolve the muscle layer, treating the Exterior syndrome of Wind injuring the Wei Qi, but it did not address the Interior of the Wei division. Therefore, Wuling San (Five-Ingredient Powder with Poria) was established to assist Guizhi Tang in harmonizing the Interior of the Wei division. In this section, Mahuang Tang (Ephedra Decoction) is used to induce sweating, treating the Exterior syndrome of Cold injuring the Ying Qi, but it does not address the Interior of the Ying division. Therefore, the Peach Kernel and Earth-Shield Decoction (Taohé Dǐdāng Fāng, referring to blood-invigorating formulas like Taohong Siwu or Didang Tang contextually) is established to assist Mahuang Tang in attacking the stasis in the Interior of the Ying division. Regarding improper sweating and purging methods: excessive sweating damages Zheng Qi (Upright Qi) and depletes Yang, while insufficient sweating allows Heat to blaze and damage Yin. Depletion of Yang leads to many Yin-transformation syndromes of Shaoyin (Lesser Yin), because Taiyang and Shaoyin are exterior-interior pairs. Damage to Yin leads to many Yang-transformation syndromes of Yangming (Bright Yang), because Taiyang and Yangming transmit sequentially. This explains why Sinixi Tang (Four-Reverse Decoction) and Chengqi Tang (Purge the Ganglion Decoctions) treatments appear in this section. All deficient pathogenic conditions of Wind injuring the Wei have been listed in the previous section; here, the excess pathogenic conditions of Cold injuring the Ying are organized as the middle section, enabling readers to grasp the general principles beforehand, so that clinical prescription will naturally avoid errors.
In Taiyang Bing (Taiyang Disease), whether fever has already appeared or has not yet appeared, there must be aversion to cold, body pain, vomiting and reflux of Qi, and pulse tightness at both cun and chi positions. This is named Shanghan (Cold Damage).
[Annotation] Taiyang Bing refers to the pulse floating, stiffness and pain in the head and neck, and aversion to cold mentioned in the first article of the previous section. Ying Qi belongs to the Yin aspect of the Exterior. Cold is a Yin pathogen. When Cold pathogen injures the person, the Ying Qi receives the injury due to similarity. "Already feverish" means Cold pathogen binds the skin and hair, closing the Yuanfu (pores), causing Yang Qi to stagnate and transform into heat. "Not yet feverish" means Cold pathogen has just entered and has not yet stagnated to form heat; soon after, fever will appear. Aversion to cold occurs because one is injured by Cold, hence the aversion. "Must be aversive to cold" means regardless of whether fever has appeared or not, aversion to cold is inevitable. Cold entering the meridian causes body pain. The Qi in the stomach is bound externally by Cold and cannot disperse, causing vomiting and reflux. Cold nature is forceful and urgent, hence the pulse is tight at both Yin (chi) and Yang (cun) positions. This follows the first article of the previous section regarding Taiyang Bing, adding these specific pulses and syndromes, naming it Shanghan. It serves as the outline for Shanghan diseases. Henceforth, whenever Shanghan is mentioned, it refers to these pulses and syndromes.
[Collected Annotations] Fang Youzhi said: "Or" indicates uncertainty; "must" indicates certainty. Saying "or" and "must" implies that the timing of fever varies, but aversion to cold is invariably present immediately.
Yu Chang said: Zhang Zhongjing feared that aversion to cold, body pain, vomiting, and the absence of fever might be mistaken for a disease of the Yin meridians. Thus, he clarified this statement at the beginning of the chapter to differentiate it.
Cheng Yingmao said: The pulse of Shanghan being tight at both Yin and Yang positions is vastly different from the moderate pulse of wind-stroke where Yang floats and Yin is weak. Only when both syndrome and pulse match reality can it be correctly named Taiyang Shanghan, distinct from wind-stroke.
Wei Litong said: Both Shanghan and wind-stroke present with a floating pulse, but wind-stroke is floating-moderate, while Shanghan is floating-tight. Yang pathogen is dispersive, hence moderate; Yin pathogen is forceful and urgent, hence tight. Both are floating in the exterior, but one is moderate and the other tight, showing the distinct difference between Wind and Cold.
In Taiyang Bing, with headache, fever, body pain, lower back pain, joint pain, aversion to wind, anhidrosis, and wheezing, Mahuang Tang (Ephedra Decoction) is the primary treatment.
[Annotation] This elaborates on the syndrome following the previous article to propose the treatment. The Taiyang meridian originates from the inner canthus, ascends to the forehead, intersects at the vertex, enters to connect with the brain, emerges again, descends separately behind the neck, follows the shoulder blades internally, flanks the spine to reach the waist, and ends at the little toe. When Cold pathogen lodges in this meridian, Ying Blood becomes stagnant and sluggish, causing pain everywhere it injures. Ying pathology causes aversion to cold; Wei pathology causes aversion to wind. Now, Ying pathology presents with aversion to wind, likely because wind movement generates cold; aversion to cold and wind often coexist. There is no case of aversion to cold without aversion to wind, nor aversion to wind without aversion to cold. Therefore, Zhang Zhongjing often mentions them interchangeably in wind-stroke and Shanghan syndromes. This shows that distinguishing wind-stroke from Shanghan lies not in aversion to cold versus wind, but in their severity. Anhidrosis occurs because Shanghan is an excess pathogen, closing the couli (pores); although feverish, sweat does not come out, unlike wind-stroke's deficient pathogen where fever comes with spontaneous sweating. Yang Qi is suppressed by Cold pathogen, reversing upward to cause wheezing. Mahuang Tang is used to release the exterior, induce sweating, expel pathogens, and protect Zheng Qi.
[Collected Annotations] Cheng Wuji said: Cold injuring the Ying causes headache, body pain, lower back pain, extending to joint pain, due to impaired circulation of Ying Blood in the Taiyang meridian.
Cheng Yingmao said: Headache and fever are common to all Taiyang diseases, but body pain, lower back pain, and joint pain indicate Cold injuring the Ying chamber; if Wind injured the Wei, these would not occur. Aversion to wind is common to Taiyang diseases, but anhidrosis and wheezing indicate Yang obstruction; if Wind injured the Wei, these would not occur. By identifying similarities, one distinguishes differences.
Shen Mingzong said: Taiyang pathogens enter via the skin and hair, stagnating and reversing Lung Qi, thus causing wheezing. Moreover, Cold governs contraction; injuring Ying closes the couli, so Mahuang Tang is used to disperse.
Mahuang Tang Formula
Ephedrae Herba (Mahuang, 麻黄) - removed nodes, 3 liang
Cinnamomi Ramulus (Guizhi, 桂枝) - 2 liang
Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) - roasted, 1 liang
Pruni Semen Armeniacae Amarum (Xingren, 杏仁) - soaked in hot water, skin and tips removed, 70 seeds
These four ingredients are boiled in 9 sheng of water. First, boil Ephedra, reducing by 2 sheng, remove the foam on top. Add the remaining herbs, boil to obtain 2.5 sheng. Strain and take 0.8 sheng warm. Cover with blankets to induce slight sweating. No need to drink porridge. Rest and care follow the method of Guizhi Tang.
[Formula Analysis] Named Mahuang Tang because Ephedra is the Sovereign herb. Ephedra is warm in nature, pungent and bitter in taste, acting with rapid ascent. Cinnamon Twig is warm in nature, pungent and sweet in taste, capable of securing the exterior. Since the syndrome is Excess, Ephedra is the decisive strategy; Cinnamon Twig acts as the supervisor to regulate. Bitter-warm Apricot Seed assists Ephedra in expelling pathogens and descending rebellious Qi. Sweet-pacifying Licorice assists Cinnamon Twig in harmonizing the interior and resisting the exterior. Upon ingestion, Qi moves in the Yuanfu, essence is transported to the skin and hair. When Hair and Vessel essence combine, profuse sweating occurs. Exterior pathogens are completely expelled without retention; pain stops, wheezing subsides, cold and heat resolve instantly. No porridge is needed to borrow grain energy for sweating. The foam must be boiled off to prevent irritability, as its light and floating nature excessively guides Qi upward. Ginger and Jujube are omitted because Ginger's nature disperses horizontally in the muscles, hindering Ephedra's rapid ascent; Jujube's nature is sticky and obstructs the diaphragm, hindering Apricot Seed's rapid descent. This formula aims for rapid direct action; delay reduces speed, horizontal dispersion prevents ascent. However, this is a Pure Yang agent with excessive sweating power, like a general charging straight ahead. Used correctly, it wins in one battle; incorrectly, it invites disaster. Thus, it should be used once, not twice. If the condition persists after sweating, substitute with Guizhi Tang. This is Zhang Zhongjing's most potent first-line formula for releasing the exterior and expelling pathogens via sweating. Unskilled practitioners do not know its potency depends on covering with blankets to induce sweating. Without covering, it is not potent, leading them to believe Ephedra only releases the exterior and treats nothing else. They fail to realize that combining this decoction with Guizhi Tang creates Mahgui Banban Tang (Half-Mahuang Half-Guizhi Decoction) to harmonize lingering cold-heat in Taiyang. Removing Apricot Seed and adding Gypsum, combined with Guizhi Tang, creates Guizhi Er Yuebi Yi Tang (Guizhi Two-Yuebi One Decoction) to resolve heat-dominant cold-heat in Taiyang. If Yang is excessive internally with anhidrosis and wheezing, Mahuang Xingren Gancao Shigao Tang (Ephedra, Apricot Seed, Licorice, and Gypsum Decoction) is used to dissipate pathogens in the Taiyin Lung. If Yin is excessive internally with anhidrosis, Mahuang Fuzi Xixin Gancao Tang (Ephedra, Aconite, Asarum, and Licorice Decoction) is used to warm and dissipate Cold in the Shaoyin Kidney. The Jingui Yaolue removes Cinnamon Twig from this formula, and the Qianjin Fang replaces Cinnamon Twig with Cassia Bark, both named Huanhun Tang (Soul-Returning Decoction) to treat sudden syncope with locked jaw and absent breath due to pathogens in Taiyin, effective upon swallowing, without requiring blanket coverage. Thus, the potency of Mahuang Tang depends on blanket coverage. This is Zhang Zhongjing's secret method of using formulas, inaccessible to ordinary people!
[Collected Solutions] Wang Kentang said: This formula is designed for those with robust Zheng Qi. If complicated by seasonal pathogens, use Shishen Tang; by summer-dampness, use Zhengqi Tang; by Cold, use Wuji San; by Heat, use Tongsheng San; by food stagnation, use Yangwei Tang; by phlegm, use Xongsu San. Note: Kentang's discussion is indeed appropriate. However, it applies only when syndromes involve both exterior and interior, with mixed pathogens, resembling but not being Shanghan. If pulses and syndromes match Mahuang or Guizhi indications, one must follow Zhang Zhongjing's methods. Even if Zheng Qi is inherently weak or there is pre-existing heat, making Mahuang/Guizhi unsuitable, one must slowly adjust treatment following Liu Wansu and Zhang Jiegu's methods to avoid harming patients. Clinicians should examine carefully.
Wu Shou said: In all Shanghan, when Cold pathogen is in the exterior, closing the couli, causing body pain, stiffness, aversion to cold, and anhidrosis, one must use the pungent and bitter properties of Ephedra to open the couli, expel Cold, and resolve via sweating. Only in midsummer heat, even with these symptoms, cool herbs should be added before use, such as Fangfeng Tongsheng San or Sanhuang Shigao Tang.
On the first day of Shanghan, the Taiyang meridian is affected. If the pulse is calm, the disease does not transmit; if there is a strong desire to vomit, or restlessness, and the pulse is rapid and urgent, the disease is transmitting.
[Annotation] On the first day of Shanghan, affecting Taiyang, the pulse should be floating and tight. Whether sweating has occurred or not, if the pulse remains calm as usual, the patient's disease pulse does not match the disease state, indicating no transmission. Initial vomiting or a strong desire to vomit, along with restlessness and a rapid, urgent pulse, indicates external pathogens are unresolved and internal heat has formed, signaling impending transmission. Daqinglong Tang (Major Green Dragon Decoction) should be used to release the exterior and resolve heat to curb the momentum; or if there are exterior and interior heat syndromes, Shuangjie Tang (Double-Resolution Decoction) should be used for simultaneous resolution.
[Collected Annotations] Shen Mingzong said: This uses pulse differentiation to judge transmission. Floating and tight pulse is the correct Taiyang pulse; if calm, it does not transmit to other meridians. If there is a desire to vomit or restlessness with a rapid, urgent pulse, the pathogen is moving inward significantly, inevitably transmitting to cause disease.
On the second or third day of Shanghan, if Yangming and Shaoyang syndromes are not seen, the disease is not transmitting.
[Annotation] On the second day, Yangming is affected; on the third day, Shaoyang is affected; this is the normal sequence. If on the second or third day, Yangming syndromes (aversion to cold replaced by aversion to heat, feverish body, restlessness, thirst, insomnia) and Shaoyang syndromes (alternating chills and fever, fullness in chest and hypochondrium, frequent vomiting, bitter taste, deafness) are absent, it is because the Taiyang pathogen is mild and heat is slight, not transmitting to Yangming or Shaoyang.
[Collected Annotations] Cheng Zhi said: Day 1-2 Taiyang, Day 2-3 Yangming, Day 3-4 Shaoyang, Day 4-5 Taiyin, Day 5-6 Shaoyin, Day 6-7 Jueyin. This merely states the norm! Variations include: staying in one meridian without transmitting, skipping meridians, stopping after transmitting one or two meridians, entering Shaoyin directly from Yang, direct attack on the Three Yin meridians, hand meridian transmission from foot meridian heat, transmission due to medication error. Generally, Heat transmits when exploiting meridian deficiency; if the meridian is solid, it resists pathogens and does not transmit. Yang pathogen dominance leads to transmission; Yin pathogen dominance rarely transmits. Hence, calm pulse means no transmission, rapid/urgent pulse means impending transmission. Also, foot meridians ascend from feet to chest, abdomen, head, and back, governing the body's main framework. Thus, Cold entering manifests in foot meridians. Hand meridians only traverse chest and hands, not governing the main framework. Once pathogens enter foot meridians, they must transmit to hand meridians. Hence, severe Wind-Cold causes pain in head/neck, shoulders, back, and elbows. The Sages spoke of foot meridians but not hand meridians because foot meridians encompass hand meridians, but not vice versa; it is not that hand meridians do not transmit. The Five Zang and Six Fu organs and twelve meridians exchange Qi and connect via collaterals; how could transmission occur in foot meridians but not hand meridians? Or injury to foot meridians but not hand meridians? Yu Tianmin said: Heat affects hands first, Cold affects feet first. These ideas can be interrelated.
Cheng Yingmao said: The six meridians of Shanghan are arranged based on depth. Skin is governed by Taiyang, hence named Taiyang; Muscle is governed by Yangming, hence named Yangming; Fascia is governed by Shaoyang, hence named Shaoyang. Hua Tuo said: Day 1 in skin, Day 2 in flesh, Day 3 in muscle, Day 4 in chest, Day 5 in abdomen, Day 6 in stomach. This roughly delineates depth within the body shell without naming Taiyang or Yangming. Thus, Zhang Zhongjing's division into Taiyang, Yangming, etc., is also about setting boundaries to manage disease locations.
If the pulse is floating, the disease is in the exterior; sweating may be induced, preferably with Mahuang Tang. If the pulse is floating and rapid, sweating may be induced, preferably with Mahuang Tang.
[Annotation] For Shanghan with floating-tight pulse, Mahuang Tang is indeed the primary agent. Now, with floating or floating-rapid pulses, which seem outside the scope of sweating, observing that the syndrome is still exterior-excess Shanghan without sweating, one may overlook the pulse and focus on the syndrome, using Mahuang Tang to induce sweating. The text says "may induce sweating" rather than "governed by" or "released by" Mahuang Tang, implying discretion.
[Collected Annotations] Fang Youzhi said: Shanghan pulse is typically tight; if floating instead, it indicates the pathogen is returning to the exterior and wanting to disperse. "Release" means pushing it out. Mahuang Tang takes advantage of this desire to disperse to push it out. If floating and rapid, indicating impending transmission, Mahuang Tang is still suitable to induce sweating, taking advantage of the floating pulse indicating outward movement to dissipate the rapidity and prevent transmission.
Cheng Yingmao said: Mahuang Tang is the primary agent for Cold injuring Ying, but one must consider pulse and syndrome together, not rigidly adhering to "tight". Floating without tightness seems unsuitable for sweating, but if the syndrome matches Cold injuring Ying's exterior disease, one may overlook the pulse and detail the syndrome: anhidrosis allows sweating, definitively using Mahuang Tang. If floating and rapid, indicating pathogen moving inward, one may overlook the syndrome and detail the pulse: anhidrosis allows sweating, also suitable for Mahuang Tang. Comparing these two aspects of pulse and syndrome, if both floating-tight pulse and Shanghan syndrome match, what prohibition exists against Mahuang Tang!
Liu Hongbi said: How do we know it is exterior Cold-excess if the pulse is floating but not tight? Only if there is anhidrosis can sweating be induced. How do we know it hasn't entered the interior if the pulse is rapid? Because the pulse is also floating, sweating is permissible.
In Taiyang Bing, if exterior syndromes are unresolved and the pulse is floating and weak, sweating should be induced, preferably with Guizhi Tang (Cinnamon Twig Decoction).
[Annotation] "Exterior syndromes unresolved" means Taiyang exterior syndromes are unresolved. If the pulse is floating and tight, it is unresolved Shanghan exterior syndrome. Now, with floating and weak pulse, it is unresolved wind-stroke exterior syndrome, so Guizhi Tang should be used to induce sweating.
[Collected Annotations] Fang Youzhi said: "Exterior syndromes unresolved" means headache, neck stiffness, aversion to cold, etc., persist. Floating and weak corresponds to Yang floating and Yin weak. This states that for any Taiyang syndrome not yet transmitted, one should still resolve the exterior, strictly warning against premature purging.
Cheng Zhi said: Exterior syndromes unresolved with floating-weak pulse requires sweating even after a long time. However, only Guizhi Tang's muscle-resolving method is suitable; erroneous use of heavy sweating agents must be avoided. Prohibition against purging goes without saying.
After inducing sweating in Shanghan, if the condition resolves but restlessness returns after half a day, and the pulse is floating and rapid, sweating may be induced again, preferably with Guizhi Tang.
[Annotation] After taking Mahuang Tang for Shanghan, sweating occurs, heat recedes, body cools, and condition resolves. If restlessness and floating-rapid pulse return after half a day, it means exterior pathogens have not fully cleared and have re-aggregated. Sweating may be induced again. Mahuang Tang is not used because fluids were previously damaged by sweating and cannot withstand Mahuang again; thus, Guizhi Tang is preferred for subsequent sweating.
[Collected Annotations] Fang Youzhi said: "Inducing sweating in Shanghan" refers to taking Mahuang Tang to induce it. "Resolve" means disperse; "return" means repeat. Why repeat after resolving for half a day? It means improper sweating technique or failure to avoid wind-cold after sweating led to recurrent restlessness and heat, with pulse turning floating and rapid. Hence, "may induce sweating again." "Geng" means change. It means changing the previous method, hence Guizhi Tang is suitable.
Yu Chang said: Guizhi Tang is used because the pathogen is heavy and invades the Wei, and Ying is deficient, unable to withstand Mahuang again.
Cheng Yingmao said: Changing the previous sweating method to muscle-resolution means using Guizhi does not violate Shanghan prohibitions.
Wang Hu said: Zhang Zhongjing's rule states that floating and rapid pulse allows sweating, preferring Mahuang Tang. But this clause already used Mahuang Tang, so a new formula is needed to induce sweating, hence Guizhi Tang.
After inducing sweating, if the disease does not resolve but aversion to cold worsens, it is a deficiency syndrome; Shaoyao Gancao Fuzi Tang (Peony, Licorice, and Aconite Decoction) is the primary treatment.
[Note] The character "not" in "disease does not resolve" is likely a textual error. If the disease did not resolve after sweating, aversion to cold would be expected. Saying "worsens aversion to cold" implies the disease has resolved, leaving only deficiency. Disease resolution with aversion to cold defines deficiency.
[Annotation] In Shanghan, if the disease does not resolve after sweating, aversion to cold is expected, indicating exterior pathogen remains unresolved, requiring further sweating. Now, after sweating, the disease has resolved, and aversion to cold should cease. If aversion to cold persists/worsens, it is not due to exterior pathogen, but Yang deficiency failing to guard the exterior. Thus, Shaoyao Gancao Fuzi Tang is used. Aconite supports Yang; Peony nourishes Yin; Licorice assists Aconite and Peony to tonify Yin and Yang and harmonize Ying and Wei.
[Collected Annotations] Fang Youzhi said: Before sweating, aversion to cold indicates pathogen excess and exterior excess. After sweating, aversion to cold indicates pathogen retreat and exterior deficiency. After sweating, major pathogens disperse, Ying Qi declines, Wei Qi becomes lax, leading to mere aversion to cold, hence called deficiency.
Shaoyao Gancao Fuzi Tang Formula
Peoniae Radix Alba (Shaoyao, 芍药) - 3 liang
Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) - roasted, 2 liang
Aconiti Lateralis Radix Praeparata (Fuzi, 附子) - processed, skin removed, broken into eight pieces, 1 piece
These three ingredients are boiled in 5 sheng of water to obtain 1.5 sheng. Strain and take warm in divided doses.
[Collected Solutions] Cheng Yingmao said: The sweating method in Shanghan was originally set to remove Cold. If the exterior is resolved and aversion to cold is worse than before, it is clearly no longer an exterior pathogen. Sweat leakage causes exterior deficiency, so Shaoyao Gancao Fuzi Tang is used. Peony with Cinnamon Twig releases the exterior; Peony with Aconite tonifies the exterior. Licorice harmonizes the middle and draws from the Yin aspect, restraining Yang. When Yang returns, the deficiency is no longer deficient.
After inducing sweating, if aversion to cold occurs, it is deficiency; if there is no aversion to cold but only heat, it is excess. One should harmonize Stomach Qi, administering Tiaowei Chengqi Tang (Harmonizing the Stomach and Purging the Ganglion Decoction).
[Annotation] After Shanghan sweating, if the condition resolves, there should be neither aversion to cold nor aversion to heat, indicating cure. If aversion to cold occurs after sweating, it is Yang deficiency, treated with Shaoyao Gancao Fuzi Tang. Now, if there is no aversion to cold but only aversion to heat after sweating, it is Stomach excess, so Tiaowei Chengqi Tang is given to purge heat and harmonize the Stomach.