羽流病伤寒。身热头痛。予诊之曰。邪在表。此表实证也。当汗之。以麻黄辈。数日愈。
论曰。或问伤寒因虚。故邪得以入之。今邪在表。何以为表实也。予曰。古人称邪之所凑。
其气必虚。留而不去为病则实。盖邪之入也。始因虚。及邪居中反为实矣。大抵调治伤寒。先要
明表里虚实。能明此四字。则仲景三百九十七法。可坐而定也。何以明之。有表实。有表虚。有
里实。有里虚。有表里俱实。有表里俱虚。予于表里虚实百证歌中。尝论之矣。仲景麻黄汤类。
为表实而设也。桂枝汤类。为表虚而设也。里实。承气之类。里虚。四逆理中之类。表里俱实。
所谓阳盛阴虚。下之则愈也。表里俱虚。所谓阴盛阳虚。汗之则愈也。
酒家朱三者。得伤寒。六七日。自颈以下无汗。手足厥冷。心下满。大便秘结。或者见其逆冷。
又汗出满闷。以为阴证。予诊其脉沉而紧。曰此证诚可疑。然大便结者为虚结也。安得为阴。脉
虽沉紧。为少阴证。然少阴证多矣。是自利未有秘结。予谓此半在表。半在里也。投以小柴胡汤。大便得通而愈。
论曰。伤寒。恶寒。手足冷。心下满。口不欲食。大便 。脉细者。此为阳微结。必有表复
有里也。脉沉亦在里也。汗出为阳微。假令纯阴结。不得复有外证。悉入在里。此为半在表半在
里也。脉虽沉紧。不得为少阴病。所以然者。阴不得有汗。今头汗出。故知非少阴也。可与小柴
胡汤。设不了了者。得屎而解也。难者曰。仲景云病患脉阴阳俱紧。及汗出者。亡阳也。此属少
阴。今云阴不得有汗。何也。今头汗出。故知非少阴也。何以头汗出。则知非少阴。予曰。此说
正是议议处。谓四肢冷。脉沉紧。腹满。全是少阴。然大便硬。头汗出。不得谓少阴。盖头者三
阳所聚。三阳自胸中而还。有头汗出。自是阴虚。故曰汗出为阳微。是阴不得有头汗也。若少阴
有头汗。则九死一生。故仲景平脉法云。心者火也。名火阴。其病。头无汗者可治。有汗者死。
心为手少阴。肾为足少阴。然相与为病。以意逆志。是谓得之。
A Daoist priest suffered from Shanghan (Cold Damage). He had fever and headache. I diagnosed him and said: The pathogenic factor is in the exterior; this is an Exterior Excess Syndrome (Biao Shi Zheng). It should be treated by inducing sweating, using formulas such as Mahuang Tang (Ephedra Decoction), and he would recover in a few days.
Discussion: Someone asked, "Shanghan occurs because of deficiency, allowing pathogens to enter. Now that the pathogen is in the exterior, why is it called an Exterior Excess Syndrome?" I replied, "The ancients said, 'Where the pathogenic factor gathers, the Qi must be deficient.' However, if the pathogen remains and does not leave, the disease condition becomes excess. Generally, when a pathogen enters, it initially exploits a deficiency, but once the pathogen resides within, the condition manifests as excess. In general, treating Shanghan requires first clarifying the concepts of Exterior, Interior, Deficiency, and Excess. If one understands these four terms, then Zhang Zhongjing's 397 treatment methods can be mastered with ease. How to distinguish them? There are Exterior Excess, Exterior Deficiency, Interior Excess, Interior Deficiency, simultaneous Exterior and Interior Excess, and simultaneous Exterior and Interior Deficiency. I have discussed these in my 'Song of Hundred Syndromes of Exterior/Interior and Deficiency/Excess'. Zhang Zhongjing's Mahuang Tang-type formulas are designed for Exterior Excess; Guizhi Tang (Cinnamon Twig Decoction)-type formulas are designed for Exterior Deficiency. For Interior Excess, formulas like Chengqi Tang (Gut-Purging Decoction) are used; for Interior Deficiency, Sini Tang (Frigid Extremities Decoction) and Lizhong Tang (Regulate the Middle Decoction) are used. Simultaneous Exterior and Interior Excess refers to what is described as Yang Excess and Yin Deficiency, which is cured by purgation; Simultaneous Exterior and Interior Deficiency refers to Yin Excess and Yang Deficiency, which is cured by diaphoresis."
Zhu San, a wine merchant, contracted Shanghan. After six or seven days, he had no sweat from the neck down, cold hands and feet (Jue Leng), fullness in the epigastrium, and dry, constipated stool. Some physicians, seeing his cold extremities along with sweating and chest/abdominal fullness, considered it a Yin Syndrome. I palpated his pulse, finding it deep and tight, and said, "This syndrome is indeed questionable. However, constipation indicates a 'deficient accumulation' (due to stagnation); how can it be a Yin Syndrome? Although the pulse is deep and tight, resembling Shaoyin Disease (Shaoyin Bing), Shaoyin Disease typically presents with spontaneous diarrhea, rarely constipation. I believe this case involves half-exterior and half-interior pathology." I administered Xiao Chai Hu Tang (Minor Bupleurum Decoction). His bowels moved freely, and he recovered.
Discussion: In Shanghan, symptoms such as aversion to cold, cold hands and feet, epigastric fullness, lack of appetite, constipation, and a fine pulse constitute "Yang Wei Jie" (a syndrome of slight Yang constraint with partial exterior and interior involvement). This implies the presence of both exterior and interior aspects. A deep pulse indicates the pathology is in the interior. Sweating indicates slight Yang deficiency/constraint. If it were a pure Yin accumulation, there would be no exterior symptoms remaining; all signs would be internal, representing a state of being half-exterior and half-interior. Although the pulse is deep and tight, it cannot be diagnosed as Shaoyin Disease. The reason is that Yin syndromes should not present with sweating. Since there is sweating on the head, we know it is not Shaoyin Disease. Xiao Chai Hu Tang may be given. If the patient still feels unwell after administration, relief will come with defecation.
A questioner asked, "Zhang Zhongjing stated that if a patient has a tight pulse at all three positions (Yin-Yang Ju Jin) and sweats, it indicates loss of Yang Qi (Wang Yang) and belongs to Shaoyin. Yet here it says Yin syndromes do not have sweating. Why? Since there is head sweating, we know it is not Shaoyin. Why does head sweating indicate it is not Shaoyin?" I replied, "This point requires careful deliberation. While cold extremities, a deep-tight pulse, and abdominal fullness are characteristic of Shaoyin, hard stools and head sweating rule out Shaoyin. The head is the gathering place of the three Yang meridians. When Yang Qi returns from the chest to the head, head sweating indicates a relative deficiency of Yin (or constrained Yang steaming upward), hence 'sweating indicates slight Yang [constraint/deficiency].' Yin syndromes should not have head sweating. If a Shaoyin disease presents with head sweating, the prognosis is extremely poor (nine deaths to one survival). Therefore, Zhang Zhongjing wrote in the 'Ping Mai Fa' (Method of Pulse Diagnosis): 'The Heart belongs to Fire... In its disease, if there is no head sweat, it is treatable; if there is head sweat, it is fatal.' The Heart corresponds to the Hand-Shaoyin meridian, and the Kidney to the Foot-Shaoyin meridian. They interact in disease; one must use intuitive reasoning to grasp the underlying mechanism."