维扬谢康中。任仪真酒官。咽干。烦渴。腰疼。身热。脉细而微急。予诊视之曰。此真少阴证也。
六经之中。少阴难治。少阴病传之经络。此证有补泻法。仲景泻者用承气。补者用四逆。误之则
相去远矣。此证当温。勿以水证为疑也。予适以事出境。后七日归。则为他医汗之矣。经络既虚。
邪毒流入大经之中。手足螈 。如惊痫状。其家野狼狈求救。予曰。不可治也。予验此甚多。是谓邪
入大经。不旋踵。其家已哭矣。
乡人吴德甫得伤寒。身热自汗。恶风。鼻出涕。关以上浮。关以下弱。予曰。此桂枝证也。
仲景法中第一方。而世人不究耳。使公服之。一啜而微汗解。翌日诸苦顿除。公曰仲景法如此径
捷。世人何以不用。予应之曰仲景论表证。一则桂枝。二则麻黄。三则青龙。桂枝则治中风。麻
黄治伤寒。青龙治中风见寒脉。伤寒见风脉。此三者人皆能言之。而不知用药对证之妙处。故今
之医者多不喜用。无足怪也。且脉浮而缓。中风也。故啬啬恶寒。淅淅恶风。翕翕发热。仲景以
桂枝对之。脉浮紧而涩。伤寒也。故头痛发热。身疼腰痛。骨节皆疼。恶风。无汗而喘。仲景以
麻黄对之。至于中风脉紧。伤寒脉浮缓。仲景皆以青龙对之。何也。予尝深究三者。审于证候。
脉息。相对用之。无不应手而愈。何以言之。风伤卫。卫。气也。寒伤营。营。血也。营行脉中。
卫行脉外。风伤卫。则风邪中于阳气。阳气不固。发越而为汗。是以汗出而表虚。故仲景用桂枝
以发汗。芍药以利其血。盖中风病在脉之外。其病稍轻。虽同曰发汗。特解肌之药耳。故桂枝证
云。令遍身 。微似有汗者。益佳。不可如水淋漓。病必不除。是知中风不可大发其汗。发其
汗。反动营血。邪乘虚而居中。故病不除也。寒伤营。则寒邪干于阴血。而营行脉中者也。寒邪客于脉中。非特营受病
也。邪自内作。则并于卫气犯之。久则浸淫及骨。是以汗不出而热烦冤。仲景以麻黄大发其汗。又以桂枝辛甘助其发散。
欲捐其内外之邪。营卫之病耳。大抵二药皆发汗。而桂枝则发卫之邪。麻黄并卫与营而治之。仲
景桂枝第十九证云。病常自汗出者。此为营气和。营气和者外不谐。以卫气不共营气和谐故耳。
营行脉中。卫行脉外。复发其汗。营卫和。则愈。宜桂枝汤。又第四十七证云。发热汗出者。此谓
营弱卫强。故使汗出。欲救风邪。宜桂枝汤。是知中风汗出者。营和而卫不和也。又第一卷云。
寸口脉浮而紧。浮则为风。紧则为寒。风则伤卫。寒则伤营。营卫俱病也。麻黄汤中。并桂枝而
用。此仲景之意欤。至于青龙。虽治伤寒见风脉。伤风见寒脉。然仲景云汗出恶风。不可服之。
服之则厥逆。筋惕肉 。故青龙一证尤难用。须是形证的当。然后可行。王 大夫证治中。止用
桂枝麻黄各半汤代之。盖慎之也夫。
Xie Kangzhong from Weiyang, who served as the wine official of Yizhen, presented with dryness in the throat, irritability and thirst, lower back pain, feverish sensation in the body, and a fine (Xi) pulse that was slightly rapid. Upon examination, I stated: This is a true Shaoyin syndrome (Shaoyin disease).
Among the Six Channels, Shaoyin disease is difficult to treat. When Shaoyin disease transmits to the meridians and collaterals, this syndrome has both tonifying and purging methods. Zhang Zhongjing uses Chengqi Tang for purging and Sini Tang for tonifying. If mistaken, the outcome will be vastly different. This syndrome should be treated with warming methods; do not doubt it as a water retention syndrome. At that time, I happened to leave the city on business. Seven days later, upon my return, I found he had been treated with sweating methods by other physicians. Since the meridians were already deficient, pathogenic toxins flowed into the large meridians, causing spasms and convulsions of the hands and feet, resembling epilepsy. His family sought help in panic. I said: This is incurable. I have verified many such cases; this is called "pathogen entering the large meridians," and death follows swiftly. His family was already weeping.
Wu Defu, a fellow townsman, contracted Cold Damage (Shanghan). He presented with fever, spontaneous sweating, aversion to wind, and nasal discharge. The pulse above the Guan position was floating (Fu), while below the Guan position it was weak. I said: This is a Guizhi syndrome (Gui Zhi Tang pattern).
This is the primary formula in Zhang Zhongjing's method, yet people today fail to investigate it thoroughly. Had Mr. Wu taken it, after one draught, he sweated slightly and recovered. The next day, all his suffering was instantly relieved. Mr. Wu asked: Zhang Zhongjing's methods are so direct and quick; why do people not use them? I replied: In Zhang Zhongjing's discussion of exterior syndromes, there are three main approaches: first Guizhi Tang, second Mahuang Tang, third Qinglong Tang. Guizhi Tang treats Wind Strike (Zhongfeng); Mahuang Tang treats Cold Damage (Shanghan); Qinglong Tang treats Wind Strike presenting with Cold pulses or Cold Damage presenting with Wind pulses. Although everyone can recite these distinctions, few understand the subtlety of matching medication to the syndrome. Thus, contemporary physicians often dislike using them, which is no surprise.
Moreover, a floating and moderate (Huan) pulse indicates Wind Strike. Hence, there is chilly aversion to cold (Sese e han), shivering aversion to wind (Xixi e feng), and mild fever (Xixi fa re). Zhang Zhongjing matches this with Guizhi Tang. A floating, tight (Jin), and choppy (Se) pulse indicates Cold Damage. Hence, there is headache, fever, body ache, lower back pain, joint pain, aversion to wind, anhidrosis, and wheezing. Zhang Zhongjing matches this with Mahuang Tang. As for Wind Strike presenting with a tight pulse, or Cold Damage presenting with a floating-moderate pulse, Zhang Zhongjing uses Qinglong Tang for both. Why? I have deeply investigated these three, carefully examining the symptoms and pulse, and applying them correspondingly, resulting in immediate recovery every time.
Why is this? Wind injures the Defensive Qi (Wei Qi); the Defensive Qi is Qi. Cold injures the Nutritive Blood (Ying Xue); the Nutritive Blood is Blood. Nutritive Blood circulates within the vessels, while Defensive Qi circulates outside the vessels. When Wind injures the Defensive Qi, the Wind pathogen attacks the Yang Qi. Because the Yang Qi is not secure, it disperses and manifests as sweat, leading to spontaneous sweating and exterior deficiency. Therefore, Zhang Zhongjing uses Guizhi Tang to induce sweating and Shaoyao to benefit the blood. Generally, Wind Strike affects the exterior of the vessels, and the pathology is relatively mild. Although both are termed "inducing sweating," Guizhi Tang is essentially a muscle-relieving agent. The Guizhi syndrome text states: "Let the whole body have a slight perspiration; this is better. Do not let it sweat profusely like water dripping, otherwise the disease will not be eliminated." From this, we know that Wind Strike cannot be treated with heavy sweating. Heavy sweating disturbs the Nutritive Blood, allowing pathogens to take residence centrally due to deficiency, thus failing to eliminate the disease.
Cold injures the Nutritive system, meaning Cold pathogens invade the Yin Blood, which circulates within the vessels. When Cold pathogens lodge within the vessels, not only does the Nutritive system suffer; the pathogen arises from within and combines with the Defensive Qi to attack. Over time, it infiltrates to the bones. Hence, there is no sweating, but rather fever, vexation, and oppression. Zhang Zhongjing uses Mahuang Tang to induce heavy sweating, and adds Guizhi for its acrid-sweet properties to assist dispersion, aiming to expel internal and external pathogens and treat the Nutritive-Defensive disharmony. Broadly speaking, both drugs induce sweating, but Guizhi Tang releases Exterior pathogens from the Defensive level, whereas Mahuang Tang treats both Defensive and Nutritive levels.
The 19th clause of Guizhi Tang states: "When a patient constantly sweats spontaneously, this is because the Nutritive Qi is harmonious. The harmony of Nutritive Qi implies disharmony externally, specifically because the Defensive Qi does not harmonize with the Nutritive Qi. Nutritive Blood circulates within the vessels, Defensive Qi circulates outside. Inducing sweating again restores harmony between Nutritive and Defensive, leading to recovery. Use Guizhi Tang." The 47th clause states: "Fever with sweating indicates Weak Nutritive and Strong Defensive Qi, causing sweating. To rescue against Wind pathogens, use Guizhi Tang." Thus, we know that spontaneous sweating in Wind Strike indicates Harmonious Nutritive but Disharmonious Defensive Qi. Volume 1 also states: "Cun Kou pulse is floating and tight. Floating indicates Wind, Tight indicates Cold. Wind injures the Defensive, Cold injures the Nutritive. This is simultaneous disease of Nutritive and Defensive." Mahuang Tang also includes Guizhi; is this Zhang Zhongjing's intent?
As for Qinglong Tang, although it treats Cold Damage with Wind pulses or Wind Strike with Cold pulses, Zhang Zhongjing states: "If there is sweating and aversion to wind, it must not be taken. Taking it leads to reversal cold (Jue Ni), twitching of tendons, and fasciculation of muscles." Therefore, the Qinglong Tang pattern is particularly difficult to apply. It requires exact correspondence between form and syndrome before administration. Physician Wang, in his treatment cases, used Guizhi Mahuang Ge Ban Tang (Half-Guizhi Half-Mahuang Decoction) instead, likely out of caution.