太阳病。发热脉沉而细者。名曰 。
谓之太阳病者。以邪由营卫而入。营卫皆太阳所属。所见皆太阳经表证故也。然但曰发热。而不叙诸
证者。以总见于下文故也。邪在太阳。若中风之脉。则当浮缓。伤寒之脉。则当浮紧。此则同是太阳发
热之表症。而其脉与中风伤寒特异。反见沉细者。因邪不独在太阳之表也。大凡沉则在里。沉则为寒。
细则为虚。细则为寒。脉沉而细。当为寒邪在里矣。而外犹发热。邪气尚在太阳之表。则表里皆有风寒
邪气。浸淫于皮肤筋骨脏腑经络之间。非若中风伤寒之邪。先表后里。以次传变之可比。乃邪之甚而病
之至者。故谓之 。乃难治危恶之证也。所以金匮此条之下。有为难治三字也。
病身热足寒。颈项强急。恶寒。时头热面赤。目脉赤。独头面摇。卒口噤。背反张者。 病也。
上文有脉无证。此条有证无脉。合而观之。 病之脉证备矣。灵枢经脉篇云。足太阳之脉。起于目
内。上额交巅。从
巅入络脑。还出别下项。循肩膊而挟脊。抵腰中。入循膂。络肾属膀胱。其支者从腰中。下挟脊贯臀。
循髀外。下合 中贯 内。出外踝之后。循京骨。至小趾外侧。是动则病冲。头目似脱。项如拔。脊痛。
腰似折。髀不可以曲。 如结。 如裂。是为踝厥。是主筋所生病者。此太阳经脉络行度。及发病之见症也。
此所谓身热者。风寒在表也。足寒者。阴邪在下也。颈项强急。背反张者。太阳之经脉四行。自巅下项。
挟背脊而行于两旁。寒邪在经。诸寒收引。其性劲急。邪发则筋脉抽掣。故颈项强急。背如角弓之反张。
所谓筋所生病也。恶寒者。寒邪在表。则当恶寒。在下焦。而阳气虚衰。亦所当恶也。时头热面赤目脉赤者。
头为诸阳之会。阳邪独盛于上。所以足寒于下也。时者。时或热炎于上而作止有时也。头面为诸阳之所聚。
乃元首也。不宜动摇。因风火扇动于上。故独头面动摇。卒然口噤而不言也。王太仆谓肾与胞脉内绝。
则不能言。以胞脉系于肾。肾脉上贯肝膈入肺中。循喉咙。挟舌本。内气阻绝。故不能言也。
太阳病。发热无汗。反恶寒者。名曰刚 。
太阳病。发热汗出。不恶寒者。名曰柔 。
上文但举 病之脉症。犹未分别其受病之源头。以正其名而核其实也。此篇仲景虽无治法。然既有定名。
自当循源溯流。因证施治也。夫 病虽为中风伤寒之变体。然终不离乎中风伤寒之见证。故仍以风寒之见证分
刚柔也。谓之刚者。寒本阴邪。以寒邪收引劲急。故颈项强急背反张也。谓之柔者。风本阳邪。以风邪性缓。
虽颈项亦强。而筋骨稍觉弛软。汗出不恶汗。则异于刚 也。然六经论中。以发热无汗为伤寒。发热汗出为中风。
此麻黄桂枝之定法也。而此篇以发热无汗为刚 。发热汗出为柔 何也。其 病之异于中风伤寒者。在反恶寒与
不恶寒之两句耳。
盖中风伤寒。邪皆在表。无有不恶风恶寒者。如太阳上编云。太阳病。发热汗出恶风脉缓者。名为中风。此中风而恶
风也。又曰太阳中风。阳浮而阴弱。阳浮者热自发。阴弱者汗自出。啬啬恶寒。淅淅恶风。此中风而恶寒。
亦恶风也。太阳中篇云。太阳病。或已发热。或未发热。必恶寒体痛。此伤寒而恶寒也。又云太阳病。头痛发热。
身疼腰痛恶风无汗而喘者。此伤寒恶风也。此以发热无汗之 病。是伤寒之变也。发热无汗。本应恶寒。
而曰反恶寒。反者。不当恶之词也。然而非也。以时头热面赤目脉皆赤之见证。似乎热甚。而仍身热足寒。颈项强
急而恶寒。故曰反也。反者。甚之之词。言寒邪太盛。因虚阳上走。而时常头热面赤目脉尽赤。究是表里皆寒甚。
故足寒颈项强急而恶寒。口噤而背如角弓之反张。寒邪已经在里。而表犹恶寒。故曰反也。寒性劲急。故称刚 。其发
热汗出之 病。乃中风之变也。亦本恶寒而曰不恶寒者。已属阳明。然阳明无项强诸症。故仍在太阳而为 病也。
既不恶寒。则知阳邪已经自表达里。所以不恶寒。而但有颈项强急等症。较之刚 稍缓。故称柔 耳。
太阳病。发汗太多。因致 。
前所论 病。皆中风伤寒深入之邪。浸淫于经络脏腑筋骨肌肉之间。乃自然感受之证也。此因邪在太阳。本非
病。因发汗太多。使卫阳败泄。而真阳亡矣。亡阳则阴寒独治。生气通天论云。阳气者。精则养神。柔则养筋。
阳气衰微。不能嘘养其筋骨。故筋脉劲急而成 。所以太阳篇云。太阳病。医发汗。遂漏不止。四肢拘急。难以屈伸者。
桂枝加附子汤主之。 之见症。虽又甚焉。然亦理之相似者也。
辨误 成注云。千金云。太阳中风。重感寒湿则变 。太阳病。发热无汗为表实。则不当恶寒。今反恶寒。则为太
阳中
风。重感于寒为 病也。此说殊误。发热无汗为表实。是寒邪实于表。故皮肤闭而为热。麻黄汤证也。
正当恶寒。如何反云不当恶寒。此一误也。仲景以发热无汗恶寒为刚 。是明言刚 为伤寒之变症。当从麻黄汤一
例求之。随证增减可也。如颈项强急。口噤。背反张。皆麻黄症也。以颈属阳明。故金匮云。太阳病。无
汗而小便反少。气上冲胸。口噤不得语。欲作刚 。葛根汤主之。此即太阳阳明篇所谓太阳病。项背强。KT KT
无汗恶风者。葛根汤主之之义也。设足寒时头热面赤等症。皆寒邪太盛。虚阳上泛之症。麻黄附子细辛汤亦
可用也。以此义推之。纯是寒邪。并无太阳中风。又重感于寒之说。此再误也。又以发热汗出不恶寒为柔 。此又明
言柔 为中风之变症。其症当从桂枝汤例中求之。随症加减可也。如发热汗出。桂枝症也。以不恶寒已属阳明。故金
匮云。太阳病。其证备。身体强。KT KT 然。脉反沉迟。此为 。栝蒌桂枝汤主之。此即阳明篇中所谓太阳病。
项背强。KT KT 反汗出恶风者。桂枝加葛根汤主之之义也。至于金匮所谓 为病。胸满口噤。卧不着席。脚挛急。
必齿。可与承气汤者。乃已入阳明之治也。伤寒论中。立法虽严。而理无不贯。但于六经条例中。分明其经络条贯。
别识其表里阴阳。则其证其治。进退出入。无往而非可由之路矣。易大传所谓往来不穷谓之通。仲景之学。其斯之谓欤。
Taiyang disease (Disease of the Taiyang/Bladder channel), characterized by fever and a deep, fine pulse, is named Zhi disease (Spasm disease).
It is called Taiyang disease because the pathogenic factor enters through Ying (Nutrient) and Wei (Defensive) levels, which both belong to the Taiyang system; thus, the manifestations are all exterior syndromes of the Taiyang channel. However, only fever is mentioned here without listing other symptoms, as they are summarized in the subsequent text. When the pathogen is in the Taiyang stage, if it is Wind-strike syndrome, the pulse should be floating and moderate; if it is Cold-strike syndrome, the pulse should be floating and tight. In this case, although it is an exterior symptom of fever from the Taiyang channel, the pulse differs significantly from Wind-strike or Cold-strike, appearing instead as deep and fine. This indicates that the pathogen is not merely on the exterior of the Taiyang channel. Generally, a deep pulse indicates interior location and cold; a fine pulse indicates deficiency and cold. A deep and fine pulse typically suggests cold pathogen in the interior. Yet, there is still fever on the exterior, meaning the pathogen remains on the exterior of the Taiyang channel. This implies that wind-cold pathogens exist in both the interior and exterior, permeating the skin, sinews, bones, zang-fu organs, and collaterals. This cannot be compared to Wind-strike or Cold-strike, where pathogens move from exterior to interior in a sequential manner. This represents an extreme severity of pathogen and illness, hence it is called Zhi disease, which is a difficult-to-treat and critical condition. Therefore, under this clause in *Jingui Yaolue* (Essential Prescriptions of the Golden Cabinet), the words "difficult to treat" appear.
The patient presents with body heat, cold feet, stiffness and tension in the neck and nape, aversion to cold, intermittent heat in the head, redness of the face, congestion of the eye vessels, isolated shaking of the head and face, sudden lockjaw, and opisthotonos (back arching like a bow). This is Zhi disease.
The previous clause had pulse but no symptoms; this clause has symptoms but no pulse. Combining them completes the pulse-syndrome picture for Zhi disease. The *Lingshu · Jingmai Chapter* states: The Foot-Taiyang Bladder channel originates at the inner canthus, ascends to the forehead, intersects at the vertex, enters to connect with the brain, emerges separately to descend down the nape, follows the shoulder blades, flanks the spine, reaches the loins, enters to follow the paraspinal muscles, connects with the Kidney, and belongs to the Bladder. Its branch descends from the loins, flanks the spine through the buttocks, follows the lateral thigh, converges in the popliteal fossa, passes through the calf muscle, emerges behind the lateral malleolus, follows the Jinggu point, and reaches the lateral side of the little toe. When this channel is disturbed, it causes headache with a sensation of eyes falling out, neck feeling like being pulled out, back pain, waist feeling like breaking, inability to bend the thighs, knotting in the popliteal fossa, and tearing sensation in the calf; this is called An-Jue (An-Vessel Reversal). This channel governs diseases generated by the sinews. This describes the course of the Taiyang channel and its clinical manifestations upon disease onset.
The "body heat" mentioned here refers to wind-cold on the exterior. The "cold feet" refer to yin pathogen in the lower jiao. Stiffness and tension in the neck/nape and opisthotonos occur because the Taiyang channel runs from the vertex down the nape and along both sides of the back. Cold pathogen in the channel causes contraction and tension due to its nature; when the pathogen activates, it causes spasms of the sinews and vessels, resulting in neck stiffness and back arching like a bow, which is what is meant by "diseases generated by the sinews." Aversion to cold occurs because cold pathogen is on the exterior, necessitating aversion to cold; additionally, if in the lower jiao, yang qi deficiency also leads to aversion to cold. Intermittent head heat, facial redness, and red eye vessels occur because the head is the meeting place of all yang channels, and excess yang pathogen concentrates above, causing cold feet below. "Intermittently" means the heat rises upward occasionally with specific timing. The head and face are the gathering places of yang and the seat of the head, and should not shake; however, wind-fire stirring above causes isolated shaking of the head and face, leading to sudden lockjaw and inability to speak. Wang Bing (Wai Taipu) stated that if the Kidney and Bao (Uterus) vessels are internally severed, speech is impossible, because the Bao vessels connect to the Kidney, and the Kidney channel ascends through the liver and diaphragm into the lung, follows the throat, and flanks the root of the tongue; internal qi obstruction prevents speech.
Taiyang disease, presenting with fever, absence of sweating, and paradoxical aversion to cold, is named Gang-Zhi (Yang Spasm).
Taiyang disease, presenting with fever, sweating, and absence of aversion to cold, is named Rou-Zhi (Yin Spasm).
The previous text only listed the pulse and symptoms of Zhi disease without distinguishing its origin to clarify its name and reality. Although Zhang Zhongjing did not provide treatment methods in this section, given the established names, one must trace the source and treat according to the syndrome. Although Zhi disease is a variant of Wind-strike and Cold-strike, it ultimately does not deviate from their manifestations; thus, it is distinguished as Gang-Zhi or Rou-Zhi based on wind-cold signs. It is called "Gang" (Hard/Yang) because cold is a yin pathogen with contracting and tense properties, causing neck stiffness and opisthotonos. It is called "Rou" (Soft/Yin) because wind is a yang pathogen with a relaxing nature; although there is neck stiffness, the sinews and bones feel slightly relaxed, and sweating with absence of aversion to cold distinguishes it from Gang-Zhi. However, in the Six Channels theory, fever without sweating is Cold-strike, and fever with sweating is Wind-strike, which are the fixed indications for Mahuang Tang (Ephedra Decoction) and Guizhi Tang (Cinnamon Twig Decoction). Why does this section define fever without sweating as Gang-Zhi and fever with sweating as Rou-Zhi? The difference of Zhi disease from Wind-strike and Cold-strike lies in the phrases "paradoxical aversion to cold" and "absence of aversion to cold."
Generally, for Wind-strike and Cold-strike, the pathogen is on the exterior, accompanied by aversion to wind or cold. As stated in the Taiyang chapter: "Taiyang disease, fever, sweating, aversion to wind, moderate pulse is named Wind-strike." This is Wind-strike with aversion to wind. It also says: "Taiyang Wind-strike, floating exterior and weak interior pulse. Floating indicates spontaneous heat; weak indicates spontaneous sweating, chilly aversion to cold, and shivering aversion to wind." This is Wind-strike with aversion to cold and wind. The Taiyang middle chapter says: "Taiyang disease, whether fever has started or not, must have aversion to cold and body pain." This is Cold-strike with aversion to cold. It also says: "Taiyang disease, headache, fever, body ache, waist pain, aversion to wind, absence of sweating, and wheezing." This is Cold-strike with aversion to wind. The Gang-Zhi described here (fever, no sweating) is a variant of Cold-strike. Fever without sweating should normally involve aversion to cold; saying "paradoxical aversion to cold" implies aversion to cold is unexpected. However, this interpretation is incorrect. Given symptoms like intermittent head heat, facial redness, and red eye vessels, it seems like intense heat, yet there is still body heat, cold feet, neck stiffness, and aversion to cold. Thus, "paradoxical" emphasizes severity: excessive cold pathogen causes deficient yang to float upward, leading to frequent head heat, facial redness, and red eye vessels, but fundamentally, both interior and exterior are severely cold. Hence, cold feet, neck stiffness, aversion to cold, lockjaw, and opisthotonos occur. The cold pathogen is in the interior, yet the exterior still shows aversion to cold, hence "paradoxical." Due to the tense nature of cold, it is called Gang-Zhi. The Rou-Zhi (fever, sweating, no aversion to cold) is a variant of Wind-strike. It originally involved aversion to cold but now shows "no aversion to cold" because the pathology involves the Yangming channel. However, Yangming does not present with neck stiffness, so the disease remains in Taiyang as Zhi disease. Since there is no aversion to cold, it indicates the yang pathogen has moved from exterior to interior. Thus, there is no aversion to cold, only neck stiffness, etc., which is milder than Gang-Zhi, hence called Rou-Zhi.
Taiyang disease, after excessive sweating, results in Zhi disease.
The previously discussed Zhi diseases were caused by pathogens from Wind-strike and Cold-strike penetrating deeply into the collaterals, zang-fu, sinews, bones, and muscles, arising from natural exposure. This case arises because the pathogen was in Taiyang, not originally Zhi disease, but excessive sweating damaged Wei-yang, causing loss of True-Yang. Loss of yang leads to exclusive dominance of yin-cold. The *Suwen · Shengqi Tongtian Lun* states: "Yang qi, when refined, nourishes the spirit; when soft, nourishes the sinews." With deficient and weak yang qi, it cannot warm and nourish the sinews and bones, causing sinew tension and Zhi disease. Thus, the Taiyang chapter states: "Taiyang disease, treated with sweating by the physician, resulting in continuous leakage of sweat, spasticity of the four limbs, and difficulty in flexion and extension, should be treated with Guizhi Jia Fuzi Tang (Cinnamon Twig Decoction plus Prepared Aconite Root)." Although the manifestations of Zhi disease are more severe, the underlying principle is similar.
Analysis of Errors: Cheng Wuji's commentary cites *Qianjin Fang*: "Taiyang Wind-strike, if re-exposed to cold-dampness, transforms into Zhi disease. Taiyang disease with fever and no sweating is exterior excess, so it should not have aversion to cold. Now it paradoxically has aversion to cold, indicating Taiyang Wind-strike re-exposed to cold becomes Zhi disease." This statement is highly erroneous. Fever without sweating indicates exterior excess, where cold pathogen is solidified on the exterior, closing the skin pores and generating heat; this is a Mahuang Tang pattern. It should indeed have aversion to cold; how can it be said that it should not? This is the first error. Zhang Zhongjing defines fever, no sweating, and aversion to cold as Gang-Zhi, clearly stating Gang-Zhi is a variant of Cold-strike, to be treated following the Mahuang Tang formula with modifications. Symptoms like neck stiffness, lockjaw, and opisthotonos fall under Mahuang patterns. Since the neck relates to Yangming, *Jingui Yaolue* states: "Taiyang disease, no sweating, abnormal scarcity of urination, qi rushing to the chest, lockjaw and inability to speak, impending Gang-Zhi, should be treated with Gegen Tang (Kudzu Decoction)." This aligns with the Sun-Yangming chapter: "Taiyang disease, stiff neck and nape, no sweating, aversion to wind, Gegen Tang." If symptoms include cold feet, intermittent head heat, and facial redness, these indicate excessive cold and floating deficient yang; Mahuang Fuxi Xixin Tang (Ephedra, Prepared Aconite, and Asarum Decoction) may also be used. By this logic, it is purely cold pathogen, refuting the claim of "Wind-strike re-exposed to cold"; this is the second error. Defining fever, sweating, and no aversion to cold as Rou-Zhi clearly indicates Rou-Zhi is a variant of Wind-strike, to be treated following Guizhi Tang with modifications. Fever and sweating are Guizhi patterns. Since no aversion to cold involves Yangming, *Jingui Yaolue* states: "Taiyang disease, full syndrome presentation, stiff body, stiff neck and nape, pulse surprisingly deep and slow, this is Zhi, should be treated with Gualou Guizhi Tang (Trichosanthes Root and Cinnamon Twig Decoction)." This corresponds to the Yangming chapter: "Taiyang disease, stiff neck and nape, sweating, aversion to wind, Guizhi Jia Gegen Tang (Cinnamon Twig Decoction plus Kudzu)." Regarding *Jingui Yaolue*'s mention of Zhi disease with chest fullness, lockjaw, lying flat impossible, leg cramps, and teeth grinding, treatable with Chengqi Tang (Downward Draining Decoctions), this is treatment after entering Yangming. Although *Shanghan Lun* establishes strict laws, the principles are consistent. By clearly understanding the meridian connections in the Six Channels regulations and distinguishing exterior-interior and yin-yang, the diagnosis and treatment, whether advancing or retreating, will always find a viable path. As the *Great Commentary of I Ching* states: "Continuous movement and transformation is called Tong (Connectivity/Understanding)." Zhang Zhongjing's learning embodies this.