【纲】仲景曰。病患脉微而涩者。此为医所病也。大发其汗。又数大下之。其人亡血。病当恶
寒。后乃发热。无休止时。夏月盛热。欲着复衣。冬月盛寒。欲裸其身。所以然者。阳微则恶寒。
阴弱则发热。此医发其汗。使阳气微。又大下者。令阴气弱。五月之时。阳气在表。胃中虚冷。以
阳气内微。不能胜冷。故欲着复衣。十一月之时。阳气在里。胃中烦热。以阴气内弱。不能胜热。
故欲裸其身。又阴脉迟涩。故知亡血也。
【目】柯琴曰。此条病因。全在妄汗下以致亡血而脉微涩。夏月四句。是写寒热发作时状。
是设辞。勿以无休止时。作连绵冬夏解也。
【纲】仲景曰。太阳之为病。脉浮。头项强痛而恶寒。太阳病。头痛发热。汗出恶风者。桂枝
汤主之。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。
【目】朱肱曰。头疼者。阳症也。太阳症头痛。必发热恶寒。无汗麻黄。有汗桂枝。若已发汗。
或未发汗。头疼如破者。连须
葱白汤。服汤不止者。葛根葱白汤。
成无己曰。头痛。邪气外在经络。上攻于头也。伤寒头痛者。太阳专主也。故阳明少阳亦有头
痛。不若太阳专主也。盖太阳为病属表。而头痛专为主表症。虽有风寒之不同。必待发散而后已。
李杲曰。太阳膀胱脉浮紧。直至寸口。所以头痛者。头与寸口。俱高之分也。盖厥阴与督脉会
于巅。逆太阳之经。上而不得下。故壅滞为头痛于上也。左手浮弦。胸中痛也。沉弦。背痛也。右
手浮弦亦然。头痛者。木也。最高之分。惟风可到。风则温也。治以辛凉。秋克春之意。故头痛皆
以风药治之。总其体之常也。然有三阴三阳之异焉。故太阳宜川芎。阳明宜白芷。少阳宜柴胡。太
阴宜苍术。少阴宜细辛。厥阴宜吴茱萸。
王肯堂曰。伤寒头痛。虽属三阳。惟太阳经独多。盖太阳为病属表。而头痛专主表。虽有伤寒
六七日。头痛不大便。有热而与承气汤下之者。却云。若小便清者。知热不在里仍在表。是知头痛
属表明矣。太阴少阴之脉。从足至胸而还。不上循头。故无头痛。惟厥阴脉循喉咙之后。上连目系。
与督脉会于巅。亦有头痛干呕吐涎沫吴茱萸汤一症。却无身热。亦与阳症不同也。然风温病在少
阴。湿温病在太阴。而头反痛。至于阴毒亦然。是又不可拘者。内因头痛。作止有时。外因头痛。常
常有之。直须传入里方罢。
鳌按。太阳经脉营于头。会于项。故头连项而强痛者。为太阳也。
【纲】仲景曰。湿家病。身上疼痛。发热面黄而喘。头痛鼻塞而烦。其脉大。自能饮食。腹中
和无病。病在头中寒湿。故鼻塞。内药鼻中则愈。
【目】朱肱曰。内瓜蒂散鼻中也。
柯琴曰。种种皆是表症。鼻塞而不鸣。脉大而不浮。不关风矣。脉不沉细。非湿痹矣。腹初不
满。非瘀热在里矣。重于头
痛。是头中寒湿可知。寒湿从鼻而入。故鼻塞。亦当从鼻而出。故内药鼻中。塞因塞用也。
【纲】仲景曰。太阳病。发汗太多。因致痉。脉沉而细。身热足寒。头项强急。恶寒。时头热。
面赤。目脉赤。独头面摇。卒口噤。背反张者。痉病也。
【目】王肯堂曰。太阳伤寒项背强。其或太阳中风。加之寒湿而成痉者。亦项强。金匮云。太
阳病。项背强KT KT 。然脉反沉迟者。此为痉。桂枝加栝蒌汤主之。
陶华曰。项背强者。太阳表邪也。发散则解。结胸项强。大陷胸汤下之。太阴结胸项强。大陷
胸丸。或频与理中丸。损甚者。兼与四逆汤。项强胁下满。身热恶风。手足温而渴。小柴胡汤。阴毒
初得病。项背强。咽痛。心腹痛。短气。厥逆吐利。身如被杖。附子汤。阴毒甘草汤、正阳散。天
行复作热。至晚则腰痛。头项强。身重。葛根生姜豉汤。
鳌按。痉病由来不一。而伤寒发汗不如法者。亦能致之。本症头痛虽止。而头项强急。尚属伤
寒。头面摇以下。乃言痉病也。此汗多亡液。不转属阳明而成痉者。
【纲】仲景曰。太阳病。项背强KT KT 。无汗恶风者。葛根汤主之。太阳病。项背强KT KT 。而
汗出恶风者。桂枝加葛根汤主之。
【目】成无己曰。太阳别脉。下项挟脊。故太阳感风寒。则经脉不利。而项为之急。颈为之强。
是太阳表症也。必发散而解之。此二条。均是项背强。而发散有轻重者。盖发热汗出恶风者。为
表虚。可解肌。无汗恶风者。为表实。可发汗也。
王肯堂曰。此二方。皆发散之剂也。而有轻重。以表虚表实之不同也。
鳌按。太阳脉。自络脑而还出下项挟脊背。此从风池而入。不上干于脑而下行于背。故头不痛。
而项背强也KT KT 。项背牵动之象。动中见有强意。
【纲】仲景曰。太阳中风。下利呕逆。表解者。乃可攻之。其人 汗出。发作有时。头痛。心
下痞硬引胁下痛。干呕短气。汗出不恶寒者。此表解里未和也。十枣汤主之。
【目】张兼善曰。或谓十枣汤与桂枝去桂加茯苓白术汤。二者皆属饮家。俱有头项强痛之病。
何也。此经络所系。非偶然也。针经曰。太阳膀胱之脉。起于目内 。皆上额交巅上。其支者。
从巅上至耳上角。直者。从巅入络脑。还出。别下项循肩膊内。挟脊抵腰中。入循膂。络肾。属
膀胱。络肾者。即三焦也。夫三焦者。为阳气之父。决渎之官。引导阴阳。开通闭塞。水导得出。
以气化而言也。缘太阳经多血少气。既病。则气愈弱。其时表病而里热未甚。微渴而恣饮水浆。为
水多气弱。不能施化。遂停伏于内。则本经血气。因而凝滞。致有头痛项强之病。若伏饮流行。经
络疏利。而头痛自愈。方中行曰。头痛本表症。此因心下水气泛溢。上攻于脑也。与伤寒不大便六
七日而头痛。与承气汤同。
【纲】仲景曰。太阳病。头痛。至七日以上自愈者。以行其经尽故也。若欲再传经者。针足阳
明。使经不传则愈。阳明病。表里大热。烦渴引饮。头痛如破者。宜竹叶石膏汤。阳明病。头痛。不恶寒。反恶热。
大便实。调胃承气汤。
【目】吴绶曰。阳明病。头痛额前。目疼鼻干。脉长也。无汗者。葛根汤加葱白、白芷汗之。
有汗。曾经发汗。头痛不解者。葛根葱白汤。不恶风。反恶热。自汗烦渴。脉洪数。饮水头疼者。
白虎加白芷汤。内有燥屎。蒸蒸发热头痛者。调胃承气汤。凡阳明头痛无汗者。葛根、麻黄、葱白、
白芷、石膏之属。有汗。则白芷、石膏、葛根、川芎。少阳经头痛。头角或耳中痛。脉弦数。口
苦发热。往来寒热者。并用小柴胡汤和之。加川芎尤妙。盖川芎亦胆经药也。凡少阳头痛。不分有
汗无汗。皆以柴胡汤主之。非次头痛。及发寒热。脉紧不大。即是上膈有痰。瓜蒂散吐之。
王好古曰。太阳头痛。有汗桂枝汤。无汗麻黄汤。阳明头痛。白虎汤。少阳头痛。小柴胡汤。
太阴头痛。脉浮桂枝汤。脉沉理中汤。俱加川芎、细辛。少阴头痛。小柴胡汤、麻黄附子细辛汤。
厥阴头痛。外传本经。桂枝麻黄合半汤。呕而微吐苦
水者。吴茱萸汤。
李杲曰。太阴头痛者。必有痰也。少阴头痛者。足寒而气逆也。盖此二经。虽不至头。然痰与
气逆壅于膈中。则头上气不得畅降而为痛也。
张云岐曰。如脉浮而头痛。过在手足太阳。刺完骨、京骨。脉浮而长。过在手足阳明。刺合谷、
冲阳。脉浮而弦。过在手足少阳。刺阳池、丘墟、风府、风池。此刺头痛之法也。
[General Principle] Zhang Zhongjing said: When a patient's pulse is faint, thready, and choppy, this is iatrogenic injury caused by the physician. The physician excessively induced sweating and repeatedly applied severe purgation. This resulted in the loss of blood (Yin blood), and the disease should manifest as aversion to cold. Subsequently, fever occurs without cessation. In the summer when heat is intense, the patient desires to wear heavy clothing; in the winter when cold is severe, the patient desires to expose their body. The reason for this is that deficient Yang leads to aversion to cold, while deficient Yin leads to fever. This occurred because the physician's excessive sweating weakened the Yang Qi, and severe purgation weakened the Yin Qi. In the fifth month (summer), Yang Qi floats on the exterior, leaving the Stomach empty and cold. Because internal Yang Qi is weak and cannot withstand the cold, the patient desires to wear heavy clothing. In the eleventh month (winter), Yang Qi stores internally, causing vexing heat in the Stomach. Because internal Yin Qi is weak and cannot withstand the heat, the patient desires to expose their body. Additionally, the Yin pulse is slow and choppy, indicating the loss of blood.
[Commentary] Ke Qin stated: The etiology of this clause lies entirely in the reckless use of diaphoresis and purgation leading to blood loss and a faint, thready pulse. The four sentences regarding summer and winter describe the state during the onset of chills and fever; they are hypothetical descriptions. One should not interpret "without cessation" as referring to continuous seasons of winter and summer.
[General Principle] Zhang Zhongjing said: The defining characteristics of Taiyang disease (Disease of the Bladder/Greater Yang Exterior) are a floating pulse, stiffness and pain in the head and neck, and aversion to cold. In Taiyang disease, if there is headache, fever, sweating, and aversion to wind, Gui Zhi Tang (Cinnamon Twig Decoction) is the primary treatment. In Taiyang disease, if there is headache, fever, body pain, lower back pain, joint pain, aversion to wind, absence of sweating, and wheezing, Ma Huang Tang (Ephedra Decoction) is the primary treatment.
[Commentary] Zhu Gong said: Headache belongs to Yang syndromes. Headache in Taiyang syndrome must be accompanied by fever and aversion to cold. For those without sweating, use Ma Huang Tang; for those with sweating, use Gui Zhi Tang. If sweating has already been induced, or not yet induced, but the headache is severe as if breaking, use Lian Xu Cong Bai Tang (Green Onion White Decoction). If symptoms persist after taking the decoction, use Ge Gen Cong Bai Tang (Kudzu and Green Onion White Decoction).
Cheng Wuji said: Headache results from pathogenic factors in the external meridians attacking upward to the head. Headache due to Cold Damage is primarily governed by the Taiyang channel. Although Yangming and Shaoyang channels also present with headache, Taiyang is specifically responsible for it. Generally, Taiyang disease belongs to the exterior, and headache is a specific exterior symptom. Regardless of whether the pathogen is Wind-Cold or Wind-Heat, resolution requires dispersal methods.
Li Gao said: The Taiyang Bladder meridian presents with a floating and tight pulse reaching the Cun position. Headache occurs because both the head and the Cun position represent the highest parts of the body. The Jueyin meridian converges with the Du vessel at the vertex. If it reverses against the Taiyang meridian, ascending without descending, stagnation occurs, causing headache in the upper region. A floating and wiry pulse on the left hand indicates chest pain; a deep and wiry pulse indicates back pain. The right hand shows similar patterns. Headache relates to Wood (Liver), located at the highest point, accessible only by Wind. Wind is warm in nature. Treatment employs acrid-cool herbs, reflecting the principle of Metal (Autumn) controlling Wood (Spring). Thus, headache is generally treated with Wind-dispelling herbs, which is the general rule. However, distinctions exist among the Three Yin and Three Yang channels. Therefore, Taiyang headache suits Chuanxiong Rhizome (Chuanxiong); Yangming headache suits Angelica Dahurica Root (Baizhi); Shaoyang headache suits Bupleurum Root (Chaihu); Taiyin headache suits Atractylodes Macrocephala Rhizome (Cangzhu); Shaoyin headache suits Asarum Root (Xixin); Jueyin headache suits Evodia Fruit (Wuzhuyu).
Wang Kentang said: In Cold Damage, headache, although belonging to the Three Yang channels, is most common in the Taiyang channel. Taiyang disease belongs to the exterior, and headache specifically indicates an exterior condition. Even if there is Cold Damage for six or seven days with headache and constipation, and heat is present requiring Chengqi Tang for purgation, the text states: "If urination is clear, it is known that the heat is not in the interior but remains in the exterior." This confirms that headache belongs to the exterior. The Taiyin and Shaoyin meridians ascend from the foot to the chest and return, not reaching the head; thus, they do not cause headache. Only the Jueyin meridian follows behind the throat, connects to the eye system, and meets the Du vessel at the vertex, presenting with headache, dry retching, and vomiting of clear saliva, treated with Wuzhuyu Tang. However, there is no fever, differing from Yang syndromes. Nevertheless, in Fengwen disease affecting Shaoyin, and Wenwen disease affecting Taiyin, headache may occur. Similarly, in Yindu (Yin Toxin) cases, these are exceptions that should not be rigidly adhered to. Headache due to internal causes has intermittent onset and cessation; headache due to external causes is constant until the pathogen transmits to the interior.
Shen Jin'ao noted: The Taiyang meridian circulates around the head and converges at the neck. Therefore, headache extending to the neck with stiffness belongs to Taiyang.
[General Principle] Zhang Zhongjing said: Patients suffering from Dampness Bi (Obstruction) experience body pain, fever, yellowish complexion, and wheezing. They have headache, nasal congestion, and vexation, with a large pulse. They can eat normally, and the abdomen is harmonious and free of disease. This indicates Cold-Dampness lodged in the head, causing nasal congestion. Administering medication into the nose will cure the condition.
[Commentary] Zhu Gong said: Administer Gua Di San (Melon Seed Powder) into the nose.
Ke Qin said: All these symptoms are exterior manifestations. Nasal congestion without rhinorrhea and a large but not floating pulse indicate the pathogen is not Wind. A pulse that is not deep and thready indicates it is not Damp-Bi. The abdomen is initially not distended, ruling out stagnant heat in the interior. The prominence of headache indicates Cold-Dampness in the head. Cold-Dampness enters through the nose, causing congestion, and should exit through the nose. Thus, administering medication nasally utilizes the method of "treating obstruction with obstruction."
[General Principle] Zhang Zhongjing said: In Taiyang disease, excessive sweating may lead to Jing Disease (Spasm). The pulse is deep and thready, with fever in the body and cold in the feet. There is stiffness and tension in the head and neck, aversion to cold, occasional heat in the head, red face, red eye vessels, isolated shaking of the head and face, sudden lockjaw, and opisthotonos (arching of the back). This is Jing Disease.
[Commentary] Wang Kentang said: In Taiyang Cold Damage, there is stiffness in the neck and back. Or, Taiyang Wind Strike complicated by Cold-Dampness resulting in Jing Disease also presents with neck stiffness. The *Jin Gui Yao Lue* states: In Taiyang disease, if there is stiffness in the neck and back, but the pulse is unexpectedly deep and slow, this is Jing Disease, treated with Gui Zhi Jia Gua Lou Tang (Cinnamon Twig Decoction plus Trichosanthes Root).
Tao Hua said: Neck and back stiffness is Taiyang exterior pathogen; dispersal resolves it. In Jie Xiong (Constraint Chest) with neck stiffness, Da Xian Xiong Tang (Major Blue Gallbladder Decoction) is used for purgation. In Taiyin Jie Xiong with neck stiffness, Da Xian Xiong Wan is used, or Li Zhong Wan is given frequently. In severe damage, Si Ni Tang (Four Reversal Decoction) is combined. With neck stiffness, fullness under the ribs, fever, aversion to wind, warm hands and feet, and thirst, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is used. In early Yindu, with neck stiffness, sore throat, heart/abdominal pain, shortness of breath, cold limbs, vomiting/diarrhea, and body pain like being beaten, Fu Zi Tang (Aconite Decoction), Yin Du Gan Cao Tang (Yin Toxin Licorice Decoction), or Zheng Yang San are used. In recurrent epidemic fevers, with evening low back pain, head/neck stiffness, and heavy body, Ge Gen Sheng Jiang Chi Tang (Kudzu, Ginger, and Fermented Soybean Decoction) is used.
Shen Jin'ao noted: The origins of Jing Disease vary, but improper sweating in Cold Damage can also induce it. Although the headache in this case has ceased, the stiffness and tension in the head and neck still belong to Cold Damage. The shaking of the head and face onwards describes Jing Disease. This results from fluid loss due to excessive sweating, failing to transmit to Yangming to become Jing Disease.
[General Principle] Zhang Zhongjing said: In Taiyang disease, with stiffness in the neck and back, absence of sweating, and aversion to wind, Ge Gen Tang (Kudzu Decoction) is the primary treatment. In Taiyang disease, with stiffness in the neck and back, presence of sweating, and aversion to wind, Gui Zhi Jia Ge Gen Tang (Cinnamon Twig Decoction plus Kudzu) is the primary treatment.
[Commentary] Cheng Wuji said: The divergent branch of the Taiyang meridian descends along the neck and flanks the spine. Thus, when Taiyang is affected by Wind-Cold, meridian qi becomes obstructed, causing urgency in the neck and stiffness in the back. This is a Taiyang exterior syndrome, resolved by dispersal. These two clauses both involve neck and back stiffness, but the degree of dispersal differs. Fever, sweating, and aversion to wind indicate Exterior Deficiency, suitable for resolving the muscle layer. Absence of sweating and aversion to wind indicate Exterior Excess, suitable for inducing sweating.
Wang Kentang said: Both formulas are dispersing agents, differing in strength due to Exterior Deficiency versus Exterior Excess.
Shen Jin'ao noted: The Taiyang meridian connects to the brain, emerges, and descends along the neck and flanking back. It enters via the Fengchi point, does not disturb the brain upward, but descends along the back. Thus, there is no headache, but rather stiffness in the neck and back. The sensation of pulling in the neck and back reveals an element of stiffness within movement.
[General Principle] Zhang Zhongjing said: In Taiyang Wind Strike, with diarrhea and vomiting/reversal of qi, one may attack the interior only after the exterior is resolved. If the patient sweats, with episodes occurring at specific times, headache, hardness/fullness in the epigastrium radiating to the hypochondrium, dry retching, shortness of breath, sweating without aversion to cold, this indicates the exterior is resolved but the interior is unharmonized. Shi Zao Tang (Ten Date Decoction) is the primary treatment.
[Commentary] Zhang Jianshan said: Some argue that Shi Zao Tang and Gui Zhi Qu Gui Jia Fu Ling Bai Zhu Tang both apply to patients with fluid retention and present with head/neck stiffness. Why? This is related to meridian connections, not accidental. The *Zhen Jing* states: The Taiyang Bladder meridian originates at the inner canthus, crosses the forehead, and meets at the vertex. Its branch ascends from the vertex to the supra-auricular angle. The straight branch enters the brain from the vertex, emerges, descends separately along the neck, passes the shoulder blade, flanks the spine to the loins, enters the paraspinal muscles, connects to the Kidney, and belongs to the Bladder. The connection to the Kidney involves the Sanjiao (Triple Burner). The Sanjiao is the father of Yang Qi, the official of drainage, guiding Yin and Yang, opening blockages, and guiding water out, described in terms of Qi transformation. Since the Taiyang meridian has abundant blood but scarce Qi, upon disease, Qi becomes weaker. At this time, with exterior disease and mild interior heat, slight thirst leads to excessive drinking. Due to excess water and weak Qi, transformation fails, causing fluid retention internally. This stagnates the blood and Qi of the primary meridian, resulting in headache and neck stiffness. If retained fluid flows freely and meridians unblock, headache heals naturally. Fang Zhongxing stated: Headache is originally an exterior symptom; here, it is caused by water qi overflowing from the heart/stomach area, attacking upward to the brain. This is similar to Cold Damage with constipation for six or seven days and headache, treated with Chengqi Tang.
[General Principle] Zhang Zhongjing said: In Taiyang disease, if headache persists for seven or more days and heals spontaneously, it is because the pathogen has exhausted its course in the meridian. If transmission to another meridian is desired, needle the Foot-Yangming meridian to prevent transmission and ensure recovery. In Yangming disease, with intense interior and exterior heat, vexation, thirst with desire to drink, and headache as if breaking, Zhu Ye Shi Gao Tang (Bamboo Leaf and Gypsum Decoction) is appropriate. In Yangming disease, with headache, aversion to cold absent but aversion to heat present, and solid stool, Tiao Wei Cheng Qi Tang (Regulate the Stomach and Direct the Qi Decoction) is used.
[Commentary] Wu Shou said: In Yangming disease, headache is in the forehead, accompanied by eye pain and nasal dryness, with a long pulse. For absence of sweating, use Ge Gen Tang with Scallion White and Baizhi to induce sweating. For presence of sweating where previous sweating failed to resolve headache, use Ge Gen Cong Bai Tang. For aversion to wind absent but aversion to heat present, spontaneous sweating, vexation/thirst, surging-rapid pulse, and headache exacerbated by drinking, use Bai Hu Jia Bai Zhi Tang (White Tiger Plus Baizhi Decoction). For headache with steaming fever due to dry feces, use Tiao Wei Cheng Qi Tang. For all Yangming headaches without sweating, use Ge Gen, Ma Huang, Scallion White, Baizhi, Shi Gao. For those with sweating, use Baizhi, Shi Gao, Ge Gen, Chuanxiong. For Shaoyang meridian headache, involving temporal or ear pain, wiry-rapid pulse, bitter taste, fever, and alternating chills/fever, use Xiao Chai Hu Tang to harmonize. Adding Chuanxiong is excellent, as it is a Gallbladder meridian herb. For all Shaoyang headaches, regardless of sweating, use Chai Hu Tang. For non-secondary headaches with chills/fever and a tight, not-large pulse, indicating phlegm in the upper jiao, use Gua Di San to induce vomiting.
Wang Haogu said: Taiyang headache: Gui Zhi Tang for sweating, Ma Huang Tang for no sweating. Yangming headache: Bai Hu Tang. Shaoyang headache: Xiao Chai Hu Tang. Taiyin headache: Gui Zhi Tang for floating pulse, Li Zhong Tang for deep pulse, both added with Chuanxiong and Xixin. Shaoyin headache: Xiao Chai Hu Tang, Ma Huang Fu Zi Xi Xin Tang. Jueyin headache: Gui Zhi Ma Huang Ban Tang (Half Cinnamon Twig and Ephedra Decoction) for external transmission to the primary meridian. For vomiting with slight expulsion of bitter fluid, use Wuzhuyu Tang.
Li Gao said: Taiyin headache necessarily involves phlegm. Shaoyin headache involves cold feet and rebellious Qi. Although these two meridians do not reach the head, phlegm and rebellious Qi obstructing the jiao cause Qi in the head to fail to descend smoothly, resulting in pain.
Zhang Yunqi said: If the pulse is floating with headache, the pathology is in the Hand and Foot Taiyang meridians; pierce Wangu and Jinggu points. If the pulse is floating and long, the pathology is in the Hand and Foot Yangming meridians; pierce Hegu and Chongyang points. If the pulse is floating and wiry, the pathology is in the Hand and Foot Shaoyang meridians; pierce Yangchi, Qiuxu, Fengfu, and Fengchi points. This is the method of acupuncture for headache.