【纲】仲景曰。心下痞。按之濡。大便硬而不恶寒。反恶热。其脉关上浮者。大黄黄连泻心
汤主之。
【目】戴原礼曰。发汗后只恶寒者为虚。虚乃表虚。发汗后只恶热者为实。实乃里实。只恶寒
者。早发其汗。或汗出太过。谓阳微则恶寒。宜芍药甘草附子汤。只恶热。是表已解而里不消。所
谓阴微则发热。宜大柴胡汤。或小承气汤。
柯琴曰。濡。当作硬。夫按之濡为气痞。是无形也。则不当下。且结胸症。其脉浮大者。不可
下。则心下痞而脉上浮者。反可下乎。小结胸按之痛者。尚不用大黄。何此比陷胸更峻。此必有当
急下之症。比结胸更甚。故制此峻攻之剂也。
鳌按。关上脉浮。是阳明少阳火势炽矣。不恶寒反恶热。是阳气盛而外越极矣。大便硬是阳邪
固结而不解矣。此即柯氏所谓必有急下之处也。如此则濡字非简编之误欤。
【纲】仲景曰。太阳之为病。脉浮。头项强痛而恶寒。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。
【目】朱肱曰。大抵太阳病。必发热而恶寒。恶寒家慎不可过当覆衣被。及近火气。寒热相薄。
脉道沉伏。愈令病患寒不可当。但去衣被微火。兼与以和表之药。自然不恶寒矣。妇人恶寒。尤
不可近火。寒气入腹。血室结聚。药不能治。
刘完素曰。恶寒者。不待风而寒。虽身大热而不欲去衣也。是由阴气上入阳中。或阳微或风虚
相搏之所致。恶寒。一
切属表。虽里症悉具。而微恶寒。亦是表未解也。治法当先解外。
王肯堂曰。恶寒者。风寒客于营卫。非寒热之寒。又非恶风也。不待见风而后怯寒也。甚则向
火添被。亦不能遏其寒。经云。发热恶寒发于阳。可发汗。无热恶寒而蜷卧。脉沉细。发于阴。可
温里。恶寒虽悉属表。亦有虚实之分。若汗出而恶寒。为表虚。无汗而恶寒。为表实。表虚解肌。
表实发汗。伤寒太阳病在表。故恶寒。少阳在半表里。亦微恶寒。阳明在里。本不恶寒。而或恶者。
与太阳合病也。
【纲】仲景曰。病有发热恶寒者。发于阳也。无热恶寒者。发于阴也。
【目】刘完素曰。恶寒者。必继之以发热。此发于阳也。恶寒而蜷卧。脉沉细而紧者。发于阴
也。在阳可汗。在阴可温。其止称背恶寒者。背为阳。腹为阴。阳气不足。阴寒气盛。则背为之恶
寒。若风寒在表而恶寒。则一身尽寒矣。
张元素曰。恶寒有发阳发阴二症。发于阳者脉必浮数。宜解表。属桂枝汤、桂枝二越婢一汤、
麻黄汤、青龙汤症也。
【纲】仲景曰。发汗。病不解。反恶寒者。虚故也。芍药甘草附子汤主之。
【目】杨士瀛曰。汗后反恶寒。表虽不解。急当救里。若反与桂枝攻表。此误也。故去桂、姜、
枣、加附子以温经散寒。助芍药、甘草以和中。
脚挛急。与芍药甘草汤。本治阴虚。此治阴阳俱虚。故加附子。皆仲景治里不治表之义。
【纲】仲景曰。脉微而恶寒者。此阴阳俱虚。不可更发汗。更吐。更下也。
【目】朱 曰。若其人热虽多。而脉甚微。无和缓之意。是阴弱而发。寒虽少。而恶之更甚。
是阳虚而恶寒。阴阳俱虚。当调其阴阳。勿妄治以虚其虚也。
【纲】仲景曰。伤寒大下后。复发汗。心下痞。恶寒者。表未解也。不可攻痞。当先解表。乃
可攻痞。解表。宜桂枝汤。攻痞。宜大黄黄连泻心汤。
【目】朱肱曰。太阳阳明少阴。皆有恶寒。要之惟太阳病。不问已发热未发热。必恶寒也。
柯琴曰。心下痞。是误下后里症。恶寒。是汗后未解症。里实表虚。内外俱病。皆因汗下倒施也。表
里交持。仍当遵先表后里先汗后下正法。盖恶寒之表。甚于身疼。心下之痞。轻于消谷。与救急之
法不同。
【纲】仲景曰。心下痞。大便硬。心烦不得眠。而复恶寒汗出者。附子泻心汤主之。太阳病。寸缓。关浮。尺弱。
其人发热汗出。复恶寒。不呕。但心下痞者。此以医下之也。
【目】柯琴曰。心下痞下。当有便硬心烦不眠。故用此汤。但心下痞而恶寒。表未解也。当先
解表。宜桂枝加附子。而反用大黄。误矣。但以医下之而心下痞。犹发热恶寒。故属太阳症。
【纲】仲景曰。阳明病。脉迟。汗出多。微恶寒者。表未解也。可发汗。宜桂枝汤。
【目】朱肱曰。此阳明之表症也。同于太阳。而属之阳明者。不头项强痛耳。要知桂枝麻黄二
汤。专为表邪而设。不为太阳而设。见麻黄症即用麻黄汤。见桂枝症即用桂枝汤。不必问其为太阳
阳明也。若恶寒一罢。则二方必禁。
鳌按。仲景云。阳明病。脉浮无汗而喘者。发汗则愈。宜麻黄汤一条。乃言阳明之表脉。其症
亦同太阳。故用麻黄汤发表。当与本条同看。
【纲】仲景曰。伤寒五六日。头汗出。微恶寒。手足冷。心下满。口不欲食。大便硬。脉沉
细者。此为阳微结。必有表复有里也。脉沉亦在里也。汗出为阳微结。假令纯阴结。不得复有外症。
悉入在里矣。此为半在表半在里也。脉虽沉细。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。
【目】王肯堂曰。三阴惟少阴有恶寒之症。然少阴恶寒。又有二症。发于少阴者。无热而恶寒。
宜温之。四逆汤、理中汤。少阴无热恶寒。似与太阳经未即热一条相似。所谓寒未即热者。为太
阳症具而未热耳。少阴之无热恶寒。盖无太
阳头痛等症。知为少阴也。若少阴恶寒而蜷卧。时时自烦。欲去衣被者。活人书用大柴胡下之。赵氏以为宜温散经邪。
导
引真阳。汗而解可也。若下之。非惟不能解表。反虚其里。使恶寒之邪。乘虚内陷。纵使其脉沉滑
而实。亦未可遽用大柴胡。必须先解表。使恶寒症罢。而后可用也。少阴病。恶寒。身蜷而利。手
足逆冷者。不治。少阴病。四逆恶寒而身蜷。脉不至。不烦而躁者。死。有太阴自利不渴。厥阴下
利厥逆。俱或恶寒。太阴。宜理中汤。厥阴。宜四逆汤。前既言二阴不恶寒。今又言或恶寒者。要
知太阴厥阴。本不恶寒。此阳传阴者也。三阴皆能恶寒者。阴入阴者也。特在少阴为多耳。
陶华曰。恶寒者。寒邪入营卫。则洒淅恶寒。虽一切属表。尚在腑。阴阳所分。若发热恶寒。
兼之头疼脊强脉浮紧。寒邪在太阳表症也。宜汗之。照时令用药。若无热恶寒体蜷。脉沉迟无力者。
寒邪入少阴里症也。宜温之。四逆汤。
鳌按。此条但就脉言。曰沉曰细。俱是少阴。固不得与柴胡汤。惟推出头汗。则犹有少阳现症。
而非尽在里矣。虽脉已属少阴而仍与柴胡也。且三阴脉不至头。其脉止在身。三阳脉盛于头。阳
结则汗在头。今阳微结。虽曰少阳而微恶寒。毕竟尚有太阳表症之意。所以此条仍列入太阳恶寒门
类。
[General Principle] Zhang Zhongjing said: When there is epigastric fullness and stuffiness (Xin Xia Pi), which feels soft upon pressure, accompanied by hard stools, aversion to cold is absent but aversion to heat is present, and the pulse is floating at the Guan position, Da Huang Huang Lian Xie Xin Tang (Rhubarb and Coptis Decoction to Drain the Heart) should be administered.
[Commentary] Dai Yuanli said: After sweating therapy, if only aversion to cold occurs, it indicates deficiency, specifically exterior deficiency. If only aversion to heat occurs after sweating, it indicates excess, specifically interior excess. Aversion to cold alone results from premature sweating or excessive sweating, leading to weak Yang Qi; Shao Yao Gan Cao Fu Zi Tang (Peony, Licorice, and Aconite Decoction) is appropriate. Aversion to heat alone indicates that the exterior pathogen has resolved but interior heat remains; this is described as weak Yin generating fever, and Da Chai Hu Tang (Major Bupleurum Decoction) or Xiao Cheng Qi Tang (Minor Order the Qi Decoction) are appropriate.
Ke Qin stated: The character "Ru" (soft) should likely be read as "Ying" (hard). If the area is soft to touch, it is Qi Pi (Qi Stagnation), which is formless, and thus purgatives should not be used. Furthermore, in Jie Xiong (Chest Binding) syndrome, if the pulse is floating and large, purgatives are contraindicated; so how can one use purgatives for Xin Xia Pi with a floating pulse? Even in Xiao Jie Xiong (Minor Chest Binding), where tenderness on pressure exists, Da Huang (Rhubarb) is not used. Why would this condition, being more severe than Xian Xiong Tang syndrome, require such a harsh purgative? There must be symptoms requiring urgent purgation, more severe than chest binding, hence the formulation of this harsh purgative agent.
Shen Jin'ao's Note: A floating pulse at the Guan position indicates blazing fire in the Yangming and Shaoyang channels. Absence of aversion to cold but presence of aversion to heat indicates extreme exuberance of Yang Qi dispersing outward. Hard stools indicate stubborn accumulation of Yang pathogens. This aligns with Ke's assertion of needing urgent purgation. Thus, the character "Ru" is likely a transcription error in the bamboo slips.
[General Principle] Zhang Zhongjing said: The characteristic of Taiyang disease is a floating pulse, stiffness and pain in the head and nape, and aversion to cold. In Taiyang disease, whether fever has already appeared or not, aversion to cold is always present. With body pain, vomiting, and a tight pulse at all three positions (Cun, Guan, Chi), it is named Shanghan (Cold Damage).
[Commentary] Zhu Gong said: Generally, Taiyang disease involves both fever and aversion to cold. Patients with aversion to cold should not be over-covered with blankets or placed near fire, as the conflict between cold and heat may cause the pulse to sink and hide, making the patient feel unbearably cold. One should remove excess coverings, use mild warmth, and administer herbs to harmonize the exterior; aversion to cold will naturally cease. For women with aversion to cold, avoiding fire is especially crucial to prevent cold qi from entering the abdomen and causing blood chamber stasis, which is difficult to treat.
Liu Wansu said: Aversion to cold is feeling cold without wind; even with high fever, the patient does not wish to remove clothes. This is caused by Yin Qi ascending into the Yang region, or by weak Yang Qi battling with Wind pathogen. Aversion to cold belongs entirely to the Exterior Syndrome. Even if interior symptoms are fully present, slight aversion to cold indicates the exterior is unresolved. Treatment should first resolve the exterior.
Wang Kentang said: Aversion to cold refers to wind-cold lodging in Ying and Wei, distinct from the "cold" in hot/cold patterns or "aversion to wind." It does not require exposure to wind to feel chilly. Severe cases may involve huddling by fire and adding quilts without relief. The Classic states: Fever with aversion to cold arises from Yang; sweating is indicated. No fever with aversion to cold, curling up, and a deep, thin pulse arises from Yin; warming the interior is indicated. Although aversion to cold generally belongs to the exterior, it has deficiency and excess types. Sweating with aversion to cold is Exterior Deficiency; no sweating with aversion to cold is Exterior Excess. Exterior Deficiency requires resolving the muscle layer; Exterior Excess requires inducing sweating. Taiyang Shanghan is in the exterior, hence aversion to cold. Shaoyang is half-exterior/half-interior, also showing slight aversion to cold. Yangming is interior and normally lacks aversion to cold; if present, it indicates combined disease with Taiyang.
[General Principle] Zhang Zhongjing said: Diseases manifesting with fever and aversion to cold arise from Yang. Diseases manifesting with no fever and aversion to cold arise from Yin.
[Commentary] Liu Wansu said: Aversion to cold is inevitably followed by fever, indicating origin from Yang. Aversion to cold with curling up, and a deep, thin, tight pulse, indicates origin from Yin. Yang origins respond to sweating; Yin origins respond to warming. Specifically, back aversion to cold occurs because the back is Yang and the abdomen is Yin; insufficient Yang Qi and excessive Yin-Cold cause back aversion to cold. If wind-cold is in the exterior, the whole body feels cold.
Zhang Yuansu said: Aversion to cold has two syndromes: originating from Yang or Yin. Originating from Yang features a floating, rapid pulse and responds to exterior resolution, fitting Gui Zhi Tang (Cinnamon Twig Decoction), Gui Zhi Er Yue Bi Yi Tang (Cinnamon Twig Twice-Bupleurum-One Decoction), Ma Huang Tang (Ephedra Decoction), or Qing Long Tang (Green Dragon Decoction).
[General Principle] Zhang Zhongjing said: After sweating, if the disease persists and aversion to cold worsens, it is due to deficiency. Shao Yao Gan Cao Fu Zi Tang (Peony, Licorice, and Aconite Decoction) should be administered.
[Commentary] Yang Shiying said: Post-sweating aversion to cold, despite unresolved exterior, requires urgent interior rescue. Using Gui Zhi Tang to attack the exterior here is an error. Therefore, Gui Zhi, Sheng Jiang, and Da Zao are removed, and Fu Zi is added to warm meridians and scatter cold, assisting Shao Yao and Gan Cao to harmonize the middle. For foot cramping, Shao Yao Gan Cao Tang treats Yin deficiency; here it treats dual Yin-Yang deficiency, hence adding Fu Zi. This reflects Zhang Zhongjing's principle of treating the interior rather than the exterior.
[General Principle] Zhang Zhongjing said: A faint pulse with aversion to cold indicates dual deficiency of Yin and Yang. Do not induce sweating, vomit, or purge again.
[Commentary] Zhu Zhenheng said: If heat signs are numerous but the pulse is very faint without a relaxed quality, it is weak Yin generating heat. If cold signs are few but aversion to cold is severe, it is weak Yang causing aversion to cold. In dual deficiency, one must regulate Yin and Yang and avoid reckless treatment that further depletes the deficient.
[General Principle] Zhang Zhongjing said: After severe purgation for Shanghan, followed by sweating, if epigastric stuffiness and aversion to cold occur, the exterior is unresolved. Do not attack the stuffiness; resolve the exterior first, then attack the stuffiness. To resolve the exterior, use Gui Zhi Tang. To attack the stuffiness, use Da Huang Huang Lian Xie Xin Tang.
[Commentary] Zhu Gong said: Taiyang, Yangming, and Shaoyang all have aversion to cold. However, only Taiyang disease invariably presents with aversion to cold, regardless of whether fever has appeared.
Ke Qin said: Epigastric stuffiness is an interior syndrome resulting from erroneous purgation. Aversion to cold is a symptom of unresolved exterior after sweating. Interior excess with exterior deficiency, affecting both inside and out, results from inverted order of sweating and purging. With exterior-interior entanglement, one must follow the correct method of treating exterior before interior, sweating before purging. Aversion to cold is more significant than body ache; epigastric stuffiness is less severe than polyphagia. These differ from emergency rescue methods.
[General Principle] Zhang Zhongjing said: Epigastric stuffiness, hard stools, irritability, insomnia, accompanied by aversion to cold and sweating, is treated with Fu Zi Xie Xin Tang (Aconite and Coptis Decoction to Drain the Epigastrium). In Taiyang disease, with a slow Cun pulse, floating Guan pulse, and weak Chi pulse, if the patient has fever, sweating, and aversion to cold, but no vomiting, only epigastric stuffiness, this is due to physician's erroneous purgation.
[Commentary] Ke Qin said: Below "epigastric stuffiness," there should be mentions of hard stools, irritability, and insomnia to justify this formula. If there is only epigastric stuffiness with aversion to cold, the exterior is unresolved and should be treated first with Gui Zhi Jia Fu Zi Tang (Cinnamon Twig Decoction plus Aconite). Using Da Huang here is an error. However, since the stuffiness resulted from erroneous purgation and fever/aversion to cold persist, it belongs to Taiyang syndrome.
[General Principle] Zhang Zhongjing said: In Yangming disease, with a slow pulse, profuse sweating, and slight aversion to cold, the exterior is unresolved. Sweating may be induced using Gui Zhi Tang.
[Commentary] Zhu Gong said: This is the exterior syndrome of Yangming, identical to Taiyang but classified under Yangming due to the absence of head/nape stiffness. Know that Gui Zhi Tang and Ma Huang Tang are designed for exterior pathogens, not specifically for Taiyang. Use Ma Huang Tang for Ma Huang symptoms and Gui Zhi Tang for Gui Zhi symptoms, regardless of whether it is Taiyang or Yangming. Once aversion to cold ceases, these two formulas are strictly prohibited.
Shen Jin'ao's Note: Zhang Zhongjing stated: "Yangming disease, floating pulse, no sweating, and wheezing; sweating leads to cure, use Ma Huang Tang." This describes the exterior pulse of Yangming, with symptoms identical to Taiyang, hence using Ma Huang Tang to release the exterior. This should be read alongside the current passage.
[General Principle] Zhang Zhongjing said: In Shanghan after five to six days, with sweating on the head, slight aversion to cold, cold hands and feet, epigastric fullness, lack of desire to eat, hard stools, and a deep, thin pulse, this is called Yang Wei Jie (Slight Yang Binding). There is both an exterior and an interior component. A deep pulse indicates interior involvement. Sweating indicates Yang Wei Jie. If it were pure Yin Binding, there would be no exterior symptoms, all entering the interior. This is half-exterior, half-interior. Although the pulse is deep and thin, it cannot be diagnosed as Shaoyin disease. The reason is that Yin syndromes do not typically sweat; now that the head sweats, we know it is not Shaoyin. Xiao Chai Hu Tang (Minor Bupleurum Decoction) may be given. If the patient remains uncomfortable, passing stool will resolve it.
[Commentary] Wang Kentang said: Among the Three Yin channels, only Shaoyin has aversion to cold. However, Shaoyin aversion to cold has two presentations. Originating in Shaoyin, with no fever and aversion to cold, warming is indicated using Si Ni Tang (Four Counterflow Decoction) or Li Zhong Tang (Regulate the Middle Decoction). Shaoyin's no-fever aversion to cold resembles the Taiyang line where heat does not immediately appear. "Cold not immediately heating" means Taiyang symptoms are present but fever has not yet arisen. Shaoyin's no-fever aversion to cold lacks Taiyang headache symptoms, identifying it as Shaoyin. If Shaoyin aversion to cold includes curling up, frequent inner irritation, and desire to remove covers, *Ren Shu* suggests purging with Da Chai Hu Tang. Zhao believed warming and dispersing meridian pathogens to guide true Yang via sweating is appropriate. Purging would fail to resolve the exterior, weaken the interior, and allow cold pathogens to sink inward. Even with a deep, slippery, excess pulse, Da Chai Hu Tang should not be used hastily; the exterior must be resolved first, eliminating aversion to cold, before use. Shaoyin disease with aversion to cold, curling up, diarrhea, and cold extremities is untreatable. Shaoyin disease with four counterflows, aversion to cold, curling up, absent pulse, no irritability but restlessness is fatal. Taiyin spontaneous diarrhea without thirst, and Jueyin diarrhea with counterflows, may both present with aversion to cold. Taiyin requires Li Zhong Tang; Jueyin requires Si Ni Tang. Previously stating Two Yin do not have aversion to cold, now mentioning possible aversion to cold: Taiyin and Jueyin originally do not have aversion to cold; this is Yang pathogen transmitting to Yin. All Three Yin can have aversion to cold when Yin pathogen transmits to Yin, most commonly in Shaoyin.
Tao Hua said: Aversion to cold occurs when cold pathogens enter Ying and Wei, causing shivering aversion to cold. Although belonging to the exterior, it remains in the Fu organs. Differentiating Yin and Yang: Fever with aversion to cold, plus headache, stiff spine, and tight floating pulse, indicates cold pathogen in Taiyang exterior; sweating is indicated, adjusting herbs by season. No fever with aversion to cold, curling up, and deep, slow, forceless pulse indicates cold pathogen in Shaoyin interior; warming is indicated using Si Ni Tang.
Shen Jin'ao's Note: This passage focuses on the pulse: deep and thin pulses belong to Shaoyin and indeed preclude Chai Hu Tang. However, deriving head sweating reveals Shaoyang manifestations, meaning it is not entirely interior. Although the pulse belongs to Shaoyin, Chai Hu Tang is still given. Furthermore, Three Yin pulses do not reach the head, stopping at the body; Three Yang pulses flourish at the head. Yang binding causes sweating on the head. Now, with Yang Wei Jie, although termed Shaoyang with slight aversion to cold, there remains the intent of Taiyang exterior syndrome. Therefore, this passage is still categorized under Taiyang aversion to cold.