鳌按。仲景自序云。着伤寒杂病论十六卷。仲景原书固合伤寒杂病而为一也。迨叔和编次。始
分伤寒杂病为两书。于本论削去杂病。然论中杂病。留而未去者正多。于是仲景原书。后人不得一
见。叔和后。注释者不下什百家。又各以意颠倒。纷纭传会。更兼日久残阙。仲景之原文益失。仲
景之书益难读矣。鳌今辑伤寒论纲目。分条析款。各循六经分次。而其论有不得分属六经者。因辑脉
症总论、六经主症、阴阳、表里、传变、愈解六篇冠于前。以为卷首。又辑诸寒热症、阴阳易、劳复食复、
百合病、狐惑病、阴毒、阳毒、阴阳交、瘥后诸病、妇人伤寒十篇。次于六经之后。实不免剪缀割
裂之讥。然仲景原书。既不复睹。而苟可以发明仲景之书之旨。将质诸冥冥。仲景当亦曲恕。而不
以剪缀割裂为余首罪也。阅者其更谅之。
【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】朱肱曰。太阳、阳明、少阳。皆阳症也。桂枝汤、麻黄汤、大青龙汤。治太阳伤风寒也。
大柴胡汤、大承气、小承气、调胃承气汤。治阳明伤寒也。小柴胡汤。治少阳伤寒也。其他药。
皆发汗吐下后症也。若阳气独盛。阴气暴绝。即为阳毒。当以酸苦之药投之。令阴气复而大汗解。
如苦参、大青、葶苈、苦酒之类。皆复其阴气也。微止用苦。甚则兼用酸苦。折热
复阴。若热极发厥。阳症似阴者。当以脉别之。太阴、少阴、厥阴。皆阴症也。三阴中寒微。则理
中汤。稍厥或中寒下利。干姜甘草汤。大段重者。四逆汤。无脉者。通脉
四逆汤。若阴气独盛。阳气暴绝。则为阴毒。急灸脐下。服以辛热之药。令复阳气而大汗解。如
桂枝、甘草、干姜、附子之类。能复其阳气也。微用辛甘。甚则用辛苦。若阴极热躁。阴症似阳
者。亦当以脉别之。
戴原礼曰。凡治伤寒。须辨阴阳二候。阳经有三。阴经亦有三。经之阴阳。以脏腑言。腑阳、
脏阴也。病之阴阳。乃是外邪之阴阳。阴气阳气也。病在太阳。则热在皮肤之分。翕翕怫怫而热。便
有头疼恶寒体痛。其脉浮紧。病在阳明。则热在肌肉之分。或壮热。或 热。或蒸蒸热。便有
头额痛。或潮热自汗。其脉长大。病在少阳。则必半表半里之热。或往来寒热。便有头角痛。口苦。
呕而胸满胁痛。其脉弦数。病在太阴。则手足渐冷。脉息渐沉。或自利腹满。呕吐不渴。病在少
阴。虽发热。手足自冷。其脉沉细。病在厥阴。则手足厥冷。甚则舌卷唇青囊缩。其脉微缓。三阴
症。虽肌表有热。以手按之。则不甚热。阴甚者。则冷透手也。阴阳二气。皆能犯脏腑。故阳气犯
太阳。则为伤风。恶风而有汗。阴气犯太阳。则为伤寒。恶寒而无汗。在太阳未得解。转入阳明
少阳二经。则纯乎阳。不如太阳之易治。若阳气未能罢。以次传入阴经。则为阴中之阳。盖缘阳经
之阳气。来入阴经。虽有自利欲寐。唇青厥冷。舌卷囊缩等症。亦不可妄投热药。宜泻其阳之在阴
经也。若阳病下之太过。阳气已脱。遂变为阴。所谓害热未已。寒病复起。或初得病便是阴症。此是
阴中之阴。盖缘阴气攻阴经。阴自得传。非自阳经传来。只当以温药回其阳。故阳入阴者变阳以救
阴。阴入阳者用阳以救阳。二者不可不辨。有伤寒正病。有伤寒杂病。伤寒杂病者。难以正病治。
如病患症状不一。有冷有热。阴阳显在目前。当就其中大节先治。其余症则徐治。然亦不可用独
热独寒之剂。又如呕渴烦热。进小柴胡汤。呕渴烦热止矣。而下利不休。以小柴胡为非。则呕渴烦
热不应止。以为是。则下利不应见。吐利厥逆。进姜附汤。吐利厥逆止矣。
而热渴谵语。昏不知人。以姜附汤为非。则吐利厥逆不应止。以为是。则热渴谵语不应见。此亦伤
寒杂病。虽无前项冷热二症显然并见之迹。而阴中有阳。阳中有阴。潜伏其间。未即发见。用药一
偏。此衰彼盛。医者当于有可疑之处。能反复体认。无举一废一。则尽善矣。
楼全善曰。素问云。脉从而病反。言症似阳者。脉亦从症似阳。而其病反是寒也。症似阴者。
脉亦从症似阴。而其病反是热也。故皆反其脉症施治。如身热微热。烦躁面赤。其脉沉而微者。阴
症似阳也。身热者。里寒故也。烦躁者。阴盛故也。面戴阳者。下虚故也。若不知脉。误谓实热。
反与凉药。则气消。成大病矣。外台秘要云。阴盛发躁。名曰阴躁。欲坐井中。宜以热药治之。故
仲景少阴症面赤者。四逆汤加葱白治之。
李氏杲曰。寒凉之药入腹。则周身之火得水则升走。阴躁之极。故欲坐井中。是阳已先亡。医
犹不悟。复认为热。重以寒药投之。其死何疑焉。或因吐。因呕。因嗽而发躁。蒸蒸身热。如坐
甑中。欲得去衣。居寒处。饮寒水。则便如故。振寒复至。则气短促。胸中满闷。甚则口开目瞪。
声闻于外。而涕泪涎痰大作。其发躁须臾而已如前。六脉弦细而涩。按之而虚。此大寒症也。以辛
寒甘寒。大泻南方。北方则愈。
张氏介宾曰。伤寒纲领。惟阴阳为最。有纯阳症。有纯阴症。当宜分治也。又有阴阳相半症。
如寒之即阴胜。热之即阳胜。或今日见阴。而明日见阳。或今日见阳。而明日见阴。然以阴变阳多
吉。以阳变阴多凶。凡病患开目、喜明、欲见人、多谈者。属阳。闭目、喜暗、不欲见人、懒言者。
属阴。论曰。阳盛阴虚。汗之则死。下之则愈。阳虚阴盛。汗之则愈。下之则死。又曰。桂枝下咽。
阳盛则毙。承气入胃。阴盛以亡。此阴阳乃以寒热为言也。阳盛阴虚。言内热有余而外寒不甚也。
夫邪必入腑。然后作热。热实于内。即阳盛也。故再用温热以汗之。则死矣。阳虚阴盛。言寒邪有
余而郁热未深也。夫邪中于表。必因风寒。寒束于外。即阴盛也。故妄用沉寒以下之。则死矣。所以阳盛者。
用桂枝则毙。阴盛者。用承气则亡也。
鳌按。三阳病。俱有不发热者。便是发于阴。三阴病。俱有反发热者。便是发于阳。
【纲】仲景曰。问曰。脉有阴阳。何谓也。答曰。凡脉浮、大、滑、动、数。此名阳也。脉沉、
弱、涩、弦、微。此名阴也。寸口脉。浮为在表。沉为在里。数为在腑。迟为在脏。凡阴病见阳
脉者生。阳病见阴脉者死。
【目】张介宾曰。按浮为在表。沉为在里。此古今相传之法也。然沉脉亦有表症。此阴实阳虚。
寒胜者然也。浮脉亦有里症。此阳实阴虚。水亏者然也。故凡欲察表邪者。不宜单据浮沉。只
当以紧数与否为辨。盖寒邪在表。脉皆紧数。紧数甚者邪亦甚。紧数微者邪亦微。紧数浮洪有力
者。邪在阳分。即阳症也。紧数浮洪无力者。邪在阴分。即阴症也。以紧数之脉而兼见表症者。
其为外感无疑。即当解散。然内伤之脉。亦有紧数者。但其来有渐。外感之紧。发于陡然。以此辨之
最切当。其有似紧非紧。但较之平昔。稍见滑疾。而不甚者。亦有外感之症。此其邪之轻者。或以
初感而未甚者。亦多此脉。又不可见症而不察之也。若其和缓。而全无紧疾意。则脉虽浮大。自无
外邪之症。陶节庵曰。夫脉浮当汗。脉沉当下。固其宜也。然其脉虽浮。亦有可下者。谓邪热入腑。
大便难也。使大便不难。岂敢下乎。脉虽沉。亦有可汗者。谓少阴病。身有热也。使身不热。岂敢
汗乎。据此。可见沉有表。浮亦有里也。伤寒之邪。实无定体。或入阳经气分。则太阳为首。或入阴
经精分。则少阴为先。其脉以浮紧而有力无力。可知表之虚实。沉紧而有力无力。可知里之虚实。
中按而有力无力。可知阴阳之吉凶。所当问症以知其外。察脉以知其内。先病为本。后病为标。合
参脉症。而知缓急先后者。乃为上工。诊法曰。浮脉为在表。凡脉见浮紧而数者。即表邪也。再加头项
痛腰脊强等症。此即太阳经病。当求本经轻重为解散之。脉见洪长有力。而外兼阳明症者。即阳明
在经之邪也。宜求本经之寒热散之。脉见弦数。而兼少阳之症者。即少阳经半表半里之病。宜
和解而散之。沉脉为在里。病属三阴。但沉数有力。是即热邪传
里也。若表症深入。而内见大满大实。阳邪热结等症。当下之。沉紧无力。而外无大热。内无烦渴
等症。此阴症也。若或畏寒厥冷。及呕吐腹痛泻利者。此即阴寒直中。宜温中。脉大者。为病进。
大因邪气胜。病日甚也。脉渐缓者。为邪退。缓则胃气至。病将愈也。故以大为病进也。然亦有宜
大不宜大者。又当详辨。如脉体本大。而再加洪数。此病进之脉。不可当也。如脉体本小。服药后
渐见滑大有力者。此自阴转阳。必将汗解。乃为吉兆。盖脉至不数者。由气虚而然。无阳岂能作汗也。
柯琴曰。脉有十种。阴阳两分。即具五法。浮沉是脉体。大弱是脉势。滑涩是脉气。动弦是脉
形。迟数是脉息。总是病脉。而非平脉。二条。寸口兼两手六部言。三条。凡字不是承接语。阳脉
指胃气言。所谓二十五阳者是也。五脏之阳和发见。故生。阴脉。指真脏言。胃脘之阳。不至于手太
阴。五脏之真阴发见。故死。要知上条沉涩弱弦迟。是病脉不是死脉。其见于阳病最多。若真脏脉
至。如肝脉中外急。心脉坚而搏。肺脉大而浮。肾脉如弹石。脾脉如啄距。反见有余之象。岂可以
阳名之。若以胃脉为迟。真阴为数。岂不误人。
【纲】仲景曰。寸脉下不至关。为阳绝。尺脉上不至关。为阴绝。此皆不治。决死也。若计余
命生死之期。期以月节克之也。问曰。脉病欲知愈未愈者。何以别之。曰。寸口关上尺中三处。大
小浮沉迟数同等。虽有寒热不解者。此脉阴阳为和平。虽剧。当愈。
【目】张介宾曰。阴病见阳脉者生。阳病见阴脉者死。脉纯弦者死。脉阴阳俱虚。热不止者死。
脉阴阳俱盛。大汗出。热不解者死。脉沉细。手足逆冷。谵语妄言者死。脉症俱虚。而见谵妄者
死。伤寒六七日。脉微。手足厥冷。烦躁。灸厥阴。厥不还者死。寸脉下不至关为阳绝。尺脉上不至
关为阴绝。此皆不治。决死。伤寒下利。日十余行。脉反实者死。
魏荔彤曰。和而均平。在脉则无过不及。故大小浮沉迟数本皆病脉。至于三处同等则为和脉也。
曰脉病。以病时脉为问也。今见此诊。竟可以和脉答之。即或病寒。或病热。而脉已同等。阴阳和平。即病剧。亦直决
之为愈而已。此辨脉察病进退之机也。
【纲】仲景曰。伤寒三日。三阳为尽。三阴当受邪。其人反能食而不呕。此为三阴不受邪也。
伤寒六七日。无大热。其人躁烦者。此为阳去入阴故也。
【目】李 曰。三阴有中有传。故三阴最不可执。有宜下者。宜温者。自三阳气分。传入三阴。
谓之传经阴症。夫传非传入脾肾肝也。乃入三阴血分。胃与大小肠之腑也。仲景谓已入于腑。可下之
是也。若不是阳经传来。直中三阴之经。初起厥逆腹痛。自利不渴。太阴自受寒也。上症加之呕吐。
少阴自受寒也。又加小便清利。厥阴自受寒也。热药温之。犹恐或迟。阴阳一差。死生立判。虽
然。传经直中。先贤发之尽矣。然岂无传变者乎。假如传经之际。轻生者。或食生冷。或犯房欲。
或粗工猛施汗下。真气衰弱。阳症变为阴症。如俗所谓阳症归阴。仍宜直中寒症法治。故内经止言
传变而不言直中者。盖言变则包直中。局方言传阴传阳。则不是。当言传阳变阴。夫传经为里热。
直中与变为里寒。临症察脉。直中三阳。传经三阳。病在于表。脉浮长弦。传经三阴。病在于里。
脉沉数实。直中三阴。病在于经。脉沉微缓。此表里虚实大小分焉。以阳为热。阴为寒也。
柯琴曰。此是阳邪自表入里之症。阴指里言。非指三阴也。或入太阳之本。而热结膀胱。或入
阳明之本。胃中干燥。或入少阳之本。而胁下硬满。或入太阴。而暴烦下利。或入少阴。而口燥
咽干。或入厥阴。而心中疼热。皆入阴之谓。
【纲】仲景曰。风家表解而不了了者。十二日愈。
【目】魏荔彤曰。此病愈后。风邪留滞之症。十二日愈者。阴气复而自神清气爽。不须妄治也。
柯琴曰。不了了。余邪未除也。此虽举风家。伤寒概之矣。仲景分别六经。各经各有中风伤寒脉症治法。叔和时。
太阳篇存者多而失者少。他经存者少而失者多。阳明篇尚有中风脉症二条。少阳经只症一条而不及脉。三阴俱有中风欲
愈脉。俱无中风欲愈脉症。以伤寒论为全书。不亦疏乎。
鳌按。据柯氏说。知仲景当时。必六经皆有中风脉症治法。今既非完书。则此条亦不得强隶太阳矣。故特列于总论
中。
Shen Jin'ao's Commentary: Zhang Zhongjing stated in his preface that he wrote "Treatise on Cold Damage and Miscellaneous Diseases" (Shanghan Zabing Lun) in sixteen volumes. Zhang Zhongjing's original work originally combined cold damage and miscellaneous diseases into one book. It was not until Wang Shuhe compiled and arranged it that cold damage and miscellaneous diseases were divided into two separate books. He removed the content on miscellaneous diseases from the "Treatise on Cold Damage," yet many discussions on miscellaneous diseases remained in the text. Consequently, later generations could no longer see the complete original work of Zhang Zhongjing. After Wang Shuhe, there were no fewer than a hundred commentators, each arbitrarily rearranging and interpreting through forced associations. Furthermore, due to the passage of time and the resulting fragmentation and loss of texts, Zhang Zhongjing's original text became even more lost, making his works increasingly difficult to read. I (Shen Jin'ao) now compile the "Outline of the Treatise on Cold Damage" (Shanghan Lun Gangmu), analyzing items point by point and arranging them according to the Six Channels (Liu Jing). For those discussions that cannot be classified under the Six Channels, I have collected six chapters: "General Discussion on Pulse and Symptoms" (Maizheng Zonglun), "Main Symptoms of the Six Channels" (Liu Jing Zhuzheng), "Yin and Yang" (Yinyang), "Exterior and Interior" (Biaoli), "Transmission and Change" (Chuanbian), and "Recovery and Resolution" (Yujie), placing them at the beginning as the volume's introduction. I also collected ten chapters: "Various Cold and Heat Symptoms" (Zhu Hanre Zheng), "Yin-Yang Transformation" (Yinyang Yi), "Relapse due to Labor or Diet" (Laofu Shifu), "Lily Disease" (Baihe Bing), "Fox-Demon Disease" (Huhuo Bing), "Yin Toxin" (Yindu), "Yang Toxin" (Yangdu), "Yin-Yang Intersection" (Yinyang Jiao), "Post-Illness Diseases" (Chaishou Zubing), and "Women's Cold Damage" (Furen Shanghan), placing them after the Six Channel sections. This inevitably invites criticism for being patchwork and fragmented. However, since Zhang Zhongjing's original book is no longer accessible, if this approach can elucidate the purport of Zhang Zhongjing's work, even questioning the spirits in the underworld, Zhang Zhongjing should forgive me and not consider patchwork and fragmentation as my primary sin. Readers are asked to understand this with greater leniency.
[General Principle] Zhang Zhongjing said: When a disease presents with fever and aversion to cold, it originates from Yang; when it presents with aversion to cold but no fever, it originates from Yin.
[Details] Zhu Gong said: Taiyang disease, Yangming disease, and Shaoyang disease all belong to Yang syndromes. Guizhi Tang (Cinnamon Twig Decoction), Mahuang Tang (Ephedra Decoction), and Da Qinglong Tang (Major Green Dragon Decoction) are used to treat Taiyang channel invasion by wind-cold. Chaihu Tang variants (Da Chaihu Tang, Da Chengqi Tang, Xiao Chengqi Tang, Tiaowei Chengqi Tang) are used to treat Yangming channel cold damage. Xiao Chaihu Tang (Minor Bupleurum Decoction) is used to treat Shaoyang channel cold damage. Other medicines address symptoms occurring after sweating, vomiting, or purging. If Yang qi alone is excessive and Yin qi suddenly fails, it is called Yang Toxin (Yangdu); sour and bitter medicines should be administered to restore Yin qi, leading to resolution through profuse sweating. Examples include Kushen (Sophora Root), Daqingye (Isatis Leaf), Tinglizi (Descurainia Seed), and Cu (Vinegar), which all replenish Yin qi. Mild cases use bitter herbs; severe cases combine sour and bitter herbs to reduce heat and restore Yin. If extreme heat leads to cold limbs, where Yang syndromes mimic Yin syndromes, differentiation must be made via pulse diagnosis. Taiyin disease, Shaoyin disease, and Jueyin disease all belong to Yin syndromes. For mild cold invasion in the Three Yin channels, Lizhong Tang (Regulate the Middle Decoction) is used; for slight cold limbs or middle-jiao cold diarrhea, Ganjiang Gancao Tang (Dried Ginger and Licorice Decoction) is used; for severe cases, Sini Tang (Frigid Extremities Decoction) is used; for absent pulses, Tongmai Sini Tang (Pulse-Returning Frigid Extremities Decoction) is used. If Yin qi alone is excessive and Yang qi suddenly fails, it is called Yin Toxin (Yindu); urgent moxibustion below the navel and administration of acrid-hot medicines (such as Guizhi, Gancao, Ganjiang, Fuzi) are required to restore Yang qi, leading to resolution through profuse sweating. Mild cases use acrid-sweet herbs; severe cases use acrid-bitter herbs. If extreme Yin cold manifests as restlessness, where Yin syndromes mimic Yang syndromes, differentiation must also be made via pulse diagnosis.
Dai Yuanli said: In treating cold damage, one must distinguish between Yin and Yang pulse manifestations. There are three Yang channels and three Yin channels. Regarding channels, Fu organs are Yang and Zang organs are Yin. Regarding disease, Yin and Yang refer to the nature of external pathogens (Yin Qi and Yang Qi). When the pathogen is in the Taiyang channel, heat is at the skin level, manifesting as a superficial, stifling heat, accompanied by headache, aversion to cold, and body ache, with a floating-tight pulse. When in the Yangming channel, heat is at the muscle level, manifesting as high fever, slight fever, or steaming heat, accompanied by forehead pain, tidal fever, or spontaneous sweating, with a large-long pulse. When in the Shaoyang channel, there is half-exterior half-interior heat, manifesting as alternating chills and fever, accompanied by temporal headache, bitter taste, vomiting, chest fullness, and hypochondriac pain, with a string-taut-numerous pulse. When in the Ta iyin channel, hands and feet gradually become cold, the pulse gradually sinks, possibly with spontaneous diarrhea, abdominal fullness, vomiting, and no thirst. When in the Shaoyin channel, despite fever, hands and feet are naturally cold, with a deep-thin pulse. When in the Jueyin channel, hands and feet are cold; in severe cases, the tongue curls, lips turn blue, and testicles retract, with a faint-slow pulse. In Three Yin syndromes, although there may be heat on the surface, pressing reveals little heat; in severe Yin cold, the cold penetrates the hand. Both Yin and Yang Qi can invade Zang-Fu organs. Thus, Yang Qi invading Taiyang causes Wind Injury (Shangfeng), characterized by aversion to wind and sweating; Yin Qi invading Taiyang causes Cold Damage (Shanghan), characterized by aversion to cold and no sweating. If unresolved in Taiyang and transferring to Yangming and Shaoyang, it becomes purely Yang, unlike Taiyang which is easier to treat. If Yang pathogen persists and sequentially enters Yin channels, it becomes Yang within Yin. Even if symptoms like spontaneous diarrhea, drowsiness, blue lips, cold limbs, curled tongue, and retracted testicles appear, hot medicines should not be recklessly administered; instead, the Yang heat residing in the Yin channel should be purged. If Yang disease is excessively purged, causing Yang Qi depletion, it transforms into Yin syndrome, described as "heat harm not ceased, cold disease arises." Or, if the disease begins as a Yin syndrome, it is Yin within Yin, caused by Yin Qi attacking Yin channels directly, not transmitted from Yang channels. Only warm medicines should be used to restore Yang. Therefore, Yang entering Yin requires transforming Yang to save Yin; Yin entering Yang requires using Yang to save Yang. These two must be distinguished. There are standard cold damage diseases and mixed cold damage diseases. Mixed diseases are hard to treat with standard methods. If symptoms vary, presenting both cold and heat, with Yin and Yang clearly visible, one should treat the major aspects first and secondary symptoms later, avoiding purely hot or cold formulas. For example, if vomiting, thirst, irritability, and fever cease after Xiaochaihu Tang, but diarrhea persists, claiming the formula was wrong contradicts the cessation of other symptoms, while claiming it was right contradicts the persistence of diarrhea. Similarly, if Jiangfu Tang stops vomiting, diarrhea, and cold limbs, but fever, thirst, delirium, and coma appear, claiming the formula was wrong contradicts the cessation of initial symptoms, while claiming it was right contradicts the appearance of new symptoms. This is also mixed cold damage, where Yin contains Yang and Yang contains Yin,潜伏 (latent) and not immediately apparent. If medication is biased, one aspect weakens while the other strengthens. Physicians must carefully examine doubtful areas, avoiding partiality, to achieve perfection.
Lou Quanshan said: The "Suwen" states: "Pulse conforms to symptoms but the disease is opposite." This means symptoms seem Yang, pulse seems Yang, but the disease is actually Cold. Symptoms seem Yin, pulse seems Yin, but the disease is actually Heat. Therefore, treatment should be contrary to the apparent pulse and symptoms. For instance, body heat, slight fever, irritability, and red face, but with a deep-micro pulse, indicate Yin syndrome mimicking Yang. Body heat is due to interior cold; irritability is due to Yin excess; facial flushing (Daiyang) is due to lower deficiency. Ignoring the pulse and mistaking this for excess heat, then administering cooling medicines, will consume Qi and cause serious illness. The "Waitai Miyao" states: "Yin excess causing agitation is called Yin Agitation (Yinzao); the patient desires to sit in a well." It should be treated with hot medicines. Thus, Zhang Zhongjing treats Shaoyin syndrome with red face using Sini Tang plus Congbai (Scallion White).
Li Gao said: When cold-cooling medicines enter the abdomen, the fire throughout the body rises upon meeting water, causing extreme Yin agitation, hence the desire to sit in a well. This indicates Yang has already perished. If physicians do not realize this and mistake it for heat, administering heavy cold medicines, death is inevitable. Agitation may arise from vomiting, coughing, etc., with steaming body heat, feeling like sitting in a steamer, wanting to remove clothes, stay in cold places, and drink cold water for temporary relief. Soon, chills return, breath becomes short, chest feels full, eyes open wide, voice is audible externally, and nasal discharge, tears, saliva, and phlegm increase profusely. This agitation lasts only a moment before returning to normal. The six pulses are string-taut-thin-choppy, empty upon pressure, indicating severe Cold. Using acrid-cold and sweet-cold medicines to strongly drain the South (Heart Fire) will heal the North (Kidney Water).
Zhang Jiebin said: The guideline for cold damage lies solely in Yin and Yang. There are pure Yang syndromes and pure Yin syndromes, requiring separate treatment. There are also mixed Yin-Yang syndromes, where cold medicine exacerbates Yin, and hot medicine exacerbates Yang. One day Yin appears, the next Yang; or vice versa. Generally, transformation from Yin to Yang is auspicious, while Yang to Yin is ominous. Patients who keep eyes open, prefer light, wish to see people, and talk much belong to Yang; those who keep eyes closed, prefer darkness, avoid people, and speak little belong to Yin. The text states: "Yang excess, Yin deficiency: sweating causes death, purging cures. Yang deficiency, Yin excess: sweating cures, purging causes death." Also: "Guizhi Tang swallowed, Yang excess leads to death; Chengqi Tang enters stomach, Yin excess leads to demise." Here, Yin and Yang refer to Cold and Heat. "Yang excess, Yin deficiency" means internal heat surplus with mild external cold. Pathogens must enter Fu organs to generate heat; heat solidifying internally is Yang excess. Using warm-hot medicines to sweat would cause death. "Yang deficiency, Yin excess" means cold pathogen surplus with shallow郁热 (stagnant heat). Pathogens strike the exterior via wind-cold; cold binding the exterior is Yin excess. Recklessly using heavy-cold purgatives would cause death. Thus, Yang excess patients die from Guizhi Tang; Yin excess patients die from Chengqi Tang.
Shen Jin'ao's Note: Among Three Yang diseases, those without fever originate from Yin; among Three Yin diseases, those with counter-fever originate from Yang.
[General Principle] Zhang Zhongjing said: Question: Pulses have Yin and Yang, what does this mean? Answer: Floating, large, slippery, moving, and rapid pulses are named Yang. Deep, weak, choppy, string-taut, and micro pulses are named Yin. At the Cun Kou position, floating indicates Exterior, deep indicates Interior, rapid indicates Fu organs, and slow indicates Zang organs. Yin diseases showing Yang pulses indicate survival; Yang diseases showing Yin pulses indicate death.
[Details] Zhang Jiebin said: Floating indicating Exterior and deep indicating Interior is an ancient method. However, deep pulses can also present Exterior symptoms due to Yin excess and Yang deficiency with cold dominance. Floating pulses can also present Interior symptoms due to Yang excess and Yin deficiency with water depletion. Therefore, to detect Exterior pathogens, one should not rely solely on floating/deep distinctions but on whether the pulse is tight/rapid. Cold pathogens in the Exterior always present tight/rapid pulses; severity correlates with pulse intensity. Tight-rapid-floating-huge-with-strength indicates Yang syndrome; tight-rapid-floating-huge-without-strength indicates Yin syndrome. Tight-rapid pulses with Exterior symptoms confirm external contraction requiring dispersal. Internal injury pulses can also be tight/rapid, but their onset is gradual, whereas external contraction is sudden. Similar-to-tight but slightly slippery-rapid pulses may indicate mild external contraction. Harmonious pulses without tight-rapid qualities, even if floating-large, indicate no external pathogen. Tao Hua said: Floating pulses require sweating; deep pulses require purging. However, floating pulses may require purging if heat-pathogen enters Fu organs causing difficult defecation. Deep pulses may require sweating if Shaoyin disease presents with body heat. Thus, deep can indicate Exterior, and floating can indicate Interior. Cold damage pathogens have no fixed form. Entering Yang Qi levels starts with Taiyang; entering Yin Jing levels starts with Shaoyin. Floating-tight strength/weakness reveals Exterior deficiency/excess; deep-tight strength/weakness reveals Interior deficiency/excess; mid-pressure strength/weakness reveals Yin-Yang prognosis. One must ask symptoms to know the Exterior, observe pulses to know the Interior, prioritize prior illness as Root and subsequent as Branch, and integrate pulse-symptom analysis to determine urgency. This defines a superior physician. Diagnostic rules state: Floating pulse indicates Exterior. Floating-tapid-numerous pulses with headache, neck stiffness, and back rigidity indicate Taiyang channel disease, requiring channel-specific dispersal. Huge-long-strong pulses with Yangming symptoms indicate Yangming channel pathogen, requiring channel-specific cold/heat dispersal. String-taut-numerous pulses with Shaoyang symptoms indicate Shaoyang half-exterior/half-interior disease, requiring harmonization and dispersal. Deep pulse indicates Interior. Disease in Three Yin: deep-numerous-strong indicates heat transmission to Interior. If Exterior symptoms deepen into Interior fullness/excess/heat-solidification, purging is needed. Deep-tight-weak without Exterior heat or Interior thirst/restlessness indicates Yin syndrome. With chills, cold limbs, vomiting, abdominal pain, or diarrhea, this is direct invasion of Cold, requiring warming the Middle. Large pulses indicate disease progression due to pathogen dominance; slowing pulses indicate pathogen retreat and recovery. Large pulses generally indicate progression, but exceptions exist. A naturally large pulse becoming huge-rapid indicates worsening; a naturally small pulse becoming slippery-large-strong after medication indicates transformation from Yin to Yang, promising sweating and recovery. Non-rapid pulses result from Qi deficiency, lacking Yang to induce sweating.
Ke Qin said: There are ten pulse types divided into Yin and Yang, comprising five methods: Floating/Deep are pulse bodies; Large/Weak are pulse momentum; Slippery/Choppy are pulse Qi; Moving/String-taut are pulse shape; Slow/Rapid are pulse rate. These are pathological, not normal pulses. The second item refers to both hands' six positions. The third item's "Fan" (all/every) is not a conjunction. Yang pulse refers to Stomach Qi ("Twenty-Five Yangs"), where harmonious Zang Yang emerges, indicating life. Yin pulse refers to True Zang pulses; if Stomach Yang does not reach Hand-Taiyin, true Zang Yin emerges, indicating death. Note that deep/choppy/weak/string-taut/slow are pathological, not necessarily fatal, often seen in Yang diseases. True Zang pulses appearing with excess signs (e.g., Liver pulse tense inside-out, Heart pulse firm/pounding, Lung pulse large/floating, Kidney pulse like rolling stones, Spleen pulse like pecking fowl) cannot be named Yang. Mistaking Stomach pulse for slow and True Yin for rapid would mislead people.
[General Principle] Zhang Zhongjing said: If the Cun pulse does not reach the Guan position, it is Yang Absence. If the Chi pulse does not reach the Guan position, it is Yin Absence. These are untreatable and indicate death. The remaining lifespan can be calculated based on monthly solar terms overcoming the pulse. Question: How to distinguish recovery from non-recovery? Answer: If Cun, Guan, and Chi positions show equal size, floating/deep, slow/rapid characteristics, even if cold/heat persist, the pulse indicates Yin-Yang harmony. Though severe, recovery is expected.
[Details] Zhang Jiebin said: Yin disease with Yang pulse survives; Yang disease with Yin pulse dies. Pure string-taut pulse dies. Yin-Yang both deficient with unceasing heat dies. Yin-Yang both excessive with profuse sweating and unceasing heat dies. Deep-thin pulse with cold limbs and delirium dies. Deficient pulse-symptoms with delirium die. Cold damage days 6-7 with micro pulse, cold limbs, and irritability: if moxibustion at Jueyin does not reverse cold limbs, death occurs. Yang Absence (Cun not reaching Guan) and Yin Absence (Chi not reaching Guan) are untreatable deaths. Diarrhea over ten times daily with a real/excessive pulse in cold damage indicates death.
Wei Litong said: Harmony and balance mean no excess or deficiency in pulses. Although large/small/floating/deep/slow/rapid are pathological, equality across three positions constitutes a Harmonious Pulse. "Pulse disease" asks about the pulse during illness. Responding with "Harmonious Pulse" applies even if cold or heat is present, as equal pulses indicate Yin-Yang harmony, predicting recovery even in severe cases. This discerns the mechanism of disease progression/regression.
[General Principle] Zhang Zhongjing said: On the third day of cold damage, Three Yang exhaustion should lead to Three Yin invasion. If the patient can eat and does not vomit, the Three Yin channels are not invaded. On days 6-7 of cold damage, without significant fever but with restlessness, this indicates Yang pathogen departing and entering Yin.
[Details] Li Chen said: Three Yin involves direct invasion and transmission, so rigid application is inadvisable. Some require purging, some warming. Transmission from Three Yang Qi levels to Three Yin is called Transmitted Yin Syndrome. Transmission here means entering the Blood levels of Three Yin (Stomach, Large Intestine, Small Intestine), consistent with Zhang Zhongjing's statement that entry into Fu organs allows purging. If not transmitted from Yang channels but directly invading Three Yin channels, initial symptoms of cold limbs, abdominal pain, and spontaneous diarrhea without thirst indicate Ta iyin self-invasion of cold. Adding vomiting indicates Shaoyin self-invasion. Adding clear urination indicates Jueyin self-invasion. Hot medicines are used, fearing delay. Yin-Yang error leads to immediate death. While ancients explained transmission and direct invasion thoroughly, relapse/transformation exists. During transmission, factors like raw food, sexual activity, or aggressive sweating/purging by incompetent physicians can weaken True Qi, transforming Yang syndrome into Yin syndrome (commonly "Yang returning to Yin"), treated as direct cold invasion. The "Neijing" mentions transformation but not direct invasion, implying transformation covers direct invasion. "Transmitting Yin/Yang" is incorrect; "Transforming Yang to Yin" is accurate. Transmitted disease is Interior Heat; Direct Invasion/Transformation is Interior Cold. Pulse diagnosis: Direct/Transmitted Three Yang (Exterior) shows floating-long-string-taut; Transmitted Three Yin (Interior) shows deep-numerous-real; Direct Three Yin (Channel) shows deep-micro-slow. Differentiate by Exterior/Interior, Deficiency/Excess, Large/Small, associating Yang with Heat and Yin with Cold.
Ke Qin said: This describes Yang pathogen moving from Exterior to Interior. "Yin" refers to Interior, not specifically Three Yin. Entry into Taiyang root causes heat binding Bladder; Yangming root causes dry Stomach; Shaoyang root causes hardness/fullness under ribs; Ta iyin causes sudden irritability/diarrhea; Shaoyin causes dry mouth/throat; Jueyin causes heart pain/heat. All constitute "entering Yin."
[General Principle] Zhang Zhongjing said: For wind-pattern patients, if Exterior resolves but the patient feels unwell ("bulele"), recovery occurs in twelve days.
[Details] Wei Litong said: This refers to residual wind pathogen after recovery. Twelve days allow Yin Qi to restore, bringing mental clarity without need for intervention.
Ke Qin said: "Bulele" means residual pathogen remains. Though citing wind-pattern, it applies to cold damage. Zhang Zhongjing differentiated Six Channels, each having wind/cold pulse-symptom treatments. Wang Shuke's era preserved most Taiyang content but lost others. Yangming retained two wind patterns; Shaoyang retained one symptom-only pattern without pulse. Three Yin had wind-recovery pulses but no wind-recovery pulse-symptom combinations. Treating "Shanghan Lun" as a complete whole is thus flawed.
Shen Jin'ao's Note: Based on Ke Qin's view, Zhang Zhongjing likely had wind/cold pulse-symptom treatments for all Six Channels. Since the current text is incomplete, this clause should not be forced into Taiyang. Hence, it is listed in the General Discussion.