楼英曰。治中风自汗。用桂枝汤。治伤寒无汗。用麻黄汤。此仲景表散之法。百世不易者也。
元气暴亏。以参、 与桂枝、麻黄等药表散。此丹溪补仲景之法。亦万世不易者也。至韩祗和戒
桂枝。以中风伤寒通作一法治之者。此当时之权变。非百世之常行也。伤寒病有可汗者。仲景但统
言其可汗症。及汗脉。或云脉浮而数。或云脉浮紧。或云脉浮无汗而喘。或云脉浮为在表。今略举
数条。后人但凭其脉之大概。并不分脉浮有阴阳虚实之理。又不知有可汗不可汗之症。误投发表药。
多成阳毒之症。今举病患有汗恶风无汗恶寒分二等。及据立春以后。立秋以前。气候轻重。各立
方治之。庶学人易为开悟耳。病患二三月以前。两手脉浮数。或缓或紧。按之差软。寸关尺若力齐
等。其力不甚大不甚小者。亦未可便投解表药。此见里症。未见表脉也。宜候寸脉力小于关尺。即
可投解表药。大抵治伤寒。见症不见脉。未可投药。见脉不见症。虽少投药亦无害。凡治杂病。以
症为先。脉为后。治伤寒。以脉为先。症为后。病患两手脉浮数而紧。名曰伤寒。若关前寸脉力小。
关后尺脉力大。不恶风。不自汗。此乃阴气已盛。先见于脉也。若不投药和之。必恶风自汗出。
若立春后至清明前。宜调脉汤。清明后至芒种前。葛根柴胡汤。芒种后至立秋前。人参桔梗汤。病
人两手脉浮数而缓。名曰中风。若寸脉力小。尺脉力大。虽不恶风。不自汗。此乃阴气已盛。先见
于脉。若不投药和之。必恶风自汗出。若立春后清明前。薄荷汤。清明后芒种前。防风汤。芒种后立
秋前。香芎汤。病患两手脉浮数。或紧或缓。寸脉短。反力小于关者。此名阴盛阳虚也。若汗出恶
风。是邪气在表。阴气有余也。素问云。阴气有余。为多汗身寒。即可投消阴助阳表剂以治之。立
春后清明前。六物麻黄汤。清明后芒种前。七物柴胡汤。芒种后立秋前。发表汤。病患脉浮数。或
紧或缓。其脉上出鱼际。寸脉大于关尺者。此名阳盛阴虚也。若发热冒闷。口燥咽干者。乃
是邪气在表。阳气独有余也。可投消阳助阴药以解表。立春后清明前。人参汤。清明后芒种前。前
胡汤。芒种后立秋前。石膏汤。病患两手脉浮数。或紧或缓。三部俱有力。无汗恶风者。此是阴阳气俱有余。可用药平
之。立春后清明前。解肌汤。清明后芒种前。芍药汤。芒种后立秋前。知母汤。仲景云。伤寒为病。脉缓者名中风。脉
紧者名伤寒。今分此二端何也。始因冬天寒毒之气中人。其内伏之阳。沉潜于骨髓之内。每至春夏发时。或因外伤寒
而引内邪。或因外伤风而引内邪。既出而为病。一也。古人云。立此二端。恐后人疑其脉紧与缓治别也。若中风伤寒脉
异。何故仲景无别法治之。此乃后人不究仲景之心也。病患始得病。一二日至五六日。尚有表邪及表症。亦可根据脉症投
药。
凡投解表及发表药。每一日可饮三服。病甚可至五服外。不可顿服药也。如症未解。次日再投。如
症仍未解。可作热粥助之。粥内加葱白亦可。如汗出。勿浓衣盖覆。恐汗多作亡阳症也。海藏云。
韩氏微旨可汗一篇。有和解因时法。言伤寒之脉。头小尾大。伤风之脉。头大尾小。李思训保命新
书。亦分尺寸。与仲景同。非若前人总言尺寸脉俱浮而紧。俱浮而缓。紧则为伤寒无汗。缓则为伤
风自汗。又有伤寒有汗者。伤风无汗者。脉亦互参。与症不同。前人已尽之矣。惟韩李所言头小尾
大即为伤寒。尾小头大即为伤风。又间有脉症未显于尺寸者。故韩子述为和解因时法也。又恐后人
疑其不与前圣合。遂于本方内又立加减法数条。亦不越前人之意。何其当哉。
又寸口脉小。饮冷。与雾露所伤。同作中焦治。今韩李云。伤寒寸小者。勿认饮冷与雾露同伤
一体也。饮冷雾露所伤。寸口举按全无。是阴气在胃不和。阳气不能升越也。伤寒寸口小者。只于
关部下至膀胱本部见之。寸口虽小。只是举之微小。沉按之有也。若果寸口举按全无。即不可解表。
只宜温中。不可不知。夫浅学人。只云病在表可发汗。病在里可下。或云不可汗下。未尝有温中
之说。仲景伤寒例云。尺寸俱沉细。太阴受病也。尺寸俱沉。少阴受病也。尺寸俱微缓。厥阴受病
也。又辨太阴症云。太阴病。脉浮可发汗。桂枝汤。手足温。自利。不渴者。四逆汤。腹满时痛。
桂枝加芍药汤。辨少阴症云。少阴病。始得之。
发热。脉沉者。麻黄附子细辛汤。少阴病。二三日。麻黄附子甘草汤。少阴病。手足寒。身体痛。
骨节疼。脉沉者。附子汤。又厥阴病。吐利。手足厥冷。烦躁欲死者。吴茱萸汤。又少阴病。脉沉。
急温之。四逆汤。今举仲景论中数条。最是三阴病之良法。近今每夏至前。有病伤寒人。十中七八。
两手脉俱沉细数。多是胸膈满闷。或呕逆气塞。肠鸣腹痛。与仲景三阴病说理同而症不同。因不
敢妄投仲景三阴病药。若以脉沉。及胸膈满。便数。下药往往不救。常斟酌仲景理中丸与服之。其
病轻者。胸中便快。重者。半日许。满闷依然。或有病患脉迟细。投仲景四逆汤温之。以药力大热。
后必发烦躁。因校量此形症。别立方以治之。药多对症。不可不传焉。如病患但两手脉沉细数。
或有力。或无力。或关脉短及小。胸膈塞满。气短不能相接者。便可随脉症投温中药以治之。病患
两手脉沉迟。或紧。皆是胃中寒也。若寸脉短。及力小于关尺。此阴盛阳虚也。或胸膈满闷。腹中
胀满。身体拘急。手足逆冷。急温之。立春后清明前。温中汤。清明后芒种前。陈皮汤。芒种后立
秋前。七物理中丸。病患脉沉细无力。虽三部脉力停等。亦是阴气盛也。更不须候寸脉短治之。或
胸胁满闷。身体拘急。手足逆冷。急宜温中药和之。立春后清明前。浓朴丸。清明后芒种前。白术
汤。芒种后立秋前。橘皮汤。病患胸膈满闷。时时呕逆。肢节痛。两胁下痛。腹中鸣。此是停饮。二苓汤。
病患服前药。胸膈不满闷者。此上焦有阳也。或药力太过。上焦有热。腹满虚鸣。时时疼痛。
此被汤药消逐得上焦阴气并入下焦也。虽是下焦积寒宿冷。奈上焦阳盛。反难用温下焦药也。病患
三部脉沉。寸小于关尺。此为阴盛。宜用温中药以消阴气。浓朴丸。神术汤亦治阴躁不渴。不可误用
凉药。若热药冷服。内有伏阳则可。若脉已虚。按之全无力。或病患素无食养者。只可温服。
Lou Ying stated: To treat wind-stroke with spontaneous sweating, Guizhi Tang (Cinnamon Twig Decoction) is used; to treat cold damage with absence of sweating, Mahuang Tang (Ephedra Decoction) is used. This is Zhang Zhongjing's method of releasing the exterior and dispersing pathogens, a principle unchangeable for a hundred generations.
When Yuan Qi (Original Qi) suffers sudden deficiency, Ren Shen (Ginseng Root) [missing character] combined with herbs such as Guizhi (Cinnamon Twig) and Mahuang (Ephedra) are used to release the exterior. This is Zhu Danxi's method of tonifying to assist Zhang Zhongjing's approach, a principle unchangeable for ten thousand generations. As for Han Zhihe's warning against using Guizhi (Cinnamon Twig), and his view of treating wind-stroke and cold damage under one unified method, this was a temporary expedient of that time, not a permanent practice for all ages.
In cold damage diseases, there are cases suitable for diaphoresis (sweating therapy). Zhang Zhongjing generally discussed symptoms suitable for diaphoresis and the corresponding pulses. Some described it as a floating and rapid pulse, some as a floating and tight pulse, some as a floating pulse with no sweating and wheezing, and some as a floating pulse indicating the pathogen is in the exterior. Now, briefly citing a few examples: later practitioners relied only on the general appearance of the pulse, failing to distinguish the principles of yin-yang, deficiency, and excess in floating pulses. They also did not know which symptoms were suitable or unsuitable for diaphoresis. Misusing exterior-releasing herbs often resulted in Yang-toxin syndromes.
Now, patients with sweating and aversion to wind, and those without sweating but with aversion to cold, are divided into two categories. Based on the severity of the climate from after Lichun (Start of Spring) to before Liqiu (Start of Autumn), specific prescriptions are established to facilitate learning.
Before the second or third month, if a patient's pulses at both hands are floating and rapid, or slow or tight, and feel soft upon deep pressure, if the Cun (inch), Guan (bar), and Chi (cubit) positions have equal strength—not too large nor too small—one should not immediately administer exterior-releasing herbs. This indicates interior symptoms are present, but exterior pulse signs are absent. One should wait until the Cun pulse strength is less than the Guan and Chi pulses before administering exterior-releasing herbs. Generally, in treating cold damage, if symptoms are seen but the pulse is not, medication should not be given; if the pulse is seen but symptoms are absent, even slight medication is harmless. In treating miscellaneous diseases, symptoms take precedence over the pulse; in treating cold damage, the pulse takes precedence over symptoms.
If a patient's pulses at both hands are floating, rapid, and tight, it is named Cold Damage. If the Cun pulse (anterior to Guan) is weak, while the Chi pulse (posterior to Guan) is strong, with no aversion to wind and no spontaneous sweating, this indicates Yin Qi is already abundant, manifesting first in the pulse. If not treated harmoniously with medication, aversion to wind and spontaneous sweating will inevitably occur. From after Lichun to before Qingming (Clear and Bright): Tiaomai Tang (Pulse-Regulating Decoction); from after Qingming to before Mangzhong (Grain in Ear): Gegen Chaihu Tang (Pueraria and Bupleurum Decoction); from after Mangzhong to before Liqiu: Renshen Jiegeng Tang (Ginseng and Platycodon Decoction).
If a patient's pulses at both hands are floating, rapid, and slow, it is named Wind-Stroke. If the Cun pulse is weak and the Chi pulse is strong, although there is no aversion to wind or spontaneous sweating, this indicates Yin Qi is already abundant, manifesting first in the pulse. If not treated harmoniously, aversion to wind and spontaneous sweating will inevitably occur. From after Lichun to before Qingming: Bohe Tang (Mint Decoction); from after Qingming to before Mangzhong: Fangfeng Tang (Saposhnikovia Decoction); from after Mangzhong to before Liqiu: Xiangxiong Tang (Aucklandia and Ligusticum Decoction).
If a patient's pulses at both hands are floating and rapid, or tight or slow, and the Cun pulse is short, actually weaker than the Guan pulse, this is named Yin Excess and Yang Deficiency. If there is sweating and aversion to wind, the pathogen is in the exterior, and Yin Qi is excessive. The *Suwen* states: "Excess of Yin Qi leads to profuse sweating and body coldness." One may administer an exterior formula that dissipates Yin and assists Yang. From after Lichun to before Qingming: Liuwu Mahuang Tang (Six-Ingredient Ephedra Decoction); from after Qingming to before Mangzhong: Qiwu Chaihu Tang (Seven-Ingredient Bupleurum Decoction); from after Mangzhong to before Liqiu: Fabiao Tang (Exterior-Releasing Decoction).
If a patient's pulse is floating and rapid, or tight or slow, extending upwards to the Yuji area, and the Cun pulse is stronger than the Guan and Chi pulses, this is named Yang Excess and Yin Deficiency. If there is fever, dizziness, and stuffiness, along with dry mouth and throat, the pathogen is in the exterior, and Yang Qi is excessively abundant alone. One may administer herbs that dissipate Yang and assist Yin to release the exterior. From after Lichun to before Qingming: Renshen Tang (Ginseng Decoction); from after Qingming to before Mangzhong: Qianhu Tang (Peucedanum Decoction); from after Mangzhong to before Liqiu: Shigao Tang (Gypsum Decoction).
If a patient's pulses at both hands are floating, rapid, or tight or slow, and all three positions (Cun, Guan, Chi) are forceful, with no sweating but aversion to wind, this indicates both Yin and Yang Qi are excessive. Medication can be used to balance them. From after Lichun to before Qingming: Jiemi Tang (Muscle-Relieving Decoction); from after Qingming to before Mangzhong: Shaoyao Tang (Peony Decoction); from after Mangzhong to before Liqiu: Zhimu Tang (Anemarrhena Decoction).
Zhang Zhongjing said: In cold damage disease, a slow pulse indicates Wind-Stroke, and a tight pulse indicates Cold Damage. Why distinguish these two now? Initially, winter cold-toxic qi invades the person, and latent Yang within sinks into the marrow. When it erupts in spring or summer, it may be triggered by external cold or external wind, leading to illness. Thus, they originate from the same source. The ancients established these two categories fearing later generations would doubt the different treatments for tight versus slow pulses. If wind-stroke and cold damage have different pulses, why did Zhang Zhongjing not use different methods? This is because later generations failed to investigate Zhang Zhongjing's intent. When a patient first falls ill, from day one or two to five or six, if exterior pathogen and exterior symptoms remain, medication can be administered based on pulse and symptoms.
Whenever administering exterior-releasing herbs, one may drink three doses per day. In severe cases, up to five or more doses. Do not take them all at once. If symptoms do not resolve, administer again the next day. If still unresolved, hot rice porridge can be taken to assist. Adding scallion white to the porridge is also acceptable. If sweating occurs, do not cover with thick clothing, lest excessive sweating lead to Collapse of Yang. Haicang (Zhang Yuansu) stated: In Han's *Weizhi*, the chapter on diaphoresis mentions harmonizing according to seasons. It states the pulse of cold damage is small at the head and large at the tail; the pulse of wind-stroke is large at the head and small at the tail. Li Sixun's *Baoming Xinshu* also distinguishes Cun and Chi, consistent with Zhang Zhongjing. This differs from predecessors who generally stated both Cun and Chi pulses are floating and tight (tight indicates cold damage without sweating) or floating and slow (slow indicates wind-stroke with spontaneous sweating). There are also cases of cold damage with sweating and wind-stroke without sweating, where pulses can be cross-referenced with symptoms, as predecessors had fully discussed. Only Han and Li specified that small-head-large-tail indicates cold damage, and small-tail-large-head indicates wind-stroke. Occasionally, pulse and symptom manifestations are not obvious in the Cun/Chi positions, hence Han elaborated the method of harmonizing according to seasons. Fearing later generations might doubt inconsistency with ancient sages, he added several modification rules to the base formulas, staying within the scope of previous teachings. How appropriate!
Furthermore, a small Cun Kou pulse due to drinking cold liquids or injury from fog/mist is treated as Middle Jiao pathology. However, Han and Li state that a small Cun pulse in cold damage should not be conflated with injury from cold drinks or mist/fog. Injury from cold drinks or mist results in a Cun Kou pulse that is completely imperceptible upon lifting and pressing, indicating Yin Qi disharmony in the Stomach and failure of Yang Qi to ascend. A small Cun pulse in cold damage appears only from the Guan position down to the Bladder's home region. Although small, it is merely subtle upon light pressure but present upon deep pressure. If the Cun Kou is indeed completely imperceptible upon lifting and pressing, exterior release is contraindicated; only warming the Middle is appropriate. This must be known. Superficial learners only say: exterior disease can be sweated, interior disease can be purged, or neither can be sweated/purged. They never mention warming the Middle.
Zhang Zhongjing's *Cold Damage Examples* state: Both Cun and Chi sinking and fine indicate Taiyin channel involvement; both Cun and Chi sinking indicate Shaoyin channel involvement; both Cun and Chi faint and slow indicate Jueyin channel involvement. Regarding Taiyin symptoms: Taiyin disease, floating pulse allows sweating, use Guizhi Tang; if hands and feet are warm, spontaneous diarrhea, and no thirst, use Sini Tang; abdominal fullness with intermittent pain, use Guizhi Jia Shaoyao Tang. Regarding Shaoyin symptoms: Shaoyin disease, just acquired, fever, sinking pulse, use Mahuang Fuzi Xixin Tang; Shaoyin disease, two to three days, use Mahuang Fuzi Gancao Tang; Shaoyin disease, cold hands and feet, body pain, bone joint pain, sinking pulse, use Fuzi Tang. Regarding Jueyin disease: vomiting and diarrhea, cold extremities, restlessness bordering on death, use Wuzhuyu Tang. Also, Shaoyin disease, sinking pulse, urgently warm with Sini Tang. These excerpts from Zhang Zhongjing are excellent methods for the Three Yin diseases.
Recently, before Summer Solstice, seven or eight out of ten patients with cold damage have both hands' pulses sinking, fine, and rapid. They often suffer from chest and diaphragm fullness/stuffiness, or retching, qi obstruction, borborygmus, and abdominal pain. The theory aligns with Zhang Zhongjing's Three Yin diseases, but symptoms differ. Dare not recklessly administer Zhang Zhongjing's Three Yin formulas. Using purgatives for sinking pulse and chest fullness/rapid stool often fails to save. Often, Lizhong Wan (Regulate the Middle Pill) from Zhang Zhongjing is斟酌 (considered/adapted) and administered. For mild cases, the chest feels relieved; for severe cases, fullness persists after half a day. Or, for patients with slow, fine pulses, administering Sini Tang to warm them causes subsequent irritability due to the herb's intense heat. Therefore, analyzing these forms and symptoms, new formulas were created. These medications are mostly symptomatic and should be transmitted. If a patient has only sinking, fine, rapid pulses at both hands, whether forceful or not, or short/small Guan pulses, with chest/diaphragm blockage and shortness of breath, warm Middle herbs should be administered according to pulse and symptoms.
If both hands' pulses are sinking, slow, or tight, it is Stomach Cold. If the Cun pulse is short and weaker than Guan/Chi, this is Yin Excess and Yang Deficiency. With chest/diaphragm fullness, abdominal distension, body stiffness, and cold extremities, urgently warm. From after Lichun to before Qingming: Wenzhong Tang (Warm the Middle Decoction); from after Qingming to before Mangzhong: Chenpi Tang (Tangerine Peel Decoction); from after Mangzhong to before Liqiu: Qiwei Lizhong Wan (Seven-Ingredient Regulate-the-Middle Pill).
If the pulse is sinking, fine, and forceless, even if all three positions are equal, it is still Yin Excess. No need to wait for a short Cun pulse to treat. With chest/hypochondriac fullness, body stiffness, and cold extremities, urgently harmonize with warm Middle herbs. From after Lichun to before Qingming: Houpo Wan (Magnolia Bark Pill); from after Qingming to before Mangzhong: Baizhu Tang (Atractylodes Macrocephala Decoction); from after Mangzhong to before Liqiu: Jupi Tang (Orange Peel Decoction).
If the patient has chest/diaphragm fullness, frequent retching, limb/joint pain, bilateral hypochondriac pain, and abdominal borborygmus, this is Fluid Retention. Use Erling Tang (Two Porias Decoction).
If the patient takes the previous medicine and chest/diaphragm fullness resolves, this indicates Yang in the Upper Jiao. Or, if the medicinal force was too great, causing Heat in the Upper Jiao, abdominal fullness with hollow sounds, and frequent pain, this is because the decoction expelled Upper Jiao Yin Qi into the Lower Jiao. Although there is accumulated cold in the Lower Jiao, the Upper Jiao Yang is excessive, making it difficult to use herbs to warm the Lower Jiao.
If all three positions' pulses are sinking, and Cun is smaller than Guan/Chi, this is Yin Excess. Use warm Middle herbs to dissipate Yin. Use Houpo Wan. Shenzhu Tang also treats Yin-restlessness without thirst; do not mistakenly use cooling herbs. If hot herbs are taken cold, and there is latent Yang inside, it is acceptable. If the pulse is already deficient and forceless upon pressing, or if the patient lacks dietary nourishment historically, only warm administration is suitable.