桂枝本为解肌。若其人脉浮紧。发热汗不出者。不可与也。当须识此。勿令误也。
仲景既详桂枝之用。后申桂枝之禁。曰桂枝、本为解肌。而不可用以发汗。解肌者。解散肌表之
邪。与麻黄之发汗不同。故惟中风发热。脉浮缓。自汗出者为宜。若其人脉浮紧。发热汗不出。
则是太阳麻黄汤证。设误与桂枝。必致汗不出而烦躁。甚则斑黄狂乱。无所不至矣。此桂枝汤之
大禁也。故曰、不可与也。当须识此。勿令误也。仲景叮咛之意至矣。
若酒客病。不可与桂枝汤。得汤则呕。以酒客不喜甘故也。
本草云、酒性热而善上。又忌诸甜物饮酒之人。甘味积中而热气时上。故虽有桂枝证。不得服桂枝汤。得之
则呕。以酒客不喜甘。而桂枝汤味甘。能增满而致呕。亦一大禁也。
凡服桂枝汤吐者。其后必吐脓血也。
凡服桂枝汤吐者。不必尽是酒客。此其脾胃素有湿热蕴蓄。可知桂枝汤其甘足以酿湿。其温
足以助热。设误服之而致吐。其湿热之积。上攻肺中。与表之邪风相得。蒸郁不解。发为肺痈。
咳吐脓血。势有必至者矣。仲景因酒客。复申其说如此。
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。
足之太阳。其脉上际巅顶。而下连腰足。而寒之为气。足以外闭卫阳。而内郁营血。故其为病。
有头痛发热。身疼腰痛。骨节疼痛。恶风无汗而喘之证。然惟骨痛、脉紧、无汗。为麻黄汤的证。
其余则太阳中风亦得有之。学人若不以骨痛、脉紧、无汗为主。而但拘头痛、发热等证。必致发非
所当发矣。虽本文不言脉紧。然可从无汗而推。犹太阳伤寒条。不言无汗。而以脉紧该之也。
麻黄汤方
麻黄（三两去节） 桂枝（三两去皮） 甘草（一两炙） 杏仁（七十个去皮尖）
上四味。以水九升。先煮麻黄减二升。去上沫。纳诸药。煮取二升半。去滓。温服八合。覆取微似
汗。不须啜粥。余如桂枝法将息。
人之伤于寒也。阳气郁而成热。皮肤闭而成实。麻黄轻以去实。辛以散寒。温以行阳。杏仁
佐麻黄。达肺气、泄皮毛、止喘急。王好古谓其治卫实之药是也。然泄而不收。升而不降。桂枝、甘
草。虽曰佐之。实以监之耳。
脉浮者。病在表。可发汗。宜麻黄汤。
脉浮而数者。可发汗。宜麻黄汤。
二条凭脉以言治。而不及证。且但举浮与数。而不言紧。而云可与麻黄汤发汗。殊为未备。
然仲景自有太阳伤寒条与麻黄汤证。在学人当会通全书而求之。不可拘于一文一字间也。
太阳病。脉浮紧。无汗发热。身疼痛八九日不解。表证仍在。此当发其汗。服药已。微除
。其人发烦目瞑。剧者必衄。衄乃解。所以然者。阳气重故也。麻黄汤主之。
脉浮紧。无汗发热。身疼痛。太阳麻黄汤证也。至八九日之久而不解。表证仍在者。仍宜
以麻黄汤发之。所谓治伤寒不可拘于日数。但见表证脉浮者。虽数日犹宜汗之是也。乃服药已。病虽
微除。而其人发烦目瞑者。卫中之邪得解。而营中之热未除也。剧者血为热搏。势必成衄。衄则
营中之热亦除。而病乃解。所以然者。阳气太重。营卫俱实。故须汗血并出。而后邪气乃解耳。
阳气、阳中之邪气也。郭白云云、麻黄汤主之五字。当在此当发其汗下。是。
伤寒脉浮紧。不发汗。因致衄者。麻黄汤主之。
太阳病。脉浮紧。发热。身无汗。自衄者愈。
伤寒脉浮紧者。邪气在表。法当汗解。而不发汗。则邪无从达泄。内搏于血。必致衄也。衄
则其邪当去。而犹以麻黄汤主之者。此亦营卫并实。如上条所云阳气重之证。上条卫已解而营未
和。故虽已发汗。犹须得衄而解。此条营虽通而卫尚塞。故既已自衄。而仍与麻黄汤发汗而愈。
然必欲衄而血不流。虽衄
而热不解者。乃为合法。不然。靡有不竭其阴者。于是仲景复着夺血无汗之例曰。脉浮紧。
发热。身无汗。自衄者愈。谓阳气重者。须汗血并出。以泄其邪。其稍轻者。设得衄血。邪必自
解。身虽无汗。固不必更以麻黄汤发之也。
太阳病。十日已去。脉浮细而嗜卧者。外已解也。设胸满胁痛者。与小柴胡汤。脉但浮者。
与麻黄汤。
太阳病。至十余日之久。脉浮不紧而细。人不躁烦而嗜卧。所谓紧去人安。其病为已解也，
下二段是就未解时说。谓脉浮细不嗜卧。而胸满胁痛者。邪已入少阳。为未解也。则当与小柴胡汤
。若脉但浮而不细。不嗜卧者。邪犹在太阳而未解也。仍当与麻黄汤。非外已解而犹和之发之之谓
也。
Cinnamon Twig Decoction (Guizhi Tang) is originally intended to resolve the muscle layer (Jieji, releasing pathogenic factors from the muscular level). If a patient's pulse is floating and tight, with fever but no sweating, it must not be administered. This point must be understood to avoid misprescription.
After detailing the indications for Cinnamon Twig Decoction, Zhang Zhongjing subsequently clarifies its contraindications. He states that Cinnamon Twig Decoction is meant to resolve the muscle layer and cannot be used to induce sweating. "Resolving the muscle layer" refers to dispersing pathogens from the muscular exterior, which differs from the sweating-inducing action of Ephedra Decoction (Mahuang Tang). Therefore, it is suitable only for Wind Strike (Zhongfeng) characterized by fever, floating and slow pulse, and spontaneous sweating. If a patient presents with a floating and tight pulse, fever, and absence of sweating, this constitutes a Taiyang disease syndrome requiring Ephedra Decoction. If Cinnamon Twig Decoction is erroneously prescribed, it will inevitably lead to an inability to sweat accompanied by irritability, and in severe cases, may result in macules, jaundice, or mania, reaching extreme degrees. This is a major contraindication for Cinnamon Twig Decoction. Hence, it is stated: "It must not be given." One must recognize this to prevent error. Zhang Zhongjing's earnest admonition is profound.
If a person addicted to alcohol falls ill, Cinnamon Twig Decoction should not be given; taking it will cause vomiting. This is because alcoholics generally dislike sweet flavors.
According to Materia Medica, alcohol has a hot nature and tends to ascend. Individuals who drink alcohol should avoid sweet foods. Sweet flavors accumulate in the middle jiao, causing heat qi to rise frequently. Thus, even if symptoms indicative of Cinnamon Twig Decoction are present, it should not be taken. Taking it causes vomiting because alcoholics dislike sweetness, and since Cinnamon Twig Decoction is sweet, it can increase fullness and induce vomiting. This is another significant contraindication.
For those who vomit after taking Cinnamon Twig Decoction, they will subsequently expectorate pus and blood.
Those who vomit after taking Cinnamon Twig Decoction are not necessarily alcoholics. This indicates that their spleen and stomach already harbor damp-heat accumulation. It can be deduced that the sweetness of Cinnamon Twig Decoction is sufficient to generate dampness, and its warmth is sufficient to assist heat. If mistakenly taken and resulting in vomiting, the accumulated damp-heat attacks upward into the lungs, combining with external wind pathogens. The steaming and stagnation fail to resolve, leading to Lung Abscess (Fei Yong), characterized by coughing up pus and blood. This outcome is inevitable. Zhang Zhongjing elaborates on this principle based on the case of alcoholics.
In Taiyang disease, presenting with headache, fever, body ache, lower back pain, joint pain, aversion to wind, absence of sweating, and wheezing, Ephedra Decoction (Mahuang Tang) is the primary treatment.
The Foot-Taiyang bladder meridian ascends to the vertex and descends to connect with the waist and feet. Cold, as a pathogenic qi, closes the defensive yang externally and constrains the nutritive blood internally. Consequently, the diseases it causes include headache, fever, body ache, lower back pain, joint pain, aversion to wind, absence of sweating, and wheezing. However, only bone pain, tight pulse, and absence of sweating constitute the specific indications for Ephedra Decoction. The other symptoms may also appear in Wind Strike Taiyang disease. Learners who do not prioritize bone pain, tight pulse, and absence of sweating, but instead rigidly adhere to symptoms like headache and fever, will inevitably induce sweating when it is not indicated. Although the text does not explicitly mention a tight pulse, it can be inferred from the absence of sweating, just as in the Taiyang Cold Damage clause where absence of sweating is implied by the tight pulse.
Ephedra Decoction Formula
Ephedrae Herba (Mahuang, 麻黄) - 3 liang, nodes removed
Cinnamomi Ramulus (Guizhi, 桂枝) - 3 liang, bark removed
Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) - 1 liang, honey-fried
Prunus Armeniaca Semen (Xingren, 杏仁) - 70 seeds, skin and tips removed
These four ingredients are boiled in 9 sheng of water. First, boil Ephedrae Herba until the volume reduces by 2 sheng, then remove the foam on the surface. Add the remaining herbs and boil to obtain 2.5 sheng of liquid. Strain the dregs. Take 8 he of the decoction warm. Cover the patient to induce a slight sweat. There is no need to consume porridge afterward. Rest and care instructions follow those for Cinnamon Twig Decoction.
When humans are injured by cold, yang qi becomes constrained and transforms into heat, while the skin pores close, creating a state of excess. Ephedrae Herba is light to dispel excess, pungent to disperse cold, and warm to promote yang circulation. Apricot Seed (Xingren) assists Ephedrae Herba in venting lung qi, releasing the exterior, and stopping wheezing. Wang Haogu considered it a medicine treating excess in the defensive level. However, since Ephedrae Herba drains without consolidating and ascends without descending, Cinnamomi Ramulus and Glycyrrhizae Radix et Rhizoma, although serving as assistant herbs, actually function to monitor and restrain Ephedrae Herba.
If the pulse is floating, the disease is at the exterior, and sweating may be induced; Ephedra Decoction (Mahuang Tang) is appropriate.
If the pulse is floating and rapid, sweating may be induced; Ephedra Decoction (Mahuang Tang) is appropriate.
These two clauses discuss treatment based on pulse alone, omitting symptoms, and mentioning only floating and rapid pulses without tightness, yet suggesting Ephedra Decoction for sweating. This appears incomplete. However, Zhang Zhongjing provides descriptions of Taiyang Cold Damage and Ephedra Decoction syndromes elsewhere. Learners should integrate the entire book to understand these points rather than restricting themselves to isolated texts.
In Taiyang disease, with a floating and tight pulse, absence of sweating, fever, and body pain persisting for eight or nine days without resolution, if the exterior syndrome remains, sweating should be induced. After taking the medicine, the condition may slightly improve, but the patient may experience irritability and blurred vision. In severe cases, epistaxis (nosebleed) will occur, and the disease will resolve through bleeding. This occurs because the yang qi is heavy/replete. Ephedra Decoction (Mahuang Tang) is the primary treatment.
Floating and tight pulse, absence of sweating, fever, and body pain characterize the Taiyang Ephedra Decoction syndrome. Even if unresolved after eight or nine days, as long as the exterior syndrome persists, Ephedra Decoction should still be used to induce sweating. This illustrates that treating Cold Damage requires not being bound by the number of days; as long as exterior signs and a floating pulse are present, sweating is indicated even after several days. After medication, if the illness slightly alleviates but the patient feels irritable and has blurred eyes, it means the pathogen in the defensive level has resolved, but the heat in the nutritive level remains. In severe cases, blood is forced by heat, inevitably leading to epistaxis. Once epistaxis occurs, the nutritive heat is cleared, and the disease resolves. This happens because yang qi is excessively replete, and both defensive and nutritive levels are full; thus, sweat and blood must exit together for the pathogen to dissipate.
"Yang qi" here refers to pathogenic qi in the yang aspect. Guo Baiyun stated that the five characters "Ephedra Decoction (Mahuang Tang) is the primary treatment" should be placed below "sweating should be induced," which is correct.
In Cold Damage, if the pulse is floating and tight, and sweating is not induced, leading to epistaxis, Ephedra Decoction (Mahuang Tang) is the primary treatment.
In Taiyang disease, if the pulse is floating and tight, there is fever, the body has no sweat, and spontaneous epistaxis occurs, the disease will heal itself.
In Cold Damage with a floating and tight pulse, the pathogen is at the exterior and should theoretically be resolved by sweating. If sweating is not induced, the pathogen has no outlet and forces inward into the blood, inevitably causing epistaxis. After epistaxis, the pathogen should depart. The reason Ephedra Decoction is still prescribed here is that this also represents a condition of replete defensive and nutritive levels, similar to the "heavy yang qi" mentioned in the previous clause. In the previous clause, the defensive level was resolved but the nutritive level was unharmonized, so even after inducing sweat, epistaxis was needed for resolution. In this clause, the nutritive level is open but the defensive level remains blocked; therefore, even after spontaneous epistaxis, Ephedra Decoction is given to induce sweating for cure. However, this is only appropriate if the patient desires epistaxis but blood flow is obstructed, and heat persists despite bleeding. Otherwise, yin fluid will inevitably be exhausted. Thus, Zhang Zhongjing further illustrates the principle that "those who lose blood should not sweat" by stating: In Taiyang disease, with floating and tight pulse, fever, and absence of sweating, if spontaneous epistaxis occurs, the disease will heal itself. This means that for those with heavy yang qi, sweat and blood must exit together to vent the pathogen. For milder cases, if epistaxis occurs, the pathogen will naturally resolve. Although the body lacks sweat, it is unnecessary to use Ephedra Decoction to induce sweating.
In Taiyang disease, after ten days have passed, if the pulse is floating and fine, and the patient desires to lie down/sleep, the exterior has resolved. If chest fullness and hypochondriac pain are present, administer Minor Bupleurum Decoction (Xiao Chaihu Tang). If the pulse is merely floating, administer Ephedra Decoction (Mahuang Tang).
In Taiyang disease, after more than ten days, if the pulse is floating but not tight and is fine, and the patient is not irritable but prefers sleeping, this indicates the tight pulse has disappeared, the person is comfortable, and the disease is resolving. The following paragraphs address cases where the disease has not resolved. If the pulse is floating and fine but the patient does not desire sleep, and presents with chest fullness and hypochondriac pain, the pathogen has entered Shaoyang, indicating the disease is unresolved; thus, Minor Bupleurum Decoction (Xiao Chaihu Tang) should be given. If the pulse is merely floating without being fine, and the patient does not desire sleep, the pathogen remains in Taiyang and is unresolved; therefore, Ephedra Decoction (Mahuang Tang) should still be administered. This does not imply harmonizing or inducing sweating after the exterior has resolved.