脉按之来缓而时一止复来者。名曰结。又脉来动而中止。更来小数中有还者反动。名曰结。阴也。
脉来动而中止。不能自还。因而复动。名曰代。阴也。得此脉者必难治。
脉来数时一止复来者。名曰促。脉来缓时一止复来者。名曰结。结者。邪气结滞。而脉之行
不利也。又结与代。相似而实不同。结脉止而即还。不失至数。但少瘥迟耳。代脉止而不还。断已
复动。有此绝而彼来。代之意。故名曰代。而俱谓之阴者。结代脉皆为阴。故谓之结阴代阴也。凡
病得此脉者。攻之则邪未必去而正转伤。补之则正未得益而邪反滞。故曰难治。仲景因上条脉结代
。而详言其状如此。
以上并太阳权变之法。权变者。谓有汗证而不得迳用汗药也。而其间或取小汗。或待其自解。
或兼清热。或兼消饮。或先救里。或建中气。或养营卫。种种不同。世道日降。人心不古。凡所
患病。类多兼证。学人于此等变法。尤当着意。故特类列于此。凡二十三条。
太阳病。初服桂枝汤。反烦不解者。先刺风池、风府。却与桂枝汤则愈。
太阳病与桂枝汤。于法为当矣。乃初服之。反加烦热而不解者。阳邪痹于阳而不去也。风池
、风府、阳维之会。阳维者。诸阳之所维。刺之所以通阳痹。痹通。然后与桂枝取汗则愈。此仲
景法中之法也。
服桂枝汤。大汗出。脉洪大者。与桂枝汤如前法。若形如疟。日再发者。汗出必解。宜桂枝二
麻黄一汤。
服桂枝汤。汗虽大出而邪不去。所谓如水淋漓。病必不除也。若脉洪大。则邪犹甚。故宜更与
桂枝取汗。如前法者。如啜热稀粥。温覆取汗之法也。若其人病形如疟。而一日再发。则正气内胜
。邪气欲退之征。设得汗出。其邪必从表解。然非重剂所可发者。桂枝二麻黄一汤以助正而兼散邪
。而又约小其制。乃太阳发汗之轻剂也。
桂枝二麻黄一汤方（论见后）
桂枝（去皮一两十七铢） 大枣（五枚擘） 炙甘草 芍药 生姜（各一两六铢） 麻黄
（十六铢去节） 杏仁（十六个去皮尖）
上七味。以水五升。先煮麻黄一二沸。去上沫。纳诸药。煮取二升。去滓。温服一升。日再服。
服桂枝汤。大汗出后。大烦渴不解。脉洪大者。白虎加人参汤主之。
服桂枝汤后。大汗出。脉洪大。与上条同。而大烦渴不解。则其邪去表而之里。不在太阳之经
。而入阳明之腑矣。阳明者。两阳之交。而津液之腑也。邪气入之。足以增热气而耗津液。是以大
烦渴不解。方用石膏。辛甘大寒。直清胃热为君。而以知母之咸寒佐之。人参、甘草、粳米之甘。
则以之救津液之虚。抑以制石膏之悍也。曰白虎者。盖取金气彻热之义云耳。
白虎加人参汤方
人参（三两） 知母（六两） 甘草（二两） 粳米（六合） 石膏（一斤碎）
上五味。以水一斗。煮米熟汤成。去滓。温服一升。日三服。
服桂枝汤。或下之。仍头项强痛。翕翕发热。无汗。心下满微痛。小便不利者。桂枝去桂加茯苓白术汤主之。头项强痛。
翕翕发热。无汗。邪在表也。心下满微痛。饮在里也。此表间之邪。与心下之饮。相得不解。是以发之而不从表出。夺
之而不从下出也。夫表邪挟饮者。不可攻表。必治其饮而后表可解。桂枝汤去桂加茯苓、白术。则不欲散邪于表。而但
逐饮于里。饮去则不特满痛除。而表邪无附。亦自解矣。
桂枝去桂加茯苓白术汤方
于桂枝汤内去桂枝。加茯苓、白术各三两。余根据前法煮服。小便利即愈。
伤寒脉浮。自汗出。小便数。心烦。微恶寒。脚挛急。反与桂枝汤。欲攻其表。此误也。得之便厥。咽中干。烦躁吐逆
者。作甘草干姜汤与之。以复其阳。若厥愈足温者。更作芍药甘草汤与之。其脚即伸。若胃气不和。谵语者。少与调胃
承气汤。若重发汗。复加烧针者。四逆汤主之。
脉浮。自汗出。微恶寒者。虽伤于寒而表不实。乃桂枝汤证也。然小便数。心烦。脚挛急。则阴虚而里热矣。
是当以甘辛攻表。而以甘寒顾里。乃反与桂枝汤。治表而遗里。宜其得之而便厥也。咽中干。烦躁吐逆。
皆阴虚阳逆之象。设非以温药徒攻其表。何至此哉。夫既阴虚于下。而又阳逆于上。则必先复阳气
而后复阴气。故作甘草干姜汤甘辛复阳之剂。阳复则厥愈而足温矣。更作芍药甘草汤甘酸复阴之剂
。阴生则两脚自伸矣。阴阳既复。而或胃气有未和。因而谵语者。则少与调胃承气汤以和其胃。胃
和则谵语止矣。盖甘草、干姜。固足以救虚阳之逆。而亦能伤胃气之和。此咸寒调胃之法。不得不斡
旋于阴阳既复之后也。若重发汗。复加烧针。是逆而再逆。其厥逆之象。必有加于前。而补救之法
。必非甘草、干姜所能胜任者矣。四逆汤甘辛大热。乃克复阳气之大药也。此条前后用药。温凉补泻
。绝不相谋。而适以相济。非深造自得。卓有成见者。乌能及此。
甘草干姜汤方
甘草（四两炙） 干姜（二两）
上 咀。以水三升。煮一升五合。去滓。分温再服。
芍药甘草汤方
芍药（四两） 甘草（四两炙）
上二味。以水三升。煮一升五合。去滓。分温再服。
问曰、证象阳旦。按法治之而增剧。厥逆咽中干。两胫拘急而谵语。师言夜半手足当温。两脚
当伸。后如师言。何以知之。答曰、寸口脉浮而大。浮则为风。大则为虚。风则生微热。虚则两胫挛。
病证象桂枝。因加附子参其间。增桂令汗出。附子温经。亡阳故也。厥逆咽中干。烦躁。阳明内
结。谵语烦乱。更饮甘草干姜汤。夜半阳气还。两足当热。胫尚微拘急。重与芍药甘草汤。尔乃
胫伸。以承气汤微溏则止其谵语。故知病可愈。
此即前条之意。而设为问答。以明所以增剧及所以病愈之故。然中间语意殊无伦次。此岂后人
之文耶。昔人读考工记谓不类于周官。余于此条亦云。成氏云、阳旦、桂枝汤别名。
The pulse, when pressed, comes slowly and occasionally stops before resuming. This is called the *Jie* (Knotted) pulse. Another case is where the pulse movement suddenly stops, then resumes with a few rapid beats followed by a return beat. This is also called the *Jie* (Knotted) pulse, indicating a Yin pattern.
When the pulse movement suddenly stops and cannot resume on its own, but instead resumes after a pause, this is called the *Dai* (Intermittent) pulse, which is also a Yin pattern. Patients presenting with this pulse will certainly be difficult to treat.
When the pulse beats rapidly and occasionally stops before resuming, it is called the *Cu* (Surging) pulse; when the pulse beats slowly and occasionally stops before resuming, it is called the *Jie* (Knotted) pulse. The *Jie* pulse occurs because pathogenic factors are knotted and stagnant, causing impediment in the flow of the pulse qi. Furthermore, although the *Jie* and *Dai* pulses appear similar, they are fundamentally different. The *Jie* pulse stops and immediately returns, maintaining its rhythm, merely being slightly slower. The *Dai* pulse stops and does not immediately return; after the interruption, it resumes, implying a sense of one area ceasing while another takes over, hence named *Dai*. Both are termed "Yin" because both *Jie* and *Dai* pulses belong to Yin categories, thus referred to as *Jie Yin* and *Dai Yin*. For any disease presenting with these pulses, if treated with purgation, the pathogen may not be expelled while healthy qi is further damaged; if treated with tonification, healthy qi gains no benefit while the pathogen becomes more stagnant. Therefore, it is said to be difficult to treat. Zhang Zhongjing, addressing the *Jie* and *Dai* pulses mentioned in the preceding clause, details their characteristics as follows.
The above all describe the adaptive methods for *Taiyang* (Greater Yang) disease. Adaptive methods refer to situations where, although indications for sweating exist, diaphoretic herbs cannot be used directly. These methods include inducing slight sweating, waiting for spontaneous resolution, combining heat-clearing, combining fluid-resolving, first rescuing interior deficiency, establishing Middle Qi, or nourishing Ying and Wei. The approaches vary greatly. As times decline and human nature becomes less pure than in antiquity, diseases often present with complex syndromes. Students should pay special attention to these adaptive methods, so they are specifically categorized here. There are twenty-three clauses in total.
In *Taiyang* disease, if after the initial dose of *Guizhi Tang* (Cinnamon Twig Decoction), vexation worsens without relief, one should first needle the Fengchi (GB20) and Fengfu (GV16) acupoints, then administer *Guizhi Tang*, after which the patient will recover.
Administering *Guizhi Tang* for *Taiyang* disease is correct according to the principles. However, if after the initial dose, vexation and heat increase without resolution, it is because Yang pathogenic factors are obstructed in the Yang aspect and cannot disperse. Fengchi and Fengfu are intersection points of the Yangwei Vessel. The Yangwei Vessel connects all Yang vessels; needling them unblocks Yang obstruction. Once the obstruction is cleared, administering *Guizhi Tang* to induce sweating will result in recovery. This is a method within Zhang Zhongjing's methods.
After taking *Guizhi Tang*, if profuse sweating occurs and the pulse is洪大 (Hongda, Great/Vigorous), administer *Guizhi Tang* again using the previous method. If the condition resembles malaria, occurring twice a day, sweating will lead to resolution; *Guizhi Er Mahuang Yi Tang* (Two Parts Cinnamon Twig and One Part Ephedra Decoction) is appropriate.
After taking *Guizhi Tang*, if profuse sweating occurs but the pathogen remains—described as "sweating like dripping water, yet the disease is not removed"—and the pulse is Hongda, the pathogen is still severe. Thus, it is suitable to give *Guizhi Tang* again to induce sweating. The "previous method" refers to drinking hot millet gruel and covering warmly to induce sweating. If the patient's symptoms resemble malaria, occurring twice daily, this indicates that healthy Qi has gained internal superiority and the pathogen is retreating. If sweating ensues, the pathogen will likely resolve from the exterior. However, heavy diaphoretic agents should not be used. *Guizhi Er Mahuang Yi Tang* assists healthy Qi while dispersing pathogens, with a reduced dosage, making it a mild diaphoretic formula for *Taiyang* disease.
Formula: Guizhi Er Mahuang Yi Tang (Discussion in subsequent clauses)
Guizhi (Cortex Cinnamomi, peeled, 1 liang 17 zhu) Dazao (Fructus Jujubae, 5 pieces, split) Zhi Gancao (Radix Glycyrrhizae Preparata) Shaoyao (Radix Paeoniae Alba) Shengjiang (Rhizoma Zingiberis Recens, each 1 liang 6 zhu) Mahuang (Herba Ephedrae, 16 zhu, nodes removed) Xingren (Semen Armeniacae Amarum, 16 pieces, skin and tips removed)
These seven ingredients are boiled in five sheng of water. First, boil Mahuang for one or two boils, remove the foam on top, then add the remaining herbs. Boil until two sheng remain, strain, and take one sheng warm. Administer twice daily.
After taking *Guizhi Tang*, if following profuse sweating, severe vexation and thirst persist without relief, and the pulse is Hongda, *Baitu Jia Renshen Tang* (White Tiger Plus Ginseng Decoction) is the primary treatment.
After taking *Guizhi Tang*, profuse sweating occurs, and the pulse is Hongda, identical to the previous clause. However, severe vexation and thirst without relief indicate that the pathogen has moved from the exterior to the interior, leaving the *Taiyang* meridian and entering the Yangming Fu organs. Yangming is the intersection of two Yangs and the Fu organ of fluids. Pathogens entering here increase heat and consume fluids, causing severe vexation and thirst. The formula uses Shigao (Gypsum Fibrosum), pungent, sweet, and very cold, to directly clear Stomach heat as the Sovereign herb, assisted by Zhimu (Rhizoma Anemarrhenae), salty and cold. The sweetness of Renshen (Radix Ginseng), Gancao (Radix Glycyrrhizae), and Jingmi (Oryza Sativa) saves fluid deficiency and moderates the harshness of Shigao. It is named "White Tiger" (Baitu), likely referring to the metal element's property of clearing heat.
Formula: Baitu Jia Renshen Tang
Renshen (Radix Ginseng, 3 liang) Zhimu (Rhizoma Anemarrhenae, 6 liang) Gancao (Radix Glycyrrhizae, 2 liang) Jingmi (Oryza Sativa, 6 he) Shigao (Gypsum Fibrosum, 1 jin, crushed)
These five ingredients are boiled in ten sheng of water until the rice is cooked and the decoction is ready. Strain and take one sheng warm, three times daily.
After taking *Guizhi Tang*, or after purgation, if there is still stiffness and pain in the head and neck, mild fever (like feathers covering), anhidrosis, fullness and mild pain in the epigastrium, and dysuria, *Guizhi Qu Guijia Fuling Baizhu Tang* (Cinnamon Twig Decoction minus Cinnamon Twig plus Poria and Atractylodes Macrocephala Decoction) is the primary treatment. Stiffness and pain in the head and neck, mild fever, and anhidrosis indicate pathogen in the exterior. Fullness and mild pain in the epigastrium indicate fluid retention in the interior. The exterior pathogen and interior fluid retention are interdependent and unresolved. Therefore, diaphoresis fails to expel from the exterior, and purgation fails to expel from the interior. When exterior pathogen carries fluid retention, one must not attack the exterior alone; treating the fluid retention allows the exterior to resolve. Removing GuiZhi from *Guizhi Tang* and adding Fuling (Poria) and Baizhu (Atractylodis Macrocephalae Rhizoma) avoids dispersing exterior pathogens and focuses on draining interior fluids. Once fluids are drained, fullness and pain cease, and the exterior pathogen, losing its attachment, resolves spontaneously.
Formula: Guizhi Qu Guijia Fuling Baizhu Tang
Remove GuiZhi from *Guizhi Tang*, add Fuling and Baizhu, each 3 liang. Prepare and administer according to the previous method. Recovery occurs when urination becomes normal.
In Shanghan (Cold Damage), if the pulse is floating, there is spontaneous sweating, frequent urination, vexation, mild aversion to cold, and cramping of the feet, administering *Guizhi Tang* to attack the exterior is an error. This mistake leads to cold limbs (Jue), dry throat, vexation, and vomiting. In such cases, prepare *Gancao Ganjiang Tang* (Licorice and Dried Ginger Decoction) to restore Yang Qi. If cold limbs resolve and feet become warm, prepare *Shaoyao Gancao Tang* (Peony and Licorice Decoction); the feet will extend. If Stomach Qi is disharmonious leading to delirium, administer a small amount of *Tiaowei Chengqi Tang* (Regulate the Stomach and Direct Downward Decoction). If excessive sweating was performed and moxibustion with burning needles was added, *Sini Tang* (Frigid Extremities Decoction) is the primary treatment.
Floating pulse, spontaneous sweating, and mild aversion to cold indicate that although affected by cold, the exterior is not solid, fitting the *Guizhi Tang* syndrome. However, frequent urination, vexation, and foot cramping indicate Yin deficiency with interior heat. One should use pungent-sweet herbs to attack the exterior and sweet-cold herbs to protect the interior. Instead, *Guizhi Tang* was given, treating the exterior while neglecting the interior, hence the resulting cold limbs. Dry throat, vexation, and vomiting are signs of Yin deficiency and Yang rebellion. Had warm herbs not been used to blindly attack the exterior, how could it have reached this state? Since there is Yin deficiency below and Yang rebellion above, Yang Qi must be restored first, then Yin Qi. Thus, *Gancao Ganjiang Tang* (pungent-sweet to restore Yang) is prepared. Restoration of Yang resolves cold limbs and warms the feet. Then, *Shaoyao Gancao Tang* (sweet-sour to restore Yin) is prepared. Generation of Yin allows the feet to extend naturally. After Yin and Yang are restored, if Stomach Qi remains disharmonious causing delirium, a small amount of *Tiaowei Chengqi Tang* harmonizes the Stomach. Harmonized Stomach Qi stops delirium. While Gancao and Ganjiang save rebellious deficient Yang, they may also damage Stomach harmony. Therefore, the salty-cold method of regulating the Stomach is necessary after Yin and Yang are restored. If excessive sweating and burning needles were used, it is error upon error; the cold limb phenomenon would be worse, and *Gancao Ganjiang Tang* would be insufficient. *Sini Tang*, pungent, sweet, and very hot, is a major medicine for restoring Yang Qi. The medications used before and after this clause, warming/cooling/tonifying/purging, seem unrelated yet complement each other perfectly. Only those with profound attainment and firm convictions could achieve this.
Formula: Gancao Ganjiang Tang
Gancao (Radix Glycyrrhizae, prepared, 4 liang) Ganjiang (Rhizoma Zingiberis Secatus, 2 liang)
Chop these two ingredients, boil in three sheng of water until one sheng five he remains. Strain and divide into two warm doses.
Formula: Shaoyao Gancao Tang
Shaoyao (Radix Paeoniae Alba, 4 liang) Gancao (Radix Glycyrrhizae, prepared, 4 liang)
Boil these two ingredients in three sheng of water until one sheng five he remains. Strain and divide into two warm doses.
Question: The symptoms resemble Yangdan syndrome. Following standard treatment, the condition worsened, leading to cold limbs, dry throat, calf cramping, and delirium. The Master said that at midnight, the hands and feet would warm, and the legs would extend. Later, this happened as predicted. How did you know? Answer: The Cun Kou pulse is floating and large. Floating indicates Wind; Large indicates Deficiency. Wind generates mild heat; Deficiency causes calf cramping. The symptoms resemble *Guizhi Tang* syndrome, so Fuzi (Radix Aconiti Lateralis Preparata) was added, and GuiZhi was increased to induce sweating. Fuzi warms the meridians due to Yang collapse. Cold limbs, dry throat, vexation, Yangming internal knotting, and delirious confusion occurred. Drinking *Gancao Ganjiang Tang* again, at midnight Yang Qi returns, and the feet become warm. With calves still slightly cramped, administering *Shaoyao Gancao Tang* allows the calves to extend. Using *Chengqi Tang* to cause slight stooling stops the delirium. Thus, we know the disease can be cured.
This clause reiterates the meaning of the previous one, using a Q&A format to explain why the condition worsened and why it recovered. However, the logic in between is disjointed; could this be text added by later generations? Ancients noted that the *Kaogong Ji* differs from the *Zhou Li*; I hold a similar view regarding this clause. Cheng Wuji states: Yangdan is an alias for *Guizhi Tang*.