伤寒项强。何以明之。太阳脉起于目内 。上额交巅。上入络脑。还出别下项。循肩
臂内挟脊。抵腰中。经曰。太阳之病。项背强痛而恶寒。以太阳感受风寒。则经脉不
利。而项为之急。颈为之强尔。伤寒颈项强急者。太阳表证也。必发散而解之可也。
太阳病。项背强KT KT 。反汗出恶风者。桂枝加葛根汤主之。太阳病项背强KT KT 。无
汗恶风者。葛根汤主之。是皆发散之剂也。二者均是项背强而发散。又有轻重者。
盖发热汗出恶风者为表虚。表虚者可解肌。无汗恶风者为表实。表实者可发汗。
是以为治不同也。桂枝加葛根汤方。是桂枝加麻黄葛根。又葛根汤方。亦是桂枝
汤中加麻黄葛根。深详究之。无汗恶风为表实。正可发汗。则于桂枝汤中加葛根
麻黄为当矣。汗出恶风为表虚。表虚者可解肌。恐是桂枝汤中。但加葛根。而不加
麻黄也几音殊。几引颈之貌。几短羽鸟也。短羽之鸟。不能飞腾。动则先伸引其头
尔。项背强者。动亦如之。非若几案之几而偃屈也。太阳伤寒项背强。其或太阳中
风。加之寒湿而成痉者。亦项强也。经曰。病者身热足寒。颈项强急。恶寒时头热。面
赤目脉赤。独头面摇。卒口噤。背反张者。痉病也。金匮耍略曰。太阳病其证项背强
KTKT 然。脉反沉迟者。此为痉。桂枝加栝蒌汤主之。虽项背强。然太阳病表证。悉当
发散。又有结胸病者。项亦强如柔 状。下之则和。宜大陷胸汤丸主之。临病之际。
审其表里。可汗可下。随证投汤则万全矣。
伤寒病出现项部僵硬。如何阐明其机理？足太阳膀胱经的经脉起于目内眦，上行至额部，交会于头顶，向上深入络属于脑，再复出，从别处下行至项部，沿着肩臂内侧，夹持脊柱，抵达腰部。医经中说：太阳病，表现为项背部强痛且恶寒。这是因为太阳经受受了风寒之邪，导致经脉运行不畅，从而使得项部拘急，颈部僵硬。伤寒病中颈项强直紧急的，属于太阳表证。必须用发散的方法治疗才能解除。
太阳病，若见项背强直不舒（KT KT 形容项背拘急不柔和之状），反而汗出、恶风的，主治方剂为桂枝加葛根汤。太阳病，若见项背强直不舒，无汗、恶风的，主治方剂为葛根汤。这些都属于发散类的方剂。这两种情况都是项背强直而使用发散法，但又有轻重之分。大概而言，发热、汗出、恶风属于表虚证，表虚证可以用解肌的方法；无汗、恶风属于表实证，表实证可以用发汗的方法。因此治疗方法有所不同。
桂枝加葛根汤的组成，是在桂枝汤的基础上加入麻黄和葛根吗？又，葛根汤的组成，也是在桂枝汤中加入麻黄和葛根吗？仔细深入研究后认为：无汗恶风属于表实证，正适合发汗，那么在桂枝汤中加入葛根和麻黄是恰当的。而汗出恶风属于表虚证，表虚证适合解肌，恐怕是在桂枝汤中只加入葛根，而不加入麻黄吧。“几”（jī）字，意为伸颈的样子。“几”也是短羽鸟的名称。短羽的鸟不能高飞远腾，活动时总是先伸长它的头颈。项背强直的人，活动状态也是如此，并不是像桌案（几案）的“几”那样弯曲俯伏。
如果是太阳伤寒导致的项背强直，或者是太阳中风，又加上寒湿侵袭而形成的痉病，也表现为项强。医经中说：病人身体发热，脚部发凉，颈项强直紧急，恶寒，同时头部发热，面色红赤，眼脉络色红赤，只有头部摇动，突然牙关紧闭，角弓反张的，这是痉病。《金匮要略》说：太阳病，其症状表现为项背强直不舒然，脉象反而沉迟的，这是痉病，主治方剂为桂枝加栝蒌根汤。虽然表现为项背强直，但这仍是太阳病的表证，都应当用发散法治疗。
另外有结胸病，项部也强直，状似柔痉（或刚痉，原文此处可能有脱漏或通假，通常指项背强几几），通过泻下治疗则病情缓和，适宜用大陷胸汤或大陷胸丸主治。在临证之际，审察病证的表里虚实，该用汗法还是下法，随证投以相应的汤药，就能万无一失了。
Neck stiffness in Shanghan (Cold Damage). How to elucidate this? The Foot-Taiyang Bladder Meridian originates from the inner canthus of the eye, ascends to the forehead, intersects at the vertex, enters deeply to connect with the brain, then emerges again and descends separately to the nape. It follows along the medial aspect of the shoulder and arm, flanking the spine, reaching the loins. The Classics state: In Taiyang disease, there is stiffness and pain in the neck and back accompanied by aversion to cold. This occurs because the Taiyang meridian has been invaded by wind-cold pathogens, causing obstruction in the meridian flow, thereby resulting in tension in the neck and stiffness in the cervical region. Neck stiffness and tightness in Shanghan disease constitute a Taiyang exterior syndrome. It must be treated with dispersing methods to resolve.
In Taiyang disease, if there is stiffness in the neck and back (described as *jǐ jǐ*, indicating a sensation of stiffness and unyielding tension), accompanied by sweating and aversion to wind, the primary formula is Guizhi Jia Gegen Tang (Cinnamon Twig Decoction with Pueraria Root). In Taiyang disease, if there is stiffness in the neck and back without sweating and with aversion to wind, the primary formula is Gegen Tang (Pueraria Root Decoction). These are all dispersing formulas. Both conditions involve neck and back stiffness treated with dispersing methods, yet they differ in severity. Generally speaking, fever, sweating, and aversion to wind indicate an Exterior Deficiency pattern; for Exterior Deficiency, muscle-releasing methods are appropriate. No sweating and aversion to wind indicate an Exterior Excess pattern; for Exterior Excess, diaphoretic (sweating) methods are appropriate. Thus, the treatments differ.
Regarding the composition of Guizhi Jia Gegen Tang: Is it Guizhi Tang added with Mahuang (Ephedrae Herba) and Gegen (Puerariae Radix)? And regarding Gegen Tang: Is it also Guizhi Tang added with Mahuang and Gegen? Upon careful investigation: No sweating and aversion to wind indicate an Exterior Excess pattern, which is suitable for inducing sweating; therefore, adding Gegen and Mahuang to Guizhi Tang is correct. However, sweating and aversion to wind indicate an Exterior Deficiency pattern, where muscle-releasing is suitable; it is likely that only Gegen is added to Guizhi Tang, without Mahuang. The character *jǐ* (几) refers to the appearance of stretching the neck. *Jǐ* also refers to a bird with short wings. Such birds cannot fly high or far; when moving, they first stretch their necks. Patients with neck and back stiffness exhibit similar behavior during movement. This is not like the *jǐ* (table/desk) which bends forward.
If neck stiffness arises from Taiyang Shanghan, or from Taiyang Zhongfeng (Wind Strike) complicated by cold-dampness leading to Jing disease (Spasm), it also presents as neck stiffness. The Classics state: When a patient has body heat, cold feet, stiff and tight neck, aversion to cold, simultaneous heat in the head, red face, red eye vessels, isolated shaking of the head, sudden lockjaw, and opisthotonos (arching of the back), this is Jing disease (Spasm). The *Jin Gui Yao Lue* states: In Taiyang disease, if the symptoms include stiffness in the neck and back (*jǐ jǐ*), but the pulse is unexpectedly deep and slow, this is Jing disease (Spasm), treated with Guizhi Jia Tianhuafen Tang (Cinnamon Twig Decoction with Trichosanthes Root). Although presenting with neck and back stiffness, this remains a Taiyang exterior syndrome and should generally be treated with dispersing methods.
Furthermore, in Jie Xiong disease (Chest Binding), the neck may also be stiff, resembling the stiffness seen in Rou Jing (Soft Spasm) or Gang Jing (Hard Spasm); treatment with purgatives brings relief, using Daxiexiong Tang or Daxiexiong Wan (Major Blue-Green Chest-Decoction or Pill). At the time of clinical examination, one must carefully assess the interior and exterior aspects. Whether to use sweating or purging methods depends on the specific syndrome; prescribing the appropriate decoction accordingly ensures complete safety.