4·认为是阳明虚热证。尤在泾在《金匮心典》中说：“脉迟胃弱，则谷化不速，谷化不速，则谷气郁而生热，而非胃有实热，故虽下之而腹满不去。”他在《伤寒贯珠集》中，也有类似的注文。喻昌也说：“因外感阳明，胃中之余热未除，故食难用饱，饱则食复生热，二热相合，而发烦头眩。……不过虚热内壅，非结热当下之比。”⑤
5·认为是太阴(脾)虚寒证。吴谦说：“谷疸属胃热，脉当数。今脉迟，脾脏寒也。……其证原属太阳寒湿郁黩而生……属脾阴寒化而不可下者也。”④今人宗此说者较多，如南京中医学院编的《金匮要略译释》说：“这显是太阴虚寒证”；成都中医学院编的《金匮要略选读》说：“本条论述谷疸从寒化的病机。……是太阴脾虚寒证。”
由于对病机认识不一致，各家的治方也就不同。柯琴说：“当用五苓散调胃利水，”；⑦张璐说：“不但下之无益，即发汗利小便之法，亦不可用，惟当用和法，如甘草于姜汤，先温其中，然后少与凋胃微和胃气可也。”⑧喻昌虽亦主和，但他认为应该用小柴胡汤⑨；近代多宗温法，如《金匮要略译释》和《金匮要略选读》说：“当用温法，如理中、四逆等方。”同一条文，在临床应用中出入如此之大，实有辨析清楚之必要。
二、证属燥淤之我见
查本条脉证有三：(1)脉迟，(2)食难用饱，饱则发烦头眩，(3)必小便难。根据“虽下之，腹满如故”一句，可知原有腹满，因此，实际共有四证。据其脉证进行分析，笔者不同意上述五种解释。
第一、阳明中寒证属虚寒，但“发烦”明是热证，不得谓“烦”为寒证。阳明中寒证，因胃中虚冷，饮水则哕，是胃气逆行，不能纳食，故称“不能食”，本条称“食难用饱”，且与“饱则发烦，，连为一句，与“不能食”用词有异，蕴义有别，不应等同。
第二、如果说是阳明经脉虚寒证，参考《伤寒论》笫236条，则应有微恶寒而不应有发烦及腹满。
第三、如果说是阳明经热证，则不应有“脉迟”“腹满”这二大腑病脉证。
第四、太阴病属虚寒，故与热证“发烦”相悖。脉迟，腹满虽可见于太阴病，但也可见于阳明腑证。称太阴病为阳明病，考诸《伤寒论》，仲景并无此种提法。太阴病既有脾虚不运，也有胃气上逆而吐，故称“食不下”，此亦不应与“食难用饱”等同，大阴病以吐利、腹满为主证，但小便不难，若谓太阴黄疸小便必难，此亦不然，因太阴黄疸有寒湿与虚寒两个证型，“若小便自利者，不能发黄”，这是针对寒湿型言，若虚寒型，小便可以自利，《金匮》有“男子黄，小便自利”、“黄疸病，小便色不变”等条文为证，如果本条是虚寒型黄痘，仲景必不谓“必小便难”，而脉迟、腹满、溲难这三证，非为太阴证及阳明中寒证所独具。故为此而置“烦”字于不论或曲解“烦”字，均为不妥。
根据以上分析，笔者认为“阳明虚热证”之说还稍近理。但尤在泾注解失之简略，奥旨未能昌明，近世多不采用；而喻昌之出方，尤悖经义，故须商榷。
我认为此条病机应届本虚标实。胃家实是阳明病之提纲，而最易损津耗液则是阳明病之特点。阳明病之脉，经病洪，腑病迟，既然是“阳明病，脉迟”，就宜作阳明腑病看。阳明病多从燥化，后期热邪虽退，而津液受伤，胃肠干燥，大便多硬，此时虽不象中寒证及太阴病那样，因有哕、呕而“不能食”或“食不下”，但“食难用饱”，这是因为胃中余热未除，若饱食则食复生热(此即说明“食难用饱”，是形容多食不适，与“不能食”“食不下”不同)，二热相合而发烦头眩。胃肠中糟粕，因津亡液燥而结实，常引起排便困难，大便坚燥准下，故腹满。至于小便难，则说明津液内竭，这与114条“阴虚小便难”情况类似，都是津液耗伤的表现，不是指湿邪内蓄，排尿不畅。这时虽“有燥屎在胃中”，但因为是津液内竭所致，故“虽硬不可攻之”。因此，本条应届本虚标实之证。其病机是津伤肠燥，因燥致结，田结实而致淤，因淤结而发黄，在这种情况下发生的黄疸，与谷物化成之糟粕壅实不去、加之多食饱食、造成食复的关系甚大，故曰；“此欲作谷疸。”吴谦说：“谷疸属胃热”，有一定道理，但谷疸之脉不一定“数”。
为什么对本条病证有时会误治？果如《金匮要略译释》所说：“本条的辨证关键在于脉迟，同时还应伴有舌淡神疲，色黄晦暗等证”，那就与属实热的阳明腑证恰恰相反。实际上，本条是因为“有燥屎在胃中”，脉证与承气汤证有相似之处，所以容易误治。但二者之间，有阴津已伤未伤之分，热邪方盛已衰之殊，故仲景特出此条，叫人明辨虚实。若谓“阳明病，脉迟”是太阴病，未免令人愕然。此证所以容易误治，正是因为有阳明腑病脉证之表现，因此仲景说：“所以然者，脉迟故也。”
三、辨清本条内容的实际意义
第一、利于合理地补出冶方，并使有关条文捐到比较确切的解释。本条当以润导行淤为大法，采用猪膏发煎较为合理。黄疸虽以湿热为常，但发热伤津之后或热病后期，邪退正虚，朋津不足，因燥致淤，因淤结而发黄者亦有之。此种黄疸是燥淤黄疸，《金匮》中论之较详，如《黄疸篇》说：“腹满，舌痿黄，躁不得睡，属黄家。”即指此种证型。但由于本条文蕴义不明，故有作湿热或寒湿的种种注释，现阐明第200条之本旨，再与此条结合看，实有互相补充，互为说明之妙，故此条·之身痿黄(舌痿是身痿)是对黄色枯燥不润泽的形容，与《湿病篇》的“熏黄”，形容黄晕如油正好相反，可对勘。腹满是胃肠燥结，干粪不去之征，燥不得睡是热罢阴虚之象，此时若饱食，则可因积食生热而产生“微烦头眩”。“诸黄，猪膏发煎主之，”一条，正是为此而出治方。此方治燥淤黄疸效果很好，古今均有喜用者，谨摘录治验二则以说明：(1)“太医校尉史脱家婢病黄，服此胃中燥粪下便瘥”(《千金方》)。(2)“予友骆天游黄疸，腹大如鼓，百药不效，用猪膏四量，发灰四量，一剂而愈”(《金匮要略译释》)。总之，《伤寒论》第200条与上述两条结合研究，则其蕴义及燥淤黄疸的证治就畅晓明通了。
第二、有益于扩大眼界，能使治黄不囿于湿热圈子。黄疸虽以湿热为常，但阳黄之治，或只强调湿热，或只强调淤热，若全然不知有燥化虚化诸证型，则不全面。有人对“黄家所得，从湿得之”和“淤热在里”等经文缺乏正确的理解，惑于疸“病虽有五，皆湿热也”等说，或认为黄疸无湿不成，或认为阳黄不外湿、热、淤，因而治疗黄疸自囿于一个“湿"字，或唯知以清热、利湿、行淤、解毒之品，杂凑威方，泛治一切阳黄，致使辨证论治之原则，降低到随症加减之水平，这就不合仲景心法。治黄疸若以“湿、热、淤”三字作茧自缚，跳不出清热、利湿、行淤之圈子，治病轻者尚可幸中藏拙，对那些治之十日以上不瘥至十八日不愈的黄疸，就束手无策，甚至忘掉“久而增气，物化之常也。气增而久，夭之由也”的告诫，反而加大苦寒、淡渗、芳化之品的剂量以冀获效，就只能徒伤阴津，绝人长命。如误人被误，俱各茫然不知，犹可慨叹！注：①此条数码采用成都中医学院主编的中医学院试用教材《伤寒论讲义》(重订本)一书。
②130页
⑧《伤寒论集注》张隐庵注，卷三
④《注解伤寒论》130页，成无己著，人民卫生出版社
⑤《校正医门法律，尚论篇·卷六·黄疸门》，喻昌著
⑥《医宗金鉴》第一分册，吴谦等著
⑦《伤寒来苏集》99页，柯琴著，上海科技出版社。
⑧同⑥55页
⑨同⑤2003-9-1422:25:00北海散人头衔：佛门弟子等级：管理员文章：3797积分：4270注册：2002-12-24
第4楼太阳六淫病初起有六型
一般认为：太阳病初起，有二个证型，即伤寒和中风。而同时又认为：太阳为六经之首，主一身之表，外邪侵袭人体，太阳首当其冲。我们知道，所谓外邪，意指失常之六气，即六淫。但如果说六淫侵犯太阳，只有伤寒、中风两个证型，这是无论如何也说不通的，有的虽将温病亦等列为一型，但仍然遗其一半，故余谓太阳六淫病，初起有六型，现即据仲景原文条列其证治以证之，并略加讨论，以供研究仲景学说之参考。
一、太阳风淫病——中风
[脉证]“太阳病，发热、汗出、恶风、脉缓者，名为中风。”(2)。
[治例]“太阳中风，阳浮而阴弱，阳浮者热自发，阴弱者汗自出，啬啬恶寒，浙浙恶风，翕翕发热，鼻呜千呕者，桂枝汤主之。”(12)
[讨论]1·风邪外袭太阳，即为太阳中风。但风邪伤人并不一定先伤太阳。《伤寒论》195条说：“阳明病，若能食，名中风。”265条说：“少阳中风，两耳无所闻，目赤，胸中满而烦者，不可吐下，吐下则悸而惊。”274条说：“太阴中风，四肢烦疼，脉阳傲阴涩而长者，为欲愈。”290条说：“少朋中风，脉阳敞阴浮者，为欲愈。"327条说：“厥阴中风，脉微浮力欲愈，不浮为未愈。”六经都有中风，这是仲景原文。要说其余五者之中风，都是从太阳传来，既乏根据，又解释不通。故中风虽是太阳病初起的一个证型，但并不是太阳病独有的证型。如果只将中风列为太阳病的一个证型，对其余五者则熟视无睹，缄口不谈，这是不太好的。
2·236条说：“阳明病，脉迟，汗出多，微恶寒者，表未解也，宜桂枝汤。”，242条说：“病人烦热，汗出则解，又如疟状，日晡所发热者，属阳明也。脉实者宜下之；脉浮虚者，宜发汗。下之，与大承气汤；发汗，宜桂枝汤。”267条说：“太阴病，脉浮者，可发汗，宜桂枝汤。”准斯以观，桂枝汤仲景并不专为太阳病设。故只能说桂枝汤是太阳中风之主剂，不能说是太阳病出专药。有人因麻、桂二方可治肺经证，便说“太阳病当解释为肺经证”，这是值得商榷的。
仲景原文说明：风邪可以先侵袭太阳，也可以不先侵袭太阳。如侵袭太阳，就用桂枝汤治疗，如先侵袭阳明或太阴，也用桂枝汤治疗，这足证桂枝汤证不等于太阳中风证，倘那样认识，就不符合仲景原旨了。
二、太阳寒淫病—一伤寒
[脉证]“太阳病，或已发热，或未发热，必恶寒，体痛、呕逆，脉阴阳惧紧者，名为伤寒。”(3)
[治例]“太阳病，头痛发热，身疼腰痛，骨节疼痛，恶风，无寒而喘者，麻黄汤主之。”(35)
仁讨论]寒邪侵袭太阳，即为太阳伤寒。但寒邪也不一定先伤太阳。如237条说：“阳明病，脉浮，无汗而喘者，发汗则愈，宜麻黄汤。”这就是寒邪伤阳明的治法。这也说明麻黄汤只是太阳伤寒之主剂，并非太阳病之专药，这个道理与太阳中风同。又301条说：“少阴病，始得之，反发热，脉沉者，麻黄附子细辛汤主之。”这也是一个佐证。因为仲景明文洗是“始得之”，我们自然也不能从太阳传来作解释，否则就不是“始得之”了。究仲景治法，卫气虚弱，寒邪侵袭太阳及阳明，都用麻黄汤，肾阳虚弱，寒邪侵袭少阴，就用麻黄附子细辛汤。同样的寒邪所伤，同样的始得之，药法就有出入。风伤太阳、太阴，仲景都用桂枝汤，寒伤太阳，少阴，仲景用麻黄即加化裁，这似乎与风、寒二邪特性不同也有关。根据仲景这一药法，笔者认为肾虚患感，当忌麻黄汤之峻汗，喻嘉言关于伤风小恙亦有戴阳证的一则医案医话，宜当引起我们的重视。总之，六经皆有表证，寒邪伤人，除了直中于里(如阳明中寒证)，可伤太阳之表，也可伤阳明之表，也可伤少阴之表。故说太阳为一身藩篱，风寒伤人，必始自太阳。就个“必”字太绝对，因为与《伤寒论》原文一核对，这个“必”字就有问题了。所以，只能说外感病常从太阳开始，不能说外感病都必从太阳开始。
三、太阳火淫病——温病
[脉证]“太阳病，发热而渴，不恶寒者，为温病。若发汗已，身灼热者，名曰风温，风温为病，脉朋阳俱浮，自汗出，身重、多眠睡、息必鼾、语言难出。”(6)
[治例]“发汗后，不可更行桂枝汤，汗出而喘，无大热者，可与麻黄杏仁甘草石膏汤。”(63)
4·认为是阳明虚热证。尤在泾在《金匮心典》中说：“脉象迟缓说明胃气虚弱，食物消化缓慢；食物消化缓慢，则谷气郁结而生内热，这并非胃中有实热，所以即使使用泻下法，腹部胀满也不会消除。”他在《伤寒贯珠集》中，也有类似的注释。喻昌也说：“因为外感邪气传入阳明，胃中的余热尚未清除，所以饮食难以吃饱，吃饱后食物又会生热，两种热邪相合，导致心烦和头晕。……这不过是虚热在内壅滞，不属于应当用攻下法治疗的结热证。”⑤
5·认为是太阴（脾）虚寒证。吴谦说：“谷疸属于胃热，脉象应当数急。现在脉象迟缓，是脾脏有寒。……其病证原本属于太阳寒湿郁遏而生成……属于脾阴虚寒转化而成，不可使用泻下法。”④如今遵循这一说法的人较多，如南京中医学院编著的《金匮要略译释》说：“这显然是太阴虚寒证”；成都中医学院编著的《金匮要略选读》说：“本条论述谷疸从寒化转化的病机。……这是太阴脾虚寒证。”
由于对病机认识不一致，各家的治疗方剂也就不同。柯琴说：“应当使用五苓散来调和胃气、通利水湿，”；⑦张璐说：“不仅使用泻下法没有益处，即使是发汗和利小便的方法，也不可使用，只应当使用和解法，比如甘草干姜汤，先温补中焦，然后少量给予以微微调和胃气即可。”⑧喻昌虽然也主张和解，但他认为应该使用小柴胡汤⑨；近代多遵循温补法，如《金匮要略译释》和《金匮要略选读》说：“应当使用温法，比如理中汤、四逆汤等方剂。”同一条文，在临床应用中差异如此之大，确实有必要辨析清楚。
二、关于证属燥瘀之我见
查阅本条的脉证有三点：(1)脉象迟缓，(2)饮食难以吃饱，吃饱后就发生心烦和头晕，(3)必定小便困难。根据“即使使用泻下法，腹部胀满依旧”一句，可知原有腹部胀满，因此，实际共有四个证候。根据其脉证进行分析，笔者不同意上述五种解释。
第一、阳明中寒证属于虚寒，但“心烦”明显是热证，不能称“烦”为寒证。阳明中寒证，因胃中虚冷，饮水则呃逆，这是胃气上逆，不能纳食，所以称为“不能食”，本条称为“食难用饱”，且与“饱则发烦”连为一句，与“不能食”用词有异，含义有别，不应等同。
第二、如果说是阳明经脉虚寒证，参考《伤寒论》第236条，则应有轻微恶寒而不应该有心烦及腹部胀满。
第三、如果说是阳明经热证，则不应该有“脉迟”“腹满”这两个腑病脉证。
第四、太阴病属于虚寒，故与热证“心烦”相违背。脉迟、腹满虽然可见于太阴病，但也可见于阳明腑实证。称太阴病为阳明病，考证《伤寒论》，仲景并无此种提法。太阴病既有脾虚不运，也有胃气上逆而呕吐，所以称为“食不下”，此亦不应与“食难用饱”等同，太阴病以吐利、腹满为主证，但小便不难，若谓太阴黄疸小便必难，这也是不对的，因为太阴黄疸有寒湿与虚寒两个证型，“若小便自利者，不能发黄”，这是针对寒湿型而言，若虚寒型，小便可以自利，《金匮》有“男子黄，小便自利”、“黄疸病，小便色不变”等条文为证，如果本条是虚寒型黄疸，仲景必定不会说“必小便难”，而脉迟、腹满、小便难这三证，并非太阴证及阳明中寒证所独有。因此为此而忽略“烦”字或曲解“烦”字，均为不妥。
根据以上分析，笔者认为“阳明虚热证”之说还稍近情理。但尤在泾注解失之简略，深奥旨意未能阐明，近世多不采用；而喻昌提出的方剂，尤其违背经义，故须商榷。
我认为此条病机应属于本虚标实。胃家实是阳明病的提纲，而最易损伤津液耗伤阴液则是阳明病的特点。阳明病的脉象，经病洪大，腑病迟缓，既然是“阳明病，脉迟”，就宜作阳明腑病看待。阳明病多从燥化，后期热邪虽退，而津液受伤，胃肠干燥，大便多硬，此时虽不像中寒证及太阴病那样，因为有呃逆、呕吐而“不能食”或“食不下”，但“食难用饱”，这是因为胃中余热未除，若饱食则食物又生热（此即说明“食难用饱”，是形容多食不适，与“不能食”“食不下”不同），两种热邪相合而发心烦头晕。胃肠中糟粕，因津亡液燥而结实，常引起排便困难，大便坚燥难下，故腹部胀满。至于小便难，则说明津液内竭，这与第114条“阴虚小便难”情况类似，都是津液耗伤的表现，不是指湿邪内蓄，排尿不畅。这时虽“有燥屎在胃中”，但因为是津液内竭所致，故“虽硬不可攻之”。因此，本条应属于本虚标实之证。其病机是津伤肠燥，因燥致结，因结实而致瘀，因瘀结而发黄，在这种情况下发生的黄疸，与谷物化成之糟粕壅实不去、加之多食饱食、造成食复的关系甚大，所以说：“此欲作谷疸。”吴谦说：“谷疸属胃热”，有一定道理，但谷疸之脉不一定“数”。
为什么对本条病证有时会误治？果如《金匮要略译释》所说：“本条的辨证关键在于脉迟，同时还应伴有舌淡神疲，面色黄晦暗等证”，那就与属实热的阳明腑证恰恰相反。实际上，本条是因为“有燥屎在胃中”，脉证与承气汤证有相似之处，所以容易误治。但二者之间，有阴津已伤未伤之分，热邪方盛已衰之殊，故仲景特出此条，叫人明辨虚实。若谓“阳明病，脉迟”是太阴病，未免令人愕然。此证所以容易误治，正是因为有阳明腑病脉证之表现，因此仲景说：“所以然者，脉迟故也。”
三、辨清本条内容的实际意义
第一、利于合理地补出治疗方剂，并使有关条文得到比较确切的解释。本条当以润导行瘀为大法，采用猪膏发煎较为合理。黄疸虽以湿热为常态，但发热伤津之后或热病后期，邪退正虚，阴津不足，因燥致瘀，因瘀结而发黄者亦有之。此种黄疸是燥瘀黄疸，《金匮》中论之较详，如《黄疸篇》说：“腹部胀满，舌体萎软色黄，烦躁不得睡，属于黄家。”即指此种证型。但由于本条文含义不明，故有作湿热或寒湿的种种注释，现阐明第200条之本旨，再与此条结合看，实有互相补充，互为说明之妙，故此条之身萎黄（舌萎是身萎）是对黄色枯燥不润泽的形容，与《湿病篇》的“熏黄”，形容黄晕如油正好相反，可对勘。腹满是胃肠燥结，干粪不去之征，燥不得睡是热罢阴虚之象，此时若饱食，则可因积食生热而产生“微烦头眩”。“诸黄，猪膏发煎主之，”一条，正是为此而出治方。此方治燥瘀黄疸效果很好，古今均有喜用者，谨摘录治验二则以说明：(1)“太医校尉史脱家婢病黄，服此胃中燥粪下便瘥”(《千金方》)。(2)“予友骆天游黄疸，腹大如鼓，百药不效，用猪膏四量，发灰四量，一剂而愈”(《金匮要略译释》)。总之，《伤寒论》第200条与上述两条结合研究，则其含义及燥瘀黄疸的证治就畅晓明通了。
第二、有益于扩大眼界，能使治黄不囿于湿热圈子。黄疸虽以湿热为常态，但阳黄之治，或只强调湿热，或只强调瘀热，若全然不知有燥化虚化诸证型，则不全面。有人对“黄家所得，从湿得之”和“瘀热在里”等经文缺乏正确的理解，惑于疸“病虽有五，皆湿热也”等说，或认为黄疸无湿不成，或认为阳黄不外湿、热、瘀，因而治疗黄疸自囿于一个“湿”字，或唯知以清热、利湿、行瘀、解毒之品，杂凑成方，泛治一切阳黄，致使辨证论治之原则，降低到随症加减之水平，这就不合仲景心法。治黄疸若以“湿、热、瘀”三字作茧自缚，跳不出清热、利湿、行瘀之圈子，治病轻者尚可幸中藏拙，对那些治之十日以上不瘥至十八日不愈的黄疸，就束手无策，甚至忘掉“久而增气，物化之常也。气增而久，夭之由也”的告诫，反而加大苦寒、淡渗、芳化之品的剂量以冀获效，就只能徒伤阴津，绝人长命。如误人被误，俱各茫然不知，犹可慨叹！注：①此条数码采用成都中医学院主编的中医学院试用教材《伤寒论讲义》(重订本)一书。
②130页
③《伤寒论集注》张隐庵注，卷三
④《注解伤寒论》130页，成无己著，人民卫生出版社
⑤《校正医门法律，尚论篇·卷六·黄疸门》，喻昌著
⑥《医宗金鉴》第一分册，吴谦等著
⑦《伤寒来苏集》99页，柯琴著，上海科技出版社。
⑧同⑥55页
⑨同⑤2003-9-1422:25:00北海散人头衔：佛门弟子等级：管理员文章：3797积分：4270注册：2002-12-24
第4楼太阳六淫病初起有六型
一般认为：太阳病初起，有二个证型，即伤寒和中风。而同时又认为：太阳为六经之首，主一身之表，外邪侵袭人体，太阳首当其冲。我们知道，所谓外邪，意指失常之六气，即六淫。但如果说六淫侵犯太阳，只有伤寒、中风两个证型，这是无论如何也说不通的，有的虽将温病亦等列为一型，但仍然遗其一半，故余谓太阳六淫病，初起有六型，现即据仲景原文条列其证治以证之，并略加讨论，以供研究仲景学说之参考。
一、太阳风淫病——中风
[脉证]“太阳病，发热、汗出、恶风、脉缓者，名为中风。”(2)。
[治例]“太阳中风，阳浮而阴弱，阳浮者热自发，阴弱者汗自出，啬啬恶寒，淅淅恶风，翕翕发热，鼻鸣干呕者，桂枝汤主之。”(12)
[讨论]1·风邪外袭太阳，即为太阳中风。但风邪伤人并不一定先伤太阳。《伤寒论》195条说：“阳明病，若能食，名中风。”265条说：“少阳中风，两耳无所闻，目赤，胸中满而烦者，不可吐下，吐下则悸而惊。”274条说：“太阴中风，四肢烦疼，脉阳涩阴涩而长者，为欲愈。”290条说：“少阴中风，脉阳涩阴浮者，为欲愈。”327条说：“厥阴中风，脉微浮者欲愈，不浮为未愈。”六经都有中风，这是仲景原文。要说其余五者之中风，都是从太阳传来，既乏根据，又解释不通。故中风虽是太阳病初起的一个证型，但并不是太阳病独有的证型。如果只将中风列为太阳病的一个证型，对其余五者则熟视无睹，缄口不谈，这是不太好的。
2·236条说：“阳明病，脉迟，汗出多，微恶寒者，表未解也，宜桂枝汤。”，242条说：“病人烦热，汗出则解，又如疟状，日晡所发热者，属阳明也。脉实者宜下之；脉浮虚者，宜发汗。下之，与大承气汤；发汗，宜桂枝汤。”267条说：“太阴病，脉浮者，可发汗，宜桂枝汤。”据此以观，桂枝汤仲景并不专为太阳病设。故只能说桂枝汤是太阳中风之主剂，不能说是太阳病之专药。有人因麻、桂二方可治肺经证，便说“太阳病当解释为肺经证”，这是值得商榷的。
仲景原文说明：风邪可以先侵袭太阳，也可以不先侵袭太阳。如侵袭太阳，就用桂枝汤治疗，如先侵袭阳明或太阴，也用桂枝汤治疗，这足证桂枝汤证不等于太阳中风证，倘那样认识，就不符合仲景原旨了。
二、太阳寒淫病——伤寒
[脉证]“太阳病，或已发热，或未发热，必恶寒，体痛、呕逆，脉阴阳俱紧者，名为伤寒。”(3)
[治例]“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。”(35)
[讨论]寒邪侵袭太阳，即为太阳伤寒。但寒邪也不一定先伤太阳。如237条说：“阳明病，脉浮，无汗而喘者，发汗则愈，宜麻黄汤。”这就是寒邪伤阳明的治法。这也说明麻黄汤只是太阳伤寒之主剂，并非太阳病之专药，这个道理与太阳中风同。又301条说：“少阴病，始得之，反发热，脉沉者，麻黄附子细辛汤主之。”这也是一个佐证。因为仲景明文说是“始得之”，我们自然也不能从太阳传来作解释，否则就不是“始得之”了。究仲景治法，卫气虚弱，寒邪侵袭太阳及阳明，都用麻黄汤，肾阳虚弱，寒邪侵袭少阴，就用麻黄附子细辛汤。同样的寒邪所伤，同样的始得之，药法就有出入。风伤太阳、太阴，仲景都用桂枝汤，寒伤太阳、少阴，仲景用麻黄即加化裁，这似乎与风、寒二邪特性不同也有关。根据仲景这一药法，笔者认为肾虚患者感受外邪，当忌麻黄汤之峻汗，喻嘉言关于伤风小恙亦有戴阳证的一则医案医话，宜当引起我们的重视。总之，六经皆有表证，寒邪伤人，除了直中于里(如阳明中寒证)，可伤太阳之表，也可伤阳明之表，也可伤少阴之表。故说太阳为一身藩篱，风寒伤人，必始自太阳。就这个“必”字太绝对，因为与《伤寒论》原文一核对，这个“必”字就有问题了。所以，只能说外感病常从太阳开始，不能说外感病都必从太阳开始。
三、太阳火淫病——温病
[脉证]“太阳病，发热而渴，不恶寒者，为温病。若发汗已，身灼热者，名曰风温，风温为病，脉阴阳俱浮，自汗出，身重、多眠睡、息必鼾、语言难出。”(6)
[治例]“发汗后，不可更行桂枝汤，汗出而喘，无大热者，可与麻黄杏仁甘草石膏汤。”(63)
4. Considered as the syndrome of deficiency-heat in Yangming (Yangming channel disease). You Zaijing, in *Jinkui Xin Dian* (Essential Insights into the Golden Cabinet), stated: "A slow pulse indicates weak stomach qi; weak stomach qi leads to slow digestion of food; slow digestion causes grain qi to stagnate and generate heat. This is not excess heat in the stomach, therefore, even if purgatives are used, abdominal fullness will not resolve." He had similar annotations in *Shanghan Guanzhu Ji* (Pearl String Collection on Cold Damage). Yu Chang also said: "Due to external pathogens affecting Yangming, residual heat in the stomach has not been cleared, so one cannot eat to fullness. Eating to fullness generates more heat. The combination of these two heats causes irritability and dizziness... This is merely internal obstruction by deficiency-heat, which does not compare to bound heat requiring purgation." ⑤
5. Considered as the syndrome of deficiency-cold in Taiyin (Spleen). Wu Qian said: "Grain jaundice belongs to stomach heat, so the pulse should be rapid. Now the pulse is slow, indicating cold in the spleen organ... The syndrome originally arises from cold-dampness stagnating in Taiyang... It transforms into Spleen yin deficiency-cold and cannot be treated with purgation." ④ Many modern scholars follow this view. For example, *Jinkui Yaolue Yishi* (Translation and Interpretation of Essential Prescriptions of the Golden Cabinet) compiled by Nanjing University of Chinese Medicine states: "This is clearly a Taiyin deficiency-cold syndrome"; *Jinkui Yaolue Xuan Du* (Selected Readings of the Golden Cabinet) compiled by Chengdu University of Chinese Medicine states: "This article discusses the pathogenesis of grain jaundice transforming from cold... it is a Taiyin spleen deficiency-cold syndrome."
Due to inconsistent understanding of the pathogenesis, the treatment formulas proposed by various schools differ. Ke Qin said: "One should use Wuling San (Five-Ingredient Powder with Poria) to harmonize the stomach and promote urination,"; ⑦ Zhang Lu said: "Not only is purgation useless, but methods of inducing sweating and promoting urination are also contraindicated. One should only use harmonizing methods, such as Gancao Ganjiang Tang (Licorice and Dried Ginger Decoction), first warming the middle jiao, then giving small amounts to slightly harmonize stomach qi." ⑧ Although Yu Chang also advocated harmonizing, he believed Xiao Chaihu Tang (Minor Bupleurum Decoction) should be used; ⑨ Modern times mostly advocate warming methods, such as *Jinkui Yaolue Yishi* and *Jinkui Yaolue Xuan Du* stating: "Warming methods should be used, such as Lizhong Tang (Regulate the Middle Decoction) or Sini Tang (Frigid Extremities Decoction)." The clinical application of the same text varies so greatly that it is necessary to clarify it.
II. My View on the Syndrome Being Dryness-Stasis
Reviewing the pulse and symptoms of this article, there are three points: (1) Slow pulse, (2) Difficulty eating to fullness, with irritability and dizziness after eating, (3) Inevitably difficult urination. Based on the phrase "even if purged, abdominal fullness remains," it is known that abdominal fullness existed originally; thus, there are actually four symptoms. Analyzing based on these pulse and symptoms, I disagree with the above five explanations.
First, Yangming Zhonghan (Cold Strike in Yangming) syndrome belongs to deficiency-cold, but "irritability" is clearly a heat symptom, so "fan" (irritability) cannot be called a cold symptom. In Yangming Zhonghan syndrome, due to empty cold in the stomach, drinking water causes hiccups; this is rebellious stomach qi unable to accept food, hence termed "unable to eat." This article says "difficulty eating to fullness," linked with "after eating, irritability occurs," differing in wording and meaning from "unable to eat," so they should not be equated.
Second, if it were Yangming meridian deficiency-cold syndrome, referring to Article 236 of *Shanghan Lun*, there should be slight aversion to cold, but no irritability or abdominal fullness.
Third, if it were Yangming meridian heat syndrome, there should not be the two major fu-organ pulse and symptoms of "slow pulse" and "abdominal fullness."
Fourth, Taiyin disease belongs to deficiency-cold, contradicting the heat symptom of "irritability." While slow pulse and abdominal fullness can appear in Taiyin disease, they can also appear in Yangming fu-organ syndrome. Calling Taiyin disease Yangming disease has no basis in *Shanghan Lun*; Zhang Zhongjing never used such terminology. Taiyin disease involves spleen deficiency failing to transport and stomach qi rebelling causing vomiting, hence termed "unable to eat down." This should not be equated with "difficulty eating to fullness." Taiyin disease's main symptoms are vomiting, diarrhea, and abdominal fullness, but urination is not difficult. If one claims Taiyin jaundice inevitably has difficult urination, this is incorrect. Taiyin jaundice has two syndromes: cold-dampness and deficiency-cold. "If urination is free, yellowing cannot occur" refers to the cold-dampness type. In the deficiency-cold type, urination can be free. *Jinkui Yaolue* has texts like "Yellow man with free urination" and "Jaundice disease with unchanged urine color" as evidence. If this article were deficiency-cold jaundice, Zhongjing would not say "inevitably difficult urination." Furthermore, the triad of slow pulse, abdominal fullness, and difficult urination is not unique to Taiyin or Yangming Zhonghan syndromes. Therefore, ignoring or distorting the word "fan" (irritability) for this reason is inappropriate.
Based on the above analysis, I believe the theory of "Yangming deficiency-heat syndrome" is closer to reason. However, You Zaijing's annotation was too brief, failing to elucidate the profound meaning, so it is rarely adopted in recent times; whereas Yu Chang's prescription particularly contradicts the classic principles, warranting discussion.
I believe the pathogenesis of this article belongs to root deficiency and branch excess. "Stomach house excess" is the outline of Yangming disease, and the easiest damage to fluids and consumption of yin is the characteristic of Yangming disease. The pulse of Yangming disease: Jing (channel) disease is surging, Fu (organ) disease is slow. Since it is "Yangming disease, slow pulse," it should be viewed as Yangming fu-organ disease. Yangming disease often transforms into dryness. In the late stage, although heat pathogens recede, fluids are damaged, intestines and stomach become dry, and stool is often hard. At this time, unlike Zhonghan or Taiyin diseases where hiccups and vomiting cause "unable to eat" or "food not going down," here it is "difficulty eating to fullness." This is because residual heat in the stomach remains; overeating generates more heat (this explains that "difficulty eating to fullness" describes discomfort from overeating, distinct from "unable to eat"). The combination of two heats causes irritability and dizziness. Waste matter in the intestines and stomach, solidified due to fluid loss and dryness, often causes difficulty defecating and hard, dry stool, leading to abdominal fullness. As for difficult urination, it indicates exhaustion of internal fluids. This is similar to Article 114's "yin deficiency causing difficult urination," both being manifestations of fluid consumption, not referring to dampness accumulation obstructing urination. Although there is "dry feces in the stomach," because it is caused by internal fluid exhaustion, "although hard, it cannot be attacked/purged." Therefore, this article belongs to root deficiency and branch excess. Its pathogenesis is fluid injury and intestinal dryness, leading to binding due to dryness, leading to stasis due to binding, and yellowing due to stasis binding. Jaundice occurring in this situation is closely related to the retention of waste matter transformed from grains and the recurrence of illness due to overeating, hence it is said: "This is about to become grain jaundice." Wu Qian said: "Grain jaundice belongs to stomach heat," which has some merit, but the pulse of grain jaundice is not necessarily "rapid."
Why is misdiagnosis sometimes made for this condition? If, as *Jinkui Yaolue Yishi* states: "The key to differentiation in this article is the slow pulse, accompanied by pale tongue, mental fatigue, dark dull yellow complexion, etc.," this would be exactly opposite to the excess-heat Yangming fu-organ syndrome. Actually, this article is because "there are dry feces in the stomach," and the pulse/symptoms resemble Chengqi Tang syndrome, making it prone to misdiagnosis. However, between the two, there is a distinction of whether yin fluids are injured, and a difference in whether heat pathogens are flourishing or declining. Thus, Zhongjing specifically presented this article to teach distinguishing deficiency and excess. To claim "Yangming disease, slow pulse" is Taiyin disease is bewildering. This condition is prone to misdiagnosis precisely because it presents with Yangming fu-organ pulse and symptoms, hence Zhongjing said: "The reason for this is the slow pulse."
III. Practical Significance of Clarifying This Content
First, it facilitates the reasonable supplementation of treatment formulas and provides clearer interpretations of related articles. The main method for this article should be moistening, guiding, and moving stasis; using Pig Fat and Hair Charcoal Decoction (Zhigao Faxian Jian) is more reasonable. Although jaundice is commonly damp-heat, after fever damages fluids or in the late stage of febrile diseases, when pathogens retreat and healthy qi is deficient, with insufficient yin fluids, yellowing due to dryness-stasis and stasis-binding does occur. This type of jaundice is dryness-stasis jaundice, discussed in detail in *Jinkui Yaolue*. For example, the *Jaundice Chapter* says: "Abdominal fullness, flaccid yellow tongue, restlessness preventing sleep, belongs to the Yellow Family." This refers to this syndrome type. Due to the unclear meaning of this text, various annotations have been made regarding damp-heat or cold-dampness. Now clarifying the original intent of Article 200 and combining it with this article reveals their mutual supplementation and explanation. The "flaccid yellow body" (tongue flaccidity implies body flaccidity) in this article describes a dry, non-lustrous yellow color, contrasting with the "smoked yellow" in the *Dampness Disease Chapter*, which describes a yellow hue like oil. Abdominal fullness is a sign of intestinal dryness-binding and retained dry feces; restlessness preventing sleep is a sign of post-heat yin deficiency. If one eats to fullness at this time, accumulated food generates heat, causing "slight irritability and dizziness." The article "All yellows are treated with Zhigao Faxian Jian" was provided precisely for this purpose. This formula works well for dryness-stasis jaundice and is favored by practitioners ancient and modern. I excerpt two case records to illustrate: (1) "The maid of Ta Yi Xiao Wei Shi Tuo suffered from jaundice; after taking this, dry feces in the stomach were discharged, and she recovered" (*Qianjin Fang*). (2) "My friend Luo Tianyou had jaundice, abdomen large as a drum, hundred medicines ineffective; using four liang of pig fat and four liang of hair ash, cured in one dose" (*Jinkui Yaolue Yishi*). In summary, studying Article 200 of *Shanghan Lun* together with the above two articles makes its meaning and the diagnosis/treatment of dryness-stasis jaundice clear and understandable.
Second, it benefits expanding horizons, allowing the treatment of jaundice not to be confined to the damp-heat circle. Although jaundice is commonly damp-heat, treating Yang jaundice either emphasizes only damp-heat or only stasis-heat. If one is completely unaware of dryness-transforming and deficiency-transforming syndrome types, it is incomplete. Some people lack correct understanding of scriptures like "What the Yellow Family obtains comes from dampness" and "Stasis-heat in the interior," confused by theories like "Although jaundice has five types, all are damp-heat," or believing jaundice cannot exist without dampness, or that Yang jaundice is nothing but damp, heat, and stasis. Consequently, treating jaundice confines itself to the character "damp," or only knows to mix clearing-heat, promoting urination, moving-stasis, and detoxifying herbs into composite formulas, treating all Yang jaundice generically. This lowers the principle of syndrome differentiation and treatment to the level of symptomatic modification, which does not conform to Zhongjing's core method. If treating jaundice binds oneself with the characters "damp, heat, stasis," unable to jump out of the circle of clearing-heat, promoting urination, and moving-stasis, mild cases might luckily succeed, but for jaundice lasting ten days or more without improvement up to eighteen days, one would be helpless. Even forgetting the warning "Long-term increase of qi is the normal transformation of things; long-term increase of qi is the cause of premature death," instead increasing doses of bitter-cold, diuretic, and aromatic-transforming herbs hoping for efficacy, one can only vainly injure yin fluids and shorten life. Such mutual misunderstanding leaves everyone茫然 (at a loss), worthy of sigh! Note: ① The numbering of this article adopts the revised edition of *Shanghan Lun Jiangyi* (Lecture Notes on Cold Damage), a trial textbook for TCM colleges edited by Chengdu University of Chinese Medicine.
② Page 130
③ *Shanghan Lun Jizhu* annotated by Zhang Yin'an, Volume 3
④ *Zhuji Shanghan Lun* Page 130, authored by Cheng Wuji, People's Health Publishing House
⑤ *Zhengli Yimen Falü, Shanglun Pian · Volume 6 · Jaundice Gate*, authored by Yu Chang
⑥ *Yizong Jinjian* First Volume, authored by Wu Qian et al.
⑦ *Shanghan Laisu Ji* Page 99, authored by Ke Qin, Shanghai Science and Technology Press.
⑧ Same as ⑥ Page 55
⑨ Same as ⑤ 2003-9-14 22:25:00 Beihai Sanren Title: Buddhist Disciple Rank: Administrator Articles: 3797 Points: 4270 Registered: 2002-12-24
Floor 4: Six Types of Initial Taiyang Liu-Yin Diseases
It is generally believed: There are two initial syndrome types for Taiyang disease, namely Shanghan (Cold Damage) and Fengzhong (Wind Strike). Simultaneously, it is believed: Taiyang is the head of the Six Channels, governing the exterior of the body. When external pathogens invade the human body, Taiyang bears the brunt. We know that "external pathogens" refer to abnormal Six Qi, i.e., Liu-Yin (Six Excesses). But if claiming that Liu-Yin invading Taiyang only has two syndrome types, Shanghan and Fengzhong, this is untenable. Some include Wenbing (Warm Disease) as a type, yet still miss half. Therefore, I propose that Taiyang Liu-Yin disease has six initial types. Here, listing their syndrome treatments according to Zhongjing's original text to prove this, with brief discussion, for reference in studying Zhongjing's theory.
I. Taiyang Wind-Yin Disease — Fengzhong
[Pulse & Symptoms] "Taiyang disease, with fever, sweating, aversion to wind, and a slow pulse, is named Fengzhong." (2).
[Treatment Example] "Taiyang Fengzhong, yang floats and yin is weak. Yang floating means heat spontaneously arises; yin weakness means sweat spontaneously exits. Shivering with aversion to cold, chilly with aversion to wind, lukewarm fever, nasal congestion, and dry retching are primarily treated with Guizhi Tang (Cinnamon Twig Decoction)." (12)
[Discussion] 1. Wind pathogen externally attacking Taiyang constitutes Taiyang Fengzhong. However, wind pathogen injuring humans does not necessarily attack Taiyang first. Article 195 of *Shanghan Lun* says: "Yangming disease, if able to eat, is named Fengzhong." Article 265 says: "Shaoyang Fengzhong, hearing loss in both ears, red eyes, chest fullness and irritability, cannot be vomited or purged; vomiting and purging cause palpitations and fright." Article 274 says: "Taiyin Fengzhong, painful limbs, pulse yang is choppy, yin is choppy and long, indicates recovery." Article 290 says: "Shaoyin Fengzhong, pulse yang is choppy, yin is floating, indicates recovery." Article 327 says: "Jueyin Fengzhong, pulse slightly floating indicates recovery, not floating means not recovered." All Six Channels have Fengzhong; this is Zhongjing's original text. To claim that Fengzhong in the other five channels is transmitted from Taiyang lacks basis and explanation. Thus, although Fengzhong is an initial syndrome type of Taiyang disease, it is not exclusive to Taiyang disease. If only listing Fengzhong as a Taiyang syndrome type and ignoring the other five, it is undesirable.
2. Article 236 says: "Yangming disease, slow pulse, much sweating, slight aversion to cold, exterior not resolved, suitable for Guizhi Tang." Article 242 says: "Patient with irritability and heat, resolves with sweating, yet resembles malaria, fever at dusk belongs to Yangming. Pulse excess suitable for purging; pulse floating/weak suitable for sweating. Purge with Dachengqi Tang; sweat with Guizhi Tang." Article 267 says: "Taiyin disease, floating pulse, can be sweated, suitable for Guizhi Tang." Observing this, Guizhi Tang was not established by Zhongjing exclusively for Taiyang disease. Thus, one can only say Guizhi Tang is the principal agent for Taiyang Fengzhong, not the exclusive medicine for Taiyang disease. Some, because Mahuang Tang and Guizhi Tang can treat Lung meridian syndromes, claim "Taiyang disease should be interpreted as Lung meridian syndrome," which is debatable.
Zhongjing's original text indicates: Wind pathogen can attack Taiyang first, or not. If attacking Taiyang, treat with Guizhi Tang; if attacking Yangming or Taiyin first, also treat with Guizhi Tang. This proves Guizhi Tang syndrome is not equal to Taiyang Fengzhong syndrome. Such recognition would not conform to Zhongjing's original intent.
II. Taiyang Cold-Yin Disease — Shanghan
[Pulse & Symptoms] "Taiyang disease, either already febrile or not yet febrile, must have aversion to cold, body pain, vomiting/reversal, pulse yin and yang both tight, is named Shanghan." (3)
[Treatment Example] "Taiyang disease, headache, fever, body ache, waist pain, bone joint pain, aversion to wind, no sweat and panting, primarily treated with Mahuang Tang (Ephedra Decoction)." (35)
[Discussion] Cold pathogen attacking Taiyang constitutes Taiyang Shanghan. However, cold pathogen does not necessarily attack Taiyang first. For example, Article 237 says: "Yangming disease, floating pulse, no sweat and panting, inducing sweat cures, suitable for Mahuang Tang." This is the treatment method for cold pathogen injuring Yangming. This also shows Mahuang Tang is merely the principal agent for Taiyang Shanghan, not the exclusive medicine for Taiyang disease, the same logic as Taiyang Fengzhong. Also, Article 301 says: "Shaoyin disease, just acquired, contrary fever, sinking pulse, primarily treated with Mahuang Fuzi Xixin Tang (Ephedra, Aconite, and Asarum Decoction)." This is also corroborative evidence. Because Zhongjing explicitly says "just acquired," we naturally cannot interpret it as transmitted from Taiyang, otherwise it wouldn't be "just acquired." Investigating Zhongjing's treatment methods: Wei qi deficiency, cold pathogen attacking Taiyang and Yangming, both use Mahuang Tang; Kidney yang deficiency, cold pathogen attacking Shaoyin, uses Mahuang Fuzi Xixin Tang. Same cold pathogen injury, same "just acquired," yet medication differs. Wind injuring Taiyang and Taiyin, Zhongjing uses Guizhi Tang; Cold injuring Taiyang and Shaoyin, Zhongjing uses Mahuang with modifications. This seems related to the different characteristics of Wind and Cold pathogens. Based on this medication method, I believe patients with Kidney deficiency contracting exogenous pathogens should avoid the severe sweating of Mahuang Tang. Yu Jiayan's medical case record regarding a minor wind injury presenting with Daiyang syndrome deserves our attention. In short, all Six Channels have exterior syndromes. Cold pathogen injuring humans, besides directly striking the interior (such as Yangming Zhonghan syndrome), can injure the exterior of Taiyang, the exterior of Yangming, or the exterior of Shaoyin. Thus, saying Taiyang is the body's fence, and wind/cold injuring humans must start from Taiyang, the word "must" is too absolute. Checking against *Shanghan Lun* original text, this "must" is problematic. So, one can only say exogenous diseases often start from Taiyang, not that they all must start from Taiyang.
III. Taiyang Fire-Yin Disease — Wenbing
[Pulse & Symptoms] "Taiyang disease, fever and thirst, no aversion to cold, is Wenbing. If after sweating, body burns hot, named Fengwen. Fengwen disease, pulse yin and yang both floating, spontaneous sweating, heavy body, much sleepiness, breathing must snore, language difficult to exit." (6)
[Treatment Example] "After sweating, cannot use Guizhi Tang again. Sweating and panting, no great heat, may give Mahuang Xinggan Ganshi Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction)." (63)