Supplementary Notes to the Book of Living Persons with Class Evidence Volume 3, (活人書補註類證三卷).3-1

 

此一卷, 論表裏. 治傷寒, 須識表裏, 表裏不分, 汗下差誤. 古人所以云, 桂枝下咽, 陽盛則斃, 承氣入胃, 陰盛以亡.

This third volume discusses the differentiation of external and internal patterns. When treating cold damage, it is essential to distinguish between external and internal patterns and not induce sweating or precipitate without differentiation. Therefore, the ancients said, "If one takes Gui Zhi Tang (Cinnamon Twig Decoction) when yang is excessive, one will die. If one takes Cheng Qi Tang (Qi-Coordinating Decoction) when yin is excessive, one will collapse."

 

傷寒有表證, 有裏證, 有半在表半在裏, 有表裏兩證俱見, 有無表裏證. 

In the case of shang han disease [cold damage], there are exterior pattern, interior pattern, patterns that are partially exterior and partially interior, patterns that manifest both exterior and interior symptoms, and patterns that have neither exterior nor interior manifestations. 

在表宜汗, 在裏宜下, 半在表半在裏宜和解, 表裏俱見隨證滲泄, 無表裏證用大柴胡湯 下之. 又四逆湯證, 有先溫裏乃發表, 桂枝湯證, 有先解表乃攻裏.

For exterior pattern, sweating is appropriate, while for interior pattern, precipitating is appropriate. For pattern that are partially exterior and partially interior, harmonization is appropriate. If both exterior and interior symptoms manifest, treatment should be based on the specific pattern and may involve inducing sweating or promoting bowel movements depending on the symptoms. If there are no exterior or interior manifestations, then Da Chai Hu Tang (Major Bupleurum Decoction) is used for precipitating.

Similarly to Si Ni Tang (Counterflow Cold Decoction), some focus on warming the interior before inducing sweating in the exterior, while others, such as Cinnamon Twig Decoction (Gui Zhi Tang), focus on releasing the exterior before attacking the interior.

仲景云, 下利淸穀, 身體疼痛, 急當救裏, 身體疼痛, 淸便自調, 急當救表, 如響應桴, 間不用木節. 非特此也.

According to Zhang Zhongjing, if there is clear-food diarrhea and generalized pain, it is urgent to treat the interior. However, if there is generalized pain, and the excretions become regulated, it is appropriate to focus on treating the exterior. It is crucial to be vigilant and act quickly, like striking a drum, as even a moment of carelessness could result in a missed opportunity for effective treatment.

均是發熱, 身熱不渴, 爲表有熱, 小柴胡加桂主之. 厥而脈滑, 爲表有熱, 白虎加人蔘湯主之. 黃帝所謂, 發表不遠熱, 攻裏不遠寒也.

In cases of heat effusion:, 

when there is generalized heat effusion but no thirsty, it indicates a condition of exterior heat, which can be treated with Xiao Chai Hu Tang (Minor Bupleurum Decoction) plus Gui Zhi (cinnamon twig). If the limbs are cold and the pulse is slippery, it indicates a condition of interior heat, which can be treated with Bai Hu Jia Ren Shen Tang (White Tiger Decoction Plus Ginseng). As the Huangdi Neijing says, "To effuse the exterior, close to the heat; in treating diseases of the interior, close to the the cold."

 

均是水氣, 乾嘔微利, 發熱而欬, 爲表有水, 小靑龍加蕘花主之. 身體凉, 表證罷, 欬而脅下痛, 爲裏有水氣, 十棗湯主之.

In cases of water-qi:

If there are dry retching, slight diarrhea, heat effusion, and coughing, it indicates the presence of water in the body. This can be treated with Minor Green-Blue Dragon Decoction (Xiao Qing Long Tang) plus Yao Hua. If the body is cold and there are no external symptoms, but there is coughing and pain under the ribs, it indicates the presence of internal water. This can be treated with Shi Zao Tang (Ten Jujube Decoction).

均是惡寒, 發熱而惡寒者, 發於陽也, 麻黃桂枝小柴胡主之. 無麻黃桂枝小柴胡湯, 只有柴胡桂枝湯., 無熱而惡寒者, 發於陰也, 附子四逆湯主之.

In casese of aversion to cold;

Having heat effusion and aversion to cold are symptoms of a disease that arises from Yang. This condition can be treated with herbal decoctions such as Ma Huang Tang (Ephedra Decoction), Gui Zhi Tang (Cinnamon Twig Decoction), and Xiao Chai Hu Tang (Minor Bupleurum Decoction). If these decoctions are not available, Chai Hu Gui Zhi Tang (Bupleurum and Cinnamon Twig Decoction) can be used instead. On the other hand, if there is aversion to cold without heat effusion, this indicates a disease that arises from Yin. Such condition can be treated with Fu Zi Si Ni Tang (Aconite Counterflow Cold Decoction).

均是身體痛, 脈浮發熱, 頭痛, 身體痛者爲表未解, 麻黃湯主之. 脈沈自利身體痛者爲裏不和, 四逆湯主之.

In cases of generalized pain ;

If the pulse is floating and there is heat effusion, headache, and body aches, this indicates that the exterior symptoms have not been resolved. This can be treated with Ma Huang Tang (Ephedra Decoction). If the pulse is sunken, there is spontaneous diarrhea and generalized pain, this indicates disharmony in the interior. This can be treated with Si Ni Tang (Counterflow Cold Decoction).

 

以此觀之, 仲景之於表裏亦詳矣, 學者宜深究之. 雖然, 傷寒六七日, 目中不了了, 無表裏證, 脈雖浮, 亦有下之者. 少陰病二三日, 無陽證, 亦有發汗者, 非表裏之所能拘, 又不可不知也.

Thus, Zhongjing was also detailed in his understanding of the exterior and interior symptoms, and those who wish to learn should study it deeply. However, in cases where six or seven days have passed since the onset of Shanghan disease and there are no clear indications of exterior or interior symptoms, but the pulse is still floating and purgation is necessary, or in cases of Shaoyin disease where there is no evidence of Yang pattern but sweating is necessary after two or three days, it may not be necessary to excessively focus on exterior and interior symptoms, but one should still be aware of them.