丁未五月。乡人邢原晖病伤寒。寒热往来。心下郁闷。舌上白滑苔。予曰。舌上滑苔有数证。
有阴阳脉紧。鼻出涕者。有脏结而不可治者。有温瘴。丹田有热者。有阳明。胁下坚者。此证属
阳明。宜栀子汤吐之于前。小柴胡继于其后。数日汗解而愈。
睢阳张士美病伤寒七八日。口燥饮水而不咽入。俄而衄血。脉浮紧。身热。医者云伤寒。脉
浮紧。不发汗。因致衄血者。属麻黄汤。予曰。不可。古人虽云当汗不汗。热化为血。此证亦有
不可汗者。仲景云阳明病。口燥。但欲饮水而不咽者。必发衄。衄家不可发汗。发汗则额上陷。
不得眠。不能 。此只可用犀角汤。地黄汤。若当时行麻黄。必额上陷。直视不眠也。
董齐贤病伤寒数日。两胁挟脐。痛不可忍。或作奔豚治。予视之曰非也。少阳胆经。循胁入
耳。邪在此经。故病心烦。喜呕。渴。往来寒热。默不能食。胸胁满闷。少阳证也。始太阳传入
此经。故有是证。仲景云太阳病不解。传入少阳。胁下满干呕者。小柴胡汤主之。三投而痛止。
续得汗解。
友人孔彦辅病伤寒。身大热。头痛。自汗。恶热。阳明证也。此公不慎将理。病未除。当风
取凉以自快。越半月。寒热大交作。予再视之。则为坏病温疟矣。仲景云若十三日以上。更感异
气。变为他病者。当依旧坏病证而治之。若脉阴阳俱盛。重感于寒。变成温疟。脉之变证。方治
如法。乃小柴胡汤之类。加桂枝。治之。愈。
论曰。往来尝见一士人施疟方。以榜睢阳市肆。柴胡白虎之类也。俗人不问是何疟证。例用
前方。往往反变大疾。呜呼。将欲济人。反致损人。岂理也哉。予尝谓疟证最多。有暑疟。食疟。
脾寒疟。手足三阴三阳皆有疟。脾肺肾肝心胃亦有疟。各各不同。安得一概与柴胡白虎汤耶。误
治尚可拟议。惟脾寒中暑二证。若水火不相将。素问曰夏伤于暑。秋为 疟。又曰夏暑汗不出者。
秋成风疟。始因伏暑。得秋气乃发。故先热后寒。或热多寒少。头目昏痛。虚则发战。汗出一时
而止。盖心恶暑气。心为君。心不受邪。而心包络痰涎所聚。暑伏于涎中。岂比脾寒而浓朴草果
所能驱温疟。而柴胡黄芩所能止也。非砒 脑麝之属不能入。故暑疟脾寒患者多。而医者不识。妄投以寒药。真气先受
病。所以连绵不已也。予尝精究疟证一病。须详审谛当。然后行药。十治十中无有失者。众人以疟为难疗。予独以为易
治。要在别其证类。识其先后耳。因论温疟言及此。亦欲使患者知药不可妄投也。素问疟论甚详。当精观之。
丁未年五月。同乡人邢原晖患伤寒。出现寒热往来的症状，心下部感到郁闷。舌面上有白色的滑腻苔。我说：舌面出现滑腻苔有多种证候。有的是阴阳脉象均紧，且流鼻涕的；有的是脏结证且无法治疗的；有的是温疟，丹田有热的；有的是阳明病，胁下坚硬的。此患者的证候属于阳明病，适宜先用栀子汤催吐，随后用小柴胡汤调理。数日后通过发汗而痊愈。
睢阳人张士美患伤寒七八天。口干燥想喝水但水咽不下去。不久后流鼻血。脉象浮紧，身体发热。医生说这是伤寒，脉象浮紧，如果不发汗，导致流鼻血的，应当用麻黄汤。我说：不可以。古人虽然说过当发汗而未发汗，热邪化为血，此证也有不可发汗的情况。张仲景说：阳明病，口干燥，只想喝水却咽不下的，一定会流鼻血。经常流鼻血的人不可发汗，发汗则会导致额头凹陷，无法入睡，不能视物（注：原文“不能 ”处似缺字，结合上下文及《伤寒论》常作“直视”或类似描述，此处依文意译为不能视物/神志异常）。此证只可用犀角汤、地黄汤。如果当时误用麻黄汤发汗，必然导致额头凹陷，直视不眠。
董齐贤患伤寒几天。两胁夹着肚脐部位，疼痛难忍。有人按奔豚病治疗。我诊察后说：不对。少阳胆经，循行于胁部进入耳中。邪气在此经，所以病人心烦，喜欢呕吐，口渴，寒热往来，沉默不想吃东西，胸胁满闷。这是少阳证的特征。起初是太阳病传入此经，所以有此证候。张仲景说：太阳病不解，传入少阳，胁下满闷干呕的，主用小柴胡汤。服用三剂后疼痛停止，接着出汗而解。
友人孔彦辅患伤寒。身体高热，头痛，自汗，怕热。这是阳明证。这位先生不慎调养，病未除，对着风取凉以求爽快。过了半个月，寒热剧烈交替发作。我再诊察时，已经变成了坏病温疟了。张仲景说：如果十三日以上，又感受异气，变成其他病的，应当依旧按照坏病证候来治疗。如果脉象寸关尺三部都盛大，再次感寒，变成温疟。脉象变化的证候，治疗方法如法度所示，乃是小柴胡汤之类，加上桂枝，进行治疗。痊愈。
评论说：曾经见过一位读书人张贴疟疾方在睢阳市场的店铺里，多是柴胡、白虎汤之类的。世俗之人不问是什么类型的疟疾，一律使用前面的方子，往往反而使病情加重变成大病。唉！想要救人，反而伤害人，这符合道理吗？我曾经说疟疾病症最多，有暑疟、食疟、脾寒疟等。手足三阴三阳经都有疟疾，脾肺肾肝心胃也都有疟疾。各不相同，怎么能一概用柴胡汤和白虎汤呢？误治还可以商量，只有脾寒和中暑两种证候，如同水火不相容。《素问》说：夏天伤于暑气，秋天变为疟疾。又说：夏天暑热不出汗的，秋天形成风疟。开始是因为伏暑，得到秋气才发作。所以先热后寒，或者热多寒少，头目昏痛，虚则发抖，出汗一时停止。因为心厌恶暑气，心为君主之官，心不受邪，而心包络痰涎聚集，暑气潜伏在痰涎中，哪里比得上脾寒可以用浓朴、草果所驱除的温疟，以及柴胡、黄芩所能止住的？非砒霜、冰片、麝香之类的药物不能进入。所以暑疟和脾寒患者多，而医生不认识，妄投寒药，真气先受病，所以连绵不断。我曾经精研疟疾这一种病，必须详细审慎，然后用药，十次治疗十次有效没有失误的。众人认为疟疾难治，我却认为容易治，关键在于辨别其证候类别，识别其先后顺序罢了。因论述温疟而说到这些，也是想让患者知道药不可乱投。《素问·疟论》讲得很详细，应当精心研读。
In the month of May in the Dingwei year, Xing Yuanhui, a fellow townsman, contracted Shanghan (Cold Damage). He presented with alternating chills and fever (Wanglai Hanre), oppression in the epigastrium, and a white, slippery coating on the tongue. I said: A slippery coating on the tongue can indicate several patterns. There are cases where both Yin and Yang pulses are tight, accompanied by nasal discharge; there are Zang-Jie (Organ Binding) patterns that are incurable; there are Wen-Nue (Warm Malaria) with heat in the Dantian; and there are Yangming patterns with hardness under the hypochondrium. This case belongs to Yangming disease. It is appropriate to first induce vomiting with Zhizi Tang (Gardenia Decoction), followed by Xiaochaihu Tang (Minor Bupleurum Decoction). After a few days, he recovered through sweating.
Zhang Shimei from Suiyang contracted Shanghan for seven or eight days. His mouth was dry, and he desired water but could not swallow it. Soon after, he suffered an epistaxis (nosebleed). His pulse was floating and tight, and his body was hot. The physician stated this was Shanghan; according to the principle that "if one should sweat but does not, leading to epistaxis," it belongs to Mahuang Tang (Ephedra Decoction). I said: No. Although ancients stated that when sweating is indicated but not performed, heat transforms into blood, there are cases where sweating is contraindicated. Zhang Zhongjing stated: In Yangming disease, if the mouth is dry and the patient desires water but cannot swallow, epistaxis will inevitably occur. One who frequently suffers from epistaxis must not be induced to sweat. If sweating is forced, it leads to sunken forehead, insomnia, and inability to see clearly. This case should only be treated with Xijiao Tang (Rhinoceros Horn Decoction) and Dihuang Tang (Rehmannia Decoction). Had Mahuang been used at that time, it would certainly have resulted in sunken forehead, fixed gaze, and insomnia.
Dong Qixian contracted Shanghan for several days. Pain between the two hypochondria and around the umbilicus was unbearable. Someone attempted to treat it as Ben-Tun (Running Piglet). Upon examination, I said: Incorrect. The Shaoyang Gallbladder Meridian circulates along the hypochondrium and enters the ear. Pathogenic factors in this meridian cause mental irritability, frequent vomiting, thirst, alternating chills and fever, silence with loss of appetite, and fullness and oppression in the chest and hypochondrium. These are Shaoyang syndrome characteristics. Initially, the Taiyang pattern transmitted to this meridian, hence these symptoms. Zhang Zhongjing stated: If Taiyang disease is unresolved and transmits to Shaoyang, presenting with hypochondriac fullness and dry retching, Xiaochaihu Tang (Minor Bupleurum Decoction) is the primary formula. After three doses, the pain ceased, and subsequent sweating led to resolution.
My friend Kong Yanfu contracted Shanghan. He had high fever, headache, spontaneous sweating, and aversion to heat. This is a Yangming syndrome. This gentleman neglected proper care; while the illness remained, he exposed himself to wind to cool off for comfort. Half a month later, chills and fever occurred violently and alternately. Upon re-examination, it had transformed into a Huai-Bing (Damaged Disease) known as Wen-Nue (Warm Malaria). Zhang Zhongjing stated: If more than thirteen days pass and one contracts different pathogenic factors, transforming into another disease, it should be treated according to the damaged disease patterns. If the pulse is vigorous in all positions (Yin and Yang), and one contracts cold again, transforming into Warm Malaria, the treatment follows standard methods, such as Xiaochaihu Tang (Minor Bupleurum Decoction) modified with Guizhi (Cinnamon Twig). He recovered.
Commentary: I once saw a scholar posting malaria prescriptions in shops in Suiyang market, mostly involving Chaihu (Bupleurum) and Baihu Tang (White Tiger Decoction). Laypeople, without distinguishing the type of malaria, routinely used these formulas, often worsening the condition into severe illness. Alas! Intending to save people, yet harming them—is this reasonable? I have often said that malaria encompasses many types: Summerheat Malaria, Food Stagnation Malaria, Spleen-Cold Malaria, etc. Malaria can affect the Three Yin and Three Yang meridians of the hands and feet, and also the Spleen, Lung, Kidney, Liver, Heart, and Stomach. They differ significantly; how can one uniformly apply Chaihu Tang and Baihu Tang? Misdiagnosis allows for discussion, but Spleen-Cold and Summerheat syndromes are particularly critical, akin to fire and water clashing. The Suwen states: "Summer injury by summerheat leads to malaria in autumn." It also says: "If summer heat causes no sweating, Wind-Malaria forms in autumn." Initially, due to latent summerheat, it manifests upon receiving autumn Qi. Thus, it presents with heat preceding chills, or more heat than chills, dizziness, head pain, and trembling when deficient, stopping after a bout of sweating. The Heart dislikes summerheat. As the Sovereign Organ, the Heart does not directly accept pathogens; rather, phlegm-fluids accumulate in the Pericardium. Summerheat lies hidden within these fluids. How can this be dispelled by the acrid-warm herbs like Houpo (Magnolia Bark) and Caoguo (Tsaoko Fruit) used for Spleen-Cold, or stopped by Chaihu (Bupleurum) and Huangqin (Scutellaria Root) for Warm Malaria? Such cases require substances like Pishuang (Arsenic Trioxide), Bingpian (Borneol), and Shexiang (Musk) to penetrate. Therefore, patients with Summerheat Malaria and Spleen-Cold are common, yet physicians fail to recognize them, recklessly administering cold medicines. The True Qi is injured first, causing the illness to linger. I have meticulously studied malaria; one must examine carefully before prescribing. My success rate has been ten out of ten. While others find malaria difficult to treat, I find it easy, provided one distinguishes the syndrome categories and understands their sequence. I mention this in the context of Warm Malaria to warn patients against reckless medication. The Suwen's chapter on Malaria is detailed; it should be studied diligently.