【纲】仲景曰。太阳病。发热而渴。不恶寒者。为温病。
【目】李杲曰。冬伤于寒者。冬行秋令也。当寒而温。火胜而水亏矣。水既已亏。则所胜妄行。
土有余也。所生受病。木不
足也。所不胜者侮之。火太过也。火土合德。湿热相助。故为温病。使民腠理开泄。少阴不藏。惟
房室劳伤辛苦之人得之。若此者。皆为温病。所以不病于冬而病于春者。以寒水居卯之分。方得其
权。大寒之令。复行于春。腠理开泄。少阴不藏。房窒劳伤辛苦之人。阳气泄于外。肾水亏于内。
当春之月。时强木长。无以滋生化之源。故为温病耳。故君子周密于冬。少阴得藏于内。腠理以闭拒
之。虽有大风苛毒。莫之能害。何温病之有。人肖天地而生。冬时阳气俱伏于地之下。人之阳气。
俱藏于肾之中。人能不扰乎肾。则六阳安静于内。内既得安。邪无自入矣。此伤寒之源。非天伤人。
乃人自伤也。伤于寒者。皆为病热。为伤寒乃热病之总称。故曰。伤寒为热邪。明矣。六阴用事于
冬。阳气在内。周密闭藏可矣。反劳动之而泄于外。时热已伤于水矣。至春之时。木当发生。气已外泄。
孰为鼓舞。肾水内竭。孰为滋养。此两者同为生化之源。源既已绝。水何赖以生乎。身之所存者。
独无热也。时强木长。故为温病矣。
王履曰。有病因。有病名。有病形。辨其因。正其名。察其形。三者俱当。庶可以言治。吾试
即伤寒温病热病而说之。如伤寒。以病因而为病名者也。温病热病。以天时与病形而为病名者也。
二者皆起于感寒。或者通以伤寒称之。通以伤寒称者。原其因之同耳。用药则不可一例施也。夫感
寒于冬。即发于寒冷之时。而寒邪在表。闭其腠理。故非辛甘温之剂。不足以散之。此仲景桂枝麻
黄等汤所必用也。温病热病。后发于暄热之时。怫热自内达外。郁其腠理。无寒在表。故非辛凉或
苦寒或酸苦之剂。不足以解之。此后人所制双解散、大黄汤、千金汤、防风通圣散之类。兼治内外
者之所可用也。夫即病之伤寒。有恶风恶寒之症者。风寒在表。而表气受伤故也。后发之温病热病。
有恶风恶寒之症者。重有风寒新中。而表气亦受伤故也。若无新中之风寒。则无恶风恶寒之症。
故仲景曰。太阳病。发热而渴。不恶寒者。为温病。温病如此。则知热病亦如此。是则不渴而恶寒
者。非温热病矣。然或有不因新中风寒。亦见恶风恶寒之症者。盖病患表气本虚。热达于表。又重
伤表气。故不禁风寒。非伤寒恶风恶寒也。但卫虚则恶风。营虚则恶寒耳。且
温病热病。亦有先见表症而后传里者。盖怫热自内达外。热郁腠理。不得外泄。遂复还里而成可攻
之症。非如伤寒从表而始也。或者不悟此理。乃于春夏温热病而求浮紧之脉。殊不知紧为寒脉。有
寒邪则见之。无寒邪则不见也。其温热病或见脉紧。乃重感不正之暴寒。与内伤过度之冷食也。岂
其本然哉。又或不识脉形。但见弦便呼为紧。断为寒而妄治。盖脉之盛而有力者。每每兼弦。岂可
错认为紧而断为寒。夫温病热病之脉。多在肌肉之分而不甚浮。且右手反盛于左手者。良由怫热在
内也。或左手盛或浮者。必有重感之风寒。否则非温病热病。是暴感风寒之病耳。凡温病热病。若
无重感。表症虽间见。而里病为多。故少有不渴者。当治里热为主。而兼解表。亦有治里而表自解
者。每见医治温热病。虽误攻其里。亦无大害。误发其表。变不可言。此足明其热之自内达外矣。
间有误攻里而致大害者。乃春夏暴寒所中之疫症。纯在表未入于里者。不可与温热病同论。夫惟世以
温热二病。混称伤寒。故每执寒字以求浮紧之脉。用温热之药。若此者因名乱实。戕人之生。名其
可不定乎。又方书多言四时伤寒。夫秋冬之伤寒。真伤寒也。春夏之伤寒。寒疫也。与温病热病。
自是两涂。岂可同治。虽然。伤寒与温热病。其攻里之法。若果是以寒除热。固不必求异。其发表之
法。断不可不异也。况伤寒之直伤阴经。与太阳虽伤。不及郁热。即伤阴经与寒症。而当温者。又
与寒热病大不同。其可妄治乎。乃知一不知二。谓仲景发表药今不可用。攻里药乃可用。呜呼。其可
用不可用之理。果何在哉。若能辨其因。正其名。察其形。治法有不当者乎。彼时行不正之气所作。
及重感异气而变者。则又当观其何时何气。参酌伤寒温热病之法。损益而治之。尤不可例以仲景
即病伤寒药通治也。
张云岐曰。伤寒汗下不愈而过经。其症尚在而不除者。亦温病也。经曰。温病之脉行在里经。
不知何经之动。随其经之所在而取之。如太阳病汗下后过经不愈。诊得尺寸俱浮者。太阳温病也。
如身热目疼汗下后过经不愈。诊得尺寸俱大者。阳明温病也。如胸胁痛汗下后过经不愈。诊得尺寸
俱弦者。少阳温病也。如腹满嗌干过经不愈。诊得尺
寸俱沉细者。太阴温病也。如口燥舌干而渴过经不愈。诊得尺寸俱沉者。少阴温病也。如烦满囊缩过
经不愈。诊得尺寸俱微缓者。厥阴温病也。随其经取之。随其症治之。如发斑。乃温毒也。
庞安常曰。温与热有轻重之分。故仲景云。若遇温气。则为温病。更遇温热。则为温毒。热比
温为尤重也。若但冬伤于寒。至春而发。不感异气。名曰温病。此病之稍轻者也。温病未已。更遇
温气。变为温病。亦可名曰温病。此病之稍重者也。伤寒例以再遇温气。名曰温疫。又有不应冬月
伤寒至春为温病者。此特感春温之气。可名曰春温。如冬之伤寒。秋之伤湿。夏之伤暑相同也。以
此观之。是春之病温有三种。有冬伤于寒。至春发为温病者。有温病未已。更遇温气而为温病。与
重感温气。相杂而为温病者。有不因冬伤于寒。不因更遇温气。只于春时感春温之气而病者。若此
三者。皆可名为温病。不必各立名色。只要知其病源之所以不同也。
李 曰。温病者。春分后。有太阳病。发热咳嗽。身痛口渴。不恶寒。其脉弦数不紧。右手反
盛于左手。怫热在内故也。或散诸经。各随其经取之。热病即与温病同。但发在夏至后。脉洪数。
热渴更甚耳。虽因冬时受寒。伏于肌骨。然人身随天气化。春分则寒变为温。夏至则寒变为热。所
以伤寒恶寒而不渴。温热不恶寒而渴。不恶寒则病非外来。渴则自内达表。热郁腠理。不得外泄。
乃复还里。终是里多表少。间有恶寒者。乃冒非时暴寒。或温热将发。又受暴寒。非冬症之甚也。
当治热为主。而解肌次之。亦有专治里而表自解者。误下犹可。误汗则变为呕哕狂斑而死。盖温热
在经而不在表。安可例用汗法。惟兼暴寒者。乃可表里双解。亦不可用冬时辛热之药。春温表症。天温。升麻葛根汤。
天寒。柴胡桂枝汤。太阳合少阳。升麻葛根汤合小柴胡汤。半
表里。小柴胡汤。里症。大柴胡汤。重者。一时表里俱发。防风通圣散。表里俱热。大便利者。柴
苓汤加山栀、木通。虚烦。竹叶石膏汤。变杂症者。治同伤寒。夏热表症。太阳。九味羌活汤。汗后烦渴。脉洪大。背
恶寒者。白虎加人参汤。益元散。里症。
大柴胡汤。重者。一时表里盛发。双解散。热病脉细无力。
足冷已得汗而躁甚者。此阴脉之极也。必死。又有冬温者。冬有非时之暖。名曰冬温。与春秋暴寒
暴温。总谓之时行气。与伤寒相似。但脉不浮耳。治法大同。春温表症。葳蕤汤、九味羌活汤。入
里加大黄。重者。双解散。轻者。加减调中汤治之。
赵献可曰。夫伤寒二字。盖冬时严寒而成杀厉之气。触冒之而实时病者。名正伤寒。不即发者。
寒毒藏于肌肤。至春变为温病。至夏变为热病。热病即暑病。热极似重于温也。然为温。即不得复
言寒。不恶寒而渴者是也。此仲景之文也。麻黄桂枝为即病之伤寒设。无与温热。受病之源虽同。
所发之时则异。仲景必别有方治。皆已遗失。是以至今未明。刘守真谓欲用麻黄、桂枝。必加凉药
于其中。以免发黄。张子和六神通解散。以石膏寒药中加麻黄、苍术。皆非也。盖麻桂辛热。冬月
所宜。不宜用于春夏。陶氏欲以九味羌活汤。谓一方可代三方。亦非也。羌活汤。易老所制。乃治
感四时不正之气。如春宜温而反寒。夏宜热而反温。秋宜凉而反热。冬宜寒而反温。又有春夏秋三
时为暴寒所折。虽有恶寒发热之症。不若冬时肃杀之气为甚。故不必麻黄散寒。惟用辛凉通内外而
解之。况此方须按六经加减法。不可全用也。不若逍遥散为尤妙。真可一方代三方也。且余有一法。
请申之。经曰。不恶寒而渴者。为温病。不恶寒。则知表无寒邪。曰渴。则知肾水干枯。盖其人
素有火。冬时冒寒。虽伤而不甚。惟有火在。内寒亦不能深入。所以不即发。而寒气藏伏于肌肤。
自冬至三四月之久。火为寒郁。于中亦久。将肾水熬煎枯竭。至此时强木旺。无以滋润发生。故发
热而渴。非有所感冒也。海藏谓新邪换出旧邪。非也。若复有所感。表又当恶寒矣。余以六味料滋
其水。以柴胡辛凉舒其木。治人皆随手而应。余又因此推展之。凡冬时伤寒者。亦是郁火症。若其
人无火。则为直中矣。惟其有火。故由皮毛而肌肉。而脏腑。今人皆曰寒邪传里。寒变为热。既曰寒邪。
何故入内而反为热。又何为而能热耶。不知即是本身中之火。为寒所郁而不得泄。日久则纯热而无
寒矣。所以用三黄解毒。解其火也。升麻葛根。即火郁发之也。三承气。即土郁夺之也。小柴胡。则木郁达之也。此理
甚简而易。只多了传经六经诸语支离。凡杂病
有发热者。皆有头疼项强。目痛鼻干。胁痛口苦等症。何必拘为伤寒。局伤寒方以治之耶。余于冬
月正伤寒。独麻桂二方作寒郁治。其余不恶寒者俱作郁火治。此不佞之创论也。闻者皆骇然吐舌。
及阅虞天民正传云。有至人传曰。传经伤寒是郁病。
余窃喜以为先得我心。又考内经云。人伤于寒而传为热。何也。寒气外凝内郁之理。腠理坚致。
元府秘密。则气不宣通。湿气内结。中外相薄。寒盛热生。故人伤于寒。转而为热。汗之则愈。
则外凝内郁之理可知。观此而余以伤寒为郁火者。不为无据。故特着此郁论一篇。
柯琴曰。温病内外皆热。所以别于中风伤寒之恶寒发热也。此条不是发明内经冬伤于寒春必
病温之义。乃概言太阳温病之症如此。若以春温释之。失仲景之旨矣。夫太阳一经。四时俱能受病。
不必于冬。人人温病。不必因于伤寒。且四时俱能温病。不必于春。推而广之。则六经俱有温病。
非独太阳一经也。
鳌按。诸家都以温病为春温。独柯氏谓概言太阳温病之症。夫以本条言之。首冠太阳病三字。
其为太阳之症。固无疑矣。然春温之病。亦多有发于太阳者。故俱存其说。学人神而明之。变而通
之可也。
赵氏医贯一书。语多偏僻。惟温病论中火郁一篇。颇为有旨。然其诋守真子和节庵三家。仍不免
偏执。且其以六味加柴胡。谓为治温妙法。尤属大谬。若以此治温病。恐十毙六七。余取其火郁之
说。又恐人误认其语之皆是。故特表之于此。
【纲】张仲景说：太阳病（太阳经受邪所致的病证），如果表现为发热且口渴，不恶寒（不怕冷）的，属于温病（由温热之邪引起的疾病）。
【目】李杲说：冬季感受寒邪的人，是因为冬季行秋令（气候反常温暖）。本该寒冷却温暖，导致火气过盛而肾水亏虚。肾水既然已经亏虚，那么被肾水克制的心火就会妄行。心火妄行导致脾土有余（功能亢进或病理积聚）。脾土有余会损害其所生的肺金（子盗母气或五行相乘）。肝木不足，则受到肺金的反侮（五行相克关系异常，弱者被强者反向克制）。心火太过，火与土结合其德性，湿热相互助长，因此形成温病。这使得民众腠理（皮肤毛孔及皮下组织间隙）开泄，少阴肾气不能闭藏。只有那些因房事过度、劳累辛苦的人才会得此病。像这样的情况，都称为温病。之所以不在冬季发病而在春季发病，是因为在卯月（农历二月，对应春分前后），寒水之气当权，大寒的命令重新在春季施行。此时腠理开泄，少阴肾气不藏，房劳和辛苦之人，阳气外泄于体表，肾水亏虚于体内。正值春季，时令使肝木旺盛生长，但体内缺乏滋生化源的物质基础，所以发生温病。因此，君子在冬季应当周密保养，使少阴肾气得以在内闭藏，腠理闭合以抵御外邪。即使有大风苛毒，也不能伤害人体，哪里会有温病呢？人禀受天地之气而生，冬季时阳气都潜伏在地之下，人的阳气也都藏在肾脏之中。人如果不扰动肾脏，那么六阳经的气机就在内部保持安静。内部既已安宁，邪气就没有入侵的途径了。这就是伤寒的根源，不是天灾伤人，而是人自己伤害自己。感受寒邪的人，都会转化为热病。所谓“伤寒”，其实是热病的总称。所以说，伤寒就是热邪，这是很明显的。冬季是六阴经主事的时候，阳气在体内，周密闭藏是可以的。如果反而进行劳动使其耗散于体外，时令的热气就已经损伤了肾水。到了春季，木气应当生发，但气机已经外泄，谁来鼓舞生机？肾水在内枯竭，谁来滋养身体？这两者都是化生万物的本源，本源既然断绝，水又依靠什么来生成呢？身体所存留的，只剩下热邪罢了。时令木气旺盛，所以发生温病。
王履说：有病因，有病名，有病状表现。辨别其病因，纠正其病名，观察其病状，这三方面都恰当，才可以谈论治疗。我试着就伤寒、温病、热病来说明它们。比如伤寒，是根据病因来作为病名的。温病和热病，是根据天时季节和病状表现来作为病名的。这两者都起因于感受寒邪，有人通称为伤寒，通称为伤寒的原因，只是追溯其病因相同罢了。但在用药上就不能一概而论地施用。如果在冬季感受寒邪，立即在寒冷之时发作，寒邪在体表，闭塞腠理，所以非用辛甘温的药物不足以发散它。这就是张仲景必须使用桂枝汤、麻黄汤等方剂的原因。温病和热病，是在温暖炎热之时后发的，郁热从内达外，郁滞腠理，体表没有寒邪，所以非用辛凉或苦寒或酸苦的药物不足以解除它。这是后人创制的双解散、大黄汤、千金汤、防风通圣散等能够兼治表里疾病的方剂可以使用的情况。即病（感寒后立即发病）的伤寒，有怕风怕冷的症状，是因为风寒在体表，导致表气受伤。后发的温病和热病，如果有怕风怕冷的症状，是因为再次新近感受了风寒，导致表气也受伤。如果没有新近感受的风寒，就不会有怕风怕冷的症状。所以张仲景说：“太阳病，发热而渴，不恶寒者，为温病。”温病是这样，那么热病也是如此。这样看来，不口渴且怕冷的，就不是温热病了。然而，有的人并没有新近感受风寒，也出现怕风怕冷的症状，这是因为患者表气本来虚弱，热气达于体表，又重伤表气，所以禁不起风寒的侵袭，这并不是伤寒的怕风怕冷。只是卫气虚则怕风，营气虚则怕冷罢了。况且温病和热病，也有先出现表症而后传入里的。这是因为郁热从内达外，热邪郁滞腠理，不能向外宣泄，于是又返回到体内形成可以攻下的里实症。这不像伤寒那样从体表开始。有人不明白这个道理，却在春夏季的温热病中寻求浮紧脉象，却不知道紧脉是寒脉，有寒邪才会出现，没有寒邪就不会出现。温热病如果出现紧脉，那是再次感受了不正的暴寒，以及内伤过度食用冷食所致。难道是本然的脉象吗？又有人不认识脉形，只要见到弦脉就称之为紧脉，判断为寒证而胡乱治疗。脉象盛大有力的，往往兼带弦象，怎么能错认为紧脉而判断为寒证呢？温病和热病的脉象，多在肌肉之分而不甚浮，而且右手脉反而比左手脉盛，确实是由于郁热在体内的缘故。如果左手脉盛或浮，必定有再次感受的风寒，否则就不是温病热病，而是暴感风寒的疾病罢了。凡是温病热病，如果没有再次感受风寒，虽然偶尔见表症，但里病居多，所以很少有口渴不出现的。应当以治疗里热为主，兼以解表。也有只治疗里热而表症自然解除的情况。常见医治温热病，即使误用攻下法治疗里证，也没有大害；但如果误用发汗法治疗表证，变证不可胜言。这足以证明热邪是从内部达于体表的。间或有误用攻下法而导致大害的，那是春夏季暴寒所中的疫病，病邪纯在体表未入于里的情况，不可以与温热病混为一谈。因为世人将温热两种病混称为伤寒，所以常常执着于“寒”字去求索浮紧脉象，使用温热性质的药物。像这种情况，是因名称混乱了实质，残害人的生命，病名怎么可以不确定呢？另外医书中多讲四时伤寒。秋冬的伤寒，是真正的伤寒；春夏的伤寒，是寒疫。这与温病热病，自然是两条不同的路径，怎么可以同样治疗呢？虽然如此，伤寒与温热病，其攻里的方法，如果确实是用寒药除热，固然不必强求不同。但其发表的方法，绝对不可以不相同。况且伤寒直接损伤阴经，与太阳经虽受伤但未导致郁热的情况，即使是损伤阴经与寒症，需要温补的，又与寒热病大不相同。怎么可以胡乱治疗呢？由此可知，只知道一点不知道两点，认为仲景的发表药现在不可用，攻里药才可用。唉，可用与不可用的道理，究竟在哪里呢？如果能辨别其病因，纠正其病名，观察其病状，治疗法会有不当的吗？那些由时行不正之气所作祟，以及再次感受异气而发生变化的，则应当观察是何时、何种气机，参照伤寒和温热病的方法，增减损益来进行治疗。尤其不可以简单地用张仲景即病伤寒的药来通治。
张云岐说：伤寒经过发汗、攻下治疗后仍未痊愈，且病邪传过一经（过经），症状仍在且不消除的，也是温病。医经说：温病的脉象运行在里经，不知道是哪一经发动，随着该经所在的位置来诊察和治疗。比如太阳病经过汗下后，过经不愈，诊得寸关尺三部脉俱浮的，是太阳温病。如果身热、目痛，汗下后过经不愈，诊得寸关尺三部脉俱大的，是阳明温病。如果胸胁痛，汗下后过经不愈，诊得寸关尺三部脉俱弦的，是少阳温病。如果腹满、咽干，过经不愈，诊得寸关尺三部脉俱沉细的，是太阴温病。如果口燥、舌干而渴，过经不愈，诊得寸关尺三部脉俱沉的，是少阴温病。如果烦闷、囊缩（阴囊收缩），过经不愈，诊得寸关尺三部脉俱微缓的，是厥阴温病。随着所属的经脉来取穴治疗，随着症状来施治。如果出现发斑，那是温毒。
庞安常说：温与热有轻重的区别，所以张仲景说：如果遇到温气，就称为温病；如果再遇到温热之气，就称为温毒。热比温更加严重。如果只是冬季感受寒邪，到春季才发作，没有感受其他异气，名叫温病。这是病情较轻的。温病未愈，再遇到温气，转变为温病，也可以名叫温病。这是病情稍重的。《伤寒例》中以再次遇到温气，名叫温疫。又有不应在冬季伤寒至春季才发为温病的情况，这是特别感受了春季的温气，可以名叫春温。就像冬季的伤寒、秋季的伤湿、夏季的伤暑一样。以此看来，春季的病温有三种：有冬季感受寒邪，到春季发为温病的；有温病未愈，再遇到温气而为温病的；有再次感受温气，相互夹杂而为温病的；有不因冬季感受寒邪，不因再次遇到温气，只在春季感受春季温气而患病的。像这三种情况，都可以名为温病，不必各自设立不同的名称，只要知道其病源之所以不同即可。
李梴说：温病，是在春分之后，出现太阳病，发热咳嗽，身体疼痛口渴，不恶寒，其脉弦数而不紧，右手脉反而盛于左手脉，这是因为郁热在体内的缘故。或者分散到各条经脉，各随其经取穴治疗。热病与温病相同，只是发生在夏至之后，脉象洪数，热渴更严重罢了。虽然是因为冬季受寒，伏匿于肌骨之间，然而人身随天气变化而变化，春分时寒气变为温气，夏至时寒气变为热气。所以伤寒怕冷而不渴，温热病不怕冷而渴。不怕冷说明病非外来，渴说明热自内达表。热邪郁滞腠理，不能向外宣泄，于是又返回到体内，终究是里热多而表证少。间或有怕冷的，那是冒犯了非时的暴寒，或者温热即将发作时，又受了暴寒，并不是冬季重症的表现。应当以治疗热邪为主，解肌次之。也有专治里热而表症自然解除的。误用攻下法还可以，误用发汗法则会导致呕吐、呃逆、狂乱、发斑而死。因为温热在经而在不在表，怎么可以例行使用发汗法呢？只有兼有暴寒的，才可以表里双解，也不可以使用冬季辛热的药物。春温的表症，天气温暖，用升麻葛根汤；天气寒冷，用柴胡桂枝汤。太阳合少阳，用升麻葛根汤合小柴胡汤。半表里，用小柴胡汤。里症，用大柴胡汤。重症，一时表里俱发，用防风通圣散。表里俱热，大便通利的，用柴苓汤加山栀、木通。虚烦，用竹叶石膏汤。变成杂症的，治疗同伤寒。夏热的表症，太阳经，用九味羌活汤。汗后烦渴，脉洪大，背部恶寒的，用白虎加人参汤、益元散。里症，用大柴胡汤。重症，一时表里盛发，用双解散。热病脉细无力，足冷，已经出汗但烦躁严重的，这是阴脉至极的表现，必死。又有冬温，冬季有非时的温暖，名叫冬温。与春秋的暴寒暴温，总称为时行气。与伤寒相似，但脉不浮。治疗方法大体相同。春温表症，用葳蕤汤、九味羌活汤。入里加大黄。重症，用双解散。轻症，用加减调中汤治疗。
赵献可说：所谓“伤寒”二字，大概是指冬季严寒形成的杀厉之气，触犯冒犯而即时发病的，名叫正伤寒。不立即发作的，寒毒藏于肌肤，到春季变为温病，到夏季变为热病。热病就是暑病，热极似乎比温病更重。然而既然是温，就不能再说寒，不怕冷而口渴的就是这类。这是张仲景的原文。麻黄、桂枝是为即病（感寒后立即发病）的伤寒设立的，与温热病无关。受病的源头虽然相同，但发作的时间则不同。张仲景一定有别的治疗方剂，都已经遗失了，所以至今不明。刘守真说想要用麻黄、桂枝，必须在其中加入凉药，以免发黄。张子和的六神通解散，在石膏等寒药中加入麻黄、苍术，都不对。因为麻黄、桂枝辛热，是冬季适宜的，不宜用于春夏。陶华想以九味羌活汤，说一方可以代替三方，也不对。羌活汤是易老（李东垣）所创制，乃是治疗感受四时不正之气，如春宜温而反寒，夏宜热而反温，秋宜凉而反热，冬宜寒而反温。又有春夏秋三时为暴寒所折，虽然有恶寒发热的症状，但不若冬季肃杀之气严重。所以不必用麻黄散寒，只用辛凉通内外而解之。况且此方须按六经加减法，不可全用。不如逍遥散更为精妙，真可一方代三方。况且我有一种方法，请陈述出来。医经说：不恶寒而渴者，为温病。不恶寒，就知道表无寒邪；曰渴，就知道肾水干枯。大概此人素来有火，冬季冒寒，虽然受伤但不严重，惟有火在，内寒也不能深入。所以不立即发作，而寒气藏伏于肌肤。自冬至三四月之久，火为寒所郁，在体内也很久，将肾水熬煎枯竭。到此时木气旺盛，无以滋润发生，所以发热而渴，并非有所感冒。海藏（张元素）说新邪换出旧邪，是不对的。如果复有所感，表又应当恶寒了。我用六味地黄丸料滋其水，以柴胡辛凉舒其木，治疗人都随手而应。我又因此推展之，凡冬季伤寒者，也是郁火症。如果其人没有火，则为直中（寒邪直中脏腑）。惟其有火，所以由皮毛而肌肉，而脏腑。今人都说寒邪传里，寒变为热。既然说是寒邪，为什么入内反而为热？又为什么能热呢？不知道即是本身中之火，为寒所郁而不得泄，日久则纯热而无寒了。所以用三黄解毒汤，是解其火；升麻葛根汤，即火郁发之也；三承气汤，即土郁夺之也；小柴胡汤，则木郁达之也。此理甚简而易懂，只是多了传经六经诸语支离破碎。凡杂病有发热者，都有头疼项强、目痛鼻干、胁痛口苦等症状，何必拘泥为伤寒，局限用伤寒方来治疗呢？我在冬季正伤寒，独独将麻黄、桂枝二方作为寒郁来治，其余不恶寒的都作为郁火来治。这是我的创论。听到的人都骇然吐舌。等到阅读虞天民的正传，说：有至人传曰：传经伤寒是郁病。我私下高兴以为先得我心。又考据《内经》说：人伤于寒而传为热，为什么呢？寒气外凝内郁的道理，腠理坚致，元府秘密，则气不宣通，湿气内结，中外相薄，寒盛热生。故人伤于寒，转而为热，汗之则愈。则外凝内郁的道理可知。观此而余以伤寒为郁火者，不为无据。故特着此郁论一篇。
柯琴说：温病内外皆热，所以区别于中风伤寒的恶寒发热。这一条不是发明《内经》“冬伤于寒春必病温”的意义，而是概言太阳温病的症状如此。如果用春温来解释，就失去了张仲景的本意了。夫太阳一经，四时都能受病，不必限于冬季。人人温病，不必因于伤寒。且四时都能温病，不必限于春季。推而广之，则六经都有温病，不仅仅太阳一经。
沈金鳌按：各家都把温病当作春温，唯独柯氏谓概言太阳温病的症状。以本条而言，首冠“太阳病”三字，其为太阳的症状，固然无疑了。然而春温的病，也多有的发于太阳的，所以都保存其说法。学人神而明之，变而通之就可以了。
赵献可的《医贯》一书，言语多偏僻，唯独温病论中的火郁一篇，颇为有旨趣。然而他诋毁刘守真、张子和、节庵三家，仍不免偏执。且他以六味地黄丸加柴胡，谓为治温妙法，尤属大谬。如果以此治温病，恐怕十毙六七。我取其火郁之说，又恐人误认其语之皆是，故特意表彰于此。
[General Principle] Zhang Zhongjing stated: In Taiyang disease (a syndrome caused by pathogenic factors affecting the Taiyang meridian), if the patient presents with fever and thirst, without aversion to cold, it is classified as Warm Disease (diseases caused by warm-heat pathogens).
[Commentary] Li Gao said: Those who were injured by cold in winter did so because winter followed the order of autumn. It should have been cold but was warm, leading to excessive Fire and deficient Water. Since Kidney Water has already been depleted, the element controlled by Water (Heart Fire) acts recklessly. This excess in Earth (Spleen/Stomach) harms its offspring (Lung Metal). Liver Wood is insufficient and thus suffers from counter-restriction by Metal. Heart Fire is excessive; Fire and Earth combine their virtues, assisting each other with Damp-Heat, thereby forming Warm Disease. This causes the pores (cou li) to open and leak, and the Qi of Shaoyin (Kidney) fails to store. Only those who suffer from sexual exhaustion and hard labor contract this illness. Such cases are all called Warm Disease. The reason they do not fall ill in winter but in spring is that during the Mao month (lunar February, around the Spring Equinox), Cold Water holds power. The command of severe cold reappears in spring. At this time, pores open and leak, and Shaoyin fails to store. For those engaged in sexual activity and hard labor, Yang Qi leaks outward, while Kidney Water is depleted inward. During the spring months, when Wood energy grows strong, there is no source to nourish and generate life, hence Warm Disease occurs. Therefore, a gentleman should be meticulous in winter, allowing Shaoyin to store within, and pores to close and resist. Even with fierce winds and toxic pathogens, harm cannot occur, let alone Warm Disease. Humans are born sharing heaven and earth's nature. In winter, Yang Qi hides beneath the ground, and human Yang Qi is stored within the Kidneys. If one does not disturb the Kidneys, the Qi of the Six Yang meridians remains quiet internally. Once internal peace is achieved, pathogens have no entry. This is the origin of Cold Damage (Shanghan); it is not heaven harming people, but people harming themselves. Those injured by cold will all transform into Heat diseases. "Cold Damage" is actually the general term for Heat diseases. Thus, it is clear that Cold Damage refers to Heat pathogens. In winter, the Six Yin meridians govern, and Yang Qi is inside; closing and storing tightly is appropriate. However, if one labors and dissipates it outward, the seasonal heat has already damaged Water. When spring arrives, Wood should sprout, but Qi has leaked out. Who will encourage growth? Kidney Water is exhausted internally; who will nourish? Both are sources of generation. If the source is cut off, how can Water be produced? What remains in the body is only Heat. With Wood growing strong seasonally, Warm Disease ensues.
Wang Lü said: There are etiology, disease names, and clinical manifestations. One must distinguish the etiology, correct the name, and observe the form. Only when all three are appropriate can treatment be discussed. Let me explain Cold Damage, Warm Disease, and Heat Disease. Cold Damage is named after its etiology. Warm Disease and Heat Disease are named after the season and clinical form. Both originate from contracting cold. Some call them all Cold Damage because their etiology is the same. However, medication cannot be applied uniformly. Contracting cold in winter and manifesting immediately in cold weather means Cold Pathogen is on the exterior, closing the pores. Therefore, pungent-sweet-warm agents are insufficient to disperse it. This is why Zhang Zhongjing must use decoctions like Guizhi Tang (Cinnamon Twig Decoction) and Mahuang Tang (Ephedra Decoction). Warm Disease and Heat Disease manifest later in warm/hot weather. Stifling heat reaches from inside to outside, stagnating the pores, with no cold on the exterior. Therefore, pungent-cool or bitter-cold or sour-bitter agents are required to resolve it. These are the types of formulas created by later generations, such as Shuangjie San (Double-Resolution Powder), Dahuang Tang (Rhubarb Decoction), Qianjin Tang (Thousand Gold Decoction), and Fangfeng Tongsheng San (Saposhnikovia Unblocking-Harmony Powder), which treat both interior and exterior. Immediate-onset Cold Damage has aversion to wind/cold because Wind-Cold is on the exterior, injuring exterior Qi. Later-onset Warm/Heat diseases with aversion to wind/cold indicate a new contraction of Wind-Cold, also injuring exterior Qi. Without new Wind-Cold, there is no aversion to wind/cold. Hence, Zhang Zhongjing said: "Taiyang disease, fever, thirst, no aversion to cold, is Warm Disease." Knowing this for Warm Disease, we know Heat Disease is similar. Thus, no thirst but aversion to cold indicates it is not a Warm/Heat disease. However, some without new Wind-Cold still show aversion to wind/cold because their exterior Qi is originally deficient. Heat reaching the exterior further injures exterior Qi, making it unable to withstand Wind-Cold. This is not the aversion of Cold Damage. Merely Wei (Defensive) deficiency causes aversion to wind, and Ying (Nutritive) deficiency causes aversion to cold. Furthermore, Warm/Heat diseases may show exterior symptoms first, then transmit inward. Stifling heat reaches from inside to outside, stagnating pores, unable to vent, returning inward to form attackable interior syndromes. This differs from Cold Damage starting at the exterior. Some fail to understand this, seeking floating-tight pulses in spring/summer Warm diseases. They do not know tight pulse indicates Cold. Tight pulse appears with Cold Pathogen, not without. If a Warm disease shows a tight pulse, it is due to secondary exposure to sudden cold or internal injury from excessive cold food. Is this the natural state? Others mistake wiry pulse for tight, diagnosing Cold and treating wrongly. Strong, forceful pulses often accompany wiry qualities; mistaking them for tight leads to erroneous Cold diagnosis. Warm/Heat disease pulses are usually in the muscle layer, not very floating, and the Right hand pulse is often stronger than the Left, due to stifling heat inside. If the Left is strong or floating, there must be secondary Wind-Cold; otherwise, it is not Warm/Heat disease but acute Wind-Cold contraction. Generally, in Warm/Heat diseases without secondary contraction, although exterior symptoms may occasionally appear, interior pathology predominates. Thus, thirst is rarely absent. Treatment should focus on clearing interior heat, resolving the exterior secondarily. Sometimes treating the interior resolves the exterior spontaneously. I have seen that mistakenly attacking the interior in Warm diseases causes little harm, but mistakenly sweating the exterior leads to untold complications. This proves heat originates from within. Rarely, mistaken interior attack causes major harm; these are epidemic conditions struck by sudden cold in spring/summer, where pathogen is purely exterior. These cannot be equated with Warm diseases. Because people confuse Warm diseases with Cold Damage, they cling to the character "Cold" to seek floating-tight pulses and use warm medicines. This confusion of name and reality harms lives; disease names must be defined. Medical texts often speak of Four Seasons Cold Damage. Winter/Autumn Cold Damage is true Cold Damage; Spring/Summer Cold Damage is Cold Epidemic. These are distinct from Warm/Heat diseases and should not be treated alike. Although, regarding interior attack methods, if using cold to remove heat, differences are unnecessary. But exterior release methods must differ. Moreover, Cold Damage directly injuring Yin meridians, or Taiyang injury without stifling heat, even if Yin meridians are injured requiring warming, differs greatly from Cold/Heat diseases. How can one treat blindly? Knowing only one aspect and not two, claiming Zhongjing's exterior-releasing drugs are unusable now, but interior-attacking ones are usable... Where lies the principle of usability? If one distinguishes etiology, corrects names, and observes forms, can treatment be inappropriate? For those caused by epidemic abnormal qi or transformed by secondary abnormal qi, one must observe the time and qi, reference Cold/Warm methods, adjust and treat. One must not simply use Zhongjing's immediate Cold Damage drugs universally.
Zhang Yunqi said: If Cold Damage fails to heal after sweating/purging and passes through meridians, yet symptoms persist, it is also Warm Disease. The Classics state: Warm disease pulses operate in the interior meridians. One does not know which meridian is moving; treat according to the location of the affected meridian. For example, Taiyang disease after sweating/purging fails to heal; if Cun/Guan/Kchi pulses are all floating, it is Taiyang Warm Disease. If fever, eye pain persist after sweating/purging; if pulses are all large, it is Yangming Warm Disease. If chest/flank pain persists; if pulses are all wiry, it is Shaoyang Warm Disease. If abdominal fullness, dry throat persist; if pulses are all deep-thin, it is Taiyin Warm Disease. If dry mouth/tongue, thirst persist; if pulses are all deep, it is Shaoyin Warm Disease. If irritability, fullness, scrotal retraction persist; if pulses are all faint-slow, it is Jueyin Warm Disease. Treat according to the meridian and symptoms. If macules appear, it is Warm Toxin.
Pang Anchang said: Warm and Heat have degrees of severity. Thus, Zhongjing said: Encountering Warm Qi causes Warm Disease; encountering further Warm-Heat causes Warm Toxin. Heat is more severe than Warm. If only injured by cold in winter, manifesting in spring without other pathogens, it is called Warm Disease (mild). If Warm Disease continues and encounters Warm Qi again, transforming into Warm Disease, it is slightly more severe. *Shanghan Lun* examples call secondary Warm Qi encounter "Warm Epidemic". There are cases not originating from winter cold manifesting in spring, but specifically contracting Spring Warm Qi, called Spring Warm, analogous to Winter Cold, Autumn Damp, Summer Heat. Thus, Spring Warm diseases have three types: 1. Winter cold manifesting in spring as Warm Disease; 2. Persistent Warm Disease encountering Warm Qi again; 3. Secondary Warm Qi mixing with existing disease; 4. No winter cold or secondary warmth, just contracting Spring Warm Qi in spring. All three can be named Warm Disease; no need for separate names, just understand the different etiologies.
Li Chan said: Warm Disease occurs after Spring Equinox, presenting as Taiyang disease with fever, cough, body ache, thirst, no aversion to cold. Pulse is wiry-rapid, not tight, Right stronger than Left, due to stifling heat inside. Disperse to respective meridians and treat accordingly. Heat Disease is same as Warm Disease but occurs after Summer Solstice, with洪-rapid pulse, more severe fever/thirst. Though caused by winter cold hiding in muscles/bones, humans change with seasons: Spring turns cold to warm, Summer turns cold to hot. Thus, Cold Damage has aversion to cold/no thirst; Warm/Heat has no aversion to cold/thirst. No aversion means pathogen is not external; thirst means heat reaches surface from inside. Heat stagnates pores, cannot vent, returns inward. Ultimately, interior heat exceeds exterior signs. Occasional aversion to cold is due to non-seasonal sudden cold or pre-manifestation cold exposure, not severe winter syndrome. Treat heat primarily, resolve muscle secondarily. Treating interior alone may resolve exterior. Mistaken purging is tolerable; mistaken sweating leads to vomiting, hiccups, mania, macules, and death. Warmth is in meridians, not exterior; sweating is inappropriate. Only with concurrent sudden cold can exterior-interior be resolved simultaneously, avoiding winter pungent-hot drugs. For Spring Warm exterior: warm weather, Shengma Gegen Tang (Bupleurum and Rhizoma Bistortis Decoction); cold weather, Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction). Taiyang-Shaoyang combination, Shengma Gegen Tang combined with Xiaochaihu Tang (Minor Bupleurum Decoction). Half-exterior/half-interior, Xiaochaihu Tang. Interior syndrome, Dachaihu Tang (Major Bupleurum Decoction). Severe simultaneous exterior-interior, Fangfeng Tongsheng San. Exterior-interior heat with loose stools, Chai Ling Tang (Bupleurum and Poria Decoction) plus Gardenia and Akebia. Deficient irritability, Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction). Complicated syndromes, treat like Cold Damage. Summer Heat exterior (Taiyang), Jiuwei Qianghuo Tang (Nine-Ingredient Notopterygium Decoction). Post-sweating irritability/thirst,洪-large pulse, back aversion to cold, Baihu Jiaren Tang (White Tiger plus Ginseng Decoction), Yiyuan San. Interior syndrome, Dachaihu Tang. Severe simultaneous exterior-interior, Shuangjie San. Heat disease with fine-weak pulse, cold feet, post-sweating severe restlessness indicates extreme Yin pulse, fatal. Winter Warm: non-seasonal warmth in winter, called Winter Warm. Similar to Spring/Autumn sudden cold/warmth, termed epidemic qi. Similar to Cold Damage but pulse not floating. Treatment largely same. Spring Warm exterior, Weirui Tang (Polygonatum Decoction), Jiuwei Qianghuo Tang. Entering interior, add Rhubarb. Severe, Shuangjie San. Mild, Jianji Tiaozhong Tang.
Zhao Xianke said: "Cold Damage" refers to killing cold air in winter. Immediate illness is True Cold Damage. Delayed onset: Cold toxin hides in skin/flesh, becoming Warm Disease in spring, Heat Disease in summer. Heat Disease is Summer Heat, seemingly more severe than Warm. But since it is Warm, it cannot be called Cold; no aversion to cold and thirst characterize it. This is Zhongjing's text. Mahuang and Guizhi are for immediate Cold Damage, irrelevant to Warm/Heat. Etiology same, timing different. Zhongjing surely had other prescriptions, now lost, hence unclear. Liu Wansu suggested adding cool drugs to Mahuang/Guizhi to prevent yellowing. Zhang Zhenzi's Liushen Tongjie San adds Mahuang/Cangzhu to ShiGao (cool drugs). Both are wrong. Mahuang/Guizhi are pungent-hot, suitable for winter, not spring/summer. Tao Hua proposed Jiuwei Qianghuo Tang to replace three formulas. Also wrong. Qianghuo Tang, created by Li Dongyuan, treats four-season abnormal qi (e.g., spring should be warm but is cold). Sudden cold in spring/summer causes aversion/fever but less severe than winter killing qi. Thus, Mahuang is unnecessary; pungent-cool resolving interior/exterior suffices. This formula requires Six Meridian modifications, cannot be used fully. Xiaoyao San is better, truly replacing three. I propose another method. Classics: No aversion to cold + thirst = Warm Disease. No aversion means no exterior cold; thirst means Kidney Water dried up. The person has inherent Fire. Winter cold injury is mild; Fire remains, preventing deep cold penetration. Thus, delayed onset; cold hides in skin. From winter to March/April, Fire is constrained by cold, boiling Kidney Water dry. When Wood grows strong, lack of nourishment causes fever/thirst. This is not external contraction. Haicang's idea of "new pathogen expelling old" is incorrect; if newly contracted, exterior would show aversion. I use Liuwei Dihuang Wan ingredients to nourish Water, Chaihu (pungent-cool) to soothe Wood. Treatment is effective. Extending this, all winter Cold Damage is Constraint Fire syndrome. Without Fire, it is Direct Transmission. With Fire, it moves from skin to muscle to organs. People say Cold transmits inward turning to Heat. If Cold, why turn to Heat inside? It is inherent Fire constrained by Cold, unable to vent. Long duration makes it pure Heat. Thus, Sanhuang Jiedu Tang clears Fire; Shengma Gegen Tang vents Fire constraint; Three Chengqi Tangs purge Earth constraint; Xiaochaihu Tang reaches Wood constraint. This logic is simple; Six Meridian transmission theories are fragmented. Any feverish miscellaneous disease has headache, stiff neck, eye pain, nasal dryness, flank pain, bitter taste. Why restrict to Cold Damage and use its formulas? In winter True Cold Damage, I treat Mahuang/Guizhi as Cold Constraint; others without aversion as Fire Constraint. This is my original theory. Listeners were shocked. Yu Tianmin's *Zhengzhuan* states: "Transmitted Cold Damage is Constraint Disease." I rejoiced. Consulting *Neijing*: "Injury by cold transmits to heat." Why? Cold congeals outside, constrains inside. Pores tight, Yuan gates secret, Qi not circulating, Dampness knots inside. External/Internal conflict, Cold excess generates Heat. Sweating cures it. Thus, external congestion/internal constraint is known. My view of Cold Damage as Constraint Fire is well-founded. Hence, this essay on Constraint.
Ke Qin said: Warm Disease has heat inside and out, distinguishing it from Wind Strike/Cold Damage's aversion-to-cold/fever. This clause does not elucidate *Neijing*'s "Winter injury by cold, Spring disease by Warm," but generally describes Taiyang Warm Disease symptoms. Interpreting it as Spring Warm misses Zhongjing's intent. Taiyang meridian can be diseased in all four seasons, not just winter. Everyone can get Warm Disease, not necessarily from Cold Damage. Warm Disease can occur in any season, not just spring. Extending this, all Six Meridians have Warm Disease, not just Taiyang.
Shen Jin'ao notes: Most regard Warm Disease as Spring Warm. Only Ke Qin says it generally describes Taiyang Warm Disease symptoms. The text starts with "Taiyang Disease," confirming Taiyang involvement. However, Spring Warm often manifests in Taiyang. Both views are preserved. Students should understand profoundly and adapt flexibly.
Zhao Xianke's *Yi Guan* is often biased, except for the "Fire Constraint" section in his Warm Disease discussion, which is insightful. However, his criticism of Liu Wansu, Zhang Zhenzi, and Jie'an remains biased. His claim that Liuwei Dihuang Wan plus Chaihu is a wonderful cure for Warm Disease is greatly erroneous; using this might kill 60-70%. I adopt his Fire Constraint theory but fear people will accept all his words as correct, so I highlight this here.