（四时伤寒不同 传变 汗下大法 可汗 不可汗 可下 不可下 可吐 不可吐 愈解 死证 阴阳 表里
伤寒杂病 类证 杂论 察色要略）
阴阳大论云春气温和夏气暑热秋气清凉冬气冷冽此则四时正气之序也冬时严寒万类深藏君子固密则不伤于寒触冒
之者乃名伤寒耳其伤于四时之气皆能为病（即下文时行之气）以伤寒为毒者以其最成杀厉之气也中而即病者名曰伤寒不
即病者寒毒藏于肌肤至春变为温病至夏变为暑病暑病者热极重于温也（内经曰先夏至日为温病后夏至日为暑病温暑之病
本伤于寒而得之故太医均谓之伤寒也）是以辛苦之人春夏多温热病者皆由冬时触寒所致非时行之气也（活人云夏月发热
恶寒头疼身重肢节疼痛其脉洪盛者是也冬伤于寒因暑气而发为热病）凡时行者春时应暖而反大寒夏时应热而反大凉秋时
应凉而反大热冬时应寒而反大温此非其时而有其气是以一岁之中长幼之病多相似者此则时行之气也（此辨伤寒时气之
异）夫欲候知四时正气为病及时行疫气之法皆当按斗历占之
四时八节二十四气七十二候决病法
立春正月节斗指艮 雨水正月中指寅
惊蛰二月节指甲 春分二月中指卯
清明三月节指乙 谷雨三月中指辰
立夏四月节指巽 小满四月中指巳
芒种五月节指丙 夏至五月中指午
小暑六月节指丁 大暑六月中指未
立秋七月节指坤 处暑七月中指申
白露八月节指庚 秋分八月中指酉
寒露九月节指辛 霜降九月中指戌
立冬十月节指干 小雪十月中指亥
大雪十一月节指壬 冬至十一月中指子
小寒十二月节指癸 大寒十二月中指丑
（二十四气节有十二中气有十二五日为一候气亦同合有七十二候决病生死此须洞解之也）
九月霜降后宜渐寒向冬大寒至正月雨水节后宜解也所以谓之雨水者以冰雪解而为雨水故也至二月惊蛰节后气渐和
暖向夏大热至秋便凉（此为四时正气）从霜降以后至春分以前凡有触冒冰雪体中寒即病者谓之伤寒也九月十月寒气尚微
为病则轻十一月十二月寒冽已严为病则重正月二月寒渐将解为病亦轻此以冬时不调适有伤寒之人即为病也（此为四时正
气中而即病者也）其冬有非节之暖者名曰冬温冬温之毒与伤寒大异冬温复有先后更相重沓亦有轻重为治不同证如后章
（此为时行之气前云冬时应寒而反大温者是也冬温应常纪者有三岁少阴司天之政五之气阳明司天之政终之气厥阴司天
之政终之气皆病冬温其不应常纪而反常者则不可候之而随时变易也）从立春节后其中无暴大寒又不冰雪而有人壮热为病
此属春时阳气发于外冬时伏寒变为温病（此为温病也内经曰冬伤于寒春必病温外邪唤出内邪也春温应常纪者有四岁少阴
司天之政初之气太阳司天之政初之气阳明司天之政初之气太阴司天之政二之气皆病温其不应常纪而反常者不可候之而
随时变易也）从春分以后至秋分节前天有暴寒者皆为时行寒疫也三月四月或有暴寒其时阳气尚弱为寒所折病热犹轻五月
六月阳气已盛为寒所折病热则重七月八月阳气已衰为寒所折病热亦微其病与温及暑病相似但治有殊耳（此辨时行与伤寒
相似治法不同要在辨其病原寒热温三者之异则用药冷热之品味判然矣）十五日得一气于四时之中一时有六气四六名为二
十四气也然气候亦有应至而不至或有未应至而至者或有至而太过者皆成病气也（素问六微旨大论帝曰其有至而至有至而
不至有至而太过何也岐伯曰至而至者和至而不至来气不及也未至而至来气有余也帝曰至而不至未至而至何如岐伯曰应
则顺否则逆逆则变生变生则病金匮要略曰有未至而至有至而不至有至而不去有至而太过何故也师曰冬至之后甲子夜半
少阳起少阳之时阳始生天得温和以未得甲子天因温和此为未至而至也以得甲子而天未温和此为至而不至也以得甲子天
大寒不解此为至而不去也以得甲子而天温如盛夏五六月时此为至而太过也）但天地动静阴阳鼓击者各正一气耳是以彼春
之暖为夏之暑彼秋之忿为冬之怒是故冬至之后一阳爻升一阴爻降也夏至之后一阳气下一阴气上也斯则冬夏二至阴阳合
也春秋二分阴阳离也阴阳交易人变病焉此君子春夏养阳秋冬养阴顺天地之刚柔也小人触冒必婴暴疹须知毒烈之气留在
何经而发何病详而取之是以春伤于风夏必飧泄夏伤于暑秋必病疟秋伤于湿冬必咳嗽冬伤于寒春必病温此必然之道可不
审明之与伤寒之病逐日浅深以施方治（经曰未满三日者可汗而已其满三日者可泄而已）今世人伤寒或始不早治或治不对
病或日数久淹困乃告医医人又不根据次第而治之则不中病皆宜临时消息制方无不效也今采仲景旧论录其证候诊脉声色对
病真方有神验者拟防世急也（仲景之书逮今千年而显用于世者王叔和之力也）又土地温凉高下不同物性刚柔飧居亦异是
故黄帝兴四方之问岐伯举四治之能以训后贤开其未悟者临病之工宜须两审也（庞 叔和非医方圆机孰能臻此也如桂枝汤自
西北二方居人四时行之无不应验自江淮间地偏暖处惟冬及春可行之自春末及夏至以前桂枝麻黄青龙内宜加黄芩也自夏
至以后桂枝内又须随证增知母大青升麻石膏辈取汗也若时行寒疫及病久虚寒者正方古方不待加减矣夏至以后虽宜白虎
汤自非新中 而变暑病乃汗后解表药耳一白虎未能驱逐表邪故也或有冬及始春寒甚之时人患斯病因汗下后偶变狂躁不
解须当作内热治之不拘于时令也南方无霜雪之地不因寒气中人地气不藏虫类泄毒岚瘴间作不用此治法别有方也又一州
之内有山居者为居积阴之所盛夏冰雪其气寒腠理闭难伤于邪其人寿其有病者多中风中寒之疾也有平泽居者为居积阳之
所严冬生草其气温腠理疏易伤于邪其人夭其有病者多中温中暑之病）
王 夫伤于寒有即病者焉有不即病者焉即病者发于所感之时不即病者过时而发于春夏也即病谓之伤寒不即病谓之温与
暑夫伤寒温暑其类虽殊其所受之原则不殊也由其原之不殊故一以伤寒而为称由其类之殊故施治不得以相混以所称而混
其治宜乎贻祸后人以归咎于仲景之法而委废其大半也吁可谓溺井怨伯益失火怨燧人矣夫法也方也仲景专为即病之伤寒
设不兼为不即病之温暑设也后人能知仲景之书本为即病者设不为不即病者设则尚恨其法散落所存不多而莫能御夫粗工
妄治之万变果可惮烦而或废之乎今人虽以治伤寒法治温暑亦不过借用耳非仲景立法之本意也虽然岂特可借以治温暑而
已凡杂病之治莫不可借也今人因伤寒治法可借以治温暑遂谓其法通为伤寒温暑设吁此非识流而昧源者与请以证之夫仲
景之书三阴经寒证居热证什之七八彼不即病之温暑但一于热耳何由而为寒哉夫惟后人以仲景书通为伤寒温暑设遂致诸
温剂皆疑焉而不敢用韩祗和虽觉桂枝汤之难用但谓今昔之世不同然未悟仲景书本为即病之伤寒设也且其所着微旨一书
又纯以温暑作伤寒立论而即病之伤寒反不言及又以夏至前胸膈满闷呕逆气塞肠鸣腹痛身体拘急手足逆冷等证视为温暑
谓与仲景三阴寒证脉理同而证不同遂别立温中法以治夫仲景所叙三阴寒证乃是冬时即病之伤寒故有此证今欲以仲景所
叙三阴寒证求对于春夏温暑之病不亦 乎以余观之其胸膈满闷呕逆气塞等证若非内伤冷物则不正暴寒所中或过服寒药
所变或内外俱伤于寒之病也且祗和但曰寒而当温然未尝求其所以为寒之故能求其故则知温暑本无寒证矣朱奉议作活人
书累数万言于仲景伤寒论多有发明其伤寒即入阴经为寒证者诸家不识而奉议识之但惜其亦不知仲景专为即病者立法故
其书中每每以伤寒温暑混杂议论竟无所别况又视伤寒论为全书遂将次传阴经热证与即入阴经寒证牵合为一立说且谓大
抵伤寒阳明证宜下少阴证宜温而于所识即入阴经之见又未免自相悖矣夫阳明证之宜下者固为邪热入胃其少阴证果是伤
寒传经热邪亦可温乎况温病暑病之少阴尤不可温也自奉议此说行而天下后世蒙害者多矣迨夫成无己作伤寒论注又作明
理论其表章名义纤悉不遗可谓善羽翼仲景者然即入阴经之寒证又不及朱奉议能识况即病立法之本旨乎宜其莫能知也惟
其莫知故于三阴诸寒证止随文解义而已未尝明其何由不为热而为寒也至于刘守真出亦以温暑作伤寒立论而遗即病之伤
寒其所处辛凉解散之剂固为昧者有中风伤寒错治之失而立盖亦不无桂枝麻黄难用之惑也既惑于此则无由悟夫仲景立桂
枝麻黄汤之有所主用桂枝麻黄汤之有其时矣故其原病式有曰夏热用麻黄桂枝之类热药发表须加寒药不然则热甚发黄或
斑出矣（此说出于庞安常而朱奉议亦从而和之）殊不知仲景立麻黄汤桂枝汤本不欲用于夏热之时也苟悟夫桂枝麻黄汤本
非治温暑之剂则群疑冰泮矣何也夫寒之初客于表也闭腠理郁阳气而为热故非辛温之药不能开腠理以泄其热此麻黄汤之
所由立也至于风邪伤表虽反疏腠理而不能闭然邪既客表则表之正气受伤而不能流通故亦发热也必以辛甘温之药发其邪
则邪去而腠理自密矣此桂枝汤之所由立也其所以不加寒药者盖由风寒在表又当天令寒冷之时而无所避故也后人不知仲
景立法之意故有惑于麻黄桂枝之热有犯于春夏之司气而不敢用于是有须加寒药之论夫欲加寒药于麻黄桂枝汤之中此乃
不悟其所以然故如此耳若仲景为温暑立方必不如此必别有法但惜其遗佚不传致使后人有多歧之患若知仲景伤寒论专为
即病伤寒作则知麻黄桂枝所以宜用之故除传经热证之外其直伤阴经与太阳不郁热即传阴经诸寒证皆有所归着而不复疑
为寒药误下而生矣若乃春夏有恶风恶寒纯类伤寒之证盖春夏暴中风寒之新病非冬时受伤过时而发者不然则或者温暑将
发而复感于风寒或因感风寒而动乎久郁之热遂发为温暑也仲景曰太阳病发热而渴不恶寒者为温病观此则知温病不当恶
寒而当渴其恶寒而不渴者非温病矣仲景虽不言暑病然暑病与温病同但复过一时而加重与温病耳其不恶寒而渴则无异也
春夏虽有恶风恶寒表证其桂枝麻黄二汤终难轻用勿泥于发表不远热之语也于是用辛凉解散庶为得宜苟不慎而轻用之诚
不能免夫狂躁斑黄衄血之变而亦无功也虽或者行桂枝麻黄于春夏而效乃是因其辛甘发散之力偶中于万一断不可视为常
道而守之今人以败毒散参苏饮通解散百解散之类不问四时中风伤寒一例施之虽非至正之道较之不慎而轻用麻黄桂枝于
春夏以致变者较必近理然败毒散等若用于春夏亦止可治暴中风寒之证而已其冬时受伤过时而发之温病暑病则不宜用也
用则非徒无益亦反害之矣若夫仲景于三阴经每用温药正由病之所必须与用之有其时耳若概以三阴寒证视为杂病而外之
得无负于仲景济人利物之至仁而误后世乎自近代先觉不示伤寒温暑异治之端绪但一以寒凉为主而诸温热之剂悉在所略
致使后之学人视仲景书欲仗焉而不敢以终决欲弃焉则犹以为立法之祖而莫能外甚则视为文具又甚则束之高阁而谓其法
宜于昔而不宜于今由治乱动静之殊治静属水乱动属火故其温热之药不可用于今属火之时也噫斯言也其果然耶否耶但能
明乎仲景本为即病者设法则桂枝麻黄自有所用诸温热之剂皆不可略矣若谓仲景法不独为即病者设则凡时行及寒疫温疟
风温等病亦通以伤寒六经病诸方治之乎伤寒例曰冬温之毒与伤寒大异为治不同又曰寒疫与温及暑病相似但治有殊耳是
则温暑及时行寒疫温疟风温等仲景必别有治法今不见者亡之也观其所谓为治不同所谓温疟风温温毒温疫脉之变证方治
如说岂非亡其法乎决不可以伤寒六经病诸方通治也叔和搜采仲景旧论之散落者以成书功莫大矣但惜其既以自己之说混
于仲景所言之中又以杂脉杂病纷纭并载于卷首故使玉石不分主客相乱若先备仲景之言而次附己帮助书其名则不致惑于
后人而累仲景矣余尝欲编类其书以伤寒例居前而六经病次之相类病又次之瘥后病又次之诊察治法治禁治误病解未解等
又次之其杂脉杂病与伤寒有所关者采以附焉其与伤寒无相关者皆删去如此庶几法度纯一而玉石有分主客不乱矣然有志
未暇姑叙此以俟他日
伤寒温病热病说
有病因有病名有病形辨其因正其名察其形三者俱当始可以言治矣且如伤寒此以病因而为病名者也温病热病此以天
时与病形而为病名者也由三者皆起于感寒或者通以伤寒称之夫通称伤寒者原其因之同耳至于用药则不可一例而施也何
也夫伤寒盖感于霜降后春分前然不即发郁热而发于春夏者也伤寒即发于天令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之所以必用也温病热病后发于天令暄热之时怫热自内而达于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仲景桂枝麻黄等汤独治外者之所以不可用而后人所处水解散大黄汤千金汤防
风通圣散之类兼治内外者之所以可用也夫即病之伤寒有恶风恶寒之证者风寒在表而表气受伤故也后发之温病热病有恶
风恶寒之证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证故仲景曰太阳病发热而渴不恶寒者为
【背景信息】
书名：伤寒证治准绳 作者：王肯堂 朝代：明 章节：总例 / 四时伤寒不同(1/2)(1/2) 类别：伤寒
（四时伤寒不同、传变、汗下大法、可汗、不可汗、可下、不可下、可吐、不可吐、愈解、死证、阴阳、表里、伤寒杂病、类证、杂论、察色要略）
《阴阳大论》说：春气温和，夏气暑热，秋气清凉，冬气冷冽，这是四季正气的次序。冬季严寒，万物深藏，君子若能固密腠理则不伤于寒；若触犯冒犯寒气，这才称为伤寒。然而，人受四时之气侵害都能致病（即下文所说的时行之气）。之所以称伤寒为毒，是因为它形成了最具有杀伤厉烈之气的病邪。感受寒邪随即发病的，名叫伤寒；若不立即发病，寒毒潜伏在肌肤之中，到春天变为温病，到夏天变为暑病。暑病的热势极重，比温病更严重。（《内经》说：夏至之前得的病叫温病，夏至之后得的病叫暑病。温病和暑病，本源都是因受了寒邪而得，所以太医都统称它们为伤寒。）因此，辛勤劳作的人，在春夏季节多患温热病，这都是因为冬季触犯了寒邪所致，并非所谓的“时行之气”。（《活人书》说：夏季发热、恶寒、头痛、身体沉重、肢节疼痛，脉象洪盛，就是这种情况。冬季伤了寒邪，因暑气激发而发为热病。）凡是时行病，是指春天本该温暖却反而大寒，夏天本该炎热却反而大凉，秋天本该凉爽却反而大热，冬天本该寒冷却反而大温。这种非其时而有其气的情况，导致一年中老少病人的症状大多相似，这就是时行之气。（这里辨析了伤寒与时行气的区别。）想要推知四时正气致病及时行疫气致病的方法，都应该依据斗历（古代观测天象定节气的仪器）来占测。
四时八节二十四气七十二候决病法：
立春正月节，斗指艮位；雨水正月中，斗指寅位。
惊蛰二月节，斗指甲位；春分二月中，斗指卯位。
清明三月节，斗指乙位；谷雨三月中，斗指辰位。
立夏四月节，斗指巽位；小满四月中，斗指巳位。
芒种五月节，斗指丙位；夏至五月中，斗指午位。
小暑六月节，斗指丁位；大暑六月中，斗指未位。
立秋七月节，斗指坤位；处暑七月中，斗指申位。
白露八月节，斗指庚位；秋分八月中，斗指酉位。
寒露九月节，斗指辛位；霜降九月中，斗指戌位。
立冬十月节，斗指干位；小雪十月中，斗指亥位。
大雪十一月节，斗指壬位；冬至十一月中，斗指子位。
小寒十二月节，斗指癸位；大寒十二月中，斗指丑位。
（二十四节气中有十二个节气是“中气”，有十二个是“节”。每五天为一候，气与候相同，合起来共有七十二候。判断疾病的生死，必须深刻理解这些规律。）
九月霜降后天气逐渐变寒，直到冬季大寒，再到正月雨水节后，寒气才宜于化解。之所以叫“雨水”，是因为冰雪融化成为雨水。到了二月惊蛰节后，气候逐渐暖和，向夏季的大热过渡，到了秋天便转凉。（这是四时正气。）从霜降以后到春分以前，凡是有触犯冰雪、体内受寒随即发病的，叫做伤寒。九月、十月寒气尚微弱，生病则较轻；十一月、十二月寒冽已严酷，生病则较重；正月、二月寒气逐渐将解，生病也轻。这是因为冬季调摄不当，有伤寒之人随即发病。（这是四时正气中感寒即病的情况。）如果冬季出现非节令的暖热，名叫冬温。冬温的毒性与伤寒大不相同。冬温又有先后之分，病情重叠，也有轻重之别，治疗方法也不同，证候如后章所述。（这是时行之气。前文说“冬时应寒而反大温”就是指这个。冬温符合常规纪年的有三种情况：少阴司天之政的五之气、阳明司天之政的终之气、厥阴司天之政的终之气，都会发生冬温。那些不符合常规纪年而是反常的，则不能按常规预测，而要随时变化来判断。）从立春节后，其中没有突然的大寒，也没有冰雪，但有人壮热生病，这属于春时阳气发散于外，冬季潜伏的寒邪变为温病。（这是温病。《内经》说：冬伤于寒，春必病温。这是外邪唤出内邪。春温符合常规纪年的有四岁少阴司天之政初之气、太阳司天之政初之气、阳明司天之政初之气、太阴司天之政二之气，都会发生温病。那些不符合常规纪年而是反常的，则不能按常规预测，而要随时变化来判断。）从春分以后到秋分节前，天空有突然的寒冷，都属于时行寒疫。三月、四月或有突然的寒冷，此时阳气尚弱，被寒气折损，生病热势较轻；五月、六月阳气已盛，被寒气折损，生病热势则重；七月、八月阳气已衰，被寒气折损，生病热势也微。其病症与温病及暑病相似，但治疗方法不同。（这里辨析了时行病与伤寒相似但治法不同，关键在于辨别病原是寒、是热、是温，三者不同，用药的冷热品味自然判然有别。）十五日得一气，在四季中，一季有六气，四六相乘名为二十四节气。然而气候也有应至而未至，或未应至而至，或虽至而太过者，这些都形成病气。（《素问·六微旨大论》黄帝问：有的气到了且相应，有的气到了但不相应，有的气到了且太过，为什么呢？岐伯回答：气至且相应，是和；气至而不相应，是来气不足；未至而至，是来气有余。黄帝问：气至而不相应，未至而至，怎么样？岐伯回答：应则顺，否则逆，逆则变异产生，变异产生则生病。《金匮要略》说：有未至而至，有至而不至，有至而不去，有至而太过，为什么呢？老师说：冬至之后的甲子夜半，少阳之气始起。少阳之时，阳气始生，天气变得温和。如果未到甲子天已温和，这叫“未至而至”。如果到了甲子天未温和，这叫“至而不至”。如果到了甲子天大寒不解，这叫“至而不去”。如果到了甲子天温暖如盛夏五六月时，这叫“至而太过”。）只是天地动静，阴阳鼓击，各自端正一气罢了。所以春天的暖是夏天的暑，秋天的肃杀是冬天的怒。因此冬至之后，一阳爻上升，一阴爻下降；夏至之后，一阳气下降，一阴气上升。这就是冬至和夏至时阴阳交合，春分和秋分时阴阳分离。阴阳交易，人就发生变化而生病。所以君子春夏养阳，秋冬养阴，顺应天地的刚柔。小人触犯冒犯，必定遭受暴烈的疹疾。必须知道毒烈之气留在哪条经络，引发什么病，详细诊察取治。因此春伤于风，夏必飧泄；夏伤于暑，秋必病疟；秋伤于湿，冬必咳嗽；冬伤于寒，春必病温。这是必然的道理，不可不审明。对于伤寒之病，要根据每日病情的深浅来施用方治。（经书说：未满三日的，可以通过发汗治愈；已满三日的，可以通过泻下治愈。）现在世人患伤寒，有的开始不早治，有的治不对病，有的拖延日久困顿才告诉医生，医生又不根据次第治疗，这样就不中病。都应当临时斟酌制方，没有不有效的。现在采集仲景旧论，记录其证候、诊脉声色，针对病的真方有神效的，拟以防备世上的急用。（仲景的书到现在千年，而在世上显扬使用，是王叔和的功劳。）又土地温凉高下不同，物性刚柔，饮食居住也各异。所以黄帝兴起四方之问，岐伯列举四治之能，以训导后贤，开启他们未悟之处。面对疾病工作的医生，应该仔细审查两方面。（庞安常说：如果不是王叔和这样的名医，谁能达到这种境界呢？比如桂枝汤，在西北两方的居民，四季使用都应验；在江淮之间地偏暖的地方，只有冬季和春季可以服用；从春末到夏至以前，桂枝、麻黄、青龙汤内部适宜加入黄芩。从夏至以后，桂枝汤内又须随证增加知母、大青、升麻、石膏之类以取汗。如果是时行寒疫及病久虚寒的人，用正方古方，不需要加减。夏至以后虽然适宜白虎汤，但如果不是新近中暑而变为暑病，那是汗后解表的药而已。单用白虎汤未能驱逐表邪的缘故。有的人在冬季及初春寒甚之时，患此病，因汗下后偶然变成狂躁不解，必须当作内热治疗，不拘泥于时令。南方无霜雪之地，不因寒气中人，地气不藏，虫类泄毒，岚瘴间作，不用此治法，另有方子。又一州之内，有山居的人，居住在积阴之所，盛夏仍有冰雪，其气寒，腠理闭塞，难伤于邪，其人长寿。有病的多是中风、中寒的疾病。有平泽居住的人，居住在积阳之所，严冬生草，其气温，腠理疏松，易伤于邪，其人短命。有病的多是中温、中暑的疾病。）
王履说：伤于寒，有随即发病的，有不随即发病的。随即发病的，发生在感受之时；不随即发病的，过时发作于春夏。随即发病的叫伤寒，不随即发病的叫温与暑。伤寒、温、暑，虽然类别不同，但所受的原则没有不同。正因为本源没有不同，所以一概称为伤寒；正因为类别不同，施治不得混淆。如果用称呼来混淆治疗，就会贻祸后人，归咎于仲景之法而废弃大半。唉，这就像掉进井里怨恨伯益，失火怨恨燧人一样。法度和方剂，仲景是专为即病之伤寒设立的，不兼为不即病之温暑设立。后人如果能知道仲景的书本是为即病者设，不为不即病者设，还遗憾其法散落所存不多，而不能抵御粗工妄治的万变，难道可以嫌麻烦而废弃吗？现在人虽然用治伤寒法治温暑，也不过是借用罢了，并非仲景立法之本意。虽然如此，岂止可以借用来治温暑而已？凡是杂病的治疗，没有不可以借用的。现在人因为伤寒治法可借以治温暑，就说其法是通为伤寒温暑设立的。唉，这不是识流而昧源的人吗？请让我证明这一点。夫仲景的书，三阴经寒证占热证的十分之七八，那些不即病的温暑只是一于热罢了，怎么会变成寒呢？正是因为后人把仲景的书通盘作为伤寒温暑设立，导致诸温剂都被怀疑而不敢用。韩祗和虽然觉得桂枝汤难用，但认为今昔之世不同，然而并未悟到仲景书本本是为即病之伤寒设立的。况且他所著的《微旨》一书，又纯以温暑作伤寒立论，而即病之伤寒反而不提。又把夏至前胸膈满闷、呕逆、气塞、肠鸣、腹痛、身体拘急、手足逆冷等证视为温暑，谓其与仲景三阴寒证脉理同而证不同，于是别立温中法来治疗。其实仲景所叙述的三阴寒证，乃是冬季即病之伤寒，故有此证。现在想用仲景所叙述的三阴寒证来对应春夏温暑之病，不也是荒谬吗？在我看来，那些胸膈满闷、呕逆、气塞等证，如果不是内伤冷物，就是不正暴寒所中，或是过服寒药所变，或者是内外俱伤于寒的病。况且祗和只说寒而当温，然而未曾探求其为寒的原因。如果能探求原因，就知道温暑本无寒证。朱奉议作《活人书》，累数万言，对仲景《伤寒论》多有发明。他认识到伤寒即入阴经为寒证，其他各家不认识而奉议认识到了。可惜他也不知道仲景专为即病者立法，所以书中每每以伤寒温暑混杂议论，竟无所分别。况且他又视《伤寒论》为全书，遂将次传阴经热证与即入阴经寒证牵合为一立说，并且说大抵伤寒阳明证宜下，少阴证宜温，而对于他所认识的即入阴经之见，又未免自相悖逆。夫阳明证之宜下者，固然是邪热入胃，其少阴证果若是伤寒传经热邪，也可以温吗？况且温病暑病的少阴尤不可温。自从奉议此说流行，天下后世蒙害者很多。等到成无己作《伤寒论注》，又作《明理论》，其表彰名义纤悉不遗，可谓善于辅翼仲景。然而对于即入阴经之寒证，又不及朱奉议能认识，何况即病立法之本旨乎？应该也是不能知晓吧。正因为不知晓，所以对于三阴诸寒证只是随文解义而已，未曾明白为何不为热而为寒。至于刘守真出来，也以温暑作伤寒立论，而遗漏即病之伤寒。他所处方辛凉解散之剂，固然是为了防备愚者有中风伤寒错治之失而立，但也并非没有桂枝麻黄难用的困惑。既然在此迷惑，就无法悟到仲景立桂枝麻黄汤有所主用，桂枝麻黄汤有其使用时机。所以他的《原病式》中说：“夏热用麻黄桂枝之类热药发表，须加寒药，不然则热甚发黄或斑出矣。”（此说出于庞安常，而朱奉议也从而附和。）殊不知仲景立麻黄汤桂枝汤，本不欲用于夏热之时。如果悟到桂枝麻黄汤本非治温暑之剂，则群疑冰泮。为什么呢？寒之初客于表，闭腠理，郁阳气而为热，所以非辛温之药不能开腠理以泄其热，这是麻黄汤之所以设立。至于风邪伤表，虽然反疏腠理而不能闭，但邪既客表，则表之正气受伤而不能流通，所以也发热。必须以辛甘温之药发其邪，则邪去而腠理自密，这是桂枝汤之所以设立。其所以不加寒药，大概是因为风寒在表，又当天令寒冷之时，无所避忌。后人不知仲景立法之意，所以对麻黄桂枝之热有疑惑，有犯于春夏之司气而不敢用，于是有须加寒药之论。想在麻黄桂枝汤中加入寒药，这是不悟其所以然才如此。如果仲景为温暑立方，必不如此，必别有法。可惜其遗佚不传，致使后人有多歧之患。如果知道仲景《伤寒论》专为即病伤寒作，就知道麻黄桂枝所以宜用之故。除传经热证之外，其直伤阴经与太阳不郁热即传阴经诸寒证，皆有所归着而不复疑为寒药误下而生。至于春夏有恶风恶寒，纯类伤寒之证，大概是春夏暴中风寒的新病，非冬时受伤过时而发者。不然，则是温暑将发而复感于风寒，或因感风寒而动乎久郁之热，遂发为温暑。仲景说：“太阳病发热而渴不恶寒者为温病。”观此则知温病不当恶寒而当渴，其恶寒而不渴者，非温病。仲景虽不言暑病，然暑病与温病同，只是复过一时而加重与温病耳。其不恶寒而渴则无异。春夏虽有恶风恶寒表证，其桂枝麻黄二汤终难轻用，勿泥于“发表不远热”之语。于是用辛凉解散庶为得宜。苟不慎而轻用之，诚不能免夫狂躁、斑黄、衄血之变，而亦无功。虽然或者行桂枝麻黄于春夏而效，乃是因其辛甘发散之力偶中于万一，断不可视为常道而守之。今人以败毒散、参苏饮、通解散、百解散之类，不问四时中风伤寒一例施之，虽非至正之道，较之不慎而轻用麻黄桂枝于春夏以致变者，比较必近理。然而败毒散等若用于春夏，亦止可治暴中风寒之证而已，其冬时受伤过时而发之温病暑病则不宜用。用则非徒无益，亦反害之。若夫仲景于三阴经每用温药，正由病之所必须，与用之有其时耳。若概以三阴寒证视为杂病而外之，得无负于仲景济人利物之至仁而误后世乎？自近代先觉不示伤寒温暑异治之端绪，但一以寒凉为主，而诸温热之剂悉在所略，致使后之学人视仲景书，欲仗焉而不敢以终决，欲弃焉则犹以为立法之祖而莫能外，甚则视为文具，又甚则束之高阁，而谓其法宜于昔而不宜于今。由治乱动静之殊，治静属水，乱动属火，故其温热之药不可用于今属火之时也。噫，斯言也，其果然耶？否耶？但能明乎仲景本为即病者设法，则桂枝麻黄自有所用，诸温热之剂皆不可略矣。若谓仲景法不独为即病者设，则凡时行及寒疫、温疟、风温等病，亦通以伤寒六经病诸方治之乎？《伤寒例》曰：“冬温之毒与伤寒大异，为治不同。”又曰：“寒疫与温及暑病相似，但治有殊耳。”是则温暑及时行寒疫、温疟、风温等，仲景必别有治法。今不见者，亡之也。观其所谓为治不同，所谓温疟、风温、温毒、温疫脉之变证方治如说，岂非亡其法乎？决不可以伤寒六经病诸方通治也。叔和搜采仲景旧论之散落者以成书，功莫大矣。但惜其既以自己之说混于仲景所言之中，又以杂脉杂病纷纭并载于卷首，故使玉石不分，主客相乱。若先备仲景之言而次附己帮助书其名，则不致惑于后人而累仲景矣。余尝欲编类其书，以《伤寒例》居前而六经病次之，相类病又次之，瘥后病又次之，诊察治法、治禁、治误、病解未解等又次之，其杂脉杂病与伤寒有所关者，采以附焉，其与伤寒无相关者皆删去。如此庶几法度纯一而玉石有分，主客不乱矣。然有志未暇，姑叙此以俟他日。
伤寒温病热病说：
有病因、有病名、有病形。辨其因，正其名，察其形，三者俱当，始可以言治矣。且如伤寒，此以病因而为病名者也；温病、热病，此以天时与病形而为病名者也。由三者皆起于感寒，或者通以伤寒称之。夫通称伤寒者，原其因之同耳。至于用药，则不可一例而施也。何也？夫伤寒盖感于霜降后、春分前，然不即发，郁热而发于春夏者也。伤寒即发于天令寒冷之时，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之所以必用也。温病热病，后发于天令暄热之时，怫热自内而达于外，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，此仲景桂枝麻黄等汤独治外者之所以不可用，而后人所处水解散、大黄汤、千金汤、防风通圣散之类兼治内外者之所以可用也。夫即病之伤寒有恶风恶寒之证者，风寒在表而表气受伤故也；后发之温病热病有恶风恶寒之证者，重有风寒新中而表气亦受伤故也。若无新中之风寒，则无恶风恶寒之证。故仲景曰：“太阳病发热而渴不恶寒者为温病。”
[Background Information]
Book: Shanghan Zhengzhi Zhunsheng (Standard of Diagnosis and Treatment of Cold Damage)
Author: Wang Kentang
Dynasty: Ming
Chapter: General Examples / Differences of Cold Damage in Four Seasons (1/2)(1/2)
Category: Cold Damage
(The differences of cold damage in four seasons, transmission and transformation, general principles of sweating and purging, indications for sweating, contraindications for sweating, indications for purging, contraindications for purging, indications for vomiting, contraindications for vomiting, recovery and resolution, death syndromes, Yin and Yang, exterior and interior, cold damage and miscellaneous diseases, syndrome differentiation, miscellaneous discussions, brief on observing complexion.)
The *Yin Yang Da Lun* states: The Qi of spring is mild and harmonious; the Qi of summer is hot and sultry; the Qi of autumn is cool and clear; the Qi of winter is cold and biting. This is the sequence of the upright Qi of the four seasons. In winter, severe cold causes all things to hide deeply. If a gentleman can secure and close his pores, he will not be injured by cold. Those who are exposed to and offend against it are named as having *Shanghan* (Cold Damage). However, injury by the Qi of any season can cause disease (i.e., the epidemic Qi mentioned below). *Shanghan* is called toxic because it forms the most lethal and destructive Qi. If illness occurs immediately upon infection, it is called *Shanghan*. If illness does not occur immediately, the cold toxin hides in the skin and muscles, transforming into *Wenbing* (Warm Disease) in spring and *Shubing* (Summerheat Disease) in summer. *Shubing* involves extreme heat, more severe than *Wenbing*. (*Neijing* states: Diseases acquired before the Summer Solstice are called *Wenbing*; those acquired after are called *Shubing*. Both originate from cold injury, hence Imperial Physicians generally refer to them as *Shanghan*.) Therefore, hardworking people often suffer from warm-heat diseases in spring and summer, caused by cold exposure in winter, not by "epidemic Qi". (*Huoren Shu* states: Fever, aversion to cold, headache, body heaviness, joint pain, and a surging pulse in summer indicate this. Winter cold injury triggered by summer heat causes heat disease.) Epidemic diseases refer to situations where spring should be warm but is extremely cold, summer should be hot but is extremely cool, autumn should be cool but is extremely hot, and winter should be cold but is extremely warm. Having such Qi out of season causes many people of all ages to fall ill with similar symptoms; this is the epidemic Qi. (This distinguishes between *Shanghan* and epidemic Qi.) To predict illnesses caused by the upright Qi of the four seasons or epidemic Qi, one must consult the Dipper Calendar (ancient astronomical instrument for determining solar terms).
**Method for Determining Disease based on Four Seasons, Eight Festivals, Twenty-Four Solar Terms, and Seventy-Two Pentads:**
Li Chun (Start of Spring), first month festival, Dipper points to Gen; Yushui (Rain Water), middle of first month, Dipper points to Yin.
Jingzhe (Awakening of Insects), second month festival, Dipper points to Jia; Chunfen (Spring Equinox), middle of second month, Dipper points to Mao.
Qingming (Clear and Bright), third month festival, Dipper points to Yi; Guyu (Grain Rain), middle of third month, Dipper points to Chen.
Lixia (Start of Summer), fourth month festival, Dipper points to Xun; Xiaoman (Grain Buds), middle of fourth month, Dipper points to Si.
Mangzhong (Grain in Ear), fifth month festival, Dipper points to Bing; Xiazhi (Summer Solstice), middle of fifth month, Dipper points to Wu.
Xiaoshu (Minor Heat), sixth month festival, Dipper points to Ding; Dashu (Major Heat), middle of sixth month, Dipper points to Wei.
Liqiu (Start of Autumn), seventh month festival, Dipper points to Kun; Chushu (End of Heat), middle of seventh month, Dipper points to Shen.
Bailu (White Dew), eighth month festival, Dipper points to Geng; Qiufen (Autumn Equinox), middle of eighth month, Dipper points to You.
Hanlu (Cold Dew), ninth month festival, Dipper points to Xin; Shuangjiang (Frost Descent), middle of ninth month, Dipper points to Xu.
Lidong (Start of Winter), tenth month festival, Dipper points to Qian; Xiaoxue (Minor Snow), middle of tenth month, Dipper points to Hai.
Daxue (Major Snow), eleventh month festival, Dipper points to Ren; Dongzhi (Winter Solstice), middle of eleventh month, Dipper points to Zi.
Xiaohan (Minor Cold), twelfth month festival, Dipper points to Gui; Dahan (Major Cold), middle of twelfth month, Dipper points to Chou.
(Twenty-four solar terms include twelve "Zhongqi" (mid-term Qi) and twelve "Jieqi" (festival Qi). Each pentad lasts five days. Understanding these seventy-two pentads is essential for determining life and death in disease.)
After Frost Descent in September, weather gradually cools until Major Cold in winter, then thaws after Rain Water in January. Hence "Rain Water," as ice and snow melt into rain. After Awakening of Insects in February, climate warms towards summer heat, cooling in autumn. (This is the upright Qi of four seasons.) From Frost Descent to Spring Equinox, anyone offended by ice/snow who falls ill immediately has *Shanghan*. In Sept/Oct, cold is slight, so illness is mild; in Nov/Dec, cold is severe, so illness is heavy; in Jan/Feb, cold wanes, so illness is mild. This results from improper regulation in winter leading to immediate *Shanghan*. (This is immediate illness from upright Qi.) Non-seasonal warmth in winter is called *Dongwen* (Winter Warmth). Its toxicity differs greatly from *Shanghan*. *Dongwen* varies in timing and severity, requiring different treatments (see later chapters). (This is epidemic Qi. "Winter should be cold but is warm." Regular occurrences involve Shaoyin, Yangming, or Jueyin ruling heaven at specific phases. Irregular cases require flexible judgment.) After Start of Spring, without sudden severe cold or ice, if someone has high fever, it is spring Yang expanding outward, transforming winter latent cold into *Wenbing*. (*Neijing*: Winter cold injury leads to spring warmth disease. External pathogen awakens internal pathogen. Regular occurrences involve Shaoyin, Taiyang, Yangming, or Taiyin ruling heaven at specific phases. Irregular cases require flexible judgment.) From Spring Equinox to before Autumn Equinox, sudden cold indicates epidemic cold plague. In Mar/Apr, Yang is weak, so heat is mild; in May/Jun, Yang is strong, so heat is heavy; in Jul/Aug, Yang declines, so heat is slight. Symptoms resemble *Wenbing* and *Shubing*, but treatment differs. (Key is distinguishing cold, heat, and warmth etiologies to determine drug temperature.) Every fifteen days yields one Qi. Six Qi per season make twenty-four Qi. Climate may arrive early, late, or excessively, causing disease. (*Suwen*: Arrival matching expectation is harmony; arrival without expectation is deficiency; non-arrival is excess. *Jingui Yaolue*: Similar variations exist. After Winter Solstice, Jiazi night marks Shaoyang rise. Warmth arriving before Jiazi is "early arrival"; lack of warmth after Jiazi is "late arrival"; persistent cold after Jiazi is "non-departure"; excessive heat after Jiazi is "excessive arrival.") Heaven and Earth move via Yin-Yang interaction, establishing distinct Qi. Spring warmth becomes summer heat; autumn austerity becomes winter anger. After Winter Solstice, Yang rises, Yin descends; after Summer Solstice, Yang descends, Yin rises. These are Yin-Yang conjunctions at solstices and separations at equinoxes. Yin-Yang exchange causes human disease. Gentlemen nourish Yang in spring/summer and Yin in autumn/winter, following Heaven and Earth's rigidity/flexibility. Commoners offending nature suffer violent rashes. One must identify which meridian holds toxic Qi and what disease arises. Thus: Spring wind injury leads to summer undigested diarrhea; summer summerheat leads to autumn malaria; autumn dampness leads to winter cough; winter cold leads to spring warmth disease. This is inevitable. Treat *Shanghan* daily according to depth. (*Classic*: <3 days, sweat; >3 days, purge.) Modern patients delay treatment or receive incorrect treatment, worsening condition. Doctors must adjust formulas dynamically. I collect Zhang Zhongjing’s old theories, recording syndromes, pulses, colors, and effective formulas for emergencies. (Wang Shuhe’s efforts made Zhongjing’s work known after a millennium.) Land varies in warmth/cold and elevation; materials vary in hardness/softness; diet/lifestyle differ. Huangdi asked about four regions; Qibo taught four treatments. Physicians must examine both context and pathology. (Pang Anchang noted Guizhi Tang works well in NW China year-round, but only in winter/spring in Jianghuai. Add Huangqin in late spring/pre-summer; add Zhimu, Daqing, Shengma, Shigao in summer. For epidemic cold or chronic deficiency-cold, use original formulas unchanged. Baihu Tang is for post-sweat exterior resolution, not new summerheat. Post-sweat mania requires treating internal heat, ignoring season. Southern regions lack frost/snow; earth Qi doesn't store; insect toxins/miasmas occur; different methods apply. Mountain dwellers live in Yin accumulation, cold pores, long life, prone to wind-cold. Plain dwellers live in Yang accumulation, warm pores, short life, prone to warmth-summerheat.)
Wang Lu stated: Cold injury causes immediate illness (*Shanghan*) or delayed illness (*Wen/Shu*). Immediate illness happens at infection time; delayed illness happens in spring/summer. Though origins are similar, categories differ, so treatments must not mix. Confusing names with treatments harms descendants, blaming Zhongjing. This is like blaming Boyi for wells or Suiren for fire. Zhongjing’s formulas were for immediate *Shanghan*, not delayed *Wen/Shu*. Knowing this prevents discarding valuable methods. Using *Shanghan* methods for *Wen/Shu* is borrowing, not original intent. However, these methods can treat miscellaneous diseases too. Claiming Zhongjing’s laws cover all *Shanghan/Wen/Shu* is confusing source and stream. Zhongjing’s book shows 70-80% Yin meridian cold syndromes, while delayed *Wen/Shu* are purely heat. How can they become cold? Later doctors mixing *Shanghan/Wen/Shu* suspect warming agents. Han Zhihe found Guizhi Tang difficult, citing era differences, but missed that Zhongjing targeted immediate *Shanghan*. His *Weizhi* focused on *Wen/Shu* as *Shanghan*, ignoring immediate *Shanghan*. He treated pre-summer solstice chest fullness, vomiting, etc., as *WenShu*, linking them to Yin cold syndromes, creating "Warming Middle" methods. Actually, Zhongjing’s Yin cold syndromes are winter immediate *Shanghan*. Matching them to spring/summer *WenShu* is absurd. Chest fullness/vomiting likely stem from cold food, sudden cold, or overuse of cold drugs. Han Zhihe said "cold needs warming" but didn't seek the cause. Zhu Fengyi’s *Huoren Shu* clarified Yin cold syndromes but mixed *Shanghan/WenShu*, combining transmitted heat and immediate cold syndromes, claiming Yangming needs purging and Shaoyin needs warming. This contradicts itself, as Shaoyin heat shouldn't be warmed. This theory harmed many. Cheng Wuji’s commentary praised terminology but missed immediate Yin cold syndromes. Liu Wansu also treated *WenShu* as *Shanghan*, omitting immediate *Shanghan*. His辛凉 (Acrid-Cool) dispersants aimed to prevent misdiagnosis of wind-cold but confused Guizhi/Mahuang usage. His *Yuanbingshi* suggested adding cold drugs to Mahuang/Guizhi in summer to prevent jaundice/rashes. Pang Anchang and Zhu Fengyi agreed. But Zhongjing didn’t intend these for summer heat. Cold trapping exterior closes pores,郁 (depresses) Yang into heat; only Acrid-Warm opens pores. Wind injuring exterior loosens pores but blocks Zheng Qi flow, causing fever; Acrid-Sweet-Warm expels pathogen, closing pores naturally. No cold drugs needed because cold-wind is exterior during cold weather. Later doctors doubted Acrid-Warm drugs in spring/summer, adding cold drugs. This misunderstanding led to confusion. If Zhongjing prescribed for *WenShu*, he would have different methods. Lost methods cause confusion. Knowing Zhongjing targeted immediate *Shanghan* clarifies why Mahuang/Guizhi are used. Except for transmitted heat, direct Yin injury or Sunyang non-depressed cold syndromes fit these formulas. Spring/summer aversion to wind/cold resembling *Shanghan* are usually new wind-cold infections, not delayed winter injuries. Or, *WenShu* emerging triggered by new wind-cold. Zhongjing: "Taiyang disease with fever, thirst, no aversion to cold is Wenbing." Thus, *Wenbing* lacks aversion to cold but has thirst. Aversion to cold without thirst is not *Wenbing*. *Shubing* resembles *Wenbing* but worsens over time; lacks aversion to cold, has thirst. Spring/summer exterior signs make Guizhi/Mahuang risky; don't cling to "exterior release ignores heat." Use Acrid-Cool dispersants cautiously. Misuse causes mania, rashes, epistaxis. Occasional success in spring/summer is luck, not rule. Using Baidu San, Susu Yin, etc., for all seasons is pragmatic compared to reckless Mahuang/Guizhi use, but still limited to acute wind-cold, not delayed *WenShu*. Using them for *WenShu* harms. Zhongjing used warming drugs for Yin meridians due to necessity and timing. Treating Yin cold as miscellaneous disease neglects Zhongjing’s benevolence. Recent scholars emphasized cold-cooling, neglecting warm agents, fearing Zhongjing’s book yet unable to discard it. Some call it obsolete, suitable only for past eras (calm/water vs. chaotic/fire). If we understand Zhongjing targeted immediate *Shanghan*, Guizhi/Mahuang have their place, and warm agents aren't negligible. If Zhongjing’s laws covered all, would epidemic cold/plague/warm-malaria/wind-warm use Six Meridian formulas? *Shanghan Example* says Winter Warmth differs from *Shanghan*; Cold Plague differs from Warm/Summerheat. Thus, Zhongjing had separate methods for these, now lost. Wang Shuhe compiled scattered texts, great merit, but mixed his views and miscellaneous topics, confusing jade with stone. Organizing by *Example*, Six Meridians, Similar Syndromes, Recovery, Diagnostics, Contraindications, Misc. Topics would clarify. I intended this but lacked time; recorded here for future.
**On Cold Damage, Warm Disease, and Heat Disease:**
Disease has etiology, name, and manifestation. Distinguishing etiology, naming correctly, and observing manifestation are prerequisites for treatment. *Shanghan* is named by etiology; *Wenbing/Shubing* by season and manifestation. All originate from cold, hence sometimes grouped under *Shanghan*. Etymologically similar, but treatments differ. *Shanghan* occurs after Frost Descent to before Spring Equinox, delaying onset until spring/summer. Immediate *Shanghan* happens in cold weather, cold pathogen at exterior closing pores; requires Acrid-Sweet-Warm (Guizhi/Mahuang). *Wenbing/Shubing* occur in warm weather, heat郁 (depressed) internally reaching exterior, no exterior cold; requires Acrid-Cool, Bitter-Cold, or Sour-Bitter (e.g., Shuijie San, Dahuang Tang, Qianjin Tang, Fangfeng Tongsheng San). Immediate *Shanghan* has aversion to wind/cold due to exterior pathogen/injury. Delayed *Wenbing/Shubing* has aversion to wind/cold only if newly infected by wind-cold. Without new infection, no aversion to wind/cold. Zhongjing: "Taiyang fever, thirst, no aversion to cold is Wenbing."