川芎一钱 全当归醋炒，三钱 赤芍一线五分 熟地四钱 人参三钱 云茯苓三钱 冬术土炒，三钱 炙甘草六分 广陈皮一钱 桃仁泥三钱 新绛一钱 苏木一线五分 五灵腊三钱 上桂心五分 延胡索一钱五分
引用生姜三片，大枣二枚，青葱管三根。再加大红鸡冠花一两，如用干者减半。
以上之方，补气用四君子，补血用四物 汤，行气用陈皮、延胡，行血用桃仁、新绛、苏木、五灵脂。用桂心者，血得温则不滞也。引用姜枣，和其营卫，青葱管直走冲脉，红鸡冠《纲目》但言活血，却能引领众药导入子宫，为此症必用之专药。因其形假猪胜中之生窠，故为子宫之引经。此说得自宜兴屠渐斋先生所传，非臆说也。如无人参，以潞党参八钱代之，加酒一杯煎服，十剂必有效验。如月分尚浅，气血少弱，则服前方。若月分已多，气血大伤，则服后方。
咸丰四年仲秋锡山顾文山氏识
细读尊论所云：瘅疟多由伏暑而成，如暑必挟湿，邪伏太阴，太阴与阳明合病则为瘅疟，太阴与少阳合病则成疟疾，以及阴气孤绝，阳气独发等说，皆极明畅，佩服之至。然以愚见观之，伏署自有伏署之病，瘅疟古有瘅疟之名。锡邑医家所称瘅疟伏暑之病居多。澄江诸医所称伏暑，其间亦有瘅疟，何以辨之？须知瘅疟热症也，细玩经文，如肺素有热，及邪气内藏于心，外合分肉之间，热而少气烦冤，消烁肌肉等句，则知夏秋瘅疟暑热居多。暑伤气，故云少气，暑先人心，故云邪气内藏于心。古方白虎汤、竹叶石膏汤乃瘅疟正治之法也。近时薛一瓢立清疟饮，亦从清解立法。至于白虎加桂枝，必见大热烦渴，而又背独恶寒，骨节烦疼，方可加用程云来《金匮注解｝）谓白虎清气，桂枝入营，治在心营肺卫，徒属纸上空谈，令人好看。恐尚非确论也。若夫伏暑初起，微寒微热，起卧自如，舌有白苔，胃能饮食，食亦无碍，不食亦不饥，淹缠旬日而后病势渐重，此真所谓伏暑，乃湿热二字为病也。治暑病与伏暑，喻嘉言暑门诸方论可云详备，再参薛生白湿热论三十三条，新法颇多，可应无穷之变。高明谅必洞悉，兹不烦缕述矣。按古语暑属火，暑必挟湿，暑伤气，暑喜归心，暑邪留恋上中，弥漫三焦等说，为治各各不同，故治暑之方温清消补，解散通利，亦种种不一，统以见证为凭，未易一言尽也。尊论升葛亦创一新法，确有意义，可法可传，有稗来学。世多明哲，自有定评，无俟鄙人诵也。
答 书
接阅尊论，至为明晰，钦佩奚似。惟此症自夏至以后至初秋发者，谓之瘅疟。自深秋至初冬发者，谓之伏暑。其实皆伤暑得来。伏暑者，秋凉已深，暑邪伏于营分也。而尊见以为伏暑，自有伏暑之病，瘅疟古有瘅疟之名，似以此病忽分为二矣。然则古有瘅疟之名，自有瘅疟之实，将以何症为瘅疟耶？抑古有瘅疟而今无瘅疟耶？捧读之下，令人不能无疑。仲师制白虎加桂枝汤，自有深义，而足下以程云来注解为纸上空谈，则从古圣贤所论都在纸上，岂亦谓之空谈而不能见诸实事耶？仆非精于此道，亦非行道之人，然既有疑，不能不问，还当明以教我为幸。
《黄帝内经》，千古不磨之作，所言经络脏腑腧穴、阴阳五行、运气，非神圣不能道只字。仲景《伤寒》《金匮》亦千古不磨之作，有论有证，有方有法，多一味便不是此方，异一脉便不是此证，非神圣不能道只字。第《内经》所言者是体，仲景所言者是用。此二书实体用相须之要道也。瘅疟一症，《内经》《金匾》俱载之，但未竟其详耳。大凡四时为病，冬月即发者谓之正伤寒。然冬寒而反暖，即有冬温，至于冬伤于寒，至春变温，至夏变热，即谓之伏气矣。故发于春末夏初者，便谓之温热病。温热病中间或有温瘅疟之形举，俗所称春温似疟，春温瘅疟，湿温似疟，湿温瘅疟。或师承相授，或习俗相传，亦非漫然而称之也。大抵夏至以后而病热者，谓之热病，新书《温病条辨》中所云暑温是也。挟湿者谓之湿温，湿温症治，古方用苍术白虎，则知无湿。而但热者，白虎汤是治暑热之正法矣。今时酷暑炎蒸，忽起凉风雷雨而病者，是暑热为暴寒遏伏，先用香薷解表，数剂之后，忽变大热大烦大渴，而又背独恶 寒，骨节烦疼，白虎加桂枝恰当。由是观之，白虎汤治暑热之正方，挟湿则加苍术，兼寒则加桂枝，岂不明且确也。程云来注解白虎清气，桂枝入营，非不有理，然欠畅达。鄙人无学，何敢批驳前贤。然而认证用药，要归着实。如柯氏《来苏集》改正越婢汤证，非有胆识者不能读古人书，须自具见识，勿为古人瞒过者，类如此。夫大暑以后，立秋初际，每多但热不寒，即是瘅疟。寒热往来，便为疟疾。当此之时，其治尚易，因暑邪内伏未深也。逮至秋分之后，寒露霜降，则邪伏递深，而其为病亦重矣。夫岂伏暑门中而无瘅疟之症哉!仲景云：太阳病，或已发热，或未发热，必恶寒体痛，呕逆脉紧，无汗者，名曰伤寒。若脉缓，有汗者，名曰中风。是从伤寒中分出中风也。若夫瘅疟，是热症也，虽当初起，必见热重烦冤，舌红无苔，或有苔而亦甚薄，与伏暑之初起微热，淹淹舌上苔滑者不同。由是观之，虽届深秋，其病初起，热重烦冤者，即属瘅疟，便不得谓之伏暑矣。暑湿内蕴，微热淹淹，舌苔白腻，虽系秋初，便与伏暑相类，但不名伏暑而名湿热病耳。尤在泾解风伤卫、寒伤营二句，云：寒之浅者仅伤于卫风，而甚者并及于营。卫之实者，风亦难泄，卫之虚者，寒犹不固。古称大青龙治风寒两伤营卫之法，讵知是中风卫实之方。风为阳邪，内郁化火，烦躁特甚，故用石膏。卫实无汗，发热恶寒，故用麻桂。此语独超千古。又有暑病解云：暑属火，暑必挟湿，故阴虚多火者暑即寓于火之中。阳虚多湿者，暑即伏于湿之内。此亦名言，非同泛泛。由是观之，患瘅疟者，阴虚火盛之人为多，即经旨肺素有热之来路也。患伏暑者，阳虚湿胜之人不少，即湿性滞濡之意也。惟湿郁必化热，六气皆从火化，故湿热伏暑，病亦有化燥而用清法者，不可不知。乃若瘅疟燥热居多，清解是其正法。清解维何，辛凉是也。如薄荷、牛蒡、桔梗、连翘、豆卷、青蒿、竹叶、芦根等味因其病方初起，后人不敢用白虎开场，但用轻清凉解，取意则同，而命剂悬殊矣。仪翁先生好学深思，特举葛升为瘅疟开首之法，岂不另具卓见。第伏暑之病，邪居足太阴脾为多，用升葛从脾胃提出伏邪，颇有意义。若瘅疟邪居手太阴肺为最多，肺主一身气化，为清肃之脏，似宜轻清解散为稳。病情变化，不可胜数，处方定法，统以见症为凭。故瘅疟见虚者，加沙参、麦冬、洋参之属，挟湿者，加芦根、滑石、川通草之流。果热甚而大烦大渴者，则竟用白虎。热甚而挟虚，则白虎加人参或竹叶石膏之类。热甚烦渴，过饮水而挟湿者，河间五苓三石甘露饮最妙。如上症挟湿而又停浊者，子和甘露饮尤妙。要皆不离肺热二字，而后传布三焦，生津降火，补气养阴，总以肺胃为主，未及脾肾。又为病湿后培元之着矣。此瘅疟症治之大略，未足为明者道也。虽然病变无常，方难执一，以余阅历，同一病也，而体气不同则洽法变矣。张璐玉《医通》有兼症晰义两卷，最为明晰，暇日观之，足令人心机活泼。叨居爱末，冒昧直言，伏祈垂察是荷。
答 书
接阅高论，引证明备，说理精详，足征学问渊深，钦佩奚似!然《内经》《金匮》以及后贤方论诸书，苟从事于医者，无人不览，无烦赘述也。鄙人因见夏秋所患伤暑之症日久淹缠，变症莫测，医家治之，不能速愈，是以稍抒所见，发此微论，专指有汗之瘅疟、无汗之瘅疟二症而言，并未旁及他病也。若是春温、冬温、湿温、温热等症，或有伤寒中来者，或有感冒时邪者，或有伏邪感新邪而发者，症不一端，治不一法。若欲缕晰条分，非一纸所能尽，《温病条辨》中亦已言其大略矣。夏秋之症，有但热不寒而无起伏者，有乍寒乍热而无定时者，俱与瘅疟有别，不得以瘅疟之例一概治之。此中有冬伤于寒，邪伏在内，至夏感暑引动而发者。有极重之症不可不知，即论夏月伤暑之病亦多，而瘁疟则暑病中之尤甚者也。古人谓夏伤于暑，秋必痎疟，未尝言夏伤于暑，春必痎疟也。可见疟疾为秋月之病而非春月之病明矣。夫春月之病亦有似疟者，乃伤寒中之涉及少阳而然也，如竟与秋后疟疾同论则误矣。更有营卫虚而往来寒热者，此系大虚之候必于脉象见之，应当议补，医者亦不可不知。<<内经》《金匮》将瘅疟列入疟症一门，则瘅疟为夏秋之病而非春月之病亦明矣。古人谓先夏至为病温，后夏至为病暑。可见时令亦不可不论，七月为之初秋，九月为之深秋。若以初秋之病为伏暑，转以深秋之病为瘅疟而不为伏暑，并为春间亦有瘅疟，不知出于何书，望为明示，以广见闻。若习俗相传，虽有师承口授，终非前贤确论，未可信为实然也。伤暑之症本应有汗，若瘅疟而至无汗，必因内蕴暑邪，外为凉风所遏，则肺气不达，腠理闭塞，故致无汗，其有汗之瘅疟尚须辛凉解表，至于无汗之瘅疟则非牛蒡、薄荷、桔梗、豆卷等所能胜任矣。非不知更为稳当，其如屡投无效，何举世茫然罔觉，不能一悟，良可慨已。因而想到大青龙汤去姜枣加葛根为法，方中重用石膏为君，少加麻桂为反佐，则无汗之瘅疟庶能发汗而邪可解矣。反佐者如白通汤之用猪胆汁，滋肾丸之用桂心是也。瘅疟魏柏卿注为热毒，视温疟较重。仲师论温疟用白虎加桂枝汤，则无汗之瘅疟用大青龙去姜枣加葛根亦可类推。去姜枣者，姜性更烈，枣恐腻滞也。加葛根者，凉散阳明之邪也。不过伤寒以麻桂为君，瘅疟以石膏为君，若用数钱石膏而以数分麻桂为反佐，亦可无虑。且无汗瘅疟，必热势起伏，日有定时，口渴烦冤，脉洪数，重按实者方可用，若似瘅疟，原不可用，当须识此，不可误也。古人处方，此一味重、彼一味轻，与此一味轻、彼一味重便即法不同而治各异，医者贵在临症权衡也。况此独为瘅疟初起立法，若延至日久，则症已变而治法亦变矣，岂可胶柱鼓瑟哉。《金匮》温疟条中有筋骨烦疼，若谓背独恶寒则未之及也。至瘅疟之初起，病情已载瘅疟浅说内，兹不复赘。至于病变无常，方难执一，无人不知，不待言矣。从前二弟媳素本耐性，偶患疟疾，因将出汗，心中烦躁，遂令打扇，以致汗不得出，邪不能达，终日烦躁异常，遂请令业师医治。议用麻杏甘石汤似矣。鄙意欲加桂枝数分，伊囿于俗见，坚执不肯，以致不效，至今深悔。可见业医者贵有胆识，独具卓见，方能超乎流俗，不致贻误无穷斯可矣。鄙人并非好为辨论，因世俗医之一道皆是浮光掠影，随声附和，毫无实际，不能独出己见。此等本不足与深谈，惟旭翁先生博学明理，超出庸众，心存济世，历练已深，故敢将鄙见直陈。盖医理本不易明，若能彼此讨论，刻意精求，庶或差少错误也。未识高明以为何如?荒谬之见，不知所云，还请教以不逮为幸。
接阅高论，谓时令不可不论。诚然，诚然。夫春温、夏热、秋凉、冬寒，四时之正气也。然春正月余寒未解，交惊蛰节而后阳气方升。秋七月余暑未消，交白露节而后阴气始降。夏至一阴生，正为热盛之候。冬至一阳生，正是寒极之时。盖剥不极则不复，理势使然也。经云：先夏至日者为病温，后夏至日者为病暑。由是推之，则知先秋分日者为病暑，后秋分日者为病凉(补天石有秋凉伤寒之说，凉极而后燥，交九十月燥病方生)。先冬至日者为病燥(喻嘉言补秋燥论谓经文脱却长夏伤干湿，以致后人不明秋伤于燥、冬生咳嗽云云)，后冬至日者为病寒。先春分日者为病寒，后春分日者为病温矣。常见春末夏初温病流行，阖门传染，屡经反覆，延至夏至后小暑节仍有战汗而愈者，原属温邪，非关伤暑，此则病之余气，非时之余气也。又常见夏至以后起病有似温邪。延及小暑节，热势朝和，过午则盛，但热不寒，竟与瘅疟相同，此温暑之交，抑或所谓温疟耶。喻氏云：夏伤于暑，长夏伤于湿。由是推之，初秋瘅疟，夏伤于暑之为病也，深秋伏暑，长夏伤于湿之为病也。瘅疟由乎夏伤暑，故热症多而病势重，病重故不易速愈也。伏暑由乎长夏伤湿，故湿症多而病势缓，缓则淹缠，故亦不易速愈耳。
再阅高论，所云无汗之瘅疟必因内蕴暑邪，外为凉风阻遏，肺气不达，腠理闭塞，亦诚确论。借用大青龙汤，重用石膏，少佐麻桂，亦无不可，但必重用石膏清肺胃之热，则知瘅疟责重肺胃无疑矣。尊见亦明知瘅疟病在肺胃，第以为肺胃之病意见相同，不遑多赘。至于白虎加桂枝，骨节烦疼，见《金匮》背独恶寒句，见伤寒审证集，引证用方要归着实，此即着实处也。语云：读书多不如临症多。果能读书、临症二者皆到，更为美备，惜言之易而行之难。其惟终日劳劳，荒疏无学，辱承教示，冒渎粗陈，伏维叹政。
答 书
川芎一钱，全当归用醋炒制三钱，赤芍一钱五分，熟地黄四钱，人参三钱，云茯苓三钱，冬术（白术）用土炒制三钱，炙甘草六分，广陈皮一钱，桃仁泥三钱，新绛一钱，苏木一钱五分，五灵脂三钱，上桂心五分，延胡索一钱五分。
引用生姜三片，大枣二枚，青葱管三根。再加大红鸡冠花一两，如果用干品则减半。
以上这个方子，补气使用四君子汤，补血使用四物汤，行气使用陈皮、延胡索，行血使用桃仁、新绛、苏木、五灵脂。使用桂心的原因，是血液得温则不凝滞。引用姜枣，是为了调和营卫；青葱管能直走冲脉；大红鸡冠花在《本草纲目》中只说它能活血，却能够引领众药导入子宫，这是治疗此症必须使用的专药。因为它的形状像猪子宫中的生窠，所以作为子宫的引经药。这种说法得自宜兴屠渐斋先生所传，并非臆测之说。如果没有人参，可以用潞党参八钱代替，加一杯酒煎服，十剂必定有效验。如果怀孕月份尚浅，气血较少虚弱，则服用前方。如果怀孕月份已多，气血大伤，则服用后方。
咸丰四年仲秋，锡山顾文山氏识。
仔细研读您论述中所言：瘅疟多由伏暑而成，如暑邪必挟湿，邪气潜伏于太阴，太阴与阳明合病则为瘅疟，太阴与少阳合病则成疟疾，以及阴气孤绝，阳气独发等说法，都非常明畅，我佩服之至。然而以我的愚见来看，伏暑自有伏暑的病证，瘅疟古已有瘅疟之名。锡邑医家所称的瘅疟伏暑之病居多。澄江诸医所称的伏暑，其间也有瘅疟，如何辨别呢？须知瘅疟是热症，细读经文，如“肺素有热”，及“邪气内藏于心，外合分肉之间，热而少气烦冤，消烁肌肉”等句，就知道夏秋季节瘅疟多为暑热所致。暑邪伤气，所以说“少气”；暑邪先入人心，所以说“邪气内藏于心”。古方白虎汤、竹叶石膏汤乃是治疗瘅疟的正治之法。近时薛一瓢创立清疟饮，也是从清解立法。至于白虎加桂枝汤，必须见到壮热烦渴，而又背部唯独恶寒，骨节烦疼，方可加用。程云来在《金匮注解》中说白虎清气，桂枝入营，治疗在心营肺卫，这纯属纸上空谈，让人好看。恐怕还不是确论。至于伏暑初起，微寒微热，起居自如，舌有白苔，胃能饮食，吃东西无碍，不吃也不觉得饿，缠绵旬日之后病势才逐渐加重，这才是真正的所谓伏暑，是由湿热二字致病。治疗暑病与伏暑，喻嘉言在暑门诸方论中可以算详备了，再参考薛生白《湿热论》三十三条，新法颇多，可以应对无穷的变化。高明之士想必洞悉，这里不再烦琐叙述。按古语说暑属火，暑必挟湿，暑伤气，暑喜归心，暑邪留恋上中焦，弥漫三焦等说法，治疗各不相同，所以治暑的方剂温清消补，解散通利，也种种不一，统以见证为依据，不容易一言尽述。您的论述中升麻葛根也是创一新法，确实有意义，可法可传，对后学有益。世间多有明哲之人，自有定评，无需鄙人颂扬。
答 书
接阅您的论述，非常明晰，钦佩至极。只是此症自夏至以后至初秋发作的，称为瘅疟。自深秋至初冬发作的，称为伏暑。其实都是伤暑得来的。伏暑，是指秋凉已深，暑邪潜伏于营分。而您的见解认为伏暑自有伏暑的病证，瘅疟古有瘅疟之名，似乎将此病忽然分为二种了。然而古有瘅疟之名，自有瘅疟之实，将以什么症状为瘅疟呢？还是古有瘅疟而今无瘅疟呢？捧读之下，令人不能不有疑问。仲景制作白虎加桂枝汤，自有深义，而足下以程云来的注解为纸上空谈，那么从古圣贤所论都在纸上，难道也称其为空谈而不能见于实事吗？我并非精通于此道，也不是行道之人，但既然有疑问，不能不问，还望明示教导，这是我的荣幸。
《黄帝内经》，是千古不朽之作，所言经络脏腑腧穴、阴阳五行、运气，非神圣之人不能说只字。仲景的《伤寒》《金匮》也是千古不朽之作，有论有证，有方有法，多一味便不是此方，异一脉便不是此证，非神圣之人不能说只字。只是《内经》所言的是体，仲景所言的是用。这两本书体现了实体用相须的要道。瘅疟一症，《内经》《金匮》都有记载，但未详尽罢了。大凡四时为病，冬月即发的称为正伤寒。然而冬寒而反暖，就有冬温，至于冬伤于寒，至春变为温病，至夏变为热病，就称为伏气了。所以发于春末夏初的，便称为温热病。温热病中间或有温瘅疟的表现，俗称为春温似疟，春温瘅疟，湿温似疟，湿温瘅疟。或是师承相授，或是习俗相传，也并非漫然而称之。大致夏至以后而病热的，称为热病，新书《温病条辨》中所说的暑温就是这类。挟湿的称为湿温，湿温症治，古方用苍术白虎汤，则知无湿。而但热的，白虎汤是治疗暑热的正法了。今时酷暑炎蒸，忽起凉风雷雨而发病的，是暑热被暴寒遏伏，先用香薷解表，数剂之后，忽变大热大烦大渴，而又背部唯独恶寒，骨节烦疼，白虎加桂枝汤恰当。由此看来，白虎汤治暑热的正方，挟湿则加苍术，兼寒则加桂枝，难道不明且确吗？程云来注解白虎清气，桂枝入营，并非没有道理，然而欠畅达。鄙人无学，何敢批驳前贤。然而认证用药，要归着实。如柯韵伯《来苏集》改正越婢汤证，非有胆识者不能读古人书，须自具见识，勿为古人瞒过者，类如此。在大暑以后，立秋初际，每多但热不寒，即是瘅疟。寒热往来，便为疟疾。当此之时，其治疗尚易，因暑邪内伏未深也。等到秋分之后，寒露霜降，则邪伏递深，而其发病也重了。这哪里是伏暑门中没有瘅疟之症呢！仲景说：太阳病，或已发热，或未发热，必恶寒体痛，呕逆脉紧，无汗者，名曰伤寒。若脉缓，有汗者，名曰中风。是从伤寒中分出中风也。至于瘅疟，是热症，虽然当初起，必见热重烦冤，舌红无苔，或有苔而亦甚薄，与伏暑之初起微热，淹淹舌上苔滑者不同。由此看来，虽届深秋，其病初起，热重烦冤的，即属瘅疟，便不得谓之伏暑了。暑湿内蕴，微热淹淹，舌苔白腻，虽系秋初，便与伏暑相类，但不名伏暑而名湿热病耳。尤在泾解释风伤卫、寒伤营二句，说：寒之浅者仅伤于卫，风而甚者并及于营。卫之实者，风亦难泄，卫之虚者，寒犹不固。古称大青龙汤治风寒两伤营卫之法，岂知是中风卫实之方。风为阳邪，内郁化火，烦躁特甚，故用石膏。卫实无汗，发热恶寒，故用麻桂。此语独超千古。又有暑病解云：暑属火，暑必挟湿，故阴虚多火者暑即寓于火之中。阳虚多湿者，暑即伏于湿之内。这也是名言，非同泛泛。由此看来，患瘅疟者，阴虚火盛的人为多，即经旨“肺素有热”的来路也。患伏暑者，阳虚湿胜的人不少，即湿性滞濡之意也。惟湿郁必化热，六气皆从火化，所以湿热伏暑，病亦有化燥而用清法的，不可不知。至于瘅疟燥热居多，清解是其正法。清解是什么，辛凉是也。如薄荷、牛蒡、桔梗、连翘、豆卷、青蒿、竹叶、芦根等味，因其病方初起，后人不敢用白虎汤开场，但用轻清凉解，取意则同，而命剂悬殊矣。仪翁先生好学深思，特举葛根升麻为瘅疟开首之法，岂不另具卓见。只是伏暑之病，邪居足太阴脾为多，用升葛从脾胃提出伏邪，颇有意义。若瘅疟邪居手太阴肺为最多，肺主一身气化，为清肃之脏，似宜轻清解散为稳。病情变化，不可胜数，处方定法，统以见症为凭。所以瘅疟见虚者，加沙参、麦冬、洋参之属，挟湿者，加芦根、滑石、川通草之流。果热甚而大烦大渴者，则竟用白虎汤。热甚而挟虚，则白虎加人参或竹叶石膏之类。热甚烦渴，过饮水而挟湿者，河间五苓三石甘露饮最妙。如上症挟湿而又停浊者，子和甘露饮尤妙。要皆不离肺热二字，而后传布三焦，生津降火，补气养阴，总以肺胃为主，未及脾肾。又为病湿后培元之着矣。这是瘅疟症治的大略，不足为明者道也。虽然病变无常，方难执一，以我阅历，同一病也，而体气不同则治法变矣。张璐玉《医通》有兼症晰义两卷，最为明晰，暇日观之，足令人心机活泼。叨居爱末，冒昧直言，伏祈垂察是荷。
答 书
接阅高论，引证明备，说理精详，足征学问渊深，钦佩至极！然而《内经》《金匮》以及后贤方论诸书，苟从事于医者，无人不览，无烦赘述也。鄙人因见夏秋所患伤暑之症日久淹缠，变症莫测，医家治之，不能速愈，是以稍抒所见，发此微论，专指有汗之瘅疟、无汗之瘅疟二症而言，并未旁及他病也。若是春温、冬温、湿温、温热等症，或有伤寒中来者，或有感冒时邪者，或有伏邪感新邪而发者，症不一端，治不一法。若欲缕晰条分，非一纸所能尽，《温病条辨》中亦已言其大略矣。夏秋之症，有但热不寒而无起伏者，有乍寒乍热而无定时者，俱与瘅疟有别，不得以瘅疟之例一概治之。此中有冬伤于寒，邪伏在内，至夏感暑引动而发者。有极重之症不可不知，即论夏月伤暑之病亦多，而瘅疟则暑病中之尤甚者也。古人谓夏伤于暑，秋必痎疟，未尝言夏伤于暑，春必痎疟也。可见疟疾为秋月之病而非春月之病明矣。夫春月之病亦有似疟者，乃伤寒中之涉及少阳而然也，如竟与秋后疟疾同论则误矣。更有营卫虚而往来寒热者，此系大虚之候必于脉象见之，应当议补，医者亦不可不知。《内经》《金匮》将瘅疟列入疟症一门，则瘅疟为夏秋之病而非春月之病亦明矣。古人谓先夏至为病温，后夏至为病暑。可见时令亦不可不论，七月为之初秋，九月为之深秋。若以初秋之病为伏暑，转以深秋之病为瘅疟而不为伏暑，并为春间亦有瘅疟，不知出于何书，望为明示，以广见闻。若习俗相传，虽有师承口授，终非前贤确论，未可信为实然也。伤暑之症本应有汗，若瘅疟而至无汗，必因内蕴暑邪，外为凉风所遏，则肺气不达，腠理闭塞，故致无汗，其有汗之瘅疟尚须辛凉解表，至于无汗之瘅疟则非牛蒡、薄荷、桔梗、豆卷等所能胜任矣。非不知更为稳当，其如屡投无效，何举世茫然罔觉，不能一悟，良可慨已。因而想到大青龙汤去姜枣加葛根为法，方中重用石膏为君，少加麻桂为反佐，则无汗之瘅疟庶能发汗而邪可解矣。反佐者如白通汤之用猪胆汁，滋肾丸之用桂心是也。瘅疟魏柏卿注为热毒，视温疟较重。仲师论温疟用白虎加桂枝汤，则无汗之瘅疟用大青龙去姜枣加葛根亦可类推。去姜枣者，姜性更烈，枣恐腻滞也。加葛根者，凉散阳明之邪也。不过伤寒以麻桂为君，瘅疟以石膏为君，若用数钱石膏而以数分麻桂为反佐，亦可无虑。且无汗瘅疟，必热势起伏，日有定时，口渴烦冤，脉洪数，重按实者方可用，若似瘅疟，原不可用，当须识此，不可误也。古人处方，此一味重、彼一味轻，与此一味轻、彼一味重便即法不同而治各异，医者贵在临症权衡也。况此独为瘅疟初起立法，若延至日久，则症已变而治法亦变矣，岂可胶柱鼓瑟哉。《金匮》温疟条中有筋骨烦疼，若谓背独恶寒则未之及也。至瘅疟之初起，病情已载瘅疟浅说内，兹不复赘。至于病变无常，方难执一，无人不知，不待言矣。从前二弟媳素本耐性，偶患疟疾，因将出汗，心中烦躁，遂令打扇，以致汗不得出，邪不能达，终日烦躁异常，遂请令业师医治。议用麻杏甘石汤似矣。鄙意欲加桂枝数分，伊囿于俗见，坚执不肯，以致不效，至今深悔。可见业医者贵有胆识，独具卓见，方能超乎流俗，不致贻误无穷斯可矣。鄙人并非好为辨论，因世俗医之一道皆是浮光掠影，随声附和，毫无实际，不能独出己见。此等本不足与深谈，惟旭翁先生博学明理，超出庸众，心存济世，历练已深，故敢将鄙见直陈。盖医理本不易明，若能彼此讨论，刻意精求，庶或差少错误也。未识高明以为何如？荒谬之见，不知所云，还请教以不逮为幸。
接阅高论，谓时令不可不论。诚然，诚然。夫春温、夏热、秋凉、冬寒，四时之正气也。然春正月余寒未解，交惊蛰节而后阳气方升。秋七月余暑未消，交白露节而后阴气始降。夏至一阴生，正为热盛之候。冬至一阳生，正是寒极之时。盖剥不极则不复，理势使然也。经云：先夏至日者为病温，后夏至日者为病暑。由是推之，则知先秋分日者为病暑，后秋分日者为病凉（补天石有秋凉伤寒之说，凉极而后燥，交九十月燥病方生）。先冬至日者为病燥（喻嘉言补秋燥论谓经文脱却长夏伤干湿，以致后人不明秋伤于燥、冬生咳嗽云云），后冬至日者为病寒。先春分日者为病寒，后春分日者为病温矣。常见春末夏初温病流行，阖门传染，屡经反覆，延至夏至后小暑节仍有战汗而愈者，原属温邪，非关伤暑，此则病之余气，非时之余气也。又常见夏至以后起病有似温邪。延及小暑节，热势朝和，过午则盛，但热不寒，竟与瘅疟相同，此温暑之交，抑或所谓温疟耶。喻氏云：夏伤于暑，长夏伤于湿。由是推之，初秋瘅疟，夏伤于暑之为病也，深秋伏暑，长夏伤于湿之为病也。瘅疟由乎夏伤暑，故热症多而病势重，病重故不易速愈也。伏暑由乎长夏伤湿，故湿症多而病势缓，缓则淹缠，故亦不易速愈耳。
再阅高论，所云无汗之瘅疟必因内蕴暑邪，外为凉风阻遏，肺气不达，腠理闭塞，亦诚确论。借用大青龙汤，重用石膏，少佐麻桂，亦无不可，但必重用石膏清肺胃之热，则知瘅疟责重肺胃无疑矣。尊见亦明知瘅疟病在肺胃，第以为肺胃之病意见相同，不遑多赘。至于白虎加桂枝，骨节烦疼，见《金匮》背独恶寒句，见伤寒审证集，引证用方要归着实，此即着实处也。语云：读书多不如临症多。果能读书、临症二者皆到，更为美备，惜言之易而行之难。其惟终日劳劳，荒疏无学，辱承教示，冒渎粗陈，伏维叹政。
Chuanxiong (Ligusticum Rhizome) 1 qian, Quan Danggui (Angelica Sinensis Root, stir-fried with vinegar) 3 qian, Chishao (Red Peony Root) 1.5 qian, Shudi (Prepared Rehmannia Root) 4 qian, Renshen (Ginseng Root) 3 qian, Yun Fuling (Poria, from Yunnan) 3 qian, Dongzhu (Atractylodis Macrocephalae Rhizoma, stir-fried with soil) 3 qian, Zhi Gancao (Honey-fried Licorice Root) 6 fen, Guang Chenpi (Tangerine Peel) 1 qian, Taoren (Peach Kernel, pounded into paste) 3 qian, Xinjiang (Safflower-infused silk) 1 qian, Sumu (Calamus Wood) 1.5 qian, Wulingzhi (Trogopterus Dung) 3 qian, Shang Guixin (Cinnamon Twig Heart) 5 fen, Yanhusuo (Corydalis Rhizome) 1.5 qian.
Reference: Shengjiang (Fresh Ginger Slice) 3 slices, Dazao (Jujube Fruit) 2 pieces, Qingcongguan (Green Onion Tube) 3 roots. Additionally add Dahong Jiguanhua (Blood-red Cockscomb Flower) 1 liang; if using dried material, reduce by half.
The above prescription uses Sijunzi Tang (Four Gentlemen Decoction) to tonify Qi, Siwu Tang (Four Substance Decoction) to nourish Blood, Chenpi and Yanhusuo to move Qi, and Taoren, Xinjiang, Sumu, and Wulingzhi to invigorate Blood. The use of Guixin is because blood does not stagnate when warmed. The reference of Jiang and Zao is to harmonize Ying and Wei (Nutritive and Defensive levels); Qingcongguan travels directly to the Chong Mai (Penetrating Vessel); Dahong Jiguanhua, although only described in Bencao Gangmu as invigorating blood, can actually lead the various herbs into the uterus. It is a specific herb essential for treating this condition. Because its shape resembles the placenta in a pig's uterus, it serves as a guiding herb for the uterus. This theory comes from Mr. Tu Jianzhai of Yixing and is not a speculative statement. If Renshen is unavailable, replace it with Lushen (Codonopsis Root) 8 qian, add one cup of wine, decoct and take; ten doses will surely show efficacy. If the pregnancy is early and Qi and Blood are slightly weak, take the former formula. If the pregnancy is advanced and Qi and Blood are severely damaged, take the latter formula.
Recorded by Gu Wenshan of Xishan in mid-autumn of the fourth year of Xianfeng.
Appendix: Discussion on Dan Nue (Hot Malaria) by Physician Wang
Carefully reading your discussion stating that Dan Nue mostly arises from latent Summerheat, such as Summerheat necessarily carrying dampness, pathogenic factors lying hidden in Taiyin, Taiyin combined with Yangming disease resulting in Dan Nue, Taiyin combined with Shaoyang disease resulting in Malaria, as well as the isolation of Yin Qi and the solitary emission of Yang Qi, all these explanations are extremely clear and lucid; I admire them deeply. However, from my humble opinion, latent Summerheat has its own pathology, and Dan Nue has had its name since ancient times. Physicians in Xi County often refer to Dan Nue and latent Summerheat diseases. Among the physicians in Chengjiang who refer to latent Summerheat, there are also cases of Dan Nue among them. How to distinguish them? One must know that Dan Nue is a heat syndrome. Carefully studying the classic texts, such as "the lungs have long possessed heat," and "pathogenic factors hide internally in the heart, externally combining between the muscle interstices, causing heat with shortness of breath, vexation and grievance, wasting and emaciation of muscles," we know that in summer and autumn, Dan Nue is mostly due to Summerheat-heat. Summerheat damages Qi, hence "shortness of breath"; Summerheat enters the heart first, hence "pathogenic factors hide internally in the heart." Ancient formulas like Baihu Tang (White Tiger Decoction) and Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction) are the correct treatment methods for Dan Nue. Recently, Xue Yipiao established Qingnie Yin (Clear Malaria Drink), which also follows the principle of clearing and resolving. As for Baihu Jia Guizhi Tang (White Tiger Decoction plus Cinnamon Twig), it should only be used when seeing severe heat, vexation, and thirst, accompanied by chills specifically on the back, and painful distension of the bone joints. Cheng Yunlai, in his *Annotations on the Golden Cabinet*, stated that Baihu clears Qi and Guizhi enters the Ying level, treating the Heart-Ying and Lung-Wei levels; this is merely empty talk on paper, pleasing to look at but likely not an accurate conclusion. Regarding the initial stage of latent Summerheat, with slight chills and slight fever, normal activities, white tongue coating, ability to eat without hindrance, no hunger when not eating, lingering for ten days before the disease condition gradually worsens, this is truly what is called latent Summerheat, caused by damp-heat. To treat Summerheat diseases and latent Summerheat, Yu Jiayan's discussions on formulas in the Summerheat chapter are quite detailed; referring additionally to Xie Shengbai's thirty-three articles on Damp-Heat offers many new methods capable of addressing infinite variations. A person of high wisdom surely understands this clearly, so there is no need to elaborate here. According to ancient sayings, Summerheat belongs to Fire, Summerheat necessarily carries dampness, Summerheat damages Qi, Summerheat tends to enter the Heart, Summerheat pathogens linger in the Upper and Middle Jiao, permeating the Three Jiao, etc., treatments vary greatly. Therefore, formulas for treating Summerheat include warming, clearing, draining, and tonifying, dispersing, unblocking, and promoting urination, varying endlessly. All rely on observing the manifestations, making it difficult to summarize in one sentence. Your proposal of using Shengma and Gegen (Kudzu Root) creates a new method, indeed meaningful, worthy of emulation and transmission, benefiting future learners. There are many wise people in the world who will have their own judgments; there is no need for my praise.
Reply Letter
Having received and read your discussion, it is very clear; I am filled with admiration. However, this condition occurring from after the Summer Solstice to early autumn is called Dan Nue. Occurring from late autumn to early winter is called latent Summerheat. In reality, both stem from Summerheat injury. Latent Summerheat refers to deep autumn coolness where Summerheat pathogens lie hidden in the Ying level. Your view seems to divide this disease suddenly into two categories based on the idea that latent Summerheat has its own pathology and Dan Nue has its ancient name. Yet, if there was an ancient name for Dan Nue, there must have been its reality. What symptoms constitute Dan Nue? Or is there ancient Dan Nue but no modern Dan Nue? Reading this leaves me full of doubts. Zhang Zhongjing formulated Baihu Jia Guizhi Tang with profound meaning. You dismiss Cheng Yunlai's annotations as empty talk on paper; then aren't all discussions by ancient sages just empty talk on paper, unable to manifest in actual practice? I am not an expert in this field, nor a practitioner, but having doubts, I cannot help but ask. I hope you will enlighten me clearly; this would be my fortune.
*Huangdi Neijing* (The Yellow Emperor's Inner Canon) is an immortal work of millennia. Its discussions on meridians, zang-fu organs, shu points, Yin-Yang, Five Elements, and Six Qi are words that only a sage could speak. Zhang Zhongjing's *Shanghan Lun* (Treatise on Cold Damage) and *Jingui Yaolue* (Essential Prescriptions of the Golden Cabinet) are also immortal works. They contain theories, signs, formulas, and methods. Adding one extra herb makes it a different formula; changing one pulse diagnosis makes it a different syndrome. Only a sage could speak even a single word regarding these. However, what *Neijing* discusses is the substance (Ti), while what Zhang Zhongjing discusses is the function (Yong). These two books embody the essential way of mutual reliance between substance and function. The syndrome of Dan Nue is recorded in both *Neijing* and *Jingui*, though not in detail. Generally, diseases caused by the four seasons appearing in winter are called Zheng Shanghan (True Cold Damage). But if winter cold turns warm unexpectedly, there is Dongwen (Winter Warmth). As for injuring cold in winter, transforming into warmth in spring, and heat in summer, this is called Fuqi (Latent Pathogen). Thus, those appearing in late spring and early summer are called Wenre Bing (Warm-Thermal Disease). Occasionally, Wenre Bing presents with forms similar to Wendan Nue, commonly known as Chunwen Simie (Spring Warmth resembling Malaria), Chunwen Dan Nue, Shiwen Simie (Damp-Warmth resembling Malaria), or Shiwen Dan Nue. Whether passed down through lineage or transmitted by custom, they are not named arbitrarily. Roughly speaking, heat diseases appearing after the Summer Solstice are called Re Bing (Heat Disease), which corresponds to Shuwen (Summerheat Warmth) in the new book *Wenbing Tiaobian*. Those carrying dampness are called Shiwen. For Shiwen treatment, ancient formulas use Cangzhu Baihu Tang (Atractylodes and White Tiger Decoction); thus, knowing there is no dampness, for pure heat, Baihu Tang is the correct method for treating Summerheat-heat. Nowadays, during intense summer heat, if sudden cool winds and thunderstorms occur causing illness, this is Summerheat-heat suppressed by violent cold. Initially use Xiangru (Mosla Herb) to release the exterior. After several doses, if it suddenly transforms into severe heat, great vexation, and thirst, accompanied by chills specifically on the back and painful distension of bone joints, Baihu Jia Guizhi Tang is appropriate. From this perspective, Baihu Tang is the standard formula for Summerheat-heat; adding Cangzhu for dampness, adding Guizhi for cold—this is clear and accurate. Cheng Yunlai's annotation that Baihu clears Qi and Guizhi enters Ying is not unreasonable, yet lacks fluency. I, being unlearned, dare not criticize former sages. However, identifying syndromes and prescribing medications must return to practicality. Like Ke Runbo correcting the syndrome of Yebibo Tang in *Laisu Ji*, only those with courage and insight can read ancient books; one must possess independent judgment and not be deceived by ancients. This is similar. After Great Heat, around Early Autumn, there is often pure heat without chills, which is Dan Nue. Alternating chills and fever indicates Malaria. At this time, treatment is still relatively easy because the Summerheat pathogen has not penetrated deeply. After the Autumn Equinox, during Cold Dew and Frost Descent, the pathogen penetrates deeper, and the disease becomes more severe. How could there be no Dan Nue syndrome in the latent Summerheat category! Zhang Zhongjing said: Taiyang disease, whether fever has already appeared or not, must present with chills, body pain, vomiting, tight pulse, and absence of sweating, named Shanghan. If the pulse is slow and there is sweating, it is named Fengzhong (Wind Strike). Thus, Fengzhong is distinguished from Shanghan. As for Dan Nue, it is a heat syndrome. Even at the onset, it must present with heavy heat, vexation, red tongue without coating, or very thin coating, differing from the initial stage of latent Summerheat which has slight heat, languid state, and slippery white coating. Therefore, even in late autumn, if the onset presents with heavy heat and vexation, it belongs to Dan Nue and cannot be called latent Summerheat. Summer-dampness internal accumulation, slight heat, languid state, white greasy tongue coating, even in early autumn, resembles latent Summerheat, but is named Shiwen Bing (Damp-Warmth Disease) rather than latent Summerheat. You Zaijing explained "Wind injures Wei, Cold injures Ying" saying: Mild cold only injures Wei, while severe wind affects Ying. When Wei is solid, wind is hard to expel; when Wei is deficient, cold fails to secure. Anciently, Daqinglong Tang (Major Green Dragon Decoction) was said to treat Wind-Cold injuring both Ying and Wei. Who knew it was actually a formula for Wind striking solid Wei. Wind is a Yang pathogen, internally郁 (stagnating) transforming into fire, causing extreme vexation, hence using Shigao (Gypsum). Solid Wei with no sweat, fever, and chills, hence using Ma Huang (Ephedra) and Gui Zhi (Cinnamon Twig). This explanation surpasses millennia. Another explanation on Summerheat disease states: Summerheat belongs to Fire, necessarily carrying dampness. Thus, those with Yin deficiency and abundant fire harbor Summerheat within fire. Those with Yang deficiency and abundant dampness harbor Summerheat within dampness. This is also a famous saying, not superficial. From this, we see that patients with Dan Nue are mostly those with Yin deficiency and flourishing fire, following the classic teaching "lungs have long possessed heat." Patients with latent Summerheat are numerous among those with Yang deficiency and dampness predominance, reflecting the nature of dampness being stagnant and moist. Only when dampness stagnates does it transform into heat; the six qi all transform from fire. Therefore, damp-heat latent Summerheat diseases may also transform into dryness requiring clearing methods; this must be known. Since Dan Nue mostly involves dry-heat, clearing and resolving is the correct method. What is clearing and resolving? It is Acrid-Cool. Such as Bohe (Mint), Niubang (Arctium Fruit), Jiegeng (Platycodon Root), Lianqiao (Forsythia Fruit), Doujuan (Soybean Sprout), Qinghao (Artemisia Annua), Zhuye (Bamboo Leaf), Lugeng (Reed Rhizome), etc. Because the disease has just begun, later generations dare not start with Baihu Tang, but use light cooling and resolving agents. The intent is the same, but the dosage differs greatly. Mr. Yi Weng, loving learning and deep thinking, specifically proposed using Gegen and Shengma as the opening method for Dan Nue. Does this not show outstanding insight? However, for latent Summerheat, the pathogen mostly resides in Foot-Taiyin Spleen; using Shengma and Gegen to extract latent pathogens from Spleen and Stomach has considerable significance. For Dan Nue, the pathogen mostly resides in Hand-Taiyin Lung. The Lung governs Qi transformation in the whole body and is a clear and descending organ; it seems appropriate to use light clearing and dispersing methods for stability. Disease conditions change infinitely; prescribing laws rely entirely on observed symptoms. Therefore, for Dan Nue presenting with deficiency, add Shashen (Glehnia Root), Maidong (Ophiopogon Tuber), Yangshen (American Ginseng); for those carrying dampness, add Lugeng, Huashi (Talcum), Chuantongcao (Akebia Stem). If heat is severe with great vexation and thirst, use Baihu Tang directly. If heat is severe with accompanying deficiency, use Baihu Jia Renshen Tang (White Tiger Decoction plus Ginseng) or Zhuye Shigao Tang. If heat is severe with vexation/thirst, excessive drinking, and carrying dampness, Hejian's Wuling Sanshi Ganlu Yin (Five Ingredients and Three Stones Sweet Dew Drink) is excellent. If the above symptoms carry dampness and turbidity retention, Hezi's Ganlu Yin is particularly good. All revolve around the two characters "Lung Heat," subsequently spreading to the Three Jiao, generating fluids, lowering fire, tonifying Qi, and nourishing Yin, always focusing on Lung and Stomach, not reaching Spleen and Kidney. This is also a measure for cultivating Yuan (Primordial) Qi after dampness disease. This is the general outline of Dan Nue treatment, insufficient to discuss with the enlightened. Although disease changes are unpredictable and formulas cannot be rigidly applied, based on my experience, the same disease treated differently depending on constitution requires varied methods. Zhang Luyu's *Yitong* has two volumes on clarifying concurrent syndromes, most lucid; reading them in spare time keeps the mind agile. Presuming familiarity, I venture to speak frankly, hoping for your consideration.
Reply Letter
Having received your high discourse, citing proofs comprehensively and explaining principles in detail, sufficient evidence of profound scholarship; I admire you immensely! However, *Neijing*, *Jingui*, and various post-historical formula discussions are books any practicing physician reads; there is no need for tedious repetition. I, because I saw Summerheat injuries in summer and autumn lingering for long periods with unpredictable transformations, and physicians failing to cure quickly, thus briefly expressed my views to propose this minor discussion, specifically referring only to Dan Nue with sweating and Dan Nue without sweating, not involving other diseases. If it is Chunwen, Dongwen, Shiwen, Wenre, etc., or coming from Shanghan, or contracting seasonal pathogens, or latent pathogens reacting with new pathogens to cause disease, the syndromes are not uniform, and treatments are not uniform. If one wishes to list them clearly, one sheet of paper is insufficient; *Wenbing Tiaobian* has already mentioned the general outline. Summer and autumn diseases include those with pure heat without chills and no fluctuations, and those with alternating chills and fever without fixed timing; both differ from Dan Nue and cannot be treated uniformly under the example of Dan Nue. Among these are cases of winter cold injury, pathogens lying hidden internally, triggered by summer heat in summer. There are extremely severe cases that must be known. Discussing summer heat injury diseases is common, but Dan Nue is the most severe among Summerheat diseases. Ancients said "Summer injury by Summerheat leads to Autumn malaria," never saying "Summer injury by Summerheat leads to Spring malaria." Thus, it is clear that Malaria is an Autumn/Winter disease, not a Spring disease. Diseases in Spring also resemble Malaria, arising from Shaoyang involvement in Shanghan; discussing them together with Autumn Malaria would be erroneous. Furthermore, those with Ying-Wei deficiency presenting alternating chills and fever represent severe deficiency, visible in pulse diagnosis, requiring tonification; physicians must know this. *Neijing* and *Jingui* categorize Dan Nue under Malaria syndromes, confirming Dan Nue is a Summer/Autumn disease, not a Spring disease. Ancients said "Before Summer Solstice is Warmth disease, after Summer Solstice is Summerheat disease." Thus, seasonality cannot be ignored. July is early autumn, September is late autumn. If considering early autumn diseases as latent Summerheat, and late autumn diseases as Dan Nue rather than latent Summerheat, and claiming Dan Nue also occurs in Spring, I do not know which book this comes from. I hope you will clarify to broaden knowledge. If transmitted by custom, despite oral instruction from teachers, it ultimately is not the confirmed theory of former sages and cannot be believed as fact. Summerheat injury diseases originally should have sweating. If Dan Nue reaches a state of no sweating, it must be due to internal Summerheat pathogens being suppressed by external cool winds, preventing Lung Qi from reaching, closing the pores, thus causing no sweating. Dan Nue with sweating still requires Acrid-Cool exterior release; Dan Nue without sweating cannot be handled by Niubang, Bohe, Jiegeng, Doujuan, etc. I do not know [other methods] are safer, but what to do when repeated prescriptions fail? The world is ignorant and unaware, unable to realize this, truly lamentable. Hence, I thought of modifying Daqinglong Tang by removing Jiang and Zao, adding Gegen. Using Shigao heavily as the sovereign herb, adding small amounts of Ma Huang and Gui Zhi as counter-agents, then Dan Nue without sweating might induce sweating and resolve the pathogen. Counter-agents are like using Pig Bile in Baitong Tang or Guixin in Zishen Wan. Wei Boqing annotated Dan Nue as Heat-Toxin, viewing it as heavier than Wen Nue (Warm Malaria). Zhang Zhongjing discussed Wen Nue using Baihu Jia Guizhi Tang; thus, Dan Nue without sweating using Daqinglong Tang minus Jiang/Zao plus Gegen can be inferred similarly. Removing Jiang and Zao: Ginger is too pungent, Jujube fears cloying/stagnation. Adding Gegen: Coolly disperses Yangming pathogen. In Shanghan, Ma Huang and Gui Zhi are sovereign; in Dan Nue, Shigao is sovereign. If using several qian of Shigao and several fen of Ma Huang/Gui Zhi as counter-agents, there is no worry. Moreover, Dan Nue without sweating must have fluctuating heat, fixed daily timing, thirst, vexation, surging rapid pulse, firm upon heavy pressure; only then can it be used. If resembling Dan Nue but originally unsuitable, it cannot be used; one must recognize this to avoid error. Ancient prescriptions weigh one herb heavily and another lightly, or vice versa; methods differ, treatments vary. Physicians value weighing symptoms clinically. Besides, this law is solely for the initial stage of Dan Nue. If prolonged, symptoms change, and methods change; how can one stick rigidly to rules? *Jingui* Wen Nue clause mentions bone and tendon pain/distress; if claiming chills specifically on the back, this is not mentioned. The initial condition of Dan Nue is already recorded in *Dan Nue Qian Shuo*, so I will not repeat. As for unpredictable changes and non-rigid formulas, everyone knows, no need to say. Formerly, my second sister-in-law was usually patient. She accidentally contracted Malaria. Just as she was about to sweat, she felt vexed inside, so she ordered someone to fan her, causing sweat not to come out, pathogen not to reach, resulting in extreme vexation all day. She asked my master physician to treat. He proposed Maxing Gan Shi Tang, which seemed appropriate. My intention was to add a few fen of Gui Zhi. She, confined by common views, firmly refused, leading to ineffectiveness, regretted deeply to this day. This shows that medical practitioners value courage and insight, possessing unique views to transcend the vulgar and avoid endless errors. I am not fond of debate; because the current medical practice is superficial, echoing others without substance, unable to express independent views. Such people are not worth deep discussion. Only Mr. Xu, learned and reasonable, transcending the mediocre, caring for saving the world, experienced deeply, do I dare to state my views directly. Medical principles are inherently difficult to understand; if we discuss each other and seek precision deliberately, perhaps errors will be fewer. I wonder what you think? My absurd views, I don't know what I'm saying; I hope you will teach me where I fall short.
Having received your high discourse, stating that seasonality cannot be ignored. Indeed, indeed. Spring Warmth, Summer Heat, Autumn Coolness, Winter Cold are the righteous Qi of the four seasons. However, in the first month of Spring, residual cold has not resolved; only after Jingzhe (Awakening of Insects) does Yang Qi rise. In the seventh month of Autumn, residual Summerheat has not dissipated; only after Bailu (White Dew) does Yin Qi descend. At Summer Solstice, one Yin is born, exactly the time of peak heat. At Winter Solstice, one Yang is born, exactly the time of extreme cold. Because peeling does not reach extremity, recovery does not occur; this is the natural trend. The Classic says: "Before Summer Solstice is Warmth disease, after Summer Solstice is Summerheat disease." Inferring from this, we know: Before Autumn Equinox is Summerheat disease, after Autumn Equinox is Coolness disease (Butian Shi has the theory of Autumn Coolness Shanghan; extreme coolness leads to dryness; entering ninth/tenth months, dryness diseases arise). Before Winter Solstice is Dryness disease (Yu Jiayan's supplement to Autumn Dryness Theory states the Classic omitted Long Summer injury by damp/dry, causing later generations to not understand Autumn injury by dryness and Winter coughing, etc.), after Winter Solstice is Cold disease. Before Spring Equinox is Cold disease, after Spring Equinox is Warmth disease. Often seen: Late Spring and Early Summer Warmth diseases epidemic, infecting entire households, recurring repeatedly, extending to Xiaoshu (Minor Heat) after Summer Solstice, still recovering with battle-sweat; originally belonging to Warm pathogens, unrelated to Summerheat injury. This is residual Qi of the disease, not residual Qi of the season. Also often seen: Illness starting after Summer Solstice resembling Warm pathogens. Extending to Xiaoshu, heat moderates in morning, peaks after noon, pure heat without chills, exactly identical to Dan Nue. Is this the intersection of Warmth and Summerheat, or what is called Wen Nue? Mr. Yu said: "Summer injury by Summerheat, Long Summer injury by Dampness." Inferring from this, early autumn Dan Nue is the disease of Summer injury by Summerheat; late autumn latent Summerheat is the disease of Long Summer injury by Dampness. Dan Nue stems from Summer injury by Summerheat, hence mostly heat syndromes and severe disease condition; severe condition means not easily cured quickly. Latent Summerheat stems from Long Summer injury by Dampness, hence mostly damp syndromes and slow disease condition; slow condition means lingering, thus also not easily cured quickly.
Reading your high discourse again, stating that Dan Nue without sweating must be due to internal Summerheat pathogens being blocked by external cool winds, Lung Qi not reaching, pores closed, is indeed an accurate conclusion. Borrowing Daqinglong Tang, using Shigao heavily, assisting slightly with Ma Huang and Gui Zhi, is also acceptable, but must use Shigao heavily to clear Lung and Stomach heat; thus, Dan Nue responsibility lies heavily in Lung and Stomach is undeniable. Your view also clearly knows Dan Nue disease is in Lung and Stomach. Since opinions on Lung/Stomach disease are the same, no need to elaborate further. As for Baihu Jia Guizhi, bone/joint distress, seen in *Jingui* "chills specifically on back" sentence, seen in *Shanghan Shen Zheng Ji*, citing proofs and using formulas must return to practicality; this is the practical point. Saying: Reading more is not as good as experiencing more clinically. If both reading and clinical experience are achieved, it would be more perfect. Regrettably, speaking is easy, doing is hard. I am only busy all day, negligent and unlearned. Honored to receive your teaching, presumptuously stating roughly, humbly requesting correction.