许叔微治一人。内寒外热而发斑。六脉沉细。肩背胸胁斑出数点。随出随隐。旋更
发出。语言狂乱。乃阳为阴逼。上入于肺。转之皮毛。故错乱如狂。非谵语也。肌表
虽热。以手按之。须臾冷透如冰。与姜、附等药数剂。乃大汗而愈。
滑伯仁治一人。身大热。脉沉实而滑。四末微清。以灯烛之。遍体皆赤斑。舌上苔黑。
而燥裂芒刺。神昏谵语。以小柴胡加知母、石膏。一夕连进三服。次用大承气下之而安。
吕沧州治一人。脉虚自汗。误与真武汤。遂至神昏。时时熟睡。脉伏不至。而肌热灼
指。此营热致斑之候。非阳病阴脉之比。先与白虎加人参汤化其斑。复以桃核承气下之而愈。
周禹载曰。发斑之证。已致慎其下。及用辛热。更无是理。而病情之变。复有如三案
者。可见病机不可执一。妙在临证化裁耳。故附之。以广识见云。
周禹载曰。喻嘉言尚论篇。阐发仲景伤寒论殊畅也。医门法律。阐发金匮要略殊
贯也。虽皆有所粉本。然学广才张。心灵笔古。以各成其妙者也。至尚论温病云。会
内经之旨。以发仲景不宣之秘。且谓仲景略于治温。而法度错出于治伤寒中。因
内经云。冬伤于寒。春必病温。此一大例也。冬不藏精。春必病温。此一大例也。既冬
伤于寒。又冬不藏精。至春月同时病发。此一大例也。奉此三例以论温证。而详其
治。然后与仲景三阳三阴之例先后合符。盖冬伤于寒。邪藏肌肤。即邪中三阳之
谓也。冬不藏精。邪入阴脏。即邪中三阴之谓也。嘉言之论如此。予谓温病无阴阳
之分也。何也。冬有温气。先开发人之腠理。而寒得以袭之。所谓邪之所凑。其气必
虚。惟不藏精之人而后虚也。虚则寒伤其经。经必少阴者。以少阴脏本虚也。然所
伤原微。且冬月大水当令。其权方盛。微邪不敢抗衡。但卧榻之侧。岂容他人鼾睡。
惟有阻彼生意。暗烁精髓。至于春。时强木长。而水不足以供其资。始则当春而温。
木旺水亏。所郁升发。火气燔灼。病温而已矣。其所伤者寒也。所病者温也。所伏者
少阴也。所发者少阳也。故病必有阳而无阴。药必用寒而远热。黄芩汤其主治也。
则嘉言之论温。有阴有阳。如伤寒三阴经可用辛热者。予曰。否否。不然也。
又曰。冬伤于寒。春必病温。是言所感者本寒也。王叔和云。从立春节后其中无暴
大寒。又不冰雪。有人壮热为病者。此属春时阳气发外。冬时伏寒。变为温病。此亦
明言寒也。变字大妙。嘉言以为非。予独以为确。寒气内伏。郁久而发。自成热矣。伤
寒寒也。暂袭营间。不久而为大热。况迟之又久耶。为热乃自然之理。但不言变。不
足以教天下也。然何以不言热而言温。以春行温令故也。如李明之所云。冬伤于
寒者。冬行春令也。当冬而温。火胜而水亏矣。水既亏。则所胜妄行。土有余也。所生
受病。金不足也。所不胜者侮之。火太过也。火土合德。湿热相助。故为温病。然由明
之所言。是冬温而感之即病者也。非伏寒也。非变也。不然。必无冬温一证也而后
可。既有冬温。则有是气。已有是证矣。由其言以悉冬温。便可垂论不磨。若论春温。
不免贻昧千古矣。经曰。逆冬气则少阴不藏。不藏则寒邪得而入之。伤于肌肤。伏
于骨髓。始知冬为藏精之时。惟逆冬气。遂使少阴之经气不闭。复遭非时之暖。致
令开泄。忽然严寒骤返。不免受伤。故受伤者。仍是寒邪也。因先被温令开泄。似乎
喜寒。且所伤不甚。故不即病。而潜伏于少阴也。然所以不病于冬而病于春者。正
因水在冬为旺时。邪伏于经。且俯首而不敢抗。内郁既久。已自成热。至行春令。开
发腠理。阳气外泄。肾水内亏。至春三月。而木当生发。孰为鼓舞。孰为滋养。生化之
源既绝。木何赖以生乎。身之所存者温也。时强木长。故为温病。余故以彼论冬时
之感温非是。而此论冬月之伏寒最精。愚性甚拙。何敢好议先贤。但以为必如此。
方与冬温两不相阻。且与仲景论温热。必推本自始。动曰伤寒之旨无悖云耳。
门人问曰。伤者寒也。何以病温。答曰。伤寒非病寒乎。而何以热也。寒郁营间。不一
二日而成大热。况伏藏于内者数十日之久耶。夫既邪伤肌肉。何以得入少阴经
中。盖惟不藏精则少阴先病。故邪伤者少阴也。春属木。则自内发出。无论兼太阳
或阳明。总无不由少阳何也。彼少阳行春令也。然既从少阴矣。何仲景专云太阳
病。盖太阳与少阴相表里也。故以发热为太阳也。曰不恶寒。明无表症也。则其热
自内出。无外邪郁之也。然则仲景复言太少合病者。见发热不恶寒。或兼有耳聋
胁满证也。言三阳合病者。以脉大属阳明。而多眠则热聚于胆也。不言法者。总以
黄芩汤为主治也。乃嘉言复谓有发表三五次而外证不除。攻里三五次而里证
不除。以为在表也又似在里。以为在里也又似在表。此温疫证。感天地人湿气热
气尸气。邪入口鼻。溷淆三焦者相近。与春温全不相涉也。愚故及之。以破后学之惑。
门人复问曰。春温亦间有一二表症者乎。曰有之。伏气之病。虽感于冬。然安保风
之伤人。不在伏气将发未发之时乎。但兼外感者。必先头痛。或恶寒而后热不已。
此新邪引出旧邪来也。或往来寒热。头痛而呕。稍愈后浑身壮热为病者。此正气
又虚。伏发更重也。总之无外证者。以黄芩汤为主治。兼外感者。必加柴胡。或以本
经药轻解。必无发汗之理。故仲景云。发汗已身灼热者。名曰风温。谓误用辛热之
药。既辛散以劫其阴。复增热以助其阳。遂使热更炽。脉俱浮。有如此之危证也。以
及误下误火。严加戒谕者。舍黄芩汤别无治法也。
许叔微治疗一个人。体内有寒，体表发热并出现斑疹。六脉沉细。肩背胸胁部位发出几点斑疹，刚出来就隐没，随即又再次发出。言语狂乱，这是阳气被阴邪逼迫，向上进入肺脏，转注于皮毛，所以神志错乱如狂，并不是谵语。虽然肌表感觉热，但用手按压，片刻后冷透如冰。给予干姜、附子等药物数剂，结果大汗出而痊愈。
滑伯仁治疗一个人。身体大热，脉象沉实而滑。四肢末端微微发凉。用灯烛照看，遍体都是红色斑疹。舌苔黑且干燥，有裂纹和芒刺。神志昏迷，说胡话。用小柴胡汤加入知母、石膏。一晚上连续服用三剂。接着使用大承气汤攻下而安定。
吕沧州治疗一个人。脉虚自汗。误用了真武汤。导致神志昏迷，时常熟睡。脉伏摸不到，但肌肤灼热烫手。这是营分热盛导致发斑的征候，不是阳病见阴脉的情况。先用白虎加人参汤化解斑疹，再用桃核承气汤攻下而痊愈。
周禹载说：发斑的病症，已经应当谨慎使用攻下法，却反而使用辛热药物，这更没有道理了。但病情的变化，又像这三则医案所示。可见病机不可固执一端，妙处在于临证时的灵活变通罢了。所以附上这些案例，以开阔见识。
周禹载说：喻嘉言的《尚论篇》，阐发张仲景《伤寒论》非常通畅。《医门法律》，阐发《金匮要略》非常贯通。虽然都有依据的本源，但他们学识广博，才华施展，心灵手巧，笔法古朴，各自成就了其精妙之处。至于《尚论篇》论述温病，领会《内经》的宗旨，来阐发张仲景未曾宣示的秘密。并且认为张仲景略于治疗温病，而法度交错出现在治疗伤寒中。因为《内经》说：“冬天感受寒邪，春天必定发生温病。”这是一个大原则。“冬天不藏精气，春天必定发生温病。”这也是一个大原则。既冬天感受寒邪，又冬天不藏精气，到了春天同时发病。这是第三个大原则。遵循这三个原则来论述温证，并详细探讨其治法，然后与张仲景三阳三阴的原则先后符合。大概冬天感受寒邪，邪气藏在肌肤，就是邪气侵犯三阳经的意思。冬天不藏精气，邪气进入阴脏，就是邪气侵犯三阴经的意思。嘉言的论述如此。我认为温病没有阴阳之分。为什么呢？冬天有温气，先开发人的腠理，而寒邪得以侵袭。所谓“邪之所凑，其气必虚”，只有不藏精气的人才会虚弱。虚弱则寒邪损伤经脉，经脉必定是少阴经，因为少阴脏本来虚弱。然而所受的邪气原本轻微，而且冬天大水当令，其势正盛，微邪不敢抗衡。只是阻碍那生机，暗中销烁精髓。到了春天，时令强盛，木气生长，而水不足以供给滋养。起初顺应春令而温，木旺水亏，所郁滞之气升发，火气燔灼，这就是温病。其所伤的是寒，所病的是温，所伏藏的是少阴，所发作的是少阳。所以病一定有阳而无阴，用药必定用寒凉而远离温热。黄芩汤是其主治方剂。那么嘉言论述温病，说有阴有阳，就像伤寒三阴经可用辛热药物一样。我说：不对，不是这样。
又说：“冬天感受寒邪，春天必定发生温病。”这是说所感受的本是寒邪。王叔和说：“从立春节后，中间没有暴大的寒冷，也没有冰雪，如果有人壮热生病，这属于春时阳气发于外，冬天伏藏的寒邪，变为温病。”这也明确说是寒邪。“变”字很妙。嘉言认为不对，我独自认为确切。寒气内伏，郁积久了而发作，自然成为热。伤寒是寒邪，暂时侵袭营分之间，不久就成为大热，何况潜伏时间很久呢？成为热乃是自然的道理，但不说“变”字，不足以教导天下人。然而为什么不说热而说温？因为春天施行温令的缘故。像李明之所说的：“冬天感受寒邪”，是冬天施行春令。应当温暖的时候却温暖，火胜而水亏。水既然亏损，则所胜（土）妄行，土有余。所生（金）受病，金不足。所不胜（火）侮之，火太过。火土合德，湿热相助，所以为温病。然而由明之所言，这是冬天感温邪而即时发病的人，不是伏寒，也不是变证。不然，就一定没有“冬温”这一证候才正确。既然有冬温，就有这种气，已有这种证候了。通过他的言论来推究冬温，就可以留下不朽的论述。如果论述春温，不免贻误千古。经文说：“逆反冬气则少阴不藏。不藏则寒邪得而入之。伤于肌肤，伏于骨髓。”这才知道冬天是藏精的时候，只有逆反冬气，遂使少阴经气不闭藏，又遭遇非时的暖热，致使开泄。忽然严寒骤返，不免受伤。所以受伤的，仍然是寒邪。因为先前被温令开泄，似乎喜欢寒冷，且所伤不重，所以不立即发病，而潜伏于少阴。然而之所以不在冬天发病而在春天发病，正是因为水在冬天为旺时，邪气伏于经脉，且俯首不敢抗衡。内郁既久，已自成热。到了施行春令，开发腠理，阳气外泄，肾水内亏。到了春季三个月，木气当生发，谁来鼓舞？谁来滋养？生化之源既然断绝，木靠什么生长呢？身体所存留的是温气。时令强盛，木气生长，所以为温病。所以我以为他论述冬天感受温邪是不对的，而这里论述冬天月伏寒最为精辟。我本性很笨拙，怎么敢喜好议论先贤。只是认为必须这样，才能与冬温两不相冲突，并且与张仲景论述温热，必推本于始，动不动就说伤寒的宗旨没有违背罢了。
门人问：伤者是寒邪，为什么会得温病？回答说：伤寒不就是病寒吗？那为什么会发热呢？寒邪郁结在营分之间，一两天就成为大热，何况潜伏在内数十天之久呢？既然邪气伤了肌肉，怎么会进入少阴经中？大概只有不藏精则少阴先病，所以受伤的也是少阴。春天属木，则从内部发出。无论兼太阳或阳明，总无不经过少阳的。为什么呢？因为少阳行春令。然而既然从少阴开始，为什么张仲景专门说太阳病？因为太阳与少阴相表里。所以以发热为太阳病。说不恶寒，明确没有表证。那么热是从内部发出的，没有外邪郁结。既然如此，张仲景又说太少合病，是见到发热不恶寒，或者兼有耳聋、胁满的症状。说三阳合病，是因为脉大属阳明，而多眠则是热聚于胆。不讲治法，总以黄芩汤为主治。然而嘉言又说有发表三五次而外证不除，攻里三五次而里证不除，认为在表又像在里，认为在里又像在表。这与温疫病，感受天地人的湿气、热气、尸气，邪气入口鼻，混淆三焦的情况相近，与春温全不相涉。我因此提及这些，以破除后学的疑惑。
门人又问：春温也有偶尔有一两个表证吗？回答说：有的。伏气之病，虽然感受于冬天，但是怎能保证风邪伤人，不在伏气将发未发的时候呢？只是兼有外感者，必须先头痛，或恶寒而后热不已。这是新邪引出旧邪。或者往来寒热，头痛而呕，稍愈后浑身壮热生病。这是正气又虚，伏邪发作更重。总之没有外证者，以黄芩汤为主治。兼外感者，必须加柴胡。或者用本经药物轻解。必定没有发汗的道理。所以张仲景说：发汗后身体灼热的，名叫风温。是说误用辛热药物，既辛散以劫夺阴液，又增加热以助长阳气，遂使热更炽盛，脉俱浮，有如此之危重证候。以及误下误火，严加戒谕的，除了黄芩汤别无治法。
Xu Shuwei treated a patient. There was internal cold and external heat, accompanied by the eruption of macules (skin spots). The six pulses were deep and fine. A few macules appeared on the shoulders, back, chest, and hypochondrium, appearing and disappearing rapidly, then reappearing. The speech was delirious and chaotic. This is due to Yang being forced by Yin, moving upward into the Lung, and transferring to the skin and hair, causing mental confusion akin to madness, rather than mere verbal incoherence (delirium). Although the surface felt hot, upon palpation with the hand, it became cold as ice within moments. Several doses of medicines such as Ginger (Shengjiang) and Aconite (Fuzi) were administered, resulting in profuse sweating and recovery.
Hua Bolin treated a patient. The body had high fever, and the pulse was deep, solid, and slippery. The four extremities were slightly cool. Upon inspection with a candle, the entire body was covered with red macules. The tongue coating was black, dry, cracked, and thorny. The spirit was confused, and there was verbal incoherence (delirium). Xiao Chai Hu Tang (Minor Bupleurum Decoction) was modified with Zhi Mu (Anemarrhenae Rhizoma) and Shi Gao (Gypsum Fibrosum). Three doses were taken consecutively in one night. Subsequently, Da Cheng Qi Tang (Major Order the Qi Decoction) was used to purge, leading to stabilization.
Lu Cangzhou treated a patient. The pulse was deficient with spontaneous sweating. Zhen Wu Tang (True Warrior Decoction) was mistakenly administered, leading to coma and frequent deep sleep. The pulse was hidden and imperceptible, yet the skin was scorching hot to the touch. This is a sign of Ying-level heat causing macules, not a case of Yang disease presenting with Yin pulses. First, Bai Hu Jia Ren Shen Tang (White Tiger Decoction plus Ginseng) was used to resolve the macules, followed by Tao He Cheng Qi Tang (Peach Kernel Decoction to Order the Qi) for purging, resulting in recovery.
Zhou Yuzai said: In cases of macule eruption, purgation should already be used with caution; using acrid-hot medicines makes even less sense. However, the variations in disease mechanisms are exemplified by these three cases. It shows that disease mechanisms cannot be rigidly adhered to; the subtlety lies in flexible adaptation during clinical practice. Therefore, these cases are attached to broaden knowledge.
Zhou Yuzai said: Yu Jiayan's *Shanglun Pian* elucidates Zhang Zhongjing's *Shanghan Lun* very clearly. *Yimen Falü* elucidates *Jingui Yaolue* very coherently. Although both have foundational sources, their broad learning and expanded talent, combined with spiritual insight and ancient brushwork, allowed them to achieve their respective excellences. Regarding the discussion of warm diseases in *Shanglun*, it grasps the essence of the *Neijing* to reveal secrets not expounded by Zhang Zhongjing. It posits that Zhang Zhongjing was brief in treating warm diseases, and his methods were intermixed with those for cold damage. As the *Neijing* states: "Injury by cold in winter leads to warm disease in spring." This is a major principle. "Failure to store essence in winter leads to warm disease in spring." This is another major principle. If both winter cold injury and failure to store essence occur, and the disease manifests simultaneously in spring, this is a third major principle. Following these three principles to discuss warm syndromes and detailing their treatment aligns sequentially with Zhang Zhongjing's principles of the Three Yang and Three Yin. Generally, winter cold injury implies evil qi hiding in the skin and muscles, meaning invasion of the Three Yang channels. Failure to store essence implies evil entering the Yin organs, meaning invasion of the Three Yin channels. Jiayan's argument is thus. I argue that warm diseases do not distinguish between Yin and Yang. Why? Winter warmth opens the pores first, allowing cold to invade. As stated, "Where evil gathers, Qi must be deficient." Only those who fail to store essence become deficient. Deficiency allows cold to damage the meridians, specifically the Shaoyin meridian, because the Shaoyin organ is inherently deficient. However, the initial injury is slight, and since water dominates in winter with strong authority, slight evil dares not resist. It merely obstructs life energy, secretly consuming essence. By spring, when wood grows vigorously but water is insufficient to nourish, the initially warm condition arises from wood flourishing and water declining. Stagnant Qi rises, fire burns fiercely, resulting in warm disease. What was injured is cold; what becomes diseased is warmth; what lies dormant is Shaoyin; what erupts is Shaoyang. Thus, the disease involves only Yang, not Yin; medication must use cold and avoid heat. Huang Qin Tang (Scutellaria Decoction) is the primary treatment. Therefore, Jiayan's theory on warm diseases includes both Yin and Yang, similar to how Shaoyin/Saoyang/Yangming cold damage might use acrid-hot medicines. I say: No, this is incorrect.
Furthermore, "Winter cold injury leads to spring warm disease" refers to the original pathogen being cold. Wang Shuhe stated: "After the Start of Spring, if there is no severe cold or snow/ice, and someone suffers from high fever, this belongs to spring yang emerging externally, where winter latent cold transforms into warm disease." This also explicitly mentions cold. The character "transform" (bian) is excellent. Jiayan disagrees, but I firmly agree. Cold qi lying dormant internally, after long stagnation, naturally generates heat. Cold damage is cold, temporarily invading the Ying level, soon becoming high fever; how much more so after months of dormancy? Generating heat is natural. Not using the word "transform" fails to teach the world. But why say "warm" instead of "heat"? Because spring enacts warm commands. As Li Mingzhi said: "Winter cold injury" means winter enacting spring commands. Warmth in winter means fire prevails and water declines. Water decline leads to Earth overacting, Metal suffering, and Fire insulting. Fire and Earth combine, damp-heat assists, hence warm disease. However, Li's view describes immediate illness from winter warmth, not latent cold or transformation. Otherwise, "winter warm" syndrome would not exist. Since it exists, the qi and syndrome exist. His words clarify winter warm but obscure spring warm for millennia. The Classic says: "Violating winter Qi causes Shaoyin to fail to store; failing to store allows cold evil to enter, injuring skin/muscles, hiding in marrow." Thus, winter is for storing essence. Violating winter Qi leaves Shaoyin open, encountering unseasonal warmth, causing pore opening. Sudden return of cold causes injury. The injury is still cold. Due to prior warmth opening pores, it seems to prefer cold, and the injury is light, so it does not manifest immediately but hides in Shaoyin. Why manifest in spring, not winter? Because water is prosperous in winter, evil hides in meridians, submitting without resistance. Long internal stagnation generates heat. When spring commands arrive, pores open, Yang escapes, Kidney water declines. In spring months, wood should grow, but lacks support/nourishment. Life source is cut off; how can wood grow? The body retains warmth. Strong spring and growing wood result in warm disease. Thus, I consider his theory on winter warmth incorrect, while his theory on winter latent cold is precise. Though humble, I dare not criticize sages, but believe this aligns with winter warm and respects Zhang Zhongjing's origins, maintaining consistency with cold damage principles.
A disciple asked: Injury is cold, why warm disease? I replied: Is cold damage not cold disease? Then why fever? Cold stagnating in Ying becomes high fever in 1-2 days; how much more after months of dormancy? If evil injures muscle/skin, how does it enter Shaoyin? Only failure to store essence causes Shaoyin to be sick first; thus, Shaoyin is injured. Spring belongs to Wood, emitting from within. Whether involving Taiyang or Yangming, it always passes through Shaoyang, because Shaoyang enacts spring commands. Since it starts from Shaoyin, why does Zhang Zhongjing specify Taiyang disease? Because Taiyang and Shaoyin are exterior-interior pairs. Fever indicates Taiyang. Non-aversion to wind indicates no exterior syndrome. Heat comes from within, without exterior stagnation. Thus, "Taiyang-Shaoyin combined disease" refers to fever without aversion, possibly with deafness or fullness in hypochondrium. "Three Yang combined disease" refers to large pulse (Yangming) and somnolence (heat gathering in Gallbladder). Treatment is not specified generally, but Huang Qin Tang is primary. Jiayan argues that repeated exterior-releasing or interior-purging fails to resolve symptoms, suggesting ambiguity between exterior/interior. This resembles epidemic warm diseases caused by heaven-earth-human damp-heat/corpse qi entering nose/mouth, confusing Sanjiao, which is unrelated to spring warm. I mention this to dispel disciples' doubts.
Another disciple asked: Does spring warm occasionally have exterior signs? I said: Yes. Latent Qi disease, though contracted in winter, may encounter wind pathogens before latent Qi erupts. If complicated by exterior contraction, headache or aversion to cold precedes persistent fever. This is new evil drawing out old evil. Or alternating chills/fever, headache, vomiting, followed by high fever after slight improvement. This indicates deficient Zheng Qi and heavier latent eruption. In short, without exterior signs, Huang Qin Tang is primary. With exterior signs, add Chai Hu (Bupleuri Radix) or lightly release with channel-specific herbs. Sweating is contraindicated. Hence Zhang Zhongjing said: "After sweating, if body is burning hot, it is named Wind-Warm," warning against mistaken use of acrid-hot medicines that deplete Yin and assist Yang, causing fierce heat and floating pulses—such critical conditions. Mistaken purgation or moxibustion are strictly forbidden. Besides Huang Qin Tang, there is no other treatment method.