诒按∶张路玉于正伤寒外，详列四时外感、类伤寒各病，并采辑各家之说，备着于篇，其论亦至悉矣。惟
篇中于冬温、春温、温疫等证与温热病，未能寻源溯流，条分缕析，学人眩焉。兹录其有关于温热病者若干条
为之详加评论，俾读者不至为旧说所淆云。
伤寒者，冬时严寒，感冒杀厉之气而病也。交霜降节后，春分节前，病发头痛者，皆谓之正伤寒。其病有
六经传变、合病、并病诸例，其治法以仲景伤寒论为圭臬。
诒按∶正伤寒病，南方不多见，即间有之，亦鲜重证。凡外感病之重且险者，皆温热病也。
若两感于寒者，一日太阳与少阴合病，二日阳明与太阴俱病，三日少阳与厥阴俱病。至水浆不入，不知人
事者，六日死。然伤寒病两感者亦少，惟温病热病居多。以温热从少阴发太阳，即是两感之证。所以守真特立
凉膈、双解、白虎、承气等汤，以两解其表里之热毒也。
诒按∶石顽每谓温病亦必由少阳而发，初起以柴胡为主
方，而此处又谓少阴出太阳，可知其于温病，未能明辨其原，故论治亦无确见也。且两感证是外内合邪，温热
病是由内达外，其外面见证虽同，而病之来源各异，本不可同日而语也。
至冬令时，反有非节之暖，此属春时阳气发于冬时，未至而至，即为不正之气。人感之而病者，名曰冬温
。其证必心烦呕逆，咽痛，身热头疼，或咳嗽自汗，或头重面肿。但始咽痛，后必下利。以邪入少阴，其经上
循喉，下入腹也。治以阳旦汤加桔梗、葳蕤。
诒按∶此外感风温之邪，冬春间时有之。叶香岩所谓温邪上受，首先犯肺。吴鞠通所用平凉轻剂，银翘、
桑菊之类，恰与此等证相合。盖此病必以清泄肺经为主也。如伤及阴分，则地、麦、元参，可随证加入，吴鞠
通亦已言之。其所主阳旦汤有桂枝之温，必有恶寒、头项强痛之太阳证方合。如有此证，则非温邪伤肺之温病
，而为伏寒内发之温病矣。总由经脉未清，故语多矛盾耳。
至春分节后，天令温暖，有人壮热为病者，乃温病也。经云∶冬伤于寒，春必病温。仲景云∶太阳病发热
而渴，不恶寒者，为温病。盖以冬时伏气，随时令温热之气而发。但所发之因不同，有感非时暴寒而发者，有
饥饱劳役而发者，有房室不慎而发者。所感之客邪既殊，则发出之经络亦异。所谓温病之脉，行在诸经，不知
何经之动也，当随其经证而治之。
诒按∶此数行，说温病源流俱彻，夫何间然。
凡温病之发，必大渴烦扰，胁满口苦，不恶寒反恶热，脉气口反盛于人迎，明系伏邪自内达表，必先少阳
经始。若因客寒而发者，宜小柴胡随所见经证加减。无客邪者，黄芩汤主之。病温病亦多传变并合，未有不及
少阳者。如太阳少阳合病，黄芩汤；少阳阳明合病，承气汤；三阳合病，柴胡汤，或双解散加减。凡三阳表证
，烦热口渴，俱宜黄芩汤之类，据此合病症治；则传变并病，可例推矣。
诒按∶此节论温病证治颇合。惟谓伏邪外达，必由少阳，则囿于旧说，不切病情。且与上文温邪行诸经，
不知何经之动，前后亦自相刺谬矣。
凡治温病热病，无正发汗之理。盖其邪自内达外，无表证明矣。若果证显非时暴寒，恶寒头痛而脉紧者，
亦不可纯用表药，宜栀豉汤或益元散加薄荷、葱、豉；重则凉隔散去硝、黄，加葱、豉，探吐取汗最妙。盖此
怫郁之热，乘春温之气而发，虽有非时暴寒，只宜辛平之剂发散。
诒按∶温邪初起，用葱、豉取汗最稳，不必探吐也。
凡下之前后，或将汗已汗，或下后余热不止，反大汗淋漓者，此实热虽去，而余邪未尽，可与小剂黄芩汤
，或解毒汤调之。
诒按∶若阴津不足之体，用清养胃阴之剂最妙。
若下后，渴虽减而饥欲得食者，此伏邪初散，阴火乘虚扰乱也。凡温热病下后多此，慎勿便与粥饮，得食
则复。
诒按∶近人不明此理，因此而致反复者甚多。
凡温病下后，热不退，下证尚在者，可再三下之，以热退为度。
诒按∶伤寒病粪多坚栗，下之宜猛而重；一下之后，可以连下者甚少。温热病粪多粘黑如酱，下之宜缓而
轻，下后停一、二日，垢热再聚，即当再下，有下至三四日始清者，不得谓已下者不宜再下也。
若下后，热不止，而脉涩咽痛，胸满多汗，此热伤血分也，葶苈苦酒汤探吐之。
诒按∶热伤血分之证，当养血以化余热，如生地、元参、银花、犀角、洋参、竹茹之类，乃合病情。若葶
苈、苦酒之法。决不可投。
所谓交阳者，非阴寒交热而为阳也。乃怫热蓄之于里，郁极乃发，则交传而出于表之阳分，是谓交阳而后
作汗也。或郁而不能出表，是否极不泰，即正气衰残，阴气先绝，阳气后竭而死矣。
夫欲汗而脉忽沉伏者，阳气并入于里故也。交阳而躁乱昏冒者，里热郁极，故神昏而躁扰也。凡战汗而不
快，或战而不汗，此并之不甚，故虽战而病不去也。通宜三一承气汤，或合黄连解毒汤下之，所以散
怫热而开郁结也。凡战汗时，频与热姜汤，助其开发最佳，可免战不快而无汗之患。
诒按∶姜性助热，不如茅根为佳。
凡可下之症，或得下而汗即出者；或服药而怫郁顿开，先汗出而后利者；或利性但随汗泄，则气和而愈竟
不利者；亦有战不快，交不通而死者；或不战而汗出者；或但战无汗而愈者。世俗不知，乃以恶寒战栗为阳虚
阴胜，因而误治者多矣。
诒按∶凡此病情疑似之际，死生反掌，均须用心。
凡温病发于三阴，脉微足冷者，多难治。
凡温病大热，脉反细小，手足逆冷者，死证也。
凡温病初起，大热神昏谵语，热甚脉小足冷，五六日而脉反躁急，呕吐昏沉，舌本焦黑，或失血躁热脉大
，或痉搐昏乱，或脉促结代沉小者，皆死。
温热病，大热不得汗者死；得汗后而反热，其脉躁盛者，亦死也。凡温热误汗之，狂言不能食，其脉躁盛
者，皆不可治也。
诒按∶此节所列温病不治之症，不外三种∶邪气郁伏不达者，一也；正虚不能托邪者，二也；阴气被烁涸
者，三也。
夏至后，炎暑司令，相火用事。有发热身疼，不恶寒但恶热而大渴者，为热病。伤寒例云∶凡伤寒而成温
者，先夏至日为病温，后夏至日为病热。盖久伏之
邪，随时令之暑热而发也。以邪非外来，故但恶热而不恶寒。热自内发，故口燥渴而引饮多。其邪既郁为热，
不宜辛温发汗，不得复指为寒；而仲景仍以伤寒目之者，谓其初受病时，皆寒气郁伏所致耳。世言仲景无温热
治法，试观太阳、阳明篇中黄芩、白虎等汤，岂治伤寒可用之药也。白虎为金神，非盛暑热病，内外热极者，
不可用。气虚人用之，往往成结胸，甚至不救。故有立夏以前、处暑以后，不可妄用白虎之戒。夫伤寒之不可
用黄芩、白虎，犹温病之不可用麻、桂、青龙也。即治温热，亦须无非时暴寒者方可用。
诒按∶此节申明黄芩、白虎，仲景本为温热而设，非伤寒方也。惟节末一转，又设为黄芩、白虎之厉禁。
于理未尝不是，特嫌其于热病正治法，未免喧宾夺主耳。
若温病七八日，或十余日，前邪未除，重感于寒，忽然寒热交作，交为温疟，方书以为坏证。按伤寒例云
∶脉阴阳俱盛，重感于寒，变为温疟。其证胸胁满，烦渴而呕，微恶寒者，治以小柴胡去参、半，如栝蒌根、
石膏。无寒但热，其脉如平，骨节烦疼，时呕者，用白虎汤加桂枝。慎不可辛温发散，以助其虐。
诒按∶前症烦渴微恶寒，宜白虎加桂枝；后症但热不寒，并不得加桂枝矣。
至内经所言，先热后寒之温疟，乃得之冬中于风，
寒气藏于骨髓之中。至春阳气大发，邪气不能出。因遇大暑，脑髓烁，肌肉消，腠理发泄，或有所用力，邪气
与汗并出。此病藏于肾，其先从内出之于外也。如是者，阴虚而阳盛，阳盛则热矣。衰则气复反入，反入则阳
虚，阳虚则寒矣。故先热而后寒，名曰温疟。治宜人参白虎汤，或有客邪，则加桂枝；更以金匮肾气丸去附子
，倍加桂枝作汤，渴则饮之。盖从肾出而大热，则其内先已如焚，故急以白虎退热。迨疟势外衰，复返于肾，
而阴精与之相持，乃为寒。设不知壮水之主，以救其阴，十数发后，阴精竭矣。此伏邪自发之温病，与温病后
重感于寒所变之温疟，名同而实异，然皆不越乎少阴一经，故详辨之，以破此异同之惑。
诒按∶两证来源稍异，而救阴撤热，其治法大致相同。惟前证重感新寒，当随证参用疏邪之意，方为周密
。
柳宝诒按语：张路玉（字石顽）在正伤寒之外，详细列举了四时外感、类伤寒等各类疾病，并采集汇编了各家的学说，记载详尽，其论述也非常周密。只是他在书中对于冬温、春温、温疫等证候与温热病，未能追溯源头、梳理脉络，进行条理分明的分析，导致学习者感到困惑。现在摘录其中关于温热病的若干条内容，加以详细评论，使读者不被旧有的说法所混淆。
所谓伤寒，是冬季感受严寒之气，感染杀厉之气而发生的疾病。从霜降节气后到春分节气前，发病出现头痛的，都称为正伤寒。这类疾病有六经传变、合病、并病等各种情况，其治疗方法以张仲景《伤寒论》为准则。
柳宝诒按语：正伤寒这种病，在南方不多见，即使偶尔有，也很少有重症。凡是外感病中严重且危险的，都是温热病。
如果是两感于寒（表里两经同时受邪），第一天太阳经与少阴经合病，第二天阳明经与太阴经同时发病，第三天少阳经与厥阴经同时发病。到了水浆不能入口、神志不清的程度，第六天就会死亡。然而，伤寒病中出现两感的较少，大多是温病和热病居多。温热之邪从少阴发出而涉及太阳，这就是两感的证候。所以刘完素（字守真）特别创立凉膈散、双解散、白虎汤、承气汤等方剂，来表里双解其热毒。
柳宝诒按语：张石顽常常说温病也必须由少阳经发起，初起以柴胡剂为主方，但在这里又说少阴出太阳，可知他对温病的本源未能明辨清楚，因此治疗观点也不确切。而且，“两感”证是内外邪气合而为病，温热病是由内达外，虽然外在表现症状相同，但疾病的来源不同，根本不可相提并论。
到了冬季时令，反常有非节令的温暖，这属于春季阳气在冬季就发动了，未到时节却提前到来，这就成了不正之气。人感受这种气而生病，名叫冬温。其症状必定有心烦呕逆、咽痛、身热头疼，或者咳嗽自汗，或者头重面肿。开始若是咽痛，后来必定会出现下利。因为邪气侵入少阴经，该经脉上行循行咽喉，下行进入腹部。治疗用阳旦汤加桔梗、葳蕤。
柳宝诒按语：这是外感风温之邪，在冬春季节时有发生。叶天士（字香岩）所说的“温邪上受，首先犯肺”。吴鞠通所用的辛凉轻剂，如银翘散、桑菊饮之类，恰好与此类证候相符。大概此病必须以清泄肺经为主。如果伤及阴分，则地黄、麦冬、玄参，可根据证候加入，吴鞠通也已经说过。他所主张的阳旦汤含有桂枝的温性，必须有恶寒、头项强痛的太阳表证才合适。如果有这些症状，那就不是温邪伤肺的温病，而是伏寒内发的温病了。总归是因为经脉理论未理清，所以言语多有矛盾之处。
到了春分节气后，天气温暖，有人出现壮热而生病的，乃是温病。《内经》说：“冬伤于寒，春必病温。”张仲景说：“太阳病发热而渴，不恶寒者，为温病。”这是因为冬季潜伏的邪气，随着时令的温热之气而发作。只是发作的原因不同，有的是感受非时节的暴寒而发，有的是因饥饱劳役而发，有的是因房事不慎而发。所感受的外来邪气既然不同，那么发出的经络也就各异。所谓温病的脉象，运行在诸经之中，不知道是哪一经动乱，应当根据该经的症状进行治疗。
柳宝诒按语：这几行文字，将温病的源流说得透彻，还有什么可挑剔的呢？
凡是温病发作，必定大渴烦躁，胁肋胀满口苦，不恶寒反而恶热，脉象寸口反盛于人迎，明显是伏邪从内达表，必定先从少阳经开始。如果是因客寒而引发的，宜用小柴胡汤根据所见到的其他经证加减。没有外来邪气的，用黄芩汤主治。温病也多传变并合，没有不涉及少阳经的。如太阳少阳合病，用黄芩汤；少阳阳明合病，用承气汤；三阳合病，用柴胡汤，或双解散加减。凡是三阳表的证候，烦热口渴，都适宜用黄芩汤之类，据此结合病症治疗，那么传变并病的情况，就可以类推了。
柳宝诒按语：这一节讨论温病的证治颇为恰当。只是说伏邪外达，必须由少阳经出发，则是拘泥于旧说，不符合病情实际。而且与前文说的“温邪行于诸经，不知何经之动”，前后也自相矛盾了。
凡是治疗温病热病，没有正发汗的道理。大概因为邪气从内达外，没有明显的表证。如果确实证候显现是非时节的暴寒，恶寒头痛且脉紧，也不可单纯使用解表药，宜用栀豉汤或益元散加薄荷、葱白、豆豉；重的话，用凉膈散去硝石、大黄，加葱白、豆豉，通过探吐取汗最好。大概这种怫郁的热邪，乘着春温之气而发，虽然有非时节的暴寒，只适宜用辛平的药剂发散。
凡是在攻下之前后，或者已经发过汗，或者攻下后余热不止，反而大汗淋漓的，这是实热虽去，但余邪未尽，可以给予小剂量的黄芩汤，或解毒汤调理。
如果攻下后，口渴虽减轻但饥饿想吃东西，这是伏邪刚刚消散，阴火乘虚扰乱所致。凡是温热病攻下后多属这种情况，千万不要立刻给粥饮，进食则会复发。
柳宝诒按语：近代人不明白这个道理，因此导致病情反复的很多。
凡是温病攻下后，热不退，下焦实证仍在的，可以多次攻下，以热退为限度。
柳宝诒按语：伤寒病的粪便多坚硬如栗，攻下宜猛而重；一下之后，很少能连续攻下的。温热病的粪便多粘黑如酱，攻下宜缓而轻，攻下后停一两天，垢热再次聚集，就应当再攻下，有攻下三四天才干净的，不能说已经攻下过的就不宜再攻下。
如果攻下后，热不止，且脉涩咽痛，胸满多汗，这是热邪伤了血分，用葶苈苦酒汤探吐。
柳宝诒按语：热伤血分的证候，应当养血以化除余热，如生地、玄参、金银花、犀角、西洋参、竹茹之类，才符合病情。至于葶苈、苦酒的方法，绝对不可投用。
所谓“交阳”，不是阴寒与热邪交争转化为阳，而是怫热蓄积在体内，郁结至极而发作，于是交传而出于体表的阳分，这叫作交阳而后出汗。或者郁结而不能透出体表，就是否极泰来的反面，即正气衰残，阴气先绝，阳气后竭而死。
想要出汗而脉突然沉伏的，是因为阳气并入于里。交阳而躁乱昏冒的，是因为里热郁结至极，所以神志昏迷而躁扰不安。凡是战汗而不畅快，或者战栗但不出汗的，这是阳气并入得不甚厉害，所以虽然战栗但病不去。通常适宜用三一承气汤，或合黄连解毒汤攻下，以此来散除怫热而开通郁结。凡是战汗时，频繁给予热姜汤，帮助其开发最佳，可以避免战而不快和无汗的祸患。
柳宝诒按语：姜性助热，不如茅根好。
凡是可以用攻下法的证候，有的得下后汗随即出来；有的服药后怫郁顿时开通，先出汗而后大便通利；有的大便通利只是伴随汗液排泄，则气和而痊愈竟然不需要攻下；也有战而不快、阴阳不通而死亡的；或不战而直接出汗的；或者只战栗无汗而痊愈的。世俗之人不懂，竟把恶寒战栗当作阳虚阴胜，因而误治的很多。
柳宝诒按语：凡是这种病情疑似的时候，生死只在反掌之间，都必须用心辨别。
凡是温病初起，大热神昏谵语，热甚脉小足冷，五六日后脉反而躁急，呕吐昏沉，舌本焦黑，或者失血躁热脉大，或者痉搐昏乱，或者脉促结代沉小的，都是死证。
温热病，大热不得汗出的，死；得汗后反而更热，脉象躁盛的，也是死证。凡是温热病误用发汗法，狂言不能食，脉象躁盛的，都不可治。
柳宝诒按语：这一节所列温病不治之症，不外乎三种：一是邪气郁伏不达；二是正气虚弱不能托举邪气外出；三是阴气被灼烧枯竭。
夏至以后，炎暑当令，相火主事。有发热身疼，不恶寒但恶热且大渴的，称为热病。《伤寒例》说：“凡是伤寒而成温病的，先夏至日为病温，后夏至日为病热。”大概是久伏的邪气，随着时令的暑热而发作。因为邪气并非外来，所以只恶热而不恶寒。热从内发，所以口燥渴而引饮多。邪气既已郁结为热，不宜用辛温发汗，不能再指其为寒；而张仲景仍称之为伤寒的，是说其最初受病时，都是由寒气郁伏所致。世人说张仲景没有温热治法，试看太阳、阳明篇中的黄芩汤、白虎汤等，难道是治伤寒可用的药吗？白虎汤属金神，若非盛暑热病，内外热极者，不可用。气虚的人用它，往往造成结胸，甚至无法挽救。所以有立夏以前、处暑以后，不可妄用白虎汤的戒律。伤寒不可用黄芩、白虎，就像温病不可用麻黄、桂枝、青龙汤一样。即使是治温热病，也只有兼有非时节暴寒的情况下才可用。
柳宝诒按语：这一节申明黄芩、白虎汤，张仲景原本是为温热病设立的，不是治伤寒的方子。只是在结尾一转，又设为黄芩、白虎汤的严厉禁忌。于理并非不对，只是嫌其在热病的正治法上，未免喧宾夺主。
如果温病七八日，或十余日，前面的邪气未除，又重感于寒，忽然寒热交作，交互成为温疟，方书认为是坏证。按《伤寒例》说：“脉阴阳俱盛，重感于寒，变为温疟。”其症状胸胁满闷，烦渴而呕，微恶寒的，治疗用小柴胡汤去人参、半夏，加栝楼根、石膏。无寒但热，脉象如常，骨节烦疼，时常呕吐的，用白虎汤加桂枝。千万不可用辛温发散药，以免助长病势。
柳宝诒按语：前症烦渴微恶寒，宜用白虎加桂枝汤；后症但热不寒，并且不得加桂枝了。
至于《内经》所言的先热后寒的温疟，是冬天受了风邪，寒气藏于骨髓之中。到了春天阳气大发，邪气不能排出。如果遇到大暑，脑髓被烤干，肌肉消瘦，腠理开泄，或者有所用力，邪气随汗并出。此病藏于肾，先从内出于外。像这样的，阴虚而阳盛，阳盛则热。衰退时气复反入，反入则阳虚，阳虚则寒。所以先热而后寒，名叫温疟。治疗宜用人参白虎汤，如果有客邪，则加桂枝；再用金匮肾气丸去掉附子，加倍加桂枝作汤剂，渴了就喝它。大概从肾出而大热，则体内先前已如火焚，所以急用白虎汤退热。等到疟势向外衰减，又返归于肾，而阴精与之相持，才表现为寒。假如不知道壮水之主以救其阴，十几次发作后，阴精就枯竭了。这是伏邪自发之温病，与温病后重感于寒所变之温疟，名称相同而实质不同，但都不越出少阴一经的范围，所以详细辨析，以破除这种异同的疑惑。
柳宝诒按语：两种证候来源稍异，但救阴撤热的治法大致相同。只是前证重感新寒，应当随证参考运用疏邪的意思，才算周密。
Liu Baozhi's commentary: Zhang Luyu (courtesy name Shiwan), beyond Zheng Shanghan (Standard Cold Damage), detailed various seasonal external contractions and diseases resembling Shanghan, compiling theories from various schools with thorough documentation. His discussions were indeed comprehensive. However, regarding Dongwen (Winter Warmth), Chunwen (Spring Warmth), Wenyi (Warm Epidemic), and other warm-heat diseases, he failed to trace their origins and analyze them systematically, leaving students confused. Herein, I excerpt several passages concerning warm-heat diseases for detailed critique, so that readers are not misled by old theories.
Shanghan (Cold Damage) refers to illness caused by contracting severe cold and lethal qi during winter. From after the Frost Descent solar term to before the Spring Equinox, if headache occurs upon onset, it is called Zheng Shanghan (Standard Cold Damage). This disease involves transmission through the Six Meridians, combined diseases (Hebing), and concurrent diseases (Bingbing). Its treatment follows Zhang Zhongjing's *Treatise on Cold Damage* (*Shanghan Lun*) as the standard.
Liu Baozhi's commentary: Zheng Shanghan is rare in the South; even when it occurs, severe cases are uncommon. Most severe and dangerous external contraction diseases are actually warm-heat diseases.
If one suffers from "Lianggan" (simultaneous involvement of exterior and interior meridians by cold), on the first day, Taiyang and Shaoyin meridians are involved together; on the second day, Yangming and Taiyin meridians are affected simultaneously; on the third day, Shaoyang and Jueyin meridians are affected simultaneously. When the patient cannot take fluids or food and loses consciousness, death occurs on the sixth day. However, Lianggan in Shanghan is rare; warm diseases and heat diseases are far more common. Warm-heat pathogens emerging from Shaoyin and affecting Taiyang constitute a form of Lianggan. Therefore, Liu Wansu (courtesy name Shouzhen) specifically created formulas such as Liange San (Cooling Pavilion Powder), Shuangjie San (Double Resolution Powder), Baihu Tang (White Tiger Decoction), and Chengqi Tang (Descending Qi Decoction) to resolve both exterior and interior heat toxins simultaneously.
Liu Baozhi's commentary: Shiwan often claimed that warm diseases must originate from the Shaoyang meridian, using Chaihu-based formulas initially. Yet here he states Shaoyin emerges to Taiyang, indicating his failure to clearly distinguish the origin of warm diseases, leading to imprecise therapeutic views. Moreover, "Lianggan" involves the combination of internal and external pathogens, whereas warm-heat diseases arise from within reaching outward. Although external symptoms may appear similar, their origins differ fundamentally and should not be compared.
During winter, unseasonable warmth may occur. This belongs to spring yang energy activating prematurely in winter, constituting abnormal qi. Contracting this leads to Dongwen (Winter Warmth). Symptoms invariably include vexation, vomiting, sore throat, fever, headache, cough with spontaneous sweating, heavy head, or facial swelling. If sore throat appears initially, diarrhea will likely follow because the pathogen enters the Shaoyin meridian, which ascends along the throat and descends into the abdomen. Treatment uses Yangdan Tang plus Jiegeng (Platycodon Root) and Weirui (Polygonatum Rhizome).
Liu Baozhi's commentary: This describes external contraction of wind-warmth, occurring occasionally between winter and spring. Ye Tianshi (courtesy name Xiangyan) stated, "Warm pathogens enter from above, first attacking the Lung." Wu Jutong's mild acrid-cool formulas, such as Yinqiao San (Honeysuckle and Forsythia Powder) and Sangju Yin (Mulberry Leaf and Chrysanthemum Decoction), fit these conditions perfectly. The primary treatment must focus on clearing and draining the Lung meridian. If yin is damaged, Dihuang (Rehmannia Root), Maidong (Ophiopogon Tuber), and Xuanshen (Scrophularia Root) can be added according to symptoms, as Wu Jutong noted. Yangdan Tang contains Guizhi (Cinnamon Twig), which is warming; it is only appropriate if Taiyang syndrome symptoms like aversion to cold and stiffness/pain of the head and neck are present. If such symptoms exist, it is not a warm disease caused by warm pathogens injuring the Lung, but rather a warm disease caused by latent cold erupting internally. The contradictions arise from unclear understanding of meridian theory.
After the Spring Equinox, when weather becomes warm, individuals suffering from high fever have a warm disease. The Classic states: "Injury by cold in winter leads to warm disease in spring." Zhang Zhongjing stated: "Taiyang syndrome with fever and thirst, without aversion to cold, is a warm disease." This occurs because latent pathogens from winter activate with the warming qi of the season. Causes of activation vary: some due to sudden unseasonable cold, some due to dietary irregularities or overwork, some due to sexual indiscretion. Since the external pathogens differ, the meridians affected also vary. As stated, the pulse of warm diseases moves through various meridians, making it unclear which meridian is disturbed; treatment should follow the specific meridian symptoms.
Liu Baozhi's commentary: These lines thoroughly explain the origin and progression of warm diseases; what could be criticized?
Whenever warm diseases manifest, there is typically intense thirst, restlessness, hypochondriac fullness, bitter taste, aversion to heat rather than cold, and a stronger pulse at the Cun Kou (radial artery) compared to Ren Ying. This clearly indicates latent pathogens moving from interior to exterior, necessarily starting from the Shaoyang meridian. If triggered by external cold, Xiaochaihu Tang (Minor Bupleurum Decoction) should be modified based on observed meridian symptoms. Without external pathogens, Huangqin Tang (Scutellaria Decoction) is indicated. Warm diseases often involve transmission and combination, rarely sparing the Shaoyang meridian. For Taiyang-Shaoyang combined disease, use Huangqin Tang; for Shaoyang-Yangming combined disease, use Chengqi Tang; for Three Yang combined disease, use Chaihu Tang or modified Shuangjie San. For all Three Yang exterior syndromes with vexation, heat, and thirst, Huangqin Tang-type formulas are suitable. Based on combined disease treatments, transmission patterns can be inferred.
Liu Baozhi's commentary: This section on warm disease diagnosis and treatment is quite accurate. However, claiming latent pathogens must reach the exterior via Shaoyang adheres too rigidly to old theories and does not fit clinical reality. It contradicts the earlier statement that warm pathogens move through various meridians unpredictably.
Treating warm and heat diseases generally lacks a rationale for standard diaphoresis (sweating), as pathogens emerge from within without clear exterior signs. If symptoms clearly indicate sudden unseasonable cold with aversion to cold, headache, and tight pulse, pure exterior-releasing drugs should not be used alone. Instead, Zhichi Tang (Gardenia and Fermented Soybean Decoction) or Yi Yuan San plus Bohe (Mint), Congbai (Green Onion White), and Chishao (Red Bean) may be used. In severe cases, Liangge San minus Xiaoshi (Mirabilite) and Dahuang (Rhubarb), plus Congbai and Chishao, administered via induced vomiting to induce sweating, is optimal. This stifled heat erupts with spring warmth; even with unseasonable cold, only acrid-ping (neutral) dispersing agents are appropriate.
Liu Baozhi's commentary: Using Congbai and Chishao to induce sweating is safest for early-stage warm pathogens; induced vomiting is unnecessary.
Before or after purgation, or after sweating, if residual heat persists causing profuse sweating, although excess heat is gone, lingering pathogens remain. Small doses of Huangqin Tang or Jiedu Tang (Detoxification Decoction) can regulate this.
Liu Baozhi's commentary: For patients with insufficient yin fluids, formulas clearing and nourishing stomach yin are best.
If after purgation, thirst decreases but hunger arises, it indicates latent pathogens have just dispersed, allowing ministerial fire to disturb due to deficiency. This is common after purging warm diseases; do not immediately give porridge or drinks, as eating causes relapse.
Liu Baozhi's commentary: Modern practitioners often misunderstand this, leading to frequent relapses.
If after purging warm diseases, heat persists and lower-jiao excess signs remain, repeated purgation is permissible until heat subsides.
Liu Baozhi's commentary: In Shanghan, stools are usually hard; purgation should be strong. Rarely is consecutive purgation needed. In warm diseases, stools are sticky and dark like paste; purgation should be gentle. After purging, if turbid heat reaccumulates after one or two days, purgation should resume. Some require three to four days of purging to clear; one cannot say previously purged cases should not be purged again.
If after purging, heat persists with choppy pulse, sore throat, chest fullness, and excessive sweating, heat has injured the blood level. Tingli Kujiu Tang (Descurainia and Vinegar Decoction) via induced vomiting is indicated.
Liu Baozhi's commentary: For heat injuring blood, nourishing blood to transform residual heat is correct, using Shengdi (Rehmannia Root), Xuanshen, Jinyinhua (Honeysuckle Flower), Xijiao (Rhinoceros Horn - now substituted), Yangshen (American Ginseng), Zhuru (Bamboo Shavings). Tingli and vinegar methods are absolutely contraindicated.
"Jiaoyang" (Transition to Yang) does not mean yin-cold transforming into yang. It means stifled heat accumulates internally, reaches extreme stagnation, and then transitions outward to the exterior yang level, resulting in sweating. If stagnation prevents emergence, it signifies extreme yin blocking yang, where righteous qi declines, yin exhausts first, and yang exhausts subsequently, leading to death.
When sweating is desired but the pulse suddenly sinks and hides, it is because yang qi merges inward. Transitioning to yang with restlessness and coma results from extreme internal heat stagnation disturbing the spirit. In "Zhanhan" (shivering sweating) that is ineffective or shivers without sweating, the merging of qi is incomplete, so the disease persists despite shivering. Generally, Sanyi Chengqi Tang or a combination with Huanglian Jiedu Tang should be used to dissipate stifled heat and open stagnation. During Zhanhan, frequently giving hot ginger soup aids development best, avoiding ineffective shivering and lack of sweat.
Liu Baozhi's commentary: Ginger promotes heat; Mugen (Imperata Rhizome) is superior.
For purgable syndromes, some sweat immediately after purging; some experience sudden opening of stagnation after medication, sweating first then having bowel movements; some pass stool merely accompanying sweat, achieving harmony and recovery without needing purgation; some die from ineffective shivering and blocked transition; some sweat without shivering; some recover with only shivering and no sweat. Laypeople mistake aversion to cold and shivering for yang deficiency and yin excess, leading to many mis-treatments.
Liu Baozhi's commentary: In ambiguous situations like these, life and death hang in the balance; careful attention is required.
Warm diseases originating in the Three Yin meridians with faint pulses and cold feet are mostly difficult to treat.
Warm diseases with high fever but surprisingly fine/small pulses and cold extremities are fatal signs.
In early warm diseases, high fever with delirium, intense heat with small pulses and cold feet, progressing after five to six days to rapid/agitated pulses, vomiting, lethargy, black scorched tongue root, hemorrhage with agitation and large pulses, spasms/confusion, or hurried/intermittent/deep/small pulses are all fatal.
In warm-heat diseases, high fever without sweating is fatal; sweating followed by increased heat and agitated pulses is also fatal. Misusing diaphoretics in warm diseases leading to delirium, inability to eat, and agitated pulses are untreatable.
Liu Baozhi's commentary: The untreatable conditions listed fall into three categories: 1. Pathogens stagnant and unable to exit; 2. Righteous qi too weak to expel pathogens; 3. Yin fluid scorched and exhausted.
After Summer Solstice, when summer heat dominates and Minister Fire is active, fever with body pain, aversion to heat but not cold, and intense thirst constitutes Rebing (Heat Disease). The *Shanghan Example* states: "Cold damage turning into warm disease before Summer Solstice is Wenbing; after Summer Solstice is Rebing." Long-latent pathogens activate with seasonal summer heat. Since the pathogen is not externally acquired, there is aversion to heat but not cold. Heat originates internally, causing dry mouth and excessive drinking. Since the pathogen is constrained as heat, acrid-warm diaphoretics are unsuitable; it cannot be classified as cold. Zhang Zhongjing still calls it Shanghan because initial infection was caused by cold qi stagnation. People claim Zhongjing lacked warm-heat treatments; yet look at Huangqin Tang and Baihu Tang in the Taiyang and Yangming chapters—are these not for warm diseases? Baihu Tang, associated with Metal, is inappropriate unless in peak summer heat with extreme internal and external heat. Using it in qi-deficient patients often causes JieXiong (Chest Binding), sometimes fatal. Hence, warnings against using Baihu Tang before Start of Summer or after End of Heat. Just as Shanghan cannot use Huangqin or Baihu, warm diseases cannot use Mahuang (Ephedra), Guizhi, or Qinglong Tang (Green Dragon Decoction). Even for treating warm diseases, they are only applicable if accompanied by unseasonable sudden cold.
Liu Baozhi's commentary: This section clarifies that Huangqin and Baihu were originally designed by Zhongjing for warm diseases, not Shanghan. However, the concluding restriction on these formulas, while theoretically sound, somewhat overshadows the proper treatment principles for heat diseases.
If warm diseases last seven to eight or ten-plus days, with previous pathogens unresolved and re-contracted cold, alternating chills and fever become Wen Nue (Warm Malaria), considered a complicated condition in medical texts. The *Shanghan Example* states: "Pulses both yin and yang are vigorous, re-contracting cold transforms into Warm Malaria." Symptoms include chest/hypochondriac fullness, vexation/thirst/vomiting, slight aversion to cold; treat with Xiaochaihu Tang removing Renshen (Ginseng) and Banxia (Pinellia), adding Gualougen (Trichosanthes Root) and Shigao (Gypsum). If no cold but heat, normal pulse, bone joint pain, occasional vomiting; use Baihu Tang plus Guizhi. Strictly avoid acrid-warm dispersants to prevent aggravating the disease.
Liu Baozhi's commentary: For the former symptoms (vexation/thirst/slight aversion to cold), Baihu Jia Guizhi Tang is appropriate; for the latter (heat only, no cold), Guizhi should not be added.
Regarding the *Neijing* description of Warm Malaria with heat preceding cold: contracted wind in winter, cold qi stored in bone marrow. In spring, abundant yang fails to expel the pathogen. Encountering intense summer heat dries brain marrow, consumes muscle, opens pores, or exertion forces pathogen out with sweat. The disease resides in the Kidney, emerging from interior to exterior. Thus, yin deficiency and yang excess cause heat. When declining, qi returns inward, causing yang deficiency and cold. Hence, heat precedes cold, named Warm Malaria. Treatment uses Renshen Baihu Tang; if external pathogens exist, add Guizhi. Alternatively, use Jin Gui Shen Qi Wan removing Fuzi (Aconite), doubling Guizhi as a decoction, taken when thirsty. Since heat erupts from Kidney, internal heat is intense; urgently use Baihu to reduce heat. As malaria intensity wanes externally and returns to Kidney, yin essence contends, resulting in cold. If one fails to strengthen water to save yin, yin essence exhausts after numerous attacks. This spontaneous latent-pathogen warm disease differs essentially from Warm Malaria caused by re-contracted cold after warm disease, though both relate to the Shaoyin meridian. Detailed distinction resolves confusion.
Liu Baozhi's commentary: Although origins differ slightly, both require saving yin and reducing heat similarly. However, the former involves new cold contraction, requiring consideration of dispersing pathogens for completeness.