(温病变幻甚多。非博考不能详尽。此特粗示规模。俾知门迳而已。)
一白舌。凡白苔之润而薄者。为滑白。初病邪在气分也。润而浓者为腻白。湿痰重也。干燥而白者。为干白。肺胃
津伤。未及化黄而已干也。先以甘寒润之。待其转黄再议攻下。俟黄退见薄滑新苔。乃为病愈。若白如积粉。板贴不松
者。为粉白。乃疫毒入踞募原也。温病见此最重。先以银翘散透解。如不效。再用达原饮法。
一黄舌。有地而浓者为浓黄。甚则老黄灰黄燥裂有纹。宜用增液承气下之。(凡苔见裂纹。下时均宜加增液汤。) 虽
黄而润。或薄而滑者。热未伤津也。犹可清热透表若薄而干者。宜甘寒养津。忌苦重之药。黄白相兼。乃气分之邪未全
入里。宜用表里兼治法。
一黑舌。苔黑而燥者为燥黑甚则生芒刺。(凡舌生芒刺。不拘黄白黑色。皆为上焦热极。)乃胃大热而津枯也。宜酌
用白虎承气等剂。如黑而润者为阴亏。不可攻下。滑黑无苔为胃燥。宜甘寒养胃。又有当下而下。病已减而舌仍黑者。
乃苔皮焦枯未脱。不久自脱。勿再误下也。
一绛舌。无苔而深红色为绛舌。绛而兼黄白色者。气分之邪未全入里。宜两清营卫。绛色中有黄白碎点。或大红点
者。热毒盛也。宜黄连金汁等清之。纯绛鲜色者。邪已入营。包络受病也。宜犀角鲜生地郁金石菖蒲等味。重则牛黄丸
至宝丹开之。若舌色紫暗。乃其人素有瘀血。与邪相搏。当加散血之品。如丹皮丹参琥珀桃仁之类。虽绛而干枯不鲜者。
肾阴涸也。急以阿胶鸡子黄地黄天冬等救之。
一自汗。温病邪热熏蒸。不因发散而汗自出。为自汗。邪退汗自止。若自汗复大热大渴。即系白虎证。里邪盛亦多
自汗。必下后续得战汗方解。均不可误认为表虚也。
一盗汗。寐则汗出。醒则汗止也。温病伏邪内盛。热蒸于外。故作盗汗。邪退汗自止。亦勿认为表虚若温病已愈。
脉静身凉。复得盗汗或饮食劳动而自汗者。乃表虚也。
一战汗。乃邪气与正气相争也。气盛则一战而汗解。邪盛虽战而无汗。当其战时。不可扰动。听其自然。汗出即解。
如不解。或次日。或隔一二日。必复战。勿疑为疟。
一肤冷。温病战汗后。肤冷如冰。甚则倦卧不语。此乃阳从汗泄之故。当任其安卧静养。待过一昼夜。阳气来复。
自然温暖如常。切勿认为脱证惊惶呼唤。盖脱证脉必急疾。躁扰不能安卧。此则脉象和缓。安神稳睡。正邪退病除之吉
兆也。
一发黄。湿热壅遏于中。小便不利。则周身发黄。其黄亮如金者名阳黄。热重也。黄暗而滞者名阴黄。湿重也。阳
黄用四苓散加茵陈栀子滑石木通。阴黄用四苓散加官桂苍术浓朴之类。
一化疟。温疟暑疟与常疟不同。常疟作止有时。此则作止无定。常疟寒热两平。此则寒轻热重。或单热不寒。常疟
发后饮食如故。无甚舌苔。此则不思饮食舌苔浓腻。常疟发于少阳此则发于阳明。若概用柴胡汤。不惟不能去病。反将
由浅引深。宜用加减清脾饮治之。
一化痢。温病湿热内蕴。气血凝滞。致成痢疾者。宜用加减芩芍汤治之。
一痹证。湿温邪滞经络。或腰膝疼重。步履艰难。或似半身不遂。起立不便。皆温热失治。伤及筋隧而然。若认为
痿证。则误矣。宜用威灵仙汉防己川萆 生苡仁牛膝桑枝桂枝之属。一结胸。胸脘按之痛者是也。宜用加味小陷胸汤。
徐徐推之使下。若但胸膈满闷。按之有形不痛者。为胸痞。宜用辛开之品。轻者杏仁橘皮薤白。重者枳实黄连半夏之类。
虽舌绛神昏。但胸下拒按。即宜参以辛开。不可率投凉润也。
一阳极似阴证。初病手足逆冷。周身如冰。面如蒙垢。头痛似劈。饮热恶凉。甚则脉亦沉伏。纯若阴邪。但以小便
赤白为辨。赤即阳厥。亟用清热败毒药。其伏热自还于表。仍照温病法治之。
一自复。疫邪已退。无因反复谓之自复。乃余邪未尽也。随其见证以轻药治之。
一食复。温病新愈后。因饮食不慎。以致吞酸嗳腐。胸腹满闷。身热又作。名曰食复。轻则减食自愈重则用药稍稍
消导之。
一劳复。病愈后脉证俱平。惟元气未复。或因多言劳动。或因沐浴梳头。以致前证复发。静养自愈。或调补气血以
待元气自复。万不可误进猛剂。再剥削之。
一转变。温病用药。须知转变。不可执定。如治湿温。于面白阳微之人。凉药用至十分六七。即勿再用。恐过凉则
阳必伤也。面苍火重之人。凉药用至十分六七。虽热减身寒。仍不可遽用温补。恐火虽熄犹有余焰也。又如复脉及大小
定风珠诸方。为温病阴液干枯。肝风内动之圣药。然用至数剂后。察其风平液复。即宜改用轻剂调理。若因见效。服之
太过。则沉阴伤胃。必有食减面肿之患。总之药期中病。过犹不及。聊举数端。余可类推也。
(温病的病情变化非常多。如果不广泛考证就无法详尽了解。这里只是粗略地展示其大致框架,以便让人知道入门的途径罢了。)
一、白舌。凡是舌苔湿润而薄的,称为滑白苔,这是初病时邪气在气分。湿润而厚腻的,称为腻白苔,这是湿痰重的表现。干燥而白的,称为干白苔,这是肺胃津液受损,尚未化黄就已经干燥了。先用甘寒的药物滋润它,等到舌苔转黄再讨论攻下法。等到黄色退去出现薄而滑的新苔,这才是病愈。如果舌苔像积粉一样,板贴不松动,称为粉白苔,这是疫毒侵入并占据募原的表现。温病见到这种舌象最严重,先用银翘散透发解表,如果无效,再用达原饮的方法。
二、黄舌。有舌底且厚实的称为浓黄苔,严重的甚至变成老黄、灰黄,干燥开裂有纹路,适宜用增液承气汤攻下。(凡是舌苔出现裂纹,攻下时都适宜加入增液汤。)虽然舌苔黄但湿润,或者薄而滑的,说明热邪未伤津液,还可以清热透表。如果薄而干的,适宜用甘寒药物滋养津液,忌用苦寒重药。黄白相兼,是气分的邪气没有完全入里,适宜用表里双解的方法。
三、黑舌。舌苔黑而干燥的称为燥黑苔,严重的甚至生出芒刺。(凡是舌生芒刺,不论黄白黑色,都是上焦热极的表现。)这是胃大热而津液枯竭,适宜酌情使用白虎承气等方剂。如果黑而湿润的,属于阴亏,不可攻下。滑黑无苔是胃燥,适宜用甘寒药物养胃。又有应当攻下而已经攻下,病势已减但舌仍黑的,这是舌苔皮焦枯未脱落,不久自然会脱落,不要再误用攻下法。
四、绛舌。无苔且深红色的称为绛舌。绛色中兼有黄白色的,是气分的邪气未完全入里,适宜两清营卫。绛色中有黄白色碎点,或大红点的,是热毒盛,适宜用黄连、金汁等清热解毒。纯绛鲜色的,是邪气已入营分,心包络受病,适宜用犀角、鲜生地、郁金、石菖蒲等药,重症用牛黄丸、至宝丹开窍。如果舌色紫暗,是此人素有瘀血,与邪气相搏,应当加入散血的药物,如牡丹皮、丹参、琥珀、桃仁之类。虽然绛色但干枯不鲜亮的,是肾阴枯竭,急用阿胶、鸡子黄、地黄、天冬等药救治。
五、自汗。温病邪热熏蒸,不因发散而汗自出,称为自汗。邪气退去汗自然停止。如果自汗后又出现大热大渴,这就是白虎汤证。里邪盛也多自汗,必须攻下后接着出现战汗才能解除,都不可误认为是表虚。
六、盗汗。睡觉时出汗,醒来后汗止。温病伏邪内盛,热蒸于外,所以造成盗汗。邪气退去汗自然停止,也不要认为是表虚。如果温病已愈,脉静身凉,又出现盗汗,或因饮食劳动而出自汗的,这才是表虚。
七、战汗。是邪气与正气相争。正气盛则一战而汗解,邪气盛虽然战栗但无汗。当它战栗的时候,不可扰动,听其自然,汗出即解。如果不解,或者第二天,或者隔一二天,必定再次战栗,不要怀疑是疟疾。
八、肤冷。温病战汗后,皮肤冷如冰,甚至疲倦卧床不语,这是因为阳气随汗泄出的缘故。应当任其安静卧养,等待过了一昼夜,阳气来复,自然温暖如常。切勿认为是脱证而惊慌呼唤。因为脱证的脉象必定急疾,躁扰不能安卧,而这则脉象和缓,安神稳睡,正是邪退病除的吉兆。
九、发黄。湿热壅遏在中焦,小便不利,则周身发黄。黄色亮如金的称为阳黄,这是热重。黄色暗而滞的称为阴黄,这是湿重。阳黄用四苓散加茵陈、栀子、滑石、木通。阴黄用四苓散加官桂、苍术、厚朴之类。
十、化疟。温疟、暑疟与常疟不同。常疟发作和停止都有定时,这则发作和停止没有定规。常疟寒热程度相当,这则寒轻热重,或者只有热没有寒。常疟发作后饮食如故,没有很厚的舌苔,这则不思饮食,舌苔浓腻。常疟发于少阳,这则发于阳明。如果一概用柴胡汤,不但不能去病,反而会将病邪由浅引深,适宜用加减清脾饮治疗。
十一、化痢。温病湿热内蕴,气血凝滞,导致形成痢疾的,适宜用加减芩芍汤治疗。
十二、痹证。湿温邪气滞留经络,或者腰膝疼痛沉重,步履艰难,或者像半身不遂,起立不便,这都是温热失治,伤及筋隧所致。如果认为是痿证,那就错了。适宜用威灵仙、汉防己、川萆薢、生苡仁、牛膝、桑枝、桂枝之类的药物。
十三、结胸。胸脘部按压疼痛的就是结胸,适宜用加味小陷胸汤,慢慢推荡使其下行。如果只是胸膈满闷,按压有形但不痛的,称为胸痞,适宜用辛开的药物,轻的用杏仁、橘皮、薤白,重的用枳实、黄连、半夏之类。虽然舌绛神昏,但只要胸下拒按,就应当参以辛开之法,不可贸然投用凉润药物。
十四、阳极似阴证。初病手足逆冷,周身如冰,面色如蒙污垢,头痛如劈,想喝热的厌恶凉的,甚至脉象也沉伏,纯粹像阴邪,但以小便赤白来辨别,小便红赤就是阳厥,亟需用清热败毒药。其伏热自然返还于体表,仍然按照温病法治之。
十五、自复。疫邪已退,无原因反复称为自复,这是余邪未尽。根据见证用轻药治疗。
十六、食复。温病新愈后,因饮食不慎,以致吞酸嗳腐,胸腹满闷,身热又作,名叫食复。轻则减少饮食自愈,重则用药稍稍消导。
十七、劳复。病愈后脉证俱平,惟元气未恢复,或因多言劳动,或因沐浴梳头,以致前证复发,静养自愈。或者调补气血以待元气自复,万不可误进猛剂,再次剥削身体。
十八、转变。温病用药,须知病情会转变,不可固执不变。比如治湿温,对于面白阳气微弱的人,凉药用到十分之六七,就不要再用,恐怕过凉则阳气必伤。面色青苍火气重的人,凉药用到十分之六七,虽然热减身寒,仍然不可立即用温补,恐怕火虽熄灭犹有余焰。又如复脉及大小定风珠诸方,是温病阴液干枯、肝风内动的圣药,然而用至数剂后,观察其风平液复,就应当改用轻剂调理。如果因为见效,服用太过,则沉阴伤胃,必有食欲减退面肿的祸患。总之药物中病,过犹不及,姑且列举几端,其余可类推。
(Wenbing diseases exhibit numerous variations. Without extensive research, they cannot be fully comprehended. This section merely outlines the general framework to provide a pathway for understanding.)
1. White Tongue Coating: A coating that is moist and thin is termed "slippery white," indicating pathogenic factors in the Qi level at the onset of illness. A coating that is moist and thick/greasy is termed "greasy white," signifying heavy damp-phlegm. A dry white coating is termed "dry white," indicating injury to Lung and Stomach fluids, where dryness occurs before transformation into yellow. Initially, treat with sweet-cold herbs to moisten; once the coating turns yellow, consider purgation. When the yellow recedes and a thin, slippery new coating appears, the disease resolves. If the coating resembles accumulated powder, tightly adhering and not loose, it is termed "powder-white," indicating epidemic toxin occupying the Mu Yuan (Master Source). This is the most severe presentation in Wenbing. First, use Yinqiao San (Honeysuckle and Forsythia Powder) to vent and resolve. If ineffective, proceed with the method of Dayuan Yin (Origin-Reaching Decoction).
2. Yellow Tongue Coating: A thick yellow coating with a tongue body visible underneath is termed "thick yellow." Severe cases present as old yellow or gray-yellow, dry, cracked, and fissured; Zengye Chengqi Tang (Fluid-Increasing Purging Decoction) should be used for purgation. (Whenever cracks appear on the coating, Zengye Tang should be added during purgation.) If the coating is yellow but moist, or thin and slippery, heat has not yet injured fluids; clearing heat and venting from the exterior remains viable. If thin and dry, use sweet-cold herbs to nourish fluids; avoid heavy bitter-cold drugs. Mixed yellow and white indicates pathogenic factors in the Qi level have not fully entered the interior; a simultaneous exterior-interior treatment is appropriate.
3. Black Tongue Coating: A black and dry coating is termed "dry black," potentially developing prickles. (Prickles on the tongue, regardless of color, indicate extreme heat in the Upper Jiao.) This signifies excessive stomach heat and fluid exhaustion; Baihu Chengqi formulas should be used judiciously. If black and moist, it indicates Yin deficiency; purgation is contraindicated. Slippery black without coating indicates stomach dryness; sweet-cold herbs should nourish the Stomach. In cases where purgation was indicated and performed, but the tongue remains black despite symptom reduction, this is due to the desiccated coating layer not yet shedding; it will shed naturally soon. Do not mistake this for a need for further purgation.
4. Crimson Tongue: A deep red tongue without coating is termed "crimson." If crimson with mixed yellow/white, Qi-level pathogens have not fully entered the interior; clear both Ying and Wei levels. Crimson with yellow/white specks or large red spots indicates intense heat-toxin; treat with Huanglian (Coptis Rhizome) and Jinzhi (Gold Water). Pure bright crimson indicates pathogens have entered the Ying level, affecting the Pericardium; use Xijiao (Rhinoceros Horn - *Note: Substitute with Buffalo Horn in modern practice*), fresh Shengdi Huang (Rehmannia Root), Yujin (Curcuma Tuber), and Shichangpu (Acorus Rhizome). For severe cases, use Niuhuang Wan (Calculus Bovis Pill) or Zhibao Dan (Precious Treasure Pill) to open the orifices. Purple-dark color indicates pre-existing blood stasis interacting with pathogens; add blood-dispersing herbs like Mudan Pi (Moutan Bark), Danshen (Salvia Root), Hupo (Amber), and Taoren (Peach Seed). Dry, dull crimson indicates exhaustion of Kidney Yin; urgently rescue with Ejiao (Donkey-Hide Gelatin), Jizihuang (Chicken Egg Yolk), Dihuang (Rehmannia), and Tiandong (Asparagus Tuber).
5. Spontaneous Sweating: Caused by Wenbing pathogenic heat steaming, occurring without diaphoretic intervention. Sweating stops when pathogens retreat. If spontaneous sweating is accompanied by high fever and intense thirst, it is a Baihu Tang syndrome. Excess interior pathogens also cause spontaneous sweating; resolution requires purgation followed by chills-sweating. Do not misinterpret this as Exterior Deficiency.
6. Night Sweating: Sweating during sleep, stopping upon waking. In Wenbing, internal excess of latent pathogens causes heat to steam outward, resulting in night sweats. Sweating stops when pathogens retreat. Do not assume Exterior Deficiency. If Wenbing has resolved (pulse calm, body cool) and night sweats occur, or if sweating occurs after eating/labor, this indicates Exterior Deficiency.
7. Chills-Sweating: Conflict between pathogenic factors and healthy Qi. If healthy Qi is strong, sweating resolves the conflict after shivering. If pathogens are strong, shivering occurs without sweating. During shivering, do not disturb; allow nature to take its course. Resolution follows sweating. If unresolved, shivering may recur the next day or after one to two days. Do not confuse this with Malaria.
8. Cold Skin: After chills-sweating in Wenbing, skin becomes ice-cold, possibly with lethargy and mutism. This results from Yang Qi escaping with sweat. Allow quiet rest; Yang Qi will recover within 24 hours, restoring warmth. Do not mistake this for Collapse Syndrome (which features rapid pulse, restlessness, and inability to lie still); here, the pulse is harmonious, and peaceful sleep indicates successful expulsion of pathogens.
9. Jaundice: Damp-heat stagnation in the Middle Jiao with difficult urination leads to generalized jaundice. Bright yellow like gold is "Yang Jaundice" (Heat predominant); dark, dull yellow is "Yin Jaundice" (Dampness predominant). Treat Yang Jaundice with Siling San plus Yinchen, Zhizi, Huashi, and Mutong. Treat Yin Jaundice with Siling San plus Guirou (Cinnamon Bark), Cangzhu, and Houpo.
10. Transformation into Malaria: Wen malaria and Summerheat malaria differ from typical malaria. Typical malaria has regular intervals; this does not. Typical malaria has balanced chills and fever; this has mild chills and heavy fever, or fever only. Typical malaria patients eat normally post-attack with little coating; this presents with anorexia and greasy coating. Typical malaria involves Shaoyang; this involves Yangming. Using Chaihu Tang indiscriminately fails to cure and draws pathogens deeper. Use Jiajian Qingpi Yin.
11. Transformation into Dysentery: Internal accumulation of damp-heat in Wenbing causing Qi and Blood stagnation leading to dysentery. Treat with Jiajian Qinshao Tang.
12. Bi Syndrome: Damp-wen pathogens stagnating in meridians cause painful/heavy waist and knees, difficulty walking, or hemiplegia-like symptoms. This results from mistreated warm-heat injuring sinews and collaterals. Do not diagnose as Wei Syndrome. Use Weilingxian, Hanfangji, Chuanshe, Shengyiren, Niuxi, Sangzhi, and Guizhi.
13. Jie Xiong (Chest Binding): Pain upon pressing the chest and epigastrium. Treat with Jiawei Xiaoxianxiong Tang to gently push downward. If only fullness/stuffiness exists without pain upon pressure, it is Chest Stagnation. Use acrid-opening herbs: light cases use Xingren, JuPi, Xiebai; heavy cases use Zhishi, Huanglian, Banxia. Even with crimson tongue and confusion, if lower chest resists pressure, use acrid-opening methods; do not rashly use cold-moistening drugs.
14. Extreme Yang Mimicking Yin: Initial cold limbs, ice-cold body, grimy face, splitting headache, preference for hot drinks, aversion to cold, and deep/faint pulse mimic Yin pathology. Differentiate by urine color: red urine indicates Yang Jue (Cold Extremities due to Heat). Urgently use heat-clearing and toxin-resolving drugs. Latent heat returns to the exterior; treat according to Wenbing principles.
15. Spontaneous Relapse: Recurrence without cause after epidemic pathogens retreat indicates residual pathogens. Treat lightly based on manifestations.
16. Food Relapse: Post-Wenbing recurrence due to improper diet, causing acid regurgitation, belching of rotten food, chest/abdominal fullness, and returning fever. Light cases resolve with dietary restriction; heavy cases require mild digestive aids.
17. Labor Relapse: Recurrence after recovery due to overexertion (speech, labor, bathing, hair combing) while Yuan Qi is not yet restored. Resolve with rest or Qi/Blood tonification. Avoid harsh drugs that further deplete the body.
18. Transformation: Understand that Wenbing conditions transform; do not adhere rigidly. For damp-wen in pale-faced, Yang-deficient patients, stop cooling herbs at 60-70% dosage to prevent Yang injury. For dark-complexioned, fire-excess patients, even if heat subsides with 60-70% cooling herbs, do not immediately switch to warming tonics to avoid reigniting residual fire. Formulas like Fumai Tang and Da/Xiao Dingfeng Zhu are sacred for dry Yin and internal Liver Wind, but after a few doses, once wind calms and fluids restore, switch to light conditioning agents. Overuse causes Sinking Yin to damage the Stomach, leading to poor appetite and edema. Medicines must hit the target; excess is as bad as insufficiency. These examples suffice for deduction.