“肺炎者，亦伤寒温病之一部也，审为肺胀，宜越婢加半夏汤，其咳嗽发热喘息不甚者，无汗宜小青龙加石膏汤，有汗宜麻杏石甘汤，非准疗之候也。然当视其脉浮大有力者，或浮紧有力者，乃可任此不疑，非是则当变矣。盖咳嗽发热，未见危侯，数日身忽壮热，加以喘息，脉反微弱，直视撮空，丧其神守者，此肺虽填满，而脉反更瓠落，血痹不利，心脏将绝，予见西医治此，有用强心剂，获神清喘止，其热浙退而愈者，初疑其偶然，推问乃知有法，且云，其专主强心，虽不冶喘咳亦效，此证在伤寒论中，当以真武汤加干姜五味细辛为主，盖神明不倾，则直视撮空自已，血脉调利，则热势自衰。喻嘉言治赵姓案，见其咳声窘迫，壮热不退，脉数无力，肌肤枯涩，医者用河柳犀角，表里不解，且引热邪直入心包，颠悸无伦，视胃实诂语，更增十倍，乃至体如烟熏，直视摇头，而终谓当用麻杏石甘汤主之(诵穆按：寓意草赵氏治案略云，“赵公太史孟冬末，三公郎患伤寒，医药无效，渐至危笃，先日进白虎汤，其热稍缓，次日进人参白虎汤，其热势渐重，皇皇求医，因而召诊，余闻其咳声窘迫，诊其脉数无力，壮热不退，肌肤干涩，沉困不食，谓太史日，此病大难，惟不肖尚可悉心图成，以报知已，疏方用仲景麻黄杏仁石膏甘草汤四味，太史韪之，其房中女伴，以不省官话，兼求悉余之生平，争用本地经验名家，乃至服河柳而表终不解，服犀角而里总不解，且引热邪直攻心脏，其颠悖无伦，较胃实站语，更增十倍，医者始辞心偏不可救药，末几，阳反独留，形如烟熏，发直头摇，竟成心绝之候，此段疑案，直若千古不决，孰知有麻黄杏仁石膏甘草汤，为扶危救颠之大药也哉，盖伤寒一证，虽云传足不传手，其实足经而兼手经者恒多，医者每遇足经六传之病，尚尔分证模糊，至遇兼手足二经之证，鲜不五色无主矣，足经譬西北也，手经譬东南也，道里之远近不同，势白不能以飞渡，然乘衅召邪，阻险割据，岂曰无之，今病者为足太阳膀胱足阳明胃经二经合病，既已难任，更加二经之邪，袭入手太阴肺经，所以其重莫支，手太阴肺者，主统一身之气者也，气通则汗出，气闭则汗壅，从前发汗而不得汗，驯至肌肤枯涩，岂非肺主皮毛，肺气壅闭，津液不通，漫无润泽耶，如某先生尝患鼻齇，咸谓肺气不清，鼻间窒塞，所以邪易凑入，才病外感，便当早为足经传手经之虑，通其肺气之壅，俾得汗出邪散，始称明哲，此病为足太阳膀胱足阳明两经合病，则足太阳之邪，由背而贯胸，足阳明之邪，由胸而彻背，肺为华盖，覆于胸背之上，如钱公素无肺患，尚且咳嗽紧迫，岂居恒肺气不清之体，可任两经之邪交射乎，又况手与手膜属相连，以手经而传手经，其事最便，所以才一用参，随领注肺之邪，直攻心脏，正如足太阳之邪，误用葛根，即领其邪传入阳明之例耳，不然，伤寒之邪，过经不解，崇蕴日久，不过袭入厥阴心包络已耳，岂有直攻心脏之理哉。”按嘉言此案，如伤寒传足不传手，袭太阴肺经，通其肺气之壅，注肺之邪直攻心脏，袭入厥阴心包络等语，与天士持论相类，疑天士之温病学说，本从嘉言套出，草蛇灰线，全体在隐约间矣。)然后可治脉紧血盛者耳，脉既无力，则解弛不收，其血自痹，麻杏石甘，适足以增痹而重虚也，麻杏石甘汤断非其治，明如喻氏，而犹不达于此，然其药既末下，故世人莫能显征其失焉，或者乃引叶氏温邪犯肺，逆传心包之说，以皮附病机，然苟非血痹，虽邪热袭心，祗为懊侬不眠而已，栀豉猪苓，黄连阿胶诸方，多足治之，安有直视站语诸危候也(诵穆按：太老称血痹不利，即肺炎之肺循环郁血也，直视撮空，丧其神守，即叶氏之逆传心包也，病机相通，绝非皮附，苟有呼吸器病之症状，即须治呼吸器病之药剂，栀豉猪苓，隔靴搔痒，至强心药之推进血行，以散郁血者，不得与栀豉猪苓等视)。血不痹者，专责之肺，自是小青龙越婢之治，血若痹者，此乃危及少阴，必责之心，乃为真武之治，仲景制真武一方，用心审谛，度越常蹊，而世人但以治老衰虚喘，其于外感咳嗽，则宋见用此者，于今乃知其精绝也。
按麻黄能扩张末梢血管，以散郁血，太老谓麻黄不利于血痹，非确论也，若脉搏微弱，则与真武合剂，即弊害不生，尝见患肺胀而脉搏微弱者，中医进麻杏石甘，西医为之注射强心剂，中西合治而愈，即令得效之由，独归强心，然麻黄之无碍病体，可以概见，太老评寓意草赵氏一案(即肺炎病治法中所引)谓彼病服白虎汤稍退者，乃暂时劫止之力，于病无损，吾以为肺胀徒服真武，虽能推进血行，然亦于病无损，必佐以消炎镇咳之麻杏石甘，其效始速，真武主药为附子，时医之所畏忌，故华实孚先生尝以六神丸代附子，六神丸中有蟾酥，卓著强心之效，虽作用较缓，然可以稍减时医之疑惧。
临证指南治肺胀，大抵用辛凉轻剂，相习成风，莫或之改，今骤易麻黄等之辛温，必相顾骇异，然时医宗师之温病条辨，亦曾以麻桂治喘，则吾侪以麻黄治肺胀，本在情理中，亦事理之当然必然，平凡无奇，无所用其骇怪者也。
温病条辨下焦篇第47条云：“秋湿内伏，冬寒外加，脉紧无汗，恶寒身痛，喘咳痰稀，胸满舌白滑，恶水不欲饮，甚则倚息不得卧，腹中微胀，小青龙汤主之。脉数有汗，小青龙去麻、辛主之。大汗出者，倍桂枝减干姜加麻黄根。”
第48条云：“喘咳息促，吐稀涎，脉洪数，右大于左，喉哑，是为热饮，麻杏石甘汤主之。”(按：此肺胀也，喉哑失音，病势已剧。)
此二条在下焦篇寒湿门中，前一条有寒象，后一条则鞠通亦自言为当清之证而用麻黄，则麻黄之无害于清可知，而古人配合方剂之妙，尤不可思议也。
温病条辨上焦篇，由第一条至第八条，病势逐渐加重，第六条但咳，身不甚热，用辛凉轻剂桑菊饮，第八条脉浮大而芤，汗大出微喘，以麻杏石甘为最的当，白虎退热，为暂时劫止，于病无损(见前)，终无补于病机，唯麻杏石甘，能为挽救，即虑其汗大出而脱，则以强心药和入麻杏石甘汤中，决无虚脱之变也。
喘促当清，知用麻杏石甘，此鞠通一隙之明也，然迟迟之于下焦，而不用于上焦篇第八条用白虎加人参汤之际，病机一失，遂不可收拾，其后玉女煎犀角地黄汤合银翘散清官汤等，皆于病无损者也，而病者从此绝望矣，故鞠通知用麻杏石甘，不得不谓一隙微明，惜乎求尽麻杏石甘之用也。
昔有某公，谓治疗湿温，当先以燥湿之药，使之化燥，然后一下而愈，此行险徼幸，而吴鞠通三仁汤之遗法，以冀一中之术也，以旧说言之，则湿固宜燥，温亦宜清，燥湿清温，无能偏废，徒用燥湿，则病随药变，足以速神昏站语之驾，此治术之下驷也，予于湿温之治，粗有所得，异日当别为专篇以论之。关于温病之讨论，至此暂告一结束。
温病问题，为近百年来争执之焦点，其学说之庞杂凌乱，足以炫人耳目，尤妙在叶吴孟英诸君，以内经仲景之温病学说，与己之温病学说，扰混一起，如油入面，不可复别，而叶吴之学说，转以内经仲景为护符，吾着笔之初，发愿欲将此纠缠不清之间题，澈底解决，以内经仲景之温病，还之内经仲景，以叶吴孟英之温病，还之叶吴孟英，抽茧剥蕉，逐层揭去，而叶吴之真面目，乃水落石出，而无从掩饰，然后其是非可得而评焉，伏气新感，其说凿空，以寒温为伤寒温病之鸿沟，亦为郢书燕说，温热家以为伤寒温病，绝对不同，吾则并时行之界线而破之，吾自信解决温病上之各种问题，寻根究底，亦有相当之魄力，惟学识谫陋，必多谬误，海内贤达，幸加指正，吾著此书竟，吾深感先哲时贤饷遗我之厚，吾愿永远作荷戈执旗之小卒，为中医之学术而努力。(《温病论衡)》
柴按，此篇对叶派治术之批评，主要集中于二点：1、谓治温热病要以撤热为第一，撤热才能保阴，而叶派治温病，撤热不力。2、谓轻清疗法作用轻微，如治肺胀，不及麻杏石甘、越婢加半夏诸力显的有力量。热病应以撤热为主，还是应以养阴为主，这一问题，应辨证而定，不可一概而论。但在侈谈壮水制阳，泛用养阴退热的历史条件下，强调撤热之重要性，有针砭时弊之作用。至于轻清疗法(如银翘、桑菊之类)不足以治大病(如脑炎之类)，这是不可否定之事实。惟谢氏认为叶派的轻清疗法对肺胀亦作用轻微，则与杨则民等人意见相一致，值得参考。
评温病条辨
近有淮阴吴鞠通先生，名瑭，著《温病条辨》一书，宗叶氏大意，从河间分三焦立法，引经正名，分析伤寒温病之异，多有发明，其提纲云，“凡病温者，始于上焦，在手太阴。”此即叶氏所云，温邪上受，首先犯肺之旨也。但将风温、温热、瘟疫、冬温，并为一类，而日初起恶风寒者，桂枝汤主之。不恶寒而渴者，均主以银翘散。以瘟疫改作温疫，仍古体也。又谓吴又可瘟疫论未善，而达原饮一方，过于削伐甚谬。予按此论，不能允当，若又可立法虽偏，其达原饮一方，犹为恰当，不可非之。何故？盖风温为轻清之邪，从皮毛口鼻而入，鼻为肺窍，皮毛肺之合也，故肺先受伤。人感虚风贼邪，而当温暖之候，即成风温之病，四时皆有，温重即热病也，故如温热冬温等名，皆可以风温二字括之，不必另分名目，以省繁惑。惟春为风木司令，而气候温暖，故风温较三时为多耳。若瘟疫一证，由五运六气，主客流行，克贼偏驳所致，如六元正纪大论所云，辰戊卯酉丑未巳亥等岁，或云民厉温病，或云厉大至，民善暴死等，即后世所称瘟疫也。古无瘟宇，温瘟同义。所谓厉者，状其气之凶暴，病之危速，或因秽污之气，与时令之邪，蕴酿而成，故方书又有温毒之名，亦即温厉之意，日毒日厉，总形其邪之恶耳，是以瘟疫一证，病势甚重，初起即厚苔满舌如粉积，邪伏募原，盘踞深固，须达原饮，始能开其浊结，使之传化，故又可有九传之说，历叙证状甚明，而与风温大有不同，非轻药玩宜，且叶氏所云温邪犯肺，正指风温而言，故肺先受伤，今观银翘散方，亦轻清开肺治风温之药，以之治瘟疫，则病重药轻，疫邪结于募原，而用开肺之法，则病深法浅，皆非所宜矣。况桂枝汤，本治风寒之方，用治风温，已不甚合，若瘟疫初起，或有恶寒，多因浊邪内结，营卫气壅，表阳不宣之故，即使外有微寒，而以达原饮开其内结，使营卫气通，内邪外达，则微寒亦散，恶寒自除，岂可用姜桂之辛热，更助热邪步甘芍大枣之甘温，反壅气机乎，可知桂枝银翘两方，均不可以治瘟疫，斯则鞠通辨证未清，立法不当，非又可之方不善也。又上焦篇，化斑汤下方论之后曰，按吴又可有托里举斑汤，不言疹者，混斑疹为一气也，考温病中发疹者，十之七八，发斑者，十之二三，盖斑乃纯赤，或大片，为肌肉之病，疹系红点高起，麻、瘄、痧皆一类，系血络中病也。观此，益见鞠通将瘟疫风温，混而不辨，并非又可不分斑疹也。盖风温以轻清之邪，伤肺家轻清之脏，故初起发热、咳嗽、喉痛、胸痛、颅胀，皆清邪在上也。舌无苔，或有微薄黄白苔，而内无浊结也。如邪郁不解，热入血络而成疹子，疹者，手太阴肺病也。若再不解，则逆传心包，而变神昏痉厥之危证矣。以其邪由肺入，虽传心包，热在血脉，与胃之主肌肉者无干，故风温之邪，但有疹而不成斑也。若瘟疫者，秽浊之邪，客于募原，募原在肺之下，胃之上，故舌苔厚滞，以浊邪壅蔽胃口，胃热郁而成斑，故斑为足阳明胃病也。如募原之邪，由肺外达，则其结已开，邪已化，必作汗而泄，故瘟疫之邪，但有斑而不成疹也。吴又可所论瘟疫，以未见有疹，故不言疹，并非将斑疹相混也。如果瘟疫，又兼风温，则斑疹互现，偶或有之，然募原在里，邪结募原，须用重药，以开里结，则表气亦通，斑化而疹自消。倘用轻药，清肺治疹，则里结不开，疹亦难化，非其法矣，若风温之邪，不兼内浊，非瘟疫证，则发斑者，十无一二，故鞠通言温病发疹，十之七八者，实为风温，而非瘟疫，岂得与又可之论相混哉。又可混称一切温病为瘟疫，是指鹿为马，鞠通又将瘟疫作风温而治，是指马为鹿，其失均也。且经云冬伤于寒，春必病温，此以伏寒化热，乘春阳上升而发为温病，故名春温。仲景所云，发热而渴，不恶寒者，为温病是也。以其内热，故初病即渴，以邪非外感，故不恶寒。与风温之邪，由外感者，又为不同，鞠通亦不辨析论治，各证原流未清，故立法不能尽当也。
【背景信息】
书名：热病衡正 章节：正文(48/49) 类别：伤寒
肺炎，也是伤寒和温病（感受温热邪气所致的外感热病）的一部分。如果确认为肺胀（肺气壅滞胀满），适宜使用越婢加半夏汤；对于咳嗽、发热、喘息症状不严重的患者，无汗的宜用小青龙加石膏汤，有汗的宜用麻杏石甘汤，这些都不是准疗（标准疗法）的候证。然而，应当观察患者的脉象，如果是浮大有力或浮紧有力的脉象，才可以放心使用上述方剂而不怀疑；如果不是这种脉象，就应当改变治疗方案。因为咳嗽发热，尚未见到危重征象，但如果数日后身体突然高热，加上喘息，脉象反而微弱，出现直视（两眼固定不动）、撮空理线（手在空中摸索动作）、神志丧失等表现，这是虽然肺部充满邪气，但脉象反而空虚无力，血行痹阻不利，心脏功能即将衰竭的表现。我曾见过西医治疗此类病症，使用强心剂后，患者神志清醒、喘息停止，热势逐渐消退而痊愈的情况。起初我怀疑这是偶然现象，深入推问后才得知其中有法度，并且他们说，这种方法专门侧重于强心，即使不治疗喘息咳嗽也有效。此证在《伤寒论》中，应当以真武汤加干姜、五味子、细辛为主方。因为神明不致倾覆，则直视撮空自然停止；血脉调畅流利，则热势自然衰减。喻嘉言治疗赵姓患者的医案，看到其咳声窘迫，壮热不退，脉数无力，肌肤枯涩，医生使用了河柳和犀角，表里之邪均未解除，且引热邪直入心包络，导致精神狂乱颠倒，比胃实谵语的症状更严重十倍，以至于身体像烟熏一样黑，直视摇头，最终却主张使用麻杏石甘汤主治。（诵穆按：阅读喻嘉言《寓意草》中赵氏治案略云：“赵公太史在孟冬末，三公郎患伤寒，医药无效，渐渐变得危重。前一天服用白虎汤，热势稍缓；第二天服用人参白虎汤，热势反而加重。惊慌求医，因而召请余诊治。余闻其咳声窘迫，诊其脉数无力，壮热不退，肌肤干涩，沉困不想进食。对太史说，此病很难治愈，只有我不才之人还可以悉心图谋成功，以报答知己之恩。开方使用张仲景的麻黄杏仁石膏甘草汤四味药，太史认可了。他房中的女伴，因为不懂官话，又要求了解余的生平，争相使用本地经验名家的药方，于是服用河柳而表邪始终不解，服用犀角而里邪总不解，且引热邪直攻心脏，其精神颠狂悖乱，较之胃实谵语，更增加十倍。医生这才声称心偏不可救药。不久，阳气反独留，形体如烟熏，头发直立头摇，竟成为心绝的候证。这段疑难案件，简直像千古未决之谜，谁知有麻黄杏仁石膏甘草汤，是扶危救颠的大药啊！大概伤寒一证，虽然说传足经不传手经，其实足经兼及手经的情况很多。医者每每遇到足经六经传变的病证，尚且分证模糊，至于遇到兼手足二经的证候，鲜有不惊慌失措的。足经譬喻西北，手经譬喻东南，道路远近不同，势不能飞渡，然而乘隙招致邪气，阻险割据，难道没有吗？现在病人是足太阳膀胱经和足阳明胃经两经合病，已经难以承受，再加上这两经的邪气，袭入手太阴肺经，所以病情沉重无法支撑。手太阴肺主统一身之气，气通则汗出，气闭则汗液壅滞。从前发汗却不得汗，逐渐导致肌肤枯涩，这难道不是肺主皮毛，肺气壅闭，津液不通，毫无润泽吗？如某先生曾患鼻齇（鼻塞流涕），大家都说是肺气不清，鼻间窒塞，所以邪气容易凑入。刚得外感，就应当早做足经传手经的考虑，通利肺气的壅滞，使得汗出邪散，这才称得上明智。此病为足太阳膀胱、足阳明两经合病，那么足太阳的邪气，由背部贯穿胸部；足阳明的邪气，由胸部彻达背部。肺为华盖，覆盖在胸背之上，如果钱公素来没有肺疾，尚且咳嗽紧迫，何况平时肺气就不清朗的体质，怎能承受两经邪气的交射呢？况且手经与手经膜属相连，以手经传手经，事情最便利，所以才一用人参，随即引导注于肺的邪气，直攻心脏，正如足太阳的邪气，误用葛根，即引导其邪传入阳明之例罢了。不然，伤寒的邪气，过经不解，蕴积日久，不过袭入厥阴心包络而已，哪里有直攻心脏的道理呢？）按照喻嘉言这个医案，如“伤寒传足不传手”、“袭太阴肺经”、“通其肺气之壅”、“注肺之邪直攻心脏”、“袭入厥阴心包络”等说法，与叶天士的持论相似，怀疑叶天士的温病学说，原本是从喻嘉言那里套出来的，草蛇灰线，整体都在隐约之间。）然后才可以治疗脉紧血盛的患者。脉既然无力，则经脉解弛不收，血液自然痹阻，麻杏石甘汤恰好足以增加痹阻并加重虚损，麻杏石甘汤绝对不是它的治疗方案。像喻氏这样明白的人，还达不到这个认识，但是他的药既然没有下肚，所以世人不能明显验证他的失误。有人或许引用叶氏“温邪犯肺，逆传心包”的说法，来牵强附会病机。然而，如果不是血痹，即使是邪热侵袭心脏，也只是懊恼失眠而已，栀豉汤、猪苓汤、黄连阿胶汤等方剂，大多足以治疗，怎么会有直视谵语等危重征象呢？（诵穆按：太老称血痹不利，就是肺炎的肺循环郁血；直视撮空，丧其神守，就是叶氏所说的逆传心包。病机相通，绝非牵强附会。如果有呼吸器病的症状，就必须用治疗呼吸器病的药剂。栀豉汤、猪苓汤等，如同隔靴搔痒。至于强心药推进血行以消散郁血的方法，绝不能与栀豉汤、猪苓汤等同视。）血不痹者，专门责之于肺，自然是小青龙汤、越婢汤的治疗范围；血若痹者，这就危及少阴，必须责之于心，才是真武汤的治疗范围。张仲景制定真武一方，用心审慎细致，超越常规路径，而世人只把它用于治疗老年衰弱的虚喘，对于外感咳嗽，很少见到使用此方的，到现在才知道它的精妙绝伦。
按：麻黄能扩张末梢血管，以消散郁血，太老说麻黄不利于血痹，不是确切的论述。如果脉搏微弱，则与真武汤合用，就不会产生弊害。曾见患肺胀而脉搏微弱的患者，中医进服麻杏石甘汤，西医为之注射强心剂，中西合治而痊愈。即使把得效的原因单独归因于强心剂，也可以概见麻黄对病体无害。太老评价《寓意草》赵氏一案（即肺炎病治法中所引用的案例），说那个病人服用白虎汤后热势稍退，是暂时劫止的力量，对疾病本身无损。我认为肺胀单纯服用真武汤，虽然能推进血行，但也对疾病本身无损，必须佐以消炎镇咳的麻杏石甘汤，疗效才会迅速。真武汤的主药是附子，是当时医生所畏惧忌讳的，所以华实孚先生曾经用六神丸代替附子。六神丸中有蟾酥，具有显著的强心效果，虽然作用较缓慢，但可以稍微减少当时医生的疑惧。
《临证指南》治疗肺胀，大致使用辛凉轻剂，相习成风，没有人去改变它。现在突然改用麻黄等辛温药物，必定会让人互相惊骇诧异。然而，当时医生宗师吴鞠通的《温病条辨》，也曾以麻黄、桂枝治疗喘息，那么我们使用麻黄治疗肺胀，本就在情理之中，也是事理的当然必然，平凡无奇，没有什么值得惊怪的地方。
《温病条辨》下焦篇第47条说：“秋湿内伏，冬寒外加，脉紧无汗，恶寒身痛，喘咳痰稀，胸满舌白滑，恶水不欲饮，甚则倚息不得卧，腹中微胀，小青龙汤主之。脉数有汗，小青龙汤去麻黄、细辛主之。大汗出者，倍桂枝减干姜加麻黄根。”
第48条说：“喘咳息促，吐稀涎，脉洪数，右大于左，喉哑，是为热饮，麻杏石甘汤主之。”（按：这就是肺胀，喉哑失音，病势已经很严重了。）
这两条在下焦篇寒湿门中，前一条有寒象，后一条则鞠通自己也承认是应当清热的证候而使用麻黄，那么麻黄对清热并无妨害可知，而古人配合方剂的奥妙，尤其不可思议。
《温病条辨》上焦篇，从第一条至第八条，病势逐渐加重。第六条仅咳嗽，身体不甚热，用辛凉轻剂桑菊饮。第八条脉浮大而芤，汗大出微喘，以麻杏石甘汤最为恰当。白虎汤退热，只是暂时的劫止，对疾病本身无损（见前文），终究无补于病机，唯有麻杏石甘汤，能够挽救。即使担心其汗大出而导致虚脱，则将强心药加入麻杏石甘汤中，绝不会发生虚脱的变故。
喘促应当清热，知道使用麻杏石甘汤，这是鞠通的一隙之明。然而迟迟将其置于下焦篇，而不用于上焦篇第八条使用白虎加人参汤之际，病机一旦失误，便不可收拾。其后玉女煎、犀角地黄汤合银翘散、清官汤等，都对疾病本身无损，而病人从此绝望了。所以鞠通知道使用麻杏石甘汤，不得不谓为一隙微明，可惜未能穷尽麻杏石甘汤的全部用途。
过去有位某公，说治疗湿温，应当先用燥湿的药物，使之化燥，然后一下而愈。这是行险徼幸，是吴鞠通三仁汤遗留的方法，希望有一中之术。以旧说来讲，湿固宜燥，温亦宜清，燥湿与清温，不能偏废。徒用燥湿，则病随药变，足以加速神昏谵语的到来，这是治术中的下驷。我对湿温的治疗，粗有所得，异日当另写专篇来论述。关于温病的讨论，至此暂告一段落。
温病问题，是近百年来争执的焦点，其学说庞杂凌乱，足以炫人耳目。尤其巧妙的是叶天士、吴鞠通、孟英诸位，将《内经》、张仲景的温病学说，与自己创立的温病学说搅混在一起，如油入面，不可再分辨，而叶、吴的学说，转而以《内经》、张仲景的理论为护身符。我在动笔之初，发誓要将这个纠缠不清的问题彻底解决，将《内经》、张仲景的温病，还给《内经》、张仲景；将叶、吴、孟英的温病，还给叶、吴、孟英。抽茧剥蕉，逐层揭去，叶、吴的真面目，乃水落石出，无从掩饰，然后其是非可得而评判。伏气与新感之说，凿空无据；以寒温作为伤寒与温病的鸿沟，也是郢书燕说（指误解原意）。温热家认为伤寒与温病绝对不同，我却连时行的界线都打破。我自信解决温病上的各种问题，寻根究底，也有相当的魄力。惟学识浅陋，必多谬误，海内贤达，希望加以指正。我著完此书，深感先哲与时贤馈赠我的丰厚，我愿永远作荷戈执旗的小卒，为中医的学术而努力。（《温病论衡》）
柴按：此篇对叶派治术的批评，主要集中于两点：1、认为治疗温热病要以撤热为第一要务，撤热才能保阴，而叶派治疗温病，撤热不力。2、认为轻清疗法作用轻微，如治疗肺胀，不及麻杏石甘汤、越婢加半夏汤等力量显赫有力。热病应以撤热为主，还是应以养阴为主，这一问题，应辨证而定，不可一概而论。但在侈谈壮水制阳、泛用养阴退热的历史条件下，强调撤热的重要性，有针砭时弊的作用。至于轻清疗法（如银翘散、桑菊饮之类）不足以治大病（如脑炎之类），这是不可否认的事实。惟谢氏认为叶派的轻清疗法对肺胀亦作用轻微，则与杨则民等人的意见相一致，值得参考。
评《温病条辨》
近来有淮阴吴鞠通先生，名瑭，著有《温病条辨》一书，宗奉叶氏大意，从刘河间分三焦立法，引经正名，分析伤寒与温病的差异，多有发明。其提纲说：“凡病温者，始于上焦，在手太阴。”这就是叶氏所说的，温邪上受，首先犯肺的宗旨。但是将风温、温热、瘟疫、冬温，并为一类，说初起恶风寒的，用桂枝汤主治；不恶寒而口渴的，均用银翘散主治。以“瘟疫”改作“温疫”，仍沿古体。又说吴又可的《瘟疫论》不完善，而达原饮一方，过于削伐，非常错误。我认为这个评论，不能允当。如果又可立法虽偏，但他创制的达原饮一方，犹为恰当，不可以非难他。为什么呢？大概风温是轻清之邪，从皮毛口鼻而入，鼻为肺窍，皮毛为肺之合，所以肺先受伤。人感受虚风贼邪，而当温暖之时，即成风温之病，四季皆有，温重即为热病。所以如温热、冬温等名称，都可以用“风温”二字概括，不必另分名目，以省繁惑。只有春季为风木司令，气候温暖，所以风温较其他三季为多耳。若瘟疫一证，由五运六气，主客流行，克贼偏驳所致，如《六元正纪大论》所说，辰戌卯酉丑未巳亥等岁，有的说民众患厉温病，有的说厉气大至，民众善暴死等，就是后世所称的瘟疫。古代没有“瘟”字，温、瘟同义。所谓“厉”，形容其气之凶暴，病之危速，或因秽污之气，与时令之邪，蕴酿而成，所以方书中又有“温毒”之名，也就是温厉的意思。曰毒曰厉，总形容其邪之恶毒。是以瘟疫一证，病势甚重，初起即厚苔满舌如粉积，邪伏募原，盘踞深固，须用达原饮，始能开其浊结，使之传化，所以又可有九传之说，历叙证状甚明，而与风温大有不同，不是轻药玩宜所能治疗的。而且叶氏所说的温邪犯肺，正指风温而言，所以肺先受伤。如今观银翘散方，也是轻清开肺治疗风温的药，用它来治瘟疫，则病重药轻，疫邪结于募原，而用开肺之法，则病深法浅，皆不适宜。况且桂枝汤，本是治疗风寒的方剂，用来治风温，已不甚合适，若瘟疫初起，或有恶寒，多因浊邪内结，营卫气壅，表阳不宣的缘故。即使外有微寒，而以达原饮开其内结，使营卫气通，内邪外达，则微寒亦散，恶寒自除，岂可用姜、桂之辛热，更助热邪，步甘、芍、大枣之甘温，反壅气机乎？可知桂枝、银翘两方，均不可以治瘟疫，这是鞠通辨证未清，立法不当，不是又可的方剂不善。又上焦篇，化斑汤下方论之后说：“按吴又可有托里举斑汤，不言疹者，混斑疹为一气也。”考温病中发疹者，十之七八，发斑者，十之二三。盖斑乃纯赤，或大片，为肌肉之病；疹系红点高起，麻、瘄、痧皆一类，系血络中之病也。观此，益见鞠通将瘟疫、风温，混而不辨，并非又可不分斑疹也。大概风温以轻清之邪，伤肺家轻清之脏，所以初起发热、咳嗽、喉痛、胸痛、颅胀，皆清邪在上也。舌无苔，或有微薄黄白苔，而内无浊结也。如邪郁不解，热入血络而成疹子，疹者，手太阴肺病也。若再不解，则逆传心包，而变神昏痉厥之危证矣。以其邪由肺入，虽传心包，热在血脉，与胃之主肌肉者无干，故风温之邪，但有疹而不成斑也。若瘟疫者，秽浊之邪，客于募原，募原在肺之下，胃之上，所以舌苔厚滞，以浊邪壅蔽胃口，胃热郁而成斑，故斑为足阳明胃病也。如募原之邪，由肺外达，则其结已开，邪已化，必作汗而泄，故瘟疫之邪，但有斑而不成疹也。吴又可所论瘟疫，以未见有疹，故不言疹，并非将斑疹相混也。如果瘟疫，又兼风温，则斑疹互现，偶或有之，然募原在里，邪结募原，须用重药，以开里结，则表气亦通，斑化而疹自消。倘用轻药，清肺治疹，则里结不开，疹亦难化，非其法矣。若风温之邪，不兼内浊，非瘟疫证，则发斑者，十无一二，所以鞠通言温病发疹，十之七八者，实为风温，而非瘟疫，岂得与又可之论相混哉？又可混称一切温病为瘟疫，是指鹿为马；鞠通又将瘟疫作风温而治，是指马为鹿，其失均也。且经云“冬伤于寒，春必病温”，此以伏寒化热，乘春阳上升而发为温病，故名春温。仲景所说，“发热而渴，不恶寒者，为温病”是也。以其内热，所以初病即渴，以邪非外感，故不恶寒。与风温之邪，由外感者，又为不同。鞠通亦不辨析论治，各证原流未清，所以立法不能尽当也。
Pneumonia is also a part of Shanghan (Cold Damage) and Wenbing (Warm Diseases). If it is confirmed as Feizhang (Lung Distension), Yuebi Jia Banxia Tang (Yuebi Decoction with Pinellia) should be used. For patients with cough, fever, and mild wheezing, those without sweating should use Xiao Qinglong Jia Shigao Tang (Minor Blue Dragon Decoction with Gypsum), while those with sweating should use Maxing Shigan Tang (Ephedra, Apricot Seed, Gypsum, and Licorice Decoction); these are not standard therapeutic indications. However, one must observe the pulse: if it is floating, large, and forceful, or floating, tight, and forceful, these formulas can be used with confidence; otherwise, the treatment plan must be changed. This is because cough and fever have not yet reached a critical stage, but if after several days the body suddenly develops high fever accompanied by wheezing, and the pulse becomes weak, with symptoms such as fixed staring (Zhishi), grasping at empty air (Cuokong), and loss of spirit, this indicates that although the lungs are filled with pathogenic factors, the pulse is hollow and weak, blood stasis is obstructive, and heart function is about to fail. I have seen Western medicine treat such conditions using cardiotonic agents, resulting in clear consciousness, cessation of wheezing, gradual subsidence of heat, and recovery. Initially, I suspected this was coincidental, but upon inquiry, I learned there was a method: they focused on strengthening the heart, which was effective even without treating wheezing or cough. In the *Shanghan Lun* (Treatise on Cold Damage), this condition should be treated primarily with Zhenwu Tang (True Warrior Decoction) added with Ganjiang (Dried Ginger), Wuweizi (Schisandra), and Xixin (Asarum). When the spirit is not overturned, fixed staring and grasping at empty air will cease naturally; when blood vessels are regulated and flow freely, heat will subside.
Yu Jiayan’s case study of Mr. Zhao showed forced coughing, unremitting high fever, rapid but weak pulse, and dry, rough skin. The physician used Heliusu (Willow Twig) and Xijiao (Rhinoceros Horn), failing to resolve exterior and interior pathogens, and inadvertently guided heat directly into the Pericardium, causing severe mental confusion worse than delirium due to stomach excess. The patient’s body turned dark like smoke, eyes stared fixedly, and head shook, yet Yu still advocated using Maxing Shigan Tang. (Songmu notes: Reading Yu Jiayan’s *Yuyi Cao*, "Grand Secretary Zhao's third son suffered from cold damage... initially Baihu Tang relieved heat slightly, but Ren Shen Baihu Tang worsened it... I prescribed Zhang Zhongjing’s Maxing Shigan Tang... The family used local remedies like Heliusu and Xijiao, which failed and drove heat into the heart... eventually becoming a sign of heart failure... Who knew Maxing Shigan Tang was a great medicine for saving lives?")
Then, one can treat patients with tight and full pulses. If the pulse is weak, meridians relax and blood becomes obstructed; Maxing Shigan Tang would only increase obstruction and deficiency, so it is definitely not the correct treatment. Even someone as wise as Yu missed this point, but since his prescription was not administered, people could not verify his error. Some might cite Ye Tianshi’s theory that "warm pathogens attack the lung and reverse-transmit to the pericardium" to explain the pathology. However, without blood stasis, even if heat attacks the heart, it merely causes restlessness and insomnia, treatable with Zhichi Tang (Gardenia and Soybean Decoction), Zhuling Tang (Polyporus Decoction), or Huanglian Ejiao Tang (Coptis and Donkey-Hide Gelatin Decoction). How could there be critical signs like fixed staring and delirium? (Songmu notes: "Blood stasis" refers to pulmonary congestion in pneumonia; "fixed staring and loss of spirit" corresponds to Ye Tianshi’s "reverse transmission to the pericardium." The pathogenesis is consistent. Respiratory symptoms require respiratory drugs. Zhichi and Zhuling are ineffective like scratching an itch through a boot. Cardiotonics that promote blood flow to dissipate congestion cannot be equated with these.)
If blood is not obstructed, the issue lies solely with the Lung, treated by Xiao Qinglong Tang or Yuebi Tang. If blood is obstructed, Shaoyin is endangered, and the Heart is responsible, requiring Zhenwu Tang. Zhang Zhongjing’s formulation of Zhenwu Tang was meticulous and innovative, yet people only use it for elderly deficiency wheezing, rarely for external contraction coughs, until now recognizing its excellence.
Mahuang (Ephedrae Herba) dilates peripheral capillaries to dissipate congestion; claiming it is unsuitable for blood stasis is incorrect. If the pulse is weak, combining it with Zhenwu Tang prevents harm. I have seen pneumonia patients with weak pulses treated with Maxing Shigan Tang combined with Western cardiotonics, achieving recovery. Even if efficacy is attributed solely to cardiotonics, Mahuang proves harmless. Regarding Tai Lao’s critique of Yu Jiayan’s case: Baihu Tang provided temporary relief but no cure. Pure Zhenwu Tang promotes circulation but does not cure; adding Maxing Shigan Tang for anti-inflammatory and antitussive effects yields faster results. Since Fuzi (Aconiti Lateralis Radix Preparata) in Zhenwu Tang is feared, Hua Shifu replaced it with Liushen Wan (Six-God Pill) containing Chan Su (Toad Venom), which has strong cardiotonic effects, albeit slower, reducing physicians' fears.
*Linzheng Zhinan* treats Feizhang mostly with light acrid-cool formulas, a habit hard to break. Suddenly using acrid-warm Mahuang causes shock, yet Wu Juztong’s *Wenbing Tiaobian* also uses Mahuang and Guizhi for wheezing, making our use logical and unremarkable.
*Wenbing Tiaobian*, Lower Jiao Chapter, Article 47: "Autumn dampness internal, winter cold external... pulse tight, no sweat, aversion to cold, body pain, wheezing cough with thin sputum... Xiao Qinglong Tang governs. Pulse rapid with sweat, remove Mahuang and Xixin. Profuse sweating, double Guizhi, reduce Ganjiang, add Mahuang Gen."
Article 48: "Wheezing cough, rapid breathing, thin saliva, pulse flooding and rapid, right larger than left, hoarse voice—this is hot fluid, governed by Maxing Shigan Tang." (Note: This is Feizhang; hoarseness indicates severe condition.)
These two articles are in the Cold-Damp section. The first shows cold signs; the second admits heat signs but uses Mahuang, proving Mahuang does not hinder clearing heat. Ancient formula combinations are miraculous.
*Wenbing Tiaobian*, Upper Jiao Chapter, Articles 1-8 show worsening conditions. Article 6: Cough only, slight fever, use Sangju Yin (Mulberry Leaf and Chrysanthemum Drink). Article 8: Floating, large, and knotted pulse, profuse sweating, slight wheezing, Maxing Shigan Tang is most appropriate. Baihu Tang offers temporary heat reduction but no fundamental benefit; only Maxing Shigan Tang saves the day. Adding cardiotonics prevents collapse from excessive sweating.
Knowing to use Maxing Shigan Tang for wheezing is a glimmer of wisdom in Wu Juztong. However, delaying it to the Lower Jiao instead of using it in Article 8 alongside Baibu Jia Renshen Tang was a fatal error. Subsequent formulas like Yunnv Jian, Xijiao Dihuang Tang, etc., were ineffective, leading to despair. Thus, Wu’s use of Maxing Shigan Tang is a minor insight, unfortunately not fully utilized.
Formerly, some claimed treating Shiwen (Damp-Warmth) requires drying dampness first, then purging. This is risky and relies on Wu’s Sanren Tang legacy. Dampness needs drying, warmth needs clearing; neglecting either accelerates coma and delirium, a poor method. I have insights on Shiwen treatment and will publish separately. Discussion on Warm Diseases ends here.
The debate on Warm Diseases over the past century has been chaotic, mixing *Neijing* and Zhang Zhongjing’s theories with those of Ye Tianshi, Wu Juztong, and Meng Ying. I aim to disentangle them: returning classical theories to classics and modern theories to their authors. The concepts of latent Qi and new sensation are baseless; separating Cold Damage and Warm Disease is erroneous. I believe in breaking boundaries. Though my scholarship is limited, I hope for correction. I dedicate myself to Traditional Chinese Medicine. (*Wenbing Lunheng*)
Chai’s Note: Criticism of Ye’s school focuses on: 1. Clearing heat is primary to preserve Yin; Ye’s methods are insufficient. 2. Light-clearing therapies are too weak for severe diseases like pneumonia compared to Maxing Shigan Tang or Yuebi Jia Banxia Tang. Whether to prioritize heat-clearing or yin-nourishing depends on differentiation. Emphasizing heat-clearing critiques the era’s overuse of yin-nourishing. Light-clearing formulas (Yinqiao, Sangju) are indeed insufficient for major illnesses like encephalitis. Xie’s view that they are weak for pneumonia aligns with Yang Zemín and is worth referencing.
Critique of *Wenbing Tiaobian*:
Wu Juztong’s *Wenbing Tiaobian* follows Ye’s ideas, dividing by Three Jiaos. His thesis: "All warm diseases begin in the Upper Jiao, affecting Hand Taiyin." This matches Ye’s "warm pathogens enter from above, first attacking the lung." However, Wu groups Fengwen, Wenre, Wenyi, and Dongwen together, suggesting Guizhi Tang for initial aversion to wind/cold and Yinqiao San for thirst without aversion. He criticizes Wu Youke’s *Wenyi Lun* and Dayuan Yin as flawed. I disagree. Wu Youke’s Dayuan Yin is appropriate despite other biases.
Fengwen is a light pathogen entering via nose/skin, damaging the Lung first. It occurs in all seasons. Wenyi (Plague) arises from climatic imbalances, characterized by thick white coating like powder, pathogen hiding in Moyuan (Diaphragm), requiring Dayuan Yin to open turbidity. Fengwen and Wenyi are distinct. Using light formulas like Yinqiao San for Wenyi is inappropriate (heavy disease, light medicine). Guizhi Tang is for Wind-Cold, not suitable for Fengwen or Wenyi. In Wenyi, aversion to cold is due to internal turbidity blocking Ying-Wei; Dayuan Yin resolves this internally, removing external chills. Using acrid-warm Guizhi would aggravate heat.
Wu claims Wu Youke confused macules (Ban) and papules (Zhen). Actually, Zhen (papules) are common in Fengwen (Lung disease), while Ban (macules) are common in Wenyi (Stomach/Muscle disease). Fengwen pathogens are light, affecting the Lung; heat enters blood collaterals causing Zhen. If it reverses to Pericardium, it causes coma. Wenyi pathogens are turbid, lodging in Moyuan (between Lung and Stomach); heat stagnates in Stomach muscles causing Ban. Wu Youke didn’t mention Zhen because he didn’t see them in pure Wenyi cases. If Wenyi combines with Fengwen, both may appear, but heavy medicines for Moyuan resolve both. Wu Juztong confusing Wenyi with Fengwen is a mistake, just as Wu Youke generalizing all warm diseases as plague was an error.
Finally, *Jingui Yaolue* states "Winter injury to cold leads to Spring Warmth" (Chunwen), where latent heat emerges. Zhang Zhongjing defines Warm Disease as fever with thirst and no aversion to cold. This differs from Fengwen caused by external contraction. Wu Juztong fails to distinguish these origins, leading to inaccurate prescriptions.