甚哉阴阳之证不可不详也遍观内经中所说变化百病其源皆由喜怒过度饮食失节寒温不适
劳役
所伤而然夫元气谷气营气清气卫气生发诸阳上升之气此六者皆饮食入胃谷气上行胃气之异名
其实一也既脾胃有伤则中气不足中气不足则六腑阳气皆绝于外故经言五脏之气已绝于外者是
六腑之元气病也气伤脏乃病脏病则形乃应是五脏六腑真气皆不足也惟阴大独旺上乘阳分
故荣卫失守诸病生焉其中变化皆由中气不足乃生发耳后有脾胃已受劳役之疾饮食又复失节耽
病日久事息心安饱食太甚病乃大作概其外伤风寒六淫客邪皆有余之病当泻不当补饮食失节中
气不足之病当补不当泻举世医者皆以饮食失节劳役所伤中气不足当补之证认作外感风寒有余
客邪之病重泻其表使荣卫之气外绝其死只在旬日之间所谓差之毫厘谬以千里可不详辨乎按阴
阳应象论云天之邪气感则害人五脏是八益之邪乃风邪伤人筋骨风从上受之风伤筋寒伤骨盖有
形质之物受病也紧在下焦肝肾是也肝肾者地之气难经解云肝肾之气已绝于内以其肝主筋肾主
骨故风邪感人则筋骨疼痛筋骨之绝则肝肾之本亦绝矣乃有余之证也又云水谷之寒热感则害人
六腑是七损之病乃内伤饮食也黄帝针经解云适饮食不节劳役所伤湿从下受之谓脾胃之气不足
而反下行极则冲脉之火逆而上是无形质之元气受病也系在上焦心肺是也心肺者天之气故难经
解云心肺之气已绝于外以其心主荣肺主卫荣者血也脉者血之府神之所居也卫者元气也神之别
行卫护周身在于皮毛之间者肺绝故皮毛先绝神无所根据故内伤饮食则亦恶风寒是荣卫失守皮肤
间无阳以滋养不能任风寒也皮毛之绝则心肺之本亦绝矣盖胃气不升元气不生无以滋养心肺乃
不足之证也谓受病之人饮食失节劳役所伤因而饱食内伤者极多外伤者间而有之世俗不知往往
将元气不足之证便作外伤风寒表实之证而反泻心肺是重绝其表也安得不死乎古人所谓实实虚
虚医杀之耳若曰不然请以众人之耳目闻见者证之向者壬辰改元京师戒严迫三月受敌者凡半月
围解之后都人之不受病者万无一二既而病死者继踵不绝都门十有二所每日各门所送多者二千
少不下一千似此者几三月此百万人岂俱感风寒外伤者耶大抵人在围城中饮食不节乃劳役所伤
不待言而知由其朝饥暮饱起居不时寒温失所动经两三月胃气亏乏久矣一旦饱食太过感而伤人
而又调治失宜其死也无疑矣非惟大梁为然远在真 与定间如东平如太原如凤翔解围之后病伤
死无不然者余在大梁凡所亲见有发表者有以巴豆推之者有以承气汤下之者俄而变结胸发黄又
以陷胸汤丸及茵陈汤下之无不死者盖初非伤寒以调治瘥互变而似真伤寒之证皆药之罪也往者
不可追来者犹可及辄以平生已试之效着内外伤辨论一篇推明前哲之余论历举近世之变故庶几
同志者审其或中触类而长之免后人无横夭耳僭易之罪将何所逃乎
上辨阴证阳证
外伤寒邪之证与饮食失节劳役形质之病及内伤饮食俱有寒热举世尽将内伤饮食失节劳役
不足
之病作外伤寒邪有余表实之证反泻其表枉死者岂胜言哉皆由不别其寒热耳今细为分解之外伤
寒邪发热恶寒寒热并作其热也翕翕发热又为之拂拂发热发于皮毛之上如羽毛之拂明其热在表
也是寒邪犯高之高者也皮肤毛腠阳之分也是卫之元气所滋养之分也以寒邪乘之郁遏阳分阳不
得伸故发热也其面赤鼻气拥塞不通心中烦闷稍以袒露其皮肤已不能禁其寒矣其表上虚热止此
而已其恶寒也虽重衣下幕逼近烈火终不能乐其寒一时一日增加愈甚必待传入里作下证乃罢
其寒热齐作无有间断也其内伤饮食不节或劳役所伤亦有头痛项强腰痛与太阳表证微有相似余
皆不同论中已辨之矣内伤不足之病表上无阳不能御风寒也此则常常有之其躁热发于肾间者间
而有之与外中寒邪略不相似其恶风寒也盖脾胃不足营气下流而乘肾肝此痿厥气逆之渐也若脾
气
平常饮食入胃其营气上行以舒于心肺以滋养上焦之皮肤腠理之元气也既下流其心肺无所禀受
皮肤间无阳失其荣卫之外护故阳分皮毛之间虚弱但见风见寒或居阴寒处无日阳处便恶之也此
常常有之无间断者也但避风寒及温暖处或添衣盖温养其皮肤所恶风寒便不见矣是热也非表伤
寒邪皮毛发热也乃肾间受脾下流之湿气闭塞其下致阴火上动作蒸蒸而燥热上彻头项傍彻皮肤
浑身躁热作须待袒衣露居近寒凉处即已或热极而汗出亦解彼外伤恶寒发热岂有汗出者乎若得
汗则病愈矣以此辨之岂不如黑白之易见乎当内虚而伤之者躁热也或因口吸风寒之气郁其阴火
使咽膈不通其吸入之气欲入为膈上冲脉之火所拒使气不得入其胸中之气为外风寒所遏而不得
伸令人口开目瞪极则声发于外气不得上下塞于咽中而气欲绝或又因哕因噎因吐而躁热发必有
所因方见此证其表虚恶风寒之证复见矣表虚之弱为阴火所乘躁发须臾而过其表虚无阳不任风
寒复见矣是表虚无阳常常有之其躁热则间而有之此二者不齐作躁作寒已寒作躁已非如外伤之
寒热齐作无有间断也百病俱有身热又为之肌热又为之皮肤间热以手扪之方知者是也乃肌体
有
形之热也亦须皆待阴阳既和汗出则愈矣慎不可于此上辨之以其虚实内外病皆有之故难辨耳只
根据先说病患自觉发热恶寒之热及躁作之热上辨之为准则矣
上辨寒热
外感八风之邪乃有余证也内伤饮食不节劳役所伤皆不足之病也其内伤亦恶风自汗若在温
暖无
风处则不恶矣与外伤鼻流清涕头痛自汗颇相似分之特异耳外感风邪其恶风自汗头痛鼻流清涕
常常有之一日一时增加愈甚直至传入里作下证乃罢语声重浊高厉有力鼻息拥塞不通能饮食腹
中和口知味大小便如常筋骨疼痛不能动摇便着床枕非扶不起其内伤与饮食不节劳役所伤然亦
恶风居露地中遇大漫风起却不恶也惟门窗隙中些小贼风来必大恶也与伤风伤寒俱不同矣况鼻
流清涕头痛自汗间而有之鼻中气短少气不足以息语则气短而怯弱妨食或食不下或不饮食三者
互有之腹中不和或腹中急而不能伸口不知五谷之味小便频数而不渴初劳役得病食少小便赤黄
大便常难或秘或结或虚坐只见些小白脓时有下气或泄黄如糜或溏泄色白或结而不通若心下痞
或
胸中闭塞如刀 之痛二者亦互作不并出也有时胃脘当心而痛上支两胁痛必脐下相火之势如巨
川之水不可遏而上行使阳明之经逆行乱于胸中其气无止息甚则高喘热伤元气令四支不收无气
以动而懒倦嗜卧其外感风寒俱无此证故易分别耳
上辨外感八风之邪或有饮食劳役所伤之重者三二日间特与外伤风者相似其余证有特异者
若不
将两证重别分解犹恐将内伤不足之证误作有余外感风邪虽词理有重复处但欲病者易辨医者易
治耳
内伤及劳役饮食不节病手心热手背不热外伤风寒则手背热手心不热此辨至甚皎然
上辨手背手心
若饮食劳役所伤其外证之显必在口必口失味必失谷味必腹中不和必不欲言纵勉强对答声
必怯
弱口沃沫多唾鼻中清涕或有或无即阴证也外伤风寒则其外证必显在鼻鼻气不利声浊不清其言
壅盛有力而口中必和伤寒则面赤鼻壅塞而干伤风则鼻流清涕而已内经云鼻者肺之候肺气通于
天外伤风寒则鼻为之不利口者坤土也脾气通于口饮食失节劳役所得口不知谷味亦不知五味又
云伤食恶食伤食明矣
上辨鼻口
外伤风寒者故其气壅盛而有余内伤饮食劳役者其口鼻中皆气短促不足以息何以分之盖外
伤风
寒者心肺元气初无减损又添邪气助之使鼻气拥塞不利面赤不通其鼻中气不能出并从口出但发
一言必前轻而后重其言高其声壮厉而有力伤寒则鼻干无涕面拥色赤其言前轻后重其声壮厉而
有力者乃有余之验也伤风则决然鼻流清涕其声嗄其言响如从瓮中出亦前轻而后重高揭而有力
皆气盛有余之验也内伤食劳役者心肺之气先损为热既伤气四肢无力以动故口鼻中皆短气少气
上喘懒语人有所问十不欲对其一纵勉强答之其气亦怯其气亦低是其气短少不足之验也明白如
此虽妇人女子亦能辨之岂有医者反不能辨之乎
上辨气少气盛
内证头痛有时而作有时而止外证头痛常常有之直须传里实方罢此又内外证之不同也
上辨头痛
内伤等病是心肺之气已绝于外必怠惰嗜卧四肢沉困不收此乃热伤元气脾主四肢既为热所
乘无
气以动经云热伤气又云热则骨消筋缓此之谓也若外伤风寒是肾肝之气已绝于内肾主骨为寒肝
主
筋为风自古肾肝之病同一治以其递相维持也故经言胆主骨膀胱主筋是也或中风或伤寒得病之
日便着床枕非扶不起筋骨为之疼痛不能动摇乃形质之伤经云寒伤形又云寒则筋挛骨痛此之
谓也
阴阳的证候不可不详细辨别啊。遍观《内经》中所说的各种变化多端的疾病，它们的根源都来自于喜怒过度、饮食失节、寒温不适以及劳役所伤。元气、谷气、营气、清气、卫气、生发诸阳上升之气，这六者都是饮食入胃后，谷气上行、胃气的不同名称，其实质是一样的。既然脾胃受到损伤，中气就会不足；中气不足，则六腑的阳气都在体表衰竭。所以经文说“五脏之气已绝于外”，这是六腑元气病变的表现。气受伤，脏腑才会生病；脏腑生病，形体才会显现出相应的症状。这说明五脏六腑的真气都已不足。只有阴气特别旺盛，上乘于阳分，导致营卫失守，各种疾病由此产生。其中的变化，都是因为中气不足，生发之机受阻而发生的。
后来，脾胃已经遭受了劳役的疾病，饮食又再次失节，患病日久，等到事情平息、心情安定时，饱食太甚，病情就大作。大抵外伤风寒六淫客邪，都属于有余的病证，应当泻而不应当补；饮食失节导致中气不足的病证，应当补而不应当泻。世间的医生都把因饮食失节、劳役所伤导致的当用补法的中气不足证，误认为是外感风寒有余的客邪病证，重泻其表，使营卫之气在体表彻底衰竭，死亡就在十天半月之间。所谓差之毫厘，谬以千里，怎能不详细辨别呢？
按照《阴阳应象大论》所说：“天之邪气，感则害人五脏。”这是八益之邪，乃是风邪伤人筋骨，风从上部受之，风伤筋，寒伤骨。这是因为有形的物质受了病，病位在下焦的肝肾。肝肾是地之气。《难经》解释说：“肝肾之气已绝于内。”因为肝主筋，肾主骨，所以风邪伤人，筋骨疼痛；筋骨衰竭，则肝肾的根本也衰竭了。这是有余的证候。
又说：“水谷之寒热，感则害人六腑。”这是七损之病，乃是内伤饮食。《黄帝针经解》说：“适饮食不节，劳役所伤，湿从下受之。”这是指脾胃之气不足反而下行，极则冲脉之火逆而上行。这是无形质的元气受了病，病位在上焦的心肺。心肺是天之气。所以《难经》解释说：“心肺之气已绝于外。”因为心主荣（营），肺主卫。荣即血，脉是血的府库，也是神居住的地方；卫即元气，是神的别行部分，护卫周身，位于皮毛之间。肺绝，所以皮毛先绝，神无所依附。因此，内伤饮食也会恶风寒，这是因为荣卫失守，皮肤间没有阳气来滋养，不能承受风寒。皮毛的衰竭，则心肺的根本也衰竭了。大概是因为胃气不升，元气不生，无法滋养心肺，这是不足的证候。
凡是受病的人，因饮食失节、劳役所伤而因饱食内伤的极多，因外伤的间或有之。世俗之人不知道，往往将元气不足的证候便当作外伤风寒表实的证候，反而泻心肺，这是重重地使体表衰竭，怎么能不死呢？古人所说的“实实虚虚”，就是医生杀死了病人啊。如果说不是这样，请拿众人的耳目见闻来证明。从前壬辰年改元时，京师戒严，被迫三月受敌共半个月。围城解除之后，城中人没有得病的万无一二，接着病死的人接踵而至。京城十二座城门，每天各门送来的尸体多的两千，少的不下一千，像这样的情况持续了近三个月。这一百万人难道都是感风寒外伤的吗？大抵人在围城中，饮食不节，又是劳役所伤，是不言而喻的。由于早晨饥饿晚上饱食，起居不时，寒温失调，经过两三个月，胃气早已亏乏。一旦饱食太过，感而伤人，再加上调治失宜，死亡是必然的了。不仅大梁是这样，远在真定与定州之间，如东平、太原、凤翔等地，解围之后因病伤死的无不如此。我在大梁，亲眼所见，有用发表法的，有用巴豆推荡的，有用承气汤攻下的。不久变成结胸、发黄，又用陷胸汤丸及茵陈汤攻下，没有不死的。起初并不是伤寒，而是因为调治不当互相变证，看起来像真的伤寒，这都是用药的罪过。往事不可追，未来犹可及，于是将我平生已试过的效验，写成《内外伤辨惑论》一篇，推明前代哲人的余论，历举近世的变故，希望志同道合的人审慎其中是否有中肯之处，触类旁通，以免后人无谓夭折。僭越轻率之罪，我将逃往何处呢？
上面辨别阴证和阳证
外伤寒邪的证候，与饮食失节、劳役形质之病及内伤饮食，都有寒热表现。举世都将内伤饮食失节、劳役不足之病，当作外伤寒邪有余表实的证候，反而泻其表，枉死者岂能说得完呢？这都是因为没有辨别寒热的原因。现在仔细分解：外伤寒邪，发热恶寒，寒热并作。其热，称为翕翕发热，又称拂拂发热，发于皮毛之上，如羽毛拂动，说明热在表。这是寒邪侵犯高位的高处，即皮肤毛腠阳之分，是卫之元气所滋养的部位。以寒邪乘袭，郁遏阳分，阳不得伸展，所以发热。其面色红赤，鼻气拥塞不通，心中烦闷，稍微袒露皮肤，就已经不能禁受寒冷了。其表上的虚热仅此而已。至于恶寒，即使穿重衣、挂帷幕、逼近烈火，最终也不能感到舒适。这种寒一时一日增加，越来越严重，必须等到传入里部，形成下部的实证才停止。其寒热同时发作，没有间断。
内伤饮食不节或劳役所伤，也有头痛、项强、腰痛，与太阳表证微有相似，其余都不同。论中已经辨别过了。内伤不足之病，表上无阳，不能御风寒，这是常常有的。其躁热发于肾间者，间或有之，与外中寒邪略不相似。其恶风寒，是因为脾胃不足，营气下流而乘袭肾肝，这是痿厥气逆的开端。如果脾气平常，饮食入胃，营气上行以舒于心肺，以滋养上焦的皮肤腠理的元气。既然下流，心肺无所禀受，皮肤间无阳，失去荣卫的外护，故阳分皮毛之间虚弱，但见风见寒，或居阴寒处，或在有日阳处，便觉得恶冷。这是常常有的，无间断的。只要避开风寒及温暖处，或添衣盖温养其皮肤，所厌恶的风寒就不见了。这种热，不是表伤寒邪皮毛发热，而是肾间受脾下流的湿气闭塞其下，致使阴火上动作，蒸蒸而燥热，上彻头项，傍彻皮肤，浑身躁热作痒，必须待袒衣露居近寒凉处即缓解，或者热极而汗出也缓解。那外伤恶寒发热，哪里有汗出的呢？若得汗则病愈了。以此辨别，岂不是像黑白一样容易看见吗？
当内虚而伤之时，是躁热。或因口吸风寒之气，郁其阴火，使咽膈不通，吸入之气欲入，为膈上冲脉之火所拒，使气不得入，胸中之气为外风寒所遏而不得伸，令人口开目瞪，极则声发于外，气不得上下，塞于咽中而气欲绝。或者又因哕、因噎、因吐而躁热发作，必有原因，方见此证。其表虚恶风寒之证复见。表虚之弱为阴火所乘，躁发须臾而过，其表虚无阳，不任风寒，复见矣。这是表虚无阳常常有之，其躁热则间而有之。这两者不齐作，躁作寒已，寒作躁已，并非如外伤之寒热齐作无有间断。
百病俱有身热，又称肌热，又称皮肤间热，以手扪之方知是，这是肌体有形之热。也都须待阴阳既和，汗出则愈。慎不可于此上辨别，因为虚实内外病皆有之，故难辨耳。只根据先说病患自觉发热恶寒的热及躁作之热上辨别，作为准则。
上面辨别寒热
外感八风之邪，乃有余证也。内伤饮食不节、劳役所伤，皆不足之病也。其内伤亦恶风自汗，若在温暖无风处则不恶了，与外伤鼻流清涕、头痛、自汗颇相似，分之特异耳。外感风邪，其恶风、自汗、头痛、鼻流清涕，常常有之，一日一时增加愈甚，直至传入里作下证乃罢。语声重浊高厉有力，鼻息拥塞不通，能饮食，腹中和，口知味，大小便如常，筋骨疼痛，不能动摇，便着床枕，非扶不起。其内伤与饮食不节、劳役所伤，虽然也恶风，居露地中遇大漫风起却不恶也，惟门窗隙中些小贼风来必大恶，也与伤风、伤寒俱不同了。况鼻流清涕、头痛、自汗间而有之。鼻中气短，少气不足以息，语则气短而怯弱，妨食或食不下，或不饮食，三者互有之。腹中不和，或腹中急而不能伸，口不知五谷之味，小便频数而不渴。初劳役得病，食少，小便赤黄，大便常难，或秘或结，或虚坐只见些小白脓，时有下气，或泄黄如糜，或溏泄色白，或结而不通。若心下痞，或胸中闭塞如刀割之痛，二者亦互作不并出。有时胃脘当心而痛，上支两胁痛，必脐下相火之势如巨川之水不可遏而上行使阳明之经逆行乱于胸中，其气无止息。甚则高喘，热伤元气，令四肢不收，无气以动而懒倦嗜卧。其外感风寒俱无此证，故易分别耳。
上面辨别外感八风之邪，或有饮食劳役所伤之重者，三二日间特与外伤风者相似，其余证有特异者。若不将两证重别分解，犹恐将内伤不足之证误作有余外感风邪。虽词理有重复处，但欲病者易辨，医者易治耳。
内伤及劳役饮食不节病，手心热，手背不热；外伤风寒则手背热，手心不热。此辨至甚皎然。
上面辨别手背手心
若饮食劳役所伤，其外证之显必在口，必口失味，必失谷味，必腹中不和，必不欲言，纵勉强对答，声必怯弱，口沃沫多唾，鼻中清涕或有或无，即阴证也。外伤风寒则其外证必显在鼻，鼻气不利，声浊不清，其言壅盛有力而口中必和。伤寒则面赤鼻壅塞而干，伤风则鼻流清涕而已。《内经》云：“鼻者，肺之候，肺气通于天。”外伤风寒则鼻为之不利。口者，坤土也，脾气通于口。饮食失节、劳役所得，口不知谷味，亦不知五味。又说：“伤食恶食，伤食明矣。”
上面辨别鼻口
外伤风寒者，故其气壅盛而有余；内伤饮食劳役者，其口鼻中皆气短促不足以息。何以分之？盖外伤风寒者，心肺元气初无减损，又添邪气助之，使鼻气拥塞不利，面赤不通，其鼻中气不能出，并从口出，但发一言，必前轻而后重，其言高，其声壮厉而有力。伤寒则鼻干无涕，面拥色赤，其言前轻后重，其声壮厉而有力者，乃有余之验也。伤风则决然鼻流清涕，其声嗄，其言响如从瓮中出，亦前轻而后重，高揭而有力，皆气盛有余之验也。内伤食劳役者，心肺之气先损为热，既伤气，四肢无力以动，故口鼻中皆短气少气，上喘懒语，人有所问，十不欲对其一，纵勉强答之，其气亦怯，其气亦低，是其气短少不足之验也。明白如此，虽妇人女子亦能辨之，岂有医者反不能辨之乎？
上面辨别气少气盛
内证头痛，有时而作，有时而止；外证头痛，常常有之，直须传里实方罢。此又内外证之不同也。
上面辨别头痛
内伤等病，是心肺之气已绝于外，必怠惰嗜卧，四肢沉困不收。此乃热伤元气，脾主四肢，既为热所乘，无气以动。经云：“热伤气。”又云：“热则骨消筋缓。”此之谓也。若外伤风寒，是肾肝之气已绝于内。肾主骨，为寒；肝主筋，为风。自古肾肝之病同一治，以其递相维持也。故经言胆主骨，膀胱主筋，是也。或中风或伤寒，得病之日便着床枕，非扶不起，筋骨为之疼痛，不能动摇，乃形质之伤。经云：“寒伤形。”又云：“寒则筋挛骨痛。”此之谓也。
The patterns of Yin and Yang must be examined in detail. A survey of the myriad diseases described in the *Neijing* (Inner Canon) reveals that their origins all stem from excessive emotions, irregular diet, inappropriate exposure to cold or heat, and injury from overwork. Yuan Qi (Original Qi), Gu Qi (Grain Qi), Ying Qi (Nutritive Qi), Qing Qi (Clear Qi), Wei Qi (Defensive Qi), and the ascending Qi of generating Yang—these six are merely different names for the same substance: the Qi rising from the stomach after food intake, derived from Grain Qi. Once the Spleen and Stomach are injured, the Central Qi becomes deficient; when Central Qi is deficient, the Yang Qi of the Six Fu Organs withers at the exterior. Thus, the Classic states that "the Qi of the Five Zang Organs has withered at the exterior," referring to a disease of the Yuan Qi of the Six Fu Organs. When Qi is injured, the Zang Organs become diseased; when Zang Organs are diseased, the physical form manifests corresponding symptoms. This indicates that the True Qi of the Five Zang and Six Fu Organs is insufficient. Only when Yin Qi becomes excessively prosperous and attacks the Yang aspect does it cause a loss of control over Ying and Wei Qi, giving rise to various diseases. These changes all occur because the deficiency of Central Qi hinders the mechanism of generation.
Later, if the Spleen and Stomach have already suffered from injuries due to overwork, and diet remains irregular, with the illness lingering for a long time, once external affairs cease and the mind is at peace, excessive fullness after eating can trigger a severe exacerbation of the disease. Generally, external invasions by Wind-Cold and the Six Excess Pathogens belong to excess patterns, which should be drained rather than tonified. In contrast, diseases caused by irregular diet leading to Central Qi deficiency belong to deficiency patterns, which should be tonified rather than drained. Physicians of the world mistakenly identify these deficiency patterns of Central Qi (caused by irregular diet and overwork, requiring tonification) as excess patterns of external Wind-Cold invasion (requiring draining). By heavily draining the exterior, they cause the Ying and Wei Qi to completely wither at the surface, leading to death within ten days. As the saying goes, "A miss is as good as a mile"; how can one fail to distinguish them carefully?
According to the *Yin Yang Ying Xiang Da Lun* (Great Treatise on the Correspondence of Yin and Yang): "Heavenly pathogenic qi, upon affecting the body, harms the Five Zang Organs." This refers to the Eight Excess Pathogens, specifically Wind invading the sinews and bones. Wind enters from above; Wind injures sinews, Cold injures bones. This occurs because tangible structures are affected, and the pathology lies in the Lower Jiao, involving the Liver and Kidneys. The Liver and Kidneys correspond to Earth Qi. The *Nan Jing* (Classic of Difficult Issues) explains: "The Qi of the Liver and Kidneys has withered internally." Since the Liver governs sinews and the Kidneys govern bones, Wind pathogens invading the body cause pain in sinews and bones; the withering of sinews and bones implies the withering of the root of the Liver and Kidneys. This is an excess pattern.
It also states: "Cold and heat from water and grain, upon affecting the body, harm the Six Fu Organs." This is the Seven Losses disease, resulting from internal dietary injury. The *Huangdi Zhenjing Jie* (Explanation of the Yellow Emperor's Needle Classic) says: "Inappropriate diet and overwork lead to Dampness entering from below." This refers to the insufficiency of Spleen-Stomach Qi causing it to descend abnormally; at its extreme, Fire from the Chong Mai (Penetrating Vessel) rebels upward. This affects intangible Yuan Qi, with pathology located in the Upper Jiao, involving the Heart and Lungs. The Heart and Lungs correspond to Heaven Qi. Thus, the *Nan Jing* explains: "The Qi of the Heart and Lungs has withered externally." The Heart governs Ying (Nutritive) Qi, and the Lungs govern Wei (Defensive) Qi. Ying is Blood; vessels are the residence of Blood and the dwelling place of Shen (Spirit). Wei is Yuan Qi, a branch of Shen, protecting the whole body and residing between the skin and hair. If Lung Qi fails, the skin and hair wither first, leaving Shen without support. Therefore, internal dietary injury also causes aversion to wind and cold because Ying and Wei control is lost, and there is no Yang Qi in the skin to nourish it, making it unable to withstand Wind-Cold. The withering of the skin and hair implies the withering of the root of the Heart and Lungs. Essentially, because Stomach Qi does not ascend and Yuan Qi is not generated, the Heart and Lungs cannot be nourished; this is a deficiency pattern.
Among those who fall ill, many suffer from internal injury due to overeating following irregular diet and overwork, while fewer suffer from external injury. Laypeople do not understand this and often mistake deficiency patterns of Yuan Qi for excess exterior patterns of Wind-Cold invasion, wrongly draining the Heart and Lungs, thereby doubly exhausting the exterior. How could such patients not die? As the ancients said, "Treating excess as excess and deficiency as deficiency" leads physicians to kill their patients. If you doubt this, consider the observations of the public. During the Renchen year, when the capital was under siege for half a month out of three months, after the siege was lifted, almost everyone fell ill, and deaths followed continuously. At the twelve gates of the capital, thousands of corpses were brought daily for nearly three months. Surely, not all of this million people contracted Wind-Cold externally. It is obvious that people in the besieged city suffered from irregular diet and overwork. After months of morning hunger and evening fullness, irregular rest, and temperature imbalance, Stomach Qi had been depleted. Once they ate too much upon relief, combined with improper treatment, death was inevitable. This was not limited to Daliang; places like Zhending, Dingzhou, Dongping, Taiyuan, and Fengxiang saw similar post-siege deaths from illness and injury. In Daliang, I witnessed cases where physicians used diaphoretic methods, purgatives like Radix Euphorbiae Pekinensis (Badou), or Decoction of Da Huang (Chengqi Tang). Subsequently, conditions transformed into Jie Xiong (Chest Binding) or Jaundice, treated with Xia Xiong Tang Wan and Yin Chen Tang, resulting in certain death. Initially, these were not Shaoyang or Taiyang syndromes; the transformations mimicking true Shaoyang/Taiyang syndromes were the fault of medication. Past mistakes cannot be undone, but future ones can be avoided. I have written this treatise based on my clinical experience to clarify the theories of past sages and document recent events, hoping colleagues will examine it carefully, apply it flexibly, and prevent unnecessary premature deaths.
**Differentiation of Yin and Yang Patterns**
Both external Cold invasion and internal injuries from irregular diet/overwork present with fever and chills. The world generally mistakes internal deficiency patterns for external excess exterior patterns, draining the exterior and causing wrongful deaths. This stems from failing to differentiate cold and heat. Now, let us analyze them in detail:
External Cold invasion presents with simultaneous fever and chills. The fever is described as "Xi Xi" (gentle/warm) or "Fu Fu" (fluttering), occurring on the skin and hair, indicating the heat is at the exterior. This is Cold invading the high Yang regions (skin, pores, hair follicles), which are nourished by Wei Qi. Cold constrains the Yang, preventing its extension, thus causing fever. The face may be red, nasal congestion present, and mental restlessness; slight exposure of the skin makes one sensitive to cold. This superficial heat is mild. However, aversion to cold is severe; even wearing heavy clothes, using curtains, or sitting near fire brings no comfort. The aversion worsens over time until the pathogen enters the interior and forms a lower Jiao excess pattern. The fever and chills occur simultaneously without interruption.
Internal injury from irregular diet or overwork may present with headache, stiff neck, and back pain, slightly resembling Taiyang exterior syndrome, but otherwise distinct. Internal deficiency means there is no Yang at the exterior to resist Wind-Cold, so aversion is constant. Restless heat arising from the Kidney area occurs intermittently and differs significantly from external Cold. The aversion to Wind-Cold here results from Spleen-Stomach deficiency causing Ying Qi to flow downward and attack the Liver-Kidneys, a precursor to flaccidity and reversal. Normally, Spleen Qi sends Ying Qi upward to the Heart-Lungs to nourish the upper Jiao skin and pores. When Ying Qi flows downward, the Heart-Lungs lack nourishment, and the skin loses Yang protection. Consequently, the Yang aspect of the skin and hair becomes weak; any encounter with Wind, Cold, shade, or sun triggers aversion. This is constant and uninterrupted. Avoiding Wind-Cold, staying warm, or adding clothing relieves the aversion. This heat is not external Cold-heat in the skin but rather Dampness from downward-flowing Spleen Qi blocking the lower Jiao, causing Yin Fire to flare up. This steaming restless heat spreads to the head, neck, and skin. Relief comes only by exposing oneself to cool air or sweating profusely. External Cold-heat rarely involves sweating; if sweating occurs, the disease resolves. Thus, differentiation is as clear as black and white.
Internal deficiency causes restless heat. Inhaling Cold-Wind may constrain Yin Fire, blocking the throat and diaphragm, preventing Qi entry. Chest Qi is constrained by external Wind-Cold, causing open mouth, staring eyes, vocalization, and suffocation sensation. Hiccups, choking, or vomiting may accompany this restless heat. The exterior deficiency aversion reappears. The weakness of the exterior allows Yin Fire to attack, causing brief restlessness. The lack of Yang in the exterior makes one susceptible to Wind-Cold again. Thus, exterior Yang deficiency is constant, while restless heat is intermittent. Unlike external patterns where fever and chills occur simultaneously without pause, here they alternate.
All diseases may present with body heat, muscle heat, or skin heat, palpable to the touch, representing tangible heat in the body structure. Recovery requires the harmony of Yin and Yang through sweating. Differentiation here is difficult because both deficiency/excess and internal/external patterns can present similarly. One must rely on the patient's subjective feeling of fever/chills and restless heat as the standard.
**Differentiation of Cold and Heat**
External invasion of the Eight Winds is an excess pattern. Internal injury from diet/overwork is a deficiency pattern. Internal injury may involve aversion to Wind and spontaneous sweating, but this disappears in warm, windless environments. This resembles external Wind invasion (clear nasal discharge, headache, sweating) but differs significantly upon analysis. External Wind invasion features constant aversion to Wind, sweating, headache, and clear nasal discharge, worsening progressively until entering the interior. Voice is heavy and resonant, nasal breathing obstructed, appetite normal, digestion normal, bowels/bladder normal, but sinews/bones hurt, preventing movement without support.
Internal injury from diet/overwork also involves aversion to Wind, but large winds outdoors do not aggravate it; only small drafts from windows/doors cause severe aversion, differing from Wind-Cold invasion. Clear nasal discharge, headache, and sweating occur intermittently. Shortness of breath, weak voice, poor appetite, abdominal discomfort, inability to extend the abdomen, loss of taste, frequent urination without thirst, constipation or loose stools, or blood/pus in stool may occur. Epigastric fullness or chest obstruction like knife pain may appear. Sometimes pain radiates from the epigastrium to the hypochondrium, driven by Min Fire (Ministerial Fire) surging upward like a river, disrupting the Yangming Meridian in the chest. Severe cases involve panting, Qi damage, limb flaccidity, lethargy, and desire to sleep. None of these occur in external Wind-Cold, making differentiation easy.
**Differentiation of Hand Temperature**
In internal injury/overwork/dietary irregularity, the palm is hot while the back of the hand is not. In external Wind-Cold, the back of the hand is hot while the palm is not. This distinction is very clear.
**Differentiation of Mouth and Nose**
If injured by diet/overwork, external signs manifest in the mouth: loss of taste, inability to digest grains, abdominal discomfort, reluctance to speak (weak voice if forced), excessive saliva, and possibly clear nasal discharge. This is a Yin pattern. If injured by external Wind-Cold, signs manifest in the nose: nasal obstruction, turbid voice, strong speech, and normal mouth taste. Cold invasion causes red face and dry nasal congestion; Wind invasion causes clear nasal discharge. The *Neijing* states: "The nose is the aperture of the Lung, connecting to Heaven." External Wind-Cold obstructs the nose. The mouth corresponds to Earth (Spleen); Spleen Qi connects to the mouth. Dietary irregularity/overwork causes loss of taste for grains and flavors. "Food stagnation causes aversion to food" is evident.
**Differentiation of Breath Strength**
External Wind-Cold presents with robust, excess Qi. Internal injury presents with short, insufficient breath from mouth and nose. Why? External Wind-Cold does not initially deplete Heart-Lung Yuan Qi but adds pathogenic Qi, causing nasal obstruction, red face, and forced exhalation through the mouth. Speech starts light and ends heavy, loud and forceful—signs of excess. Wind invasion causes clear nasal discharge, hoarse voice, resonant speech (like from a jar), starting light and ending heavy, loud and forceful—also signs of excess Qi. Internal injury/depletion damages Heart-Lung Qi first, causing heat and Qi deficiency. Limbs lack strength. Mouth and nose show shortness of breath, panting, reluctance to speak. If questioned, the patient answers reluctantly, with weak and low Qi—signs of deficiency. This is clear enough for anyone to distinguish.
**Differentiation of Headache**
Internal headache comes and goes. External headache is constant until the pathogen enters the interior and becomes excess. This distinguishes internal from external patterns.
**Differentiation of Limb Condition**
Internal injury implies Heart-Lung Qi has withered externally, causing lethargy, drowsiness, and heavy, flaccid limbs. This is Heat damaging Yuan Qi; the Spleen governs limbs, and Heat deprives it of Qi. The Classic says: "Heat damages Qi" and "Heat causes bone wasting and sinew laxity." External Wind-Cold implies Liver-Kidney Qi has withered internally. Kidneys govern bones (Cold); Livers govern sinews (Wind). Ancient texts treat Liver-Kidney diseases together as they support each other. The Classic states Gallbladder governs bones and Bladder governs sinews. Stroke or Cold invasion causes immediate bedridden state, inability to move, and sinew/bone pain—tangible structural injury. The Classic says: "Cold damages form" and "Cold causes sinew spasm and bone pain."