此一卷论治法。古人治伤寒有法。非杂病之比。五种不同。六经各异。阴阳传受。日数浅深。
药剂温凉。用有先后。差之毫厘。轻者危殆。况不识法者乎。伤寒唯两感不治。其余证候。虽感异
气。能消息之。无不愈者。其有差失。仲景所谓医杀之耳。知其法者。若网在纲。如此而汗。如此
而吐。如此而下。桂枝承气。瓜蒂四逆。用之无不瘥。唯其应汗而下。为痞为结胸。为懊 。应下
而汗。为亡阳。为谵语。为下厥上竭。又有当温反吐。疗热以温。变证百出。无复纪律。扰扰万绪
起矣。大抵伤于寒为病热。孙真人云。服承气汤。得利瘥。慎不中补也。热气得补复成。王叔和云。
虚热不可大攻之。热去则寒起。二人之论。疑若相戾。然热气有实有虚。非深得仲景之意。岂能至
此耶。
（三十一）问冬谓之伤寒。春谓之温病。夏谓之热病。
素问云。冬三月。是谓闭藏。水冰地坼。无扰乎阳。又云。彼春之暖。为夏之暑。彼秋之忿。
为冬之怒。是以严寒冬令。为杀厉之气。君子善摄生。当严寒之时。行住坐卧。护身周密。故不犯
寒毒。彼奔驰荷重。劳房之人。皆辛苦之徒也。当阳闭藏而反扰动之。则郁发腠理。津液强渍。为
寒所薄。肤腠致密。寒毒与营卫相浑。当是之时。壮者气行则已。怯者、则着而成病矣。其实时而
病者。头痛身疼。肌肤热而恶寒。名曰伤寒。其不实时而病者。寒毒藏于肌肤之间。至春夏阳气发
生。则寒毒与阳气相搏于营卫之间。其病与冬时即病。无异。
但因春温气而变。名曰温病。因夏热气而变。名曰热病。温热二名。直以热之多少为义。阳热未盛。
为寒所制。病名为温。阳热已盛。寒不能制。病名为热。故大医均谓之伤寒也。
（三十二）问三日以前当汗。三日以后当下。
古人云。未满三日者。可汗而已。其满三日者。可泄而已。此大略之言耳。病患有虚有实。邪
气传受。迟速不等。岂可拘以日数。仲景云。日数虽多。但有表证而脉浮者。由宜发汗。日数虽少。
若有里证而脉沉者。即宜下之。正应随脉以汗下之。（伤寒固有始得病便变阳盛之证。须便下之。又
有腠理寒。一二日便成少阴病者。须急温之）又况六气之邪。乘虚入经。自背得之则入太阳。或
入少阴。（缘少阴有伏脉在背）自面感之。则入阳明之类。不必皆始于太阳。兼寒邪有首尾止在
一经。或间传一二经。不可以一理推。但据脉与外证治之。此活法也。假令有人脉浮头项强痛。发热
而恶寒。每日如此。不以日数多少。只是太阳经受之。其余经络皆仿此。大抵伤寒凭脉与外证以汗
下之。若过日多。脉尚大浮数。按之不足者。尚责太阳也。可发汗而愈。若按之实者。汗之必死。
须下之而愈也。若始得病脉细沉数。外证或腹满咽干。或口燥舌干而渴。为正责属里。可下之而愈。
若无此证。但发热脉沉者。误下必死。须行麻黄附子甘草汤（正二十二）、麻黄细辛附子汤（正二十三）、
小发汗。此皆仲景之确论也。
（三十三）问阳虚阴盛。汗之则愈。下之则死。阳盛阴虚。汗之则死。下之则愈。
素问云。阳虚则外寒。阴虚则内热。阳盛则内热。阴盛则外寒。故治伤寒者。阳虚阴盛。汗之
则愈。下之则死。阳盛阴虚。汗之则死。下之则愈也。阴阳虚盛。非谓分脉尺寸也。表、阳也。里、
阴也。外台云。表病里和。汗之则
愈。表和里病。下之则愈。亦只是论表里阴阳以汗下之。（难经云阴阳虚实者。说脉也。素问云阴阳
虚盛者。说表里也。仲景论伤寒汗下。故引素问表里之义。与外台所论合矣）○大抵营卫为表属
阳。胃腑为里属阴。寒毒争于营卫之中。必发热而恶寒。尺寸俱浮大。内必不躁。设有微烦。其人饮
食欲温而恶冷。为阳虚阴盛也。汗之则愈。误下则死。○若寒毒相搏于营卫之内。而阳胜阴衰。极
阴变阳。寒盛生热。而阳热之气盛而入里。热毒居胃。水液干涸。燥粪结聚。其人外不恶寒。必蒸
蒸发热而躁。甚则谵语。其脉浮滑而数。或洪实。为阳盛阴虚也。下之则愈。误汗则死。
谨按黄帝素问调经论云。阳虚则外寒。阴虚则内热。阳盛则外热。阴盛则内寒。盖阳主外而阴
主内。又曰。阳虚阴盛。汗出而愈。下之则死。阳盛阴虚。汗出而死。下之则愈。今三十三问误写
作阳盛则内热。阴盛则外寒。窃详内外寒热不同。则汗下差误。便分死生。又按将作监簿王宗正难
经疏义有阴阳盛虚汗下图。与素问合。以理考之。此是三十三问误写。合行刊正。勿误后人。
（三十四）问仲景有发汗者。有和解之者。
伤寒表证须看营卫浅深。故仲景有正发汗汤剂。如麻黄汤（正二十）、桂枝汤（正一）、大青龙汤（正三五）、是也。
有和解
其表。如小青龙汤（正三六）、桂枝麻黄各半汤（正二）、白虎汤（正六四）、桂枝二越婢一汤（正四）、柴胡桂枝汤（正
三十一）、小柴胡汤（正二十九）、之类是
也。后人不能深究寒热浅深。药性紧慢。一概用药。因兹夭伤。其间纵获生全。往往汗后虚乏。遂
致劳复。或变生百病。淹引岁月。卒至不救。此皆由汗下过度。阴阳并竭。血气羸损。以致此祸。
如遇病轻。但当和解之。所谓和其营卫以通津液。令其自解也。
（三十五）问仲景有宜下之。有微和其胃气者。
伤寒里证须看热气浅深。故仲景有宜下之。如大承气汤（正四一）、小承气汤（正四二）、十枣汤（正八九）、大柴胡
汤（正三十）、是也。
有微和其胃气。如调胃承气汤（正四三）、脾约丸、（杂六六）少与小承气（正四二）、微和之之类是也。金匮玉函云。虚
者十补勿
一泻。强实者泻之。虚实等者。泻勿大泄之。故王叔和序伤寒有承气之戒。○又问转药孰紧。答曰。
大承气最紧。小承气次之。调胃承气汤又次之。大柴胡又次之。仲景治法。荡涤热积。皆用汤液。
不得用丸子药。不可不知也。（大柴胡加大黄。小柴胡加芒硝。方为转药。盖为病轻者设也）
（三十六）问伤寒一日头疼口干烦满而渴。二日腹满身热不欲食谵语。三日耳聋囊缩而厥。水浆
不入不知人。
此名两感伤寒也。两感者。表里俱病也。太阳与少阴为表里。阳明与太阴为表里。少阳与厥阴
为表里。阴阳双传。脏腑俱病。此为难治。六日而死矣。故一日太阳与少阴俱病。则头痛口干烦满
而渴。二日阳明与太阴俱病。则腹满身热不欲食谵语。三日少阳与厥阴俱病。则耳聋囊缩而厥。仲
景无治法。但云两感病俱作。治有先后。发表攻里。本自不同。寻至第三卷中。言伤寒下之后复下
利不止、身疼痛者。当急救里。宜四逆汤。（正七五）复身体疼痛清便自调者。急当救表。宜桂枝汤（正一）。遂以意
寻比仿效。治两感有先后。宜先救里。若阳气内正。即可医也。内才正。急当救表。盖内尤为急。
才温内。则急救表。亦不可缓也。
（三十七）问伤寒已经发汗吐下仍不解。（古人谓之坏病）
仲景云。太阳病三日已发汗。若吐若下若温针。仍不解者。为坏病。桂枝不中与也。当知何逆。
随证治之。又云。太阳病不解。转入少阳者。胁下硬满。干呕不能食。往来寒热。尚未吐下。其脉
沉紧者。可与小柴胡汤。（正二十九）若已吐下发汗。小柴胡证罢。此为坏病。知犯何逆。以法治之。盖为病中
又感异气。变为坏病。以时令寒暑燥湿风气不节。脉息与少阳相异。（小柴胡证罢）证候与伤寒
不同。（麻黄桂枝不中与也）明当消息其由。以法治之。若脉尺寸俱盛。重感于寒。变为温疟。
（先热后寒。名曰温疟。在第六卷四十四问）阳脉浮滑。阴脉濡弱。更遇于风。变为风温。（四
肢不收。头疼身热。常自汗出。在第六卷四十五问）阳脉浮数。阴脉实大。更遇温热。变为温毒。
为病最重。（春月肌肉发斑。名曰温毒。在第六卷又五十问）阳脉濡弱。阴脉弦紧。更遇温气。
变为温疫。（一岁之中。长幼疾状多相似。感四时不正之气。在第六卷四十六问）脉证之变。方
治不同。仲景谓温病之脉。行在诸经。不知何经之动。随其经而取之也。又有伤寒过经。再受热邪。
留蓄脏腑。病候多变。久而不瘥。阴阳无复纲纪。及伤寒解后虚羸少气。皆名坏伤寒也。知母麻
黄汤（杂二十八）鳖甲散（杂二十九）黑奴丸（杂二十）检方与病证相参选用之。若伤寒解后。虚羸少
气。气逆吐者。竹叶石膏汤主之。（正九五）
这一卷论述治疗方法。古人治疗伤寒有固定的法则，这与治疗杂病不同。五种情况各不相同，六经的病证也各有差异。阴阳的传变、病程日数的深浅，药剂的温凉属性，使用时机有先后之分。如果差错毫厘，原本轻浅的病证就会变得危重，更何况是不懂这些法则的人呢？伤寒中只有“两感”（表里两经同时受邪）难以治愈，其余的证候，虽然感受了不同的邪气，只要能够仔细斟酌病情，没有不能痊愈的。那些出现差错的，正如张仲景所说，是医生治死的。懂得这些法则的人，就像掌握了网的总纲一样，该发汗就发汗，该催吐就催吐，该攻下就攻下。桂枝汤、承气汤、瓜蒂散、四逆汤等方剂，使用得当没有不痊愈的。唯独那些应当发汗却误用攻下，导致形成痞证或结胸证；或者应当攻下却误用发汗，导致亡阳、谵语、下厥上竭（下部厥冷而上部阴血枯竭）等变证。又有应当温补却误用催吐，用温热药治疗热证，导致变证百出，失去了纪律，纷乱万端。大抵来说，伤于寒邪而发病表现为热证。孙思邈说：服用承气汤后，大便通畅病愈，切记不可立即进补。因为热气得到补益会再次形成实热。王叔和说：虚热不可猛烈攻伐，热邪去除后寒邪就会兴起。两人的言论似乎矛盾，然而热气有实热和虚热之分，如果不是深得张仲景的心意，怎么能达到这种境界呢？
（第三十一问）有人问：冬天称为伤寒，春天称为温病，夏天称为热病，这是为什么？
《素问》说：冬季三个月，叫做闭藏，水结冰地裂开，不要扰动阳气。又说：春天的温暖，是夏天暑热的基础；秋天的肃杀，是冬天严寒的基础。因此，严冬的寒气是杀厉之气。君子善于养生，在严寒的时候，无论行走、站立、坐着还是躺着，都要周密地保护身体，所以不触犯寒毒。那些奔波劳碌、负重劳累以及房事过度的人，都是辛苦劳作之人。当阳气应当闭藏的时候反而扰动它，那么阳气就会郁积发散在腠理之间，津液被迫浸渍，被寒邪所迫，皮肤腠理致密，寒毒与营卫之气混杂在一起。在这个时候，体质强壮的人，气血运行通畅则病愈；体质虚弱的人，邪气留着不去就形成疾病了。其实是在当时季节发病的，症状是头痛身疼，肌肤发热且恶寒，名叫伤寒。如果不是在当时季节发病，而是寒毒潜伏在肌肤之间，到了春夏季阳气发生的时候，寒毒与阳气在营卫之间相搏争，其病症与冬季即时发病没有区别。
只是由于春季温和之气的影响而发生变化，名叫温病；由于夏季炎热之气的影响而发生变化，名叫热病。“温”和“热”这两个名称，直接以热的程度多少来定义。阳热尚未旺盛，被寒邪制约，病名叫做温；阳热已经旺盛，寒邪不能制约，病名叫做热。所以大医家都统称为伤寒。
（第三十二问）有人问：发病三天以前应当发汗，三天以后应当攻下，对吗？
古人说：未满三天的，可以通过发汗治愈；满三天的，可以通过泄下治愈。这只是大概的说法罢了。患者有虚有实，邪气传变的快慢不等，怎么能拘泥于日数呢？张仲景说：日数虽然多，但只要还有表证且脉象浮的，适宜发汗；日数虽然少，如果有里证且脉象沉的，就适宜攻下。正应该根据脉象来决定发汗或攻下。（伤寒中固有开始得病就变成阳盛证候的，必须立即攻下；也有因为腠理寒冷，一两天就变成少阴病的，必须紧急温补。）况且六淫邪气乘虚侵入经络，从背部感受的则进入太阳经，或者进入少阴经（因为少阴经伏脉在背部）。从面部感受的，则进入阳明经之类。不一定都始于太阳经。加上寒邪有的从头到尾只在一经，或者间传一二经，不能用一个道理去推断。只要依据脉象和外证来治疗，这就是灵活的方法。假使有人脉象浮，头项强痛，发热且恶寒，每天如此，不论日数多少，只是太阳经受邪。其余经络都仿照这个原则。大抵治疗伤寒凭借脉象和外证来决定发汗或攻下。如果过了很多天，脉象仍然大而浮数，按之不足的，责任仍在太阳经，可以发汗而愈。如果按之有力的，发汗必死，必须攻下才能愈。如果刚得病时脉象细沉数，外证或有腹满咽干，或口燥舌干而渴，这是正气归属于里，可以攻下而愈。如果没有这些证候，只是发热而脉沉的，误用攻下必死，必须使用麻黄附子甘草汤、麻黄细辛附子汤进行轻微的发汗。这都是张仲景的确切论断。
（第三十三问）有人问：阳虚阴盛，发汗则愈，攻下则死；阳盛阴虚，发汗则死，攻下则愈，对吗？
《素问》说：阳虚则外部寒冷，阴虚则内部发热，阳盛则内部发热，阴盛则外部寒冷。所以治疗伤寒，阳虚阴盛的，发汗则愈，攻下则死；阳盛阴虚的，发汗则死，攻下则愈。阴阳的虚实盛衰，并不是指寸关尺三部脉的分野。表属阳，里属阴。《外台秘要》说：表病里和，发汗则愈；表和里病，攻下则愈。也只是论述表里阴阳来决定发汗或攻下。（《难经》说的阴阳虚实是指脉象，《素问》说的阴阳虚盛是指表里。张仲景论述伤寒的发汗攻下，所以引用《素问》表里的含义，与《外台秘要》的论述相合。）○大抵营卫属于表属阳，胃腑属于里属阴。寒毒在营卫之中争斗，必然发热且恶寒，寸脉尺脉都浮大，内部一定不躁动，即使有轻微烦躁，其人饮食喜温而恶冷，这是阳虚阴盛的表现。发汗则愈，误用攻下则死。○如果寒毒在营卫之内相搏争，而阳胜阴衰，极端的阴转化为阳，寒盛生热，阳热之气旺盛而入里，热毒居于胃，水液干涸，燥粪结聚，其人外部不恶寒，必然蒸蒸发热且躁动，甚至谵语，脉象浮滑而数，或洪实，这是阳盛阴虚的表现。攻下则愈，误用发汗则死。
谨按《黄帝素问·调经论》说：阳虚则外寒，阴虚则内热，阳盛则外热，阴盛则内寒。盖因阳主外而阴主内。又说：阳虚阴盛，发汗而愈，攻下则死；阳盛阴虚，发汗而死，攻下则愈。现在第三十三问误写作“阳盛则内热，阴盛则外寒”。我仔细推敲内外寒热的不同，汗法和下法的差错失误，便区分生死。又按将作监簿王宗正的《难经疏义》中有阴阳盛虚汗下图，与《素问》相合。以理考察，这是第三十三问的误写，应当刊正，以免误导后人。
（第三十四问）有人问：张仲景有发汗的方法，有和解的方法，是怎么回事？
伤寒表证需要看营卫受邪的深浅，所以张仲景有专门发汗的汤剂，如麻黄汤、桂枝汤、大青龙汤等。有和解其表的，如小青龙汤、桂枝麻黄各半汤、白虎汤、桂枝二越婢一汤、柴胡桂枝汤、小柴胡汤等。后人不能深入探究寒热的深浅，药性的峻缓，一概用药，因此造成夭折伤亡。其中即使获得生存，往往汗后虚乏，导致劳复，或者变生百病，拖延岁月，最终无法救治。这都是因为汗法下法过度，阴阳俱竭，血气亏损，以致招致此祸。如果遇到病轻的，只应当和解，所谓调和营卫以通津液，让它自然解散。
（第三十五问）有人问：张仲景有适宜攻下的，有轻微调和胃气的，是怎么回事？
伤寒里证需要看热气的深浅，所以张仲景有适宜攻下的，如大承气汤、小承气汤、十枣汤、大柴胡汤等。有轻微调和胃气的，如调胃承气汤、脾约丸、少量给予小承气汤轻微调和等。《金匮玉函经》说：虚者只宜十次补益不要一次泻下，强实者泻下它，虚实相当的，泻下不要过于猛烈。所以王叔和在《伤寒序例》中有使用承气汤的告诫。○又问：转药哪个最峻猛？回答是：大承气汤最峻猛，小承气汤次之，调胃承气汤又次之，大柴胡汤再次之。张仲景的治疗方法，荡涤热积，都用汤剂，不得使用丸药，不可不知道。（大柴胡汤加大黄，小柴胡汤加芒硝，才算是转药，这是为病轻者设立的。）
（第三十六问）有人问：伤寒第一天头疼口干烦满而渴，第二天腹满身热不欲食谵语，第三天耳聋囊缩而厥，水浆不入不知人，这是什么病？
这名叫两感伤寒。两感，就是表里两经同时生病。太阳与少阴为表里，阳明与太阴为表里，少阳与厥阴为表里。阴阳双传，脏腑都生病，这属于难治，六天就会死亡。所以第一天太阳与少阴同时生病，则头痛口干烦满而渴；第二天阳明与太阴同时生病，则腹满身热不欲食谵语；第三天少阳与厥阴同时生病，则耳聋囊缩而厥。张仲景没有具体的治法，只说两感病同时发作，治疗有先后顺序，发表和攻里，本来就不相同。寻找到第三卷中，提到伤寒攻下之后又攻下，利不止、身疼痛的，应当急救里，适宜用四逆汤。如果身体疼痛但大小便正常，急当救表，适宜用桂枝汤。于是凭心意寻比仿效，治疗两感病有先后顺序，适宜先救里。如果阳气内部端正，就可以医治了。内部刚刚端正，急当救表。因为内部尤为紧急，才温补内部，就要紧急救表，也不可迟缓。
（第三十七问）有人问：伤寒经过发汗、吐、下后仍然不解（古人称之为坏病），怎么办？
张仲景说：太阳病三天，已经发汗，如果用吐法、下法或温针，仍然不解的，叫做坏病，桂枝汤不再适用。应当知道是什么逆乱，随证治疗。又说：太阳病不解，转入少阳的，胁下硬满，干呕不能食，往来寒热，还没有经过吐下，脉象沉紧的，可以与小柴胡汤。如果已经经过吐下发汗，小柴胡汤证消失，这叫坏病。知道犯了什么逆乱，依法治疗。这是因为病中又感受异气，变为坏病，因为时令寒暑燥湿风气不调，脉息与少阳证不同，证候与伤寒不同。明当斟酌病因，依法治疗。如果脉象寸尺俱盛，重感于寒，变为温疟（先热后寒，名叫温疟，在第六卷第四十四问）。阳脉浮滑，阴脉濡弱，更遇风邪，变为风温（四肢不收，头疼身热，常自汗出，在第六卷第四十五问）。阳脉浮数，阴脉实大，更遇温热，变为温毒，为病最重（春月肌肉发斑，名叫温毒，在第六卷第五十问）。阳脉濡弱，阴脉弦紧，更遇温气，变为温疫（一岁之中，长幼疾状多相似，感四时不正之气，在第六卷第四十六问）。脉证的变易，方治不同。张仲景说温病的脉象，行走在各经，不知道哪一经发动，随其经而取之。又有伤寒过经，再受热邪，留蓄脏腑，病候多变，久而不愈，阴阳失去纲纪，以及伤寒解后虚羸少气，都名叫坏伤寒。知母麻黄汤、鳖甲散、黑奴丸，检查方剂与病证参酌选用。如果伤寒解后，虚羸少气，气逆呕吐的，竹叶石膏汤主治。
This volume discusses treatment methods. The ancients had established laws for treating Shanghan (Cold Damage), which differs from treating miscellaneous diseases. There are five distinct categories, and the Six Channels (Taiyang, Yangming, Shaoyang, Taiyin, Shaoyin, Jueyin) each have their own characteristics. The transmission of Yin and Yang, the depth and duration of the disease days, the warming or cooling nature of the prescriptions, and the timing of their use all follow a sequence. A discrepancy of even a hair's breadth can turn a mild condition into a critical one, let alone those who do not understand these laws. Among Shanghan conditions, only "Lianggan" (simultaneous involvement of exterior and interior channels) is difficult to cure. For other syndromes, although different pathogenic factors may be involved, careful assessment ensures recovery in all cases. Errors in treatment, as Zhang Zhongjing stated, result in the physician killing the patient. Those who understand these laws act like holding the headrope of a net: if sweating is indicated, sweat; if vomiting is indicated, induce vomiting; if purging is indicated, purge. Formulas such as Guizhi Tang (Cinnamon Twig Decoction), Chengqi Tang (Gastro-Regulating Decoction variants), Gualti San (Melon Seed Powder), and Sini Tang (Frigid Extremities Decoction) are used effectively without failure. However, if sweating is indicated but purging is mistakenly used, Pi syndrome (glomus) or Jie Xiong syndrome (chest binding) may result. If purging is indicated but sweating is mistakenly used, Wang Yang (loss of Yang), Zanyu (delirious speech), Xia Jue Shang Jie (cold extremities with upper depletion) may occur. Furthermore, using emesis when warming is needed, or using warm treatments for heat syndromes, leads to hundreds of variable syndromes and loss of discipline, creating chaos. Generally, injury by cold pathogens manifests as heat diseases. Sun Simiao said: After taking Chengqi Tang and achieving bowel movement with recovery, one must be cautious against tonification, as heat qi combined with tonics will re-form excess heat. Wang Shuhe said: Deficiency heat should not be aggressively attacked; once the heat is gone, cold will arise. These two theories seem contradictory, yet heat has both excess and deficiency aspects. Only by deeply understanding Zhang Zhongjing’s intent can one grasp this nuance.
(Question 31) Why is winter called Shanghan, spring called Wenbing (Warm Disease), and summer called Rebing (Heat Disease)?
The Suwen states: The three months of winter are called "closing and storing," where water freezes and earth cracks; one should not disturb Yang. It also states: The warmth of spring becomes the summer heat; the severity of autumn becomes the winter cold. Therefore, severe winter cold is a killing and harsh qi. Gentle people who know how to preserve life protect themselves meticulously whether walking, standing, sitting, or lying down during extreme cold, thus avoiding cold toxins. Those who travel hard, carry heavy loads, or engage in excessive sexual activity are laborers who disturb Yang when it should be stored. This causes Yang to stagnate and diffuse through the cou li (skin and interstices), forcing fluids to soak, leading to cold pathogens attacking dense skin and interstices, mixing with Ying and Wei qi. At this time, robust individuals recover as Qi flows freely, while weak individuals develop disease as the pathogen lingers. When illness occurs immediately in season, symptoms include headache, body ache, hot skin, and aversion to cold, named Shanghan. When illness does not occur immediately, cold toxin hides in the skin and interstices. When Yang qi arises in spring and summer, the cold toxin battles with Yang qi between Ying and Wei. The pathology is no different from immediate seasonal onset.
However, due to the influence of spring's warm qi, it changes name to Wenbing. Due to summer's hot qi, it changes name to Rebing. The terms "Wen" and "Re" define the degree of heat. When Yang heat is not yet strong and is controlled by cold, it is named Wen. When Yang heat is strong and cannot be controlled by cold, it is named Re. Thus, great physicians generally refer to them all as Shanghan.
(Question 32) Is it true that one should sweat within three days and purge after three days?
The ancients said: If less than three days have passed, sweating suffices; if three days or more have passed, purging suffices. This is a general statement. Patients vary in deficiency and excess, and the speed of pathogen transmission varies. How can one rigidly adhere to days? Zhang Zhongjing said: Even if many days have passed, if exterior signs exist and the pulse is floating, sweating is appropriate. Even if few days have passed, if interior signs exist and the pulse is deep, purging is appropriate. One must decide on sweating or purging based on the pulse. (Note: Some Shanghan cases begin with Yang excess signs requiring immediate purging; others involve cold cou li progressing to Shaoyin disease within one or two days, requiring urgent warming.) Moreover, six types of pathogenic qi enter meridians via deficiency. Invasion from the back enters Taiyang or Shaoyin (as Shaoyin has hidden pulses at the back). Invasion from the face enters Yangming, etc. It does not always start in Taiyang. Cold pathogens may stay in one channel or skip channels; one cannot apply a single rule. Treatment must rely on pulse and external signs—this is the living method. For example, if a patient has a floating pulse, stiff neck/head pain, fever, and aversion to cold daily, regardless of days, it is Taiyang channel involvement. Other channels follow this logic. Generally, treat Shanghan by sweating or purging based on pulse and signs. If many days pass but the pulse remains large, floating, and rapid, yet empty upon pressure, the issue remains in Taiyang; sweating will cure it. If the pulse is solid upon pressure, sweating will cause death; purging is required. If initially the pulse is fine, deep, and rapid, with external signs like abdominal fullness, dry throat, or dry mouth/tongue with thirst, the pathogen belongs to the interior; purging will cure it. Without these signs, if there is only fever and a deep pulse, mistaken purging will cause death; instead, use Mahuang Fuzi Gancao Tang (Mahuang, Prepared Aconite, and Licorice Decoction) or Mahuang Xixin Fuzi Tang (Mahuang, Asarum, and Prepared Aconite Decoction) for mild sweating. These are definitive conclusions of Zhang Zhongjing.
(Question 33) Regarding "Yang deficiency and Yin excess: sweating cures, purging kills; Yang excess and Yin deficiency: sweating kills, purging cures."
The Suwen states: Yang deficiency causes external cold; Yin deficiency causes internal heat; Yang excess causes internal heat; Yin excess causes external cold. Therefore, in treating Shanghan, for Yang deficiency and Yin excess, sweating cures and purging kills; for Yang excess and Yin deficiency, sweating kills and purging cures. "Yin/Yang deficiency/excess" here does not refer to specific pulse positions but to Exterior (Yang) and Interior (Yin). The Waitai Mi Yao states: Exterior disease with harmonious interior is cured by sweating; harmonious exterior with interior disease is cured by purging. This discusses treating based on Exterior/Interior Yin/Yang. (The Nan Jing discusses Yin/Yang deficiency/excess regarding pulses; the Suwen discusses it regarding Exterior/Interior. Zhang Zhongjing cites the Suwen's meaning of Exterior/Interior for Shanghan sweating/purging, aligning with the Waitai Mi Yao.) ○ Generally, Ying and Wei belong to the Exterior and are Yang; the Stomach Fu belongs to the Interior and is Yin. When cold toxin struggles within Ying and Wei, fever and aversion to cold occur. Both Cun and Chi pulses are floating and large; internally there is no restlessness. Even with slight irritability, if the patient prefers warm drinks and dislikes cold, it indicates Yang deficiency and Yin excess. Sweating cures; mistaken purging kills. ○ If cold toxin struggles within Ying and Wei, leading to Yang overcoming Yin, extreme Yin transforming into Yang, cold generating heat, and Yang heat entering the interior, heat toxin resides in the Stomach, drying fluids and forming dry feces. The patient has no external aversion to cold but experiences steaming fever and restlessness, possibly delirium. Pulses are floating, slippery, rapid, or surging and solid. This indicates Yang excess and Yin deficiency. Purging cures; mistaken sweating kills.
According to Huangdi Suwen Tiaojing Lun: Yang deficiency causes external cold, Yin deficiency causes internal heat, Yang excess causes external heat, Yin excess causes internal cold. Yang governs the exterior, Yin governs the interior. It states: Yang deficiency and Yin excess are cured by sweating and killed by purging; Yang excess and Yin deficiency are killed by sweating and cured by purging. Question 33 mistakenly writes "Yang excess causes internal heat, Yin excess causes external cold." Careful analysis shows that confusing internal/external cold/heat leads to fatal errors in sweating/purging. Wang Zongzheng’s diagram in his commentary on the Nan Jing aligns with the Suwen. Thus, Question 33 contains a transcription error and should be corrected to avoid misleading future generations.
(Question 34) Zhang Zhongjing uses sweating and harmonizing methods. What is the distinction?
Shanghan exterior signs require assessing the depth of Ying and Wei involvement. Thus, Zhang Zhongjing has specific sweating formulas like Mahuang Tang (Ephedra Decoction), Guizhi Tang (Cinnamon Twig Decoction), and Da Qinglong Tang (Major Green Dragon Decoction). He also has formulas to harmonize the exterior, such as Xiao Qinglong Tang (Minor Green Dragon Decoction), Guizhi Mahuang Ban Ge Tang (Half-and-Half Cinnamon Twig and Ephedra Decoction), Baihu Tang (White Tiger Decoction), Guizhi Er Yuebi Yi Tang (Two Parts Cinnamon Twig to One Part Yuebi Decoction), Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction), and Xiao Chaihu Tang (Minor Bupleurum Decoction). Later practitioners failed to deeply investigate the depth of cold/heat and the intensity/slowness of drug properties, applying medicines indiscriminately, causing premature death. Even survivors often suffered post-sweat deficiency, leading to relapse from exertion or generation of myriad diseases, dragging on until death. This results from excessive sweating and purging, exhausting Yin and Yang, and depleting blood and Qi. For mild illnesses, one should only harmonize, i.e., harmonize Ying and Wei to unblock Jin Ye (body fluids) so they resolve naturally.
(Question 35) Zhang Zhongjing uses purging and mild stomach-harmonizing methods. What is the distinction?
Shanghan interior signs require assessing the depth of heat. Thus, Zhang Zhongjing uses purging formulas like Dachengqi Tang (Major Gastro-Regulating Decoction), Xiaochengqi Tang (Minor Gastro-Regulating Decoction), Shizao Tang (Ten Jujube Decoction), and Daxiehu Tang (Major Bupleurum Decoction). He also uses mild stomach-harmonizing methods like Tiaowei Chengqi Tang (Stomach-Regulating Gastro-Regulating Decoction), Piyue Wan (Splee-Restriction Pill), and small doses of Xiaochengqi Tang for mild harmonization. The Jingui Yufan Jing states: For deficiency, ten times tonify, never purge; for excess/strength, purge; for equal deficiency and excess, purge moderately. Wang Shuhe warned about using Chengqi formulas in his preface. ○ Question: Which formula is most intense? Answer: Dachengqi Tang is most intense, followed by Xiaochengqi Tang, then Tiaowei Chengqi Tang, then Daxiehu Tang. Zhang Zhongjing’s method for sweeping away heat accumulation uses decoctions, not pills. (Note: Adding Rhubarb to Daxiehu Tang or adding Mirabilite to Xiao Chaihu Tang creates "transformation formulas" for milder cases.)
(Question 36) Shanghan Day 1: headache, dry mouth, irritability, fullness, thirst. Day 2: abdominal fullness, body heat, anorexia, delirium. Day 3: deafness, retraction of genitals, cold extremities, inability to swallow, unconsciousness.
This is named Lianggan Shanghan (Double-Injury Cold Damage). Lianggan means simultaneous disease of exterior and interior. Taiyang and Shaoyin are exterior-interior pairs; Yangming and Taiyin are pairs; Shaoyang and Jueyin are pairs. Dual transmission of Yin and Yang affects all Zang-Fu organs. This is difficult to treat and leads to death on the sixth day. Day 1: Taiyang and Shaoyin both diseased → headache, dry mouth, irritability, fullness, thirst. Day 2: Yangming and Taiyin both diseased → abdominal fullness, body heat, anorexia, delirium. Day 3: Shaoyang and Jueyin both diseased → deafness, genital retraction, cold extremities. Zhang Zhongjing provides no direct treatment for Lianggan but states that treatment has priorities: releasing the exterior and attacking the interior differ fundamentally. In Volume 3, it is noted that if after purging, diarrhea persists and body pain remains, one must urgently rescue the interior with Sini Tang. If body pain exists but bowels/bladder are normal, urgently rescue the exterior with Guizhi Tang. Following this logic, treating Lianggan requires prioritizing the interior first. If internal Yang is rectified, treatment can proceed. Once the interior is stabilized, urgently rescue the exterior, as the interior is more critical. Warming the interior must be followed immediately by rescuing the exterior; delay is not permitted.
(Question 37) Shanghan persists despite sweating, vomiting, or purging (called Huai Bing/Broken Disease by ancients).
Zhang Zhongjing said: If Taiyang disease for three days has been treated with sweating, vomiting, purging, or moxibustion and remains unresolved, it is called Huai Bing (Broken Disease). Guizhi Tang is no longer applicable. One must identify the deviation and treat according to the syndrome. Also: If Taiyang disease transitions to Shaoyang, presenting with hardness/fullness under the hypochondrium, dry retching, inability to eat, alternating chills and fever, and before vomiting/purging, with a deep-tight pulse, Xiao Chaihu Tang is suitable. If vomiting/purging/sweating have already occurred and Xiao Chaihu signs disappear, it is Huai Bing. Identify the deviation and treat accordingly. This occurs when a new pathogen infects the existing disease, altering it due to seasonal irregularities (cold, heat, dryness, dampness, wind), changing the pulse and syndrome from typical Shanghan. One must analyze the cause and treat legally. If Cun-Chi pulses are both strong and cold is re-contracted, it transforms into Wen Nue (Warm Malaria, hot then cold). If Yang pulse is floating-slippery and Yin pulse is soggy-weak, encountering wind transforms it into Feng Wen (Wind-Warmth, flaccid limbs, headache, fever, spontaneous sweating). If Yang pulse is floating-rapid and Yin pulse is solid-large, encountering warmth transforms it into Wen Du (Warm Toxicity, most severe, macules in spring). If Yang pulse is soggy-weak and Yin pulse is string-tight, encountering warm qi transforms it into Wen Yi (Warm Epidemic, similar symptoms across ages due to abnormal four-season qi). Pulse and syndrome variations dictate different formulas. Zhang Zhongjing states Wen Bing pulses move through various channels; treat according to the affected channel. Also, Shanghan passing its stage, re-infected with heat, lingering in Zang-Fu, causing variable syndromes and chronic non-resolution, losing Yin-Yang order, or post-Shanghan emaciation and shortness of breath, are all named Huai Shanghan. Use Zhimu Mahuang Tang, Biejia San (Turtle Shell Powder), or Heinu Wan (Black Slave Pill) based on formula-syndrome matching. For post-Shanghan emaciation, shortness of breath, and rebellious Qi with vomiting, Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction) is the primary treatment.