左沉细。按之搏数。右反浮大虚软。此水阴随热下注。郁火反从上冲。仲景所谓少阴病
。脉细沉数。病为在里。不可发汗是也。治宜滋水泄火。猪苓汤、猪苓三钱、陈阿胶钱
半（烊冲）赤苓、泽泻各二钱、飞滑石三钱、加辰砂染灯心（三十支）、童便（二钟
冲）、枇杷叶（去毛、抽筋、五钱）等主之。
（辰）邪传厥阴。亦当分手足二经。手厥阴为包络。内含胆火。主行血通脉。
足厥阴为肝脏。下含肾水。主藏血活络。内经虽云厥阴之上。风气治之。然包络挟胆火
发动于上。则为热风。肝气挟肾水相应而起。则为寒风。火性热。水性寒。故其证最多
寒热错杂。阴阳疑似。约计之则有四。（一）外寒内热。厥则但指头寒。热则微觉烦躁
。默默不欲食。渴欲饮水。微热汗出。小便不利。舌苔浅黄薄腻。或正黄带微白。脉右沉滑搏
指。左微弦而数。此外虽厥而里有热。仲景所谓厥微热少。数日小便利。色白者热除。
遂欲得食而病愈是也。法当辛凉泄热以利溺。新加白虎汤主之。若厥而兼呕。胸胁烦满
。热利下重。继即便血。甚或圊脓血。舌紫苔黄。脉寸浮数。尺弦涩。此包络挟胆火而
肆虐。仲景所谓厥深热亦深。内经所谓暴注下迫。皆属于热。阴络伤则血下溢是也。法
当凉血清肝以坚肠。加味白头翁汤主之。（二）内寒外热。下利清谷。汗出肢厥。身有
微热。面少赤。或郁冒。舌苔青滑。脉沉而迟。此阴多阳少。肝挟肾水之寒而肆发。仲
景所谓面戴阳。下虚故也。急急温通回阳。通脉四逆汤主之。（三）下寒上热。热在膈
脘。水在肠中。心下痞硬。嗳腐食臭。腹中雷鸣下利。医误吐之。遂致水食入口即吐。
复认作热结旁流。更逆以下。从此下利不止。舌苔黄白相兼。脉弦而涩。此寒格于下。
热拒于上。火逆水泻之错杂证也。当清上热开寒格为君。佐以益气健胃。先与生姜泻心
汤去甘草。（生姜汁一小匙、冲、干姜六分、姜半夏三钱、川连八分、青子芩钱半。米
炒潞党参二钱、大红枣四枚劈）加淡竹茹（三钱）枇杷叶（五钱，去毛筋炒黄）。止其吐
。继与乌梅丸。（乌梅肉三十个、干姜一两、川连一两六钱、细辛、淡附片、桂枝、川
柏、潞党参各六钱、炒川椒、当归各四钱各研细末、加醋与蜜、共杵二千下、丸如
梧桐子大、先服十丸、日三服、稍加至二十丸、禁生冷滑物食臭等）。止其利。（四）
上寒下热。水结胸胁。热结在肠。呕吐清水。或吐黄黑浊饮。饥不欲食。食则吐蛔。肢
厥心悸。腹痛热泻。泻而不畅。或便脓血。里急后重。溲短赤热。舌苔前半白滑。后根
黄腻而浓。脉右弦迟。左沉弦数。此寒格于上。热结于下。水逆火郁之错杂证也。法当
先逐其水。蠲饮万灵汤主之。继则清肝泄热。加味白头翁汤主之。
以上太阴。少阴厥阴。各脏变证。皆伤寒邪从水火合化之传变也。
就予所验。凡太阳伤寒。其邪有但传少阳阳明而止者。有不传少阳阳明。越传三阴者。各随其人之
体质阴阳。脏腑寒热。从火化者为热证。从水化者为寒证。从水火合化者。则为寒热错
杂之证。医者能审其阴阳盛衰。寒热虚实。为之温凉补泻于其间。对证发药随机应变。
心灵手敏。庶可以治伤寒变证矣。若拘守朱南阳传经为热。直中为寒。则执一不通。活
人者适以杀人。良可慨焉。
【秀按】此节论伤寒传变证。抉择原论之精华。补助仲景之缺略。发明火化、水化
、水火合化三端。独出心裁。非经验宏富者不能道。学人当奉为准绳。
【廉勘】四时皆有伤寒。惟冬三月乃寒水司令。较三时之寒为独盛。故前哲以冬月
感寒即病者。为正伤寒。非谓春夏秋并无伤寒也。医者苟能求原确实。辨证清楚。用药
自不泥于时令矣。所最误人者。一切时感证。古人皆谓之伤寒。遂致后世只知伤寒。且
但知温散发汗。若温热暑湿诸病。随时感发。并不由于风寒诱起者。自当辛凉开达。芳
淡清化。对病定方。奈医家病家。无不通称曰伤寒。一见此等方药。即斥为凉遏。世俗
竟成为习惯。以致冤死载涂。不得不归咎于创始者之定名失实也。至循经传递。太阳由
阳明而少阳。而太阴。而少阴。而厥阴。自临证经验以来。千万人中实无一人。无怪南
方无真伤寒之说。若照俞氏所论。经验上数见不鲜。可谓知所取舍。不为古人所欺。但
予犹有怀疑者。伤寒一证。轻则用葱白香豉汤加味。重则用苏羌达表汤加减。或用麻黄
汤减其用量。往往一汗即解。热退身凉而愈。何至于缠绵床席。传变有如斯之多。变证
轻重如斯之不一耶。推原其故。半由因循失治。半由纵横杂治。或由别兼他邪。或由另
夹宿病。或由素禀阴虚多火。或由素体阳虚多湿。或由素性嗜好太多。或由素情忧怒无
常。有此种种原因。故变证层出不穷。方法亦随机策应。俞氏特立火化水化水火合化三
端。已握传变之主脑。然后审定各人之特性素因。再将气候。风土。寒热燥
湿。老幼男女等之各异。及其体质强弱、脏性阴阳，与夫生活状态、旧病有无等关系。
辨其经络脏腑之外候。断其寒热虚实之真相。以决方剂。虽多引用成方。略为加减。而
信手拈来。适中病情。细绎其诊察之法。大抵以头项背腰之变化察表。以面目九窍之变
化察里。以血脉睛舌之变化。察其病势之安危。断其病机之吉凶。予平日研求。服膺叶
法。旁参众法以补助之。兹将叶天士先生伤寒看法及其治例。节述于后。为初学作导线
。（一）凡看伤寒。先观两目。黑白分明者内无热。目视不明者里有热。（二）看唇舌
。唇红而润者内无热。唇干而焦者里热重。若舌白滑者表未解。舌黄者热渐深。舌黑者
热已剧。（三）审胸腹。胸满而痛者为结胸。不痛者为痞气。如未经下而有之。上焦痰
水也。已经下而有之。误下坏证也。腹中痛硬者燥粪。脐下痛硬者燥粪与蓄血。脐间动
跃或痛。上冲于心者冲气。腹中响。气下趋者欲作泻。燥粪者小便不利。脐下如疙瘩状
。蓄血者小便利。脐下如怀孕状。（四）问口渴否。渴不饮水者邪在表。渴饮水多者内
热甚。漱水不欲咽者欲作衄。（五）凡治伤寒。先辨表里。不论日数。但有头疼身痛。
怕风恶寒。脉来浮紧浮数。皆是表证。虽有便难。小便不利。亦当先解其表。后攻其里
。脉浮紧者为正伤寒。宜用辛温之药以发之。浮数者为寒包火。宜用辛凉之药以解之。
既有腹疼吐利。溺白或赤。脉来沉弱沉滑。皆是里证。间有恶风怕冷。亦当先治其里。
后解其表。脉沉弱者为中寒证。宜用辛热之药以温之。沉滑者为里热证。宜用苦寒之药
以攻之。如病在表而反下。则邪乘虚入里。微为痞气结胸。甚为肠滑洞泄。此皆误下坏
证。在里反汗。则表益虚而里益实。轻为衄血斑黄。重为痉厥亡阳。此皆误汗坏证。凡
服汗药。如一剂无汗。再与之。复无汗。此营卫乏绝。当养阴辅正而再汗之。三治无汗者
死。凡服下药。先燥后溏者已解。如但利清水而无燥粪。痞满如故者未解。再下之。三
下不通者液枯肠燥。当镇润之。通者生。不通者死。（六）详辨阴阳。初起时。头疼身
痛。发热恶寒。脉来浮紧浮大。即是阳经之表证也。此后烦躁作渴。纯热无寒。便闭溺
热。即是阳经传入阳腑之热证也。脉虽沉伏。不可误作阴证
治。如初起时。脐腹绞痛。肢厥唇青。脉来沉迟沉微。即是直中阴经之寒证也。虽面赤
烦躁。不可误作阳证治。阳证宜汗宜透。宜清宜下。阴证宜温宜补。其大要也。然亦有
辨。阳证而其体素虚。不胜下。下之太过。忽然脐腹绞痛。洞泄不止。手足厥逆。此阳
证而转为阴证也。急温之。阴证而其体素热。勿过温。温之太过。忽然烦躁大渴。自汗
昏谵。二便不通。此阴证而转为阳证也。速清之。（七）凡伤寒得死证。脉尚可治者。
弃证从脉。虚则补之。实则泻之。（八）凡伤寒得死脉。证有可治者。弃脉从证。表急
解之。里急攻之。热则清之。寒则温之。总之定其名。分其经。审其证。察其脉。明表
里。识阴阳。度虚实。知标本。此八者。为治伤寒之要诀也。
脉象左部沉细，重按搏动急促而数；右部反而浮大、虚弱而柔软。这是肾阴（水）随热邪下行灌注，郁结之火反而向上冲逆。正如张仲景所说：少阴病，脉象细沉且数，病位在里，不可使用发汗法治疗。治疗应当滋补肾阴、清泄火热，以猪苓汤为主方。处方：猪苓三钱、陈阿胶一钱半（烊化后冲服）、赤茯苓、泽泻各二钱、飞滑石三钱，加辰砂染灯心草三十支、童便二钟冲服、枇杷叶五钱（去毛及筋）。
若邪气传入厥阴经，也应当区分手厥阴和足厥阴两条经脉。手厥阴心包络，内蕴胆火，主要功能是运行血液、通畅血脉；足厥阴肝脏，下含肾水，主要功能是贮藏血液、疏通经络。《内经》虽然记载“厥阴之上，风气治之”，但是心包络挟带胆火发动于上，就会形成热风；肝气挟带肾水相应而起，就会形成寒风。火性热，水性寒，所以厥阴病的证候最多表现为寒热错杂、阴阳疑似难辨。大约归纳起来有四种情况：
（一）外寒内热。四肢厥冷仅指头寒冷，发热则轻微烦躁，神情沉默不欲言语，不想吃东西，口渴想喝水，轻微发热出汗，小便不利，舌苔浅黄薄腻，或者正黄色带微白，脉象右部沉滑搏指，左部微弦而数。这是外表虽厥冷但体内有热。张仲景所谓“厥微热少，数日后小便通利，颜色清白者，热除，随即想要进食而病愈”说的就是这种情况。治法应当用辛凉药物清泄热邪以利小便，以新加白虎汤为主方。如果厥冷兼有呕吐，胸胁烦闷胀满，热性腹泻伴有肛门重坠感，随后出现便血，甚至排出脓血，舌质紫暗苔黄，脉象寸部浮数，尺部弦涩，这是心包络挟带胆火肆虐。张仲景所谓“厥深热亦深”，《内经》所谓“暴注下迫，皆属于热，阴络伤则血下溢”说的就是这种情况。治法应当凉血清肝以固护肠道，以加味白头翁汤为主方。
（二）内寒外热。下利完谷不化，出汗且四肢厥冷，身体有轻微发热，面色微红，或者出现郁冒（头晕目眩如物蒙蔽），舌苔青滑，脉象沉而迟。这是阴盛阳衰，肝挟带肾水之寒气肆意发作。张仲景所谓“面戴阳，下虚故也”。应当紧急温通回阳，以通脉四逆汤为主方。
（三）下寒上热。热邪在膈脘部位，水饮在肠中。心下痞塞硬满，嗳气带有腐食臭味，腹中雷鸣并下利。医生误用吐法，导致水食入口即吐。又误认为是热结旁流，再次误用攻下法，从此下利不止。舌苔黄白相间，脉象弦而涩。这是寒气格拒于下，热邪抗拒于上，是火逆与水泻错杂的证候。治疗当以清上热、开寒格为君药，佐以益气健胃。先给予生姜泻心汤去掉甘草（生姜汁一小匙冲服、干姜六分、姜半夏三钱、川黄连八分、青子芩一钱半、米炒潞党参二钱、大红枣四枚劈开），加淡竹茹三钱、枇杷叶五钱（去毛筋炒黄），以止住呕吐。继而又给予乌梅丸（乌梅肉三十个、干姜一两、川黄连一两六钱、细辛、淡附片、桂枝、川黄柏、潞党参各六钱、炒川椒、当归各四钱，各研成细末，加醋与蜂蜜，共捣两千下，制成梧桐子大小的丸剂，先服用十丸，每日三次，稍后增加至二十丸，禁食生冷、滑腻食物及腐败气味食物），以止住腹泻。
（四）上寒下热。水饮结聚在胸胁，热邪结聚在肠道。呕吐清水，或者呕吐黄黑浑浊的痰饮，饥饿但不想吃东西，吃东西则吐出蛔虫，四肢厥冷心悸，腹痛且热性腹泻，排便不畅，或者便脓血，里急后重，小便短少赤热。舌苔前半部分白滑，后根部黄腻而厚。脉象右部弦迟，左部沉弦数。这是寒气格拒于上，热邪结聚于下，是水逆与火郁错杂的证候。治法应当先驱逐水饮，以蠲饮万灵汤为主方。继则清肝泄热，以加味白头翁汤为主方。
以上太阴、少阴、厥阴各脏的变证，都是伤寒邪气从水火合化传变而来的。
根据我的临床经验，凡是太阳伤寒，邪气有的只传到少阳、阳明就停止了，有的不传少阳阳明，反而越传进入三阴经。这都随着人的体质阴阳、脏腑寒热的不同，从火化者为热证，从水化者为寒证，从水火合化者，则为寒热错杂之证。医生若能审察其阴阳盛衰、寒热虚实，在其中进行温凉补泻的治疗，对证用药，随机应变，心灵手巧，才可以治疗伤寒的变证。如果拘泥坚守朱南阳所说的“传经为热，直中为寒”，那就固执不通，本来想救人反而害死人，实在令人感慨。
【秀按】这一节论述伤寒的传变证候，抉择了原论的精华，补充了张仲景的缺略，阐发了火化、水化、水火合化三个方面，独出心裁，不是经验丰富的人不能说出。学习者应当奉为标准。
【廉勘】四季都有伤寒，只有冬季三个月是寒水当令，比其它三个季节的寒气更盛。所以前代哲人认为冬天感受寒邪立即发病的，称为正伤寒，并不是说春夏秋没有伤寒。医生如果能探求病因确实，辨证清楚，用药自然就不会拘泥于时令了。最误导人的是，一切时行感冒证候，古人都称之为伤寒，导致后世只知道伤寒，而且只知道用温散发汗的方法。像温热暑湿等病，随时感发，并不由于风寒诱起的，自然应当用辛凉开达、芳淡清化的方法，对病定方。无奈医家和病家都通称其为伤寒，一见这些方药，就斥责为凉遏。世俗竟成为习惯，以致冤死的人满地都是，不得不归咎于创始者定名失实。至于循经传递，太阳由阳明而少阳，而太阴，而少阴，而厥阴，从我临证经验以来，千万人中实在没有一个人是这样传的，难怪南方没有真伤寒的说法。如果照俞氏所论，经验上屡见不鲜，可以说是知道取舍，不被古人欺骗。但我仍有怀疑之处：伤寒一证，轻的用葱白香豉汤加味，重的用苏羌达表汤加减，或者用麻黄汤减少用量，往往一汗即解，热退身凉而痊愈，怎么会至于缠绵床席，传变如此之多，变证轻重如此不一呢？推究其原因，一半是因为因循延误治疗，一半是因为纵横杂乱治疗。或者另外兼夹其他邪气，或者另外夹杂宿疾，或者素体阴虚多火，或者素体阳虚多湿，或者素性嗜好太多，或者素情忧怒无常。有此种种原因，所以变证层出不穷，方法也随机策应。俞氏特别立火化、水化、水火合化三方面，已经抓住了传变的主脑，然后审定每个人的特性素因，再将气候、风土、寒热燥湿、老幼男女等的差异，及其体质强弱、脏性阴阳，以及生活状态、旧病有无等关系，辨明其经络脏腑的外候，断明其寒热虚实的真相，来决定方剂。虽然多引用成方，略为加减，但信手拈来，适中病情。仔细推究他的诊察方法，大抵通过头项背腰的变化来察表证，通过面目九窍的变化来察里证，通过血脉睛舌的变化，来察病势的安危，断病机的吉凶。我平日研究，信奉叶天士的方法，旁参众法以补助它。现将叶天士先生看伤寒的方法及其治例，节述如下，作为初学者的向导。
（一）凡看伤寒，先观察两眼。黑白分明者体内无热，视物不明者里有热。
（二）看唇舌。唇红润泽者体内无热，唇干焦者里热重。如果舌苔白滑者表证未解，舌苔黄者热邪渐深，舌苔黑者热邪已剧烈。
（三）审察胸腹。胸满而痛的是结胸，不痛的是痞气。如果未经攻下而出现，是上焦痰水；已经攻下后出现，是误下导致的坏证。腹中痛硬的是燥屎，脐下痛硬的是燥屎与蓄血。脐间跳动或疼痛，上冲于心的是冲气。腹中响，气向下趋的是欲作腹泻。燥屎者小便不利，脐下如疙瘩状的是蓄血，蓄血者小便利，脐下如怀孕状。
（四）询问是否口渴。渴但不想喝水的是邪在表，渴且饮水多的是内热甚，漱口但不想咽下的是欲作鼻衄。
（五）凡治伤寒，先辨别表里。不论患病天数，只要有头疼身痛，怕风恶寒，脉来浮紧或浮数，都是表证。即使有大便困难、小便不利，也应当先解表，后攻里。脉浮紧的是正伤寒，宜用辛温药发汗；浮数的是寒包火，宜用辛凉药解表。既有腹痛吐利，小便白或赤，脉来沉弱或沉滑，都是里证。间或有恶风怕冷，也应当先治里，后解表。脉沉弱的是中寒证，宜用辛热药温里；沉滑的是里热证，宜用苦寒药攻里。如果病在表却反用下法，则邪气乘虚入里，轻则痞气结胸，重则肠滑洞泄，这都是误下的坏证。在里却反用汗法，则表更虚而里更实，轻则衄血斑黄，重则痉厥亡阳，这都是误汗的坏证。凡服发汗药，如一剂无汗，再给一剂，仍无汗，这是营卫乏绝，应当养阴辅正后再发汗。三次发汗无汗的会死。凡服攻下药，先干燥后溏薄的已解，如果只是拉清水而没有燥屎，痞满依旧的未解，再攻下。三次攻下不通的是液枯肠燥，应当镇润。通的生，不通的死。
（六）详细辨别阴阳。初起时，头疼身痛，发热恶寒，脉来浮紧浮大，即是阳经的表证。此后烦躁作渴，纯热无寒，便秘溺热，即是阳经传入阳腑的热证。脉虽沉伏，不可误作阴证治疗。如初起时，脐腹绞痛，四肢厥冷唇青，脉来沉迟沉微，即是直中阴经的寒证。虽然面赤烦躁，不可误作阳证治疗。阳证宜汗宜透，宜清宜下，这是大体原则。然而也有辨别：阳证而其人体质素虚，不胜攻下，下之太过，忽然脐腹绞痛，洞泄不止，手足厥逆，这是阳证转为阴证，应急温之。阴证而其人体质素热，勿过温，温之太过，忽然烦躁大渴，自汗昏谵，二便不通，这是阴证转为阳证，应急清之。
（七）凡伤寒得死证，脉尚可治的，弃证从脉，虚则补之，实则泻之。
（八）凡伤寒得死脉，证有可治的，弃脉从证，表急解之，里急攻之，热则清之，寒则温之。总之，定其名，分其经，审其证，察其脉，明表里，识阴阳，度虚实，知标本。这八条，是治疗伤寒的要诀。
The pulse on the left is deep and fine; upon heavy pressure, it beats rapidly and with a rapid rate (Shu). The pulse on the right is conversely floating, large, deficient, and soft. This indicates that Kidney Yin (Water) follows the heat pathogen downward into the lower jiao, while the constrained fire counterflows upward. As Zhang Zhongjing stated: In Shaoyin disease, the pulse is fine, deep, and rapid; the pathology is in the interior, and sweating methods are contraindicated. The treatment should nourish Water and drain Fire. Zhu Ling Tang (Polyporus Decoction) is the primary formula. Prescription: Zhu Ling (Polyporus) 3 qian, Chen E Jiao (Donkey-hide Gelatin) 1.5 qian (melted and taken with decoction), Chi Fu Ling (Red Poria) 2 qian, Ze Xie (Alisma) 2 qian, Fei Hua Shi (Prepared Talcum) 3 qian, added with Chen Sha-dyed Deng Xin Cao (Acorus Rhizome dyed with Cinnabar) 30 strands, Tong Bian (Child's Urine) 2 zhong (mixed in), and Pi Pa Ye (Loquat Leaf) 5 qian (deprived of hairs and veins).
If the pathogen transmits to the Jueyin channel, it must be distinguished between the Hand Jueyin and Foot Jueyin channels. The Hand Jueyin Pericardium contains Gallbladder Fire and governs the movement of Blood and unblocking of vessels. The Foot Jueyin Liver contains Kidney Water below and governs the storage of Blood and activation of collaterals. Although the *Neijing* states "Above Jueyin, Wind Qi governs," when the Pericardium moves with Gallbladder Fire upward, it becomes Wind-Heat; when Liver Qi rises in response with Kidney Water, it becomes Wind-Cold. Fire nature is hot, Water nature is cold; thus, Jueyin diseases most often present as complex mixtures of Cold and Heat, with Yin and Yang symptoms being difficult to distinguish. Approximately, there are four types:
(1) Exterior Cold and Interior Heat. Limb coldness is limited to the fingertips; fever brings slight irritability, silence, anorexia, thirst for water, slight fever with sweating, and dysuria. The tongue coating is shallow yellow and thin greasy, or bright yellow with slight white. The pulse is right-side deep, slippery, and bounding; left-side slightly wiry and rapid. This is exterior coldness with interior heat. Zhang Zhongjing said, "Slight coldness and little heat; after several days, if urination is smooth and clear, the heat is removed, appetite returns, and the disease heals." The method should use Acrid-Cool herbs to drain heat and promote urination. Xin Jia Bai Hu Tang (Modified White Tiger Decoction) is the primary formula. If coldness is accompanied by vomiting, chest and hypochondriac fullness and irritability, hot diarrhea with tenesmus, followed by bloody stool, or even purulent blood in stool, with a purple tongue and yellow coating, and pulse floating-rapid at Cun and wiry-choppy at Chi, this is Pericardium carrying Gallbladder Fire rampant. Zhang Zhongjing said, "The deeper the coldness, the deeper the heat"; the *Neijing* said, "Sudden diarrhea with urgency belongs to Heat; injury to Yin collaterals causes bleeding downward." The method should cool Blood, clear the Liver, and firm the intestines. Jia Wei Bai Tou Weng Tang (Modified Pulsatilla Decoction) is the primary formula.
(2) Interior Cold and Exterior Heat. Diarrhea with undigested food, sweating, limb coldness, slight body fever, facial flushing, or mental cloudiness. The tongue coating is blue and slippery; the pulse is deep and slow. This is excess Yin and deficient Yang, with Liver carrying Kidney Water coldness rampant. Zhang Zhongjing said, "Facial flushing is due to deficiency below." Urgent warming and unblocking to restore Yang is required. Tong Mai Si Ni Tang (Pulse-Recovering Four Reversal Decoction) is the primary formula.
(3) Lower Cold and Upper Heat. Heat is in the diaphragm and epigastrium; water is in the intestines. Epigastric fullness and hardness, belching with rotten food odor, borborygmus, and diarrhea. The physician mistakenly used emesis, causing immediate vomiting of ingested water and food. It was further mistaken for Heat Binding with Loose Stools, leading to more purgatives, resulting in incessant diarrhea. The tongue coating is mixed yellow and white; the pulse is wiry and choppy. This is Cold blocking below and Heat rejecting above, a complex syndrome of Fire Counterflow and Water Diarrhea. Treatment should prioritize clearing Upper Heat and opening Cold Block as the sovereign herb, assisted by Qi-tonifying and Stomach-strengthening herbs. First, give Sheng Jiang Xie Xin Tang (Ginger Heart-Draining Decoction) removing Gan Cao (Licorice): Sheng Jiang Zhi (Ginger Juice) 1 small spoon (mixed), Gan Jiang (Dried Ginger) 6 fen, Jiang Ban Xia (Pinellia prepared with Ginger) 3 qian, Chuan Lian (Coptis) 8 fen, Qing Zi Qin (Scutellaria) 1.5 qian, Mi Chao Lu Dang Shen (Codonopsis stir-fried with rice) 2 qian, Da Hong Zao (Jujube) 4 pieces split. Add Dan Zhu Ru (Bamboo Shavings) 3 qian and Pi Pa Ye (Loquat Leaf) 5 qian (deprived of hairs and veins, stir-fried yellow) to stop vomiting. Subsequently, give Wu Mei Wan (Mume Pill) to stop diarrhea: Wu Mei Rou (Mume Flesh) 30 pieces, Gan Jiang (Dried Ginger) 1 liang, Chuan Lian (Coptis) 1.6 liang, Xi Xin (Asarum), Dan Fu Pian (Aconite slice), Gui Zhi (Cinnamon Twig), Chuan Bai (Phellodendron), Lu Dang Shen (Codonopsis) each 6 qian, Chao Chuan Jiao (Sichuan Pepper stir-fried), Dang Gui (Angelica Sinensis) each 4 qian. Grind all into fine powder, add vinegar and honey, pound 2000 times, make pills the size of paulownia seeds. Take 10 pills initially, three times daily, gradually increasing to 20 pills. Avoid raw, cold, slippery foods, and foul odors.
(4) Upper Cold and Lower Heat. Water binding in chest and hypochondrium; Heat binding in intestines. Vomiting clear water or yellow-black turbid fluid, hunger without desire to eat, vomiting roundworms upon eating, limb coldness, palpitations, abdominal pain with hot diarrhea, incomplete defecation, or pus and blood in stool, tenesmus, short red-hot urine. Tongue coating is white and slippery anteriorly, thick and greasy yellow posteriorly. Pulse is right-side wiry-slow, left-side deep-wiry-rapid. This is Cold blocking above and Heat binding below, a complex syndrome of Water Counterflow and Fire Constraint. The method should first expel Water using Juan Yin Wan Ling Tang (Drink-Eliminating Ten-Thousand Miracle Decoction). Subsequently, clear Liver and drain Heat using Jia Wei Bai Tou Weng Tang (Modified Pulsatilla Decoction).
The above variations of Taiyin, Shaoyin, and Jueyin organs are all transmission changes where the Shanghan pathogen transforms through the combination of Water and Fire.
Based on my experience, in Taiyang Shanghan, the pathogen may transmit only to Shaoyang and Yangming and stop, or skip Shaoyang and Yangming and transmit directly to the Three Yin channels. This depends on the individual's constitution regarding Yin-Yang and the Cold-Heat of the Zang-Fu. Transformation via Fire results in Heat syndromes; transformation via Water results in Cold syndromes; transformation via the combination of Water and Fire results in complex Cold-Heat syndromes. Physicians who can assess the excess and deficiency of Yin-Yang and Cold-Heat, applying warming/cooling and tonifying/draining treatments accordingly, and adapting formulas flexibly to symptoms, with mental agility and manual dexterity, can treat Shanghan variations. If one rigidly adheres to Zhu Nanyang's theory that "transmission is Heat and direct attack is Cold," it is inflexible and harmful rather than life-saving, which is lamentable.
[Commentary by Xiu] This section discusses Shanghan transmission variations, selecting the essence of the original text, supplementing Zhang Zhongjing's omissions, and elucidating the three aspects of Fire transformation, Water transformation, and Water-Fire combined transformation. It is innovative and cannot be articulated by those without rich clinical experience. Students should take it as a standard.
[Commentary by Lian] Shanghan occurs in all seasons, but only in the three winter months does Cold Water dominate, making the cold stronger than in other seasons. Therefore, ancient sages considered Shanghan contracted in winter and immediately manifesting as "True Shanghan," not implying no Shanghan in spring, summer, or autumn. If physicians seek the true cause and differentiate clearly, medication will not be stuck to seasonal constraints. The greatest error is that ancients called all seasonal infectious diseases "Shanghan," leading later generations to know only Shanghan and only use acrid-warming sweating methods. Diseases like Warm-Heat, Summer-Heat, and Damp-Heat arise spontaneously without Wind-Cold induction and should be treated with Acrid-Cool opening, aromatic-light clearing, and specific formulas. However, both doctors and patients commonly call them Shanghan, and upon seeing such formulas, they reject them as "Cooling Constriction." This custom has led to many unjust deaths, attributable to the founder's inaccurate naming. Regarding meridian transmission, from Taiyang to Yangming, then Shaoyang, Taiyin, Shaoyin, to Jueyin, in my clinical experience among thousands of cases, I have never seen such a transmission. Hence the saying "No True Shanghan in the South." Following Yu's discussion, these cases are common in experience, showing discernment and freedom from ancient dogma. Yet I remain skeptical: Mild Shanghan is treated with Cong Bai Xiang Chi Tang (Scallion and Fermented Soybean Decoction) modified; severe cases with Su Qiang Da Biao Tang (Perilla and Notopterygium Surface-Releasing Decoction) modified, or Ma Huang Tang (Ephedra Decoction) with reduced dosage. Often, one sweat resolves it, fever subsides, body cools, and health returns. Why does it linger in bed with so many transmissions and varying severity? The reasons are partly neglect/delayed treatment, partly chaotic/mixed treatment, plus concurrent pathogens, chronic diseases, Yin-deficiency with excessive Fire, Yang-deficiency with excessive Dampness, excessive habits, or emotional instability. These factors cause endless variations requiring flexible methods. Yu's establishment of Fire, Water, and Water-Fire transformations grasps the main thread of transmission. By assessing individual constitutions, climate, geography, Cold-Heat-Dryness-Dampness, age, gender, physical strength, Zang-Fu Yin-Yang, lifestyle, and existing diseases, and differentiating meridian/Zang-Fu signs and Cold-Heat-Deficiency-Excess truth, one determines the formula. Although borrowing established formulas with modifications, they fit the condition well. His diagnostic methods generally observe head/neck/back/waist for exterior, face/eyes/nine orifices for interior, and vessels/eyes/tongue for prognosis. I follow Ye Tianshi's methods, supplemented by others. Below are excerpts from Mr. Ye Tianshi's Shanghan diagnosis and treatment examples as a guide for beginners:
(1) When diagnosing Shanghan, first observe the eyes. Clear black and white indicate no interior Heat; blurred vision indicates interior Heat.
(2) Observe lips and tongue. Red and moist lips indicate no interior Heat; dry and scorched lips indicate severe interior Heat. White slippery coating means exterior unresolved; yellow coating means Heat deepening; black coating means Heat extreme.
(3) Examine chest and abdomen. Chest fullness with pain is Jie Xiong (Chest Binding); painless is Pi Qi (Pi Syndrome). If appearing before purging, it is Phlegm-Water in Upper Jiao; if after purging, it is a bad complication from erroneous purging. Abdominal pain and hardness indicate Dry Stool; umbilical pain and hardness indicate Dry Stool and Blood Stasis. Pulsation or pain at the umbilicus rushing up to the heart indicates Chong Qi (Penetrating Qi). Abdominal rumbling with gas moving downward indicates impending diarrhea. Dry Stool presents with dysuria; Blood Stasis presents with smooth urination and a mass below the umbilicus resembling pregnancy.
(4) Ask about thirst. Thirst without desire to drink indicates pathogen in Exterior; thirst with copious drinking indicates severe Interior Heat; rinsing mouth without swallowing indicates impending epistaxis.
(5) In treating Shanghan, first differentiate Exterior and Interior, regardless of days. Headache, body ache, aversion to wind/cold, and floating-tight or floating-rapid pulse are Exterior syndromes. Even with constipation or dysuria, resolve Exterior first, then purge Interior. Floating-tight is True Shanghan, treat with Acrid-Warm to sweat; floating-rapid is Cold Wrapping Fire, treat with Acrid-Cool to release. Abdominal pain, vomiting/diarrhea, white or red urine, and deep-weak or deep-slippery pulse are Interior syndromes. Even with aversion to wind/cold, treat Interior first, then resolve Exterior. Deep-weak is Middle Cold, treat with Acrid-Hot to warm; deep-slippery is Interior Heat, treat with Bitter-Cold to purge. Purging an Exterior syndrome allows pathogen to enter Interior, causing mild Pi/Jie Xiong or severe intestinal slipping/diarrhea (bad complication from erroneous purging). Sweating an Interior syndrome makes Exterior more deficient and Interior more solid, causing mild epistaxis/ecchymosis or severe spasms/coma/Yang collapse (bad complication from erroneous sweating). If sweating fails after one dose, repeat; if still no sweat after two doses, Ying and Wei are exhausted, nourish Yin and support Righteousness before sweating again. Three failed sweats lead to death. If purging yields dry stool then loose stool, it is resolved; if only clear water passes with persistent fullness, it is unresolved, purge again. Three failed purges indicate fluid exhaustion and intestinal dryness, require moistening/lubricating. Openings mean survival, blockage means death.
(6) Detail differentiation of Yin and Yang. Initial headache, body ache, fever, aversion to cold, floating-tight/large pulse is Yang Meridian Exterior syndrome. Later irritability, thirst, pure Heat without Cold, constipation, hot urine is Yang Meridian transmitting to Yang Fu Heat syndrome. Even if pulse is deep-hidden, do not mistake for Yin syndrome. Initial umbilical/abdominal colic, limb coldness, cyan lips, deep-slow/micro pulse is Direct Attack on Yin Meridian Cold syndrome. Even with facial flushing/irritability, do not mistake for Yang syndrome. Yang syndromes require sweating/venting, clearing/purging. Yin syndromes require warming/tonifying. However, distinctions exist: Yang syndrome with deficient constitution unable to tolerate purging, excessive purging causing sudden colic, profuse diarrhea, limb coldness, transforms into Yin syndrome; urgently warm it. Yin syndrome with hot constitution, excessive warming causing sudden irritability/thirst, spontaneous sweating, coma/delirium, urinary/fecal retention, transforms into Yang syndrome; urgently clear it.
(7) For fatal Shanghan syndromes where pulse is still treatable, abandon syndrome analysis and follow pulse: tonify deficiency, drain excess.
(8) For fatal Shanghan pulses where syndrome is still treatable, abandon pulse analysis and follow syndrome: resolve urgent Exterior, purge urgent Interior, clear Heat, warm Cold. In summary, name the disease, classify the meridian, examine the syndrome, inspect the pulse, clarify Exterior/Interior, recognize Yin/Yang, measure Deficiency/Excess, know Root/Branch. These eight are the essential principles of treating Shanghan.