张元素曰。凡小儿伤寒表症。有恶风恶寒者。当发表。如气盛能食。不大便。无表症者。可攻里。春主温。属木。
身
温当发汗。夏主长。属火。身热而烦躁。合大发散。长夏主化。属土。四季月同。当调其饮食。秋主收。属金。身凉内
温。合微下。冬主脏。属水。身热而恶寒。是热在外而寒在内。身凉而恶热。是热在内而寒在外。热在内者。调胃承气
汤。寒在内者。调中汤丸。凡小儿伤寒。宜根据四时阴阳升降顺逆刚柔而施治。气升浮则发之。收藏则下之。有汗发热恶
风。脉浮缓者。风伤卫。桂枝汤。无汗发热恶寒。不当风而自憎寒。脉浮紧者。寒伤荣。麻黄汤。有汗发热恶风。脉浮
紧。无汗发热恶寒。脉浮缓。谓之荣卫俱伤。桂枝麻黄合半汤。无汗发热。不恶风寒。脉沉洪者。可下之。更详其厥与
不厥。量寒热浅深而治之。有汗四肢厥。脉沉微者。名阴厥。四逆汤。无汗四肢厥。脉沉微者。名阳厥。大承气汤。如
四肢不厥。
身热内外皆阳。不动三焦。宜凉药三五服下之。黄芩甘草汤、黄芩白术汤、黄芩苍术汤、黄芩栀子汤、连翘饮子、小柴
胡汤、八正散、凉膈散、白虎汤、五黄散。此上中下三焦药。宜选用。中暑脉虚。背寒恶。自汗而渴者。白虎汤。身凉。
脉紧。热在内者。急下之。口燥咽干。不大便是也。无汗。身大热者。可发汗。升麻汤、大青膏、天麻膏。有汗。身大
热者。惺惺散、桂枝汤、解肌汤、小柴胡汤、白术防风汤。可选用。发汗者。量四时暄暑燥湿风寒。各宜春凉夏寒秋温
冬热而发之。如身表无大热。而小便不利。是有湿热结膀胱。仍用胜湿药。白术、白茯苓之类。以利小便。则其热自退。
伤寒咳嗽。吐清水。哽气。长出气。是肺不足也。阿胶散。面白如枯骨者。死不治。身热咳嗽吐痰者。褊银丸。若有表
症。恶风
寒而嗽者。惺惺散、加减鼠粘子汤。身大热。吐逆不止者。茯苓半夏汤。大吐者。当下之。消积丸。潮热有时。胸满短
气呕吐者。桃奴丸。
张云岐曰。小儿有寒邪。及瘟气时疫疮疹。身疼头痛。壮热多眠不语。潮热烦渴。痰实咳嗽。人参羌活汤。时气头
昏体热。七宝散。小儿同乳母服。大人亦可用。小儿表伤寒。则皮肤闭而为热。盛即生风。欲为惊搐。血气未实。不能
胜邪。故发搐也。大小便根据度。口中气热。当发之。宜大青膏。肺盛复有风冷。则胸满短气。气急喘嗽。上气。当先散
肺。泻白散、后发散、大青膏。若止伤寒。则不胸满。设令小儿卒暴身壮热。恶寒。四肢冷。或耳尻冷。鼻气冷。为斑
疹也。与伤寒表症相似。此胎气始发。自内之外。若与伤寒表症同治者。误也。当作斑疹治之。
王好古曰。小儿伤寒时气。风热痰壅咳嗽。及气不和者。四君子汤加细辛、栝蒌、桔梗、薄荷、生姜。或加防风、
川芎。内有寒。或遇天寒欲发散者。则去栝蒌。虚汗夜啼。加麦冬。
杨士瀛曰。小儿头额痛。身体发热。大便黄赤。腹中有热。四顺散、连翘饮、三黄丸。身体潮热。头目昏痛。心神
烦躁。小便赤。大便秘。此热剧也。调胃承气汤。头额身体温热。大便白而酸臭者。胃中有食积也。双圣丸。
虞抟曰。小儿伤风。贪睡。口中气热。呵欠烦闷。当发散。大青膏。表症也。寻常风壅发热。鼻涕痰嗽。烦渴。惺
惺散。有
风热。里热。口中气热。大小便秘赤。饮水不止。有下症者。大黄丸。大热饮水不止。而善食者。可微下。如清便自调。
不可下也。恐外热逐于内。而变结胸危症。
张兼善曰。小儿伤风兼脏者。兼心则惊悸。兼肺则闷乱。喘息哽气。长出气。咳嗽。兼肾则畏明。各随补母脏。虚
见故也。如伤风手足冷。脾脏怯也。当先和脾。益黄散。而后发散。大青膏。未瘥。调中丸。有下症。大黄丸。后服温
惊丸。伤风
腹胀。亦脾脏虚也。当补肺。必不喘。后发散。仍补脾也。去胀。塌气丸。发散。大青膏。伤风吐泻。白术散。夹惊
伤寒。热极生风。薄荷散。
庞安常曰。小儿伤寒自汗。当补虚。和阴阳。小建中汤减桂加黄 、人参、地黄。
吴绶曰。小儿伤寒。六经治例皆同。但有胎热、惊热、血热、客热、寒热、潮热、痰热、食热、变蒸热、伤风热、
痘疹热。一皆发作。状似伤寒。要在明辨之耳。况肌体嫩弱。血气未定。脉法不同。药剂轻小之别。故略具节要于后。
凡小儿病。详察面色为先。伤寒尤宜加意。凡食热伤乳则吐 。奶瓣不消。口中醋气。伤食则心下满硬。嗳气作酸。恶
食。右手气口脉盛。手心热。手背不热。肚背先热。以此别之。凡治小儿伤寒。发热。必以六君子汤为主。或加神曲、
麦芽、山楂、砂仁、香附之类。内实者。加枳实、青皮。热不解者。加柴胡、黄连、黄芩之类。如无热。香砂保和丸。
凡变蒸发热。长气血也。夫变者。气上。蒸者。体热也。轻者发热虚惊。耳冷微汗。唇中有白泡如珠子是也。三日而愈。
重者寒热脉乱。腹痛啼叫。不食。凡乳食即吐 。五日愈也。凡伤寒发热。则贪睡眼涩。呵欠烦
闷。鼻塞喷嚏。或流清涕。口中气热。咳嗽声重。或自汗怕风。人参羌活散。其余治例。宜同伤寒表症例也。要在详辨
而治之耳。凡伤寒则怕寒。拘急。发热翕翕然。在表。昼夜不止。直待汗出方解。钱氏曰。男子则面黄体重。女子则面
赤喘急憎寒。口中气热。呵欠烦闷项急也。大抵伤寒则手背热。手心不热。左手人迎脉紧盛也。其余六经治法。同大人
伤寒。但药宜轻小耳。亦有夹惊夹食伤寒。要在详审。凡痘疹发热。钱氏曰。腮赤多躁。喷嚏眼涩。呵欠烦闷。时发惊
悸。身重发热。耳尖鼻尖手足稍冷。乍凉乍热。睡中惊惕。起卧不安。乃其候也。切不可认作伤寒。发汗。盖覆取汗。
则大误。须仔细辨之。
鳌按。小儿伤寒。虽云六经治例。与大人无异。然毕竟有别。小儿多一切杂症。如前辈所云。固当一一分辨施
治。即真属伤寒。而小儿必夹惊夹食之症为多。故即用六经分治之剂。其中必兼去惊消食之品。方可奏功。至小儿
伤寒形症。亦属有定。如头痛。体重。鼻塞流涕。喘息。颊赤眼涩。或眼赤黄。口干。咳嗽。喷嚏。或口鼻出水。
山根青色。身上寒毛起。或畏人。或恶寒。两手脉必洪数。凡此等症。皆属伤寒之候。必明辨之。方不与一切之症
相混。而可以伤寒之治为治。而即此等症。亦不必悉具。随见数症便是。如吴氏详列诸症。本与伤寒无涉。今特录
之者。所以别于伤寒。欲医者知一切诸症之各有形症。盒饭各随症治。而可不混于伤寒也。
Zhang Yuansu stated: For pediatric exterior syndromes of Shanghan (Cold Damage), if there are aversion to wind or cold, exterior-releasing methods should be employed. If the child has robust Qi, can eat, and suffers from constipation without exterior symptoms, interior-purging methods may be used. Spring governs warmth and belongs to Wood; when the body is warm, sweating should be induced. Summer governs growth and belongs to Fire; when the body is hot with restlessness, vigorous dispersing is required. The late summer governs transformation and belongs to Earth; the situation is the same in the last month of each season, so diet should be regulated. Autumn governs gathering and belongs to Metal; when the body is cool but internally warm, mild purging is appropriate. Winter governs storage and belongs to Water; fever with aversion to cold indicates heat on the exterior and cold on the interior; coolness with aversion to heat indicates heat on the interior and cold on the exterior. For heat on the interior, Tiaowei Chengqi Tang (Regulate the Stomach Order the Yellows Decoction) is used; for cold on the interior, Tiaozhong Tang/Wan (Regulate the Middle Decoction/Pill) is used. In all cases of pediatric Shanghan, treatment should be administered according to the ascending/descending, smooth/reverse, and rigid/flexible changes of Yin and Yang across the four seasons. When Qi ascends and floats, disperse it; when it stores, purge it. With sweating, fever, aversion to wind, and a floating-slow pulse, Wind has injured the Wei (Defensive) Qi; Guizhi Tang (Cinnamon Twig Decoction) is indicated. Without sweating, fever, aversion to cold, spontaneous chilliness even without exposure to wind, and a floating-tight pulse, Cold has injured the Ying (Nutritive) Blood; Mahuang Tang (Ephedra Decoction) is indicated. Sweating with fever, aversion to wind, and a floating-tight pulse, or no sweating with fever, aversion to cold, and a floating-slow pulse, are termed "injury to both Ying and Wei"; Guizhi Mahuang Ban Tang (Half-Dose Combination of Cinnamon Twig and Ephedra Decoction) is used. No sweating, fever, no aversion to wind/cold, and a deep-rapid pulse indicate that purging is possible; further examine whether there is Jue (cold extremities) and treat based on the depth of cold/heat. Sweating with cold extremities and a deep-micro pulse is named Yin Jue (Yin Cold Extremity); Sini Tang (Frigid Extremities Decoction) is used. No sweating with cold extremities and a deep-micro pulse is named Yang Jue (Yang Cold Extremity); Dachengqi Tang (Major Order the Yellows Decoction) is used. If extremities are not cold, and the body is hot inside and out (pure Yang syndrome) without affecting the Sanjiao (Triple Burner), cooling herbs should be taken three to five times. Suitable formulas include Huangqin Gancao Tang (Scutellaria and Licorice Decoction), Huangqin Baizhu Tang (Scutellaria and Atractylodes Macrocephala Decoction), Huangqin Cangzhu Tang (Scutellaria and Atractylodes Lancea Decoction), Huangqin Zhizi Tang (Scutellaria and Gardenia Decoction), Lianqiao Yinzi (Forsythia Infusion), Xiaochaihu Tang (Minor Bupleurum Decoction), Bazheng San (Eight Uprights Powder), Liangge San (Cool the Diaphragm Powder), Baihu Tang (White Tiger Decoction), and Wuhuang San (Five Yellows Powder). These are remedies for the Upper, Middle, and Lower Sanjiao, suitable for selection. For heatstroke with a weak pulse, aversion to cold on the back, spontaneous sweating, and thirst, Baihu Tang (White Tiger Decoction) is used. Cool body, tight pulse, and heat on the interior require urgent purging, manifesting as dry mouth/throat and constipation. No sweating and high fever allow for sweating induction; Shengma Tang (Cimicifuga Decoction), Daqing Gao (Great Blue Ointment), and Tianma Gao (Gastrodia Ointment) are options. Sweating and high fever allow for selection of Xingxing San (Stupor-Dispelling Powder), Guizhi Tang (Cinnamon Twig Decoction), Jiemi Tang (Release Muscle Decoction), Xiaochaihu Tang (Minor Bupleurum Decoction), and Baizhu Fangfeng Tang (Atractylodes and Saposhnikovia Decoction). When inducing sweat, consider the seasonal climate (warmth, heat, dryness, dampness, wind, cold) and induce sweat according to spring-cool, summer-cold, autumn-warm, and winter-hot principles. If there is no significant surface heat but difficulty urinating, this is Damp-Heat binding in the Bladder; use damp-dispelling herbs like Baizhu (Atractylodes Macrocephala Rhizome) and Baifuling (Poria) to promote urination, after which the heat will subside.
Shanghan cough with clear fluid expectoration, belching, and sighing indicates Lung Qi deficiency; Ejiao San (Donkey-Hide Gelatin Powder) is used. Pale face resembling dead bone signifies a fatal, untreatable condition. Fever with cough and phlegm expectoration is treated with Pianyin Wan (Narrow Silver Pill). If exterior symptoms exist with aversion to wind/cold and cough, Xingxing San (Stupor-Dispelling Powder) or Jiajian Shuniuzi Tang (Modified Arctium Decoction) are used. High fever with persistent vomiting requires Fuling Banxia Tang (Poria and Pinellia Decoction). Severe vomiting requires purging; Xiaoji Wan (Accumulation-Dissolving Pill) is used. Periodic fever with chest fullness, shortness of breath, and vomiting is treated with Taonuo Wan (Peach Bud Pill).
Zhang Yunqi stated: Children suffering from Cold pathogens, epidemic toxins, or maculopapular rashes presenting with body pain, headache, high fever, lethargy, mutism, tidal fever, restlessness, thirst, and phlegm-fullness cough should receive Renshen Qianghuo Tang (Ginseng and Notopterygium Decoction). For epidemic conditions causing dizziness and body heat, Qibao San (Seven Treasures Powder) is used; children and wet nurses take it together, and adults may also use it. Pediatric exterior Shanghan causes skin closure and heat; severe cases generate Wind leading to convulsions. Due to immature Blood and Qi, they cannot overcome the pathogen, hence convulsions occur. With normal bowel/bladder function and hot breath, disperse the exterior using Daqing Gao (Great Blue Ointment). Excessive Lung Qi combined with Wind-Cold causes chest fullness, shortness of breath, rapid breathing, wheezing cough, and rebellious Qi; first disperse the Lung using Xiebai San (Drain White Powder), then disperse the exterior with Daqing Gao (Great Blue Ointment). Pure Shanghan does not cause chest fullness. If a child suddenly develops high fever, aversion to cold, cold limbs, cold ears/tailbone/nose, these are signs of Maculopapular Rash (Ban Zhen), similar to exterior Shanghan but originating internally from fetal Qi. Treating it as exterior Shanghan is an error; it must be treated as a rash condition.
Wang Haogu stated: For pediatric Shanghan and epidemic conditions with Wind-Heat, Phlegm obstruction, cough, and Disharmony of Qi, Sijunzi Tang (Four Gentlemen Decoction) is modified with Xixin (Asarum), Gualou (Trichosanthes Fruit), Jiegeng (Platycodon Root), Bohe (Mint), and Shengjiang (Fresh Ginger). Alternatively, add Fangfeng (Saposhnikovia Root) and Chuanxiong (Ligusticum Rhizome). For internal Cold or desire to disperse in cold weather, remove Gualou. For spontaneous sweating and night crying, add Maidong (Ophiopogon Tuber).
Yang Shiyin stated: Head/forehead pain, fever, yellow-red stool, and abdominal heat in children are treated with Sishun San (Four Smooth Powders), Lianqiao Yin (Forsythia Drink), and Sanhuang Wan (Three Yellows Pill). Tidal fever, dizzy/head pain, mental restlessness, red urine, and constipation indicate severe Heat; Tiaowei Chengqi Tang (Regulate the Stomach Order the Yellows Decoction) is used. Warm forehead/body with white, sour-smelling stool indicates Food Stagnation in the Stomach; Shuangsheng Wan (Double Sage Pill) is used.
Yu Tun stated: Pediatric Wind Injury with lethargy, hot breath, yawning, and restlessness requires dispersion using Daqing Gao (Great Blue Ointment), indicating an exterior syndrome. Common Wind obstruction with fever, runny nose, phlegm cough, and thirst is treated with Xingxing San (Stupor-Dispelling Powder). Wind-Heat with interior Heat, hot breath, constipated/red urine, and incessant drinking with downward indications uses Dahuang Wan (Rhubarb Pill). High fever with incessant drinking and good appetite allows mild purging. If stools are normal, do not purge, lest exterior Heat be driven inward causing Jie Xiong (Chest Binding) critical syndrome.
Zhang Jianshan stated: Pediatric Wind Injury involving organs: involvement of Heart causes palpitations/fright; Lung causes oppression/confusion, wheezing, belching, sighing, cough; Kidney causes photophobia. Treat by tonifying the mother organ due to deficiency. Cold hands/feet in Wind Injury indicates Spleen weakness; harmonize Spleen first with Yihuang San (Yellow Emperor Powder), then disperse exterior with Daqing Gao (Great Blue Ointment). If unresolved, use Tiaozhong Wan (Regulate Middle Pill). With downward indications, use Dahuang Wan (Rhubarb Pill), followed by Wenjing Wan (Warm Fright Pill). Wind Injury with abdominal distension is Spleen deficiency; tonify Lung (no wheezing expected), then disperse exterior, then tonify Spleen again to reduce distension using Taqi Wan (Collapse Qi Pill). Disperse exterior with Daqing Gao (Great Blue Ointment). Wind Injury with vomiting/diarrhea uses Baizhu San (Atractylodes Powder). Clashing Fright Shanghan with extreme Heat generating Wind uses Bohe San (Mint Powder).
Pang Anchang stated: Pediatric Shanghan with spontaneous sweating requires tonifying deficiency and harmonizing Yin/Yang using Jianzhong Tang (Construct the Middle Decoction) modified by removing Guizhi (Cinnamon Twig) and adding Huangqi (Astragalus Root), Renshen (Ginseng Root), and Dihuang (Rehmannia Root).
Wu Shou stated: Pediatric Shanghan follows the same Six Channels treatment principles as adults, but differentiates from Tai Re (Fetal Heat), Jing Re (Fright Heat), Xue Re (Blood Heat), Ke Re (Guest Heat), Han Re (Cold Heat), Chao Re (Tidal Heat), Tan Re (Phlegm Heat), Shi Re (Food Heat), Bian Zheng Re (Metamorphosis Heat), Shang Feng Re (Wind Injury Heat), and Dou Zhen Re (Smallpox/Rash Heat). All present similarly to Shanghan; differentiation is key. Given tender flesh, unsettled Blood/Qi, and different pulse patterns, prescriptions are lighter/smaller. Key points follow: Observe complexion first, especially in Shanghan. Vomiting after hot food/milk with undigested milk curds and sour breath indicates Food Injury: epigastric fullness/hardness, acid belching, food aversion, strong Right Qi Kou pulse, hot palms, cool backs of hands, hot abdomen/back. For pediatric Shanghan fever, Liu Junzi Tang (Six Gentlemen Decoction) is primary, possibly adding Shenqu (Medicated Leaven), Maiya (Barley Sprout), Shanzha (Hawthorn Fruit), Sharen (Amomum Fruit), Xiangfu (Cyperus Rhizome). For interior excess, add Zhishi (Immature Bitter Orange) and Qingpi (Green Tangerina Peel). For unresolved heat, add Chaihu (Bupleurum Root), Huanglian (Coptis Rhizome), Huangqin (Scutellaria Root). Without heat, use Xiangsha Baohe Wan (Fragrant Amomum Harmonize the Stomach Pill).
Bian Zheng (Metamorphosis) fever grows Qi/Blood. "Bian" is Qi rising; "Zheng" is body heat. Mild cases: fever, false fright, cold ears, slight sweating, pearl-like white blisters on lips; resolves in 3 days. Severe cases: alternating cold/heat, chaotic pulse, abdominal pain, crying, anorexia, vomiting upon feeding; resolves in 5 days. Shanghan fever involves lethargy, heavy eyes, yawning, restlessness, nasal congestion/sneezing, clear rhinorrhea, hot breath, heavy cough, spontaneous sweating, aversion to wind; Ren Shen Qiang Huo San (Ginseng and Notopterygium Powder) is used. Other treatments follow exterior Shanghan principles. Differentiation is crucial. Shanghan features aversion to cold, stiffness, fluttering fever at the exterior, persisting day/night until sweating occurs. Qian Yi stated: Males have yellow face/heavy body; females have red face, panting, aversion to cold, hot breath, yawning, restlessness, stiff neck. Generally, Shanghan presents with hot backs of hands, cool palms, and tight/full Left Ying Chong pulse. Six Channels treatments match adults but use lighter doses. Differentiate clashing Fright/Food Shanghan carefully.
Dou Zhen (Rash) fever per Qian Yi: red cheeks, restlessness, sneezing, heavy eyes, yawning, restlessness, intermittent palpitations, heavy body fever, cold ear tips/nose tip/extremities, alternating cold/heat, startle during sleep, restless lying/sitting. Do not mistake for Shanghan and induce sweat via covering; this is a major error. Careful differentiation is required.
Shen Jin'ao notes: Although pediatric Shanghan Six Channels treatments resemble adults', differences exist. Children often have mixed syndromes requiring precise differentiation. Even true Shanghan in children frequently involves clashing Fright and Food. Thus, Six Channels formulas must include anti-fright and digestion-promoting herbs to be effective. Pediatric Shanghan signs are fixed: headache, heavy body, nasal congestion/rhinorrhea, wheezing, red cheeks/heavy eyes, red/yellow eyes, dry mouth, cough, sneezing, oral/nasal discharge, blue Shan Gen (root of nose), gooseflesh, fear of people, aversion to cold, surging-rapid pulses. These are Shanghan signs; distinguish them clearly to avoid confusion with other syndromes and apply correct treatment. Symptoms need not all be present; a few suffice. Wu's detailed list differs from Shanghan but is recorded to distinguish syndromes, teaching physicians to treat each according to its specific signs, avoiding confusion with Shanghan.