传于阳明。而少阴亦传于太阴。身热谵语者。阳明。腹满不欲食者。太阴。至三日。阳
明传于少阳。而太阴又传于厥阴。耳聋者。少阳。囊缩而厥者。厥阴。水浆不入。不知
人者。胃气不通也。内经曰。五脏已伤。六腑不通。荣卫不行。如是之后。三日乃死。
何也。岐伯曰。阳明者。十二经脉之长也。其血气盛。故云不知人三日。其气乃尽。故
死矣。谓三日。六经俱病。荣卫之气。不得行于内外。腑脏之气。不得通于上下。至六
日。腑脏之气俱尽。荣卫之气俱绝。则死矣。
王三阳云。二三日内。谵语囊缩。水浆不入。不知人者。此真两感也。其死必矣。太
阳经。少阴经头痛。口干、烦满、而口渴者。有似于暑病热病。宜仔细辨之。且太阳证。
人本亦作渴。不可便断是两感病也。然两感先少阴。传经先太阴者。何也。盖两感太阳
与少阴俱病者。太阳。膀胱也。少阴。肾也。肾与膀胱为表里。表里同病
也。阳证传经先入太阴者。阳邪内陷。脾胃为仓廪之官也。况木来克土。势易侵也。
王宇泰云。太阳为膀胱。少阴为肾。肾与膀胱为合。太阴为脾。阳明为胃。胃与脾
合少阳为胆。厥阴为肝。肝与胆合。阴道从阳。譬之妯娌。但以夫年为次。不以已齿
为序也。
其不两感于寒。更不传经。不加异气者。至七日。太阳病衰。头痛少愈也。八日。
阳明病衰。身热少歇也。九日。少阳病衰。耳聋微闻也。十日。太阴病衰。腹减如故。
则思饮食。十一日。少阴病衰。渴止。舌干已而嚏也。十二日。厥阴病衰。囊纵。少腹
微下。大气皆去。病患精神爽慧也。
六日传遍。三阴三阳之气皆和。大邪之气皆去。病患精神爽慧也。
若过十三日以上。不间。尺寸陷者。大危。
间者。瘳也十二日传经尽。则当瘳愈。若过十三日以上。不瘳。尺寸之脉沉陷者。
即正气内衰。邪气独胜故云大危。
戴元礼云。伤寒先犯太阳。以次而传。此特言其概耳。然其中变证不一。有发于
阳。即少阴受之者。有夹食伤寒。食动脾。脾太阴之经。一得病。即腹满痛者。亦有不
循经而入。如初得病。径犯阳明之类。不皆始于太阳也。亦有首尾止在一经。不传他经。
亦有止传一二经而止者。不必尽传诸经也。至如病之逾越。不可泥于次序。当随证施治。
所以伤寒得外证为多。
活人书云凡寒邪自背而入者。或中太阳。或中少阴。自面而入者。则中阳明之类。亦
不专主于太阳也。
王宇泰云。有寒客三阴。极而生热。则传阳明。凡邪国中三阴则寒。故宜温药发汗。
及寒极变热。则复宜寒药下之。盖三阴三阳。皆能自受邪。不止自太阳经传也。
若更感异气。变为他病者。当依旧坏证病而治之。若脉阴阳俱盛。重感于寒者。变
为温疟。
异气者。为先病未已。又感别异之气也。两邪相合。变为他病。脉阴阳俱盛者。伤
寒之脉也。难经曰。伤寒之脉。阴阳俱盛而紧涩。经曰。脉盛身寒。得之伤寒。则为前
病热未已。再感于寒。寒热相搏。变为温疟。
王三阳云。阴阳俱盛者。伤寒脉也。十三日以上。脉已传里。变为热病矣。脉当沉
数。今复见伤寒脉。岂非重感于外寒乎。寒热相搏。故曰变为温疟。
阳脉浮滑。阴脉濡弱者。更遇于风。变为风温。
此前热未歇。又感于风者也。难经曰。中风之脉。阳浮而滑。阴濡而弱。风来乘热。
故变风温。
阳脉洪数。阴脉实大者。遇温热变为温毒。温毒为病最重也。
此前热未已。又感温热者也。阳主表。阴主里。洪数、实大、皆热也。两热相合。变
为温毒。以其表里俱热。故为病最重。
阳脉濡弱。阴脉弦紧者。更遇温气。变为温疫。以此冬伤于寒。发为温病。脉之变
症。方治如说。
此前热未已。又感温气者也。温热相合。变为温疫。王宇泰云。按活人所云。温病
有二。其用升麻解肌者。乃正伤寒太阳证。恶寒而不渴者。特以其发于温暖之时。故谓之温
病尔。其用竹叶石膏汤者。乃仲景所谓渴不恶寒之温病也。要须细别。勿令误也。然不
恶寒而渴之温病。四时皆有之。不独春时而已。
凡人有疾。不时即病。隐忍冀瘥。以成痼疾。
凡觉不佳。急须求治。苟延时日。则邪气入深。难可复制。千金曰。凡有少苦。以
不如平常。即须早道。若隐忍不治。冀望自瘥。须臾之间。以成痼疾。此之谓也。
小儿女子。益以滋甚。
小儿气血未全。女子血室多病。凡所受邪。易于滋蔓。
时气不和。盒饭早言。寻其邪由。及在腠理。以时治之。罕有不愈者。
腠理者。津液腠泄之所。文理缝会之中也。金匮要略曰。腠者。是三焦通会元真之
处。为血气所注。理者。是皮肤脏腑之文理也。邪客于皮肤。则邪气浮浅。易为散发。
若以时治之。罕有不愈者矣。金匮玉函曰。主候长存。形色未病。未入腠理。针药及时。
服将调节。委以良医。病无不愈。
患人忍之。数日乃说。邪气入脏。则难可制。此为家有患备虑之要。
邪在皮肤。则外属阳而易治。邪传入里。则内属阴而难治。内经曰。善治者治皮毛。
其次治肌肤。其次治筋脉。其次治六腑。其次治五脏。治五脏者。半死半生也。昔桓侯
怠于皮肤之微疾。以至骨髓之病。家有患者。可不备虑。
凡作汤药。不可避晨夜。觉病须臾。即宜便治。不等早晚。则易愈矣。
千金曰。凡始觉不佳。即须治疗。迄至于病。汤食竞进。折其毒势。自然而瘥。
若或瘥迟。病即传变。虽欲除治。必难为力。
传。有常也。变、无常也。传为循经而传。如太阳传阳明是也。变为不常之变。如
阳证变阴证是也。邪既传变。病势深也。本草曰。病势已成。可得半愈。病势已过。命
将难全。
服药不如方法。纵意违师。不须治之。
内经曰。拘于鬼神者。不可与言至德。恶于针石者。不可与言至巧。病不许治者。
病必不治。治之无功矣。
凡伤寒之病。多从风寒得之。
凡中风与伤寒为病。自古通谓之伤寒。千金曰。夫伤寒病者。起自风寒。入于腠理。
与精气分争。荣卫偏隔。周身不通而病。
始表中风寒。入里则不消矣。
始自皮肤。入于经络。传于脏腑。是也。
未有温覆而当。不消散者。
风寒初客于皮肤。便投汤药。温暖发散而当者。则无不消散之邪。
不在证治。拟欲攻之。尤当先解表。乃可下之。
先解表而后下之。则无复传之邪也。
若表已解而内不消。非大满。尤生寒热。则病不除。
表症虽罢。里不至大坚满者。亦未可下之。是邪未收敛成实。下之。则里虚而邪复
不除。尤生寒热也。
若表已解而内不消。大满大实。坚有燥屎。自可除下之。虽四五日。不能为祸也。
外无表症。里有坚满。为下症悉具。外台云。表和里病。下之则愈。下症既具。则不
必拘于日数。
若不宜下而便攻之。内虚热入。协热遂利。烦躁诸变。不可胜数。轻者困笃。重者
必死矣。
下之不当。病轻者。症尤变易而难治。又矧重者乎。
夫阳盛。阴虚。汗之则死。下之则愈。阳虚阴盛。汗之则愈。下之则死。
表为阳。里为阴。阴虚者。阳必凑之。阳盛之邪。乘其里虚而入于腑者。为阳盛阴
虚也。经曰。尺脉弱。名曰阴不足。阳气下陷入阴中。则发热者是矣。下之。除其内热
而愈。若反汗之。则竭其津液而死。阴脉不足。阳往从之。阳脉不足。阴往乘之。阴邪
乘其表虚。客于荣卫之中者。为阳虚阴盛也。经曰。假令寸口脉微。名曰阳不足。阴气
上入阳中。则洒淅恶寒者是矣。汗之。散其表寒则愈。若反下之。则脱其正气而死。经
曰。本发汗而复下之。此为逆也。本先下之。而反汗之。为逆。
夫如是。则神丹安可以误发。甘遂何可以妄攻。虚盛之治。相背千里。吉凶之机。
应若影响。岂容易哉。
神丹者。发汗之药也。甘遂者。下药也。若汗下当则吉。汗下不当则凶。其应如影
随形。如附应声。
况桂枝下咽。阳盛则毙。承气入胃。阴盛以亡。
桂枝汤者。发汗药也。承气汤者。下药也。金匮玉函曰。不当汗而强与汗之者。令
人夺其津液。枯槁而死。不当下而强与下之者。令人开肠洞泄。便溺不禁而死。
死生之
要。在乎须臾。视身之尽。不暇计日。
投汤不当。则灾祸立见。岂暇计其日数哉。
此阴阳虚实之交错。其候至微。发汗吐下之相反。其祸至速。而医术浅狭。懵然不
知病源。为治乃误。使病者殒殁。自谓其分。至今冤魂塞于冥路。死尸盈于旷野。仁者
鉴此。岂不痛欤。凡两感病俱作。治有先后。发表攻里。本自不同。而执迷妄意者。乃
云神丹甘遂。合而饮之。且解其表。又除其里。言巧似是。其理实违。夫智者之举错也。
常审以慎。愚者之动作也。必果而速。安危之变。岂可诡哉。世上之士。但务彼翕习之
荣。而莫见此倾危之败。惟明者居然能护其本。近取诸身。夫何远之有焉。
两感病俱作。欲成不治之疾。医者大宜消息。审其先后次第而治之。若妄意攻治。以
求速效者。必致倾危之败。
赵嗣真云。经曰。邪气盛则实。精气夺则虚。因正气先虚。以致邪气客之而为盛实。
于是有阴虚阳盛。阳虚阴盛二证之别。盖盛者。指邪气而言。虚者。指正气而言。且正
气在人。阳主表而阴主里。邪气中人。表为阴而里为阳。若夫表之真阳先虚。故阴邪乘
阳而盛实。表受邪者。阳虚也。脉浮紧者。阴邪盛于外也。是谓阳虚阴盛。所以用桂枝
辛甘之温剂。汗之则阴邪消。温之则真阳长。使邪去正安
故愈。又若里之真阴先虚。故阳邪入阴而盛实。里受邪者。阴虚也。脉沉实者。阳邪盛
于内也。是谓阴虚阳盛。所以用承气酸苦之寒剂。下之则阳邪消。寒之则真阴长。使邪
去正安故愈。如其不然。阳盛而用桂枝。下咽即毙。阴盛而用承气。入胃即亡。是皆盛
盛虚虚。而致邪失正也。
王履云。邪之伤于人也。有浅深焉。浅则居表。深则入里。居表。则闭腠理。发怫
热。见恶寒恶风头痛等症。于斯时也。惟辛温解散而可愈。入里。则为燥屎。作潮热形。
狂言谵语。大渴等症。于斯时也。惟咸寒攻下而可平。夫寒邪外客。非阴盛而阳虚乎。
热邪内炽。非阳盛而阴虚乎。汗下一差。生死反掌。
又云。所谓阳盛即毙者。是言表证已罢。而里证既全。可攻而不可汗。所谓阴盛以
亡者。是言里证未形。而表证独具。可汗而不可攻。
戴元礼云。伤寒要紧处。在分表里而为汗下。有病患自汗自下者。有医用药汗之下
之者。中间节目颇多。汗药宜早。下药宜迟。此亦大纲之论耳。
王三阳云。表证急。先解表。后即治里。里证急。先治里。后即解表。此先后次第
也。若欲作一汤治之。神丹甘遂。合饮之谓矣。虽然。大羌活汤。亦可用之。但必表里
齐等。不容先后治者。万不得已而用也。
凡发汗。温服汤药。其方虽言日三服。若病剧不解。当促其间。可半日中尽三服。若
与病相阻。即便有所觉。重病者。一日一夜。当 时观之。如服一剂。病证犹在。故当
复作本汤服之。至有不肯汗出。服三剂乃解。若汗不出者。死病也。
发汗药。须温暖服者。易为发散也。日三服者。药势续也。病势稍重。当促急服之。
以折盛热。不可拘于本方。设药病不相对。汤入即便知之。如阴多者。投以凉药。即寒
逆随生。阳多者。饮以温剂。则热毒即起。是便有所觉。 时者。周时也。一日一夜。服
汤药尽剂。更看其传。如病证犹在。当复作本汤。以发其汗。若服三剂不解。汗不出者。
邪气大甚。汤不能胜。必成大疾。千金曰。热病。脉躁盛而不得汗者。此阳脉之极也。死。
王三阳云。亦有黄 建中补之。而后汗出者。若服三剂发汗药。汗复不出。其死必
矣。宜仔细候脉消息之。毋妄治也。
凡得时气病。至五六日而渴欲饮水。饮不能多。不当与也。何者。以腹中热尚少。不
能消之。便更与人作病也。至七八日大渴。欲饮水者。犹当根据证与之。与之常令不
足。勿极意也。言能饮一斗。与五升。若饮而腹满。小便不利。若喘若哕。不可与之。
忽然大汗出。是为自愈也。
热在上焦。则为消渴。言热消津液。而上焦干燥。则生渴也。大热则能消水。热少
不能消之。若强饮。则停饮变为诸病。至七八日。阳胜气温。向解之时多。尚生大渴。
亦须少少与之。以润胃气。不可极意饮也。若饮而腹满。小便不利。若喘若哕者。为水饮
内停而不散。不可更与之。忽然阳气通。水气散。先发于外。作大汗而解。
凡得病。反能饮水。此为欲愈之病。其不晓病者。但闻病饮水自愈。小渴者。亦强
与饮之。因成其祸。不可复数。
小渴者。为腹中热少。若强与水。水饮不消。复为诸饮病也。
凡得病厥脉动数。服汤药更迟。脉浮大减小。初躁后静。此皆愈证也。
The pathogenic factor transmits to the Yangming channel. Meanwhile, the Shaoyin channel also transmits to the Taiyin channel. Symptoms of body heat and delirium indicate a Yangming channel disorder; symptoms of abdominal fullness and loss of appetite indicate a Taiyin channel disorder. By the third day, the Yangming transmission reaches the Shaoyang channel, while the Taiyin transmission reaches the Jueyin channel. Deafness indicates a Shaoyang channel disorder; retraction of the scrotum and cold extremities indicate a Jueyin channel disorder. Inability to take fluids or food, and unconsciousness, are due to the obstruction of Stomach Qi. The *Neijing* states: When the Five Zang organs are damaged, the Six Fu organs fail to circulate, and Ying (Nutritive) and Wei (Defensive) Qi cease to flow. After such a condition persists for three days, death ensues. Why? Qibo stated: The Yangming channel is the leader of the Twelve Channels, possessing abundant blood and Qi. Therefore, if a patient remains unconscious for three days, the Qi of this channel will be exhausted, leading to death. This refers to a state where all Six Channels are diseased within three days, causing Ying and Wei Qi to fail to circulate internally and externally, and Zang-Fu Qi to fail to communicate between upper and lower regions. By the sixth day, when Zang-Fu Qi and Ying-Wei Qi are both exhausted and severed, death occurs.
Wang Sanyang stated: Delirium, scrotal retraction, inability to take fluids, and unconsciousness occurring within two or three days constitute "Lianggan" (simultaneous involvement of exterior and interior channels). Such cases inevitably result in death. Headache associated with simultaneous involvement of the Taiyang and Shaoyin channels; dry mouth, irritability, fullness, and thirst resemble Summerheat disease or Heat disease, requiring careful differentiation. However, patients with Taiyang syndrome may naturally experience thirst; thus, one should not hastily diagnose Lianggan disease. Why does Lianggan disease first involve the Shaoyin channel, and why does the transmission sequence of Yang syndromes first enter the Taiyin channel? In Lianggan, Taiyang and Shaoyin are simultaneously affected. Taiyang corresponds to the Bladder, and Shaoyin to the Kidney. Since the Kidney and Bladder are exterior-interior paired, exterior and interior are diseased together. For Yang syndrome transmission entering Taiyin first, it is because Yang pathogenic factors sink inward. The Spleen and Stomach serve as the granaries. Moreover, Wood overacting on Earth facilitates invasion.
Wang Yutai stated: The Taiyang channel corresponds to the Bladder, and Shaoyin to the Kidney, which are paired. The Taiyin channel corresponds to the Spleen, and Yangming to the Stomach, which are paired. The Shaoyang channel corresponds to the Gallbladder, and Jueyin to the Liver, which are paired. Yin pathways follow Yang, similar to sisters-in-law who rank by their husbands' ages rather than their own.
If there is no Lianggan from Cold, no further transmission, and no superimposed heterogeneous pathogens, by the seventh day, the Taiyang disease wanes, and headache improves slightly. By the eighth day, Yangming disease wanes, and body heat subsides slightly. By the ninth day, Shaoyang disease wanes, and deafness allows slight hearing. By the tenth day, Taiyin disease wanes, abdominal fullness decreases to normal, and appetite returns. By the eleventh day, Shaoyin disease wanes, thirst ceases, dry tongue resolves, and sneezing occurs. By the twelfth day, Jueyin disease wanes, the scrotum relaxes, lower abdominal tension subsides, vital Qi is expelled, and the patient regains mental clarity.
After six days, transmission completes, harmonizing the Three Yin and Three Yang channels, expelling major pathogens, resulting in mental clarity.
If beyond thirteen days, without remission, and Cun (inch) and Chi (cubit) pulses are sunken, the prognosis is critical.
"Jian" (intermission) indicates recovery. Transmission completes by twelve days, implying recovery. If beyond thirteen days without recovery, and Cun-Chi pulses are sunken, it indicates internal decline of Righteous Qi and dominance of Pathogenic Qi, hence critical.
Dai Yuanli stated: Shanghan (Cold Damage) typically begins in the Taiyang channel and transmits sequentially; this is a generalization. Variations exist: some begin in Yang channels but immediately affect Shaoyin; some involve food stagnation affecting the Spleen (Taiyin), causing abdominal fullness and pain; some bypass standard sequences, directly attacking Yangming. Not all begin in Taiyang. Some remain confined to one channel; others stop after one or two channels. One must not rigidly adhere to transmission order but treat according to syndrome. Thus, Shanghan often presents with exterior signs.
The *Huoren Shu* states: Cold pathogens entering from the back may strike Taiyang or Shaoyin; those entering from the face may strike Yangming, etc. It is not exclusively Taiyang.
Wang Yutai stated: Cold pathogens lodging in the Three Yin channels may generate extreme heat, transmitting to Yangming. Pathogens in Three Yin cause cold, warranting warm diaphoretic herbs. When cold極 transforms into heat, cold purgative herbs are appropriate. All Six Channels can independently receive pathogens, not just via transmission from Taiyang.
If superimposed heterogeneous pathogens transform the disease, treat according to the modified syndrome. If both Yin and Yang pulses are full, and cold is re-contracted, it transforms into Wen Nue (Warm Malaria).
"Heterogeneous pathogens" refer to new pathogens contracted before the initial illness has resolved. Two pathogens combine to form a new disease. Full Yin-Yang pulses characterize Shanghan. The *Nanjing* states: Shanghan pulses are full, tight, and choppy. The *Neijing* states: Full pulse with cold body indicates Shanghan. If prior heat remains unresolved and cold is re-contracted, cold and heat contend, transforming into Warm Malaria.
Wang Sanyang stated: Full Yin-Yang pulses are characteristic of Shanghan. Beyond thirteen days, pulses should have entered the interior, becoming rapid and deep (Heat disease). Reappearance of Shanghan pulses suggests re-exposure to external cold. Cold-heat contention causes transformation into Warm Malaria.
Floating-slippery Yang pulses and weak-rheum Yin pulses, upon encountering Wind, transform into Fengwen (Wind-Warmth). Prior unresolved heat combined with Wind causes this. The *Nanjing* states: Wind-strike pulses are floating-slippery on Yang and weak-rheum on Yin. Wind exploiting heat causes Wind-Warmth.
Surging-numerate Yang pulses and solid-large Yin pulses, upon encountering Warmth, transform into Wendu (Warm Toxin). Wendu is the most severe. Prior unresolved heat combined with Warmth causes this. Yang governs exterior, Yin governs interior. Surging-numerate and solid-large are heat signs. Dual heat combines to form Warm Toxin; due to interior-exterior heat, it is most severe.
Weak-rheum Yang pulses and string-tight Yin pulses, upon encountering Warm Qi, transform into Wenyi (Warm Epidemic). Winter Cold damage manifesting as Warm Disease involves pulse variations and treatments as described. Prior unresolved heat combined with Warm Qi causes Warm Epidemic. Wang Yutai noted: *Huoren Shu* describes two types of Warm Disease. Those treated with Shengma to resolve muscle layer are Zheng Shanghan (True Cold Damage) Taiyang syndrome, characterized by aversion to cold without thirst, named Warm Disease only due to occurrence in warm seasons. Those treated with Zhuye Shigao Tang are Zhang Zhongjing's Warm Disease, characterized by thirst without aversion to cold. Differentiation is crucial. Thirst-without-aversion-to-cold Warm Disease occurs in all seasons, not just spring.
Any illness untreated promptly becomes chronic; enduring it hoping for spontaneous cure leads to stubborn disease.
Upon feeling unwell, seek treatment immediately. Delay allows pathogens to deepen, making control difficult. *Qianjin Fang* states: Any minor discomfort differing from normal requires early intervention. Enduring without treatment hoping for self-healing quickly leads to stubborn disease.
Children and women are more severely affected. Children have incomplete Qi and Blood; women frequently suffer from Blood Chamber disorders. Pathogens easily spread in them.
When seasonal Qi is discordant, seek help early. Identify the pathogen source while it resides in the Couli (skin pores and interstices). Timely treatment rarely fails.
Couli are sites of fluid excretion and texture intersections. *Jingui Yaolue* states: Cou are where Sanjiao connects with primal true Qi,注 (infused) by Blood and Qi. Li are the textures of skin and Zang-Fu. Pathogens in skin are superficial and easy to disperse. Timely treatment rarely fails. *Jingui Yuhan* states: If main symptoms persist but appearance shows no disease, and pathogens have not entered Couli, timely acupuncture and medication, managed by skilled physicians, ensure recovery.
Patients enduring symptoms for days before reporting allow pathogens to enter Zang organs, becoming hard to control. This highlights the need for vigilance in households with illness.
Pathogens in skin belong to Exterior (Yang) and are easy to treat; pathogens entering Interior belong to Yin and are difficult. *Neijing* states: Good doctors treat hair and skin; next, muscles and skin; next, sinews and vessels; next, Six Fu; next, Five Zang. Treating Zang results in half deaths, half survivals. Huan Hou neglected minor skin issues, leading to bone marrow disease. Households must be vigilant.
Decocting medicine should not avoid day or night. Treat immediately upon detection, regardless of time, for easier recovery.
*Qianjin Fang* states: Treat at the first sign of discomfort. Continue decoctions until illness resolves, reducing toxicity, ensuring natural cure.
Delayed cure allows transmission. Even if treatment is attempted, efficacy is limited.
"Transmission" follows regular patterns (e.g., Taiyang to Yangming); "Transformation" is irregular (e.g., Yang to Yin). Once transmitted/transformed, disease depth increases. *Bencao* states: Established disease potential yields partial recovery; passed disease potential threatens life.
Improper medication or ignoring medical advice renders treatment futile.
*Neijing* states: Those bound by ghosts cannot hear high virtue; those hating needles/stones cannot hear high skill. Patients refusing treatment cannot be cured; treatment yields no merit.
Shanghan mostly arises from Wind-Cold.
Wind-strike and Shanghan are collectively called Shanghan. *Qianjin Fang* states: Shanghan originates from Wind-Cold entering Couli, contending with Essence-Qi, causing Ying-Wei separation and systemic blockage.
Initial exterior Wind-Cold, once entering interior, does not dissipate.
Starting from skin, entering collaterals, transmitting to Zang-Fu.
With proper warming and covering, no pathogen remains undissipated.
Initial Wind-Cold in skin, treated with appropriate warm-diffusing decoctions, dissipates all pathogens.
If not suitable for syndrome treatment, intending to purge, one must first resolve the exterior before purging.
Resolving exterior first prevents further transmission.
If exterior resolves but interior remains uneliminated, and it is not a major fullness syndrome, yet chills and fever arise, the disease persists.
Even if exterior signs cease, if interior is not significantly firm/full, purging is contraindicated. Pathogens have not consolidated; purging causes interior deficiency and pathogen retention, exacerbating chills/fever.
If exterior resolves but interior remains uneliminated, presenting with major fullness, solidity, and dry feces, purging is indicated. Even after four-five days, it poses no harm.
No exterior signs, significant interior fullness/solidity indicate purging indications. *Waitai Miyao* states: Exterior harmonious, interior diseased; purging cures. With purging indications established, day count is irrelevant.
Inappropriate purging causes interior deficiency, heat entry,協熱 (collateral heat) diarrhea, and numerous irritability transformations. Light cases become critical; heavy cases die.
Inappropriate purging makes light cases harder to treat due to symptom changes; heavy cases fare worse.
Excess Yang, Deficient Yin: Diaphoresis causes death, purging cures. Deficient Yang, Excess Yin: Diaphoresis cures, purging causes death.
Exterior is Yang, Interior is Yin. In Yin deficiency, Yang encroaches. Excess Yang pathogen invading deficient interior/Fu organs constitutes Yang Excess/Yin Deficiency. *Classic* states: Weak Chi pulse indicates Yin insufficiency. Yang Qi sinking into Yin causes fever. Purging clears internal heat. Diaphoresis depletes fluids, causing death. Insufficient Yin pulse attracts Yang; insufficient Yang pulse invites Yin. Yin pathogen invading deficient exterior/Wei-Ying constitutes Yang Deficiency/Yin Excess. *Classic* states: Microscopic Cunkou pulse indicates Yang insufficiency. Yin Qi ascending into Yang causes shivering/chills. Diaphoresis disperses exterior cold. Purging depletes Righteous Qi, causing death. *Classic* states: Diaphoresis followed by purging is reverse treatment; purging followed by diaphoresis is reverse treatment.
Thus, Shen Dan (diaphoretic) must not be misused; Gansui (purgative) must not be recklessly applied. Deficiency/excess treatments differ vastly; outcomes are precise as shadows/sounds.
Ganzhi Tang (Cinnamon Twig Decoction) taken when Yang is excess causes death; Chengqi Tang (Stomach-Eliminating Decoction) taken when Yin is excess causes death.
Ganzhi Tang is diaphoretic; Chengqi Tang is purgative. *Jingui Yuhan* states: Forced diaphoresis depletes fluids, causing withering death; forced purging causes intestinal洞泄 (cavity diarrhea) and incontinence, causing death.
Life and death hinge on moments; attending to the dying leaves no time to count days.
Improper medication brings immediate disaster; counting days is irrelevant.
This illustrates the complexity of Yin-Yang deficiency/excess, subtle signs, and the rapid catastrophe of opposing diaphoretic/vomiting/purgative methods. Shallow knowledge leads to misdiagnosis, death, and unjust souls. Benevolent physicians should grieve.
For Lianggan (simultaneous exterior-interior disease), treatment has priority: resolve exterior then purge interior. Confused practitioners mix Shen Dan and Gansui, claiming dual action. This is clever but erroneous. Wise men act cautiously; fools act rashly. Society seeks fleeting glory, ignoring peril. Only the wise protect the root.
Lianggan requires careful assessment of priority. Reckless pursuit of quick results leads to collapse.
Zhao Sizhen stated: *Classic* says: Pathogen excess is Shi (Excess); Essence depletion is Xu (Deficiency). Initial Righteous Qi deficiency allows Pathogen dominance, creating Yang Excess/Yin Deficiency or Yang Deficiency/Yin Excess. "Excess" refers to Pathogen; "Deficiency" to Righteous Qi. Righteous Qi: Yang governs Exterior, Yin governs Interior. Pathogen: Exterior is Yin, Interior is Yang. If True Yang of Exterior is deficient, Yin Pathogen dominates (Yang Deficiency/Yin Excess). Floating-tight pulse indicates exterior Yin excess. Use Guizhi Tang (Cinnamon Twig Decoction), a pungent-sweet-warm agent, to diaphorese Yin Pathogen and nourish True Yang. If True Yin of Interior is deficient, Yang Pathogen dominates (Yin Deficiency/Yang Excess). Deep-solid pulse indicates interior Yang excess. Use Chengqi Tang, a sour-bitter-cold agent, to purge Yang Pathogen and nourish True Yin. Deviating causes death. This is "exaggerating excess and diminishing deficiency," harming Righteous Qi.
Wang Lü stated: Pathogens have depth. Superficial ones lodge in Exterior, closing Couli, causing Fu Re (pent-up heat), chills, wind-aversion, headache. Pungent-warm dispersion cures. Deep ones lodge in Interior, forming dry feces, tidal fever, mania, delirium, extreme thirst. Salty-cold purging cures. External Cold is Yin Excess/Yang Deficiency; Internal Heat is Yang Excess/Yin Deficiency. A slip in sweating/purging determines life/death.
He added: "Yang excess causes death" means Exterior signs ceased, Interior signs complete; purging allowed, diaphoresis forbidden. "Yin excess causes death" means Interior signs absent, Exterior signs distinct; diaphoresis allowed, purging forbidden.
Dai Yuanli stated: Key to Shanghan is distinguishing Exterior/Interior for sweating/purging. Spontaneous sweating/loose stools occur; iatrogenic sweating/purging occurs. Many variables. Sweating herbs early, purging late is a general principle.
Wang Sanyang stated: Urgent Exterior: resolve Exterior first, then Interior. Urgent Interior: resolve Interior first, then Exterior. Simultaneous treatment implies mixing Shen Dan and Gansui. Daqianghuo Tang may be used if Exterior/Interior are equal and simultaneous treatment is necessary.
For diaphoresis, take decoctions warm. Though prescribed three times daily, if severe/unresolved, shorten intervals to finish three doses in half a day. If drug-pathogen conflict arises, notice symptoms. Severe cases: monitor day and night. If one dose fails, repeat. Some require three doses to sweat. No sweat after three doses indicates fatal disease.
Warm administration aids diffusion. Three daily doses maintain drug potency. Severe cases require urgent dosing to reduce heat, not rigid adherence to formula. Mismatched drugs cause immediate adverse reactions (cold reversal with cool drugs in Yin-excess; heat toxicity with warm drugs in Yang-excess). "Shi" means a full cycle (24 hours). Finish a dose, observe transmission. If signs persist, repeat. Failure to sweat after three doses indicates overwhelming Pathogen; decoction cannot overcome it, leading to severe illness. *Qianjin Fang* states: Rapid pulse without sweat in Heat disease indicates extreme Yang pulse; fatal.
Wang Sanyang stated: Huangqi Jianzhong Tang (Astragalus Middle-Nourishing Decoction) may be used to tonify before sweating. If sweat fails after three diaphoretic doses, death is certain. Monitor pulses carefully; do not treat recklessly.
For Seasonal Qi diseases, days 5-6: thirst for water but unable to drink much. Do not force fluids. Internal heat is low, unable to digest; forcing fluids causes pathology. Days 7-8: extreme thirst. Provide fluids according to syndrome, but keep intake insufficient. If patient claims capacity for one dou, give five sheng. If drinking causes abdominal fullness, urinary difficulty, wheezing, or hiccuping, stop. Sudden profuse sweating indicates spontaneous recovery.
Heat in Upper Jiao causes Xiao Ke (Consumption-Thirst), consuming fluids and drying Upper Jiao. High heat consumes water; low heat cannot. Forcing fluids causes fluid retention and various diseases. By days 7-8, Yang wins, warmth returns, nearing resolution. Extreme thirst persists; provide small amounts to moisten Stomach Qi. Do not force. Abdominal fullness, urinary difficulty, wheezing, or hiccups indicate retained fluids; stop giving fluids. Sudden Yang circulation disperses fluid Qi, causing profuse sweating and resolution.
Ability to drink water in illness indicates impending recovery. Ignorant people force fluids for minor thirst, causing祸 (disaster).
Minor thirst indicates low internal heat. Forcing water causes retention diseases.
Pulse moving-numerous in Jue syndrome, slowing after medication; pulse floating-large decreasing; initial restlessness becoming quiet: these are signs of recovery.