在伤寒、温病的治疗过程中，常常发现一种所谓的战汗现象。伤寒、温病学家认为这是邪气长期逗留在气分不解，且正气又衰，无力抗邪，经过治疗，正气稍复，稍能聚力抗邪外出的一种现象。这种现象如兵家之大决战，故称战汗，此证在汗出以前，常常表现为突然战栗难止，如病情恶化状，继而汗出得解。这种情况，有一次发战而汗出即愈者，有二次，甚至数次发战始愈者。正如清·戴麟郊《瘟疫明辨》所云：“明疫不论初起传变与否，俱以战汗为佳兆，以战则邪正相应，汗则正逐邪出，然有透与不透之分。凡透者，汗必淋漓，汗后身凉，口不渴，舌苔净，二便清，胸腹胁无阻滞结痛，始为全解之战汗，否则余邪未尽而复热，则有再作战汗而解者，有战汗须三四次而后解者，有战汗一次不能再战，待屡下而退者，有不能再作战汗再加沉困而死者，总视其本气之强弱何如耳。”明·吴又可《瘟疫论》列狂汗一证，云：“狂汗者，伏邪中溃，欲作汗解，因其人禀赋亢盛，阳气冲击，不能顿开，忽然坐卧不安，且狂且躁，少时大汗淋漓，狂躁顿止，脉静身凉，霍然而愈。”并在书中列出了战汗时的注意事项。《瘟疫明辨》云：“凡战汗之时，不可服药，补则战止而汗出不透，留邪为患，汗下则太过而成虚脱，应听战汗透彻，再观脉证施治。当战汗时，或多与热汤饮之，助其作汗，战汗之时，脉多停止，勿讶，待战汗之后，脉自见也。大抵战汗之脉，以浮为佳，邪出于表也，虚散微濡应有变，煎独参汤以待之，防其脱也，贫者米饮聊待之，然必察其战后系邪净气欲脱方可用。凡战汗后，神静者吉，昏躁者危，气细者吉，气粗而短者危，戴眼反折者死，形体不仁水浆不下者死。战汗虽为佳兆，亦有吉凶，得战汗固由治得其宜，邪退正复而致，然不可强也。尝见服大发汗药毫不得汗，而饮冷水得汗者，又有用下药得战汗者，凉血活血得战汗者，生津益气得战汗者，种种不一，当知战汗乃阴阳交和，表里通达，自然而然，非可强致也。”
及至临床较久，发现不但伤寒、温病之应汗不汗、正气较虚者有战汗，即如其他诸科病证邪气留恋，正气较虚，用药之后，正气稍复，欲驱邪外出者，亦有出现烦乱不安，全身酸痛加剧，甚或战栗，咽痛，或汗出，或疹出之如战汗状，才得突然而解者。这种情况，有一次即愈者，有数次才愈者，有一次即脱者，种种不一。
例如：荨麻疹、湿疹、牛皮癣之于皮科；胃痛、痹证、郁证、失眠．浮肿、哮喘、内伤发热之于内科；崩漏、带下之于妇科等等，均可突然出现症状加剧，始得全解。
例如：患者高××，男，35岁。4年多来，头痛头晕，肩背酸痛，口苦咽干，胸满心烦，时或全身窜痛，脘腹不适。中、西医久冶不效。察其两脉弦紧稍数，舌苔黄白。综合脉证，诊为少阳枢机不利，湿郁不化，表里同病，虚实互见之证。治用和解泻热，除湿化饮，重镇安神。处方：柴胡10克，半夏10克，黄芩10克，党参10克，生姜3片，甘草10克，大枣5个，桂枝10克，茯苓15克，熟军4克，龙骨15克，牡砺15克。服药2剂，头痛身痛，胸满心烦加剧，且出现咽喉疼痛，鼻干。继服4剂，诸证消失，愈。
耿××，女，35岁。3年多来，胸满心烦，咽喉不利，全身酸痛，头晕头痛，手足憋胀，时或全身窜痛，手足心烦热，失眠纳差。医诊神经官能症。前后以中、西药，以及针灸、按摩、气功等治疗，诸证不但不减，反见日渐加重。细审其证，除上述诸证外，并见昼夜不得入睡，舌苔白，脉沉缓。综合脉证，诊为肝胆气郁，湿郁不化，表里俱在，虚实互见之证。治以疏肝解郁，调理三焦，补虚泻实之剂。处方：柴胡10克，枳壳10克，桔梗10克，陈皮10克，青皮10克，郁金10克，黄芩10克，苏叶10克。服药2剂后，突然发现烦躁狂乱不安，全身疼痛，恶寒发热，欲吐不得吐，欲泻不得泻。急邀某医抢救之。因该医不知其为何病，嘱其转院治疗之。医云：此中药中毒所致，应再找原来的医生追查之。恰在此时，患者突然全身汗出如珠，1小时后，诸证俱失，仅感全身疲乏无力。次日，全身症状全失，再邀余诊。予原方4剂，3年宿恙，霍然得愈。
周×，男，53岁。贫血浮肿近30年。中、西医遍治不效。察其面色皓白，疲乏无力，脉弦而大。血色素6．5克。综其脉证，诊为气阴两虚。治宜补阴益气煎加减。处方：升麻10克，柴胡10克，黄芪15克，人参10克，白术10克，陈皮10克，甘草6克，当归10克，熟地15克，山药10克，山茱萸10克，茯苓10克，泽泻10克，丹皮10克。服药2剂后，浮肿尿少明显加重，且见烦躁难眠，全身酸痛不适。继服1剂，尿量突然增加，浮肿全消，失眠烦躁，全身酸痛顿失，血色素亦增至10克。继服10剂，血色素增至14克，后果愈。
刘××，女，60岁。胃脘疼痛30多年。医诊慢性胃炎。遍用中、西药物治疗无效。查其两脉浮而弦紧，舌苔薄白，头痛身痛，胃脘胀痛，心烦易怒，口苦咽干。予人参败毒散加减治之。处方：党参10克，茯苓10克，炙甘草10克，枳壳；10克，桔梗10克，柴胡10克，前胡10克，羌活10克，独活10克，川芎10克，防风10克，薄荷6克，生姜3片。服药1剂之后，突然头痛身痛加剧，胃脘剧痛，愠愠欲吐，继而全身战栗，汗出身痒，全身大片大片荨麻疹样皮疹。急请某医治之；云：此乃中药中毒所致。宜急送医院求治。然因条件限制不能前往。其后突然诸证俱失，微微汗出。追访数年，宿疾俱愈。
观其脉证，知犯何逆，随证治之
汉·张仲景在说到辨证论冶的方法学时，发表了这样一条警句。云：太阳病三日，已发汗，若吐，若下，若温针，仍不解者，此为坏病，桂枝不中与之也。观其脉证，知犯何逆，随证治之。称在疾病的治疗与发展过程中：①必须随时注意观察；疾病的脉与证的变化。②必须随时注意不同治法引起的不同证候。③必须注意辨证论治时的第一脉，第二证的辨证次序方法。④必须注意随时根据证的不同特点，采用不同的治疗方法。其后历代注家大都根据原文的基本涵义进行比较正确的分析。例如：金·成无己《注解伤寒论》云：太阳病中，曾经发汗吐下温针，虚其正气，病仍不解者，谓之坏病，言为医所坏病也，不可复与桂枝汤。审观脉证，知犯何逆而治之。逆者，随所而救之。清·尤在泾《伤寒贯珠集》云：若与或回，言或汗，或吐，或下，或温针，而病仍不解，即为坏病，不必诸法杂投也。坏病者，言为医药所坏，其病形脉证不复如初，不可以原法治也，故曰桂枝不中与也。须审脉证，知犯何逆，而后随证依法治之。清·柯韵伯《伤寒来苏集》云：《内经》日：未满三日者，可汗而已，汗不解者，须当更汗，吐下温针之法非太阳所宜，而三日中亦非吐下之时也，治之不当，故病仍不解。坏病者，即变症也。若误汗则有遂漏不止，心下悸、脐下悸等症，妄下则有结胸痞鞭、协热下利、胀满清谷等症，火逆则有发黄囿血、亡阳奔豚等症。是桂枝症已罢，故不可更行桂枝汤也。桂枝以五味成方，减一增一，便非桂枝汤，非谓桂枝汤竟不可用。下文皆随症治逆法。近世医家亦有如此之论者。如成都中医学院《伤寒论释义》云：太阳病三日，是太阳病已过数日，曾经发汗，或吐下温经等法治疗，而病仍不解，以为坏病。因太阳病施治不当，往往变为坏病。坏病治法，当观其脉证，并须知其所犯的何种误治，随证施治。”可是近人却有的将若字之或意改为肯定语气，将误治后引起的不同改变一律释为恶化，致使一条活活泼泼的辨证论治方法学的条文变成了死死板板的格式。如南京中医学院伤寒教研组编《伤寒论译释》云：太阳表证，用汗法本当有效，但有时或因病人体质关系，或因给药方法不当，如不能一汗而解的，只要表邪仍在，可再三汗之而解。现在医生见发汗后病仍不解，以为邪已人里，疑在上焦而用吐法，疑在中焦而用下法，或疑汤剂不行，更用温针逼汗，这样诸法杂治，以致变证纷繁，而无名可称，故称为坏病。此时已绝不是原来证候，所以说桂枝不中与也。至于救治方法上，应该根据病人的脉搏症状而辨证论治。一定要了解坏病的成因，是从误汗、误下、或误吐，或误温针的，属于哪一方面，就可以从哪一方面施治。假如属于误汗，而发生汗出不止，或心下悸，或脐下悸等证，当分别以桂枝加附子汤(治汗出不止)，苓桂术甘汤(治汗出过多，心下悸，欲得按)，茯苓桂枝甘草大枣汤(治误汗后，脐下悸、欲作奔豚)，真武汤(治心下悸，头眩身困动，振振欲擗地)、芍药甘草附子汤(汗出恶寒者)等选择使用。假使是属于误下而成结胸痞鞭下利胀满等证，当分别以大小陷胸汤(误下邪陷热与痰水互结)，诸泻心汤(误下后痞气内结)，而下利当分协热，虚寒；胀满又当分虚实以治。假使误吐，则有不能食、心烦等证出现。误用温针，则有发黄、圊血、亡阳、奔豚诸证的产生。当用不同的具体治疗方法，即是条文中所说的随证治之了。病的变化是千头万绪，而方药的功效却具有一定的范畴，不可执一方一药以统治百病。如桂枝汤本是适应范围较广，而且疗效很好的方子，但它的作用是有一定限度的，它的特长是解肌发汗，用之于脉浮缓自汗属于表虚的病人，效果最著。假使脉浮紧发热汗不出的表实证就不可用，这是应用桂枝汤的必备常识。因为脉紧无汗是寒邪束缚肌肤，腠理闭塞的表现，假使误服了桂枝汤，势必促使邪气壅遏，而导致病变，所以仲景谆谆告诫常须识此，勿令误也。湖北中医学院《伤寒沦选读》云：太阳病经过数日，已用过发汗、吐、下、温针，不仅病证不除，而且反使病情恶化，是为坏病。坏病证候复杂，变化多端，难以六经证候指其名，治疗原则应根据脉证变化而定，不可拘守定法，故仲景指出观其脉证，知犯何遂，随证治之。
瘙痒与昼夜之变
痒是皮肤病的一个主要症状，因此治痒就成了治疗皮肤病的重大问题之一。《中医外科学》认为痒的发病原因有四：一者风，二者湿，三者热，四者虫。并指出它的辨证方法是：“风胜：走窜无定，遍身作痒，抓破血溢，随破随收，不致化腐，多为干性。”“湿胜：浸淫四窜，黄水淋漓，最易沿表皮蚀烂，越腐越痒，多为湿性，或有传染。热胜：皮肤瘾疹，掀红灼热作痒，或只发于暴露部位，或遍布全身，甚则糜烂，滋水淋漓，结痂成片，常不传染。虫淫：浸淫漫延，黄水频流，状如虫行皮中，其痒尤烈，最易传染。血虚：皮肤变厚，干燥脱屑，作痒，很少糜烂流水。”至论治法，称风寒证者宜疏风散寒，风热证者宜疏风清热，湿热或暑热证者宜清热利湿，热毒或血热证者宜凉血解毒，气滞血瘀证者宜凉血化瘀，虫积证者宜杀虫驱虫。余临床试用此法虽然常获佳效，然而常因辨证粗疏而难于下药。为此才不得不结合《灵枢·顺气一日分为四时》语而深究之，疗效果然有所提高。例如：患者赵××，男，20岁。皮肤各处皱折部位，如指侧、指缝、腕关节屈侧，肘关节屈侧，腋窝前缘、少腹、外阴、臀沟、大腿内侧等处，出现针尖大小的丘疹及水疱4个多月。医诊疥疮。先予硫磺洗剂等中、西药外用，久治无效。审之：除上述诸证以外，并见全身遍布抓痕，结痂、黑色斑点，手指缝间有少许脓疱，夜间奇痒难忍，白昼大减，舌苔白，脉弦细。综合脉证，思之：夜间属阴，白天属阳，其证昼轻夜重者，血虚燥热也。治宜养血活血，清热解毒。处方：丹参15克，当归10克，川芎10克，生地10克，白芍10克，银花10克，连翘10克，薄荷3克。服药2剂后，痒疹大减。继服6剂，诸证俱失。某医云：疥疮者，虫淫之疾也，何用硫黄治虫而不效?而改用不治虫之剂反效呢?答曰：经云：正气存内，邪不可干。此疾之虫淫为病者，因正气之不足耳。正气不足者何?血虚燥热也。故治以养血活血而愈。
在伤寒和温病的治疗过程中，常会发现一种所谓的“战汗”现象。伤寒和温病学派认为，这是邪气长期滞留于气分而未能解除，且正气虚弱，无力抵抗邪气；经过治疗后，正气稍作恢复，能够聚集力量将邪气驱逐外出的一种反应。这种现象如同军事上的大决战，因此称为“战汗”。此证在出汗之前，常表现为突然剧烈寒战不止，看似病情恶化，随后通过出汗而得以缓解。这种情况，有的发作一次寒战后出汗即痊愈，有的需要两次甚至多次发作寒战才能痊愈。正如清代戴麟郊在《瘟疫明辨》中所说：“无论瘟疫初起还是传变之后，都以出现战汗为吉兆，因为战时是邪正相争，汗出则是正气驱逐邪气外出。然而有透发透彻与不透彻的区别。凡是透发透彻的，汗水必定淋漓，汗后身体凉爽，口不渴，舌苔干净，大小便清利，胸腹胁肋没有阻滞结痛，这才是完全解除的战汗；否则余邪未尽而再次发热，则会有再次发生战汗而解的情况，有的需要战汗三四次才能解除，有的战汗一次后不能再战，需等待多次攻下才能退热，有的不能再发生战汗且加重困顿而死亡的，总归取决于患者本气的强弱。”明代吴又可的《瘟疫论》中列出了“狂汗”一证，说道：“狂汗，是指伏匿之邪在中焦溃散，欲作汗解，但因患者禀赋亢盛，阳气冲击，不能立即开通，忽然坐卧不安，既狂躁又烦躁，片刻后大汗淋漓，狂躁顿时停止，脉象平静身体凉爽，霍然痊愈。”并在书中列出了战汗时的注意事项。《瘟疫明辨》中说：“凡是在战汗的时候，不可服药，补益药会使战止但汗出不透，留邪为患；攻下药或发汗药则太过而导致虚脱，应听任战汗透彻，再观察脉证进行治疗。当战汗时，可以多给喝热汤，帮助其作汗。战汗之时，脉搏多会暂时停止，不要惊讶，待战汗之后，脉搏自然会出现。大致战汗的脉象，以浮脉为佳，表示邪气出于体表；若脉象虚散微濡应有变化，可煎独参汤以待之，防止其虚脱；贫穷者可用米饮暂代，但必须察看在战汗后确实是邪气已净、气欲脱时才可使用。凡战汗后，神志安静者为吉，昏乱烦躁者为危，呼吸细微者为吉，呼吸粗短者为危，瞪眼反折者为死，形体麻木不知疼痛、水浆不进者为死。战汗虽为吉兆，但也有吉凶之分，得到战汗固然由于治疗得当，邪退正复所致，但不能强求。曾见服用大发汗药却不得汗，而饮用冷水得汗的；又有用攻下药得战汗的；凉血活血得战汗的；生津益气得战汗的，种种情况不一。应当知道战汗乃是阴阳交和、表里通达，自然而然的结果，并非可以强求得到的。”
到了临床较久以后，发现不仅伤寒、温病中应当出汗而未出汗、正气较虚的患者会出现战汗，即使是其他各科病证中邪气留恋、正气较虚，用药之后正气稍复，欲驱邪外出的情况，也会出现烦躁不安、全身酸痛加剧，甚至寒战、咽痛，或者出汗、出疹等类似战汗的表现，才突然得以解除。这种情况，有一次即愈的，有数次才愈的，有一次即导致虚脱的，种种情况不一。
例如：荨麻疹、湿疹、牛皮癣属于皮肤科疾病；胃痛、痹证、郁证、失眠、浮肿、哮喘、内伤发热属于内科疾病；崩漏、带下属于妇科疾病等等，均可突然出现症状加剧，然后才得以完全解除。
例如：患者高某某，男，35岁。4年多来，头痛头晕，肩背酸痛，口苦咽干，胸满心烦，时而全身窜痛，脘腹不适。中医、西医久治不效。诊察其两脉弦紧稍数，舌苔黄白。综合脉证，诊断为少阳枢机不利，湿郁不化，表里同病，虚实互见的证候。治疗采用和解泻热，除湿化饮，重镇安神的方法。处方：柴胡10克，半夏10克，黄芩10克，党参10克，生姜3片，甘草10克，大枣5个，桂枝10克，茯苓15克，熟大黄4克，龙骨15克，牡蛎15克。服药2剂后，头痛身痛、胸满心烦加剧，且出现咽喉疼痛、鼻干。继服4剂，诸证消失，痊愈。
耿某某，女，35岁。3年多来，胸满心烦，咽喉不利，全身酸痛，头晕头痛，手足憋胀，时而全身窜痛，手足心烦热，失眠纳差。医生诊断为神经官能症。前后以中西药，以及针灸、按摩、气功等治疗，诸证不但没减，反而日渐加重。仔细审察其证，除上述诸证外，并见昼夜不得入睡，舌苔白，脉沉缓。综合脉证，诊断为肝胆气郁，湿郁不化，表里俱在，虚实互见的证候。治疗以疏肝解郁，调理三焦，补虚泻实的方剂。处方：柴胡10克，枳壳10克，桔梗10克，陈皮10克，青皮10克，郁金10克，黄芩10克，苏叶10克。服药2剂后，突然发现烦躁狂乱不安，全身疼痛，恶寒发热，欲吐不得吐，欲泻不得泻。急忙邀请某医抢救。因该医不知为何病，嘱其转院治疗。医生说：这是中药中毒所致，应再找原来的医生追查。恰在此时，患者突然全身汗出如珠，1小时后，诸证俱失，仅感全身疲乏无力。次日，全身症状全失，再邀请我诊治。给予原方4剂，3年宿疾，霍然痊愈。
周某，男，53岁。贫血浮肿近30年。中西医药遍治不效。诊察其面色皓白，疲乏无力，脉弦而大。血色素6.5克。综合其脉证，诊断为气阴两虚。治疗宜用补阴益气煎加减。处方：升麻10克，柴胡10克，黄芪15克，人参10克，白术10克，陈皮10克，甘草6克，当归10克，熟地黄15克，山药10克，山茱萸10克，茯苓10克，泽泻10克，丹皮10克。服药2剂后，浮肿尿少明显加重，且见烦躁难眠，全身酸痛不适。继服1剂，尿量突然增加，浮肿全消，失眠烦躁、全身酸痛顿失，血色素亦增至10克。继服10剂，血色素增至14克，后果痊愈。
刘某某，女，60岁。胃脘疼痛30多年。医生诊断为慢性胃炎。遍用中西药物治疗无效。查其两脉浮而弦紧，舌苔薄白，头痛身痛，胃脘胀痛，心烦易怒，口苦咽干。予人参败毒散加减治疗。处方：党参10克，茯苓10克，炙甘草10克，枳壳10克，桔梗10克，柴胡10克，前胡10克，羌活10克，独活10克，川芎10克，防风10克，薄荷6克，生姜3片。服药1剂之后，突然头痛身痛加剧，胃脘剧痛，愠愠欲吐，继而全身战栗，汗出身痒，全身大片大片荨麻疹样皮疹。急忙请某医治之，说：这是中药中毒所致。宜急送医院求治。但因条件限制不能前往。其后突然诸证俱失，微微汗出。追访数年，宿疾俱愈。
观察患者的脉象和证候，了解犯了什么错误（误治），根据证候进行治疗。
汉代张仲景在论述辨证论治的方法学时，发表了这样一条警句。他说：太阳病三日，已经发汗，如果用吐法、下法、温针，仍然不解的，这叫做坏病，桂枝汤不再适用了。观察其脉象和证候，了解犯了什么逆乱（误治），随证治之。这是在疾病的治疗与发展过程中：①必须随时注意观察疾病的脉与证的变化。②必须随时注意不同治法引起的不同证候。③必须注意辨证论治时的第一脉、第二证的辨证次序方法。④必须注意随时根据证的不同特点，采用不同的治疗方法。其后历代注家大都根据原文的基本含义进行比较正确的分析。例如：金代成无己在《注解伤寒论》中说：太阳病中，曾经发汗、吐、下、温针，使正气虚弱，病仍不解的，叫做坏病，意思是被医生治坏了的病，不可再给予桂枝汤。审观脉证，了解犯了什么逆乱而治之。逆乱者，随着所犯的错误而救治之。清代尤在泾在《伤寒贯珠集》中说：如果用了汗、吐、下、温针等方法，而病仍不解，即为坏病，不必诸法杂投也。坏病者，言为医药所坏，其病形脉证不复如初，不可以原法治也，故曰桂枝不中与也。须审脉证，知犯何逆，而后随证依法治之。清代柯韵伯在《伤寒来苏集》中说：《内经》曰：未满三日者，可汗而已，汗不解者，须当更汗，吐下温针之法非太阳所宜，而三日中亦非吐下之时也，治之不当，故病仍不解。坏病者，即变症也。若误汗则有遂漏不止，心下悸、脐下悸等症，妄下则有结胸痞鞭、协热下利、胀满清谷等症，火逆则有发黄囿血、亡阳奔豚等症。是桂枝症已罢，故不可更行桂枝汤也。桂枝以五味成方，减一增一，便非桂枝汤，非谓桂枝汤竟不可用。下文皆随症治逆法。近世医家亦有如此之论者。如成都中医学院《伤寒论释义》云：太阳病三日，是太阳病已过数日，曾经发汗，或吐下温经等法治疗，而病仍不解，以为坏病。因太阳病施治不当，往往变为坏病。坏病治法，当观其脉证，并须知其所犯的何种误治，随证施治。”可是近人却有的将“若”字之“或”意改为肯定语气，将误治后引起的不同改变一律释为恶化，致使一条活活泼泼的辨证论治方法学的条文变成了死死板板的格式。如南京中医学院伤寒教研组编《伤寒论译释》云：太阳表证，用汗法本当有效，但有时或因病人体质关系，或因给药方法不当，如不能一汗而解的，只要表邪仍在，可再三汗之而解。现在医生见发汗后病仍不解，以为邪已入里，疑在上焦而用吐法，疑在中焦而用下法，或疑汤剂不行，更用温针逼汗，这样诸法杂治，以致变证纷繁，而无名可称，故称为坏病。此时已绝不是原来证候，所以说桂枝不中与也。至于救治方法上，应该根据病人的脉搏症状而辨证论治。一定要了解坏病的成因，是从误汗、误下、或误吐，或误温针的，属于哪一方面，就可以从哪一方面施治。假如属于误汗，而发生汗出不止，或心下悸，或脐下悸等证，当分别以桂枝加附子汤(治汗出不止)，苓桂术甘汤(治汗出过多，心下悸，欲得按)，茯苓桂枝甘草大枣汤(治误汗后，脐下悸、欲作奔豚)，真武汤(治心下悸，头眩身困动，振振欲擗地)、芍药甘草附子汤(汗出恶寒者)等选择使用。假使是属于误下而成结胸痞鞭下利胀满等证，当分别以大小陷胸汤(误下邪陷热与痰水互结)，诸泻心汤(误下后痞气内结)，而下利当分协热，虚寒；胀满又当分虚实以治。假使误吐，则有不能食、心烦等证出现。误用温针，则有发黄、圊血、亡阳、奔豚诸证的产生。当用不同的具体治疗方法，即是条文中所说的随证治之了。病的变化是千头万绪，而方药的功效却具有一定的范畴，不可执一方一药以统治百病。如桂枝汤本是适应范围较广，而且疗效很好的方子，但它的作用是有一定限度的，它的特长是解肌发汗，用之于脉浮缓自汗属于表虚的病人，效果最著。假使脉浮紧发热汗不出的表实证就不可用，这是应用桂枝汤的必备常识。因为脉紧无汗是寒邪束缚肌肤，腠理闭塞的表现，假使误服了桂枝汤，势必促使邪气壅遏，而导致病变，所以仲景谆谆告诫常须识此，勿令误也。湖北中医学院《伤寒沦选读》云：太阳病经过数日，已用过发汗、吐、下、温针，不仅病证不除，而且反使病情恶化，是为坏病。坏病证候复杂，变化多端，难以六经证候指其名，治疗原则应根据脉证变化而定，不可拘守定法，故仲景指出观其脉证，知犯何遂，随证治之。
瘙痒与昼夜之变
瘙痒是皮肤病的一个主要症状，因此治痒就成了治疗皮肤病的重大问题之一。《中医外科学》认为痒的发病原因有四：一者风，二者湿，三者热，四者虫。并指出它的辨证方法是：“风胜：走窜无定，遍身作痒，抓破血溢，随破随收，不致化腐，多为干性。”“湿胜：浸淫四窜，黄水淋漓，最易沿表皮蚀烂，越腐越痒，多为湿性，或有传染。热胜：皮肤瘾疹，掀红灼热作痒，或只发于暴露部位，或遍布全身，甚则糜烂，滋水淋漓，结痂成片，常不传染。虫淫：浸淫漫延，黄水频流，状如虫行皮中，其痒尤烈，最易传染。血虚：皮肤变厚，干燥脱屑，作痒，很少糜烂流水。”至论治法，称风寒证者宜疏风散寒，风热证者宜疏风清热，湿热或暑热证者宜清热利湿，热毒或血热证者宜凉血解毒，气滞血瘀证者宜凉血化瘀，虫积证者宜杀虫驱虫。余临床试用此法虽然常获佳效，然而常因辨证粗疏而难于下药。为此才不得不结合《灵枢·顺气一日分为四时》语而深究之，疗效果然有所提高。例如：患者赵某某，男，20岁。皮肤各处皱折部位，如指侧、指缝、腕关节屈侧，肘关节屈侧，腋窝前缘、少腹、外阴、臀沟、大腿内侧等处，出现针尖大小的丘疹及水疱4个多月。医生诊断为疥疮。先予硫磺洗剂等中西药外用，久治无效。审之：除上述诸证以外，并见全身遍布抓痕、结痂、黑色斑点，手指缝间有少许脓疱，夜间奇痒难忍，白昼大减，舌苔白，脉弦细。综合脉证，思之：夜间属阴，白天属阳，其证昼轻夜重者，血虚燥热也。治宜养血活血，清热解毒。处方：丹参15克，当归10克，川芎10克，生地10克，白芍10克，银花10克，连翘10克，薄荷3克。服药2剂后，痒疹大减。继服6剂，诸证俱失。某医云：疥疮者，虫淫之疾也，何用硫黄治虫而不效?而改用不治虫之剂反效呢?答曰：经云：正气存内，邪不可干。此疾之虫淫为病者，因正气之不足耳。正气不足者何?血虚燥热也。故治以养血活血而愈。
During the treatment of Shanghan (Cold Damage diseases) and Wenbing (Warm Disease diseases), a phenomenon known as "Zhanhan" (Battle Sweat) is often observed. Scholars of Shanghan and Wenbing believe this occurs when pathogenic factors remain stagnant in the Qi level for a prolonged period without resolving, while the Zhengqi (Upright Qi/Righteous Qi) is deficient and unable to resist the pathogens. After treatment, if the Zhengqi recovers slightly and gathers strength to expel the pathogens outward, this reaction manifests. This phenomenon is likened to a decisive battle in military strategy, hence the term "Battle Sweat." Before sweating occurs, this condition often presents with sudden, uncontrollable shivering, resembling a deterioration of the illness, followed by resolution through sweating. In some cases, recovery follows a single episode of shivering and sweating; in others, it requires two or even multiple episodes. As stated by Dai Linjiao in *Yiwen Mingbian* (Clarification of Plague Diseases) during the Qing Dynasty: "Regardless of whether plague has just started or has transmitted, the appearance of Battle Sweat is considered an auspicious sign. Shivering indicates the struggle between pathogenic factors and Zhengqi, while sweating indicates Zhengqi driving out the pathogens. However, there is a distinction between thorough penetration and incomplete penetration. In cases of thorough penetration, sweat will be profuse; after sweating, the body becomes cool, thirst ceases, the tongue coating clears, urination and defecation become normal, and there is no obstruction or pain in the chest, abdomen, or hypochondrium. Only then is it considered a complete resolution via Battle Sweat. Otherwise, if residual pathogens remain and fever recurs, there may be subsequent episodes of Battle Sweat leading to resolution. Some require three or four episodes. Some cannot undergo another Battle Sweat after one episode and require repeated purgation to reduce the pathogen. Some cannot undergo Battle Sweat again, become increasingly debilitated, and die. Ultimately, it depends on the strength of the patient's Benqi (Root Qi)." Wu Keyou in the Ming Dynasty's *Wenbing Lun* (Treatise on Warm Epidemics) described a condition called "Kuanghan" (Madness Sweat): "Kuanghan refers to latent pathogens breaking down in the middle jiao, attempting to resolve through sweating. Due to the patient's robust constitution and surging Yang qi, which cannot open immediately, the patient suddenly becomes restless, sitting and lying down uneasily, exhibiting madness and agitation. After a short time, profuse sweating occurs, the madness and agitation cease instantly, the pulse becomes calm, the body cools, and the patient recovers abruptly." The book also lists precautions during Battle Sweat. *Yiwen Mingbian* states: "During Battle Sweat, medication should not be administered. Tonifying herbs will stop the shivering but prevent thorough sweating, leaving pathogens behind as a hazard. Purgatives or diaphoretics are too harsh and may lead to deficiency collapse. One should allow the Battle Sweat to penetrate thoroughly, then observe the pulse and symptoms to guide treatment. During Battle Sweat, providing hot water can help induce sweating. The pulse often stops during shivering; do not be alarmed. The pulse will reappear after the sweat. Generally, a floating pulse during Battle Sweat is auspicious, indicating pathogens exiting the exterior. If the pulse is deficient, scattered, fine, or soggy, changes are expected; decocting Ginseng Decoction alone (Dushen Tang) can be used to prevent collapse. For those who are poor, rice water can suffice, but it must be confirmed that pathogens are cleared and Qi is about to collapse before use. After Battle Sweat, a calm spirit is auspicious, while confusion and agitation are critical. Fine breathing is auspicious, while coarse and short breathing is critical. Eyes fixed upward and opisthotonos indicate death. Numbness of the body and inability to take food or fluids indicate death. Although Battle Sweat is generally an auspicious sign, it carries both good and bad omens. Achieving Battle Sweat relies on appropriate treatment, where pathogens retreat and Zhengqi recovers, but it cannot be forced. I have seen cases where strong diaphoretics failed to produce sweat, but cold water did; cases where purgatives induced Battle Sweat; cases where cooling blood and invigorating blood induced it; and cases where generating fluids and benefiting Qi induced it. These vary greatly. One must understand that Battle Sweat is the natural result of Yin-Yang harmony and communication between the interior and exterior, not something that can be forced."
After extended clinical practice, it was found that not only patients with Shanghan or Wenbing who needed sweating but did not, and had deficient Zhengqi, experience Battle Sweat, but also patients in other specialties with lingering pathogens and deficient Zhengqi. After medication restores Zhengqi slightly, aiming to expel pathogens, they may exhibit restlessness, intensified generalized muscle soreness, even shivering, sore throat, or sweating/rash resembling Battle Sweat, before sudden resolution. Cases vary: some recover after one episode, some after several, and some suffer collapse after one episode.
For example: Urticaria, eczema, and psoriasis in dermatology; stomach pain, Bi syndrome (painful obstruction), Yu syndrome (depressive disorder), insomnia, edema, asthma, and internal injury fever in internal medicine; and Benglou (metrorrhagia and metrostaxis), Daixia (leukorrhea) in gynecology, can all suddenly present with exacerbated symptoms before full resolution.
Case 1: Patient Gao XX, male, 35 years old. For over 4 years, he suffered from headache, dizziness, shoulder and back soreness, bitter taste in the mouth, dry throat, chest fullness, irritability, occasional wandering pain throughout the body, and epigastric discomfort. Both TCM and Western medicine treatments were ineffective. Examination revealed wiry, tight, and slightly rapid pulses bilaterally, with a yellowish-white tongue coating. Synthesizing the pulse and symptoms, the diagnosis was dysfunction of the Shaoyang pivot, stagnation of dampness failing to transform, simultaneous involvement of the exterior and interior, and mixed deficiency and excess. Treatment employed harmonization and heat-clearing, dampness-resolving and fluid-transforming, and heavy sedation to calm the spirit. Prescription: Chai Hu (Bupleuri Radix) 10g, Ban Xia (Pinelliae Rhizoma) 10g, Huang Qin (Scutellariae Radix) 10g, Dang Shen (Codonopsis Radix) 10g, Sheng Jiang (Zingiberis Rhizoma Recens) 3 slices, Gan Cao (Glycyrrhizae Radix et Rhizoma) 10g, Da Zao (Jujubae Fructus) 5 pieces, Gui Zhi (Cinnamomi Ramulus) 10g, Fu Ling (Poria) 15g, Shu Jun (Rhei Radix et Rhizoma processed) 4g, Long Gu (Fossilia Ossis Mastodi et Scapulae) 15g, Mu Li (Ostreae Concha) 15g. After 2 doses, headache, body pain, chest fullness, and irritability worsened, accompanied by sore throat and dry nose. After continuing for 4 more doses, all symptoms disappeared, and the patient recovered.
Case 2: Patient Geng XX, female, 35 years old. For over 3 years, she experienced chest fullness, irritability, throat discomfort, generalized soreness, dizziness, headache, distension of hands and feet, occasional wandering pain, heat sensation in palms and soles, insomnia, and poor appetite. Diagnosed with neurosis. Previous treatments with Chinese and Western medicines, acupuncture, massage, and Qigong failed to alleviate symptoms, which instead worsened daily. Detailed examination revealed, in addition to the above, inability to sleep day or night, white tongue coating, and deep, slow pulse. Synthesizing pulse and symptoms, the diagnosis was Liver-Gallbladder Qi stagnation, dampness stagnation failing to transform, simultaneous involvement of exterior and interior, and mixed deficiency and excess. Treatment employed soothing the Liver and resolving stagnation, regulating the Sanjiao (Triple Burner), and tonifying deficiency while purging excess. Prescription: Chai Hu (Bupleuri Radix) 10g, Zhi Ke (Aurantii Fructus) 10g, Jie Geng (Platycodonis Radix) 10g, Chen Pi (Citri Reticulatae Pericarpium) 10g, Qing Pi (Citri Reticulatae Pericarpium Viride) 10g, Yu Jin (Curcumae Radix) 10g, Huang Qin (Scutellariae Radix) 10g, Su Ye (Perillae Folium) 10g. After 2 doses, the patient suddenly became extremely restless and agitated, with generalized pain, aversion to cold and fever, urge to vomit but unable to, and urge to defecate but unable to. Emergency medical assistance was sought. The doctor, unfamiliar with the condition, advised transfer to another hospital, suspecting herb poisoning. At that moment, the patient suddenly sweated profusely like pearls. One hour later, all symptoms vanished, leaving only general fatigue. The next day, systemic symptoms disappeared completely. Upon re-examination, the original prescription was given for 4 doses, curing the 3-year chronic ailment abruptly.
Case 3: Patient Zhou X, male, 53 years old. Suffering from anemia and edema for nearly 30 years, unresponsive to various TCM and Western treatments. Examination showed pale complexion, fatigue, wiry and large pulses. Hemoglobin was 6.5 g/dL. Synthesizing pulse and symptoms, the diagnosis was dual deficiency of Qi and Yin. Treatment utilized a modified Bu Yin Yi Qi Jian (Tonify Yin and Benefit Qi Decoction). Prescription: Sheng Ma (Cimicifugae Rhizoma) 10g, Chai Hu (Bupleuri Radix) 10g, Huang Qi (Astragali Radix) 15g, Ren Shen (Ginseng Radix) 10g, Bai Zhu (Atractylodis Macrocephalae Rhizoma) 10g, Chen Pi (Citri Reticulatae Pericarpium) 10g, Gan Cao (Glycyrrhizae Radix et Rhizoma) 6g, Dang Gui (Angelicae Sinensis Radix) 10g, Shu Di Huang (Rehmanniae Radix Preparata) 15g, Shan Yao (Dioscoreae Rhizoma) 10g, Shan Zhu Yu (Corni Fructus) 10g, Fu Ling (Poria) 10g, Ze Xie (Alismatis Rhizoma) 10g, Dan Pi (Moutan Cortex) 10g. After 2 doses, edema and oliguria significantly worsened, accompanied by irritability, insomnia, and generalized soreness. After 1 more dose, urine output suddenly increased, edema resolved completely, insomnia, irritability, and soreness vanished, and hemoglobin rose to 10 g/dL. After 10 more doses, hemoglobin reached 14 g/dL, and the patient ultimately recovered.
Case 4: Patient Liu XX, female, 60 years old. Suffering from epigastric pain for over 30 years, diagnosed with chronic gastritis. Unresponsive to various TCM and Western medications. Examination revealed floating, wiry, and tight pulses bilaterally, thin white tongue coating, headache, body pain, distending epigastric pain, irritability, bitter taste, and dry throat. Treatment employed a modified Ren Shen Bai Du San (Ginseng Powder to Overcome Pathogenic Factors). Prescription: Dang Shen (Codonopsis Radix) 10g, Fu Ling (Poria) 10g, Zhi Gan Cao (Prepared Glycyrrhizae Radix et Rhizoma) 10g, Zhi Ke (Aurantii Fructus) 10g, Jie Geng (Platycodonis Radix) 10g, Chai Hu (Bupleuri Radix) 10g, Qian Hu (Peucedani Radix) 10g, Qiang Huo (Notopterygii Rhizoma et Radix) 10g, Du Huo (Angelicae Pubescentis Radix) 10g, Chuan Xiong (Chuanxiong Rhizoma) 10g, Fang Feng (Saposhnikoviae Radix) 10g, Bo He (Menthae Haplocalycis Herba) 6g, Sheng Jiang (Zingiberis Rhizoma Recens) 3 slices. After 1 dose, headache and body pain intensified, epigastric pain became severe, nausea arose, followed by generalized shivering, sweating with itching, and widespread urticaria-like rashes. Emergency medical consultation suggested herb poisoning and hospital transfer, which was impossible due to conditions. Subsequently, all symptoms suddenly vanished, with slight sweating. Follow-up over several years confirmed the cure of the chronic disease.
Observe the pulse and symptoms, determine the nature of the deviation (error in treatment), and treat according to the syndrome.
Han Dynasty physician Zhang Zhongjing, discussing the methodology of syndrome differentiation and treatment, issued this warning: "In Taiyang disease, after three days, if sweating, vomiting, purgation, or warm needle therapy have been applied and the disease remains unresolved, this is termed 'Huai Bing' (Damaged Disease). Guizhi Tang (Cinnamon Twig Decoction) is no longer applicable. Observe the pulse and symptoms, identify the nature of the deviation, and treat accordingly." This implies that during the treatment and development of disease: ① One must constantly monitor changes in the pulse and symptoms. ② One must note the different syndromes caused by different therapeutic methods. ③ One must pay attention to the sequence of differentiating the first pulse and second symptom. ④ One must adopt different treatment methods based on the specific characteristics of the syndrome. Later commentators largely analyzed this correctly based on the original meaning. For instance, Cheng Wuji in the Jin Dynasty's *Zhujie Shanghan Lun* (Annotated Treatise on Cold Damage) stated: "In Taiyang disease, if sweating, vomiting, purgation, or warm needles have weakened the Zhengqi and the disease persists, it is called 'Damaged Disease,' meaning damaged by medical intervention. Guizhi Tang should not be used. Examine the pulse and symptoms to identify the deviation and treat accordingly. 'Deviation' means rescuing according to the error." You Zaijing in the Qing Dynasty's *Shanghan Guan Zhu Ji* (Pearl String Collection on Cold Damage) said: "If sweating, vomiting, purgation, or warm needles fail to resolve the disease, it becomes 'Damaged Disease.' It is not necessary to mix all methods. 'Damaged Disease' means the disease form, pulse, and symptoms are no longer as they were initially, so the original method cannot be used. Hence, Guizhi Tang is not applicable. One must examine the pulse and symptoms, identify the deviation, and treat according to the syndrome." Ke Yunbo in the Qing Dynasty's *Shanghan Lai Su Ji* (Spring Dew Collection on Cold Damage) cited the *Neijing*: "If less than three days, sweating suffices. If sweating fails, further sweating is needed. Vomiting, purgation, and warm needles are not suitable for Taiyang, nor is purgation within three days. Improper treatment leads to persistent disease. 'Damaged Disease' refers to changed symptoms. Mis-sweating may cause continuous leakage, palpitations in the epigastrium or below the umbilicus. Mis-purgation may cause Chest Binding, abdominal fullness, diarrhea with heat, or bloating with undigested food. Fire reversal may cause jaundice, blood stasis, Yang collapse, or running piglet syndrome. Thus, the Guizhi syndrome has ceased, and Guizhi Tang cannot be used. Guizhi Tang consists of five ingredients; changing one makes it a different formula, not that Guizhi Tang is absolutely unusable. The following text describes treating deviations according to symptoms." Modern scholars like Chengdu University of TCM in *Shanghan Lun Shi Yi* (Explanation of Shanghan Lun) agree: "Taiyang disease lasting several days, treated with sweating, vomiting, purgation, or warm needles, yet unresolved, is 'Damaged Disease.' Improper treatment of Taiyang often leads to this. Treatment requires observing pulse and symptoms, identifying the specific error, and treating accordingly." However, some modern interpreters changed the conditional 'ruo' (if/possibly) to a definitive tone, interpreting all post-error changes as deterioration, turning a dynamic methodology into a rigid format. Nanjing University of TCM's *Shanghan Lun Yi Shi* (Translation and Explanation of Shanghan Lun) argues: "For Taiyang exterior syndrome, sweating should work. But due to constitution or improper administration, if one sweat doesn't resolve it, repeat sweating is okay if exterior pathogens remain. Doctors seeing unresolved disease after sweating assume pathogens entered the interior. Suspecting upper jiao, they use vomiting; mid jiao, purgation; or if decoctions fail, use warm needles. Mixing these methods creates complex, unnamed 'Damaged Disease.' The original syndrome is gone, hence Guizhi Tang is not applicable. Rescue requires syndrome differentiation based on pulse and symptoms. Identify if the damage came from mis-sweating, purgation, vomiting, or warm needles, and treat accordingly. If mis-sweating caused continuous sweating or palpitations, use Guizhi Jia Fuzi Tang, Ling Gui Zhu Gan Tang, etc. If mis-purgation caused Chest Binding or diarrhea, use Da/Xiao Xianxiong Tang or Xiexin Tangs. If mis-vomiting caused inability to eat or irritability, or mis-warm needles caused jaundice or Yang collapse, use specific treatments. This is 'treating according to the syndrome.'" Disease changes are myriad, while formulas have limited scopes. One cannot use one formula for all diseases. Guizhi Tang is effective for exterior deficiency with floating, slow pulse and spontaneous sweating. It is contraindicated for exterior excess with floating, tight pulse, fever, and no sweating, as this indicates cold binding the skin and closed pores. Misusing Guizhi Tang would trap pathogens. Thus, Zhang Zhongjing warned to recognize this to avoid errors. Hubei University of TCM's *Shanghan Lun Xuandu* states: "After several days of Taiyang disease, if sweating, vomiting, purgation, and warm needles have been used and the disease worsens, it is 'Damaged Disease.' Symptoms are complex and variable, hard to name by Six Channels. Treatment principles must follow pulse and symptom changes, not rigid methods. Hence, Zhang Zhongjing advises observing pulse and symptoms to identify deviations and treat accordingly."
Itch and Daily Variation
Itch is a primary symptom of skin diseases, making its treatment crucial. *TCM Dermatology* identifies four causes of itch: Wind, Dampness, Heat, and Parasites. Differentiation methods include: "Wind predominance: Wandering and不定, generalized itch, scratching causes bleeding, heals quickly without rotting, usually dry." "Dampness predominance: Spreading exudation, oozing yellow fluid, easily erodes skin, worse with decay, usually wet, possibly contagious." "Heat predominance: Urticaria, red and burning itch, localized or generalized, may ulcerate with oozing and crusting, often non-contagious." "Parasite infestation: Spreading exudation, frequent yellow flow, feeling like insects crawling under skin, intense itch, highly contagious." "Blood deficiency: Thickened, dry, scaly skin, itch, rarely ulcerates or oozes." Regarding treatment: Wind-Cold requires dispersing Wind and scattering Cold; Wind-Heat requires dispersing Wind and clearing Heat; Damp-Heat or Summer-Heat requires clearing Heat and draining Dampness; Heat-Toxin or Blood-Heat requires cooling Blood and detoxifying; Qi Stagnation and Blood Stasis requires cooling Blood and resolving Stasis; Parasites require killing and expelling parasites. Although this method often yields good results, rough differentiation sometimes makes precise prescribing difficult. Therefore, combining insights from *Lingshu: Shun Qi Yi Ri Fen Wei Si Shi* (Spiritual Pivot: Regulating Qi Divided into Four Times of a Day), therapeutic efficacy improved.
Case 5: Patient Zhao XX, male, 20 years old. For over 4 months, papules and vesicles the size of pinheads appeared in skin folds such as finger sides, interdigital spaces, flexor aspects of wrists and elbows, anterior axillary folds, lower abdomen, external genitalia, gluteal cleft, and inner thighs. Diagnosed with Scabies. Topical sulfur lotion and other TCM/Western medicines failed. Examination revealed widespread scratch marks, crusts, black spots, and small pustules between fingers. Intense itch at night, significantly reduced during the day. Tongue coating white, pulse wiry and fine. Synthesizing pulse and symptoms: Night belongs to Yin, Day to Yang. Symptoms lighter by day and heavier by night indicate Blood deficiency with Dryness-Heat. Treatment required nourishing and invigorating Blood, clearing Heat, and detoxifying. Prescription: Dan Shen (Salviae Miltiorrhizae Radix et Rhizoma) 15g, Dang Gui (Angelicae Sinensis Radix) 10g, Chuan Xiong (Chuanxiong Rhizoma) 10g, Sheng Di Huang (Rehmanniae Radix) 10g, Bai Shao (Paeoniae Radix Alba) 10g, Yin Hua (Lonicerae Japonicae Flos) 10g, Lian Qiao (Forsythiae Fructus) 10g, Bo He (Menthae Haplocalycis Herba) 3g. After 2 doses, itch and rash significantly reduced. After 6 more doses, all symptoms vanished. A colleague asked: "Scabies is caused by parasites; why didn't sulfur work, but a non-parasitic formula succeeded?" Answer: The Classics state: "When Zhengqi is stored within, pathogens cannot interfere." The parasite infestation here resulted from deficient Zhengqi. What is deficient Zhengqi? Blood deficiency with Dryness-Heat. Thus, nourishing and invigorating Blood cured the disease.