族有乳媪。患伤寒七八日发斑。肌体如火。脉洪数而牢。心中烦满不快。俄而变赤黑斑。其
家甚惊惶。予曰。此温毒也。温毒为病最重。而年齿为迈。是诚可忧也。仲景云伤寒脉洪数。阴
脉实大。更遇湿热。变成温毒。温毒最重也。故斑疹生。心下不快。痞闷。遂以升麻玄参汤与之。
日夜四五服。斑退而愈。
论曰。华佗云伤寒五日在腹。六日在胃。入胃则可下也。若热毒未入于
胃。而先下之者。其热乘虚入胃。则胃烂。然热入胃。要须复下之。不得留在胃中也。胃若实。
为致此病。三死一生。其热微者赤斑出。剧者黑斑出。赤斑出者五死一生。黑斑出者十死一生。
但看人有强弱耳。病者至日。不以时下之。热不得泄。亦胃烂斑出。盖此是恶候。若下之早。则
热乘虚入胃。或下迟。则热入不得泄。须是乘机不可失时。庶几轻可也。
甲辰。盐商舣舟江次。得伤寒。胸膈痞。连脐下旁不可忍。饮食不进。予诊之曰。此非结胸。
乃脏结也。不可救矣。脏结者寸脉浮。关脉细小沉紧者。尚有白苔。痛引小腹则死。仲景云痛引
小腹。入阴经者死。次日痛引小腹。午时果死。
豫章刘商人。伤寒。发热。口苦咽干。腹满。能食。大便闭。医作阳明治。召予视。同坐。
予问医曰。何以见证属阳明。医曰。仲景云阳明中风。口苦咽干腹满。又云阳明病若能食名曰中
风。不能食名曰伤寒。又曰少阳阳明者胃中烦。大便难。是审兹三者。全是阳明证也。予曰。阳
明之脉长而实。中风者必自汗。今证虽阳明。然脉反见数。而身无汗。果可作阳明治否。医无以
应。予曰。以仆观之。所谓阳结也。今计其日已十六日矣。来日当病剧。当与公治之。其家疑而
不决。来日病果大作。亟召。予曰。是阳结证也。仲景云脉有阴结阳结。何以别之。答曰其脉浮
而数。能食不大便。此为实。名阳结也。其脉沉而迟。不能食。身体重。大便反 。名曰阴结。
期十四日当剧。今病者十七日而剧者。是其候也。乃投以大柴胡。两啜而病除矣。
论曰。仲景云。脉来霭霭如车盖者。名曰阳结。脉来累累如循长竿者。名曰阴结。霭霭如车
盖。则是浮是数之状。仲景所谓善取象矣。然则阳结何以十七日当剧。阴结何以十四日当剧。盖
十七日老阳少阳之数。十四日老阴少阴之数也。老阳之数九。少阳之数七。七九计十六。更进一
数。阳之数而其道常绕。又阳数奇。故也。老阴之数六。少阴之数八。八六计十四日。不进者。
阴主静。而其道常乏。又阴数偶也。如此盈虚消长。不能逃乎时数。
我的家族中有一位乳母，患伤寒七八日后出现发斑症状。肌肤灼热如火，脉象洪大、数急且坚实有力，心中烦闷胀满不适。不久之后，斑点变为赤黑色。家属非常惊恐慌乱。我说：这是温毒病。温毒致病最为严重，加之患者年事已高，这确实令人担忧。张仲景说：伤寒脉象洪数，阴脉实大，如果再遇上湿热之邪，就会变成温毒。温毒是最为严重的病证，因此会出现斑疹。心下（胃脘部）感觉不快，痞塞闷胀。于是我用升麻玄参汤给她服用，日夜服用四五次，斑点消退后痊愈。
评论说：华佗说，伤寒第五天病邪在腹，第六天在胃。病邪进入胃腑就可以使用下法。如果热毒尚未进入胃腑，就过早使用下法，那么热邪就会乘虚深入胃中，导致胃壁腐烂。然而，热邪进入胃腑后，必须再次使用下法，不能让热邪留在胃中。如果胃气充实，会导致这种病症，死亡率极高（三死一生）。热邪轻微者，出现红色斑点；热邪剧烈者，出现黑色斑点。出现红色斑点的，十人中有五人死亡一人存活；出现黑色斑点的，十人中有九人死亡一人存活。这主要取决于患者的体质强弱。病人到了发病的日子，如果不及时使用下法，热邪无法宣泄，也会导致胃烂发斑。这属于恶候。如果攻下太早，热邪会乘虚入胃；如果攻下太迟，热邪入里却无法宣泄。必须抓住时机，不可延误，这样或许还能治愈轻症。
甲辰年，一位盐商将船停靠在江边，患上伤寒。胸膈部痞塞不适，疼痛牵连至脐下两侧，痛苦难忍，饮食无法进用。我诊察后说：这不是结胸证，而是脏结证，无法救治了。脏结证的特征是寸脉浮，关脉细小沉紧，舌苔尚白。如果疼痛牵引至小腹，则主死。张仲景说：疼痛牵引至小腹，病邪侵入阴经的，预后不良致死。第二天，疼痛果然牵引至小腹，午时患者果然去世。
豫章的一位刘姓商人，患伤寒，发热，口苦咽干，腹部胀满，能进食，但大便闭塞不通。医生按阳明病治疗，召我去会诊。当时同坐一室。我问那位医生：为什么认为此证属于阳明？医生说：张仲景说阳明中风，会出现口苦、咽干、腹满的症状；又说阳明病若能进食叫作中风，不能进食叫作伤寒；还说少阳阳明证表现为胃中烦扰，大便困难。综合这三点，完全是阳明证的表现。我说：阳明脉象长而实，中风者必然自汗。现在虽然症状像阳明病，但脉象反而见数，且身上无汗，果真可以按阳明病治疗吗？医生无言以对。我说：依我看，这是阳结证。现在计算病程已经十六天了，明天病情将会加重，届时我会为您治疗。家属怀疑犹豫不决。第二天病情果然急剧加重，急忙召我。我说：这是阳结证。张仲景说：脉象有阴结和阳结，如何区别呢？回答说：脉象浮而数，能进食但大便不通，这是实证，名叫阳结。脉象沉而迟，不能进食，身体沉重，大便反而溏泄，名叫阴结。预计十四天时病情会加重。现在病人十七天病情加重，符合这一征候。于是投以大柴胡汤，服用两次后病愈。
评论说：张仲景说：脉象来势盛大如车盖般起伏不定，名叫阳结；脉象累累如抚摸长竿般坚硬挺直，名叫阴结。“霭霭如车盖”，就是浮数和缓的状态，张仲景善于取象比喻。那么为什么阳结会在十七天病情加重？为什么阴结会在十四天病情加重？因为十七日是老阳和少阳的数理，十四日是老阴和少阴的数理。老阳之数为一九，少阳之数为一七，七九合计十六，再进一位即为十七，阳数的运行之道是循环环绕的，且阳数为奇数，所以是十七日。老阴之数为一六，少阴之数为一八，八六合计十四日，不再增加，是因为阴主静，其道常显匮乏，且阴数为偶数。如此盈虚消长的规律，无法逃脱时日的数理限制。
My clan had a wet nurse who, after suffering from *Shanghan* (Cold Damage) for seven or eight days, developed macules. Her skin was burning hot like fire, her pulse was surging (*Hong*), rapid (*Shu*), and firm (*Lao*). She felt vexed, full, and uncomfortable in her heart. Soon, the macules turned red-black. Her family was extremely alarmed. I said, "This is *Wendu* (Warm Toxicity). *Wendu* is the most severe among diseases, and considering her advanced age, it is indeed worrying." Zhang Zhongjing said, "In *Shanghan*, if the pulse is surging and rapid, and the Yin pulses are solid and large, and this is compounded by damp-heat, it transforms into *Wendu*. *Wendu* is the most severe, hence macules and rashes appear. There is discomfort under the heart, stifling oppression." Therefore, I administered *Shengma Xuanshen Tang* (Cimicifugae Rhizoma and Scrophulariae Decoction) to her. She took it four or five times day and night. The macules receded, and she recovered.
Commentary: Hua Tuo said that on the fifth day of *Shanghan*, the pathogen is in the abdomen; on the sixth day, it is in the stomach. Once it enters the stomach, purgation can be used. However, if the heat toxin has not yet entered the stomach and purgation is applied prematurely, the heat will enter the stomach vacuously, causing the stomach lining to rot. Yet, once heat enters the stomach, it must be purged again so that no heat remains in the stomach. If the stomach is full/excess, this disease occurs, with a mortality rate of three deaths for every one survival. If the heat is mild, red macules appear; if severe, black macules appear. Those with red macules have a mortality rate of five out of ten; those with black macules have a mortality rate of nine out of ten. This depends on the strength of the patient's constitution. When the patient reaches the critical day, if purgation is not applied in time, the heat cannot be vented, leading to stomach rot and macule eruption. This is an ominous sign. If purgation is too early, heat enters the stomach vacuously; if too late, heat enters but cannot be vented. One must seize the opportunity and not miss the timing, so that even mild cases might be cured.
In the year Jiachen, a salt merchant moored his boat by the river and contracted *Shanghan*. He suffered from chest and diaphragm oppression, with pain radiating to both sides below the umbilicus, unbearable in intensity, and unable to eat or drink. I diagnosed him and said, "This is not *Jie Xiong* (Binding Chest), but *Zang Jie* (Organ Binding), which is incurable." In *Zang Jie*, the Cun pulse is floating, and the Guan pulse is fine, small, deep, and tight, with white tongue coating remaining. If pain radiates to the lower abdomen, death ensues. Zhang Zhongjing said, "If pain radiates to the lower abdomen, indicating invasion of the Yin meridians, death results." The next day, pain did radiate to the lower abdomen, and he died at noon.
A merchant named Liu from Yuzhang contracted *Shanghan*. He had fever, bitter taste in the mouth, dry throat, abdominal fullness, ability to eat, but closed bowels. The physician treated it as Yangming disease and summoned me for consultation. We sat together. I asked the physician, "Why do you judge this as Yangming?" The physician replied, "Zhang Zhongjing states that Yangming Wind Strike presents with bitter taste, dry throat, and abdominal fullness. It also says that in Yangming disease, ability to eat indicates Wind Strike, while inability to eat indicates Cold Damage. Furthermore, Shaoyang-Yangming presents with vexation in the stomach and difficulty defecating. Considering these three aspects, it is entirely a Yangming syndrome." I said, "The Yangming pulse is long and solid. In Wind Strike, there must be spontaneous sweating. Although the symptoms resemble Yangming, the pulse is instead rapid, and there is no sweat. Can it truly be treated as Yangming?" The physician had no response. I said, "In my view, this is *Yang Jie* (Yang Binding). The course of the disease has now reached sixteen days. Tomorrow, the condition will worsen. I will treat you then." The family was suspicious and undecided. The next day, the illness indeed flared up severely, and they urgently summoned me. I said, "This is the Yang Jie syndrome. Zhang Zhongjing said, 'There are Yin Binding and Yang Binding pulses. How to distinguish them?' The answer is: A pulse that is floating and rapid, with ability to eat but constipation, is excess and named Yang Binding. A pulse that is deep and slow, with inability to eat, heavy body, and loose stools, is named Yin Binding. The crisis is expected on the fourteenth day. Now, on the seventeenth day, the crisis has occurred, matching the prognosis." Thus, I administered *Da Chaihu Tang* (Greater Bupleurum Decoction). After two doses, the illness was cured.
Commentary: Zhang Zhongjing said, "When the pulse comes rushing like a chariot canopy, it is named Yang Binding; when it comes rolling like feeling a long bamboo pole, it is named Yin Binding. 'Rushing like a chariot canopy' indicates a floating and rapid quality. Zhang Zhongjing was adept at using imagery. So why does Yang Binding worsen on the 17th day? Why does Yin Binding worsen on the 14th day? Because 17 corresponds to the numbers of Old Yang and Young Yang, and 14 corresponds to Old Yin and Young Yin. The number of Old Yang is nine, and Young Yang is seven. Seven plus nine equals sixteen; advancing one more number gives seventeen. The way of Yang numbers is circular, and Yang numbers are odd, hence seventeen. The number of Old Yin is six, and Young Yin is eight. Eight plus six equals fourteen. It does not advance further because Yin governs stillness, its way is often lacking, and Yin numbers are even. Such waxing and waning, growth and decline, cannot escape the constraints of time and numerical cycles."