门人问曰。仲景言太阳病发热而渴不恶寒者为温病。湿症兼温。以渴辨证矣。然太阳中
。
其初起亦汗出而渴。与湿温之渴。又何以别之。答曰。此当以舌上胎为辨。凡热邪之在经者
。口虽渴。舌上无胎。且渴能引饮。湿温之病。阳明胃腑。先为湿困。内伏之温邪。被湿邪
郁遏。不能遽出于阳经。故当湿温病初起之时。虽渴不能引饮。必待传变之后。邪入于胃。
而成阳明可攻之证。方大渴引饮。故仲景云。湿家病。舌上如胎者。以丹田有热。胸中有寒
。渴欲饮水而不得饮。则口燥烦也。此一段文本。虽未明言湿温恰确是湿温初起之候。仲景
于此证虽有下早则哕之禁。若邪已入胃大渴引饮而成阳明可攻之证。则此时下不宜迟。又仲
景言外之意矣。而谓仲景书中无从窥湿温真面目者。彼其人实未窥仲景藩篱。恶足与言治
病哉。
门人问曰。夫子本仲景法而勘破湿温之源流。可谓详且尽矣。究之主治若何。愿并明之
。答曰。欲知其治。当先明其禁。予从仲景书推展其义。按仲景言湿家不可发汗。又温病不宜发
汗。若见头痛发热之太阳病而妄发其汗。卒之汗出热不退。且津液内夺。里邪愈锢。变证蜂
起。此首禁也。湿温病一经传胃。盒饭急下以存阴。切不可误信后人下不厌迟之谬说。若当
初起之时。全是一团蒸郁之气。未传到胃。遽予妄下。转致壅遏。胃气无由输邪外泄。此二禁
也。燥能胜湿。此理之常。今湿邪又兼温邪。若纯用香燥。破气立致。劫津化热。此三禁也
。温者清之。亦理之常。今温邪又兼湿邪。若纯用寒凉直折。转致助湿壅邪。此四禁也。湿
痹之病。可利小便。若兼温邪。全藉内中津液。足胜病气。病虽剧可治。若用苓泽等渗泄之
剂。强责其小便。则有着之邪。安能从膀胱宣泄。一经传变。内外灼热。真阴随涸。此五禁也
。温邪内伏。与湿交蒸。热淫之气。上蒙清窃。往往病起。即见昏谵。但当逐去其邪。则神识
自清。若遽指为热入心营。遂予犀角牛黄之属。是谓诛伐无过。究之膈间之邪。分毫不动。
徒
扰营血。反致引邪深入。立召斑狂喘厥诸变。此六禁也。凡此皆湿温病初起之禁例。至于传
变之后。仍当按仲景种种救逆诸法。分别施治。然则初起之时。汗之不可。下之又不可。燥
之不可。清之又不可。利之不可。开之又不可。果何从着手耶。则惟化湿之中。佐以清温。
其庶几乎。
学生问道：“仲景说，太阳病表现为发热、口渴且不恶寒的，属于温病。湿证兼有温热，可以通过‘渴’来辨证。然而，太阳中暍（中暑）在初起时也会出汗且口渴，这与湿温病的‘渴’，又该如何区别呢？”
回答说：“这应当通过观察舌苔来辨别。凡是热邪在经络的，口中虽然觉得渴，但舌上没有苔垢，并且患者能大量饮水。而湿温病，是因为阳明胃腑先被湿邪困阻，体内潜伏的温热邪气被湿邪郁遏，不能迅速透发于阳经。所以在湿温病初起之时，虽然口渴但不能大量饮水；必须等到病情传变之后，邪气进入胃中，形成阳明腑实可攻下的证候，才会出现大渴且能大量饮水的情况。所以仲景说：‘患湿家病的人，舌上好像有苔垢一样，这是因为丹田有热，胸中有寒，想喝水却喝不下去，导致口燥心烦。’这段文字，虽然没有明确说明湿温确切的初起症状，但仲景对此证虽有‘误下则哕’的禁忌，如果邪气已经入胃，出现大渴引饮并构成阳明可攻下的证候，那么此时使用下法不宜迟缓。这也是仲景话中的深意。如果说从仲景书中无法窥探到湿温的真面目，那是这些人确实没有窥探到仲景学术的门槛，哪里足以与他们谈论治病之道呢。”
学生又问道：“老师本乎仲景之法，勘破了湿温病的源流，可谓详尽无遗了。究竟主治原则是什么？希望能一并阐明。”
回答说：“想要知道治疗方法，应当先明白治疗禁忌。我根据仲景的书推展其义理。按仲景所说，患湿家病不可发汗，同时温病也不宜发汗。如果见到头痛发热的太阳病症状而妄用发汗法，最终导致汗出而热不退，且津液内伤耗夺，里邪更加固结，各种变证蜂拥而起。这是第一条禁忌。湿温病一旦传入胃腑，就应当急用下法以保存阴液，切不可错误地相信后人‘下法不厌迟’的错误说法。如果在初起之时，全身只是一团蒸腾郁滞之气，尚未传到胃中，就仓促使用下法，反而会导致气机壅遏，胃气无法将邪气输泄外出。这是第二条禁忌。燥性能胜湿，这是常理。如今湿邪又兼有温邪，如果纯用香燥药物，会立刻破气，劫夺津液并化热。这是第三条禁忌。温邪应当用清凉药物治疗，也是常理。如今温邪又兼有湿邪，如果纯用寒凉药物直折火势，反而会导致助长湿邪、壅滞病邪。这是第四条禁忌。湿痹病可以用利小便的方法治疗，但如果兼有温邪，全赖体内的津液足以战胜病气，即使病情严重也可治愈。如果使用茯苓、泽泻等渗泄利尿的药物，强行要求小便通畅，那么附着之邪怎么能从膀胱宣泄呢？一旦病情传变，内外灼热，真阴随之枯竭。这是第五条禁忌。温邪内伏，与湿邪交蒸，热淫之气上蒙清窍，往往病起时就出现神昏谵语。这时只应当祛除邪气，神识自然会清醒。如果仓促将其指认为热入心营，于是给予犀角、牛黄之类的药物，这叫作诛伐无辜。究其结果，膈间的邪气分毫未动，徒然扰乱营血，反而导致引邪深入，立即召致发斑、狂乱、喘促、厥逆等各种变证。这是第六条禁忌。以上都是湿温病初起的禁忌条例。至于传变之后，仍当按照仲景的各种救逆诸法，分别施治。既然如此，初起之时，发汗不可，攻下不可，燥湿不可，清热不可，利小便不可，开窍也不可，究竟从哪里着手呢？那只有在化湿之中，佐以清解温热，大概就可以了。”
The student asked, "Zhongjing stated that Taiyang disease presenting with fever, thirst, and aversion to cold absent constitutes Warm Disease (Wen Bing). Dampness complicated by warmth can be differentiated by the symptom of thirst. However, Sun-Yang Zhong Yue (Heatstroke) at its onset also presents with sweating and thirst. How, then, can one distinguish the thirst in Warm-Dampness from that in Heatstroke?"
The response was: "This differentiation should be based on the tongue coating. When pathogenic heat resides in the meridians, although there is a sensation of thirst, there is no coating on the tongue, and the patient desires to drink copiously. In Warm-Dampness disease, the Yangming Stomach Fu-organ is first constrained by dampness. The latent warm pathogen within is suppressed by the damp pathogen and cannot rapidly emerge into the Yang meridians. Therefore, at the initial stage of Warm-Dampness, although there is thirst, the patient cannot drink copiously. It is only after the disease transforms and the pathogen enters the stomach, forming a Yangming syndrome suitable for purgation, that severe thirst with a desire to drink large amounts occurs. Thus, Zhongjing said: 'In patients suffering from Dampness, if the tongue appears coated, it indicates heat in the lower abdomen (Dantian) and cold in the chest. There is a desire to drink water but an inability to do so, resulting in dry mouth and restlessness.' Although this passage does not explicitly define the exact initial presentation of Warm-Dampness, Zhongjing’s prohibition against premature purgation leading to hiccups implies that if the pathogen has entered the stomach, causing severe thirst and a Yangming purgable syndrome, purgation should not be delayed. This is the implicit meaning in Zhongjing’s words. Those who claim they cannot discern the true nature of Warm-Dampness from Zhongjing’s texts have truly failed to penetrate the threshold of his scholarship; how could such people be worthy of discussing medical treatment?"
The student asked again, "Master, by adhering to Zhongjing’s methods, you have thoroughly elucidated the origin and evolution of Warm-Dampness. What are the primary treatment principles? Please clarify them."
The response was: "To understand the treatment, one must first know the contraindications. Expanding upon Zhongjing’s teachings: Zhongjing stated that patients with Dampness should not undergo diaphoresis (sweating therapy), nor should Warm Diseases. If one sees Taiyang symptoms like headache and fever and recklessly induces sweating, the result is sweating without subsiding fever, internal depletion of fluids, and further consolidation of interior pathogens, leading to numerous complications. This is the first contraindication. Once Warm-Dampness transmits to the stomach, urgent purgation is required to preserve Yin; one must not erroneously believe the later theory that 'purgation is never too late.' At the initial stage, when the body is filled with steaming and stagnant Qi, before it reaches the stomach, premature purgation causes obstruction, preventing the Stomach Qi from venting the pathogen outward. This is the second contraindication. Dryness overcomes dampness, which is normal logic. However, since dampness is combined with warmth, using purely aromatic-drying herbs will immediately damage Qi, deplete fluids, and generate heat. This is the third contraindication. Cooling treats warmth, which is also normal logic. But since warmth is combined with dampness, using purely cold-natured herbs to directly suppress fire will instead aid dampness and obstruct the pathogen. This is the fourth contraindication. Bi-syndrome due to dampness can be treated by promoting urination. However, if combined with warmth, the body relies on internal fluids to overcome the pathogen; even if severe, it is treatable. Using permeating diuretics like Poria (Fuling) and Alisma (Zexie) to force urination means attached pathogens cannot be excreted via the Bladder. Upon transformation, internal and external burning heat ensues, and True Yin dries up. This is the fifth contraindication. Latent warm pathogens steaming with dampness produce excessive heat Qi that clouds the clear orifices upward. Often, confusion and delirium appear at onset. One should only dispel the pathogen, and consciousness will naturally clear. If one hastily diagnoses this as Heat entering the Ying (Nutritive) Level and administers Rhinoceros Horn (Xijiao) or Calculus Bovis (Niuhuang), it is called punishing the innocent. Ultimately, the pathogen in the diaphragm remains untouched, merely disturbing the Ying and Blood levels, leading the pathogen deeper, and immediately summoning complications such as macules, mania, asthma, and syncope. This is the sixth contraindication. These are all the contraindications for the initial stage of Warm-Dampness. After transformation, one should still apply Zhongjing’s various rescue methods according to the specific condition. Since at the initial stage, diaphoresis, purgation, drying, cooling, diuresis, and opening the orifices are all contraindicated, where does one begin? The solution lies in resolving dampness while assisting with clearing warmth. This is likely the correct approach."