华元化云。夫伤寒始得。一日在皮。当摩膏火灸。即愈若不解者。至二日在肤。可法针。服解肌散。发汗。汗出。
即愈。若不解者。至三日。在肌复发汗。则愈。若不解者。止。勿复发汗也。至四日。在胸。宜服藜芦丸。微吐则愈若
更困。藜芦丸不能吐者。服小豆瓜蒂散。吐之。则愈。视病。尚未醒。醒者。复一法针之。五日在腹。六日入胃。入胃。
则可下也。若热毒在胃外。未入于胃。而先下之者。其热乘虚便入胃。则烂胃也。然热入胃病。要当复下去之。不得留
于胃中也。胃若实热。致此为病。三死一生。此辈皆多不愈。胃虚热入烂胃也。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。病者过日。不以时下之。热不得泄。亦胃烂斑出。
（琥）按伤寒之邪。自外而着于经络。入于胃腑。故始得在皮。继在肤。继在肌。更进而在胸。在腹以入于胃。入
胃不解。则热不得泄。胃烂而死者多矣。据元化此论。虽不言阴阳六经。然其意实与仲景例相合。其言在皮肤。在肌者。
此即仲景三阳经。未入于腑之病也。其言在胸腹。与入胃者。此即仲景三阴经。已入于腑之病也。摩膏法。惜今不传。
针法及吐法。伤寒科又不讲。俗医所议者。止汗下与和解。三法而已汗下。得宜犹可以为上工。至有汗下和解。错治不
效。轻投温补。以治中寒法治伤寒。其为害人。不知几许。盍于上例一致思之。
或问云。元化摩膏火灸法。此以热药治寒证也。子何以伤寒为热病邪。予答云。经言发表不远热。仲景治太阳病一
二日。用麻黄桂枝二汤以发之。亦甘温辛热之剂。至邪已入里。叔和即相戒云。桂枝下咽。阳盛即毙。明乎此。则治伤
寒之法。可无误矣。
巢元方云。伤寒者。起自风寒。入于腠理。与精气交争。营卫痞隔。周行不通。病一日至二日。气在孔窍皮肤之间。
故病者。头痛恶寒。腰背强重。此邪气在表。洗浴发汗即愈。病三日以上。气浮在上部。胸心填塞。故头痛。胸中满闷。
当吐之。则愈。病五日以上。气深。（千金作沉）结在脏。故腹胀身重。骨节烦疼。当下之则愈。（在脏脏字。当作腑字
解。仲景云已入腑者。可下而已。其义相通。或疑骨节烦疼。当是太阳表证未罢。恐不宜下。殊不知上云腹胀。此为胃
腑实热已极。热气自内蒸发于外。所以骨节烦疼。巢氏用下法。至当无疑。）
（琥）按上巢氏治伤寒。不过用汗吐下三法。乃知其病。总系实热之证。与仲景汗下例。同出一义刘守真云。伤寒
表证。当汗而不可下。里证。当下而不可汗。半在表。半在里。则当和解。不可发汗。吐下。在上则通之。在下则泄之。
伤寒无汗。表病里和者。则麻黄汤汗之。或天水散之类。亦佳。表不解。半入于里。半尚在表者。小柴胡汤和解之。或
天水。凉膈散。甚良。表里热势俱甚者。大柴胡汤微下之。更甚者。大承气汤下之。表热多。里热少者。天水一。凉膈
半和解之。里热多。表热少。未可下者。凉膈天水。一半调之。势更甚者。小承气汤下之。表证解。但有里证者。大承
气汤下之。凡此诸可下者。通宜三一承气汤下之。发汗不解。下后。前后别无异证者。通宜凉膈散调之。以退其热。两
感仿此而已。伤风自汗。表病里和者。桂枝汤解肌。半在表。半在里。白虎汤和解之。病在里者。大承气汤下之。
（琥）按上守真氏论治伤寒法。所取仲景汗下和解之方。自麻黄桂枝二汤外。不过是大小柴胡。大小承气。及白虎
汤。又复自制天水散。凉膈散。三一承气汤。大都是甘寒苦寒辛凉之剂。此以伤寒之病。表里俱热。以寒治热。固其宜
也。但上文云。伤寒表证无汗。用麻黄汤之时。复云。或天水散之类亦佳。斯言不可为例。夫天水散。乃甘寒之药。纵
用葱豉之苦辛。煎汤调服。但能清阳明气分肌肉间热。何能散太阳经皮表之寒气邪。经云发表不远热。麻桂之辛热。亦
伤寒初起时必用之药。若谓寒气所郁。发热过甚。竟以滑石一味为君。而欲清之。遂谓表病之能愈。吾不信矣。至于邪
已入里。热势甚。而用三一承气。或表里俱热。而用天水凉膈。斯为治热病之要法。学人所当参合而用其方也。
张子和云。凡人冒风时气温病伤寒三日以里。头痛身热恶寒。可用通圣散。益元散。入生姜豉葱。煎一大碗。去滓。
稍热先以多一半投之。良久。用钗子于咽喉中。探引吐了。次用少半。亦稍热投之。更用葱醋酸辣汤投之。衣被盖覆。
汗出则愈矣。如遇世乱。内经曰。岁火太过。炎暑流行。火气太盛。肺金受邪。上应荧惑。大而明现。用辛凉之剂解之。
则万举万全也。若遇治世人安。可用升麻汤。葛根汤。败毒散。辛温之剂解之。亦加葱根白豆豉。上涌而表汗。内经曰。
因其轻而扬之。扬者。发扬也。谓吐汗。以发扬寒热之邪也。（世乱者。谓疫气传染。人病卒暴而死之时也。治世人安。
谓人病不卒暴而痊安者多。）
又云。伤寒温疫。时气冒风。中暑。俱四时不正之气也。人若初感之。皆头痛恶寒身热。及寒热往来。腰脊强。是
太阳经受病也。内经曰。可先治内。而后治外。先用生姜葱白豆豉。煎双解散。上涌。及汗出则解。如不解者。至五六
日或不大便。喘满谵语。实热两手脉沉。可用调胃大小承气汤下之。此先治外。而后治内也。（先治内后治外。谓先涌之。
是治内。吐时汗出。即是治外。先治外后治内。谓汗后不解方。用下药。）
伤寒七八日。发黄有斑。潮热腹满者。或痰实作止。虽诸承气汤下过者。仲景云。寸口脉浮滑者。可用瓜蒂散吐之。
启玄子云。上盛不已。吐而夺之是也。
（琥）按上吐汗之法。极是但云。投以葱醋酸辣汤。不可为。则虽经云酸者。令人上涌。然其性能收敛。外寒汤中
之醋。不宜用也。又上云温疫时气冒风中暑。总以伤寒贯之。可见热病所该者。广其名虽异。而治法颇同矣。
王海藏云冬伤于寒。春必温病。盖因房室劳伤与辛苦之人。腠理开泄。少阴不藏。肾水涸竭。而得之无水。则春木
无以发生。故为温病。至长夏之时。时强木长。因绝水之源。无以滋化。故为大热病也。伤寒之源如此。春为温病。夏
为热病长夏为大热病。其变亦随乎时而已。邪之所感。浅者。其病轻而易治深者。其病重而难治尤深者。其病死而不治。
（琥）按上海藏之论。是三秋时无伤寒矣。盖古人言不尽意。上文既云变随乎时。则秋令多燥热秋之伤寒。当为燥
热病。至深秋时。则同正伤寒矣。至于治法。则随其邪之浅深。热之轻重。或汗或吐或和解及下。在学人通变用之而已。
陶节 云。伤寒者冬月寒邪。伤于足太阳经。实时病者。为正伤寒。其证便有头疼发热恶寒。脉浮紧而无汗治。宜
发表。自然热退身凉。若传阳明经。便有目痛鼻干不眠。脉微洪之证。治宜解肌。若传至少阳经。便有胸胁痛而耳聋。
寒热呕而口苦。脉弦数。之证。治宜和解表里。若表证皆除。传进三阴。反见怕热。揭去衣被。燥渴谵语。潮热斑黄往
乱。大便不通脉沉实而有力。治宜急下。大便通而其热愈矣。若伤风者。初起头疼发热恶寒。脉浮缓。自汗。鼻塞声重。
此名伤风。亦是太阳病起。若传至各经。根据前伤寒条下治之。其春夏秋三时。虽有恶寒身热微头疼。即为感冒。非时暴
寒之轻。非比冬时正伤寒为重也。
（琥）按上节 论伤寒三阳经证。传入三阴。大便不通。治宜急下。据仲景法。凡云急下者。皆用大承气汤。夫三
阴有太少。厥之不同。而治法总以一汤下之者。何也。盖仲景云。三阴证。已入于府者。可下而已。其时病患肠胃实热
已极。阴经近里。热气蒸郁三阴之经。当见腹满嗌干。口舌燥渴。烦满囊缩等证。但用承气汤。下其肠胃中之实。而阴
经之热自解。所以阴经有三。用药治之。止一法也。至于仲景论太阳中风。（中与伤同一义）与伤寒无异。但以脉缓自汗
为别。陶氏云鼻塞声重。此即丹溪所云伤风属肺。戴院使云。新咳嗽者是也。其证饮食如故。大小便如常。乃另是一种
病。乌得入于太阳经例。见证不明。徒遗世诮。
（琥）总按上昔贤论伤寒例。大都宗内经热病之旨。且其义与仲景伤寒例。互相发明。故其治法。或汗或吐或下或
和解或针刺。无殊疗也。读仲景书者。可不玩索而旁通之。
华佗说：伤寒病刚发作时，邪气在皮肤层。应当使用药膏按摩和火灸治疗，即可痊愈。如果病情没有缓解，到了第二天，邪气在肌肤层，可以采用针刺法，服用解肌散来发汗。汗出后，即可痊愈。如果病情仍未缓解，到了第三天，邪气在肌肉层，再次发汗，就会痊愈。如果病情仍然没有缓解，就停止治疗，不要再发汗了。到了第四天，邪气在胸膈，适宜服用藜芦丸，引起轻微呕吐即可痊愈。如果病人更加困顿，藜芦丸不能引起呕吐的，服用小豆瓜蒂散，催吐，即可痊愈。观察病情，如果神志尚未清醒，清醒后，再用另一种针刺法治疗。第五天，邪气在腹部。第六天，邪气进入胃腑。邪气进入胃腑，就可以用泻下法治疗。如果热毒在胃外，尚未进入胃中，而先用了泻下法，那么热邪就会乘虚进入胃中，导致胃烂。然而，热邪入胃致病，必须再次用泻下法去除它，不能让热邪留在胃中。如果胃中有实热，导致这种病症，十个人中有九个死亡，只有一个人能活下来，这类病大多无法治愈。如果是胃虚导致热邪侵入并烂胃，热势轻微的，会出现红色斑疹；热势剧烈的，会出现黑色斑疹。出现红色斑疹的，十个人中有五个死亡，只有一个人能活下来；出现黑色斑疹的，十个人中有九人死亡，只有一个人能活下来。患病者过了六天，如果不及时用泻下法，热邪无法排泄，也会导致胃烂和斑疹出现。
（王琥）按：伤寒之邪，从外部侵袭经络，进而进入胃腑。所以刚开始时在皮肤，继而在肌肤，继而在肌肉，进一步发展到胸膈、腹部，最后进入胃中。邪气进入胃中若不能解除，热邪就无法排泄，导致胃烂而死的情况很多。根据华元化（华佗）的这个论述，虽然他没有提及阴阳六经，但其意思实际上与张仲景的伤寒例相符合。他说邪气在皮肤、在肌肉，这对应张仲景所说的三阳经病证，即邪气未进入腑脏的病。他说邪气在胸腹，以及进入胃中，这对应张仲景所说的三阴经病证，即邪气已进入腑脏的病。摩膏法，可惜现在失传了。针刺法和催吐法，在伤寒科中又不被重视。世俗医生所议论的治疗手段，仅限于发汗、泻下和解表和解这三种方法而已。发汗和泻下，如果运用得当，还可以称为高明医生。至于那些发汗、泻下和解表和解都治错了且无效的，轻率地投以温补药物，用治疗中寒的方法来治疗伤寒，其害人之深，不知有多少。何不对此类例子深入思考一下呢？
有人问：华元化的摩膏火灸法，这是用热药治疗寒证，您为什么认为伤寒是热病呢？我回答说：经典记载发表不远热，张仲景治疗太阳病一两天，用麻黄汤和桂枝汤来发汗，也是甘温辛热的药剂。等到邪气已经入里，王叔和就告诫说：桂枝汤喝下去，如果阳气盛就会致死。明白这一点，那么治疗伤寒的方法，就不会有误了。
巢元方说：伤寒，起因于风寒，侵入腠理，与精气交争，导致营卫阻滞，周身运行不通。病一到两天，邪气在孔窍皮肤之间，所以病人头痛、恶寒、腰背强直沉重。这是邪气在表，洗浴发汗即可痊愈。病三天以上，邪气浮越在上部，胸心填塞，所以头痛、胸中满闷，应当用催吐法，即可痊愈。病五天以上，邪气深沉结聚在脏腑，所以腹胀、身重、骨节烦痛，应当用泻下法，即可痊愈。（注：原文“在脏”的“脏”字，应解释为“腑”字。张仲景说“已入腑者，可下而已”，其义相通。有人怀疑骨节烦疼，应该是太阳表证未罢，恐怕不宜用泻下法。殊不知上文提到腹胀，这是因为胃腑实热已到极点，热气从内部蒸发到外部，所以导致骨节烦痛。巢氏使用泻下法，是非常恰当无疑的。）
（王琥）按：上述巢元方治疗伤寒，不过是用汗、吐、下三种方法，可知他的病总属于实热证，与张仲景的汗下例，出自同一道理。刘守真说：伤寒表证，应当发汗而不可泻下；里证，应当泻下而不可发汗；半在表半在里，则应当和解，不可发汗、催吐或泻下。邪气在上则通导之，在下则泄导之。伤寒无汗，表病里和的，就用麻黄汤发汗，或者天水散之类的药也很好。表邪未解，一半进入里，一半还在表的，用小柴胡汤和解，或者天水散、凉膈散，效果很好。表里热势都很严重的，用大柴胡汤轻微泻下，更严重的，用大承气汤泻下。表热多，里热少的，用一份天水散加半份凉膈散和解；里热多，表热少，还不可泻下的，用一半凉膈散加一半天水散调和；病情更严重的，用小承气汤泻下。表证解除，只有里证的，用大承气汤泻下。凡是可以泻下的，通通适宜用三一承气汤泻下。发汗后病不解，泻下后，前后没有其他异常症状的，通通适宜用凉膈散调理，以退去热邪。两感病仿照此法处理即可。伤风自汗，表病里和的，用桂枝汤解肌；半在表半在里的，用白虎汤和解；病在里的，用大承气汤泻下。
（王琥）按：上述刘守真论述治疗伤寒的方法，所选取的张仲景汗、下、和解的方剂，除了麻黄汤、桂枝汤之外，不过是大小柴胡汤、大小承气汤及白虎汤，又加上他自己创制的水散、凉膈散、三一承气汤。大多是甘寒、苦寒、辛凉的药剂。这是用寒凉药治疗伤寒病表里俱热的情况，固然是适宜的。但上文说，伤寒表证无汗，用麻黄汤的时候，又说“或者天水散之类的药也很好”，这话不能作为典范。因为天水散是甘寒的药物，纵然用葱豉的苦辛煎汤调服，只能清阳明气分和肌肉间的热，怎么能发散太阳经皮表的寒气邪气呢？经典说发表不远热，麻黄、桂枝的辛热，也是伤寒初起时必用的药物。如果说寒气郁结，发热过甚，竟以滑石一味为主药，想要清解它，就说表病能愈，我不相信。至于邪气已经入里，热势很盛，而用三一承气汤，或者表里俱热，而用水散、凉膈散，这才是治疗热病的关键方法，学医的人应当参考合并使用这些方剂。
张子和说：凡人冒风、时气、温病、伤寒三日以内，出现头痛、身热、恶寒，可用通圣散、益元散，加入生姜、豆豉、葱白，煎一大碗，去渣，稍热后，先喝大半碗，过了一会儿，用钗子在咽喉中探引催吐，然后再喝剩下的少半碗，也稍热后服用，再用葱醋酸辣汤服用，盖好衣被，出汗后就痊愈了。如果遇到世道混乱，内经说：岁火太过，炎暑流行，火气太盛，肺金受邪，上应荧惑星，大而明亮显现，用辛凉药剂解之，则万举万全。如果遇到治世，世人安康，可用升麻汤、葛根汤、败毒散等辛温药剂解之，也加入葱根、白豆豉，向上涌吐并发汗。内经说：因其轻而扬之。扬，就是发扬的意思，指通过吐、汗来发扬散发寒热之邪。（所谓世乱，是指疫气传染，人病卒暴而死的时候。所谓治世人安，是指人病不卒暴而痊愈的多。）
他又说：伤寒、温疫、时气、冒风、中暑，都是四时不正之气。人如果刚感染，都会头痛、恶寒、身热，以及寒热往来、腰脊强直，这是太阳经受病。内经说：可先治内，而后治外。先用生姜、葱白、豆豉煎双解散，向上涌吐，以及出汗则病解。如果还不解，到了五六天或者不大便、喘满、谵语，实证两手脉沉，可用调胃承气汤、大小承气汤泻下。这是先治外，而后治内。（先治内后治外，是指先涌吐，这是治内，吐的时候出汗，即是治外。先治外后治内，是指发汗后不解才用下药。）
伤寒七八日，发黄有斑，潮热腹满的，或者痰实作止，虽然经过各种承气汤泻下过的，张仲景说：寸口脉浮滑的，可用瓜蒂散催吐。启玄子说：上盛不已，吐而夺之，就是这个意思。
（王琥）按：上述吐、汗之法，非常正确。但说投以葱醋酸辣汤，不可以这样做。虽然经典说酸味令人上涌，但其性质具有收敛作用，外寒汤中的醋，不宜使用。又上面提到的温疫、时气、冒风、中暑，总以伤寒贯穿其中，可见热病所包含的范围很广，名称虽然不同，但治疗方法颇为相同。
王海藏说：冬伤于寒，春必温病。大概是因为房劳损伤与辛苦之人，腠理开泄，少阴不藏，肾水涸竭，从而得病。无水则春木无以发生，所以成为温病。到了长夏之时，时令强盛木气生长，因为断绝了水的源头，无以滋生化育，所以成为大热病。伤寒的源流如此。春季为温病，夏季为热病，长夏为大热病，其变化也随着时令而已。邪气所感，浅的，病轻而易治；深的，病重而难治；尤深的，病死而不治。
（王琥）按：上述海藏的论述，似乎意味着三秋时无伤寒了。大概古人言不尽意。上文既然说变化随乎时令，那么秋季多燥热，秋天的伤寒，应当为燥热病。到了深秋时，则同正伤寒一样了。至于治法，则随着邪气的浅深、热势的轻重，或汗、或吐、或和解及泻下，由学医的人灵活变通使用罢了。
陶节庵说：伤寒是冬季寒邪，伤于足太阳经，即时发病的，为正伤寒。其证便有头疼、发热、恶寒、脉浮紧而无汗。治疗，宜发表，自然热退身凉。如果传入阳明经，便有目痛、鼻干、不眠、脉微洪的证候。治疗，宜解肌。如果传入少阳经，便有胸胁痛而耳聋、寒热、呕而口苦、脉弦数的证候。治疗，宜和解表里。如果表证皆除，传入三阴，反见怕热、揭去衣被、燥渴、谵语、潮热、斑黄、妄乱、大便不通、脉沉实而有力。治疗，宜急下。大便通而其热愈矣。如果是伤风，初起头疼、发热、恶寒、脉浮缓、自汗、鼻塞声重，此名伤风，也是太阳病起。如果传入各经，根据前伤寒条下的方法治疗。其春夏秋三时，虽有恶寒、身热、微头疼，即为感冒，是非时暴寒之轻症，不比冬季正伤寒为重。
（王琥）按：上述节庵论述伤寒三阳经证，传入三阴，大便不通，治疗宜急下。根据张仲景的法度，凡是说急下的，都用大承气汤。三阴有太阴、少阴、厥阴的不同，而治法总用一个汤剂泻下的，为什么呢？因为张仲景说：三阴证，已入于腑者，可下而已。此时病患肠胃实热已到极点，阴经近里，热气蒸郁三阴之经，当见腹满、嗌干、口舌燥渴、烦满、囊缩等证。只用承气汤，泻下肠胃中的实热，而阴经的热自然解除。所以阴经有三，用药治疗它们，只有一种方法罢了。至于张仲景论太阳中风（中与伤同一意义）与伤寒无异，只是以脉缓、自汗为区别。陶氏说鼻塞声重，这就是丹溪所说的伤风属肺，戴院使说的新咳嗽是这种情况。其证饮食如故，大小便如常，乃是另一种病，怎能列入太阳经例？见证不明，徒留于世人的讥诮。
（王琥）总按：上述昔贤论述伤寒例，大都宗奉内经热病的旨意，而且其义与张仲景伤寒例，互相发明。所以他们的治法，或汗、或吐、或下、或和解、或针刺，没有不同的疗法。读张仲景书的人，能不玩味探索而旁通之吗？
Hua Yuanhua (Hua Tuo) said: When cold damage (Shanghan, a disease caused by cold pathogenic factors) first occurs, the pathogen is in the skin layer. One should apply medicinal ointments and use fire moxibustion; it will then heal. If it does not resolve, on the second day, the pathogen is in the flesh layer. Acupuncture can be employed, and Ji Jie San (Muscle-Relieving Powder) can be taken to induce sweating. Once sweat is produced, it will heal. If it still does not resolve, on the third day, the pathogen is in the muscle layer. Inducing sweating again will lead to recovery. If it remains unresolved, stop treatment; do not induce sweating again. On the fourth day, the pathogen is in the chest/diaphragm area. Li Lu Wan (Veratrum Pill) should be taken; mild vomiting will lead to recovery. If the patient becomes more distressed and Li Lu Wan fails to induce vomiting, Xiao Dou Gua Di San (Cowpea and Melon Seed Powder) should be administered to induce vomiting, which will lead to recovery. Observe the illness; if consciousness has not yet returned, once it returns, apply another acupuncture method. On the fifth day, the pathogen is in the abdomen. On the sixth day, it enters the Stomach Fu organ. Once it enters the Stomach, purgation (downward-draining therapy) can be used. If heat-toxin is outside the Stomach and has not yet entered, but purgation is applied prematurely, the heat will enter the Stomach vacuously, causing the Stomach to rot. However, when heat enters and causes Stomach disease, it must be removed via purgation again; it cannot be allowed to remain in the Stomach. If the Stomach has excess heat leading to this condition, nine out of ten die, and only one survives; such cases are mostly incurable. If the Stomach is deficient and heat enters causing Stomach rot, mild heat manifests as red macules (skin eruptions), while severe heat manifests as black macules. With red macules, five out of ten die, and one survives; with black macules, nine out of ten die, and one survives. If the patient passes the six-day mark without timely purgation, heat cannot be discharged, also leading to Stomach rot and macule eruption.
(Wang Hu) Note: The pathogen of cold damage invades from the exterior into the meridians and then enters the Stomach Fu organ. Thus, it starts in the skin, then moves to the flesh, then to the muscles, further advancing to the chest, abdomen, and finally entering the Stomach. If the pathogen enters the Stomach and is not resolved, heat cannot be discharged, leading to many deaths due to Stomach rot. According to Hua Yuanhua’s theory, although he does not mention Yin-Yang or the Six Meridians, his intent actually aligns with Zhang Zhongjing’s examples of cold damage. His mention of the pathogen being in the skin and muscles corresponds to the Three Yang Meridian diseases in Zhang Zhongjing’s system, i.e., diseases where the pathogen has not entered the Fu organs. His mention of the pathogen being in the chest/abdomen and entering the Stomach corresponds to the Three Yin Meridian diseases in Zhang Zhongjing’s system, i.e., diseases where the pathogen has already entered the Fu organs. The medicinal ointment massage method is unfortunately lost today. Acupuncture and emesis methods are not emphasized in cold damage departments. What secular physicians discuss are limited to three methods: sweating, purgation, and harmonizing. If sweating and purgation are applied appropriately, one can still be considered a skilled physician. However, for those whose sweating, purgation, and harmonizing treatments fail and are incorrect, rashly administering warming and tonifying agents to treat cold damage using methods for middle-jiao cold injury harms countless people. Why not reflect deeply on these examples?
Someone asked: Hua Yuanhua’s ointment massage and fire moxibustion method uses hot medicines to treat cold syndromes. Why do you consider cold damage to be a heat disease? I replied: The classics state that releasing the exterior does not distance itself from heat. Zhang Zhongjing treats Taiyang disease (Taiyang Meridian Disease) in its first one or two days with Ma Huang Tang (Ephedra Decoction) and Gui Zhi Tang (Cinnamon Twig Decoction) to induce sweating; these are also sweet-warm and acrid-hot preparations. Once the pathogen has entered the interior, Shu He (Wang Shuhe) warns: If Gui Zhi Tang is swallowed and Yang is excessive, death ensues. Understanding this, the methods for treating cold damage will not err.
Chao Yuanfang said: Cold damage originates from wind-cold invading the interstices (Cou Li), clashing with essential Qi, causing stagnation between Ying (Nutritive) and Wei (Defensive) Qi, blocking circulation throughout the body. On the first to second days, the pathogen is between the orifices and skin, so the patient experiences headache, aversion to cold, and stiffness/heaviness in the waist and back. This is pathogen in the exterior; bathing and inducing sweating will lead to recovery. After three days, the pathogen floats upward, causing chest and heart congestion, leading to headache and chest fullness/stuffiness. Emesis should be used to achieve recovery. After five days, the pathogen sinks deeply and knots in the Zang/Fu organs, causing abdominal distension, heaviness of the body, and painful movement of bone joints. Purgation should be used to achieve recovery. (Note: The character "Zang" in "in Zang" should be interpreted as "Fu". Zhang Zhongjing states, "If it has entered the Fu, it can be purged," which shares the same meaning. Some doubt that painful movement of bone joints indicates unresolving Taiyang exterior syndrome and fear purgation is inappropriate. However, the aforementioned abdominal distension indicates extreme excess heat in the Stomach Fu, with heat steaming outward from within, thus causing painful movement of bone joints. Chao’s use of purgation is undoubtedly appropriate.)
(Wang Hu) Note: The above treatment of cold damage by Chao relies solely on sweating, emesis, and purgation, indicating his view that the disease is fundamentally an excess-heat syndrome, consistent with Zhang Zhongjing’s principles of sweating and purgation. Liu Shouzhen said: For cold damage exterior syndrome, sweating is indicated but not purgation; for interior syndrome, purgation is indicated but not sweating; for half-exterior half-interior syndrome, harmonizing is indicated, avoiding sweating, emesis, and purgation. Pathogens above are guided downward; pathogens below are drained. For cold damage with no sweat, where the exterior is diseased but the interior is harmonious, Ma Huang Tang is used to induce sweating, or Tian Shui San (Heavenly Water Powder) is also good. If the exterior is unresolved, with half the pathogen entering the interior and half remaining in the exterior, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is used to harmonize, or Tian Shui San and Liang Ge San (Cooling Chest Powder) are excellent. If exterior and interior heat are both severe, Da Chai Hu Tang (Major Bupleurum Decoction) is used for mild purgation; if more severe, Da Cheng Qi Tang (Major Order the Qi Decoction) is used for purgation. If exterior heat is predominant and interior heat is slight, one part Tian Shui San and half part Liang Ge San are used to harmonize. If interior heat is predominant and exterior heat is slight, and purgation is not yet suitable, half part Liang Ge San and half part Tian Shui San are used to regulate; if conditions worsen, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is used for purgation. If the exterior syndrome resolves leaving only interior syndrome, Da Cheng Qi Tang is used for purgation. For all cases suitable for purgation, San Yi Cheng Qi Tang (Three-One Order the Qi Decoction) is generally appropriate. If sweating fails to resolve the condition, and after purgation there are no other abnormal symptoms in the front or back, Liang Ge San is generally used to regulate and clear heat. Two-in-one (Liang Gan) cases follow this pattern. For wind-strike with spontaneous sweating, where the exterior is diseased but the interior is harmonious, Gui Zhi Tang is used to release the muscle layer; for half-exterior half-interior, Bai Hu Tang (White Tiger Decoction) is used to harmonize; for interior disease, Da Cheng Qi Tang is used for purgation.
(Wang Hu) Note: In Liu Shouzhen’s discussion on treating cold damage, the formulas selected from Zhang Zhongjing’s sweating, purgation, and harmonizing methods, besides Ma Huang Tang and Gui Zhi Tang, are mainly the Major and Minor Chai Hu Tangs, Major and Minor Cheng Qi Tangs, and Bai Hu Tang, along with his own creations: Tian Shui San, Liang Ge San, and San Yi Cheng Qi Tang. These are mostly sweet-cold, bitter-cold, and acrid-cool preparations. This applies cold to treat the exterior-interior heat of cold damage, which is indeed appropriate. However, earlier it was stated that for cold damage exterior syndrome with no sweat, Ma Huang Tang is used, yet here it says "Tian Shui San or similar is also good." This statement cannot serve as a standard. Tian Shui San consists of sweet-cold herbs; even if mixed with decoctions of scallion and fermented soybean (Cong Chi) which are bitter-acrid, they can only clear heat in the Yangming Qi level and muscle layer, but cannot disperse cold-pathogen in the Taiyang exterior skin. The classics state that releasing the exterior does not distance itself from heat; the acrid-hot nature of Mahuang and Guizhi is essential for early-stage cold damage. To claim that because cold qi is constrained and fever is excessive, one should use solely Shi Gao (Gypsum) or Hua Shi (Talc) as the sovereign herb to clear heat, thereby curing the exterior disease, I do not believe. As for when the pathogen has entered the interior with severe heat, using San Yi Cheng Qi Tang, or when exterior and interior are both hot, using Tian Shui San and Liang Ge San, these are key methods for treating heat diseases, which students should study and apply.
Zhang Zihe said: For commoners exposed to wind, seasonal qi, warm diseases, or cold damage within three days, presenting with headache, body heat, and aversion to cold, Tong Sheng San and Yi Yuan San can be used, added with fresh ginger, fermented soybean, and scallion white, decocted in a large bowl. Strain, keep slightly warm, and drink more than half first. After a while, probe the throat with a hairpin to induce vomiting. Then drink the remaining small portion, also slightly warm. Follow with scallion-vinegar spicy-sour soup, cover with blankets, and induce sweating for recovery. If encountering chaotic times, the Neijing states: When Fire Qi is excessive, summer heat prevails, Fire Qi is too strong, damaging Lung Metal, corresponding to the star Yinghuo appearing large and bright. Use acrid-cool agents to resolve it, ensuring success in every attempt. If encountering peaceful times, Sheng Ma Tang (Cimicifuga Decoction), Ge Gen Tang (Pueraria Decoction), and Bai Du San (Detoxify Powder) with acrid-warm agents can be used to resolve, adding scallion root and white fermented soybean, inducing upper emesis and exterior sweating. The Neijing states: Because it is light, scatter it. Scatter means to uplift and disperse, referring to emesis and sweating to uplift and disperse cold-heat pathogens. (Chaotic times refer to periods of epidemic contagion where people die suddenly and violently. Peaceful times refer to periods where people recover from illness without sudden violent death.)
He also said: Cold damage, warm epidemics, seasonal qi, wind exposure, and summerheat are all irregular Qi of the four seasons. Upon initial infection, patients experience headache, aversion to cold, body heat, alternating chills and fever, and stiffness of the waist and spine, indicating Shaoyang Meridian involvement. The Neijing states: Treat the interior first, then the exterior. First decoct Sheng Jiang (Fresh Ginger), Cong Bai (Scallion White), and Dou Chi (Fermented Soybean) to make Shuang Jie San (Double Resolution Powder), induce upper emesis, and sweating will resolve the disease. If unresolved, by the fifth or sixth day, if there is constipation, wheezing/fullness, and delirium, with solid heat and deep pulses in both hands, Tiao Wei Cheng Qi Tang, Da Cheng Qi Tang, or Xiao Cheng Qi Tang can be used for purgation. This is treating the exterior first, then the interior. (Treating interior first then exterior refers to inducing emesis first, which treats the interior; sweating during emesis treats the exterior. Treating exterior first then interior refers to using purgatives only after sweating fails to resolve the condition.)
For cold damage lasting seven to eight days, presenting with jaundice, macules, tidal fever, and abdominal fullness, or phlegm-solidity alternating, even if various Cheng Qi Tangs have been used for purgation, Zhang Zhongjing states: If the Cun Kou (Inch Position) pulse is floating and slippery, Gua Di San (Melon Seed Powder) can be used for emesis. Qi Xuanzi said: When excess is at the top and persists, emesis deprives it; this is what is meant.
(Wang Hu) Note: The above emesis and sweating methods are extremely correct. However, stating that scallion-vinegar spicy-sour soup should be administered is inadvisable. Although the classics state that sour flavors induce upper emesis, their nature is astringent. Vinegar in external-cold soups should not be used. Furthermore, grouping warm epidemics, seasonal qi, wind exposure, and summerheat under cold damage shows that the scope of heat diseases is broad; although names differ, treatment methods are quite similar.
Wang Haizang said: Winter injury by cold leads to warm diseases in spring. This is often due to sexual exhaustion or hard labor, causing interstitial pores to open, Shaoyin failing to store, and Kidney Water drying up. Without water, Spring Wood cannot generate, resulting in warm disease. By late summer, when Wood Qi grows strongly, the source of Water is cut off, unable to nourish transformation, resulting in major heat disease. Thus originates cold damage. Spring brings warm disease, Summer brings heat disease, Late Summer brings major heat disease. Variations follow the seasons. Pathogens affecting superficially result in mild, easily treated disease; deeper affects result in severe, difficult-to-treat disease; deepest affects result in death with no cure.
(Wang Hu) Note: Wang Haizang’s argument implies there is no cold damage in the last three autumn months. Ancient words may not fully capture intent. Since it was stated that variations follow the season, Autumn having much dry-heat means autumn cold damage should be considered dry-heat disease. By late autumn, it becomes identical to regular cold damage. Regarding treatment, it depends on the depth of the pathogen and severity of heat, utilizing sweating, emesis, harmonizing, or purgation, adaptable by students.
Tao Jie’an said: Cold damage is winter cold pathogen injuring the Foot Taiyang Meridian. Immediate onset is called Zheng Shanghan (True Cold Damage). Symptoms include headache, fever, aversion to cold, floating-tight pulse, and absence of sweat. Treatment should release the exterior, naturally resolving heat and cooling the body. If transmitting to Yangming Meridian, symptoms include eye pain, dry nose, insomnia, and slightly flooding pulse. Treatment should release the muscle layer. If transmitting to Shaoyang Meridian, symptoms include hypochondriac pain, deafness, alternating chills/fever, vomiting, bitter taste, and wiry-rapid pulse. Treatment should harmonize exterior and interior. If exterior symptoms resolve and it transmits to the Three Yin, paradoxical heat aversion, removing clothes/blankets, dry thirst, delirium, tidal fever, macules/jaundice, confusion, constipation, and deep-solid-forceful pulse appear. Treatment requires urgent purgation. Once stool passes, heat resolves. For wind-strike, initial symptoms include headache, fever, aversion to cold, floating-relaxed pulse, spontaneous sweating, nasal congestion, and heavy voice. This is named Wind-Strike, also starting as Taiyang disease. If transmitting to other meridians, treat according to previous cold damage clauses. In Spring, Summer, and Autumn, mild aversion to cold, body heat, and slight headache constitute Gan Mao (Common Cold), which is mild non-seasonal cold, not as severe as Winter True Cold Damage.
(Wang Hu) Note: Tao Jie’an discusses Three Yang Meridian symptoms of cold damage transmitting to Three Yin with constipation, requiring urgent purgation. According to Zhang Zhongjing’s method, urgent purgation always uses Da Cheng Qi Tang. The Three Yin (Taiyin, Shaoyin, Jueyin) differ, yet treatment uses one formula for purgation. Why? Zhang Zhongjing states: For Three Yin syndromes entering the Fu, purgation suffices. At this time, the patient’s intestines and stomach have extreme excess heat. Yin meridians are close to the interior; heat steams and郁 (constrains) the Three Yin meridians, manifesting as abdominal fullness, dry throat, dry tongue/mouth, irritability/fullness, and retraction of the genitals. Using Cheng Qi Tang to purge intestinal-stomach excess heat naturally resolves Yin meridian heat. Thus, although there are three Yin meridians, there is only one treatment method. Regarding Zhang Zhongjing’s discussion of Taiyang Wind Strike (Zhong and Shang share the same meaning) vs. Cold Damage, they are similar except for relaxed pulse and spontaneous sweating. Tao mentions nasal congestion and heavy voice, which Danxi attributes to Wind-Strike involving the Lung, and Dai Yuanshi calls new cough. Symptoms include normal diet and bowel/bladder function, constituting a different disease. It cannot be included in Taiyang Meridian examples. Unclear symptom presentation leads only to worldly ridicule.
(Wang Hu) General Note: The above ancient experts’ discussions on cold damage examples largely follow the Neijing’s principles of heat diseases and mutually illuminate Zhang Zhongjing’s cold damage examples. Their treatments involve sweating, emesis, purgation, harmonizing, or acupuncture, with no difference in therapeutic approach. Those studying Zhang Zhongjing’s works should not fail to explore and extend these principles.