经以冬伤于寒，春必病温。寒乃冬月之正邪，乘肾虚潜伏夹脊之内，横连膜原，去少阴尚近，离阳明不远，故溲赤而浑，神烦不寐，身热汗自出，不恶寒而微渴，显系邪气先从内出之于外也。所服之方，多从表散，延今二十三朝，身热转为潮热，如瘅疟之状，反无汗，大便易，色如漆，中有血块，肉全消，筋脉动惕，苔刺唇焦，神昏如醉，伏热稽留，无由以泄，夺血无汗，夺汗无血，表液已枯，里血复竭，邪正两亡，殊难奏捷，勉拟一方，质诸明哲。 大生地（八钱） 乌犀角（钱半） 大白芍（三钱） 生甘草（八分） 当归身（三钱） 桃仁泥（二钱） 粉丹皮（三钱） 怀牛膝（三钱） 活水芦根（二两）
达原饮，达膜原之邪。冲和汤，开太阳之表。服后大汗淋漓，衣被俱湿，身反大热，消渴引饮，舌根黄，舌尖绛，中央苔白不润，溲浑赤，便不解，脉长洪而数，伏邪中溃，郁热暴伸，散漫经中，不传胃府，欲作战汗，宜白虎加人参汤。 生石膏（八钱） 人参（钱半） 知母（三钱） 生甘草（一钱） 粳米（五钱）
过经不解，便溏色绛，苔淡黄，溲浑赤，热潮寅卯，指时而发，伏邪尚在少阳经也。 北柴胡根（一钱） 黄芩（钱半） 炙甘草（五分） 麸炒枳实（一钱） 赤芍（二钱） 桔梗（一钱） 赤茯苓（三钱） 大荸荠（六个）
伏邪盘踞膜原，内与阴争则寒，外与阳争则热，寒热往来，热多寒少，溲赤而浑，便溏色绛，虚烦少寐，汗出如浆，藏阴营液俱伤，伏热邪氛猖獗，正气不支，难以直折，避其来锐，暂以小柴陷胸，从乎中治。 柴胡根（一钱） 黄芩（钱半） 人参（一钱） 炙甘草（五分） 制半夏（钱半） 川黄连（八分） 栝蒌根（三钱） 生姜（一片） 大枣（一枚）
小柴胡守少阳之枢，小陷胸抑纵横之热，服后熟寐移时，大便迤逦而解，从初更至平旦共六次，俱如败酱，溲频数，浑赤之色渐清，寒热往来，热势减半，濈然汗出，遍体凉和，数脉已缓，黄苔亦腐，伏邪中溃，表里分传，正复不能容邪，余氛散漫，击其惰归，宜开鬼门，洁净府。 柴胡根（一钱） 黄芩（钱半） 生甘草梢（八分） 赤茯苓（三钱） 猪苓（钱半） 福泽泻（二钱） 麸炒枳实（一钱） 桔梗（一钱） 飞滑石（三钱）
第八日，寒热如疟，一日数发，苔白溲红，虚烦少寐，旦慧夕加，昼轻夜甚，经水适来，热入血室，殊难调治。不可汗，不可吐，不可下，不可温，不可补，且不可和，姑拟小柴胡，加生地、丹皮、归、芍、红花、青蒿、鳖甲、茯苓、泽泻，从少阳开甲木，帅中正之气入气街，导营热归膀胱，庶不犯中胃二焦，或用犀角地黄汤近于是也。 柴胡根（一钱） 黄芩（钱半） 南沙参（三钱） 炙甘草（五分） 制半夏（钱半） 大生地（三钱） 粉丹皮（钱半） 青蒿梗（钱半） 赤芍（二钱） 红花（一钱） 当归身（三钱） 炙鳖甲（三钱） 赤茯苓（三钱） 福泽泻（钱半）
病经二十八日，口禁不语，身卧如塑，溲浑如柏汁，便解如豚肝，脉空弦无力，肉全消，皮肤甲错，舌卷目上视，心下热炽手，伏邪深陷厥阴，液脱阴枯已著，攻之不可，补之不及，两无生理。勉拟黄龙法，取攻补兼施之意，以副百一之望。 人参（一钱） 生大黄（四钱） 当归身（三钱） 炙甘草（五分） 枳实（一钱） 大生地（四钱）
昨服黄龙法，燥屎仍不下，溲浑赤如故，口禁不能言，身强直，形消脉夺，目眩然不瞑，舌桥而不下，液脱阴亡，髓热发痉，化原已绝，无复资生，神机已息，枯魄独存，虽扁鹊仓公复起，乌能措其手足，或以原方再服一剂。
蒋宝素曰：伏邪者，本篇创立之名。本之《内经》，参之诸家，验之今世，即世人泛指伤寒、温疫、春邪、秋邪、时邪、温病、热病诸证之本原也。然所谓伏者，冬寒伏于膜原之间，化热伤阴，表里分传，多为热证。以始得病，溲即浑浊，或黄或赤为据，（兰亭注曰：小便乃州都气化，邪在表无关于里，何至变色。色变浑浊，显是邪伏于中，化热伤阴之明验也。）其证则溲赤而浑，神烦少寐，或洒洒振寒，或蒸蒸发热，或但热不寒，或汗出热不退，或潮热往来，或寒热如疟，或头疼身痛，或狂躁谵语，或渴或不渴，或反欲热饮，或有汗，或无汗，或汗不达下，舌苔或白或黄，或灰或黑，或滑或涩，或生芒刺，或反无苔而色紫赤，大便或秘或溏，或下利臭水，或如败酱，或带瘀血，或遇湿土司令，酿成湿温，则身痛异常，溲更浑浊，当与湿证门参治。然湿从土化，土无成位，湿无专证，但治伏邪为主，辅以温通治湿之意。其解或战汗自汗，躁汗狂汗，发斑发疹，其剧或发痉，或神昏如醉，或黑苔起刺，唇齿焦枯，或鼻煤舌裂，或呃逆从少腹上冲，或摇头，肢体振掉，或气急痰涌，其脉则忌紧涩细数，而喜和缓滑大。其治或先用吴氏达原饮加减，从乎中治。然后或汗或下。如见三阳表证，加羌活、葛根、柴胡之类。见三阴里证，加大黄、芒硝之类。或先汗而后下，或先下而后汗，或汗而再汗，或下而再下，或但汗不下，或但下不汗，或养阴化邪，或补泻兼施。无为夹阴所惑，误服桂、附则死。（兰亭注曰：夹阴二字，流俗相传，本无所据。若因房室致病，男子为夹阴，则女子为夹阳，殊属可笑，或谓夹虚可也。病在三阴为阴证，孩提之童亦有之，房室何与焉。阴证乃正伤寒家事，伏邪温疫无阴证，或有不过千万中之一二耳。）察其证脉表里虚实，老少强弱，风土寒暄，高粱藜藿，参合为治。善后则宜和胃养阴，汗则九味羌活汤、活人败毒散、柴葛解肌汤、小柴胡汤、吴氏达原饮，加三阳表药，医话柴胡白虎汤之类。下则大小承气汤、调胃承气汤、桃仁承气汤、大柴胡汤、柴胡加芒硝汤、凉膈散、拔萃犀角地黄汤、吴氏达原饮加大黄，医话中承气汤、蒌贝二陈汤之类。养阴化邪，则犀角地黄汤、医话柴胡生地汤之类。补泻兼施，则陶氏黄龙汤、医话大黄人参汤，或半夏泻心汤、十味温胆汤之类。善后则医话归芍二陈汤，加谷芽、神曲之类。此其大略，神而明之，存乎其人。《黄帝内经灵枢·邪气藏府病形篇》曰：正邪之中人也微，先见于色，不知于身，若有若无，若亡若存，有形无形，莫知其情。又五变篇曰：百病之始期也，必先生于风雨寒暑，循毫毛而入腠理，或复还，或留止。《素问·生气通天论》曰：冬伤于寒，春必病温。又八正神明论曰：正邪者，身形若用力，汗出腠理开，逢虚风，其中人也微，故莫知其情，莫见其形。又热论篇曰：今夫热病者，皆伤寒之类也。此《内经》诸篇，分明以正邪内伏，而后发为温疫。又六元正纪大论，六经司天之气，气温草荣民康之际，温厉乃作，远近咸若。此其先有伏邪可据。《难经》温病之脉，行在诸经，不知何经之动。此经中有伏气可知。《周礼》四时皆有厉疾。盖邪伏之深，亦可期年而发。《吕览》《礼记》，以非时之气为疫，即伏邪因感而发。（兰亭注曰：外感之病卒而少，内伏之病迟而多。外受之邪，数日之间。内伏之气，数月之久，则多少可较，证名可征矣。）《史记》齐中御府长信，冬时堕水濡衣，病热伏寒，化热可证。《金匮要略》百合病，必待日数足而后解，亦伏邪之类。《伤寒论》平脉篇，直以伏气为病名。又伤寒例，以寒毒藏于肌肤，春变为温，夏变为暑。春时阳气发于冬时伏寒。冬伤于寒，发为温病，本于经旨。又太阳篇，太阳病发热而渴，不恶寒者为温病，即不恶寒，邪非在表，而渴属内热伏气显然。又阳明篇诸下证，与伏邪入胃之意同。又少阴篇之自利，心下痛，厥阴篇之厥深热亦深诸下证，与伏邪化热伤阴之意同。《太平御览》，（七百四十二卷。）载曹植说疫气致病，悉被褐茹藿之子，荆室蓬户之人，若夫殿处鼎食之家，若是者鲜矣。此亦饥寒伤正，邪伏而后发。巢元方以疫厉与时气温热相类，盖不知由于一气所伏，而有轻重多寡之分耳。《通鉴·唐纪》，关中比岁饥馑，兵民率皆瘦黑，至是麦始熟，市有醉人，当时以为嘉瑞，人乍饱食，死者五之一。此人饱食，非受风寒，盖有伏邪内动。刘河间《宣明方》，治疫厉不宜热药解表，而用白虎汤、凉膈散，明其伏热在内。李东垣《辨惑论》，载壬辰改元，京师戒严，受敌半月，解围之后，都人之不病者，万无一二，既病而死者，继踵不绝，将近百万。岂俱感风寒，皆伏邪所致。《丹溪心法》，温疫，众人一般病者是，治有三法，宜补，宜散，宜降，首用大黄、黄连、黄芩，先攻其里，亦见其内有伏邪。《丹溪心法附余》，附《伤寒直格》心要论，证治诸法，治伏邪甚善，当与吴氏《温疫论》互阅。方约之谓温热之病，因外感内伤，触动郁火，自内而发之于外，此明指邪伏于中。《元史》耶律楚材，用大黄治士卒病疫，足见邪伏于里。王履《溯洄集》，温病热病发于天令暄热之时，怫热自内而达之于外。又云：每见世人治温热病虽误，攻其里亦无大害，误发其表，变不可言，足以明其热之自内达外矣。张景岳以温疫本即伤寒，多发于春夏，必待日数足，然后得汗而解，此与《金匮》百合病之义同，皆有内伏之邪故也。吴又可《温疫论》，治伏邪最切，而反以冬伤于寒，春必病温为非是，盖不知寒乃冬月之正邪，正邪之中人也微，先见于色，不知于身，若有若无，若亡若存，及身形若用力，汗出腠理开，逢虚风为正邪，可伏而后发也。医案医话诸方，治得其中，切于时用，可谓备前人之未备。由是观之，伏邪所从来远矣。然人之强弱不同，攻守有异，大法有三，攻邪为上策，辅正祛邪为中策，养阴固守为下策。盖邪伏于中，犹祸起萧墙之内，邪正交争，势不两立，正气无亏，直攻其邪，邪退而正自复也。若正气有亏，不任攻邪，权宜辅正，且战且守，胜负未可知也。若正气大亏，不能敌邪，惟有养阴一法，悉力固守，冀其邪氛自解，不已危乎。是以正气不虚，伏邪虽重，治得其宜，可奏全捷。惟正虚可畏。不知者反以攻邪太峻，乐用平稳之方，致使邪氛日进，正气日亏，正不胜邪，则轻者重，重者危，卒至不起，乃引为天数，岂不谬哉。
略曰：道光壬午，余合家染疾，长幼相似，祖母氏杨年八十三，其势尤重，亦用达原饮，继进承气汤而愈，寿至九十五而卒。况年少力强者乎。
伏邪论列方
滚痰丸（二十七） 犀角地黄汤（二十八） 调胃承气汤（二十九） 生脉散（十三） 九味羌活汤（三十） 活人败毒散（三十一） 柴葛解肌汤（三十二） 小柴胡汤（三十三） 达原饮（三十四） 大承气汤（三十五） 小承气汤（三十六） 桃仁承气汤（三十七） 大柴胡汤（三十八） 柴胡加芒硝汤（三十九） 凉膈散（四十） 拔萃犀角地黄汤（四十一） 黄龙汤（四十二） 半夏泻心汤（四十三） 十味温胆汤（四十四）
痎疟第九
《内经》说：冬天感受寒邪，春天必定发生温病。寒是冬季的正当邪气，趁着人体肾气虚弱潜伏在脊骨内部，横向连接至膜原（半表半里的部位），距离少阴经尚近，离开阳明经不远，所以出现小便赤黄浑浊，心神烦躁不能入睡，身体发热且自然出汗，不恶寒而轻微口渴，这明显是邪气先从体内向外透发的表现。所服用的方剂，大多从解表发散入手，拖延至今二十三天，身体发热转为潮热，像瘅疟那样的症状，反而无汗，大便容易排出，颜色像漆一样黑，其中有血块，肌肉完全消瘦，筋脉跳动抽搐，舌苔生刺嘴唇焦枯，神志昏迷像喝醉了一样，伏留的热邪稽留不去，没有途径可以宣泄，失血则无汗，大汗则伤血，体表津液已经枯竭，体内血液又已耗尽，邪气和正气都极度衰弱，很难迅速见效，勉强拟定一方，请教给明智的人。大生地（八钱） 乌犀角（一钱半） 大白芍（三钱） 生甘草（八分） 当归身（三钱） 桃仁泥（二钱） 粉丹皮（三钱） 怀牛膝（三钱） 活水芦根（二两）
达原饮，旨在通达膜原之邪。冲和汤，旨在开通太阳经之表。服用后大汗淋漓，衣被都湿透了，身体反而更加高热，消渴想喝水，舌根发黄，舌尖绛红，中间苔白且不润，小便浑浊赤色，大便不通，脉象长洪而数，伏邪从中溃散，郁积的热邪暴烈伸展，散漫在经络之中，不传入胃腑，想要通过战汗来解除，适宜用白虎加人参汤。生石膏（八钱） 人参（一钱半） 知母（三钱） 生甘草（一钱） 粳米（五钱）
过了经期病仍未解，大便溏泄颜色绛红，苔淡黄，小便浑浊赤色，热潮在寅卯时发作，手指时而抽动，伏邪还在少阳经。北柴胡根（一钱） 黄芩（一钱半） 炙甘草（五分） 麸炒枳实（一钱） 赤芍（二钱） 桔梗（一钱） 赤茯苓（三钱） 大荸荠（六个）
伏邪盘踞在膜原，向内与阴气相争则发冷，向外与阳气相争则发热，寒热往来，热多寒少，小便赤黄浑浊，大便溏泄颜色绛红，虚烦少寐，出汗如浆，脏阴和营液都受到损伤，伏热邪气猖獗，正气无法支撑，难以直接折服，避开其锐气，暂时用小柴陷胸汤，从半表半里之间治疗。柴胡根（一钱） 黄芩（一钱半） 人参（一钱） 炙甘草（五分） 制半夏（一钱半） 川黄连（八分） 栝蒌根（三钱） 生姜（一片） 大枣（一枚）
小柴胡汤守护少阳枢机，小陷胸汤抑制纵横交结的热邪，服用后熟睡了一段时间，大便缓缓排出，从初更到平旦共六次，都像败酱草的颜色，小便频数，浑浊赤色逐渐变清，寒热往来，热势减半，持续出汗，全身凉爽平和，数脉已经缓和，黄苔也开始腐化，伏邪从中溃散，表里分别传变，正气恢复后不能容纳邪气，余下的邪气散漫，趁其懈怠归去之时攻击，适宜开鬼门（发汗），洁净府（利小便）。柴胡根（一钱） 黄芩（一钱半） 生甘草梢（八分） 赤茯苓（三钱） 猪苓（一钱半） 福泽泻（二钱） 麸炒枳实（一钱） 桔梗（一钱） 飞滑石（三钱）
第八天，寒热像疟疾，一天发作多次，苔白小便红，虚烦少寐，早晨清醒晚上加重，白天轻晚上重，月经刚好来潮，热入血室，非常难调理。不可发汗，不可催吐，不可攻下，不可温补，也不可用和解法，姑且拟定小柴胡汤，加入生地、丹皮、当归、芍药、红花、青蒿、鳖甲、茯苓、泽泻，从少阳开启甲木之气，率领中正之气进入气街，引导营分之热归于膀胱，这样才不会侵犯中焦胃和二焦，或者使用犀角地黄汤也接近这个意思。柴胡根（一钱） 黄芩（一钱半） 南沙参（三钱） 炙甘草（五分） 制半夏（一钱半） 大生地（三钱） 粉丹皮（一钱半） 青蒿梗（一钱半） 赤芍（二钱） 红花（一钱） 当归身（三钱） 炙鳖甲（三钱） 赤茯苓（三钱） 福泽泻（一钱半）
患病二十八天，牙关紧闭不能说话，身体躺卧僵硬如塑像，小便浑浊像柏树汁，大便排出像猪肝色，脉象空弦无力，肌肉完全消瘦，皮肤粗糙如鳞甲，舌头卷缩眼睛向上视，心下部灼热手按之烫手，伏邪深陷厥阴经，津液脱失阴精枯竭已经很明显，攻邪不可以，补益来不及，两方都没有生机。勉强拟定黄龙汤法，取攻补兼施的意思，以符合百中救一的希望。人参（一钱） 生大黄（四钱） 当归身（三钱） 炙甘草（五分） 枳实（一钱） 大生地（四钱）
昨天服用黄龙汤法，燥屎仍然没有下来，小便浑浊赤色照旧，牙关紧闭不能说话，身体强直，形体消瘦脉象衰夺，目眩然不闭眼，舌体僵硬不下垂，津液脱失阴精亡失，髓热引发痉证，化源已经断绝，不再有资生之源，神机已经停止，枯魄独存，即使扁鹊仓公复活，又能如何措手足呢，或许用原方再服一剂。
蒋宝素说：伏邪，是本文创立的名称。依据《内经》，参考各家学说，验证于当今时代，就是世人泛指伤寒、温疫、春邪、秋邪、时邪、温病、热病各种证候的根本原因。然而所谓的“伏”，是指冬天的寒邪潜伏在膜原之间，化为热邪损伤阴液，表里分别传变，多为热证。以刚得病时，小便即浑浊，或黄或赤为依据。（兰亭注曰：小便乃州都气化功能，邪在表与里无关，怎么会变色。颜色变得浑浊，显然是邪气潜伏在中焦，化为热邪损伤阴液的明证。）其症状则是小便赤黄浑浊，心神烦躁少寐，或洒洒恶寒，或蒸蒸发热，或但热不寒，或出汗后热不退，或潮热往来，或寒热像疟疾，或头疼身痛，或狂躁谵语，或渴或不渴，或反想喝热饮，或有汗，或无汗，或汗出不达下肢，舌苔或白或黄，或灰或黑，或滑或涩，或生芒刺，或反无苔而色紫赤，大便或秘结或溏泄，或下利臭水，或像败酱，或带瘀血，如果遇到湿土当令，酿成湿温，则身体疼痛异常，小便更加浑浊，应当与湿证门类参照治疗。然而湿从土化，土没有固定的位置，湿没有专门的证候，只以治疗伏邪为主，辅以温通治湿的意思。其解除方式或是战汗自汗，或是躁汗狂汗，或是发斑发疹，其剧烈者或发痉，或神志昏迷像喝醉，或黑苔起刺，唇齿焦枯，或鼻煤舌裂，或呃逆从少腹上冲，或摇头，肢体震颤抖动，或气急痰涌，其脉象忌讳紧涩细数，而喜欢和缓滑大。其治疗方法或先用吴氏达原饮加减，从半表半里之间治疗。然后或发汗或攻下。如果见到三阳经表证，加羌活、葛根、柴胡之类。见到三阴经里证，加大黄、芒硝之类。或先发汗而后攻下，或先攻下而后发汗，或发汗后再发汗，或攻下后再攻下，或只发汗不攻下，或只攻下不发汗，或养阴化邪，或补泻兼施。不要被夹阴所迷惑，误服桂枝、附子则会死亡。（兰亭注曰：夹阴二字，流俗相传，本无依据。如果因房事致病，男子为夹阴，则女子为夹阳，实在可笑，或者说夹虚也可以。病在三阴为阴证，孩童也有，房事有什么关系呢。阴证乃是正伤寒的家事，伏邪温疫没有阴证，或许有不过千万中之一二罢了。）观察其证候脉象表里虚实，老少强弱，风土寒暖，饮食粗细，综合参合进行治疗。善后调理则宜和胃养阴，发汗则用九味羌活汤、活人败毒散、柴葛解肌汤、小柴胡汤、吴氏达原饮，加上三阳经表药，医话中的柴胡白虎汤之类。攻下则用大小承气汤、调胃承气汤、桃仁承气汤、大柴胡汤、柴胡加芒硝汤、凉膈散、拔萃犀角地黄汤、吴氏达原饮加大黄，医话中的中承气汤、蒌贝二陈汤之类。养阴化邪，则用犀角地黄汤、医话中的柴胡生地汤之类。补泻兼施，则用陶氏黄龙汤、医话中的大黄人参汤，或半夏泻心汤、十味温胆汤之类。善后调理则用医话中的归芍二陈汤，加谷芽、神曲之类。这是大概情况，神妙而明白它，在于个人运用。《黄帝内经灵枢·邪气藏府病形篇》说：正邪中人很轻微，先见于面色，身体不知道，若有若无，若亡若存，有形无形，没人知道它的真情。又说五变篇：百病开始的时候，一定先生于风雨寒暑，顺着毫毛进入腠理，有的返回，有的停留。《素问·生气通天论》说：冬天伤害于寒，春天必定病温。又说八正神明论：正邪，身形如果用力，汗出腠理开，逢遇虚风，其中人很轻微，所以没人知道它的真情，没人看见它的形状。又说热论篇：现在的热病，都是伤寒之类。这些《内经》各篇，分明以正邪内伏，而后发为温疫。又说六元正纪大论，六经司天之气，气温草荣民康之际，温厉乃作，远近都一样。这是先有伏邪可依据。《难经》温病的脉，行在诸经，不知道哪经发动。这说明经中有伏气可知。《周礼》四季都有厉疾。大概邪气伏藏很深，也可以期待一年才发作。《吕览》《礼记》，把非时之气称为疫，就是伏邪因感而发。（兰亭注曰：外感之病突然而少，内伏之病迟缓而多。外受之邪，数日之间。内伏之气，数月之久，则多少可以比较，证名可以征验了。）《史记》记载齐中御府长信，冬天落水湿衣，病热伏寒，化为热邪可以证明。《金匮要略》百合病，必须等到日数足而后解，也是伏邪之类。《伤寒论》平脉篇，直接把伏气作为病名。又说伤寒例，以寒毒藏于肌肤，春天变为温病，夏天变为暑病。春天阳气发于冬天伏寒。冬天伤害于寒，发为温病，本于经旨。又说太阳篇，太阳病发热而渴，不恶寒者为温病，即不恶寒，邪不在表，而渴属内热伏气显然。又说阳明篇诸下证，与伏邪入胃的意思相同。又说少阴篇之自利，心下痛，厥阴篇之厥深热亦深诸下证，与伏邪化热伤阴的意思相同。《太平御览》，（七百四十二卷。）记载曹植说疫气致病，都被穿粗布吃野菜的孩子，住在荆棘蓬户的人，至于那些殿处鼎食之家，这样的人很少了。这也是饥寒伤正，邪伏而后发。巢元方认为疫厉与时气温热相似，大概不知道由于一气所伏，而有轻重多寡之分罢了。《通鉴·唐纪》，关中连年饥荒，兵民大都瘦黑，这时麦子才熟，市场上有醉人，当时认为是嘉瑞，人突然饱食，死者五分之一。这人饱食，不是受风寒，大概是有伏邪内动。刘河间《宣明方》，治疫厉不宜用热药解表，而用白虎汤、凉膈散，明确其伏热在内。李东垣《辨惑论》，记载壬辰改元，京师戒严，受敌半月，解围之后，都城中不生病的人，万无一二，既病而死的，继踵不绝，将近百万。难道都感风寒，都是伏邪所致吗？《丹溪心法》，温疫，众人一般病的是，治有三法，宜补，宜散，宜降，首用大黄、黄连、黄芩，先攻其里，也见其内有伏邪。《丹溪心法附余》，附《伤寒直格》心要论，证治诸法，治伏邪甚好，应当与吴氏《温疫论》互阅。方约之说温热之病，因外感内伤，触动郁火，自内而发之于外，这明确指邪伏于中。《元史》耶律楚材，用大黄治士卒病疫，足以见邪伏于里。王履《溯洄集》，温病热病发于天令暄热之时，怫热自内而达之于外。又说：每见世人治温热病虽误，攻其里亦无大害，误发其表，变不可言，足以明其热之自内达外矣。张景岳认为温疫本就是伤寒，多发于春夏，必须等到日数足，然后得汗而解，这与《金匮》百合病的意思相同，都有内伏之邪的缘故。吴又可《温疫论》，治伏邪最切，却反以冬伤于寒，春必病温为非是，大概不知道寒是冬季的正当邪气，正邪中人很轻微，先见于面色，身体不知道，若有若无，若亡若存，及身形如果用力，汗出腠理开，逢遇虚风为正邪，可伏而后发也。医案医话诸方，治得其中，切于时用，可谓备前人之未备。由此看来，伏邪由来已久。然而人的强弱不同，攻守有异，大法有三，攻邪为上策，辅正祛邪为中策，养阴固守为下策。大概邪伏于中，犹祸起萧墙之内，邪正交争，势不两立，正气无亏，直攻其邪，邪退而正自复也。若正气有亏，不任攻邪，权宜辅正，且战且守，胜负未可知也。若正气大亏，不能敌邪，惟有养阴一法，悉力固守，冀其邪氛自解，不已危乎。是以正气不虚，伏邪虽重，治得其宜，可奏全捷。惟正虚可畏。不知者反以攻邪太峻，乐用平稳之方，致使邪氛日进，正气日亏，正不胜邪，则轻者重，重者危，卒至不起，乃引为天数，岂不谬哉。
简略地说：道光壬午年，我全家染病，长幼症状相似，祖母杨氏八十三岁，病情尤其严重，也用达原饮，接着进服承气汤而痊愈，寿至九十五岁去世。何况年轻力壮的人呢。
伏邪论列方
滚痰丸（二十七） 犀角地黄汤（二十八） 调胃承气汤（二十九） 生脉散（十三） 九味羌活汤（三十） 活人败毒散（三十一） 柴葛解肌汤（三十二） 小柴胡汤（三十三） 达原饮（三十四） 大承气汤（三十五） 小承气汤（三十六） 桃仁承气汤（三十七） 大柴胡汤（三十八） 柴胡加芒硝汤（三十九） 凉膈散（四十） 拔萃犀角地黄汤（四十一） 黄龙汤（四十二） 半夏泻心汤（四十三） 十味温胆汤（四十四）
痎疟第九
The *Neijing* states: "If one is injured by cold in winter, one will surely suffer from warm diseases in spring." Cold is the proper pathogen of winter. It takes advantage of kidney deficiency to lie latent within the spine, extending horizontally to connect with the membrane source (a location between the interior and exterior). Being close to the Shaoyin meridian and not far from the Yangming meridian, it manifests as dark and turbid urine, mental restlessness and insomnia, body heat with spontaneous sweating, aversion to cold being absent but slight thirst present. This clearly indicates that the pathogenic factor first emerges from the interior to the exterior. The formulas taken so far have mostly focused on releasing the exterior, delaying the condition for twenty-three days. The body heat has turned into tidal fever, resembling the symptoms of Dan Malaria (severe malaria), yet there is no sweat. Stool is easy to pass, black like lacquer, containing blood clots. Muscles are completely wasted, tendons and vessels twitch and tremble, tongue coating has prickles, lips are scorched, and consciousness is clouded as if drunk. The latent heat lingers without a way to vent. Loss of blood leads to lack of sweat; excessive sweating depletes blood. Exterior fluids are exhausted, and interior blood is depleted. Both pathogen and healthy qi are exhausted, making rapid recovery difficult. I tentatively prescribe a formula for the consideration of the wise. Sheng Dihuang (Rehmanniae Radix Preparata) 8 qian, Wu Xijiao (Rhinocerotis Cornu) 1.5 qian, Da Baishao (Paeoniae Radix Alba) 3 qian, Sheng Gancao (Glycyrrhizae Radix et Rhizoma) 8 fen, Danggui Shen (Angelicae Sinensis Radix) 3 qian, Taoren Ni (Persicam Semen cum pulpa) 2 qian, Fen Danpi (Moutan Cortex) 3 qian, Huai Niuxi (Achyranthis Bidentatae Radix) 3 qian, Huoshui Lugeng (Phragmitis Rhizoma cum aqua viva) 2 liang.
Dayuan Yin (Decoction to Reach the Membrane Source) aims to reach the pathogen in the membrane source. Chonghe Tang (Harmonizing Decoction) aims to open the Taiyang exterior. After taking it, profuse sweating occurs, wetting clothes and bedding. The body becomes even hotter, with intense thirst and desire to drink. Tongue root is yellow, tongue tip is crimson, center coating is white and unmoistened. Urine is turbid and red. Stool is blocked. Pulse is long, surging, and rapid. The latent pathogen collapses from within, stagnant heat violently expands, scattering through the meridians without transmitting to the stomach fu-organ. It desires to resolve via battle-sweat. Baihu Jia Renshen Tang (White Tiger Decoction plus Ginseng) is suitable. Sheng Shigao (Gypsum Fibrosum) 8 qian, Renshen (Ginseng Radix et Rhizoma) 1.5 qian, Zhimu (Anemarrhenae Rhizoma) 3 qian, Sheng Gancao (Glycyrrhizae Radix et Rhizoma) 1 qian, Jingmi (Oryza Sativa) 5 qian.
After passing the meridian stage, the disease remains unresolved. Stool is loose and crimson-colored, coating is pale yellow, urine is turbid and red. Tidal fever occurs at Yin-Mao hours (5-7 AM), with occasional finger twitching. The latent pathogen remains in the Shaoyang meridian. Bei Chaihu Gen (Bupleuri Radix) 1 qian, Huangqin (Scutellariae Radix) 1.5 qian, Zhi Gancao (Prepared Glycyrrhizae Radix et Rhizoma) 5 fen, Fu Chao Zhishi (Immature Bitter Orange Fruit fried with bran) 1 qian, Chi Shao (Paeoniae Radix Rubra) 2 qian, Jiegeng (Platycodonis Radix) 1 qian, Chi Fuling (Poria with Red Hostwood) 3 qian, Da Biqi (Dioscoreae Bulbiferae) 6 pieces.
The latent pathogen occupies the membrane source. Contending internally with yin causes chills; contending externally with yang causes fever. There is alternating chills and fever, with more heat than chills. Urine is red and turbid, stool is loose and crimson. There is empty irritability and little sleep. Sweat flows like syrup. Visceral yin and nutritive fluids are both damaged. The latent heat and pathogenic atmosphere are rampant. Healthy qi cannot support itself, making direct suppression difficult. Avoiding its sharpness, temporarily use Xiaochai Hu Xiongtan Tang (Minor Bupleurum and Phlegm-Resolving Decoction) to treat from the middle (half-exterior/half-interior). Chaihu Gen (Bupleuri Radix) 1 qian, Huangqin (Scutellariae Radix) 1.5 qian, Renshen (Ginseng Radix et Rhizoma) 1 qian, Zhi Gancao (Prepared Glycyrrhizae Radix et Rhizoma) 5 fen, Zhi Banxia (Pinelliae Rhizoma preparatum) 1.5 qian, Chuan Huanglian (Coptidis Rhizoma) 8 fen, Gualou Gen (Trichosanthis Radix) 3 qian, Shengjiang (Zingiberis Rhizoma Recens) 1 slice, Dazao (Jujubae Fructus) 1 piece.
Xiaochai Hu Tang (Minor Bupleurum Decoction) guards the pivot of Shaoyang. Xiaoxiantan Tang (Minor Phlegm-Resolving Decoction) suppresses crisscrossing heat. After taking it, deep sleep lasts for a while. Stool passes gradually. From early night to dawn, six times total, all resembling fermented bean curd residue. Urination is frequent, turbid red color gradually clears. Alternating chills and fever, heat intensity halves. Continuous sweating, whole body cool and harmonious. Rapid pulse has slowed. Yellow coating has rotted. Latent pathogen collapses from within, transmitting separately to exterior and interior. Healthy qi recovers and cannot tolerate the pathogen. Remaining pathogen scatters. Strike when it is lazy and retreating. It is appropriate to open the ghost gate (induce sweating) and purify the bladder (promote urination). Chaihu Gen (Bupleuri Radix) 1 qian, Huangqin (Scutellariae Radix) 1.5 qian, Sheng Gancao Shao (Tip of Prepared Glycyrrhizae Radix et Rhizoma) 8 fen, Chi Fuling (Poria with Red Hostwood) 3 qian, Zhuling (Polyporus) 1.5 qian, Fu Zexie (Alismatis Rhizoma) 2 qian, Fu Chao Zhishi (Immature Bitter Orange Fruit fried with bran) 1 qian, Jiegeng (Platycodonis Radix) 1 qian, Fei Huashi (Talcum) 3 qian.
On the eighth day, chills and fever resemble malaria, occurring several times a day. Coating is white, urine is red. Empty irritability and little sleep. Clearer in morning, worse in evening. Lighter by day, severe by night. Menstruation just started. Heat enters the Blood Chamber (Xue Shi). Very difficult to regulate. Do not induce sweating, do not provoke vomiting, do not purge, do not warm-tonify, do not harmonize. Tentatively prescribe Xiaochai Hu Tang, adding Shengdi, Danpi, Danggui, Shaoyao, Honghua, Qinghao, Biejia, Fuling, Zexie. Open Jia Wood from Shaoyang, lead the central-righteous qi into the Qi Street, guide nutritive heat back to the Bladder. Thus avoiding the Middle Jiao Stomach and Lower Jiao. Or use Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction), which is close to this intent. Chaihu Gen (Bupleuri Radix) 1 qian, Huangqin (Scutellariae Radix) 1.5 qian, Nanshashen (Adenophorae Radix) 3 qian, Zhi Gancao (Prepared Glycyrrhizae Radix et Rhizoma) 5 fen, Zhi Banxia (Pinelliae Rhizoma preparatum) 1.5 qian, Da Shengdi (Rehmanniae Radix Preparata) 3 qian, Fen Danpi (Moutan Cortex) 1.5 qian, Qinghao Geng (Artemisiae Annuae Herba Caulis) 1.5 qian, Chi Shao (Paeoniae Radix Rubra) 2 qian, Honghua (Carthami Flos) 1 qian, Danggui Shen (Angelicae Sinensis Radix) 3 qian, Zhi Biejia (Testudinis et Carapax et Plastrum preparatum) 3 qian, Chi Fuling (Poria with Red Hostwood) 3 qian, Fu Zexie (Alismatis Rhizoma) 1.5 qian.
Ill for twenty-eight days. Jaw locked, unable to speak. Body lying stiff as a statue. Urine turbid like cypress juice. Stool passed like pig liver. Pulse empty, wiry, and powerless. Muscles completely wasted. Skin rough like scales. Tongue curled, eyes looking up. Heat blazing in the epigastrium, hot to touch. Latent pathogen deeply sinks into Jueyin meridian. Fluid depletion and yin exhaustion are evident. Attack is impossible, tonification is too late. No physiological basis for either. Tentatively apply Huanglong Fa (Method of Yellow Dragon), taking the meaning of attacking and tonifying simultaneously, to fulfill the hope of saving one in a hundred. Renshen (Ginseng Radix et Rhizoma) 1 qian, Sheng Dahuang (Rhei Radix et Rhizoma raw) 4 qian, Danggui Shen (Angelicae Sinensis Radix) 3 qian, Zhi Gancao (Prepared Glycyrrhizae Radix et Rhizoma) 5 fen, Zhishi (Immature Bitter Orange Fruit) 1 qian, Da Shengdi (Rehmanniae Radix Preparata) 4 qian.
Yesterday took Huanglong Fa. Dry feces still not down. Urine turbid red as before. Jaw locked, unable to speak. Body rigid. Form wasted, pulse depleted. Eyes dizzy, unable to close. Tongue bridge stiff, unable to lower. Fluid depletion and yin loss. Marrow heat induces spasms. Origin of transformation is cut off. No more nourishment. Divine mechanism has ceased. Withered soul remains alone. Even if Bian Que or Cang Gong rose again, how could they manage their hands and feet? Perhaps take the original formula for another dose.
Jiang Baosu says: "Latent Pathogen" (Fu Xie) is a term created in this chapter. Based on the *Neijing*, referencing various schools, verified in modern times, it refers to the root origin of what people generally refer to as Cold Damage, Warm Epidemic, Spring Evil, Autumn Evil, Seasonal Evil, Warm Disease, and Hot Disease. However, what is meant by "latent" is winter cold lying latent between the membrane sources, transforming into heat and damaging yin, transmitting separately to exterior and interior, mostly manifesting as heat syndromes. The basis is that upon initial onset, urine is immediately turbid, either yellow or red. (Lanting notes: Urine is the result of Qi transformation in the State Capital (Bladder). If pathogen is in the exterior, it has nothing to do with the interior, why would color change? Color becoming turbid is clear evidence of pathogen lying latent in the middle, transforming into heat and damaging yin.) Symptoms include red and turbid urine, mental restlessness and little sleep, or shivering chills, or steaming fever, or only heat without chills, or heat not subsiding after sweating, or tidal fever and alternation, or chills and fever like malaria, or headache and body pain, or mania and delirium, or thirst or no thirst, or desire for hot drinks, or sweating or no sweating, or sweat not reaching below, tongue coating white or yellow, gray or black, slippery or rough, or having prickles, or conversely no coating but purple-red color, stool constipated or loose, or diarrhea of foul water, or resembling fermented bean curd residue, or carrying stasis blood. If encountering damp-earth ruling time, brewing Damp-Warmth, then body pain is abnormal, urine even more turbid. Should be treated with reference to the Damp Syndrome category. However, damp transforms from earth, earth has no fixed position, damp has no specific syndrome. Treat latent pathogen as primary, assisted by warming and unblocking to treat damp. Resolution may come via battle-sweat or spontaneous sweat, restless sweat or wild sweat, eruption of macules or papules. Severe cases may induce spasms, clouded consciousness like drunkenness, black coating with prickles, scorched lips and teeth, coal-like nose and cracked tongue, hiccups rushing up from lower abdomen, head shaking, limb trembling, shortness of breath and gurgling phlegm. Pulse should avoid tight, choppy, fine, and rapid; prefer harmonious, slow, slippery, and large. Treatment may first use Wu's Dayuan Yin modified, treating from the middle. Then either sweat or purge. If seeing Taiyang, Yangming, Shaoyang exterior signs, add Qianghuo, Gegen, Chaihu etc. If seeing Taiyin, Shaoyin, Jueyin interior signs, add Dahuang, Mangxiao etc. Or sweat first then purge, or purge first then sweat, or sweat twice, or purge twice, or only sweat not purge, or only purge not sweat, or nourish yin to transform pathogen, or tonify and purge together. Do not be confused by "夾阴" (Clasping Yin); mistakenly using Guizhi and Fuzi will cause death. (Lanting notes: "Clasping Yin" is a folk saying without basis. If caused by sexual activity, men are Clasping Yin, then women would be Clasping Yang, which is ridiculous. One might say "Clasping Deficiency". Yin syndromes in the Three Yin meridians occur even in children; what does sex have to do with it? Yin syndromes belong to proper Cold Damage. Latent pathogen warm epidemics have no Yin syndromes, perhaps one or two in ten thousand.) Observe syndrome, pulse, exterior/interior, deficiency/excess, age, strength, local climate, diet rich/coarse, combine for treatment. Post-recovery should harmonize stomach and nourish yin. For sweating, use Jiwei Qianghuo Tang, Huren Baidu San, Chaige Jieji Tang, Xiaochai Hu Tang, Wu's Dayuan Yin, adding Taiyang exterior herbs, or Chaihu Baihu Tang from medical conversations. For purging, use Da Chengqi Tang, Xiaochengqi Tang, Tiaowei Chengqi Tang, Tao Ren Chengqi Tang, Da Chaihu Tang, Chaihu Jia Mangxiao Tang, Liangge San, Bacui Xijiao Dihuang Tang, Wu's Dayuan Yin plus Dahuang, or Zhong Chengqi Tang, Loubei Erchen Tang from medical conversations. For nourishing yin to transform pathogen, use Xijiao Dihuang Tang, or Chaihu Shengdi Tang from medical conversations. For tonifying and purging together, use Tao's Huanglong Tang, Dahuang Renshen Tang from medical conversations, or Banxia Xiexin Tang, Shiwei Wendan Tang. Post-recovery use Guishao Erchen Tang from medical conversations, adding Guya and Shenqu. This is the general outline. To understand it divinely and clearly depends on the individual. *Lingshu · Xieqi Zangfu Bingxing Pian* says: When Zheng (Upright/Proper) evil attacks humans, it is subtle. First seen in complexion, unknown in body, seeming to exist and not exist, seeming to perish and remain, visible or invisible, no one knows its true nature. Also *Wubian Pian* says: At the beginning of all diseases, they must arise from wind, rain, cold, and summer heat, entering through hair follicles into Couli. Some return, some stay. *Suwen · Shengqi Tongtian Lun* says: Winter injury by cold leads to warm disease in spring. *Bazheng Shenming Lun* says: Zheng evil, if body exerts force, sweat opens Couli, meeting deficient wind, attack is subtle, so no one knows its nature or sees its form. *Relun Pian* says: Current hot diseases are all categories of Cold Damage. These chapters of *Neijing* clearly show that Zheng evil lies latent inside, then erupts as warm epidemic. *Liuyuan Zhengji Dalun* discusses Six Meridians ruling Qi. When temperature warms, grass flourishes, people are healthy, yet warm plagues arise, near and far alike. This shows prior latent pathogen exists. *Nanjing* says pulse of warm disease travels through various meridians, not knowing which meridian moves. This shows latent Qi in meridians can be known. *Zhouli* says there are plague diseases in all four seasons. Probably because pathogen lies deep, it can wait a year to erupt. *Lüshi Chunqiu* and *Liji* call non-seasonal Qi "Epidemic", which is latent pathogen erupting due to stimulation. (Lanting notes: External attacks are sudden and few; internal latent diseases are delayed and many. External pathogens take days; internal latent Qi takes months. Thus quantity can be compared, syndrome names verified.) *Shiji* records Changxin of Qi's Imperial Library, who fell into water in winter, wet clothes, suffered heat from latent cold, transforming into heat proves this. *Jingui Yaolue* Helue Disease requires sufficient days to resolve, also a type of latent pathogen. *Shanghan Lun* Pingmai Pian directly uses "Latent Qi" as a disease name. *Shanghan Li* says cold poison hides in skin and muscles, changing to warm in spring, summer heat in summer. Spring Yang Qi erupts from winter latent cold. Winter injury by cold erupts as warm disease, based on classic principles. *Taiyang Pian* says Taiyang disease with fever, thirst, and no aversion to cold is warm disease. No aversion means pathogen is not in exterior; thirst belongs to interior heat latent Qi, obviously. *Yangming Pian* various purgative syndromes match the meaning of latent pathogen entering stomach. *Shaoyin Pian* spontaneous diarrhea, epigastric pain; *Jueyin Pian* deep cold with deep heat, various purgative syndromes match the meaning of latent pathogen transforming heat and damaging yin. *Taiping Yulan* Vol 742 records Cao Zhi saying plague qi causes illness, affecting those wearing coarse cloth and eating vegetables, living in thorny huts. Those in palaces with tripod meals rarely get it. This is hunger and cold damaging upright Qi, pathogen lying latent then erupting. Chao Yuanfang considers plague similar to seasonal warm heat, probably not knowing it stems from one latent Qi with differences in severity and quantity. *Tongjian · Tang Ji* records Guanzhong famine years, soldiers and people thin and black. Wheat ripened, market had drunk people, considered auspicious. People suddenly ate full, one-fifth died. This full eating was not from wind-cold, likely latent pathogen moving internally. Liu Hejian's *Xuanming Fang* treats plague不宜热药解表 (not suitable for hot herbs to release exterior), using Baihu Tang and Liangge San, clarifying latent heat inside. Li Dongyuan's *Bianhuo Lun* records Renchen era change, capital under siege, enemy for half month. After relief, among citizens, not sick was one in ten thousand. Those sick and dying followed each other, nearing a million. Did they all catch wind-cold? All caused by latent pathogen? *Danxi Xinfa* says warm epidemic, where everyone gets same sickness, has three treatments: tonify, disperse, descend. First use Dahuang, Huanglian, Huangqin, attack interior first, showing latent pathogen inside. *Danxi Xinfa Fuyu* attaches *Shanghan Zhige* core theory, various syndrome treatments, treats latent pathogen very well, should be read with Wu's *Wenyi Lun*. Fang Yuezhi says warm-hot diseases, due to external attack and internal injury, stirring stagnant fire, erupting from interior to exterior, clearly pointing to pathogen lying latent in middle. *Yuan Shi* Ye Lü Chucai used Dahuang to treat soldiers' plague, showing pathogen lying in interior. Wang Lü's *Suhui Ji* says warm-hot diseases erupt during warm weather, stifled heat reaches exterior from interior. Also: Often see people treating warm-hot diseases wrongly. Attacking interior causes little harm; mistakenly releasing exterior causes indescribable changes, enough to prove heat reaches exterior from interior. Zhang Jingyue considers warm epidemic originally Cold Damage, mostly occurring in spring/summer, requiring sufficient days to sweat and resolve, same meaning as *Jingui* Helue Disease, both having internal latent pathogen. Wu Youke's *Wenyi Lun* treats latent pathogen closely, yet denies "Winter injury by cold, spring warm disease" is wrong, probably not knowing cold is winter's proper pathogen, Zheng evil attacks subtly, seen in complexion, unknown in body, seeming exist/not exist, seeming perish/remains. If body exerts force, sweat opens Couli, meeting deficient wind as Zheng evil, can lie latent then erupt. Medical cases and conversations formulas treat appropriately, fitting current needs, preparing what predecessors lacked. Thus, latent pathogen has ancient origins. However, human strength varies, attack/defense differs. Three major methods: Attacking pathogen is best strategy; assisting upright to expel pathogen is medium; nourishing yin and holding fast is worst. Pathogen lying in middle is like disaster rising from within walls. Pathogen and upright contend, incompatible. If upright is not deficient, directly attack pathogen; pathogen retreats, upright recovers. If upright is deficient, cannot bear attack, temporarily assist upright, fight and defend, victory uncertain. If upright greatly deficient, cannot oppose pathogen, only method is nourishing yin, fully defending, hoping pathogen resolves itself, isn't this dangerous? Therefore, if upright is not deficient, even heavy latent pathogen, if treated appropriately, complete success can be achieved. Only upright deficiency is feared. Ignorant ones think attacking pathogen is too harsh, preferring mild formulas, causing pathogen to advance daily, upright to decline daily. Upright cannot overcome pathogen, light becomes heavy, heavy becomes critical, finally fatal, then blaming fate, how absurd!
Briefly: In Renwu year of Daoguang, my whole family contracted disease, elders and young similar. Grandmother Yang, 83 years old, condition especially severe. Also used Dayuan Yin, followed by Chengqi Tang, recovered, lived to 95 then died. How much more for young and strong?
Formulas Listed in Latent Pathogen Discussion:
Guntan Wan (27), Xijiao Dihuang Tang (28), Tiaowei Chengqi Tang (29), Shengmai San (13), Jiwei Qianghuo Tang (30), Huren Baidu San (31), Chaige Jieji Tang (32), Xiaochai Hu Tang (33), Dayuan Yin (34), Dachengqi Tang (35), Xiaochengqi Tang (36), Tao Ren Chengqi Tang (37), Dacha Hu Tang (38), Chaihu Jia Mangxiao Tang (39), Liangge San (40), Bacui Xijiao Dihuang Tang (41), Huanglong Tang (42), Banxia Xiexin Tang (43), Shiwei Wendan Tang (44).
Jie Malaria Chapter 9