经义
冬伤于寒，春必病温。○冬不藏精，春必病温，○凡病伤寒而成温者，先夏至日为病温。○太阳之脉，色
荣颧骨，热病也。荣未交，曰今且得汗，待时而已；与厥阴脉争见者，死期不过三日，其热病内连肾。少阳之
脉，色荣颊前，热病也。荣未交，曰今且得汗，待时而已；与少阴脉争见者，死期不过三日。○帝曰∶有病温
者，汗出辄复热，而脉躁疾，不为汗衰，狂言不能食，病
名为何？岐伯曰∶病名阴阳交，交者死也。帝曰∶愿闻其说。岐伯曰∶人所以汗出者，皆生于谷，谷生于精。
今邪气交争于骨肉而得汗者，是邪却而精胜也。精胜，则当能食而不复热。复热者，邪气也。汗者，精气也。
今汗出而辄复热者，是邪盛也。不能食者，精无俾也。病而留者，其寿可立而倾也。（《素问》）
热病不可刺者有九∶一曰汗不出，大颧发赤，哕者死；二曰泄而腹满甚者死；三曰目不明，热不已者死；
四曰老人婴儿，热而腹满者死；五曰汗不出，呕下血者死；六曰舌本烂，热不已者死，七曰咳而衄，汗不出，
出不至足者死；八曰髓热者死；九曰热而痉者死。（《灵枢》）
哲言
发热而渴，不恶寒者，为温病。○发汗已，身灼热者，名曰风温。风温为病，脉阴阳俱浮，自汗出，身重多
眠睡，鼻息必鼾，语言难出。若被下者，小便不利，直视失溲；若被火者，微发黄色，剧如惊痫状，时螈 ；
若火熏之，一逆尚引日，再逆促命期。（张仲景）
仲景书详于治伤寒，略于治温，以法度俱错出于治伤寒中耳。后人未解义例，故春温一证，漫无成法可
师，而况触冒寒邪之病少，感发温气之病多；寒病之伤人什之三，温病之伤人什之七。古今缺典，莫此为大。
昌特会《内经》之旨，以畅发仲景不宣之奥。厥旨维何？《内经》云∶冬伤于寒，春必病温。此一大例也。
又云∶冬不藏精，春必病温。此一大例也。既冬伤于寒，又冬不藏精，至春月同时病发，此一大例也。举此三
例，以论温证，而详其治，然后与三阳三阴之例先后合符。盖冬伤于寒，邪藏肌肤，即邪中三阳之谓也；冬不
藏精，邪入阴脏，即邪中三阴之谓也。阳分之邪，浅而易疗；阴分之邪，深而难愈。所以病温之人，有发表
三、五次而外证不除者，攻里三、五次而内证不除者，以为在表也，又似在里，以为在里也，又似在表，用
温热则阴立亡，
用寒凉则阳随绝。凡伤寒之种种危候，温证皆得有之，亦以正虚邪盛，不能胜其任耳。至于热证，尤为什中
八、九。缘真阴为热邪久耗，无以制亢阳而燎原不熄也。以故病温之人，邪退而阴气犹存一线者，方可得生。
然多骨瘦皮干，津枯肉烁，经年善调，始复未病之体。实缘医者于此一证，茫然不识病之所在，用药不当，
邪无从解，留连辗转，莫必其命。○冬伤于寒，藏于肌肤，感春月之温气而始发。肌肤者，阳明胃经之所主也。
阳明经中久郁之热，一旦发出而外达于太阳，有略恶寒而即发热者；有大热而全不恶寒者；有表未除而里已先
实者；有邪久住太阳一经者；有从阳明而外达于太阳者；有从太阳复传阳明，不传他经者；有自三阴传入胃腑
者；有从太阳循经遍传三阴，如冬月伤寒之例者。大率太阳、阳明二经，是邪所蟠据之地。在太阳，则寒伤营
之证十不一见；在阳明，则谵语发斑，衄血蓄血，发黄脾约等热证每每兼见。而凡发表不远热之法，适以增温
病之困 耳。况于治太阳经之证，其法度不与冬月相同。盖春月风伤卫之证或有之，而寒伤营之证则无矣；且
由阳明而达太阳者，多不尽由太阳而阳明少阳也。似此，则温证之分经用法，比之伤寒大有不同。而世方屈
指云∶某日某经，某日传经已尽。究竟于受病之经，不能摸索以求良治。所谓一盲而引众盲，相将入火坑也。
○人身至冬月，阳气潜藏于至阴之中，《内经》教人于此时若伏若匿，重藏精也。故谓冬不藏精，春必病温。见
病所由来，为一定之理，必然之事。盖以精动则关开气泄，寒风得入之矣。关屡开，气屡泄，则寒风屡入之矣。
而肾主闭藏者，因是认贼作子，贼亦无门可出，弥甚相安，及至春月，地气上升，肝木用事，肝主疏泄，木主
风，于是吸引肾邪，勃勃内动，而劫其家宝矣。然邪入既深，不能遽出，但觉愦愦无奈。其发热也，全在骨
髓之间，自觉极热，而扪之反不烙手，任行表散，汗出而邪不出，徒伤津液，以取危困。其候比之冬伤于寒一
例，则倍重矣。○按冬不藏精之例，乃《内
经》之例，非仲景之例也。然观仲景之论温证第一条，已启发其端矣。其曰∶发汗已，身灼热者，名曰风温。
风温为病，脉阴阳俱浮，自汗出，身重，多眠睡，鼻息必鼾，语言难出。若被下者，小便不利，直视失溲；若
被火者，微发黄色，剧如惊痫状，时螈 ；若火熏之，一逆尚引日，再逆促命期。此一段至理，千古若明若昧，
不思既名温病，即是时行外感，何又汗之、下之、火之俱为逆耶？盖热邪久蓄少阴，肾中精水既为素伤，重加
汗、下、火劫阴之法，乃为逆耳。其自汗出，身重，多眠睡，鼻息鼾，语言难者，一一皆少阴之本证也。膀胱
为肾之府，故少阴证具。若被下，则膀胱之阴亦伤，而直视失溲者，肾精不上荣，肾气欲外夺也。若被火劫则
阴愈亏，而邪愈无制，甚则如惊痫状，而时为螈 也。一逆再逆，言汗、下、火之误，可一不可二，非汗而又
下而又汗之为再误也。由此观之，冬不藏精之温证，显然昭着矣。○按∶发汗已，身灼热者，名曰风温。此语
将冬不藏精之温证，形容殆尽。盖凡外感之邪，发汗已则身热自退；惟风温之证，发汗已身始灼热者，明明始
先热在骨髓，发汗已，然后透出肌表也。至于风温二字，取义更微，与《内经》劳风之义颇同。劳风者，劳其
肾而生风也。然则冬不藏精之人，讵非劳其肾而风先内炽欤？故才一发汗，即带出自汗、身重、多眠、鼻鼾、
语难诸多肾经之证；设不发汗，则诸证尚隐伏，不尽透出也。夫肾中之风邪内炽，而以外感汗、下及火攻之
法治之，岂不促其亡耶？后人不知风温为何病，反谓温证之外更有风温、湿温、温毒、温疫。观其言曰重感于
风，变为风温，则是外受之邪，与身重、鼻鼾、多眠、少语之故绝不相涉，可知是梦中说梦也。客有难昌者
曰∶《内经》论冬伤于寒，寒毒藏于肌肤，感春月之温气始发，故名曰温病，未尝言寒毒感藏于骨髓，今谓冬
不藏精者，寒邪藏于骨髓，或未尽然耶！昌应之曰∶此正《内经》之言，非余之臆说也。黄帝问温疟舍于何
脏？岐伯曰∶温疟得之冬中于风，寒气藏于骨
髓之中，至春则阳气大发，邪气不能自出，因遇大暑，脑髓烁，肌肉消，腠理发泄，或有所用力，邪气与汗
皆出。此病藏于肾，其气先从内出之于外也。如是者，阴虚而阳盛，阳盛则热矣；衰则气复反入，入则阳虚，
阳虚则寒矣。故先热而后寒，名曰温疟。由是观之，温疟且然，而况于温病乎？○按∶冬既伤于寒，又不藏精，
至春月两邪同发，则冬伤于寒者，阳分受邪，太阳膀胱经主之；冬不藏精者，阴分受邪，少阴肾经主之。与两
感伤寒证中，一日太阳受之，即与少阴俱病，则头痛、口干、烦满而渴之例，纤毫不差。但伤寒证自外入内，
转入转深，故三日传遍六经；温证自内达外，既从太阳之户牖而出，势不能传遍他经，表里只在此二经者为恒
也。所以温证两感之例，原有可生之理。昌治金鉴一则，先以麻黄附子细辛汤汗之，次以附子泻心汤下之，两
剂而愈。可见仲景法度森森具列，在人之善用也。○按∶冬伤于寒，又不藏精，春月病发，全似半表半里之证，
乃以半表半里药用之，病不除而反增，所以者何？此证乃太阳少阴互为标本，与少阳之半表半里绝不相涉也。
然随经用药，个中之妙，难以言传。盖两经俱病，从太阳汗之，则动少阴之血；从少阴温之，则助太阳之邪。
仲景且谓其两感于寒者，必不免于死，况经粗工之手，尚有活命之理耶？所云治有先后，发表攻里，本自不
同。此十二字秘诀，乃两感传心之要，即治温病万全之规。圣言煌煌，学人苟能参透此关，其治两感之温证，
十全八、九矣。○按∶温热病亦有先见表证而后传里者。盖温热自内达外，热郁腠理，不得外泄，遂复还里，
而成可攻之证，非如伤寒从表而始也。伤寒从表而始，故误攻而生变者多；温证未必从表始，故攻之亦不为
大逆。然郁热必从外泄为易，误攻而引邪深入，终非法也。○按∶温热病，表证间见，而里病为多，故少有不
渴者，法当以治里为主，而解肌兼之；亦有治里而表自解者。其间有误攻里而致害者，乃春夏暴寒所中之疫证，
邪纯在表，未入于里故也，不可
与温热病同论。○按∶温病，或有新中风寒者，或有表气虚不禁风寒者，卫虚则恶风，营虚则恶寒，又不可因
是遂指为非温病也。然即有之，亦必微而不甚。除太阳一经，则必无之矣。○按∶温热病，原无风伤卫、寒伤
营之例，原无取于桂麻二方也。表药中即败毒散、参苏饮等方，亦止可用于春令未热之时，若过时而发之，尚
嫌其药性之带温，况于桂、麻之辛热乎？然仲景不言桂、麻为不可用者，有二说焉∶一者以剔出桂、麻则三
阴绝无表药也；一者以桂、麻用之不当，在冬月已屡致戒，春月更可无赘也。后之纷纷訾议桂、麻之热者，未
尝计及于冬不藏精之治耳。惟知春夏有不得不用也，庶知仲景立方之神哉！○按∶仲景治温证，凡用表法，皆
用桂枝汤，以示微发于不发之意也；凡用下法，皆用大承气汤，以示急下无所疑之意也。不知者，鲜不以为表
在所轻，而里在所重。殊大不然。盖表里无可轩轾。所以然者，只虑热邪久据阳明，胃中津液先伤，故当汗，
惟恐过于汗反重伤其津液；当下，惟恐不急于下以亟存其津液也。○仲景于冬月太阳中风之证，而用桂枝为
例，不为春月之病温者设也。春月病温，用桂枝势必佐之以辛凉。而不藏精之温，属在少阴，不得不用桂枝
之温解之，以少阴本阴标寒，邪入其界，非温不散也。岂惟桂枝，甚则麻黄附子在所必用。所贵倍加阴药以辅
之，如芍药、地黄、猪胆汁之类是也。今人未达此理，但知恶药性之温，概以羌活、柴、葛为表，则治太阳而
遗少阴，屡表而病不除，究竟莫可奈何，而病者无幸矣。○按∶伤寒少阴证，乃从三阳经传入者。此证乃少
阴与膀胱一脏一腑自受之邪，故三阳传入之例多不合。惟两感之例，一日太阳受之，即与少阴俱病，其例吻
合。然仲景又不立治法，但曰治有先后，发表攻里，本自不同。是则一药之中，决无兼治两经笼统之法矣。而
治有先后，于义何居？昌尝思之，传经之邪，先表后里；直中之邪，但先其里。温证之邪，里重于表；两感之
邪，表里不可预拟，惟先其偏重处。假如其人阴水将竭，
真阳发露，外见种种躁扰之证，加以再治太阳之邪，顷刻亡阳而死矣。是必先温其在经之阳，兼益其阴，以培
阳之基，然后乃治其太阳之邪，犹为庶几也。此则与少阴宜温之例合也。又如其人平素消瘦，兼以内郁之邪灼
其肾水，外见鼻煤、舌黑种种枯槁之象，加以再治太阳，顷刻亡阴而死矣。是必急下以救将绝之水，水液既回，
然后乃治太阳之邪，犹为庶几也。此则与少阴宜下之例合也。又如其人邪发于太阳经者，极其势迫，大热恶
寒，头疼如劈，腰脊、颈项强痛莫移，胸高气喘，种种危急，温之则发斑发狂，下之则结胸谵语，计惟有先从
太阳经桂枝之法解之，解已，然后或温或下，以去其在阴之邪也。此则当用太阳经之表例，而与少阴可汗之例
略同也。讵非先后攻发之可预拟者耶？但两感伤寒之攻里，单取攻下，原不兼温；而两感温证之攻里，亡阳之
候颇多，不得不兼温与下而并拟之也。此又变例而从病情者也。○神哉！仲景之书，既详不藏精之证，又出不
藏精之治，特未显然挈示，后人不维其义耳。即如桂枝一汤，本为太阳中风设也，而汗、下、和、温已具于一
方之内。至于温法，尤为独详，如加附子，加人参、白术、干姜、甘草，加桂心、茯苓、蜀漆、红花等类，岂太
阳表证中所宜有乎？惟病有不得不先温经，又不得不兼散邪者，故以诸多温经之法隶于桂枝项下，一方而两擅
其用，与麻黄附子细辛汤同意。凡遇冬不藏精之证，表里之邪交炽，阴阳之气素亏者，按法用之裕如也。（喻嘉言）
叔和云∶从立春节后，其中无暴大寒，又不冰雪，有人壮热为病者，此属春时阳气发外，冬时伏寒变为
温病。变字大妙，嘉言以为非，予独以为确。寒气内伏，郁久而发，自成热矣。伤寒，寒也，暂袭营间，不久
而为大热，况迟之又久耶？为热乃自然之理，但不言变不足以教天下也。然何以不言热而言温？以春行温令故
【经文原义】
冬季感受寒邪，春季必定发生温病。○冬季肾精不固藏，春季必定发生温病。○凡是患伤寒而转化为温病的，在夏至之前发生的称为温病。○足太阳膀胱经的脉象，若颧骨部位出现赤色荣润之象，是热病。如果邪气尚未与正气交争（即病情未至危重阶段），说现在若能出汗，等待时辰过去病就会好；如果足太阳脉与足厥阴肝经的脉象同时显现（阴阳脉争见），死亡日期不超过三天，这是因为热病内连于肾。足少阳胆经的脉象，若脸颊前方出现赤色荣润之象，是热病。如果邪气尚未与正气交争，说现在若能出汗，等待时辰过去病就会好；如果足少阳脉与足少阴肾经的脉象同时显现，死亡日期不超过三天。○黄帝问：有患温病的人，出汗后随即又发热，且脉搏躁动疾速，不因出汗而减弱，胡言乱语不能进食，这病叫什么名字？岐伯回答：这病名叫“阴阳交”，阴阳交争者死。黄帝问：希望听听其中的道理。岐伯说：人之所以出汗，都是因为水谷精微化生，水谷精微又源于精气。现在邪气在骨肉之间与正气交争而能出汗，这是邪气退却而精气胜利的表现。精气胜利，就应当能够进食且不再次发热。再次发热的，是因为邪气仍在。汗液是由精气化生的。现在出汗后随即又发热，这是邪气盛实。不能进食，说明精气得不到补充。病邪滞留体内，寿命可以立刻终结。（出自《素问》）
不可针刺的热病有九种：一是汗不出，大颧发赤，呃逆的，死；二是腹泻且腹部胀满严重的，死；三是眼睛视物不清，热势不退的，死；四是老人和婴儿，发热且腹部胀满的，死；五是汗不出，呕吐且便血的，死；六是舌根腐烂，热势不退的，死；七是咳嗽且鼻出血，汗不出，或者汗出不到足的，死；八是髓热的，死；九是发热且出现痉挛的，死。（出自《灵枢》）
【哲人言论】
发热且口渴，不恶寒的，称为温病。○发汗后，身体依然灼热的，名叫风温。风温这种病，寸关尺三部脉都浮，自汗出，身体沉重，嗜睡，呼吸必然有鼾声，说话困难。如果被误用攻下法，会导致小便不利，直视，大小便失禁；如果被误用火疗，轻微的发黄，严重的像惊痫发作，时而抽搐；如果用火熏法，一次误治还能拖延时日，两次误治就会加速死亡。（张仲景）
张仲景的书中详细论述了治疗伤寒的方法，略于治疗温病，因为治疗方法都混杂在治伤寒的法度中。后人没有理解其中的义例，所以春温这一证候，漫无现成的法则可遵循，更何况触犯寒邪的病少，感受温热之气而发病的多；寒邪伤人的占十分之三，温邪伤人的占十分之七。古今医籍中的缺憾，没有比这更大的了。我（程昌/喻嘉言注者语境，此处指作者或引文观点）特别领会《内经》的宗旨，来阐发张仲景未曾明说的奥妙。其主旨是什么呢？《内经》说：冬季感受寒邪，春季必定发生温病。这是一个大原则。又说：冬季肾精不固藏，春季必定发生温病。这也是一个大原则。既冬季感受寒邪，又冬季肾精不固藏，到了春季同时发病，这是第三个大原则。列举这三个原则来论述温证，并详细说明治法，然后才能与三阳三阴的传变规律先后吻合。大概冬季感受寒邪，邪气潜伏在肌肤，就是邪气侵犯三阳经的意思；冬季肾精不固藏，邪气进入阴脏，就是邪气侵犯三阴经的意思。阳分的邪气，浅表而易治；阴分的邪气，深重而难愈。所以患温病的人，有发汗三四次甚至五六次而表证不除的，有攻里三四次甚至五六次而里证不除的，以为病在表，却又好像病在里；以为病在里，却又好像病在表。用温热药则阴液立亡，用寒凉药则阳气随之绝灭。凡是伤寒的各种危重证候，温证也都可能出现，也是因为正气虚弱、邪气强盛，身体无法承受所致。至于热证，尤为常见，占十分之八九。原因是真阴被热邪长期消耗，无法制约亢盛的阳气，导致火势燎原不息。因此，患温病的人，只有邪气退去而阴气还存留一线希望的，才可以得救。然而大多表现为骨瘦如柴、皮肤干枯、津液枯竭、肌肉消烁，经过一年的精心调养，才能恢复未病时的体质。实在是因为医生对这一证候茫然不识病机所在，用药不当，邪气无从解除，缠绵辗转，性命难保。○冬季感受寒邪，潜伏在肌肤，感受春季的温热之气才发作。肌肤是足阳明胃经所主的部位。阳明经中久郁的热邪，一旦发出并向外达于足太阳膀胱经，有的略微恶寒随即发热；有的大热而完全不恶寒；有的表证未除而里证已先实；有的邪气长久停留在太阳一经；有的从阳明向外达于太阳；有的从太阳再传回阳明，不传其他经；有的从三阴传入胃腑；有的从太阳循经遍传三阴，如同冬季伤寒的规律。大体上，太阳、阳明二经是邪气盘踞的地方。在太阳经，寒伤营分的证候十不见一；在阳明经，谵语、发斑、衄血、蓄血、发黄、脾约等热证常常兼见。而凡是发表不远热的方法，恰好增加了温病的困境。况且治疗太阳经的证候，其法度与冬季不同。大概春季风伤卫分的证候或许有，但寒伤营分的证候则没有了；而且由阳明达于太阳的，多不完全由太阳传至阳明、少阳。像这样，温证的分经用药，比起伤寒大有不同。而世间的方书屈指可数地说：某日某经受邪，某日传经已尽。究竟对于受病的经脉，不能摸索出良好的治疗方法。这就是一盲引众盲，相携入火坑啊。○人身到冬季，阳气潜藏在至阴之中，《内经》教导人在此时要像潜伏、隐匿一样，重在闭藏精气。所以说冬季肾精不固藏，春季必定发生温病。这是见到病来的源头，是确定的道理，必然的事情。大概因为精气妄动则关门打开，气泄漏，寒风得以侵入。门屡次打开，气屡次泄漏，寒风就屡次侵入。而主闭藏的肾脏，因此认贼作子，贼也没有门路出去，双方反而相安无事，日益严重。等到春季，地气上升，肝木当令，肝主疏泄，木主风，于是吸引肾中的邪气，蓬勃内动，劫掠肾中精气。然而邪气既然深入，不能立即排出，只觉得昏沉无奈。其发热，全在骨髓之间，自觉极热，但触摸反而不烫手，任凭使用发散表邪的方法，汗出而邪气不出，徒然损伤津液，从而招致危困。其证候比起冬季感受寒邪的例子，要加倍严重。○按：冬季肾精不固藏的例子，是《内经》的原则，不是张仲景的原则。但是看张仲景论温证的第一条，已经启发了这个端倪。他说：发汗后，身体灼热的，名叫风温。风温这种病，寸关尺三部脉都浮，自汗出，身体沉重，嗜睡，呼吸必然有鼾声，说话困难。如果被误用攻下法，小便不利，直视，大小便失禁；如果被误用火疗，轻微发黄，严重的像惊痫发作，时而抽搐；如果用火熏法，一次误治还能拖延时日，两次误治就会加速死亡。这一段至理名言，千古以来似明似暗，人们不思考：既然名叫温病，就是时令外感，为什么汗法、下法、火法都是逆治呢？大概热邪长期蓄积在少阴，肾中精水既然原本受损，再加用汗、下、火劫阴的方法，才是逆治。其自汗出、身重、多眠睡、鼻息鼾、语言难，一一都是少阴的本证。膀胱是肾的府邸，所以具备少阴证。如果被误下，则膀胱的阴也受伤，而直视失禁，是肾精不能上荣，肾气欲外脱。如果被火劫，则阴更亏，邪气更无法制约，甚至像惊痫发作，时而抽搐。一逆再逆，是说汗、下、火的错误，犯一次不可犯第二次，不是说汗了又下、下了又汗叫再误。由此看来，冬季肾精不固藏的温证，显然昭著了。○按：发汗后，身体灼热的，名叫风温。这句话将冬季肾精不固藏的温证形容殆尽。大概凡外感邪气，发汗后身热自然消退；只有风温证，发汗后身体才开始灼热的，明明开始热在骨髓，发汗后，然后透出肌表。至于“风温”二字，取义更深微，与《内经》中“劳风”的意义颇为相同。劳风，是劳损其肾而生风。那么冬季肾精不固藏的人，岂不是劳损其肾而风邪先在体内炽盛吗？所以才一发汗，就带出自汗、身重、多眠、鼻鼾、语难等诸多肾经的证候；如果不发汗，则诸证还隐伏，不会全部透出。夫肾中风邪内炽，而用外感的汗、下及火攻法治它，岂不是加速其死亡吗？后人不知道风温是什么病，反而认为温证之外还有风温、湿温、温毒、温疫。看他们说：重新感受风邪，变为风温，那就是外受的邪气，与身重、鼻鼾、多眠、少语的缘故完全不相干，可知这是梦中说梦。客人质问我说：《内经》论冬季感受寒邪，寒毒潜伏在肌肤，感受春季的温热之气才发作，所以名叫温病，未曾说寒毒潜伏在骨髓，现在说冬季肾精不固藏，寒邪潜伏在骨髓，或许不完全对吧！我回答说：这正是《内经》的话，不是我的臆说。黄帝问温疟舍于何脏？岐伯说：温疟得之于冬季中风，寒气藏在骨髓之中，到春季阳气大发，邪气不能自行排出，如果遇到大暑，脑髓被烧灼，肌肉消瘦，腠理发泄，或者有所用力，邪气随汗而出。这病藏在肾，其气先从内出于外。像这样，阴虚而阳盛，阳盛则热；衰退时气复反入，入则阳虚，阳虚则寒。所以先热后寒，名叫温疟。由此看来，温疟尚且如此，何况温病呢？○按：冬季既感受寒邪，又不固藏精气，到春季两邪同发，则冬季感受寒邪的，是阳分受邪，由足太阳膀胱经主管；冬季肾精不固藏的，是阴分受邪，由足少阴肾经主管。这与两感伤寒证中，一日太阳受邪，即刻与少阴俱病，出现头痛、口干、烦满而渴的例子，纤毫不差。但伤寒证是从外入内，转入转深，所以三日传遍六经；温证是从内达外，既然从太阳的门户而出，势不能传遍他经，表里只在这二经的情况是常态。所以温证两感的例子，原本有可生的道理。我治疗金鉴一例，先用麻黄附子细辛汤发汗，后用附子泻心汤攻下，两剂而愈。可见张仲景的法度森严具备，在于人善于运用。○按：冬季感受寒邪，又不固藏精气，春季发病，全像半表半里的证候，但用治疗半表半里的药，病不除反而加重，为什么呢？此证是太阳、少阴互为标本，与少阳的半表半里绝不相涉。然而随经用药，其中的奥妙，难以言传。大概两经都病，从太阳发汗，则扰动少阴的血；从少阴温补，则助长太阳的邪气。张仲景还说两感于寒的，必定不免于死，何况经过粗劣医生的手，还有活命的道理吗？所说的治疗有先后，发表攻里，本来不同。这十二字秘诀，是两感传心的关键，也是治温病万全的规则。圣言煌煌，学习者如果能参透这一关，治疗两感温证，十全八九了。○按：温热病也有先见表证而后传里的。大概温热从内达外，热郁在腠理，不得外泄，遂又返回里，而成可攻的证候，不像伤寒从表开始。伤寒从表开始，所以误用攻下而生变的多；温证未必从表开始，所以攻下也不算大逆。然而郁热必从外泄为易，误用攻下而引邪深入，终究不是正法。○按：温热病，表证间或出现，而里病居多，所以很少有不觉渴的，法当以治里为主，兼解肌；也有治里而表自解的。其中有误攻里而致害的，那是春夏暴寒所中的疫病，邪气纯在表，未入于里，所以不能与温热病同论。○按：温病，或者有新近中风寒的，或者有表气虚不耐风寒的，卫虚则恶风，营虚则恶寒，又不可因此就指为非温病。然而即使有，也必定轻微而不严重。除了太阳一经，则一定没有了。○按：温热病，原本没有风伤卫、寒伤营的例子，原本不需要桂枝汤、麻黄汤两方。表药中即使是败毒散、参苏饮等方，也只可用于春季未热之时，如果过时发作，还嫌其药性带温，何况桂枝、麻黄的辛热呢？然而张仲景没说桂枝、麻黄不可用的原因，有两种说法：一是剔除桂枝、麻黄，则三阴经绝无表药可用；一是桂枝、麻黄使用不当，在冬季已屡加告诫，春季更可不必赘述。后之人纷纷非议桂枝、麻黄的温热，未曾考虑到冬季肾精不固藏的治疗。只知道春夏有不得不用的时候，才知道张仲景立方之神妙啊！○按：张仲景治温证，凡用表法，都用桂枝汤，以示微微发汗而非大汗的意思；凡用下法，都用大承气汤，以示急下毫不犹豫的意思。不知情的人，很少不认为表证轻而里证重。这非常不对。大概表里没有轻重之分。之所以这样，只是担心热邪长期占据阳明，胃中津液先伤，所以当汗时，惟恐过汗反而重伤津液；当下时，惟恐不急下以亟存津液。○张仲景在冬季太阳中风证中，以桂枝为例，并非为春季病温者设立。春季病温，用桂枝势必佐以辛凉。而不固藏精气的温病，属在少阴，不得不用桂枝的温解之法，因为少阴本阴标寒，邪入其界，非温不散。岂止桂枝，甚至麻黄附子也在所必用。可贵的是倍加阴药以辅助它，如芍药、地黄、猪胆汁之类。今人不懂这个道理，只知道厌恶药性的温热，一概用羌活、柴胡、葛根为表药，则治太阳而遗忘了少阴，屡用表药而病不除，最终无可奈何，病人就没有希望了。○按：伤寒少阴证，是从三阳经传入的。此证是少阴与膀胱一脏一腑直接感受的邪气，所以三阳传入的规律多不合。只有两感的例子，一日太阳受邪，即刻与少阴俱病，其规律吻合。然而张仲景又不设立治法，只说治疗有先后，发表攻里，本来不同。这就是一药之中，决无兼治两经笼统的方法了。而治疗有先后，道理何在？我曾思考，传经的邪气，先表后里；直中的邪气，只先治其里。温证的邪气，里重于表；两感的邪气，表里不可预先拟定，只先治其偏重处。假如其人阴水将竭，真阳发露，外见种种躁扰之证，再加上再治太阳的邪气，顷刻亡阳而死。那就必须先温其在经的阳气，兼益其阴，以培补阳气的基础，然后才治太阳的邪气，还差不多。这与少阴宜温的例子相合。又如其人平素消瘦，兼以内郁之邪灼伤肾水，外见鼻煤、舌黑种种枯槁之象，再加上再治太阳，顷刻亡阴而死。那就必须急下以救将绝之水，水液既回，然后才治太阳的邪气，还差不多。这与少阴宜下的例子相合。又如其人邪发于太阳经，极其势迫，大热恶寒，头疼如劈，腰脊、颈项强痛不可移动，胸高气喘，种种危急，温之则发斑发狂，下之则结胸谵语，计惟有先从太阳经桂枝之法解之，解已，然后或温或下，以去除其在阴的邪气。这与当用太阳经的表例，而与少阴可汗的例子略同。难道不是先后攻发可以预先拟定的吗？但两感伤寒的攻里，单取攻下，原不兼温；而两感温证的攻里，亡阳的证候颇多，不得不兼温与下而一并拟定。这又是变例而从病情的。○神妙啊！张仲景的书，既详细论述不藏精的证候，又提出不藏精的治法，特未明显提举示人，后人未能体察其义罢了。就像桂枝一汤，本是为太阳中风设立的，而汗、下、和、温已具备于一方之内。至于温法，尤为详尽，如加附子，加人参、白术、干姜、甘草，加桂心、茯苓、蜀漆、红花等类，难道是太阳表证中所应有的吗？只有病有不得不先温经，又不得不兼散邪的情况，所以将诸多温经之法隶属于桂枝项下，一方而两擅其用，与麻黄附子细辛汤用意相同。凡遇冬季肾精不固藏的证候，表里邪气交炽，阴阳之气素亏者，按法使用游刃有余。（喻嘉言）
叔和说：从立春节后，其中没有暴大的寒冷，又没有冰雪，有人壮热为病的，这属于春时阳气发外，冬时伏寒变为温病。“变”字用得极妙，喻嘉言认为不对，我独自认为确切。寒气内伏，郁积久而发，自然成热。伤寒，是寒邪，暂时侵袭营分，不久就变成大热，何况延迟了很久呢？成为热乃是自然的道理，但不说“变”不足以教导天下人。然而为什么不说热而说温？因为春季施行温和的命令。
[Scriptural Meaning]
If one is injured by cold in winter, one will inevitably suffer from warm disease (Wen Bing) in spring. ○ If one fails to conserve essence (Jing) in winter, one will inevitably suffer from warm disease in spring. ○ For those who contract cold damage (Shang Han) and transform into warm disease, if it occurs before the Summer Solstice, it is called warm disease. ○ The pulse of the Taiyang (Greater Yang) meridian, if the cheekbone area shows a reddish luster, indicates heat disease. If the pathogenic factor has not yet interacted with the healthy qi (meaning the condition is not yet critical), and it is said that sweating can occur now, waiting for the appropriate time will lead to recovery; however, if the Taiyang pulse appears simultaneously with the Jueyin (Terminal Yin) pulse (indicating a clash between Yin and Yang meridians), death will occur within three days, as the heat disease internally connects to the Kidney. The pulse of the Shaoyang (Lesser Yang) meridian, if the front of the cheek shows a reddish luster, indicates heat disease. If the pathogenic factor has not yet interacted with the healthy qi, and it is said that sweating can occur now, waiting for the appropriate time will lead to recovery; however, if the Shaoyang pulse appears simultaneously with the Shaoyin (Lesser Yin) pulse, death will occur within three days. ○ The Yellow Emperor asked: In cases of warm disease where sweating is followed immediately by recurrent fever, with a rapid and restless pulse that does not diminish after sweating, accompanied by delirium and inability to eat, what is the name of this disease? Qibo replied: This disease is named "Yin-Yang Jiao" (Interaction of Yin and Yang), and those with this interaction die. The Yellow Emperor asked: I wish to hear the explanation. Qibo said: Human sweating is generated from grain (food), and grain generates essence. When pathogenic factors contend with healthy qi in the muscles and bones and sweating occurs, it means the pathogen is retreating and essence is victorious. With victorious essence, one should be able to eat and not have recurrent fever. Recurrent fever indicates the presence of pathogenic factors. Sweat is derived from essence. Now, sweating followed immediately by recurrent fever indicates that the pathogen is exuberant. Inability to eat means essence receives no supplementation. With the disease lingering, life can end instantly. (From *Su Wen*)
There are nine types of heat diseases that should not be treated with acupuncture: 1. No sweating, redness of the large cheekbones, and hiccups indicate death; 2. Diarrhea with severe abdominal fullness indicates death; 3. Unclear vision with persistent heat indicates death; 4. Elderly people and infants with heat and abdominal fullness indicate death; 5. No sweating, vomiting, and hematochezia indicate death; 6. Ulceration of the tongue root with persistent heat indicates death; 7. Coughing with epistaxis, no sweating, or sweating that does not reach the feet indicate death; 8. Marrow heat indicates death; 9. Heat with spasms indicates death. (From *Ling Shu*)
[Philosophical Discourse]
Fever accompanied by thirst and aversion to cold absent characterizes warm disease. ○ After sweating, if the body remains burning hot, it is named Feng Wen (Wind-Warmth). In Feng Wen disease, the pulses at the cun, guan, and chi positions on both hands are all floating, there is spontaneous sweating, heaviness of the body, excessive sleepiness, snoring breath, and difficulty speaking. If mistakenly treated with purgation, it leads to difficult urination, fixed gaze, and incontinence of urine and stool; if mistakenly treated with fire therapy, mild cases develop yellow discoloration, while severe cases resemble convulsions and epilepsy with occasional twitching; if treated with fire fumigation, one error may prolong the illness, but two errors will hasten death. (Zhang Zhongjing)
Zhang Zhongjing’s writings detail the treatment of Shang Han (Cold Damage) but are brief regarding Warm Disease, as the methods are intermixed with those for Shang Han. Later generations failed to understand the principles, leaving the syndrome of Spring Warmth without established rules to follow. Moreover, diseases caused by exposure to cold pathogens are few, while those triggered by warm pathogens are many; cold pathogens injure three out of ten people, whereas warm pathogens injure seven out of ten. Among ancient and modern medical texts, no deficiency is greater than this. I specifically comprehend the purport of *Nei Jing* to elucidate the profound secrets Zhang Zhongjing did not explicitly state. What is this purport? *Nei Jing* states: "Injury by cold in winter leads to warm disease in spring." This is a major principle. It also states: "Failure to conserve essence in winter leads to warm disease in spring." This is another major principle. If one is injured by cold in winter AND fails to conserve essence, leading to simultaneous onset in spring, this is the third major principle. By citing these three principles to discuss warm syndromes and detailing their treatment, one can align them with the transmission patterns of the Three Yang and Three Yin meridians. Generally, injury by cold in winter implies pathogens hiding in the skin and muscles, which corresponds to pathogens invading the Three Yang meridians; failure to conserve essence implies pathogens entering the Yin organs, corresponding to pathogens invading the Three Yin meridians. Pathogens in the Yang aspect are superficial and easy to treat; pathogens in the Yin aspect are deep and difficult to cure. Therefore, patients with warm disease may undergo diaphoresis three to five times without resolution of exterior symptoms, or purgation three to five times without resolution of interior symptoms. They appear to be in the exterior but seem interior; they appear interior but seem exterior. Using warming herbs causes immediate destruction of Yin fluids; using cooling herbs causes immediate extinction of Yang Qi. All critical conditions seen in Shang Han can also occur in warm disease, due to deficiency of healthy qi and excess of pathogenic factors overwhelming the body. Heat syndromes are particularly common, accounting for eight or nine out of ten cases. This is because True Yin has been long consumed by heat pathogens, unable to restrain hyperactive Yang, causing the fire to rage uncontrollably. Thus, only when the pathogen recedes and a thread of Yin Qi remains can the patient survive. However, most present with emaciation, dry skin, depleted fluids, and wasted muscles, requiring a year of careful regulation to recover their pre-illness constitution. This is largely because physicians are ignorant of the pathology, use inappropriate medications, fail to resolve the pathogen, and allow the disease to linger, making survival uncertain. ○ Injury by cold in winter hides in the skin and muscles, manifesting upon exposure to the warm Qi of spring. The skin and muscles are governed by the Stomach Meridian of Foot-Yangming. Long-stagnant heat in the Yangming meridian, once released and reaching the Taiyang meridian externally, may present as slight aversion to cold followed by fever; or high fever with no aversion to cold; or exterior symptoms unresolved while interior excess arises; or pathogens lingering solely in the Taiyang meridian; or moving from Yangming to Taiyang; or returning from Taiyang to Yangming without transmitting to other meridians; or transmitting from the Three Yin to the Stomach Fu organ; or circulating from Taiyang through the meridians to the Three Yin, similar to winter Shang Han. Generally, the Taiyang and Yangming meridians are the strongholds of pathogens. In Taiyang, signs of cold injuring the Ying (Nutritive) level are rarely seen; in Yangming, heat syndromes such as delirium, macules, epistaxis, blood stasis, jaundice, and spleen constraint often coexist. Methods of releasing the exterior that do not avoid heat merely exacerbate warm disease. Furthermore, the treatment principles for Taiyang syndromes differ from those in winter. While wind injuring the Wei (Defensive) level may occur in spring, cold injuring the Ying level does not; moreover, pathogens reaching Taiyang from Yangming do not necessarily pass through Taiyang to Yangming and Shaoyang. Thus, the meridian-based differentiation and treatment for warm disease differ significantly from Shang Han. Yet, popular formulas simply count days and meridians, claiming transmission is complete by a certain day. Ultimately, they cannot grasp the affected meridians to provide effective treatment. This is like a blind person leading other blind people into a pit. ○ In winter, Yang Qi hides within extreme Yin. *Nei Jing* teaches that during this time, one should remain hidden and deeply conserve essence. Hence, "failure to conserve essence in winter leads to warm disease in spring." This reveals the origin of the disease as a certain and inevitable principle. Essence movement opens the gates, allowing Qi to leak and cold wind to enter. Repeated opening and leaking allow repeated invasion. The Kidney, which governs closure, mistakes the thief for a son; the thief has no exit, and they coexist peacefully, worsening over time. By spring, Earth Qi rises, Liver Wood takes command. The Liver governs dispersion, and Wood governs wind, attracting Kidney pathogens to move vigorously internally and plunder the family treasures (essence). Since the pathogen is deep-seated and cannot be quickly expelled, the patient feels confused and helpless. The fever originates in the marrow; the patient feels intense heat internally, but the skin is not hot to the touch. Regardless of dispersing treatments, sweat does not expel the pathogen, merely damaging fluids and leading to crisis. Compared to winter cold injury, this is twice as severe. ○ Note: The principle of "failure to conserve essence" comes from *Nei Jing*, not Zhang Zhongjing. However, Zhang’s first discussion on warm disease hints at it. He says: "After sweating, if the body is burning hot, it is named Feng Wen... pulses are floating, spontaneous sweating, body heaviness, sleepiness, snoring, difficulty speaking. If purged, urinary difficulty, fixed gaze, incontinence; if fired, yellowing, convulsions... one error delays death, two errors hasten it." This profound truth has been ambiguous for millennia. People fail to realize: if it is named warm disease, it is an external seasonal contraction; why are sweating, purging, and fire therapies considered contraindications? The reason is that heat pathogens accumulate in Shaoyin for a long time, and Kidney essence water is already damaged. Adding sweating, purging, and fire therapies that consume Yin constitutes a contraindication. Spontaneous sweating, body heaviness, sleepiness, snoring, and speech difficulties are all original syndromes of Shaoyin. The Bladder is the mansion of the Kidney, so Shaoyin syndromes manifest. If purged, Bladder Yin is injured, leading to fixed gaze and incontinence as Kidney essence fails to nourish upward and Kidney Qi escapes. If fired, Yin is further depleted, pathogens unchecked, leading to convulsions. "One error, then another" refers to the mistake of sweating, purging, and firing; committing one is unacceptable, let alone repeating them. Thus, the warm disease of "failure to conserve essence" is clearly evident. ○ Note: "After sweating, if the body is burning hot, it is named Feng Wen" describes the warm disease of "failure to conserve essence" completely. Generally, after sweating, external pathogen fever subsides; only in Feng Wen does fever intensify after sweating, indicating the heat was originally in the marrow and only emerged to the surface after sweating. The term "Feng Wen" carries subtle meaning, similar to "Lao Feng" (Labor Wind) in *Nei Jing*. Lao Feng results from exhausting the Kidney and generating wind. Thus, those who fail to conserve essence in winter exhaust their Kidneys, allowing wind to blaze internally. Sweating brings out Kidney-related symptoms like sweating, heaviness, sleepiness, snoring, and speech difficulty. Without sweating, these symptoms would remain latent. Treating internal Kidney wind with external sweating, purging, and fire therapies accelerates death. Later generations, not knowing Feng Wen, claimed there were separate Wind-Warmth, Damp-Warmth, Warm-Toxin, and Warm-Epidemic diseases. They argued that re-exposure to wind changes warmth into wind-warmth, disconnecting it from symptoms like heaviness and snoring. This is dreaming within a dream. A skeptic asked: *Nei Jing* says cold toxin hides in skin/muscles and manifests in spring as warm disease, never mentioning bone marrow. Is your claim that cold hides in bone marrow correct? I replied: This is exactly what *Nei Jing* says. The Yellow Emperor asked about Wen Nue (Warm Malaria): Qibo said it originates from wind in winter, with cold air hiding in the marrow. In spring, Yang Qi expands, but the pathogen cannot exit. With summer heat, brain marrow melts, muscles waste, pores open, and exertion forces the pathogen out with sweat. This disease hides in the Kidney, emerging from inside to outside. Yin is deficient, Yang is exuberant, causing heat; when Yang declines, Qi returns inward, causing Yin deficiency and cold. Hence, heat precedes cold, named Wen Nue. If Wen Nue is like this, how much more so is warm disease? ○ Note: Winter cold injury plus failure to conserve essence leads to dual-pathogen onset in spring. Cold injury affects Yang, governed by Taiyang Bladder; failure to conserve essence affects Yin, governed by Shaoyin Kidney. This matches the "Two-Feelings" (Liang Gan) Shang Han pattern where Taiyang and Shaoyin are affected simultaneously, causing headache, dry mouth, irritability, and thirst. However, Shang Han moves from exterior to interior, deepening over three days to cover all six meridians. Warm disease moves from interior to exterior; exiting via Taiyang, it cannot transmit to all meridians, usually remaining confined to these two. Thus, dual-feeling warm disease has potential for survival. I treated a case with Mahuang Fuzi Xixin Tang for sweating, followed by Fuzi Xiexin Tang for purging, curing it in two doses. This shows Zhang’s rigorous methods depend on skillful application. ○ Note: Dual-onset warm disease resembles Half-Exterior Half-Interior syndromes, but using Ban Xia Xie Xin Tang type remedies worsens it. Why? Because this syndrome involves Taiyang and Shaoyin as root and branch, unrelated to Shaoyang’s half-exterior half-interior. Medication must follow the meridians. Treating both: sweating from Taiyang disturbs Shaoyin blood; warming Shaoyin aids Taiyang pathogens. Zhang stated Two-Feelings Shang Han is fatal; how much more so under incompetent doctors? The secret lies in "treatment has sequence; releasing exterior and attacking interior are fundamentally different." These twelve characters are the key to Two-Feelings transmission and the perfect rule for warm disease. Understanding this ensures 80-90% success. ○ Note: Warm diseases may show exterior signs first, then transmit interior. Heat stagnates in pores, cannot vent, returns interior to become purgable. Unlike Shang Han starting exteriorly. Shang Han starts exteriorly, so mistaken purging causes many changes; warm disease doesn't always start exteriorly, so purging isn't always a major error. However, stagnant heat should vent outward; mistaken purging drawing pathogens deeper is incorrect. ○ Note: Warm diseases often have mixed exterior signs but predominantly interior pathology, so thirst is common. Treatment should focus on interior, with muscle-releasing as adjunct; sometimes treating interior resolves exterior. Mistaken purging causing harm applies to epidemic cold in spring/summer where pathogens are purely exterior. These cannot be equated with warm disease. ○ Note: Warm disease patients may have recent wind-cold exposure or weak exterior Qi intolerant to wind/cold. Wei deficiency causes aversion to wind; Ying deficiency causes aversion to cold. This does not exclude warm diagnosis, though symptoms are usually mild. Except for Taiyang, this is rare. ○ Note: Warm disease lacks the Wind-injuring-Wei/Cold-injuring-Ying distinction and does not require Guizhi Tang or Mahuang Tang. Even exterior formulas like Baidu San or Shen Su Yin are only suitable before spring heat arrives; if used late, their warming nature is suspect, let alone the acrid-hot Guizhi and Mahuang. Zhang didn't forbid them for two reasons: 1. Removing them leaves no exterior formula for Three Yin; 2. Misuse in winter was warned against, making spring warnings redundant. Critics focusing on their heat ignore the "failure to conserve essence" context. Only recognizing their necessity in spring/summer reveals Zhang’s genius. ○ Note: Zhang uses Guizhi Tang for exterior warm disease to indicate mild sweating; he uses Dachengqi Tang for interior to indicate urgent purging. Ignorants think exterior is light and interior heavy. This is wrong. Exterior and interior are equal. The concern is Yangming heat consuming stomach fluids. When sweating, fear excessive loss of fluids; when purging, fear delay in preserving fluids. ○ Zhang used Guizhi for winter Taiyang wind-strike, not specifically for spring warm disease. Spring warm disease using Guizhi requires acrid-cool adjuvants. For essence-deficient warm disease (Shaoyin), Guizhi’s warming dispersion is necessary because Shaoyin is Yin with Cold as its manifestation; non-warming methods cannot disperse. Even Mahuang Fuzi may be needed, supplemented heavily with Yin-nourishing herbs like Shaoyao, Dihuang, or pig bile. Modern doctors, fearing warmth, use Qianghuo, Chaihu, Ge Gen, treating Taiyang but neglecting Shaoyin, failing to cure. ○ Note: Shang Han Shaoyin syndrome transmits from Three Yang. This warm disease involves direct Shaoyin-Bladder infection, so transmission rules don't apply. Only the Two-Feelings pattern (Taiyang-Shaoyin simultaneous) fits. Zhang gave no specific method, only "sequence matters; exterior release and interior attack differ." One drug cannot treat both meridians indiscriminately. Sequence depends on priority. For transmitted pathogens, treat exterior then interior; for direct pathogens, treat interior first. In warm disease, interior is heavier; in Two-Feelings, prioritize the dominant aspect. If Yin fluid is exhausted with false Yang flare-up, treating Taiyang causes instant Yang collapse; must first warm meridian Yang and tonify Yin. If emaciated with internal heat scorching Kidney Water showing black tongue/nose coal, treating Taiyang causes instant Yin collapse; must urgently purge to save water, then treat Taiyang. If Taiyang pathogen is acute with severe fever/chills/headache/stiffness/panting, warming causes macules/delirium, purging causes chest binding/delirium; must first release Taiyang with Guizhi method, then warm or purge Yin pathogens. This aligns with Taiyang exterior and Shaoyin sweating principles. Can sequence be predetermined? Yes. But Shang Han interior attack is pure purgation; Warm Disease Two-Feelings often has Yang collapse signs, requiring combined warming and purging. This adapts to pathology. ○ Marvelous! Zhang detailed essence-deficient syndromes and treatments but didn't highlight them explicitly. Take Guizhi Tang: intended for Taiyang wind-strike, yet contains sweating, purging, harmonizing, and warming methods. Warming methods are detailed (adding Fuzi, Renshen, Baizhu, Ganjiang, Rougui, Fuling, etc.), unusual for pure exterior syndromes. It serves to warm meridians and dispel pathogens, similar to Mahuang Fuzi Xixin Tang. For essence-deficient cases with mixed exterior-interior pathogens and deficient Yin-Yang, applying these methods works well. (Yu Jiayan)
He Suhe said: After Start of Spring, without extreme cold or ice/snow, if someone has high fever, it belongs to Spring Yang expanding outward, transforming winter-hidden cold into warm disease. The word "transform" is excellent. Yu Jiayan disagreed, but I agree. Hidden cold stagnates and transforms into heat naturally. Shang Han is cold, briefly invading Ying, quickly becoming high heat; delayed heat is natural. Saying "transform" teaches the world. Why "Warm" and not "Heat"? Because Spring commands warmth.