伤寒一经有一经之症。则有一经之治。或伤于阳。或伤于阴。固不同也。经
何以言两感哉。伤寒有并病矣。如云太阳未已。复过阳明或少阳。并之已
尽。则入里。未尽。犹在表。是阳与阳并也。乌知阴不与阴并耶。有合病矣。如
云太阳阳明齐病。阳明少阳齐病。或三阳合病。则自下利是阳与阳合也。
乌知阴不与阴合耶。有传经矣。如云一日太阳受之。二日阳明受之。三日
少阳受之。四日太阴受之。五日少阴受之。六日厥阴受之。然有始终只在
一经者。有传一二经而止者。有越经而传者。有过经不解者。是由阳传入
阴也。若阴出之阳则愈矣。有直中矣。三阴受邪。始终不发热。乃不从阳经
传入。是阴自受病也。则与阳不相侔矣。若此者。俱不可谓之两感。而所谓
两感者。则一阴一阳同受病也。如云太阳与少阴俱病。则头痛口干而烦
满。阳明与太阴俱病。则腹满身热不欲食谵语。少阳与厥阴俱病。则耳聋
囊缩而厥。水浆不入。不知人。虽然。三阳之头疼身热耳聋。感于寒者。则诚
有之。三阴之烦满谵语囊缩。则是传经热证。若初感于寒。则固未之或见
也。且传经热证。与两感之证。既已相同。何以于传经者。曰热虽甚不死。于
两感者。曰必不免于死。余不能无辨焉。盖传经者。由三阳入三阴。始终发
热。乃脉与证相合者也。两感者。则一阴一阳。外受寒为表实。内受寒为里
虚。必脉证不相合者也。如嗣真云太阳症得少阴脉。少阴症反发热之例。
差足以当之。故予尝谓传经之邪。感之者多实。故不即犯三阴而无虑其
为甚。两感之邪。受之者必虚。故即兼及三阴而触之即不免。经虽不言虚
实。而虽甚必不免之辞。不可充而见之哉。若嗣真注两感篇。则根据文配释。
求之病情。终不相符。故予以嗣真太阳少阴之例。推之于阳明太阴。少阳
厥阴。当无不然。又何疑之有。
附嗣真少阴症似太阳太阳脉似少阴不同论
盖太阳病。脉似少阴。少阴病。证似太阳。所以谓之反。而治当异也。今深
究其旨。均自脉沉发热。以其有头疼。故为太阳病。脉当浮。今反脉不浮
而沉者。以里虚久寒正气衰微所致。今身体疼痛。故宜救里。使正气内
强。逼邪外出。而干姜生附。亦能出汗而解。假若里不虚寒。则见脉浮。而
正属太阳麻黄证也。均自脉沉发热。以其无头疼。故名少阴病。当无热。
今反寒邪在表。但皮肤郁闭而为热。如在里。则外必无热。故用麻黄细
辛以发表间之热。附子以温少阴之经。假使寒邪惟在里。当见吐利厥
逆等症。而正属少阴四逆汤证也。以此观之。表邪浮浅。发热之反尤轻。
正气衰微。脉沉之反为重。此四逆为剂。不为不重于麻黄附子细辛汤
也。可见熟附配麻黄。发中有补。生附配干姜。补中有发。所谓太阳少阴
脉沉发热虽同。而受病有无头疼与用药自别。故并言之耳。若误治之。其死必矣。
按嗣真云。太阳症头疼身热。是太阳感寒也。脉当浮而反沉。是少阴脉。
又非少阴感寒乎。用四逆汤。治少阴。救里为急。不虑太阳之邪不出也。
又云少阴症脉沉。是少阴感寒也。不应热而反发热。是太阳症。又非太
阳感寒乎。用麻黄附子细辛汤。兼治太阳。以发表热。不虑少阴之经不
温也。虽然。太阳症而脉浮。复兼吐利。将独治太阳乎。少阴脉沉而发热。
不兼太阳。则又当专主少阴矣。不可不知。由此推之。如阳明身热潮热。
而脉微弱下利四肢厥冷。则又是太阴矣。宁独主阳明也乎。不得不参
附子理中等汤。救太阴之里也。少阳寒热往来。而脉细蛔厥烦躁腹疼。
则又是厥阴矣。宁独主少阳也乎。不得不参吴茱萸等汤。救厥阴之逆
也。盖阳症阳脉。易辨也。阳症阴脉。症假脉真也。又有症假而脉亦假者。
如阴极发躁。欲投水中。脉来鼓指。重按全无。内真寒而外假热也。更有
脉涩肢冷。呕逆便秘。伏热于中。水极似火。火极亦似水也。凡此者又岂
可与两感同论哉。要之治其本者。百不一失。治其标者。百不一得。临症
者慎旃。
四逆汤
附子（二钱） 甘草 干姜（各一钱五分）
水煎服
麻黄附子细辛汤
麻黄 细辛（各二钱） 附子（一钱）
水煎服
理中汤
人参 白术 干姜（各一钱） 甘草（八分）
水煎服。腹痛甚。加附子。寒而吐者。加生姜。小便不利。加茯苓。肾气动者。去术。
吴茱萸汤
吴茱萸 生姜（各三钱） 人参（一钱）
水钟半。枣一枚。煎七分服。
伤寒病中，每一经都有其特定的症状表现，也就有针对该经的治疗方法。或者是感受阳邪，或者是感受阴邪，这本来就是不同的。既然这样，为什么还要谈论“两感”呢？
伤寒中有“并病”的情况。比如太阳病的症状尚未消失，又出现了阳明或少阳的症状，这就是并病。如果并病已经传遍所有相关经络，病邪就会入里；如果并未传遍，病邪仍然在表。这是阳经与阳经相并。怎么知道阴经不与阴经相并呢？
伤寒中有“合病”的情况。比如太阳和阳明同时发病，或者阳明和少阳同时发病，甚至三阳经同时发病，就会出现自下利的症状，这是阳经与阳经相合。怎么知道阴经不与阴经相合呢？
伤寒中有“传经”的情况。比如第一天太阳经受邪，第二天阳明经受邪，第三天少阳经受邪，第四天太阴经受邪，第五天少阴经受邪，第六天厥阴经受邪。但是，有的病始终只在一经发生，有的病只传变一到两经就停止了，有的病跨越经络传变，有的病过了该经的病程时间而病邪未解。这是由阳经传入阴经。如果阴经的病转出到阳经，就会痊愈。
伤寒中有“直中”的情况。三阴经受邪，始终不发热，这不是从阳经传入的，而是阴经直接受病。这就与阳经的情况不相匹配了。像上述这些情况（并病、合病、传经、直中），都不能称之为“两感”。所谓的“两感”，是指一阴经和一阳经同时受病。例如：太阳经和少阴经同时发病，会出现头痛、口干、烦闷胀满；阳明经和太阴经同时发病，会出现腹部胀满、身体发热、不想吃东西、说胡话；少阳经和厥阴经同时发病，会出现耳聋、睾丸收缩、四肢厥冷、水浆不能入口、神志不清不知道人。
虽然如此，三阳经的头痛、身热、耳聋，确实是感受寒邪所致。但三阴经的烦闷胀满、说胡话、睾丸收缩，则是传经过程中产生的热证。如果是初感寒邪，这些症状本来是不会出现的。况且，传经的热证与两感的证候，既然已经相同，为什么对于传经者说“即使发热很严重也不会死”，而对于两感者说“必然难免于死”呢？我不能不对此进行辨析。
大概来说，传经的病，是由三阳经传入三阴经，始终发热，这是脉象与症状相符的情况。两感的病，则是一阴一阳同时受病，外部感受寒邪导致表实，内部感受寒邪导致里虚，必然是脉象与症状不相符的情况。如嗣真所说“太阳病症却出现少阴脉，少阴病症反而发热”的例子，差足以用来解释这种情况。所以我曾经说，传经的邪气，感邪者多属实证，所以不立即侵犯三阴经，无需担心病情过重；两感的邪气，受邪者必定是虚证，所以即兼及三阴经，一旦触动就难免于死。经典中虽然没有明确提到虚实，但“即使严重也难免于死”的说法，是不可夸大或违背事实的。至于嗣真对《两感篇》的注释，只是根据文字进行配释，推究病情，终究不相符合。所以我用嗣真关于太阳和少阴的例子，类推到阳明和太阴、少阳和厥阴，应当没有不是这样的，还有什么可怀疑的呢？
附：嗣真关于少阴症似太阳、太阳脉似少阴的不同论述
大概太阳病，脉象似少阴；少阴病，症状似太阳。之所以称为“反”，是因为治疗方法应当不同。现在深入探究其旨意，都是脉沉且发热。因为伴有头痛，所以诊断为太阳病，脉应当浮。现在反而脉不浮而沉，这是因为里虚、久寒、正气衰微所致。现在身体疼痛，所以适宜救里，使正气在内增强，逼迫邪气外出，此时使用干姜、生附子，也能出汗而解。假如里不虚寒，则见脉浮，那正属于太阳病的麻黄汤证。
同样都是脉沉发热，因为没有头痛，所以命名为少阴病，应当无热。现在反而发热，是因为寒邪在体表，只是皮肤郁闭而产生热象。如果在里，则外部一定无热。所以使用麻黄、细辛来发表间的热，使用附子来温通少阴经。假如寒邪只在里，应当出现呕吐、下利、四肢厥逆等症状，那正属于少阴病的四逆汤证。由此看来，表邪浮浅，发热的“反常”现象较轻；正气衰微，脉沉的“反常”现象较重。因此，四逆汤这一方剂，并不比麻黄附子细辛汤轻。由此可见，熟附子配合麻黄，是在发汗中有补益作用；生附子配合干姜，是在补益中有发汗作用。所谓太阳和少阴都出现脉沉发热，虽然相同，但受病是否有头痛以及用药自然区别开来。所以一并讨论它们。如果误治，病人必死无疑。
按：嗣真说，太阳病症表现为头痛身热，这是太阳感受寒邪。脉应当浮反而沉，这是少阴脉，难道不是少阴感受寒邪吗？使用四逆汤治疗少阴，以救里为急务，不必担忧太阳的邪气不能排出。又说，少阴病症脉沉，这是少阴感受寒邪。不应发热反而发热，这是太阳病症，难道不是太阳感受寒邪吗？使用麻黄附子细辛汤，兼治太阳，以发散表热，不必担忧少阴的经脉不温暖。虽然如此，太阳病症而脉浮，又兼有呕吐下利，难道只治疗太阳吗？少阴脉沉而发热，不兼太阳症状，那么又应当专门主治少阴了。这一点不可不知道。由此类推，如阳明病身热潮热，而脉微弱、下利、四肢厥冷，这又是太阴病了，难道只主治阳明吗？不得不参用附子理中汤等方剂，来救太阴的里虚。少阳病寒热往来，而脉细、蛔厥、烦躁、腹痛，这又是厥阴病了，难道只主治少阳吗？不得不参用吴茱萸汤等方剂，来救厥阴的逆乱。
大概阳症阳脉，容易辨别。阳症阴脉，是症状虚假而脉象真实。又有症状虚假而脉象也虚假的情况，如阴极发躁，想要跳入水中，脉来鼓指有力，但重按全无，这是内真寒而外假热。更有脉涩、肢冷、呕逆、便秘，伏热于中，这是水极似火，火极亦似水的情况。凡此种种，又岂能与两感相提并论呢？总之，治疗根本的，百次不会失手；治疗标症的，百次不会成功。临症施治者务必谨慎。
理中汤
人参 白术 干姜（各一钱） 甘草（八分）
用水煎服。如果腹痛严重，加附子；寒邪致呕吐者，加生姜；小便不利者，加茯苓；肾气动者，去掉白术。
In Shaoyang disease, each meridian has its specific symptoms and corresponding treatments. Whether one is injured by Yang pathogens or Yin pathogens, they are inherently different. Given this, why speak of "Liang Gan" (Double Meridian Infection)?
There is the condition of "Bing Bing" (Concurrent Disease) in Shanghan (Cold Damage). For instance, when Taiyang symptoms have not yet subsided, Yangming or Shaoyang symptoms appear subsequently. This is concurrent disease. If the concurrent transmission is complete, the pathogen enters the interior; if incomplete, it remains in the exterior. This represents Yang meridians joining with Yang meridians. How do we know that Yin meridians do not join with Yin meridians?
There is the condition of "He Bing" (Combined Disease). For example, Taiyang and Yangming occur simultaneously, or Yangming and Shaoyang occur simultaneously, or even all three Yang meridians are combined, leading to spontaneous diarrhea. This represents Yang meridians combining with Yang meridians. How do we know that Yin meridians do not combine with Yin meridians?
There is the condition of "Chuan Jing" (Meridian Transmission). For instance, on the first day, Taiyang is affected; on the second day, Yangming; on the third, Shaoyang; on the fourth, Taiyin; on the fifth, Shaoyin; and on the sixth, Jueyin. However, some diseases remain confined to a single meridian throughout, while others transmit through only one or two meridians before stopping. Some skip meridians during transmission, and some persist beyond their designated time frame. This constitutes transmission from Yang meridians into Yin meridians. If Yin conditions transform into Yang, recovery occurs.
There is also "Zhi Zhong" (Direct Invasion). When the three Yin meridians are invaded, there is no fever throughout the course. This is not transmitted from Yang meridians but rather the Yin meridians are directly afflicted. Thus, it does not correspond with Yang conditions. All such cases—Bing Bing, He Bing, Chuan Jing, and Zhi Zhong—cannot be termed "Liang Gan." True "Liang Gan" refers to one Yin meridian and one Yang meridian being diseased simultaneously. For example:
- Taiyang and Shaoyin both diseased: headache, dry mouth, irritability, and fullness.
- Yangming and Taiyin both diseased: abdominal fullness, body heat, anorexia, and delirium.
- Shaoyang and Jueyin both diseased: deafness, retraction of the testicles, cold limbs, inability to swallow fluids, and unconsciousness.
Although headaches, body heat, and deafness in the three Yang meridians are indeed caused by cold invasion, irritability, fullness, delirium, and testicular retraction in the three Yin meridians are heat syndromes resulting from meridian transmission. These would not be seen upon initial cold invasion. Furthermore, since the heat syndromes of meridian transmission and Liang Gan share similarities, why is it said that for meridian transmission, "even severe fever will not result in death," whereas for Liang Gan, "death is inevitable"? I must clarify this distinction.
Generally, meridian transmission involves pathogens moving from the three Yang meridians to the three Yin meridians, characterized by persistent fever, where pulse and symptoms correspond. In contrast, Liang Gan involves simultaneous invasion of one Yin and one Yang meridian: external cold causes exterior excess, while internal cold causes interior deficiency, resulting in a discrepancy between pulse and symptoms. The example cited by Sizhen—"Taiyang symptoms presenting with Shaoyin pulse, or Shaoyin symptoms presenting with fever"—adequately illustrates this. Hence, I have stated that pathogens in meridian transmission often affect those with excess constitutions, sparing the three Yin meridians initially without grave concern. Conversely, pathogens in Liang Gan affect those with deficient constitutions, immediately involving the three Yin meridians, making death unavoidable upon contact. Although the classics do not explicitly discuss excess and deficiency here, the phrase "inevitable death despite severity" cannot be dismissed as exaggeration. Sizhen’s commentary on the Liang Gan chapter merely aligns textually without fitting clinical reality. Therefore, applying Sizhen’s Taiyang-Shaoyin example to Yangming-Taiyin and Shaoyang-Jueyin yields consistent results, leaving no room for doubt.
Appendix: Sizhen’s Discussion on the Differences Between Shaoyin Symptoms Resembling Taiyang and Taiyang Pulse Resembling Shaoyin
Typically, Taiyang disease presents with a pulse resembling Shaoyin, and Shaoyin disease presents with symptoms resembling Taiyang. This reversal necessitates distinct treatments. Upon deep investigation, both present with a deep pulse and fever. If accompanied by headache, it is diagnosed as Taiyang disease, where the pulse should be floating. A deep pulse instead indicates interior deficiency, chronic cold, and衰竭 of healthy Qi. With body pain present, treatment should prioritize rescuing the interior to strengthen healthy Qi internally and expel pathogens externally. In this context, dried ginger and raw Aconite can induce sweating and resolve the condition. If the interior were not deficient and cold, a floating pulse would appear, indicating a Ma Huang Tang syndrome for Taiyang.
Similarly, with a deep pulse and fever but no headache, it is named Shaoyin disease, which typically lacks fever. The presence of fever here arises from cold pathogens trapped in the exterior, causing skin constriction and heat generation. If the pathogen were interior, there would be no exterior heat. Thus, Ephedra, Asarum, and Aconite are used to release exterior heat and warm the Shaoyin meridian. If the cold pathogen were solely interior, symptoms like vomiting, diarrhea, and cold limbs would appear, indicating a Si Ni Tang syndrome for Shaoyin. From this perspective, superficial exterior pathogens cause milder "reversal" symptoms (fever), while depleted healthy Qi causes more significant "reversal" symptoms (deep pulse). Therefore, Si Ni Tang is considered heavier/more critical than Ma Huang Fu Zi Xi Xin Tang. This demonstrates that cooked Aconite paired with Ephedra provides tonification within dispersion, while raw Aconite paired with dried ginger provides dispersion within tonification. Although Taiyang and Shaoyin may both show deep pulses and fever, the presence or absence of headache dictates different treatments, justifying their joint discussion. Misdiagnosis leads inevitably to death.
According to Sizhen: Taiyang symptoms of headache and fever indicate cold invasion of Taiyang. A deep pulse instead of a floating one indicates Shaoyin pulse, suggesting cold invasion of Shaoyin. Using Si Ni Tang treats Shaoyin, prioritizing interior rescue without worrying about failing to expel Taiyang pathogens. Conversely, Shaoyin symptoms of deep pulse indicate cold invasion of Shaoyin. Fever instead of cold indicates Taiyang symptoms, suggesting cold invasion of Taiyang. Using Ma Huang Fu Zi Xi Xin Tang treats both Taiyang (dispersing exterior heat) and Shaoyin (warming the meridian).
However, if Taiyang symptoms include a floating pulse plus vomiting and diarrhea, should one treat only Taiyang? If Shaoyin presents with a deep pulse and fever without Taiyang symptoms, should one focus solely on Shaoyin? This must be understood. By analogy, if Yangming symptoms include body heat and tidal fever but with a weak pulse, diarrhea, and cold limbs, it becomes a Taiyin condition, requiring Fuzi Lizhong Tang to rescue the interior. If Shaoyang symptoms include alternating chills and fever but with a fine pulse, ascariasis-induced convulsions, irritability, and abdominal pain, it becomes a Jueyin condition, requiring Wuzhuyu Tang to rescue the counterflow.
Yang symptoms with Yang pulses are easy to distinguish. Yang symptoms with Yin pulses represent false symptoms and true pulses. There are also cases of both false symptoms and false pulses, such as extreme Yin causing restlessness (desire to jump into water) with a surging pulse that vanishes under pressure, indicating true interior cold and false exterior heat. Or, a choppy pulse with cold limbs, vomiting, constipation, and hidden heat, representing water resembling fire at extremes, or fire resembling water at extremes. Such cases cannot be equated with Liang Gan. Ultimately, treating the root ensures success; treating the branch ensures failure. Clinicians must exercise caution.
Si Ni Tang (Recovery Decoction)
Fuzi (Aconiti Lateralis Radix Praeparata, 2 qian)
Gancao (Glycyrrhizae Radix et Rhizoma, unspecified amount)
Ganjiang (Zingiberis Rhizoma, 1.5 qian each)
Decoct in water and take orally.
Ma Huang Fu Zi Xi Xin Tang (Ephedra, Aconite, and Asarum Decoction)
Mahuang (Ephedrae Herba, 2 qian each)
Xixin (Asari Radix et Rhizoma, 2 qian each)
Fuzi (Aconiti Lateralis Radix Praeparata, 1 qian)
Decoct in water and take orally.
Li Zhong Tang (Regulate the Middle Decoction)
Renshen (Ginseng Radix, 1 qian each)
Baizhu (Atractylodis Macrocephalae Rhizoma, 1 qian each)
Ganjiang (Zingiberis Rhizoma, 1 qian each)
Gancao (Glycyrrhizae Radix et Rhizoma, 0.8 qian)
Decoct in water and take orally. Add Fuzi if abdominal pain is severe; add Shengjiang (Zingiberis Rhizoma Recens) if vomiting due to cold occurs; add Fuling (Poria, unspecified amount) if urination is difficult; remove Baizhu if Kidney Qi moves.
Wu Zhu Yu Tang (Evodia Decoction)
Wuzhuyu (Evodiae Fructus, 3 qian each)
Shengjiang (Zingiberis Rhizoma Recens, 3 qian each)
Renshen (Ginseng Radix, 1 qian)
Decoct with half a zhong of water and one jujube until reduced to seven-tenths, then take orally.