彼天士之好用寒凉，环境使之然也，有清中叶，医者好用人参，习重温补，士大夫以受赐人参为荣，庶人以持赠人参为礼，士多养尊处优，民多安居乐业，浸浸百余年，相习成时风，驯至感冒发热，亦佐以人参，如参苏饮之类，比比皆然，天士出类拔萃，力矫时弊，知感之不宜温补也，创温热之门，以立异于伤寒，其用辛凉，乃为气盛而误补失表之用，所谓时时轻扬法也，彼时之人，气盛者多，疾病之反应，每易趋向太过，故可凉可清者亦多，叶氏力反时尚，独创新法，亦医林之俊杰也，后人不识气盛可清之理，恣用寒凉，去真远矣。
苏生曰：甚矣，环境之足以左右医术也，吾人处天地之间，动焉息焉，饮食起居，喜怒好恶，积之既久，气质多变，气质既变，治法亦易，当叶氏之世，民情失补，医多失表，疾病之反应，每易趋向太过，天士著述温热，取法辛凉，乃适应当时之环境也。
医之用药，所以救弊补偏也，历来方术理论，都是时代之产物，今之以为非者，当其时，以为真理也，今之以为不适于用者，当其时，冈皆应手而效也。
吾人研究医学，当以历史目光，追溯昔贤之环境，与其著书立说之动机，勿拘泥其所用之术语，惟推求其真义之所在，则前人之经验，皆我青囊中物也，叶氏为有清一代名医，声誉噪大江南北，其所著外感温热篇，·后人奉为温热之准绳，今之所谓时医者，其处方用药，皆不离叶氏之范围，吾师谓叶法仅宜于体实气盛，反应有余者，恐时师末能心折也，叶氏创作温热篇之动机，今已了然于心矣，温热篇之著述，其大要如何，疗法如何，何者为可取，何者为不当，原夫子阐明之。
师曰：叶著外感温热篇，其立名之义，乃自别于伏气、伤寒也，言外感，所以别伏气也，言温热，所以别伤寒也。
当时之所谓伤寒，所谓温热，都是一种想象之邪，邪者，害正之物也，本无而忽有，名曰受邪，邪病之用温药而愈者，遂名之曰寒邪，邪病之用凉药而愈者，遂名之曰温邪，其因发汗解肌而愈者，曰邪在于表也，其因清泄攻导而已者，曰邪伏于里也，邪机之推测，乃从药效反溯而得之。
当叶氏之世，误补失表者多，其民体气充实，有感则邪从火化，火化者，人体抗力旺盛，反应敏锐也。
大凡气盛者，激之则怒，阳旺者，激之则亢，亢盛之体，投热则燥，与凉即安。
叶氏适应环境，而著述温热之篇，所以别于适用温药之伤寒，非另有温热之邪也。夫伤寒温病，二而一，一而二也，言刺激则有伤寒之邪，言反应则有亢盛之体，邪正相搏，其抵抗之趋势，倾向太过者，即是温热之病，温热者，病之偏于热也，热者人体反应之偏于亢进也。
叶著外感温热篇者，叙述温热病变之历程也，其所以揭外感二字者，言邪机之趋势多从表解也，因其可从表解，故名曰外感，揭温热二字者，言温病之证候，多从火化也，因其适于寒凉，故名曰温热。
叶氏治温热，其看法，卫之后方言气，营之后方言血，营卫气血，乃代表病机之浅深，如伤寒之有六经也。
温热篇之著述，不外描写四种病变之历程，所谓病变历程者，疾病演变之过程也，疾病之发展，因人而殊，因药而异，体质强弱有强弱之过程，药石当否有当否之演变，叶著之温热篇，非是探求病原之论，实乃应付病变之作也，其所叙之证候；不外各个病变之描写而已，其引用之术语，不过其私人之艺术思想而已，非真有温邪入营入卫入气入血也，凡是术语，皆不可执着，吾于叶著之温热篇，综其大要，如是而已。
苏生曰：晰乎哉，吾师对于叶著温热篇之评论也，如炽犀烛，洞见幽微，虽起叶氏于地下，当亦为之心折也，师言邪机之推测，乃从药效反溯而得之，温热之著述，不外乎病变历程之描写，可谓超于象外，别具慧眼者矣，然吾师一再否定术语，小子期期以为不可，夫术语者，学术上之代名词也，亦即病理解释上之重要符号也，吾国医学精粹之所在也，临床诊断所赖以融会贯通也，当叶氏之世，不闻科学之原理，不知细菌为何物，其恃以为疗病者，全赖术语为之运用也，师而曰中医之书，言表非表，言里非里，表无风可祛，里无热可清，营卫气血，尽是虚构，是自决其藩篱也，若是则吾人诊疗，究竟将以何者为准绳乎，西医每讥中医为不科学，以其所用术语，为不可解也，而吾中医言之成理，用之有效，祛风则风散，散热则热解，解表则表之症状平，平里则里之宿疴以愈，立竿见影，固可以事实证明者也，术语之应用，彼之不及知，而我之深自知也。
师革新医学，并中医精神所寄之术语而非之，不将为西医所窃笑、中医所齿冷耶。
师曰：吾非有厌于术语也，术语之合符真理者，，吾将阐扬之，其不然者，吾将修正之，真理无国界，宁有术语，永为中医所独有者。
伤寒之形成，一方力致病之菌，一方为受病之人，中医因无科学工具，故对于病原体之形态性能，祗可略焉不详，是诚为缺憾，然吾人于人体应变之能力，则综合分析颇为扼要，中医之言病体，凡是害正者，都名曰邪，其可以感觉意会者，六淫之邪也，其不可以形视目睹而足以危害人体者，都名日毒，所谓疫疠不正之气也，邪也毒也，此皆病菌之代名词也，名虽近乎逻辑，然而约矣，中医之言人也，于体工反应之表现，则有八纲，邪正相争之趋势；则分五段，提纲挈要，有证候可稽，有色脉可合，积数千年之经验，形成各种之术语，有方式，有逻辑，可以观察，可以实验，特略于病而独详于人耳。
吾人但须阐明术语之真义夕本古训而不拘泥，采新知而不狂悖，惟真理是求，则术语何尝不用哉。
古人著书立说，皆有环境色彩，东垣生于戎马仓皇之秋，民多伤于饥饱劳疫，故有补中益气之论，丹溪处于渔盐之乡；地多卑湿，民病内热，故有清利滋阴之说；叶氏之著温热篇，亦为适应当时环境之作也，营卫气血，不过解释叶氏所习见之四种病型而已，此项病型之造成，半为叶氏矫正时医之误，半为叶氏自作聪明之误，故其书有可取，有不可取也。
苏生曰：顾问叶著可取之处。
师曰：叶著所谓温热病者，即余之所谓阳明伤寒也，叶氏所谓外感者，非今之所谓外感也，外感无形之邪，表且不留，何法入营，何法入血，更何法逆传心包耶。
叶氏以临床之经验，知气盛之人，其反应趋向于亢进，故避用温热，知病变之趋势，表者多吉，故法取轻扬，观察病变之过程，斑疹白痞，厥脱詀妄，何者为顺，何者为逆，示人以予后之吉凶，描写证候之状态，舌苔牙齿，色泽声音，以致津汗便溺，何者当清，何者当温，启发辨证之机括，既详且明，足为临床之借镜，此其可取之处也。
苏生曰：然则叶著何法不可取耶。
师曰：叶氏之视温热也，以为实有温热之邪也，以为温热之邪，于法宜用寒凉也，故曰在表初用辛凉，到气才可清气，入营犹可透热转气，入血就恐耗血动血，直须凉血散血，其处方虽有前后缓急之法，而赏用清凉，其揆一也，唯其主观以为温邪当凉，故曰：“虽在吴人阳微之体，亦应用清凉”，明知阳微过清必死，故又曰：“清凉到六七分，即不可过于寒凉，恐成功反弃也”。
总是立名不正，遂令其言不顺。夫外感发热，气盛而表闭者，与辛凉则热退，此热体(气盛之意)之外感也，而口十氏曰此乃外感温邪也，宜辛凉解之，倒因为果，此急需更正者一也。
伤寒内有所激，气盛而表闭者，辛凉解表，则表开气和矣，气不旺者，妄用清凉，则正馁而表气慑矣，表闭而放温障碍，则热更炽矣，热炽则熏灼神经，宜有躁烦不寐之症矣，此误凉失表之咎也。叶氏曰：“温邪热变最速，辛凉不解，是渐欲入营也，营分受热，则血液受劫，心神不安，夜甚无寐，即撤去气药，参入凉血清热，”此一误再误也，表闭里怯，当予辛温，叶氏以为温邪宜凉，岂知不当之凉，将自馁其气，此一误也，凉表则表气不宣，秽毒堵留；生温益亢，热之亢也，意欲冲开痞塞，解表而自舒其困也，不开其表，而反撤去气药，一意于清营，是正欲伸而又抑之也，是不能拯之于涂炭，而反驱之于深渊也，叶氏名重一时，临证甚多，曾见辛凉解表，表解而愈者，亦曾见表开而热不解者，又见表不解而热更炽者，于是口授及门以各种病变之符号，曰营曰卫，曰气曰血，列举症状，朗若列眉，此虽有先见之明，难免失真之咎，此其师心自用，尤须更正者二也。
夫伤寒有五，温病乃伤寒之一种，柯韵伯曰，阳明为成温之薮，陆九芝曰，伤寒传入阳明，遂成温病，其言是也，金元以前，并无温病专书，叶氏温热篇，叙述详明，轻浅入时，宜其为时师所喜也。
叶氏之后，吴鞠通王孟英辈推波助澜，以为叶氏之温热，廷以颜颃仲景之伤寒，疵谬矛盾，不胜枚举，戴北山详评之矣。此篇风行一时，深入人心，以盲引盲，贻误滋多，异日当按条纠正之。
总之，当叶氏生存时代，甚多可凉之体，可寒之证，然其所述病变，强半为叶氏本人所造成，是以遵其法，则见其证，必有其前后缓急之法，乃有其营卫气血之传，其先见之明，正其谬误之处，吾人不当以予测为能，应以救逆为工，顺逆者，胜败之机枢也，医之为工，工于救逆也。吾人观察证候之衷现，洞悉疾病之趋势，而晓之于病家曰，明日当见何证，当见何舌，见何证当危，见何舌当死，知机识变，患者至死而不悔，巧言令色，病家心折而无辞，然司命者，心知其变，目送其危，既不能扶顺，又不能挽逆，将何以为工乎。
吾闻之，天土一代名医也，勤敏好学，淹有众家之长，其著作是否出于本人之手，是乃考据之事。天士亦人也，人尽有智也，焉知今人之不昔若也，吾人就该篇而论，允宜明辨其瑕瑜而不可盲从者也，须知一应著述，半是适应环境之作，后之览者，不思揣摩，而惟师古自荣，不亦愍乎。
苏生曰：甚矣，读书之下可胶柱鼓瑟也，孟子云，尽信书不如无书，良有以也，昔贤著述医论，或为发扬心得，或为叙述经验，或为启迪后学，或为矫正时弊，其立说也，必有真义在焉，其真义之精神，未可言宣词达者，则有术语为之逻辑，逻辑者，罗织也，学说上之组织法也，读古书而不知揣摩其精神，而徒拘执其术语，是乃食古不化也。
人类生活于环境之中，其所得之知识，因人因时因地而不同，著者之主观不同，则其学说之见解亦各异，吾人读书而不知揣摩其精神，一味盲从，如戴有色之镜，以为物尽有色也。
彼深于门户之见者，攻讦异己，曰，我时方派也，叶王之嫡传也，彼持经方疗病者，成功不足，肇祸有余，体质不同，今人岂古人之比哉；经方派曰，时方者，时俗之方也，学之不遵规矩绳墨者，江湖之医也，岂足以疗大病哉。一方之言，不能使彼方折服，则日道不同，不相为谋，各有所宗，各行其道可耳，是不欲求其真也，是不去其镜，而各是其色也。
叶氏之温热篇，适应环境之作也，北山之非难叶氏，亦适应环境之作也，叶氏所说之营卫气血，病理上之逻辑法也，鞠通三焦之辨，又可九传之论，陈无择之三因鼎立，张仲景之六经分治，亦皆病理上之逻辑法也，古人以逻辑目光，解释病理，纯为私人之主观，故不可盲从，其著述，乃临床之记录，纯为客观之描写，足资借镜。
是故，叶氏前后缓急之法，未必可循，营卫气血之称，不可拘执，此即吾师明辨瑕瑜之义也。”，伤寒合度之抵抗为太阳，外视表机之开合，内察正气之盛衰，开表以辛，和表以甘，制亢以凉，扶怯以温，小子亦已默喻之矣，今当进聆少阳之论。(《伤寒质难》)
柴按：祝氏认为：医者不当以能够预知疾病之转归为能，更重要的是要在病势发展中，能够掌握截断的方法。他曾虚心下气地考察过叶派药法的实效，认为叶派药法在逆转病势方面效果令人不能满意，并认为叶派理论也有不正确的地方。所以强调“医之为工，工于救逆”，这无疑是正确的。祝氏治学，具有创新精神，他认为“学说之成立，言之凿凿，往往昨是而今非。”推陈出新本来就是科学发展的必然规律，而“不务实际，澜翻瞽说，中医之所以不进步”的毛病，也正在此。时医以叶派温热之学为圭臬，“以为道在于兹矣，将令天下后世，宗此道以长相守矣，昧者从之，贤者疑之，学者试之而不应，必有从而斥之者矣！”事实就是如此。惜乎中医学术论坛，几为一派所独占，使抨击叶派之学术观，不复为广大医者所了解，这也已成为事实，正是有鉴于以上二个事实，故余有此书之撰作。此书撰旨，非为意在讥弹叶派，求事理之真相而已，冀百家争鸣之兴起而已，此目的，余于自序中已详之，不复赘言。知我罪我，一凭当世可也。
温病学说思想变迁考察后之结论
【背景信息】
书名：热病衡正 章节：正文(46/49) 类别：伤寒
叶天士之所以喜欢使用寒凉药物，是当时的环境使他这样的。在清朝中期，医生们喜欢用人参，习惯性地重视温补，士大夫以接受人参赏赐为荣，平民百姓以赠送人参为礼物，士人多养尊处优，百姓多安居乐业，渐渐过了一百多年，这种风气相沿成习，甚至到了感冒发热时，也辅助使用人参，像参苏饮之类的方剂，比比皆是。叶天士出类拔萃，极力纠正这种时弊，知道感受外邪不宜用温补，创立了温热学派，以此与伤寒学说区别开来。他使用辛凉药物，是为了应对体质强盛而误用温补导致邪气未能从表解的情况，这就是所谓的“时时轻扬法”。当时的人，体质强盛的很多，疾病的反应往往容易趋向于太过（亢进），所以可以用清凉药物的情况也很多。叶氏极力反对当时的时尚，独创新的治疗方法，也是医学界的俊杰。后人不懂得体质强盛可以用清法的道理，肆意使用寒凉药物，这就离真理很远了。
苏生说：环境足以左右医术，真是严重啊！我们生活在天地之间，动静作息，饮食起居，喜怒好恶，积累久了，气质就会发生变化；气质既已变化，治疗方法也随之改变。在叶天士那个时代，民情倾向于失于温补，医生多失于解表，疾病的反应往往容易趋向于太过。叶天士撰写温热著作，采用辛凉之法，是适应当时的环境。
医生用药，是为了补救弊端、纠正偏差。历来的方术理论，都是时代的产物。现在认为不对的，在当时被认为是真理；现在认为不适用的，在当时都是应手而效的。
我们研究医学，应当用历史的目光，追溯前贤所处的环境以及他们著书立说的动机，不要拘泥于他们所使用术语，只要推求其真正的含义所在，那么前人的经验就都成为我们的囊中之物了。叶天士是清朝一代名医，声誉震动大江南北，他所著的《外感温热篇》，被后人奉为温热学的准绳。现在的所谓时医，他们的处方用药，都不离开叶氏的范围。我的老师认为叶氏的方法只适用于体质结实、气机旺盛、反应有余的人，恐怕当时的医生们不能心服。叶氏创作《温热篇》的动机，现在已经了然于心了。《温热篇》的著述，大体要点是什么？疗法如何？哪些是可以取的，哪些是不当的？请老师阐明。
老师说：叶氏所著的《外感温热篇》，其立名的意义，是为了区别于伏气温病和伤寒。说“外感”，是为了区别于伏气；说“温热”，是为了区别于伤寒。
当时所说的伤寒、所说的温热，都是一种想象中的邪气。邪，是伤害正气的东西，本来没有却忽然有了，叫做受邪。邪病用温药而痊愈的，就命名为寒邪；邪病用凉药而痊愈的，就命名为温邪。因为发汗解肌而痊愈的，叫邪在表；因为清泄攻下而痊愈的，叫邪伏于里。对邪气的推测，是从药效反推得来的。
在叶天士那个时代，误用温补、失于解表的人很多，百姓体质充实，一旦感受外邪，邪气就从火化（转化为热证）。火化，是指人体抗力旺盛，反应敏锐。
大凡气机旺盛的人，受到刺激就容易愤怒；阳气旺盛的人，受到刺激就容易亢奋。亢盛的身体，投以热药就会燥烈，给予凉药就能安宁。
叶氏适应环境，而著述温热篇章，是为了区别于适用温药的伤寒，并不是另有温热之邪存在。夫伤寒和温病，是二而一、一而二的关系。言刺激则有伤寒之邪，言反应则有亢盛之体。邪正相搏，其抵抗的趋势倾向太过（亢进）的，就是温热病。温热，是病偏于热；热，是人体反应偏于亢进。
叶氏著《外感温热篇》，是叙述温热病变的过程。之所以揭示“外感”二字，是说邪气的趋势多从表而解；因为可以从表解，所以名叫外感。揭示“温热”二字，是说温病的证候多从火化；因为适于寒凉治疗，所以名叫温热。
叶氏治疗温热病，其看法是：卫分之后才讲气分，营分之后才讲血分。营卫气血，代表病机的浅深，就像伤寒有六经一样。
《温热篇》的著述，不外乎描写四种病变的过程。所谓病变过程，就是疾病演变的过程。疾病的发展，因人而异，因药而异。体质强弱有不同的过程，用药恰当与否有不同的演变。叶氏的《温热篇》，不是探求病原的理论，实际上是应付病变的记录。其所叙述的证候，不过是各个病变的描述而已。其所引用的术语，不过是他个人的艺术思想罢了，并不是真有温邪入营、入卫、入气、入血这回事。凡是术语，都不可以执着。我对叶氏《温热篇》的综合大意，就是这样。
苏生说：透彻啊！我老师对于叶氏《温热篇》的评论，如炽热的犀角烛照幽微，洞察细微。即使叶氏复活，也会心服口服。老师说邪气的推测是从药效反推得来的，《温热篇》的著述不外乎是对病变过程的描写，可以说是超脱于表象之外，别具慧眼。然而，我老师一再否定术语，学生我坚决认为不可。夫术语，是学术上的代名词，也就是病理解释上的重要符号，是我国医学精粹所在，临床诊断赖以融会贯通的工具。在叶氏那个时代，不懂科学原理，不知道细菌为何物，他们依靠用来治病的全赖术语来运用。如果老师说中医的书，言表非表，言里非里，表无风可祛，里无热可清，营卫气血尽是虚构，这是自我封闭藩篱啊。如果是这样，那么我们诊疗，究竟以什么为准绳呢？西医常讥笑中医不科学，是因为所用术语不可理解。而我们中医言之成理，用之有效，祛风则风散，散热则热解，解表则表证平，治里则里疾愈，立竿见影，固然是事实可以证明的。术语的应用，西医不及知，而我中医深知其中奥妙。
老师革新医学，并否定中医精神所寄托的术语，难道不会让西医窃笑、让中医齿冷吗？
老师说：我并非厌恶术语。符合真理的术语，我将阐扬它；不符合真理的，我将修正它。真理没有国界，哪有术语永远为中医所独有的道理。
伤寒的形成，一方面是致病之菌，一方面是人体的受病状态。中医因为没有科学工具，所以对于病原体的形态性能，只能简略不详述，这确实是遗憾。然而，我们对人体应变能力的综合分析颇为扼要。中医所说的病体，凡是伤害正气的，都名为邪。那些可以感觉意会的，是六淫之邪；那些不可以形视目睹但足以危害人体的，都名为毒，即所谓疫疠不正之气。邪和毒，都是病菌的代名词。名称虽近乎逻辑，但是简约。中医所说的人，对于机体反应的表现，有八纲；邪正相争的趋势，分为五段。提纲挈要，有证候可查，有色脉可合，积累数千年经验，形成各种术语，有方式，有逻辑，可以观察，可以实验，只是略于病而独详于人罢了。
我们只要阐明术语的真正含义，遵循古训而不拘泥，采纳新知而不狂悖，只求真理，那么术语何尝不能用呢？
古人著书立说，都有环境的色彩。李东垣生于战乱饥荒之时，百姓多伤于饥饱劳役疫病，所以有补中益气的论述；朱丹溪处于渔盐之乡，地势多卑湿，百姓病内热，所以有清利滋阴的说法；叶氏著《温热篇》，也是适应当时环境的著作。营卫气血，不过是解释叶氏所习见的四种病型而已。这种病型的造成，一半是叶氏矫正时医之误，一半是叶氏自作聪明之误。所以他的书有可取之处，也有不可取之处。
苏生问：请问叶氏著作可取之处在哪里？
老师说：叶氏所说的温热病，就是我所说的阳明伤寒。叶氏所谓的外感，不是现在所谓的外感。外感无形之邪，表证尚且留不住，用什么方法入营？用什么方法入血？更用什么方法逆传心包呢？
叶氏凭借临床经验，知道气盛之人，其反应趋向于亢进，所以避免使用温热药；知道病变的趋势，表证多吉，所以法取轻扬。观察病变的过程，斑疹白痞，厥脱谵妄，什么是顺证，什么是逆证，示人以预后吉凶，描述证候状态，舌苔牙齿，色泽声音，以致津液汗便溺，什么该清，什么该温，启发辨证的机括，既详细又明确，足以为临床借鉴，这是可取之处。
苏生说：那么叶氏著作有什么不可取的呢？
老师说：叶氏看待温热病，认为实有温热之邪存在，认为温热之邪，依法宜用寒凉。所以说在表初用辛凉，到气分才可清气，入营犹可透热转气，入血就恐耗血动血，直须凉血散血。其处方虽有前后缓急之法，但崇尚清凉，其宗旨是一致的。正因为主观认为温邪当凉，所以说：“即使在吴地人阳微之体，也应应用清凉。”明知阳微过清必死，所以又说：“清凉用到六七分，就不可过于寒凉，恐怕成功反弃也。”
总是立名不正，遂令其言不顺。夫外感发热，气盛而表闭者，用辛凉则热退，这是热体（气盛之意）之外感，而叶氏却说这是外感温邪，宜辛凉解之，倒因为果，这是急需更正的第一点。
伤寒内有所激，气盛而表闭者，用辛凉解表，则表开气和矣。气不旺者，妄用清凉，则正气馁弱而表气慑缩矣。表闭而放温障碍，则热更炽矣。热炽则熏灼神经，应有躁烦不寐之症矣，这是误用凉药失于解表的罪过。叶氏说：“温邪热变最速，辛凉不解，是渐欲入营也。营分受热，则血液受劫，心神不安，夜甚无寐，即撤去气药，参入凉血清热。”这是一误再误。表闭里怯，当予辛温，叶氏以为温邪宜凉，岂知不当之凉，将自馁其气，这是一误。凉表则表气不宣，秽毒堵留，生温益亢，热之亢也，意欲冲开痞塞，解表而自舒其困也，不开其表，而反撤去气药，一意于清营，是正欲伸而又抑之也，是不能拯之于涂炭，而反驱之于深渊也。叶氏名重一时，临证甚多，曾见辛凉解表，表解而愈者，亦曾见表开而热不解者，又见表不解而热更炽者，于是口授及门以各种病变之符号，曰营曰卫，曰气曰血，列举症状，朗若列眉，此虽有先见之明，难免失真之咎，此其师心自用，尤须更正的第二点。
夫伤寒有五，温病乃伤寒之一种。柯韵伯说，阳明为成温之薮；陆九芝说，伤寒传入阳明，遂成温病，这话是对的。金元以前，并无温病专书，叶氏《温热篇》，叙述详明，轻浅入时，宜其为时医所喜也。
叶氏之后，吴鞠通、王孟英辈推波助澜，认为叶氏之温热，足以抗衡仲景之伤寒，疵谬矛盾，不胜枚举，戴北山详评之矣。此篇风行一时，深入人心，以盲引盲，贻误滋多，异日当按条纠正之。
总之，在叶氏生存时代，甚多可凉之体，可寒之证，然其所述病变，强半为叶氏本人所造成。是以遵其法，则见其证，必有其前后缓急之法，乃有其营卫气血之传。其先见之明，正是其谬误之处。吾人不当以预测为能，应以救逆为工。顺逆者，胜败之机枢也。医之为工，工于救逆也。吾人观察证候之表现，洞悉疾病之趋势，而晓之于病家曰，明日当见何证，当见何舌，见何证当危，见何舌当死，知机识变，患者至死而不悔，巧言令色，病家心折而无辞，然司命者，心知其变，目送其危，既不能扶顺，又不能挽逆，将何以为工乎？
我听说，叶天士是一代名医，勤敏好学，淹有众家之长。其著作是否出于本人之手，是考据之事。天士亦人也，人尽有智也，焉知今人之不昔若也？吾人就该篇而论，允宜明辨其瑕瑜而不可盲从者也。须知一应著述，半是适应环境之作。后之览者，不思揣摩，而惟师古自荣，不亦愍乎。
苏生说：读书不可胶柱鼓瑟，真是严重啊！孟子云，尽信书不如无书，良有以也。昔贤著述医论，或为发扬心得，或为叙述经验，或为启迪后学，或为矫正时弊，其立说也，必有真义在焉。其真义之精神，未可言宣词达者，则有术语为之逻辑。逻辑者，罗织也，学说上之组织法也。读古书而不知揣摩其精神，而徒拘执其术语，是乃食古不化也。
人类生活于环境之中，其所得之知识，因人因时因地而不同。著者之主观不同，则其学说之见解亦各异。吾人读书而不知揣摩其精神，一味盲从，如戴有色之镜，以为物尽有色也。
彼深于门户之见者，攻讦异己，曰，我时方派也，叶王之嫡传也。彼持经方疗病者，成功不足，肇祸有余。体质不同，今人岂古人之比哉？经方派曰，时方者，时俗之方也，学之不遵规矩绳墨者，江湖之医也，岂足以疗大病哉？一方之言，不能使彼方折服，则曰道不同，不相为谋，各有所宗，各行其道可耳，是不欲求其真也，是不去其镜，而各是其色也。
叶氏之《温热篇》，适应环境之作也。北山之非难叶氏，亦适应环境之作也。叶氏所说之营卫气血，病理上之逻辑法也。鞠通三焦之辨，又可九传之论，陈无择之三因鼎立，张仲景之六经分治，亦皆病理上之逻辑法也。古人以逻辑目光，解释病理，纯为私人之主观，故不可盲从。其著述，乃临床之记录，纯为客观之描写，足资借镜。
是故，叶氏前后缓急之法，未必可循，营卫气血之称，不可拘执，此即吾师明辨瑕瑜之义也。
伤寒合度之抵抗为太阳，外视表机之开合，内察正气之盛衰，开表以辛，和表以甘，制亢以凉，扶怯以温，小子亦已默喻之矣，今当进聆少阳之论。（《伤寒质难》）
柴胡按：祝氏认为：医者不当以能够预知疾病之转归为能，更重要的是要在病势发展中，能够掌握截断的方法。他曾虚心下气地考察过叶派药法的实效，认为叶派药法在逆转病势方面效果令人不能满意，并认为叶派理论也有不正确的地方。所以强调“医之为工，工于救逆”，这无疑是正确的。祝氏治学，具有创新精神，他认为“学说之成立，言之凿凿，往往昨是而今非。”推陈出新本来就是科学发展的必然规律，而“不务实际，澜翻瞽说，中医之所以不进步”的毛病，也正在此。时医以叶派温热之学为圭臬，“以为道在于兹矣，将令天下后世，宗此道以长相守矣，昧者从之，贤者疑之，学者试之而不应，必有从而斥之者矣！”事实就是如此。惜乎中医学术论坛，几为一派所独占，使抨击叶派之学术观，不复为广大医者所了解，这也已成为事实，正是有鉴于以上二个事实，故余有此书之撰作。此书撰旨，非为意在讥弹叶派，求事理之真相而已，冀百家争鸣之兴起而已，此目的，余于自序中已详之，不复赘言。知我罪我，一凭当世可也。
温病学说思想变迁考察后之结论
[Background Information]
Book: Re Bing Heng Zheng (Balanced Corrections on Febrile Diseases) Chapter: Main Text (46/49) Category: Shang Han (Cold Damage)
Ye Tianshi’s preference for using cold and cool herbs was dictated by the environment of his time. During the mid-Qing Dynasty, physicians favored the use of Ginseng Radix et Rhizoma (Renshen, 人参), habitually emphasizing warm and tonifying methods. Scholars regarded receiving Ginseng as an honor, while commoners considered gifting it a proper courtesy. The literati lived in comfort and luxury, and the populace enjoyed peace and prosperity. Over more than a century, this became a prevailing trend. It even reached a point where, in cases of common cold with fever, Ginseng was added to prescriptions, such as in Shen Su Yin (Ginseng and Perilla Decoction), which were ubiquitous. Ye Tianshi stood out from the crowd and vigorously corrected these contemporary abuses. He understood that exogenous pathogens should not be treated with warm tonification, thus establishing the Warm Disease school to differentiate it from the Cold Damage theory. His use of acrid-cool methods was intended for cases where patients had strong constitution but were mistakenly treated with warm tonification, preventing the pathogen from being released via the exterior. This is what is referred to as the "method of frequent lightness and floating" (Shi Shi Qing Yang Fa). At that time, many people had robust constitutions, and disease responses tended to lean towards excess (hyperactivity). Therefore, there were many situations suitable for cooling and clearing. Ye deliberately opposed the fashion of his time and created new therapeutic methods, making him a杰出 figure in the medical field. Later generations failed to understand the principle that robust constitutions can be treated with clearing methods; instead, they recklessly used cold and cool substances, moving far away from the truth.
Su Sheng said: The influence of the environment on medical practice is profound. We live within heaven and earth, our movements and rest, diet and起居 (daily life), joys and anger, likes and dislikes, accumulate over time, altering our temperament. Once the temperament changes, the treatment methods must also change. In Ye Tianshi’s era, the public tendency was towards deficiency due to lack of warming/tonifying, and physicians often neglected releasing the exterior. Disease responses tended to lean towards excess. Ye Tianshi’s writings on warm diseases and his adoption of acrid-cool methods were adaptations to the environment of his time.
Physicians use medications to remedy deficiencies and correct deviations. Past formulas and theories are products of their respective eras. What is considered incorrect today was once regarded as truth at its time; what is deemed unsuitable today was once effective upon application.
When studying medicine, we should adopt a historical perspective, tracing the environments of past sages and their motivations for writing. We should not be bound by their terminology but should seek their true meaning. In doing so, the experiences of predecessors become part of our own medical arsenal. Ye Tianshi was a renowned physician of the Qing Dynasty, with a reputation spanning the rivers and lakes. His work *Wai Gan Wen Re Pian* (Treatise on Exogenous Warm Diseases) is revered by later generations as the standard for warm disease studies. Contemporary physicians’ prescriptions rarely deviate from Ye’s scope. My teacher believes that Ye’s methods are only suitable for those with solid constitutions, vigorous qi, and excessive reactive capacity. I fear contemporary doctors may not fully accept this view. The motivation behind Ye’s creation of the *Warm Disease Treatise* is now clear. What are the main points of this treatise? How are the therapies applied? What is acceptable and what is inappropriate? Please elucidate, Master.
The Master said: The naming significance of Ye’s *Exogenous Warm Disease Treatise* is to distinguish it from latent heat diseases and Cold Damage. "Exogenous" distinguishes it from latent heat; "warm disease" distinguishes it from Cold Damage.
The "Cold Damage" and "Warm Disease" discussed at that time were conceptualizations of pathogens. A "pathogen" (Xie, 邪) is something that harms healthy qi. It appears suddenly where there was none before, termed "contracting a pathogen." If a disease responds to warm herbs, it is named "cold pathogen"; if it responds to cool herbs, it is named "warm pathogen." If recovery follows sweating and muscle-releasing methods, the pathogen is said to be in the exterior; if recovery follows purging and draining, the pathogen is said to be hidden in the interior. The speculation on pathogenic mechanisms was derived retrospectively from therapeutic effects.
In Ye Tianshi’s time, many were mistakenly treated with tonification and neglected exterior release. The populace had robust constitutions; upon contracting a pathogen, it transformed into fire (heat). "Fire transformation" indicates vigorous human resistance and sharp reactivity.
Generally, those with vigorous qi become angry when stimulated; those with abundant yang become hyperactive when stimulated. In hyperactive constitutions, administering hot herbs causes dryness, while administering cool herbs brings peace.
Ye Tianshi adapted to the environment by writing on warm diseases to differentiate them from Cold Damage, which uses warm herbs. He did not posit the existence of a separate "warm pathogen." Cold Damage and warm diseases are two aspects of one entity. Stimulation involves the Cold Damage pathogen; reaction involves the hyperactive constitution. When pathogen and healthy qi contend, if the resistance trend leans towards excess (hyperactivity), it is a warm disease. "Warm" means the disease leans towards heat; "heat" means the human reaction leans towards hyperactivity.
Ye’s *Exogenous Warm Disease Treatise* narrates the course of warm disease pathology. The term "exogenous" is used because the pathogenic trend often resolves from the exterior; since it can resolve from the exterior, it is called exogenous. The term "warm disease" is used because the symptoms often transform into fire; since they respond to cold/cool treatments, it is called warm disease.
Ye’s approach to treating warm diseases posits that after the Wei (Defensive) level, one discusses the Qi level; after the Ying (Nutritive) level, one discusses the Xue (Blood) level. Ying, Wei, Qi, and Blood represent the depth of pathological mechanisms, analogous to the Six Channels in Cold Damage.
The *Warm Disease Treatise* essentially describes the progression of four types of pathological changes. "Pathological progression" refers to the process of disease evolution. Disease development varies by individual and medication. Strong and weak constitutions have different progression patterns; appropriate or inappropriate medications lead to different evolutionary outcomes. Ye’s *Warm Disease Treatise* is not a theory exploring pathogens but a record responding to pathological changes. The symptoms described are merely descriptions of various pathological states. The terminology used reflects his personal artistic thought rather than the literal entry of warm pathogens into Ying, Wei, Qi, or Blood levels. Terminology should not be clung to rigidly. My summary of Ye’s *Warm Disease Treatise* is as follows.
Su Sheng said: Profound! Your commentary on Ye’s *Warm Disease Treatise* is like a lit rhinoceros horn illuminating the obscure. Even if Ye were resurrected, he would be convinced. You stated that pathogenic speculation is derived retrospectively from therapeutic effects, and that the treatise merely describes pathological progressions. This shows insight beyond appearances. However, your repeated negation of terminology is something I firmly oppose. Terminology serves as academic shorthand and crucial symbols in pathological explanation. It is the essence of Chinese medicine and the tool for clinical integration. In Ye’s time, lacking scientific principles and knowledge of bacteria, therapy relied entirely on the application of terminology. If you say that Chinese medicine texts speak of exterior but mean no exterior, interior but mean no interior, that there is no wind to dispel in the exterior and no heat to clear in the interior, and that Ying, Wei, Qi, and Blood are fictitious, you are closing off your own boundaries. Then, what standard shall we use for diagnosis and treatment? Western medicine often criticizes Chinese medicine as unscientific because its terminology is incomprehensible. Yet, our Chinese medicine is logical and effective: dispelling wind disperses wind, clearing heat resolves heat, releasing the exterior calms exterior symptoms, and treating the interior cures internal ailments. These results are evident and verifiable by fact. The application of terminology is known deeply to us, though unknown to them.
If you innovate medicine while rejecting the terminology that embodies the spirit of Chinese medicine, will you not be laughed at by Western medicine and despised by Chinese medicine?
I said: I do not hate terminology. I will promote terminology that aligns with truth and correct that which does not. Truth has no borders; why should terminology be exclusively owned by Chinese medicine?
The formation of Cold Damage involves both pathogenic bacteria and the susceptible host. Lacking scientific tools, Chinese medicine can only briefly mention the morphology and properties of pathogens, which is indeed a regret. However, our comprehensive analysis of the body’s adaptive capacity is concise. In Chinese medicine, anything harming healthy qi is named "pathogen" (Xie). Those perceptible through sensation and intuition are the Six Evils (Liu Yin, 六淫); those imperceptible visually yet harmful are named "toxin" (Du, 毒), i.e., epidemic miasma. Pathogens and toxins are synonyms for bacteria. Although the nomenclature seems logical, it is concise. Regarding humans, Chinese medicine uses the Eight Principles (Ba Gang, 八纲) to manifest bodily reactions and divides the trend of pathogen-healthy qi contention into five stages. This outlines the essentials, providing observable syndromes and combinable pulse-color signs. Accumulating millennia of experience, various terminologies were formed, possessing logic, observability, and experimental potential, focusing detailedly on the human response rather than the specific disease.
As long as we clarify the true meaning of terminology, follow ancient teachings without rigidity, adopt new knowledge without arrogance, and seek only truth, why cannot terminology be used?
Ancient writings always bear environmental colors. Li Dongyuan lived during wartime famine, where people suffered from hunger, fullness, labor, and epidemics, leading to his theory of tonifying middle qi and boosting vitality. Zhu Danxi lived in a fishing and salt region with damp lowlands, where people suffered from internal heat, leading to his theories of clearing, draining, and nourishing yin. Ye’s *Warm Disease Treatise* was also an adaptation to his contemporary environment. Ying, Wei, Qi, and Blood merely explained the four disease patterns Ye commonly encountered. These patterns arose half from Ye correcting contemporary medical errors and half from Ye’s own intellectual overreach. Thus, his book has merits and demerits.
Su Sheng asked: What are the merits of Ye’s work?
The Master said: The "warm disease" Ye described is what I call Yangming Cold Damage. The "exogenous" Ye mentioned is not the modern concept of exogenous pathogens. Exogenous formless pathogens do not linger in the exterior; how could they enter Ying or Xue? How could they reverse-transmit to the Pericardium?
Based on clinical experience, Ye knew that individuals with vigorous qi tend towards hyperactive reactions, so he avoided warm herbs. Knowing that exterior trends are generally auspicious, he adopted light and floating methods. Observing the pathological process—macules, papules, white pruritic spots, cold extremities, delirium—he distinguished between favorable and unfavorable prognoses, describing symptom states, tongue coating, teeth, color, voice, fluids, sweat, stool, and urine, indicating what to clear and what to warm. This inspired diagnostic mechanisms, detailed and clear, serving as a mirror for clinical practice. This is its merit.
Su Sheng asked: Then, what is unacceptable about Ye’s work?
The Master said: Ye viewed warm diseases as having a real "warm pathogen" requiring cold/cool treatment. Hence, he said: initially in the exterior, use acrid-cool; only at the Qi level can one clear heat; entering Ying, one can still透热转气 (transmit heat out via Qi); entering Xue, one fears consuming blood and stirring blood, requiring direct cooling of blood and dispersing blood stasis. Although his prescriptions had methods of priority and urgency, his emphasis on cooling was consistent. Subjectively believing warm pathogens require cooling, he stated: "Even in Wu-region patients with deficient yang, cooling should be used." Knowing that excessive cooling in deficient yang leads to death, he added: "When cooling reaches 60-70%, do not overuse cold/cool, lest success be abandoned."
The root cause is improper naming, leading to illogical statements. For exogenous fever with vigorous qi and exterior closure, acrid-cool reduces heat. This is exogenous disease in a heat-type (vigorous qi) constitution. But Ye called it "exogenous warm pathogen," requiring acrid-cool resolution. This reverses cause and effect, needing correction (Point 1).
In Cold Damage, internal stimulation causes vigorous qi and exterior closure. Acrid-cool releases the exterior, harmonizing qi. In those with weak qi, reckless use of cooling depletes healthy qi and suppresses exterior qi. Exterior closure hinders warmth release, intensifying heat. Intense heat irritates nerves, causing restlessness and insomnia. This is the fault of misusing cooling and neglecting exterior release. Ye said: "Warm pathogens change heat rapidly. If acrid-cool fails, it gradually enters Ying. Ying heat hijacks blood, disturbing heart-mind, causing worse night insomnia. Remove Qi-level herbs, add blood-cooling and heat-clearing." This is error compounded by error. With exterior closure and interior weakness, warm-acrid should be used. Ye believed warm pathogens require cooling, unaware that inappropriate cooling depletes qi (Error 1). Cooling the exterior prevents exterior qi from venting, trapping turbid toxins, generating warmth and hyperactivity. Intent to open blockage and relieve exterior distress, yet removing Qi-level herbs to focus solely on clearing Ying is suppressing what should be extended. This fails to save from misery and drives into abyss. Ye, famous and experienced, saw cases where acrid-cool resolved exterior and cured, cases where exterior opened but heat persisted, and cases where exterior remained unresolved with intensified heat. He orally taught disciples symbols of pathological changes: Ying, Wei, Qi, Xue, listing symptoms clearly. While prescient, this inevitably lacks accuracy. This subjective self-reliance needs correction (Point 2).
Cold Damage encompasses five types; warm disease is one of them. Ke Yunbo said Yangming is the source of warm disease; Lu Jiuzhi said Cold Damage transmitting to Yangming becomes warm disease. Their words are correct. Before Jin-Yuan dynasties, there were no specialized warm disease books. Ye’s *Warm Disease Treatise*, detailed and accessible, was naturally favored by contemporary physicians.
After Ye, Wu Jutong and Wang Mengying fueled the trend, claiming Ye’s warm disease could rival Zhang Zhongjing’s Cold Damage. Contradictions and flaws are numerous, as detailed by Dai Beishan. This treatise spread widely, influencing minds, leading blind guides leading the blind, causing much harm. Future corrections will address these point by point.
In summary, in Ye’s era, many bodies were suitable for cooling, and many conditions were cold. However, half the pathological changes described were created by Ye himself. Following his methods yields his syndromes, implying his priorities and the transmission of Ying, Wei, Qi, and Blood. His prescience is also his error. We should not pride ourselves on prediction but excel in saving from reversal. Favorable/unfavorable trends are the pivot of victory/defeat. A physician’s skill lies in saving from reversal. Observing symptoms and understanding disease trends, we inform patients: "Tomorrow you will see such-and-such syndrome, such-and-such tongue. Seeing such syndrome indicates danger; seeing such tongue indicates death." Knowing opportunities and changes, patients die without regret, charmed by eloquent words. But the healer, knowing the change and watching the crisis, unable to support the favorable or reverse the adverse, how can they be skilled?
I heard Ye Tianshi was a master physician, diligent and learned, integrating strengths of many schools. Whether his works were entirely his own is a matter of textual research. Ye was human, endowed with wisdom. Who knows if modern people are inferior to ancients? Regarding this treatise, we should discern its flaws and merits, not follow blindly. All writings are partly adaptations to environment. Readers who do not ponder the spirit but only boast of following antiquity are pitiable.
Su Sheng said: Relying rigidly on books is dangerous. Mencius said, "Believing all of a book is worse than having no book." Ancient medical writings aimed to express insights, record experience, enlighten students, or correct abuses. Their theories contain true meaning. Where spirit cannot be fully expressed in words, terminology provides logic. Logic is organization. Reading ancient books without grasping their spirit, clinging only to terminology, is eating old food without digesting.
Humans live in environments; knowledge varies by person, time, and place. Authors’ subjectivities differ, leading to varied scholarly views. Reading without pondering spirit, following blindly, is like wearing tinted glasses, seeing everything as colored.
Those deep in sectarian prejudice attack others: "I am of the Time Formula School, direct descendant of Ye and Wang." Those holding Classical Formulas claim: "Time formulas are vulgar; learning without rules makes one a quack, unfit for major diseases." One side’s words cannot convince the other, so they say "different paths," each following their own宗 (school). This avoids seeking truth, refusing to remove lenses and accepting only their own color.
Ye’s *Warm Disease Treatise* is an environmental adaptation. Dai Beishan’s criticism of Ye is also an environmental adaptation. Ye’s Ying, Wei, Qi, Blood are pathological logic. Jutong’s Three Burners, Kejiu’s Nine Transmissions, Chen Wuze’s Three Causes, and Zhongjing’s Six Channels are all pathological logics. Ancients used logical perspectives to explain pathology, purely subjective, thus not to be followed blindly. Their writings are clinical records, objective descriptions, worthy of reference.
Therefore, Ye’s methods of priority and urgency may not be universally applicable, and the terms Ying, Wei, Qi, and Blood should not be rigidly adhered to. This is my teacher’s meaning in discerning flaws and merits.
Moderate resistance in Cold Damage manifests as Taiyang. Externally observe exterior opening/closing; internally inspect healthy qi strength/weakness. Open exterior with acrid, harmonize exterior with sweet, restrain hyperactivity with cool, support weakness with warm. I have silently understood this. Now I await the discussion on Shaoyang. (*Shang Han Zhi Nan*)
Chai’s Note: Zhu believed that a physician’s ability should not lie in predicting disease outcome, but in mastering interception methods during disease progression. He humbly investigated the efficacy of Ye-school methods, finding them unsatisfactory in reversing disease trends, and believed Ye-school theory had inaccuracies. Thus, emphasizing "physician’s skill lies in saving from reversal" is undoubtedly correct. Zhu’s scholarship showed innovation, believing "theories established with certainty often turn from right yesterday to wrong today." Pushing out the old to make way for the new is the inevitable law of scientific development. The flaw of "ignoring reality, speaking nonsense, hindering Chinese medicine progress" lies here. Contemporary physicians took Ye-school warm disease theory as the standard, believing "the Way lies here, to be upheld forever by future generations." Ignorant followed, wise doubted, practitioners tried and failed, leading to rejection. Facts are so. Regrettably, TCM forums are dominated by one school, silencing critiques of Ye-school views from most physicians. This is a fact. Given these two facts, I wrote this book. Its purpose is not to mock Ye-school but to seek truth and encourage hundred schools of thought. I detailed this in the preface. Judge me as you will.
Conclusion on the Evolution of Warm Disease Theory Thought