尚兄体素清 ，夏月病温，延诊，金麦伦翁偕往。据述昨午先寒后热，头痛汗出，热灼
不退
，口渴心烦，夜不安卧，形倦莫支。就榻诊之，脉虚浮大而数，视舌无胎，抚如干版。予为
之骇曰∶此证乃春温两感，至危至急。仲圣云∶发热而渴不恶寒者，为温病，发汗已身灼热
者，名曰风温。《内经》云∶冬伤于寒，春必病温。冬不藏精，春必病温。既伤于寒，又
不藏精，同时病发，谓之两感。凡伤寒瘟疫，热盛舌干，亦须至一候之外始见。今病才一日
，舌即干涸，足征肾水素亏，冬伤于寒，邪伏少阴，暗吸肾真，劫其家宝，故一见发热，津
液无以上供，舌即干矣。热论篇云∶伤寒一日，巨阳与少阴俱病，则头痛口干而烦满，断为
两感，不可救药。比类而推，殊难着手。爰用熟地一两，当归三钱，料豆五钱，玉竹五钱，
甘草一钱。疏方讫，告迈翁曰∶予生平治少阴，先溃于里，太阳复感于表，伤寒春温两感危
殆之候，初起悉宗景岳新方，理阴托邪，往往获效，无如此证津液既涸，再投姜附，则阴立
亡。故但师其意，以广期前辈风温汤佐之。虽一时之权宜，亦经营之惨淡耳。迈翁曰∶善。
遂服其药，热减神安，舌稍转润，再加沙参、麦冬、女贞、石斛，更进复脉、左归渐次而愈
。
安波按∶形倦句不妥，盖外感一病，人人皆倦。
郑晋康兄，侨居潜口，设帐汪宅，予因其居停延诊。晤间云∶舍弟抱恙，便托一看。予
问恙
经几日矣，曰昨日起病，发热至今未退。予曰∶此感证也。汪宅去伊芳家不数武，即与偕行。
途次谈及时下患感证者颇多，须验其舌。若初起舌苔腻浓，则受邪深重，缠绵难愈。既至其
室，病者出房就诊，令其伸舌，干涸无苔，形如镜面。予曰殆矣。晋兄惊问所以，予曰∶适
言感证轻重，须验舌苔浓薄，不意令弟舌毫无苔，光明如镜，初病见之，甚非佳兆。晋兄云
∶子言感证苔薄病轻，今舌无苔，反以为殆，此曷故耶?因将曩视吴尚时兄病情向说，即照
所用治法，疏方付之。并告之曰∶服药应效则吉，否则难救。渠以予言为过，另更他医，日
甚一日。挨至六朝，势已沉笃，予言果验。欲复相招。恐予不至，乃札托家 生兄劝驾。予
曰∶非不肯往，奈彼病本重，即服予药，亦难必效，况复稽迟，内经论两感之危，在于六日
，今已届期，卢扁再世，亦无能为。 兄曰∶固难如此，但渠昆仲与吾交契，今急而相求，
且屈一行，以全吾之友谊耳。勉为呼舆。将及门，其疾已革。
安波按∶两证舌俱无苔，外感固属阴候，但亦须问其平日舌苔无苔否。倘若体质如是
，不在此例也。
门人问曰∶叔和序例云，寒毒藏于肌肤，思肌肤浅近，岂容邪栖数月，而病始发与。答
曰∶
喻氏云，寒邪由肌肤而入，辛苦之人，邪藏肌肤则有之。苦膏粱之辈，冬不藏精者，其寒邪
且有藏于骨髓者矣。程扶生云∶藏于肌肤，当云藏于骨髓。周禹载云∶逆冬气则少阴不藏，
不藏，寒邪得而入之，伤于肌肤，伏于骨髓
。合三条而观之，谓伤于肌肤则可，谓藏于肌肤则不可。又问曰∶序例又云，至春变为温病
。喻氏谓变字下得怪诞骇人，周禹载言变字大妙，未审孰是。答曰∶内经论伏气为病，如冬
伤于寒，春必病温，春伤于风，夏生飧泄，夏伤于暑，秋必 疟，秋伤于湿，冬生咳嗽等条
，未言变也。又如夏暑汗不出者，秋成风疟，亦未言变也。其有称变者，如高粱之变，足生
大疔，逆春气则少阳不生，肝气内变，逆之则伤肝，夏为寒变等条，乃谓病之由此变。彼如
实证变虚，热证变寒之类，始可言变。若春温则本冬伤于寒，至春病作，流异源同，似未可
言变也。经又云∶秋阳伤于湿，上逆而咳，发为痿厥，曷不一宗经旨，曰至春发为温病，岂
不韪乎?又问曰∶经云冬不藏精，春必病温。然则室女童男，旷夫嫠妇，皆无温病乎?答曰
∶经语浑融，在人之意会耳。盖冬不藏精一语，亦指天时，非专指人事也。试观天明则日月
不明之句，义可见矣。夫一日之中，早明而夜晦者，即藏精也。一岁之中，春生而冬藏者，
亦藏精也。使入夜不晦，入冬不藏，人物能无夭札疵疠乎，轩岐于此分定两例，曰冬伤于寒
，春必病温，冬不藏精，春必病温。但寒乃冬令之正气，人知畏避，受病尚少，冬阳开泄，
天暖而雷，乃为淫气，受病殊多。此虽予之臆说，然揆其理，似当不谬。又问曰∶刘松峰谓
《内经》冬伤于寒，春必病温，云笈七签改作冬伤于汗，盖言冬时过暖，以致汗出，来春必
病温，冬日严寒，来春并无瘟疫，以其应寒而寒，得时令之正故耳。以汗易寒可乎?答曰∶
此创论也，似亦近理。但《内经》格言，岂容率改耶。
吴尚时的兄长体质向来清瘦，夏季患温病，我去诊治时，金麦伦老先生一同前往。据家属描述，昨天中午先出现恶寒随后发热，头痛出汗，热势灼人且持续不退，口渴心烦，夜间无法安睡，身体极度疲倦无力。在床边诊察，脉象虚浮大而数，观察舌苔无苔，抚摸舌面干燥如干板。我为此感到震惊说：这个证候是春温两感，极其危险紧急。仲景说：发热而口渴不恶寒的，称为温病；发汗后身体更加灼热的，称为风温。《内经》说：冬天受寒，春天必定发生温病。冬天精气不藏，春天必定发生温病。既受了寒邪，又精气不藏，同时发病，称为两感。凡是伤寒瘟疫，热盛舌干，也必须要过了一候（五天）之后才会显现。现在病才一天，舌头就干涸，足以证明肾水素来亏损，冬天受寒，邪气潜伏在少阴经，暗中吸取肾中真阴，掠夺其根本，所以一见发热，津液就无法上承滋润，舌头就干了。《热论篇》说：伤寒第一天，太阳经与少阴经同时发病，就会出现头痛、口干和烦满，断定为两感，是不可救治的。以此类推，确实很难着手治疗。于是我用熟地黄一两，当归三钱，料豆五钱，玉竹五钱，甘草一钱。开完方后，告诉迈翁说：我生平治疗少阴病，先内部溃败，太阳经又感受表邪，伤寒春温两感这种危重证候，初起通常遵循张景岳的新方，用理阴煎托举邪气外出，往往能获效，但像这个证候津液已经枯竭，如果再投用姜、附子等温热药，那么阴气立刻就会亡失。所以我只是借鉴他的意旨，用广期前辈的风温汤来辅助治疗。这虽然是一时的权宜之计，也是苦心经营的结果。迈翁说：好。于是服用他的药，热势减退，神志安宁，舌面稍微转润，再加沙参、麦冬、女贞子、石斛，更进复脉汤、左归丸，逐渐痊愈。
安波按：关于“身体极度疲倦无力”这一句不妥当，因为外感病，人人都会疲倦。
郑晋康兄，侨居在潜口，在汪家设馆教书，我因为汪家的主人邀请去诊治。见面时他说：我的弟弟生病了，拜托您看一看。我问病情几天了，他说：昨天开始发病，发热到现在还没退。我说：这是感证（外感病）。汪宅离他家不远，我就与他同行。路上谈到当下患感证的人很多，必须查验他们的舌苔。如果初起舌苔腻厚，说明受邪深重，缠绵难愈。到了他家房间，病人出房就诊，让他伸出舌头，干燥无苔，形状像镜面一样。我说：危险了。晋康兄惊讶地问原因，我说：刚才说感证的轻重，必须查验舌苔的浓薄，没想到令弟的舌头毫无苔垢，光亮如镜，初病就见这种症状，非常不是好兆头。晋康兄说：你说感证苔薄病轻，现在舌头无苔，反而认为危险，这是什么缘故呢？于是我将之前诊治吴尚时兄的病情向他讲述，即按照所用的治法，开方给他。并告诉他：服药应该有效则吉利，否则难以救治。他认为我的话过分，另外换了其他医生，病情一天比一天加重。挨到第六天（六朝），形势已经沉重笃实，我的话果然应验。想再次请我，怕我不去，于是写信托付家生兄劝我前往。我说：不是我不肯去，无奈他病本已重，即使服我的药，也难保证有效，何况又拖延了时间，《内经》论述两感的危险在于第六天，现在已经到了期限，即使是卢医扁鹊再生，也无能为力。家生兄说：固然难做到这样，但他们兄弟与我交情深厚，现在危急时来求助，且委屈你走一趟，以成全我们的友谊吧。勉强叫来车舆。快到门口时，他的病情已经危重。
安波按：两个病例的舌头都无苔，外感病固然是阴证的表现，但也必须问平时舌苔是否无苔。倘若体质就是这样，就不在此例了。
门人问：叔和在序例中说，寒毒藏在肌肤，思考一下，肌肤浅近，怎么能容许邪气栖息几个月，然后才发病呢？回答说：喻嘉言说，寒邪从肌肤进入，辛苦劳作的人，邪气藏在肌肤是有这种情况的。但对于吃精细食物的人，冬天精气不藏的，他们的寒邪甚至有藏在骨髓里的。程扶生说：藏在肌肤，应该说藏在骨髓。周禹载说：违背冬天的养生之气，则少阴不藏，不藏，寒邪得以进入，伤于肌肤，伏于骨髓。综合这三条来看，说是伤于肌肤可以，说是藏在肌肤则不可以。又问：序例又说，到了春天变为温病。喻嘉言认为“变”字下得怪诞骇人，周禹载说“变”字大妙，不知谁对。回答说：《内经》论述伏气为病，如冬天受寒，春天必病温，春天受风，夏天生飧泄，夏天受暑，秋天必疟疾，秋天受湿，冬天生咳嗽等条文，没有说“变”。又如夏天暑热汗不出的人，秋天成风疟，也没有说“变”。那些称“变”的，如高粱之变，足生大疔，违背春气则少阳不生，肝气内变，违背它则伤肝，夏天发生寒变等条文，是说病由此演变。比如实证变虚证，热证变寒证之类，才可以称为变。如果是春温，本是冬天受寒，到春天发病，流异源同，似乎不能称为变。经文又说：秋天阳气受伤于湿，上逆而咳，发为痿厥，为什么不统一遵循经旨，说到了春天发作成为温病，难道不对吗？又问：经文说冬天不藏精，春天必病温。那么童男童女，寡妇鳏夫，都没有温病吗？回答说：经文语意浑融，在于人的意会罢了。大概“冬天不藏精”这句话，也是指天时，并非专指人事。试看“天明则日月不明”这句，意义就可以看到了。一天之中，早晨明亮而夜晚昏暗的，就是藏精。一年之中，春天生发而冬天闭藏的，也是藏精。如果入夜不昏暗，入冬不闭藏，人物能不夭折患病吗？轩岐在这里分定两个例子，说冬天受寒，春天必病温，冬天不藏精，春天必病温。但寒是冬天的正气，人们知道畏惧躲避，受病还少，冬天阳气开泄，天气温暖打雷，这才是淫气，受病非常多。这虽然是我的臆测，但推究其理，似乎应当不错。又问：刘松峰说《内经》“冬伤于寒，春必病温”，《云笈七签》改为“冬伤于汗”，大概是说冬天过于暖和，导致出汗，来年春天必病温，冬日严寒，来年并无瘟疫，因为顺应寒冷而寒冷，得到时令的正气缘故。用“汗”替换“寒”可以吗？回答说：这是创论，似乎也接近道理。但《内经》的格言，岂容随意更改呢。
Wu Shangshi's elder brother had a constitution that was inherently slender. In summer, he contracted a warm disease (Wenbing). When I went to diagnose him, Old Man Jin Mailun accompanied me. According to the account, at noon yesterday, he first experienced chills followed by fever, headache with sweating, burning heat that did not subside, thirst and vexation, inability to sleep peacefully at night, and extreme physical fatigue and weakness. Upon examining him in bed, his pulse was deficient, floating, large, and rapid. His tongue showed no coating, and upon palpation, it felt dry like a wooden board. I was startled and said: This syndrome is Chunwen Lianggan (Spring Warmth with simultaneous Taiyang and Shaoyin involvement), which is extremely critical and urgent. Zhong Jing stated: Fever with thirst but no aversion to cold indicates a warm disease; if after sweating, the body becomes even more burning hot, it is called Fengwen (Wind-Warmth). The *Neijing* states: Injury by cold in winter leads to warmth disease in spring. Failure to store essence in winter leads to warmth disease in spring. Having been injured by cold and failing to store essence, with simultaneous onset of illness, it is called Lianggan (Dual Involvement). In cases of Shanghan (Cold Damage) or epidemics, where heat is excessive and the tongue is dry, this usually appears only after one five-day period (Yi Hou). Here, the illness has lasted only one day, yet the tongue is already dried up, fully demonstrating that Kidney Water was originally deficient. Winter cold injury caused pathogenic factors to lie latent in the Shaoyin channel, secretly absorbing Kidney True Essence and plundering its treasures. Thus, as soon as fever appeared, fluids could not ascend to moisten, resulting in a dry tongue. The *Re Lun* chapter states: On the first day of Shanghan, if both Taiyang and Shaoyin channels are diseased, symptoms include headache, dry mouth, and fullness/vexation; this is diagnosed as Lianggan, which is incurable. By analogy, it is indeed difficult to initiate treatment. Therefore, I prescribed Shudi (Prepared Rehmannia Root) 1 liang, Danggui (Angelica Sinensis) 3 qian, Liaodou (Soybeans) 5 qian, Yuzhu (Polygonatum Odoratum Rhizome) 5 qian, and Gancao (Licorice Root) 1 qian. After writing the prescription, I told Maiweng: Throughout my career, when treating Shaoyin diseases where internal collapse precedes external contraction by Taiyang, such critical conditions of Shanghan-Chunwen Lianggan, I initially followed Zhang Jingyue's new formulas, using Liyin Tang to support Yin and expel pathogens, often achieving success. However, in this case, since fluids are exhausted, administering Jiang (Ginger) and Fuzi (Aconite) again would cause immediate loss of Yin. Thus, I merely adopted his principle and assisted it with Guangqi Senior's Fengwen Tang. Although this is a temporary expedient, it represents painstaking effort. Maiweng said: Good. He took the medicine, the heat subsided, spirit calmed, and the tongue slightly regained moisture. Sha Shen (Glehnia Root), Maidong (Ophiopogon Tuber), Nvzhenzi (Ligustrum Fruit), and Shihu (Dendrobium Stem) were added, followed by Fumai Tang (Pulse-Recovering Decoction) and Zuogui Wan (Left Restoring Pill), leading to gradual recovery.
An Bo notes: The phrase "extreme physical fatigue" is inappropriate, as everyone suffers fatigue with exogenous diseases.
Brother Zheng Jinkang resided as a guest in Qiankou, teaching at the Wang residence. I visited for diagnosis at the invitation of the host. During our meeting, he said: My younger brother is ill; please take a look. I asked how many days the illness had lasted. He replied: It started yesterday, with fever persisting until now. I said: This is a Gan Zheng (Exogenous Syndrome). The Wang residence is very close to his home, so I went with him. On the way, we discussed that many people were suffering from exogenous syndromes recently, and one must examine the tongue coating. If the coating is greasy and thick at the onset, the pathogen is deep-seated and difficult to cure. Upon arriving at the room, the patient came out for examination. Asked to extend his tongue, it was dry, devoid of coating, and smooth like a mirror surface. I said: It is perilous. Brother Jin was surprised and asked why. I explained: Just now I mentioned that the severity of exogenous syndromes depends on the thickness of the tongue coating. Unexpectedly, your brother's tongue has absolutely no coating, bright and mirror-like. Seeing this at the onset of illness is a very bad omen. Brother Jin said: You said thin coating means mild illness; now with no coating, you consider it perilous. Why? I then recounted the condition of Wu Shangshi's brother and the treatment used, prescribing the same method. I also told him: If the medicine takes effect, it will be auspicious; otherwise, it will be hard to save. He thought my words were too harsh, changed to another doctor, and the condition worsened day by day. By the sixth day, the situation became critical, and my prediction proved correct. They wanted to invite me again. Fearing I might refuse, they entrusted Brother Jiasheng to persuade me. I said: It is not that I am unwilling to go, but his illness is fundamentally severe. Even if he took my medicine, efficacy is not guaranteed, let alone the delay. The *Neijing* states the danger of Lianggan lies on the sixth day. Now that time has arrived. Even if Lu Bian (Lu Guo and Bian Que) were reborn, they could do nothing. Brother Jiasheng said: It is indeed difficult, but since they are brothers and close friends of mine, and they seek help in their emergency, please make one trip to fulfill our friendship. Reluctantly, I ordered a carriage. As we approached the door, his condition had become critical.
An Bo notes: Both cases presented tongues without coating. While exogenous diseases can manifest as Yin patterns, one must ask if the patient normally lacks tongue coating. If the constitution is naturally like this, it does not fall under this category.
A student asked: Shuhe's preface states that cold toxins hide in the skin and muscles. Considering the skin and muscles are superficial, how can pathogens reside there for months before disease manifests? I answered: Yu Jia Yan said, cold pathogens enter through the skin and muscles; for those who work hard, pathogens hiding in the skin and muscles is possible. But for those consuming rich foods, whose essence is not stored in winter, their cold pathogens may even hide in the bone marrow. Cheng Fusheng said: "Hiding in skin and muscles" should be read as "hiding in bone marrow." Zhou Yu Zai said: Violating the Qi of winter causes Shaoyin not to store; due to non-storage, cold pathogens enter, injuring the skin and muscles, and lying latent in the bone marrow. Observing these three statements together, saying "injured by skin and muscles" is acceptable, but saying "hidden in skin and muscles" is not. Another question arose: The preface also states that by spring, it transforms into a warm disease. Yu Jia Yan considered the character "transform" (Bian) strange and shocking, while Zhou Yu Zai said it was excellent. Who is correct? I answered: The *Neijing* discusses latent Qi diseases, such as "Winter injury by cold leads to warmth disease in spring," "Spring injury by wind leads to undigested stool diarrhea in summer," "Summer injury by heat leads to malaria in autumn," "Autumn injury by dampness leads to cough in winter," etc., none of which use the word "transform." Similarly, "Summer heat with no sweat leads to wind-malaria in autumn" does not use "transform." Those instances calling it "transform," such as "Transformations of rich food causing carbuncles on feet," "Violating spring Qi causes Shaoyang not to generate, Liver Qi internally transforms," or "Violating it injures the Liver, causing cold transformation in summer," refer to pathological changes. For example, excess transforming to deficiency, or heat transforming to cold, can be called "transform." However, Chunwen originates from winter cold injury, manifesting in spring; although the manifestation differs, the source is the same, so it cannot strictly be called "transform." The classic also says: "Autumn Yang injured by dampness, rising upward causes cough, developing into flaccidity and cold extremities." Why not uniformly follow the classic's intent and say "manifests as warm disease in spring"? Is that not correct? Another question: The classic says "Failure to store essence in winter leads to warmth disease in spring." Does this mean children, maidens, widows, and widowers never get warm disease? I answered: The classic's language is holistic and requires intuitive understanding. The phrase "failure to store essence in winter" refers to heavenly timing, not specifically human affairs. Consider the phrase "If heaven is bright, sun and moon are not clear"; the meaning is visible. Within a day, brightness in morning and darkness at night constitutes storing essence. Within a year, generation in spring and storage in winter also constitute storing essence. If nights were not dark and winters did not store, could beings avoid premature death or disease? Xuan Qi established two examples here: "Winter injury by cold leads to warmth disease in spring," and "Winter failure to store essence leads to warmth disease in spring." Cold is the proper Qi of winter; people know to avoid it, so fewer fall ill. However, when winter Yang opens and leaks, weather warms and thunder occurs, this is excessive Qi, and many fall ill. This is my speculation, but reasoning suggests it is likely correct. Another question: Liu Songfeng claimed that the *Neijing*'s "Winter injury by cold, spring warmth disease" was altered in *Yunji Qiqian* to "Winter injury by sweat," implying that excessive warmth in winter causes sweating, leading to warmth disease in spring, whereas severe cold in winter prevents epidemics because it aligns with seasonal correctness. Is replacing "cold" with "sweat" valid? I answered: This is a creative theory, seemingly reasonable. But how can the maxims of the *Neijing* be casually altered?