温热，伏邪也。凡言夹者，伏邪夹实、夹虚，二邪夹发者也。如夹痰水、食、郁、蓄血等邪属实者，则以
夹邪为先，伏邪为后，盖清其夹邪，而伏邪始得透发，透发方能传变，传变乃可解利也。如夹脾虚、肾虚及诸
亡血家症，则以治伏邪为主，养正为辅，盖邪留则正益伤，故不可养正遗邪也。如夹哮喘、心胃痛、疝气诸旧
病，则但治伏邪，旧病自已，盖旧病乃新邪所迫而发也。约计之则有十。
一、夹痰水 饮入于胃，经蒸变而稠浊者为痰，未经蒸变而清稀者为水，痰与水一物也。痰能作热，水
能作冷，温热属伏火症，故夹痰者更增其热，每见昏眩痞闷，右脉滑盛。治法宜桔梗汤加化橘红、栝蒌、贝母，
甚则可加稀涎散先吐膈上之伏痰；如痰迷清窍，神昏如迷，口吐涎沫，胸腹按之不痛者，宜加味导痰汤加牛黄清
心丸，或昌阳泻心汤加万氏牛黄丸。若夹水，则脉往往相悖，治法亦有不同，不可不细辨也。温热之脉必数，而
有水在胸膈，其脉多缓，甚则迟弦，此脉夹水之辨也。温热之舌，一经传里，则转黄、转燥、转黑∶若有水在胸
膈，则烦躁、谵妄、沉昏诸症具备，而舌色白润，间有转黄、转黑者，亦必仍有滑苔，或满舌黄黑，半边夹一二
条白色，或舌尖舌本
俱黄，中间夹一段白色，此舌夹水之辨也。温热胸满，心下硬痛，手不可按；一有水在胸隔，心下虽满痛，按
之则软，略加揉按，漉漉有声，甚则肠下抽痛，干呕短气，或腰重足肿，下利溺少，此症夹水之辨也。温热症见夹
水脉症，虽有表，不宜纯用辛凉发散，纯用则表不能解，而转见沉困；有里症，不可早用苦寒，早用则必转加
昏愦。此水气郁遏热邪，阳气受困，宜于发表清里药中，加辛燥利水、利气之品，以祛水气。迨水气去，郁
遏发，然后议攻、议凉，则无不效者矣。燥湿，则半夏、苍术；利水，则木通、苓、泽；利气，则莱菔子、草果
仁、青木香。甚则有可投控涎丹、大陷胸汤者。故温热虽属伏火，往往有投三承气、黄芩、白虎，而偶用温燥
药收功。遂至讼清热之非者，不知伏火乃其本气，夹杂乃其间气耳！
二、夹食滞 温热夹食滞者最多，而有食填胸膈，食入肠胃之不同。入肠胃则为阳明积热症，治法备于三
承气汤。惟食在胸膈，虽症见恶食、吞酸、嗳气、腹满、欲吐不吐、呕逆痞闷，而往往有脉沉手足冷者。误认三
阴，投以温剂，却无一毫热渴，而烦躁倍增，甚则一二日即死。盖膈间为阴阳升降之路，食填之则气闭，气闭则
郁热无所疏泄，误温则热愈郁。热郁于内，故外无发热症；热郁于下，故上无口渴症。伏邪以出表为浅，入里为深，
此病一温，则逼邪入里，故并至死而不见热症也。由前五辨法，既辨得为温热症矣，而遇脉沉手足冷，即当细询其
胸膈，若痞塞闷痛，即是夹食。再辨其舌苔白浓，而微兼淡黄，益为食填膈上明证，可于桔梗汤中加枳壳、青皮、
莱菔、曲 ，甚则用吐法以宣之，外治用连豆散敷之，使膈间阳气宣达，然后热症自见，则解表清里，无或误矣。
三、夹气郁 温热症夹气郁者，初起时症悉同，而多脉沉、手足冷、呕逆、胸满，颇类夹食。但夹食为
有物，为实邪，舌
苔浓白而微黄，胸膈满痛不可按，按亦不移。夹气为无物，为虚邪，舌苔白薄，胸膈满痛，半软而可按。先宜宣
通其郁，然后解表清里，自无不效。若不舒郁而徒发表，则里气不能外达，而难于彻汗；遽用清下，则上气不
宣，多致痞逆。惟于解表药中加苏梗、青皮、郁金、香附之类，以宣其气，则表易解；于清里药中加栝蒌、川
贝，以舒其郁，则里易和。但川贝母虽为舒郁要药，而力薄性缓，必用至五钱一两，方能奏效，若加四磨饮子
则尤捷。
四、夹蓄血 伏邪传经之后，蓄血最多，从治攻里，兹不具论。惟本有内伤停瘀，复感伏邪，于初起
一二日，病之表症悉具，而脉或芤或涩，颇类阳症阴脉，但须细询其胸腹、胁肋、四肢，有痛不可按而涩者，
即为蓄血；确知其非阳症见阴脉，则是表症见里脉矣。治法必兼消瘀，红花、桃仁、归尾、赤芍、元参、元胡、
山楂之类，量加一二味；重则加炮穿山甲一钱，则表邪易解，而芤涩之脉亦易起。若误认芤涩为阴，而投温剂，
轻则变剧，重则危矣。至于里症发现，宜用吴氏桃仁承气汤，加干漆、炒川连，泻火攻血。其蓄血或从呕出，
或从泄出，须审其色。红紫而散者可治，色如败衄，而凝结成块，多兼血水，此正气已脱，邪不能留也。又或
如污泥而粘腻不断，臭秽异常者，此津气已败，与浊腐同下也，症多不治。如胁痛、少腹痛，手不可按，甚至
昏迷不省，少顷复苏，乃瘀血上冲，症名血厥，大便或秘或黑，轻则香壳散，重则代抵当丸、拔萃犀角地黄汤，
加炮穿山甲一钱，最破瘀积。若瘀结不散，必发热如狂，咳喘呕逆；若发汗太过，误触瘀血，则或呕或泄，或
发呃逆。但活血消瘀，则呕泄呃逆自止。
五、夹脾虚 温热较之风寒本为难治，以风寒传变有次序，温热传变无常经∶风寒表邪，一发即散，伏
邪散而复集，且
往复再三；风寒传里症，一攻即和，伏邪攻而复合，有下之又下而不和者，此伏邪所以难治也。而脾虚者，则
更为难治。盖温热必得汗、清、下而后解，脾虚者，表不能作汗，里不任攻下，或得汗矣，而气随汗脱；得下
矣，而气从下脱；即纯用清泄，中气亦不克支持，往往药愈凉而邪愈遏。今时习俗，尤偏于温热伤阴之说，不
知中气内虚、热郁灼津之理，每见苔赤，便用大剂清滋。是浊热已遏中焦气分，又用浊药，两浊相合，逼令邪
气深入膏肓，深入骨髓，遂成锢结不解之势。又或舌苔黄腻，明是中焦气分被湿热熏蒸，法宜苦辛开化；乃不用
开化，而用大剂凉药，如三黄、白虎、三石、玉女煎之类，有阖无开，亦足逼令邪气深伏。邪伏则脾气不得上
升，舌苔因之亦伏，转成舌绛无苔。见其舌绛无苔，又用犀角地黄、清宫、增液诸汤，更令邪气深伏。药愈清滋，
舌肉愈燥，愈赤愈黑，甚至音哑、神昏窍闭，变在须臾，故治此等症，汗不强汗，解表必兼养正，如参苏饮、
七味葱白汤之类；下勿轻下，攻里必兼顾本，如三黄、枳术丸、黄龙汤之类；凉不纯凉，清中必兼益气生液，
如人参白虎汤、竹叶石膏汤、黄连泻心汤、参胡温胆汤、参胡芍药汤之类。其外症似无甚分别，惟脉必虚弱，不
任寻按可据；然邪有进退，当其邪焰方张，虽虚而脉亦寻按有力，不可泥也，又必以神情、气色、脉症相参，如
面色萎黄，神情倦怠，气息微促，皆脾虚中气不振之象。更须通体合参，如通体皆有余实象，而独见一二虚象，
则虚象反为吃紧；通体俱见虚象，而独见一二实症，则实症又为吃紧，是故权衡标本为尤急也。如实症居标，
虚症居本，则虚症为重；如虚症居标，实症居本，则实症为重，到此虚实关头，苟不精心诊察，则草菅人命矣！
六、夹肾虚 温热症夹脾虚者，为难治矣，夹肾虚者，更难治。温热属伏火，肾气虚，则手足反冷；温
热属实邪，肾气
虚，则眩晕惊悸，腰膝痿软。肾虚之中，又有阴虚、阳虚之分。温热必待汗、下、清而后解，阳虚者，一经汗、
下、清，则脱绝之症随见∶阴虚者，一经汗、下、清，则枯竭之症随见，必须时时谛察。凡在表时，见腰痛异
常、小便频数、膝胫冷软、精泄如注，当细询其人之平日，如有淋浊、遗泄、阳痿等症，则当于疏表药中加人
参、白芍，阳虚兼官桂、杜仲，阴虚兼元参、知母，以照顾本元，免后来意外之虞。若入里当下，必千金生地
黄汤、陶氏黄龙加减为主；当清气分，人参白虎汤；血分，犀角地黄汤加减为主。或屡清屡下，而热更甚，舌
上燥而无苔，或有黑苔，愈清而愈长，或有燥苔，愈下而愈裂者，是皆属于肾阴虚，察其阳明无实症可据，即
当治以六味地黄汤，熟地改用生地，加知母、黄柏，或甘露饮。熟地切片，泡汤代水煎药。王太仆所谓寒之不
寒，责其无水，壮水之主，以制阳光者，此也。再不应，则合生脉散，以滋水之上源，或用黄连阿胶汤、小甘
露饮，滋阴泻火；但似此热势燎原，非杯水所能救，故必大作汤液，乃有济耳。见机若早，十救二三；涸竭已
见，十难救一。或更兼脾胃败症，如呕呃、哕利之类，润药难任，甚或汤药不下，百不救一矣。
七、夹诸亡血 温热症亡血有三∶
其一，未病之先素亡血而阴虚，一受伏邪，则邪热乘虚煎熬，亡阴最易。用药解表、清里，必步步照顾营
血，如七味葱白汤之用生地、麦冬，刘氏双解散之用归身、白芍是也。
其二，当病之时，忽然吐衄，女子崩漏，甚至血晕昏厥，热甚危急。病家但知血之可骇，医家亦忽其伏邪，
惟汲汲于止血。清凉滋补，多至危殆。不知血由邪逼，惟当清其伏邪，伏邪解，血自止也。惟此症徐见于伏邪
既盛，发热数日后者易知，而猝见于邪郁阴经，并无发热、头痛时者难识，但见微恶
寒而大作呕，急当如前，用五辨法辨之。若舌有白苔，即属湿温伤络，当以新定达原饮为主，呕加竹茹广皮，胀
加青皮、大腹皮。舌有黄苔，或紫绛色，即属温热伤络，宜用凉膈散加茅根、童便；血大溢者，加大黄、黄连，
但治伏邪，血症自已。若脱血太甚，而气欲绝者，必用人参、麦、味以固中气，俟伏邪传变归经，然后按经治
之，此温热症夹亡血之最危者。
其三，伏邪大张之后，烦热躁渴之余，而见亡血症，则又温热症之常态，详后血症各条。
八、夹哮喘 哮喘乃肺家所时有，本有寒痰、热痰二症，一受温热，则无非痰火，由其湿热之气，从其类
而入肺，发其哮喘。遇此，当行前五辨法。有伏邪，但治伏邪，而哮喘自除；或于治伏邪药中，加栝蒌、川贝、
苏子、白前、千金苇茎汤合文蛤散尤捷，二邪并解，法更精密。若哮喘势重，则白果定喘汤、苏子降气汤二方
亦可借用以治标；惟麻黄必须蜜炙，沉香亦宜磨汁，再加生石膏、海蛤壳以清镇之，庶免辛燥劫液之弊。
九、夹胃痛 温热症有夹胃痛者，于其痛时，先用前五辨法。若有伏邪见症，但治伏邪可也。虽平时因寒
而发，于此则但治其热。盖湿温伏于膜原，温热伏于血络，蕴酿蒸变，必从火化。伏邪自里达表，而发其胃痛
痼疾者，多属热痛，则但于治伏邪药中，加乳香、没药以止痛，延胡、桃仁以活络，速使其伏邪透发，而胃痛自
已。若误认平常寒胃痛，用桂、附、姜、萸，必致危殆。
十、夹疝气 伏邪夹疝，其肾囊、少腹引痛，全是疝症，当如前五辨法。一有伏邪，不必治疝，但于治
伏邪药中，加橘核、青皮，而疝自消。若根据常治疝法，用吴萸、桂、附、茴香诸燥品，轻者变为囊痈，重者变
为呃逆，哕厥昏沉，而莫救矣。
总而言之，温热夹症最多，非刻意精别，用药必致差误。
凡遇有内伤宿病之人，更患伏气温热，不得用峻汗、峻攻、峻清之法；必参其人之形气盛衰，伏邪微甚，本病
之新久虚实，向来之宜寒宜热，宜补宜泻，宜燥宜润，宜降宜升，或近日服过何药之相安不相安，其间或夹痰
水，或夹食滞，或夹积瘀，或夹气郁，或夹气虚，或夹血虚，或夹阳虚，或夹阴虚。务在审症详明，投剂果决，
自然随手克应，而无颟顸之弊矣。
温热病，属于伏邪致病。凡是说“夹症”，是指伏邪夹杂实证或虚证，两种邪气共同发作。如果夹杂痰饮、水湿、食积、气郁、蓄血等实邪，治疗应以祛除夹邪为先，透发伏邪为后，因为清除了夹邪，伏邪才能透发；伏邪透发后才能传变，传变之后才可以解除病邪。如果夹杂脾虚、肾虚以及各种失血患者的病症，则以治疗伏邪为主，扶正养阴为辅，因为邪气停留会进一步损伤正气，所以不能只顾扶正而遗留邪气。如果夹杂哮喘、心胃痛、疝气等旧疾，则只需治疗伏邪，旧疾自然痊愈，因为旧疾是由新感邪气逼迫而引发的。大概统计起来共有十种情况。
一、夹痰水：饮水进入胃中，经过蒸腾气化变得稠浊的称为痰，未经过蒸腾气化保持清稀的称为水，痰和水本质上是同一种物质。痰能导致发热，水能导致寒冷。温热病属于伏火证，所以夹杂痰邪会加重热势，常出现头晕目眩、胸脘痞闷，右脉滑盛。治疗方法宜用桔梗汤加化橘红、瓜蒌、贝母，严重时可用稀涎散先涌吐膈上的伏痰；如果痰迷心窍，神志昏迷如痴，口吐涎沫，胸腹部按压不痛的，宜用加味导痰汤加牛黄清心丸，或用昌阳泻心汤加万氏牛黄丸。如果夹杂水饮，脉象往往相反，治法也有不同，不可不仔细辨别。温热病的脉象必然数急，而有水饮停留在胸膈，脉象多迟缓，甚至迟弦，这是脉象夹杂水饮的鉴别点。温热病的舌苔，一旦传入里证，就会转为黄色、干燥、黑色；如果有水饮在胸膈，虽然具备烦躁、谵语妄言、昏沉等症状，但舌色白润，间或有转黄、转黑的，也必定仍有滑苔，或者满舌黄黑，半边夹杂一二条白色，或者舌尖舌根都黄，中间夹杂一段白色，这是舌象夹杂水饮的鉴别点。温热病见胸满，心下硬痛，手不可触碰；若夹杂水饮在心膈，心下虽满痛，但按压则软，稍微揉按，有漉漉的水声，甚至肠道牵引作痛，干呕短气，或者腰重脚肿，腹泻尿少，这是症状夹杂水饮的鉴别点。温热病见到夹杂水饮的脉症，虽然有表证，不宜单纯使用辛凉发散药，单纯使用则表证不解，反而转为沉重困倦；有里证，不可过早使用苦寒药，过早使用则必然加重神志昏愦。这是因为水气郁遏热邪，阳气受困，应在发表清里的药物中，加入辛燥利水、行气的药物，以祛除水气。待水气去除，郁遏解开，然后再讨论攻下或清热，就没有不奏效的了。燥湿药，可用半夏、苍术；利水药，可用木通、茯苓、泽泻；行气药，可用莱菔子、草果仁、青木香。严重的甚至可以使用控涎丹、大陷胸汤。所以温热病虽然属于伏火，往往有时投用三承气汤、黄芩、白虎汤无效，偶然使用温燥药却收效。于是有人诉讼指责清热法的错误，不知道伏火是其本气，夹杂才是其间的气机变化！
二、夹食滞：温热病夹杂食滞的情况最多，但有食物填塞胸膈和食物进入肠胃的不同。进入肠胃则成为阳明积热证，治法备载于三承气汤中。只有食物在胸膈，虽然症状表现为厌恶饮食、吞酸、嗳气、腹胀、想吐吐不出、呕吐逆乱痞闷，但往往有脉沉、手足冷的表现。误认为是三阴病，投用温补药剂，患者却没有丝毫热渴，反而烦躁倍增，甚至一两天内死亡。因为膈间是阴阳升降的道路，食物填塞则气机闭塞，气机闭塞则郁热无法疏泄，误用温药则热更郁结。热郁结在内，所以体表没有发热症状；热郁结在下，所以上部没有口渴症状。伏邪以透出体表为浅，深入体内为深，此病一经温药，则逼迫邪气入里，所以即使致死也看不到热症。通过前五种辨证方法，既然辨明是温热病，遇到脉沉手足冷时，就应当详细询问其胸膈情况，如果痞塞闷痛，就是夹杂食滞。再辨别其舌苔白厚，且微兼淡黄，更是食填膈上的明显证据，可以在桔梗汤中加入枳壳、青皮、莱菔、神曲，严重时用吐法宣发，外治用连豆散敷贴，使膈间阳气宣达，然后热症自然显现，此时解表清里，就不会有误了。
三、夹气郁：温热病夹杂气郁的，初起时症状完全相同，但多表现为脉沉、手足冷、呕逆、胸满，颇像夹食滞。但夹食是有形之物，属实邪，舌苔浓白而微黄，胸膈满痛不可按压，按压也不移动。夹气是无物之邪，属虚邪，舌苔白薄，胸膈满痛，半软而可按。先宜宣通其郁结，然后解表清里，自然无不奏效。如果不舒展郁结而只发表，则里气不能外达，难以透彻出汗；急于用清下药，则上焦气机不宣，多导致痞逆。只在解表药中加入苏梗、青皮、郁金、香附之类，以宣通气机，则表易解；在清里药中加入瓜蒌、川贝，以舒展郁结，则里易和。但川贝母虽然是舒郁的要药，而力薄性缓，必须用到五钱至一两，才能奏效，如果加入四磨饮子则尤其快捷。
四、夹蓄血：伏邪传经之后，蓄血最多，从治攻里，这里不再详论。只有原本有内伤停瘀，又感受伏邪，在初起的一两天，疾病的表症全部具备，但脉象或芤或涩，颇像阳证见阴脉，但须详细询问其胸腹、胁肋、四肢，有疼痛不可按压且脉涩的，就是蓄血；确知不是阳证见阴脉，而是表症见里脉。治法必须兼用消瘀，红花、桃仁、归尾、赤芍、玄参、元胡、山楂之类，酌情加一二味；重的加炮穿山甲一钱，则表邪易解，而芤涩之脉也容易恢复。如果误认芤涩为阴证，而投用温剂，轻则病情加重，重则危及生命。至于里症发现，宜用吴氏桃仁承气汤，加干漆、炒黄连，泻火攻血。蓄血或从呕吐而出，或从大便泄出，须审察其颜色。红紫而散开的可以治疗，色如败坏的血块，凝结成块，多兼血水，这是正气已脱，邪气不能留存的征象。又或者如污泥般粘腻不断，臭秽异常的，这是津气已败，与浊腐一同下行，症状大多不治。如胁痛、少腹痛，手不可触碰，甚至昏迷不省人事，片刻后复苏，乃瘀血上冲，症状名为血厥，大便或秘结或黑，轻则用香壳散，重则用代抵当丸、拔萃犀角地黄汤，加炮穿山甲一钱，最能破除瘀积。如果瘀结不散，必发热如狂，咳喘呕逆；如果发汗太过，误触瘀血，则或呕吐或泄泻，或发呃逆。但只要活血消瘀，则呕泄呃逆自然停止。
五、夹脾虚：温热病比风寒病本来难治，因为风寒传变有次序，温热传变无常经：风寒表邪，一发即散，伏邪散而复聚，而且往复再三；风寒传入里证，一攻即和，伏邪攻而复合，有下之又下而不和的，这就是伏邪难治的原因。而夹杂脾虚的，则更为难治。因为温热病必须得汗、清、下而后解，脾虚者，表不能作汗，里不任攻下，或者得汗后，气随汗脱；得下后，气从下脱；即使纯用清泄，中气也不能支持，往往药越凉邪气越被遏制。当今习俗，尤其偏重于温热伤阴的说法，不知道中气内虚、热郁灼津的道理，每见舌苔赤红，便用大剂清滋药。这是浊热已遏制中焦气分，又用浊药，两浊相合，逼迫邪气深入膏肓，深入骨髓，遂成锢结不解之势。又或者舌苔黄腻，明是中焦气分被湿热熏蒸，法宜苦辛开化；却不用开化，而用大剂凉药，如三黄、白虎、三石、玉女煎之类，有阖无开，也足以逼迫邪气深伏。邪伏则脾气不得上升，舌苔因此也伏，转成舌绛无苔。见其舌绛无苔，又用犀角地黄、清宫、增液诸汤，更令邪气深伏。药愈清滋，舌肉愈燥，愈赤愈黑，甚至音哑、神昏窍闭，变化在顷刻之间，所以治疗这类病症，不强求发汗，解表必兼扶正，如参苏饮、七味葱白汤之类；不轻易攻下，攻里必兼顾根本，如三黄、枳术丸、黄龙汤之类；不纯用凉药，清中必兼益气生津，如人参白虎汤、竹叶石膏汤、黄连泻心汤、参胡温胆汤、参胡芍药汤之类。其外症似乎没有什么分别，只有脉象必然虚弱，不耐寻按可作为依据；然而邪气有进退，当其邪焰正盛时，虽然体虚，脉象寻按也有力，不可拘泥，还必须神情、气色、脉症相互参照，如面色萎黄，神情倦怠，气息微促，都是脾虚中气不振的表现。更要整体合参，如全身皆有余实象，而独见一二虚象，则虚象反而是关键；全身俱见虚象，而独见一二实症，则实症反而是关键，所以权衡标本尤为紧急。如实症居标，虚症居本，则虚症为重；如虚症居标，实症居本，则实症为重，到了这虚实关头，如果不精心诊察，就会草菅人命！
六、夹肾虚：温热病夹杂脾虚的，已经难治，夹杂肾虚的，更难治。温热属伏火，肾气虚，则手足反冷；温热属实邪，肾气虚，则眩晕惊悸，腰膝痿软。肾虚之中，又有阴虚、阳虚之分。温热病必须待汗、下、清而后解，阳虚者，一经汗、下、清，则脱绝的症状随即出现；阴虚者，一经汗、下、清，则枯竭的症状随即出现，必须时时仔细察看。凡在表时，见腰痛异常、小便频数、膝胫冷软、精泄如注，应当详细询问此人平日是否有淋浊、遗泄、阳痿等症，则应当在疏表药中加入人参、白芍，阳虚兼加官桂、杜仲，阴虚兼加玄参、知母，以照顾本元，免后来意外之虞。若入里当下，必以千金生地黄汤、陶氏黄龙加减为主；当清气分时，用人参白虎汤；血分时，用犀角地黄汤加减为主。或者屡清屡下，而热更甚，舌上燥而无苔，或有黑苔，愈清而愈长，或有燥苔，愈下而愈裂的，这都是属于肾阴虚，察其阳明无实症可据，就应当治以六味地黄汤，熟地改用生地，加知母、黄柏，或者甘露饮。熟地切片，泡汤代水煎药。王太仆所谓“寒之不寒，责其无水，壮水之主，以制阳光者”，就是这个道理。再不应，则合用生脉散，以滋水之上源，或者用黄连阿胶汤、小甘露饮，滋阴泻火；但像这样热势燎原，非杯水所能救，所以必须大作汤液，才有济事。见机若早，十救二三；涸竭已见，十难救一。或者更兼脾胃败症，如呕呃、哕利之类，润药难任，甚至汤药不下，百不救一矣。
七、夹诸亡血：温热病亡血有三种：
其一，未病之前素来亡血而阴虚，一旦感受伏邪，则邪热乘虚煎熬，亡阴最容易发生。用药解表、清里，必须步步照顾营血，如七味葱白汤之用生地、麦冬，刘氏双解散之用归身、白芍是也。
其二，当病之时，忽然吐血衄血，女子崩漏，甚至血晕昏厥，热势危急。病家只知道血液骇人，医家也忽视伏邪，只急切于止血。清凉滋补，多致危殆。不知道血由邪逼，只当清其伏邪，伏邪解，血自止也。只有此症徐见于伏邪既盛，发热数日后的容易知道，而猝见于邪郁阴经，并无发热、头痛时的难以识别，但见微恶寒而大作呕，急当如前，用五辨法辨之。若舌有白苔，即属湿温伤络，当以新定达原饮为主，呕加竹茹广皮，胀加青皮、大腹皮。舌有黄苔，或紫绛色，即属温热伤络，宜用凉膈散加茅根、童便；血大溢者，加大黄、黄连，但治伏邪，血症自已。若脱血太甚，而气欲绝者，必用人参、麦冬、五味子以固中气，俟伏邪传变归经，然后按经治之，此温热病夹亡血之最危者。
其三，伏邪大张之后，烦热躁渴之余，而见亡血症，则又是温热病的常态，详见后血症各条。
八、夹哮喘：哮喘乃肺家常有的病，本有寒痰、热痰二症，一旦感受温热，则无非痰火，由其湿热之气，从其类而入肺，引发哮喘。遇到这种情况，应当实行前五辨法。有伏邪，只治伏邪，而哮喘自除；或者在治伏邪药中，加瓜蒌、川贝、苏子、白前、千金苇茎汤合文蛤散尤其快捷，二邪并解，法更精密。若哮喘势重，则白果定喘汤、苏子降气汤二方也可借用以治标；惟麻黄必须蜜炙，沉香亦宜磨汁，再加生石膏、海蛤壳以清镇之，庶免辛燥劫液之弊。
九、夹胃痛：温热病有夹胃痛的，在其痛时，先用前五辨法。若有伏邪见症，只治伏邪即可。虽然平时因寒而发，于此则只治其热。盖湿温伏于膜原，温热伏于血络，蕴酿蒸变，必从火化。伏邪自里达表，而引发胃痛痼疾的，多属热痛，则只在治伏邪药中，加乳香、没药以止痛，延胡索、桃仁以活络，速使其伏邪透发，而胃痛自己。如果误认平常寒胃痛，用桂枝、附子、干姜、吴茱萸，必致危殆。
十、夹疝气：伏邪夹疝，其肾囊、少腹引痛，全是疝症，应当如前五辨法。一有伏邪，不必治疝，只在治伏邪药中，加橘核、青皮，而疝自消。如果根据常治疝法，用吴茱萸、桂枝、附子、茴香诸燥品，轻者变为囊痈，重者变为呃逆，哕厥昏沉，而莫救矣。
总而言之，温热夹症最多，非刻意精细辨别，用药必致差误。
凡是遇到有内伤宿病之人，更患伏气温热，不得使用峻汗、峻攻、峻清之法；必须参考此人的形气盛衰，伏邪微甚，本病的新久虚实，向来适宜寒热、补泻、燥润、升降，或者近日服过何药之相安不相安，其间或夹痰水，或夹食滞，或夹积瘀，或夹气郁，或夹气虚，或夹血虚，或夹阳虚，或夹阴虚。务必在审症详明，投剂果决，自然随手克应，而无颟顸之弊矣。
Warm-heat diseases belong to latent pathogenic factors (Fu Xie, latent pathogens). Whenever "complicated syndromes" (Jia Zheng) are mentioned, it refers to latent pathogens complicated with excess or deficiency patterns, where two pathogens manifest simultaneously. If complicated with excess pathogens such as phlegm-fluids, food stagnation, qi stagnation, and blood stasis, treatment should prioritize eliminating the complicated pathogens and secondarily venting the latent pathogens. This is because clearing the complicated pathogens allows the latent pathogens to vent; only after venting can they transform and transmit, and only then can the disease be resolved. If complicated with Spleen deficiency, Kidney deficiency, or conditions involving various types of blood loss, treatment should focus primarily on addressing the latent pathogens, with supporting healthy Qi (Zheng Qi) as secondary. This is because lingering pathogens further damage healthy Qi, so one must not support healthy Qi while leaving pathogens behind. If complicated with old diseases such as asthma, heart-stomach pain, or hernia, only the latent pathogens need to be treated, and the old diseases will resolve spontaneously, because old diseases are triggered by newly acquired pathogens. Generally, there are ten categories.
1. Complicated with Phlegm and Fluids: Water entering the stomach undergoes steaming and transformation; if it becomes thick and turbid, it is called phlegm (Tan); if it remains clear and thin without transformation, it is called fluids (Shui). Phlegm and fluids are essentially the same substance. Phlegm generates heat, while fluids generate cold. Warm-heat diseases belong to latent fire syndromes; thus, complicating with phlegm exacerbates the heat, often presenting with dizziness, vertigo, chest and epigastric fullness and oppression, and a slippery, vigorous pulse on the right side. The treatment method should use Jiegeng Tang (Platycodon Decoction) added with Huajuhong (Exocarpium Citri Grandis), Gualou (Trichosanthes Fruit), and Beimu (Fritillaria Bulb). In severe cases, Xixian San (Sialagogue Powder) can be used first to induce vomiting to expel latent phlegm from the diaphragm. If phlegm confuses the clear orifices, causing mental confusion akin to trance, foaming at the mouth, and no pain upon pressing the chest and abdomen, Jiawei Daotan Tang (Modified Phlegm-Resolving Decoction) added with Niuhuang Qingxin Wan (Calculus Bovis Heart-Calming Pill), or Changyang Xiexin Tang (Changyang Draining Heart Decoction) added with Wanshi Niuhuang Wan, should be used. If complicated with fluids, the pulse often contradicts expectations, and the treatment method differs; careful differentiation is essential. The pulse in warm-heat diseases is invariably rapid, whereas fluid retention in the chest and diaphragm often presents with a slow pulse, even delayed and wiry; this distinguishes the pulse in fluid complications. Regarding the tongue coating in warm-heat diseases, once transmitting to the interior, it turns yellow, dry, and black. However, if fluids exist in the chest and diaphragm, despite symptoms like irritability, delirious speech, and deep coma, the tongue color remains white and moist. Occasionally turning yellow or black, it must still have a slippery coating, or a full yellow-black coating with one or two white strips on one half, or yellow at the tip and root with a white segment in the middle; this distinguishes tongue signs in fluid complications. Warm-heat diseases present with chest fullness and hard, painful epigastrium intolerant to pressure. If complicated with fluids in the chest-diaphragm, although there is fullness and pain, pressing yields softness, and slight kneading produces gurgling sounds, potentially leading to intestinal pulling pain, dry retching, shortness of breath, heavy waist, swollen feet, diarrhea, and scanty urination; this distinguishes symptom signs in fluid complications. When warm-heat diseases show pulse and symptom signs of fluid complication, even if exterior signs exist, pure acrid-cool dispersing methods should not be used exclusively, as this fails to resolve the exterior and leads to heaviness and lethargy. If interior signs exist, bitter-cold drugs should not be used early, as this worsens mental confusion. This is because fluid qi restrains heat pathogens, trapping Yang Qi. Acrid-drying diuretics and Qi-moving agents should be added to exterior-resolving and interior-clearing formulas to dispel fluid qi. Once fluid qi is removed and restraint released, then attacking or cooling methods can be considered, ensuring efficacy. For drying dampness, Banxia (Pinellia Rhizome) and Cangzhu (Atractylodis Rhizoma); for promoting urination, Mutong (Akebia Caulis), Lingzhi (Poria), and Zexie (Alisma Rhizome); for moving Qi, Laifuzi (Raphani Semen), Caoguoren (Arecae Pericarpium), and Qingmuxiang (Aucklandiae Radix). In severe cases, Kongxian Dan or Daxiexiong Tang may be administered. Thus, although warm-heat diseases involve latent fire, sometimes San Chengqi Tangs, Huangqin (Scutellariae Radix), or Baihu Tang fail, while acrid-warming drugs occasionally succeed. Some sue against the error of clearing heat, unaware that latent fire is the fundamental nature, while compounding is the intermediate Qi variation!
2. Complicated with Food Stagnation: Warm-heat diseases complicated with food stagnation are most common, differing between food filling the chest-diaphragm and food entering the intestines-stomach. Entering the intestines-stomach forms Yangming accumulated heat syndrome, treated by San Chengqi Tangs. Only when food fills the chest-diaphragm, despite symptoms like anorexia, acid regurgitation, belching, abdominal fullness, desire to vomit but inability, and retching with oppression, there are often deep pulses and cold hands and feet. Misidentifying this as Shaoyin/Taiyin/Yueyin (Three Yin) diseases and administering warming agents, yet finding no heat or thirst, leads to increased irritability and death within one to two days. Because the diaphragm is the pathway for Yin-Yang ascent and descent, food blockage closes Qi flow; closed Qi prevents heat dispersion, and warming drugs exacerbate heat retention. Heat retained internally manifests as no exterior fever; heat retained lower manifests as no upper thirst. Latent pathogens are shallow when venting to the exterior and deep when entering the interior. One warming drug forces pathogens inward, causing death without visible heat signs. Having differentiated warm-heat disease via the previous five methods, encountering deep pulses and cold extremities requires detailed inquiry into the chest-diaphragm. If obstructed, stuffy, and painful, it indicates food complication. Further differentiating white, thick tongue coating slightly mixed with pale yellow confirms food filling the diaphragm. Jiegeng Tang can be added with Zhike (Aurantii Fructus), Qingpi (Citri Reticulatae Pericarpium), Laifu (Raphani Semen), and Shenqu (Medicated Leaven). In severe cases, emesis can be induced to ventilate, and Liandou San applied externally to promote Yang Qi ventilation in the diaphragm, revealing heat signs, allowing correct exterior-resolving and interior-clearing without error.
3. Complicated with Qi Stagnation: Warm-heat diseases complicated with Qi stagnation initially present identical symptoms but often feature deep pulses, cold extremities, retching, and chest fullness, resembling food stagnation. However, food stagnation involves有形 (tangible) excess pathogens, with thick white-slightly yellow coatings, chest-diaphragm fullness/pain intolerable to pressure, unmovable upon pressing. Qi stagnation involves intangible deficiency pathogens, with thin white coatings, chest-diaphragm fullness/pain semi-soft and pressable. First, ventilate the stagnation, then resolve the exterior and clear the interior for efficacy. Without soothing stagnation, merely resolving the exterior prevents interior Qi from reaching the surface, hindering thorough sweating; hastily using purging clears fails to ventilate upper Qi, causing oppression and rebellion. Adding Su Geng (Perillae Caulis), Qingpi, Yujin (Curcumae Radix), and Xiangfu (Cyperi Rhizoma) to exterior-resolving drugs moves Qi, facilitating exterior resolution; adding Gualou and Chuanbei (Fritillariae Thunbergii Bulbus) to interior-clearing drugs soothes stagnation, facilitating interior harmony. Although Chuanbei is a key herb for soothing stagnation, its action is mild; doses of 5 qian to 1 liang are required for effect. Adding Simo Yinzi (Four-Marrow Decoction) is particularly effective.
4. Complicated with Blood Stasis: After latent pathogens transmit through meridians, blood stasis is most common; treating from the interior is not detailed here. Only when pre-existing internal injury causes blood stasis, compounded by latent pathogens, in the first one or two days, exterior signs are complete, but pulses are either K ou (hollow) or Se (choppy), resembling Yang syndrome with Yin pulses. Detailed inquiry into chest/abdomen, hypochondrium, and limbs reveals pain intolerable to pressure and choppy pulses, indicating blood stasis. Confirming it is not Yang syndrome with Yin pulse, but exterior signs with interior pulse. Treatment must include blood-breaking herbs: Honghua (Carthami Flos), Taoren (Persicae Semen), Guiwei (Angelicae Sinensis Radix), Chishao (Paeoniae Radix Rubra), Xuanshen (Scrophulariae Radix), Yuanhu (Corydalis Rhizoma), Shanzha (Crataegi Fructus), adding one or two items. In severe cases, add Pao Chuanshanjia (Phrynosomatis Carapax) 1 qian to facilitate exterior resolution and restore hollow/choppy pulses. Mistaking hollow/choppy pulses for Yin syndrome and using warming drugs aggravates or endangers life. Upon appearance of interior signs, Wu Shi Tao Ren Chengqi Tang (Wu’s Peach Kernel Cathartic Decoction) added with Ganqi (Drynariae Rhizoma) and Chao Chuanlian (Coptidis Rhizoma fried) drains fire and attacks blood. Blood stasis may exit via vomiting or defecation; observe color. Red-purple and scattered is treatable; color like spoiled blood, coagulated into clumps, mixed with bloody fluid, indicates righteous Qi depletion and pathogen expulsion. Or mud-like, sticky, continuous, extremely foul-smelling, indicating failure of Jin-Ye (body fluids/Qi) and downward discharge of turbid decay, usually untreatable. Hypogastric pain, suprapubic pain, intolerable to touch, even coma followed by recovery, indicates blood stasis rushing upward, named Blood Jue (Blood Syncope). Bowel movements may be constipated or black. Mild cases use Xiang Qiao San; severe cases use Dai Didang Wan or Bmcui Xi Jiao Di Huang Tang (Extract of Rhinoceros Horn Rehmannia Decoction) added with Pao Chuanshanjia 1 qian to break up stasis. If stasis persists, fever and mania, coughing/wheezing/retching occur. Excessive sweating or touching stasis erroneously causes vomiting/diarrhea or hiccups. Activating blood and breaking stasis stops these automatically.
5. Complicated with Spleen Deficiency: Warm-heat diseases are inherently harder to treat than Wind-Cold, as Wind-Cold transmission follows order, while Warm-heat has no fixed meridian path: Wind-Cold exterior pathogens disperse upon release; latent pathogens disperse and re-aggregate repeatedly. Wind-Cold interior pathogens harmonize after purging; latent pathogens re-combine after purging, sometimes requiring repeated purging without harmony, making latent pathogens difficult to treat. Spleen deficiency complicates this further. Warm-heat diseases require sweating, clearing, and purging to resolve. Spleen deficiency cannot sweat from the exterior nor tolerate purging from the interior. Sweating depletes Qi; purging depletes Qi downwards. Even pure clearing/draining fails to support Middle Qi, often causing colder drugs to restrain pathogens more. Current customs favor the theory that warm-heat damages Yin, ignoring Middle Qi deficiency and heat stagnation burning fluids. Seeing red tongue coatings, large doses of clearing-nourishing drugs are used. This combines turbid heat restraining Middle Jiao Qi with turbid drugs, forcing pathogens deep into Marrow and Gu-Huang (deep tissues), creating stubborn impaction. Yellow-greasy coatings indicate Damp-Heat steaming Middle Jiao Qi, requiring bitter-acrid opening/transformation. Using large cold doses like San Huang (Scutellariae/Coptidis/Gardeniae Radix), Baihu Tang, San Shi, or Yvnu Jian (Jade Woman Decoction) without opening traps pathogens deeply. Deeply trapped pathogens prevent Spleen Qi ascending, causing tongue coating to vanish, turning crimson and coating-less. Seeing this, using Xi Jiao Di Huang Tang, Qing Gong Tang, or Zeng Ye Tang traps pathogens further. Clearing-nourishing drugs dry tongue flesh, turning it redder/black, causing hoarseness and spirit-confusion/orifice closure rapidly. Treating such cases: do not force sweating; exterior resolution must support Zheng Qi, e.g., Shen Su Yin or Qi Wei Cong Bai Tang. Do not lightly purge; interior attacking must protect the root, e.g., San Huang, Zhizhu Wan, or Huang Long Tang. Do not purely cool; clearing must benefit Qi and generate fluids, e.g., Renshen Baihu Tang, Zhuye Shigao Tang, Huanglian Xiexin Tang, Canhu Wendan Tang, or Canhu Shaoyao Tang. Exterior signs seem similar, but pulses are weak and tender to pressure. However, during peak pathogen flare-ups, even deficient patients may have strong pulses; do not rigidly adhere. Correlate spirit, complexion, and pulse-symptoms. Sallow complexion, fatigue, rapid/shallow breathing indicate Spleen deficiency/Middle Qi weakness. Holistic correlation is vital: if excess signs dominate with few deficiency signs, deficiency is critical; if deficiency signs dominate with few excess signs, excess is critical. Balancing root and branch is urgent. If excess is branch and deficiency is root, deficiency is heavy; if deficiency is branch and excess is root, excess is heavy. At this juncture, careless diagnosis risks lives.
6. Complicated with Kidney Deficiency: Warm-heat with Spleen deficiency is hard; with Kidney deficiency, it is harder. Warm-heat is latent fire; Kidney Qi deficiency causes cold extremities. Warm-heat is excess pathogen; Kidney Qi deficiency causes dizziness, palpitations, and sore/weak waist/knees. Kidney deficiency divides into Yin and Yang deficiency. Warm-heat resolves via sweat, purge, clear. Yang deficiency after these shows collapse signs; Yin deficiency shows exhaustion signs. Observe carefully. During exterior stage, abnormal lower back pain, frequent urination, cold/weak knees/shins, seminal emission indicate asking about past history of strangury, nocturnal emission, or impotence. Add Renshen (Ginseng Radix et Rhizoma) and Baishao (Paeoniae Radix Alba) to exterior-resolving drugs. Yang deficiency adds Guigui (Cinnamomi Cortex) and Duzhong (Eucommiae Cortex); Yin deficiency adds Xuanshen and Zhimu (Anemarrhenae Rhizoma) to protect Yuan Qi. If interior purging is needed, Qianjin Shengdi Huang Tang or Tao Shi Huang Long Tang modifications are primary. For Qi level, Renshen Baihu Tang; for Blood level, Xi Jiao Di Huang Tang modifications. If repeated clearing/purging increases heat, dry coating-less tongue, or growing black/dry cracks, this is Kidney Yin deficiency. If Yangming has no excess signs, treat with Liuwei Dihuang Tang, replacing Shudi (Rehmanniae Radix Preparata) with Shengdi (Rehmanniae Radix), adding Zhimu and Huangbai (Phellodendri Cortex), or Ganlu Yin. Slice Shudi, soak in water to decoct herbs. Wang Taipou said: "Cold does not cease, blame lack of Water; strengthen the Master of Water to control Solar Fire." If ineffective, combine Shengmai San to nourish Upper Source of Water, or use Huanglian Ejiao Tang or Xiao Ganlu Yin to nourish Yin and drain fire. With raging heat, small amounts fail; large decoctions are necessary. Early intervention saves 2-3 out of 10; exhaustion saves 1 in 10. Accompanying Spleen-Stomach failure like vomiting/hiccups/diarrhea makes nourishing drugs intolerable, even preventing ingestion, saving 0 in 100.
7. Complicated with Various Blood Losses: Warm-heat blood loss has three types:
First, prior chronic blood loss causing Yin deficiency; upon latent pathogen infection, pathogenic heat scalds deficiency, easily causing Yin loss. Exterior-resolving and interior-clearing drugs must care for Ying-Blood step-by-step, e.g., Shengdi and Maidong (Ophiopogonis Radix) in Qi Wei Cong Bai Tang, or Danggui (Angelicae Sinensis Radix) and Baishao in Liu Shi Shuangjie San.
Second, sudden hematemesis/epistaxis or uterine bleeding during illness, even blood syncope/coma, critically hot. Families fear blood; doctors ignore latent pathogens, focusing solely on stopping bleeding. Cooling/nourishing leads to danger. Blood is forced by pathogens; clear latent pathogens, and bleeding stops. This is easy to identify if appearing gradually after several days of high fever, but hard to recognize if suddenly appearing in Yin meridian stagnation without fever/headache. Slight aversion to wind and violent retching require the Five Differentiation Methods. White coating indicates Damp-Warmth damaging collaterals; Xin Ding Dayin Yin (Newly Formulated Reaching the Original Site Decoction) is primary, adding Zhuru (Bambusae Caulis in Taeniam) and Guangpi (Tangerine Peel) for retching, Qingpi and Dafupi (Arecae Pericarpium) for distension. Yellow or purple-crimson coating indicates Warm-Heat damaging collaterals; Liangge San (Cool the Epigastrium Powder) with Maogen (Imperatae Rhizoma) and Tongbian (Child's Urine) is suitable. For massive bleeding, add Dahuang (Rhei Radix et Rhizoma) and Huanglian (Coptidis Rhizoma). Treating latent pathogens resolves blood issues. If excessive blood loss threatens Qi, use Renshen, Maidong, and Wuweizi (Schisandrae Fructus) to secure Middle Qi. Wait for latent pathogens to transmit and enter meridians, then treat by meridian. This is the most critical warm-heat complication with blood loss.
Third, after latent pathogens rage, following irritability/thirst, blood loss appears as a normal state of warm-heat diseases (see later sections).
8. Complicated with Asthma: Asthma is common in Lung disorders, originally Cold-Phlegm or Hot-Phlegm. Upon warm-heat infection, it becomes Phlegm-Fire, as Damp-Heat Qi enters the Lung by affinity. Use the Five Differentiation Methods. Treat latent pathogens, and asthma resolves. Or add Gualou, Chuanbei, Suzi (Perillae Fructus), Baiqian (Cynanchi Stauntonii Rhizoma et Radix), Qianjin Weijing Tang (Thousand Gold Reed Stalk Decoction) combined with Wen Ge San to both pathogens, a precise method. If asthma is severe, Baiguo Dingchuan Tang or Suzi Jiangqi Tang can treat symptoms temporarily. Mahuang (Ephedrae Herba) must be honey-fried; Chenxiang (Aquilariae Lignum Resinatum) ground to juice; add Shigypsum (Gypsum Fibrosum) and Haigekiao (Clam Shell) to clear/settle, avoiding acrid-drying fluid consumption.
9. Complicated with Stomach Pain: Warm-heat with stomach pain uses the Five Differentiation Methods during pain. If latent pathogen signs appear, treat latent pathogens. Though usually cold-induced, treat heat here. Damp-Warmth hides in Membrane Source; Warm-Heat hides in Blood Collaterals, fermenting into Fire. Latent pathogens move from interior to exterior, triggering chronic stomach pain, mostly heat-pain. Add Ruxiang (Olibanum) and Moyao (Myrrha) for pain, Yanhu (Corydalis Rhizoma) and Taoren for collaterals, speeding latent pathogen venting to resolve pain. Mistaking for cold stomach pain and using Guizhi (Cinnamomi Ramulus), Fuzi (Aconiti Lateralis Radix Preparata), Jiang (Zingiberis Rhizoma), or Yuyu (Evodiae Fructus) causes danger.
10. Complicated with Hernia: Latent pathogen with hernia involves testicular/scrotal and hypogastric pulling pain, entirely hernia syndrome. Use Five Differentiation Methods. With latent pathogens, do not treat hernia directly; add Juhe (Aurantii Fructus) and Qingpi to latent pathogen treatments, and hernia resolves. Following standard hernia treatments with Wuyu (Evodiae Fructus), Guizhi, Fuzi, Huixiang (Foeniculi Fructus) and other drying drugs causes scrotal abscess (mild) or hiccups/syncope/coma (severe), untreatable.
In summary, warm-heat complications are numerous; meticulous differentiation is essential to avoid medication errors.
For patients with internal injuries and chronic diseases contracting latent warm-heat, harsh sweating, purging, or clearing methods must not be used. Assess physical strength, latent pathogen severity, chronic disease duration/deficiency/excess, historical preference for cold/heat, tonification/purging, drying/moistening, descending/ascending, and recent medication tolerance. Identify complications: phlegm-fluids, food stagnation, blood stasis, Qi stagnation, Qi deficiency, Blood deficiency, Yang deficiency, or Yin deficiency. Ensure clear symptom differentiation and decisive prescribing for spontaneous recovery without negligence.