庚戌仲春。艾道先染伤寒。近旬日。热而自汗。大便不通。小便如常。神昏多睡。诊其脉。
长大而虚。予曰。阳明证也。乃兄景先曰。舍弟全似李大夫证。又属阳明。莫可行承气否。予曰。
虽为阳明。此证不可下。仲景。阳明。自汗。小便利者。为津液内竭。虽坚不可攻。宜蜜兑导之。
作三剂。三易之。先下燥粪。次泄溏。已而汗解。
论曰。二阳明证虽相似。然自汗小便利者。不可荡涤五脏。为无津液也。然则伤寒大证相似。
脉与证稍异。通变为要。仔细斟酌。正如以格局看命。虽年月日时皆同。贵贱穷通不相侔者。于
一时之顷。又有浅深也。
朱保义抚辰。庚戌春。权监务。予一日就务谒之。见拥炉忍痛。若不禁状。予问所苦。小肠
气痛。求予诊之。予曰。六脉虚浮而紧。非但小肠气。恐别生他疾。越数日再往。卧病已五日矣。
入其室。见一市医孙尚者供药。予诊之曰。此阴毒证。肾虚阳脱。脉无根蒂。独见于皮肤。黄帝
所谓悬绝。仲景所谓瞥如羹上肥也。早晚喘急。未几而息已高矣。孙生尚与术附汤。灸脐下。予曰。
虽卢扁之妙无及矣。是夕死。故论伤寒以真气为主。
论曰。伤寒不拘阴证阳证。阴毒阳毒。要之真气强壮者易治。真气不守。受邪才重。便有必
死之道。何也。阳证宜下。真气弱。则下之便脱。阴证宜温。真阴弱。温之则客热便生。故医者
难于用药。非病不可治也。主本无力也。经曰。阳胜则身热。腠理闭。喘粗。为之俯仰。汗不出
而热。齿干。以烦冤腹满死。阴胜则身寒。寒则厥。厥则腹满死。帝曰。调此二者奈何。岐伯曰。
女子二七天癸至。七七止。男子二八精气溢。八八止。妇人月事。以时下。故七欲损也。男子精。
欲满不欲竭。故八欲益也。如此则男妇身常无病。无病精气常固。虽有寒邪。易于调治。故曰二
者可调。是知伤寒真气壮者易治也。
In the mid-spring of the Gengxu year, Ai Daoxian contracted Shanghan (Cold Damage). For nearly ten days, he experienced fever with spontaneous sweating, constipation, normal urination, lethargy, and excessive sleepiness. Upon palpating his pulse, it was found to be large and long but empty upon pressure. I stated: This is a Yangming syndrome. His brother, Jingxian, remarked: My younger brother's symptoms resemble those described by Dr. Li, and since it also belongs to Yangming, can we administer Chengqi Tang (Bowel-Regulating Decoction) for purgation? I replied: Although it is a Yangming condition, this specific presentation must not be treated with purgation. Zhang Zhongjing pointed out that in Yangming disease, spontaneous sweating combined with free urination indicates exhaustion of body fluids internally; even if the stool is hard and dry, it cannot be forcibly purged. Instead, honey suppositories (Mi Dui) should be used to guide evacuation. Three doses were prepared, changed three times. First, dry feces were expelled, followed by loose stools, and subsequently, the patient recovered through sweating.
The commentary states: Although these two Yangming syndromes appear similar, when spontaneous sweating and free urination are present, one must not use drastic methods to cleanse the five zang organs, as there are no body fluids available. Thus, although major Shanghan presentations may look alike, slight differences in pulse and symptoms require flexible adaptation and careful deliberation. This is akin to analyzing destiny using Bazi (Four Pillars); even if the year, month, day, and hour are identical, the outcomes of nobility or poverty differ, varying in depth within mere moments.
Zhu Baoyi Fuchen, who temporarily served as supervisor in the spring of the Gengxu year, was visited by me one day at his office. He was seen huddled around a stove, enduring pain as if unbearable. When asked about his suffering, he cited Xiao Chang Qi (Small Intestine Qi disorder) pain and requested a pulse diagnosis. I noted: The six pulses are deficient, floating, and tight. This is not merely Small Intestine Qi disorder; other diseases may arise. A few days later, upon visiting again, he had been bedridden for five days. Entering his room, I saw a local physician named Sun Shang administering medicine. After diagnosing, I said: This is Yin Du (Yin Toxin) syndrome, characterized by Kidney deficiency leading to Yang collapse. The pulse lacks root, appearing only superficially on the skin. This corresponds to what Huangdi termed "Xuan Jue" (Hanging Extinction) and what Zhang Zhongjing described as "Pie Ru Geng Shang Fei" (scattered like fat floating on soup surface). With rapid breathing morning and evening, his breath soon became high-pitched and failing. Sun Shang administered Shu Fu Tang (Atractylodes and Aconite Decoction) and moxa points below the umbilicus. I remarked: Even the miraculous skills of Lu Yi (Bian Que) would be insufficient. That night, the patient died. Therefore, in discussing Shanghan, priority must be given to preserving Zhen Qi (True Vital Energy).
The commentary states: Shanghan is not restricted to Yin or Yang syndromes, nor to Yin or Yang toxins. Ultimately, those with strong Zhen Qi are easier to treat. If Zhen Qi fails to remain secure, even a slight pathogenic invasion leads to inevitable death. Why? Yang syndromes are suitable for purgation; if Zhen Qi is weak, purgation causes collapse. Yin syndromes are suitable for warming; if True Yin is weak, warming generates exogenous heat. Hence, physicians find medication difficult, not because the disease is incurable, but because the fundamental strength is lacking. The Classics state: Excess Yang results in fever, closed pores, coarse breathing, restlessness, anhidrosis with heat, dry teeth, and death due to irritability and abdominal fullness. Excess Yin results in cold limbs, cold-induced rigidity, and death due to abdominal fullness. The Yellow Emperor asked: How to regulate these two? Qibo answered: Women reach Tian Gui (menstrual essence) at age fourteen and cease at forty-nine; men's essence overflows at sixteen and ceases at sixty-four. Women's menstruation occurs regularly, so the number seven implies a tendency toward depletion; men's essence should be full rather than exhausted, so the number eight implies a tendency toward enrichment. In this way, men and women remain healthy, their essence solid, making them resilient to cold pathogens and easy to treat. Thus, it is known that Shanghan patients with robust Zhen Qi are easier to cure.