天津杨氏女，年十五岁，先患月闭，继又染温疹靥急。
病因 自十四岁月信已通，后因肝气不舒，致月信半载不至，继又感发温疹，初见点即靥。
证候 初因月信久闭，已发热瘦弱，懒于饮食，恒倦卧终日不起。继受温疹，寒热往来，其寒
时觉体热减轻，至热时，较从前之热增加数倍，又加以疹初见点即靥，其毒热内攻。心中烦躁怔忡，剧
时精神昏愦，恒作谵语，舌苔白而中心已黄，毫无津液。大便数日未行，其脉觉寒时似近闭塞，觉热
时又似洪大而重按不实，一息五至强。
诊断 此证因阴分亏损将成痨瘵，又兼外感内侵，病连少阳，是以寒热往来，又加以疹毒之热，不
能外透而内攻，是以烦躁怔忡，神昏谵语，此乃内伤外感两剧之证也。宜用大剂滋其
真阴清其毒热，更佐以托疹透表之品当能奏效。
处方 生石膏（二两捣细） 野台参（三钱） 玄参（一两） 生怀山药（一两）
大甘枸杞（六钱） 知母（四钱） 连翘（三钱） 蝉蜕（二钱）
茵陈（二钱） 僵蚕（钱半） 鲜芦根（四钱）
共煎汤三盅，分三次温饮下。嘱其服一剂热不退时，可即原方再服，若服至大便通下且微溏时，即宜停药勿服。
复诊 将药煎服两剂，大热始退，不复寒热往来，疹未表出而心已不烦躁怔忡。知其毒由
内消，当不变生他故。大便通下一次亦未见溏，再诊其脉已近和平，惟至数仍数，和其外感已愈十
之八九，而真阴犹未复也。拟再滋补其真阴，培养其血脉，俾其真阴充足，血脉调和，月信自然通顺而不愆期矣。
处方 生怀山药（一两） 大甘枸杞（一两） 玄参（五钱） 地骨皮（五钱）
龙眼肉（五钱） 北沙参（五钱） 生杭芍（三钱） 生鸡内金（钱半黄色的捣）
甘草（二钱）
共煎汤一大盅，温服。
三诊 将药连服四剂，饮食增加，精神较前振作，自觉诸病皆无，惟腹中间有疼时，此月信欲
通而未能即通也。再诊其脉已和平四至矣。知方中凉药宜减，再少加活血化瘀之品。
处方 生怀山药（一两） 大甘枸杞（一两） 龙眼肉（六钱）当归（五钱）
玄参（三钱） 地骨皮（三钱） 生杭芍（三钱） 生鸡内金（钱半黄色的捣）
土鳖虫（五个大者捣） 甘草（钱半） 生姜（三片）
共煎汤一大盅，温服。
效果 此药连服十剂，腹已不疼，身形已渐胖壮，惟月信仍未至，俾停药静候。旬日后月
信遂见，因将原方略为加减，再服数剂以善其后。
或问 方书治温疹之方，未见有用参者。开首之方原以治温疹为急务，即有内伤亦当从缓
治之，而方中用野台参者其义何居？答曰∶《伤寒论》用白虎汤之例，汗吐下后加人参，以其
虚也；渴者加人参，以其气虚不能助津液上潮也。令此证当久病内亏之余，不但其血分虚损，其
气分亦必虚损。若但知用白虎汤以清其热，不知加参以助之，而热转不清，且更有病转加剧之
时（观白虎加人参以山药代粳米汤后附载医案可知）。此证之用人参，实欲其热之速退也。且此证疹
靥之急，亦气分不足之故。用参助石膏以清外感之热，即借其力以托疹毒外出，更可借之以补从前
之虚劳。是此方中之用参，诚为内伤外感兼顾之要药也。
或问 凡病见寒热往来者，多系病兼少阳，是以治之者恒用柴胡以和解之。今方中未用柴胡，而
寒热往来亦愈何也？答曰∶柴胡虽能和解少阳，而其升提之力甚大。此证根本已虚，实
不任柴胡之升提。方中茵陈其性凉而能散，最能宣通少阳之
郁热，可为柴胡之代用品。实为少阳病兼虚者无尚之妙药也。况又有芦根亦少阳药，更可与
之相助为理乎？此所以不用柴胡亦能愈其寒热往来也。
Tianjin Yang’s daughter, aged fifteen. Initially suffered from amenorrhea (cessation of menstruation), and subsequently contracted warm-heat rash with rapid retraction of the lesions.
Etiology: Her menstrual cycle had been regular since age fourteen. Later, due to liver qi stagnation and constraint, her menstruation ceased for half a year. Subsequently, she contracted warm-heat pathogen leading to rash, where the lesions appeared as spots but immediately retracted inward.
Symptoms: Initially, due to prolonged amenorrhea, she exhibited fever, emaciation, weakness, anorexia, and constant fatigue with bedridden state all day. Following the onset of warm-heat rash, she experienced alternating chills and fever. During chills, body heat decreased; during fever, it increased several-fold compared to before. Additionally, because the rash spots appeared and immediately retracted, toxic heat attacked inwardly. She experienced mental restlessness, palpitations, and in severe cases, mental confusion and delirious speech. The tongue coating was white with a yellow center, lacking fluids. Bowel movements had not occurred for several days. The pulse felt nearly obstructed during chills, and surging yet empty upon heavy pressure during fever, beating more than five breaths per minute.
Diagnosis: This condition resulted from yin deficiency progressing toward consumptive disease (lao zhai), complicated by external pathogenic invasion affecting the Shaoyang channel, causing alternating chills and fever. Furthermore, the toxic heat of the rash failed to vent outward and instead attacked inwardly, causing restlessness, palpitations, mental confusion, and delirium. This is a severe condition combining internal injury and external contraction. It is appropriate to use a large dose of herbs to nourish true yin and clear toxic heat, assisted by agents that support the expulsion of rash toxins and vent them through the exterior, which should yield results.
Prescription: Sheng Shi Gao (Gypsum Fibrosum, 2 liang, crushed fine) Ye Tai Shen (Codonopsis Radix, 3 qian) Xuan Shen (Scrophulariae Radix, 1 liang) Sheng Huai Shan Yao (Dioscoreae Oppositifoliae Rhizoma, 1 liang) Da Gan Gou Qi Zi (Lycii Fructus, 6 qian) Zhi Mu (Anemarrhenae Rhizoma, 4 qian) Lian Qiao (Forsythiae Fructus, 3 qian) Chan Tui (Cicadae Periostracum, 2 qian) Yin Chen (Artemisiae Scopariae Herba, 2 qian) Jiang Can (Bombyx Batryticatus, 1.5 qian) Xian Lu Gen (Phragmitis Rhizoma, 4 qian)
Decoct together to obtain three bowls of decoction, taken warm in three divided doses. Instructed that if fever persists after one dose, the original prescription may be repeated immediately. If bowel movements become unformed and slightly loose after administration, discontinue the medication.
Follow-up Visit 1: After two doses, high fever subsided, and alternating chills and fever ceased. Although the rash had not fully erupted, mental restlessness and palpitations resolved. It was deduced that the toxin was dissipating internally, and no further complications were expected. Bowel movement occurred once without looseness. Pulse was near normal but remained rapid. The external contraction had improved by eighty to ninety percent, but true yin had not yet recovered. The plan was to further nourish true yin and cultivate blood vessels, ensuring sufficient true yin and harmonized blood vessels, so that menstruation would naturally resume regularly.
Prescription: Sheng Huai Shan Yao (Dioscoreae Oppositifoliae Rhizoma, 1 liang) Da Gan Gou Qi Zi (Lycii Fructus, 1 liang) Xuan Shen (Scrophulariae Radix, 5 qian) Di Gu Pi (Lycii Cortex, 5 qian) Long Yan Rou (Longan Aril, 5 qian) Bei Sha Shen (Glehniae Radix, 5 qian) Sheng Hang Shao (Paeoniae Radix Alba, 3 qian) Sheng Ji Nei Jin (Galli Gigerii Endothelium Corneum, 1.5 qian, yellow variety, crushed) Gan Cao (Glycyrrhizae Radix et Rhizoma, 2 qian)
Decoct together to obtain one large bowl of decoction, taken warm.
Follow-up Visit 2: After four consecutive doses, appetite increased, spirit was more vigorous, and subjective symptoms resolved. Only occasional pain in the middle abdomen remained, indicating that menstruation was attempting to flow but had not yet fully commenced. Pulse was now normal at four beats per breath. Cooling herbs in the formula should be reduced, and slight additions of blood-invigorating and stasis-resolving herbs are needed.
Prescription: Sheng Huai Shan Yao (Dioscoreae Oppositifoliae Rhizoma, 1 liang) Da Gan Gou Qi Zi (Lycii Fructus, 1 liang) Long Yan Rou (Longan Aril, 6 qian) Dang Gui (Angelicae Sinensis Radix, 5 qian) Xuan Shen (Scrophulariae Radix, 3 qian) Di Gu Pi (Lycii Cortex, 3 qian) Sheng Hang Shao (Paeoniae Radix Alba, 3 qian) Sheng Ji Nei Jin (Galli Gigerii Endothelium Corneum, 1.5 qian, yellow variety, crushed) Tu Bie Chong (Eupolyphaga seu Steleophaga, 5 large specimens, crushed) Gan Cao (Glycyrrhizae Radix et Rhizoma, 1.5 qian) Sheng Jiang (Zingiberis Rhizoma Recens, 3 slices)
Decoct together to obtain one large bowl of decoction, taken warm.
Outcome: After ten consecutive doses, abdominal pain ceased, and body shape gradually became robust. Menstruation still had not arrived, so the patient was advised to stop medication and wait quietly. Ten days later, menstruation finally occurred. The original formula was slightly modified and administered for a few more doses to conclude treatment.
Q&A: Someone asked: Formulas in medical texts for treating warm-heat rash rarely use Ren Shen (Ginseng). Since the initial priority was treating the warm-heat rash, internal injury should theoretically be treated secondarily. What is the rationale for using Ye Tai Shen (Codonopsis Radix) in this formula? Answer: In the Shang Han Lun (Treatise on Cold Damage), when Bai Hu Tang (White Tiger Decoction) is used, Ren Shen (Ginseng) is added after sweating, vomiting, or purging methods due to deficiency; it is added for thirst because qi deficiency fails to assist fluids in rising. In this case, following prolonged internal depletion, both blood and qi levels are deficient. If only Bai Hu Tang (White Tiger Decoction) is used to clear heat without adding Ren Shen (Ginseng) to support it, the heat may not clear effectively, and the condition could worsen (as seen in the attached case study for Bai Hu Jia Ren Shen Yi Mi Tang modified with Shan Yao). The use of Ren Shen (Ginseng) here aims to facilitate rapid heat resolution. Moreover, the rapid retraction of the rash is also due to qi insufficiency. Using Ren Shen (Ginseng) to assist Shi Gao (Gypsum Fibrosum) in clearing external heat also leverages its power to support the expulsion of rash toxins outward, while simultaneously replenishing previous consumptive deficiency. Thus, the inclusion of Ren Shen (Ginseng) in this formula is indeed a crucial herb for addressing both internal injury and external contraction.
Another question: Conditions presenting with alternating chills and fever often involve the Shaoyang channel, typically treated with Chai Hu (Bupleuri Radix) to harmonize Shaoyang. Why did the current formula omit Chai Hu (Bupleuri Radix) yet cure the alternating chills and fever? Answer: Although Chai Hu (Bupleuri Radix) can harmonize Shaoyang, its ascending and lifting force is very strong. Given the fundamental deficiency in this case, the patient cannot tolerate the strong ascending action of Chai Hu (Bupleuri Radix). Yin Chen (Artemisiae Scopariae Herba) in the formula is cool in nature and dispersing, effectively venting constrained heat in the Shaoyang channel, serving as a substitute for Chai Hu (Bupleuri Radix). It is an unparalleled excellent herb for Shaoyang disease combined with deficiency. Furthermore, Lu Gen (Phragmitis Rhizoma) is also a Shaoyang channel herb, assisting in this therapeutic action. This explains why alternating chills and fever resolved even without Chai Hu (Bupleuri Radix).