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Tianjin had an elderly surnamed Zhang, over fifty years old, who first contracted a warm disease (Wenbing), followed by abdominal pain and dysentery.

Etiology: Because her husband and son had successively fallen ill and died, she was repeatedly distressed, leading to internal heat accumulation. Additionally, it was after the Dragon Boat Festival, with exceptionally dry and hot weather, thus resulting in this condition.

Symptoms: The abdomen experienced twisting pain, with loud crying and tossing about, unable to lie still. The whole body felt warm, and the heart region also felt very hot. Due to her restlessness, her hands and feet were restless, making fine pulse diagnosis difficult; however, generally, the presentation leaned towards heat signs. Her tongue color was purplish and dry, with a slight yellow coating at the root. Bowel movement had not occurred for two days.

Diagnosis: This is due to daily emotional distress causing physical depletion. Initially, grief caused heat in the zang-fu organs; subsequently, prolonged heat consumed yin, generating deficiency heat. Later, seasonal dry-heat invaded internally and combined with the accumulated internal heat, stirring up Liver fire that pressed downward into the abdomen, causing pain. With intense fire-heat, both exterior and interior felt feverish. Treatment should clear the warm-heat, calm the Liver fire, regulate abdominal pain, and prevent the pain from progressing into dysentery.

Prescription: First, use Sheng Hang Shao (Raw Paeoniae Radix Alba) 30g and Gan Cao (Licorice Root) 9g, decocted in one large bowl of water, taken in two doses warm. Each dose is accompanied by forty pills of Weisheng Fangyi Baodan (Health Protection Epidemic Prevention Treasure Pill). After approximately half an hour, completing the two doses, the abdominal pain ceased. Then, have her decoct Lian Qiao (Forsythia Fruit) 30g and Gan Cao (Licorice Root) 9g in one large bowl of water, divided into three warm doses. Each dose is accompanied by 9g of Li Zhong Dan (My Proposed Middle-Fire Clearing Pill), instructed to be taken warm every two hours.

Second Visit: At 3:00 PM the next day, examined again. She kept her eyes closed, drowsy, and unresponsive to calls. Her family stated that after finishing the medicine the previous day, the internal and external heat sensations had lessened, and her spirit was quite clear in the forenoon. However, tidal fever gradually returned in the afternoon, and the condition worsened progressively. Half an hour prior, she could respond to calls, but now even loud calls elicited no response. They also reported that pus and blood discharge began at dawn, occurring more than ten times by afternoon, and had stopped near 2:00 PM. Palpation revealed pulses on both sides appearing large and forceful, but empty upon heavy pressure, with a rate nearing six strokes per breath (approx. 90-100 bpm). Knowing her constitution was originally deficient, further depleted by frequent dysentery, and scorched by exogenous excess heat, her spirit was confused and unable to sustain itself. I decided to boldly administer a large dose of Baihu Jia Renshen Tang (White Tiger Decoction plus Ginseng), slightly modifying the original formula to suit the pathogenesis.

Prescription: Sheng Shi Gao (Raw Gypsum Fibrosum) 90g (crushed), Ye Tai Shen (Wild Taishan Ginseng) 15g, Sheng Hang Shao (Raw Paeoniae Radix Alba) 30g, Sheng Huai Di Huang (Raw Rehmanniae Radix) 30g, Gan Cao (Licorice Root) 9g, Sheng Huai Shan Yao (Raw Dioscoreae Rhizoma) 24g.
Decoct together to yield three bowls of liquid, take warm slowly in three doses.

This formula replaces Zhi Mu (Anemarrhenae Rhizoma) in the original formula with Sheng Di Huang (Rehmanniae Radix Praeparata), and replaces Jing Mi (Oryza Sativa) with Shan Yao (Dioscoreae Rhizoma), while adding Shao Yao (Paeoniae Radix). The combination of Shao Yao and Gan Cao constitutes Gancao Shaoyao Tang (Licorice and Peony Decoction) from Shanghan Lun, a miraculous formula by Zhang Zhongjing to restore true yin. Used within this formula, it effectively treats tenesmus and abdominal pain, serving as a key herb for treating dysentery.

Second Visit (Follow-up): After taking the medicine in three doses, past midnight, the patient suddenly regained consciousness. Her family said that after the pulse diagnosis and prescription, she passed pus and blood several more times, but once the medicine was finished, the discharge ceased. Re-palpation showed the pulse becoming very harmonious. Upon inquiry, she still felt slight heat in the heart region and palpitations/unease. I planned to treat with cooling, moistening, and yin-nourishing agents to clear residual heat, and add herbs to preserve qi transformation to treat the palpitations.

Prescription: Xuan Shen (Scrophulariae Radix) 30g, Sheng Hang Shao (Raw Paeoniae Radix Alba) 18g, Jing Yu Rou (Cleaned Corni Fructus) 18g, Sheng Long Gu (Raw Fossilia Ossis Mastodi) 18g (crushed), Sheng Mu Li (Raw Ostreae Concha) 18g (crushed), Sha Shen (Glehniae Radix) 12g, Suan Zao Ren (Ziziphi Spinosae Semen) 12g (stir-fried and crushed), Gan Cao (Licorice Root) 6g.
Decoct together to yield two bowls of liquid, take warm in two doses. Mix in one raw chicken egg yolk with each dose.

Outcome: After taking the medicine continuously for three doses, all residual heat disappeared, and the palpitations ceased. The decoction was then stopped. Instead, she was advised to consume nearly 30g of finely powdered Sheng Huai Shan Yao (Raw Dioscoreae Rhizoma) boiled as tea, mixed with fresh pear juice, taken as a snack for convalescence.

Commentary: I have treated many cases of warm diseases complicated by dysentery, none as severe as this one. The abdominal pain here was so severe that she tossed and cried, preventing pulse diagnosis. This was not only due to Liver fire pressing downward threatening dysentery, but also because exogenous toxic pestilential qi was assisting in exacerbating the condition. Therefore, Shao Yao was used to drain Liver heat, Gan Cao to relieve Liver urgency, and Weisheng Fangyi Baodan to expel the invading pathogen. Once the abdominal pain resolved, fearing the worsening of warm-heat, Lian Qiao and Gan Cao decoction was given with Li Zhong Dan to clear warm-heat, which led to significant improvement by the next morning. If pulse diagnosis and medication had been administered promptly during this period of improvement, subsequent lethargy could have been avoided. However, due to delay, the condition became critically dangerous. Fortunately, appropriate medication managed to reverse it, though it was perilous. The proverb "watch Shanghan like a galloping horse" refers to the rapid changes in disease progression. Does this not apply equally to treating warm diseases? Furthermore, the aggravation in the afternoon was due to her inherent yin deficiency, compounded by multiple episodes of pus and blood dysentery since dawn, increasing deficiency. Combined with deficiency heat from yin loss and excess heat from exogenous factors, her spirit could not sustain itself. Fortunately, the formula contained few ingredients, comprehensively addressing deficiency heat, excess heat, and heat generated by dysentery without omission. By decocting a large batch and dividing it into three warm doses, the medicinal power remained continuous, following the ancient method of one decoction taken in three doses. I have saved many critical cases using this method. Otherwise, a light dose would fail to save a serious illness, while a heavy dose taken at once would overwhelm the patient. Only by decocting a large amount and taking small doses frequently—without needing to finish the entire course if cured—can one balance caution with boldness, which is indeed crucial for reversing critical conditions.