天津迟氏妇，年二十二岁，于季秋得温病。
病因 其素日血分不调，恒作灼热，心中亦恒发热，因热贪凉，薄受外感，即成温病。
证候 初受外感时，医者以温药发其汗，汗出之后，表里陡然大热，呕吐难进饮食，饮水亦
恒吐出，气息不调，恒作呻吟，小便不利，大便泄泻日三四次，其舌苔薄而黄，脉象似有力
而不实，左部尤不任重按，一分钟百零二至，摇摇有动象。
诊断 其胃中为热药发表所伤，是以呕吐，其素日阴亏，肝肾有热，又兼外感之热内迫，致小
便不利水归大肠是以泄泻，其舌苔薄而黄者，外感原不甚剧（舌苔薄，亦主胃气虚），而治以滋阴、
清热、上止呕吐、下调二便之剂。
处方 生怀山药（一两） 滑石（八钱） 生杭芍（八钱） 生怀地黄（六钱）
清半夏（五钱温水洗三次） 碎竹茹（三钱） 生麦芽（三钱） 净青黛（二钱）
连翘（二钱） 甘草（三钱） 鲜茅根（四钱）
药共十一味，先将前十味水煎十余沸，再入茅根同煎七八沸，其汤即成，取清汤两盅，分三次温
饮下。服医药后防其呕吐可口含生姜一片，或于煎药时加生姜三片亦可。至药局中
若无鲜茅根，可用干茅根两半煎汤，以之代水煎药。
方解 方中之义，山药与滑石并用，一滋阴以退热而能固大便，一清火以退热而善利小便；
芍药与甘草并用，为甘草芍药汤，仲师用之以复真阴，而芍药亦善利小便，甘草亦善补大
便，汇集四味成方，即拙拟之滋阴清燥汤也。以治上有燥热下焦滑泻之证，莫不随手奏效。半
夏善止呕吐，然必须洗净矾味（药局清半夏亦有矾），屡洗之则药力减，是以用至五钱。竹茹亦
善止呕吐，其碎者为竹之皮，津沽药局名为竹茹粉，其止呕之力较整者为优。至于青黛、生姜亦
止呕吐之副品也。用生麦芽、鲜茅根者，以二药皆善利小便，而又善达肝木之郁以调气分也。用生
地黄者，以其为滋补真阴之主药，即可为治脉数动摇者之要药也。
复诊 将药煎服一剂，呕吐与泄泻皆愈，小便已利，脉象不复摇摇，仍似有力，至数未减，其表里
之热稍退，气息仍似不顺，舌苔仍黄，欲投以重剂以清其热，犹恐大便不实，拟再治以清解之剂。
处方 生怀地黄（一两） 玄参（八钱） 生杭芍（六钱） 天花粉（六钱）
生麦芽（三钱） 鲜茅根（三钱） 滑石（三钱） 甘草（三钱）
共煎汤一大盅，分两次温服下。
三诊 将药煎服后，病又见轻，家人以为病愈无须服药矣，至翌日晚十一点钟后，见其面红，精
神昏愦，时作呻吟，始知其病犹未愈。及愚诊视时，夜已过半，其脉左右皆弦硬而长，数近七至，两
目直视，其呻吟之声，似阻隔不顺，舌苔变黑，问其心中何如？自言热甚，且觉气息不接续，此其气分
虚而且郁，又兼血虚阴亏，而阳明之热又炽盛也。其脉近七至者，固为阴虚有热之象，而正气虚损
不能抗拒外邪者，其脉亦恒现数象，至其脉不为洪滑而为弦硬者，亦气血两亏邪热炽盛之现象也。拟
用白虎加人参汤，再加滋阴理气之品，盖此时大便已实，故敢放胆治之。
处方 生石膏（五两轧细） 野台参（六钱） 知母（六钱） 天花粉（六钱）
玄参（六钱） 生杭芍（五钱） 生莱菔子（四钱捣碎） 生麦芽（三钱）
鲜茅根（三钱） 粳米（三钱） 甘草（三钱）
共煎汤一大碗，分四次温饮下，病愈不必尽剂。
效果 将药分四次服完，热退强半，精神已清，气息已顺，脉象较前缓和，而大便犹未通下，
因即原方将石膏改用四两，莱菔子改用二钱，如前煎服，服至三次后，大便通下，其热全退，遂停后服。
帮助 愚用白虎加人参汤，或以玄参代知母（产后寒温证用之）、或以芍药代知母（寒温兼下痢
者用之）、或以生地黄代知母（寒温兼阴虚者用之）、或以生山药代粳米（寒温热实下焦气化不固者用之、
产后寒温证用之），又恒于原方之外，加生地黄、玄参、沙参诸药以生津液，加鲜茅根、芦根、生
麦芽诸药以宣通气化，初未有加莱菔子者，惟此证之气分虚而且郁，白虎汤中加人参可补其
气分之虚，再加莱菔子更可理其气分之郁也。至于莱菔子必须生用者，取其有升发之力也。又须
知此证不治以白虎汤而必治以白虎加人参汤者，不但为其气分虚也，凡人外感之热炽盛，真阴
又复亏损，此乃极危险之证，此时若但用生地黄、玄参诸滋阴之品不能奏效，即将此
等药加于白虎汤中亦不能奏效，惟生石膏与人参并用，独能于邪热炽盛之时立复真阴，此所
以伤寒汗吐下后与渴者治以白虎汤时，仲圣不加他药而独加人参也。
Tianjin, a woman surnamed Chi, aged twenty-two, contracted Warm Disease (Wen Bing) in late autumn.
Etiology: She had previously suffered from irregularities in the Blood aspect (Xue Fen), often experiencing burning heat, and her Heart (Xin) was also constantly feverish. Due to craving coolness because of internal heat, she slightly caught an external pathogenic factor, which immediately resulted in Warm Disease.
Symptoms: When initially exposed to the external pathogen, the physician used warm-natured herbs to induce sweating. After sweating, sudden intense heat appeared both on the exterior and interior. She suffered from severe vomiting, unable to retain food; even drinking water often caused vomiting. Her breathing was irregular, accompanied by constant moaning. Urination was difficult, and diarrhea occurred three to four times daily. Her tongue coating was thin and yellow. The pulse seemed forceful but lacked substance; the left side was particularly sensitive to heavy pressure. The pulse rate was 102 beats per minute, with a trembling and unstable quality.
Diagnosis: Her Stomach (Wei) was injured by the warm-natured diaphoretic herbs, causing vomiting. Her chronic Yin deficiency and Heat in the Liver (Gan) and Kidney (Shen), combined with the internal pressure of external Heat, led to difficulty in urination. Water diverted into the Large Intestine (Da Chang) caused diarrhea. The thin yellow tongue coating indicated that the external contraction was not originally severe (a thin coating also suggests deficiency of Stomach Qi). Treatment should employ formulas that nourish Yin, clear Heat, stop vomiting above, and regulate bowel movements and urination below.
Prescription: Raw Huai Yam (Shan Yao, 1 liang), Talcum (Hua Shi, 8 qian), Raw Hang Peony (Shao Yao, 8 qian), Raw Huai Rehmannia Root (Di Huang, 6 qian), Clear Pinellia Rhizome (Ban Xia, 5 qian, washed three times with warm water), Crushed Bamboo Shavings (Zhu Ru, 3 qian), Raw Malt (Mai Ya, 3 qian), Purified Indigo Naturalis (Qing Dai, 2 qian), Forsythia Fruit (Lian Qiao, 2 qian), Licorice Root (Gan Cao, 3 qian), Fresh Imperata Rhizome (Mao Gen, 4 qian).
The eleven ingredients were first decocted together for about ten boils. Then, the fresh Imperata Rhizome was added, and decoction continued for seven or eight more boils. Two cups of the clear liquid were obtained and taken in three divided doses at a warm temperature. To prevent vomiting after taking the medicine, one slice of fresh Ginger (Sheng Jiang) could be held in the mouth, or three slices could be added during decoction. If fresh Imperata Rhizome was unavailable at the pharmacy, half a liang of dried Imperata Rhizome could be decocted in water to substitute for water when decocting the other herbs.
Formula Analysis: The combination of Shan Yao and Hua Shi serves to nourish Yin to reduce fever while consolidating the stool, and Hua Shi clears fire to reduce fever while promoting urination. The combination of Shao Yao and Gan Cao constitutes the Gancao Shaoyao Decoction. Zhang Zhongjing used this to restore True Yin; additionally, Shao Yao promotes urination, and Gan Cao benefits the stool. These four herbs form my proposed Ziyin Qingzao Tang (Nourishing Yin and Clearing Dryness Decoction). It is effective for conditions characterized by dry-heat above and slippery diarrhea below. Ban Xia stops vomiting but must be washed to remove alum residue; excessive washing reduces efficacy, hence the high dose of 5 qian. Zhu Ru also stops vomiting; its crushed form, known as Zhu Ru Powder, is superior to whole pieces for this purpose. Qing Dai and Sheng Jiang are auxiliary anti-emetics. Raw Mai Ya and fresh Mao Gen are used because they promote urination and soothe Liver Qi stagnation to regulate the Qi aspect. Raw Di Huang is used as the primary herb for nourishing True Yin and treating rapid, trembling pulses.
Follow-up Visit 1: After one dose, vomiting and diarrhea ceased, urination normalized, and the pulse lost its trembling quality, though it remained seemingly forceful with the same rate. Exterior and interior heat subsided slightly, but breathing remained irregular, and the tongue coating stayed yellow. I intended to use a heavier formula to clear Heat but feared loose stools, so I planned to continue with a clearing and resolving formula.
Prescription: Raw Huai Rehmannia Root (Di Huang, 1 liang), Scrophularia Root (Xuan Shen, 8 qian), Raw Hang Peony (Shao Yao, 6 qian), Trichosanthes Root (Tian Hua Fen, 6 qian), Raw Malt (Mai Ya, 3 qian), Fresh Imperata Rhizome (Mao Gen, 3 qian), Talcum (Hua Shi, 3 qian), Licorice Root (Gan Cao, 3 qian).
Decocted in one large cup, taken in two divided warm doses.
Follow-up Visit 3: After taking the medicine, symptoms improved further. The family believed she was cured and stopped medication. However, after 11:00 PM the next night, she exhibited facial redness, mental confusion, and intermittent moaning, indicating the disease persisted. Upon examination past midnight, the pulse was wiry, hard, and long on both sides, extremely rapid (nearly seven breaths per pulse beat). Her eyes were fixed, moaning sounded obstructed, and the tongue coating turned black. She reported intense internal heat and a sensation of disconnected Qi. This indicated Qi deficiency and stagnation, compounded by Blood deficiency, Yin deficiency, and blazing Yangming Heat. A pulse rate near seven beats per breath indicates Yin deficiency with Heat. Deficiency of Healthy Qi failing to resist pathogens can also cause a rapid pulse. The wiry and hard quality, rather than surging and slippery, reflects dual deficiency of Qi and Blood alongside blazing Pathogenic Heat. I prescribed Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) with added herbs to nourish Yin and regulate Qi. Since the stool had become firm, I felt confident to proceed boldly.
Prescription: Raw Gypsum (Shi Gao, 5 liang, finely ground), Wild Taishan Codonopsis (Ye Tai Shen, 6 qian), Anemarrhena Rhizome (Zhi Mu, 6 qian), Trichosanthes Root (Tian Hua Fen, 6 qian), Scrophularia Root (Xuan Shen, 6 qian), Raw Hang Peony (Shao Yao, 5 qian), Raw Radish Seed (Lai Fu Zi, 4 qian, crushed), Raw Malt (Mai Ya, 3 qian), Fresh Imperata Rhizome (Mao Gen, 3 qian), Rice Grains (Jing Mi, 3 qian), Licorice Root (Gan Cao, 3 qian).
Decocted in one large bowl, taken in four divided warm doses. Discontinue if cured before finishing all doses.
Outcome: After completing four doses, fever reduced by more than half, mental clarity returned, breathing normalized, and the pulse became milder. Bowel movement remained unpassed. Therefore, the original formula was adjusted: Shi Gao reduced to 4 liang and Lai Fu Zi to 2 qian. After the third dose of this adjustment, bowel movement occurred, fever completely resolved, and subsequent doses were stopped.
Commentary: In using Baihu Jia Renshen Tang, I sometimes replace Zhi Mu with Xuan Shen (for postpartum Cold-Warm diseases), Shao Yao (for Cold-Warm with dysentery), Di Huang (for Cold-Warm with Yin deficiency), or Jing Mi with Shan Yao (for Cold-Warm with excess heat and insecure Lower Jiao Qi transformation/postpartum cases). I frequently add Di Huang, Xuan Shen, and Sha Shen to generate fluids, and Mao Gen, Lu Gen, and Mai Ya to promote Qi transformation. Previously, I never added Lai Fu Zi. However, in this case of Qi deficiency and stagnation, Renshen in Baihu Tang tonifies Qi deficiency, and adding Lai Fu Zi resolves Qi stagnation. Lai Fu Zi must be used raw to leverage its ascending and dispersing power. Note that Baihu Jia Renshen Tang is chosen over plain Baihu Tang not only for Qi deficiency but also because extreme Heat with True Yin depletion is critical. Merely using Yin-nourishing herbs like Di Huang or Xuan Shen is ineffective, even if added to Baihu Tang. Only the combination of Shi Gao and Renshen can rapidly restore True Yin amidst blazing Heat. This explains why Zhang Zhongjing added Renshen alone to Baihu Tang for thirst following sweating, vomiting, or purgation in Cold Damage (Shang Han).