天津马××，年二十八岁，于季秋得温病兼喉痧痰喘证。
病因 初因外出受风感冒甚微，医者用热药发之，陡成温病，而喉病喘病遂同时发现。
证候 表里俱壮热，喘逆咳嗽，时吐痰涎，咽喉左边红肿作疼（即西人所谓扁桃体炎）。其外
边项左侧亦肿胀，呼吸皆有窒碍。为其病喉且兼喘逆，则吸气尤形困难，必十分努力始能将气吸入。
其舌苔白而薄，中心微黄。小便赤涩，大便四日未行。其脉左右皆弦长，右部重诊有力，一分钟九十六至。
诊断 此乃外感之热已入阳明之府，而冲气又挟胃气肝火上冲也。为其外感之热已入阳明之府，
是以右脉之力胜于左脉，为其冲气挟胃气肝火上冲，是以左右脉皆弦长。病现喘逆及咽喉
肿疼，其肿痛偏左者，正当肝火上升之路也。拟治以麻杏甘石汤，兼加镇冲降胃纳气利痰之
品以辅之，又宜兼用针刺放血以救目前之急。
处方 麻黄（一钱） 生石膏（二两捣细） 生赭石（一两轧细） 生怀山药（八钱）
杏仁（三钱去皮炒捣） 连翘（三钱） 牛蒡子（三钱捣碎） 射干（二钱） 甘草（一钱）
共煎汤两盅，分两次温服。
又于未服药之前，用三棱针刺其两手少商出血，用有尖小刀刺其咽喉肿处，开两小口令其
出血，且用硼砂、西药盐酸盖理，融以三十倍之水，俾其含漱。又于两手合谷处为之行
针。其咽喉肿处骤然轻减，然后服药。
复诊 将药服后，其喘顿愈强半，呼吸似无妨碍，表里之热亦愈强半。脉象亦较前平和，其右
部仍然有力。胸膈似觉郁闷，有时觉气上冲，仍然咳嗽，大便犹未通下。拟再治以开郁降
气清热理嗽之剂。
处方 糖栝蒌（二两切碎） 生石膏（一两捣细） 生赭石（五钱轧细） 生杭芍（三钱）
川贝母（三钱） 碎竹茹（三钱） 牛蒡子（三钱捣碎）
共煎汤一大盅，温服。
效果 将药煎服一剂，大便通下，诸病皆愈。唯一日之间犹偶有
咳嗽之时，俾用川贝母细末和梨蒸食之以善其后。
帮助 凡用古人成方治病，其药味或可不动，然必细审其药之分
量或加或减，俾与病机相宜。如麻杏甘石汤原方，石膏之分
量仅为麻黄之两倍，而此证所用麻杏甘石汤则石膏之分量二十倍于麻黄矣。盖《伤寒论》之
麻杏甘石汤原非为治喉证而设，今借之以治喉证。原用麻黄以散风定喘，又因此证之喉肿太甚，
有碍呼吸，而方中犹用麻黄，原为行险之道，故麻黄仅用一钱，而又重用生石膏二两以监制之。且于
临服药时先用刀开其患处，用针刺其少商与合谷，此所以于险中求稳也。尝闻友人杨××言，
有一名医深于《伤寒论》，自着有《注解伤寒论》之书行世，偶患喉证，自服麻杏甘石汤竟至
不起，使其用麻杏甘石汤时，亦若愚所用者如此加减，又何患喉证不愈乎？纵使服药不能即愈，
又何至竟不起乎？由此知非古人之方误人。麻杏甘石汤，原为发汗后及下后汗出而喘无大热者
之的方，原未言及治喉证也。而欲借之以治喉证，能勿将药味之分量为之加减乎？尝总核《伤寒论》
诸方用于今日，大抵多稍偏于热，此非仲景之不善制方也。自汉季至今，上下相隔已一千六
百余年，其天地之气化，人生之禀赋，必有不同之处，是以欲用古方皆宜细为斟酌也。
Tianjin patient Ma XX, aged 28, contracted a warm disease complicated with throat sand (throat scarlet fever) and phlegm-wheezing syndrome in late autumn.
Etiology Initially, he caught a slight wind-cold while going out. The physician used hot-natured herbs to induce sweating, which suddenly transformed the condition into a warm disease, causing throat pathology and wheezing to appear simultaneously.
Signs and Symptoms There was high fever both on the exterior and interior, accompanied by rebellious wheezing, coughing, and frequent expectoration of phlegm-saliva. The left side of the throat was red, swollen, and painful (corresponding to tonsillitis in Western medicine). Additionally, the left side of the neck was swollen, causing obstruction in breathing. Due to the combination of throat pathology and rebellious wheezing, inhalation was particularly difficult, requiring great effort to draw air in. The tongue coating was white and thin, slightly yellow in the center. Urine was dark and scanty/dysuric; stool had not been passed for four days. The pulse was wiry and long on both sides; the right side was forceful upon heavy pressure, beating 96 times per minute.
Diagnosis This is a case where the heat from external contraction has entered the Yangming Fu organ, while the Chong Qi (Penetrating Vessel Qi) is carrying Stomach Qi and Liver Fire upward. Because the external heat has entered the Yangming Fu, the right pulse is stronger than the left. Because the Chong Qi carries Stomach Qi and Liver Fire upward, both pulses are wiry and long. The manifestation of rebellious wheezing and throat swelling/pain, with the swelling biased to the left, corresponds to the pathway of ascending Liver Fire. The proposed treatment is Maxing Shigan Tang (Ephedra, Apricot Seed, Gypsum, and Licorice Decoction), supplemented with herbs that calm the Chong Qi, descend Stomach Qi, grasp Qi, and resolve phlegm. Acupuncture bloodletting is also indicated to address the current emergency.
Prescription Ephedrae Herba (Mahuang, 麻黄) - 1 qian; Raw Gypsum Fibrosum (Sheng Shigao, 生石膏) - 2 liang, crushed; Raw Hematitum (Sheng Zheshi, 生赭石) - 1 liang, finely ground; Raw Dioscoreae Hypoglaucae Rhizoma (Sheng Huai Shanyao, 生怀山药) - 8 qian; Armeniacae Semen Amarum (Xingren, 杏仁) - 3 qian, peeled, stir-fried, and crushed; Forsythiae Fructus (Lianqiao, 连翘) - 3 qian; Arctii Fructus (Niubangzi, 牛蒡子) - 3 qian, crushed; Belamcandae Rhizoma (Shegan, 射干) - 2 qian; Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) - 1 qian.
Decoct together to obtain two bowls of liquid, taken warm in two divided doses.
Before taking the medicine, three-edged needles were used to prick the Shaoshang points (LU-11) on both hands to bleed. A sharp small knife was used to puncture the swollen areas of the throat, making two small incisions to allow bleeding. Borax and a Western antiseptic (Hydrochloride Capryl) dissolved in thirty times its volume of water were used for gargling. Needling was performed at the Hegu points (LI-4) on both hands. The throat swelling decreased significantly immediately after this procedure, after which the decoction was administered.
Second Visit After taking the medicine, the wheezing improved by more than half, breathing seemed unobstructed, and the exterior-interior heat subsided by more than half. The pulse became milder compared to before, though the right side remained forceful. The chest and diaphragm felt somewhat stifled, with occasional sensations of Qi rushing upward. Cough persisted, and stool had not yet been passed. The proposed treatment is a formula to relieve stagnation, descend Qi, clear heat, and regulate cough.
Prescription Trichosanthis Fructus Preparatus (Tang Gualou, 糖栝蒌) - 2 liang, chopped; Raw Gypsum Fibrosum (Sheng Shigao, 生石膏) - 1 liang, crushed; Raw Hematitum (Sheng Zheshi, 生赭石) - 5 qian, finely ground; Paeoniae Radix Alba (Sheng Baishao, 生杭芍) - 3 qian; Fritillariae Cirrhosae Bulbus (Chuan Beimu, 川贝母) - 3 qian; Bambusae Medulla Suta (Sui Zhuru, 碎竹茹) - 3 qian; Arctii Fructus (Niubangzi, 牛蒡子) - 3 qian, crushed.
Decoct together to obtain one large bowl of liquid, taken warm.
Outcome After one dose of the decoction, stool was passed, and all diseases resolved. Only occasional coughing occurred within one day thereafter. The patient was advised to steam pear slices with fine powder of Fritillariae Cirrhosae Bulbus (Chuan Beimu) for convalescence.
Discussion When using ancient established formulas to treat diseases, the ingredients may remain unchanged, but their dosages must be carefully examined and adjusted (added or reduced) to suit the pathogenesis. For instance, in the original Maxing Shigan Tang, the dosage of Gypsum Fibrosum is only twice that of Ephedrae Herba. However, in this case, the dosage of Gypsum Fibrosum was twenty times that of Ephedrae Herba. Essentially, the Maxing Shigan Tang in *Shanghan Lun* was not originally designed for treating throat conditions but is borrowed here for that purpose. Originally, Ephedrae Herba was used to disperse wind and stabilize wheezing. Given the severe throat swelling obstructing respiration in this case, using Ephedrae Herba was a risky maneuver; thus, only 1 qian was used, while 2 liang of Raw Gypsum Fibrosum was heavily employed to restrain it. Furthermore, prior to ingestion, the affected area was incised, and Shaoshang (LU-11) and Hegu (LI-4) were needled, representing a strategy of seeking stability within risk. I once heard my friend Yang XX say that a famous physician, deeply versed in *Shanghan Lun* and author of an annotated edition, suffered from a throat condition and self-administered Maxing Shigan Tang, resulting in death. Had he adjusted the dosages as I did, would he not have recovered? Even if immediate recovery was not achieved, why would it lead to death? This demonstrates that it is not the ancient formulas that harm people. Maxing Shigan Tang is specifically indicated for wheezing with sweating after emesis or purgation, without significant fever; it does not mention treating throat conditions. If borrowing it for throat conditions, how can one fail to adjust the dosages? Upon reviewing the formulas of *Shanghan Lun* applied today, most tend to be slightly warm in nature. This is not due to Zhang Zhongjing's poor formulation skills. From the late Han Dynasty to now, over 1,600 years have passed. The environmental Qi transformations and human constitutions must differ. Therefore, when using ancient formulas, careful deliberation is essential.