通。小便利。津液少。口干燥。其脉大而虚。作蜜煎导之。下燥粪得溏利而解。其家曰。皆
阳明不通。何以治之异。许曰。二证虽相似。然自汗小便利者。不可荡涤五脏。为无津液
也。然则伤寒脉证大同小异之间。即宜分别斟酌。奈何以温疫论为快捷方式哉。
一人年四十五。正月间。路途跋涉劳倦。发热。身体略痛而头不痛。自以为外感。而用
九味羌活汤三帖。汗出热不退。前后又服小柴胡汤五六帖。热愈甚。经八日。延虞诊视。至
卧榻前。见煎成汤饮一盏在案。问之。乃大承气汤。将欲饮。切其脉。右三部浮洪。略弦而
无力。左三部略小。亦浮软不足。虞曰。汝几自杀。此内伤虚证。服此药大下。必死。伊芳曰
我平生元气颇实。素无虚损证。明是外感无疑也。虞曰。将欲作阳明内实治而下之欤。脉
既不沉实。又无舌干潮热谵语等证。将欲作太阳表实治而汗之欤。脉虽浮洪而且虚。又无头
痛脊强等证。今经八日。非表非里。汝欲作何经治之乎。伊芳无以答。乃用补中益气汤加附子
大剂与之。是夜连进二服。天明往诊。脉略平和。伊芳犹疑属前效。欲易外感退热之药。虞
曰。前药再饮二服。不效当罪我。又如前二服。脉证俱减半。伊芳始曰。我几误矣。去附子。
再煎二帖与之。热退气和而愈。但体犹困倦如前。服前药二十余帖。始得强健。
震按此案与前案迥然不同。同一汗后热愈甚。同一凉解热不退。彼则连用寒下。此则连
用温补。合观之自益人神智。而此案非表非里之论。尤足为辨证之准绳。
郭雍治一人。盛年恃健不善养。过饮冷酒食肉。兼感冒。初病即身凉自利。手足厥逆。
额上冷汗不止。遍身痛。呻吟不绝。偃卧不能转侧。却不昏愦。亦不恍惚。郭曰。病患甚静
并不昏妄。其自汗自利。四肢逆冷。身重不能起。身痛如被杖。皆为阴证无疑。令服四逆
汤。灸关元及三阴交。未应。加服丸炼金液丹。利厥汗皆少止。若药艾稍缓。则诸证复出。
如此进退者凡三日夜。阳气虽复。证复如太阳病。未敢服药。静以待汗。二三日复大烦躁。
饮水。次则谵语斑出。热甚。无可奈何。乃与调胃承气汤。得利。大汗而解。阴阳反复有如
震按此案与前二案又复不同。阴阳反复如此。诚不可一途而取。
薛院使已治一人。年七十九。仲冬将出行。少外家入房。致头痛发热。眩晕喘急。痰涎壅
盛。小便烦数。口干引饮。遍舌生刺。缩敛如荔枝然。下唇黑裂。面目俱赤。烦躁不寝。或
时喉间如烟火上冲。急饮凉茶少解。已滨于死。脉洪大而无伦。且有力。扪其身烙手。此肾
经虚火游行于外。投以十全大补合六味地黄汤、生脉散。再加附子。服一剂。熟寝良久。脉
证各减三四。再与八味丸服之。诸证悉退。后忌冷物而痊。
震按少外家入房。病者之隐事。头痛发热。必自疑感冒外邪。观其口渴舌刺等证。及脉洪
大有力。医者必以温疫论伤寒直格一致思矣。白虎泻心。死复何疑。此惟张景岳可与谈心。
张景岳曰。余在燕都。治一王生。患阴虚伤寒。年出三旬。而舌黑之甚。其芒刺干裂。
焦黑如炭。身热便结。大渴喜冷。而脉则无力。神则昏沉。群医谓阳证阴脉。必死无疑。余
察其形气未脱。遂以甘温壮水等药。大剂进之以救其本。仍间用凉水以滋其标。盖水为天一
之精。凉能解热。甘可助阴。非若苦寒伤气者之比。故于津液干燥。阴虚便结。而热渴火盛
之证。亦所不忌。由是水药并进。前后凡用人参、熟地辈各一二斤。附子、肉桂各数两。冷
水亦一二斗。然后诸证渐退。饮食渐进。神气俱复矣。但察其舌黑则分毫不减。余甚疑之。
莫得其解。再后数日。忽舌上脱一黑壳。而内则新肉灿然。始知其肤腠焦枯。死而复活。使
非大为滋补。安望再生。若此一证。特举其甚者纪之。此外凡舌黑用补而得以保全者。盖不
可枚举矣。所以凡诊伤寒者。当以舌色辨表里。以舌色辨寒热。皆不可不知也。若以舌色辨
虚实。则不能无误。盖实固能黑。以火盛而焦也。虚亦能黑。以水亏而枯也。若以舌黄舌黑
悉认为实热。则阴虚之证。万无一生矣。
杨乘六治吴长人。于三月初。身大热。口大渴。唇焦裂。目赤色。两颧娇红。语妄神昏
手冷过肘。足冷过膝。其舌黑滑而胖。其脉洪大而空。一医欲用白虎。杨曰。身虽壮热如
烙。而不离覆盖。口虽大渴引饮。而不耐寒凉。面色虽红却娇嫩。而游移不定。舌胎虽黑。
却浮胖而滋润不枯。如果属白虎。则更未有四肢厥冷而上过乎肘下过乎膝。六脉洪大。而浮
取无伦。沉取无根者也。此为格阳戴阳。若用白虎。必立毙矣。遂以大剂八味加人参。浓煎
数碗。冷冻饮料。诸证乃退。继以理中加附子。六君加归、芍。各数剂调理而愈。
又治归安医者张学海。疲于临证。微寒壮热。头痛昏沉。服发散药数剂。目直耳聋。口
渴便闭。改用泻火解毒等剂。热势尤炽。油汗如珠。谵语撮空。恶候悉具。云峰观之。其脉
洪大躁疾而空。其舌干燥焦黄而胖。杨曰。证有真假凭诸脉。脉有真假凭诸舌。果系实证。
则脉必洪大躁疾而重按愈有力者也。果系实火。则舌必干燥焦黄而敛束且坚卓者也。岂有重
按全无脉者。而尚得谓之实证。满舌俱胖壮者。而尚得谓之实火哉。用养营汤。参、附各三
钱。服后得睡。热退。舌变红润而愈。
震按杨氏谓阴亏而干燥。其舌必坚敛。火旺而焦黑。其舌必苍老。万无干燥焦黑。属阴
虚火旺。而舌见胖嫩者。说亦奇矣。实未曾试。不敢轻信。
李士材治韩茂远。伤寒九日以来。口不能言。目不能视。体不能动。四肢俱冷。皆曰阴
证。士材诊之。六脉皆无。以手按腹。两手护之。眉皱作楚。按其趺阳。大而有力。乃知
有燥屎也。与大承气汤。得燥屎六七枚。口能言。体能动矣。故按手不及足者。何以救此垂
绝之证耶。
震按六脉无而诊趺阳。鉴于仲景之自叙。读书诚有用也。
王月怀伤寒至五日。下利不止。懊 腹胀。诸药不效。有以山药茯苓与之。虑其泻脱也
士材诊之。六脉沉数。按其脐则痛。此协热自利。中有结粪。小承气倍大黄服之。果得结
粪数枚。利遂止。懊 遂安。
儒者吴君明。伤寒六日。谵语狂笑。头痛有汗。大便不通。小便自利。众议承气汤下之
士材诊其脉浮而大。因思仲景曰。伤寒不大便六七日。头痛有热。小便清者。知不在里。
仍在表也。方今仲冬。宜与桂枝汤。众皆咋舌。以谵狂为阳盛。桂枝入口必毙矣。李曰。汗
多神昏。故发谵妄。虽不大便。腹无所苦。和其荣卫。必自愈耳。遂违众用之。及夜而笑语
皆止。明日大便自通。故病变多端。不可胶执。向使狐疑而用下药。其可活乎。
震按自利而用承气汤。谵语而用桂枝汤。仲景集中原有此法。只要认得真耳。
卢子由治梁秀才。于三月间。作文受寒。服发散药十余帖。热盛汗多。蒸蒸如云雾。高
一二尺。湿透衣被。日易十数番。十四日昏不识人。舌短眼瞀。脉浮大无伦。乃先以温粉
身。使汗孔收敛。次用人参五钱。生附三钱。煎服。便能识人。惟言语谵妄。七日始苏。有
客问曰。浮表脉也。热盛神昏。舌短眼瞀。邪盛也。何竟以温补收功。子由曰。凡治病先求
其本。不可泥其形证。如寒水为邪。必然心火受病。此病原从思虑受寒。政为心火不及。而
受水侮。是谓之本。况多行发散。重虚其心。心液既已散漫。精神便无主宰。故用黑附顺从
水色。而横助火力。人参转回阳气。而保定精神。然非先固其外。则内无旋理。此予治法
先后之旨也。
震按思虑受寒。为心火不及而寒水侮之。议论颇新奇。治法却平正。至谓黑附形从水而
性助火。说反陈腐矣。
缪仲淳治铨部章衡阳。患热病。头痛壮热。渴甚且呕。鼻干燥不得眠。其脉洪大而实。
一医曰。阳明症也。当用葛根汤。仲淳曰。阳明之药。表剂有二。一为葛根汤。一为白虎汤
不呕吐而解表。用葛根汤。今吐甚。是阳明之气逆升也。葛根升散。用之非宜。乃与大剂
白虎汤加麦冬、竹叶。医骇药太重。仲淳曰。虏荆非六十万人不可。李信二十万则奔还矣。
别后进药。天明遂瘥。
一仆受寒发热。头痛如裂。两目俱痛。浑身骨节痛。下部尤甚。状如刀割不可忍。口渴
甚。大便日去一次。胸膈饱胀。不得眠。已待毙矣。仲淳曰。此太阳阳明病也。贫人素多作
劳。故下体疼痛尤甚。以石膏一两五钱。麦冬八钱。知母三钱。干葛三钱。竹叶一百片。解
阳明之热。羌活二钱五分。去太阳之邪。大栝蒌实半个。枳、桔各一钱。疏利胸膈之留邪。
王肯堂治太史余云衢。向来形气充壮。饮啖兼人。忽于六月患热病。肢体不甚热。而间
扬掷手足。如躁扰状。昏愦不知人事。时发一二语不可了。而非谵也。脉微细欲绝。有谓是
阴证宜温者。有谓当下者。皆取决于王。王曰。若阳病见阴脉。在法为不治。然素禀如此。
又值酷暑外烁。酒炙内炎。宜狂热如焚。脉洪数有力。而此何为者。岂热气怫郁不得伸而然
耶。且不大便七日矣。姑以大柴胡汤下之。时大黄止用二钱。又熟煎。而太医王雷庵力争以
为太少。金坛曰。如此脉证。岂宜峻下。待其不应。加重可也。及服药。大便即行。脉已出
手足温矣。继以黄连解毒汤。数服而平。此即刘河间伤寒直格所谓蓄热内甚。而脉道不利
反致脉沉细欲绝者。通宜解毒合承气下之。俗医不知。认为阴寒。多致危殆者是也。
震按以上三条。治法渐与今人相近。盖世运风气使然。原不必过为好奇也。
喻嘉言治徐国珍。伤寒六七日。身寒目赤。索水到前。复置不饮。异常大躁。门牖洞启
身卧地上。展转不快。更求入井。一医急治承气将服。喻诊其脉。洪大无伦。重按无力。
乃曰。是为阳虚欲脱。外显假热。内有真寒。观其得水不欲咽。而尚可咽大黄、芒硝乎。天
气燠蒸。必有大雨。此证顷刻一身大汗。不可救矣。即以附子、干姜各五钱。人参三钱。甘
草二钱。煎成冷服。服后寒战戛齿有声。以重绵和头覆之。缩手不肯与诊。阳微之状始着
再与前药一剂。微汗。热退而安。
震按此条脉大无伦。重按无力。与李士材治吴文哉案同。较之金坛之案何以别之。须看
王案脉微细欲绝。喻李二案脉浮大沉小也。喻案有漱水不欲咽一证可据。王案则壮盛人病于
暑月醉饱之后可疑也。若薛院使案脉大无伦且有力。舌刺唇黑。频饮凉茶。全似阳证阳脉。
其可据者。高年御女。气喘溺频也。
〔附〕葛可久治一士人。得伤寒病。不得汗。比葛往视。则发狂循河而走。葛就 置水
中。良久乃出之。裹以重绵。得汗解。又类编载婺源程元章。夫妇皆嗜鳖。一婢奉命屠一大
者。睹其伸缩颤悸。为之不忍。解缚纵入后池。池广且深。夫妇怒甚。杖婢数十。经二年。
婢患热病。发狂奔躁。不纳粥饮。体倦昏愦。家人谓不可疗。舁置池上茅亭。半夜后。忽觉
心下开豁。四肢清快。惟身上皆是湿泥草。复静伺之。见巨鳖自池出。衔水藻浮萍。遍覆其
体。因得外凉内爽也。天明霍然。入室详述其事。程夫妇感动。不复食鳖。洪作霖梦弼言。
热证之极。猝未可解者。汲新井水浸青布互熨之为妙。不谓水族细微。亦能知此。此放生之
震按此二则全似小说。然亦可以增益见识。使知道理无穷。切勿执泥也。但 置水中。
终属荒唐。设遇欲求入井之徐国珍。不竟杀之乎。
喻嘉言治陆平叔。平素体虚气怯。面色痿黄。药宜温补。不宜寒凉。秋月偶患三疟。孟
冬复受外寒。遂寒热频作。医者以为疟后虚邪。不知其为新受实邪也。投以参术补剂。转致
奄奄一息。迁延两月。昏昏嘿嘿。家已治木。漫延西昌诊之。脉弦浮大而短气。鼻干不得汗
嗜卧。一身及面目悉黄。与阳明中风条。过经二十余日不解。悉同此例。但未至于不尿腹
满加哕耳。西昌以为脉未大坏。九分可治。但筋脉牵掣不停。只恐手足痿废。吾今用法。治
则兼治。然仲景止有大柴胡汤。两解表里之法。而无治痿之法。因以防风通圣散成方。减白
术。取荆、防、麻、薄、桔梗为表药。硝、黄、芩、翘、栀、膏、滑石为里药。原与大柴胡
之制相仿。内有芎、归、芍药。正可领诸药深入血分而通经脉。减白术者。以前既用之贻误
不可再误耳。当晚连服二剂。第一剂即觉相安。第二剂大便始通。少顷睡去。体间津津有
汗。次早再诊。筋脉不为牵掣。但阳明胃脉。洪大反加。随用大剂白虎汤。加柴胡、花粉、
芩、柏、连翘、栀子一派苦寒。连进十余剂。其舌始不向唇外吮咂。神识始渐清。粥饮始渐
加。经半月。始起坐于床。经一月。始散步于地。略一过啖。即腹痛便泄。俨似虚证。西昌
全不反顾。但于行滞药中。加用柴胡、桂枝升散余邪。不使下溜而变痢以取惫。然后改用萎
蕤、二冬。略和胃气。间用人参。不过五分。缘此证所受外邪。不在太阳而在阳明。故不但
Smooth. Urination is unobstructed. Body fluids are scanty. Dryness of the mouth and lips. The pulse is large and deficient. Treat with honey suppository (Mi Jian Dao). After expelling dry feces, loose stools occur and the disease resolves. The family said: Both cases involve Yangming obstruction, why are the treatments different? Xu Shuwei said: Although these two presentations are similar, for patients with spontaneous sweating and unobstructed urination, one must not use drastic purgatives to scour the five zang organs, because there are no longer sufficient body fluids. Therefore, between the similarities and differences in the pulses and symptoms of Cold Damage, one should carefully distinguish and deliberate. How can one treat *Wen Yi Lun* (Treatise on Warm Epidemics) as a shortcut?
A man, forty-five years old. In January, after traveling and laboring on the road, he developed fever, slight body pain but no headache. He considered it an external contraction and took three doses of Ji Wei Qiang Huo Tang (Nine-Ingredient Decoction of Notopterygium), sweating occurred but the fever did not recede. Subsequently, he took five or six doses of Xiao Chai Hu Tang (Minor Bupleurum Decoction), and the fever became even more severe. After eight days, Yu Tun was summoned to examine him. Arriving at the bedside, he saw a cup of prepared decoction on the table. Upon inquiry, it was Da Cheng Qi Tang (Major Order the Qi Decoction), which the patient was about to drink. Taking his pulse, the right cun, guan, and chi positions were floating and flooding, slightly wiry but powerless; the left cun, guan, and chi positions were slightly small, also floating and soft, insufficient. Yu Tun said: You nearly killed yourself. This is an internal injury deficiency syndrome. Taking such strong purgatives will certainly lead to death. The man said: My primordial qi has always been quite substantial, and I have never had deficiency syndromes. It is clearly an external contraction without doubt. Yu Tun said: Do you intend to treat this as a Yangming interior excess syndrome and purge it? The pulse is neither deep nor solid, and there are no symptoms such as dry tongue, tidal fever, or delirium. Do you intend to treat this as a Taiyang exterior excess syndrome and induce sweating? Although the pulse is floating and flooding and deficient, there are no symptoms such as headache or neck stiffness. Now that eight days have passed, it is neither exterior nor interior. Which channel do you intend to treat? The man had no answer. Thus, Bu Zhong Yi Qi Tang (Decoction to Supplement the Middle and Enrich the Qi) with added Fu Zi (Prepared Aconite Root) was prescribed in a large dose. Two doses were taken continuously that night. At dawn, upon examination, the pulse was slightly harmonious. The man still suspected it was the effect of previous medications and wanted to switch to herbs for clearing external heat. Yu Tun said: Drink two more doses of the previous medicine. If it is ineffective, blame me. After taking another two doses as before, the pulse and symptoms both decreased by half. The man then said: I almost made a mistake. Remove the Fu Zi, prepare two more doses. The fever subsided, qi harmonized, and he recovered. However, his body remained weary and fatigued as before. After taking over twenty doses of the previous medicine, he regained strength.
Zhen An (Commentary by Zhen): This case is completely different from the previous one. Both involved fever worsening after sweating and fever persisting despite cooling measures. The former used cold purgatives repeatedly; this one used warm tonics repeatedly. Viewing them together naturally benefits the mind and intellect, and the discussion of "neither exterior nor interior" in this case serves as a standard for differentiation.
Guo Yong treated a person. In the prime of life, relying on health and neglecting self-care, he drank excessive cold wine and ate meat, contracting an external pathogen. Initially, the illness presented with cool body temperature, spontaneous diarrhea, cold extremities, continuous cold sweat on the forehead, generalized body pain, incessant groaning, inability to turn over while lying supine. However, he was not confused or delirious. Guo Yong said: The patient is very quiet, not confused or妄言 (speaking nonsense). His spontaneous sweating, spontaneous diarrhea, cold limbs, heaviness preventing movement, and body pain like being beaten are undoubtedly Yin syndromes. He was ordered to take Si Ni Tang (Frigid Extremities Decoction) and moxa applied to Guan Yuan (CV4) and San Yin Jiao (SP6). There was no response. Pill-form Jin Lian Ye Dan (Golden Liquid Elixir) was added. Diarrhea, cold extremities, and sweating stopped slightly. If medication or moxibustion was relaxed, all symptoms reappeared. Such adjustments continued for three days and nights. Although yang qi recovered, the presentation resembled a Taiyang syndrome, so medication was withheld. Waiting quietly for sweating. Two or three days later, severe irritability returned, followed by drinking water, then delirium and eruption of macules. The fever was intense, and nothing could be done. Thus, Tiao Wei Cheng Qi Tang (Regulate the Stomach and Order the Qi Decoction) was given. After defecation, profuse sweating occurred and the disease resolved. The yin and yang fluctuated repeatedly...
Zhen An (Commentary by Zhen): This case differs again from the previous two. With such repeated fluctuations of yin and yang, one certainly cannot rely on a single approach.
Xue Yi cured a person. Seventy-nine years old. In mid-winter, preparing to travel, he engaged in sexual intercourse with a young concubine, resulting in headache, fever, vertigo, panting, abundant phlegm-saliva, frequent and painful urination, dry mouth desiring drinks, prickles covering the tongue, shrinking and contracting like a lychee pit, black cracking of the lower lip, redness of face and eyes, irritability and insomnia. Occasionally feeling smoke and fire rushing up the throat, relieved slightly by drinking cold tea. He was on the verge of death. The pulse was flooding and boundless, yet forceful. His body felt burning hot to the touch. This was deficiency fire of the Kidney channel wandering on the exterior. He was administered Shi Quan Da Bu Tang (Ten-Agent Great Tonifying Decoction) combined with Liu Wei Di Huang Wan (Six-Ingredient Rehmannia Pill) and Sheng Mai San (Generate the Pulse Powder), with added Fu Zi (Prepared Aconite Root). After one dose, he slept soundly for a long time. The pulse and symptoms each decreased by three or four tenths. Then Ba Wei Wan (Eight-Ingredient Pill) was given. All symptoms retreated. He recovered after avoiding cold foods.
Zhen An (Commentary by Zhen): Sexual activity with a young concubine is the patient's private matter. Headache and fever would naturally lead one to suspect an external cold pathogen. Observing symptoms like thirst and tongue prickles, along with a flooding and forceful pulse, physicians would likely think in terms of *Wen Yi Lun* (Treatise on Warm Epidemics) or *Shang Han Zhi Ge* (Direct Grid of Cold Damage). Using Bai Hu Tang (White Tiger Decoction) or Xie Xin Tang (Drain the Epigastrium Decoctions) would surely result in death. Only Zhang Jingyue could converse with him on this level.
Zhang Jingyue said: While in Yanjing, I treated a scholar named Wang suffering from Yin-deficiency Cold Damage. He was in his thirties, but his tongue was extremely black, with prickles, dry cracks, scorched black like charcoal. He had fever, constipation, extreme thirst preferring cold drinks, yet the pulse was powerless and spirit was dull. Physicians claimed it was a Yang syndrome with Yin pulse, inevitably fatal. I observed that his form and qi had not collapsed, so I administered large doses of sweet-warm herbs to nourish water and save the root. I occasionally used cool water to moisten the branch. Water is the essence of Tianyi (Heaven One); coolness clears heat, sweetness assists yin, unlike bitter-cold herbs that damage qi. Therefore, for conditions of dry body fluids, yin-deficiency constipation, and intense heat/thirst/fire, I did not hesitate. Thus, water and medicine were administered together. In total, I used Ren Shen (Ginseng Root) and Shu Di Huang (Prepared Rehmannia Root) each for one or two jin, Fu Zi (Prepared Aconite Root) and Rou Gui (Cinnamon Bark) for several liang, and cool water for one or two dou. Gradually, symptoms receded, diet improved, and spirit/qi recovered. However, the black tongue did not diminish at all. I was very suspicious and could not find an explanation. Several days later, suddenly a black crust peeled off the tongue, revealing fresh, bright flesh inside. I realized the skin and pores were scorched and withered, dead yet revived. If not for vigorous tonification, how could rebirth be hoped for? For this type of condition, I record only the most severe examples. Beyond this, cases where black tongue was preserved using tonification are countless. Therefore, when diagnosing Cold Damage, one must use tongue color to differentiate exterior/interior and cold/heat; this must be known. Differentiating deficiency/excess solely by tongue color leads to error. Excess can cause black tongue due to fire scorching; deficiency can also cause black tongue due to water depletion. If yellow and black tongues are all assumed to be excess-heat, then deficiency-yin conditions would have zero survival rate.
Yang Chengliu treated Wu Changren. In early March, he had high fever, extreme thirst, cracked dry lips, red eyes, rosy-red cheeks, delirious speech and coma, hands cold past elbows, feet cold past knees. His tongue was black, slippery, and swollen/puffy. His pulse was flooding and empty. A physician wanted to use Bai Hu Tang (White Tiger Decoction). Yang Chengliu said: Although the body is blazing hot, he refuses to uncover; although thirsty and drinking much, he cannot tolerate cold; although face is red, it is delicate and shifting; although tongue coating is black, it is puffy, moist, and not dry. If it were Bai Hu Tang syndrome, there would never be cold limbs extending past elbows and knees, nor a flooding pulse that is boundless on superficial palpation and rootless on deep palpation. This is Ge Yang (Gridding Yang) and Dai Yang (Floating Yang). Using Bai Hu Tang would cause immediate death. Thus, a large dose of Ba Wei Wan (Eight-Ingredient Pill) with Ren Shen (Ginseng Root) was decocted thickly in several bowls, served cold. Symptoms subsided. Subsequently, Li Zhong Tang (Regulate the Middle Decoction) with Fu Zi (Prepared Aconite Root), and Liu Jun Zi Tang (Six-Gentlemen Decoction) with Dang Gui (Angelica Sinensis Root) and Bai Shao (White Peony Root) were used for several doses to regulate recovery.
He also treated Zhang Xuehai, a physician from Gui'an. Exhausted by clinical practice, he had mild chills and high fever, headache and dizziness. After several doses of dispersing herbs, his eyes became fixed, ears deaf, mouth dry, and stool blocked. Switching to fire-clearing and detoxifying agents, the fever intensified, oily sweat formed beads, delirium and grasping at empty air appeared, all ominous signs present. Yang Chengliu observed: Pulse was flooding, rapid, restless, and empty; tongue was dry, scorched yellow, and puffy. Yang said: Syndrome has truth and falsehood, judged by pulse; pulse has truth and falsehood, judged by tongue. If truly excess, the pulse must be flooding, rapid, restless, and stronger upon heavy pressure. If truly excess-fire, the tongue must be dry, scorched yellow, contracted, and firm. How can one call it excess if the pulse vanishes under heavy pressure? How can one call it excess-fire if the entire tongue is puffy and enlarged? Use Yang Ying Tang (Nourish the Ying Decoction) with Ren Shen (Ginseng Root) and Fu Zi (Prepared Aconite Root) each 3 qian. After taking it, he slept, fever subsided, tongue turned red and moist, and he recovered.
Zhen An (Commentary by Zhen): Yang stated that yin-deficiency with dryness results in a firm/tight tongue; fire-excess with scorching/blackening results in an aged/coarse tongue. It is impossible for dry/scorched/black tongue to belong to yin-deficiency/fire-excess while showing a puffy/tender tongue. This theory is strange. Having not tested it myself, I dare not easily believe it.
Li Shicai treated Han Maoyuan. After nine days of Cold Damage, he could not speak, see, move, and limbs were cold. All said it was a Yin syndrome. Li Shicai diagnosed: Six pulses were absent. Pressing the abdomen, the patient protected it with both hands, frowning in pain. Palpating the Dub Yang pulse, it was large and forceful. He realized there was dry feces. He gave Da Cheng Qi Tang (Major Order the Qi Decoction). Seven or six pieces of dry feces were passed. He could speak and move. Thus, palpating the hand but not the foot—how could one save this near-death condition?
Zhen An (Commentary by Zhen): Diagnosing the Dub Yang pulse when six pulses are absent draws from Zhang Zhongjing's own narrative. Reading books is indeed useful.
Wang Yuehuai suffered from Cold Damage until the fifth day, with incessant diarrhea, mental restlessness, and abdominal distension. Various medicines failed. Someone gave Shan Yao (Dioscorea Rhizome) and Fu Ling (Poria), fearing collapse from diarrhea. Li Shicai diagnosed: Six pulses were deep and rapid. Pressing the navel caused pain. This was協熱自利 (diarrhea accompanying heat), with accumulated dry feces inside. He gave Xiao Cheng Qi Tang (Minor Order the Qi Decoction) with doubled Da Huang (Rhubarb Root and Rhizome). Indeed, several pieces of accumulated feces were passed, diarrhea stopped, and restlessness resolved.
Scholar Wu Junming, sixth day of Cold Damage, delirious speech and manic laughter, headache with sweating, constipation, free urination. The consensus was to purge with Cheng Qi Tang. Li Shicai diagnosed the pulse as floating and large. Recalling Zhang Zhongjing: "Cold damage with no bowel movement for six or seven days, headache with fever, clear urine indicates the pathogen is not in the interior but remains in the exterior." It is now mid-winter; Gui Zhi Tang (Cinnamon Twig Decoction) is appropriate. Everyone gasped, believing delirium/manic behavior indicated Yang excess, and Gui Zhi entering the mouth would be fatal. Li said: Profuse sweating causes spirit confusion, hence delirium. Although constipated, the abdomen suffers no distress. Harmonizing Ying and Wei will lead to self-healing. Thus, defying the crowd, he used it. By night, laughter and speech ceased. The next day, bowel movement occurred spontaneously. Therefore, disease changes are manifold; one must not be rigid. Had he hesitated and used purgatives, could he have survived?
Zhen An (Commentary by Zhen): Using Cheng Qi Tang for diarrhea, and Gui Zhi Tang for delirium—these methods exist in Zhang Zhongjing's collected works. One simply needs to recognize them truly.
Lu Ziyou treated Scholar Liang. In March, composing essays led to cold exposure. After ten-plus doses of dispersing herbs, fever was high with profuse sweating, steaming like clouds/mist, one or two chi high, soaking clothes and bedding, changing ten times daily. On the fourteenth day, he was unconscious, tongue short, eyes dim, pulse floating and large beyond measure. First, warm powder was applied to the body to close sweat pores. Then, Ren Shen (Ginseng Root) 5 qian and Sheng Fu Zi (Raw Aconite Root) 3 qian were decocted and taken. He regained consciousness. Only delirious speech remained. He woke fully after seven days. A guest asked: Floating pulse indicates exterior. High fever, unconsciousness, short tongue, dim eyes indicate excess pathogen. Why did warm tonification succeed? Lu Ziyou said: In treating disease, seek the root first; do not stick to manifestations. If cold-water acts as pathogen, Heart Fire must be affected. This disease originated from mental strain and cold, precisely indicating Heart Fire insufficiency, allowing Water to insult it. This is the root. Moreover, excessive dispersing heavily damages the Heart. Once Heart fluid scatters, spirit loses mastery. Thus, Hei Fu Zi (Black Aconite) follows the color of Water to assist Fire power horizontally. Ren Shen turns back Yang qi and secures spirit. However, without first securing the exterior, there is no internal rotation/reasoning. This is my principle of sequence in treatment.
Zhen An (Commentary by Zhen): Mental strain causing cold, leading to Heart Fire insufficiency and Water insulting, is a novel argument. The treatment method is however orthodox. Saying Black Aconite follows Water's form to assist Fire's nature is rather clichéd.
Miu Zhongchun treated Zhang Hengyang, a ministry official. Suffering from Heat Disease, headache, high fever, extreme thirst with vomiting, dry nose preventing sleep. Pulse was flooding and solid. A physician said: Yangming syndrome. Should use Ge Gen Tang (Kudzu Decoction). Miu Zhongchun said: For Yangming, there are two exterior-releasing formulas: Ge Gen Tang and Bai Hu Tang (White Tiger Decoction). Without vomiting, use Ge Gen Tang to release exterior. Now vomiting is severe, indicating reversal of rising Yangming qi. Ge Gen is ascending and dispersing; using it is inappropriate. Thus, a large dose of Bai Hu Tang (White Tiger Decoction) with Mai Dong (Ophiopogon Tuber) and Zhu Ye (Bamboo Leaf) was given. The physician was shocked by the heavy dosage. Miu Zhongchun said: To defeat rebels, sixty thousand troops are needed; Li Xin with twenty thousand flees. Later, medication was taken, and by dawn, he recovered.
A servant contracted cold with fever, splitting headache, bilateral eye pain, whole-body joint pain, worse in the lower part, like knife-cutting unbearable pain. Extreme thirst, one bowel movement daily, chest/diaphragm fullness, insomnia. Already awaiting death. Miu Zhongchun said: This is Taiyang-Yangming syndrome. Poor people often labor, hence lower body pain is severe. Use Shi Gao (Gypsum Fibrosum) 1.5 liang, Mai Dong (Ophiopogon Tuber) 8 qian, Zhi Mu (Anemarrhena Rhizome) 3 qian, Gan Ge (Kudzu Root) 3 qian, Zhu Ye (Bamboo Leaf) 100 leaves to clear Yangming heat. Qiang Huo (Notopterygium Rhizome) 2.5 qian to remove Taiyang pathogen. Gua Lou Shi (Trichosanthes Fruit) half, Zhi Ke (Bitter Orange Fruit) and Jie Geng (Platycodon Root) 1 qian each to ventilate and drain lingering pathogen in chest/diaphragm.
Wang Kentang treated Yu Yunqu, Grand Secretary. Always robust in form and qi, eating and drinking double others. Suddenly in June, he suffered Heat Disease. Limbs not very hot, but intermittently tossing limbs, agitated state, confused unaware of people, occasionally speaking incomprehensible words, not delirium. Pulse was minute, fine, nearly vanished. Some said Yin syndrome suitable for warming; some said purging was needed. Decision lay with Wang Kentang. Wang said: If Yang disease shows Yin pulse, it is untreatable by law. However, his constitution is like this, plus intense summer heat external forcing, and wine/roasted food internal inflammation, fever should be burning like fire, pulse flooding/rapid/forceful. Why is it thus? Could it be heat qi stagnating unable to extend? And no bowel movement for seven days. Tentatively purge with Da Chai Hu Tang (Major Bupleurum Decoction). At that time, Da Huang (Rhubarb Root and Rhizome) was only 2 qian, and decocted thoroughly. Imperial Physician Wang Leian strongly argued it was too little. Jin Tan (Wang Kentang's pseudonym) said: With such pulse and syndrome, harsh purging is unsuitable. Wait if ineffective, then increase dose. After taking medicine, bowel movement occurred immediately, pulse emerged, hands and feet warmed. Subsequently, Huang Lian Jie Du Tang (Coptis Decoction to Resolve Toxicity) was given. After several doses, peace was restored. This is what Liu Hejian's *Shang Han Zhi Ge* refers to as accumulated heat internally severe, blocking pulse channels, causing pulse to sink/fine/nearly vanish. Generally,解毒 (resolving toxicity) combined with Cheng Qi purging is suitable. Common physicians do not know this, mistaking it for Yin-cold, often leading to danger.
Zhen An (Commentary by Zhen): The above three cases' treatments are gradually closer to modern practitioners. Probably due to the trends of the era, no need to be overly curious.
Yu Jiayan treated Xu Guozhen. Sixth/seventh day of Cold Damage, cold body, red eyes, asking for water, placing it away when brought, extreme agitation, doors/windows wide open, lying on ground, rolling uncomfortably, seeking to enter a well. A physician urgently prepared Cheng Qi for administration. Yu Jiayan diagnosed pulse: Flooding and boundless, powerless upon heavy pressure. Said: This is Yang deficiency about to collapse, false heat appearing externally, true cold inside. Seeing he wants water but does not swallow, how could he swallow Da Huang (Rhubarb Root and Rhizome) and Mang Xiao (Mirabilite)? Weather is sultry, heavy rain must follow. This syndrome will cause sudden profuse sweating, incurable. Immediately use Fu Zi (Prepared Aconite Root) and Gan Jiang (Dried Ginger) 5 qian each, Ren Shen (Ginseng Root) 3 qian, Gan Cao (Licorice Root) 2 qian, decocted and served cold. After taking, shivering and teeth chattering occurred. Covered head and body with heavy cotton. Withdrew hand, refusing pulse taking. Signs of Yang weakness became apparent. Given another dose of previous medicine, slight sweating, fever retreated, and he was safe.
Zhen An (Commentary by Zhen): This case has a flooding pulse boundless, powerless upon heavy pressure, same as Li Shicai's case of Wu Wenzai. How to distinguish from Jin Tan's case? Look at Wang's case: pulse minute/fine/nearly vanished; Yu and Li's cases: pulse floating/large/sinking/small. Yu's case has "rinsing water but not swallowing" as evidence. Wang's case involves a robust person sick in summer month after drunkenness/full meal, which is suspicious. If Xue Yuan Shi's case: pulse flooding/boundless AND forceful, tongue prickles, black lips, frequently drinking cold tea, looks entirely like Yang syndrome/Yang pulse. What supports it? Elderly age, sexual activity, panting, frequent urination.
[Appendix] Ge Kejiu treated a scholar. Contracted Cold Damage, no sweating. When Ge visited, he ran madly along the river. Ge placed him in water, kept him there for a long time, then took him out. Wrapped in heavy cotton, sweating occurred and disease resolved. Another compilation records Cheng Yuanzhang of Wuyuan. Couple loved eating turtles. A maid was ordered to slaughter a large one. Seeing its stretching and trembling, she felt pity. Untied and released it into the back pond. Pond was wide and deep. Couple furious, beat maid dozens of times. Two years later, maid suffered Heat Disease, running madly, refusing porridge/drinks, body weary/confused. Family thought incurable, carried her to thatched pavilion by pond. After midnight, suddenly felt heart opening/clearing, limbs refreshing, only body covered in wet mud/grass. Quietly watched, saw giant turtle emerge from pond, carrying water algae duckweed, covering her body completely, thus getting external coolness and internal refreshment. Dawn came, suddenly recovered. Entered room, detailed the event. Cheng couple moved, stopped eating turtles. Hong Zuolin Mengbi said: For extreme Heat syndromes suddenly unresolvable, drawing new well water, soaking green cloth, and alternating ironing is wonderful. Did not expect subtle aquatic creatures to know this either. This is [merit of] releasing life...
Zhen An (Commentary by Zhen): These two anecdotes are entirely like novels. Yet they can broaden knowledge, making one realize principles are infinite. Do not stick rigidly. But placing someone in water is ultimately absurd. If encountering Xu Guozhen who sought to enter a well, wouldn't he have been killed?
Yu Jiayan treated Lu Pingshu. Normally weak qi and timid, sallow complexion, suitable for warm tonification, not cold/cooling. Autumn month, accidentally suffered San Nü (Triplet Malaria). Early Winter, re-contracted external cold, thus frequent chills and fever. Physicians thought it was deficiency-pathogen post-malaria, not knowing it was newly acquired excess-pathogen. Administered Shen Zhu (Ginseng/Atractylodes) tonics, leading to near-death state, lingering two months, dull and silent, family already prepared coffin. Yu Jiayan (Western Chang) diagnosed: Pulse wiry, floating, large, shortness of breath, dry nose, no sweating,嗜卧 (desire to sleep), whole body and face yellow. Matches Yangming Wind-Strike clause, passing beyond the stage for twenty-plus days unresolved, exactly same example. Just not to the extent of no urination, abdominal fullness, and hiccups. Western Chang thought pulse not severely damaged, nine parts treatable. But muscle/tendon pulling constantly, fear limbs become flaccid/useless. My current method treats both. However, Zhang Zhongjing only has Da Chai Hu Tang (Major Bupleurum Decoction) for simultaneous releasing exterior/interior, no method for treating flaccidity. Thus, using Fang Feng Tong Sheng San (Wind-Barrier Unblocking Powder) as established formula, reducing Bai Zhu (Atractylodes Macrocephala Rhizome), taking Jing Jie (Schizonepeta Spike), Fang Feng (Saposhnikovia Root), Ma Huang (Ephedra Stem), Bo He (Mint Herb), Jie Geng (Platycodon Root) as exterior herbs. Xiao (Niter), Huang (Rhubarb), Qin (Scutellaria Root), Qiao (Barberry Fruit), Zhi (Gardenia Fruit), Gao (Lodestone), Hua Shi (Talcum) as interior herbs. Originally similar to Da Chai Hu system. Contains Xiong (Chuanxiong Rhizome), Gui (Angelica Sinensis Root), Shao (White Peony Root), precisely capable of leading various herbs deep into blood level to unblock meridians. Reducing Bai Zhu because previously used it causing error, cannot err again. That night took two doses continuously. First dose felt comfortable. Second dose bowel movement started. Shortly fell asleep, body had gentle sweating. Next morning re-diagnosed, muscle/tendon no longer pulling. But Yangming Stomach pulse, flooding/large increased. Immediately used large dose Bai Hu Tang (White Tiger Decoction), adding Chai Hu (Bupleurum Root), Hua Fen (Trichosanthes Root), Qin (Scutellaria Root), Bai (Phellodendron Bark), Lian Qiao (Forsythia Fruit), Zhi Zi (Gardenia Fruit), a batch of bitter-cold herbs. Took continuously over ten doses. Tongue finally stopped sucking/protruding towards lips. Spirit gradually cleared. Porridge/drinks gradually increased. After half a month, sat on bed. After one month, walked on ground. Slightly overate, then abdominal pain and diarrhea, resembling deficiency syndrome. Western Chang did not look back. Only in moving-stagnation herbs, added Chai Hu (Bupleurum Root) and Gui Zhi (Cinnamon Twig) to ascend/disperse remaining pathogen, preventing downward slipping into dysentery to exhaust. Then switched to Yu Zhu (Polygonatum Odoratum Rhizome), Er Dong (Tian Dong/Ophiopogon Tuber and Mai Dong/Ophiopogon Tuber), slightly harmonizing Stomach qi, occasionally using Ren Shen (Ginseng Root), not exceeding 5 fen. Because this syndrome's external pathogen was not in Taiyang but in Yangming, therefore not only