孙兆治一姜姓酒家。病久将绝。腹满。不省人事。遍身皆润。两足冷至膝下。诊之。六
脉皆小弱而急。问其所服药。皆阴病药也。孙曰。此非受病重。药能重病耳。遂用五苓散利
小便而腹减。白虎汤解邪热而病愈。盖病本伤暑。始则阳微厥而脉小无力。众医遽以阴证治
其病愈厥。不知阴证胫冷。两臂亦冷。今胫冷臂不冷。则非下厥上行。所以知是阳微厥也
震按孙公辨证诚妙。然胫冷臂亦冷尚非阴证之确据。须视其冷之微甚。再合兼见之证以
参之。此条因不省人事。难问所苦。姑就阳微厥为辨耳。又有疑者。斯人多服阴病药。何以
不死。既曰暑湿。何以不用桂苓甘露饮。而先用五苓散。五苓有肉桂。与阴病药亦不甚相远
谅系暑证夹阴。前医未为大谬。
滑伯仁治临安沈君彰。自汗如雨不止。面赤身热。口燥心烦。居楼中。当盛暑。帷幕周
密。自云至虚亡阳。服术、附药已数剂。伯仁诊其脉。虚而洪数。视其舌上胎黄。曰。前药
误矣。轻病重治。医者死之。素问曰。必先岁气。毋伐天和。术附之热。其可轻用以犯时
令耶。又曰。脉虚身热。得之伤暑。暑家本多汗。加以刚剂。脉洪数则病益甚。悉令撤幔开
窗。初亦难之。少顷。渐觉清爽。为制黄连人参白虎等汤。三进而汗止大半。诸证稍解。又
兼以既济汤。渴用冰水调天水散。服七日而病悉去。后遍身发疡疹。更服防风通圣散。乃已
朱丹溪治徐三官人。年五十余。六月间。发热大汗。恶寒战栗。不自禁持。且烦渴。朱
曰。此暑病。脉之。皆虚微细弱而数。其人好赌。致劳而虚。遂以人参竹叶汤调四苓散。八
震合三案参之。知暑脉必虚必数。虚者暑伤气也。数者暑为热也。但有细与洪之不同。
孙案之小弱而急。急亦数也。数主热。又主虚。故暑病宜凉宜补者多。宜温者诚少。下条之
脉细数而实。指为热药伤血。见解更上一层。
项彦章治一人病甚。医皆以为瘵。束手矣。项诊之。脉细数而实。细数者暑也。暑伤气
脉宜虚。今不虚而反实。乃热伤血。药为之也。以白虎饮之。即瘥。
吴茭山治一妇。冬月洒洒恶寒。翕翕发热。恶食干呕。大便欲去不去。诸医皆以虚弱痰
饮治之。用二神补心等药不效。延及半月。吴诊其脉。虚而无力。类乎伤暑。众不然之。究
问病因。妇曰。因天寒换着绵衣。取绵套一床盖之。须臾烦渴。寒热呕吐。绵延至今耳。吴
曰。诚哉伤暑也。盖绵套晒之盛暑。夹热收入笥中。必有暑气尚未开泄。体虚者得之易入。
故病如是。妇曰然。遂制黄连香薷饮。连进二服而愈。
震按此说殊未可信。绵套久收笥中。暑气能有几何。顿令寒热呕吐。烦渴绵延不愈耶。
但脉虚无力。用黄连香薷饮而愈。则诚暑矣。留之作疑案以待试。
汪石山治一儿。年十余岁。色白神怯。七月间。发热连日。父令就学。内外俱劳。循至
热炽。头痛吐泻食少。其父知医。乃进理中汤。吐泻少止。渐次眼合。咽哑不言。昏昧不省
人事。粥饮有碍。手常 住阴囊。为灸百会尾 。不应。其父来问。汪曰。儿本气怯。又兼
暑月过劳。经云。劳则气耗。又云。劳倦伤脾。虽在暑月。乃内伤证耳。身热者。经云阳气
者。烦劳则张。盖为气本阳和。劳则阳和之气变为邪热矣。头痛者。经云诸阳皆会于头。今
阳气亢极。则邪热熏蒸于头而作痛也。吐泻者。脾胃之清气不升。浊气不降也。目闭者。盖
诸脉皆属于目。而眼眶又脾所主。脾伤不能荣养诸脉。故眼闭而不开也。咽哑者。盖脾之络
连舌本。散舌下。脾伤则络失养。故不能言也。经云。脾胃者。水谷之海。五脏皆禀气
于脾。脾虚则五脏皆失所养。故肺之咽嗌为之不利而食难咽。心之神明为之昏瞀而不知人。
常欲手 阴囊者。盖无病之人。阴升阳降。一有所伤。则升者降。降者升。经云。阴阳反作
是也。是以阴升者反降。从其类而入厥阴之囊。阴多阳少。故手欲 之也。此皆脾胃之病。
经谓土极似木。亢则害。承乃制也。证似风木。乃虚象耳。不治脾胃之虚。而治肝木之风。
欲求活难矣。且用参、 三钱。附子一钱。灌半杯。病无进退。连服三日。神稍清。目稍开
如有生意。食仍难咽。汪诊之。脉皆浮缓。不及四至。汪曰。药病相宜。可去附子再服。
渐渐稍苏。初医或作风热。而用荆、防、芩、连之类。或作惊证。而用牛黄、朱砂之类。此
皆损胃之物。岂可轻投。儿今得生幸耳。实赖其父之知医也。
震按发热连日。仍令就学。似乎不避风暑。再感外邪。以致热炽头痛吐泻。及进理中汤
吐泻少止。渐次眼合咽哑。昏昧不言。人必认为受邪既重。误用温补。邪陷难解。则用荆
防、芩、连及至宝丹、牛黄丸。皆意中事也。用之而死。仍归咎于理中。冤枉谁辨。石山
独从平素之色白神怯。病中之内外俱劳起见。作内伤虚证治。其议论皆有精义。至阳和之气
变为邪热。及阴阳反作等训。学人书诸绅可也。
江应宿治其岳母。年六十余。六月中旬。劳倦中暑。身热如火。口渴饮冷。头痛如破。
脉虚豁。二三至一止。投人参白虎汤三帖。渴止热退。惟头痛。用白萝卜汁吹入鼻中。良愈
又治孙子华赴试南都。六月初旬。梦遗。畏寒惊惧。重裘浓被。取汗过多。身热。六脉
滑数无力。与清暑益气汤。次日舌强。语言不清如癫。目瞪不识人。江曰。此为暑风。与人
参白虎汤加胆星、僵蚕、秦艽、天麻、竹沥、姜汁、渐愈。数日后。舌心黑如墨。与黄连解
毒汤、凉膈散。不退。与犀角地黄汤而愈。
又一人瘦长而脆。暑月过劳。饥饮烧酒。遂身热汗出。昏懵语乱。江视之。脉皆浮小而
缓。按之虚豁。曰。暑伤心。劳伤脾也。盖心藏神。脾藏意。二脏俱伤。宜有是证。法宜清
暑益脾。用八物汤加麦冬、山栀、陈皮。十余帖而愈。
震按江公三案。平正可法。其第二案解毒凉膈不应。换犀角地黄汤始愈。又知同一凉药
亦有对与不对之别。
张路玉治金鲁公。触热劳形。醉饱不谨后受凉。遂发热头痛。胀满喘逆。大汗如蒸。面
赤戴阳。足冷阳缩。脉弦数无力。曰。此伤暑夹食而复夹阴也。与大顺散一服。不应。转胀
急不安。因与枳实理中加浓朴、大黄。是夜更衣二次。身凉足暖而痊。
震按此案于不谨后受凉。及戴阳阳缩足冷汗多且喘。最易认作阴证。其辨在发热头痛胀
满与阴证不合。要知不谨之前。尚有醉饱之病因也。大顺散不应。转加胀满。病情易辨矣。
更衣二次而痊。设误服白通四逆奈何。
又按张洁古云。动而得之者。为中 。为阳证。静而得之者。为中暑。为阴证。以暑
二字析作两项。殊属不然。夫夏之暑 。犹冬之寒冷也。指 为阳。指暑为阴。亦将派冷作
阳。派寒作阴耶。内经曰。先夏至日者为病温。后夏至日者为病暑。明以时令别其病名耳。
病暑之有阴有阳。一如伤寒之有阴有阳。大顺散、冷香饮子之类。实为纳凉食冷。因避暑而
受寒。固暑月之阴证也。非中暑也。所以罗谦甫治参政商公泄泻、完颜小将军斑衄二案。俱
用热药。俱不名之曰中暑。吴球治暑月远行之人。直曰中寒。恐后世误以热药治暑。乃举
病因以称之。诚为名正而言顺。故以动静分阴阳则可。以暑 分阴阳则不可。惟以脉证辨阴
阳。斯可矣。近阅临证指南。每用滑石、芦根、通草、白蔻、杏仁等药。以暑气从鼻吸入。
必先犯肺。故用轻清之药。专治上焦。其西瓜翠衣、鲜荷叶、及荷叶边汁、鲜莲子、绿豆皮
丝瓜叶、银花露、竹叶心等。皆取轻清以解暑邪之上蒙空窍。不犯中下二焦。殊有巧思。
盖暑病必究三焦。非比伤寒温病矣。若来复丹、大顺散。案中偶一见之。又足征暑天阳证居
多。阴证原少耳。
Yu Zhen's compilation "Gu Jin Yi An An" (Record of Medical Cases Ancient and Modern, Annotated), section on "Summerheat" (Shu Bing):
Sun Zhao treated a tavern keeper surnamed Jiang. The patient had been ill for a long time and was near death. His abdomen was distended, he was unconscious, and his skin was moist all over. His feet were cold down to the knees. Upon palpation, the pulses in all six positions were small, weak, and rapid. When asked about previous medications, it was found that they were all medicines for treating Yin syndromes. Sun Zhao said, "This is not due to the severity of the pathogen, but rather the medication has aggravated the condition." He then used Wu Ling San (Five-Ingredient Powder with Poria) to promote urination, which reduced abdominal distension, followed by Bai Hu Tang (White Tiger Decoction) to clear pathogenic heat, leading to recovery. The root cause was injury from summerheat; initially, Yang Qi was weak causing cold limbs and a small, forceless pulse. The physicians hastily treated it as a Yin syndrome, worsening the cold limbs. They failed to realize that in Yin syndromes, both the lower legs and arms are cold. Here, only the lower legs were cold while the arms were not, indicating this was not "cold extremities rising from below" (a sign of severe Yin cold or Yang collapse), but rather cold limbs due to weak Yang Qi.
Yu Zhen's commentary: Master Sun's differentiation is indeed exquisite. However, coldness in the lower legs accompanied by coldness in the arms is not definitive proof of a Yin syndrome; one must observe the degree of coldness and combine it with accompanying symptoms for analysis. In this case, because the patient was unconscious and unable to describe his suffering, differentiation was tentatively based on cold limbs due to weak Yang Qi. Another doubt arises: why did the patient not die after taking so many Yin-syndrome medicines? Since it was summerheat-dampness, why was Gui Ling Gan Lu Yin (Cassia Twig, Atractylodes Macrocephala, Polyporus, Alisma, Angelica Dahurica, and Licorice Decoction) not used initially, but rather Wu Ling San? Wu Ling San contains Rou Gui (Cinnamon Bark), which is not far from medicines for Yin syndromes. It is likely that the summerheat syndrome was complicated by internal Yin-cold, so the previous physician was not entirely mistaken.
Hua Bolin (Bo Ren) treated Shen Junzhang of Lin'an. The patient suffered from profuse sweating like rain, red face, body heat, dry mouth, and irritability. He lived upstairs during midsummer with curtains drawn tightly around him. He claimed to be extremely deficient with Yang Qi escaping, having already taken several doses of Zhu (Atractylodes) and Fu Zi (Aconite). Bo Ren palpated his pulse, finding it empty, large, surging, and rapid. Observing yellow coating on his tongue, he said, "The previous treatment was erroneous. Treating a mild disease severely kills the patient. The *Su Wen* states: 'First ascertain the seasonal climate, do not violate the harmony of Heaven and Humanity.' The heat of Zhu and Fu Zi—how could it be lightly used to offend the season?" He further stated, "Empty pulse with body heat results from summerheat injury. Summerheat patients naturally sweat; adding harsh hot agents makes the surging, rapid pulse indicate worsening disease." He ordered the curtains removed and windows opened. Initially reluctant, the patient soon felt refreshed. He prescribed Huang Lian Ren Shen Bai Hu Tang (Coptis, Ginseng, and White Tiger Decoction). After three doses, sweating stopped significantly, and other symptoms alleviated. He also used Ji Ji Tang (Jiao Tai Wan variation or similar balancing formula), and for thirst, administered Tian Shui San (Tianshui Powder) mixed with ice water. After seven days, the illness completely resolved. Later, ulcers and rashes appeared on the body; he took Fang Feng Tong Sheng San (Saposhnikovia and Magnolia Bark Powder) until they ceased.
Zhu Danxi treated Official Xu San. Over fifty years old. In June, he had fever, profuse sweating, aversion to cold with shivering, uncontrollable trembling, irritability, and thirst. Zhu said, "This is a summerheat disease." Palpation revealed pulses that were all empty, minute, fine, weak, and rapid. The man liked gambling, leading to exhaustion and deficiency. Zhu prescribed Ren Shen Zhu Ye Tang (Ginseng and Bamboo Leaf Decoction) to regulate Si Ling San (Four-Poria Powder).
Comparing these three cases, we know that summerheat pulses are necessarily empty and rapid. Emptiness indicates summerheat damaging Qi; rapidity indicates summerheat is Heat. However, pulses may differ between fine and surging. In Sun's case, the pulse was small, weak, and rapid ("rapid" implies "quick/rapid"). Rapidity governs Heat and also Deficiency. Thus, summerheat diseases often require cooling and tonifying methods, rarely warming ones. In the following case, the pulse was fine, rapid, and full/excess, attributed to hot medicines damaging Blood, showing a higher level of insight.
Xiang Yanzhang treated a man who was very ill; doctors considered it consumption (TB-like wasting disease) and gave up. Xiang palpated, finding the pulse fine, rapid, and full/excess. Fine and rapid indicate summerheat; summerheat damages Qi, so the pulse should be empty. Now it is not empty but full/excess, indicating Heat damaged Blood, caused by medication. He treated him with Bai Hu Yin (White Tiger Drink), and he recovered immediately.
Wu Jiaoshan treated a woman. In winter, she had chills, low-grade fever, anorexia, dry retching, and difficulty defecating. Doctors treated her as deficiency-phlegm-fluid retention using Er Shen Bu Xin etc., without effect. Half a month later, Wu palpated her pulse: empty and forceless, resembling summerheat injury. Others disagreed. Upon inquiry, she said, "Due to cold weather, I changed into cotton clothes and covered myself with a cotton quilt. Soon after, I felt irritable thirst, alternating chills and fever, vomiting. This has persisted since." Wu said, "Indeed, it is summerheat injury. That cotton quilt was sun-dried in midsummer, folded with heat trapped inside, retaining summerheat qi. Those with weak constitutions easily absorb it, hence the illness." She agreed. He prescribed Huang Lian Xiang Ru Yin (Coptis and Elsholtzia Decoction). Two consecutive doses cured her.
Yu Zhen's commentary: This explanation is highly questionable. A cotton quilt stored for a long time cannot retain much summerheat qi to suddenly cause chills, fever, vomiting, and persistent irritability/thirst. However, given the empty-forceless pulse and cure with Huang Lian Xiang Ru Yin, it was indeed summerheat. I leave this as a doubtful case for verification.
Wang Shishan treated a boy, over ten years old, pale complexion, timid spirit. In July, he had continuous fever for days. His father made him attend school, causing both external and internal exertion, leading to intense heat, headache, vomiting/diarrhea, and poor appetite. His father knew medicine and administered Li Zhong Tang (Regulate the Middle Decoction). Vomiting/diarrhea slightly stopped, but gradually his eyes closed, voice became hoarse, he spoke no more, became comatose/unconscious, and had difficulty swallowing food/drink. His hands constantly pulled at his scrotum. Moxibustion at Baihui and Weizhong/Weiyang points failed. The father consulted Wang. Wang said, "The child has inherent Qi deficiency, compounded by overexertion in summer. The *Classic* says: 'Exhaustion depletes Qi,' and 'Laborious fatigue injures the Spleen.' Although in summer, this is an Internal Injury syndrome. Body heat: The *Classic* says, 'Yang Qi, when subjected to excessive labor, expands/blooms.' This is because normal Qi is harmonious Yang; labor transforms this harmonious Yang into pathogenic Heat. Headache: The *Classic* says, 'All Yang meridians converge at the head.' Now Yang is hyperactive, so pathogenic Heat steams the head causing pain. Vomiting/diarrhea: Spleen/Stomach Clear Yang fails to ascend, Turbid Yin fails to descend. Eyes closed: All meridians connect to the eyes, and eye sockets are governed by the Spleen. Spleen injury fails to nourish meridians, so eyes close and stay shut. Hoarse voice: Spleen collaterals connect to the root of the tongue and spread under it. Spleen injury causes collateral malnourishment, preventing speech. The *Classic* says, 'Spleen and Stomach are the Sea of Water and Grain; all Five Zang organs derive Qi from the Spleen.' Spleen deficiency causes all Five Zang to lose nourishment. Thus, Lung's throat becomes obstructed making swallowing difficult; Heart's Spirit becomes confused causing unconsciousness. Pulling at scrotum: Normally, Yin ascends and Yang descends. Injury causes reversal: ascending becomes descending, descending becomes ascending. The *Classic* calls this 'Yin and Yang reverse their functions.' Thus, Yin ascends but instead descends, entering the Jueyin Liver meridian's domain (scrotum). Yin is abundant, Yang scarce, hence the desire to pull it. These are all Spleen/Stomach disorders. The *Classic* states 'Earth extreme resembles Wood; Hyperactivity brings disaster, Restraint brings control.' Symptoms resemble Wind-Wood pathology, but are actually deficiency images. If one does not treat Spleen/Stomach deficiency but treats Liver-Wind, survival is difficult." He used Ren Shen (Ginseng) 3 qian, Fu Zi (Aconite) 1 qian, infused half a cup. No change. Continued for three days; consciousness slightly cleared, eyes slightly opened, showing signs of life, but swallowing remained difficult. Wang palpated: pulses floating, slow, less than four beats per breath. Wang said, "Medicine matches the disease; remove Fu Zi and continue." Gradually revived. Initial doctors treated as Wind-Heat (using Jing Jie, Fang Feng, Huang Qin, Huang Lian) or Shock/Fright (using Niu Huang, Zhu Sha). These damage Stomach Qi; how could they be lightly administered? The child survived thanks to his father's medical knowledge.
Yu Zhen's commentary: Fever for days yet still sent to school suggests exposure to wind/summerheat, re-injuring with external pathogens, leading to intense heat, headache, vomiting/diarrhea. After Li Zhong Tang, symptoms improved slightly, then eyes closed, voice hoarse, coma. People would assume severe pathogen invasion worsened by warm-tonics, leading to use of Jing Jie, Fang Feng, Huang Qin, Huang Lian, Zhi Bao Dan, Niu Huang Wan. Death would follow, blamed on Li Zhong Tang, creating injustice. Wang Shishan alone focused on the pale/timid constitution and internal/external exertion, treating as Internal Injury Deficiency. His arguments have profound meaning. Concepts like "harmonious Yang transforming into pathogenic Heat" and "Yin/Yang reversal" should be memorized by students.
Jiang Yingsu treated his mother-in-law, over sixty. Mid-June, exhausted and struck by summerheat. Body hot as fire, thirsty for cold drinks, headache like splitting. Pulse empty and wide, skipping every 2-3 beats. Administered Ren Shen Bai Hu Tang (Ginseng and White Tiger Decoction) for three doses. Thirst stopped, heat subsided, only headache remained. Treated with radish juice insufflated into nose, cured well.
Also treated Sun Zihua going to Nanjing for exams. Early June, nocturnal emission, aversion to cold, fear, wearing heavy furs/quilts, excessive sweating, body heat. Six pulses slippery, rapid, forceless. Prescribed Qing Shu Yi Qi Tang (Clear Summerheat and Tonify Qi Decoction). Next day, stiff tongue, incoherent speech like madness, staring blankly, unrecognized people. Jiang said, "This is Summerheat Wind." Gave Ren Shen Bai Hu Tang plus Dan Nan Xing (Arisaema cum Bile), Jiang Can (Silkworm), Qin Jiao (Gentiana Macrophylla), Tian Ma (Gastrodia), Zhu Li (Bamboo Sap), Jiang Zhi (Ginger Juice). Gradually improved. Days later, center of tongue black as ink. Given Huang Lian Jie Du Tang (Coptis Detoxification Decoction), Liang Ge San (Cool the Chest Powder), no improvement. Given Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction), cured.
Another case: Thin, tall, fragile man. Overworked in summer, drank strong liquor while hungry. Resulted in body heat, sweating, confusion, delirium. Jiang saw pulses floating, small, slow, empty upon pressure. Said, "Summerheat injured Heart, Labor injured Spleen. Heart stores Spirit, Spleen stores Intent. Both organs injured, thus these symptoms. Method: Clear summerheat, benefit Spleen. Used Ba Wu Tang (Eight-Agent Decoction) plus Mai Dong (Ophiopogon), Shan Zhi (Gardenia), Chen Pi (Tangerine Peel). Over ten doses, cured."
Yu Zhen's commentary: Jiang's three cases are standard and instructive. In the second case, detoxification and cooling chest formulas failed; switching to Xi Jiao Di Huang Tang worked. This shows even cooling herbs must be correctly matched.
Zhang Luyu treated Jin Lugong. Exposed to heat and labor, careless after drinking/eating, caught cold. Resulted in fever, headache, distension, wheezing/reversal of Qi, profuse sweating like steam, red face (floating Yang), cold feet, retracted genitals. Pulse wiry, rapid, forceless. Said, "This is Summerheat injury with Food Retention complicated by Yin-Cold." Gave Da Shun San (Great Smooth Powder) once, no response. Distension and anxiety increased. Then gave Zhi Shi Li Zhong Jia Hou Po Da Huang Tang (Immature Bitter Orange, Regulate the Middle plus Magnolia Bark and Rhubarb Decoction). Defecated twice that night, body cooled, feet warmed, recovered.
Yu Zhen's commentary: This case, with coldness after carelessness, floating Yang, retracted genitals, cold feet, profuse sweat, and wheezing, is easily mistaken for Yin syndrome. Differentiation lies in fever, headache, distension, incompatible with pure Yin syndrome. Remember the prior cause: drinking/eating before catching cold. Da Shun San failed, distension worsened, making diagnosis clearer. Recovery after two bowel movements; what if Bai Tong Tang or Si Ni Tang (Yin-cold warming formulas) were mistakenly used?
Furthermore: Zhang Jiegu said, "Active acquisition is Zhong Yue (Severe Summerheat), a Yang syndrome. Passive acquisition is Zhong Shu (Mild Summerheat/Cooling), a Yin syndrome." Splitting "Shu" into two categories is incorrect. Summerheat in summer is like Cold in winter. To call Yue Yang and Shu Yin is like classifying Cold as Yang and Chill as Yin. The *Nei Jing* states: "Before Summer Solstice, diseases are Warm; after Summer Solstice, diseases are Summerheat." This distinguishes names by season. Summerheat diseases have Yin and Yang aspects, just as Cold Damage does. Da Shun San, Leng Xiang Yin Zi, etc., are for cooling off and eating cold things, catching cold while avoiding heat; they are Yin syndromes of summer, not true Summerheat injury. Thus, Luo Qianfu treated Shang Gong's diarrhea and Wanyan Xiao Jiangjun's petechiae/epistaxis with hot medicines, never calling them Summerheat. Wu Qiu treated travelers in summer as "Cold Strike," fearing later generations might misuse hot medicines for summerheat, citing etiology for correct naming. Therefore, distinguishing Yin/Yang by activity/rest is acceptable; distinguishing by "Shu" vs "Yue" is not. Only differentiating Yin/Yang via pulse and symptoms is valid. Recently reading *Lin Zheng Zhi Nan*, frequent use of Shi Hui, Lu Gen, Tong Cao, Bai Kou, Xing Ren assumes summerheat enters via nose, first affecting Lung, thus using light/clear drugs for Upper Jiao. Watermelon rind, fresh lotus leaf/juice, fresh lotus seeds, mung bean skin, luffa leaf, honeysuckle dew, bamboo leaf heart all use light/clear properties to resolve summerheat clouding orifices, sparing Middle/Lower Jiao. Clever thinking. Summerheat diseases must investigate the Three Jiao, unlike Cold Damage or Warm Diseases. Occasional appearance of Lai Fu Dan, Da Shun San in cases proves Yang syndromes dominate summer, Yin syndromes are rare.