(一)关于脉象与舌质的研究强临床体会从幼年背诵《濒湖脉学》时，就曾反复琢磨过脉象与病变的关系。人体是一个统一的整体，五脏六腑的功能活动都可影响气血的运行，因之五脏六腑的病变都能够而且应该从脉象上反映出来。所以脉诊在临床诊断上有重要意义。但不同脏腑的布同疾病对脉象的影响，如何通过现代科学的方法，用仪器和数据确切地反映出来，作为诊断的客观依据，是我们梦寐以求的。
我在临床实践中发现，虽地有方土之剐，人有男女老幼之分，但患病之病位所反映到脉象上的深浅恰与人体卫、气、营、血的层次相应。因之，切脉应有浮、中、按、沉之别，且能分别诊在卫、气、营、血部位之病。我根据多年的临床体会认为，抓住了主脉与兼脉，用浮、中、按、沉确定病位深浅层次的脉诊方法，再参照其它三诊，以确定治法方药，取得较满意的临床效果，因之对脉学的认识就有新的提高(我有《临床脉诊》一书待出)。
关于舌诊著述不太多，《内经》、《伤寒论》中论述较少，自清代温病学家提出「辨舌验齿」后，舌诊遂被重视起来。舌苔多反映功能，即卫，气部位的病变』舌质多反映实质，即营血部位的病变。但我在临床中发现，一些心烦急躁内有郁热的病人，其舌面淡而苔自，其脉弦细急数。粗心之人，一见舌淡苔白，即认为是「虚」，便用温补，致使病情增重。因苔布于舌面，素体阴分不足之人，舌瘦小，其舌质之红为白苔所掩盖，因内有热，舌面虽淡，若让病人将舌翘起，舌之背面见红或深红，甚或红绛。在通常情况下，咏、证、舌应是统一的。通过临床，我觉得舌质看其背面更为确切实在，不会被表面现象所迷惑。这对临床诊断，特别对于温病临床有重要参考价值(我已写好《临床舌诊》待出)。
(二)对「在卫汗之可也」的认识关于温病卫分病的治法，叶天士谓：「在卫汗之可也。」一般认为就是「汗法」，或「辛凉发汗」、「辛凉解表」。而我在教学过程中认为「辛凉清解」的提法更为确切，并强调指出「汗之」并非「汗法」，也是从临床实践中总结出来的。
考吴鞠通《温病条辨》治疗卫分证(上焦)时列辛凉轻剂、辛凉平剂，通书并无「解表」、「发汗」字样，且谆谆告诫：「温病忌汗，汗之不惟不解，反生他患。」因温病「自口鼻吸受而生，徒发其表亦无益也，且汗为心液，心阳受伤，必有神明内乱，谵语癫狂，内闭外脱之变。」又因「汗法」伤阴助热，吴氏谓「温病最善伤阴，用药又复伤阴，岂非为贼立帜乎?」温病初起，为温邪犯肺，肺气贲郁，卫阳之气宣发受阻，；H气壅滞郁而发热。病在肺卫，虽属轻浅，但其津已轻度受伤，故有「口微渴」之见证。此与伤寒之风寒外束，卫阳受伤，迥然不同。其治法，太阳伤寒，宜辛温发汗，而温病卫分证，叶天士认为其治法「与伤寒大异也」，因之「汗之」绝非「汗法」。
温病卫分证属「郁热」，《素问·六元正纪大论》日；「火郁发之。」王冰注之日：「发，谓汗之令其疏散也。」柳宝诒则进一步论述说：「暴感风温，其邪专在于肺，以辛凉清散为主，热重者兼甘寒清化。」①均不认为是「汗法」。先父对此曾解释说：「外感风寒是为表闭，内热温邪是温从口鼻而入，其病在卫。在表宜解表，在卫当疏卫，如房中热郁，必须打开门窗，以令气流则热退矣。」所以卫分证之「汗之」，实为辛凉清解之法。辛可开郁，凉能清热。郁开热清卫必疏，邪去则三焦通畅，营卫调和，津液得布，故表清里和微汗而愈。此不用发汗之法而达到了汗出的目的，即「汗之」之意。
《温病条辨》银翘散方，在大队清凉药中辛温者仅豆豉、荆芥穗二味，且用量很轻，绝非发汗之意。
其作用有二；其一，是开郁，卫分郁热，邪在上焦，豆豉、荆芥辛温开郁，宣畅肺卫。其二，凉虽能清热，但一派寒凉则易使气机涩滞不流，故少佐辛温，以制其弊，仅取之味，断无温燥之性，合称辛凉平剂，实为开郁清热，并无发汗之意，绝非「汗法」。
「汗之」并非「汗法」之论，其理论根据是温病与伤寒的病因病机不同，这并非文字游戏，因为临床上有重要意义。首先明确指出了治疗卫分温病，不可用辛温发汗，也不能用一派寒凉之法。过用辛温则伤阴助热，发为昏厥之变；一派寒凉，则郁不能开而热不易清，闭塞气机也会使病情加重。必须辛温与寒凉相配始成辛凉之剂。在卫分证中，因「热」与「郁?又有轻重之不同，所以「寒凉」与「辛温」的配伍也要有一定的比例。一般来说，热重郁轻者，以寒凉为主，少佐辛温；郁重热轻者，则以辛温为主，佐以寒凉。只要比例恰当，就能使郁开热清，达到表里清和，营卫调和，三焦通畅，微微汗出而愈。这一认识避免了误治，并指出了组方原则和用药根据。
(三)对「入营犹可透热转气」的认识温病邪入营分，病情深重，一般常用「清营汤」、「清官汤」及
「三宝」，并云此即「透营转气」之法，对何谓「透热转气」，并无明确论述。通过临床实践，我认识到营分具有营热、阴伤、气机不畅三个特点。对于前两个特点，叶天士曾明确指出：「营分受热则血液受劫。」「血液受劫」，即营阴为热邪所伤。因「营气者泌其津液，注之于脉，化以为血」且「循脉上下，贯五脏而络六腑」。所以热邪入营，必伤其营阴，清营、养阴则是治疗营分证的根本方法。
营分证的类型是复杂的，且除营热阴伤外，还常兼有痰热、湿阻、瘀血、食滞、腑实等，都会阻滞气机，使营热外达之路不通，已入营之热不能外透。所以治疗营分证，除清营养阴外还要宣通气机，畅营热外达之路，以「透热转气」。
考《吴医汇讲》中搜集叶天士「温证论治」，原作：「乍入营分，犹可透热，仍转气分而解。」后世据此，多认为初入营分才能透热转气，而王孟英将其收入《温热经纬》，改为「入营犹可透热转气」，则把透热转气的应用范围扩大到整个营分。但一般仍根据清营汤中银花、连翘、竹叶三味药都有透热转气的作用，便认为此三味药才是透热转气的专药。这样，就把透热转气局限于初入营分和用银花、连翘、竹叶三味药的范围内，忽视了其在营分证治中的普遍意义。
清营汤方出《温病条辨》，吴氏自注云其「清宫中之热而保离中之虚也」，并未论及透热转气。仔细研究叶氏对营分证治的论述和《临证指南医案》，对营分证的治疗都体现了「透热转气」的方法。如叶氏说「从风热入营者，用犀角、竹叶之屑」}「从湿热入营者，则以犀角花露之品」。其由风热入营者，除营热阴伤外，尚有「风热阻滞气机，使营热不能外透，故以竹叶清风热而宣郁以畅气机，从湿热入营者，则为湿热阻滞气机，故以花露芳香化湿，清热开郁，以疏通气机，使营热外透。「若加烦躁，大便不通者」，则加金汁，对「老年或平素有寒者」，则以人中黄代替金汁，清泄热毒，宣畅气机，导营热外达。
「斑出热不解者」，为气血两燔，热邪消灼胃阴，应以石膏、知母等急撒气热，导营热外达。
「舌绛而鲜泽者」，为热陷心包之轻证，治以「犀角、鲜生地、连翘、郁金、石菖蒲等」，即以菖蒲、郁金清心开窍通闭，连翘轻清宣透，合以宣畅气机，导营热外达。「若乎素心虚有痰，外热一陷，里络就闽」，则「非菖蒲、郁金所能开」，必须用「牛黄丸、至宝丹之类以开其闭」，始能使营热外透。舌绎而中心干者」，为心胃火燔，应以黄连、石膏等清气分热以透热转气。
若「素有瘀伤宿血在胸膈中』，阻滞气机而邪热入营者，则应以「散血之品如琥珀、桃仁、丹皮等」，活血散瘀通络，排除阻碍，宣通气机，导营热外达。
热邪入营而「挟秽浊之气者」，则应以芳香逐之。
吴氏论述了在不同情况下的透热转气方法，就是根据造成气机不畅的原因，选用相应的药物排除阻碍而宣畅气机，使营热外达。
清代以来的温病学家如章虚谷、吴锡璜、陈光淞、梆宝诒等从不同角度对透热转气作了论述。如章虚谷在批注「透热转气」时说：「故虽入营，犹可开达，转出气分而解……」③提出了开郁闭、畅气机，使营热外透。：
陈光凇在批注「急急透斑为要」时说；「按营分受热……透斑之法，不外凉血清热，甚者下之，所谓炀灶减薪，去其壅塞，则光焰白透。若金汁、人中黄所不能下者，大黄、元明粉亦宜加入。」巳明确提出了去其壅塞、排除障碍而宣展气机以透热转气的问题。
我在临床中体会到，温邪入营，多由误治造成的。如病在卫分，用药宜轻清宣透，即辛凉清解之法。若误用辛温，则伤明助热，致使邪热内陷，成痰热蒙蔽心包，闭塞心窍之证。治之当清心开窍，即透热转气。若过用寒凉，则遏滞气机，重则冰伏，使热无外达之路，必内迫入营。开之必辛温芳香，如草蔻、干姜，甚则桂附之类。但用之必须恰如其分，寒遏已散，冰伏消之即可，切勿过用。
温病不论在卫在气，若误用，过用滋腻温补，都可闭塞气机。而使热邪入营，其透热转气之法，即选相应的药宣畅气机，开营热外达之路。
热邪入营，若舌苔厚腻者，不仅有湿阻，且有食滞，应相台其它症状，必加入消食化滞之品，宣畅气机，才能使营热外达。
治疗营分证，只用清营养阴不用透热转气之品行不行呢?根据本人临床经验，只清营、养阴，疗效差。因病久营热不去，必进一步耗伤肝血肾精而入血分。热陷心包，为痰热堵塞心窍，蒙蔽心包。内窍不开，气机闭塞，「热邪无外达之路，则清之不去}营热炽盛，炼濠成痰，养阴也不易收功。必须急开内窍，使热有去路，清营养阴才能收功。曾治一病人，画家，年逾古稀，膀胱癌手术半年后，复感受温邪，咳喘痰黄粘，尿频，且患有冠心病，入北京某医院，诊为：泌尿系感染、前列腺增生、膀胱癌术后、肺炎、冠心病。经西医组织抢救不效，遂陷入昏迷，一周后邀余会诊。见其面色黧黑，形态消瘦，神志昏沉，舌绛干裂中剥，咳嗽痍黄，喘促气急。高年下元已损，温热久羁，阴津大伤，痰热内迫，热邪入营f前所服药物全属寒凉，气机被遏，肺失宣降，以养阴之法求其津回而脉复，用宣气机开痰郁之品以冀营热外透。方用生杭芍、天门冬、沙参、元参、石斛、前胡、黄芩、杏仁、黛蛤散、川贝粉、羚羊角粉，二剂。服后即神苏、喘咳皆轻，且知饥索食，都是气机舒畅、营热外迭之征。
对「透热转气」的认晶为营分证的治疗提供了处方依撼即治疗营分证(包括气营两燔、卫营同病)，其方剂都应由清营热、养营阴、透熟转气三部分药物组成，其透热转气之品，重在宣通造成营分证中气机不畅的原因。据此我治疗营分证之昏迷，每多获效(其病例当另行撰文介绍)。
(四)宣畅兰焦方法治疗内科杂病汪老治疗湿温十法，体现了展气机、畅三焦，辛开苦降，分消走泄，抓住了湿温的病机特点。因「三焦眷，原气之另q使也，主通行三气，历五脏六腑」，又是「决凑之官，水道出焉」。湿温病，为湿热台邪，互相裹结，难解难分，且湿郁热盛，热蒸湿动，弥漫三焦，阻滞气机，遏伤阳气，水掖运行受阻。遇湿热之证，按汪老法，每获良效。在临床实践中，常遇到一些虽不是湿热病，但因脾虚、肝郁、食滞或其它原因，造成气机不畅，湿不得运，阻止于三焦，其舌苔多腻，脉见濡滑，也可用宣畅三焦法，行气化湿，辄取良效。如曾治一女患者，三十余岁；体丰多痰，咳嗽胸满，小便不爽月涂，入夜益甚，前医诊为癃闭，迭用八正散之类月余不效，且有增重之势。诊其脉濡软，按之沉涩，舌苔白腻滑润，此乃湿郁肺气不宣之象，极宜宣通肺气，以畅三焦，所谓「提壶揭盖」之法也，药用苏叶、杏仁、荷梗各10克，五剂后诸恙若失。
我几十年的中医生涯，就是勤奋读书和不断实践，而且认识到中医理论必须和临床实践结合起来，才能不断提高。
我所走过的学医道路
湖南中医学院副院长，教授谭日强
【作者简介】谭日强(1913～)，湖南湘乡人。十七岁拜师学徒，一九三六年毕业子湖南国医专科学校。擅长内、妇科，对心血管病、血液病、肝脏病，颇有研究。曾着有《传染性肝炎的辨证治疗》、《金匮要略浅述》等书。现任湖南中医学院副院长、中华金国中医学会湖南分会副会长、湖南省第五届人大常委等职。
学徒三年初入医门
(I) Research on Pulse Diagnosis and Tongue Diagnosis, and Clinical Experience
Since memorizing *Binhu Maixue* (Pulse Studies of the Lakeside) in my childhood, I have repeatedly pondered the relationship between pulse characteristics (pulse morphology) and pathological changes. The human body is a unified whole; the functional activities of the Zang-Fu organs (five zang organs and six fu organs) all affect the circulation of Qi and Blood. Therefore, pathological changes in the Zang-Fu organs can and should be reflected through the pulse. Thus, pulse diagnosis holds significant importance in clinical practice. However, how to use modern scientific methods, instruments, and data to accurately reflect the impact of different diseases in different Zang-Fu organs on the pulse, serving as an objective basis for diagnosis, remains our long-held aspiration.
In my clinical practice, I have found that although there are differences in geography and among people (gender, age), the depth of the pulse reflection corresponding to the site of disease precisely corresponds to the levels of Wei (Defensive), Qi, Ying (Nutritive), and Xue (Blood) in the human body. Therefore, palpating the pulse should distinguish between floating (Fu), middle (Zhong), pressing (An), and deep (Chen) pressures, enabling the differentiation of diseases located at the Wei, Qi, Ying, or Xue levels. Based on years of clinical experience, I believe that by grasping the main pulse (Zhu Mai) and accompanying pulses (Jian Mai), and using the floating, middle, pressing, and deep techniques to determine the depth of the pathological location, combined with reference to the other three diagnostic methods (inspection, listening/smelling, inquiry), one can determine treatment principles and prescriptions, achieving satisfactory clinical results. Consequently, my understanding of pulse studies has been elevated (I have a book titled *Clinical Pulse Diagnosis* forthcoming).
There are few writings on tongue diagnosis; discussions in *Neijing* (The Inner Canon) and *Shanghan Lun* (Treatise on Cold Damage) are sparse. It was only after Qing Dynasty Wenbing (Warm Disease) experts proposed "differentiating the tongue and examining teeth" that tongue diagnosis gained prominence. Tongue coating mostly reflects functional states, i.e., pathological changes in the Wei and Qi levels; tongue body mostly reflects substantial states, i.e., pathological changes in the Ying and Xue levels. However, in clinical practice, I have observed that some patients with mental restlessness, irritability, and internal stagnant heat present with a pale tongue surface and white coating, yet their pulse is wiry, thin, rapid, and urgent. An careless practitioner, seeing a pale tongue and white coating, might diagnose it as "deficiency" and apply warming tonification, thereby aggravating the condition. Since the coating covers the tongue surface, in individuals with inherent Yin deficiency, the tongue may be thin and small, with its red color masked by the white coating. Due to internal heat, although the tongue surface appears pale, if the patient lifts their tongue, the dorsal side may appear red, dark red, or even crimson. Under normal circumstances, pulse, symptoms, and tongue should be consistent. Through clinical practice, I feel that observing the dorsal side of the tongue body is more accurate and reliable, preventing deception by superficial phenomena. This has important reference value for clinical diagnosis, especially in Warm Diseases (I have completed *Clinical Tongue Diagnosis*, forthcoming).
(II) Understanding of "Sweat it when in the Wei Level"
Regarding the treatment of Wei-level diseases in Warm Diseases, Ye Tianshi stated: "Sweat it when in the Wei level." This is generally understood as the "Sweating Method," or "Acrid-Cool Sweating" or "Acrid-Cool Releasing the Exterior." However, in my teaching, I consider the term "Acrid-Cool Clearing and Resolving" to be more precise, emphasizing that "sweating it" does not mean the "Sweating Method." This conclusion is also derived from clinical practice.
Examining Wu Jutong's *Wenbing Tiaobian* (Systematic Differentiation and Treatment of Warm Diseases) regarding the treatment of Wei-level syndromes (Upper Jiao), he lists Acrid-Cool Light Agents and Acrid-Cool Moderate Agents, but the text contains no words like "releasing the exterior" or "inducing sweating." He earnestly warns: "Warm diseases contraindicate sweating; sweating will not resolve the condition but may generate other complications." Because warm diseases arise from inhalation via the nose and mouth, merely inducing sweating at the exterior is of no benefit. Moreover, sweat is the fluid of the Heart; damaging Heart Yang will inevitably lead to mental confusion, delirium, mania, internal closure with external collapse. Furthermore, since the "Sweating Method" damages Yin and aids heat, Wu stated, "Warm diseases easily damage Yin; if medication further damages Yin, is this not helping the thief?" In the early stage of warm diseases, warm pathogens attack the Lung, causing Lung Qi stagnation and obstruction of the diffusion of Wei Yang Qi. Qi stagnates and generates heat. Although the disease in the Lung and Wei is mild, the fluids are already slightly damaged, hence the symptom of "slight thirst." This is completely different from Wind-Cold constraining the exterior in Cold Damage, which injures Wei Yang. For Taiyang Cold Damage, Acrid-Warm sweating is appropriate. However, Ye Tianshi believed the treatment for Warm Disease Wei-level syndromes is "greatly different from Cold Damage"; thus, "sweating it" is absolutely not the "Sweating Method."
Wei-level syndromes in Warm Diseases belong to "Stagnant Heat." *Suwen: Liuyuan Zhengji Dalun* states: "For Fire stagnation, disperse it." Wang Bing annotated: "Disperse means to induce sweating to allow dispersion." Liu Baozhi further elaborated: "For acute contraction of Wind-Warmth, the pathogen resides specifically in the Lung; the primary treatment is Acrid-Cool clearing and dispersing, with sweet-cold clearing added if heat is severe." None of these consider it the "Sweating Method." My father explained: "External contraction of Wind-Cold causes exterior closure; internal contraction of Warm pathogens enters via the nose and mouth, affecting the Wei level. For exterior conditions, release the exterior; for Wei conditions, vent the Wei. Just as heat stagnation in a room requires opening windows and doors to allow airflow and reduce heat, so too must the Wei be vented." Therefore, "sweating it" in Wei-level syndromes is actually the method of Acrid-Cool clearing and resolving. Acridness opens stagnation, coolness clears heat. When stagnation opens and heat clears, the Wei becomes unblocked; when pathogens leave, the Triple Burner flows freely, Ying and Wei harmonize, and fluids distribute, leading to resolution with slight sweating. This achieves the goal of sweating without using the sweating method, which is the meaning of "sweating it."
In the *Yinqiao San* (Honeysuckle and Forsythia Decoction) from *Wenbing Tiaobian*, among the large number of cooling herbs, only Dou Chi (Fermented Soybean) and Jingjie Sui (Schizonepeta Spikes) are acrid-warm, and their dosages are very light, certainly not for inducing sweating. Their functions are two-fold: First, to open stagnation. With stagnant heat in the Wei level and pathogens in the Upper Jiao, Dou Chi and Jingjie use their acrid-warm nature to open stagnation and diffuse the Lung and Wei. Second, while coolness clears heat, a mass of cold-cooling herbs can easily cause Qi mechanism stagnation. Therefore, a small amount of acrid-warm herbs is added to counteract this drawback. They are used only for their flavor, lacking drying-warming properties. Together called an Acrid-Cool Moderate Agent, they truly function to open stagnation and clear heat, having no intent to induce sweating, and are definitely not the "Sweating Method."
The argument that "sweating it" is not the "Sweating Method" is based on the different etiology and pathogenesis of Warm Diseases versus Cold Damage. This is not mere wordplay, as it has significant clinical implications. It clearly points out that treating Wei-level Warm Diseases, one must not use Acrid-Warm sweating, nor a pure cold-cooling approach. Overuse of Acrid-Warm herbs damages Yin and aids heat, leading to coma and syncope; a pure cold-cooling approach fails to open stagnation and clear heat, blocking the Qi mechanism and worsening the condition. One must combine Acrid-Warm and cold-cooling herbs to form an Acrid-Cool formula. In Wei-level syndromes, due to varying degrees of "heat" and "stagnation," the ratio of "cold-cooling" to "acrid-warm" must be adjusted. Generally, if heat is heavy and stagnation is light, prioritize cold-cooling with a little acrid-warm; if stagnation is heavy and heat is light, prioritize acrid-warm with cold-cooling. As long as the proportion is appropriate, stagnation opens, heat clears, interior and exterior harmonize, Ying and Wei balance, the Triple Burner flows freely, and slight sweating leads to recovery. This understanding avoids misdiagnosis and treatment errors, and clarifies prescription principles and medication rationale.
(III) Understanding of "Even if entering the Ying Level, Heat Can Still Be Transmitted Out to the Qi Level"
When Warm Disease pathogens enter the Ying (Nutritive) level, the condition is severe. Commonly used formulas include *Qingying Tang* (Clear the Nutritive Level Decoction), *Qinggong Tang* (Clear the Palace Decoction), and the "Three Treasures" (Sanbao), claiming these constitute the method of "transmitting Nutritive heat to Qi." However, there is no clear definition of what "transmitting heat to transmit to Qi" entails. Through clinical practice, I recognize that the Ying level has three characteristics: Ying heat, Yin injury, and Qi mechanism obstruction. Regarding the first two, Ye Tianshi explicitly stated: "When the Ying level receives heat, blood is robbed." "Blood being robbed" means Ying Yin is injured by heat pathogens. Since "Ying Qi secretes its fluids, injects them into the vessels, and transforms them into blood," and "circulates up and down the vessels, connecting the five Zang organs and linking the six Fu organs," heat pathogens entering the Ying level inevitably damage Ying Yin. Clearing the Ying level and nourishing Yin are therefore the fundamental methods for treating Ying-level syndromes.
The types of Ying-level syndromes are complex. Besides Ying heat and Yin injury, they often involve Phlegm-Heat, Dampness obstruction, Blood stasis, Food stagnation, or Fu organ excess. These all obstruct the Qi mechanism, blocking the path for Ying heat to reach the exterior, preventing heat already in the Ying level from penetrating outward. Therefore, treating Ying-level syndromes requires not only clearing the Ying and nourishing Yin but also promoting Qi movement and smoothing the path for Ying heat to exit, thereby "transmitting heat to transmit to Qi."
Researching *Wu Yi Hui Jiang* (Compilation of Wu Doctors' Discussions), which collects Ye Tianshi's "Treatment of Warm Syndromes," the original text reads: "Upon just entering the Ying level, heat can still be transmitted, returning to the Qi level for resolution." Later generations, based on this, believed that transmitting heat could only occur upon initially entering the Ying level. However, Wang Mengying included it in *Wenre Jingwei* (Classic Lines of Warm and Febrile Diseases), changing it to "Even if entering the Ying level, heat can still be transmitted to Qi," thereby expanding the application scope of this method to the entire Ying level. Nevertheless, most still believe that because Jin Yin Hua (Honeysuckle), Lian Qiao (Forsythia), and Zhu Ye (Bamboo Leaf) in *Qingying Tang* all have the effect of transmitting heat to Qi, these three herbs are the specific drugs for this method. This limits "transmitting heat to Qi" to the initial entry into the Ying level and the use of these three herbs, ignoring its universal significance in treating Ying-level syndromes.
*Qingying Tang* originates from *Wenbing Tiaobian*. Wu Jutong annotated it as "clearing heat in the Palace and preserving the emptiness of the Li [Heart]," without mentioning transmitting heat to Qi. Carefully studying Ye's discussions on Ying-level treatment in *Linzheng Zhinan Yi'an* (Medical Cases Guided by Clinical Practice), the treatment of Ying-level syndromes consistently embodies the method of "transmitting heat to Qi." For example, Ye said, "For those entering the Ying from Wind-Heat, use Rhinoceros Horn and Bamboo Leaf dust"; "For those entering the Ying from Damp-Heat, use Rhinoceros Horn Flower Dew." For cases entering from Wind-Heat, besides Ying heat and Yin injury, there is "Wind-Heat obstructing the Qi mechanism, preventing Ying heat from exiting; thus, Bamboo Leaf clears Wind-Heat, vents stagnation, and smooths the Qi mechanism." For cases entering from Damp-Heat, Damp-Heat obstructs the Qi mechanism; thus, Flower Dew uses aromatic damp-resolving, clears heat, opens stagnation, and unblocks the Qi mechanism to allow Ying heat to penetrate outward. "If accompanied by irritability and constipation," add Jin Zhi (Golden Juice); for "elderly or those with chronic cold," replace Jin Zhi with Ren Zhong Huang (Human Feces Processed Herb) to clear toxic heat, promote Qi flow, and guide Ying heat outward.
"For rashes appearing but heat not resolving," this indicates simultaneous burning of Qi and Blood, with heat pathogens consuming Stomach Yin. One should urgently withdraw Qi heat using Shi Gao (Gypsum) and Zhi Mu (Anemarrhena) to guide Ying heat outward.
"For tongue crimson and fresh/moist," this is a mild syndrome of Heat Trapping the Pericardium. Treat with "Rhinoceros Horn, Fresh Rehmannia, Forsythia, Curcuma Aromatica, Acorus Tatarinowii," using Acorus and Curcuma to clear the Heart, open orifices, and unblock closure, combined with Forsythia's light and clear diffusing action to smooth Qi mechanism and guide Ying heat outward. "If the person inherently has Heart deficiency with Phlegm, and external heat sinks in, closing the interior collaterals," then "Acorus and Curcuma cannot open it"; one must use "Niuhuang Wan (Calculus Bovis Pill) or Zhibao Dan (Precious Treasure Pill)" to open the closure, allowing Ying heat to penetrate outward. "For tongue crimson with dry center," this indicates Fire blazing in the Heart and Stomach; treat with Huang Lian (Coptis) and Shi Gao (Gypsum) to clear Qi-level heat and transmit heat to Qi.
"If there is pre-existing Blood stasis in the chest and diaphragm," obstructing Qi mechanism while heat pathogens enter the Ying, use "blood-dispersing agents such as Hupo (Amber), Tao Ren (Peach Seed), and Mudan Pi (Tree Peony Bark)" to invigorate Blood, scatter stasis, unblock collaterals, remove obstructions, promote Qi movement, and guide Ying heat outward.
"When heat pathogens enter the Ying carrying turbid foul qi," use aromatic herbs to dispel them.
Wu Jutong discussed methods of transmitting heat to Qi under different circumstances, selecting appropriate herbs to remove obstructions and smooth the Qi mechanism based on the causes of Qi stagnation, allowing Ying heat to reach the exterior.
Warm Disease experts since the Qing Dynasty, such as Zhang Xugu, Wu Xihuang, Chen Guangsong, and Liu Baozhi, discussed "transmitting heat to Qi" from different angles. For instance, Zhang Xugu, annotating "transmitting heat to Qi," said: "Thus, even if entering the Ying, one can still open and reach, transferring out to the Qi level for resolution..." proposing to open stagnation and closure, smooth the Qi mechanism, and allow Ying heat to penetrate outward.
Chen Guangsong, annotating "urgently transmitting rashes is essential," said: "According to heat receiving in the Ying... the method of transmitting rashes involves nothing but cooling Blood and clearing heat; if severe, purging. This is akin to reducing fuel to diminish the fire, removing blockages so the light shines through naturally. If Jin Zhi and Ren Zhong Huang cannot purge, Da Huang (Rhubarb) and Yuan Ming Fen (Mirabilite) should also be added." This clearly proposes removing blockages and obstructions to expand Qi mechanism and transmit heat to Qi.
In my clinical experience, Warm pathogens entering the Ying are often caused by misdiagnosis/treatment. For example, if the disease is in the Wei level, medication should be light, clear, and diffusing (Acrid-Cool clearing and resolving). If mistakenly treated with Acrid-Warm herbs, Yin is damaged and heat aided, causing heat pathogens to sink inward, forming Phlegm-Heat obscuring the Pericardium and closing the heart orifices. Treatment should clear the Heart and open orifices, i.e., transmit heat to Qi. If overused cold-cooling herbs, the Qi mechanism is suppressed; severely, it becomes "ice-frozen," leaving no path for heat to exit, forcing it inward to the Ying. To open this, one must use Acrid-Warm aromatic herbs, such as Cao Kou (Black Cardamom) or Gan Jiang (Dried Ginger), even Gui Fu (Cinnamon Twig and Aconite). However, they must be used precisely; once cold suppression is scattered and ice-frozen state melted, stop. Do not overuse.
In Warm Diseases, whether in Wei or Qi levels, mistaken or excessive use of cloying, warming tonics can close the Qi mechanism, causing heat pathogens to enter the Ying. The method of transmitting heat to Qi here involves selecting appropriate herbs to smooth Qi mechanism and open the path for Ying heat to exit.
When heat pathogens enter the Ying, if the tongue coating is thick and greasy, there is not only Dampness obstruction but also Food stagnation. Combining other symptoms, one must add food-resolving and stagnation-dispersing herbs to smooth Qi mechanism, allowing Ying heat to exit.
Is it acceptable to treat Ying-level syndromes using only clearing Ying and nourishing Yin, without transmitting heat to Qi? Based on my clinical experience, using only clearing Ying and nourishing Yin yields poor results. If Ying heat persists due to prolonged illness, it will further consume Liver Blood and Kidney Essence, entering the Blood level. Heat trapping the Pericardium involves Phlegm-Heat blocking the heart orifices and obscuring the Pericardium. If internal orifices are not opened and Qi mechanism is closed, "heat pathogens have no path to exit, so clearing alone cannot remove them." If Ying heat is intense, refining fluids into Phlegm, nourishing Yin alone is difficult to succeed. One must urgently open internal orifices to provide a path for heat; only then can clearing Ying and nourishing Yin succeed.
I once treated a patient, a painter, over seventy years old, who contracted Warm pathogens half a year after bladder cancer surgery. Symptoms included cough, wheezing, yellow sticky sputum, frequent urination, and coronary heart disease. He was admitted to a hospital in Beijing, diagnosed with urinary tract infection, prostatic hyperplasia, post-bladder cancer surgery status, pneumonia, and coronary heart disease. Western medical rescue was ineffective, and he fell into a coma. A week later, I was consulted. His complexion was dark, he was emaciated, consciousness was dull, tongue was crimson, dry, cracked, and peeled in the center, coughing yellow sputum, wheezing and short of breath. At an advanced age, the Lower Yuan was damaged; warm-heat had lingered, greatly injuring Yin fluids; Phlegm-Heat pressed internally, and heat pathogens entered the Ying. Previous medications were all cold-cooling, suppressing Qi mechanism, causing Lung loss of diffusion and descent. Seeking fluid return and pulse recovery via nourishing Yin was insufficient; I used herbs to promote Qi mechanism and open Phlegm stagnation to hope for Ying heat penetration. The formula included Sheng Hang Shao (Raw Paeonia Lactiflora), Tian Men Dong (Asparagus Root), Sha Shen (Glehnia Root), Yuan Shen (Scrophularia Root), Shi Hu (Dendrobium Stem), Qian Hu (Peucedani Radix), Huang Qin (Scutellaria Root), Xing Ren (Apricot Seed), Dai Ge San (Indigo Naturalis and Clam Shell Powder), Chuan Bei Fen (Fritillaria Cirrhosa Powder), and Ling Yang Jiao Fen (Antelope Horn Powder). After two doses, consciousness recovered, wheezing and coughing lightened, and hunger arose—all signs of smooth Qi mechanism and penetrating Ying heat.
This understanding of "transmitting heat to Qi" provides a prescription basis for treating Ying-level syndromes. That is, treating Ying-level syndromes (including simultaneous Qi-Ying burning and Wei-Ying involvement), the formula should consist of three parts: herbs clearing Ying heat, herbs nourishing Ying Yin, and herbs transmitting heat to Qi. The herbs for transmitting heat to Qi focus on promoting the movement of Qi mechanism obstructions causing Ying-level syndromes. Based on this, my treatment of comas in Ying-level syndromes often succeeds (cases will be introduced in separate articles).
(IV) Using Methods to Smooth the Triple Burner to Treat Internal Medicine Miscellaneous Diseases
Old Master Wang's ten methods for treating Wet-Warm diseases embody promoting Qi movement, smoothing the Triple Burner, Acrid-opening and Bitter-descending, and separating/dispersing leakage, capturing the pathogenic characteristics of Wet-Warm diseases. Since "the Triple Burner is the special envoy of Original Qi, governing the passage of Three Qi through the five Zang and six Fu organs," and is the "Official of Dredging, where water passages emerge." Wet-Warm disease involves Dampness and Heat combining, entangling each other, hard to separate. Dampness stagnates with abundant Heat, Heat steams Dampness moving, filling the Triple Burner, obstructing Qi mechanism, suppressing and injuring Yang Qi, and hindering fluid circulation. Encountering Damp-Heat syndromes, following Old Master Wang's methods often yields good results. In clinical practice, I often encounter cases that are not Wet-Warm diseases but suffer from Qi mechanism obstruction, Dampness failing to transform, and stagnation in the Triple Burner due to Spleen deficiency, Liver stagnation, Food stagnation, or other causes. Their tongue coating is often greasy, and pulse is soggy and slippery. One can also use methods to smooth the Triple Burner, moving Qi and resolving Dampness, often achieving good results. For example, I once treated a female patient, over thirty years old, obese with much Phlegm, suffering from cough, chest fullness, and dysuria for over a month, worsening at night. Previous doctors diagnosed it as Lin Syndrome (difficulty/painful urination), repeatedly using Ba Zheng San (Eight-Herb Correcting Powder) for over a month without effect, and the condition worsened. Her pulse was soggy and soft, deep and choppy upon pressure; tongue coating was white, greasy, and slippery. This indicated Dampness stagnating and Lung Qi failing to diffuse. It was highly suitable to diffuse Lung Qi to smooth the Triple Burner, known as the "lifting the lid of the teapot" method. Medication included Su Ye (Perilla Leaf), Xing Ren (Apricot Seed), and He Geng (Lotus Stem) 10g each. After five doses, all ailments disappeared.
My decades-long career in Traditional Chinese Medicine has been characterized by diligent reading and continuous practice. I have realized that TCM theory must be combined with clinical practice to continuously improve.
The Path of My Medical Study
Tan Riqiang, Vice President and Professor, Hunan College of Traditional Chinese Medicine
[Author Profile] Tan Riqiang (1913–), from Xiangxiang, Hunan. Apprenticed at seventeen, graduated from Hunan National Medical College in 1936. Specialized in Internal and Gynecological medicine, with considerable research on cardiovascular, hematological, and hepatic diseases. Authored books such as *Syndrome Differentiation and Treatment of Infectious Hepatitis* and *Brief Commentary on Jin Gui Yao Lue*. Currently serves as Vice President of Hunan College of Traditional Chinese Medicine, Vice President of Hunan Branch of China Association of Traditional Chinese Medicine, and Standing Committee Member of the 5th Hunan Provincial People's Congress.
Three Years of Apprenticeship, Entering the Door of Medicine