季蘅翁禀丰躯伟。望七之龄。神采不衰。近得半身不遂之证。已二年矣。病发左半。口往右 。昏厥遗
溺。初服参术颇当。为黠医簧以左半属血。不宜补气之说。几致大坏。云间施笠泽以参附疗之。稍得向安。
然概从温补。未尽病情也。诊得脉体。软滑中时带劲疾。盖痰与风杂合之证。痰为主。风为标也。又热
与寒杂合之证。热为主。寒为标也。平时手冷如冰。故痰动易至于厥。然厥已复苏。苏已呕去其痰。眠食
自若。虽冬月亦能耐寒。无取重 复絮。可知寒为外显之假寒。而热为内蕴之真热。既有内蕴之热。自蒸脾湿
为痰。久久阻塞窍隧。而卫气不周。外风易入。加以房帏不节。精气内虚。与风相召。是以杂合而成是
证耳。及今大理右半脾胃之气。以运出左半之热痰虚风。此其间有微细曲折。非只温补一端所能尽者。何也。
治杂合之病。必须用杂合之药。而随时令以尽无穷之变。即如冬月严寒用事。身内之热。为外寒所束。不得从
皮肤外泄。势必深入筋骨为害矣。故用姜附以暂撤外寒。而内热反得宣泄。若时令之热。与内蕴之热相合。复
助以姜附。三热交煽。有灼筋腐肉而已。孰是用药之权衡。可以一端尽耶。或者曰。左半风废。而察脉辨证。
指为兼痰兼热似矣。痰者脾湿所生。寄居右畔。是则先宜中右。而
何以反中左耶。既已中左。明系左半受病。而何以反治右耶。不知此正病机之最要者。但为丹溪等方书说。病
在左血多。病在右气多。教人如此认证。因而起后人之偏执。至内经则无此说也。内经但言左右者。阴阳之道
路。夫左右既为阴阳往还之道路。何尝可偏执哉。况左半虽血为主。非气以统之则不流。右半虽气为主。非血
以丽之则易散。故肝胆居左。其气常行于右。脾胃居右。其气常行于左。往来灌注。是以生生不息也。肝木主
风。脾湿为痰。而风与痰之中人。原不分于左右。但翁恃其体之健。过损精血。是以八八天癸已尽之后。左半
先亏。而右半饮食所生之痰。与皮毛所入之风。以渐积于空虚之府。而骤发始觉耳。风脉劲疾。痰脉软滑。
惟劲疾故病则大筋短缩。即舌筋亦短而蹇于言。小筋弛长。故从左而 于右。从左 右。即可知左畔
之小筋。弛而不张也。若小筋能张。则左 矣。凡治一偏之病。法宜从阴引阳。从阳引阴。从左引右。从右
引左。盖观树木之偏枯者。将溉其枯者乎。抑溉其未枯者使荣茂。而因以条畅其枯者乎。治法以参术为君臣。
以附子干姜为佐使。寒月可恃无恐。以参术为君臣。以羚羊角柴胡知母石膏为佐使。而春夏秋三时。
可无热病之累。然宜刺手足四末。以泄荣血而通气。恐热痰虚风。久而成疠也。
门人问曰。经文左右者。阴阳之道路。注解以运气之司天在泉。而有左间右间为训。遂令观者茫然。今先
生贴以往还二字。与太极动而生阳。静而生阴。天地生成之数。春秋自然之运。适相符契矣。但不知往于何
始。还于何终。可得闻乎。答曰。微哉问也。天地之道。春气始于左。而终于右。秋气始于右。而
终于左。夏气始于上。而终于下。冬气始于下。而终于上。人身亦然。经云。欲知其始。先建其母。母者五
脏相承之母也。又曰。五脏以生克而互乘。如右之肺金。往左而生肾水克肝木。左之
心火。往右而生脾土克肺金之类。其往还交织无端。然始于金
者。生则终于土。克则终于火。始于火者。生则终于木。克则终于水。此则交织中之次第也。推之十二经。如
子时注少阳胆。丑时注厥阴肝之类。亦交织中之次第也。诚建其母推其类。而始终大略睹矣。
又问曰。病机之左右上下。其往还亦有次第乎。答曰。病机往还之次第。不过顺传逆传两端。顺传者传
其所生。乃天地自然之运。如春传夏。夏传长夏。长夏传秋。秋传冬。冬复传春。原不为病。即病亦轻。逆传
者。传其所克。病轻者重。重者死矣。如春传长夏。长夏传冬。冬传夏。夏传秋。秋传春。非天地自然之
运。故为病也。曰经言间传者生。七传者死。则间传为顺传。七传为逆传无疑。曰。非也。注难经者。言间传
是顺行。隔一位而传。误认病机但从右旋左。不从左旋右。皆繇不知左右往还之理。而以讹传讹。试诘以
肾水间一位传心火。为逆传之贼邪。则无可置喙矣。故间传七传。俱于逆传中分生死耳。间传者。心病
当逆传肺。乃不传肺。而传肺所逆传之肝。肺病当逆传肝。乃不传肝。而传肝所逆传之脾。推之肝病脾病肾病
皆然。此则脏腑不受克贼。故可生也。七传者前六传已逆周五脏。第七传重复逆行。如心脏初受病。二传于肺
则肺脏伤。三传于肝则肝脏伤。四传脾。五传肾。六传仍归于心。至七传再入于肺。则肺已先伤。重受贼邪。
气绝不支矣。所谓一脏不两伤。是以死也。不比伤寒传经之邪。经尽再传。反无害也。针经云。善针者以左治
右。以右治左。夫人身之穴。左右同也。乃必互换为治。推之上下。莫不皆然。于往还之机。益明矣。
又问曰。半身不遂之病。原有左右之分。岂左右分属之后。病遂一往不返乎。而治之迄无成效者。何
也。答曰。风与痰之中人。各随所造。初无定体。病成之后。亦非一往不返也。盖有往有复者。天运人事病
机。无不皆然。如风者四时八方之气。从鼻而入。乃天之气也。痰者五谷百物之味。从口而入。脾胃之湿所
结。乃地之气也。势本相辽。亦尝相兼。全似内伤之与外感。每夹杂而易炫。故风胜者先治其风。痰胜者先治
其痰。相等则治风兼治痰。此定法也。内经云。风之中人也。先从皮毛而入。次传肌肉。次传筋。次传骨髓。
故善治者。先治皮毛。其次治肌肉。繇此观之。乃从右而渐入于左也。皮毛者右肺主之。肌肉者右胃主之。
筋脉者左肝主之。骨髓者左肾主之。从外入者转入转深。故治皮毛治肌肉。不使其深入也。又曰。湿之中人
也。先从足始。此则自下而之上。无分左右者也。但内风素胜之人。偏与外风相召。内湿素胜之人。偏与外湿
相召。内风之人。大块之噫气未动。而身已先伤。内湿之人。室中之础磉未润。而体已先重。是以治病必从其类
也。从外入者。以渐而驱之于外。从下上者。以渐而驱之于下。若任其一往不返。安贵其为治乎。
又问曰。从外入者。驱而之外。从下上者。驱而之下。骤闻令人爽然。不识古法亦有合欤。答曰。此正古
人已试之法。但未挈出。则不知作者之意耳。如治风大小续命汤。方中桂附苓术麻防等药。表里庞杂。今
人见为难用。不知用附桂者。驱在里之邪也。用苓术者。驱在中之邪也。而用麻防等表药独多者。正欲
使内邪从外而出也。至于病久体虚。风入已深。又有一气微汗之法。一旬微利之法。平调半月十日。又微微驱
散。古人原有规则也。至于治痰之规则。不见于方书。如在上者。用瓜蒂散栀豉汤等方。在左者用龙荟丸。在右
者用滚痰丸。以及虚人用竹沥达痰丸。沉寒锢冷用三建汤之类。全无奥义。岂得心应手之妙。未可传之纸上耶。
吾今为子辈传之。盖五味入口。而藏于胃。胃为水谷之海。五脏六腑之总司。人之食饮太过。而结为痰涎者。
每随脾之健运。而渗灌于经隧。其间往返之机。如海潮然。脾气行则潮去。脾气止则潮回。所以治沉锢之法。
但取辛热。微动寒痰。已后止而不用。恐痰得热而妄行。为害不浅也。不但痰得热
而妄行。即脾得热而亦过动不息。如潮之有去无回。其痰病之
决裂。可胜道哉。从来服峻补之药者。深夜亦欲得食。皆不知其故。反以能食为庆。曾不思爱惜脾气。令其
昼运夜息。乃可有常。况人身之痰。既繇胃以流于经隧。则经隧之痰。亦必返之于胃。然后可从口而上越。
从肠而下达。此惟脾气静息之时。其痰可返。故人有痰症者。早食午食而外。但宜休养。脾气不动。使
经隧之痰。得以返之于胃。而从胃之气上下。不从脾之气四达。乃为善也。试观人痰病轻者。夜间安卧。次早
即能呕出泄出。痰病重者。昏迷复醒。反能呕出泄出者。岂非未曾得食。脾气静息。而予痰以出路耶。世之喜
用热药峻攻者。能知此乎。噫。天下之服辛热。而转能夜食者多矣。肯因俚言而三思否。
胡卣臣先生曰。知之深。故言之详。然皆根据内经。而非创说。又自
有神悟。而非袭说。予向者极叹服王宇泰缪仲淳。真是齐人知管晏耳。
Mr. Yang Jiheng possessed a robust and tall physique. At the age of seventy, his spirit and vitality remained unimpaired. Recently, he developed hemiplegia (half-body paralysis), which has persisted for two years. The onset occurred on the left side of the body, with the mouth deviating to the right, accompanied by syncope (fainting) and urinary incontinence. Initially, the administration of Ginseng Radix et Rhizoma (Renshen) and Atractylodis Rhizoma (Baizhu) was quite appropriate. However, a cunning physician misled him with the theory that "the left half belongs to blood and should not be supplemented with Qi," nearly causing severe deterioration. Shi Lizé from Yunjian treated him with Ginseng Radix et Rhizoma (Renshen) and Aconiti Lateralis Radix Praeparata (Fuzi), bringing slight relief. Nevertheless, adopting a blanket approach of warming and tonification does not fully address the complexity of the condition.
Pulse diagnosis revealed a pulse quality that was soft and slippery, occasionally interspersed with forceful and rapid characteristics. This indicates a syndrome where Phlegm (Tan) and Wind (Feng) are mixed, with Phlegm as the root and Wind as the branch; simultaneously, it is a syndrome where Heat (Re) and Cold (Han) are mixed, with Heat as the root and Cold as the branch. His hands and feet are usually cold like ice, so when Phlegm stirs, it easily leads to syncope. However, after regaining consciousness, he vomits up the Phlegm, and his sleep and appetite return to normal. He can endure the cold even in winter without needing heavy cotton padding. This reveals that the coldness is merely an external false appearance (False Cold), while the heat retained internally is the true nature (True Heat). Since there is internal heat, it naturally steams Spleen dampness into Phlegm. Over time, this obstructs the collaterals and orifices, preventing the proper circulation of Wei Qi (Defensive Qi), making the exterior susceptible to invasion by External Wind. Additionally, immoderate sexual activity has depleted his Essence and Qi internally, attracting Wind. Thus, these factors combine to form this complex syndrome.
Currently, it is necessary to vigorously regulate the Qi of the Spleen and Stomach on the right side to transport and eliminate the Heat-Phlegm and Deficient Wind from the left side. There are subtle complexities here that cannot be addressed solely by warming and tonifying. Why? Treating such mixed syndromes requires the use of complex herbal combinations and adapting to the endless variations brought by seasonal changes. For instance, during the severe cold of winter, internal heat is constrained by external cold and cannot dissipate through the skin, inevitably penetrating deep into the sinews and bones to cause harm. Therefore, using dried Ginger (Shengjiang) and Prepared Aconite Root (Fuzi) temporarily dispels the external cold, allowing the internal heat to vent. If, however, in warmer seasons, the seasonal heat combines with internal heat, and one still assists with Ginger and Aconite, the three heats will fan each other, burning sinews and rotting flesh. Who can master the balance of medication to handle all situations with a single method?
One might ask: In left-sided wind paralysis, pulse diagnosis and symptom differentiation indicate the presence of Phlegm and Heat, which seems correct. Phlegm is generated from Spleen dampness and resides on the right side; thus, one should first treat the right side, yet why treat the left? Since the disease is clearly on the left, why treat the right? This is precisely the most critical aspect of the pathogenesis. It stems from the teachings in Fangshu (medical formularies) by Danxi, stating "disease on the left involves more blood, disease on the right involves more Qi," which led later generations to hold biased views. However, the *Huangdi Neijing* (Yellow Emperor's Inner Canon) contains no such statement. The *Neijing* only states that the left and right are the pathways of Yin and Yang. If the left and right are pathways for the mutual movement of Yin and Yang, how can one be partial? Moreover, although the left side is primarily governed by Blood, without Qi to command it, Blood cannot flow. Although the right side is primarily governed by Qi, without Blood to anchor it, Qi easily scatters. Thus, the Liver and Gallbladder reside on the left, but their Qi often circulates to the right; the Spleen and Stomach reside on the right, but their Qi often circulates to the left. Their mutual infusion ensures continuous life processes. The Liver Wood governs Wind, and Spleen Dampness generates Phlegm; when Wind and Phlegm attack the human body, they do not distinguish between left and right. However, relying on his strong constitution, the patient overconsumed his Essence and Blood. After the age of sixty-four (eight times eight), when Tian Gui (reproductive essence) had exhausted, the left side became deficient first. Consequently, Phlegm generated from diet on the right side and Wind entering from the skin pores gradually accumulated in the empty organs, manifesting suddenly. Wind presents with a forceful and rapid pulse; Phlegm presents with a soft and slippery pulse. Due to the forceful pulse, the large sinews shorten, causing the tongue sinews to also shorten, leading to speech impediment. The small sinews become lax and elongated, causing symptoms to spread from the left to the right. Observing this spread indicates that the small sinews on the left are lax and lack tension. If the small sinews could tense up, the left side would recover. For treating unilateral diseases, the method should follow "drawing Yang from Yin, drawing Yin from Yang, drawing from the left to the right, and drawing from the right to the left." Consider a tree with one side withered: do you water the withered part, or do you water the healthy part to make it flourish, thereby indirectly nourishing the withered part?
In treatment, Ginseng Radix et Rhizoma (Renshen) and Atractylodis Rhizoma (Baizhu) serve as Sovereign (Jun) and Minister (Chen) herbs. With Aconiti Lateralis Radix Praeparata (Fuzi) and Zingiberis Rhizoma Recens (Shengjiang) as Assistant (Zuo) and Envoy (Shi) herbs, one can fearlessly use this formula in cold months. Conversely, with Renshen and Baizhu as Sovereign and Minister, and Antelopis Cornu (Lingyangjiao), Bupleuri Radix (Chaihu), Anemarrhenae Rhizoma (Zhimu), and Gypsum Fibrosum (Shigao) as Assistant and Envoy herbs, one can avoid heat-related complications in spring, summer, and autumn. Additionally, acupuncture at the four extremities of the hands and feet is suitable to drain Ying Blood (Nutritive Blood) and promote Qi circulation, fearing that Heat-Phlegm and Deficient Wind may eventually become leprosy-like conditions.
A disciple asked: The classic text states, "The left and right are the pathways of Yin and Yang." Annotations explain this using the Luck Theory (Yunqi) of Si Tian and Zai Quan, and the Left/Right Intercalaries, leaving readers confused. Now, you interpret this with the word "mutual movement" (Wang Huan), which aligns perfectly with Taiji generating Yang through motion and Yin through stillness, the numbers of Heaven and Earth's creation, and the natural cycles of Spring and Autumn. However, I do not know where "movement" begins and where "return" ends. Could you explain? I replied: This is a profound question. The Way of Heaven and Earth dictates that Spring Qi begins on the left and ends on the right; Autumn Qi begins on the right and ends on the left; Summer Qi begins above and ends below; Winter Qi begins below and ends above. The human body follows the same pattern. The classics say, "To know the beginning, first establish the mother." The "mother" refers to the source of the mutual generation of the Five Zang Organs. It is also said that the Five Zang Organs mutually overcome via generation and restriction. For example, Lung Metal on the right moves to the left to generate Kidney Water, which then restricts Liver Wood; Heart Fire on the left moves to the right to generate Spleen Earth, which then restricts Lung Metal. This mutual movement is interwoven endlessly. However, starting from Metal, generation ends in Earth, and restriction ends in Fire; starting from Fire, generation ends in Wood, and restriction ends in Water. This is the sequence within the interweaving. Extending this to the Twelve Meridians, such as Zi hour injecting Shaoyang Gallbladder and Chou hour injecting Jueyin Liver, also follows this sequence. Indeed, by establishing the root and deducing the categories, the general outline of beginnings and endings becomes clear.
Another question: Does the mutual movement of pathogenesis in the left/right and upper/lower have a sequence? I answered: The sequence of pathogenesis movement consists only of Smooth Transmission (Shun Chuan) and Reverse Transmission (Ni Chuan). Smooth transmission passes to what it generates, following the natural order of Heaven and Earth (e.g., Spring to Summer, Summer to Late Summer, Late Summer to Autumn, Autumn to Winter, Winter back to Spring). This is not considered pathological, or if it is, it is mild. Reverse transmission passes to what it restricts; mild illness becomes severe, and severe illness leads to death. For example, Spring transmitting to Late Summer, Late Summer to Winter, Winter to Summer, Summer to Autumn, and Autumn to Spring—this contradicts the natural order and causes disease. Some say: The classics state "intermittent transmission implies survival, seven-fold transmission implies death," so intermittent transmission must be smooth, and seven-fold transmission must be reverse. I say: No. Commentators on the *Nanjing* claim intermittent transmission is smooth, skipping one organ. This error arises from mistakenly believing pathogenesis only rotates right-to-left and not left-to-right, due to ignorance of the left-right mutual movement principle. If we question whether Kidney Water skipping one organ to transmit to Heart Fire is reverse transmission (a thief pathogen), they would have no answer. Thus, both intermittent and seven-fold transmissions determine life and death within the context of reverse transmission. Intermittent transmission means: Heart disease should reverse-transmit to Lung, but instead transmits to Liver (which Lung restricts); Lung disease should reverse-transmit to Liver, but instead transmits to Spleen (which Liver restricts). This applies to Liver, Spleen, and Kidney diseases as well. Because the organs are not subjected to restrictive theft, survival is possible. Seven-fold transmission means: The previous six transmissions have already covered the five Zang organs in reverse order. The seventh transmission repeats the reverse cycle. For instance, Heart disease starts; second transmission injures Lung; third injures Liver; fourth Spleen; fifth Kidney; sixth returns to Heart; seventh enters Lung again. Since Lung was already injured earlier, it suffers a second blow from the thief pathogen, leading to Qi exhaustion and death. This is the "one Zang cannot bear two injuries" principle. Unlike Shanghan (Cold Damage) meridian transmission, where completing the cycle and re-transmitting is harmless. The *Zhenjing* (Classic of Acupuncture) states: "A skilled acupuncturist treats the right with the left, and the left with the right." Acupoints on the body are symmetrical left and right, yet treatment must be exchanged. This applies to upper and lower parts as well, clarifying the mechanism of mutual movement.
Another question: Hemiplegia originally distinguishes between left and right. After distinguishing left and right, does the disease proceed irreversibly? Why has treatment been ineffective? I answered: Wind and Phlegm attack humans according to their own nature, initially having no fixed form. Once the disease forms, it does not proceed irreversibly. Generally, there is forward movement and return. This applies to Heavenly cycles, human affairs, and pathogenesis. Wind is the Qi of the four seasons and eight directions, entering through the nose—it is Heavenly Qi. Phlegm is the taste of grains and foods, entering through the mouth, condensed from Spleen-Stomach dampness—it is Earthly Qi. Their forces are distant but can combine. They resemble Internal Injury combined with External Contraction, often mixing and confusing diagnosis. Therefore, if Wind dominates, treat Wind first; if Phlegm dominates, treat Phlegm first; if equal, treat both. This is the fixed rule. The *Neijing* says: Wind attacking humans enters first through the skin and hair, then muscles, then sinews, then bone marrow. Skilled practitioners treat the skin/hair first, then muscles. From this, we see the progression from right to left. Skin/hair is governed by the Right Lung; muscles by the Right Stomach; sinews/meridians by the Left Liver; bone marrow by the Left Kidney. Pathogens entering from outside go deeper; thus, treating skin/muscles prevents deep penetration. Also: Dampness attacks humans starting from the feet, moving upward regardless of left or right. However, individuals with inherent excess Internal Wind are prone to attracting External Wind; those with inherent excess Internal Dampness attract External Dampness. Those with Internal Wind are injured before the great atmospheric changes occur; those with Internal Dampness feel heavy before the room's foundation stones become moist. Therefore, treatment must follow the category. Pathogens entering from outside should be gradually driven out; pathogens rising from below should be gradually driven down. Allowing them to proceed irreversibly defeats the purpose of treatment.
Another question: Driving out pathogens from outside and down from below sounds refreshing. Do ancient methods align with this? I answered: These are methods tested by ancients but not explicitly stated, so their intent is unknown. For example, in Da Xiao Xu Ming Tang (Large and Small Life-Extending Decoctions) for treating Wind, formulas contain Guizhi Tang (Cinnamon Twig Decoction) ingredients like Cinnamomi Ramulus (Guizhi), Fuzi, Poria (Fuling), Baizhu, Ephedrae Herba (Mahuang), and Saposhnikoviae Radix (Fangfeng). The combination of interior and exterior treatments is complex, and modern practitioners find it difficult to use. However, using Fuzi and Guizhi drives out interior pathogens; using Fuling and Baizhu drives out middle-jiao pathogens; using more Mahuang and Fangfeng (exterior-releasing herbs) aims to expel interior pathogens from the exterior. For chronic illness with deficiency and deep-penetrating Wind, there are methods for slight sweating with one breath, slight purgation over ten days, balancing for fifteen to thirty days, and gentle dispersal. Ancients had established rules. Rules for treating Phlegm are not found in formularies. For Phlegm in the upper jiao, use Citri Reticulatae Pericarpium Verum (Gua Di San) and Gardeniae Fructus cum Soja Fermentata (Zhi Chi Tang); on the left, use Longdan Xiegan Wan (Dragon Gallbladder Draining Pill); on the right, use Gun Tan Wan (Rolling Phlegm Pill); for deficient patients, use Zhuli Datang Wan (Bamboo Juice Phlegm-Expelling Pill); for deep cold and stagnation, use San Jian Tang (Three Establishments Decoction). These seem simple, but perhaps the subtlety of mastery cannot be written down. I now teach you these principles. Five flavors enter the mouth and store in the Stomach. The Stomach is the Sea of Water and Grain and the commander of the Five Zang and Six Fu organs. Excessive eating condenses into Phlegm-Saliva, which spreads into the collaterals along with the Spleen's transportation function. This mutual movement resembles tides. When Spleen Qi moves, the tide goes out; when Spleen Qi stops, the tide returns. Therefore, treating deep stagnation uses only pungent-hot herbs to slightly stir cold Phlegm, then stops. If continued, Phlegm may move recklessly due to heat, causing significant harm. Not only Phlegm, but the Spleen itself may overwork incessantly, like a tide with no return, leading to catastrophic Phlegm disorders. People taking harsh tonics often desire food late at night, unaware of the reason, rejoicing in their appetite. They fail to cherish Spleen Qi, allowing it to transform by day and rest by night to maintain regularity. Furthermore, since body Phlegm flows from the Stomach to the collaterals, Phlegm in the collaterals must return to the Stomach to be expelled via vomiting or defecation. This can only happen when Spleen Qi is at rest. Therefore, Phlegm patients should rest between breakfast and lunch, keeping Spleen Qi inactive so Phlegm in collaterals can return to the Stomach and move up/down via Stomach Qi, rather than spreading via Spleen Qi. Observe that patients with mild Phlegm disease sleep peacefully at night and vomit/defecate Phlegm early the next morning. Severe patients, upon waking from coma, can also expel Phlegm. Is this not because fasting allows Spleen Qi to rest, providing an exit for Phlegm? Those who love using hot herbs for aggressive attack rarely understand this. Alas, many take pungent-hot herbs and gain nighttime appetite. Will they ponder these humble words?
Mr. Hu Youchen said: Your knowledge is profound, hence your explanation is detailed. Yet all is based on the *Neijing*, not original invention; yet it possesses divine insight, not mere imitation. I previously admired Wang Yutai and Miu Zhongchun greatly; they truly understood Guan Zhong and Yan Ying as the people of Qi did.