叶派之轻以去实，辛凉透邪，如桑叶者，治肺也，陆氏之轻以去实，辛凉透邪，如葛根者，治胃也。轻以去实虽同，治肺治胃大别。叶氏治温病，独重肺系，故谓“温邪上受，首先犯肺”；陆氏治温病，独重胃系，故谓；“温病即阳明病”。故叶氏之治温病，初起必用桑叶、薄荷，桔梗、牛蒡之属，肺药也，陆氏之治温病，初起必用葛根，黄芩，黄连、山栀之类，胃药也。唯叶氏亦知伏气温病不与暴感门同法，故曰：春温一证，冬寒内伏，藏于少阴，以黄芩汤为主方，苦寒直清里热，乃正治也，陆氏亦知温病之邪，在肺胃者，不得独用胃经药，故《不谢方》之治春温、风温者，亦用桑，薄、翘，桔之类也。温病初起，有在肺者，有在胃者，有肺胃二及者，有竟在三阴者。或伏邪从内而出外，或新感由表而入里，或新感引动伏邪，或伏邪又兼新感，或始终但病一经，或发即数经同病，故《难经》云：“温病之脉，行在诸经，不知何经之动，各随其经所在而取之。”温病初起之治，原不可以一经印定眼目，然吴鞠通固执叶氏之说，以为温病初起，必先犯肺，竟谓凡病温者，均始于上焦，在手太阴。后世盲从，踵其讹误，遂以轻清平淡为一切温病初起之治规，盖惑于“温邪上受，首先犯肺”，“治上焦如羽，非轻不举”等说也。叶氏以肺药治肺经病，未误。后人以肺药治胃经病，大谬。治肺宜辛淡轻宣，不可卑用芩、连苦寒者，盖恐胃本无热，而早投苦寒凉中，中寒气馁，则转失托邪外出之力，反招冰伏之弊也。治胃宜积极撤热，不可但用桑叶、薄荷者，盖恶病属中焦，而反治上焦，射不中的，坐使热灼阴伤，用药轻淡如儿戏，终至步步深入也。惟邪机概以从更出表为顺，故病之在肺者，初起必以辛散为宗，宜桑叶之类以轻举之；病之在胃者，初起亦以达邪为旨，宜葛根之类以透解之。然若因此小同，竟忽彼大异，则陆氏斥叶吴学派似肺药治胃之旨，固不得大白于世矣！“麻黄之轻扬，可去伤寒之实，葛根之轻扬，可去温病之实。”其去实亦同，然寒温相异也。斯陆氏已辨之矣。葛根之轻扬，可去手阳明之实，桑叶之轻扬，可去手太阴之实。此陆氏所未言，然亦正其砭斥时弊之宗旨，何后人反于此昧昧耶。须知只须辛凉轻剂，如桑叶配薄、桔之类，其病即可立愈者，无非伤风、肺胀之属也。而必须旱投苦泄，如葛根合芩、连之类，尚恐热盛蒸脑者，乃是暑痉，湿温之属也。病之轻重悬绝，用药肺胃有异，未可同日语也。总之，能“遽入心包，为一场大病，以致于死者。”必非肺经温病，如伤风、肺胀之属，故陆氏重阳明之治，有轻则芩连葛根，重则硝黄石膏之主张。用轻剂病不解，入营入血，动风发痉，而仍曰：病属上焦，初用辛凉宣其肺，终用芳香开心窍，有是证，用是药，治未尝误。此正犯病中治上，撤热被动之误。乃后人既不解叶氏慎苦寒，是为邪热在肺，故主用桑叶、薄，桔之类宣散之以解郁热；又不解陆氏之激言，是为砭时医肺胃不分，初起概用肺药之弊而发，故力倡用葛根、芩、连之类清透以祛胃热，乃终至从陆氏之抨击叶吴学说中，得出益可证叶派这一治疗学思想科学性之认识，则诚非陆氏生前之所能料！
周姓案前后共十四诊，病程较长，记录完整。通过此案，我们可以看到银翘散，桑菊饮，三仁汤，化斑汤、复脉汤、增液承气汤等方在温病治疗中的具体运用。就反映吴鞠通的温病之学来说，这是一个很有代表性的例案，故特详加析评，以与伺仁共研究。
壬戌八月十六日周十四岁伏暑内发，新凉外加，脉右大左弦，身热如烙，无汗，吐胶痰，舌苔满黄，不宜再见泄泻，不渴，腹胀，少腹痛。是谓阴阳并病，两太阴互争，难；台之症，议先清上焦湿热，盖气化湿热亦化也。
飞滑石三钱连翘二钱象贝母一钱杏仁泥三钱银(：二钱白通草一钱老厚朴二钱鲜梨皮二钱生苡仁一钱五分竹叶一钱今晚一帖，明早一帖。析：鞠通根据“暑温伏暑，名虽异而病实同”，“暑兼湿热，偏于暑之湿者为湿温”等认识，初诊选方，采用三仁汤加减。因发热很高，故去蔻仁、半夏之温燥；加银花、连翘以清热；并加芦根、梨皮以护津，而象贝一味，是为咳吐胶痰设。
评：此案热自内发，寒从外束，证见高热无汗，苔黄痰帖，脉证合参，的系手太阴温病，但与足太阴脾实无涉。值此口不渴，津液尚未大伤之际，若能不受“温病忌用麻黄”等观念之束缚，投以大剂麻杏石甘汤(但《温病条辨》之麻杏石甘汤麻黄石膏等分，则不可用)，积极撤热，津即可保，若能汗出热解，肺气自然清肃。倘若是处理，力挫病势，原可指望。但吴氏计不及此，不但于撤热一项轻描淡写，且以淡渗芳化为重点，此所以后来有阴津大伤之变。
十七日案仍前。
飞滑石三钱连翘二钱鲜梨皮一钱-五分杏仁泥一钱五分冬桑叶一钱银花二钱老厚朴一钱五分薄荷八分扁豆皮二钱苦桔梗一钱五分芦根二钱荷叶边一钱五分炒知母一钱五分午一帖，晚一帖，明早一帖。
析：前方服后未效，故二诊更弦易辙，改用银翘散加减。《温病条辨》治太阴伏暑，不论表虚表实，不论气分血分，概以此为基本方。鞠通说：“太阴伏暑，舌白口渴，无汗者，银翘散去牛蒡、玄参加杏仁，滑石主之。”其自注说这是邪在气分而表实的治法。今观此诊，药法正是属此。因高热未退，故去性温之荆芥、豆豉，代之以凉散之桑叶；并加知母之苦寒，与芦根、梨皮之甘寒，合化阴气，以治热淫所胜。为病属伏暑，故复加扁豆衣、厚朴、荷叶边偕滑石等以清暑化湿。
比较前两诊之用药，有异有同。初诊虽亦用银、翘等清热，但重点在化湿；二诊虽亦用滑、朴等化湿，但重点在散热，故主方各异。但治疗上注重调畅气机，目的都在冀暑湿分解、肺得清肃，此则相同。这种药法，与“冶上焦如羽，非轻不举”的理论相一致。
评：凡外感病初起即见高热无汗、痰粘苔黄等脉证者，其轻重与伤风感冒类小病相悬绝，若用轻清芳淡之剂如三仁汤、银翘散等去治疗，往往不能有效地截断逆转病势，这是鞠通的经验，所以说是“难治之症”。但由于他崇信叶氏学说太过，明知这样的治疗未必有效，仍然用这样的方药去处理，一若舍此别无他法，故以后的日治日重，原都是意料中事。实际上中医治法很多，此诊如果不受“到气才可清气”观念的束缚，在辛散药中及早加入鸭跖草、鱼腥草、黄芩，瓜萎仁、桑皮之类，积极控制肺部炎证，有效地截断逆转，不是没有可能的。
十八日两与清上焦，热已减其丰，手心热甚于手背，谓之里热，舌苔红黄而厚，为实热。宜宣之，用苦辛寒法。再按：暑必夹湿，腹中按之痛胀，故不得不暂用苦燥。杏仁泥三钱真山连(姜汁炒黄)一钱五分广木香一钱黄苓炭一钱厚朴一钱五分小茴香(炒黑)一钱五分梧蒌(连皮仁)八分炒知母一钱五分小枳实(打碎)一钱五分槟榔八分广皮炭一钱煮二杯，分二次服。
析：热邪己由表入里，故三诊时撤去银、翘、桑、薄类卫分药，改用芩、连、通、知等气分药。对腹胀腹痛，鞠通一直认为是湿阻太阴，气机不利所致，有鉴以前用厚朴，滑石等化湿理气未效，故复加入茴香、木香、枳实、槟榔、广皮炭等许多的温燥理气药。结合《温病条辨》“暑兼湿热，偏于暑之热者为暑温，多手太阴证而宜清；偏于暑之湿者力湿温，多足太阴证而宜温”这段文字来分析比较前后两诊的用药，可以认为：二诊是以轻宣郁热为主，其治侧重于手太阴，三诊虽用了芩、连等苦寒品，但与大量温燥药为伍，目的主要在燥湿理气，其治疗重点已从手经移到了足经。故前两诊治疗重心在上焦，三诊之治则重点已在中焦了。
评：此案为肺系疾病，相当于肺炎一类。肺与大肠相表里，肺炎高热伴有肠燥便闭者时有之。鞠通制宣白承气汤一方，对此类证是比较合适的。但三诊时由于受“暑必夹湿”说之影响，将热灼津伤，肠中燥屎引起的“腹中按之痛胀”，误作湿阻气机所致，故自然不会想到应该用宣白承气汤之类去治疗。三诊时由于误燥屎为湿阻，故用药燥湿理气竞重于清热，在实热正炽的情况下，这样处理，就不可避免地加速了病从燥化的进程，故服后第二天，即舌苔干燥黄黑，津伤之象毕露。
十九日腹之痛胀俱减，舌苔干燥黄黑，肉色绛，呛咳痰粘。幼童阴气未坚，当与存阴退热。
麦冬(不去心)六钱煅石膏四钱丹皮五钱沙参三钱细生地四钱杏仁三钱元参五钱炒知母二钱蛤粉三钱犀角二钱生甘单一钱煮三杯，分三次服。
析：病变从卫而气，继续向营血分发展，阴津亦迅速为邪热所劫伤，所以舌绛苔干，有鉴于此，故治疗上来了个180度的大转弯，从主以淡渗香燥改为甘寒滋润了，这在本案之治疗，是一个明显的转折点。分析四诊之药，可以认为是合并了化斑汤、增液汤、犀角地黄汤数方后加以化裁而成。其目的是在存阴退热、养阴敌阳，但因呛咳痰粘，故再加沙参、蛤粉、杏仁，以冀发挥化痰止咳之作用。
评：此案初起，阴津本未大损，因治疗中撤热不力，又屡用淡渗苦燥，才加速了津液的灼伤，今责之幼童阴气未坚，是不事实的。当热正劫阴之际，当急清其劫阴之热；治疗以养阴为主，也显得本末倒置。化斑汤清热作用得力于石膏、知母，今此二味之剂量不及原方之半，且石膏又用煅而不用生，此均不得法。至于犀角一味昂贵不必说，且“能耗散气血”，用于此证，亦无必要。
二十日津液稍回，潮热，因宿粪未除，夜间透汗，因邪气还表，右脉仍然浮大，未可下，宜保津液，护火克肺金之嗽。
细生地六钱元参六钱霍石斜三钱焦白芍四钱麦冬六线柏于霜三钱煅石膏三钱牡蛎粉一钱五分杏仁泥二钱犀角一钱煮三杯，陆续服。
析：此诊提到宿粪，说明对燥屎已开始有所注意。对热从燥化之温病，鞠通“并苦寒亦设禁条”，他说：“举世但知苦能降火，寒能泻热，坦然用之而无疑，不知苦先入心，其化以燥，服之不应，愈化愈燥”，“吾见温病而恣用苦寒，津液干涸不救者甚多”，此案先前用了不少淡渗苦燥品，现在津伤十分明显，故此时用药，对此已十分小心，秉着“增水可以行舟”，“养阴可以敌阳”的认识，故去掉知母、丹皮之苦寒，加入石斛、白芍之柔润，以冀避免“苦能化燥”并增强养阴生津之作用。至于甘草一味，“其有阴既亏而实邪正盛”者，即不合拍，此案右脉浮大，邪热正盛，故去之。而牡蛎既能养阴，且能清热，故加用之。
评：此案先见卫气证，后见营血证；先见上焦证，后见下焦证，病情明明是逐步的加重，但案语：予清上焦，则“热已减半”；暂用苦燥，则“腹之痛胀俱减”，改与存阴，则“津液稍回”，养阴保肺，则“诸证悉减”。好象是每诊有效，这样饰词，就写医案来说，是不够朴实的。五诊时热邪尚炽，泻火正可保阴，今将知母、丹皮减去，芩、连等药绝不一用，亦是小心过度，这可能是受叶氏“营分受热，即撤去气药”说之影响。
廿一日诸证悉解，小有潮热，舌绛苔黑，深入血分之热未除也，用育阴法。
沙参三钱大生地五钱牡蛎三钱麦冬(不去心)六钱焦白芍四钱丹皮三钱天冬一钱五分柏子霜三钱甘草(炙)二钱头煎二杯，二煎一杯，分三次服。
廿二日津液消亡，舌黑干燥，用复脉法。
大生地六钱麦冬(不去心)六钱拍子霜四钱炒白芍六钱丹皮四钱火麻仁三钱生鳖甲六钱阿胶(冲)三钱炙甘草三钱生牡蛎四钱头煎三杯，今日服；二煎一杯，明早服。
析：六诊时阴虚症状日显，而石斛、石膏、杏仁偏重于治肺胃，今去此数味而加入炙草，与地、芍、麦冬等合用，移步转换，已有准备用复脉意。此时复用丹皮，是因血分之热未除，加入天冬，是为加强清热养阴之作用。至廿二日，津液消亡，已无可讳言，乃遂按“复脉为热邪劫阴之总司”的认识，正式作下焦温病处理。鞠通认为：凡热邪深入下焦，舌干齿黑，当防痉厥发生，不应俟其已厥而后治，故“以复脉复阴，加入介属潜阳”，组成二甲复脉汤，加减化裁，以冀“使阴阳交纽，庶厥可不作也”。
评：从19日开始，天天以存阴为念，淡渗温燥一列摒绝，连苦寒清热药都十分谨慎，然三天之后，仍然“津液消亡”，这正是忽视清肺撤热所造成的。此案因肺部炎证一直未能有效地控制，在邪热灼阴伤津，势若奔马之际，仍胶柱鼓瑟，徒曰存阴，结果，阴津之伤于药后者，反更甚。陆九芝之所以猛烈抨击叶派药法，说其撤热不力，就是为此。其间用石斛养胃，亦不得法，对此，恽铁樵已有批评，此及“复脉为热邪劫阴之总司”等问题，笔者已另有专文评述，故不再复赘。
麦冬(不去心)一两细生地五钱象贝三钱沙参三钱杏仁泥三钱冬桑叶三钱玉竹三钱苦桔梗三钱甘草三钱丹皮二钱茶菊花三钱梨皮三钱一帖分二次煎，每煎二茶杯，共分四次服。
廿四日舌黑苔退，脉仍数，仍咳，腹中微胀。
[Background Information]
Book: Re Bing Heng Zheng (Standardization of Heat Diseases) Chapter: Main Text (17/49) Category: Shang Han (Cold Damage)
The Ye School advocates using light and clear herbs to dispel excess pathogens, employing acrid-cool methods to vent the pathogens. For example, Sang Ye (Mulberry Leaf) treats Lung diseases. The Lu School also advocates using light and clear herbs to dispel excess pathogens, employing acrid-cool methods to vent the pathogens. For example, Ge Gen (Kudzu Root) treats Stomach diseases. Although both schools use "lightness to remove excess," treating the Lung and treating the Stomach are fundamentally different. Ye Tianshi, when treating Wen Bing (Warm Diseases), places special emphasis on the Lung system, hence he stated: "Warm pathogens enter from above and first invade the Lung." Lu Jiuzhi, when treating Wen Bing, places special emphasis on the Stomach system, hence he stated: "Wen Bing is essentially Yangming disease." Therefore, in the early stage of treating Wen Bing, Ye Tianshi invariably uses herbs such as Sang Ye (Mulberry Leaf), Bo He (Mint), Jie Geng (Platycodon Root), and Niu Bang Zi (Burdock Fruit); these are Lung herbs. In contrast, Lu Jiuzhi invariably uses Ge Gen (Kudzu Root), Huang Qin (Scutellaria Root), Huang Lian (Coptis Rhizome), and Shan Zhi (Gardenia Fruit) in the early stage; these are Stomach herbs. Only Ye Tianshi understood that Hidden-onset Warm Disease differs from Acute-onset Warm Disease and should not be treated with the same method, stating: "For Spring Warmth, winter cold hides internally within the Shaoyin Meridian; Huangqin Decoction is the primary formula, using bitter-cold herbs to directly clear interior heat, which is the correct treatment." Lu Jiuzhi also knew that if Wen Bing pathogens are in the Lung and Stomach, one cannot use only Stomach meridian herbs. Thus, in *Bu Xie Fang*, when treating Spring Warmth and Feng Wen (Wind Warmth), he also used Sang Ye (Mulberry Leaf), Bo He (Mint), Lian Qiao (Forsythia Fruit), and Jie Geng (Platycodon Root). In the early stage of Wen Bing, the pathology may be in the Lung, in the Stomach, in both Lung and Stomach, or even in the Three Yin Meridians. Pathogens may emerge from the interior to the exterior, or new pathogens may enter from the exterior to the interior. New pathogens may trigger hidden pathogens, or hidden pathogens may coexist with new ones. The disease may remain confined to one meridian throughout, or multiple meridians may be affected simultaneously upon onset. Thus, *Nan Jing* states: "The pulse of Wen Bing circulates through various meridians; without knowing which meridian is affected, one must treat according to the location of the pathology." The treatment of early-stage Wen Bing should not be rigidly fixed to a single meridian pattern. However, Wu Jutong stubbornly adhered to Ye Tianshi's view, believing that Wen Bing always begins by invading the Lung, claiming that all cases of Wen Bing start in the Upper Jiao, specifically the Hand-Taiyin Lung Meridian. Later generations blindly followed, perpetuating this error, and established light, clear, and bland herbs as the standard for all early-stage Wen Bing treatments. This was likely due to being misled by statements like "Warm pathogens enter from above and first invade the Lung" and "Treating the Upper Jiao is like feathers; only lightness can lift it." Ye Tianshi using Lung herbs to treat Lung meridian disease was not erroneous. However, later practitioners using Lung herbs to treat Stomach meridian disease was a major mistake. Treating the Lung requires acrid-bland and light dispersal methods; one should not humbly resort to bitter-cold herbs like Huang Qin and Huang Lian. This is because if the Stomach has no inherent heat, administering bitter-cold and cooling herbs too early will cause coldness and weakness in the Middle Jiao, thereby losing the power to push pathogens outward, instead causing "ice-stagnation" (pathogens frozen inside). Treating the Stomach requires actively clearing heat; one should not merely use Sang Ye and Bo He. If the disease belongs to the Middle Jiao but is treated as Upper Jiao, it is like missing the target, allowing heat to scorch and damage Yin fluids. Using light and bland medications is like child's play, leading to progressive deepening of the disease. Only by viewing the emergence of pathogens from the interior to the exterior as favorable can we understand that for diseases in the Lung, early treatment must prioritize acrid dispersal, suitable for light lifting with Sang Ye; for diseases in the Stomach, early treatment aims to vent pathogens, suitable for resolving with Ge Gen. However, if one ignores the significant differences due to minor similarities, Lu Jiuzhi's criticism of the Ye-Wu school's misuse of Lung herbs for Stomach diseases would never have been clarified. "Ma Huang (Ephedra Herb)'s lightness can remove excess in Shang Han; Ge Gen's lightness can remove excess in Wen Bing." Their ability to remove excess is similar, yet Cold and Warm pathogens differ. Lu Jiuzhi had already distinguished this. Ge Gen's lightness removes excess in the Hand-Yangming Large Intestine Meridian; Sang Ye's lightness removes excess in the Hand-Taiyin Lung Meridian. Lu Jiuzhi did not explicitly state this, but it aligns with his purpose of criticizing contemporary medical flaws. Why are later generations so confused? One must realize that conditions curable immediately with acrid-cool light agents, such as Sang Ye combined with Bo He and Jie Geng, are limited to Common Cold and Lung Distension. Conditions requiring early administration of bitter-draining agents, such as Ge Gen combined with Huang Qin and Huang Lian, where heat steams the brain, are Summer Heat Spasm and Damp-Warmth. The severity of diseases varies greatly, and medication differs based on Lung or Stomach involvement; they cannot be compared. In short, if "pathogens suddenly enter the Pericardium, causing severe illness and death," it is definitely not a Lung meridian Wen Bing like Common Cold or Lung Distension. Therefore, Lu Jiuzhi advocated prioritizing Yangming treatment: mild cases use Huang Qin, Huang Lian, and Ge Gen; severe cases use Mang Xiao (Mirabilite), Da Huang (Rhubarb Root), and Shi Gao (Gypsum). If light agents fail and pathogens enter the Ying Level or Blood Level, causing wind stirring and spasms, yet one still claims the disease is in the Upper Jiao, initially using acrid-cool to ventilate the Lung and finally using aromatic herbs to open the orifices of the Heart—this is "treating according to symptoms"—the treatment itself is not wrong. This is precisely the error of treating the Middle Jiao disease via the Upper Jiao and passively clearing heat. Later generations failed to understand that Ye Tianshi's caution against bitter-cold herbs was because pathogens were in the Lung, thus advocating Sang Ye, Bo He, and Jie Geng to disperse stagnant heat. They also failed to understand that Lu Jiuzhi's sharp remarks were aimed at criticizing contemporary doctors' failure to distinguish between Lung and Stomach, leading to the indiscriminate use of Lung herbs in early stages. Consequently, they vigorously advocated using Ge Gen, Huang Qin, and Huang Lian to clear and vent Stomach heat. Ultimately, deriving support for the scientific nature of Ye School's therapeutic ideology from Lu Jiuzhi's critique of the Ye-Wu school was something Lu Jiuzhi could not have anticipated!
Analysis and Commentary on Case of Surname Zhou in the Hidden Summer-Heat Section of *Wu Jutong's Medical Cases*
Case of Surname Zhou comprises fourteen consultations over a long course, with complete records. Through this case, we observe the specific application of formulas such as Yinqiao Powder, Sangju Decoction, Sanren Decoction, Huaban Decoction, Fumai Decoction, and Zengye Chengqi Decoction in treating Wen Bing. Reflecting Wu Jutong's theory of Wen Bing, this is a highly representative case, warranting detailed analysis and commentary for joint study with Yun Tieqiao.
On the 16th day of the 8th month of Renxu Year, a 14-year-old patient named Zhou suffered from internal onset of Hidden Summer-Heat and external contraction of fresh coolness. The pulse was large on the right and wiry on the left. Body temperature was high as if branded, with no sweat, expectoration of gelatinous phlegm, yellow coating covering the entire tongue, absence of diarrhea, no thirst, abdominal distension, and lower abdominal pain. This is termed simultaneous disease of Yin and Yang, with mutual contention between the two Taiyin systems, making it difficult to treat. It is proposed to first clear damp-heat from the Upper Jiao, as Qi-transforming damp-heat can also be resolved.
Fei Hua Shi (Talcum) 3 qian, Lian Qiao (Forsythia Fruit) 2 qian, Xiang Bei Mu (Fritillaria Thunbergii Bulb) 1 qian, Xing Ren Ni (Almond Paste) 3 qian, Yin Hua (Honeysuckle Flower) 2 qian, Bai Tong Cao (Akebia Stem) 1 qian, Lao Hou Po (Magnolia Bark) 2 qian, Xian Li Pi (Fresh Pear Peel) 2 qian, Sheng Yi Ren (Coix Seed) 1.5 qian, Zhu Ye (Bamboo Leaf) 1 qian. One dose tonight, one dose tomorrow morning.
Analysis: Based on the understanding that "Shu Wen and Fu Shu, though named differently, share the same pathology," and "Summer Heat combines with Damp-Heat; when biased towards dampness, it is called Damp-Warmth," Wu Jutong selected Sanren Decoction with modifications for the first consultation. Due to high fever, he removed the warm-drying Cardamom Seed and Pinellia Tuber; added Honeysuckle Flower and Forsythia Fruit to clear heat; and added Reed Rhizome and Pear Peel to protect fluids. Xiang Bei Mu was included specifically for expectorating gelatinous phlegm.
Commentary: In this case, heat originates internally while cold binds externally. Symptoms include high fever, anhidrosis, yellow coating, and sticky phlegm. Pulse and symptoms confirm Hand-Taiyin Lung Wen Bing, unrelated to Foot-Taiyin Spleen excess. At this stage, with no thirst and undamaged Yin fluids, if not bound by concepts like "avoid Ma Huang in Wen Bing," administering a large dose of Ma Xing Shi Gan Tang (note: the version in *Wen Bing Tiao Bian* with equal parts Ma Huang and Shi Gao should not be used) to actively clear heat could preserve Yin fluids. If sweating occurs and heat resolves, Lung Qi would naturally become clear and descending. Such management could have checked the disease progression. However, Wu Jutong overlooked this, downplaying heat clearance and focusing on mild diuresis and aromatic transformation, leading to subsequent severe Yin fluid depletion.
Consultation on the 17th Day remains the same.
Fei Hua Shi 3 qian, Lian Qiao 2 qian, Xian Li Pi 1.5 qian, Xing Ren Ni 1.5 qian, Dong Sang Ye (Winter Mulberry Leaf) 1 qian, Yin Hua 2 qian, Lao Hou Po 1.5 qian, Bo He (Mint) 0.8 fen, Bian Dou Pi (Lablab Bean Coat) 2 qian, Ku Jie Geng (Bitter Platycodon Root) 1.5 qian, Lu Gen (Reed Rhizome) 2 qian, He Ye Bian (Lotus Leaf Edge) 1.5 qian, Chao Zhi Mu (Stir-fried Anemarrhena Rhizome) 1.5 qian. One dose at noon, one at night, one tomorrow morning.
Analysis: Since the previous prescription was ineffective, the second consultation changed strategy, switching to modified Yinqiao Powder. *Wen Bing Tiao Bian* states that for Taiyin Hidden Summer-Heat, regardless of deficiency/excess of the exterior or Qi/Blood levels, this is the basic formula. Wu Jutong noted: "For Taiyin Hidden Summer-Heat with white tongue coating, thirst, and anhidrosis, use Yinqiao Powder removing Niu Bang Zi and Xuan Shen, adding Xing Ren and Hua Shi as chief herbs." His annotation explains this treats pathogens in the Qi level with exterior excess. Observing this consultation, the method aligns with this. Due to persistent high fever, warm herbs Schizonepeta Spike and Fermented Soybean were removed and replaced with cooling-dispersing Sang Ye; bitter-cold Zhi Mu was added along with sweet-cold Lu Gen and Pear Peel to transform Yin Qi and counteract excessive heat. As the disease is Hidden Summer-Heat, Lablab Bean Coat, Hou Po, Lotus Leaf Edge, and Hua Shi were added to clear summer-heat and transform dampness.
Comparing the first two consultations: there are similarities and differences. The first focused on transforming dampness despite using heat-clearing herbs; the second focused on dissipating heat despite using damp-transforming herbs, hence different main formulas. Both emphasized regulating Qi mechanism to resolve summer-heat/dampness and clear Lung Qi. This aligns with the theory "Treating the Upper Jiao is like feathers; only lightness can lift it."
Commentary: For exogenous diseases presenting with high fever, anhidrosis, sticky phlegm, and yellow coating at onset, the severity is vastly different from common colds. Using light, clear, aromatic, and bland agents like Sanren Decoction or Yinqiao Powder often fails to effectively intercept and reverse the disease trend, a lesson learned by Wu Jutong, hence termed "difficult to treat." However, overly revering Ye Tianshi's theories, Wu continued using these ineffective prescriptions despite knowing their limitations, acting as if no other options existed. Thus, the gradual worsening was predictable. In reality, many TCM methods exist. If not bound by "only clear Qi level after reaching it," adding Commelina Herb, Houttuynia Herb, Huang Qin, Trichosanthes Seed, and Mulberry Root Bark to acrid-dispersing herbs early on could actively control pulmonary inflammation and intercept the disease.
On the 18th Day, after two doses clearing the Upper Jiao, heat reduced by half. Palm heat exceeds back hand heat, indicating interior heat. Red-yellow thick tongue coating indicates excess heat. Dispersal is needed using bitter-acrid-cool method. Note: Summer Heat must combine with dampness; tenderness and distension upon abdominal palpation necessitate temporary use of bitter-drying herbs. Xing Ren Ni 3 qian, Zhen Shan Lian (Jiang Zhi Chao Huang) 1.5 qian, Guang Mu Xiang (Aucklandia Root) 1 qian, Huang Qin Tan 1 qian, Hou Po 1.5 qian, Xiao Hui Xiang (Chao Hei) 1.5 qian, Wu Lou (with peel and seed) 0.8 fen, Chao Zhi Mu 1.5 qian, Xiao Zhi Shi (Crushed) 1.5 qian, Bing Lang (Areca Seed) 0.8 fen, Guang Pi Tan 1 qian. Decoct into two cups, take in two divided doses.
Analysis: Heat pathogen moved from exterior to interior. Third consultation removed Wei-level herbs like Yin Hua, Lian Qiao, Sang Ye, and Bo He, switching to Qi-level herbs like Huang Qin, Huang Lian, Bai Tong Cao, and Zhi Mu. Wu Jutong consistently attributed abdominal distension/pain to dampness obstructing Taiyin and Qi mechanism dysfunction. Seeing previous attempts with Hou Po and Hua Shi failed, he added warm-drying Qi-regulating herbs like Hui Xiang, Mu Xiang, Zhi Shi, Bing Lang, and Guang Pi Tan. Comparing with *Wen Bing Tiao Bian*: "Summer Heat combines with Damp-Heat; biased towards heat is Shu Wen, mostly Hand-Taiyin, suitable for clearing; biased towards dampness is Shi Wen, mostly Foot-Taiyin, suitable for warming." Analysis shows: Second consultation focused on light dispersal of stagnant heat, emphasizing Hand-Taiyin. Third consultation, despite using bitter-cold Huang Qin/Lian, combined them with warm-drying herbs primarily to dry dampness and regulate Qi, shifting focus from Hand to Foot meridians. Thus, first two consultations focused on Upper Jiao; third shifted to Middle Jiao.
Commentary: This case involves Lung system diseases, akin to pneumonia. Lung and Large Intestine are exterior-interior related; pneumonia with high fever and intestinal dryness/constipation occurs. Wu Jutong's Xuan Bai Cheng Qi Decoction is suitable for such patterns. However, influenced by "Summer Heat must combine with dampness," he misattributed abdominal tenderness/distension caused by heat-scorched fluids and dry feces to dampness obstruction. Thus, he did not consider Xuan Bai Cheng Qi Decoction. Misidentifying dry feces as dampness led to prioritizing damp-drying/Qi-regulating over heat-clearing. Under intense excess heat, this accelerated drying transformation. Next day, tongue coating became dry yellow-black, revealing severe fluid damage.
On the 19th Day, abdominal pain/distension decreased. Tongue coating dry yellow-black, flesh color crimson, choking cough with sticky phlegm. Children's Yin Qi is not firm; treatment should preserve Yin and reduce heat. Mai Dong (without heart) 6 qian, Duan Shi Gao 4 qian, Dan Pi (Moutan Cortex) 5 qian, Sha Shen (Glehnia Root) 3 qian, Xi Sheng Di 4 qian, Xing Ren 3 qian, Yuan Shen (Scrophularia Root) 5 qian, Chao Zhi Mu 2 qian, Ha Fen 3 qian, Xi Jiao 2 qian, Sheng Gan Cao 1 qian. Decoct into three cups, take in three divided doses.
Analysis: Pathology progressed from Wei to Qi, continuing to Ying-Blood levels. Yin fluids rapidly damaged by pathogenic heat, resulting in crimson tongue and dry coating. Treatment made a 180-degree turn from mild diuretic/aromatic-drying to sweet-cold-moistening, a turning point. Fourth consultation herbs resemble modified combinations of Huaban Decoction, Zengye Decoction, and Xijiao Dihuang Decoction. Purpose: preserve Yin, reduce heat, nourish Yin to counter Yang. Added Sha Shen, Ha Fen, Xing Ren for expectoration/cough suppression.
Commentary: Initially, Yin fluids were not severely damaged. Ineffective heat clearance and repeated use of mild diuretics/bitter-drying herbs accelerated fluid consumption. Blaming children's immature Yin Qi is factually incorrect. When heat attacks Yin, urgently clearing the attacking heat is priority; prioritizing Yin nourishment reverses cause and effect. Huaban Decoction relies on Shi Gao and Zhi Mu for heat clearance; here doses were less than half original, and Shi Gao was calcined rather than raw, both inappropriate. Xi Jiao is expensive and "consumes Qi and Blood," unnecessary here.
On the 20th Day, fluids slightly recovered. Tidal fever persists due to retained stool. Night sweats indicate pathogen returning to exterior. Right pulse still floating-large; purgation not yet indicated. Preserve fluids, protect against Fire overcoming Lung Metal cough. Xi Sheng Di 6 qian, Yuan Shen 6 qian, Huo Shi Hu (Dendrobium Stem) 3 qian, Jiao Bai Shao (Paeonia Radix Alba) 4 qian, Mai Dong 6 qian, Bai Zi Shuang 3 qian, Duan Shi Gao 3 qian, Mu Li Fen 1.5 qian, Xing Ren Ni 2 qian, Xi Jiao 1 qian. Decoct into three cups, administer gradually.
Analysis: Mention of retained stool indicates attention to dry feces. Regarding Wen Bing transforming from dryness, Wu Jutong set prohibitions even for bitter-cold herbs: "World knows bitter lowers fire, cold clears heat, using them confidently unaware bitter enters Heart first, transforms to dryness... I have seen many Wen Bing cases where indulgence in bitter-cold led to irreversible fluid exhaustion." Previous use of mild diuretics/bitter-drying herbs caused obvious fluid damage. Now cautious, following "increasing water floats the boat" and "nourishing Yin counters Yang," he removed bitter-cold Zhi Mu/Dan Pi, adding moistening Shi Hu and Bai Shao to avoid "bitter transforming to dryness" and enhance Yin generation. Gan Cao excluded as unsuitable for Yin deficiency with excess pathogen; right pulse floating-large indicates strong pathogenic heat. Mu Li added for its Yin-nourishing and heat-clearing properties.
Commentary: Case progressed from Wei-Qi to Ying-Blood, Upper Jiao to Lower Jiao, clearly worsening. Yet case notes claim "heat halved" after clearing Upper Jiao, "pain/distension reduced" after bitter-drying, "fluids recovered" after preserving Yin, "symptoms resolved" after nourishing Lung. This embellishment lacks honesty. Fifth consultation: heat still fierce, purging fire preserves Yin. Removing Zhi Mu/Dan Pi and avoiding Huang Qin/Huang Lian shows excessive caution, possibly influenced by Ye Tianshi's "remove Qi herbs once entering Ying level."
On the 21st Day, all symptoms resolved, slight tidal fever. Crimson tongue, black coating, heat deeply entered Blood level not cleared. Use Yin-nourishing method. Sha Shen 3 qian, Da Sheng Di 5 qian, Mu Li 3 qian, Mai Dong (without heart) 6 qian, Jiao Bai Shao 4 qian, Dan Pi 3 qian, Tian Dong (Asparagus Root) 1.5 qian, Bai Zi Shuang 3 qian, Gan Cao (Zhi) 2 qian. First decoction 2 cups, second 1 cup, take in three divided doses.
On the 22nd Day, fluids exhausted, black dry tongue. Use Fumai Method. Da Sheng Di 6 qian, Mai Dong (without heart) 6 qian, Bai Zi Shuang 4 qian, Chao Bai Shao 6 qian, Dan Pi 4 qian, Huo Ma Ren (Hemp Seed) 3 qian, Sheng Bie Jia 6 qian, E Jiao (dissolved) 3 qian, Zhi Gan Cao 3 qian, Sheng Mu Li 4 qian. First decoction 3 cups, take today; second 1 cup, take tomorrow morning.
Analysis: Sixth consultation showed increasing Yin deficiency. Shi Hu, Shi Gao, Xing Ren focused on Lung/Stomach; removed now. Added Zhi Cao with Di/Shao/Mai Dong, preparing for Fumai Decoction. Reusing Dan Pi addresses lingering Blood-level heat; adding Tian Dong enhances heat-clearing/Yin-nourishing. By 22nd, fluid exhaustion undeniable. Following "Fumai is master for heat damaging Yin," formally treated as Lower Jiao Wen Bing. Wu Jutong believed: "When heat enters Lower Jiao, dry tongue/black teeth, prevent spasms/fainting; do not wait for occurrence. Use Fumai to restore Yin, add shellfish/shells to subdue Yang," forming Er Jia Fumai Decoction to "harmonize Yin-Yang and prevent spasms."
Commentary: From 19th, daily focus on preserving Yin, rejecting mild diuretics/warm-drying, cautiously using bitter-cold. Yet after three days, "fluids exhausted." This resulted from neglecting Lung heat clearance. With uncontrolled pulmonary inflammation and heat ravaging Yin, clinging to "preserving Yin" alone worsened fluid damage. Lu Jiuzhi's fierce critique of Ye School's ineffective heat clearance stems from this. Using Shi Hu to nourish Stomach was also inappropriate, criticized by Yun Tieqiao. Issues like "Fumai as master for heat damaging Yin" are discussed elsewhere, so omitted here.
On the 23rd Day, right pulse still rapid, residual pathogens trapped in Lung, severe cough with difficult phlegm. Propose sweet-moistening combined with cool-ventilating Lung Qi. Mai Dong (without heart) 1 liang, Xi Sheng Di 5 qian, Xiang Bei 3 qian, Sha Shen 3 qian, Xing Ren Ni 3 qian, Dong Sang Ye 3 qian, Yu Zhu (Polygonatum Odoratum Rhizome) 3 qian, Ku Jie Geng 3 qian, Gan Cao 3 qian, Dan Pi 2 qian, Cha Ju Hua 3 qian, Li Pi 3 qian. One dose decocted twice, each time 2 teacups, total four doses.
On the 24th Day, black tongue coating receded, pulse still rapid, cough persists, slight abdominal distension.