【按】此方之药值贱甚，仅需铜元三枚而已。药铺中先生微笑曰，此能愈疾乎？吴君得药，仍取大黑枣，先去其中核，却纳入牙皂末，用线扎枣两端，使勿漏出，计需枣七枚，已将牙皂末装毕，即煎与服。服后，竟又峰回路转，别见柳暗花明。陡有多许白腻之痰浊，悉从大便出，口中吐痰反少，一如师预告。非第此也，前数日饮食常带呕意。予曰：呕者，胃不和也。凡大病久病，有胃则生，胃不和则危，此定例也。今则非第不呕，而且胃纳转佳，又能自起坐大便，或为其他动作矣。又前此卧不得左胁着席者，今则能之。所以然者，前此右肺蓄脓方盛，使用左胁着席，则脓将压诸其他脏器上，因而不舒乎？胸前隆起处，前服三诊方后，即开始降落，今乃悉平。咳嗽时，胸部不再牵痛。又安福消肿膏自经西医敷用，即时常更换，至此乃免除。此方连服三日，功效甚著。自八日起又服前之悬拟方，但去生山梔。其中之醒消丸计守服迄今，自三钱减为一钱，犹未间也，自是顿入坦途，能食饭，怕吃药，嬉戏如常矣。二十九日，吴君又叩调理之方，师曰：五诊夏历八月十四日肺痈已经出险，而阴气大伤，宜《千金》黄昏汤。
合欢皮如手掌大一块用水三碗煎至一碗半作两次服
【按】服此甚佳，食量增，而肌肉丰，虽不时尚有微咳，并带薄痰，是为病后余波．不足虑也。
本病有一特性，即但恶热，不恶寒。夫不恶寒，但恶热者为阳明病。故吾曰肺痈者，阳明病之一格也。夫阳明病以清、吐、下为三大正治，故肺痈之用苇茎，清法也；用桔梗，吐法也；用葶苈牙皂，下法也。《经》曰肺与大肠相表里，故大肠能移热于肺，夫知此，方可以言治肺痈。
曹颖甫曰：凡治此证，痈脓结聚肺部，当开泄肺气，清其郁热，为第一步。及肺藏气疏，咯痰不畅，则以决去痈脓为第二步。及腥臭之痰出尽，而胶痰之未成脓者，尚吐之不已，则以破除痰结为第三步。及胶痰渐少，肺之破碎处当用补救，则以扶养肺阴为第四步。惟补救之方推千金黄昏汤为最。黄昏为合欢皮，张璐玉称其两干相著，即粘合不解，取其粘性实足以补肺藏之罅漏，而收其全功，较世传白芨尤为稳当。敢布腹心，以告同仁。按合欢为马缨花，花红如马缨，五六月始开，校干多连理，予亲见之。盖肺主皮毛，此树之皮彼此易为粘合，故能补肺之绽裂也，又前按谓肺痈病原实出阳明，此说甚精确。盖肠胃燥实，郁热上熏于肺，则肺燥而胶痰生，一日之燥气不除，则一日之胶痰不去。久久热伤肺藏，因变痈脓。故治之之法，第一当开壅清热，其次则当破顽痰，皆所以抉其壅也。
悬饮其一
张任夫劳神父路仁兴里六号初诊二十四年四月四日水气凌心则悸，积于胁下则胁下痛，冒于上膈则胸中胀，脉来双弦，证属饮家，兼之干呕短气，其为十枣汤证无疑。
先用黑枣十枚煎烂，去渣，入药末，略煎和服。
【按】张君任夫，余至友也。先患左颊部漫肿而痛，痛牵耳际，牙内外缝出脓甚多。余曰：此骨糟风也。余尝以阳和汤治愈骨槽风病多人，惟张君之状稍异，大便闭而舌尖起刺，当先投以生石膏，凉膈散各五钱，后予提托而愈。越日，张君又来告曰：请恕烦扰，我尚有宿恙乞诊。曰：请详陈之。曰：恙起于半载之前，平日喜运动蹴球，恒至汗出浃背，率不易衣。嗣觉两胁作涨，按之痛。有时心悸而善畏，入夜，室中无灯炬，则惴惴勿敢入，头亦晕，搭车时尤甚。嗳气则胸隔稍舒。夜间不能平卧，平卧则气促，辗转不宁。当夜深人静之时，每觉两胁之里有水声漉漉然，振荡于其间。……余曰：请止辞，我知之矣。是证非十枣汤不治，药值甚廉，而药力则甚剧。君欲服者，尚须商诸吾师也。君曰：然则先试以轻剂可乎？曰：诺。当疏厚朴，柴胡、藿、佩、半夏、广皮、车前子、茯苓、清水豆卷、白术等燥湿行气之药与之。计药一剂，值银八角余。服之，其效渺然，张君曰：然则惟有遵命偕谒尊师矣。
翌日，余径叩师门，则师诊视张君甫毕，并在立案矣。走笔疾书，方至脉来双弦之句。余问曰；先生，是何证也？曰：小柴胡也。予曰：不然，柴胡之力不胜，恐非十枣不效。先生搁笔沉思，急检《伤寒论》十枣汤条曰：太阳中风，下利呕逆，表解者，乃可攻之。其人执水执水汗出，发作有时，头痛，心下痞鞕满。引胁下痛，乾呕，短气，汗出，不恶寒者，此表解里未和也，十枣汤主之。
因问张君曰：君气短而乾呕乎？曰：良然。师乃顾谓余曰：尔识证确，所言良是也。师乃续其案而书其方，即如上载者是。
又按《金匮》曰：脉沉而弦者，悬饮内痛。又曰：病悬饮者，十枣汤主之。余尝细按张君之脉，觉其滑之成分较多，弦则次之，沈则又次之。以三部言，则寸脉为尤显，与寸脉主上焦之说适合。以左右言，则左脉为较显，盖张君自言左胁之积水较右胁为剧也。
今当报告张君服汤后之情形。张君先购药，价仅八分，惊其值廉。乃煮大枣拾枚，得汤去滓，分之为二。入药末一半，略煎，成浆状物。其夜七时许，未进夜饭，先服药桨，随觉喉中辛辣，甚于胡椒。张君素能食椒，犹尚畏之，则药性之剧可知。并觉口乾，心中烦，若发热然。九时起，喉哑不能作声，急欲大便，不能顷刻停留，所下非便，直水耳。其臭颇甚。于是略停，稍进夜饭，竟得安眠，非复平日之转侧不宁矣。夜二时起，又欲大便，所下臭水更多，又安眠。六时，又大便，所下臭水益增多。又睡至十时起床，昨夜之喉哑者，今乃愈矣。且不料乾呕，嗳气，心悸，头晕者恙均减，精神反佳。张君自知肋膜炎为难愈之疾，今竟得速效如此，乃不禁叹古方之神奇！次日中午，喉间完全复原。下午七时，夜膳如常。九时半，进药，枣汤即前日所留下者。药后，胃院甚觉难堪，胃壁似有翻转之状，颇欲吐，一面心烦，觉热，喉哑，悉如昨日，但略差可。至深夜一时，即泄水，较第一夜尤多。翌晨，呕出饭食少许，并带痰水，又泄臭水，但不多矣。至午，喉又复原，能进中膳如常，嗳气大除，两胁之胀大减。惟两胁之上（乳偏下）反觉比平日为胀。张君自曰，此胁上之胀，必平日已有，只因胁下剧胀，故反勿觉。今胁下之胀除，改胁上反彰明耳。而胆量仍小，眼目模糊，反有增无减，但绝无痛苦而已。
吾人既知服后经验，试更细阅十枣汤之煎服法，两相参研，乃知煎服法虽仅寥寥二三行，而其中所蕴蓄之精义甚多。煎服法曰：右三味，捣筛，以水一升五合，先煮肥大枣十枚，取八合；去滓，内药末，强人服一钱匕，羸人服半钱，平旦温服之，不下者，明日更加半钱，得快下后，糜粥自养。观张君之第一口先药后饭而不呕，第二日之先饭后药而呕，可知也。先药后饭，较先饭后药为愈，亦安知平旦服之云者，不饭而服之也，较先药后饭为更愈乎。又云：快下后，糜粥自养。则其未下以前，不能进食可知。实则下后糜粥自养，较先后俱不饭者为尤佳，此其第一义也。
曰：不下者，明日更加半钱。而不言：不下，更作服。可知明日二字，大有深义，即明日平旦之省文。盖平旦之时，胃府在一夜休养之后，机能较为亢盛，故借其天时之利，以与此剧药周旋耳。且一日一服，不似其他汤药之可以多服，盖一以见药有大毒，不宜累进，一以为胃府休养地步，此其第二义也。
强人一钱匕，羸人则改半钱，斤斤较其药量，倍显慎重之意。何者？其义与上述者正同，此其第三义也。
十枣汤以十枣为君，亦安知十枣之功用为何如乎？东人曰：大枣甘草等药功用大同而小异，要为治挛急而已。说殊混统不可从。吾友吴君凝轩尝历考经方中大枣之功用，称其能保胃中之津液。今观十枣汤之下咽即起燥痛，则甘遂大戟芫花三者吸收水分之力巨可知，入胃之后，虽能逐水驱邪，然克伤津液，在所不免，故投＋枣以卫之，方可正邪兼顾。又吴君谓十枣汤之服法，应每日用十枣煎汤，不可十枣分作两服，以弱保正之功，其说颇有见地。况旧说以枣为健脾之品，又曰脾能为胃行其津液。由此可知枣与胃液实有密切之关系。惟其语隐约，在可解不可解之间，今得吾友之说，乃益彰耳，此其第四义也。
甘遂、芜花、大戟为何作药末以加入，而不与大枣同煎，盖有深意，以余研究所得，凡药之欲其直接入肠胃起作用者，大都用散。薏苡附子败酱歌，世人用之而不效，不知其所用者非散，乃药之汤耳。五苓散，世人用之又不效，谓其功不及车前子通草远甚，不知其所用者非散，亦药之汤耳。至于承气亦直接在肠中起作用，所以不用散而用汤者，盖肠胃不能吸收硝黄，用汤无异散也。其他诸方，用散效、用汤而不效者甚伙。虽然，甘遂等三药为末，入胃逐水，有此说在。又何能逐两胁间之积水乎？曰：水饮先既有道以入胁间，今自可循其道，追之使出，事实如此，理论当循事实行也，此其第五义也。
呜呼！仲圣之一方，寥寥二三行字，而其所蕴蓄之精义，竟至不可思议。凡此吾人所殚精竭虑，思议而后得之者，尚不知其是耶非耶？二诊四月六日两进十枣汤，胁下水气减去大半，惟胸中尚觉胀懑，背痠，行步则两胁尚痛，脉沈弦，水象也。下后，不宜再下，当从温化。
姜半夏五钱北细辛二钱干姜三钱熟附块三钱炙甘草五钱菟丝子四钱杜仲五钱椒目三钱防已四钱
【按】师谓十枣汤每用一剂已足，未可多进。所谓大毒治病，十去其四五是也。又谓甘遂大戟皆性寒之品，故二诊例以温药和之。此方系从诸成方加减而得，不外从温化二字着想。惟据张君自言，服此方后，不甚适意。觉胁上反胀，背亦不舒，目中若受刺，大便亦闭结。按此或因张君本属热体，而药之温性太过欤？三诊四月八日前因腰痠胁痛，用温化法，会天时阳气张发，腰胁虽定，而胸中胀懣，左胁微觉不舒。但脉之沈弦者渐转浮弦。病根渐除，惟大便颇艰，兼之热犯脑部，目脉为赤，当于胸胁着想，用大柴胡汤加厚朴芒硝。
软柴胡三钱淡黄芩三钱制半夏三钱生川军三钱后下枳实三钱厚朴二钱芒硝钱半冲
【按】张君言：服药后，夜间畅下四五次，次日觉胁背均松，胸中转适，精神爽利。诸恙霍然。观此方，知师转笔之处，锐利无比。前后不过三剂，药费不过三元，而竟能治愈半载宿恙之肋膜炎病。呜呼，其亦神矣！曹颖甫曰：凡胸胁之病多系柴胡证，《伤寒 ·太阳篇》中累出，盖胸中属上焦，胁下则由中焦而达下焦，为下焦水道所从出，故胁下水道瘀塞即病悬饮内痛，而为十枣汤证。胸中水痰阻滞，上湿而下燥不和，则为大陷胸汤证。若胸中但有微薄水气，则宜小柴胡汤以汗之。胁下水气既除，转生燥热，则宜大柴胡汤以下之，可以观其通矣。
悬饮其二
宋子载之妻年已望五，素病胸隔胀痛，或五六日不得大解，夜睡初醒，则咽燥舌干。医家或以为浮火，或指为肝气，花粉连翘玉竹麦冬山梔之属，多至三十余剂。沉香青皮木香白芍之属，亦不下十余方。
二年以来，迄无小效。去年四月，延余诊治。余诊其脉双弦，曰：此痰饮也。因用细辛干姜等，以副仲师温药和之之义。宋见方甚为迟疑。
曰：前医用清润之品，尚不免咽中干燥，况于温药？余曰：服此当反不渴。宋口应而心疑之。其妻毅然购药，一剂而渴止。惟胸膈胀痛如故，余因《金匮》悬饮内痛者用十枣汤下之，遂书：制甘遂一钱大戟一钱炙芜花一钱用十枣浓煎为汤，去滓令服，如《金匮》法，并开明每服一钱。
医家郑仰山与之同居，见方力阻，不听，令减半服之，不下，明日延余复诊。知其未下，因令再进一钱，日晡始下。胸膈稍宽，然大便干燥，蓄痰未下。因令加芒硝三钱，使于明早如法服之。三日后，复延余复诊，知其下甚畅，粪中多痰涎。遂令暂行停药，日饮糜粥以养之。
此时病者眠食安适，步履轻捷，不复如从前之蹒跚矣。后一月，宋又延余诊治，且曰：大便常五六日不行，头面手足乳房俱肿。余曰：痰浊既行，空隙之处，卫气不充，而水饮聚之。《金匮》原有发汗利小便之法以通阳气。今因其上膈壅阻特甚，且两乳胀痛，不得更用缓攻之剂，方用：制甘遂一钱大戟末一钱王不留行二钱生大黄三钱芒硝三钱一泻而胀痛俱止。宋因询善后之法，余因书：苍术一两白术一两炎甘草五钱生麻黄一钱杏仁三钱令煎汤代茶，汗及小便俱畅。即去麻杏，一剂之后，永不复发云。
余按十枣汤一方，医家多畏其猛峻，然余用之屡效，今存此案，非惟表经方之功，亦以启世俗之蔽也。
【按】此吾师十年前之治案也。是时，余有志于医，顾未尝学焉。师另有本汤验案多则，悉详金匮发微。然则人犹是也，病犹是也，方犹是也，效亦犹是也。
所谓古人不见今时月，今月曾经照古人，其间同具妙理。若曰古方不可治今病，犹曰古月不可照今人，得毋痴不可及？南宗景先生曰：舍妹曾患胀病，初起之时，面目两足皆微肿。继则腹大如鼓，漉漉有声，渴喜热饮，小溲不利，呼吸迫促，夜不成寐。愚本《内经》开鬼门（玄府也，亦即汗腺），洁净府（膀胱也）之旨，投以麻附细辛合胃苓散加减。
[Commentary] The cost of the herbs in this formula is extremely low, requiring only three copper coins. The pharmacist smiled and said, "Can this cure the disease?" Mr. Wu obtained the medicine and still took large black dates, first removing the pits, then inserting powder of Gleditsia sinensis (Yazao, 牙皂), tying both ends of the date with thread to prevent leakage. A total of seven dates were needed. After filling them with Yazao powder, they were decocted and taken immediately. After taking the medicine, the condition surprisingly turned for the better, revealing a new prospect. Suddenly, a large amount of white, greasy phlegm-turbidity was discharged through the stool, while expectoration from the mouth decreased, exactly as the master had predicted. Furthermore, for the past few days, food intake was often accompanied by nausea. I said: "Vomiting indicates disharmony of the Stomach Qi. In cases of severe or chronic illness, life depends on the presence of Stomach Qi, while danger arises when Stomach Qi is disharmonious; this is a fixed principle." Now, not only has vomiting ceased, but appetite has improved, and the patient can rise, sit, defecate independently, or perform other movements. Additionally, previously he could not lie on his left side on the mat, but now he can. The reason is that previously, when pus accumulation in the right lung was at its peak, lying on the left side would cause the pus to compress other organs, leading to discomfort? The protrusion on the chest, which began to subside after taking the prescriptions from the first three consultations, has now completely flattened. There is no longer pulling pain in the chest during coughing. Moreover, the Anfu Xiao Zhong Gao (Anfu Swelling-Reducing Ointment), which required frequent changes since being applied by Western doctors, has now been dispensed with. This formula, taken continuously for three days, showed remarkable efficacy. From the eighth day, the previously proposed formula was taken again, except for Sheng Shan Zhi (Raw Gardenia Fruit). Xingxiao Wan (Xingxiao Pill) is planned to be continued until now, with the dosage reduced from 3 qian to 1 qian without interruption. Since then, the condition has entered a smooth path; the patient can eat rice, fears taking medicine, and plays as usual. On the 29th, Mr. Wu came again to ask for a conditioning formula. The Master said: "In the fifth consultation, on the 14th day of the eighth lunar month, Lung Abscess (Fei Yong, 肺痈) had passed the critical stage, but Yin Qi was severely damaged. It is appropriate to use Huang Hun Tang (Huanghun Decoction) from Qian Jin Fang."
He Huan Pi (Albizia Bark) the size of a palm, decocted with three bowls of water until one and a half bowls remain, taken in two doses.
[Commentary] Taking this formula yielded excellent results; appetite increased, and muscles became plump. Although there are occasional slight coughs with thin sputum, this is merely a residual wave after the illness and need not be worried about.
This disease has a characteristic: it involves aversion to heat but not aversion to cold. Since there is no aversion to cold but only aversion to heat, this constitutes Yangming Disease (Yangming Bing, 阳明病). Therefore, I say that Lung Abscess is a type of Yangming Disease. The three major correct treatments for Yangming Disease are Clearing (Qing, 清), Vomiting (Tu, 吐), and Purgation (Xia, 下). Thus, using Jing Shi Wei (Ejindewei/Reed Rhizome) for Lung Abscess is the Clearing method; using Jie Geng (Platycodon Root) is the Vomiting method; using Ting Li Zi (Descurainia Seed) and Ya Zao (Gleditsia Powder) is the Purgation method. The Classic states that the Lung and Large Intestine are exteriorly-interiorly related, so the Large Intestine can transfer heat to the Lung. Understanding this allows one to discuss the treatment of Lung Abscess.
Cao Yingfu said: In treating this syndrome, where abscess-pus accumulates in the lungs, the first step is to open and drain Lung Qi and clear stagnant heat. Once the Lung's Qi mechanism is unobstructed but expectoration remains difficult, the second step is to eliminate the abscess-pus. When foul-smelling sputum is fully expelled, but thick, sticky phlegm that has not yet formed pus continues to be coughed up, the third step is to break down phlegm nodules. As thick phlegm gradually decreases, the damaged areas of the Lung require repair; thus, nourishing Lung Yin becomes the fourth step. Among repair formulas, Qian Jin Huang Hun Tang is recommended as the best. Huang Hun refers to He Huan Pi (Albizia Bark); Zhang Luyu stated that when two trunks touch, they fuse inseparably. Its stickiness is sufficient to fill the gaps in the Lung organ, achieving complete success, and is more reliable than the commonly used Bai Ji (Bletilla Rhizome). I dare to share these insights with colleagues. Note: He Huan is the Silk Tree (Albizia julibrissin), with flowers red like horse tassels, blooming in May and June. The trunks often grow fused together, which I have seen personally. Since the Lung governs skin and hair, and the bark of this tree easily fuses with itself, it can repair lung fissures. Also, my previous commentary stating that the etiology of Lung Abscess lies in the Yangming is very accurate. Generally, dryness and excess in the intestines and stomach cause stagnant heat to harass the Lung upward, leading to Lung dryness and the generation of sticky phlegm. As long as the dryness of one day is not removed, the sticky phlegm of that day will not go away. Over time, heat damages the Lung organ, transforming into abscess-pus. Therefore, the treatment method should first focus on opening obstruction and clearing heat, and secondly on breaking stubborn phlegm, both aiming to resolve obstruction.
Case 1 of Metastatic Fluid (Xuan Yin, 悬饮)
Patient: Zhang Renfu. Address: No. 6 Renxing Lane, Father Lawrence Road. First Consultation: April 4, Republic of China Year 24. Water-Qi harassing the Heart causes palpitations; accumulating under the hypochondrium causes hypochondriac pain; rising to the upper diaphragm causes chest distension. The pulse is double-string-like (Shuang Xian, 双弦). The syndrome belongs to a fluid-retention constitution. Accompanied by dry retching and shortness of breath, this is undoubtedly a Shi Zao Tang (Ten Date Pill) syndrome.
Zhi Yuan Hua (Prepared Genkwa Flower) 5 fen, Zhi Gan Sui (Prepared Kansui Root) 5 fen, Da Ji (Knoxia Root) 5 fen. The above three ingredients are ground into fine powder and divided into two doses.
First, decoct ten large black dates until soft, remove the dregs, add the medicine powder, boil briefly, and take mixed.
[Commentary] Mr. Zhang Renfu is my close friend. Previously, he suffered from diffuse swelling and pain in the left cheek, radiating to the ear, with much pus exuding from the gum margins inside and outside the teeth. I said, "This is Gu Cao Feng (Bone Trough Wind)." I have cured many cases of Bone Trough Wind with Yang He Tang (Yanghe Decoction), but Mr. Zhang's condition was slightly different. His stool was constipated, and his tongue tip had prickles. I administered Sheng Shi Gao (Raw Gypsum) and Liang Ge San (Cool the Diaphragm Powder), each 5 qian, followed by drainage, which led to recovery. A few days later, Mr. Zhang came again and said, "Please forgive my disturbance; I have a chronic ailment requesting diagnosis." I said, "Please state it in detail." He said, "The illness started half a year ago. I usually enjoy playing soccer, often sweating profusely, and rarely change clothes. Subsequently, I felt distension in both hypochondria, painful upon pressure. Sometimes I have palpitations and fearfulness. At night, if there is no light in the room, I dare not enter, trembling. My head also feels dizzy, especially when riding a car. Belching provides slight relief to the chest and diaphragm. I cannot lie flat at night; lying flat causes shortness of breath and restlessness. In the deep silence of night, I often hear a gurgling water sound inside both hypochondria, oscillating within...," I said, "Stop describing; I understand." This syndrome cannot be treated without Shi Zao Tang. The drug cost is very cheap, but the potency is drastic. If you wish to take it, you must consult my teacher. He said, "Then can we try a mild dose first?" I said, "Okay." So I prescribed Hou Po (Magnolia Bark), Chai Hu (Bupleurum Root), Huo Xiang (Pogostemon), Pei Lan (Eupatorium), Ban Xia (Pinellia), Guang Pi (Tangerine Peel), Che Qian Zi (Plantago Seed), Fu Ling (Poria), Qing Shui Dou Juan (Soaked Soybean Sprout), and Bai Zhu (Atractylodes Macrocephala Rhizome), herbs for drying dampness and moving Qi. One dose cost over 0.8 silver dollars. After taking it, the effect was negligible. Mr. Zhang said, "Then I must follow orders and visit your teacher."
The next day, I went directly to my teacher's door. The teacher had just finished examining Mr. Zhang and was writing the case record. Writing rapidly, the prescription reached the phrase "pulse comes double-string-like." I asked, "Teacher, what syndrome is this?" He said, "Xiao Chai Hu Tang (Minor Bupleurum Decoction)." I said, "No, the power of Chai Hu is insufficient; likely only Shi Zao Tang will be effective." The teacher put down his pen, pondered, and quickly checked the Shi Zao Tang clause in Shang Han Lun (Treatise on Cold Damage): "Taiyang wind-stroke, with diarrhea, vomiting, and reversal; if the exterior is resolved, then attack may be used. If the person sweats profusely, attacks occur at certain times, with headache, epigastric hardness and fullness, pulling pain from the hypochondrium, dry retching, shortness of breath, sweating, and no aversion to cold, this indicates the exterior is resolved but the interior is not harmonized. Shi Zao Tang governs."
I then asked Mr. Zhang, "Do you have shortness of breath and dry retching?" He replied, "Indeed." The teacher then looked at me and said, "Your identification of the syndrome is accurate; what you say is correct." The teacher then continued the case record and wrote the prescription as recorded above.
Furthermore, according to Jin Gui Yao Lue (Essential Prescriptions from the Golden Cabinet): "When the pulse is deep and string-like, there is internal pain from metastatic fluid." It also states: "For diseases of metastatic fluid, Shi Zao Tang governs." I carefully examined Mr. Zhang's pulse and felt that the slippery component was predominant, followed by string-like, and then deep. From the perspective of the three positions, the Cun (inch) pulse was particularly prominent, consistent with the theory that the Cun pulse governs the Upper Jiao. From the perspective of left and right, the Left pulse was more prominent, as Mr. Zhang himself stated that the fluid accumulation in the left hypochondrium was more severe than in the right.
Now, reporting the situation after Mr. Zhang took the decoction. Mr. Zhang bought the medicine first, costing only eight cents, surprised by its cheapness. He boiled ten large dates, obtained the soup, removed dregs, and divided it into two portions. He added half the medicine powder, boiled briefly until it became a paste. Around 7 PM that night, before dinner, he took the medicine paste first. He immediately felt spiciness in the throat, worse than pepper. Mr. Zhang was accustomed to eating peppers, yet he feared it, indicating the drastic nature of the drug. He also felt dry mouth, mental restlessness, and a sensation of fever. At 9 AM, he woke up, his throat was hoarse and voiceless, urgently needing to defecate, unable to hold back. What was discharged was not feces, but pure water. The odor was quite strong. He paused slightly, ate a little dinner, and managed to sleep peacefully, no longer tossing and turning as usual. At 2 AM, he woke up wanting to defecate again; more foul water was discharged, followed by peaceful sleep. At 6 AM, another bowel movement with even more foul water. He slept until 10 AM. The hoarseness from last night had healed. Unexpectedly, dry retching, belching, palpitations, and dizziness all decreased, and spirit improved. Knowing pleurisy is a difficult-to-cure disease, he was amazed by such rapid efficacy and couldn't help sighing at the magic of ancient formulas! By noon the next day, his throat had completely recovered. At 7 PM, dinner was normal. At 9:30 PM, he took medicine; the date soup was the remainder from the previous day. After taking the medicine, he felt very uncomfortable in the stomach, as if the stomach wall was turning inside out, wanting to vomit. Meanwhile, he felt mental restlessness, heat, and hoarseness, similar to yesterday but slightly milder. At 1 AM late at night, he had watery diarrhea, even more than the first night. The next morning, he vomited a small amount of food mixed with phlegm-water, and passed some foul water, but not much. By noon, his throat recovered again, he could eat lunch normally, belching largely ceased, and hypochondriac distension significantly reduced. However, the area above both hypochondria (below the nipples) felt more distended than usual. Mr. Zhang said, "This distension above the hypochondria must have existed previously; it was just masked by the severe distension below. Now that the lower distension is gone, the upper distension becomes apparent." His courage remained small, and blurred vision worsened, though without pain.
Knowing the post-medication experience, let us carefully review the decoction and administration method of Shi Zao Tang. Comparing the two, we see that although the instructions are only a few lines, they contain profound meaning. The instructions say: "The above three ingredients, pound and sieve. With one sheng and five he of water, first decoct ten fat large dates until eight he remain; remove dregs, add medicine powder. Strong persons take one qian bi; frail persons take half a qian. Take warm at dawn. If no evacuation occurs, increase by half a qian tomorrow. After rapid evacuation, nourish with millet porridge." Observing Mr. Zhang's first dose: medicine before food, no vomiting; second day: food before medicine, vomiting ensued. This shows that medicine before food is better than food before medicine. Who knows that "take at dawn" implies taking on an empty stomach, which is even better than medicine before food? It also says: "After rapid evacuation, nourish with millet porridge." This implies that before evacuation, one should not eat. In reality, nourishing with porridge after evacuation is better than not eating either before or after. This is the first point.
It says: "If no evacuation occurs, increase by half a qian tomorrow." It does not say: "If no evacuation, prepare another dose." The word "tomorrow" has deep meaning, being a shorthand for "tomorrow at dawn." At dawn, after a night of rest, the Stomach's function is relatively vigorous, so one takes advantage of this timing to deal with this drastic medicine. Also, taking it once a day, unlike other decoctions that can be taken multiple times, shows that the medicine has great toxicity and should not be advanced continuously, and provides time for the Stomach to rest. This is the second point.
Strong persons take one qian bi, frail persons take half a qian, meticulously calculating the dosage, showing extreme caution. Why? The meaning is the same as above. This is the third point.
Shi Zao Tang uses ten dates as the sovereign herb. What is the function of ten dates? Japanese scholars say: Large dates, licorice, etc., have similar functions with minor differences, mainly treating spasms. This statement is vague and unacceptable. My friend Mr. Ningxuan Wu once extensively studied the function of large dates in classical formulas, stating they can preserve fluids in the Stomach. Now, seeing that swallowing Shi Zao Tang immediately causes dryness and pain, it is known that the water-absorbing power of Gan Sui (Kansui Root), Da Ji (Knoxia Root), and Yuan Hua (Genkwa Flower) is huge. After entering the Stomach, although they can drive out water and evil, damaging fluids is inevitable. Therefore, adding ten dates protects the healthy Qi, allowing consideration of both righteous and evil factors. Mr. Wu also suggested that the administration of Shi Zao Tang should use ten dates to decoct soup daily, not divided into two doses, to weaken the protective function. His view is insightful. Old theories consider dates as spleen-strengthening items, saying the Spleen transports fluids for the Stomach. Thus, dates have a close relationship with gastric fluids. The language is implicit, between understandable and unintelligible, but now clarified by my friend's theory. This is the fourth point.
Why are Gan Sui, Yuan Hua, and Da Ji made into powder and added, rather than decocted with dates? There is deep meaning. Based on my research, drugs intended to act directly in the intestines and stomach are mostly used as powders. Yi Yi Fu Zi Bai Jiang Tang (Coix Seed, Aconite, and Patrinia Decoction) is ineffective when people use it, not knowing they are using the decoction instead of the powder. Wu Ling San (Five-Ingredient Powder with Poria) is also ineffective when people use it, claiming it is far inferior to Che Qian Zi and Tong Cao, not knowing they are using the decoction instead of the powder. Cheng Qi Tang (Descending Qi Decoction) also acts directly in the intestines; it uses decoction instead of powder because the intestines cannot absorb Mang Xiao (Mirabilite) and Da Huang (Rhubarb), so using decoction is equivalent to powder. Many other formulas are effective as powders but ineffective as decoctions. Although Gan Sui, etc., as powder enters the Stomach to drive out water, how can it drive out fluid between the hypochondria? Answer: Since the fluid previously entered the hypochondria via a specific pathway, it can now follow that path and be driven out. Facts are facts; theory should follow facts. This is the fifth point.
Alas! One formula by Zhong Jing, in just a few lines, contains unimaginable profundity. All these insights we painstakingly sought are still uncertain whether correct or incorrect. Second Consultation: April 6. After two doses of Shi Zao Tang, fluid under the hypochondria reduced by more than half. Only chest distension remains, back soreness, and pain in both hypochondria when walking. Pulse is deep and string-like, indicating water imagery. After purgation, further purgation is inappropriate; one should proceed with warming and transforming.
Jiang Ban Xia (Ginger-processed Pinellia) 5 qian, Bei Xi Xin (Asarum) 2 qian, Gan Jiang (Dried Ginger) 3 qian, Shu Fu Kuai (Prepared Aconite) 3 qian, Zhi Gan Cao (Honey-fried Licorice) 5 qian, Tu Si Zi (Dodder Seed) 4 qian, Du Zhong (Eucommia Bark) 5 qian, Jiao Mu (Zanthoxylum Seed) 3 qian, Fang Ji (Stephania Root) 4 qian.
[Commentary] The Master said that one dose of Shi Zao Tang is sufficient per use and should not be advanced frequently. This aligns with the principle that for medicines with great toxicity, eliminating four or five parts of the disease is sufficient. He also stated that Gan Sui and Da Ji are cold-natured substances, so in the second consultation, warm medicines are used to harmonize. This formula is derived from modifying existing formulas, focusing on the concept of "warming and transforming." However, according to Mr. Zhang, he did not feel comfortable after taking this formula. He felt distension above the hypochondria, back discomfort, stinging eyes, and constipation. Perhaps this is because Mr. Zhang has a hot constitution, and the warmth of the medicine was excessive? Third Consultation: April 8. Previously, due to lower back soreness and hypochondriac pain, the warming-transforming method was used. Coinciding with the development of Yang Qi in the weather, the lower back and hypochondria settled, but chest distension persisted, and the left hypochondrium felt slightly uncomfortable. The deep-string-like pulse gradually changed to floating-string-like. The root of the disease is gradually eliminated, but defecation is difficult. Additionally, heat affects the brain, causing red eye vessels. Treatment should focus on the chest and hypochondria, using Da Chai Hu Tang (Major Bupleurum Decoction) plus Hou Po (Magnolia Bark) and Mang Xiao (Mirabilite).
Ruan Chai Hu (Soft Bupleurum) 3 qian, Dan Huang Qin (Light Scutellaria) 3 qian, Zhi Ban Xia (Processed Pinellia) 3 qian, Sheng Chuan Jun (Raw Rheum) 3 qian (add later), Zhi Shi (Immature Bitter Orange) 3 qian, Hou Po (Magnolia Bark) 2 qian, Mang Xiao (Mirabilite) 1.5 qian (dissolve).
[Commentary] Mr. Zhang said: After taking the medicine, he had smooth bowel movements four or five times at night. The next day, his hypochondria and back felt relaxed, chest comfort improved, and spirit was refreshed. All ailments vanished. Observing this formula, one sees the Master's decisive shift in strategy. In just three doses, costing only three yuan, he cured a half-year chronic pleurisy. Alas, how miraculous! Cao Yingfu said: Diseases of the chest and hypochondria are mostly Chai Hu syndromes, repeatedly mentioned in the Taiyang Chapter of Shang Han Lun. The chest belongs to the Upper Jiao; the hypochondria extend from the Middle Jiao to the Lower Jiao, where the water pathways of the Lower Jiao emerge. Thus, blockage of water pathways in the hypochondria causes internal pain from metastatic fluid, constituting a Shi Zao Tang syndrome. Blockage of water-phlegm in the chest, with upper dampness and lower dryness disharmony, constitutes a Da Xian Xiong Tang (Major Chest-Rigidifying Decoction) syndrome. If there is only slight water-Qi in the chest, Xiao Chai Hu Tang (Minor Bupleurum Decoction) should be used to induce sweating. Once fluid under the hypochondria is removed, transforming into dry-heat, Da Chai Hu Tang should be used to purge. One can observe the comprehensive approach here.
Case 2 of Metastatic Fluid (Xuan Yin, 悬饮)
Wife of Song Zizai, nearly fifty years old, has always suffered from chest and diaphragm distension and pain, or constipation for five or six days. Upon waking at night, her throat is dry and tongue parched. Physicians considered it floating fire or Liver Qi stagnation. Treatments included Hua Fen (Trichosanthes Powder), Lian Qiao (Forsythia), Yu Zhu (Polygonatum Odoratum), Mai Dong (Ophiopogon), Shan Zhi (Gardenia), totaling over thirty doses. Chen Xiang (Aquilaria Wood), Qing Pi (Green Tangerine Peel), Mu Xiang (Aucklandia), Bai Shao (White Peony), totaling over ten prescriptions.
For two years, there was no minor effect. Last April, I was invited to treat her. I diagnosed her pulse as double-string-like and said, "This is Phlegm-Fluid." Therefore, I used Xi Xin (Asarum) and Gan Jiang (Dried Ginger), conforming to Master Zhong's principle of "harmonizing with warm medicines." Mr. Song was very hesitant seeing the prescription.
He said: "Previous physicians used cooling and moistening agents, yet throat dryness persisted; how much more so with warm medicines?" I said: "Taking this should result in no thirst." Mr. Song agreed verbally but doubted mentally. His wife resolutely bought the medicine. One dose stopped the thirst. However, chest and diaphragm distension and pain remained. Citing Jin Gui that metastatic fluid with internal pain is treated with Shi Zao Tang to purge, I prescribed: Zhi Gan Sui (Prepared Kansui) 1 qian, Da Ji (Knoxia) 1 qian, Zhi Yuan Hua (Prepared Genkwa) 1 qian. Decoct ten dates strongly to make soup, remove dregs, and take as per Jin Gui method, specifying each dose takes 1 qian.
Physician Zheng Yangshan, who lived with him, saw the prescription and strongly opposed it. They did not listen, halving the dose. No evacuation occurred. The next day, Mr. Song invited me for re-examination. Knowing no evacuation had occurred, I instructed him to take another 1 qian. Evacuation began at dusk. Chest and diaphragm widened slightly, but stool was dry, and retained phlegm was not discharged. I instructed adding Mang Xiao (Mirabilite) 3 qian to be taken as directed the next morning. Three days later, Mr. Song invited me again. Knowing evacuation was smooth, with much phlegm-saliva in stool, I instructed temporary cessation of medicine and drinking millet porridge to nourish.
At this time, the patient slept and ate comfortably, walked lightly, no longer stumbling as before. One month later, Mr. Song invited me again, saying: "Stool often does not pass for five or six days; head, face, hands, feet, and breasts are all swollen." I said: "Since turbid phlegm has moved, the void spaces lack defensive Qi, allowing fluid accumulation. Jin Gui originally has methods of inducing sweating and promoting urination to unblock Yang Qi. Now, due to severe blockage in the upper diaphragm and distension/pain in both breasts, gentle attacking agents cannot be used. Prescription: Zhi Gan Sui 1 qian, Da Ji Powder 1 qian, Wang Bu Liu Xing (Vaccaria Seed) 2 qian, Sheng Da Huang (Raw Rhubarb) 3 qian, Mang Xiao 3 qian. One purge stops distension and pain. Mr. Song asked for follow-up care. I prescribed: Cang Zhu (Atractylodes Lancea) 1 liang, Bai Zhu (Atractylodes Macrocephala) 1 liang, Zhi Gan Cao (Honey-fried Licorice) 5 qian, Sheng Ma Huang (Raw Ephedra) 1 qian, Xing Ren (Apricot Seed) 3 qian. Decoct as tea to promote sweating and urination. Then remove Ma Huang and Xing Ren. After one dose, it never recurs."
My commentary: Many physicians fear Shi Zao Tang for its ferocity, yet I have used it with repeated success. Preserving this case aims not only to demonstrate the merit of classical formulas but also to enlighten worldly prejudices.
[Commentary] This is a treatment case from my teacher ten years ago. At that time, I was interested in medicine but had not yet studied it. The teacher has many other verified cases of this decoction, detailed in Jin Gui Fa Wei. Yet, the person is the same, the disease is the same, the formula is the same, and the efficacy is the same.
As the saying goes: "Ancients did not see today's moon, but today's moon once shone on ancients." The subtle principles are identical within. To say ancient formulas cannot treat modern diseases is like saying the ancient moon cannot shine on modern people; is this not foolish and unreachable? Mr. Nan Zongjing said: "My younger sister once suffered from distension disease. Initially, her face, eyes, and both feet were slightly swollen. Subsequently, her abdomen became large as a drum, with gurgling sounds. She craved hot drinks, had difficulty urinating, rapid breathing, and insomnia. Following the Nei Jing principle of 'opening the ghost gate' (pores/sweat glands) and 'cleaning the bladder,' I administered modified Ma Fu Xi Xin combined with Wei Ling San."