同乡姻亲高长顺之女嫁王鹿萍长子，住西门路，产后六七日，体健能食，无病，忽觉胃纳反佳，食肉甚多。数日后，日晡所，觉身热烦躁，中夜略瘥，次日又如是。延恽医诊，断为阴亏阳越。投药五六剂，不效。改请同乡朱医，谓此乃桂枝汤证，如何可用养阴药？即予轻剂桂枝汤，内有桂枝五分，白芍一钱。二十日许，病益剧。长顺之弟长利与余善，乃延余诊。知其产后恶露不多，腹胀，予桃核承气汤，次日稍愈。但仍发热，脉大，乃疑《金匮》有产后大承气汤条，得毋指此证乎？即予之，方用：生大黄五钱枳实三钱芒硝三钱厚朴二钱方成，病家不敢服，请示于恽医。恽曰：不可服。病家迟疑，取决于长顺。长顺主与服，并愿负责。服后，当夜不下，次早，方下一次，干燥而黑。午时又来请诊，谓热已退，但觉腹中胀，脉仍洪大，嘱仍服原方。实则依余意，当加重大黄，以病家胆小，姑从轻。次日，大下五六次，得溏薄之黑粪，粪后得水，能起坐，调理而愈。独怪近世医家遇虚羸之体，虽大实之证，不敢竟用攻剂。不知胃实不去，热势日增，及其危笃而始议攻下，惜其见机不早耳！
【按】王季寅先生作《产后之宜承气汤者》篇曰：产后虚证固多，实证间亦有之，独怪世医动引丹溪之说，谓产后气血双虚，惟宜大补，虽有他证，均从末治，执此以诊，鲜不贻误。余友王百安君于月前治一郭姓妇人。该妇于双产后，发狂见鬼，多言骂詈，不认亲疏。其嫂曾被其掐颈，几至惊毙。家人因使强有力者罗守之。遂延王君往诊，车至中途，病家喘急汗流奔告曰，病者角弓反张，口吐涎沫，现已垂危，后事均已备妥，特询还可医否？如不可医，毋徒劳先生往返也。王君答以果系实症，不妨背城借一，或可挽回，然未敢必也。及至病所，见病人反张抽搐，痰涎如涌，诊其脉，数而疾，因病者躁动，未得细诊。询以恶露所见多寡，腹中曾否胀痛，二便若何，该家惊吓之余，视病者如虎狼，此等细事全无人知。王君以无碻凿左证，力辞欲去。病家苦求立方，坚不放行。王君默念重阳则狂，经有明文，加以脉象疾数无伦，遍体灼热，神昏流涎，在在均露热征。
其角弓反张当系热极成痉。综合以上各点，勉拟下方。生石膏四钱，知母三钱，寸冬三钱，川连三钱，条芩三谈，阿胶三钱，白薇三钱，生地三钱，半夏三钱，木通三钱，只壳三钱，生军三钱，粉草一钱，竹叶三钱。一剂，痉愈，躁动略安。
复延往诊，病者固拒不令诊脉，询以大便情形，据云水泄挟有燥粪，遂为立大承气汤加桃仁丹皮，嘱其分三次灌之。如初次服后矢气，便为对证，可将余药服下。
次日，病家来云，躁动若失，已能进食，惟仍狂言不寐。遂处下方：川连、炒梔子、条芩、杭芍、阿胶、云苓、茯神、远志、柏子仁、琥珀、丹皮、当归、生地、鸡子黄。据称服后熟睡竟夜，此后可以无虑。其母因其灌药艰难，拟令静养，不复服药矣。似此病症，若仍以产后多虚，妄用十全八珍，或生化汤加减，岂不促其命期耶？（录《医界春秋》）按本证初起，似属桃核承气汤证，或竟抵当汤证。
仲圣曰：其人如狂，但少腹急结者，乃可攻之。又曰：其人发狂者，以热在下焦，少腹当鞕满是也。此二条，如狂与发狂异，急结与鞕满异，是其辨也，迨后角弓反张，当为大承气汤证。仲圣曰：卧不着席，脚挛急，必齿介齿，可与大承气汤是也。最后，狂言不寐，亦如仲圣所谓心中烦，不得卧，黄连阿胶汤主之之证。故用药近似，即可以起死回生。呜呼，此仲圣之所以为万世法也！此证甚剧，亦属产后，引之可与吾师原案互证。
曹颖甫曰：产后宜温之说，举世相传，牢不可破。而生化汤一方，几视为金科玉律，何怪遇大实大热之证，而束手无策也。大凡治一病，必有一病之主药，要当随时酌定，不可有先入之见。甚有同一病证，而壮实虚羸之体不当同治者，此尤不可不慎也。
陈左住马浪路十四岁初诊八月十七日发热有汗，阙上痛，右髀牵掣，膝外廉痛，时欲呕，大便不行，渴饮，舌苔黄燥，腹满，脉滑，阳明证备，于法当下，宜大承气汤加黄连。
生锦纹军四钱后入枳实四钱中朴钱半芒硝三钱冲服淡吴萸五分细川连二分二诊八月二十日拟方下后，但见燥矢，脚上仍痛，时欲吐，痰多，是阳明燥气未尽，上膈津液化为痰涎也，宜小半夏加硝黄。
【按】若仍用大承气汤加重厚朴，似亦甚佳，因厚朴并能去上湿也。
三诊八月二十二日进小半夏合承气，下后，热除，痛止，知饥。经食煮红枣六枚，顿觉烦闷，夜中谵语不休，甚至昏晕。此特下后肠中燥热上熏脑部，而又发于下后，要为无根毒热，不足为患。夜不能寐，当用酸枣仁汤加减。
酸枣仁五钱辰砂五分潞党参三钱知母三钱天花粉一两生姜三片红枣三枚
【按】本汤之用，似不得当，盖此时热势方稍稍受折，转瞬当复炽。观其仅服红枣六枚，即转为谵语昏晕，不可终日，可以知矣。酸枣仁汤功能安和神经，使人入睡，为病后调理之良方，而不宜于此热势嚣张之时，故服后少效，宜其然也。或者当时病家见两服硝黄，遂惧病者虚脱，故乃恳师用此似较平稳之方欤？四诊八月二十三日拟方阳明之热未清，故尚多谵语，阙上痛，渴饮，宜白虎汤加味。
生石膏八钱知母四钱生甘草二钱天花粉一两洋参片五钱滑石六钱粳米一撮牡蛎二两生打先煎五诊八月二十四日服人参白虎汤加味，渴饮，阙上痛定，夜无谵语，今尚微渴，饮粥汤便止，仍宜前法。
生石膏一两知母三钱生草三钱天花粉一两北沙参八钱潞党参五钱块滑石一两左牡蛎二两先煎拙巢注：此证不大便二十余日，始来就诊，两次攻下，燥热依然未尽。予所治阳明证未有若此之重者，自十七日至今，前后凡八日，方凡五易，始得出险。
曹颖甫曰：此证下后，湿痰未去。二诊悬拟方，因病家来告贫苦，减去厚朴，以致湿热留于上膈。三诊，但治不寐，未尝顾及阳明实证。下后胃热未除，以致病根不拔，诚如佐景所言。盖胃不和，固寐不安也。附志于后，以志吾过，而警将来。曾记八年以前，同乡周巨臣绍介一汪姓病人，初诊用生大黄四钱，厚朴二钱，枳实四钱，芒硝三钱，其人病喘不得眠，壮热多汗，脉大而滑，下后稍稍安眠，而时吐黄浊之痰，予用承气汤去大黄加皂荚末一钱，二剂而愈，与此证相似，并附存之。
阳明战汗
陆左初诊三月二十二日阳明病，十日不大便，恶气冲脑，则阙上痛，脑气昏，则夜中谵语，阳明燥气熏灼，则右髀牵掣，膝屈而不伸，右手亦拘挛，夜不安寐，当急下之，宜大承气汤。
生川军四钱后入枳实三钱中朴一钱芒硝三钱冲服拙巢注：此证服药后，夜中大下二次，稍稍安睡。二诊三诊用白虎汤为主，以其右手足不伸，而加芍药，以其渴饮，而加天花粉。三诊后，闻延张衡山两次，又以无效中止。三十日后，闻其恶热甚，家人饮以雪水，颇安适，此即病人欲饮水者，少少与之，即愈之证也。予为之拟方用生石膏二两，知母五钱，生甘草三钱，西洋参一钱，和米一撮。煎汤服后，病者甚觉清醒。四月一日服二煎，至午后，病者忽然寒战，闭目若死，既而壮热汗出，此当在伤寒论战而汗出之例，非恶侯也。
续诊四月六日拟方此证自三月二十二日用大承气汤下后，两服凉营清胃之剂，不效。其家即延张衡山二次，不效中止。后于三十日闻其恶热渴饮，用白虎加人参汤，至一日战而汗出，意其愈矣。至四日，病家谓其右手足不伸，而痠痛，为之拟方用芍药甘草汤加味（赤白芍各一两，炙甘草五钱，炙乳没各三钱，丝瓜络三钱），手足乃伸。今日病家来云能食，但欲大便不得，小便赤，更为之拟方如左：生川军一钱五分芒硝一钱冲生甘草二钱拙巢注：下后诸恙悉愈，胃纳大畅。
【按】战而汗出，是为战汗。若本案之战汗，是阳明之战汗也。大论曰：凡柴胡汤病证，而柴胡证不罢者，复与柴胡汤，必蒸蒸而振，却复发热汗出而解。是少阳之战汗也。又曰：太阳病未解，脉阴阳俱停，必先振栗，汗出而解。是太阳之战汗也。粗观之，似三阳皆有战汗。试问病人何以欲汗？曰：假此以逐邪耳。设其人正气充实，受邪不重，又得药力以助之，则濈然汗出，了无烦苦。设不假药力之助，但凭正气与邪相搏，则其人略有烦苦矣。故大论曰：欲自解者，必当先烦，乃有汗而解。设其人正气虚弱，邪气充实，即使得药力之助，亦必须鼓额懔栗，努力挣扎，方能得汗，而其外表不仅为烦，甚当为战矣。故大论又曰：问曰：病有战而汗出，因得解者，何也？答曰：脉浮而紧，按之反芤，此为本虚，故生战而汗出也。其人本虚，是以发战，以脉浮，故当汗出而解，若脉浮而数，按之不芤，此人本不虚，若欲自解，但汗出耳，不发战也。本条词句重叠，不类仲圣口吻，然而说理至精，可以奉信。抑余尤有说焉，伸之如下：
凡汗出而愈，属于太阳病居多，属于少阳病次之，属于阳明病者尠。夫太阳之战汗，原不足以为异。少阳病服柴胡汤已，其濈然或战而汗出解者，或亦有太阳之邪错杂于其间也。至本案阳明病之战汗，亦无非旧日太阳或少阳之宿邪，寄于肌表三焦，医者不能善为汗解，及其病已转为阳明，则液灼不能化汗，医更无暇及之。及其后，阳明病愈，阴液少复，病者自己之正气欲除久伏之宿邪，故不得已出于一战耳。由是观之，谓本案曰阳明之战汗者，特就其近病而言之耳，犹非至通之论也。
战汗者，破釜沉舟，背城借一之谓也。战而胜，则生。不胜，则死。一战不决，则再三战，以求其果。盖久病之后，正气不堪病魔之缠扰，故宁与一决雌雄，以判胜负。是故战汗乃生死之枢机，阴阳所从分，医者病家，当共深晓，爰录三则，以为参考。
《伤寒证治明条》云：凡伤寒疫病战汗者，病人忽身寒鼓颔战栗，急与姜米汤热饮，以助其阳。须臾战定，当发热汗出而解。或有病人恶热，尽去衣被，逆闭其汗，不得出者，当以生姜豆豉紫苏等发之。有正气虚不能胜邪，作战而无汗者，此为难治。若过半日或至夜而有汗，又为愈也。如仍无汗，而神昏脉渐脱者，急以人参姜枣煎汤以救之。又有老人虚人，发战而汗不行，随即昏闷，不知人事，此正气脱而不复苏矣。又云：余见疫病有五六次战汗者，不为害也。盖为邪气深，不得发透故耳。又有二三次复举者，亦当二三次作战，汗出而愈。
《医林绳墨》云：应汗而脉虚弱者，汗出必难。战不得汗，不可强助，无汗即死。当战不得用药，用药有祸无功，要助其汗，多用姜汤。
《温疫论》云：应下失下，气消血耗，即下亦作战汗。但战而不汗者危，以中气亏微，但能降陷，不能升发也。次日，当期复战，厥回汗出者生，厥不回，汗不出者死，以正气脱，不胜其邪也。战而厥回无汗者，真阳尚在，表气枯涸也，可使渐愈。凡战而不复，忽痉者必死。痉者身如尸，牙关紧，目上视。凡战不可扰动，但可温覆，扰动则战而中止，次日当期复战。又云：狂汗者伏邪中溃，欲作汗解，因其人禀赋充盛，阳气冲击，不能顿开，故忽然坐卧不安，且狂且躁，少顷大汗淋漓，狂躁顿止，脉静身凉，霍然而愈。
《温疫论》又云：温疫得下证，日久失下，逐日下利纯臭水，昼夜十数行，乃致口燥唇乾，舌裂如断。医者按仲景协热下利治法，与葛根黄连黄芩汤，服之转剧。余诊视，乃热结旁流，急与大承气汤一服，去宿粪甚多，色如败酱，状如粘胶，臭恶异常。是晚利止，次日服清燥汤一剂，脉尚沈，再下之，脉始浮。下证减去，肌表尚存微热。此应汗解，虽不得汗，然里邪先尽，中气和平，所以饮食渐进。半月后，忽作战汗，表邪方解。盖缘下利日久，表里枯燥之极，饮食半月，津液渐回，方能得汗，所谓积流而渠自通也。可见脉浮身热，非汗不解，血燥津枯，非液不汗。昔人以夺血无汗，今以夺液亦无汗，血液虽殊。枯燥则一，则知温疫非药可得汗者矣。本节上半可作自利清水大承气证之补注，下半可作余说战汗多属太阳病之别解。
曹颖甫曰：战汗多属太阳，为前人所未发，盖太阳有寒水，他经不当有寒水也。凡战汗而愈之病，皆由太阳失表所致。在少阳一经，犹曰手少阳三焦为寒水下行之经隧。而阳明已经化燥，则断断不应有此。而卒见此证者，或由其人水分太多，上膈水气犹在，肠胃已经化燥，水气被蒸，化为湿热，与燥矢相持而不动，燥矢一去，湿热不能独留，乃战汗而外出，数十年来偶然一见，要未可据为成例也。
The daughter of my fellow townsman and relative by marriage, Gao Changshun, married the eldest son of Wang Luping. They resided on West Gate Road. Six or seven days after childbirth, her constitution was robust, she could eat, and had no illness. Suddenly, her appetite improved remarkably, and she consumed a large amount of meat. Several days later, in the late afternoon (Ri Bu Suo), she felt feverish and irritable, with slight improvement around midnight, only for the pattern to repeat the next day. Physician Yun was consulted and diagnosed it as Yin deficiency with Yang floating outward (Yin Kui Yang Yue). After taking five or six doses of medicine, there was no effect. The family then invited Physician Zhu, a fellow townsman, who stated this was a Guizhi Tang syndrome and asked how yin-nourishing medicines could be used. He prescribed a mild dose of Guizhi Tang containing Guizhi (Cinnamon Twig) 5 fen and Baishao (White Peony Root) 1 qian. Approximately twenty days later, the condition worsened. Changli, the younger brother of Changshun, was friendly with me and thus invited me for consultation. Knowing that lochia discharge was scant and abdominal distension was present, I prescribed Taoheshengqi Tang (Peach Kernel and Rhubarb Decoction). The next day, she improved slightly. However, fever persisted, and the pulse was large. I suspected that the clause regarding Dachengqi Tang for postpartum conditions in *Jinkui Yaolue* might refer to this syndrome. Therefore, I prescribed it using: Sheng Dahuang (Raw Rhubarb) 5 qian, Zhishi (Immature Bitter Orange) 3 qian, Mangxiao (Mirabilite) 3 qian, and Houpo (Magnolia Bark) 2 qian. Once the decoction was prepared, the family dared not administer it and sought advice from Physician Yun. Yun said, "It must not be taken." Hesitant, the family deferred to Changshun. Changshun advocated for administration and assumed responsibility. After ingestion, no bowel movement occurred that night. Early the next morning, one bowel movement occurred; the stool was dry and black. At noon, they requested another consultation, reporting that the fever had subsided but abdominal distension remained, and the pulse was still surging. I advised continuing the original prescription. In fact, according to my judgment, the dosage of Dahuang should have been increased, but due to the family's timidity, I kept it light. The following day, she had five or six bowel movements, passing loose, black stools. After defecation, she regained strength, could sit up, and recovered with further regulation. It is strange that modern physicians, encountering patients with weak constitutions, dare not boldly use purgative agents even in cases of excess syndromes. They fail to realize that if gastric excess is not resolved, heat will increase daily. Only when the condition becomes critical do they discuss purgation; alas, their failure to seize the opportunity early!
[Commentary] Mr. Wang Jiyin wrote an article titled "Postpartum Cases Suitable for Chengqi Tangs," stating: Although deficiency syndromes are common postpartum, excess syndromes occasionally occur. It is strange that physicians often cite Zhu Danxi's theory that postpartum involves dual deficiency of Qi and Blood, recommending only strong tonification. Even if other syndromes exist, they are treated as secondary. Adhering rigidly to this view leads to frequent misdiagnosis. My friend, Mr. Wang Bai'an, treated a woman surnamed Guo a month ago. After two deliveries, she became manic, saw ghosts, spoke excessively, cursed, and failed to recognize relatives. Her sister-in-law had nearly died from being strangled by her. Family members employed strong guards. Mr. Wang was summoned. En route, the family ran to him, panting and sweating, reporting that the patient exhibited opisthotonos (body arched backward like a bow), foaming at the mouth, and was near death. Funeral arrangements were already made, and they asked if treatment was possible. If not, they wished to avoid wasting his time. Mr. Wang replied that if it were an excess syndrome, a desperate attempt might save her, though he could not guarantee success. Upon arrival, he saw the patient convulsing with opisthotonos and profuse salivation. The pulse was rapid and hurried. Due to the patient's agitation, detailed diagnosis was difficult. He asked about lochia volume, abdominal pain/distension, and urination/defecation. The terrified family, viewing the patient as dangerous, knew nothing of these details. Lacking conclusive evidence, Mr. Wang tried to leave. The family begged for a prescription and refused to let him go. Recalling the classic principle "Excess Yang leads to mania," and noting the extremely rapid pulse, burning body heat, coma, and salivation—all signs of heat—he reasoned that the opisthotonos resulted from extreme heat causing spasms. Synthesizing these points, he tentatively prescribed: Sheng Shigao (Raw Gypsum) 4 qian, Zhimu (Anemarrhena) 3 qian, Cundong (Ophiopogon) 3 qian, Chuanlian (Coptis) 3 qian, Tiaoqin (Scutellaria) 3 qian, Ejiao (Donkey-hide Gelatin) 3 qian, Baiwei (Cynanchum Atratum) 3 qian, Shengdi (Rehmannia) 3 qian, Banxia (Pinellia) 3 qian, Mutong (Akebia) 3 qian, Zhiqiao (Bitter Orange Peel) 3 qian, Shengjun (Rhubarb) 3 qian, Fencǎo (Licorice) 1 qian, and Zhuye (Bamboo Leaf) 3 qian. After one dose, spasms ceased, and agitation subsided slightly.
He was consulted again. The patient firmly refused pulse diagnosis. Regarding bowel movements, she reported watery diarrhea mixed with hard feces. Thus, Dachengqi Tang plus Taoren (Peach Kernel) and Danpi (Moutan Bark) was prescribed, to be administered in three divided doses via enema/gavage. If flatus occurred after the first dose, indicating correctness, the remainder could be given.
The next day, the family reported that agitation had ceased, and she could eat, but continued with manic speech and insomnia. The following prescription was issued: Chuanlian, Chao Zhizi (Fried Gardenia), Tiaoqin, Hangshao (White Peony), Ejiao, Yunling (Poria), Fushen (Poria with Hostwood), Yuanzhi (Polygala), Baiziren (Biota Seed), Hupo (Amber), Danpi, Danggui (Angelica Sinensis), Shengdi, and Jizihuang (Egg Yolk). They reported she slept soundly all night thereafter, with no further worries. Her mother, finding gavage difficult, planned to let her rest quietly without further medication. For such a case, if one wrongly assumes postpartum deficiency and indiscriminately uses Shiquan Dabu Tang, Bazhen Tang, or Huasheng Tang modifications, would it not hasten death? (Recorded in *Medical World Spring and Autumn*) Initially, this case resembled a Taoheshengqi Tang syndrome, or possibly Didang Tang syndrome.
Zhongjing stated: "If the patient appears manic, with only urgency and binding in the lower abdomen, attack may be considered." He also said: "If the patient is truly manic, it is due to heat in the Lower Jiao, and the lower abdomen should be hard and full." These two clauses distinguish "appearing manic" from "true mania," and "urgency/binding" from "hard/fullness." Later, when opisthotonos appeared, it became a Dachengqi Tang syndrome. Zhongjing said: "When lying flat is impossible, legs are cramped, and teeth are clenched, Dachengqi Tang may be given." Finally, manic speech and insomnia resemble Zhongjing's description of "vexation in the heart, inability to sleep," treated with Huanglian Ejiao Tang. Thus, similar medications can bring the dying back to life. Alas, this is why Zhongjing is the model for all generations! This severe postpartum case corroborates my teacher's original case.
Cao Yingfu stated: The notion that postpartum requires warming is universally accepted and unbreakable. Huasheng Tang is treated as an inviolable rule. No wonder physicians are helpless against major excess-heat syndromes. Treating any disease requires identifying its primary herb, determined flexibly, without preconceived notions. Even with the same syndrome, robust and emaciated constitutions require different treatments; this demands great caution.
Yangming Major Excess
Patient Chen (Female), residing on Malang Road, age 14. First visit, August 17. Fever with sweating, pain above the glabella, pulling sensation in the right thigh, pain at the lateral knee, occasional nausea, constipation, thirst with desire to drink, yellow and dry tongue coating, abdominal fullness, slippery pulse. Yangming syndrome is complete. According to method, purgation is indicated. Dachengqi Tang plus Huanglian is suitable.
Sheng Jinwen Jun (Rhubarb) 4 qian (added later), Zhishi 4 qian, Houpo 1.5 qian, Mangxiao 3 qian (dissolved), Dan Wuyu (Evodia) 0.5 fen, Xi Chuanlian (Coptis) 0.2 fen.
Second visit, August 20. After purgation, only dry feces passed. Leg pain persists, occasional vomiting, profuse phlegm. This indicates residual Yangming dryness transforming upper Jiao fluids into phlegm-saliva. Xiaobanxia Tang plus Xiaoming is suitable.
Zhi Banxia 4 qian, Sheng Chuanjun (Rhubarb) 2 qian (added later), Mangxiao 1.5 qian (dissolved), Shengjiang (Fresh Ginger) 5 slices.
[Commentary] Using Dachengqi Tang with increased Houpo would also be excellent, as Houpo can resolve upper dampness.
Third visit, August 22. After administering Xiaobanxia combined with Chengqi Tang, fever and pain ceased, and hunger returned. She ate six boiled red dates and suddenly felt vexatious and stuffy. At night, she experienced delirium continuously, even fainting. This is likely dry-heat from the intestines steaming upward to the brain after purgation, representing rootless toxic heat, which is not dangerous. Insomnia at night suggests Suanzaoren Tang modification.
Suanzaoren 5 qian, Chensha (Cinnabar) 0.5 fen, Lu Dangshen (Codonopsis) 3 qian, Zhimu 3 qian, Tianhuafen (Trichosanthes Root) 1 liang, Shengjiang 3 slices, Hongzao (Red Date) 3 pieces.
[Commentary] The use of this decoction seems inappropriate here. Heat was just slightly suppressed and would likely flare up again. Merely eating six red dates triggered delirium and fainting, indicating the severity. Suanzaoren Tang soothes the nerves and aids sleep, suitable for post-illness recovery, but unsuitable during rampant heat. Hence, little effect was expected. Perhaps the family, seeing two doses of Mangxiao and Dahuang, feared collapse and urged a milder formula?
Fourth visit, August 23. Yangming heat remains unresolved, causing delirium, glabellar pain, and thirst. Baihu Tang modification is suitable.
Sheng Shigao 8 qian, Zhimu 4 qian, Sheng Gancao 2 qian, Tianhuafen 1 liang, Yangshen Pian (American Ginseng) 5 qian, Huashi (Talc) 6 qian, Jingmi (Rice) 1 pinch, Muli (Oyster Shell) 2 liang (raw, decocted first).
Fifth visit, August 24. After Ren Shen Baihu Tang modification, thirst and glabellar pain resolved, no nocturnal delirium. Mild thirst remains, relieved by rice soup. Continue previous method.
Sheng Shigao 1 liang, Zhimu 3 qian, Sheng Cao 3 qian, Tianhuafen 1 liang, Beishashen (Glehnia) 8 qian, Lu Dangshen 5 qian, Kuai Huashi 1 liang, Zuo Muli 2 liang (decocted first).
Zhuochao Note: This patient had not had a bowel movement for over twenty days before seeking care. Two purgations were performed, yet dry-heat remained unresolved. Among my Yangming cases, none were so severe. From the 17th to today, eight days passed, and the prescription changed five times before she emerged from danger.
This resembles the case of Mrs. Wu at Sanjiao Street. Prolonged stagnant heat had long depleted stomach fluids.
Cao Yingfu stated: After purgation, damp-phlegm remained. In the second visit, Houpo was omitted due to the family's poverty, allowing damp-heat to linger in the upper Jiao. The third visit focused only on insomnia, neglecting the Yangming excess syndrome. Stomach heat remained, failing to eradicate the root cause, as Zuojing noted. "When the stomach is disharmonious, sleep is disturbed." I record this to acknowledge my error and warn future practitioners. Eight years ago, introduced by Zhou Juchen, I treated a patient surnamed Wang. Initial prescription: Sheng Dahuang 4 qian, Houpo 2 qian, Zhishi 4 qian, Mangxiao 3 qian. The patient suffered from asthma, insomnia, high fever, sweating, and a large, slippery pulse. After purgation, sleep improved slightly, but yellow turbid phlegm was expectorated. I used Chengqi Tang minus Dahuang plus Zaojia powder (1 qian). Two doses cured him. This case is similar and is attached for reference.
Yangming Battle Sweat
Patient Lu (Female). First visit, March 22. Yangming disease, ten days without bowel movement. Foul qi rushing to the head causes glabellar pain. Brain mistiness causes nocturnal delirium. Yangming dryness scorching causes right thigh pulling, knee flexion inability, and right hand spasm. Nighttime insomnia necessitates urgent purgation. Dachengqi Tang is suitable.
Sheng Chuanjun (Rhubarb) 4 qian (added later), Zhishi 3 qian, Houpo 1 qian, Mangxiao 3 qian (dissolved).
Zhuochao Note: After medication, two large bowel movements occurred at night, allowing slight sleep.
Second and Third visits focused on Baihu Tang. Shaoyao was added for limb immobility; Tianhuafen for thirst. After the third visit, Zhang Hengshan was consulted twice without effect. Thirty days later, hearing of intense aversion to heat, the family gave snow water, providing comfort. This aligns with the principle: "If the patient desires water, give it sparingly, and they will recover." I prescribed: Sheng Shigao 2 liang, Zhimu 5 qian, Sheng Gancao 3 qian, Xiyangshen (Western Ginseng) 1 qian, and He Mi (Rice) 1 pinch. After decoction, the patient felt very clear-headed. On April 1, drinking the second decoction, by afternoon, the patient suddenly shivered, closed eyes as if dead, followed by high fever and sweating. This follows the *Shanghan Lun* example of battle sweat resolving the disease, not a malignant sign.
Continued Consultation, April 6. Since Dachengqi Tang on March 22, two doses of cooling nutritive-clearing stomach agents failed. Zhang Hengshan was consulted twice without effect. On the 30th, hearing of aversion to heat and thirst, Baixu Jiaren Tang was used. On the 1st, battle sweat occurred, suggesting recovery. By the 4th, the family reported right arm/leg immobility and soreness. I prescribed Shaoyao Gancao Tang modification (Chibai Shao and Baishao 1 liang each, Zhi Gancao 5 qian, Zhi Ruxiang and Moyao 3 qian each, Sigualuo 3 qian), restoring limb movement. Today, the family reports ability to eat but inability to defecate, with dark urine. Prescription below: Sheng Chuanjun 1.5 qian, Mangxiao 1 qian (dissolved), Sheng Gancao 2 qian.
Zhuochao Note: After purgation, all symptoms resolved, and appetite greatly improved.
[Commentary] Sweating after shaking is called Battle Sweat. In this case, it is Yangming Battle Sweat. The Great Treatise states: "In all Chaihu Tang syndromes, if Chaihu syndrome does not resolve, re-administering Chaihu Tang will cause shivering, followed by fever and sweating for resolution." This is Shaoyang Battle Sweat. Also: "In Taiyang disease unresolved, if pulse Yin and Yang both stop, shivering precedes sweating for resolution." This is Taiyang Battle Sweat. Superficially, it seems all three Yang meridians experience battle sweat. Why does the patient desire sweat? To expel pathogens. If righteous Qi is sufficient, pathogen light, and aided by medicine, sweat comes easily without distress. Without medicinal aid, mere Qi-pathogen struggle causes some distress. Thus, the Great Treatise says: "For spontaneous resolution, vexation must precede sweating." If Qi is weak and pathogen strong, even with medicine, trembling and struggle are needed for sweat, appearing as battle rather than just vexation. Thus: "Why does battle sweat lead to resolution?" Answer: "Floating-tight pulse, thready upon pressure, indicates root deficiency, hence battle sweat." Root deficiency causes trembling; floating pulse allows sweat resolution. If floating-rapid and not thready, root is not deficient; spontaneous resolution brings simple sweating without battle. The wording here is repetitive, unlike Zhongjing's style, but the reasoning is precise and trustworthy. Furthermore:
Most recoveries via sweating belong to Taiyang,其次 Shaoyang, rarely Yangming. Taiyang battle sweat is not unusual. Shaoyang patients taking Chaihu Tang may sweat or battle-sweat, possibly due to mixed Taiyang pathogens. This Yangming battle sweat case likely involves old Taiyang or Shaoyang pathogens lodged in skin/muscle and San Jiao. Physicians failed to resolve them via sweating. As the disease transformed into Yangming, fluids were scorched, unable to form sweat, and physicians neglected this. Later, as Yangming healed and Yin fluids partially recovered, the patient's own righteous Qi attempted to expel long-dormant pathogens, resulting in a necessary battle. Thus, calling it "Yangming Battle Sweat" refers only to the recent manifestation, not a comprehensive theory.
Battle sweat is like breaking cauldrons and sinking boats—a last stand. Victory means life; defeat means death. If one battle is inconclusive, repeated battles occur. After chronic illness, righteous Qi cannot endure pathogen entanglement, preferring a decisive battle. Thus, battle sweat is the pivot of life and death, separating Yin and Yang. Physicians and families must understand this deeply. Three references are recorded for consideration.
*Shanghan Zhengzhi Mingtiao* states: In epidemic battle sweat, sudden chills and jaw quivering occur. Immediately give hot ginger-rice soup to assist Yang. Soon, battle stabilizes, fever arises, and sweating resolves. If the patient hates heat, removes clothes, and blocks sweat, use Shengjiang, Douchi, Zisu to induce sweating. If righteous Qi is too weak to overcome pathogens, battle occurs without sweat—this is difficult to treat. If sweat occurs after half a day or night, recovery ensues. If still no sweat, with coma and fading pulse, urgently decoct Ren Shen, Jiang, Zao to rescue. Elderly or weak persons battling without sweating, followed by coma, indicate righteous Qi collapse and non-recovery. Epidemics may see five or six battle sweats without harm, as pathogens are deep and need thorough expulsion. Repeated battles may occur two or three times until sweat resolves the disease.
*Yilin Shengmo* states: If sweating is indicated but pulse is weak, sweating will be difficult. If battle occurs without sweat, do not force assistance; no sweat means death. Do not medicate during battle; medication brings disaster without merit. To assist sweat, use much ginger soup.
*Wenyi Lun* states: Failure to purge when indicated depletes Qi and Blood. Purging may still result in battle sweat. Battle without sweat is critical, as Middle Qi is weak, able to descend but not ascend. The next day, if battle returns, reversal of cold limbs and sweating indicate life; no reversal/no sweat indicates death due to Qi collapse. Battle with reversal but no sweat indicates True Yang remains but exterior Qi is exhausted; gradual recovery is possible. Any battle followed by sudden spasms is fatal. Spasms involve corpse-like stiffness, clenched jaws, and upward-gazing eyes. Do not disturb during battle; only keep warm. Disturbance stops the battle, requiring repetition the next day. "Manic sweat" occurs when latent pathogens collapse internally, attempting to exit via sweat. Due to strong constitution and vigorous Yang, opening is delayed, causing restlessness and mania. Suddenly, profuse sweat occurs, mania ceases, pulse calms, body cools, and recovery is swift.
*Wenyi Lun* further states: In plague with purgation indications, prolonged failure to purge leads to daily passage of pure foul water, dozens of times day and night, causing dry mouth/lips and cracked tongue. Physicians treating this as coordinated heat diarrhea with Gegen Huanglian Huangqin Tang worsened the condition. I diagnosed it as heat accumulation with side-flow (Re Jie Pang Liu) and urgently gave Dachengqi Tang. Many old feces were expelled, resembling spoiled sauce, sticky, and foul-smelling. Diarrhea stopped that night. Next day, Qingzao Tang was given. Pulse remained deep; purgation was repeated, and pulse became floating. Purgation indications decreased, leaving slight surface heat. This should resolve via sweating. Although no sweat occurred, interior pathogens were cleared, Middle Qi harmonized, and diet gradually resumed. Half a month later, battle sweat suddenly occurred, resolving exterior pathogens. Prolonged diarrhea caused extreme dryness of interior/exterior. Half a month of diet restored fluids, enabling sweat—"accumulated flow naturally clears the channel." Thus, floating pulse and body heat require sweat for resolution; blood dryness and fluid depletion require fluids for sweat. Ancients said "blood loss means no sweat"; now we know "fluid loss means no sweat." Though blood and fluids differ, dryness is the same. Plague cannot be cured by inducing sweat with herbs alone. The first half of this section supplements the Dachengqi indication for self-purging clear water; the second half offers an alternative explanation that battle sweat mostly belongs to Taiyang.
Cao Yingfu stated: Battle sweat mostly belongs to Taiyang, a point previously unexplored, as Taiyang governs Cold Water, which other meridians do not. All battle sweat recoveries result from Taiyang failure to release the exterior. In Shaoyang, the Hand Shaoyang San Jiao is the pathway for Cold Water descent. Yangming has already transformed into dryness and should not exhibit this. If seen, it may be due to excessive water retention, with upper Jiao water vapor remaining while intestines/stomach are dry. Vaporized water transforms into damp-heat, clashing with dry feces. Once feces are removed, damp-heat cannot remain alone and exits via battle sweat. Seen once in decades, it should not be established as a standard example.