昏迷(尿路感染合并肺炎)
王某某，男，79岁
病史：持续性尿频尿急已两个月，近两周加重，于1980年2月8日入院。患者1977年9月忽然出现无痛性肉眼全程血尿，经膀胱镜检查诊为膀胱癌，1977年u月行膀胱部分切除术。近两个月来尿频，两周前发烧39.5℃，五天后体温才有所下降，但咳嗽加剧，痰黄粘，呼吸不畅，诊断为肺炎。同时尿频愈甚，排尿困难，以膀胱癌术后尿路感染收入院。
有高血压病史二十余年，过去血压经常在200／l00毫米汞柱，1963年曾患右手麻木。
入院时体温37.5℃，脉搏84次／分，呼吸21次／分，血压134／70毫米汞柱。发育营养中等，神清合作，表浅淋巴结不肿大，肝脾未触及，前列腺两恻叶增大，中间沟消失，表面光滑。
化验；白细胞：4800／立方毫米，中性细胞；72％，杆状核细胞16％，单核细胞9％，血红蛋白11.3克，血钠134毫当量／升，血钾3.67毫当量／升，氯化物588毫克“，血糖127毫克％，二氧化碳结合力47容积％，非蛋白氮46毫克％，尿检：蛋白(++)，糖(士)，白细胞50～60个／高倍视野，红细胞2～3个／高倍视野。
心电图提示：间歇性频发性房性早搏，左前柬支阻滞，弥漫性心肌改变。×线检查：有慢性支管炎伴感染表现。
入院诊断：泌尿系感染，前列腺增生，膀胱癌术后肺炎、冠心病。
治疗经过：入院后给抗感染治疗，先后用红霉素、白霉素、万古霉素及中药清热解毒，但感染未能控制?白细胞增至9400～n，000／立方毫米，中性细胞82％，尿检结果也未见改善，神志不清，重病容，心率130次／分，有停跳，血压不稳，忽高忽低，肺部病变亦未改善，2月17日在痰里找到酵母样菌，病情重笃，于2月17日邀赵师会诊。
初诊
身热不退，面色黧黑，形体消瘦，神志昏沉，咳嗽痰黄，气喘气急，脉象细小沉弦按之不稳，且有停跳。舌绛千裂中剥，唇焦齿燥，七～八日未进饮食，全靠输液输血维持。
辨证：患者年逾古稀，下元已损，热病已久、阴津大伤，痰热内追，热邪深入营分浦所服药物全属寒凉，气机被遏，肺失宣降，郁热内迫，营阴重伤，致使昏迷谵语，舌绛唇焦咳喘痰鸣，形消脉细，诸症丛起。暂以养阴之法求其津回而脉复，用宣气机开疲郁之药以冀营热外透。
处方：生白芍15克，天麦冬各6克，沙参20克，元参15克，石斛10克，前胡6克，黄芩10克，杏仁10克，黛蛤散12克(包)，川贝粉3克(冲)，羚羊角粉0.5克(冲)，服二剂
二诊
服药后喘咳轻，神志苏，知饥素食，脉搏80次／分，患者欣喜万分，吃面汤两碗，蛋羹两份，西红柿加糖一碗。入晚病情突变，呕吐频作，头昏目眩，血压上升，阵阵汗出，遂陷昏迷，舌绛中裂，两脉细弦滑数。
辨证：此属食复。一诊神清知饥，营热已开始外透于气，是属佳象。然久病之躯，胃脾俱弱，饮食不慎，过食，滞于中焦，阻塞气机，壅遏生热。呕吐频频，复伤阴助焚，且郁热上蒸包络，与痰热相搏，上蒙清窍，内闭心包，致使病情急转，神志昏迷，舌绛中裂。再拟甘寒养阴，涤痰开窍，兼以化滞和胃，宣展气机仍希有透热转气之机：
处方：生地15克，玄参15克，麦冬10克，沙参15克，牡蛎30克，石斛10克，菖蒲6克，杏仁10克，黛蛤散10克(包)，珍珠母20克，焦谷芽20克，竹茹6克，服二剂。
另；安宫牛黄丸半丸，分两次服。
三诊
药后神志已请，体温正常，心率不快，血压平稳，两目有神，舌绛有津，薄苔渐布，两脉渐起，细数已减，咳喘皆平。此属内窍已开，营热开始外透，且胃津已回，痰热渐除，再以原方进退。
处方：沙参15克，玉竹10克，麦冬10克，石斛10克，五味子10克，远志10克，茯苓10克，黛y自散10克，杏仁10克，鸡内金10克，服二剂
四诊
舌绛已去，薄白苔生，神色皆好，二便如常，唯皮肤作痒，心烦难寐，此乃阴分未复，虚热扰神，拟复脉汤合黄连阿胶汤加减：
处方：白芍15克，山药10克，阿胶10克(烊化)，沙参15
克，白扁豆10克，远志10克，海蜇皮10克，马尾连3克，鸡子黄2枚(搅匀冲)，服三剂
药后已能下床活动，饮食及二便正常，×线检查“两肺阴影吸收”，血常规化验正常，调理数日痊愈出院。年后随访一切正常，已上班工作。
原按：本案患者年逾七旬，正气已衰；且膀胱癌手术后，气血大伤，热邪久羁，津液耗惫。近患肺炎、泌尿系感染，叠进中西药，全属寒凉，遏阻气机，肺不宣降，津液不布，遂成痰浊。本证属热邪入营漕阴重伤，且肺失宣降，痰浊阻滞气机。所以初诊即以白芍、生地、麦冬、元参、沙参、石斛等甘寒生津，即王孟英所说：“阴气枯竭，甘寒溺润，不厌其多，”因“若留得一分津液，便有一分生机，”本案始终抓住地这一点，“刻刻顾其津液，”以保生机不绝。以羚羊角清营分之热；因痰浊阻滞肺失宣降，气机不畅，入营之热不得外达，故以前胡、杏仁、川贝、黛蛤散宣降肺气以化痰浊，黄芩清气分之余热，舍以畅营热外达之路而透热转气所以服后神清知饥，均为营热外透的标志。
二诊为食复。因食滞中阻，郁热上蒸，不仅阴伤，且有痰热蒙蔽心包之势，故除甘寒养阴之外，又加安宫牛黄丸以开内窍之闭，并加化滞和胃之品，宣畅气机，导营热外达，服后舌质虽绛有津，薄苔渐布，神志转清，均说明营热已开始外透。
两诊虽为同一病人，但因造成气机不畅，营热不能外透的原因不同，所以作为透热转气的用药也随之而异，温热一旦透转，则按其证辨证论治。
[按]：赵师认为叶氏“透热转气”法适用于温病任何阶段，透转的目的是给邪气以出路。温热邪所乃无形之邪，必凭藉有形而胶固难解。故欲使透热转气，必分析找出不能透转的原因，而后针对性用药。本案两用透热转气法，初诊神昏，乃因痰浊阻滞，气机不畅，故治用宣肺气化痰浊以为透热转气之法，服后神即转清。二诊时患者贪食过多，以致食复，复陷昏迷，此为食滞中焦，气机不畅，故于方中加入消食导滞之品以为透热转气之用。服之热退神清。可见透热转气用药原无定法，但总以调畅气机，令三焦通畅为要，则邪气自能透转外泄矣。
麻疹(麻疹合并肠炎)
方某，男，4岁
初诊
麻疹透见四日，昨日大便作泄，日行五、六次，便中带有脓血，身热较甚，体温38.4℃，神志欠佳，腹中作痛，大便气坠不畅，家属焦急特甚，故夜间来寓求医。
望之遍体麻疹透发甚佳，体温38.5℃，两手指纹色紫至气关，两手脉象滑数有力，尺部滑实，舌苔黄厚。小便短少，观其大便色深黄粘稠，似带脓血，腹中微痛，仍时咳嗽，夜问不能安静睡眠，手足心灼热特甚。此温热卫营合邪，疹毒特重，病中饮食失当，胃肠积滞蕴郁化痢，属麻疹合并痢疾之证。治须外以宣透其疹，内以泄化其滞，切不可再予饮食，必须慎食忌口，否则因循增重，而导致本不胜病。嘱病儿之母，一定只吃点稀粥，俟烧退痢愈，始可逐渐增些饮食，否则仍变坏证，莫谓言之不预也。
荆穗炭3克，葛根1 5克，黄芩4.5克，黄连3克，生甘草3克，焦山楂6克，二付
二诊
身热渐退，体温37 8℃，神志甚佳，麻疹似将透齐，昨日大便三次，后坠沉重已减，大便仍粘色深，腹痛亦有好转，两手指纹紫色较淡，已降至风关，两手脉象滑数，咳嗽较前大减。麻疹透齐已还，胃肠积滞渐化，舌苔黄厚渐轻，再“疏调胃肠，兼以导滞。
荆穗炭3克，葛根1.5克，黄连3克，赤芍6克，黄芩3克，炙草3克，焦山楂6克，二付
三诊
身热已退净，体温36.5℃，麻疹已愈，腹泄未作，昨目大便已正常，仅一次，夜间睡眠甚佳，指纹已降至风关，脉象濡滑。疹邪已愈，胃肠滞热亦轻，再以调理胃肠，以善其后，饮食寒暖千万小心，忌生冷荤腥之物。
蝉衣3克，僵蚕3克，黄连3克，焦麦芽6克。炙草3克，二付
四诊
诸恙皆愈，眠食如常，体温36.6℃，指纹脉象皆如常。停药慎食二周，避风凉，慎起居，以清淡饮食为消息善后之法。
[按]，本例属麻疹合并肠炎，虽疹已透出，然洁不如法，必致内陷，则成逆证。故治疗宜将两顾。外以宣透其疹，内以清肠治痢。方选葛根芩连汤，一举两得，葛根有解肌透疹之功，芩连奏清肠止痢之效，加荆芥炭引入血分，仍具升和之力，焦三仙消导食滞，而除作痢之本，组方严密，投之即效。二诊、三诊均宗其法进退而愈。此案中值得玩味之处还在于强调忌口，不但病中忌之，病后嵌然当忌。先生嘱咐再三，用意至深。麻疹兼痢，全属滞热，是小儿常见之温病。经云“热病稍愈，当何禁之?曰：食肉则复，多食则遗，此其禁也。”凡温热病之治，例皆仿此。
肺痈1(大叶肺炎)
崔某，男，58岁，于1989年10月9日初诊。患者自二周前困患感冒，自觉发冷发热一天后出现咳嗽有白泡沫疲，胸痛胸闷，随去北大医院就诊，检查血白细胞21300／mm3，中性80%，×线片示右下肺大片浓密阴影，提示左下肺炎，用抗生素治疗一周，仍高热不退，症状加重，病人要求请赵老会诊。诊时见z身热恶寒，阵阵汗出，咳嗽气喘，痰多黄浊；胸闷且痛，舌质紫暗，苔白腻垢厚，脉濡滑且数，体温38.5℃。
辨证：痰湿郁热互阻，肺失宣降。
立法：清热化痰，宣郁肃降，防成肺痈，饮食清痰，忌食辛辣肥甘。
方药；苏叶子各10克，前胡6克，浙贝母10克，杏仁10克，枇杷叶10克，茅芦根各10克，冬瓜仁10克，苡米仁10克，葶苈子10克，焦三仙各10克，海浮石10克。
二诊10月11日
服上方3剂，咳嗽气喘、发热胸痛见轻，唯咳吐大量脓痰，腥臭无比，体温37℃。肺痈已成，用清热化痰，活瘀解毒消痈方法。处方z苇茎30克，桃仁6克，冬瓜仁20克，苡米仁10克，葶苈子10克，黄芩6克，苏叶10克，前胡6克，杏仁10克，浙贝母10克，枇杷叶10克，瓜萎仁30克，桔梗10克，生甘草10克，牛蒡子10克。男加西犀黄丸6克，分二次服。
三诊10月21日
服上方5剂，热退，痰量减少，臭味减轻。又服5剂，咳嗽脓痰以及臭味皆止，精神振作，纳食较佳，舌红苔白，胸透(一)，体温36.5℃，血白细胞5000／mm3，中性70％。肺痈已愈，饮食当慎，防其复发。再以宣肺肃降，养阴清热方法。药用z杏仁10克，前胡6克，浙贝母10克，苇茎30克，沙参10克，桔梗10克，茯苓10克，炒莱菔子10克，焦三仙各10克，水红花子10克。服药10剂，以巩固疗效。
[按]；肺痈是一种肺叶生疮形成脓疡的病证舭患者平素嗜酒不节，恣食厚味，湿热互结，上蒸于肺，肺失清肃，宣降不利，又复感燥热之邪，内外之邪相引，蕴部成痈，肉腐血败成脓。在治疗上必须分层次按阶段辨证施治。但是，无论是哪一期，哪一阶段，宣展肺气，保持气道通畅，贯彻始终，此乃赵师治疗肺痈的总原则。不单纯是在用药上注意，饮食调养尤为重要，饮食宜清淡，忌一切辛辣厚腻以及助湿生热之品。另外绝对卧床休息并非上策，须适当的活动，有利于痰的排出，促进康复。
Coma (Urinary Tract Infection Complicated with Pneumonia)
Patient Wang, Male, 79 years old
Medical History: Persistent urinary frequency and urgency for two months, aggravated in the last two weeks, admitted to the hospital on February 8, 1980. In September 1977, the patient suddenly developed painless gross hematuria throughout the urine stream. Cystoscopy diagnosed bladder cancer, and a partial cystectomy was performed in November 1977. For the past two months, urinary frequency has persisted. Two weeks prior to admission, the patient had a fever of 39.5°C. Five days later, the body temperature decreased slightly, but coughing intensified, sputum became yellow and sticky, and breathing was difficult; pneumonia was diagnosed. Meanwhile, urinary frequency worsened, accompanied by dysuria. The patient was admitted for urinary tract infection following bladder cancer surgery.
The patient has a history of hypertension for over twenty years, with blood pressure frequently reaching 200/100 mmHg previously. In 1963, he suffered from numbness in the right hand.
Upon admission: Body temperature 37.5°C, pulse 84 beats/min, respiration 21 breaths/min, blood pressure 134/70 mmHg. Development and nutrition were moderate. Conscious and cooperative. Superficial lymph nodes were not enlarged. Liver and spleen were not palpable. Both lobes of the prostate were enlarged, the median sulcus disappeared, and the surface was smooth.
Laboratory tests: White blood cells (WBC): 4,800/mm³, neutrophils: 72%, band forms: 16%, monocytes: 9%, hemoglobin: 11.3 g/dL, serum sodium: 134 mEq/L, serum potassium: 3.67 mEq/L, chlorides: 588 mg/dL, blood glucose: 127 mg%, carbon dioxide combining power: 47 vol%, non-protein nitrogen: 46 mg%. Urinalysis: Protein (++), Sugar (±), WBC 50-60/high-power field (HPF), RBC 2-3/HPF.
Electrocardiogram indicated: Intermittent frequent atrial premature beats, left anterior fascicular block, diffuse myocardial changes. X-ray examination showed signs of chronic bronchitis with infection.
Admission Diagnosis: Urinary tract infection, prostatic hyperplasia, post-operative pneumonia from bladder cancer, coronary heart disease.
Treatment Course: After admission, anti-infective therapy was administered. Erythromycin, spectinomycin, vancomycin, and Chinese herbal medicine for clearing heat and detoxifying were used sequentially. However, the infection could not be controlled. WBC increased to 9,400-11,000/mm³, neutrophils 82%. Urinalysis results did not improve. Mental status was unclear, appearance was critical. Heart rate was 130 beats/min with skipped beats. Blood pressure was unstable, fluctuating high and low. Pulmonary lesions also did not improve. On February 17, yeast-like fungi were found in the sputum. The condition was severe, and Master Zhao was invited for consultation on February 17.
First Visit
Persistent fever, dark complexion, emaciation, lethargy, cough with yellow sputum, panting and shortness of breath. Pulse is fine, small, deep, wiry, unstable upon pressing, with skipped beats. Tongue is crimson, dry, cracked, and peeled in the center. Lips are scorched, teeth are dry. No food intake for 7-8 days, maintained solely by intravenous fluids and blood transfusions.
Pattern Differentiation: The patient is over seventy years old, with depletion of the lower origin (Kidney essence). The febrile disease has been prolonged, causing significant damage to Yin and body fluids. Phlegm-heat forces inward, and pathogenic heat has penetrated into the Ying (Nutritive) level. All medications taken were cold and cooling in nature, suppressing the Qi mechanism. The Lung lost its dispersing and descending functions. Depressed heat forced inward, severely injuring Ying-Yin, resulting in coma and delirium, crimson tongue, scorched lips, coughing, panting, and phlegm rales. Emaciation and fine pulse indicate various symptoms arising together. Temporarily employ the method of nourishing Yin to seek return of fluids and restoration of the pulse. Use herbs that promote Qi mechanism and resolve stagnation to hope for the exteriorization of Ying-level heat.
Prescription: Raw Bai Shao (Paeoniae Radix Alba) 15g, Tian Dong (Ophiopogonis Tuber) and Mai Dong (Ophiopogonis Tuber) 6g each, Sha Shen (Glehniae Radix) 20g, Yuan Shen (Scrophulariae Radix) 15g, Shi Hu (Dendrobii Caulis) 10g, Qian Hu (Peucedani Radix) 6g, Huang Qin (Scutellariae Radix) 10g, Xing Ren (Armeniacae Semen Amarum) 10g, Dai Ge San (Indigo Naturalis and Fritillaria Powder) 12g (wrapped), Chuan Bei Fen (Fritillariae Bulbus Powder) 3g (dissolved), Ling Yang Jiao Fen (Capricornis Cornu Powder) 0.5g (dissolved). Take two doses.
Second Visit
After taking the medicine, panting and coughing lightened, mental status recovered, appetite returned. Pulse 80 beats/min. The patient was extremely happy, consuming two bowls of noodle soup, two portions of egg custard, and one bowl of tomato with sugar. That evening, the condition changed suddenly: frequent vomiting, dizziness, rising blood pressure, paroxysmal sweating, leading to coma. Tongue crimson with central crack, pulses fine, wiry, slippery, and rapid.
Pattern Differentiation: This belongs to relapse due to dietary indiscretion (Shi Fu). At the first visit, mental clarity and hunger indicated that Ying-heat had begun to exteriorize to the Qi level, which was a good sign. However, in a chronically ill body, both Stomach and Spleen are weak. Dietary carelessness and overeating caused stagnation in the Middle Jiao, blocking the Qi mechanism and generating heat. Frequent vomiting further injures Yin and aids burning. Depressed heat steams upward to the Pericardium, combats with phlegm-heat, covers the clear orifices, and internally closes the Pericardium, causing sudden deterioration, coma, and a crimson tongue with central crack. Re-prescribe sweet-cold herbs to nourish Yin, wash away phlegm and open orifices, simultaneously transform stagnation and harmonize the Stomach, and promote Qi mechanism to still hope for the opportunity of transmitting heat outwards (Tou Re Zhuan Qi).
Prescription: Sheng Di (Rehmanniae Radix) 15g, Xuan Shen (Scrophulariae Radix) 15g, Mai Dong (Ophiopogonis Tuber) 10g, Sha Shen (Glehniae Radix) 15g, Mu Li (Ostreae Concha) 30g, Shi Hu (Dendrobii Caulis) 10g, Chang Pu (Acori Tatarinowii Rhizoma) 6g, Xing Ren (Armeniacae Semen Amarum) 10g, Dai Ge San (Indigo Naturalis and Fritillaria Powder) 10g (wrapped), Zhen Zhu Mu (Margaritifera Ostreum) 20g, Jiao Gu Ya (Ziziphus Spinosa Seed, Charred) 20g, Zhu Ru (Bambusae Caulis in Taenia) 6g. Take two doses.
Additionally: An Gong Niu Huang Wan (Calculus Bovis Pill) half pill, divided into two doses.
Third Visit
After medication, mental status cleared, body temperature normalized, heart rate not fast, blood pressure stable. Eyes have spirit. Tongue crimson but moist, thin coating gradually appearing. Pulses gradually rising, fine-rapid quality reduced. Coughing and panting ceased. This indicates internal orifices opened, Ying-heat beginning to exteriorize, Stomach fluids returned, and phlegm-heat gradually eliminated. Adjust the original prescription accordingly.
Prescription: Sha Shen (Glehniae Radix) 15g, Yu Zhu (Polygonati Odorati Rhizoma) 10g, Mai Dong (Ophiopogonis Tuber) 10g, Shi Hu (Dendrobii Caulis) 10g, Wu Wei Zi (Schisandrae Fructus) 10g, Yuan Zhi (Polygalae Radix) 10g, Fu Ling (Poria) 10g, Dai Ge San (Indigo Naturalis and Fritillaria Powder) 10g, Xing Ren (Armeniacae Semen Amarum) 10g, Ji Nei Jin (Galli Gigerii Endothelium Corneum) 10g. Take two doses.
Fourth Visit
Crimson tongue color gone, thin white coating grown. Complexion and spirit good. Bowel and bladder movements normal. Only skin itching and irritability with difficulty sleeping remain. This indicates Yin levels not yet restored, deficiency heat disturbing the Spirit. Prescribe Fu Mai Tang (Pulse-Restoring Decoction) combined with Huang Lian E Jiao Tang (Coptis and Donkey-Hide Gelatin Decoction) with modifications.
Prescription: Bai Shao (Paeoniae Radix Alba) 15g, Shan Yao (Dioscoreae Rhizoma) 10g, E Jiao (Colla Corii Asini) 10g (melted), Sha Shen (Glehniae Radix) 15g, Bai Bian Dou (Phaseoli Multiflori Semen) 10g, Yuan Zhi (Polygalae Radix) 10g, Hai Zhe Pi (Metapenaeopsis Carapace) 10g, Ma Wei Lian (Coptidis Rhizoma, branched) 3g, Ji Zi Huang (Egg Yolk) 2 pieces (beaten and dissolved). Take three doses.
After medication, able to get out of bed and move around. Diet and bowel/bladder movements normal. X-ray shows "absorption of shadows in both lungs." Blood routine test normal. Recovered after several days of regulation and discharged. Follow-up after New Year showed everything normal, returned to work.
Original Commentary: The patient in this case is over seventy, with depleted Zheng Qi (Upright Qi). Furthermore, after bladder cancer surgery, Qi and Blood were severely injured. Pathogenic heat lingered for a long time, exhausting body fluids. Recently suffering from pneumonia and urinary tract infection, successive Western and Chinese medicines were all cold and cooling, obstructing the Qi mechanism. The Lung failed to disperse and descend, fluids were not distributed, thus forming turbid phlegm. This syndrome involves pathogenic heat entering the Ying level, severely injuring Ying-Yin, and Lung failing to disperse and descend, with turbid phlegm obstructing the Qi mechanism. Therefore, at the first visit, sweet-cold herbs like Bai Shao, Sheng Di, Mai Dong, Yuan Shen, Sha Shen, and Shi Hu were used to generate fluids. As Wang Mengying said: "When Yin energy is exhausted, sweet-cold moistening is never too much," because "if one part of body fluid is preserved, there is one part of vitality." This case consistently grasped this point, "constantly attending to body fluids," to ensure vitality does not cease. Ling Yang Jiao (Capricornis Cornu) clears heat in the Ying level. Because turbid phlegm obstructed the Lung, causing failure to disperse and descend, and unsmooth Qi mechanism, the heat entering the Ying level could not reach the exterior. Therefore, Qian Hu, Xing Ren, Chuan Bei, and Dai Ge San were used to disperse and descend Lung Qi to transform turbid phlegm. Huang Qin clears residual heat in the Qi level. This opens the path for Ying-heat to reach the exterior, achieving "transmitting heat outwards" (Tou Re Zhuan Qi). Thus, after taking the medicine, mental clarity and hunger are signs of Ying-heat exteriorizing.
The second visit was a relapse due to diet. Food stagnation blocked the middle, depressed heat steamed upward. Not only was Yin injured, but there was a tendency for phlegm-heat to cover the Pericardium. Besides sweet-cold herbs to nourish Yin, An Gong Niu Huang Wan was added to open the closure of internal orifices, along with herbs to transform stagnation and harmonize the Stomach, promoting Qi mechanism to guide Ying-heat outward. After taking it, although the tongue remained crimson but moist, and thin coating appeared, mental status cleared, all indicating Ying-heat had begun to exteriorize.
Although the two visits were for the same patient, the reasons for unsmooth Qi mechanism preventing Ying-heat exteriorization differed, so the herbs for "transmitting heat outwards" varied accordingly. Once warm-heat is transmitted, treatment follows pattern differentiation based on the syndrome.
[Commentary]: Master Zhao believes Ye Tianshi's method of "transmitting heat outwards" (Tou Re Zhuan Qi) applies to any stage of warm diseases. The purpose of transmission is to provide an exit for pathogenic factors. Warm-heat pathogens are formless evils that must rely on tangible substances to become stuck and hard to resolve. Therefore, to achieve "transmitting heat outwards," one must analyze and find the reasons preventing transmission, then prescribe targeted herbs. This case used the method twice. At the first visit, coma was due to turbid phlegm obstruction and unsmooth Qi mechanism, so treating with herbs to disperse Lung Qi and transform phlegm served as the method for transmitting heat outwards; mental status cleared after taking it. At the second visit, the patient ate too much, causing relapse and coma again. This was food stagnation in the Middle Jiao and unsmooth Qi mechanism, so digestive and stagnation-resolving herbs were added to facilitate transmitting heat outwards. Heat subsided and mental status cleared after taking it. It can be seen that there is no fixed method for herbs used in "transmitting heat outwards," but the key is always to smooth the Qi mechanism and ensure the Three Jiao are unobstructed, so that pathogenic factors can naturally transmit and excrete.
Measles (Measles Complicated with Enteritis)
Patient Fang, Male, 4 years old
First Visit
Measles spots visible for four days. Yesterday, diarrhea occurred, five to six times a day, stool containing pus and blood. Fever was significant, body temperature 38.4°C. Mental status was poor. Abdominal pain present. Stool sensation of heaviness and incomplete evacuation. Family members were extremely anxious, seeking medical help at night.
Observation: Measles eruption on the whole body was very good. Body temperature 38.5°C. Finger veins purple up to the Qi Guan (middle segment). Pulses slippery, rapid, and forceful in both hands, slippery and solid at the Chi position. Tongue coating yellow and thick. Urine scanty. Stool dark yellow, sticky, resembling pus and blood. Mild abdominal pain. Occasional cough. Unable to sleep peacefully at night. Palms and soles extremely hot. This is warm-heat pathogen combining in the Wei (Defensive) and Ying (Nutritive) levels, with particularly severe rash toxin. Improper diet during illness caused accumulation and stagnation in the stomach and intestines, transforming into dysentery. This belongs to measles complicated with dysentery. Treatment requires exteriorly dispersing and venting the rash, and interiorly draining and transforming stagnation. Absolutely no more food should be given; strict dietary restrictions are necessary. Otherwise, delaying will worsen the condition, leading to the body being unable to overcome the disease. Instructed the mother to feed only thin rice gruel. Once fever subsides and dysentery heals, diet can be gradually increased. Otherwise, it will still turn into a bad syndrome. Do not say I did not warn you.
Jing Sui Tan (Nepetae Spica, Charred) 3g, Ge Gen (Puerariae Lobatae Radix) 15g, Huang Qin (Scutellariae Radix) 4.5g, Huang Lian (Coptidis Rhizoma) 3g, Sheng Gan Cao (Glycyrrhizae Radix et Rhizoma) 3g, Jiao Shan Zha (Crataegi Fructus, Charred) 6g. Two doses.
Second Visit
Fever gradually subsided, body temperature 37.8°C. Mental status very good. Measles seems about to fully erupt. Stool three times yesterday, heavy bearing-down sensation reduced. Stool still sticky and dark. Abdominal pain improved. Finger vein purple color lighter, descended to Feng Guan (proximal segment). Pulses slippery and rapid. Cough significantly reduced compared to before. Measles fully erupted and receding. Gastrointestinal stagnation gradually resolving. Tongue coating yellow and thick becoming lighter. Continue to "regulate and adjust stomach and intestines, simultaneously guiding out stagnation."
Jing Sui Tan (Nepetae Spica, Charred) 3g, Ge Gen (Puerariae Lobatae Radix) 1.5g, Huang Lian (Coptidis Rhizoma) 3g, Chi Shao (Paeoniae Radix Rubra) 6g, Huang Qin (Scutellariae Radix) 3g, Zhi Cao (Glycyrrhizae Radix et Rhizoma, Honey-fried) 3g, Jiao Shan Zha (Crataegi Fructus, Charred) 6g. Two doses.
Third Visit
Fever completely subsided, body temperature 36.5°C. Measles healed. Diarrhea stopped. Stool normal yesterday, only once. Sleep very good at night. Finger vein descended to Feng Guan. Pulse soggy and slippery. Rash pathogen healed, gastrointestinal stagnant heat also light. Continue to regulate stomach and intestines to conclude treatment. Be extremely careful with diet and warmth. Avoid raw, cold, meat, and fish products.
Chan Yi (Bombyx Batryticatus) 3g, Jiang Can (Bombyx Batryticatus) 3g, Huang Lian (Coptidis Rhizoma) 3g, Jiao Mai Ya (Hordei Fructus Germinatus, Charred) 6g. Zhi Cao (Glycyrrhizae Radix et Rhizoma, Honey-fried) 3g. Two doses.
Fourth Visit
All ailments cured. Sleep and diet normal. Body temperature 36.6°C. Finger veins and pulses normal. Stop medication and observe diet for two weeks. Avoid wind and cold. Carefully manage daily life. Use light diet as the method for recovery and follow-up.
[Commentary]: This case is measles complicated with enteritis. Although the rash has erupted, improper nursing will inevitably lead to internal sinking, resulting in adverse syndromes. Therefore, treatment must attend to both aspects. Exteriorly disperse and vent the rash, interiorly clear the intestines and treat dysentery. Select Ge Gen Qin Lian Tang (Kudzu, Scutellaria, and Coptis Decoction), achieving two goals with one stroke. Ge Gen has the function of releasing the muscle layer and venting the rash. Qin and Lian have the effect of clearing the intestines and stopping dysentery. Add Jing Jie Tan (Nepetae Spica, Charred) to introduce into the Blood level, retaining lifting power. Jiao San Xian (Charred Hawthorn, Medicated Leaven, and Malt) digest and guide out food stagnation, removing the root cause of dysentery. The formula is rigorous, effective upon administration. Second and third visits followed this method with adjustments and achieved cure. A noteworthy point in this case is the emphasis on dietary restriction, not only during illness but also after recovery. The master instructed repeatedly, with profound intent. Measles complicated with dysentery is entirely due to stagnant heat, a common warm disease in children. The Classics state: "When a febrile disease has slightly improved, what should be prohibited? Answer: Eating meat causes recurrence, eating too much leaves residual pathogen. This is the prohibition." Treatment of all warm diseases generally follows this principle.
Lung Abscess 1 (Lobar Pneumonia)
Patient Cui, Male, 58 years old, First Visit on October 9, 1989. The patient caught a cold two weeks ago. Feeling chills and fever, one day later developed cough with white foamy sputum, chest pain and tightness. Went to Peking University Hospital for examination. Blood WBC 21,300/mm³, neutrophils 80%. X-ray showed large dense shadow in the right lower lung, suggesting left lower lobe pneumonia. Treated with antibiotics for one week, but high fever persisted, symptoms worsened. Patient requested consultation with Master Zhao. Upon diagnosis: Fever and aversion to cold, paroxysmal sweating, coughing and panting, copious yellow turbid sputum. Chest tightness and pain. Tongue body purple-dark, coating white, greasy, dirty, and thick. Pulse soggy, slippery, and rapid. Body temperature 38.5°C.
Pattern Differentiation: Phlegm-dampness and depressed heat mutually obstructing, Lung losing dispersing and descending functions.
Treatment Principle: Clear heat and transform phlegm, disperse depression and descend Lung Qi, prevent formation of Lung Abscess. Diet should be light; avoid spicy and rich/greasy foods.
Herbal Prescription: Su Ye (Perillae Folium) 10g, Qian Hu (Peucedani Radix) 6g, Zhe Bei Mu (Fritillariae Cirrhosae Bulbus) 10g, Xing Ren (Armeniacae Semen Amarum) 10g, Pi Pa Ye (Loquat Leaf) 10g, Mao Gen (Imperatae Rhizoma) and Lu Gen (Phragmitis Rhizoma) 10g each, Dong Gua Ren (Benincasae Semen) 10g, Yi Mi Ren (Coicis Semen) 10g, Ting Li Zi (Lepidii Semen) 10g, Jiao San Xian (Charred Hawthorn, Medicated Leaven, and Malt) 10g each, Hai Fu Shi (Spongiosa) 10g.
Second Visit, October 11
Took 3 doses of the above prescription. Coughing, panting, fever, and chest pain lightened. Only coughing up large amounts of purulent sputum, extremely foul-smelling. Body temperature 37°C. Lung abscess formed. Use method of clearing heat, transforming phlegm, activating blood, resolving toxicity, and eliminating abscess. Prescription: Wei Jing (Euphorbiae Henanensis Caulis) 30g, Tao Ren (Persicae Semen) 6g, Dong Gua Ren (Benincasae Semen) 20g, Yi Mi Ren (Coicis Semen) 10g, Ting Li Zi (Lepidii Semen) 10g, Huang Qin (Scutellariae Radix) 6g, Su Ye (Perillae Folium) 10g, Qian Hu (Peucedani Radix) 6g, Xing Ren (Armeniacae Semen Amarum) 10g, Zhe Bei Mu (Fritillariae Cirrhosae Bulbus) 10g, Pi Pa Ye (Loquat Leaf) 10g, Gua Lou Ren (Trichosanthis Semen) 30g, Jie Geng (Platycodonis Radix) 10g, Sheng Gan Cao (Glycyrrhizae Radix et Rhizoma) 10g, Niu Bang Zi (Arctii Fructus) 10g. Male patient add Xi Xi Huang Wan (Calculus Bubali Pill) 6g, divided into two doses.
Third Visit, October 21
Took 5 doses of the above prescription. Fever subsided, sputum volume decreased, odor reduced. Took another 5 doses. Coughing, purulent sputum, and odor all stopped. Spirit refreshed, appetite better. Tongue red, coating white. Chest fluoroscopy (-). Body temperature 36.5°C. Blood WBC 5,000/mm³, neutrophils 70%. Lung abscess healed. Diet should be cautious to prevent recurrence. Use method of dispersing Lung and descending Qi, nourishing Yin and clearing heat. Medicinal materials: Xing Ren (Armeniacae Semen Amarum) 10g, Qian Hu (Peucedani Radix) 6g, Zhe Bei Mu (Fritillariae Cirrhosae Bulbus) 10g, Wei Jing (Euphorbiae Henanensis Caulis) 30g, Sha Shen (Glehniae Radix) 10g, Jie Geng (Platycodonis Radix) 10g, Fu Ling (Poria) 10g, Chao Lai Fu Zi (Radish Seed, Stir-fried) 10g, Jiao San Xian (Charred Hawthorn, Medicated Leaven, and Malt) 10g each, Shui Hong Hua Zi (Alternantherae Philoxeroides Semen) 10g. Take 10 doses to consolidate efficacy.
[Commentary]: Lung Abscess is a syndrome where lung tissue generates sores forming a purulent ulcer. Patients usually drink alcohol immoderately and indulge in rich foods. Damp-heat binds internally, steams upward to the Lung. Lung loses purity and肃 (descending) function, dispersing and descending are unfavorable. Additionally contracting dry-heat pathogen, internal and external pathogens attract each other, accumulating to form abscess, flesh rots and blood fails, forming pus. In treatment, one must differentiate and treat according to stages and levels. However, regardless of which stage or level, promoting Lung Qi and keeping airways unobstructed runs through the entire process. This is Master Zhao's general principle for treating Lung Abscess. Not only attention to medication is needed, but dietary regulation is particularly important. Diet should be light, avoiding all spicy, thick, greasy, and dampness-generating/heat-producing products. Also, absolute bed rest is not the best strategy; appropriate activity is necessary, beneficial for expectoration and promoting recovery.