高热昏迷1(老年肺炎)
刘某，女，78岁，于19拈年儿月15日初诊。
患者高热40余天。自10月初因感冒发热，咳嗽，有黄色粘痰，胸痛，校医室诊断为“老年性肺炎”，经用青霉素、链霉素、红霉素以及中药等治疗月余，咳嗽减轻，痰亦减少，但仍持续高热不退，腋下体温：上午37.5～38℃，下午至晚上39～40，5℃，近几天来并出现心烦急躁，时有谵语，转诊于赵老。现症；身热夜甚，心烦不寐，时有谵语，口干渴而不欲饮，小便短赤，大便数日未行，舌红绛少苔，脉沉滑细数。听诊：两肺底部大量湿性罗音，体温39.5℃。辨证：热邪蕴部，壅塞肺金。治则养阴清热，宣郁肃降。药用苏叶子各6克，前胡6克，杏仁10克，沙参10克，枇杷叶10克，黛蛤粉10克(包煎)，炒莱菔子10克，焦麦芽10克，茅芦根各10克。
二诊
10月18日，服上药3剂，发热见轻，神清、夜寐转安，但见咳嗽痰多，舌红绛苔薄，脉滑数，小便黄，大便排出几枚如干球状，体温37 1℃。仍余热未尽，前法进退。药用炒山栀6克，淡豆豉10克，前胡6克，杏仁10克，枇杷叶10克，沙参10克，麦冬10克，远志肉10克，浙皿母10克，茅芦根各10克，焦三仙各10克。
服上方三剂，热退身凉，咳嗽痰止，夜寐较安，二便正常，又服4剂而愈。
[按]，老年性肺炎比较难治。此患者年愈七旬，正气已衰，又患肺炎，肺热壅盛，肺失宣降，热郁不发。本应清热养阴、宣部化痰、扶正祛邪，而观前药多是苦寒清热、消炎泻火之属，反徒伤正气、阻塞气机，致使痰热内陷入营。赵师用养阴清热，佐以透热转气之法，以沙参养阴、扶正气，用苏叶、苏子、前胡、杏仁宣通气机，黛蛤粉清热消痰、祛邪气，莱菔子、焦麦芽消食导滞。仅服三剂，热郁渐解，神志转清。但见咳嗽痰多，乃气机得宣，内陷之痰由里排出。因此在前方基础上又加炒山栀、淡豆豉苦宣折热去余邪，麦冬、沙参养阴生津扶正气，加远志肉、浙贝母止咳化痰。前后共服6剂，已延40余天的老年肺炎得以痊愈。
高热昏迷2(流行性感冒)
陈某某，男，80岁
初诊
发热时重时轻，曾服治感冒之剂，半月来未能好转，困其年老体衰，缠绵已十六日。昨日高烧昏迷，体温38.9℃，大便4～5日未行，顷诊两脉按之弦滑而数，关尺有力，舌苔老黄根厚，一派温热内陷，阳明腑实之象。虽年已杖朝而邪热腑实内聚，日久津液已伤，必须通腑泄热，开郁展气，佐以生津之法，仿牛黄承气汤。
僵蚕9克，蝉衣6克，姜黄6克，前胡3克，杏仁9克，元参24克，竹叶3克，生大黄粉1.5克分二次药送下，安宫牛黄丸一丸分化，二付。以大便得通即停药。
二诊
连服二付之后，昨日大便畅通一次，今晨小汗，身热已退至37.1℃，神志已清小便短黄，夜寐甚安，两脉已起，中取弦精，数象已退，舌苔黄而不老，质红较前有液，老年温病，阳明腑实，气机不通，连服牛黄承气，大便通而神志开，再增甘寒增液，益气通幽之法。
细生地15克，元参15克，沙参15克，麦冬9克，前胡3
克，杏仁9克，瓜蒌24克，枳壳9克，二付。
三诊
甘寒育阴增液之后，神志清爽，大便今日又通一次，连日夜寐甚安，脉象渐渐有神，舌苔已化，胃纳渐佳，体温正常，再以调理中焦为法。
北沙参15克，麦门冬9克，五味子9克，杭白芍24克，陈皮6克，鸡内金9克，生苡米24克，焦麦芽9克，三付。
药后家属前来告知患者已完全康复，问尚须服药否，遂嘱只进食易消化食物，清淡为佳，以养胃气，即可无虞。
[按]：结阳明腑实之候，故断然用牛黄承气攻下热结。因其年高病久，故又嘱其得便通即停药。二诊使改用增水行舟之法。正是当大胆时便大胆，该小心处须小必。孙思邈所谓胆大心细，行园智方，此其谓欤!
高热昏迷3(病毒性脑炎)
邹某某，女，25岁
初诊
发热已半月，由于经济情况过差，无力求医，从昨日起开始高烧昏迷抽风，遂请往诊。顷诊两脉细弦而数，高烧昏迷，形体削瘦，极度营养不良，头胀痛，躁扰不安，手足抽搐，角弓反张，舌绛干无藏，质老，苔根略厚，唇焦色紫，大便三日不通小溲色赤。西医检查怀疑为病毒性脑炎。
素体阴虚血少，温邪蕴热直追血分，热邪上蒸则头胀头痛。热扰心神则昏迷躁动，血虚肝阴失养，筋脉拘急，故手足抽搐而颈项强直。此营热动风，血少筋急，必须清营热，佐以凉肝熄风方法。正虚邪实，深恐本不胜病，备候高明政定。
细生地30克，生白芍孔克，茯神9克，桑叶9克，钩藤12克(后下)，川n1母6克，菊花9克，珍珠母30克(先煎)，羚羊角粉O，6克(分二冲服)，二付
二诊
药后身热渐退，体温38℃，抽搐未作，神志已渐清醒，今晨大便一次丽干，小便黄少，昨夜渐能入睡，两脉细数无力，弦势已减，舌苔干势已缓，质仍绛，头仍痛，口千不欲饮，唇紫且干。体质薄弱，血虚已久，温邪蕴热，阴分大伤，药后肝热已减，抽搐未作，热在营血，阴虚津亏，再以养血育阴增液，清心安神定抽，病势深重，防其厥变，诸当小心。
鲜生地30克，生白芍24克，鲜石斛30克，晚蚕砂12克，知母9克，元参18克，丹皮9克，钩藤12克，鲜茅芦根各30克，羚羊角粉O，6克(分二次冲服)，二付。
三诊
身热渐退，日哺仍重，体温37.6℃，四天未抽，神志清醒，言语对答正确。昨日大便又通一次，色深不多，小便新畅，夜寐安，两脉细弱略数，沉取似有弦象，舌已渐润，逝尖红，根略厚。温邪渐解，营热己清，胃肠滞热，化而未清。再以养血育阴，兼化滞热，以退哺热。饮食当慎。
淡豆豉9克，香青蒿6克，鲜生地30克，生白芍24克，元参15克，丹皮9克。钩藤9克，鲜茅芦根各30克，焦三仙各9克，二付
四诊
哺热已退净，体温正常，胃纳渐开，二便如常，舌苔已化，脉象细弱，温邪蕴热已解，胃肠滞热已化，再以疏调胃肠，以善其后。
北沙参12克，细生地24克，白芍15克，焦三仙各9克，鸡内金9克，砂仁1.5克(研冲)，五付
药后胃纳大增，精神体力渐复。嘱其清淡饮食，休息一周，即可恢复工作。
[按]：素体阴血不足，复感温邪，深入血分，热盛动风，病厦厥阴风木。阴伤是本，风动为标，治当标本兼顾。故重用生地黄，白芍药养阴柔肝，合入羚角钩藤汤凉肝息风，药中病机，故药后即神清风定。二诊即增加育阴之力。三诊以其低热不退，日哺为甚，辨为胃肠滞热，遂加入疏调肠胃之药。终以调理脾胃收功。全案治疗以育阴为主导，随证变药，既体现了温病存阴的原则性，又体现出随证治之的灵活性。
High Fever and Coma 1 (Senile Pneumonia)
Liu, female, 78 years old, first consultation on October 15, 1978.
The patient had suffered from high fever for over 40 days. Since early October, due to a cold with fever, cough, yellow sticky sputum, and chest pain, the school clinic diagnosed "senile pneumonia." After more than a month of treatment with penicillin, streptomycin, erythromycin, and Chinese herbal medicine, the cough subsided and sputum decreased, but persistent high fever remained. Axillary temperature: 37.5–38°C in the morning, rising to 39–40.5°C in the afternoon and evening. In recent days, mental restlessness and irritability appeared, along with occasional delirium (confusion with incoherent speech). The patient was referred to Master Zhao Shaoqin. Current symptoms: body heat worse at night, mental restlessness with insomnia, occasional delirium, dry mouth with thirst but no desire to drink, short and dark urine, no bowel movement for several days, red and crimson tongue with little coating, deep, slippery, fine, and rapid pulse. Auscultation: abundant moist rales in both lung bases, temperature 39.5°C. Syndrome differentiation: Heat pathogen stagnating and obstructing Lung Metal (Lung Qi). Treatment principle: Nourish Yin and clear heat, diffuse depression and descend Lung Qi. Prescription: Su Ye Zi (Perilla Leaf and Seed) 6g each, Qian Hu 6g, Xing Ren 10g, Sha Shen 10g, Pi Pa Ye 10g, Dai Ge Fen 10g (wrapped and decocted), Chao Lai Fu Zi 10g, Jiao Mai Ya 10g, Mao Gen and Lu Gen 10g each.
Second Consultation
October 18. After taking three doses of the above prescription, fever lightened, consciousness cleared, and nighttime sleep improved. However, cough with profuse sputum persisted. Tongue was red and crimson with thin coating; pulse was slippery and rapid. Urine was yellow; stool consisted of several hard, ball-like pellets. Temperature was 37.1°C. Residual heat remains; adjust the previous method slightly. Prescription: Chao Shan Zhi 6g, Dan Dou Chi 10g, Qian Hu 6g, Xing Ren 10g, Pi Pa Ye 10g, Sha Shen 10g, Mai Dong 10g, Yuan Zhi Rou 10g, Zhe Bei Mu 10g, Mao Gen and Lu Gen 10g each, Jiao San Xian 10g each.
After three doses, fever subsided and body cooled, cough and sputum stopped, nighttime sleep was peaceful, and bowel/bladder functions normalized. Four additional doses led to recovery.
[Commentary]: Senile pneumonia is difficult to treat. This patient, over seventy years old, has depleted healthy Qi and suffers from pneumonia with excessive Lung heat, loss of Lung diffusion and descending functions, and stagnant heat unable to disperse. The appropriate approach should have been clearing heat, nourishing Yin, diffusing depression, resolving phlegm, supporting healthy Qi, and expelling pathogens. However, previous prescriptions mainly consisted of bitter-cold herbs for clearing heat and reducing inflammation/fire, which inadvertently damaged healthy Qi and blocked Qi mechanism, causing phlegm-heat to sink into the Ying level (a deeper level of Wei-Ying-Qi-Blood differentiation). Master Zhao used nourishing Yin and clearing heat, assisted by methods to transmit heat out from Ying to Qi. Sha Shen nourishes Yin and supports healthy Qi; Su Ye, Su Zi, Qian Hu, and Xing Ren diffuse and unblock Qi mechanism; Dai Ge Fen clears heat, resolves phlegm, and expels pathogens; Lai Fu Zi and Jiao Mai Ya promote digestion and resolve stagnation. After only three doses, heat stagnation gradually resolved, and consciousness cleared. The presence of cough and sputum indicated that Qi mechanism had been unblocked, allowing internalized phlegm to be expelled outward. Therefore, Chao Shan Zhi and Dan Dou Chi were added to bitterly diffuse and reduce residual heat; Mai Dong and Sha Shen were added to nourish Yin and generate fluids; Yuan Zhi Rou and Zhe Bei Mu were added to stop cough and resolve phlegm. A total of six doses cured the senile pneumonia that had persisted for over 40 days.
High Fever and Coma 2 (Influenza)
Chen, male, 80 years old.
First Consultation
Fever fluctuated in intensity. Despite taking cold remedies, there was no improvement for half a month. Due to advanced age and physical decline, the illness had lingered for sixteen days. Yesterday, high fever and coma occurred, with a temperature of 38.9°C. Bowel movements had not occurred for 4–5 days. Palpation revealed wiry, slippery, and rapid pulses, strong at Guan and Chi positions. Tongue coating was thick, old yellow, especially at the root, indicating a pattern of warm pathogen sinking inward and Yangming Fu organ excess (accumulation of heat and feces in the intestines). Although elderly, the accumulation of heat and excess in the Fu organs has damaged fluids over time. It is necessary to unblock the bowels to drain heat, open depression and move Qi, assisted by generating fluids, following the formula Niu Huang Cheng Qi Tang (Bovine Calculus and Cathartic Decoction).
Jiang Can 9g, Chan Yi 6g, Jiang Huang 6g, Qian Hu 3g, Xing Ren 9g, Yuan Shen 24g, Zhu Ye 3g, Sheng Da Huang Powder 1.5g taken separately with medication, An Gong Niu Huang Wan one pill dissolved, two doses. Stop medication once bowel movement occurs.
Second Consultation
After two doses, bowel movement was smooth yesterday. This morning, slight sweating occurred, and body temperature dropped to 37.1°C. Consciousness cleared, urine was short and yellow, nighttime sleep was peaceful. Pulses rose, middle pressure felt wiry, rapidness subsided. Tongue coating was yellow but not thick/old; tongue substance was red with some moisture. For elderly warm disease with Yangming Fu excess and blocked Qi mechanism, after using Niu Huang Cheng Qi to unblock bowels and clear consciousness, increase sweet-cold fluid-generating and Qi-moving methods.
Xi Sheng Di 15g, Yuan Shen 15g, Sha Shen 15g, Mai Dong 9g, Qian Hu 3g, Xing Ren 9g, Gua Lou 24g, Zhi Ke 9g, two doses.
Third Consultation
After sweet-cold nourishment of Yin and generation of fluids, consciousness was clear. Bowel movement occurred again today. Sleep was peaceful night and day. Pulses became vigorous. Tongue coating transformed. Appetite improved. Temperature normalized. Focus on regulating Middle Jiao (Spleen and Stomach).
Bei Sha Shen 15g, Mai Men Dong 9g, Wu Wei Zi 9g, Hang Bai Shao 24g, Chen Pi 6g, Ji Nei Jin 9g, Sheng Yi Mi 24g, Jiao Mai Ya 9g, three doses.
Family reported full recovery. Advised to eat easily digestible, bland food to nourish Stomach Qi. No further medication needed.
[Commentary]: Given the Yangming Fu excess syndrome, decisively used Niu Huang Cheng Qi to purge heat accumulation. Due to advanced age and prolonged illness, instructed to stop medication upon successful bowel movement. Second consultation shifted to "increasing water to navigate the boat" (moistening intestines to relieve constipation). One must be bold when necessary and cautious when required. As Sun Simiao said, "Bold in courage, careful in mind, round in action, wise in prescription," this exemplifies such wisdom.
High Fever and Coma 3 (Viral Encephalitis)
Zou, female, 25 years old.
First Consultation
Fever had lasted half a month. Due to poor economic conditions, medical care was inaccessible. Starting yesterday, high fever, coma, and convulsions began. Palpation revealed fine, wiry, and rapid pulses. High fever and coma, emaciated body, extreme malnutrition, head distension and pain, restlessness, twitching of hands and feet, opisthotonos (backward arching of the body like a bow), crimson dry tongue without coating, aged tongue substance, slightly thick coating at root, scorched purple lips, no bowel movement for three days, dark red urine. Western medical examination suspected viral encephalitis.
Constitutionally deficient in Yin and Blood, warm pathogen heat directly invaded Blood level. Heat steaming upward caused head distension and pain. Heat disturbing Heart Spirit caused coma and agitation. Blood deficiency and Liver Yin neglect led to tendon spasm, causing hand/foot twitching and neck stiffness. This is Ying heat stirring wind, blood deficiency with tendon urgency. Must clear Ying heat, assisted by cooling Liver and extinguishing wind. Healthy Qi is weak, pathogen is strong; fear that the body cannot withstand the disease. Awaiting expert judgment.
Xi Sheng Di 30g, Sheng Bai Shao 10g, Fu Shen 9g, Sang Ye 9g, Gou Teng 12g (added later), Chuan Bei Mu 6g, Ju Hua 9g, Zhen Zhu Mu 30g (decocted first), Ling Yang Jiao Powder 0.6g (taken in two divided doses), two doses.
Second Consultation
Body heat gradually subsided, temperature 38°C. Convulsions ceased. Consciousness gradually cleared. Morning bowel movement was dry. Urine was yellow and scant. Sleep improved last night. Pulses were fine, rapid, and weak; wiriness decreased. Tongue dryness eased, substance still crimson. Head pain persisted. Dry mouth with no desire to drink. Lips purple and dry. Constitution is weak, long-standing blood deficiency. Warm pathogen heat severely damaged Yin. Liver heat reduced after medication, convulsions stopped. Heat remains in Ying and Blood levels; Yin deficiency and fluid depletion persist. Further nourish Blood, nurture Yin, generate fluids, clear Heart heat, calm Spirit, and stop convulsions. Disease is severe; prevent collapse or transformation. Be cautious.
Xian Sheng Di 30g, Sheng Bai Shao 24g, Xian Shi Hu 30g, Wan Can Sha 12g, Zhi Mu 9g, Yuan Shen 18g, Dan Pi 9g, Gou Teng 12g, Xian Mao Lu Gen 30g each, Ling Yang Jiao Powder 0.6g (taken in two divided doses), two doses.
Third Consultation
Body heat gradually subsided, but heavier in late afternoon (Ri Bu), temperature 37.6°C. No convulsions for four days. Consciousness clear, speech coherent. Bowel movement occurred yesterday, dark and scant. Urine flow normal. Sleep peaceful. Pulses fine, weak, slightly rapid; deep palpation shows slight wiriness. Tongue moistening, tip red, root slightly thick. Warm pathogen resolving, Ying heat cleared. Gastrointestinal stagnant heat transforming but not fully cleared. Continue nourishing Blood and Yin, simultaneously resolving stagnant heat to reduce afternoon fever. Diet must be careful.
Dan Dou Chi 9g, Xiang Qing Hao 6g, Xian Sheng Di 30g, Sheng Bai Shao 24g, Yuan Shen 15g, Dan Pi 9g, Gou Teng 9g, Xian Mao Lu Gen 30g each, Jiao San Xian 9g each, two doses.
Fourth Consultation
Afternoon fever completely resolved. Temperature normal. Appetite opening. Bowel and bladder functions normal. Tongue coating transformed. Pulses fine and weak. Warm pathogen heat resolved, gastrointestinal stagnant heat cleared. Regulate and harmonize Stomach and Intestines to conclude treatment.
Bei Sha Shen 12g, Xi Sheng Di 24g, Bai Shao 15g, Jiao San Xian 9g each, Ji Nei Jin 9g, Sha Ren 1.5g (powdered and taken with medicine), five doses.
Appetite increased significantly. Spirit and physical strength recovered. Advised bland diet and one week of rest before resuming work.
[Commentary]: Constitutionally deficient in Yin and Blood, exposed to warm pathogen, which penetrated deeply into Blood level. Excessive heat stirred wind, affecting Jueyin Wind-Wood (Liver). Yin damage is the root; wind stirring is the branch. Treatment must address both root and branch. Thus, heavy use of Sheng Di Huang and Bai Shao to nourish Yin and soften Liver, combined with Ling Yang Gou Teng Tang to cool Liver and extinguish wind. The prescription matched the pathology, resulting in immediate clearing of consciousness and cessation of convulsions. Second consultation increased Yin-nourishing power. Third consultation addressed persistent low fever, worse in late afternoon, identified as gastrointestinal stagnant heat, adding herbs to regulate intestines. Finally, Spleen and Stomach regulation concluded the case. The entire treatment was guided by nourishing Yin, adjusting herbs according to symptoms, reflecting both the principle of preserving Yin in warm diseases and the flexibility of treating based on syndrome differentiation.