医中一得
清·梁溪七世家医雅亭氏顾尔元拜撰
《医中一得》提要
夫医之为道，贵手实验。裘君吉生藏书至数千种，不以大部凑集众说之书为重，恒调单本小册之著作在往出自心得，多有发明之处，如外科王洪绪《全生集》、内症王清任《医林改增》等，立论不多，要皆独具创见，尤以所载方法无不历经试验，遂有不屈不挠之学说垂示于人。此书系顾仪卿先生所著，为裘君假录于同社曹炳章君。亦因其所论皆属心得，刊以禆益医林也。
《医中一得》序
诗曰：我思古人，实获我心。获之为言，得也，有得于心也。圣人之于学也，未得则发愤而忘食，已得则乐之而忘忧。学贵乎有得也如是。医之为道，亦何独不然。奥稽古圣上自轩歧中及仲景为医中之圣，圣则得之全也。厥后刘河间、李东垣、朱丹溪辈各执一见，各成一家。亦各有所得而为之也。迄今如叶香岩之批刻陶氏《全生集》，徐灵胎又评点《叶氏方案》，孰非有得于心而为之欤？余虽业医半生，碌碌于医道，茫无所得。每念前人，不胜惶愧，乃无何而仪卿宗台来，手执其所著《医中一得》示余，余受而读之，其中瘅疟一说发前人之所未发，葛升一方制前人之所未制。至如产后房劳与蓐劳异，既有明辨，又有定方，余以之治人，无不应手，知仪乡先生固有得于心而为之也。一得之所以名书也，原世之阅是书者，勿以管见视之。以之行世，参以己见，旁推类及，或者更有所得，并不止一得，何莫非是书之有所稗益而垂之不替耶？是为序。
癸亥仲春月，梁溪七世家医雅亭氏顾尔元拜撰，时年七十有四
瘅疟浅说
时交夏至以后，连日身体发热，午后更甚，至夜半出汗稍和，明日午后仍复大热，心胸懊侬，舌胎黄腻，脉数而洪，或有上午即大热者，或有大热前手足厥冷而热者，人皆称为瘴疟。方中无不用表里双解，以伤寒之法治之。其感邪极轻者，虽不药亦愈。如稍重者，屡投无效。藉云：瘴疟本难速愈，必延至月余，元气津液大伤，热仍不解。一病愈淹，无从措手，殊不知伤暑与伤寒病本不同，治亦各异。叶氏云：暑为无形之气，先从口鼻而入，法当轻扬解散。此语深得治此症之法。切思暑气入鼻，必先犯肺，入口必先犯胃。然肺胃热邪清之散之，似可易愈，何以治之无效？盖肺与脾为子母清与脾为表里，故肺胃之病最易及脾。午后更剧者，阳明之见端也。辰刻亦属阳明，巳属太阴，每日如是者，脾主信也。胃为腑，脾为脏，其病缠绵不已者，在腑易愈，在脏难愈也。且暑必夹湿，脾又恶湿，温在脾，不易去也。治法当以辛谅解散为主，用药宜轻清上升，不宜重浊下降。经所谓火郁发之是也。夫脾为坤土，其气本升，既为淫热所蕴，已失健运之机，若早用普降之药遏住热邪，阻其上升之性，势必其邪由表入里，变成下痢而难愈矣。是以治当纯用辛凉解表，务令将辟经所沾暑湿之邪导其仍从麻胃而出，所贵提邪外越，勿使引邪人里，是为要着。尤不可杂以里药下药，杂则药便有所牵制，其力不专，难以奏效，更防邪易陷脾耳。因此症从无专治之法，兹特本诸前贤参以己意，聊拟一方，通病用之，多能获效，奉劝高明，请尝试之。
葛升汤 治热势起伏，有汗不解方。
葛根一钱五分 升麻八分 连翘。钱 杏仁去皮尖，二钱 炒牛蒡子三钱 六一散三钱广皮一钱 蝉衣去足，一钱 川通草四分 香薷一钱 引用芦根一两 荷花露一两 鲜荷便一尺 鲜佛手一钱
以上之味平淡无奇，人人皆用。惟升麻为此方必用之药，与六一散通草能提脾家之暑湿，使之外达肺胃。葛根、芦根为凉散阳明之专药，杏仁为心果，连翘能清心包络热，香薷、荷梗、荷露清其暑，广皮、佛手开其气。蝉得秋气最先，乃金风奏而炎暑消之意。更与牛蒡为解散暑风之佐使也。若大热前先手足厥冷者，病机已兼少阳，当加柴胡四分。时交白露而发病者，方中须加赤芍药一钱五分，乃邪气入营故也。再加薄荷一钱，以往香薷之不逮。若深秋后脉不甚洪，口不甚渴，当去芦根四钱，小儿则分量酌减。此方连服三剂或五剂，重者即轻，轻者即愈。或有变为疟疾，数日而愈者。若但热无汗，脉洪数而懊烦者，不用此方，用大青龙汤去姜枣加葛根，因暑蕴于中而外为寒所束也。
此方之用神，全在升麻一味。盖暑必夹湿，若脾中蕴湿则清气不升，浊气不降，暑湿之邪交阻则外壮热而内懊侬，舌胎黄腻，大便秘结，小便短少诸症见矣。惟升麻升其清气则浊亦易降，并助葛根诸药涤邪外散，可以效灵。如无升麻则难奏效。或云升麻非常用之药，抑恐阴虚之人提动肝阳，故不敢轻投。不知升麻入肺、脾、胃、大肠四经，非同柴胡之入肝胆可比，可以无虑。东垣先生亦常用之。惟胃虚气逆呕吐者，自宜慎用耳。且此症两候之内，若能早用此方，可无邪闭邪陷之虞，亦无气粗痉厥之险，业医者未可轻视也。又云：表里双解亦是前人之法，何以此症独不可用？答云：先表后里，古人治病贵有次第。表未解未可攻里，仲师亦尝言之。若邪势表轻里重者，偶用双解是专意攻里带疏表也。表重者断无此法。况治伤署之症，务令将脾家所蕴之邪导其仍从肺胃而出，若用里药，不外槟榔、枳实、焦查、神曲、厚朴之类，性燥入脾，虽与肺胃之药同用，而药方有所牵制，不能提邪外越。里药若轻，尚无大患，倘或重投多服，则津液愈亏，元气愈弱。正虚邪陷，虽有良医，难为方矣。若杂下药则热邪陷脾，易成滞下，此所以谆谆奉劝世之业医者考之于书，揆之于理，验之于病，深望明哲之士颖悟而信从之。务将旧日所习之成法为之一变，则病者幸甚。
附录澄江华墅镇俯恬吴 君阅此寄来书并答书
仪卿先生阁下：两奉教言，浣读大著，发前人之所未发，启后学之所未悟，业已黏之通行，广布仁风于大地矣。另附跋语于尾，并将臆见质之有导，尚析指教为幸。立论明畅，皆穷源探本之言，用药轻清，有批郄导窾之妙。洵为暑门宝筏，治暍良方。有禆来兹，功德不浅。江浙卑下之地，交春分以后即有热蒸湿郁之气，足以病人到五六七月尤甚，俗谓之湿温，即暑湿热三气合病也，经谓先夏至为病温，故曰湿温。后夏至为病暑，故曰伤暑。若暑湿潜伏三焦募原，乃半表半里之界，至处署后新凉外束，伏热内动而发者，谓之伏暑。其候最难速愈，大抵转疟则轻，人里则重。从古无人发明此理，虽洁古以动静分阴阳，东垣以升得温燥为清暑，按之今病，殊为未备。淮河间刘氏理法清真如天水散、桂苓甘露饮，诚为三焦之妙剂，借引其端而未竟其绪。喻氏以暑湿热三气汇为一门，言之颇详，而于伏暑一症盖阙如也。意者自宋元明以来，其证尚少耶，抑当时有是病而以伤寒混治耶。闻张凤逵有《暑症》一书，购之未得，惟叶香岩前辈以江苏人言江苏病，独辟鸿溕，如曰暑与湿皆地中之气，无形无质，从口鼻吸受，不宜以重药推销。又曰：仲景伤寒先辨六经，河间温暑必究三焦，以手经为重，忌足六经药。片言扼要，允为后学津梁。瑛每见秋后伏暑，最属纠缠，患者极多，必转疟乃愈。若转滞下，乃邪陷二肠，宜宗喻氏逆流挽舟法，百无一失。若不先行逆挽，势必愈趋愈下，变为不治者甚多。又有早用黄连、石膏，致邪陷厥阴，变为痉厥神昏而成坏病者，十中仅救一二。瑛目击心伤，蕴于中者久矣。著有《伏邪论用代暑刍言》《痧麻》及《烂喉丹痧指迷》等说，俟脱稿后录呈，削政为荷。再接瘅疟之说，《内经》与《金匮》所言大略相同，皆阴气先绝，阳气独发，但热不寒耳。惟《内经》言肺素有热，《金匮》言气藏于心，要不外心营肺卫之旨，细绎之，似冬令金水两亏之人，邪伏手太阴，足少阴，至春三而发。有寒热往来者，有但热不寒者，有咳嗽者，有咳久失血者，与热病温病两感之病同源异流。治不得法，或误散或误补，迁延时日，每成损怯，故日令人消铄肌肉。似与暑病不符。贵邑明医甚多，以暑病为瘅疟，其得之师承口授乎？抑别有所阐发经义而云热乎？循名核实，不能无疑，尚祈明以教我，曷胜幸甚。
甫恬先生阁下：接诵手书，藉悉起居安善，动定咸宜，以欣以慰。所呈瘅疟浅说，皆属肤浅之论，或即为患者之一得亦未可知，乃蒙嘉奖过当，实觉汗颜。惟方中之葛根升麻并未论及，窃有所疑。然鄙意以为此方之关键全在此二味，盖葛根为凉散阳明之专药，若不以升麻、六一散佐之，尚不足以升举脾胃之暑湿，使之外达。六一散中滑石亦属阳明之药，必用六分而佐以甘草一分者，欲令滑石导入脾经，方能将脾之暑湿外泄也。古人制方之义如此，后人以为湿家忌甘草而专用滑石，大失此方之旨矣。古方中用升麻者甚多，何今之医士都畏而不用耶？即烂喉痧亦须用升麻。《伤寒论》中有越婢汤，以后诸家不明其义，强为解释，不知婢乃脾字之讹，越婢者，为发越脾气之义，故方中兼用姜枣，亦从脾经导邪之意，犹六一散之用甘草也。夫脾为坤土，位居中宫，为营血之源，上这则可传肺胃，下陷则易入肝肾。病机之出入，医家之挽回，须在此参究耳。所以东垣先生亦着意乎此。至于瘅疟之名，乃通称，其实即伤暑也。此亦仍其旧而已。若无汗而用大青龙汤，亦自有说。世皆以暑月忌用麻黄者，盖以麻黄性温，非夏令所宜。又以夏月腠理已开，若再用麻黄，恐有汗多亡阳之虑，不知伤寒中之用大青龙因寒已化火，故有口渴脉洪烦躁之证。以麻黄、桂校发汗为君，而以石膏之辛凉佐之，取龙腾雨降之意。此症脉洪数，口渴无汗相同，若不用麻黄、桂枝发汗，石膏清热，则汘无从出，而邪无从解。湿热蕴伏中宫，津液日伤，元气日耗，变症不可测矣。故必用斩关夺隘法以救之。不过伤寒以麻黄、桂枝为君，石膏为臣，此症当以石膏为君，麻黄、桂枝为臣，分量有轻重，贵在临症权衡也。经云：肺素有热，邪尚在卫。《金匮》言：气藏于心则入营矣。若不辨明营卫经络，概从气分发散，尚属隔膜，焉能愈病？所谓治不得法也。更有此种热邪，尚从上年伏于营中，冬令闭藏，至春而剧，医者当市其或在脾经，或在肝肾，对症用药，方能获效。若邪伏在脾胃营分，则右关之脉沉分必独洪数，先辈有以葛根、犀角并用，葛根散邪，犀角清热，二味为君，参入地味，最为合法。至或有咳嗽者，或有咳久失血者，皆属热伏营分之征。若迁延时日，每成损怯，及令人消烁肌肉，总是阴分为伏热所伤之故。若不知清热而但知用补，则大谬矣。清热总须邪有出路，不可一味寒凉，此病乃从前所伏之邪暑，病为暑月新受之气，故病不符，治各不同也。愚意如此，未识高明以为何如？还当有以教我为幸。高论中云：伏暑症必转疟乃愈，若转滞下，变为不治者多。此亦显而易见者。盖少阳为半表半里六经之枢机。转疟者，是太阴之邪传变少阳，由阴出阳也，故易愈。若转为滞下，则太阴而传入厥阴矣，故难治。可见伏邪亦应分六经，若河间之究三焦，似言受病之始，尚非伏邪之确论也。败毒方中之用柴胡、羌活，亦是从阴经导出阳经之意。故曰逆流挽舟，是从趋下之势而挽之使上也。由此悟入，一隅三反矣。
俯恬吴君又有书来并答书
《医中一得》提要
医学之道，贵在亲手实践验证。裘吉生先生藏书多达数千种，他不重视那些堆砌大部头、汇集众说的大杂烩式书籍，而常常推崇那些单本小册子的著作，认为这些书往往出自作者的心得体会，多有独到见解。例如外科领域的王洪绪《全生集》、内科领域的王清任《医林改错》等，立论虽不多，但都独具创见，尤其是所载方法无不经过反复试验，从而形成了不屈不挠的学说流传于世。这本书是顾仪卿先生所著，由裘先生向同社曹炳章先生处借录而来。也是因为书中论述皆属心得之谈，所以刊印出来以裨益中医界。
《医中一得》序
《诗经》说：我思念古人，实在契合我的心意。“获”的意思就是“得”，即心中有所领悟。圣人对待学问，未得到时发愤努力以至于忘记吃饭，已得到时以此为乐以至于忘记忧愁。学问贵在有所领悟，正是如此。医学之道，难道唯独不是这样吗？考察古代圣贤，上自黄帝、岐伯，中至张仲景，都是医学中的圣人。所谓圣人，是因为他们掌握得全面。此后刘完素、李东垣、朱丹溪等人各执己见，各自成家。也都是因为各自有所领悟才这样做的。到现在像叶天士批注陶氏《全生集》，徐灵胎又评点《叶氏方案》，谁不是心中有所领悟才去做的呢？我虽然行医半生，在医道上碌碌无为，茫然无所获。每当想到前人，不胜惶恐惭愧。不久之后，仪卿宗台来到，手持他所著的《医中一得》给我看，我接过来阅读，其中关于瘅疟（一种以高热为主要表现的疟疾）的说法，阐发了前人未曾阐发的内容；葛升汤一方，制定了前人未曾制定的方剂。至于产后房劳与蓐劳（产后因劳累或房事引起的虚损病证）的区别，既有明确的辨析，又有确定的方剂，我用它来治疗病人，没有不随手奏效的，由此知道仪卿先生确实是心中有所领悟才去写的。这本书之所以命名为《医中一得》，是希望世上的读者不要把它看作浅薄的见识。让它流行于世，结合自己的见解，旁推类及，或许能有更多的收获，并不止于一得，这难道不是这本书对世人有所裨益并长久流传的原因吗？这就是序言。
癸亥年仲春月，梁溪七世家医雅亭氏顾尔元恭敬撰写，当时年龄七十四岁
瘅疟浅说
时令进入夏至以后，连续几天身体发热，午后更加严重，到了半夜出汗后稍微缓和，第二天午后仍然再次大热，心胸烦闷不适，舌苔黄腻，脉象数且洪大，有的上午就出现大热的情况，有的在发大热之前手足冰冷而后发热，人们都称之为瘴疟（此处指暑湿引起的类似疟疾的病证）。治疗方剂中无不用表里双解的方法，用治疗伤寒的方法来治疗它。感受邪气极轻的人，即使不吃药也能痊愈。如果病情稍重，多次投药无效。借口说：瘴疟本来难以迅速痊愈，必须拖延到一个多月，元气和津液大伤，热势仍不解。病情越拖延，无从下手，殊不知伤暑与伤寒病的本质不同，治疗方法也各异。叶天士说：暑是无形的邪气，先从口鼻而入，治法应当轻扬解散。这句话深得治疗此症的法度。仔细思考暑气入鼻，必定先侵犯肺脏，入口必定先侵犯胃腑。然而肺胃的热邪通过清法和散法，似乎容易治愈，为什么治疗无效？这是因为肺与脾是母子关系，肺与胃互为表里，所以肺胃的病最容易波及脾脏。午后加重的，是阳明经病变的端倪。辰时（早上7-9点）也属于阳明，巳时（早上9-11点）属于太阴，每天如此，是因为脾主信（按时令规律）。胃为腑，脾为脏，病情缠绵不断的，在腑容易治愈，在脏难治愈。而且暑邪必定夹带湿气，脾又厌恶湿气，湿气困阻在脾，不容易去除。治法应当以辛凉解表为主，用药宜轻清上升，不宜重浊下降。这就是《内经》所说的“火郁发之”。脾属坤土，其气本应上升，既然被淫热蕴结，已经失去了健运的机能，如果过早使用普降的药物遏制热邪，阻碍其上升的特性，势必导致邪气由表入里，变成下痢而难以治愈。因此治疗应当纯用辛凉解表，务必让经络沾染的暑湿邪气引导它们仍从肺胃而出，贵在提升邪气使其外越，不要引邪入里，这是关键所在。尤其不可夹杂使用治里的药物或泻下药，夹杂则药物力量受到牵制，不够专一，难以奏效，更要防止邪气容易陷入脾脏。因为这个病症从来没有专门的治疗方法，现在特别依据前贤经验参酌己意，暂拟一方，通病通用，大多能获效，奉劝高明之士，请尝试一下。
葛升汤 治疗热势起伏，有汗而不解的方剂。
葛根一钱五分，升麻八分，连翘一钱，杏仁去皮尖二钱，炒牛蒡子三钱，六一散三钱，广皮一钱，蝉衣去足一钱，川通草四分，香薷一钱。引用芦根一两，荷花露一两，鲜荷梗一尺，鲜佛手一钱。
分量根据人体强弱加减。虚弱体质者减少升麻用量，强壮之人酌情增加升麻用量。
以上药材平淡无奇，人人皆可用。只有升麻是这个方剂必用的药，配合六一散、通草能提升脾脏的暑湿，使之外达肺胃。葛根、芦根是凉散阳明经邪气的专用药，杏仁为心果（此处指其性味归经关联），连翘能清心包络热，香薷、荷梗、荷露清除暑邪，广皮、佛手理气开郁。蝉衣得秋气最早，象征金风奏响而炎暑消退之意。再配合牛蒡子作为解散暑风的佐使药。如果在发大热前先出现手足厥冷，说明病机已兼涉少阳，应当加柴胡四分。时令进入白露后发病的，方中须加赤芍药一钱五分，这是邪气进入营分的缘故。再加薄荷一钱，以弥补香薷作用的不足。如果是深秋后脉象不甚洪大，口不甚渴，应当去掉芦根四钱，小儿则酌情减少分量。此方连续服用三剂或五剂，重症即减轻，轻症即痊愈。有的转变为疟疾，数日而愈。如果只有发热而无汗，脉象洪数且心烦懊恼，不使用此方，改用大青龙汤去掉生姜、大枣加上葛根，因为暑邪蕴结于内而被寒邪束缚于外。
这个方子的神妙之处，全在于升麻一味药。因为暑邪必定夹湿，如果脾中蕴积湿气，则清气不升，浊气不降，暑湿邪气交结阻滞，就会出现外壮热而内烦闷，舌苔黄腻，大便秘结，小便短少等症状。只有升麻提升清气，则浊气也容易下降，并帮助葛根等药物涤荡邪气向外发散，可以见效。如果没有升麻则难以奏效。有人说升麻不是常用药，恐怕阴虚之人使用会提动肝阳，所以不敢轻易使用。不知道升麻入肺、脾、胃、大肠四经，不同于柴胡入肝胆经，可以不用担心。李东垣先生也常用它。只有胃虚气逆呕吐者，自然应当慎用罢了。而且这个病症在两个节气之内，如果能早用此方，就没有邪气闭阻或陷入的危险，也没有气粗痉厥的风险，业医者不可轻视。又有人说：表里双解也是前人的方法，为什么这个病症独独不可用？回答说：先解表后治里，古人治病贵在有序。表证未解不可攻里，仲景也曾说过。如果邪气势头表轻里重，偶尔使用双解法是专心攻里兼带疏表。表证重的绝对没有这种方法。况且治疗伤暑的病症，务必将脾脏蕴积的邪气引导它们仍从肺胃而出，如果使用治里的药物，不外乎槟榔、枳实、焦山楂、神曲、厚朴之类，性质燥烈入脾，虽然与肺胃的药同用，但药力受到牵制，不能提升邪气外越。里药如果轻，还没有大患，倘若重用多服，则津液更亏，元气更弱。正气虚弱邪气陷入，虽然有良医，也难以施治了。如果夹杂泻下药，则热邪陷入脾脏，容易变成痢疾，这就是我谆谆告诫世上的业医者要在书中考证，按道理推究，在病案中验证，深望明智之士聪慧领悟并信奉遵从。务必将旧日所习成的方法改变一下，那么病人的幸运啊。
附录 澄江华墅镇俯恬吴君阅此寄来书并答书
仪卿先生阁下：两次收到您的教诲之言，洗净双手拜读大作，阐发了前人未曾阐发的内容，启发了后学未曾领悟的知识，已经粘贴通行，广泛传播仁德之风于大地了。另外附上跋语在末尾，并将我的浅见请教给有识之士，尚祈分析指教为幸。立论明畅，都是穷源探本的话，用药轻清，有剖析肯綮导引空穴的妙处。确实是暑门宝筏，治疗中暑的良方。有益于未来，功德不浅。江浙地势低下的地方，进入春分以后就有热蒸湿郁之气，足以让人生病，到五六七月尤其严重，俗称为湿温，就是暑湿热三气合病。《内经》说先夏至为病温，所以叫湿温。后夏至为病暑，所以叫伤暑。如果暑湿潜伏在三焦募原，那是半表半里的界限，到了处暑后新凉外束，伏热内动而发作的，叫做伏暑。这种候证最难迅速痊愈，大体转为疟疾则轻，陷入体内则重。从古以来没有人发明这个道理，虽然洁古（张元素）以动静分阴阳，东垣以升发温燥为清暑，按照现在的病症来看，殊为不完备。河间刘氏的理法清真如天水散、桂苓甘露饮，诚然是三焦的妙剂，只是借用其端而未竟其绪。喻嘉言以暑湿热三气汇为一门，说得颇详细，但对于伏暑一症却缺失了。猜想自从宋元明以来，这种证候还很少吗？还是当时有这个病却用伤寒混治？听说张凤逵有《暑症》一书，购买未果，只有叶天士前辈以江苏人讲江苏病，独辟蹊径，比如他说：暑与湿都是地中之气，无形无质，从口鼻吸入，不宜用重药推销。又说：仲景伤寒先辨六经，河间温暑必究三焦，以手经为重，忌用足六经药。片言扼要，确实是后学的津梁。我每次见到秋后伏暑，最属纠缠，患者极多，必须转为疟疾乃愈。如果转为痢疾，那是邪气陷入大小肠，应当遵循喻氏逆流挽舟法，百无一失。如果不先行逆挽，势必越来越下，变为不治的很多。又有早用黄连、石膏，导致邪气陷入厥阴，变为痉厥神昏而成坏病的，十人中仅救一二。我亲眼目睹内心悲伤，积压在心中很久了。著有《伏邪论用代暑刍言》《痧麻》及《烂喉丹痧指迷》等说法，等到脱稿后抄录呈上，恳请指正为荷。再接瘅疟之说，《内经》与《金匮》所言大致相同，都是阴气先绝，阳气独发，只热不寒罢了。只有《内经》说肺素有热，《金匮》说气藏于心，总不外乎心营肺卫的宗旨，细细推敲，似乎是冬季金水两亏之人，邪气伏在手太阴、足少阴，到春季而发作。有的寒热往来，有的但热不寒，有的咳嗽，有的咳久失血，与热病温病两感之病同源异流。治疗不得法，或误散或误补，迁延时日，每成损怯，所以说令人消瘦肌肉。似乎与暑病不符。贵县明医甚多，把暑病当作瘅疟，这是师承口授吗？还是另有阐发经义而说是热呢？循名核实，不能不怀疑，尚祈明示教我，不胜荣幸。
甫恬先生阁下：接到拜读您的手书，借此得知起居安善，动静适宜，既高兴又欣慰。所呈送的瘅疟浅说，都属于肤浅的议论，或许就是为患者的一得之见也未可知，承蒙过当嘉奖，实在觉得汗颜。只有方中的葛根、升麻并未论及，私下有些疑惑。然而我认为此方的关键全在这两味药，因为葛根是凉散阳明经的专用药，如果不以升麻、六一散辅助，还不足以升举脾胃的暑湿，使之外达。六一散中的滑石也属阳明经药，必须用六份而佐以一份甘草，是想让滑石导入脾经，方能将脾的暑湿外泄。古人制方的意义如此，后人认为湿家忌甘草而专用滑石，大大失掉了此方的宗旨。古方中使用升麻的很多，为什么现在的医士都畏惧而不用呢？即使是烂喉痧也必须用升麻。《伤寒论》中有越婢汤，后来各家不明白其义，强行解释，不知道“婢”是“脾”字的讹误，越婢的意思是发越脾气，所以方中兼用姜枣，也是从脾经导邪的意思，就像六一散中使用甘草一样。脾属坤土，位居中宫，是营血的源头，向上则可以传肺胃，向下陷入则易入肝肾。病机的出入，医家的挽回，必须在此参究。所以李东垣先生也着重于此。至于瘅疟之名，乃是通称，其实即伤暑。这也是沿袭旧称而已。如果无汗而用大青龙汤，自有说法。世人都认为暑月忌用麻黄，是因为麻黄性温，非夏令所宜。又以夏月腠理已开，若再用麻黄，恐有汗多亡阳的顾虑，不知道伤寒中使用大青龙是因为寒已化火，所以有口渴脉洪烦躁的证候。以麻黄、桂枝发汗为君，而以石膏的辛凉佐之，取龙腾雨降之意。此症脉洪数，口渴无汗相同，若不用麻黄、桂枝发汗，石膏清热，则汗无从出，而邪无从解。湿热蕴伏中宫，津液日伤，元气日耗，变症不可测矣。所以必须用斩关夺隘法来救它。不过是伤寒以麻黄、桂枝为君，石膏为臣，此症应当以石膏为君，麻黄、桂枝为臣，分量有轻重，贵在临症权衡。《内经》说：肺素有热，邪尚在卫分。《金匮》说：气藏于心则入营分了。如果不辨明营卫经络，一概从气分发散，尚属隔膜，怎么能治愈疾病？这就是所谓的治不得法。更有这种热邪，还从上一年伏在营中，冬季闭藏，到春季加剧，医者应当审察其在脾经，或在肝肾，对症用药，方能获效。如果邪伏在脾胃营分，则右关脉沉分必独洪数，先辈有用葛根、犀角并用，葛根散邪，犀角清热，二味为君，参入地黄味，最为合法。至于或有咳嗽者，或有咳久失血者，都属热伏营分的征象。如果迁延时日，每成损怯，以及令人消烁肌肉，总是阴分为伏热所伤的缘故。如果不知清热而只知道用补，那就大谬了。清热总须邪有出路，不可一味寒凉，此病是从前所伏的邪暑，病为暑月新受之气，所以病不符，治各不同。愚意如此，不知高明以为如何？还望有以教我为幸。高论中说：伏暑症必须转为疟疾乃愈，如果转为痢疾，变为不治者多。这也是显而易见的。因为少阳为半表半里六经的枢机。转疟者，是太阴的邪气传变少阳，由阴出阳，所以易愈。如果转为痢疾，则是太阴传入厥阴，所以难治。可见伏邪也应分六经，如果河间之究三焦，似言受病之初，尚非伏邪的确论。败毒方中使用柴胡、羌活，也是从阴经导出阳经的意思。所以说逆流挽舟，是从趋下之势而挽之使上也。由此悟入，举一反三了。
俯恬吴君又有书来并答书
A Gleanings from Medicine (Yi Zhong Yi De) - Synopsis
The Way of medicine values hands-on practical verification. Mr. Ju Jisheng collected books numbering in the thousands, yet he did not value large compilations that merely gathered various theories. Instead, he often advocated for single-volume small booklets, believing these works often stemmed from personal insights and contained many original discoveries. For instance, Wang Hongxu's *Quan Sheng Ji* (Complete Life Collection) in surgery and Wang Qingren's *Yi Lin Gai Cuo* (Correction of Errors in Medical Forest) in internal medicine, though their arguments were few, all possessed unique insights. Especially, the methods recorded had undergone repeated trials, thereby establishing an unyielding doctrine to be passed down to others. This book was authored by Mr. Gu Yiqing and borrowed by Mr. Ju from his fellow society member, Cao Bingzhang. It was published to benefit the medical community because its discussions all belonged to personal insights.
Preface to A Gleanings from Medicine
The *Classic of Poetry* says: "I think of the ancients, and it truly captures my heart." The meaning of "capture" is "to gain," implying a realization within the mind. Regarding learning, sages strive so hard they forget to eat when they have not yet attained understanding, and rejoice so much they forget their worries once they have attained it. Learning is valuable precisely because of such attainments. Is the Way of medicine any different? Examining ancient sages, from Huangdi and Qibo in antiquity to Zhang Zhongjing in later times, they are all sages of medicine. To be a sage means to possess comprehensive knowledge. Later figures like Liu Wansu, Li Dongyuan, and Zhu Danxi each held their own views and established their own schools. They did so because each had their own attainments. Up to the present, Ye Tianshi's commentary on Tao's *Quan Sheng Ji*, and Xu Lingtai's evaluation of *Ye Shi Fang An* (Case Records of Ye), who among them did not act based on inner realization? Although I have practiced medicine for half a life, I have been mediocre in the Way of medicine,茫然ly obtaining nothing. Whenever I think of predecessors, I feel overwhelmed with fear and shame. Soon after, Zongtai Yiqing came, holding in hand his authored work *Yi Zhong Yi De* and showing it to me. I received it and read it; its discussion on Dan Nue (a type of malaria characterized by high fever) expounded upon what predecessors had not, and the Ge Sheng Tang (Kudzu and Cimicifuga Decoction) formulated prescriptions previously unseen. Regarding the distinction between postpartum sexual indiscretion and Ru Lao (postpartum consumptive disease due to overexertion), there is both clear differentiation and fixed prescriptions. Using them to treat patients, I encountered no case that did not respond promptly. Thus, I know that Mr. Yixiang indeed wrote based on inner realization. The reason this book is named *A Gleanings from Medicine* is to hope that readers of this book do not view it as superficial insight. Let it circulate in the world, combined with one's own views and extended by analogy, perhaps more will be gained, not limited to just one gleanings. Would this not be the benefit this book offers to the world and ensures its lasting legacy? This is the preface.
In the mid-spring month of the Guihai year, Gu Eryuan, family physician of the Liangxi Seven Generations, Ya Ting style, respectfully composed, at the age of seventy-four.
Brief Discussion on Dan Nue
After the Summer Solstice arrives, the body has been feverish for consecutive days, worsening in the afternoon, slightly easing after sweating around midnight, only to return with high fever the next afternoon. There is chest discomfort, yellow and greasy tongue coating, and a rapid, surging pulse. Some experience high fever even in the morning; some have cold extremities before the high fever. People generally call this Zhang Nue (malaria-like illness caused by pathogenic factors). In prescriptions, double resolution of exterior and interior is invariably used, treating it according to the methods for Cold Damage (Shang Han). Those with very light pathogenic invasion may recover without medication. If slightly heavier, repeated prescriptions prove ineffective. The excuse is given: "Zhang Nue is inherently difficult to cure quickly; it must drag on for over a month, severely damaging primordial Qi and Body Fluids, while the heat remains unresolved." As the illness lingers, treatment becomes difficult. Little do they know that Heatstroke (Shang Shu) and Cold Damage differ fundamentally in nature and require different treatments. Ye Tianshi said: "Heat is formless Qi, entering first through the mouth and nose; the method should be light and dispersing." This statement deeply grasps the method for treating this syndrome. Carefully considering, heat entering the nose first attacks the Lung, and entering the mouth first attacks the Stomach. However, clearing and dispersing heat in the Lung and Stomach seems easy to cure, so why is treatment ineffective? This is because the Lung and Spleen have a mother-son relationship, and the Lung and Stomach are exterior-interior pairs; thus, diseases of the Lung and Stomach easily affect the Spleen. Worsening in the afternoon indicates signs of the Yangming channel. The Chen hour also belongs to Yangming, and the Si hour to Taiyin. Daily recurrence reflects the Spleen's adherence to timing. The Stomach is a Fu organ, the Spleen is a Zang organ; diseases in Fu organs are easier to cure, while those in Zang organs are harder. Moreover, Heat inevitably carries Dampness, and the Spleen dislikes Dampness. When Dampness resides in the Spleen, it is difficult to eliminate. The treatment method should primarily focus on acrid-cool exterior resolution. Medicinals should be light, clear, and ascending, not heavy, turbid, and descending. This corresponds to the Classic saying: "For fire stagnation, emit it." The Spleen belongs to Kun Earth, and its Qi naturally ascends. Once constrained by excessive heat, it loses its function of transformation and transportation. If降 (descending) medicines are used early to suppress heat, obstructing its ascending nature, the pathogen will inevitably move from exterior to interior, transforming into dysentery which is hard to cure. Therefore, treatment should purely use acrid-cool exterior resolution, ensuring that the heat-dampness pathogens adhering to the meridians are guided to exit still through the Lung and Stomach. The value lies in lifting the pathogen outward, preventing it from entering the interior; this is the key point. One must especially avoid mixing in interior-treating or purgative drugs. Mixing causes mutual restraint, reducing efficacy, and increases the risk of pathogens sinking into the Spleen. Since this syndrome lacks specific treatment methods, I hereby base my approach on former sages' experiences combined with my own intent, tentatively proposing one formula for general use, which often yields results. I urge experts to try it.
Ge Sheng Tang (Kudzu and Cimicifuga Decoction): Treats fluctuating heat intensity where sweating does not resolve the condition.
Puerariae Radix (Gegen) 1.5 qian, Cimicifugae Rhizoma (Shengma) 0.8 qian, Forsythiae Fructus (Lianqiao) 1 qian, Apricot Kernel (Xingren) peeled and cored 2 qian, Fried Arnebiae Semen (Niu Bang Zi) 3 qian, Liu Yi San 3 qian, Citri Reticulatae Pericarpium (Guangpi) 1 qian, Cicadae Periostracum (Chanyi) de-footed 1 qian, Chuan Tongcao 0.4 qian, Moslae Herba (Xiangru) 1 qian.
Decoction ingredients: Phragmitis Rhizoma (Lugen) 1 liang, Lotus Flower Dew (Hehua Lu) 1 liang, Fresh Lotus Stem (Xian Hegeng) 1 chi, Fresh Bergamot (Xian Foshou) 1 qian.
Dosage should be adjusted according to the patient's strength. Reduce Shengma for weak constitutions; increase appropriately for strong constitutions.
The above ingredients are plain and unremarkable, usable by everyone. Only Shengma is essential in this formula. Combined with Liu Yi San and Tongcao, it lifts damp-heat from the Spleen, allowing it to reach the Lung and Stomach externally. Gegen and Lugen are specialized for cooling and dispersing Yangming heat. Xingren is associated with the Heart; Lianqiao clears heat from the Pericardium. Xiangru, Hegeng, and Helu clear summer-heat. Guangpi and Foshou regulate Qi. Cicadae Periostracum receives autumn Qi earliest, symbolizing the arrival of metal wind and the消散 of summer heat. Paired with Niu Bang Zi, it acts as an assistant to disperse summer-wind. If cold extremities precede high fever, the pathology involves Shaoyang; add Bupleuri Radix (Chaihu) 0.4 qian. If onset occurs after White Dew solar term, add Red Peony Root (Chishaoyao) 1.5 qian, indicating pathogen entering Ying level. Add Mint (Bohe) 1 qian to supplement the insufficiency of Xiangru. If late autumn presents with non-surging pulse and non-thirsty mouth, remove Lugen 4 qian; reduce dosage for children. Taking this formula continuously for three to five doses, severe cases lighten, mild cases resolve. Some transform into Malaria and resolve in a few days. If there is heat without sweat, surging-rapid pulse, and restlessness, do not use this formula. Use Da Qing Long Tang (Major Blue Dragon Decoction) minus Ginger and Jujube plus Gegen, because summer-heat is trapped inside and constrained by cold outside.
The efficacy of this formula relies entirely on Shengma. Because summer-heat carries dampness, if dampness accumulates in the Spleen, clear Qi fails to ascend, turbid Qi fails to descend, and summer-damp pathogens block each other, leading to external high fever, internal restlessness, yellow-greasy tongue coating, constipation, and scanty urine. Only by using Shengma to ascend clear Qi can turbid Qi descend easily, assisting Gegen and other herbs to wash out pathogens outwardly, achieving efficacy. Without Shengma, efficacy is unlikely. Some argue Shengma is not a common drug, fearing it might stir Liver Yang in Yin-deficient individuals, hence hesitating to use it lightly. However, Shengma enters the Lung, Spleen, Stomach, and Large Intestine channels, unlike Chaihu entering the Liver and Gallbladder, so there is no need to worry. Mr. Dongyuan also frequently used it. Only in cases of Spleen deficiency with rebellious Qi causing vomiting should it be used cautiously. Furthermore, within two solar terms of this syndrome, early use of this formula avoids risks of pathogen closure or sinking, and prevents coarse breathing, spasms, or syncope. Practitioners must not underestimate it. Others ask: "Double resolution of exterior and interior is also a method of predecessors; why is it uniquely unsuitable here?" Answer: Treating exterior first, then interior, requires order. If exterior is unresolved, interior cannot be attacked, as Zhongjing stated. If exterior is light and interior heavy, occasional double resolution focuses on attacking interior while lightly releasing exterior. If exterior is heavy, this method is absolutely inappropriate. Moreover, treating Heatstroke requires guiding Spleen-stagnated pathogens to exit via Lung and Stomach. Interior drugs like Areca Seed (Binglang), Immature Bitter Orange (Zhishi), Charred Hawthorn (Jiao Shan Zha), Medicated Leaven (Shen Qu), and Magnolia Bark (Houpo) are drying and enter the Spleen. Even used with Lung/Stomach drugs, they restrict efficacy and fail to lift pathogens outward. Light interior drugs cause little harm, but heavy or prolonged use further depletes fluids and weakens Qi. With deficient Zheng and sinking Xie, even good doctors cannot help. Mixing purgatives sinks heat into the Spleen, easily becoming Dysentery (Zhi Xia). Hence, I earnestly advise practitioners to verify in books, deduce by principles, and test in cases, hoping wise scholars understand and follow. Change old habitual methods, and patients will be fortunate.
Appendix: Letter from Wu Futian of Huashu Town, Chengjiang, upon Reading This, and Reply
To Mr. Yiqing: Received your teachings twice, washed hands to read your great work. It expounds what predecessors missed and enlightens students. I have circulated it widely, spreading benevolence. Attached is a postscript and my humble opinions for your guidance. Your arguments are clear and profound, exploring origins. Medicinals are light and clear, possessing the subtlety of following natural openings. Truly a treasure raft for summer diseases and a good prescription for heatstroke. Beneficial for the future, merit is immense. Jiangsu and Zhejiang are lowlands; after Spring Equinox, steaming heat and stagnant dampness arise, causing illness, peaking in May-July. Commonly called Shi Wen (Damp-Warmth), it is the combination of Summer-heat, Dampness, and Warmth. The Classic says: Pre-Summer Solstice illnesses are Warmth, hence Shi Wen. Post-Summer Solstice illnesses are Summer-heat, hence Shang Shu. If Summer-Dampness lurks in the San Jiao Mu Yuan (origin), the boundary of half-exterior half-interior, and erupts after End of Heat due to new cool constraining outside and latent heat moving inside, it is called Fu Shu (Latent Summer-heat). This syndrome is hardest to cure quickly; transforming into Malaria lightens it, sinking into interior worsens it. No one since antiquity has elucidated this theory. Although Jieguzhang divided Yin/Yang by movement/stillness, and Dongyuan used ascending/warm-drying for clearing summer-heat, applying this to current diseases is insufficient. Hejian Liu's methods like Tian Shui San and Gui Ling Gan Lu Yin are excellent for San Jiao, but only started the thread. Yu Jia Yan grouped Summer-heat, Dampness, and Warmth together, speaking in detail, but omitted Latent Summer-heat. Perhaps since Song-Yuan-Ming, such cases were rare? Or were they treated as Cold Damage? I heard Zhang Fengkui wrote *Shu Zheng*, but could not acquire it. Only Ye Tianshi, a Jiangsu native discussing Jiangsu diseases, broke new ground, stating: "Summer-heat and Dampness are earth Qi, formless, absorbed via nose/mouth, not suitable for heavy expulsion." Also: "Zhongjing distinguishes Six Channels for Cold Damage; Hejian investigates San Jiao for Warmth/Summer-heat, prioritizing Hand channels, avoiding Foot Six Channel drugs." These concise words are guides for students. I often see Autumn Latent Summer-heat is entangled, affecting many, resolving only after transforming into Malaria. If transforming into Dysentery, pathogen sinks into Large/Small Intestines; follow Yu's "Retrieving the Boat Against the Current" method, nearly foolproof. Without retrieving against the current, it sinks deeper, becoming incurable. Early use of Coptis (Huanglian) and Gypsum (Shigao) sinks pathogen into Jueyin, causing spasms/syncoma, becoming ruined disease; only 1-2 saved out of 10. Witnessing this breaks my heart. I have written *Fu Xie Lun*, *Sha Ma*, and *Lan Hou Dan Sha Zhi Mi*. Will submit upon completion for correction. Regarding Dan Nue, *Nei Jing* and *Jin Gui* are similar: Yin Qi exhausted first, Yang Qi alone flares, only heat no chills. *Nei Jing* says Lung has prior heat; *Jin Gui* says Qi hides in Heart. Essentially concerning Heart Ying and Lung Wei. Detailed analysis suggests people deficient in Metal/Water in Winter harbor pathogen in Hand Taiyin/Foot Shaoyin, erupting in Spring. Cases vary: alternating chills/heat, only heat, cough, chronic cough with blood loss. Same source as Warm Diseases and Two-Infections, divergent streams. Improper treatment (wrong dispersion or tonification) leads to consumption and muscle wasting, seeming inconsistent with Summer-heat. Many bright doctors in your county equate Summer-heat with Dan Nue. Is this oral transmission or new interpretation of classics? Verifying name and reality raises doubts. Please instruct me.
To Mr. Futian: Received your letter, glad you are well. Your *Brief Discussion on Dan Nue* is shallow, perhaps a patient's gleanings, but praised excessively, making me blush. You did not discuss Gegen and Shengma in the formula, which I question. However, I believe the formula's key lies in these two. Gegen is specialized for cooling/dispersing Yangming. Without Shengma and Liu Yi San assisting, it cannot lift Spleen-Stomach summer-dampness outward. Talc (Huashi) in Liu Yi San is also Yangming drug. Using six parts Talc with one part Licorice (Gancao) guides Talc into Spleen channel to vent Spleen dampness. Ancient formula design follows this logic. Later practitioners thought Dampness cases forbid Gancao, using only Talc, missing the formula's essence. Many ancient formulas use Shengma; why do modern physicians fear it? Even for Lan Hou Sha, Shengma is needed. *Shang Han Lun* has Yue Bi Tang. Later families misunderstood, forcing explanations. "Bi" is a typo for "Pi" (Spleen). Yue Pi means stimulating Spleen Qi. Hence Ginger and Jujube are used to guide pathogen from Spleen, like Gancao in Liu Yi San. Spleen is Kun Earth, central palace, source of Ying/Blood. Upward transmission reaches Lung/Stomach; downward sinking enters Liver/Kidney. Pathogen entry/exit and doctor's intervention must be studied here. Dongyuan emphasized this too. "Dan Nue" is a general term, actually Shang Shu.沿用旧称. If no sweat, using Da Qing Long Tang has reasons. People forbid Ephedra (Mahuang) in summer due to warm nature and open pores risking Yang collapse. But in Cold Damage, Da Qing Long Tang is used because Cold transformed to Fire, causing thirst, surging pulse, irritability. Mahuang/Guizhi release sweat as Sovereign, Gypsum cools as Minister, aiming for dragon rising/rain falling. This syndrome has surging-rapid pulse, thirst, no sweat—similar. Without Mahuang/Guizhi to release sweat and Gypsum to clear heat, sweat cannot emerge, pathogen cannot resolve. Damp-heat traps in center, fluids drain, Qi耗, unpredictable changes. Must use decisive breakthrough method. Unlike Cold Damage where Mahuang/Guizhi are Sovereign and Gypsum Minister, here Gypsum is Sovereign, Mahuang/Guizhi are Ministers. Dosage weight matters. *Nei Jing*: Lung has prior heat, pathogen in Wei. *Jin Gui*: Qi in Heart enters Ying.若不 distinguishing Ying/Wei/Channels and dispersing from Qi level is disconnected. How can it cure? Worse, some heat lurked in Ying last winter, closed in Winter, worsens in Spring. Doctor must check if in Spleen or Liver/Kidney. If pathogen in Spleen/Stomach Ying, Right Guan pulse deep level is surging-rapid. Ancients used Gegen and Rhinoceros Horn (Xijiao); Gegen scatters pathogen, Xijiao clears heat, paired with Rehmannia (Dihuang), most appropriate. Cough or chronic cough with blood loss indicate heat lurking in Ying. Dragging time leads to consumption and muscle wasting, due to Yin damaged by latent heat. Not knowing to clear heat but only tonifying is wrong. Clearing heat requires pathogen exit; cannot use only cold/bitter. This disease is prior latent summer-heat, contracted as new summer-qi. Disease differs, treatment differs. My opinion is thus. Hope you instruct me. You said Latent Summer-heat must transform into Malaria to cure; if Dysentery, mostly incurable. Obvious. Shaoyang is pivot of Six Channels. Transforming to Malaria means Taiyin pathogen transmits to Shaoyang, from Yin to Yang, hence easy to cure. Transforming to Dysentery means Taiyin transmits to Jueyin, hence hard to cure. Thus Latent Pathogens should also be distinguished by Six Channels. Hejian's San Jiao investigation seems to describe initial infection, not exact theory of Latent Pathogens. Bai Du San uses Chaihu/Qianghuo to export from Yin to Yang channels. "Retrieving Boat Against Current" pulls upward against downward trend. Understanding this allows举一反三.
Mr. Wu Futian has another letter and reply.