者，因大气下陷之脉大抵皆迟，非因寒凉而迟也，用知母以济黄 之热，则药性和平，始能久服无弊。
奉天袁姓少妇，小便处常若火炙，有时觉腹中之气下坠，则炙热益甚。诊其脉关前微弱，关后重按又似有
力。其呼吸恒觉短气，心中时或发热。知其素有外感伏邪，久而化热，又因胸中大气下陷，伏邪亦随之下陷也。
治以升陷汤加生石膏八钱，后渐加至二两，服药旬日全愈。
或疑大气下陷者，气不上达也，喘者，气不下降也，何以历述大气下陷之病状，竟有努力呼吸有似乎喘者？
答曰∶此理不易骤解，仍宜以治愈之案证之。一人，年二十余。因力田劳苦过度，致胸中大气下陷，四肢
懒动，饮食减少，自言胸中满闷，其实非满闷乃短气也，病患不善述病情，往往如此。医者不能自审病因，投
以开胸理气之剂，服之增重。又改用半补半破之剂，服两剂后，病又增重。又延他医，投以桔梗、当归、木香
各数钱，病大见愈，盖全赖桔梗升提气分之力也，医者不知病愈之由，再服时，竟将桔梗易为苏梗，升降易性，
病骤反复。自此不敢服药。迟延二十余日，病势垂危，喘不能卧，昼夜倚壁而坐；假寐片时，气息即停，心下
突然胀起，急呼醒之，连连喘息数口，气息始稍续；倦极偶卧片时，觉腹中重千斤，不能转侧，且不敢仰卧；
其脉乍有乍无，寸关尺或一部独见，或两部同见，又皆一再动而止。此病之危，已至极点。因确知其为大气下
陷，遂放胆投以生箭 一两，柴胡、升麻、净萸肉各二钱。煎服片时，腹中大响一阵，有似昏愦，苏息片时，
恍然醒悟。自此呼吸复常，可以安卧，转侧轻松。其六脉皆见，仍有雀啄之象。自言百病皆除，惟觉胸中烦热，
遂将方中升麻、柴胡皆改用钱半，又加知母、玄参各六钱，服后脉遂复常。惟左关三五不调，知其气分之根柢
犹未实也，遂用野台参一两，玄参、天冬、麦冬（带心）各三钱，两剂全愈。
盖人之胸中大气，实司肺脏之呼吸。此证因大气下陷过甚，呼吸之机关将停，遂勉强鼓舞肺气，努力呼吸
以自救，其迫促之形有似乎喘，而实与气逆之喘有天渊之分。观此证假寐片时，肺脏不能努力呼吸，气息即无，
其病情可想也。设以治气逆作喘者治此证之喘，以治此证之喘者治气逆作喘，皆凶危立见。然欲辨此二证，原
有确实征验∶凡喘证，无论内伤外感，其剧者必然肩息（《内经》谓喘而肩上抬者为肩息）；大气下陷者，虽
至呼吸有声，必不肩息。盖肩息者，因喘者之吸气难，不肩息者，因大气下陷者之呼气难
也。欲辨此证，可作呼气难与吸气难之状，以默自体验，临证自无差谬。又喘者之脉多数，或有浮滑之象，或
尺弱寸强，大气下陷之脉，皆与此成反比例，尤其明征。
一人，年四十许。每岁吐血两三次，如此四年，似有一年甚于一年之势。其平素常常咳嗽，痰涎壅滞，动
则作喘，且觉短气。其脉沉迟微弱，右部尤甚。知其病源系大气下陷，投以升陷汤，加龙骨、牡蛎（皆不用 ）、
生地黄各六钱，又将方中知母改用五钱，连服三剂，诸病皆愈。遂减去升麻，又服数剂以善其后。
或问∶吐血之证，多由于逆气上干，而血随气升。此证既大气下陷，当有便血溺血之证，何以竟吐血乎？
答曰∶此证因大气陷后，肺失其养，劳嗽不已，以致血因嗽甚而吐出也。究之胸中大气，与上逆之气原迥异。
夫大气为诸气之纲领，大气陷后，诸气无所统摄，或更易于上干。且更有逆气上干过甚，排挤胸中大气下陷者
（案详参赭镇气汤下）。至便血溺血之证，由于大气下陷者诚有之，在妇女更有因之血崩者（案详固冲汤下）。
又转有因大气下陷，而经血倒行，吐血衄血者（案详加味麦门冬汤下）。是知大气既陷，诸经之气无所统摄，
而或上或下错乱妄行，有不能一律论者。
或问∶龙骨、牡蛎为收涩之品，大气陷者宜升提，不宜收涩。今方中重用二药，皆至六钱，独不虑其收
涩之性，有碍大气之升乎？答曰∶龙骨、牡蛎最能摄血之本源。此证若但知升其大气，恐血随升气之药复妄动，
于升陷汤中，加此二药，所以兼顾其血也。且大气下陷后，虑其耗散，有龙骨、牡蛎以收敛之，转能辅升陷汤
之所不逮。况龙骨善化瘀血（《神农本草经》主 瘕），牡蛎善消坚结（观其治瘰 可知）。二药并用，能使
血之未离经者，永安其宅，血之已离经者，尽化其滞。加于升陷汤中，以治气陷兼吐血之证，非至稳善之妙药乎。
按∶吐血证最忌升麻。此证兼吐血，服升陷汤时，未将升麻
减去者，因所加之龙骨、牡蛎原可监制之，而服药之时，吐血之证，犹未反复也。若恐升麻有碍血证时，亦可
减去之，多加柴胡一钱。
一人，年四十余。小便不利，周身漫肿，自腰以下，其肿尤甚。上焦痰涎杜塞，剧时几不能息。咳嗽痰中
带血，小便亦有血色。迁延半载，屡次延医服药，病转增剧。其脉滑而有力，疑是湿热壅滞，询之果心中发热。
遂重用滑石、白芍以渗湿清热，佐以柴胡、乳香、没药以宣通气化。为其病久，不任疏通，每剂药加生山药两
许，以固气滋阴。又用药汁，送服三七末二钱，以清其血分。数剂热退血减，痰涎亦少，而小便仍不利。偶于
诊脉时，见其由卧起坐，因稍费力，连连喘息十余口，呼吸始顺。且其脉从前虽然滑实，究在沉分。此时因火
退，滑实既减，且有濡象。恍悟此证确系大气下陷。遂投以升陷汤，知母改用六钱，又加玄参五钱，木通二钱，
一剂小便即利。又服数剂，诸病全愈。
一人，年四十七。咳嗽短气，大汗如洗，昼夜不止，心中怔忡，病势危急。遣人询方，俾先用山萸肉
（去净核）二两煎服，以止其汗。翌日迎愚诊视，其脉微弱欲无，呼吸略似迫促。自言大汗虽止，而仍有出汗
之时，怔忡见轻，仍觉短气。知其确系大气下陷，遂投以升陷汤，为其有汗，加龙骨、牡蛎（皆不用 ）各五
钱，三剂而愈。
一妇人，年二十余。资禀素羸弱，因院中失火，惊恐过甚，遂觉呼吸短气，心中怔忡，食后更觉气不上
达，常作太息。其脉近和平，而右部较沉。知其胸中大气，因惊恐下陷，《内经》所谓恐则气陷也。遂投以升
陷汤，为心中怔忡，加龙眼肉五钱，连服四剂而愈。
一妇人，年二十余。因境多拂郁，常作恼怒，遂觉呼吸短气，咽干作渴，剧时，觉气息将停，努力始能
呼吸。其脉左部如
常，右部来缓去急，分毫不能鼓指。《内经》谓宗气贯心脉，宗气即大气也。此证盖因常常恼怒，致大气下陷，
故不能鼓脉外出，以成波澜也。遂投以升陷汤，为其作渴，将方中知母改用六钱，连服三剂，病愈强半，右脉
亦较前有力，遂去升麻，又服数剂全愈。
或问∶《内经》谓恐则气陷，前案中已发明之。然《内经》又谓怒则气逆也，何以与此案中之理，相矛盾
乎？答曰∶《内经》所谓怒则气逆者，指肝胆之气而言，非谓胸中大气也。然肝胆之气上逆，上冲大气亦上逆
者，故人当怒急之时，恒有头目眩晕，其气呼出不能吸入，移时始能呼吸，此因大气上逆也。有肝胆之气上逆，
排挤大气转下陷者，拙拟参赭镇气汤下，有治验之案可考也。况大气原赖谷气养之，其人既常恼怒，纳谷必少，
大气即暗受其伤，而易下陷也。
一妇人，因临盆努力过甚，产后数日，胁下作疼，又十余日，更发寒热。其翁知医，投以生化汤两剂，病
大见愈。迟数日，寒热又作。遂延他医调治，以为产后瘀血为恙，又兼受寒，于活血化瘀药中，重加干姜。数
剂后，寒热益甚，连连饮水，不能解渴。时当仲夏，身热如炙，又复严裹浓被，略以展动，即觉冷气侵肤。后
愚诊视，左脉沉细欲无，右脉沉紧，皆有数象。知其大气下陷，又为热药所伤也。其从前服生化汤觉轻者，全
得芎 升提之力也。治以升陷汤，将方中知母改用八钱，又加玄参六钱，一剂而寒热已，亦不作渴。从前两日
不食，至此遂能饮食。惟胁下微疼，继服拙拟理郁升陷汤，二剂全愈。
按∶产后虽有实热，若非寒温外感之热，忌用知母，而不忌用玄参，以玄参原为治产乳之药，《神农本草
经》有明文也。此证虽得之产后，时已逾月，故敢放胆重用知母。
或问∶紧为受寒之脉，故伤寒麻黄汤证，其脉必紧。此证既为热药所伤，何以其右脉沉紧？答曰∶脉沉紧
者，其脉沉而有力
也。夫有力当作洪象，此证因大气下陷，虽内有实热，不能鼓脉作起伏之势，故不为洪而为紧，且为沉紧也。
其独见于右部者，以所服干姜之热，胃先受之也。
按∶脉无起伏为弦，弦而有力，即紧脉也。若但弦，则为寒矣。仲景平脉篇谓“双弦者寒，偏弦者饮。”
究之饮为稀涎，亦多系因寒而成也。
一妇人，年三十余。得下痿证，两腿痿废，不能屈伸，上半身常常自汗，胸中短气，少腹下坠，小便不利，
寝不能寐。延医治疗数月，病势转增。诊其脉细如丝，右手尤甚。知其系胸中大气下陷，欲为疏方。病家疑而
问曰∶“大气下陷之说，从前医者，皆未言及。然病之本源，既为大气下陷，何以有种种诸证乎？”答曰∶人
之大气虽在胸中，实能统摄全身，今因大气下陷，全身无所统摄，肢体遂有废而不举之处，此两腿之所以痿废
也。其自汗者，大气既陷，外卫之气亦虚也。其不寐者，大气既陷，神魂无所根据附也。小便不利者，三焦之气
化，不升则不降，上焦不能如雾，下焦即不能如渎也。至于胸中短气，少腹下坠，又为大气下陷之明征也。遂
治以升陷汤，因其自汗，加龙骨、牡蛎（皆不用 ）各五钱，两剂汗止，腿稍能屈伸，诸病亦见愈。继服拙拟
理郁升陷汤数剂，两腿渐能着力。然痿废既久，病在筋脉，非旦夕所能脱然。俾用舒筋通脉之品，制作丸药，
久久服之，庶能全愈。
一妇人，年三十许。胸中满闷，不能饮食。医者纯用开破之药数剂，忽然寒热，脉变为迟。医者见脉迟，
又兼寒热，方中加黄 、桂枝、干姜各数钱，而仍多用破气之药。购药未服，愚应其邻家延请，适至其村，病
家求为诊视，其脉迟而且弱，问其呼吸觉短气乎？答曰∶今于服药数剂后，新添此证。知其胸中大气因服破气
之药下陷。时医者在座，不便另为疏方，遂谓医曰∶子方中所加之药，极为对证，然此时其胸中大气下陷，破
气药分毫不可再用。遂单将所加之黄 、桂枝、干姜煎服。寒热顿已，呼吸亦觉畅舒。后医者即方略为加减，
又服数剂全愈。
门人高××曾治一人，年三十余。因枵腹劳力过度，致大气下陷。寒热往来，常常短气，大汗淋漓，头疼咽
干，畏凉嗜睡，迁延日久，不能起床。医者误认为肝气郁结，投以鳖甲、枳实、麦芽诸药，病益剧。诊其脉，
左寸关尺皆不见，右部脉虽见，而微弱欲无。知其为大气下陷，投以升陷汤，加人参三钱，一剂左脉即见，又
将知母改用五钱，连服数剂全愈。
高××又治一妇人，年三十许。胸中短气，常常出汗，剧时觉气不上达，即昏不知人，移时始苏，睡时恒自
惊寤。诊其脉，微弱异常，知其胸中大气下陷甚剧。遂投以升陷汤，知母改用五钱，又加人参、萸肉（去净核）
各三钱，连服数剂全愈。
大气下陷之证，不必皆内伤也，外感证亦有之。一人年四十许，于季春得温证，延医调治不愈，留连两旬，
病益沉重。后愚诊视，其两目清白无火，竟昏愦不省人事，舌干如磋，却无舌苔。问之亦不能言语，周身皆凉，
其五六呼吸之顷，必长出气一口。其脉左右皆微弱，至数稍迟，此亦胸中大气下陷也。盖大气不达于脑中则神
昏，大气不潮于舌本则舌干，神昏舌干，故问之不能言也。其周身皆凉者，大气陷后，不能宣布于营卫也。其
五六呼吸之顷，必长出气者，大气陷后，胸中必觉短气，故太息以舒其气也。遂用野台参一两、柴胡二钱，煎
汤灌之，一剂见轻，两剂全愈。
按∶此证从前原有大热，屡经医者调治，大热已退，精神愈惫。医者诿为不治，病家亦以为气息奄奄，待
时而已。乃迟十余日，而病状如故，始转念或可挽回，而迎愚诊视。幸投药不瘥，随手奏效，是知药果对证，
诚有活人之功也。
又按∶此证若不知为大气下陷，见其舌干如斯，但知用熟地、阿胶、枸杞之类滋其津液，其滞泥之性，
填塞膺胸，既陷之大气将何由上达乎？愚愿业医者，凡遇气分不舒之证，宜先存一大气下陷理想，以细心体察，
倘遇此等证，庶可挽回人命于顷刻也。
一人，年三十余。于初夏得温病，医者用凉药清解之，兼用枳实、青皮破气诸品，连服七八剂，谵语不省
人事，循衣摸床，周身颤动。再延他医，以为内风已动，辞不治。后愚诊视，其脉五至，浮分微弱，而重按似
有力，舌苔微黄，周身肌肤不热，知其温热之邪，随破气之药下陷已深，不能外出也。遂用生石膏二两，知母、
这是因为大气下陷的脉象大多迟缓，并非因为寒凉所致。使用知母来制约黄芪的热性，使药性平和，才能长期服用而不出弊端。
奉天袁姓的一位年轻妇女，尿道口常感觉像火烤一样灼热，有时觉得腹中的气向下坠，那么灼热感就更严重。诊察她的脉象，关前（寸部）微弱，关后（尺部）重按似乎有力。她呼吸时常觉得短气，心中有时发热。知道她素来有外感伏邪，日久化热，又因胸中大气下陷，伏邪也随之陷入。治疗用升陷汤加生石膏八钱，后来逐渐增加至二两，服药十天后完全痊愈。
有人怀疑：大气下陷的人，气不能上达；喘证是气不能下降。为什么在历述大气下陷的病状时，竟然有努力呼吸看起来像喘的情况？
回答说：这个道理不容易立刻解释清楚，还是应该用治愈的案例来证明。有一人，二十多岁。因为田间劳作过度劳累，导致胸中大气下陷，四肢懒动，饮食减少，自己说胸中满闷，其实不是满闷而是短气，病人不善于描述病情，往往如此。医生不能自行审察病因，投以开胸理气的药剂，服用后病情加重。又改用半补半破的药剂，服用两剂后，病又加重。又请其他医生诊治，投以桔梗、当归、木香各数钱，病大有好转，这全赖桔梗升提气分的力量。医生不知道病愈的原因，再服药时，竟将桔梗换为苏梗，升降性质改变，病势突然反复。从此不敢再服药。拖延了二十多天，病势垂危，喘得不能躺卧，昼夜倚靠墙壁坐着；假睡片刻，气息就停止，心里突然胀起，急忙叫醒他，连连喘息几口，气息才稍微接续；疲倦至极偶尔躺卧片刻，觉得腹中重如千斤，不能翻身，且不敢仰卧；他的脉象忽有忽无，寸关尺三部或只有一部独见，或两部同见，而且都是一两次跳动后就停止。这个病的危险，已到了极点。因为确切知道这是大气下陷，于是大胆投以生箭芪一两，柴胡、升麻、净山茱萸各二钱。煎服片刻，腹中大响一阵，好像昏迷过去，苏醒片刻，恍然醒悟。从此呼吸恢复正常，可以安卧，翻身轻松。六脉皆现，仍有雀啄脉的象。自己说百病都除，只觉得胸中烦热，于是将方中的升麻、柴胡都改为钱半，又加知母、玄参各六钱，服用后脉象恢复常态。只是左关脉三五不调，知道气分的根基还不充实，于是用野台参一两，玄参、天冬、麦冬（带心）各三钱，两剂后完全痊愈。
大概人的胸中大气，确实主管肺脏的呼吸。这个病例因为大气下陷过甚，呼吸的机关将要停止，于是勉强鼓舞肺气，努力呼吸以自救，其迫促的形态看起来像喘，但实际上与气逆之喘有天壤之别。看这个病例，假睡片刻，肺脏不能努力呼吸，气息就没有，其病情就可以想见了。如果用治气逆作喘的方法治这个病例的喘，或者用治这个病例的喘的方法治气逆作喘，都会立即出现凶险危急的情况。然而要辨别这两个证候，原本有确实的征验：凡是喘证，无论内伤外感，严重的必然会出现肩息（《内经》说喘而肩上抬高的叫肩息）；大气下陷者，虽然到呼吸有声的地步，一定不会出现肩息。因为肩息是因为喘证患者吸气困难，不肩息是因为大气下陷者呼气困难。想要辨别这个证候，可以做出呼气难和吸气难的样子，默默自我体验，临证自然没有差错。另外，喘证的脉象多数偏数，或有浮滑的象，或尺弱寸强，大气下陷的脉象，都与这些成反比例，这是尤其明显的征验。
有一人，四十岁左右。每年吐血两三次，这样持续四年，似乎一年比一年严重。他平时常常咳嗽，痰涎壅滞，一动就喘，并且觉得短气。他的脉象沉迟微弱，右部尤其严重。知道病源系大气下陷，投以升陷汤，加龙骨、牡蛎（都不煅）、生地黄各六钱，又将方中的知母改为五钱，连服三剂，各种病都好了。于是减去升麻，又服几剂以善后。
有人问：吐血的证候，多由于逆气上干，血随气上升。这个病例既然大气下陷，应当有便血溺血的证候，为什么竟然吐血呢？
回答说：这个病例因为大气下陷后，肺失去滋养，劳嗽不止，以致血因为咳嗽剧烈而吐出。究其根本，胸中大气与上逆之气原本截然不同。大气是诸气的纲领，大气下陷后，诸气无所统摄，或许更容易上干。况且更有逆气上干过甚，排挤胸中大气下陷的（案详见参赭镇气汤下）。至于便血溺血的证候，由于大气下陷的确实存在，在妇女更有因此导致血崩的（案详见固冲汤下）。又有因为大气下陷，而经血倒行，吐血衄血的（案详见加味麦门冬汤下）。由此可知，大气既已下陷，诸经之气无所统摄，从而或上或下错乱妄行，有不能一概而论的。
有人问：龙骨、牡蛎是收涩的药物，大气下陷者宜升提，不宜收涩。现在方中重用这两味药，都至六钱，难道不怕它们的收涩之性，妨碍大气的升提吗？回答说：龙骨、牡蛎最能摄纳血的根源。这个病例如果只知道升提大气，恐怕血随着升提气的药物再次妄动，在升陷汤中加入这两味药，所以兼顾止血。而且大气下陷后，担心其耗散，有龙骨、牡蛎来收敛它，反而能辅助升陷汤所不及的地方。况且龙骨善于化瘀血（《神农本草经》主治癥瘕），牡蛎善于消除坚结（看它治疗瘰疬就知道了）。两药并用，能使未离经的血永远安定其宅，已离经的血全部化解其瘀滞。加入升陷汤中，用来治疗气陷兼吐血的证候，不是最稳妥巧妙的药物吗？
按语：吐血证最忌用升麻。这个病例兼有吐血，服用升陷汤时，没有将升麻减去的，是因为所加的龙骨、牡蛎原本可以监制它，而且服药的时候，吐血的证候还没有反复。如果担心升麻妨碍血证，也可以减去它，多加柴胡一钱。
有一人，四十多岁。小便不利，周身漫肿，从腰部以下，肿胀尤其严重。上焦痰涎堵塞，严重时几乎不能呼吸。咳嗽痰中带血，小便也有血色。拖延半年，屡次请医服药，病势转剧。他的脉象滑而有力，怀疑是湿热壅滞，询问果然心中发热。于是重用滑石、白芍来渗湿清热，佐以柴胡、乳香、没药来宣通气化。因为病久，不耐疏通，每剂药加生山药一两左右，以固气滋阴。又用药汁，送服三七末二钱，以清血分。几剂后热退血减，痰涎也少，但小便仍不利。偶然在诊脉时，见他由卧起坐，因为稍费力，连连喘息十余口，呼吸才顺。而且他的脉从前虽然滑实，终究在沉分。此时因为火退，滑实既减，且有濡象。恍然大悟这个病例确系大气下陷。于是投以升陷汤，知母改为六钱，又加玄参五钱，木通二钱，一剂小便即利。又服几剂，各种病全愈。
有一人，四十七岁。咳嗽短气，大汗如洗，昼夜不止，心中怔忡，病势危急。派人来询问方子，让先用山茱萸（去净核）二两煎服，以止汗。第二天迎我诊治，脉象微弱欲无，呼吸略似迫促。自己说大汗虽止，但仍有出汗的时候，怔忡减轻，仍觉得短气。知道确系大气下陷，于是投以升陷汤，因为有汗，加龙骨、牡蛎（都不煅）各五钱，三剂而愈。
一位妇人，二十多岁。禀赋素来羸弱，因为院中失火，惊恐过甚，于是觉得呼吸短气，心中怔忡，食后更觉得气不上达，常作太息。她的脉象近和平，但右部较沉。知道她的胸中大气，因惊恐下陷，《内经》所谓恐则气陷。于是投以升陷汤，因为心中怔忡，加龙眼肉五钱，连服四剂而愈。
一位妇人，二十多岁。因为境遇多拂郁，常发恼怒，于是觉得呼吸短气，咽干作渴，严重时，觉得气息将停，努力始能呼吸。她的脉左部如常，右部来缓去急，分毫不能鼓指。《内经》谓宗气贯心脉，宗气即大气也。这个病例大概因为常常恼怒，致大气下陷，故不能鼓脉外出，以成波澜。于是投以升陷汤，因为她作渴，将方中的知母改为六钱，连服三剂，病好了一半，右脉也比前有力，于是去升麻，又服几剂全愈。
有人问：《内经》谓恐则气陷，前面的案例中已经阐明了。然而《内经》又说怒则气逆，为什么与此案例中的道理相矛盾呢？回答说：《内经》所谓怒则气逆，是指肝胆之气而言，不是说胸中大气。然而肝胆之气上逆，上冲大气亦上逆的，所以人当发怒急时，常有头目眩晕，气呼出不能吸入，过了一会儿才能呼吸，这是因为大气上逆。有肝胆之气上逆，排挤大气转而下陷的，拙拟参赭镇气汤下，有治疗验证的案例可考。况且大气原赖谷气养之，其人既常恼怒，纳谷必少，大气即暗受其伤，而易下陷。
一位妇人，因为临盆努力过甚，产后数日，胁下作疼，又十余日，更发寒热。她的公公懂医，投以生化汤两剂，病大有好转。过了几天，寒热又发作。于是请其他医生调治，认为产后瘀血致病，又兼受寒，于活血化瘀药中，重加干姜。几剂后，寒热更甚，连连饮水，不能解渴。当时正值仲夏，身热如炙，又复严裹浓被，略微动弹，即觉冷气侵肤。后来我诊治，左脉沉细欲无，右脉沉紧，都有数象。知道她大气下陷，又被热药所伤。她从前服生化汤觉得轻的，全得川芎升提之力。治疗用升陷汤，将方中的知母改为八钱，又加玄参六钱，一剂而寒热已，也不作渴。从前两天不食，至此遂能饮食。只是胁下微疼，继服我拟的理郁升陷汤，两剂全愈。
按语：产后虽有实热，若非寒温外感之热，忌用知母，而不忌用玄参，因为玄参原是治产乳的药，《神农本草经》有明文。这个病例虽得之于产后，时间已过一月，所以敢放胆重用知母。
有人问：紧脉是受寒的脉象，所以伤寒麻黄汤证，其脉必紧。这个病例既为热药所伤，为什么其右脉沉紧？回答说：脉沉紧，是指脉沉而有力。夫有力当作洪象，这个病例因为大气下陷，虽内有实热，不能鼓脉作起伏之势，故不为洪而为紧，且为沉紧。其独见于右部的，是因为所服的干姜之热，胃先受之。
按语：脉无起伏为弦，弦而有力，即紧脉。若但弦，则为寒。仲景平脉篇谓“双弦者寒，偏弦者饮。”究之饮为稀涎，也多系因寒而成。
一位妇人，三十多岁。得下痿证，两腿痿废，不能屈伸，上半身常常自汗，胸中短气，少腹下坠，小便不利，寝不能寐。延医治疗数月，病势转增。诊其脉细如丝，右手尤甚。知道系胸中大气下陷，欲为疏方。病家疑而问曰：“大气下陷之说，从前医者，皆未言及。然病之本源，既为大气下陷，何以有种种诸证乎？”回答说：人的大气虽在胸中，实能统摄全身，今因大气下陷，全身无所统摄，肢体遂有废而不举之处，此两腿之所以痿废也。其自汗者，大气既陷，外卫之气亦虚也。其不寐者，大气既陷，神魂无所根据附也。小便不利者，三焦之气化，不升则不降，上焦不能如雾，下焦即不能如渎也。至于胸中短气，少腹下坠，又为大气下陷之明征。于是治以升陷汤，因其自汗，加龙骨、牡蛎（都不煅）各五钱，两剂汗止，腿稍能屈伸，诸病亦见愈。继服我拟的理郁升陷汤数剂，两腿渐能着力。然痿废既久，病在筋脉，非旦夕所能脱然。让用舒筋通脉之品，制作丸药，久久服之，庶能全愈。
一位妇人，三十岁左右。胸中满闷，不能饮食。医者纯用开破之药数剂，忽然寒热，脉变为迟。医者见脉迟，又兼寒热，方中加黄芪、桂枝、干姜各数钱，而仍多用破气之药。购药未服，我应其邻家延请，适至其村，病家求为诊视，其脉迟而且弱，问其呼吸觉短气乎？回答说：现在于服药数剂后，新添此证。知道其胸中大气因服破气之药下陷。当时医者在座，不便另为疏方，遂谓医曰：“你方中所加之药，极为对证，然此时其胸中大气下陷，破气药分毫不可再用。”遂单将所加之黄芪、桂枝、干姜煎服。寒热顿已，呼吸亦觉畅舒。后医者即方略为加减，又服几剂全愈。
门人高××曾治一人，三十多岁。因为空腹劳力过度，致大气下陷。寒热往来，常常短气，大汗淋漓，头疼咽干，畏凉嗜睡，迁延日久，不能起床。医者误认为肝气郁结，投以鳖甲、枳实、麦芽诸药，病益剧。诊其脉，左寸关尺皆不见，右部脉虽见，而微弱欲无。知其为大气下陷，投以升陷汤，加人参三钱，一剂左脉即见，又将知母改为五钱，连服几剂全愈。
高××又治一妇人，三十岁左右。胸中短气，常常出汗，严重时觉得气不上达，即昏不知人，过了一会儿才苏醒，睡时恒自惊寤。诊其脉，微弱异常，知其胸中大气下陷甚剧。于是投以升陷汤，知母改为五钱，又加人参、山茱萸（去净核）各三钱，连服几剂全愈。
大气下陷的证候，不一定都是内伤，外感证也有。一人四十岁左右，于季春得温证，延医调治不愈，留连两旬，病益沉重。后来我诊治，其两目清白无火，竟昏愦不省人事，舌干如磋，却无舌苔。问之亦不能言语，周身皆凉，其五六呼吸之顷，必长出气一口。其脉左右皆微弱，至数稍迟，这也是胸中大气下陷。盖大气不达于脑中则神昏，大气不潮于舌本则舌干，神昏舌干，故问之不能言也。其周身皆凉者，大气陷后，不能宣布于营卫也。其五六呼吸之顷，必长出气者，大气陷后，胸中必觉短气，故太息以舒其气也。于是用野台参一两、柴胡二钱，煎汤灌之，一剂见轻，两剂全愈。
按语：这个病例从前原有大热，屡经医者调治，大热已退，精神愈惫。医者推诿为不治，病家也以为气息奄奄，等待死亡而已。乃延迟十余日，而病状如故，始转念或许可以挽回，而迎我诊治。幸投药不谬，随手奏效，是知药果对证，诚有活人之功。
又按语：这个病例若不知道为大气下陷，见其舌干如此，只知道用熟地、阿胶、枸杞之类滋其津液，其滞泥之性，填塞膺胸，既陷之大气的将何以上达呢？我希望业医者，凡遇气分不舒的证候，宜先存一大气下陷的理想，以细心体察，倘遇这种证候，庶可挽回人命于顷刻。
一人，三十多岁。于初夏得温病，医者用凉药清解之，兼用枳实、青皮破气诸品，连服七八剂，谵语不省人事，循衣摸床，周身颤动。再延他医，以为内风已动，辞不治。后来我诊治，其脉五至，浮分微弱，而重按似有力，舌苔微黄，周身肌肤不热，知道温热之邪，随破气之药下陷已深，不能外出。于是用生石膏二两，知母、
This is because the pulse of Qi sinking in the chest (Qi Xian) generally appears slow, not due to cold or coolness. Using Zhi Mu (Anemarrhenae Rhizoma) to counteract the heat of Huang Qi (Astragali Radix) makes the medicinal properties mild and balanced, allowing for long-term use without adverse effects.
A young woman surnamed Yuan from Fengtian often felt a burning sensation in her urethra as if scalded by fire. Sometimes she felt the Qi in her abdomen sinking downward, which intensified the burning sensation. Her pulse was weak at the Cun position (front of the guan) and seemed forceful upon heavy pressing at the Chi position (back of the guan). She constantly felt shortness of breath and occasional fever in the heart region. It was determined that she had latent pathogenic factors from external contraction that had transformed into heat over time, and due to the sinking of the Great Qi in the chest, these latent factors also sank with it. Treatment involved Sheng Xi Tang (Decoction to Lift the Sunken Qi) with added Sheng Shi Gao (Raw Gypsum Fibrosum), initially 8 qian, gradually increased to 2 liang. After ten days of medication, she fully recovered.
One might doubt: In cases of Qi sinking, the Qi fails to ascend; in cases of panting (Chuan), the Qi fails to descend. Why do descriptions of Qi sinking include symptoms resembling panting, such as labored breathing?
The answer is: This principle is not easily grasped immediately; it should be verified through cured cases. One patient, in his twenties, suffered from excessive physical labor in the fields, leading to Qi sinking in the chest. He had lethargic limbs, reduced appetite, and complained of chest fullness, although it was actually shortness of breath. Patients often fail to describe their conditions accurately. The physician failed to identify the cause and prescribed formulas to open the chest and regulate Qi, which worsened the condition. A subsequent prescription combining tonification and breaking stagnation also worsened the condition after two doses. Another physician prescribed Jie Geng (Platycodonis Radix), Dang Gui (Angelicae Sinensis Radix), and Mu Xiang (Aucklandiae Radix), each in small amounts. The condition improved significantly, primarily due to the ascending power of Jie Geng. Unaware of the reason for recovery, the physician replaced Jie Geng with Su Geng (Perillae Caulis) in the next prescription, changing the ascending-descending nature, causing an immediate relapse. The patient refused further medication. After twenty days, the condition became critical: he could not lie down due to panting, sat leaning against the wall day and night; during brief sleep, his breathing would stop, his epigastrium would suddenly distend, and he would wake up gasping for air to resume breathing. When lying down briefly from exhaustion, he felt his abdomen weigh a thousand jin, unable to turn over, and dared not lie on his back. His pulse was intermittent, appearing only in one or two of the three positions (Cun, Guan, Chi), stopping after one or two beats. The danger was extreme. Knowing this was Qi sinking, I boldly prescribed Sheng Jian Xi (Raw Astragali Radix) 1 liang, Chai Hu (Bupleuri Radix), Sheng Ma (Cimicifugae Rhizoma), and Jing Yu Rou (Corni Fructus), each 2 qian. After brewing and drinking, there was rumbling in the abdomen, followed by a fainting-like state. Upon waking, he regained consciousness. Breathing normalized, allowing him to lie down comfortably and move easily. All six pulses appeared, though with a "sparrow-pecking" quality. He reported all diseases were gone except for chest irritability. The dosages of Sheng Ma and Chai Hu were reduced to 1.5 qian each, and Zhi Mu (Anemarrhenae Rhizoma) and Xuan Shen (Scrophulariae Radix) 6 qian each were added. The pulse returned to normal afterward. However, the left Guan position remained irregular (3-5 beats then pause), indicating the root of Qi was still deficient. Therefore, Ye Tai Shen (Wild Codonopsis Radix) 1 liang, Xuan Shen, Tian Dong (Asparagi Radix), and Mai Dong (Ophiopogonis Radix, keeping the heart) 3 qian each were used. Two doses resulted in full recovery.
Generally, the Great Qi in the chest governs lung respiration. In this case, severe Qi sinking caused the respiratory mechanism to nearly cease, forcing the lungs to struggle to breathe to save themselves. This urgency resembles panting but is fundamentally different from panting due to rebellious Qi. Observing this case, when the patient slept briefly, the lungs could not struggle to breathe, and breath stopped, illustrating the severity. Treating this type of panting with methods for rebellious Qi panting, or vice versa, would lead to immediate danger. However, there are reliable signs to distinguish them: Severe panting, whether from internal injury or external contraction, invariably involves "shoulder breathing" (lifting shoulders while inhaling, as described in the *Nei Jing*). In Qi sinking, even if breathing is noisy, shoulder breathing does not occur. Shoulder breathing occurs because inhalation is difficult in panting; its absence in Qi sinking is because exhalation is difficult. To distinguish, one can simulate difficulty in exhaling versus inhaling for self-experience. Additionally, panting pulses are usually rapid, floating-slippery, or weak at Chi and strong at Cun. Qi sinking pulses are the opposite, a clear distinction.
One patient, around forty years old, experienced hemoptysis (coughing blood) two or three times a year for four years, worsening annually. He frequently coughed with copious phlegm, panted upon exertion, and felt shortness of breath. His pulse was deep, slow, and weak, especially on the right. The source was identified as Qi sinking. Treatment used Sheng Xi Tang with Long Gu (Fossilia Ossis Mastodi) and Mu Li (Concha Ostreae) (both uncalcined) and Sheng Di Huang (Rehmanniae Radix) 6 qian each. Zhi Mu was changed to 5 qian. Three doses cured all symptoms. Sheng Ma was then removed, and several more doses were taken for consolidation.
Question: Hemoptysis is usually due to rebellious Qi pushing blood upward. If Qi is sinking, shouldn't there be bleeding from stool or urine instead of hemoptysis?
Answer: In this case, after Qi sank, the lungs lost nourishment, leading to chronic coughing, which caused blood to be vomited due to severe coughing. Fundamentally, Great Qi differs from rebellious Qi. Great Qi is the commander of all Qi; when it sinks, other Qi lacks control and may rebel. Moreover, severe rebellious Qi can squeeze Great Qi downward (see Case under Can Zhe Zhen Qi Tang). Bleeding from stool or urine due to Qi sinking does exist, as does metrorrhagia in women (see Gu Chong Tang). Also, inverted menstruation causing hemoptysis or epistaxis can result from Qi sinking (see Jia Wei Mai Men Dong Tang). Thus, when Great Qi sinks, Qi in all meridians loses control and may flow erratically up or down, defying uniform explanation.
Question: Long Gu and Mu Li are astringents. Qi sinking requires lifting, not astringing. Why use large doses (6 qian) of these in the formula? Are you not worried their astringent nature hinders Qi ascent?
Answer: Long Gu and Mu Li best secure the root of blood. If only Qi is lifted, blood might follow the ascending herbs and bleed again. Adding these two drugs in Sheng Xi Tang addresses both Qi and blood. Furthermore, fearing consumption after Qi sinking, Long Gu and Mu Li prevent dispersion, assisting Sheng Xi Tang where it falls short. Long Gu resolves blood stasis (*Shennong Ben Cao Jing* states it treats masses), and Mu Li dissolves hardness (seen in treating scrofula). Together, they keep non-escaped blood in place and resolve escaped blood stasis. Added to Sheng Xi Tang for Qi sinking with hemoptysis, they are excellent and safe.
Note: Sheng Ma is contraindicated in hemoptysis. In this case, Sheng Ma was not removed initially because Long Gu and Mu Li controlled its effect, and hemoptysis had not recurred. If concerned about Sheng Ma affecting blood disorders, it can be removed, and Chai Hu increased by 1 qian.
One patient, over forty, had dysuria and generalized edema, worse below the waist. Phlegm obstructed the upper jiao, causing severe dyspnea. Cough produced blood-streaked sputum, and urine was bloody. After half a year of ineffective treatment, the condition worsened. Pulse was slippery and forceful; the patient reported heart fever. Heavy doses of Hua Shi (Talcum) and Bai Shao (Paeoniae Radix Alba) were used to drain dampness and clear heat, assisted by Chai Hu, Ru Xiang (Olibanum), and Mo Yao (Myrrha) to promote Qi transformation. Due to chronic illness, raw Shan Yao (Dioscoreae Rhizoma) ~1 liang was added per dose to consolidate Qi and nourish Yin. San Qi (Notoginseng Radix) powder 2 qian was taken with decoction to clear the blood level. After several doses, heat subsided, bleeding decreased, and phlegm reduced, but dysuria persisted. During pulse diagnosis, seeing him sit up from lying required effort, causing十余 gasps before breathing smoothed. The pulse, previously slippery and solid but deep, now showed deficiency characteristics as heat subsided. Realizing this was Qi sinking, Sheng Xi Tang was prescribed, Zhi Mu changed to 6 qian, Xuan Shen 5 qian, and Tong Cao (Tetrapanacis Medulla) 2 qian added. Dysuria resolved after one dose. Several more doses led to full recovery.
One patient, forty-seven, suffered from cough, shortness of breath, profuse sweating day and night, palpitations, and critical condition. He was instructed to take Shan Zhu Yu (Corni Fructus, seeds removed) 2 liang decocted to stop sweating. Next day, pulse was weak and faint, breathing slightly hurried. Sweating stopped but recurred occasionally; palpitations improved, but shortness of breath persisted. Confirmed as severe Qi sinking. Sheng Xi Tang was given, with Long Gu and Mu Li (uncalcined) 5 qian each added due to sweating. Three doses cured him.
A woman, over twenty, constitutionally weak. After a house fire and severe fright, she felt shortness of breath, palpitations, and Qi failing to ascend after eating, sighing frequently. Pulse was near normal but deeper on the right. The Great Qi sank due to fright ("Fear causes Qi sinking," *Nei Jing*). Sheng Xi Tang was prescribed, with Long Yan Rou (Longan Aril) 5 qian added for palpitations. Four doses cured her.
Another woman, over twenty, frustrated and angry frequently. She felt shortness of breath, dry throat, and thirst. At worst, she felt breath stopping, requiring effort to breathe. Left pulse was normal; right pulse was slow coming and urgent going, lacking force. *Nei Jing* states Zong Qi (Gathering Qi, i.e., Great Qi) penetrates the heart vessels. Anger caused Qi sinking, preventing the pulse from surging. Sheng Xi Tang was prescribed, Zhi Mu changed to 6 qian for thirst. Three doses improved her by half, right pulse strengthened. Sheng Ma was removed, and several more doses cured her.
Question: *Nei Jing* says "Fear causes Qi sinking," explained in previous cases. But it also says "Anger causes Qi rebellion." How does this contradict the current case?
Answer: "Anger causes Qi rebellion" refers to Liver and Gallbladder Qi, not necessarily Chest Great Qi. However, rebellious Liver/Gallbladder Qi can push Great Qi upward, causing dizziness and inability to inhale temporarily (Great Qi rebellion). Conversely, rebellious Qi can squeeze Great Qi downward (see Can Zhe Zhen Qi Tang). Moreover, Great Qi relies on Grain Qi for nourishment. Chronic anger reduces appetite, damaging Great Qi and predisposing it to sinking.
A woman, after difficult labor, had hypochondriac pain for days, then chills and fever after ten days. Her father-in-law, knowing medicine, gave Sheng Hua Tang (Decoction for Generating Blood) for two doses, improving greatly. Days later, chills and fever returned. Another doctor treated postpartum blood stasis and cold, adding heavy Gan Jiang (Zingiberis Rhizoma) to blood-invigorating herbs. Chills and fever worsened; she drank constantly but remained thirsty. In midsummer, she felt hot but wrapped in thick quilts, feeling cold air upon movement. My pulse diagnosis showed left pulse deep, thin, and faint; right pulse deep, tight, and rapid. Diagnosed as Qi sinking injured by hot herbs. The initial improvement from Sheng Hua Tang was due to Xiong Gui (Ligustici Chuanxiong Rhizoma) lifting Qi. Treatment: Sheng Xi Tang, Zhi Mu changed to 8 qian, Xuan Shen 6 qian added. One dose resolved chills/fever and thirst. Appetite returned. Mild hypochondriac pain remained. Continued with Li Yu Sheng Xi Tang (Regulating Depression Lifting Qi Decoction) for two doses, curing her.
Note: Postpartum excess heat usually contraindicates Zhi Mu unless due to external cold/warmth, but Xuan Shen is allowed as it treats postpartum conditions (*Shennong Ben Cao Jing*). Since this case was over a month postpartum, Zhi Mu was safely used heavily.
Question: Tight pulse indicates cold (e.g., Ma Huang Tang syndrome). Why is the right pulse deep and tight here if injured by hot herbs?
Answer: Deep-tight means deep and forceful. Forcefulness usually suggests Surging pulse. Here, Qi sinking prevents the pulse from surging despite internal excess heat, resulting in a Tight, Deep-Tight pulse instead. It appears only on the right because Gan Jiang's heat affected the Stomach first.
Note: Pulse without fluctuation is Wiry (Xian); wiry and forceful is Tight (Jin). Purely wiry indicates cold. Zhang Zhongjing's *Ping Mai Pian* states "Double wiry is cold, single wiry is fluid retention." Fluid retention is often due to cold.
A woman, over thirty, suffered from lower limb flaccidity (Wei Syndrome), unable to bend or extend legs. Upper body sweated spontaneously, chest shortness of breath, lower abdominal bearing-down sensation, dysuria, and insomnia. Months of treatment worsened the condition. Pulse was thread-like, worse on the right. Diagnosed as Qi sinking. Family questioned why Qi sinking caused various symptoms. Answer: Great Qi controls the whole body. Sinking leads to loss of control, causing limb paralysis (flaccidity). Spontaneous sweating occurs because defensive Qi is deficient when Great Qi sinks. Insomnia occurs because Spirit lacks attachment. Dysuria occurs because San Jiao Qi transformation fails to ascend/descend; upper jiao cannot mist, lower jiao cannot drain. Shortness of breath and bearing-down are clear signs of Qi sinking. Treatment: Sheng Xi Tang, Long Gu and Mu Li (uncalcined) 5 qian each added for sweating. Two doses stopped sweating, legs moved slightly, symptoms improved. Continued with Li Yu Sheng Xi Tang for several doses, legs gained strength. However, chronic flaccidity affects sinews and vessels, requiring long-term pill therapy with sinew-relaxing and vessel-unblocking herbs for full recovery.
A woman, around thirty, had chest fullness and inability to eat. Physicians used opening/breaking herbs for several doses, causing sudden chills/fever and a slow pulse. Seeing slow pulse and chills/fever, the doctor added Huang Qi, Gui Zhi (Cinnamomi Ramulus), and Gan Jiang, continuing to use Qi-breaking herbs. Before taking the medicine, I visited the village at a neighbor's request. Pulse was slow and weak. Asked if she felt shortness of breath, she said yes, newly developed after medication. Diagnosed as Qi sinking due to Qi-breaking herbs. With the physician present, I advised that while his additions were correct for the original pattern, Qi-breaking herbs must stop now due to Qi sinking. He decocted only the added Huang Qi, Gui Zhi, and Gan Jiang. Chills/fever stopped, breathing smoothed. The physician adjusted the formula slightly, and several more doses cured her.
Disciple Gao XX treated a man, over thirty. Empty stomach labor caused Qi sinking. Alternating chills/fever, shortness of breath, profuse sweating, headache, dry throat, aversion to cold, lethargy, bedridden for days. Misdiagnosed as Liver Qi stagnation, treated with Bie Jia (Testudinis Carapax), Zhi Shi (Aurantii Fructus), Mai Ya (Hordei Fructus Germinatus), worsening condition. Pulse: Left Cun, Guan, Chi absent; Right pulse visible but faint. Diagnosed as Qi sinking. Sheng Xi Tang with Ren Shen (Ginseng Radix) 3 qian added. Left pulse appeared after one dose. Zhi Mu changed to 5 qian. Several doses cured him.
Gao XX also treated a woman, around thirty. Chest shortness of breath, frequent sweating. Severe episodes caused Qi failure to ascend, leading to unconsciousness, recovering after a while. Startled from sleep. Pulse extremely weak. Severe Qi sinking diagnosed. Sheng Xi Tang, Zhi Mu changed to 5 qian, Ren Shen and Yu Rou (Corni Fructus, seeds removed) 3 qian each added. Several doses cured her.
Qi sinking is not solely internal injury; external contraction cases exist. A man, around forty, contracted Warm Disease in late spring. Ineffective treatment lasted twenty days, worsening condition. My examination: Eyes clear without fire, coma, tongue dry like whetstone without coating, unable to speak, body cold. Every five-six breaths, he sighed deeply. Pulses bilateral weak, slightly slow. Diagnosed as Qi sinking. Great Qi failing to reach brain causes coma; failing to moisten tongue base causes dry tongue; thus inability to speak. Body cold because Great Qi cannot distribute to Ying and Wei. Deep sighs compensate for chest shortness due to sinking. Treated with Ye Tai Shen 1 liang, Chai Hu 2 qian decocted and灌 (administered). One dose improved, two doses cured.
Note: Initially high fever, subsided after treatments, leaving exhaustion. Doctors gave up, family waited for death. After ten days, no change, they sought help. Fortunately, the prescription worked, proving correct prescriptions save lives.
Note: If this case were misdiagnased as Yin deficiency due to dry tongue, using Shu Di Huang (Rehmanniae Radix Preparata), E Jiao (Asini Corii Colla), Gou Qi Zi (Lycii Fructus) would clog the chest with their sticky nature, preventing already sunk Great Qi from ascending. Physicians should always consider Qi sinking when encountering Qi stagnation patterns to save lives instantly.
A man, over thirty, contracted Warm Disease in early summer. Treated with cooling/clearing herbs and Qi-breaking agents (Zhi Shi, Qing Pi), seven-eight doses led to delirium, unconsciousness, picking at clothes, tremors. Other doctors diagnosed internal wind and refused treatment. My examination: Pulse five beats per breath, weak at superficial level, seemingly forceful at deep level, slight yellow coating, body skin not hot. Heat pathogen had sunk deeply due to Qi-breaking herbs, unable to exit. Used Sheng Shi Gao 2 liang, Zhi Mu,