抚顺一童，九岁，因有外感实热久留不去，变为虚劳咳嗽证。
病因 从前曾受外感，热入阳明。医者纯用甘寒之药清之，致病愈之后，犹有些些余热稽留脏
腑，久之阴分亏耗，浸成虚劳咳嗽证。
证候 心中常常发热，有时身亦觉热，懒于饮食，咳嗽频吐痰涎，身体瘦弱。屡服清热宁
嗽之药，即稍效病仍反复，其脉象弦数，右部尤弦而兼硬。
诊断 其脉象弦数者，热久涸阴血液亏损也。其右部弦而兼硬者，从前外感之余热，犹留滞
于阳明之腑也。至其咳嗽吐痰，亦热久伤肺之现象也。欲治此证，当以清其阳明余热为初步，热
清之后，再用药滋养其真阴，病根自不难除矣。
处方 生石膏（两半捣细） 大潞参（三钱） 玄参（五钱） 生怀山药（五钱） 鲜茅根（三
钱） 甘草（二钱）
共煎汤一盅半，分两次温饮下。若无鲜茅根时，可用鲜芦根代之。
方解 此方即白虎加人参汤以玄参代知母，生山药代粳米，而又加鲜茅根也。盖阳明久郁之邪
热，非白虎加人参汤不能清之，为其病久阴亏，故又将原方少为变通，使之兼能滋阴
也。加鲜茅根者，取其具有升发透达之性，与石膏并用，能清热兼能散热也。
复诊 将药煎服两剂，身心之热大减，咳嗽吐痰已愈强半，脉象亦较前和平。知外邪之热已清，
宜再用药专滋其阴分，俾阴分充足自能尽消其余热也。
处方 生怀山药（一两） 大甘枸杞（八钱） 生怀地黄（五钱） 玄参（四钱）
沙参（四钱） 生杭芍（三钱） 生远志（二钱） 白术（二钱） 生鸡内金（二钱黄色的捣） 甘草（钱半）
共煎汤一盅温服。
效果 将药连服三剂，饮食加多，诸病皆愈。
方解 陆九芝谓∶“凡外感实热之证，最忌但用甘寒滞泥之药治之。其病纵治愈，亦恒稽留
余热；永锢闭于脏腑之中，不能消散，致热久耗阴，浸成虚劳，不能救药者多矣。”此诚见道之
言也。而愚遇此等证，其虚劳不至过甚，且脉象仍有力者，恒治以白虎加人参汤，复略为变通，使
之退实热兼能退虚热，约皆可随手奏效也。
【背景信息】
书名：《医学衷中参西录》 作者：张锡纯 朝代：清 章节：4．虚劳咳嗽兼外感实热证 类别：医论
【待处理原文】
抚顺一童，九岁，因有外感实热久留不去，变为虚劳咳嗽证。
病因 从前曾受外感，热入阳明。医者纯用甘寒之药清之，致病愈之后，犹有些些余热稽留脏腑，久之阴分亏耗，浸成虚劳咳嗽证。
证候 心中常常发热，有时身亦觉热，懒于饮食，咳嗽频吐痰涎，身体瘦弱。屡服清热宁嗽之药，即稍效病仍反复，其脉象弦数，右部尤弦而兼硬。
诊断 其脉象弦数者，热久涸阴血液亏损也。其右部弦而兼硬者，从前外感之余热，犹留滞于阳明之腑也。至其咳嗽吐痰，亦热久伤肺之现象也。欲治此证，当以清其阳明余热为初步，热清之后，再用药滋养其真阴，病根自不难除矣。
处方 生石膏（两半捣细） 大潞参（三钱） 玄参（五钱） 生怀山药（五钱） 鲜茅根（三钱） 甘草（二钱）
共煎汤一盅半，分两次温饮下。若无鲜茅根时，可用鲜芦根代之。
方解 此方即白虎加人参汤以玄参代知母，生山药代粳米，而又加鲜茅根也。盖阳明久郁之邪热，非白虎加人参汤不能清之，为其病久阴亏，故又将原方少为变通，使之兼能滋阴也。加鲜茅根者，取其具有升发透达之性，与石膏并用，能清热兼能散热也。
复诊 将药煎服两剂，身心之热大减，咳嗽吐痰已愈强半，脉象亦较前和平。知外邪之热已清，宜再用药专滋其阴分，俾阴分充足自能尽消其余热也。
处方 生怀山药（一两） 大甘枸杞（八钱） 生怀地黄（五钱） 玄参（四钱）
沙参（四钱） 生杭芍（三钱） 生远志（二钱） 白术（二钱） 生鸡内金（二钱黄色的捣） 甘草（钱半）
共煎汤一盅温服。
效果 将药连服三剂，饮食加多，诸病皆愈。
方解 陆九芝谓∶“凡外感实热之证，最忌但用甘寒滞泥之药治之。其病纵治愈，亦恒稽留余热；永锢闭于脏腑之中，不能消散，致热久耗阴，浸成虚劳，不能救药者多矣。”此诚见道之言也。而愚遇此等证，其虚劳不至过甚，且脉象仍有力者，恒治以白虎加人参汤，复略为变通，使之退实热兼能退虚热，约皆可随手奏效也。
[Background Information]
Book: *Yixue Zhongzhong Canxi Lu* (Records of Medical Practice Integrating Chinese and Western Medicine)
Author: Zhang Xichun
Dynasty: Qing
Chapter: 4. Deficiency Consumption with Cough Complicated by Exogenous Excess Heat Syndrome
Category: Medical Discussion
[Fresh Text]
A nine-year-old boy from Fushun developed a deficiency consumption cough syndrome due to exogenous excess heat lingering for a long time.
**Etiology:** Previously, he contracted an exogenous pathogen, and the heat entered the Yangming channel. The physician exclusively used sweet-cold herbs to clear the heat. After the illness was cured, some residual heat remained stagnant in the zang-fu organs. Over time, this depleted the yin aspect, gradually evolving into a deficiency consumption cough syndrome.
**Symptoms:** Frequent sensation of heat in the heart region; sometimes the whole body feels hot; poor appetite; frequent coughing with expectoration of phlegm-saliva; emaciation. Repeated administration of heat-clearing and cough-calming herbs provided only slight relief, with the disease recurring. The pulse was wiry and rapid, particularly wiry and hard on the right side.
**Diagnosis:** The wiry and rapid pulse indicates that prolonged heat has dried up the yin and depleted blood. The wiry and hard quality on the right side suggests that residual heat from the previous exogenous pathogen remains stagnant in the Yangming fu organs. The coughing and expectoration are also manifestations of prolonged heat damaging the lungs. To treat this syndrome, the initial step should be to clear the residual heat in the Yangming. After the heat is cleared, herbs nourishing true yin should be administered, making it easy to eradicate the root cause of the disease.
**Prescription:**
Raw Gypsum (Sheng Shigao) [1.5 taels, crushed fine]
Large Lu Shen (Da Lushen, Radix Codonopsis) [3 qian]
Scrophularia Root (Xuan Shen) [5 qian]
Fresh Huai Yam (Sheng Huai Shanyao) [5 qian]
Fresh Imperata Rhizome (Xian Maogen) [3 qian]
Licorice Root (Gancao) [2 qian]
Decoct together to make one and a half bowls of decoction, taken warm in two divided doses. If fresh Imperata rhizome is unavailable, fresh Arundo rhizome (Xian Lugeng) may be substituted.
**Formula Analysis:** This formula is essentially Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction), substituting Scrophularia Root (Xuan Shen) for Anemarrhena Rhizome (Zhi Mu), Fresh Huai Yam (Sheng Shanyao) for Rice (Jingmi), and adding fresh Imperata rhizome (Xian Maogen). The pathogenic heat stagnating in the Yangming for a long time cannot be cleared without Baihu Jia Renshen Tang. However, since the disease has been prolonged and yin is deficient, the original formula was slightly modified to also nourish yin. Fresh Imperata rhizome was added for its ascending and penetrating properties; when used with Gypsum, it clears heat and dissipates it simultaneously.
**Follow-up Visit:** After taking two doses of the prescription, the heat in the mind and body decreased significantly, and the cough with expectoration improved by more than half. The pulse became more harmonious compared to before. Knowing that the heat from the exogenous pathogen has been cleared, it is appropriate to use herbs specifically to nourish the yin aspect. Once the yin aspect is sufficient, it will naturally eliminate any remaining residual heat.
**Prescription:**
Fresh Huai Yam (Sheng Huai Shanyao) [1 liang]
Large Sweet Goji Berry (Da Gan Gouqi) [8 qian]
Fresh Rehmannia Root (Sheng Huai Dihuang) [5 qian]
Scrophularia Root (Xuan Shen) [4 qian]
Glehnia Root (Shashen) [4 qian]
Raw Hang Peony Root (Sheng Hangshao) [3 qian]
Raw Polygala Root (Sheng Yuanzhi) [2 qian]
Atractylodes Macrocephala Rhizome (Baizhu) [2 qian]
Raw Chicken Gizzard Lining (Sheng Jineijin) [2 qian, yellow ones, crushed]
Licorice Root (Gancao) [1.5 qian]
Decoct together to make one bowl of decoction, taken warm.
**Outcome:** After taking three consecutive doses of the prescription, food intake increased, and all diseases were cured.
**Formula Analysis:** Lu Jiuzhi stated: "In cases of exogenous excess heat syndrome, it is most taboo to treat them solely with sweet-cold, cloying, and sticky herbs. Even if the illness is cured, residual heat often lingers; it becomes permanently sealed within the zang-fu organs, unable to dissipate. This leads to prolonged heat consuming yin, gradually developing into deficiency consumption, with many cases becoming incurable." These are indeed profound insights. In my experience with such cases, where the deficiency consumption is not too severe and the pulse still has strength, I consistently treat them with Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction), slightly modifying it to reduce both excess heat and deficiency heat, which generally yields immediate results.