李东垣曰。脾胃受劳役之疾。饮食又复失节。耽病日久。及事息心安。饱食太甚。病乃
大作。向者壬辰改元。京师戒严。迨三月下旬。受敌者凡半月。解围之后。都人之不受病者
万无一二。既病而死者。继踵而不绝。都门十有二所。每日各门所送。多者二千。少者不
下一千。似此者几三月。此百万人岂俱感风寒外伤者耶。大抵人在围城中。饮食失节。劳役
所伤。不待言而知。由其朝饥暮饱。起居不时。寒温失所。动经两三月。胃气亏乏久矣。一
旦饱食太过。感而伤人。而又调治失宜。或发表。或攻下。致变结胸发黄。又以陷胸茵陈等
汤下之。无不死者。盖初非伤寒。以误治而变似真伤寒之证。皆药之罪也。因以生平已试之
效。着内外伤辨论一篇。
震按此即大兵之后继以大疫之谓也。观此论而始晓然于劳役饥饱之病原。诚哉其为内伤
矣。如是之疫。宜补不宜泻。若达原饮白虎承气。正犯东垣所呵责也。考其时是金天兴元年
因蒙古兵退而改元耳。寻以疫后医师僧道园户鬻棺者擅浓利。命有司倍征之以助国用。民
生其时。岂不苦极。若今太平之世。民皆安乐饱暖。纵有劳役。及饮食失节者。不过经营辛
苦之辈。设不兼外感。亦不遽病。故大疫绝无。而恰合东垣内伤论者亦甚少。惟是饱暖思淫
欲。真阴却早内伤。则外感病中之虚症。反不少耳。
卫生宝鉴曰。总帅相公。年近七旬。南征过扬州。俘虏万余口。内选美色室女近笄者四
置于左右。予曰。新虏之人。其惊忧之气蓄于内。加以饮食失节。多致疾病。近之则邪气
传染。为害最大。况年高气弱。尤宜慎也。总帅不听。至腊月班师。大雪。新虏人冻馁。皆
病头疼咳嗽。自利腹痛。多致死亡。正月至汴。相公因赴贺宴。痛饮数次。遂病。脉沉细而
弦。三四动一止。现证与新虏人病无异。三日而卒。内经云。乘年之虚。遇月之空。失时之
和。因而感邪。其气至骨。可不畏哉。
震按喻嘉言疫病论。引仲景平脉篇中寸口脉阴阳俱紧者一节。阐发奥理。谓清邪中上。
从鼻而入于阳。浊邪中下。从口而入于阴。在阳则发热头痛项强颈挛。在阴则足膝逆冷。便
溺妄出。大凡伤寒之邪。由外廓而入。故递传六经。瘟疫之邪。由口鼻而入。故直达三焦。
三焦相溷。内外不通。致有口烂舌断。声 咽塞。痈脓下血。脐筑湫痛等变。治法。未病前
预饮芳香正气药。使邪不能入。若邪既入。则以逐秽为第一义。此与吴又可之论暗合。较之
罗二家所述劳役忧惊冻馁致病者迥别。惟云因病致死。病气尸气。混合不正之气。种种恶秽
交结互蒸。人在其中。无隙可避。斯无人不病。是诚诸疫所同。然向来辟疫方法。或以雄
黄塞鼻。或吃蒜头烧酒。或于发中簪霹雳木。然有验有不验。相传崇正十六年。自八月至十
月。京城大疫。猝然而死。医祷不及。后有外省人员到京。能识此病。看膝湾后有筋肿起。
紫色无救。红色速刺出血。可无患。人争就看。死者已二十余万。
汪石山治一少年。房劳后。忽洒洒恶寒。自汗发热。头背胃脘皆痛。唇赤舌强。呕吐。
眼胞青色。医投补中益气。午后谵语恶热。小便长。初日脉皆细弱而数。次日脉浮弦而数。
医以手按脐下痛。议欲下之。汪曰。此疫也。疫兼两感。内伤重。外感轻耳。脐下痛者。肾
水亏也。若用利药。是杀之也。兹宜合补降二法以治。用清暑益气汤。去苍术、泽泻、五味
加生地、黄芩、石膏。服十余帖而安。
震按房劳后患疫。喻氏所谓太阳少阴两感也。汪公则以内伤外感为两感。义殊不同。补
中益气清暑益气药颇相同。而一则变剧。一则取效者。妙在加减诸味也。
壶仙翁治张文学。病时疫。他医诊其脉。两手俱伏。曰。阳证见阴不治。欲用阳毒升
汤升提之。壶曰。此风热之极。火盛则伏。非阴脉也。升之则死矣。卒用连翘凉膈之剂。一
震按此条是温疫病以证为则。勿专以脉为凭之一据。
虞恒德治一妇。三月间。患瘟疫证三日。经水适来。发热愈甚。至七八日。病剧。胸中
气筑作痛。不能卧。众医技穷。入夜迎翁。病者令婢磨胸不已。六脉俱微数。极无伦次。又
若虾游状。翁问曰。恐下早成结胸耳。主人曰。未也。翁曰。三日而经水行。则里虚与下同
乃用四物汤、黄龙汤、小陷胸汤共为一剂。加姜、枣。主人曰。此药何名。翁曰。三合汤
也。一服而诸证悉减。震按此以大黄、黄连、生地、人参同用。亦近日治热病之常法。
吴又可曰。朱海畴者。年四十五岁。患疫。得下症。四肢不举。身卧如塑。目闭口张。舌上
胎刺。问其所苦不能答。因问其子。两三日所服何药。云进承气汤三剂。每剂投大黄两许不
效。更无他策。求决死期。余诊得脉尚有神。下症悉具。药浅病深也。先投大黄一两五钱。
目有时而少动。再投。舌刺无芒。口渐开。能言。三剂。舌胎少去。神思少爽。四日。服柴
服清燥汤。五日。复生芒刺。烦热又加。再下之。七日又投承气养荣汤。热少退。八日仍用
大承气。肢体自能少动。计半月。共服大黄十二两而愈。又数日。始进糜粥。调理两月半平复
凡治千人。所遇此等。不过三四人而已
震按此条结句云。千人中不过三四人。自言其不可以为法也。案中不载神昏谵语。可见昏谵
之至者多不能救。此人原非绝证也。惜不载脉象虚实若何。然云脉尚有神。想即陶氏所谓有
力为有神也。
辍耕录载元伯颜平宋后。搜取大黄数十车。满载而去。班师过淮。俘掠之民。及降卒与北来
大兵咸病疫。以大黄疗之。全活甚众。宋元通鉴载作耶律楚材灭夏之事。则大黄洵治疫之妙
品也。吴又可瘟疫论赞大黄为起死神丹。原非杜撰。然与东垣所论则迥别矣。要之两家各有
至理。惟明乎运气。熟于脉证者。两家之说俱可救人也。
孙东宿有仆孙安。远行途次食面三碗。劳倦感疫。又加面伤。表里皆热。昏闷谵语。头痛身
痛腹痛。医以遇仙丹下之。大便泻三四十行。邪因陷下而为挟热下利之候。舌沉香色。额疼
口干。燥渴烦闷。昏昏愦愦。脉左弦数。右洪数。但不充指。知为误下坏证。以柴胡。石膏
各三钱。白芍、黄芩、竹茹、葛根各一钱。花粉、甘草各五分。山栀、枳实各七分。葱白五
茎。煎服后。斗夜吐蛔一条。稍得睡。次早。大便犹泻二次。呕吐酸水。腹仍痛。改用小柴
胡加滑石、竹茹。夜热甚。与丝瓜汁一碗。饮既。神顿清爽。少顷。药力过时。烦热如前。
再以丝瓜汁一大碗进之。即大发战。东宿谓此非寒战。乃作汗下之征耳。不移时。汗果出而
热依然。因忆活人书云。再三汗下热不退。以人参白虎汤加苍术一钱如神。迹此再加元参、升
麻、柴胡、白芍、黄连。饮后。身上发斑。先发者紫。后发者红。中夜后。乃得睡而热散。
斑寻退去。腹中微疼。肠鸣口渴。右脉尚滑。左脉已和。再与竹叶石膏汤加白芍、苍术。服
后睡安。腹仍微痛。用柴胡、白芍各一钱。人参、酒芩、陈皮、半夏各六分。甘草三分。乌
梅一个。腹痛渐减而愈。惟两胯痛不能转动。此大病后汗多而筋失养之故。用参、 、白芍
枸杞、苡仁、木瓜、熟地、归身、川柏、牛膝、桑寄生。调养全安。
震按战汗后热不退。势亦危矣。引用活人书治法佳极。再看其石膏、人参之去取。并不执着
两胯疼痛之调养方更周到。的是高手。
程家内眷。其夫殁于疫疠。新寡七日。疫即及之。大热。头疼口渴。胸胁迸痛。医与小柴胡
汤。夜忽梦夫交。泄而觉。冷汗淫淫。四肢如解。略不能动。神昏谵语。面如土色。舌黑干硬。迓孙东宿
诊之。六脉沉弦而数。大小便俱秘。乃曰。此亦阴阳易类也。疫后有是。危已极矣。以生脉散加柴、芩、桂
枝、甘草。水煎。将根据夫昔
肢始能运动。徐进粥汤而愈。震按梦中之阴阳易大奇。故夫之烧 散更巧。
张路玉曰。瘟有虾蟆瘟、鸬 瘟、疙瘩瘟、瓜瓤瘟。形证各别。庞安
常又有玳瑁瘟之说。余
疼痛。不时奔响。屡欲圊而不可得。口鼻上唇忽起黑色成片。光亮如漆。与玳瑁无异。见者大
骇。余诊之。喘汗脉促。神气昏愦。虽脉证俱危。喜其四围有红晕鲜泽。若痘疮之根脚。紧
附如线。他处肉色不变。许以可治。先与葛根黄芩黄连汤。加犀角、连翘、荆、防、紫荆皮、
人中黄。解其肌表毒邪。俟其黑色发透。乃以凉膈散加人中黄、紫荆、犀角、微下二次。又
与犀角地黄汤加人中黄之类。调理半月而安。
震按戈存橘补天石有黄耳、赤膈二证。赤膈亦头疼身痛发热。但胸膈赤肿。或起 。用荆防败毒散去参
加犀角、芩、连、紫荆皮。表证退后便燥者。用凉膈散。张公之案。蓝本于此。但所叙诸瘟
近不概见。故屠苏饮久不同。而老君神明散、务成子萤火丸、太仓公辟瘟丹、李子建杀鬼
丸等。皆无人道及。惟五瘟丹、消毒丸、黑奴丸、人中黄丸、香苏散、清凉救苦散等方尚有
用者。以其药平稳而方简易也。
外纪载哥阿岛患疫。有名医卜加得。令城内外遍举大火烧一昼夜。火息而病愈。盖疫为
邪气所侵。火气猛烈。能焚烬诸邪。邪尽则病愈。有至理焉。
李东垣说：脾胃因劳役过度而受损，饮食又再次失去节制，患病日久。等到事务平息、心境安定时，饱食过度，病情便突然加重。此前壬辰年改元（金宣宗兴定五年，1221年），京城戒严。到了三月下旬，受敌围困长达半个月。解围之后，城中百姓没有染病的万中无一二。既然后病死的，接连不断。城门十二座，每天各门运送出的尸体，多的两千，少的不下一千。像这样的情况持续了将近三个月。这百万人难道都是感受风寒外邪吗？大抵人在围城之中，饮食失节，劳役所伤，是不言而喻的。由于他们早晨饥饿晚上饱食，起居不规律，寒温失调，经过两三个月，胃气早已亏乏。一旦饱食太过，感邪伤人，再加上治疗不当，有的用发汗法，有的用攻下法，导致变成结胸、发黄等证。又用陷胸汤、茵陈蒿汤等方剂攻下，没有不死亡的。起初并非伤寒，是因为误治而变得像真伤寒的证候，这都是用药的错误。因此，他根据平生已验证有效的经验，撰写了《内外伤辨惑论》一篇。
俞震按语：这就是大军之后继以大瘟疫的情况。看了这篇论述，才明白劳役和饥饱导致的病因，确实属于内伤。这样的疫病，应当补益而不宜泻下。如果用达原饮、白虎汤、承气汤，正是犯了李东垣所谴责的错误。考证当时的时间是金天兴元年，因为蒙古军队撤退而改元。不久，疫后医师、僧道、棺材铺贩卖棺材牟取暴利，朝廷命令有关部门加倍征税以资助国家开支。百姓的生活在那个时候，岂不痛苦至极？像现在太平盛世，百姓安乐饱暖，即使有劳役及饮食失节的人，也不过是经营辛苦之辈，如果不兼感外邪，也不会立刻生病。所以大瘟疫绝无，恰好符合李东垣内伤论的情况也很少。只是饱暖思淫欲，真阴却早已内伤，那么外感病中的虚证，反而不少。
《卫生宝鉴》记载：总帅相公，年纪近七十岁，南征经过扬州，俘虏万余口，其中挑选美貌且接近成年的女子四人放在身边。我说：“新俘虏的人，惊恐忧虑之气郁结在体内，加上饮食失节，多会致病。亲近他们则邪气传染，危害最大。况且年高气弱，更应谨慎。”总帅不听。到了腊月班师回朝，大雪纷飞，新俘虏的人冻饿交加，都患上头痛咳嗽、自利腹痛的病，多导致死亡。正月到达汴京，相公去参加贺宴，痛饮数次，于是发病。脉象沉细而弦，三四次跳动才歇止一次。现症与新俘虏人的病无异，三天后去世。《内经》说：“逢上年运不及之虚，遇月空之时，违逆四时之和，因而感受邪气，其气深入至骨，能不畏惧吗？”
俞震按语：喻嘉言在《疫病论》中，引用张仲景《平脉篇》中“寸口脉阴阳俱紧者”这一节，阐发深奥的道理，认为清邪从上而入，从鼻进入阳分；浊邪从下而入，从口进入阴分。在阳分则发热、头痛、项强、颈挛；在阴分则足膝逆冷、大小便失禁。大凡伤寒之邪，由体表廓入，所以依次传变六经；瘟疫之邪，由口鼻而入，所以直达三焦。三焦混杂，内外不通，导致口腔溃烂、舌断、咽喉阻塞、痈脓下血、脐腹绞痛等变证。治疗方法，未病之前预先服用芳香正气药，使邪气不能侵入；如果邪气已经侵入，则以祛除秽浊为第一要义。这与吴又可的论述暗合。与罗氏两家所述因劳役、忧惊、冻馁致病的情况截然不同。只说因病致死，病气和尸气混合不正之气，种种恶秽交结互蒸，人在其中，无处可避，这是无人不病的原因，确实是各种瘟疫共同的特点。然而向来辟疫的方法，有用雄黄塞鼻的，有吃蒜头烧酒的，有的在头发中插霹雳木，但有的有效有的无效。相传崇祯十六年，从八月到十月，京城大疫，猝死之人众多，医生祈祷来不及救治。后来外省人员来到京城，能识别此病，看膝盖弯后有筋肿起，紫色无救，红色速刺出血，可无祸患。人们争相去看，死者已有二十余万。
汪石山治疗一个少年，房事后，忽然洒洒恶寒，自汗发热，头、背、胃脘皆痛，唇赤舌强，呕吐，眼胞青色。医生投予补中益气汤，午后出现谵语、恶热，小便长。初日脉象皆细弱而数，次日脉浮弦而数。医生用手按压脐下痛，打算用攻下法。汪石山说：“这是疫病，疫病兼有两感，内伤重，外感轻罢了。脐下痛，是肾水亏虚。如果用利药，是杀他啊。现在应该结合补法和降法来治疗。用清暑益气汤，去掉苍术、泽泻、五味子，加入生地、黄芩、石膏。服用十余帖而痊愈。”
俞震按语：房劳后患疫病，是喻氏所说的太阳少阴两感。汪公则以内伤外感为两感，义理不同。补中益气汤和清暑益气汤药物颇相同，而一变剧，一取效，妙在加减诸味上。
壶仙翁治疗张文学，患时疫。其他医生诊其脉，两手脉都伏匿，说：“阳证见阴脉，不治。”想用阳毒升汤升提。壶仙翁说：“这是风热之极，火盛则脉伏，不是阴脉。升提则会死。”最终用连翘凉膈散一类药剂，一服即愈。（注：原文此处似有缺漏或排版错误，“一震按”应为下一条的开头，但根据上下文逻辑，壶仙翁案结束于“卒用连翘凉膈之剂”，后续“一震按”是对该案的评论，但原文将评论混入或排版错乱，此处依文意整理）。
虞恒德治疗一位妇人，三月间，患瘟疫证三天，月经适来，发热更甚。到七八日，病势加剧，胸中气筑作痛，不能卧。众医技穷，夜间迎请虞翁。病人让婢女不停按摩胸部。六脉俱微数，极无伦次，又像虾游状。虞翁问：“恐怕是下早而成结胸吧？”主人说：“还没有。”虞翁说：“三天而月经行，则里虚与下同。”于是用四物汤、黄龙汤、小陷胸汤共为一剂，加姜、枣。主人问：“这药叫什么名？”虞翁说：“三合汤也。”一服而诸证悉减。俞震按语：此案以大黄、黄连、生地、人参同用，也是近日治疗热病的常法。
吴又可说：朱海畴，四十五岁，患疫病，出现下症，四肢不能举，身卧如塑像，目闭口张，舌上有胎刺，问其所苦不能答。于是问他的儿子，两三天吃了什么药。回答说进服承气汤三剂，每剂投大黄一两许，不效，更无他策，请求决定死期。我诊得脉尚有神，下症悉具，是药浅病深。先投大黄一两五钱，眼睛有时稍微转动。再投，舌刺无芒，口渐开，能言。三剂，舌苔稍去，神思稍爽。第四天，服柴胡清燥汤。第五天，复生芒刺，烦热又加，再下之。第七天又投承气养荣汤，热稍退。第八天仍用大承气汤，肢体自能稍动。共计半月，共服大黄十二两而愈。又数日，才开始进糜粥，调理两半月平复。凡是治疗千人，遇到这种情况的，不过三四人而已。
俞震按语：此条结语说“千人中不过三四人”，是说自己的方法不可以作为常规法则。案中不载神昏谵语，可见昏谵严重的多不能救。此人原本不是绝证。可惜不载脉象虚实如何，然说“脉尚有神”，想就是陶氏所谓有力为有神。
《辍耕录》记载元朝伯颜平宋后，搜取大黄数十车，满载而去。班师过淮河，俘掠的百姓，以及降卒与北来的大军都患疫病，用大黄治疗，保全活命的人很多。《宋元通鉴》记载作耶律楚材灭夏之事，则大黄确实是治疗疫病的妙品。吴又可《瘟疫论》称赞大黄为起死神丹，原非杜撰。然而与李东垣的论述则截然不同。总之两家各有至理，只有明白运气学说，熟悉脉证的，两家的说法都可以救人。
孙东宿有一个仆人叫孙安，远行途中吃了三碗面，劳倦感疫，又加上面食积滞，表里皆热，昏闷谵语，头痛身痛腹痛。医生用遇仙丹攻下，大便泻三四十行，邪气因陷下而为挟热下利的证候。舌色沉香色，额疼口干，燥渴烦闷，昏昏愦愦。脉左弦数，右洪数，但不充指。知道是误下坏证。用柴胡、石膏各三钱，白芍、黄芩、竹茹、葛根各一钱，花粉、甘草各五分，山栀、枳实各七分，葱白五茎，煎服后，半夜吐出一条蛔虫，稍得睡。次早，大便犹泻二次，呕吐酸水，腹仍痛。改用小柴胡汤加滑石、竹茹。夜热甚，给丝瓜汁一碗，饮后，神顿清爽。少顷，药力过时，烦热如前。再以一大碗丝瓜汁进之，即大发战。孙东宿说这不是寒战，乃是作汗下的征兆。不移时，汗果出而热依然。于是回忆《活人书》说：“再三汗下热不退，用人参白虎汤加苍术一钱如神。”据此再加元参、升麻、柴胡、白芍、黄连，饮后，身上发斑，先发者紫，后发者红。中夜后，乃得睡而热散。斑随即退去。腹中微疼，肠鸣口渴，右脉尚滑，左脉已和。再与竹叶石膏汤加白芍、苍术。服后睡安，腹仍微痛。用柴胡、白芍各一钱，人参、酒芩、陈皮、半夏各六分，甘草三分，乌梅一个，腹痛渐减而愈。惟两胯痛不能转动，这是大病后汗多而筋失养的缘故。用人参、[缺字，疑为黄芪或类似补气药]、白芍、枸杞、苡仁、木瓜、熟地、归身、川柏、牛膝、桑寄生，调养全安。
俞震按语：战汗后热不退，形势也危矣。引用《活人书》治法极佳。再看其石膏、人参的去取，并不执着。两胯疼痛的调养方更周到，确实是高手。
程家内眷，其夫死于疫疠，新寡七日，疫病即感染了她。大热，头疼口渴，胸胁迸痛。医生与小柴胡汤，夜里忽然梦见丈夫性交，泄精而醒，冷汗淋漓，四肢如解，略不能动，神昏谵语，面如土色，舌黑干硬。迎接孙东宿诊之，六脉沉弦而数，大小便俱秘。乃曰：“这也是阴阳易类证。”疫病后有此证，危已极矣。用生脉散加柴胡、黄芩、桂枝、甘草，水煎。服后将尽，四肢始能运动，徐进粥汤而愈。俞震按语：梦中之阴阳易大奇，故用亡夫之烧裈散更巧。
张路玉说：瘟有虾蟆瘟、鸬鹚瘟、疙瘩瘟、瓜瓤瘟，形证各别。庞安常又有玳瑁瘟之说。余[某人名，原文似缺]疼痛，不时奔响，屡欲圊而不可得。口鼻上唇忽起黑色成片，光亮如漆，与玳瑁无异。见者大惊。余诊之，喘汗脉促，神气昏愦。虽脉证俱危，喜其四围有红晕鲜泽，若痘疮之根脚，紧附如线，他处肉色不变。许以可治。先与葛根黄芩黄连汤，加犀角、连翘、荆芥、防风、紫荆皮、人中黄，解其肌表毒邪。俟其黑色发透，乃以凉膈散加人中黄、紫荆、犀角，微下二次。又与犀角地黄汤加人中黄之类，调理半月而安。
俞震按语：戈存橘《补天石》有黄耳、赤膈二证。赤膈亦头疼身痛发热，但胸膈赤肿，或起[缺字]。用荆防败毒散去参加犀角、芩、连、紫荆皮。表证退后便燥者，用凉膈散。张公之案，蓝本于此。但所叙诸瘟近不概见，故屠苏饮久不同，而老君神明散、务成子萤火丸、太仓公辟瘟丹、李子建杀鬼丸等，皆无人道及。惟五瘟丹、消毒丸、黑奴丸、人中黄丸、香苏散、清凉救苦散等方尚有用者。以其药平稳而方简易也。
《外纪》记载哥阿岛患疫，有名医卜加得，令城内外遍举大火烧一昼夜，火息而病愈。盖疫为邪气所侵，火气猛烈，能焚烬诸邪，邪尽则病愈。有至理焉。
Li Dongyuan said: The spleen and stomach are damaged by overwork, and diet is again irregular. After being ill for a long time, when affairs cease and the mind is at peace, excessive fullness causes the disease to flare up severely. Previously, in the Renchen year (the first year of Xingding era of Jin Dynasty, 1221), the capital was under martial law. By late March, those under siege had endured for half a month. After the siege was lifted, among the city dwellers, not one or two out of ten thousand remained uninfected. Those who fell ill and died followed each other without ceasing. There were twelve gates in the city walls; each day, the number of corpses transported through each gate ranged from more than two thousand to no less than one thousand. Such conditions lasted for nearly three months. Could it be that all these million people contracted wind-cold external pathogens? Generally speaking, people within the besieged city suffered from irregular diet and damage due to overwork, which goes without saying. Due to their pattern of morning hunger and evening fullness, irregular daily routines, and improper adaptation to cold and heat, after two or three months, the Stomach Qi had been deficient for a long time. Once they ate too much, they became susceptible to pathogenic factors, and due to improper treatment—some using sweating methods, others using purgative methods—the condition transformed into Jie Xiong (Chest Binding) and Jaundice. Furthermore, using formulas like Xian Xiong Tang (Trap Chest Decoction) and Yin Chen Hao Tang (Artemisia Capillaris Decoction) to purge them resulted in death in every case. Initially, it was not Shang Han (Cold Damage); rather, mistreatment made it resemble true Shang Han syndromes. This was entirely the fault of the medication. Therefore, based on his lifelong experience of effective treatments, he wrote an essay titled "Differentiation between Internal Injury and External Contraction."
Yu Zhen commented: This refers to the situation where a great plague follows a major war. Reading this treatise clarifies the etiology of diseases caused by overwork and irregular eating; indeed, these are internal injuries. For such plagues, tonification is indicated rather than purgation. Using Da Yuan Yin (Origin-Reaching Powder), Bai Hu Tang (White Tiger Decoction), or Cheng Qi Tang (Descending Qi Decoction) would precisely violate Li Dongyuan's criticism. Historical records indicate this occurred in the first year of Tianxing era of Jin, following the retreat of Mongol troops. Soon after, physicians, monks, Taoists, and coffin sellers profited excessively from selling coffins post-plague. The court ordered authorities to double taxes to aid state finances. The people's suffering at that time must have been extreme. In contrast, in today's peaceful times, people live in comfort and warmth. Even if there is overwork or dietary irregularity, it usually affects only those engaged in arduous business. If not complicated by external contraction, illness does not occur abruptly. Thus, great plagues are non-existent, and cases fitting Li Dongyuan's theory of internal injury are also rare. However, with satiety comes lust, leading to early internal injury of True Yin. Consequently, deficiency syndromes within external contraction diseases are actually quite common.
*Weisheng Baojian* (Precious Mirror of Health) records: The Commander-in-Chief, near seventy years old, passed through Yangzhou during a southern campaign. He captured over ten thousand people and selected four beautiful maidens approaching adulthood to keep by his side. I said, "The newly captured individuals harbor qi of shock and anxiety internally. Coupled with irregular diet, they are prone to disease. Close contact leads to transmission of pathogenic qi, causing maximum harm. Moreover, given his advanced age and weak constitution, he should exercise extra caution." The Commander did not listen. In the twelfth lunar month, upon returning from campaign, heavy snow fell. The new captives, suffering from cold and hunger, all developed headaches, coughs, spontaneous diarrhea, and abdominal pain, leading to many deaths. In the first lunar month, upon reaching Bianjing, the Commander attended celebratory banquets and drank heavily several times, subsequently falling ill. His pulse was deep, fine, and wiry, with a pause every three or four beats. His presenting symptoms were identical to those of the captives. He died three days later. *Neijing* states: "When encountering the deficiency of the annual luck, the emptiness of the moon phase, and the disharmony of the seasons, and thereby contracting pathogens, the qi penetrates to the bone. Can one not fear this?"
Yu Zhen commented: Yu Jiayan, in his *Yi Bing Lun* (Treatise on Plagues), cites Zhang Zhongjing's *Ping Mai Pian* regarding the section "when both yin and yang pulses at the Cun position are tight," elucidating profound principles. He posits that clear pathogens enter from above via the nose into the Yang aspect, while turbid pathogens enter from below via the mouth into the Yin aspect. Involvement of Yang manifests as fever, headache, neck stiffness, and cervical spasms; involvement of Yin manifests as cold feet and knees, and involuntary urination and defecation. Generally, Shang Han pathogens enter from the exterior surface and transmit sequentially through the Six Channels. Plague pathogens enter via the mouth and nose and directly reach the San Jiao (Triple Burner). When the San Jiao becomes mixed, internal and external communication is blocked, leading to oral ulcers, tongue severance, throat obstruction, abscesses with pus, lower bleeding, and severe umbilical pain. The treatment method involves pre-emptively administering aromatic qi-regulating herbs before illness to prevent pathogen entry. If pathogens have already entered, removing turbidity is the primary principle. This aligns implicitly with Wu Youke's theories. It differs significantly from the Luo family's descriptions of diseases caused by overwork, worry, shock, cold, and hunger. The assertion that death results from the mixing of disease qi and corpse qi with incorrect qi, creating various foul accumulations that leave no escape, is a common feature of all plagues. However, traditional anti-plague methods, such as using realgar in the nose, consuming garlic and liquor, or wearing thunderbolt wood in the hair, show variable efficacy. It is recorded that during the Chongzhen 16th year (1643), from August to October, a great plague struck the capital, causing sudden deaths beyond medical intervention. Later, officials from other provinces arrived who could identify the disease: swelling of tendons behind the knee indicated prognosis; purple color meant incurable, red color required immediate bloodletting to avoid disaster. People flocked to get checked; over 200,000 had already died.
Wang Shishan treated a young man who, after sexual activity, suddenly experienced aversion to cold, spontaneous sweating, and fever. Pain affected the head, back, and epigastrium. His lips were red, tongue stiff, and he vomited. The eyelids were bluish. A physician administered Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction). In the afternoon, he developed delirium and aversion to heat, with long urine stream. On the first day, the pulse was fine, weak, and rapid. On the second day, it was floating, wiry, and rapid. Upon palpating the hypogastrium, pain was elicited, suggesting the use of purgatives. Wang Shishan stated, "This is a plague. Plague can involve both aspects simultaneously; here, internal injury is severe, and external contraction is mild. Hypogastric pain indicates Kidney Water deficiency. Using draining medicines would be fatal. We should combine tonification and descending methods. Use Qing Shu Yi Qi Tang (Clear Summerheat and Augment Qi Decoction), remove Cang Zhu, Ze Xie, and Wu Wei Zi, add Sheng Di Huang, Huang Qin, and Shi Gao. After taking more than ten doses, he recovered."
Yu Zhen commented: Contracting plague after sexual activity corresponds to Yu's concept of Taiyang-Shaoyin simultaneous contraction. Wang Gong defines simultaneous contraction as internal and external injury, differing in meaning. Although Bu Zhong Yi Qi Tang and Qing Shu Yi Qi Tang share similar ingredients, one led to deterioration while the other succeeded; the妙 (subtlety) lies in the modifications.
Hu Xianweng treated Scholar Zhang, who suffered from seasonal plague. Other physicians found both hands' pulses hidden (Fu). They stated, "Yang syndrome presenting with Yin pulse is untreatable," and intended to use Yang Du Sheng Tang (Yang Toxin Ascending Decoction) to lift the pulse. Hu Xianweng said, "This is extreme wind-heat; fire excess causes the pulse to hide; it is not a Yin pulse. Lifting it will cause death." Ultimately, he used Lian Qiao Liang Ge San (Forsythia Cooling the Chest Decoction), resulting in recovery after one dose.
Yu Zhen commented: This case demonstrates that for warm plague, clinical signs should take precedence over pulse alone.
Yu Hengde treated a woman who, in March, had suffered from plague symptoms for three days when her menstruation began, causing fever to intensify. By the seventh or eighth day, the condition worsened. She experienced throbbing chest pain preventing sleep. Physicians exhausted their skills. At night, Yu was summoned. The patient instructed her maid to continuously massage her chest. All six pulses were faint, rapid, chaotic, resembling shrimp swimming. Yu asked, "Is this because premature purgation led to Jie Xiong?" The host replied, "No." Yu said, "Menstruation starting on the third day indicates interior deficiency and downward flow." He combined Si Wu Tang (Four Substances Decoction), Huang Long Tang (Yellow Dragon Decoction), and Xiao Xian Xiong Tang (Minor Trap Chest Decoction) into one dose, adding Ginger and Jujube. The host asked the name of the medicine. Yu replied, "San He Tang (Three Combined Decoction)." After one dose, all symptoms subsided.
Yu Zhen commented: Using Da Huang, Huang Lian, Sheng Di Huang, and Ren Shen together is a common modern method for treating heat diseases.
Wu Youke stated: Zhu Haichou, aged forty-five, contracted plague and presented with Fu Syndrome (Excess Syndrome requiring purgation). His limbs could not move; he lay still as a statue, eyes closed, mouth open, with prickles on the tongue coating. Unable to answer complaints, his son reported that three doses of Cheng Qi Tang had been given, each containing approximately one liang of Da Huang, without effect. With no other options, they sought a prognosis of death. I diagnosed that although the pulse retained spirit (Shen), the pathology was deep while the medication was shallow. I initially administered one liang and five qian of Da Huang. His eyes moved slightly. Upon re-administration, the tongue prickles lost their sharpness, his mouth opened gradually, and he could speak. After three doses, the tongue coating decreased, and mental clarity improved. On the fourth day, he took Chai Hu Qing Zao Tang (Bupleurum Clearing Dryness Decoction). On the fifth day, prickles reappeared, and irritability/heat increased; another purge was performed. On the seventh day, Cheng Qi Yang Rong Tang (Descending Qi Nourishing Blood Decoction) was given, reducing heat slightly. On the eighth day, Da Cheng Qi Tang (Major Descending Qi Decoction) was used, allowing slight limb movement. Over half a month, he consumed a total of twelve liang of Da Huang and recovered. Several days later, he resumed consuming congee. After two and a half months of regulation, he fully recovered. Among a thousand patients treated, such cases accounted for only three or four.
Yu Zhen commented: The conclusion "three or four out of a thousand" implies this method should not be applied routinely. The absence of coma and delirium in the record suggests that severe cases often cannot be saved. This patient was not in a terminal state. Regrettably, the pulse's excess or deficiency was not recorded, but "pulse retaining spirit" likely refers to Tao's definition of strength indicating spirit.
*Zhe Geng Lu* records that after Yuan General Bayan conquered Song, he seized dozens of carts of Da Huang (Rhubarb) and took them away. Returning past the Huai River, captured civilians, surrendered soldiers, and northern troops all contracted plague. Treating them with Da Huang saved many lives. *Song-Yuan Tongjian* attributes this to Yelü Chucai destroying Xia, confirming Da Huang as an excellent remedy for plague. Wu Youke praised Da Huang as a miraculous drug reviving the dying, which was not fabricated. However, this contrasts sharply with Li Dongyuan's views. Both schools possess valid logic; understanding Luck Theory and mastering pulse-symptom differentiation allows practitioners to utilize either approach effectively.
Sun Dongsu's servant, Sun An, ate three bowls of noodles while traveling, suffering from fatigue, plague contraction, and noodle stagnation. Exterior and interior were both hot, causing confusion, delirium, headache, body ache, and abdominal pain. A physician used Yu Xian Dan (Encounter Immortal Pill) to purge him, resulting in thirty to forty bowel movements. The pathogen sank inward, causing heat-binding diarrhea. The tongue was dark brown; forehead hurt, mouth dry, thirst, irritability, and drowsiness prevailed. Left pulse was wiry and rapid; right pulse was large and rapid but lacked fullness. Recognizing this as a mishandled condition due to erroneous purgation, Sun prescribed Chai Hu and Shi Gao (3 qian each), Bai Shao, Huang Qin, Zhu Ru, Ge Gen (1 qian each), Hua Fen, Gan Cao (5 fen each), Shan Zhi, Zhi Shi (7 fen each), and Cong Bai (5 stalks). After decoction and ingestion, he vomited one roundworm around midnight and slept briefly. Next morning, he had two more bowel movements, vomited sour water, and abdominal pain persisted. The formula was changed to Xiao Chai Hu Tang (Minor Bupleurum Decoction) plus Hua Shi and Zhu Ru. Night fever intensified; he was given one bowl of Loofah juice. Spirit cleared instantly. Shortly after, as the medicinal effect waned, irritability returned. Another large bowl of Loofah juice induced severe shaking chills. Sun Dongsu noted this was not cold chills but a sign of impending sweating. Sweat emerged shortly after, yet heat remained. Recalling *Huo Ren Shu*: "If heat persists despite repeated sweating and purging, use Ren Shen Bai Hu Tang plus Cang Zhu." Accordingly, Yuan Shen, Sheng Ma, Chai Hu, Bai Shao, and Huang Lian were added. After ingestion, macules appeared on the body: purple first, then red. He slept after midnight, and heat dissipated. Macules faded. Mild abdominal pain, borborygmus, and thirst remained; right pulse was slippery, left pulse harmonized. Ye Zhu Gao Shi Tang (Bamboo Leaf and Gypsum Decoction) plus Bai Shao and Cang Zhu was administered. Sleep improved, but mild abdominal pain persisted. Chai Hu and Bai Shao (1 qian each), Ren Shen, Jiu Qin, Chen Pi, Ban Xia (6 fen each), Gan Cao (3 fen), and one W Mei (Dark Plum) reduced abdominal pain until cure. Only bilateral hip pain preventing movement remained, attributed to tendon malnourishment due to excessive sweating post-major illness. Treatment involved Ren Shen, [missing character, likely Huang Qi], Bai Shao, Gou Qi, Yi Yi Ren, Mu Gua, Shu Di, Dang Gui, Chuan Bai, Niu Xi, and Sang Ji Sheng for recuperation, leading to full recovery.
Yu Zhen commented: Heat persisting after battle sweat is critical. Citing *Huo Ren Shu* is excellent. The judicious use of Shi Gao and Ren Shen, along with the thorough management of hip pain, demonstrates high expertise.
A female relative of the Cheng family, whose husband died of plague, contracted the disease seven days after becoming a widow. Symptoms included high fever, headache, thirst, and bursting chest/hypochondriac pain. A physician prescribed Xiao Chai Hu Tang. That night, she dreamt of intercourse with her deceased husband, ejaculated in the dream, woke up with profuse cold sweats, flaccid limbs unable to move, coma, delirium, sallow complexion, and black, dry, hard tongue. Sun Dongsu diagnosed the pulse as deep, wiry, and rapid in all six positions, with constipation. He stated, "This resembles Yin-Yang Exchange syndrome." Post-plague occurrence of this syndrome is extremely critical. He used Sheng Mai San (Generate Pulse Powder) plus Chai Hu, Huang Qin, Gui Zhi, and Gan Cao. After consumption, limb movement returned gradually, and slow introduction of congee led to recovery.
Yu Zhen commented: Dream-induced Yin-Yang Exchange is rare; using the deceased husband's burnt underwear powder (Shao Kun San) would be even more ingenious.
Zhang Luyu stated: Plagues include Toad Plague, Cormorant Plague, Lump Plague, and Melon Pulp Plague, each with distinct manifestations. Pang Anchang mentioned Tortoise Shell Plague. [Name missing] experienced pain, rumbling intestines, and frequent urge to defecate without success. Black patches appeared on the nose and upper lip, shiny like lacquer, resembling tortoise shell. Observers were terrified. Diagnosis revealed panting, sweating, rapid pulse, and confused spirit. Despite critical signs, the presence of a fresh red halo around the lesions, resembling pockmark roots tightly attached like a thread, while surrounding skin remained normal, indicated treatability. Initially, Ge Gen Huang Qin Huang Lian Tang (Kudzu, Scutellaria, and Coptis Decoction) was given with Xi Jiao, Lian Qiao, Jing Jie, Fang Feng, Zi Jing Pi, and Ren Zhong Huang to resolve exterior toxin. Once the blackness surfaced, Liang Ge San plus Ren Zhong Huang, Zi Jing, and Xi Jiao was used for mild purgation twice. Then, Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) plus Ren Zhong Huang was used for regulation, leading to recovery after half a month.
Yu Zhen commented: Ge Cunju's *Bu Tian Shi* describes Yellow Ear and Red Diaphragm syndromes. Red Diaphragm involves headache, body ache, fever, but specifically red/swollen diaphragm or eruptions. Jing Fang Bai Du San minus Ren Shen plus Xi Jiao, Qin, Lian, Zi Jing Pi is used. After exterior resolution, if stool is dry, Liang Ge San is applied. Zhang's case is based on this. However, the described plagues are rarely seen now. Thus, Tu Su Yin is obsolete, and formulas like Lao Jun Shen Ming San, Wu Cheng Zi Ying Huo Wan, Tai Cui Gong Bi Wen Dan, and Li Zijian Sha Gui Wan are unheard of. Only Wu Wen Dan, Xiao Du Wan, Hei Nu Wan, Ren Zhong Huang Wan, Xiang Su San, and Qing Liang Jiu Ku San remain in use due to their safety and simplicity.
*Wai Ji* records that on Goao Island, a plague occurred. Physician Bu Jiade ordered massive fires to be lit throughout the city for a day and night. After the fires extinguished, the disease ceased. Since plague is caused by pathogenic invasion, the fierce fire energy burns away pathogens; once pathogens are gone, the disease resolves. This contains profound truth.