试就胸腔积液而论，临床上以渗出性胸膜炎较为常见(当然，可能还有其它疾病)。以渗出性胸膜炎来说，其病变开始阶段，往往先出现恶寒发热，或胸胁疼痛、咳嗽等表证作为前驱。《伤寒论》对有表证者，一般先解袁，表解乃可攻里。所以，我认为文中「病发子阳」的「阳」字，可能是指结胸证的开始阶段有恶寒发热等表证而言。因此，认为不宜过早攻下，并认为过早攻下，损伤正气，于病不利。但是，渗出性胸膜炎由于炎症的进展，恶寒、脉浮之类的表证，可以自罢。相反，胸膜积液增多，则肺部压迫症状，如胸闷、胸痛、气急或咳嗽等，势必加重，而且热型，也往往转变为驰张热。由于古代无x线的检查，又无穿刺抽液的方法，而能认识「此为水结在胸胁者也」，能采用具有泻下作用的大陷胸汤(或丸)，诱导积液排泄，藉以减轻胸部之压迫，法虽古老，以当时历史条件来说，殊属可贵。由此可见，《伤寒论》结胸证先认为不宜下之过早，嗣后，仍以攻下而取效，此实非因攻下过早而造成结胸，也不是结胸证不宜攻下，而是因为病变的发生和发展阶段有表里证之不同，故冶法有先表后攻之分寸，这亦是显示辨证论治之特点。诸如此类，弓l用西说解释，借助他山，义理易明，较之以经解经，迈出了一步。
临床经验贵在实践
《千金要方》说：「读方三年，使谓天下无病不治；治病三年，乃知天下无可用之方。」的确，我也有这样的感受。回顾我在开业当年的盛夏，诊治一例女性患者，二十余岁，病头痛高热已五日，体温高达40．5。c，神识朦胧，自汗，烦躁，口渴引饮，舌苔薄黄，边尖质红，脉象滑大而数(未作其它理化检验)，根据【临床表现，诊断为暑热熏蒸，热蒙清窍，投以白虎汤加减，方用生石膏15克，鲜生地24克，知母6克，菖蒲3克，银花12克，黑山栀、竹叶各g克，芦根15克，甘草1．8克。服上方二剂。翌日下午复诊，体温虽降至36．2。c，而神识昏迷加深，呼吸不匀，汗出肢厥，舌苔干枯，质淡红，脉象微细，呈心气衰竭之象，急改投生脉散加附片以救逆，终归无效。自我分析：其一，究属何病?诊断不明。其二，只知白虎汤证悉俱，而对其初诊脉象未详辨虚实。其三，更未顾及暑热伤气，和壮火食气之患。只知寒凉清热，未佐益气之品以扶正。由此种种，促其恶化，这与我审证不详，用药过偏有关，咎无可辞，良深自疚。
再如曾治同学刘君之妻，病往来寒热，日发二、三次，发时头痛甚剧，呈嗜睡状，频频呕吐，水饮不入，舌苔黄浊，脉象弦数，证属暑温，投以蒿芩清胆汤加减，方用青蒿、黄芩、竹茹各9克，姜半夏6克，连翘12克，六一散9克，玉枢丹1．8克，扁豆花9克等，连诊三日，病情有增无减。乃向患者家属提出，邀请西医会诊，以明诊断。经西医检验血液，找到恶性疟原虫，诊断为脑型恶性疟疾，即施以抗疟针药。同时，还邀陆君斡夫、吴君国栋与我会诊。磋商结果，因患者寒热往来不解，头痛项强，鼻齿衄血，呕吐仍频，舌质转绛，脉象细数，已呈疟邪入营动血、肝风扇动之象，乃改投清营熄风之剂，方用羚羊角1．8克，鲜生地30克，丹皮g克，青蒿12克，连翘15克，菖蒲3克，黄芩0克，玉枢丹3克。但眼药时入口即吐，不起作用。迅即陷入昏迷，终于在发病之第六日，医治无效而死亡。
以上二例，皆系初次接触的重症，病情迅猛，不仅诊断感有困难，在治疗方面，我初出茅庐，缺乏经验，无可讳言。经此教训之后(当然，不只是这一、二次)，每遇重症，必查考有关文献，或请教于同道，用以增进知识，弥补不足。对于死亡病例，必加以分析研究，并记之，以旌我过。
自从一九三二年起，开业之余，尚参加某医务所工作。所中设有病床四十余张，并有小化验室及配药部。收治病种，在急性病方面有伤寒，斑疹伤寒、疟疾、痢疾、肺炎等；慢性病方面有肺结核、溃疡病、肾炎、肝硬变、维生素c缺乏症等。主其事者，虽为西医，除抢救病例用西医外，大部均以中医治疗为主，历时六载，得以对多种疾病进行系统观察。
在长期的临床实践中，我认识到中医处理疾病，通过四诊方法，识证辨性，是关键所在。关于识证辨性、随证论治的方式方法，试举一九四一年在沪行医时所治的两个病例加以说明；
其一，戴氏妇，年约五十，浴中突觉左下腹剧痛，牵及腰部，即呼家人扶之卧床，遂延二、三位西医诊治，有的诊为尿路结石，有的诊为腹膜炎，也有的诊为肠梗阻，施以针药，经三昼夜，未能缓解，乃邀我诊治。证见胸腹痞满，左下腹疼痛，不喜按，其痛牵及腰部不得辗转，不欲食，体温37．8。C，大便已四日未行，舌苔中黄厚，两边薄，质微红，脉象紧数。询问发病经过，曾因家务，情绪激动，旋又进食年糕，未入浴前，已感胸腹不舒。审其病因，显因气机失调，兼挟宿食，腑气不通，不通则痛，理所当然。征属阳明少阳同病，投以大柴胡汤加减，方用柴胡、枳壳各6克，生白芍12克，制大黄g克，厚朴2．4克，制香附6克，延胡索、川楝子各9克，生谷芽12克，炙甘草3克。进药一剂，当晚大便二次，病势。顿减。次日复诊，改用四逆散合越鞠丸加减，调理四日，病即霍然。
另一例，徐某，男性，三十五岁，系外地来沪，当晚入浴，突觉脘腹疼痛，起而登厕。便后，腹痛虽减，而全身无劲，大汗淋漓，由友人来邀急诊。证见患者面容苍白，精神倦怠，懒言短气，额上汗出如珠，四肢厥冷，脉象微细，舌苔自腻，体温36．4。c。自诉头晕心悸，腹阵痛。询其病史，素有胃病。证因舟车劳顿，寒温失调，以致亡阳欲脱。急拟参附汤加昧，方用别直参9克，淡附片6克，龙骨12克，生牡蛎24克，茯苓g克，陈皮6克，炙甘草4．5克棚乏药一剂后，汗敛肢温，继以异功散加归、芪等药，调理旬余，恢复健康。以上二例，虽同因入浴而发腹痛，但前者系属气机阻滞，兼有宿食之实证；后者虽亦腹痛，系因劳顿过度，寒气入中，属亡阳欲脱之虚证，显有不同。故前者治法，主以柴胡、白芍之疏肝，大黄、厚朴之通腑，香附、枳壳之调气，延胡、川楝之止痛，后者主以参、附之回阳，龙、牡之固脱。一虚一实，证似同而性异，故治法亦各悬殊。足见，辨证论治，确有它的优越性。但是，对它优越性的认识，必须通过实践，才能体验。
现在，就辨病与辨证相结合的问题，谈一些看法。
辨病和辨证相结台，实际就是双重诊断。对中医临床研究，制订诊断指标及疗效标准，用以观察中医中药对某种疾病的疗效确有帮助。但是，目前在中西医结合的临床中，有的不是按照中医辨证论治的特点，而是执一方或一药以试病，我实未敢赞同。此外，尚有中医跟着西医亦步亦趋，如西医在用抗菌素的同时，中医不分寒热虚实，亦随着而用大量清热解毒药，诸如此类，仅是中药加西药，不是有机的中西医结合。我的意见，对某些病情比较危重或复杂的疾病，在治疗过程中，中西医，尤其是西学中的医师，应该首先共同将病情加以分析研究，认为对某些症状的疗效，西优于中，则以西为主，另一些症状的疗效，中胜于西，则以中为主，相互取长补短，紧密协作，反复实践，摸索规律，如能做到这一点，虽是中西医结合的雏形，却可以大大提高治疗效果。
学以致用勤能补拙
作为一个医务工作者来说，知识面越广越好。但限于主客观条件，不可能样样都通。在我来讲，认为学以致用，勤能补拙，是治学的一贯守则。
祖国医学，自轩岐以降，一脉相承，代有发展。宋、元以后，虽有流派兴起，然其理论基础，大体上不逾越《内经》、《难经》、《伤寒杂病论》等古典著作的内容。正如宋濂题《格致余论·序言》中所说：「金元以善名，凡三家：日刘守真氏，臼张子和氏，臼李明之氏。皆以《内经》为宗，而莫之有异也。」这意味着中医投有什么派系，不过各人在各个不同的角度上有所发展和特长而已。
祖国医学的文献，浩如烟海。我们学习和研究，应从何着手，实有探讨之必要。我的体会，对中医古籍的学习，可分为必读，览阅及稽考三种方式。为了有的放矢，学以致用，又可分为「晓其意」的粗读和「达其理」的精读。而且精读，必须要在实践中反复阅读，才能一次又一次地加深理解。
必读之书，一般认为如《内经》、《难经》、《伤寒论》、《金匮要略》、《神农本草经》、《温病条辨》和《温热经纬》等。必读书中，如《内经》的「上古天真论」、「四气调神论」、「六节脏象论」、「脉要精微论」、「至真要大论」之类的有关基础理论诸篇，对中医各科均具有普遍的指导意义，需要精读。如习内科者叉应细读「热论」、「疟论」、「款论」等}习针灸者又应细读「经脉别论」、「刺要论」、「缪刺论」。九针十二原」等。总之，对一部《内经》，读时要有一般和重点之分。
对《伤寒论》的学习，我曾在《浙江中医杂志》(1980年11期)发表过「怎样学习伤寒论」一文，可供参考，不再赘述。
《金匮要略》原与《伤寒论》同是张仲景全书《伤寒杂病论》的重要组成部分，后世分为二书。它当然也是从幸存的残稿中，发掘和整理出来的。现存之书，分为二十五篇(据《金匮玉函要略辑义》)，计二百二十六方，是内科(包括部分外科、妇科)杂病分型辨证和治疗的典范，至今仍有效地指导l临床。因此，它与《内经》、州灯寒论》等，同样是必读之书。学习的基本方法，可参照《伤寒论》。
但是，《金匮要略》以各个证候为基础，它与六经辨证，有哪些关系?而且此证和彼证之间，如湿痹之与历节，溢饮之与水气，有哪些区别?特别是同一症征，为什么提出两张主方?如「胸痹，心中痞气，气结在胸……枳实薤白桂枝汤主之，人参汤亦主之」}又如，病溢饮者，当发其汗，大青龙汤主之，小青龙汤亦主之」。诸如此类，都要通过独立思考，才能晓其义、达其理。如果仅停留在字句的解释，还只是隔靴搔痒。
此外，就是温热病学，它是伤寒学说的发展，对急性热病舶辨证和治疗，积累了丰富的经验，有关的文献也较多，值得必读的有《温病条辨》、《温热经纬》。此外，《温疫论》亦可选读。
可以览阅之书，历代著作，汗牛充栋，不胜枚举。值得推荐的，如金元四大家、明清八大家的著作，当为首选。我的体会，览阅历代名家的著作，能明其学术观点，领会其医疗经验，是览阅的主要目的，。因此，亦有粗读和精读之分，有一般和重点韵区别。如李东垣的《睥胃论》、徐灵胎的《源流论》等，应作为重点书读。
历代医家的医案、医话、随笔等等，也有不少的独特经验和见解，值得览阅。个人认为在医案方面，如《寓意草》、《王孟英医案》，《谢映庐得心集》、《程杏轩医案》之类，对症状的描述、处方的意义、治疗的效果等，叙述得较为详明，端绪易寻。如《临证指南》、《王旭高医案》、《丁甘仁医案》之类，要从其同一类门的医案中，通过综合分析，推求其辨证和论治的规律，吸取经验，确有很大的意义。稽考之书，大都是方书和本草之类，近似工具书。譬如览阅《巢氏病源》，虽有病因、症状的记述，而无论治的方药。对此，须与《外台秘要})、《圣济总录》等，互相对照，才能得其全面。但是，祖国医学，方多于药，全部记忆，殊不可能。如对某一疾病，根据需要，能将治疗同一疾病的有关方剂、药品及其主要适应症，以统计方式处理，从而得知某证哪些为常用药品，哪些为少用药品。尤其要明其组方的规律，具有一定意义。
我虽年逾古稀，不论在中医的理论和临床方面，始终感到多有不足而耿耿于怀，限于水平，谨述区区，就正有道。
试以胸腔积液为例，临床上以渗出性胸膜炎较为常见（当然，可能还有其他疾病）。就渗出性胸膜炎而言，其病变初期，往往先出现恶寒发热，或胸胁疼痛、咳嗽等表证作为前驱症状。《伤寒论》对于有表证的患者，一般先解表，表解之后才可攻里。因此，我认为文中“病发于阳”的“阳”字，可能是指结胸证（痰水互结于胸膈的病证）的开始阶段有恶寒发热等表证而言。所以，认为不宜过早攻下，并认为过早攻下会损伤正气，对病情不利。但是，渗出性胸膜炎由于炎症的进展，恶寒、脉浮之类的表证，可以自行消退。相反，胸膜积液增多，则肺部压迫症状，如胸闷、胸痛、气急或咳嗽等，势必加重，而且热型，也往往转变为弛张热。由于古代没有X线的检查，又没有穿刺抽液的方法，而能认识到“此为水结在胸胁者也”，能采用具有泻下作用的大陷胸汤（或丸），诱导积液排泄，藉以减轻胸部之压迫，法虽古老，以当时历史条件来说，实属可贵。由此可见，《伤寒论》结胸证先认为不宜下之过早，嗣后，仍以攻下而取效，这实在不是因为攻下过早而造成结胸，也不是结胸证不宜攻下，而是因为病变的发生和发展阶段有表里证之不同，故治法有先表后攻之分寸，这亦是显示辨证论治（根据证候确定治疗方法）之特点。诸如此类，引用西医说法解释，借助他山之石，义理容易明白，较之以经解经（用中医经典解释中医经典），迈出了一步。
临床经验贵在实践
《千金要方》说：“读方三年，便谓天下无病不治；治病三年，乃知天下无可用之方。”的确，我也有这样的感受。回顾我在开业当年的盛夏，诊治一例女性患者，二十余岁，病头痛高热已五日，体温高达40.5℃，神识朦胧，自汗，烦躁，口渴引饮，舌苔薄黄，边尖质红，脉象滑大而数（未作其它理化检验），根据临床表现，诊断为暑热熏蒸，热蒙清窍（暑热之邪熏蒸，热邪蒙蔽心窍），投以白虎汤加减，方用生石膏15克，鲜生地24克，知母6克，菖蒲3克，银花12克，黑山栀、竹叶各9克，芦根15克，甘草1.8克。服上方二剂。翌日下午复诊，体温虽降至36.2℃，而神识昏迷加深，呼吸不匀，汗出肢厥，舌苔干枯，质淡红，脉象微细，呈心气衰竭之象，急改投生脉散加附片以救逆，终归无效。自我分析：其一，究属何病？诊断不明。其二，只知白虎汤证悉俱，而对其初诊脉象未详辨虚实。其三，更未顾及暑热伤气，和壮火食气之患。只知寒凉清热，未佐益气之品以扶正。由此种种，促其恶化，这与我审证不详，用药过偏有关，咎无可辞，良深自疚。
再如曾治同学刘君之妻，病往来寒热，日发二、三次，发时头痛甚剧，呈嗜睡状，频频呕吐，水饮不入，舌苔黄浊，脉象弦数，证属暑温（夏季感受暑热病邪所致的外感热病），投以蒿芩清胆汤加减，方用青蒿、黄芩、竹茹各9克，姜半夏6克，连翘12克，六一散9克，玉枢丹1.8克，扁豆花9克等，连诊三日，病情有增无减。乃向患者家属提出，邀请西医会诊，以明诊断。经西医检验血液，找到恶性疟原虫，诊断为脑型恶性疟疾，即施以抗疟针药。同时，还邀陆君斡夫、吴君国栋与我会诊。磋商结果，因患者寒热往来不解，头痛项强，鼻齿衄血，呕吐仍频，舌质转绛，脉象细数，已呈疟邪入营动血、肝风扇动之象，乃改投清营熄风之剂，方用羚羊角1.8克，鲜生地30克，丹皮9克，青蒿12克，连翘15克，菖蒲3克，黄芩9克，玉枢丹3克。但服药时入口即吐，不起作用。迅即陷入昏迷，终于在发病之第六日，医治无效而死亡。
以上二例，皆系初次接触的重症，病情迅猛，不仅诊断感到有困难，在治疗方面，我初出茅庐，缺乏经验，无可讳言。经此教训之后（当然，不只是这一、二次），每遇重症，必查考有关文献，或请教于同道，用以增进知识，弥补不足。对于死亡病例，必加以分析研究，并记之，以旌我过。
自从一九三二年起，开业之余，尚参加某医务所工作。所中设有病床四十余张，并有小化验室及配药部。收治病种，在急性病方面有伤寒，斑疹伤寒、疟疾、痢疾、肺炎等；慢性病方面有肺结核、溃疡病、肾炎、肝硬变、维生素C缺乏症等。主其事者，虽为西医，除抢救病例用西医外，大部均以中医治疗为主，历时六载，得以对多种疾病进行系统观察。
在长期的临床实践中，我认识到中医处理疾病，通过四诊方法（望、闻、问、切），识证辨性，是关键所在。关于识证辨性、随证论治的方式方法，试举一九四一年在沪行医时所治的两个病例加以说明；
其一，戴氏妇，年约五十，浴中突觉左下腹剧痛，牵及腰部，即呼家人扶之卧床，遂延二、三位西医诊治，有的诊为尿路结石，有的诊为腹膜炎，也有的诊为肠梗阻，施以针药，经三昼夜，未能缓解，乃邀我诊治。证见胸腹痞满，左下腹疼痛，不喜按，其痛牵及腰部不得辗转，不欲食，体温37.8℃，大便已四日未行，舌苔中黄厚，两边薄，质微红，脉象紧数。询问发病经过，曾因家务，情绪激动，旋又进食年糕，未入浴前，已感胸腹不舒。审其病因，显因气机失调，兼挟宿食，腑气不通，不通则痛，理所当然。征属阳明少阳同病，投以大柴胡汤加减，方用柴胡、枳壳各6克，生白芍12克，制大黄9克，厚朴2.4克，制香附6克，延胡索、川楝子各9克，生谷芽12克，炙甘草3克。进药一剂，当晚大便二次，病势顿减。次日复诊，改用四逆散合越鞠丸加减，调理四日，病即霍然。
另一例，徐某，男性，三十五岁，系外地来沪，当晚入浴，突觉脘腹疼痛，起而登厕。便后，腹痛虽减，而全身无劲，大汗淋漓，由友人来邀急诊。证见患者面容苍白，精神倦怠，懒言短气，额上汗出如珠，四肢厥冷，脉象微细，舌苔白腻，体温36.4℃。自诉头晕心悸，腹阵痛。询其病史，素有胃病。证因舟车劳顿，寒温失调，以致亡阳欲脱。急拟参附汤加味，方用别直参9克，淡附片6克，龙骨12克，生牡蛎24克，茯苓9克，陈皮6克，炙甘草4.5克。服药一剂后，汗敛肢温，继以异功散加归、芪等药，调理旬余，恢复健康。以上二例，虽同因入浴而发腹痛，但前者系属气机阻滞，兼有宿食之实证；后者虽亦腹痛，系因劳顿过度，寒气入中，属亡阳欲脱之虚证，显有不同。故前者治法，主以柴胡、白芍之疏肝，大黄、厚朴之通腑，香附、枳壳之调气，延胡、川楝之止痛，后者主以参、附之回阳，龙、牡之固脱。一虚一实，证似同而性异，故治法亦各悬殊。足见，辨证论治，确有它的优越性。但是，对它优越性的认识，必须通过实践，才能体验。
现在，就辨病与辨证相结合的问题，谈一些看法。
辨病和辨证相结合，实际就是双重诊断。对中医临床研究，制订诊断指标及疗效标准，用以观察中医中药对某种疾病的疗效确有帮助。但是，目前在中西医结合的临床中，有的不是按照中医辨证论治的特点，而是执一方或一药以试病，我实未敢赞同。此外，尚有中医跟着西医亦步亦趋，如西医在用抗菌素的同时，中医不分寒热虚实，亦随着而用大量清热解毒药，诸如此类，仅是中药加西药，不是有机的中西医结合。我的意见，对某些病情比较危重或复杂的疾病，在治疗过程中，中西医，尤其是西学中的医师，应该首先共同将病情加以分析研究，认为对某些症状的疗效，西优于中，则以西为主，另一些症状的疗效，中胜于西，则以中为主，相互取长补短，紧密协作，反复实践，摸索规律，如能做到这一点，虽是中西医结合的雏形，却可以大大提高治疗效果。
学以致用勤能补拙
作为一个医务工作者来说，知识面越广越好。但限于主客观条件，不可能样样都通。在我来讲，认为学以致用，勤能补拙，是治学的一贯守则。
祖国医学，自轩岐以降，一脉相承，代有发展。宋、元以后，虽有流派兴起，然其理论基础，大体上不逾越《内经》、《难经》、《伤寒杂病论》等古典著作的内容。正如宋濂题《格致余论·序言》中所说：“金元以善名，凡三家：曰刘守真氏，曰张子和氏，曰李明之氏。皆以《内经》为宗，而莫之有异也。”这意味着中医没有什么派系，不过各人在各个不同的角度上有所发展和特长而已。
祖国医学的文献，浩如烟海。我们学习和研究，应从何着手，实有探讨之必要。我的体会，对中医古籍的学习，可分为必读、览阅及稽考三种方式。为了有的放矢，学以致用，又可分为“晓其意”的粗读和“达其理”的精读。而且精读，必须要在实践中反复阅读，才能一次又一次地加深理解。
必读之书，一般认为如《内经》、《难经》、《伤寒论》、《金匮要略》、《神农本草经》、《温病条辨》和《温热经纬》等。必读书中，如《内经》的“上古天真论”、“四气调神论”、“六节脏象论”、“脉要精微论”、“至真要大论”之类的有关基础理论诸篇，对中医各科均具有普遍的指导意义，需要精读。如习内科者又应细读“热论”、“疟论”、“咳论”等；习针灸者又应细读“经脉别论”、“刺要论”、“缪刺论”、“九针十二原”等。总之，对一部《内经》，读时要有一般和重点之分。
对《伤寒论》的学习，我曾在《浙江中医杂志》(1980年11期)发表过“怎样学习伤寒论”一文，可供参考，不再赘述。
《金匮要略》原与《伤寒论》同是张仲景全书《伤寒杂病论》的重要组成部分，后世分为二书。它当然也是从幸存的残稿中，发掘和整理出来的。现存之书，分为二十五篇(据《金匮玉函要略辑义》)，计二百二十六方，是内科(包括部分外科、妇科)杂病分型辨证和治疗的典范，至今仍有效地指导临床。因此，它与《内经》、《伤寒论》等，同样是必读之书。学习的基本方法，可参照《伤寒论》。
但是，《金匮要略》以各个证候为基础，它与六经辨证，有哪些关系？而且此证和彼证之间，如湿痹之与历节，溢饮之与水气，有哪些区别？特别是同一症征，为什么提出两张主方？如“胸痹，心中痞气，气结在胸……枳实薤白桂枝汤主之，人参汤亦主之”；又如，病溢饮者，当发其汗，大青龙汤主之，小青龙汤亦主之”。诸如此类，都要通过独立思考，才能晓其义、达其理。如果仅停留在字句的解释，还只是隔靴搔痒。
此外，就是温热病学，它是伤寒学说的发展，对急性热病的辨证和治疗，积累了丰富的经验，有关的文献也较多，值得必读的有《温病条辨》、《温热经纬》。此外，《温疫论》亦可选读。
可以览阅之书，历代著作，汗牛充栋，不胜枚举。值得推荐的，如金元四大家、明清八大家的著作，当为首选。我的体会，览阅历代名家的著作，能明其学术观点，领会其医疗经验，是览阅的主要目的。因此，亦有粗读和精读之分，有一般和重点的区别。如李东垣的《脾胃论》、徐灵胎的《源流论》等，应作为重点书读。
历代医家的医案、医话、随笔等等，也有不少的独特经验和见解，值得览阅。个人认为在医案方面，如《寓意草》、《王孟英医案》、《谢映庐得心集》、《程杏轩医案》之类，对症状的描述、处方的意义、治疗的效果等，叙述得较为详明，端绪易寻。如《临证指南》、《王旭高医案》、《丁甘仁医案》之类，要从其同一类门的医案中，通过综合分析，推求其辨证和论治的规律，吸取经验，确有很大的意义。稽考之书，大都是方书和本草之类，近似工具书。譬如览阅《巢氏病源》，虽有病因、症状的记述，而无论治的方药。对此，须与《外台秘要》、《圣济总录》等，互相对照，才能得其全面。但是，祖国医学，方多于药，全部记忆，殊不可能。如对某一疾病，根据需要，能将治疗同一疾病的有关方剂、药品及其主要适应症，以统计方式处理，从而得知某证哪些为常用药品，哪些为少用药品。尤其要明其组方的规律，具有一定意义。
我虽年逾古稀，不论在中医的理论和临床方面，始终感到多有不足而耿耿于怀，限于水平，谨述区区，就正有道。
Taking pleural effusion as an example, exudative pleurisy (pleurisy with exudate) is relatively common in clinical practice (of course, there may be other diseases). Regarding exudative pleurisy, in the initial stage of the lesion, prodromal symptoms often appear first, such as aversion to cold and fever, or chest and hypochondriac pain, cough, etc., which are exterior syndromes (syndromes caused by pathogenic factors attacking the exterior). According to *Shanghan Lun* (Treatise on Cold Damage), for patients with exterior syndromes, one should generally resolve the exterior first; only after the exterior is resolved can one attack the interior. Therefore, I believe that the character "Yang" (Yang) in the phrase "disease originates from Yang" refers to the presence of exterior syndromes such as aversion to cold and fever in the initial stage of Jie Xiong syndrome (a syndrome characterized by the accumulation of phlegm-fluids in the chest and diaphragm). Thus, it is considered inappropriate to use purgation too early, as premature purgation damages healthy Qi (vital energy) and is detrimental to the disease. However, due to the progression of inflammation in exudative pleurisy, exterior syndromes such as aversion to cold and a floating pulse (pulse felt lightly at the surface) may subside spontaneously. Conversely, as pleural fluid increases, pulmonary compression symptoms such as chest tightness, chest pain, shortness of breath, or cough will inevitably worsen, and the fever pattern often changes to remittent fever. Since ancient times lacked X-ray examination and methods for puncture and aspiration, yet recognized that "this is water accumulating in the chest and hypochondrium," and employed Da Xian Xiong Tang (Major Intra-thoracic Trap Decoction) or Wan (Pill), which has a purgative effect, to induce the discharge of effusion and thereby relieve chest compression, this method, though ancient, was truly valuable given the historical conditions of the time. It can be seen that in *Shanghan Lun*, Jie Xiong syndrome was initially considered unsuitable for premature purgation, but later achieved efficacy through purgation. This is not because premature purgation caused Jie Xiong syndrome, nor is it that Jie Xiong syndrome is unsuitable for purgation, but rather because different stages of the occurrence and development of the lesion present different exterior and interior syndromes, thus requiring treatment methods that distinguish between resolving the exterior first and then attacking the interior. This also demonstrates the characteristics of Bian Zheng Lun Zhi (Syndrome Differentiation and Treatment). Such cases, explained by referencing Western medicine theories, borrowing insights from other fields, make principles easier to understand, representing a step forward compared to interpreting classics solely through other classics.
Clinical Experience Values Practice
*Qianjin Yaofang* (Essential Prescriptions Worth a Thousand Gold) states: "After studying formulas for three years, one believes there is no disease in the world that cannot be cured; after treating diseases for three years, one realizes there is no formula in the world that can be used [universally]." Indeed, I share this feeling. Looking back to the midsummer of my first year in private practice, I treated a female patient in her twenties who had suffered from headache and high fever for five days. Her body temperature reached 40.5°C. She presented with clouded consciousness, spontaneous sweating, irritability, thirst with desire to drink, thin yellow tongue coating, red edges and tip of the tongue, and a slippery, large, and rapid pulse (without other laboratory tests). Based on the clinical manifestations, she was diagnosed with Summer-heat steaming and Heat confusing the clear orifices (Summer-heat pathogen steaming and Heat pathogen obscuring the heart orifices). I prescribed Bai Hu Tang (White Tiger Decoction) with modifications, using Sheng Shi Gao (Raw Gypsum Fibrosum) 15g, Xian Sheng Di Huang (Fresh Rehmanniae Radix) 24g, Zhi Mu (Anemarrhenae Rhizoma) 6g, Chang Pu (Acori Tatarinowii Rhizoma) 3g, Yin Hua (Lonicerae Japonicae Flos) 12g, Hei Shan Zhi (Gardeniae Fructus) and Zhu Ye (Bambusae Folium) 9g each, Lu Gen (Phragmitis Rhizoma) 15g, and Gan Cao (Glycyrrhizae Radix et Rhizoma) 1.8g. After taking two doses of the above prescription, she returned for a follow-up visit the next afternoon. Although her body temperature dropped to 36.2°C, her consciousness became more comatose, breathing was irregular, sweating occurred with cold limbs, the tongue coating was dry and cracked, the tongue body was pale red, and the pulse was faint and fine, presenting signs of Heart Qi failure. I urgently switched to Sheng Mai San (Generate the Pulse Powder) with Fu Pian (Prepared Aconiti Lateralis Radix) to rescue from collapse, but ultimately without success. Self-analysis: First, what was the specific disease? The diagnosis was unclear. Second, I only knew that all symptoms of Bai Hu Tang syndrome were present, but failed to carefully differentiate deficiency and excess in the initial pulse. Third, I did not consider the damage of Summer-heat to Qi, nor the danger of "vigorous fire consuming Qi." I only knew to use cold-natured herbs to clear heat, without adding Qi-tonifying herbs to support healthy Qi. All these factors contributed to her deterioration, which was related to my inadequate syndrome differentiation and overly biased medication. I bear full responsibility and feel deeply remorseful.
Another case involved the wife of my student, Mr. Liu. She suffered from alternating chills and fever, occurring two or three times a day. During attacks, she had severe headaches, appeared lethargic, vomited frequently, and could not retain fluids. Her tongue coating was yellow and turbid, and her pulse was wiry and rapid. The syndrome belonged to Summer-warmth (Warm-heat disease occurring in summer), so I prescribed Hao Qin Qing Dan Tang (Artemisiae Annuae and Scutellariae Gallbladder-Clearing Decoction) with modifications, using Qing Hao (Artemisiae Annuae Herba), Huang Qin (Scutellariae Radix), and Zhu Ru (Bambusae Caulis in Taenia) 9g each, Jiang Ban Xia (Pinelliae Rhizoma Preparatum) 6g, Lian Qiao (Forsythiae Fructum) 12g, Liu Yi San (Six-to-One Powder) 9g, Yu Shu Dan (Jade Pivot Pill) 1.8g, and Bian Dou Hua (Dolichoris Flos) 9g, etc. After three days of consultation, the condition worsened. I then suggested to the family inviting a Western medical consultation to clarify the diagnosis. Blood tests by Western medicine identified malignant malaria parasites, leading to a diagnosis of cerebral malignant malaria, and antimalarial injections and medications were administered. Simultaneously, I invited Dr. Lu Wofu and Dr. Wu Guodong for joint consultation. After discussion, since the patient's alternating chills and fever persisted, accompanied by severe headache and neck stiffness, epistaxis and gingival bleeding, frequent vomiting, a crimson tongue body, and a fine and rapid pulse, it indicated that the Malaria pathogen had entered the Ying (Nutrient) level causing blood movement, and Liver Wind was stirring. I changed to a formula for clearing the Ying level and extinguishing Wind, using Ling Yang Jiao (Capricornis Cornu) 1.8g, Xian Sheng Di Huang (Fresh Rehmanniae Radix) 30g, Dan Pi (Moutan Cortex) 9g, Qing Hao (Artemisiae Annuae Herba) 12g, Lian Qiao (Forsythiae Fructum) 15g, Chang Pu (Acori Tatarinowii Rhizoma) 3g, Huang Qin (Scutellariae Radix) 9g, and Yu Shu Dan (Jade Pivot Pill) 3g. However, upon administration, the medicine was vomited immediately and had no effect. She quickly fell into a coma and died on the sixth day of illness despite treatment efforts.
The above two cases were both severe illnesses I encountered for the first time. The conditions progressed rapidly, making diagnosis difficult. Moreover, as a novice practitioner lacking experience, this is undeniable. After these lessons (and certainly not just these one or two instances), whenever I encounter severe cases, I always consult relevant literature or seek advice from colleagues to enhance knowledge and弥补 deficiencies. For fatal cases, I must analyze and study them, recording them to highlight my errors.
Since 1932, in addition to private practice, I participated in the work of a certain medical clinic. The clinic had over forty beds, a small laboratory, and a dispensary. Diseases treated included acute conditions such as Typhoid Fever, Typhus, Malaria, Dysentery, Pneumonia, etc.; chronic conditions included Tuberculosis, Peptic Ulcer, Nephritis, Liver Cirrhosis, Vitamin C Deficiency, etc. Although the director was a Western physician, except for emergency cases treated with Western medicine, most were primarily treated with Traditional Chinese Medicine (TCM). Over six years, I was able to conduct systematic observations of various diseases.
In long-term clinical practice, I realized that for TCM handling diseases, identifying syndromes and determining their nature through the Four Diagnostic Methods (Inspection, Auscultation-Olfaction, Inquiry, Palpation) is key. Regarding the methods of syndrome identification and treatment according to syndrome, let me illustrate with two cases treated in Shanghai in 1941:
First, Mrs. Dai, about fifty years old, suddenly felt severe pain in the lower left abdomen while bathing, radiating to the waist. She called family members to help her lie down. Two or three Western physicians were consulted; some diagnosed ureteral stones, others peritonitis, and another intestinal obstruction. Acupuncture and medications were administered, but after three days and nights, there was no relief. I was then invited. Symptoms included chest and abdominal fullness and stuffiness, pain in the lower left abdomen that was worse with pressure, pain radiating to the waist preventing turning over, loss of appetite, body temperature 37.8°C, no bowel movement for four days, thick yellow tongue coating in the center with thin edges, slightly red tongue body, and a tight and rapid pulse. Upon inquiry into the onset, she had become emotionally agitated due to household chores, then ate rice cakes. Before bathing, she already felt chest and abdominal discomfort. Analyzing the etiology, it was clearly due to dysfunction of Qi mechanism, complicated by retained food, leading to blockage of Fu organ Qi. Blockage causes pain, which is logical. The syndrome belonged to simultaneous involvement of Yangming and Shaoyang channels. I prescribed Da Chai Hu Tang (Major Bupleurum Decoction) with modifications, using Chai Hu (Bupleuri Radix), Zhi Ke (Aurantii Fructus) 6g each, Sheng Bai Shao (Raw Paeoniae Radix Alba) 12g, Zhi Da Huang (Prepared Rheomi Radix et Rhizoma) 9g, Hou Po (Magnoliae Officinalis Cortex) 2.4g, Zhi Xiang Fu (Cyperi Rhizoma Preparatum) 6g, Yan Hu Suo (Corydalis Rhizoma), and Chuan Lian Zi (Meliae Fructus) 9g each, Sheng Gu Ya (Hordei Fructus Germinatus) 12g, and Zhi Gan Cao (Prepared Glycyrrhizae Radix et Rhizoma) 3g. After one dose, she had two bowel movements that night, and the disease势头 decreased significantly. On the next day's follow-up, I switched to Si Ni San (Four Counterflow Powder) combined with Yue Ju Wan (Solving Depression Pill) with modifications. After four days of regulation, she recovered completely.
Another case involved Mr. Xu, a 35-year-old male from out of town. After arriving in Shanghai, he took a bath that evening and suddenly felt epigastric and abdominal pain. He got up to go to the toilet. After defecation, abdominal pain decreased slightly, but he felt weak all over, sweated profusely, and was invited for emergency care by a friend. Symptoms included pale complexion, mental fatigue, reluctance to speak, shortness of breath, beads of sweat on the forehead, cold limbs, faint and fine pulse, white greasy tongue coating, and body temperature 36.4°C. He complained of dizziness, palpitations, and intermittent abdominal pain. Inquiry into medical history revealed a chronic stomach disease. The syndrome was caused by exhaustion from travel, imbalance of cold and warmth, leading to collapse of Yang Qi impending depletion. I urgently formulated Shen Fu Tang (Ginseng and Aconite Decoction) with modifications, using Bie Zhi Shen (American Ginseng) 9g, Dan Fu Pian (Prepared Aconiti Lateralis Radix Preparata) 6g, Long Gu (Fossilia Ossis Mastodi) 12g, Sheng Mu Li (Ostreae Concha) 24g, Fu Ling (Poria) 9g, Chen Pi (Citri Reticulatae Pericarpium) 6g, and Zhi Gan Cao (Prepared Glycyrrhizae Radix et Rhizoma) 4.5g. After one dose, sweating stopped, limbs warmed. Subsequently, Yi Gong San (Yi Gong's Powder) with Dang Gui (Angelicae Sinensis Radix) and Huang Qi (Astragali Radix) was used for regulation for over ten days, leading to recovery. In the above two cases, although both developed abdominal pain after bathing, the former was an Excess syndrome due to Qi stagnation and retained food; the latter, although also abdominal pain, was a Deficiency syndrome due to excessive fatigue and cold invading the interior, leading to impending Yang collapse. They were distinctly different. Therefore, the treatment for the former focused on Chai Hu and Bai Shao to soothe the Liver, Da Huang and Hou Po to unblock the Fu organs, Xiang Fu and Zhi Ke to regulate Qi, and Yan Hu and Chuan Lian Zi to stop pain. The treatment for the latter focused on Shen and Fu to restore Yang, and Long and Mu to secure collapse. One Deficient, one Excess; although the symptoms seemed similar, the nature was different, so the treatments were vastly different. This sufficiently shows that Syndrome Differentiation and Treatment indeed has its superiority. However, understanding this superiority requires practical experience.
Now, regarding the combination of Disease Differentiation and Syndrome Differentiation, I would like to share some views.
Combining Disease Differentiation and Syndrome Differentiation is essentially dual diagnosis. For TCM clinical research, establishing diagnostic criteria and efficacy standards to observe the effectiveness of TCM on specific diseases is indeed helpful. However, currently in integrated Chinese and Western medicine clinical practice, some do not follow the characteristics of TCM syndrome differentiation and treatment, but instead apply a single formula or herb to test against a disease, which I cannot agree with. Additionally, some TCM practitioners follow Western medicine step-by-step; for example, while Western doctors use antibiotics, TCM practitioners indiscriminately use large amounts of Heat-clearing and Toxin-resolving herbs regardless of Cold, Heat, Excess, or Deficiency. Such practices are merely adding Chinese herbs to Western medicines, not organic integration. My opinion is that for certain critical or complex diseases, during treatment, both Chinese and Western physicians, especially those trained in Western medicine learning TCM, should jointly analyze and study the condition. If Western medicine is superior for certain symptoms, prioritize Western treatment; if TCM is superior for others, prioritize TCM. Complementing each other's strengths, collaborating closely, practicing repeatedly, and exploring patterns—if this can be achieved, although it is merely a prototype of integrated Chinese and Western medicine, it can greatly improve therapeutic effects.
Applying Learning Diligently Compensates for Lack of Talent
As a medical worker, a broader knowledge base is better. But limited by subjective and objective conditions, one cannot master everything. For me, applying learning to practice and diligence compensating for lack of talent is a consistent principle of scholarship.
Chinese Medicine, since the legendary Yellow Emperor (Xuanyuan) and Qibo, has been passed down continuously, developing generation by generation. After the Song and Yuan dynasties, although various schools emerged, their theoretical foundations largely did not exceed the content of classical works such as *Neijing* (Inner Canon), *Nanjing* (Classic of Difficult Issues), and *Shanghan Zabing Lun* (Treatise on Cold Damage and Miscellaneous Diseases). As Song Lian wrote in the preface to *Gezhi Yulun*: "In Jin and Yuan dynasties, three scholars were famous for their excellence: Liu Shouzhen, Zhang Zihe, and Li Mingzhi. All took *Neijing* as their ancestor, without any difference." This means TCM does not have rigid sects; it simply means individuals have developed specialties and strengths from different perspectives.
The literature of Chinese Medicine is vast. Where should we begin our study and research? This warrants exploration. My experience suggests that studying TCM ancient texts can be divided into three modes: Must-Read, Review, and Reference. To be targeted and apply learning, these can be further divided into "Understanding Meaning" (Rough Reading) and "Comprehending Principles" (Intensive Reading). Moreover, intensive reading must be repeated in practice to deepen understanding step by step.
Must-Read books generally include *Neijing*, *Nanjing*, *Shanghan Lun*, *Jingui Yaolue*, *Shennong Bencao Jing*, *Wenbing Tiaobian*, and *Wenre Jingwei*. Among must-reads, chapters in *Neijing* such as "Shanggu Tianzhen Lun" (Discourse on Heavenly Truth in Antiquity), "Siqi Tiaoshen Lun" (Discourse on Regulating Spirit According to Four Seasons), "Liujie Zangxiang Lun" (Discourse on Six Periods and Viscera Manifestations), "Maiyao Jingwei Lun" (Discourse on Essentials of Pulse Diagnosis), and "Zhi Zhen Yao Da Lun" (Great Discourse on the Most Essential Truths), which concern basic theories, have universal guiding significance for all TCM disciplines and require intensive reading. Those studying Internal Medicine should carefully read "Relun" (Discourse on Heat), "Malun" (Discourse on Malaria), "Kelun" (Discourse on Cough); those studying Acupuncture should carefully read "Jingmai Belun" (Discourse on Differences in Meridians), "Ciyaolun" (Discourse on Needling Essentials), "Miocilun" (Discourse on Oblique Needling), "Jiu Zhen Shier Yuan" (Nine Needles and Twelve Source Points). In short, when reading *Neijing*, one must distinguish between general and key points.
Regarding the study of *Shanghan Lun*, I published an article titled "How to Study Shanghan Lun" in *Zhejiang Journal of Traditional Chinese Medicine* (Issue 11, 1980), which can serve as a reference, so I will not elaborate further.
*Jingui Yaolue* (Essential Prescriptions of the Golden Cabinet) was originally part of Zhang Zhongjing's complete work *Shanghan Zabing Lun*, later separated into two books. It was naturally excavated and organized from surviving fragments. The existing book is divided into twenty-five chapters (according to *Jingui Yuyao Lüejie Jiyi*), containing 226 formulas. It is a model for differential syndrome differentiation and treatment of internal medicine (including some surgical and gynecological) miscellaneous diseases and still effectively guides clinical practice today. Therefore, it is equally a must-read alongside *Neijing* and *Shanghan Lun*. The basic method of study can refer to *Shanghan Lun*.
However, *Jingui Yaolue* is based on various syndromes. What is its relationship with Six-Meridian Syndrome Differentiation? And what are the differences between syndromes, such as Damp-Bi (Obstruction) versus Li Jie (Periarthritis), Yi Yin (Overflowing Fluid) versus Shui Qi (Water Qi)? Especially, why are two main formulas proposed for the same symptom complex? For example, "Chest Bi, with stifling sensation in the heart and Qi knotting in the chest... Zhi Shi Ye Bai Gui Zhi Tang is the primary formula, Ren Shen Tang is also the primary formula"; similarly, for Yi Yin disease, sweating should be induced, Da Qing Long Tang is the primary formula, Xiao Qing Long Tang is also the primary formula". All such cases require independent thinking to understand their meaning and principles. If one only stops at literal explanation, it is like scratching an itch from outside the boot (ineffective).
Furthermore, Warm-Heat Pathology is a development of the Cold Damage theory, accumulating rich experience in the differentiation and treatment of acute febrile diseases. There are many relevant documents worth reading, including *Wenbing Tiaobian* and *Wenre Jingwei*. Additionally, *Wenyi Lun* (Treatise on Pestilential Qi) can be selected for reading.
Books suitable for review are countless, with volumes filling warehouses. Recommended selections include the works of the Four Great Masters of Jin-Yuan and the Eight Masters of Ming-Qing. My experience is that reviewing the works of past masters aims to clarify their academic viewpoints and comprehend their medical experiences. Therefore, there is also a distinction between rough and intensive reading, and general and key points. For instance, Li Dongyuan's *Pi Wei Lun* (Treatise on Spleen and Stomach) and Xu Lingtai's *Yuanliu Lun* (Discourse on Origins and Development) should be read as key texts.
Medical records, anecdotes, and essays by physicians of past dynasties also contain unique experiences and insights worth reviewing. Personally, in terms of medical records, works like *Yuyi Cao*, *Wang Mengying Yi An*, *Xie Yinglu Dexin Ji*, and *Cheng Xingxuan Yi An* describe symptoms, prescribe meanings, and treatment effects in detail, making clues easy to find. For works like *Linzheng Zhinan*, *Wang Xugao Yi An*, and *Ding Ganren Yi An*, one must analyze medical records within the same categories comprehensively to deduce patterns of syndrome differentiation and treatment, absorbing experience, which is of great significance. Reference books are mostly formularies and materia medica, resembling toolbooks. For example, reviewing *Chaoshi Bingyuan* (Source of Diseases of the Chao Family) contains descriptions of etiology and symptoms but lacks treatment formulas. For this, one must cross-reference with *Waitai Miyao* (Secret Essentials of the Outer Palace) and *Shengji Zonglu* (General Records of Holy Relief) to gain a comprehensive view. However, in Chinese Medicine, there are more formulas than herbs, making memorization of all impossible. For a specific disease, according to needs, one can process relevant formulas, drugs, and main indications for treating the same disease statistically, thereby knowing which drugs are commonly used and which are rarely used for a certain syndrome. Particularly, understanding the rules of formula composition holds certain significance.
Although I am over seventy years old, whether in TCM theory or clinical practice, I always feel there is much room for improvement and remain concerned. Limited by my level, I briefly state my humble opinions for correction by experts.