书云∶卫虚则恶寒，营虚则发热。证见日晡寒热往来，已经数月，洵为营卫二气之虚，
断非
客邪外感也。病既属虚，虚则当补，昨服补剂，胸鬲反增滞闷，此中消息，颇难窥测。盖非
药不能应病，乃胃气不行药力耳。夫上损过胃，下损过脾，越人且畏，姑遵经旨，虚痨不足
，当与甘药。两进甘药，寒热依然，惟粥食稍增，咳嗽略缓药病尚觉相符。稽古补虚方法，
千蹊万径，而其关键，总以脾胃为之主脑。夫人之一身，内而五脏六腑，外而皮肉经脉，何
一非藉谷气长养之功。苟土母倾颓，既难输化饮食之精微，焉能传送药力，宜乎虚不纳补也
。难经发明五损，勿过脾胃，仲景治虚痨诸不足，出活人手眼，其所立建中方法，亦皆稼穑
作甘。此古圣贤明训，内伤大病，可不以脾胃为首重耶?然病真药假，终难图功。
恙经半载，脉证合参，究属质亏烦劳，以致坎离不交，水火失济，五液内涸，虚阳不藏
。误
服苦寒，重伐胃气，诸证蜂生，纠缠不已。揆之古训，以虚能受补者可治，虚火可补，参
之类，实火可泻，芩连之类。劳伤之火，虚乎实乎，泻之可乎。赵氏谓阴虚之火，如盏中油
干，灯焰自炽，须以膏油养之，专主补阴
。其说是已。然阴生于阳，血生于气，顾此食少欲呕，脘闷不快，又难强投滋腻。反复推详
，计惟培养脾胃，默运坤元，以为先着，脾为土母，安谷则昌。《金匮》治虚劳，首用建中
。越人言损其脾者，调其饮食。脾元日健，饮食日增，变化精微，滋荣脏腑，不治火而火自
熄，不润燥而燥自濡，充肤热肉之功，可渐见矣。然内伤之病，宜内观静养，所谓大病须服
大药。大药者，天时春夏，吾心寂然秋冬也。参透此关，以佐草木之不逮，为妙。服药旬余
，脉象稍转，寝食略安，惟足膝酸软，项脊时疼，形神疲倦。考治五脏之虚，难经言之甚悉
，曰损其肺者益其气，损其心者调其营卫，损其脾者，调其饮食，适其寒温，损其肝者缓其
中，损其肾者益其精，阐发精微，了无遗蕴。再考《金匮》云∶男子脉大为劳，极虚亦为劳
。夫脉大为真气泄越，心脾耗伤，此归脾、建中、养营、四君等汤之所宜。极虚亦为劳，乃
精血内夺，肝肾下衰，此六味、八味、天真、大造等丸之所宜也。但病证多端，治须次第。
首先稼穑作甘，培补中宫，专崇其土，次当荣养心脾。盖心为离阳，补心阳以生胃土，虚则
补母之义。至于皮枯肉瘠，肢懈形羸，精髓内竭，筋骨废弛，明属本实先拨，舍填纳固摄，
则解 何由而振?枯槁何由而回?特草木无情，须假物类之脂膏，益人身之血液，煎丸并服，
脾肾分施。炼石补天，而收桑榆之效矣。调治两旬，虽未大效，然处境烦剧，犹能支撑，未
始非赖药饵扶持之力。七年之病，三年之艾，原无速功。春三月此谓发陈，恪服煎丸，春气
得生，夏可得长。一阴来复，自可霍然。病机前案已详，其中奥义难测者，尚有数端，请再
陈之。凡人病若劳动，反觉精神强健者，此阴火沸腾，扶助于内，不觉其元气之衰，若静养
调适，反觉神疲气弱者，此阴火退，本相露故也。病情有类乎此者一也。解 一证，由于肝
肾二经之虚。肝虚则筋软无力以束周身，肌肉皆涣散而若解，肾虚则骨痿不能自强，遍体骨
节皆松懈而多 ，故恹恹悒悒。若不知所以为人，病情有类乎此者，二也。男子精未满而早
摇其精，五脏有不满之处，异日有难状之病。病情有类乎此者，三也。卫气昼行于阳主寤，
夜行于阴主寐。平人夜卧，则阳升阴降，阴阳交合，然后渐入睡乡。若营弱卫强，坎离失媾
，神明之地，扰乱不安，万虑纷云，却之不去，卫气刚入于阴，契合浅而脱离快，升者复升
，降者复降，是以欲寐之时，忽惊而寤矣。病情有类乎此者，四也。至若饮食虽能强餐，腹
中常觉不畅者，胃得受纳之司，脾失健运之职也。大便燥结，数日始一更衣者，肠脂枯涩，
传导艰难也。脘中时痛者，木失水涵，肝吐怒张而迫鬲也。心乍怔忡，营虚之故。臂多青脉
，血脱之征。更有皮肉之间，时如冰水滴溜，证状之奇，方书未载。曾治一妇患此疾，数年
投补药百剂而愈。岂非血气空虚，失其温分肉、实腠理之司耶。
安波按∶先生阐发经义，善发古人之意。
《内经》记载：卫气虚弱则怕冷，营血不足则发热。患者表现为每天傍晚时分寒热交替往来，已经持续数月，这确实是营气和卫气两虚的表现，绝非外感客邪所致。既然病属虚证，虚证就应当用补法，昨天服用补药后，胸膈反而更加胀闷滞塞，其中的机理很难揣测。并不是药物不能对症治病，而是胃气无法推动药力运行。上部的虚损如果影响到胃，下部的虚损如果影响到脾，即使是扁鹊（越人）也会感到棘手。暂且遵循经典旨意，虚劳不足之证，应当使用甘味药物。连续两次使用甘药后，寒热症状依旧，只是粥食摄入量稍增，咳嗽略微缓解，药症似乎还算相符。考察古代治疗虚损的方法，千条路径万种途径，但其关键核心，总以脾胃为主宰。人的身体，内而五脏六腑，外而皮肉经脉，哪一样不是依靠水谷之气滋养的功效？如果脾胃（土母）衰败，既难以转化饮食中的精微物质，又怎能传送药力，难怪虚证不能耐受滋补。《难经》阐明了五种虚损，告诫不要超过脾胃的承受能力；张仲景治疗虚劳诸不足，展现了高超的手眼，他所创立的建中汤等方法，也都符合“稼穑作甘”（脾属土，其味为甘）的道理。这是古圣先贤的明训，内伤大病，难道可以不把脾胃放在首位重视吗？然而病情真实而用药虚假（指药不对证或药力未达），终究难以取得功效。
患病已半年，脉象与症状合参，究其根本属于体质亏损、烦劳过度，导致心肾不交（坎离不交）、水火失济，体内五液枯竭，虚阳不能潜藏。误服苦寒药物，严重损伤了胃气，各种病症蜂拥而至，纠缠不休。根据古训，以虚证能受补的可以治愈，虚火可以用补法，如人参之类；实火可以用泻法，如黄芩、黄连之类。劳伤引起的火，是虚还是实？能否用泻法？赵献可认为阴虚之火，就像灯盏里的油干了，灯焰自然炽盛，必须用膏油来滋养，主张专门补阴。这种说法是正确的。然而阴生于阳，血生于气，现在患者饮食减少想呕吐，胃脘闷堵不舒服，又难以强行投用滋腻的药物。反复推敲详查，计策唯有培养脾胃，默默运化坤元之气，作为首要步骤。脾为土母，能安纳谷物则生机昌盛。《金匮要略》治疗虚劳，首先使用建中汤。扁鹊说损伤脾脏的，要调理饮食。脾元日渐强健，饮食日渐增加，变化出精微物质，滋润荣养脏腑，不直接灭火而火自熄灭，不直接润燥而燥自湿润，充盈皮肤、温煦肌肉的功效，可以逐渐显现。然而内伤疾病，宜于向内观照、静养，所谓大病须服大药。所谓大药，是指顺应天时春夏的生发，内心保持寂然如秋冬的收敛。参透这一关窍，以辅助草木药物的不足，才是妙法。服药十几天后，脉象稍微好转，睡眠和饮食略微安稳，只有足膝酸软，项部和脊背时常疼痛，形体和精神疲倦。考察治疗五脏虚损的方法，《难经》阐述得非常详尽，说：损伤肺脏的益其气，损伤心脏的调其营卫，损伤脾脏的调其饮食，适应寒温，损伤肝脏的缓其中，损伤肾脏的益其精，阐发精微，毫无遗漏。再考察《金匮要略》说：男子脉大为劳，极虚也是劳。脉大是因为真气泄越，心脾耗伤，这是归脾汤、建中汤、养营汤、四君子汤等方剂适宜治疗的。脉极虚也是劳，是因为精血内夺，肝肾下衰，这是六味丸、八味丸、天真丸、大造丸等丸剂适宜治疗的。但是病证多种多样，治疗必须有先后次序。首先运用“稼穑作甘”，培补中焦脾胃，专门尊崇土气；其次应当荣养心脾。因为心为离阳，补心阳以生胃土，这是“虚则补母”的意义。至于皮肤干枯、肌肉消瘦，肢体懈怠、形体羸弱，精髓内部枯竭，筋骨废弛不用，明显属于根本动摇，除了填纳固摄，还有什么办法能使身体振作？枯槁状态怎么能恢复？特别是草木药物无情，必须借助动物类的脂膏，来补充人身体的血液，煎剂和丸剂同时服用，分别调理脾肾。如同炼石补天，才能收到晚年的疗效。调理治疗二十天，虽然未见大效，但在处境烦躁急迫的情况下，还能支撑，未尝不是依赖药物扶持的力量。七年的老病，需要三年的陈艾来灸治，本来就没有速效。春季三个月叫做发陈，严格服用煎剂和丸剂，春气得以生发，夏季就可以生长。一阳来复，自然可以霍然痊愈。前面的医案已经详细说明了病机，其中奥义难以揣测的，还有几点，请再陈述一下。凡人患病如果是劳累所致，反而觉得精神强健的，这是因为阴火沸腾，在内部扶助（掩盖了正气），不觉察到元气的衰弱；如果静养调适，反而觉得神疲气弱的，这是因为阴火退去，本来的真相显露出来的缘故。病情有类似这种情况的，是一。
“解㑊”（肢体松懈无力）这一症状，是由于肝肾二经的虚损。肝虚则筋软无力以约束周身，肌肉都涣散而像解体一样；肾虚则骨痿不能自强，遍体骨节都松懈而多软弱，所以神情抑郁。好像不知道自己是个人似的，病情有类似这种情况的，是二。男子精气未满而早早地耗泄精气，五脏就有不满的地方，日后会有难以形容的疾病。病情有类似这种情况的，是三。卫气白天行于阳分主清醒，夜晚行于阴分主睡眠。普通人夜间躺卧，则阳气上升阴气下降，阴阳交合，然后渐渐进入梦乡。如果营弱卫强，心肾失交，神明之地扰乱不安，万般思绪纷乱，驱赶不去，卫气刚进入阴分，契合浅薄而脱离迅速，升者又升，降者又降，所以在想要入睡的时候，忽然惊醒而醒了。病情有类似这种情况的，是四。至于饮食虽然能勉强进食，腹中常觉得不畅快的，是胃负责受纳的功能正常，但脾失去健运的职责。大便干燥结硬，几天才排便一次的，是肠道脂液枯涩，传导艰难。胃脘部时常疼痛的，是木缺乏水的涵养，肝气愤怒张狂而逼迫膈膜。心脏偶尔悸动怔忡的，是营血虚的缘故。手臂上有很多青色的脉络，是血脱的征象。更有皮肤肌肉之间，时常感觉像冰水滴落，证状奇特，医书未曾记载。曾治疗一位妇女患此疾，数年投用补药一百剂而痊愈。这难道不是因为气血空虚，失去了温煦分肉、充实腠理的功能吗？
安波按语：先生阐发经典义理，善于发掘古人的深意。
The *Neijing* states: When Wei Qi (Defensive Qi) is deficient, there is aversion to cold; when Ying Blood (Nutritive Blood) is deficient, there is fever. The patient presents with alternating chills and heat every afternoon/evening, persisting for several months. This is indeed a deficiency of both Ying and Wei Qi, and certainly not an external pathogenic invasion. Since the disease belongs to deficiency, deficiency should be treated with tonification. Yesterday, after taking tonic prescriptions, the chest and diaphragm became more distended and stifled. The mechanism here is difficult to fathom. It is not that the medicine cannot address the disease, but rather that Stomach Qi fails to transport the medicinal power. If upper deficiency extends to the Stomach, or lower deficiency extends to the Spleen, even Bian Que (Yue Ren) would find it daunting. For now, let us follow the classic principles: for consumptive deficiency diseases, sweet medicines should be used. After administering sweet medicines twice, the chills and heat remain unchanged, although food intake has slightly increased and coughing has eased somewhat; the prescription seems to match the symptoms. Examining ancient methods for tonifying deficiency, though there are thousands of paths, the key always lies in the Spleen and Stomach as the mainstay. The human body, internally the five zang and six fu organs, externally the skin, flesh, meridians, and collaterals, all rely on the nourishing power of Gu Qi (Grain Qi). If the Earth Mother (Spleen/Stomach) collapses, it can neither transform the essence from dietary intake nor transmit medicinal power; hence, why deficiency cannot tolerate tonification. The *Nanjing* elucidates the five types of damage, warning not to exceed the capacity of the Spleen and Stomach; Zhang Zhongjing, in treating various deficiencies of consumptive disease, demonstrated exceptional skill. His established Jianzhong methods all adhere to the principle that "sowing and reaping produce sweetness" (referring to the Spleen's association with Earth and the Sweet flavor). This is a clear instruction from ancient sages; in severe internal injury diseases, how can one fail to prioritize the Spleen and Stomach? However, if the condition is real but the treatment is false (ineffective), success will ultimately be hard to achieve.
The illness has lasted half a year. Correlating pulse and symptoms, it fundamentally stems from constitutional deficiency and excessive mental/physical labor, leading to a failure of communication between Kan (Water/Kidney) and Li (Fire/Heart), loss of mutual assistance between Water and Fire, depletion of the Five Fluids internally, and floating Yang failing to anchor. Misuse of bitter-cold herbs severely attacked Stomach Qi, causing various symptoms to arise蜂-like and persist endlessly. According to ancient teachings, deficiency that can accept tonification is treatable; deficiency-fire can be treated with tonification, such as Ginseng (Renshen); excess-fire can be treated with purgation/clearing, such as Scutellariae Radix (Huangqin) and Coptidis Rhizoma (Huanglian). Is the fire caused by labor injury deficiency or excess? Can it be purged? Zhao Xianke stated that fire due to Yin deficiency is like a lamp where the oil is dry, causing the flame to burn fiercely; it must be nourished with oil/ghee, advocating specifically for tonifying Yin. This view is correct. However, Yin is born from Yang, and Blood is born from Qi. Given the current symptoms of poor appetite, desire to vomit, and epigastric fullness/discomfort, it is difficult to forcefully administer cloying/nourishing herbs. After repeated deliberation, the only strategy is to cultivate the Spleen and Stomach, silently operating the Kun Yuan (Earthly Origin), as the first move. The Spleen is the Mother of Earth; if it can secure grain, vitality prospers. The *Jinkui Yaolue* treats consumptive disease primarily with Jianzhong Decoction. Yue Ren said, for damage to the Spleen, regulate the diet. As Spleen Yuan strengthens daily, dietary intake increases, transforming into essence to nourish the zang-fu organs. Without directly extinguishing fire, fire self-extinguishes; without directly moistening dryness, dryness self-moistens. The functions of filling the skin and warming the flesh can gradually appear. However, internal injury diseases require introspection and quiet rest. It is said that major illnesses require major medicines. What is called a "major medicine" is aligning with the Heaven and Earth: following Spring and Summer for generation, while keeping the mind silent like Autumn and Winter for storage. Penetrating this barrier, assisting the limitations of herbal medicines, is the subtlety. After ten days of medication, the pulse image slightly improved, sleep and appetite slightly stabilized, but the knees and feet remained sore and weak, the neck and spine occasionally painful, and the form and spirit exhausted. Examining the treatment of five zang deficiencies, the *Nanjing* explains it thoroughly: damage to the Lung benefits Qi; damage to the Heart regulates Ying and Wei; damage to the Spleen regulates diet and adjusts to cold/warmth; damage to the Liver moderates the interior; damage to the Kidney benefits Essence. It elucidates the subtle details without omission. Re-examining the *Jinkui*, it states: In men, a large pulse indicates Lao (consumptive disease), and extreme emptiness also indicates Lao. A large pulse signifies leakage of True Qi and exhaustion of Heart and Spleen; this is suitable for Guipi Tang, Jianzhong Tang, Yangying Tang, and Six Gentlemen Decoction. Extreme emptiness indicates internal deprivation of Essence and Blood and decline of Liver and Kidney below; this is suitable for Liuwei Wan, Bawei Wan, Tianzhen Wan, and Dazao Wan. However, since symptoms are diverse, treatment must proceed in order. First, use "sowing and reaping produces sweetness" to cultivate the Middle Palace, specifically revering Earth; second, nourish Heart and Spleen. Because the Heart is Li-Yang, tonifying Heart Yang generates Stomach Earth, which is the meaning of "tonifying the mother when deficient." As for dry skin, emaciated flesh, flaccid limbs, wasted form, internal exhaustion of essence and marrow, and laxity of sinews and bones, this clearly indicates the root has been uprooted. Apart from filling and securing, how can the body be revitalized? How can the withered state return? Specifically, herbaceous medicines are emotionless; one must borrow animal fats and oils to replenish human blood. Decoctions and pills should be taken together, administered separately to Spleen and Kidney. Like smelting stones to repair the sky, one can achieve results in later years. After twenty days of regulation, although no great effect was seen, being able to endure the烦躁 and urgency suggests reliance on the support of medication. A seven-year illness requires three-year-old Mugwort (Ai Ye); there is naturally no quick cure. The three months of Spring are called "Fa Chen" (releasing the old); strictly taking decoctions and pills allows Spring Qi to generate, and Summer to grow. With the return of one Yin (or Yang, context implies recovery), recovery will naturally occur. The disease mechanism was detailed in previous cases; among the profound meanings difficult to fathom, there are several points, please allow me to elaborate further.
When a person is ill due to labor/exertion but feels spiritually robust, this is because Yin Fire is boiling and assisting internally, masking the weakness of Yuan Qi. Conversely, if quiet rest leads to feeling spiritually tired and Qi weak, this is because Yin Fire recedes, revealing the true state. One type of condition resembles this. The symptom of "Xie Jie" (limb laxity/sagging) stems from deficiency in the Liver and Kidney meridians. Liver deficiency causes sinews to be soft and unable to bind the body, making muscles scatter as if disintegrating; Kidney deficiency causes bone萎 (flaccidity) and inability to support oneself, making joints throughout the body loose and weak, resulting in depression. It feels as if one does not know they are human. Another type resembles this. If a man exhausts his Jing (Essence) before it is fully developed, the five zang will have unfulfilled aspects, leading to indescribable diseases in the future. Another type resembles this. Wei Qi travels through Yang during the day (maintaining wakefulness) and Yin at night (maintaining sleep). In healthy people lying down at night, Yang rises and Yin descends, Yin and Yang interact, and then sleep gradually ensues. If Ying is weak and Wei is strong, Kan and Li fail to mate, disturbing the realm of Shen (Spirit), causing chaotic thoughts that cannot be dispelled. When Wei Qi enters Yin, the connection is shallow and separation is rapid; what rose rises again, what descended descends again. Thus, when trying to sleep, one suddenly startles awake. Another type resembles this. Even if one can force food intake, feeling discomfort in the abdomen indicates the Stomach performs its receiving function, but the Spleen loses its transportation role. Dry, constipated stools occurring only once every few days indicate dry intestines and difficult transmission. Occasional epigastric pain indicates Wood lacking Water nourishment, with Liver Qi angry and distending, pressing against the Diaphragm. Occasional palpitations are due to Ying deficiency. Many blue veins on the arms are a sign of Blood depletion. Furthermore, sometimes feeling like ice drops falling between skin and flesh is a bizarre symptom not recorded in medical books. I once treated a woman with this disease who recovered after taking 100 doses of tonics over several years. Is this not because Qi and Blood were empty, losing the function of warming the muscle spaces and solidifying the cou li (pores)?
An Bo's Note: The Master elucidates classic theories and excels at uncovering the intentions of the ancients.