汪琥注曰：大约治伤寒之法，表证急者，即宜汗，里证急者，即宜下。不可拘拘于先汗而后下也。汗下得宜，治不为逆。何其明澈允当也！由是观之，仲圣假桃核承气汤及抵当汤二条，示人以太阳阳明经权之治，同时引出阳明之方，实无疑义。在仲圣当日临床，原有此种实例，但吾人居今日而读大论，却不可固执此例，以为用二方之法门。使其过于胶执，恐二方将永无可用之时，而患二方证者反永不得主治之方，宁不可哀乎？读者试察所列二方各案，其有太阳病者乎？无有也，斯可知二方实专属阳明无疑矣。窃以太阳经府之说盛行，贤者不发其非，而反惑焉，用是不殚辞费而辨之。
抵当丸证
常熟鹿苑钱钦伯之妻，经停九月，腹中有块攻痛，自知非孕。医予三棱、莪术多剂，未应。当延陈葆厚先生诊。先生曰：三棱、莪术仅能治血结之初起者，及其已结，则力不胜矣。吾有药能治之。顾药有反响，受者幸勿骂我也。主人诺。当予抵当丸三钱，开水送下。入夜，病者在床上反复爬行，腹痛不堪，果大骂医者不已。天将旦，随大便，下污物甚多。其色黄白红夹杂不一，痛乃大除。次日复诊，陈先生诘曰：昨夜骂我否？主人不能隐，具以情告。乃予加味四物汤，调理而瘥。
曹颖甫曰：痰饮证之有十枣汤，蓄血证之有抵当汤丸，皆能斩关夺隘，起死回生。近时岐黄家往住畏其猛峻，而不敢用，即偶有用之者，亦必力为阻止，不知其是何居心也。
白头翁汤证
米右方浜路肇方弄十四号年七十有八，而体气壮实，热利下重，两脉大，苔黄，夜不安寐，宜白头翁汤为主方。
白头翁三钱秦皮三钱川连五分黄蘗三钱生川军三钱后下枳实一钱桃仁泥三钱芒硝二钱另冲
【按】米姓妇家贫。有一子，现年三十余龄，卖旧货为业，不娶妻，母病卧床匝月，无力延医，安奉汤药！便器秽物悉其子亲洁之。史君惠甫有姑母居相近，闻妇苦病，慨代延师出诊。本案方系初诊方，即系末诊方。何者，老妇服此之后，得快利，得安寐，复何求者？依法，病后当事调理。但妇以劳师远驾，心实不安，即任之。竟复健康如中年人。
余尚忆曾治一杨左白头翁汤证，其脉案曰：利下，色鲜红，日二十行，无表证，渴欲饮水，脉洪大。论曰：热利下重者，又曰：下利欲饮水者，以有热故也，白头翁汤主之。其药味为白头翁三钱，秦皮三钱，枳实二钱，黄连五分，生甘草钱半，黄芩钱半，黄蘗三钱，覆诊大效。
夫肠中热而有燥矢者，此为实热，宜承气汤。肠中热而无燥矢者，此为虚热，（在比较上言，犹言空虚之意）宜白头翁汤。胃里有实邪者，宜吐法，用瓜蒂散。
胃里有虚热（亦在比较上言）者，宜清法，用白虎汤。故胃之有白虎，无异肠之有白头翁。肠之有承气，无异胃之有瓜蒂。然而胃患虚热时多，患实邪时少，肠患实热时多，患虚热时少。仲圣取其多者常者为法，故立白虎承气为阳明正治，而以瓜蒂白头翁为阳明辅治。若问肠何以患实时多，胃何以患虚时多？曰：胃居肠上，肠生胃下，上者可以传之下，下者莫能还之上也。经旨点穿，令人微笑。
猪胆汁导证
门人张永年述其戚陈姓一证，四明医家周某用猪胆汁导法奏效，可备参究。其言曰：陈姓始病咯血，其色紫黑，经西医用止血针，血遂中止。翌日病者腹满，困顿日甚。延至半月，大便不行。始用蜜导不行，用灌肠法，又不行。复用一切通大便之西药，终不行。或告陈曰：同乡周某良医也。陈喜，使人延周，时不大便已一月矣。周至，察其脉无病，病独在肠。乃令病家觅得猪胆，倾于盂，调以醋，借西医灌肠器以灌之。甫灌入，转矢气不绝。不逾时，而大便出。凡三寸许，掷于地，有声，击以石，不稍损。乃浸以清水，半日许，盂水尽赤。乃知向日所吐之血，本为病血，因西医用针止住，反下结大肠，而为病也。越七日，又不大便，复用前法，下燥矢数枚，皆三寸许，病乃告痊。予于此悟蜜煎导法惟证情较轻者宜之。土瓜根又不易得。惟猪胆汁随时随地皆有。近世医家弃良方而不用，为可惜也。
【按】本案见《伤寒发微》，以其可备一格，故特转录于此，凡大便多日未行，甚且在十日以上，又不下利清水者，是盖燥矢结于直肠部分。矢与肠壁粘合甚切，故愈结愈不能下。此时倘用硝黄以治之，不惟鞭长莫及，抑将徒损胃气，伐其无辜，此导法之所由作也。蜜煎导法为轻，但能用之合度，亦每克奏肤功。
友人黄君有祖母，年已九十余龄矣。遘病旬日，不大便，不欲食，神疲不支。群医束手，不敢立方。卒用灌肠器，灌入蜜汁。粪秽既下，诸恙竟退，获享天年，此其例也。近者药房制有甘油锭，施用较便，可以为代。倘用二三锭后，依然无效者，不妨续施。因肠壁热甚者，二三锭尚不敷濡润用也。若蜜汁或锭皆不胜任，则须用猪胆汁。盖人之胆汁本有润肠之功，今以猪胆为代，亦所谓藏器疗法之变局也。
猪胆汁须和醋少许者，似欲借醋以刺激其肠壁，而促进其蠕动。故蜜锭之制，有时亦加以少许皂角末，实同此意。皂角粉少许吹入鼻孔中，即作喷嚏，其刺激之功为何如？
麻子仁丸证
徐左能食，夜卧则汗出，不寐，脉大，大便难，此为脾约。
脾约麻仁丸一两作三服，开水送下。
【按】麻子仁丸原方为麻子仁二升，芍药半斤，枳实半斤炙，大黄一斤去皮，厚朴一尺炙去皮，杏仁一升去皮尖熬别作脂，等六味，蜜和丸，如梧桐子大。今药铺中通称曰脾约麻仁丸者，即是也。本方以麻子仁为君，凡仁中皆有油质，功能润下，故借之以通便，施于虚弱体质之不胜攻伐者允宜。
以上自大陷胸汤至麻子仁丸凡七证，虽有缓急之分，皆不离下法。或以结胸为主，或以瘀血为主，或以蓄血为主，或以热利为主，或以肠燥为主，其病所或偏于上，或偏于中，或偏于下。夫下则通，通则不痛，此治阳明热结之总诀也。
下卷
神志恍惚
【按】友人施君，崇明人也，服务上海电报局。甲戌孟秋某晚，匆匆邀诊乃弟病。入其室，见病者仰卧塌上。叩其所苦，绝不应。余心异之。私谓施君曰：乃弟病久耳聋，无所闻乎，抑舌蹇不能言乎？则皆曰：否。余益惊异。按其脉，一手洪大，一手沈细，孰左孰右，今已莫能记忆。因询家人以致病之由。曰：渠前任某军电职，因事受惊，遂觉神志恍惚。每客来，恒默然相对，客去，则歌唱无序。饮食二便悉如常人，惟食时阙上时有热气蒸腾，轻则如出岫朝云，甚则如窑中烟，状颇怪特。前曾将渠送往本市某著名医院诊冶，经二十余日，医者终不识其为何病，既无术以疗，故于昨日迁出，请先生一断。余细按其腹，绝不胀满，更不拒按。沈思良久，竟莫洞其症结。于是遂谢不敏，郝然告辞。越日，施君告余曰：舍弟之病，昨已延曹颖甫先生诊治。服药后，大泄，阙上热气减。余闻而愕然，遂急访之，并视所服方。忆其案尾略曰：此张仲景所谓阳明病也，宜下之，主以大承气汤。方为：生大黄三钱枳实三钱芒硝三钱冲厚朴一钱又越数日，余再晤施君，悉其弟服药后，已能起床，且不歌唱。惟两肋胀痛，经曹师诊治，顷又愈矣。审其方，乃小柴胡汤也。
柴胡三钱黄芩三钱党参三钱半夏三钱生姜三片大枣十二枚甘草二钱嗣是施君之弟似可告无恙矣，顾尚苦自汗，精神不振。又经曹师投以桂枝加龙牡汤，一剂而愈。
川桂枝三钱大白芍三钱生草二钱生姜三片大枣十二枚花龙骨五钱煅牡蛎五钱以上二味先煎自此以后，健康逾常人。一日与兄俱出，值余于途，各微笑额首以过。翌日遇施君，问其弟昨日途间作何语。施曰：无他。固诘之，乃笑曰：彼说吾兄脉理欠精耳。余不禁重为郝然。于是深服吾师医术之神，遂执贽而列门墙焉。
【又按】本案病者所患似系所谓精神病，或神经病。顾西医用神经药治之，绝不见效。中医用经方治之，反奏肤功。其理深奥，莫可究诘，殆所谓治病必求其本欤？按初方系阳明方，次方系少阳方，末方系太阳方。以三方疏其三经之阻滞，诸恙乃痊，殆当日受凉之时，周身筋络器官，即因惊而有所滞乎？顾饮食二便如常，腹不痛，又不拒按，谁复有胆，敢用承气？乃吾师独以阙上热气之故，遂尔放胆用之，殆所谓但见一证便是，不必悉具之意乎？曹颖甫曰：此证予亦不能识，惟诊其脉，则右极洪大，左极微细，阴不足而阳有余，意其为少阴负趺阳之脉，而初非逆证。加以热气出于阙上，病情正属阳明，与右脉之洪大正合。故决为大承气汤的证，而不料其应乃如响也。
肠痈其一
史惠甫住上海城内方浜路七七五号三楼
【按】史惠甫君前以病来诊，曰：我时患腹痛，药则少瘥，隔日辄发，医者以为疝气，常用理气之剂云云。余细诊之，乃肠痈也，即西医所称盲肠炎，腹膜炎之类是。当用药攻之，稍瘥，数日又发，案及处方如下。
腹痛偏右，瘥而复发，便燥结，拟大黄牡丹汤。
生川军钱半元明粉三钱冲桃仁二钱丹皮二钱败酱草三钱生苡仁四钱熟附块一钱枳实炭二钱大白芍二钱佛手钱半此四月十八日方也，服三剂，所下甚多，腹痛大减。至二十五日，仅觉患处隐隐作痛矣，易医治之，与以疏泄厥气之剂，方为： 软柴胡钱半枳实炭二钱大白芍二钱青陈皮各钱半云苓三钱香附二钱金铃子三钱炙乳没各八分小茴香八分炙枸桔三钱青桔叶钱半路路通三钱服后一日，病无进退。二日，腹胀转剧，又来请诊。察之，向之腹偏右胀痛者，今则满腹左右皆胀矣。按之不甚有反抗力，经文中腹皮急，按之濡六字，确是形容尽致，不能更易。病者蹙頞相告曰：将如之何？余曰：无虑，前方尚可用。乃书曰：肠痈旋瘥旋发，刻诊小腹四围作胀，按之濡，隐隐痛，大便不爽，再拟原法。
生川军三钱粉丹皮三钱冬瓜子四钱芒硝三钱冲桃仁三钱败酱草三钱熟附块钱半大白芍四钱焦查炭三钱细青皮钱半此方午刻服下，下午无动静，至夜半方欲便，下秽物甚多。次日又来诊，曰：下后腹中略舒矣。余视之，病虽减其一二，殊不了了。曰：昨方虽合，尚嫌轻也。
史君曰：然则如之何？曰：当请吾师用重方，君有胆量服之否？曰：愿听命。乃谒师，作初诊。
初诊肠痈屡经攻下，病根未拔。昨由姜君用大黄牡丹汤，腹胀略减。以证情论，仍宜攻下，仍用原法加减。
生川军五钱后入冬瓜仁一两桃仁八十粒粉丹皮一两当归五钱芒硝三钱冲杜赤豆四两煎汤浓后入前药
【按】史君持本方至药铺配药，铺中人有难色。曰：安用若许剧药耶？史君曰：毋虑，此种药予已屡服之矣。铺中人曰：然则此郎中年几何矣？曰：七十余龄矣。曰：然，是诚有经验学问之医也。乃慨予药。据史君言，服后四小时即得便下，较向之服予方用大黄三钱，须逾十小时方得下者，爽快多矣。其夜所下最多，皆黑色臭秽之物。更衣频数，至不可数。而快下之后，腹痛大减，肿胀亦消，次日乃来二诊。
二诊昨用大黄牡丹汤，加当归赤豆。所下粘腻赤色之物，非脓非血。此种恶浊久留肠中，必化为黑色之河泥状。服汤后，肠中有水下行，作漉漉声。盖此证肠中必有阻塞不通之处，故谓之痈。痈者，壅也。然则不开其壅，宁有济乎？病根未拔，仍宜前法减轻。
生川军三钱丹皮五钱桃仁五十粒当归五钱冬瓜仁一两赤芍五钱芒硝二钱冲败酱草五钱杜赤豆四两煎汤后入前药
【按】史君服此方凡二日，计二剂，夜间皆大下，甚至疲于奔波床第与便具之间。所下除河泥状污物外，更有白色之脓水。下此水时，每作剧痛。史君自曰，计吾三日夜所下之物，当已满一器有半。吾腹虽大，乃何来若许污物，斯亦奇矣！第三日史君服此原方，余亲访之于其私宅。史君曰：我昨未告老师以所下之物如河泥状，而老师立案，乃径曰：必化为黑色之河泥，噫，何其神也！余笑颔之。坐谈有顷，因询史君以得病之由。曰：昔年患病，常不服药。家严笃信仙佛，每以香灰令服，病因其在此乎？但斯时史君所下者，已由黑色渐变为紫红之咖啡色矣。
三诊两进加味大黄牡丹汤，肠中宿垢渐稀。惟脐右斜下近少腹处，按之尚痛，则病根尚未尽去也。仍用前法，减硝黄以和之。
粉丹皮一两冬瓜子一两生苡仁一两桃仁泥五钱败酱草五钱京赤芍六钱生甘草二钱当归五钱桔梗三钱杜赤豆四两煎汤代水
【按】史君服此凡六剂，所下之物，渐由咖啡色转为绿色。而绿色之中更杂有如蚕砂之黑粒。少腹痛处较瘥，惟上行之筋反觉微微牵引不舒。六剂之后，停药二天，乃行四诊。
四诊肠痈近已就痊，惟每日晨起大便，患处尚觉胀满，恐系夙根未除。然下经多次，血分大亏，时时头晕，脉大，虚象也。当以补正主治，佐以利下焦水道。
大川芎一两全当归五钱大熟地四钱春砂仁一钱赤白芍各三钱猪苓三钱明天麻四钱陈皮三钱泽泻二钱生白术五钱冬葵子五钱
【按】史君服此补正分利之剂后，前之大便时痛者，今已不痛矣。且其前色绿者，今亦转黄矣。惟七分黄之中，仍有三分绿耳。史君前有遗精宿恙，此时又发。或系本方分利药太重之故欤？惟遗后绝不疲劳，则亦无妨焉。
肠痈其二
汪琥注释说：大抵治疗伤寒的方法，表证急迫的，就应当发汗；里证急迫的，就应当攻下。不可以拘泥于必须先发汗然后才攻下的顺序。汗法和下法使用得当，治疗就不会出现逆乱。这话说得多么明澈恰当啊！由此看来，张仲景借用桃核承气汤和抵当汤这两条条文，是向人们展示太阳病与阳明病在经权和变通上的治法，同时引出阳明病的方剂，这是毫无疑问的。在张仲景当时的临床实践中，原本就有这样的实例，但是我们生活在今天来阅读《伤寒论》，却不可固执地认为这是使用这两个方子的固定法门。如果过于胶着执着，恐怕这两个方子将永远没有机会被使用，而患有这两个方子对应证候的患者反而永远得不到主治的方药，这难道不可悲吗？读者试着考察所列的两个方子的各则医案，其中有太阳病的吗？没有啊，由此可知这两个方子确实专属于阳明病，这是毫无疑问的。我私下认为，关于“太阳经府”的说法盛行，贤能的人不指出其错误，反而感到困惑，因此我不惜言辞烦琐来辨析这个问题。
抵当丸证
常熟鹿苑的钱钦伯的妻子，月经停止九个月，腹中有肿块攻冲作痛，自己知道不是怀孕。医生给予三棱、莪术多剂服用，没有见效。于是延请陈葆厚先生诊治。先生说：“三棱、莪术只能治疗血结初起的情况，等到已经结成块了，力量就不够了。我有药能治好它。但是服药后会有反应，希望患者不要骂我。”主人答应了。当时给予抵当丸三钱，用开水送服。入夜，病人在床上反复爬行，腹痛难忍，果然大骂医生不停。天快亮时，随着大便排出，排出了很多污物。颜色黄白红夹杂不一，疼痛才大大缓解。第二天复诊，陈先生问：“昨晚骂我了吗？”主人不能隐瞒，把事情原委告诉了他。于是给予加味四物汤，调理后痊愈。
曹颖甫说：痰饮证有十枣汤，蓄血证有抵当汤和抵当丸，都能斩关夺隘，起死回生。近代中医往往畏惧其猛烈峻烈，而不敢使用，即使偶尔有人使用，也必定极力阻止，不知道他们是什么居心。
白头翁汤证
米右方浜路肇方弄十四号，一位七十八岁的老人，体质壮实，热利且伴有里急后重，两脉洪大，舌苔黄，夜间不能安睡，适宜以白头翁汤为主方。
白头翁三钱 秦皮三钱 川连五分 黄蘗三钱 生川军三钱（后下） 枳实一钱 桃仁泥三钱 芒硝二钱（另冲）
【按】米姓妇人家里贫穷。有一个儿子，现年三十多岁，以卖旧货为业，没有娶妻。母亲卧床生病一个月，无力请医生，怎么供养汤药呢！便器中的秽物都是她儿子亲自清理的。史君惠甫有一位姑母住在附近，听说妇人苦于疾病，慷慨地代为延请医生出诊。本案的方子是初诊方，也就是末诊方。为什么呢？老妇人服用此方后，得到了通畅的大便，能够安睡，还有什么可求的呢？按照常理，病后应当进行调理。但妇人因为劳师远道而来，心里实在不安，于是就听任她回家。竟然恢复得像中年人一样健康。
我还记得曾治疗过一位杨姓患者的白头翁汤证，其脉案记载如下：腹泻，血色鲜红，每天二十次，没有表证，口渴想喝水，脉象洪大。经文说：热利且伴有里急后重者，又说：下利想要喝水的，是因为有热，用白头翁汤主治。其药物组成是：白头翁三钱，秦皮三钱，枳实二钱，黄连五分，生甘草钱半，黄芩钱半，黄蘗三钱。复诊时效果显著。
肠道中有热且有燥屎的，这是实热，适宜用承气汤。肠道中有热但没有燥屎的，这是虚热（从比较的角度来说，犹言空虚之意），适宜用白头翁汤。胃里有实邪的，适宜用吐法，用瓜蒂散。
胃里有虚热（也从比较的角度来说）的，适宜用清法，用白虎汤。所以胃中有白虎汤，就像肠中有白头翁汤一样。肠中有承气汤，就像胃中有瓜蒂散一样。然而，胃患虚热的情况多，患实邪的情况少；肠患实热的情况多，患虚热的情况少。张仲景选取多的、常见的作为法则，所以确立白虎汤和承气汤为阳明病的正治法，而以瓜蒂散和白头翁汤为阳明病的辅治法。如果问为什么肠患实热的情况多，胃患虚热的情况多？回答说：胃位于肠之上，肠位于胃之下，上面的可以传导到下面，下面的却不能返还到上面。经典旨意点破这一点，令人会心微笑。
猪胆汁导证
门人张永年叙述他亲戚陈姓的一例病例，四明医家周某用猪胆汁导法奏效，可供参考研究。他说：陈姓起初患病咯血，血色紫黑，经过西医注射止血针，血随即停止。第二天病人腹部胀满，困顿日益加重。拖延到半个月，大便不通。开始用蜜导法不行，用灌肠法，也不行。再用各种通便的西药，最终也不通。有人告诉陈某说：“同乡周某是良医。”陈某很高兴，派人去请周某。此时不大便已经一个月了。周某来到，诊察其脉象无病，病独独在肠道。于是让病人家属找来猪胆，倒在盆中，调和醋，借西医灌肠器进行灌入。刚灌入，转矢气（放屁）不断。不到一个时辰，大便排出。大约三寸长，扔在地上，发出声响，用石头击打，丝毫不受损伤。于是浸泡在清水中，约半天时间，盆水尽变红色。才知道往日所吐之血，本是病血，因为西医用针止住，反而下行凝结在大肠，成为致病原因。过了七天，又不大便，再次用前法，排出干燥粪便数枚，都长约三寸，病才告痊愈。我于此领悟到，蜜煎导法只适用于病情较轻者。土瓜根又不容易得到。只有猪胆汁随时随地都有。近代医家抛弃良方不用，真是可惜。
【按】本案见于《伤寒发微》，因为它可以作为一种范例，所以特意转录在此。凡是多天未行大便，甚至十天以上，又没有下利清水的，这是燥屎结于直肠部分。粪便与肠壁粘合紧密，所以越结越不能下行。此时如果用硝黄来治疗，不仅鞭长莫及，而且将会徒然损伤胃气，伐及无辜，这就是导法产生的原因。蜜煎导法较为轻缓，但只要使用得当，也能取得皮肤之功（指表面或轻微的效果）。
友人黄先生的祖母，年龄已九十多岁。生病十天，不大便，不想吃东西，精神疲惫不堪。众医束手无策，不敢开方。最终用灌肠器，灌入蜜汁。粪秽既下，诸病竟退，得以享尽天年，这就是例子。近来药房制有甘油锭，施用较方便，可以代替。如果使用二三锭后，依然无效的，不妨继续施用。因为肠壁热甚者，二三锭尚不够濡润之用。如果蜜汁或锭都不胜任，就必须用猪胆汁。因为人的胆汁本来有润肠的功效，现在用猪胆代替，这也算是藏器疗法的一种变局。
猪胆汁须和少许醋，似乎是借醋来刺激其肠壁，从而促进蠕动。所以蜜锭的制作，有时也加入少许皂角末，实则是同样的意思。将少许皂角粉吹入鼻孔中，就会打喷嚏，其刺激作用是何等强烈？
麻子仁丸证
徐左能进食，夜间睡觉出汗，失眠，脉大，大便困难，这是脾约证。
脾约麻仁丸一两，分三次服用，用开水送下。
【按】麻子仁丸原方为：麻子仁二升，芍药半斤，枳实半斤（炙），大黄一斤（去皮），厚朴一尺（炙，去皮），杏仁一升（去皮尖，熬，别作脂），共六味，蜜和丸，如梧桐子大。如今药铺中通常称为脾约麻仁丸的，就是此方。本方以麻子仁为君药，凡种子仁类中都含有油质，功能润下，所以借此来通便，施用于虚弱体质、不胜受攻伐的患者是适宜的。
以上自大陷胸汤至麻子仁丸共七个证候，虽然有缓急之分，都离不开下法。有的以结胸为主，有的以瘀血为主，有的以蓄血为主，有的以热利为主，有的以肠燥为主，病位有的偏于上，有的偏于中，有的偏于下。下法则通畅，通则不痛，这是治疗阳明热结的总诀。
下卷
神志恍惚
【按】友人施君，是崇明人，在上海电报局工作。甲戌年初秋某晚，匆匆邀请我去诊治他弟弟的病。进入他的房间，见病人仰卧在榻上。询问病人的痛苦，完全不应答。我心里很奇怪。私下对施君说：“你弟弟病了很久耳聋，听不见吗？还是舌强不能说话？”他们都回答：“不是。”我更感惊异。诊察其脉，一手洪大，一手沉细，哪边左哪边右，现在已经记不清了。于是询问家人导致发病的原因。说：“他前任某军队电报职务，因事受惊，于是觉得神志恍惚。每当客人来，总是默默相对，客人走后，就无序地歌唱。饮食和二便都像常人，只是在吃饭时阙上（眉心上方）时有热气蒸腾，轻则像山间早晨的云气，重则像窑中的烟，形状颇为怪异奇特。之前曾将他送到本市某著名医院诊治，经过二十多天，医生始终不认识这是什么病，既然没有办法治疗，所以在昨天搬出来，请先生诊断。”我仔细按压他的腹部，绝不胀满，更不拒按。沉思良久，竟然无法洞察症结所在。于是便推辞说自己无能，羞愧地告辞。第二天，施君告诉我：“舍弟的病，昨天已延请曹颖甫先生诊治。服药后，大泻，阙上热气减少。”我听了愕然，急忙去拜访，并查看所服的方子。记得案尾略写：“这是张仲景所说的阳明病，适宜攻下，主以大承气汤。”方药为：生大黄三钱，枳实三钱，芒硝三钱（冲），厚朴一钱。又过了几天，我再见到施君，得知他弟弟服药后，已经能起床，且不唱歌了。只是两肋胀痛，经曹老师诊治，刚才又好了。审查其方，乃小柴胡汤。
柴胡三钱 黄芩三钱 党参三钱 半夏三钱 生姜三片 大枣十二枚 甘草二钱。此后施君的弟弟似乎可以告无恙了，但仍苦于自汗，精神不振。又经曹老师投以桂枝加龙牡汤，一剂而愈。
川桂枝三钱 大白芍三钱 生草二钱 生姜三片 大枣十二枚 花龙骨五钱 煅牡蛎五钱（以上二味先煎）。自此以后，健康超过常人。一天与哥哥一起出门，在路上遇到我，各自微笑点头而过。第二天遇到施君，问他弟弟昨天在路上说了什么。施君说：“没什么。”我坚持追问，他才笑着说：“他说我哥哥脉理欠精罢了。”我不禁再次感到羞愧。于是深深佩服老师的医术之神妙，于是带着礼物列入门墙拜师。
【又按】本案病人所患似乎是所谓精神病，或神经病。但西医用神经药治疗，绝不见效。中医用经方治疗，反而取得显著疗效。其道理深奥，不可究诘，大概就是所谓治病必求其本吧？按初方系阳明方，次方系少阳方，末方系太阳方。用三方疏通这三经的阻滞，诸病乃痊愈，大概是当日受凉之时，周身筋络器官，即因惊吓而有阻滞吗？但饮食二便如常，腹部不痛，又不拒按，谁又有胆量敢用承气汤？然而我的老师唯独因为阙上热气的原因，就大胆使用，这大概就是所谓但见一证便是，不必悉具的意思吧？曹颖甫说：这个证我也不能识别，惟独诊察其脉，则右脉极洪大，左脉极微细，阴不足而阳有余，意思是其为少阴负趺阳之脉，而非逆证。加上热气出于阙上，病情正属阳明，与右脉之洪大正合。所以决断为大承气汤的确切证候，而没有料到应验如此迅速。
肠痈其一
史惠甫住上海城内方浜路七七五号三楼
【按】史惠甫君之前因病来就诊，说：“我经常患腹痛，吃药则稍好，隔天就发作，医生认为是疝气，常用理气的药剂等等。”我仔细诊察，乃是肠痈，即西医所称的盲肠炎、腹膜炎之类。应当用药攻之，稍有好转，几天后又发作，案卷及处方如下。
腹痛偏右，好转后复发，大便燥结，拟大黄牡丹汤。
生川军钱半 元明粉三钱（冲） 桃仁二钱 丹皮二钱 败酱草三钱 生苡仁四钱 熟附块一钱 枳实炭二钱 大白芍二钱 佛手钱半。这是四月十八日的方子，服三剂，所下之物甚多，腹痛大减。到了二十五日，仅觉得患处隐隐作痛，换医生治疗，给予疏泄厥气之剂，方药为：软柴胡钱半，枳实炭二钱，大白芍二钱，青陈皮各钱半，云苓三钱，香附二钱，金铃子三钱，炙乳没各八分，小茴香八分，炙枸桔三钱，青桔叶钱半，路路通三钱。服后一日，病无进退。二日，腹胀转剧，又来请诊。察之，先前腹偏右胀痛的地方，现在则满腹左右皆胀。按压不甚有反抗力，《内经》中“腹皮急，按之濡”六个字，确实是形容得淋漓尽致，不能更改。病人皱眉告诉我说：“该怎么办？”我说：“不用担心，前方还可以用。”于是写道：“肠痈旋瘥旋发，此刻诊察小腹四周作胀，按之濡，隐隐痛，大便不爽，再拟原法。”
生川军三钱 粉丹皮三钱 冬瓜子四钱 芒硝三钱（冲） 桃仁三钱 败酱草三钱 熟附块钱半 大白芍四钱 焦查炭三钱 细青皮钱半。此方午刻服下，下午无动静，至夜半才想排便，排出秽物甚多。第二天又来诊，说：“下后腹中略舒矣。”我看了一下，病虽减轻一二，仍不理想。说：“昨方的方义虽合，尚嫌药力轻。”
史君说：“那么怎么办？”我说：“应当请我的老师用重方，你有胆量服用吗？”他说：“愿听命令。”于是谒见老师，作初诊。
初诊 肠痈屡经攻下，病根未拔。昨日由姜君用大黄牡丹汤，腹胀略减。以证情论，仍宜攻下，仍用原法加减。
生川军五钱（后入） 冬瓜仁一两 桃仁八十粒 粉丹皮一两 当归五钱 芒硝三钱（冲） 杜赤豆四两（煎汤浓后入前药）
【按】史君拿着本方到药铺配药，铺中人面露难色。说：“为什么要用这么多猛药？”史君说：“不用担心，这种药我已经多次服用了。”铺中人问：“那么这位郎中年纪多大？”说：“七十多岁了。”铺中人叹道：“是的，这确实是有经验学问的医生。”于是慷慨给药。据史君说，服后四小时即得便下，比先前服用我方用大黄三钱，须逾十小时方得下者，爽快多了。那晚所下最多，皆是黑色臭秽之物。更衣频数，以至于数不清。而在畅快排泄之后，腹痛大减，肿胀亦消，第二天便来二诊。
二诊 昨日用大黄牡丹汤，加当归赤豆。所下粘腻赤色之物，非脓非血。这种恶浊久留肠中，必化为黑色之河泥状。服汤后，肠中有水下行，作漉漉声。大概此证肠中必有阻塞不通之处，故谓之痈。痈者，壅也。然而不开其壅塞，哪里有济于事？病根未拔，仍宜前法减轻。
生川军三钱 丹皮五钱 桃仁五十粒 当归五钱 冬瓜仁一两 赤芍五钱 芒硝二钱（冲） 败酱草五钱 杜赤豆四两（煎汤后入前药）
【按】史君服用此方共两天，计二剂，夜间皆大下，甚至疲于奔波于床第与便具之间。所下除河泥状污物外，更有白色之脓水。下此水时，每作剧痛。史君自己说，计算我三个夜晚所下的东西，应当已满一器有半。我肚子虽然大，哪里来这么多污物，这也太奇怪了！第三天史君服用此原方，我亲自去他家私宅拜访。史君说：“我昨天没告诉老师所下的东西如河泥状，而老师立案，竟然直接说：‘必化为黑色之河泥’，唉，何其神妙！”我笑着点头。坐谈片刻，于是询问史君得病的原因。说：“往年患病，常不服药。家父笃信仙佛，每每以香灰令服，病因该在此处乎？但此时史君所下的，已由黑色渐变为紫红之咖啡色了。”
三诊 两次进服加味大黄牡丹汤，肠中宿垢渐稀。惟脐右斜下近少腹处，按压尚痛，则病根尚未尽去也。仍用前法，减硝黄以和之。
粉丹皮一两 冬瓜子一两 生苡仁一两 桃仁泥五钱 败酱草五钱 京赤芍六钱 生甘草二钱 当归五钱 桔梗三钱 杜赤豆四两（煎汤代水）
【按】史君服用此方共六剂，所下的东西，逐渐由咖啡色转为绿色。而绿色之中更杂有如蚕砂之黑粒。少腹痛处较前好转，惟上行之筋反觉微微牵引不舒。六剂之后，停药两天，乃行四诊。
四诊 肠痈近已就痊，惟每日晨起大便，患处尚觉胀满，恐系夙根未除。然下经多次，血分大亏，时时头晕，脉大，虚象也。当以补正主治，佐以利下焦水道。
大川芎一两 全当归五钱 大熟地四钱 春砂仁一钱 赤白芍各三钱 猪苓三钱 明天麻四钱 陈皮三钱 泽泻二钱 生白术五钱 冬葵子五钱
【按】史君服用此补正分利之剂后，之前大便时痛的情况，现在已经不痛了。且之前色绿者，现在也转黄了。惟七分黄之中，仍有三分绿耳。史君前有遗精宿恙，此时又发。或许是本方分利药太重之故欤？惟遗后绝不疲劳，则也无妨焉。
肠痈其二
Wang Hu commented: Generally speaking, in the treatment of cold damage (Shanghan), if the exterior syndrome is urgent, sweating should be induced immediately; if the interior syndrome is urgent, purgation should be applied immediately. One should not rigidly adhere to the sequence of sweating first and then purging. If sweating and purging are applied appropriately, the treatment will not result in adverse reactions. How clear and appropriate this statement is! From this perspective, Zhang Zhongjing's use of the Taohe Chengqi Tang (Peach Kernel Decoction to Order the Qi) and Didang Tang (Definitely Sinking Decoction) in these two clauses demonstrates to people the treatment principles of flexibility and adaptation between the Taiyang (Greater Yang) and Yangming (Yang Brightness) channels. Simultaneously, it introduces formulas for Yangming disease, which is beyond doubt. In Zhang Zhongjing's clinical practice at that time, such instances originally existed. However, we living today reading the *Treatise on Cold Damage* (Shanghan Lun) must not stubbornly regard this as a fixed method for using these two formulas. If one is overly dogmatic, these two formulas may never be used again, and patients suffering from the syndromes corresponding to these formulas will forever be deprived of their primary treatment. Is this not lamentable? Readers, please examine the medical records listed for each of the two formulas. Are there any cases of Taiyang disease? None. Thus, it can be known that these two formulas indeed belong exclusively to Yangming disease, without doubt. I privately believe that the theory of "Taiyang Channel and Fu-organ" has become prevalent. Wise men do not point out its errors but are instead confused by it. Therefore, I do not spare words to analyze and refute it.
Syndrome of Didang Wan (Definitely Sinking Pill)
The wife of Qian Qinbo from Luyuan, Changshu, had her menstruation stopped for nine months. There was a mass in her abdomen causing attacking pain, and she knew herself that it was not pregnancy. The doctor prescribed multiple doses of Sanleng (Sparganii Rhizoma) and Ezhu (Curcumae Rhizoma), but there was no response. They then invited Mr. Chen Baohou for diagnosis. Mr. Chen said: "Sanleng and Ezhu can only treat blood stasis in its initial stage. Once it has already formed a mass, their strength is insufficient. I have medicine that can cure it. However, there will be a reaction after taking the medicine; hopefully, the patient will not curse me." The host agreed. At that time, three qian of Didang Wan were given, taken with boiled water. During the night, the patient crawled repeatedly on the bed, unable to bear the abdominal pain, and indeed cursed the doctor incessantly. Just before dawn, accompanied by stool passage, a large amount of foul matter was discharged. The color varied, mixed with yellow, white, and red. Only then was the pain greatly relieved. On the second day, during the follow-up visit, Mr. Chen asked: "Did you curse me last night?" The host could not hide the truth and told him everything. Then, Jiawei Siwu Tang (Modified Four Substances Decoction) was prescribed. After regulation, the patient recovered.
Cao Yingfu said: For phlegm-fluid retention syndrome, there is Shizao Tang (Ten Date Decoction); for blood-stasis syndrome, there are Didang Tang and Didang Wan. All of these can break through barriers and save lives from deathbeds. Modern practitioners of Huangdi and Neijing (traditional Chinese medicine) often fear their fierce and drastic nature and dare not use them. Even when occasionally used, they are strongly opposed. I do not know what their intentions are.
Syndrome of Baitouweng Tang (Baitouweng Decoction)
No. 14, Zhaofang Nong, Fangbang Road, Mi You. An eighty-year-old woman, whose constitution was robust, suffered from heat-dysentery with tenesmus. Both pulses were large, the tongue coating was yellow, and she could not sleep peacefully at night. It was appropriate to use Baitouweng Tang as the main formula.
Baitouweng (Pulsatillae Radix) 3 qian, Qinpi (Aceris Cortex) 3 qian, Chuanlian (Coptidis Rhizoma) 5 fen, Huangbo (Phellodendri Cortex) 3 qian, Sheng Chuanjun (Rhei Radix et Rhizoma) 3 qian (added later), Zhishi (Aurantii Fructus Immaturus) 1 qian, Taoren (Persicae Semen) paste 3 qian, Mangxiao (Natrii Sulfas) 2 qian (dissolved separately).
[Commentary] The surnamed Mi woman was poor. She had one son, now over thirty years old, who sold second-hand goods and was unmarried. Her mother lay in bed ill for a month. With no money to hire a doctor, how could she afford herbal medicine? The son personally cleaned all excrement from the chamber pots. Mr. Shi Huifu had an aunt living nearby. Hearing of the woman's suffering, he generously paid for a doctor to visit. This case's prescription was both the initial and final prescription. Why? After the old woman took this formula, she achieved free bowel movements and peaceful sleep. What more could she ask for? According to standard practice, post-illness regulation should follow. But the woman felt uneasy about troubling the doctor to travel far, so she was allowed to go home. She eventually regained health comparable to that of a middle-aged person.
I still recall treating a patient surnamed Yang with Baitouweng Tang. The pulse record stated: Diarrhea with bright red blood, twenty times a day, no exterior syndrome, thirst with desire to drink water, pulse was flooding (Hongda). The classic states: "Heat dysentery with tenesmus," and also: "Diarrhea with desire to drink water is due to heat; Baitouweng Tang governs it." The ingredients were: Baitouweng 3 qian, Qinpi 3 qian, Zhishi 2 qian, Huanglian (Coptidis Rhizoma) 5 fen, Sheng Gancao (Glycyrrhizae Radix et Rhizoma) 1.5 qian, Huangqin (Scutellariae Radix) 1.5 qian, Huangbo 3 qian. The follow-up visit showed great efficacy.
When there is heat in the intestines accompanied by dry fecal masses, this is excess heat, and Chengqi Tang (Order the Qi Decoction) is appropriate. When there is heat in the intestines without dry fecal masses, this is deficiency heat (speaking comparatively, meaning emptiness), and Baitouweng Tang is appropriate. When there is excess pathogenic factor in the stomach, the vomiting method is appropriate, using Gouti San (Melon Dispersant Powder).
When there is deficiency heat in the stomach (also speaking comparatively), the clearing method is appropriate, using Baihu Tang (White Tiger Decoction). Thus, having Baihu Tang in the stomach is no different from having Baitouweng Tang in the intestines. Having Chengqi Tang in the intestines is no different from having Gouti San in the stomach. However, the stomach suffers from deficiency heat more often than from excess pathogens; the intestines suffer from excess heat more often than from deficiency heat. Zhang Zhongjing selected the common and frequent patterns as the rule. Therefore, he established Baihu Tang and Chengqi Tang as the principal treatments for Yangming disease, while using Gouti San and Baitouweng Tang as auxiliary treatments. If one asks why the intestines suffer from excess heat more often and the stomach from deficiency heat more often, the answer is: The stomach is above the intestines, and the intestines are below the stomach. What is above can transmit downward, but what is below cannot return upward. The classic insight reveals this, making one smile.
Syndrome of Pig Gallbladder Suppository
My disciple Zhang Yongnian narrated a case of his relative, surnamed Chen. A physician from Siming, Mr. Zhou, achieved success using the pig gallbladder suppository method, which is worth reference. He said: The Chen patient initially suffered from hemoptysis, with purple-black blood. After Western doctors used a hemostatic injection, the bleeding stopped. The next day, the patient's abdomen became full, and exhaustion increased daily. Half a month passed, and defecation did not occur. Honey suppositories were tried first but failed; enemas were tried but failed. Various Western laxatives were used, but ultimately failed. Someone told Chen: "Your fellow townsman Mr. Zhou is a good doctor." Chen was pleased and sent for Mr. Zhou. By then, it had been a month since the last bowel movement. Upon arrival, Mr. Zhou examined the pulse and found no abnormality; the disease was solely in the intestines. He instructed the family to find a pig gallbladder, pour it into a bowl, mix with vinegar, and use a Western enema device to administer it. As soon as it was infused, continuous flatus occurred. Within an hour, stool was discharged. It was about three cun long, made a sound when thrown on the ground, and was undamaged even when struck with a stone. It was soaked in clear water, and within half a day, the water turned completely red. It was realized that the blood vomited earlier was pathological blood. Because Western doctors stopped it with needles, it descended and coagulated in the large intestine, becoming the cause of disease. Seven days later, defecation ceased again. The previous method was repeated, and several hard fecal masses, each about three cun long, were discharged. The illness was then cured. From this, I realized that honey suppositories are suitable only for milder conditions. Tuagen (Trichosanthes Root) is difficult to obtain. Only pig gallbladder is available anytime and anywhere. Modern physicians abandoning good prescriptions is truly regrettable.
[Commentary] This case appears in *Shanghan Fawei*. Since it serves as a unique model, it is specially transcribed here. Whenever defecation has not occurred for many days, even more than ten days, and there is no diarrhea of clear fluid, this indicates dry fecal masses lodged in the rectum. The feces adhere tightly to the intestinal wall, so the more they accumulate, the harder they are to pass. At this time, if treated with Xiaoshi (Mirabilitum) and Dahuang (Rhei Radix et Rhizoma), not only would it be ineffective due to distance, but it would also vainly damage stomach qi and harm the innocent. This is why suppository methods were created. Honey suppositories are mild, but if used correctly, they can achieve superficial results.
A friend, Mr. Huang, had a grandmother over ninety years old. After being ill for ten days, she had no bowel movement, no appetite, and extreme fatigue. Doctors were at a loss and dared not prescribe. Finally, an enema device was used to infuse honey juice. After the feces were discharged, all symptoms receded, and she lived out her natural lifespan. This is an example. Recently, pharmacies have produced glycerin suppositories, which are more convenient to use and can serve as a substitute. If two or three suppositories fail to produce results, further application is permissible. Because if the intestinal wall has severe heat, two or three suppositories may not be sufficient for lubrication. If honey juice or suppositories are inadequate, pig gallbladder must be used. Human bile naturally has the function of moistening the intestines; using pig gallbladder as a substitute is a variation of organ therapy.
Mixing pig gallbladder with a little vinegar seems intended to borrow the vinegar's ability to stimulate the intestinal wall and promote peristalsis. Therefore, in the preparation of honey suppositories, a small amount of soap pod powder is sometimes added, which is essentially the same idea. Blowing a small amount of soap pod powder into the nostrils induces sneezing; how powerful is its stimulating effect?
Syndrome of Maziren Wan (Hemp Seed Pill)
Xu Zuo could eat, sweated at night during sleep, suffered from insomnia, had a large pulse, and difficulty passing stool. This is Pi Yue (Spleen Confinement).
Pi Yue Ma Ren Wan (Spleen Confinement Hemp Seed Pill), one liang, divided into three doses, taken with boiled water.
[Commentary] The original formula for Maziren Wan consists of: Maziren (Cannabis Fructus) two sheng, Shaoyao (Paeoniae Radix) half a jin, Zhishi (Aurantii Fructus Immaturus) half a jin (stir-fried), Dahuang (Rhei Radix et Rhizoma) one jin (peeled), Houpo (Magnoliae Officinalis Cortex) one chi (stir-fried, peeled), Xingren (Armeniacae Semen Amarum) one sheng (peeled, tip removed, roasted, processed separately into fat). These six ingredients are mixed with honey and formed into pills the size of paulownia seeds. What is commonly called Pi Yue Ma Ren Wan in modern pharmacies is exactly this formula. This formula uses Maziren as the sovereign herb. All seed kernels contain oil, which functions to moisten and descend. Thus, it is borrowed to relieve constipation and is suitable for patients with weak constitutions who cannot withstand harsh purgation.
The above seven syndromes, from Da Xiexiong Tang (Major Chest-Sinking Decoction) to Maziren Wan, although differing in urgency, all involve the purgative method. Some focus on chest binding (Jie Xiong), some on blood stasis, some on stored blood, some on heat dysentery, and some on intestinal dryness. The disease location may bias toward the upper, middle, or lower parts. Purgation leads to unblocking; unblocking leads to cessation of pain. This is the general principle for treating Yangming heat accumulation.
Lower Volume
Mental Confusion
[Commentary] My friend, Mr. Shi, is from Chongming and works at the Shanghai Telegraph Bureau. One evening in early autumn of the Jiaxu year, he hurriedly invited me to treat his younger brother. Entering his room, I saw the patient lying supine on a couch. Asking about his complaints, he gave no response. I found this strange. Privately, I said to Mr. Shi: "Has your brother been deaf for a long time and cannot hear, or does he have a stiff tongue and cannot speak?" Both replied: "No." I was even more astonished. Palpating his pulse, one hand was flooding (Hongda), the other was deep and thin. Which was left and which was right, I cannot remember now. I then asked the family about the cause of the illness. They said: "He previously held a telegraph position in a certain army. Due to an incident, he was frightened, and subsequently felt mentally confused. Whenever guests came, he would sit silently facing them; after they left, he would sing disorderly. His diet and bowel/bladder functions were like those of a normal person. Only when eating, there was occasional steaming of hot qi from the Que Shang (area above the nose/bridge of the nose). Lightly, it resembled morning clouds emerging from mountains; heavily, it resembled smoke from a kiln. The appearance was quite strange. Previously, he was sent to a famous hospital in this city for treatment. After more than twenty days, the doctors still did not recognize what disease it was. Since they had no method to treat it, he was discharged yesterday. Please, sir, diagnose him." I carefully palpated his abdomen. It was absolutely not distended, nor did he resist pressure. I pondered for a long time but could not discern the crux of the syndrome. Thus, I declined, citing my incompetence, and left shamefully. The next day, Mr. Shi told me: "My brother's illness was treated by Mr. Cao Yingfu yesterday. After taking medicine, he had a massive purge, and the hot qi in the Que Shang subsided." I was startled upon hearing this, rushed to visit, and viewed the prescribed formula. I recalled the end of the case note briefly stating: "This is what Zhang Zhongjing calls Yangming disease. It is appropriate to purge, governed by Da Chengqi Tang (Major Order the Qi Decoction)." The formula was: Sheng Dahuang 3 qian, Zhishi 3 qian, Mangxiao 3 qian (dissolved), Houpo 1 qian. Several days later, I met Mr. Shi again. He informed me that his brother, after taking the medicine, could get up and had stopped singing. However, he suffered from distending pain in both hypochondria. After treatment by Master Cao, it had just healed. Examining the formula, it was Xiao Chaihu Tang (Minor Bupleurum Decoction).
Chaihu (Bupleuri Radix) 3 qian, Huangqin 3 qian, Dangshen (Codonopsis Radix) 3 qian, Banxia (Pinelliae Rhizoma) 3 qian, Shengjiang (Zingiberis Rhizoma Recens) 3 slices, Dazao (Jujubae Fructus) 12 pieces, Gancao 2 qian. Since then, Mr. Shi's brother seemed to be recovering. However, he still suffered from spontaneous sweating and lack of spirit. Master Cao administered Guizhi Jia Longgu Muli Tang (Cinnamon Twig Decoction plus Dragon Bone and Oyster Shell), and one dose cured him.
Chuan Guizhi (Cinnamomi Ramulus) 3 qian, Da Baishao (Paeoniae Radix Alba) 3 qian, Sheng Gancao 2 qian, Shengjiang 3 slices, Dazao 12 pieces, Hua Longgu (Fossilia Ossis Mastodi) 5 qian, Duan Muli (Concha Ostreae) 5 qian (the latter two decocted first). From then on, his health exceeded that of ordinary people. One day, walking with his brother, he encountered me on the road. They smiled and nodded as they passed. The next day, meeting Mr. Shi, I asked what his brother said on the road yesterday. Mr. Shi said: "Nothing." I insisted on asking, and he laughed, saying: "He said my brother's pulse diagnosis was inaccurate." I could not help but feel ashamed again. Thus, I deeply admired my master's miraculous medical skills and presented gifts to join his school.
[Further Commentary] The patient in this case seemed to suffer from what is called mental illness or neurosis. However, Western medicine using neurological drugs showed no effect. Traditional Chinese medicine using classical formulas achieved significant results. The principle is profound and unfathomable. It is perhaps what is meant by 'treating diseases requires seeking the root.' The initial formula was a Yangming formula, the second a Shaoyang (Lesser Yang) formula, and the final a Taiyang formula. Using these three formulas to unblock the stagnation of these three channels, all illnesses were cured. Perhaps when he caught a chill that day, the meridians and organs throughout the body became stagnant due to fright? However, diet and bowel/bladder functions were normal, the abdomen did not hurt, and he did not resist pressure. Who would dare use Chengqi Tang? Yet my master, solely because of the hot qi in the Que Shang, boldly used it. This is likely what is meant by 'seeing one symptom is sufficient; it is not necessary that all symptoms be present.' Cao Yingfu said: "I could not identify this syndrome either. Only by palpating the pulse did I see that the right pulse was extremely flooding and the left pulse was extremely minute. Yin was insufficient and Yang was excessive. I thought it was the pulse of Shaoyin losing to Duyang, and not a counterflow syndrome. Combined with the hot qi emerging from the Que Shang, the condition belonged to Yangming, matching the flooding right pulse. Thus, I decided it was a definite indication for Da Chengqi Tang, without expecting such a rapid response."
Intestinal Abscess I
Shi Huifu resided on the third floor, No. 775, Fangbang Road, inside the city of Shanghai.
[Commentary] Mr. Shi Huifu previously came for consultation regarding his illness. He said: "I frequently suffer from abdominal pain. Medication provides slight relief, but it recurs every other day. Doctors consider it hernia and commonly use qi-regulating agents." I examined him carefully and determined it was intestinal abscess, which Western medicine calls appendicitis or peritonitis. It should be treated with purgation. It improved slightly but relapsed after a few days. The case and prescription are as follows.
Abdominal pain biased to the right, recurring after improvement, dry and bound stool. Prescribe Dahuang Mudan Tang (Rhubarb and Moutan Decoction).
Sheng Chuanjun 1.5 qian, Yuanmingfen (Mirabilitum) 3 qian (dissolved), Taoren 2 qian, Danpi (Moutan Cortex) 2 qian, Baijiangcao (Patriniae Herba) 3 qian, Sheng Yiren (Coicis Semen) 4 qian, Shu Fuku (Aconiti Lateralis Radix Praeparata) 1 qian, Zhishi Tan (Aurantii Fructus Immaturus Charred) 2 qian, Da Baishao 2 qian, Foshou (Citri Sarcodactylis Fructus) 1.5 qian. This was the prescription for April 18th. After three doses, a large amount of material was discharged, and abdominal pain decreased significantly. By the 25th, only faint pain remained in the affected area. A different doctor treated him with formulas to vent Jueyin qi. The formula was: Ruan Chaihu (Bupleuri Radix) 1.5 qian, Zhishi Tan 2 qian, Da Baishao 2 qian, Qingchenpi (Citri Reticulatae Pericarpium) and Chenpi each 1.5 qian, Yunling (Poria) 3 qian, Xiangfu (Cyperi Rhizoma) 2 qian, Jinlingzi (Meliosmae Fructus) 3 qian, Zhi Rumei (Commiphora Resina and Boswelliae Resina) each 0.8 fen, Xiaohuixiang (Foeniculi Fructus) 0.8 fen, Zhi Gouji (Evodiae Fructus) 3 qian, Qingjieye (Citri Reticulatae Folium) 1.5 qian, Lulutong (Liquidambaris Fructus) 3 qian. After one day of administration, the illness neither advanced nor retreated. On the second day, abdominal distension worsened, and he requested consultation again. Examination revealed that the previously right-sided abdominal distending pain had now spread to distension on both sides of the entire abdomen. Pressure elicited little resistance. The six characters from the classic, "abdominal skin tight, soft upon pressure" (Fu Pi Ji, An Zhi Ru), accurately described the situation and could not be altered. The patient frowned and reported: "What shall we do?" I said: "Do not worry, the previous formula can still be used." So I wrote: "Intestinal abscess recurs after temporary relief. Current examination shows distension around the lower abdomen, soft upon pressure, faint pain, and unsatisfactory bowel movements. Again prescribing the original method."
Sheng Chuanjun 3 qian, Fen Danpi 3 qian, Dongguazi (Benincasae Semen) 4 qian, Mangxiao 3 qian (dissolved), Taoren 3 qian, Baijiangcao 3 qian, Shu Fuqian 1.5 qian, Da Baishao 4 qian, Jiao Zha Tan (Crataegi Fructus Charred) 3 qian, Xi Qingpi (Citri Reticulatae Pericarpium Viride) 1.5 qian. This formula was taken at noon. There was no movement in the afternoon. By midnight, the urge to defecate arose, and a large amount of foul matter was discharged. The next day, he returned for consultation, saying: "My abdomen feels slightly relieved after defecation." I examined him. Although the illness had reduced by one or two degrees, it was still unresolved. I said: "Although the previous formula matched the pattern, it was still too light."
Mr. Shi said: "Then what should be done?" I said: "You should ask my master to use a heavy formula. Do you have the courage to take it?" He said: "I am willing to obey." He then visited my master for the initial consultation.
Initial Consultation: Intestinal abscess has undergone multiple purgations, but the root cause remains. Yesterday, Dr. Jiang used Dahuang Mudan Tang, and abdominal distension slightly decreased. Based on the syndrome, purgation is still indicated. Continue with the original method with modifications.
Sheng Chuanjun 5 qian (added later), Donggua Ren (Benincasae Semen) 1 liang, Taoren 80 grains, Fen Danpi 1 liang, Danggui (Angelicae Sinensis Radix) 5 qian, Mangxiao 3 qian (dissolved), Du Chidou (Vignaumbellatae Semen) 4 liang (decocted thickly, then add previous medicines).
[Commentary] Mr. Shi took this formula to the pharmacy to prepare the herbs. The pharmacist showed reluctance. He said: "Why use such drastic medicines?" Mr. Shi said: "Do not worry. I have taken such medicines many times before." The pharmacist asked: "How old is this gentleman?" Mr. Shi replied: "Over seventy." The pharmacist said: "Indeed, this is truly an experienced and learned physician." He generously provided the medicine. According to Mr. Shi, he had a bowel movement four hours after taking it, much more refreshing than when he took my previous prescription with 3 qian of Dahuang, which took over ten hours to work. The most material was discharged that night, all black and foul-smelling. He changed clothes frequently, too many times to count. After the vigorous discharge, abdominal pain decreased greatly, and swelling subsided. He came for the second consultation the next day.
Second Consultation: Yesterday, Dahuang Mudan Tang was used, adding Danggui and Chidou. The discharged sticky reddish material was neither pus nor blood. Such evil turbidity remaining in the intestines for a long time must transform into black river-mud-like substance. After taking the decoction, water flowed down in the intestines, making gurgling sounds. This syndrome must have an obstruction in the intestines, hence called abscess (Yong). Yong means blockage. If the blockage is not opened, how can there be any benefit? The root cause is not eliminated. The previous method should be continued but with reduced dosage.
Sheng Chuanjun 3 qian, Danpi 5 qian, Taoren 50 grains, Danggui 5 qian, Donggua Ren 1 liang, Chi Shao (Paeoniae Radix Rubra) 5 qian, Mangxiao 2 qian (dissolved), Baijiangcao 5 qian, Du Chidou 4 liang (decocted, then add previous medicines).
[Commentary] Mr. Shi took this formula for two days, totaling two doses. He had massive bowel movements at night, exhausting himself running between the bed and the toilet. Besides the river-mud-like filth, white pus-water was also discharged. Passing this water caused severe pain. Mr. Shi said, calculating the material discharged over three nights, it must have filled more than one vessel. My abdomen is large, but where did so much filth come from? This is amazing! On the third day, Mr. Shi took the original formula. I visited him personally at his home. Mr. Shi said: "I didn't tell the teacher yesterday that the discharged material was like river mud, yet the teacher recorded in the case: 'Must transform into black river mud.' Alas, how miraculous!" I smiled and nodded. After sitting and talking for a while, I asked Mr. Shi about the cause of his illness. He said: "In past years, when ill, I often refused medication. My father firmly believed in immortals and Buddhas and often ordered me to take incense ash. Was the illness caused by this?" But at this time, the material discharged by Mr. Shi had gradually changed from black to purple-red coffee color.
Third Consultation: After two administrations of modified Dahuang Mudan Tang, the accumulated filth in the intestines gradually thinned. However, pressing the area diagonally below the navel near the lower abdomen still caused pain, indicating the root cause was not entirely gone. Continue with the previous method, reducing Mangxiao and Dahuang to harmonize.
Fen Danpi 1 liang, Donggua Zi 1 liang, Sheng Yiren 1 liang, Taoren Ni (Persicae Semen Paste) 5 qian, Baijiangcao 5 qian, Jing Chi Shao (Paeoniae Radix Rubra) 6 qian, Sheng Gancao 2 qian, Danggui 5 qian, Jiegeng (Platycodonis Radix) 3 qian, Du Chidou 4 liang (decocted to replace water).
[Commentary] Mr. Shi took this formula for six doses. The discharged material gradually changed from coffee color to green. Mixed within the green were black particles resembling silkworm feces. The lower abdominal pain improved, but the ascending tendons felt slightly pulled and uncomfortable. After six doses, medication was stopped for two days, leading to the fourth consultation.
Fourth Consultation: The intestinal abscess is nearly cured. However, upon waking each morning to defecate, the affected area still feels distended, fearing the chronic root remains. Yet, after multiple purgations, the blood aspect is severely deficient. He experiences frequent dizziness, and the pulse is large, indicating deficiency. Treatment should primarily tonify righteousness (Zheng Qi), assisted by promoting the water passages of the lower jiao.
Da Chuanxiong (Ligustici Chuanxiong Rhizoma) 1 liang, Quan Danggui 5 qian, Da Shudi (Rehmanniae Radix Praeparata) 4 qian, Chun Sharen (Amomi Fructus Rotundus) 1 qian, Chi Baishao (Paeoniae Radix Rubra and Alba) each 3 qian, Zhuling (Polyporus) 3 qian, Ming Tianma (Gastrodiae Rhizoma) 4 qian, Chenpi 3 qian, Zexie (Alismatis Rhizoma) 2 qian, Sheng Baizhu (Atractylodis Macrocephalae Rhizoma) 5 qian, Dongkui Zi (Malvae Semen) 5 qian.
[Commentary] After Mr. Shi took this formula for tonifying righteousness and separating turbidity, the previous pain during bowel movements ceased. Also, the previous green color turned yellow. However, among seven parts yellow, three parts remain green. Mr. Shi had a history of spermatorrhea, which recurred at this time. Perhaps this was due to the strong diuretic nature of the formula? However, he felt absolutely no fatigue after emission, so it was not a concern.
Intestinal Abscess II