【又按】以上吾师各案，皆为依法治之而得生者，所谓验案是也。然而验案之书多矣，掩不善而著善，何足贵者？吾今特选吾师治而不验之案，详述于后，以存真迹，而昭大信。考其不治之由，或因病情之过重，或因证方之未合，或因药量之嫌轻，或因人事之未尽。拙按内悉旁征博引，细为推求，间有越仲圣之大范者，不计也。总冀阅者获此，庶了若观火，洞垣一方，以后即遇此种疑难险证，亦能治之而验。夫如是则今兹不验之案尤远胜于吾前此之验案也钦？
陆左八月二十九日住大兴街伤寒八九日，哕而腹满，渴饮，小便多，不恶寒，脉急数，此即仲师所谓知其何部不利，利之而愈之证也。
生锦纹军三钱后入生甘草二钱枳实二钱芒硝二钱冲服拙巢注：此证下后，呃不止，二日死。
【按】大论曰：伤寒呕多，虽有阳明证，不可攻之。按呕多与呕异，凡呕多不止者，其胃机能必衰逆，更加硝黄苦寒以伤其气，是为误治。法当先治其呕为是。吾师《伤寒发微》注本条云：盖即《金匮》病人欲吐者，不可下之之说也。胃中郁热上泛，湿痰壅于上膈，便当用瓜蒂散以吐之。胃中虚气上逆，而胸满者，则吴茱萸汤以降之。否则，无论何药入咽即吐，虽欲攻之，乌得而攻之。
故必先杀其上逆之势，然后可行攻下。予每遇此证，或先用一味吴萸汤。间亦有肝胆郁热，而用萸连汤者。呕吐既止，然后以大承气汤继之，阳明实热乃得一下而尽。须知有阳明证四字，即隐示人以可攻。若不于无字处求之，但狃于胃气之虚，视芒硝大黄如蛇蝎，真瞌睡汉耳。薛生白先贤曰：湿热证，呕恶不止，昼夜不差欲死者，宜用川连三四分，苏叶二三分，两味煎汤呷下，即止。可以互参。
曹颖甫曰：于昔治肉庄范阿良妇十五日不大便，终日呕吐，渴而饮水，吐尤甚。予诊其脉洪大而实，用大承气汤，生军三钱，枳实三钱，川朴二钱，芒硝三钱。以其不能进药也，先用吴萸三钱，令其煎好先服，一剂愈。后治菜市街福兴祥衣庄男子，大热，脉实，大便七日不行，亦以其茶水入口即吐也，先用姜汁半夏三钱，吴萸一钱，川连三分，今其先行煎服，然后用大黄三钱，枳实四钱，厚朴一钱，芒硝三钱，亦以一剂愈。盖见呕吐者易治，见哕逆者难治，世有能治此者，吾当北面事之。
甘右初诊四月八日阳明病，十四日不大便，阙上痛，谵语，手足濈然汗出，脉滑大，宜大承气汤。
生川军五钱后入枳实四钱川朴钱半芒硝三钱冲服二诊四月九日下经三次，黑而燥，谵语如故，脉大汗出，前方加石膏知母。
【按】张氏锡纯曰：愚临证实验以来，知阳明病既当下，其脉迟者固可下，即其脉不迟而又不数者，亦可下。惟脉数及六至，则不可下，即强下之，病必不解，或病更加剧。而愚对于此等病，则有变通之下法，即用白虎加入参汤，将石膏不煎入汤中，而以所煎之汤将石膏送服者是也。愚因屡次用此方奏效，遂名之为白虎承气汤。方为生石膏八钱捣细，大潞党参三钱，知母八钱，甘草二钱，粳米二钱。药共五味，将后四味煎汤一钟半，分二次将生石膏细末用温药汤送下。
服初次药后，迟两点钟，若腹中不见动作，再服第二次，若腹中已见动作，再迟点半钟，大便已下者，停服。若仍未下者，再将第二次药服下。至若其脉虽数而洪滑有力者，用此方时，亦可不加党参。愚从来遇寒温证之当下，而脉象数者，恒投以大剂白虎汤，或白虎加人参汤，其大便亦可通下。然生石膏必须用至四五两，煎一大碗，分数次温服，大便始可通下。间有服数剂后，大便仍不通下者，其人亦恒脉静身凉，少用玄明粉二三钱，和蜜冲服，大便即可通下。然终不若白虎承气用之较便也。按生石膏若服其研细之末，其退热之力一钱抵煎汤者半两，若以之通大便，一钱可抵煎汤者一两。是以方中止用生石膏八钱，而又慎重用之，必分二次服下也。寒温阳明病，其热甚盛者，投以大剂白虎汤，其热稍退。翌日，恒病仍如故。如此反覆数次，病家终疑药不对证，而转延他医，因致病不起者多矣。愚复拟得此方，初次用大剂白虎汤不效，二次即将生石膏细末送服。其汤中用五六两者，送服其末不过两余，或至二两，其热即可全消矣。张氏谓脉迟可下，脉数难下，吾师则谓下后脉和者安，脉转洪数者危，其理正有可通之处。要皆经验之谈，不可忽视者也，张氏谓生石膏研细末送服，一钱可抵煎汤者一两，信然。余则谓生石膏研细煎服，一钱亦可抵成块煎服者三钱。大论原文本谓打碎绵裹，可以知之。若夫熟石膏有凝固痰湿之弊，切不可用。张氏为此，曾大声疾呼以告国人，诚仁者之言也。
三诊四月十日两次大下，热势渐平，惟下后津液大伤，应用白虎加人参汤，无如病家贫苦，姑从生津著意。
生石膏五钱知母三钱生草二钱天花粉一两北沙参一两元参三钱粳米一撮先煎拙巢注：此证当两次下后，脉仍洪大，舌乾不润，竟以津液枯竭而死，可悲也。
【按】张氏又曰：愚用白虎加人参汤，或以玄参代知母（产后寒温证用之），或以芍药代知母（寒温兼下利者用之），或以生地黄代知母（寒温兼阴虚者用之），或以生山药代粳米（产后寒温证用之，寒温热实下焦气化不固者用之），或于原方中加生地黄玄参花粉诸药，以滋阴生津，加鲜茅根鲜芦根生麦芽诸药，以宣通气化。凡人外感之热炽盛，真阴反复亏损，此乃极危险之症。此时若但用生地玄参沙参诸药以滋阴，不能奏效，即将此等药加于白虎汤中，亦不能奏效。惟石膏与人参并用，独能于邪热炽盛之时立复真阴，此仲师制方之妙实有挽回造化之权也。观本案以病家贫苦，无力用人参，卒致不起，可证张氏之言为不虚。
津竭而反当下之证，固不可冒然用大承气，除张氏之白虎承气汤法外，尚有麻子仁丸法，惟麻仁如不重用，依然无效。又有猪胆汁导法，取其苦寒软坚，自下及上，亦每有效。若节庵陶氏黄龙汤法，即大承气汤加人参地黄当归，正邪兼顾，屡建奇功。降至承气养营汤，即小承气汤加知母当归芍药地黄，效相仿佛。
又闻有名医仿白虎加人参之例，独加人参一味于大承气汤中，预防其下后之脱，亦是妙策。至吴鞠通之增液承气汤，其功原在承气，而不在增液。若其单独增液汤仅可作病后调理之方，决不可倚为病时主要之剂。故《温病条辨·中焦篇》十·一条增液汤主之句下，复曰服增液汤已，周十二时观之，若大便不下者，合调胃承气汤微和之。盖彼亦知通幽荡积，非增液汤所能也。
陈右住九亩地年二十九岁初诊四月十七日十八日不大便，腹胀痛，脉洪大，右足屈而不伸，壮热，证属阳明，予调胃承气汤。
生川军三钱生甘草钱半芒硝二钱二诊四月十八日昨进调胃承气汤，下经四次，阳明之热上冲脑部，遂出鼻衄，渴饮，脉仍洪数，法当清热。
鲜芦根一两天花粉一两地骨皮三钱鲜生地六钱生石膏五钱肥知母三钱玉竹三钱生草二钱元参三钱拙巢注：此证卒以不起，大约以下后脉大，阳气外张。与前所治之甘姓相似，盖阴从下竭，阳从上脱，未有不死者也。
【按】本证至于鼻衄，似宜犀角地黄汤，即小品芍药地黄汤。汤中犀角能降低血压，除血中之热，丹支能调剂血运，去血中之瘀，生地内有铁质，足资生血之源，芍药中含酸素，善令静脉回流，四物皆为血药，诚治血热之良方也。本证未下之先，热结肠中一处，既下之后，热散周身血脉，亦有不经攻下而然者。血热既臻极点，乃从脆弱之处溢射，或从鼻出，或从口出，或从溺出，或从便出，其形虽异，其治则一。《千金》曰：犀角地黄汤治伤寒及温病，应发汗而不汗之，内蓄血者，及鼻衄吐血不尽，内余瘀血，面黄，大便黑，消瘀血。可以证之。
《温病条辨》曰：太阴温病，血从上溢者，犀角地黄汤合银翘散治之。又曰：时欲漱口，不欲咽，大便黑而易者，有瘀血也，犀角地黄汤主之。悉不出《千金》范围。细审本汤或系仲圣之方，而《伤寒》《金匮》所遗落者。不然，则本方殊足以补二书之未备，弥足珍也！《千金》《外台》诸方以犀角为主药者甚多，悉可覆按。后人以此加神灵之品，如羚羊牛黄，增香窜之物，如安息麝香，添重镇之药，如金银朱砂，扩而充之，乃成紫雪至宝之属，善自施用，原不失为良方。
惜乎俗医信之过专，用之过滥，一遇神昏谵语，动谓邪迷心包，不问其是否承气之证，悉假之作孤注一掷。及其不效，则病家无怨词，医家无悔意，至足悯也！至犀角早用，亦多弊端，故太炎章氏有言曰：有以为温病药总宜凉，每令早服犀角，而反致神昏谵语者比比。观仲景方未有用犀角者，《本草》谓犀角解毒，《千金》《外台》方中多以犀角止血，故凡大吐衄，大崩下，或便血等，多以犀角治之，盖犀角有收缩血管之功用也。阳明病原自有汗，今反以犀角收之，于是将邪逼入肠胃，神昏谵语，自然起矣。人每不明此理，以为神昏谵语，终是邪入包络，因此犀角之误治，终不了然。惟陆九芝为能知之耳。由是以观，河间已逊仲景，叶、吴辈更不如河间远矣。盖亦有感而发。然而陆氏犀角膏黄辨最后之结论曰：病岂必无膏黄之不能愈，而待愈于犀角者哉？然必在用过膏黄之后，必不在未用膏黄之前，盖亦有可决者。方是持平之论也。
至犀角与羚羊角之功用，大同小异之处，亦当求其几微之辩。吴兄凝轩与余共研此事，得结论曰：犀角能降低血压，其主在血液，羚羊角能凉和神经，其主在神经。依旧说，血液为心所主，故曰犀角为心经药。神经为肝所属，故曰羚羊角为肝经药。然而血热者，神经每受灼，神经受灼者其血必更热，二者常互为因果，故二药常相须而用。同中之异，如此而已。
【又按】以上各节，皆为医理之探讨。夫阳明无死证，在理论固是，然而阳明病之不起，又有属于人事之未尽者。试言一点，以为证明。余谓凡属险证，类皆变化多端，忽而神昏谵语，忽而撮空摸床，忽而寒战若死，忽而汗出几脱，忽而热化，忽而寒化。犹如夏令酷蒸，仰观则万里无云，俯视则流金烁石，忽而油云密布，沛然下雨，其变之倏也，乃间不容发。故治若此之病，理当医者不离病人，一医之不足恃，会数医而共图之，随脉证之传变，作迅捷之处置，以是赴之，庶或有济。然而通常病家力不能办此，一诊之后，须待来日，不知其间变化已多，即其获救之机会失去者亦多。举例以明之，有用大承气下后，即当用参耆归芍以救其虚者。然而病家不知，徒事惊惶，乱其所措，而病者撤手矣。
【又按】以上我老师的各个医案，都是依法治疗而获救的病例，这就是所谓的“验案”（验证有效的医案）。然而记载验案的书籍已经很多了，掩盖不善之处而彰显善处，有什么值得珍贵的呢？我现在特意选取老师治疗无效的案例，详细叙述在后面，以保存真实记录，并昭示极大的诚信。考察其未能治愈的原因，有的因为病情过于严重，有的因为证候与方药不相符合，有的因为药量嫌轻，有的因为人事方面未尽努力。我的按语中全面旁征博引，细致推求，间或有违背仲景大法的，就不计较了。总的希望读者获得这些内容，就能像看火一样清楚明白，洞察病机，以后即使遇到这种疑难险重的证候，也能治疗有效。如果这样，那么现在这些无效的医案就远胜于我以前那些有效的医案了，不是吗？
陆姓患者，男，八月二十九日住大兴街。患伤寒八九日，呃逆且腹部胀满，口渴想喝水，小便频多，不怕冷，脉象急数。这就是仲景所说的知道哪一部气机不利，通利之后就能痊愈的证候。
生锦纹大黄三钱（后下），生甘草二钱，枳实二钱，芒硝二钱（冲服）。拙巢注：此证攻下后，呃逆不止，两日后死亡。
【按】《伤寒论》大论中说：伤寒呕吐频繁者，即使有阳明证，也不可用攻下法。按“呕多”与“呕”不同，凡是呕吐频繁不止的，其胃气机能必然衰败逆乱，再加上使用硝黄（芒硝、大黄）苦寒之品来损伤正气，这是误治。治法应当先治疗呕吐才是正确的。我的老师《伤寒发微》注本条时说：这也就是《金匮要略》中“病人想吐的，不可用下法”的说法。如果是胃中郁热上泛，湿痰壅塞在上膈，就应当用瓜蒂散来催吐。如果是胃中虚气上逆，并且胸满的，就用吴茱萸汤来降逆。否则，无论什么药入口即吐，虽然想攻下，怎么能攻得下去呢？
所以必须先遏制其上逆的势头，然后才可以进行攻下。我每次遇到这个证候，或者先用一味吴茱萸汤。间或有肝胆郁热的，就用萸连汤。呕吐停止后，然后再用大承气汤继之，阳明的实热才能一次攻下清除干净。须知有“阳明证”这三个字，就是隐含地提示人们可以攻下。如果不于无字处寻求真意，只拘泥于胃气虚弱，视芒硝、大黄如蛇蝎一般，真是瞌睡汉罢了。薛生白先贤说：湿热证，呕吐恶心不止，昼夜不停，痛苦欲死的，宜用川黄连三四分，苏叶二三分，这两味药煎汤呷下，即可停止。可以参考。
曹颖甫说：以前治疗肉庄范阿良的妻子，十五天不大便，整天呕吐，口渴饮水，吐得更厉害。我诊察她的脉象洪大而实，用大承气汤，生大黄三钱，枳实三钱，厚朴二钱，芒硝三钱。因为她不能进药，先用吴茱萸三钱，让她煎好先服用，一剂就好了。后来治疗菜市街福兴祥衣庄的男子，高热，脉实，大便七天不通，也是因为他茶水入口即吐，先用姜汁半夏三钱，吴茱萸一钱，川黄连三分，让他先行煎服，然后用大黄三钱，枳实四钱，厚朴一钱，芒硝三钱，也以一剂痊愈。大概见到呕吐者容易治疗，见到呃逆者难治疗，世间如果有能治好这种病的医生，我愿意北面称师侍奉他。
甘姓患者，女，初诊四月八日。患阳明病，十四天不大便，眉心上方疼痛，说胡话，手足濈濑然出汗，脉滑大，适宜用大承气汤。
生川军（大黄）五钱（后下），枳实四钱，厚朴钱半，芒硝三钱（冲服）。
二诊四月九日。服药后大便三次，色黑而燥结，说胡话如故，脉大汗出，前方加石膏、知母。
【按】张锡纯先生说：我临证实验以来，知道阳明病既然应当攻下，其脉迟的固然可以攻下，即使脉不迟又不数的，也可以攻下。只有脉数达到六至（每分钟脉搏跳动次数），则不可攻下，即使强行攻下，病必不解，或者病情更加剧烈。而我对于这类病，则有变通的攻下法，即用白虎加人参汤，将石膏不煎入汤中，而是用煎好的药汤送服石膏粉。我因屡次用此方奏效，于是命名为白虎承气汤。方为生石膏八钱（捣细），大潞党参三钱，知母八钱，甘草二钱，粳米二钱。药共五味，将后四味煎汤一钟半，分二次将生石膏细末用温药汤送下。
服用初次药后，过两个小时，如果腹中没有动静，再服第二次；如果腹中已有动静，再过半小时，大便已下的，停服。如果仍未下的，再将第二次药服下。至于其脉虽数但洪滑有力的，用此方时，也可以不加党参。我从来遇到寒温病应当攻下，而脉象数的，常投以大剂白虎汤，或白虎加人参汤，其大便也可通下。然而生石膏必须用到四五两，煎一大碗，分数次温服，大便才可通下。间有服几剂后，大便仍不通的，其人往往脉静身凉，少用玄明粉二三钱，和蜜冲服，大便即可通下。然而终究不如白虎承气汤用起来方便。按生石膏如果服用研细的粉末，其退热之力一钱抵得上煎汤者半两，如果用其通大便，一钱可抵得上煎汤者一两。所以在方中只用生石膏八钱，而又慎重使用，必须分二次服下。寒温阳明病，其热势极盛的，投以大剂白虎汤，热势稍退。第二天，往往病仍如故。如此反复数次，病家最终怀疑药不对证，转而延请其他医生，因而导致病亡的很多了。我又拟得此方，初次用大剂白虎汤不效，第二次即将生石膏细末送服。汤中用五六两的，送服其末不过一两余，或至二两，其热即可全消矣。张氏谓脉迟可下，脉数难下，吾师则谓下后脉象平和者安，脉转洪数者危，其理正有可通之处。都是经验之谈，不可忽视。张氏谓生石膏研细末送服，一钱可抵煎汤者一两，确实如此。我则认为生石膏研细煎服，一钱亦可抵成块煎服者三钱。大论原文本谓打碎绵裹，可以知之。若夫熟石膏有凝固痰湿的弊端，切不可用。张氏为此，曾大声疾呼以告国人，确实是仁者的言论。
三诊四月十日。两次大下后，热势渐平，只是下后津液大伤，应用白虎加人参汤，无奈病家贫苦，姑且从生津着眼。
生石膏五钱，知母三钱，生草二钱，天花粉一两，北沙参一两，元参三钱，粳米一撮，先煎。拙巢注：此证当两次攻下后，脉仍洪大，舌干不润，竟因津液枯竭而死，可悲啊。
【按】张氏又说：我用白虎加人参汤，或用玄参代替知母（产后寒温证用之），或用芍药代替知母（寒温兼下利者用之），或用生地黄代替知母（寒温兼阴虚者用之），或用生山药代替粳米（产后寒温证用之，寒温热实下焦气化不固者用之），或在原方中加生地黄、玄参、花粉诸药，以滋阴生津，加鲜茅根、鲜芦根、生麦芽诸药，以宣通气化。凡人外感之热炽盛，真阴反复亏损，这是极其危险的症候。此时如果只用生地、玄参、沙参诸药以滋阴，不能奏效，即使将这些药加于白虎汤中，也不能奏效。只有石膏与人参并用，独能在邪热炽盛之时立即恢复真阴，这是仲景制方的妙处，实在有挽回造化之权。看本案因病家贫苦，无力用人参，最终导致不治，可证明张氏的话不虚。
津液枯竭而反需攻下的证候，固然不可贸然用大承气汤，除张氏的白虎承气汤法外，尚有麻子仁丸法，只是麻仁如果不重用，依然无效。又有猪胆汁导法，取其苦寒软坚，自下及上，也每每有效。若节庵陶氏黄龙汤法，即大承气汤加人参、地黄、当归，正邪兼顾，屡建奇功。降至承气养营汤，即小承气汤加知母、当归、芍药、地黄，效果相仿佛。
又听说有名医仿照白虎加人参之例，独加人参一味于大承气汤中，预防其下后之脱证，也是妙策。至于吴鞠通的增液承气汤，其功原在承气，而不在增液。如果其单独增液汤仅可作为病后调理之方，决不可倚为病时主要之剂。所以《温病条辨·中焦篇》第十一条增液汤主之句下，复曰服增液汤已，周十二时观之，若大便不下者，合调胃承气汤微和之。大概他也知道通幽荡积，非增液汤所能做到。
陈姓患者，女，住九亩地，年二十九岁。初诊四月十七日。十八天不大便，腹胀痛，脉洪大，右足屈曲不能伸展，壮热，证属阳明，予调胃承气汤。
二诊四月十八日。昨天进服调胃承气汤，大便四次，阳明之热上冲脑部，遂出现鼻衄，口渴想喝水，脉仍洪数，治法当清热。
鲜芦根一两，天花粉一两，地骨皮三钱，鲜生地六钱，生石膏五钱，肥知母三钱，玉竹三钱，生草二钱，元参三钱。拙巢注：此证最终不治，大约是因为下后脉大，阳气外张。与前所治的甘姓患者相似，大概是阴从下竭，阳从上脱，没有不死亡的。
【按】本证至于鼻衄，似乎适宜用犀角地黄汤，即小品芍药地黄汤。汤中犀角能降低血压，除血中之热，丹皮能调剂血运，去血中之瘀，生地内有铁质，足资生血之源，芍药中含酸素，善令静脉回流，四物皆为血药，诚为治血热之良方也。本证未下之前，热结肠中一处，既下之后，热散周身血脉，也有不经攻下而然的。血热既臻极点，乃从脆弱之处溢射，或从鼻出，或从口出，或从小便出，或从大便出，其形虽异，其治则一。《千金方》说：犀角地黄汤治伤寒及温病，应发汗而不汗之，内蓄血者，及鼻衄吐血不尽，内余瘀血，面黄，大便黑，消瘀血。可以证明这一点。
《温病条辨》说：太阴温病，血从上溢者，犀角地黄汤合银翘散治之。又说：时欲漱口，不欲咽，大便黑而易者，有瘀血也，犀角地黄汤主之。都不出《千金方》的范围。仔细审察本汤，或许是仲景之方，而《伤寒论》《金匮要略》所遗落的。不然，则本方殊足以补二书之未备，弥足珍贵！《千金方》《外台秘要》诸方以犀角为主药的甚多，都可查考。后人以此加神灵之品，如羚羊角、牛黄，增香窜之物，如安息香、麝香，添重镇之药，如金银箔、朱砂，扩而充之，乃成紫雪、至宝丹之类，善于施用，原本不失为良方。
可惜世俗医生信之过专，用之过滥，一遇神昏谵语，动辄谓邪迷心包，不问其是否承气之证，悉假之作孤注一掷。及其不效，则病家无怨词，医家无悔意，真是令人怜悯！至于犀角早用，也多弊端，所以太炎章氏有言曰：有以为温病药总宜凉，每令早服犀角，而反致神昏谵语者比比皆是。看仲景方未有用犀角者，《本草》谓犀角解毒，《千金》《外台》方中多以犀角止血，故凡大吐衄，大崩下，或便血等，多以犀角治之，盖犀角有收缩血管之功用也。阳明病原自有汗，今反以犀角收之，于是将邪逼入肠胃，神昏谵语，自然起矣。人每不明此理，以为神昏谵语，终是邪入包络，因此犀角之误治，终不了然。只有陆九芝能知之耳。由是以观，河间已逊仲景，叶、吴辈更不如河间远矣。盖亦有感而发。然而陆氏犀角膏黄辨最后之结论曰：病岂必无膏黄之不能愈，而待愈于犀角者哉？然必在用过膏黄之后，必不在未用膏黄之前，盖亦有可决者。方是持平之论也。
至于犀角与羚羊角之功用，大同小异之处，亦当求其几微之辩。吴兄凝轩与我共同研究此事，得出结论曰：犀角能降低血压，其主在血液，羚羊角能凉和神经，其主在神经。依旧说，血液为心所主，故曰犀角为心经药。神经为肝所属，故曰羚羊角为肝经药。然而血热者，神经每受灼，神经受灼者其血必更热，二者常互为因果，故二药常相须而用。同中之异，如此而已。
【又按】以上各节，皆为医理之探讨。夫阳明无死证，在理论固是，然而阳明病之不起，又有属于人事之未尽者。试言一点，以为证明。我认为凡是属于险证，类皆变化多端，忽而神昏谵语，忽而撮空摸床，忽而寒战若死，忽而汗出几脱，忽而热化，忽而寒化。犹如夏令酷蒸，仰观则万里无云，俯视则流金烁石，忽而油云密布，沛然下雨，其变之倏也，乃间不容发。所以治疗这样的病，理当医者不离病人，一医之不足恃，会数医而共图之，随脉证之传变，作迅捷之处置，以是赴之，庶或有济。然而通常病家力不能办此，一诊之后，须待来日，不知其间变化已多，即其获救之机会失去者亦多。举例以明之，有用大承气下后，即当用参耆归芍以救其虚者。然而病家不知，徒事惊惶，乱其所措，而病者撤手矣。
[Further Note] The above cases from my teacher were all treated according to the law and resulted in survival; these are what is called "verified cases" (cases verified as effective). However, there are already many books recording verified cases. To conceal the failures while highlighting the successes—what value is there in that? I now specifically select the cases where my teacher's treatment failed, detailing them below, to preserve the truth and demonstrate great integrity. Examining the reasons for their non-cure: some were due to the severity of the condition, some because the syndrome did not match the formula, some because the dosage was considered too light, and some because human efforts were not fully exerted. My annotations comprehensively cite various sources and conduct detailed deductions. Occasionally, there may be deviations from Zhongjing's major principles, which I will disregard. Ultimately, I hope readers who acquire this will understand it clearly as if watching a fire, penetrating the pathology, so that even when encountering such difficult and critical syndromes in the future, they can treat them effectively. If this is the case, then these current non-verified cases far surpass my previous verified cases, do they not?
Yangming Frequent Vomiting
Patient Lu, Male. Admitted to Daxing Street on August 29th. Suffering from Shanghan (Cold Damage) for eight or nine days, with hiccups and abdominal fullness, thirst with desire to drink, frequent urination, aversion to cold absent, and pulse rapid and urgent. This is precisely the syndrome described by Zhongjing: knowing which part has qi obstruction, and upon unblocking it, the patient recovers.
Raw Rhubarb (Da Huang) 3 qian (added later), Raw Licorice (Gan Cao) 2 qian, Immature Bitter Orange (Zhi Shi) 2 qian, Mirabilite (Mang Xiao) 2 qian (dissolved and taken). Zhu Chao's Note: After purgation in this case, hiccups did not cease, and death occurred after two days.
[Annotation] The Great Treatise states: In Shanghan, if vomiting is frequent, even if Yangming symptoms are present, one must not use purgation. "Frequent vomiting" differs from simple vomiting. When vomiting is frequent and incessant, the stomach's functional mechanism must be declining and rebellious. Adding bitter-cold agents like Mang Xiao and Da Huang would further damage righteous Qi, constituting erroneous treatment. The correct method should be to first treat the vomiting. My teacher, in his commentary on *Shanghan Fawei*, stated regarding this clause: This aligns with the saying in *Jingui Yaolue*: "For patients desiring to vomit, do not use purgation." If damp-phlegm obstructs the upper diaphragm due to stagnant heat in the stomach rising upward, one should use Geng Ti San (Melon Sprout Powder) to induce vomiting. If deficiency Qi in the stomach rebels upward accompanied by chest fullness, one should use Wu Zhu Yu Tang (Evodia Decoction) to descend it. Otherwise, no matter what medicine is taken, if it is vomited immediately upon entering the throat, although one wishes to purge, how can one proceed?
Therefore, one must first suppress the rebellious momentum before proceeding with purgation. Whenever I encounter this syndrome, I either first use a single-herb Wu Zhu Yu Tang. Occasionally, for liver-gallbladder stagnant heat, I use Yu Lian Tang (Evodia and Coptis Decoction). Once vomiting ceases, I then follow up with Da Cheng Qi Tang (Major Order the Golden Chain Decoction), allowing the excess heat of Yangming to be cleared in one go. It must be understood that the phrase "Yangming syndrome" implicitly indicates that purgation is permissible. If one does not seek meaning in the unwritten aspects but merely clings to the concept of deficient Stomach Qi, viewing Mang Xiao and Da Huang as snakes and scorpions, one is truly a sleepwalker. Xianxian Xue Shengbai said: For damp-heat syndromes where vomiting and nausea are incessant, day and night without relief, causing extreme distress, one should use Huang Lian (Coptis Rhizome) 3-4 fen and Su Ye (Perilla Leaf) 2-3 fen, decocted together and sipped slowly, which will stop the symptoms. This can be referred to for mutual reference.
Cao Yingfu said: Previously, I treated the wife of Fan Aliang from the meat shop, who had not had a bowel movement for fifteen days, vomited constantly throughout the day, was thirsty and drank water, with vomiting worsening. Her pulse was surging and large yet firm. I used Da Cheng Qi Tang: Raw Rhubarb 3 qian, Immature Bitter Orange 3 qian, Magnolia Bark 2 qian, Mirabilite 3 qian. Because she could not retain medication, I first used Evodia (Wu Zhu Yu) 3 qian, instructing her to decoct and take it first. One dose resulted in recovery. Later, I treated a man from the Fuxingxiang clothing store in Caishi Street, who had high fever, a firm pulse, and no bowel movement for seven days. Similarly, his tea was vomited immediately upon entry. I first used Ginger Juice Pinellia (Ban Xia) 3 qian, Evodia 1 qian, and Coptis (Huang Lian) 3 fen, instructing him to decoct and take this first. Then I administered Rhubarb 3 qian, Immature Bitter Orange 4 qian, Magnolia Bark 1 qian, and Mirabilite 3 qian. He also recovered with one dose. Generally, seeing vomiting indicates an easier-to-treat condition, whereas seeing hiccups indicates a difficult-to-treat condition. If there exists anyone in the world who can cure this, I would bow to him as a master.
Yangming Exhaustion of Fluids
Patient Gan, Female. First visit, April 8th. Suffering from Yangming disease, no bowel movement for fourteen days, pain above the glabella, delirium, continuous sweating on hands and feet, pulse slippery and large. Suitable for Da Cheng Qi Tang (Major Order the Golden Chain Decoction).
Raw Rhubarb (Chuan Jun) 5 qian (added later), Immature Bitter Orange 4 qian, Magnolia Bark 1.5 qian, Mirabilite 3 qian (dissolved and taken).
Second visit, April 9th. After taking the prescription, three bowel movements occurred. Stool was black and dry. Delirium persisted. Pulse was large with sweating. Added Shi Gao (Gypsum Fibrosum) and Zhi Mu (Anemarrhena Rhizome) to the previous formula.
Gypsum Fibrosum 1 liang, Anemarrhena Rhizome 5 qian, added to the previous formula.
[Annotation] Mr. Zhang Xichun stated: Since my clinical experiments, I have known that when Yangming disease requires purgation, if the pulse is slow, it is certainly suitable for purgation. Even if the pulse is neither slow nor rapid, purgation is also permissible. Only when the pulse is rapid, reaching six beats per breath (approx. 90-100 bpm), should purgation be avoided. Forcing purgation in such cases will not resolve the disease and may exacerbate it. For such diseases, I employ a modified purgative method: using Bai Hu Jia Ren Shen Tang (White Tiger Decoction plus Ginseng), where Gypsum Fibrosum is not decocted but administered as a fine powder delivered by the warm decoction of the other herbs. Having used this formula successfully multiple times, I named it Bai Hu Cheng Qi Tang (White Tiger Order the Golden Chain Decoction). The formula consists of Raw Gypsum Fibrosum 8 qian (finely ground), Radix Codonopsis 3 qian, Anemarrhena Rhizome 8 qian, Licorice Root 2 qian, and Rice Grain 2 qian. These five herbs are processed by decocting the latter four in one-and-a-half zhong of water. The fine powder of Raw Gypsum Fibrosum is taken in two doses, washed down with the warm decoction.
After the first dose, if there is no abdominal activity after two hours, administer the second dose. If abdominal activity is already present, wait half an hour; if stool has passed, stop administration. If still no stool, administer the remaining second dose. If the pulse is rapid but surging, slippery, and forceful, Codonopsis may be omitted when using this formula. Whenever I encounter exogenous febrile diseases requiring purgation but presenting with a rapid pulse, I often prescribe large doses of Bai Hu Tang (White Tiger Decoction) or Bai Hu Jia Ren Shen Tang, which can also facilitate bowel movement. However, Raw Gypsum Fibrosum must be used in doses of 4-5 liang, decocted into a large bowl, and taken in divided warm doses for the stool to pass. Occasionally, after several doses, if stool remains unpassed, the patient often presents with a quiet pulse and cool body temperature. In such cases, using a small amount of Xuan Ming Fen (Mirabilite) 2-3 qian mixed with honey and taken orally can facilitate stool passage. Nevertheless, it is not as convenient as using Bai Hu Cheng Qi Tang. Regarding Raw Gypsum Fibrosum, if taken as a fine powder, its heat-clearing efficacy of 1 qian equals half a liang of decocted herb; for promoting bowel movement, 1 qian of powder equals one liang of decocted herb. Thus, only 8 qian of Raw Gypsum Fibrosum is used in the formula, administered cautiously in two doses. In exogenous febrile Yangming disease with intense heat, prescribing large doses of Bai Hu Tang may temporarily reduce heat. However, the next day, the illness often persists. Repeating this several times leads families to doubt the prescription's accuracy, seeking other physicians, often resulting in death. I subsequently devised this formula: if the initial large dose of Bai Hu Tang fails, the second time involves administering fine Gypsum Fibrosum powder. If the decoction uses 5-6 liang, sending down only slightly over 1 liang or up to 2 liang of powder can completely eliminate the heat. Mr. Zhang stated that slow pulses allow purgation, while rapid pulses make it difficult. My teacher stated that after purgation, a harmonious pulse indicates safety, while a transforming surging-rapid pulse indicates danger. Their theories have points of convergence. Both are empirical statements that cannot be ignored. Mr. Zhang's claim that 1 qian of powdered Gypsum Fibrosum equals one liang of decocted herb is indeed true. I contend that finely ground Gypsum Fibrosum decocted, 1 qian equals three qian of block-form decocted herb. The original text specifies crushing and wrapping in silk, which confirms this. Cooked gypsum has the drawback of consolidating phlegm-dampness and must never be used. Mr. Zhang loudly warned the public about this, truly words of a benevolent person.
Third visit, April 10th. After two massive purgations, heat intensity gradually subsided. However, fluids were severely damaged post-purgation. Bai Hu Jia Ren Shen Tang (White Tiger Decoction plus Ginseng) should have been applied. Unfortunately, due to the family's poverty, we focused tentatively on generating fluids.
Raw Gypsum Fibrosum 5 qian, Anemarrhena Rhizome 3 qian, Raw Licorice 2 qian, Trichosanthes Root 1 liang, Glehnia Root 1 liang, Scrophularia Root 3 qian, Rice Grain a pinch, decocted first. Zhu Chao's Note: In this case, after two purgations, the pulse remained surging and large, and the tongue was dry and unmoistened. Death eventually occurred due to exhaustion of fluids. How sorrowful!
[Annotation] Mr. Zhang also stated: When I use Bai Hu Jia Ren Shen Tang (White Tiger Decoction plus Ginseng), I may substitute Xuan Shen (Scrophularia Root) for Zhi Mu (used in postpartum exogenous febrile diseases), or Bai Shao (White Peony Root) for Zhi Mu (used when exogenous febrile disease is complicated by diarrhea), or Sheng Di Huang (Rehmannia Root) for Zhi Mu (used when exogenous febrile disease is complicated by Yin deficiency), or Shan Yao (Dioscorea Rhizome) for Jing Mi (Rice Grain) (used in postpartum exogenous febrile diseases, or when lower jiao Qi transformation is unstable due to heat-excess), or add Sheng Di Huang, Xuan Shen, and Tian Hua Fen to the original formula to nourish Yin and generate fluids, or add fresh Mao Gen (Imperata Rhizome), fresh Lu Gen (Phragmites Rhizome), and Sheng Mai Ya (Sprouted Hordeum Fructus) to promote Qi transformation. When external pathogenic heat is intense and True Yin is repeatedly depleted, this is an extremely dangerous syndrome. At this time, using only Sheng Di Huang, Xuan Shen, Sha Shen (Glehnia Root) to nourish Yin will not be effective. Even adding these herbs to Bai Hu Tang will not work. Only the combination of Gypsum Fibrosum and Ginseng can instantly restore True Yin amidst intense pathogenic heat. This is the brilliance of Zhongjing's formula formulation, possessing the power to reverse fate. Observing this case, where the family's poverty prevented the use of Ginseng, leading to death, proves Mr. Zhang's words are not false.
In cases of fluid exhaustion requiring purgation, one must not rashly use Da Cheng Qi Tang (Major Order the Golden Chain Decoction). Besides Mr. Zhang's Bai Hu Cheng Qi Tang method, there is also Ma Zi Ren Wan (Hemp Seed Pill) method, though ineffective unless Hemp Seed is heavily dosed. There is also Pig Gallbladder Suppository method, utilizing its bitter-cold property to soften hardness, acting from below upwards, which is also often effective. Mr. Jie'an Tao's Huang Long Tang (Yellow Dragon Decoction) method, which is Da Cheng Qi Tang plus Ginseng, Rehmannia, and Angelica, addresses both righteous Qi and pathogen, achieving remarkable results frequently. Descending to Cheng Qi Yang Ying Tang (Order the Golden Chain Nourishing Blood Decoction), which is Xiao Cheng Qi Tang plus Anemarrhena, Angelica, White Peony, and Rehmannia, yields similar effects.
I also heard that famous doctors, imitating the example of Bai Hu Jia Ren Shen Tang, added only Ginseng to Da Cheng Qi Tang to prevent collapse after purgation, which is also a clever strategy. As for Wu Jutong's Zeng Ye Cheng Qi Tang (Increase Fluids Order the Golden Chain Decoction), its merit lies originally in the purgative aspect, not in increasing fluids. If its standalone Zeng Ye Tang (Increase Fluids Decoction) is only suitable for post-illness regulation, it absolutely cannot be relied upon as the primary agent during illness. Therefore, under the clause "Zeng Ye Tang governs it" in Article 11 of the Middle Jiao Chapter of *Wen Bing Tiao Bian*, it adds: After taking Zeng Ye Tang, observe for twelve hours. If stool does not pass, combine with Tiao Wei Cheng Qi Tang (Regulate the Stomach Order the Golden Chain Decoction) to gently harmonize. He likely knew that clearing obstructions and sweeping away accumulation is beyond the capability of Zeng Ye Tang alone.
Yangming Epistaxis
Patient Chen, Female. Residing at Jiumu Di, aged 29. First visit, April 17th. No bowel movement for eighteen days, abdominal distension and pain, pulse surging and large, right foot flexed and unable to extend, high fever. Syndrome belongs to Yangming. Prescribed Tiao Wei Cheng Qi Tang (Regulate the Stomach Order the Golden Chain Decoction).
Raw Rhubarb 3 qian, Raw Licorice 1.5 qian, Mirabilite 2 qian.
Second visit, April 18th. Yesterday, after taking Tiao Wei Cheng Qi Tang, four bowel movements occurred. Heat from Yangming rushed upward to the brain, resulting in epistaxis. Thirst with desire to drink. Pulse remains surging and rapid. Treatment method should focus on clearing heat.
Fresh Imperata Rhizome 1 liang, Trichosanthes Root 1 liang, Cortex Lycii 3 qian, Fresh Rehmannia Root 6 qian, Raw Gypsum Fibrosum 5 qian, Anemarrhena Rhizome 3 qian, Polygonatum Rhizome 3 qian, Raw Licorice 2 qian, Scrophularia Root 3 qian. Zhu Chao's Note: This case ultimately proved fatal. Approximately because the pulse was large after purgation, indicating outward expansion of Yang Qi. Similar to the previously treated Patient Gan. Likely, Yin exhausted from below, Yang escaping from above. Death was inevitable.
[Annotation] For this syndrome manifesting as epistaxis, Xi Jiao Di Huang Tang (Rhino Horn and Rehmannia Decoction), i.e., Xiao Pin Bai Shao Di Huang Tang (Small Fragment White Peony and Rehmannia Decoction), seems appropriate. In this decoction, Rhino Horn lowers blood pressure and clears heat from the blood; Mu Dan Pi regulates blood circulation and removes blood stasis; Sheng Di Huang contains iron, sufficient to support the source of blood generation; Bai Shao contains organic acids, facilitating venous return. All four ingredients are blood-invigorating herbs, truly an excellent formula for treating blood heat. Before purgation, heat was consolidated in one area of the intestines. After purgation, heat dispersed throughout the body's blood vessels. There are also cases where this occurs without purgation. When blood heat reaches its peak, it spills from fragile areas, exiting through the nose, mouth, urine, or stool. Although the forms differ, the treatment principle is identical. *Qian Jin Fang* states: Xi Jiao Di Huang Tang treats Shanghan and Wenbing (Warm Diseases) where sweating should have been induced but wasn't, leading to internal blood accumulation, as well as incomplete epistaxis or hematemesis, residual internal blood stasis, yellow complexion, and black stool, eliminating blood stasis. This corroborates the point.
*Wen Bing Tiao Bian* states: For Taiyin Wenbing, when blood flows from above, treat with Xi Jiao Di Huang Tang combined with Yin Qiao San. It also states: Frequent rinsing of the mouth without swallowing, and easy passage of black stool, indicates blood stasis; Xi Jiao Di Huang Tang governs it. All fall within the scope of *Qian Jin Fang*. Carefully examining this formula, it might be a formula from Zhongjing lost in *Shanghan Lun* and *Jingui Yaolue*. Otherwise, this formula sufficiently supplements the deficiencies of these two books, making it extremely precious! Many formulas in *Qian Jin Fang* and *Waitai Miyao* use Rhino Horn as the main herb, all of which can be verified. Later generations added spiritual substances like Antelope Horn and Calculus Bovis, aromatic volatile substances like Benzoin and Musk, and heavy sedatives like Gold/Silver foil and Cinnabar, expanding it into Zixue San (Purple Snow Powder) and Zhibao Dan (Precious Treasure Pill). Used skillfully, these remain good formulas.
Alas, vulgar doctors believe in it too exclusively and use it too lavishly. Upon encountering coma and delirium, they immediately attribute it to pathogen confusing the Pericardium, regardless of whether it is a Cheng Qi syndrome, gambling everything on it. When it fails, the family bears no resentment, and the doctor feels no regret, which is truly pitiable! Furthermore, early use of Rhino Horn has many drawbacks. Thus, Zhang Taiyan stated: Some believe warm disease medications should generally be cooling, often ordering early administration of Rhino Horn, which instead causes coma and delirium, a common occurrence. Looking at Zhongjing's formulas, none used Rhino Horn. *Bencao* states Rhino Horn detoxifies. *Qian Jin Fang* and *Waitai Miyao* often use Rhino Horn to stop bleeding. Thus, for massive hematemesis/epistaxis, metrorrhagia/metrostaxis, or melena, Rhino Horn is often used, as it has vasoconstrictive properties. Yangming syndrome naturally involves sweating. Now, using Rhino Horn to constrict/sweat stops this, thereby forcing pathogens into the intestines and stomach, naturally causing coma and delirium. People often fail to understand this logic, believing that coma and delirium always indicate pathogen entering the Pericardium, thus remaining unclear about the errors caused by Rhino Horn. Only Lu Jiuzhi understands this. From this perspective, Liu Wansu lags behind Zhongjing, and Ye Tianshi and Wu Jutong lag far behind Liu Wansu. This statement arises from specific reflections. However, the final conclusion of Lu's *Xi Jiao Gao Huang Bian* states: Can it be said that diseases cannot be cured by Gypsum and Rhubarb but require Rhino Horn for cure? However, this must be after using Gypsum and Rhubarb, certainly not before. This is a decisive judgment. This is a balanced argument.
Regarding the functions of Rhino Horn and Antelope Horn, the similarities and minor differences should be sought in subtle distinctions. My brother Wu Ningxuan and I researched this matter and concluded: Rhino Horn lowers blood pressure, primarily affecting blood; Antelope Horn cools and harmonizes nerves, primarily affecting nerves. According to traditional theory, blood is governed by the Heart, hence Rhino Horn is considered a Heart Meridian herb. Nerves belong to the Liver, hence Antelope Horn is considered a Liver Meridian herb. However, when blood is hot, nerves are often scorched; when nerves are scorched, blood becomes hotter. The two often cause each other, hence the two herbs are often used together. The difference within similarity is thus limited.
[Further Note] The above sections are all explorations of medical principles. Theoretically, Yangming has no fatal syndromes, which is correct. However, deaths from Yangming disease also involve factors of insufficient human effort. Let me mention one point as proof. I believe that all critical syndromes are characterized by多变 (multiple changes): suddenly coma and delirium, suddenly grasping at empty air and touching beds, suddenly chills resembling death, suddenly sweating nearly leading to collapse, suddenly transforming into heat, suddenly transforming into cold. It is like the intense heat of summer: looking up, the sky is cloudless; looking down, metals flow and stones melt; suddenly, dark clouds gather, and rain pours down. The suddenness of change allows no interval. Therefore, treating such illnesses, the physician must not leave the patient's side. Relying on one physician is insufficient; convene several physicians to plan together. Follow the transmission of pulse and syndrome manifestations, making swift dispositions. Approaching it this way, there might be a chance of success. However, usually, families lack the strength to do this. After one consultation, they must wait until the next day. They do not know that many changes occur in between, and opportunities for rescue are lost. To illustrate with an example: after using Da Cheng Qi Tang for purgation, one should immediately use Ginseng, Astragalus, Angelica, and White Peony to save the deficiency. However, the family does not understand this, panicking and losing composure, and the patient passes away.