传兵火之余，难免遗亡之憾，一隅三反，在读者之善悟焉。且细绎仲圣书，亦未尝不微露其
意
注云∶温病始发，即当用黄芩汤去热为主。若伤寒必传至少阳，热邪渐入里，方可用黄芩佐
柴胡解之。盖黄芩汤乃温病之主方，即桂枝汤以黄芩易桂枝而去生姜，以桂枝主在表风寒，
黄芩主在里风热，乃不易之定法，其生姜辛散，非温热所宜，故去之。此表里寒热之不可不
知者也。周禹载注云∶明言太少二阳，何不用二经药，非伤寒也。伤寒由表入里，此则自内
发外，无表何以知太少二阳，或胁满，或头痛，或口苦引饮，或不恶寒而即热，故不得谓之
表也。如伤寒合病，皆表病也，今不但无表，且有下利里证，伤寒协热利，必自传经而入，
不若此之即利也。温何以即利？其人中气本虚，内伏已深，不能尽泄于外，势必下走利矣。
雄案∶此论温邪外发未久，即可下走为利。本文更有若呕者句，岂非温病可转霍乱，早逗
端倪于此乎。曩纂《温热经纬》，于此条下附注云∶少阳胆木，挟火披猖，呕是上冲，利由
下迫，何必中虚始利，饮聚而呕。半夏生姜，专开饮结，如其热炽，宜易连茹。杨素园先生评云∶
此注精当，非前人所及。今治温病转为霍乱者，似当奉此以为法也。慎庵闻之，极为折服，
再质宗匠，还望有以教我。
（愚意此证栀子似亦可用，轻者亦可不必黄连，未知是否，惟大枣太守，必宜去之。
五月初三日，余抵上洋，霍乱转筋，已流行成疫。居镇海周君采山家，不谒一客
，借以藏拙，且杜酬应之劳也。初八日，绍武近族稼书家，有南浔二客，同患此证。一韩
姓，须臾而死，一纪运翔，年十七，势亦垂危。采山强拉余往视曰∶岂可见死而不救哉？然
已手面皆黑，目陷睛窜，厥逆音嘶，脉伏无溺，舌紫苔腻，大渴汗淋，神情瞀乱，危象毕
呈。时未交芒种，暑湿之令未行，仍是冬寒内伏，春令过冷，入夏犹凉，气机郁遏不宣，故
欲变温病者，皆转为此证。与伏暑为患者，殊涂同归。但不腹痛耳，以寒邪化热，究与暑湿
较异也。亟令刺曲池、委中，出血如墨。方以黄芩为君，臣以栀、豉、连、茹、苡、半。佐
以蚕矢、芦根、丝瓜络，少加吴萸为使。阴阳水煎，候温徐徐服之，遂不吐。次日，脉稍起
。
又两剂，黑色稍淡，肘膝稍和，反加睛赤烦躁，是伏邪将从外泄也。去吴萸、蚕矢，加连翘
、益母草、滑石、而斑发遍身，苔始渐化，肢温得寐，小溲亦行，随与清搜化毒之药，多剂
而痊。采山因嘱余详述病因治法，刊印传布，名其方曰黄芩定乱汤。嗣治多人，悉以此法增
损获效。如利泰一洞庭史客，素吸洋烟，而患此证。与此方数帖后，反便秘目赤，渴、汗、昏
狂。
亦是久伏之邪，渐欲外越也。予竹叶石膏汤加减而瘳。其湿盛者，加茵陈、滑石；气实者，
加
枳、桔；饮阻食滞者，加浓朴、芦菔；肝郁气结者，加紫苏、楝实；口渴用茅根汤。或藕
汁频灌。活法在人，不能缕述。绍武在屠甸市，得余此方，劝人合药施送，几及千料云。
（此方加减有法，较前尤妥善也。谢城。）
夏至后仍无大热，而霍乱转筋不息，虽与芒种以前者，同为伏邪所发，然证因略
有不同，其病似较深一层。何也？按先曾祖《重庆堂随笔》云∶温病、热病、湿温病，治不得
法，皆易致死。流行不已，即成疫疠，犹之治盗不得其法，则贼党日众，变为流寇也。因热气病气尸
气，互相 ，即成毒疠之气而为疫.岂真天地之间，
另有一种异气哉。故疫之流行，必在人烟萃聚之区。盖人气最热，纪文达公杂诗云:万家烟
火暖云蒸，销尽天山太古冰。自注∶迪化自设郡县以来，婴儿出痘，与内地同，盖彼处
气候极寒，今则渐同内地，人气盛也。纪氏此言，可谓独窥其微矣。上古无痘，至汉始有，今
时罕有不出痘者。以生齿日繁，地气日热，所以古人最重伤寒，今世偏多温热也。雄案∶此
段名
亦
能升，挥霍闷乱，而为吐泻转筋之危证。是伏邪欲发，客邪外入，两邪交讧，肠胃乃乱。故气
道立时闭塞，血脉因而瘀滞，四肢厥冷，手面皆黑。阳明多气多血之经，见证若是之骤者，非
气血忽然枯槁也。夫人气以成形耳，气不流行，血肉即死。故初起亟宜开闭，俾气通血活，
邪得外泄，则正自复。昧者，不知邪闭血凝，热深厥深之理，见其肢冷脉伏，即以为寒，又
疑为脱，即不敢刺，更投热药，使邪无宣泄，愈闭愈冷。尚谓服此热药，一身尽冷，可见黍谷春回
之不易，再遇此证，仍用此法，死者之冤，无可呼吁。虽有七窍流血而死者，亦不悔悟，亦
有邪闭，则正气无以自容而外脱者。阳从上脱，则汗多而气夺；阴从下脱，则泻多而液亡。
所谓内闭外脱也。欲其不外脱，必开其内闭，如紫雪、绛雪、行军散，皆开闭透伏之良方也
。而飞龙夺命丹，即合行军、绛雪二方而加峻者，且有人中白引浊下行，尤具斩关夺命之能
。上虞陈君香谷闻之，概为制送，嘱余详叙方治刊布，因而救全不少，厥功伟哉。
自纪运翔之证治愈后，凡患此者，纷纷踵门求诊，情不能已，徼幸成功者，颇多。然夏至
以后，病由内外合邪，其势更剧，故必先以夺命丹开其闭伏，愈后变证不一，然随机而应，甚
费经营，非比往年之霍乱，虽系危证，但得转机，即可霍然也。其故良由流离困苦，失志劳
神，先有内伤，遂多曲折，故愈后调理，极宜详慎。而上海多懋迁窜难之人，病得转机，往
往大意。所谓病加于小愈，因而致堕前功者不少。如余杭褚子耘茂才，余亲家也。其使女患
此，已身僵矣，适余往访知之，遂以香谷所赠夺命丹二分，嘱其灌入，顷刻活动，随予解毒
活血汤，数服得生。嗣余往返崇明，闻其仍淹缠不健而亡。一王大生烟铺伙友，余治愈后，
已溺行能食，余热外泄，满面赤瘰，忽然神气瞀乱而死。一澧记钱铺石某，余为治愈，二
便已如常矣。越数日，云∶饮食不得下，戴眼呃忒而逝。一绿荫书坊陶姓，业已向愈，忽然神
情恍惚，药不及救，此丽云为余述者。又四明陈解香之弟，患此垂危，延余治愈，遂不服药月
余，复来请勘，已咽痛碍进水谷，颐肿舌糜，牙关甚紧，痰嗽胁疼，溺赤管痛，便溏色酱，
此余毒蕴隆，失于清解，遂致燎原若此。是限于贫困，养痈成患。而脉已弦紧数疾，莫可
措手，久之果毙。并录为案以为贾旅告。或云∶此地药肆甚忙，每致误付，病者误服骤变，
彼此不知，医家、病家，皆须留意。嗣阅《冷庐医话》云∶吾邑陈庄李氏子患霍乱，医定方
有制半夏二钱，药肆中误以制附子与之，服后腹大痛，发狂，口中流血而卒。李归咎于医，医谓用药不
误，必有他故。索视药渣，则附子在焉，遂控于官，罚药肆以金和息之。观此则或人之言
尤信，然此案若病家良懦，隐忍而不言；医者惶窘，走避而不辨；或药渣弃无可证。则此狱
虽皋陶莫断矣。服药可不慎哉。
朱鸣岐，患下利转筋，医见肢冷，即投温补。而服药即吐，既而呃忒不已。温补加峻，病日
以危，延至九朝，已万无生理，备后事矣。子耘主其家，嘱请余援，脉至左弦滑，右弱不应
指
得吐，否则早为泉下人也。予枳、桔、芩、连、茹、夏、苏、翘、芦根、枇杷叶、滑石，开
痰行食，舒结通阳，两剂呃果止，而遍身赤斑。又两剂燥矢下，而苔化溺行，右脉渐振，随
与清肃调养法而瘳。
勘朱证时，适子耘令弟子方茂才在座。曰∶如此重证，君胡以为病原不重也。余谓世间重证
，大半因误治而成，此证若初治得法，一二剂可愈也。奈举世以泻证、吐证、霍乱证、霍乱转筋证、
皆为寒证，往往不察病情，辄投热药，今见肢冷而右脉软弱，彼方以为虚寒的据。况服药即
吐，呃忒随来，以霍乱转筋而见呃忒，何暇更问其余。皇皇然以为虚脱之象，故温补日以加
峻。纵使一蹶不起，病家无怨，医者不悔也。每见此地市医临证，虽极轻之病，必立重案，
预为避罪邀功之地，授受相承，伎俩如是，良可慨已。此外如胸腹疼痛，疟疾哮喘，经阻产
后
等证，世俗亦多指为寒病，虽以热药杀之，而彼此不知者，而呃忒则尤多枉死焉。余尝治
一角妓，患呃累日，破身太早，固是虚证。然血去阴伤，岂可反以温燥助热。遂致下焦不摄
，素性畏药。余用一味鸡子黄，连进数服而安。
吴竹溪时感将瘥，患呃三日，声闻于邻，人皆危之。予通府行气法，便行痰吐而痊。
南浔朱君浦香，年五十六，自幼患童劳，继以吐血，三十外即绝欲得延至此。而平素便如
羊
矢，其血分之亏如是。今秋陡患呃忒，连服滋镇温纳之药，势濒于危。陆定圃进士，嘱延余
诊，脉至弦滑搏数，苔黄浓而腻，口苦溺赤。遂力排众议，主大剂凉润，如雪羹、蒌仁、竹
沥、枇杷叶、芦根、元参、紫菀、射干、兜铃、菖蒲等多剂，连下赤矢始瘳。如此衰年虚体
，尚因痰热致呃，故虚寒之呃，殊不多见，而医者不知辨证察脉，率以丁香、姜、桂为不祧
之药。何哉？
谢氏妇，怀孕五月，便泻四日，医投姜、附、桂、朴药一帖。遂四肢麻冷，气塞神昏，溺闭
汗淋，大渴呕吐。急延余援，脉未全伏，先饮以酱油汤，吐渐止。随予参、连、芩、柏、茹
、斛、银花、扁豆叶、蒲桃干、芦根、绿豆，以冬瓜汤煎，徐徐温服。外用炭醋熏之，各恙
皆瘥。次日，脉弦滑，泻未止。以白头翁汤加参、草、银花、扁豆、蒲公英、蒲桃干、砂仁
，两剂而痊。
婺源詹耀堂子，年二十，患霍乱，服姜、桂数剂，泻不止。素吸鸦片，疑为虚漏，补之，泻
益甚。始延余视，大渴而脉弦数。幸而起病不因暑热，然阴分素亏，虽饮冷贪凉，热药岂堪过
剂，设无便泻以分其药力，则津液早枯矣。予白头翁汤合封髓丹，加银花、绿豆、石斛，一
剂知，二剂已。
余赴申时过石门，吴君仁山在濮院，承其关切曰∶毗陵张仲远观察，秀水杨啸溪孝廉，皆
已自楚至申，句当公事，君可往访也。余感其意，唯唯而谢，缘久闻张氏家学渊源，虽闺阁
皆通翰墨，然向见其宛邻书屋医书数种，似偏尚温补者。曾与故人太仓王子能参军言之，子
能亦善医。叹曰∶人之才识学力，各有能至不能至，不可强也。王半山不入相，即是伊芳川
一
若张氏者，何必谈医，世人信其学问，而并信
而贻误者实多。余弟季旭，仲远之妹婿也。即为其所误。噫！言犹在耳，子能已下世十余年
矣。
于扶正却邪之说，犹之寇来不战，但知守城，卒以自毙耳。秋间仲远亦亡，后蒋寅
大理信来，颇以余求书不与为是。昔某侍郎督学吾渐，亦
以上工自命，尝浼邵位西枢部求书，余亦不与。所谓道不人谈免俗讥，备录为案，愿世人毋
轻言医，事必量而后入也。
钱塘姚欧亭协转，复宰崇明。闻余在沪，新秋嘱余弟HT 庵比部持函聘余往游，以初夏偶患大
泻，后苦脾约，更旬始一更衣，既而匝月一行，甚至月余一行，极其艰滞，而先
硬后溏，汗出神惫。年逾六秩，步履蹇滞，虽广服人乳及润导诸
药，率不效。间或纳食如梗，呕吐酸辣，六脉迟软，苔色白润不渴，小便清长，腹无胀痛，此真
中气不足，溲便为之变也。岂肠燥便秘，可以润药濡之哉。既不宜润，更不可下，以中虚开阖无
权，恐一开而不复阖，将何如耶？亦不可升提。盖吐酸食梗，已形下秘上冲之势。又素吸洋
烟，设一阖而竟不开，又将何如耶？爰以参、术、橘、半、旋、芍、鸡金、木瓜、枇杷叶为
方，服六剂，更衣两次，解四弹丸。又三剂，解十五六丸。又三剂，下九丸而始畅，并不坚燥
，亦无溏矣。毫不怯力，是药证已符，为留调理法而别。设或吐酸食梗，则暂用参、连、
橘、半、旋、茹、苏叶、枇杷叶、紫石英以清肃镇息之。八月初，秋阳正烈，欧亭因公来申，久
住
白苔满布
叶二剂，热退神清。而左脉仍弦，关上高，呕酸无寐，手足振惕，客邪虽解，土受木乘也。
去滑、朴、蚕沙、扁豆叶，加茯神、蛤壳、紫菜、绿豆、白蔻仁。三剂。苔化能眠，知饥泻减，去
蔻、蛤，加菖蒲、白术，五剂而痊。霍乱之开阖失常，中枢为邪所乱也。此证之开阖无权，中
虚不能主持也。一实一虚，正可互勘，至愈后之呕泻振惕，又为风暑乘虚扰中之霍乱证，故
详列拙治，统质通方。
汪谢城孝兼，招勘婺源石雨田司马令慈，年近五旬，陡患霍乱转筋，苔黄大渴，神情烦躁，
证属伏暑，脉颇不恶，而浑身冷汗，摇扇不停，已为阳越之象，不敢与方。寻即告殒，此
证书不凭脉也。次日， 斋荐视朱君巽泉之尊人，年已六旬，患霍乱转筋，证不甚剧，问答音
清
逾半月， 斋于丙夜患此证，刺出黑血，侵晓速余往视，形脉两脱，大汗如淋，目陷音嘶，
溺无苔腻。平素嗜饮少谷，好善忘劳，暑湿蕴中，正气溃散，勉投参药，竟不能救。惜哉！
（这段文字是）在经历战火劫难后流传下来的，难免有散佚缺失的遗憾。举一反三，在于读者善于领悟。况且仔细研读张仲景的著作，也未曾不隐约透露出其中的意旨。
注释说：温病刚开始发作时，就应当以黄芩汤清热为主治方。如果是伤寒，必须传到少阳经，热邪逐渐进入体内，才可以用黄芩配合柴胡来解表。因为黄芩汤是治疗温病的主方，它是由桂枝汤去掉桂枝、生姜，用黄芩替换桂枝而成的。桂枝主治在表的风寒，黄芩主治在里的风热，这是不可改变的一定法则。生姜辛温发散，不适合温热病，所以去掉它。这是表里寒热之理不可不知的地方。周禹载注释说：文中明确提到了太阳和少阳两经，为什么不用这两经的药？这说明不是伤寒。伤寒是由表入里的，而此病则是从内发于外的，如果没有表证，怎么知道是太阳和少阳两经呢？或者出现胁肋胀满，或者头痛，或者口苦想喝水，或者不恶寒而直接发热，所以不能称之为表证。如果是伤寒的合病，都是表病，现在不仅没有表证，还有下利的里证。伤寒的协热利，一定是经过传经才出现的，不像这种病一开始就下利。温病为什么会一开始就下利？是因为病人中气本来虚弱，邪气潜伏得很深，不能完全发泄于体表，势必向下走导致下利。
王士雄按语：这段论述温邪向外发散时间不久，就可以向下走导致下利。原文中还有“如果呕吐”这一句，难道不是说温病可以转化为霍乱吗？这早就显露了端倪在此处。过去我编纂《温热经纬》时，在这条下面附注说：少阳胆木挟带火热之气猖獗，呕吐是气机上冲，下利是由于气机下迫，何必一定要中气虚才会下利？这是水饮停聚导致的呕吐。半夏和生姜专门开通水饮结滞，如果热势炽盛，应该改用黄连和黄连根须（连茹）。杨素园先生评论说：这个注释精当确切，不是前人所及的。现在治疗温病转化为霍乱的，似乎应当奉行这个作为准则。慎庵听了之后，非常信服，再次向专家请教，还希望有人能教导我。
（我的意见是这个证候栀子似乎也可以使用，轻症也可以不必用黄连，不知道是否正确，只是大枣太守，一定应该去掉。）
五月初三日，我到达上海，霍乱转筋已经流行成为疫病。住在镇海的周采山君家里，不拜访客人，借此隐藏自己的拙劣，并且杜绝应酬的劳累。初八日，绍武的近族稼书家，有两位来自南浔的客人，同时患了这个病。一个姓韩的，一会儿就死了；一个叫纪运翔的，十七岁，病情也很危重。采山强行拉我去诊治说：“怎么能看见死人而不救呢？”但是此时病人已经手面发黑，眼睛凹陷眼球上窜，四肢厥冷声音嘶哑，脉搏伏匿无尿，舌质紫苔腻，极度口渴大汗淋漓，神情昏乱，危象全部呈现。当时还没有到芒种节气，暑湿的时令还没施行，仍然是冬天的寒气内伏，春天的时令过于寒冷，进入夏天仍然凉爽，气机郁结遏制不能宣通，所以想要变成温病的，都转化为此证。这与伏暑为患者，殊途同归。只是没有腹痛罢了，因为寒邪化热，终究与暑湿有所不同。急忙让人针刺曲池穴、委中穴，放出像墨汁一样的血。方剂以黄芩为君药，臣药用栀子、豆豉、黄连、黄连根须、薏苡仁、半夏。佐药用蚕砂、芦根、丝瓜络，少加吴茱萸为使药。用阴阳水煎煮，待温后慢慢服用，于是就不吐了。第二天，脉象稍微起复。
又服两剂，黑色稍微变淡，肘膝稍微温和，反而出现眼睛发红烦躁，这是伏邪将要向外发泄的表现。去掉吴茱萸、蚕砂，加入连翘、益母草、滑石，然后斑疹发遍全身，舌苔开始逐渐化解，肢体温暖能够入睡，小便也开始通行，随即给予清搜化毒的药物，多剂后痊愈。采山因此嘱咐我详细叙述病因治法，刊印传播，将此方命名为黄芩定乱汤。后来治疗多人，都是用这个方法增减获得疗效。比如利泰一洞庭史客，平时吸食鸦片，却患了这个病。给他这个方子几帖后，反而便秘目赤，口渴、出汗、昏狂。这也是久伏的邪气，渐渐想要向外透发的表现。我给予竹叶石膏汤加减而治愈。湿气盛的，加茵陈、滑石；气实的，加枳实、桔梗；水饮阻滞食物停滞的，加厚朴、萝卜；肝郁气结的，加紫苏、川楝子；口渴用茅根汤。或者频繁灌服藕汁。活法在于人，不能一一详述。绍武在屠甸市，得到我这个方子，劝人合药施送，差不多有一千料之多。
（这个方子加减有法度，比之前的更加妥善。谢城评。）
夏至后仍然没有大热，但霍乱转筋不停息，虽然与芒种以前的病，都是由伏邪引发，然而病因略有不同，病情似乎较深一层。为什么呢？按照先曾祖《重庆堂随笔》所说：温病、热病、湿温病，治疗不得法，都容易致死。流行不止，就成为疫疠，就像治理盗贼不得其法，那么贼党日益增多，变为流寇一样。因为热气、病气、尸气，互相混杂，就成为毒疠之气而为疫病。难道真是天地之间，另外有一种异气吗？所以疫病的流行，一定在人烟聚集的地区。大概人气最热，纪文达公杂诗云：“万家烟火暖云蒸，销尽天山太古冰。”自注说：迪化自从设立郡县以来，婴儿出痘，与内地相同，大概那里气候极寒，现在则逐渐同于内地，人气旺盛啊。纪氏这番话，可以说是独自窥探到了微妙之处。上古没有痘，到汉代才有，现在很少有不出痘的人。因为人口日益繁多，地气日益炎热，所以古人最重伤寒，今世偏多温热。
王士雄按语：这一段名……也能升发，挥霍闷乱，从而成为吐泻转筋的危重证候。这是伏邪想要发作，客邪外入，两邪交争，肠胃于是混乱。所以气道立刻闭塞，血脉因而瘀滞，四肢厥冷，手面皆黑。阳明是多气多血的经络，见证如此急剧的，不是气血忽然枯槁。人的形体由气构成，气不流行，血肉就会死亡。所以初起时亟宜开闭，使气通血活，邪气得以外泄，正气自然恢复。愚昧的人，不知道邪闭血凝、热深厥深的道理，见到他们肢冷脉伏，就认为是寒证，又怀疑为脱证，就不敢针刺，更投用热药，使邪气无法宣泄，越闭越冷。还说服用这些热药，一身尽冷，可见黍谷春回的不易，再遇到此证，仍用此法，死者的冤屈，无处呼吁。虽然有七窍流血而死的人，也不悔悟。也有邪气闭阻，正气无法自容而外脱的。阳气从上脱，则汗多而气夺；阴气从下脱，则泻多而液亡。这就是所谓的内闭外脱。要想不让它外脱，必须打开它的内闭，如紫雪、绛雪、行军散，都是开闭透伏的良好方剂。而飞龙夺命丹，就是合并行军散、绛雪二方而加重药力的，并且有人中白引导浊气下行，尤其具有斩关夺命的功能。上虞陈香谷君听说后，一概制作赠送，嘱咐我详细叙述方治刊布，因而救活不少人，功德伟大啊。
自从纪运翔的病治愈后，凡是患此病的，纷纷登门求诊，情不能已，侥幸成功的，很多。然而夏至以后，病由内外合邪，气势更剧烈，所以必须先以夺命丹打开其闭伏，痊愈后变证不一，然而随机应变，很费经营，不像往年之霍乱，虽然是危重证，只要得到转机，就可以霍然痊愈。其原因确实是由于流离困苦，失志劳神，先有内伤，遂多曲折，所以痊愈后调理，极宜详细谨慎。而上海多是经商奔波之人，病得转机，往往大意。所谓病加于小愈，因而致堕前功者不少。比如余杭褚子耘茂才，是我的亲家。他的使女患此病，已经身体僵硬了，恰好我去拜访得知，就用香谷所赠的夺命丹二分，嘱咐灌入，顷刻间活动，随即给予解毒活血汤，几服后得生。后来我往返崇明，听说她仍然缠绵不健而亡。还有一个王大生烟铺伙友，我治愈后，已经小便通畅能吃饭，余热外泄，满面赤瘰，忽然神气昏乱而死。还有一个澧记钱铺的石某，我为他治愈，二便已经正常了。过了几天，他说：“饮食不得下”，戴眼呃逆而逝。还有一个绿荫书坊陶姓，业已向愈，忽然神情恍惚，药不及救，这是丽云为我讲述的。还有四明陈解香的弟弟，患此病危重，延请我治愈，于是不服药月余，又来请我看诊，已经咽痛碍进水谷，腮肿舌糜，牙关甚紧，痰嗽胁疼，溺赤管痛，便溏色酱，这是余毒蕴隆，失于清解，遂致燎原若此。这是因为限于贫困，养痈成患。而脉已弦紧数疾，莫可措手，久之果然毙命。并记录为医案以告贾旅。有人说：此地药肆很忙，每致误付，病者误服骤变，彼此不知，医家、病家，皆须留意。后来阅读《冷庐医话》说：我们县陈庄李氏之子患霍乱，医生定方中有制半夏二钱，药肆中误以制附子与之，服后腹大痛，发狂，口中流血而卒。李归咎于医生，医生谓用药无误，必有他故。索视药渣，则附子在焉，遂控于官，罚药肆以金和息之。观此则或人之言尤信，然而此案若病家良懦，隐忍而不言；医者惶窘，走避而不辨；或药渣弃无可证。则此狱虽皋陶莫断矣。服药可不慎哉。
朱鸣岐，患下利转筋，医生见肢冷，即投温补。而服药即吐，继而呃逆不已。温补加重，病日益危重，延至九天，已万无生理，准备后事了。子耘主持他家事务，嘱咐请我援助，脉至左弦滑，右弱不应指。予枳实、桔梗、黄芩、黄连、黄连根须、半夏、紫苏、连翘、芦根、枇杷叶、滑石，开痰行食，舒结通阳，两剂呃果止，而遍身赤斑。又两剂燥屎下，而苔化溺行，右脉渐振，随即给予清肃调养法而痊愈。
勘察朱证时，适逢子耘令弟子方茂才在座。说：“如此重证，您为何认为病原不重呢？”我说：“世间重证，大半因误治而成，此证若初治得法，一二剂可愈也。无奈举世以泻证、吐证、霍乱证、霍乱转筋证，皆为寒证，往往不察病情，辄投热药，今见肢冷而右脉软弱，彼方以为虚寒的的确据。何况服药即吐，呃逆随来，以霍乱转筋而见呃逆，何暇更问其余。慌慌张张地以为是虚脱之象，所以温补日以加峻。纵使一蹶不起，病家无怨，医者不悔也。每见此地市医临证，虽极轻之病，必立重案，预为避罪邀功之地，授受相承，伎俩如是，良可慨已。此外如胸腹疼痛，疟疾哮喘，经阻产后等证，世俗亦多指为寒病，虽以热药杀之，而彼此不知者，而呃逆则尤多枉死焉。我曾治一角妓，患呃累日，破身太早，固是虚证。然血去阴伤，岂可反以温燥助热。遂致下焦不摄，素性畏药。我用一味鸡子黄，连进数服而安。
吴竹溪时感将愈，患呃三日，声闻于邻，人都认为危险。我予通腑行气法，便行痰吐而痊愈。
南浔朱浦香君，年五十六，自幼患童劳，继以吐血，三十外即绝欲得延至此。而平素便如羊矢，其血分之亏如是。今秋陡患呃逆，连服滋镇温纳之药，势濒于危。陆定圃进士，嘱延我诊，脉至弦滑搏数，苔黄浓而腻，口苦溺赤。遂力排众议，主大剂凉润，如雪羹、瓜蒌仁、竹沥、枇杷叶、芦根、玄参、紫菀、射干、款冬花、石菖蒲等多剂，连下赤矢始痊愈。如此衰年虚体，尚因痰热致呃，故虚寒之呃，殊不多见，而医者不知辨证察脉，率以丁香、姜、桂为不祧之药。何哉？
谢氏妇，怀孕五月，便泻四日，医生投姜、附、桂、厚朴药一帖。遂四肢麻冷，气塞神昏，溺闭汗淋，大渴呕吐。急延我援助，脉未全伏，先饮以酱油汤，吐渐止。随即给予人参、黄连、黄芩、黄柏、黄连根须、石斛、银花、扁豆叶、葡萄干、芦根、绿豆，以冬瓜汤煎，徐徐温服。外用炭醋熏之，各恙皆瘥。次日，脉弦滑，泻未止。以白头翁汤加人参、甘草、银花、扁豆、蒲公英、葡萄干、砂仁，两剂而痊愈。
婺源詹耀堂之子，年二十，患霍乱，服姜、桂数剂，泻不止。素吸鸦片，疑为虚漏，补之，泻益甚。始延我看诊，大渴而脉弦数。幸而起病不因暑热，然阴分素亏，虽饮冷贪凉，热药岂堪过剂，设无便泻以分其药力，则津液早枯矣。予白头翁汤合封髓丹，加银花、绿豆、石斛，一剂知，二剂已。
我赴上海时经过石门，吴仁山君在濮院，承蒙其关切说：“毗陵张仲远观察，秀水杨啸溪孝廉，都已从楚地到上海，办理公事，您可以去拜访。”我感激他的心意，唯唯而谢，因为久闻张氏家学渊源，虽闺阁皆通翰墨，然而向来见其宛邻书屋医书数种，似偏尚温补者。曾与故人太仓王子能参军言之，子能亦善医。叹曰：“人之才识学力，各有能至不能至，不可强也。王半山不入相，即是伊芳川一……若张氏者，何必谈医，世人信其学问，而并信……而贻误者实多。我弟季旭，是仲远的妹婿。即为其所误。噫！言犹在耳，子能已下世十余年矣。
至于扶正却邪之说，犹如寇来不战，但知守城，最终自毙罢了。秋天仲远也亡故，后来蒋寅大理来信，颇以我不给书为是。昔某侍郎督学吾浙，也以上工自命，曾拜托邵位西枢部求书，我也不给。所谓道不人谈免俗讥，备录为案，愿世人毋轻言医，事必量而后入也。
钱塘姚欧亭协转，复宰崇明。听说我在上海，新秋嘱咐我弟HT庵比部持函聘我前往游玩，因为初夏偶患大泻，后苦脾约，更旬始一更衣，既而匝月一行，甚至月余一行，极其艰滞，而先硬后溏，汗出神惫。年逾六秩，步履蹇滞，虽广服人乳及润导诸药，率不效。间或纳食如梗，呕吐酸辣，六脉迟软，苔色白润不渴，小便清长，腹无胀痛，此真中气不足，溲便为之变也。岂肠燥便秘，可以润药濡之哉。既不宜润，更不可下，以中虚开阖无权，恐一开而不复阖，将何如耶？亦不可升提。盖吐酸食梗，已形下秘上冲之势。又素吸洋烟，设一阖而竟不开，又将何如耶？爰以人参、白术、橘皮、半夏、旋覆花、白芍、鸡内金、木瓜、枇杷叶为方，服六剂，更衣两次，解四弹丸。又三剂，解十五六丸。又三剂，下九丸而始畅，并不坚燥，亦无溏矣。毫不怯力，是药证已符，为留调理法而别。设或吐酸食梗，则暂用人参、黄连、橘皮、半夏、旋覆花、黄连根须、苏叶、枇杷叶、紫石英以清肃镇息之。八月初，秋阳正烈，欧亭因公来申，久住白苔满布，服滑石、厚朴、蚕沙、扁豆叶二剂，热退神清。而左脉仍弦，关上高，呕酸无寐，手足振惕，客邪虽解，土受木乘也。去滑、朴、蚕沙、扁豆叶，加茯神、蛤壳、紫菜、绿豆、白蔻仁。三剂。苔化能眠，知饥泻减，去蔻、蛤，加菖蒲、白术，五剂而痊。霍乱之开阖失常，中枢为邪所乱也。此证之开阖无权，中虚不能主持也。一实一虚，正可互勘，至愈后之呕泻振惕，又为风暑乘虚扰中之霍乱证，故详列拙治，统质通方。
汪谢城孝兼，招勘婺源石雨田司马令慈，年近五旬，陡患霍乱转筋，苔黄大渴，神情烦躁，证属伏暑，脉颇不恶，而浑身冷汗，摇扇不停，已为阳越之象，不敢与方。寻即告殒，此证书不凭脉也。次日，斋荐视朱君巽泉之尊人，年已六旬，患霍乱转筋，证不甚剧，问答音清……逾半月，斋于丙夜患此证，刺出黑血，侵晓速余往视，形脉两脱，大汗如淋，目陷音嘶，溺无苔腻。平素嗜饮少谷，好善忘劳，暑湿蕴中，正气溃散，勉投参药，竟不能救。惜哉！
(These words were) passed down after surviving the ravages of war, inevitably carrying the regret of loss and omission. Drawing inferences about other cases from one instance depends on the reader's ability to comprehend. Moreover, upon careful study of Zhang Zhongjing's works, one finds that their intent is subtly revealed.
The annotation states: When a warm disease (Wenbing, febrile diseases caused by warm pathogens) first manifests, Huangqin Tang (Scutellaria Decoction) should be used primarily to clear heat. If it is a cold damage (Shanghan, diseases caused by cold pathogens), it must transmit to the Shaoyang (Lesser Yang) channel, and only when the pathogenic heat gradually enters the interior can Scutellaria be combined with Bupleurum to resolve the condition. This is because Huangqin Tang is the principal formula for treating warm diseases; it is derived from Guizhi Tang (Cinnamon Twig Decoction) by replacing Cinnamon Twig with Scutellaria and removing Ginger. Cinnamon Twig treats exterior wind-cold, while Scutellaria treats interior wind-heat; this is an unchangeable rule. Ginger is acrid and dispersing, which is not suitable for warm-heat conditions, hence it is removed. One must understand the distinction between exterior-interior and cold-heat.
Zhou Yuzai annotated: The text explicitly mentions the Taiyang (Greater Yang) and Shaoyang channels, yet asks why medicines for these two channels are not used? This indicates it is not Shanghan. Shanghan proceeds from the exterior to the interior, whereas this condition originates from the interior and emerges outward. Without an exterior syndrome, how can one identify the involvement of the Taiyang and Shaoyang channels? Symptoms may include fullness in the hypochondrium, headache, bitter taste in the mouth with desire to drink, or fever without aversion to cold. Therefore, it cannot be called an exterior syndrome. In cases of combined syndromes in Shanghan, all are exterior diseases. Now, there is not only no exterior syndrome but also diarrhea indicating an interior syndrome. The heat-associated diarrhea in Shanghan must result from transmission through channels, unlike this condition where diarrhea occurs immediately. Why does warm disease cause immediate diarrhea? It is because the patient's Middle Qi (Spleen/Stomach energy) is inherently deficient, the pathogen has deeply latent within, and cannot be fully vented outward; thus, it inevitably moves downward causing diarrhea.
Wang Shixiong's clinical note: This discussion describes how warm pathogens, having been externalized for a short time, can move downward to cause diarrhea. The original text also contains the phrase "if vomiting occurs," does this not imply that warm disease can transform into Huoluan (cholera-like syndrome)? The clues have appeared here early on. Previously, when compiling *Wenre Jingwei* (Classic of Warm Heat), I added a note under this passage: The Wood of the Shaoyang Gallbladder, carrying rampant fire, causes vomiting due to upward rushing Qi, and diarrhea due to downward pressing Qi. It is not necessary for Middle deficiency to cause diarrhea; this is vomiting caused by fluid accumulation. Pinellia and Ginger specifically open fluid stagnation; if heat is blazing, Lianru (Scutellaria Root and Rhizome) should be substituted instead. Mr. Yang Suyuan commented: This annotation is precise and appropriate, surpassing previous scholars. For current treatments of warm disease transforming into Huoluan, this method should be followed as a standard. Shen'an was highly convinced after hearing this and sought further advice from experts, hoping for instruction.
(My opinion is that Gardenia seems applicable for this syndrome; for mild cases, Coptis might not be necessary, though I am unsure. However, Jujube Fruit should definitely be removed.)
On the third day of the fifth month, I arrived in Shanghai. Huoluan with tendon retraction had already become epidemic. I stayed at the residence of Mr. Zhou Caishan from Zhenhai, avoiding visitors to conceal my inadequacies and to avoid the fatigue of social obligations. On the eighth day, at the home of Jiashu, a close relative of Shaowu, two guests from Nanxun suffered from this illness simultaneously. One surnamed Han died within moments; the other, Ji Yunxiang, aged seventeen, was also critically ill. Caishan insisted I visit, saying, "How can we see death and not save?" However, the patients' hands and faces were black, eyes sunken with rolling pupils, limbs cold, voice hoarse, pulse hidden with no urination, tongue purple with greasy coating, extreme thirst with profuse sweating, and mental confusion, presenting all signs of critical danger. Although it was before the Mangzhong solar term and the season of summer-dampness had not yet begun, winter cold remained latent inside. Spring had been excessively cold, and even entering summer, it remained cool. Qi mechanism was depressed and unable to circulate freely. Thus, those who would develop warm diseases transformed into this syndrome. This shares the same outcome as cases of latent summerheat, differing only in the absence of abdominal pain. Since cold transforms into heat, it is ultimately distinct from summer-dampness. I urgently ordered acupuncture at Quchi (LI11) and Weizhong (BL40) to bleed until the blood resembled ink. The prescription used Huangqin (Scutellaria Root) as the sovereign drug, with Gardenia, Fermented Soybean, Coptis, Scutellaria Root and Rhizome, Coix Seed, and Pinellia as minister drugs. Mulberry Twig Ash, Reed Rhizome, and Loofah Network served as assistant drugs, with a small amount of Evodia as envoy. Decocted in Yin-Yang water (half boiled, half cold water), administered warm and slowly, vomiting ceased. The next day, the pulse slightly recovered.
After two more doses, the black color lightened slightly, elbows and knees became warmer, but red eyes and irritability appeared, indicating latent pathogens were venting outward. Evodia and Mulberry Twig Ash were removed; Forsythia, Motherwort, and Talc were added. Spots broke out over the body, the tongue coating began to resolve, limbs warmed, sleep returned, and urination resumed. Subsequently, herbs for clearing and resolving toxins were given, leading to recovery after several doses. Caishan urged me to detail the etiology and treatment methods for publication, naming the formula Huangqin Dingluan Tang (Scutellaria Stabilizing Cholera Decoction). Later, many others were treated successfully using variations of this method. For example, a guest from Dongting staying at Litai, who habitually smoked opium, contracted this illness. After several doses of this formula, he developed constipation, red eyes, thirst, sweating, and delirium. This too indicated long-latent pathogens attempting to emerge externally. I prescribed modified Zhuye Shigao Tang (Leaf of Bamboo and Gypsum Decoction), resulting in recovery. For cases with heavy dampness, Yinchen and Talc were added; for excess Qi, Zhiqiao (Aurantium and Magnolia Bark) were added; for fluid obstruction and food stagnation, Houpo and Radish were added; for Liver Qi stagnation, Perilla and Chinaberry Fruit were added; for thirst, Mugwort Root juice was used, or fresh Lotus Root juice was frequently administered. Treatment flexibility lies with the practitioner and cannot be exhaustively listed. Shaowu, in Tudian Market, obtained my formula and advised people to prepare and distribute it, totaling nearly a thousand portions.
(This formula's modifications follow specific rules and are even more appropriate than the previous ones. Reviewed by Xie Cheng.)
After Summer Solstice, there was still no intense heat, yet Huoluan with tendon retraction persisted. Although similar to pre-Mangzhong cases caused by latent pathogens, the etiology differed slightly, suggesting a deeper pathological level. Why? According to my late great-grandfather's *Chongqing Tang Suibi*: Warm diseases, heat diseases, and damp-warm diseases, if treated improperly, easily lead to death. Continuous spread becomes epidemic, just as failing to suppress bandits leads to their growth into roaming marauders. Heat Qi, pathogenic Qi, and corpse Qi mix to form toxic epidemic Qi. Is it truly that heaven and earth generate a unique abnormal Qi? Therefore, epidemics occur in densely populated areas. Human Qi generates the most heat. As Ji Wenda wrote in his miscellaneous poems: "Ten thousand homes' smoke and fire warm the clouds, melting the ancient ice of Tianshan Mountain." His self-note stated: Since Dihua established counties, infant smallpox resembles that of the interior regions. There, the climate is extremely cold, but now it gradually resembles the interior due to abundant human Qi. Ji's words reveal profound insight. Smallpox did not exist in antiquity but appeared in the Han Dynasty; nowadays, few escape it. With increasing population and heating earth Qi, ancients feared Cold Damage most, while moderns suffer more from Warm Heat.
Wang Shixiong's clinical note: This section... [Text fragment] ...can ascend, causing chaotic confusion, leading to the critical syndrome of vomiting, diarrhea, and tendon retraction. This occurs when latent pathogens attempt to erupt and external pathogens enter; the two pathogens clash, disrupting the intestines and stomach. Consequently, the Qi pathway closes instantly, blood vessels stagnate, limbs turn cold, and hands/faces darken. The Yangming channel, rich in Qi and Blood, presents such sudden symptoms not because Qi and Blood suddenly wither. Human form is constituted by Qi; without Qi circulation, flesh and blood die. Thus, initially, opening blockage is urgent to allow Qi and Blood flow, enabling pathogen expulsion and Zheng Qi restoration. Ignorant practitioners, unaware of the principle that deep heat causes deep cold (Re Shen Jue Shen), seeing cold limbs and hidden pulses, assume cold or collapse, fearing acupuncture and administering hot medicines. This traps pathogens, worsening cold. They claim that feeling cold after hot medicine proves the difficulty of restoring spring warmth. Repeating this method kills victims whose grievances go unheard. Some die with bleeding from seven orifices, yet remain unrepentant. Others suffer external collapse due to internal blockage preventing Zheng Qi retention. Yang collapsing from above causes excessive sweating and Qi loss; Yin collapsing from below causes excessive diarrhea and fluid loss. This is termed "internal blockage and external collapse." To prevent external collapse, internal blockage must be opened. Formulas like Zixue (Purple Snow), Jiangxue (Crimson Snow), and Xingjun San (Marching Army Powder) are excellent for opening blockage and venting latent pathogens. Feilong Duoming Dan (Flying Dragon Life-Grasping Pill) combines Xingjun San and Jiangxue with stronger potency, plus Renzhongbai (Calcined Human Bone Ash) to guide turbidity downward, possessing the power to break gates and seize life. Mr. Chen Xianggu from Shangyu prepared and distributed this, urging me to publish the details, saving many lives—a great merit.
Since curing Ji Yunxiang, many sought my help, achieving success often. However, post-Summer Solstice, illnesses involve both internal and external pathogens, making them more severe. Thus, Duoming Dan must first be used to open blockage. Post-recovery complications vary, requiring flexible response, demanding significant effort, unlike previous years' Huoluan where mere turning points led to quick recovery. The reason lies in displacement and hardship, losing will and exhausting spirit, causing prior internal injury and complex courses. Hence, post-recovery care requires extreme caution. Many in Shanghai are merchants prone to negligence once recovery begins. "Illness worsens during slight recovery," leading to failure. For instance, Mr. Chu Ziyun from Yuhang, my relative by marriage, had a maid suffering from this, already rigid. Upon visiting, I administered 2 fen of Duoming Dan gifted by Xianggu. She revived quickly. I then gave Jiedu Huoxue Tang (Detoxifying and Invigorating Blood Decoction); she survived after several doses. Later, traveling to Chongming, I heard she remained weak and eventually died. Another employee of Wang Dasheng Opium Shop, cured by me, regained appetite and urination, showed residual heat with facial boils, but suddenly died of mental confusion. Shi from Liiji Money Exchange, cured by me, had normal excretion for days, then complained of inability to swallow, stared upward, hiccuped, and died. Tao from Lvyin Bookstore, recovering, suddenly became trance-like and died despite medication. These accounts were narrated by Liyun. Also, Brother Chen Jiexiang from Siming, critically ill, recovered after my treatment, stopped medication for a month, then returned with sore throat, swollen cheeks, ulcerated tongue, locked jaw, phlegm cough, rib pain, red painful urination, and dark loose stools. Residual toxicity accumulated due to lack of clearing/resolving, spreading like wildfire. Poverty prevented proper convalescence. Pulse was wiry, tight, rapid, and difficult to treat; he died later. Recorded as a case to warn travelers. Some say local pharmacies are busy and make errors, causing sudden changes in patients who don't realize it. Both doctors and families must be vigilant. Reading *Lenglu Yihua*, I found a case: A boy in Chen Village, Yi County, had Huoluan. The doctor prescribed processed Pinellia, but the pharmacy mistakenly dispensed processed Aconite. He suffered severe abdominal pain, madness, oral bleeding, and death. The family blamed the doctor, who insisted the prescription was correct and suspected other causes. Examining dregs revealed Aconite. The case went to court, fined the pharmacy. This confirms the warning about pharmacy errors. If the family were timid and silent, or the doctor fled, or dregs were discarded, even Judge Gaoyao could not judge. How cautious must one be with medication!
Zhu Mingqi suffered diarrhea and tendon retraction. Seeing cold limbs, the doctor administered warming tonics. Vomiting occurred immediately after ingestion, followed by incessant hiccups. Intensifying tonics worsened the condition daily. By the ninth day, survival seemed impossible, and funeral arrangements were made. Ziyun, managing the household, asked for my aid. Left pulse was wiry and slippery; right pulse was weak and imperceptible. I prescribed Zhiqiao, Jiegeng, Huangqin, Huanglian, Lianru, Banxia, Zisu, Lianqiao, Lugeng, Pipaye, and Huashi to resolve phlegm, move food, soothe knots, and unblock Yang. Hiccups stopped after two doses, accompanied by widespread red spots. After two more doses, dry stool passed, coating resolved, urination resumed, right pulse strengthened. Clearing and regulating methods led to recovery.
When examining Zhu's case, Ziyun's disciple Fang Maocai was present. He asked, "For such a severe case, why do you consider the pathogen not severe?" I replied, "Most severe cases arise from misdiagnosis. Had this been treated correctly initially, it would have healed in one or two doses. Unfortunately, the world generally classifies diarrhea, vomiting, Huoluan, and Huoluan with tendon retraction as cold syndromes. Practitioners often fail to observe symptoms and administer hot medicines. Seeing cold limbs and a weak right pulse, they take it as definitive evidence of deficiency-cold. Furthermore, immediate vomiting and subsequent hiccups in Huoluan with tendon retraction leave no time to investigate further. Panicking at signs of deficiency-collapse, they intensify warming tonics. Even if the patient dies, the family bears no resentment, and the doctor feels no remorse. I often see local physicians, even for very mild illnesses, create grave diagnoses to avoid blame or seek credit. This practice is passed down, lamentable indeed. Additionally, chest/abdominal pain, malaria, asthma, menstrual obstruction, and postpartum conditions are often labeled as cold by laypeople. Though killed by hot medicines, neither side realizes it. Hiccups, in particular, cause many wrongful deaths. I once treated a courtesan with persistent hiccups. Early sexual activity caused deficiency, but blood loss injured Yin. Using warming/drying herbs to assist heat was wrong, leading to lower Jiao insecurity. She feared medicine, so I used only Egg Yolk consecutively, bringing relief.
Wu Zhuxi, recovering from seasonal infection, suffered hiccups for three days, audible to neighbors, considered critical. I used a method to unblock the Fu organs and move Qi; bowel movement and phlegm/spit discharge led to recovery.
Mr. Zhu Puxiang from Nanxun, aged 56, suffered from childhood consumption and hematemesis, abstaining from sex after thirty to prolong life. He normally passed hard, pellet-like stools, indicating severe Blood deficiency. Suddenly, this autumn, he developed hiccups. Consecutive doses of nourishing, sedating, warming, and grasping Qi medicines brought him to the brink of death. Scholar Lu Dingpu invited me to examine him. Pulse was wiry, slippery, forceful, and rapid; coating was thick, yellow, and greasy; bitter taste and red urine. Defying consensus, I prescribed large doses of cooling/moistening herbs: Xue Geng (Snow Broth), Trichosanthes Seed, Bamboo Juice, Loquat Leaf, Reed Rhizome, Scrophularia, Aster, Belamcanda, Patrinia, and Acorus. After multiple doses, passing red stools, he recovered. Even in old age with deficiency, hiccups caused by phlegm-heat are common; true deficiency-cold hiccups are rare. Yet doctors, ignoring differentiation and pulse diagnosis, blindly use Clove, Ginger, and Cinnamon as eternal remedies. Why?
Mrs. Xie, five months pregnant, suffered diarrhea for four days. A doctor prescribed Ginger, Aconite, Cinnamon, and Magnolia Bark. She developed numb/cold limbs, chest oppression, coma, urinary retention, profuse sweating, extreme thirst, and vomiting. Urgently summoned me. Pulse was not completely hidden. First, soy sauce soup was given, stopping vomiting. Then, Ginseng, Coptis, Scutellaria, Phellodendron, Scutellaria Root/Rhizome, Dendrobium, Honeysuckle, Lablab Leaf, Raisins, Reed Rhizome, and Mung Bean were decocted in Winter Melon Soup and taken warm slowly. External fumigation with charcoal and vinegar cured all symptoms. Next day, pulse wiry/slippery, diarrhea continued. Bai Tou Weng Tang was given with Ginseng, Licorice, Honeysuckle, Lablab, Dandelion, Raisins, and Amomum. Recovered after two doses.
Zhan Yaotang's son from Wuyuan, aged 20, had Huoluan. Several doses of Ginger/Cinnamon failed to stop diarrhea. Habitual opium smoker, suspected deficiency leakage, received tonics, worsening diarrhea. Finally consulted me. Extreme thirst, wiry/rapid pulse. Fortunately, onset was not due to summerheat, but Yin deficiency was inherent. Despite drinking cold/water chilling, hot medicines were excessive. Without diarrhea to dissipate drug power, fluids would have dried up. Bai Tou Weng Tang combined with Feng Sui Dan, plus Honeysuckle, Mung Bean, and Dendrobium. Improved after one dose, recovered after two.
Traveling to Shanghai via Shimen, Mr. Wu Renshan in Puyuan expressed concern: "Zhang Zhongyuan from Piling and Yang Xiaoxi from Xiushui have arrived from Chu to Shanghai handling official business. You should visit." Grateful, I declined politely. Having long heard of the Zhang family's scholarly medical heritage, including books in their Wanlin Study favoring warming tonics, I mentioned this to my old friend Wang Zineng from Taicang, also a skilled physician. He sighed: "Talent and learning vary; one cannot force attainment. Wang Anshi failed to become Chancellor, becoming merely a poet. Regarding the Zhangs, why discuss medicine? People trust their scholarship and extend that trust to their medicine, causing much harm. My brother Jixu, Zhang's brother-in-law, was misled by him. Alas! Words remain, but Zineng has been dead for over ten years."
Regarding the theory of supporting Righteous Qi and expelling Evil, it is like facing invaders without fighting, only guarding the city, leading to self-destruction. Mr. Zhang died in autumn. Later, Jiang Yin sent a letter praising my refusal to provide books. Formerly, a Vice Commissioner overseeing education in Zhejiang, considering himself a superior physician, asked Shao Weixi to request my books, which I also refused. Avoiding vulgar ridicule, I record this case, wishing people do not speak lightly of medicine and act only after careful consideration.
Yao Outing from Qiantang, returning to govern Chongming, heard I was in Shanghai. In early autumn, he instructed my brother HT An to deliver a letter inviting me. Due to a sudden severe diarrhea in early summer, followed by spleen constraint, bowel movements became infrequent (once every ten days, month, or even longer), difficult, hard initially then loose, with sweating and exhaustion. Over sixty years old, walking stiffly. Despite consuming cow's milk and moistening/laxative herbs, ineffective. Occasionally felt food stuck, vomited sour/spicy fluids, six pulses slow/weak, white moist coating, no thirst, clear copious urine, no abdominal distension/pain. This is true Middle Qi deficiency causing urinary/bowel changes. Can intestinal dryness/constipation be treated with moistening herbs? Not suitable for moistening, nor purging. Middle deficiency lacks control over opening/closing; fear that once opened, it won't close again. Nor should lifting/astringing be used. Sour vomiting/stuck food indicates downward blockage with upward rushing. Plus, habitual opium smoking risks complete closure if opened once. Prescription: Ginseng, Atractylodes, Tangerine Peel, Pinellia, Rotating Flower, White Peony, Chicken Gizzard Lining, Quince, Loquat Leaf. Six doses: two bowel movements, four pellets passed. Three more doses: fifteen-six pellets passed. Three more doses: nine pellets passed smoothly, not hard, not loose. No weakness felt; medicine matched syndrome. Left regulation method and departed. If sour vomiting/stuck food recurs, temporarily use Ginseng, Coptis, Tangerine Peel, Pinellia, Rotating Flower, Scutellaria Root/Rhizome, Perilla Leaf, Loquat Leaf, and Hematite to clear/ascertain. In August, intense autumn sun, Outing came to Shanghai on business, staying long. White coating covered tongue. Took Talc, Magnolia Bark, Mulberry Twig Ash, Lablab Leaf for two doses; heat subsided, mind cleared. Left pulse still wiry, Guan position high, sour vomiting, insomnia, limb tremors. External pathogen resolved, but Earth受 Wood oppression. Removed Talc, Magnolia Bark, Mulberry Twig Ash, Lablab Leaf; added Poria, Clam Shell, Seaweed, Mung Bean, White Cardamom. Three doses: coating resolved, sleep returned, hunger sensed, diarrhea reduced. Removed Cardamom, Clam Shell; added Acorus, Atractylodes. Five doses: recovered. Huoluan's opening/closing dysfunction is due to central hub disrupted by evil. This syndrome's lack of opening/closing control is due to Middle deficiency unable to preside. One excess, one deficiency, allowing mutual comparison. Post-recovery vomiting/diarrhea/tremors indicate wind-summerheat disturbing Middle due to deficiency, another Huoluan type. Thus, detailing my treatment for general reference.
Wang Xiecheng invited me to examine Mrs. Shi, mother of Sima Shiyutian from Wuyuan, nearly fifty, sudden Huoluan with tendon retraction, yellow coating, extreme thirst, irritability, syndrome belonging to latent summerheat. Pulse not unfavorable, but whole body cold sweat, fanning constantly, indicating Yang floating away. Dare not prescribe. Died soon. This case shows syndrome cannot rely solely on pulse. Next day, Zhai examined Father of Mr. Zhu Xuanquan, aged sixty, Huoluan with tendon retraction, mild syndrome, clear speech... Half a month later, Zhai contracted this at midnight, black blood bled out, rushed for me at dawn. Form and pulse both collapsed, profuse sweating like rain, sunken eyes, hoarse voice, no urine, greasy coating. Habitually drank alcohol, ate little grain, charitable, forgot labor. Summer-dampness accumulated internally, Zheng Qi scattered. Reluctantly gave Ginseng, but could not save. Regrettable!