数脉者何?恐怕多数医家都会一致回答，曰：“数脉者，来去快速，一息六至，每分钟超过90次。”如《脉经》云：“数脉来去促急，一息六七至。”《濒湖脉学》：“一息六至，脉流薄疾。”至论其主病，恐怕大多数医家亦会一致回答，曰：“数脉主热证。其脉理是邪热亢盛而正气不衰，气血运行加快则脉来数而有力；久病阴虚生热，则脉来数而无力。”至于《中医诊断学》所云之“若阳虚外浮而见数脉，必数大而无力，按之豁然而空”，“阴不敛阳，虚阳外越，则脉来数而无力。”《伤寒论》所云之“若脉浮而数，按之不芤，此人本不虚，若欲自解，但汗出耳。”“脉大而浮数，故知不战，汗出而解也。”“脉浮数而微，病人身凉和者……此为欲解也。”《三因方》所云：“数为热，为虚，为吐，为痛。”则多不重视。景岳所云：“数脉有阴有阳，今后世相传皆以数为热脉，及详考《内经》则但曰诸急者多寒，缓者多热，滑者阳气盛，微有热，曰粗大者，阴不足阳有余，为热中也，曰缓而滑者，曰热中，舍此之外，则并无以数言热者。而迟冷数热之说，乃始自《难经》，云：数则为热，迟则为寒，今举世所宗皆此说也。不知数热之说大有谬误。何以见之?盖自余历验以来，凡见内热伏火等证，脉反不数，而惟洪滑有力，如经文所言者是也。至于数脉之辨，大约有七：此义失真，此至相传遗害者，弗胜纪矣。兹列其要者如左，诸所未尽，可以类推。一外邪有数脉：凡寒邪外感，脉必暴见紧数。然初感便数者，原未传经，热自何来?所以只宜温散，即或传经日久，但其数而滑实，方可言热，若数而无力者，到底仍是阴证，只宜温中，此外感之数不可尽以为热也，若概用寒凉，无不杀人。一虚损有数脉：凡患阳虚而数者，脉必数而无力，或兼细小而证见虚寒，此则温之且不暇，尚堪作热治乎?又有阴虚之数者，脉必数而弦滑，虽有烦热诸证，亦宜慎用寒凉，若但清火必致脾泄而败。且凡见虚损者，脉无不数，数脉之病，惟损最多，愈虚则愈数，愈数则愈危，岂数皆热病乎?若以虚数作热数，则万无不败者矣。一疟疾有数脉：凡疟作之时，脉必紧数，疟止之时，脉必和缓，岂作即有火而止则无火乎?且火在人身，无则无矣，有则无止时也，能作能止者，惟寒邪之进退也，真火真热，则不然也。此疟疾之数，故不可尽以为热。一痢疾之有数脉：凡痢疾之作，率由寒湿内伤，脾肾俱损，所以脉数，但兼弦涩细弱者，总皆虚数，非热数也，悉宜温补命门，百不失一。其形证多火，年力强壮者，方可以热数论治，然必兼洪滑实数之脉，方是其证。一痈疡有数脉：凡脉数身无热而反恶寒，饮食如常者，或身有热而得汗不解者，即痈疽之候也，然疮疡之发，有阴有阳，可攻可补，亦不得尽以脉数者为热证。一痘疹有数脉：以邪毒未达也，达则不数矣。此当以虚实大小分阴阳，亦不得以数为热脉。一症癖有数脉：凡胁腹之下有块如盘者，以积滞不行，脉必见数，若积久成疳，阳明壅实而致口臭牙疳发热等证者，乃宜清胃清火，如无火证而脉见细数者，亦不得认以为热。一胎孕有数脉：以冲任气阻，所以脉数，本非火也。此当以强弱分寒热，不可因其脉数，而执以黄芩为圣药也。”诸语则更少问津。致使寒者愈寒，虚者愈虚，病证缠绵，久久不愈，甚或不治而死。余临证之时，非但注意数脉之主热，亦且注意数脉之主寒，数脉之主虚，数脉之主正邪交争。非但注意数脉之数，亦且注意数脉之相兼，且多以兼脉论数脉之所主。如数脉之兼滑者则为痰热、实热；数脉之兼弦者则为肝胆之实火，数脉之兼紧者则为寒热夹杂证中的寒多热少证或寒邪凝滞证；数脉之兼细涩者，为寒凝血滞；数脉之兼细者，则为阴虚有热，或血虚有热；数脉之兼弦细者，为心阳不足；数脉之兼濡者，为湿热或气阴两虚或痰热；数脉之兼洪大有力者，为阳明实火或暑热之邪；数脉之兼弦大者，为气阴俱虚或气血俱虚或阴阳两虚；数脉之兼促者，为心肾阳虚；数脉之兼实者，为实热；数脉之兼浮者，为表热等。
例如，霍××，女，49岁。风湿性心脏病，二尖瓣狭窄手术后，全心衰竭一直不能控制。转请中医治疗。医云：身热口渴，舌紫苔少，喘而短气，脉数时见促者，阴虚有热也。治宜养阴清热。处方：生地、麦冬、五味子、天花粉、石斛、玉竹、沙参、元参、黄连。一剂后，病情更剧，改请余诊。视之：全身高度浮肿，气短难续，神色慌张，口渴身热，舌质紫黯少苔，脉细数兼有促象。余云：细数之脉非为热脉乃虚脉也。时见促象者，非热之极，乃心阳之大虚也。其身热口渴，非为火证，乃虚阳外越也。宜急投真武汤加减治之。处方：附子、白芍、白术、茯苓、人参。服药一剂诸证果减。
苏××，男，65岁。背部、胸胁烦热不适，气短心悸一年多。医诊冠状动脉硬化性心脏病，心肌梗死。先以西药久治不效，改请中医治之。医查其脉数，诊为气阴俱虚，阳明实火。予补气养阴，清热泻火治之。2个月后，诸证加剧。又改请某医治之。医云：脉滑而数尤见于寸部，乃痰热蕴肺也。治，宜清化热痰。处方：胆南星、半夏、橘红、杏仁、贝母、瓜蒌、黄芩、枳壳、生姜。始服2剂，诸证稍减，继服2剂，诸证又剧。邀余诊视。查其全身烦热，口苦口干，恶心欲吐，胸满胸痛，脘腹隐隐作痛，心烦心悸，大便稀溏，1日3-4次，小便少，四肢颜面轻度浮肿，舌苔黄白厚腻，脉弦紧数时见促象。云：脉弦者肝胆脉也，紧者寒也结也；弦紧相合，肝胆为病，且兼寒饮凝结；紧数相合，非热也，乃寒饮凝结较甚，搏结不散也。治宜疏肝和胃，燥湿行水，温阳化饮。处方：柴胡、半夏、人参、黄芩、甘草、千姜、大枣、苍术、厚朴、陈皮、肉桂、茯苓。服药1剂，诸证稍减，20剂后，诸证大部消失。
吴××，男，68岁。阵发性逆气上冲，冲则心悸心烦，呼吸困难。医诊冠心病，心房纤颤。先用西药治疗4个多月不效，继又请某医以养心安神，滋阴益气之剂治疗2个多月仍无效验。邀余诊治。查其两脉乍疏乍数，数时兼见细弦，疏时兼见弦涩或结。综合脉证后，云：乍疏乍数者，阳虚也，寒盛也；弦涩而时兼结者，寒凝气滞也；又其脉见沉候，沉候者，气滞也。治宜理气温阳降冲。处方：人参、乌药、沉香、肉桂、甘草、半夏。服药2剂，渚证减。10剂后，诸证消失。
任××，男，4岁。发热咳嗽一周。医诊肺炎。子抗生素与中药清热解毒，宣肺止咳之剂治疗后，诸证不减。查其脉弦紧而数，纳呆食减，腹满微喘。乃云：弦紧之脉者，寒邪结于太阳少阳也；数脉虽可主热，然其兼弦紧之寒脉则不可尽以为热也。治宜达原饮加减。处方：厚朴、草果、槟榔、羌活、白芷、桂枝、柴胡、黄芩、知母。一剂后，热退证减。继进2剂，诸证消失。
郝××，女，25岁。3个多月来，身热汗出，心悸心烦，双侧甲状腺日渐肿大。医诊甲状腺炎。先用西药治疗1个月其证不减，继又用中药人参白虎汤及滋阴清热诸方1个多月，诸证反剧。审其除上证外，并见脉虚弦数，舌苔白。乃云：弦数相兼脉者，肝胆有热也；虚数相兼脉者，气阴俱不足也。治宜补气养阴，疏肝泻火。处方：柴胡、人参、麦冬、五味子、当归、白芍、半夏、黄芩、陈皮、青皮。服药4剂，诸证俱减。20剂后，诸证俱失。
周××，男，40岁。胃脘疼痛3年多。医诊溃疡病，十二指肠壅积症。先用西药久治不效，后用中药养阴清热，诸证亦不减，审其证见口干口苦，脘腹疼痛，纳呆食减，腰困腰痛，舌苔黄厚、脉弦大紧数尺脉尤甚。乃云：脾肾虚寒也。宜理中地黄汤加减。处方：附子、肉桂、党参、白术、干姜、甘草、熟地、山药、山萸肉、茯苓、泽泻、丹皮。服药2剂，诸证俱减。继服10剂，诸证消失。某医问：脉数为热，何老师反用附、桂?答曰：此数脉之见非数主热也，乃寒邪凝结之脉也。君不见此数与紧大之脉相兼乎?故以大辛大热之药以破阴邪也。
小大不利治其标，小大利治其本
余始读《素问·标本病传论》：“先病而后逆者治其本，先逆而后病者治其本，先寒而后生病者治其本，先病而后生寒者治其本，先热而后生病者治其本，先热而后生中满者治其标，先病而后泄者治其本，先泄而后生他病者治其本，必且调之，乃治其他病。先病而后生中满者治其标，先中满而后烦心者治其本。人有客气有同气。小大不利治其标，小大利治其本。病发而有余，本而标之，先治其奉，后治其标。病发而不足，标而本之，先治其标，后治其奉”句，言诸病之治均予治本．惟中满与大小便不利治其标。感到甚难理解。其难理解者何?一者《素问·阴阳应象大论》早就有言治病必求于本，何此处又言治其标?且夫明，张景岳《景岳全书·传忠录》亦云：“万事皆有本，而治病之法尤惟求本为首务。”此难理解者一也。二者中医基本理论中阐述治则时明言急则治其标，缓则治其本，而本论何独有治标者，此难理解者二也。及至读到《景岳全书·传忠录》：“盖中满则上焦不通，大小不利则下焦不通，此不得不为治标以开通道路而为升降之所，由是则虽曰治标而实亦所以治本也。”《伤寒论》：“少阴病，得之二三日，口燥咽干者，急下之，宜大承气汤。”“少阴病六七日，腹胀不大便者，急下之，宜大承气汤”句，始知治标者，为促其升降之机也。
《素问·六节藏象论》云：“凡十一脏取决于胆也。”李东垣云：“胆者，少阳春升之气，春气升则万化安，故胆气春升，则余脏从之。”其言胆者乃言人体之气非升降不得安也。《素问·六微旨大论》云：“成败倚伏生乎动，动而不已，则变作矣……出入废则神机化灭，升降息则气立孤危。故非出入，则无以生长壮老已；非升降，则无以生长化收藏。是以升降出入，无器不有。故器者生化之宇，器散则分之，生化息矣。故无不出人，无不升降。化有小大，期有近远，四者之有，而贵常守，反常则灾害至矣。”其小大不利，中满者，升降滞也。升降滞则气立孤危，故诸病之小大不利，中满者，先治其小大不利、中满，以复升降生化也。例如：曾治患者高××，男，30岁。流行性乙型脑炎持续高热昏迷7天。医始以大剂清瘟败毒饮、安宫牛黄丸与西药配合治疗不效。余察其深度昏迷，肢厥脉微，舌苔黄燥。询其家属，云：大便已6日不行。按其腹亦胀满。思之：此体厥证也。如此危重之证，不治其升降之机则生化息矣，急宜通腑以促升降。予大承气汤一剂。次日，神清，欲食。后果愈。又如：患者孙××，女，28岁。神经性呕吐9年。时或朝食暮吐，暮食朝吐，时或饮水或饭后即吐，时或数天饮食全废。为此只能靠输液、输血维持生命。为此遍用中、西药物均无效果。邀治于余。察其形销骨立，纳呆食减，畏寒肢厥，舌质淡黯，苔薄白，脉弦大紧。综合脉证，思之：脉弦大紧者，脾胃虚寒也。治宜健脾温中。处方：半夏10克，陈皮10克，人参10克，白术10克，干姜10克，甘草10克。服药10剂，寸效不见。因思《素问·标本病传论》云：“小大不利治其标。”乃问：素日大小便通泰否?答曰：因素日饮食甚少，几乎一昼夜不小便一次。因悟，曰：仲景之治阳虚证必问小便利与不利，不利者，必利小便。此证之不效，恐在于斯也。乃处温中健脾，利水化饮。处方：人参10克，白术10克，干姜10克，甘草10克，附子10克，肉桂10克，泽泻10克，猪苓10克，茯苓10克。汤药入口，非但不吐，且胃脘觉舒。3剂后，饮食后即时有不吐，且微有食欲。20剂后，呕吐全止，饮食增加，每日约吃250g左右。40剂后，饮食如常，体重增加20千克。
战汗与过敏反应
什么是数脉？恐怕大多数医生都会一致回答，说：“数脉是指脉搏来去快速，一息跳动六次，每分钟超过90次。”如《脉经》所说：“数脉来去急促急迫，一息跳动六七次。”《濒湖脉学》中说：“一息跳动六次，脉流急迫疾速。”至于论及其所主疾病，恐怕大多数医生也会一致回答，说：“数脉主热证。其脉理是邪热亢盛而正气未衰，气血运行加快则脉来数而有力；久病阴虚生内热，则脉来数而无力。”至于《中医诊断学》中所说的“若阳虚外浮而出现数脉，必定数大而无力，按之豁然空虚”，“阴不敛阳，虚阳外越，则脉来数而无力。”《伤寒论》所说的“若脉浮而数，按之不芤（中空），此人原本不虚，若想自愈，只会出汗罢了。”“脉大而浮数，所以知道不会战栗，出汗而病解也。”“脉浮数而微，病人身体凉爽平和的……这是将要痊愈的表现。”《三因方》所说的：“数为热，为虚，为呕吐，为疼痛。”则大多不被重视。张景岳所说的：“数脉有阴有阳，但后世相传都把数脉当作热脉，等到详细考证《内经》时，只说诸急者多寒，缓者多热，滑者阳气盛，微有热，粗大者，阴不足阳有余，为热中，缓而滑者，为热中，除此之外，并没有以数言热的说法。而迟冷数热的说法，是从《难经》开始的，说：数则为热，迟则为寒，如今举世所尊崇的都是这个说法。不知道数热之说大有谬误。凭什么知道呢？大概从我临床经验来看，凡是见到内热伏火等证候，脉象反而不数，而是洪滑有力，像经文所说的那样。至于数脉的辨别，大约有七种：这种义理失真，世代相传遗害无穷，不胜枚举。现在列出重要的如下，其余未尽之处，可以类推。第一，外感病有数脉：凡是寒邪外感，脉象必定突然呈现紧数。然而初感即见数脉的，原未传经，热从何来？所以只宜温散，即使传经日久，但只要脉数而滑实，才可以说是热，若数而无力的，到底仍是阴证，只宜温中，此外感之数不可全认为是热，如果一概用寒凉药，没有不杀人的。第二，虚损病有数脉：凡是患阳虚而见数脉的，脉必数而无力，或兼细小而证见虚寒，这则温补都来不及，还能当作热治吗？又有阴虚之数脉的，脉必数而弦滑，虽然有烦热诸证，也宜慎用寒凉，若只清火必然导致脾泄而败坏。而且凡见虚损者，脉无不数，数脉之病，唯虚损最多，愈虚则愈数，愈数则愈危，难道数脉都是热病吗？如果把虚数当作热数，那么万无一不败坏的。第三，疟疾有数脉：凡是疟疾发作之时，脉必紧数，疟止之时，脉必和缓，难道发作就有火而停止就没有火吗？且火在人身，无则无矣，有则无止的时候，能作能止的，唯有寒邪的进退，真火真热，就不是这样了。此疟疾之数，故不可全认为是热。第四，痢疾有数脉：凡是痢疾发作，大都由寒湿内伤，脾肾俱损，所以脉数，但兼弦涩细弱的，总皆虚数，非热数，全都宜温补命门，百不失一。其形证多火，年力强壮者，才可以按热数论治，但必须兼洪滑实数之脉，才是其证。第五，痈疡有数脉：凡是脉数身无热而反恶寒，饮食如常的，或身有热而得汗不解的，就是痈疽的征候，然而疮疡之发，有阴有阳，可攻可补，也不得全以脉数者为热证。第六，痘疹有数脉：因为邪毒未达，达则不数了。这应当以虚实大小分阴阳，也不得以数为热脉。第七，症癖有数脉：凡是胁腹之下有块如盘的，因为积滞不行，脉必见数，若积久成疳，阳明壅实而致口臭牙疳发热等证的，才宜清胃清火，如无火证而脉见细数的，也不得认以为热。第八，胎孕有数脉：因为冲任气阻，所以脉数，本非火也。这应当以强弱分寒热，不可因其脉数，而执以黄芩为圣药。”这些话则更少有人问津。致使寒者愈寒，虚者愈虚，病证缠绵，久久不愈，甚或不治而死。我临证之时，不仅注意数脉之主热，也注意数脉之主寒、主虚、主正邪交争。不仅注意数脉之数，也注意数脉之相兼，且多以兼脉论数脉之所主。如数脉之兼滑者则为痰热、实热；数脉之兼弦者则为肝胆之实火，数脉之兼紧者则为寒热夹杂证中的寒多热少证或寒邪凝滞证；数脉之兼细涩者，为寒凝血滞；数脉之兼细者，则为阴虚有热，或血虚有热；数脉之兼弦细者，为心阳不足；数脉之兼濡者，为湿热或气阴两虚或痰热；数脉之兼洪大有力者，为阳明实火或暑热之邪；数脉之兼弦大者，为气阴俱虚或气血俱虚或阴阳两虚；数脉之兼促者，为心肾阳虚；数脉之兼实者，为实热；数脉之兼浮者，为表热等。
例如，霍××，女，49岁。风湿性心脏病，二尖瓣狭窄手术后，全心衰竭一直不能控制。转请中医治疗。医生说：身热口渴，舌紫苔少，喘而短气，脉数时见促者，阴虚有热也。治宜养阴清热。处方：生地、麦冬、五味子、天花粉、石斛、玉竹、沙参、元参、黄连。一剂后，病情更剧，改请余诊。视之：全身高度浮肿，气短难续，神色慌张，口渴身热，舌质紫黯少苔，脉细数兼有促象。我说：细数之脉非为热脉乃虚脉也。时见促象者，非热之极，乃心阳之大虚也。其身热口渴，非为火证，乃虚阳外越也。宜急投真武汤加减治之。处方：附子、白芍、白术、茯苓、人参。服药一剂诸证果减。
苏××，男，65岁。背部、胸胁烦热不适，气短心悸一年多。医诊冠状动脉硬化性心脏病，心肌梗死。先以西药久治不效，改请中医治之。医查其脉数，诊为气阴俱虚，阳明实火。予补气养阴，清热泻火治之。2个月后，诸证加剧。又改请某医治之。医云：脉滑而数尤见于寸部，乃痰热蕴肺也。治，宜清化热痰。处方：胆南星、半夏、橘红、杏仁、贝母、瓜蒌、黄芩、枳壳、生姜。始服2剂，诸证稍减，继服2剂，诸证又剧。邀余诊视。查其全身烦热，口苦口干，恶心欲吐，胸满胸痛，脘腹隐隐作痛，心烦心悸，大便稀溏，1日3-4次，小便少，四肢颜面轻度浮肿，舌苔黄白厚腻，脉弦紧数时见促象。我说：脉弦者肝胆脉也，紧者寒也结也；弦紧相合，肝胆为病，且兼寒饮凝结；紧数相合，非热也，乃寒饮凝结较甚，搏结不散也。治宜疏肝和胃，燥湿行水，温阳化饮。处方：柴胡、半夏、人参、黄芩、甘草、千姜、大枣、苍术、厚朴、陈皮、肉桂、茯苓。服药1剂，诸证稍减，20剂后，诸证大部消失。
吴××，男，68岁。阵发性逆气上冲，冲则心悸心烦，呼吸困难。医诊冠心病，心房纤颤。先用西药治疗4个多月不效，继又请某医以养心安神，滋阴益气之剂治疗2个多月仍无效验。邀余诊治。查其两脉乍疏乍数，数时兼见细弦，疏时兼见弦涩或结。综合脉证后，我说：乍疏乍数者，阳虚也，寒盛也；弦涩而时兼结者，寒凝气滞也；又其脉见沉候，沉候者，气滞也。治宜理气温阳降冲。处方：人参、乌药、沉香、肉桂、甘草、半夏。服药2剂，渚证减。10剂后，诸证消失。
任××，男，4岁。发热咳嗽一周。医诊肺炎。予抗生素与中药清热解毒，宣肺止咳之剂治疗后，诸证不减。查其脉弦紧而数，纳呆食减，腹满微喘。我说：弦紧之脉者，寒邪结于太阳少阳也；数脉虽可主热，然其兼弦紧之寒脉则不可尽以为热也。治宜达原饮加减。处方：厚朴、草果、槟榔、羌活、白芷、桂枝、柴胡、黄芩、知母。一剂后，热退证减。继进2剂，诸证消失。
郝××，女，25岁。3个多月来，身热汗出，心悸心烦，双侧甲状腺日渐肿大。医诊甲状腺炎。先用西药治疗1个月其证不减，继又用中药人参白虎汤及滋阴清热诸方1个多月，诸证反剧。审其除上证外，并见脉虚弦数，舌苔白。我说：弦数相兼脉者，肝胆有热也；虚数相兼脉者，气阴俱不足也。治宜补气养阴，疏肝泻火。处方：柴胡、人参、麦冬、五味子、当归、白芍、半夏、黄芩、陈皮、青皮。服药4剂，诸证俱减。20剂后，诸证俱失。
周××，男，40岁。胃脘疼痛3年多。医诊溃疡病，十二指肠壅积症。先用西药久治不效，后用中药养阴清热，诸证亦不减，审其证见口干口苦，脘腹疼痛，纳呆食减，腰困腰痛，舌苔黄厚、脉弦大紧数尺脉尤甚。我说：脾肾虚寒也。宜理中地黄汤加减。处方：附子、肉桂、党参、白术、干姜、甘草、熟地、山药、山萸肉、茯苓、泽泻、丹皮。服药2剂，诸证俱减。继服10剂，诸证消失。某医问：脉数为热，何老师反用附、桂？答曰：此数脉之见非数主热也，乃寒邪凝结之脉也。君不见此数与紧大之脉相兼乎？故以大辛大热之药以破阴邪也。
我开始读《素问·标本病传论》：“先病而后逆者治其本，先逆而后病者治其本，先寒而后生病者治其本，先病而后生寒者治其本，先热而后生病者治其本，先热而后生中满者治其标，先病而后泄者治其本，先泄而后生他病者治其本，必且调之，乃治其他病。先病而后生中满者治其标，先中满而后烦心者治其本。人有客气有同气。小大不利治其标，小大利治其本。病发而有余，本而标之，先治其奉，后治其标。病发而不足，标而本之，先治其标，后治其奉”句，言诸病之治均予治本．惟中满与大小便不利治其标。感到甚难理解。其难理解者何？一者《素问·阴阳应象大论》早就有言治病必求于本，何此处又言治其标？且夫明，张景岳《景岳全书·传忠录》亦云：“万事皆有本，而治病之法尤惟求本为首务。”此难理解者一也。二者中医基本理论中阐述治则时明言急则治其标，缓则治其本，而本论何独有治标者，此难理解者二也。及至读到《景岳全书·传忠录》：“盖中满则上焦不通，大小不利则下焦不通，此不得不为治标以开通道路而为升降之所，由是则虽曰治标而实亦所以治本也。”《伤寒论》：“少阴病，得之二三日，口燥咽干者，急下之，宜大承气汤。”“少阴病六七日，腹胀不大便者，急下之，宜大承气汤”句，始知治标者，为促其升降之机也。
《素问·六节藏象论》云：“凡十一脏取决于胆也。”李东垣云：“胆者，少阳春升之气，春气升则万化安，故胆气春升，则余脏从之。”其言胆者乃言人体之气非升降不得安也。《素问·六微旨大论》云：“成败倚伏生乎动，动而不已，则变作矣……出入废则神机化灭，升降息则气立孤危。故非出入，则无以生长壮老已；非升降，则无以生长化收藏。是以升降出入，无器不有。故器者生化之宇，器散则分之，生化息矣。故无不出人，无不升降。化有小大，期有近远，四者之有，而贵常守，反常则灾害至矣。”其小大不利，中满者，升降滞也。升降滞则气立孤危，故诸病之小大不利，中满者，先治其小大不利、中满，以复升降生化也。例如：曾治患者高××，男，30岁。流行性乙型脑炎持续高热昏迷7天。医始以大剂清瘟败毒饮、安宫牛黄丸与西药配合治疗不效。余察其深度昏迷，肢厥脉微，舌苔黄燥。询其家属，云：大便已6日不行。按其腹亦胀满。思之：此体厥证也。如此危重之证，不治其升降之机则生化息矣，急宜通腑以促升降。予大承气汤一剂。次日，神清，欲食。后果愈。又如：患者孙××，女，28岁。神经性呕吐9年。时或朝食暮吐，暮食朝吐，时或饮水或饭后即吐，时或数天饮食全废。为此只能靠输液、输血维持生命。为此遍用中、西药物均无效果。邀治于余。察其形销骨立，纳呆食减，畏寒肢厥，舌质淡黯，苔薄白，脉弦大紧。综合脉证，思之：脉弦大紧者，脾胃虚寒也。治宜健脾温中。处方：半夏10克，陈皮10克，人参10克，白术10克，干姜10克，甘草10克。服药10剂，寸效不见。因思《素问·标本病传论》云：“小大不利治其标。”乃问：素日大小便通泰否？答曰：因素日饮食甚少，几乎一昼夜不小便一次。因悟，曰：仲景之治阳虚证必问小便利与不利，不利者，必利小便。此证之不效，恐在于斯也。乃处温中健脾，利水化饮。处方：人参10克，白术10克，干姜10克，甘草10克，附子10克，肉桂10克，泽泻10克，猪苓10克，茯苓10克。汤药入口，非但不吐，且胃脘觉舒。3剂后，饮食后即时有不吐，且微有食欲。20剂后，呕吐全止，饮食增加，每日约吃250g左右。40剂后，饮食如常，体重增加20千克。
战汗与过敏反应
What is the rapid pulse (Shu Mai, 数脉)? It is likely that most physicians would answer in unison: "The rapid pulse comes and goes quickly, beating six times per breath (Yi Xi, 一息), exceeding 90 beats per minute." As stated in *Mai Jing* (Pulse Classic): "The rapid pulse comes and goes hurriedly and urgently, beating six or seven times per breath." In *Binhu Maixue* (Pulse Studies of Binhu): "Beating six times per breath, the pulse flow is urgent and swift." Regarding the diseases it indicates, it is likely that most physicians would also answer in unison: "The rapid pulse indicates Heat syndromes. The pathophysiology is that when pathogenic heat is hyperactive and healthy qi is not depleted, the accelerated circulation of Qi and Blood causes the pulse to be rapid and forceful; in chronic illness with Yin deficiency generating internal heat, the pulse is rapid but weak." As for what is said in *Zhongyi Zhenduanxue* (TCM Diagnostics): "If Yang deficiency leads to floating outward and presents with a rapid pulse, it must be large and weak, feeling hollow upon pressure," and "When Yin fails to contain Yang, and deficient Yang floats outward, the pulse is rapid but weak," these are often overlooked. Similarly, statements from *Shanghan Lun* (Treatise on Cold Damage) such as "If the pulse is floating and rapid, and feels empty (Kou, 芤) upon pressure, this person was originally not deficient; if self-healing is desired, sweating will occur," "A large, floating, and rapid pulse indicates no shivering, and healing occurs through sweating," and "A floating, rapid, and faint pulse, where the patient's body is cool and harmonious... indicates impending resolution," as well as statements from *Sanyin Fang*: "Rapid indicates Heat, deficiency, vomiting, and pain," are largely ignored. Zhang Jingyue stated: "The rapid pulse can indicate both Yin and Yang conditions. However, since ancient times, it has been transmitted that the rapid pulse is a Heat pulse. Upon detailed examination of *Neijing*, it only says: 'All urgent pulses mostly indicate Cold; slow pulses mostly indicate Heat; slippery pulses indicate abundant Yang with slight Heat; coarse/large pulses indicate insufficient Yin and excess Yang, indicating internal Heat; slow and slippery pulses indicate internal Heat.' Apart from these, there is no mention of using 'rapid' to describe Heat. The saying 'Slow indicates Cold, Rapid indicates Heat' originated from *Nan Jing*, stating: 'Rapid implies Heat, Slow implies Cold.' This view is universally respected today. I do not know why the theory that 'Rapid equals Heat' is greatly erroneous. How do I know this? From my clinical experience, whenever I encounter syndromes of internal Heat and hidden Fire, the pulse is actually not rapid, but rather surging, slippery, and forceful, as described in the classics. Regarding the differentiation of the rapid pulse, there are approximately seven categories. This distortion of truth, passed down through generations causing endless harm, cannot be fully enumerated. I now list the main points below; other未尽 cases can be inferred by analogy. First, external pathogens present with a rapid pulse: Whenever cold pathogens invade externally, the pulse must suddenly appear tight and rapid. However, if a rapid pulse appears immediately upon initial infection, the disease has not yet transmitted to another channel; where does the Heat come from? Therefore, only warming and dispersing methods should be used. Even if transmission has occurred over a long period, only if the pulse is rapid, slippery, and full can it be considered Heat. If the pulse is rapid but weak, it remains a Yin (Cold/Deficiency) syndrome, requiring warming the Middle Jiao. Thus, external rapid pulses cannot all be considered Heat; indiscriminate use of cold-cooling herbs will inevitably cause death. Second, consumptive diseases present with a rapid pulse: In cases of Yang deficiency presenting with a rapid pulse, the pulse must be rapid but weak, or fine and small with signs of deficiency-cold. In such cases, warming treatment is urgent enough, let alone treating it as Heat! For Yin deficiency presenting with a rapid pulse, the pulse is typically rapid, wiry, and slippery. Although symptoms like vexation and heat may exist, cold-cooling herbs must be used cautiously; merely clearing Fire will lead to Spleen diarrhea and deterioration. Moreover, in all consumptive diseases, the pulse is invariably rapid. Among diseases indicated by a rapid pulse, consumptive diseases are the most common; the more deficient, the more rapid the pulse; the more rapid, the more critical the condition. Can all rapid pulses be Heat diseases? If deficient rapidness is mistaken for Heat rapidness, failure is inevitable. Third, Malaria presents with a rapid pulse: During malaria attacks, the pulse is tight and rapid; during remission, the pulse is harmonious and slow. Does attack imply Fire and remission imply absence of Fire? Fire in the human body either exists or does not; if it exists, it does not cease intermittently. Only cold pathogens advance and retreat, causing intermittent symptoms. True Fire and true Heat do not behave this way. Therefore, the rapid pulse in malaria cannot all be considered Heat. Fourth, Dysentery presents with a rapid pulse: Dysentery usually arises from internal injury by cold-dampness, damaging both Spleen and Kidney, resulting in a rapid pulse. However, if accompanied by wiry, choppy, fine, and weak qualities, it is always deficient rapidness, not Heat rapidness. All cases should be treated with warming and tonifying the Mingmen (Gate of Life). Success rate is nearly 100%. Only in patients with strong constitution and signs of excessive Fire can it be treated as Heat rapidness, but this requires a surging, slippery, full, and rapid pulse. Fifth, Carbuncles and sores present with a rapid pulse: When the pulse is rapid but the body has no fever and instead feels aversion to cold, or appetite is normal, or there is fever but sweating does not resolve it, these are signs of carbuncles and sores. However, sores have Yin and Yang types, and treatments can be attacking or tonifying; one cannot assume all rapid pulses indicate Heat syndromes. Sixth, Smallpox/Rashes present with a rapid pulse: This is because pathogenic toxins have not yet reached the surface; once they reach, the pulse ceases to be rapid. Differentiation should be based on deficiency/excess and size to distinguish Yin/Yang; one cannot take rapidness as Heat. Seventh, Masses and accumulations present with a rapid pulse: When masses like plates are felt under the ribs or abdomen due to stagnation, the pulse must show rapidness. If stagnation persists leading to malnutrition (Gan syndrome), Yangming fullness and excess causing bad breath, gum ulcers, and fever, then clearing Stomach Heat and Fire is appropriate. If there are no Heat signs but the pulse is fine and rapid, it should not be recognized as Heat. Eighth, Pregnancy presents with a rapid pulse: This is due to obstruction of Chong and Ren vessels; thus the pulse is rapid, but it is not Fire. Differentiation should be based on strength to distinguish Cold/Heat; one should not insist on using Huangqin (Scutellariae Radix) as a panacea solely because of a rapid pulse." Such words are rarely consulted. Consequently, Cold becomes colder, Deficiency becomes weaker, syndromes linger and fail to heal for a long time, or even become incurable and fatal. In my clinical practice, I pay attention not only to the rapid pulse indicating Heat, but also to it indicating Cold, Deficiency, and the struggle between Healthy Qi and Pathogenic factors. I focus not only on the rapidity itself but also on its accompanying pulses, discussing the indications of the rapid pulse primarily through its combinations. For example, a rapid pulse combined with slippery indicates Phlegm-Heat or Excess-Heat; combined with wiry indicates Excess-Fire of Liver/Gallbladder; combined with tight indicates Cold-excess in Cold-Heat complex syndromes or Cold-pathogen stagnation; combined with fine and choppy indicates Cold coagulation and blood stasis; combined with fine indicates Yin deficiency with Heat or Blood deficiency with Heat; combined with wiry and fine indicates insufficiency of Heart Yang; combined with soggy indicates Damp-Heat, Qi-Yin dual deficiency, or Phlegm-Heat; combined with surging and large and forceful indicates Yangming Excess-Fire or Summerheat-evil; combined with wiry and large indicates dual deficiency of Qi-Yin, Qi-Blood, or Yin-Yang; combined with interrupted (Cu, 促) indicates deficiency of Heart-Kidney Yang; combined with full indicates Excess-Heat; combined with floating indicates Exterior-Heat, etc.
For example, Huo XX, female, 49 years old. Rheumatic heart disease, post-mitral stenosis surgery, total heart failure remained uncontrollable. TCM treatment was sought. The physician stated: Fever, thirst, purple tongue with little coating, panting and shortness of breath, rapid pulse occasionally showing interruption (Cu, 促), indicating Yin deficiency with Heat. Treatment should nourish Yin and clear Heat. Prescription: Shengdi (Rehmanniae Radix), Maidong (Ophiopogonis Radix), Wuweizi (Schisandrae Fructus), Tianhuafen (Trichosanthis Radix), Shihu (Dendrobii Caulis), Yuzhu (Polygonati Odorati Rhizoma), Shashen (Glehniae Radix), Yuan Shen (Scrophulariae Radix), Huanglian (Coptidis Rhizoma). After one dose, the condition worsened, and I was consulted. Examination revealed: severe generalized edema, difficult breathing, anxious expression, thirst and fever, purple-dark tongue with little coating, fine-rapid pulse with intermittent interruptions. I said: A fine-rapid pulse is not a Heat pulse but a Deficiency pulse. The occasional interruptions indicate not extreme Heat, but severe deficiency of Heart Yang. Her fever and thirst are not Fire syndromes, but deficient Yang floating outward. Urgent treatment with Zhenwu Tang (True Warrior Decoction) modified is required. Prescription: Fuzi (Aconiti Lateralis Radix Praeparata), Baishao (Paeoniae Radix Alba), Baizhu (Atractylodis Macrocephalae Rhizoma), Fuling (Poria), Renshen (Ginseng Radix et Rhizoma). After one dose, symptoms indeed decreased.
Su XX, male, 65 years old. Vexatious heat and discomfort in back and hypochondrium, shortness of breath and palpitations for over a year. Diagnosed with coronary atherosclerotic heart disease and myocardial infarction. Western medicine treatment failed after prolonged use, so TCM was sought. The physician found a rapid pulse, diagnosed Qi-Yin dual deficiency and Yangming Excess-Fire. Prescribed tonifying Qi and nourishing Yin, clearing Heat and purging Fire. After 2 months, symptoms worsened. Another physician was consulted. He stated: Slippery and rapid pulse, especially at the Cun (inch) position, indicates Phlegm-Heat accumulating in the Lung. Treatment should clear and transform Phlegm-Heat. Prescription: Dantanxing (Arisaematis Cum Bile), Banxia (Pinelliae Rhizoma), Juhong (Citri Reticulatae Pericarpium Rubrum), Xingren (Armeniacae Semen), Beimu (Fritillariae Thunbergii Bulbus), Gualou (Trichosanthis Fructus), Huangqin (Scutellariae Radix), Zhike (Aurantii Fructus Immaturus), Shengjiang (Zingiberis Rhizoma Recens). After 2 doses, symptoms slightly improved; after another 2 doses, symptoms worsened again. I was invited to examine. Findings: Generalized vexatious heat, bitter taste, dry mouth, nausea, chest fullness and pain, dull abdominal pain, mental restlessness and palpitations, loose stools 3-4 times daily, scant urine, mild edema of limbs and face, yellow-white thick greasy tongue coating, wiry-tight-rapid pulse with occasional interruptions. I said: Wiry pulse belongs to Liver/Gallbladder; tight indicates Cold and knotting. Wiry and tight together indicate Liver/Gallbladder disease with Cold-fluid accumulation. Tight and rapid together do not indicate Heat, but severe Cold-fluid accumulation and binding. Treatment should soothe Liver and harmonize Stomach, dry dampness and promote water metabolism, warm Yang and transform fluids. Prescription: Chaihu (Bupleuri Radix), Banxia, Renshen, Huangqin, Gancao (Glycyrrhizae Radix et Rhizoma), Jiangcan (Ginger), Dazao (Jujubae Fructus), Cangzhu (Atractylodis Rhizoma), Houpo (Magnoliae Officinalis Cortex), Chenpi (Citri Reticulatae Pericarpium), Rougui (Cinnamomi Cortex), Fuling. After 1 dose, symptoms slightly improved; after 20 doses, most symptoms disappeared.
Wu XX, male, 68 years old. Paroxysmal upward rushing of Qi, causing palpitations, mental restlessness, and dyspnea. Diagnosed with coronary heart disease and atrial fibrillation. Western medicine treatment for over 4 months was ineffective. Another physician prescribed calming Heart and nourishing Spirit, nourishing Yin and tonifying Qi for over 2 months with no effect. I was consulted. Pulses were alternately sparse and rapid; when rapid, accompanied by fine and wiry; when sparse, accompanied by wiry-choppy or knotted (Jie, 结). Synthesizing pulse and symptoms, I said: Alternating sparse and rapid indicates Yang deficiency and severe Cold. Wiry-choppy with occasional knotting indicates Cold coagulation and Qi stagnation. Pulse appearing at the Chen (deep) position indicates Qi stagnation. Treatment should regulate Qi, warm Yang, and descend rebellious Qi. Prescription: Renshen, Wuyao (Litseae Fructus), Chenxiang (Aquilariae Lignum Resinatum), Rougui, Gancao, Banxia. After 2 doses, symptoms decreased. After 10 doses, symptoms disappeared.
Ren XX, male, 4 years old. Fever and cough for one week. Diagnosed with pneumonia. Antibiotics and TCM herbs for clearing Heat and detoxifying, diffusing Lung and stopping cough were given, but symptoms did not improve. Pulse was wiry-tight and rapid, poor appetite, reduced food intake, abdominal fullness, slight wheezing. I said: Wiry-tight pulse indicates Cold pathogen knotting in Taiyang and Shaoyang channels. Although rapid pulse can indicate Heat, combined with wiry-tight Cold pulse, it cannot all be considered Heat. Treatment should use Daoyin Yin (Origin-Reaching Decoction) modified. Prescription: Houpo, Caoguo (Amomi Fructus Rotundus), Binglang (Arecae Semen), Qianghuo (Notopterygii Rhizoma et Radix), Baizhi (Angelicae Dahuricae Radix), Guizhi (Cinnamomi Ramulus), Chaihu, Huangqin, Zhimu (Anemarrhenae Rhizoma). After 1 dose, fever subsided and symptoms improved. After 2 more doses, symptoms disappeared.
Hao XX, female, 25 years old. For over 3 months, fever with sweating, palpitations, mental restlessness, bilateral thyroid gland gradually enlarged. Diagnosed with thyroiditis. Western medicine for 1 month showed no improvement. Then Chinese medicine including Renshen Baihu Tang (Ginseng White Tiger Decoction) and various Yin-nourishing and Heat-clearing formulas for over 1 month made symptoms worse. Examination revealed besides above symptoms, deficient-wiry-rapid pulse, white tongue coating. I said: Wiry-rapid combination indicates Heat in Liver/Gallbladder; deficient-rapid combination indicates insufficiency of both Qi and Yin. Treatment should tonify Qi and nourish Yin, soothe Liver and purge Fire. Prescription: Chaihu, Renshen, Maidong, Wuweizi, Danggui (Angelicae Sinensis Radix), Baishao, Banxia, Huangqin, Chenpi, Qingpi (Citri Reticulatae Pericarpium Viride). After 4 doses, symptoms decreased. After 20 doses, symptoms vanished.
Zhou XX, male, 40 years old. Epigastric pain for over 3 years. Diagnosed with peptic ulcer and duodenal stasis. Prolonged Western medicine treatment failed. TCM Yin-nourishing and Heat-clearing treatment also failed. Symptoms included dry mouth, bitter taste, epigastric/abdominal pain, poor appetite, lower back fatigue/pain, yellow-thick tongue coating, wiry-large-tight-rapid pulse, especially prominent at Chi (cubit) position. I said: Spleen-Kidney deficiency-Cold. Should use Lizhong Dihuang Tang (Regulate Middle Rehmannia Decoction) modified. Prescription: Fuzi, Rougui, Dangshen (Codonopsis Radix), Baizhu, Ganjiang (Zingiberis Rhizoma), Gancao, Shudi (Rehmanniae Radix Preparata), Shanyao (Dioscoreae Rhizoma), Shanzhuyu (Corni Fructus), Fuling, Zexie (Alismatis Rhizoma), Danpi (Moutan Cortex). After 2 doses, symptoms decreased. After 10 doses, symptoms disappeared. Another physician asked: Rapid pulse indicates Heat, why did Teacher He use Fuzi and Rougui? Answer: This rapid pulse does not indicate Heat dominance, but is a pulse of Cold pathogen condensation. Do you not see this rapidness combined with tight and large qualities? Therefore, great acrid-great hot herbs were used to break Yin evil.
"If urination and defecation are obstructed, treat the branch; if free, treat the root."
When I first read *Suwen: Biaoben Bingchuan Lun* (Basic Questions: Treatise on Root and Branch Disease Transmission): "If disease precedes rebellion, treat the root; if rebellion precedes disease, treat the root; if Cold precedes disease, treat the root; if disease precedes Cold, treat the root; if Heat precedes disease, treat the root; if Heat precedes middle-fullness, treat the branch; if disease precedes diarrhea, treat the root; if diarrhea precedes other diseases, treat the root, must regulate first, then treat other diseases. If disease precedes middle-fullness, treat the branch; if middle-fullness precedes vexatious heart, treat the root. People have external pathogens and same-nature pathogens. If urination and defecation are obstructed, treat the branch; if free, treat the root. If disease onset shows excess, treat root then branch; if disease onset shows deficiency, treat branch then root..." it stated that for all diseases, treat the root, except for middle-fullness and obstruction of urination/defecation, which are treated as branch. This was very hard to understand. Why? First, *Suwen: Yingxiang Dalun* (Basic Questions: Great Treatise on Yin-Yang Correspondence) long ago stated "In treating disease, one must seek the root." Why here speak of treating the branch? Furthermore, Zhang Jingyue in *Jingyue Quanshu: Chuanzhong Lu* (Complete Works of Jingyue: Records of Transmission) also said: "All things have a root, and in treating disease, seeking the root is the primary task." This is the first difficulty. Second, basic TCM theory clearly states "In acute cases, treat the branch; in chronic cases, treat the root." Why does this treatise single out treating the branch? This is the second difficulty. Until reading *Jingyue Quanshu*: "Since middle-fullness blocks the Upper Jiao, and obstruction of urination/defecation blocks the Lower Jiao, one must treat the branch to open pathways for ascent and descent, thereby although called treating the branch, it is essentially treating the root." And *Shanghan Lun*: "Shaoyin disease, within 2-3 days, dry mouth and throat, urgent purgation is needed, Da Chengqi Tang is suitable." "Shaoyin disease, 6-7 days, abdominal fullness and constipation, urgent purgation is needed, Da Chengqi Tang is suitable." Only then did I understand that treating the branch is to promote the mechanism of ascent and descent.
*Suwen: Liujie Zangxiang Lun* (Basic Questions: Treatise on Six Sections and Zang-Fu Manifestations) says: "All eleven Zang organs depend on the Gallbladder." Li Dongyuan said: "The Gallbladder is the ascending Qi of Shaoyang Spring. When Spring Qi ascends, all transformations are peaceful. Thus, when Gallbladder Qi ascends in Spring, the other organs follow." His mention of the Gallbladder refers to the fact that human Qi cannot be peaceful without ascent and descent. *Suwen: Liuweizhi Dalun* (Basic Questions: Great Treatise on Six Micro Principles) says: "Success and failure lie in motion; continuous motion leads to transformation... If exit and entry cease, the Spirit mechanism perishes; if ascent and descent stop, Qi establishment becomes isolated and dangerous. Without exit and entry, there is no growth, maturity, decline, and end; without ascent and descent, there is no growth, transformation, storage, and collection. Thus, ascent, descent, exit, and entry exist in every vessel. The vessel is the realm of production and transformation; if the vessel scatters, division occurs, and production/transformation cease. Therefore, nothing lacks exit/entry, nothing lacks ascent/descent. Transformations vary in size, periods vary in length. The existence of these four is precious for constant adherence; deviation leads to disaster." Obstruction of urination/defecation and middle-fullness represent stagnation of ascent and descent. Stagnation of ascent and descent leads to isolated and dangerous Qi establishment. Therefore, for all diseases with obstruction of urination/defecation or middle-fullness, one must first treat the obstruction/fullness to restore ascent/descent and production/transformation. Example: I once treated patient Gao XX, male, 30 years old. Epidemic encephalitis B with persistent high fever and coma for 7 days. Initially treated with large doses of Qingwen Baidu Yin (Clear Plague and Resolve Toxin Decoction), Angong Niuhuang Wan (Calming the Palace Bull-Horn Pill), and Western medicine, but ineffective. I observed deep coma, cold extremities, faint pulse, yellow-dry tongue coating. Asked family: Bowel movement stopped for 6 days. Abdomen was full upon palpation. I thought: This is a Body-Jue syndrome. In such critical condition, if the mechanism of ascent/descent is not treated, production and transformation will cease. Urgent bowel purgation is needed to promote ascent/descent. Prescribed Da Chengqi Tang (Great Order the Qi Decoction) one dose. Next day, consciousness cleared, desire for food appeared. Eventually healed. Another example: Patient Sun XX, female, 28 years old. Neurotic vomiting for 9 years. Sometimes morning food vomited at night, night food vomited at morning, sometimes drinking or post-meal vomiting, sometimes days without any food intake. Could only maintain life via IV fluids and blood transfusions. Various Chinese and Western medicines were ineffective. I was consulted. Patient was emaciated, poor appetite, aversion to cold, cold extremities, pale-dark tongue, thin-white coating, wiry-large-tight pulse. Synthesizing pulse and symptoms, I thought: Wiry-large-tight pulse indicates Spleen-Stomach deficiency-Cold. Treatment should strengthen Spleen and warm Middle. Prescription: Banxia 10g, Chenpi 10g, Renshen 10g, Baizhu 10g, Ganjiang 10g, Gancao 10g. After 10 doses, no effect. Recalling *Suwen*: "Obstruction of urination/defecation treats the branch." I asked: Are your urination and defecation normally smooth? Answer: Due to very little food intake, almost no urination in a day and night. I realized: Zhongjing, when treating Yang deficiency syndromes, always asks about urination convenience. If inconvenient, diuresis is necessary. The ineffectiveness of this case might lie here. So I prescribed warming Middle, strengthening Spleen, promoting water metabolism and transforming fluids. Prescription: Renshen 10g, Baizhu 10g, Ganjiang 10g, Gancao 10g, Fuzi 10g, Rougui 10g, Zexie 10g, Zhuling (Polyporus), Fuling 10g. Upon taking the decoction, not only did vomiting stop, but epigastrium felt comfortable. After 3 doses, occasional non-vomiting after meals, slight appetite. After 20 doses, vomiting completely stopped, diet increased to approx. 250g/day. After 40 doses, diet normalized, weight increased by 20 kg.
Shivering sweat and allergic reactions