伐之药耶。方虎述病状曰。初病寒热起。月事适至。医用发散未效。继用大柴胡下之。利行而病
不解。舌始燥。始痰起填膈。又用陷胸
加化痰药。又不效。热益甚。乃用三黄合犀角地黄汤服之。舌始黑。唇始生皮。烦惋不得卧。今
当如何。予曰。少阳之邪。不得上达。热抑在下。病及冲任。以苦寒逼之。火急水烁。逆乘于上
。肾肝竭矣。乃投熟地生地各一两。当归芍药丹皮茯苓山药麦冬山萸肉甘草佐之。顿安。而唇舌
症未退。予曰。无虑。得汗而便即解矣。 曰。前已下而益甚。今何言便解也。予笑曰。正唯此
处须读书耳。遂大进参 归术而汗至。下黑矢甚伙。诸症悉退。唯痰尚多。舌胎尚有未尽。每至
夜则烦惋不了了。予曰。此冲任病未解也。仍用初方加芍药及桃仁泥各三钱。一剂而起。
据所述病状云。初病寒热起。则知邪在少阳。显属小柴胡症矣。斯时若以小柴胡汤养汗以开
玄府。使少阳之邪。得以上达。何至热抑在下。而病及冲任哉。即病及冲任。经水适来矣。不以
苦寒逼之。而仍以小柴胡汤加归尾等调之。又何至唇焦舌黑。变出尔许肝肾阴亏之危候哉。然此
等处吾不咎若辈之悍于诛伐也。咎若辈之昧于审症耳。并不咎若辈之昧于审症也。咎若辈之误于
读书耳。东庄医道。得力于四明。四明于左归饮条下云。伤寒舌黑唇焦。大渴引饮。此必服攻伐
寒凉之药过多也。此方主之。今即就此一案一一按其论病处方。足见高吕两家。固自心心相印也。
时方虎病三阴疟。已四年矣。幸所治皆武林名医。服药得法。不至溃败。用人参几十余斤。
然年久病深。至
此遂不能支。形肉尽脱。饮食不进。每觉有气从左胁上冲。即烦乱欲脱。奄奄几殆。乃重用桂附
芍药地黄。加以养荣逐翳之药。冬至日。正发期。是日遂不至。
四明治久疟不愈。诸药不效者。以养荣汤送八味丸。仍于汤中加熟附子一钱。谓十剂必除。
东庄亦云久疟用补中益气不效者。八味丸有神应。予每得其力。按八味丸乃益火之原以消阴翳者
。然则案中所谓养荣逐翳者。固即祖四明以养荣汤送八味丸之家法也。而其愈于冬至日者。盖阳
生于子。阳回则阴自退舍耳。
未几又有适蔡氏妹病感症。遣力迎予。时以事滞武林。不得往。来促数次。及予至。则病亟
矣。方虎道病状。谓此病甚怪。攻之不可。补之不可。调和之又不可。真反复无计。予曰。攻法
吾可臆度得之。请问其补法调法。方虎曰。始用疏表及降火清痰之剂。半月愈甚。胸则胀痛。用
温胆汤及花粉栝蒌等。此调剂也。服之呕逆。痰气反急。昨用理中。加肉桂延胡索陈皮枳壳香附
半夏等。此补剂也。服之痛结不可忍。至今号呼不绝。医谓调补不应。治法穷矣。予笑曰。所谓
补与调和者是耶。无论理中汤外加入破气伤胃之药。反益其痛。即理中汤中。甘草一味。若蛔发
作痛。即非所宜。不记仲景安蛔散去甘草加椒梅乎。方虎曰。向多蛔结症。今补不止。无疑矣。
然则如何。余曰。吾仍用理中汤。去甘草。加白芍药三钱。木香五分。进之。痛减半。按其
脉细数甚。口渴欲饮水。不能咽。进汤啜吐。手足时冷时热。面颧娇红不定。体如燔炙。余曰。
此邪火内沸。怒木乘上。五阳火随之上燔。下烁真阴。龙雷飞越。以药驱之。阳格于外。伏阴冱
结而致。遂将大八味丸作饮与之。曰。得汗病已。黄昏初服药少顷。方虎出曰。服药讫。即少睡
。看面上娇红。立退为白。顷乃索被盖。予曰。俟之至矣。及三鼓。有老妪叩门曰。此刻热急。
气促烦乱不可言。请再进视之。予曰。无庸。吾欲卧。无扰我。至黎明起。诊之。脉紧数至八九
至。予曰。汗已泊矣。而虚不能发也。急煎人参一两。黄 白术当归白芍五味子甘草为佐。饮之
。汗大至沾席。余曰。未也。次日再服。汗又大至。通身如雨。诸症顿愈。方虎曰。前之甘草不
宜服。今两剂俱重用甘草。何也。曰。初胃中气血攻竭。空虚寒凝。故蛔发而痛。得甘则蛔愈昂
上。故不可。今得濡润之药。胃气冲和。蛔头下伏。虽浓煎甘草汁数杯饮之。何害哉。法不可执
。类如是也。方虎叹以为精言。
同此一症耳。且同此一方耳。他人用之而痛益甚者。名手用之而痛即减。可见凡方加减。俱
有精义。不可不细讲也。
沈凝芝内人。时当就卧。忽作寒热。至夜半即不能言。喘急。医视之。或以为感伤。或以为
往来寒热。气逆痰结。用乌药顺气散不效。邀予视之。则声如曳锯。手撒遗溺。口开不能言。自
汗如雨。余曰。此类中风也。已伤
脏。不可治矣。凝芝曰。即无救理。应用何药。余曰。初发即当用易简乌附子散。今无及矣。凝
芝自进之。喘声忽止。且稍发语。疑尚可救。予曰。五脏俱绝。今得参附。气少苏耳。终无济也
。果三日而殁。
甲午馆安邑。九月间。仲弟以痢病。误杀于庸手。悲愤交集。始究心医理。至冬底十有二日
。馆尚未解。而家君复以先母中风遣人走召。迨归时则五脏俱绝。与是案所列诸症具见无异矣。
急煎参附等剂。挖而灌之。不能挽也。翌日酉刻遂殁。因思病未见之先。与暴发之际。予若在家或有挽回。乃以十数金
薄资远馆外邑。致抱无涯之戚。仰天锥心恨何如之。每阅此案。不禁潸然泪下。
未几其侧室复病伤寒。继壮热不止。医疏散之。愈甚。神情昏愦。不寐。凝芝恐蹈前辙。忧
甚。予往诊之。曰。此则感症。无妨也。然起于劳倦。不当重虚其虚。即投以参术等药。得汗。
神情顿清。次用地黄饮子。下黑矢。熟寐。唯热尚未尽退。余曰。此甚易事。于昨方中加炙甘草
一钱。如言即安。观者皆以为奇。继以滋肾养荣等药。调理复初。
汗以参术。下以地黄。除热以炙甘草。此等治感症法。在病家未有不以用补为嫌。旁观未有
不以用补为异。即令庸医见之。亦未有不骇然吐舌者。然其中有妙义焉。盖感症而起于劳倦。则
非助正无以托邪也。非滋阴无以润便也。非甘温难以除热也。彼惟不知此义。故妄骇以为奇耳。
姊丈劳仲虎。初夏劳倦致感。体作寒热。口苦。医用重药发散之。复用山楂浓朴枳实花粉栝蒌半
夏之属。
攻其中。热益甚。痰嗽喘急。语言无序。予往诊之曰。误矣。急止其余药。重用滋水清金之
药。一服而痰嗽渐退。神情觉清。次日往诊。脉浮洪而数。语急遽而收轻。手指时作微胀。予曰。
此皆虚症也。邪未尝入阳明。而先攻之。伤其元气。邪反随而入阳明矣。重虚其虚。愈不能鼓邪
外出。今虽稍定。夜必发诂妄。当急以人参救之。适箧中所带不多。止用人参二钱。黄 一两。
至次日。家人来言。夜来甚悖乱不安。其势甚迫。似不可救。予曰。无妨。参力不足故耳。时鼓
峰在邑。予拉之同往。曰。汗已至矣。何虑为。乃用参两许。仍入前药进之。其亲友犹议参之与
痰喘 妄相背也。予与鼓峰曰。无庸疑。吾辈在此坐一刻许。待其汗至而别。何如。众在犹豫间
。因出酒食。过午。举杯未尽。内出报曰。汗大发矣。是夜热退。痰喘悉平。继用补中调土之剂
而起。此症与前案。俱系劳倦致感。则得病之源。彼此固无或异也。乃其治法则两不相同。何哉
。盖前案未经庸手发表攻中。则阴液尚未受伤。故宜先以参术补中之剂。鼓邪外出。此症则发表
既多。攻中又峻。其热益甚。有火得风而愈炽也。其痰嗽喘急者。阴被劫而益亏也。若遽投以参
术补土之剂。而不先以滋水清金之药。则阴液必亡。而气自何生。汗从何化乎。夫药之后先。即
关病之生死。甚矣。用药者不可不讲次第也。
从子有园丁。忽咯血求诊。视其血。鲜红中间有紫小块。脉之濡涩。色白。问胸中作恶否。曰然
。时颇作痛。直映至背。予曰。知之矣。用桃仁泥三钱。红花三钱。合理中汤。加肉桂一钱。戒
之曰。频服之。必有黑血大至。待黑尽而鲜者来。乃再来告。园丁如言。吐瘀积数升。胸痛即平
。复再求诊。则脉圆实矣。与以理胃养荣之剂。复用填补命门丸子一料。全愈。
治吐血一症。大法有三。然其要只在胸中辨验。如胸中作恶者。乃七情饥饱劳力等因也。胸
中作痛者。乃瘀血抑蓄。折上而奔注也。若不见恶心不见胸痛。而骤涌出者。乃伤寒变热。迫窍
而出也。今案中血见紫块。脉见濡涩。则症属蓄血。东庄固已了了。而问及胸中。又云时颇作痛
。则其为蓄血也。愈明白无疑。而去蓄利瘀之剂。自宜投之立应矣。 明村王义方。医学甚明。
其室人患血症。因气禀怯薄。自进归脾养荣等剂。咯血如故。痰嗽殊甚。邀予诊之。脉俱涩滞。
予曰。据脉论之。其血色当见紫黑。胸中必有微痛。义方曰。诚如所言。予曰。此蓄血症也。遂
用此案法治之。一剂而血见鲜红。脉见充润矣。仍用归脾养荣都气等。三十余剂。诸症悉愈。附
识以见前辈成案。俱是后学楷模。第变通则在善学耳。孙子用久患下血。夏末忽滞下。口渴不饮
食。继而体热。脉洪数。余曰。若论滞下。则诸症皆死候也。今在下血之后。则不可尽责之滞
下。当变法治之。先用白术茯苓山药神曲薏苡仁陈皮甘草等药。强其中以统
血。次用黄连泽泻黄芩丹皮等药。以解郁积之热。后用熟地黄当归芍药等药。以复其阴。次第进
之乃痊。开手便用白术等以助脾。则其久患下血者。脾虚不能统血也。然其人必素多郁结者。郁
久则积而生热。故又患滞下耳。其实原只一串也。彼头痛救头脚痛救脚者。试从此参之。吴弁玉
偶患寒热。旋至热不退。胸中作恶。予诊之曰。此肝郁而致感也。遂用加减小柴胡汤。一剂减半
。次进柴胡地黄饮子。予适欲往旁邑。遂留数方与之。次日仍用地黄饮子。后日用六君子汤加黄
芩。再后日用补中益气汤。加黄芩调之。且戒之曰。明日若尚有微热在内。则后日须再用地黄饮
子一帖。而后用六君子。此后皆有次第。不可乱也。弁玉因服地黄饮子觉热已退尽。遂意用补中
益气汤一帖。是夜即烦热不安。弁玉曰。用晦言有次第。果不可紊。仍用地黄饮子即安。然后根据
次服至第三日。再用补中益气汤。泰然得力矣。时予尚未归。弁玉觉病后烦怒易动。体时虚劣。
与友人商之。言今可改用归脾汤矣。如言服之。予归诊之。曰。今脉已无病。但夜寐不着耳。弁玉
惊曰。正苦此。奈何。予曰。当用加味归脾汤。弁王曰。今已服此方而未效。何也。予曰。君试
服我归脾汤。白愈矣。一剂而鼾睡达旦。
阅此案。愈见处方必有次第。其序不可稍乱。然方以立法。法以制宜。则方中之分两。须有
圆机焉。必当相所主以为轻重也。方中之加减。皆有妙义焉。必当参兼症以为出入也。予于是编
。但列某方某药及
加减法。而不填注分两者。非敢略也。意正为此耳。
杭人沈禹玉妻。夏月发寒热。迎邑医治之。则以为疟也。时月事适下。遂淋漓不断。医又以
为热入血室。用药数帖。寒热益厉。月事益下。色紫黑。或如败酱。医且云服此药势当更甚。乃
得微愈耳。其家疑其说。请予诊之。委顿不能起坐。脉细数甚。按之欲绝。问其寒热。则必起未
申而终于子亥。予曰。此郁火虚症耳。因出彼药示。则小柴胡汤也。彼意以治往来寒热。兼治热
入血室也。又加香薷一大握。则又疑暑毒作疟也。予不觉大笑曰。所谓热入血室者。乃经水方至
。遇热适断不行。故用清凉以解之。今下且不止。少腹 痛。与此症何与。而进黄芩等药乎。即
灼知热入血室矣。当加逐瘀通经之味。香薷一握。又何为者。予用肉桂二钱。白术四钱。炮姜二
钱。当归芍药各三钱。人参三钱。陈皮甘草各四分。一服而痛止经断。寒热不至。五服而能起。
惟足心时作痛。此去血过多。肝肾伤也。投都气饮子。加肉桂牛膝各一钱而全愈。使卒进前药。
重阴下逼。天僵地坼。生气不内。水泉冰溃。不七日死矣。乃云更甚方愈。夫谁欺哉。庸妄之巧
于脱卸。而悍于诛伐如此夫。以小柴胡汤治往来寒热。兼治热入血室。彼且以为见病治病。药甚
对症矣。乃寒热益厉。月事益下。直非对症者。盖其所为治病者。本非其治。其所为见病者。实
未尝见耳。案中辨驳。爽快分明。每读一过。心
胸为之一拓。
桐乡朱绮崖。文战苦久。得补饩。临闱适丁内艰。哀毁愤郁。几不自胜。旋又以内病忧劳。
百感致疾。初发寒热。渐进不解。时方隆夏。医进九味羌活汤不效。又易医大进发表消中之药。
凡狠悍之味悉备。杂乱不成方。三剂。势剧。又进大黄利下等物。下黑水数升。遂大热发狂。昏
愦晕绝。汤水入口即吐。其家无措。试以参汤与之。遂受。垂绝更苏。次日予至。尚溃乱不省人
事。承灵正营及长强。俱发肿毒。时时躁乱。诊其脉数而大。予曰。幸不内陷。可生也。遂重用
参归术。加熟地一两许。时村医在坐。欲进连翘角刺等败毒药。且力言熟地不可用。其家从予
这是攻伐性质的药物吗？方虎陈述病情说：起初发病时出现寒热交替，月经恰好来潮。医生使用发散表邪的药物治疗，没有见效。接着又用大柴胡汤进行攻下。虽然大便通畅了，但病并没有解除。舌头开始变得干燥，痰液涌起堵塞胸膈。医生又用陷胸汤加入化痰药物，依然无效。发热更加严重，于是服用三黄汤合犀角地黄汤。舌头开始变黑，嘴唇开始生皮，心中烦闷懊恼无法入睡。现在该怎么办呢？我说：少阳经的邪气，不能向上透达，热邪被郁遏在下焦，病势波及冲任二脉。如果用苦寒药物逼迫，会导致火势急迫、肾水枯竭，逆乱之气上冲。肾和肝的精血已经耗竭。于是我投以熟地黄、生地黄各一两，配合当归、芍药、牡丹皮、茯苓、山药、麦冬、山茱萸、甘草作为辅助。服后症状立刻安定，但嘴唇和舌头的症状没有消退。我说：不用担心，只要出汗并且大便通畅，病就会解除。方虎问：之前已经用过攻下法反而加重了，现在为什么说大便通就能解呢？我笑着说：正是在这里需要研读医书啊。于是大量进用人参、当归、白术，结果汗出而排出大量黑色粪便，各种症状全部消退，只有痰还比较多，舌苔还没有完全退尽。每到夜晚就感到烦闷不适。我说：这是冲任的病还没有解除。仍然用最初的方子，加入芍药和桃仁泥各三钱。一剂药后病就好了。
根据所述的病情来看，起初发病就是寒热交替，可知邪气在少阳经，明显属于小柴胡汤证。这时候如果用小柴胡汤调和营卫以发汗，开启玄府（汗孔），使少阳的邪气能够向上透达，怎么会导致热邪被郁遏在下焦，进而病及冲任呢？即使病已波及冲任，且月经正来，如果不使用苦寒药物逼迫，而是仍然用小柴胡汤加入当归尾等药物来调理，又怎么会导致嘴唇焦裂、舌头变黑，出现如此严重的肝肾阴亏危候呢？然而对于这种情况，我不责怪那些医生鲁莽地滥用攻伐药物，而是责怪他们不懂得审察病症。甚至不责怪他们不懂审症，而是责怪他们读书读错了。东庄先生的医学之道，得力于四明先生。四明先生在左归饮条下记载：伤寒出现舌黑唇焦、大渴引饮，这一定是因为服用攻伐寒凉药物过多的缘故。这个方子主治此症。现在就以此案逐一对照他的论病处方，足见高鼓峰与吕留良两家，确实是心心相印。
当时方虎患有三阴疟疾，已经四年了。幸好所治疗的都是武林的名医，服药得当，不至于身体溃败。他服用了人参几十斤。然而因病久根深，到了这个时候便支撑不住了。形体肌肉全部脱失，饮食不进。每觉得有气从左胁向上冲撞，就心烦意乱想要昏厥，气息微弱几乎濒死。于是重用桂枝、附子、芍药、地黄，加上养荣除翳的药物。冬至日，正是疟疾发作的时期，那天病情竟然没有发作。
四明先生治疗经久不愈、诸药无效的久疟，主张用养荣汤送服八味丸，并在汤剂中加入熟附子一钱，说十剂药必然能治愈。东庄先生也说，久疟使用补中益气汤无效的，八味丸有神奇疗效。我每次都能体会到它的效力。按八味丸是益火之源以消除阴翳的方子。那么案中所谓的“养荣逐翳”，固然是遵循四明先生用养荣汤送服八味丸的家法。而他能在冬至日痊愈，大概是因为阳气生于子时（冬至），阳气回复则阴邪自然退避的缘故。
不久，又有方虎的蔡氏妹妹患外感病，派人来请我去。当时因为有事滞留武林，不能前往。来人催促多次，等我到了，病情已经很危急了。方虎描述病情，说这病很奇怪，攻邪不可，补虚不可，调和也不可，真是反复无常无计可施。我说：攻法我可以推测出来，请问你们的补法和调法是怎样的？方虎说：开始时用疏表和降火清痰的药物，半个月后病情加重，胸部胀痛。用温胆汤及天花粉、瓜蒌等，这就是调法。服用后呕吐逆气，痰气反而急促。昨天用理中汤，加入肉桂、延胡索、陈皮、枳壳、香附、半夏等，这就是补法。服用后疼痛结聚难以忍受，至今号叫不停。医生说调补都不见效，治法穷尽了。我笑着说：你们所说的补法和调和法就是这样吗？且不说理中汤外面加入了破气伤胃的药物，反而增加了疼痛，就是在理中汤中，单凭甘草这一味药，如果是蛔虫引起的发作性疼痛，就不适宜。难道不记得张仲景的安蛔散去掉甘草，加入花椒、乌梅吗？方虎说：以前多有蛔虫结聚的病症，现在补法不止，无疑是有蛔虫了。那么该怎么办呢？我说：我还是用理中汤，去掉甘草，加入白芍药三钱，木香五分。服下后，疼痛减轻了一半。诊察他的脉象细数得很厉害，口渴想喝水，但不能咽下，喝汤进去就吐出来。手脚有时冷有时热，面颊颧骨处娇红不定，身体像火烧一样烫。我说：这是邪火在内沸腾，愤怒之肝木乘袭上部，五阳之火随之向上焚烧，向下灼烧真阴，龙雷之火飞越。用药物驱赶它，阳气格拒于外，伏藏的阴寒凝结所致。于是将大八味丸做成汤剂给他喝，说：出汗后病就好了。黄昏刚服下一点药，方虎出来说：药服完后，稍微睡了一会儿。看面上娇红色，立刻退去变为白色。过了一会儿却索要被子盖。我说：等着吧，时候到了。等到三更天，有个老妇人敲门说：此刻热得紧急，气促烦乱无法形容，请再进去看看。我说：不用了，我想睡觉，别打扰我。到黎明起床，诊脉，脉紧数达到八九至。我说：汗已经湿润了，但是正气虚弱不能发出。急忙煎煮人参一两，黄芪、白术、当归、白芍、五味子、甘草作为辅助。服下后，大汗淋漓沾湿席子。我说：还没完。第二天再服，汗又大量流出，全身如雨，各种症状顿时痊愈。方虎说：之前说不宜服甘草，现在两剂都重用甘草，为什么呢？我说：起初胃中气血攻伐枯竭，空虚寒凝，所以蛔虫发作而痛。得到甘味药，蛔虫就会更昂扬向上，所以不可以。现在得到了濡润的药物，胃气冲和，蛔头向下潜伏，即使浓煎甘草汁几杯喝下去，有什么害处呢？治法不可固执，大抵就像这样。方虎感叹这是精辟的言论。
同样是这个病症，而且用的是同一个方子。别人用之疼痛加剧，名医用之疼痛即减。可见凡是方剂的加减，都有精深的含义，不可不仔细研讨。
沈凝芝的妻子，当时正准备躺下休息，忽然出现寒热，到半夜就不能说话，气喘急促。医生看她，有的认为是外感伤风，有的认为是往来寒热、气逆痰结。用乌药顺气散治疗无效，邀请我去诊治。听到声音像拉锯一样，手撒开遗尿，口张开不能说话，自汗如雨。我说：这是类中风的症状。已经损伤内脏，不可治了。凝芝说：即使没有救理，应该用什么药？我说：初发时应当用易简乌附子散，现在已经来不及了。凝芝自己喂服，喘声忽然停止，并且稍微能说些话，怀疑还可以救。我说：五脏都已绝，现在得到人参、附子，气稍微复苏罢了，终究无济于事。果然三天后去世。
甲午年我在安邑馆舍教书。九月间，我的二弟因痢疾病，被庸医误治致死。悲愤交集，才开始钻研医理。到年底十二月十二日，馆舍尚未解聘，家父又派人来召我回家，因为母亲中风。等到回去时，五脏都已经衰竭，与前面案例所列的各种症状完全一样。急忙煎煮人参、附子等药剂，挖开牙齿灌进去，也不能挽回。第二天酉时去世。因此想到，在病未见之前，或暴发之际，如果我在家或许还能挽回。却因为十几金微薄的薪水，远在外县馆舍教书，导致抱憾无穷。仰天锥心之恨，如何表达！每次翻阅此案，不禁潸然泪下。
不久，方虎的侧室又患伤寒，继之以壮热不止。医生用疏散药物治疗，病情加重。神情昏愦，不眠。凝芝担心重蹈覆辙，非常忧虑。我去诊治，说：这是外感病，不要紧。但是因为起于劳倦，不应当再次虚损其本已虚弱的身体。于是投以人参、白术等药物，出汗后，神情立刻清醒。其次用地黄饮子，排出黑色粪便，熟睡。只有热还没有完全退尽。我说：这很容易处理，在昨天的方子中加入炙甘草一钱。照做后立刻安宁。旁观者都觉得很奇怪。继以滋肾养荣等药物调理，恢复如初。
用参、术发汗，用地黄通便，用炙甘草除热。这种治疗外感病的方法，在病人家属看来，无不认为用补药是忌讳；旁观者无不认为用补药是怪异。即使是庸医看到，也无不惊骇吐舌。然而其中有奥妙义理。因为外感病起于劳倦，那么不扶助正气就无法托举邪气外出；不滋阴就无法润燥通便；不用甘温就难以除热。那些人只是不知道这个道理，所以妄自惊骇以为奇怪罢了。
姐夫劳仲虎，初夏因劳倦导致外感，身体出现寒热，口苦。医生用重药发散，又复用山楂、厚朴、枳实、天花粉、瓜蒌、半夏之类攻伐其中。热更加严重，痰嗽气喘急促，言语无序。我去诊治说：误了。立即停止其余药物，重用滋水清金的药物。一服药后痰嗽逐渐减退，神情觉得清醒。第二天再去诊治，脉浮洪而数，语速急遽但收声轻缓，手指时常微微肿胀。我说：这些都是虚证。邪气未曾进入阳明经，却先攻伐，损伤了元气，邪气反而随之内入阳明。重重地虚损其虚，更不能鼓动邪气外出。现在虽然稍微安定，夜里必定出现谵语狂妄。应当紧急用人参救治。恰好箱中所带的药不多，只用人参二钱，黄芪一两。到第二天，家人来说，夜里非常悖乱不安，形势很紧迫，似乎不可救。我说：不要紧，是人参力量不足的缘故。当时鼓峰在县城，我拉着他同往。他说：汗已经出了，有什么可担心的呢？于是用人参一两许，仍然加入前面的药进服。他的亲友还在议论人参与痰喘谵妄相违背。我对鼓峰说：不要怀疑，我们在这里坐一刻左右，等他的汗出来再告别，怎么样？众人还在犹豫间，拿出酒食。过了中午，酒杯还没喝完，里面出来报告说：大汗大发出来了。这天夜里热退，痰喘全平。继用补中调土的药剂而痊愈。这个病例与前一个病例，都是劳倦导致外感，那么得病的根源，彼此固然没有不同。但是治疗方法却完全不同，为什么呢？前一个病例未经庸手发表攻中，那么阴液还没有受伤，所以适宜先用参术补中的药剂，鼓动邪气外出。这个病例则发表药过多，攻中药又峻烈，热更加严重，如同火遇到风而更炽烈。那个痰嗽气喘急促，是因为阴液被劫夺而更加亏损。如果急于投以参术补土之剂，而不先用滋水清金的药物，那么阴液必亡，气从哪里生？汗从哪里化呢？药物的先后顺序，关系到病人的生死，非常重要。用药的人不可不讲求次第。
侄子有个园丁，忽然咯血求诊。看他吐出的血，鲜红中间有紫黑色小块。诊脉濡涩，面色白。问他胸中恶心吗？回答说：是的。时常很痛，一直放射到背部。我说：我知道了。用桃仁泥三钱，红花三钱，配合理中汤，加肉桂一钱。告诫他说：频繁服用，必然会有大量黑血吐出。等黑血排尽鲜红的血来了，再来告诉我。园丁照做，吐出瘀积的血几升，胸痛立刻平息。再次求诊，脉象圆实了。给予理胃养荣的药剂，再用填补命门丸一料，完全痊愈。
治疗吐血一症，大法有三。但其要点只在胸中辨别验证。如果胸中恶心，那是七情、饥饱、劳力等原因造成的。如果胸中作痛，那是瘀血蓄积，折返向上奔注造成的。如果不见恶心也不见胸痛，而突然涌出的，那是伤寒变热，逼迫窍道而出造成的。现在案中血见紫块，脉见濡涩，那么病症属于蓄血。东庄先生本来已经很清楚，而问到胸中，又说时常很痛，那么其为蓄血就更加明白无疑了。而去蓄利瘀的药剂，自然适宜投下并立即见效。
明村王义方，医学很精通。他的妻子患血症，因为气禀怯弱单薄，自行服用归脾养荣等药剂，咯血如故，痰嗽特别严重。邀请我去诊治。脉象都涩滞。我说：据脉象论述，血色应当见紫黑，胸中必有微痛。义方说：确实像您说的。我说：这是蓄血症。于是用这个案例的方法治疗。一剂药后血见鲜红，脉见充润了。仍然用归脾养荣都气等药，三十多剂，各种症状全部痊愈。附带记录以见前辈成案，都是后学的楷模。只是变通在于善于学习而已。
孙子长期患有下血，夏末忽然患痢疾，口渴但不欲饮食，继而身体发热，脉洪数。我说：如果论痢疾，那么各种症状都是死候。现在在下血之后，那么不可全都归咎于痢疾，应当改变法治疗。先用白术、茯苓、山药、神曲、薏苡仁、陈皮、甘草等药，强健脾胃以统摄血液。其次用黄连、泽泻、黄芩、丹皮等药，以解除郁积的热。后用熟地黄、当归、芍药等药，以恢复其阴。次第进服才痊愈。起手就用白术等以助脾，那么他长期患下血，就是脾虚不能统血。然而这个人一定素来多郁结，郁久则积而生热，所以又患痢疾。其实原本只是一串因果。那些头痛医头脚痛医脚的人，试着从此参考。
吴弁玉偶然患寒热，随即热不退，胸中恶心。我诊察说：这是肝郁导致的外感。于是用加减小柴胡汤，一剂减半。其次进柴胡地黄饮子。我正好要去旁县，于是留下几个方子给他。第二天仍用地黄饮子，后日用六君子汤加黄芩，再后日用补中益气汤加黄芩调理。并且告诫他说：明天如果还有微热在内，那么后天必须再用地黄饮子一帖，然后用六君子。此后都有次第，不可混乱。弁玉因为服地黄饮子觉得热已退尽，于是擅自用补中益气汤一帖。当天晚上就烦热不安。弁玉说：用晦言说有次第，果然不可紊乱。仍用地黄饮子即安。然后根据次服至第三日，再用补中益气汤，泰然得力了。当时我尚未回来。弁玉觉得病后烦怒易动，身体时时虚弱劣弱。与友人商量，说现在可以改用归脾汤了。照说服用。我回来诊察说：现在脉已无病，只是夜间睡不着觉罢了。弁玉惊讶说：正为此苦恼，怎么办？我说：当用加味归脾汤。弁玉说：现在已服此方而未效，为什么？我说：你试试服我的归脾汤，自然会好。一剂药就打呼噜睡到天亮。
阅读此案，越发见到处方必有次第，其顺序不可稍乱。然而方剂以立法，法以制宜，那么方中的分量，须有圆融机变。必须根据主治来决定轻重。方中的加减，都有奥妙义理。必须参考兼症来决定出入。我在这个编著中，只列出某方某药及加减法，而不填写注分量，不是敢疏忽大意。用意正是为此。
杭州人沈禹玉的妻子，夏天发寒热，迎请县城医生医治，则认为疟疾。当时月经刚好来潮，于是淋漓不断。医生又认为是热入血室，用药数帖，寒热更加厉害，月经更加下行，颜色紫黑，有的像败酱。医生还说服用此药势头应当更甚，然后才能微愈。家里人怀疑他的说法，请我去诊治。委顿不能起坐，脉细数得很厉害，按之欲绝。问他的寒热，则一定起于未申时终于子亥时。我说：这是郁火虚证。拿出他们的药给我看，则是小柴胡汤。他们的意图是以治往来寒热，兼治热入血室。又加香薷一大把，则又怀疑暑毒作疟。我不禁大笑说：所谓热入血室，乃是经水刚到，遇热适断不行，所以用清凉药来解之。现在下血还不止，少腹疼痛，与此症有什么关系，而进黄芩等药呢？即使确知是热入血室，应当加逐瘀通经的药物，香薷一把，又是做什么用的？我用肉桂二钱，白术四钱，炮姜二钱，当归芍药各三钱，人参三钱，陈皮甘草各四分。一服而痛止经断，寒热不再发作。五服而能起立。只有足心时常作痛，这是去血过多，肝肾受伤。投都气饮子，加肉桂牛膝各一钱而全愈。如果贸然进前药，重阴下逼，天僵地坼，生气不内，水泉冰溃，不到七天就死了。却说更甚方愈，欺骗谁呢？庸医妄巧于推卸责任，而悍于攻伐，竟至于此。用小柴胡汤治往来寒热，兼治热入血室，他们尚且以为是见病治病，药很对症了。然而寒热更厉，月经更下，简直不对症。大概他们所治的病，根本就不是那个治法。他们所见的病，实在未曾看见。案中辨驳，爽快分明。每读一遍，心胸为之开阔。
桐乡朱绮崖，科举考试辛苦很久，得了补饩资格。临考适逢母亲去世，哀毁愤郁，几乎不能自持。随即又因内部疾病忧劳，百感致疾。初发寒热，渐进不解。当时正值盛夏，医生进九味羌活汤无效，又换医生大进发表消中之药。凡狠悍的味道都备齐，杂乱不成方。三剂，病情加剧，又进大黄利下等物。下黑水几升，遂大热发狂，昏愦晕绝，汤水入口即吐。家里人无计可施，试以参汤给他，遂能接受，垂死之际更苏。第二天我到，他还溃乱不省人事。承灵、正营及长强穴，都发肿毒，时时躁乱。诊其脉数而大。我说：幸而没有内陷，可以生。于是重用参归术，加熟地一两许。当时村医在座，欲进连翘、角刺等败毒药，且力言熟地不可用。家里人听从了我……
Is this a drug for attacking and purging? Fang Hu described the condition: Initially, the illness began with alternating chills and fever (Han Re), coinciding with the onset of menstruation. The physician used diaphoretic drugs to release the exterior, but it was ineffective. Subsequently, Da Chai Hu Tang (Greater Bupleurum Decoction) was used to purge downwards. Although bowel movements occurred, the disease did not resolve. The tongue became dry, and phlegm rose to fill and obstruct the chest and diaphragm. The physician then used Xian Xiong Tang (Chest-Trap Decoction) added with phlegm-resolving drugs, which also failed. The heat intensified further, so San Huang Tang (Three Yellows Decoction) combined with Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) was administered. The tongue turned black, the lips developed peeling skin, and there was severe irritability and restlessness preventing sleep. What should be done now? I said: The pathogenic factor in the Shaoyang (Lesser Yang) channel cannot ascend and diffuse outward. Heat is suppressed in the lower jiao, and the disease has affected the Chong and Ren vessels. By using bitter-cold drugs to force the pathogen, fire became urgent and water (Kidney Yin) was scorched, causing rebellious qi to rush upward. The Kidneys and Liver were exhausted. Therefore, I prescribed Shu Di Huang (Prepared Rehmannia Root) and Sheng Di Huang (Raw Rehmannia Root), one liang each, assisted by Dang Gui (Angelica Sinensis), Bai Shao (White Peony Root), Mu Dan Pi (Moutan Cortex), Fu Ling (Poria), Shan Yao (Dioscorea Rhizome), Mai Dong (Ophiopogon Tuber), Shan Yu Rou (Cornus Fruit), and Gan Cao (Licorice Root). Symptoms stabilized immediately, but the lip and tongue signs persisted. I said: Do not worry. Once sweating occurs and stool passes freely, the disease will resolve. He asked: We already used purgation before, which made it worse; why do you say passing stool will resolve it now? I smiled and said: It is precisely here that one must study medical texts carefully. Thus, I heavily advanced Shen (Ginseng), Dang Gui, and Bai Zhu (Atractylodes Macrocephala Rhizome). Sweating ensued, and a large amount of black feces were passed. All symptoms subsided, except for excessive phlegm and residual tongue coating. Every night, he felt irritable and uncomfortable. I said: This indicates the Chong and Ren diseases have not yet resolved. I continued using the initial formula, adding Bai Shao and Tao Ren Mud (Peach Kernel Paste), three qian each. After one dose, he recovered.
Based on the described symptoms, the initial onset of alternating chills and fever indicates the pathogen is in the Shaoyang channel, clearly belonging to Xiao Chai Hu Tang (Lesser Bupleurum Decoction) syndrome. At that time, if Xiao Chai Hu Tang had been used to harmonize and induce mild sweating to open the Xuán Fǔ (pores), allowing the Shaoyang pathogen to ascend and diffuse, how could the heat have been suppressed in the lower jiao, affecting the Chong and Ren vessels? Even if the disease affected the Chong and Ren vessels while menstruation was present, if bitter-cold drugs had not been used to force the pathogen, but rather Xiao Chai Hu Tang added with Dang Gui Wei (Angelica Sinensis Tail) to regulate, how could it have led to cracked lips, a black tongue, and such critical signs of Liver-Kidney Yin deficiency? However, regarding this situation, I do not blame these physicians for their reckless use of attacking drugs, but for their failure to examine the syndrome accurately. In fact, I do not even blame them for failing to examine the syndrome, but for misreading their books. Dong Zhuang's medical expertise was derived from Si Ming. Si Ming stated under the entry for Zuo Gui Yin (Left Restoring Drink): "In Shanghan (Cold Damage), black tongue and scorched lips with intense thirst and desire to drink indicate excessive consumption of attacking and cold-cooling drugs. This formula treats it." Comparing this case with his discussions and prescriptions, it is evident that Gao Gufeng and Lü Liuliang were indeed spiritually aligned.
At that time, Fang Hu suffered from Sān Yīn Nüè (Three-Yin Malaria) for four years. Fortunately, he was treated by famous physicians in Wulin who prescribed correctly, preventing total collapse. He consumed dozens of jin of Ren Shen (Ginseng). However, due to the chronic nature and deep-seated pathology, he eventually could no longer sustain himself. His flesh wasted away, he refused food, and often felt Qi rushing up from the left hypochondrium, causing extreme irritability and near-syncope, with his breath faint and life nearly gone. Heavy doses of Gui Zhi (Cinnamon Twig), Fu Zi (Aconite Lateralis Preparata), Bai Shao, and Di Huang (Rehmannia Root) were used, along with herbs to nourish Ying and remove nebulae (pathological obstructions). On the Winter Solstice, the day of expected recurrence, the malaria did not manifest.
Si Ming taught that for persistent malaria unresponsive to other treatments, one should administer Ba Wei Wan (Eight-Ingredient Pill) with Yang Rong Tang (Nourish Ying Decoction), adding one qian of Shu Fu Zi (Prepared Aconite) to the decoction, claiming ten doses would cure it. Dong Zhuang also stated that for chronic malaria where Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) fails, Ba Wei Wan works miraculously. I have personally experienced its efficacy. Ba Wei Wan tonifies the source of Fire to eliminate Yin shadows. Thus, the "nourishing Ying and removing nebulae" mentioned in the case follows Si Ming's family method of using Yang Rong Tang with Ba Wei Wan. His recovery on the Winter Solstice likely occurred because Yang Qi is born at Zi hour (midnight/Winter Solstice); when Yang returns, Yin naturally retreats.
Shortly after, Fang Hu's sister-in-law, Ms. Cai, contracted an exogenous disease. She sent a messenger to summon me. I was detained in Wulin for business and could not go. After several urgent requests, I arrived only to find her condition critical. Fang Hu described the illness as bizarre: attacking was impossible, tonifying was impossible, and harmonizing was impossible. Truly, it seemed hopeless. I said: I can deduce the attacking method. Please tell me your tonifying and harmonizing methods. Fang Hu said: Initially, exterior-releasing and fire-clearing/phlegm-resolving agents were used. After half a month, the condition worsened with chest distension and pain. Wen Dan Tang (Warm the Gallbladder Decoction) plus Hua Fen (Tian Hua Fen/Trichosanthes Root) and Gua Lou (Trichosanthes Fruit) were used. This was the harmonizing method. It caused vomiting and reverse flow, and phlegm-Qi became more urgent. Yesterday, Li Zhong Tang (Regulate the Middle Decoction) was used with Rou Gui (Cinnamon Bark), Yan Hu Suo (Corydalis Rhizome), Chen Pi (Citrus Peel), Zhi Ke (Aurantium Fructus), Xiang Fu (Cyperus Rhizome), and Ban Xia (Pinellia Tuber). This was the tonifying method. It caused unbearable constriction pain, and she has been screaming incessantly. Physicians said harmonizing and tonifying failed, and treatment options were exhausted. I laughed and said: Is this what you call tonifying and harmonizing? Regardless of the fact that Li Zhong Tang was combined with Qi-breaking and Stomach-damaging herbs, exacerbating the pain, even within Li Zhong Tang alone, Gan Cao (Licorice Root) is unsuitable if the pain is caused by roundworms. Do you not remember Zhang Zhongjing's An Hui San (Roundworm-Calming Powder) which removes Gan Cao and adds Hua Jiao (Sichuan Pepper) and Wu Mei (Mume Fruit)? Fang Hu said: Previously, there were many cases of roundworm accumulation. Now, with continuous tonification, it is undoubtedly roundworms. Then what should be done? I said: I will still use Li Zhong Tang, remove Gan Cao, add Bai Shao (White Peony Root) three qian and Mu Xiang (Aucklandiae Radix) five fen. Upon administration, pain reduced by half. Her pulse was fine and rapid. She was thirsty and wanted to drink but could not swallow; any liquid taken was vomited. Her hands and feet alternated between cold and hot. Her malar region showed fluctuating rosy redness. Her body felt like burning. I said: This is internal boiling of pathogenic fire. Angry Wood (Liver) overacts upwards. The Five Yang fires follow and scorch upwards, while scorching True Yin downwards. Dragon and Thunder fire fly away. Using drugs to drive it causes Yang to be rejected externally, while hidden Yin freezes and knots. Thus, I prepared Da Ba Wei Wan (Eight-Ingredient Pill) as a decoction and gave it to her, saying: Once sweat appears, the disease will be cured. At dusk, shortly after taking a small amount, Fang Hu came out and said: After finishing the medicine, she slept briefly. The rosy redness on her face instantly faded to white. Soon after, she requested blankets. I said: Wait, the time is coming. At third watch, an old woman knocked, saying: The heat is urgent now, with shortness of breath and indescribable irritability. Please come again. I said: No need. I wish to sleep. Do not disturb me. At dawn, upon rising, I palpated the pulse: tight and rapid, reaching 8-9 beats per breath. I said: Sweat has moistened the skin, but deficiency prevents full emission. I urgently decocted Ren Shen (Ginseng) one liang, assisted by Huang Qi (Astragalus Root), Bai Zhu, Dang Gui, Bai Shao, Wu Wei Zi (Schisandra Berry), and Gan Cao. Upon drinking, profuse sweat soaked the mat. I said: Not yet. Take it again the next day. Sweat flowed heavily again, drenching the whole body like rain. All symptoms vanished instantly. Fang Hu asked: Previously, you said Gan Cao was unsuitable. Now both doses heavily use Gan Cao. Why? I said: Initially, Qi and Blood in the Stomach were exhausted by attack, leading to emptiness and cold coagulation, causing roundworms to move and pain. Sweetness makes roundworms rise higher, hence it was contraindicated. Now, with moistening drugs, Stomach Qi is harmonized, and roundworm heads settle downward. Even drinking several cups of thick Gan Cao decoction, what harm could it do? Treatment principles cannot be rigid; they are like this. Fang Hu sighed, calling it profound wisdom.
It is the same syndrome and the same formula. Others using it saw increased pain; skilled physicians using it saw immediate relief. This shows that every modification in a prescription has profound meaning and must be studied carefully.
Shen Ningzhi's wife, while preparing to lie down, suddenly developed chills and fever. By midnight, she lost her voice, gasped for breath. Physicians examined her; some thought it was exogenous injury, others considered alternating chills/fever with rebellious Qi and phlegm knotting. Wu Yao Shun Qi San (Wu Yao Regulating Qi Powder) was ineffective. I was invited to examine her. Her voice sounded like a saw dragging. Her hand relaxed, she urinated involuntarily, mouth open unable to speak, sweating profusely like rain. I said: This is Lei Zhong Feng (Stroke-like Syndrome). The Zang organs are damaged; it is incurable. Ningzhi asked: If there is no hope, what medicine should be used? I said: At onset, Yi Jian Wu Fu Zi San (Simple Aconite Powder) should have been used. It is too late now. Ningzhi administered it herself. The gasping stopped, and she spoke slightly, suggesting possible rescue. I said: The Five Zang are exhausted. The Ginseng and Aconite merely revived Qi temporarily. Ultimately, it will not help. Indeed, she died three days later.
In the year Jia Wu, I was teaching in Anyi. In September, my second brother died of dysentery due to quackery. Overcome by grief and anger, I began to study medical theory seriously. By late December, on the 12th, I had not yet left my post when my father sent for me because my mother had suffered a stroke. When I returned, her Five Zang were exhausted, presenting symptoms identical to those listed in previous cases. I urgently decocted Ren Shen and Fu Zi, pried her teeth open, and forced the medicine down, but could not save her. She died at You hour the next day. Reflecting on this, if I had been home before the illness manifested or at its sudden onset, I might have saved her. Instead, driven by a small salary to teach far away, I am left with boundless sorrow. Looking up at the sky, my heart feels like it is pierced. Whenever I read this case, tears fall uncontrollably.
Soon after, Fang Hu's concubine contracted Shanghan (Cold Damage) with persistent high fever. Physicians used dispersing drugs, worsening the condition. She became delirious and insomniac. Ningzhi, fearing a repeat of previous tragedies, was very worried. I examined her and said: This is an exogenous disease, no cause for alarm. However, since it arose from fatigue, we must not further deplete her deficiency. I prescribed Ren Shen and Bai Zhu. After sweating, her mental state cleared instantly. Next, Di Huang Yin Zi (Rehmannia Drink) was given, resulting in the passage of black stool and sound sleep. Only slight heat remained. I said: This is easy to handle. Add Zhi Gan Cao (Honey-fried Licorice) one qian to yesterday's formula. As instructed, she stabilized. Observers found it miraculous. Subsequently, Zhi Shen Yang Rong (Nourish Kidney and Ying) herbs regulated her back to health.
Using Ren Shen and Bai Zhu to induce sweat, Di Huang to promote bowel movement, and Zhi Gan Cao to clear heat—these methods for treating exogenous diseases are often viewed with suspicion by families who fear tonics, and seen as strange by bystanders. Even quacks would be shocked. Yet, there is subtle logic. Exogenous disease arising from fatigue requires supporting Zheng Qi (Upright Qi) to expel pathogens, nourishing Yin to moisten bowels, and using sweet-warm herbs to clear heat. Those who do not understand this logic are merely startled by the apparent strangeness.
My brother-in-law, Lao Zhonghu, contracted an exogenous disease due to summer fatigue, experiencing chills, fever, and bitter taste. Physicians used heavy diaphoretics, followed by Shan Zha (Hawthorn), Hou Po (Magnolia Bark), Zhi Shi (Bitter Orange), Hua Fen, Gua Lou, and Ban Xia to attack the interior. Heat intensified, accompanied by phlegm, cough, asthma, and disordered speech. I examined her and said: Mistake! Stop all other drugs immediately. Use heavy doses of herbs to nourish Water and clear Metal (Lung). One dose reduced phlegm and cough, and mental clarity improved. Next day, pulse was floating, surging, and rapid. Speech was hurried but ended lightly. Fingers occasionally swelled slightly. I said: These are deficiency signs. The pathogen had not entered the Yangming channel, yet attack was used first, damaging Yuan Qi (Primal Qi). The pathogen followed inward. Further depletion made it harder to expel the pathogen. Although slightly stable now, she will likely experience delirium at night. Urgently use Ren Shen to rescue. I had little of the herb on me, so I used two qian of Ren Shen and one liang of Huang Qi. The next day, family reported extreme confusion and distress, seemingly incurable. I said: No problem. The dose of Ren Shen was insufficient. Gufeng was in the county, so I invited him to visit together. He said: Sweat has appeared. Why worry? So, I used over one liang of Ren Shen, continuing the previous herbs. Relatives questioned the use of Ren Shen against phlegm, asthma, and delirium. Gufeng and I said: Do not doubt. Let us sit here for a moment until sweat appears, then we leave. While they hesitated, wine and food were brought. Past noon, before finishing the cup, a report came: Profuse sweating occurred. That night, heat subsided, and phlegm/asthma ceased. Subsequently, Bu Zhong Diao Tu (Tonify Middle and Regulate Earth) formulas restored her health.
This case and the previous one both resulted from fatigue-induced exogenous disease, sharing the same origin. Yet, treatments differed completely. Why? The previous case had not undergone quack exterior-release or interior-attack, so Yin fluids were intact. Thus, Ren Shen and Bai Zhu were appropriate to tonify the middle and expel pathogens. This case involved excessive exterior-release and harsh interior-attack, intensifying heat (like fire fanned by wind). Phlegm and asthma resulted from Yin depletion. If Ren Shen and Bai Zhu were used immediately without first nourishing Water and clearing Metal, Yin would perish, and Qi/Sweat could not be generated. The sequence of herbs determines life or death. Physicians must prioritize order.
A gardener in my nephew's household suddenly hemoptysis. The blood was bright red with purple clots. Pulse was soft and choppy. Complexion was pale. Chest nausea and pain radiating to the back were present. I said: I know. Use Tao Ren Mud (Peach Kernel Paste) three qian, Hong Hua (Carthamus Flower) three qian, combined with Li Zhong Tang, plus Rou Gui one qian. Instructed frequent intake, predicting massive black blood expulsion. Once black blood cleared and fresh blood appeared, return. The gardener followed instructions, expelling several sheng of stasis. Chest pain ceased. Pulse became round and solid. Given Li Wei Yang Rong (Regulate Stomach and Nourish Ying) formulas, followed by Tian Di Ming Men Wan (Tonify Life Gate Pill), he fully recovered.
There are three major principles for treating hemoptysis, centered on distinguishing chest sensations. Nausea indicates emotional stress, hunger/fullness, or labor. Pain indicates blood stasis obstructing and forcing blood upward. Absence of nausea/pain with sudden gushing indicates Shanghan transforming into heat forcing blood from orifices. In this case, purple clots and soft/choppy pulse indicate blood stasis. Dong Zhuang knew this well. The chest pain confirmed stasis. Drugs to remove stasis and benefit blood should work immediately.
Wang Yifang from Mingcun, knowledgeable in medicine, had a wife with blood disorder. Due to weak constitution, she self-administered Gui Pi (Restore the Spleen) and Yang Rong formulas, but hemoptysis persisted with severe phlegm/cough. Pulse was choppy and stagnant. I said: Based on the pulse, blood should be purple-black, with slight chest pain. Wang agreed. I diagnosed blood stasis and applied the previous method. One dose yielded bright red blood and a充盈 (full/moist) pulse. Continued with Gui Pi, Yang Rong, and Du Qi formulas for over thirty doses until cured. This illustrates that past cases serve as models, but adaptation requires skillful learning.
My grandson suffered chronic lower bleeding. Late summer, he developed dysentery with thirst but no desire to eat, followed by fever and surging-rapid pulse. I said: If viewed solely as dysentery, all signs are fatal. Since it follows chronic bleeding, do not attribute everything to dysentery. Change treatment strategy. First, use Bai Zhu, Fu Ling, Shan Yao, Shen Qu (Medicated Leaven), Yi Yi Ren (Coix Seed), Chen Pi, and Gan Cao to strengthen the Spleen and control bleeding. Second, use Huang Lian (Coptis), Ze Xie (Alisma), Huang Qin (Scutellaria), and Dan Pi (Moutan) to clear accumulated heat. Third, use Shu Di Huang, Dang Gui, and Bai Shao to restore Yin. Sequential administration led to recovery. Starting with Bai Zhu addresses Spleen deficiency failing to control blood. Chronic stagnation generates heat, causing dysentery. It is a single chain of causality. Treating head for headache and foot for footache is misguided; consider this reference.
Wu Bianyu occasionally had chills/fever, progressing to persistent heat and chest nausea. I diagnosed Liver depression causing exogenous invasion. Jia Wei Xiao Chai Hu Tang (Modified Lesser Bupleurum Decoction) reduced symptoms by half in one dose. Next, Chai Hu Di Huang Yin Zi (Bupleurum and Rehmannia Drink) was used. I traveled to another county, leaving formulas. Next day, Di Huang Yin Zi continued. Day after, Liu Jun Zi Tang (Six Gentlemen Decoction) with Huang Qin. Later, Bu Zhong Yi Qi Tang with Huang Qin. I warned: If slight heat remains tomorrow, use Di Huang Yin Zi the day after, then Liu Jun Zi. Order is crucial. Bianyu, feeling heat gone, skipped to Bu Zhong Yi Qi Tang. That night, he became irritable and restless. He realized my warning about order was correct. Resuming Di Huang Yin Zi brought peace. Following the sequence to the third day, then Bu Zhong Yi Qi Tang, he recovered steadily. Upon my return, he complained of post-illness irritability and weakness. Friends suggested Gui Pi Tang. I examined him: Pulse normal, only insomnia remains. He was surprised, asking what to do. I prescribed Jia Wei Gui Pi Tang. He objected, having tried it before without effect. I insisted he try mine. One dose brought deep sleep until dawn.
Reading this case reinforces that prescriptions must have sequence. Formulas establish methods; methods adapt to conditions. Dosages require flexibility based on the primary indication. Modifications depend on accompanying symptoms. In this compilation, I list formulas, herbs, and modifications but omit dosages, not out of negligence, but to emphasize this principle.
Ms. Shen, wife of Shen Yuyu from Hangzhou, developed chills/fever in summer. Local doctors diagnosed malaria. Menstruation started, dripping continuously. Doctors diagnosed Re Ru Xue Shi (Heat Entering Blood Chamber) and prescribed several doses. Chills/fever worsened, menstruation increased, color purple-black or like spoiled sauce. Doctors claimed symptoms would worsen before improving. Family doubted this and summoned me. She was prostrate, pulse fine-rapid and nearly imperceptible. Chills/fever started around Wei/Shen hours and ended at Zi/Hai hours. I said: This is deficiency with constrained fire. Their prescription was Xiao Chai Hu Tang. They intended to treat alternating chills/fever and Heat Entering Blood Chamber. Adding a large handful of Xiang Ru (Mosla Herb) suggested suspicion of summerheat-malaria. I laughed: Heat Entering Blood Chamber applies when menstruation just starts and stops due to heat, requiring cooling. Here, bleeding continues, with lower abdominal pain. How does this relate? Why use Huang Qin? Even if Heat Entering Blood Chamber were certain, blood-invigorating and meridian-unblocking herbs should be added. What is Xiang Ru doing? I used Rou Gui two qian, Bai Zhu four qian, Pao Jiang (Roasted Ginger) two qian, Dang Gui and Bai Shao three qian each, Ren Shen three qian, Chen Pi and Gan Cao four fen each. One dose stopped pain and bleeding, resolving chills/fever. Five doses allowed her to rise. Only sole-of-foot pain remained, indicating Liver/Kidney damage from excessive blood loss. Du Qi Yin Zi with Rou Gui and Niu Xi (Achyranthes Root) one qian each cured her. Had they continued the previous drugs, heavy Yin would have forced downward, destroying life energy, leading to death within seven days. Claiming "worse before better" is deception. Quacks are cunning in evasion and ruthless in attack. Using Xiao Chai Hu Tang for alternating chills/fever and Heat Entering Blood Chamber seems targeted, yet symptoms worsened. They were not targeting the right disease, nor seeing the real disease. The case refutation is clear and refreshing, expanding the mind upon reading.
Zhu Qiya from Tongxiang, exhausted by long examination preparation, obtained a stipend. Just before the exam, his mother died. Grief and depression overwhelmed him. Internal illness arose from worry and labor. Initial chills/fever progressed unresolved. Mid-summer, Jiu Wei Qiang Huo Tang (Nine-Ingredient Ephedra Decoction) failed. Another doctor used strong exterior-releasing and interior-purging drugs, mixing harsh ingredients杂乱ly. Three doses worsened the condition. Da Huang (Rhubarb) and purgatives were given, evacuating several sheng of black fluid. High fever, mania, coma, and syncope ensued. Liquids were vomited immediately. Family tried Ren Shen soup, which he accepted, reviving him from near-death. Next day, I arrived; he was confused and unconscious. Swelling and sores appeared at Cheng Ling, Zheng Ying, and Chang Qiang acupoints. Restlessness continued. Pulse was rapid and large. I said: Fortunately, the pathogen has not penetrated inward. Survival is possible. Heavy doses of Ren Shen, Dang Gui, and Bai Zhu, plus one liang of Shu Di Huang were used. Village physicians present wanted to use Lian Qiao (Forsythia) and Ci Ji Li (Tribulus) to detoxify, arguing strongly against Shu Di Huang. The family followed my advice...