许学士治乡人邱生者。病伤寒发热。头痛烦渴。脉虽浮数而无力。尺以下迟而弱。许曰
虽麻黄证。而尺迟弱。仲景曰。尺中迟者。营气不足。未可发汗。用建中汤加当归、黄
翌日脉尚尔。其家索发汗药。言几不逊。许忍之。只用建中调营而已。至五日。尺部方应
遂投麻黄汤二服。发狂须臾。稍定略睡。已得汗矣。信乎医者当察其表里虚实。待其时日
若不循次第。取效临时。亏损五脏。以促寿限。何足贵也。
〔附南史〕范云初为梁武帝属官。时武帝有九锡之命。云忽感伤寒。恐不得预庆事。召
徐文伯诊视。问曰。可便得愈乎。文伯曰。便瘥甚易。正恐二年后不起耳。云曰。朝闻道。
夕死可矣。况二年乎。文伯于是先以火 地。布桃叶。铺席。置云其上。顷刻汗出。以温粉
扑之。翌日遂愈。云甚喜。文伯曰。不足喜也。后二年果卒。夫取汗先期。尚促寿限。况不
顾表里。不待时日。欲速愈者耶。故书此为戒。
一人病伤寒。大便不利。日晡潮热。两手撮空。直视喘急。更数医矣。许曰。此诚恶候
见之者九死一生。仲景虽有证而无治法。况已经吐下。难于用药。勉强救之。若大便得通
而脉弦。则可生。乃与小承气一服。大便利。诸疾渐退。脉且微弦。半月愈。或问曰。下之
而脉弦者生。此何谓也。许曰。仲景云。循衣妄撮。怵惕不安。微喘直视。脉弦者生。涩者
死。微者但发热谵语者。承气汤主之。予观钱氏直诀云。手循衣领及捻物者。肝热也。此症
在仲景列于阳明部。盖阳明者胃也。肝有热邪。淫于胃经。故以承气汤泻之。且得弦脉。则
肝平而胃不受克。所以有生之理也。
〔附〕楼全善曰。尝治寻衣撮空。得愈者数人。皆用大补气血之剂。唯一人兼 振脉代
遂于补剂中加桂二分。亦振止脉和而愈。
一人病伤寒。初呕吐。俄为医下之。已八九日。而内外发热。许诊之。曰。当用白虎加
人参汤。或曰。既吐复下。宜重虚矣。白虎可用乎。许曰。仲景云。若吐下后。七八日不解
热结在里。表里俱热者。白虎加人参汤。盖始吐者。热在胃脘。今脉洪滑。口大渴。欲饮
水。舌干燥而烦。非人参白虎不可也。
一人病伤寒。心烦喜呕。往来寒热。医以小柴胡与之。不除。许曰。脉洪大而实。热结
在里。小柴胡安能去之。仲景云。伤寒十余日。热结在里。复往来寒热者。与大柴胡汤。三
服而病除。
一人太阳症。因发汗不止。恶风。小便数。足挛急。屈而不伸。脉浮而大。许曰。此证
在仲景方中有两条。大同小异。一则太阳病。发汗。遂漏不止。恶风。小便难。四肢微急。
难以屈伸。一则伤寒脉浮。自汗出。小便数。心烦。微恶寒。脚挛急。一属漏风小便难。一
属有汗小便数。不可混治。此当用桂枝加附子汤。三啜而汗止。佐以芍药甘草汤。足便得伸
一舟子伤寒发黄。鼻内酸痛。身与目如金。小便赤而数。大便如常。或欲用茵陈五苓。
许曰。非其治也。小便和。大便如常。则知病不在脏腑。今眼睛疼。鼻酸痛。是病在清道中
若下大黄。必腹胀为逆。宜用瓜蒂散。先含水。次搐之。鼻中黄水尽。乃愈。
一武官为寇执。置舟中 板。数日得脱。乘饥恣食。良久解衣扪虱。次日遂伤寒。自汗
而鬲不利。一医作伤食而下之。一医作解衣中邪而汗之。杂治数日。渐觉昏困。上喘息高。
许诊之。曰。太阳下之。表未解。微喘者。桂枝加浓朴杏仁汤。此仲景法也。命令医者治此
药。一啜喘定。再啜热缓微汗。至晚身凉而脉已和矣。医曰。某平生未尝用仲景方。不知其
一妇人患热入血室证。医者不识。用补血调气药。延滞数日。遂成血结胸。或劝用小柴
胡汤。许曰。小柴胡已迟。不可行也。惟刺期门穴。斯可矣。予不能针。请善针者治之。如
言而愈。或问曰。热入血室。何为而成结胸也。许曰。邪气传入经络。与正气相搏。上下流
行。遇经水适来适断。邪气乘虚而入血室。血为邪迫。上入肝经。肝受邪则谵语而见鬼。复
入膻中。则血结于胸也。何以言之。妇人平居。血藏于肝。未受孕则下行为月水。既妊则中
蓄以养胎。已产则上壅以为乳。皆此血也。今邪气蓄血。并归肝经。聚于膻中。结于乳下。
故手触之则痛。非汤剂可及。故当刺期门也。
震按仲景伤寒论。犹儒书之大学中庸也。文词古奥。理法精深。自晋迄今。善用其书者
惟许学士叔微一人而已。所存医案数十条。皆有发明。可为后学楷模。惜限于卷帙。不能
全录。留此数则。以窥一斑。
项彦章治一人。病发热。恶风自汗。气奄奄勿属。医作伤寒治。发表退热而益剧。项诊
其脉。阴阳俱沉细。且微数。以补中益气进之。医曰。表有邪而以参 补之。邪得补而愈甚
必死此药矣。项曰。脉沉。里病也。微数者。五性之火内煽也。气不属者。中气虚也。是
名内伤。经云。劳者温之。损者益之。饮以前药而验。
震按名医类案有内伤一门。此条亦在其内。但予细观诸案所叙病证。皆与伤寒仿佛。则
其病之为伤寒为内伤。惟在医者之能辨耳。非另有一种情形也。东垣内外伤辨。殊不足凭。
诸案皆以脉为辨。大抵内伤之脉。皆虚大无力。或微数无力。其药不外补中益气汤甘温为主
有风寒加入表药。有停滞加入消导。有火亦加一二味凉药。无他奇巧。故今采取数条。编
入伤寒温暑各门。删去内伤。免滋眩惑。外感风寒者伤其形。故曰伤寒。劳役过度饮食失节
者伤其气。故曰内伤。此言受病之原也。及其为病。一般发热头疼恶风恶寒。甚则痞闷谵妄
岂可就其述病原而作凭据。医者见得真。乃能分晰之曰。彼是伤寒。此是内伤。亦如伤寒
一门为虚为实。为热为寒。头绪纷纭。听人审辨。故区而别之。不若汇而参之之有所得也。
李东垣治西台椽葛君瑞。二月中病伤寒发热。医以白虎汤投之。病者面黑如墨。本证遂
不复见。脉沉细。小便不禁。东垣初不知也。及诊之。曰。此立夏前误用白虎之故。白虎大
寒。非行经之药。不善用之。则伤寒本病。曲隐于经络之间。或更以大热之药求以去阴邪。
则他证必起。非所以救白虎也。宜用温药之升阳行经者。或难曰。误用大寒。若非大热。何
以救乎。李曰。本病隐于经络间。阳不升则经不行。经行而本证见矣。果如其言而愈。
震按东垣所谓温药之升阳者。想即桂枝、干姜、细辛、川芎、羌、防、升、柴之类耳。
误于寒药而不急救以热药。有此一法。
冯内翰之侄栎。年十六。病伤寒。目赤而烦渴。脉七八至。医欲以承气下之。东垣诊之
脉虽七八至。按之不鼓击。内经所谓脉至而从。按之不鼓。诸阳皆然。此阴盛格阳于外。
非热也。与姜附之剂。汗出而愈。
〔附〕刘宗浓曰。此与王海藏治狂言发斑。身热。脉沉细。阴症例同。东垣又有治脚膝
痿弱。下尻臀皆冷。阴汗臊臭。精滑不固。脉沉数有力。为火郁于内。逼阴内外。名阳盛拒
阴。用苦寒下之者。此水火征兆之微。脉证治例之妙也。
王海藏治侯辅之病。脉极沉细。内寒外热。肩背胸胁斑出十数点。语言狂乱。或曰。发
斑谵语。非热乎。王曰。非也。阳为阴逼。上入于肺。传之皮毛。故斑出。神不守舍。故错
语如狂。非谵语也。肌表虽热。以手按执须臾。冷透如冰。与姜附等药二十余两。乃大汗而
愈。后因再发。脉又沉迟。三四日不大便。与理中丸。三日内约半斤。其疾全愈。侯公之狂
非阳狂之狂。乃失神之狂。即阴也。
〔附〕准绳载一人。伤寒七八日。服凉药太过。遂变身凉。手足厥冷。通身黑斑。惟心
头温暖。诊其六脉沉细。昏沉不知人事。亦不能语言。状似尸厥。遂用人参三白汤。加熟附
子半枚。干姜二钱。服下一时许。斑色渐红。手足渐暖而苏醒。然黑斑有因余热不清者。又
当以黄连解毒。竹叶石膏汤调之而愈。
罗谦甫治南省参议官常德甫。至元甲戌三月间。赴大都。路感伤寒证。邀罗治之。两手
脉皆沉数。外证却身凉。四肢厥逆。发斑微紫。见于皮肤。唇及齿龈破裂无色。咽干声哑。
默默欲眠。目不能闭。反侧不安。大便闭结。此证乃热深厥亦深。变成狐惑。其证最急。询
之从者。曰。自初病感冒至今。服发汗药。汗出极多。渐至于此。罗曰。平昔膏粱。积热于
内。已燥津液。又兼发汗过多。津液重竭。因转属阳明。故大便难也。急以大承气下之。得
更衣。再用黄连解毒汤。病减大半。复与黄连犀角汤。数日而愈。
〔附〕准绳载一妇人。狐惑声哑。多眠。目不闭。恶闻食臭。不省人事。半月后。又手
足拘强。脉数而微细。先与竹沥、姜汁一盏服之。忽胸中有汗。肠鸣。即目闭省人事。遂用
参、术、归、陈。入竹沥、姜汁饮之。五六帖而愈。
震按同是狐惑证。虚实不同如此。故并录以便参考。
浙东宪使曲公病。召沧洲翁吕元膺往视。翁察色切脉。则面带阳气。寸口皆长而弦。盖
伤寒三阳合病也。以方涉海。为风涛所惊。遂血菀而神慑。血为热所搏。吐血一升许。且胁
痛烦渴谵语。适是年岁运。左尺当不应。其辅行京医。泣告其左右曰。监司脉病皆逆。不禄
在旦夕。家人皆惶惑无措。翁曰。此天和脉。无忧也。为投小柴胡汤。减参加生地黄
俟其胃实。以承气汤下之愈。
震按许学士以尺脉迟弱为营气不足。吕沧洲以左尺不应为天和脉。二义亦皆古书所载。
非二公新得。而引证恰当。各奏功效。由于诊候熟而心思灵也。
赵氏子病伤寒十余日。身热而人静。六脉尽伏。俚医以为死人也。弗与药。吕元膺诊之
三部举按皆无。其舌胎滑。而两颧赤如火。语言不乱。因告之曰。此子必大发赤斑。周身
如锦纹。夫脉血之波澜也。今血为热邪所搏。淖而为斑。外见于皮肤。呼吸之气。无形可根据
犹沟渎之水。虽有风。不能成波澜。斑消则脉出矣。及揭其衾。而赤斑烂然。即用白虎加
人参汤化其斑。脉乃复常。继投承气下之愈。发斑无脉。长沙所未论。元膺盖以意消息耳。
全本然伤寒旬日。邪入于阳明。俚医以津液外出。脉虚自汗。进真武汤实之。遂致神昏
如熟睡。其家邀元膺问死期。切其脉。皆伏不见。而肌热灼指。告其家曰。此必荣热致斑而
脉伏。非阳病见阴脉比也。见斑则应候。否则蓄血耳。乃视其隐处及小腹。果见赤斑。脐下
石坚。且痛拒按。为进化斑汤。半剂即斑消脉出。复用韩氏生地黄汤逐其血。是夕下黑血。
后三日。腹又痛。遂用桃仁承气以攻之。所下如前。乃愈。
震阅二案而知发斑蓄血。有脉伏之一候。然窃思斑未出而脉伏。理或有之。斑既透矣。
何以必待化斑脉始复耶。吴又可有脉厥之说。用承气微下则脉出。与此用白虎仿佛。但发斑
脉伏。势亦可畏。上条妙在语言不乱。次条虽神昏如睡。由于误服真武。故皆证书以医之。
翁云见斑则应候。思及蓄血。已勉强矣。
发斑情形。种种不同。再附数条以备览。
云间怀抱奇治一妇。夏月饮火酒。烦热面赤发斑。诊其脉绝无。怀曰。此火郁而热极。
用栀豉汤加葛根、浓朴、黄连清之。斑大出而脉遂见。恰与此条大同小异。又一人伤寒过经
不解。遍体黑斑。唇口焦枯。脉大便结。以三黄石膏汤饮之痊。此可与准绳所载黑斑一条合
观之。又一妇热入血室后。发斑点。以小柴胡汤加生地、丹皮获愈。又一人身热发斑。胃有
停滞。胀闷不堪。用枳、朴、消导药而斑出热退。因信朱奉议所谓凡见斑不可专以斑治。须
察脉之浮沉。病之虚实。而分别用药。真至言也。忆昔年娄县小港叶念劬兄。身热发斑不透
群用提斑药无效。予见其吐涎不止。手足软不能动。脉大无力。正合内伤发斑例。用补中
益气汤而愈。故友孝廉张素安兄尊壶身热足冷。目肿溏泄。发斑不透。其脉沉细无力。正合
阴症发斑例。用真武汤加人参而愈。此实效法海藏及准绳之治法也。然舌不燥。神不昏。故
可用温补耳。若夏秋时行疫病。又多有以大黄黄连下之而斑出者。盖内邪之壅塞。得通而斑
出。与虚寒之得温补以鼓舞而斑出。同一理也。又生平见蓝斑二人。一则脉细神昏。辞不治
其蓝斑之大者如棋子。发烂而死。一女人蓝斑。色如翠羽。咯血齿衄。舌红不干。神不昏
犹可扶行登圊。用犀角地黄汤。间以大黄微下之。后竟愈。又按龚云林治一人。夏月因劳
倦。饮食不节。又伤冷冻饮料得疾。医以时证治之不愈。至十日。苦身体沉重。四肢逆冷。自利
清谷。引衣自盖。气难布息。懒言语。此脾受寒湿。中气不足之病也。口干但欲水不欲咽。
早晨身凉而生粟。午后烦躁。不欲去衣。昏昏睡而面赤。隐隐红斑见于皮肤。此表实里虚。
故内虚则外证随时而变。遂用钱氏白术散加升麻。合本方之干葛、甘草以解其斑。少加白术
茯苓以除湿而利小便。人参、藿香、木香以安脾胃。进饮食。两服而斑退身温利止。次服
许学士治疗同乡人邱生。他患伤寒发热，头痛，心烦口渴。脉象虽然浮数但无力，尺部以下迟而弱。许学士说：
虽然有麻黄汤证（太阳表实证），但尺脉迟弱，张仲景说：尺中脉迟的，是营气不足，不可以发汗。于是使用建中汤加入当归、黄芪。
第二天脉象还是这样。邱生的家人索要发汗药，言语几乎不恭敬。许学士忍耐下来，只用建中汤调和营卫罢了。到了第五天，尺部脉象才应指有力，
于是投予麻黄汤两服。患者片刻后出现狂躁，稍定略睡，已经出汗了。确实啊，医生应当审察表里虚实，等待时日。
如果不遵循次第，临时求取疗效，亏损五脏，缩短寿命，有什么值得推崇的呢？
〔附《南史》〕范云起初担任梁武帝的属官。当时武帝有接受九锡的任命，范云忽然感染伤寒，担心不能参与庆贺之事，召
徐文伯诊视。问道：可以立刻痊愈吗？文伯说：立刻痊愈很容易，只怕两年后不起床（去世）罢了。范云说：早上听闻大道，晚上死去也可以，何况是两年呢？文伯于是先在地下烧火，铺上桃叶，铺设席子，让范云躺在上面。顷刻间出汗，用温粉扑身。第二天就痊愈了。范云非常高兴，文伯说：不值得高兴。两年后果然去世。像这种提前取汗的方法，尚且缩短寿命，何况是不顾表里，不待时日，想要快速痊愈的人呢？所以记录此案例作为警戒。
一人患伤寒，大便不通利，下午申时潮热，两手无意识地抓空，直视，喘急，经过多位医生诊治。许学士说：这确实是恶候，
见到这种情况的九死一生。张仲景虽然有这个证候但没有治法，况且已经经过吐下，难以用药。勉强救治，如果大便得通
而脉象弦，则可以存活。于是给予小承气汤一服，大便大便利，各种疾病逐渐消退，脉象微弦，半个月痊愈。有人问：攻下之后
脉象弦的能活，这是什么意思？许学士说：张仲景说：循衣摸床，惊恐不安，微喘直视，脉象弦的能活，脉象涩的死。症状轻微的只是发热谵语的，用承气汤主治。我观察钱乙的《小儿药证直诀》说：手循衣领及捻弄物品的，是肝热。此症
在张仲景书中列于阳明部。大概阳明就是胃。肝有热邪，淫溢于胃经，所以用承气汤泻之。并且得到弦脉，则
肝气平和而胃不受克制。所以有存活的道理。
〔附〕楼全善说：曾经治疗循衣摸床而痊愈的几个人，都用大补气血的药剂。只有一人兼有振颤和代脉，
于是在补剂中加入桂枝二分，也是振颤停止脉象调和而痊愈。
一人患伤寒，起初呕吐，不久被医生攻下。已经八九日，而内外发热。许学士诊察后说：应当用白虎加
人参汤。有人说：既已呕吐又攻下，应该严重虚损了。白虎汤可以用吗？许学士说：张仲景说：如果吐下后，七八日不解，
热结在里，表里俱热的，用白虎加人参汤。起初呕吐，是因为热在胃脘。现在脉象洪滑，口大渴，想喝
水，舌干燥而烦躁，非人参白虎汤不可。
一人患伤寒，心烦喜欢呕吐，寒热往来。医生用小柴胡汤给他服用，病未除。许学士说：脉象洪大而实，热结
在里，小柴胡汤怎么能去除它？张仲景说：伤寒十余日，热结在里，又寒热往来的，给大柴胡汤。三
服后病除。
一人患太阳病，因为发汗不止，恶风，小便频数，脚挛急，弯曲不能伸直。脉象浮而大。许学士说：此证
在张仲景方中有两条记载，大同小异。一条是太阳病，发汗，于是汗漏不止，恶风，小便难，四肢轻微拘急，
难以屈伸。一条是伤寒脉浮，自汗出，小便频数，心烦，微恶寒，脚挛急。一条属于漏汗小便难，一条
属于有汗小便频数，不可以混淆治疗。这应当用桂枝加附子汤。服用三次后汗止。辅以芍药甘草汤，脚就能伸直。
一个船夫患伤寒发黄，鼻内酸痛，身体和眼睛像金子一样黄，小便赤红而频数，大便正常。有人想用茵陈五苓散。
许学士说：不是正确的治法。小便调和，大便正常，就知道病不在脏腑。现在眼睛疼，鼻酸痛，是病在清道中
如果用大黄攻下，必然腹胀成为逆证。宜用瓜蒂散，先含水，然后搐鼻。鼻中黄水流尽，才痊愈。
一位武官被寇贼俘虏，关在船舱底板上，几天后逃脱，趁着饥饿大吃一顿，很久后脱衣捉虱子，第二天就患伤寒。自汗
而且膈气不利。一个医生当作伤食而攻下，一个医生当作解衣受邪而发汗。混杂治疗数日，渐渐觉得昏困，上喘息促。
许学士诊察后说：太阳病误下，表证未解，微喘的，用桂枝加厚朴杏子汤。这是张仲景的法度。命令医生治疗此
药。一服喘定，再服热缓微汗，到晚上身体凉而脉象已经调和了。医生说：我平生未曾用过张仲景方，不知道它的
一个妇人患热入血室证。医生不认识，用补血调气药，拖延数日，遂成血结胸。有人劝用小柴
胡汤。许学士说：小柴胡汤已经晚了，不可行。只有针刺期门穴，才可以。我不能针灸，请擅长针灸的人治疗。按照
说的做了而痊愈。有人问：热入血室，为什么形成结胸？许学士说：邪气传入经络，与正气相搏，上下流
行，遇到月经适来适断，邪气乘虚而入血室。血为邪气逼迫，上入肝经。肝受邪则谵语而见鬼怪，又
入膻中，则血结于胸。为什么这样说？妇人平时，血藏于肝，未受孕则下行成为月水，既怀孕则中
蓄以养胎，已生产则上壅成为乳汁，都是这个血。现在邪气蓄血，并归肝经，聚于膻中，结于乳下。
所以手触摸则痛，非汤剂可以达到，所以应当刺期门。
俞震按：张仲景的《伤寒论》，就像儒家经典的《大学》《中庸》。文词古奥，理法精深。从晋朝到现在，善用这本书的
只有许叔微一个人而已。所保存的医案几十条，都有发明，可以作为后学的楷模。可惜限于篇幅，不能
全部收录。留下这几条，以窥见一斑。
项彦章治疗一人。患发热，恶风自汗，气息奄奄不相连续。医生当作伤寒治疗，发表退热反而加重。项彦章诊
察他的脉，阴阳俱沉细，且微数。用补中益气汤进服。医生说：表有邪而以人参黄芪补之，邪气得补而更甚，
必死于此药了。项彦章说：脉沉，是里病。微数是五行之火内煽。气不相续是中气虚。这
名叫内伤。《内经》说：劳者温之，损者益之。饮用前面的药而见效。
俞震按：《名医类案》有内伤一门，这一条也在其中。但我细看诸案所叙述的病证，都与伤寒相似，那么
其病是伤寒还是内伤，只在医生能否辨别罢了。并非另有一种情形。李东垣的内外伤辨，殊不足凭信。
诸案都以脉象为辨别依据。大致内伤的脉，都虚大无力，或微数无力。其药不外乎补中益气汤甘温为主，
有风寒加入解表药，有停滞加入消导药，有火也加一二味凉药，没有别的奇巧。所以现在采取几条，编
入伤寒温暑各门，删去内伤，以免滋扰迷惑。外感风寒者伤其形，所以叫伤寒。劳役过度饮食失节
者伤其气，所以叫内伤。这是说受病的根源。等到发病，一般发热头疼恶风恶寒，甚至痞闷谵妄，
难道就根据他们叙述病因而作凭据？医生看得真切，才能分晰地说：那是伤寒，这是内伤。也像伤寒
一门有为虚为实，为热为寒，头绪纷纭，听人审辨。所以区分而别之，不如汇总而参之有所收获。
李东垣治疗西台椽葛君瑞。二月中患伤寒发热。医生用白虎汤投予。病人面色黑如墨，本证遂
不再显现。脉沉细，小便不禁。李东垣起初不知道。等到诊察后说：这是立夏前误用白虎的缘故。白虎大
寒，不是行经的药，不善用的话，则伤寒本病，曲折隐没在经络之间。或者再用大热药以求去除阴邪，
则其他证候必定兴起，这不是救白虎的方法。宜用温药的升阳行经者。有人质疑说：误用大寒，若非大热，何
以补救呢？李东垣说：本病隐没在经络间，阳不升则经不行。经行而本证显现了。果然像他说的那样痊愈。
俞震按：李东垣所说的温药之升阳者，想必就是桂枝、干姜、细辛、川芎、羌活、防风、升麻、柴胡之类。
误用寒药而不急救以热药，有此一法。
冯内翰的侄子栎，十六岁。患伤寒，目赤而烦渴，脉七八至。医生想用承气汤攻下。李东垣诊察
脉虽七八至，按之不鼓击。《内经》所谓脉至而从，按之不鼓，诸阳皆然。这是阴盛格阳于外，
不是热证。给予姜附之剂，出汗而痊愈。
〔附〕刘宗浓说：这与王海藏治疗狂言发斑，身热，脉沉细，阴症例相同。李东垣又有治疗脚膝
痿弱，下尻臀皆冷，阴汗臊臭，精滑不固，脉沉数有力，为火郁于内，逼阴外出，名阳盛拒
阴，用苦寒攻下的案例。这是水火征兆之微，脉证治例之妙。
王海藏治疗侯辅的病。脉极沉细，内寒外热，肩背胸胁斑出十数点，语言狂乱。有人说：发
斑谵语，不是热证吗？王说：不是。阳为阴逼，上入于肺，传之皮毛，故斑出。神不守舍，故错
语如狂。不是谵语。肌表虽热，用手按压片刻，冷透如冰。给予姜附等药二十余两，乃大汗而
痊愈。后来再次发作，脉又沉迟，三四日不大便。给予理中丸，三日内约半斤，其疾全愈。侯公的狂
不是阳狂的狂，乃是失神的狂，即阴证。
〔附〕《准绳》记载一人。伤寒七八日，服凉药太过，遂变身凉，手足厥冷，通身黑斑，惟心
头温暖。诊其六脉沉细，昏沉不知人事，也不能语言，状似尸厥。于是用人参三白汤，加熟附
子半枚，干姜二钱，服下一时许，斑色渐红，手足渐暖而苏醒。然而黑斑有因余热不清者，又
当以黄连解毒汤、竹叶石膏汤调治而痊愈。
罗谦甫治疗南省参议官常德甫。至元甲戌三月间，赴大都，路感伤寒证。邀请罗治疗。两手
脉皆沉数，外证却身凉，四肢厥逆，发斑微紫，见于皮肤，唇及齿龈破裂无色，咽干声哑，
默默欲眠，目不能闭，反侧不安，大便闭结。此证乃热深厥亦深，变成狐惑。其证最急。询问
随从者，说：从初病感冒至今，服发汗药，汗出极多，渐至于此。罗说：平昔膏粱厚味，积热于
内，已燥津液，又兼发汗过多，津液重竭。因转属阳明，故大便难也。急以大承气汤攻下。得排便，
再用黄连解毒汤，病减大半。复与黄连犀角汤，数日而痊愈。
〔附〕《准绳》记载一妇人。狐惑声哑，多眠，目不闭，恶闻食臭，不省人事。半月后，又手
足拘强，脉数而微细。先与竹沥、姜汁一盏服之。忽胸中有汗，肠鸣，即目闭省人事。遂用参、术、归、陈，
入竹沥、姜汁饮之，五六帖而痊愈。
俞震按：同样是狐惑证，虚实不同如此。所以一并记录以便参考。
浙东宪使曲公患病，召沧洲翁吕元膺前往诊视。翁观察面色切脉，则面带阳气，寸口皆长而弦。大概
是伤寒三阳合病。因为刚涉海，为风涛所惊，遂血菀而神慑。血为热所搏，吐血一升许。且胁
痛烦渴谵语。适是年岁运，左尺当不应。其辅行京医，哭着告诉左右说：监司脉病皆逆，不禄
在旦夕。家人皆惶惑无措。翁说：这是天和脉，无忧也。为他投予小柴胡汤，减参加生地黄，
俟其胃实，以承气汤攻下而痊愈。
俞震按：许学士以尺脉迟弱为营气不足，吕沧洲以左尺不应为天和脉。两种意义也都古书所载，
并非二位先生新得，而引证恰当，各奏功效。由于诊候熟而心思灵也。
赵氏之子患伤寒十余日，身热而人静，六脉尽伏。民间医生以为死人，不给药。吕元膺诊察
三部举按皆无。其舌苔滑，而两颧赤如火，语言不乱。因而告诉他：这孩子必定大发赤斑，周身
如锦纹。夫脉是血的波澜。现在血为热邪所搏，淖而为斑，外见于皮肤。呼吸之气，无形可根据，
犹沟渎之水，虽有风，不能成波澜。斑消则脉出矣。等到揭开他的被子，而赤斑烂然。即用白虎加
人参汤化其斑，脉乃复常。继投承气汤攻下而痊愈。发斑无脉，长沙太守张仲景所未论述。元膺盖以意消息耳。
全本然患伤寒旬日，邪入于阳明。民间医生以津液外出，脉虚自汗，进真武汤实之。遂致神昏
如熟睡。其家邀元膺问死期。切其脉，皆伏不见。而肌热灼指。告诉其家说：这必定是荣热致斑而
脉伏，不是阳病见阴脉相比。见斑则应候，否则蓄血耳。于是视其隐处及小腹，果见赤斑，脐下
石坚，且痛拒按。为进化斑汤，半剂即斑消脉出。复用韩氏生地黄汤逐其血。是夕下黑血。
后三日，腹又痛。遂用桃仁承气汤以攻之。所下如前，乃痊愈。
俞震阅二案而知发斑蓄血，有脉伏之一候。然而私下思考斑未出而脉伏，理或有之。斑既透矣，
何以必待化斑脉始复耶？吴又可曾有脉厥之说，用承气汤微下则脉出，与此用白虎汤仿佛。但发斑
脉伏，势亦可畏。上条妙在语言不乱，次条虽神昏如睡，由于误服真武汤，故皆证书以医之。
翁云见斑则应候，思及蓄血，已勉强矣。
发斑情形，种种不同。再附数条以备览。
云间怀抱奇治疗一妇人。夏月饮火酒，烦热面赤发斑。诊其脉绝无。怀说：此火郁而热极。
用栀豉汤加葛根、厚朴、黄连清之。斑大出而脉遂见。恰与此条大同小异。又一人生伤寒过经
不解，遍体黑斑，唇口焦枯，脉大便结。以三黄石膏汤饮之痊愈。此可与《准绳》所载黑斑一条合
观之。又一妇热入血室后，发斑点，以小柴胡汤加生地、丹皮获愈。又一人身热发斑，胃有
停滞，胀闷不堪。用枳壳、厚朴、消导药而斑出热退。因此相信朱奉议所谓凡见斑不可专以斑治。须
察脉之浮沉，病之虚实，而分别用药，真是至理名言。忆昔年娄县小港叶念劬兄，身热发斑不透，
群医用提斑药无效。我见他吐涎不止，手足软不能动，脉大无力，正合内伤发斑例。用补中
益气汤而痊愈。故友孝廉张素安兄尊壶身热足冷，目肿溏泄，发斑不透。其脉沉细无力，正合
阴症发斑例。用真武汤加人参而痊愈。此实效法海藏及《准绳》之治法也。然而舌不燥，神不昏，故
可用温补耳。若夏秋时行疫病，又多有以大黄黄连下之而斑出者。盖内邪之壅塞，得通而斑
出，与虚寒之得温补以鼓舞而斑出，同一理也。又生平见蓝斑二人，一则脉细神昏，辞不治
其蓝斑之大者如棋子，发烂而死。一女人蓝斑，色如翠羽，咯血齿衄，舌红不干，神不昏，
犹可扶行登圊。用犀角地黄汤，间以大黄微下之。后竟痊愈。又按龚云林治疗一人。夏月因劳
倦，饮食不节，又伤冷冻饮料得疾。医生以时证治之不愈。至十日，苦身体沉重，四肢逆冷，自利
清谷，引衣自盖，气难布息，懒言语。此脾受寒湿，中气不足之病也。口干但欲水不欲咽，
早晨身凉而生粟，午后烦躁，不欲去衣，昏昏睡而面赤，隐隐红斑见于皮肤。此表实里虚，
故内虚则外证随时而变。遂用钱氏白术散加升麻，合本方之干葛、甘草以解其斑。少加白术
茯苓以除湿而利小便。人参、藿香、木香以安脾胃。进饮食。两服而斑退身温利止。次服
Scholar Xu treated a fellow townsman, Mr. Qiu. He suffered from Shanghan (Cold Damage) with fever, headache, mental restlessness, and thirst. Although his pulse was floating and rapid, it was forceless; the chi (cun kou) position below was slow and weak. Scholar Xu said:
Although this presents as a Mahuang Tang syndrome (Taiyang exterior excess pattern), the chi pulse being slow and weak indicates that Zhang Zhongjing stated: "A chi pulse that is slow signifies insufficiency of Ying Qi (Nutritive Qi)." Sweating therapy should not be used. Instead, he employed Jianzhong Tang (Middle-Builder Decoction) added with Danggui (Angelicae Sinensis Radix) and Huangqi (Astragali Radix).
The next day, the pulse remained unchanged. The patient's family demanded sweating medicine, their words becoming almost disrespectful. Scholar Xu endured this and only used Jianzhong Tang to harmonize Ying and Wei (Nutritive and Defensive Qi). By the fifth day, the chi pulse finally responded strongly.
He then administered Mahuang Tang (Ephedra Decoction) for two doses. The patient became manic for a moment, then settled slightly and slept, after which sweat appeared. Indeed, a physician must examine the exterior and interior, deficiency and excess, and wait for the appropriate time.
If one does not follow the proper sequence but seeks temporary efficacy, damaging the five zang organs and shortening life span, what is there to praise?
[Attached from *History of the Southern Dynasties*] Fan Yun, initially an official under Emperor Wu of Liang, suddenly contracted Shanghan when the Emperor was bestowed the Nine Bestowals. Fearing he could not participate in the celebration, he summoned Xu Wenbo for diagnosis. He asked: "Can I recover immediately?" Wenbo replied: "Recovering immediately is very easy, but I fear you will not rise again in two years." Fan Yun said: "If I hear the Dao in the morning, I can die content in the evening, let alone two years." Wenbo then heated the ground with fire, spread peach leaves, laid a mat, and placed Fan Yun upon it. In an instant, sweat appeared, and warm powder was applied to his body. He recovered the next day. Fan Yun was very pleased, but Wenbo said: "There is no need to rejoice. Two years later, you will indeed pass away." Taking sweat prematurely still shortens life, let alone those who disregard the exterior and interior, do not wait for the right time, and desire rapid recovery? Therefore, this case is recorded as a warning.
One person suffered from Shanghan with difficulty in bowel movements, tidal fever in the afternoon (shen hour), unconscious grasping at empty air (clutching at bedclothes/air), staring fixedly, and急促 breathing. After several physicians had treated him, Scholar Xu said: "This is indeed a critical condition; nine out of ten die. Although Zhang Zhongjing described this syndrome without a specific treatment method, considering that purging and vomiting have already been performed, medication is difficult. If we attempt rescue, if the bowels open and the pulse becomes wiry, survival is possible." He then gave Xiao Chengqi Tang (Minor Order the Yang Treasury Decoction) once. The bowels moved freely, various symptoms gradually receded, and the pulse became slightly wiry. He recovered in half a month. Someone asked: "Why does a wiry pulse after purging indicate survival?" Scholar Xu said: "Zhang Zhongjing said: 'Clutching at clothes, terrified and uneasy, slight panting, and fixed staring; a wiry pulse indicates survival, a choppy pulse indicates death.' For mild cases with only fever and delirium, Chengqi Tang is the primary treatment. I observe in Qian Yi's *Xiao'er Yao Zheng Zhi Jue* that 'hand clutching at clothing collar and picking at objects' indicates Liver Heat. This syndrome is listed in the Yangming section by Zhang Zhongjing. Yangming refers to the Stomach. Liver heat overflowing into the Stomach meridian is why Chengqi Tang is used to purge it. Furthermore, obtaining a wiry pulse means the Liver is pacified and the Stomach is not over-controlled. Hence, there is a rationale for survival."
[Attached] Lou Quanshan said: "I once treated several people who clutched at clothes and recovered, using large tonics for Qi and Blood. Only one person also had tremors and a intermittent pulse (Dai Mai). I added two fen of Guizhi (Cinnamon Twig) to the tonic, and the tremors stopped and the pulse harmonized, leading to recovery."
One person suffered from Shanghan, initially vomiting, then shortly after being purged by a physician. It had been eight or nine days, yet there was internal and external fever. Scholar Xu diagnosed: "Baitu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) should be used." Someone said: "After both vomiting and purging, the deficiency should be severe. Can Baitu Tang be used?" Scholar Xu said: "Zhang Zhongjing said: 'After vomiting and purging, if unresolved after seven or eight days, with heat consolidated internally and both exterior and interior presenting heat, use Baitu Jia Renshen Tang.' The initial vomiting indicated heat in the stomach epigastrium. Now, with a flooding and slippery pulse, great thirst desiring water, dry tongue, and irritability, only Renshen Baitu Tang will suffice."
One person suffered from Shanghan with mental restlessness, frequent vomiting, and alternating chills and fever. A physician gave Xiaochaihu Tang (Minor Bupleurum Decoction), but the illness did not resolve. Scholar Xu said: "The pulse is flooding and solid, with heat consolidated internally. How can Xiaochaihu Tang remove it? Zhang Zhongjing said: 'In Shanghan for more than ten days, with heat consolidated internally and alternating chills and fever, administer Dachaihu Tang (Major Bupleurum Decoction).' After three doses, the illness resolved."
One person presented with Taiyang syndrome. Due to excessive sweating, he experienced aversion to wind, frequent urination, and spasmodic cramping of the legs, unable to extend them. The pulse was floating and large. Scholar Xu said: "This syndrome appears in two entries in Zhang Zhongjing's formulas, largely similar with minor differences. One is: Taiyang disease, after sweating, leakage of sweat continues, aversion to wind, difficult urination, slight stiffness of the four limbs, difficult flexion and extension. The other is: Shanghan with floating pulse, spontaneous sweating, frequent urination, mental restlessness, slight aversion to cold, and leg spasms. One belongs to leakage of wind and difficult urination; the other to spontaneous sweating and frequent urination. They cannot be treated indiscriminately. This case requires Guizhi Jia Fuzi Tang (Cinnamon Twig Plus Aconite Decoction). After three administrations, sweating stopped. Assisted by Shaoyao Gancao Tang (Peony and Licorice Decoction), the legs could extend."
A boatman suffered from Shanghan with jaundice, nasal soreness, body and eyes yellow like gold, red and frequent urination, but normal stools. Someone wanted to use Yinchen Wuling San (Artemisia Capillaris Five-Ling Powder). Scholar Xu said: "This is not the correct treatment. With harmonious urination and normal stools, we know the disease is not in the zang-fu organs. Now, eye pain and nasal soreness indicate the disease is in the clear pathways. Using Dahuang (Rhubarb) to purge would certainly cause abdominal distension and adverse effects. Use Gouti San (Melon Spore Powder). First, hold water in the mouth, then insufflate into the nose. When yellow fluid flows completely from the nose, he will recover."
A military officer was captured by bandits and confined on a boat plank. After escaping days later, he ate greedily due to hunger. Later, while undressing to catch lice, he contracted Shanghan the next day. He had spontaneous sweating and diaphragmatic obstruction. One physician treated it as food stagnation and purged him; another treated it as pathogenic invasion from undressing and induced sweating. Mixed treatments for several days led to increasing confusion and drowsiness, high-pitched wheezing. Scholar Xu diagnosed: "Taiyang disease after purging, with unresolving exterior and slight panting, requires Guizhi Houpo Xingren Tang (Cinnamon Twig, Magnolia Bark, and Apricot Seed Decoction). This is Zhang Zhongjing's method." He ordered the physician to prepare this medicine. After one dose, panting stabilized; after two doses, heat eased and slight sweat appeared. By evening, the body was cool and the pulse harmonized. The physician said: "In my life, I have never used Zhang Zhongjing's formulas; I did not know..."
A woman suffered from Re Ru Xue Shi (Heat Entering the Blood Chamber). The physician did not recognize it and used blood-tonifying and qi-regulating herbs, delaying for several days until it became Xue Jie Xiong (Blood Accumulation in the Chest). Someone advised using Xiaochaihu Tang. Scholar Xu said: "Xiaochaihu Tang is now too late; it cannot be used. Only puncturing the Qimen acupoint will work. I cannot perform acupuncture; please ask a skilled practitioner to treat her." She recovered as instructed. Someone asked: "Why does Heat Entering the Blood Chamber form Chest Accumulation?" Scholar Xu said: "Pathogenic factors enter the collaterals and contend with healthy Qi, flowing up and down. Meeting menstruation that has just started or stopped, pathogens enter the Blood Chamber due to deficiency. Blood is forced by pathogens upward into the Liver meridian. The Liver receiving pathogens causes delirium and hallucinations. Returning to the Danzhong (Chest Center), blood accumulates in the chest. Why say this? In women, blood resides in the Liver. Before pregnancy, it flows downward as menstruation; during pregnancy, it is retained internally to nourish the fetus; after childbirth, it rises upward to become milk. All this is blood. Now, pathogenic factors accumulate blood, returning to the Liver meridian, gathering at Danzhong, and knotting below the breasts. Thus, touching it causes pain. Medicine cannot reach here, so puncturing Qimen is necessary."
Yu Zhen notes: Zhang Zhongjing's *Shanghan Lun* is like the Confucian classics *Da Xue* and *Zhong Yong*. The language is ancient and profound, the principles and methods deep. From the Jin dynasty to now, only Scholar Xu Shuwei has skillfully utilized this book. The dozens of medical cases preserved all offer insights and serve as models for later learners. Regrettably limited by volume, they cannot be fully recorded. Leaving these few cases allows us to glimpse the whole.
Xiang Yanzhang treated one person suffering from fever, aversion to wind, spontaneous sweating, and faint, discontinuous Qi. Physicians treated it as Shanghan, using exterior-releasing methods to reduce fever, but the condition worsened. Xiang diagnosed the pulse as deeply submerged and fine-yin, slightly rapid in both yin and yang positions. He administered Buzhong Yiqi Tang (Middle-Boosting Qi-Enhancing Decoction). The physician said: "With exterior pathogens, using Renshen (Ginseng) and Huangqi to tonify will cause pathogens to strengthen with the tonification, leading to certain death from this medicine." Xiang said: "A submerged pulse indicates interior disease. Slight rapidity indicates internal stirring of the Five Elements' fire. Discontinuous Qi indicates deficiency of Middle Qi. This is named Neishang (Internal Injury). The *Classic* says: 'For exhaustion, warm it; for deficiency, benefit it.' Drinking the previous medicine proved effective."
Yu Zhen notes: *Mingyi Leian* has a section on Internal Injury, and this case is included therein. However, observing carefully, the syndromes described in various cases resemble Shanghan closely. Whether the disease is Shanghan or Internal Injury depends solely on the physician's ability to distinguish. It is not a separate condition. Li Dongyuan's differentiation of External and Internal Injury is hardly reliable. These cases rely on pulse differentiation. Generally, Internal Injury pulses are deficient, large, and forceless, or slightly rapid and forceless. The medications are primarily Buzhong Yiqi Tang with sweet-warm properties. Wind-cold additions include exterior-releasing herbs; stagnation additions include digestion-promoting herbs; fire additions include one or two cooling herbs. There is nothing else magical. Therefore, I have selected several cases to compile into the Shanghan, Warmth, and Summerheat sections, removing Internal Injury to avoid confusion. Exterior contraction of wind-cold damages the form, hence called Shanghan. Overwork and dietary irregularities damage Qi, hence called Internal Injury. This describes the origin of disease. Once manifested, both present with fever, headache, aversion to wind/cold, and even fullness, delirium, and madness. How can one rely merely on the narrated etiology? Only when the physician sees clearly can they distinguish: "That is Shanghan, this is Internal Injury." Just as within the Shanghan category, there are deficiencies and excesses, heat and cold, with complex threads requiring careful discrimination. Thus, categorizing them separately is less fruitful than compiling and comparing them.
Li Dongyuan treated Ge Junrui, a clerk of the Western Terrace. In mid-spring, he contracted Shanghan with fever. A physician administered Baitu Tang (White Tiger Decoction). The patient's face turned black as ink, and the original symptoms disappeared. The pulse was submerged and fine, with urinary incontinence. Li Dongyuan initially did not understand. Upon diagnosis, he said: "This is due to the mistaken use of Baitu Tang before Lixia (Start of Summer). Baitu Tang is extremely cold and not a meridian-traveling medicine. Misuse causes the original Shanghan pathology to hide曲折ly within the meridians. Using extremely hot medicines to dispel yin pathogens would likely cause other syndromes to arise; this does not rescue the effects of Baitu Tang. One should use warming medicines that raise Yang and travel through meridians." A skeptic asked: "If mistakenly used with extreme cold, how can extreme heat rescue it?" Li said: "The original pathology hides in the meridians. If Yang does not rise, meridians do not flow. When meridians flow, the original symptoms appear." It healed exactly as he predicted.
Yu Zhen notes: Li Dongyuan's "warming medicines that raise Yang" were likely Cinnamon Twig, Dried Ginger, Asarum, Ligusticum, Notopterygium, Saposhnikovia, Bupleurum, and Cimicifuga. Mistakenly using cold medicines without urgent rescue with hot medicines, this is one method.
The nephew of Hanlin Academician Feng, Yue, aged sixteen, suffered from Shanghan with red eyes, mental restlessness, and thirst. The pulse was seven or eight beats per breath. A physician wanted to purge with Chengqi Tang. Li Dongyuan diagnosed: "Although the pulse is seven or eight beats, pressing it reveals no drumming force. The *Neijing* states: 'Pulse arrives following the condition, but pressing reveals no drumming; this applies to all Yang conditions.' This is Yin excess repelling Yang to the exterior, not heat. He administered Ginger and Aconite preparations, and recovery followed sweating."
[Attached] Liu Zongnong said: "This is similar to Wang Haicang's treatment of delirium with macules, fever, and submerged-fine pulse, classified as Yin Syndrome. Li Dongyuan also treated weakness of legs and knees, coldness of buttocks and hips, foul-smelling genital sweat, and seminal emission with a submerged-rapid-forceful pulse, identifying it as Fire郁 (Stagnant) internally forcing Yin outward, named Yang Excess Rejecting Yin, treated with bitter-cold purgatives. This illustrates the subtlety of Water-Fire signs and the excellence of pulse-syndrome-treatment examples."
Wang Haicang treated Hou Fu. The pulse was extremely submerged and fine, with internal cold and external heat. Macules appeared on shoulders, back, chest, and ribs, numbering over ten. Speech was chaotic and manic. Someone said: "Macules and delirium are not heat?" Wang said: "No. Yang is forced by Yin, rising to the Lung, transmitting to skin and hair, thus macules appear. Spirit fails to reside in its house, thus confused speech resembling mania, not true delirium. Although skin surface is hot, pressing with hand for a moment reveals cold penetrating like ice. He administered over twenty taels of Ginger and Aconite, resulting in profuse sweating and recovery. Later, it relapsed with a submerged-slow pulse and constipation for three to four days. He administered Lizhong Wan (Regulate the Middle Pill). Consuming about half a jin within three days, the illness completely resolved. Hou Gong's mania was not Yang mania, but loss of spirit mania, i.e., Yin syndrome."
[Attached] *Zhunsheng* records one person. After seven or eight days of Shanghan, taking cooling medicines excessively caused body temperature to drop, cold extremities, black macules over the whole body except warmth at the heart. Six pulses were submerged and fine, coma, unconsciousness, inability to speak, resembling corpse-like syncope. Ren Shen San Bai Tang (Ginseng Three Whites Decoction) plus half a prepared Fuzi (Aconite Root) and two qian of Ganjiang (Dried Ginger) were administered. After about an hour, macule color gradually reddened, extremities warmed, and consciousness returned. However, some black macules are due to lingering residual heat, which should be regulated with Huanglian Jiedu Tang (Coptis Detoxification Decoction) and Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction) for recovery.
Luo Qianfu treated Chang Defu, Counselor of the Southern Province. In March of Ji Xu year, traveling to Dadu, he contracted Shanghan. Luo treated him. Both hands' pulses were submerged and rapid, yet externally the body was cool, extremities cold, faint purple macules visible on skin, lips and gums cracked and colorless, dry throat, hoarse voice, silent desire to sleep, eyes unable to close, restless turning, constipation. This syndrome is "Heat deep, Cold deep," transforming into Huhe (Chancroid/Ulcerative syndrome). It is most urgent. Asking attendants, he learned: "From initial cold to now, sweating medicines were taken, causing excessive sweating, gradually leading to this state." Luo said: "Usually consuming rich foods, accumulating heat internally, drying fluids. Combined with excessive sweating, fluids are doubly exhausted. Thus transferring to Yangming, causing difficult defecation." Urgently purged with Da Chengqi Tang (Major Order the Yang Treasury Decoction). After defecation, Huanglian Jiedu Tang was used, reducing illness by half. Then Huanglian Xijiao Tang (Coptis and Rhinoceros Horn Decoction) was given, recovering in several days.
[Attached] *Zhunsheng* records a woman with Huhe, hoarseness, hypersomnia, eyes unable to close, aversion to food odor, unconsciousness. Half a month later, limb rigidity, rapid and fine pulse. First administered one cup of Bamboo Juice and Ginger Juice. Suddenly, sweat appeared in the chest, borborygmus occurred, eyes closed, and consciousness returned. Then Renshen, Baizhu, Danggui, and Chenpi were added to Bamboo and Ginger Juice drink. After five or six doses, she recovered.
Yu Zhen notes: Both are Huhe syndromes, yet different in deficiency and excess. So recording both for reference.
Qu Gong, Constitutional Commissioner of Eastern Zhejiang, fell ill. Cangzhou Weng, Lu Yuanying, was summoned. Observing complexion and pulse, Lu saw Yang Qi on the face, and cunkou pulses long and wiry. It was likely a combined disease of the three Yang channels of Shanghan. Having just crossed the sea, startled by wind and waves, blood became congested and spirit frightened. Blood contended with heat, causing hematemesis of about one sheng. Also胁 pain, restlessness, thirst, and delirium. Coinciding with the annual运气 (climate cycle), the left chi should not respond. His accompanying capital physician cried and told relatives: "The monitor's pulse and illness are contrary; death is imminent." Family was panicked. Lu said: "This is Tianhe Pulse (Natural Harmony Pulse), no worry." He administered Xiaochaihu Tang, reducing Renshen dosage and adding Shengdihuang (Rehmannia Root). Waiting for stomach solidity, he purged with Chengqi Tang, leading to recovery.
Yu Zhen notes: Scholar Xu considered slow-weak chi pulse as Ying Qi insufficiency; Lu Cangzhou considered non-responsive left chi as Tianhe Pulse. Both meanings are recorded in ancient books, not new discoveries of the two gentlemen, but citations were appropriate, each achieving efficacy. This is due to familiar diagnostic skills and agile thinking.
Son of Zhao family suffered from Shanghan for over ten days, fever but quiet demeanor, six pulses completely submerged. Folk doctors thought him dead and gave no medicine. Lu Yuanying diagnosed: No pulse felt in lifting or pressing in three positions. Tongue coating slippery, malar flush red like fire, speech coherent. He told them: "This boy will surely develop extensive red macules, body like brocade. Pulse is the wave of blood. Now blood is contended by heat pathogens, becoming macules, appearing externally on skin. Breath is formless, like water in ditches; though windy, it cannot form waves. When macules disappear, pulse will emerge." Uncovering him revealed bright red macules. Immediately, Baitu Jia Renshen Tang was used to transform macules, pulse then returned to normal. Subsequently, Chengqi Tang was administered for purging, leading to recovery. Macules without pulse was not discussed by Changsha [Zhang Zhongjing]; Yuanying likely inferred this.
Quan Benran suffered from Shanghan for ten days, pathogens entering Yangming. Folk doctors, seeing fluids exiting, deficient pulse, and spontaneous sweating, administered Zhenwu Tang to tonify. This led to coma resembling deep sleep. Family invited Yuanying to ask about death date. Pulses were submerged and unseen, skin hot burning fingers. Told family: "This is likely Ying heat causing macules and submerged pulse, not comparable to Yang disease showing Yin pulse. Seeing macules should correspond to prognosis; otherwise, it is Blood Accumulation." Inspecting hidden areas and lower abdomen, red macules were indeed seen, hardness like stone below navel, painful and rejecting pressure. Huaban Tang (Transform Macules Decoction) was administered. Half a dose, macules faded, pulse emerged. Then Han Shi Shengdihuang Tang (Han's Rehmannia Root Decoction) was used to expel blood. That night, black blood was passed. Three days later, abdominal pain recurred. TaoRen Chengqi Tang (Apricot Seed Chengqi Decoction) was used to purge. Passage was as before, then recovery.
Yu Zhen reviewed these two cases and knew that macules and blood accumulation have a sign of submerged pulse. However, pondering privately, submerged pulse before macules emergence might be logical. But once macules are transparent, why must pulse recovery wait until macules transform? Wu Youke proposed "Pulse Jue" (Extinction), where slight purging with Chengqi Tang makes pulse emerge, similar to using Baitu Tang here. But macules with submerged pulse is formidable. The first case's brilliance lies in coherent speech; the second, though comatose like sleep, was due to mistaken Zhenwu Tang, so both were treated based on confirmed evidence. Lu saying "seeing macules corresponds to prognosis" and thinking of blood accumulation was already forced.
Macule manifestations vary greatly. Attaching a few more cases for review.
Huai Baoqi from Yunjian treated a woman. In summer, drinking fiery wine, she had mental restlessness, red face, and macules. Pulse was absent. Huai said: "This is Fire stagnation with extreme heat." Used Zhichi Tang (Gardenia and Fermented Soybean Decoction) added with Gegen (Kudzu Root), Houpo (Magnolia Bark), and Huanglian (Coptis) to clear. Macules erupted extensively, and pulse appeared. Largely similar to this case. Another person had Shanghan passing stages unresolved, black macules all over, dry scorched lips and mouth, constipated stool. Sanhuang Shigao Tang (Three Yellows and Gypsum Decoction) cured him. This can be viewed together with the black macule case in *Zhunsheng*. Another woman, after Heat Entering Blood Chamber, developed macules; recovered with Xiaochaihu Tang added with Shengdihuang and Mudanpi. Another person with fever and macules had gastric stagnation, unbearable distension. Using Zhike, Houpo, and digestion-promoting herbs resulted in macule eruption and heat reduction. Thus believing Zhu Fengyi's saying: "Whenever macules appear, do not treat macules exclusively. Must examine pulse floating/sinking, disease deficiency/excess, and medicate accordingly." Truly profound words. Recalling brother Ye Ningqu from Xiaogang, Louxian, years ago, with fever and incomplete macule eruption, many doctors used macule-elevating medicines without effect. I saw him spitting saliva incessantly, soft limbs unable to move, large forceless pulse, fitting the Internal Injury Macule example. Buzhong Yiqi Tang cured him. Late friend Zhang Su'an, elder brother Zunhu, had fever, cold feet, swollen eyes, loose stools, incomplete macules. Pulse submerged, fine, forceless, fitting Yin Syndrome Macule example. Zhenwu Tang added with Renshen cured him. This effectively follows Haicang and *Zhunsheng* methods. However, tongue not dry, spirit not confused, so warm tonification can be used. If summer-autumn epidemic diseases, many have macules emerging after purging with Dahuang and Huanglian. Because internal pathogen obstruction, getting unblocked leads to macule emergence, same principle as deficiency-cold getting warm tonification to encourage macule emergence. Also, in my life, I saw two people with blue macules. One, fine pulse, confused spirit, refused treatment; large blue macules like chess pieces, rotted and died. One woman with blue macules, color like kingfisher feathers, hemoptysis, epistaxis, red tongue not dry, spirit not confused, could still walk to toilet. Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction) was used, occasionally slight purging with Dahuang. Eventually recovered. Also, Gong Yunlin treated one person. In summer, due to fatigue, irregular diet, and injury from cold drinks, illness ensued. Treated as seasonal disease without success. By tenth day, suffering heavy body, cold extremities, spontaneous diarrhea with undigested food, pulling clothes to cover, difficult breathing, lazy to speak. This is Spleen affected by Cold-Damp, insufficient Middle Qi disease. Mouth dry, wanting water but not swallowing. Morning body cool with gooseflesh, afternoon irritability, unwilling to remove clothes, drowsy with red face, faint red macules on skin. This is exterior excess, interior deficiency. Thus interior deficiency causes exterior symptoms to change with time. Used Qian Shi Baizhu San (Qian's Atractylodes Macrocephala Powder) added with Shengma (Cimicifuga), combined with Gan Ge (Kudzu) and Gancao (Licorice) from this formula to resolve macules. Added small amounts of Baizhu and Fuling to drain dampness and promote urination. Renshen, Huoxiang, and Muxiang to calm Spleen and Stomach. Advance diet. Two doses, macules retreated, body warmed, diarrhea stopped. Next dose...