张戴人治HT 阳刘氏男子。年二十余。病劳嗽咯血。吐唾粘臭不可闻。秋冬少缓。春夏则
甚。寒热往来。日晡发作。状如 疟。寝汗如水。累服麻黄根、败蒲扇止汗。汗自若也。又
服宁神散、宁肺散止嗽。嗽自若也。戴人先以独圣散涌其痰。痰如鸡黄。汗随涌出。昏愦三
日不醒。时时饮以凉水。精神稍开。饮食加进。乃与桂苓甘露饮、人参半夏丸。服之不辍。
数日乃愈。
又治东门高三郎。咳嗽年半。耳鸣三月矣。嗽脓血。面多黑 。身热。喉中不能发声。
戴人曰。嗽之源。心火之胜也。秋伤于湿。冬生咳嗽。冬水既旺。水湿相接。隔绝于心火。火不下降。反而炎上。肺金
被烁。发而为嗽。金 既久。声不能发。医
者补肺肾。皆非也。令备西瓜、冰雪等物。乃用涌泄之法。继以去湿之药。病日已矣。
丹溪治一男子。三十五岁。因连夜劳倦不得睡。感嗽疾。痰如黄白脓。嗽声不出。时初
春大寒。医与小青龙汤四帖。觉咽喉有血腥气上逆。遂吐血线自口中左边出一条。顷遂止。
如此每一昼夜十余次。诊其脉弦大散弱。左大为甚。人倦而苦于嗽。丹溪云。此劳倦感寒。
因服燥热之剂以动其血。不急治。恐成肺痿。遂与参、 、术、归、芍、陈皮、炙甘草、生
甘草、不去节麻黄。煎成。入藕汁。服两日而病减嗽止。却于前药去麻黄。又与四帖。而血
证除。脉之散大未收敛。人亦倦甚。食少。遂于前药去藕汁。加黄芩、砂仁、半夏。至半月
而安。
丹溪治一人。年五十余。患咳嗽。恶风寒。胸痞满。口稍干。心微痛。脉浮紧而数。左
大于右。盖表盛里虚。问其素嗜酒肉。有积。后因接内。涉寒冒雨忍饥。继以饱食酒肉而病
先用人参四钱。麻黄连根节一钱五分。与二三帖。嗽止寒除。改用浓朴、枳实、青陈皮、
栝蒌、半夏为丸。参汤送下。痞除。
震按咳嗽痰血声不出。今人不过养阴清肺而已。有敢用吐下药者哉。又敢用参、 、归
术、麻黄者哉。至如暴嗽恶风寒。其脉证皆属表邪。而其因则系里虚。今人不过轻剂散之
和之而已。敢以人参、麻黄并用哉。然非麻黄、人参并用。势必淹缠日久。合于伤风不醒积
成痨之说矣。可见善医者法门广大无边。不善医者小心与大胆均误也。
汪石山治一妇。年三十。质弱。产后咳嗽痰臭。或作肺痈治。愈剧。两脚渐肿至膝。大
便溏泄。小腹胀痛。午后发热。面红气促。不能向右卧。汪诊脉虚小而数。曰。凡咳嗽左右
向不得眠者。上气促下泄泻者。发热不为泻减者。皆逆候也。按此病原于脾。经曰。脾主诸
臭。入肺为腥臭。入心为焦臭。入肝为腐臭。自入为秽臭。盖脾不能营运其湿。湿郁为热。
酿成痰之臭也。经曰。左右者。阴阳之道路。脾虚则肺失所养。气劣行迟。壅遏道路。故咳
嗽气促。不能右卧也。脾虚必夺母气以自养。故心虚发热而见于午也。脾主湿。湿胜则内渗
于肠胃为溏泄。外渗于肌肉为浮肿。今用参、术、甘草补脾为君。茯苓渗湿为臣。麦冬保肺
气。枣仁安心神为佐。陈皮、前胡消痰下气为使。东壁土受阳气最多。用之为引。盖土能解
诸臭。亦能补土。取钱氏黄土汤之义也。服一帖。前病略减。病者喜。汪曰未也。过时失治
午后发热。真阳脱矣。泄而脚肿。脾气绝矣。必数服后无反复。方是佳兆。
震按难经本文。心主臭。入肝为臊臭。入肾为腐臭。入脾为香臭。盖腐即秽也。汪公以
臊臭作腐臭。香臭作秽臭。换易字面。牵合已说。殊属未妥。何不于酿成痰臭之下。继之曰
脾虚则土陷水中。反现所胜之脏之臭而秽也。第其立方。专主于补。不用清热药以解臭。而
佐东壁土以解臭。洵是高手。
又按脾臭主香者。如无病患见饮食。自有馨香气味。即脾脏本体之臭为用也。若病患见
饮食。不以为香。反以为恶。是脾失其职。体变而用亦变也。此义汪公未曾详说。
一人年十九。面白质弱。因劳思梦遗。遂吐血碗余。自是微咳倦弱。后忽身发大热。出
疹。疹愈。阴囊痒甚。搓擦水流。敷以壁土。囊肿如盏大。遂去土。以五倍子涂少蜜。炙燥
为末敷之。遂愈。复感风寒。其嗽尤甚。继以左右胁痛。石山诊其脉虚而数。外证畏风寒。
呕恶。倦动。粪溏气促。曰。此金极似火也。夫心属火而藏神。肾属水而藏志。二经俱属少
阴。而上下相通。今劳思则神不宁而梦。志不宁而遗。遗则水不升而火独亢也。肝属木。主
藏血。其象震。震为雷。心火既亢。同类相应。引动龙雷之火。载血而溢出于上窍矣。肝脉
环绕阴器。亦因火扰而痛痒肿胀也。火胜金。故肺经虚而干咳。皮毛为肺之合。更因火郁而
发疹。大肠为肺之府。故亦传导失宜而粪溏。金虚不能平木。木火愈旺而凌脾。脾虚则呕恶
食减。经曰。壮火食气。脾肺之气为壮火所食。故倦于动作。而易感风寒也。经言。两胁者
阴阳往来之道路也。为火阻碍。则气不利而痛矣。然火有虚有实。有似火而实非火。故经言
有者求之。无者求之。虚者责之。实者责之。此治火大法。前证之火。皆虚火也。非水湿所
能折。惟甘温之剂。可以祛除。且经言形寒饮冷则伤肺。又谓脾胃喜温而恶寒。当用甘温健
其脾。则肺经不虚。而咳嗽气促自愈。肝木有制。而咳嗽吐血自除。虚妄之火亦自息矣。以
参各四钱。神曲、山楂各七分。白术、麦冬、贝母各一钱。甘草五分。炒干姜四分。服十
余帖。脉数减。嗽渐平。
震按此证似宜养阴。其复感风寒。似宜清理。即见识高者。亦必先以轻剂解表。后用养
阴健脾。乃汪公竟进参、 各四钱。佐干姜少许。岂今人所能及哉。脉数减。嗽渐平。信非
熟地、阿胶所能胜任。
薛立斋治儒者张克明咳嗽。用二陈、芩、连、枳壳。胸满气喘。清晨吐痰。加苏子、杏
仁。口出痰涎。口干作渴。薛曰。侵晨吐痰。脾虚不能消化饮食也。胸满气喘。脾虚不能生
肺金也。涎沫自出。脾虚不能收摄也。口干作渴。脾虚不能生津液也。遂用六君、炮姜、肉
果补脾。更用八味丸以补土母。而愈。
震按此条不载脉象。以意度之。脉必虚数。观前医之用芩、连。脉数可知矣。若脉虚软
不数。谁不能用六君、八味哉。汪薛二公高处在此。然又不可奉为秘诀。请阅后述诸案。便
知法非一例。
〔附〕韩飞霞旅寓北方。夏秋久雨。天行咳嗽头痛。用天水散。以葱姜汤调服。应手取
效。日发数十斤。此盖甲己土运。湿令痰壅肺气上窍。但泻膀胱下窍而已。不在咳嗽例也。
李士材治太学史明 。经年咳嗽。历医无效。自谓必成虚痨。李曰。不然。脉不数不虚
惟右寸浮大而滑。是风痰未解。必多服酸收。故久而弥盛。用麻黄、杏仁、半夏、前胡、
桔梗、甘草、橘红、苏子。五剂知。十剂已。
张远公三年久嗽。服药无功。委命待尽。偶遇士材而乞诊。李曰。饥时胸中痛否。远公
曰。大痛。视其上唇白点如粞者十余处。此虫啮其肺。用百部膏一味。加乌梅、槟榔与服。
不十日而痛若失。咳顿止矣。令其家人从净桶中觅之。有寸白虫四十余条。自此不复发。
孙东宿治许卓峰。多酒多怒人也。上吐血。下溲血。咳嗽声哑。医皆以为瘵。辞不治。
孙诊其脉。左关弦大。右寸下半指。累累如薏苡子状。乃曰。此有余证也。作瘵治者非。盖
其人好酒。酒属湿热。助火生痰。火性炎上。迫肺不降。积而生痰。壅于肺窍。以致失音。
此痰壅之哑。非肺痿之哑也。其性又多怒。怒气伤肝。故血妄行而不归经。以致吐血尿血。
法宜清热开郁化痰。导血归原。若二地、二冬辈滋阴之药。反助其塞而益其热。声音何由而
开。况血随气行。气不清。血又何得归原哉。乃用滑石、青蒿。解酒热为君。贝母、郁金、
山栀仁、香附。开郁为臣。杏仁、桔梗、丹皮、丹参、小蓟、甘草。化痰清血为佐使。服十
帖。血果止。又以贝母一两。童便浸一日。为末。柿霜等分。时时抄舌上化下。五日而声音
爽矣。
张路玉治包山金孟珍。正月间。忽咳吐清痰。咽痛。五六日后。大便下瘀晦血甚多。延
至十余日。张诊其脉。六部皆沉弦而细。此水冷金寒之候也。遂与麻黄附子细辛汤。其血顿
止。又与麻黄附子甘草汤。咽痛亦可。而觉心下动悸不宁。询其受病之源。乃醉卧渴引冷冻饮料
所致。改用小青龙去麻黄加附子。悸即止。咳亦大减。但时吐清痰一二口。乃以桂、酒制白
芍。入真武汤中与之。咳吐俱止。尚觉背微恶寒倦怠。更与附子汤二剂而安。
震按咽痛下血。不以风火治。而以辛温燥热药始终获效者。由其善于识脉也。
又治礼科姜如农长媳。喘咳无痰。灼热自汗。而怀妊七月。先曾服和解清肺药二十余剂
其咳转剧。胎渐不安。邀张诊之。六脉皆濡大无力。右手寸关独盛而涩。曰。此热伤肺气
也。反与和解药。逼令汗出。致肺气益燥而咳逆愈甚。不得已。复用苦寒折之。则火转郁伏
而不散也。遂用大剂葳蕤。及川芎、杏仁、白薇、甘草。取葳蕤汤之半。更以当归、桔梗、
五味、黄 。益气生津。固肌敛肺。二剂汗止咳减。胎亦向安。更加生诃子皮。四剂而痊。
又治吴佩玉次女。伤风咳嗽。先前自用疏风润肺止嗽之药。不应。转加呕渴咽痛。石顽
诊之。六脉浮滑应指。因与半夏散三啜而病如失。或问咳嗽咽痛而渴。举世咸禁燥剂。今用
半夏辄效。何也。曰。用药之权衡。非一言而喻也。凡治病必求其本。此风邪挟饮上攻之暴
嗽。故用半夏、桂枝。开通经络。迅扫痰涎。兼甘草之和脾胃而致津液。风痰散。营卫通。
则咽痛燥渴自已。设泥其燥渴而用清润。滋其痰湿。经络愈壅。津液愈结。燥渴咽痛。愈无
宁宇矣。不独此也。近世治风寒咳嗽。虽用表药。必兼桑皮、黄芩、花粉。甚则知、柏之类
少年得之。必种吐血虚损之根。中年以后得之。多成痰火喘嗽之患。然此辈之妙用。在于
预为地步。诊时泛谓阴虚。防变不足之证。初时元气未衰。服之邪热暂伏。似觉稍可。久之
真
气渐伤。转服转甚。安虑其不成虚损耶。及见吐血。则不问何经腑脏。属火属伤。血之散结
色之晦鲜。瘀之有无。概以犀角地黄寒凉止截之剂投之。致血蓄成根。向后或二月一月一
发。虽日服前药不应矣。凡此之类。未遑枚举。尝见一人患项肿发热。延伤寒家视之。则曰
大头伤寒。以表药发之。并头亦胀。确然大头无疑矣。病家以其治之益甚。又延杂证家视之
则曰湿热痰火。以里药攻之。则头与项前左半皆消。但项后右侧偏肿。则又确乎非大头而
为杂证矣。病家又以肿在偏旁。疑为痈毒。更延痈疽家视之。则曰对口偏疽。以托里敷外药
治之。则气血益滞。热不得泄。郁遏竟成溃疡矣。本一病也。治之迥异。证亦屡迁。可见其
病随药变之不诬耳。第末俗所趋。非此不足以入时。何怪乎圣人性命之学。沦胥不返。遂至
若是耶。
震按张公此论。曲尽时医丑态。然谓表药必兼桑皮、芩、粉。血证必用犀角、地黄。恐
不至众人皆醉如此。至于病随药变。实有其事。所以旧有不服药为中医之说。若欲见病知源
投药辄效。随其寒热虚实。应以温凉补泻。不执一法。不胶一例。变化生心。进退合辙者
其惟丹溪先生乎。丹溪则药随病变。病随药愈。宁有病随药变。药为病困之理哉。临证指
南咳嗽门。方法大备。温凉补泻皆全。而轻松灵巧处。与丹溪未易轩轾也。
张戴人治疗阳刘氏的一位男子，二十多岁。患有虚劳咳嗽并咯血，吐出的唾液粘稠且气味恶臭难闻。秋冬季节病情稍缓，春夏季节则加重。出现寒热往来，每天下午发作，症状像疟疾一样。夜间盗汗如水般流出。多次服用麻黄根、败蒲扇来止汗，但出汗依旧。又服用宁神散、宁肺散来止咳，咳嗽依旧。戴人先用独圣散催吐痰涎，吐出的痰像鸡黄一样浓稠，汗液随着催吐随之排出。患者昏迷三天不醒，期间不时喂饮凉水，精神逐渐清醒，饮食也增加了。接着给予桂苓甘露饮、人参半夏丸，连续服用，几天后痊愈。
又治疗东门高三郎。咳嗽半年多，耳鸣三个月了。咳出脓血，面色发黑，身体发热，喉咙中无法发声。戴人说：“咳嗽的根源，是心火过盛所致。秋季感受湿邪，冬季产生咳嗽。冬季水气旺盛，水湿相接，隔绝了心火，导致心火不能下降，反而炎上灼烧。肺金被灼烧，引发咳嗽。肺金受损日久，声音无法发出。医生们补益肺肾，都不对。”让他准备西瓜、冰雪等物，于是采用涌泄（催吐和泻下）的方法，继以祛湿的药物，病情日渐好转。
朱丹溪治疗一名男子，三十五岁。因连夜劳累不得睡眠，感染咳嗽病，痰像黄白色的脓液，咳嗽声出不来。当时正值初春大寒，医生给他服用了四帖小青龙汤，感觉咽喉有血腥气上逆，随即吐血，从口中左边流出一条血线，不久便停止。如此一天一夜发生十几次。诊察他的脉象弦大散弱，左侧尤为明显。人疲倦且苦于咳嗽。丹溪说：“这是劳倦感寒，因为服用了燥热的药物而动血。如果不紧急治疗，恐怕会形成肺痿。”于是给予人参、白术、当归、白芍、陈皮、炙甘草、生甘草、不去节的麻黄。煎好后，加入藕汁，服用两天后病情减轻，咳嗽停止。随后在前药中去掉麻黄，又给四帖，血证消除。但脉象散大未收敛，人也十分疲倦，食量减少。于是又在前方中去掉藕汁，加入黄芩、砂仁、半夏。半个月后康复。
丹溪治疗一人，五十多岁。患咳嗽，怕风怕冷，胸脘痞闷胀满，口稍干，心脏微痛，脉象浮紧而数，左侧大于右侧。这是表实里虚。问他平时嗜好酒肉，体内有积滞。后来因房事，冒雨忍饥，接着又饱食酒肉而发病。先用人参四钱，麻黄连根节一钱五分，给二三帖，咳嗽停止，寒气消除。改用厚朴、枳实、青皮、陈皮、瓜蒌、半夏制成丸药，用人参汤送服，痞闷消除。
俞震按语：咳嗽伴有痰血、声音不出，现在的人不过是用养阴清肺的方法罢了。有谁敢用吐下药呢？又有谁敢用人参、白术、当归、麻黄呢？至于突发咳嗽、怕风怕冷，其脉证都属于表邪，但其病因却是里虚。现在的人不过是用轻剂发散和解罢了。谁敢将人参、麻黄并用呢？然而如果不是麻黄、人参并用，势必缠绵日久，符合“伤风不醒积成痨”的说法了。可见善于治病的医生法门广大无边，不善于治病的医生，无论是小心还是大胆都会出错。
汪石山治疗一位妇女，三十岁。体质虚弱，产后咳嗽痰臭。有人当作肺痈治疗，病情反而加剧。两脚逐渐肿胀至膝盖，大便溏泄，小腹胀痛，午后发热，面红气促，不能向右侧卧。汪诊察脉象虚小而数，说：“凡是咳嗽左右侧卧都不得安眠，上气喘促下泄泻，发热不因泄泻而减低的，都是逆证。”考察此病源于脾。经书说：脾主各种臭味。湿气入肺为腥臭，入心为焦臭，入肝为腐臭，自入为秽臭。大概是脾不能运化湿气，湿气郁结化为热，酿成痰的臭味。经书说：左右是阴阳的道路。脾虚则肺失去滋养，气力衰弱运行迟缓，壅塞在道路，所以咳嗽气促，不能向右卧。脾虚必然掠夺母脏（心）之气来自养，所以心虚发热表现在午时。脾主湿，湿胜则内渗于肠胃成为溏泄，外渗于肌肉成为浮肿。现在用人参、白术、甘草补脾作为君药，茯苓渗湿作为臣药，麦冬保肺气，枣仁安心神作为佐药，陈皮、前胡消痰下气作为使药。东壁土受阳气最多，用它作为引经药。因为土能解诸臭，也能补土，取钱乙黄土汤的意思。服用一帖，前面的病略见减轻，病人很高兴。汪石山说：“还不行。如果过时失治，午后发热，是真阳脱绝；泄泻且脚肿，是脾气绝灭。必须经过几服药后没有反复，才是好兆头。”
俞震按语：《难经》原文说：心主臭。入肝为臊臭，入肾为腐臭，入脾为香臭。大概腐就是秽。汪公把臊臭换成腐臭，把香臭换成秽臭，换易字面，牵合自己的说法，很不妥当。为什么不接着说：脾虚则土陷水中，反现所胜之脏（肾）的臭味而变为秽臭呢？只是他立方，专门主张补益，不用清热药来解臭，而是佐以东壁土来解臭，确实是高手。
又按语：脾的臭味主香，如果没有病患看见饮食，自然有馨香气味，这就是脾脏本体之臭的作用。如果病患看见饮食，不觉得香，反而觉得厌恶，这是脾失去了职能，体变而用也变了。这个意思汪公未曾详细说明。
一人十九岁，面白体质弱。因劳思梦遗，于是吐血一碗多。从此轻微咳嗽疲倦虚弱。后来忽然身体发大热，出疹子。疹子退去后，阴囊瘙痒严重，搓擦出水流，敷以壁土，阴囊肿胀如盏大，于是去掉土，用五倍子涂少许蜂蜜，烤干研末敷之，于是痊愈。又感受风寒，咳嗽更加严重。接着左右胁痛。石山诊察他的脉象虚而数，外证畏风寒，呕吐恶心，疲倦懒动，大便溏泄气促。说：“这是金极似火。”心属火而藏神，肾属水而藏志。二经都属于少阴，上下相通。现在劳思则神不宁而做梦，志不宁而遗精。遗精则水不升而火独亢。肝属木，主藏血，其象为震，震为雷。心火既已亢盛，同类相应，引动龙雷之火，载血而上溢出于上窍。肝脉环绕阴器，也因火扰而痛痒肿胀。火胜金，所以肺经虚而干咳，皮毛为肺之合，更因火郁而发疹。大肠为肺之府，所以传导失宜而大便溏泄。金虚不能平抑木，木火愈旺而欺凌脾。脾虚则呕吐恶心食量减少。经书说：壮火食气。脾肺之气被壮火所食，所以疲倦于动作，而易感风寒。经书说：两胁是阴阳往来的道路。被火阻碍，则气不利而疼痛。然而火有虚有实，有似火而实非火。所以经书说：有者求之，无者求之，虚者责之，实者责之。这是治火的大法。前面的证候之火，都是虚火，不是水湿所能折服的，只有甘温的药剂，可以祛除。而且经书说：形寒饮冷则伤肺，又说脾胃喜温而恶寒。应当用甘温健其脾，则肺经不虚，而咳嗽气促自愈。肝木有制，而咳嗽吐血自除，虚妄之火也自然平息了。用人参各四钱，神曲、山楂各七分，白术、麦冬、贝母各一钱，甘草五分，炒干姜四分。服用十余帖，脉数减少，咳嗽渐渐平稳。
俞震按语：此证似乎适宜养阴，其复感风寒，似乎适宜清理。即使是见识高的人，也必定先用轻剂解表，后用养阴健脾。然而汪公竟然进用参、术各四钱，佐以少许干姜。难道是今人能及得上的吗？脉数减，咳嗽渐平，确实不是熟地、阿胶所能胜任的。
薛立斋治疗儒者张克明咳嗽。使用二陈汤加黄芩、黄连、枳壳，出现胸满气喘，清晨吐痰，加苏子、杏仁，口出痰涎，口干作渴。薛立斋说：“侵晨吐痰，是脾虚不能消化饮食。胸满气喘，是脾虚不能生肺金。涎沫自出，是脾虚不能收摄。口干作渴，是脾虚不能生津液。”于是使用六君子汤、炮姜、肉果补脾。更用八味丸以补土母（补肾），而痊愈。
俞震按语：这一条没有记载脉象，凭意推测，脉必虚数。看前医使用芩、连，可知脉数。如果脉虚软不数，谁不能用六君子、八味丸呢？汪、薛二位公的高明之处在此，但又不可奉为秘诀。请阅读后面所述的医案，就知道法非一例。
〔附〕韩飞霞旅居北方。夏秋久雨，天行咳嗽头痛。使用天水散，用葱姜汤调服，应手取效。每天吐出数十斤痰。这大概是甲己土运，湿令痰壅肺气上窍，只泻膀胱下窍而已。不在咳嗽例中。
李士材治疗太学史明。经年咳嗽，历医无效。自认为必成虚劳。李士材说：“不对。脉不数不虚，惟右寸浮大而滑，是风痰未解，必须多服酸收药物，所以久而更盛。”使用麻黄、杏仁、半夏、前胡、桔梗、甘草、橘红、苏子。五剂见效，十剂痊愈。
张远公三年久嗽，服药无功，委命待尽。偶遇士材乞求诊治。李士材问：“饥饿时胸中痛吗？”远公说：“很痛。”看他上唇白点如米粒者十余处。这是虫啮其肺。使用百部膏一味，加乌梅、槟榔与服。不到十日而痛若失，咳嗽顿止。让家人从净桶中找，有一寸白虫四十余条。自此不再复发。
孙东宿治疗许卓峰。多酒多怒的人。上吐血，下尿血，咳嗽声哑。医生都以为是痨病，推辞不治。孙诊察他的脉，左关弦大，右寸下半指，累累如薏苡子状。于是说：“这是有余证。当作痨病治是不对的。大概此人好酒，酒属湿热，助火生痰。火性炎上，迫肺不降，积而生痰，壅于肺窍，以致失音。这是痰壅之哑，不是肺痿之哑。他的性格又多怒，怒气伤肝，所以血妄行而不归经，以致吐血尿血。法宜清热开郁化痰，导血归原。如果用二地、二冬辈滋阴的药，反而助其塞而益其热，声音何由而开？况且血随气行，气不清，血又何得归原哉？”于是使用滑石、青蒿，解酒热为君药；贝母、郁金、山栀仁、香附，开郁为臣药；杏仁、桔梗、丹皮、丹参、小蓟、甘草，化痰清血为佐使药。服用十帖，血果然停止。又以贝母一两，童便浸一日，研末，柿霜等分，时时抄舌上化下，五日而声音清爽了。
张路玉治疗包山金孟珍。正月间，忽然咳吐清痰，咽痛。五六日后，大便下瘀晦血甚多。延至十余日，张诊察他的脉，六部皆沉弦而细。这是水冷金寒的候象。于是给予麻黄附子细辛汤。其血顿时停止。又给予麻黄附子甘草汤，咽痛也可缓解，但觉心下动悸不宁。询问其受病之源，乃是醉卧渴引冷冻饮料所致。改用小青龙汤去麻黄加附子。悸即止，咳嗽也大大减轻。但时常吐清痰一二口，于是以桂枝、酒制白芍，入真武汤中与服。咳吐俱止。尚觉背微恶寒倦怠，更给予附子汤二剂而安。
俞震按语：咽痛下血，不以风火治，而以辛温燥热药始终获效，是因为他善于识脉。
又治疗礼科姜如农的长媳。喘咳无痰，灼热自汗，而怀妊七月。先前曾服和解清肺药二十余剂，其咳转剧，胎渐不安。邀张诊之。六脉皆濡大无力，右手寸关独盛而涩。说：“这是热伤肺气。”反与和解药，逼令汗出，致肺气益燥而咳逆愈甚。不得已，复用苦寒折之，则火转郁伏而不散也。于是使用大剂葳蕤，及川芎、杏仁、白薇、甘草，取葳蕤汤之半。更以当归、桔梗、五味子、黄芪。益气生津，固肌敛肺。二剂汗止咳减，胎亦向安。更加生诃子皮，四剂而痊。
又治疗吴佩玉次女。伤风咳嗽，先前自用疏风润肺止嗽之药，不应。转加呕渴咽痛。石顽诊之。六脉浮滑应指。因而给予半夏散三啜而病如失。有人问：咳嗽咽痛而渴，举世咸禁燥剂，今用半夏辄效，为什么呢？回答说：“用药之权衡，非一言而喻也。凡治病必求其本。此风邪挟饮上攻之暴嗽，故用半夏、桂枝，开通经络，迅扫痰涎，兼甘草之和脾胃而致津液。风痰散，营卫通，则咽痛燥渴自已。设泥其燥渴而用清润，滋其痰湿，经络愈壅，津液愈结，燥渴咽痛，愈无宁宇矣。不独此也。近世治风寒咳嗽，虽用表药，必兼桑皮、黄芩、花粉，甚则知母、黄柏之类。少年得之，必种吐血虚损之根。中年以后得之，多成痰火喘嗽之患。然此辈之妙用，在于预为地步。诊时泛谓阴虚，防变不足之证。初时元气未衰，服之邪热暂伏，似觉稍可。久之真气渐伤，转服转甚，安虑其不成虚损耶。及见吐血，则不问何经腑脏，属火属伤，血之散结色之晦鲜，瘀之有无，概以犀角地黄寒凉止截之剂投之。致血蓄成根，向后或二月一月一发，虽日服前药不应矣。凡此之类，未遑枚举。尝见一人患项肿发热，延伤寒家视之，则曰大头伤寒，以表药发之，并头亦胀，确然大头无疑矣。病家以其治之益甚，又延杂证家视之，则曰湿热痰火，以里药攻之，则头与项前左半皆消。但项后右侧偏肿，则又确乎非大头而为杂证矣。病家又以肿在偏旁，疑为痈毒，更延痈疽家视之，则曰对口偏疽，以托里敷外药治之，则气血益滞，热不得泄，郁遏竟成溃疡矣。本一病也，治之迥异，证亦屡迁，可见其病随药变之不诬耳。第末俗所趋，非此不足以入时，何怪乎圣人性命之学，沦胥不返，遂至若是耶。”
俞震按语：张公此论，曲尽时医丑态。然而谓表药必兼桑皮、芩、粉，血证必用犀角、地黄，恐不至众人皆醉如此。至于病随药变，实有其事。所以旧有不服药为中医之说。若欲见病知源，投药辄效，随其寒热虚实，应以温凉补泻，不执一法，不胶一例，变化生心，进退合辙者，其惟丹溪先生乎。丹溪则药随病变，病随药愈，宁有病随药变，药为病困之理哉。临证指南咳嗽门，方法大备，温凉补泻皆全，而轻松灵巧处，与丹溪未易轩轾也。
Zhang Dairen treated a man surnamed Liu from Yang, in his twenties. He suffered from consumptive cough with hemoptysis, and the saliva he expectorated was sticky and had an unbearable foul odor. The condition eased slightly in autumn and winter but worsened in spring and summer. He experienced alternating chills and fever, occurring daily in the late afternoon, resembling malaria (malaria-like symptoms). He suffered from night sweats profuse as water. Multiple administrations of Mahuang Gen (Ephedrae Radix et Rhizoma) and Baipu Shan (Pennisetum Spicatum Inflorescence) to stop sweating were ineffective; the sweating persisted. Subsequent use of Ning Shen San (Soothing Spirit Powder) and Ning Fei San (Calming Lung Powder) to stop coughing also failed; the cough continued. Zhang first employed Dusheng San (Single Miracle Powder) to induce vomiting (emesis) for phlegm. The vomited phlegm resembled chicken yolk. Sweating occurred simultaneously with the emesis. The patient fell into a coma for three days without regaining consciousness. During this time, cool water was administered intermittently. Gradually, his spirit cleared, and his appetite improved. Then, Guiling Ganlu Yin (Cassia Twig, Poria, and Talc Decoction) and Renshen Banxia Wan (Ginseng and Pinellia Pill) were prescribed continuously. After several days, he recovered.
He also treated Gao Sanlang from Dongmen. The man had been coughing for over half a year and had experienced tinnitus for three months. He expectorated pus and blood, had a dark complexion, suffered from body heat, and could not produce sound from his throat. Zhang stated, "The root of the cough lies in the excess of Heart Fire. Injury by dampness in autumn leads to cough in winter. When Winter Water is prosperous, water and dampness connect, isolating the Heart Fire. Because the Fire cannot descend, it flares upward instead. The Lung Metal is scorched, triggering the cough. Due to prolonged damage to the Lung Metal, voice production fails. Physicians who tonify the Lung and Kidney are incorrect." He instructed the preparation of watermelons and ice/snow. He then applied methods of emesis and purgation (vomiting and draining), followed by dampness-dispelling herbs. The illness gradually resolved.
Zhu Danxi treated a thirty-five-year-old man. Due to sleepless nights caused by overwork, he contracted a cough disease. His phlegm resembled yellow-white pus, and his cough was hoarse/inaudible. It was early spring with severe cold. A physician administered four doses of Xiao Qinglong Tang (Minor Blue Dragon Decoction). He felt a bloody odor rising in his throat, followed by hemoptysis where a stream of blood flowed from the left side of his mouth, stopping shortly after. This occurred more than ten times a day and night. His pulse was wiry, large, scattered, and weak, especially on the left. He was fatigued and distressed by the cough. Danxi said, "This is due to fatigue-induced cold invasion, aggravated by dry-heat herbs that disturbed the blood. If not treated urgently, it may develop into Lung萎 (Lung Flaccidity)." He prescribed Renshen (Ginseng), Baizhu (Atractylodes Macrocephala), Danggui (Angelica Sinensis), Shaoyao (Peony Root), Chenpi (Tangerine Peel), Zhigancao (Honey-fried Licorice), Shenggancao (Raw Licorice), and Mahuang (Ephedra) with nodes retained. After decoction, Ouzhi (Lotus Root Juice) was added. After two doses, the illness lessened, and the cough stopped. Mahuang was then removed from the formula, and four additional doses were given, eliminating the bleeding. However, the pulse remained scattered and large, and the patient was very fatigued with poor appetite. Ouzhi was removed, and Huangqin (Scutellaria Root), Sharen (Amomum Fruit), and Banxia (Pinellia Tuber) were added. Recovery occurred within half a month.
Danxi treated another man, over fifty years old, suffering from cough, aversion to wind and cold, chest fullness and distension, slight dryness of the mouth, and mild heart pain. The pulse was floating, tight, and rapid, larger on the left than the right. This indicated exterior excess and interior deficiency. He was known to indulge in alcohol and meat, leading to internal accumulation. Later, after sexual intercourse, exposure to rain, hunger, and subsequent heavy meals of alcohol and meat, the illness began. Initially, Qian qian of Renshen (Ginseng) and 1.5 qian of Mahuang Lian Gen Jie (Ephedra with roots and nodes) were given for two to three doses. The cough stopped, and the cold sensation vanished. Thickopium (Houpo), Zhishi (Immature Bitter Orange), Qingpi (Green Tangerine Peel), Chenpi (Tangerine Peel), Gualou (Trichosanthes Fruit), and Banxia (Pinellia Tuber) were made into pills, taken with Renshen decoction. The chest fullness resolved.
Yu Zhen commented: For cough with phlegm-blood and loss of voice, contemporary physicians merely employ Yin-nourishing and Lung-clearing methods. Who dares to use emetic or purgative drugs? Who dares to combine Renshen, Baizhu, Danggui, and Mahuang? In cases of sudden cough with aversion to wind and cold, the pulse and symptoms indicate exterior pathogenic factors, yet the etiology involves interior deficiency. Contemporary physicians use only mild dispersing and harmonizing agents. Who dares to combine Renshen and Mahuang? Without this combination, the condition would likely linger, aligning with the saying that unresolved wind-cold accumulates into consumption. Thus, skilled physicians possess boundless methodologies, whereas incompetent ones err whether cautious or bold.
Wang Shishan treated a thirty-year-old woman with a weak constitution. Postpartum, she suffered from cough with foul-smelling phlegm. Treatment as Lung Abscess (Fei Yong) exacerbated the condition. Her legs swelled up to the knees, she had loose stools, lower abdominal pain, afternoon fever, facial redness, shortness of breath, and inability to lie on her right side. Wang palpated a deficient, small, and rapid pulse. He stated, "Inability to sleep in any position due to cough, upper shortness of breath with lower diarrhea, and fever unrelieved by diarrhea are all adverse signs." He traced the origin to the Spleen. The Classics state: The Spleen governs odors. Dampness entering the Lung causes fishy odor; entering the Heart, scorched odor; entering the Liver, putrid odor; and internally, foul odor. Essentially, the Spleen fails to transport dampness, which stagnates and transforms into heat, brewing foul-smelling phlegm. The Classics also state: Left and right are the pathways of Yin and Yang. Spleen deficiency deprives the Lung of nourishment; Qi becomes weak and slow, obstructing these pathways, causing cough and shortness of breath, preventing lying on the right. Spleen deficiency steals Qi from its mother organ (Heart) for self-nourishment, causing Heart deficiency heat manifesting at noon. Spleen governs dampness; excess dampness infiltrates the intestines causing loose stools and muscles causing edema. He prescribed Renshen, Baizhu, and Gancao (Licorice) to tonify the Spleen as Sovereign herbs; Fuling (Poria) to leach out dampness as Minister herbs; Maidong (Ophiopogon Tuber) to protect Lung Qi and Suanzaoren (Ziziphus Seed) to calm the Spirit as Assistant herbs; Chenpi (Tangerine Peel) and Qianhu (Peucedanum Root) to resolve phlegm and direct Qi downward as Envoy herbs. Earth from the east wall, receiving abundant Yang Qi, was used as a guide. Earth resolves various odors and tonifies the Spleen, following the principle of Qian Yi's Huangtu Tang (Yellow Earth Decoction). After one dose, symptoms slightly improved. Wang warned that if treatment were delayed, afternoon fever would indicate True Yang collapse, and diarrhea with leg swelling would indicate Spleen Qi exhaustion. Only after several doses without recurrence would it be a good omen.
Yu Zhen commented: The Nan Jing states the Heart governs odors: Liver corresponds to rank odor, Kidney to putrid odor, Spleen to fragrant odor. Wang substituted rank with putrid and fragrant with foul, forcing his theory. He should have explained that Spleen deficiency causes Earth to sink into Water, revealing the odor of the conquered organ (Kidney) as foul. Nevertheless, his prescription focused solely on tonification, avoiding cooling herbs for odor, and using East Wall Earth, demonstrating high skill.
Furthermore, the Spleen's natural odor is fragrant; healthy individuals find food aromatic. Patients who find food repulsive exhibit Spleen dysfunction, where form changes and function alters. Wang did not elaborate on this.
A nineteen-year-old man, pale and weak, suffered massive hemoptysis (over a bowl) due to mental exertion and nocturnal emissions. He developed mild cough and weakness. Later, he had high fever and rash. After the rash subsided, his scrotum became severely itchy, weeping fluid. Applying wall earth reduced swelling. Removing the earth, he applied Wubeizi (Galla Chinensis) mixed with honey, dried and powdered, applied topically, curing the itch. Subsequently, he caught wind-cold, worsening the cough, followed by bilateral hypochondriac pain. Wang palpated a deficient and rapid pulse. External signs included aversion to wind/cold, nausea, fatigue, loose stools, and shortness of breath. Wang diagnosed "Metal extreme resembling Fire." Heart belongs to Fire and houses the Spirit; Kidney belongs to Water and houses Will. Both belong to Shaoyin, connecting upper and lower. Mental exertion disturbs the Spirit (dreams) and Will (emissions). Emissions prevent Water from ascending, leaving Fire hyperactive. Liver belongs to Wood, stores Blood, and corresponds to Zhen (Thunder). Hyperactive Heart Fire resonates with Wood, stirring Dragon-Thunder Fire, carrying blood upward through orifices. Liver meridians surround the genitals, causing pain/itch/swelling from Fire disturbance. Fire conquers Metal, causing Lung deficiency and dry cough. Skin, the exterior of Lung, develops rash from trapped Fire. Large Intestine, the Fu organ of Lung, suffers impaired transmission, causing loose stools. Lung deficiency fails to control Wood; Wood-Fire overwhelms Spleen, causing nausea/poor appetite. As stated, "Blazing Fire consumes Qi," explaining fatigue and susceptibility to wind-cold. The hypochondrium is the pathway of Yin-Yang exchange; Fire obstruction causes Qi stagnation and pain. Fire can be deficient or excess. The Classics advise investigating presence/absence and deficiency/excess. These cases involved Deficient Fire, not subdued by water/dampness, requiring sweet-warm formulas. Since "cold injury damages Lung" and "Spleen/Stomach prefer warmth," sweet-warm herbs tonify Spleen, benefiting Lung, resolving cough/shortness of breath, controlling Liver-Wood, stopping hemoptysis, and extinguishing deficient fire. Prescription: Renshen and Baizhu 4 qian each; Shenqu and Shanzha 0.7 qian each; Baizhu, Maidong, Beimu 1 qian each; Gancao 0.5 qian; Chao Ganjiang (Fried Dried Ginger) 0.4 qian. After ten-plus doses, rapid pulse decreased, cough stabilized.
Yu Zhen commented: This case seemed suitable for Yin-nourishing, and subsequent wind-cold for clearing. Even skilled physicians would use mild exterior-releasing agents first, then Yin-nourishing and Spleen-tonifying. Wang’s bold use of large doses of Renshen and Baizhu with Ganjiang is impressive. The improvement confirms that Shudi (Rehmannia) and Ejiao (Donkey-hide Gelatin) would not suffice.
Xue Lizhai treated scholar Zhang Keming for cough. Using Erchen Tang plus Huangqin, Huanglian, and Zhike resulted in chest fullness, wheezing, morning phlegm expectoration. Adding Suzi and Xingren led to salivation, dry mouth, and thirst. Xue stated: "Morning phlegm indicates Spleen deficiency failing to digest food. Chest fullness/wheezing indicates Spleen deficiency failing to generate Lung Metal. Salivation indicates Spleen deficiency failing to secure fluids. Dry mouth/thirst indicates Spleen deficiency failing to generate body fluids." He prescribed Liujun Zi Tang (Six Gentlemen Decoction) with Paojiang (Baked Ginger) and Rouguol (Myristica Seed) to tonify the Spleen, followed by Bawei Wan (Eight Ingredient Pill) to tonify the Mother of Earth (Kidney). The patient recovered.
Yu Zhen commented: Pulse was not recorded, but likely deficient and rapid, inferred from previous use of cooling herbs. If the pulse were soft and non-rapid, anyone could use Liujunzi or Bawei. The insight of Wang and Xue is valuable but not a rigid secret. Subsequent cases show varied methods.
[Appendix] Han Feixia, traveling in the North, suffered epidemic cough and headache during prolonged summer-autumn rains. He used Tianshui San (Tianshui Powder), taken with Scallion-Ginger decoction, achieving immediate effect. He expectorated dozens of jin of phlegm daily. This relates to Ji-Ji Earth transport and dampness causing Phlegm congestion in Lung Qi orifices, resolved by draining the Bladder lower orifice. It falls outside standard cough categories.
Li Shicai treated Shi Ming, a Grand Secretary, for chronic cough unresponsive to many physicians. Shi feared consumptive disease. Li stated: "Incorrect. The pulse is neither rapid nor deficient; the Right Cun is floating, large, and slippery, indicating unresolved Wind-Phlegm. Long-term use of sour-astringents caused worsening." He prescribed Mahuang, Xingren, Banxia, Qianhu, Jiegeng, Gancao, Juhong, and Suzi. Improvement after five doses, cure after ten.
Zhang Yuangong suffered chronic cough for three years, unresponsive to medicine, awaiting death. Li asked: "Does your chest hurt when hungry?" Zhang: "Severely." Li observed ten white spots like rice grains on the upper lip. Diagnosis: Worms gnawing the Lung. He prescribed Baibu Gao (Stemonae Extract) alone, plus Wumei (Mume Fruit) and Binglang (Areca Seed). Pain ceased in ten days, cough stopped. Forty tapeworms were found in the chamber pot. No recurrence.
Sun Dongsu treated Xu Zhuofeng, a man indulging in alcohol and anger. He had upper hemoptysis and lower hematuria, with hoarse cough. Physicians diagnosed tuberculosis and refused treatment. Sun palpated a wiry-large Left Guan pulse and a bead-like Right Cun pulse. He diagnosed Excess Syndrome, rejecting tuberculosis diagnosis. Alcohol generates Damp-Heat and Fire, producing Phlegm. Fire flares upward, forcing Lung Qi down, accumulating Phlegm in Lung orifices, causing aphonia due to Phlegm congestion, not Lung Flaccidity. Anger injures Liver, causing reckless Blood flow (hemoptysis/hematuria). Treatment required clearing Heat, opening Stagnation, resolving Phlegm, and guiding Blood back to channels. Yin-nourishing herbs (Dihuang, Maidong) would worsen congestion and Heat. Since Blood follows Qi, unclear Qi prevents Blood return. Prescription: Huashi (Talcum) and Qinghao (Artemisia Annua) to clear alcohol-Heat as Sovereign; Beimu, Yujin, Zhizi Ren (Gardenia Seed), and Xiangfu (Cyperus Rhizome) to open Stagnation as Ministers; Xingren, Jiegeng, Danpi (Moutan Cortex), Danshen (Salvia Root), Xiaoji (Small Thistle), and Gancao to resolve Phlegm and clear Blood as Assistants/Envoys. After ten doses, bleeding stopped. Further treatment: Beimu soaked in Child’s Urine for one day, powdered, mixed equally with Shishuang (Persimmon Frost), held on tongue. Voice cleared in five days.
Zhang Luzhu treated Jin Mengzhen. In January, sudden cough with clear phlegm and sore throat. Five-six days later, passage of large amounts of dark瘀 blood. After ten-plus days, Zhang palpated deep, wiry, thin pulses in all positions. Diagnosed Cold Water and Cold Metal. Prescribed Mahuang Fuzi Xixin Tang (Ephedra, Aconite, and Asarum Decoction). Bleeding stopped immediately. Followed by Mahuang Fuzi Gancao Tang. Sore throat improved, but palpitations arose. Etiology: Drinking frozen beverages while drunk and thirsty. Changed to Xiao Qinglong Tang minus Mahuang plus Fuzi. Palpitations ceased, cough greatly reduced. Occasional clear phlegm remained. Added Guizhi (Cinnamon Twig) and Jiubaishao (Wine-processed Peony) to Zhenwu Tang. Cough/phlegm stopped. Mild back chills and fatigue persisted. Two doses of Fuzi Tang brought stability.
Yu Zhen commented: Sore throat and bleeding treated successfully with acrid-warm-dry herbs despite not being Wind-Fire cases, demonstrates Zhang’s pulse diagnostic skill.
He also treated the eldest daughter-in-law of Councilor Jiang Runong. She had wheezing cough without phlegm, burning heat, and spontaneous sweating, at seven months pregnancy. Previous twenty-plus doses of harmonizing/Lung-clearing herbs worsened cough and threatened fetus. Pulses were soggy, large, and forceless; Right Cun/Guan were particularly strong and choppy. Zhang diagnosed Heat injuring Lung Qi. Harmonizing herbs forced sweating, drying Lung Qi further. Bitter-cold herbs would trap Fire. He used large doses of Weirui (Polygonatum), Chuanxiong, Xingren, Baiwei, and Gancao (half of Weirui Tang). Added Danggui, Jiegeng, Wuweizi (Schisandra), and Huangqi (Astragalus) to tonify Qi, generate fluids, secure muscle, and astringe Lung. Two doses reduced sweating/cough, fetus stabilized. Added raw Heqizi (Chebula Epicarp) skin. Four doses cured.
He also treated Wu Peiyu’s second daughter. Wind-cold cough, unresponsive to self-administered wind-dispersing/moistening herbs. Symptoms worsened to vomiting, thirst, and sore throat. Shiwan palpated floating-slippery pulses. Prescribed Banxia San (Pinellia Powder) three times; illness vanished. Questioned why Banxia worked despite contraindications for thirst/cough. Answer: Treatment seeks the root. This was acute cough from Wind-Evil carrying Fluid retention attacking upward. Banxia and Guizhi opened meridians, swept phlegm, while Gancao harmonized Spleen/Stomach to generate fluids. Once Wind-Phlegm dispersed and Ying-Wei circulated, sore throat/thirst resolved. Using moistening herbs would nourish Dampness, clog meridians, and worsen symptoms. Modern physicians treating wind-cold cough often add Sangbai Pi, Huangqin, and Huafen, even Zhimu/Huangbai. Youth suffer hemoptysis/consumption roots; middle-aged suffer Phlegm-Fire wheezing. While these herbs prevent Yin-deficiency transformation, initial Yuan Qi is intact, so Heat hides temporarily. Long-term use injures True Qi, worsening condition into consumption. Upon hemoptysis, indiscriminate use of Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) causes Blood stasis, leading to recurrent bleeding. Various misdiagnoses (Big Head Plague vs. Damp-Heat vs. Carbuncle) illustrate how disease changes with medication. Popular trends favor such practices, corrupting sacred medical arts.
Yu Zhen commented: Zhang’s critique exposes contemporary flaws. However, claiming all exterior treatments require Sangbai Pi/Huangqin/Huafen, and all bleeding cases use Xijiao/Dihuang, is an exaggeration. Disease changing due to medication is real, supporting the saying "not taking medicine is the best medicine." To see disease source and treat effectively requires adapting warming/cooling/tonifying/draining to cold/heat/deficiency/excess, without rigidity. Only Danxi achieved such flexibility. Danxi’s approach allowed medicine to follow disease changes, ensuring recovery. The Linzheng Zhinan Cough section offers comprehensive methods comparable to Danxi.