后经了解，那位医生认为痧毒已经入里内陷，虽在透疹之期，已非透发所能引邪外泄。当务之急是毒邪化火，病涉营分，而阴液亏损，出现液劫化燥，肝风蠢动，非大剂凉营解毒，养阴清热，难剎其威。处方用的是：鲜生地、淡豆豉、丹皮、鲜石斛、鲜芦茅根、川连、大黄、山栀、连翘蕊等，并以紫雪丹冲服。据说，患儿服药后，大便畅解一次，色褐、气味臭秽，旋即全身微汗潮润，疹点亦得外透，从而身热渐退，气喘渐平，烦躁转宁，抽风止，神志清，病情向愈。
麻疹在出诊期应用透法，这是谁也不会否认的。但透疹的方法很多，如辛温宣透，辛凉宣透，益气透托等等，而未见有用苦寒泻下者。细审该证系有毒热炽盛，痧邪不从外泄，必致内陷。毒热化火，液劫风生，「炎」虽在肺，而毒在阳明。清热解毒，固为常法，但「杯水车薪」，无济于事。所以不用「扬汤止沸」之法，而用「釜底抽薪」之计。故事后细想，我的过失，就在于不能知常达变。
(二)诊病不尚「四诊」，岂能辨证小儿腹泻的主要成因，外为暑湿所感，内多乳食中伤，病在脾胃。发病机理则为清阳不升，浊阴不降，清浊混淆，升降失司，故见泄利或伴呕恶。其因偏于暑热者，多伴发热，症见暴注下迫，湿邪偏盛者，则为洞泄稀水；乳食内伤，粪便气秽，多挟残渣；若素体脾虚，中阳不振，则见淡黄溏便，其若出现脾虚术旺之虚风证者，则属险候。
一般泄泻，治有常法，毋庸赘述。而因泻伤耗胃阴者，必有明显的烦躁口干等症象出现，临床易于防范，对损脾伤阳，产生慢睥风时，可导致卒然脱变者，则往往措手不及。故对各类腹泻之防治，务必随时注意有否伤阳之先兆，及时护卫脾阳，此对婴幼儿腹泻更为关键。曾冶一患儿，五个月，因泄泻三天，干恶不进乳食而就诊。此时患儿「安睡」在摇篮里，既不哭，又不闹，颇似「安静」，两目张开，若有「左右盼顾」之状，微有摇首，额有微汗，前囟不高，舌干，偶有弄舌状，肌肤干滑，并不灼热，肢端欠温，呼吸时不粗亦不急，偶有叹气状。询之家长云：前两天大便如稀水，口夜二十余次，刻已减少，夹有绿色粘液，本有哭闹烦躁，现已安静，惟有干恶不食。当时其家长认为病情已在好转，再服些药，可以好得快一些。而我未细致审察，仅凭家长代诉而处方，不料家属上街买药尚未回来，而孩子已经死了。第三天消息传来，外面沸沸扬扬地对我评头论足：「连快要死的人都看不出来，还医得好病?」
我对这一病例有两点教训：首先是主观上的失职，未能按四诊的要求去诊察病，第二是识见浅薄，缺乏实际的临床经验。所以，当病儿出现表情淡漠、摇首弄舌的虚风内动，以及额汗肢冷、呼吸深长等慢脾风的临危症候(现在想来，可能已是失水、酸中毒，伴有循环障碍的休克症状)毫不觉察，焉有不偾事者l
(三)临证慌张，缺乏沉着果断有一例患者，病已六日，仍头裹包巾，拥被怕风，面红耳赤，日干喜凉饮，声音略有嘶哑，自诉头痛如裂，心中烦热，遍身如披杖，转侧不利。近两天来大便溏泄，按其脉浮而数，察其舌，苔白上盖黄色，质尖红，咽部红肿，见其状，呼吸气促，摸其肌肤，灼手无汗，而下肢反觉不温。病者起病突然，属外感时病无疑。其突出的证情为头痛、骨楚、恶风、喜冷饮。属何证为主，当时颇费思索。考仲景有「身体疼烦，不能自转侧」与「恶风不欲去衣」的条文，似属「风湿相搏」证。但风湿方中均有桂枝、附子之大辛大热，与舌干、渴喜凉饮，药不符症。如从烦渴喜冷饮、呼吸气喘、肌肤灼热的里热实证着手，然苔无老黄，底白不厚，腹软不按痛，且大便溏泄，则热邪无入腑之证。虽有大渴，但尚恶风无汗，亦非阳明经的白虎汤证，因白虎汤有「其表不解，不可与」禁例。若以麻黄汤先解其表，再清其里，阅遍麻黄汤证却无渴饮提及。同时咽红声嘶，温热之证显而易见，如投辛温，则势同「抱薪救火」。又思表寒不解，里热已炽，咳而气喘，则麻杏甘石汤可谓对症矣。思维再三，拟用麻杏甘石汤。《伤寒论》中有两条明文，一为下后，一为汗后，即「汗出而喘，无大热」者，明确指出了该方的适应症在于表证已罢之时。此例患者麻杏甘石亦非对症之方，似用大青龙汤较为合拍。由于认识不清，识见浅陋，拿不定主见，重剂怕担风险，更怕腾讥医坛，肇事生变，乃以一般辛凉解表之稳妥轻趔与之。究因药不对症，病情有增无减，乃改延前辈老医两剂药而痊愈。窥其方果然是大青龙汤。
考大青龙条文所叙，十之八九为麻黄汤之脉证，所增者惟「烦躁」两字而已。原文中又有「不汗出而烦躁者」，说明烦躁的由来为不汗出。大青龙汤之所以获效，系解其表寒又清里热，有其症用其方。
窃思该病之所以日益鸥张者，乃起病之初，未能及时投以麻黄汤。因寒邪郁表，病在太阳，应汗不汗，郁而生热，从当初之微热口渴，继则转为渴饮凉水，咽喉略痛，进为咽喉红肿，声音嘶哑。腠理闭塞，内生之热，更无外泄之门路。因此，炎肺则喘，下趋则便泄，种种见证，概括为「表寒里热」四字而已。事后羞愧倍至，自惭读其书丽不究其义，临证慌张，无沉着审辨胆大心细的果断精神，兼之心怀私念，岂医道之所能容忍。
学人之长断以己律
书本上的经验，固然要学，而老师朋辈中的实践心得，更为可贵。故凡有「一事长己者，不远千里，服膺取决」。治学精神，贵在不耻下问，才能真正学到别人「刀口」上的经验。
(一)片言只语，都有「零金碎玉」曾治一例失眠患者，颧红升火，彻夜烦躁不宁。多次投以平肝潜阳，养心宁神之剂，连服十多天，药沉大海，并无寸效。老师就在我原方中加入猪胆汁、龙胆草双重苦昧药，仅服三剂，即能安然入睡，霍然病愈。老师谓：「虚火宜潜，实火宜泄。该病有颧红升火，烦躁不宁者，即肝胆有实火也。」
又一例女童尿潴留，长期导屎，引起下阴严重感染，外阴部红肿溃破，迭经中西药物并治，小便仍滑滴不下，痛苦万分，邀我诊治。认证湿火下注，经治一周，病情未见改善，反而增加肢体浮肿，呼吸气粗，恶风发热。乃请同窗老友会诊，他详询病情，反复检阅所有处理方法，思考再三，若有所悟，告余日：「此实『提壶揭盖』之证也。」即疏生黄芪20克，桔梗18克，升麻、生甘草各9克，浓煎代茶，少量多次口服，并以生银花、生甘草煎汤熏洗下阴，每日二至三次。三至四灭后，小便已能自剎，取出导尿管，嗣后阴部肿胀溃破处亦得逐渐消退愈合。
「提壶揭盖」法，为癃闭少尿症中属于气虚下陷者，理法并非陌生，而下阴部红肿溃破，明为温火证，加之小便涓消，似与证情有违。孰知肺主一身之气化，肺气不足，气化岂能下达州都。生黄芪配伍升麻、桔梗，既益其气，又举其陷。且黄芪托毒消肿，对久溃不敛之疮疡有生肌收口作用，为外科之要药。医学是至精至微一门学问，由于读书不十分仔细，不求甚解，圆圈脊枣，就会成为头痛医头、脚病治脚的庸医。
(二)点滴经验，实包含着普遍性规律在内「痢无止法」是一个普遍性规律，但并非所有的痢疾病人，都不能用止和补的方法。「暴痢属实」，「久痢多虚」，也是基本的规律，但亦不能奉为一成不变的定律。
忆随师诊治一痢疾患者，缠绵病榻已三月余，形瘦骨立。夏秋患病，已值隆冬，痢仍不止，赤白夹杂，兀行无度，量少不爽，腹痛后重，纳食则恶，胃气索然，面色萎黄，精神极为疲弱，舌苔干而呆白，质淡红，边有碎腐。遍阅前方，皆为补涩止痢，亦有温运脾胃者。当时认证：中气已虚，邪毒内踞，鸨阴耗伤，脾阳已困。欲导其积，正气益伤，温中则耗劫胃阴，滋阴则脾阳益困，治疗上大有顾此失彼之虑。老师挠首寻思，毅然投以温通并用，药仅大黄、肉桂二昧，不用煎煮，而以泡浸，取其气味，药后下宿积脓血便甚畅，臭秽不堪，证情逐渐好转而愈。
按此证乃由失治而来，使邪积留于大肠屈曲之间，因病致虚，非因虚为病，故虽见大赢但有大实。
不用攻补，而以温通之法者，恐参、术碍脾之运，且阻大黄通下之功。肉桂性温理气，监制大黄之苦寒，得脾阳之鼓舞，而助大黄推荡之力，达到相辅相成的协同作用。当时还恐一泻而脱，在床边置以糯米稀粥一蠡，得泻后即温取饮下。法颇可取，考虑亦极周详。后来我把该方改为粉剂，使用于小儿的迁延性菌痢以及急性菌痢中经抗菌素治疗效果不佳的病例，常获得较为满意的疗效。
．(三)学习「刀口」上的经验，贵在「活」用所谓「刀口」上的经验，就是说在学术上具有独特的见解，在临床上经得起重复，能解决「关键」性的问题。这种经验的宝贵之处，在于通过长期实践而总结出来的。
昔年从上海徐小圃氏学习儿科。他以擅长使用温热药而著名于时，常在小儿急性热病的重危病例、特别是麻疹合并肺炎时运用温药。当时我很不理解：①麻疹为温热病，温病怎能用温药治疗?②小儿纯阳之体，为什么不禁忌温药?③温药与寒凉药同时并用时，其作用和意义何在?我真正弄通这些问题，化了好几年的过程。第一，徐老所治的急性热病中的麻疹肺炎，基本上属于麻疹中的坏证和变证，临床具有面色灰滞，精神淡漠，脉细数无力之气阳不足证。从现代医学看，多数是肺炎并发心力衰竭、呼吸和循环障碍等虚证，故病不在邪盛，而在正虚。及时应用温阳救逆法，以防其脱变。如待脱象毕露，则已晚矣。徐老之所以善用温药的经验，关键在于抓得早，抓得准。第二，关于小儿生理「体禀纯阳」的问题，虽有不同的理解，但在病理上的「易虚易实」，「易寒易热」是客观存在的。因此，温热病中使用温药并非常法，而是治其变。第三，温清并用，古已有之，虽非徐氏所创，但徐老对温清并用确有独特之处。尤其对一些急性热病中出现邪毒盛而正气不支的重危病例，在温阳救逆法中参与苦寒解毒之晶，确能起到良好的作用。过去，我们在收治「麻疹并发肺炎」时，对合并腺病毒感染或金黄色葡萄球菌感染的病例，通过中西医两法长期治疗无效时，在正不胜邪的情况下，使用上述方法而获效者，亦屡见不鲜。我们还对某些合并化脓性病灶的病例，在未见正气衰败时，重用生大黄通腑解毒，效果也是可喜的。
求古训走新路
作为一个年资较高的中医，身负着承前启后的双重任务，肩挑着医疗、教学、科研几付担子，责任是重大的。事物在发展，形势在前进，应当活到老，学到老，不断实践，不断探索，向新的水平前进。近年来，我是这样做的：
(一)对待不同的学术观点，要立足手实践关于小儿时期的生理体质特点，历代的儿科学者，长期以来就持有「纯阳之体」和「稚阴稚阳」的不同观点，对后世的影响很大。持「纯阳」立论者，认为小儿体禀纯阳，罹病之后，易以化热化火。所以在治疗上要重视寒凉药物的应用，力避辛温之品，困温药能助热化火，列为禁忌。而持「稚阴稚阳」论者，则认为幼儿时期，生机蓬勃，正在向完善、成熟方面发展。在发育的过程中，依阳以生，赖阴而长，然而阳既不足，阴又未盛，所以在治疗上要注意卫护阳气。为了进一步学习这一不同的学术观点，我们从三百例住院病例中的六十一例危重病儿中，作了偏于伤阴和偏于伤阳的初步比较。六十一例中二岁以内的有四十一例，二至六岁的十二例，十岁左右的八倒。病种方面，以急性病为主，其中以小儿肺炎、中毒性消化不良、伤寒等占多数。入院时病情都较严重，且有十九例已伴有心力衰竭和循环障碍。我们根据病情记录及用药法度来探索其「稚阴稚阳」在疾病过程中的临床现象及其实际意义。
1．颜面望诊。以青灰觥白为多，占总病铡的50％以上。年龄愈小，其出现的机会愈多。
2．精神状态。多见者为萎靡淡漠，日光无神。幼、婴儿表现更明显。
3．舌苔与舌质。光苔滑白、舌质淡红、淡白者占总数57％，黄苔、荻苔、白苔、舌质红者占总数43％。其舌质舌苔的表现与患儿的临床体征是一致的。
4．脉象。较大儿童的脉象以沉细，细数的偏多。
在六十一例重危病僦的治疗记录中，有二十六倒是完全使用了以参、附为主的回阳救逆法，十二例是阴阳并伤，以生脉散加附子、龙骨、牡蛎等；单纯甩养阴清热、苦寒解毒方法的为十三例，且均为年龄较大的儿童。
后来经了解，那位医生认为痧毒（麻疹等出疹性疾病的毒邪）已经深入体内并内陷，虽然正处于透发疹子的时期，但已不是通过透发方法就能引邪气向外排出的。当务之急是毒邪化火，病位涉及营分（温病辨证层次之一，较血分为浅），且阴液亏损，出现津液被劫持而化燥，肝风蠢动，如果不使用大剂量的凉营解毒、养阴清热药物，很难遏制其威势。处方使用的是：鲜生地、淡豆豉、丹皮、鲜石斛、鲜芦茅根、川连、大黄、山栀、连翘蕊等，并用紫雪丹冲服。据说，患儿服药后，大便畅解一次，颜色褐黑、气味臭秽，随即全身微微出汗且湿润，疹点也得以透出体外，从而身热逐渐消退，气喘逐渐平息，烦躁转为安宁，抽风停止，神志清醒，病情向愈。
麻疹在出疹期应用透法，这是谁也不会否认的。但透疹的方法很多，如辛温宣透、辛凉宣透、益气透托等等，却未见有用苦寒泻下法的。仔细审查该证候，系有毒热炽盛，痧邪不从外部排泄，必然导致内陷。毒热化火，津液被劫而风生，“炎”（热邪）虽然在肺，但毒邪在阳明经。清热解毒固然是常规治法，但如同“杯水车薪”，无济于事。所以不用“扬汤止沸”之法，而用“釜底抽薪”之计。事后细想，我的过失，就在于不能知常达变。
(二) 诊病不崇尚“四诊”，怎能辨证？
小儿腹泻的主要成因，外因多为暑湿所感，内因多为乳食损伤，病位在脾胃。发病机理则是清阳不升，浊阴不降，清浊混淆，升降功能失调，故见泄泻或伴有呕吐恶心。病因偏于暑热的，多伴发热，症状表现为急迫暴注；湿邪偏盛的，则为洞泄稀水；乳食内伤的，粪便气味臭秽，多夹杂残渣；若素体脾虚，中阳不振，则见淡黄色溏便；如果出现脾虚木旺之虚风证者，则属于险恶证候。
一般泄泻，治疗有常规方法，毋庸赘述。但因泻伤耗胃阴者，必有明显的烦躁口干等症状出现，临床易于防范；对损脾伤阳，产生慢脾风时，可导致突然脱变者，则往往措手不及。所以对各类腹泻的防治，务必随时注意是否有伤阳的先兆，及时护卫脾阳，这对婴幼儿腹泻更为关键。曾治疗一患儿，五个月大，因腹泻三天，干呕不进乳食而就诊。此时患儿“安睡”在摇篮里，既不哭，又不闹，颇似“安静”，两目张开，若有“左右盼顾”之状，微有摇头，额上有微汗，前囟不高，舌干，偶有弄舌状，肌肤干滑，并不灼热，肢端欠温，呼吸时不粗亦不急，偶有叹气状。询问家长说：前两天大便如稀水，日夜二十余次，现已减少，夹有绿色粘液，本有哭闹烦躁，现已安静，惟有干呕不食。当时其家长认为病情已在好转，再服些药，可以好得快一些。而我未细致审察，仅凭家长代诉而处方，不料家属上街买药尚未回来，孩子已经死了。第三天消息传来，外面沸沸扬扬地对我评头论足：“连快要死的人都看不出来，还医得好病？”
我对这一病例有两点教训：首先是主观上的失职，未能按四诊的要求去诊察疾病；第二是识见浅薄，缺乏实际的临床经验。所以，当病儿出现表情淡漠、摇首弄舌的虚风内动，以及额汗肢冷、呼吸深长等慢脾风的临危症候（现在想来，可能已是失水、酸中毒，伴有循环障碍的休克症状）毫不觉察，焉有不失败者！
(三) 临证慌张，缺乏沉着果断
有一例患者，病已六日，仍头裹包巾，拥被怕风，面红耳赤，口干喜凉饮，声音略有嘶哑，自诉头痛如裂，心中烦热，遍身如受杖击，转侧不利。近两天来大便溏泄，按其脉浮而数，察其舌，苔白上盖黄色，质尖红，咽部红肿，看其状，呼吸气促，摸其肌肤，灼手无汗，而下肢反觉不温。病者起病突然，属外感时病无疑。其突出的证情为头痛、骨楚、恶风、喜冷饮。属何证为主，当时颇费思索。考仲景有“身体疼烦，不能自转侧”与“恶风不欲去衣”的条文，似属“风湿相搏”证。但风湿方中均有桂枝、附子之大辛大热，与舌干、渴喜凉饮，药不符症。如从烦渴喜冷饮、呼吸气喘、肌肤灼热的里热实证着手，然苔无老黄，底白不厚，腹软不按痛，且大便溏泄，则热邪无入腑之证。虽有大渴，但尚恶风无汗，亦非阳明经的白虎汤证，因白虎汤有“其表不解，不可与”禁例。若以麻黄汤先解其表，再清其里，阅遍麻黄汤证却无渴饮提及。同时咽红声嘶，温热之证显而易见，如投辛温，则势同“抱薪救火”。又思表寒不解，里热已炽，咳而气喘，则麻杏甘石汤可谓对症矣。思维再三，拟用麻杏甘石汤。《伤寒论》中有两条明文，一为下后，一为汗后，即“汗出而喘，无大热”者，明确指出了该方的适应症在于表证已罢之时。此例患者麻杏甘石亦非对症之方，似用大青龙汤较为合拍。由于认识不清，识见浅陋，拿不定主见，重剂怕担风险，更怕遭讥议于医坛，肇事生变，乃以一般辛凉解表之稳妥轻剂与之。究因药不对症，病情有增无减，乃改延前辈老医两剂药而痊愈。窥其方果然是大青龙汤。
考大青龙条文所叙，十之八九为麻黄汤之脉证，所增者惟“烦躁”两字而已。原文中又有“不汗出而烦躁者”，说明烦躁的由来为不汗出。大青龙汤之所以获效，系解其表寒又清里热，有其症用其方。
窃思该病之所以日益猖獗者，乃起病之初，未能及时投以麻黄汤。因寒邪郁表，病在太阳，应汗不汗，郁而生热，从当初之微热口渴，继则转为渴饮凉水，咽喉略痛，进为咽喉红肿，声音嘶哑。腠理闭塞，内生之热，更无外泄之门路。因此，热肺则喘，下趋则便泄，种种见证，概括为“表寒里热”四字而已。事后羞愧倍至，自惭读其书而不究其义，临证慌张，无沉着审辨胆大心细的果断精神，兼之心怀私念，岂医道之所能容忍。
学人之长断以己律
书本上的经验，固然要学，而老师朋辈中的实践心得，更为可贵。故凡有“一事长己者，不远千里，服膺取决”。治学精神，贵在不耻下问，才能真正学到别人“刀口”上的经验。
(一) 片言只语，都有“零金碎玉”
曾治疗一例失眠患者，颧红升火，彻夜烦躁不宁。多次投以平肝潜阳、养心宁神之剂，连服十多天，药沉大海，并无寸效。老师就在我原方中加入猪胆汁、龙胆草双重苦味药，仅服三剂，即能安然入睡，霍然病愈。老师谓：“虚火宜潜，实火宜泄。该病有颧红升火，烦躁不宁者，即肝胆有实火也。”
又一例女童尿潴留，长期导尿，引起下阴严重感染，外阴部红肿溃破，迭经中西药物并治，小便仍点滴不下，痛苦万分，邀我诊治。认证湿火下注，经治一周，病情未见改善，反而增加肢体浮肿，呼吸气粗，恶风发热。乃请同窗老友会诊，他详询病情，反复检阅所有处理方法，思考再三，若有所悟，告余曰：“此实‘提壶揭盖’之证也。”即疏生黄芪20克，桔梗18克，升麻、生甘草各9克，浓煎代茶，少量多次口服，并以生银花、生甘草煎汤熏洗下阴，每日二至三次。三至四天后，小便已能自剎，取出导尿管，嗣后阴部肿胀溃破处亦得逐渐消退愈合。
“提壶揭盖”法，为癃闭少尿症中属于气虚下陷者，理法并非陌生，而下阴部红肿溃破，明为湿热证，加之小便涓滴，似与证情有违。孰知肺主一身之气化，肺气不足，气化岂能下达州都（膀胱）。生黄芪配伍升麻、桔梗，既益其气，又举其陷。且黄芪托毒消肿，对久溃不敛之疮疡有生肌收口作用，为外科之要药。医学是至精至微一门学问，由于读书不十分仔细，不求甚解，囫囵吞枣，就会成为头痛医头、脚病治脚的庸医。
(二) 点滴经验，实包含着普遍性规律在内
“痢无止法”是一个普遍性规律，但并非所有的痢疾病人，都不能用止和补的方法。“暴痢属实”，“久痢多虚”，也是基本的规律，但亦不能奉为一成不变的定律。
忆随师诊治一痢疾患者，缠绵病榻已三月余，形瘦骨立。夏秋患病，已值隆冬，痢仍不止，赤白夹杂，兀行无度，量少不爽，腹痛后重，纳食则恶，胃气索然，面色萎黄，精神极为疲弱，舌苔干而呆白，质淡红，边有碎腐。遍阅前方，皆为补涩止痢，亦有温运脾胃者。当时认证：中气已虚，邪毒内踞，耗阴耗伤，脾阳已困。欲导其积，正气益伤，温中则耗劫胃阴，滋阴则脾阳益困，治疗上大有顾此失彼之虑。老师挠首寻思，毅然投以温通并用，药仅大黄、肉桂二味，不用煎煮，而以泡浸，取其气味，药后下宿积脓血便甚畅，臭秽不堪，证情逐渐好转而愈。
按此证乃由失治而来，使邪积留于大肠屈曲之间，因病致虚，非因虚为病，故虽见大赢但有大实。
不用攻补，而以温通之法者，恐参、术碍脾之运，且阻大黄通下之功。肉桂性温理气，监制大黄之苦寒，得脾阳之鼓舞，而助大黄推荡之力，达到相辅相成的协同作用。当时还恐一泻而脱，在床边置以糯米稀粥一碗，得泻后即温取饮下。法颇可取，考虑亦极周详。后来我把该方改为粉剂，使用于小儿的迁延性菌痢以及急性菌痢中经抗菌素治疗效果不佳的病例，常获得较为满意的疗效。
(三) 学习“刀口”上的经验，贵在“活”用
所谓“刀口”上的经验，就是说在学术上具有独特的见解，在临床上经得起重复，能解决“关键”性的问题。这种经验的宝贵之处，在于通过长期实践而总结出来的。
昔年从上海徐小圃氏学习儿科。他以擅长使用温热药而著名于时，常在小儿急性热病的重危病例、特别是麻疹合并肺炎时运用温药。当时我很不理解：①麻疹为温热病，温病怎能用温药治疗？②小儿纯阳之体，为什么不禁忌温药？③温药与寒凉药同时并用时，其作用和意义何在？我真正弄通这些问题，化了好几年的过程。第一，徐老所治的急性热病中的麻疹肺炎，基本上属于麻疹中的坏证和变证，临床具有面色灰滞，精神淡漠，脉细数无力之气阳不足证。从现代医学看，多数是肺炎并发心力衰竭、呼吸和循环障碍等虚证，故病不在邪盛，而在正虚。及时应用温阳救逆法，以防其脱变。如待脱象毕露，则已晚矣。徐老之所以善用温药的经验，关键在于抓得早，抓得准。第二，关于小儿生理“体禀纯阳”的问题，虽有不同的理解，但在病理上的“易虚易实”，“易寒易热”是客观存在的。因此，温热病中使用温药并非常法，而是治其变。第三，温清并用，古已有之，虽非徐氏所创，但徐老对温清并用确有独特之处。尤其对一些急性热病中出现邪毒盛而正气不支的重危病例，在温阳救逆法中参与苦寒解毒之品，确能起到良好的作用。过去，我们在收治“麻疹并发肺炎”时，对合并腺病毒感染或金黄色葡萄球菌感染的病例，通过中西医两法长期治疗无效时，在正不胜邪的情况下，使用上述方法而获效者，亦屡见不鲜。我们还对某些合并化脓性病灶的病例，在未见正气衰败时，重用生大黄通腑解毒，效果也是可喜的。
求古训走新路
作为一个年资较高的中医，身负着承前启后的双重任务，肩挑着医疗、教学、科研几付担子，责任是重大的。事物在发展，形势在前进，应当活到老，学到老，不断实践，不断探索，向新的水平前进。近年来，我是这样做的：
(一) 对待不同的学术观点，要立足于实践
关于小儿时期的生理体质特点，历代的儿科学者，长期以来就持有“纯阳之体”和“稚阴稚阳”的不同观点，对后世的影响很大。持“纯阳”立论者，认为小儿体禀纯阳，罹病之后，易以化热化火。所以在治疗上要重视寒凉药物的应用，力避辛温之品，因温药能助热化火，列为禁忌。而持“稚阴稚阳”论者，则认为幼儿时期，生机蓬勃，正在向完善、成熟方面发展。在发育的过程中，依阳以生，赖阴而长，然而阳既不足，阴又未盛，所以在治疗上要注意卫护阳气。为了进一步学习这一不同的学术观点，我们从三百例住院病例中的六十一例危重病儿中，作了偏于伤阴和偏于伤阳的初步比较。六十一例中二岁以内的有四十一例，二至六岁的十二例，十岁左右的八例。病种方面，以急性病为主，其中以小儿肺炎、中毒性消化不良、伤寒等占多数。入院时病情都较严重，且有十九例已伴有心力衰竭和循环障碍。我们根据病情记录及用药法度来探索其“稚阴稚阳”在疾病过程中的临床现象及其实际意义。
1. 颜面望诊。以青灰苍白为多，占总病例的50％以上。年龄愈小，其出现的机会愈多。
2. 精神状态。多见者为萎靡淡漠，目光无神。幼、婴儿表现更明显。
3. 舌苔与舌质。光苔滑白、舌质淡红、淡白者占总数57％，黄苔、腻苔、白苔、舌质红者占总数43％。其舌质舌苔的表现与患儿的临床体征是一致的。
4. 脉象。较大儿童的脉象以沉细、细数的偏多。
在六十一例重危病例的治疗记录中，有二十六例是完全使用了以参、附为主的回阳救逆法，十二例是阴阳并伤，以生脉散加附子、龙骨、牡蛎等；单纯用养阴清热、苦寒解毒方法的为十三例，且均为年龄较大的儿童。
Later, it was understood that the physician believed the sha toxin (toxic pathogen of exanthematous diseases such as measles) had penetrated deeply into the interior and collapsed inward. Although it was still in the period for venting the rash, it was no longer possible to guide the pathogenic factor outwards through venting methods. The immediate priority was that the toxic heat transformed into fire, the disease involved the Ying level (a level in warm disease differentiation, shallower than the Xue level), and there was a depletion of Yin fluids, leading to fluid exhaustion transforming into dryness, with the Liver wind stirring up. Without large doses of cooling the Ying level and detoxifying, nourishing Yin and clearing heat, it would be difficult to curb its momentum. The prescription used included: fresh Shengdi Huang (Rehmanniae Radix), Dan Dou Chi (Sojae Semen Praeparatum), Mu Dan Pi (Moutan Cortex), fresh Shi Hu (Dendrobii Caulis), fresh Lu Gen (Phragmitis Rhizoma) and Mao Gen (Imperatae Rhizoma), Chuan Lian (Coptidis Rhizoma), Da Huang (Rhei Radix et Rhizoma), Shan Zhi (Gardeniae Fructus), Lian Qiao Rui (Lonicerae Flos), etc., taken with Zi Xue Dan (Purple Snow Pill). It is said that after taking the medicine, the infant had a smooth bowel movement once, with dark brown stool and foul odor; immediately afterwards, the whole body sweated slightly and became moist, and the rash points were able to emerge outward. Consequently, the fever gradually subsided, wheezing eased, irritability turned to calm, convulsions stopped, consciousness cleared, and the condition improved.
The application of venting methods during the eruptive stage of measles is undeniable by anyone. However, there are many methods for venting rashes, such as acrid-warm diffusing and venting, acrid-cool diffusing and venting, Qi-tonifying supporting and venting, etc., but the use of bitter-cold purging has rarely been seen. Carefully examining this syndrome, it was characterized by rampant toxic heat, where the sha pathogen did not exit from the exterior, inevitably leading to internal collapse. Toxic heat transformed into fire, fluid exhaustion generated wind. Although the "fire" (heat pathogen) was in the Lung, the toxin was in the Yangming channel. Clearing heat and detoxifying is indeed a standard method, but it is like "pouring a cup of water on a cartload of burning charcoal," which is of no avail. Therefore, instead of using the method of "stirring boiling soup to stop boiling," the strategy of "removing firewood from under the pot" was adopted. Reflecting later, my fault lay in failing to understand the constant principles and adapt to changes.
(II) How can one differentiate syndromes without adhering to the "Four Diagnostic Methods"?
The main causes of infantile diarrhea are external contraction of summer-heat and dampness, and internal injury from milk and food. The disease location is in the Spleen and Stomach. The pathogenesis involves the failure of clear Yang to ascend and turbid Yin to descend, confusion of clear and turbid, and dysfunction of ascending and descending mechanisms, resulting in diarrhea or accompanied by vomiting and nausea. If the cause leans towards summer-heat, it is often accompanied by fever, with symptoms of sudden, urgent diarrhea; if dampness pathogen predominates, it presents as profuse watery diarrhea; if injured by milk and food, the feces have a foul odor and often contain undigested residues; if the constitution is inherently Spleen-deficient with weak Middle Warmth, pale yellow loose stools appear; if deficiency wind syndrome due to Spleen deficiency and Wood hyperactivity occurs, it belongs to dangerous conditions.
General diarrhea has standard treatment methods, which need not be elaborated. When diarrhea damages and depletes Stomach Yin, obvious symptoms such as irritability and dry mouth will appear, which are easy to prevent clinically. However, when Spleen damage and Yang injury lead to Slow Spleen Wind (Man Pi Feng), causing sudden collapse, one is often caught off guard. Therefore, in the prevention and treatment of various types of diarrhea, one must always pay attention to any precursors of Yang injury and timely protect Spleen Yang, which is particularly critical for infantile diarrhea. I once treated an infant, five months old, who presented with three days of diarrhea, dry retching, and refusal of milk and food. At this time, the infant was "sleeping peacefully" in the cradle, neither crying nor fussing, appearing quite "quiet," with eyes open, looking around as if "scanning left and right," slight head shaking, slight sweat on the forehead, anterior fontanelle not bulging, dry tongue, occasional tongue protrusion movements, dry and smooth skin not hot to touch, extremities cool, breathing neither coarse nor rapid, occasional sighing. Inquiring of the parents, they said: "For the past two days, the stool was like watery diarrhea, more than twenty times day and night, now reduced, mixed with green mucus. There was originally crying and irritability, now quiet, only dry retching and not eating." At that time, the parents believed the condition was improving, and with some more medicine, it could heal faster. I failed to examine carefully and prescribed based solely on the parents' report. Unexpectedly, before the family returned from buying medicine, the child had already died. News came on the third day, and outside, people were gossiping about me: "If you can't even see someone who is about to die, how can you cure illnesses?"
I learned two lessons from this case: First, subjective dereliction of duty, failing to examine the disease according to the requirements of the Four Diagnostic Methods; second, shallow insight and lack of practical clinical experience. Thus, when the sick child exhibited signs of deficiency wind stirring internally, such as indifferent expression, head shaking, and tongue playing, along with臨危 symptoms of Slow Spleen Wind, such as sweat on the forehead, cold limbs, and deep long breathing (now thinking, it might have been dehydration, acidosis, accompanied by shock symptoms of circulatory obstruction), without any awareness, how could one not fail?
(III) Panic during clinical practice, lacking composure and decisiveness
There was a patient who had been ill for six days, still wearing a head wrap, huddled under blankets fearing wind, with a red face and ears, dry mouth preferring cool drinks, slightly hoarse voice, complaining of headache like splitting, vexation and heat in the heart, body feeling as if beaten, difficulty turning over. For the past two days, there had been loose stools. Palpating the pulse, it was floating and rapid; observing the tongue, the coating was white covered with yellow, the substance tip was red, the pharynx was red and swollen. Looking at the condition, breathing was hurried; touching the skin, it was burning hot without sweat, yet the lower limbs felt unwarmed. The onset was sudden, undoubtedly an external contracted seasonal disease. The prominent symptoms were headache, bone ache, aversion to wind, and preference for cold drinks. Determining the primary syndrome required considerable thought. Consulting Zhang Zhongjing's texts, there are clauses describing "body pain and vexation, unable to turn oneself" and "aversion to wind, unwilling to remove clothing," resembling the "Wind-Dampness Combining" syndrome. However, formulas for Wind-Dampness all contain Gui Zhi (Cinnamomi Ramulus) and Fu Zi (Aconiti Lateralis Radix Praeparata), which are extremely acrid and hot, inconsistent with the dry tongue and preference for cold drinks. If approaching from the perspective of interior heat excess syndrome characterized by vexation, thirst, preference for cold drinks, wheezing, and burning skin, yet the coating lacked old yellow, the base was thin white, the abdomen was soft and non-tender, and there was loose stool, indicating no evidence of heat entering the Fu organs. Although there was great thirst, the presence of aversion to wind and no sweat meant it was not the Bai Hu Tang (White Tiger Decoction) syndrome of the Yangming channel, because Bai Hu Tang has the contraindication "if the exterior is not resolved, do not administer." If using Ma Huang Tang (Ephedra Decoction) first to resolve the exterior and then clear the interior, reviewing Ma Huang Tang syndromes revealed no mention of thirst. Meanwhile, red throat and hoarseness clearly indicated a warm-heat syndrome; administering acrid-warm herbs would be like "carrying firewood to save a fire." Thinking further, if exterior cold remained unresolved and interior heat was blazing, with cough and wheezing, then Ma Xing Gan Shi Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction) seemed appropriate. After much deliberation, I planned to use Ma Xing Gan Shi Tang. The *Shang Han Lun* (Treatise on Cold Damage) contains two explicit clauses, one after purgation and one after sweating, stating "sweating with wheezing and no significant heat," clearly indicating that the indication for this formula is when the exterior syndrome has ceased. For this patient, Ma Xing Gan Shi Tang was also not the correct formula; Da Qing Long Tang (Great Blue Green Dragon Decoction) seemed more suitable. Due to unclear understanding and shallow insight, hesitating on decisions, fearing the risks of heavy doses, and even more afraid of ridicule in the medical community and causing trouble, I administered a mild, safe acrid-cool exterior-resolving formula. Ultimately, because the medicine did not match the syndrome, the condition worsened. I then invited a senior physician, who cured the patient in two doses. Inspecting his prescription, it was indeed Da Qing Long Tang.
Examining the clauses for Da Qing Long Tang, ninety percent describe the pulse and syndrome of Ma Huang Tang, with the addition of only "vexation." The original text also states "no sweating with vexation," explaining that the origin of vexation is the lack of sweating. Da Qing Long Tang achieved efficacy by resolving exterior cold and clearing interior heat; using the formula for the corresponding syndrome.
Reflecting privately, the reason this disease escalated was that at the beginning, Ma Huang Tang was not administered promptly. Because cold pathogen constrained the exterior, the disease was in the Taiyang channel. Sweating should have occurred but did not, leading to stagnation generating heat. From initial slight fever and thirst, it progressed to craving cold water, slight sore throat, advancing to red and swollen throat and hoarseness. Pores closed, internal heat had no outlet. Therefore, heat affecting the Lung caused wheezing, descending downward caused loose stools. Various manifestations can be summarized as "Exterior Cold and Interior Heat." Afterwards, I felt doubly ashamed, regretting reading the books without investigating their meaning, panicking during clinical practice, lacking the decisive spirit of composure, careful examination, boldness, and caution, coupled with selfish thoughts, which surely cannot be tolerated by the Way of Medicine.
Learning from others' strengths while maintaining one's own judgment
Book knowledge is certainly to be learned, but practical insights from teachers and peers are even more valuable. Therefore, whenever there is something that surpasses oneself, one should travel thousands of miles to accept it and seek guidance. The spirit of scholarship lies in being unashamed to ask subordinates, truly learning the "knife-edge" experiences of others.
(I) Every word contains "fragments of gold and jade"
I once treated a patient with insomnia, with red malar flush, rising fire, and restless irritation throughout the night. Multiple administrations of liver-calming, yang-subduing, heart-nourishing, and spirit-calming agents, taken for over ten days, yielded no effect. My teacher added Pig Bile (Zhu Dan) and Gentian Root (Long Dan Cao), both bitter medicines, to my original prescription. After just three doses, the patient slept peacefully and recovered suddenly. The teacher said: "Deficiency fire should be subdued, excess fire should be drained. This patient, with malar flush, rising fire, and restlessness, indicates excess fire in the Liver and Gallbladder."
Another case involved a young girl with urinary retention. Long-term catheterization caused severe infection of the perineum, with redness, swelling, and ulceration of the vulva. Despite repeated treatments with Chinese and Western medicines, urine still dripped drop by drop, causing extreme suffering. She invited me for consultation. Differentiating as Damp-Heat pouring downward, after one week of treatment, the condition did not improve, but limb edema, coarse breathing, aversion to wind, and fever increased. I invited an old classmate for consultation. He inquired in detail, reviewed all previous management methods, thought for a long time, and seemed to realize something, telling me: "This is actually a 'lifting the lid off the teapot' syndrome." He prescribed Sheng Huang Qi (Astragali Radix) 20g, Jie Geng (Platycodonis Radix) 18g, Sheng Ma (Cimicifugae Rhizoma) and Sheng Gan Cao (Glycyrrhizae Radix et Rhizoma) 9g each, decocted strongly to replace tea, taken orally in small amounts multiple times daily. Additionally, Jin Yin Hua (Lonicerae Japonicae Flos) and Sheng Gan Cao were decocted to fumigate and wash the perineum, twice to three times daily. After three to four days, urination resumed spontaneously, the catheter was removed, and subsequently, the swelling and ulceration of the genital area gradually receded and healed.
The "lifting the lid off the teapot" method applies to oliguria/urinary retention cases belonging to Qi deficiency with sinking. The theory and method are not unfamiliar, but redness, swelling, and ulceration of the perineum clearly indicate a Damp-Heat syndrome, combined with scanty urine, seemingly contradicting the syndrome. Who would know that the Lung governs the Qi transformation of the whole body; if Lung Qi is insufficient, how can Qi transformation reach the Zhou Du (Bladder)? Sheng Huang Qi combined with Sheng Ma and Jie Geng both tonifies Qi and lifts the sinking. Moreover, Huang Qi expels toxicity and reduces swelling, having a flesh-generating and wound-closing effect on chronic non-healing ulcers, making it an essential herb for surgery. Medicine is a highly refined and subtle discipline. Due to careless reading and superficial understanding, swallowing things whole without chewing, one becomes a quack doctor who treats the head when the head hurts and the foot when the foot is sick.
(II) Bit-by-bit experience actually contains universal laws
"The dysentery has no stopping method" is a universal law, but it does not mean that all dysentery patients cannot use stopping and tonifying methods. "Acute dysentery belongs to Excess," "Chronic dysentery mostly belongs to Deficiency," are also basic laws, but they cannot be regarded as immutable dogmas.
I recall accompanying my teacher to treat a dysentery patient who had been bedridden for over three months, emaciated. Contracted in summer and autumn, now in mid-winter, the dysentery still did not stop, mixing red and white, frequent and uncontrollable, small amount and unsatisfactory, abdominal pain and tenesmus, aversion to eating, loss of stomach Qi, sallow complexion, extremely weak spirit, dry and dull white coating, pale red substance, with fragmented erosion at the edges. Reviewing previous prescriptions, they were all tonifying, astringing, and stopping dysentery, or warming and moving the Spleen and Stomach. At that time, the differentiation was: Middle Qi already deficient, pathogenic toxins entrenched internally, consuming Yin and damaging, Spleen Yang already trapped. To guide out the accumulation would further injure righteous Qi; warming the Middle would consume Stomach Yin; nourishing Yin would further trap Spleen Yang. Treatment faced the dilemma of attending to one aspect while neglecting another. The teacher scratched his head, pondered, and resolutely administered a combination of warming and unblocking. The medicine consisted only of Da Huang (Rhei Radix et Rhizoma) and Rou Gui (Cinnamomi Cortex), not decocted, but soaked, extracting their aroma. After administration, the passage of accumulated pus and bloody stool was very smooth, extremely foul-smelling, and the condition gradually improved and healed.
According to this case, it arose from mismanagement, causing pathogenic accumulation to remain in the convolutions of the Large Intestine. The disease caused deficiency, rather than deficiency causing the disease. Thus, although there was great emaciation, there was also great excess.
Not using attacking or tonifying methods, but employing warming and unblocking, was because Ren Shen (Ginseng Radix) and Bai Zhu (Atractylodis Macrocephalae Rhizoma) might hinder Spleen transportation and obstruct Da Huang's purgative action. Rou Gui is warm and regulates Qi, restraining the bitter-cold nature of Da Huang. With the encouragement of Spleen Yang, it assists Da Huang's pushing power, achieving a synergistic complementary effect. At that time, fearing collapse from a single purge, a bowl of rice porridge was placed by the bedside. After purging, it was warmed and drunk. The method was quite commendable, and the consideration extremely thorough. Later, I changed this prescription into a powder form and used it for cases of persistent bacterial dysentery in children and acute bacterial dysentery with poor response to antibiotics, often obtaining satisfactory results.
(III) Learning "knife-edge" experience, the key lies in "flexible" application
The so-called "knife-edge" experience means having unique insights academically, standing up to repetition clinically, and being able to solve "key" problems. The value of such experience lies in its summary through long-term practice.
In the past, I studied pediatrics with Xu Xiaopu from Shanghai. He was famous for his skill in using warm and hot medicines, often applying warm herbs in severe cases of pediatric acute febrile diseases, especially measles complicated with pneumonia. At that time, I did not understand: ① Measles is a warm-heat disease; how can warm medicines be used to treat warm diseases? ② Children have a "Pure Yang" constitution; why are warm medicines not prohibited? ③ What is the role and significance when warm and cold medicines are used simultaneously? It took me several years to truly understand these issues. First, the measles pneumonia in acute febrile diseases treated by Old Xu basically belonged to adverse and altered syndromes within measles. Clinically, it presented with grayish-dull complexion, indifferent spirit, and fine, rapid, and forceless pulse, indicating Qi-Yang insufficiency. From a modern medical perspective, most were deficiency syndromes such as pneumonia complicated with heart failure, respiratory and circulatory disorders. Thus, the disease was not due to pathogenic excess, but righteous deficiency. Timely application of warming Yang and saving from collapse methods prevented collapse. If waiting until collapse signs fully appeared, it would be too late. The key to Old Xu's skill in using warm medicines lay in grasping early and accurately. Second, regarding the physiological "Pure Yang Constitution" of children, although there are different interpretations, the pathological "prone to deficiency and excess," "prone to cold and heat" is objectively existing. Therefore, using warm medicines in warm-heat diseases is not a standard method, but a treatment for alterations. Third, the simultaneous use of warming and clearing has existed since ancient times. Although not created by Mr. Xu, he had unique approaches to combining warming and clearing. Especially for severe cases of acute febrile diseases where pathogenic toxins are rampant and righteous Qi cannot withstand them, participating bitter-cold detoxifying agents in the warming Yang and saving from collapse method can indeed play a good role. In the past, when treating "measles complicated with pneumonia," for cases complicated with adenovirus or Staphylococcus aureus infection, when long-term treatment with both Chinese and Western medicines was ineffective, and righteous Qi could not overcome pathogens, using the above methods resulted in success, which was not uncommon. We also found that for certain cases complicated with purulent lesions, reusing raw Da Huang to purge the bowels and detoxify, when righteous Qi had not yet declined, yielded gratifying results.
Seeking ancient teachings while forging new paths
As a TCM practitioner with high seniority, bearing the dual task of inheriting the past and ushering in the future, shoulder-to-shoulder with medical, teaching, and research responsibilities, the duty is heavy. Things are developing, situations are advancing. One should live and learn until old age, continuously practice, continuously explore, and advance to new levels. In recent years, I have done the following:
(I) Regarding different academic viewpoints, one must stand on practice
Regarding the physiological and constitutional characteristics of childhood, pediatric scholars of past generations have long held different views of "Pure Yang Constitution" and "Young Yin and Young Yang," which have had a great impact on later generations. Those arguing for "Pure Yang" believe that children inherit Pure Yang, and after contracting disease, they easily transform into heat and fire. Therefore, in treatment, emphasis should be placed on the application of cold and cool medicines, avoiding acrid-warm products, as warm medicines can assist heat and generate fire, listed as contraindicated. Those arguing for "Young Yin and Young Yang" believe that in infancy, vitality is vigorous, developing towards perfection and maturity. In the process of development, relying on Yang for growth and Yin for nourishment, however, Yang is insufficient, and Yin is not yet abundant. Therefore, in treatment, attention should be paid to protecting Yang Qi. To further study these different academic viewpoints, we made a preliminary comparison between Yin-injury-predominant and Yang-injury-predominant cases among sixty-one critically ill children from three hundred hospitalized cases. Among the sixty-one cases, forty-one were under two years old, twelve were between two and six years old, and eight were around ten years old. Regarding disease types, acute diseases predominated, mainly pediatric pneumonia, toxic indigestion, typhoid fever, etc. The condition upon admission was serious, and nineteen cases were already accompanied by heart failure and circulatory disorders. We explored the clinical phenomena and actual significance of "Young Yin and Young Yang" during the disease process based on condition records and medication rules.
1. Facial inspection. Cyanotic-gray and pale faces were common, accounting for more than 50% of total cases. The younger the age, the more frequent the occurrence.
2. Mental state. The most common was listlessness and indifference, with dull eyes. Infants showed this more obviously.
3. Tongue coating and substance. Smooth white coating, pale red or pale white substance accounted for 57% of the total; yellow coating, greasy coating, white coating, and red substance accounted for 43%. The manifestation of tongue substance and coating was consistent with the clinical signs of the children.
4. Pulse. For older children, the pulse was predominantly deep and fine, or fine and rapid.
Among the treatment records of the sixty-one critically ill cases, twenty-six completely used the Yang-restoring and collapse-saving method dominated by Ren Shen (Ginseng Radix) and Fu Zi (Aconiti Lateralis Radix Praeparata); twelve cases involved simultaneous Yin and Yang injury, treated with Sheng Mai San (Generate the Pulse Powder) plus Fu Zi, Long Gu (Fossilia Ossis Mastodi), and Mu Li (Concha Ostreae); thirteen cases purely used Yin-nourishing, heat-clearing, and bitter-cold detoxifying methods, all of whom were older children.