陆平叔文学。平素体虚气怯。面色痿黄。药宜温补。不宜寒凉。固其常也。秋月犹患三疟。孟冬复受
外寒。虽逗寒热一班。而未至大寒大热。医者以为疟后虚邪。不知其为新受实邪也。投以参术补剂。转致奄
奄一息。迁延两旬。间有从外感起见者。用人参白虎汤。略无寸效。昏昏嘿嘿。漫无主持。弥留之顷。昆
弟子侄仓皇治木。召昌诊视。以决行期之早暮。非求治疗也。昌见其脉未大坏。腹未大满。小水尚利。但筋脉
牵掣不停。因谓此病九分可治。只恐手足痿废。仲景有云。经脉动惕者。久而成痿。今病已廿三日之久。血
枯筋燥。从可识矣。吾今用法。治则兼治。当于仲景之外。另施手眼。以仲景虽有大柴胡汤两解表
里之法。而无治痿之法。变用防风通圣散成方。减白术。以方中防风荆芥薄荷麻黄桔梗为表药。大黄芒硝黄芩
连翘栀子石膏滑石为里药。原与大柴胡之制相仿。但内有当归川芎芍药。正可领诸药深入血分。而通经脉。
减白术者。以前既用之贻误。不可再误耳。当晚连服二剂。第一剂殊若相安。第二剂大便始通。
少顷睡去。体间津津有汗。次早再诊。筋脉不为牵掣。但阳明胃脉洪大反加。随用大剂白虎汤。石膏知母。
每各两许。次加柴胡花粉芩柏连翘栀子。一派苦寒。连进十余剂。神识始得渐清。粥
饮始得渐加。经半月始起坐于床。经一月始散步于地。人见其康复之难。咸忧其虚。抑且略一过啖。即尔腹痛
便泄。俨似虚证。昌全不反顾。但于行滞药中加用柴胡桂枝。升散余邪。不使
下溜而变痢以取惫。然后改用葳蕤二冬。略和胃气。间用人参不过五分。前后用法。一一不违矩
。乃克起九死于一生也。门人
不解。谓先生治此一病。藉有天幸。内经云。盛者责之。虚者责之。先生今但责其邪盛。而不责其体虚。是明
与内经相背也。余笑曰。吾非骛末忘本。此中奥义。吾不明言。金针不度也。缘平叔所受外邪。不在太阳。
而在阳明。故不但不恶寒。且并无传经之壮热。有时略显潮热。又与内伤发热相仿。误用参术补之。
邪无出路。久久遂与元气混合为一。如白银中倾入铅铜。则不成银色。所以神识昏惑。嘿嘿不知有人理耳。
又阳明者。十二经脉之长。能束筋骨而利机关。阳明不治。故筋脉失养。而动惕不
宁耳。然经虽阳明。而治法迥出思议之表。仲景云。阳明居中土也。万物所归。无所复传。又云。伤寒欲再
传经者。针足阳明。使邪不传则愈。凡此皆指已汗已下已传经之邪为言。故中土可以
消受。若夫未经汗下。未周六经。方盛之邪。中土果能消之否耶。所以仲景又云。阳明中风脉弦浮大而短气。
腹都满。胁下及心痛。久按之气不通。鼻干不得汗。嗜卧。一身及面目悉黄。小便难。有潮热。时时哕。耳
前后肿。刺之小瘥。外不解。病过十日。脉续浮者。与小柴胡汤。脉但浮无余证老。与麻黄汤。若不
尿。腹满加哕者不治。平叔之脉。弦浮大而短气。鼻干不得汗。嗜卧。一身及面目悉黄。过经二十余日不解。
悉同此例。第其腹未满。小水尚利。则可治无疑。然治之较此例倍难者。以非一表所能办也。今为子辈畅
发其义。夫天包地外。地处天中。以生以长。以收以藏。玄穹不尸其功。而功归后土。故土膏一动。百草
莫不蕃茂。土气一收。万物莫不归根。仲景之言中土。但言收藏。而生长之义。在学人自会。设偏主收藏。
则是地道有秋冬。无春夏。能化物而不能造物矣。治病之机亦然。平叔之病。举外邪而锢诸中土。则其土为
火燔之焦土。而非膏沐之沃土矣。其土为灰砂打和之燥土。而非冲纯之柔土矣。焦土燥土。全无生
气。而望其草木之生也。得乎。吾乘一息生机。大用苦寒。引北
方之水。以润泽其枯槁。连进十余剂。其舌始不向唇外吮咂。所
谓水到渠成。乃更甘寒一二剂。此后绝不置力者。知其饮食入胃。散精于脾。如灵雨 。日复一日。
优渥沾足。无藉人工灌溉。而中土可复稼穑之恒耳。必识此意。乃知吾前此滥用苦寒。
正以培生气也。生气回而虚者实矣。夫岂不知其素虚。而反浚其生耶。
陆平叔是一位文人。他平时体质虚弱，气机怯弱。面色萎黄无华。用药应当以温补为主，不宜使用寒凉药物。这是通常的常理。秋季时他还患有三日疟（每三日发作一次的疟疾）。初冬时节又感受了外来的寒邪。虽然表现出寒热交替的症状，但并未达到极寒或极热的程度。医生们认为这是疟疾之后的虚性邪气，却不知道这是新近感受的实性邪气。于是投用参、术等补益药剂，反而导致患者气息奄奄，生命垂危。病情拖延了二十天，期间偶尔有从外感角度考虑治疗的，使用了人参白虎汤，但毫无效果。患者神志昏沉，默默不语，医者茫然无主，不知所措。在病情弥留之际，昆山的弟子和侄子们惊慌失措地准备后事，召请我诊治，是为了决定出殡时间的早晚，并非寻求治疗。
我查看他的脉象尚未完全败坏，腹部没有严重胀满，小便尚且通利，只是筋脉牵拉抽搐不停。因此我说这个病九成可以治愈，只担心会导致手足痿废不用。张仲景说过：“经脉跳动惕惧不安的，时间久了会发展成痿证。”现在患病已经二十三天之久，血枯筋燥，是可以识别出来的。我现在采用的方法，治疗原则是表里兼治，应当在张仲景的方法之外，另施手段。虽然张仲景有大柴胡汤表里双解的方法，但没有治疗痿证的方法。因此变通使用防风通圣散这一成方，减去白术。因为方中的防风、荆芥、薄荷、麻黄、桔梗作为解表药；大黄、芒硝、黄芩、连翘、栀子、石膏、滑石作为清里药。这原本与大柴胡汤的体制相仿，但其中含有当归、川芎、芍药，正好可以引领诸药深入血分，从而疏通经脉。减去白术的原因，是因为之前已经用过它导致了误治，不能再犯同样的错误。当晚连续服用两剂。第一剂服下后似乎相安无事，第二剂服下后大便才通畅。过了一会儿睡去，身体微微出汗。第二天早上再诊，筋脉不再牵拉抽搐，但阳明胃经的脉象洪大反而加重。随即使用大剂量的白虎汤，石膏、知母各用一两左右。随后加入柴胡、天花粉、黄芩、黄柏、连翘、栀子，一派苦寒之药，连续进服十余剂，神志才逐渐清醒，粥饮才能逐渐增加。经过半个月才能够在床上坐起，经过一个月才能够在地上散步。人们看到康复如此艰难，都担忧他是虚证，而且稍微多吃一点食物，就会腹痛腹泻，俨然像是虚证的表现。我却完全不回头顾念这些，只是在行滞气的药物中加入柴胡、桂枝，升散残留的邪气，不让邪气下溜而变成痢疾来消耗体力。然后改用葳蕤（玉竹）、天冬、麦冬，略微调和胃气，间或使用人参不过五分。前后的用法，一一不违背法度，这才使得他在九死一生之中得以痊愈。
门人不能理解，说先生治疗这一个病，是借助了天幸。《内经》说：“实证要责求其实，虚证要责求其虚。”先生现在只责怪邪气盛实，而不责怪体质虚弱，这明显与《内经》相违背。我笑着说：我并不是追逐末节而忘记根本，其中的奥妙深义，我不明说，因为金针不度人（比喻秘法不轻易传授）。这是因为陆平叔所受的外邪，不在太阳经，而在阳明经。所以不仅不恶寒，而且也没有传经的壮热，有时略显潮热。这又与内伤发热相似。误用了参、术等补药，邪气没有出路，久而久之便与元气混合为一，就像白银中倾入铅铜，就不再是白银的颜色了。所以神志昏惑，默默不知人事。另外，阳明经是十二经脉之长，能够束筋骨而利关节。阳明经得不到治理，所以筋脉失养，而动惕不安。然而，虽然病在阳明经，但治疗方法却超出了常人的思议范围。张仲景说：“阳明居中土，是万物所归，无所复传。”又说：“伤寒想要再传经的，针刺足阳明经，使邪气不传则愈。”凡此种种，都是指已经发汗、已经攻下、已经传经的邪气而言的。所以中土可以承受这种治疗。如果是未经发汗、未经攻下，未遍历六经，正盛实的邪气，中土果真能消受吗？所以张仲景又说：“阳明中风，脉弦浮大而短气，腹部都胀满，胁下及心痛，久按之气不通，鼻干不得汗，嗜卧，全身及面目都发黄，小便难，有潮热，时时呃逆，耳前后肿胀，刺之稍好，外证不解，病过十日，脉续浮者，与小柴胡汤。脉但浮而无其他症状的，与麻黄汤。如果不排尿，腹满加重并出现呃逆的，属不治之症。”陆平叔的脉象，弦浮大而短气，鼻干不得汗，嗜卧，全身及面目都发黄，超过病程二十多天不解，完全与此例相同。只是他的腹部没有胀满，小便尚且通利，则可以肯定可以治疗。然而治疗起来比这个例子困难一倍，因为不是单一解表所能办到的。现在我为你们畅发其中的义理。天包裹在地外，地处于天中，负责生长、收藏。玄穹（天）不居功，而功劳归于后土（地）。所以土壤膏润一动，百草无不繁茂；土气一收，万物无不归根。张仲景所说的中土，只说了收藏的意义，而生长的意义，需要学习者自己领会。如果偏重于收藏，那就是地道只有秋冬，没有春夏，只能化物而不能造物了。治病的机理也是如此。陆平叔的病，将外邪全部禁锢在中土，那么他的土就被火烧成了焦土，而不是肥沃湿润的沃土了；他的土变成了灰砂混合的燥土，而不是纯净柔和的土了。焦土燥土，完全没有生气，指望草木生长，可能吗？我乘着仅存的一丝生机，大用苦寒之药，引导北方之水，来润泽他的枯槁。连续进服十余剂，他的舌头才开始不向唇外吮咂。这就是所谓的水到渠成。然后再用甘寒一二剂。此后绝不费力，因为知道饮食进入胃中，散精于脾，如同灵雨滋润，日复一日，优渥充足，无需人工灌溉，中土就可以恢复耕种的常态了。必须认识这一点，才知道我之前滥用苦寒，正是为了培养生气。生气回归，虚损就变为实了。难道不知道他素来体虚，反而要疏通他的生机吗？
Lu Pingshu was a scholar. He usually had a weak constitution and timid qi. His complexion was sallow and withered. The medication should be warming and tonifying, not cold and cooling. This is the general rule. In autumn, he still suffered from san nue (malaria occurring every three days). In early winter, he contracted external cold. Although he exhibited alternating chills and fever, it did not reach extreme cold or extreme heat. Physicians considered it deficiency pathogenic factors following malaria, unaware that it was newly acquired excess pathogenic factors. They administered tonics containing Ginseng Radix et Rhizoma (Renshen) and Atractylodis Macrocephalae Rhizoma (Baizhu), which instead caused his breath to become faint and life to hang by a thread. The condition dragged on for twenty days. Occasionally, some considered it an exterior syndrome and used Ren Shen Bai Hu Tang (Ginseng and White Tiger Decoction), but with no effect. He was unconscious and silent, and physicians were at a loss. At the point of lingering death, disciples and nephews in Kunshan panicked and prepared for the funeral, summoning Chang for diagnosis to decide the timing of the departure, not seeking treatment.
Chang observed that his pulse was not severely damaged, his abdomen was not severely distended, and his urination was still free, but his sinews and vessels were constantly twitching and pulling. Therefore, he said this disease could be cured nine parts out of ten, only fearing paralysis of the hands and feet. Zhang Zhongjing stated: "When meridians move and tremble, over time it becomes Wei syndrome." Now that the illness has lasted for twenty-three days, blood is dry and sinews are brittle, which can be recognized. The method I use now treats both the exterior and interior simultaneously. Beyond Zhang Zhongjing's methods, I must employ different techniques. Although Zhang Zhongjing has Da Chai Hu Tang (Major Bupleurum Decoction) for resolving both exterior and interior, there is no method for treating Wei syndrome. Thus, I modified Fang Feng Tong Sheng San (Wind-Protecting Universal Relief Powder), reducing Baizhu. Because Fangfeng, Jingjie, Bohe, Mahuang, Jiegeng act as exterior-resolving herbs; Dahuang, Mangxiao, Huangqin, Lianqiao, Zhizi, Shigao, Huashi act as interior-clearing herbs. This originally resembles the formulation of Da Chai Hu Tang, but contains Danggui, Chuanxiong, and Shaoyao, which can lead the other herbs deep into the blood level to unblock meridians. Baizhu was reduced because its previous use caused misguidance, and we must not repeat the error. That night, two doses were taken consecutively. After the first dose, there seemed to be peace; after the second dose, bowel movement finally occurred. Shortly after, he fell asleep, and his body sweated slightly. The next morning upon re-examination, the sinew twitching had ceased, but the Yangming stomach pulse was even more surging and large. Immediately, a large dose of Bai Hu Tang (White Tiger Decoction) was used, with Shigao and Zhimu each about one tael. Subsequently, Chaihu, Huafen, Huangqin, Huangbai, Lianqiao, and Zhizi were added, a batch of bitter-cold herbs, taken continuously for over ten doses, until consciousness gradually cleared and porridge/drink intake gradually increased. It took half a month to sit up in bed, and one month to walk on the ground. People saw the difficulty of recovery and all worried about deficiency, especially since any slight overeating led to abdominal pain and diarrhea, resembling a deficiency syndrome. Chang completely disregarded this, adding Chaihu and Guizhi to stagnation-moving herbs to ascend and disperse residual pathogens, preventing them from sinking down and changing into dysentery to exhaust strength. Then, Yu Zhu (Polygonatum Odoratum Rhizome), Dong Quai (Tian Dong), and Mai Dong (Mai Dong) were used to slightly harmonize stomach qi, with occasional use of Renshen not exceeding five fen. The methods used before and after strictly adhered to principles, thus saving him from near-death to life.
Disciples did not understand, saying Master treated this illness relying on heavenly luck. Nei Jing says: "For excess, blame the excess; for deficiency, blame the deficiency." You now only blame the excess pathogen, not the physical deficiency, which clearly contradicts Nei Jing. I smiled and said: I am not chasing the end while forgetting the root. The profound meaning here, I do not state explicitly, for the golden needle is not passed on. The reason is that the external pathogen Lu Pingshu received was not in Taiyang, but in Yangming. Therefore, he not only lacked aversion to cold, but also lacked the high fever of transmission. Sometimes showing tidal fever, it resembled internal injury fever. Mistakenly using Renshen and Baizhu to tonify, the pathogen had no exit, and over time mixed with Yuan Qi, like lead and copper poured into silver, losing its silver color. Thus, consciousness was confused, silent and unaware of people. Furthermore, Yangming is the leader of the twelve meridians, capable of binding sinews and bones and benefiting joints. If Yangming is not treated, sinews and vessels lose nourishment and tremble restlessly. However, although the meridian involved is Yangming, the treatment method exceeds ordinary reasoning. Zhang Zhongjing said: "Yangming resides in the central earth, where all things return, having nowhere else to transmit." He also said: "If cold damage wants to transmit again, puncture Foot Yangming so the pathogen does not transmit and heals." All these refer to pathogens that have already been sweating, purged, or transmitted. Thus, central earth can bear this. But if the pathogen is not yet sweating or purged, has not traversed the six meridians, and is fully flourishing, can central earth truly bear it? So Zhang Zhongjing also said: "Yangming wind strike, pulse stringy, floating, large, shortness of breath, abdomen full, hypochondrium and heart pain, pressing long makes qi blocked, dry nose unable to sweat, drowsiness, whole body and face yellow, difficult urination, tidal fever, frequent hiccups, swelling around ears, acupuncture slightly improves, exterior unresolved, illness passes ten days, pulse continues floating, give Xiao Chai Hu Tang. Pulse only floating without other symptoms, give Ma Huang Tang. If no urine, abdominal fullness adds hiccups, untreatable." Lu Pingshu's pulse, stringy, floating, large, shortness of breath, dry nose unable to sweat, drowsiness, whole body and face yellow, passing twenty-plus days unresolved, exactly matches this case. Only his abdomen was not full, and urination was free, so treatability is certain. However, treatment is twice as difficult as this case because it cannot be handled by single exterior resolution alone. Now I expound the principle for you. Heaven wraps outside Earth, Earth is within Heaven, responsible for growth and storage. Xuan Qong (Heaven) does not claim merit, but merit returns to Hou Tu (Earth). When soil moisture moves, hundred grasses flourish; when Earth qi gathers, all things return roots. Zhang Zhongjing's words on central earth only speak of storage, while the meaning of growth requires students to comprehend themselves. If biased towards storage, then Earth Dao has only Autumn/Winter, no Spring/Summer, able to transform things but not create them. The mechanism of treating disease is the same. Lu Pingshu's disease locked external pathogens in central earth, making his soil scorched by fire, not fertile moist soil; his soil became dry sand mixed with ash, not pure soft soil. Scorched and dry soil has no vitality; expecting grass and trees to grow, is it possible? I seized the remaining spark of vitality, heavily using bitter-cold herbs to guide Northern Water to moisten his withering. Continuously taking over ten doses, his tongue finally stopped sucking inward toward lips. This is what is called water arrives, channel forms. Then, one or two doses of sweet-cold herbs. Afterwards, absolutely no effort needed, knowing food enters stomach, scatters essence to spleen, like spiritual rain, day after day, abundant and sufficient, needing no artificial irrigation, central earth can resume farming constants. Must recognize this meaning, then know my previous abuse of bitter-cold was precisely to cultivate vital qi. Vital qi returns, deficiency becomes excess. How could I not know his inherent deficiency, yet reverse dredge his generation?"