寒邪潜伏少阴，得阳气鼓动而化热。苟肾气不至虚馁，则邪不能容而外达。其最顺者，邪不留恋于阴，而
径出于三阳，则见三阳经证。太阳则恶寒发热，头项疼，腰脊强，治宜豉、芩，合阳旦汤。阳明则壮热鼻干，
不得卧，治宜豉、芩，合葛根、知母等味。少阳则寒热往来，口苦胁痛，治宜芩、豉，合柴胡、山栀等味。其
邪初出三阳，或兼新感，外有恶寒无汗等证，则桂、葛、柴胡，自当参用。若里热已甚则不宜桂枝，壮热汗多
则不宜葛根，内风易动则不宜柴胡，此则又在临时之化裁矣。难经曰∶温邪行在诸经，不知何经之动也。故其
发也，本无定处，大略乘经气之虚，或挟别邪而发。如太阳虚则发于太阳，阴气虚则恋于阴分。其有温邪化热
已出三阳，而未尽之邪尚有伏于少阴而未化者（此肾气不充，宜兼温托）；即或全数化热，而其热有半出于阳，
半恋于阴者（此阴气不足，不能托邪，当兼养阴）；用药总宜随证化裁，活泼泼地，方能应手取效也。
伏温化热而达，其证由少阴而出三阳者，于法为顺。惟无形之热，可从经气而达。若中焦挟有形食积浊痰
，则邪热蕴蒸，每每乘机入胃，热结于中，而为可攻之证。盖胃为五脏六腑之海，位居中土，最善容纳。邪热
入胃，则不复他传。故温
热病热结胃腑，得攻下而解者，十居六七。前人如又可所论，虽名瘟疫，其实亦系伏邪。所列治法，用攻下者
，十之七八。盖伤寒重在误下，温病重在误汗；温病早投攻下，不为大害，前贤本有此论。吴氏又确见病证之
可下者多，故放胆言之，而不自觉其言之偏重也。陆九芝谓温病热自内燔，其最重者，只有阳明经腑两证。经
证用白虎汤，腑证用承气汤。有此两法，无不可治之温病矣。其意专重阳明，若温病决不涉及别经者，其言亦
未免太偏。总之，温病邪热蒸郁，入于阳明者居多。热在于经，犹属无形之热。其证烦渴多汗，狂谵脉洪，此
白虎证也。若热结于腑，则齿垢唇焦，晡热，舌苔焦黄，神昏谵语，脉沉实，此承气证也。只要认证清楚，确
系热在于胃，则白虎、承气，根据法投之，可以取效反掌。切勿因疑生怯，反致因循贻误也。
前人用大黄下夺，有因泄热而用者（如三黄泻心）；有因解毒而用者（如三黄解毒），有因疏瘀化痰而用
者（如大黄 虫、滚痰丸），有因疏泄结气而用者（如大黄黄连泻心），原不专为积滞而设。无如不明医理者
，见方中有大黄一味，即谓之承气，即谓之攻积；因而疑忌多端，当用不用，坐此贻误者多矣。
伤寒热结胃腑者，粪多黑而坚燥∶温病热结于胃者，粪多酱色而溏。藜藿之子，热结者粪多栗燥；膏粱之
人，多食油腻，即有热灼，粪不即燥，往往有热蕴日久，粪如污泥，而仍不结为燥栗者，此不可不知也。有初
起病时，便溏作泻，迨两三日后，热势渐重，乃结于胃而便秘者，仍宜根据法下之。又有热势已重，渴饮频多，
或用清泄之剂，因而便泄稀水，坚粪不行者，此热结旁流也。古法用大承气下之，吴鞠通改为调胃承气，甚合
。
热结而成燥粪者，行一二次后，燥粪已完，热邪即尽。若溏粪如烟膏霉酱者，或一节燥、一节溏者，此等
证，其宿垢最不易清，即邪热亦不易净。往往有停一二日再行，有行至五六次，
多至十余次者。须看其病情如何，以定下与否。慎勿震于攻下之虚声，遂谓已下不可再下，因致留邪生变，而
受养痈之实祸也。
光绪初年冬仲，徐君声之，因欲服补剂，属为定方。予诊其脉，两尺浮数弦动而不静。予谓据此脉证，当
发冬温，补剂且从缓进。因疏方，黄芩汤加生地，嘱其多服几剂。当其时饮啖如常，并无疾苦。勉服三两剂，
即停不服。迨十二月十七，忽振寒发热。两日后，渐觉神情昏糊困倦，热势蒸郁不达，神呆耳聋面垢。此少阴
伏邪，化热外达。其势外已入胃，而内发于阴者，尚未离少阴之界，而并有窜入厥阴之势，病情深重而急。予
以至戚，谊无可诿，不得不勉力图之。先与栀、豉、黄芩二剂，继进清心凉膈法两剂，均无大效。而痉厥昏谵
，舌燥唇焦，病势愈急。乃用调胃承气，加洋参、生地、犀角、羚羊、元参养阴清泄之品。两剂之后，始得溏
粪如霉酱者二遍。间进犀、羚、地、芍、豆豉、栀、丹、芩、元参，养阴熄热，清透少阴之剂，而热仍不减。
乃再与调胃承气合增液法，又行垢粪一次。此后即以此法，与养阴清泄之法相间迭用。自十二月二十三起，至
正月初十，通共服承气八剂，行宿垢溏黑者十余次，里热始得渐松，神情亦渐清朗。用养阴之剂，调理两月而
痊。按∶此证少阴伏邪本重，其化热而发也，设热邪全聚于胃，即使热壅极重，犹可以下泄之药，背城借一，
以图幸功。乃中焦之热势已剧，而伏热之溃阴分者，又内炽于少、厥两阴之界，岌岌乎有蒙陷痉厥之险。不得
已用助阴托邪之法，从阴厘清化，使其渐次外透。其已达于胃者，用缓下法，使之随时下泄。战守兼施，随机
应变。如是者，将及两旬，邪热始得退清。假使攻下一两次后，即畏其虚而疑不能决，则其险有不堪设想者。
然则焦头烂额，得为今日之上客者，幸也。
长媳徐氏，戊戌七月，患感冒挟肝气发热，脘痛呕恶不纳者，五六日。八月朔，得大解颇畅。余谓大便一
通，病可松也。不意至夜，寒热大作，恶心干呕，彻夜不止。与左金、平胃、温胆、泻心，均无寸效。至初五
日，烦躁口渴，舌燥起刺。予以其质弱阴亏，虑其不耐壮热，急思乘早击退，冀免淹缠，遂用凉膈合泻心法，
佐以洋参、石斛等。连进两剂，得大
解两遍，呕恶即止，而里热不减，间服养阴泄热药一二剂，大便仍不行，而舌苔灰热转浓。乃改用调胃承气合
增液法，间日一进。每进一剂，即行一次，粪色或黄或黑，或溏或结。又进三次，至十五日，方中大黄重至五
钱，乃腹中大痛，宿粪畅行。当时冷汗肢厥，几乎气脱不回。急进人参以扶正气，始渐定。自此次畅行后，里
热渐松，用药总以养阴扶胃为主。每间三四日，大解不行，即用人参汤送大黄丸药一服，或泻叶汤一盏，大便
始行，而粪色仍黑紫如酱。至九月初，乃能渐进米汤稀粥。然每至三五日大解不通，即觉胃热熏郁，须与清泄
，得大解始平。至九月十九日，
服泻叶汤后，忽然宿垢大行，得黑粪半桶之多∶然后积热浊热，始得一律整肃，不再有余热熏蒸矣。自初病至
此，共享大黄三两零，元明粉一两零，人参参须二三两，洋参、麦冬各十余两，鲜地，石斛各一斤，其犀、羚
、珠粉等味，用数少者不计焉。此证因阴虚质弱之体，患此大病，米饮不沾唇者一月，而得全性命者，缘自病
迄今始终以扶正养阴为主，故虽屡频危殆，而卒获保全。其积垢行至一月有余而始净，则初念亦不及料也。然
从此可知，时病之余热不除，皆由积垢不清所致，断不可顾虑其虚，转致留邪生变也。又此证最易惑者，其脉
始终细弱，毫无实象。惟将见证细意审察，究属体虚证实，惟有用洋参、鲜地、石斛、大黄，以养阴泄热，为
至当不易之治。 守不移，始得回一生于九死也，亦幸已哉！
寒邪潜伏在少阴经，得到阳气的鼓动而化为热邪。如果肾气不虚弱，那么邪气就无法停留而向外透达。其中最顺利的情况是，邪气不在阴分留恋，而是直接出于三阳经，从而出现三阳经的病证。如果是太阳经受邪，则表现为恶寒发热、头项疼痛、腰脊强直，治疗宜用豆豉、黄芩，配合阳旦汤。如果是阳明经受邪，则表现为高热、鼻干、无法安卧，治疗宜用豆豉、黄芩，配合葛根、知母等药物。如果是少阳经受邪，则表现为寒热往来、口苦胁痛，治疗宜用黄芩、豆豉，配合柴胡、山栀等药物。当邪气刚出三阳经时，或者兼有新感外邪，体表有恶寒无汗等症状，那么桂枝、葛根、柴胡应当参合使用。如果里热已经很严重，就不宜用桂枝；如果高热汗多，就不宜用葛根；如果体内风邪容易妄动，就不宜用柴胡，这些都需要根据临证情况灵活变通。《难经》说：温邪运行在各条经脉中，不知道是哪条经脉发生病变。所以它的发作，本来就没有固定的部位，大略是趁着经气虚弱之时，或者挟带其他邪气而发作。如太阳经虚则发于太阳经，阴气虚则留恋于阴分。有的温邪化热已经出于三阳经，但未尽的邪气还有潜伏在少阴经而未化热的（这是肾气不充实，应当兼用温补托毒之法）；即使全部化热，但热邪有一半出于阳分，一半留恋于阴分（这是阴气不足，不能托举邪气外出，应当兼用养阴之法）；用药总宜随证候灵活变通，活泼灵动，才能应手取效。
伏气温病化热而外达，其病证由少阴经而出三阳经的，在治法上属于顺证。只有无形之热，可以从经气而外达。如果中焦挟带有形的食积浊痰，那么邪热蕴结蒸腾，常常乘机进入胃腑，热邪结聚在中焦，形成可以攻下的证候。因为胃是五脏六腑的海，位居中土，最善于容纳。邪热进入胃腑，就不再向其他地方传变。所以温热病中热结胃腑，通过攻下法而解的，占十分之六七。前人如吴又可所论述的，虽然名为瘟疫，其实也是伏邪。所列出的治法中，使用攻下法的，占十分之七八。大概伤寒重在避免误用下法，温病重在避免误用汗法；温病早期投用攻下法，并不构成大害，前贤本就有此论断。吴氏又确实见到可下证的病例很多，所以大胆直言，而不自觉其言论偏重。陆九芝认为温病的邪热自内燔灼，最严重的，只有阳明经证和腑证两种。经证用白虎汤，腑证用承气汤。有了这两种方法，就没有不可治疗的温病了。他的意思专重阳明经，好像温病绝对不会涉及其他经脉，这种说法未免太偏颇了。总之，温病邪热蒸郁，进入阳明的居多。热邪在于经，还属于无形之热。其症状为烦渴多汗、狂乱谵语、脉象洪大，这是白虎汤证。如果热邪结聚于腑，则齿垢唇焦、下午发热加重、舌苔焦黄、神昏谵语、脉象沉实，这是承气汤证。只要辨证清楚，确系热邪在胃，那么白虎汤、承气汤，依据法则投用，可以轻易取效。千万不要因为犹豫而生怯意，反而导致拖延贻误病情。
前人使用大黄进行攻下，有的是为了泄热而用（如三黄泻心汤）；有的是为了解毒而用（如三黄解毒汤）；有的是为了疏通瘀血化痰而用（如大黄䗪虫丸、滚痰丸）；有的是为了疏泄结滞之气而用（如大黄黄连泻心汤），原本不专门是为了积滞而设。无奈不明医理的人，见方中有大黄一味，就称之为承气汤，就称之为攻积滞；因而产生种种疑忌，该用而不用，因此导致贻误病情的很多。
伤寒热结胃腑者，粪便多呈黑色且坚硬干燥；温病热结胃腑者，粪便多呈酱色且稀溏。平民百姓（饮食粗劣），热结者粪便多呈栗子状且干燥；富贵之人（多食油腻），即使有热邪灼烧，粪便也不立即干燥，往往有热邪蕴结日久，粪便如污泥，但仍然不结成燥屎的，这一点不可不知。有的初起病时，大便稀溏作泻，等到两三天后，热势逐渐加重，才结于胃腑而便秘的，仍然应当依据法则使用下法。又有热势已经很重，口渴饮水频多，或者用了清泄的药剂，因而排泄稀水，但坚硬的粪块仍不排出的，这就是“热结旁流”。古法用大承气汤攻下，吴鞠通改为调胃承气汤，非常合乎法度。
热结而成燥屎的，排便一两次后，燥屎已排完，热邪也就尽了。如果粪便像烟膏霉酱一样稀溏，或者一段干燥、一段稀溏的，这类证候，宿存的垢腻最不容易清除，即邪热也不容易净尽。往往有停一二天再行排便，有行至五六次，多至十余次的。必须看病人的病情如何，来决定是否继续攻下。千万不要被攻下会致虚的虚名所震慑，就说已经攻下过就不能再下，因而导致留邪生变，遭受养痈遗患的实际祸害。
光绪初年冬月，徐君声之，因为想服用补药，委托我定方。我诊察他的脉象，两尺脉浮数弦动而不静。我对他说，根据这个脉证，应当发作冬温病，补剂暂且缓进。于是开方，用黄芩汤加生地，嘱咐他多服几剂。当时他饮食如常，并无疾苦。勉强服了三两剂，就停止不服了。到了十二月十七日，忽然恶寒发热。两天后，渐渐觉得神情昏糊困倦，热势蒸郁不得外达，神情呆滞、耳聋、面色污垢。这是少阴伏邪，化热外达。其势外已入胃，而内发于阴分的，尚未离开少阴的范围，并且有窜入厥阴的趋势，病情深重而急迫。我因为是至亲，情义上无可推卸，不得不勉力救治。先给予栀子、豆豉、黄芩两剂，继而又进清心凉膈法两剂，都没有大的疗效。而痉厥昏谵、舌燥唇焦，病势更加急迫。于是用调胃承气汤，加入西洋参、生地、犀角、羚羊角、元参等养阴清泄的药物。两剂之后，才排出像霉酱一样的稀便两次。间歇性进用犀角、羚羊角、生地、芍药、豆豉、栀子、丹皮、黄芩、元参等养阴熄热、清透少阴的药剂，但热势仍不减。于是再用调胃承气汤合增液法，又排出垢腻粪便一次。此后就用这种方法，与养阴清泄之法交替使用。从十二月二十三日起，到正月初十，共服用承气汤八剂，排出宿垢稀黑粪便十余次，里热才得以逐渐松弛，神情也逐渐清醒明朗。后用养阴药剂调理两个月而痊愈。按语：此证少阴伏邪本来很重，其化热而发作时，假如热邪全聚于胃，即使热壅极重，还可以用攻下泄热的药物，背城借一，以求侥幸成功。然而中焦的热势已经剧烈，而伏热溃散侵入阴分的，又在少阴、厥阴两阴之间内炽，岌岌乎有蒙蔽心窍、陷入痉厥的危险。不得已采用助阴托邪的方法，从阴分厘清化解，使其逐渐向外透达。其已达于胃部的，用缓下法，使之随时向下排泄。战守兼施，随机应变。像这样将近二十天，邪热才得以退清。假如攻下一两次后，就畏惧其虚而犹豫不决，那么其中的危险就不堪设想了。然而，那些救死扶伤的人，能成为今日的上客，也是幸运啊。
长媳徐氏，戊戌年七月，患感冒挟肝气发热，脘腹痛呕吐恶心不能进食，已有五六天。八月一日，大便通畅。我认为大便一通，病就可以缓解。没想到到了晚上，寒热大作，恶心干呕，彻夜不止。给予左金丸、平胃散、温胆汤、泻心汤，都没有一点效果。到了初五日，烦躁口渴，舌燥起刺。考虑到她体质弱、阴液亏，担心她不耐受壮热，急切想着趁早击退病邪，希望避免缠绵难愈，于是用凉膈散合泻心法，佐以西洋参、石斛等。连续进服两剂，大便通了两次，呕吐恶心即止，但里热不减，间歇服用养阴泄热药一二剂，大便仍不行，而舌苔灰暗热象转浓。于是改用调胃承气汤合增液法，隔日进服一剂。每进一剂，就排便一次，粪便颜色或黄或黑，或溏或结。又进服三次，到十五日，方中大黄重用至五钱，于是腹中大痛，宿粪畅行。当时冷汗淋漓、四肢厥冷，几乎气脱不回。紧急进服人参以扶助正气，才逐渐安定。自从此次畅行后，里热逐渐松弛，用药总以养阴扶胃为主。每隔三四天，大便不通，就用参汤送服大黄丸药一服，或者泻叶汤一盏，大便才通行，而粪便颜色仍黑紫如酱。到了九月初，才能逐渐进米汤稀粥。然而每到三五天大便不通，就觉得胃热熏郁，须给予清泄，得大便才平息。到九月十九日，服用泻叶汤后，忽然宿垢大行，排出黑粪半桶之多：然后积热浊热，才得以一律整肃，不再有余热熏蒸了。从初病至此，共用大黄三两零，元明粉一两零，人参参须二三两，西洋参、麦冬各十余两，鲜地黄、石斛各一斤，犀角、羚羊角、珍珠粉等味，用量少的不计在内。此证因阴虚质弱的体质，患此大病，一个月米饮不沾唇，而能保全性命，是因为自发病以来始终以扶正养阴为主，所以虽然屡次危殆，最终得以保全。其积垢行至一月有余才干净，则最初的念头也料想不到。然而从此可知，时病之余热不除，都是由积垢不清所致，绝对不可顾虑其虚，反而导致留邪生变。另外此证最容易迷惑人的是，其脉始终细弱，毫无实象。只有将见证仔细审察，究属体虚证实，唯有使用西洋参、鲜地黄、石斛、大黄，以养阴泄热，才是最为恰当不易的治疗原则。坚守不移，才得以从九死一生之中挽回生命，也是幸运啊！
Cold pathogen latent in the Shaoyin (Lesser Yin) channel, transforms into heat upon stimulation by Yang Qi. If Kidney Qi is not deficient, the pathogen cannot reside and will reach outward. The most favorable scenario is that the pathogen does not linger in the Yin aspect but directly emerges through the Three Yang channels, presenting as syndromes of the Three Yang meridians. Involvement of the Taiyang (Greater Yang) channel manifests as aversion to cold and fever, headache and stiffness of the head and neck, and stiffness of the lower back and spine; treatment should employ fermented soybean (Douchi) and Scutellaria root (Huangqin), combined with Yangdan Decoction. Involvement of the Yangming (Yang Brightness) channel manifests as high fever, dry nose, and inability to lie down; treatment should employ fermented soybean (Douchi) and Scutellaria root (Huangqin), combined with Pueraria root (Gegen) and Anemarrhena rhizome (Zhimu). Involvement of the Shaoyang (Lesser Yang) channel manifests as alternating chills and fever, bitter taste in the mouth, and hypochondriac pain; treatment should employ Scutellaria root (Huangqin) and fermented soybean (Douchi), combined with Bupleurum root (Chaihu) and Gardenia fruit (Shanzhi). When the pathogen first emerges from the Three Yang channels, or when accompanied by a new external contraction manifesting as aversion to cold and absence of sweating on the exterior, Cinnamon twig (Guizhi), Pueraria root (Gegen), and Bupleurum root (Chaihu) should be used in combination. However, if interior heat is severe, Cinnamon twig (Guizhi) is contraindicated; if there is high fever with profuse sweating, Pueraria root (Gegen) is contraindicated; if internal wind tends to stir easily, Bupleurum root (Chaihu) is contraindicated. These require flexible adjustment based on the clinical presentation. The *Nan Jing* states: "Warm pathogen travels through various meridians, it is unknown which meridian is affected." Therefore, its onset has no fixed location, generally occurring when meridian Qi is deficient, or accompanying other pathogens. For instance, if Taiyang is deficient, it manifests in the Taiyang channel; if Yin Qi is deficient, it lingers in the Yin aspect. There are cases where warm pathogen has transformed into heat and emerged through the Three Yang channels, yet residual pathogen remains latent in the Shaoyin without transforming (this indicates insufficient Kidney Qi, requiring concurrent warming and supporting methods); even if fully transformed into heat, the heat may be half in the Yang and half lingering in the Yin (this indicates insufficient Yin Qi unable to push out the pathogen, requiring concurrent nourishing of Yin). Medication must always be adjusted flexibly according to symptoms, acting with agility, to achieve immediate efficacy.
When latent warmth transforms into heat and reaches outward, with syndromes emerging from Shaoyin to the Three Yang channels, this is considered a favorable progression in treatment principles. Only formless heat can reach outward via meridian Qi. If the Middle Jiao is complicated by tangible food stagnation or turbid phlegm, the pathogenic heat will accumulate and steam, often taking the opportunity to enter the Stomach, binding in the center and forming a syndrome amenable to purgation. The Stomach is the sea of the five Zang and six Fu organs, located in the central Earth element, and is most capable of accommodation. Once pathogenic heat enters the Stomach, it ceases to transmit elsewhere. Thus, in warm-heat diseases, cases of heat binding in the Stomach resolved by purgation account for six out of ten. Predecessors such as Wu Keyou discussed these, although naming them pestilence, they are essentially latent pathogens. Among the treatments listed, purgation was used in seven or eight out of ten cases. Generally, Shanghan (Cold Damage) emphasizes avoiding erroneous purgation, while Wenbing (Warm Diseases) emphasizes avoiding erroneous sweating; early use of purgation in warm diseases does not constitute major harm, a view held by former sages. Wu Shi indeed observed many cases suitable for purgation, hence speaking boldly, unaware of the bias in his statements. Lu Jiuzhi argued that warm disease pathogenic heat burns from within, with the most critical cases involving only Yangming channel and fu-organ syndromes. Channel syndromes are treated with White Tiger Decoction (Baihu Tang), and fu-organ syndromes with Chengqi Decoction. With these two methods, no warm disease is untreatable. His focus is exclusively on Yangming, implying warm diseases never involve other meridians, which is somewhat biased. In summary, warm disease pathogenic heat steaming and郁 (stagnating) mostly enters Yangming. Heat in the channel remains formless. Symptoms include irritability, thirst, profuse sweating, mania, delirium, and a surging pulse, constituting a Baihu Tang syndrome. If heat binds in the fu-organ, symptoms include dental plaque, scorched lips, afternoon fever exacerbation, scorched yellow tongue coating, coma, delirium, and a deep, solid pulse, constituting a Chengqi Tang syndrome. As long as differentiation is clear and heat is confirmed in the Stomach, administering Baihu Tang or Chengqi Tang according to protocol yields rapid results. Do not let hesitation breed timidity, causing delay and worsening the condition.
Former physicians used Rhubarb (Dahuang) for purgation for various reasons: some to drain heat (e.g., Sanhuang Xiexin Decoction); some to detoxify (e.g., Sanhuang Jiedu Decoction); some to resolve stasis and transform phlegm (e.g., Dahuang Zhechong Wan, Guntan Wan); some to vent stagnant Qi (e.g., Dahuang Huanglian Xiexin Decoction). It was not originally designed solely for stagnation. Unfortunately, those unfamiliar with medical theory see Rhubarb in a formula and call it Chengqi Decoction or purgation for accumulation; thus generating numerous doubts, failing to use it when necessary, leading to much延误 (delay/neglect).
In Shanghan, heat binding in the Stomach typically presents with black, hard, and dry stools. In warm diseases, heat binding in the Stomach typically presents with sauce-colored, loose stools. Commoners (with coarse diets) with heat binding have chestnut-like dry stools. Nobles (consuming rich foods) may have heat scorching but stools do not immediately dry; often, with prolonged heat accumulation, stools resemble mud without forming hard pellets. This must be known. Some patients have loose stools at onset, but after two to three days, as heat intensifies, it binds in the Stomach causing constipation; these still require purgation according to protocol. Others have severe heat, frequent thirst, or use cooling-draining agents resulting in watery diarrhea while hard stool remains unpassed; this is "heat binding with peripheral flow" (Rejie Pangliu). Ancient methods used Da Chengqi Tang for purgation; Wujutong modified it to Tiaowei Chengqi Tang, which is highly appropriate.
When heat binding forms dry feces, one or two bowel movements complete the expulsion of dry feces, clearing the pathogenic heat. If stools are like moldy paste, or alternating between dry and loose, the retained filth is hardest to clear, and pathogenic heat is hardest to eradicate. Bowel movements may stop for one or two days before resuming, or occur five to ten times. One must assess the patient's condition to decide whether to continue purgation. Do not be intimidated by the false notion that purgation causes deficiency, thinking purgation cannot be repeated, thereby retaining pathogen and causing complications, suffering the real disaster of nurturing an abscess.
In the winter of the second month of the Guangxu era, Mr. Xu Shengzhi wished to take tonics and asked me to prescribe. I palpated his pulse: both Chi positions were floating, rapid, wiry, and restless. I told him, based on this pulse and syndrome, Winter Warmth would likely erupt, and tonics should be delayed. I prescribed Huangqin Tang plus Rehmannia root (Shengdi), advising him to take several doses. At that time, he ate and drank normally, feeling no illness. He reluctantly took three doses then stopped. On December 17th, he suddenly experienced chills and fever. Two days later, he felt mental confusion and fatigue, with heat steaming and unable to reach the exterior, mental dullness, deafness, and dirty complexion. This was Shaoyin latent pathogen transforming into heat and reaching outward. The pathogen had reached the Stomach externally, but internally emanating from Yin had not yet left the Shaoyin boundary, showing signs of invading Jueyin. The condition was deep, severe, and urgent. Being close relatives, I could not decline treatment. Initially, I gave Gardenia (Zhizi) and Fermented Soybean (Chichi) with Scutellaria (Huangqin) for two doses, followed by Qingxin Liangge method for two doses, with little effect. Spasms, convulsions, coma, delirium, dry tongue, and scorched lips worsened the urgency. I then used Tiaowei Chengqi Tang added with American Ginseng (Yangshen), Rehmannia (Shengdi), Rhinoceros horn (Xijiao - *note: modern substitutes used*), Antelope horn (Lingyang), and Scrophularia (Yuanshen) for nourishing Yin and clearing heat. After two doses, he passed moldy-paste-like loose stools twice. Intermittently, I administered formulas with Rhinoceros/Antelope horn, Rehmannia, Peony (Shaoyao), Fermented Soybean, Gardenia, Moutan (Danpi), Scutellaria, and Scrophularia to nourish Yin, extinguish heat, and clear/vent Shaoyin, but heat persisted. I then used Tiaowei Chengqi Tang combined with Zengye method, passing another batch of filthy stools. Thereafter, I alternated this method with nourishing-Yin-and-clearing-heat methods. From December 23rd to January 10th, he took Chengqi Decoction eight times, passing over ten batches of dark, loose retained filth, allowing interior heat to gradually relax and mental clarity to return. He recovered after two months of Yin-nourishing regulation. Commentary: This case had heavy Shaoyin latent pathogen. If heat had gathered entirely in the Stomach, even if extremely congested, purgative drugs could have been used decisively for a chance of success. However, middle-jiao heat was severe, and latent heat invading Yin burned fiercely between Shaoyin and Jueyin, risking clouding the mind and convulsions. Forced to use methods to assist Yin and support the pathogen outward, clearing from the Yin aspect to allow gradual exteriorization. For what reached the Stomach, gentle purgation was used to drain it. Combining offense and defense, adapting to changes. This lasted nearly twenty days until heat cleared. If purgation had been stopped after one or two times due to fear of deficiency, the danger would have been unimaginable. Yet, those who save lives become honored guests today, which is fortunate.
Eldest daughter-in-law Xu, in July of Wuxu year, suffered from cold complicated by Liver Qi stagnation and fever, epigastric pain, vomiting, and inability to eat for five to six days. On August 1st, she had a smooth bowel movement. I said once bowels moved, the illness would ease. Unexpectedly, that night, severe chills and fever erupted, with nausea and dry retching all night. Zuojin Pill, Pingwei San, Wendan Tang, and Xiexin Tang yielded no effect. By the 5th day, irritability, thirst, dry prickly tongue. Considering her weak constitution and Yin deficiency, fearing intolerance to high fever, I urgently sought to repel it early to avoid lingering. I used Liangge San combined with Xiexin method, aided by American Ginseng (Yangshen) and Dendrobium (Shihu). After two doses, two bowel movements occurred, vomiting stopped, but interior heat remained. Intermittent Yin-nourishing and heat-draining herbs failed to move bowels; tongue coating turned gray and hot. I switched to Tiaowei Chengqi Tang combined with Zengye method, given every other day. Each dose resulted in one bowel movement, stool color varying from yellow to black, loose to hard. After three more doses, on the 15th, Rhubarb (Dahuang) dosage increased to five qian, causing severe abdominal pain and passage of retained filth. Cold sweat and cold limbs ensued, nearly collapsing. Emergency Ren Shen (Ginseng) restored Qi stability. Since this smooth passage, interior heat relaxed; treatment focused on nourishing Yin and supporting Stomach. Every three to four days of constipation, Ginseng decoction delivered Dahuang pills or Xieye soup moved bowels, though stool remained black-purple like sauce. By early September, she could slowly consume rice gruel. However, every few days of constipation caused stomach heat oppression, requiring clearing/draining until bowel movement resumed. On September 19th, after Xieye soup, massive passage of retained filth occurred, expelling half a bucket of black stool: finally, accumulated and turbid heat were cleared, with no residual heat steaming. Total usage: Rhubarb >3 liang, Mang Xiao (Yuanmingfen) >1 liang, Ginseng rootlets 2-3 liang, American Ginseng and Ophiopogon (Maidong) >10 liang each, Fresh Rehmannia and Dendrobium 1 jin each. Rhinoceros/Antelope horn and Pearl powder amounts negligible. This case involved a weak, Yin-deficient body suffering severe illness, abstaining from liquids for a month, yet surviving because treatment consistently prioritized supporting Zheng Qi and nourishing Yin. Thus, despite critical moments, life was preserved. Retained filth took over a month to clear, exceeding initial expectations. This shows that residual heat in seasonal diseases stems from uncleared filth; one must not fear deficiency and retain pathogen. Most confusing about this case was the pulse remaining fine and weak throughout, lacking excess signs. Careful examination revealed deficiency of body but excess of pathogen. Only using American Ginseng, Fresh Rehmannia, Dendrobium, and Rhubarb to nourish Yin and drain heat was the correct principle. Adherence to this saved her from death, which is fortunate.