病有纯虚纯实，非补即泻，何有乘除？设遇既虚，且实者，补泻间用，当详孰先孰
后，从少从多，可缓可急，随其证而调之。
医案，吴江沈青来正，少寡，素多郁怒，而有吐血证
岁三四发，吐后即已，无有他证，盖不以为事也。三月间，别无他故，忽有小发热，头疼身
痛，不恶寒而微渴，恶寒不渴者，感冒风寒，今不恶寒微渴者，疫也。至第二日，旧证
大发，吐血胜常，更加眩晕，手振烦躁，种种虚躁，饮食不进，且热渐加重，医者病者，但见
吐血，以为旧证复发，不知其为疫也，故以发热认为阴虚，头疼身痛，认为血虚，不察未吐
血前一日，已有前证，非吐血后所加之证也。诸医议补，问予可否？余曰∶失血补虚，权宜
则可。盖吐血者内有结血，正血不归经，所以吐也。结血牢固，岂能吐乎？能去其结，于中无
阻，血自归经，方冀不发。若吐后专补内则血满，既满不归，血从上溢也。设用寒凉尤误。投
补剂者，只顾目前之虚，用参暂效，不能拔去病根，日后又发也。况又兼疫，今非昔比，今
因疫而发，血脱为虚，邪在为实，是虚中有实，若投补剂，始则以实填虚，沾其补益，既而
以实填实，灾害并至。于是暂用人参二钱，以茯苓、归、芍佐之，两剂后，虚证咸退，热减
六七，医者病者皆谓用参得效，均欲速进，余禁之不止，乃恣意续进，便觉心胸烦闷，腹中
不和，若有积气，求哕不得，此气不时上升，便欲作呕，心
下难过，遍体不舒，终夜不寐，喜按摩
捶击，此皆外加有余之变证也。所以然者，止有三分之疫，只应三分之热，适有七分之虚，
经络枯涩，阳气内陷，故有十分之热。分而言之，其间是三分实热，七分虚热也。向则本气
空虚，不与邪搏，故无有余之证。但虚不任邪，惟懊
、郁冒、眩晕而已，今投补剂，是以
虚证减去，热减六七，所余三分之热者，实热也，乃是病邪所致，断非人参可除者，今再服
之，反助疫邪，邪正相搏，故加有余之变证，因少与承气微利之而愈。按此病设不用利药，
宜静养数日亦愈。以其人大便一二日一解，则知胃气通行，邪气在内，日从胃气下趋，故自
愈。间有大便自调而不愈者，内有湾粪，隐曲不得下，下得宿粪极臭者，病始愈。设邪未去
，恣意投参，病乃益固，日久不除，医见形体渐瘦，便指为怯证，愈补愈危，死者多矣。
要之，真怯证世间从来罕有，令患怯证者，皆是人参造成。近代参价若金，服者不便，是以此证不生于贫家，多生于富
室也。
疾病有纯虚或纯实的情况，非补即泻，哪里会有“乘除”（指虚实夹杂时的权衡处理）呢？如果遇到既虚且实的病证，补法和泻法交替使用，应当详细斟酌先补后泻还是先泻后补，用量多少，治疗缓急，根据具体证候来调整。
医案：吴江沈青来先生，年少丧妻，平素多郁怒，患有吐血病证，每年发作三四次，吐完就好了，没有其他症状，所以不把它当回事。三月间，没有其他缘故，忽然出现轻微发热、头痛、身痛，不恶寒而微渴。不恶寒而渴的是感冒风寒；现在不恶寒而微渴的，是疫病。到了第二天，旧病大发，吐血比平时严重，更加眩晕，手抖烦躁，各种虚性躁动表现，饮食不进，而且热势逐渐加重。医生和患者只看到吐血，以为旧病复发，不知道这是疫病，所以把发热认为是阴虚，头痛身痛认为是血虚，没有察觉在吐血前一天就已经有了这些前驱症状，而不是吐血后才加上的新证。众医商议用补法，问我是否可行？我说：失血后补虚，作为权宜之计是可以的。因为吐血者体内有瘀血阻滞，正常血液不能归经，所以才会吐血。如果瘀血牢固不散，怎么能吐出来呢？如果能去除瘀血阻滞，血脉通畅，血液自然归经，才希望不再发作。如果在吐血后专门进补，体内血液会壅满，既然满了就不能归经，血液就会从上窍溢出。如果用寒凉药更是错误。投用补剂的人，只顾眼前的虚损，用人参暂时见效，但不能拔除病根，日后还会复发。况且又兼有疫病，今非昔比，现在是因疫病诱发，血脱导致虚，邪气存在导致实，这是虚中有实。如果投用补剂，开始是以实填虚，沾点补益的光；随后是以实填实，灾害并至。于是暂时用人参二钱，以茯苓、当归、白芍辅助，两剂后，虚证全部消退，热势减轻六七成，医生和患者都认为用人参有效，都想快速继续进补，我禁止不住，他们就肆意继续服用，便觉得心胸烦闷，腹中不和，好像有积气，想打嗝打不出来，这股气不时上升，就想作呕，心下难受，全身不舒服，整夜睡不着，喜欢按摩捶击，这些都是外加有余（实证）的变化证候。之所以这样，是因为只有三分的疫邪，只应产生三分的热象，恰好有七分的虚损，经络枯涩，阳气内陷，所以表现出十分的热象。分开来说，其中是三分实热，七分虚热。以前是本气空虚，不与邪气搏斗，所以没有有余（实证）的表现。只是虚不受邪，仅有懊恼、头昏目眩、眩晕而已。现在投用补剂，使得虚证减去，热势减轻六七成，所剩下的三分热象，其实是实热，这是病邪所致，绝对不是人参能清除的。现在再服用人参，反而助长疫邪，邪正相搏，所以增加了有余的变化证候，因此少量给予承气汤轻微通利大便而痊愈。按：这个病如果不使用通利药，静养几天也会好。因为他大便一两天解一次，就知道胃气通行，邪气在内，每天随着胃气向下趋走，所以自愈。也有大便自调但没好的，是因为内有燥屎，隐蔽曲折不得下行，排出宿粪极臭时，病才开始愈。如果邪气未去，肆意投用人参，病情会更加顽固，日久不除，医生见形体渐瘦，就指为怯证（虚劳），越补越危险，死的人很多。总之，真正的怯证世间从来罕见，现在患怯证的，都是人参造成的。近代人参价格如金，服用不便，所以此证不生于贫家，多生于富室。
Diseases may present as purely deficient or purely excess, requiring either tonification or purgation; where is there room for "Cheng Chu" (the balancing of deficiency and excess)? If one encounters a condition that is both deficient and excess, alternating between tonification and purgation requires careful consideration of whether to tonify first or purge first, the proportion of each, and whether the treatment should be slow or urgent, adjusting according to the specific syndrome.
Medical Case: Mr. Shen Qinglai from Wujiang, who became widowed young, had a history of frequent depression and anger, and suffered from hemoptysis (coughing up blood) occurring three to four times a year. After vomiting blood, he would recover without other symptoms, so he did not consider it a serious matter. In March, without any other cause, he suddenly developed slight fever, headache, and body pain. He did not have aversion to cold but had slight thirst. Aversion to cold with thirst indicates wind-cold invasion; however, no aversion to cold with slight thirst indicates epidemic pestilence (Yi). On the second day, his old condition flared up severely, with hemoptysis exceeding usual amounts, accompanied by dizziness, hand tremors, and irritability, manifesting various signs of deficiency-induced restlessness. He lost his appetite, and the fever gradually intensified. The physicians and the patient only saw the hemoptysis and assumed it was a recurrence of his old condition, unaware that it was an epidemic disease. Therefore, they attributed the fever to Yin deficiency and the headache and body pain to Blood deficiency. They failed to observe that these precursor symptoms had appeared the day before the hemoptysis, rather than being new symptoms added after bleeding. The physicians discussed using tonification and asked if I agreed. I said: Tonifying deficiency after blood loss can be acceptable as a temporary measure. This is because in cases of hemoptysis, there is stagnant blood internally obstructing the vessels, causing normal blood to fail to return to its channels, thus leading to bleeding. If the stagnant blood remains firm and unresolved, how can it be expelled? If the obstruction is removed, allowing free flow, the blood will naturally return to its channels, offering hope that it will not recur. However, if one specializes in tonification after bleeding, the interior will become full of blood; once full, it cannot return to the channels, and blood will overflow from the upper orifices. Using cold-natured herbs would be even more erroneous. Those administering tonics only focus on the immediate deficiency; using Ginseng may provide temporary relief but cannot eradicate the root cause, leading to future recurrences. Moreover, since there is also an epidemic pathogen, the situation differs from before. Now, the episode is triggered by the epidemic; blood loss causes deficiency, while the presence of the pathogen causes excess. This is a case of deficiency containing excess. If tonics are administered, initially, the excess fills the deficiency, gaining some benefit from tonification; subsequently, the excess fills the excess, leading to disaster. Thus, I temporarily used two qian of Ren Shen (Ginseng Radix et Rhizoma), assisted by Fu Ling (Poria), Dang Gui (Angelicae Sinensis Radix), and Bai Shao (Paeoniae Radix Alba). After two doses, the deficiency symptoms subsided, and the fever decreased by six or seven tenths. The physicians and patient believed the Ginseng was effective and wanted to continue rapidly. I could not stop them, so they continued recklessly. They then felt chest and epigastric oppression, abdominal discomfort, and a sensation of accumulated Qi, unable to belch. This Qi rose intermittently, causing nausea, distress in the epigastrium, general body discomfort, and insomnia throughout the night. They preferred massage and percussion. These are all changes indicating external excess syndromes. The reason is that there were only three parts of epidemic pathogen, which should produce only three parts of heat, but coincidentally, there were seven parts of deficiency. The meridians were dry and sluggish, and Yang Qi sank inward, resulting in ten parts of heat manifestation. Analyzed separately, this consisted of three parts excess heat and seven parts deficiency heat. Previously, when the vital Qi was empty, it did not struggle with the pathogen, so there were no excess symptoms. There was only internal restlessness (Ao Nu), dizziness, and vertigo due to weakness failing to resist the pathogen. Now, by administering tonics, the deficiency symptoms were reduced, and the fever decreased by six or seven tenths. The remaining three parts of heat are actually excess heat caused by the pathogen, which absolutely cannot be cleared by Ginseng. Taking Ginseng again now would instead aid the epidemic pathogen. The struggle between pathogen and healthy Qi resulted in the addition of excess change syndromes. Therefore, I administered a small amount of Cheng Qi Tang (Cathartic Decoction) to induce mild purgation, and the patient recovered. Note: If purgatives had not been used, resting quietly for a few days would also have led to recovery. Since his bowel movements occurred once every one to two days, it indicated that Stomach Qi was circulating, and the pathogen was inside, descending daily with the Stomach Qi, hence self-recovery. Some patients with regular bowel movements did not recover because there was dry stool hidden within, obstructing downward movement; recovery began only after expelling foul-smelling old stool. If the pathogen has not been eliminated and Ginseng is administered recklessly, the disease becomes more entrenched. Over time, if not resolved, physicians seeing gradual emaciation might diagnose it as Qie Zheng (Timidity Syndrome/Deficiency Consumption). Further tonification increases danger, and many die. In short, true Qie Zheng is rare in the world; those suffering from it nowadays are largely caused by Ginseng. In recent times, the price of Ginseng is like gold, making consumption inconvenient; therefore, this condition rarely arises in poor families but mostly in wealthy households.