汝兄乃郎，年方龆龀，秋间咳嗽，入冬不止，初起呛嗽痰涩，气急面红，渐次潮热脉数
，食
减肌瘦，药如泻白散、止嗽散、清燥救肺汤，遍尝无验。汝兄虑成童怯，嘱予筹治。令且停
药，每日用甜悉尼一枚，去皮渣，雄猪肉四两，同切块，清水煮汤啜之。其肉与粳米稀粥同
食。儿病日久，戒食荤油，复为药苦，得此可口，食而甘之，数日而效，浃旬而痊。汝兄称
谢，并问其故。予曰∶斯证即喻西昌所谓秋伤于燥，冬生咳嗽之候也。夫燥者濡之，其所以
服诸清润之剂而不应者，缘童质向亏，嗽久阴伤，凡药皆草木根 ，只可濡其时邪之燥，未
能滋其津液之干耳。经云∶阴之所生，本在五味，五谷为养，五果为助，五畜为益，故用猪
肉悉尼粳米，诸多濡液滋干之品，气味合而服之，以补精益气，岂寻常方剂可同语耶。汝兄
慨然曰∶人知药能疗病，不知药反增病。人知食肉病复，不知食肉病愈。今而后益信医理渊
深，不易知也。
安波按∶读斯案字字珠玉，可见医贵圆通，徒执成方于胸中，亦复何益。
汝兄令爱，笄年在室，时届季夏，薄暮忽觉微寒，夜发壮热，头痛呕吐，次早迓予，其
女出
房就诊。脉弦急数，舌苔白腻。谓汝兄曰∶证属时感暑风，来势不轻，防其生变。方用葛根
防风以祛风，香薷茯苓甘草半夏滑石扁荚叶以清暑。诘朝入房诊视，脉证如故，舌苔转黄，
热盛口渴，目定神呆。方除葛根防风半夏，加入连翘知母花粉鲜荷叶，四朝再视，病者扶坐
榻上，昏昏不语，令其伸舌，勉伸半截，尖绛起刺。汝兄云∶小女夜来热炽，烦渴呻吟不安
，黎明稍定，以为病减，不意神更昏迷，肢渐厥冷，未识何故。予曰∶此暑入心包，邪陷于
里，热深厥深，肝风欲萌，势属危险，可延他医酌之。汝兄坚嘱拯治。思暑由上受，首先犯
卫，渐传入营，叶氏有清络热，必佐芳香，开里窍，以清神识，用至宝丹一法。吾乡苦无此
药，姑用生地、元参、银花、麦冬、川连、犀角、鲜菖蒲、西瓜翠衣，令取荷露煎药。翌日
复召，病势益剧。目阖肢掣，口噤牙咬。予曰∶肝风已动，证成痉厥，不可为矣。汝兄乞筹
以希万一。揣诸病情，治法不过如此，奈服药不应。无已再想外法，令桃黄土摊地上，铺荷
叶，将病患抬置其上，另用紫雪牛黄蜜调涂舌，方加钩藤、桑寄生、羚羊角，平肝熄风。
至第六朝，汝兄来云∶昨晚肢掣不作，口噤已开，似有生意，再烦视之。至见病患眼戴口张
，痰声漉漉，切脉如丝。予曰∶此非掣定，乃元气内夺，无力鼓动故也。脉证俱败，危期速
矣。延至七朝而殁。未几，又见鲍 莪翁令媳之证。
翁邀视媳病，云日前因热贪凉，起初头痛呕恶，旋即怯风发热。至今热犹未退，似属
外感
，烦为解散，免致成疟。导予入室。诊际问其头痛乎，病者不答。转令使女询之，亦复默然
。予曰∶殆证也。辞不治。 翁云∶小媳病才两日，其候不过发热头痛，何以言殆?予曰∶
害虽未形，其机已露。盖此病因于冒暑，夫暑喜伤心，心者君主之官，神明出焉。顷问病原
，蔑知应对。足征邪犯心包，神明为之紊乱，按心肝为脏，脏者藏也。邪已入脏，断难驱逐
。且手足厥阴相表里，肝风痉厥，蝉联而至，预期一候，恐有风波，并将张汝兄令爱病状告
之。翁虽唯唯，然未深信。续延他医疗治，诸证蜂生。果至七朝而逝，始信予言不虚。后旬
日又见许礼门翁令侄媳之证。
礼翁儒而通医。因乃侄媳病见招。晤间予告以近视张鲍两女病。均不治之故。翁蹙然云
∶舍
侄媳病候，与此仿佛，奈何?予问病经几日矣。曰五日。问其状。曰身热肢凉，昏迷螈 。
予曰，邪已入脏，不可救矣。其姑坚托诊视，脉证俱殆。翁求举方，予曰∶适谈前视张鲍两
女证，维时病患犹能行动，尚不可疗，况如是乎?辞欲登车，其仆乞诊妇病，询其何疾，云
病起三朝，发热不退，神渐昏冒，今早手足微掣。予曰∶此亦暑入心包之候也，可不必往。
翁强之。皆至其家，见妇昏卧于床，热盛息粗，面赤唇干，舌伸不前，抉视色绛，苔黄，切
脉弦数。辞不用药。仆人跪恳，勉议清解暑邪芳香宣窍之剂，并嘱用黄土荷叶垫卧。越日仆
来言，主母已故。妻病服药热缓掣定，神识稍清，复为加减，幸得获痊。后期年再见洪蕊春
兄令媳之证。
蕊兄乃媳，长夏患病，四朝热盛神昏，舌黄口渴，肢冷脉细。予诊之曰∶此暑邪内犯心
包，
棘手之候。蕊兄嘱治，勉商清暑涤邪，参以芳香开窍，并语之曰∶服药热减神苏，庶可图幸
，若肝风一动，则难救矣。旁议予方过凉，另延他医，以病者肢冷脉细，认为阴寒，遂用姜
附，置诸阳证不问。歙俗病家服药，喜热畏凉，膏粱殆甚，维时姻娅咸集，度其少年新婚，
当从阴证治法。蕊兄自不知医，因听众咻，信以为是。友人方瑞征，病者之表兄也，予视病
时，渠亦在座，见后医之方，与予相左，私叩所以，予曰∶病属暑邪入脏，热极似寒，实非
阴证。亟为清解，犹恐不及，再投姜附，岂不火上添油乎。瑞兄云∶家姑现下伊芳宅，吾往告
之，勿服其药如何?予曰∶子固婆心，但予虽能决其服彼药而必死，然未能料其服予药而必
生。续闻竞服彼药，肝风大动，颠簸反张，凭空跃起数尺，爬床搔席，啮舌断齿，未至一候
而亡。予所见数证，临危俱动风抽掣，然不若此之剧，盖由姜附燥烈，以刚与刚，益助其威
耳。后十余年，复见吴蔚扬兄令爱之证。
蔚兄令爱，适本里洪宅，即星恒翁之乃媳也。年近二旬，形瘦质弱，星翁乃郎，向外贸
易，
因病遄归，媳侍汤药，忧劳交集，时值溽暑，偶作寒热，次日热发不退，头痛呕吐，逆予诊
之，拟属暑风相搏，投以轻解之剂，诘朝脉证如故，神识欠慧，予谓星翁曰∶令媳病势颇剧
，刻防传变，可速告知令亲，切勿轻忽。原方佐以清热辟邪，四朝再召，蔚兄在座，据言昨
夕热盛烦躁，今晨人事更迷。予入房诊毕曰∶邪已入脏，旦晚肝风即至。病患体薄，且多忧
劳，料难支撑。并将畴昔所见诸证向说，嘱早延医斟酌。蔚兄务求画策，勉于昨剂中参入芳
香开窍，以尽人工。五日黎明，星翁遣价来请，予辞不往，再四相邀，至见病者昏卧肢掣，
喉中痰鸣。予曰∶内闭外脱，蔑能为力，他医用药，亦无效灵，越日而殂。
安波按∶于壬小春初二，治钱清场司秦积卿公祖，年将古稀，神采矍铄，六旬余得类
中症
，后以大补获痊。今岁秋季。忽觉形寒怕热，溺短便涩，素善饭膳，须豚蹄之属，饥必以大
碗燕窝，其余茶食之类，常不辍于口，寒热之际，啖食亦恐失饿，致见神采蒙 ，口牵指搐
，目闭溲遗，切脉沉伏，撬视舌苔，干燥黄浓。余曰∶此伏暑候也。年高怯弱，慎防内闭外
脱之险，辞以不起。彼人固求立方，余勉拟芳香开窍，辛凉豁痰之剂。今伊芳速觅妙手评酌，
医
亦吾药仿佛，竟服彼方。次日复诊，余视脉病仍然，令搜真西黄几厘，调至宝丹抹涂舌上，
倘得神定搐回，可望万一。如是弥留者五日矣。渠竟获得西黄几厘，调至宝丹将涂，讵期舌
初沾染，而公竟仙逝矣。兹阅斯案，益奇先生之明决于一候之间，神乎神乎。
门人问曰∶暑入心包一证，古人略而不详，近叶氏案载证治数条，似非不救之候，且六
淫首
重伤寒，其危莫如两感，虽轩岐只有死期，而无治法。然后贤谓用药先后，发表攻里，复推
出可生之机，今读先生所着暑入心包数案，咸辞不治，或拯无功，果斯候之危甚于两感，而
竟不可救耶?答曰∶伤寒两感固危，毕竟其邪表里双传，犹或可据可疗，暑邪变幻无常，彼
暴中之激烈，扁鹊不及 指而投咀，盖缘心为君主之官，心包乃其外郭，邪犯心包，至危至
急，乌可同类而语乎。又问曰∶暑入心包，危急之故，已闻命矣。然三因病候多端，岂无一
二可与比类者乎?答曰∶安得无之。小儿夏月冒暑发热，陡然神昏肢搐，俗呼暑风急惊，其
证仿佛，其原相同，洵可以称比类也。但暑邪感触，小儿即作惊搐者多，大人即入心包者少
。小儿暑风急惊，十中可救七八。大人暑入心包，十中难拯一二。此中奥义，不可不明。盖
小儿质弱，脏气未实，邪入易，故病多。大人体强，脏气已实，邪入难，故病少。惟其入之
易，则其出亦易，故治易。入之难，则其出亦难，故治难。即此观之，病情思过半矣。又问
曰∶夫子发蒙解惑，畅论病机，顿开茅塞，顽钝辈以为古人治病，证分寒热，药析温凉。今
见数案，治法悉是清暑辟邪，参以芳香通窍，不识此外尚有他法可施与?答曰∶凡治他病证
，有寒热之殊，药有温凉之异，惟此一证，有热无寒。比例温病，病必有阳而无阴，药必用
寒而远热。夫暴病暴死，皆属于火。苦寒则凝冱稽迟，焉有如此之激烈哉。予为子辈再伸其
义。医方八法，汗吐下和温清补渗是也，此证邪已入脏，汗之不宜，腑病宜通，脏无下法，
温则以刚与刚，和解渗利，绝无干涉，痰食结胸则吐之，脏邪从无吐出之理，至于补法，伤
寒中风，邪陷于里，往往用之，无如此证，邪入弥漫，虚灵闭塞，不涤其邪，徒补无益，故
舍清法，别无可施。譬诸救焚，舍水他无可用。再按小儿暑风惊证，质实能受清凉者可治，
质虚不受清凉者不可治，此证亦然。曩治许礼门翁仆妇之证得愈者，亦因其藜藿体坚，能受
清凉故也。膏粱羸弱，患此欲求幸免者，几希。又问曰∶《伤寒论》云∶太阳病头痛至七日
以上自愈者，以行其轻尽故也。若欲作再经者，针足阳明，使经不传则愈。此仲师验治伤寒
传经之法也。夫子言暑入心包之候，危于伤寒，但寒之伤人尚少，暑之伤人甚多，暑邪之入
脏，如伤寒之传经，应可预知，曷不仿仲师针法，使其不入可乎?答曰∶此未可易言也。夫
寒邪未传之先，有证可据，暑邪未入之先，无证可凭。当其疾作之始，身热头疼，呕吐口渴
，与寻常暑证不殊。有此慧眼，能预知其邪之欲入，而为设法堵御耶，《内经》论卒中云∶
急虚身中卒至，譬如堕溺，不可为期，可类推矣。虽然邪之未入，固难预知，而邪之既入，
不可不识。凡诊暑证，二三日间，视病者神识微呆，即是邪入之征。此语未经人道，舟子望
云而知风汛。予阅历有年之一得耳，既知邪之已入，维时其入尚浅，肝风未萌，似可极力验
之，勿令入深可也。无如暑邪变幻，电掣雷奔，迅速异常，纵使验逐，枉竭其力，罕见其功
，亦非临证目击，不能知之。兹因子辈之问，一伸病机，惜未水饮上池，无浣肠涤胃之术，
能起人于九死一生之中，徒自歉耳。
安波按∶病至危证毕聚，虽有慧心妙手，亦奚以为。姑立方者，聊尽良工之婆心耳。
【背景信息】
书名：程杏轩医案 作者：程杏轩 朝代：清 章节：张汝功兄乃郎嗽久伤阴奇治验 / 又令爱暑入心包拯治无功后见数人证同皆不可救并答门人四问 类别：医论
【原文翻译】
你哥哥的儿子，年纪才刚过童年（龆龀，指儿童换牙的时期，约七八岁），秋天开始咳嗽，到了冬天也没有停止。起初是呛咳、痰液黏稠难出，气急面红，逐渐出现午后潮热、脉搏快，食欲减退、肌肉消瘦。用药如泻白散（清泻肺热）、止嗽散（宣肺止咳）、清燥救肺汤（清燥润肺），都试遍了没有效果。你哥哥担心孩子体质虚弱形成“童怯”（小儿体虚易感之症），嘱咐我筹划治疗。我建议暂时停药，每天用甜悉尼（一种水果，即枇杷）一枚，去皮去核，雄猪肉四两，一起切成块，用清水煮汤饮用。肉与粳米稀粥一起吃。孩子病久了，忌食荤腥油腻，又因药味苦涩，得到这个可口的美味，吃得香甜，几天就见效，十天就好了。你哥哥道谢，并询问其中的缘故。我说：这个病症就是喻昌（字西昌）所说的“秋伤于燥，冬生咳嗽”的情况。燥邪应当用滋润的方法治疗，之所以服用各种清润药剂而没有反应，是因为孩子先天体质亏虚，咳嗽日久损伤了阴液，凡是药物都是草木根茎，只能滋润当时的外感燥邪，未能滋养体内津液的干枯。《内经》说：阴精的产生，根本在于五味，五谷为养，五果为助，五畜为益。所以使用猪肉、悉尼、粳米，这些都是许多濡润生津、滋补干燥的物品，气味相合而服用，可以补精益气，这哪里是寻常方剂能相比的呢？你哥哥感慨地说：人们只知道药能治病，不知道药反而增病；人们只知道吃肉会导致疾病复发，不知道吃肉能使疾病痊愈。从今以后更加相信医理深奥，不容易掌握啊。
安波按：读这个医案，字字珠玑，可见医学贵在圆通灵活，如果胸中只执着于固定的成方，又有什么益处呢？
你哥哥的女儿，已到及笄之年（女子十五岁成年），待字闺中。时值夏末，傍晚忽然觉得微恶寒，夜里发高热，头痛呕吐。第二天早上我去迎接诊治，她女儿走出房间就诊。脉象弦急数，舌苔白腻。我对她说：病症属于感受时令暑风，来势不轻，防止发生变证。方子用葛根、防风来祛风，香薷、茯苓、甘草、半夏、滑石、扁豆叶来清暑。第二天进入房间诊视，脉证如故，舌苔转黄，热盛口渴，眼睛呆滞、神情迟钝。方中去掉葛根、防风、半夏，加入连翘、知母、天花粉、鲜荷叶。第四天再诊视，病人扶着坐起在榻上，昏昏沉沉不说话，让她伸舌头，勉强伸出半截，舌尖绛红起刺。你哥哥说：小女昨晚热势炽盛，烦躁口渴呻吟不安，黎明时稍定，以为病情减轻，没想到神志更昏迷，四肢渐渐厥冷，不知什么原因。我说：这是暑邪侵入心包，邪气陷入体内，热越深则四肢厥冷越严重（热深厥深），肝风将要萌动，形势危险，可以请其他医生斟酌治疗。你哥哥坚决嘱托救治。我想暑邪从上受入，首先侵犯卫分，逐渐传入营分，叶天士有言：清络热，必须佐以芳香，开通里窍，以清醒神识，采用至宝丹一法。我们家乡苦于没有此药，暂且用地黄、玄参、金银花、麦冬、黄连、犀角、鲜石菖蒲、西瓜翠衣，让取荷露煎药。第二天再次召诊，病势更加剧烈。眼睛闭合，四肢抽搐，牙关紧闭咬齿。我说：肝风已经发动，病症已成痉厥（痉挛抽搐昏厥），无法救治了。你哥哥乞求想办法以求万一。揣测病情，治法不过如此，无奈服药无效。不得已再想外法，让桃黄土摊在地上，铺上荷叶，将病患抬置其上，另外用紫雪丹、牛黄蜜调涂舌上，方中加入钩藤、桑寄生、羚羊角，平肝熄风。到第六天，你哥哥来说：昨晚四肢抽搐不再发作，牙关已开，似乎有生机，再烦劳诊视。见到病患眼戴口张，痰声漉漉，切脉如丝。我说：这不是抽搐停止，而是元气内夺，无力鼓动所致。脉证俱败，危期速至。延至第七天去世。不久，又见到鲍莪翁儿媳的病证。
鲍翁邀请我看他儿媳的病，说前几天因为贪凉受热，起初头痛呕恶，随即怕风发热。到现在热还未退，似乎属于外感，烦劳为她解散表邪，免致成为疟疾。引导我进屋。诊脉时问她头痛吗，病人不回答。转而让侍女询问，也沉默不语。我说：大概是有死征吧。推辞不治。鲍翁说：小媳病才两天，症状不过是发热头痛，为什么说会有死征？我说：害处虽然还没显现，但机理已经暴露。因为这个病因是冒受暑邪，暑邪喜欢伤心，心是君主之官，神明由此发出。刚才询问病因，完全不知道应对。足证邪气侵犯心包，神明为之紊乱。按心肝为脏，脏者藏也。邪气已进入脏，断难驱逐。而且手足厥阴经相表里，肝风痉厥会接连而至，预期一个疗程（一候，五日），恐怕会有变故，并将张汝公兄女儿的病状告诉了他。鲍翁虽然答应，但未深信。随后请其他医生治疗，各种病症蜂拥而生。果然到第七天去世，才开始相信我的话不虚。后来十几天又见到许礼门翁侄媳的病证。
许礼翁儒雅且通晓医理。因为侄媳生病被招请。见面时我告诉他最近看张、鲍两家女子的病，都不治的原因。许翁皱眉说：舍侄媳的病候，与此相似，怎么办？我问病了几天了？说五天。问其状况。说身热肢凉，昏迷抽搐。我说：邪气已进入脏，不可救了。她的婆婆坚决托付诊治，脉证都危急。许翁请求开方，我说：刚才谈前次看张、鲍两家女子的证，当时病人还能行动，尚且不可疗，何况像现在这样呢？推辞要上车离开，他的仆人跪下恳求诊治妇人病，询问什么病，说病起三天，发热不退，神志渐渐昏蒙，今天早上手脚微抽。我说：这也是暑邪侵入心包的证候，可以不必去了。许翁强求前往。都到了他家，见妇人昏卧在床上，热盛呼吸粗重，面赤唇干，舌头伸不出来，拨开看颜色绛红，苔黄，切脉弦数。推辞不用药。仆人跪地恳求，勉强商议清解暑邪、芳香宣窍的药剂，并嘱咐用黄土荷叶垫着睡。第二天仆人来说，主母已故。妻子病服药后热缓抽搐停止，神识稍清，经过加减调理，幸好得以痊愈。后来一年又见到洪蕊春兄侄媳的病证。
洪蕊春的侄媳，长夏患病，四天热盛神昏，舌黄口渴，肢冷脉细。我诊察后说：这是暑邪内犯心包，棘手的证候。洪蕊春嘱咐治疗，勉强商量清暑涤邪，参以芳香开窍，并告诉他：服药后热减神苏，或许可以侥幸存活，如果肝风一动，就难救了。旁边议论我的方子太凉，另外请其他医生，因为病人肢冷脉细，认为是阴寒证，于是用姜、附子，置诸阳证不问。歙县风俗病家服药，喜热畏凉，饮食膏粱厚味极多，当时亲戚朋友都聚集，推测他是少年新婚，应当从阴证治法。洪蕊春自己不懂医，因为听从众人喧哗，信以为是。友人方瑞征，是病人的表兄，我看病时，他也在座，看到后医的方子，与我相反，私下问我原因，我说：病属暑邪入脏，热极似寒，实在不是阴证。急切地清解，还怕来不及，再投姜附，岂不是火上浇油吗？方瑞征说：家姑现在在我家，我去告诉她，不服他们的药怎么样？我说：你固然出于好心，但我虽然能断定服他们的药必死，然而不能料定服我的药必生。后来听说竟服了他们的药，肝风大动，颠簸反张，凭空跃起几尺，爬床搔席，咬舌断齿，不到一个疗程就死了。我所见的几个病例，临危都动风抽搐，但不如这个剧烈，大概是由姜附燥烈，以刚克刚，更加助长其威势罢了。十多年后，又见到吴蔚扬兄女儿的病证。
吴蔚扬的女儿，嫁在本村洪宅，也就是星恒翁的侄媳。年纪近二十岁，形体瘦弱，体质差。星翁的儿子，一向在外贸易，因病匆忙回来，媳妇侍奉汤药，忧劳交集，时值酷暑，偶尔出现寒热，第二天热发不退，头痛呕吐，逆着我诊察，拟属暑风相搏，投以轻解的药剂。第二天脉证如故，神识不清，我对星翁说：令媳病势颇剧，此刻防止传变，可迅速告知你的亲人，切勿轻视。原方佐以清热辟邪，第四天再次召诊，蔚扬在座，据他说昨晚热盛烦躁，今晨人事更迷。我进房诊毕说：邪气已进入脏，早晚肝风就会到来。病患身体单薄，且多忧劳，料难支撑。并将以前所见的各病例状说明，嘱咐早请医生斟酌。蔚扬务必寻求对策，勉强在昨天的药中参入芳香开窍，以尽人力。第五天黎明，星翁派人来请，我推辞不去，再三邀请，见到病人昏卧抽搐，喉中痰鸣。我说：内闭外脱，无能为力，其他医生用药，也无效灵，第二天去世。
安波按：在壬小春初二日，治疗钱清场司秦积卿公祖，年纪将近七十，神采矍铄，六十多岁得类中风症，后来以大补获痊。今年秋季。忽然觉得形寒怕热，尿短便涩，素来善饭膳，须吃猪蹄之类，饿了必以大碗燕窝，其余茶食之类，常不停口，寒热之际，吃饭也怕失饿，导致神采蒙蔽，口牵指搐，目闭遗尿，切脉沉伏，撬开看舌苔，干燥黄浓。我说：这是伏暑证候。年高体弱，慎防内闭外脱的危险，推辞说不行。那人坚持要求开方，我勉强拟定芳香开窍、辛凉豁痰的药剂。今天他迅速寻找妙手评判斟酌，医生开的药也差不多，竟然服了那个方子。第二天复诊，我看脉病仍然，让人搜索真西黄几厘，调至宝丹抹涂舌上，倘若得神定搐回，可望万一。这样弥留了五天了。他竟获得西黄几厘，调至宝丹准备涂抹，岂料舌头初沾染，而公竟仙逝矣。现在阅读这个医案，更加惊奇先生在一候之间明决，神乎其神啊。
门人问：暑入心包一证，古人略而不详，近来叶天士案中记载证治数条，似乎不是不救的证候，而且六淫首重伤寒，其危莫如两感（太阳与少阴两感），虽然黄帝岐伯只有死期，而无治法。但后世贤人说用药先后，发表攻里，又推出可生的机会，现在读先生所著暑入心包数案，都推辞不治，或拯救无功，果真这个证候比两感更危重，而竟不可救吗？回答说：伤寒两感固然危重，毕竟邪气表里双传，或许还可以依据和疗治，暑邪变幻无常，那暴中的激烈程度，扁鹊来不及指切脉象而投药，大概因为心是君主之官，心包是其外郭，邪犯心包，至危至急，怎么可以同类而语呢？又问：暑入心包，危急的缘故，已听明白了。然而三种因病候多端，难道没有一二个可以比拟的吗？回答说：怎么会没有呢。小儿夏月冒暑发热，陡然神昏肢搐，俗呼暑风急惊，其证仿佛，其源相同，确实可以称为比类。但暑邪感触，小儿即作惊搐的多，大人即入心包的少。小儿暑风急惊，十中可救七八。大人暑入心包，十中难救一二。其中奥义，不可不明。大概小儿体质弱，脏气未实，邪入易，所以病多。大人身体强，脏气已实，邪入难，所以病少。正因为入之易，则出亦易，所以治易。入之难，则出亦难，所以治难。就此看来，病情思过半矣。又问：夫子启发蒙昧解惑，畅论病机，顿开茅塞，愚钝辈以为古人治病，证分寒热，药析温凉。现在见数案，治法全是清暑辟邪，参以芳香通窍，不识此外尚有他法可施吗？回答说：凡治他病证，有寒热之殊，药有温凉之异，惟此一证，有热无寒。比例温病，病必有阳而无阴，药必用寒而远热。夫暴病暴死，皆属于火。苦寒则凝冱稽迟，哪有如此之激烈哉。我为你们再伸其义。医方八法，汗吐下和温清补渗是也，此证邪已入脏，汗之不宜，腑病宜通，脏无下法，温则以刚与刚，和解渗利，绝无干涉，痰食结胸则吐之，脏邪从无吐出之理，至于补法，伤寒中风，邪陷于里，往往用之，无如此证，邪入弥漫，虚灵闭塞，不涤其邪，徒补无益，故舍清法，别无可施。譬诸救焚，舍水他无可用。再按小儿暑风惊证，质实能受清凉者可治，质虚不受清凉者不可治，此证亦然。从前治许礼门翁仆妇的病得愈者，也是因其藜藿体坚，能受清凉故也。膏粱羸弱，患此欲求幸免者，几乎没有。又问：《伤寒论》说：太阳病头痛至七日以上自愈者，以行其经尽故也。若欲作再经者，针足阳明，使经不传则愈。这是仲师验证治疗伤寒传经之法。夫子说暑入心包之候，危于伤寒，但寒之伤人尚少，暑之伤人甚多，暑邪之入脏，如伤寒之传经，应可预知，何不仿仲师针法，使其不入可乎？回答说：这不可以轻易说。夫寒邪未传之前，有证可据，暑邪未入之前，无证可凭。当其疾作之初，身热头疼，呕吐口渴，与寻常暑证不殊。有此慧眼，能预知其邪之欲入，而为设法堵御耶，《内经》论卒中云：急虚身中卒至，譬如堕溺，不可为期，可类推矣。虽然邪之未入，固难预知，而邪之既入，不可不识。凡诊暑证，二三日间，视病者神识微呆，即是邪入之征。此语未经人道，舟子望云而知风汛。予阅历有年之一得耳，既知邪之已入，此时其入尚浅，肝风未萌，似可极力验之，勿令入深可也。无如暑邪变幻，电掣雷奔，迅速异常，纵使验逐，枉竭其力，罕见其功，亦非临证目击，不能知之。兹因子辈之问，一伸病机，惜未饮上池之水，无浣肠涤胃之术，能起人于九死一生之中，徒自歉耳。
安波按：病至危证毕聚，虽有慧心妙手，亦奚以为。姑立方者，聊尽良工之婆心耳。
[Background Information]
Book: Cheng Xingxian's Medical Cases (Cheng Xingxuan Yi An)
Author: Cheng Xingxuan (Cheng Xingxuan)
Dynasty: Qing Dynasty
Chapter: A Miraculous Case of Cough Due to Yin Injury in the Son of Mr. Zhang Rugong's Elder Brother / Subsequently, Several Cases of Summer-Heat Invading the Pericardium in His Daughter and Others Were Untreatable, Along with Four Questions Answered to Disciples
Category: Medical Discussion
[English Translation]
The son of your elder brother was just a child (replacing teeth, approx. 7-8 years old). He began coughing in autumn, which persisted into winter. Initially, he had spasmodic cough with thick, difficult-to-expectorate phlegm, shortness of breath, and facial redness. Gradually, afternoon tidal fever and rapid pulse developed, accompanied by decreased appetite and emaciation. Medications such as Xiebai San (White Powder Decoction for Clearing Lung Heat), Zhisou San (Cough-Stopping Powder), and Qingzao Jiufei Tang (Decoction for Clearing Dryness and Nourishing the Lungs) were tried extensively without effect. Your brother, worried that his frail constitution would lead to "Tong Qie" (pediatric deficiency syndrome susceptible to external pathogens), instructed me to plan treatment. I advised temporarily stopping medication and using one sweet loquat (Shi Xi Ni) daily, peeled and seeded, along with four taels of lean pork, cut into pieces and boiled in clear water for drinking. The meat was eaten with rice gruel. As the child had been ill for a long time, avoiding greasy food, and finding medicine bitter, he enjoyed this palatable remedy. It showed effect within a few days and cured him within ten days. Your brother thanked me and asked for the reason. I said: This case corresponds to Yu Chang's (Yu Xichang) description of "Autumn injury by dryness, winter generation of cough." Dryness should be treated with moistening. The reason previous clearing and moistening agents failed is that the child had innate constitutional deficiency and prolonged cough damaged Yin. All herbal medicines are plant roots/stems; they can only moisten the external dry pathogen but cannot nourish the internal dryness of body fluids. The *Classic of Internal Medicine* states: The production of Yin essence originates from the Five Flavors; five grains nourish, five fruits assist, and five meats benefit. Therefore, using pork, loquat, and rice—substances that moisten and generate fluids—combined in taste and nature, can replenish essence and Qi. How can ordinary formulas compare? Your brother exclaimed: People know medicine cures disease, but do not realize medicine can exacerbate it; people know eating meat may cause relapse, but do not know eating meat can cure disease. From now on, I deeply believe medical principles are profound and difficult to master.
An Bo comments: Reading this case, every word is precious. It shows that medicine requires flexibility and adaptability. Clinging rigidly to fixed prescriptions yields no benefit.
Your brother's daughter had reached her coming-of-age (15 years old) and remained unmarried. At the end of summer, she suddenly felt slight aversion to cold in the evening, followed by high fever at night, headache, and vomiting. I visited the next morning. Her pulse was wiry, urgent, and rapid; tongue coating was white and greasy. I told your brother: The condition belongs to seasonal summer-heat wind invasion, with a severe onset, risking complications. The formula used Ge Gen (Puerariae Radix) and Fang Feng (Saposhnikoviae Radix) to dispel wind, and Xiang Ru (Elsholtziae Herba), Fu Ling (Poria), Gan Cao (Glycyrrhizae Radix), Ban Xia (Pinelliae Rhizoma), Hua Shi (Talcum), and Bian Dou Ye (Vigna umbellatae Folium) to clear summer-heat. The next day, upon re-examination, the pulse and symptoms remained unchanged, but the tongue coating turned yellow, with intense heat, thirst, fixed gaze, and dull spirit. Ge Gen, Fang Feng, and Ban Xia were removed from the formula; Lian Qiao (Forsythiae Fructus), Zhi Mu (Anemarrhenae Rhizoma), Hua Fen (Trichosanthis Radix), and fresh He Ye (Nelumbinis Folium) were added. On the fourth day, the patient sat up on the couch, drowsy and mute. When asked to extend her tongue, she barely extended half, revealing a crimson tip with prickles. Your brother said: Last night, her heat was intense, with irritability, thirst, moaning, and restlessness. At dawn, it subsided slightly, so I thought the illness improved. Unexpectedly, her consciousness became more comatose, and limbs grew cold. Why? I said: This is summer-heat invading the Pericardium (Xin Bao), with pathogenic factors sinking inward. The deeper the heat, the deeper the cold extremities (Re Shen Jue Shen). Liver wind is about to stir. The situation is dangerous; other physicians should be consulted. Your brother insisted on my treatment. I reasoned that summer-heat enters from above, first affecting the Wei (Defensive) level, then gradually entering the Ying (Nutritive) level. Ye Tianshi stated: To clear collateral heat, aromatic herbs must be added to open the orifices internally and clarify the spirit, employing the method of Zhibao Dan (Precious Treasure Pill). Our region lacked this medicine, so I temporarily used Sheng Di Huang (Rehmanniae Radix), Yuan Shen (Scrophulariae Radix), Yin Hua (Lonicerae Japonicae Flos), Mai Dong (Ophiopogonis Radix), Chuan Lian (Coptidis Rhizoma), Xi Jiao (Rhinocerotis Cornu - note: use substitutes in practice), Xian Chang Pu (Acori Tatarinowii Rhizoma), and Xi Gua Cui Yi (Watermelon Rind), decocted with lotus dew. The next day, summoned again, the condition worsened significantly. Eyes closed, limbs convulsing, jaw clenched and teeth grinding. I said: Liver wind has stirred; the condition has become Jing Jue (spasm-coma), which is untreatable. Your brother begged for any chance. Analyzing the condition, the treatment options were limited, and medication failed. Desperately seeking an external method, I had peach-colored loess spread on the ground, covered with lotus leaves, and placed the patient on it. Zixue Dan (Purple Snow Pill) and Niu Huang (Bovis Calculus) mixed with honey were applied to the tongue. Gou Teng (Uncariae Ramulus cum Uncis), Sang Ji Sheng (Taxilli Caulis), and Ling Yang Jiao (Saigae Tataricae Cornu) were added to calm the liver and extinguish wind. On the sixth day, your brother reported: Last night, limb convulsions stopped, jaw opened, showing signs of life. Please examine again. Upon seeing the patient, eyes wide open, mouth agape, with rattling phlegm sounds, and thread-like pulse. I said: This is not cessation of convulsions, but depletion of primordial Qi, lacking strength to move. Pulse and symptoms indicate collapse; death is imminent. She died on the seventh day. Soon after, I saw the case of Mr. Bao E's daughter-in-law.
Mr. Bao invited me to see his daughter-in-law, who, due to greed for coolness amidst heat, initially suffered headache and nausea/vomiting, followed by aversion to wind and fever. Fever persisted. It seemed like an external contraction; I was asked to release the exterior to prevent malaria. In the room, I asked if she had a headache; she did not answer. Asking the maid yielded silence. I said: There are likely signs of death. I declined to treat. Mr. Bao said: Illness is only two days, symptoms are merely fever and headache. Why predict death? I said: Although the harm hasn't manifested, the mechanism is revealed. This illness stems from summer-heat exposure. Summer-heat loves to damage the Heart. The Heart is the Sovereign Official, where Shen (Spirit/Mind) resides. She could not respond to questions, proving pathogenic factors invaded the Pericardium, disrupting the Spirit. According to theory, Heart and Liver are Zang organs. Pathogens entering Zang organs are hard to expel. Since Hand-Foot Jueyin meridians are interior-exterior related, Liver wind and spasm-coma will follow. Within one cycle (five days), disaster is expected. I also described the case of Mr. Zhang's daughter. Mr. Bao agreed but didn't fully believe. Other doctors were consulted, and various symptoms emerged. Indeed, she died on the seventh day, confirming my words. Ten days later, I saw Mr. Xu Limen's niece-in-law.
Mr. Xu Limen was scholarly and knowledgeable in medicine. He summoned me for his niece-in-law. I told him why the cases of the Zhang and Bao women were untreatable. Mr. Xu frowned: My niece-in-law's symptoms are similar. What should be done? I asked duration: five days. Symptoms: Body heat, cold limbs, coma, and convulsions. I said: Pathogens have entered the Zang organs; it is incurable. Her mother-in-law insisted on treatment. Pulse and symptoms were critical. Mr. Xu requested a prescription. I said: Previously, when treating the Zhang and Bao cases, patients could still move, yet were untreatable. How much worse is this? I tried to leave. His servant knelt, begging to treat the woman. She had had fever for three days, unrelenting, with gradual mental confusion and mild hand/foot twitching this morning. I said: This is also summer-heat invading the Pericardium; no need to go. Mr. Xu insisted. We arrived to find the woman lying comatose, with intense heat, coarse breathing, red face, dry lips, inability to extend tongue, crimson color upon inspection, yellow coating, and wiry-rapid pulse. I refused medication. The servant pleaded. Reluctantly, I proposed a formula to clear summer-heat and open orifices aromatically, advising a bed of loess and lotus leaves. The next day, the servant reported the mistress had died. The wife's fever subsided, convulsions stopped, and spirit cleared after medication adjustments; she recovered. A year later, I saw Mr. Hong Ruichun's niece-in-law.
Mr. Hong's niece-in-law fell ill in mid-summer. After four days, intense heat, coma, yellow tongue, thirst, cold limbs, and fine pulse. I diagnosed: Summer-heat invading the Pericardium internally, a棘手 (thorny/difficult) condition. Mr. Hong urged treatment. I suggested clearing summer-heat and eliminating pathogens, aided by aromatic orifice-opening herbs, warning: If heat reduces and spirit returns, there might be hope. If Liver wind stirs, it is incurable. Critics argued my formula was too cooling. Another doctor was hired, diagnosing Yin-cold due to cold limbs and fine pulse, prescribing Ginger (Gan Jiang) and Aconite (Fu Zi), ignoring Yang-pathogen aspects. Local custom favors hot over cold meds; diet is rich/greasy. Relatives gathered, assuming young newlyweds should be treated as Yin-cold. Mr. Hong, ignorant of medicine, followed the crowd. Friend Fang Ruizheng (patient's cousin) was present, saw the conflicting prescription, and asked why. I explained: Summer-heat entering Zang organs causes extreme heat mimicking cold; it is not Yin-cold. Urgent clearing is needed; adding Ginger/Aconite is like adding oil to fire. Fang suggested telling the aunt-in-law not to take the other meds. I replied: You are kind, but while I can predict death from wrong meds, I cannot guarantee life from mine. They took the other meds. Liver wind stirred violently: back arching, jumping feet high, crawling on bed/mats, biting tongue/teeth. Died within five days. Among my cases, none were as severe, largely due to the drying/hot nature of Ginger/Aconite clashing with the heat. Over ten years later, I saw Wu Weiyang's daughter.
Mr. Wu's daughter, married to the Hong family (Grandpa Xingheng's niece-in-law), nearly twenty, thin and weak. Grandpa Xingheng's son returned from trade due to illness; the daughter-in-law cared for him, accumulating worry and fatigue during muggy summer. She had alternating chills/fever, then persistent fever, headache, vomiting. I diagnosed Summer-Heat Wind conflict, prescribed light resolving agents. Next day, pulse/symptoms unchanged, spirit unclear. I warned Grandpa Xingheng: Condition is severe, risk of transmission. Inform relatives. Add heat-clearing/pathogen-resisting herbs. Fourth day: Intense heat, irritability last night, deeper confusion this morning. I examined and said: Pathogens entered Zang organs; Liver wind will arrive soon. Patient is frail and overworked; unlikely to survive. I recounted previous cases and urged early consultation. Mr. Wu sought strategies. I reluctantly added aromatic orifice-openers to yesterday's formula to exhaust human effort. Fifth day dawn: Grandpa Xingheng sent messenger. I declined, but was persuaded. Found patient comatose, convulsing, phlegm rattle in throat. I said: Internal closure and external collapse. No power to help. Other doctors' meds ineffective. Died next day.
An Bo comments: When critical symptoms converge, even skilled hands are useless. Prescribing is merely to fulfill a physician's compassionate heart.
Disciple asks: Summer-heat invading Pericardium is rarely detailed by ancients. Ye Tianshi's cases show treatments, implying it's not always fatal. Two-meridian contraction (Liang Gan) in Cold Damage is considered most critical, yet Ye implies treatability. Are Mr.'s cases truly more critical than Liang Gan and incurable?
Reply: Liang Gan is critical, but pathogens affect both exterior and interior, allowing some basis for treatment. Summer-heat changes unpredictably; its violent onset is so fast that even Bian Que couldn't diagnose and prescribe in time. The Heart is the Sovereign; Pericardium is its outer shield. Invasion here is extremely critical and urgent, unlike other conditions.
Disciple: Understood. But among many summer-heat patterns, are there comparable ones?
Reply: Yes. Pediatric summer-heat fever causing sudden coma and convulsions (Summer-Heat Wind Acute Convulsion) is similar in presentation and origin. However, children often get convulsions, while adults get Pericardium invasion. Pediatric cases are 70-80% curable; adult cases are 10-20% curable. Children have weak constitutions and immature Zang Qi, making pathogen entry easy and exit easy (easy to treat). Adults have strong constitutions and mature Zang Qi, making entry hard and exit hard (hard to treat). Thus, understanding this clarifies the pathology.
Disciple: Ancient texts distinguish cold/heat and warm/cool drugs. These cases all use heat-clearing, pathogen-resisting, and aromatic opening. Are there other methods?
Reply: Most diseases have cold/heat variations and warm/cool drugs. This specific condition has heat but no cold. Like Warm Diseases, it involves Yang but not Yin; thus, cold drugs are used, avoiding heat. Sudden death belongs to Fire. Bitter-cold drugs might stagnate, but summer-heat is fierce. Regarding the Eight Methods: Sweating is unsuitable for Zang invasion; Purging is for Fu organs, not Zang; Warming clashes with heat; Harmonizing/Diuretics are irrelevant; Vomiting is for phlegm/food in chest, not Zang pathogens; Tonification is for sinking pathogens in Cold Damage, but here pathogens are pervasive and blocking, so tonification is useless without clearing. Like fighting a fire, only water works. For pediatric summer-heat convulsions, those with solid constitutions tolerating cooling can be treated; those with deficient constitutions cannot. Similarly for adults. The servant girl I cured survived because she had a robust constitution from poor diet. Those with rich diets and weak constitutions rarely survive.
Disciple: *Shanghan Lun* says Taiyang headache resolves in 7+ days as the meridian cycle ends; otherwise, needle Foot-Yangming to stop transmission. Can we prevent summer-heat from entering Zang like preventing Cold Damage transmission?
Reply: Not easily. Before Cold Damage transmits, there are signs. Before summer-heat enters, there are no specific signs. Early symptoms (fever, headache, vomiting, thirst) mimic common summer-heat. Only with wisdom eye can one predict invasion. *Neijing* compares stroke to falling into water—sudden and unpredictable. However, once entered, it must be recognized. In summer-heat diagnosis, if after 2-3 days the patient's spirit appears slightly dull, it signals invasion. This insight comes from experience. Once known, if invasion is shallow and Liver wind hasn't stirred, one might try to prevent deepening. But summer-heat moves like lightning; efforts are often futile without clinical observation. I share this due to your questions, regretting I lack the legendary ability to save lives from near-death.
An Bo comments: When critical symptoms gather, even wise minds fail. Prescribing is but a gesture of compassion.