徐 迩日天令骤冷。诊左脉忽现芤涩。痛时筋挛。绕掣耳后。此营虚脉络失养。风动筋急。前法
清络。凉剂不应。营虚不受辛寒。仿东垣舒筋汤意。（痛绕耳后）
当归 生黄 片姜黄 桂枝 防风 生于术 煎药化活络丹一丸。
某 劳倦。肩臂疼。（肩臂痛）
川桂枝木 木防己 五加皮 茯苓 生苡仁 炒白蒺
涂（六二） 痛起肩胛。渐入环跳髀膝。是为络虚。
黄 （五钱） 于术（三钱） 当归（三钱） 茯苓（二钱） 防己（八分） 防风根（五分）
羌活（五分）
又 照前方去防风羌活加杞子沙苑。
邹 五旬又四。阳明脉衰。肩胛筋缓。不举而痛。治当通补脉络。莫进攻风。
生黄 于术 当归 防风根 姜黄 桑枝
王（四二） 阳明气衰。厥阴风动头眩目昏。右肩痛麻。胁下有聚气。足厥阴主治。
枸杞子（四两） 归身（三两） 羚羊角（生研二两） 制白蒺（去刺三两） 嫩黄 皮（四两）
胡天麻（二两煨）
菊花二两熬汁桑枝四两熬汁丸。
徐（五二） 左指胀痛引肩。男子血虚风动。病在肝。形脉不足。以柔药温养。
制首乌 枸杞子 归身 三角胡麻 菊花炭 柏子仁 刺蒺藜 桑枝膏丸。
俞（妪） 高年阳明气乏。肩胛痛难屈伸。法当理卫阳通补。
黄 桂枝 归身 片姜黄 海桐皮 夏枯草
孙（二四） 肾气攻背项强。溺频且多。督脉不摄。腰重头疼。难以转侧。先与通阳。宗许学士法。（背痛）
川椒（炒出汗三分） 川桂枝（一钱） 川附子（一钱） 茯苓（一钱半） 生白术（一钱）
生远志（一钱）
凡冲气攻痛。从背而上者。系督脉主病。治在少阴。从腹而上者。治在厥阴。系冲任主病。或
填补阳明。此治病之宗旨也。
汪（十二） 肝浊逆攻。痛至背。
淡干姜（八分） 炒黑川椒（三分） 炒焦乌梅肉（五分） 小川连（三分） 川桂枝木（五分）
北细辛（二分） 黄柏（五分） 川楝子肉（一钱） 生白芍（二钱）
陈（氏） 内经论诸痛皆寒。时当冬腊。口鼻吸受寒冷。阻气隧之流行。痛自胸引及背。甚则手足厥
冷。只宜两通气血主治。
川楝子 延胡 生香附 橘红 吴萸 乌药 红花
沈（氏） 脉芤汗出失血。背痛。此为络虚。
人参 炒归身 枣仁 炒白芍 炙草 茯神
庄（三四） 督虚背疼。脊高突。
生毛鹿角（切片三钱） 鹿角霜（一钱半） 杞子（三钱） 归身（一钱） 生杜仲（一钱半）
沙苑（一钱） 茯苓（一钱半） 青盐（调入三分）
张（三八） 督虚背痛。遗泄。
生毛鹿角 鹿角霜 生菟丝子 生杜仲 沙苑子 白龙骨
茯苓 当归
肺朝百脉。肺病则不能管摄一身。故肺俞为病。即肩背作痛。又背为阳明之府。阳明有
亏。不能束筋骨。利机关。即肩垂背曲。至于臂。经络交会不一。而阳明为十二经络之长。臂
痛亦当责之阳明。但痛有内外两因。虚实迥。异治分气血二致。通补攸殊。如营虚脉络失
养。风动筋急者。不受辛寒。当仿东垣舒筋汤之意。佐以活络丹。劳倦伤阳。脉络凝塞。肩臂
作痛者。以辛甘为君。佐以循经入络之品。阳明气衰。厥阴风动。右肩痛麻者。用枸杞归身
黄羚羊桑枝膏。为阳明厥阴营气两虚主治。血虚风动者。因阳明络虚。受肝脏风阳之
扰。用首乌枸杞归身胡麻柏子仁刺蒺藜药等味。以柔甘为温养。失血背痛者。其虚亦在阳
明之络。用人参归身枣仁白芍炙草茯神。以填补阳明。若肾气上逆。则督虚为主病。宜用
奇经之药以峻补真阳。至于口鼻吸受寒冷。阻郁气隧。痛自胸引及背者。宗内经诸痛
皆寒之义。以温药两通气血。更有古法。如防风汤散肺俞之风。指迷丸治痰流臂痛。控涎
丹治流痹牵引。此皆从实症而治。所谓通则不痛也。医者不拘守一法。洞悉病源。运巧思
以制方。而技于是进。（龚商年）
徐评 痛定于肩背。此着痹之类。必用外治之药。以攻之提之。煎药不能取效也。
徐 近日天气骤然变冷。诊察左脉忽然出现芤涩之象。疼痛发作时筋脉拘挛。牵引至耳后。这是营血虚弱导致脉络失于濡养。风邪内动致使筋脉紧急。之前的治法采用清络、凉剂，没有见效。因为营血虚弱的体质不能耐受辛寒药物。仿照李东垣舒筋汤的意旨。（疼痛环绕耳后）
当归 生黄芪 片姜黄 桂枝 防风 炒白术 煎药时化开活络丹一丸。
某 因劳累疲倦。肩臂疼痛。（肩臂痛）
川桂枝木 木防己 五加皮 茯苓 生薏苡仁 炒白蒺藜
涂（六十二岁） 疼痛起于肩胛。逐渐蔓延至环跳穴及大腿膝盖部位。这是络脉虚弱所致。
黄芪（五钱） 炒白术（三钱） 当归（三钱） 茯苓（二钱） 防己（八分） 防风根（五分）
羌活（五分）
邹 五十四岁。阳明脉气衰退。肩胛部筋脉弛缓。手臂不能上举且疼痛。治疗应当通补脉络。不要使用攻伐祛风的药物。
生黄芪 炒白术 当归 防风根 姜黄 桑枝
王（四十二岁） 阳明气衰。厥阴风动导致头晕眼花。右肩疼痛麻木。胁下有聚结之气。病在足厥阴肝经主治范围。
枸杞子（四两） 当归身（三两） 羚羊角（生研二两） 制白蒺藜（去刺三两） 嫩黄芪皮（四两）
胡天麻（二两煨制）
菊花二两熬汁，桑枝四两熬汁，制成丸药。
徐（五十二岁） 左手手指胀痛牵引至肩部。男子血虚导致风动。病位在肝。形体和脉象均显不足。应用柔润药物温养。
制何首乌 枸杞子 当归身 三角胡麻 菊花炭 柏子仁 刺蒺藜 桑枝膏丸。
俞（老年妇女） 年高体弱，阳明气乏。肩胛疼痛难以屈伸。治法应当调理卫阳，通补经脉。
黄芪 桂枝 当归身 片姜黄 海桐皮 夏枯草
孙（二十四岁） 肾气上逆攻冲背部，项部强直。小便频数且多。督脉固摄无力。腰部沉重头痛。难以转身侧卧。先给予通阳之法。遵循许学士的方法。（背痛）
川椒（炒至出汗三分） 川桂枝（一钱） 川附子（一钱） 茯苓（一钱半） 生白术（一钱）
生远志（一钱）
凡是冲气攻痛，从背部向上走的，属于督脉主病，治疗在少阴肾经。从腹部向上走的，治疗在厥阴肝经，属于冲任二脉主病。或者填补阳明经。这是治病的基本原则。
汪（十二岁） 肝浊之气上逆攻冲。疼痛放射至背部。
淡干姜（八分） 炒黑川椒（三分） 炒焦乌梅肉（五分） 小川连（三分） 川桂枝木（五分）
北细辛（二分） 黄柏（五分） 川楝子肉（一钱） 生白芍（二钱）
陈（氏） 《内经》论述各种疼痛多由寒邪引起。时值冬腊月。口鼻吸入寒冷之气。阻碍气隧的正常运行。疼痛从胸部牵引至背部。严重时手足厥冷。只宜气血双通作为主治原则。
川楝子 延胡索 生香附 橘红 吴茱萸 乌药 红花
沈（氏） 脉象芤，汗出失血。背痛。这是络脉虚弱所致。
人参 炒当归身 枣仁 炒白芍 炙甘草 茯神
庄（三十四岁） 督脉虚弱导致背疼。脊柱高耸突起。
生毛鹿角（切片三钱） 鹿角霜（一钱半） 枸杞子（三钱） 当归身（一钱） 生杜仲（一钱半）
沙苑子（一钱） 茯苓（一钱半） 青盐（调入三分）
张（三十八岁） 督脉虚弱导致背痛。遗精滑泄。
生毛鹿角 鹿角霜 生菟丝子 生杜仲 沙苑子 白龙骨
茯苓 当归
肺朝百脉。肺病则不能统摄一身之气。所以肺俞发生病变，就会肩背作痛。另外，背部是阳明经所主的府部。阳明经有亏损，就不能约束筋骨，滑利关节，就会出现肩膀下垂、背部弯曲。至于手臂，经络交会不一，而阳明经是十二经络之长。手臂疼痛也应当责之于阳明经。但是疼痛有内外两种病因，虚实截然不同，治疗方法分为气血两类，通补各有不同。如营血虚弱脉络失养，风动筋急者，不耐受辛寒药物，应当仿照李东垣舒筋汤的意旨，佐以活络丹。劳倦损伤阳气，脉络凝塞，肩臂作痛者，以辛甘药物为君药，佐以循经入络的药物。阳明气衰，厥阴风动，右肩痛麻者，用枸杞、归身、黄芪、羚羊角、桑枝膏。这是针对阳明、厥阴营气两虚的主治方。血虚风动者，因阳明络脉虚弱，受到肝脏风阳的干扰，用何首乌、枸杞、归身、胡麻、柏子仁、刺蒺藜等药物。以柔甘药物进行温养。失血背痛者，其虚也在阳明之络，用人参、归身、枣仁、白芍、炙甘草、茯神。以填补阳明。若肾气上逆，则督脉虚弱为主病，宜用奇经药物以峻补真阳。至于口鼻吸入寒冷，阻郁气隧，疼痛从胸部牵引至背部者，遵循《内经》诸痛皆寒的意义，用温药气血双通。更有古法，如防风汤疏散肺俞之风，指迷丸治疗痰流导致的臂痛，控涎丹治疗流痹引起的牵引痛。这些都是从实证角度治疗，所谓通则不痛。医者不拘泥于一种方法，洞悉病源，运用巧思来制定方剂，技艺因此进步。（龚商年评注）
Xu Recently, the weather has turned suddenly cold. Palpation of the left pulse reveals a sudden appearance of Kou (hollow) and Se (choppy) qualities. During pain episodes, the sinews spasm, radiating to behind the ear. This indicates Ying Blood deficiency leading to malnourishment of the collaterals, with internal Wind movement causing sinew tension. Previous methods using clearing collaterals and cooling agents were ineffective. The deficient Ying Blood cannot tolerate acrid-cold herbs. Following the intent of Li Dongyuan's Shujin Decoction. (Pain circles behind the ear)
Danggui (Radix Angelicae Sinensis), Sheng Huangqi (Astragali Radix), Pian Jianghuang (Curcumae Longae Rhizoma), Guizhi (Ramulus Cinnamomi), Fangfeng (Radix Saposhnikoviae), Chao Baizhu (Atractylodis Macrocephalae Rhizoma). Decoct these herbs and dissolve one pill of Huoluo Dan (Living Collateral Pill) in the liquid.
Certain Patient Fatigue and overwork. Pain in the shoulder and arm. (Shoulder and arm pain)
Chuan Guizhimu (Cinnamomi Ramulus et Cortex), Mufangji (Stephaniae Tetrandrae Radix), Wujiapi (Acanthopanacis Cortex), Fuling (Poria), Sheng Yiyiren (Coicis Semen), Chao Baijili (Tribuli Fructus).
Tu (62 years old) Pain originates in the scapula, gradually extending to the Huantiao point and thigh/knee. This is due to collateral deficiency.
Huangqi (5 qian), Baizhu (3 qian), Danggui (3 qian), Fuling (2 qian), Fangji (8 fen), Fangfenggen (5 fen), Qianghuo (5 fen).
Second visit Follow the previous prescription, remove Fangfeng and Qianghuo, add Gouqizi (Fructus Lycii) and Shayuanzi (Astragali Complanati Semen).
Zou 54 years old. Yangming pulse qi declines. Scapular sinews become flaccid. Inability to raise the arm accompanied by pain. Treatment should focus on unblocking and tonifying the collaterals. Do not use attacking wind-dispersing methods.
Sheng Huangqi, Baizhu, Danggui, Fangfenggen, Jianghuang, Sangzhi (Ramulus Mori).
Wang (42 years old) Yangming qi declines. Jueyin Wind moves, causing dizziness and blurred vision. Right shoulder pain and numbness. Qi accumulation under the ribs. Managed via Foot Jueyin Liver Meridian.
Gouqizi (4 liang), Guishen (Radix Angelicae Sinensis, 3 liang), Lingyangjiao (Cornu Saigae Tataricae, raw ground, 2 liang), Zhi Baijili (Tribuli Fructus, thorns removed, 3 liang), Nen Huangqipi (Astragali Cortex, 4 liang), Hutianma (Gastrodiae Rhizoma, baked, 2 liang).
Jujuhua (Chrysanthemi Flos, 2 liang) decocted juice, Sangzhi (4 liang) decocted juice, made into pills.
Xu (52 years old) Left finger distending pain radiating to the shoulder. Men with Blood deficiency experience Wind movement. Disease location is in the Liver. Physical form and pulse indicate insufficiency. Use soft/moistening herbs for warm nourishment.
Zhi Shouwu (Polygoni Multiflori Preparata Radix), Gouqizi, Guishen, Sanjiao Huma (Sesami Semini Nigrum), Jujuhtan (Chrysanthemi Flos carbonized), Baiziren (Biota Semen), Cijili (Tribuli Fructus), Sangzhigao (Mori Ramulus Extract) pills.
Yu (Elderly Woman) Advanced age, Yangming qi deficiency. Scapular pain difficult to flex/extend. Method: Regulate Wei Yang and tonify through unblocking.
Huangqi, Guizhi, Guishen, Pian Jianghuang, Haitongpi (Saposhnikoviae Radix? No, likely Celastrus or similar bark contextually, but literally Haitongpi), Xiakucao (Prunellae Spica).
Sun (24 years old) Kidney qi attacks upward, back stiffness. Frequent and abundant urination. Du Mai (Governor Vessel) fails to secure. Heavy waist, headache, difficulty turning. First apply unblocking Yang method. Follow Scholar Xu's method. (Back pain)
Chuanjiao (Zanthoxyli Pericarpium, fried until sweat appears, 3 fen), Chuan Guizhi (1 qian), Chuan Fuzi (Aconiti Lateralis Radix Preparata, 1 qian), Fuling (1.5 qian), Sheng Baizhu (1 qian), Sheng Yuanzhi (Polygalae Radix, 1 qian).
Generally, when rushing Qi attacks pain moving upward from the back, it is a disease of the Du Mai, treated in Shaoyin (Kidney). When moving upward from the abdomen, it is treated in Jueyin, belonging to Chong and Ren vessels. Or tonify Yangming. This is the fundamental principle of treatment.
Wang (12 years old) Liver turbid Qi rebels and attacks. Pain extends to the back.
Dan Ganjiang (Zingiberis Rhizoma, 8 fen), Chaohei Chuanjiao (Zanthoxyli Pericarpium, charred black, 3 fen), Chaojiao Wumeirou (Mume Fructus, charred, 5 fen), Xiao Chuanlian (Corydalis Rhizoma, 3 fen), Chuan Guizhimu (5 fen), Beixixin (Asari Radix et Rhizoma, 2 fen), Huangbai (Phellodendri Cortex, 5 fen), Chuanlianzi Rou (Toosendan Fructus, 1 qian), Sheng Baishao (Paeoniae Radix Alba, 2 qian).
Chen (Family) Nei Jing states all pains are due to Cold. It is winter. Cold inhaled via mouth/nose obstructs the flow of Qi tunnels. Pain radiates from chest to back. Severe cases have cold extremities. Only appropriate to treat by unblocking both Qi and Blood.
Chuanlianzi, Yanhusuo (Corydalisis Rhizoma), Sheng Xiangfu (Cyperi Rhizoma), Juhong (Citri Reticulatae Pericarpium Rubrum), Wuyu (Evodiae Fructus), Wuyao (Linderae Radix), Honghua (Carthami Flos).
Shen (Family) Pulse is Kou, sweating, blood loss. Back pain. This is collateral deficiency.
Renshen (Ginseng Radix), Chao Guishen (Angelicae Sinensis Radix, stir-fried), Zaoren (Ziziphi Spinosae Semen), Chao Baishao (Paeoniae Radix Alba, stir-fried), Zhigancao (Glycyrrhizae Radix et Rhizoma Preparata), Fushen (Poria with Hostwood).
Zhuang (34 years old) Du Mai deficiency causes back pain. Spine protrudes high.
Sheng Mao Lu jiao (Cervi Cornus Pantotrichum, sliced, 3 qian), Lu jiaoshuang (Cervi Cornus Degelatinatum), Gouqi (3 qian), Guishen (1 qian), Sheng Duzhong (Eucommiae Cortex, 1.5 qian), Shayuanzi (1 qian), Fuling (1.5 qian), Qingyan (Halitum, mixed in 3 fen).
Zhang (38 years old) Du Mai deficiency causes back pain. Spermatorrhea/emission.
Sheng Mao Lu jiao, Lu jiaoshuang, Sheng Tusizi (Cuscutae Semen), Sheng Duzhong, Shayuanzi, Bailonggu (Ossis Femoris), Fuling, Danggui.
The Lung governs all collaterals. Lung disease prevents control over the whole body. Thus, when Feishu (Bladder 13) is diseased, shoulder and back pain occur. Furthermore, the back is the domain of the Yangming. If Yangming is deficient, it cannot bind sinews and bones or facilitate joints, leading to drooping shoulders and curved back. Regarding the arm, meridians intersect variously, but Yangming is the chief of the twelve meridians. Arm pain should also be attributed to Yangming. However, pain has external and internal causes; deficiency and excess differ greatly, requiring distinct treatments for Qi and Blood, with specific approaches for unblocking and tonifying. For example, if Ying Blood deficiency leads to collateral malnourishment and Wind-induced sinew tension, acrid-cold herbs are contraindicated; follow Li Dongyuan's Shujin Decoction intent, assisted by Huoluo Dan. If fatigue damages Yang, causing collateral stagnation and shoulder/arm pain, use acrid-sweet herbs as sovereign, assisted by channel-entering collaterals. If Yangming qi declines and Jueyin Wind moves, causing right shoulder pain/numbness, use Gouqi, Guishen, Huangqi, Lingyangjiao, Sangzhigao. This treats dual deficiency of Ying Qi in Yangming and Jueyin. If Blood deficiency causes Wind movement, due to Yangming collateral weakness disturbed by Liver Wind-Yang, use Shouwu, Gouqi, Guishen, Huma, Baiziren, Cijili. Use soft-sweet herbs for warm nourishment. If back pain follows blood loss, the deficiency lies in Yangming collaterals; use Renshen, Guishen, Zaoren, Baishao, Zhigancao, Fushen to tonify Yangming. If Kidney Qi rebels, Du Mai deficiency is primary; use extraordinary vessel herbs to vigorously tonify True Yang. If cold inhaled obstructs Qi tunnels causing chest-to-back pain, follow Nei Jing's "all pains are cold" principle, use warming herbs to unblock Qi and Blood. Ancient methods include: Fengfang Tang dispersing Wind at Feishu; Zhimi Wan treating phlegm-flow arm pain; Kongxian Dan treating flowing bi traction. These treat excess syndromes, embodying "if unblocked, no pain." Physicians must not stick rigidly to one method, must understand the disease source, apply ingenuity in prescribing, and thus advance their skills. (Commentary by Gong Shangnian)
Xu's Commentary: Pain fixed in shoulder/back belongs to Zhuo Bi (Heavy Bi Syndrome). External treatments must be used to attack and lift. Internal decoctions cannot achieve efficacy.