邻村李姓妇，年近四旬，得胁下疼证。
病因 平素肝气不舒，继因暴怒，胁下陡然作疼。
证候 两胁下掀疼甚剧，呻吟不止，其左胁之疼尤甚，倩人以手按之则其疼稍愈，心中时
觉发热，恶心欲作呕吐，脉左右两部皆弦硬。
诊断 此肝气胆火相助横恣，欲上升而不能透膈，郁于胁下而作疼也。当平其肝气泻其胆火，其疼自愈。
处方 川楝子（八钱捣碎） 生杭芍（四钱） 生明没药（四钱） 生麦芽（三钱）
三棱（三钱） 莪术（三钱） 茵陈（二钱） 龙胆草（二钱） 连翘（三钱）
磨取生铁锈浓水，煎药取汤一大盅，温服。
方解 方中川楝、芍药、龙胆，引气火下降者也。茵陈、生麦芽，引气火上散者也。三棱、莪
术，开气火之凝结，连翘、没药，消气火之弥漫，用铁锈水煎药者，借金之余气，以镇
肝胆之木也。
效果 煎服一剂后其疼顿止，而仍觉气分不舒，遂将川楝、三棱、莪术各减半，再加柴胡
二钱，一剂全愈。
天津李××，年三十四岁，得腰疼证。
病因 劳心过度，数日懒食，又勉强远出操办要务，因得斯证。
证候 其疼剧时不能动转，轻时则似疼非疼绵绵不已，亦恒数日不疼，或动气或劳力时则疼
剧。心中非常发闷，其脉左部沉弦，右部沉牢，一息四至强。观其从前所服之方，虽不一
致，大抵不外补肝肾强筋骨诸药，间有杂似祛风药者，自谓得病之初，至今已三年，服
药数百剂，其疼卒未轻减。
诊断 《内经》谓通则不痛，此证乃痛则不通也。肝肾果系虚弱，其脉必细数，今左部沉弦，
右部沉牢，其为腰际关节经络有瘀而不通之气无疑，拟治以利关节通经络之剂。
处方 生怀山药（一两） 大甘枸杞（八钱） 当归（四钱） 丹参（四钱） 生明没
药（四钱） 生五灵脂（四钱） 穿山甲（二钱炒捣） 桃仁（二钱去皮捣碎） 红花（钱半） 土鳖
虫（五枚捣碎） 广三七（二钱轧细）
药共十一味，先将前十味煎汤一大盅，送服三七细末一半，至煎渣重服时，再送其余一半。
效果 将药连服三剂腰已不疼，心中亦不发闷，脉象虽有起色，仍未复常，遂即原方去山甲加川续
断、生杭芍各三钱，连服数剂，脉已复常，自此病遂除根。
帮助 医者治病不可预有成见，临证时不复细审病因。方书谓腰者肾之府，腰疼则肾脏衰惫，又
谓肝主筋肾主骨，腰疼为筋骨之病，是以肝肾主之。治腰疼者因先有此等说存于胸中，
恒多用补肝肾之品。究之，此在由于肝肾虚者甚少，由于气血瘀者颇多，若因努力任重而腰疼
者尤多瘀证。曾治一人因担重物后腰疼，为用三七、土鳖虫等分共为细末，每服二钱，日两次，服三
日全愈。又一人因抬物用力过度，腰疼半年不愈，忽于疼处发出一疮，在脊梁之旁，微似红肿，状若
复盂，大径七寸。疡医以为腰疼半年始发现此疮，其根蒂必深，不敢保好，转求愚为治疗，调治两
旬始愈（详案载内托生肌散后）。然使当腰初觉疼之时，亦服三七、土鳖以开其瘀，又何至有
后时之危险乎。又尝治一妇，每当行经之时腰疼殊甚，诊其脉气分甚虚，于四物汤中加黄 八钱，
服数剂而疼愈，又一妇腰疼绵绵不止，亦不甚剧，诊其脉知其下焦虚寒，治以温补下焦之药，又于
服汤药之外，俾服生硫黄细末一钱，日两次，硫黄服尽四两，其疼除根。是知同是腰疼而其致病之因
各异，治之者安可胶柱鼓瑟哉。
邻村李姓妇女，年龄接近四十岁，患胁下疼痛证。
病因 平时肝气不舒展，继而又因暴怒，导致胁下突然剧烈疼痛。
证候 两侧胁下掀动性剧痛，呻吟不止，其中左侧胁下的疼痛尤为严重，请人用手按压则疼痛稍缓解，心中时常感觉发热，恶心欲呕吐，左右两部脉象皆呈现弦硬之象。
诊断 这是肝气与胆火相互助长、横逆肆虐，想要上升却无法穿透膈肌，郁结于胁下而引发疼痛。应当平抑肝气、清泻胆火，疼痛自然痊愈。
处方 川楝子（八钱，捣碎） 生杭芍（四钱） 生明没药（四钱） 生麦芽（三钱）
三棱（三钱） 莪术（三钱） 茵陈（二钱） 龙胆草（二钱） 连翘（三钱）
磨取生铁锈的浓水，用来煎煮药物，取一大盅药汤，温服。
方解 方中川楝子、芍药、龙胆草，是引导气火下降的药物。茵陈、生麦芽，是引导气火向上向外疏散的药物。三棱、莪术，是开通气火凝结的药物；连翘、没药，是消散气火弥漫的药物。使用铁锈水煎药，是借用铁余留之气，以镇摄肝胆之木气。
效果 煎服一剂后，疼痛顿时停止，但仍感觉气分不舒畅，于是将川楝子、三棱、莪术各减半量，再加柴胡二钱，服用一剂后完全痊愈。
天津李××，年龄三十四岁，患腰疼证。
病因 用脑过度，连续几天食欲不振，又勉强远出办理重要事务，因此患上此病。
证候 疼痛剧烈时无法转动身体，轻微时则似痛非痛，绵绵不断，也常常有几天不疼，或者在动气或劳累用力时疼痛加剧。心中非常憋闷，其脉象左部沉弦，右部沉牢，一息跳动四次且强劲。观察他之前所服的方子，虽然不一致，但大体上不外乎补肝肾、强筋骨的药物，偶尔夹杂一些类似祛风的药。自述得病之初到现在已经三年，服药数百剂，疼痛始终没有减轻。
诊断 《内经》说“通则不痛”，此证乃是“痛则不通”。如果肝肾确实虚弱，脉象必定细数，现在左部脉沉弦，右部脉沉牢，这显然是腰部关节经络中有瘀滞而不通的气机无疑，打算采用疏通关节、通利经络的方剂治疗。
处方 生怀山药（一两） 大甘枸杞（八钱） 当归（四钱） 丹参（四钱） 生明没药（四钱） 生五灵脂（四钱） 穿山甲（二钱，炒后捣碎） 桃仁（二钱，去皮捣碎） 红花（一钱半） 土鳖虫（五枚，捣碎） 广三七（二钱，轧成细末）
药物共十一味，先将前十味煎汤一大盅，送服一半三七细末，等到煎煮药渣再次服用时，再送服剩下的一半。
效果 将药连续服用三剂后，腰部已不疼痛，心中也不觉得憋闷了，脉象虽有起色，但仍未恢复正常，于是就在原方中去掉穿山甲，加入川续断、生杭芍各三钱，连续服用数剂，脉象恢复常态，从此病根彻底消除。
帮助 医生治病不可预先存有成见，临证时不再仔细审察病因。方书说腰是肾的府邸，腰疼则是肾脏衰惫，又说肝主筋、肾主骨，腰疼属于筋骨之病，因此由肝肾主管。治疗腰疼的人因为胸中先存有这样的说法，往往多用补益肝肾的药物。究其实，这是由于肝肾虚弱的很少，由于气血瘀滞的很多，如果是因努力负重而导致腰疼的，更是多为瘀证。曾治疗一人因担重物后腰疼，为他用三七、土鳖虫等份共研为细末，每次服用二钱，每日两次，服用三日完全痊愈。又有一人因抬物用力过度，腰疼半年不愈，忽然在疼痛处发出一疮，在脊梁旁边，微微有些红肿，形状像倒扣的盆，直径七寸。外科医生认为腰疼半年才出现这个疮，其根蒂必然很深，不敢保证能治好，转而请求我治疗，调理治疗二十天才痊愈（详细医案记载在内托生肌散之后）。然而如果在刚觉腰疼之时，也服用三七、土鳖虫来开通瘀滞，又何至于会有后来的危险呢。又曾治疗一妇人，每当行经之时腰疼特别严重，诊察其脉气分很虚，在四物汤中加入黄芪八钱，服用数剂后疼痛痊愈；又一妇人腰疼绵绵不止，也不甚剧烈，诊察其脉象知道是下焦虚寒，治疗以温补下焦的药物，又在服用汤药之外，让她服用生硫黄细末一钱，每日两次，硫黄服尽四两，疼痛彻底除根。由此可知同样是腰疼，但其致病原因各异，治疗者怎么能拘泥固执不知变通呢。
A woman surnamed Li from a neighboring village, nearly forty years old, suffered from pain in the hypochondrium.
Etiology: Her Liver Qi was normally stagnant, and subsequently, due to sudden anger, severe pain suddenly erupted in the hypochondrium.
Symptoms: Severe, throbbing pain in both hypochondriac regions, with incessant groaning; the pain on the left side was particularly intense. The pain subsided slightly when pressure was applied by another person. She occasionally felt heat in the Heart (心), nausea, and a desire to vomit. The pulse was wiry and hard in both the left and right positions.
Diagnosis: This is caused by Liver Qi and Gallbladder Fire assisting each other in their rampant and uncontrolled ascent. Unable to penetrate through the diaphragm, they stagnate in the hypochondrium, causing pain. The treatment should focus on soothing the Liver Qi and draining the Gallbladder Fire, after which the pain will resolve spontaneously.
Prescription: *Chuan Lian Zi* (Fructus Toosendan, 8 qian, crushed); *Sheng Hang Shao* (Radix Paeoniae Alba, raw, 4 qian); *Sheng Ming Mo Yao* (Resina Myrrhae, raw, 4 qian); *Sheng Mai Ya* (Fructus Hordei Germinatus, raw, 3 qian); *San Leng* (Rhizoma Sparganii, 3 qian); *E Zhu* (Rhizoma Curcumae, 3 qian); *Yin Chen* (Herba Artemisiae Scopariae, 2 qian); *Long Dan Cao* (Radix Gentianae, 2 qian); *Lian Qiao* (Fructus Forsythiae, 3 qian).
Decoct these herbs using a concentrated water of rust from raw iron (generated by grinding raw iron), obtain one large cup of decoction, and take it warm.
Analysis of the Prescription: *Chuan Lian Zi*, *Shao Yao*, and *Long Dan Cao* guide the Qi and Fire downward. *Yin Chen* and *Sheng Mai Ya* guide the Qi and Fire upward and outward for dispersion. *San Leng* and *E Zhu* open the coagulation of Qi and Fire; *Lian Qiao* and *Mo Yao* dissipate the diffusion of Qi and Fire. Using rust water to decoct the herbs utilizes the residual energy of metal to subdue the Wood of the Liver and Gallbladder.
Outcome: After taking one dose, the pain ceased immediately, but she still felt stagnation in the Qi mechanism. Therefore, the dosages of *Chuan Lian Zi*, *San Leng*, and *E Zhu* were halved, and *Chai Hu* (Radix Bupleuri, 2 qian) was added. One more dose resulted in complete recovery.
Li XX from Tianjin, aged thirty-four, suffered from lower back pain.
Etiology: Excessive mental labor led to loss of appetite for several days. He then forced himself to travel far to handle important affairs, resulting in this condition.
Symptoms: During severe episodes, he could not move or turn his body; during mild episodes, the pain was lingering and indistinct. There were also periods of several days without pain. Pain intensified during emotional agitation or physical exertion. He felt significant chest oppression. The pulse was deep and wiry on the left, and deep and firm on the right, beating four times per breath with strong force. Reviewing his previous prescriptions, although inconsistent, they generally consisted of herbs tonifying the Liver and Kidneys and strengthening sinews and bones, occasionally mixed with wind-dispelling herbs. He stated that three years had passed since the onset, and after taking hundreds of doses, the pain had never lessened.
Diagnosis: The *Neijing* states, "When there is free flow, there is no pain"; this case exemplifies "when there is pain, there is obstruction." If the Liver and Kidneys were truly deficient, the pulse would be fine and rapid. Since the left pulse is deep and wiry, and the right pulse is deep and firm, it is undoubtedly due to stagnant Qi obstructing the joints and collaterals of the waist. The proposed treatment is a formula to unblock the joints and unblock the collaterals.
Prescription: *Sheng Huai Shan Yao* (Rhizoma Dioscoreae Hypoglaucae, raw, 1 liang); *Da Gan Gou Qi* (Fructus Lycii, 8 qian); *Dang Gui* (Radix Angelicae Sinensis, 4 qian); *Dan Shen* (Radix et Rhizoma Salviae Miltiorrhizae, 4 qian); *Sheng Ming Mo Yao* (Resina Myrrhae, raw, 4 qian); *Sheng Wu Ling Zhi* (Faeces Trogopterori, raw, 4 qian); *Chuan Shan Jia* (Squama Manis, 2 qian, stir-fried and crushed); *Tao Ren* (Semen Persicae, 2 qian, peeled and crushed); *Hong Hua* (Flos Carthami, 1.5 qian); *Tu Bie Chong* (Scorpio, 5 pieces, crushed); *Guang San Qi* (Radix Notoginseng, 2 qian, finely powdered).
There are eleven ingredients in total. First, decoct the first ten ingredients to obtain one large cup of liquid. Take half of the *San Qi* powder with this decoction. When decocting the dregs for the second administration, take the remaining half of the *San Qi* powder.
Outcome: After taking the medicine continuously for three doses, the lower back pain stopped, and the chest oppression resolved. Although the pulse showed improvement, it had not yet returned to normal. Therefore, *Chuan Shan Jia* was removed from the original prescription, and *Chuan Xu Duan* (Radix Dipsaci, 3 qian) and *Sheng Hang Shao* (Radix Paeoniae Alba, raw, 3 qian) were added. After taking several more doses, the pulse returned to normal, and the disease was eradicated.
Discussion: Physicians must not hold preconceived notions and must carefully examine the etiology during clinical practice. Medical texts state that the waist is the mansion of the Kidney, and lower back pain indicates Kidney deficiency. It is also said that the Liver governs the sinews and the Kidneys govern the bones, so lower back pain is a disorder of sinews and bones governed by the Liver and Kidneys. Because physicians harbor these ideas beforehand, they often use herbs that tonify the Liver and Kidneys. In reality, cases caused by Liver and Kidney deficiency are rare, while those caused by Qi and Blood stasis are common. Cases resulting from strenuous effort and heavy lifting are especially prone to stasis. I once treated a patient who developed lower back pain after carrying a heavy load. I prescribed equal parts of *San Qi* and *Tu Bie Chong* ground into fine powder, two qian per dose, twice daily. He recovered completely after three days. Another patient suffered from lower back pain for half a year due to excessive strain from lifting objects. Suddenly, a sore appeared next to the spine, slightly red and swollen, resembling an inverted bowl, with a diameter of seven cun. A surgeon believed that since the sore appeared after six months of pain, its root must be deep and refused to guarantee a cure, referring the patient to me. After twenty days of treatment, he recovered (the detailed case is recorded after the description of *Nei Tuo Sheng Ji San*). However, if he had taken *San Qi* and *Tu Bie Chong* to resolve the stasis at the initial onset of pain, how could such danger have arisen later? I also treated a woman whose lower back pain was severe during menstruation. Her pulse indicated significant Qi deficiency. I added Huang Qi (Radix Astragali, 8 qian) to *Si Wu Tang* (Four Substances Decoction). After several doses, the pain ceased. Another woman suffered from continuous, mild lower back pain. Her pulse indicated deficiency-cold in the Lower Jiao. I treated her with herbs to warm and tonify the Lower Jiao, and additionally prescribed *Sheng Liu Huang* (Sulfur, 1 qian) as a fine powder, twice daily. After consuming four liang of sulfur, the pain was eradicated. Thus, although the symptom is lower back pain, the etiologies vary. How can physicians be rigid and inflexible in their treatment?