天津姚××，年五十二岁，得肝郁胃逆证。
病因 劳心太过，因得斯证。
证候 腹中有气，自下上冲，致胃脘满闷，胸中烦热，胁下胀疼，时常呃逆，间作呕吐。大便
燥结，其脉左部沉细，右部则弦硬而长，大于左部数倍。
诊断 此乃肝气郁结，冲气上冲，更迫胃气不降也。为肝气郁结，是以左脉沉细，为冲气上冲，
是以右脉弦长，冲脉上隶阳明，其气上冲不已，易致阳明胃气不下降。此证之呕吐呃逆，胃脘
满闷，胸间烦热，皆冲胃之气相并冲逆之明征也。其胁下胀疼，肝气郁结之明征也。其大便燥结者，
因胃气原宜息息下行，传送饮食下为二便，今其胃气既不下降，是以
大便燥结也。拟治以舒肝降胃安冲之剂。
处方 生赭石（一两轧细） 生怀山药（一两） 天冬（一两） 寸麦冬（六钱去心）
清半夏（四钱水洗三次） 碎竹茹（三钱） 生麦芽（三钱） 茵陈（二钱）
川续断（二钱） 生鸡内金（二钱黄色的捣） 甘草（钱半）
煎汤一大盅，温服。
方解 肝主左而宜升，胃主右而宜降，肝气不升则先天之气化不能由肝上达，胃气不降则后天之
饮食不能由胃下输，此证之病根，正因当升者不升，当降者不降也。故方中以生麦芽、茵陈以升肝；生
赭石、半夏、竹茹以降胃，即以安冲；用续断者，因其能补肝，可助肝气上升也；用生山药二冬者，取
其能润胃补胃，可助胃气下降也，用鸡内金者，取其能化瘀止疼，以营运诸药之力也。
复诊 上方随时加减，连服二十余剂，肝气已升，胃气已降，左
右脉均已平安，诸病皆愈。惟肢体乏力，饮食不甚消化，拟再治以补气健胃之剂。
处方 野台参（四钱） 生怀山药（一两） 生赭石（六钱轧细） 天冬（六钱）
寸麦冬（六钱） 生鸡内金（三钱黄色的捣） 生麦芽（三钱） 甘草（钱半）
煎汤一大盅，温服。
效果 将药煎服三剂，饮食加多，体力渐复。于方中加枸杞五钱，白术三钱，俾再服数剂以善其后。
帮助 身之气化，原左升右降，若但知用赭石降胃，不知用麦芽升肝，久之，肝气将有郁遏之
弊，况此证之肝气原郁结乎？此所以方中用赭石，即用麦芽，赭石生用而麦芽亦生用也。
且诸家本草谓麦芽炒用者为丸散计也，若入汤剂何须炒用，盖用生者煮汁饮之，则消食之力愈大也。
或问 升肝之药，柴胡最效，今方中不用柴胡而用生麦芽者，将毋别有所取乎？答曰∶柴胡升提
肝气之力甚大，用之失宜，恒并将胃气之下行者提之上逆。曾有患阳明厥逆吐血者，初不甚剧。医者误
用柴胡数钱即大吐不止，须臾盈一痰盂，有危在顷刻之惧，取药无及，适备有生赭石细末若干，俾急用
温开水送下，约尽两半，其血始止，此柴胡并能提胃气上逆之明征也。况此证之胃气原不降乎？
至生麦芽虽能升肝，实无妨胃气之下降，盖其萌芽发生之性，与肝木同气相求，能
宣通肝气之郁结，使之开解而自然上升，非若柴胡之纯于升提也。
病因：因过度操劳心神而患上此病。
证候：腹中有气自下向上冲撞，导致胃脘部胀满憋闷，胸中烦热，胁肋下方胀痛，时常打嗝，偶尔发生呕吐。大便干燥结滞，脉象左侧沉细，右侧则弦硬且长，比左侧大数倍。
诊断：这是肝气郁结，冲脉之气上冲，进而迫使胃气不能下降所致。因为肝气郁结，所以左脉沉细；因为冲气上冲，所以右脉弦长。冲脉在上方隶属于阳明经，其气不断上冲，容易导致阳明胃气不下降。这个病症中的呕吐、打嗝、胃脘满闷、胸间烦热，都是冲脉与胃气相并而上逆的明显征象。胁肋下方的胀痛，是肝气郁结的明显征象。大便干燥结滞，是因为胃气本应持续下行，传导饮食转化为二便，如今胃气不下降，所以导致大便干燥结滞。拟用舒肝、降胃、安冲的方剂进行治疗。
处方：生赭石（一两，轧成细粉）、生怀山药（一两）、天冬（一两）、寸麦冬（六钱，去心）、清半夏（四钱，水洗三次）、碎竹茹（三钱）、生麦芽（三钱）、茵陈（二钱）、川续断（二钱）、生鸡内金（二钱，黄色的，捣碎）、甘草（一钱半）。
煎服法：加水一大盅煎汤，温服。
方解：肝位于左侧主升发，胃位于右侧主肃降。肝气不升，则先天之气化不能通过肝脏上达；胃气不降，则后天之饮食不能通过胃部下输。此病的根本原因，正是该升的不升，该降的不降。因此方中使用生麦芽、茵陈来升发肝气；使用生赭石、半夏、竹茹来降胃气，同时以此安定冲脉之气；使用续断，是因为它能补益肝脏，有助于肝气上升；使用生山药和天冬、麦冬，是取它们能滋润和补益胃腑，有助于胃气下降；使用鸡内金，是取它能化瘀止痛，以运化推动诸药的力量。
复诊：上方根据病情随时加减，连续服用二十多剂后，肝气已升，胃气已降，左右脉象均已平和，各种病症都痊愈了。只是肢体乏力，饮食消化不佳，拟再用补气健胃的方剂治疗。
处方：野台参（四钱）、生怀山药（一两）、生赭石（六钱，轧成细粉）、天冬（六钱）、寸麦冬（六钱）、生鸡内金（三钱，黄色的，捣碎）、生麦芽（三钱）、甘草（一钱半）。
煎服法：加水一大盅煎汤，温服。
效果：将药煎服三剂后，饮食量增加，体力逐渐恢复。在原方中加入枸杞五钱、白术三钱，以便再服几剂以巩固疗效。
按语：人身的气化运动，原本是左边升发、右边肃降。如果只知道用赭石降胃，不知道用麦芽升肝，久而久之，肝气将有郁遏的弊端，何况此证的肝气原本就郁结呢？这就是方中用赭石的同时必用麦芽的原因，且赭石和麦芽都使用生品。另外，各家本草认为麦芽炒制是为了制作丸散，若入汤剂何必炒制？大概是用生品煮汁饮用，其消食的力量更大。
有人问：升发肝气的药物，柴胡最为有效，现在方中不用柴胡而用生麦芽，难道另有取意吗？回答说：柴胡升提肝气的力量很大，使用不当，常常会将本该下行的胃气一并提引而上逆。曾有一位患阳明厥逆吐血的病人，起初症状不严重。医生误用了几钱柴胡，结果导致大吐血不止，一会儿就装满一个痰盂，有顷刻间死亡的恐惧，取药来不及，恰好备有一些生赭石细末，让患者急忙用温开水送服，大约服完两半，血才停止，这是柴胡能提引胃气上逆的明显证据。何况此证的胃气原本就不下降呢？至于生麦芽虽然能升发肝气，实际上并不妨碍胃气的下降，因为它萌芽发生的特性，与肝木同气相求，能宣通肝气的郁结，使其开解而自然上升，不像柴胡那样纯粹是升提作用。
Tianjin's Mr. Yao, aged fifty-two, suffered from a syndrome of Liver Qi Stagnation complicated by Stomach Qi Rebellious Flow (Wei Qi Bu Jiang).
Etiology: The condition arose from excessive mental exertion.
Symptoms: There was a sensation of Qi rushing upward from the lower abdomen to the upper abdomen, causing fullness and oppression in the epigastrium, irritability and heat in the chest, distending pain under the hypochondrium, frequent hiccups, and occasional vomiting. The stool was dry and constipated. The pulse was deep and fine on the left side, while on the right side it was wiry, hard, long, and several times larger than the left side.
Diagnosis: This is due to Liver Qi Stagnation and the rebellious flow of Chong Qi (Penetrating Vessel Qi) upward, which further forces Stomach Qi to fail to descend. Because of Liver Qi Stagnation, the left pulse is deep and fine; because of the rebellious Chong Qi, the right pulse is wiry and long. The Chong Mai (Penetrating Vessel) connects superiorly with the Yangming Meridian; its continuous upward rush easily leads to the failure of Yangming Stomach Qi to descend. The vomiting, hiccups, epigastric fullness, and chest irritability in this case are clear signs of Chong and Stomach Qi rebelling and flowing upward together. The distending pain under the hypochondrium is a clear sign of Liver Qi Stagnation. The dry constipation occurs because Stomach Qi should continuously descend to transport food and fluids into the two bowels; since the Stomach Qi fails to descend now, dry constipation results. A prescription to soothe the Liver, descend the Stomach, and calm the Chong Qi is proposed.
Prescription: Sheng Zhe Shi (Raw Hematitum, 1 liang, finely ground), Sheng Huai Shan Yao (Raw Dioscoreae Hypoglaucae Rhizoma, 1 liang), Tian Dong (Asparagi Radix, 1 liang), Cun Mai Dong (Ophiopogonis Radix, 6 qian, heart removed), Qing Ban Xia (Prepared Pinelliae Tuber, 4 qian, washed three times), Sui Zhu Ru (Bamboo Shavings, 3 qian), Sheng Mai Ya (Raw Hordei Fructus Germinatus, 3 qian), Yin Chen (Artemisiae Scopariae Herba, 2 qian), Chuan Xu Duan (Dried Radix Dipsaci, 2 qian), Sheng Ji Nei Jin (Raw Gavis Corneum, 2 qian yellow ones, crushed), Gan Cao (Licorice Root, 1.5 qian).
Decoction Method: Decoct with one large cup of water and take warm.
Formula Analysis: The Liver governs the left side and prefers ascending; the Stomach governs the right side and prefers descending. If Liver Qi does not ascend, the Qi transformation of the congenital foundation cannot reach upward through the Liver; if Stomach Qi does not descend, the dietary essence of the acquired foundation cannot be transported downward through the Stomach. The root cause of this disease lies precisely in the failure of what should ascend to ascend and what should descend to descend. Therefore, the formula uses Sheng Mai Ya and Yin Chen to ascend Liver Qi; Sheng Zhe Shi, Ban Xia, and Zhu Ru to descend Stomach Qi, thereby calming the Chong Qi; Xu Duan is used because it tonifies the Liver and assists the ascent of Liver Qi; Sheng Shan Yao, Tian Dong, and Mai Dong are used for their ability to moisten and tonify the Stomach, assisting the descent of Stomach Qi; Ji Nei Jin is used for its ability to resolve stasis and relieve pain, facilitating the action of the other herbs.
Second Visit: The above prescription was modified as needed and taken for over twenty doses. The Liver Qi had ascended, the Stomach Qi had descended, and both left and right pulses were peaceful. All diseases were cured. However, there was limb fatigue and poor digestion of food. A prescription to tonify Qi and strengthen the Stomach is proposed.
Prescription: Ye Tai Shen (Wild Ginseng Radix et Rhizoma, 4 qian), Sheng Huai Shan Yao (Raw Dioscoreae Hypoglaucae Rhizoma, 1 liang), Sheng Zhe Shi (Raw Hematitum, 6 qian, finely ground), Tian Dong (Asparagi Radix, 6 qian), Cun Mai Dong (Ophiopogonis Radix, 6 qian), Sheng Ji Nei Jin (Raw Gavis Corneum, 3 qian yellow ones, crushed), Sheng Mai Ya (Raw Hordei Fructus Germinatus, 3 qian), Gan Cao (Licorice Root, 1.5 qian).
Decoction Method: Decoct with one large cup of water and take warm.
Effect: After taking three doses, food intake increased, and physical strength gradually recovered. Wu Wei Gou Qi Zi (Lycii Fructus, 5 qian) and Bai Zhu (Atractylodis Macrocephalae Rhizoma, 3 qian) were added to the formula to be taken for a few more doses to consolidate the effect.
Commentary: The Qi transformation of the body naturally ascends on the left and descends on the right. If one only knows how to use Zhe Shi to descend the Stomach without using Mai Ya to ascend the Liver, over time, Liver Qi will suffer from stagnation and suppression, especially since the Liver Qi in this case was originally stagnant. This is why Zhe Shi is used alongside Mai Ya in the formula, and both are used in their raw state. Furthermore, materia medica texts state that fried Mai Ya is used for pills and powders; there is no need to fry it for decoctions. Using the raw herb boiled in water maximizes its digestive power.
Question: Among herbs that ascend Liver Qi, Chai Hu (Bupleuri Radix) is most effective. Why is Chai Hu not used in this formula instead of raw Mai Ya? Is there another reason? Answer: Chai Hu has strong power to lift and raise Liver Qi. Improper use often causes the Stomach Qi, which should descend, to be lifted and rebel upward. I once treated a patient with Yangming Jue Ni (Rebellious Flow) and hematemesis. Initially, the symptoms were not severe. The physician mistakenly used several qian of Chai Hu, resulting in massive hematemesis that filled a sputum basin in an instant, creating a fear of imminent death. It was too late to fetch medicine, but some raw Zhe Shi powder was available. The patient was instructed to swallow it quickly with warm water. After consuming about half a liang, the bleeding stopped. This is clear evidence that Chai Hu can induce rebellious upward flow of Stomach Qi. Moreover, in this case, the Stomach Qi was already failing to descend. Although raw Mai Ya can ascend Liver Qi, it does not hinder the descent of Stomach Qi. Its nature of sprouting and generating corresponds to the Wood element of the Liver, promoting the unblocking of Liver Qi stagnation so that it resolves and ascends naturally, unlike Chai Hu which purely lifts and raises.