东垣治一人。宿有阳明血证。因五月大热。吃杏。肠 下血。唧远散漫如筛。腰沉沉然
腹中不和。血色黑紫。病名湿毒肠癖。阳明少阳经血证也。以芍药一钱五分。升麻、羌活
黄各一钱。生熟地黄、独活、牡丹皮、炙甘草、柴胡、防风各五分。归身、葛根各三分
桂少许。作二服。
震按腰沉沉然。腹中不和。湿也。血色紫黑。湿兼热也。方中用风药以胜湿。不用凉药
以清热者。欲其行春生升发之令。使血不下走。无取苦寒之降沉也。加桂少许。如风熏日暖
不特血止。胃气亦旺矣。
罗谦甫治真定总管史侯男。年四十余。肢体本瘦弱。于至元辛巳。因秋收租。佃人致酒
味酸。不欲饮。勉饮数杯。少时腹痛。次传泄泻无度。日十余行。越旬。便后见血红紫。肠
鸣腹痛。医曰。诸见血者为热。用芍药柏皮丸治之。不愈。仍不欲食。食则呕酸。形体愈瘦
面色青黄不泽。心下痞。恶冷物。口干。时有烦躁。不得安卧。罗诊之。脉弦细而微迟。
手足稍冷。内经曰。结阴者。便血一升。再结二升。三结三升。又云。邪在五脏。则阴脉不
和。而血留之。结阴之病。阴气内结。不得外行。无所禀。渗肠间。故便血也。以苍术、升
麻、熟附子各一钱。地榆七分。陈皮、浓朴、白术、干姜、白茯苓、干葛各五分。甘草、益
智仁、人参、当归、神曲、炒白芍药各三分。上十六味作一服。加姜、枣煎。温服食前。名
曰平胃地榆汤。此药温中散寒。除湿和胃。数服。病减大半。仍灸中脘三七壮。乃胃募穴。
引胃上升。滋荣百脉。次灸气海百余壮。生发元气。灸则强食羊肉。又以还少丹服之。则喜
饮
食。添肌肉。至春再灸三里二七壮。壮脾温胃。生发元气。此穴乃胃之合穴也。改服芳香之
剂良愈。
震按此条证因易辨。脉又可凭。无甚疑难。妙在制方。升温通补分量轻重合宜。的属东
垣高弟。
丹溪治一老妇。性沉多怒。大便下血十余年。食减形困。心摇动。或如烟熏。早起面微
浮。血或暂止。则神思清。忤意则复作。百法不治。脉左浮大虚甚。久取滞涩而不匀。右沉
涩细弱。寸沉欲绝。此气郁生涎。涎郁胸中。心气不升。经脉壅遏不降。心血绝。不能自养
故也。非开涎不足以行气。非气升则血不归隧道。以壮脾药为君。二陈汤加红花、升麻、归
身、酒黄连、青皮、贝母、泽泻、黄 、酒芍药。每帖加附子一片。煎服。四帖后血止。去
附。加干葛、丹皮、栀子。而烟熏除。乃去所加药。再加砂仁、炒曲、熟地黄、木香。倍参
、术。服半月愈。
震按此条脉证。似虚似实。非寒非热。较之罗案。难辨多矣。及观其讲病源与用药法。
及药之轻重去取。俱有精义。又极平和。十年之病。半月而愈。仙乎仙乎。
虞恒德治一男子。四十余。素饮酒无度。得大便下血证。一日如厕二三次。每次便血一
碗。以四物汤加条芩、防风、荆芥、白芷、槐花等药。连日服之不效。后用橡斗烧灰二钱七
分。调入前药汁内服之。又灸脊中对脐一穴。血遂止。自是不发。
震按橡斗烧灰未为巧。灸脊中对脐一穴殊巧。
一男子。每怒必便血。或吐血。即服犀角地黄汤之类。薛立斋曰。当调理脾胃。彼不信。仍
服之。日加倦怠。面色萎黄。又用四物、芩、连、丹皮之类。饮食少思。心烦热渴。吐血如
涌。竟至不起。此证久服寒凉损胃。必致误人。其脾虚不能摄血。不用四君、芎、归、补中
益气之类。吾未见其生者。
一妇但怒必便血。寒热口苦。或胸胁胀痛。或小腹痞闷。薛曰。此怒动肝火而侮土。用
六君子加柴胡、山栀而愈。用补中益气、加味逍遥二药。乃不复作。
震按此条。是吐血便血正理正法。
李士材治学宪黄贞父。患肠风。久用四物汤芩、连、槐花之属。屡发不止。面色颇黄。
诊其脉。惟脾部浮而缓。此土虚而风湿交乘也。遂用苍术三钱。茯苓、人参、黄 、升麻、
柴胡、防风各一钱。四剂而血止。改服十全大补汤。调养而愈。
震按此条。是从李罗二案参合为治。
孙东宿治新市陈鹿塘。有肠风脏毒之证。大便燥结。数日不能一行。痛苦殊甚。百医不
效。其脉两寸皆数。两关皆弦而无力。两尺洪滑而左尤甚。孙曰。东垣谓大肠喜清而恶热。
脾胃喜温而恶寒。以胃属土而大肠属金也。今此乃胃寒肠热之证。当以肠风脏毒之药为君主
外以养血之剂裹之。使不伤胃气。盖药先入胃。而后传入大肠。入胃时裹药未化。及入大
肠。则裹药化而君药始见。亦假途灭虢之策也。因以大黄酒浸九蒸九晒二两。木耳二两。槐
花三两。郁李仁、皂角子、象牙屑、条芩各一两。血余灰、升麻、荆芥各五钱。为末。炼蜜
丸。外以四物汤加蒲黄各一两为衣。空心午后。各以米汤下二钱。果血止而大便不燥。饮食
日加矣。
震按裹药法以治肠风便燥颇相宜。盖裹药晒使坚干。诚可传入大肠。非比走经络及他脏
腑。必由脾胃转送也。
又治董宗伯公子龙山夫人。即宪副茅鹿门公女。年三十五。病便血。日二三下。腹不疼
医治三年不效。孙诊之。左脉沉涩。右脉漏出关外。诊不应病。因血既久下。且用补中益
气汤加阿胶、地榆、侧柏叶服八剂。血不下者半月。彼自喜病愈矣。偶因劳而血复下。又索
煎药。孙曰。夫人之病。必有瘀血积于经隧。前因右脉漏关难凭。故以升提兼补兼涩。以探
虚实耳。今得病情。法当下而除其根也。龙山曰。三年间便血。虽一日二三下。而月汛之期
不爽。每行且五日。何尚有瘀血停蓄耶。孙曰。此予因其日下月至。而知其必有瘀血停蓄也
经云。不塞不流。不行不止。今之瘀。实由塞之行也。不可再涩。古人治痢。必先下之。
亦此意也。即用桃仁承气汤加丹参、五灵脂、荷叶蒂。水煎夜服。五更下黑瘀血半桶。其日
血竟不来。乃以理脾药养之。过五日。复用下剂。又下黑瘀如前者半。乃以补中益气汤、参
苓白术散。调理全愈。
震按便血日二三下。已三年之久。而敢用逐瘀下药。非有确见。不可漫试。
周慎斋治一人。患肠风。血大下不止。头晕倒地。三四年不愈。皆曰不可治。周诊脉。
左手沉细。右手豁大。此因内伤寒凉太过。致阳不鼓。故右脉沉细。血不归络。火浮于中。
故尺脉豁大。用补中益气汤十帖。再用荆芥四两。川乌一两。醋面糊丸。空心服愈。
震按此丸名乌荆丸。恰与脏连丸为对待之方。一热一寒。判如裘葛。用得其宜。神应无
比。
〔附〕洛阳一女子。年十七。耽饮无度。多食鱼虾。蓄毒在脏。日夜二三十次。大便与
脓血杂下。大肠肛门痛不堪任。医以止血痢药。不效。又以肠风药。则益甚。盖肠风有血无
脓也。如此半年。气血渐弱。食渐减。肌肉渐消。稍服热药。则腹愈痛。血愈下。稍服凉药
则泄注气羸。粥食愈减。服温平药。则如不知。将期岁。医告术穷。待毙而已。或教服人
参樗皮散。谩试之。一服知。二服减。三服脓血皆定。不十服而愈。乃求其方。云治大肠风
虚
饮酒过度。挟热下利脓血。疼痛。多日不瘥。樗根白皮、人参各二两为末。二钱匕。空心
温酒调下。不饮酒。以温米饮下。忌油腻湿面青菜果子甜物鸡鱼蒜等。
震按此方。治久病则可。治暴病则不可。以补涩之药。恐留痼病邪也。叶案有用余粮石
脂者。亦主固涩下煎。或佐以人参、木瓜、炒乌梅、炒粳米。取甘酸合固涩。使阳明主阖也
或佐以萸肉、五味、黄柏、地榆。各炒成炭。取酸苦合固涩。可熄风坚阴也。皆从人参樗
皮散化出。
〔附〕嘉兴府尊王竺庐公祖办事勤敏。凡案牍书禀。靡不亲阅手裁。积劳而得便血证。
初用天王补心丹及玉女煎、知柏地黄丸等方。屡愈屡发。至丙申三月渐剧。食减面黄形瘦。
精神衰弱。无锡龚商年兄用补中益气汤。以醋炒升麻、归身而血止。半月后。偶食青菜腐汤
血复下。龚谓寒湿伤脾。用苍术理中汤。遂愈。十月中。值府考阅卷过劳。血又大发。龚
诊其脉。弦劲带数。腹胀不思食。易怒。进加味逍遥散。不应。改用桃花散、归脾汤。转加
口干咳嗽。佐以阿胶、熟地。又溏泻肠鸣不食。困惫难支。值抚宪荐胡灏轩先生来。毅然曰
归脾须合右归。重用人参则效。定方人参五钱。山药三钱。枸杞、菟丝、枣仁各四钱。茯
神、白芍、文蛤炒各钱半。炙草、炮姜各七分。地榆炭八分。乌梅、大枣各二枚。一剂而血
止。递加 、术、熟地。再去地榆、文蛤。佐以附子。而谷纳渐增。病遂全愈。斯真得力于
景岳者。
【背景信息】
书名：古今医案按 作者：俞震篡 朝代：清 章节：下血 类别：医论
李东垣治疗一个人。他素来有阳明经（足阳明胃经）的血证。因为五月天气大热，吃了杏子，导致肠道下血，血液喷射状散漫如筛孔般细密，腰部沉重感，腹部不适，血色黑紫。病名叫做湿毒肠癖，属于阳明、少阳（足少阳胆经）经的血证。处方用芍药一钱五分，升麻、羌活、黄芩各一钱，生地黄、熟地黄、独活、牡丹皮、炙甘草、柴胡、防风各五分，当归身、葛根各三分，桂枝少许。分为两服。
俞震按语：腰部沉重感，腹部不适，这是湿邪的表现。血色紫黑，是湿兼热的表现。方中使用风药（具有升散作用的药物）以胜湿，而不使用凉药以清热，是为了顺应春季生发之气，使血液不向下流失，避免使用苦寒药物导致的沉降之性。加入少许桂枝，如同风吹日晒温暖身体，不仅能使血止，胃气也能旺盛。
罗谦甫治疗真定总管史侯的儿子。年龄四十多岁。肢体本来瘦弱。在至元辛巳年，因为秋天收租，佃户送来酒，味道酸，不想喝，勉强喝了几杯。不久后腹痛，接着发生无度数的泄泻，每天十多次。过了十天，便后见血，血色红紫，肠鸣腹痛。医生认为：凡是见到出血的都是热证，用芍药柏皮丸治疗，没有痊愈。仍然不想吃东西，吃东西就呕吐酸水，形体更加消瘦，面色青黄无光泽，心下痞满，厌恶冷物，口干，时有烦躁，不能安卧。罗谦甫诊脉，脉象弦细而微迟，手脚稍冷。《内经》说：结阴病，便血一升，再结二升，三结三升。又说：邪气在五脏，则阴脉不和，血液留滞。结阴的病，是阴气在内结聚，不能向外运行，无处禀受，渗入肠间，所以便血。处方用苍术、升麻、熟附子各一钱，地榆七分，陈皮、厚朴、白术、干姜、白茯苓、干葛各五分，甘草、益智仁、人参、当归、神曲、炒白芍药各三分。以上十六味药作一服，加生姜、大枣煎煮，饭前温服。名叫平胃地榆汤。此药温中散寒，除湿和胃。服用几剂后，病情减轻大半。仍然灸中脘穴三七壮，这是胃的募穴，能引胃气上升，滋养百脉。其次灸气海穴百余壮，以生发元气。灸后加强饮食羊肉，又服用还少丹，于是喜欢饮食，增加肌肉。到了春天再灸足三里穴二七壮，以壮脾温胃，生发元气。此穴是胃的下合穴。改服芳香的药物，痊愈。
俞震按语：这一条证候容易辨别，脉象也可凭依，没有什么疑难。妙处在于制方，升温通补的分量轻重合宜，确实属于李东垣的高徒。
朱丹溪治疗一位老妇人。性格沉静多怒，大便下血十多年，食欲减退，身体困倦，心神动摇，有时感觉如烟熏一般，早起面部轻微浮肿，血暂时停止时，神思清爽，违逆心意时就复发，各种方法都治不好。脉象左手浮大虚甚，久取滞涩而不均匀，右手沉涩细弱，寸脉沉欲绝。这是气郁生痰涎，痰涎郁结胸中，心气不升，经脉壅遏不降，心血断绝，不能自我滋养的缘故。不开除痰涎不足以行气，气不升则血不能回归正常通道。以健脾药为君药，二陈汤加红花、升麻、当归身、酒黄连、青皮、贝母、泽泻、黄芩、酒芍药。每帖加附子一片，煎服。四帖后血止，去掉附子，加干葛、牡丹皮、栀子，烟熏感消除。于是去掉所加的药物，再加砂仁、炒神曲、熟地黄、木香，倍用人参、白术。服用半月痊愈。
俞震按语：这一条脉证，似虚似实，非寒非热，比罗谦甫的案例难辨多了。但看其讲解病源与用药法则，以及药物的轻重取舍，都有精义，又极平和。十年的病，半个月就痊愈了，真是神仙啊。
虞恒德治疗一个男子。四十多岁。素来饮酒无度，得了大便下血的证候。一天上厕所二三次，每次便血一碗。用四物汤加条芩、防风、荆芥、白芷、槐花等药，连日服用无效。后来用橡斗烧成灰二钱七分，调入前面的药汁内服用。又灸脊中对脐的一个穴位，血就停止了。从此不再发作。
有一个男子，每次发怒必定便血，或者吐血。立即服用犀角地黄汤之类的药物。薛立斋说：应当调理脾胃。他不相信，仍然服用犀角地黄汤。日渐倦怠，面色萎黄。又用四物汤、黄芩、黄连、牡丹皮之类的药物，饮食减少思虑，心烦热渴，吐血如涌，最终致死。这个证候长期服用寒凉药物损伤胃气，必然导致误人。他的脾虚不能摄血，不用四君子汤、川芎、当归、补中益气汤之类的药物，我没有见过能活的。
有一个妇人，只要发怒必定便血，伴有寒热口苦，或者胸胁胀痛，或者小腹痞闷。薛立斋说：这是发怒触动肝火而侮犯脾土。用六君子汤加柴胡、山栀而痊愈。用补中益气汤、加味逍遥散两种药，就不再发作。
俞震按语：这一条，是吐血便血的正理正法。
李士材治疗学宪黄贞父。患有肠风，长期用四物汤、黄芩、黄连、槐花之类的药物，屡次发作不止。面色颇黄。诊其脉，只有脾部脉浮而缓，这是土虚而风湿交乘。于是用苍术三钱，茯苓、人参、黄芪、升麻、柴胡、防风各一钱。四剂后血止。改服十全大补汤，调养而痊愈。
孙东宿治疗新市陈鹿塘。有肠风脏毒的证候。大便燥结，数日不能一行，痛苦非常严重。众多医生治疗无效。他的脉象两寸皆数，两关皆弦而无力，两尺洪滑而左侧尤其严重。孙东宿说：李东垣认为大肠喜清而恶热，脾胃喜温而恶寒，因为胃属土而大肠属金。现在这是胃寒肠热的证候，应当以治疗肠风脏毒的药物为主，外用养血的药物包裹它，使其不伤胃气。因为药物先进入胃，然后传入大肠，进入胃时包裹的药物未化开，等到进入大肠，包裹的药物化开而主药才显现，这也是假途灭虢的策略。于是用大黄黄酒浸渍九蒸九晒二两，木耳二两，槐花三两，郁李仁、皂角子、象牙屑、条芩各一两，血余灰、升麻、荆芥各五钱，研为末，炼蜜为丸。外用四物汤加蒲黄各一两为衣。空腹及午后，各用米汤送服二钱。果然血止而大便不干燥，饮食日渐增加。
俞震按语：裹药法治疗肠风便燥很相宜。因为包裹的药晒干使坚干，确实可以传入大肠，不像走经络及其他脏腑，必须经由脾胃转送。
又治疗董宗伯公子龙山夫人，即宪副茅鹿门公的女儿。年龄三十五岁。病便血，每天二三次，腹部不疼。医治三年无效。孙东宿诊脉，左脉沉涩，右脉漏出关外，脉诊与病情不相符。因为血已经长期下泄，先用补中益气汤加阿胶、地榆、侧柏叶服用八剂，血不下泄半个月。她自己高兴病好了。偶然因为劳累而血又下泄，又索取煎药。孙东宿说：夫人的病，必有瘀血积于经络隧道。之前因为右脉漏关难以凭依，所以用升提兼补兼涩的方法，以探求虚实。现在得知病情，法当攻下以去除病根。龙山说：三年间便血，虽然一天二三次，但月经周期不差，每次行经且五日，怎么还有瘀血停蓄呢？孙东宿说：这是我因为她每日下血直到月经期，从而知道她必有瘀血停蓄。《内经》说：不塞不流，不行不止。现在的瘀，实际上是由堵塞引起的。不可再使用涩药。古人治疗痢疾，必须先攻下，也是这个意思。于是就用桃仁承气汤加丹参、五灵脂、荷叶蒂，水煎夜间服用。五更时分排出黑瘀血半桶，当天血竟不来。于是用理脾药调养。过了五天，再用下剂，又排出黑瘀血如前的一半。于是用补中益气汤、参苓白术散，调理全愈。
俞震按语：便血每天二三次，已经三年之久，却敢用逐瘀攻下的药物，如果没有确切的见解，不可以随意尝试。
周慎斋治疗一个人。患肠风，血大下不止，头晕倒地，三四年不愈。大家都说不可治。周慎斋诊脉，左手沉细，右手豁大。这是因为内伤寒凉太过，导致阳气不能鼓动，所以右脉沉细，血不归络，火浮于中，所以尺脉豁大。用补中益气汤十帖，再用荆芥四两，川乌一两，醋面糊丸，空腹服用痊愈。
俞震按语：此丸名叫乌荆丸，恰与脏连丸为对待的方子，一热一寒，判若裘葛。用得适宜，神效无比。
〔附〕洛阳一个女子。年龄十七岁。贪饮无度，多吃鱼虾，蓄毒在脏，日夜二三十次，大便与脓血杂下，大肠肛门痛不堪忍受。医生用止血痢药，无效。又用肠风药，则更加严重。因为肠风有血无脓。如此半年，气血渐弱，饮食渐减，肌肉渐消。稍微服用热药，则腹痛加剧，血更多下泄。稍微服用凉药则泄注气弱，粥食更少。服用温平药，则如不知。将近一年，医生告术穷尽，等待死亡而已。有人教服人参樗皮散，随便试试。一服见效，二服减轻，三服脓血皆定。不到十服而痊愈。于是求其方，说治大肠风虚，饮酒过度，挟热下利脓血，疼痛，多日不瘥。樗根白皮、人参各二两为末，二钱匕，空腹温酒调下。不饮酒，以温米饮下。忌油腻湿面青菜果子甜物鸡鱼蒜等。
俞震按语：此方，治疗久病可以，治疗暴病不可以。因为补涩的药物，恐怕留下顽固的病邪。叶天士案有用余粮石脂的，也主固涩下焦。或佐以人参、木瓜、炒乌梅、炒粳米，取甘酸合固涩，使阳明主阖。或佐以萸肉、五味、黄柏、地榆，各炒成炭，取酸苦合固涩，可熄风坚阴。都是从人参樗皮散化出。
〔附〕嘉兴府尊王竺庐公祖办事勤敏。凡是案牍书禀，无不亲阅手裁。积劳而得便血证。初用天王补心丹及玉女煎、知柏地黄丸等方，屡愈屡发。到丙申三月逐渐加重，食减面黄形瘦，精神衰弱。无锡龚商年兄用补中益气汤，以醋炒升麻、归身而血止。半月后，偶然吃青菜腐汤，血又下泄。龚谓寒湿伤脾，用苍术理中汤，遂愈。十月中，值府考阅卷过劳，血又大发。龚诊其脉，弦劲带数，腹胀不思食，易怒。进加味逍遥散，不应。改用桃花散、归脾汤，转加口干咳嗽。佐以阿胶、熟地，又溏泻肠鸣不食，困惫难支。值抚宪荐胡灏轩先生来，毅然说：归脾须合右归，重用人参则效。定方人参五钱，山药三钱，枸杞、菟丝、枣仁各四钱，茯神、白芍、文蛤炒各钱半，炙草、炮姜各七分，地榆炭八分，乌梅、大枣各二枚。一剂而血止。递加黄芪、白术、熟地。再去地榆、文蛤。佐以附子，而谷纳渐增，病遂全愈。这真是得力于张景岳的。
[Background Information]
Book: *Gujin Yi An An* (Arranged Medical Cases of Past and Present)
Author: Yu Zhen (compiled)
Dynasty: Qing
Chapter: Lower Bleeding (Xià Xuè)
Category: Medical Discussion
Li Dongyuan treated a patient who had a history of blood disorders in the Yangming channel. Due to the intense heat in May, he consumed apricots, which led to intestinal bleeding. The blood sprayed out diffusely like a sieve, accompanied by a heavy sensation in the lower back and abdominal discomfort. The blood color was dark purple. The disease was named "Damp-Toxic Intestinal Dysentery," belonging to the blood disorders of the Yangming and Shaoyang channels. The prescription consisted of Paeoniae Radix (Shaoyao) 1.5 qian, Rhizoma Cimicifugae (Shengma), Radix Notopterygii (Qianghuo), and Radix Scutellariae (Huangqin) each 1 qian; Radix Rehmanniae Preparata (Shu Dihuang), Radix Rehmanniae Recens (Sheng Dihuang), Radix Angelicae Dahuricae (Duohuo), Cortex Moutan (Mudanpi), Radix Glycyrrhizae Preparata (Zhi Gancao), Radix Bupleuri (Chaihu), and Radix Saposhnikoviae (Fangfeng) each 0.5 qian; Radix Angelicae Sinensis (Guishen) and Radix Puerariae (Gegen) each 0.3 qian; and a small amount of Ramulus Cinnamomi (Guizhi). This was divided into two doses.
Yu Zhen’s commentary: The heavy sensation in the lower back and abdominal discomfort indicate dampness. The purple-black blood color indicates dampness combined with heat. The use of wind-dispelling herbs (herbs with ascending and dispersing properties) in the formula aims to overcome dampness, rather than using cooling herbs to clear heat. This is intended to promote the spring-like rising and generating qi, preventing blood from flowing downward, and avoiding the sinking effect of bitter-cold herbs. Adding a small amount of Cinnamon Twig helps warm the body like wind and sun, stopping the bleeding and strengthening stomach qi.
Luo Qianfu treated the son of Prefect Shi of Zhending. He was over forty years old and naturally thin and weak. In the Xin-Si year of the Zhiyuan era, while collecting autumn rents, tenants offered him wine. It tasted sour, and he did not wish to drink it, but forced himself to drink several cups. Soon after, he experienced abdominal pain, followed by profuse diarrhea, occurring more than ten times a day. Ten days later, bright red blood appeared after defecation, accompanied by borborygmus and abdominal pain. Physicians stated that "all bleeding cases are due to heat" and prescribed Shaoyao Bopi Wan, but there was no improvement. He still had no appetite, vomited acid when eating, became increasingly emaciated, and his complexion was sallow and lusterless. He suffered from epigastric fullness, aversion to cold objects, dry mouth, occasional irritability, and inability to sleep peacefully. Luo Qianfu diagnosed the pulse as wiry, fine, and slightly slow. His hands and feet were slightly cold. The *Neijing* states: "In Jieyin disease, one sheng of blood is passed; if it binds twice, two shengs are passed; if three times, three shengs." It also says: "When pathogens are in the five zang organs, the yin pulses become disharmonious, causing blood to stagnate." In Jieyin disease, yin qi knots internally and cannot circulate externally, lacking nourishment, and seeps into the intestines, causing hematochezia. The prescription included Rhizoma Atractylodis Macrocephalae (Cangzhu), Rhizoma Cimicifugae (Shengma), and Radix Aconiti Lateralis Preparata (Shu Fuzi) each 1 qian; Radix Sanguisorbae (Diyu) 0.7 qian; Pericarpium Citri Reticulatae (Chenpi), Cortex Magnoliae Officinalis (Houpo), Rhizoma Atractylodis Macrocephalae (Baizhu), Rhizoma Zingiberis Secundi (Ganjiang), Poria (Fuling), and Radix Puerariae (Gegen) each 0.5 qian; Radix Glycyrrhizae (Gancao), Semen Alpiniae Oxyphyllae (Yizhiren), Radix Ginseng (Renshen), Radix Angelicae Sinensis (Danggui), Massa Medicata Fermentata (Shenqu), and Radix Paeoniae Alba Preparata (Chao Baishao) each 0.3 qian. These sixteen ingredients were taken as one dose, decocted with ginger and jujube, and taken warm before meals. It was named Pingwei Diyu Tang. This medicine warms the middle, dispels cold, removes dampness, and harmonizes the stomach. After several doses, the condition improved by more than half. Acupoint Zhongwan (CV12), the front-mu point of the stomach, was moxibusted for 37 moxa cones to guide stomach qi upward and nourish the vessels. Subsequently, Qihai (CV6) was moxibusted for over 100 cones to generate primordial qi. After moxibustion, mutton was added to the diet, and Huanshao Dan was administered, leading to increased appetite and muscle gain. In spring, Zusanli (ST36), the lower-he sea point of the stomach, was moxibusted for 14 cones to strengthen the spleen and warm the stomach. Finally, aromatic formulas were used, resulting in a cure.
Yu Zhen’s commentary: This case is easy to diagnose based on symptoms and pulse, with few difficulties. The brilliance lies in the formulation, where the dosage of warming, ascending, unblocking, and tonifying agents is perfectly balanced, truly reflecting the skill of Li Dongyuan’s senior disciple.
Zhu Danxi treated an elderly woman who was quiet and prone to anger. She had suffered from hematochezia for over ten years, with reduced appetite and physical fatigue. Her spirit was unsettled, sometimes feeling as if smoke were filling her chest. Her face was slightly swollen in the morning; when the bleeding temporarily stopped, her mind cleared, but upon emotional upset, it recurred. Various treatments failed. The left pulse was floating, large, and extremely deficient, becoming choppy and irregular upon prolonged pressure. The right pulse was deep, choppy, fine, and weak, with the cun position nearly imperceptible. This indicated qi stagnation generating phlegm-fluids, which accumulated in the chest, preventing heart qi from ascending and causing vessel obstruction preventing descent. Heart blood was exhausted and unable to self-nourish. Without resolving phlegm-fluids, qi could not move; without ascending qi, blood could not return to its proper channels. Tonifying spleen herbs were used as the sovereign drug, combined with Erchen Tang plus Safflower (Honghua), Rhizoma Cimicifugae (Shengma), Radix Angelicae Sinensis (Guishen), Wine-processed Radix Scutellariae (Jiu Huanglian), Pericarpium Citri Reticulatae (Qingpi), Fructus Morus (Beimu), Radix Alismatis (Zexie), Radix Scutellariae (Huangqin), and Wine-processed Radix Paeoniae Alba (Jiu Shaoyao). One slice of Radix Aconiti Lateralis (Fuzi) was added per dose. After four doses, bleeding stopped. Fuzi was removed, and Radix Puerariae (Gegen), Cortex Moutan (Danpi), and Fructus Gardeniae (Zhizi) were added to resolve the smoky sensation. Then these additions were removed, and Amomum Fruit (Sharen), Fermented Rice (Chao Qu), Radix Rehmanniae Preparata (Shu Dihuang), and Radix Aucklandiae (Muxiang) were added, doubling the dosage of Radix Ginseng (Renshen) and Rhizoma Atractylodis Macrocephalae (Baizhu). The patient recovered after half a month.
Yu Zhen’s commentary: This case presents a pulse and symptom picture that appears both deficient and excess, neither cold nor hot, making it much harder to distinguish than Luo’s case. However, the explanation of the pathology and the method of medication, including the selection and dosage, show profound insight and extreme gentleness. A ten-year illness was cured in half a month; truly miraculous.
Yu Hengde treated a man in his forties who drank excessively and developed hematochezia. He visited the toilet two or three times a day, passing a bowl of blood each time. Siwu Tang plus Huangqin, Fangfeng, Jingjie, Bai Zhi, and Huaihua was taken continuously for days without effect. Later, ash from oak cups (Xiangdou) weighing 2.7 qian was burned and mixed into the previous herbal decoction. Additionally, moxibustion was applied to an acupoint on the spine opposite the umbilicus, which stopped the bleeding. There was no recurrence thereafter.
Yu Zhen’s commentary: Burning oak cups is not particularly clever, but moxibusting the specific acupoint on the spine opposite the umbilicus is quite ingenious.
A certain man would bleed from the rectum or vomit blood whenever he became angry. He immediately took Xijiao Dihuang Tang. Xue Lizhai advised regulating the spleen and stomach, but the patient did not believe him and continued taking the formula. His fatigue increased, and his complexion turned sallow. When treated with Siwu Tang plus Huangqin, Huanglian, and Mudanpi, his appetite decreased, he felt irritable, thirsty, and vomited blood copiously, eventually dying. Long-term use of cold-cooling herbs damages stomach qi and leads to misdiagnosis. Since spleen deficiency fails to control blood, failure to use Sijunzi Tang, Chuanxiong, Danggui, or Buzhong Yiqi Tang means survival is unlikely.
A certain woman would bleed from the rectum whenever she became angry, accompanied by alternating chills and fever, bitter taste, or distension and pain in the chest and hypochondrium, or fullness in the lower abdomen. Xue Lizhai diagnosed this as liver fire stirring due to anger, insulting the earth (spleen/stomach). Liu Junzi Tang plus Chaihu and Zhizi cured her. Subsequent use of Buzhong Yiqi Wan and Jiawei Xiaoyao San prevented recurrence.
Yu Zhen’s commentary: This case illustrates the correct principles and methods for treating vomiting and rectal bleeding.
Li Shicai treated Huang Zhenfu, an academic censor, who suffered from Changfeng (intestinal wind). Long-term use of Siwu Tang, Huangqin, Huanglian, and Huaihua failed to stop recurrent bleeding. His complexion was yellowish. The pulse at the spleen position was floating and slow, indicating earth deficiency with concurrent wind-dampness. Cangzhu 3 qian, along with Fuling, Renshen, Huangqi, Shengma, Chaihu, and Fangfeng each 1 qian, was prescribed. Bleeding stopped after four doses. He then switched to Shiquan Dabu Tang for recovery.
Yu Zhen’s commentary: This treatment integrates insights from the cases of Li Dongyuan and Luo Qianfu.
Sun Dongsu treated Chen Lutang from Xinshi, who suffered from Changfeng and Zhangdu (visceral toxin). His stool was dry and hard, difficult to pass for several days, causing severe pain. Many doctors failed to treat him. The pulse was rapid in both cun positions, wiry and forceless in both guan positions, and surging and slippery in both chi positions, especially on the left. Sun said: Li Dongyuan stated that the large intestine prefers clarity and dislikes heat, while the spleen and stomach prefer warmth and dislike cold, because the stomach belongs to earth and the large intestine to metal. This case involves stomach cold and intestinal heat. The treatment should prioritize herbs for Changfeng and Zhangdu, wrapped in blood-nourishing herbs to protect stomach qi. Since herbs enter the stomach first before reaching the large intestine, wrapping them ensures they remain intact until reaching the target organ, similar to the strategy of "borrowing a path to destroy Guo." The prescription used Da Huang (rhubarb) steamed nine times and dried nine times in wine (2 liang), Mu'er (2 liang), Huaihua (3 liang), Yuliren, Zaojiaozi, Ivory Dust (Xiangyasui), and Huangqin (each 1 liang), Xuyuhui, Shengma, and Jingjie (each 5 qian). These were powdered and formed into pills with honey. The coating consisted of Siwu Tang plus Puhuang (each 1 liang). Taken empty-stomached and in the afternoon with rice soup, bleeding stopped, stools softened, and appetite improved.
Yu Zhen’s commentary: The wrapping method is suitable for Changfeng with dry stools. The dried coating allows passage to the large intestine, unlike herbs acting on meridians or other organs that must pass through the spleen and stomach.
He also treated Mrs. Longshan, daughter of Mao Lumen, wife of Dong Zongbo’s son. At thirty-five, she suffered from hematochezia two to three times daily without abdominal pain. Three years of treatment failed. Sun’s pulse diagnosis showed a deep, choppy left pulse and a right pulse leaking beyond the guan position, inconsistent with the chronic nature of the disease. Initially, Buzhong Yiqi Tang plus Ejiao, Diyu, and Ce Baiye was given for eight doses, stopping bleeding for half a month. The patient believed she was cured. However,劳累 caused recurrence. Sun explained that stagnant blood must exist in the collaterals. The previous pulse was unreliable, so ascending, tonifying, and astringent methods were used to probe the condition. Now understanding the pathology, purgation is needed to remove the root. Longshan questioned how stagnant blood could exist given regular menstruation. Sun replied that daily bleeding until the menstrual period indicated hidden stagnation. As the classics state, "without blockage, there is no flow; without movement, there is no cessation." The current stagnation is caused by blockage. Further astringents are contraindicated. Ancient treatments for dysentery began with purgation. Tao Ren Cheng Qi Tang plus Danshen, Wulingzhi, and Helodie was decocted and taken at night. Half a bucket of black clotted blood was evacuated at dawn, and bleeding ceased for the day. Spleen-regulating herbs were then used. Five days later, another purgative was given, evacinating half the previous amount of black clots. Finally, Buzhong Yiqi Tang and Shenling Baizhu San restored health.
Yu Zhen’s commentary: Treating chronic hematochezia with strong purgatives requires absolute certainty; it cannot be attempted casually.
Zhou Shenzhai treated a patient with Changfeng, experiencing massive continuous rectal bleeding, dizziness, and fainting, lasting three to four years. Others deemed it incurable. Zhou’s pulse was deep and fine on the left, and hollow/large on the right. This resulted from excessive internal consumption of cold-cooling herbs, suppressing yang qi, causing blood to fail to return to the vessels, with fire floating internally. Buzhong Yiqi Tang for ten doses was followed by a pill made of Jingjie (4 liang) and Chuanwu (1 liang) bound with vinegar paste, taken empty-stomached, resulting in a cure.
Yu Zhen’s commentary: This pill, Wu Jing Wan, contrasts with Zanglian Wan—one cold, one hot. Used appropriately, it is miraculously effective.
[Appendix] A seventeen-year-old girl in Luoyang drank excessively and ate much fish and shrimp, accumulating toxins in the viscera. She passed stool mixed with pus and blood twenty to thirty times daily, with unbearable anal pain. Hemostatic drugs for dysentery failed. Changfeng formulas worsened the condition, as Changfeng involves blood only, not pus. After six months, qi and blood weakened, appetite dropped, and muscles wasted. Hot herbs increased pain and bleeding; cold herbs caused diarrhea and weakness; neutral herbs had no effect. Near death, someone recommended Ren Shen Chu Pi San. One dose brought relief, two reduced symptoms, three stopped pus and blood. Less than ten doses cured her. The formula treats large intestine wind-deficiency, excessive drinking, heat-induced dysentery with pus/blood/pain. Chupi (Cortex Stemonae) and Renshen (2 liang each) are powdered. Two qian are taken warm with wine (or rice water) empty-stomached. Avoid greasy, wet dough, vegetables, fruits, sweets, chicken, fish, garlic.
Yu Zhen’s commentary: This formula suits chronic cases but not acute ones, as astringents may retain pathogens. Ye Tianshi used Yuliang Shizhi for similar astringent purposes, often adding Renshen, Mugua, Chao Wumei, and Chao Jingmi for sweet-sour astringency to close Yangming, or Shan Zhu Yu, Wuweizi, Huangbai, and Diyu (charred) for sour-bitter astringency to extinguish wind and secure yin. All derive from Ren Shen Chu Pi San.
[Appendix] Wang Zhulu, Prefect of Jiaxing, worked diligently, reviewing all documents personally. Accumulated labor led to hematochezia. Initial treatments with Tianwang Buxin Dan, Yuni Jian, and Zhibai Dihuang Wan provided temporary relief but relapsed. By March of Bing-Shen year, symptoms worsened: poor appetite, sallow complexion, emaciation, and mental exhaustion. Gong Shangnian prescribed Buzhong Yiqi Tang with vinegar-processed Shengma and Guishen, stopping bleeding. Half a month later, eating vegetable and tofu soup caused recurrence. Gong attributed this to cold-damp damaging the spleen and prescribed Cangzhu Lizhong Tang, which cured him. In October, grading exam papers caused heavy labor and severe bleeding again. Pulse was wiry, strong, and rapid, with abdominal distension, anorexia, and irritability. Jiawei Xiaoyao San failed. Taohua San and Guipi Tang worsened symptoms with dry mouth, cough, loose stools, and bowel sounds. Hu Haoxuan was recommended. He insisted Guipi Tang must be combined with You Gui Wan, heavily dosed with Renshen. Prescription: Renshen 5 qian, Shanyao 3 qian, Gouqi, Tusizi, Zaoren each 4 qian, Fushen, Baishao, Wenge (stir-fried) each 1.5 qian, Zhigancao, Paojiang each 0.7 qian, Diyutan 0.8 qian, Wumei, Dazao each 2 pieces. One dose stopped bleeding. Huangqi, Baizhu, and Shudihuang were gradually added; Diyuan and Wenge removed; Fuzi added. Appetite increased, and the patient fully recovered. This demonstrates mastery of Zhang Jingyue’s methods.