丹溪治一人。因心痛。久服热药多。兼患吞酸。以二陈汤加芩、连、白术、桃仁、郁李
仁、泽泻。服之累涌出酸苦黑水如烂木耳者。服久。心痛既愈。酸仍频作。有酸块自胸膈间
筑上咽喉甚恶。以黄连浓煎冷。候酸块欲升。即与数滴饮之。半日许。下数次而愈。乃罢药
淡粥调之一月。时已交春节旬余。中脘处微胀急。面带青。气微喘。时天尚寒。盖脾土久
病衰弱。遇木气行令。脾受肝凌也。急以索矩六和汤与之。四日而安。
立斋治一儒者。面色痿黄。胸膈不利。吞酸嗳腐。频服理气化痰之药。大便不实。食少
体倦。此脾胃虚寒也。用六君加炮姜、木香。渐愈。兼用四神丸而元气复。
震按二条治热治寒。各极其妙。朱案不用左金之反佐。识见最高。薛案之四神。不若去
五味、肉果。换以参、术、姜、附为更妥也。薛又有一案。现证皆同。更加足指肿痛。指缝
出水。其人先服二陈、二妙、黄连、枳实。薛用补中益气加茯苓、半夏而愈。真丝丝入扣之
方矣。盖脾虚挟寒。脾虚挟湿。同中有异耳。周慎斋治吞酸。专用吴茱萸。历叙其效。则又
单管得寒湿二字。
孙东宿治叶润斋。年近四十。心鬲嘈杂。好啖肉。尤好鸡。一日不能缺。缺即身浮力倦
神魂无措。必急得肉。见则大嚼。及入腹。腹又大痛。痛极则吐酸水稠涎然后定。稍定又
思肉啖也。人疑为祟。孙诊之。六脉大小不等。观其色唇红脸黄。问之。则曰痛虽苦。尚能
熬。若嘈杂则遍身淫淫苏苏。左右无可奈何。手足无所把捉。有近于死。急需肉以救命。孙
曰。据色脉。乃虫证。非祟也。先予雄黄丸一服。不瘳。改以腻粉五分。使君子末一钱。用
鸡子打饼。五更空心饲之。辰刻下长蛲十条。内有二大者。长尺余。下午又下小虫百余。自
此不喜肉。而嘈杂良愈。
震按嘈杂证。丹溪谓是痰因火动。乃噎膈之渐。故多用黄连、山栀、苍术、半夏、白芍
之类。然亦有思虑伤血者。有肾阴虚而胃火旺者。又宜用生地、阿胶、柏子仁、麦冬、石斛
芦根之类。若此案乃虫蚀脂膏。嘈杂门中所未载。故特选之。昔年曾见叶天翁治一妇人胸
痞心嘈。用盐水煮石决明三钱。经霜桑叶二钱。丹皮一钱。黑栀一钱。三角黑胡麻二钱。细
生地三钱。四帖而愈。此又肝火郁于胃之嘈杂也。
朱丹溪治疗一个人。因为心痛，长期服用热性药物过多，又兼患吞酸症。用二陈汤（燥湿化痰、理气和中的基础方）加入黄芩、黄连、白术、桃仁、郁李仁、泽泻。服药后多次涌吐出像烂木耳一样的酸苦黑水。服久了，心痛虽然好了，但吞酸仍然频繁发作。有酸块从胸膈间向上冲至咽喉，非常难受。于是将黄连浓煎后放冷，等到酸块将要升起时，立即喂几滴药汁。半天左右，排出数次后痊愈。此后停药，用清淡的粥调养一个月。当时已经进入春节十多天，中脘穴处微微胀满急迫，面色发青，气息微喘。此时天气尚寒，这是因为脾土久病衰弱，遇到肝木之气当令，脾受到肝的克制。急忙给予索矩六和汤（调和脾胃、行气除满的方剂），四天后病情安定。
薛立斋治疗一位读书人。面色萎黄，胸膈部感觉不顺畅，吞酸并伴有嗳出腐臭气味，频繁服用理气化痰的药物，导致大便不成形，饮食减少，身体疲倦。这是脾胃虚寒的症状。使用六君子汤（益气健脾、燥湿化痰）加入炮姜、木香。逐渐好转。同时配合服用四神丸（温肾暖脾、固肠止泻），元气得以恢复。
我（俞震）按语：以上两条案例，一条治热，一条治寒，都达到了极高的境界。朱丹溪的案例没有使用左金丸（清肝泻火、降逆止呕）的反佐法，见识最高。薛立斋案例中的四神丸，不如去掉五味子、肉豆蔻，换成人参、白术、干姜、附子更为妥当。薛立斋还有另一个案例，现证表现相同，只是增加了足趾肿痛、指缝流水的症状。患者之前服用二陈汤、二妙散（清热燥湿）、黄连、枳实。薛立斋用补中益气汤（补中益气、升阳举陷）加入茯苓、半夏而治愈。真是丝丝入扣的处方啊。这是因为脾虚夹寒与脾虚夹湿，同中有异罢了。周慎斋治疗吞酸，专门使用吴茱萸，详细叙述了其疗效，则是单管抓住了“寒湿”这两个字。
孙东宿治疗叶润斋。年纪接近四十岁，心膈部嘈杂不适，喜欢吃肉，尤其喜欢吃鸡肉，一天都不能缺少，如果缺少就身体浮肿、力气疲倦、神魂不定。必须急着得到肉，见到肉就大口咀嚼。等到肉进入腹中，腹部又大痛，痛到极点则吐出酸水和稠厚的涎液后才停止。稍微缓解后又想吃肉。人们怀疑是鬼怪作祟。孙东宿诊察发现，六脉大小不等，观察其面色，嘴唇红、脸黄。询问病情，他说疼痛虽然痛苦，还能忍受；如果是嘈杂感，则全身瘙痒不安，左右无可奈何，手足无法把持，近乎死亡，急需吃肉来救命。孙东宿说：根据色脉，这是虫证，不是鬼祟。先给予雄黄丸服用一次，没有见效。改为使用腻粉五分，使君子末一钱，用鸡蛋做成饼，在凌晨五更时分空腹喂食。辰时排出了十条长蛲虫，其中两条大的，长度有一尺多。下午又排出一百多条小虫。从此不再喜欢肉，而嘈杂症也大大好转。
我（俞震）按语：嘈杂证，朱丹溪认为是痰因火动，是噎膈（吞咽困难、胸膈阻塞的病证）的开端，所以多用黄连、山栀、苍术、半夏、白芍等药。然而也有因思虑过度伤血的情况，有肾阴虚而胃火旺的情况，又适宜用地黄、阿胶、柏子仁、麦冬、石斛、芦根等药。至于这个案例，乃是虫蚀脂膏（体内脂肪或精微物质），在嘈杂门的记载中未曾收录，所以特意选录。早些年我曾见过叶天士治疗一个妇人，胸痞心嘈，用盐水煮石决明三钱，经霜桑叶二钱，丹皮一钱，黑栀子一钱，三角黑胡麻二钱，细地黄三钱，四帖药后痊愈。这又是肝火郁结于胃引起的嘈杂症。
Zhu Danxi treated a patient. Due to heart pain, the patient had taken excessive amounts of hot-natured medicines for a long time and also suffered from acid regurgitation (swallowing acid). Zhu prescribed Erchen Tang (Phlegm-Resolving Decoction) with added Huangqin (Scutellariae Radix), Lianzi (Coptidis Rhizoma), Baizhu (Atractylodis Macrocephalae Rhizoma), Taoren (Persicae Semen), Yuliren (Prunus Armeniaca Seed), and Zexie (Alismatis Rhizoma). After taking the medicine, the patient vomited up sour, bitter, black fluid resembling rotten wood ear mushrooms multiple times. After prolonged use, the heart pain was cured, but acid regurgitation remained frequent. A lump of acid would surge from the chest and diaphragm up to the throat, causing great distress. Therefore, Huanglian (Coptidis Rhizoma) was decocted strongly and cooled. When the acid lump was about to rise, several drops were administered. Within half a day, after several bowel movements, the condition healed. The medication was then stopped, and the patient was nourished with light congee for one month. By this time, it had been over ten days since the Spring Festival. There was slight distension and urgency at the Zhongwan (CV12) point, the complexion appeared bluish, and there was slight panting. The weather was still cold. This was because the Spleen Earth had been weakened by long-term illness, and upon encountering the Wood Qi in command, the Spleen was overwhelmed by the Liver. Suju Liuhe Tang (Six-Harmony Decoction) was urgently administered, and the patient stabilized in four days.
Xue Lizhai treated a scholar. The patient had a sallow complexion, discomfort in the chest and diaphragm, acid regurgitation accompanied by belching of putrid food, and frequent use of Qi-regulating and phlegm-resolving medicines led to loose stools, poor appetite, and physical fatigue. This indicated deficiency-cold of the Spleen and Stomach. Liu Junzi Tang (Six-Gentlemen Decoction) with Paojiang (Prepared Ginger) and Muxiang (Aucklandiae Radix) was used, leading to gradual improvement. Simultaneously, Sishen Wan (Four-Spirit Pill) was taken to restore Yuan Qi (Primordial Qi).
My commentary: The above two cases, one treating heat and the other treating cold, both achieved excellence. In Zhu’s case, the use of the counter-assistance method of Zuojin Wan (Left Metal Pill) was avoided, showing the highest insight. In Xue’s case, regarding Sishen Wan, it would be more appropriate to remove Wuweizi (Schisandrae Fructus) and Roudoukou (Myristicae Semen) and replace them with Renshen (Ginseng Radix et Rhizoma), Baizhu (Atractylodis Macrocephalae Rhizoma), Jiang (Zingiberis Rhizoma), and Fuzi (Aconiti Lateralis Radix Praeparata). Xue had another case where the presenting symptoms were identical, except for swelling and pain in the toes and oozing between the fingers. The patient had previously taken Erchen Tang, Ermiao San (Two-Awesome Powder), Huanglian (Coptidis Rhizoma), and Zhishi (Aurantii Fructus Immaturus). Xue cured him using Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) with added Fuling (Poria) and Banxia (Pinelliae Rhizoma). This was indeed a meticulously tailored prescription. It illustrates that Spleen deficiency with cold and Spleen deficiency with dampness are similar yet distinct. Zhou Shenzhai treated acid regurgitation using only Wuzhuyu (Evodiae Fructus), detailing its efficacy, which focused solely on the characters "cold-dampness."
Sun Dongsu treated Ye Runzhai. Approaching forty years of age, he suffered from epigastric clanging (zao re - a sensation of hunger mixed with discomfort). He loved eating meat, especially chicken, and could not go a day without it. If deprived, his body would swell, he would feel weak, and his spirit would be unsettled. He urgently needed meat; seeing it, he would devour it. However, once the meat entered his stomach, severe abdominal pain ensued. Only after vomiting thick sour water and saliva did the pain subside. Once slightly relieved, he craved meat again. People suspected demonic possession. Sun diagnosed unequal pulse sizes across the six positions. Observing his face, his lips were red and his cheeks yellow. Upon inquiry, he said that although the pain was bitter, he could endure it; but when the clanging occurred, his whole body felt itchy and restless, leaving him helpless and unable to control his limbs, feeling as if near death. He urgently needed meat to save his life. Sun said: Based on the complexion and pulse, this is a worm infestation, not demonic possession. First, Xionghuang Wan (Realgar Pill) was given, but without effect. It was changed to Nifen (Calomel) 5 fen, Shijunzi powder (Quisqualis Indica Seed) 1 qian, made into a cake beaten with an egg, and fed on an empty stomach at wu geng (3-5 AM). At chen shi (7-9 AM), ten long pinworms were passed, two of which were large, over chi (approx. 30 cm) in length. In the afternoon, over a hundred small worms were passed. From then on, he no longer desired meat, and the clanging symptom greatly improved.
My commentary: Regarding clanging (zao re), Zhu Danxi attributed it to phlegm stirred by fire, considering it a precursor to ye ge (dysphagia/chest obstruction). Thus, he often used Huanglian (Coptidis Rhizoma), Shanzhi (Gardeniae Fructus), Cangzhu (Atractylodis Rhizoma), Banxia (Pinelliae Rhizoma), and Baishao (Paeoniae Radix Alba). However, there are cases caused by excessive thinking damaging blood, or Kidney Yin deficiency with Stomach Fire, which require Dihuang (Rehmanniae Radix), Ejiao (Asini Corii Colla), Baiziren (Biota Semen), Maidong (Ophiopogonis Radix), Shihu (Dendrobii Caulis), and Lugeng (Phragmitis Rhizoma). This case, however, involved worms eroding fat and essence, which was not recorded in the clanging section, so it was specially selected. Years ago, I saw Ye Tianshi treat a woman with chest stuffiness and epigastric clanging using Shi Jueming (Haliotidis Concha) boiled in salt water 3 qian, Shuang Sangye (Mulbai Folium frosted by frost) 2 qian, Danpi (Moutan Cortex) 1 qian, Hei Zhi (Gardeniae Fructus charred) 1 qian, Sanjiao Heihuma (Sesamum indicum seed) 2 qian, Xi Dihuang (Rehmanniae Radix Preparata) 3 qian. She recovered after four doses. This represents clanging caused by Liver Fire stagnating in the Stomach.