丹溪治一室女。素强健。六月发烦闷。困惫不食。时欲入井。脉沉细数弱。口渐渴。医
作暑病治不效。又加呕而瘦。手心热。喜在暗处。脉渐伏而妄语。朱制局方妙香丸。如芡实
大。井水下一丸。半日大便。药已出矣。病不减。遂以麝香水洗药。以针穿三孔。凉水吞。
半日下稠痰数升。得睡渐愈。因记金匮云。昔肥而今瘦者痰也。
震按此证必须妙香丸。若温胆导痰等方无益也。但以芡实大之丸药而囫囵吞下。一奇。
再以便出之药。而水洗针穿。又复吞之。更奇。
立斋治一儒者。背肿一块。按之则软。肉色如故。饮食如常。劳则吐痰体倦。此脾虚而
痰滞。用补中益气加茯苓、半夏。少加羌活。外用阴阳散。以姜汁调搽而消。后因劳。头晕
作呕。仍以前药去羌活。加蔓荆子而愈。
震按此即世人所谓湿痰流注也。劳则吐痰体倦。脾虚易明矣。
阁老梁浓斋。气短有痰。小便赤涩。足跟作痛。尺脉浮大。按之则涩。此肾虚而痰饮也
用四物送六味丸。不月而康。仲景云。气虚有饮。用肾气丸补而逐之。诚开后学之蒙 。
济无穷之夭枉。肾气丸。即六味丸。
震按四物汤送六味丸。专补肾阴也。若仲景所谓肾气丸。必以六味加桂附为是。况气短
足跟痛尺脉涩。仅用六味。恐不效。此案与治孟都宪案同法。梁则小便赤涩。孟则遗尿。梁
则尺浮大而按之涩。孟则尺浮大按之如无。孟加眩晕。尤易辨也。
李士材曰。翰林李集虚。劳而无度。醉而使内。汗出多痰。服宽膈化痰之药。转觉滞闷
诊其脉沉而涩。两尺尤甚。余谓其婿曰。痰得涩脉。一时难愈。况尺中涩甚。精伤之象也
在法不治。勉用补中益气加半夏、茯苓。二剂有小效。众皆喜。余曰。涩象不减。脉法无
根。死期近矣。果十余日而殁。
震按此与梁浓斋案同一涩脉而死生不同者。彼惟尺脉浮大。按之则涩。此是六部沉涩。
两尺尤甚。轻重自别也。况又云脉法无根。想是沉而细涩。按之欲绝耳。不然。哮嗽门中顾
明华案。亦系涩脉。何以先补养而继吐下。仍能愈之耶。
李士材治秦景明。素有痰饮。每岁必四五发。发即呕吐不能食。此病久结成窠囊。非大
涌之。弗愈也。须先进补中益气。十日后。以瓜蒂散频投。涌如赤豆沙者数升。已而复得水
晶色者升许。如是者七补之。七涌之。百日而窠囊始尽。专服六君子八味丸。经年不辍。
震按长于治痰者。前有张戴人。后有王隐君。然可施于人强证实。若虚者非所宜也。此
案七补七涌。足以匡救两家之法。夫人身本无所谓痰。痰因病而生耳。惟治其所以生痰之病
则痰自除。至方书所载有风痰、寒痰、火痰、湿痰、燥痰、清痰、老痰、味痰、酒痰、郁
痰、顽痰、惊痰、虚痰种种名色。而变现诸证。千态万状。又似种种杂病。此又不得以种种
杂病法治。但治其痰则病自去。盖标而本之。本而标之。总在医家之变通也。
朱丹溪治疗一位未婚女子。她平时身体强健。六月时出现心烦闷乱、困倦疲乏、不想进食的症状，时常想要跳进井里（以求凉快）。脉象沉细、数而弱，口逐渐感到口渴。医生将其当作暑病治疗，但无效。病情加重后出现呕吐和消瘦，手心发热，喜欢待在昏暗的地方，脉象逐渐伏匿不起并伴有胡言乱语。朱丹溪配制了局方妙香丸，大小如芡实。让患者用井水送服一丸，半天后大便排出，药已排出体外。但病未减轻。于是用麝香水清洗药丸，用针在药丸上穿三个孔，再用凉水吞服。半天后吐出稠痰数升，随后入睡，病情逐渐痊愈。因此记起《金匮要略》中说：过去肥胖现在消瘦的，是痰证。
俞震按语：这个病症必须使用妙香丸，像温胆汤、导痰汤等方剂是没有效果的。但是将如芡实大小的药丸囫囵吞下，这是一个奇特之处。再次将已经排出的药丸用水洗、用针穿，又重新吞服，更是奇特。
薛立斋治疗一位读书人。背部肿起一块，按压时感觉柔软，皮肤颜色正常，饮食如常，劳累时则吐痰且身体疲倦。这是脾虚导致痰湿停滞。使用补中益气汤加入茯苓、半夏，少量加入羌活。外用阴阳散，用姜汁调匀后涂抹，肿块消散。后来因为劳累，出现头晕作呕，仍然用前面的方剂去掉羌活，加入蔓荆子而痊愈。
俞震按语：这就是世人所说的湿痰流注。劳累时吐痰且身体疲倦，脾虚很容易明白。
阁老梁浓斋，气短且有痰，小便赤红涩痛，足跟疼痛，尺脉浮大，重按则涩滞。这是肾虚兼有痰饮。用四物汤送服六味地黄丸，不到一个月就康复了。张仲景说：气虚有水饮，用肾气丸补益并驱逐水饮。这确实开启了后学的蒙昧，救济了无数夭折之人。肾气丸，就是六味地黄丸。
俞震按语：四物汤送服六味地黄丸，专门补肾阴。如果像张仲景所说的肾气丸，必须在六味地黄丸基础上加入肉桂、附子才是正确的。况且气短、足跟痛、尺脉涩，仅用六味地黄丸，恐怕效果不佳。这个医案与治疗孟都宪的医案方法相同。梁浓斋是小便赤涩，孟都宪是遗尿；梁浓斋是尺脉浮大重按涩，孟都宪是尺脉浮大重按如无；孟都宪还加上眩晕，更容易辨别。
李士材说：翰林李集虚，过度劳累，酒后行房，出汗多且痰多。服用宽膈化痰的药物后，反而觉得滞闷。诊察他的脉象沉而涩，两尺部尤其严重。我对他的女婿说：痰证遇到涩脉，一时难以治愈，何况尺部涩象严重，这是精血损伤的迹象。按照医法属于难治之症。勉强使用补中益气汤加入半夏、茯苓。两剂药后有一点小效，众人都很高兴。我说：涩象没有减少，脉法显示无根，死期临近了。果然十几天后就去世了。
俞震按语：这个医案与梁浓斋医案都是涩脉而死生不同，那是因为梁浓斋只是尺脉浮大重按才涩，而这个病例是六部脉皆沉涩，两尺部尤其严重，轻重自然有别。况且又说“脉法无根”，想是脉象沉细涩，重按几乎摸不到。不然的话，哮嗽门中的顾明华医案，也是涩脉，为什么先补养继以吐下，仍能痊愈呢？
李士材治疗秦景明。平素有痰饮病，每年必定发作四五次，发作时就呕吐不能进食。这个病日久结成窠囊，如果不采用强烈的涌吐法，就不能痊愈。必须先服用补中益气汤，十天后，频繁投予瓜蒂散，涌吐出的东西像赤豆沙一样数升。之后又吐出水晶色样的痰液约一升。像这样七次补益、七次涌吐，一百天后窠囊才清除干净。之后专门服用六君子汤和八味丸，坚持一年不间断。
俞震按语：擅长治疗痰证的，前有张戴人，后有王隐君。然而这些方法只适用于体质强壮、实证的患者，对于虚证患者是不适宜的。这个医案中七次补益七次涌吐，足以纠正这两家方法的偏颇。人体本来没有所谓的痰，痰是因为生病而产生的。只要治疗产生痰的病源，痰自然消除。至于方书中记载的风痰、寒痰、火痰、湿痰、燥痰、清痰、老痰、味痰、酒痰、郁痰、顽痰、惊痰、虚痰等各种名称，以及表现出的各种症状，千姿百态，又似乎像各种杂病。这又不能简单地用治疗各种杂病的方法来对待。但如果只治其痰，病自然去除。盖标而本之，本而标之，全在于医生的变通运用。
Zhu Danxi treated an unmarried young woman. She was usually robust. In the sixth month, she developed mental restlessness and oppression, fatigue, loss of appetite, and a frequent desire to enter a well (to seek coolness). Her pulse was deep, fine, rapid, and weak; her mouth gradually became thirsty. Physicians treated it as Summerheat disease (Shu Bing) without effect. The condition worsened with vomiting and emaciation, heat in the palms, a preference for dark places, a pulse that gradually became hidden (Fu Mai), and delirious speech. Zhu Danxi prepared Miaoxiang Wan from the Bureau Formulas, sized like a Chinese chestnut (Qianshi). He instructed the patient to swallow one pill with well water. Half a day later, stool was passed, and the medicine had been excreted. However, the illness did not subside. Therefore, he washed the pills with musk-infused water, pierced three holes in them with a needle, and had the patient swallow them with cool water. Half a day later, several sheng (a traditional unit of volume) of thick phlegm were expectorated. She then fell asleep and gradually recovered. This recalls the statement in *Jingui Yaolue*: "Those who were formerly fat but are now thin have Phlegm."
Yu Zhen's commentary: This case requires Miaoxiang Wan; formulas such as Wendan Tang (Warm the Gallbladder Decoction) or Daotan Tang (Guide Out Phlegm Decoction) would be ineffective. Yet, swallowing a pill the size of a Chinese chestnut whole is a peculiarity. Furthermore, washing the excreted pill with water, piercing it with a needle, and swallowing it again is even more peculiar.
Xue Lizhai treated a scholar. A swelling appeared on his back; it was soft upon pressure, with normal skin color and normal diet. Upon exertion, he expectorated phlegm and felt fatigued. This indicated Spleen deficiency with Phlegm stagnation. He prescribed Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) added with Fuling (Poria) and Banxia (Pinellia Rhizome), with a small amount of Qianghuo (Notopterygium Rhizome). Externally, Yinyang San (Yin-Yang Powder) was applied with ginger juice, leading to the resolution of the swelling. Later, due to overexertion, he experienced dizziness and vomiting. The previous prescription was used minus Qianghuo, plus Manjingzi (Vittatis Fructus), resulting in recovery.
Yu Zhen's commentary: This is what common people call Wet-Phlegm flowing into the collaterals (Shi Tan Liu Zhu). Expectoration of phlegm and fatigue upon exertion clearly indicates Spleen deficiency.
Grand Secretary Liang Nongzhai suffered from shortness of breath and phlegm, red and scanty urine, and pain in the heels. His Chi (Cun-Guan-Chi) pulse at the radial artery was floating and large, but rough (Se Mai) upon heavy pressure. This indicated Kidney deficiency with Phlegm-fluid retention. Siwu Tang (Four Substances Decoction) was used to deliver Liuwei Dihuang Wan (Six-Ingredient Pill with Rehmannia). Within a month, he recovered. Zhang Zhongjing stated: "For Qi deficiency with fluid retention, use Shenqi Wan (Kidney Qi Pill) to tonify and expel." This indeed enlightens later learners and saves countless premature deaths. Shenqi Wan is essentially Liuwei Dihuang Wan.
Yu Zhen's commentary: Siwu Tang delivering Liuwei Dihuang Wan specifically tonifies Kidney Yin. If referring to Zhang Zhongjing's Shenqi Wan, it must include Rougui (Cinnamon Bark) and Fuzi (Aconite Root) added to Liuwei Dihuang Wan. Moreover, given shortness of breath, heel pain, and a rough Chi pulse, using only Liuwei Dihuang Wan might be ineffective. This case follows the same method as the case treating Censor Meng. Liang had red, scanty urine, whereas Meng had enuresis; Liang had a floating-large Chi pulse that was rough upon pressure, whereas Meng had a floating-large Chi pulse that felt empty upon pressure; Meng also had dizziness, making differentiation easier.
Li Shicai said: Hanlin Li Jixu engaged in excessive labor and sexual activity after drinking, resulting in profuse sweating and much phlegm. After taking medicines to widen the diaphragm and resolve phlegm, he felt more obstructed and oppressed. His pulse was deep and rough, especially in both Chi positions. I told his son-in-law: "Phlegm presenting with a rough pulse is difficult to cure in the short term. Moreover, severe roughness in the Chi position indicates damage to Essence (Jing). According to medical principles, this is untreatable. I will tentatively prescribe Buzhong Yiqi Tang added with Banxia and Fuling." After two doses, there was slight improvement, and everyone was pleased. I said: "The roughness remains unchanged, and the pulse lacks root; death is near." Indeed, he died ten days later.
Yu Zhen's commentary: This case and Liang Nongzhai's case both involve a rough pulse, yet the outcomes differed in life and death. In Liang's case, only the Chi pulse was floating-large and rough upon pressure; here, all six positions were deep and rough, especially the Chi positions, indicating a difference in severity. Furthermore, the phrase "pulse lacks root" suggests a deep, fine, and rough pulse that nearly disappears upon pressure. Otherwise, in the Asthma and Cough section, the case of Gu Minghua also presented with a rough pulse, yet why did he recover after initial tonification followed by emesis and purgation?
Li Shicai treated Qin Jingming. He had chronic Phlegm-fluid retention, exacerbating four or five times a year, accompanied by vomiting and inability to eat during attacks. This disease had formed nests (Ke Nang) over time; without strong emesis, it could not be cured. First, Buzhong Yiqi Tang was administered. Ten days later, Gudi San (Melon Stalk Powder) was frequently given. Several sheng of material resembling red bean paste were vomited up. Subsequently, about one sheng of crystal-clear phlegm was expelled. This cycle of seven tonifications and seven emeses continued until, after one hundred days, the nests were completely cleared. Thereafter, he exclusively took Liujunzi Tang (Six Gentlemen Decoction) and Bawei Wan (Eight-Ingredient Pill) continuously for a year.
Yu Zhen's commentary: Those skilled in treating Phlegm include Zhang Dairen in the past and Wang Yinjun in recent times. However, these methods are suitable only for patients with strong constitution and excess syndromes, not for deficiency cases. This case, with seven tonifications and seven emeses, serves to correct the biases of both schools. Fundamentally, there is no such thing as Phlegm in the human body; Phlegm arises due to pathology. Treating the cause of Phlegm generation naturally eliminates the Phlegm. Although formularies list various types such as Wind-Phlegm, Cold-Phlegm, Fire-Phlegm, Damp-Phlegm, Dry-Phlegm, Clear-Phlegm, Old-Phlegm, Dietary-Phlegm, Wine-Phlegm, Stagnant-Phlegm, Stubborn-Phlegm, Shock-Phlegm, and Deficiency-Phlegm, manifesting in myriad symptoms resembling various miscellaneous diseases, one cannot simply treat them as miscellaneous diseases. If one treats the Phlegm directly, the disease resolves. Whether addressing the branch first then the root, or the root first then the branch, depends entirely on the physician's flexibility.