谢 四十四岁 辛巳三月二十四日 病起肝郁胁痛，痰中带血，病名肝着。医者不识络
病因
由，与络病治法，非见血投凉，即见血补阴，无怪乎愈治愈穷也。大凡血症之脉，左脉坚搏
，治在下焦血分；右坚搏，治在上焦气分。兹左手脉浮取弦，沉取洪大而数，重按即芤，
前曾痰有气味，现下痰挟瘀滞黑色，唇舌皓白，其为肝经络瘀挟痰饮，咳血无疑。势已惫极
，勉与宣络止血，兼之两和肝胃，以逐痰定咳。（方此未服）
新绛纱（三钱） 旋复花（三钱） 归须（钱半） 桃仁泥（三钱） 半夏（三钱） 广皮炭（二
钱） 苏子霜（一钱） 降香末（钱半） 广郁金（二钱）
煮两茶杯，分四次服。二帖。
四月初三日 血家左手脉坚搏，治在下焦血分。此症先因肝络瘀滞，以致血不归经，日
久不
治，由阴经损及阳气，自汗溺变痿弱，阳虚也，左脉洪数而芤，阴伤也。如是阴阳两伤之极
，而瘀滞仍然未净，通络则虚急，补虚又络滞，两难措手。不得已用新绛一方，缓通其络，
其补药则用阴阳两摄法，聊尽人力而已。（从此服起）
辽参（一钱） 麦冬（四钱，连心） 海参（二钱） 五味子（一钱） 沙苑蒺藜（三钱） 茯神
（五钱） 枸杞子（三钱） 龟板（五钱） 牡蛎（六钱）
初四日 病起于胁痛，瘀血致壅，久嗽成劳，至骨痿不能起床，仍有瘀滞不化之象，且
痰有
臭味，即系肝着成痈。前日脉虽芤大而涩，昨日大见瘀血后，今日则纯然芤矣，岂非瘀血之
明征乎？若一味贪补，断难再起，兼之宣络，万一得苏，妄诞之诊，高明酌之。
新绛纱（三钱） 旋复花（二钱） 归横须（八分） 半夏（钱半） 广皮炭（一钱） 桃仁泥（
三钱） 丹皮炭（五钱）
此方《金匮》 载在妇人虚劳门，有识者其悟之。上半日服此方完，下半日服前补方。
初五日 痰中臭味太甚，黑痰未净，是活络之方不能除；脉芤自汗甚，是补摄之方又不
可缓
。痰稀纯白，内有支饮，于补方中去牡蛎、海参。盐味之碍饮者。此症极虚极实，时人但知
其虚而不知其实，所以日误一日，以至于此。治实碍虚，治虚碍实，焉望成功。一通一补，
俱每日照前服法未改。
初七日 脉较前敛戢，于新绛方内半夏加钱半，作三钱，余仍旧，服法亦如之。
初八日 今日左尺脉独大，加封固肾气法，余有原案二方，每日间服如前。
人参（一钱） 炙龟板（八钱） 莲子（五钱） 炙甘草（三钱） 制五味（一钱） 杞子（三钱
，炒
黑） 沙蒺藜（二钱） 左牡蛎（六钱） 云茯苓（五钱） 麦冬（三钱，连心） 炒白芍（三钱）
初十日 于前方内加辽参五分作钱半，又加海参一条，淡苁蓉三钱，四帖，余悉如前。
十三日 仍照前服，每日间服一通一补方。
十七日 左脉空大未敛，精神较前虽好，犹宜收摄下焦，于前方内去龟板、五味子、白
芍、海参、苁蓉，余如旧间服法。煮好去渣，再上火煎成二杯，分二次服。
同日 痰色犹不能清白，气味亦不净，仍须宣络。
新绛纱（三钱） 旋复花（二钱） 半夏（五钱，姜制） 广皮炭（钱半） 广郁金（钱半） 当
归须（一钱）
上半日服，四帖。
二十一日 脉少敛，通补二方间服如前，四帖。
二十四日 痰浊未变，脉象少敛，午后微热不寐，饮食由渐而加，不可太过不及。
人参（钱半） 莲肉（五钱，连心皮） 炙甘草（三钱） 枸杞（三钱，炒黑） 沙蒺藜（三钱）
云
茯苓（五钱） 左牡蛎（五钱） 麦冬（三钱，连心） 熟五味子（一钱） 炒枣仁（三钱） 海参（
二条，洗去砂） 大淡菜（三钱）
午后服此。
又方∶
新绛纱（二钱） 旋复花（二钱） 半夏（三钱，姜制） 广郁金（二钱） 归须（一钱） 桃仁
泥（二钱） 广陈皮（八分） 香附（二钱）
煮两小茶杯，午前服。
初九日 复诊于补方去牡蛎、五味子，余仍二方间服如前。
十三日 痰已渐清，肝亦渐平，精神渐旺，拟去搜逐而补中，与外台茯苓饮意。（专用
一方）。
云茯苓块（六钱） 人参（二钱） 香附（三钱） 生于术（五钱） 炙甘草（二钱） 半夏（五
钱） 生薏仁（五钱） 小枳实（二钱）
谢某，四十四岁。辛巳年三月二十四日发病。起因是肝气郁结导致胁肋疼痛，痰中带有血丝，病名为“肝着”。医生不了解络脉病因及络病的治疗方法，见到出血就用寒凉药，或者用滋阴药，难怪病情越来越重。一般来说，血症的脉象，如果左脉坚实搏指，病位在下焦血分；右脉坚实搏指，病位在上焦气分。现在患者左手脉轻取弦紧，重按洪大且数，再重按则出现芤脉（中空如葱管），之前痰有异味，现在痰中夹杂黑色瘀滞物，嘴唇和舌头颜色苍白，这显然是肝经络脉瘀阻兼夹痰饮，导致咳血，这是毫无疑问的。病情已经极度疲惫虚弱，勉强给予宣通络脉、止血的方法，同时调和肝胃，以祛除痰饮、平息咳嗽。（此方当时未服用）
新绛纱（三钱） 旋复花（三钱） 归须（一钱半） 桃仁泥（三钱） 半夏（三钱） 广皮炭（二钱） 苏子霜（一钱） 降香末（一钱半） 广郁金（二钱）
煮成两茶杯药液，分四次服用。共两帖。
四月初三日。血症患者左手脉坚实搏指，病治在下焦血分。此症起初因肝络瘀滞，导致血液不循常道，日久不愈，由阴经损伤波及阳气，出现自汗、小便异常、肢体痿弱，这是阳虚的表现；左脉洪大数而芤，这是阴伤的表现。像这样阴阳两伤到了极点，而瘀滞仍然没有清除干净，通络则担心正气更虚，补虚又恐加重络脉阻滞，两难下手。不得已使用新绛一方，缓慢疏通络脉，补益药物则采用阴阳双摄的方法，姑且尽人事罢了。（从此开始服用）
辽参（一钱） 麦冬（四钱，带心） 海参（二钱） 五味子（一钱） 沙苑蒺藜（三钱） 茯神（五钱） 枸杞子（三钱） 龟板（五钱） 牡蛎（六钱）
初四日。病起于胁痛，瘀血导致壅塞，久咳形成劳损，发展到骨痿不能起床，仍有瘀滞未化的迹象，且痰有臭味，这就是肝着发展成痈脓。前日脉象虽然芤大而涩，昨日排出大量瘀血后，今日脉象纯然变为芤脉，这难道不是瘀血排出的明显征象吗？如果一味贪求进补，断难恢复生机，必须兼用宣通络脉之法，万一得以苏醒，也是妄诞的诊断，请高明者斟酌。
新绛纱（三钱） 旋复花（二钱） 归横须（八分） 半夏（一钱半） 广皮炭（一钱） 桃仁泥（三钱） 丹皮炭（五钱）
此方记载于《金匮要略》妇人虚劳门，有识之士应当领悟。上半日服完此方，下半日服用之前的补益方。
初五日。痰中臭味太重，黑痰未净，说明活血通络的方剂不能根除病邪；脉象芤且自汗严重，说明补益固摄的方剂也不可迟缓。痰稀薄纯白，内有支饮（支撑胸膈之饮邪），在补益方中去掉牡蛎、海参，因为咸味会阻碍饮邪的化解。此症极虚极实，时人只知道其虚而不知道其实，所以一天误比一天，以至于此。治疗实证妨碍虚证，治疗虚证妨碍实证，哪里能指望成功。通络与补益，都每日按照之前的方法服用，没有改变。
初七日。脉象较前收敛，在新绛方中半夏加至一钱半，总量作三钱，其余照旧，服用方法也相同。
初八日。今日左尺脉独大，加入封固肾气的方法，其余参考原案中的两个方子，每日交替服用，如同以前。
人参（一钱） 炙龟板（八钱） 莲子（五钱） 炙甘草（三钱） 制五味子（一钱） 杞子（三钱，炒黑） 沙蒺藜（二钱） 左牡蛎（六钱） 云茯苓（五钱） 麦冬（三钱，带心） 炒白芍（三钱）
初十日。在前方的基础上加辽参五分，总量作一钱半，又加海参一条，淡苁蓉三钱，四帖，其余悉照前法。
十三日。仍照前法服用，每日交替服用通络和补益两个方子。
十七日。左脉空大未收敛，精神虽然比以前好，但仍宜收摄下焦，在前方的基础上去掉龟板、五味子、白芍、海参、苁蓉，其余照旧交替服用。煮好后去渣，再上火煎成两杯，分两次服用。
同日。痰色还不能清白，气味也不干净，仍需宣通络脉。
新绛纱（三钱） 旋复花（二钱） 半夏（五钱，姜制） 广皮炭（一钱半） 广郁金（一钱半） 当归须（一钱）
上半日服用，四帖。
二十一日。脉象稍收敛，通络和补益两个方子交替服用，如同以前，四帖。
二十四日。痰浊没有变化，脉象稍收敛，午后微热失眠，饮食逐渐增加，不可太过或不及。
人参（一钱半） 莲肉（五钱，带心皮） 炙甘草（三钱） 枸杞（三钱，炒黑） 沙蒺藜（三钱） 云茯苓（五钱） 左牡蛎（五钱） 麦冬（三钱，带心） 熟五味子（一钱） 炒枣仁（三钱） 海参（两条，洗去砂） 大淡菜（三钱）
午后服用此方。
又一方：
新绛纱（二钱） 旋复花（二钱） 半夏（三钱，姜制） 广郁金（二钱） 归须（一钱） 桃仁泥（二钱） 广陈皮（八分） 香附（二钱）
煮两小茶杯，午前服用。
初九日。复诊时在补益方中去掉牡蛎、五味子，其余仍两个方子交替服用，如同以前。
十三日。痰已渐渐清稀，肝气渐渐平和，精神渐渐旺盛，打算去掉搜逐瘀血的药物而侧重补益，用意类似于《外台秘要》中的茯苓饮。（专用一方）。
云茯苓块（六钱） 人参（二钱） 香附（三钱） 生于术（五钱） 炙甘草（二钱） 半夏（五钱） 生薏仁（五钱） 小枳实（二钱）
Xie, male, 44 years old. On the 24th day of the 3rd month in the Xinsi year, the illness began with liver qi stagnation causing hypochondriac pain, and blood-streaked sputum; the disease name is Gan Zhuo (Liver Fixation). The physician did not understand the etiology of collateral diseases or the treatment methods for such conditions. Upon seeing bleeding, he either administered cooling herbs to stop bleeding or nourished yin. No wonder the condition worsened with each treatment. Generally speaking, regarding hemoptysis syndromes: if the left pulse is firm and forceful, the pathology lies in the blood aspect of the Lower Jiao; if the right pulse is firm and forceful, the pathology lies in the qi aspect of the Upper Jiao. Currently, the patient's left pulse is wiry on superficial palpation, large, rapid, and forceful on deep palpation, and becomes hollow (Kou Pulse) upon heavy pressure. Previously, the sputum had an odor; now it contains black stagnant blood clots. The lips and tongue are pale white. This clearly indicates liver collateral stasis complicated by phlegm-fluid retention, leading to hemoptysis without doubt. The condition has become extremely exhausted. I tentatively prescribed a method to unblock collaterals and stop bleeding, while simultaneously harmonizing the Liver and Stomach to expel phlegm and calm coughing. (This prescription was not taken at that time.)
Xinjiang Sha (New Crimson Gauze, 3 qian), Xuan Fu Hua (Inula Flower, 3 qian), Gui Xu (Root Branches of Angelica Sinensis, 1.5 qian), Tao Ren Ni (Peach Kernel Paste, 3 qian), Ban Xia (Pinellia Tuber, 3 qian), Guang Pi Tan (Charred Tangerine Peel, 2 qian), Su Zi Shuang (Perilla Seed Frost, 1 qian), Jiang Xiang Mo (Aquilaria Wood Powder, 1.5 qian), Guang Yu Jin (Curcuma Aromatica Rhizome, 2 qian).
Decoct with water to yield two tea cups, divide into four doses. Two prescriptions total.
On the 3rd day of the 4th month. For patients with bleeding disorders, a firm and forceful left pulse indicates pathology in the blood aspect of the Lower Jiao. This case initially involved liver collateral stasis, causing blood to fail to remain within its vessels. Due to prolonged neglect, the damage extended from the Yin meridians to affect Yang Qi, resulting in spontaneous sweating, abnormal urination, and flaccidity/weakness of the limbs, indicating Yang deficiency. The left pulse being large, rapid, and hollow indicates Yin injury. Thus, both Yin and Yang are severely damaged, yet the stasis remains uncleaned. Unblocking collaterals would exacerbate the deficiency, while tonifying deficiency would worsen the collateral obstruction, presenting a dilemma. Reluctantly, I used the Xinjiang formula to slowly unblock the collaterals. For tonification, I employed a method to simultaneously secure both Yin and Yang, merely doing my utmost as a human practitioner. (Treatment started from this point.)
Liao Shen (Ginseng Root from Liaoning, 1 qian), Mai Dong (Ophiopogon Tuber, 4 qian, including heart), Hai Shen (Sea Cucumber, 2 qian), Wu Wei Zi (Schisandra Fruit, 1 qian), Sha Yuan Ji Li (Astragalus Complanatus Seed, 3 qian), Fu Shen (Poria with Hostwood, 5 qian), Gou Qi Zi (Goji Berry, 3 qian), Gui Ban (Tortoise Shell, 5 qian), Mu Li (Oyster Shell, 6 qian).
On the 4th day. The illness originated in hypochondriac pain, where blood stasis caused obstruction. Chronic cough led to consumption (Lao syndrome), progressing to bone flaccidity preventing one from getting out of bed. There were still signs of unresolved stasis, and the sputum had a foul odor, indicating that Gan Zhuo had developed into an abscess (Yong). Although the pulse was previously large, hollow, and choppy, after the significant expulsion of dark blood yesterday, today the pulse is purely hollow. Is this not clear evidence of blood stasis being expelled? If one greedily pursues only tonification, recovery is impossible. One must combine unblocking collaterals. If there is any chance of revival, it would be due to this approach, though such a diagnosis might seem presumptuous; please consider it wisely.
Xinjiang Sha (New Crimson Gauze, 3 qian), Xuan Fu Hua (Inula Flower, 2 qian), Gui Heng Xu (Horizontal Root Branches of Angelica Sinensis, 8 fen), Ban Xia (Pinellia Tuber, 1.5 qian), Guang Pi Tan (Charred Tangerine Peel, 1 qian), Tao Ren Ni (Peach Kernel Paste, 3 qian), Dan Pi Tan (Charred Moutan Cortex, 5 qian).
This prescription is recorded in the "Women's Consumption" chapter of *Jin Gui Yao Lue* (Essential Prescriptions from the Golden Cabinet). Those with insight should ponder this. Take this prescription in the first half of the day, and the previous tonifying prescription in the second half.
On the 5th day. The foul odor in the sputum is severe, and black sputum has not cleared, indicating that the blood-activating and collateral-unblocking formula cannot eliminate the pathogen. The hollow pulse and severe spontaneous sweating indicate that the tonifying and securing formula cannot be delayed. The sputum is thin and pure white, indicating Zhi Yin (Fluids supporting the chest/diaphragm). In the tonifying formula, remove Mu Li (Oyster Shell) and Hai Shen (Sea Cucumber), as salty flavors obstruct fluid resolution. This case is extremely deficient and extremely excess. Contemporary physicians only perceive the deficiency and ignore the excess, leading to daily deterioration. Treating excess hinders the deficient state, and treating deficiency hinders the excess state; how can success be expected? Both unblocking and tonifying methods are continued daily as before, unchanged.
On the 7th day. The pulse has become more restrained compared to before. In the Xinjiang formula, increase Ban Xia (Pinellia Tuber) by 1.5 qian to make a total of 3 qian. The rest remain unchanged, and the administration method is the same.
On the 8th day. Today, the Left Chi (Kidney) pulse is exclusively enlarged. Add a method to seal and secure Kidney Qi. Refer to the two original prescriptions in the case record, taking them alternately daily as before.
Ren Shen (Ginseng Root, 1 qian), Zhi Gui Ban (Prepared Tortoise Shell, 8 qian), Lian Zi (Lotus Seed, 5 qian), Zhi Gan Cao (Honey-fried Licorice Root, 3 qian), Zhi Wu Wei (Prepared Schisandra Fruit, 1 qian), Qi Zi (Goji Berry, 3 qian, stir-fried until black), Sha Ji Li (Astragalus Complanatus Seed, 2 qian), Zuo Mu Li (Left-sided Oyster Shell, 6 qian), Yun Fu Ling (Poria, 5 qian), Mai Dong (Ophiopogon Tuber, 3 qian, including heart), Chao Bai Shao (Stir-fried White Peony Root, 3 qian).
On the 10th day. In the previous formula, add Liao Shen (Ginseng Root from Liaoning) by 5 fen to make a total of 1.5 qian. Also add one Hai Shen (Sea Cucumber) and Dan Cong Rong (Cistanche Deserticola, 3 qian). Four prescriptions. The rest remain as before.
On the 13th day. Continue as before, taking the unblocking and tonifying formulas alternately daily.
On the 17th day. The Left pulse is empty and large, not yet restrained. Although spirit/mind is better than before, it is still appropriate to secure the Lower Jiao. Remove Gui Ban (Tortoise Shell), Wu Wei Zi (Schisandra Fruit), Bai Shao (White Peony Root), Hai Shen (Sea Cucumber), and Cong Rong (Cistanche) from the previous formula. The rest remain unchanged, taken alternately. Decoct well, strain dregs, return to fire, and boil down to two cups. Divide into two doses.
Same day. The sputum color is still not clear and white, and the odor is not clean. Unblocking collaterals is still necessary.
Xinjiang Sha (New Crimson Gauze, 3 qian), Xuan Fu Hua (Inula Flower, 2 qian), Ban Xia (Pinellia Tuber, 5 qian, ginger-processed), Guang Pi Tan (Charred Tangerine Peel, 1.5 qian), Guang Yu Jin (Curcuma Aromatica Rhizome, 1.5 qian), Dang Gui Xu (Angelica Sinensis Root Branches, 1 qian).
Take in the first half of the day. Four prescriptions.
On the 21st day. The pulse is slightly restrained. Take the unblocking and tonifying formulas alternately as before. Four prescriptions.
On the 24th day. The turbid sputum has not changed, and the pulse is slightly restrained. There is slight fever and insomnia in the afternoon. Dietary intake is gradually increasing. Do not overdo or underdo anything.
Ren Shen (Ginseng Root, 1.5 qian), Lian Rou (Lotus Seed Meat, 5 qian, including heart and skin), Zhi Gan Cao (Honey-fried Licorice Root, 3 qian), Gou Qi (Goji Berry, 3 qian, stir-fried until black), Sha Ji Li (Astragalus Complanatus Seed, 3 qian), Yun Fu Ling (Poria, 5 qian), Zuo Mu Li (Left-sided Oyster Shell, 5 qian), Mai Dong (Ophiopogon Tuber, 3 qian, including heart), Shu Wu Wei Zi (Prepared Schisandra Fruit, 1 qian), Chao Zao Ren (Stir-fried Ziziphus Seed, 3 qian), Hai Shen (Sea Cucumber, 2 pieces, washed to remove sand), Da Dan Cai (Large Mussel, 3 qian).
Take in the afternoon.
Another Formula:
Xinjiang Sha (New Crimson Gauze, 2 qian), Xuan Fu Hua (Inula Flower, 2 qian), Ban Xia (Pinellia Tuber, 3 qian, ginger-processed), Guang Yu Jin (Curcuma Aromatica Rhizome, 2 qian), Gui Xu (Root Branches of Angelica Sinensis, 1 qian), Tao Ren Ni (Peach Kernel Paste, 2 qian), Guang Chen Pi (Tangerine Peel, 8 fen), Xiang Fu (Cyperus Rhizome, 2 qian).
Decoct with water to yield two small tea cups. Take in the forenoon.
On the 9th day (of the next cycle/month). Follow-up examination: Remove Mu Li (Oyster Shell) and Wu Wei Zi (Schisandra Fruit) from the tonifying formula. Continue taking the two formulas alternately as before.
On the 13th day. The sputum has gradually cleared, the Liver Qi has gradually calmed, and the spirit has gradually strengthened. Plan to remove the searching and purging herbs and focus on tonification, following the intent of *Wai Tai Mi Yao*'s Fu Ling Yin (Poria Drink). (Use a single exclusive formula).
Yun Fu Ling Kuai (Poria Blocks, 6 qian), Ren Shen (Ginseng Root, 2 qian), Xiang Fu (Cyperus Rhizome, 3 qian), Sheng Bai Zhu (Raw Atractylodes Macrocephala Rhizome, 5 qian), Zhi Gan Cao (Honey-fried Licorice Root, 2 qian), Ban Xia (Pinellia Tuber, 5 qian), Sheng Yi Yi Ren (Raw Coix Seed, 5 qian), Xiao Zhi Shi (Immature Bitter Orange, 2 qian).