四诊：所进饮食，不化为津液而变为痰涎。一俟水中火发，咳嗽作焉，权以化法。
玉竹饮子玉竹、苓、草、桔、橘、菀，贝、姜。合麦门冬汤 加阿胶 百合 款冬
原注：前两方，六昧加减法也。脉数左弦，咽痛，水不涵木，阴火上冲。惟苔白二字，为胃气不清之证。此病头绪甚繁，方中一一还他的对之药。
诒按：此等证，本无必效之方，似此斟酌妥帖，即使难期必效，亦觉心苦为分明矣。
邓评：论理透彻。
脉形细数，细属阴亏，数为有火；火上刑金，水即绝其生源，未可以咳嗽小恙目之。幸而气息未喘，脉象未促，如能静养，犹可以作完人。
诒按：此清滋金水两脏之平剂。但患阴虚而不挟别项邪机者，可仿此调之。
邓评；未见潮热失血，亦尚幸事。苟至气喘脉促，更且临危矣。
评选继志堂医案下卷
上焦吐者从乎气。气属阳，是阳气病也；胸为阳位，阳位之阳既病，则其阴分之阳更属大虚，不言而喻。恐增喘汗。
吴萸 干姜 人参 川附 茯苓 半夏 木香 丁香 炙草饴糟 食盐 陈皮
邓评：此病必脉小、色白，小便清利，故可进以温热重剂，即启峻汤方法也。饴糟或饴糖之误。
再诊：进温养法，四日不吐，今晨又作。想是阳气大虚，浊阴上泛。究属膈证之根，不能不虑其喘汗。
原注：阳气大虚，浊阴上泛，此病之枢纽也。吴莱萸汤补胃阳，佐以熟附、丁香，温之至矣；辅以二陈燥其痰，饴糟去其垢，更加炙草以和中，食盐以润下，用意极其周密。
邓评：祛浊止呕，生姜比干姜为胜。谓其属膈症之根者，想必营阴下亏，故转方更加当归以和营润燥耳，然究不足以监姜、附之燥也。
食则右胁下痛，痰自上升，升则得吐而安，右脉弦滑，左关坚急，寸部独小。此心气下郁于肝经，脾弱生痰为膈。放开怀抱，第一要义。
另丸方：六君子汤 加当归 白芍 生地 苁蓉 沉香 白芥子 竹油姜汁泛丸
原注；心气下郁，脾弱生痰。方中于术、干姜、二陈、竹油，补脾化痰之药也；更有白芥子消膜外之痰，旋覆花开心气之结，赭石镇肝气之逆，用意层层都到。
邓评，食则右胁下痛，是气被痰阻，郁窜于络。赭石重镇，恐非所宜。
孙评：痰不在膜外，何得用芥子，反耗气而伤液。凡药病不的切者，必反有害，古人所以分脏腑经络上下内外也。
食则噎痛，吐去浊痰而止，胸前常闷，脉象弦滑，舌苔满白，肌肉瘦削之人，阴血本亏，今阳气又结，阴液与痰浊交阻上焦，是以胃脘狭窄也。久则防膈。
干姜 薤白 炙草 杵头糠 神曲 丁香 木香 熟地 白蔻仁 归身 白芍 沉香 牛黄 竹油
邓评；食下咽痛，痰瘀交阻所致，法当兼导痰瘀，非滋燥之剂所能建功。杵头糠专治噎膈，亦辛热之品。
孙评：阴血本亏，阳气又结，胃脘狭窄，何得再用诸多燥热耗阴损气乎
再诊：胸前所结之邪，原有化意。无如阴之亏，阳之结，尚与前日相等，非一两剂所能奏效。
干姜 薤白 炙草 茯苓 丁香 木香 陈皮 麻仁 旋覆花代赭石 归身 白芍 杞子 牛黄 竹油
诒按：此气结痰阻之证，用药极周到。
邓评：加减一二，自较前方为胜也。
嗜酒中虚，湿热生痰，痰阻膈问，食下不舒，时欲上泛。年已甲外，营血内枯，气火交结，与痰相并，欲其不成膈也，难矣。
原注：嗜酒者必多湿热，须用竹茹、连、蔻，又易挟瘀，参入藕汁、红花；薤白辛而兼滑，又是一格。绝去温热刚燥之品。先生日：惟善用温药者，不轻用温药，信然。
邓评。膈症之源，无不由于营血内枯，痰火交结所致，故宜于温燥者绝少。
向患偏枯于左，左属血。血主濡之。此偏枯者，既无血以濡经络，且无气以调营卫，营卫就枯，久病成膈。然一饮一食，所吐之中，更有浊痰紫血；此所谓病偏枯者，原从血痹而来，初非实在枯槁也。勉拟方：
每日服人乳两三次 间日服鹅血一二次。
诒按：偏枯已属难治，更加以膈，愈难措手矣。方祗寥寥两味，而润液化瘀，通痹开结，面面都到。此非见理真切，而又达于通变者，不能有此切实灵动之方。愚意再增韭汁一味，似乎更觉亲切。
邓评：此二味均润导血液之品，人乳偏于润，鹅血偏于导，以治血液枯耗之膈，实良剂也。柳师加味，固无不可；倘参入竹油、姜汁，兼导痰浊，亦属相宜。
孙评：此等联络法，岂时下所能。非精于书卷，历练广阔者，万不能办。
脉形细涩，得食则噎，胸前隐隐作痛。瘀血内阻，胃络不通，此膈证之根。
瘀血挟痰，阻于胸膈，食则作痛，痛则呕吐，右脉涩数，惟左关独大且弦。是痰瘀之外，更有肝经之气火，从而和之为患，乃膈证重候。慎之。
原注；以上三病，皆瘀膈也。第一证，从偏枯中想出血痹，用人乳以润其枯燥，鹅血以动其瘀血，此证非特刚剂不受，并柔补之药亦不可投，万不得已，而为此法，仍是润液化瘀之意，柔和得体。第二证，从胸前隐痛，而知其瘀阻胃络，用桃仁．醋煅瓦楞子以化其瘀。此证血瘀液涸，无论干姜不可用，即薤白辛温通气，亦与此隔膜。然非辛不能通，计惟用濡润之韭汁以通之，蜜、芦、归、芍奠安营分，以其液涸也。此病不见痰，所以纯从濡润去瘀之法。第三证见痰，所以瓦楞子、红花外，又加竹油一味。
邓评：噎膈之症，其肝经之气火理必相兼、特有微甚不同耳。方却轻清可喜。
以上三案，同属瘀膈，惟其中稍有异者，第一症偏于血液枯耗，第二症为瘀血而兼气弱者，此第三症则瘀血而更兼肝火亢盛矣。学者苟能一隅三反，则自可变化无穷耳。
孙评：分析精细，所谓如分水犀者此也。
原注：指为湿热，想因苔带黄色也。用七圣散者，中有橘皮竹茹汤，又有温胆汤，两方在内，更加枇杷叶泄肺，查炭消瘀，鸡距子消酒积。总不外湿热二字，此犹是膈之浅者。
邓评：此病必系酒客，胎质浊腻，故用药如是。
邓评：食已即吐，尚非朝食暮吐，终有火也，仍可姜、连并用，参入方内，虽则湿痰内胜，但须姜重于连，即为合法。
诒按：此证阴液未曾大亏，通阳开结，专理其痰，痰降而呕逆自减，尚非证之重者。
邓评：前方已合病机，故其吐逆大减；惟仍胸痞，嗳气不舒，究属痰气内结，务须宣痹，非赭石重镇所宜。
原注：此咽膈也。痰结于肺，用四七汤，以理其气；合温胆汤，以化其痰；去枳实换牛膝者，欲其达下焦也。
邓评：《金匮》四七汤，专能主治此症，惟气必挟火而逆，今加味最为中窾。
原注；此枇杷叶散去香薷一味也。此另是一种暑邪，挟寒饮内停，或食瓜果，致中气不调，而呕哕者，不当深求之里也；去香薷者，无表证也。
邓评：此痰气阻遏于胃，故方以温胃祛痰理气。用枇杷叶，茅根者，恐内有郁热也，更借以宣达肺气。
食已即吐，本属胃病，宜用温通。然口虽干，苔反白，将吐之时，其味先酸。此必有肝火郁于胃府，似与胃家本病有间。
诒按；辨证精细，用药妥切。
邓评：将吐而先有酸味，是有肝火之着眼处；苦降辛通，正合此病。湿 病 门脾阳不足，湿浊有余，少纳多胀，舌白脉迟。茅术理中汤合四七汤诒按：此湿滞而兼气郁之证。邓评：此症纯乎痰湿伤阳之象，故用药亦惟温通，毫无顾忌。痹气 门
胸痛彻背，是名胸痹。痹者，胸阳不旷，痰浊有余也。此病不惟痰浊，且有瘀血交阻膈间，所以得食梗痛，口燥不欲饮，便坚且黑，脉形细涩；昨日紫血从上吐出，究非顺境，必得下行为妥。
诒按：方法周到，不蔓不支，拟加参三七磨冲。胸痹证，前人无有指为瘀血者。如此证，纳食梗痛，乃瘀血阻于胃口，当归入噎膈证内论治矣。
邓评；得食梗痛，便坚脉涩，却已能归入膈门。惟如此等方法，自有胆识。
心痛彻背，是名胸痹，久而不化，适值燥气加临，更增咳嗽咽干，痰中带红，脉形细小，治之不易。
诒按：既因燥气加临，痰红嗌干，似当参用清润，如喻氏法。拟加旋覆花、南沙参、麦冬、桑皮。
邓评：咽干痰红，或以胸痹之证，本有肝火郁窜于其间，未必新感燥气。拟加丹皮。脘腹 痛门
心痛有九，痰食气居其三。三者交阻于胃，对痛时止，或重或轻，中脘拒按，饮食失常，痞闷难开，大便不通，病之常也。即有厥证，总不离乎痛极之时。兹乃反是，其厥也，不发于痛极之时，而每于小便之余，陡然而作，作则手足牵动，头项强直，口目歪邪，似有厥而不返之形；及其返也，时有短长，如是者三矣，此名痫厥。良以精夺于前，痛伤于后，龙雷之火，挟痰涎乘势上升，一身而兼痛厥两病。右脉不畅，左脉太弦，盖弦则木乘土位而痛，又挟阴火上冲而厥。必当平木为主，兼理中下次之。盖恐厥之愈发愈勤，痛之不肯全平耳。
川椒七粒 乌梅三分 青盐一分 龙齿三钱 楂炭三钱 神曲三钱 莱菔子三钱 延胡钱半 川楝子钱半 青皮七分 橘叶一钱 竹油一两
诒按：厥发于小解之时，其厥之关于肾气可知矣。用药似宜兼顾。立方选药，熨贴周到。
邓评：中脘拒按，痞闷便秘，究属不通之实象。惟肝气久郁，则阳内亢而化火生风，风阳升动则厥且痫矣。今转发于溺余者，以肝脉络阴器，溺则肝阴虚而风阳乘机陡动耳。始而郁极故痛厥，继则动甚故痫厥，横乘于中则痛，直升于上则厥。法当用酸苦辛药以制肝之旺气、疏肝之郁气，清火化痰，并具于内，故此方合病焉。惟连、柏、姜、萸，尚可参用也。
孙评：此等清灵贴切之方，岂能易得。惟神曲宜易姜、夏。柳氏云肾宜兼顾，一定之理，如代赭石、蒺藜之类。
再诊；据述厥已全平，痛犹未止，便黑溺黄，右脉反弦，想诸邪都合于胃也，胃为腑，以通为补。悬拟方。
芍药 青皮 陈皮 黑栀 川贝 丹皮 楂肉 竹油 莱菔子 青盐 延胡
邓评：便黑者抉瘀故也，或为肝火所煅烁，理亦有之，然其粪必坚燥也。进酸敛而右脉反弦，是肝之旺气已减，故胃脉得较畅也，当属佳象。此方更觉松灵活泼。
三诊；痛厥已平，尚有背部隐疼之候，腰部亦疼，气逆咳呛，脉形细数。想肝肾阴虚，气滞火升，肺俞络脉因之俱受其伤也。
邓评：见证是肝家之气火留窜于络脉，宜加山栀、钩钩、丝瓜络，以清经络之郁火，更宜姜汁以反佐之。
四诊：腰脊尚疼，咳嗽不止，苔白底红，脉形弦细。是阴虚而挟湿热也。
原注：此素有痰积，又肾虚而相火上冲于胃，胃中痰饮阻滞窍隧，痫厥见焉。第一方用泄肝和胃法，以化其阻滞，合金铃子散以清肝火，加查曲以消食，菔子、竹油以化痰。厥平而痛未愈，故第二方用景岳化肝煎，以代金铃子散，兼以化痰。第三方通其络。第四方仿白蒺藜丸，专于治痰。
邓评：苔白痰也，底红火也，是火被痰遏之象，山栀须用姜汁炒乃妙。
脾气素虚，湿郁难化，而木之郁于内者，更不能伸，所以酸水酸味，虽有减时，而灰白之苔，终无化日，无怪乎脉小左弦，脘胁胀痛也。此臌胀之根，毋忽。
八仙长寿丸（八珍汤加麦冬、五味子）加玄参、阿胶、陈皮、甘草、枇杷叶露。
邓评：所述病证，已经犯了正气虚弱而邪气实盛的禁忌。虽然有好药方，恐怕也难以治愈了。
第三次诊疗：夜间咳嗽，有时重有时轻，想是阴火（阴虚内热之火），因静躁状态不同所致。
第四次诊疗：所吃的饮食，不能化为津液反而变成痰涎。一旦水中火发（肾中虚火上炎），咳嗽就会发作，暂且用化痰的方法治疗。
玉竹饮子（玉竹、茯苓、甘草、桔梗、橘红、菟丝子，贝母、生姜）。合用麦门冬汤加阿胶、百合、款冬花。
原注：前两方，是六味地黄丸的加减法。脉象数而左关弦，咽痛，是水不涵木（肾水不足不能滋养肝木），阴火上冲。只有“苔白”二字，是胃气不清爽的证候。这个病头绪很繁杂，方中的药物一一都有针对的药。
诒按：这种证候，本来没有必定有效的方子，像这样斟酌得妥帖，即使难以期望必定见效，也让人觉得用心良苦且思路分明。
邓评：论述道理透彻。
这个方子则兼治其实邪了。然而还需要加入人参、蛤蚧、青黛、桑白皮、知母等来降伏阴火。
脉形细数，细属于阴亏，数是有火；火向上刑克肺金，水源就断绝了其生源，不可以把咳嗽当作小病看待。幸好气息没有喘息，脉象没有急促，如果能安静调养，还可以恢复健康。
诒按：这是清润滋补肺肾两脏的平和方剂。但患阴虚而不夹杂其他邪气的，可以仿照此方调理。
邓评：没有出现潮热失血，也是庆幸的事。如果到了气喘脉促，就更加危险了。
评选继志堂医案下卷
上焦呕吐源于气机失调。气属阳，这是阳气病变；胸为阳位，阳位的阳气既然有病，那么其阴分中的阳气更属于大虚，不言而喻。恐怕会加重喘息和出汗。
吴茱萸、干姜、人参、川附子、茯苓、半夏、木香、丁香、炙甘草、饴糟、食盐、陈皮。
邓评：这个病必然脉象细小、面色苍白、小便清利，所以可以用温热重剂，这就是启峻汤的方法。饴糟可能是饴糖的误写。
再诊：服用温养法后，四天没有呕吐，今晨又发作了。想是阳气大虚，浊阴之气上泛。终究属于膈证的根源，不能不担心出现喘息和出汗。
原注：阳气大虚，浊阴上泛，是这个病的枢纽。吴茱萸汤补胃阳，佐以熟附子、丁香，温补至极；辅以二陈汤燥湿化痰，饴糟去除污垢，再加炙甘草调和脾胃，食盐滋润下行，用意极其周密。
邓评：祛浊止呕，生姜比干姜更好。说它属于膈症之根，想必是营阴下亏，所以转方更加入当归来调和营血、滋润干燥，然而终究不足以制约姜、附子的燥性。
进食则右胁下疼痛，痰自然上升，上升则通过呕吐而安适，右脉弦滑，左关脉坚急，寸部独小。这是心气下郁于肝经，脾弱生痰导致膈证。放开怀抱，是第一要义。
旋覆代赭汤去掉生姜，加入炒白术、白芥子、炙甘草、广陈皮、竹沥油。
另制丸方：六君子汤加当归、白芍、生地、肉苁蓉、沉香、白芥子、竹沥油，姜汁泛丸。
原注：心气下郁，脾弱生痰。方中白术、干姜、二陈汤、竹沥油，是补脾化痰的药物；更有白芥子消除膜外的痰，旋覆花开通心气的结滞，赭石镇降肝气的逆乱，用意层层周到。
邓评：进食则右胁下疼痛，是气被痰阻滞，郁窜于络脉。赭石重镇，恐怕不太适宜。
孙评：痰不在膜外，怎么能用白芥子，反而耗气伤液。凡是药不对症的，必然反受其害，古人所以要区分脏腑经络上下内外啊。
进食则噎痛，吐出浊痰后停止，胸前常感闷塞，脉象弦滑，舌苔满布白色，肌肉瘦削之人，阴血本已亏损，现在阳气又结滞，阴液与痰浊交阻于上焦，所以胃脘狭窄。久则预防发展为膈证。
干姜、薤白、炙甘草、杵头糠、神曲、丁香、木香、熟地、白蔻仁、归身、白芍、沉香、牛黄、竹沥油。
邓评：食下咽痛，是痰瘀交阻所致，治法应当兼导痰瘀，不是滋燥的药剂所能建功。杵头糠专门治疗噎膈，也是辛热之品。
孙评：阴血本已亏损，阳气又结滞，胃脘狭窄，怎么能再用诸多燥热耗阴损气的药呢？
再诊：胸前所结滞的病邪，原本有化解之意。无奈阴亏、阳结，尚且与前日相等，不是一两剂药所能奏效的。
干姜、薤白、炙甘草、茯苓、丁香、木香、陈皮、麻仁、旋覆花、代赭石、归身、白芍、杞子、牛黄、竹沥油。
诒按：这是气结痰阻的证候，用药极周到。
邓评：加减一二味，自然比前方更好。
嗜酒导致中气虚弱，湿热生痰，痰阻膈间，进食后不舒，时常想要上泛。年过六十，营血内部干枯，气火交结，与痰相并，想要他不形成膈证，很难了。
原注：嗜酒的人必然多有湿热，须用竹茹、黄连、白蔻，又容易夹杂瘀血，参入藕汁、红花；薤白辛而兼滑，又是一格。完全去除温热刚燥的药物。先生说：只有善于使用温药的人，才不轻易用温药，确实如此。
邓评：膈症的根源，无不由于营血内枯，痰火交结所致，所以适宜用温燥药的极少。
向来患有左侧偏瘫，左侧属血。血主濡养。这个偏瘫患者，既没有血来濡养经络，也没有气来调畅营卫，营卫枯竭，久病成膈。然而每一次饮食，所吐出的东西中，还有浊痰紫血；这就是所说的患偏瘫的人，原本从血痹而来，起初并非真正的干枯槁灭。勉强拟定方子：
每日服人乳两三次，隔日服鹅血一二次。
诒按：偏瘫已经属于难治之症，再加上膈证，更难下手了。方子只有寥寥两味药，而润液化瘀、通痹开结，面面俱到。这不是见解真切，而又通达变化的人，不能有此切实灵动之方。我的意见再增加韭汁一味，似乎更觉亲切。
邓评：这两味都是润导血液的药物，人乳偏向润，鹅血偏向导，用来治疗血液枯耗的膈证，确实是良方。柳师加味，固然无不可；如果参入竹沥油、姜汁，兼导痰浊，也属相宜。
孙评：这种联络疗法，岂是时下医生所能做到的。不是精于书卷，历练广阔的人，万万不能办到。
脉形细涩，得食则噎，胸前隐隐作痛。瘀血内阻，胃络不通，这是膈证的根源。
瘀血挟痰，阻于胸膈，进食则作痛，痛则呕吐，右脉涩数，只有左关脉独大且弦。是痰瘀之外，更有肝经的气火，从而和合为患，乃是膈证的重症。谨慎对待。
归身、白芍、芦根、瓦楞子、红花、丝瓜络、橘络、竹沥油、白蜜。
原注：以上三个病案，都是瘀膈证。第一个证候，从偏瘫中想到血痹，用人乳来润其枯燥，鹅血来动其瘀血，这个证候不仅刚猛的药物不能接受，就连柔补的药物也不可投用，万不得已，才用此法，仍是润液化瘀的意思，柔和得体。第二个证候，从胸前隐痛，知道是瘀阻胃络，用桃仁、醋煅瓦楞子来化瘀。这个证候血瘀液涸，无论干姜不可用，即薤白辛温通气，也与这个证候隔膜。然而非辛不能通，计策唯有用濡润的韭汁来通之，蜜、芦、归、芍奠安营分，因为液涸。这个病不见痰，所以纯从濡润去瘀的方法。第三个证候见痰，所以在瓦楞子、红花外，又加竹沥油一味。
邓评：噎膈之症，其肝经的气火理应相兼，只是有轻微严重不同罢了。方子却轻清可喜。
以上三案，同属瘀膈，其中稍有不同的是，第一症偏于血液枯耗，第二症为瘀血而兼气弱，这第三症则瘀血而更兼肝火亢盛了。学者如果能举一反三，则自然可以变化无穷。
孙评：分析精细，所谓如分水犀者就是这个意思。
半夏、陈皮、川黄连、竹茹、白蔻仁、生姜、鸡距子、枇杷叶、山楂炭。
原注：指为湿热，想是因为舌苔带黄色。用七圣散的，其中有橘皮竹茹汤，又有温胆汤，两方在内，再加枇杷叶泄肺，山楂炭消瘀，鸡距子消酒积。总不外乎湿热二字，这还是膈证的浅层。
邓评：这个病必然是酒客，体质浊腻，所以用药如此。
邓评：食后即吐，尚非朝食暮吐，终归有火，仍可姜、连并用，参入方内，虽然湿痰内盛，但须姜重于连，即为合法。
诒按：这个证候阴液未曾大亏，通阳开结，专理其痰，痰降而呕逆自减，尚非证候的重者。
邓评：前方已合病机，所以吐逆大减；惟仍胸痞，嗳气不舒，终究属痰气内结，务必宣痹，不适合用赭石重镇。
咽中介介，如有炙脔（感觉咽喉中有异物感，像烤肉块一样）。痰气交阻为患。
原注：这是咽膈证。痰结于肺，用四七汤，来理其气；合温胆汤，来化其痰；去枳实换牛膝，是想让其达于下焦。
邓评：《金匮》四七汤，专门能主治此症，惟气必挟火而逆，现在加味最为中肯。
进食多呃逆，许氏法主治。
原注：这是枇杷叶散去香薷一味。这是另一种暑邪，挟寒饮内停，或食瓜果，致中气不调，而呕哕的，不应当深求于里证；去香薷，是因为无表证。
邓评：这是痰气阻遏于胃，所以方以温胃祛痰理气。用枇杷叶、茅根的，是恐内有郁热，更借以宣达肺气。
食后即吐，本属胃病，宜用温通。然而口虽干，苔反白，将吐之时，其味先酸。这必有肝火郁于胃府，似乎与胃家本病有间隔。
诒按：辨证精细，用药妥切。
邓评：将吐而先有酸味，是有肝火的着眼点；苦降辛通，正合此病。
湿 病 门
脾阳不足，湿浊有余，少纳多胀，舌白脉迟。茅术理中汤合四七汤。
邓评：此症纯乎痰湿伤阳之象，所以用药亦惟温通，毫无顾忌。
痹气 门
胸痛彻背，是名胸痹。痹者，胸阳不旷（舒展），痰浊有余也。此病不惟痰浊，且有瘀血交阻膈间，所以得食梗痛，口燥不欲饮，便坚且黑，脉形细涩；昨日紫血从上吐出，终究不是顺境，必须得下行为妥。
诒按：方法周到，不蔓不枝，拟加参三七磨冲。胸痹证，前人无有指为瘀血者。如此证，纳食梗痛，乃瘀血阻于胃口，当归入噎膈证内论治矣。
邓评：得食梗痛，便坚脉涩，却已能归入膈门。惟如此等方法，自有胆识。
心痛彻背，是名胸痹，久而不化，适值燥气加临，更增咳嗽咽干，痰中带红，脉形细小，治之不易。
诒按：既因燥气加临，痰红嗌干，似当参用清润，如喻氏法。拟加旋覆花、南沙参、麦冬、桑白皮。
邓评：咽干痰红，或以胸痹之证，本有肝火郁窜于其间，未必新感燥气。拟加丹皮。
脘腹 痛门
心痛有九种，痰食气居其三。三者交阻于胃，对痛时止，或重或轻，中脘拒按，饮食失常，痞闷难开，大便不通，病之常也。即有厥证，总不离乎痛极之时。兹乃反是，其厥也，不发于痛极之时，而每于小便之余，陡然而作，作则手足牵动，头项强直，口目歪邪，似有厥而不返之形；及其返也，时有短长，如是者三矣，此名痫厥。良以精夺于前，痛伤于后，龙雷之火，挟痰涎乘势上升，一身而兼痛厥两病。右脉不畅，左脉太弦，盖弦则木乘土位而痛，又挟阴火上冲而厥。必当平木为主，兼理中下次之。盖恐厥之愈发愈勤，痛之不肯全平耳。
川椒七粒、乌梅三分、青盐一分、龙齿三钱、山楂炭三钱、神曲三钱、莱菔子三钱、延胡索钱半、川楝子钱半、青皮七分、橘叶一钱、竹沥油一两。
诒按：厥发于小解之时，其厥之关于肾气可知矣。用药似宜兼顾。立方选药，熨贴周到。
邓评：中脘拒按，痞闷便秘，终究属不通之实象。惟肝气久郁，则阳内亢而化火生风，风阳升动则厥且痫矣。今转发于溺余者，以肝脉络阴器，溺则肝阴虚而风阳乘机陡动耳。始而郁极故痛厥，继则动甚故痫厥，横乘于中则痛，直升于上则厥。法当用酸苦辛药以制肝之旺气、疏肝之郁气，清火化痰，并具于内，故此方合病焉。惟连、柏、姜、萸，尚可参用也。
孙评：此等清灵贴切之方，岂能易得。惟神曲宜易姜、夏。柳氏云肾宜兼顾，一定之理，如代赭石、蒺藜之类。
再诊：据述厥已全平，痛犹未止，便黑溺黄，右脉反弦，想诸邪都合于胃也，胃为腑，以通为补。悬拟方。
芍药、青皮、陈皮、黑栀子、川贝母、丹皮、楂肉、竹沥油、莱菔子、青盐、延胡索。
邓评：便黑者抉瘀故也，或为肝火所煅烁，理亦有之，然其粪必坚燥也。进酸敛而右脉反弦，是肝之旺气已减，故胃脉得较畅也，当属佳象。此方更觉松灵活泼。
三诊：痛厥已平，尚有背部隐疼之候，腰部亦疼，气逆咳呛，脉形细数。想肝肾阴虚，气滞火升，肺俞络脉因之俱受其伤也。
邓评：见证是肝家之气火留窜于络脉，宜加山栀、钩藤、丝瓜络，以清经络之郁火，更宜姜汁以反佐之。
四诊：腰脊尚疼，咳嗽不止，苔白底红，脉形弦细。是阴虚而挟湿热也。
豆卷、蒺藜、黑栀子、川芎、归身、麦冬、沙参、甘草、雪羹汤、半夏。
原注：此素有痰积，又肾虚而相火上冲于胃，胃中痰饮阻滞窍隧，痫厥见焉。第一方用泄肝和胃法，以化其阻滞，合金铃子散以清肝火，加查曲以消食，菔子、竹油以化痰。厥平而痛未愈，故第二方用景岳化肝煎，以代金铃子散，兼以化痰。第三方通其络。第四方仿白蒺藜丸，专于治痰。
邓评：苔白痰也，底红火也，是火被痰遏之象，山栀须用姜汁炒乃妙。
脾气素虚，湿郁难化，而木之郁于内者，更不能伸，所以酸水酸味，虽有减时，而灰白之苔，终无化日，无怪乎脉小左弦，脘胁胀痛也。此臌胀之根，毋忽。
Baxian Changshou Wan (Eight Immortals Longevity Pill, a modification of Bazhen Tang with Ophiopogonis Radix and Schisandrae Fructus) added with Scrophulariae Radix (Xuanshen), Ecliptae Herba (Ejiao), Citri Reticulatae Pericarpium (Chenpi), Glycyrrhizae Radix et Rhizoma (Gancao), and Fritillariae Thunbergii Bulb Dew (Pipaye Lu).
Comment by Deng: The described pathology has already violated the taboo of deficiency of righteous qi and excess of pathogenic factors. Although there are excellent prescriptions, it is feared that they may be difficult to cure.
Third consultation: Coughing at night presents with varying degrees of severity, likely due to Yin fire (fire from yin deficiency), differing according to states of stillness or agitation.
To the previous prescription, add American Ginseng (Yangshen), Testudinis Carapax et Plastrum (Guiban), and Armeniacae Semen Amarum (Xingren).
Comment by Deng: Nighttime coughing is a definitive indication of rising Yin fire.
Fourth consultation: Ingested food fails to transform into body fluids but instead becomes phlegm-saliva. Once fire arises from water (kidney deficiency fire flaring up), coughing occurs; temporarily employ methods to resolve phlegm.
Yuzhu Yinzi (Polygonati Odorati Rhizoma, Poria, Licorice, Platycodon, Tangerine Peel, Cuscuta, Fritillaria, Ginger). Combined with Maimendong Tang (Ophiopogon Decoction) added with Ecliptae Herba (Ejiao), Lilii Bulbus (Baihe), and Adenophorae Radix (Kuaodonghua).
Original Note: The first two prescriptions are modifications of Liuwei Dihuang Wan (Six-Ingredient Rehmannia Pill). The pulse is rapid and the left guan position is wiry; throat pain indicates water failing to nourish wood (kidney yin deficiency failing to nourish liver wood), with Yin fire rushing upward. Only the "white tongue coating" indicates unclear stomach qi. This disease is complex in its threads; each herb in the prescription corresponds precisely to the pathology.
Comment by Yi: Such conditions inherently lack a universally effective formula. To deliberate so meticulously, even if a guaranteed cure is not expected, one can feel that the effort was clear-minded and well-intentioned.
Comment by Deng: The reasoning is thorough.
This prescription also treats the excess pathogen. However, it is still necessary to add Ginseng, Gecko (Gejie), Indigo Naturalis (Qingdai), Mulberry Bark (Sangbai Pi), and Anemarrhenae Rhizoma (Zhimu) to subdue the Yin fire.
Comment by Sun: A white tongue coating does not indicate unclear stomach qi; a red coating would indicate exhaustion of stomach yin.
The pulse form is fine and rapid; fine indicates yin deficiency, rapid indicates heat; fire insulting metal (lungs) cuts off the source of water (kidneys); this cannot be dismissed as a minor cough. Fortunately, breathing is not panting, and the pulse is not hurried; if rest can be maintained, recovery is still possible.
Rehmanniae Radix Preparata (Shengdi), Ophiopogonis Radix (Maidong), Glehniae Radix (Shashen), Halitae Concha (Shijueming), Cortex Lycii (Digupi), Mori Cortex (Sangbai Pi), Ecliptae Herba (Ejiao), and Fritillariae Thunbergii Bulb Dew (Pipaye Lu).
Comment by Yi: This is a mild formula for clearing and nourishing the Lung and Kidney organs. For patients with yin deficiency without other pathogenic factors, this method can be imitated for regulation.
Comment by Deng: The absence of tidal fever and hemoptysis is fortunate. If panting and a hurried pulse were to occur, the condition would become critical.
Selected Cases of Jizhitang Clinic, Volume II
Written by Cao Cunxin Renbo of Changshu
Vomiting and Hiccups Section
Vomiting from the upper jiao stems from qi dysfunction. Qi belongs to Yang; thus, this is a disease of Yang qi. The chest is a Yang location; if Yang qi in a Yang location is diseased, then the Yang within the Yin aspect is even more severely deficient, which goes without saying. There is fear of worsening panting and sweating.
Evodiae Fructus (Wuyu), Zingiberis Rhizoma (Ganjiang), Ginseng Radix et Rhizoma (Renshen), Aconiti Lateralis Radix Preparata (Chuanfu), Poria (Fuling), Pinelliae Rhizoma (Banxia), Aucklandiae Radix (Muxiang), Caryophylli Flos (Dingxiang), Prepared Licorice Root (Zhigancao), Malt Syrup Residue (Yizao), Salt (Yan), and Citri Reticulatae Pericarpium (Chenpi).
Comment by Deng: This disease must present with a fine pulse, pale complexion, and clear profuse urination, hence warm and heavy tonics can be administered; this is the method of Qijun Tang. Yizao is likely a typo for Yitang (Malt Syrup).
Second consultation: After administering warm nourishment, vomiting ceased for four days, but recurred this morning. It is thought to be severe Yang deficiency with turbid Yin rising. Ultimately, this is the root of Obstruction Syndrome (Ge Zheng), and one must worry about panting and sweating.
Remove Zingiberis Rhizoma (Ganjiang) from the previous prescription, add Angelicae Sinensis Radix (Danggui) and Zingiberis Recens Rhizoma (Shengjiang).
Original Note: Severe Yang deficiency and rising turbid Yin is the pivot of this disease. Wuzhuyu Tang tonifies Stomach Yang, assisted by Prepared Aconite and Clove to warm thoroughly; combined with Erchen Tang to dry dampness and resolve phlegm, Yizao to remove filth, plus Prepared Licorice to harmonize the middle, and Salt to moisten and direct downward; the intention is extremely meticulous.
Comment by Deng: To dispel turbidity and stop vomiting, Fresh Ginger (Shengjiang) is superior to Dried Ginger (Ganjiang). Saying it is the root of Obstruction Syndrome implies a deficiency of Ying blood below; thus, Danggui is added to harmonize Ying and moisten dryness, yet this is insufficient to control the dryness of Ginger and Aconite.
Pain in the right hypochondrium upon eating, phlegm rises naturally, and relief comes after vomiting. The right pulse is wiry and slippery, the left guan is firm and urgent, and the cun position is uniquely small. This is Heart qi depressed downward into the Liver meridian, with Spleen weakness generating phlegm leading to Obstruction. Opening the mind and letting go is the primary principle.
Inula Decoction with Hematitum (Xuanfu Daizhe Tang) removing Ginger, adding Stir-fried Atractylodes Macrocephala Rhizoma (Baizhu), White Mustard Seed (Baijiezi), Prepared Licorice (Zhigancao), Broad-leaved Tangerine Peel (Guangpi), and Bamboo Sap (Zhuyou).
Separate Pill Formula: Liujunzi Tang added with Angelicae Sinensis Radix (Danggui), Paeoniae Radix Alba (Baishao), Rehmanniae Radix Preparata (Shengdi), Cynomorii Herba (Rongrong), Aquilariae Lignum Resinatum (Chenxiang), White Mustard Seed (Baijiezi), and Bamboo Sap (Zhuyou), pilled with Ginger Juice.
Original Note: Heart qi depression and Spleen weakness generating phlegm. Baizhu, Dried Ginger, Erchen Tang, and Bamboo Sap in the formula are herbs to tonify the Spleen and resolve phlegm; additionally, White Mustard Seed eliminates phlegm outside the membranes, Inula Flower opens the knot of Heart qi, and Hematitum stabilizes rebellious Liver qi; the layers of intention are all comprehensive.
Comment by Deng: Pain in the right hypochondrium upon eating indicates Qi obstructed by Phlegm,郁窜 (wandering) into the collaterals. Hematitum is heavy and sedating, which may not be appropriate.
Comment by Sun: If phlegm is not outside the membranes, how can White Mustard Seed be used? It consumes Qi and injures fluids. Any medicine that does not hit the target precisely will inevitably cause harm; this is why the ancients distinguished between Zang-Fu, meridians, upper/lower, and interior/exterior.
Choking pain upon eating, stopping after vomiting turbid phlegm, constant chest stuffiness, wiry and slippery pulse, full white tongue coating. In individuals with emaciated muscles, Yin blood is originally deficient; now Yang Qi is also knotted, causing Yin fluids and turbid phlegm to obstruct the Upper Jiao, resulting in a narrow epigastrium. Over time, fear of developing Obstruction Syndrome.
Zingiberis Rhizoma (Ganjiang), Allii Macrostemonis Bulbus (Xiebai), Prepared Licorice (Zhigancao), Rice Husk (Chutoukuang), Saccharomyces (Shenqu), Caryophylli Flos (Dingxiang), Aucklandiae Radix (Muxiang), Rehmanniae Radix Preparata (Shudi), Amomi Fructus Rotundus (Baokouren), Angelicae Sinensis Radix (Guishen), Paeoniae Radix Alba (Baishao), Aquilariae Lignum Resinatum (Chenxiang), Realgar (Niuhuang - *Note: Context suggests Borneol or similar, but literal translation is Realgar/Niuhuang*), and Bamboo Sap (Zhuyou).
Comment by Deng: Pain upon swallowing is caused by intermingled Phlegm and Blood stasis; the method should simultaneously guide out Phlegm and Stasis; moistening-drying agents cannot achieve success. Rice Husk specifically treats dysphagia/obstruction and is also acrid-warm.
Comment by Sun: With original Yin blood deficiency and current Yang Qi knotting, and a narrow epigastrium, how can so many drying-hot, yin-consuming, and qi-damaging herbs be used?
Second consultation: The pathogenic factor knotted in the chest originally had intentions to resolve. Unfortunately, the Yin deficiency and Yang knotting remain equal to previous days; one or two doses cannot produce results.
Zingiberis Rhizoma (Ganjiang), Allii Macrostemonis Bulbus (Xiebai), Prepared Licorice (Zhigancao), Poria (Fuling), Caryophylli Flos (Dingxiang), Aucklandiae Radix (Muxiang), Citri Reticulatae Pericarpium (Chenpi), Cannabis Fructus (Maren), Inula Flower (Xuanfuhua), Hematitum (Daizhishi), Angelicae Sinensis Radix (Guishen), Paeoniae Radix Alba (Baishao), Lycii Fructus (Qizi), Realgar (Niuhuang), and Bamboo Sap (Zhuyou).
Comment by Yi: This is a case of Qi knotting and Phlegm obstruction; the medication is extremely comprehensive.
Comment by Deng: Adding or subtracting one or two herbs makes it naturally superior to the previous prescription.
Chronic alcohol consumption leads to Middle Jiao deficiency, generating damp-heat and phlegm; phlegm obstructs the diaphragm, causing discomfort after eating and frequent regurgitation. Over sixty years old, Ying blood is internally dried up; Qi and Fire interlock and combine with Phlegm; it is difficult for him not to develop Obstruction Syndrome.
Qisheng San added with Angelicae Sinensis Radix (Danggui), Paeoniae Radix Alba (Baishao), Allii Macrostemonis Bulbus (Xiebai), Hematitum (Daizhishi), Lotus Root Juice (Ou zhi), and Carthami Flos (Honghua).
Original Note: Those who drink alcohol necessarily have much damp-heat; one must use Bamboo Sheath (Zhuru), Coptidis Rhizoma (Lian), and Amomi Fructus (Kou); it is easy to complicate with Blood stasis, so add Lotus Root Juice and Safflower; Allii Macrostemonis Bulbus is acrid and slippery, forming another category. Completely remove warm-hot and rigid-dry substances. The Master said: Only those skilled in using warm medicines do not lightly use them; this is true.
Comment by Deng: The source of Obstruction Syndrome invariably stems from internal drying of Ying blood and interlocking of Phlegm and Fire; thus, it is rarely suitable to use warm-dry substances.
Previously suffered from left-sided hemiplegia; the left belongs to Blood. Blood primarily moistens. This hemiplegia patient, lacking Blood to moisten the collaterals and Qi to regulate Ying and Wei, sees Ying and Wei exhausted, leading to Obstruction over time. However, in every vomitus from drinking or eating, there is turbid phlegm and purple blood; this is what is meant by hemiplegia originating from Blood Bi (obstruction), initially not true withering. Tentatively prescribe:
Consume Human Milk (Renru) two to three times daily; consume Goose Blood (E xue) once or twice every other day.
Comment by Yi: Hemiplegia is already difficult to treat; adding Obstruction makes it even harder to handle. The prescription has only two ingredients, yet moistens fluids, resolves stasis, unblocks Bi, and opens knots, covering all aspects. This requires clear understanding and adaptability to achieve such practical and flexible formulas. I suggest adding Garlic Juice (Jiu zhi), which seems more fitting.
Comment by Deng: These two substances are both moistening and guiding agents for blood; Human Milk leans towards moistening, Goose Blood leans towards guiding; to treat Obstruction from blood exhaustion, this is indeed an excellent formula. Master Liu's additions are certainly acceptable; if Bamboo Sap and Ginger Juice are added to simultaneously guide turbid phlegm, it is also appropriate.
Comment by Sun: Such connected therapies are not achievable by contemporary physicians. Without being well-read and experienced, it is impossible to accomplish.
Pulse form is fine and choppy; choking upon eating, dull pain in the chest. Internal Blood stasis obstruction, Stomach collaterals blocked; this is the root of Obstruction Syndrome.
Angelicae Sinensis Radix Tip (Guixu), Paeoniae Radix Alba (Baishao), White Honey (Baimi), Reed Rhizome (Lugen), Vinegar-calcined Arcaea Concha (Walengzi), Garlic Juice (Jiu zhi), Ginseng Radix et Rhizoma (Renshen), and Persicae Semen (Taoren).
Comment by Yi: This is Blood Stasis Obstruction; the pulse and symptoms match, and the medication focuses precisely on this.
Comment by Deng: The diagnosis is accurate, and the prescription is pertinent. Consider adding Bovis Lac (Niu ru) and Ginger Juice (Jiang zhi).
Blood stasis combined with Phlegm obstructs the chest and diaphragm; eating causes pain, pain causes vomiting. The right pulse is choppy and rapid, while only the left guan is large and wiry. Besides Phlegm and Stasis, there is Qi and Fire of the Liver meridian combining to cause harm; this is a severe presentation of Obstruction Syndrome. Be cautious.
Angelicae Sinensis Radix (Guishen), Paeoniae Radix Alba (Baishao), Reed Rhizome (Lugen), Arcaea Concha (Walengzi), Carthami Flos (Honghua), Luffae Fructus Retinervus (Sigualuo), Citri Reticulatae Pericarpium (Juluo), Bamboo Sap (Zhuyou), and White Honey (Baimi).
Original Note: The above three cases are all Blood Stasis Obstruction. The first case, deducing Blood Bi from hemiplegia, uses Human Milk to moisten dryness and Goose Blood to move stasis; this condition accepts neither rigid nor soft tonics; out of desperation, this method is used, retaining the intent of moistening fluids and resolving stasis, gentle and appropriate. The second case, inferring Stomach collateral obstruction from dull chest pain, uses Persicae Semen and Vinegar-calcined Arcaea Concha to resolve stasis. In this condition, with blood stasis and fluid exhaustion, Dried Ginger is unusable, and even the acrid-warm Qi-moving Allii Macrostemonis Bulbus is incompatible. However, non-acrid substances cannot unblock; the strategy is to use moistening Garlic Juice to unblock, while Honey, Reed Rhizome, Angelica, and Peony stabilize the Ying level due to fluid exhaustion. This case shows no phlegm, so the method is purely moistening and resolving stasis. The third case shows phlegm, so besides Arcaea Concha and Safflower, Bamboo Sap is added.
Comment by Deng: In Dysphagia/Obstruction, Qi and Fire of the Liver meridian should logically coexist, differing only in degree. The prescription is light, clear, and pleasing.
The above three cases all belong to Blood Stasis Obstruction, with slight differences: the first leans towards Blood exhaustion, the second is Blood stasis with Qi deficiency, and the third is Blood stasis with hyperactive Liver Fire. If students can apply this analogy to infer other situations, changes will be infinite.
Comment by Sun: The analysis is precise, like a rhino horn dividing water.
Damp-heat generates phlegm, obstructing the epigastrium; choking upon eating, severe choking leads to vomiting; this is the root of Obstruction.
Pinelliae Rhizoma (Banxia), Citri Reticulatae Pericarpium (Chenpi), Coptidis Rhizoma (Chuanlian), Bamboo Sheath (Zhuru), Amomi Fructus Rotundus (Baikou), Zingiberis Recens Rhizoma (Shengjiang), Berberidis Radix (Jiju Zi), Fritillariae Thunbergii Bulb (Pipaye), and Crataegi Fructus Carbonized (Zha Tan).
Original Note: Designated as damp-heat, likely due to yellow tongue coating. Using Qisheng San contains JuPi ZhuRu Tang and Wendan Tang; plus Fritillaria to vent the Lung, Hawthorn Charcoal to resolve stasis, and Berberis to resolve wine accumulation. It all boils down to "damp-heat"; this is still a superficial stage of Obstruction.
Comment by Deng: This disease must belong to a chronic drinker with turbid and greasy constitution, hence the medication is as such.
Vomiting immediately after eating, wiry pulse, white coating, loose stools, clear urine. Internal dominance of damp-phlegm, rushed by excessive Qi of the Liver meridian.
Inula Flower (Xuanfuhua), Hematitum (Daizhishi), Citri Reticulatae Pericarpium (Chenpi), Pinelliae Rhizoma (Banxia), Raphani Fructus (Laifuzi), Zingiberis Recens Rhizoma (Shengjiang), Poria (Fuling), and Xue Geng Tang.
Comment by Deng: Vomiting immediately after eating is not "morning food evening vomit," indicating underlying heat; Ginger and Coptis can still be used together in the formula. Although damp-phlegm dominates internally, Ginger must outweigh Coptis to be correct.
Second consultation: Vomiting and reflux greatly reduced, but chest remains stuffed, belching is uncomfortable.
Inula Decoction with Hematitum (Xuanfu Daizhe Tang) combined with Xue Geng Tang.
Comment by Yi: In this condition, Yin fluids are not significantly depleted; unblocking Yang and opening knots, focusing solely on phlegm, reduces vomiting and reflux naturally; this is not a severe condition.
Comment by Deng: The previous prescription matched the pathology, hence great reduction in vomiting; however, chest stuffiness and uncomfortable belching remain, ultimately due to internal knotting of Phlegm and Qi;务必 (must) disperse Bi obstruction; Hematitum's heavy sedation is not suitable.
A sensation of something stuck in the throat, like a roasted meat lump. Phlegm and Qi interlocking cause harm.
Perilla Leaf (Suye), Pinelliae Rhizoma (Banxia), Magnoliae Officinalis Cortex (Chuanpu), Poria (Fuling), Bamboo Sheath (Zhuru), Citri Reticulatae Pericarpium (Chenpi), Halitae Concha (Shijueming), and Achyranthis Bidentatae Radix (Niuxi).
Original Note: This is Yan Ge (Throat Obstruction). Phlegm knotted in the Lung, using Siqi Tang to regulate Qi; combined with Wendan Tang to resolve Phlegm; replacing Zhi Shi with Niuxi aims to reach the Lower Jiao.
Comment by Deng: Siqi Tang from Jin Gui specifically treats this symptom; however, Qi must carry Fire and rebel; the current modifications are most pertinent.
Excessive hiccups after eating, treated by Xu's method.
Caryophylli Flos (Dingxiang), Citri Reticulatae Pericarpium (Chenpi), Magnoliae Officinalis Cortex (Chuanpu), Pinelliae Rhizoma (Banxia), Poria (Fuling), Glycyrrhizae Radix et Rhizoma (Gancao), Fritillariae Thunbergii Bulb (Pipaye), and Imperatae Rhizoma (Maogen).
Original Note: This is Pipaye San minus Xiangru. This is a different type of Summer-heat pathogen, combined with Cold-fluid retention inside, or caused by eating melons/fruits, leading to Middle Qi disharmony and vomiting/hiccups; it should not be sought deeply in the interior; Xiangru is removed because there is no exterior syndrome.
Comment by Deng: This is Phlegm-Qi obstructing the Stomach, hence the formula warms the Stomach, dispels Phlegm, and regulates Qi. Using Fritillaria and Imperata is to fear internal stagnant heat, further borrowing their ability to vent Lung Qi.
Vomiting immediately after eating, originally a Stomach disease, should use warm-unblocking methods. However, although the mouth is dry, the coating is white; before vomiting, the taste is sour. This indicates Liver Fire depressed in the Stomach organ, seemingly distinct from the Stomach's primary disease.
Zuojin Wan combined with Wendan Tang and Xue Geng Tang.
Comment by Yi: Differentiation is precise, medication is appropriate.
Comment by Deng: The sour taste before vomiting is the key indicator of Liver Fire; bitter descending and acrid unblocking perfectly matches this disease.
Damp Disease Section
Spleen Yang insufficiency, excess damp-turbidity, poor appetite, bloating, white tongue, slow pulse. Maoyu Lizhong Tang combined with Siqi Tang.
Comment by Yi: This is a condition of damp stagnation combined with Qi depression.
Comment by Deng: This case purely shows Phlegm-Damp injuring Yang, hence medication is exclusively warm-unblocking, without hesitation.
Bi Qi Section
Chest pain radiating to the back is named Chest Bi. Bi means Chest Yang is not expansive, and there is excess phlegm-turbidity. This disease involves not only phlegm-turbidity but also Blood stasis interlocking in the diaphragm, causing choking pain upon eating, dry mouth without desire to drink, hard black stools, and a fine-choppy pulse; yesterday purple blood was vomited from above, which is not a favorable sign; it must descend downwards to be proper.
Whole Trichosanthes Fruit (Quangualu), Allii Macrostemonis Bulbus (Xiebai), Inula Flower (Xuanfuhua), Persicae Semen (Taoren), Carthami Flos (Honghua), Arcaea Concha (Walengzi), Mirabilite (Xuanmingfen) combined with Erchen Tang.
Comment by Yi: The method is comprehensive, not sprawling. Consider adding Panax Notoginseng Radix (Sanqi) ground and taken with water. Previous authors did not identify Chest Bi as Blood stasis. In such a case, choking pain upon eating indicates Blood stasis blocking the stomach entrance; Angelica is discussed within Dysphagia/Obstruction treatments.
Comment by Deng: Choking pain upon eating, hard stools, and choppy pulse allow classification into the Obstruction category. Such methods demonstrate courage and insight.
Heart pain radiating to the back is named Chest Bi; lingering unresolved, coinciding with Dryness Qi attacking, increasing cough, dry throat, and blood-streaked sputum; fine-small pulse; difficult to treat.
Trichosanthes Fruit (Gualou), Allii Macrostemonis Bulbus (Xiebai), Aurantii Fructus (Zhike), Citri Reticulatae Pericarpium (Juhong), Armeniacae Semen Amarum (Xingren), Morus Folium (Sangye), and Fritillariae Thunbergii Bulb (Pipaye).
Comment by Yi: Since Dryness Qi attacks, with blood-streaked sputum and dry throat, Qing-moistening herbs should be considered, following Yu's method. Consider adding Inula Flower, Glehniae Radix (Nanshashen), Ophiopogonis Radix (Maidong), and Mori Cortex (Sangpi).
Comment by Deng: Dry throat and blood-streaked sputum may stem from Liver Fire郁窜 (wandering) inherent in Chest Bi, rather than new Dryness attack. Consider adding Moutan Cortex (Danpi).
Epigastric and Abdominal Pain Section
There are nine types of heart pain; Phlegm, Food, and Qi account for three. The three interlock in the Stomach, pain stops intermittently, varying in severity, Zhongwan tenderness, irregular diet, stifling difficulty opening, constipation; this is common. Even if there are syncope syndromes, it generally does not depart from the time of extreme pain. Here it is opposite; syncope does not occur at peak pain, but suddenly arises after urination, causing limb twitching, neck stiffness, facial deviation, resembling syncope without return; upon return, duration varies, happening three times; this is named Epileptic Syncope (Xian Jue). Indeed, essence was depleted previously, pain injured subsequently; Dragon-Lei Fire, carrying phlegm-saliva, rises with momentum; the body suffers both pain and syncope. Right pulse is unsmooth, left pulse is very wiry; wiry indicates Wood overcoming Earth causing pain, and carrying Yin fire rushing upward causing syncope. One must primarily calm Wood,其次 (secondarily) regulate the Middle; fearing syncope will recur frequently and pain will not fully subside.
Zanthoxyli Fructus (Chuanjiao) 7 grains, Vitis Vinifera Fructus (Wumei) 3 fen, Green Salt (Qingyan) 1 fen, Dragon Tooth (Longchi) 3 qian, Crataegi Fructus Carbonized (Zha Tan) 3 qian, Saccharomyces (Shenqu) 3 qian, Raphani Fructus (Laifuzi) 3 qian, Corydalis Rhizoma (Yanhusuo) 0.5 qian, Toosendan Fructus (Chuanlianzi) 0.5 qian, Citri Reticulatae Pericarpium Viride (Qingpi) 0.7 fen, Citrus Nobilis Leaf (Juye) 1 qian, Bamboo Sap (Zhuyou) 1 liang.
Comment by Yi: Syncope occurring during urination indicates its relation to Kidney Qi. Medication should consider both. The prescription selection is careful and comprehensive.
Comment by Deng: Tenderness at Zhongwan, stuffiness, and constipation ultimately indicate an excess pattern of blockage. However, long-term Liver Qi depression leads to internal Yang hyperactivity transforming into Fire and Wind; rising Wind-Yang causes syncope and epilepsy. Now manifesting after urination because the Liver meridian connects to the genitalia; urination depletes Liver Yin, allowing Wind-Yang to surge opportunistically. Initially, extreme depression causes pain-syncope; subsequently, vigorous movement causes epileptic syncope; horizontal invasion in the middle causes pain, straight ascent to the top causes syncope. The method should use sour-bitter-acrid herbs to restrain hyperactive Liver Qi, soothe depressed Liver Qi, clear Fire, and resolve Phlegm; all contained herein, hence this formula matches the disease. However, Coptis, Phellodendron, Ginger, and Evodia can still be considered.
Comment by Sun: Such clear, agile, and pertinent formulas are hard to come by. Shenqu should be replaced with Ginger and Pinellia. Master Liu says the Kidney should be considered; this is a fixed principle, such as Hematitum and Tribulus.
Second consultation: According to the description, syncope has completely subsided, but pain persists; black stools, yellow urine, right pulse is unexpectedly wiry; it is thought that all pathogens converge in the Stomach. The Stomach is a Fu organ, where unblocking is tonification. Tentatively prescribe.
Paeoniae Radix Alba (Shaoyao), Citri Reticulatae Pericarpium Viride (Qingpi), Citri Reticulatae Pericarpium (Chenpi), Gardeniae Fructus Carbonized (Heizhi), Fritillariae Cirrhosae Bulbus (Chuanbei), Moutan Cortex (Danpi), Crataegi Fructus (Zharou), Bamboo Sap (Zhuyou), Raphani Fructus (Laifuzi), Green Salt (Qingyan), Corydalis Rhizoma (Yanhusuo).
Comment by Yi: All pathogens converging in the Stomach is seen from the wiry right pulse; this is the crucial point of the pathology.
Comment by Deng: Black stools are due to extracting stasis, or possibly smoldered by Liver Fire; this logic exists, but the stool must be hard and dry. Administering sour-astringent herbs and the right pulse becoming wiry indicates Liver hyperactivity has decreased, hence Stomach pulse is smoother; this is a good sign. This formula feels looser and more lively.
Third consultation: Pain-syncope has subsided, but there is still dull back pain, waist pain, rebellious Qi causing coughing/wheezing; pulse is fine and rapid. It is thought to be Liver-Kidney Yin deficiency, Qi stagnation and Fire rising, injuring the Lung Shu collaterals.
Siwu Tang combined with Xuanfuhua Tang added with Anemarrhenae Rhizoma (Er Mu), Asparagi Radix (Xue Geng Tang components implied or separate), and Xue Geng Tang.
*Correction based on text*: Siwu Tang + Xuanfuhua Tang + Er Mu (Anemarrhenae & Botrychii/Botryocaulis?) + Xue Geng Tang. (Text says "二母", usually Zhi Mu and Bei Mu).
Comment by Deng: The manifestations show Liver Qi-Fire wandering into collaterals; add Gardenia, Uncaria, and Luffa Fruit to clear郁火 (stagnant fire) in collaterals; Ginger Juice should be added as a counter-agent.
Fourth consultation: Waist and spine still painful, coughing continues; white tongue coating with red base, wiry-fine pulse. This is Yin deficiency combined with damp-heat.
Sojae Semen Praeparatum (Doujuan), Tribuli Fructus (Jili), Gardeniae Fructus Carbonized (Heizhi), Ligusticum Chuanxiong Rhizoma (Chuanxiong), Angelicae Sinensis Radix (Guishen), Ophiopogonis Radix (Maidong), Glehniae Radix (Shashen), Glycyrrhizae Radix et Rhizoma (Gancao), Xue Geng Tang, and Pinelliae Rhizoma (Banxia).
Original Note: This patient has chronic phlegm accumulation, plus Kidney deficiency with Minister Fire rushing to the Stomach; Stomach phlegm-fluid obstructs orifices and tunnels, leading to epileptic syncope. First prescription uses draining Liver and harmonizing Stomach method to resolve obstruction, combined with Jinlingzi San to clear Liver Fire, added Hawthorn and Saccharomyces to digest food, Radish seed and Bamboo Sap to resolve phlegm. Syncope subsided but pain persisted, so the second prescription uses Jingyue's Huagann Jian to replace Jinlingzi San, combined with resolving phlegm. Third prescription unblocks collaterals. Fourth prescription imitates Baijili Wan, specializing in treating phlegm.
Comment by Yi: This case relies entirely on the first two prescriptions; soothing Liver and resolving phlegm, fitting perfectly.
Comment by Deng: White coating is Phlegm, red base is Fire; this is Fire suppressed by Phlegm; Gardenia must be stir-fried with Ginger Juice to be excellent.
Ophiopogon and Glehnia are somewhat forced.
Spleen Qi is originally deficient, dampness depression is hard to transform, and internal Wood depression cannot extend; thus, sour water and sour taste, though occasionally reduced, the gray-white coating never transforms; no wonder the pulse is small and left wiry, with epigastric and hypochondriac distension-pain. This is the root of Distension Syndrome (Gu Zhang); do not neglect it.
Fuzi Lizhong Tang combined with Erchen Tang added with Magnoliae Officinalis Cortex (Chuanpu), Cyperi Rhizoma (Xiangfu), Ligusticum Chuanxiong Rhizoma (Chuanxiong), and Saccharomyces (Shenqu).