隐癖僭逆中宫，脐虽未突，青筋渐露，势欲散而为臌。况大便时溏时结，脾气久虚，更属棘手。拟以攻补兼施法。
枳实消痞丸枳、连、朴、术，夏、苓、参，姜、麦芽、草。加鸡内金 当归 鳖甲 白芍 牡蛎
诒按：此已成胀病矣。而中宫先虚，又难攻克。此等证最费经营，而又最难得效。
邓评：癖散成臌，必土弱而木乘，有虚中夹实之义。故治之最为棘手。此方有虚实兼顾，肝脾并调之妙。
头 痛 门
头痛取少阳、阳明主治，是为正法。即有前后之别，不过分手足而已。
石膏 竹叶 生地 知母 甘菊丹皮黑栀 橘红 赤苓 桑叶 蔓荆子 天麻
邓评：此必有一派火盛见端。
大川芎汤川芎、天麻。合茶酒调散芷、草、羌、荆、芎、辛、防、薄。二陈汤加首乌 归身 白芍
诒按：此亦少阳、阳明两经之病。但风阳既已上逆，似当参用清熄之意，乃合芎、辛、羌、芷，未免偏于升动矣。
邓评；方案不甚融洽。
高巅之上，惟风可到，到则百会肿疼且热。良以阴虚之体，阴中阳气每易随之上越耳。
肢 体 痛 门
肝居人左，左胁不时攻痛，甚则厥逆，左关沉小带弦，是肝气郁而不升也；右脉弦滑，舌苔薄白，喜饮热汤，又有湿痰内阻。当兼治之。
邓评：肝气久郁，必从火化。推气散内有肉桂，若不与清肝疏郁之品并用，恐其气火化燥。即使寒饮满积，亦可暂不可久之剂也。盖痛在左胁，大都挟肝经郁火耳。
脉沉弦滑，腿骱刺痛，腰部疫疼，背脊作响，诸节亦然，舌苔白浊。风湿痰三者着于肝肾之络也。
邓评：断其为风湿痰实邪者，全于苔脉得之。惟风善上行，今所以陷着肝肾之络者，内被湿痰阻遏故也，岂得拘一例论之。
遗精门
肾者主蛰，封藏之本，精之处也。精之所以能安其处者，全在肾气充足，封藏乃不失其职；虚者反是，增出胫痠、体倦、口苦、耳鸣、便坚等证，亦势所必然。然左尺之脉浮而不静，固由肾气下虚；而关部独弦独大独数，舌苔黄燥，厥阴肝脏又有湿热助其相火；火动乎中，必摇其精，所谓肝主疏泄也。虚则补之，未始不美；而实则泻之，亦此证最要之义。
邓评；湿热助其相火，为此症之要旨，于关尺脉与舌苔上见出。故肾脏虽虚，尤必须参实则泻之之法矣。
再诊：大便畅行，口中干苦亦愈，左关之脉大者亦小。惟弦数仍然，尺亦未静。可以前方增损。
邓评：炎上作苦，火能下降，故口苦亦愈。惟脉尚弦数未静，是以苦寒泻火，还当着意。
三诊：久积之湿热，下从大便而泄。然久病之体，脾肾元气内亏，又不宜再泻，当以守中法。
邓评：三诊似乎湿热已去，当以守中。谁知邪势初衰之际，须防余邪未尽，所谓炉烟虽熄，灰中有火，故至此脉象复见弦数，仍不能舍苦寒泻火之剂也。当邪势初衰，速尔进补者，每有此弊。
四诊：大便已和，脉形弦数，数为有火，弦主乎肝。肝经既有伏火，不但顺乘阳明，而且容易摇精。精虽四日未动，究须小心。
原注：此证拈定左关独大、独弦、独数，所以重用胆草、黑 栀，直折其肝家郁火，俾湿热之邪从大便而出。
金本制木，今木火太旺，反侮肺金，肺金尚受其克，则 其吸取肾水，疏泄肾精，更属易易。此梦泄、咳嗽之所由 来也。
再诊：接来札，知所言梦遗者，有梦而遗者也，比之 无梦者，大有分别。无梦为虚，有梦为实。就左脉弦数而 论，弦主肝，数主热，热伏肝家，动而不静，势必摇精。盖 肾之封藏不固，由肝之疏泄太过耳。
三诊。迭进封髓秘元，而仍不主蛰。细诊脉息，左关 独见沉弦且数。肝经之疏泄显然。
加龙胆草
邓评：左关独见弦数，由于肝火之亢，当无疑义，岂得因无效 而速尔变法，故四诊则病已大减矣。设非手段老练，其孰能之。
四诊；病已大减，仍守前法。
前方加白芍
诒按：首案遗泄咳嗽并提，方凡四易，而未曾有一味顾及咳嗽，想以肝火为本，治其本而标病可置之耳。
邓评：原注谓得萆薢、瞿麦而大减，观前方并无瞿麦，不识何敬?想加胆草，或即瞿麦之误否?
梦中遗泄，久而无梦亦遗，加以溺后漏精，近日无精，而小水之淋漓而下者，亦如漏精之状。始而气虚不能摄精，继而精虚不能化气。
三才封髓丹加蛤粉 芡实 金樱子
邓评：肾气不固，亦云极矣，理宜加重补肾。惟方用黄柏，谅必有湿火未清也。
曾经失血，现在遗精，精血暗伤，当脐之动气攻筑，漫无愈期，肢体从此脱力，语言从此轻微，饮食从此减少，无怪乎脉息芤而无神也。病情如此，虚已甚矣。而舌苔腻浊，中宫又有湿邪，治须兼理。
另清暑益气汤去术泻草
邓评：证见中虚挟湿，与清暑益气法甚为合拍，俾中枢有权，饮食增进，则自能化生精血，默运湿邪，又何取乎熟地之补肾，莲须之涩精也。
再诊：前方小效，小变其制。
另猪肚丸
原注：膏淋有便浊、精浊两种。便浊是胃中湿热渗入膀胱，与肾绝无相干；精浊牵丝粘腻，不溺亦有，是肾虚淫火易动，精离其位，渐渍而出，治宜滋肾清心、健脾固脱。九龙丹方中杞地归，滋阴以制阳，樱莲芡涩以固脱，石莲子苦寒清心，心清则火不炽，白茯苓甘平益土，以制肾邪，尤妙在山楂一味，能消阴分之障。前一案气虚抉湿热，故含清暑益气；后一案心火挟湿热，故合补心、猪肚。
分别便浊、精浊，两种自能了了。至宜滋肾清心、健脾固脱，即九龙丹方意也。惟还须看其偏重那一边，药即随之更换可也。
诒按：案语简洁老当，方亦周到。
小 便 门
阴虚之体，心火下郁于小肠，传入膀胱之府，尿中带血，时作时止，左脉沉数，小水不利。
另大补阴丸
诒按：此用导赤散合火府丹以清心火，即用大补阴丸以滋阴，虚实兼到。
邓评：论证有曲折之妙，用药无牵拘之弊。
经曰：胞移热于膀胱则癃溺血。又日：水液浑浊，皆属于热。又日：小肠有热者，其人必痔。具此三病于一身，若不以凉血之品，急清其热，迁延日久，必有性命之忧。
诒按：火甚者阴必伤，火清之后，随进丸药，以滋其阴。
邓评：如此探源，最属高见。惟证归一贯，无所遁情耳。
孙评：柳氏火甚者阴必伤句，是格致之言。
膏淋、血淋同病，未有不因乎虚，亦未有不因乎热者。热如化尽，则膏淋之物必且下而不痛，始可独责乎虚。
诒按；议论隽爽，方亦切实。
邓评：膏淋、血淋，必因乎热，不但同病使然也。惟有阴虚挟热与湿热并甚者不同，还当审察于间。
再诊：所下之淋，薄且少矣，而当便之时，尚属不利，既便之后，反觉隐痛，肢膝不温，脉小弦，唇红嗌干。热未全消，虚已渐著。
曾患淋证，小便本难，近来变为癃闭，少腹硬满，小便肿胀，苔白不渴，脉小而沉。下焦湿热，被外寒所遏，膀胱气化不行，最为急证，恐其喘汗。
诒按：此温通法也。惟由淋变癃，气分必虚，补中、肾气等法，亦可随宜佐用。
治癃闭症本有此外治之法。曾患淋症，更不免抉败精阻窍。惟麝香能窜入窍络而驱精，与是症为一举两得焉。
孙评：贴脐无益，细考自知：
泄 泻 门
邓评：未可以脉迟，便谓系乎阳弱，或者阳气窒滞有之。且脘痛之证，不免木气内阻，中挟相火，附子一味，极宜慎用。
诒按：由利转泻，或有因湿邪未净者。方中用四苓、伏龙肝，即此意否?
诒按；此时邪下陷之证
大 便 门
邓评：此等方案，洵非老手不办。想缘营阴未损，故无庸杂入滋养之品耳。惟白术、伏龙肝、薏仁等味，例可加入。
再诊：无毒治病，不必愈半而不取也，仍服原方可耳。
原注：此茅术地榆汤。其人便血，挟水而下，已及半载，人不团惫而面黄，大约湿热有余之体。此病两帖愈半，四帖全愈。
诒按：审证的确，用药精当，有以匙勘钥之妙。
肠游便血，时重时轻，或痛或否，脉形细小，饮食少。此虚也，恐增浮喘
诒按；此补脾摄血之正法也。稍加和胃之品，如广皮、砂仁辈，更为周密。
便血之前，先见盗汗，盗汗之来，由于寒热，寒热虽已，而盗汗便血之证不除，脉小而数。气阴两虚之病也。
诒按：此证营分中必有留热，宜于清营一边着意。但顾其虚，犹未周到。
邓评：便血、盗汗之来，由于寒热，固必有邪热溜陷于营分也，拟将方内参、芪易入细生地、牡蛎乃妥。
阴络伤则血内溢，为日已久，阴分固伤，阳分亦弱。而身中素有之湿热，仍未清楚，恐增浮喘。
大熟地伏龙肝 阿胶 白术赤小豆 附子 黄芩炙草当归 地榆炭 乌侮肉
诒按：此《金匮》黄土汤加味，阴阳并治，而兼清湿热，立方颇为周到。
邓评：凡血内溢者，病源甚多。大都见证面黄兼白，浮肿眩悸、肢痠力乏。惟血色淡红而非深赤，脉象虚濡而不弦实，阳分受伤偏重者，附子始能合用，否则有助火灼阴之弊。
湿热伤营，腹臌便血，久而不愈，左脉细涩，右芤、寸大尺小；加以浮肿，气分亦虚，不但不能摄血，而且不能清化湿热。防喘。
黄土汤草，地、术、附、胶、芩，土。 加大腹皮 桑皮五加皮党参槐花
原注：原方之妙，附子扶脾之母，黄芩清肝之热，熟地滋肾之阴，白术培脾之本，阿胶凉血之热，各脏照顾，非仲景不能作也。
诒按：增入之药，亦能与病机恰当。
【背景信息】
书名：增补评注柳选医案 章节：正文(15/17) 类别：医论
隐癖（腹内结块）僭越逆行至中宫（脾胃），肚脐虽未突出，但青筋逐渐显露，病情有散开发展为臌胀（腹部胀大如鼓）的趋势。况且大便时而稀溏时而干结，脾气长期虚弱，更加棘手。拟用攻补兼施的方法。
枳实消痞丸（枳实、黄连、厚朴、白术、半夏、茯苓、人参、干姜、麦芽、甘草）。加鸡内金、当归、鳖甲、白芍、牡蛎。
诒按：这已经形成胀病了。而中宫先虚，又难以攻克。这种证候最费心思经营，而又最难见效。
邓评：癖积散开变成臌胀，必定是土弱而木乘（肝木克脾土），有虚中夹实的含义。所以治疗最为棘手。此方有虚实兼顾、肝脾并调的妙处。
头痛门
治疗头痛选取少阳经、阳明经主治，这是正法。即使有前后部位的区别，不过是手经和足经的不同而已。
石膏、竹叶、生地、知母、甘菊、丹皮、黑栀、橘红、赤苓、桑叶、蔓荆子、天麻。
邓评：这必然有一派火盛的征象。
脉弦数大，苔厚中黄，头痛及旁侧。这是阳明湿热，挟带胆经风阳上逆所致。
大川芎汤（川芎、天麻）。合茶酒调散（白芷、甘草、羌活、荆芥、川芎、细辛、防风、薄荷）。二陈汤加首乌、归身、白芍。
诒按：这也是少阳、阳明两经的病。但风阳既然已经上逆，似乎应当参用清熄的意思，现在合用川芎、细辛、羌活、白芷，未免偏于升动发散。
邓评：方案不甚融洽。
头为诸阳之会，高巅之上，只有风能到达，到了就会引起百会穴肿痛且热。实在是因为阴虚体质，阴中的阳气容易随之上越。
生地、归身、白芍、羚羊角、石决明、煨天麻、甘菊、黑栀、丹皮、刺蒺藜。
邓评：证候只是风阳上升，用药只是滋阴凉熄和阳。而舌绛脉数，也可以由此推知。
肢体痛门
肝位于人身体左侧，左胁不时攻痛，严重时厥逆，左关脉沉小带弦，这是肝气郁结而不升；右脉弦滑，舌苔薄白，喜欢喝热汤，又有湿痰内阻。应当兼治。
诒按：用推气散来疏肝郁，合二陈汤来治湿痰，竟然像两扇题作的文章一样工整。
邓评：肝气久郁，必然会化火。推气散内有肉桂，如果不与清肝疏郁的药物并用，恐怕其气火化燥。即使是寒饮满积，也是暂不可久的药剂。大概痛在左胁，大都挟带肝经郁火。
脉沉弦滑，腿关节刺痛，腰部酸痛，背脊作响，各个关节也是如此，舌苔白浊。这是风湿痰三者附着在肝肾之络。
邓评：判断其为风湿痰实邪，完全依据苔脉得出。只有风善于上行，如今之所以陷着在肝肾之络，是因为内部被湿痰阻遏的缘故，怎么能拘泥于一种常例来论述呢？
遗精门
肾主蛰藏，是封藏的根本，是精液所在之处。精液之所以能安守其位，全在于肾气充足，封藏才能不失其职；虚损者则相反，出现小腿酸软、身体疲倦、口苦、耳鸣、大便干结等症状，也是势所必然。然而左尺脉浮而不静，固然由于肾气下虚；而关部独弦、独大、独数，舌苔黄燥，厥阴肝脏又有湿热助长相火；火动于内，必动摇精室，这就是所谓的肝主疏泄。虚则补之，未尝不好；但实则泻之，也是此证最重要的意义。
诒按：这是三才封髓丹加胆草、山栀、柴胡，方子与医案若合符节。
邓评：湿热助长相火，是这个病症的要旨，从关尺脉与舌苔上可以看出。所以肾脏虽然虚，尤其必须参用实则泻之的方法。
再诊：大便畅行，口中干苦也好了，左关脉大的也变小了。只是弦数仍然，尺脉也未静。可以用前方增减。
邓评：炎上作苦，火能下降，所以口苦也好了。只是脉尚弦数未静，所以苦寒泻火，还当着重注意。
三诊：久积的湿热，从大便排泄出去。但是久病之体，脾肾元气内亏，又不宜再泻，应当用守中法。
邓评：三诊似乎湿热已去，应当守中。谁知邪势初衰之际，须防余邪未尽，所谓炉烟虽熄，灰中有火，所以至此脉象复见弦数，仍不能舍弃苦寒泻火的药剂。当邪势初衰，迅速进补的，往往有此弊端。
四诊：大便已调和，脉形弦数，数是因有火，弦主肝。肝经既有伏火，不但顺乘阳明，而且容易摇动精室。精虽然四天未动，终究要小心。
原注：这个证候拈定左关独大、独弦、独数，所以重用胆草、黑栀，直折其肝家郁火，使湿热之邪从大便而出。
金本制木，今木火太旺，反侮肺金，肺金尚受其克制，那么吸取肾水，疏泄肾精，更是容易。这就是梦遗、咳嗽的原因。
再诊：接到来信，知道所说的梦遗，是有梦而遗的，比之无梦的，大有分别。无梦为虚，有梦为实。就左脉弦数而论，弦主肝，数主热，热伏肝家，动而不静，势必摇精。盖肾之封藏不固，由肝之疏泄太过耳。
三诊：迭进封髓秘元，而仍不主蛰藏。细诊脉息，左关独见沉弦且数。肝经之疏泄显然。
萆薢分清饮（石菖蒲、萆薢、甘草、乌药、益智仁、青盐）去石菖蒲合三才封髓丹，加龙胆草。
邓评：左关独见弦数，由于肝火之亢盛，当无疑义，怎能因无效而迅速变法，所以四诊则病已大减。如果不是手段老练，谁能做到这样。
四诊：病已大减，仍守前法。
前方加白芍。
诒按：首案遗泄咳嗽并提，方凡四易，而未曾有一味顾及咳嗽，想是以肝火为本，治其本而标病可置之不理。
邓评：原注谓得萆薢、瞿麦而大减，观前方并无瞿麦，不知何故？想加胆草，或即瞿麦之误否？
梦中遗泄，久而无梦亦遗，加以溺后漏精，近日无精，而小水之淋漓而下者，亦如漏精之状。始而气虚不能摄精，继而精虚不能化气。
三才封髓丹加蛤粉、芡实、金樱子。
诒按：这是肾中精气两损的证候，再合肾气聚精等方法，较为精密。
邓评：肾气不固，也极严重了，理宜加重补肾。惟方用黄柏，谅必有湿火未清。
曾经失血，现在遗精，精血暗伤，当脐之动气攻筑，漫无愈期，肢体从此脱力，语言从此轻微，饮食从此减少，无怪乎脉息芤而无神。病情如此，虚已甚矣。而舌苔腻浊，中宫又有湿邪，治须兼理。
枸杞子、熟地、芡实、楂炭、石莲子、当归、茯苓、金樱子、莲须。
邓评：证见中虚挟湿，与清暑益气法甚为合拍，使中枢有权，饮食增进，则自能化生精血，默运湿邪，又何取乎熟地之补肾，莲须之涩精呢？
再诊：前方小效，小变其制。
另猪肚丸。
原注：膏淋有便浊、精浊两种。便浊是胃中湿热渗入膀胱，与肾绝无相干；精浊牵丝粘腻，不溺亦有，是肾虚淫火易动，精离其位，渐渍而出，治宜滋肾清心、健脾固脱。九龙丹方中杞地归，滋阴以制阳，樱莲芡涩以固脱，石莲子苦寒清心，心清则火不炽，白茯苓甘平益土，以制肾邪，尤妙在山楂一味，能消阴分之障。前一案气虚挟湿热，故含清暑益气；后一案心火挟湿热，故合补心、猪肚。
分别便浊、精浊，两种自能了了。至宜滋肾清心、健脾固脱，即九龙丹方意也。惟还须看其偏重哪一边，药即随之更换可也。
诒按：案语简洁老当，方亦周到。
小便门
阴虚之体，心火下郁于小肠，传入膀胱之府，尿中带血，时作时止，左脉沉数，小水不利。
另大补阴丸。
诒按：这是用导赤散合火府丹以清心火，即用大补阴丸以滋阴，虚实兼到。
邓评：论证有曲折之妙，用药无牵拘之弊。
经曰：胞移热于膀胱则癃溺血。又说：水液浑浊，皆属于热。又说：小肠有热者，其人必痔。具此三病于一身，若不以凉血之品，急清其热，迁延日久，必有性命之忧。
诒按：火甚者阴必伤，火清之后，随进丸药，以滋其阴。
邓评：如此探源，最属高见。惟证归一贯，无所遁情耳。
孙评：柳氏火甚者阴必伤句，是格致之言。
膏淋、血淋同病，未有不因乎虚，亦未有不因乎热者。热如化尽，则膏淋之物必且下而不痛，始可独责乎虚。
大补阴丸加瓜蒌、瞿麦、牛膝、皿余（此处原文可能有误，疑为其他药名或笔误，保留原译）。
诒按：议论隽爽，方亦切实。
邓评：膏淋、血淋，必因乎热，不但同病使然也。惟有阴虚挟热与湿热并甚者不同，还当审察于间。
再诊：所下之淋，薄且少矣，而当便之时，尚属不利，既便之后，反觉隐痛，肢膝不温，脉小弦，唇红嗌干。热未全消，虚已渐著。
曾患淋证，小便本难，近来变为癃闭，少腹硬满，小便肿胀，苔白不渴，脉小而沉。下焦湿热，被外寒所遏，膀胱气化不行，最为急证，恐其喘汗。
诒按：这是温通法。惟由淋变癃，气分必虚，补中、肾气等法，亦可随宜佐用。
治癃闭症本有此外治之法。曾患淋症，更不免挟败精阻窍。惟麝香能窜入窍络而驱精，与是症为一举两得焉。
孙评：贴脐无益，细考自知。
泄泻门
邓评：未可以脉迟，便谓系乎阳弱，或者阳气窒滞有之。且脘痛之证，不免木气内阻，中挟相火，附子一味，极宜慎用。
诒按：由利转泻，或有因湿邪未净者。方中用四苓、伏龙肝，即此意否？
诒按：此时邪下陷之证。
大便门
邓评：此等方案，洵非老手不办。想缘营阴未损，故无庸杂入滋养之品耳。惟白术、伏龙肝、薏仁等味，例可加入。
再诊：无毒治病，不必愈半而不取也，仍服原方可耳。
原注：此茅术地榆汤。其人便血，挟水而下，已及半载，人不团惫而面黄，大约湿热有余之体。此病两帖愈半，四帖全愈。
诒按：审证的确，用药精当，有以匙勘钥之妙。
肠游便血，时重时轻，或痛或否，脉形细小，饮食少。此虚也，恐增浮喘。
诒按：此补脾摄血之正法也。稍加和胃之品，如广皮、砂仁辈，更为周密。
便血之前，先见盗汗，盗汗之来，由于寒热，寒热虽已，而盗汗便血之证不除，脉小而数。气阴两虚之病也。
诒按：此证营分中必有留热，宜于清营一边着意。但顾其虚，犹未周到。
邓评：便血、盗汗之来，由于寒热，固必有邪热溜陷于营分也，拟将方内参、芪易入细生地、牡蛎乃妥。
阴络伤则血内溢，为日已久，阴分固伤，阳分亦弱。而身中素有之湿热，仍未清楚，恐增浮喘。
大熟地、伏龙肝、阿胶、白术、赤小豆、附子、黄芩、炙草、当归、地榆炭、乌梅肉。
诒按：此《金匮》黄土汤加味，阴阳并治，而兼清湿热，立方颇为周到。
邓评：凡血内溢者，病源甚多。大都见证面黄兼白，浮肿眩悸、肢痠力乏。惟血色淡红而非深赤，脉象虚濡而不弦实，阳分受伤偏重者，附子始能合用，否则有助火灼阴之弊。
湿热伤营，腹臌便血，久而不愈，左脉细涩，右芤、寸大尺小；加以浮肿，气分亦虚，不但不能摄血，而且不能清化湿热。防喘。
黄土汤（甘草、熟地、白术、附子、阿胶、黄芩、伏龙肝）。加大腹皮、桑皮、五加皮、党参、槐花。
原注：原方之妙，附子扶脾之母，黄芩清肝之热，熟地滋肾之阴，白术培脾之本，阿胶凉血之热，各脏照顾，非仲景不能作也。
诒按：增入之药，亦能与病机恰当。
[Background Information]
Book: Zengbu Pingzhu Liu Xuan Yi An (Supplemented and Commented Medical Cases Selected by Liu)
Chapter: Main Text (15/17)
Category: Medical Discussion
Yinpi (subcutaneous masses) overstep and rebel into the Middle Palace (Spleen and Stomach). Although the umbilicus has not yet protruded, green veins are gradually appearing, and the condition is trending towards dispersing and developing into Guzhang (abdominal distension resembling a drum). Moreover, bowel movements alternate between loose and constipated, indicating long-standing deficiency of Spleen Qi, making it even more thorny. The proposed method is to combine attacking and tonifying.
Zhishi Xiaopi Wan (Bitter Orange Decoction for Reducing Epigastric Fullness) [Zhishi (Immature Bitter Orange), Lian (Coptis Rhizome), Po (Magnolia Bark), Zhu (Atractylodes Macrocephala Rhizome), Xia (Pinellia Tuber), Ling (Poria), Shen (Ginseng Root), Jiang (Dried Ginger), Maiya (Malt), Cao (Licorice Root)]. Add Jineijin (Chicken Gizzard Lining), Danggui (Angelica Sinensis Root), Biejia (Turtle Shell), Baishao (White Peony Root), Muli (Oyster Shell).
Zhi's Commentary: This has already formed a Zhang disease (distension disease). Since the Middle Palace is deficient first, it is difficult to attack. Such conditions require the most careful management and are the hardest to achieve effective results.
Deng's Commentary: When Piji (accumulated masses) disperse and become Guzhang, it must be due to weak Earth being overcome by Wood (Liver overacting on Spleen), implying a mixture of deficiency and excess. Therefore, treatment is most thorny. This formula has the subtlety of balancing deficiency and excess, and regulating both Liver and Spleen.
Sun's Commentary: Whenever there is Yinpi, one must add Yanhusuo (Corydalis Rhizome) and Xiangfu (Cyperus Rhizome) to promote circulation.
Headache Section
Treating headache by selecting Shaoyang (Lesser Yang) and Yangming (Greater Yang) meridians as the main approach is the correct method. Differences in anterior or posterior locations merely distinguish between Hand and Foot meridians.
Shigao (Gypsum Fibrosum), Zhuye (Bamboo Leaf), Shengdi (Rehmannia Root Prepared), Zhimu (Anemarrhenae Rhizome), Ganju (Chrysanthemi Flos), Danpi (Moutan Cortex), Heizhi (Scutellariae Fructus Carbonized), Juhong (Citri Reticulatae Pericarpium Rubrum), Chiling (Polyporus), Sangye (Mori Folium), Manjingzi (Vittagiae Fructus), Tianma (Gastrodiae Rhizoma).
Zhi's Commentary: This is headache biased towards Wind-Fire, so the medication focuses specifically on clearing and purging.
Deng's Commentary: There must be signs of a surge of Fire.
The pulse is wiry, rapid, and large; the coating is thick with yellow in the center; headache extends to the sides. This is Yangming Damp-Heat carrying Gallbladder Wind-Yang upward rebellion.
Da Chuanxiong Tang (Large Ligusticum Decoction) [Chuanxiong (Ligusticum Chuanxiong Rhizome), Tianma (Gastrodiae Rhizoma)]. Combined with Chajiu Tiaosan (Tea and Wine Modulating Powder) [Baizhi (Angelicae Dahuricae Radix), Cao (Licorice Root), Qianghuo (Notopterygii Rhizoma et Radix), Jingjie (Schizonepetae Spica), Chuanxiong (Ligusticum Chuanxiong Rhizome), Xixin (Asari Radix et Rhizoma), Fangfeng (Saposhnikoviae Radix), Bohe (Menthae Haplocalycis Herba)]. Erchen Tang (Two-Cured Decoction) plus Shouwu (Polygoni Multiflori Preparatum), Guishen (Angelicae Sinensis Radix), Baishao (Paeoniae Radix Alba).
Zhi's Commentary: This is also a disease of the Shaoyang and Yangming meridians. However, since Wind-Yang has already rebelled upward, one should consider adding methods to clear and extinguish. Using Chuanxiong, Xixin, Qianghuo, and Baizhi together tends too much towards ascending and dispersing.
Deng's Commentary: The prescription is not very harmonious.
At the highest peak, only Wind can reach; upon reaching, it causes swelling, pain, and heat at Baihui (GV20). This is truly because in a Yin-deficient constitution, the Yang energy within Yin easily ascends and escapes.
Shengdi (Rehmanniae Radix), Guishen (Angelicae Sinensis Radix), Baishao (Paeoniae Radix Alba), Lingyangjiao (Saigae Tataricae Cornu), Shijueming (Haliotidis Concha), Wei Tianma (Prepared Gastrodiae Rhizoma), Ganju (Chrysanthemi Flos), Heizhi (Scutellariae Fructus Carbonized), Danpi (Moutan Cortex), Cijili (Tribuli Fructus).
Zhi's Commentary: This is Yin deficiency with ascending Wind-Yang, so the medication focuses on nourishing Yin and extinguishing Wind.
Deng's Commentary: The syndrome is merely ascending Wind-Yang, and the medication is merely nourishing Yin, extinguishing Wind, and harmonizing Yang. The crimson tongue and rapid pulse can be inferred from this.
Body Pain Section
The Liver resides on the left side of the human body. Occasional attacking pain in the left hypochondrium, severe cases leading to JueNi (cold extremities/reversal cold), with the Left Guan pulse being deep, small, and wiry, indicates Liver Qi stagnation failing to ascend; the Right pulse is wiry and slippery, the tongue coating is thin and white, and there is a preference for hot drinks, indicating internal obstruction by Damp-Phlegm. Treatment should address both.
Tuiqi San (Pushing Qi Powder) combined with Erchen Tang (Two-Cured Decoction).
Zhi's Commentary: Using Tuiqi San to soothe Liver stagnation, combined with Erchen Tang to treat Damp-Phlegm, is remarkably like writing an essay with two parallel themes.
Deng's Commentary: Long-term stagnation of Liver Qi will inevitably transform into Fire. Tuiqi San contains Rougui (Cinnamon Bark); if not used concurrently with herbs that clear Liver heat and soothe stagnation, its Qi and Fire may transform into dryness. Even if it is full accumulation of Cold-Fluid, it is a temporary remedy not suitable for long-term use. Generally, pain in the left hypochondrium mostly involves stagnant Fire of the Liver meridian.
The pulse is deep, wiry, and slippery; stabbing pain in the leg joints, soreness in the waist, clicking sounds in the spine, and similar symptoms in all joints; the tongue coating is white and turbid. This is Wind-Damp-Phlegm attaching to the collaterals of the Liver and Kidney.
Lanzhuo Tang (Liver Settling Decoction) combined with Shen Zhuo Tang (Kidney Settling Decoction) [Ling (Poria), Zhu (Atractylodes Macrocephala Rhizome), Jiang (Dried Ginger), Cao (Licorice Root)]. Guizhi Tang (Cinnamon Twig Decoction).
Zhi's Commentary: In this condition, the disease lies in the collaterals, so attention should be paid to the meridians and collaterals.
Deng's Commentary: Judging it as Excess pathogens of Wind-Damp-Phlegm relies entirely on the tongue and pulse. Wind naturally tends to move upward; the reason it now sinks and attaches to the collaterals of the Liver and Kidney is due to obstruction by internal Damp-Phlegm. How can one rigidly adhere to a single pattern?
Nocturnal Emission Section
The Kidney governs hibernation/storage and is the root of sealing and storing, the residence of Essence. For Essence to remain in its place, it depends entirely on sufficient Kidney Qi so that sealing and storing do not fail in their duty; in deficiency, the opposite occurs, leading to symptoms such as sore calves, fatigue, bitter taste in the mouth, tinnitus, and hard stools, which is inevitable. However, the Left Chi pulse floating and unstable is indeed due to deficiency of lower Kidney Qi; while the Guan position being uniquely wiry, large, and rapid, along with a yellow and dry tongue coating, indicates that the Jueyin Liver has Damp-Heat assisting Mingmen Fire (Ministerial Fire). Fire moving internally must shake the Essence chamber, which is what is meant by "Liver governs dispersion and excretion." Tonifying deficiency is good, but purging excess is also the most crucial principle for this condition.
Tiantong (Asparagi Radix), Shengdi (Rehmanniae Radix), Dangshen (Codonopsis Radix), Huangbai (Phellodendri Cortex), Zhicao (Prepared Licorice Root), Sharen (Amomi Fructus), Longdancao (Gentianae Radix), Shanzhi (Gardeniae Fructus), Chaihu (Bupleuri Radix).
Zhi's Commentary: This is Santian Fengsui Dan (Three Capabilities Sealing Marrow Pill) added with Longdancao and Shanzhi, Chaihu. The formula matches the case perfectly.
Deng's Commentary: Damp-Heat assisting Ministerial Fire is the key point of this syndrome, visible in the Guan and Chi pulses and tongue coating. Thus, although the Kidney is deficient, one must particularly employ the method of purging excess.
Second Visit: Bowel movements flow freely, dryness and bitterness in the mouth have resolved, and the previously large Left Guan pulse has become smaller. However, the wiry and rapid quality remains, and the Chi pulse is still unsettled. The previous formula can be modified.
Santian Fengsui Dan (Three Capabilities Sealing Marrow Pill) plus Fushen (Poria with Hostwood), Longdancao (Gentianae Radix), Baiziren (Biota Seed).
Deng's Commentary: Heat rising creates bitterness; as Fire descends, bitterness resolves. However, since the pulse is still wiry and rapid and unsettled, emphasis must be placed on bitter-cold herbs to purge fire.
Third Visit: Long-accumulated Damp-Heat has been discharged through the bowels. However, in a chronic illness, Spleen and Kidney Yuan Qi are internally deficient, and further purging is inappropriate. One should adopt the method of guarding the Center.
Yigong San (Extraordinary Merit Powder) plus Baishao (White Peony Root), Heti (Lotus Petiole Peduncle), Shumi (Sorghum Grain).
Deng's Commentary: The third visit seems to indicate Damp-Heat has gone, suggesting guarding the Center. Who would know that when pathogenic strength is initially declining, one must guard against incomplete residual pathogens, as the saying goes, "Although the stove smoke has extinguished, there is still fire in the ashes." Hence, the pulse image returns to wiry and rapid, and one cannot abandon bitter-cold purging formulas. Rushing to tonify when pathogenic strength is initially declining often leads to this drawback.
Fourth Visit: Bowel movements are harmonized, pulse is wiry and rapid. Rapid indicates Fire; wiry indicates Liver. With latent Fire in the Liver meridian, not only does it smoothly invade Yangming, but it also easily shakes the Essence. Although Essence has not moved for four days, caution is still required.
Santian Fengsui Dan (Three Capabilities Sealing Marrow Pill) plus Chenpi (Aged Tangerine Peel), Baishao (White Peony Root).
Separately, Zhudu Wan (Pig Stomach Pill) [Kushen (Sophorae Flavescentis Radix), Baizhu (Atractylodis Macrocephalae Rhizoma), Muli (Oyster Shell), Zhudu (Sus Scrofa Domesticus Ventriculus)].
Original Note: This condition is determined by the Left Guan being uniquely large, wiry, and rapid, hence heavy use of Longdancao and Heizhi to directly break the stagnant Fire of the Liver, allowing Damp-Heat pathogens to exit via the bowels.
Sun's Commentary: This formula should add raw Muli (Oyster Shell) to heavily clear Liver Fire.
Metal originally controls Wood. Now Wood-Fire is too vigorous, counter-rebelling against Lung Metal. Since Lung Metal is still being controlled, absorbing Kidney Water and dispersing Kidney Essence becomes even easier. This is the origin of nocturnal emission and cough.
Santian Fengsui Dan (Three Capabilities Sealing Marrow Pill) plus Baishao (White Peony Root), Longdancao (Gentianae Radix).
Deng's Commentary: Nocturnal emission and cough occurring together cannot be treated without bitter-cold herbs directly purging Ministerial Fire.
Second Visit: Received letter, knowing the mentioned nocturnal emission refers to emission with dreams, which is significantly different from emission without dreams. Emission without dreams is deficiency; emission with dreams is excess. Regarding the Left pulse wiry and rapid: wiry indicates Liver, rapid indicates Heat. Heat lurking in the Liver moves restlessly, inevitably shaking the Essence. Because Kidney sealing and storing are insecure, it is due to excessive Liver dispersion and excretion.
Santian Fengsui Dan (Three Capabilities Sealing Marrow Pill) plus Muli (Oyster Shell), Longdancao (Gentianae Radix), Qingyan (Halitum).
Third Visit: Repeatedly administering Fengsui Mi Yuan (Sealing Marrow Securing Origin) methods, yet still failing to govern hibernation. Carefully examining the pulse, the Left Guan is uniquely deep, wiry, and rapid. Liver meridian dispersion is evident.
Bixie Fenqing Yin (Grassleaf Fastweed Decoction for Differentiating Turbidity) [Shichangpu (Acori Tatarinowii Rhizoma), Bixie (Smilacis Glabrae Rhizoma), Cao (Licorice Root), Wuyao (Linderae Radix), Yizhi (Alpiniae Oxyphyllae Fructus), Qingyan (Halitum)] minus Shichangpu, combined with Santian Fengsui Dan (Three Capabilities Sealing Marrow Pill), plus Longdancao (Gentianae Radix).
Deng's Commentary: The Left Guan being uniquely wiry and rapid is undoubtedly due to hyperactive Liver Fire. How can one rapidly change the method due to ineffectiveness? Thus, by the fourth visit, the illness had greatly decreased. If not for experienced skill, who could achieve this?
Fourth Visit: Illness has greatly decreased, still adhering to the previous method.
Previous formula plus Baishao (White Peony Root).
Original Note: The illness greatly decreased after receiving Bixie and Qumai, indicating Dampness is heavier than Fire.
Zhi's Commentary: The first case mentions both emission and cough. The formula changed four times, yet not a single herb addressed the cough. I assume Liver Fire is the root cause; treating the root allows the branch symptoms to be set aside.
Deng's Commentary: The original note says it greatly decreased after receiving Bixie and Qumai, but observing the previous formula, there is no Qumai. I wonder why? Perhaps adding Longdancao was a mistake for Qumai?
Nocturnal emission in dreams, and later emission without dreams, accompanied by leakage of essence after urination. Recently there is no essence, and the dripping urine resembles leakage of essence. Initially, Qi deficiency fails to control essence; subsequently, Essence deficiency fails to transform Qi.
Santian Fengsui Dan (Three Capabilities Sealing Marrow Pill) plus Haifen (Concha Tridacnidae), Qianshi (Euryales Semen), Jinyingzi (Chrysobalanus Fruit).
Zhi's Commentary: This is a condition of dual damage to Kidney Essence and Qi. Combining methods like Shenqi Jujing (Kidney Qi Gathering Essence) would be more precise.
Deng's Commentary: Kidney Qi insecurity is extremely severe; logically, heavy Kidney tonification is appropriate. However, using Huangbai suggests Damp-Fire has not cleared.
History of blood loss, current nocturnal emission, dark injury to Essence and Blood. Pulsating Qi at the umbilicus attacks and builds up with no end in sight. Limbs lose strength, speech becomes faint, food intake decreases. No wonder the pulse is Kou (cunet-like) and spiritless. The condition is thus, deficiency is extreme. Yet the tongue coating is greasy and turbid, and there is Dampness in the Middle Palace; treatment must address both.
Gouqi (Lycium Fruit), Shudi (Rehmanniae Radix Preparata), Qianshi (Euryales Semen), Zhatan (Crataegi Fructus Carbonized), Shilianshi (Nelumbinis Plumula), Danggui (Angelicae Sinensis Radix), Fuling (Poria), Jinyingzi (Chrysobalanus Fruit), Lianxu (Nelumbinis Stamen).
Separately, Qingshu Yiqi Tang (Clear Summerheat and Boost Qi Decoction) minus Baizhu (Atractylodis Macrocephalae Rhizoma) and Gancao (Licorice Root).
Original Note: This is Jiulong Dan (Nine Dragon Pill). Wu Hegao said: It treats Jingzhuo (turbid essence).
Deng's Commentary: The condition shows Middle deficiency with Dampness, which fits well with the Qingshu Yiqi method. Empowering the central pivot increases food intake, thereby naturally generating Essence and Blood and silently transforming Dampness. Why rely on Shudi to tonify Kidney and Lianxu to astringe Essence?
Second Visit: Previous formula had slight effect, slightly changing its formulation.
Jiulong Dan (Nine Dragon Pill) plus Zhuyu (Atractylodis Macrocephalae Rhizoma), Banxia (Pinelliae Tuber), Fuling (Poria), Chenpi (Aurantii Pericarpium Rubrum), Wubeizi (Galla Chinensis), decocted and taken with Weiyi Wan (Weiyi Pill).
Zhi's Commentary: Yin deficiency with Dampness is the hardest to medicate; one must look at how to care for both aspects.
Deng's Commentary: Greasy and turbid coating is incompatible with Shudi.
White turbidity lasting long without cure, causing Kidney to lose sealing and storing, nocturnal emission worsens, little sleep, poor appetite, sallow complexion, small pulse.
Jiulong Dan (Nine Dragon Pill) combined with Tianwang Buxin Dan (Emperor of Heaven Special Pill for Nourishing the Heart).
Separately, Zhudu Wan (Pig Stomach Pill).
Original Note: Gaolin (seminal discharge) has two types: Bianzhuo (turbid urine) and Jingzhuo (turbid essence). Bianzhuo is Damp-Heat from the Stomach seeping into the Bladder, having nothing to do with the Kidney; Jingzhuo is sticky and stringy, occurring even without urination, caused by Kidney deficiency and hyperactive Lust Fire easily moving, causing Essence to leave its position and slowly渗出 (ooze out). Treatment should nourish Kidney, clear Heart, strengthen Spleen, and secure collapse. In Jiulong Dan, Gouqi, Shudi, Danggui nourish Yin to control Yang; Jinyingzi, Lianshi, Qianshi astringe to secure collapse; Shilianshi is bitter-cold to clear Heart; clearing Heart prevents Fire from blazing; Baifuling is sweet and neutral to benefit Earth to control Kidney pathogens. Especially wonderful is Hawthorn, which eliminates obstacles in the Yin aspect. In the previous case, Qi deficiency with Damp-Heat included Qingshu Yiqi; in the latter case, Heart Fire with Damp-Heat combined Buxin and Zhudu.
Deng's Commentary: Emission with dreams and poor appetite mean clearing Damp-Heat requires attention.
Differentiating Bianzhuo and Jingzhuo makes both clear. As for nourishing Kidney, clearing Heart, strengthening Spleen, and securing collapse, this is the intent of Jiulong Dan. One just needs to see which side is heavier and change the herbs accordingly.
Sun's Commentary: Differentiating and treating Bianzhuo and Jingzhuo separately, how could it not heal?
Qi deficiency fails to control essence; Essence deficiency fails to transform Qi. Consumed food merely increases Phlegm-Dampness.
Liujunzi Tang (Six Gentlemen Decoction) plus Tusiji Bing (Cuscutae Seed Cake), Paojiangtan (Prepared Ginger Charcoal), Jiuzai Zi (Allii Tuberosi Fructus).
Original Note: Solely based on Spleen organ Qi deficiency.
Zhi's Commentary: The case language is concise and seasoned; the formula is also thorough.
Deng's Commentary: Tonifying Qi is primary, securing Essence assists; this truly fits the theme.
Urination Section
In a Yin-deficient constitution, Heart Fire sinks and stagnates in the Small Intestine, transmitting to the Bladder Fu organ. Blood appears in urine, intermittent. Left pulse is deep and rapid, urination is difficult.
Shengdi (Rehmanniae Radix), Mutong (Akebiae Caulis), Gancao (Licorice Root), Zhuye (Bamboo Leaf), Huofu Dan (Fire Mansion Pill).
Separately, Dabu Yin Wan (Great Tonify Yin Pill).
Zhi's Commentary: This uses Daochi San (Guide Out Red Powder) combined with Huofu Dan to clear Heart Fire, and uses Dabu Yin Wan to nourish Yin, addressing both deficiency and excess.
Deng's Commentary: The argument has subtle twists; the medication avoids rigidity.
The Classics say: If Bladder receives heat from Bao (Uterus/Bladder), there is Gong (difficulty in urination) and hematuria. Also: Turbid fluids all belong to Heat. Also: Those with heat in the Small Intestine must have hemorrhoids. Having these three diseases in one body, if not urgently cleared with cooling-blood herbs, prolonged delay will endanger life.
Daochi San (Guide Out Red Powder) combined with Huofu Dan (Fire Mansion Pill) plus Dengxincao (Juncus Effusus Achenes).
Another Pill Formula: Guben Wan (Root-Securing Pill) combined with Dabu Yin Wan (Great Tonify Yin Pill) and Zhushiwan (Pig Marrow Pill) plus Bixie (Smilacis Glabrae Rhizoma).
Zhi's Commentary: When Fire is severe, Yin must be injured. After clearing Fire, follow up with pills to nourish Yin.
Deng's Commentary: Probing the source like this is a high view. However, the syndrome follows a consistent pattern, leaving no room for evasion.
Previously clearing heat while simultaneously tonifying Yin naturally maintains proper hierarchy.
Sun's Commentary: Liu's statement "When Fire is severe, Yin must be injured" is a profound insight.
Gaolin (seminal discharge) and Xulin (blood strangury) occurring together are invariably due to deficiency, and invariably due to Heat. If Heat is completely transformed, the material from Gaolin will pass down without pain, only then can deficiency be solely blamed.
Dabu Yin Wan (Great Tonify Yin Pill) plus Gualou (Trichosanthis Fructus), Qumai (Dianthi Herba), Niuxi (Achyranthis Bidentatae Radix), Min Yu (Textual error, likely referring to another herb or placeholder).
Zhi's Commentary: The discussion is sharp; the formula is practical.
Deng's Commentary: Gaolin and Xulin must be due to Heat, not just because they occur together. It differs from Yin deficiency with Heat and severe Damp-Heat; one must examine the nuances.
Sun's Commentary: Non-painful implies deficiency, not just for Gaolin; this can be called concise and essential.
Second Visit: The discharged strangury is thinner and less; during urination, it is still difficult; after urination, dull pain is felt; limbs and knees are not warm; pulse is small and wiry; lips are red, throat is dry. Heat is not fully eliminated, deficiency is gradually manifest.
Gualou Qumai Qu Fu Tang (Trichosanthus and Dianthus Decoction Removing Aconite) plus Maidong (Ophiopogonis Radix), Bixie (Smilacis Glabrae Rhizoma), Heizhi (Scutellariae Fructus Carbonized), Zhujijing (Porcine Spinal Cord).
Zhi's Commentary: Dull pain after urination, cold knees, and dry throat are all signs of deficiency; nourishment should be combined.
Deng's Commentary: Since the illness leans towards deficiency, even if residual heat remains, one must tonify Yin to harmonize Yang.
History of Lin syndrome, urination was originally difficult, recently changed to Gongbi (retention of urine), lower abdomen hard and full, urinary swelling, white coating, no thirst, pulse small and deep. Lower Jiao Damp-Heat is constrained by external Cold, Bladder Qi transformation fails. This is an urgent condition, fearing asthma and sweating.
Rougui (Cinnamon Bark) Wuling San (Five-Ling Powder) plus Muxiang (Aucklandiae Radix), Wuyao (Linderae Radix), Zhike (Aurantii Fructus).
Separately, one bunch of Congbai (Scallion White) and three li of Shexiang (Musk) pounded into a cake applied to the umbilicus.
Zhi's Commentary: This is a warming and unblocking method. Since Lin changed to Gong, Qi aspect must be deficient; Buzhong (Tonify Middle) and Shenqi (Kidney Qi) methods can also be used as auxiliaries as appropriate.
Deng's Commentary: Tongue and pulse indicate Cold, hence warming and unblocking are suitable as assistants.
There is this external treatment method for Gongbi. Having suffered from Lin, there is inevitably obstructed stale Essence blocking orifices. Only Musk can penetrate orifices and collaterals to drive out Essence, achieving two goals with one stroke for this condition.
Sun's Commentary: Applying to the umbilicus is useless; careful examination will reveal this.
Diarrhea Section
Sunxie (undigested food diarrhea) is either due to Stomach stagnation or Yang weakness; this case has both. Pulse is slow, belching with rotten smell, epigastric pain.
Fuzi Lizhong Tang (Aconite Regulate the Middle Decoction) combined with Erchen Tang (Two-Cured Decoction) plus Chuanpo (Magnolia Officinalis Bark), Wuyu (Evodiae Fructus), Fangfeng (Saposhnikoviae Radix).
Zhi's Commentary: Belching with rotten smell and epigastric pain indicate significant food stagnation. I propose removing Erchen Tang and adding Shenqu (Medicated Leaven), Sharen (Amomi Fructus), and Fuzi (Radish Seed).
Deng's Commentary: One cannot judge Yang weakness solely based on a slow pulse; perhaps it is Qi stagnation. Furthermore, epigastric pain inevitably involves Wood Qi internal obstruction with accompanying Ministerial Fire; Fuzi must be used with extreme caution.
Lower profit turning into diarrhea, Kidney disease transmitting to Spleen. Spleen accepts pathogens due to deficiency; warming and transforming is appropriate.
Lizhong Tang (Regulate the Middle Decoction) combined with Siling San (Four-Ling Powder) plus Chenpi (Aurantii Pericarpium Rubrum), Fangfeng (Saposhnikoviae Radix), Fulonggan (Dragon's House Earth).
Zhi's Commentary: Turning from profit to diarrhea might be due to unresolved Dampness. Does using Siling San and Fulonggan imply this?
Deng's Commentary: Lower profit turning into diarrhea implies less pathogen and more deficiency, Heat gone and Cold remaining. This method is highly appropriate.
After fever, abdominal pain and loose stools. Exterior pathogen sinking inward.
Xiaochaihu Tang (Minor Bupleurum Decoction) plus Baishao (White Peony Root), Muxiang (Aucklandiae Radix), Fuling (Poria), Zexie (Alismatis Rhizoma).
Zhi's Commentary: This is a condition of exterior pathogen sinking inward.
Deng's Commentary: Residual heat turning into diarrhea, exterior pathogen sinking inward, indeed Yang cannot overcome Yin. The formula should increase warming and transforming.
Sun's Commentary: A wonderful method for those without fever. If there is fever, it is not suitable.
Stool Section
Spleen deficiency fails to transform Dampness, how can it control Blood? Blood mixes with water and Dampness, flowing downward incessantly.
Maoyu (Atractylodis Rhizoma), Diyupi (Ulmus Cortex), Huaihuatan (Sophorae Flavescentis Flos Carbonized), Yujin (Curcumae Radix).
Deng's Commentary: Such prescriptions are indeed beyond the capability of novices. Perhaps Ying Yin is not damaged, so there is no need to mix in tonifying herbs. However, Baizhu, Fulonggan, and Yiren are typically added.
Second Visit: Treating non-toxic illness, one need not stop halfway; continuing the original formula is fine.
Original Note: This is Maoyu Diyu Tang. The patient has bloody stool mixed with water, lasting half a year. The person is not exhausted but sallow, roughly a constitution with excess Damp-Heat. This illness improved by half in two doses, fully healed in four doses.
Zhi's Commentary: Accurate syndrome differentiation, precise medication, like a key fitting a lock.
Changyou (Intestinal ulcer) bloody stool, varying severity, painful or not, pulse is small and thin, poor appetite. This is deficiency, fearing increased floating asthma.
Guipi Tang (Return the Spleen Decoction) plus Qicaihua (Shepherd's Purse Flower), Heye (Lotus Leaf), Hangmi (Oryza Sativa Japonica Group).
Zhi's Commentary: This is the correct method for tonifying Spleen and controlling blood. Adding mild stomach-harmonizing herbs like Guangpi (Tangerine Peel) and Sharen would be more thorough.
Deng's Commentary: Pain implies pathogen obstruction; a formula combining soothing and tonifying is suitable. This formula is too cloying and stagnant.
Before bloody stool, night sweats appeared. Night sweats come from alternating chills and fever. Although chills and fever have ceased, night sweats and bloody stool persist, pulse is small and rapid. This is a disease of dual Qi and Yin deficiency.
Guipi Tang (Return the Spleen Decoction) minus Guiyuan (Longan Aril) plus Danpi (Moutan Cortex), Shanzhi (Gardeniae Fructus), Diyu (Arnebiae seu Lithospermi Radix), Sangye (Mori Folium).
Zhi's Commentary: This condition must have lingering Heat in the Ying level; attention should be paid to clearing Ying Heat. Focusing only on deficiency is not thorough.
Deng's Commentary: Bloody stool and night sweats coming from chills and fever certainly imply pathogenic Heat sinking into the Ying level. I suggest replacing Ginseng and Astragalus in the formula with Shengdi (Rehmanniae Radix) and Muli (Oyster Shell) for better suitability.
Sun's Commentary: Sangye is unsuitable for night sweats.
Damage to Yin collaterals causes internal bleeding. Having lasted long, Yin aspect is injured, and Yang aspect is also weak. The inherent Damp-Heat in the body is still unclear, fearing increased floating asthma.
Dashudi (Rehmanniae Radix Preparata), Fulonggan (Dragon's House Earth), Ejiao (Donkey-Hide Gelatin), Baizhu (Atractylodis Macrocephalae Rhizoma), Chixiaodou (Adzuki Bean), Fuzi (Aconiti Lateralis Radix Preparata), Huangqin (Scutellariae Radix), Zhicao (Prepared Licorice Root), Danggui (Angelicae Sinensis Radix), Diyutan (Arnebiae seu Lithospermi Radix Carbonized), Wumei (Mume Fructus).
Zhi's Commentary: This is Jin Gui Huangtu Tang (Yellow Earth Decoction from the Golden Cabinet) with additions, treating both Yin and Yang while clearing Damp-Heat. The formulation is quite thorough.
Deng's Commentary: For internal bleeding, there are many sources. Most present with sallow and white complexion, edema, dizziness, palpitations, limb soreness, and fatigue. Only if the blood color is pale red rather than deep crimson, and the pulse is deficient and soggy rather than wiry and solid, indicating predominant Yang aspect injury, can Fuzi be combined. Otherwise, it risks aiding Fire and burning Yin.
Damp-Heat injuring Ying, abdominal distension and bloody stool, lasting long without cure. Left pulse is fine and choppy, Right is Kou and Cun large Chi small; plus edema, Qi aspect is also deficient. Not only failing to control blood, but also failing to clear and transform Damp-Heat. Prevent asthma.
Huangtu Tang (Yellow Earth Decoction) [Caog (Licorice Root), Di (Rehmanniae Radix Preparata), Zhu (Atractylodis Macrocephalae Rhizoma), Fu (Aconiti Lateralis Radix Preparata), Jiao (Donkey-Hide Gelatin), Qin (Scutellariae Radix), Tu (Fulonggan)]. Plus Dafupi (Arecae Pericarpium), Sangpi (Mori Cortex), Wujia pi (Acanthopanacis Cortex), Dangshen (Codonopsis Radix), Huaihua (Sophorae Flavescentis Flos).
Original Note: The brilliance of the original formula: Fuzi supports the Mother of Spleen, Huangqin clears Liver Heat, Shudi nourishes Kidney Yin, Baizhu cultivates Spleen Root, Ejiao cools Blood Heat. Each Zang organ is attended to; only Zhang Zhongjing could compose this.
Zhi's Commentary: The added herbs also fit the pathology appropriately.