邓评：既至肿胀，而用此胶、地浊腻之品，惟血不维气者相宜，如所云气不摄血，究当责重气分用药。
红白痢变为便血，当时血色尚鲜，后又转为紫黑，或带血水，而不了结。暑湿深入营中，气虚无力以化，降而不升也。
诒按：此证血分中有留邪，尚宜参用和血之品。
再诊：血虽渐止，气犹降而不升。
诒按：立方精到。拟再增银花、丹皮。
邓评：单方有桂圆肉包苦参子七粒，数服便愈。吡种症情，最为相宜，亦汤剂之一助云。
大小便易位而出，名目交肠。骤然气乱于中，多属暴病。此症乃久病，良由瘀血内阻，新血不生，肠胃之气无所附而失治，故所食之水谷，悉从前阴而出。所谓幽门者，不司泌别清浊，而闢为坦途，比之交肠证，有似是而实非者。此时论治，主以化瘀润肠，必大肠之故道复通，乃可拨乱者而返之正。
另旧纱帽一只炙灰每服一钱五分酒下
原注；纱帽--发漆胶粘而成，其亦取通瘀之意耶。
诒按：论证用药，均有巧思，特未知效否何如?忆喻西昌《寓意草》中，所载姜宜人交肠病，与此相似；特病原有虚实之异耳，学者当参观之。
邓评；所谓病有千变，用药亦有千变。如此症岂可执古法治交肠而守五苓一方乎。
此瘀结肠燥，气失附而迫趋前阴，故粪亦从前阴而出矣。
《爱庐》中仅用明矾一味，腐衣五层包，盐汤下，日三服，三日九服，取其导痰涩大肠。
孙评：后《爱庐》案是暴得者，乃真交肠，宜与喻氏书三证同参。
发漆胶粘而成之帽，近日未见。惟有棕漆粘成者，或即是此欤。
虫 病 门
阳络曾伤，阴气素虚，更有湿热郁于营分，日久生虫，扰乱于上中下三焦，以致咳嗽喉痹，恶闻食臭，起卧不安，肛部不舒，舌质深红，其苔黄浊。即仲景所谓狐惑病是也。久延不愈，即入劳怯之途。
川连三分 犀角兰分 乌梅五分 人中白一钱百部一钱 丹皮一钱半 甘草三分
邓评：《金匮》狐惑病有蚀于上部则声嗄，蚀于下部则咽干，与蚀于肛者之不同。此证则上中下三焦被扰，故见象如是，方亦从《金匮》扩充而来。
脘腹作疼，满腹苦热，初起得食则痛，继而不食亦痛。此肝胃不和，湿热生虫之状。
邓评：得食则痛，固是蛔动一症；惟有食积者亦能如此；肝气横郁于中宫者亦能如此。
再诊：服前方，脘腹之痛而苦热者，时作时止，止则右胁下必有一块攻筑。是属蛔未安也。
治按：蛔未安者，似宜仍用乌梅丸。此则固右胁攻筑，故用金铃子散以泄肝耳。
邓评：服前方不效，而胁下一块攻筑，岂非开气之不平乎。
湿热挟风，生虫作痒，有似攻注之形，无处不至。难治之证也。 獭肝一钱磨开水冲服 邓评：惟其作痒，故谓有虫。 再诊：攻注有形，而不攻注时无迹。湿热风虫，踞于痰中所致。
另医通沉香化气丸大黄、黄芩、沉香、六曲、辰砂、术、竹油，姜汁。
诒按：獭肝治虫，法本《千金》。惟案中所云攻注有形，无处不到，究竟或在肢体，或在腹里，均未叙明，无从揣测也。
邓评：此方重理湿热风痰，或系疑其非虫乎。至云湿热风虫踞于痰中，亦是影响之谈。
孙评：汤丸与虫均不贴切。
人之涎下者，何气使然?日：胃中有热则虫动，虫动则胃缓，胃缓则廉泉开，故涎下。 黄连丸连、萸、木香、诃子、龙骨．合乌梅丸诒按：方案俱高简稳实。邓评：用一段经文作案，自是高古。既是胃热虫动，又何取诃子、龙骨以摄涎?
评选环溪草堂医案三卷
环溪草堂医案三卷，梁溪王旭皋先生所著也。先生名泰林，字旭皋，世为无锡人。嘉道间有以疡医驰名江浙者，日高锦亭先生，著有外科心得集、景岳方歌括等书行世，即旭皋先生之舅氏也。高先生殁后，先生传其业。其始先以疡医行，逮后求治者日益多，寝及内科，无不应手奏效，于是遂专以内科行。门下士习业者，每年以十数计。先生读书，上自轩岐，下迄国朝诸家，无不精心贯串。于古书则研求故训，于后人书则必分别疑似。所著有西溪书屋夜话录、医方歌括串解、及环溪草堂医案诸书，均未梓行。其医案为门弟子随时钞录，未经分别去取，不免繁复者多。余所得见者，盖有五六本，详略互异。因属及门诸子删其繁乱，重为钞辑。最后得王家桥顾君莲卿本，系先生晚年之作。又得方君耕霞新刊本，案甚繁富，颇有方案足取而为他本所未载者，一并补录，简其精粹，分为三卷。间有未尽之意，随加按语以阐明之，阅一年而竣事。先生居锡城，去余家不百里，余弱冠时犹及见之。吾乡有疑难证，无不求治于先生者，先生必沉思渺虑，疏方与之，厥后或效或否，或有无力再往者，先生必访悉之，令其再诊，以竟厥功。故其所存方案，无不光坚响切，无模糊影响之谈。盖较近贤之专以灵变取巧者，不啻上下床之别矣。先生博极群书，所用诸法，如治小儿喘嗽之药枣，从葛可久之白凤丹化出；治上热下寒之八味丸，用紫雪为衣，从喻西昌外廓之论悟出。若此之类，不胜枚举，是皆因古法而变化出之。彼胸无古书者，每读之而猝难领会。余于此等处，均为一一指出，学者苟能即是而得读书用古之法焉，则庶乎不负先生之苦心也夫。光绪二十六年重阳日江阴柳宝诒谨识
评选环溪草堂医案上卷 无锡王泰林旭高著
内伤杂病门
病将一载，肝气横逆而不平，中气久虚而不振。惟肝逆，故胸脘阻塞而攻冲；惟中虚，故营卫不和而寒热。凡大便溏、饮食少、右脉细、左脉弦，是其证也；四君子合逍遥、加左金，是其治也。
党参 冬术 陈皮 茯苓 归身 神曲 白芍 柴胡盐水炒 香附盐水炒 川连吴萸炒 谷芽 玫瑰花
邓评：论证明晰，用药不紊。惟寒热而便溏，脉细弦者，总宜兼温理脾胃营卫，如桂枝、煨姜、大枣之类；肝逆攻冲，金铃子亦在需用。方内川连或可删去。
再诊：阳虚恶寒，阴虚发热，脾虚则便溏而乏力，木旺则脘痞而气塞。前方补中泄木，肝气已平，合以盖火生土、气皿双补。
党参 冬术 苁蓉 鹿角霜 杞子 木香 菟丝子 归身 白芍 陈皮
茯苓 杜仲 砂仁 玫瑰花 诒按：肝气平后，续用培补，是一定层次。惟既有寒热见证，似可参用桂技建中之意以和之。
三焦相火，挟肝阳而上升，每日侵晨，则气自脐左而上冲，心胸痞塞，自觉胸中热，舌尖辣，面色红，过午则气渐下降，至夜则安，而火降则下或遗泄。此皆无形之火为患也。推其原始，由乎阴虚；今则相火妄行，蒸炼胃液成痰，所以吐痰粘腻灰黑，而咽嗌胃管之间，常觉不流利也。法当清相火、导虚阳，而下归窟宅，更佐以化痰钲逆。病来已久，难期速效。
黄柏盐水炒一钱二分桂心三分 砂仁炒三分 蛤壳一两 甘草三分知母盐水炒一钱二分 川连盐水炒四分 茯苓三钱玄精石三钱长流水煎
诒按：此方取交济、封髓之法，用意极为精到。惟病因肝肾不摄，虚阳浮逆，拟再加牡蛎、龟板以摄下，旋覆、竹茹以清上，似于病情更为周匝。
邓评：推论病源，不外乎是，制方亦极精切不泛。脉虽未见，而关尺想必弦大且数。
孙评：牡蛎似须必加，白芍亦为要药。黄柏、砂仁名封髓，川连、内桂多交济，人参、枳实名补泻法，川连、干姜名泻心法。此皆法之巧者也。
痰之标在肺胃，痰之本在脾肾，肾虚则水泛，脾虚则湿聚，二者均酿痰之本也。经日：脾恶湿，肾恶燥。脾肾两虚，法当滋燥兼行；而痰恋肺胃，又宜标本同治。
诒按：案语斟酌病机，切实不泛，用药亦丝丝入筘。用黑地黄法以两补脾肾，合二陈以和胃，菀贝以利肺。药品无多，而层层都到，非有简炼工夫，不能作此。
邓评：治一病而标本虚实悉到，且无浮泛牵拘之弊。
孙评：川贝易杏仁何如?
凡脏邪，惟虚则受之，而实则不受；惟实者能传，而虚则不传。仲景云：肝病实脾，治肝邪之盛也；内经云；肝病缓中，治肝体之虚也。此证肝气有余，肝血不足，法宜两顾为得。
归身 白芍 沙苑 杞子 冬术 茯神 青皮 陈皮 香附 金铃子 砂仁
诒按：议论确凿，非胸中有古书者不能道；方亦精到。方中归、芍、杞、苑，所以养肝血；青、陈、香、铃，所以疏肝气。药品看似平常，用意恰已周到。
邓评：此段议论，引用未能的当。方尚平稳，惟香燥泄气之品太多。凡肝体既亏，肝用自旺，廿润柔肝，是所以补肝体即所以平肝用也。
孙评：开口即从至情实理立论。
肾水不足，君火上炎，相火下炽。心中如燔，舌光如柿，阳事易举，阴精易泄。拟清君火以制相火，益肾阴以制肝阳。所虑酷热炎蒸，恐药力无权，将亢阳为害，而增剧耳。
另大黄三钱 研末将鸡子一个 破头纳大黄三分 蒸熟每日服一个。
此种丹方亦足取法。
孙评：制相火、益肾阴，须藉成寒，前人明训；第宜择介类以潜之，庶为贴切。方中加煅牡蛎何如?
再诊t投苦咸寒坚阴降火，以制亢阳，心中之燔灼，与舌色之光红，俱减三分之一。然上午之身热如燎者未退；幸纳食颇增，苦寒可进。再望转机为妙。
邓评：上午身热，即偏于阳盛之征。若由乎阴虚者，则热必作于暮夜矣。
三诊：舌干红，知饥善纳。水亏阳亢，土燥于中，咸苦坚阴之剂，虽衰其燔亢之势，而未能尽除其焰。时当炎暑，湿热与相火蒸腾。拟复入清中固下祛湿之法，仍不出咸苦之例。
洋参石膏知母 甘草麦冬 川连 阿胶 生地蛤壳黄柏猪胆汁丸每朝服三钱
诒按：君相交燔，肾阴被灼，所谓一水不能胜二火，此证是也。仅与壮水，犹难胜任，必得苦以泄之，成以制之，而火乃退；更得苦以坚之，成以滋之，而阴乃复。
孙评；苦泄是大黄、川连，苦坚是黄芩、黄柏，成制是玄精石、玄参，咸滋是阿胶，牡蛎。
营阴虚，则气火易升；肝木横，则脾土受侮。腹满头晕，肝脾之病；耳鸣喉燥，虚火之愆。阴虚生内热，肾虚故腰痛。拟补阴潜阳、扶土抑木法。
生地砂仁炒四两茯苓烘三两山药炒三两 萸肉酒炒三两丹皮酒炒二两 泽泻炒三两 龟板炙三两 沙苑盐水炒三两 党参炒三两 杜仲盐水炒三两归身酒炒三两白芍炒二两 石决明煅四两
上药为末，炼蜜打和为丸，晒干，泛上后药：
香附三两分三分一分盐水炒，一分醋炒、一分蜜水炒 陈皮盐水炒七钱 沉香三钱 神曲一两
上药为末，用橘叶汤泛上前丸为衣。
诒按：以补药为丸，而以和气之药末，泛上为衣，与喻嘉言药用外廓之意相合。虽无精义可取，而心思灵巧，可备一格。
邓评：药用外廓，固一巧法。然证见腹满，阴柔之品，终虑碍脾。愚拟一方于下，以备同学采择：
川连、益智、广皮、茯苓、制香附、白蒺藜、归身、白芍、首乌、木瓜。
孙评：喻西昌外廓之法，用姜附猛烈，用参苓为衣，过胃入下，始露威灵，其法本巧；今则以呆滞为心，而以流动为衣，仿其意而变通之，真善读书者也。
夜凉昼热，热在上午，此东垣所谓劳倦伤脾之证也。上午热，属气虚，用补中益气汤，补气升。
邓评：热在上午，责之阳气，斯为不易之理。惟虚而发热，当或有形寒见证。此病本尚未咳，咳则升柴不宜用也。
寒邪伤阳，亦每多上午寒热。
泄为脾病，呕为胃病，脾胃属土，居中而司升降。脾宜升，不升则泄；胃宜降，不降则呕；土衰则木横，木横而土益衰。高年当此，颇虑土败木贼。古人治肝，当先实脾。况兹土弱，尤当先补其中，稍佐平肝可也。
邓评：既然已经出现肿胀，却使用阿胶、熟地黄这样滋腻厚重的药物，只适用于血液不能固摄气机的情况；如果是文中所说的“气不摄血”，终究应当着重在调理气分的药物上下功夫。
红白痢疾转化为便血，起初血色还鲜艳，后来转为紫黑色，或者带有血水，病情迁延不愈。这是暑湿之邪深入营分，因气虚无力运化，导致气机降而不升。
驻车丸包含黄连、阿胶、干姜、当归。加入广木香、党参、甘草、伏龙肝、荠菜花。
诒按：此证是血分中有留滞的邪气，适宜参用调和血液的药物。
复诊：出血虽然逐渐停止，但气机仍然降而不升。
邓评：有一个单方是用桂圆肉包裹七粒苦参子服用，服几次就能痊愈。这种病症情最为适宜，也可以作为汤剂治疗的辅助。
大小便交换部位排出，名叫“交肠”病。突然气机在中焦紊乱，多属于急暴之病。此症却是久病，大概是由于瘀血内阻，新血不生，肠胃之气无所依附而失去正常功能，所以吃进去的水谷，都从前阴排出。所谓的幽门，不能主持分别清浊的功能，反而开辟为坦途，这与交肠证看似相似实则不同。此时治疗，主要以化瘀润肠为主，必须让大肠的旧路重新通畅，才能拨乱反正。
旋覆花、猩绛（犀角染色的丝织品，代指犀角或清热凉血药）、葱管、当归须、何首乌、柏子仁、荠菜花。
另取旧纱帽一顶，烧成灰，每次服用一钱五分，用酒送下。
原注：纱帽——由头发和漆胶粘合而成，这里也是取其通瘀的意思吧。
诒按：论证用药，都有巧妙的构思，只是不知道效果如何？记得喻嘉言《寓意草》中记载的姜宜人交肠病，与此相似；只是病因有虚实之分罢了，学者应当参考对照。
邓评：所谓病有千变万化，用药也有千变万化。像这样的病，怎么能拘泥于古法治疗交肠病而死守五苓散一方呢？
这是瘀血阻滞肠道干燥，气机失去依附而逼迫趋向于前阴，所以粪便也从前面排出。
《爱庐》中只用明矾一味药，用腐衣五层包裹，盐汤送下，每天三次，三天共九次，取其引导痰浊、涩肠止泻的作用。
孙评：后文《爱庐》的案例是突然得的病，才是真正的交肠病，应该与喻氏书中记载的三个案例一同参考。
用发漆胶粘成的帽子，现在看不到了。只有棕漆粘成的，或许就是这种吧。
虫 病 门
阳络曾经受伤，阴气素来虚弱，更有湿热郁结在营分，日久生虫，扰乱上中下三焦，以致咳嗽、喉痹，厌恶食物气味，坐卧不安，肛门部不适，舌质深红，苔黄浊。这就是张仲景所说的狐惑病。拖延久了不愈，就会进入虚劳怯证的途径。
川黄连三分、犀角二分、乌梅五分、人中白一钱、百部一钱、丹皮一钱半、甘草三分。
邓评：《金匮要略》中狐惑病有“蚀于上部则声嗄，蚀于下部则咽干，与蚀于肛者”的不同。此证则是上中下三焦被扰乱，所以症状如此，方子也是从《金匮要略》扩充而来。
胃脘腹部疼痛，满腹感觉苦热，初起时吃东西就痛，后来不吃东西也痛。这是肝胃不和，湿热生虫的表现。
邓评：吃东西就痛，固然是蛔虫扰动的一种症状；但有食积的人也能这样；肝气横逆郁结在中焦的人也能这样。
复诊：服用前方后，胃脘腹部的疼痛和苦热感，时作时止，停止时右胁下一定有一块东西攻冲筑痛。这是蛔虫尚未安定的表现。
治按：蛔虫未安定的，似乎应该仍用乌梅丸。此症是因为右胁攻冲筑痛，所以用金铃子散来疏泄肝气。
邓评：服用前方无效，而胁下一块攻冲筑痛，难道不是气机不平吗？
湿热挟带风邪，生虫作痒，有类似攻注的形状，无处不到。这是难治的病证。獭肝一钱，磨开水冲服。邓评：正因为作痒，所以说是有虫。
复诊：攻注时有形状，不攻注时无痕迹。这是湿热风虫踞留在痰中所致。
推气散（枳壳、桂心、姜黄、甘草）。加入白芥子、橘红、羌活、獭肝、竹油。
另医通沉香化气丸（大黄、黄芩、沉香、六曲、辰砂、术、竹油），姜汁送服。
诒按：獭肝治虫的方法本于《千金方》。只是案中所说的攻注有形，无处不到，究竟是在肢体还是在腹里，都没有叙述清楚，无从推测。
邓评：此方重在调理湿热风痰，或许是怀疑它不是虫造成的吧。至于说湿热风虫踞留在痰中，也是牵强附会的谈论。
孙评：汤剂和丸药都与虫证不太贴切。
人为什么流口水？回答说：胃中有热则虫动，虫动则胃缓，胃缓则廉泉穴开，所以流口水。黄连丸（黄连、吴茱萸、木香、诃子、龙骨）合乌梅丸。诒按：方案都高简稳实。邓评：用一段经文作为医案，自然很高古。既然是胃热虫动，又何必取诃子、龙骨来收敛口水呢？
评选环溪草堂医案三卷
环溪草堂医案三卷，是梁溪王旭皋先生所著。先生名泰林，字旭皋，世代是无锡人。嘉庆、道光年间，有一位以外科医生闻名江浙的人，叫高锦亭先生，著有《外科心得集》、《景岳方歌括》等书流行于世，他就是旭皋先生的舅舅。高先生去世后，先生继承了他的事业。起初他以外科医生行医，后来求治的人越来越多，逐渐涉及到内科，没有不随手奏效的，于是便专门从事内科。门下的学生每年有十多人学习医术。先生读书，上自黄帝内经、难经，下到清朝各位医家，无不精心贯通。对于古书则研究训诂，对于后人的书则必分辨疑似之处。所著的《西溪书屋夜话录》、《医方歌括串解》及《环溪草堂医案》等书，均未刊印。他的医案由门生弟子随时抄录，未经过筛选取舍，不免繁杂重复。我所见到的，大概有五六本，详略各异。因此嘱咐门下弟子删去繁杂混乱的部分，重新抄录编辑。最后得到王家桥顾莲卿的本子，是先生晚年的作品。又得到方耕霞新刊的本子，病例非常繁富，颇有值得取法的方案而其他本子所未记载的，一并补录，精简其精华，分为三卷。间或有未尽之意，随即加上按语以阐明它，阅读一年才完成。先生居住在无锡城，离我家不到百里，我二十岁时还见过他。我们乡里有疑难病症，没有不向先生求治的，先生必定深思熟虑，开出方子给他，后来或有效或无效，有的因为无力再去的，先生必定打听清楚，让他再来诊治，以完成治疗。所以他保存的方案，无不光明坚定、响亮切实，没有模糊牵强的谈论。这比起近代那些专门以灵变取巧的人，简直有天壤之别。先生博览群书，所用诸法，如治疗小儿喘嗽的药枣，是从葛可久的白凤丹化出；治疗上热下寒的八味丸，用紫雪为衣，是从喻嘉言的外廓理论悟出。像这类情况，不胜枚举，都是因古法而变化出来的。那些胸无古书的人，每读到这里往往难以领会。我在此等处，均一一指出，学者如果能借此得到读书用古的方法，那么就不辜负先生的苦心啊。光绪二十六年重阳节江阴柳宝诒谨识
评选环溪草堂医案上卷 无锡王泰林旭高著
内伤杂病门
患病将近一年，肝气横逆而不平，中气久虚而不振。因为肝气逆，所以胸脘阻塞且攻冲作痛；因为中气虚，所以营卫不和而寒热往来。凡是大便溏薄、饮食减少、右脉细、左脉弦，就是这些证候；四君子汤合逍遥散，加左金丸，就是治疗方法。
党参、冬术（白术）、陈皮、茯苓、归身、神曲、白芍、柴胡（盐水炒）、香附（盐水炒）、川连（吴茱萸炒）、谷芽、玫瑰花。
邓评：论证清晰明确，用药有条不紊。只是既有寒热又有便溏，脉象细弦的，总宜兼用温理脾胃营卫的药物，如桂枝、煨姜、大枣之类；肝气逆攻冲，金铃子也在需用之列。方中的川连或许可以删去。
复诊：阳虚则恶寒，阴虚则发热，脾虚则便溏而乏力，肝木旺则脘痞而气塞。前方补中泄木，肝气已平，合用以盖火生土、气血双补之法。
党参、冬术、肉苁蓉、鹿角霜、杞子、木香、菟丝子、归身、白芍、陈皮。
茯苓、杜仲、砂仁、玫瑰花。诒按：肝气平后，继续培补，是一定的层次。只是既有寒热见证，似乎可参用桂枝建中的意思来调和它。
三焦相火，挟带肝阳上升，每天清晨，气就从脐左侧向上冲，心胸痞塞，自觉胸中热，舌尖辣，面色红，过了中午气渐下降，到晚上就安静，而火降则下面可能遗泄。这都是无形之火为患。推究其根源，由于阴虚；如今相火妄行，蒸炼胃液成痰，所以吐出的痰粘腻灰黑，而在咽喉胃管之间，常觉得不流利。治法应当清相火、导虚阳，使其下归窟宅，更佐以化痰降逆。病来已久，难期速效。
黄柏（盐水炒）一钱二分、桂心三分、砂仁（炒）三分、蛤壳一两、甘草三分、知母（盐水炒）一钱二分、川连（盐水炒）四分、茯苓三钱、玄精石三钱，长流水煎。
诒按：此方取交通心肾、封髓之法，用意极为精到。只是病因是肝肾不摄，虚阳浮逆，建议再加牡蛎、龟板以摄纳下元，旋覆花、竹茹以清上焦，似乎对病情更为周全。
邓评：推论病源，不外乎是这样，制方也极精切不泛泛。脉虽未见，但关尺脉想必弦大且数。
孙评：牡蛎似乎必须加，白芍也是要药。黄柏、砂仁名为封髓，川连、肉桂多为交济，人参、枳实名补泻法，川连、干姜名泻心法。这些都是法的巧妙之处。
痰的标在肺胃，痰的本在脾肾，肾虚则水泛，脾虚则湿聚，这两者都是酿痰的根本。经云：脾恶湿，肾恶燥。脾肾两虚，治法应当滋燥兼行；而痰恋肺胃，又宜标本同治。
诒按：案语斟酌病机，切实不泛泛，用药也丝丝入扣。用黑地黄法以两补脾肾，合二陈汤以和胃，紫菀、川贝以利肺。药品不多，而层层都到位，没有简炼的工夫，不能做到这样。
邓评：治一个病而标本虚实都照顾到，且没有浮泛牵拘的弊病。
孙评：川贝换成杏仁怎么样？
凡是脏腑受邪，只有虚的时候才接受，实的时候不接受；只有实者能传变，虚者不能传变。张仲景说：肝病实脾，是治疗肝邪盛的方法；内经说：肝病缓中，是治疗肝体虚的方法。此证肝气有余，肝血不足，治法宜兼顾两者为得。
归身、白芍、沙苑、杞子、冬术、茯神、青皮、陈皮、香附、金铃子、砂仁。
诒按：议论确凿，不是胸中有古书的人不能说得出；方子也精到。方中归、芍、杞、苑，是用来养肝血的；青、陈、香、铃，是用来疏肝气的。药品看似平常，用意却已周到。
邓评：这段议论，引用不够恰当。方子尚平稳，只是香燥泄气的药太多。凡肝体既亏，肝用自旺，滋润柔肝，就是补肝体即所以平肝用。
孙评：开口即从至情实理立论。
肾水不足，君火上炎，相火下炽。心中如火烧，舌头光亮如柿子，性功能易兴奋，阴精易泄。拟清君火以制约相火，益肾阴以制约肝阳。所担心的是酷热炎蒸，恐怕药力无权，将亢阳为害，而加重病情。
另大黄三钱，研末，将一个鸡蛋破头，纳入大黄三分，蒸熟，每日服一个。
邓评：此方是为阳亢而导致阴亏的情况设立的。只是阿胶似乎宜换成龟板更好。
这种丹方也足以取法。
孙评：制相火、益肾阴，须借助咸寒，前人明确教导；但宜选择介类药物以潜阳，才算贴切。方中加入煅牡蛎怎么样？
复诊：投用苦咸寒坚阴降火的药物，以制约亢阳，心中的灼热感，与舌色之光红，都减少了三分之一。然而上午身体热如火燎的症状未退；幸好进食颇增，苦寒药可以继续进服。再观察转机为妙。
川黄连、阿胶、生地、玄精石、黄芩、甘草、玄参、蛤壳、鸡子黄。
邓评：上午身热，就是偏于阳盛的征象。如果是由阴虚引起的，那么热一定发作在夜晚。
三诊：舌干红，知道饥饿且善于进食。水亏阳亢，土燥于中，咸苦坚阴的药剂，虽然削弱了燔亢之势，但未能尽除其焰。时值炎热夏季，湿热与相火蒸腾。拟再次加入清中固下祛湿的方法，仍不出咸苦的范畴。
洋参、石膏、知母、甘草、麦冬、川连、阿胶、生地、蛤壳、黄柏、猪胆汁丸，每早晨服三钱。
诒按：君相交燔，肾阴被灼，所谓一水不能胜二火，此证就是如此。仅给予壮水，犹难胜任，必须得苦以泄之，咸以制之，而火乃退；更得苦以坚之，咸以滋之，而阴乃复。
孙评：苦泄是大黄、川连，苦坚是黄芩、黄柏，咸制是玄精石、玄参，咸滋是阿胶、牡蛎。
营阴虚，则气火易升；肝木横逆，则脾土受侮。腹满头晕，是肝脾的病；耳鸣喉燥，是虚火的过失。阴虚生内热，肾虚故腰痛。拟补阴潜阳、扶土抑木法。
生地（砂仁炒）四两、茯苓（烘）三两、山药（炒）三两、萸肉（酒炒）三两、丹皮（酒炒）二两、泽泻（炒）三两、龟板（炙）三两、沙苑（盐水炒）三两、党参（炒）三两、杜仲（盐水炒）三两、归身（酒炒）三两、白芍（炒）二两、石决明（煅）四两。
以上药为末，炼蜜打和为丸，晒干，泛上后药：
香附三两（分三份：一份盐水炒，一份醋炒，一份蜜水炒）、陈皮（盐水炒）七钱、沉香三钱、神曲一两。
以上药为末，用橘叶汤泛上前丸为衣。
诒按：以补药为丸，而以和气之药末，泛上为衣，与喻嘉言药用外廓的意思相合。虽然没有精义可取，但心思灵巧，可备一格。
邓评：药用外廓，固然是巧法。但证见腹满，阴柔之品，终究担心碍脾。我拟一方在下面，以备同学采择：
川连、益智、广皮、茯苓、制香附、白蒺藜、归身、白芍、首乌、木瓜。
孙评：喻嘉言的外廓之法，用姜附猛烈，用参苓为衣，过胃入下，始露威灵，其法本巧；如今则以呆滞为心，而以流动为衣，仿其意而变通之，真是善于读书的人。
夜凉昼热，热在上午，这是东垣所说的劳倦伤脾的证候。上午热，属气虚，用补中益气汤，补气升提。
邓评：热在上午，责之于阳气，这是不易之理。只是虚而发热，应当或有形寒见证。此病本来尚未咳嗽，若咳嗽则升麻、柴胡不宜用。
寒邪伤阳，也每每多有上午寒热。
泄泻是脾病，呕吐是胃病，脾胃属土，居中而司升降。脾宜升，不升则泄；胃宜降，不降则呕；土衰则木横，木横而土益衰。高龄之人遇到这种情况，很担心土败木贼。古人治肝，当先实脾。何况此刻土弱，尤当先补其中，稍佐平肝即可。
Deng's Commentary: Since swelling has already occurred, using thick and cloying substances like Ejiao (Donkey-hide gelatin) and Shudi (Prepared Rehmannia Root) is only suitable for cases where blood fails to control qi. If it is as stated in the text, "qi failing to hold blood," ultimately, emphasis should be placed on medications that regulate the qi aspect.
Red and white dysentery transforming into hematochezia (blood in stool), with fresh blood color initially, later turning purplish-black, or accompanied by bloody fluid, lingering without resolution. This indicates summer-heat and dampness penetrating deeply into the Ying (Nutritive) level. Due to qi deficiency lacking the power to transform, the Qi mechanism descends but does not ascend.
Chuzhi Wan contains Huanglian (Coptis Rhizome), Ejiao (Donkey-hide Gelatin), Ganjiang (Dried Ginger), and Danggui (Angelica Sinensis). Add Guangmuxiang (Vetiver Root), Dangshen (Codonopsis Root), Gancao (Licorice Root), Fulonggan (Stove Earth), and Qicaihua (Shepherd's Purse Flower).
Yi's Note: In this condition, pathogenic factors remain in the Blood level; it is appropriate to incorporate herbs that harmonize the blood.
Deng's Commentary: The prescription is quite excellent. I propose adding Diyutanz (Smoked Sanguisorba Root) and Wumeitan (Charred Mume Fruit) to harmonize the Ying and Blood.
Second Visit: Although bleeding has gradually stopped, the Qi mechanism still descends but does not ascend.
Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) with Chenpi (Tangerine Peel) removed, combined with Chuzhi Wan, plus ChiShao (Red Peony Root), and Fulonggan (Stove Earth).
Deng's Commentary: With spleen Qi sinking for a long time, how can it suddenly recover its ascending and vigorous function?
Hemorrhoids, dysentery, and Zangdu (Visceral Toxin) are all caused by damp-heat in the Lower Jiao.
Di Yu San (Sanguisorba Powder) combined with San Qi San (Three Wonders Powder: Huangqi (Astragalus Root), Fangfeng (Saposhnikovia Root), Zhike (Bitter Orange)). Add Guangmuxiang (Vetiver Root).
Yi's Note: The prescription is precise and thorough. I suggest adding Jin Yin Hua (Honeysuckle Flower) and Danpi (Moutan Bark).
Deng's Commentary: There is a single herb formula: wrapping seven seeds of Kushen (Sophora Root) in Guiyuanrou (Longan Aril). Taking it several times leads to recovery. This matches the pathology well and can serve as an aid to decoction therapy.
Excretion of urine and feces through reversed orifices is named "Jiao Chang" (Intertwined Intestines). Sudden chaos of Qi in the middle often belongs to acute diseases. This case, however, is a chronic disease, likely due to internal obstruction by blood stasis, failure of new blood generation, and loss of attachment for the Qi of the stomach and intestines, causing ingested food and water to exit from the anterior yin (urethra/vagina). The so-called "You Men" (Pylorus) fails to separate the clear from the turbid, instead opening a smooth path. This resembles Jiao Chang but is fundamentally different. Treatment at this stage should focus on resolving stasis and moistening the intestines. Only when the old pathway of the large intestine is restored can order be re-established.
Xuan Fu Hua (Inula Flower), Xing Jiang (Rhino Horn-dyed silk, representing Xi Jiao/Rhino Horn substitute for cooling blood), Cong Guan (Scallion Tube), Danggui Xu (Angelica Sinensis Tail), Shouwu (Polygonum Multiflorum Root), Baizi Ren (Biota Seed), Qicaihua (Shepherd's Purse Flower).
Separately, take one old gauze cap, burn to ash, take 1.5 qian each time, washed down with wine.
Original Note: Gauze cap -- made of hair glued with lacquer; perhaps here it also intends to promote blood circulation and resolve stasis.
Yi's Note: The argumentation and medication show clever thinking, though it is unknown if it was effective. I recall Jiang Yi Ren's case of Jiao Chang recorded in Yu Xichang's *Yuyi Cao*, which is similar; the difference lies in the excess or deficiency of the pathogen. Scholars should consult both.
Deng's Commentary: As the saying goes, diseases change in thousands of ways, and so do treatments. For such a case, how can one rigidly apply ancient methods for Jiao Chang and stick solely to Wu Ling San (Five-Ingredient Poria Decoction)?
This is blood stasis obstructing the intestines causing dryness, with Qi losing its attachment and being forced toward the anterior yin, hence feces also exit from there.
*Ai Lu* uses only Ming Fan (Alum), wrapped in five layers of rotten cloth, taken with salt water, three times a day, nine doses over three days, aiming to guide phlegm and astringe the large intestine.
Sun's Commentary: The later case in *Ai Lu* was acquired suddenly, representing true Jiao Chang, and should be referenced together with the three cases in Yu Shi's writings.
Caps made of hair glued with lacquer are rarely seen nowadays. Perhaps those made of palm fiber glued with lacquer are the same.
**Worm Disease Section**
The Yang collaterals were previously injured, and Yin Qi has always been deficient. Furthermore, damp-heat stagnates in the Ying level. Over time, worms generate and disturb the Upper, Middle, and Lower Jiao, resulting in cough, throat bi (obstruction), aversion to food odors, restlessness, anal discomfort, deep red tongue body, and yellow turbid coating. This is what Zhong Jing called Hu Huo Bing (Fox-Sore Disease). If prolonged without cure, it enters the realm of Lao Que (Consumptive Disease).
Chuan Lian (Coptis Rhizome) 3 fen, Xi Jiao (Rhinoceros Horn) 2 fen, Wu Mei (Mume Fruit) 5 fen, Renzhong Bai (Human Urine Sediment) 1 qian, Bubu (Stemona Root) 1 qian, Danpi (Moutan Bark) 1.5 qian, Gancao (Licorice Root) 3 fen.
Yi's Note: Reading the section on Hu Huo Bing in *Jin Gui Yao Lue* clarifies the origin and details of this condition.
Deng's Commentary: In *Jin Gui Yao Lue*, Hu Huo Bing presents differently depending on the site: erosion in the upper part causes hoarseness, erosion in the lower part causes dry throat, and erosion in the anus differs. Here, the Upper, Middle, and Lower Jiao are disturbed, hence the symptoms are as described. The prescription is expanded from *Jin Gui Yao Lue*.
Epigastric and abdominal pain, full abdomen feeling bitter heat. Initially, eating causes pain; later, pain occurs even without eating. This is Liver-Stomach disharmony and damp-heat generating worms.
Wumei Wan (Mume Pill) added with Qingpi (Green Tangerine Peel), Baishao (White Peony Root), and Jinlingzi (Black Walnut Juglans Regia Fruit).
Yi's Note: Pain upon eating initially; could there be concomitant food retention?
Deng's Commentary: Pain upon eating is indeed a symptom of moving roundworms; however, food retention can also cause this; Liver Qi stagnating horizontally in the Middle Jiao can also cause this.
Second Visit: After taking the previous prescription, the epigastric/abdominal pain and bitter heat come and go. When they stop, there is always a mass attacking and beating under the right hypochondrium. This indicates the roundworms are not yet settled.
Xuan Fu Hua Tang (Inula Flower Decoction) combined with Jinlingzi San (Black Walnut Powder), added with Xingren (Apricot Seed), Leiwan (Oryzoborus Beetle), and Feizi (Teak Seed).
Zhi's Note: For unsettled roundworms, one might consider continuing with Wumei Wan. However, since there is attacking pain under the right hypochondrium, Jinlingzi San is used to drain the Liver.
Deng's Commentary: If the previous prescription failed, and there is attacking pain under the hypochondrium, is this not due to uneven Qi movement?
Master Liu's commentary hits the nail on the head. Otherwise, why use Xuan Fu Hua Tang to unblock the Liver collaterals?
Sun's Commentary: Xuan Fu Hua Tang is used for the right hypochondrium; Jinlingzi San specializes in the left hypochondrium.
Damp-heat carrying wind generates worms causing itching, resembling migratory attacks, reaching everywhere. This is a difficult-to-treat condition. Ta Gan (Hyena Liver) 1 qian, ground and mixed with water to take. Deng's Commentary: Because there is itching, we say there are worms.
Second Visit: Migratory attacks have form, but leave no trace when not attacking. This is caused by damp-heat, wind, and worms occupying Phlegm.
Tui Qi San (Push Away Qi Powder: Zhike (Bitter Orange), Guixin (Cinnamon Heart), Jianghuang (Turmeric Rhizome), Gancao (Licorice Root)). Add Baijiezi (White Mustard Seed), Juhong (Aged Tangerine Peel), Qianghuo (Notopterygium Rhizome), Ta Gan (Hyena Liver), Zhu You (Bamboo Oil).
Separately, Yitong Chenxiang Huaqi Wan (Immortal Pass Agarwood Digestion Pill: Dahuang (Rhubarb Root), Huangqin (Scutellaria Root), Chenxiang (Agarwood), Liuqu (Medicated Leaven), Chensha (Cinnabar), Zhu (Atractylodes), Zhu You (Bamboo Oil)), taken with Ginger Juice.
Yi's Note: Using Hyena Liver to treat worms originates from *Qian Jin Fang*. However, the case mentions migratory attacks with form, reaching everywhere, but does not specify whether it is in the limbs or abdomen, making speculation impossible.
Deng's Commentary: This prescription focuses on regulating damp-heat, wind, and phlegm, perhaps suspecting it is not caused by worms. Saying damp-heat, wind, and worms occupy phlegm is also speculative talk.
Sun's Commentary: Both the decoction and pill are not quite fitting for worm diseases.
Why does saliva flow? Answer: Heat in the Stomach causes worms to move; moving worms cause the Stomach to relax; relaxed Stomach opens the Lianquan acupoint, hence saliva flows. Huanglian Wan (Coptis Pill: Huanglian (Coptis Rhizome), Yuzhu (Cornus Fruit - *Note: Text says Yu, likely Wuyu/Euodia based on context of Wen Dan Tang variations or specific pairing, but literal is Yu*), Muxiang (Aucklandia Root), Hezi (Chebula Fruit), Longgu (Fossilized Bone)) combined with Wumei Wan (Mume Pill). Yi's Note: The plans are high, simple, stable, and solid. Deng's Commentary: Using a scripture passage as a medical case is naturally archaic and noble. Since it is Stomach heat causing worm movement, why use Hezi (Chebula Fruit) and Longgu (Fossilized Bone) to astringe saliva?
**Selected Cases of Huanxi Caotang, Three Volumes**
*Selected Cases of Huanxi Caotang, Three Volumes*, authored by Mr. Wang Xugao of Liangxi. His name was Tailin, courtesy name Xugao, from a family originally in Wuxi. During the Jiaqing and Daoguang reigns, Mr. Gao Jinting was famous as a surgeon in Jiangsu and Zhejiang, authoring books like *Waike Xin De Ji* and *Jingyue Fangge Kua*, which were circulated; he was Mr. Xugao's maternal uncle. After Mr. Gao passed away, Mr. Wang inherited his profession. Initially practicing surgery, as patients increased, he gradually moved to Internal Medicine, achieving success in every case, and thus specialized in Internal Medicine. Dozens of students studied under him annually. Mr. Wang studied extensively, from the Yellow Emperor's classics to contemporary physicians, integrating them carefully. For ancient texts, he researched philology; for later works, he distinguished between authentic and doubtful ones. His works, including *Xixi Shuwu Yehua Lu*, *Yifang Ge Kuazhuanjie*, and *Huanxi Caotang Yi'an*, were not printed. His medical cases were copied by disciples as they occurred, without selection, leading to redundancy. I saw about five or six versions with varying detail. I instructed disciples to delete redundancies and recompile. Finally, I obtained the version from Mr. Lianqing of Wangjiaqiao, from his late years, and the newly published version by Mr. Gengxia, which was rich in cases with unique entries not found elsewhere. I supplemented these, refined the essence, and divided them into three volumes. Where meanings were incomplete, I added notes. It took one year to complete. Mr. Wang lived in Wuxi, less than fifty li from my home. I met him when I was twenty. In our hometown, no difficult cases were sought elsewhere; Mr. Wang would think deeply, prescribe, and follow up, ensuring treatment completion regardless of outcome or financial status. Thus, his records are clear, firm, and resonant, without vague speculation. Compared to modern practitioners relying on clever tricks, his approach is vastly superior. Mr. Wang read widely; his methods, such as using dates for pediatric asthma derived from Ge Kejiu's *Baifeng Dan*, or using Bazhen Wan coated with Zixue for upper heat/lower cold inspired by Yu Xichang's outer-coat theory, are numerous examples of adapting ancient methods. Those without knowledge of classics find this hard to grasp. I point these out so scholars may learn how to read and apply ancient methods, honoring Mr. Wang's painstaking effort. Written respectfully by Liu Baozhi of Jiangyin on the Double Ninth Day of the 26th Year of Guangxu.
**Selected Cases of Huanxi Caotang, Upper Volume, by Wang Tailin (Xugao) of Wuxi**
**Internal Injury and Miscellaneous Diseases Section**
Ill for nearly a year, Liver Qi is horizontal and unbalanced; Middle Qi has been deficient and weak for a long time. Due to Liver rebellion, there is chest/epigastric blockage and attacking pain; due to Middle deficiency, Ying and Wei are disharmonious causing alternating chills and fever. Symptoms include loose stools, poor appetite, thin Right pulse, and wiry Left pulse. Treatment is Sizijunzi Tang (Four Gentlemen Decoction) combined with Xiaoyao San (Free and Easy Wanderer Powder), plus Zuojin Wan (Left Metal Pill).
Dangshen (Codonopsis Root), Dongzhu (Atractylodes Macrocephala Rhizome), Chenpi (Tangerine Peel), Fuling (Poria), Guishen (Angelica Sinensis Body), Shenqu (Medicated Leaven), Baishao (White Peony Root), Chaihu (Bupleurum Root, stir-fried with salt water), Xiangfu (Cyperus Rhizome, stir-fried with salt water), Chuanlian (Coptis Rhizome, stir-fried with Evodia), Guya (Sprouted Grain), Meiguihua (Rose Bud).
Yi's Note: The case analysis is crisp, and the prescription is appropriate. I suggest adding Chenxiang (Agarwood) and Yujin (Curcuma Longa Rhizome).
Deng's Commentary: The argument is clear, and medication is orderly. However, with chills/fever and loose stools, and thin/wiry pulses, one should generally combine warming agents for Spleen/Stomach Ying/Wei, such as Guizhi (Cinnamon Twig), Weijiang (Ginger), and Dazao (Jujube). For Liver attacking pain, Jinlingzi (Black Walnut) is also needed. Chuanlian in the formula might be deleted.
Second Visit: Yang deficiency causes aversion to cold; Yin deficiency causes fever; Spleen deficiency causes loose stools and fatigue; Wood excess causes epigastric fullness and Qi blockage. The previous prescription tonified the center and drained Wood; Liver Qi has now calmed. Combine with Fire covering Earth and dual tonification of Qi and Blood.
Dangshen (Codonopsis Root), Dongzhu (Atractylodes Macrocephala Rhizome), Rongrong (Cistanche Stem), Lujiaoshuang (Deer Antler Frost), Qizi (Goji Berry), Muxiang (Aucklandia Root), Tusizi (Cuscuta Seed), Guishen (Angelica Sinensis Body), Baishao (White Peony Root), Chenpi (Tangerine Peel).
Fuling (Poria), Duzhong (Eucommia Bark), Sharen (Amomum Fruit), Meiguihua (Rose Bud). Yi's Note: After calming Liver Qi, continuing with tonification follows a definite sequence. However, given chills/fever symptoms, one might consider incorporating the intent of Guizhi Jianzhong Tang (Cinnamon Twig Decocted Middle-Jiao Supplementing Decoction) to harmonize.
Deng's Commentary: Seeing this visit shows you understand my mind.
Sanjiao Ministerial Fire, carrying Liver Yang upward, causes Qi to rush from the left of the navel upward every morning, chest/epigastric stuffiness, sensation of heat in the chest, spicy tip of the tongue, red face. After noon, Qi descends; at night, peace returns, but fire descending may cause seminal emission. These are disorders of formless fire. Tracing the origin, it stems from Yin deficiency; now Ministerial Fire acts recklessly, steaming Stomach fluids into Phlegm, causing sticky gray-black sputum and a feeling of obstruction in the throat and esophagus. Method: Clear Ministerial Fire, guide deficient Yang back to its residence, assist with resolving Phlegm and directing rebellious Qi downward. Chronic illness, unlikely to respond quickly.
Huangbai (Phellodendron Bark, stir-fried with salt water) 1.2 qian, Guixin (Cinnamon Heart) 3 fen, Sharen (Amomum Fruit, stir-fried) 3 fen, Haqiao (Clam Shell) 1 liang, Gancao (Licorice Root) 3 fen, Zhimu (Anemarrhena Rhizome, stir-fried with salt water) 1.2 qian, Chuanlian (Coptis Rhizome, stir-fried with salt water) 4 fen, Fuling (Poria) 3 qian, Xuanjingshi (Crystal) 3 qian, decocted with flowing water.
Yi's Note: This prescription uses the method of communicating Heart and Kidney and sealing the Marrow, with very precise intent. However, since the cause is Liver/Kidney failing to secure, and deficient Yang floating/rebellious, I suggest adding Muli (Oyster Shell) and Guiban (Turtle Shell) to secure the lower, Xuanfu (Inula Flower) and Zhuru (Bamboo Shavings) to clear the upper, which seems more comprehensive for the condition.
Deng's Commentary: The deduction of the disease source is accurate, and the formulation is precise and not superficial. Although the pulse was not felt, the Guan and Chi positions must surely be wiry, large, and rapid.
Sun's Commentary: Muli seems essential; Baishao is also a key herb. Huangbai and Sharen are named Fengsui (Sealing Marrow); Chuanlian and Rougui (Cinnamon Bark) facilitate communication; Renshen and Zhishi represent tonifying and draining methods; Chuanlian and Ganjiang represent Xiexin (Draining Heart) method. These are all clever applications of methods.
The branch of Phlegm is in the Lung and Stomach; the root is in the Spleen and Kidney. Kidney deficiency causes water flooding; Spleen deficiency causes dampness gathering; both are roots of Phlegm production. The Classics state: The Spleen dislikes dampness; the Kidney dislikes dryness. With Spleen and Kidney dual deficiency, the method should moisten and dry simultaneously; while Phlegm lingers in Lung and Stomach, treating both root and branch is appropriate.
Shudi (Prepared Rehmannia Root), Maozhu (Atractylodes Lancea Rhizome, stir-fried with sesame), Chenpi (Tangerine Peel), Chuanbei (Fritillaria Bulb), Fuling (Poria), Banxia (Pinellia Tuber), Ziwan (Aster Root).
Yi's Note: The case analysis weighs the pathology practically and precisely; the medication is meticulous. Using Hei Di Huang Fa (Black Earth-Kidney Tonification Method) to tonify Spleen and Kidney, combined with Erchen Tang (Two-Aged Phlegm Resolving Decoction) to harmonize the Stomach, and Ziwan/Beimu to benefit the Lung. Few herbs, yet every layer is addressed; this requires refined skill.
Deng's Commentary: Treating one disease while addressing root/branch and excess/deficiency, without superficiality or rigidity.
Sun's Commentary: How about replacing Chuanbei with Xingren (Apricot Seed)?
For viscera pathogens, only deficiency accepts them; excess does not accept. Only excess transmits; deficiency does not transmit. Zhong Jing said: Treat Liver disease by strengthening the Spleen, addressing excessive Liver Pathogen; Nei Jing said: Treat Liver disease by soothing the center, addressing deficient Liver Substance. This case has excess Liver Qi and deficient Liver Blood; the method should attend to both.
Guishen (Angelica Sinensis Body), Baishao (White Peony Root), Shayuan (Astragalus Complanatus Seed), Qizi (Goji Berry), Dongzhu (Atractylodes Macrocephala Rhizome), Fushen (Poria with Hostwood), Qingpi (Green Tangerine Peel), Chenpi (Tangerine Peel), Xiangfu (Cyperus Rhizome), Jinlingzi (Black Walnut Juglans Regia Fruit), Sharen (Amomum Fruit).
Yi's Note: The discussion is conclusive; only one versed in ancient classics could speak thus. The prescription is also refined. Gu, Shao, Qi, Yuan nourish Liver Blood; Qing, Chen, Xiang, Ling soothe Liver Qi. Herbs seem ordinary, but intent is thorough.
Deng's Commentary: This discussion cites references inadequately. The prescription is stable, but too many aromatic/drying Qi-draining herbs. When Liver Substance is depleted, Liver Function becomes hyperactive; moistening and softening the Liver is how one tonifies Liver Substance and thereby calms Liver Function.
Sun's Commentary: Opening with profound truth and logic.
Kidney Water is insufficient; Ministerial Fire flares upward; Ministerial Fire blazes downward. Heart feels like burning, tongue is smooth like a persimmon, sexual arousal is easy, Yin essence leaks easily. Plan: Clear Ministerial Fire to control Ministerial Fire, tonify Kidney Yin to control Liver Yang. Worried that intense heat may render medicine ineffective, allowing Hyperactive Yang to cause harm and worsen the condition.
Chuanlian (Coptis Rhizome, stir-fried with salt water), Huangqin (Scutellaria Root), Huangbai (Phellodendron Bark), Ejiao (Donkey-hide Gelatin), Shengdi (Rehmannia Root), Gancao (Licorice Root), Jizihuang (Egg Yolk).
Separately, Dahuang (Rhubarb Root) 3 qian, ground to powder. Take one egg, break the top, insert 3 fen of Dahuang powder, steam until cooked, take one daily.
Deng's Commentary: This prescription is set for Yin deficiency caused by Yang hyperactivity. However, Ejiao might be better replaced with Guiban (Turtle Shell).
This kind of pill formula is also worthy of emulation.
Sun's Commentary: Controlling Ministerial Fire and tonifying Kidney Yin requires salty-cold properties, as predecessors taught; but selecting shellfish-type minerals to subdue Yang is more fitting. How about adding Du Muli (Calcined Oyster Shell) to the formula?
Second Visit: Administering bitter-salty-cold herbs to solidify Yin and descend fire to control hyperactive Yang reduced heart burning and tongue redness by one-third. However, morning body heat like burning remains fortunately, appetite has increased significantly, allowing bitter-cold herbs to continue. Hope for a turning point.
Chuanlianhuan (Coptis Rhizome), Ejiao (Donkey-hide Gelatin), Shengdi (Rehmannia Root), Xuanjingshi (Crystal), Huangqin (Scutellaria Root), Gancao (Licorice Root), Xuanshen (Scrophularia Root), Haqiao (Clam Shell), Jizihuang (Egg Yolk).
Deng's Commentary: Morning body heat is a sign of Yang excess. If caused by Yin deficiency, heat would occur at night.
Third Visit: Tongue dry and red, hungry and able to eat. Water deficiency and Yang hyperactivity, Earth dry in the center. Salty-bitter herbs to solidify Yin have weakened the blazing/hyperactive trend but not extinguished the flame. It is hot summer season; damp-heat and Ministerial Fire steam together. Plan to again enter clearing the center, securing the lower, and removing dampness methods, still within the salty-bitter category.
Yangshen (American Ginseng), Shigao (Gypsum), Zhimu (Anemarrhena Rhizome), Gancao (Licorice Root), Maidong (Ophiopogon Tuber), Chuanlian (Coptis Rhizome), Ejiao (Donkey-hide Gelatin), Shengdi (Rehmannia Root), Haqiao (Clam Shell), Huangbai (Phellodendron Bark), Zhu Danzhi (Pig Gallbladder Bile Pills), take 3 qian every morning.
Yi's Note: Ministerial and Sovereign fires scorch each other, Kidney Yin is scorched, known as "one water cannot overcome two fires," which is this case. Merely tonifying Water is insufficient; one must use bitter to drain, salty to control, so fire retreats; further use bitter to solidify, salty to nourish, so Yin recovers.
Deng's Commentary: This case often involves damp-heat, not just seasonal influence.
Sun's Commentary: Bitter-draining refers to Dahuang and Chuanlian; bitter-solidifying refers to Huangqin and Huangbai; salty-controlling refers to Xuanjingshi and Xuanshen; salty-nourishing refers to Ejiao and Muli.
Ying Blood deficiency allows Qi-Fire to rise easily; Liver Wood horizontal invades Spleen Earth. Abdominal fullness and dizziness are Liver/Spleen diseases; tinnitus and throat dryness are faults of deficient fire. Yin deficiency generates internal heat; Kidney deficiency causes lower back pain. Plan: Tonify Yin, subdue Yang, support Earth, suppress Wood.
Shengdi (Rehmannia Root, stir-fried with Sharen) 4 liang, Fuling (Poria, baked) 3 liang, Shanyao (Dioscorea Rhizome, stir-fried) 3 liang, Yurou (Cornus Fruit, wine-stir-fried) 3 liang, Danpi (Moutan Bark, wine-stir-fried) 2 liang, Zexie (Alisma Rhizome, stir-fried) 3 liang, Guiban (Turtle Shell, roasted) 3 liang, Shayuan (Astragalus Complanatus Seed, salt-stir-fried) 3 liang, Dangshen (Codonopsis Root, stir-fried) 3 liang, Duzhong (Eucommia Bark, salt-stir-fried) 3 liang, Guishen (Angelica Sinensis Body, wine-stir-fried) 3 liang, Baishao (White Peony Root, stir-fried) 2 liang, Shijueming (Hinge Shell, calcined) 4 liang.
Grind above herbs to powder, mix with refined honey to make pills, dry, then coat with the following powder:
Xiangfu (Cyperus Rhizome) 3 liang (divided: 1 part salt-stir-fried, 1 part vinegar-stir-fried, 1 part honey-water-stir-fried), Chenpi (Tangerine Peel, salt-stir-fried) 7 qian, Chenxiang (Agarwood) 3 qian, Shenqu (Medicated Leaven) 1 liang.
Grind above herbs to powder, use Orange Leaf Decoction to coat the aforementioned pills.
Yi's Note: Using tonics as pills, coated with Qi-regulating powder, aligns with Yu Jiayan's concept of "medicine outer coat." Though lacking profound meaning, the clever design offers another style.
Deng's Commentary: The outer coat method is indeed clever. But with abdominal fullness, Yin-nourishing herbs may hinder the Spleen. I propose a formula below for students' reference:
Chuanlian (Coptis Rhizome), Yizhi (Alpinia Oxyphylla Fruit), Guangpi (Tangerine Peel), Fuling (Poria), Zhi Xiangfu (Processed Cyperus Rhizome), Baijili (Tribulus Fruit), Guishen (Angelica Sinensis Body), Baishao (White Peony Root), Shouwu (Polygonum Multiflorum Root), Mugua (Chaenomeles Fruit).
Sun's Commentary: Yu Xichang's outer coat method uses fierce Ginger/Aconite, coated with Ginseng/Poria to pass the Stomach and act lower, revealing efficacy; this method is inherently clever. Now, using stagnant herbs as the core and flowing herbs as the coat, imitating the intent but varying it, truly demonstrates good reading skills.
Night cool, day hot, heat in the morning, this is Dongyuan's syndrome of fatigue injuring the Spleen. Morning heat belongs to Qi deficiency; use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) to tonify Qi and raise.
Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction), added with Shenqu (Medicated Leaven), Fuling (Poria).
Yi's Note: Argumentation and prescription are like opening the door to see the mountain, clear to the eye and mind.
Deng's Commentary: Heat in the morning is attributed to Yang Qi, which is an unchangeable principle. However, deficiency fever may present with aversion to cold. This patient currently has no cough; if cough develops, Shengma (Cimicifuga Rhizome) and Chaihu (Bupleurum Root) should not be used.
Cold pathogen injuring Yang also often presents with morning chills/fever.
Diarrhea is a Spleen disease; vomiting is a Stomach disease. Spleen and Stomach belong to Earth, centered, governing ascending and descending. Spleen prefers ascending; if not ascending, diarrhea results. Stomach prefers descending; if not descending, vomiting results. Earth decline leads to Wood horizontal invasion; Wood horizontal invasion further declines Earth. In advanced age, one fears Earth collapse and Wood attacking. Ancients treated Liver disease by first solidifying the Spleen. Especially now with weak Earth, one must first tonify the center, slightly assisting with calming Liver.
Lizhong Tang (Regulate the Middle Decoction), added with Fuling (Poria), Jubing (Preserved Orange Peel).
Yi's Note: Case language is logical and articulate; methods are practical and not superficial. However, with vomiting symptoms, Banxia (Pinellia Tuber) seems indispensable. I suggest adding Mugua (Chaenomeles Fruit), Baishao (White Peony Root), and Sharen (Amomum Fruit).