人身有九窍。阳窍七。眼耳鼻口是也。阴窍二。前后二阴是也。阳气走上窍。而下入于阴位。则有溺
泄腹鸣之候。阴气走下窍。而上入于阳位。则有窒塞耳鸣之候。故人当五十以外。肾气
渐衰于下。每每从阳上逆。而肾之窍开于耳。耳之聪司于肾。肾
主闭藏。不欲外泄。因肝木为子。疏泄母气而散于外。是以谋虑郁怒之火一动。阴气从之上逆。耳窍窒塞不
清。故能听之近不碍。而听远不无少碍。高年之体。大率类然。然较之聋病。一天一渊。聋病者。其窍中另
有一膜。遮蔽外气。不得内入。故以开窍为主。而方书所用石菖蒲麝香等药。及外填内攻等法者。皆
为此而设。至于高年。阴气不自收摄。越出上窍。此理从无一人会及。反以治少壮耳聋药。及发表散气药。
兼带阴虚为治。是以百无一效。不知阴气至上窍。亦隔一膜。不能越出窍外。止于窍
中 有声。如蛙鼓蚊锣。鼓吹不已。以故外入之声。为其内声所混。听之不清。若气稍不逆上。则听稍清。
气全不逆上。则听全清矣。不肖悟明此理。凡治高年逆上之气。屡有奇效。方中大意。全以磁石为主。以其
重能达下。性主下吸。又能制肝木之上吸故也。而用地黄龟胶群阴之药辅之。更用五味子山茱萸之酸
以收之。令阴气自旺于本宫。不上触于阳窍。繇是空旷无碍。耳之于声。似谷之受响。万籁之音。尚可细聆。
岂更与人声相拒。艰于远听耶。此实至理所在。但医术浅薄之辈。不能知之。试观
人之收视而视愈明。返听而听愈聪者。然后知昌之斯言。非臆说也。谨论。
附答岵翁公祖书 捧读祖台钧论。耳中根原甚悉。且考究方书。揣察仲景。即深于医旨者。不能道只字。
不肖昌竦然于金石之音。从兹倍加深入矣。庆幸庆幸。昨方论中。明知左耳有一
膜遮蔽。姑置未论。但论右耳。所以时清时混之故。在于阴气上触耳。盖人两肾之窍。虽开于耳。而肾气上入
耳际。亦为隔膜所蔽。不能越于耳外。止于耳根下。少则微鸣。多则大鸣。甚且将萦耳之筋。触之跳动。
直似撞穿耳叶之象者。然实必不可出也。设阴气能出耳外。而走阳窍。则阴阳相混。非三才之理矣。故耳
之用。妙在虚而能受也。外入之气。随大随小。至耳无碍。惟内触之气。 有声。所以外入之气。仅
通其半。若郁怒之火动。
内气转增。则外入之气转混。必内气渐走下窍。上窍复其虚而能受之体。然后清清朗朗。声入即通。无壅
碍也。方书指为少阳胆。厥阴肝。二经热多所致。是说左耳分部。然少阳之气。能走上窍。其穴皆络于脑巅。
无触筋中耳之理。不当与厥阴混同立说。其通圣散一方。汗下兼用。乃治壮火之法。丹溪所取。亦无
确见。惟滚痰丸一方。少壮用之。多有效者。则以大黄黄芩沉香之苦。最能下气。而礞石之重堕。大约与磁
石之用相仿也。不肖昌所以不用此方者。以其大损脾胃。且耗胸中氤氲之气耳。至于肾虚耳鸣。指作胱膀相
火上升。则阳火必能透出上窍。不为鸣也。尤见丹溪无据之谭。易言水中有火。原说真火。故坎中之
一点真阳。即真火也。年高之人。肾水已竭。真火易露。故肾中之气。易出难收。况有厥阴之水。为之挹取乎。
然则壮水之主。以制阳光。如盏中添油。而灯焰自小诚为良治。乃云作阴虚治不效者。知其泛论世人。不为
老人立法也。夫收摄肾气。原为老人之先务。岂丹溪明哲而为此等议论乎。不肖昌昨方论中欲返
祖台右耳十余年之聪。以仰答帝鉴。慰藉苍生耳。非为左耳数十年之锢论也。草野不恭。统惟亮宥。谨复。
胡卣臣先生曰。耳鸣之故。从来无人说透。此案方大开法门。
人体有九个孔窍。阳窍有七个，即眼、耳、鼻、口；阴窍有两个，即前阴和后阴。阳气运行于上部的阳窍，若下行进入阴位，就会出现小便失禁、腹泻或腹中肠鸣的症状。阴气运行于下部的阴窍，若上行进入上部的阳位，就会出现鼻塞不通和耳鸣的症状。因此，人到了五十岁以后，肾气在下部逐渐衰退，常常伴随阳气上逆。肾的窍穴开于耳，耳朵的听觉功能由肾所主管。肾主闭藏精气，不希望其外泄。由于肝属木为肾之子，肝的疏泄功能会带动母脏（肾）的气机向外发散。所以，当谋虑过度或愤怒导致肝火一动时，阴气就会随之上逆，导致耳窍堵塞不清。因此，听力在近处尚可，但在远处则略有障碍。老年人的体质大抵如此。但这与耳聋病截然不同，一个是浅表，一个是深重。耳聋病患者，其耳窍内部另有一层膜遮蔽，使外界的声音无法进入，所以治疗以开通窍道为主，方书中使用的石菖蒲、麝香等药物，以及外敷内服等方法，都是为此而设。
至于老年人，是因为阴气不能自我收敛摄持，越出而上冲至阳窍，这个道理从未有人深入探讨过。反而有人用治疗青壮年耳聋的药物，以及发表散气的药物，兼带治疗阴虚的方法，结果百无一效。他们不知道阴气到达上窍时，也隔着一层膜，不能穿出窍外，只是停留在窍中发出声音，像蛙鼓蚊锣一样，不停地鼓吹。因此，外界传入的声音被内部的声响混杂，导致听不清楚。如果气不再上逆，听力就会稍微清晰；如果气完全不上逆，听力就能完全恢复清晰。我悟明了这个原理，凡是治疗老年人气机上逆引起的病症，屡获奇效。处方的大意全以磁石为主药，因为磁石质地沉重能达下部，性味主向下吸引，又能制约肝木之气向上吸引。再配合地黄、龟胶等滋阴药物辅助，更用五味子、山茱萸的酸味来收敛，使阴气在肾的本宫旺盛，不向上冲击阳窍。由此耳窍空旷无碍，耳朵对于声音的反应，就像山谷接受回响一样，各种细微的声音都可以仔细聆听，怎么会与人声相抗拒，难以听取远处的声音呢？这确实是至理所在，但医术浅薄的人不能理解。试看人们收敛视线视力反而更明亮，返听内视听力反而更聪敏的例子，就知道我的话不是凭空臆测。谨此论述。
附上答复岵翁公祖的信：拜读您的高论，对耳鸣的根本原因阐述得非常详尽，并且考究了方书，揣度张仲景的医理，即使是精通医学旨意的人，也不能说出只言片语。听到您如金石般铿锵有力的言论，我不胜惶恐敬畏，从此加倍深入钻研，真是庆幸之至。在前面的方论中，明知左耳有一层膜遮蔽，暂时搁置未论，主要讨论右耳时清时混的原因，在于阴气上触耳窍。大概人的两肾窍穴虽开于耳，但肾气上入耳际，也被隔膜遮蔽，不能透出耳外，只停留在耳根下方。少则轻微鸣响，多则大声鸣响，甚至牵连缠绕耳朵的筋脉，触动时跳动，直像要撞穿耳叶的样子。然而实际上是不可能出来的。假如阴气能穿出耳外，走向阳窍，那么阴阳就会混杂，不符合天地人的常理了。所以耳的功能，妙在虚空而能接受声音。外界传入的气，无论大小，到耳都没有阻碍。只有内部触动的气有声，所以外界传入的气只能通一半。如果郁怒之火发动，内气转增，那么外界传入的气就转为混杂。必须让内气逐渐走向下窍，上窍恢复其虚空能受的状态，然后才能清清朗朗，声音进入即刻通畅，没有壅塞阻碍。
方书将耳鸣指认为少阳胆经、厥阴肝经二经热盛所致，这是针对左耳分部的说法。然而少阳之气能走上窍，其穴位都联络于脑巅，没有触动耳中筋脉的道理，不应当与厥阴经混同立论。防风通圣散一方，汗法下法兼用，是治疗壮火的方法，朱丹溪所取用，也没有确切的见解。只有滚痰丸一方，青壮年使用，大多有效，这是因为大黄、黄芩、沉香的苦味最能降气，而礞石的沉重坠降作用，大约与磁石的作用相似。我不采用此方的原因，是因为它大大损伤脾胃，并且耗散胸中氤氲的元气。至于肾虚耳鸣，将其指作膀胱相火上升，那么阳火必然能透出上窍，不会发生鸣响。这更可见朱丹溪的说法是无根据的谈论。《易经》说“水中有火”，原本说的是真火，所以坎卦中的一点点真阳，就是真火。年老之人，肾水已经枯竭，真火容易显露，所以肾中的气容易外出难以收回，何况还有厥阴之水从中汲取呢？既然如此，那么“壮水之主，以制阳光”，就像在灯盏中添加油料，灯焰自然变小，这确实是良好的治疗方法。如果说按阴虚治疗无效，那是知道他在泛泛议论世人，并没有专门为老年人立法。收摄肾气，原本是老年人的首要任务，难道朱丹溪这样明哲的人会发表这样的议论吗？我不才，昨天在方论中想要挽回您右耳十余年的听力，以仰答皇帝的知遇之恩，慰藉百姓罢了，并不是为了左耳几十年的固疾定论。草野之人言辞不恭，恳请谅解宽恕。谨复。
The human body has nine orifices. There are seven yang orifices, namely the eyes, ears, nose, and mouth; and two yin orifices, namely the anterior and posterior yin openings. Yang Qi (vital energy) travels to the upper yang orifices, and if it descends into the yin positions, symptoms such as urinary incontinence, diarrhea, or abdominal borborygmus (intestinal rumbling) will occur. Yin Qi travels to the lower yin orifices, and if it ascends into the upper yang positions, symptoms such as nasal obstruction and tinnitus (ringing in the ears) will occur. Therefore, after the age of fifty, Kidney Qi gradually declines in the lower body, often accompanying an upward reversal of Yang Qi. The orifice of the Kidney opens at the ears, and auditory acuity is governed by the Kidneys. The Kidneys govern closure and storage, desiring not to leak essence outward. Since Liver Wood is the child of Kidney Water, the dispersing function of the Liver draws out the Qi of its mother organ (the Kidneys) and scatters it outward. Thus, when fire from excessive planning or anger arises, Yin Qi reverses upward, causing blockage and turbidity in the ear orifices. Consequently, hearing near objects is unobstructed, but hearing distant objects is slightly impaired. This is generally the case for the elderly. However, this condition is vastly different from deafness; one is superficial, the other profound. In cases of deafness, there is another membrane inside the ear orifice that blocks external air/sound from entering, so treatment focuses on opening the orifices. Medicines such as Rhizoma Acori Tatarinowii (Shichangpu) and Moschus (Shexiang) used in formularies, as well as methods of external application and internal attack, are all designed for this purpose.
As for the elderly, it is because Yin Qi fails to self-restrain and control itself, overflowing and ascending to the upper yang orifices. This principle has never been fully understood by anyone. Instead, people use medicines for treating deafness in young and strong adults, along with medicines that release the exterior and dissipate Qi, combined with treatments for Yin deficiency, resulting in almost no efficacy. They do not realize that when Yin Qi reaches the upper orifices, it is also separated by a membrane and cannot exit the orifice externally; it merely stays within the orifice producing sound, like a frog drum or mosquito gong, blowing incessantly. Therefore, sounds entering from outside are mixed with internal noises, making hearing unclear. If the Qi does not reverse upward slightly, hearing becomes slightly clear; if the Qi does not reverse upward at all, hearing becomes completely clear. I comprehended this principle. Whenever I treat Qi reversal in the elderly, I have achieved remarkable effects. The main idea of the prescription relies entirely on Magnetitum (Cishi) as the principal herb, because its heaviness allows it to reach the lower body, its nature primarily directs downward attraction, and it can restrain the upward suction of Liver Wood. It is assisted by Yin-nourishing herbs such as Radix Rehmanniae Preparata (Dihuang) and Carapax et Plastrum Testudinis (Guijiao). Furthermore, sour herbs such as Fructus Schisandrae Chinensis (Wuweizi) and Fructus Corni Officinalis (Shanzhuyu) are used to astringe, causing Yin Qi to flourish in its home palace (Kidneys) without touching the upper yang orifices. Consequently, the ear orifice becomes open and unobstructed. The ear's reception of sound becomes like a valley receiving echoes; various subtle sounds can be carefully listened to. How could it resist human voices and struggle to hear distant sounds? This is indeed the ultimate truth, but those with shallow medical skills cannot understand it. Observe how people who retract their gaze see more clearly, and who turn their listening inward hear more keenly; then you will know that my words are not baseless speculations. Respectfully discussed.
Attached is the reply to Grandfather Huweng: Having read your esteemed discourse, the root causes of tinnitus are explained in great detail, and you have investigated medical formularies and speculated upon Zhang Zhongjing’s principles. Even those deeply versed in medical intent cannot utter a single word. Hearing your resonant voice like metal and stone, I stood in awe and redoubled my efforts to study deeply. How fortunate. In yesterday’s discussion on prescriptions, knowing that there was a membrane blocking the left ear, I temporarily set it aside, focusing only on discussing the right ear, where the reason for intermittent clarity and turbidity lies in Yin Qi contacting the ear. Generally, although the orifices of both Kidneys open at the ears, Kidney Qi ascending to the vicinity of the ears is also obscured by membranes and cannot pass outside the ears, stopping only below the root of the ear. Slightly, it produces faint ringing; largely, it produces loud ringing. It may even cause the tendons winding around the ear to twitch upon touch, appearing as if they might burst through the earlobe. However, in reality, it is impossible for them to exit. If Yin Qi could exit the ear and travel to the yang orifices, Yin and Yang would mix, violating the principles of Heaven, Earth, and Humanity. Therefore, the function of the ear lies in its subtlety and ability to receive. External Qi, whether large or small, enters the ear without hindrance. Only internally triggered Qi produces sound. Thus, external Qi only passes halfway. If fire from stagnation and anger activates, internal Qi increases, and external Qi becomes mixed. It is necessary for internal Qi to gradually descend to the lower orifices, allowing the upper orifices to regain their state of emptiness and receptivity. Then, clarity returns, sounds enter and flow freely without obstruction.
Medical formularies attribute tinnitus to excessive heat in the Shaoyang Gallbladder and Jueyin Liver meridians, specifically regarding the left ear distribution. However, Shaoyang Qi travels to the upper orifices, and its acupoints connect to the brain vertex; there is no mechanism for it to touch the tendons in the middle ear. It should not be conflated with the Jueyin meridian in theory. Fangfeng Tongsheng San combines sweating and purging methods, which is a treatment for vigorous fire, adopted by Zhu Danxi, yet lacks definitive insight. Only Gun Tan Wan is effective for young and strong individuals, primarily because the bitterness of Radix Rheomi Palmatae (Dahuang), Radix Scutellariae (Huangqin), and Lignum Aquilariae Resinatum (Chenxiang) best descends Qi, while the heavy descending nature of Calamitas Auripigmenti et Antimonii (Mengshi) is roughly similar to the use of Magnetitum (Cishi). I did not use this formula because it severely damages the Spleen and Stomach and depletes the ethereal Qi in the chest. Regarding tinnitus due to Kidney deficiency, attributing it to the ascent of Minister Fire from the Bladder implies that Yang Fire must penetrate the upper orifices and would not produce ringing. This further reveals that Zhu Danxi’s statements are unfounded. The I Ching states "fire within water," originally referring to True Fire. Thus, the single point of True Yang in Kan (Water) is True Fire. In elderly people, Kidney Water is exhausted, and True Fire easily emerges. Therefore, Qi in the Kidneys easily exits but is hard to retain, especially when drawn by Jueyin Water. Consequently, "strengthening the master of Water to control the sunlight" (nourishing Yin to suppress Yang), like adding oil to a lamp to make the flame smaller, is indeed an excellent treatment. To say that treating it as Yin deficiency is ineffective shows that he was speaking generally about ordinary people, not establishing laws specifically for the elderly. Gathering and restraining Kidney Qi is originally the primary task for the elderly. Could Zhu Danxi, a wise man, make such remarks? I, humble Chang, in yesterday’s prescription discussion, sought to restore your grandfather’s right ear hearing of over ten years to repay imperial scrutiny and comfort the common people, not to address the entrenched issue of the left ear lasting decades. As a rustic person, I am impolite; please forgive me. Respectfully replied.
Mr. Hu Youchen said: The causes of tinnitus have never been thoroughly explained by anyone. This case’s prescription opens a wide gate to understanding.