蔚兄来诊云∶病初右胁刺痛，皮肤如烙，渐致大便闭结，坐卧不安，每便努挣，痛剧难
耐，
理气清火，养血润肠，药皆不应。切脉弦急欠柔，谓曰易治耳，一剂可愈。蔚兄云∶吾病日
久，诸药无灵，何言易治?予曰∶此乃燥证。肺苦燥，其脉行于右，与大肠相表里，方书论
胁痛以左属肝，右属肺，今痛在右胁而便闭结，肺病显然。但肝虽位于左，而其脉萦于两胁
，内经言邪在肝，则两胁中痛。今痛虽在右胁，不得谓其专属肺病已也。夫金制木，忧伤肺
，金失其刚，转而为柔，致令木失其柔，转而为刚，辛香益助其刚，苦寒愈资其燥，润肠养
血，缓不济急。订方用栝蒌一枚，甘草二钱，红花五分。蔚兄见方称奇，乃询所以。予曰∶
方出《赤水元珠》。夫栝蒌柔而润下，能治插胁之痛，合之甘草缓中濡燥，稍入红花，流通
血脉，肝柔肺润，效可必矣。服药便通痛减，能以定卧，随服复渣，微溏两次，其痛如失。
安波按∶怀抱奇，肋痛法，亦可参用。
静翁孙女，年甫三龄，夏月发热，医作暑风治，投清散药两剂，忽颏脱音哑，食莫能嚼
，饮
莫能啜。又以为风中会厌，仍用散药，静翁迟疑，邀予商酌。谓曰∶颏属肾，颏脱肾虚之征
。肾脉循喉咙，挟舌本，为声音之根。经云∶内夺而厥，则为喑痱。儿质本薄，暑复伤气，
更服辛散，元气益漓，致变若此。倘再行疏泄，肝风一动，慢惊旋至，不可救矣。仿左归饮
合生脉散，服之而瘥。
安波按∶勘此等证，腹中无《内经》，犹瞎子行路。
【背景信息】
书名：程杏轩医案 作者：程杏轩 朝代：清 章节：叶蔚如兄胁痛便闭一剂而效 / 曹静川翁孙女颏脱音哑 类别：医论
【待处理原文】
叶蔚如兄来诊时说：我的病起初是右胁部刺痛，皮肤感觉像被火烫一样，逐渐导致大便闭塞不通，坐立不安，每次排便用力努挣时，疼痛剧烈难以忍受。之前使用理气清火、养血润肠的药物，都没有效果。我切脉发现脉象弦急且缺乏柔和之象，我对他说：这病容易治疗，只需一剂药就能痊愈。叶蔚如说：我的病已经很久了，各种药物都无效，怎么能说是容易治呢？我说：这是燥证（因津液亏损导致的病证）。肺脏厌恶干燥，其经脉行于右侧，与大肠互为表里。医书论述胁痛时，认为左侧属于肝，右侧属于肺。现在疼痛在右胁且大便闭塞，显然是肺的病。但是肝脏虽然位于左侧，但其经脉环绕两胁，《内经》说邪气在肝，则两胁中间疼痛。现在疼痛虽然在右胁，不能断定它专属肺病。金（肺）克制木（肝），忧伤肺，使金失去刚硬，转而变得柔弱，导致木失去柔和，转而变得刚强。辛香类药物更加助长其刚强，苦寒类药物更加资助其燥热，润肠养血的药物，见效缓慢救不了急。我开方用栝蒌一枚，甘草二钱，红花五分。叶蔚如看到方子称奇，于是询问原因。我说：这个方子出自《赤水元珠》。栝蒌性质柔润下行，能治疗插入胁肋的疼痛，配合甘草缓和其中焦并濡润燥热，稍加红花以流通血脉，使肝柔和、肺滋润，疗效必定显著。服药后大便通畅，疼痛减轻，能够安静躺卧，接着服用剩下的药渣，轻微腹泻两次，疼痛完全消失。安波按语：怀抱奇医生的《肋痛法》，也可以参考使用。
曹静川老先生的孙女，年仅三岁，夏季发热，医生当作暑风（夏季感受暑邪引起的类似中风的症状）治疗，投用清热发散的药物两剂，突然下巴脱位（或指下颌关节功能失常）、声音嘶哑，吃东西不能咀嚼，喝水不能吸吮。又以为是风邪中伤会厌，仍然使用发散药物。曹静川迟疑不决，邀请我商量。我说：下巴归属于肾，下巴脱位是肾虚的表现。肾脉沿着喉咙，夹持舌根，是声音的根本。《内经》说：精气内夺而厥逆，就会变成失音和足废不用（喑痱）。孩子体质本来薄弱，暑邪又损伤了气，再服用辛散药物，元气更加耗损，导致变成这样。如果再行疏泄，肝风一动，慢惊风（小儿慢性惊风）随即到来，就无法救治了。仿照左归饮合生脉散，服用后病愈。
安波按语：诊治这类证候，如果腹中没有《内经》的理论基础，就像瞎子走路一样。
[Background Information]
Book: *Cheng Xingxuan's Medical Cases* Author: Cheng Xingxuan Dynasty: Qing Chapter: Case of Brother Ye Weiru with Hypochondriac Pain and Constipation Cured in One Dose / Case of Granddaughter of Old Man Cao Jingchuan with Chin Dislocation and Aphonia Category: Medical Discourse
[Original Text to Process]
Brother Ye Weiru came for consultation and said: "My illness began with stabbing pain in the right hypochondrium, with the skin feeling as if scalded by fire. It gradually led to constipation, causing restlessness whether sitting or lying down. Every time I strained during defecation, the pain was severe and unbearable. Treatments aimed at regulating Qi and clearing fire, as well as nourishing blood and moistening the intestines, were all ineffective." Upon taking his pulse, I found it wiry (Xian) and rapid but lacking softness. I told him, "This is easy to treat; one dose will suffice." Ye Weiru said, "My illness has persisted for a long time, and various medicines have failed. How can you say it is easy to treat?" I replied, "This is a Dryness syndrome (Zao Zheng). The Lung dislikes dryness, its meridian runs on the right side, and it stands in exterior-interior relationship with the Large Intestine. Medical texts discuss hypochondriac pain, stating that the left belongs to the Liver and the right belongs to the Lung. Now that the pain is in the right hypochondrium accompanied by constipation, the pathology of the Lung is evident. However, although the Liver is located on the left, its meridian winds around both hypochondria. The *Neijing* states: 'When pathogenic factors are in the Liver, there is pain in the middle of both hypochondria.' Although the pain is currently in the right hypochondrium, we cannot assert that it exclusively belongs to Lung pathology. Metal (Lung) controls Wood (Liver). Sorrow injures the Lung, causing Metal to lose its rigidity and become soft. This leads to Wood losing its softness and becoming rigid. Pungent and aromatic herbs further assist this rigidity, while bitter-cold herbs further fuel the dryness. Moistening the intestines and nourishing blood acts too slowly to address the emergency." I prescribed one Trichosanthis Fructus (Gualou), two qian of Glycyrrhizae Radix et Rhizoma (Gancao), and five fen of Carthami Flos (Honghua). Seeing the prescription, Ye Weiru expressed surprise and asked for the rationale. I said, "This formula comes from *Chishui Yuanzhu*. Trichosanthis Fructus is soft and moistening, directing downwards, capable of treating stabbing pain in the hypochondrium. Combined with Glycyrrhizae Radix et Rhizoma to moderate the middle and moisten dryness, along with a small amount of Carthami Flos to promote blood circulation, the Liver will become soft and the Lung moistened, ensuring efficacy." After taking the medicine, bowel movement became smooth, pain decreased, and he could lie quietly. He then took the remaining dregs, had mild diarrhea twice, and the pain disappeared completely. An Bo's commentary: The method for treating hypochondriac pain from Huai Baoqi can also be referenced.
The granddaughter of Old Man Cao Jingchuan was only three years old. In summer, she had a fever. The physician treated it as Summerheat-Wind (Shu Feng) and administered two doses of cooling and dispersing herbs. Suddenly, her chin dislocated (or mandibular dysfunction occurred), her voice became hoarse, she could not chew food, nor could she sip drinks. Others assumed it was wind invading the epiglottis and continued using dispersing herbs. Cao Jingchuan hesitated and invited me to consult. I said, "The chin is governed by the Kidney. Chin dislocation is a sign of Kidney deficiency. The Kidney meridian follows the throat and flanks the root of the tongue, serving as the root of voice. The *Neijing* states: 'If essence is depleted internally leading to厥 (Jue/fainting or reversal), it results in aphonia and leg paralysis (Yin Fei).' The child's constitution was inherently thin. Summerheat further damaged Qi, and administering pungent-dispersing herbs caused Yuan Qi (Primary Qi) to deteriorate further, resulting in such changes. If we continue with dispersing and draining methods, when Liver Wind stirs, Slow Convulsion (Man Jing Feng) will follow immediately, and it will be incurable." I imitated Zuogui Yin combined with Shengmai San. After taking it, she recovered.
An Bo's commentary: To diagnose such syndromes, if one lacks the theoretical foundation of the *Neijing* in mind, it is like walking blindfolded.