赵左 溺血之症，痛者为血淋，不痛者为尿血，肾阴不足，君相之火下移小肠，逼血下行，小溲带血，溺管
不痛，脉象细小而数。王太仆曰∶壮水之主，以制阳光。当宜育坎藏之真阴，清离明之相火。
大生地（三钱） 抱茯神（三钱） 小川连（四分） 蒲黄炭（三钱） 粉丹皮（一钱五分） 玄武版（四钱）
生甘草（六分） 生白芍（二钱） 淮山药（三钱） 阿胶珠（三钱） 黄柏炭（一钱） 藕节炭（二枚）
黄左 肝为藏血之经，脾为统血之脏。肝脾两亏，藏统失司，溲血甚多，小便频数，大便溏薄，舌中剥边黄
腻，脉濡弦而数。阴无阳化，阳不生阴，膀胱宣泄无权，足肿面浮，脾虚之象见矣。拟归脾汤法引血归经，合滋
肾通关丸生阴化阳。
西洋参（三钱） 抱茯神（三钱） 紫丹参（二钱） 焦谷芽（三钱） 清炙黄 （三钱） 炒枣仁（三钱）
茜草根炭（一钱） 焦白芍（一钱五分） 活贯众炭（三钱） 炒于术（一钱五分） 滋肾通关丸（包煎，二钱）
二诊 溲血有年，血色紫黑，少腹胀满，小溲频数。
大便溏薄，内热心悸，耳鸣头眩，面色萎黄，腿足浮肿，脉左弦小而数，右濡弦。肝虚不能藏血，脾虚不能统
血，血随溲下。色紫黑，少腹满，宿瘀尚未清也。前进归脾法合滋肾丸，尚觉合度，再从原方复入通瘀之品。
前方去活贯众，加生草梢、蒲黄炭、琥珀屑、鲜藕。
三诊 溲血色紫，小溲频数，少腹酸胀，大便溏薄，兼有脱肛，头眩心悸耳鸣，腿足浮肿，两进归脾，病无进
退，脾虚固属显然；小溲频数，少腹酸胀，肝热有瘀，亦为的当不移之理。惟病本虽在肝脾，病标却在膀胱。
经云∶胞移热于膀胱，则病溺血。膀胱者，州都之官，藏津液而司气化。气化不行，则病肿满。肺者，膀胱水道
之上源也。治肝脾不应，治膀胱不应，今拟清宣肺气，去瘀生新，下病上取，另辟途径，以观后效。
西洋参（三钱） 抱茯神（三钱） 茜草根（二钱） 通天草（一钱五分） 川贝母（二钱） 炙远志（一钱）
紫丹参（二钱） 活贯众炭（三钱） 清炙枇杷叶（去毛、包，三钱） 生草梢（八分） 另鲜车前汁 鲜藕汁
（各一两） 炖温冲服。
四诊 昨投清宣肺气，去瘀生新之剂，溲血已减，小便亦爽，下病治上，已获效征。惟面浮足肿，脘腹作
胀，纳谷减少，头眩心悸，大便不实。明系肝体不足，肝
用有余，脾弱不磨，运化失其常度。急其所急，缓其所缓，又当从肝脾着手。肝为乙木，脾为戊土，脾虚木横，
顺乘脾土，固在意中，则治肝实脾，下病治上，亦一定不移之法矣。
生于术（三钱） 扁豆衣（三钱） 紫丹参（二钱） 荸荠梗（一钱五分） 远志肉（一钱） 云茯苓（三钱）
陈广皮（一钱） 生草梢（八分） 生熟苡仁（各三钱） 生熟谷芽（各三钱） 清炙枇杷叶（去毛、包，三钱）
五诊 溲血已止，小便不爽，足肿面浮，纳谷减少，脉尺部细小，寸关濡弦。此血虚肝气肝阳易升，脾弱水
谷之湿不化也。血虚宜滋养，脾弱宜温燥，顾此失彼，动形掣肘。今拟健运中土，而化水湿。
炒白术（三钱） 陈广皮（一钱） 炒神曲（三钱） 滋肾通关丸（包煎，三钱） 连皮苓（四钱）
煨木香（五分） 谷麦芽（各三钱） 冬瓜皮（煎汤代水，一两） 清炙草（八分） 春砂壳（八分） 炒苡仁（三钱）
六诊 健运分消，肿仍不退，便溏口干不欲饮，面无华色，头眩耳鸣，纳谷减少，脉象尺部细小，寸关虚
弦。血虚之体，肝阳易升，脾弱水谷之湿泛滥，欲扶脾土，须益命火，经所谓少火生气，气能生血，血不能自
生，全赖水谷之精液所化。拟崇土渗湿法，再进一层。
炒于术（三钱） 连皮苓（四钱） 煨木香（五分） 滋肾通关丸（包煎，一钱） 红枣（三枚） 熟附片
（五分） 陈广皮（一钱） 炒神曲（三钱） 焦苡仁（三钱） 清炙草（四分） 春砂壳（八分） 焦谷芽（三钱）
冬瓜皮（五钱）
七诊 身半以下肿依然，胸闷纳少，大便溏泄，小便短少，口干不多饮，舌薄腻，脉象尺部细小，寸关濡
弦无力。皆由肝肾阳虚，水谷之湿，生痰聚饮，横溢于募原之间。中气已虚，肝木来乘，气化不及州都，膀胱
宣化无权也。再拟崇土渗湿，滋肾通关。
前方去木香、神曲，加炒淮药、炒车前子。
Mr. Zhao, Left side. Regarding the syndrome of hematuria (blood in urine), if there is pain during urination, it is called blood strangury (Xue Lin); if there is no pain, it is called urinary bleeding (Niao Xue). This is due to insufficiency of Kidney Yin, with Ministerial Fire and Sovereign Fire shifting downward to the Small Intestine, forcing blood to flow downward, resulting in blood in the urine without pain in the urethra. The pulse is fine, small, and rapid. Wang Bing (Wang Taipu) stated: "Strengthen the master of Water to control the brightness of Yang." It is appropriate to nourish the true Yin of the Kidney (Kan Zang) and clear the Ministerial Fire of the Heart (Li Ming).
Sheng Di Huang (Rehmanniae Radix Preparata, 3 qian) Bao Fu Shen (Poria with Hostwood, 3 qian) Xiao Chuan Lian (Coptidis Rhizoma, 4 fen) Pu Huang Tan (Typhae Pollen Carbonisatum, 3 qian) Fen Dan Pi (Moutan Cortex, 1.5 qian) Xuan Wu Ban (Testudinis et Chelonis Carapax et Plastrum, 4 qian)
Sheng Gan Cao (Glycyrrhizae Radix et Rhizoma, 6 fen) Sheng Bai Shao (Paeoniae Radix Alba, 2 qian) Huai Shan Yao (Dioscoreae Rhizoma, 3 qian) E Jiao Zhu (Asini Corii Colla, processed, 3 qian) Huang Bo Tan (Phellodendri Cortex Carbonisatum, 1 qian) Ou Jie Tan (Nelumbinis Nodus Carbonisatum, 2 pieces)
Mr. Huang, Left side. The Liver is the meridian that stores blood, and the Spleen is the zang organ that controls blood. Deficiency of both Liver and Spleen leads to dysfunction in storage and control, resulting in profuse hematuria, frequent urination, and loose stools. The tongue center is peeled with a yellow greasy coating on the edges, and the pulse is soggy, wiry, and rapid. Without Yang transformation, Yin cannot be generated; without Yang generating Yin, the Bladder lacks authority over excretion. Swelling of the feet and face indicates the manifestation of Spleen deficiency. We propose the method of Gui Pi Tang to guide blood back to its vessels, combined with Zi Shen Tong Guan Wan to generate Yin and transform Yang.
Xi Yang Shen (American Ginseng Radix, 3 qian) Bao Fu Shen (Poria with Hostwood, 3 qian) Zi Dan Shen (Salviae Miltiorrhizae Radix et Rhizoma, 2 qian) Jiao Gu Ya (Zeize Fructus Preparatus, 3 qian) Qing Zhi Huang Qi (Astragali Radix Prepared with Honey, 3 qian) Chao Zao Ren (Ziziphi Spinosae Semen, stir-fried, 3 qian)
Qian Cao Gen Tan (Rubiae Radix et Rhizoma Carbonisatum, 1 qian) Jiao Bai Shao (Paeoniae Radix Alba Preparated, 1.5 qian) Huo Guan Zhong Tan (Cyathulae Caulis Carbonisatum, 3 qian) Chao Yu Zhu (Atractylodis Macrocephalae Rhizoma, stir-fried, 1.5 qian) Zi Shen Tong Guan Wan (Zi Shen Tong Guan Pill, wrapped and decocted, 2 qian)
Second visit: Hematuria has persisted for years, with dark purple-black blood, distension and fullness in the lower abdomen, and frequent urination. Loose stools, internal heat, palpitations, tinnitus, and dizziness are present. The complexion is sallow, and there is edema of the legs and feet. The left pulse is wiry, fine, and rapid; the right pulse is soggy and wiry. Liver deficiency fails to store blood, and Spleen deficiency fails to control blood, causing blood to follow the urine. The dark purple-black color and lower abdominal fullness indicate that old stasis has not yet been cleared. The previous combination of Gui Pi method and Zi Shen Wan was deemed appropriate. Now, we add herbs to promote blood circulation and remove stasis from the original prescription.
From the previous formula, remove Huo Guan Zhong Tan. Add Sheng Cao Shao (Glycyrrhizae Radix et Rhizoma tip), Pu Huang Tan, Hu Po Xie (Succinum), and fresh Ou (Nelumbinis Rhizoma).
Third visit: Urine blood is purple, urination is frequent, lower abdomen is sore and distended, stools are loose, accompanied by rectal prolapse. Dizziness, palpitations, tinnitus, and leg/foot edema are present. Two courses of Gui Pi Tang showed no significant improvement or regression; Spleen deficiency is indeed obvious. Frequent urination and lower abdominal soreness indicate Liver heat with stasis, which is an indisputable principle. Although the root of the disease lies in the Liver and Spleen, the branch lies in the Bladder. The Classics state: "When heat shifts from the uterus to the Bladder, hematuria occurs." The Bladder is the official of the capital, storing fluids and governing Qi transformation. If Qi transformation does not occur, swelling and fullness result. The Lung is the upper source of the water passages of the Bladder. Since treating the Liver and Spleen was ineffective, and treating the Bladder directly was also ineffective, we now propose clearing and diffusing Lung Qi, removing stasis and generating new blood, treating lower diseases from above, opening a new pathway, to observe subsequent effects.
Xi Yang Shen (American Ginseng Radix, 3 qian) Bao Fu Shen (Poria with Hostwood, 3 qian) Qian Cao Gen (Rubiae Radix et Rhizoma, 2 qian) Tong Tian Cao (Herba Siegesbeckiae, 1.5 qian) Chuan Bei Mu (Fritillariae Cirrhosae Bulbus, 2 qian) Zhi Yuan Zhi (Polygalae Radix Prepared, 1 qian)
Zi Dan Shen (Salviae Miltiorrhizae Radix et Rhizoma, 2 qian) Huo Guan Zhong Tan (Cyathulae Caulis Carbonisatum, 3 qian) Qing Zhi Pi Pa Ye (Eriobotryae Folium Prepared with Honey, de-haired, wrapped, 3 qian) Sheng Cao Shao (Glycyrrhizae Radix et Rhizoma tip, 8 fen) Additionally, fresh Che Qian Zhi (Plantaginis Juice) and fresh Ou Zhi (Nelumbinis Rhizoma Juice) (each 1 liang), warmed and taken after stewing.
Fourth visit: Yesterday, administering agents to clear/diffuse Lung Qi and remove stasis/generate new blood reduced hematuria and improved urination. Treating lower disease from above has yielded effective signs. However, facial/foot edema, epigastric/abdominal distension, reduced appetite, dizziness, palpitations, and loose stools persist. This clearly indicates insufficient Liver substance (Ti) and excessive Liver function (Yong), weak Spleen failing to grind and digest, and loss of normal transport and transformation. Addressing the urgent before the non-urgent, we must start from the Liver and Spleen. The Liver belongs to Yi Wood, and the Spleen to Wu Earth. Spleen deficiency allows Liver Wood to invade horizontally, overcoming Spleen Earth, which is expected. Thus, treating the Liver to strengthen the Spleen, and treating lower disease from above, is a fixed and unchangeable method.
Sheng Yu Zhu (Atractylodis Macrocephalae Rhizoma, raw, 3 qian) Bian Dou Yi (Phaseoli Cochinchinensis Pericarpium, 3 qian) Zi Dan Shen (Salviae Miltiorrhizae Radix et Rhizoma, 2 qian) Bi Qi Geng (Dioscoreae Hypoglaucae Caulis, 1.5 qian) Yuan Zhi Rou (Polygalae Radix flesh, 1 qian) Yun Fu Ling (Poria, 3 qian)
Chen Guang Pi (Citri Reticulatae Pericarpium, 1 qian) Sheng Cao Shao (Glycyrrhizae Radix et Rhizoma tip, 8 fen) Sheng Shu Yi Ren (Coicis Semen Raw and Prepared, each 3 qian) Sheng Shu Gu Ya (Hordei Fructus Germinatus Raw and Prepared, each 3 qian) Qing Zhi Pi Pa Ye (Eriobotryae Folium Prepared with Honey, de-haired, wrapped, 3 qian)
Fifth visit: Hematuria has stopped, but urination is not smooth. Edema of feet and face, reduced appetite, pulse at the Chi position is fine/small, Cun and Guan positions are soggy/wiry. This is Blood deficiency leading to easy rising of Liver Qi and Liver Yang, and Spleen weakness failing to transform dampness from food and water. Blood deficiency requires nourishment; Spleen weakness requires warming and drying. Attending to one while neglecting the other causes mutual obstruction. Now, we propose strengthening and moving the Middle Burner to transform dampness.
Chao Bai Zhu (Atractylodis Macrocephalae Rhizoma, stir-fried, 3 qian) Chen Guang Pi (Citri Reticulatae Pericarpium, 1 qian) Chao Shen Qu (Massae Medicatae Fermentatae, stir-fried, 3 qian) Zi Shen Tong Guan Wan (Zi Shen Tong Guan Pill, wrapped and decocted, 3 qian) Lian Pi Ling (Poria with skin, 4 qian)
Wei Mu Xiang (Aucklandiae Radix, baked, 5 fen) Gu Mai Ya (Hordei Fructus Germinatus and Maydis Semen, each 3 qian) Dong Gua Pi (Benincasae Exocarpium, decocted as water substitute, 1 liang) Qing Zhi Cao (Glycyrrhizae Radix et Rhizoma prepared with honey, 8 fen) Chun Sha Ke (Amomi Fructus Shell, 8 fen) Chao Yi Ren (Coicis Semen, stir-fried, 3 qian)
Sixth visit: After strengthening/moving and separating/clearing, swelling remains. Loose stools, dry mouth without desire to drink, lackluster complexion, dizziness, tinnitus, reduced appetite. Pulse at Chi position is fine/small; Cun and Guan positions are deficient/wiry. In a Blood-deficient constitution, Liver Yang rises easily; Spleen weakness causes flooding of dampness from food/water. To support Spleen Earth, one must benefit Mingmen Fire. As the Classics say: "Lesser Fire generates Qi; Qi generates Blood." Blood cannot generate itself; it relies entirely on the essence of food and water. We propose the method of Re-enriching Earth and Leaching out Dampness, advancing one step further.
Chao Yu Zhu (Atractylodis Macrocephalae Rhizoma, stir-fried, 3 qian) Lian Pi Ling (Poria with skin, 4 qian) Wei Mu Xiang (Aucklandiae Radix, baked, 5 fen) Zi Shen Tong Guan Wan (Zi Shen Tong Guan Pill, wrapped and decocted, 1 qian) Hong Zao (Jujubae Fructus, 3 pieces) Shu Fu Pian (Aconiti Lateralis Radix Preparata, 5 fen)
Chen Guang Pi (Citri Reticulatae Pericarpium, 1 qian) Chao Shen Qu (Massae Medicatae Fermentatae, stir-fried, 3 qian) Jiao Yi Ren (Coicis Semen, scorched, 3 qian) Qing Zhi Cao (Glycyrrhizae Radix et Rhizoma prepared with honey, 4 fen) Chun Sha Ke (Amomi Fructus Shell, 8 fen) Jiao Gu Ya (Hordei Fructus Germinatus, scorched, 3 qian) Dong Gua Pi (Benincasae Exocarpium, 5 qian)
Seventh visit: Swelling below the waist persists. Chest tightness, reduced appetite, loose diarrhea, scanty urine, dry mouth with little desire to drink. Tongue coating is thin and greasy. Pulse at Chi position is fine/small; Cun and Guan positions are soggy/wiry and powerless. All this is due to deficiency of Liver-Kidney Yang, where dampness from food/water generates phlegm and fluid retention, overflowing between the Mu Yuan (interstices). Middle Qi is already deficient, Liver Wood invades, Qi transformation fails to reach the Capital (Bladder), and the Bladder lacks authority in diffusion and transformation. We again propose Re-enriching Earth and Leaching out Dampness, benefiting the Kidney and unblocking the passage.
From the previous formula, remove Mu Xiang and Shen Qu. Add Chao Huai Yao (Dioscoreae Rhizoma, stir-fried) and Chao Che Qian Zi (Plantaginis Semen, stir-fried).