诒按：似可参用柴、芍辈，于土中泄木。
邓评：脉既左弦，附子终怕碍肝，参用柴、芍自合，金铃子散亦所需要。
病分气血，不病于气，即病于血，然气血亦有同病者。即如此病，胃脘当心而痛，起于受饥，得食则缓，岂非气分病乎。如独气分为病，理其气即可向安，而此痛虽得食而缓，午后则剧，黄昏则甚，属在阳中之阴，阴中之阴之候，其为血病无疑。况但头汗出，便下紫色，脉形弦细而数，更属血病见证。但此血又非气虚不能摄血之血，乃痛后所瘀者，瘀则宜消，虚则宜补，消补兼施，庶几各得其所。
原注：分明两病，一是脾虚，气分不能畅达而痛，得食则缓，宜补可知。然人每疑痛无补法者，以痛必有痰气凝滞也。先生用理中以补脾，即加青皮、陈皮以通气；至便紫脉弦数，肝家之血必有瘀于胃脘者，此时不去其有形之瘀滞，痛必不除，病根不拔也。此种病，世医不能治，往往以为痼疾，不知不去瘀，则补无力，徒去瘀则脾胃更伤。先生则双管齐下，立案清沏，度尽金针，非名家恶能如是。
邓评：其痛起于受饥，得食则缓，是中虚无疑，非甘温补中以缓肝不可。惟便下紫黑，则为血瘀所致，自宜兼导。方案朗若眉列，洵非老手不办。至于但头汗出者，必有肝阳郁冒，金铃、白芍、蒺藜等，尚可加入。
末药须用参汤过下，方不戕伐中气。
胃脘当心而痛，少腹气升，呕吐酸苦痰涎，脉形弦数。显系寒热错杂之邪，郁于中焦，肝属木，木乘土位，所有积饮，从此冲逆而上，病已年余，当以和法。
附子理中汤 加川连姜汁炒 川椒 黄柏 归身 细辛半夏 桂枝 乌梅肉
原注：此连理汤合乌梅丸。吐涎酸苦，是胃中错杂之邪，用姜连、半夏以化之，逆冲而上之肝气，用乌梅法以和之。
诒按：半夏反附子，在古方多有同用者，然可避则避之，亦不必故犯也。
邓评：据其呕吐酸苦，脉形弦数，则肝胆郁火必盛，虽属寒热错杂，附子究恐有碍郁火，若竟服乌梅丸则有碍。
胃脘当心而痛，脉形弦数，舌绛苔黄，口干苦，小便赤。一派火热之象，气从少腹上冲于心，岂非上升之气自肝而出，中挟相火乎。
化肝煎（芍、青、栀、泽、丹、陈、贝。）
邓评：确系热厥心痛，宜与金铃子散合用，或可参清肝蠲痛饮，则较能着力也。
孙评：景岳法之所以不善者，其立方多夹杂之故也。如名为化肝，何得用贝清肺，若用连，则名实相符矣。
脘痛下及于脐，旁及于胁，口干心悸，便栗溺黄，脉弦而数，此郁气化火也 化肝煎合雪羹 原注；此景岳化肝煎也。必肝有实火者可用，口干、脉数，溺黄是其的证也。
中焦失治为痛，以治中汤为法，是正治也。不知中焦属土，土既虚不能升木，木即郁于土中，亦能作痛，以逍遥散佐之，更属相宜 治中汤逍遥散雪羹 诒按：此木郁土中之病，立方妥贴易施。
邓评：为木郁而佐以逍遥散者，其脉必兼弦象可知。雪羹参入方内，似属不妥。
瘀血腹痛，法宜消化。然为日已久，脾营暗伤，又当兼补脾阴为妥。
诒按：此病用补，是专在痛久上着眼。
当脐胀痛，按之则轻，得食则减，脉形细小而数，舌上之苔左黄右剥，其质深红，中虚伏热使然。
治中汤 加川连雪羹
诒按：此等证不多见，立方亦甚难，须看其用药的当处。
邓评：此必连重于姜，方不有碍伏热。
少腹久痛未痊，手足挛急而疼，舌苔灰浊，面色不华，脉象弦急。此寒湿与痰，内壅于肝经，而外攻于经络也。现在四肢厥冷，宜以当归四逆汤加减。
邓评：此营虚挟寒邪，立方殊平妥。
再诊：少腹之痛已止，惟手冷挛急未愈。专理上焦。
邓评；营气未复，上焦之寒痰未解，方法转换得当。
少腹作痛，甚则呕吐，脉右弦左紧俱兼数，舌苔浊腻，口中干苦，头胀溺赤。此湿热之邪内犯肝经，挟痰浊上升所致。泄之化之，得无厥逆之虞为幸。
另乌梅丸
诒按：旋覆、金铃以止痛，三子以除痰，更用乌梅丸以泄肝，所以面面都到也。
邓评：此肝经气火与湿热交阻，似不如金铃子散合清肝蠲痛饮为善治。
再诊：呕吐已减，白苔稍化，头胀身热亦缓。惟腹之作痛、便之下痢、脉之紧数，以及口中之干苦、小水之短赤，尚不肯平。肝经寒热错杂之邪，又挟食滞痰浊为患也。仍宜小心。
另乌梅丸
诒按：想因下利较甚，故用药如此转换。
三诊：余邪流入下焦，少腹气坠于肛门，大便泄，小便短，舌苔未净，更兼痔痛。
诒按：至此而内伏之湿热，从两便而外泄矣。
邓评：前两方敛降太过，故有此余邪下陷之象。是方堪称熨贴。倘再参入防风、白芍以疏泄厥阴，似较周到。
肝脉布于两胁，抵于少腹，同时作痛，肝病无疑。肝旺必乘脾土，土中之痰浊湿热，从而和之为患，势所必然。
诒按：此治肝气胁痛，诚然合剂，案所云湿热痰浊，虽能兼顾，嫌未着力。
气结于左，自下而盘之于上，胀而且疼，发则有形，解则无迹，甚则脉形弦数，口舌干燥，更属气有余便是火之见证，急须化肝
中脘属胃，两胁属肝，痛在于此，忽来忽去。肝胃之气滞显然，已历二十余年，愈发愈虚，愈虚愈痛。气分固滞，血亦因之干涩也。推气为主，逍遥散佐之。
邓评：拟再加通络之品
再诊：病势不增不减，诊得左脉细涩，右部小弱。气血久虚，致使营卫失流行之象，非大建其中不可。
原注：前方严氏推气散也。先生谓左胁作痛，是肝火，用抑青即左金以泻心平木。右胁作痛，是痰气，用推气法以理气化痰。按姜黄入脾，能治血中之气，蓬术入肝，能治气中之血；郁金入心，专治心胞之血；三物形状相近，而功用各有所宜。
诒按：久病中虚，故转方用大建中法。
邓评：想必痛时喜按，故可大建其中。总嫌少通络之品。抑青者，用吴萸炒川连，仍去萸是也。
腹左气攻胀痛，上至于脘，下及少腹，久而不愈，疝瘕之累也。痛极之时，手足厥冷、呕逆，当从肝治。
当归四逆汤归、桂、芍、草、辛、通、姜、枣。合二陈汤 吴仙散吴萸、茯苓。
诒按：病偏于左，更加支厥，此肝病确据也。
再诊；痛势已缓，尚有时上时下之形，邪未尽也。
疝 气 门
原注：疝气一症，论其本末，有不由气虚而湿浊随之下陷者，故以补中益气汤为主方，俾脾之清气得以上升，则小肠膀胱之浊气自然下降。又有挟劳倦外感而发者，方中柴胡借用亦妙，寒加温药，湿火甚加知、柏。
诒按：此因下坠过甚，故用补中以升清气，其实亦非治疝正法也。
邓评：《金匮》治狐疝，出一蜘蛛散，以攻阴毒之邪，取以毒攻毒之义。今挟脾肾气虚，故备方如此。可见良工治病，应变无穷矣。
孙评：柳氏指点确切，可见治病不宜拘执。
脾宜升主健，胃宜降主和。此病气升而呕，胃不降也j疝气下坠，脾不升也。而所以升降不调者，由脾虚下陷，湿痰中结，而冲逆于胃脘也。理其中阳，则上下白调。
诒按：此因呕吐有上逆之势，故不用补中，而变法治之。
又按：此证若用乌梅丸，则上下均在治中，缘痛呕、疝气，均由肝病故也。
邓评：脾胃之升降不调者，不独由于湿痰中结，抑且因乎肝邪内扰也。
再诊：治中胃痛已和，疝气仍然下坠。拟于补脾之外，佐以补肾，使其火土合德，则阳旺于中，而生气勃然，不升自升矣。
邓评：胃痛已平，温中之效。疝气仍然下坠，则失于治肝故也。虽佐补肾，犹未尽然。
狐疝，原属肝经之湿，随气下陷，脾阳必衰。而今夏多食冷物，阳气又被所遏，苔白不干，指冷脉小，右睾丸胀大，当以温散。
诒按：此因生冷伤中，故用大顺，亦非治疝正法。
邓评：纯属阴寒见象，当以温散无疑。如肾气、理中，以及补中益气丸类，亦可随宜辅用。
瘕 癖 门
寒气客于肠外，与血沫相搏，脐下结瘕，胀大下坠，不时作痛，痛则气升自汗，脉形弦涩。此为臌胀之根。毋忽。
诒按：既因于寒，似可再加温通之品。既与血沫相搏，似宜兼和营血。
邓评。似尚可加桂、芍，延胡、牡蛎之属。
瘕聚脘中，久而不化，变为攻痛升逆，妨食便坚，理之不易
川楝子 延胡 当归 白芍 陈皮 鳖甲 红花 血余 茯苓 牛膝 丹皮
诒按；此病之偏于血分者，故方中兼用疏瘀之品。特所叙病情，尚无瘀血的据。
邓评：妨食便坚，将有成噎膈之虑矣。如瘕聚中脘，必当兼理痰气，专于导血，尚未尽然
最虚之处，便是容邪之处。肝络本虚，隐癖久踞，中宫又弱，隐癖潜入其间。欲治此病，培补肝脾为主，和化次之。
另小温中丸
诒按：此亦虚实兼治之法，然而收效甚难。
邓评：凡隐癖僭于中宫，其脾土必弱，故宜培补兼和化之法，今更参用小温中丸，想有成臌之患。
脉来细而附骨者，积也。已经半载，不过气行作响而已。而其偏于胁下者，牢不可破，是寒食挟痰，阻结于气分也。此等见证，每为胀病之根。
邓评：积于胁下，邪在肝络。拟加金铃、延胡、内桂，以平肝散结。
诒按：议论则见微知著，用药则思患豫防，此为高识。
邓评：此症更必有痰饮留积，白芥子亦为要品。惟竹油阴寒，似属不妥；苟其正气未衰，控涎丹当用也。
食入而痛，是有积也。积非一端，就脉弦数、二便黄热、干咳不爽、面黄苔白言之，必有湿热痰食互相阻滞，经年累月，无路可出，无力以消。
邓评：据此症脉，是火被寒郁，为郁火腹痛之候。然食入而痛，或有蛔动于中也，以并无食积见端耳。拟加椒、萸、梅、连之属。
孙评：食入而痛，痛在胃也。纵使有痰，亦当从脾胃着想，如二陈之类。何得用贝、杏治肺。
寒热后，脘左隐癖作疼，脉形弦细，舌苔浊厚。湿热痰食，交相为患。
二陈汤去甘草合鸡金散（砂、沉，陈、鸡、香橼。）加苏梗楂肉 青皮
诒按：此尚是初起实证，故用攻消法取效，立方亦极平稳。
邓评：起于寒热之后，内有留邪可知。惟癖疼偏左，脉细兼弦，此湿热痰食之中，更必挟肝气为患也。宜参金铃子散兼平其肝。
再诊；脘左之隐癖渐消，舌上之浊苔渐化。仍宗前法，参入补脾之品。
前方去苏梗加于术炙草
另服水泛资生丸
诒按：此亦初起之病，想由肝郁而起，故专从泄肝立法。但恐药轻不能奏效耳。
邓评：如此分经辨络，确无移易。化肝煎未始不合，尚恐不足以消其隐癖，再合金铃子散可也。
Note by Yi: It seems appropriate to incorporate herbs such as Chaihu (Bupleuri Radix) and Baishao (Paeoniae Radix Alba) to vent Liver Wood within the Spleen Earth.
Commentary by Deng: Since the pulse is wiry on the left, Fuzi (Aconiti Lateralis Radix Praeparata) may ultimately obstruct Liver Qi; incorporating Chaihu and Baishao is naturally suitable, and Jinlingzi San (Corydalis Decoction) is also needed.
Diseases are divided into Qi level and Blood level; if not diseased at the Qi level, then it is diseased at the Blood level. However, Qi and Blood can also be diseased simultaneously. Take this case: pain in the epigastrium centered behind the heart, originating from hunger and relieved by eating—is this not a disease of the Qi level? If it were solely a Qi-level disease, regulating Qi would lead to recovery. Yet, although this pain is relieved by eating, it worsens in the afternoon and becomes severe at dusk, belonging to the pattern of Yin within Yang and Yin within Yin. This is undoubtedly a Blood-level disease. Moreover, sweating only on the head, passage of purple stool, and a wiry, fine, and rapid pulse are further confirmations of Blood-level pathology. However, this blood loss is not due to Qi deficiency failing to control blood, but rather stasis formed after pain. Stasis should be resolved, deficiency should be tonified; combining resolution and tonification allows each to find its proper place.
Zhizhong Tang combined with Shixiao San
Additionally, Honghua (Carthami Flos) and Xuanmingfen (Natrii Sulfas) ground into powder and mixed evenly; take two qian when pain occurs.
Original Note: Clearly, there are two diseases here. One is Spleen deficiency, where Qi fails to flow freely causing pain, which is relieved by eating, indicating the need for tonification. However, people often doubt that pain has no tonification method, believing that pain must involve phlegm and Qi stagnation. The Master uses Lizhong Tang to tonify the Spleen, adding Qingpi (Citri Reticulatae Pericarpium Viride) and Chenpi (Citri Reticulatae Pericarpium) to move Qi. Regarding the purple-black stool and wiry-rapid pulse, it indicates that Liver Blood must have stasis in the epigastrium. At this time, if the tangible stasis is not removed, the pain will not cease, and the root of the disease will not be uprooted. Such diseases are often untreatable by worldly physicians, who mistakenly consider them chronic stubborn conditions. They do not know that without removing stasis, tonification is ineffective; removing only stasis damages the Spleen and Stomach further. The Master employs both methods simultaneously, with clear and thorough case records, mastering the golden needle technique. Only a renowned master could achieve this.
Commentary by Deng: The pain originates from hunger and is relieved by eating, confirming Middle Jiao deficiency. It cannot be treated without sweet-warm herbs to tonify the Middle and soothe the Liver. However, the passage of purple-black stool indicates blood stasis, requiring concurrent guidance of stasis. The plan is clear and orderly, indeed achievable only by an experienced hand. As for sweating only on the head, it must be Liver Yang depression and oppression; Jinlingzi, Baishao, and Jili (Tribuli Fructus) can be added.
The powdered medicine must be taken with Ginseng decoction to avoid damaging Middle Qi.
Commentary by Sun: Lizhong Tang plus Qingpi and Chenpi is named Zhizhong Tang. The usage is quite clever.
Epigastric pain centered behind the heart, Qi rising from the lower abdomen, vomiting sour-bitter phlegm-saliva, wiry-rapid pulse. This clearly indicates mixed cold-heat pathogens depressing in the Middle Jiao. The Liver belongs to Wood; Wood overacts on Earth. All accumulated fluids rise violently from here. The disease has lasted over a year; the Harmonizing method should be used.
Fuzi Lizhong Tang added with Chuanlian (Coptidis Rhizoma, stir-fried with ginger juice), Chuanjiao (Zanthoxyli Pericarpium), Huangbai (Phellodendri Cortex), Guishen (Angelicae Sinensis Radix), Xixin (Asari Radix et Rhizoma), Banxia (Pinelliae Rhizoma), Guizhi (Cinnamomi Ramulus), Wumei (Mume Fructus).
Original Note: This is Lianli Tang combined with Wu Mei Wan. Vomiting sour-bitter phlegm-saliva indicates mixed pathogens in the Stomach; Jianglian (Gastrodiae Rhizoma stir-fried with ginger juice) and Banxia resolve them. The rebellious Liver Qi is harmonized using the Wu Mei method.
Note by Yi: Banxia is incompatible with Fuzi, though ancient formulas often use them together. Avoid if possible, but do not deliberately violate the prohibition.
Commentary by Deng: Based on vomiting sour-bitter substances and wiry-rapid pulse, Liver-Gallbladder depressed fire must be abundant. Although it is mixed cold-heat, Fuzi may hinder the depressed fire; taking Wu Mei Wan directly would be obstructive.
Commentary by Sun: Qi rising from the lower abdomen requires Xuansu (Inulae Flos) and Zhezhé (Heteropappi Herba) to suppress it, fearing Liver Qi rebellion and dispersion.
Epigastric pain centered behind the heart, wiry-rapid pulse, crimson tongue with yellow coating, dry mouth and bitter taste, red urine. A manifestation of pure heat-fire. Qi rushes from the lower abdomen to the heart; is this not ascending Qi originating from the Liver, accompanied by Ministerial Fire?
Huagan Jian (Baishao, Qingpi, Zhizi, Zexie, Danpi, Chenpi, Beimu).
Commentary by Deng: This is indeed Heat-Jue Heart Pain; it should be combined with Jinlingzi San, or one might consider Qinggan Juan Tong Yin for greater efficacy.
Commentary by Sun: Jingyue’s methods are flawed because his prescriptions are often cluttered. Named Huagan (Transforming Liver), why use Beimu to clear the Lungs? If Chuanlian were used, the name would match the reality.
Abdominal pain extending to the umbilicus and flanks, dry mouth, palpitations, constipation, yellow urine, wiry-rapid pulse. This is Depression transforming into Fire. Huagan Jian combined with Xue Geng Soup. Original Note: This is Jingyue’s Huagan Jian. It is applicable only when the Liver has Excess Fire; dry mouth, rapid pulse, and yellow urine are definitive signs.
Commentary by Deng: Abdominal pain due to depressed fire often involves phlegm; thus, Xue Geng is added to Huagan Jian.
When the Middle Jiao is mistreated, pain results; using Zhizhong Tang is the direct treatment. However, the Middle Jiao belongs to Earth. If Earth is deficient and cannot raise Wood, Wood becomes depressed within Earth and causes pain. Assisting with Xiaoyao San is more appropriate. Zhizhong Tang, Xiaoyao San, Xue Geng. Note by Yi: This is a disease of Wood depression within Earth; the prescription is appropriate and easy to apply.
Commentary by Deng: Using Xiaoyao San to assist Wood depression implies the pulse must be wiry. Adding Xue Geng seems inappropriate.
Blood stasis abdominal pain should be treated by resolving stasis. However, the duration is long, secretly injuring Spleen Ying; supplementing Spleen Yin is prudent.
Guipi Tang minus Huangqi and Baizhu, added Danshen (Salviae Miltiorrhizae Radix) and Yanhu (Corydalisis Rhizoma).
Note by Yi: Using tonification for this disease focuses specifically on the chronic nature of the pain.
Commentary by Deng: With such a prescription, symptoms of palpitations and insomnia must exist.
Distending pain at the umbilicus, relieved by pressure, reduced by eating, fine-rapid pulse, yellow coating on the left side of the tongue and peeled on the right, deep-red tongue substance. This is caused by Middle deficiency with latent heat.
Zhizhong Tang added with Chuanlian and Xue Geng Soup.
Note by Yi: Such cases are rare, and prescribing is difficult; one must observe the appropriateness of the medication.
Commentary by Deng: Here, Chuanlian must outweigh Jiang to avoid hindering latent heat.
Commentary by Sun: Peeling coating indicates Yin has been depleted; Baishao should be added, following the intent of Wuji Tang.
Chronic lower abdominal pain unhealed, spasmodic pain in hands and feet, turbid gray tongue coating, sallow complexion, wiry-tense pulse. Cold-dampness and Phlegm are internally obstructing the Liver Meridian and externally attacking the collaterals. Currently, the four limbs are cold; Danggui Sini Tang should be modified.
Danggui, Xiaohuixiang (Foeniculi Fructus, stir-fried), Baishao (stir-fried with Rougui), Mutong (Akebiae Caulis), Banxia, Yiren (Coicis Semen), Fangfeng (Saposhnikoviae Radix), Fuling (Poria), Juhong (Citri Reticulatae Pericarpium Rubrum).
Note by Yi: Cold-dampness entering the Liver Meridian resembles Hernia; the treatment is similar.
Commentary by Deng: This is Ying deficiency with Cold pathogen; the prescription is very balanced.
Second visit: Lower abdominal pain has stopped, but cold hands and spasms persist. Focus on regulating the Upper Jiao.
Juanbi Tang (Fangfeng, Qianghuo, Jianghuang, Danggui, Huangqi, Gancao, Chishao), remove Fangfeng, combined with Zhimi Fuling Wan.
Commentary by Deng: Ying Qi has not recovered, and Cold-Phlegm in the Upper Jiao remains unresolved; the change in method is appropriate.
Lower abdominal pain, even vomiting, wiry-right and tight-left pulses both rapid, turbid-greasy tongue coating, dry-bitter mouth, distended head, red urine. Damp-Heat pathogens invade the Liver Meridian internally, carrying turbid Phlegm upward. Purging and resolving may prevent Jue cold; this is fortunate.
Xuanfu Hua Tang, Sanzi Yangqin Tang (Suzi, Baijiezi, Laifuzi), Jinlingzi San.
Additionally, Wu Mei Wan.
Note by Yi: Xuanfu and Jinlingzi stop pain; Sanzi removes phlegm; Wu Mei Wan vents the Liver. Thus, all aspects are covered.
Commentary by Deng: This is obstruction of Liver Qi-Fire and Damp-Heat; Jinlingzi San combined with Qinggan Juan Tong Yin is better.
Second visit: Vomiting has decreased, white coating slightly transformed, head distension and body heat eased. However, abdominal pain, dysentery, tight-rapid pulse, dry-bitter mouth, and short red urine remain uncalmed. Mixed cold-heat pathogens in the Liver Meridian, complicated by food stagnation and turbid Phlegm. Caution is still required.
Gegen Huangqin Huanglian Tang added with Yanhu, Zhaka (Crataegi Fructus charred), Chiling (Polypori Cum Gummi Resina), Chenpi, Laifuzi.
Additionally, Wu Mei Wan.
Note by Yi: Presumably due to severe diarrhea, the medication was changed accordingly.
Commentary by Deng: This disease involves internal damp-heat; Wu Mei Wan seems unnecessary.
Third visit: Residual pathogens enter the Lower Jiao, Qi sinks to the anus, loose stools, short urine, tongue coating not cleared, plus hemorrhoid pain.
Siling San combined with Sini San added with Huangqin, Huangbai, Muxiang.
Note by Yi: By now, the internally latent damp-heat is excreting through both urination and defecation.
Commentary by Deng: The previous two prescriptions were too astringent and descending, causing residual pathogens to sink. This prescription is fitting. If Fangfeng and Baishao were added to vent Jueyin, it would be more comprehensive.
The Liver Meridian distributes along both flanks and reaches the lower abdomen; simultaneous pain confirms Liver disease. Liver excess inevitably overacts on Spleen Earth; turbid Damp-Heat and Phlegm within Earth combine to cause harm, which is inevitable.
Xiaoyao San (Chaihu, Heye, Fuling, Baizhu, Danggui, Baishao, Gancao), added Zhizi, Danpi. Combined with Huagan Jian.
Note by Yi: This treats Liver Qi flank pain; it is indeed a combined formula. While addressing damp-heat and turbid phlegm mentioned in the case, it lacks sufficient force.
Commentary by Deng: Xiangfu and Xuansu should be added.
Huagan Jian already contains Zhizi and Danpi; no need to add them under Xiaoyao San.
Qi knots on the left, coiling from below upwards, distending and painful,有形 when active, invisible when resolved, even wiry-rapid pulse, dry mouth and tongue. This confirms "Excess Qi becomes Fire." Urgent Liver transformation is needed.
Huagan Jian.
Note by Yi: Whenever Liver Qi rebels upward, it often carries Ministerial Fire; thus, Huagan Jian is a key formula.
Zhongwan belongs to the Stomach, flanks belong to the Liver. Pain here comes and goes suddenly. Liver-Stomach Qi stagnation is evident, lasting over twenty years. The more it recurs, the more deficient it becomes; the more deficient, the more painful. Qi stagnation leads to Blood dryness. Pushing Qi is primary, assisted by Xiaoyao San.
Rougui, Zhike, Pianjianghuang, Yanhu, Zhi Gancao, Xiaoyao San.
Commentary by Deng: Proposes adding collateral-unblocking agents.
Second visit: Disease severity unchanged, left pulse fine-choppy, right pulse weak-small. Long-term Qi-Blood deficiency causes Ying-Wei circulation failure; major construction of the Middle is necessary.
Rougui, Guishen, Baishao, Chuanjiao, Yitang (Maltose), Ganjiang, Chenpi, Zhi Gancao, Sharen.
Original Note: The previous formula is Yan Shi’s Tuiqi San. The Master states left hypochondriac pain is Liver Fire, treated with Yiqing Wan (i.e., Zuojin Wan) to drain Heart and calm Wood. Right hypochondriac pain is Phlegm-Qi, treated with Tuiqi method to regulate Qi and transform Phlegm. Jianghuang enters the Spleen, treating Qi within Blood; Pengzhu enters the Liver, treating Blood within Qi; Yujin enters the Heart, specifically treating Pericardium Blood. These three resemble each other in shape but differ in function.
Note by Yi: Chronic illness with Middle deficiency leads to changing the formula to Dajianzhong method.
Commentary by Deng: Presumably pain prefers pressure, allowing major construction of the Middle. Still lacks collateral-unblocking agents. Yiqing refers to Wuzhuyu stir-fried with Chuanlian, removing Wuzhuyu.
Left abdominal Qi attack and distending pain, extending to epigastrium and lower abdomen, chronic, burdened by Hernia and Masses. During extreme pain, cold extremities and vomiting occur; treat from the Liver.
Danggui Sini Tang (Danggui, Guizhi, Baishao, Gancao, Xixin, Mutong, Shengjiang, Dazao). Combined with Erchen Tang, Wuxian San (Wuzhuyu, Fuling).
Note by Yi: Disease偏向 left, with cold extremities, confirming Liver disease.
Commentary by Deng: This is Cold entering Jueyin; pulse should be slow-fine-wiry.
Second visit: Pain intensity eased, but episodic rising and sinking persists; pathogens not exhausted.
Wuxian San combined with Liangfu San, Erchen Tang minus Gancao, added Danggui (stir-fried with Xiaohuixiang), Baishao (stir-fried with Rougui).
Commentary by Deng: Accumulated Cold gradually resolves; episodic rising and sinking indicates Liver Jue Qi is not harmonized.
Hernia Gate
Fox Hernia: enters abdomen when lying down, protrudes when standing.
Buzhong Yiqi Tang.
Additionally, Jin Gui Shenqi Wan combined with Xiao An Shen Wan (Xiangchuanwu, Huixiang, Jiaomu, Chuanlian, Shudi).
Original Note: Hernia, discussing origin and end, some arise not from Qi deficiency but Damp-Turbidity sinking due to deficiency. Thus, Buzhong Yiqi Tang is the main formula, raising Spleen Clear Qi so Small Intestine and Bladder Turbid Qi naturally descends. Some arise with fatigue and external contraction; borrowing Chaihu in the formula is clever. Add warm herbs for Cold, Zhi Mu and Huangbai for severe Damp-Fire.
Note by Yi: Because prolapse is severe, Buzhong Yiqi raises Clear Qi; actually, this is not the standard treatment for hernia.
Commentary by Deng: *Jin Gui* treats Fox Hernia with Zhizhu San to attack Yin-Toxic pathogens, using poison to counter poison. Now with Spleen-Kidney Qi deficiency, the prepared formula is thus. Good physicians adapt infinitely.
Commentary by Sun: Liu’s guidance is precise; treating disease should not be rigid.
Spleen prefers ascending and governing health; Stomach prefers descending and harmonizing. This disease has rising Qi and vomiting (Stomach not descending); hernia prolapse (Spleen not ascending). The reason for disorder is Spleen deficiency sinking, Damp-Phlegm knotting in the middle, rebelling to the epigastrium. Regulating Middle Yang adjusts upper and lower.
Liujunzi Tang added with Ganjiang, Qingpi, Xiaohuixiang, Bibo, Jiuxiangchong.
Note by Yi: Due to vomiting with upward rebellion, Buzhong is not used; instead, alternative methods are employed.
Another Note: If Wu Mei Wan were used for this case, both upper and lower would be treated, as pain, vomiting, and hernia stem from Liver disease.
Commentary by Deng: Spleen-Stomach ascending-descending disorder is not only due to Damp-Phlegm knotting but also Liver pathogen internal disturbance.
Second visit: Zhizhong stomach pain harmonized, hernia still prolapsing. Besides tonifying Spleen, assist Kidney tonification so Fire and Earth cooperate, Yang prospers in the Middle, Sheng Qi rises naturally.
Xiangsha Liujun Wan combined with Jin Gui Shenqi Wan.
Note by Yi: Focusing on the Liver Meridian is more flexible; solely tonifying Spleen-Kidney risks being rigid.
Commentary by Deng: Stomach pain flat, effect of warming Middle. Hernia still prolapses, neglecting Liver treatment. Even assisting Kidney is insufficient.
Fox Hernia originally belongs to Liver Meridian Dampness, sinking with Qi, Spleen Yang must decline. Eating cold foods this summer suppressed Yang; white non-dry coating, cold fingers, small pulse, right testicle swollen. Must warm and disperse.
Dashun San (Ganjiang, Rougui, Xingren, Gancao). Added Danggui, Muxiang, Lizhihe.
Note by Yi: Due to cold/raw injury to Middle, Dashun is used; also not the standard hernia treatment.
Commentary by Deng: Purely Yin-Cold manifestations; warming dispersal is certain. Jin Gui, Lizhong, Buzhong Yiqi pills can be auxiliary as needed.
Mass and Stagnation Gate
Cold pathogen lodges outside intestines, struggles with blood foam, forms mass below umbilicus, distends and sinks, intermittent pain, pain causes Qi rising and spontaneous sweating, wiry-choppy pulse. Root of Drum Distension. Do not ignore.
Wuzhuyu, Fuling, Danggui, Chuanlianzi, Juhong, Wuyao, Xiangfu, Zharon.
Note by Yi: Since caused by Cold, warming-unblocking herbs should be added. Since struggling with blood foam, nourishing Blood should be included.
Commentary by Deng: Guizhi, Baishao, Yanhu, Muli could be added.
Mass gathers in epigastrium, untransformed for long, becomes attacking pain and rebellion, hinders food, hard stool, difficult to treat.
Chuanlianzi, Yanhu, Danggui, Baishao, Chenpi, Biejia, Honghua, Xueyu, Fuling, Niuxi, Danpi.
Note by Yi: Disease偏向 Blood level, hence blood-resolving herbs in formula. However, described condition lacks stasis evidence.
Commentary by Deng: Hindering food and hard stool suggests risk of Dysphagia. Mass in Zhongwan must address Phlegm-Qi; focusing only on guiding Blood is incomplete.
The most deficient place is where pathogens lodge. Liver collaterals originally deficient, hidden stagnation occupies long, Middle Palace weak, hidden stagnation infiltrates. To treat, tonify Liver-Spleen primarily, harmonize-resolve secondarily.
Guishao Liujunzi Tang added with Jineijin.
Additionally, Xiaowenzhong Wan.
Note by Yi: This is simultaneous deficiency-excess treatment, but effect is hard to achieve.
Commentary by Deng: Hidden stagnation usurping Middle Palace implies weak Spleen Earth; tonifying and harmonizing is suitable. Adding Xiaowenzhong Wan may lead to Drum Distension.
Pulse fine and adhering to bone indicates accumulation. Half a year duration, only Qi movement makes noise. But those偏向 hypochondrium are firm and unbreakable; Cold-food carrying Phlegm obstructs Qi level. Such manifestations often become root of distension disease.
Lizhong Tang added with Shenqu, Fuling, Banxia, Chenpi, Maiya, Xuansu, Zhike, Guishen.
Commentary by Deng: Accumulation in hypochondrium, pathogen in Liver collaterals. Propose Jinlingzi, Yanhu, Rougui to calm Liver and dissipate nodules.
Second visit: Hypochondriac hidden stagnation firm and unbreakable, Qi either rebels or attacks. Must warm-resolve to eliminate root of distension.
Lizhong Tang combined with Erchen Tang added with Houpo, Zhike, Shenqu, Zhuyu (Perillae Caulis sap?), Xuansu, Baijiezi.
Note by Yi: Discussion sees subtle beginnings; medication anticipates trouble; this is high insight.
Commentary by Deng: This case must have retained Phlegm-Fluid; Baijiezi is essential. Zhuyu is Yin-cold, seemingly inappropriate; if Zheng Qi not depleted, Kongxian Dan should be used.
Pain upon eating indicates accumulation. Accumulation is not one type; based on wiry-rapid pulse, yellow-hot urine/stool, dry cough, sallow face, white coating, Damp-Heat Phlegm-Food mutually obstruct, year after year, no exit, powerless to resolve.
Maoyu, Chuanxiong, Zhaka, Shenqu, Chuanbei, Shanzhi, Chiling, Pipa Ye Lu, Xingren.
Note by Yi: This is Yueju Wan modified. I suggest adding Baishao and Zhishi.
Commentary by Deng: Based on pulse, Fire depressed by Cold, indicating Depressed Fire abdominal pain. However, pain upon eating may imply Ascaris movement in Middle, though no food stagnation signs. Propose花椒, Wuzhuyu, Wumei, Chuanlian.
Commentary by Sun: Pain upon eating, pain in Stomach. Even with Phlegm, consider Spleen-Stomach, like Erchen. Why use Beimu and Xingren for Lungs?
After cold-heat, left epigastric hidden stagnation hurts, wiry-fine pulse, thick turbid coating. Damp-Heat Phlegm-Food mutually harming.
Erchen Tang minus Gancao combined with Jijin San (Sharen, Chenxiang, Chenpi, Jineijin, Xiangyuan). Added Sugen, Zharon, Qingpi.
Note by Yi: Still initial Excess syndrome, thus attacking-resolving method effective; prescription stable.
Commentary by Deng: Originating after cold-heat, internal lingering pathogens known. Stagnation pain偏向 left, fine-wiry pulse, within Damp-Heat Phlegm-Food, Liver Qi must also harm. Should add Jinlingzi San to calm Liver.
Second visit: Left epigastric hidden stagnation gradually消, turbid tongue coating gradually transforms. Follow previous method, add Spleen-tonifying herbs.
Previous formula minus Sugen, added Yuzhu, Zhi Gancao.
Additionally, take Shuifan Zisheng Wan.
Commentary by Deng: Adding Spleen-strengthening herbs to消 residual accumulation is correct.
Hidden stagnation occupying hypochondrium, Liver Meridian disease.
Huagan Jian.
Note by Yi: Also initial disease, likely from Liver depression, thus specifically venting Liver legislation. But fear light medicine ineffective.
Original Note: Previous case mostly Damp-Heat, this case Liver Fire heavy; treat according to opportunity, each with order.
Commentary by Deng: Differentiating meridians and collaterals accurately, no change needed. Huagan Jian is not incorrect, but fear insufficient to消 hidden stagnation; combine with Jinlingzi San.
Malaria long-standing, pathogen deeply enters collaterals, forms Malaria Mother. Malaria Mother on left, attacks rebelliously from below. Plus right flank stagnation, upper-lower ascending-descending blocked, no wonder Middle Palace gradually full, difficult to treat.
Jijin San added with Zhike, Jianghuang, Baijiezi, Zhuyu.