显庆寺僧应公。有沉积数年。每于四更后。心头痛硬。不能安卧。须起行寺中。习以为
常。人莫知为何病。因求治于戴人。戴人令涌出胶涎一二升。如黑矾水。继出黄绿水。又下
之。去脓血数升。自尔胸中如失巨山。饮饵无算。安眠至晓。
果园刘子平妻。腹中有块如瓢十八年矣。经水断绝。诸法不治。戴人令一月内涌四次。
下六次。所去痰约一二桶。其中有不化之物。如菜叶者。如烂鱼肠者。觉病积如刮。渐渐而
平。及积既尽。块痕反 如臼。略无少损。至是面有童色。经水复行。
修弓杜匠。其子妇年三十。有孕已岁半矣。每发痛。则召收生妪。以为将产也。一二日
复故。凡数次。乃问戴人。戴人诊其脉涩而小。断之曰。块病也。非孕也。脉诀所谓涩脉如
刀刮竹行。主丈夫伤精。女人败血。治法。下有病。当泻之。用舟车丸百余粒。后以调胃承
气汤加当归、桃仁。三两日又以舟车丸、桃仁承气汤。泻青黄脓血。杂然而下。每更衣。以
手向下推之揉之则出后。二三日。又用舟车丸、猪肾散、通经散等。连下数日。俟晴明。当
未食时。以针泻三阴交。不再旬。病已失矣。
震按子和此种治验。约十余条。其载脉象也。不曰沉细。则曰沉迟。此条则曰小而涩。
而其用药也。积在上者。茶调散、三圣散、瓜蒂散为主。积在下者。舟车丸、神 丸、承气
汤、通经散为主。积在中者。兼而用之。凡吐下约数十次。盈五六缶。此种病患。岂非项籍
樊哙之流亚耶。然如樊将军鸿门会切生彘肩啖之。又当怒时不见其成积也。故曰。壮盛人无
积。虚人则有之。洁古养正积自除之论。最有见识。何麻知几辈侈张其说。以惑世诬民耶。
又按子和系睢州人。河南水土浓实。或有此理。后人师其意而用倒仓法。亦以吐泻去积
王金 极赞之。谓肠胃中得肉液充满。流行如洪水泛涨。浮槎陈朽。皆推逐荡漾而出。沉
悉去矣。然徐东皋曰。此法惟宜用于元气实者。若虚损劳瘵鼓胀反胃。真病已成。六脉无
力者。皆不可用。予见不善用者。往往杀人。观此说益惕然于三圣三花辈之难以轻试矣。
陈自明云。予族子妇。腹中有大块如杯。每发痛不可忍。予诊之。知为血瘕。投黑神丸
尽三丸。块气尽消。终身不复作。
震按黑神丸载在济阴纲目。以弹子大一丸。分四服。据云。 气十服。膈气 瘕五服。
血瘕三丸。当瘥。想系神效之方。并注漆有飞补之力。但世间有一种人。沾染漆气即患漆疮
者。若误投之。宁不为害。所当慎也。予又见一妇。先因痞块经闭。里医用生漆浓涂纸上。
阴干 灰。同诸行血药服之。数服后。顿下鲜血盈桶。遂困惫不堪。就予治。虽大进补剂。
终淹成弱证而死。所谓飞补者安在哉。
丹溪治一妇人。死血食积痰饮成块。或在两胁。动作。腹鸣嘈杂。眩晕身热。时发时止
用黄连一两。用茱萸、益智各炒其半。去茱、益不用。香附童便浸。楂肉各一两。萝卜子
一两五钱。三棱、莪术俱醋煮。桃仁留尖去皮。青皮、麦芽曲、山栀、台芎各五钱。炒为末
炊饼丸服。
又治吕宗信。年六十。素好酒。因行暑途得疾。足冷过膝。上脘有块如拳。牵引胁痛。
不可眠。饮食减半。却不渴。已自服生料五积散三帖。朱诊之。六脉俱沉涩而小。按之不为
弱。皆数。右甚。大便如常。小便赤色。遂用大承气汤。将大黄炒熟。加黄连、干葛、芎、
芍、甘草作汤。以蒌仁、黄连、半夏、贝母为丸。至二十帖。块减半。遂止药。至半月。饮
食复进。诸证悉除。
丹溪曰。一妇年四十余。面白形瘦。性急。因有大不如意。乳房下帖肋骨间结一块。渐
长掩心。微痛。膈闷口苦。饮食减四之三。两手脉微而短涩。予知其月经不来矣。为之甚惧
勿与治。思至半夜。其人尚能出外见医。梳妆言语如旧。料其尚有胃气。遂以人参、白术
当归、川芎。佐以气药。大剂与之。外用琥珀膏贴块上。防其块长。两三月间。约服二百
帖。食及平时之半。脉渐充。仍与前药吞润下丸。又百余帖。月经行。不及两日而止。涩脉
减三分之二。时天气热。意其经行时。必带紫色。仍与前药加醋炒三棱。吞润下丸。以抑青
丸十五粒佐之。又经一月。块消其半。月经及期。尚欠平时半日。饮食甘美如常。但食肉不
觉爽快。予令止药。且待来春木旺时区处。至次年六月。忽报块一夜大作。比旧反加指半。
脉略弦。左略怯于右。至数日平和。自言饱食后则块微闷。食行却自平。予意其必有动心事
激之。问之果然。仍于前药中加炒黄芩、黄连。少以木通、生姜佐之。去三棱。煎汤吞润下
丸。外以琥珀膏贴之。半月。经行而块散。此是肺金为火所烁。木邪胜土。土不能运。清浊
相干。旧块轮廓尚在。皆因气血未能尽复。故浊气稍留。旧块复起也。补其血气。使肺不受
邪。木气平而土气正。浊气行而块自散矣。
又一妇人。年三十六。家贫多劳。性褊急。自七月经断。八月小腹下有块偏左。如掌大
块起即痛。至半月后。腹渐肿胀。食减。夜发热。其脉十月间得虚微短涩。左尤甚。初与
白术一斤。和白陈皮半斤。作二十帖煎服。外以三圣膏贴块上。经宿则块软。再宿则块小。
近下一寸。旬日后。食进热减。又与前药一料。加木香三两。每帖研桃仁九个。尽此剂。病
除。
丹溪又曰。一婢色紫。稍肥。性沉多忧。年四十。经不行三月矣。小腹当中一块。渐如
炊饼。脉皆涩。重按稍和。块按则痛甚。试扪之。高半寸。与千金硝石丸。至四五次。彼忽
自言乳头黑。且有汁。恐是孕。予曰。涩脉无孕之理。又与三五帖。脉稍虚豁。予悟曰。药
太峻矣。令止前药。用四物汤。倍白术。佐以陈皮、炙甘草。至三十帖。候脉充。再与硝石
丸。至四五次。忽自言块消一晕。便令勿与。又半月。经行痛甚。下黑血近半升。内有如椒
核者数十粒。而块消一半。又来索药。晓之曰。块已破。勿再攻。但守禁忌。次月经行。当
自消尽。已而果然。大凡攻击之药。有病即病受之。邪轻则胃受伤矣。夫胃气清纯中和者也
惟与谷肉果菜相宜。药石皆偏胜之气。虽参、 性亦偏。况攻击者乎。此妇胃气弱。血亦
少。若待块尽而却药。胃气之存者几希矣。
又一妇因经水过多。每用涩药。致气痛。胸腹有块十三枚。遇夜痛甚。脉涩而弱。丹溪
曰。此因涩药。致败血不行。用蜀葵根煎汤。再煎参、术、青皮、陈皮、甘草梢、牛膝。入
元明粉少许。研桃仁调。热服二帖。连下块二枚。以其病久血耗。不敢顿下。乃去葵根明粉
服之。块渐消。
震按丹溪诸案。消补兼施。而佐清肝者居多。间有用攻击者。内经所谓大积大聚。其可
犯也。又不得矫子和之弊。而一味培补。反蹈养痈豢寇之害。但丹溪用药。轻重次第。各合
机宜。非比子和千篇一律。
王金 曰。予内弟于中甫。饮茶过度。且多愤懑。腹中常漉漉有声。秋来发寒热似疟。
以十枣汤料黑豆煮。晒干研末。枣肉和丸芥子大。而以枣汤下之。初服五分不动。又服五分
无何腹痛甚。以大枣汤饮。大便五六行。皆溏粪无水。时盖晡时也。夜半。乃大下数斗积
水而疾平。当其下时。瞑眩特甚。手足厥冷。绝而复苏。举家号泣。咸咎药峻。嗟乎。药可
轻用哉。
张三锡曰。曾治一少年。体薄弱。且咳血。左边一块。不时上攻作痛。左金、芦荟俱不
应。诊其脉三部虽强。而细涩不流利。因作阴虚治。四物加知、柏、元参、丹皮。不六剂顿
愈。此阴虚似肝积也。由此推之。虽因部分名积。诊视之际。犹当详审。惟圆机者。乃不昧
此。
震按此二条。一系饮积。以证与因断之。一系阴虚似肝积。以脉断之。即圆机也。两家
垂训。裨益尤多。
喻嘉言治袁聚东。年二十岁。生痞块。日进化坚削痞之药。渐至毛瘁肉脱。面黧发卷。
殆无生理。喻视之。少腹脐旁三块。坚硬如石。以手拊之。痛不可忍。其脉两尺洪盛。余俱
微细。谓曰。此由见块医块。不究其源而误治也。初起时块必不坚。以峻猛之药攻至。真气
内乱。转护邪气为害。如人 打。纽结一团。迸紧不散。其实全是空气聚成。非如女子月经
凝而不行。即成血块之比。观两尺脉洪盛。明是肾气传于膀胱。因服破气药多。膀胱之气不
能传前后二便而出。乃结为石块耳。治法须内收肾气。外散膀胱之气。以解其 结。三剂可
愈也。先以理中汤加附子五分。块即减十之三。再用桂、附大剂。腹中气响甚喧。三块一时
顿没。然有后虑者。肾气之收藏未固。膀胱之气化未旺。倘犯房室。块必再作。乃用补肾药
加桂、附。多加河车为丸。取其以胞补胞而助膀胱之化源也。服之后。方不畏寒。腰围渐大
年余且得子。
震按此人克伐太过。换以温补。未足为奇。惟两尺脉洪盛。非此诠解。谁不面涩。至于
桂、附、河车。同补肾药为善后计。则与肾气传膀胱之论紧切不泛。非通套治痞成法可比。
李士材治郡守于鉴如。每酒后腹痛。渐至坚硬。得食辄痛。李诊之曰。脉浮大而长。脾
有大积矣。然两尺按之软。不可峻攻。令服四君子汤七日。投以阴阳攻积丸三钱。但微下。
更以四钱服之。下积十余次。皆黑而韧者。察其形不倦。又进四钱。于是腹大痛。所下甚多
仍服四君子汤十日。又进丸药四钱。去积三次。又进二钱。下积至六七碗。脉大而虚。按
至关部豁如矣。乃以补中益气调补一月。全愈。
震按脉浮大而长。为脾有大积。较之丹溪诸案。或沉涩而小且数。或微而短涩。或虚微
短涩。或脉涩而弱者。大不同矣。须于临证时。能以古人各种脉法。俱为我之正鹄。庶期中
的。若两尺按之软。不可峻攻。固是正理。然亦要看得灵变。盖两尺软为虚。则喻案之两尺
洪盛。宁不认为实而峻攻之耶。故又当以形色及病情参讨也。
给谏侯启东腹中嘈痛。士材按其左胁。手不可近。凡饮食到口。喉间若有一物接之者然
李曰。脉大而数。腹痛呕涎。面色痿黄。此虚而有湿。湿热相兼。虫乃生焉。当煎人参汤
送槟黄丸以下虫积。虫若不去。虽补何益乎。病者畏不敢用。后竟不起。
震按此是虫积。犹之饮积。俱无块者耳。彼肯服十枣丸而愈。此不肯服槟黄丸而殂。因
知病之宜补宜攻。总贵用其所当用。诚不可专守洁古之说为稳着也。
周慎斋治一妇。素善怒。左胁下有块。身肥大。经将行。先一二日。且吐且下。此肝木
乘脾。脾虚生痰不生血也。善怒胁块。肝气亢也。吐下者。脾气虚也。身肥则多痰。痰盛者
中焦多湿。故经行时气血流通。冲动脾湿。且吐且下也。久而不治。必变中满。宜理脾燥湿
白术一两。半夏五钱。生姜七钱。沉香二钱。共末。白糖和服。
一人左胁下有块。右关脉豁大。周用乌药一两。以附子五钱浓煎制之。将乌药日磨二三
分。酒送下。俟积行动。乃以补中益气汤加附子服之。丸用六君子。
震按慎斋书云。凡积不可用下药。徒损真气。病亦不去。当用消积药。使之溶化。则除
根矣。积去须大补。诚格言也。即此二案。亦平淡之神奇。又尝考消积之方。如桃仁煎用大
黄。虻虫、芒硝。黑神丸用生漆、熟漆。东垣五积丸俱用川乌、巴霜。局方圣散子、三棱煎
丸俱用 砂、干漆。此皆峻厉之药。用而中病。固有神效。若妄尝轻试。鲜不败事矣。千金
硝石
丸人参、硝黄并用。丹溪犹以为猛剂。治婢一案。每与补药迭进。此真善治病者也。丹溪治
积聚案有数十条。轻重曲折。适至病所。惜不能重载。再阅叶氏医案积聚门。只用鸡肫皮、
莱菔子、蛤粉、芥子、蜣螂、 虫、青、朴等。并无古方狠药。其理尤可想见。予曾亲见叶
先生治一妇。产后着恼。左边小腹结一块。每发时。小腹胀痛。从下攻上。膈间乳上皆痛。
饮食入胃即吐。遍医不效。先生用炒黑小茴香一钱。桂酒炒当归二钱。自制鹿角霜一钱五分
生楂肉三钱。川芎八分。菟丝子一钱五分。水送阿魏丸七分。八剂而愈。次用乌鸡煎丸原
方半料。永不复发。又一人患疟疾补早。左胁成痞。连于胃腕。按之痛甚。用炒桃仁为君。
佐以阿魏、穿山甲、鳖甲、麝香。丸服。全消。此二条较之临证指南所载者为更佳。故附于
此。予又亲见杭州一富家妇患痞块。用黑神丸大效。每痛作呕胀不堪。服此即愈。数十服后
百苦皆除。然半年外。以他病暴殒。因思漆身为癞之言。脏腑岂堪常漆耶。清纯冲和之气
耗丧于此药而不觉也。再观丹溪治方提领。用参、术、归、芍等煎汤。下保和丸二十五。
龙荟丸十五。治冯氏女。先用左金丸、青六丸。后用参橘桃芍丸。治卢子裕疟后食酒肉而成
块在左胁。用参、术、柴、苓、枳壳煎汤。下阿魏五。保和二十。抑青十。与点十。攻块五
攻块者。青皮、三棱、桃仁、桂枝、海藻、醋调神曲为丸也。治下邳钱郎。用保和二十。
显庆寺的僧人应公，体内有积滞已数年。每逢四更天过后，心口和头部疼痛且发硬，无法安睡。必须起身在寺中行走，这已成为常态。人们不知道这是什么病。于是向戴人求治。戴人让他涌吐，吐出胶状涎液一二升，颜色像黑矾水。接着又吐出黄绿色的水。随后又用泻下法，排出脓血数升。从此以后，他感觉胸中如同失去了巨大的山峦，饮食无数，安稳地睡到天亮。
果园的刘子平之妻，腹中有肿块如瓢大小已有十八年。月经已经断绝，各种治疗方法都无效。戴人让她在一个月内涌吐四次，泻下六次。排出的痰液约有一二桶，其中有不消化的东西，有的像菜叶，有的像烂鱼肠。她感觉体内的积滞像被刮除一样，渐渐平复。等到积滞完全清除后，腹部的痕迹反而凹陷如臼，身体没有任何损伤。至此，她的面色恢复了红润光泽，月经也重新来潮。
修弓杜匠人的儿媳，三十岁，怀孕已一年半了。每次发作疼痛，就召接生婆来，以为快要生产了。过一两天又恢复原状。这样反复多次，于是去问戴人。戴人诊察她的脉象涩而小，判断说：“这是块状病证，不是怀孕。”《脉诀》中说涩脉像刀刮竹子前行，主治男子伤精、女子败血。治疗方法是：下有病邪，应当泻下。使用舟车丸一百多粒。后来用调胃承气汤加当归、桃仁。两三天后又用舟车丸、桃仁承气汤。泻出青黄色的脓血，混杂而下。每次排便时，用手向下推揉帮助排出。两三天后，又用舟车丸、猪肾散、通经散等药。连续泻下数日。等到天气晴朗，在未进食时，针刺三阴交穴以泻实邪。不到十天，病就好了。
俞震按语：子和（戴人）的这种治疗验案，大约有十余条。他记载的脉象，不是沉细就是沉迟。这一条则是小而涩。而他的用药方面，积滞在上的，以茶调散、三圣散、瓜蒂散为主；积滞在下的，以舟车丸、神芎丸、承气汤、通经散为主；积滞在中的，兼而用之。大约吐下数十次，装满五六罐。这样的病患，难道不是项羽、樊哙那一类勇猛的人吗？然而像樊哙在鸿门宴上切生猪肩肉吃，又是在愤怒的时候，并不会因此形成积滞。所以说，身体壮盛的人没有积滞，体虚的人才会有。洁古“养正积自除”的理论，最有见识。为什么麻知几那些人夸大其说，来迷惑世人欺骗百姓呢？
我又按语：子和是睢州人，河南水土浓厚坚实，或许有这个道理。后人学习他的意图而使用倒仓法，也以吐泻去除积滞。王金极极力称赞它，认为肠胃中得到肉液的充满，流行起来像洪水泛滥，浮木和陈朽之物，都被推逐荡漾而出，沉滞悉去。然而徐东皋说：这种方法只适宜用于元气实证者。如果是虚损、劳瘵、鼓胀、反胃，真病已成，六脉无力的，都不可用。我看见不善用此法的人，往往导致死亡。看了这个说法，更加警惕三圣散、三花方之类难以轻易尝试。
陈自明说：我的族侄媳妇，腹中有大块如杯大小。每次发作疼痛难以忍受。我诊察她，知道是血瘕。投予黑神丸，吃完三丸，块气全部消散，终身不再发作。
俞震按语：黑神丸记载在《济阴纲目》中，以弹子大一丸，分四次服用。据说膈气服十服，膈气癥瘕服五服，血瘕服三丸，当痊愈。想是神效的方剂。并注释说漆有飞补之力。但是世间有一种人，沾染漆气就会患漆疮的，如果误投用之，岂不是有害吗？应当谨慎。我又看见一个妇人，先前因为痞块经闭，里医将生漆浓涂在纸上，阴干研成灰，同其他行血药一起服用。服用几剂后，顿时排出鲜血盈桶，于是困倦疲惫不堪，来找我治疗。虽然大量进服补剂，最终拖延成弱证而死。所谓的飞补在哪里呢？
丹溪治疗一个妇人，死血、食积、痰饮结成块状。有时在两胁，动作时腹部鸣响嘈杂，眩晕身热，时发时止。用黄连一两，吴茱萸、益智各炒一半，去掉茱萸、益智不用。香附用童便浸泡，山楂肉各一两，萝卜子一两五钱。三棱、莪术都用醋煮。桃仁留尖去皮。青皮、麦芽曲、山栀、台芎各五钱。炒为末，用炊饼做丸服用。
又治疗吕宗信，六十岁，平时喜好喝酒。因为在暑天路途行走得病，脚冷超过膝盖，上脘有拳头大小的块状物，牵引胁痛，不能睡眠，饮食减半，却不口渴。已经自行服用生料五积散三帖。朱丹溪诊察他，六脉都沉涩而小，按之不弱，都数，右脉尤其明显。大便正常，小便赤色。于是用大承气汤。将大黄炒熟，加黄连、干葛、川芎、芍药、甘草作汤。以瓜蒌仁、黄连、半夏、贝母为丸。服用二十帖，块状物减半，于是停药。到半个月，饮食恢复，诸证全部消除。
丹溪说：一个四十多岁的妇人，面白形瘦，性格急躁。因为有大不如意的事，乳房下贴着肋骨间结成一塊，逐渐长大掩盖心口，微痛，膈闷口苦，饮食减少四分之三。两手脉微而短涩。我知道她月经不来了。为她非常担忧，不要给她治疗。想到半夜，那人还能出门见医生，梳妆言语如旧。料定她还有胃气。于是用人参、白术、当归、川芎，佐以理气药，大剂量给予。外用琥珀膏贴在块上，防止块继续长大。两三个月间，大约服用二百帖，饮食恢复到平时的一半，脉渐充盈。仍然给前药吞服润下丸。又一百余帖，月经来潮，不到两天就停止。涩脉减少了三分之二。当时天气热，猜想她行经时，必定带有紫色。仍然给前药加醋炒三棱，吞服润下丸。以抑青丸十五粒佐助。又过一个月，块消减了一半。月经按期而来，还比平时少半天。饮食甘美如常，只是吃肉不觉爽快。我令她停药，暂且等到明年春天木气旺盛时再处理。到了次年六月，忽然报告块一夜之间大作，比以前反而增加半个手指粗。脉略弦，左脉略怯于右脉。过几天平和。自己说饱食后则块微闷，食物消化后却自然平复。我猜想必有动心事激怒了她，一问果然如此。仍然在前药中加入炒黄芩、黄连，少许木通、生姜佐助。去掉三棱，煎汤吞服润下丸。外用琥珀膏贴敷。半个月，月经来潮而块消散。这是肺金被火所灼，木邪胜土，土不能运化，清浊相干，旧块的轮廓还在，都是因为气血未能完全恢复，所以浊气稍留，旧块复发。补益其血气，使肺不受邪，木气平和而土气端正，浊气运行而块自然消散。
又一个妇人，三十六岁，家贫多劳作，性格偏狭急躁。自七月月经断绝，八月小腹下有块偏左，如手掌大。块起即痛，到半月后，腹部渐渐肿胀，饮食减少，夜间发热。其脉十月间得虚微短涩，左脉尤其严重。起初给白术一斤，和白陈皮半斤，作二十帖煎服。外用三圣膏贴在块上。过一夜则块软，再过一夜则块变小，位置下降一寸。十天后，饮食增进，热退。又给前药一料，加木香三两。每帖研入桃仁九个。服完此剂，病除。
丹溪又说：一个婢女肤色紫，稍胖，性格沉静多忧，四十岁，月经不行已有三月。小腹当中一块，逐渐如炊饼大小。脉皆涩，重按稍和。块按压则疼痛剧烈。试着抚摸，高半寸。给予千金硝石丸。至四五次，她忽然自己说乳头黑，且有乳汁，恐怕是怀孕。我说：涩脉没有怀孕的道理。又给三五帖，脉稍虚豁。我醒悟道：药太峻烈了。令停止前药。用四物汤，倍加白术，佐以陈皮、炙甘草。至三十帖，候脉充盈，再与硝石丸。至四五次，她忽然自己说块消了一圈。便令不要再给。又半月，月经来潮疼痛剧烈，排出黑血近半升，内有如椒核者数十粒，而块消了一半。又来索药。晓谕她说：块已破，不要再攻伐。只要遵守禁忌，下次月经来潮，自然会消尽。后来果然如此。大凡攻击的药物，有病则病受之。邪气轻则胃受伤了。胃气是清纯中和的，只与谷肉果菜相宜。药石都是偏胜之气，即使是人参、黄芪性也偏，何况攻击性的药物呢？这个妇人胃气弱，血也少。如果等到块尽才停药，存活的胃气就很少了。
又一个妇人因为经水过多，每次用涩药，导致气痛，胸腹有块十三枚，遇夜痛甚。脉涩而弱。丹溪说：这是因为涩药，导致败血不行。用蜀葵根煎汤，再煎人参、白术、青皮、陈皮、甘草梢、牛膝。入元明粉少许，研桃仁调匀。热服二帖，连下块二枚。因为病久血耗，不敢顿下。于是去掉葵根、明粉服用。块渐渐消减。
俞震按语：丹溪的各案，消补兼施，而佐以清肝的居多。间或有用攻击法的。《内经》所谓大积大聚，是可以犯（攻伐）的。但又不能矫枉过正，一味培补，反而蹈入养痈遗患的危害。但丹溪用药，轻重次第，各合机宜，不像子和千篇一律。
王金极说：我的内弟于中甫，饮茶过度，且多愤懑。腹中常漉漉有声。秋天发寒热似疟疾。用十枣汤料黑豆煮，晒干研末，枣肉和丸如芥子大，而以枣汤送下。初服五分不动。又服五分，不久腹痛甚。以大枣汤饮用。大便五六行，都是溏粪无水。时间大约是傍晚。半夜，乃大下数斗积水而疾病平复。当其泻下时，瞑眩反应特别严重，手足厥冷，几乎断气而复苏。全家号泣，都责怪药太峻烈。唉！药可以轻用吗？
张三锡说：曾治疗一个少年，体质薄弱，且咳血。左边一块，不时上攻作痛。左金丸、芦荟都不应。诊其脉三部虽强，而细涩不流利。因而作为阴虚治疗。四物汤加知母、黄柏、玄参、丹皮。不到六剂顿愈。这是阴虚似肝积。由此推之，虽然因部位名积，诊视之际，还应当详审。只有圆机活法的人，才不会蒙蔽于此。
俞震按语：这两条，一条是饮积，以证与因断之。一条是阴虚似肝积，以脉断之。这就是圆机。两家垂训，裨益尤多。
喻嘉言治疗袁聚东，二十岁，生痞块。每天进化坚削痞的药，渐渐至毛发憔悴肌肉脱失，面色黧黑头发卷曲，几乎没有生机。喻嘉言看之，少腹脐旁三块，坚硬如石。用手抚摸，痛不可忍。其脉两尺洪盛，其余都微细。说道：这是由于见块医块，不究其源而误治。初起时块必不坚，以峻猛之药攻伐，真气内乱，反而护持邪气为害。如人被打，纽结一团，迸紧不散。其实全是空气聚成，不像女子月经凝而不行，即成血块那样。观两尺脉洪盛，明是肾气传于膀胱，因服破气药多，膀胱之气不能传前后二便而出，乃结为石块耳。治法须内收肾气，外散膀胱之气，以解其郁结。三剂可愈。先以理中汤加附子五分，块即减十分之三。再用桂枝、附子大剂，腹中气响甚喧，三块一时顿没。然有后虑者，肾气的收藏未固，膀胱的气化未旺，倘若犯房事，块必再作。乃用补肾药加桂枝、附子，多加紫河车为丸。取其以胞补胞而助膀胱之化源也。服用之后，方才不畏寒，腰围渐大，一年多且得子。
俞震按语：此人克伐太过，换以温补，不足为奇。惟有两尺脉洪盛，非此解释，谁不面露难色。至于桂枝、附子、紫河车，同补肾药作为善后之计，则与肾气传膀胱之论紧密切合不泛泛，不是通套治痞的成法可比。
李士材治疗郡守于鉴如，每酒后腹痛，渐渐至坚硬，得食辄痛。李士材诊之曰：脉浮大而长，脾有大积矣。然而两尺按之软，不可峻攻。令服四君子汤七日。投以阴阳攻积丸三钱。但微下。更以四钱服之。下积十余次，都是黑而韧的。观察其形体不倦，又进四钱。于是腹大痛，所下很多。仍服四君子汤十日。又进丸药四钱。去积三次。又进二钱。下积至六七碗。脉大而虚，按至关部豁如矣。乃以补中益气汤调补一月，全愈。
俞震按语：脉浮大而长，为脾有大积。较之丹溪诸案，或沉涩而小且数，或微而短涩，或虚微短涩，或脉涩而弱者，大不同矣。须在临证时，能以古人各种脉法，俱为我之正鹄，庶期中的。若两尺按之软，不可峻攻，固是正理。然而也要看得灵变。盖两尺软为虚，则喻案之两尺洪盛，宁不认为实而峻攻之耶？故又当以形色及病情参讨也。
给谏侯启东腹中嘈痛。士材按其左胁，手不可近。凡饮食到口，喉间若有一物接之者然。李士材曰：脉大而数，腹痛呕涎，面色痿黄。此虚而有湿，湿热相兼，虫乃生焉。当煎人参汤送槟黄丸以下虫积。虫若不去，虽补何益乎？病者畏不敢用。后竟不起。
俞震按语：这是虫积，犹如饮积，都无块状物罢了。那个人肯服十枣丸而愈，这个不肯服槟黄丸而殂。因而知道病之宜补宜攻，总贵用其所当用。确实不可专守洁古之说为稳着也。
周慎斋治疗一个妇人，素来易怒，左胁下有块，身体肥大。月经将要来时，先一两天，既吐又泻。这是肝木乘脾，脾虚生痰不生血也。善怒胁块，肝气亢也。吐下者，脾气虚也。身肥则多痰，痰盛者中焦多湿，故经行时气血流通，冲动脾湿，既吐又泻也。久而不治，必变中满。宜理脾燥湿。白术一两，半夏五钱，生姜七钱，沉香二钱。共为末，白糖和服。
一人左胁下有块，右关脉豁大。周慎斋用乌药一两，以附子五钱浓煎制之。将乌药日磨二三分，酒送下。俟积行动，乃以补中益气汤加附子服之。丸用六君子汤。
俞震按语：慎斋书云：凡积不可用下药，徒损真气，病亦不去。当用消积药，使之溶化，则除根矣。积去须大补，诚格言也。即此二案，亦平淡之神奇。又尝考消积之方，如桃仁煎用大黄、虻虫、芒硝，黑神丸用生漆、熟漆，东垣五积丸俱用川乌、巴豆霜，局方圣散子、三棱煎丸俱用硇砂、干漆。此皆峻厉之药，用而中病，固有神效。若妄尝轻试，鲜不败事矣。千金硝石丸人参、硝黄并用，丹溪犹以为猛剂。治婢一案，每与补药迭进，此真善治病者也。丹溪治积聚案有数十条，轻重曲折，适至病所，惜不能重载。再阅叶氏医案积聚门，只用鸡肫皮、莱菔子、蛤粉、芥子、蜣螂、䗪虫、青皮、朴硝等，并无古方狠药。其理尤可想见。我曾亲眼见叶先生治疗一个妇人，产后着恼，左边小腹结一块。每次发作时，小腹胀痛，从下攻上，膈间乳上皆痛。饮食入胃即吐，遍医不效。先生用炒黑小茴香一钱，桂酒炒当归二钱，自制鹿角霜一钱五分，生楂肉三钱，川芎八分，菟丝子一钱五分，水送阿魏丸七分。八剂而愈。次用乌鸡煎丸原方半料，永不复发。又一人患疟疾补早，左胁成痞，连于胃腕，按之痛甚。用炒桃仁为君，佐以阿魏、穿山甲、鳖甲、麝香，丸服，全消。此二条较之临证指南所载者为更佳，故附于此。我又亲见杭州一富家妇患痞块，用黑神丸大效。每痛作呕胀不堪，服此即愈。数十服后百苦皆除。然半年外，以他病暴殒。因思漆身为癞之言，脏腑岂堪常漆耶？清纯冲和之气耗丧于此药而不觉也。再观丹溪治方提领，用参、术、归、芍等煎汤，下保和丸二十五，龙荟丸十五。治冯氏女，先用左金丸、青六丸，后用参橘桃芍丸。治卢子裕疟后食酒肉而成块在左胁，用参、术、柴、苓、枳壳煎汤，下阿魏五，保和二十，抑青十，与点十。攻块者，青皮、三棱、桃仁、桂枝、海藻、醋调神曲为丸也。治下邳钱郎，用保和二十。
The monk Ying Gong of Xingqing Temple had had internal stagnation for several years. Every night after the fourth watch (1:00 AM - 3:00 AM), he suffered from pain and hardness in the heart and head, unable to lie down peacefully. He had to get up and walk around the temple, which became a routine. No one knew what disease this was. He sought treatment from Dairen (Zhang Congzheng). Dairen instructed him to induce vomiting, expelling one or two *sheng* (a unit of volume) of gelatinous phlegm-fluid, black like alum water. Subsequently, yellow-green water was expelled. Then, purgation was applied, expelling pus and blood by several *sheng*. From then on, he felt as if a huge mountain had been removed from his chest. He ate and drank without limit and slept soundly until dawn.
The wife of Liu Ziping from the Orchard had an abdominal mass the size of a ladle for eighteen years. Her menstruation had ceased, and various treatments were ineffective. Dairen instructed her to undergo emesis four times and purgation six times within one month. The expelled phlegm amounted to about one or two buckets, containing undigested matter resembling vegetable leaves or rotten fish intestines. She felt that the accumulated pathogen was being scraped away, gradually flattening out. Once the accumulation was completely cleared, the abdominal indentation became concave like a mortar, with no damage to her body. At this point, her face regained a youthful ruddy color, and her menstruation resumed.
The daughter-in-law of a bow-maker Du, aged thirty, had been pregnant for a year and a half. Whenever she experienced pain, she would summon a midwife, believing labor was imminent. However, after one or two days, she returned to normal. This happened several times. She then consulted Dairen. Dairen palpated her pulse, finding it choppy (*Se*) and small, and diagnosed: "This is a mass disease (*Ji Bing*), not pregnancy." The *Mai Jue* states that a choppy pulse resembles a knife scraping along bamboo, indicating essence injury in men and ruined blood in women. The treatment principle is: when there is pathology below, purge it. He administered over one hundred pills of *Zhouche Wan* (Boat Cart Pill). Later, he used *Tiaowei Chengqi Tang* (Regulate the Stomach and Direct Downward Decoction) added with *Dang Gui* (Angelicae Sinensis Radix) and *Tao Ren* (Persicae Semen). Two or three days later, he again used *Zhouche Wan* and *Tao Ren Chengqi Tang*. Green and yellow pus and blood were mixed and expelled. During each bowel movement, she pushed and rubbed downwards with her hand to assist expulsion. Two or three days later, he used *Zhouche Wan*, *Zhushen San* (Pig Kidney Powder), and *Tongjing San* (Unblock Menstruation Powder), etc., continuing purgation for several days. When the weather cleared, before meals, he punctured the *Sanyinjiao* (SP6) acupoint to drain excess. Within ten days, the illness disappeared.
Yu Zhen's commentary: Hezi (Dairen) has about ten such verified treatment cases. In recording the pulse manifestations, they are either deep and fine (*Chen Xi*) or deep and slow (*Chen Chi*). This case describes a pulse that is small and choppy. Regarding medication, for accumulations above, *Chatiao San*, *Sansheng San*, and *Gaditu San* are primary; for accumulations below, *Zhouche Wan*, *Shenxiong Wan*, *Chengqi Tang*, and *Tongjing San* are primary; for accumulations in the middle, they are used in combination. Emesis and purgation were performed dozens of times, filling five or six jars. Such patients must belong to the vigorous type like Xiang Yu or Fan Kuai. However, just as General Fan ate raw pork shoulder at the Hongmen Banquet while angry without forming an accumulation, it is said that robust individuals do not form accumulations, only deficient ones do. Jiegu’s theory that "nourishing the upright causes the accumulation to remove itself" shows great insight. Why did Ma Zhiji and others exaggerate this view to confuse the world?
I further note: Hezi was from Suizhou. The soil and water of Henan are dense and solid, which might explain this. Later generations learned his intent and used the *Dao Cang Fa* (Stomach Lining Method), also using emesis and purgation to remove accumulation. Wang Jinji highly praised it, stating that meat juices fill the intestines and stomach, flowing like a flood, pushing floating wood and decay out through agitation. However, Xu Donggao stated: This method is only suitable for those with substantial Yuan Qi. For deficiency consumption, tuberculosis, drum distension, or regurgitation where the true disease is established and all six pulses are powerless, it must not be used. I have seen improper use often leading to death. Seeing this, I am more wary of easily trying formulas like *Sansheng San* and *Sanhua Fang*.
Chen Ziming said: My clan nephew's wife had a large mass in her abdomen like a cup. Each attack caused unbearable pain. I diagnosed it as *Xue Jia* (Blood Mass). I administered *Heishen Wan* (Black Divine Pill). After finishing three pills, the mass qi dissipated completely, never recurring in her lifetime.
Yu Zhen's commentary: *Heishen Wan* is recorded in *Jiyin Gangmu*. One pill the size of a bullet is divided into four doses. It is claimed that for *Ge Qi* (Diaphragmatic Qi stagnation), ten doses are needed; for diaphragmatic masses, five doses; for *Xue Jia*, three pills until recovery. It is likely a miraculous formula. It is noted that lacquer has a "flying tonification" power. However, some people develop lacquer dermatitis upon contact. Misuse could be harmful. Caution is required. I once saw a woman who, due to epigastric masses and amenorrhea, had a local physician apply raw lacquer thickly on paper, dry it, grind it to ash, and mix it with blood-invigorating herbs. After a few doses, she suddenly expelled a bucketful of bright red blood, becoming extremely weak. Although I treated her with massive tonics, she eventually died of a chronic weak condition. Where is this "flying tonification"?
Danxi treated a woman whose dead blood, food stagnation, and phlegm-fluid formed a mass. It appeared in both hypochondria, causing abdominal borborygmus and dyspepsia, dizziness, and fever when moving, coming and going intermittently. He used *Huang Lian* (Coptidis Rhizoma) 1 liang. *Zhu Yu* (Evodiae Fructus) and *Yi Zhi* (Alpiniae Oxyphyllae Fructus) were stir-fried separately, half each; the Zhu Yu and Yi Zhi were discarded. *Xiang Fu* (Cyperi Rhizoma) was soaked in child's urine. *Zha Rou* (Crataegi Fructus flesh) was 1 liang. *Luobo Zi* (Raphani Semen) was 1.5 liang. *San Leng* (Curcumae Rhizoma) and *E Zhu* (Zedoariae Rhizoma) were boiled in vinegar. *Tao Ren* (Persicae Semen) retained its tip and was peeled. *Qing Pi* (Citri Reticulatae Pericarpium Viride), *Mai Ya Qu* (Hordei Fructus Germinatus with yeast), *Shan Zhi* (Gardeniae Fructus), and *Tai Xiong* (Ligustici Chuanxiong Rhizoma) were each 5 qian. These were stir-fried, ground into powder, and made into pills with steamed wheat dough.
He also treated Lv Zongxin, aged sixty, who loved alcohol. He fell ill while traveling in summer heat. His feet were cold above the knees. An epigastric mass the size of a fist caused radiating hypochondriac pain, preventing sleep. Food intake was halved, yet he felt no thirst. He had already taken three doses of *Shengliao Wuji San* (Raw Material Five Accumulations Powder). Zhu Danxi diagnosed his six pulses as all deep, choppy, and small, but firm upon pressure, and rapid, especially on the right. Bowel movements were normal; urine was red. He prescribed *Da Chengqi Tang* (Major Order the Qi Decoction). The *Da Huang* (Rhei Radix et Rhizoma) was stir-fried熟 (cooked). Added were *Huang Lian*, *Gan Ge* (Puerariae Radix), *Xiong* (Chuanxiong), *Shao* (Baishao), and *Gan Cao* (Glycyrrhizae Radix) as a decoction. Pills were made from *Lou Ren* (Trichosanthis Semen), *Huang Lian*, *Ban Xia* (Pinelliae Rhizoma), and *Bei Mu* (Fritillariae Bulbus). After twenty doses, the mass reduced by half, so medication stopped. Half a month later, diet recovered, and all symptoms vanished.
Danxi said: A woman in her forties, pale-faced and thin, with a quick temper. Due to significant dissatisfaction, a mass formed under the breast against the ribs, gradually growing to cover the heart area. It was slightly painful, with diaphragmatic fullness and bitter taste. Food intake dropped to one-quarter of normal. Both hands' pulses were faint, short, and choppy. Knowing her menstruation had stopped, I feared for her greatly and advised against treatment. Thinking until midnight, she could still go out to see doctors and spoke normally. I deduced she still had Stomach Qi. So, I gave large doses of *Ren Shen* (Ginseng Radix), *Bai Zhu* (Atractylodis Macrocephalae Rhizoma), *Dang Gui* (Angelicae Sinensis Radix), and *Chuan Xiong* (Ligustici Chuanxiong Rhizoma), assisted by Qi-regulating herbs. Externally, *Hupo Gao* (Amber Plaster) was applied to the mass to prevent growth. Over two to three months, she took about two hundred doses. Diet reached half of normal, and pulses became fuller. She continued the previous medicine swallowing *Runxia Wan* (Moisten and Descend Pill). After another hundred-plus doses, menstruation started but lasted less than two days. The choppy pulse reduced by two-thirds. As the weather was hot, I anticipated her menses would be purple. I added vinegar-processed *San Leng* to the previous prescription, swallowing *Runxia Wan*, assisted by fifteen pills of *Yiqing Wan* (Suppress Liver Fire Pill). After another month, the mass reduced by half. Menstruation arrived on time, though half a day shorter than usual. Diet was sweet and normal, but eating meat felt unsatisfying. I told her to stop medication and wait for spring when Wood Qi is prosperous to plan further. In June of the next year, she reported the mass suddenly enlarged overnight, half a finger thicker than before. The pulse was slightly wiry, left weaker than right. After a few days, it normalized. She said the mass felt slightly stuffy after full meals but flattened after digestion. I suspected emotional agitation triggered it, which proved true. I added stir-fried *Huang Qin* (Scutellariae Radix) and *Huang Lian* to the previous formula, with a little *Mu Tong* (Akebiae Caulis) and *Sheng Jiang* (Zingiberis Rhizoma Freshum). *San Leng* was removed. The decoction was taken swallowing *Runxia Wan*. Externally, *Hupo Gao* was applied. Half a month later, menstruation occurred and the mass dispersed. This was Lung Metal scorched by Fire, Wood evil overcoming Earth, Earth failing to transport, clear and turbid Qi interfering. The outline of the old mass remained because Qi and Blood had not fully recovered, leaving turbid Qi behind, causing the mass to reappear. Tonifying Qi and Blood prevents Lung from suffering evil, levels Wood Qi, rectifies Earth Qi, moves turbid Qi, and the mass disperses naturally.
Another woman, thirty-six, poor and overworked, narrow-minded and irritable. Since July, menstruation ceased. In August, a mass appeared on the lower left abdomen, palm-sized. Pain arose with the mass. By half a month, the abdomen swelled, food decreased, and night fevers occurred. In October, the pulse was deficient, faint, short, and choppy, worse on the left. Initially, I gave 1 jin of *Bai Zhu* and half a jin of *Bai Chen Pi* (White Tangerine Peel), prepared as twenty doses of decoction. Externally, *Sansheng Gao* (Three Saints Plaster) was applied. After one night, the mass softened; after two nights, it shrank and moved down one cun. Ten days later, food intake increased, fever subsided. Another dose of the previous medicine was given, adding 3 liang of *Mu Xiang* (Vladimiriae Radix). Nine *Tao Ren* were ground into each dose. Upon finishing this course, the illness was cured.
Danxi also said: A maid with purple skin, slightly fat, quiet and worried, aged forty. Menstruation had stopped for three months. A mass in the center of the lower abdomen grew to the size of a steamed bun. Pulses were all choppy, slightly harmonious upon heavy pressure. Pressing the mass caused severe pain. Palpation showed it protruded half a cun. I gave *Qianjin Xiaoshi Wan* (Thousand Gold Niter Pill). After four or five times, she suddenly said her nipples were dark and had discharge, fearing pregnancy. I said: A choppy pulse does not indicate pregnancy. After three or five more doses, the pulse became slightly empty and hollow. I realized: The medicine was too harsh. I ordered stopping the previous medicine. I used *Siwu Tang* (Four Substances Decoction), doubling *Bai Zhu*, assisted by *Chen Pi* (Tangerine Peel) and *Zhi Gan Cao* (Prepared Licorice Root). After thirty doses, waiting for the pulse to fill, I gave *Xiaoshi Wan* again. After four or five times, she suddenly said the mass had shrunk by one circle. I ordered stopping immediately. Half a month later, menstruation came with severe pain, expelling nearly half a *sheng* of dark blood containing dozens of particles like pepper seeds. The mass reduced by half. She came for more medicine. I explained: The mass has broken. Do not attack further. Just observe taboos. Next month, menstruation will cause it to disappear completely. This indeed happened. Generally, attacking medicines are borne by the disease. If the pathogen is light, the Stomach is injured. Stomach Qi is pure, clear, and harmonious, suited only to grains, meats, fruits, and vegetables. Medicinal stones possess biased energies. Even *Ren Shen* and *Huang Qi* have bias, let alone attacking drugs. This woman had weak Stomach Qi and little Blood. If we waited until the mass was gone to stop medication, very little Stomach Qi would remain.
Another woman, due to excessive menstrual flow, repeatedly used astringent herbs, causing Qi pain. Thirteen masses formed in the chest and abdomen, severe pain at night. Pulse was choppy and weak. Danxi said: This is due to astringent herbs causing stagnant blood to fail to move. He used *Shuhui Gen* (Malvae Radix) decoction, then decocted *Ren Shen*, *Bai Zhu*, *Qing Pi*, *Chen Pi*, *Gan Cao Shao* (Licorice Tip), and *Niu Xi* (Achyranthis Bidentatae Radix). A little *Yuan Ming Fen* (Mirabilite) was added, mixed with ground *Tao Ren*. Taken hot for two doses. Two masses were expelled consecutively. Because the illness was long and blood depleted, I dared not purge heavily. Thus, *Shuhui Gen* and *Yuan Ming Fen* were removed. The mass gradually diminished.
Yu Zhen's commentary: Danxi's cases combine reduction and tonification, mostly assisting with clearing the Liver. Occasionally, attacking methods are used. As the *Neijing* states, major accumulations can be attacked. Yet, one must not correct Hezi's errors by blindly tonifying, which leads to nurturing the tumor and feeding the bandit. However, Danxi's medication, in weight and sequence, fits the indications perfectly, unlike Hezi's uniform approach.
Wang Jinji said: My brother-in-law Yu Zhongfu drank tea excessively and was often resentful. His abdomen often gurgled. In autumn, he developed chills and fever resembling malaria. He boiled *Shizao Tang* ingredients with black beans, dried them, ground them to powder, mixed with jujube paste to make mustard-seed-sized pills, taken with jujube decoction. Initial dose of 5 fen had no effect. Another 5 fen caused severe abdominal pain shortly after. Given jujube decoction, he had five or six bowel movements of watery stool without water content. It was late afternoon. At midnight, he purged several dou of accumulated water, and the illness calmed. During the purge, the adverse reaction was severe; limbs were cold, he nearly died and revived. The family wailed, blaming the harsh medicine. Alas! Can medicine be used lightly?
Zhang Sanxi said: I once treated a youth, weak constitution, coughing blood. A mass on the left occasionally attacked upwards causing pain. *Zuojin Wan* and *Luhui* (Aloe) were ineffective. The pulse in all three positions was strong but fine, choppy, and unsmooth. I treated it as Yin deficiency. *Siwu Tang* added with *Zhi Mu* (Anemarrhenae Rhizoma), *Huang Bai* (Phellodendri Cortex), *Yuan Shen* (Scrophulariae Radix), and *Dan Pi* (Moutan Cortex). In less than six doses, he was cured. This is Yin deficiency mimicking Liver accumulation. From this, we infer that although accumulations are named by location, diagnosis requires careful examination. Only those with flexible wisdom avoid being misled.
Yu Zhen's commentary: These two cases: one is fluid accumulation, diagnosed by signs and cause. The other is Yin deficiency mimicking Liver accumulation, diagnosed by pulse. This is flexibility. Their teachings are very beneficial.
Yu Jiayan treated Yuan Judong, aged twenty, who developed a痞块 (epigastric mass). Daily administration of hardening-resolving and mass-reducing medicines led to hair loss, muscle wasting, dark wrinkled face, and curly hair, nearing death. Yu Jiayan observed three masses beside the navel in the lower abdomen, hard as stone. Touching caused unbearable pain. The pulses at both *Chi* positions were surging and abundant, while others were faint and fine. He said: This is treating the mass without investigating the source. Initially, the mass was not hard. Harsh attacks disrupted True Qi, protecting the pathogen. Like being beaten, knots tighten and do not disperse. It is actually air accumulation, unlike female menstrual blood stasis forming clots. The surging *Chi* pulses clearly indicate Kidney Qi transmitting to the Bladder. Due to excessive Qi-breaking medicines, Bladder Qi cannot transmit to the anterior and posterior orifices, knotting into stone-like masses. Treatment must internally gather Kidney Qi and externally scatter Bladder Qi to resolve the knot. Three doses should cure. First, *Lizhong Tang* (Regulate the Middle Decoction) added with 5 fen of *Fu Zi* (Aconiti Lateralis Radix Praeparata). The mass reduced by three-tenths. Then, large doses of *Gui Zhi* (Cinnamomi Ramulus) and *Fu Zi*. Abdominal Qi sounded loudly. All three masses disappeared at once. However, concern remained: Kidney storage was not solid, Bladder transformation not vigorous. If sexual activity occurred, the mass would recur. Thus, Kidney-tonifying medicine added with *Gui Zhi* and *Fu Zi*, plus much *He Che* (Placenta Humana), was made into pills. Using the womb to tonify the womb aids Bladder transformation source. After taking it, he no longer feared cold, waist circumference increased, and over a year later, he fathered a child.
Yu Zhen's commentary: This patient suffered excessive depletion; switching to warming and tonifying is not surprising. Only the surging *Chi* pulses require this explanation; otherwise, who wouldn't hesitate? Using *Gui Zhi*, *Fu Zi*, and *He Che* with Kidney tonics for follow-up care closely aligns with the theory of Kidney Qi transmitting to the Bladder, unlike standard痞 treatment routines.
Li Shicai treated Prefect Yu Jianru. Post-alcohol abdominal pain gradually hardened, pain upon eating. Li diagnosed: Pulse floating, large, and long indicates a major Spleen accumulation. However, pressing the *Chi* positions yields softness; harsh attack is contraindicated. He prescribed *Sijunzi Tang* (Four Gentlemen Decoction) for seven days. Then administered 3 qian of *Yinyang Gongji Wan* (Yin-Yang Attacking Accumulation Pill). Mild purgation resulted. Increased to 4 qian. Purged accumulation over ten times, black and tough. Observing his energy remained, he took another 4 qian. Severe abdominal pain followed, with massive expulsion. He resumed *Sijunzi Tang* for ten days. Another 4 qian of pills. Three more purges. Then 2 qian. Expelled six or seven bowls of accumulation. Pulse became large and deficient, empty at the *Guan* position. He then used *Buzhong Yiqi Tang* (Tonify the Middle and Augment the Qi Decoction) for one month of regulation, resulting in full recovery.
Yu Zhen's commentary: Floating, large, and long pulse indicates major Spleen accumulation. This differs greatly from Danxi's cases, which featured deep/choppy/small/rapid, faint/short/choppy, deficient/faint/short/choppy, or choppy/weak pulses. Clinicians must master various ancient pulse methods to hit the target accurately. While soft *Chi* pulses contraindicating harsh attack is correct reasoning, flexibility is key. Soft *Chi* indicates deficiency, whereas Yu's case had surging *Chi* pulses, which might be mistaken for excess requiring harsh attack. Thus, appearance and condition must be considered together.
Censor Hou Qidong had abdominal嘈杂 (borborygmus/pain). Li Shicai palpated his left hypochondrium; it was tender to touch. Food entering the mouth felt obstructed in the throat. Li said: Pulse large and rapid, abdominal pain, vomiting saliva, sallow complexion. This is deficiency with dampness, combined damp-heat generating parasites. One should decoct *Ren Shen* soup to send *Binghuang Wan* (Areca Seed and Realgar Pill) to expel parasitic accumulation. If parasites are not removed, what good is tonification? The patient feared and refused. He eventually died.
Yu Zhen's commentary: This is parasitic accumulation, similar to fluid accumulation, lacking a distinct mass. That patient recovered with *Shizao Wan*, while this one died refusing *Binghuang Wan*. Thus, whether to tonify or attack depends on appropriateness. One cannot rigidly adhere to Jiegu's theories for safety.
Zhou Shenzhai treated a woman prone to anger, with a mass in the left hypochondrium, obese. Before menstruation, one or two days prior, she vomited and had diarrhea. This is Liver Wood overacting on Spleen; Spleen deficiency generates phlegm instead of blood. Anger and hypochondriac mass indicate hyperactive Liver Qi. Vomiting and diarrhea indicate Spleen Qi deficiency. Obesity implies phlegm; phlegm abundance implies middle Jiao dampness. Thus, during menstruation, Qi and Blood flow, stirring Spleen dampness, causing vomiting and diarrhea. Untreated, it becomes abdominal fullness. Treatment: Regulate Spleen and dry dampness. *Bai Zhu* 1 liang, *Ban Xia* (Pinelliae Rhizoma) 5 qian, *Sheng Jiang* 7 qian, *Chen Xiang* (Aquilariae Lignum) 2 qian. Ground to powder, taken with white sugar.
A man had a mass in the left hypochondrium, right *Guan* pulse wide and large. Zhou used 1 liang of *Wu Yao* (Linderae Radix), processed by decocting with 5 qian of *Fu Zi*. He ground 2-3 fen of *Wu Yao* daily, taken with wine. Once the accumulation moved, he used *Buzhong Yiqi Tang* added with *Fu Zi*. Pills were made from *Liujunzi Tang*.
Yu Zhen's commentary: Shenzhai wrote: Accumulations must not be treated with purgatives, which only damage True Qi without removing the disease. Use resolving medicines to dissolve them, eliminating the root. After removal, major tonification is essential. This is a golden rule. These two cases are miracles in simplicity. Examining resolving formulas: *Taoren Jian* uses *Da Huang*, *Meng Chong* (Aselli), *Mang Xiao* (Mirabilite); *Heishen Wan* uses raw and cooked lacquer; Dongyuan's *Wuji Wan* uses *Chuan Wu* (Aconiti Radix) and *Ba Shuang* (Crotonis Semen); Bureau Formula's *Shengsanzi* and *San Leng Jian Wan* use *Nao Sha* (Sal Ammoniac) and *Gan Qi* (Dry Lacquer). These are harsh medicines. Effective when hitting the mark, but reckless testing fails. *Qianjin Xiaoshi Wan* combines *Ren Shen* with *Xiao Shi* (Natrii Sulfas) and *Da Huang*, which Danxi considered fierce. In treating the maid, he alternated with tonics, truly mastering disease treatment. Danxi has dozens of accumulation cases, varying severity and sequence to fit the pathology. Ye Tianshi's accumulation cases use only chicken gizzard lining, radish seed, clam shell powder, mustard seed, dung beetle, ground beetle, Qingpi, and Poxiao, without harsh ancient formulas. The logic is evident. I personally saw Mr. Ye treat a postpartum woman angered, with a left lower abdominal mass. Attacks caused lower abdominal pain radiating upward to diaphragm and breasts. Vomiting upon eating. Various doctors failed. Mr. Ye used stir-fried black *Xiao Huixiang* (Foeniculi Fructus) 1 qian, *Gui Jiu Chao Dang Gui* (Cinnamon Wine-Fried Angelica) 2 qian, self-made *Lujiaoshuang* (Deer Horn Frost) 1.5 qian, raw *Zha Rou* 3 qian, *Chuan Xiong* 8 fen, *Tusizi* (Cuscutae Semen) 1.5 qian, taken with water and 7 fen of *awei Wan* (Asafoetida Pill). Cured in eight doses. Followed by half dose of *Wuji Jian Wan*, no recurrence. Another malaria patient treated too early developed a left hypochondriac痞 connected to the stomach, painful on pressure. *Chao Taoren* (Stir-fried Peach Kernel) was chief, assisted by *awei*, *Chuanshanjia* (Manis Squama), *Biejia* (Testudinis Carapax), and *Shexiang* (Moschus), made into pills. Completely resolved. These two cases are better than those in *Linzheng Zhinan*. I also saw a wealthy Hangzhou woman with a痞 treated effectively with *Heishen Wan*. Vomiting and distension ceased upon taking it. After dozens of doses, all bitterness removed. However, she died suddenly six months later from another illness. Considering the saying "lacquer makes one leprous," how can organs withstand constant lacquer? Pure and harmonious Qi is consumed unknowingly. Danxi treated Fang Tiling with *Ren Shen*, *Bai Zhu*, *Dang Gui*, *Bai Shao* decoction, taking 25 *Baohe Wan* and 15 *Longhui Wan*. For Feng's daughter, first *Zuojin Wan* and *Qingliu Wan*, then *Shenju Tao Shao Wan*. For Lu Ziyu's post-malaria mass from alcohol/meat in left hypochondrium, *Ren Shen*, *Bai Zhu*, *Chai Hu*, *Fu Ling*, *Zhi Ke* decoction, taking 5 *awei*, 20 *Baohe*, 10 *Yiqing*, and 10 *Yudian*. Attacking the mass used *Qing Pi*, *San Leng*, *Tao Ren*, *Gui Zhi*, *Haizao* (Sargassum), and vinegar-mixed *Shenqu* (Medicated Leaven). For Qian Lang from Xiapi, 20 *Baohe...*