增补评注柳选医案
评选静香楼医案两卷
此案为尤在泾先生所著。先生名怡，字在泾，自号饲鹤山人，江苏长洲县人。邃于医学，于仲景书尤能钻研故训，独标心得。时吴下以医名者，如叶氏桂、徐氏大椿、王氏子接，均煊耀一时。先生与之联镖接轸，辉映后先，于医道中可谓能树一帜者。所著有伤寒论贯珠集、金匮心典、医学读书记，均刊行。惟此案未经授梓，其附刻于读书记后者，仅有三十余条，非全本也。此本为吾邑吴氏所钞藏，咸丰兵燹后，诒于詹文桥张氏斋头见之，假归钞录。复就其中选精粹者，得十之五，评录如左。分上下两卷。窃念近时医学荒废，其简陋剽袭，毫无心得者，无论已。间有钻研古籍，不知通变者，动辄以仲景为家法，而咎今人不能用古方，目为庸陋。其实古方今病，往往枘凿不相入，执而用之，偾事者多矣。及读先生此案，而不觉憬然有悟也。先生博极群籍，尤服膺仲景之书，所著伤寒论金匮两注，上溯仲景心传，独抒己见。读其书者，无不知先生之于仲景，不啻升其堂而入其室已。乃观此案，论病则切理餍心，源流俱沏，绝不泛引古书，用药则随证化裁，活泼泼地，从不蹈袭成方。可见食古期乎能化，裁制贵乎因时。彼徒执古书者，不且与王安石之周官，房琯之车战，其弊适相当哉。是故读他人之案，有不用古方者，或犹疑其服古未深，未能得力于仲景也。若先生则读书不可谓不多，用功不可谓不切，其沉酣于仲景之书，尤不可谓其不深，乃其论病之平易近情也如是，立方之妥帖易施也如是。是则此案不第为治病之良规，并可为读古之心法已。用书之以谛后之读此案者。光绪二十六年庚子二月下旬江阴后学柳宝诒识。
评选静香楼医案上卷
长洲尤 怡在泾著
内伤杂病门
阴亏于下，阳浮于上。服八味丸不效者，以附子走窜不能收纳耳。宜加减法
诒按：议论精细，可为用药者开一悟境。
邓评：附子既已不合，则桂亦恐碍浮阳，何不参介类以潜之。
肝阳盛，肝阴虚，吸引及肾，肾亦伤矣。益肝体，损肝用，滋养肾阴，俾水木相荣，病当自愈。
诒按：此必因肝火而见血者，故方药如此，
左关独大，下侵入尺。知肝阳亢甚，下吸肾阴，阴愈亏则阳益张矣。滋水清肝，乃正法也
诒按：方中似宜再增清肝之品
邓评：核参方案，此病当有遗精、淋浊之类。
阴不足者，阳必上亢而内燔。欲阳之降，必滋其阴，徒恃清凉无益也。
诒按：案语精粹，有名隽气。
邓评：治病求本，此之谓欤。
孙评：必阴大伤而热炽者，但清其热则阴愈伤。
肾阴不足，肝火乘之，故有筋挛骨痿，耳窍二阴气出等证。夫肝火宜泄，肾精宜闭，于一方之中，兼通补之法，庶几合理，然非旦夕所能奏功也。
诒按：既有胁痛见证，似当兼与通络清肝，宜加丹皮、山栀，青皮、橘络、旋覆等味。
清金以制木，是亦一法。兼与通络，尤为尽善。
咯血胁痛，项下有核，脉数恶热，咽痛便溏。此肝火乘脾之证，反能食者，脾求助于食，而又不能胜之则痞耳。治在制肝益脾
诒按：论病明快，方中拟加丹、栀、夏枯草。
邓评：此必阴虚而抉痰湿，滋燥最难偏任，惟有主用制肝，足以取胜。选药尚称平善。或以丹、栀易川连。
饮食既少，血去过多，阴气之伤，盖已甚矣。兹复忧劳惊恐，志火内动，阴气益伤，致有心烦、体痛、头疼等证。是当滋养心肝血液，以制浮动之阳者也。
诒按：肝阴既亏，肝火上升，宜再加归、芍，以滋养之；羚羊，菊，栀，以清泄之。
邓评：层层推测，则病无遁情矣。
柳师加味较原方切实。若脉非弦大，惟羚羊去之。
肝藏失调，侵脾则腹痛，侮肺则干咳，病从内生，非外感客邪之比。是宜内和藏气，不当外夺卫气者也。但脉弱而数，形瘦色槁，上热下寒，根本已漓，恐难全愈。
诒按：此内补建中法，宜于腹痛，而不宜于干咳。宜加清肝保肺之味，乃为周匝。
邓评：议病确凿。方内惟桂枝不妥。参入吴萸炒桑白皮、蜜炙陈皮，较为胜着；乌梅、桔梗，亦可参用。
孙评：此方与叶氏并驾齐驱。清肝保肺，如石斛、麦冬，亦颇相宜。
形盛脉充，两尺独虚，下体麻痹，火浮气急。此根本不固，枝叶虽盛，未足恃也。
诒按：如此脉证，似可参用肾气法以温摄之。
邓评：能于虚实疑似之间探出真谛，胸中既能了了，笔下自无余蕴。
真阳以肾为宅，以阴为妃，肾虚阴衰，则阳无偶而荡矣。由是上炎则头耳口鼻为病，下走则膀胱二阴受伤。白春及秋，屡用滋养清利之剂，欲以养阴，而适以伤阳，不能治下，而反以戕中。内经所谓热病未已，寒病复起者是也。鄙意拟以肾气丸，直走少阴，据其窟宅而招之，同声相应，同气相求之道也。所虑者，病深气极，药入不能制病，而反为病所用，则有增剧耳。
诒按：立论透切，医案中仅见之作。
邓评：要知滋清大过，每有是症。缘虚阳游行于三焦经络，非阳火亢盛、上充下斥之比。
此案洵属可法。非阅历有得者不能道只字。
反为病所用者，恐其杜、附助阳耳。病至深权，每有此弊。
孙评：议论非名大家，其孰能之。
真阳气弱，不荣于筋则阴缩，不固于里则精出，不卫于表则汗泄。此三者，每相因而见，其病在三阴之枢，非后世方法可治。古方八味丸，专服久服，当有验也。
诒按：见识老到，议论明确，此为可法可传之作。
邓评：《金匮》桂枝龙牡汤，似与此症适合，记出以资博雅。
胃寒背冷，食入则倦，喜温恶清。以背为阳位，胃为阳土，土寒则食不运，阳伤则气不振也。治宜温养阳气。
诒按：此温中和气，平正通达之方。
邓评：一派虚寒，温养奚疑。
中气虚寒，得冷则泻，而又火升齿衄。古人所谓胸中聚集之残火，腹内积久之沉寒也。此当温补中气，俾土厚则火自敛。
诒按：议病立方，均本喻氏。近时黄坤载亦有此法。
邓评：辨真假之关键处，学者最宜留意。若属夫肾者，又须八味丸治之。干姜宜易炮姜。
类 中 门
类中偏左，于法为逆，犹幸病势尚轻，可以缓图取效。原方补少通多，最为合理。惟是阳脉则缓，阴脉则急，所以指节能屈不能伸，此亦病之关键处，刁；可忽也。经云：肝苦急，宜食甘以缓之。于前方中增进阴药之甘润者一二，更为完备。
邓评：左半属阴血，病机较深，故为逆。
指节屈不能伸，病在厥阴肝经，是阴脉则急之义。若治痿取阳明，即阳脉则缓者矣。
再诊：加当归
脉虚而涩，左半手足麻痹，食不知味。此气血不能运行周体，乃类中之渐也。
诒按：滋养疏化，虚实兼到。
邓评：此从金匮血痹例治。
内风本皆阳气之化，然非有余也，乃二气不主交合之故。今形寒跗冷，似宜补阳为是。但景岳云：阳失阴而离者，非补阴无以摄既散之元阳。此证有升无降，舌绛牵掣，瘩不出声，足蹵不堪行动。当与河间肝肾气厥同例，参用丹溪虎潜法。
诒按：持论明通，立方筒当。
邓评：此少阴不至则为痔厥，下虚上实之候也。堪为妄用附、桂，动辄谓引火归源者告。虎骨易苁蓉，较与舌绛无碍，
孙评；此等句今不得而见之矣
邓评：方内温润益阳之品足矣，何必再加此味。
肾气丸 淡盐汤送下
诒按：先清之，继滋之，终用引火下行之法。步伐井然，凌躐急功者，可取法焉。
邓评：统阅三方，第一方偏于清火，第二方专重滋阴，第三方复参温导。虽似有步伐，究未能认真病源，归于一律。
方书每以左瘫属血虚，右痪属气虚。据述频年已来，齿疼舌赤，常有精浊。纳谷如昔，卒然右偏，肢痿舌强，口喁语蹇，脉浮数动。此乃肝肾两虚，水不涵木，肝风暴动，神必昏迷。河间所谓肝肾气厥，舌瘩不语，足痱无力之证。伹肾属坎水，真阳内藏，宜温以摄纳；而肝藏相火内寄，又宜凉以清之。温肾之方，参入凉肝，是为复方之用。
诒按：即古法而化裁之。参详脉证，斟酌尽善。
邓评：以各证推之，虽偏中于右，而精水亦自亏也。此即临证之活泼处。
肝阳旺者，温肾不用桂、附；肾气虚者，凉肝只以天冬，斯为斟酌尽善之法。
孙评：案语分析爽快。惟叶氏开此一解，振千古之聋赎。
寒热后，邪走手少阴之络，猝然不语，肩背牵引不舒。宜辛以通之。
诒按：方法轻灵，恰合余邪入络治法。
邓评：此症必有痰火窜闭络脉，再加钩钩、姜汁，竹沥，于痰火一层，稍为着力。
孙评：似宜兼用万氏牛黄清心丸。
脉濡，按之则弦，右肩及手指麻木，两腿酸痒，难以名状。此脾饮肝风，相合为病，乃类中之渐，不可不慎。
首乌 天麻 刺蒺藜 羚羊角 炙草 茯苓 半夏 白芍 丹皮 广皮 姜汁和竹沥泛丸
诒按：以二陈、姜汁、竹沥除痰饮，以丹、芍、羚、蒺，首乌、天麻治肝风，两层俱到。就见证论，归身、牛膝、橘络，亦可加入。
邓评：脉濡属湿，弦则为风，风与湿合，放麻木酸痒，所谓饮者正由湿化也。羚羊宜与桂枝并用始妥，即木瓜，薏仁亦可参入。
孙评：牛膝、橘络，既可导之下行，又能通络，心思灵通。惟肢麻腿痒，是痰流入络，筋为痰滞，宜加桑枝、丝瓜络，通之为要。
痿 痹 门
脉虚而数，两膝先软后肿，不能屈伸。此湿热乘阴气之虚而下注，久则成鹤膝风矣。
诒按：正虚着邪，故补散宜并用；湿而兼热，故滋燥不可偏。此以六味治阴虚，增入牛膝、木瓜、薏仁、茸藓以除湿热，所谓虚实兼顾也。
邓评：此确属阴虚湿热，竟能由痹成痿。
立方殊妥善。再加广皮或生姜，则着痹之邪较克流行。
孙评：柳氏指点分明，可为读书者开一便径，于初学大有补益也
内 风 门
肢麻头运，此肝病也。便溏食减，脾亦病矣。宜节劳养气，毋致风动为佳。
邓评：方论俱朗朗，无片云纤翳。惟羚羊尚恐碍脾阳，入牡蛎较妥。
眩运呕恶胸满，小便短而数，口中干。水亏于下，风动于上，饮积于中，病非一端也。
诒按：病非一端，方欲打成一片，非熟于制方之义者不能。拟再增生牡蛎。
邓评：即阴虚挟痰饮之候。
孙评：病来三端，打成一片，是最难之事。呕恶胸满，可加川楝子、枳实，或左金丸。
肝阴不足，则火动生风；脾失健运，则液聚成痰。调理肝脾，当渐愈也。
邓评：苟非过于阴亏者，宜将生地易首乌，钩钩易木瓜，既能柔息肝阳，却无妨中之害；即方内之竹沥、麻仁，总不利于脾病，想用之者，亦出于不得已耳。
再诊：和养中气。
增补评注柳选医案
评选静香楼医案两卷
此医案由尤在泾先生撰写。先生名怡，字在泾，自号饲鹤山人，江苏长洲县人。他精通医学，尤其对《伤寒论》等经典著作能深入钻研古义，独辟蹊径，有所心得。当时吴地以医术闻名的人，如叶天士（叶桂）、徐大椿、王孟英（王学权）等人，都名噪一时。先生与他们并驾齐驱，前后辉映，在医学界可谓独树一帜。他所著的《伤寒论贯珠集》、《金匮心典》、《医学读书记》均已刊行。只有此案未曾刻印出版，附刻在《医学读书记》后的仅有三十余条，并非全貌。此版本为我县吴氏抄写收藏，咸丰年间战乱后，流传到詹文桥张氏书斋中被发现，借回抄录。又从其中精选出精华部分，约占原书的五成，评语记录如下。分为上下两卷。我私下认为近世医学荒废，那些简陋抄袭、毫无心得的人，就不必说了。偶尔有钻研古籍但不知变通的人，动辄以张仲景的学说为家法，责怪今人不能运用古方，视之为庸俗浅陋。其实古方治疗今病，往往格格不入，固执地使用，导致失败的情况很多。等到读了先生的此案，不禁豁然开朗，有所领悟。先生博览群书，尤其推崇张仲景的著作，所著的《伤寒论》和《金匮要略》注解，上溯张仲景的心传，独自发表见解。读他书的人，没有不知道先生对于张仲景的学术，可以说是登堂入室了。然而看此案，论述病情则切中事理，透彻源流，绝不泛泛引用古书；用药则随证候灵活化裁，活泼生动，从不机械套用成方。可见学习古人贵在能够融会贯通，处方贵在因时制宜。那些死守古书的人，不就和王安石拘泥于《周礼》、房琯拘泥于车战一样，弊端恰好相当吗？因此，读别人的医案，如果有不用古方的，或许还会怀疑他们研读古人不够深，未能从张仲景那里得力。至于先生，读书不可谓不多，用功不可谓不切，沉溺于张仲景的书不可谓不深，但他论述病情如此平易近人，立方如此妥帖易用。那么此案不仅是治病的良好规范，也可以作为研读古籍的心法。特将此书交付后人阅读此案者参考。光绪二十六年庚子二月下旬，江阴后学柳宝诒识。
评选静香楼医案上卷
长洲 尤 怡 在泾 著
内伤杂病门
下焦阴液亏虚，阳气浮越于上。服用八味丸无效的原因，是因为附子的走窜之性不能收纳浮阳。适宜采用加减法。
柳宝诒按：议论精细，可以为用药者开启一种悟境。
邓评：既然附子不合适，那么肉桂恐怕也会妨碍浮阳，为何不加入介类药物来潜镇浮阳呢？
肝阳亢盛，肝阴不足，牵连及肾，肾也受损了。应当滋养肝体，抑制肝用，滋补肾阴，使水木相生荣养，病当自愈。
生地、白芍、小蓟、赤芍、当归、血余炭、丹皮、阿胶、甘草、茅根
柳宝诒按：这必定是因肝火迫血妄行而见出血症状，所以方药如此。
左关脉独大，向下侵入尺部。可知肝阳亢盛甚烈，向下吸耗肾阴，阴愈亏则阳更张狂。滋水清肝，才是正法。
邓评：核参方案，此病应当有遗精、淋浊之类的症状。
阴液不足的，阳气必然上亢而内焚。想要阳气下降，必须滋补肾阴，单靠清凉药物无益。
柳宝诒按：案语精粹，有名隽之气。
邓评：治病求本，说的就是这个吧。
孙评：必定是阴液大伤而热势炽盛，只清热则阴液更伤。
肾阴不足，肝火乘袭，所以出现筋挛骨痿、耳窍及二阴气泄等症状。肝火宜疏泄，肾精宜固闭，在一方之中，兼用通补之法，比较合理，但这不是短时间内能奏效的。
柳宝诒按：既有胁痛见证，似乎应当兼用通络清肝的方法，宜加丹皮、山栀、青皮、橘络、旋覆花等药。
邓评：咳嗽由肝火引起，正好在胁痛中体现出来。这样看病，就没有难题了。
清金制木，也是一种方法。兼用通络，尤为完善。
咯血、胁痛、项下有核、脉数恶热、咽痛便溏。这是肝火乘脾的证候，反而能进食，是因为脾求助于食物，但又不能承受而痞塞。治疗在于制约肝火、补益脾气。
邓评：这必定是阴虚挟痰湿，滋润与燥湿最难兼顾，唯有主用制肝，足以取胜。选药还算平和妥善。或者用丹皮、栀子代替黄连。
饮食减少，失血过多，阴气的损伤，已经很严重了。现在又忧劳惊恐，志火内动，阴气更加受伤，导致有心烦、体痛、头疼等症状。此时应当滋养心肝血液，以制约浮动之阳。
柳宝诒按：肝阴既亏，肝火上升，宜再加当归、白芍以滋养；羚羊角、菊花、栀子以清泄。
邓评：层层推测，则病情无处遁形。
柳师加味比原方切实。如果脉象不是弦大，只需去掉羚羊角。
肝藏功能失调，侵脾则腹痛，侮肺则干咳，病从内生，不同于外感客邪。此时应当调和内脏之气，不应当外夺卫气。但脉弱而数，形体消瘦面色枯槁，上热下寒，根本已漓，恐怕难以痊愈。
柳宝诒按：这是内补建中法，适宜于腹痛，而不适宜于干咳。宜加清肝保肺的药物，才算周全。
邓评：议病确凿。方中惟独桂枝不妥。参入吴茱萸炒桑白皮、蜜炙陈皮，较为高明；乌梅、桔梗，也可参用。
孙评：此方与叶天士的方剂并驾齐驱。清肝保肺，如石斛、麦冬，也很相宜。
形体壮实脉象充盛，唯独两尺脉虚弱，下肢麻痹，火浮气急。这是根本不固，枝叶虽盛，也不足依靠。
邓评：能在虚实疑似之间探出真谛，胸中既然明了，笔下自然没有遗漏。
真阳以肾为宅，以阴为妃，肾虚阴衰，则阳无配偶而荡散。由此向上炎蒸则头耳口鼻发病，向下走窜则膀胱及二阴受伤。春夏及秋季，屡用滋养清利之剂，本想养阴，却反而伤了阳，不能治下，反而戕害中焦。这就是《内经》所说的“热病未已，寒病复起”。我的意见拟用肾气丸，直走少阴经，占据其巢穴而招引它，这是同声相应、同气相求的道理。所担心的是，病深气极，药入不能控制病情，反而被病邪所用，则有加重之弊。
柳宝诒按：立论透切，医案中仅见的佳作。
邓评：要知道滋阴清热太过，常有这种病症。因为虚阳游行于三焦经络，并非阳火亢盛、上充下斥的情况。
此案确实值得效法。不是阅历丰富有所得的人不能说出一字。
所谓“反为病所用”，恐怕是杜仲、附子助阳的缘故。病至深重，常有此弊。
孙评：如果不是名家大家，谁能做到这样议论。
真阳气弱，不能荣养筋脉则阴缩，不能固护于里则精泄，不能卫护于表则汗出。这三者，往往相继出现，病在三阴之枢机，不是后世方法可以治疗的。古方八味丸，专服久服，应当有效。
柳宝诒按：见识老到，议论明确，这是可法可传之作。
邓评：《金匮要略》中的桂枝龙骨牡蛎汤，似乎与此症适合，记出以供博雅之士参考。
胃寒背冷，食入则疲倦，喜温恶凉。以背部为阳位，胃为阳土，土寒则食物不运化，阳伤则气不振。治疗宜温养阳气。
柳宝诒按：这是温中和气，平正通达的方剂。
邓评：一派虚寒，温养有何可疑。
中气虚寒，遇冷则腹泻，而又火升齿衄。古人所说的胸中聚集的残火，腹内积久的沉寒。此时应当温补中气，使土厚则火自敛。
邓评：辨真假的关键处，学者最应留意。如果是肾虚者，又须用八味丸治疗。干姜宜改为炮姜。
类中风门
类中风偏左，于法为逆，幸好病势尚轻，可以缓图取效。原方补少通多，最为合理。只是阳脉缓，阴脉急，所以指节能屈不能伸，这也是病的关键处，不可忽视。经云：肝苦急，宜食甘以缓之。在前方的基础上增进一两味甘润的阴药，更为完备。
邓评：左半属阴血，病机较深，故为逆。
指节屈不能伸，病在厥阴肝经，就是阴脉急的意思。如果治痿取阳明，就是阳脉缓的情况了。
再诊：加当归
脉虚而涩，左半身手足麻痹，食不知味。这是气血不能运行周身，是类中风的先兆。
柳宝诒按：滋养疏化，虚实兼到。
邓评：这是从《金匮要略》血痹例治疗。
内风本来都是阳气化生，但并非有余，而是阴阳二气不主交合的缘故。现在形寒脚冷，似乎宜补阳。但张景岳说：阳失阴而离者，非补阴无以摄既散之元阳。此证有升无降，舌绛牵掣，哑不出声，足蜷不堪行动。应当与河间肝肾气厥同例，参用丹溪虎潜法。
柳宝诒按：持论明通，立方妥当。
邓评：这是少阴不至则为痔厥，下虚上实的候象。可以作为妄用附子、桂枝，动辄说是引火归源者的告诫。虎骨改用肉苁蓉，较与舌绛无碍。
孙评：这样的句子如今看不到了。
邓评：方内温润益阳之品足够了，何必再加此味。
肾气丸淡盐汤送下
柳宝诒按：先清之，继滋之，终用引火下行法。步伐井然，急躁求功者，可取法于此。
邓评：统阅三方，第一方偏于清火，第二方专重滋阴，第三方复参温导。虽然似有步伐，终究未能认真探究病源，归于一律。
方书每以左瘫属血虚，右痪属气虚。据述近年来，齿疼舌赤，常有精浊。纳谷如昔，突然右偏，肢痿舌强，口眼歪斜言语不清，脉浮数动。这是肝肾两虚，水不涵木，肝风暴动，神必昏迷。河间所说的肝肾气厥，舌哑不语，足痱无力的证候。但肾属坎水，真阳内藏，宜温以摄纳；而肝藏相火内寄，又宜凉以清之。温肾之方，参入凉肝，是为复方之用。
柳宝诒按：即古法而化裁之。参详脉证，斟酌尽善。
邓评：以各证推之，虽偏中于右，而精水亦自亏也。这就是临证的活泼处。
肝阳旺者，温肾不用桂、附；肾气虚者，凉肝只以天冬，这才是斟酌尽善的方法。
孙评：案语分析爽快。只有叶天士开此一解，振聋发聩。
寒热后，邪走手少阴之络，猝然不语，肩背牵引不舒。宜辛以通之。
柳宝诒按：方法轻灵，恰合余邪入络治法。
邓评：此症必有痰火窜闭络脉，再加钩藤、姜汁、竹沥，对痰火一层稍为着力。
孙评：似宜兼用万氏牛黄清心丸。
脉濡，按之则弦，右肩及手指麻木，两腿酸痒，难以名状。这是脾饮肝风，相合为病，是类中风的先兆，不可不慎。
首乌、天麻、刺蒺藜、羚羊角、炙甘草、茯苓、半夏、白芍、丹皮、广皮、姜汁和竹沥泛丸
柳宝诒按：以二陈、姜汁、竹沥除痰饮，以丹皮、白芍、羚羊角、蒺藜、首乌、天麻治肝风，两层俱到。就见证论，当归身、牛膝、橘络，亦可加入。
邓评：脉濡属湿，弦则为风，风与湿合，故麻木酸痒，所谓饮者正由湿化也。羚羊角宜与桂枝并用始妥，即木瓜、薏仁亦可参入。
孙评：牛膝、橘络，既可导之下行，又能通络，心思灵通。惟肢麻腿痒，是痰流入络，筋为痰滞，宜加桑枝、丝瓜络，通之为要。
痿痹门
脉虚而数，两膝先软后肿，不能屈伸。这是湿热乘阴气之虚而下注，久则成鹤膝风矣。
生地、牛膝、茯苓、木瓜、丹皮、薏仁、山药、山茱萸、泽泻、萆薢
柳宝诒按：正虚着邪，故补散宜并用；湿而兼热，故滋燥不可偏。此以六味地黄丸治阴虚，增入牛膝、木瓜、薏仁、萆薢以除湿热，所谓虚实兼顾也。
邓评：此确属阴虚湿热，竟能由痹成痿。
立方殊妥善。再加广皮或生姜，则着痹之邪较易流行。
孙评：柳氏指点分明，可为读书者开一便径，于初学大有补益也。
内风门
肢麻头晕，这是肝病。便溏食减，脾也病了。宜节劳养气，毋致风动为佳。
邓评：方论俱朗朗，无片云纤翳。惟羚羊角尚恐碍脾阳，入牡蛎较妥。
眩晕呕恶胸满，小便短而数，口中干。水亏于下，风动于上，饮积于中，病非一端也。
柳宝诒按：病非一端，方欲打成一片，非熟于制方之义者不能。拟再增生牡蛎。
邓评：即阴虚挟痰饮之候。
孙评：病来三端，打成一片，是最难之事。呕恶胸满，可加川楝子、枳实，或左金丸。
三诊：人参、茯苓、麦冬、羚羊角、天麻、半夏、炙甘草、石斛、广皮
肝阴不足，则火动生风；脾失健运，则液聚成痰。调理肝脾，当渐愈也。
邓评：苟非过于阴亏者，宜将生地易首乌，钩藤易木瓜，既能柔息肝阳，却无妨中之害；即方内之竹沥、麻仁，总不利于脾病，想用之者，亦出于不得已耳。
再诊：和养中气。
Supplemented and Annotated Liu's Selected Medical Cases
Selected Jingxianglou Medical Cases, Two Volumes
This medical case was written by Mr. You Zaijing. His given name was Yi, courtesy name Zaijing, and his pseudonym was Sihe Shanshen (Mountain Man Feeding Cranes). He was from Changzhou County, Jiangsu Province. He was profound in medicine, especially able to delve into the ancient texts of Zhang Zhongjing's works, offering unique insights. At that time, those famous for medicine in the Wu region, such as Ye Tianshi (Ye Gui), Xu Dachun, and Wang Mengying (Wang Xuequan), were all renowned for a time. Mr. You competed with them on equal footing, shining before and after, and could be said to have established a distinct school within the medical arts. His works, *Shanghan Lun Guanzhu Ji* (A Series of Pearls on the Treatise on Cold Damage), *Jingui Xin Dian* (Core Principles of the Golden Cabinet), and *Yixue Dujilu* (Records of Reading Medicine), were all published. Only this case was not printed; the thirty-odd entries appended to *Yixue Dujilu* were not the complete version. This copy was handwritten and preserved by the Wu family of my county. After the turmoil of the Xianfeng era, it came into the possession of the Zhang family at Zhanwen Bridge, where I borrowed it to transcribe. From it, I selected the most exquisite parts, about half, and recorded the comments as follows. Divided into upper and lower volumes. I privately reflect that medicine has declined in recent times. Those who are crude, plagiaristic, and devoid of insight need not be mentioned. Occasionally, there are those who study ancient texts but fail to adapt to changing circumstances, constantly citing Zhang Zhongjing as their standard and blaming modern practitioners for not using ancient prescriptions, labeling them as mediocre and vulgar. In reality, ancient prescriptions often do not fit modern diseases; rigidly applying them leads to failure more often than success. Upon reading Mr. You's cases, I could not help but feel enlightened. Mr. You had read extensively and held Zhang Zhongjing's works in high esteem. His annotations on the *Shanghan Lun* and *Jingui Yaolue* traced back to Zhang Zhongjing's core transmission, expressing independent views. Readers know that Mr. You's mastery of Zhang Zhongjing's scholarship was akin to entering the innermost chamber. Yet, in these cases, his discussion of diseases is logical and penetrating, tracing origins thoroughly, without indiscriminately quoting ancient books; his prescription is flexible and adapted to symptoms, lively and never mechanically copying established formulas. This shows that learning from the ancients requires assimilation, and prescribing requires adaptation to the times. Those who rigidly cling to ancient books are no different from Wang Anshi adhering to the *Rites of Zhou* or Fang Guan relying on chariot warfare; their drawbacks are equivalent. Therefore, when reading others' cases, if they do not use ancient prescriptions, one might suspect they haven't studied deeply enough to benefit from Zhang Zhongjing. But Mr. You, whose reading was extensive and effort intense, deeply immersed in Zhang Zhongjing's works, discusses diseases so approachably and prescribes so appropriately. Thus, this case is not only an excellent guide for treatment but also a methodological key for studying classics. I entrust this book to future readers of these cases. Late scholar Liu Baozhi of Jiangyin, late February of Gengzi Year, 26th year of Guangxu.
Selected Jingxianglou Medical Cases, Upper Volume
Written by You Yi (Zaijing) of Changzhou
Internal Injury and Miscellaneous Diseases Section
Yin deficiency below, Yang floating above. The reason Eight Flavor Pill failed is that Aconite's dispersing nature cannot secure the floating Yang. Modification is appropriate.
Guizhi Diqui Wan (Cinnamon Twig and Rehmannia Pill, i.e., Liuwei Dihuang Wan plus Cinnamon Twig and Schisandra)
Liu's Note: The discussion is refined, opening a realm of understanding for prescribers.
Deng's Comment: Since Aconite is unsuitable, Cinnamon Twig may also hinder floating Yang. Why not add shell-type minerals to anchor it?
Liver Yang excess, Liver Yin deficiency, affecting the Kidney, which is also damaged. Nourish Liver substance, suppress Liver function, tonify Kidney Yin, allowing Water and Wood to nourish each other; the disease should heal itself.
Shengdi Huang (Rehmanniae Radix Preparata), Baishao (Paeoniae Radix Alba), Xiaoji (Cirsii Herba), Chishao (Paeoniae Radix Rubra), Danggui (Angelicae Sinensis Radix), Xuyurtan (Hominis Calcinatus), Danpi (Moutan Cortex), Ejiao (Colla Corii Asini), Gancao (Glycyrrhizae Radix et Rhizoma), Maogen (Imperatae Rhizoma)
Liu's Note: This must be bleeding due to Liver Fire, hence the formula.
Deng's Comment: The pathology is clear. Imperata Rhizoma seems unsuitable for Liver Yang.
Left Guan pulse alone is large, extending down to Chi. Liver Yang is hyperactive, draining Kidney Yin; as Yin depletes, Yang expands. Nourishing Water to Clear Liver is the correct method.
Zhibai Bawei Wan (Anemarrhenae, Phellodendri, and Rehmanniae Pill) plus Tiandong (Asparagi Radix), Guiban (Testudinis Carapax et Plastrum), Qizi (Lycii Fructus)
Liu's Note: The formula seems to need more Liver-clearing herbs.
Deng's Comment: Comparing with the plan, this disease likely involves spermatorrhea or turbid urine.
Sun's Comment: Zhi Mu, Huang Bai, and Tian Dong are all Liver-clearing; why add more!
When Yin is insufficient, Yang must rise and burn internally. To descend Yang, one must nourish Yin; relying solely on cooling is useless.
Shengdi Huang, Zhimu (Anemarrhenae Rhizoma), Gancao, Heizhi (Gardeniae Fructus Carbonis), Maidong (Ophiopogonis Radix), Xuanshen (Scrophulariae Radix), Danpi, Digupi (Lycii Cortex)
Liu's Note: The case commentary is concise and elegant.
Deng's Comment: Treating the root, as it should be.
Sun's Comment: Must be severe Yin injury with blazing heat; clearing heat alone will further injure Yin.
Kidney Yin deficiency, Liver Fire attacking, causing tendon spasms, bone weakness, and leakage from ears, eyes, and orifices. Liver Fire should be drained, Kidney Essence secured. Using both unblocking and tonifying methods in one formula is reasonable, but results won't come overnight.
Shengdi Huang, Chuanlianzi (Toosendan Fructus), Fuling (Poria), Ejiao, Danpi, Nvzhenzi (Ligustri Lucidi Fructus)
Liu's Note: Pathology analysis hits the mark; add Baishao and Muli (Ostreae Concha) to the formula.
Deng's Comment: This is Wei Syndrome (flaccidity); the formula is derived from Hujian Wan.
Liver Yin deficiency, Liver Fire dominant, injuring Lung causes cough, self-injury causes hypochondriac pain;
Ejiao, Doulou (Stemonae Radix), Danshen (Salviae Miltiorrhizae Radix), Zhigancao (Prepared Licorice), Guishen (Angelicae Sinensis Radix), Baishao, Yuzhu (Polygonati Odorati Rhizoma), Chuanhu (Dendrobii Caulis)
Liu's Note: With hypochondriac pain, collateral-unblocking and Liver-clearing methods should be added: Danpi, Shanzhi, Qingpi, Jieluo, Xuanfuhua.
Deng's Comment: Cough from Liver Fire is evident in hypochondriac pain. Viewing disease this way leaves no难题 (difficulties).
Clearing Metal to control Wood is another method. Adding collateral-unblocking is even better.
Spitting blood, hypochondriac pain, neck lumps, rapid pulse, aversion to heat, sore throat, loose stools. This is Liver Fire invading Spleen. The ability to eat suggests Spleen seeking aid from food but failing, causing stagnation. Treatment focuses on restraining Liver and benefiting Spleen.
Baishao, Fuling, Chuanlian (Coptidis Rhizoma), Muli, Zhigancao, Mugua (Chaenomelis Fructus), Yizhiren (Alpiniae Oxyphyllae Semen), Ejiao
Liu's Note: Pathology is clear; propose adding Danpi, Zhizi, Xiakucao.
Deng's Comment: Likely Yin deficiency with phlegm-dampness; balancing moistening and drying is hard. Restraining Liver is key. Selection is moderate. Replace Chuanlian with Danpi/Zhizi.
Sun's Comment: Sore throat indicates deficient fire rising; Yizhiren is too drying. Use Bian Dou, Shanyao.
Reduced diet, excessive blood loss, Yin injury is severe. Now worry, labor, fear, and anger stir internal fire, further injuring Yin, causing restlessness, body pain, headache. Nourish Heart and Liver Blood to restrain floating Yang.
Shengdi Huang, Shihu (Dendrobii Caulis), Maidong, Danpi, Xuanshen, Zhimu, Fuling, Gancao
Liu's Note: Liver Yin deficient, Fire rising; add Danggui, Baishao to nourish; Lingyangjiao, Juhua, Zhizi to clear.
Deng's Comment: Layered deduction reveals the disease's true state.
Master Liu's modification is more practical. If pulse is not wiry-large, remove Lingyangjiao.
Liver storage dysfunction invades Spleen causing abdominal pain, insults Lung causing dry cough. Disease arises internally, unlike external pathogens. Harmonize internal organs, do not attack exterior Wei Qi. But weak rapid pulse, emaciation, upper heat/lower cold indicate depleted root; hard to cure completely.
Guishen, Baishao, Zhigancao, Fuling, Guizhi (Cinnamomi Ramulus), Yitang (Maltose)
Liu's Note: This is Neibu Jianzhong method, suitable for abdominal pain, not dry cough. Add Liver-clearing/Lung-nourishing herbs for completeness.
Deng's Comment: Diagnosis is accurate. Guizhi is inappropriate. Add Wuzhuyu-fried Sangbaipi, Honey-fried Chenpi; Wumei, Jiegeng can be used.
Sun's Comment: This formula rivals Ye Tianshi's. Shihu, Maidong for clearing Liver/nourishing Lung are suitable.
Robust physique, full pulse, but Chi pulses empty; lower body numbness, floating fire,急促 qi. Root is unstable; lush branches are unreliable.
Shudi (Prepared Rehmanniae Radix), Shanyao (Dioscoreae Rhizoma), Shayuan (Astragali Complanati Semen), Qizi, Danpi, Fuling, Sangshen (Mori Fructus), Niuxi (Achyranthis Bidentatae Radix)
Liu's Note: For these signs, Shenqi Wan method to warm and secure is suggested.
Deng's Comment: Finding truth amidst deficiency/excess ambiguity shows clarity; writing reflects this.
True Yang resides in Kidney, paired with Yin. Kidney deficiency/Yin decline means Yang has no partner and scatters. Rising up causes head/ear/mouth/nose issues; going down damages Bladder and orifices. Spring/Autumn treatments used nourishing/clearing/diuretic agents intended to nourish Yin but injured Yang, failing to treat below while harming middle. This is "Heat disease not resolved, Cold disease reappears" from *Neijing*. My proposal: Shenqi Wan, targeting Shaoyin directly, occupying its fortress, following resonance principles. Fear: deep disease/extreme qi may cause medicine to be overpowered, worsening condition.
Shenqi Wan (Kidney Qi Pill)
Liu's Note: Argument is thorough; a rare gem in medical cases.
Deng's Comment: Over-nourishing/clearing often causes this. Deficient Yang wanders Sanjiao meridians, not like excess Fire.
This case is truly exemplary. Only experienced physicians can articulate this.
"Overpowered by disease" likely refers to Dudu/Fuzi aiding Yang excessively. Deep disease often has this flaw.
Sun's Comment: Only a master could discuss thus.
True Yang/Qi weak, failing to nourish tendons causes Yin retraction, failing to secure interior causes essence loss, failing to guard exterior causes sweating. These three appear together; disease is at the pivot of Three Yin, beyond later methods. Ancient Bawei Wan, taken long-term, should work.
Bawei Wan (Eight Flavor Pill)
Liu's Note: Insightful, clear argument; worthy of transmission.
Deng's Comment: *Jingui*'s Guizhi Longgu Muli Tang fits well; noted for erudition.
Stomach cold, back cold, fatigue after eating, likes warmth/dislikes cool. Back is Yang position, Stomach is Yang Earth; Earth cold means food doesn't transform, Yang injury means Qi fails. Treatment: Warm/Nourish Yang.
Renshen (Ginseng Radix et Rhizoma), Guizhi, Yizhiren, Houpo (Magnoliae Officinalis Cortex), Paojiang (Zingiberis Rhizoma Preparatum), Fuling, Zhigancao, Baizhu (Atractylodis Macrocephalae Rhizoma)
Liu's Note: Warm Middle, harmonize Qi; balanced and effective.
Deng's Comment: Pure deficiency-cold; warming/nourishing is obvious.
Middle Qi deficiency-cold, diarrhea when cold, yet Fire rises causing toothbleeding. Ancient term: residual Fire gathered in chest, deep Cold accumulated in abdomen. Warm/Tonify Middle Qi; thick Earth contains Fire naturally.
Sijunzi Tang (Four Gentlemen Decoction) plus Yizhiren, Ganjiang (Zingiberis Rhizoma)
Liu's Note: Diagnosis/prescription based on Yu Jia Yan. Huang Kunzai also uses this.
Deng's Comment: Key to distinguishing true/false; students must note. If Kidney deficiency, use Bawei Wan. Ganjiang should be Paojiang.
Stroke-like Illness Section
Stroke-like illness affecting left side is adverse in method, fortunately mild, can improve slowly. Original formula balances tonification and unblocking reasonably. Pulse: Yang slow, Yin urgent; fingers bend but don't extend. Key point, don't ignore. Classic: Liver suffers urgency, sweet foods relieve. Add 1-2 sweet/moistening Yin herbs to previous formula.
Renshen, Fuling, Banxia (Pinelliae Rhizoma), Baizhu, Zhigancao, Qiaohong (Citri Reticulatae Pericarpium), Maidong, Zhuli (Bambusae Succus), Jiangzhi (Zingiberis Succus)
Liu's Note: Liujunzi Tang plus Maidong, Zhuli, Jiangzhi.
Deng's Comment: Left side belongs to Yin Blood; deeper pathology, hence adverse.
Finger inability to extend indicates Jueyin Liver Meridian disease, meaning Yin pulse is urgent. Treating Wei by taking Yang implies Yang pulse is slow.
Second Visit: Add Danggui
Pulse void and choppy, left limb numbness, loss of taste. Qi/Blood fail to circulate; early stroke-like stage.
Guizhi, Fuling, Guishen, Banxia, Zhigancao, Huangqi (Astragali Radix), Tianma (Gastrodiae Rhizoma), Shouwu (Polygoni Multiflori Radix)
Liu's Note: Nourish and unblock, addressing both deficiency and excess.
Deng's Comment: Follows *Jingui* Blood Bi example.
Internal Wind originates from Yang transformation, but isn't excess; it's failure of Yin/Yang interaction. Cold limbs suggest Yang tonification. But Zhang Jingyue says: Yang separated from Yin needs Yin tonification to gather scattered Yuan Yang. This case has ascending but no descending, crimson tongue with spasm, aphasia, curled feet. Similar to Hejian's Liver/Kidney Qi Reversal; use Danxi's Hujian method.
Shudi, Yurou (Corni Fructus), Niuxi, Suoyang (Cynomorii Herba), Hugut (Pantheris Os - *Note: Substitute legally*), Guiban
Liu's Note: Theory clear, prescription appropriate.
Deng's Comment: Shaoyin failure causes hemorrhoidal/reversal syndrome, lower deficiency/upper excess. Warning against reckless Fuzi/Guizhi "guiding fire back to source". Hugut replace with Rongrong (Cynomorii Herba) to avoid conflict with crimson tongue.
Sun's Comment: Such sentences are rare now.
Second Visit: Dihuang Yinzi minus Fuzi, add Lubianzi (Cervi Penis), decoct glue, make pills.
Deng's Comment: Formula already has sufficient warming/nourishing Yang herbs; no need for extra.
Heat Wind invading collaterals. Facial deviation, stiff tongue, sore throat. Treat with clearing/nourishing.
Lingyangjiao (Capricornis Cornu), Xuanshen, Gouteng (Uncariae Ramulus cum Uncis), Ganju (Chrysanthemi Flos), Gancao, Shichangpu (Acori Tatarinowii Rhizoma), Shengdi, Zhuli
Second Visit: Shengdi, Ejiao, Maidong, Zhimu, Beimu (Fritillariae Bulbus), Ganju, Gancao, Xuanshen
Third Visit: Dry/sore throat. Clearing/nourishing ineffective; use descending/guiding method.
Shenqi Wan taken with light salt water
Liu's Note: First clear, then nourish, finally guide fire down. Orderly steps; impatients should learn.
Deng's Comment: Reviewing three formulas: 1st clears fire, 2nd nourishes Yin, 3rd adds warming/guiding. Though orderly, fails to address root uniformly.
Books say left paralysis is Blood deficiency, right hemiplegia is Qi deficiency. Recent years: toothache, red tongue, seminal emissions. Appetite normal, sudden right deviation, limb flaccidity, stiff tongue, facial distortion, rapid floating pulse. Liver/Kidney dual deficiency, Water failing to nourish Wood, Liver Wind storm, coma likely. Hejian's Liver/Kidney Qi Reversal, aphasia, foot weakness. Kidney is Kan Water, True Yang hidden, needs warming/securing; Liver houses Minister Fire, needs cooling/clearing. Warming Kidney formula combined with cooling Liver is compound method.
Dihuang Yinzi minus Guizhi/Fuzi, add Tiandong, Ejiao
Liu's Note: Adapted from ancient method. Pulse/signs analyzed perfectly.
Deng's Comment: Pushing from signs, though right-sided, Jing/Water is also deficient. This is clinical flexibility.
For Hyperactive Liver Yang, warming Kidney avoids Guizhi/Fuzi; for Qi deficiency, cooling Liver uses only Tiandong. Perfect balance.
Sun's Comment: Case analysis is crisp. Ye Tianshi opened this path, awakening ages.
After chills/fever, pathogen enters Hand Shaoyin collaterals, sudden aphasia, shoulder/back traction discomfort. Use pungent to unblock.
Shichangpu, Yuanzhi (Polygalae Radix), Gancao, Mutong (Akebiae Caulis), Danggui, Danpi, Danshen, Fuling
Liu's Note: Light method, fits residual pathogen in collaterals.
Deng's Comment: Likely Phlegm-Fire blocking collaterals. Add Gouteng, Jiangzhi, Zhuli for Phlegm-Fire.
Sun's Comment: Consider Wan's Niuhuang Qingxin Wan.
Pulse soft/rule, pressing wiry; right shoulder/fingers numb, legs sore/itchy. Spleen Fluid + Liver Wind combining; early stroke-like stage. Caution needed.
Shouwu, Tianma, Cijili (Tribuli Fructus), Lingyangjiao, Zhigancao, Fuling, Banxia, Baishao, Danpi, Guangpi (Citri Reticulatae Pericarpium), Jiangzhi mixed with Zhuli for pills.
Liu's Note: Erchen/Jiangzhi/Zhuli remove Phlegm-Fluid; Dan/Bao/Ling/Ji/Shouwu/Tianma treat Liver Wind. Both layers addressed. Danggui, Niuxi, Jieluo could be added.
Deng's Comment: Soft pulse = damp, wiry = wind. Wind/Damp combine causing numbness/itching. Lingyangjiao should pair with Guizhi; Mugua, Yiren can be added.
Sun's Comment: Niuxi/Jieluo guide down/unblock collaterals. Numbness/itching is Phlegm in collaterals/stagnant tendons; add Sangzhi, Sigualuo to unblock.
Wei Bi (Flaccidity/Obstruction) Section
Pulse void/rapid, knees first soft then swollen, unable to bend/extend. Damp-Heat exploiting Yin deficiency, sinking down; chronic stage becomes Crane Knee Wind.
Shengdi Huang, Niuxi, Fuling, Mugua, Danpi, Yiren (Coicis Semen), Shanyao, Yurou, Zexie (Alismatis Rhizoma), Bibo (Dioscoreae Hypoglaucae Rhizoma)
Liu's Note: Righteous deficiency, pathogenic attachment; tonify/unblock together. Damp-Heat; moisten/dry balanced. Liuwei treats Yin deficiency; add Niuxi/Mugua/Yiren/Bibo for Damp-Heat. Balance of deficiency/excess.
Deng's Comment: Indeed Yin deficiency with Damp-Heat, progressing from Bi to Wei.
Formula is good. Add Guangpi or Shengjiang to help move Obstructive Bi pathogen.
Sun's Comment: Liu's guidance is clear; helpful shortcut for students.
Internal Wind Section
Limb numbness, dizziness; Liver disease. Loose stools, reduced appetite; Spleen disease. Rest, nourish Qi, prevent Wind movement.
Lingyangjiao, Baizhu, Cijili, Fuling, Zhigancao, Tianma, Baishao, Guangpi
Liu's Note: Treat Liver/Spleen together; thorough method.
Deng's Comment: Clear theory/formula. Lingyangjiao may harm Spleen Yang; add Muli.
Sun's Comment: Add Mugua/Muli to extinguish Wind in Liver and stop diarrhea.
Dizziness, nausea, chest fullness, scant frequent urination, dry mouth. Water deficiency below, Wind moving above, Fluid accumulation middle. Disease is complex.
Lingyangjiao, Xi Shengdi (Young Shengdi), Gouteng, Tianma, Fuling, Guangpi, Banxia, Zhuru (Bambusae Caulis in Taenia)
Liu's Note: Complex disease, unified formula requires expertise. Propose adding Sheng Muli.
Deng's Comment: Yin deficiency with Phlegm-Fluid.
Why no Huanglian for nausea? Avoid due to Water deficiency/Fluid accumulation? Or Liver Yang transformed to Wind?
Sun's Comment: Unifying three aspects is hard. For nausea/chest fullness, add Chuanlianzi, Zhishi, or Zuojin Wan.
Second Visit: Remove Shengdi, add Maidong.
Deng's Comment: Maidong superior to Shengdi here.
Third Visit: Renshen, Fuling, Maidong, Lingyangjiao, Tianma, Banxia, Zhigancao, Shihu, Guangpi
Liver Yin deficiency generates Fire/Wind; Spleen dysfunction creates Fluid/Phlegm. Regulate Liver/Spleen, gradual recovery expected.
Banxia, Fuling, Guangpi, Gouteng, Shengdi, Zhuli, Mahrenzhi (Semen Cannabis Juice)
Liu's Note: General discussion. Add Baishao to cover Liver Meridian.
Deng's Comment: Unless severe Yin deficiency, replace Shengdi with Shouwu, Gouteng with Mugua to soften Liver Yang without harming middle. Zhuli/Hemp seed hurt Spleen; used reluctantly.
Second Visit: Harmonize/Nourish Middle Qi.
Renshen, Chenpi (Citri Reticulatae Pericarpium), Sheng Guya (Setariae Italicae Germens), Shihu, Fuling, Mugua,