另鳖甲煎丸
原注；左属血属肝，疟邪滞于血中，主以鳖甲煎丸。右属气属胃，或痰或食，主以鸡金推气，加竹油、白芥子。
诒按：此两层兼治之法。
肿 胀 门
营血本亏，肝火本旺，责在先天。乃后天脾气不健，肝木乘之。所进饮食，生痰生湿，贮之于胃，尚可从呕而出，相安无事；迟之又久，渗入膜外，气道不清，胀乃作焉。脾为生痰之源，胃为贮痰之器。若非运化中宫，兼透膜外，则病势有加无已，成为臌病，亦属易易。夫脾统血，肝藏血，病久血更衰少，不得不佐以和养。古人之燥湿互用，正为此等证设也。
归芍六君子汤去参 草 加白芥子 莱菔子车前子 川朴 苏子 腹皮 竹油 雪羹
邓评：久呕之后，痰饮渗透膜外，致成臌胀者甚众。此案论病透彻，立法精当。
诸腹胀大，皆属于热;诸湿肿满，皆属于脾。脾经湿热交阻于中，先满后见肿胀，肤热微汗，口渴面红，理之不易。
邓评：此《金匮》之木防己汤加减，其所以去桂枝之温者，为热多故也。然观其转方，仍诸恙不减，或者须藉桂枝以温通气化，始能效耶。若谓病重药轻，再加鲜地、知、麦等味，恐究非胀病所宜，既云湿满三焦，何不竟用子和桂苓甘露饮治之。
再诊：湿热满三焦，每多肿胀之患。如邪势偏于下焦，小便必少，前人之质重开下者，原为此等证而设。然此病已久，尚盛于中上二焦，胡以中上两焦法施之?诸恙不减，或者病重药轻之故。将前方制大其剂。
原注：此十二岁女子，腹暴胀大，面跗俱肿，面红口渴，小便黄。此证属热，所见甚少。
脘腹膨胀，二便失调，经络痠痛，四肢无力，脉形弦细，舌苔白腻而厚。此湿邪内郁。当用苦辛宣泄。
邓评：纯乎湿胜见端，何以知其湿中有热，兼参栀、萎，不用姜、桂。读案语二便失调，其眼在小便黄少可知。盖此等证最易误作寒湿医，而用热药。
脉细而弦，是脾弱而兼木郁；苔白而腻，知湿胜且有热蒸，俾湿热化解，脾健木达，则诸恙向安矣。
原注：此越鞠改方，而加胃苓之半。本方治湿郁，其眼在舌苔白腻而厚，在所必效，余每借以治黄疸亦效，挟痰头项痛亦效。
孙评：越鞠治疸，想系气湿热三者交阻而成之症。若头项痛，挟痰者必兼郁乃效，且须加涤痰之味方妥。
脾主湿，湿因脾虚而郁，郁蒸为热，所以隐癖僭逆中宫；大腹胀满，纳少便溏，面黄溺赤，咳嗽，身热时作，脉息弦细，极易成臌。
原注：此越鞠证，而兼隐癖。湿化热者，故合鸡金消癖，芩蒿化热。
原注：以上越鞠丸证。大约越鞫治无形湿热之痞，从泻心化出；鸡金治有形食积之癖，从陷胸化出。且如脘痛门中，郁痰作痛，脉数多渴者，用清中蠲痛汤。山栀、姜汁炒，干姜、川芎、童便炒，黄连、姜汁炒，苍术、童便浸切麻油炒，香附、醋炒，神曲、姜汁炒，托红、姜、枣。治中脘火郁作痛，发即寒热。中以寒热为主，即越鞠加姜、连、橘、枣。可知此方治气火湿食血五者之郁，信极妙矣。说者以栀主火，术主湿，香附主气，芎主血，曲主食，分为五郁，似可不必，正如五音必合奏而始和也。
邓评：大腹胀满，臌之候也；咳嗽身热，劳之象也。乃营卫阴阳并伤，用药则宁偏于燥，未可偏滋，如归、芍以养营制木，亦正不妨添入耳。
大腹胀满，已经四十余日，近来气更急促，足跗浮肿，溺黄口干，脉形弦数。湿热之邪，因气而阻，因食而剧，理之不易。
廓清饮（廓清飲用芥陈朴，枳泽茯苓同大腹，菔子生研壅滞通，气逆胀满均堪服。）去芥枳
邓评：大腹胀满是病也，溺黄口干是证也，脉形弦数是脉也。凭证脉以推求，则是病之系乎何邪，自无遁情矣。
诒按；腹满由于脾之不运，其所以不能运者，痰也、湿也、浊也、气也、瘀也。故方中多用疏气化痰、清利湿热之品。
邓评：此方亦仅疏化湿热，胡必拘拘于芜花、戟、遂等峻以攻导欤。用廓清法去芥子者，想病不重于痰饮故也。
大腹主脾，腹大而至脐突，属脾无疑。然胀无虚日，痛又问作，舌苔薄白，脉息沉弦，见于经期落后之体，显系血虚不能敛气，气郁于中，寒加于外，而脾经之湿，因而不消。
诒按：沉弦与沉细不同，沉细色萎则理中证。此证拈住郁字，散用逍遥。
是病之大概，不越中寒木郁，立方之大意，亦不外乎温中达木，拟加吴仙散可也。
单腹胀，脾气固虚，久则肾气亦虚，大便溏者，气更散而不收矣。所用之药，比之寻常温补脾肾者，当更进一层；然用之已晚。惜乎。
诒按：案云较之寻常温补，更进一层，观方中所加肉果、当归，是启峻法也。
邓评；虚寒腹胀，固当责之脾肾。至偏于肾虚或偏于脾虚，须观其胀处之甚于小腹，抑或脘腹矣。参入生脉者，想其舌光苔微也。
大腹胀满，便溏，舌苔冷白，干喜热饮，肤热脉数。脾阳大虚，无力运化湿浊，而成臌也。理之棘手。
邓评：此阳虚挟湿热之候，固宜理中汤为急，然后兼清湿热，层次未尝不合。予拟东垣升阳除湿法，参入五苓为善。然不治者多矣。
再诊：进温补四剂，腹胀浙和，其邪从下焦而泄，所以大便作泻。然肤热未退，小便未长，干欲热饮，胃不思谷，白苔已薄，舌质转红。中阳稍振，湿热未清。
原注：舌苔冷白，是桂附把柄。四剂而能便泄，邪从下出，中阳尚好，脾气尚未衰尽。更以舌质转红，知湿热壅甚，所以转方减去附桂。参术己足扶脾，外加四苓驱湿而己。
大便作泻，小水又长，肝脾肾三经即有阴邪，亦可从此而消。何以隐癖尚踞于中，腹胀不和，是阳虚也。
四君子汤 加黄芪 当归 桂枝 附子 陈皮肉果 沉香 干姜 牡蛎 鳖甲 鸡内金
原注：此启峻汤也，附子理中加黄芪、当归、肉罘，比附子理中更进一层。
太阴腹满，寒湿有余，真阳不足，咏弦，下体不温，干不欲饮，妨食气短。其势颇险。拟以温通化湿法。
诒按：此亦通补兼施之法。
温补元阳，浮肿胀满有增无减，阳之衰也极矣。脐平脉迟之候，非温不可，非补亦不可；然温补亦不见长，盖下泄者肾更伤耳。
诒按：此法较肾气丸更进一层。
此病何不进商禹余粮丸。
中满者，泻之于内，其始非不遽消，其后攻之不消矣，其后再攻之如铁石矣。此病虽不至如铁石，而正气久伤，终非易事也。
原注：以上皆理中加减法也。因记当年侍先生时，问理中之变换如何?曰：理中是足太阴极妙之方，加以中宫之阳气不舒，用干姜者取其散；少腹之阳气下陷，用炮姜者取其守；其变换在大便之溏与不溏。湿甚而无汗者用茅术，湿轻而中虚者用冬术；其变换在舌苔之浊与不浊。此本方之变换也。设脾家当用理中，而胃家有火，则古人早定连理一方矣。设气机塞滞，古人早定治中一方矣。设脾家当用理中，而其人真阴亏者，景岳早有理阴煎矣。其肾中真阳衰者，加附子固然矣；其衰之甚者，古人又有启峻一方矣。此外，加木瓜则名和中，必兼肝病；加枳实、茯苓，治胃虚挟实。古人成方，苟能方方如此用法，何患不成名医哉。因附录之，以为用理中之法。
诸湿肿满，皆属于脾。因劳倦所伤，内湿与外湿合而为一，郁于土中，致太阴之气化不行。治病必求其本，先以实脾法。
初起痞满，继增腹胀，脐突筋露，足跗浮肿，大便溏泄。此湿热内壅，中虚不化，势从下走也。用药最为棘手，且从口苦、舌红、小便短赤立方。
邓评：此等方法，非洞彻病情者则不可浪用。必须脉形洪数者，始能放胆用之，恐其湿热未去而中阳已惫也。
孙评：口苦舌红溺短，是阴已大伤，化源欲绝，岂宜再以三石沉暴泻其实火。总之如此险征，挽回非易，虽有良法，终于无济。
咳而腹满，经所谓三焦咳也。苔黄干苦，卧难着枕，肢冷阳缩，股痛囊肿，便溏溺短。种种见证，都属风邪湿热，满布三焦，无路可出，是实证也，未可与虚满者同日而语。
桑皮 骨皮 苓皮 蒌皮大腹皮 姜皮防己 杏仁 苏子 葶苈子 车前子
诒按：湿热壅盛，脾不输运，肺不肃降，故立方专用疏化，仿五皮五子法。
邓评：肢冷阳缩，湿热阻遏其阳气故也。断其为湿热实证者，全在苔黄干苦见出。盖一病有一病之关键，不可移易之理。此方选药亦善。
中阳不足，寒湿有余，脘痞纳少，舌白便溏，脉细小。法当温化，即平为妙。
茅术钱半川附钱半干姜饯半 党参三钱肉桂七分防风二钱茯苓三钱五加皮三钱陈皮一钱
邓评：进此方而即效，足征第一方尚是病重药轻。凡胀满系阳虚挟寒者，非温热大剂不可。
诒按：茅术改于术，想重浊之白苔已化也。此证纯以温化得效，所谓阳运则湿自化也。
隐癖日久，散而为臌，所以左胁有形作痛，大腹渐满，便出红色垢积。更兼脘中因食而痛，久吐痰涎带瘀。元气益虚，竟有不克支持之象。收散两难，洵属棘手。
香橼皮 人中自 桃仁泥 鸡内金 炙鳖甲射干牡蛎川贝母 陈皮砂仁雪羹
再诊；大便之红积已除，胃中之痰涎仍泛，大腹之胀满如此，何堪磨耐。
原注：此癖散成臌，上下见血，分明有瘀，消瘀消癖，一定之理。无如此证元气大亏，不任攻消，又不可补，乃组织此化瘀化癣，不甚克伐之方。病虽减半，究属难痊。
邓评：今红积已除，痰涎仍泛，何转方反去陈、贝之祛痰，而加延、丹之导瘀?不无背谬。
素有隐癖，肝脾之不调可知。去年血痢于下，痞结于中，久未向愈，大腹胀满，溺赤舌黄，脉形弦细而数。湿热内聚，脾虚无力以消，极易成臌。毋忽。
邓评：此症固必有湿热留积。拟于煎方内增入桃仁、楂炭以导之，甚则酒制军亦可参用。
胀者，皆在脏腑之外。此病之胀，不从腹起，自足跗先肿，而后至腹，是由下以及上。因脾虚不能运湿，湿趋于下，尚在本经；肿胀及中，又属犯本也；肿胀之处，按之如石。阳气大伤，理之棘手。
另肾气丸
另用鳖甲煎丸。
原注：左侧病位属血、属肝，疟邪滞留于血分之中，治疗以鳖甲煎丸为主。右侧病位属气、属胃，或因痰饮或因食积，治疗以鸡内金推气汤为主，加竹沥、白芥子。
柳诒按：这是兼顾左右两方面的治疗方法。
邓评：左右胁下结聚成痞块，最容易拖延发展成中满胀病。而针对病势迎头痛击进行治疗，思路清晰严谨。
【肿胀门】
患者营血本已亏虚，肝火本已旺盛，根源在于先天禀赋不足。加上后天脾气不健运，导致肝木乘虚克制脾土。所进食物的水谷精微，化为痰湿，贮存在胃中，如果还能通过呕吐排出，尚且相安无事；但时间久了，痰湿渗入膜原之外，气道不清利，胀病便发作了。脾是生痰的源头，胃是贮存痰液的容器。如果不能运化中焦脾胃之气，兼透达膜原之外的痰湿，那么病情只会加重不会停止，形成臌胀病，也是很容易的事。脾统摄血液，肝贮藏血液，病程久了血液更加衰少，不得不辅助以调和滋养之法。古人燥湿并用的治法，正是为这类证候设立的。
归芍六君子汤（当归、白芍、党参、白术、茯苓、甘草、陈皮、半夏）去掉人参、甘草，加白芥子、莱菔子、车前子、厚朴、苏子、大腹皮、竹沥、雪羹汤（海蜇、荸荠）。
柳诒按：用药虚实兼顾，贴切而不浮泛。
邓评：长期呕吐之后，痰饮渗透至膜原之外，从而形成臌胀病的很多。此案对病情的论述透彻，立法精当。
陈评：方中的厚朴、白芥子、莱菔子、大腹皮等药，即张景岳的廓清饮，能治疗湿热痰饮引起的胀病。
《内经》说：各种腹胀大，都归属于热；各种湿肿满闷，都归属于脾。脾经湿热交阻于中焦，先出现满闷，随后见到肿胀，皮肤发热微汗，口渴面红，治疗起来不容易。
邓评：这是《金匮要略》中木防己汤的加减方，之所以去掉桂枝的温性，是因为热象较多。然而看其转方后，各种症状仍未减轻，或许需要借助桂枝来温通气化，才能见效呢？如果说病重药轻，再加鲜地黄、知母、麦冬等味，恐怕终究不适合胀病的治疗。既然说是湿满三焦，为何不用刘河间的桂苓甘露饮来治疗呢？
孙评：对书理的解读确实符合。
复诊：湿热充满三焦，常常多患肿胀之病。如果邪气偏重于下焦，小便必然减少，前人中质重开泄下行的治法，原本就是为这类证候设立的。然而此病已久，邪气仍盛于中上二焦，为何不对中上两焦施以相应的治法？各种症状未减，或许是病重药轻的缘故。将前方剂量加大。
原注：此病例为十二岁女子，腹部突然胀大，面部和足背都浮肿，面红口渴，小便黄。这种证候属于热证，所见很少。
柳诒按：此类方剂治疗胀病，没有卓越见识的人不能保留它，以此增加临证者的两种见解。
脘腹膨胀，大小便失调，经络酸痛，四肢无力，脉象弦细，舌苔白腻而厚。这是湿邪内郁。应当用苦辛宣泄之法。
苍术、川芎、香附、黑栀子、神曲、大腹皮、厚朴、赤茯苓、泽泻、瓜蒌皮。
柳诒按：这也是湿郁而化热的情况，所以兼用栀子、瓜蒌清热泄浊。
邓评：完全是湿胜的表现，怎么知道湿中有热？兼用栀子、瓜蒌，不用干姜、肉桂。读案语中提到“二便失调”，其关键在小便黄少可知。大概这类证候最容易误作寒湿医治，而使用热药。
脉细而弦，说明脾弱兼有肝木郁结；苔白而腻，知道湿胜且有热蒸腾，使湿热化解，脾健肝达，那么各种症状就会趋向安宁。
原注：这是越鞠丸的改方，加入了一半的胃苓汤。本方治疗湿郁，关键在于舌苔白腻而厚，在所必效，我每次借用它治疗黄疸也有效，挟痰的头项痛也有效。
孙评：越鞠丸治疗黄疸，想必是气、湿、热三者交阻而成的病症。如果是头项痛，挟痰者必须兼有郁结才有效，而且须加入涤痰的药物才稳妥。
脾主湿，湿因脾虚而郁滞，郁久蒸腾化为热，所以隐癖僭逆侵犯中焦；大腹胀满，纳食少，大便溏，面色黄，小便赤，咳嗽，身体发热时作，脉息弦细，极易形成臌胀病。
越鞠丸（香附、苍术、川芎、神曲、栀子）加鸡内金散，加赤茯苓、青蒿、黄芩、厚朴。
原注：这是越鞠丸证，兼有隐癖。湿化为热，所以合用鸡内金消散癖积，黄芩、青蒿化热。
原注：以上是越鞠丸证。大约越鞠丸治疗无形湿热之痞，是从泻心汤化裁而来；鸡内金散治疗有形食积之癖，是从陷胸汤化裁而来。况且如脘痛门中，郁痰作痛，脉数多渴者，用清中蠲痛汤。山栀用姜汁炒，干姜用童便炒，黄连用姜汁炒，苍术用童便浸后切麻油炒，香附用醋炒，神曲用姜汁炒，托红（可能是指某种药物或笔误，此处保留原名）、生姜、大枣。治疗中脘火郁作痛，发作时伴有寒热。以寒热为主症，即是越鞠丸加干姜、黄连、橘皮、大枣。可知此方治疗气、火、湿、食、血五者之郁，确实非常巧妙。有人说栀子主火，苍术主湿，香附主气，川芎主血，神曲主食，分为五郁，似乎不必如此，正如五音必须合奏才能和谐一样。
邓评：大腹胀满是臌胀的征候；咳嗽身热，是劳损的象。这是营卫阴阳都受伤，用药则宁可偏于燥，不可偏于滋，如当归、白芍用来养营制木，也正不妨添入。
大腹胀满，已经四十多天，近来气息更急促，足背浮肿，小便黄口干，脉象弦数。湿热之邪，因气机阻滞而发病，因饮食停滞而加剧，治疗起来不容易。
廓清饮（廓清饮用白芥子、陈皮、厚朴，枳壳、泽泻、茯苓同大腹皮，莱菔子生研通壅滞，气逆胀满均堪服。）去掉白芥子、枳壳，加黑栀子、猪苓、苏梗、黄连、香附。
原注：温药留手之处，在口干溺黄这四个字上。
邓评：大腹胀满是病，小便黄口干是证，脉象弦数是脉。凭证件脉来推求病因，那么病邪的性质自然无所遁形。
脾虚则湿热内郁，形成臌胀。按照去郁陈莝（清除陈腐积聚）的法则治疗。
另服小温中丸，早晚各一钱半。
柳诒按：腹满由于脾的不运化，其所以不能运化的原因，是痰、湿、浊、气、瘀。所以方中多用疏气化痰、清利湿热的药物。
邓评：此方也只是疏化湿热，为什么一定要拘泥于芜花、甘遂、大戟等峻猛攻导的药物呢？用廓清法去掉芥子的原因，想是病不重于痰饮吧。
大腹主脾，腹部大至肚脐突出，无疑属于脾病。然而胀病无一日缓解，疼痛又不时发作，舌苔薄白，脉息沉弦，见于经期落后的体质，明显是血虚不能敛气，气郁于中，寒邪加于外，而脾经的湿气，因此不能消除。
柳诒按：沉弦脉与沉细脉不同，沉细脉伴面色萎黄则是理中证。此证抓住“郁”字，故用逍遥散疏散。
这个病的大概，不离中寒木郁，立方的大意，也不外乎温中达木，拟加吴茱萸散即可。
单腹胀，脾气固然虚弱，日久肾气也虚，大便溏者，气更散漫而不收敛了。所用的药，比之寻常温补脾肾的药，应当更进一层；然而用之已晚。可惜啊。
柳诒按：案中说较之寻常温补更进一层，看方中所加的肉豆蔻、当归，是开启峻补之法的意思。
邓评：虚寒腹胀，固然应当责之于脾肾。至于偏于肾虚还是偏于脾虚，须看胀处是小腹严重还是脘腹严重。参入生脉散，想是其舌光苔微的原因。
大腹胀满，大便溏，舌苔冷白，口干喜热饮，皮肤发热脉数。脾阳大虚，无力运化湿浊，而成臌胀病。治疗棘手。
邓评：这是阳虚挟湿热的证候，固然宜急用理中汤，然后兼清湿热，层次未尝不合。我拟用李东垣升阳除湿法，参入五苓散为好。然而不治的患者很多了。
复诊：进温补药四剂，腹胀逐渐缓和，邪气从下焦排泄，所以大便作泻。然而皮肤发热未退，小便未增多，口干欲热饮，胃不思食，白苔已变薄，舌质转红。中阳稍振，湿热未清。
理苓汤。
原注：舌苔冷白，是使用桂附的关键依据。四剂后能大便泄泻，邪从下出，中阳尚可，脾气尚未衰尽。再结合舌质转红，知道湿热壅盛甚重，所以转方减去附子、肉桂。人参、白术已足以扶脾，外加四苓散驱湿而已。
大便作泻，小便又长，肝脾肾三经即使有阴邪，也可从此而消。为什么隐癖还占据在中焦，腹胀不和，这是阳虚啊。
四君子汤加黄芪、当归、桂枝、附子、陈皮、肉豆蔻、沉香、干姜、牡蛎、鳖甲、鸡内金。
原注：这是启峻汤，附子理中汤加黄芪、当归、肉豆蔻，比附子理中汤更进一层。
在峻补之内，存留疏启之意，所以叫启峻。
太阴腹满，寒湿有余，真阳不足，脉弦，下体不温，口干不欲饮，妨碍进食气短。其势颇险。拟用温通化湿法。
柳诒按：这也是通补兼施的方法。
温补元阳，浮肿胀满有增无减，阳气衰败至极。脐平脉迟的证候，非温不可，非补亦不可；然而温补也不见增长，盖因下泄伤及肾脏更甚。
柳诒按：此法较肾气丸更进一层。
此病为何不进商禹余粮丸？
中满的病，泻之于内，开始并非不迅速消退，其后攻之不消，之后再攻之如铁石般坚硬。此病虽不至如铁石，但正气久伤，终究不是易事。
原注：以上都是理中汤的加减法。因为记得当年侍奉老师时，问理中汤的变化如何？老师说：理中汤是足太阴脾经极妙的方剂，加以中宫阳气不舒，用干姜取其发散；少腹阳气下陷，用炮姜取其守中；其变化在大便溏与不溏。湿甚而无汗的用苍术，湿轻而中虚的用白术；其变化在舌苔浊与不浊。这是本方的变化。假如脾家当用理中汤，而胃家有火，则古人早定连理一方了。假如气机塞滞，古人早定治中一方了。假如脾家当用理中汤，而其人真阴亏者，张景岳早有理阴煎了。其肾中真阳衰者，加附子固然可以；其衰甚者，古人又有启峻一方了。此外，加木瓜则名和中汤，必兼肝病；加枳实、茯苓，治胃虚挟实。古人的成方，如果能方方如此用法，何愁不成名医呢？因此附录于此，作为运用理中汤的方法。
孙评：说得透彻可取。
《内经》说：各种湿肿满闷，都归属于脾。因劳倦所伤，内湿与外湿合而为一，郁于脾土之中，致太阴的气化不行。治病必求其本，先以实脾法治疗。
孙评：肿满因此而起的情况居多。
初起痞满，继增腹胀，脐突筋露，足背浮肿，大便溏泄。这是湿热内壅，中虚不化，病势从下走也。用药最为棘手，且从口苦、舌红、小便短赤立方。
柳诒按：这是刘河间的甘露饮。用五苓散以降湿，三石（石膏、寒水石、滑石）以清热。
邓评：此类方法，非洞彻病情者不可滥用。必须脉象洪数者，始能放胆用之，恐其湿热未去而中阳已疲惫。
孙评：口苦舌红尿短，是阴液已大伤，化源欲绝，岂宜再以三石沉寒暴烈之品泻其实火？总之如此险恶征象，挽回非易，虽有良法，终于无济于事。
咳而腹满，经所谓三焦咳也。苔黄干苦，卧难着枕，肢冷阳缩，股痛囊肿，便溏溺短。种种见证，都属风邪湿热，满布三焦，无路可出，是实证也，不可与虚满者同日而语。
桑白皮、地骨皮、茯苓皮、瓜蒌皮、大腹皮、生姜皮、防己、杏仁、苏子、葶苈子、车前子。
柳诒按：湿热壅盛，脾不输运，肺不肃降，故立方专用疏化，仿五皮五子法。
邓评：肢冷阳缩，是湿热阻遏其阳气所致。断其为湿热实证者，全在苔黄干苦显现出来。盖一病有一病的关键，不可移易的道理。此方选药也很好。
中阳不足，寒湿有余，脘痞纳少，舌白便溏，脉细小。法当温化，即以平和为妙。
苍术一钱半，附子一钱半，干姜一钱半，党参三钱，肉桂七分，防风二钱，茯苓三钱，五加皮三钱，陈皮一钱。
邓评：进此方而即效，足证第一方尚是病重药轻。凡胀满系阳虚挟寒者，非温热大剂不可。
附子一钱，桂枝一钱，党参三钱，白术一钱半，干姜四分，茯苓一钱半。
柳诒按：苍术改为白术，想是重浊的白苔已化也。此证纯以温化得效，所谓阳运则湿自化也。
隐癖日久，散而为臌，所以左胁有形作痛，大腹渐满，便出红色垢积。更兼脘中因食而痛，久吐痰涎带瘀。元气益虚，竟有不克支持之象。收散两难，确属棘手。
香橼皮、人中白、桃仁泥、鸡内金、炙鳖甲、射干、牡蛎、川贝母、陈皮、砂仁、雪羹汤。
复诊：大便之红积已除，胃中之痰涎仍泛，大腹之胀满如此，何堪磨耐。
原注：此癖散成臌，上下见血，分明有瘀，消瘀消癖，一定之理。无奈此证元气大亏，不任攻消，又不可补，乃组织此化瘀化癖，不甚克伐之方。病虽减半，究属难痊。
邓评：今红积已除，痰涎仍泛，为何转方反去陈皮、川贝之祛痰，而加延胡索、丹参之导瘀？不无背谬。
素有隐癖，肝脾之不调可知。去年血痢于下，痞结于中，久未向愈，大腹胀满，溺赤舌黄，脉形弦细而数。湿热内聚，脾虚无力以消，极易成臌。勿忽视。
邓评：此症固必有湿热留积。拟于煎方内增入桃仁、山楂炭以导之，甚则酒制大黄亦可参用。
胀病，皆在脏腑之外。此病之胀，不从腹起，自足跗先肿，而后至腹，是由下以及上。因脾虚不能运湿，湿趋于下，尚在本经；肿胀及中，又属犯本也；肿胀之处，按之如石。阳气大伤，治疗棘手。
另服肾气丸。
Additionally, use Biejia Jian Wan (Turtle Shell Decoction for Reducing Masses).
Original Note: The left side pertains to Blood and the Liver; Malaria pathogens stagnate within the Blood aspect. Treatment is primarily with Biejia Jian Wan (Turtle Shell Decoction for Reducing Masses). The right side pertains to Qi and the Stomach, involving either Phlegm or Food Stagnation. Treatment is primarily with Jijin Tuiqi Tang (Chicken Gizzard Lining Pushing Qi Decoction), added with Zhuyu (Bamboo Sap) and Baijiezi (White Mustard Seed).
Liu Yi's Comment: This is a method of treating both aspects simultaneously.
Deng's Comment: Biomasms (masses) forming on the left and right are most likely to prolong into Zhongman (Central Fullness/Bloating). Treating them head-on clears the logical path of treatment.
[Section on Swelling and Distension]
Ying Blood (Nutritive Blood) is originally deficient, and Liver Fire is originally vigorous; the responsibility lies in congenital endowment. Furthermore, acquired Spleen Qi is not robust, allowing Liver Wood to overact upon it. The ingested food generates Phlegm and Dampness, which store in the Stomach. If they can still be expelled through vomiting, peace prevails without incident; but after a long time, they infiltrate outside the membranes (Membrane Origin), the Qi mechanism becomes unclear, and distension arises. The Spleen is the source of Phlegm production; the Stomach is the vessel storing Phlegm. Unless the Middle Jiao (Spleen/Stomach) is transformed and transported, and the exterior of the membranes is penetrated, the disease trend will only increase, easily becoming Gu Disease (Abdominal Distension/Tympanites). The Spleen governs Blood, and the Liver stores Blood. After a long illness, Blood becomes even more depleted, necessitating assistance with harmonizing and nourishing methods. The ancients' use of drying and moistening agents together was precisely designed for such syndromes.
Guishao Liujunzi Tang (Angelica Sinensis and White Peony Root Six Gentlemen Decoction): Remove Renshen (Ginseng) and Gancao (Licorice); add Baijiezi (White Mustard Seed), Laifuzi (Radish Seed), Cheqianzi (Plantago Seed), Chuanpu (Atractylodes Lancea - *Note: Text says Chuan Pu, usually Houpo, assuming Houpo based on context of distension*), Suzi (Perilla Seed), Fupi (Areca Peel), Zhuyu (Bamboo Sap), Xiegeng (Snow Soup - Sea Cucumber and Water Chestnut).
Liu Yi's Comment: The medication addresses both deficiency and excess, being pertinent and not superficial.
Deng's Comment: After prolonged vomiting, Phlegm-Fluid infiltrates outside the membranes, leading to many cases of Gu Distension. This case discusses the pathology thoroughly and establishes precise treatment principles.
Chen's Comment: Houpo (Magnolia Bark), Baijiezi (White Mustard Seed), Laifuzi (Radish Seed), Dafupi (Areca Peel), etc., constitute Kuqing Yin (Clearing Decoction) from Zhang Jingyue, capable of treating distension caused by Damp-Heat and Phlegm-Fluid.
"The Classic" states: All abdominal fullness and enlargement belong to Heat; all damp swelling and fullness belong to the Spleen. Spleen Meridian Damp-Heat obstructs the Middle Jiao, first causing fullness, then manifesting as swelling, skin heat with slight sweating, thirst, and red face. Treatment is difficult.
Fangji (Stephania Root), Fuling (Poria), Shigao (Gypsum), Fupi (Areca Peel), Chenpi (Tangerine Peel).
Deng's Comment: This is a modification of Mugufangji Tang (Cinnamon Twig and Stepia Decoction) from "Jin Gui Yao Lue". The reason for removing Guizhi (Cinnamon Twig)'s warmth is due to excessive Heat. However, observing that symptoms persist after changing formulas, perhaps one must rely on Guizhi to warm and unblock Qi transformation to achieve efficacy? If one claims the disease is severe and the medicine light, adding fresh Dihuang (Rehmannia), Zhimu (Anemarrhena), and Maidong (Ophiopogon) might ultimately be unsuitable for distension diseases. Since it is stated as Damp-Fullness of the Three Jiaos, why not simply use Hezi's Guiling Ganlu Yin (Cassia Twig, Poria, and Melon Dew Decoction)?
Sun's Comment: The interpretation of the text is indeed accurate.
Second Visit: Damp-Heat filling the Three Jiaos often leads to swelling. If the pathogenic factor leans towards the Lower Jiao, urination will surely be scant. The ancients' heavy, purgative methods were originally designed for such syndromes. However, this disease has been present for a long time, yet remains prevalent in the Middle and Upper Jiaos. Why not apply methods targeting the Middle and Upper Jiaos? Various symptoms remain unchanged, possibly due to the disease being severe and the medication too light. Increase the dosage of the previous formula.
Zhuye (Bamboo Leaf), Shigao (Gypsum), Xianshengdi (Fresh Rehmannia), Maidong (Ophiopogon), Zhimu (Anemarrhena), Banxia (Pinellia), combined with Wupi Yin (Five Peel Decoction).
Original Note: This patient is a twelve-year-old girl with sudden abdominal distension, facial and ankle edema, red face, thirst, and yellow urine. This syndrome belongs to Heat, which is rarely seen.
Liu Yi's Comment: Such prescriptions for treating distension require extraordinary insight to preserve; they serve to broaden the understanding of clinicians.
Epigastric and abdominal distension, dysfunction of bowel and bladder, meridian soreness and pain, limb weakness, wiry-thin pulse, white greasy and thick tongue coating. This is internal depression of Dampness. One should employ bitter-pungent venting and draining.
Cangzhu (Atractylodes Lancea), Chuanxiong (Sichuan Lovage Rhizome), Xiangfu (Cyperus Rhizome), Heizhi (Black Gardenia), Shenqu (Medicated Leaven), Fupi (Areca Peel), Chuanpu (Magnolia Bark), Chiling (Red Poria), Zexie (Alisma), Loupi (Trichosanthes Peel).
Liu Yi's Comment: This is also a case of Dampness depression transforming into Heat, hence the concurrent use of Zhizi (Gardenia) and Lou (Trichosanthes) for clearing and draining.
Deng's Comment: It purely presents signs of Dampness predominance. How do we know there is Heat within the Dampness? By adding Zhizi and Lou, while avoiding Jiang (Ginger) and Gui (Cinnamon). Reading the case note "dysfunction of bowel and bladder," the key lies in the yellow and scanty urine. Generally, such syndromes are easily misdiagnosed as Cold-Damp and treated with hot medicines.
Fine and wiry pulse indicates Spleen weakness combined with Liver depression; white and greasy coating indicates Dampness predominance with steaming Heat. Once Damp-Heat is resolved, Spleen health restored, and Liver Qi unblocked, various symptoms will tend toward peace.
Second Visit: Various symptoms tend toward peace, limb weakness persists; focus on strengthening the Spleen.
Xiangsha Liujunzi Tang (Aucklandia and Amomum Six Gentlemen Decoction).
Original Note: This is a modified Yueju Wan, incorporating half of Weiling San. This formula treats Dampness depression; its key indicator is the white, greasy, and thick tongue coating, ensuring efficacy. I often borrow it to treat Jaundice with good results, and for Head/Neck pain with Phlegm, it is also effective.
Sun's Comment: Yueju Wan treating Jaundice likely addresses syndromes formed by the interlocking obstruction of Qi, Dampness, and Heat. For head/neck pain with Phlegm, depression must be present for efficacy, and phlegm-resolving herbs must be added for safety.
The Spleen governs Dampness; Dampness depresses due to Spleen deficiency, steams into Heat, thus invading the Middle Jiao with hidden masses. Abdominal distension, poor appetite, loose stools, yellow complexion, red urine, cough, intermittent body heat, wiry-thin pulse. It easily develops into Gu Disease (Tympanites).
Yueju Wan (Xiangfu, Cangzhu, Chuanxiong, Shenqu, Zhizi) plus Jijin San (Chicken Gizzard Lining Powder), added with Chiling (Red Poria), Qinghao (Sweet Wormwood), Huangqin (Scutellaria), Chuanpu (Magnolia Bark).
Original Note: This is a Yueju Wan syndrome complicated by hidden masses. As Dampness transforms into Heat, Jijin San is combined to dissipate masses, and Huangqin/Qinghao to resolve Heat.
Original Note: Above are Yueju Wan syndromes. Generally, Yueju Wan treats formless Damp-Heat biomasms, derived from Xiexin Tang; Jijin San treats tangible Food Stagnation masses, derived from Xiaoxiongan Tang. Furthermore, in the Epigastric Pain section, for pain due to depressed Phlegm with rapid pulse and thirst, use Qingzhong Juan Tong Tang. Zhizi stir-fried with Ginger Juice, Ganjiang (Dried Ginger) stir-fried with Child's Urine, Huanglian (Coptis) stir-fried with Ginger Juice, Cangzhu soaked in Child's Urine then sliced and stir-fried with Hemp Oil, Xiangfu stir-fried with Vinegar, Shenqu stir-fried with Ginger Juice, Tuohong (likely a typo or specific preparation), Ginger, Jujube. Treats epigastric Fire-depression pain with chills and fever. Using chills/fever as main indicators implies Yueju Wan plus Ginger, Coptis, Tangerine Peel, Jujube. Thus, this formula treats the depression of Qi, Fire, Dampness, Food, and Blood. It is truly exquisite. Some say Zhizi governs Fire, Cangzhu governs Dampness, Xiangfu governs Qi, Chuanxiong governs Blood, Shenqu governs Food, dividing them into Five Depressions. This seems unnecessary, just as five tones must play together to harmonize.
Deng's Comment: Large abdominal distension is a sign of Gu; cough and body heat are signs of Lao (Consumption). Here, Ying, Wei, Yin, and Yang are all injured. Medication should lean towards drying rather than moistening. Adding Guizhi (Angelica) and Shaoyao (Peony) to nourish Ying and subdue Wood is acceptable.
Sun's Note: Jijin San consists of Sharen (Amomum), Chenpi (Tangerine Peel), Chenxiang (Agarwood), Jineijin (Chicken Gizzard Lining), Xiangyuan (Citron).
Large abdominal distension for over forty days, recent急促 (rapid) breathing, ankle edema, yellow urine, dry mouth, wiry-rapid pulse. Damp-Heat pathogens, obstructed by Qi, exacerbated by Food. Treatment is difficult.
Kuqing Yin (Clearing Decoction: remove Baijiezi, Zhike): Add Heizhi (Black Gardenia), Zhuling (Polyporus), Sugeng (Perilla Stem), Chuanlian (Coptis), Xiangfu (Cyperus).
Original Note: The place where warm medicines are retained lies in the four characters: Dry Mouth, Yellow Urine.
Deng's Comment: Large abdominal distension is the disease; yellow urine and dry mouth are the manifestations; wiry-rapid pulse is the pulse. Inferring from manifestations and pulse, the nature of the pathogen will reveal itself without hiding.
Spleen deficiency causes internal Damp-Heat depression, forming Gu. Treat according to the principle of removing depression and eliminating stale accumulation.
Kuqing Yin (remove Baijiezi): Add Suye (Perilla Leaf), Xiangfu (Cyperus), Dongzhu (White Atractylodes).
Separately take Xiao Wenzhong Wan (Minor Warming Center Pill), morning and evening, each 1 qian.
Liu Yi's Comment: Abdominal fullness stems from the Spleen's failure to transport. The reasons for this failure are Phlegm, Dampness, Turbidity, Qi, and Blood Stasis. Hence, the formula uses many herbs to move Qi, resolve Phlegm, and clear/drain Damp-Heat.
Deng's Comment: This formula merely疏 (disperses) and resolves Damp-Heat. Why insist on harsh purgatives like Huarua (Kadoka), Ji (Euphorbia Kansui), and Sui (Euphorbia Esula)? Using Kuqing method without Baijiezi suggests the disease is not severe regarding Phlegm-Fluid.
The abdomen belongs to the Spleen. Abdominal enlargement reaching the umbilicus protrusion undoubtedly belongs to the Spleen. However, distension does not cease daily, pain recurs intermittently, thin white tongue coating, deep-wiry pulse, appearing in a constitution with delayed menstruation. Clearly, Blood deficiency fails to contain Qi, Qi depresses in the Middle, Cold adds externally, and Spleen Meridian Dampness consequently fails to dissipate.
Xiaoyao San (Free and Easy Wanderer Powder) combined with Jijin San, added with Xiangfu.
Liu Yi's Comment: Deep-wiry differs from deep-thin. Deep-thin with sallow complexion indicates Lizhong Syndrome. This case grasps the character "Depression," using Xiaoyao San to disperse.
Deng's Comment: Deep-wiry pulse does not compare to Blood deficiency failing to contain Qi.
The general nature of this disease does not exceed Middle Cold and Liver Depression. The main idea of the prescription is warming the Middle and unblocking Liver Wood. One might add Wuxian San (Evodia Powder).
Single Abdominal Distension: Spleen Qi is certainly deficient; over time, Kidney Qi also becomes deficient. Loose stools indicate Qi scattering and failing to gather. The medications used should be one step further than ordinary Spleen/Kidney warming tonics; however, it is already late. Pity.
Fugui Lizhong Tang (Aconite and Cinnamon Warming Center Decoction) added with Rougu (Nutmeg), Danggui (Angelica), Muli (Oyster Shell), Mugua (Chaenomeles), Fuling (Poria), separately taken with Shengmai San (Generate Pulse Powder).
Liu Yi's Comment: The case states "one step further than ordinary warming," and looking at the added Rougu and Danggui, this initiates a峻 (severe/powerful) method.
Deng's Comment: Deficient-Cold distension should indeed be attributed to Spleen and Kidney. Whether it leans towards Kidney deficiency or Spleen deficiency depends on whether the distension is worse in the lower abdomen or the epigastrium. Adding Shengmai San suggests a glossy tongue with slight coating.
Large abdominal distension, loose stools, cold-white tongue coating, dry mouth preferring hot drinks, skin heat, rapid pulse. Spleen Yang is greatly deficient, powerless to transform Damp-Turbidity, resulting in Gu Disease. Treatment is tricky.
Fugui Zhizhong Tang (Aconite and Cinnamon Regulating Center Decoction) added with Mugua (Chaenomeles), Caoguo (Black Cardamom), Danggui (Angelica).
Deng's Comment: This is a pattern of Yang deficiency with夹杂 (intermixed) Damp-Heat. Indeed, Lizhong Tang is urgent, followed by clearing Damp-Heat. The layers are not inconsistent. I would propose Dongyuan's Ascending Yang and Draining Dampness method, incorporated with Wuling San. However, many patients are untreatable.
Second Visit: After four doses of warming tonics, abdominal distension gradually harmonizes. Pathogens exit via the Lower Jiao, hence diarrhea. However, skin heat has not receded, urine volume has not increased, dry mouth desires hot drinks, stomach lacks appetite, white coating has thinned, tongue body turns red. Middle Yang slightly revives, Damp-Heat not cleared.
Liling Tang (Regulating Poria Decoction).
Original Note: Cold-white tongue coating is the handle for using Guifu (Aconite/Cinnamon). Four doses leading to bowel evacuation means pathogens exit downwards; Middle Yang is still okay, Spleen Qi not exhausted. Combined with tongue body turning red, knowing Damp-Heat stagnation is severe, hence changing formula to reduce Fu/Gui. Renshen/Atractylodes are sufficient to support Spleen; additionally, Siling San (Four Poria Powder) drives out Dampness.
Diarrhea occurs, urine volume increases. Even if Yin pathogens exist in Liver, Spleen, and Kidney meridians, they can dissipate from here. Why do hidden masses still occupy the Middle, and abdominal distension remain unharmonized? This is Yang deficiency.
Sijunzi Tang (Four Gentlemen Decoction) added with Huangqi (Astragalus), Danggui (Angelica), Guizhi (Cinnamon Twig), Fuzi (Aconite), Chenpi (Tangerine Peel), Rougu (Nutmeg), Chenxiang (Agarwood), Ganjiang (Dried Ginger), Muli (Oyster Shell), Biejia (Turtle Shell), Jineijin (Chicken Gizzard Lining).
Original Note: This is Qijun Tang (Initiating Severe Tonification Decoction). Fuzi Lizhong Tang added with Huangqi, Danggui, Rougu is one step further than Fuzi Lizhong Tang.
Deng's Comment: The reason Yin pathogens do not dissipate is that Yang deficiency lacks power to transform them.
Within severe tonification, preserving the intent of dispersing and initiating is why it is called Qijun.
Taiyin abdominal fullness, excess Cold-Damp, insufficiency of True Yang. Pulse wiry, lower body not warm, dry mouth not desiring drink, difficulty eating, shortness of breath. The situation is quite dangerous. Propose warming-unblocking and resolving Dampness method.
Fuzi Maozhu Zhizhong Tang (Aconite and Atractylodes Regulating Center Decoction) added with Chuanpu (Magnolia Bark), Banxia (Pinellia).
Liu Yi's Comment: This is also a method of unblocking and tonifying combined.
Deng's Comment: Wiry pulse, difficulty eating, shortness of breath seem to indicate Cold-Fluid internally, further mixed with Liver Qi depression.
Warming and tonifying Yuan Yang, floating swelling and fullness increase without decrease; Yang decline is extreme. Umbilical flattening and slow pulse indicate necessity for warming and tonifying; however, warming/tonifying shows no gain, likely because downward leakage injures the Kidney further.
Fuzi Lizhong Tang combined with Sishen Wan (Four Spirit Pill), separately take Laifu Dan (Returning Life Pellet).
Liu Yi's Comment: This method is one step further than Shenqi Wan (Kidney Qi Pill).
Deng's Comment: Floating swelling and fullness often involve Damp-Heat and Wind pathogens; incompatibility with warming tonification is common.
Why not use Shang Yu Yuliang Wan (Shang's Hematite Pellet) for this disease?
Taiyin abdominal fullness, caused by Cold-Damp. If Yang is not vigorous, it will inevitably become Gu Disease.
Fuzi Lizhong Tang added with Chuanpu (Magnolia Bark), Dafupi (Areca Peel), Zexie (Alisma), Zhuling (Polyporus).
Liu Yi's Comment: This is a syndrome of Spleen Yang不振 (failure to rise) and Cold-Damp stagnation, hence using warming-resolution method.
Deng's Comment: Unresolved Cold-Damp requires warming-hot and unblocking-Yang, like the sun shining brightly, dispelling haze.
Middle fullness: Drain it internally. Initially, it may disappear rapidly, but later attacks fail to resolve it, and subsequent attacks meet resistance like iron or stone. This disease, though not like iron/stone, involves long-term injury to Righteous Qi, making it not an easy matter.
Zhizhong Tang combined with Wuling San (Five Poria Powder).
Original Note: Above are all modifications of Lizhong Tang. Remembering asking my master about Lizhong variations when attending him: "Lizhong is an excellent formula for Foot Taiyin." If Middle Jiao Yang Qi is uncomfortable, use Ganjiang (Dried Ginger) for its dispersing property; if Lower Abdomen Yang Qi sinks, use Paojiang (Roasted Ginger) for its retaining property. Variation depends on loose vs. normal stool. Heavy Dampness with no sweat uses Maozhu (Atractylodes Lancea); Light Dampness with Middle deficiency uses Dongzhu (White Atractylodes). Variation depends on turbid vs. clean tongue coating. This is the variation of this formula. If Spleen needs Lizhong but Stomach has Fire, ancients established Lianli Tang. If Qi mechanism is blocked, ancients established Zhizhong Tang. If Spleen needs Lizhong but person has True Yin deficiency, Jingyue established Liyin Jian. If Kidney True Yang declines, adding Fuzi is natural; for severe decline, ancients had Qijun Tang. Additionally, adding Mugua makes Hezhong Tang (for Liver disease); adding Zhishi/Fuling treats Stomach deficiency with Excess. If ancient formulas are used this way, how could one fail to become a famous doctor? Therefore appended as a method for using Lizhong.
Deng's Comment: Single abdominal distension inevitably injures Spleen Yang. Even with Excess pathogens, beware of hasty purging.
Sun's Comment: Thoroughly explained and worthy of emulation.
"All damp swelling and fullness belong to the Spleen." Injured by fatigue, Internal Dampness combines with External Dampness, depressing in Earth, causing Taiyin Qi transformation to fail. Treating disease must seek its root; first use Shi Pi (Solidify Spleen) method.
Chuanfu (Aconite), Yuzhu (White Atractylodes), Fuling (Poria), Chenpi (Tangerine Peel), Caoguo (Black Cardamom), Dafupi (Areca Peel), Wuyao (Lindera), Mugua (Chaenomeles), Zexie (Alisma).
Liu Yi's Comment: Case says "Solidify Spleen," but formula contains warming-unblocking herbs; this is not the orthodox method of Solidifying Spleen.
Deng's Comment: This intends for Spleen Yang to transport and sufficiently resolve Dampness; suitable for Dampness combined with Cold.
Sun's Comment: Most swellings/fullness arise from this.
Initial bloating, subsequently increasing distension, umbilical protrusion, visible veins, ankle edema, loose stools. This is internal Damp-Heat congestion, Middle deficiency failing to transform, trend moving downwards. Medication is most tricky. Prescribe based on bitter taste, red tongue, short red urine.
Guixin (Cinnamon Heart), Fuling (Poria), Zhuling (Polyporus), Baizhu (Atractylodes Macrocephala), Zexie (Alisma), Shigao (Gypsum), Hanshuishi (Calcitum), Huashi (Halloysite).
Liu Yi's Comment: This is Hejian's Ganlu Yin (Sweet Dew Decoction). Uses Wuling San to descend Dampness, Three Stones (Shigao, Hanshuishi, Huashi) to clear Heat.
Deng's Comment: Such methods cannot be used rashly by those who do not thoroughly understand the condition. Only when pulse is洪数 (Surging-Rapid) can one boldly use them, fearing Damp-Heat remains while Middle Yang exhausts.
Sun's Comment: Bitter taste, red tongue, short urine indicate Yin is greatly injured, Source of Transformation nearly extinct. How can one use the three stones' heavy/cold violent nature to drain Real Fire? In short, such dangerous signs are hard to reverse; despite good methods, ultimately futile.
Cough with abdominal fullness, known as Sanjiao Cough in Classics. Yellow, dry, bitter tongue coating, difficulty lying down, cold limbs, retracted genitals, thigh pain, scrotal swelling, loose stools, short urine. Various signs all belong to Wind-Pathogen and Damp-Heat, filling the Three Jiaos with no exit. This is Excess Syndrome, incomparable to Deficiency Fullness.
Sangpi (Mulberry Bark), Gupi (Dogwood Bark), Lingpi (Poria Peel), Loupi (Trichosanthes Peel), Dafupi (Areca Peel), Jiangpi (Ginger Peel), Fangji (Stephania), Xingren (Apricot Seed), Suzi (Perilla Seed), Tinglizi (Descurainia Seed), Cheqianzi (Plantago Seed).
Liu Yi's Comment: Damp-Heat congestion, Spleen fails to transport, Lung fails to descend. Hence formula specializes in dispersing/resolving, imitating Wupi (Five Peel) and Wuzi (Five Seed) methods.
Deng's Comment: Cold limbs and retracted genitals are due to Damp-Heat blocking Yang Qi. Diagnosing it as Damp-Heat Excess relies entirely on the yellow, dry, bitter tongue coating. Every disease has its key, immutable principle. This formula selects herbs well.
Middle Yang insufficient, excess Cold-Damp, epigastric blockage, poor appetite, white tongue, loose stools, fine-small pulse. Method should be warming-resolution, aiming for peace.
Maozhu Liling Tang (Atractylodes Regulating Poria Decoction) added with Dafupi (Areca Peel), Jineijin (Chicken Gizzard Lining), Gegua (Kudzu Flower), Chuanpu (Magnolia Bark).
Deng's Comment: Signs purely Cold-Damp, suitable for warming-resolution undoubtedly. Formula uses Gegua, implying the patient is a drinker.
Second Visit: Warming-resolution insufficient to eliminate distension; Yang deficiency is severe. Increase dosage to assist.
Maozhu 1.5 qian, Chuanfu 1.5 qian, Ganjiang 1.5 qian, Dangshen 3 qian, Rougui 0.7 qian, Fangfeng 2 qian, Fuling 3 qian, Wujiapi 3 qian, Chenpi 1 qian.
Deng's Comment: Efficacy upon taking this formula proves the first formula was disease-severe/medicine-light. For distension due to Yang deficiency with Cold, non-warming-hot large doses are ineffective.
Third Visit: Various symptoms tend toward peace, maintain previous method to dispel lingering Dampness.
Chuanfu 1 qian, Guizhi 1 qian, Dangshen 3 qian, Sheng Baizhu 1.5 qian, Ganjiang 0.4 qian, Fuling 1.5 qian.
Liu Yi's Comment: Changing Maozhu to Baizhu suggests heavy/turbid white coating has transformed. This case achieves efficacy purely through warming-resolution, as Yang movement naturally transforms Dampness.
Hidden masses for long duration, dispersing into Gu, hence left hypochondriac mass painful, large abdomen gradually full, passing red turbid feces. Plus epigastric pain after eating, chronic vomiting of Phlegm-Saliva with Blood Stasis. Yuan Qi increasingly deficient, showing inability to support. Difficult to gather or disperse, truly tricky.
Xiangyuanpi (Citron Peel), Renzhongbai (Human Midsection Ash), Taoren Ni (Peach Kernel Paste), Jineijin (Chicken Gizzard Lining), Zhi Biejia (Processed Turtle Shell), Shegan (Belamcanda), Muli (Oyster Shell), Chuanbeimu (Fritillaria), Chenpi (Tangerine Peel), Sharen (Amomum), Xiegeng (Snow Soup).
Liu Yi's Comment: "Ben Cao Jing Shu" states: Shegan treats old Blood pain.
Deng's Comment: This is Phlegm, Blood Stasis, and Food Stagnation mixed causing harm, plus increasingly deficient Yuan Qi. Treatment is difficult.
Second Visit: Red turbid feces removed, Stomach Phlegm-Saliva still overflowing, large abdominal distension so severe, unbearable endurance.
Previous formula removes Chenpi, Beimu; adds Walengzi (Arca Shell), Yanhu (Corydalis), Danshen (Salvia), Xianou (Fresh Lotus Root).
Original Note: Masses disperse into Gu, bleeding above and below clearly indicates Blood Stasis. Resolving Stasis and Masses is a fixed principle. Unfortunately, Yuan Qi is greatly deficient, unable to withstand attacking/resolving, yet cannot be tonified. Thus organizing this formula to resolve Stasis/Masses without severe depletion. Disease halved, yet ultimately difficult to cure.
Deng's Comment: Now red feces removed, Phlegm-Saliva still overflowing. Why change formula to remove Chenpi/Beimu (Phlegm-resolving) and add Yanhu/Danshen (Blood-moving)? This seems contradictory.
History of hidden masses indicates Liver/Spleen disharmony. Last year bloody dysentery below, masses in middle, long unresolved, large abdominal distension, red urine, yellow tongue, wiry-thin-rapid pulse. Internal Damp-Heat aggregation, Spleen deficiency powerless to resolve, easily becoming Gu. Do not neglect.
Guishao Yigong San (Angelica and White Peony Extraordinary Skill Powder) added with Chuanlian (Coptis), Chuanpu (Magnolia Bark), Muxiang (Aucklandia).
Separately take Zhishi Xiaopi Wan (Immature Bitter Orange Reducing Epigastrium Pill), Xiao Wenzhong Wan.
Liu Yi's Comment: Prescription is stable/solid. However, Guishao Yigong San seems to have too much tonification and too little resolution.
Deng's Comment: This syndrome definitely has Damp-Heat retention. Propose adding Taoren (Peach Kernel) and Zhata (Charred Hawthorn) to guide it in decoction; if severe, Jiuzhi Jun (Wine-processed Rhubarb) can be considered.
Master Liu's comments are like a blow to the head.
Distension is always outside the Zang-Fu. This disease's distension does not start in the abdomen, but swells from ankles first, then reaches abdomen, rising from below to above. Due to Spleen deficiency failing to transport Dampness, Dampness tends downward, remaining in its own meridian; swelling reaching the center violates the root. Swollen areas feel like stone. Yang Qi greatly injured, treatment tricky.
Fugui Zhizhong Tang added with Rougu (Nutmeg), Danggui (Angelica), Fangji (Stephania), Niuxi (Achyranthes).
Separately take Shenqi Wan (Kidney Qi Pill).
Liu Yi's Comment: Besides Fangji in the formula, no other Dampness-resolving herbs. Based on condition, should incorporate diuretic/draining herbs.
Deng's Comment: Swelling starting from ankles indicates injury to Kidney Yang. Hence prescription focuses on warming-assisting Kidney Qi.