年逾花甲，天真既薄，酒多谷少，脾胃复亏，书称胃主四肢，脾主肌肉，脾宜升则健，
胃宜
降则和。睹此手足牵强，肤腠绷急麻痒，岂非脾胃不和，失其升降之道乎?内经以胃之大络
，名曰虚里，出于左乳下，即今乳房肿胀，胃络不和之征。又按痰生于湿，湿生于脾，由土
薄也。土浓则无湿，无湿则无痰矣。阅所服诸方，均从肝治，以为凡病皆生于郁，但土为万
物之母，试以五行言之，木虽生于水，然江河湖海无土之处，则无木生。是故树木之枝叶萎
悴，必由土气之衰。一培其土，则根木坚固，津汁上升，布达周流，木欣欣以向荣矣。又问
肾气丸能治手足麻木否?答曰∶天一生水，水之疑处为土，坚者为石，其最坚者为金。水土
金原同一气，凡人戴九履一，心肺居上，脾胃居中，肝肾居下，胚胎始基，先具两肾，此肾
为先天之根，元牝之宅，肾气丸先天药也，能助右肾命门火，使肾火生脾土，脾土生肺金，
肺金生肾水，肾水生肝木，一方而五脏皆调，一法而水火两备。且夫人之手足，犹树之有枝
也。人之肾命，犹树之有根也。乌有根本充盈，而枝叶不敷荣畅茂者乎。引指使臂，灌叶救
根，何可与言至道。
安波按∶确论，引喻亦妙。
诊脉细濡，恙经多时，始而便泻，继则下血，渐致食少欲呕，形疲心愦，药无灵效。略
投辛温，血下即多，稍用清凉，饮食即减。辗转却难借箸。然医贵变通，未可见病治病，印
定眼目，经曰∶湿多成五泻。病始于泻，脾虚酿湿，治湿固宜于燥，但脾为血之统，刚燥过
剂，致动其血，内溢不已，阴络受伤。无如养阴之品，恒多腻滞，又与脾胃欠合。此培其中
州，抉其土母，不得不为之亟亟也。昔贤治血证，每以胃药收功，土浓自能胜湿耳。酌以淡
养胃气，甘益脾阴，宗嘉禾饮。服药数日，谷食稍增，视其病状，与痢相似，即痢久正气未
有不亏，亦当培养本元，资其生气。据述脘中如饥如嘈，是属下多亡阴，兼伤其气，观其
得食则安，情已显露，方内参力加重，佐以乌梅，取其酸能生津，并可摄血。再考方书，论
久痢病根在大肠曲折之处，药力所不能到，有用至圣丹一方，余仿其法，治验颇多，可备采
择。经云∶阴络伤血内溢。然药用清热养阴而不效者何耶?经曰∶营出中焦，中焦取汁，变
化而赤，是谓血。中焦盖指胃而言。夫胃为水谷之海，气血俱多之经。病之浅者，饮食如常
，旋去旋生，病之深者，谷少气衰，所生不偿所耗，脾与胃以膜相连，胃弱则生化无权，脾
虚则统摄失职。书称不问阴阳与冷热，先将脾胃为调和。万物以土为根，元气以土为宅，议
进归脾理当如是。又述向有肝阳冲逆之恙，近兼举发，方内加入首乌，既可益阴，又可固摄
，非熟地滋腻可比。乌梅畏酸，不用亦可。但肠滑已久，须参涩以固脱。李先知云∶下焦有
病患难会，须用余粮赤石脂。便稀食进，大有好机，病缠两月，气血受伤，以故尻骨酸楚，
颊车乍痛，便时急坠，行动乏力。初议专培脾胃，乃血脱益气之法，续进归脾，乃虚则补母
之方。李士材先生云∶先天之本在肾，后天之本在脾。二脏安和，百骸皆治。今既食增泻减
，脾胃已调，自当进加肾药。治疗匝月，诸证均减，寝食俱安，精神渐长，体素阴亏，加以
便血，久伤阴络，屡服胃药，气分虽充，阴犹未夏。金为生水之源，金燥不能生水，是以上
膈焦干，鼻痒咳呛。夫药随病转，移步换形，医如珠之走盘，贵乎活泼。气不足便是寒，气
有余便是火。改议养阴润肺，金水相生，津回燥自濡矣。经言∶虚邪贼风避之有时。恙后体
亏，加受外因，形寒头痛，脘闷欲呕。然舌无苔，脉不急，受邪知不甚重，正气不充，未可
直行表散，治宜辅正驱邪。外感已解，痔疮举发，肛痛便复见红。然每日便止一次，并不溏
泻，此乃痔血，非前肠血可比。痔平血当自止，知饥能食，食后脘中微痛，按胃司受纳，脾
主运化，脾健失职，运化较迟，若果食滞致痛，则饱闷不饥矣。地黄益阴固妙，稍嫌其腻，
不利于脾。暂商养胃调脾，复诊再筹进步。据谕向来冬春左畔畏风，夏秋上焦热闷，药投清
散，服时虽效，过后依然。揆度其故，谅缘营卫失和， 篱不固，邪之所凑，其气必虚。断
无六淫之邪，久羁人身之理。使非探本寻源，徒泛治标无益，且俟新病瘥后，再为图之。下
极为魄门，魄门亦为五脏使，痔血去多，阴亏阳冒，上焦燥热干咳，阳加于阴，谓之汗。前
则泻多纳少，故仿胃药收功。兹则大便如常，多食善饥，病情迥别。丹溪谓男子阳常有余，
阴常不足，阳主动，阴主静，理当育阴济阳，静以制动。据言每届秋时即患咳嗽，服清润之
剂颇验。目前感后，恐有余邪，地黄滋腻，似未可服。按质虚偶感，邪本无多，既已驱逐，
谅无逗留。肺与大肠相表里，肠热上熏，肺燥则痒，痒则咳，此咳嗽之故，非关于风，而实
由于燥也。经云∶燥者濡之，痔血咳嗽，同归一途，无烦分治矣。
安波按∶大肠为燥府，以润为补。拟桑麻丸意，以表里同治。
年过六十，先天元气已经薄弱，饮食中酒类过多而谷物不足，导致脾胃再次亏损。医书说胃主司四肢，脾主司肌肉，脾气宜升发则功能健旺，胃气宜通降则调和。看到患者手足牵引僵硬，皮肤腠理紧绷、拘急、麻木和瘙痒，这难道不是脾胃不和，失去了升降的规律吗？《内经》提到胃的大络，名叫虚里，出于左侧乳下，现在乳房肿胀，正是胃络不和的表现。另外，痰产生于湿，湿产生于脾，这是因为土（脾）气薄弱的缘故。土气厚实就没有湿，没有湿就没有痰了。查阅所服用的各方，都是从肝论治，认为凡是病都生于郁结。但土是万物的母亲，试从五行角度分析，木虽然生于水，然而江河湖海中如果没有土的地方，就没有树木生长。所以树木枝叶枯萎憔悴，必定是因为土气衰败。只要培补其土，那么树根就会坚固，津液汁浆上升，布达周身流通，树木就能欣欣向荣。又问肾气丸能否治疗手足麻木？回答说：天一生水，水的凝滞处化为土，坚硬的是石，最坚硬的是金。水、土、金原本同属一气。凡人头顶九（阳）、足履一（阴），心肺居上，脾胃居中，肝肾居下。胚胎形成的基础阶段，先具备两肾，这是先天的根本，元气的宅舍。肾气丸是调理先天的药物，能助益右肾命门之火，使肾火生脾土，脾土生肺金，肺金生肾水，肾水生肝木，一方药能使五脏皆调，一种方法使水火两备。况且人的手足，就像树的枝条；人的肾命，就像树的根部。哪有根本充盈，而枝叶不茂盛荣润的呢？指着树枝去引导手臂，浇灌树叶来救树根，怎么能与之谈论至高之道呢？
安波按语：确切的论述，引用的比喻也很精妙。
诊脉细弱濡软，疾病经过很长时间，起初是大便泄泻，随后出现便血，逐渐导致食欲减少、想呕吐，身体疲倦、心中烦乱，用药没有灵验的效果。稍微投用辛温药物，便血就增多；稍用清凉药物，饮食就减少。辗转之间难以找到合适的治疗方法。然而医学贵在变通，不能见到病就治病，死板地固定思路。经书说：湿气多会导致五种泄泻。病始于泄泻，脾虚酿生湿邪，治疗湿邪固然适宜用燥法，但脾统摄血液，如果刚燥药物使用过量，导致动血，内溢不止，阴络受伤。无奈养阴的药物，往往多有腻滞之弊，又不利于脾胃。因此培补中焦脾胃，确立土为万物之母的地位，不得不急切进行。古代贤人治疗血证，常常以调理胃药收功，土气厚实自然能胜湿。斟酌选用淡味养胃气，甘味益脾阴，依据嘉禾饮方。服药数日后，谷物食物稍增，观察其病状，与痢疾相似，既然痢疾日久正气无不亏损，也应当培养本元，资助生气。据描述胃脘中像饥饿又像嘈杂，这是属于下部失血亡阴，兼伤其气，看其进食后舒适，病情已显露，方中人参力量加重，佐以乌梅，取其酸味能生津，并可收敛止血。再考方书，论述久痢的病根在大肠曲折之处，药力所不能到达，有用至圣丹一方，我仿效其法，治疗验证颇多，可供参考选择。经书说：阴络受伤血内溢。然而药物用清热养阴而不生效为什么呢？经书说：营气出自中焦，中焦化取汁液，变化而赤色，这就是血。中焦大概指胃而言。胃是水谷的海，气血俱多的经脉。病浅的，饮食如常，去旧生新；病深的，谷物少、气衰，所生不足以补偿所耗。脾与胃以膜相连，胃弱则生化无权，脾虚则统摄失职。医书称：不问阴阳与冷热，先将脾胃调和。万物以土为根，元气以土为宅，建议进用归脾汤，应当如此。又叙述向来有肝阳冲逆的疾病，近来兼有发作，方中加入首乌，既可益阴，又可固摄，不像熟地黄那样滋腻。乌梅因畏酸，不用也可以。但肠道滑脱已久，必须参入涩药以固脱。李先知说：下焦有病难会诊，须用余粮赤石脂。大便稀溏但进食增加，大有好转之机，疾病缠身两个月，气血受伤，所以尾骨酸痛，颊车穴突然疼痛，排便时急迫下坠，行动乏力。起初议定专培脾胃，这是血脱益气的治法；续进归脾汤，这是虚则补母的方剂。李士材先生说：先天之本在肾，后天之本在脾。两脏安和，全身百骸都能治愈。现在已经食量增加、泄泻减少，脾胃已调，自然应当进加补肾药物。治疗一个月，各种症状均减轻，睡眠饮食都安稳，精神逐渐增长。体质素来阴亏，加上便血，久伤阴络，屡次服用胃药，气分虽然充盛，阴分仍未充实。金为生水之源，金燥不能生水，所以上膈焦干，鼻痒咳嗽呛咳。药物随病情转变，移步换形，医生如同珠子在盘中滚动，贵在灵活。气不足便是寒，气有余便是火。改议养阴润肺，金水相生，津液回返燥邪自然滋润。经书说：虚邪贼风要适时避开。疾病之后体虚，加之感受外因，形体寒冷头痛，胃脘闷塞想呕吐。然而舌无苔，脉不急，受邪知道不重，正气不充，不可直接强行发散解表，治疗宜辅助正气驱除邪气。外感已解，痔疮发作，肛门疼痛大便又见红。然而每日大便仅一次，并不稀溏泄泻，这是痔血，不同于之前的肠道出血。痔疮平复血当自止。知饥能食，进食后胃脘微痛，按胃主受纳，脾主运化，脾健运失职，运化较慢，如果确实是食积停滞导致疼痛，则会饱闷不饥。地黄益阴固然好，稍嫌其腻，不利于脾。暂时商量养胃调脾，复诊再筹划进步。据告知向来冬春左侧怕风，夏秋上焦热闷，药物投用清散，服用时虽有效，过后依然如故。揣度其原因，想必是营卫不和，藩篱不固，邪气聚集的地方，正气必虚。断不会有六淫邪气长久羁留人身的道理。如果不是探本寻源，徒泛治标无益，暂且等新病痊愈后，再为之谋划。下极为魄门（肛门），魄门也为五脏役使，痔血去多，阴亏阳冒，上焦燥热干咳，阳加于阴，谓之汗。前则泻多纳少，所以仿照用胃药收功。现在则大便如常，多食善饥，病情截然不同。丹溪说男子阳常有余，阴常不足，阳主动，阴主静，理应育阴济阳，以静制动。据言每到秋季即患咳嗽，服用清润药剂颇有效验。目前感冒后，恐怕有余邪，地黄滋腻，似乎不可服用。按体质虚弱偶然感受，邪气本不多，既然已驱逐，谅无逗留。肺与大肠相表里，肠热上熏，肺燥则痒，痒则咳，这是咳嗽的原因，非关于风邪，而实由于燥邪。经书说：燥者濡之，痔血咳嗽，同归一途，无需分开治疗。
Over sixty years of age, the innate vitality (Tianzhen) is already thin. With excessive alcohol intake and insufficient grain consumption, the Spleen and Stomach are further depleted. Medical texts state that the Stomach governs the four limbs, and the Spleen governs the muscles. The Spleen Qi should ascend to be vigorous, and the Stomach Qi should descend to be harmonious. Observing the patient's stiff and spasmodic hands and feet, along with tightness, tension, numbness, and itching in the skin and pores, is this not a sign of disharmony between the Spleen and Stomach, losing their pathway of ascending and descending? The *Neijing* mentions the great collateral of the Stomach, named Xuli (虚里), emerging from below the left breast; the current swelling of the breast is a sign of disharmony in the Stomach collaterals. Furthermore, phlegm arises from dampness, and dampness arises from the Spleen, due to the weakness of Earth (Spleen). When Earth is thick, there is no dampness; without dampness, there is no phlegm. Reviewing the various prescriptions taken, they all treated from the perspective of the Liver, assuming that all diseases arise from stagnation. However, Earth is the mother of all things. Let us analyze it through the Five Elements: although Wood is born from Water, where there is no Earth in rivers, lakes, and seas, there is no Wood growth. Therefore, the withering and drooping of tree branches and leaves must be due to the decline of Earth Qi. By cultivating the Earth, the roots become firm, fluids rise, and circulate throughout the body, allowing the Wood to flourish joyfully. Asked whether Shenqi Wan (Kidney Qi Pill) can treat numbness in the hands and feet, the answer is: Heaven generates One Water; where Water condenses, it becomes Earth; solidified, it becomes Stone; the most solid is Metal. Water, Earth, and Metal originally share one Qi. In humans, the head represents Nine (Yang) and the feet represent One (Yin); Heart and Lung reside above, Spleen and Stomach in the middle, Liver and Kidney below. At the embryonic stage, two Kidneys are formed first; these Kidneys are the root of congenital essence and the residence of Yuan Qi (Primal Qi). Shenqi Wan is a medicine for regulating the congenital aspect; it can assist the Fire of the Mingmen (Gate of Life) in the right Kidney, so that Kidney Fire generates Spleen Earth, Spleen Earth generates Lung Metal, Lung Metal generates Kidney Water, and Kidney Water generates Liver Wood. One prescription regulates all five Zang organs, and one method prepares both Water and Fire. Moreover, human hands and feet are like the branches of a tree; human Kidney and Mingmen are like the roots of a tree. How could the roots be full and robust while the branches fail to flourish luxuriantly? Directing fingers to guide arms, or watering leaves to save roots—how can one discuss the supreme Dao with such approaches?
An Bo’s commentary: A definite argument, and the metaphor is also exquisite.
The pulse is fine, weak, and soggy. The illness has persisted for a long time, starting with diarrhea, followed by bloody stools, gradually leading to poor appetite and nausea, physical fatigue, and mental confusion, with medicines proving ineffective. Slightly administering acrid-warm herbs causes increased bleeding; slightly using cooling herbs reduces food intake. It is difficult to find a way forward. However, medicine values flexibility; one should not see a disease and merely treat the disease, nor fixate on a single viewpoint. The Classics state: "Excessive dampness leads to five types of diarrhea." The illness began with diarrhea; Spleen deficiency酿 (brews) dampness. Treating dampness is indeed suitable with drying methods, but the Spleen commands blood. If overly harsh drying agents are used excessively, they disturb the blood, causing continuous internal hemorrhage and injury to the Yin collaterals. Unfortunately, Yin-nourishing substances are often cloying and stagnant, which does not suit the Spleen and Stomach well. Therefore, tonifying the Central Palace (Middle Jiao) and extracting the Mother of Earth (Spleen) is an urgent necessity. Ancient sages treating blood disorders often achieved success with Stomach medicines; when Earth is thick, it naturally overcomes dampness. Prescribing light flavors to nourish Stomach Qi and sweet flavors to benefit Spleen Yin, based on Jiahe Yin (Grain Nourishing Decoction). After taking the medicine for a few days, grain intake slightly increased. Observing the symptoms, they resembled dysentery. Since prolonged dysentery invariably depletes righteous Qi, one must cultivate the original essence to support vital energy. Described as feeling hungry and uncomfortable in the epigastrium, this belongs to Yin loss from lower hemorrhage, accompanied by Qi injury. Seeing that eating brings comfort, the condition is revealed. Increase the dosage of Renshen (Ginseng Radix et Rhizoma) in the formula, assist with Wumei (Mume Fructus), utilizing its sour property to generate fluids and astringe blood. Further consulting medical books, discussing the root of chronic dysentery lying in the convoluted parts of the Large Intestine, where drug power cannot reach, there is a prescription called Zhisheng Dan (Supreme Holy Pill). I imitated this method, with many verified treatments, available for reference. The Classics say: "Injury to Yin collaterals causes internal blood overflow." Why did clearing heat and nourishing Yin fail? The Classics state: "Ying (Nutrient) Qi originates from the Middle Jiao; the Middle Jiao extracts juices, transforms them into red, which is called Blood." The Middle Jiao refers to the Stomach. The Stomach is the sea of water and grain, a meridian abundant in Qi and Blood. For superficial illnesses, diet remains normal, old goes and new comes; for deep illnesses, grain is scarce, Qi declines, generation cannot compensate for consumption. The Spleen and Stomach are connected by membranes; if the Stomach is weak, transformation and transportation lack authority; if the Spleen is deficient, commanding and controlling blood fails. Texts state: "Regardless of Yin/Yang or Cold/Heat, first harmonize the Spleen and Stomach." All things take Earth as their root; Yuan Qi takes Earth as its dwelling. It is proposed to advance Guipi Tang (Restore the Spleen Decoction), which should be done thus. Also described is a history of Liver Yang rushing upward, recently exacerbated. Add Shouwu (Polygoni Multiflori Radix) to the formula, which can nourish Yin and secure containment, unlike the cloying nature of Shudi (Rehmanniae Radix Preparata). Wumei is avoided due to acidity, so it may be omitted. However, intestinal sliding has lasted long; astringents must be added to prevent collapse. Li Xianzhi said: "Diseases in the Lower Jiao are hard to diagnose; one must use Yuliang (Kaolin) and Chishizhi (Halloysitum Rubrum)." Loose stools but increased food intake indicate a good opportunity. The illness has plagued for two months, injuring Qi and Blood, hence soreness in the sacrum, sudden pain at Jiache (ST6), urgency during defecation, and weakness in movement. Initially, the plan was to specifically tonify Spleen and Stomach, which is the method of benefiting Qi when Blood is lost. Subsequently advancing Guipi Tang is the formula for tonifying the Mother when deficient. Mr. Li Shicai said: "The root of congenital essence is in the Kidney; the root of acquired essence is in the Spleen. If these two Zang organs are harmonious, the whole body is cured." Now that food intake has increased and diarrhea decreased, and Spleen and Stomach are regulated, it is appropriate to add Kidney tonics. After a month of treatment, all symptoms reduced, sleep and appetite were peaceful, and spirit gradually grew. The constitution is inherently Yin-deficient; plus bloody stools, long-term injury to Yin collaterals. Repeatedly taking Stomach medicines filled the Qi aspect, but Yin remained unfulfilled. Metal is the source of generating Water; dry Metal cannot generate Water, hence upper chest dryness, nasal itching, coughing, and wheezing. Medicines follow the disease's shift; strategies change like moving steps. Physicians should be like pearls rolling on a plate, valued for agility. Insufficient Qi is Cold; excess Qi is Fire. Revised plan: Nourish Yin and moisten the Lung, promote Metal-Water mutual generation; returning fluids will naturally moisten dryness. The Classics say: "Avoid empty evils and thieving winds in due time." After the illness, the body is deficient, compounded by external factors, causing chills, headache, and epigastric stuffiness with nausea. However, the tongue has no coating, and the pulse is not rapid; the pathogenic factor is known to be not severe. Righteous Qi is insufficient, so direct exterior-dispersing is inappropriate; treatment should support righteousness to drive out evil. Once the exterior contraction is resolved, hemorrhoids flare up, with anal pain and recurrent red blood. However, bowel movements occur only once daily, not loose or diarrheal; this is hemorrhoidal blood, distinct from previous intestinal bleeding. When hemorrhoids subside, bleeding should stop spontaneously. Feeling hunger and able to eat, slight pain in the epigastrium after meals: the Stomach governs reception, the Spleen governs transportation. If Spleen health fails, transportation is slow. If pain were truly caused by food stagnation, there would be fullness and lack of hunger. Dihuang (Rehmanniae Radix) benefits Yin excellently but is slightly cloying, unfavorable to the Spleen. Temporarily discuss nourishing the Stomach and regulating the Spleen; reassess progress at the next visit. According to reports, usually fearing wind on the left side in winter and spring, and experiencing upper Jiao heat and stuffiness in summer and autumn, prescribing clearing and dispersing herbs works while taken but returns afterward. Estimating the cause, it is likely disharmony of Ying and Wei (Nutrient and Defensive) Qi, with the fence not solid; where evil gathers, Qi must be deficient. There is no principle that six excesses (pathogens) linger in the body for a long time. Unless seeking the root, merely treating symptoms superficially is useless. Wait until the new illness resolves, then plan again. The lower extreme is the Po Men (anus); the Po Men serves the five Zang organs. Excessive loss of hemorrhoidal blood leads to Yin deficiency and Yang floating, causing upper Jiao dry heat and dry cough. Yang adding to Yin is called sweat. Previously, diarrhea was heavy and intake low, so imitating the method of concluding with Stomach medicines was used. Now, bowel movements are normal, with increased appetite and frequent hunger; the condition is completely different. Danxi stated that men have constant excess of Yang and insufficiency of Yin; Yang moves, Yin stills. Reasonably, one should nourish Yin to balance Yang, using stillness to control movement. Reported that every autumn, coughs occur, and clearing-moistening agents are quite effective. Currently, after infection, fearing residual pathogens, Dihuang is too cloying and seems unsuitable. Considering the constitution is deficient and the infection occasional, the pathogen was not much; since expelled, it is unlikely to remain. Lung and Large Intestine are exterior-interior related; intestinal heat steams upward, Lung dryness causes itching, itching causes coughing. This is the cause of coughing, not related to Wind, but actually due to Dryness. The Classics say: "For Dryness, moisten it." Hemorrhoidal blood and coughing return to the same path; no need to treat separately.
An Bo’s commentary: The Large Intestine is a Fu organ of Dryness, nourished by Moisture. Proposing the intent of Sangma Wan (Mulberry Seed Pill), treating interior and exterior simultaneously.