陆左初诊痛在脐右斜下一寸，西医所谓盲肠炎也，脉大而实，当下之，用仲景法。
生军五钱芒硝三钱桃仁五钱冬瓜仁一两丹皮一两二诊痛已略缓，右足拘急，不得屈伸，伸则牵腹中痛，宜芍药甘草汤。
【按】俗所谓缩脚肠痈者，此也。吾师移伤寒之方，治要略之病，神乎技矣！三诊右足已伸，腹中剧痛如故。仍宜大黄牡丹汤以下之。
【按】肠痈病证，变化多端。上述各案尚不足以尽其情。吾友蒋冠周君偶抱孩上下阶沿不慎，稍一惊跌，顷之心中剧痛，不可耐。次日痛处移于少腹右旁盲肠处。医以定痛丸止之，而不能治其病。其令正来嘱余诊。余适以感暑卧床，荐就吾师治。吾师予以大黄牡丹汤加减，二剂将愈。不知何故，忽又发剧痛如前，改就西医诊，用药外数，约十余日，徐徐向愈。自后盲肠部分有一硬块如银元大，隐隐作痛，按之更显。蒋君以为病根犹在，虑其再发，意欲开刀，作一劳永逸之计。余力止之，用阳和膏瑙砂膏加桂麝散等香窜之品，交换贴之，一月而消，此一例也。
曹颖甫曰：肠痈一证舍大黄牡丹汤以外，别无良法。《千金》肠痈汤虽与此方大略相似，而配合犹未尽善。但有时药虽对病，而治愈正未可必。尝治庄翔生次妻张氏，屡用本汤攻下，而腰间忽起流火，以至于死。考其原因，实由平日有雅片瘾，戒烟后，不复吸烟，常用烧酒浸雅片灰吞之，以至肠燥成痈。下后，雅片灰毒内发，遂发流火，以至由肿而烂，终于不救，要不得归咎于方治之猛峻也。
肠痈其三
周住小西门复发初诊大便不甚畅行，自以他药下之，痛而不行，仲师所谓非其治也。今拟用承气汤加桃仁主之。
【按】周小姐先于本年五月间病肠痈，经吾师暨俞哲生师兄后先治愈，体健回校肄业。至十二月间，因运动过度，饮食不节，前之盲肠患处又见隐痛，火大便不行。乃市某西药房所制之丸药服之，冀其缓下。孰知仅服二丸，便不得下，痛反增剧，不能耐，自悔孟浪。无已，仍请吾师赐方，即本案复发初诊方也。服后，便畅下，痛大除，惟有时按之还作小痛耳。越日，乃来二诊。
二诊昨经下后，旧时患处按之尚痛。脉弦而数，用《千金》肠痈汤以和之。
粉丹皮三钱丹参三钱白芍三钱生地黄五钱生甘草一钱败酱草三钱茯苓三钱生苡仁八钱大麦冬五钱桔梗一钱柏子仁一两佛手二钱生姜三片
【按】周女士来二诊时，余方恭侍师侧。师令余按脉，得弦细而数。察其面色，似未甚荣润。惟据述痛已大减，无任私慰。师令余拟方。余曰：《千金》肠痈汤差足以和之。承赐诺，即用焉。以其下经多次，故不加大黄。以其夜寐不安而性易燥怒，故加柏子仁。以其偶或气郁不舒，故加佛手。以其经欠调，故仍用丹参。药味既多，竟不似吾师之方矣，相与一笑。
周女士服此二剂，大觉舒适，夜寐竟安。闻师将返江阴度岁，重来乞调理长方，余乃知之稔。本案可以示复发及调理之一格。其初病之经过，极曲折侥幸之奇观，兹续述之。
先是五月间，周女士病腹痛偏右，就诊于中医孙先生。孙先生与以理气定痛之剂，续治二月有余，不见效。改请西医王先生诊察究系何病，断谓盲肠炎。欲求根治，当用手术。病家不敢从命，乞施别法。西医乃用冰置其患处，痛止，周女士得仍回校中攻读。未逾十日，病又作，倍剧于前。至是西医坚决主张用手术，且谓时不可失，后将无及。但须家长签字，即可实行。此时也适周女士之父因事在杭，接家报如此云云，急覆电谓待我返再议。而女士之痛已不可忍，且拒按，右足不能伸，证情岌岌，不可终日。周母无主，惶急异常。会有戚祝先生至，曰：何不请中医治？周母曰：中医之方积叠成簿，惟其不能治，乃请教西医耳！曰：我有友人或能治此，曷请一试？于是俞哲生师兄应运而出。晚七时许，诊之，洒淅恶寒，口渴，脉弦滑而数，苔抽心而绛，边反白腻，急疏大黄牡丹汤加味，内用生大黄三钱。周母急令购药煎服，待其服已，俞师兄乃返寓。夜十一时，周先生忽作不速客访俞兄，惊问曰：生大黄竟可服至三钱耶？我昔延请之孙先生用药数十剂，仅末剂有蜜炙大黄五分。俞兄问服后病倩，曰：腹加痛矣，将奈何？俞兄慰之。周先生曰：姑待我返舍看变化如何。倘不幸转剧，我必以电话相告。未越一小时，俞家之电话铃声果响。事出望外，但闻周父曰：病者得下，而足已伸矣。续诊三次，颇告顺手。并知服第一剂后，下如血筋等污物。服第二剂后，下瘀血。服第三剂后，下血水。服第四剂后，竟得黄色粪。其日适值病者经来，病情未免夹杂，当延老师诊治。视已，师曰：病根未除也！依然用下剂。晚六时服药，其夜病者竟作瞑眩。四肢厥逆，冷汗出，下经六七次。至天亮，痛休。自是方真入坦途，了却无限风波。
余于本病素加注意，前年参观同济大学人体解剖展览会时，曾检阅盲肠及蚓突之种种异状至详。余并有一臆想，即大黄牡丹汤可代西医之刀与钳，且本汤能驱除蚓突中之污物，有刀与钳之利，而无刀与钳之弊。肠中污物之所以得入蚓突中者，因盲肠部分肠内容物拥挤不堪，不能上行，以致从旁溢入蚓突耳。服大黄牡丹汤即得泻出污物者，因肠壁受药力之刺激，故能推送内容物上行，平行，下行，以达肛门。盲肠之处既空，蚓突又得药力之刺激，乃返挤污物于盲肠，由是蚓突之炎以消而病以已。故云本汤可代刀与钳者，乃言其药力能刺激肠壁及蚓突，使自起力量，排出污物耳。
肠痈初起，每有恶寒之状。故《金匮 ·疮痈汤痈浸淫病脉证并治篇》第一条即曰：诸浮数脉，应当发热，而反洒淅恶寒，若有痛处，当发其痈。内而反洒淅恶寒大堪着目。世人竟有误认为疟疾之初起者。又发字诸家多凿解，窃意为痈生于体内，无从目睹，当其初起之时，甚不自知病所何在，故曰若有痛处，则当发其痈者，犹曰当觅其痈，盖发，犹发现之谓也。
《金匮》曰：肠痈者，少腹肿痞，按之即痛如淋，小便自调，时时发热，自汗出，复恶寒，其脉迟紧者，脓未成，可下之，当有血，脉洪数者，脓已成，不可下也，大黄牡丹汤主之。历来注家对于脓已成，不可下也一语，殆无异辞。甚且以此为大黄牡丹汤与慧苡附子败酱散主治之分野，此殆不思之过也。
《金匮》所谓未成已成之脓所包至广，一切炎性渗出物，腐化之白血球，腐烂之肠壁皮肉等均是，要在当去之例一也。夫肠痈当未成脓之前，日可下之，试问欲下者何物？依余之说，下其肠中一切污积，使蚓突得挤出病根是矣。当已成脓之后，反曰不可下之，试问其脓作何处置？将使脓复返为血乎，此乃绝无之事。
将任脓突脐而出乎，此乃速死之图。《方伎杂志》略云：一商家女（中略）自腹心至面部四肢悉肿，少腹右方之底有酿脓。因思取脓则可保十日，以此告病家。
病家相惊吐舌，谓前医皆不知有脓，但云补药以助元气，则水气自治耳。遂乞施针。余曰：针则至多延命一月。取脓则十日。但识病在医，而死生任诸天数，姑针之可也。遂用铍针刺入寸许，脓汁迸射，上及承尘，臭气扑鼻，病家人人惊愕，乃与薏苡附子败酱散，疮口纳细棉条以出瘀脓。然其人元气渐脱，十一日而毙。
可谓一证。犹曰薏苡附子败酱散主之。试问服散之后，散能与脓起化学作用，齐化为乌有乎？吾俱其未能也。若曰散将与脓结而俱下，则依然是下法，乌得曰不可下？或曰：不可下者犹言不胜下，下之终危也。余则谓果下之，犹不失背城借－之计，不下即是束手待毙之策。孰得孰失，明眼者自能辨之。况脓去正虚，大可用补，活法在人，宁难善后。故窃于不可下三字大起疑惑，即使的系仲圣遗文，犹当据事实以改正之。如何改正，曰：当作当急下也。（又经文称本病小便自调，按之事实，不尔，改正之责，委之贤者。）《金匮》大黄牡丹汤方后曰：顿服之，有脓当下，如无脓当下血。本已昭示后人无脓当下，有脓当急下，悉主以本汤之意，人自不察耳。以病例言，本集肠痈案其一史君之大下河泥状污物，为有脓当下之例。吾师《金匮发微》本汤条下师母之下血半净桶，及本集肠痈案其三周女士之下血筋瘀血血水等物，皆无脓当下血之例。是故下血云者，此乃当下之恶血，血去则病除，绝非失血之谓也。
客曰：审如君言，薏苡附子败酱散将无用武之地矣。答曰：非也，特其用武之时不同耳。依《金匮》法，肠痈实分为二种。一种为热性者，为大黄牡丹汤所主。一种为寒性者，为薏苡附子败酱散所主。热性者多急性，寒性者多慢性。热性者痛如淋，寒性者痛缓。热性者时时发热，寒性者身无热。热性者常右足屈，患起于瞬时。寒性者则身甲错，恙生于平日。热性者属阳明，故大黄牡丹汤即诸承气之改方，寒性者属太阴，故薏苡附子败酱散乃附子理中之变局，且散与丸为近。热性者病灶多在盲肠。寒性者病灶不限于盲肠。能知乎此，则二汤之分，明矣。客憬然若悟而退。
肺痈其一
辛未七月中旬，余治一陈姓疾。初发时，咳嗽，胸中隐隐作痛，痛连缺盆。其所吐者，浊痰腥臭，与悬饮内痛之吐涎沫，固自不同，决为肺痈之始萌。遂以桔梗汤，乘其未集而先排之。进五剂，痛稍止，诸证依然，脉滑实。因思是证确为肺痈之正病，必其肺藏壅阻不通而腐，腐久乃吐脓，所谓久久吐脓如米粥者，治以桔梗汤。今当壅塞之时，不去其壅，反排其腐，何怪其不效也。《淮南子》云：葶苈愈胀，胀者，壅极不通之谓。《金匮》曰：肺痈，喘而不得眠，即胀也。《千金》重申其义曰：肺痈胸满胀，故知葶苈泻肺汤非泻肺也，泻肺中壅胀。今有此证，必用此方，乃以葶苈子五钱大黑枣十二枚凡五进，痛渐止，咳亦爽。其腥臭挟有米粥状之痰，即腐脓也。
后乃以《千金》苇茎汤，并以大小蓟、海藻、桔梗、甘草、杜赤豆出入加减成方。至八月朔日，先后凡十五日有奇，用药凡十余剂，始告全瘥。九月底其人偶受寒凉，宿恙又发，乃嘱兼服犀黄醒消丸，以一两五钱分作五服。服后，腥臭全去。但尚有绿色之痰，复制一料服之，乃愈，而不复来诊矣。
【按】本案并略见《金匮发微》。后历检吾师医案，乃得本案之先后全方。两相对照，更易昭然。特再附诸方于下，谅阅者当不嫌重复也。
陈左住浦东陆家渡初诊七月十二日肺痈，咳嗽，胸中痛，上连缺盆，而所吐绝非涎沫，此与悬饮内痛者，固自不同，宜桔梗甘草汤。
桔梗五钱甘草五钱二诊七月十八日五进桔梗汤，胸中痛止，而左缺盆痛。此肺藏雍阻不通也，宜葶苈大枣泻肺汤。
葶苈子五钱黑大枣十二枚先煎三诊七月二十四日五进泻肺汤，左缺盆痛止。痰黄厚，时见腥臭，及如米粥者。此湿邪去，而燥气胜也。宜《千金》苇茎汤。
鲜芦根四两生薏仁一两桃仁五十粒冬瓜子五钱四诊七月二十九日服《千金》苇茎汤五剂后，咯出之痰腥臭止，而如米粒者亦除。惟痰尚黄厚，肺痈消，而胃热尚盛也。右三部脉浮滑，不复见沈弦之象，可以无后患矣。
粉前胡三钱生苡仁一两桔梗三钱生草三钱冬瓜子八十粒桃仁三钱杜赤豆六钱大小蓟各三钱海藻二钱芦根五两拙巢注：服此二三日，全愈。
续发初诊九月二日肺痈愈后，复发。咯痰腥臭，见血，心下痛，咳时气从中脘上冲。宜清胆胃之火，防其乘肺。
柴胡三钱生石膏二两生甘草三钱淡芩三钱肥知母五钱生苡仁一两芦根四两冬瓜仁一两桃仁三钱杜赤豆一两全当归四钱二诊九月十日肺痈未能断根，咯痰腥臭如昔，但不似米粥耳。痰不黄而色绿，味酸，咳不甚，脉细数，仍宜桔梗甘草汤，不当攻伐，佐以消毒，以清病原。
桔梗一两生甘草五钱冬瓜仁一两昆布一钱五分海藻二钱前胡三钱大小蓟各钱五分犀黄醒消丸三钱另服拙巢注：后不复服药，专服犀黄醒消丸，愈。醒消丸系王鸿绪法，马培之颇非议之。然用之而效，则马说不足信也。
【按】夫肺痈重病也。仲圣云：脓成则死。今本案病者脓成而腥臭，吾师乃能愈之。岂吾师之术迈于仲圣乎？非也。所谓则死者，极言其危，而教人药量之不可轻也！夫桔梗今人仅用数分至一钱，葶苈今人少用之，用之亦不出数分，苇茎今人通常用一尺，今吾师用此三者乃至五钱，五钱，五两，不其骇人乎？虽然，此皆仲圣之教也。
Lu, initial visit: Pain was located one cun diagonally below and to the right of the umbilicus, which Western medicine calls appendicitis. The pulse was large and solid (excess pattern), indicating the need for purgation. Treatment followed Zhang Zhongjing's method.
Prescription: Sheng Jun (Radix et Rhizoma Rhei, raw) 5 qian, Mang Xiao (Natrii Sulfas, 芒硝) 3 qian, Tao Ren (Semen Persicae, 桃仁) 5 qian, Dong Gua Ren (Semen Benincasae, 冬瓜仁) 1 liang, Dan Pi (Cortex Moutan, 牡丹皮) 1 liang.
Second visit: The pain had slightly eased, but the right leg was stiff and cramped, unable to flex or extend; extension would pull on the abdomen causing pain. It was appropriate to use Shaoyao Gancao Tang (Peony and Licorice Decoction).
Prescription: Chi Shao (Radix Paeoniae Rubra, 赤芍) and Bai Shao (Radix Paeoniae Alba, 白芍) each 5 qian, Sheng Gancao (Radix Glycyrrhizae, 生甘草) 3 qian, Zhi Ru Xiang (Resina Olibani, processed, 炙乳香) and Zhi Mo Yao (Resina Myrrhae, processed, 炙没药) each 3 qian.
[Commentary] This is what is commonly known as "Shrink-leg Intestinal Abscess" (Suojiao Changyong). My teacher transferred formulas from *Shanghan Lun* to treat diseases described in *Jingui Yaolue*; his skill was truly miraculous!
Third visit: The right leg could now be extended, but severe abdominal pain persisted. It was still appropriate to use Dahuang Mudan Tang (Rhubarb and Moutan Decoction) for purgation.
Prescription: Sheng Chuan Jun (Radix et Rhizoma Rhei, raw) 1 liang, Mang Xiao (Natrii Sulfas, 芒硝) 7 qian (added after decoction), Tao Ren (Semen Persicae, 桃仁) 5 qian, Dong Gua Ren (Semen Benincasae, 冬瓜仁) 1 liang, Dan Pi (Cortex Moutan, 牡丹皮) 1 liang. Note by Zhuochao: Cured.
[Commentary] The syndrome of Intestinal Abscess (Changyong) is complex and variable. The above cases are insufficient to fully describe its manifestations. My friend, Mr. Jiang Guanzhou, accidentally stumbled while carrying a child up and down stairs. Shortly after, he experienced severe central chest pain that was unbearable. The next day, the pain shifted to the lower abdomen on the right side, at the cecum. Doctors used Dingtong Wan (Pain-Relieving Pill) to stop the pain but could not cure the disease. His wife came to entrust me with his treatment. I was then bedridden with heatstroke, so I recommended my teacher. My teacher prescribed modified Dahuang Mudan Tang. After two doses, he was nearly cured. For some reason, severe pain suddenly recurred as before. He switched to Western medicine treatment with external applications, and after about ten days, gradually recovered. However, a hard mass the size of a silver coin remained in the cecal region, causing dull pain that intensified upon pressure. Mr. Jiang believed the root cause remained and feared recurrence, intending to undergo surgery for a permanent solution. I strongly advised against it, using Yanghe Gao (Yanghe Plaster) and Naosha Gao mixed with Guixie San (Cinnamon and Musk Powder), applying them alternately. The mass resolved in one month. This is one example.
Cao Yingfu said: Regarding the syndrome of Intestinal Abscess, apart from Dahuang Mudan Tang, there is no other good method. Although the Changyong Tang in *Qianjin Fang* is roughly similar to this formula, its combination is not yet perfect. Sometimes, even if the medicine matches the disease, a cure is not guaranteed. I once treated Mrs. Zhang, the second wife of Zhuang Xiangsheng. After repeatedly using this decoction for purgation, she suddenly developed "flowing fire" (erysipelas) on her waist, leading to death. Investigating the cause, it was due to her long-term opium addiction. After quitting smoking, she often swallowed opium ash soaked in liquor, causing intestinal dryness and abscess formation. After purgation, the toxicity of the opium ash erupted internally, triggering the flowing fire, which progressed from swelling to ulceration, ultimately resulting in untreatable condition. This should not be blamed on the harshness of the prescription.
Intestinal Abscess Case Three
Zhou, residing at Xiaoximen, relapse, initial visit. Bowel movements were not very smooth. She used other laxatives herself, resulting in pain without defecation. This is what Master Zhongjing called "not the correct treatment." Now, I propose using Chengqi Tang (Gut-Regulating Decoction) added with Tao Ren (Semen Persicae, 桃仁) as the main formula.
Prescription: Sheng Chuan Jun (Radix et Rhizoma Rhei, raw) 3 qian (added late), Zhishi (Fructus Aurantii Immaturus, 枳实) 4 qian, Chuan Po (Cortex Magnoliae Officinalis, 川朴), Taoren (Semen Persicae, 桃仁) 4 qian, Mang Xiao (Natrii Sulfas, 芒硝) 2 qian (added after decoction).
[Commentary] Miss Zhou first suffered from intestinal abscess in May of this year, cured successively by my teacher and Senior Brother Yu Zhesheng. She recovered and returned to school. In December, due to excessive exercise and irregular diet, the previous site of the cecal abscess began to ache faintly, accompanied by constipation ("fire"). She bought pills from a Western pharmacy hoping for mild laxative effects. However, after just two pills, she could not defecate, and the pain worsened unbearably. Regretting her rash action, she asked my teacher for a prescription again, which is the initial visit formula for this relapse case. After taking it, stool passed smoothly, and pain greatly subsided, though slight pain remained upon pressing occasionally. The next day, she came for the second visit.
Second Visit: After purgation yesterday, the old lesion site was still tender to pressure. The pulse was wiry and rapid. Use Qianjin Changyong Tang (*Qianjin* Intestinal Abscess Decoction) to harmonize.
Prescription: Fen Danpi (Cortex Moutan, 粉丹皮) 3 qian, Danshen (Radix Salviae Miltiorrhizae, 丹参) 3 qian, Baishao (Radix Paeoniae Alba, 白芍) 3 qian, Sheng Dihuang (Radix Rehmanniae Preparata, raw, 生地黄) 5 qian, Sheng Gancao (Radix Glycyrrhizae, 生甘草) 1 qian, Baijiangcao (Herba Patriniae, 败酱草) 3 qian, Fuling (Poria, 茯苓) 3 qian, Sheng Yiren (Semen Coicis, 生薏苡仁) 8 qian, Da Maidong (Rhizoma Ophiopogonis, 大麦冬) 5 qian, Jiegeng (Radix Platycodonis, 桔梗) 1 qian, Baizi Ren (Semen Platycladi, 柏子仁) 1 liang, Foshou (Fructus Citri Sarcodactylis, 佛手) 2 qian, Shengjiang (Rhizoma Zingiberis Recens, 生姜) 3 slices.
[Commentary] When Miss Zhou came for the second visit, I was respectfully standing beside my teacher. The teacher asked me to take her pulse, which was wiry, fine, and rapid. Observing her complexion, it did not appear very lustrous. However, she reported that the pain had significantly decreased, bringing me private comfort. The teacher asked me to draft the prescription. I said, "*Qianjin* Changyong Tang is sufficient to harmonize." The teacher approved, and we used it. Since she had undergone multiple purgations previously, we did not add Dahuang. Because she suffered from insomnia and irritability, we added Baizi Ren. Because she occasionally had qi stagnation, we added Foshou. Because her menstruation was irregular, we retained Danshen. With so many herbs, the prescription did not resemble my teacher's usual style; we shared a laugh.
Miss Zhou felt very comfortable after taking these two doses, and her sleep became peaceful. Hearing that my teacher was returning to Jiangyin for the New Year, she came again to request a long-term conditioning prescription, allowing me to understand the case thoroughly. This case serves as a model for relapse and conditioning. The initial course of the illness was extremely tortuous and fortunate, a spectacle worth recounting.
Earlier, in May, Miss Zhou suffered from right-sided abdominal pain and consulted TCM Doctor Sun. Dr. Sun gave Qi-regulating and pain-relieving agents. After more than two months of treatment, there was no effect. She then consulted Western Doctor Wang, who diagnosed appendicitis and recommended surgery for a radical cure. The family refused, asking for alternative methods. The doctor applied ice to the affected area, stopping the pain, allowing Miss Zhou to return to school. Less than ten days later, the illness returned, twice as severe. The doctor insisted on surgery, stating time was critical. Parental signature was required. At that time, Miss Zhou's father was in Hangzhou. Upon receiving the news, he telegraphed back to wait for his return. However, the lady's pain became unbearable, she rejected pressure, and her right leg could not extend. The condition was critical. Her mother was panicked. A relative, Mr. Zhu, suggested consulting a TCM doctor. Her mother replied that they had tried many TCM prescriptions without success, hence seeking Western medicine. Mr. Zhu said he knew someone who might help. Thus, Senior Brother Yu Zhesheng stepped forward. Around 7 PM, examination revealed aversion to cold (chills), thirst, wiry-slippery-rapid pulse, and a tongue coating that was crimson in the center with white-greasy edges. Urgently, a modified Dahuang Mudan Tang was prescribed, including 3 qian of raw Dahuang. Her mother hurried to buy and decoct the medicine. After she took it, Brother Yu returned to his residence. At 11 PM, Mr. Zhou visited unexpectedly, shocked, asking, "Can raw Dahuang be taken in doses of 3 qian? The previous doctor used only 5 fen of honey-fried Dahuang in the final dose." Brother Yu asked about the condition. Mr. Zhou said, "The abdominal pain increased. What should we do?" Brother Yu comforted him. Mr. Zhou said, "Let me go home and see. If it worsens, I will call." Within an hour, the phone rang. It was Mr. Zhou saying, "The patient has defecated, and her leg can now extend." Subsequent visits went smoothly. It was learned that after the first dose, blood-like filaments and foul matter were passed. After the second dose, blood clots. After the third, bloody water. After the fourth, yellow stool. Coincidentally, her menstruation started, complicating the condition. My teacher was consulted. He examined her and said, "The root cause remains!" He continued with purgatives. Medicine taken at 6 PM caused a "Mingxuan" reaction (herxheimer-like reaction) that night: cold limbs, sweating, and six to seven bowel movements. By dawn, the pain ceased. From then on, the path to recovery was clear.
I have always paid attention to this disease. Last year, at a Tongji University anatomy exhibition, I carefully studied various anomalies of the cecum and vermiform appendix. I have a hypothesis: Dahuang Mudan Tang can replace Western surgical knives and forceps. This decoction can expel debris from the appendix, offering the benefits of surgery without its drawbacks. Debris enters the appendix because the cecum is overcrowded, forcing contents sideways into the appendix. Dahuang Mudan Tang stimulates the intestinal wall, promoting peristalsis (upward, horizontal, downward) to expel debris. Once the cecum is empty, the stimulated appendix squeezes debris back into the cecum, resolving inflammation and curing the disease. Thus, the decoction replaces surgery by stimulating the intestine and appendix to self-expel debris.
Intestinal abscess often begins with aversion to cold. Hence, Article 1 of *Jingui Yaolue · Chapter on Pulse, Symptoms, and Treatment of Carbuncles, Abscesses, and Eczema* states: "Floating and rapid pulses usually indicate fever, but if there is chivering aversion to cold and a painful area, an abscess is developing." The "aversion to cold" is particularly noteworthy. People often mistake this for early-stage malaria. Regarding the character "Fa" (develop/emerge), commentators often interpret it rigidly. I believe since internal abscesses cannot be seen, and patients are unaware of the location initially, "if there is a painful area, an abscess is developing" means "one should seek the abscess." "Fa" here means "to discover."
*Jingui Yaolue* states: In intestinal abscess, the lower abdomen is swollen and distended, painful upon pressure like strangury, urination is normal, with intermittent fever, spontaneous sweating, and recurrent aversion to cold. If the pulse is slow and tight, pus is not yet formed; purgation is indicated, and blood may pass. If the pulse is surging and rapid, pus is formed; purgation is contraindicated. Dahuang Mudan Tang governs. Commentators unanimously agree on "pus formed, purgation contraindicated," using this as the dividing line between Dahuang Mudan Tang and Yiyi Fuzi Baijiang San. This is likely due to lack of critical thinking.
The "pus" mentioned in *Jingui* covers a wide range: inflammatory exudates, degenerated leukocytes, necrotic intestinal tissue, etc. The key is whether it needs to be removed. Before pus forms, purgation removes intestinal debris to squeeze out the root cause from the appendix. After pus forms, saying "purgation is contraindicated" raises the question: what happens to the pus? Can it turn back into blood? Impossible. Should it burst through the navel? That leads to rapid death. *Fangji Zazhi* records a case where a merchant's daughter had extensive swelling and pus in the lower right abdomen. The doctor predicted survival for ten days if pus was drained. Family members were terrified, noting previous doctors only used tonics. They begged for acupuncture. The doctor said acupuncture might prolong life by a month, but draining pus offers ten days. He proceeded with acupuncture, draining pus that sprayed to the ceiling. He then prescribed Yiyi Fuzi Baijiang San and inserted cotton strips. The patient died eleven days later due to qi depletion. This proves the point. Yet, it is still said that Yiyi Fuzi Baijiang San governs. Does the powder chemically react with pus to vanish? No. If it binds with pus and expels it, that is still a purgative method. Why say "contraindicated"? Some argue "contraindicated" means the body cannot withstand purgation. I argue that purgation is a last stand; doing nothing is waiting for death. Clearly, purgation is better. If qi is deficient after pus removal, tonification can follow. Therefore, I doubt the phrase "contraindicated." Even if it is Zhang Zhongjing's original text, it should be corrected based on facts. Correction: It should read "Urgent purgation is indicated." (*Jingui* also notes normal urination, which is often not the case; correction left to scholars.) The post-script of Dahuang Mudan Tang says: "Take in one dose. If pus exists, it will be purged; if no pus, blood will be purged." This clearly indicates that for pus, urgent purgation is needed, and for no pus, blood purgation is needed, all governed by this decoction. Cases include Mr. Shi passing mud-like debris (pus present, purged) and Teacher's wife/Miss Zhou passing blood/clots/water (no pus, blood purged). "Passing blood" refers to expelling evil blood, curing the disease, not hemorrhage.
Guest: If so, is Yiyi Fuzi Baijiang San useless?
Reply: No, its timing differs. According to *Jingui*, intestinal abscess has two types: Heat-type (governed by Dahuang Mudan Tang) and Cold-type (governed by Yiyi Fuzi Baijiang San). Heat-type is acute, painful like strangury, febrile, right leg flexed, sudden onset, Yangming channel, related to Chengqi formulas, lesion in cecum. Cold-type is chronic, dull pain, non-febrile, skin rough like scales, gradual onset, Taiyin channel, related to Fuzi Lizhong variation, lesion not limited to cecum. Understanding this clarifies the distinction. The guest departed enlightened.
Lung Abscess Case One
In mid-July of the Xinwei year, I treated a patient surnamed Chen. Initially, cough, dull chest pain radiating to the supraclavicular fossa (Quepen). Sputum was turbid, foul-smelling, distinct from the saliva of Xuan Yin (fluid retention). It was definitely the beginning of Lung Abscess (Feiyong). I used Jiegeng Tang (Platycodon Decoction) to drain it before it matured. After five doses, pain subsided slightly, but symptoms persisted; pulse was slippery and solid. I reasoned this is a true Lung Abscess where lung congestion leads to putrefaction and pus. As stated, "long-term spitting of pus like rice porridge" is treated with Jiegeng Tang. But during congestion, draining putrefaction without removing congestion explains the inefficacy. *Huainanzi* says: Tingli resolves distension, where distension means extreme blockage. *Jingui Yaolue* says: Lung abscess causes wheezing and insomnia, i.e., distension. *Qianjin Fang* reiterates: Lung abscess causes chest fullness and distension. Thus, Tingli Xiefei Tang does not drain the lung, but drains lung distension. Given this syndrome, this formula is necessary. I used Tingli Zi (Semen Lepidii, 葶苈子) 5 qian and large black dates (Da Zao, 大枣) 12 pieces. After five administrations, pain stopped, cough improved. The foul, rice-porridge-like sputum was putrid pus.
Later, I used Qianjin Weijing Tang (*Qianjin* Reed Shoot Decoction) modified with Da Xiao Ji (Herba Taraxaci, 大小蓟), Haizao (Thallus Sargassii, 海藻), Jiegeng (Radix Platycodonis, 桔梗), Gancao (Radix Glycyrrhizae, 甘草), and Du Chidou (Semen Phaseoli, 杜赤豆). By August 1st, after 15 days and over ten doses, full recovery was achieved. In late September, exposure to cold triggered a relapse. I advised concurrent use of Xi Huang Xing Xiao Wan (Amaranth and Awakening Elimination Pills). Five doses of 1.5 qian each eliminated the foul smell. Green sputum remained. Another dose cured the patient, who never returned.
[Commentary] This case is briefly mentioned in *Jingui Fawei*. Later, reviewing my teacher's medical records, I found the complete prescriptions. Comparing them makes it clearer. I attach the formulas below for readers' reference.
Chen, Left, residing at Pudong Lujia Du. Initial Visit, July 12: Lung Abscess, cough, chest pain radiating to Quepen. Sputum is not saliva, distinct from Xuan Yin. Appropriate: Jiegeng Gancao Tang.
Prescription: Jiegeng (Radix Platycodonis, 桔梗) 5 qian, Gancao (Radix Glycyrrhizae, 甘草) 5 qian.
Second Visit, July 18: After five doses of Jiegeng Tang, chest pain stopped, but left Quepen hurts. Lung congestion and blockage. Appropriate: Tingli Dazao Xiefei Tang.
Prescription: Tingli Zi (Semen Lepidii, 葶苈子) 5 qian, Black Dates (Da Zao, 大枣) 12 pieces (decocted first).
Third Visit, July 24: After five doses of Xiefei Tang, left Quepen pain stopped. Sputum is yellow, thick, sometimes foul-smelling and rice-porridge-like. Dampness gone, dryness prevails. Appropriate: Qianjin Weijing Tang.
Prescription: Fresh Lu Gen (Rhizoma Imperatae, 鲜芦根) 4 liang, Sheng Yiren (Semen Coicis, 生薏苡仁) 1 liang, Tao Ren (Semen Persicae, 桃仁) 50 grains, Dong Gua Zi (Semen Benincasae, 冬瓜子) 5 qian.
Fourth Visit, July 29: After five doses of Qianjin Weijing Tang, foul smell and rice-grain-like sputum stopped. Sputum remains yellow and thick. Lung abscess resolved, but stomach heat persists. Right three positions pulse is floating and slippery, no longer deep and wiry. No future complications expected.
Prescription: Fen Qianhu (Radix Peucedani, 粉前胡) 3 qian, Sheng Yiren (Semen Coicis, 生薏苡仁) 1 liang, Jiegeng (Radix Platycodonis, 桔梗) 3 qian, Sheng Cao (Radix Glycyrrhizae, 生草) 3 qian, Dong Gua Zi (Semen Benincasae, 冬瓜子) 80 grains, Tao Ren (Semen Persicae, 桃仁) 3 qian, Du Chidou (Semen Phaseoli, 杜赤豆) 6 qian, Da Xiao Ji (Herba Taraxaci, 大小蓟) each 3 qian, Haizao (Thallus Sargassii, 海藻) 2 qian, Lu Gen (Rhizoma Imperatae, 芦根) 5 liang. Note by Zhuochao: Fully cured after 2-3 doses.
Relapse Initial Visit, Sept 2: Relapse after Lung Abscess cure. Foul-smelling sputum with blood, epigastric pain, qi rushing up from Zhongwan during cough. Clear Gallbladder and Stomach fire to prevent invasion of Lung.
Prescription: Chai Hu (Radix Bupleuri, 柴胡) 3 qian, Sheng Shi Gao (Gypsum Fibrosum, 生石膏) 2 liang, Sheng Gancao (Radix Glycyrrhizae, 生甘草) 3 qian, Dan Huang Qin (Radix Scutellariae, 淡芩) 3 qian, Fei Zhi Mu (Rhizoma Anemarrhenae, 肥知母) 5 qian, Sheng Yi Ren (Semen Coicis, 生薏仁) 1 liang, Lu Gen (Rhizoma Imperatae, 芦根) 4 liang, Dong Gua Ren (Semen Benincasae, 冬瓜仁) 1 liang, Tao Ren (Semen Persicae, 桃仁) 3 qian, Du Chi Dou (Semen Phaseoli, 杜赤豆) 1 liang, Quan Dang Gui (Radix Angelicae Sinensis, 全当归) 4 qian.
Second Visit, Sept 10: Lung Abscess not eradicated. Foul sputum as before, but not rice-porridge-like. Sputum green, sour taste, mild cough, fine-rapid pulse. Still appropriate: Jiegeng Gancao Tang. Do not attack vigorously; assist with detoxification to clear the source.
Prescription: Jiegeng (Radix Platycodonis, 桔梗) 1 liang, Sheng Gancao (Radix Glycyrrhizae, 生甘草) 5 qian, Dong Gua Ren (Semen Benincasae, 冬瓜仁) 1 liang, Kun Bu (Thallus Laminariae, 昆布) 1.5 qian, Haizao (Thallus Sargassii, 海藻) 2 qian, Qian Hu (Radix Peucedani, 前胡) 3 qian, Da Xiao Ji (Herba Taraxaci, 大小蓟) each 0.5 qian, Xi Huang Xing Xiao Wan (Amaranth and Awakening Elimination Pills, 犀黄醒消丸) 3 qian (taken separately). Note by Zhuochao: Patient stopped other medicines, took only Xi Huang Xing Xiao Wan, and was cured. Xi Huang Xing Xiao Wan is based on Wang Hongxu's method; Ma Peizhi criticized it. However, since it worked, Ma's criticism is unreliable.
[Commentary] Lung Abscess is a serious disease. Master Zhongjing said: "When pus forms, death ensues." In this case, the patient had formed pus and foul sputum, yet my teacher cured him. Is my teacher's skill superior to Zhongjing's? No. "Death ensues" emphasizes the severity and warns against light-mindedness in dosage. Today, people use Jiegeng in small amounts (fen to 1 qian), Tingli rarely and in small amounts, and Weijing typically one chi. My teacher used these in amounts up to 5 qian or 5 liang, which seems shocking. Nevertheless, this follows Zhongjing's teachings.