疮者。血所凝结而成者也。或者寒凝。或者热结。或者风肿。或者湿郁。总是凝聚其血而成。初起总宜散血。
血散则寒热风湿。均无遗留之迹矣。其继则调脓化毒。此即吐脓条内所言。瘀血化脓之义。治宜托里。使
气达疮。所以蒸血成脓。盖疮之成。由于血结。脓之成亦由血化。血何以能化成脓。得气之蒸。而腐化成脓
也。气即是水。吾已论之屡矣。惟其气即是水。故血随气化。亦变为水。不名为水而名脓。以其由血所化。较
水更浓耳。毒既化脓。自不内攻。方其未溃。气虚者难于蒸化。及其既化。虽气实者。亦随脓渗泄。而转为气
虚矣。法宜固元以大补其气。此与本书内证。原不干涉。然同是血病。故兼论之。以互相发明。盖气迫血。则
逆而为吐衄。血滞气。则凝而为疮疽。气迫血者。宜破气以和血。血滞气者。宜破血以和气。故吐衄宜补血。
血旺则气平。诸疮宜补气。气旺则血行也。至于既穿溃后。则躯壳已有破损。与壅闭之证迥别。试看针功。
刺期门泻肝。刺肺 泻气。以一针之孔。尚能大泻脏气。况溃脓之孔甚大。其能大泻内气可知矣。故凡溃
后。宜大补元气。不似吐衄。乃气盛血虚。只宜滋血以平气。而不宜助气以动血也。然疮溃之余。亦有瘀热
未清者。亦不得骤用温补。吐血之后。亦有元阳大虚者。又不得拘守清凉。故吐血家。审其血亡。而气亦随
亡。与阳气不能摄血者。十全养荣归脾参附等汤。亦所宜用。疮家溃后。固为必需之方。而亦有余毒未尽。
诸上方又其所忌。医者不容执一。
诸疮内治。初起肿硬。总宜散血。仙方活命饮主之。恶寒无汗。加麻黄。发热心烦。加老连石膏。大便燥结。加
大黄。疮肉顽梗黯滞。乃阴证结毒。无气以发之也。加桂枝尖生姜大枣。疮内平塌不起。以及走散。恐毒内
攻。加黄 大枣生姜。盖血凝于气分之际。血行则气行。故以破血为主。是善调气之法也。若吐衄。则是气
乘乎血分之内。气降则血降。当以破气为主。一内一外。反观自知。
诸疮调脓。宜以托里消毒散为主。盖血既凝而不化。则须补气以与之战。使蒸腾腐化。托令速溃。以疮乃
血凝气分之病。惟恐气不足以化之。故宜补气而制血。若吐衄。则是气乘血分。惟恐气逆而血升。故宜平
气以调血。与此不同。
诸疮既溃。属于虚损。宜固元以益气。内补黄 汤主之。又审脓干者。其气虚。盖气既是水。气不足。故水少
而干。且气既不足。则不能送脓外出。故留滞而结脓管。黄 建中汤。重加银花赤豆芽当归治之。若脓清
者。是血虚。脓为血所化。血少故脓清。当归补血汤主之。炙甘草汤。加黄 亦治之。养荣汤。亦治之。
又曰。溃后属虚。然亦有瘀未化尽者。仍不得峻补以留毒。内服托里消毒散。外用乌金膏化之。此如失血
虚中夹瘀。亦不得关门逐贼。溃久而仍有脓管者。尤宜用乌金膏化之。若徒生其口。内毒攻发。终不愈也。
此如干血痨。内有干血。非去其干血。而新血亦不能生。皆虚中夹实。治血则虚虚。补虚则实实。未易疗治。
只得攻补兼施。以尽人事。
又曰。吐血止后。宜补血以调气。疮疽溃后。宜补气以生血。吐衄在血分。气实血虚也。疮疽在气分。血实气虚也。
外治之法。消肿宜远志膏。用远志酒煮捣敷。及金黄散。化腐去瘀。宜巴豆炒黑研点。名乌金膏。田螺捻子
亦佳。生肌宜乳香没药为末。名海浮散。再加珍珠。化腐生肌散。亦佳。
治疮之法。此不足以尽之。兹不过举外证以勘内证。明于诸疮之血。而吐衄之血乃愈明。
Chuang (sores/ulcers) are formed by the coagulation of blood. Sometimes it is due to cold stagnation, sometimes to heat accumulation, sometimes to wind-induced swelling, and sometimes to dampness obstruction. In all cases, it is the coagulation of blood that forms them. In the initial stage, dispersing blood is generally indicated.
Once the blood is dispersed, traces of cold, heat, wind, and dampness will be left without residue. Subsequently, regulating pus and resolving toxins is required. This refers to the principle mentioned in the "Expectoration of Pus" section: the transformation of blood stasis into pus. The treatment should employ the method of supporting the interior (Tuo Li), allowing Qi to reach the sore, thereby steaming the blood into pus. Generally, the formation of a sore is due to blood coagulation, and the formation of pus is also due to the transformation of blood. How can blood transform into pus? It is through the steaming action of Qi that causes putrefaction and transformation into pus. Qi is water, as I have discussed many times. Precisely because Qi is water, blood follows Qi's transformation and also becomes water. It is not called water but pus because it is transformed from blood and is thicker than water. Once the toxin transforms into pus, it naturally will not attack inward. Before the sore ulcerates, those with Qi deficiency find it difficult to steam and transform; after it has formed pus, even those with robust Qi may become Qi deficient as it drains out with the pus. The method should be to consolidate the primal Qi and greatly tonify Qi. This does not directly interfere with the internal diseases discussed elsewhere in this book, but since it is also a blood disorder, it is discussed together to elucidate each other. Generally, when Qi forces Blood, it rebels and causes hematemesis or epistaxis; when Blood stagnates and obstructs Qi, it coagulates and forms sores and carbuncles. For Qi forcing Blood, one should break Qi to harmonize Blood; for Blood obstructing Qi, one should break Blood to harmonize Qi. Therefore, for hematemesis and epistaxis, tonifying Blood is appropriate; when Blood is abundant, Qi calms down. For various sores, tonifying Qi is appropriate; when Qi is vigorous, Blood flows. As for after the sore has ulcerated, the body surface is already damaged, which is distinctly different from conditions of blockage and closure. Consider acupuncture: puncturing Qimen (LR14) drains Liver Qi, and puncturing Lung-related points drains Lung Qi; even a single needle hole can significantly drain Zang-Fu Qi. How much more so can a large ulcerating pore drain internal Qi! Therefore, after ulceration, one should greatly tonify Primal Qi. This differs from hematemesis and epistaxis, where there is excess Qi and deficient Blood, requiring nourishment of Blood to calm Qi rather than assisting Qi which might agitate Blood. However, after ulceration, there may still be unresolved stasis-heat, so warm tonification should not be used abruptly. After hematemesis, there may be severe deficiency of Yuan Yang, so one should not rigidly stick to cooling methods. Thus, for patients with hematemesis, if one assesses that both Blood and Qi have been lost, or that Yang Qi fails to control Blood, formulas such as Shiquan Dabu Tang (Ten Great Tonics Decoction), Yangrong Tang (Nourishing Prosperity Decoction), Guipi Tang (Restore the Spleen Decoction), and Shenfu Tang (Ginseng and Aconite Decoction) are suitable. These formulas are indeed necessary for post-ulceration sores, but if residual toxins remain, these tonifying formulas are contraindicated. Physicians must not adhere rigidly to one approach.
For the internal treatment of various sores, if they are initially swollen and hard, dispersing blood is indicated, primarily using Xianfang Huoming Yin (Immortal Life Elixir). If there is aversion to cold and no sweating, add Ephedrae Herba (Mahuang); if there is fever and irritability, add Coptidis Rhizoma (Lianhua/Lian) and Gypsum Fibrosum (Shigao); if there is dry constipation, add Rheum Radix et Rhizoma (Dahuang); if the sore tissue is stubborn, dark, and stagnant, indicating Yin-type toxic accumulation lacking Qi to disperse it, add Cinnamomi Ramulus Acumen (Guizhi Jian), Zingiberis Rhizoma Recens (Shengjiang), and Jujubae Fructus (Dazao); if the sore is flat and sunken or spreading, fearing internal attack of toxins, add Astragali Radix (Huangqi), Jujubae Fructus (Dazao), and Zingiberis Rhizoma Recens (Shengjiang). Generally, when blood coagulates at the interface of Qi and Blood, moving Blood moves Qi; thus, breaking Blood is primary, which is a skillful method of regulating Qi. In contrast, for hematemesis and epistaxis, Qi invades the interior of the Blood level; descending Qi descends Blood, so breaking Qi is primary. One is internal, one external; observing them inversely reveals the difference.
For regulating pus in various sores, Tuoli Xiaodu San (Support Interior and Eliminate Toxin Powder) is primarily indicated. Since blood has coagulated and not transformed, tonifying Qi is necessary to fight against it, causing steaming and putrefaction, and supporting its rapid ulceration. Because sores are diseases of blood coagulation in the Qi level, there is fear that Qi is insufficient to transform it, so tonifying Qi to control Blood is appropriate. For hematemesis and epistaxis, however, Qi attacks the Blood level, and there is fear that rebellious Qi causes Blood to rise, so calming Qi to regulate Blood is appropriate, which is different from sores.
After various sores have ulcerated, the condition belongs to deficiency and damage, requiring consolidation of Yuan Qi and tonification of Qi, primarily using Neibu Huangqi Tang (Internal Tonification with Astragalus Decoction). Furthermore, if the pus is dry, it indicates Qi deficiency. Since Qi is water, insufficient Qi leads to scanty water and dryness. Moreover, insufficient Qi cannot transport pus outward, leading to stagnation and the formation of sinus tracts. Huangqi Jianzhong Tang (Astragalus and Middle-Warming Decoction), heavily supplemented with Chrysanthemi Flos (Jinyinhua/Yinjinhua - note: text says Jin Yin Hua, usually Honeysuckle), Viciae Semen Rubrum (Chi Dou Ya), and Angelicae Sinensis Radix (Danggui), is used for treatment. If the pus is clear and thin, it indicates Blood deficiency. Since pus is transformed from Blood, scanty Blood results in clear pus. Danggui Buxue Tang (Angelica Tonifying Blood Decoction) is primarily indicated. Zhigancao Tang (Prepared Licorice Decoction) with added Astragali Radix (Huangqi) also treats it. Yangrong Tang (Nourishing Prosperity Decoction) also treats it.
It is also said that post-ulceration belongs to deficiency, but there may also be unresolved stasis. Therefore, harsh tonification should not be used to retain toxins. Internally, Tuoli Xiaodu San is taken; externally, Wujin Gao (Black Gold Ointment) is applied to resolve it. This is like deficiency with夹杂 stasis in blood loss; one cannot simply close the door to drive out the thief. For chronic ulcers with persistent sinus tracts, Wujin Gao is especially indicated. If one merely promotes skin regeneration to close the wound while internal toxins attack, it will never heal. This is like Ganxuelao (Dry Blood Consumption), where dry blood exists internally; unless the dry blood is removed, new Blood cannot be generated. These are all deficiencies mixed with excesses. Treating Blood makes deficiency worse; tonifying deficiency makes excess worse. They are difficult to treat. One can only combine attacking and tonifying, doing one's utmost.
It is also said that after hematemesis stops, tonifying Blood to regulate Qi is appropriate; after sores and carbuncles ulcerate, tonifying Qi to generate Blood is appropriate. Hematemesis and epistaxis involve the Blood level, characterized by excess Qi and deficient Blood. Sores and carbuncles involve the Qi level, characterized by excess Blood and deficient Qi.
For external treatment, reducing swelling is best done with Yuanzhi Gao (Polygala Ointment), made by boiling Polygalae Radix (Yuanzhi) in wine, pounding, and applying; and Jinhuang San (Golden Yellow Powder). Resolving putrefaction and removing stasis is best done with Crotonis Fructus (Badou) stir-fried until black, ground and applied, named Wujin Gao (Black Gold Ointment). Snail paste is also good. Promoting tissue regeneration is best done with Frankincense (Ruxiang) and Myrrh (Moyao) ground into powder, named Haifu San (Sea Floating Powder). Adding Pearl (Zhenzhu) to make a powder for resolving putrefaction and promoting tissue regeneration is also good.
The methods for treating sores are not exhausted here. This merely lists external signs to verify internal signs. Understanding the blood aspects of various sores makes the blood aspects of hematemesis and epistaxis even clearer.