两肩臂结节疼痛，疲乏无力半年多。医诊脂膜炎。先以西药治疗4个多月不效，后以中药养阴清热，活血凉血之剂治疗2个多月亦无功。细审其证，在两臂有20多个皮色不变如黄豆大的结节，按之稍痛，身热乏力，舌苔白，脉弦滑。综合脉证，思之：脉弦滑者，痰热凝结于肌与筋也。治宜化痰通络。清热散结。处方：钩藤15克，地龙12克，香橼10克，佛手10克，枳壳10克，木瓜10克，连翘10克，赤芍10克，丝瓜络10克，桑枝30克。
服药4剂，身热乏力好转，结节有的消失，有的开始缩小，继服40剂，诸证全失，愈。
某医云：前用诸药数月而无功，今用上药不久即获愈，其故何也?答曰：喻嘉言云：“不明脏腑经络，开口动手便错。”前药之治一未通络而治脏腑者一也，治血而不治气二也，养血而不消痰者三也，三者俱误，故不效也。
2．谨察脉舌，注意兼证，治之果愈
周××，男，18岁。
身热乏力，皮下结节1年多。医诊脂膜炎、皮肤结核。先以西药治疗半年不效，继以中药清热解毒，清热养阴之剂配合治疗7个来月仍无功。细察其证，身热乏力，体温38．8℃，两臂、两腿酸痛，两臂、上腹部有30多个皮色不变的黄豆大小的结节，两腿有12个紫红色的结节，舌苔薄白，脉虚大紧数。综合脉证，思之：脉虚大者，气血俱虚也；紧数相合者，寒湿郁久化热也。脉证合参，乃气阴两虚为本，湿热内郁，表寒闭郁为标。治宜补气养阴以培本，除湿清热，散寒解表以治标。处方：人参10克，甘草6克，黄芪15克，当归6克，麦冬10克，五味子10克，青皮10克，陈皮10克，神曲10克，黄柏10克，葛根15克，苍术15克，白术10克，升麻10克，泽泻10克，生姜3片，大枣5个。
服药4剂，精神好转；继服10剂，发热消失，结节消失。停药1个月后，诸证又复出现，但很轻微，又服上药1个月，愈。
某医问：同是脂膜炎何用药不同也?答曰：脉证有异也。前证之重用化痰通络因其为实证，后证之用清热燥湿，补气养阴，散寒解表，因其主要为虚证，故用法迥异也。
第二节外、皮、骨伤、肛门大肠病
疖
1．不审季节，不审上下，但予解毒，其病缠绵
刘××，男，18岁。
颈项部疖肿此起彼伏2个月，少时4～5个，多时7～8个，上有黄白色脓头，基底为硬结。前医屡用青霉素、磺胺类药物与中药清热解毒之剂，疗效一直不够显著。细审脉证，无甚特殊。因思《难经》有云：“春夏刺浅，秋冬刺深者，何谓也?然，春夏者阳气在上，人气亦在上，故当浅取之，秋冬者，阳气在下，人气亦在下，故当深取之。”太阳经者，为人身之大表，其经络于项，宜取太阳经穴之血。急取委中放血治之，一次愈。
某医云：取委中放血治疖肿何故如此之效耶?答曰：春夏者阳气在上在表，前用之药多为治里治下，病非所在，故治之不愈也。委中之穴者，既为太阳经之合穴能主表主上，又能凉血泻热，活血逐瘀，故取其穴位以放血也。
2．能合脉象，非仅解毒，始得治愈
文××，男，55岁。
头项部疖肿，此起彼伏，少则3～4个，多则7～8个已2年多。医诊疖病。先用西药间断治疗1年多不效，后又配合中药清热解毒之剂近8个月亦不效。细审其证，除项部疖肿之外，并见头晕头重，有时眩晕的不敢站立，恶心呕吐，且日渐健忘乏力，神情呆痴，纳呆食减，舌苔白，脉濡缓。综合脉证，思之：脉濡缓，且久病不愈者，气阴两虚，痰郁气结，郁而化火也。治宜补气养阴，理气化痰。处方：黄芪15克，当归10克，麦冬10克，党参10克，五味子10克，竹茹10克：枳实10克，半夏10克，陈皮10克，茯苓10克，甘草10克，菖蒲10克，远志10克，生地10克。
服药4剂，不但头晕头重，神疲乏力，健忘失眠，纳呆食减俱减，且疖肿亦明显改善，继服10剂，疖肿全部消失，它症亦减七八，又服25剂，诸证全失。
某医云：疖肿诸书均云其属火毒，若病久不愈者多云气血俱虚为本，热毒为标。然其何先用抗生素，清热解毒方药，后用补气养血，清热解毒均无效耶?答曰：本病从脉证来看，此病一方面有气阴俱虚，一方面有痰郁火毒，前用诸方治火者未化痰理气，补气养阴；治气阴俱虚者，未予理气化痰，郁火不解，但用清降，其何能散?故治之不愈也。
3．实火当泻，尤当看下，参之与脉，其病得治
郑××，男，25岁。
面、颈、肩、臂疖肿，此起彼伏2个多月。医诊为疖病。先用西药治疗1个多月不效，后又配合中药清热解毒之剂近1个月，仍然此起彼伏。细审其证，面、额、颈、项有数个如红枣大的疖肿，其中前额之两个已破溃出脓，其他疖肿均红肿疼痛，且头晕头痛，烦躁易怒，小便黄，大便干，舌苔黄干，脉弦数。综其脉证，思之：弦数者，肝胆实火也；舌苔黄干，大便秘结者，阳明实热也。合而论之，乃心肝胃火所致也。治宜清肝泻火。处方：川芎10克，当归10克，防风10克，龙胆草10克，大黄10克，元参15克，羌活6克。又：牛黄解毒丸，凉水化开，涂局部。
药进6天，疖肿消失，愈。
某医云：余久用抗生素与中药清热解毒之剂不效，先生仅用少量清热泻火之药反愈者何也?答曰：清热解毒之剂为治疖肿之有效方法之一，然疖大都属火，火邪当泻，此之但予解毒不愈者一也；火有脏腑经络之异，若妄施泻火，不分脏腑，此之但予解毒不愈者二也；治火不看其下，不予通便泻火，此之但予解毒不愈者三也。三者俱备，何能效?今余用少量解毒之药而效者，一者有泻火，二者分经络脏腑，三者通下大便也。
丹毒
1．火郁三焦，表里俱热，但予解毒，火郁不散，其病不愈
弓××，男，30岁。
两足、膝红肿热痛，其色如丹，发热恶寒25天。医诊丹毒。先予清热解毒之剂不效，继又配合西药治之亦无功。细审其证，体温39．3℃，两膝、两足红肿疼痛，并见大量不高出皮肤之皮疹，按之疼痛，舌苔黄白，脉浮弦数。综合脉证，恩之：脉浮者，病在表，在上也；弦者，在三焦也，在半表半里之间也；舌苔黄者，病在里也。皮损红赤如丹，火也，火邪及于阴分也。治宜解表清里，清泄三焦。处方：板蓝根30克，升麻10克，马勃10克，僵蚕10克，蝉蜕10克，大黄10克，薄荷10克，牛蒡子10克，元参30克。
服药3剂，体温下降至37．5℃，膝、足红肿热痛明显改善，继服6剂，诸证俱失，愈。
某医云：何大剂抗生素，清热解毒之剂不效，而本方2剂即体温下降，3．剂肿痛大部消失耶?答曰：郁火于表者必散之，郁火于里者必下之，此病表里皆郁，必须解表，攻里同施。今本证虽用大剂清热解毒，但未予解表，未予攻里，致郁者更郁而火邪不解，而上方所以取效者，乃一散，二下俱备也。
2．但宗解毒，不辨色脉，其病延期郑××，女，29岁。
10天前，突然出现两足大趾、小趾红肿热痛，急至某院外科诊治，诊为丹毒。予青霉素等治疗后，非但大趾、小趾肿痛不见好转，亦且发现两个足背均红肿疼痛。乃自动出院求中医诊治。医诊流火。急予清热解毒之剂普济消毒饮治之，3剂后仍然效果不够明显。又转邀余诊治。审其两足趾与足背均红肿热痛，按之有可凹性浮肿，身热，全身酸痛，舌苔白，脉滑数。综合脉证论之：此痰湿挟风热为患也。治宜疏风清热，化痰除湿。处方：黄柏10克，苍术10克，胆南星10克，桂枝10克，防己10克，威灵仙10克，桃仁10克，红花10克，龙胆草10克，羌活10克，白芷10克，川芎10克。同时配用：牛黄解毒丸，冷水调化涂局部。
服药3剂后，两足肿痛明显好转，体温亦降至正常。继服10剂，愈。
某医问：丹毒用普济消毒饮加减多称有效，而本例何故不效也?答曰：丹毒虽本属火热，然有干湿之分，其干者治宜清热解毒，尤多见于上焦，其湿者治宜除湿清热，尤多见于下焦。正如陈实功《外科正宗》云：“火丹者，心火妄动，三焦风热乘之，故发于肌肤之表。有干湿不同，红白之异。干者，色红形如云片，上起风粟作痒，发热，此属心肝二经之火，治以凉心泻肝，化斑解毒汤是也；湿者，色多黄白，大小不等，流水作烂，又且多疼，此属肺脾二经湿热，宜清肺泻脾，除湿胃苓汤是也”。本证虽非湿热之典型者，然其病在下肢，且见浮肿，故其亦为湿热为主之证，因此用疏风清热，化痰除湿进行治疗。又问：牛黄解毒丸本为清热解毒，用于火热内盛，咽喉肿痛，牙龈肿痛，口舌生疮，目赤肿痛的口服药，今先生何用其治丹毒也?答曰：牛黄解毒丸者，非仅清热解毒，亦且能除湿耳，故非但实火所致之疾可用，亦且可用于湿热之疾耳。至于为何外用治疗丹毒，因其组成药味牛黄、雄黄、石膏、大黄、黄芩、桔梗、冰片、甘草均系外用解毒、清热、除湿之品，故用之也。
3．冷敷热敷，不分寒热，病势加剧
李××，女，48岁。
3天前，突然右足中趾、无名趾红肿热痛。某医诊为炎症，嘱其内服磺胺、注射青霉素进行治疗，并嘱其用热毛巾不断热敷以助其消散。患者为求其速效，改用热水浸足法进行治疗。1个小时后红肿热痛迅速殃及右足，并出现全身寒战高热，体温38．8℃，且又见左足中趾、无名趾亦微红肿。此时患者仍不醒悟，继续以热水浸泡两足，并以热水毛巾湿敷两足，至夜间8时左右，两腿均出现红赤如丹，肿胀疼痛，体温39．8℃。患者迫于西药不能速效，且急剧恶化。乃邀中医诊治，云：此丹毒也。急宜清热解毒大剂予之。处方：生地15克，黄连6克，黄芩10克，丹皮10克，生石膏40克，栀子10克，竹叶10克，犀角10克，元参30克，连翘30克，银花30克，板蓝根30克，赤芍10克，甘草10克。
患者家属于夜间1时邀余会诊。云：虽用大剂青霉素及中药1剂，病证不但不减，反更加剧。现红肿之势已及小腹，且高热，神志时昧时清。审之，从少腹至两足赤肿如丹，按之烙手，脉洪大滑数。综合脉证，思之：药证合拍，何用药反不效也?久久不解。再查其患处均盖有热水毛巾。顿悟，乃云：此热敷之弊也，急宜去热改冷，用冷水泡牛黄解毒丸淋洗。l小时后，痛、热俱减，查体温已由39．9℃降至38．9℃，继以上法淋洗2小时，从小腿至小腹红肿之状全部消退，体温亦降至37．3℃，仍以原方治之，愈。
患者问：所用药物前后相同，何你看后徒然大效，而前医用之反剧也?答曰：外敷之法不同耳。又问：冷水、热水均无杀菌之药，何杀菌之速也?答曰：本证乃热毒炽盛之证，稍予火邪则如《伤寒论》所说：“火邪虽微，内攻有力，焦骨伤筋。”故予热水而加剧，及至冷水淋洗而解者，乃热者寒之之故也。所以热敷、冷敷均当宗《经》所训，否则不可也。
纤维瘤
1．谨察其脉，思其病因，化痰散结始愈
文××，男，12岁。
右锁骨下肿瘤如鹅蛋大3年多。医诊侵袭性纤维瘤。细审其证，3年前，始见右锁骨下有，一鸡蛋大，质地较硬之肿块。乃至某肿瘤医院行第1次手术。1年后，又在原来的部位生长出如鸭蛋大小的肿块1个，乃再至某肿瘤医院行第2次手术¨’术后病理学诊断仍为纤维瘤，并发现增生活跃。术后半年多，在原发部位又长出一鹅蛋大的肿块，右臂肌肉明显萎缩，活动受限，既不能上抬至头，亦不能握笔写字。为此不得不改请中医以活血散结之剂治之，半年后，非但未见缩小，亦且日渐纳呆乏力，不得已，乃再易医治之。细审其脉证，除右侧锁骨下有一比鹅蛋还大的肿块，不红不肿，不痛，右臂肌肉萎缩外，并见舌苔白，脉滑数。综合脉证，思之：古代医家论瘤之病因有痰、瘀、郁三种，今脉滑数，滑数之脉者，痰热互结也。治宜化痰清热，佐以活血。处方：瓜蒌30克，桔梗10克，半夏12克，赤芍12克，橘叶10克，青皮10克，枳实10克，葱白4克。
服药4剂，精神、食欲大增，肿块缩小；继服60剂，肿块消失，食欲正常。
2．谨察色脉，知其为瘀，活血化瘀，软坚散结，始愈
何××，女，45岁。
两肩臂出现结节并伴有疼痛，身体疲乏无力已半年多。医生诊断为脂膜炎。先用西药治疗4个多月无效，后用中药养阴清热、活血凉血的方剂治疗2个多月也毫无功效。仔细审查病情，发现双臂有20多个皮色不变、大小如黄豆的结节，按压时稍感疼痛，身体发热且乏力，舌苔白，脉象弦滑。综合脉象与症状思考：脉象弦滑，说明痰热凝结在肌肉与筋脉之间。治疗应当化痰通络，清热散结。处方：钩藤15克，地龙12克，香橼10克，佛手10克，枳壳10克，木瓜10克，连翘10克，赤芍10克，丝瓜络10克，桑枝30克。
服用4剂后，身体发热和乏力症状好转，结节有的消失，有的开始缩小。继续服用40剂，所有症状全部消失，痊愈。
某医生说：“之前用那些药几个月都没效果，现在用上这些药不久就治愈了，这是什么原因呢？”回答说：“喻嘉言说：‘如果不明白脏腑经络，一开口动手就会出错。’之前的药物治疗，一是没有通络而只治脏腑，二是治血而不治气，三是养血而不消痰。这三点都错了，所以无效。”
2．谨慎诊察脉象和舌苔，注意兼夹症状，治疗果然痊愈
周××，男，18岁。
身体发热乏力，皮下结节1年多。医生诊断为脂膜炎、皮肤结核。先用西药治疗半年无效，继而又用中药清热解毒、清热养阴的方剂配合治疗7个多月仍无功效。仔细考察病情，身体发热乏力，体温38.8℃，两臂、两腿酸痛，两臂、上腹部有30多个皮色不变的黄豆大小的结节，两腿有12个紫红色的结节，舌苔薄白，脉象虚大紧数。综合脉象与症状思考：脉象虚大，说明气血俱虚；紧数相合，说明寒湿郁久化热。脉证合参，乃是气阴两虚为本，湿热内郁，表寒闭郁为标。治疗应当补气养阴以培补根本，除湿清热，散寒解表以治疗标症。处方：人参10克，甘草6克，黄芪15克，当归6克，麦冬10克，五味子10克，青皮10克，陈皮10克，神曲10克，黄柏10克，葛根15克，苍术15克，白术10克，升麻10克，泽泻10克，生姜3片，大枣5个。
服用4剂后，精神好转；继续服用10剂，发热消失，结节消失。停药1个月后，所有症状又再次出现，但很轻微，又服用上述药物1个月，痊愈。
某医生问：“同样是脂膜炎，为什么用药不同呢？”回答说：“因为脉证不同啊。前一个病例重用化痰通络是因为它是实证，后一个病例使用清热燥湿、补气养阴、散寒解表，是因为它主要是虚证，所以用法截然不同。”
第二节 外科、皮肤科、骨伤科、肛门大肠病
疖（毛囊炎/疖肿）
1．不审季节，不审上下，仅予解毒，病情缠绵难愈
刘××，男，18岁。
颈项部疖肿此起彼伏2个月，少时4～5个，多时7～8个，上面有黄白色脓头，基底为硬结。前医屡次使用青霉素、磺胺类药物与中药清热解毒的方剂，疗效一直不够显著。仔细审查脉证，没有什么特殊之处。于是想到《难经》中有云：“春夏刺浅，秋冬刺深者，何谓也？回答是：春夏时节阳气在上，人气亦在上，所以应当浅取；秋冬时节阳气在下，人气亦在下，所以应当深取。”太阳经是人身的最大体表经络，其经络循行于项部，适宜选取太阳经穴的血分。急忙选取委中穴放血治疗，一次即愈。
某医生说：“选取委中穴放血治疗疖肿，为何如此有效呢？”回答说：“春夏时节阳气在上在表，之前用的药物多为治里治下，病位不在那里，所以治疗不愈。委中穴既是太阳经的合穴，能主表主上，又能凉血泻热，活血逐瘀，所以选取该穴位进行放血。”
2．能结合脉象，不仅解毒，始得治愈
文××，男，55岁。
头项部疖肿，此起彼伏，少则3～4个，多则7～8个，已2年多。医生诊断为疖病。先用西药间断治疗1年多无效，后又配合中药清热解毒的方剂近8个月也无效。仔细审查病情，除项部疖肿外，还见头晕头重，有时眩晕得不敢站立，恶心呕吐，且日渐健忘乏力，神情呆痴，食欲不振，舌苔白，脉象濡缓。综合脉象与症状思考：脉象濡缓，且久病不愈，说明气阴两虚，痰郁气结，郁而化火。治疗应当补气养阴，理气化痰。处方：黄芪15克，当归10克，麦冬10克，党参10克，五味子10克，竹茹10克，枳实10克，半夏10克，陈皮10克，茯苓10克，甘草10克，石菖蒲10克，远志10克，生地10克。
服用4剂后，不但头晕头重、神疲乏力、健忘失眠、食欲不振等症状减轻，且疖肿也明显改善，继续服用10剂，疖肿全部消失，其他症状也减轻了七八成，又服用25剂，所有症状全部消失。
某医生说：“各种书籍都说疖肿属于火毒，如果病久不愈的多说是气血俱虚为本，热毒为标。然而为什么先用抗生素、清热解毒方药，后用补气养血、清热解毒均无效呢？”回答说：“从脉证来看，本病一方面有气阴俱虚，一方面有痰郁火毒。之前用的各方治疗火的没有化痰理气、补气养阴；治疗气阴俱虚的没有给予理气化痰，郁火不解，只用清降之法，怎么能消散呢？所以治疗不愈。”
3．实火当泻，尤其要看下部，参考脉象，病情得以治愈
郑××，男，25岁。
面、颈、肩、臂疖肿，此起彼伏2个多月。医生诊断为疖病。先用西药治疗1个多月无效，后又配合中药清热解毒的方剂近1个月，仍然此起彼伏。仔细审查病情，面、额、颈、项有数个如红枣大的疖肿，其中前额的两个已破溃出脓，其他疖肿均红肿疼痛，且头晕头痛，烦躁易怒，小便黄，大便干，舌苔黄干，脉象弦数。综合脉证思考：脉弦数，是肝胆实火；舌苔黄干，大便秘结，是阳明实热。合起来论述，乃心肝胃火所致。治疗应当清肝泻火。处方：川芎10克，当归10克，防风10克，龙胆草10克，大黄10克，玄参15克，羌活6克。另外：牛黄解毒丸，凉水化开，涂局部。
服药6天，疖肿消失，痊愈。
某医生说：“我长久使用抗生素与中药清热解毒的方剂无效，先生仅用少量清热泻火的药反而治愈了，为什么呢？”回答说：“清热解毒的方剂是治疗疖肿的有效方法之一，然而疖大都属火，火邪应当泻，这里只予解毒不愈是第一点原因；火有脏腑经络的区别，如果妄施泻火，不分脏腑，这是只予解毒不愈的第二点原因；治火不看其下，不予通便泻火，这是只予解毒不愈的第三点原因。三者兼备，怎么能有疗效呢？现在我使用少量解毒的药而有效，第一是有泻火，第二是分经络脏腑，第三是通下大便。”
丹毒
1．火郁三焦，表里俱热，仅予解毒，火郁不散，病情不愈
弓××，男，30岁。
两足、膝红肿热痛，颜色如丹，发热恶寒25天。医生诊断为丹毒。先予清热解毒的方剂无效，继而又配合西药治疗也无功。仔细审查病情，体温39.3℃，两膝、两足红肿疼痛，并见大量不高出皮肤的皮疹，按压疼痛，舌苔黄白，脉象浮弦数。综合脉证思考：脉浮，说明病在表，在上；脉弦，在三焦，在半表半里之间；舌苔黄，说明病在里。皮损红赤如丹，是火邪，火邪及于阴分。治疗应当解表清里，清泄三焦。处方：板蓝根30克，升麻10克，马勃10克，僵蚕10克，蝉蜕10克，大黄10克，薄荷10克，牛蒡子10克，玄参30克。
服用3剂，体温下降至37.5℃，膝、足红肿热痛明显改善，继续服用6剂，所有症状全部消失，痊愈。
某医生说：“为什么大剂量抗生素、清热解毒的方剂无效，而本方2剂即体温下降，3剂肿痛大部消失呢？”回答说：“郁火在表的必须发散，郁火在里的必须攻下，此病表里皆郁，必须解表，攻里同施。现在本证虽然用了大剂清热解毒，但未予解表，未予攻里，导致郁者更郁而火邪不解，而上方的取效，乃是一散、二下俱备的缘故。”
2．只宗解毒，不辨色脉，病情延期
郑××，女，29岁。
10天前，突然出现两足大趾、小趾红肿热痛，急至某院外科诊治，诊断为丹毒。予青霉素等治疗后，非但大趾、小趾肿痛不见好转，而且发现两个足背均红肿疼痛。乃自动出院求中医诊治。医生诊断为流火。急予清热解毒的方剂普济消毒饮治疗，3剂后仍然效果不够明显。又转邀我诊治。审视两足趾与足背均红肿热痛，按压有可凹性浮肿，身热，全身酸痛，舌苔白，脉象滑数。综合脉证论述：这是痰湿挟风热为患。治疗应当疏风清热，化痰除湿。处方：黄柏10克，苍术10克，胆南星10克，桂枝10克，防己10克，威灵仙10克，桃仁10克，红花10克，龙胆草10克，羌活10克，白芷10克，川芎10克。同时配用：牛黄解毒丸，冷水调化涂局部。
服用3剂后，两足肿痛明显好转，体温亦降至正常。继续服用10剂，痊愈。
某医生问：“丹毒用普济消毒饮加减多称有效，而本例为何不效呢？”回答说：“丹毒虽本属火热，但有干湿之分，干的适宜清热解毒，多见于上焦；湿的适宜除湿清热，多见于下焦。正如陈实功《外科正宗》所说：‘火丹者，心火妄动，三焦风热乘之，故发于肌肤之表。有干湿不同，红白之异。干的，色红形如云片，上起风粟作痒，发热，这属于心肝二经之火，治疗以凉心泻肝，化斑解毒汤是也；湿的，色多黄白，大小不等，流水作烂，又且多疼，这属于肺脾二经湿热，宜清肺泻脾，除湿胃苓汤是也’。本证虽然不是湿热的典型者，但其病在下肢，且见浮肿，所以也是以湿热为主的证候，因此用疏风清热，化痰除湿进行治疗。”又问：“牛黄解毒丸本是清热解毒，用于火热内盛，咽喉肿痛，牙龈肿痛，口舌生疮，目赤肿痛的口服药，现在先生为何用它来治丹毒呢？”回答说：“牛黄解毒丸，不仅清热解毒，也能除湿，所以不仅是实火所致的疾病可用，也可用于湿热的疾病。至于为何外用治疗丹毒，因为其组成药味牛黄、雄黄、石膏、大黄、黄芩、桔梗、冰片、甘草均系外用解毒、清热、除湿之品，所以使用它。”
3．冷敷热敷，不分寒热，病势加剧
李××，女，48岁。
3天前，突然右足中趾、无名趾红肿热痛。某医诊断为炎症，嘱其内服磺胺、注射青霉素进行治疗，并嘱其用热毛巾不断热敷以助其消散。患者为了求速效，改用热水浸足法进行治疗。1个小时后红肿热痛迅速殃及右足，并出现全身寒战高热，体温38.8℃，且又见左足中趾、无名趾亦微红肿。此时患者仍不醒悟，继续以热水浸泡两足，并以热水毛巾湿敷两足，至夜间8时左右，两腿均出现红赤如丹，肿胀疼痛，体温39.8℃。患者迫于西药不能速效，且急剧恶化。乃邀中医诊治，说：“这是丹毒。急宜大剂予清热解毒之药。”处方：生地15克，黄连6克，黄芩10克，丹皮10克，生石膏40克，栀子10克，竹叶10克，犀角10克，玄参30克，连翘30克，银花30克，板蓝根30克，赤芍10克，甘草10克。
患者家属于夜间1时邀我会诊。说：“虽然用了大剂青霉素及中药1剂，病证不但不减，反而更加剧。现在红肿之势已及小腹，且高热，神志时昧时清。”审视，从少腹至两足赤肿如丹，按压烫手，脉象洪大滑数。综合脉证思考：药证合拍，为何用药反而不效呢？久久不解。再查其患处均盖有热水毛巾。顿悟，于是说：“这是热敷的弊端，急宜去热改冷，用冷水泡牛黄解毒丸淋洗。”1小时后，痛、热俱减，查体温已由39.9℃降至38.9℃，继续以上法淋洗2小时，从小腿至小腹红肿之状全部消退，体温亦降至37.3℃，仍以原方治疗，痊愈。
患者问：“所用药物前后相同，为何你看后徒然大效，而前医用之反剧呢？”回答说：“外敷的方法不同罢了。”又问：“冷水、热水均无杀菌之药，为何杀菌这么快呢？”回答说：“本证乃是热毒炽盛的证候，稍予火邪则如《伤寒论》所说：‘火邪虽微，内攻有力，焦骨伤筋。’所以予热水而加剧，及至冷水淋洗而解者，乃是热者寒之的缘故。所以热敷、冷敷均应当遵循《内经》的训诫，否则不可以。”
纤维瘤
1．谨慎诊察脉象，思考病因，化痰散结始愈
文××，男，12岁。
右锁骨下肿瘤如鹅蛋大3年多。医生诊断为侵袭性纤维瘤。仔细审查病情，3年前，始见右锁骨下有一个鸡蛋大、质地较硬的肿块。乃至某肿瘤医院行第1次手术。1年后，又在原来的部位生长出如鸭蛋大小的肿块1个，乃再至某肿瘤医院行第2次手术。术后病理学诊断仍为纤维瘤，并发现增生活跃。术后半年多，在原发部位又长出一个鹅蛋大的肿块，右臂肌肉明显萎缩，活动受限，既不能上抬至头，亦不能握笔写字。为此不得不改请中医以活血散结的方剂治疗，半年后，非但未见缩小，而且日渐纳呆乏力，不得已，乃再换医生医治。仔细审查脉证，除右侧锁骨下有一个比鹅蛋还大的肿块，不红不肿，不痛，右臂肌肉萎缩外，并见舌苔白，脉象滑数。综合脉证思考：古代医家论瘤的病因有痰、瘀、郁三种，现在脉滑数，滑数之脉，是痰热互结。治疗应当化痰清热，佐以活血。处方：瓜蒌30克，桔梗10克，半夏12克，赤芍12克，橘叶10克，青皮10克，枳实10克，葱白4克。
服用4剂，精神、食欲大增，肿块缩小；继续服用60剂，肿块消失，食欲正常。
Nodules and pain appeared in both shoulders and arms, accompanied by fatigue and weakness for over half a year. The physician diagnosed lipoid dermatitis (Panniculitis). Western medicine was administered for over four months without effect, followed by Chinese herbal medicine aimed at nourishing Yin and clearing heat, invigorating blood and cooling blood for over two months, also without efficacy. Upon careful examination of the syndrome, more than twenty nodules the size of soybeans with unchanged skin color were found on both arms; they were slightly painful upon pressure. The patient presented with fever, fatigue, a white tongue coating, and a wiry-slippery pulse (Xian Hua Mai). Synthesizing the pulse and symptoms: a wiry-slippery pulse indicates phlegm-heat congealing in the muscles and sinews. The treatment should focus on resolving phlegm and unblocking collaterals, clearing heat and dissipating nodules. Prescription: Uncariae Ramulus cum Uncis (Gouteng) 15g, Pheretima (Dilong) 12g, Citri Reticulatae Fructus (Xiangyuan) 10g, Bergamia Fructus (Foshou) 10g, Aurantii Fructus (Zhiqiao) 10g, Papaw (Mugua) 10g, Forsythiae Fructus (Lianqiao) 10g, Paeoniae Radix Rubra (Chishao) 10g, Luffae Fibrosum Retinervum (Sigualuo) 10g, Mori Ramulus (Sangzhi) 30g.
After taking 4 doses, the fever and fatigue improved; some nodules disappeared, while others began to shrink. After continuing for 40 doses, all symptoms vanished, and the patient recovered.
A certain doctor asked: "Why did previous medications fail after months, yet this prescription worked quickly?" The answer was: "As Yu Jiayan stated, 'Without understanding the Zang-Fu organs and meridians, any action taken will be erroneous.' The previous treatments failed because: first, they treated the Zang-Fu without unblocking collaterals; second, they treated blood but not Qi; third, they nourished blood but did not resolve phlegm. All three approaches were mistaken, hence the lack of efficacy."
2. Carefully observing pulse and tongue, noting concurrent syndromes, treatment resulted in recovery
Patient Zhou XX, Male, 18 years old.
Fever and fatigue, subcutaneous nodules for over one year. Diagnosed with lipoid dermatitis and cutaneous tuberculosis. Western medicine was used for six months without effect, followed by seven months of combined Chinese medicine therapy aimed at clearing heat and detoxifying, and clearing heat and nourishing Yin, still without success. Detailed examination revealed fever and fatigue, body temperature 38.8°C, soreness and pain in both arms and legs, over thirty soybean-sized nodules with unchanged skin color on both arms and upper abdomen, and twelve purplish-red nodules on both legs. The tongue coating was thin and white, and the pulse was deficient-large-tight-rapid (Xu Da Jin Shu Mai). Synthesizing pulse and symptoms: a deficient-large pulse indicates deficiency of both Qi and Blood; tightness and rapidity together indicate cold-dampness stagnating and transforming into heat over time. Integrating pulse and signs, the root is deficiency of Qi and Yin, while the branch is internal stagnation of damp-heat and exterior closure of cold. Treatment should tonify Qi and nourish Yin to support the root, and dispel dampness, clear heat, scatter cold, and release the exterior to treat the branch. Prescription: Ginseng Radix (Renshen) 10g, Glycyrrhizae Radix et Rhizoma (Gancao) 6g, Astragali Radix (Huangqi) 15g, Angelicae Sinensis Radix (Danggui) 6g, Ophiopogonis Radix (Maidong) 10g, Schisandrae Fructus (Wuweizi) 10g, Aurantii Fructus Viridis (Qingpi) 10g, Citri Reticulatae Pericarpium (Chenpi) 10g, Massae Fermentatae Medicinalis (Shenqu) 10g, Phellodendri Cortex (Huangbai) 10g, Puerariae Radix (Gegen) 15g, Atractylodis Rhizoma (Cangzhu) 15g, Atractylodis Macrocephalae Rhizoma (Baizhu) 10g, Cimicifugae Rhizoma (Shengma) 10g, Alismatis Rhizoma (Zexie) 10g, Zingiberis Rhizoma Recens (Shengjiang) 3 slices, Jujubae Fructus (Dazao) 5 pieces.
After 4 doses, spirit improved; after another 10 doses, fever disappeared and nodules vanished. One month after stopping medication, symptoms recurred but mildly. Taking the same prescription for another month led to recovery.
A doctor asked: "Why are the prescriptions different for the same diagnosis of lipoid dermatitis?" The answer: "Because the pulse and symptoms differ. The former case emphasized resolving phlegm and unblocking collaterals due to an excess syndrome; the latter required clearing heat, drying dampness, tonifying Qi, nourishing Yin, scattering cold, and releasing the exterior due to a deficiency syndrome. Hence, the methods are vastly different."
Section 2: External Medicine, Dermatology, Orthopedics/Traumatology, Anorectal Diseases
Boils (Furuncles)
1. Ignoring seasons and location, merely using detoxification leads to lingering illness
Patient Liu XX, Male, 18 years old.
Boils on the neck appeared and disappeared intermittently for two months, ranging from 4-5 to 7-8 at a time, with yellow-white pus heads and indurated bases. Previous doctors repeatedly used penicillin, sulfonamides, and Chinese medicine for clearing heat and detoxifying, with insignificant results. Careful examination of pulse and symptoms showed no special features. Recalling the *Nan Jing*: "Why prick shallowly in spring and summer, and deeply in autumn and winter? It is said that in spring and summer, Yang Qi is above, and human Qi is also above, so shallow needling is appropriate; in autumn and winter, Yang Qi is below, and human Qi is also below, so deep needling is appropriate." The Taiyang Meridian is the major exterior meridian of the body, traversing the nape. It is suitable to select blood points from the Taiyang Meridian. Urgently selecting Weizhong (BL40) for bloodletting cured it in one session.
A doctor asked: "Why is bloodletting at Weizhong so effective for boils?" The answer: "In spring and summer, Yang Qi is above and in the exterior. Previous medications mostly treated the interior and lower parts, missing the disease site. Weizhong is the He-Sea point of the Taiyang Meridian, governing the exterior and upper body, and can cool blood, drain heat, invigorate blood, and expel stasis. Thus, bloodletting at this acupoint was chosen."
2. Combining pulse analysis, not just detoxification, leads to cure
Patient Wen XX, Male, 55 years old.
Boils on the head and neck appeared and disappeared intermittently for over two years, ranging from 3-4 to 7-8. Diagnosed as furunculosis. Intermittent Western medicine treatment for over a year failed, followed by nearly eight months of combined Chinese medicine for clearing heat and detoxifying, also ineffective. Careful examination revealed, besides neck boils, dizziness and heavy head, occasional vertigo preventing standing, nausea and vomiting, progressive forgetfulness and fatigue, dull expression, poor appetite, white tongue coating, and a soggy-slow pulse (Ru Huan Mai). Synthesizing pulse and symptoms: a soggy-slow pulse with chronic illness indicates deficiency of Qi and Yin, with phlegm stagnation and Qi binding, transforming into fire. Treatment should tonify Qi and nourish Yin, regulate Qi and resolve phlegm. Prescription: Astragali Radix (Huangqi) 15g, Angelicae Sinensis Radix (Danggui) 10g, Ophiopogonis Radix (Maidong) 10g, Codonopsis Radix (Dangshen) 10g, Schisandrae Fructus (Wuweizi) 10g, Bamboo Shavings (Zhuru) 10g, Immature Bitter Orange (Zhishi) 10g, Pinelliae Tuber (Banxia) 10g, Citri Reticulatae Pericarpium (Chenpi) 10g, Poria (Fuling) 10g, Glycyrrhizae Radix et Rhizoma (Gancao) 10g, Pogostemonis Herba (Shichangpu) 10g, Polygalae Radix (Yuanzhi) 10g, Rehmanniae Radix (Shengdi) 10g.
After 4 doses, dizziness, heaviness, fatigue, forgetfulness, insomnia, and poor appetite decreased, and boils improved significantly. After another 10 doses, all boils disappeared, and other symptoms reduced by 70-80%. After another 25 doses, all symptoms vanished.
A doctor asked: "Books state boils are Fire-Toxin, and chronic cases are Root Deficiency of Qi/Blood with Branch Heat-Toxin. Why did antibiotics, heat-clearing/detoxifying herbs, and later Qi/Blood tonifying with heat-clearing/detoxifying all fail?" The answer: "From pulse and symptoms, this case has both Qi/Yin deficiency and Phlegm-Stagnation/Fire-Toxin. Previous formulas treating fire lacked phlegm-resolving/Qi-regulating and Qi/Yin tonifying. Formulas treating Qi/Yin deficiency lacked Qi-regulating/phlegm-resolving. Without resolving stagnant fire, mere clearing and descending cannot disperse it. Hence, failure."
3. Excess Fire must be drained, especially checking the lower jiao, referencing pulse, disease cured
Patient Zheng XX, Male, 25 years old.
Boils on face, neck, shoulders, and arms appeared and disappeared for over two months. Diagnosed as furunculosis. Western medicine for over a month failed, followed by nearly one month of Chinese medicine for clearing heat and detoxifying, still recurring. Careful examination revealed several date-sized boils on face, forehead, neck, and nape; two on the forehead had ruptured with pus; others were red, swollen, and painful. Accompanied by dizziness, headache, irritability, yellow urine, dry stool, yellow-dry tongue coating, and wiry-rapid pulse (Xian Shu Mai). Synthesizing pulse and symptoms: wiry-rapid indicates Excess Fire of Liver and Gallbladder; yellow-dry coating and constipation indicate Excess Heat of Yangming. Combined, this is Fire of Heart, Liver, and Stomach. Treatment should clear Liver and drain Fire. Prescription: Ligustici Chuanxiong Rhizoma (Chuanxiong) 10g, Angelicae Sinensis Radix (Danggui) 10g, Saposhnikoviae Radix (Fangfeng) 10g, Gentianae Radix (Longdancao) 10g, Rheomi Radix et Rhizoma (Dahuang) 10g, Scrophulariae Radix (Yuanshen) 15g, Notopterygii Rhizoma et Radix (Qianghuo) 6g. Additionally: Niuhuang Jiedu Wan (Calculus Bovis Detoxification Pill), dissolved in cold water, applied locally.
Medication for 6 days cleared the boils; cured.
A doctor asked: "Why did long-term antibiotics and heat-clearing/detoxifying herbs fail, while your small dose of heat-clearing/draining herbs succeeded?" The answer: "Heat-clearing/detoxifying is one method, but boils are mostly Fire, which must be drained. Failure reason 1: merely detoxifying without draining fire. Reason 2: Fire differs by Zang-Fu/Meridians; indiscriminate draining fails. Reason 3: Treating fire without checking the lower jiao and promoting bowel movement fails. My success lies in draining fire, distinguishing meridians/Zang-Fu, and promoting bowel movements."
Erysipelas
1. Fire constrained in Sanjiao, interior/exterior heat, merely detoxifying fails to disperse constrained fire
Patient Gong XX, Male, 30 years old.
Redness, swelling, heat, and pain in both feet and knees, colored like erysipelas, with fever and aversion to cold for 25 days. Diagnosed as erysipelas. Heat-clearing/detoxifying herbs failed, followed by Western medicine, also ineffective. Examination: Temperature 39.3°C, red/swollen/painful knees and feet, numerous non-elevated rashes, painful on pressure, yellow-white tongue coating, floating-wiry-rapid pulse (Fu Xian Shu Mai). Synthesizing: Floating pulse indicates exterior/upper pathogen; wiry indicates Sanjiao/between exterior and interior; yellow coating indicates interior pathogen. Red rash like erysipelas is Fire-Toxin affecting Yin level. Treatment should release exterior and clear interior, drain Sanjiao. Prescription: Isatidis Radix (Banlangen) 30g, Cimicifugae Rhizoma (Shengma) 10g, Malvae Flos (Mabo) 10g, Bombyx Batryticatus (Jiangcan) 10g, Bombyx Batryticatus (Chantui) 10g, Rheomi Radix et Rhizoma (Dahuang) 10g, Menthae Haplocalycis Herba (Bohe) 10g, Arctii Fructus (Niubangzi) 10g, Scrophulariae Radix (Yuanshen) 30g.
After 3 doses, temperature dropped to 37.5°C, knee/foot symptoms improved. After another 6 doses, all symptoms vanished; cured.
A doctor asked: "Why did large doses of antibiotics and heat-clearing/detoxifying herbs fail, while this formula worked in 2-3 doses?" The answer: "Constrained fire in the exterior must be dispersed; constrained fire in the interior must be purged. This case has exterior-interior constraint, requiring simultaneous exterior release and interior purging. Previous treatments lacked these, causing deeper constraint. Success here came from combining dispersion and purgation."
2. Solely relying on detoxification, ignoring color and pulse, delays recovery
Patient Zheng XX, Female, 29 years old.
Sudden redness, swelling, heat, and pain in big and little toes of both feet 10 days ago. Diagnosed as erysipelas at a surgical department. Penicillin treatment worsened symptoms, spreading to dorsum of feet. Discharged to seek TCM. Diagnosed as "Flowing Fire" (Liuhuo). Puji Xiaodu Yin (Universal Benefit Decoction) for clearing heat and detoxifying was given for 3 doses with minimal effect. Referred to me. Examination: Red/swollen/hot/painful toes and dorsum, pitting edema on pressure, fever, generalized body ache, white tongue coating, slippery-rapid pulse (Hua Shu Mai). Synthesizing: Phlegm-Dampness with Wind-Heat. Treatment should disperse Wind, clear Heat, resolve Phlegm, and remove Dampness. Prescription: Phellodendri Cortex (Huangbai) 10g, Atractylodis Rhizoma (Cangzhu) 10g, Arisaematis Cum Bile (Dannanxing) 10g, Cinnamomi Ramulus (Guizhi) 10g, Stephaniae Tetrandrae Radix (Fangji) 10g, Salviae Miltiorrhizae Radix et Rhizoma (Weilingxian - *Note: Text says Weilingxian, usually Saposhnikoviae, but context implies moving wind-damp*), Peoniae Radix Rubra (Taoren - *Note: Text says Taoren, Peach Kernel*), Carthami Flos (Honghua) 10g, Gentianae Radix (Longdancao) 10g, Notopterygii Rhizoma et Radix (Qianghuo) 10g, Angelicae Dahuricae Radix (Baizhi) 10g, Ligustici Chuanxiong Rhizoma (Chuanxiong) 10g. Additionally: Niuhuang Jiedu Wan, mixed with cold water, applied locally.
After 3 doses, foot swelling/pain improved, temperature normalized. After another 10 doses, cured.
A doctor asked: "Puji Xiaodu Yin is often effective for erysipelas; why did it fail here?" The answer: "Erysipelas is fundamentally Heat-Fire, but distinguishes Dry vs. Wet. Dry requires heat-clearing/detoxifying (often Upper Jiao); Wet requires damp-draining/heat-clearing (often Lower Jiao). As Chen Shigong wrote in *Waike Zhengzong*: 'Fire Dan... Dry type is red, cloud-like, itchy, Fever, Heart/Liver Fire, treat with Huaban Jiedu Tang; Wet type is yellow-white, weeping, painful, Lung/Spleen Damp-Heat, treat with Chushi Weiling Tang.' This case, though not typical, involves lower limbs and edema, indicating Damp-Heat. Hence, Wind-dispersing/Damp-draining was used." Asked about Niuhuang Jiedu Wan: "It clears heat/detoxifies, why use externally?" Answer: "It also removes dampness. Its ingredients (Calculus Bovis, Realgar, Gypsum, Rhubarb, Scutellaria, Platycodon, Borneol, Licorice) have external detoxifying/clearing/damp-draining properties."
3. Cold/Hot compresses without distinguishing Cold/Heat exacerbate condition
Patient Li XX, Female, 48 years old.
Sudden redness, swelling, heat, and pain in right middle and ring toes 3 days ago. Diagnosed as inflammation. Prescribed sulfonamides, penicillin, and hot towel compresses. Patient switched to hot water foot soak. Within 1 hour, symptoms spread to right foot, with chills, high fever (38.8°C), and mild swelling in left toes. Patient continued hot soaks/compresses. By 8 PM, both legs were red like erysipelas, swollen/painful, temperature 39.8°C. Condition worsened rapidly despite Western medicine. Sought TCM. Diagnosed as erysipelas. Prescription: Rehmanniae Radix (Shengdi) 15g, Coptidis Rhizoma (Huanglian) 6g, Scutellariae Radix (Huangqin) 10g, Moutan Cortex (Danpi) 10g, Gypsum Fibrosum (Shengshigao) 40g, Gardeniae Fructus (Zhizi) 10g, Lophatheri Herba (Zhuye) 10g, Rhinocerotis Cornu (Xijiao) 10g, Scrophulariae Radix (Yuanshen) 30g, Forsythiae Fructus (Lianqiao) 30g, Lonicerae Japonicae Flos (Yinhua) 30g, Isatidis Radix (Banlangen) 30g, Paeoniae Radix Rubra (Chishao) 10g, Glycyrrhizae Radix et Rhizoma (Gancao) 10g.
Consulted at 1 AM. Family reported worsening despite large doses of penicillin and herbs. Redness/swelling extended to lower abdomen, high fever, altered consciousness. Examination: Red/swollen like erysipelas from lower abdomen to feet, burning to touch, flooding-large-slippery-rapid pulse (Hong Da Hua Shu Mai). Synthesizing: Formula matched syndrome, yet failed? Investigation revealed hot towels covering lesions. Realization: Harm of hot compresses. Ordered removal of heat, switching to cold. Washed with cold water infused with Niuhuang Jiedu Wan. After 1 hour, pain/heat reduced, temp dropped to 38.9°C. Continued washing for 2 hours; redness/swelling subsided, temp 37.3°C. Continued original prescription; cured.
Patient asked: "Same drugs, why did you succeed where previous doctors failed?" Answer: "Different external application methods." Asked: "Cold/hot water has no antibacterial properties; why such fast resolution?" Answer: "This is Excessive Heat-Toxin. Adding Fire-Toxin acts as per *Shanghan Lun*: 'Even slight Fire-Toxin attacks internally, scorching bones and damaging sinews.' Hot water exacerbated it; cold water resolved it via 'Heat treated with Cold' principle. Compresses must follow *Neijing* guidelines; otherwise, harmful."
Fibroma
1. Carefully observing pulse, analyzing etiology, resolving phlegm and dissipating nodules leads to cure
Patient Wen XX, Male, 12 years old.
Tumor under right clavicle, egg-sized, for over 3 years. Diagnosed as invasive fibroma. History: 3 years ago, egg-sized hard mass under right clavicle. First surgery at oncology hospital. One year later, recurrence, duck-egg sized. Second surgery. Pathology confirmed fibroma with active proliferation. Half a year post-op, goose-egg sized mass recurred at primary site. Right arm muscle atrophy, limited mobility (cannot raise to head, cannot hold pen). Switched to TCM for invigorating blood and dissipating nodules. After 6 months, no reduction, worsening appetite/fatigue. Changed doctors again. Examination: Goose-egg sized mass under right clavicle, non-red/non-swollen/non-painful, right arm atrophy, white tongue coating, slippery-rapid pulse (Hua Shu Mai). Synthesizing: Ancient texts cite Phlegm, Stasis, Depression as causes. Slippery-rapid pulse indicates Phlegm-Heat intermingling. Treatment: Resolve Phlegm, Clear Heat, assist with Invigorating Blood. Prescription: Trichosanthis Fructus (Gualou) 30g, Platycodonis Radix (Jiegeng) 10g, Pinelliae Tuber (Banxia) 12g, Paeoniae Radix Rubra (Chishao) 12g, Citri Reticulatae Pericarpium (Juye - *Note: Text says Juye, Tangerine Leaf*) 10g, Aurantii Fructus Viridis (Qingpi) 10g, Immature Bitter Orange (Zhishi) 10g, Allii Tuberosi Bulbus (Congbai) 4g.
After 4 doses, spirit/appetite increased, mass shrank. After another 60 doses, mass disappeared, appetite normal.
2. Carefully observing color and pulse, identifying Stasis, invigorating blood, softening hardness and dissipating nodules leads to cure
Patient He XX, Female, 45 years old.