既然风寒湿三气不与荣气合则不为痹，与荣气合则为痹，那么痹的形成也就当然存在着荣气之行涩和荣血衰少的不同问题，所以医家之治痹很多采用活血通络与养血补血之法以事区别。其中活血止痛者，如乳香、没药、桃仁、红花、赤芍、当归、川芎、鸡血藤、蜈蚣、全蝎、蜂房、地龙、廣虫。养血药，如当归、白芍、熟地、杜仲、川断、鹿茸、鹿角、鹿角胶。正如孙一奎《赤水玄珠》说：“活血丹，治遍身骨节疼痛如神。熟地、当归、白术、白芍、续断、人参各一两。”“麒麟散，治寒湿传于经络，疼痛不可忍。血竭、乳香、没药、白芍、当归、水蛭、麝香、虎胫骨。”
七、化痰通络问题
既然《灵枢．周痹》篇认为：“风寒湿气，客于外分肉之间，迫切而为沫，沫得寒则聚，聚则排分肉而分裂也，分裂则痛，痛则神归之，神归之则热，热则痛解，痛解则厥，厥则他痹发，发则如是。”那么痹证当然常常存在一个痰的问题，但痰有挟风、挟寒、挟热的不同，所以治疗起来就有着化痰祛风、温化寒痰、清化热痰的不同。正如方隅《医林绳墨》所说：“不疼不痒而麻木者，此属气虚湿痰死血之为病也。又曰手麻气虚，手木湿痰或死血病，其足亦然。又曰遍体麻木者，多因湿痰为病，非死血也……如湿痰者，或走注有核，肿起有形，但色白而已，治宜清湿降痰，用二陈汤加苍术、枳实、黄连、厚朴之类。”
八、五脏痹问题
既然治疗疾病“不明脏腑经络，开口动手便错。”那么自伏若“淫气喘息，痹聚在肺”者，当治在肺。“淫气忧思，痹聚在心”者，当治在心。“淫气遗溺，痹聚在肾”者，当治在肾．“淫气乏竭，痹聚在肝”者，当治在肝；“淫气肌绝，痹聚在脾”者，当治在脾。正如林佩琴《类证治裁》所说：“五脏痹，经病人脏，邪胜正虚，五痹汤(人参、茯苓、当归、白芍、川芎、白术、五味子、细辛)。肾痹，本方加独活、肉桂、杜仲、牛膝、黄芪、萆薢。肝痹，本方加枣仁、柴胡。心痹，本方加远志、茯苓、麦冬、犀角(现代已禁用)。脾痹，本方加厚朴、枳实、砂仁、神曲。肺痹、本方加半夏、杏仁、麻黄、紫菀。”
九、筋骨脉肌皮痹问题
既然痹有筋骨脉肌皮痹的区别，那么痹证的治疗就应该根据筋骨脉肌皮痹的不同分别论治。正如朱（木肃）《普济方》所说：“筋痹……其状拘急，屈而不伸是也……筋痹，四肢挛腕……天麻丸。”“筋痹不能屈伸……舒筋丸。”“筋痹多悲思，颜色苍白，四肢不敛，诸筋挛急，伸动缩急，肠中转痛……五加皮酒。”“筋挛缩，腰背不伸，强直吋痛……牛膝汤。”“筋痹，肢体拘急，不得伸展……独活散。”“肝虚气痹，两胁胀满，筋脉拘急，不得喘息，四肢少力，且不明……细辛汤。”“筋痹，肢节束痛……羚羊角汤。”
“脉痹……则皮毛萎悴，肌肉痛痹……脉痹，血道壅涩……导痹汤。”“脉痹，面脱颜色，脉空，口唇赤色干燥，消痹蠲热，润悦颜色……升麻汤。”“脉痹，荣卫不通，四肢烬痛……芍药汤。”“麻痹身体不仁……黄芪汤。”
“肌痹，其状皮肤弗荣，肌肉痛痹而不仁是也……肌肉痛痹，肢体怠惰缓溺，恶风头痛，舌本强，言语謇涩……天麻丸。”“内热极，则体上如鼠走，或如风痹，唇口干，皮肤色变……石南散。”“肌肤淫淫，如鼠走四肢，津液脱，腠理开，汗大泄，此为脾风……麻黄汤。”“肌痹，淫淫如虫行，或腠理开疏，汗出皮肤，肉色不泽，唇鼻黄……细辛汤。”
“皮痹……皮肤不荣，而为不仁……皮肤（病－丙c君/巾）痹，项强痛，四肢缓弱，目昏塞，心脑短气者……赤箭丸．”“皮痹如虫行，腹胀大便不利，语言不出……羌活汤。”“肺中寒湿，项强头昏，胸满短气，嘘吸颤掉，言语声嘶，四肢缓弱，皮肤顽痛……防风汤。”
“皮痹，肌肉不仁，心烦气促，项背硬强……天麻散。”“风寒湿气感于肺经，皮肤顽痹不仁……麻黄汤。”“皮痹不仁……蔓荆实丸。”“皮肤痛痹…一．天麻丸。”“皮肤间有麻木……补气汤。”
林佩琴《类证治载》云：“骨痹，即寒痹痛痹也，苦痛切骨，安肾丸。”“筋痹，即风痹也，风热攻注，筋弛脉缓，羚羊角散；若湿邪入筋，续断丹。”“脉痹，即热痹也，风湿郁热，经隧为壅，升麻汤去桂、麻，加萆薢、石膏，或秦艽四物汤。”“肌痹，即湿痹着痹也，浑身上下左右麻木，属卫气不行，本方去蔓荆、倍黄芪，加防风；肌肉麻木，属营气不行，本方去蔓荆，加桂枝、羌活、防风。”“皮痹，邪在皮毛，搔如隔帛，或瘾疹风疮，宜疏风养血，秦艽地黄汤。”
十、叶天士治痹问题
遍查诸书论治痹证者大多重视关节痛证，而全面进行论述者则比较少见，致使后学者遇见疑难问题时常感无方可施。惟叶氏医案论之颇为深刻，兹录邹滋九所言者于后。云：“此证与风病相似，但风则阳受之，痹则阴受之，故多重著沉痛。其在《内经》不越乎风寒湿三气，然四时之令，皆能为邪，五脏之气，各能受病。其实痹者，闭而不通之谓也。正气为邪所阻，脏腑经络，不能畅达，皆由气血亏损，腠理疏豁，风寒湿三气，得以乘虚外袭，留滞于内，致湿痰浊血，流注凝涩而得夕．故经云三气杂至合而为痹，又云风胜为行痹，寒胜为痛痹．湿胜为著痹，以及骨痹、筋痹、脉痹、肌痹、皮痹之义。”可知痹病之证，非偏受一气足以致之也。然而病证多端，治法亦异，余亦不能尽述。兹以先生治痹之法为申明一二。
有卫阳疏风邪人络而成痹者，以宣通经脉，甘寒去热为主。有经脉受伤，阳气不为护持而为痹者，以温养通补，扶持生气为主。有暑伤气湿热人络而为痹者，用舒通络脉之剂，使清阳流行为主。有风湿肿痛而为痹者，用参术益气，佐以风药壮气为主。有湿热伤气及温热人血络而成痹者，用固卫阳以却邪及宣通营络，兼治奇经为主。有肝阴虚，疟邪人络而成痹者，以咸苦滋阴，兼以通逐缓攻为主。有寒湿人络而成痹者，以微通其阳，兼以通补为主。有气滞热郁而成痹者，从气分宣通为主。有肝胃虚滞而成痹者，以两补厥阴阳明为治。有风寒湿人下焦经隧而为痹者，用辛温宣通经气为主。有肝胆风热而成痹者，用甘寒和阳，宣通脉络为主。有血虚络涩及营虚而成痹者，以养营养血为主。又有周痹行痹肢痹筋痹及风寒湿杂合之痹，亦不外乎流畅气血，祛邪养正，宣通肠络诸法。故张景岳云：“治痹之法，只宜峻补真阴，宣通脉络，使气血得以流行。不得过用风燥等药，以再伤其阴气，亦见道之合也。”
肛门灼热
肛门者，大肠之所主也，其证灼热者多因大肠湿热，故清热燥湿之法尤为多用，然久用寒凉克伐，中阳大衰，格阳于外者亦有之，其辨之法，莫如求于脉舌。曾治一男性患者，任×x，23岁。细菌性痢疾9个多月，医先予西药治之不减，继予中药芍药汤加减治之亦不减，口苦口干，大便一日3—4次，里急后重，不得已转来太原治疗。医云：热痢下重，宜白头翁物。服药4剂，非但里急后重、大便次数增多不见好转，反见肛门灼热难忍，不得已，又易医治疗。医云：大肠实热较严重，宜白头翁汤加马齿苋、金银花、苦参。服药20剂，肛门灼热更甚。邀余诊治。细审其证，除肛门灼热难忍外，尚见大便一日2～3次，里急后重，然其口干不喜饮，面色萎黄，舌质淡，舌苔白润，脉弦紧而涩。综其脉证云：此久用苦寒，脾胃阳衰，格阳之证也。宜温中散寒，以破阴寒之气也。拟附桂理中汤加减：附子4克，肉桂4克，党参4克，白术4克，干姜4克，茯苓4克。服药1剂，灼热减轻，继服3剂，灼热消失大半，食欲增加，里急后重消失，去茯苓，加甘草4克以补中，服药6剂诸症消失而愈。一实习学生问：诸医均云热而予寒凉之剂，而朱老却用大热之剂，其故何也?答曰：面色、舌色、脉象在辨证论治时尤当详审，《内经》告诫我们说：心主舌，面色为五脏之华，脉为决五脏死生之本，此病已达9月余，五脏已损，故当求脉、色、舌以辨证。证虽见热，而舌、脉、色均为寒，故知其为阴盛格阳之证，用附桂理中而取效。
便血与便秘
曾治一男性患者，孔××，48岁。便血、便秘反复发作4。5年。某院诊为肛裂、内痔。先用西药治疗不效，后用中药清热凉血润便，苦寒攻下，凉血止血等仍无效，特别是近3个月来，应用上法治疗不但不效，反见便秘更加严重，便血，疼痛难忍。邀治于余。审其证，除便血、便秘外，并见小腹隐隐作痛，纳呆乏味，口干喜饮，疲乏思睡，记忆力衰退，脉沉细无力，指趾厥冷，面色萎黄虚浮，舌质暗，舌苔黄白而润。证脉合参，诊为脾虚不运，摄血不能。为拟黄土汤：灶心土30克，阿胶9克(烊化)，黄芩9克，生地9克，白术9克，附子9克，甘草9克。3剂。刚欲停笔，患者视之，曰：便秘反用附子、白术之温燥，岂不更甚?答曰：指趾厥冷，面色萎黄，两脉沉，舌暗苔润，显系阳虚，脾非阳气不化不运，胃非阳气不纳不降，附、术温脾肾之阳而助化助运，正如《伤寒论》179条所云之“若其人大便鞕，小便自利，去桂加术汤”意。患者又云：“口渴、便血非热乎?”答曰：“口渴虽然热盛伤津者多，阳虚水湿不化者亦不少。此证便血已久，阴血已伤，但因脾虚失运是当前病机的关键，所以若施之于寒凉滋腻，必败伤阳气，阳气匮乏，必然摄血不能，故应先予黄土汤之养阴清热，凉血止血之药附于附子、白术之中，以使阳生阴长。”患者始半信半疑，曰：“似称有理，可以试服。”服药4剂后来诊，云：“何如此之神也!一剂便血止，二剂大便通，三剂食欲大增。”答曰：“学中医首在学理，学辨证论治方法，其意义就在此。”患者曰：“余久学中医，多从偏方、验方学，弯路甚多，吾当从头学起。”
乳衄
曾治患者贾××，女，29岁。怀孕8个多月，近两个多月来，乳头不断的有血水流出，用手挤时有时流出血块，隐隐作痛，某院诊为乳腺导管内乳头状瘤，舌苔薄白，脉滑而数。思之，乳房居于胸上，胸为肺之外廓，肝经之所络，痰热互结，络脉瘀滞，血不归经者，治宜瓜蒌之宽胸散结，化痰清热；白芍、青皮、橘叶、枳壳之疏肝理气，茜草之活血凉血止血，乃拟瓜蒌90克，白芍9克，青皮9克，橘叶9克，茜草15克，枳壳9克，黄芩1．5克。6剂后，衄血减，25剂衄血止而愈。
脉结代
既然风寒湿三气不与营气相合，就不形成痹证；若与营气相合，则形成痹证。那么痹证的形成，自然存在着营气运行涩滞和营血衰少等不同问题，所以医家治疗痹证，很多采用活血通络与养血补血的方法来加以区别对待。其中具有活血止痛作用的药物，如乳香、没药、桃仁、红花、赤芍、当归、川芎、鸡血藤、蜈蚣、全蝎、蜂房、地龙、虻虫。具有养血作用的药物，如当归、白芍、熟地黄、杜仲、续断、鹿茸、鹿角、鹿角胶。正如孙一奎在《赤水玄珠》中所说：“活血丹，治疗全身骨节疼痛，效果神奇。由熟地黄、当归、白术、白芍、续断、人参各一两组成。”“麒麟散，治疗寒湿传入经络，疼痛难以忍受。由血竭、乳香、没药、白芍、当归、水蛭、麝香、虎胫骨组成。”
七、化痰通络的问题
既然《灵枢·周痹》篇认为：“风寒湿气，客居在分肉之间，逼迫津液凝聚成沫，沫遇到寒冷则聚集，聚集后便排挤分肉使其分裂，分裂则产生疼痛，疼痛时神气归于患处，神气归去则产生热感，热感使疼痛缓解，疼痛缓解后出现气机逆乱，气机逆乱则其他部位发生痹证，发作时就是这样。”那么痹证当然常常存在一个痰的问题，但痰有挟风、挟寒、挟热的不同，所以治疗起来就有化痰祛风、温化寒痰、清化热痰的不同。正如方隅在《医林绳墨》中所说：“不疼不痒而麻木的，这属于气虚、湿痰、死血导致的疾病。又说手麻是气虚，手木（麻木）是湿痰或死血病，脚也是如此。又说遍体麻木，多因湿痰致病，不是死血……如果是湿痰，或者游走性结节，肿起有形，只是颜色发白而已，治疗宜清利湿浊、降泄痰浊，用二陈汤加苍术、枳实、黄连、厚朴之类的药物。”
八、五脏痹的问题
既然治疗疾病“如果不明白脏腑经络，开口动手就会出错。”那么根据伏若的说法，“淫气喘息，痹聚在肺”者，应当治在肺。“淫气忧思，痹聚在心”者，应当治在心。“淫气遗溺，痹聚在肾”者，应当治在肾。“淫气乏竭，痹聚在肝”者，应当治在肝；“淫气肌绝，痹聚在脾”者，应当治在脾。正如林佩琴在《类证治裁》中所说：“五脏痹，邪气由经入脏，邪胜正虚，使用五痹汤（人参、茯苓、当归、白芍、川芎、白术、五味子、细辛）。肾痹，在本方基础上加独活、肉桂、杜仲、牛膝、黄芪、萆薢。肝痹，本方加枣仁、柴胡。心痹，本方加远志、茯苓、麦冬、犀角（现代已禁用）。脾痹，本方加厚朴、枳实、砂仁、神曲。肺痹，本方加半夏、杏仁、麻黄、紫菀。”
九、筋骨脉肌皮痹的问题
既然痹证有筋骨脉肌皮痹的区别，那么痹证的治疗就应该根据筋骨脉肌皮痹的不同分别论治。正如朱肱在《普济方》中所说：“筋痹……其症状表现为拘急，屈伸不利……筋痹，四肢挛缩……天麻丸。”“筋痹不能屈伸……舒筋丸。”“筋痹多悲思，面色苍白，四肢不收摄，诸筋挛急，伸展时收缩急迫，肠中转痛……五加皮酒。”“筋挛缩，腰背不能伸展，强直且痛……牛膝汤。”“筋痹，肢体拘急，不得伸展……独活散。”“肝虚气痹，两胁胀满，筋脉拘急，不得喘息，四肢无力，且视力不明……细辛汤。”“筋痹，肢节束痛……羚羊角汤。”
“脉痹……则皮毛枯萎憔悴，肌肉痛痹……脉痹，血道壅塞涩滞……导痹汤。”“脉痹，面色脱失，脉象空虚，口唇赤色干燥，消痹蠲热，润泽容颜……升麻汤。”“脉痹，营卫不通，四肢灼痛……芍药汤。”“麻痹身体不仁……黄芪汤。”
“肌痹，其症状表现为皮肤不荣润，肌肉痛痹且不仁……肌肉痛痹，肢体怠惰缓纵，恶风头痛，舌根强直，言语謇涩……天麻丸。”“内热极盛，则体表感觉像老鼠爬行，或者像风痹，嘴唇口干，皮肤颜色改变……石南散。”“肌肤瘙痒如鼠走四肢，津液耗脱，腠理开泄，汗大泄，这是脾风……麻黄汤。”“肌痹，瘙痒如虫行，或者腠理开疏，汗出皮肤，肉色无光泽，唇鼻发黄……细辛汤。”
“皮痹……皮肤不荣润，而为不仁……皮肤痹，项强痛，四肢缓弱，目昏塞，心脑短气者……赤箭丸。”“皮痹如虫行，腹胀大便不利，语言不出……羌活汤。”“肺中寒湿，项强头昏，胸满短气，呼吸颤动，言语声嘶，四肢缓弱，皮肤顽痛……防风汤。”
“皮痹，肌肉不仁，心烦气促，项背硬强……天麻散。”“风寒湿气感于肺经，皮肤顽痹不仁……麻黄汤。”“皮痹不仁……蔓荆实丸。”“皮肤痛痹……天麻丸。”“皮肤间有麻木……补气汤。”
林佩琴在《类证治裁》中说：“骨痹，即寒痹痛痹也，痛苦彻骨，使用安肾丸。”“筋痹，即风痹也，风热攻注，筋弛脉缓，使用羚羊角散；若湿邪入筋，使用续断丹。”“脉痹，即热痹也，风湿郁热，经隧为壅，使用升麻汤去桂枝、麻黄，加萆薢、石膏，或者秦艽四物汤。”“肌痹，即湿痹着痹也，浑身上下左右麻木，属卫气不行，本方去蔓荆子、倍用黄芪，加防风；肌肉麻木，属营气不行，本方去蔓荆子，加桂枝、羌活、防风。”“皮痹，邪在皮毛，搔抓如隔帛，或者瘾疹风疮，宜疏风养血，使用秦艽地黄汤。”
十、叶天士治痹的问题
遍查各种书籍论述治疗痹证的，大多重视关节痛证，而进行全面论述的则比较少见，致使后学者遇见疑难问题时常常感到无方可施。只有叶氏医案论述得颇为深刻，这里记录邹滋九所说的内容在后面。他说：“此证与风病相似，但风邪侵犯阳分，痹邪侵犯阴分，所以多重着沉痛。其在《内经》中不外乎风寒湿三气，然而四时的时令，都能成为邪气，五脏之气，各自能受病。其实痹，就是闭而不通的意思。正气被邪气阻遏，脏腑经络，不能畅达，都是由气血亏损，腠理疏松，风寒湿三气，得以乘虚外袭，留滞于内，导致湿痰浊血，流注凝涩而得病。所以经文说三气杂至合而为痹，又说风胜为行痹，寒胜为痛痹，湿胜为着痹，以及骨痹、筋痹、脉痹、肌痹、皮痹的含义。”可知痹病的证候，并非偏受一气就足以导致它。然而病证多种多样，治法也不同，我也不能完全叙述。这里以先生治疗痹证的方法申明一二。
有卫阳疏漏，风邪入络而成痹者，以宣通经脉，甘寒清热为主。有经脉受伤，阳气不为护持而成痹者，以温养通补，扶持生气为主。有暑伤气湿热入络而成痹者，用舒通络脉的药剂，使清阳流行为主。有风湿肿痛而成痹者，用人参、白术益气，佐以风药壮气为主。有湿热伤气及温热入血络而成痹者，用固护卫阳以驱邪及宣通营络，兼治奇经为主。有肝阴虚，疟邪入络而成痹者，以咸苦滋阴，兼以通逐缓攻为主。有寒湿入络而成痹者，以微通其阳，兼以通补为主。有气滞热郁而成痹者，从气分宣通为主。有肝胃虚滞而成痹者，以两补厥阴阳明为治。有风寒湿入下焦经隧而成痹者，用辛温宣通经气为主。有肝胆风热而成痹者，用甘寒和阳，宣通脉络为主。有血虚络涩及营虚而成痹者，以养营养血为主。又有周痹、行痹、肢痹、筋痹及风寒湿杂合之痹，也不外乎流畅气血，祛邪养正，宣通肠络诸法。所以张景岳说：“治疗痹证的方法，只宜峻补真阴，宣通脉络，使气血得以流行。不得过用风燥等药，以再伤其阴气，这也是见道之合。”
肛门灼热
肛门，是大肠所主管的部位，其症状表现为灼热的，多因大肠湿热，所以清热燥湿的方法尤为多用，然而久用寒凉克伐，中阳大衰，格阳于外的情况也有，其辨别的方法，不如求之于脉象和舌苔。曾治疗一名男性患者，任某某，23岁。细菌性痢疾9个多月，医生先用西药治疗不减，继用中药芍药汤加减治疗也不减，口苦口干，大便一日3—4次，里急后重，不得已转来太原治疗。医生说：热痢下重，宜用白头翁汤。服药4剂，不仅里急后重、大便次数增多不见好转，反而出现肛门灼热难忍，不得已，又换医生治疗。医生说：大肠实热较严重，宜用白头翁汤加马齿苋、金银花、苦参。服药20剂，肛门灼热更甚。邀请我诊治。仔细审查其证候，除肛门灼热难忍外，尚见大便一日2～3次，里急后重，然而其口干但不喜饮水，面色萎黄，舌质淡，舌苔白润，脉弦紧而涩。综合其脉证说：这是久用苦寒，脾胃阳衰，格阳的证候。宜温中散寒，以破阴寒之气。拟定附桂理中汤加减：附子4克，肉桂4克，党参4克，白术4克，干姜4克，茯苓4克。服药1剂，灼热减轻，继服3剂，灼热消失大半，食欲增加，里急后重消失，去掉茯苓，加甘草4克以补中气，服药6剂诸症消失而痊愈。一名实习学生问：各位医生都说是热证而给予寒凉药剂，而朱老却用大热药剂，这是什么原因？回答说：面色、舌色、脉象在辨证论治时尤其应当详审，《内经》告诫我们说：心主舌，面色为五脏之华，脉为决五脏死生之本，此病已达9月余，五脏已损，故当求脉、色、舌以辨证。证候虽然见热，而舌、脉、色均为寒，故知其为阴盛格阳的证候，用附桂理中汤而取效。
便血与便秘
曾治疗一名男性患者，孔某某，48岁。便血、便秘反复发作4.5年。某医院诊断为肛裂、内痔。先用西药治疗无效，后用中药清热凉血润便，苦寒攻下，凉血止血等仍无效，特别是近3个月来，应用上法治疗不但无效，反而便秘更加严重，便血，疼痛难忍。邀请我诊治。审查其证候，除便血、便秘外，并见小腹隐隐作痛，纳呆乏味，口干喜饮，疲乏思睡，记忆力衰退，脉沉细无力，指趾厥冷，面色萎黄虚浮，舌质暗，舌苔黄白而润。证脉合参，诊断为脾虚不运，摄血不能。为此拟定黄土汤：灶心土30克，阿胶9克（烊化），黄芩9克，生地9克，白术9克，附子9克，甘草9克。3剂。刚要停笔，患者看了，说：便秘反用附子、白术的温燥，岂不是更严重？回答说：指趾厥冷，面色萎黄，两脉沉，舌暗苔润，显系阳虚，脾非阳气不化不运，胃非阳气不纳不降，附子、白术温脾肾之阳而助化助运，正如《伤寒论》第179条所说的“若其人大便硬，小便自利，去桂加术汤”之意。患者又说：“口渴、便血不是热吗？”回答说：“口渴虽然多是热盛伤津，阳虚水湿不化的也不少。此证便血已久，阴血已伤，但因脾虚失运是当前病机的关键，所以如果施用于寒凉滋腻，必败伤阳气，阳气匮乏，必然摄血不能，故应先予黄土汤中的养阴清热，凉血止血之药附于附子、白术之中，以使阳生阴长。”患者始半信半疑，说：“似乎有理，可以试服。”服药4剂后来诊，说：“为何如此神奇！一剂便血止，二剂大便通，三剂食欲大增。”回答说：“学中医首在学理，学辨证论治方法，其意义就在这里。”患者说：“我久学中医，多从偏方、验方学，弯路甚多，我当从头学起。”
乳衄
曾治疗患者贾某某，女，29岁。怀孕8个多月，近两个多月来，乳头不断的有血水流出，用手挤时有时流出血块，隐隐作痛，某医院诊断为乳腺导管内乳头状瘤，舌苔薄白，脉滑而数。思考之，乳房居于胸上，胸为肺之外廓，肝经之所络，痰热互结，络脉瘀滞，血不归经者，治疗宜用瓜蒌之宽胸散结，化痰清热；白芍、青皮、橘叶、枳壳之疏肝理气，茜草之活血凉血止血，于是拟定瓜蒌90克，白芍9克，青皮9克，橘叶9克，茜草15克，枳壳9克，黄芩1.5克。6剂后，衄血减少，25剂衄血停止而痊愈。
脉结代
Since the three pathogenic factors of wind, cold, and dampness do not combine with Ying-Qi (Nutritive Qi), Bi syndrome does not form; if they combine with Ying-Qi, Bi syndrome forms. Therefore, the formation of Bi syndrome naturally involves different issues such as sluggish circulation of Ying-Qi and deficiency of Ying-Blood. Consequently, many physicians treat Bi syndrome by employing methods to invigorate blood and unblock collaterals, as well as nourish blood, to differentiate treatment. Among these, herbs that invigorate blood and relieve pain include Ru Xiang (Frankincense), Mo Yao (Myrrh), Tao Ren (Peach Seed), Hong Hua (Safflower), Chi Shao (Red Peony Root), Dang Gui (Angelica Sinensis), Chuan Xiong (Ligusticum), Ji Xue Teng (Spatholobus Stem), Wu Gong (Centipede), Quan Xie (Scorpion), Feng Fang (Honeycomb), Di Long (Earthworm), and Meng Chong (Blue Bottle Fly Larva). Herbs that nourish blood include Dang Gui (Angelica Sinensis), Bai Shao (White Peony Root), Shu Di Huang (Prepared Rehmannia Root), Du Zhong (Eucommia Bark), Xu Duan (Dipsacus Root), Lu Rong (Deer Antler Velvet), Lu Jiao (Deer Antler), and Lu Jiao Jiao (Deer Antler Glue). As Sun Yikui stated in *Chishui Xuanzhu*: "Huoxue Dan (Blood-Invigorating Pill) is miraculous for treating pain throughout the body and joints. It consists of Shu Di Huang, Dang Gui, Bai Zhu, Bai Shao, Xu Duan, and Ren Shen, each one liang." "Qilin San (Kylin Powder) treats pain unbearable due to cold-dampness invading the collaterals. It consists of Xue Jie (Dragon's Blood), Ru Xiang, Mo Yao, Bai Shao, Dang Gui, Shui Zhi (Leech), She Xiang (Musk), and Hu Jing Gu (Tiger Tibia Bone)."
VII. Issues Regarding Phlegm-Dampness Unblocking Collaterals
Since the chapter "Zhou Bi" in *Ling Shu* states: "Wind-cold-dampness pathogens lodge between the fen-rou (muscle intervals), pressing fluids into foam. When foam encounters cold, it aggregates; aggregation pushes apart the fen-rou causing splitting. Splitting causes pain. When pain occurs, Shen (Spirit/Mind) returns to the site. When Shen returns, heat is generated. Heat relieves pain. After pain relief, Jue (reversal/collapse) occurs. Jue leads to the onset of Bi in other areas. This is how it happens." Thus, Bi syndrome often involves an issue of Tan (Phlegm). However, Tan may be accompanied by Wind, Cold, or Heat. Therefore, treatments differ: resolving phlegm and dispelling wind, warming and transforming cold-phlegm, or clearing and transforming heat-phlegm. As Fang Yu stated in *Yilin Shengmo*: "Numbness without pain or itching belongs to diseases caused by Qi deficiency, damp-phlegm, and dead blood. It is said that hand numbness is due to Qi deficiency; hand stiffness/numbness is due to damp-phlegm or dead blood, and the same applies to the feet. It is also said that generalized numbness is mostly due to damp-phlegm disease, not dead blood... If it is damp-phlegm, there may be migrating nodules, swelling with defined shape but white color. Treatment should clear dampness and descend phlegm, using Er Chen Tang added with Cang Zhu, Zhi Shi, Huang Lian, Hou Po, etc."
VIII. Issues Regarding Five-Zang Bi Syndrome
Since treating disease requires understanding the Zang-Fu organs and meridians, otherwise "opening the mouth and moving the hands will lead to errors," then according to Fu Ruo: "For Yin Qi panting, Bi gathers in the Lung," treatment should focus on the Lung. "For Yin Qi worry/thought, Bi gathers in the Heart," treatment should focus on the Heart. "For Yin Qi enuresis, Bi gathers in the Kidney," treatment should focus on the Kidney. "For Yin Qi exhaustion, Bi gathers in the Liver," treatment should focus on the Liver; "For Yin Qi muscle atrophy, Bi gathers in the Spleen," treatment should focus on the Spleen. As Lin Peiqin stated in *Leizheng Zaicai*: "Five-Zang Bi, where pathogens enter the Zang from the meridians, excess pathogen and deficient righteous Qi, use Wu Bi Tang (Ren Shen, Fu Ling, Dang Gui, Bai Shao, Chuan Xiong, Bai Zhu, Wu Wei Zi, Xi Xin). For Kidney Bi, add Du Huo, Rou Gui, Du Zhong, Niu Xi, Huang Qi, Bi Xie to this formula. For Liver Bi, add Suan Zao Ren, Chai Hu. For Heart Bi, add Yuan Zhi, Fu Ling, Mai Dong, Xi Jiao (banned in modern times). For Spleen Bi, add Hou Po, Zhi Shi, Sha Ren, Shen Qu. For Lung Bi, add Ban Xia, Xing Ren, Ma Huang, Zi Wan."
IX. Issues Regarding Tendon, Bone, Vessel, Muscle, and Skin Bi
Since Bi syndrome distinguishes between Tendon, Bone, Vessel, Muscle, and Skin Bi, treatment must address these distinctions separately. As Zhu Su (Zhu Gong) stated in *Puji Fang*: "Tendon Bi... its manifestation is stiffness, inability to flex and extend... Tendon Bi, limb spasms... Tian Ma Wan." "Tendon Bi unable to flex and extend... Shu Jin Wan." "Tendon Bi associated with sadness/thought, pale complexion, limbs unrestrained, tendon spasms, extension causes contraction/pain in intestines... Wu Jia Pi Jiu." "Tendon spasm, back stiff unable to extend, rigid and painful... Niu Xi Tang." "Tendon Bi, limb stiffness unable to extend... Du Huo San." "Liver deficiency Qi Bi, hypochondriac fullness, tendon/vessel stiffness, inability to breathe deeply, limb weakness, vision unclear... Xi Xin Tang." "Tendon Bi, joint binding pain... Ling Yang Jiao Tang."
"Vessel Bi... skin/hair withered, muscle pain/bi... Vessel Bi, blood pathways obstructed/sluggish... Dao Bi Tang." "Vessel Bi, sallow complexion, empty pulse, red dry lips, dissipate Bi and remove heat, nourish complexion... Sheng Ma Tang." "Vessel Bi, Ying-Wei obstruction, burning limb pain... Shao Yao Tang." "Numbness and insensitivity of body... Huang Qi Tang."
"Muscle Bi, its state is skin lacking nourishment, muscle pain/bi with insensitivity... Muscle pain/bi, limb lethargy/flaccidity, aversion to wind/headache, stiff tongue base, slurred speech... Tian Ma Wan." "Extreme internal heat, sensation like mice running on body or like wind-bi, dry lips/mouth, skin color change... Shi Nan San." "Skin itching like mice running on limbs, fluid depletion, pores open, profuse sweating, this is Pi Feng (Spleen Wind)... Ma Huang Tang." "Muscle Bi, itching like insects crawling, or open pores, sweating skin, flesh lusterless, yellow lips/nose... Xi Xin Tang."
"Skin Bi... skin lacks nourishment, leading to insensitivity... Skin Bi, stiff neck/pain, weak limbs, blurred vision, shortness of breath in heart/brain... Chi Jian Wan." "Skin Bi like insect crawling, abdominal distension, difficult defecation, inability to speak... Qiang Huo Tang." "Cold-dampness in Lung, stiff neck/dizziness, chest fullness/shortness of breath, trembling breathing, hoarse voice, weak limbs, stubborn skin pain... Fang Feng Tang."
"Skin Bi, muscle insensitivity, restlessness/shortness of breath, stiff neck/back... Tian Ma San." "Wind-cold-dampness affecting Lung meridian, stubborn skin bi-insensitivity... Ma Huang Tang." "Skin bi-insensitivity... Man Jing Shi Wan." "Skin pain/bi... Tian Ma Wan." "Numbness in skin... Bu Qi Tang."
Lin Peiqin in *Leizheng Zaizai* says: "Gu Bi (Bone Bi) is Han Bi (Cold Bi) Tong Bi (Pain Bi), severe bone pain, use An Shen Wan." "Jin Bi (Tendon Bi) is Feng Bi (Wind Bi), wind-heat attacking, flaccid tendons/slack vessels, use Ling Yang Jiao San; if dampness enters tendons, use Xu Duan Dan." "Mai Bi (Vessel Bi) is Re Bi (Heat Bi), wind-damp stagnating heat, meridians blocked, use Sheng Ma Tang removing Gui Zhi and Ma Huang, adding Bi Xie and Shi Gao, or Qin Jiao Si Wu Tang." "Ji Bi (Muscle Bi) is Shi Bi/Dropping Bi (Damp Bi), whole-body numbness, belonging to Wei-Qi non-circulation, remove Man Jing Zi from base formula, double Huang Qi, add Fang Feng; muscle numbness belongs to Ying-Qi non-circulation, remove Man Jing Zi, add Gui Zhi, Qiang Huo, Fang Feng." "Pi Bi (Skin Bi), pathogen in skin/hair, scratching feels like隔着 cloth, or urticaria/wind sores, should disperse wind and nourish blood, use Qin Jiao Di Huang Tang."
X. Ye Tianshi's Treatment of Bi
Reviewing various books discussing Bi treatment, most emphasize joint pain, while comprehensive discussions are rare, leaving later learners helpless when facing difficult cases. Only Ye Tianshi's medical records offer profound discussion. Here is what Zou Zijiu recorded: "This condition resembles Wind disease, but Wind affects Yang aspects, while Bi affects Yin aspects, hence often heavy and deep-seated pain. In *Nei Jing*, it does not exceed the three qi of wind, cold, and damp. However, seasonal commands can all become pathogens, and Qi of the five Zang can each suffer disease. Actually, Bi means closure and blockage. Righteous Qi is obstructed by pathogens, Zang-Fu and meridians cannot flow freely, all due to deficiency of Qi and Blood, loose cun-li (pores/skin texture), allowing wind-cold-damp to invade externally upon deficiency, lingering internally, causing damp-phlegm, turbid blood to flow and stagnate. Hence the classic says 'three qi mixed together form Bi,' and 'wind excess is Xing Bi (Wandering Bi), cold excess is Tong Bi (Pain Bi), damp excess is Zhuo Bi (Fixed Bi),' as well as the meanings of Gu Bi, Jin Bi, Mai Bi, Ji Bi, Pi Bi." Thus, Bi disease syndromes are not caused by a single pathogenic factor alone. However, syndromes vary, and methods differ; I cannot list them all. Here I clarify Mr. Ye's methods for treating Bi.
For those where Wei-Yang is deficient, wind-pathogen enters collaterals forming Bi, prioritize unblocking meridians and sweet-cold clearing heat. For those where meridians are injured, Yang Qi fails to protect, forming Bi, prioritize warm-nourishing unblocking-tonifying and supporting vital Qi. For those where summer-heat injures Qi and damp-heat enters collaterals forming Bi, use agents to soothe/unblock collaterals, prioritizing smooth flow of Clear Yang. For those with wind-damp swelling/pain forming Bi, use Ren Shen and Bai Zhu to tonify Qi, assisted by wind-dispersing herbs to strengthen Qi. For those where damp-heat injures Qi and warm-heat enters blood collaterals forming Bi, prioritize securing Wei-Yang to repel pathogens and unblocking Ying-collaterals, simultaneously treating the Extraordinary Vessels. For those with Liver Yin deficiency, malaria-pathogen enters collaterals forming Bi, prioritize salty-bitter nourishing Yin, combined with unblocking/draining mild attack. For those where cold-damp enters collaterals forming Bi, prioritize slightly unblocking Yang, combined with unblocking-tonifying. For those where Qi stagnation and heat depression form Bi, prioritize unblocking from the Qi level. For those with Liver-Stomach deficiency/stagnation forming Bi, treat by tonifying both Jueyin and Yangming. For those where wind-cold-damp enters Lower Jiao meridians forming Bi, use pungent-warm unblocking of Jing-Qi. For those with Liver-Gallbladder wind-heat forming Bi, use sweet-cold harmonizing Yang, unblocking collaterals. For those with Blood deficiency, collateral sluggishness, and Ying deficiency forming Bi, prioritize nourishing Ying and Blood. Furthermore, Zhou Bi, Xing Bi, Zhi Bi, Jin Bi, and mixed wind-cold-damp Bi do not exceed methods of smoothing Qi/Blood, expelling pathogens, nourishing righteousness, and unblocking intestinal collaterals. Thus Zhang Jingyue said: "The method for treating Bi is only suitable for severely tonifying True Yin and unblocking collaterals, allowing Qi and Blood to flow. One must not overuse pungent-dry herbs to further injure Yin Qi; this is also consistent with the Way."
Anal Burning Sensation
The anus is governed by the Large Intestine. A burning sensation here is mostly due to Damp-Heat in the Large Intestine, so clearing heat and drying dampness is commonly used. However, prolonged use of cold-cooling purgatives can severely damage Middle Yang, leading to False Yang floating outward (Ge Yang). Differentiation relies on pulse and tongue. I once treated a male patient, Ren XX, 23 years old. Bacterial dysentery for over 9 months. Doctors first used Western medicine without improvement, then Chinese medicine Shao Yao Tang modified without improvement. Symptoms: bitter taste, dry mouth, stool 3-4 times/day, tenesmus. Reluctantly transferred to Taiyuan. Doctor said: Hot dysentery with heaviness, use Bai Tou Weng Tang. Took 4 doses; tenesmus and frequency did not improve, instead anal burning became unbearable. Changed doctors. Doctor said: Severe Large Intestine Excess Heat, use Bai Tou Weng Tang plus Chi Xian Cao (Purslane), Jin Yin Hua (Honeysuckle), Ku Shen (Sophora Root). Took 20 doses; anal burning worsened. Invited me to treat. Careful examination: besides unbearable anal burning, stool 2-3 times/day, tenesmus, yet dry mouth but no desire to drink, sallow complexion, pale tongue body, white moist coating, string-tight and choppy pulse. Synthesizing pulse and symptoms: This is due to prolonged bitter-cold usage, Spleen-Stomach Yang decline, Ge Yang syndrome. Should warm middle and scatter cold to break Yin-Cold. Prescribed Fu Gui Li Zhong Tang modified: Fu Zi 4g, Rou Gui 4g, Dang Shen 4g, Bai Zhu 4g, Gan Jiang 4g, Fu Ling 4g. After 1 dose, burning reduced. After 3 more doses, burning largely disappeared, appetite increased, tenesmus vanished. Remove Fu Ling, add Gan Cao 4g to tonify middle. After 6 doses, all symptoms resolved. An intern asked: All doctors said it was heat and gave cold herbs, why did you use hot herbs? Answer: Complexion, tongue color, and pulse must be carefully examined during differentiation. *Nei Jing* warns: Heart governs tongue, complexion is the flower of five Zang, pulse is the root of life/death of five Zang. Disease lasted 9+ months, five Zang damaged, so seek pulse, color, tongue for differentiation. Although symptoms show heat, tongue, pulse, and color indicate cold, thus knowing it is Yin excess repelling Yang. Used Fu Gui Li Zhong Tang with success.
Hematochezia and Constipation
I once treated a male patient, Kong XX, 48 years old. Recurrent hematochezia and constipation for 4.5 years. Diagnosed with anal fissure and internal hemorrhoids at a hospital. Western medicine ineffective. Then Chinese medicine clearing heat/cooling blood/moistening bowels, bitter-cold purging, cooling blood/stopping bleeding ineffective. Especially in recent 3 months, previous methods failed, worsening constipation, hematochezia, unbearable pain. Invited me to treat. Examination: besides hematochezia/constipation, dull lower abdominal pain, poor appetite/lack of taste, dry mouth desiring drink, fatigue/sleepiness, memory decline, deep-thin-weak pulse, cold fingers/toes, sallow puffy complexion, dark tongue body, yellow-white moist coating. Pulse-symptom synthesis: Diagnosis is Spleen deficiency failing to transport, failing to control blood. Prescribed Huang Tu Tang: Zao Xin Tu (Furnace Hearth Earth) 30g, E Jiao (Donkey-hide Gelatin) 9g (melted), Huang Qin 9g, Sheng Di 9g, Bai Zhu 9g, Fu Zi 9g, Gan Cao 9g. 3 doses. Just as I finished writing, the patient looked and said: Constipation treated with warming-drying Fu Zi and Bai Zhu, won't it worsen? Answer: Cold fingers/toes, sallow complexion, deep pulse, dark tongue moist coating clearly indicates Yang deficiency. Spleen cannot transform/transport without Yang Qi; Stomach cannot receive/descend without Yang Qi. Fu Zi and Bai Zhu warm Kidney/Spleen Yang to assist transformation/transport, just as *Shang Han Lun* Article 179 implies "if person has hard stool, free urination, remove Gui Zhi add Bai Zhu." Patient said: "Dry mouth, hematochezia not heat?" Answer: "Dry mouth is mostly heat injuring fluids, but Yang deficiency failing to transform water-damp is also common. Hematochezia long-standing, Yin blood injured, but Spleen deficiency failing to transport is key current pathology. If using cold-cooling cloying herbs, surely damages Yang Qi. Lack of Yang Qi leads to failure to control blood. So first use Huang Tu Tang's nourishing Yin-clearing heat/cooling blood-stopping blood herbs attached within Fu Zi and Bai Zhu, to allow Yang generating Yin." Patient half-believed, said: "Seems reasonable, can try." After 4 doses returned: "How miraculous! 1st dose stopped bleeding, 2nd dose bowel movement, 3rd dose great appetite increase." Answer: "Learning TCM starts with theory and differentiation methods, meaning lies here." Patient said: "I studied TCM long, mostly from folk prescriptions, took many detours, I must start from scratch."
Breast Bleeding (Ru Nu)
I once treated patient Jia XX, female, 29 years old. Pregnant 8+ months. For 2+ months, nipple continuously leaking bloody fluid, sometimes blood clots when squeezed, dull pain. Hospital diagnosed intraductal papilloma. Tongue thin white coating, slippery-rapid pulse. Thinking: Breast located upper chest, chest exterior of Lung, connected by Liver meridian. Phlegm-heat knotting, collateral stasis, blood not returning to vessels. Treatment should use Gua Lou (Trichosanthes Fruit) to broaden chest/scatter knots, resolve phlegm-clear heat; Bai Shao, Qing Pi, Ju Ye, Zhi Ke to soothe Liver/regulate Qi; Qian Cao (Rubia Cordifolia) to invigorate blood/cool blood-stop bleeding. Prescribed: Gua Lou 90g, Bai Shao 9g, Qing Pi 9g, Ju Ye 9g, Qian Cao 15g, Zhi Ke 9g, Huang Qin 1.5g. After 6 doses, bleeding reduced. After 25 doses, bleeding stopped and cured.
Knotted and Intermitting Pulse (Mai Jie Dai)