金匮云。肠痈之为病。其身甲错。腹支急。按之濡如肿状。腹无积聚。身无热。此为肠内有
痈脓。薏苡附子败酱散主之。详肠痈始发。证未昭着。但以腹之支急。按之如肿。或身有块垒。
便为真候。若腹无积聚。身无热。洵为沉寒固结。虽下无济。故用薏苡附子败酱散。专以破散沉
寒为务也。周禹载云。附子辛散以破结。败酱苦寒以排脓。务令脓化。仍从水道而出。将血病解
而气亦开矣。
肠痈者。少腹肿痞。按之则痛如淋。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。
详上条用薏苡附子败酱散。是主寒沫初搏于肠。未郁为热。腹濡满而脉不洪数。身无热而甲
错如鳞。故当用辛热以散其结。即内经肾移寒于脾。则为痈脓是也。若痈已成。又非此方所宜。
观次条言脉迟紧。脓未成。可下之。当有血。则知脓未成时。其脉尚带迟紧。盒饭下而不可温矣。
下法。用桃核承气。可不言而喻。至于脉洪数者。脓已成。不可下也。大黄牡丹汤主之。夫既曰
不可下。而仍用大黄者。何也。盖痈脓既成于内。不下。毒从何泄。以意逆之。非谓概不可下也。
必得排脓破瘀之剂。始为合宜。但戒泛用下药耳。
病者脉数无热。微烦默默。但欲卧。汗出。初得之三四日。目赤如鸠眼。七八日。目四 黑。
若能食者。脓已成也。赤小豆当归散主之。
脉数而烦热。邪之征也。何反无热耶。脉法有云。无故脉数。必生痈疽。今痈发于内。故无
热。瘀蓄于内。故汗出。初得三四日。毒邪内盛。势必上蒸。故目赤如鸠眼。至七八日。脓成而
滞。未得下泄。故四 黑。毒势方张。故默默不欲食。毒邪将化。故渐能食。方用赤小豆令芽出。
以通营分之热毒。当归以散肠胃之积血。用散不用汤者。取有质之物。以迅扫在下之脓血也。金
匮此条。向在狐惑例中。并治肠痈便毒。及下部恶血诸疾。
千金云。卒得肠痈。而不晓其病候。愚医治之错则杀人。肠痈之为病。小腹重而强。抑之则
痛。小便数似淋。时时汗出。复恶寒。其身皮皆甲错。腹皮急如肿状。其脉数者。已有脓也。其
脉迟紧者。未有脓也。甚者腹胀大。转侧闻水声。或绕脐生疮。或脓从脐中出。或大便出脓血。
一羽军官妇病。医脉之。知肠中有脓。下之即愈。何以知之。曰。寸口脉滑而数。滑则为实。数
则为热。滑则为营。数则为卫。卫数下降。营滑上升。营卫相干。血为浊败。小腹痞坚。小便或
涩。或复汗出。或复恶寒。脓为已成。设脉迟紧。即为瘀血。血下即愈。
肠痈下血。腹中 痛。其始发热恶寒。欲验其证。必小腹满痛。小便淋涩。反侧不便。即为
肠痈之确候。无论已成未成。俱用大黄牡丹汤加犀角急服之。小腹痛。若肿满不食。小便不利。
脓壅滞也。用薏苡、丹皮、桃仁、蒌仁。煎服以排之。若至反侧作水声。此脓已成熟也。千金托
里散下太乙膏。若脓从大便出者。为直肠痈。可治。若从脐中出者。为盘肠痈。多不治。经云。
肠痈为病不可惊。惊则肠断而死。
《金匮要略》说：肠痈这种病，患者皮肤干燥粗糙如鳞甲（身甲错），腹部拘急紧绷，按压时感觉柔软像肿胀的样子，但腹部没有积块，身体没有发热，这是肠道内有痈脓。应当用薏苡附子败酱散主治。详细分析肠痈初发时，症状尚未明显显露，只要见到腹部拘急紧绷，按压时像有肿块，或者身上有硬块，就可以确定为真证候。如果腹部没有积块，身体没有发热，这确实是沉寒固结之证，虽然不能用攻下法治疗，所以使用薏苡附子败酱散，专门以破除消散沉寒为任务。周禹载说：附子辛温发散以破除结滞，败酱草苦寒以排脓，务必使脓液化解，仍从水道排出，这样血分病解除了，气机也能通畅。
肠痈的症状是：少腹部肿胀痞满，按压时疼痛如同淋病，小便正常，时常发热，自汗出，又伴有恶寒。脉象迟紧的，说明脓未形成，可以用攻下法，大便中可能会有瘀血；脉象洪数的，说明脓已形成，不可用攻下法，应当用大黄牡丹汤主治。
详细分析上一条文中使用薏苡附子败酱散，是因为主要病机是寒湿浊气初搏结于肠道，尚未郁结化为热邪，腹部柔软胀满而脉象不洪数，身体无发热且皮肤干燥如鳞甲，所以应当用辛热药物来散结，这正是《内经》所说的“肾移寒于脾，则为痈脓”的道理。如果痈脓已经形成，就不再适合此方。看下一条条文说脉象迟紧，脓未形成，可以攻下，会有瘀血排出，由此可知在脓未形成时，脉象尚带迟紧，应当攻下而不可温补。攻下的方法，使用桃核承气汤，是不言而喻的。至于脉象洪数，说明脓已形成，不可攻下，用大黄牡丹汤主治。既然说不可攻下，为什么还用大黄呢？大概因为痈脓既已在体内形成，如果不通过排泄途径，毒邪从哪里宣泄？推测其意，并非指一概不可攻下，而是必须得到排脓破瘀的药剂，才算是适宜，只是告诫不要泛用一般的泻下药罢了。
病人脉数但没有发热，轻微烦躁，沉默寡言，只想躺卧，出汗。刚得病三四天，眼睛红得像斑鸠的眼睛；到了七八天，眼四角发黑。如果能吃东西，说明脓已形成，用赤小豆当归散主治。
脉数且烦热，是邪气的征象，为什么反而没有发热呢？脉法中有云：无故脉数，必然生痈疽。现在痈发于体内，所以体表无热；瘀血蓄积于内，所以出汗。刚得病三四天，毒邪内盛，势必向上蒸腾，所以眼睛红得像斑鸠的眼睛。到了七八天，脓已成且停滞，未能向下排泄，所以眼四角发黑。毒势正盛，所以沉默不想进食；毒邪即将化散，所以渐渐能进食。方中使用赤小豆令其发芽，以疏通营分的熱毒；当归以消散肠胃中的积血。使用散剂而不是汤剂，是取有形之物，以迅速扫除在下部的脓血。《金匮要略》这一条，过去放在狐惑病条目中，同时治疗肠痈、便毒以及下部恶血等各种疾病。
《千金方》说：突然患上肠痈，如果不了解其病症表现，医生误治则会杀人。肠痈这种病，小腹沉重且僵硬，按压则疼痛，小便频数似淋病，时常出汗，又伴有恶寒，全身皮肤都干燥粗糙如鳞甲，腹皮紧绷像肿胀的样子。脉象数的，说明已有脓；脉象迟紧的，说明尚无脓。严重的腹胀大，转动身体时能听到水声，或者肚脐周围生疮，或者脓从脐中流出，或者大便排出脓血。
有一位羽林军军官的妻子患病，医生诊脉后，知道肠中有脓，用攻下法治疗后痊愈。怎么知道的？回答说：寸口脉滑而数，滑脉主实，数脉主热；滑脉主营血，数脉主卫气。卫气之数下降，营血之滑上升，营卫相互干扰，血液变得浑浊败坏，导致小腹痞硬，小便或涩滞，或者又出汗，或者又恶寒。这说明脓已生成。假如脉象迟紧，就是瘀血，瘀血下行即愈。
肠痈下血，腹中疼痛。起初发热恶寒，要验证其证候，必须见小腹满痛，小便淋涩，翻身不便，这就是肠痈的确切证候。无论脓成与否，都用大黄牡丹汤加犀角急服。小腹痛，如果肿胀满闷不能进食，小便不利，这是脓液壅滞。用薏苡仁、丹皮、桃仁、瓜蒌仁煎服以排出脓液。如果到翻身时听到水声，说明脓已成熟。用千金托里散配合太乙膏外敷。如果脓从大便排出，称为直肠痈，可治；如果从脐中流出，称为盘肠痈，大多不治。经书说：肠痈这种病不可受惊，受惊则肠断而死。
The *Jin Gui Yao Lue* states: Regarding the disease of Chang Yong (Intestinal Abscess), the patient presents with skin dry and rough like scales (Shen Jia Cuo), abdominal stiffness and tension, which feels soft upon palpation as if swollen, yet there are no accumulations in the abdomen, and the body has no fever. This indicates pus and abscess within the intestines. It should be treated with Yiyi Fuzi Baijiang San (Coix Seed, Aconite, and Patrinia Decoction).
Detailed analysis: When Chang Yong first begins, symptoms are not yet manifest. If one observes abdominal stiffness and tension, a sensation of swelling upon palpation, or lumps on the body, these can be taken as true signs. If there are no abdominal accumulations and no fever, this is indeed a condition of deep-cold solidification. Although purgative methods are ineffective here, Yiyi Fuzi Baijiang San is used specifically to break up and dissipate the deep cold. Zhou Yu Zai stated: Fuzi (Aconiti Lateralis Radix Praeparata) is pungent and dispersing to break up stagnation; Baijiang Cao (Patriniae Herba) is bitter and cold to drain pus. The goal is to ensure the pus dissolves and exits via the water passages. Once the blood pathology is resolved, the Qi mechanism will also open.
Chang Yong is characterized by swelling and fullness in the lower abdomen. Palpation causes pain resembling Lin syndrome (Dysuria), while urination remains normal. There is intermittent fever, spontaneous sweating, and aversion to cold. If the pulse is slow and tight (Chi Jin), the pus has not yet formed; purgatives may be used, and bloody stool may appear. If the pulse is surging and rapid (Hong Shu), the pus has already formed; purgatives are contraindicated. Da Huang Mu Dan Tang (Rhubarb and Moutan Decoction) should be administered.
Detailed analysis: The previous clause utilized Yiyi Fuzi Baijiang San because the primary pathogenesis was cold-damp turbid qi initially clashing in the intestines, without yet stagnating into heat. The abdomen was soft and full, the pulse was not surging and rapid, and the body had no fever, with skin dry like scales. Therefore, acrid-hot herbs were used to dissipate the knotting, consistent with the *Nei Jing* saying: "When kidney cold transfers to the spleen, it becomes an abscess and pus." If the abscess has already formed, this formula is no longer suitable. Observing the next clause stating that a slow and tight pulse means pus has not formed and purgatives can be used to expel blood, we know that when pus has not formed, the pulse carries a slow and tight quality, indicating purgation is required rather than warming. The method of purgation would naturally involve Tao He Cheng Qi Tang (Peach Kernel Decoction to Order the Qi). As for the surging and rapid pulse indicating formed pus, purgatives are contraindicated, and Da Huang Mu Dan Tang is used. Since it says purgatives are contraindicated, why use Da Huang (Rhei Radix et Rhizoma)? Presumably, because once the abscess and pus have formed internally, if not expelled through excretion, from where can the toxicity be vented? Inferring the intent, it does not mean purgatives are absolutely forbidden in all cases, but rather that agents capable of draining pus and breaking stasis are appropriate. The warning is against the indiscriminate use of general laxatives.
If the patient has a rapid pulse without fever, slight irritability, silence, desire to lie down, and sweating: within three to four days of onset, the eyes become red like those of a turtledove; by seven to eight days, the corners of the eyes turn black. If the patient can eat, it indicates the pus has formed. Chi Xiao Dou Dang Gui San (Adzuki Bean and Angelica Decoction) should be used.
A rapid pulse with irritability and heat is a sign of pathogenic factors; why is there no fever? Pulse methodology states: "Unexplained rapid pulse inevitably leads to carbuncles and sores." Here, the abscess arises internally, hence no external fever; blood stasis accumulates internally, hence sweating. Within three to four days, pathogenic toxins are abundant internally and must steam upward, causing the eyes to redden like a turtledove's. By seven to eight days, pus forms and stagnates, unable to discharge downward, causing the eye corners to darken. With toxin strength peaking, the patient is silent and lacks appetite; as toxins begin to transform, appetite gradually returns. The formula uses Chi Xiao Dou (Adzuki Bean) sprouted to clear heat-toxin from the Ying (Nutritive) level, and Dang Gui (Angelicae Sinensis Radix) to dissipate accumulated blood in the intestines and stomach. A powder form is used instead of a decoction to utilize substantial material for rapidly sweeping away pus and blood in the lower jiao. This clause from *Jin Gui* was previously categorized under Hu Huo (Foxes' Disease), treating simultaneously Chang Yong, Bian Du (Genital Sores), and various diseases of stagnant blood in the lower part.
The *Qian Jin Fang* states: Sudden onset of Chang Yong, if its clinical presentation is unknown, misdiagnosis by physicians can be fatal. Chang Yong presents with heaviness and rigidity in the lower abdomen, pain upon pressure, frequent urination resembling Lin syndrome, intermittent sweating, and aversion to cold. The whole body skin is dry and rough like scales, and the abdominal wall is tense as if swollen. A rapid pulse indicates pus has formed; a slow and tight pulse indicates pus has not formed. Severe cases present with abdominal distension and enlargement, audible fluid sounds when turning, ulcers around the umbilicus, pus discharging from the umbilicus, or pus and blood in the stool.
Regarding the wife of a military officer: The physician diagnosed intestinal pus via pulse taking and cured her with purgatives. How did he know? He said: The Cun Kou (Radial artery) pulse was slippery and rapid. Slippery indicates excess; rapid indicates heat. Slippery relates to Ying (Nutritive) blood; rapid relates to Wei (Defensive) Qi. The rapidity of Wei descends, the slipperiness of Ying ascends. Ying and Wei interfere with each other, causing blood to become turbid and degenerate, leading to lower abdominal hardness and fullness, urinary obstruction or difficulty, sweating, or aversion to cold. This indicates pus has formed. If the pulse were slow and tight, it would indicate blood stasis, which resolves upon expulsion.
Intestinal abscess with bloody stool and abdominal pain. Initially presenting with fever and aversion to cold, to verify the syndrome, one must look for lower abdominal fullness and pain, dysuric urine, and difficulty turning over. These are definitive signs of Chang Yong. Regardless of whether pus has formed, Da Huang Mu Dan Tang plus Xi Jiao (Rhinocerotis Cornu - *Note: Substitute with Water Buffalo Horn in modern practice*) should be administered urgently. Lower abdominal pain with swelling, fullness, anorexia, and dysuria indicates pus stagnation. Use Yiyi Ren (Coicis Semen), Mu Dan Pi (Moutan Cortex), Tao Ren (Persicae Semen), and Lou Ren (Trichosanthis Semen) decocted to drain the pus. If turning over produces fluid sounds, the pus is mature. Apply Qianjin Tuoli San (Thousand Gold Supporting Interior Powder) combined with Taiyi Gao (Supreme Emperor Plaster). If pus discharges from the stool, it is called Zhichang Yong (Rectal Abscess), which is treatable. If pus discharges from the umbilicus, it is called Panchang Yong (Coiled Intestine Abscess), which is mostly untreatable. The Classics state: Chang Yong must not startle the patient; startling causes the intestine to rupture and death.