仲景治伤寒，有汗吐下三法。东垣治疮疡，有疏通、托里、和营卫之三法。用之得宜，
厥疾瘳矣。假如疮疡肿硬木闷，烦热便秘，脉沉而实，其邪在内，当先疏其内以下之。 肿
作痛，便利调合，脉浮而洪，其邪在表，当先托其里以汗之。仲景曰∶疮家虽身体疼痛，不
可发汗，汗之则发痉。苟不详审，而妄为汗下，以致血气亏损，毒反延陷，少壮者难以溃敛
，老弱者多致不救。（见《外科枢要》。）
罗谦甫云∶丁巳岁冬月，予从军曹州，有牛经历者，病头目赤肿，身前后尤甚，疼痛不
可忍，发热恶寒，牙关紧急，涕唾稠粘，饮食难下，不得安卧。一疡医，于肿上砭刺四五百
针，肿亦不减，其痛益甚，莫知所由。予往诊视，其脉浮紧，按之洪缓。此证乃寒覆皮毛，
郁遏经络，热不得散，聚而为肿。经云∶天寒则地冻水冰，人气在身中，皮肤致密，腠理闭
，汗不出，气血强，肉坚涩。当是之时，善行水者不能往冰，善穿地者不能凿冻，善用针者
亦不能取四厥。必待天温冻解，而后水可行，地可穿，人脉亦犹是也。又云∶冬月闭藏，用
药多而少针石也。宜以苦温之剂，温经散寒，其病自已。所谓寒致腠理，以苦发之，以辛散
之也，遂用托里温中汤，根据方饵之。以薄衣覆其首，以浓被覆其身，卧于暖处，使经血温，
腠理开，寒气散，阳气升。大汗出后，肿减八九。再服则去麻黄、防风，加连翘、鼠粘子，
肿痛悉愈。经言∶汗之则疮已。信哉斯言。或云∶仲景言，疮家虽身痛不可发汗，其理何也
。余曰∶此说乃营气不从，逆于肉理，而生疮肿作身疼痛，非外感寒邪之病，故戒之，以不可
发汗，汗之则成痉也。又问∶仲景言鼻衄者不可发汗，复言脉浮紧者当以麻黄汤发之，衄血
自止，所说不同，其故何也。予曰∶此正与疮家概同，夫人身血之与汗，异名而同类，夺汗
者无血，夺血者无汗，今衄血妄行，为热所逼，更发其汗，是反助热邪，重竭津液，必变凶
证，故不可汗。若脉浮则在表，脉紧则在寒，寒邪郁遏，阳不得伸，热伏营中，迫血妄行，
上出于鼻，故当用麻黄汤散其寒邪，使阳气得舒，其血自止，又何疑焉。或者叹曰∶知其要
者，一言而终，不知其要，流散无穷。洁古之学，可谓知其要者矣。
东垣云∶疮疡有因风热外郁，其人多怒，其色赤，其肿高，结硬而痛，其脉洪紧而弦，
是邪客于血脉之上，皮肤之间，故发其汗而通其营卫，则邪气去矣。又曰∶疮疡诸病，凡面
赤者，虽伏大热，禁不得攻里，攻里则下利，此以阳邪怫郁在经，宜发表以去之，故曰火郁
则发之。虽大便数日不见，宜多攻其表，以发散阳气，少加润燥之药以润之。如见风脉风证，
只宜用风药发表，风邪解则大便自通也。若只干燥闭涩，止宜润之，切不可下也。但疮疡郁
冒，俗乎昏迷是也，宜汗之则愈。
初虞氏云∶凡痈疽始作，须以大黄等药亟转利之，勿以困苦为念。与其溃烂而死，不若
利之而死，况有生道哉。古人立法，率用五香连翘漏芦等药，贫乏者单煮大黄汤以利之，至
于脓溃乃服黄 等药以排脓，《千金》、《外台》备矣。世以疮发于外，不行转利而死者多
矣。立斋曰∶按前证，若肿高 痛，脏腑闭结，属内外俱实者，当用前药泻之。若漫肿微痛
，脏腑不实，属内外俱虚者，当用内托补之。若患肿无头，肉色不变，当助胃壮气，令其内
消。若疼痛不止， 肿不消，当用人参黄 汤以托里排脓。若饮食少思，肌肉不生，当用
参托里散，以补养脾胃。
立斋曰∶王德之患发背，脉浮数按之则涩，大便五六日不行，腹不加胀。余曰∶邪在表
不在里，但因气血虚，饮食少，故大便不行，非热结也，宜生气血为主。彼不信，以为积毒
在内，仍用大黄，遂连泻不止，更加发热呃逆，饮食不进而死。其子曰∶泻亦能为害乎。余
曰∶服利药而利不止者死。不当泻而强泻，令人洞泻不禁者死。下多亡阴者死。曰∶疮疡
乃积毒在脏，若不驱逐，何以得解。余曰∶疮疡虽积毒在脏腑，治法先当助胃气，使根本坚固
，参以行经活血时宜之药，非宜妄用大黄也。今其病在表，而反以峻利之剂，重夺其阴，其
可乎哉。故曰表病里和而反下之，则中气虚表邪乘虚而入，由是变证百出。虽云脉浮数者邪
在表，当用托里复煎散，然其间黄芩、苍术亦不敢妄用。脉沉实者邪在里，当用内疏黄连汤
，然其中大黄槟榔亦不敢妄用。况浮数涩主气血皆虚，且邪既在表，而反用峻剂重伤其里，
诛伐无过，不死何俟。
愚谓疮肿之属表邪者，惟时毒、丹毒、斑疹，及头面、颈项、上焦之证多有之。察其果
有外邪而脉见紧数，证有寒热者，方宜表散。然散之之法，又必辨其阴阳盛衰，故或宜温散
，或宜凉散，或宜平散，或宜兼补而散，或宜解毒而散，此散中自有权宜也。又如里证用下
之法，则毒盛势剧者大下之，滞毒稍轻者微下之，营虚便结而毒不解者养血滋阴而下之，中
气不足而便结壅滞者润导而出之。凡此皆通下之法，但宜酌缓急轻重而用得其当耳。故必察
其毒果有余及元气壮实，下之必无害者，方可用下，否则不但目前，且尤畏将来难治之患。
是以表证不真者不可汗，汗之则亡阳。里证不实者不可下，下之则亡阴。亡阴亦死，亡阳亦
死，医固可以孟浪乎。
张仲景治疗伤寒，采用汗、吐、下三种治法。李东垣治疗疮疡，采用疏通、托里、调和营卫三种治法。使用得当，疾病即可痊愈。假如疮疡肿胀坚硬、麻木闷痛，伴有烦热、便秘，脉象沉而实，说明邪气在体内，应当先疏通内部以攻下之。如果肿胀处作痛，二便通畅调和，脉象浮而洪大，说明邪气在体表，应当先托补内部以发汗解表。张仲景说：患有疮疡的人即使身体疼痛，也不可使用发汗法，若强行发汗则会引发痉病（肌肉痉挛）。如果不详细审察病情，而胡乱使用汗法或下法，导致气血亏损，毒邪反而内陷蔓延，年轻力壮者难以溃破收敛，年老体弱者多会导致死亡。（见《外科枢要》。）
罗谦甫说：丁巳年冬天，我随军驻扎在曹州，有一位牛经历（官职名），患病后头目红肿，身体前后尤为严重，疼痛难忍，发热恶寒，牙关紧闭，鼻涕唾液稠粘，饮食难以下咽，无法安卧。一位外科医生，在肿胀处砭刺了四五百针，肿胀也没有减轻，疼痛更加剧烈，不知原因所在。我去诊治，发现其脉象浮紧，重按则洪缓。这个病症是由于寒邪覆盖皮毛，郁遏经络，热气不得散发，聚集而成肿胀。《内经》说：天气寒冷时地面冻结水冰，人体在内，皮肤致密，腠理闭合，不出汗，气血强盛，肌肉坚实涩滞。在这个时候，善于治水的人不能使冰流动，善于挖掘的人不能凿开冻土，善于用针的人也取不到四肢厥逆的病邪。必须等到天气温暖冰冻消融，然后水才能流动，地才能挖掘，人体的经脉也是如此。又说：冬季是闭藏的季节，用药宜多而针刺宜少。适宜使用苦温的药剂，温经散寒，病自然痊愈。所谓寒邪导致腠理闭塞，用苦味药发散它，用辛味药疏散它。于是使用托里温中汤，按照方剂服用。用薄衣覆盖头部，用厚被覆盖身体，睡在温暖的地方，使经脉血液温暖，腠理开放，寒气消散，阳气升发。大汗出后，肿胀消退八九成。再次服药时去掉麻黄、防风，加入连翘、鼠粘子（牛蒡子），肿痛全部痊愈。经文说：发汗则疮疡自愈。这话确实可信。有人说：张仲景说，疮家即使身痛也不可发汗，其中的道理是什么？我说：这种说法是指营气运行不畅，逆乱于肌肉纹理之间，而生疮肿并引起身体疼痛，这不是外感寒邪的疾病，所以告诫不可发汗，发汗则会变成痉病。又问：张仲景说鼻出血的人不可发汗，又说脉浮紧的人应当用麻黄汤发汗，鼻血自止，说法不同，这是什么缘故？我说：这与疮家的情况大体相同。人的血与汗，名称不同但同类，夺汗者无血，夺血者无汗。现在鼻血妄行，是被热邪逼迫所致，如果再发汗，这是反而助长热邪，严重耗竭津液，必然变为凶险证候，所以不可发汗。如果脉浮说明邪气在表，脉紧说明有寒，寒邪郁遏，阳气不得伸展，热伏在营分中，逼迫血液妄行，向上从鼻子流出，所以应当用麻黄汤疏散寒邪，使阳气得以舒展，血液自然停止，又有什么可疑的呢？有人感叹道：懂得要领的人，一句话就能终结问题；不懂得要领的人，议论流散无穷。洁古（张元素）的学问，可以说是懂得要领的人了。
李东垣说：疮疡有因风热外郁引起的，患者多易怒，疮色红赤，肿胀高突，结硬且痛，脉象洪紧而弦，这是邪气客居在血脉之上、皮肤之间，所以发汗以通调营卫，邪气就去除了。他又说：疮疡各种疾病，凡是面红的，虽然潜伏着大热，禁止攻下里实，攻下则会导致腹泻，这是因为阳邪怫郁在经络，适宜发表以去除它，所以说“火郁则发之”。即使大便几天不通，也宜多攻其表，以发散阳气，少加润燥的药物来滋润它。如见到风脉风证，只宜用风药发表，风邪解除则大便自然通畅。如果只是干燥闭涩，只宜润燥，切不可攻下。至于疮疡郁冒，也就是俗称的昏迷，适宜发汗则痊愈。
初虞氏说：凡是痈疽刚开始发作，必须用大黄等药物迅速通便泻下，不要顾虑病人的痛苦。与其溃烂而死，不如通便泻下而死，何况还有生路呢？古人制定法则，通常使用五香、连翘、漏芦等药物，贫穷的人单煮大黄汤来通便泻下，直到脓液溃破后才服用黄芪等药物来排脓，《千金方》、《外台秘要》记载得很完备。世人认为疮疡发于外部，不实行通便泻下而死亡的很多。薛立斋说：根据前面的证候，如果肿胀高突、疼痛，脏腑闭结，属于内外俱实的，应当用前面的药物泻下。如果漫肿微痛，脏腑不虚，属于内外俱虚的，应当用内托补益的方法。如果患肿没有脓头，肉色不变，应当助胃壮气，使其内部消散。如果疼痛不止，肿胀不消，应当用人参黄芪汤来托里排脓。如果饮食减少思虑，肌肉不生，应当用参托里散，来补养脾胃。
薛立斋说：王德之患发背疽，脉象浮数，重按则涩，大便五六天不通，腹部不胀满。我说：邪气在表不在里，只是因为气血虚弱，饮食少，所以大便不通，不是热结，应当以补生气血为主。他不相信，认为积毒在内部，仍然使用大黄，于是连续腹泻不止，更加发热呃逆，饮食不进而死。他的儿子说：泻下也能造成危害吗？我说：服用泻药而腹泻不止的会死。不当泻而强行泻下，导致人洞泄不禁的会死。泻下过多亡失阴液的会死。他说：疮疡是积毒在脏腑，若不驱逐，怎么能解除？我说：疮疡虽然是积毒在脏腑，治疗方法首先应当助胃气，使根本坚固，配合行经活血的适时药物，而不是妄用大黄。现在病在表，却反用峻猛的泻利剂，严重耗夺其阴液，这可以吗？所以说表病里和而反用下法，则中气虚弱，表邪乘虚而入，由此变证百出。虽然说脉浮数是邪气在表，应当用托里复煎散，但其中黄芩、苍术也不敢妄用。脉沉实是邪气在里，应当用内疏黄连汤，但其中大黄、槟榔也不敢妄用。况且浮数涩主气血皆虚，而且邪气既在表，却反用峻猛药剂重伤其里，诛伐无罪之处，不死还等什么？
我认为疮肿属于表邪的，只有时毒、丹毒、斑疹，以及头面、颈项、上焦的证候多有这种情况。观察其确实有外邪且脉象紧数，证候有寒热的，才适宜表散。然而散的方法，又必须辨别阴阳盛衰，所以有的适宜温散，有的适宜凉散，有的适宜平散，有的适宜兼补而散，有的适宜解毒而散，这散之中自有权衡变通。又如里证用下的方法，则毒盛势剧的用大下法，滞毒稍轻的用微下法，营虚便结而毒不解的用养血滋阴而下法，中气不足而便结壅滞的用润导而出法。凡此都是通下的方法，只是适宜斟酌缓急轻重而用得恰当罢了。所以必须观察其毒确实有余且元气壮实，下之必无害的，才可以运用下法，否则不但目前，而且更担心将来难以治疗的祸患。因此表证不真实的不可发汗，发汗则亡阳。里证不实的不可攻下，攻下则亡阴。亡阴也会死，亡阳也会死，医生怎么可以鲁莽呢？
Zhang Zhongjing treated cold damage (Shanghan) using three methods: sweating (Han), vomiting (Tu), and purging (Xia). Li Dongyuan treated sores and ulcers (Chuangyang) using three methods: unblocking and draining, supporting the interior (Tuo Li), and harmonizing Ying and Wei (nutritive and defensive qi). When applied appropriately, chronic diseases can be cured. For instance, if a sore or ulcer is swollen, hard, numb, and stifling, accompanied by vexation, heat, constipation, and a deep, forceful pulse, indicating pathogenic factors inside, one should first unblock the interior and purge it. If the swelling becomes painful, bowel movements and urination are smooth and regulated, and the pulse is floating and surging, indicating pathogenic factors on the exterior, one should first support the interior and induce sweating to release the exterior. Zhang Zhongjing stated: "Patients with sores, even if they have body pain, should not undergo sweating therapy; inducing sweat will lead to spasms." If the condition is not carefully examined and sweating or purging are used recklessly, causing depletion of Qi and Blood, the toxin may instead sink inward and spread. Young and strong individuals may fail to suppurate and heal, while old and weak individuals often die from it. (See *Waike Shuyao*.)
Luo Qianfu said: In the winter of the Ding Si year, I followed the army to Caozhou. An official named Niu Jingli suffered from redness and swelling of the head and eyes, worse on the front and back of the body, unbearable pain, fever, aversion to cold, lockjaw, thick and sticky nasal discharge and saliva, difficulty swallowing food, and inability to lie down comfortably. A surgeon pricked the swelling with four or five hundred needles using a stone needle (Bianshi), but the swelling did not decrease, and the pain intensified, leaving everyone puzzled about the cause. I went to examine him and found his pulse floating and tight, becoming surging and slow upon heavy pressure. This condition was caused by cold covering the skin and hair, obstructing the meridians, preventing heat from dissipating, and accumulating to form swelling. The *Classic of Acupuncture and Moxibustion* (*Ling Shu*) states: "When heaven is cold, the earth freezes and water turns to ice. Inside the human body, the skin is dense, pores are closed, no sweat is produced, Qi and Blood are strong, and flesh is firm and stiff. At this time, those skilled in managing water cannot make ice flow, those skilled in digging cannot break frozen ground, and those skilled in acupuncture cannot treat cold limbs (Si Jue). One must wait for warm weather and thawed ice before water can flow and ground can be dug; similarly, human meridians require warmth." It also states: "In winter, when storage prevails, medication is used more frequently than acupuncture or moxibustion." It is appropriate to use bitter-warm formulas to warm the meridians and disperse cold, after which the disease will resolve naturally. As stated, when cold causes pore closure, bitter flavors disperse it, and pungent flavors scatter it. Thus, I prescribed *Tuoli Wenzhong Tang* (Support Interior and Warm Middle Decoction) according to the formula. The patient covered his head with thin cloth and his body with thick blankets, lying in a warm place to warm the meridian blood, open the pores, disperse cold, and raise Yang Qi. After profuse sweating, the swelling reduced by eight or nine tenths. In the next dose, Ephedrae Herba (Mahuang) and Saposhnikoviae Radix (Fangfeng) were removed, and Forsythiae Fructus (Lianqiao) and Arctii Fructus (Niubangzi) were added, resulting in complete resolution of swelling and pain. The classics say: "Sweating cures sores." This statement is indeed true. Some ask: Zhang Zhongjing said that patients with sores should not undergo sweating therapy even if they have body pain. What is the rationale? I reply: This refers to cases where Nutritive Qi does not flow smoothly, reverses into the muscle tissue, causing sores and body pain. This is not an external cold pathogen invasion, hence the warning against sweating, as it would lead to spasms. Another question: Zhang Zhongjing said those with epistaxis (nosebleed) should not sweat, yet he also said those with a floating and tight pulse should use Mahuang Tang to induce sweating, after which the nosebleed stops. These statements seem contradictory. Why? I reply: This is similar to the case of sores. Blood and sweat share the same origin but have different names. Depletion of sweat leaves no blood; depletion of blood leaves no sweat. Now, spontaneous epistaxis is forced by heat. Inducing sweat further aids the heat pathogen and severely depletes fluids, leading to critical conditions; thus, sweating is contraindicated. However, a floating pulse indicates exterior pathology, and a tight pulse indicates cold. Cold obstruction prevents Yang Qi from extending, while heat hides in the Nutritive level, forcing blood to move recklessly upward through the nose. Therefore, Mahuang Tang should be used to disperse cold, allowing Yang Qi to expand and bleeding to stop spontaneously. Someone sighed and said: "Those who grasp the essence need only one word to conclude; those who do not wander endlessly. Jiegu's (Zhang Yuansu's) learning can be said to grasp the essence."
Li Dongyuan said: Sores caused by external constraint of wind-heat present with irritability, red color, high swelling, hardness, pain, and a surging, tight, and wiry pulse. This indicates pathogens lodging above the blood vessels and between the skin. Sweating to unblock and regulate Ying and Wei will expel the pathogens. He also stated: For various sores, if the face is red, despite latent intense heat, purging the interior is forbidden, as it leads to diarrhea. This is because Yang pathogens are constrained in the meridians, and releasing the exterior is appropriate. Hence, "Fire constrained should be dispersed." Even if there is constipation for several days, one should focus on releasing the exterior to disperse Yang Qi, adding only a small amount of moistening drugs. If wind-pulse or wind-symptoms are present, only wind-dispersing drugs should be used; once wind pathogens are resolved, bowel movements will naturally clear. If it is merely dryness and constipation, only moistening is appropriate; purging must be avoided. Regarding "Yu Mao" (depression and dizziness/coma) in sores, sweating leads to recovery.
Chu Yushi said: When carbuncles and malignant sores first appear, purgatives like Rhubarb (Dahuang) should be urgently administered to promote bowel movements, disregarding the patient's distress. It is better to die from purging than from suppuration and decay, and there remains a chance of survival. Ancient laws typically used formulas containing Benzoin (Wuxiang), Forsythiae Fructus (Lianqiao), and Euphorbiae Radix (Loulu). Poor patients boiled Rhubarb decoction alone to promote purgation. Only after pus formed were tonics like Astragali Radix (Huangqi) used to drain pus. *Qianjin Fang* and *Waitai Miyao* record these methods extensively. Many people die from neglecting purgation for external sores. Xue Lizhai stated: Regarding the aforementioned symptoms, if swelling is high and painful with internal blockage, indicating excess in both interior and exterior, purgatives should be used. If swelling is diffuse with slight pain and internal organs are deficient, indicating deficiency in both interior and exterior, interior-supporting tonification should be used. If swelling has no head and skin color is unchanged, strengthen Stomach Qi to allow internal resolution. If pain persists and swelling does not subside, use Renshen Huangqi Tang (Ginseng and Astragalus Decoction) to support the interior and drain pus. If appetite is poor and muscles do not regenerate, use Cantuo Li San to nourish Spleen and Stomach.
Xue Lizhai recounted: Wang Dezhi suffered from a dorsal carbuncle. His pulse was floating and rapid, becoming choppy upon pressure. Bowel movements had not occurred for five or six days, but the abdomen was not distended. I said: The pathogen is in the exterior, not the interior. The constipation is due to Qi and Blood deficiency and poor diet, not heat accumulation. Treatment should primarily generate Qi and Blood. He did not believe this, assuming toxic accumulation internally, and continued using Rhubarb. This led to continuous diarrhea, increased fever, hiccups, loss of appetite, and death. His son asked: Can purging cause harm? I replied: Death occurs if diarrhea continues after purgative administration. Death occurs if purging is forced when inappropriate, causing uncontrollable洞泄 (profuse watery diarrhea). Death occurs from Yin depletion due to excessive purging. He asked: Sores are toxic accumulation in the Zang-Fu; how can they resolve without expulsion? I replied: Although sores involve toxic accumulation, treatment must first strengthen Stomach Qi to solidify the root, combined with appropriate herbs to move meridians and invigorate blood. Rhubarb should not be used recklessly. The disease is currently in the exterior; using harsh purgatives to severely deplete Yin is unjustifiable. Thus, if the exterior is diseased but the interior is harmonious, purging weakens Middle Qi, allowing exterior pathogens to invade. Consequently, myriad complications arise. Although a floating and rapid pulse suggests exterior pathogens warranting *Tuoli Fujian San* (Support Interior and Re-boil Powder), one should not recklessly use Scutellariae Radix (Huangqin) or Atractylodis Rhizoma (Cangzhu) within it. A deep and forceful pulse suggests interior pathogens warranting *Nishu Huanglian Tang* (Interior-Draining Coptis Decoction), but Rhubarb and Arecae Semen (Binglang) therein should not be used recklessly. Moreover, floating, rapid, and choppy pulses indicate Qi and Blood deficiency. Using harsh agents to injure the interior when pathogens are in the exterior is punishing the innocent; death is inevitable.
I consider that sores attributable to exterior pathogens include seasonal toxins (Shidu), erysipelas (Dandu), macules and papules (Ban Zhen), and conditions affecting the head, face, neck, and Upper Jiao. Only when external pathogens are confirmed with a tight and rapid pulse, accompanied by chills and fever, should dispersing methods be employed. However, dispersing methods must distinguish Yin-Yang excess and deficiency: some require warm dispersal, some cool dispersal, some neutral dispersal, some combined with tonification, and some combined with detoxification. There is discretion within dispersal. Similarly, for interior conditions requiring purgation, severe toxicity and vigorous patterns require strong purgation; mild stagnation requires gentle purgation; Nutritive deficiency with constipation and unresolved toxin requires nourishing Blood and Yin to facilitate purgation; Middle Qi deficiency with constipation and stagnation requires moistening and guiding. All these are methods of unblocking purgation, applied according to urgency and severity. One must observe whether toxicity is truly excessive and Yuan Qi (Original Qi) is robust enough to withstand purgation without harm. Otherwise, not only current risks exist, but future difficult-to-treat complications are feared. Therefore, if exterior signs are false, sweating leads to Yang collapse. If interior signs are false, purging leads to Yin collapse. Both Yin and Yang collapse result in death. How can physicians be reckless?