此表里气血药也，治一切风毒积热疮肿，脉候弦洪实数浮紧、气血盛实者不可缺此。丹
溪曰∶《秘传》以此方加人参、黄 、苍术、赤茯苓、金银花，名消肿托里散，虽以参 为
主，复云人参无亦可，则又不能无疑而难用也。且临症加减，须较表里，如表证多者，当
从此方，以辛甘为主散之也；里证多者，须当从变。
《精要》云∶大黄宣热散毒，治痈疽要药。痈疽始作，皆须大黄等汤，亟转利之，排
日不废。又曰∶疮疽泄利，皆是恶候。
丹溪曰∶此皆不能使人无疑。借曰用大黄，恐因大府秘而病体实，有积热沉固者发也，
止可破结导滞，推令转动而已，岂可谓亟转利之，而且排日不废耶？若下利之后，又与利药，
恐非防微杜渐之意。疮之始作，肿在肌肉，若非大满大坚实之证，自当行仲景发表之法，借五
香汤为例，散之于外可也，何必遽用峻下之药夺其里哉？或曰痈疽用大黄，走泄以去毒，孙
真人常言之，良甫祖述其说耳。曰∶孙以盛名行奇术于公卿间者，良
甫宋人，若其交游，亦皆公卿，免猛浪之过乎？况有心劳而虚者，忧怒而虚者，强力劳动而
虚者，大醉饱而虚者，皆气少而涩，血少而浊。生疽固是难治，若大府秘而稍安，谷甘淡薄而守
戒律，犹为可治，不免尚费调补。苟因旬日半月大府秘实，不知亦有其气不降而然者，便以
为实，而行大黄，岂不杀人？
这是治疗表里气血疾病的药物，适用于一切风毒积热引起的疮肿，对于脉象呈现弦、洪、实、数、浮、紧，且气血充盛实证的患者，此药不可或缺。朱丹溪说：《秘传》将此方加入人参、黄芪、苍术、赤茯苓、金银花，命名为消肿托里散，虽然以人参为主药，却又说没有人参也可以，这就让人产生疑虑而难以使用。况且临证时加减用药，必须比较表证和里证的多少，如果表证较多，应当遵循此方，以辛甘味的药物为主来发散邪气；如果里证较多，就必须根据情况变化调整。
《精要》说：大黄能宣散热毒，是治疗痈疽的重要药物。痈疽刚开始发作时，都必须用大黄等汤剂，急切地通利大便，每天都不间断。又说：疮疽出现泄泻痢疾，都是不良的征兆。
朱丹溪说：这些说法都让人产生疑虑。假设使用大黄，恐怕是因为患者大便干结且病体实证，有深固的积热才引发的，只可用来破除结滞、导引积滞，推动其转动而已，怎么能说是急切地通利大便，而且每天都不间断呢？如果在已经下利之后，再用泻利药物，恐怕不符合预防细微病变、杜绝渐生祸患的本意。疮疡刚开始发作时，肿胀在肌肉层面，如果不是大满、大坚实的证候，自然应当采用张仲景发表的方法，借用五香汤为例，从外部发散即可，何必急于使用峻猛的泻下药来攻夺里气呢？有人说痈疽使用大黄，是为了走泄以去除毒素，孙思邈经常这样说，良甫（王好古）只是沿袭他的学说罢了。我说：孙思邈是以盛名在公卿贵族间施行奇特医术的人，良甫是宋朝人，如果他交往的朋友也都是公卿贵族，难道就能避免猛浪粗疏的错误吗？何况有心劳致虚的，忧怒致虚的，强力劳动致虚的，大醉饱食致虚的，这些都是气少而涩滞，血少而浑浊的情况。生发疽病本来就已经难治，如果大便干结但病情稍安，饮食甘淡薄味并遵守戒律，还是可治的，不免还需要耗费精力进行调补。如果因为十天半个月大便干结实证，不知道也有因气不下降而导致的情况，就认为是实证，而使用大黄，这岂不是会害死人？
This is a formula for treating disorders of the exterior and interior, qi and blood. It is indicated for all sores and swellings caused by wind-toxin and accumulated heat. For patients with pulse patterns that are wiry (Xian), flooding (Hong), excess (Shi), rapid (Shu), floating (Fu), or tight (Jin), and who present with an excess syndrome of abundant qi and blood, this medicine is indispensable. Zhu Danxi stated: In the *Secret Transmission* (*Mi Chuan*), this formula was modified by adding Ren Shen (Ginseng Root), Huang Qi (Astragalus Root), Cang Zhu (Atractylodis Rhizoma), Chi Fu Ling (Poria Cocos with Red Cortex), and Yin Hua (Lonicerae Flos), and named Xiao Zhong Tuo Li San (Swelling-Reducing and Interior-Supporting Powder). Although it takes Ren Shen as the principal ingredient, it also states that Ren Shen can be omitted, which raises doubts and makes its application difficult. Furthermore, when modifying the prescription according to clinical presentation, one must compare the extent of exterior versus interior syndromes. If exterior symptoms predominate, one should follow this formula, using acrid and sweet herbs as the main components to disperse the pathogen; if interior symptoms predominate, adjustments must be made accordingly.
The *Jing Yao* (Essentials) states: Da Huang (Rhei Radix et Rhizoma) disseminates heat and scatters toxins; it is a crucial herb for treating carbuncles and ulcers. When carbuncles and ulcers first appear, decoctions containing Da Huang should be used urgently to promote bowel movement, without interruption day after day. It further states: Diarrhea or dysentery occurring in the course of sores and ulcers are ominous signs.
Zhu Danxi commented: These statements raise considerable doubt. Assuming Da Huang is used, it is likely because the patient suffers from constipation and an excess condition, with deep-seated accumulated heat triggering the disease. In such cases, it may only be appropriate to break up stagnation and guide it out, promoting motility. How can it be said that urgent purgation is required, continued daily without cessation? If laxatives are administered after diarrhea has already occurred, this would likely contradict the principle of preventing minor issues from escalating. When a sore first appears, the swelling is located in the muscle layer. Unless there is a syndrome of severe fullness and hardness, one should naturally adopt Zhang Zhongjing’s method of releasing the exterior. Taking Wu Xiang Tang (Five-Aromatic Decoction) as an example, dispersing the pathogen from the exterior is sufficient; why resort hastily to harsh purgatives to attack the interior? Some argue that Da Huang is used for carbuncles and ulcers to drain and eliminate toxins, a view frequently expressed by Sun Simiao, and Liangfu (Wang Haogu) merely followed this theory. I respond: Sun Simiao practiced his unique arts among high officials due to his great reputation. Liangfu was a Song dynasty scholar; if his associates were also high officials, could he have avoided the error of being rash and reckless? Moreover, consider those who are deficient due to mental overwork, deficiency due to worry and anger, deficiency due to strenuous labor, and deficiency due to excessive drinking and eating. These individuals suffer from scanty qi that is stagnant and scanty blood that is turbid. Developing a carbuncle is already difficult to treat. If the bowels are constipated but the condition is relatively stable, and the patient adheres to a bland diet and moral precepts, treatment is still feasible, though it will require effort in regulation and tonification. However, if one assumes that constipation persisting for ten days or half a month indicates an excess syndrome, failing to recognize that it might result from descending qi failure, and consequently administering Da Huang, would this not be fatal?