夫疽之发于背也。在脊之正中者为真发背。在脊之两旁者为搭手。其名虽多。惟辨其阴阳为诀耳。原
委症治。已载首卷。而疡科独重于背疽者。盖以背为足太阳膀胱经。乃六经之首领。乃督脉经之所主。
乃十二经之统脉也。所以发于背者多阴。今则复加详焉。
初起肿赤痛甚。脉洪数而有力。热毒之症也。易治。漫肿微痛。色黯作渴。脉洪数而无力。阴虚之症也。难
治。不肿不痛。或漫肿色黯。脉微细。此阳气虚甚也。尤为难治。
初起。未发出而寒热痛疼。作渴饮冷。此邪气内蕴也。宜卫生散。口干饮热。漫肿微痛。此元气内虚也。宜
托里消毒散。饮食少思。肢体倦怠。此脾胃虚也。宜六君子汤。如未应。加以姜桂。其有死者。乃邪气盛。真
气虚。而不能发出也。在于旬余之间见之。
已发出。用托里消毒散而不腐溃。急宜温补脾胃。如不应有死者。乃真气虚不能腐溃也。在二旬之间
见之。
已溃。用托里药。脱腐生肌。如色不红活。疮口黑晕。大而不敛。用参、附、姜、桂。如不应有死者。乃脾气虚极
而不能收敛也。在月余间见之。实则泻。虚则痒。此阴症阳症之分也。惟宜大补阳气。庶可挽回。不发者
不治。溃而不敛者亦不治。不肿痛。不寒热。脉沉微。乃脉病而形不病也。忌之。色黯漫肿。作渴便数。尺脉
洪数者。肾水涸也。当殁于火旺之际。疽发于 髀。经络交错。皮薄骨高之处。难医。
初发头痛寒热拘急者。表症也。用绀珠丹葱汤化服汗之。如 痛。以金银花散或槐花散清之。
肿 作痛。寒热作渴。饮食如常者。此形气病气。俱有余也。先用神授卫生散清之。次用托里消毒散解
之。如肿 硬痛。脉实者。贵金丸下之。肿硬闷痛。发热烦躁。饮冷便闭。脉沉实者。用内疏黄连汤、贵金丸
导之。欲作脓者。用托里散、矾蜡丸。外兼敷之。
背疽因开迟。迨二日重若负石。热如KT 火。痛楚倍常。脉沉数而有力者。此膏粱积热之变也。时虽严寒。
急用清凉饮子。加黄连两许作一服。利二三行。痛减。翌日再一服。痛止。次则随症调理。数日而愈。此经
为有假者。反之虽违其时。必从其症也。
漫肿。微红微痛。食少。此形气病气。俱不足也。用托里散调补之。不作脓。或脓成不溃。为阳气虚也。用
托里散。倍加肉桂、参、 。脓出而反痛。或脓清稀者。此气血俱虚也。用八珍汤。恶寒形寒。或不收敛
者。阳气虚也。十全大补汤。晡热内热。或不收敛者。阴血虚也。参术四物汤。欲呃作呕。或不收敛者。
胃气虚也。六君子汤加炮姜、芎、归。食少体倦。或不收敛者。脾气虚也。补中益气汤加茯苓、半夏。肉
赤而不收敛者。血热也。四物汤加栀子、连翘。肉白而不收敛者。脾虚也。四君子汤加木香、酒炒芍药。
小便频数者。肾阴虚损也。加减八味丸。遍身作痛者。荣卫虚也。十全大补汤。
痈疡呕逆。寒伤于胃也。温补之。使荣卫充而气血周贯。则毒随脓出。呕自止矣。且易生肌。
痈痛甚。咳逆。十余日水谷不下。脉伏如绝者。用四君子汤加姜、桂。三进而瘥。
肿而不溃。脉大而浮。此阳气虚也。宜托里散倍加参、 。内热作渴。脉洪大而鼓指。此虚火也。前方更加
肉桂。脉症顿退。仍用托里药而瘥。
中央肉死。此毒瓦斯盛而脾气虚也。用玄珠膏涂之。大便不通。此胃气虚而肠不能传送也。小便赤浊。此
脾土虚而火下陷也。虽曰难治。惟大补之。朝用补中益气汤。夕用加减地黄丸料。
疮口出鲜血。由脾虚不能摄血也。宜十全大补汤加陈皮、半夏、炮姜。
疮口不敛。用托里药罔效者。药力未及也。须用人参五七钱。外加附子服之。精神顿爽。手足自温。不旬
日而口合。疮口不敛。脾虚也。咳嗽不止。肺虚也。法当补之。书云。补可去弱。人参、羊肉。令每日食之不
彻。旬余而疮敛嗽止。疮口不敛。 肿发热。口干体倦。小便赤涩。脉洪数而无力。用十全大补汤加麦
冬、五味子。补元气引火归原。而脉症更甚。此药力未能及也。再剂顿退。却去肉桂。数剂而瘥。
背疽不起。泄泻作呕。食少肢厥。脉息如无。此阳气虚寒也。宜大补药加桂、附。而不应者。再加附子二剂
而泻愈甚。即用大附子一枚。姜、桂各三钱。参、 归、术各五钱。作一剂服之。腹内始热。诸症悉退。
背疽服十宣散之类。更加喘渴内热。脉大而无力。用补中益气汤。加酒芩、麦冬、五味子而愈。背疽。服
五香、十宣等不应。更加呕逆不睡。且其素有淋症。予以参 归术膏用牛膝煎汤。入竹沥饮之。则淋止
而思食。药尽四斤。脓自涌出。
发于背部的疽证，位于脊柱正中的称为真发背，位于脊柱两旁称为搭手。虽然名称繁多，但辨证的要点只在于区分阴阳。其病因、病机及治疗原则，已在本书首卷记载。然而外科特别重视背疽，是因为背部是足太阳膀胱经所过之处，为六经之首领，也是督脉经所主，更是十二经脉的统脉。所以发于背部的多为阴证。现在对此再作详细论述。
初起时肿胀发红、疼痛剧烈，脉象洪数而有力，这是热毒之症，容易治疗。若漫肿微痛，肤色黯黑且口渴，脉象洪数但无力，这是阴虚之症，难以治疗。若不肿不痛，或漫肿色黯，脉象微细，这是阳气极度虚弱，尤为难治。
初起阶段，疮毒尚未发出，出现寒热、疼痛、口渴喜冷饮，这是邪气内蕴所致，宜用卫生散。若口干但喜饮热水，漫肿微痛，这是元气内虚所致，宜用托里消毒散。若饮食减少、思食不佳，肢体倦怠，这是脾胃虚弱所致，宜用六君子汤。如果服用后无效，可加入干姜、肉桂。那些死亡的病例，是由于邪气盛而真气虚，导致毒邪不能发出，这种情况通常在发病十余天内出现。
疮毒已经发出，使用托里消毒散后却不化脓溃破，急需温补脾胃。如果仍无效且有死亡风险，这是因为真气虚弱不能腐溃成脓，这种情况通常在发病二十天内出现。
疮毒已经溃破，使用托里药促使脱腐生肌。如果疮面色泽不红活，疮口有黑色晕圈，疮口大而不收敛，应使用人参、附子、干姜、肉桂。如果仍无效且有死亡风险，这是因为脾气极度虚弱而不能收敛，这种情况通常在发病一个多月后出现。实则泻，虚则痒，这是阴证与阳证的区别所在。此时只宜大补阳气，或许可以挽回生机。不发者不治，溃破后不收敛者亦不治。若不肿痛、不寒热，脉象沉微，这是脉象有病而形体看似无病，应当忌讳（慎用攻伐）。若肤色黯黑、漫肿、口渴、小便频数，尺脉洪数，这是肾水枯竭，应当在火旺之时死亡。发于髀部的疽，因经络交错、皮薄骨高之处，难以医治。
初发时头痛、恶寒发热、身体拘急，这是表证，用绀珠丹葱汤送服以发汗。如果疼痛，用金银花散或槐花散清热。
若肿胀作痛，伴有寒热、口渴，但饮食如常，这是形气与病气都有余的表现。先用神授卫生散清解，次用托里消毒散调理。如果肿胀坚硬疼痛，脉象实，用贵金丸攻下。如果肿胀坚硬、闷痛，发热烦躁，喜冷饮，大便闭塞，脉象沉实，用内疏黄连汤、贵金丸导滞通便。欲作脓时，用托里散、矾蜡丸，并外敷药物。
背疽因为切开太迟，等到两天后，背部沉重得像背着石头，热得像烈火，痛苦加倍，脉象沉数而有力，这是膏粱厚味积热导致的变证。虽然时值严寒，也应急用清凉饮子，加黄连一两左右一次服用，使大便通利二三行，疼痛减轻。第二天再服一次，疼痛停止。随后随症调理，数日痊愈。这是经文中提到的“有假”情况，反之，即使违背时令，也必须顺从病症治疗。
漫肿，微红微痛，食少，这是形气与病气都不足的表现。用托里散调补。如果不作脓，或脓成但不溃破，是阳气虚，用托里散，倍加肉桂、人参、黄芪。脓出后反而疼痛，或脓液清稀，这是气血俱虚，用八珍汤。恶寒、形体寒冷，或不收敛，是阳气虚，用十全大补汤。午后潮热、内热，或不收敛，是阴血虚，用参术四物汤。欲呃逆作呕，或不收敛，是胃气虚，用六君子汤加炮姜、川芎、当归。食少体倦，或不收敛，是脾气虚，用补中益气汤加茯苓、半夏。疮肉赤红而不收敛，是血热，用四物汤加栀子、连翘。疮肉苍白而不收敛，是脾虚，用四君子汤加木香、酒炒芍药。小便频数，是肾阴虚损，用加减八味丸。遍身疼痛，是营卫虚，用十全大补汤。
痈疡呕吐，是寒气伤胃，应温补，使营卫充盈、气血周流贯通，则毒随脓出，呕吐自止，且易生肌。
痈痛剧烈，咳嗽气逆，十余日水谷不进，脉伏绝似无，用四君子汤加生姜、肉桂，服三次而愈。
肿胀而不溃破，脉大而浮，这是阳气虚，宜用托里散倍加人参、黄芪。内热口渴，脉洪大且搏指有力，这是虚火，前方更加肉桂，脉症顿时消退，仍用托里药而愈。
中央肌肉坏死，这是毒瓦斯盛而脾气虚，用玄珠膏涂抹。大便不通，这是胃气虚而肠道不能传送；小便赤浊，这是脾土虚而火下陷。虽然曰难治，只宜大补。早晨用补中益气汤，晚上用加减地黄丸料。
疮口流出鲜血，是由于脾虚不能摄血，宜用十全大补汤加陈皮、半夏、炮姜。
疮口不收敛，使用托里药无效，是药力未达，须用人参五至七钱，外加附子服用，精神顿时清爽，手足自然温暖，不到十天疮口愈合。
疮口不收敛，是脾虚；咳嗽不止，是肺虚，法当补益。书云：补可去弱。人参、羊肉，令每日食用且不中断，十余天后疮口收敛、咳嗽停止。
疮口不收敛，局部肿胀发热，口干体倦，小便赤涩，脉洪数而无力，用十全大补汤加麦冬、五味子，补元气引火归原，但脉症反而加重，这是药力未能及时到达。再服一剂后症状顿退，去掉肉桂，数剂后痊愈。
背疽不起发，泄泻作呕，食少四肢厥冷，脉息如无，这是阳气虚寒，宜用大补药加桂、附。如果无效，再加附子二剂，腹泻反而更甚。即改用大附子一枚，生姜、肉桂各三钱，人参、黄芪、当归、白术各五钱，作一剂服用。腹内始觉温热，诸症悉退。
背疽服用十宣散之类，反而出现喘渴、内热，脉大而无力，用补中益气汤，加酒黄芩、麦冬、五味子而愈。背疽服用五香、十宣等药无效，反而出现呕吐、失眠，且患者素有淋证，给予人参、黄芪、当归、白术膏，用牛膝煎汤，调入竹沥饮用，则淋证停止且思食。药尽四斤，脓自然涌出。
Abscesses occurring on the back: those located in the midline of the spine are called "True Back Carbuncle" (Zhen Fa Bei), while those on both sides of the spine are called "Reaching Hands" (Da Shou). Although there are many names, the key to differentiation lies solely in distinguishing between Yin and Yang syndromes. The etiology, pathogenesis, and treatment principles have been recorded in the first volume. However, the Department of Surgery places particular emphasis on back carbuncles because the back is the pathway of the Foot-Taiyang Bladder Meridian (Zu Taiyang Pang Guang Jing), which is the leader of the Six Meridians, also governed by the Du Meridian (Du Mai), and serves as the统脉 (master channel) of the Twelve Meridians. Therefore, abscesses occurring on the back are mostly Yin syndromes. Detailed discussion follows.
In the early stage, if there is swelling, redness, severe pain, and a flooding, rapid, and forceful pulse, this is a Heat-Toxin syndrome, which is easy to treat. If there is diffuse swelling, slight pain, dark complexion, thirst, and a flooding, rapid but weak pulse, this is a Yin Deficiency syndrome, which is difficult to treat. If there is no swelling or pain, or only diffuse swelling with dark color, and a faint, thin pulse, this indicates extreme deficiency of Yang Qi, which is particularly difficult to treat.
In the initial phase, before the lesion erupts, if there are chills, fever, pain, and thirst for cold drinks, this is due to internal accumulation of Pathogenic Factors; Wei Sheng San (Health Preservation Powder) should be used. If there is dry mouth but preference for hot drinks, diffuse swelling, and slight pain, this is due to internal deficiency of Yuan Qi (Primal Qi); Tuo Li Xiao Du San (Support Interior and Eliminate Toxin Powder) should be used. If appetite is poor, thinking of food is lacking, and limbs feel fatigued, this is Spleen-Stomach deficiency; Liu Jun Zi Tang (Six Gentlemen Decoction) should be used. If there is no response, add Gan Jiang (Dried Ginger) and Rou Gui (Cinnamon Bark). Cases resulting in death occur when Pathogenic Factors are excessive and True Qi is deficient, preventing the toxin from being expelled; this is typically seen within ten days of onset.
Once the lesion has erupted, if Tuo Li Xiao Du San fails to promote suppuration and ulceration, urgent warming and tonification of the Spleen and Stomach are required. If there is still no response and risk of death persists, it is because True Qi is too deficient to腐溃 (putrefy and ulcerate); this is typically seen within twenty days of onset.
After ulceration, use interior-supporting medicines to promote the discharge of necrotic tissue and generation of muscle. If the tissue color is not vibrant red, the wound edge has a black halo, and the wound is large without closing, use Ren Shen (Ginseng), Fu Zi (Aconite), Gan Jiang (Dried Ginger), and Rou Gui (Cinnamon Bark). If there is no response and risk of death persists, it is because Spleen Qi is extremely deficient and cannot converge; this is typically seen after more than a month. Excess leads to purging, deficiency leads to itching; this distinguishes Yin and Yang syndromes. At this stage, only vigorous tonification of Yang Qi can potentially reverse the condition. Lesions that do not erupt are untreatable; lesions that ulcerate but do not close are also untreatable. Absence of swelling/pain and chills/fever with a deep, faint pulse indicates disease in the pulse but not in the form; aggressive treatment should be avoided. Dark complexion, diffuse swelling, thirst, frequent urination, and a flooding, rapid Chi pulse indicate exhaustion of Kidney Water; death is expected during periods of strong Fire. Carbuncles developing on the thigh (Bi) are difficult to treat due to intersecting meridians and areas where skin is thin and bone is prominent.
Initial headache, chills, fever, and stiffness indicate a Exterior Syndrome; Zhan Zhu Dan Cong Tang (Indigo Pearl Pill with Scallion Decoction) should be taken to induce sweating. If painful, use Jin Yin Hua San (Honeysuckle Powder) or Huai Hua San (Sophora Flower Powder) to clear heat.
If swollen and painful with chills, fever, thirst, but normal diet, this indicates excess in both Form-Qi and Disease-Qi. First use Shen Shou Wei Sheng San (Divine Grant Health Preservation Powder) to clear, then Tuo Li Xiao Du San to resolve. If swollen, hard, and painful with a solid pulse, Gui Jin Wan (Noble Gold Pill) should be used to purge. If swollen, hard, stiflingly painful, with fever, irritability, preference for cold drinks, constipation, and a deep, solid pulse, use Nei Shu Huang Lian Tang (Internal Purging Coptis Decoction) and Gui Jin Wan to guide out stagnation. When pus is about to form, use Tuo Li San (Support Interior Powder) and Fan La Wan (Alum Wax Pill), applied externally as well.
Back carbuncles treated late may, after two days, feel heavy as if carrying a stone, hot as fire, with doubled pain, and a deep, rapid, forceful pulse. This is a transformation caused by accumulated heat from rich foods. Even in severe cold, Qing Liang Yin Zi (Cooling Drink) with an extra ounce of Huang Lian (Coptis) should be taken at once to induce two or three bowel movements, reducing pain. A second dose the next day stops the pain. Subsequent symptom-based regulation leads to recovery in a few days. This is a case of "false presentation" mentioned in classics; contrary to seasonal norms, treatment must follow the symptoms.
Diffuse swelling, slight redness, slight pain, and poor appetite indicate insufficiency in both Form-Qi and Disease-Qi. Use Tuo Li San to regulate and tonify. Failure to form pus or failure of formed pus to ulcerate indicates Yang Qi deficiency; use Tuo Li San with increased Rou Gui (Cinnamon Bark), Ren Shen (Ginseng), and Huang Qi (Astragalus). Increased pain after pus discharge or thin pus indicates dual deficiency of Qi and Blood; use Ba Zhen Tang (Eight Treasures Decoction). Aversion to cold, cold body, or lack of closure indicates Yang Qi deficiency; use Shi Quan Da Bu Tang (Comprehensive Great Tonifying Decoction). Afternoon tidal fever, internal heat, or lack of closure indicates Yin Blood deficiency; use Shen Zhu Si Wu Tang (Ginseng-Atractylodes Four Substances Decoction). Hiccups, vomiting, or lack of closure indicates Stomach Qi deficiency; use Liu Jun Zi Tang (Six Gentlemen Decoction) with Pao Jiang (Prepared Ginger), Chuan Xiong (Sichuan Lovage), and Dang Gui (Angelica Sinensis). Poor appetite, fatigue, or lack of closure indicates Spleen Qi deficiency; use Bu Zhong Yi Qi Tang (Tonify Middle and Augment Qi Decoction) with Fu Ling (Poria) and Ban Xia (Pinellia). Red granulation tissue without closure indicates Blood Heat; use Si Wu Tang (Four Substances Decoction) with Zhi Zi (Gardenia) and Lian Qiao (Forsythia). Pale granulation tissue without closure indicates Spleen deficiency; use Si Jun Zi Tang (Four Gentlemen Decoction) with Mu Xiang (Aucklandia) and Jiu Chao Shao Yao (Wine-fried Peony Root). Frequent urination indicates Kidney Yin damage; use Jia Jian Ba Wei Wan (Modified Eight Flavor Pill). Generalized body pain indicates deficiency of Ying and Wei (Nutritive and Defensive Qi); use Shi Quan Da Bu Tang (Comprehensive Great Tonifying Decoction).
Vomiting in carbuncles results from Cold injuring the Stomach; warm and tonify to replenish Ying and Wei and circulate Qi and Blood, allowing toxins to exit with pus, stopping vomiting and promoting healing.
Severe carbuncle pain with coughing and regurgitation, inability to eat or drink for over ten days, and a submerged, nearly absent pulse: use Si Jun Zi Tang (Four Gentlemen Decoction) with Sheng Jiang (Fresh Ginger) and Rou Gui (Cinnamon Bark); three doses lead to recovery.
Swelling without ulceration and a large, floating pulse indicate Yang Qi deficiency; use Tuo Li San with increased Ren Shen (Ginseng) and Huang Qi (Astragalus). Internal heat, thirst, and a flooding, rapid, and pounding pulse indicate Deficient Fire; add Rou Gui (Cinnamon Bark) to the previous formula. Pulse and symptoms will suddenly recede; continue with interior-supporting medicine for recovery.
Central tissue necrosis indicates abundant Toxins and deficient Spleen Qi; apply Xuan Zhu Gao (Black Pearl Ointment). Constipation indicates deficient Stomach Qi and inability of intestines to transport; reddish turbid urine indicates deficient Spleen Earth and sinking of Fire. Though difficult to treat, vigorous tonification is required: Bu Zhong Yi Qi Tang (Tonify Middle and Augment Qi Decoction) in the morning, and Jia Di Huang Wan (Modified Rehmannia Pill) in the evening.
Bright red blood from the wound indicates Spleen deficiency failing to control blood; use Shi Quan Da Bu Tang (Comprehensive Great Tonifying Decoction) with Chen Pi (Tangerine Peel), Ban Xia (Pinellia), and Pao Jiang (Prepared Ginger).
Failure of the wound to close despite interior-supporting medicines indicates insufficient medicinal power; use 5-7 qian of Ren Shen (Ginseng) plus Fu Zi (Aconite). Spirit will instantly refresh, hands and feet will warm, and the wound will close within ten days.
Failure to close indicates Spleen deficiency; persistent coughing indicates Lung deficiency; the method is to tonify. As stated: "Tonification removes weakness." Consume Ren Shen (Ginseng) and Lamb meat daily without interruption; the wound will close and cough stop within ten days.
Failure to close, local swelling, fever, dry mouth, fatigue, reddish-burning urination, and a flooding, rapid, weak pulse: use Shi Quan Da Bu Tang (Comprehensive Great Tonifying Decoction) with Mai Dong (Ophiopogon) and Wu Wei Zi (Schisandra) to tonify Yuan Qi and guide Fire back to its source. If pulse and symptoms worsen initially, it is because the medicinal power has not yet reached the target. After another dose, symptoms will subside; remove Rou Gui (Cinnamon Bark) and continue for several doses to recover.
Back carbuncle failing to erupt, diarrhea, vomiting, poor appetite, cold limbs, and absent pulse indicate Yang Qi deficiency and Cold; use major tonifying medicines with Gui (Cinnamon) and Fu Zi (Aconite). If ineffective, adding Fu Zi for two doses worsens diarrhea. Immediately switch to one large Fu Zi (Aconite), 3 qian each of Sheng Jiang (Fresh Ginger) and Rou Gui (Cinnamon Bark), and 5 qian each of Ren Shen (Ginseng), Huang Qi (Astragalus), Dang Gui (Angelica), and Bai Zhu (Atractylodes) as one dose. Abdominal warmth returns, and all symptoms recede.
Back carbuncle treated with Shi Xuan San (Ten Auspicious Powders) leading to wheezing, thirst, internal heat, and a large, weak pulse: use Bu Zhong Yi Qi Tang (Tonify Middle and Augment Qi Decoction) with Jiu Huang Qin (Wine-processed Coptis), Mai Dong (Ophiopogon), and Wu Wei Zi (Schisandra) for recovery. Back carbuncle treated with Wu Xiang (Five Fragrances) or Shi Xuan San without effect, leading to vomiting, insomnia, and pre-existing Lin Syndrome (Strangury): give a paste of Ren Shen (Ginseng), Huang Qi (Astragalus), Dang Gui (Angelica), and Bai Zhu (Atractylodes) decocted with Niu Xi (Achyranthes) and mixed with Zhu Li (Bamboo Sap) for drinking. Strangury stops, appetite returns. After consuming four jin of medicine, pus naturally drains.