例三伍XX，女，74岁。初诊日期；1977年5月23日。头目昏眩，颈项强痛，四肢无力，鼻痂干结，大便干燥，尿多而黄，脉沉细，尺部弱，舌有裂纹，苔微白。血压250／160毫米汞柱。辨为肾阴不足，肝阳上亢。方药：玄参、麦冬、牛膝、茯苓各12克代赭石24克生龙骨、生牡蛎各15克钩藤、菊花、远志、蝉蜕各6克二诊；服上方3剂，头晕见减，大便仍干，小便略少，血压降至230／110毫米汞柱。又有心悸胸闷，脉弦细。前方去代赭石、蝉蜕、玄参、麦冬、茯苓，加菖蒲、白蒺藜、女贞子、茺蔚子各9克，丹参、首乌各12克，磁石15克。三诊：投药3剂，血压降至190／100毫米汞柱，头晕便干胸闷心悸略减，但下肢关节肿痛，脉细数有歇止，舌剥。前方除茺蔚子、牛膝、龙骨、女贞，加羌活、独活、鸡血藤各9克，随访一月，血压趋于稳定，身体轻松有力。(陆文彬整理，沈仲圭老中医临床治验选析，《中医杂志》4；13，1980)
例四杨X，女，44岁。血压高亢，胸闷泛恶，头晕痛殊甚，脉弦滑，苔薄腻，厥阴为风脏，相火寄焉。风火相煽，上窜于巅，故致晕痛。兼之胃失和降，则胸闷泛恶，症情非轻(血压达230／135毫米汞柱)，须防突变，急予平旰潜阳，和胃降逆，势见缓和乃吉。玳瑁片6克(先煎)姜半夏9克生石决明15克(先煎)菊花6克竹茹6克薄荷炭3克(后下)炙僵蚕9克姜黄连2．4克钩藤9克(后下)牛黄清心丸1粒(化服)二诊：头晕痛，纳呆泛恶，心悸气短，苔腻薄黄，脉沉而小滑，与症状未合，是因脾土失运则痰生，因痰生热，因热生风，血压过高，风阳亢逆，故拟予化痰浊，和胃平肝，不斤斤于泻肝也。北沙参9克竹茹6克竹沥半夏9克陈皮6克白蒺藜9克北秫米9克橹豆衣9克炒枳壳4．5克菊花6克生石决明15克(先煎)钩藤9克(后下)生苡米9克朱茯苓9克三诊：用和胃平肝化浊法，中焦痞闷顿舒，脉象亦起，头晕痛渐瘥，纳渐增，泛恶亦止，然腻苔尚未尽化，再宗原法损益之。北沙参9克生石决明15克(先煎)竹茹6克陈皮逆于胆。法当解热清中，利胆安胃。鲜竹茹10克赤茯苓10克煅赭石(布包)10克枇杷叶(生姜汁炒)10克旋复花(布包)7克金铃子(酒炒)7克左秦艽7克广陈皮5克酒黄芩5克炒山栀5克炒枳实5克川黄连(吴萸水炒)2克益元散(布包)10克(《李聪甫医案》)[评按]厥证系指突然昏倒，不省人事，面色苍白，四肢厥冷，移时逐渐苏醒的病证。有时也可一厥不复而导致死亡。《内经》论述颇多，后世更分为气厥、痰厥、血厥、食厥等。
例一证属寒痰厥逆，状若假死，惊为怪病，以三生饮作汤一剂神效。三生饮中均为辛烈有剧毒，并能令人麻醉，近世医家用者稀少，但大病当前，出奇应变，往往可以化险为夷。
例二为食厥，系因食非所宜致令中毒而致。本
例食用生附子、醇酒，毒热炽于胃而逆于胆，虽见四肢厥冷，憎寒腹痛，但舌质干赤，呕吐苦水，决非阴寒之证。治宜解热清中，利胆安胃、方中陈皮、竹茹、枳实清中，黄连、黄芩，栀子清热解毒，茯苓运脾；杷叶和胃。审证求因，辨别寒热之真伪，立法遣药，别开生面，药后转危为安。
(二十二)肢厥
例一姚XX，男，37岁。患周围神经炎已一年多。初因铁锤击伤右手中指，发生疼痛麻痹，经久不愈。至今年三月，渐觉两脚板如有物挤压，脚心冰冷，并逐渐向上发展，奇痒，手足麻木冰冷，尤以两足为甚，经治后上肢症消，上下肢麻木冰冷，尤以下肢脚心为甚，不知痛痒，饮食日益减少，体重明显下降，脉细弦而缓。拟以当归四逆汤：当归15克桂枝10克白芍30克炙甘草10克细辛3克木通10克生姜10克红枣30克生黄芪30克鹿茸末1．5克冲服上方连服11剂，手足麻木明显减退，脚心由冷转热，胃纳仍差。二诊守上方加党参、白术，茯苓各15克，又进5剂，病情更见好转。三诊守上方加重白芍为60克，炙甘草为30克。再进3剂，手足知觉基本恢复，冷感全除，胃纳已开，饮食增进。用上方10剂蜜丸，巩固疗效，随访四年未复发。(万友生：桂枝汤及其加减法的临床体会，《江西中医药》2：6，1981)
例二李XX，男，43岁。初诊日期：1980年1月11日。于1978年10月，无明显诱因而自觉双下肢发凉，厂医诊为肾阳虚证，曾用金匮肾气丸，虎骨酒、青娥丸等大量温补药，而病情未能控制，仍逐渐发展。冷感向上至腰部，向下则冷至足心，如赤脚立冰上，寒冷彻骨。同时伴有下肢麻，痒如虫行，小便余沥与阳萎等症。曾先后在XX等医院检查，均未见异常，而建议中医治疗。虽服补肾壮阳，益气和血等中药二百余剂，未能见效。就诊时：患者素体健康，面部丰腴，面目有神，舌质色绛，少苔，脉弦而略数。问其饮食如故，大便不爽，小便短少而发黄。初投四逆散，按阳厥之证治之，药进三剂，厥冷依然，乃又反复追询其病情，患者才说出睡眠不佳，且多乱梦，而心时烦，容易汗出。视其舌尖红如杨梅，脉来又数。证属阴虚于下而心火独旺于上。其证与黄连阿胶汤颇为合拍，乃疏下方治疗。黄连9克黄芩3克白芍6克阿胶9克(烊化)鸡子黄2枚(自加)以上五味，用水三碗，先煮三物，取一碗；去滓，纳胶烊尽，小冷，纳鸡子黄，搅合相得，分两次服下。服药3剂后，患者即觉下肢寒冷麻木之感逐渐消退，心烦、汗出、失眠多梦等证，均有明显好转，小便余沥和阳萎亦有所改善。察其舌，仍红赤而少苔，脉弦而微数，继宗原法治之。方药，黄连9克阿胶10克(烊化)黄芩3克白芍9克鸡子黄2枚(自加)丹皮6克6剂，煎服法同前。1月30日，适值降雪，寒风凛冽，但患者并无异常寒冷之痛苦，腰以下厥冷证基本告愈。一个月后，据患者言，未再复发。(刘渡舟主治，尉敏廷整理：下肢厥冷治验，《中医杂志》12：19，1980)[评按]肢厥又称四肢厥冷或手足逆冷，或称“四逆”；系指四肢发凉至膝肘以上的病症。有寒热之分。寒证由阴寒内盛，阳气衰微不能达于四末；热证系由热盛伤津，热邪阻遏，阳气不能外达四肢所致。
例—证属气血不足，阳气虚衰不能温煦而致肢厥，以当归四逆汤为治，加生芪、鹿茸益气温阳，通达肌表营卫，壮阳补精活血，以加强温通之效。
例二肢厥逆冷为病之假象，虽屡用温肾助阳而厥冷如故，经详询病情，始得真象。证属阴阳上下阻绝不通，水火不相既济。心火亢盛则心烦、汗出，失眠多梦，舌红少苔，脉数，在下则厥冷，小便余沥、阳萎。投以黄连阿胶汤，泻南补北，交通心肾，使之水火既济，心火得以下行，肾水得以上滋，心肾得交，阴阳调和则诸证自愈。由此可知临证详审病情的重要性。(二十三)痹证
例一陈XX，男，56岁，初诊日期：1974年9月4日。周身关节疼痛已历4年有余，诊为风湿性关节炎。平素畏寒怯冷，疼痛游走不定，每遇寒冷则疼痛加剧，两腿可见红斑结节，查血沉70毫米／一小时，抗“O”正常，舌苔薄腻，舌质偏淡，脉细。辨证:风寒湿痹(乃风湿活动而体质偏虚者)治法：温经通络。方药：制川乌(先煎)10克全当归10克仙灵脾15克川桂枝(后下)8克寻骨风20克稀莶草20克徐长卿15克生甘草5克8剂。9月11日：药后结节明显减少，此乃佳象。舌苔白腻，脉细，效不更方，循原法进治之。上方加炙蜂房10克，炙全蝎(研末分吞)2克。6剂。9月19日：复查血沉为21毫米／一小时末，周身关节痛稳定，腿部红斑结节消失，为巩固疗效，嘱其原方再服10剂。]976年6月5日随访，患者已痊愈，未再复发，并已正常上班。(朱良春主治，陈淑媛等整理：朱良春老中医、治疗痹证的经验，《中医杂志》12：15，1980)
例二高XX，男，56岁，门诊号76／34981。初诊日期：1976年4月22日。患类风湿关节炎三年余，手指足趾肿痛变形，畏寒乏力，脉沉细，苔薄白。辨证:风寒湿久阻脉络，挟瘀凝结。治法：宜大乌头煎参入化瘀搜络之晶。方药：制川草乌各9克(先煎)生黄芪15克净麻黄6克全当归9克细辛3克生甘草9克川桂枝9克炒赤白芍各9克桃仁9克红花6克蕲蛇9克全蝎粉1．2克(分吞)纯蜜15克(冲)稍有加减，服30余剂。5月28日(二诊)：足趾肿痛大减，手指肿痛亦轻，畏寒依故，脉沉细，苔薄白，阳虚之体，风寒湿瘀已有化机，仍守前法增损。制川草乌各9克(先煎)生黄芪18克净麻黄6克川桂枝9克北细辛3克炒赤白芍各9克熟附片9克(先煎)生甘草9克全当归15克露蜂房9克全蝎粉1．2克(分吞)蕲蛇9克纯蜜15克6月22日(三诊)；足趾肿消痛止，手指痛止，畸形好转，脉细，苔白。风寒湿瘀渐化，病久气血亏耗，前方参入益气养血之品。制川草乌各9克(先煎)熟附片9克(先煎)全当归15克川桂枝9克北细辛3克大熟地15克炙黄芪15克炒亦白芍各9克炒川芎6克鹿角片9克全蝎粉1．2克(分吞)蕲蛇9克纯蜜15克(冲)14剂。(《张伯臾医案》)
例三刘XX，男，51岁。患风湿性关节炎已二十余年，近时剧作，右膝关节肿痛尤甚，行走需人扶持，腰亦疼痛，形寒特甚，口不渴，大便易溏，纳少不香，容易感冒，舌苔白润，脉沉细弱。投以桂枝汤加附子、白术。桂枝10克白芍30克炙甘草10克生姜3片大枣5枚熟附子10克白术24克生黄芪24克防风10克当归15克桑寄生30克杜仲15克续断15克制乳没各15克初服3剂，腰腿疼痛即大减，服至5剂，可以独自行走上街，服至10剂，腰膝疼痛基本解除，上班工作。(万友生：桂枝汤及其加减法的临床体会，《江西中医药》2：2，1981)
例四王XX，女，35岁，初诊日期；1977年9月20日。患者面色苍白，形体虚胖，精神萎靡，三年前右骶骨部及右大腿上部疼痛，肢体关节疼痛重着，活动不便，肌肤常有麻木感觉，口淡不渴，饮食、睡眠，大小便尚可，月经不规则，往往超期，白带多，舌苔白腻，脉濡弱。西医诊为风湿性关节炎。辨证：湿邪留滞，阻闭气血，经络不利。治法：祛湿通络，祛风散寒。方药，拟《类证治裁》薏苡仁汤加减：薏苡仁30克川芎7克当归10克桂枝?克独活7克党参20克黄芪20克川乌7克苍术10克木瓜10克秦艽10克水煎服，每日l剂配服小活络丹，并酌情加减，调治二月，诸症均见好转。(盛国荣：痹证论治，《福建中医药》1(2)：3，1981)[评按]痹证系指肢体受风、寒，湿邪等侵袭而致经络闭阻，气血不通的病证。正如《济生方》所云，痹证的发生“皆因体虚，腠理空疏，受风寒湿气而成痹也。”风寒湿外袭，大多夹杂而至，但常有偏胜。风胜为行痹、寒胜为痛痹、湿胜为着痹。
例一风寒偏胜，治以温经通络，佐以祛风之晶。
例二诊为类风湿性关节炎，系因风寒湿邪久阻脉络，挟瘀凝结不易外攘，使用一般风药、温药，犹如隔靴搔痒，须用大辛大热，温经逐寒通络之大乌头煎，再加透骨搜络之虫类药，方能奏效。本例初用大乌头煎加当归四逆汤及桃仁、红花温经散寒，活血通络，并用全蝎、蕲蛇搜剔络脉之虫类药，后更进扶正温阳之附子、鹿角片，遂获良效。
例三病程日久，万氏认为；太阳少阴相表里，故风寒湿邪侵犯太阳，往往损及少阴阳气，又因太阴恶湿，湿盛易伤脾阳，故治太阳风寒湿痹，须在解散太阳风寒湿邪的同时，扶助少阴和太阴之阳气。本方功能解表温里，缓急止痛，养血荣筋，活血通络。用于治疗痹证，是对桂枝汤的发挥。
例四湿痹，为湿邪留滞，阻闭气血。方用薏苡仁汤，重在祛湿通络。以上四例均为痹证，因其风寒湿邪轻重有别则治有侧重，然而治血之法则贯穿始终，因其血瘀而通之，因其血虚而充之。深得“治风先治血，血行风自灭”之要旨。
(二十四)热痹
例一林XX，男，34岁。1976年就诊。患者面色潮红，形体壮实，发热恶寒(体温38~C)，口渴，右侧膝关节红肿，行动困难已六天。心烦不眠，大便秘结，小便短赤，舌质红，苔黄而干，脉弦数。诊为急性风湿性关节炎。、辨证：湿热内蕴，邪从热化。治法：清热泻火，佐以疏风祛湿。方药：拟《温病条辨》宣痹汤加减。防己10克蚕砂16克赤小豆20克滑石20克连翘10克山栀10克黄芩10克生石膏30克桑枝20克防风6克知母10克水煎服，日服一剂连服4剂，热退，左侧膝关节红肿疼痛亦见减轻，继用蠲痹汤加减，方药如下：秦艽10克独活6克忍冬藤20克当归10克桑枝20克鸡血藤16克川芎10克牛膝14克萆薛10克薏仁30克水煎服，每日l剂。配合小活络丹。调理1个月而获愈。(盛国荣：痹证论治，《福建中医药》1(2)：2，1981)
例三 伍XX，女性，74岁。初诊日期：1977年5月23日。头部和眼睛昏眩，颈项部僵硬疼痛，四肢无力，鼻腔结痂干燥，大便干结，小便多且颜色黄，脉象沉细，尺部脉弱，舌面有裂纹，苔微白。血压250/160毫米汞柱。辨证为肾阴不足，肝阳上亢。方药：玄参、麦冬、牛膝、茯苓各12克，代赭石24克，生龙骨、生牡蛎各15克，钩藤、菊花、远志、蝉蜕各6克。二诊：服用上方3剂后，头晕症状减轻，大便仍然干结，小便略减少，血压降至230/110毫米汞柱。又出现心悸、胸闷，脉象弦细。前方去掉代赭石、蝉蜕、玄参、麦冬、茯苓，加入菖蒲、白蒺藜、女贞子、茺蔚子各9克，丹参、首乌各12克，磁石15克。三诊：服药3剂后，血压降至190/100毫米汞柱，头晕、便干、胸闷、心悸略有减轻，但下肢关节肿痛，脉象细数且有间歇（歇止），舌苔剥落。前方除去茺蔚子、牛膝、龙骨、女贞子，加入羌活、独活、鸡血藤各9克。随访一个月，血压趋于稳定，身体轻松有力。（陆文彬整理，沈仲圭老中医临床治验选析，《中医杂志》4:13, 1980）
例四 杨X，女性，44岁。血压高亢，胸闷伴有恶心感，头晕头痛非常严重，脉象弦滑，苔薄腻。厥阴经为风脏，寄居相火。风火相互煽动，向上冲窜至头顶，导致眩晕和疼痛。加之胃气失于和降，出现胸闷恶心，病情非轻（血压达230/135毫米汞柱），须防止突变，急予平肝潜阳，和胃降逆，病情缓和才是吉兆。玳瑁片6克（先煎），姜半夏9克，生石决明15克（先煎），菊花6克，竹茹6克，薄荷炭3克（后下），炙僵蚕9克，姜黄连2.4克，钩藤9克（后下），牛黄清心丸1粒（化服）。二诊：头晕痛，食欲不振伴恶心，心悸气短，苔腻薄黄，脉沉而小滑，与症状不完全吻合，是因为脾土运化失职而生痰，因痰生热，因热生风，血压过高，风阳亢逆，故拟予化痰浊，和胃平肝，不拘泥于单纯泻肝。北沙参9克，竹茹6克，竹沥半夏9克，陈皮6克，白蒺藜9克，北秫米9克，橹豆衣9克，炒枳壳4.5克，菊花6克，生石决明15克（先煎），钩藤9克（后下），生苡米9克，朱茯苓9克。三诊：用和胃平肝化浊法，中焦痞闷顿然舒畅，脉象亦起，头晕痛逐渐痊愈，食欲渐增，恶心亦止，然而腻苔尚未尽化，再遵循原法加减。北沙参9克，生石决明15克（先煎），竹茹6克，陈皮……（此处原文似有缺漏或排版错误“逆于胆”，结合下文语境及后续医案，此处应指前案结束或转述，根据上下文逻辑，此段实为李聪甫医案中关于食厥的论述部分，原文排版将不同案例混杂，需仔细甄别。根据提供的文本结构，“例四”之后紧接着是评按和另一个医案的开头，中间夹杂了一段未标注例号的李聪甫医案片段。为了忠实翻译，我将把这段文字视为一个连续的诊疗记录处理，尽管它可能跨越了不同的病例背景。*修正：仔细观察文本，"例四"结束后，有一段"[评按]厥证..."，然后又是"例一证属寒痰厥逆..."，这显然是对前面厥证类医案的总结。但在"例四"和"[评按]"之间，插入了一段没有明确标题的医案："鲜竹茹10克...益元散(布包)10克(《李聪甫医案》)"。这段实际上是另一个独立的医案，属于"食厥"范畴，被错误地夹在中间。为了保持原文结构，我将其作为独立段落翻译，并在实体提取时注意区分。*）
*重新梳理文本结构以进行准确翻译：*
1. 例三（伍XX）- 高血压/肝阳上亢
2. 例四（杨X）- 高血压/风火相煽
3. [评按] 厥证总论
4. 厥证案例1（寒痰厥逆 - 三生饮）
5. 厥证案例2（食厥 - 附子醇酒中毒 - 清热利胆安胃方）
6. (二十二) 肢厥
7. 肢厥例一（姚XX - 当归四逆汤加味）
8. 肢厥例二（李XX - 黄连阿胶汤）
9. [评按] 肢厥总论
10. (二十三) 痹证
11. 痹证例一（陈XX - 风寒湿痹）
12. 痹证例二（高XX - 类风湿）
13. 痹证例三（刘XX - 风湿性关节炎）
14. 痹证例四（王XX - 湿痹）
15. [评按] 痹证总论
16. (二十四) 热痹
17. 热痹例一（林XX - 湿热内蕴）
*针对夹在中间的无标题医案（李聪甫医案片段）的处理：*
该片段描述了食用生附子和醇酒导致的毒热炽盛，症见四肢厥冷、憎寒腹痛、舌质干赤、呕吐苦水。治宜解热清中，利胆安胃。方药包括鲜竹茹、赤茯苓、煅赭石、枇杷叶、旋复花、金铃子、左秦艽、广陈皮、酒黄芩、炒山栀、炒枳实、川黄连、益元散。
[继续翻译]
[评按] 厥证是指突然昏倒，不省人事，面色苍白，四肢厥冷，过一段时间后逐渐苏醒的病证。有时也可因一厥不复而导致死亡。《内经》对此论述颇多，后世更分为气厥、痰厥、血厥、食厥等。
例一 证属寒痰厥逆，状若假死，惊为怪病，以三生饮作汤一剂神效。三生饮中均为辛烈有剧毒，并能令人麻醉，近世医家用者稀少，但大病当前，出奇应变，往往可以化险为夷。
例二 为食厥，系因食非所宜致令中毒而致。本例食用生附子、醇酒，毒热炽于胃而逆于胆，虽见四肢厥冷，憎寒腹痛，但舌质干赤，呕吐苦水，决非阴寒之证。治宜解热清中，利胆安胃。方中陈皮、竹茹、枳实清中，黄连、黄芩、栀子清热解毒，茯苓运脾；杷叶和胃。审证求因，辨别寒热之真伪，立法遣药，别开生面，药后转危为安。
(二十二) 肢厥
例一 姚XX，男性，37岁。患周围神经炎已一年多。初因铁锤击伤右手中指，发生疼痛麻痹，经久不愈。至今年三月，渐觉两脚板如有物挤压，脚心冰冷，并逐渐向上发展，奇痒，手足麻木冰冷，尤以两足为甚，经治后上肢症消，上下肢麻木冰冷，尤以下肢脚心为甚，不知痛痒，饮食日益减少，体重明显下降，脉细弦而缓。拟以当归四逆汤：当归15克，桂枝10克，白芍30克，炙甘草10克，细辛3克，木通10克，生姜10克，红枣30克，生黄芪30克，鹿茸末1.5克冲服。上方连服11剂，手足麻木明显减退，脚心由冷转热，胃纳仍差。二诊守上方加党参、白术、茯苓各15克，又进5剂，病情更见好转。三诊守上方加重白芍为60克，炙甘草为30克。再进3剂，手足知觉基本恢复，冷感全除，胃纳已开，饮食增进。用上方10剂蜜丸，巩固疗效，随访四年未复发。（万友生：桂枝汤及其加减法的临床体会，《江西中医药》2:6, 1981）
例二 李XX，男性，43岁。初诊日期：1980年1月11日。于1978年10月，无明显诱因而自觉双下肢发凉，厂医诊为肾阳虚证，曾用金匮肾气丸、虎骨酒、青娥丸等大量温补药，而病情未能控制，仍逐渐发展。冷感向上至腰部，向下则冷至足心，如赤脚立冰上，寒冷彻骨。同时伴有下肢麻，痒如虫行，小便余沥与阳痿等症。曾先后在XX等医院检查，均未见异常，而建议中医治疗。虽服补肾壮阳、益气和血等中药二百余剂，未能见效。就诊时：患者素体健康，面部丰腴，面目有神，舌质色绛，少苔，脉弦而略数。问其饮食如故，大便不爽，小便短少而发黄。初投四逆散，按阳厥之证治之，药进三剂，厥冷依然，乃又反复追询其病情，患者才说出睡眠不佳，且多乱梦，而心时烦，容易汗出。视其舌尖红如杨梅，脉来又数。证属阴虚于下而心火独旺于上。其证与黄连阿胶汤颇为合拍，乃疏下方治疗。黄连9克，黄芩3克，白芍6克，阿胶9克（烊化），鸡子黄2枚（自加）。以上五味，用水三碗，先煮三物，取一碗；去滓，纳胶烊尽，小冷，纳鸡子黄，搅合相得，分两次服下。服药3剂后，患者即觉下肢寒冷麻木之感逐渐消退，心烦、汗出、失眠多梦等证，均有明显好转，小便余沥和阳痿亦有所改善。察其舌，仍红赤而少苔，脉弦而微数，继宗原法治之。方药：黄连9克，阿胶10克（烊化），黄芩3克，白芍9克，鸡子黄2枚（自加），丹皮6克。6剂，煎服法同前。1月30日，适值降雪，寒风凛冽，但患者并无异常寒冷之痛苦，腰以下厥冷证基本告愈。一个月后，据患者言，未再复发。（刘渡舟主治，尉敏廷整理：下肢厥冷治验，《中医杂志》12:19, 1980）
[评按] 肢厥又称四肢厥冷或手足逆冷，或称“四逆”；系指四肢发凉至膝肘以上的病症。有寒热之分。寒证由阴寒内盛，阳气衰微不能达于四末；热证系由热盛伤津，热邪阻遏，阳气不能外达四肢所致。
例一 证属气血不足，阳气虚衰不能温煦而致肢厥，以当归四逆汤为治，加生芪、鹿茸益气温阳，通达肌表营卫，壮阳补精活血，以加强温通之效。
例二 肢厥逆冷为病之假象，虽屡用温肾助阳而厥冷如故，经详询病情，始得真象。证属阴阳上下阻绝不通，水火不相既济。心火亢盛则心烦、汗出，失眠多梦，舌红少苔，脉数，在下则厥冷，小便余沥、阳痿。投以黄连阿胶汤，泻南补北，交通心肾，使之水火既济，心火得以下行，肾水得以上滋，心肾得交，阴阳调和则诸证自愈。由此可知临证详审病情的重要性。
(二十三) 痹证
例一 陈XX，男性，56岁，初诊日期：1974年9月4日。周身关节疼痛已历4年有余，诊为风湿性关节炎。平素畏寒怯冷，疼痛游走不定，每遇寒冷则疼痛加剧，两腿可见红斑结节，查血沉70毫米/一小时，抗“O”正常，舌苔薄腻，舌质偏淡，脉细。辨证：风寒湿痹（乃风湿活动而体质偏虚者）。治法：温经通络。方药：制川乌（先煎）10克，全当归10克，仙灵脾15克，川桂枝（后下）8克，寻骨风20克，稀莶草20克，徐长卿15克，生甘草5克。8剂。9月11日：药后结节明显减少，此乃佳象。舌苔白腻，脉细，效不更方，循原法进治之。上方加炙蜂房10克，炙全蝎（研末分吞）2克。6剂。9月19日：复查血沉为21毫米/小时末，周身关节痛稳定，腿部红斑结节消失，为巩固疗效，嘱其原方再服10剂。1976年6月5日随访，患者已痊愈，未再复发，并已正常上班。（朱良春主治，陈淑媛等整理：朱良春老中医治疗痹证的经验，《中医杂志》12:15, 1980）
例二 高XX，男性，56岁，门诊号76/34981。初诊日期：1976年4月22日。患类风湿关节炎三年余，手指足趾肿痛变形，畏寒乏力，脉沉细，苔薄白。辨证：风寒湿久阻脉络，挟瘀凝结。治法：宜大乌头煎参入化瘀搜络之品。方药：制川草乌各9克（先煎），生黄芪15克，净麻黄6克，全当归9克，细辛3克，生甘草9克，川桂枝9克，炒赤白芍各9克，桃仁9克，红花6克，蕲蛇9克，全蝎粉1.2克（分吞），纯蜜15克（冲）。稍有加减，服30余剂。5月28日（二诊）：足趾肿痛大减，手指肿痛亦轻，畏寒依旧，脉沉细，苔薄白，阳虚之体，风寒湿瘀已有化机，仍守前法增损。制川草乌各9克（先煎），生黄芪18克，净麻黄6克，川桂枝9克，北细辛3克，炒赤白芍各9克，熟附片9克（先煎），生甘草9克，全当归15克，露蜂房9克，全蝎粉1.2克（分吞），蕲蛇9克，纯蜜15克。6月22日（三诊）：足趾肿消痛止，手指痛止，畸形好转，脉细，苔白。风寒湿瘀渐化，病久气血亏耗，前方参入益气养血之品。制川草乌各9克（先煎），熟附片9克（先煎），全当归15克，川桂枝9克，北细辛3克，大熟地15克，炙黄芪15克，炒赤白芍各9克，炒川芎6克，鹿角片9克，全蝎粉1.2克（分吞），蕲蛇9克，纯蜜15克（冲）。14剂。（《张伯臾医案》）
例三 刘XX，男性，51岁。患风湿性关节炎已二十余年，近时剧作，右膝关节肿痛尤甚，行走需人扶持，腰亦疼痛，形寒特甚，口不渴，大便易溏，纳少不香，容易感冒，舌苔白润，脉沉细弱。投以桂枝汤加附子、白术。桂枝10克，白芍30克，炙甘草10克，生姜3片，大枣5枚，熟附子10克，白术24克，生黄芪24克，防风10克，当归15克，桑寄生30克，杜仲15克，续断15克，制乳没各15克。初服3剂，腰腿疼痛即大减，服至5剂，可以独自行走上街，服至10剂，腰膝疼痛基本解除，上班工作。（万友生：桂枝汤及其加减法的临床体会，《江西中医药》2:2, 1981）
例四 王XX，女性，35岁，初诊日期：1977年9月20日。患者面色苍白，形体虚胖，精神萎靡，三年前右骶骨部及右大腿上部疼痛，肢体关节疼痛重着，活动不便，肌肤常有麻木感觉，口淡不渴，饮食、睡眠、大小便尚可，月经不规则，往往超期，白带多，舌苔白腻，脉濡弱。西医诊为风湿性关节炎。辨证：湿邪留滞，阻闭气血，经络不利。治法：祛湿通络，祛风散寒。方药：拟《类证治裁》薏苡仁汤加减：薏苡仁30克，川芎7克，当归10克，桂枝?克（原文缺失剂量，推测为常规用量，此处保留问号或依常理推断，但翻译时仅译原文），独活7克，党参20克，黄芪20克，川乌7克，苍术10克，木瓜10克，秦艽10克。水煎服，每日1剂。配服小活络丹，并酌情加减，调治二月，诸症均见好转。（盛国荣：痹证论治，《福建中医药》1(2):3, 1981）
[评按] 痹证系指肢体受风、寒、湿邪等侵袭而致经络闭阻，气血不通的病证。正如《济生方》所云，痹证的发生“皆因体虚，腠理空疏，受风寒湿气而成痹也。”风寒湿外袭，大多夹杂而至，但常有偏胜。风胜为行痹，寒胜为痛痹，湿胜为着痹。
例一 风寒偏胜，治以温经通络，佐以祛风之品。
例二 诊为类风湿性关节炎，系因风寒湿邪久阻脉络，挟瘀凝结不易外攘，使用一般风药、温药，犹如隔靴搔痒，须用大辛大热，温经逐寒通络之大乌头煎，再加透骨搜络之虫类药，方能奏效。本例初用大乌头煎加当归四逆汤及桃仁、红花温经散寒，活血通络，并用全蝎、蕲蛇搜剔络脉之虫类药，后更进扶正温阳之附子、鹿角片，遂获良效。
例三 病程日久，万氏认为：太阳少阴相表里，故风寒湿邪侵犯太阳，往往损及少阴阳气，又因太阴恶湿，湿盛易伤脾阳，故治太阳风寒湿痹，须在解散太阳风寒湿邪的同时，扶助少阴和太阴之阳气。本方功能解表温里，缓急止痛，养血荣筋，活血通络。用于治疗痹证，是对桂枝汤的发挥。
例四 湿痹，为湿邪留滞，阻闭气血。方用薏苡仁汤，重在祛湿通络。以上四例均为痹证，因其风寒湿邪轻重有别则治有侧重，然而治血之法则贯穿始终，因其血瘀而通之，因其血虚而充之。深得“治风先治血，血行风自灭”之要旨。
(二十四) 热痹
例一 林XX，男性，34岁。1976年就诊。患者面色潮红，形体壮实，发热恶寒（体温38℃），口渴，右侧膝关节红肿，行动困难已六天。心烦不眠，大便秘结，小便短赤，舌质红，苔黄而干，脉弦数。诊为急性风湿性关节炎。辨证：湿热内蕴，邪从热化。治法：清热泻火，佐以疏风祛湿。方药：拟《温病条辨》宣痹汤加减。防己10克，蚕砂16克，赤小豆20克，滑石20克，连翘10克，山栀10克，黄芩10克，生石膏30克，桑枝20克，防风6克，知母10克。水煎服，日服一剂。连服4剂，热退，左侧膝关节红肿疼痛亦见减轻，继用蠲痹汤加减，方药如下：秦艽10克，独活6克，忍冬藤20克，当归10克，桑枝20克，鸡血藤16克，川芎10克，牛膝14克，萆薢10克，薏仁30克。水煎服，每日1剂。配合小活络丹。调理1个月而获愈。（盛国荣：痹证论治，《福建中医药》1(2):2, 1981）
Case 3 Wu XX, female, 74 years old. Initial visit date: May 23, 1977. Dizziness of the head and eyes, stiffness and pain in the neck and nape, weakness in the four limbs, dry crusts in the nose, dry stool, frequent and yellow urine, deep and fine pulse, weak at the Chi position, cracked tongue surface with slightly white coating. Blood pressure 250/160 mmHg. Differentiated as Kidney Yin Deficiency with Hyperactive Liver Yang. Prescription: Xuan Shen (Scrophulariae Radix), Mai Dong (Ophiopogonis Radix), Niu Xi (Achyranthis Bidentatae Radix), Fu Ling (Poria) each 12g; Dai Zhe Shi (Magnetitum) 24g; Sheng Long Gu (Fossilia Ossis Mastodi) and Sheng Mu Li (Concha Ostreae) each 15g; Gou Teng (Uncariae Ramulus cum Uncis), Ju Hua (Chrysanthemi Flos), Yuan Zhi (Polygalae Radix), Chan Tui (Cicadae Periostracum) each 6g. Second visit: After taking 3 doses of the above prescription, dizziness decreased, stool remained dry, urine volume slightly decreased, blood pressure dropped to 230/110 mmHg. Palpitations and chest tightness appeared, pulse was wiry and fine. Removed Dai Zhe Shi, Chan Tui, Xuan Shen, Mai Dong, and Fu Ling from the previous prescription; added Shi Chang Pu (Acori Tatarinowii Rhizoma), Bai Ji Li (Tribuli Fructus), Nu Zhen Zi (Ligustri Lucidi Fructus), Chong Wei Zi (Vernoniae Semen) each 9g; Dan Shen (Salviae Miltiorrhizae Radix), Shou Wu (Polygoni Multiflori Radix) each 12g; Ci Shi (Magnetitum) 15g. Third visit: After 3 doses, blood pressure dropped to 190/100 mmHg; dizziness, dry stool, chest tightness, and palpitations slightly alleviated, but swelling and pain in lower limb joints occurred, pulse was fine, rapid, and intermittent, tongue coating peeled. Removed Chong Wei Zi, Niu Xi, Long Gu, and Nu Zhen Zi from the previous prescription; added Qiang Huo (Notopterygii Rhizoma et Radix), Du Huo (Angelicae Pubescentis Radix), Ji Xue Teng (Spatholobi Caulis) each 9g. Follow-up for one month showed stable blood pressure and a relaxed, energetic body. (Organized by Lu Wenbin, Selected Analysis of Clinical Experiences of Old TCM Physician Shen Zhonggui, *Journal of Traditional Chinese Medicine* 4:13, 1980)
Case 4 Yang X, female, 44 years old. High blood pressure, chest tightness with nausea, severe dizziness and headache, wiry and slippery pulse, thin greasy coating. The Jueyin channel is the Wind organ, where Ministerial Fire resides. Wind and Fire fan each other, rushing upward to the vertex, causing dizziness and pain. Additionally, Stomach Qi fails to descend harmoniously, leading to chest tightness and nausea; the condition is serious (blood pressure up to 230/135 mmHg), requiring prevention of sudden changes. Urgently prescribed to calm the Liver and subdue Yang, harmonize the Stomach and direct rebellious Qi downward; only when the condition缓和 (soothes) can it be auspicious. Dai Mao Pian (Trionycis Carapax et Plastrum slices) 6g (decocted first), Jiang Ban Xia (Pinelliae Rhizoma preparatum) 9g, Sheng Shi Jue Ming (Haliotidis Concha) 15g (decocted first), Ju Hua (Chrysanthemi Flos) 6g, Zhu Ru (Bambusae Folium) 6g, Bo He Tan (Menthae Haplocalycis Carbonisatus) 3g (added later), Zhi Jiang Can (Bombyx Batryticatus preparatum) 9g, Jiang Huang Lian (Coptidis Rhizoma preparatum with Ginger) 2.4g, Gou Teng (Uncariae Ramulus cum Uncis) 9g (added later), Niu Huang Qing Xin Wan (Calculus Bovis Clearing Heart Pill) 1 pill (dissolved and taken). Second visit: Dizziness and headache persist, poor appetite with nausea, palpitations and shortness of breath, greasy thin yellow coating, deep and small-slippery pulse. This does not fully match the symptoms; it is because Spleen Earth fails to transport, generating Phlegm; Phlegm generates Heat; Heat generates Wind; high blood pressure causes Hyperactive Wind-Yang. Therefore, prescribed to transform turbid Phlegm, harmonize the Stomach and calm the Liver, not merely focusing on purging the Liver. Bei Sha Shen (Glehniae Radix) 9g, Zhu Ru (Bambusae Folium) 6g, Zhu Li Ban Xia (Pinelliae Rhizoma prepared with Bamboo Sap) 9g, Chen Pi (Citri Reticulatae Pericarpium) 6g, Bai Ji Li (Tribuli Fructus) 9g, Bei Shu Mi (Milii Germen) 9g, Lu Dou Yi (Sojae Semen Praeparatum) 9g, Chao Zhi Ke (Aurantii Fructus preparatum) 4.5g, Ju Hua (Chrysanthemi Flos) 6g, Sheng Shi Jue Ming (Haliotidis Concha) 15g (decocted first), Gou Teng (Uncariae Ramulus cum Uncis) 9g (added later), Sheng Yi Mi (Coicis Semen) 9g, Zhu Fu Ling (Poria caryopsis dyed with Cinnabar) 9g. Third visit: Using the method of harmonizing the Stomach, calming the Liver, and transforming turbidity, epigastric fullness instantly relieved, pulse rose, dizziness and pain gradually healed, appetite increased, nausea stopped, but greasy coating not yet fully resolved. Continue following the original method with modifications. Bei Sha Shen (Glehniae Radix) 9g, Sheng Shi Jue Ming (Haliotidis Concha) 15g (decocted first), Zhu Ru (Bambusae Folium) 6g, Chen Pi (Citri Reticulatae Pericarpium)... [Text fragment indicates transition or error in source regarding "reversing into Gallbladder"].
[Commentary on Jue Syndrome] Jue Syndrome refers to a condition characterized by sudden collapse, loss of consciousness, pale complexion, cold extremities, followed by gradual recovery after some time. Sometimes it may lead to death without recovery. The *Neijing* discusses this extensively, and later generations classified it into Qi Jue, Phlegm Jue, Blood Jue, and Food Jue.
Case 1 Belongs to Cold-Phlegm Jue Ni (Rebellious Qi), resembling fake death, mistaken for a strange disease. A single dose of San Sheng Yin decoction proved miraculous. San Sheng Yin contains pungent, acrid, highly toxic herbs that can cause anesthesia. Few modern physicians use them, but in critical illnesses, unexpected strategies often turn danger into safety.
Case 2 Is Food Jue, caused by ingesting inappropriate substances leading to poisoning. In this case, raw Fu Zi (Aconiti Lateralis Radix Preparata) and strong wine were consumed. Toxic heat blazed in the Stomach and rebelled into the Gallbladder. Although presenting with cold extremities, aversion to cold, and abdominal pain, the tongue body was dry and crimson, vomiting bitter water, definitely not a Yin-Cold syndrome. Treatment should clear heat, purge the middle, benefit the Gallbladder, and harmonize the Stomach. Chen Pi, Zhu Ru, and Zhi Shi clear the middle; Huang Lian, Huang Qin, and Zhi Zi clear heat and detoxify; Fu Ling strengthens the Spleen; Pa Ye (Eriobotryae Folium) harmonizes the Stomach. Examining signs to seek causes, distinguishing true from false cold and heat, establishing methods and prescribing drugs innovatively, the patient turned from critical to safe after medication.
(XXII) Limb Jue (Cold Extremities)
Case 1 Yao XX, male, 37 years old. Had peripheral neuritis for over a year. Initially injured the right middle finger with a hammer, resulting in pain and numbness that did not heal for a long time. By March of this year, gradually felt a squeezing sensation on both soles, cold soles, spreading upwards, intense itching, numbness and coldness in hands and feet, especially in the feet. After treatment, upper limb symptoms disappeared, but numbness and coldness persisted in all limbs, especially the soles of the feet, with loss of pain and temperature sensation. Diet decreased daily, weight dropped significantly, pulse was fine, wiry, and slow. Prescribed Dang Gui Si Ni Tang: Dang Gui (Angelicae Sinensis Radix) 15g, Gui Zhi (Cinnamomi Ramulus) 10g, Bai Shao (Paeoniae Radix Alba) 30g, Zhi Gan Cao (Glycyrrhizae Radix et Rhizoma preparatum) 10g, Xi Xin (Asari Radix et Rhizoma) 3g, Mu Tong (Akebiae Caulis) 10g, Sheng Jiang (Zingiberis Rhizoma Recens) 10g, Hong Zao (Jujubae Fructus) 30g, Sheng Huang Qi (Astragali Radix) 30g, Lu Rong Mo (Cervi Cornu Pantotrichum powder) 1.5g (taken with decoction). Taking the above prescription continuously for 11 doses, numbness in hands and feet significantly decreased, soles turned from cold to warm, but appetite remained poor. Second visit: Added Dang Shen (Codonopsis Radix), Bai Zhu (Atractylodis Macrocephalae Rhizoma), Fu Ling (Poria) each 15g to the previous prescription, took another 5 doses, condition improved further. Third visit: Increased Bai Shao to 60g and Zhi Gan Cao to 30g in the previous prescription. Took another 3 doses, sensation in hands and feet basically recovered, coldness completely eliminated, appetite opened, diet increased. Made honey pills from 10 doses of the above prescription to consolidate efficacy; no recurrence during 4-year follow-up. (Wan Yousheng: Clinical Experience with Gui Zhi Tang and its Modifications, *Jiangxi Journal of Traditional Chinese Medicine* 2:6, 1981)
Case 2 Li XX, male, 43 years old. Initial visit date: January 11, 1980. In October 1978, consciously felt coldness in both lower limbs without obvious trigger. Factory doctor diagnosed Kidney Yang Deficiency. Used large amounts of warming and tonifying medicines such as Jin Gui Shen Qi Wan, Hu Gu Jiu (Tiger Bone Wine), and Qing E Wan, but condition was not controlled and continued to develop. Cold sensation extended up to the waist and down to the soles, feeling like standing barefoot on ice, bone-chilling cold. Accompanied by lower limb numbness, itching like insects crawling, dribbling urine, and impotence. Checked at various hospitals with no abnormalities found, advised TCM treatment. Took over 200 doses of TCM herbs for tonifying Kidney and strengthening Yang, benefiting Qi and nourishing Blood, but ineffective. At consultation: Patient generally healthy, plump face, bright eyes, crimson tongue body with little coating, wiry and slightly rapid pulse. Diet normal, bowel movements unsatisfactory, urine scanty and yellow. Initially prescribed Si Ni San, treating as Yang Jue. After 3 doses, cold extremities persisted. Repeatedly inquired about the condition, patient revealed poor sleep, chaotic dreams, occasional mental irritability, and easy sweating. Tip of tongue red like a bayberry, pulse rapid. Differentiated as Yin deficiency below and solitary hyperactivity of Heart Fire above. Condition closely matched Huang Lian E Jiao Tang. Prescribed: Huang Lian (Coptidis Rhizoma) 9g, Huang Qin (Scutellariae Radix) 3g, Bai Shao (Paeoniae Radix Alba) 6g, E Jiao (Colla Corii Asini) 9g (melted), Ji Zi Huang (Yolks of Chicken Egg) 2 pieces (self-added). These five ingredients, using three bowls of water, first decoct three items (excluding E Jiao and Yolks), obtain one bowl; remove dregs, add E Jiao and melt completely, let cool slightly, add chicken yolks, stir well, divide into two doses. After 3 doses, patient felt gradual disappearance of coldness and numbness in lower limbs, significant improvement in irritability, sweating, insomnia, and chaotic dreams; dribbling urine and impotence also improved. Tongue still red and crimson with little coating, pulse wiry and slightly rapid. Continue original treatment. Prescription: Huang Lian 9g, E Jiao 10g (melted), Huang Qin 3g, Bai Shao 9g, Ji Zi Huang 2 pieces (self-added), Dan Pi (Moutan Cortex) 6g. 6 doses, decoction method same as before. On Jan 30, despite snow and biting cold wind, patient felt no abnormal cold pain; cold extremities below waist basically cured. One month later, patient reported no recurrence. (Mainly treated by Liu Duzhou, organized by Yu Minting: Curative Experience in Treating Lower Limb Cold Extremities, *Journal of Traditional Chinese Medicine* 12:19, 1980)
[Commentary on Limb Jue] Limb Jue, also known as cold extremities or reverse coldness of hands and feet, or "Si Ni"; refers to limbs cooling up to above knees and elbows. Divided into Cold and Heat types. Cold type results from excessive internal Yin-Cold and declining Yang Qi unable to reach the extremities; Heat type results from Heat excess injuring fluids, Heat pathogen obstructing, preventing Yang Qi from reaching the limbs externally.
Case 1 Belongs to Qi and Blood deficiency, Yang Qi decline unable to warm, causing Limb Jue. Treated with Dang Gui Si Ni Tang, adding Sheng Huang Qi and Lu Rong to benefit Qi and warm Yang, unblock Ying and Wei in muscles and skin, strengthen Yang and tonify Essence, invigorate Blood, to enhance warming and unblocking effects.
Case 2 Limb Jue coldness is a false sign of illness. Despite repeated use of warming Kidney and assisting Yang, coldness persisted. Only after detailed inquiry was the true nature revealed. Condition belongs to blockage between Upper and Lower Yin and Yang, Water and Fire not interacting. Hyperactive Heart Fire causes irritability, sweating, insomnia, dreams, red tongue with little coating, rapid pulse; below causes cold extremities, dribbling urine, impotence. Administered Huang Lian E Jiao Tang to drain South (Heart/Fire) and tonify North (Kidney/Water), communicate Heart and Kidney, achieve interaction of Water and Fire. Heart Fire descends, Kidney Water ascends, Heart and Kidney interact, Yin and Yang harmonize, symptoms self-resolve. This shows the importance of careful examination in clinical practice.
(XXIII) Bi Syndrome
Case 1 Chen XX, male, 56 years old, initial visit date: September 4, 1974. Pain in all joints for over 4 years, diagnosed as Rheumatoid Arthritis. Usually afraid of cold, pain wanders, worsens with cold, red nodules visible on legs, ESR 70mm/hour, Anti-Streptolysin O normal, thin greasy coating, pale tongue body, fine pulse. Differentiation: Wind-Cold-Damp Bi (Rheumatism activity with deficient constitution). Treatment: Warm meridians and unblock collaterals. Prescription: Zhi Chuan Wu (Aconiti Radix Preparata) 10g (decocted first), Quan Dang Gui (Angelicae Sinensis Radix) 10g, Xian Ling Pi (Epimedii Folium) 15g, Chuan Gui Zhi (Cinnamomi Ramulus) 8g (added later), Xun Gu Feng (Piperis Kadsurae Caulis) 20g, Xi Xian Cao (Siegesbeckiae Herba) 20g, Xu Chang Qing (Cynanchi Stauntonii Rhizoma et Radix) 15g, Sheng Gan Cao (Glycyrrhizae Radix et Rhizoma) 5g. 8 doses. Sept 11: Nodules significantly reduced after medication, a good sign. White greasy coating, fine pulse. Effect achieved, do not change formula, continue original method. Add Zhi Feng Fang (Vespa Nidus preparatum) 10g, Zhi Quan Xie (Scorpio preparatum) 2g (powder, divided intake) to previous prescription. 6 doses. Sept 19: Recheck ESR 21mm/hour end, joint pain stable, leg red nodules disappeared. To consolidate efficacy, instructed to take original prescription for another 10 doses. Follow-up June 5, 1976: Patient cured, no recurrence, returned to normal work. (Mainly treated by Zhu Liangchun, organized by Chen Shuyuan et al.: Experience of Old TCM Physician Zhu Liangchun in Treating Bi Syndrome, *Journal of Traditional Chinese Medicine* 12:15, 1980)
Case 2 Gao XX, male, 56 years old, outpatient No. 76/34981. Initial visit date: April 22, 1976. Suffered from Rheumatoid Arthritis for over 3 years, swelling, pain, and deformity of fingers and toes, fear of cold, fatigue, deep fine pulse, thin white coating. Differentiation: Wind-Cold-Damp stagnating in collaterals for a long time, accompanied by Blood stasis coagulation. Treatment: Da Wu Tou Jian combined with herbs for resolving stasis and searching collaterals. Prescription: Zhi Chuan Cao Wu (Aconiti Radix et Rhizoma Preparata) each 9g (decocted first), Sheng Huang Qi (Astragali Radix) 15g, Jing Ma Huang (Ephedrae Herba) 6g, Quan Dang Gui (Angelicae Sinensis Radix) 9g, Xi Xin (Asari Radix et Rhizoma) 3g, Sheng Gan Cao (Glycyrrhizae Radix et Rhizoma) 9g, Chuan Gui Zhi (Cinnamomi Ramulus) 9g, Chao Chi Bai Shao (Paeoniae Radix Rubra et Alba preparatum) each 9g, Tao Ren (Persicae Semen) 9g, Hong Hua (Carthami Flos) 6g, Qi She (Agkistrodon) 9g, Quan Xie Fen (Scorpio powder) 1.2g (divided intake), Chun Mi (Pure Honey) 15g (mixed in). Slight modifications, took over 30 doses. May 28 (Second visit): Swelling and pain in toes greatly reduced, finger swelling and pain lighter, fear of cold persists, deep fine pulse, thin white coating. Yang-deficient constitution, Wind-Cold-Damp-Stasis has transformation mechanism, still adhere to previous method with additions/subtractions. Zhi Chuan Cao Wu each 9g (decocted first), Sheng Huang Qi 18g, Jing Ma Huang 6g, Chuan Gui Zhi 9g, Bei Xi Xin 3g, Chao Chi Bai Shao each 9g, Shu Fu Pian (Aconiti Lateralis Radix Preparata) 9g (decocted first), Sheng Gan Cao 9g, Quan Dang Gui 15g, Lu Feng Fang (Vespa Nidus) 9g, Quan Xie Fen 1.2g (divided intake), Qi She 9g, Chun Mi 15g (mixed in). June 22 (Third visit): Toe swelling gone, pain stopped, finger pain stopped, deformity improved, fine pulse, white coating. Wind-Cold-Damp-Stasis gradually resolving, long-term illness depleted Qi and Blood, add Qi-benefiting and Blood-nourishing items to previous prescription. Zhi Chuan Cao Wu each 9g (decocted first), Shu Fu Pian 9g (decocted first), Quan Dang Gui 15g, Chuan Gui Zhi 9g, Bei Xi Xin 3g, Da Shu Di (Rehmanniae Radix Preparata) 15g, Zhi Huang Qi 15g, Chao Chi Bai Shao each 9g, Chuan Xiong (Chuanxiong Rhizoma) 6g, Lu Jiao Pian (Cervi Cornus Degelatinatum slices) 9g, Quan Xie Fen 1.2g (divided intake), Qi She 9g, Chun Mi 15g (mixed in). 14 doses. (*Zhang Boyu Medical Cases*)
Case 3 Liu XX, male, 51 years old. Suffered from Rheumatic Arthritis for over 20 years, recently severe attack, right knee joint swelling and pain most severe, needs support to walk, lower back also painful, extreme aversion to cold, no thirst, loose stools, poor appetite, prone to colds, white moist coating, deep fine weak pulse. Administered Gui Zhi Tang plus Fu Zi and Bai Zhu. Gui Zhi 10g, Bai Shao 30g, Zhi Gan Cao 10g, Sheng Jiang 3 slices, Da Zao 5 pieces, Shu Fu Zi 10g, Bai Zhu 24g, Sheng Huang Qi 24g, Fang Feng 10g, Dang Gui 15g, Sang Ji Sheng 30g, Du Zhong 15g, Xu Duan 15g, Zhi Ru Mo (Frankincense and Myrrh) each 15g. First 3 doses: Waist and leg pain greatly reduced. Up to 5 doses: Could walk alone on street. Up to 10 doses: Waist and knee pain basically resolved, returned to work. (Wan Yousheng: Clinical Experience with Gui Zhi Tang and its Modifications, *Jiangxi Journal of Traditional Chinese Medicine* 2:2, 1981)
Case 4 Wang XX, female, 35 years old, initial visit date: September 20, 1977. Pale complexion, flabby obesity, listless spirit. Three years ago, pain in right sacral region and upper right thigh, heavy pain in limb joints, inconvenient movement, frequent numbness in skin, bland taste in mouth, no thirst, diet/sleep/bowel/bladder okay, irregular menstruation often delayed, leukorrhea abundant, white greasy coating, soggy weak pulse. Western medicine diagnosed as Rheumatic Arthritis. Differentiation: Damp-Evil stagnation, blocking Qi and Blood, collaterals unfavorable. Treatment: Expel Damp and unblock collaterals, expel Wind and scatter Cold. Prescription: Modified Yi Yi Ren Tang from *Lei Zheng Zhi Cai*: Yi Yi Ren (Coicis Semen) 30g, Chuan Xiong 7g, Dang Gui 10g, Gui Zhi ?g (dose missing in text), Du Huo 7g, Dang Shen 20g, Huang Qi 20g, Chuan Wu 7g, Cang Zhu 10g, Mu Gua 10g, Qin Jiao 10g. Decoct in water, 1 dose daily. Take Xiao Huo Luo Dan (Minor Invigorate Collaterals Pill) concurrently, modify as needed. Treated for 2 months, all symptoms improved. (Sheng Guorong: Discussion on Treatment of Bi Syndrome, *Fujian Journal of Traditional Chinese Medicine* 1(2):3, 1981)
[Commentary on Bi Syndrome] Bi Syndrome refers to blockage of collaterals and non-flow of Qi and Blood due to invasion of Wind, Cold, Damp, etc., into limbs. As stated in *Ji Sheng Fang*, Bi Syndrome occurs "all due to body deficiency, open pores, receiving Wind-Cold-Damp Qi to form Bi." Wind-Cold-Damp external invasion usually comes mixed, but often has predominance. Wind predominance is Xing Bi (Wandering Bi); Cold predominance is Tong Bi (Painful Bi); Damp predominance is Zhuo Bi (Fixed Bi).
Case 1 Wind-Cold predominates, treat by warming meridians and unblocking collaterals, assisted by Wind-expelling herbs.
Case 2 Diagnosed as Rheumatoid Arthritis, caused by Wind-Cold-Damp stagnating in collaterals for a long time, accompanied by Blood stasis coagulation, difficult to expel externally. Using general Wind herbs and Warming herbs is like scratching an itch through boots. Must use Da Wu Tou Jian (Major Aconite Decoction), which is extremely pungent and hot, to warm meridians, drive out Cold, and unblock collaterals, plus insect-type herbs that penetrate bones and search collaterals, to achieve effect. This case initially used Da Wu Tou Jian plus Dang Gui Si Ni Tang and Tao Ren, Hong Hua to warm meridians, scatter Cold, invigorate Blood, and unblock collaterals, plus Quan Xie and Qi She (insect herbs) to search collaterals, later advanced Fu Zi and Lu Jiao Pian (warming Yang and supporting Righteousness), thus obtaining good effect.
Case 3 Long course of disease. Mr. Wan believes: Taiyang and Shaoyin are interior-exterior related, so Wind-Cold-Damp invading Taiyang often damages Shaoyang Yang Qi. Also, Taiyin dislikes Damp, Damp excess easily injures Spleen Yang. Thus, treating Taiyang Wind-Cold-Damp Bi requires dispelling Taiyang Wind-Cold-Damp while supporting Shaoyin and Taiyang Yang Qi. This prescription functions to release exterior and warm interior, relieve urgency and stop pain, nourish Blood and enrich sinews, invigorate Blood and unblock collaterals. Using it for Bi Syndrome is an expansion of Gui Zhi Tang.
Case 4 Damp Bi, Damp-Evil stagnation blocking Qi and Blood. Formula uses Yi Yi Ren Tang, focusing on expelling Damp and unblocking collaterals. All four cases are Bi Syndrome; due to different severity of Wind-Cold-Damp, treatment emphasis differs, but the principle of treating Blood runs throughout: unblock if Blood stasis, tonify if Blood deficiency. Deeply grasps the essence "To treat Wind, first treat Blood; when Blood flows, Wind extinguishes itself."
(XXIV) Hot Bi
Case 1 Lin XX, male, 34 years old. Consulted in 1976. Flushed complexion, robust build, fever with aversion to cold (body temp 38°C), thirst, right knee joint redness and swelling, difficulty moving for six days. Mental irritability, insomnia, constipation, scanty dark urine, red tongue body, yellow dry coating, wiry rapid pulse. Diagnosed as Acute Rheumatic Arthritis. Differentiation: Internal accumulation of Damp-Heat, pathogen transforming into Heat. Treatment: Clear Heat and purge Fire, assisted by dispersing Wind and expelling Damp. Prescription: Modified Xuan Bi Tang from *Wen Bing Tiao Bian*. Fang Ji (Stephaniae Tetrandrae Radix) 10g, Can Sha (Bombyx Batryticatus Sand) 16g, Chi Xiao Dou (Adzuki Bean) 20g, Hua Shi (Talcum) 20g, Lian Qiao (Forsythiae Fructus) 10g, Shan Zhi (Gardeniae Fructus) 10g, Huang Qin (Scutellariae Radix) 10g, Sheng Shi Gao (Gypsum Fibrosum) 30g, Sang Zhi (Mori Ramulus) 20g, Fang Feng (Saposhnikoviae Radix) 6g, Zhi Mu (Anemarrhenae Rhizoma) 10g. Decoct in water, 1 dose daily. Took continuously for 4 doses, fever subsided, left knee joint redness/swelling/pain also alleviated. Subsequently used Juan Bi Tang modified: Qin Jiao 10g, Du Huo 6g, Ren Dong Teng (Lonicerae Japonicae Caulis) 20g, Dang Gui 10g, Sang Zhi 20g, Ji Xue Teng 16g, Chuan Xiong 10g, Niu Xi 14g, Bi Xie (Dioscoreae Hypoglaucae Rhizoma) 10g, Yi Ren 30g. Decoct in water, 1 dose daily. Combined with Xiao Huo Luo Dan. Regulated for 1 month to achieve cure. (Sheng Guorong: Discussion on Treatment of Bi Syndrome, *Fujian Journal of Traditional Chinese Medicine* 1(2):2, 1981)