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)
例二洪XX，男，34岁。初诊日期：1964年6月5日。患感冒已20多天。现证两足趾热痛，痛甚不可忍，不敢着地，夜卧必置于被外，面黄赤，口唇舌质紫红，舌苔白腻，根部微黄，午后发热，脉濡数。辨证：湿热闭阻经络。治法：清热祛湿，活血开痹。方药：苍术12克防己12克通草12克苡米24克地龙12克牛膝12克苏木9克蒲公英30克甘草6克水煎服外用桃仁12克，杏仁12克，薄荷9克，荆芥9克，栀子12克，上药为面加白面少许，白酒合调糊状，外敷痛处。内服外糊并用，翌日痛止，服3剂能走路，8剂痊愈。(《老中医经验汇编》第一集，郑桥医案)
例三蔡XX，女，30岁。于1961年因关节疼痛全身发热，肌肤灼热(体温380(3上下)，烦渴引饮，大便秘结，盗汗颇多，住院治疗。罹病二月，四肢关节疼痛剧烈，手足不能举动，甚至不能触摸。脉弦大数，舌质绛，苔黄腻少津，曾服白虎加桂枝汤、独活寄生汤等均未效。辨证：阴血虚极，阴伤热炽，热甚灼筋，筋脉失养。治法：滋阴清热，固表止汗。方药；当归六黄汤加减。黄芪24克生地15克当归9克黄连4．5克黄芩6克黄柏6克花粉9克桑枝15克秦艽9克连服4剂，热象盗汗大减，舌苔渐润，又进3剂，燥屎下，上肢关节疼痛渐有好转，自能持杯饮水吃饭。效不更方，再连服4剂，关节疼痛减轻。半月后能下床步履，同时配合针灸隔日一次，二旬之间，身凉脉静，诸证悉愈。(《席梁丞治验录》)[评按]热痹系因湿热痹阻经络，或因素体阳盛，风寒湿邪侵袭经络，郁而化热所致。一般发病较急，除关节灼热肿痛外，多兼有热病证候。治以清热疏风、祛湿通络为法。
例一证属热痹而热胜于湿，故以清热泻火为主，佐以疏风祛湿，待热退痛减，续服蠲痹汤，以加强活血通络之功。
例二病值湿盛之际，素有蕴热而复感湿邪，由于透发不力而湿热互结下注，经络阻滞，治以清热祛湿、活血开痹通络，内外兼治而奏效。
例三虽为热痹而证候殊异，发热盗汗肢节剧痛，历时二月之久，汗愈出阴愈伤，阴愈伤而热愈炽，热甚灼筋，筋脉失养，故关节疼剧，服白虎加桂枝汤而热不解，用风药而痛愈剧，乃阴血虚极不能濡筋之故，复用独活寄生汤以致“风假火威，火乘风势”，痛热反而增剧，改用当归六黄汤以矫妄，滋阴清热、固表止汗而告愈。(二十五)血痹赵XX，女，34岁，初诊日期：1975年7月半月前因洗衣被等物30余件，劳累出汗，当天晚上卧床后，即觉右肘至肩部沉重，麻木、怕冷，酸痛，尤以肩部疼痛较甚。次日右上肢抬举困难，活动受限，入夜疼甚。望之患者痛苦病容，面色咣白少华。脉沉细无力，舌淡白而润。右臂欠温。辨证：寒湿侵伤，血行不畅，阳气痹阻而致血痹。治法：温阳行痹。方药：黄芪桂枝五物汤加味。黄芪30克桂枝9克白芍9克生姜15克大枣10枚姜黄12克羌活6克5剂复诊：右臂麻木沉重大减，但怕冷仍如前，且肩疼仍甚，脉沉细，舌苔白润。原方加制附片9克，嘱服5剂。三诊，臂已不麻，肩部酸痛，抬肩举臂自如，但仍伯冷，沉重，脉舌如前，原方加苡仁15克，蚕砂12克，以增除湿之功，嘱服5剂。四诊时病已痊愈。(《窦伯清医案》)[评按]血痹系指“卧出而风吹之，血凝于肤者为痹”(《素问·五藏生成篇》)，与风寒湿所致痹证不同。血痹以肌肉麻痹无痛感，痹证则麻痛并见。正虚之体劳而汗出，则阳气更虚，风邪侵袭则血行不畅，故见肌肉麻痹，若风邪较重，也可发生疼痛，故曰“如风痹状”。本病在《金匮要略》记述较详。本案证状尚属典型，方用黄芪桂枝五物汤加羌活、附子等辛温之晶，药证相符，疗效卓著。治法在遵古的基础上有所变化。(二十六)瘘证附；重症肌无力
例一封X；女，温病后，阴液已伤，虚火灼金，肺热叶焦则生痿躄，两足不能任地，咳呛不爽，谷食减少，咽喉干燥，脉濡滑而数，舌质红，苔黄，延经数月，恙根已深，姑拟养肺阴、清阳明，下病治上，乃古之成法。南沙参9克川石斛9克天花粉9克生甘草1．5克川贝母9克肥知母4．5克瓜萎皮9克甜光杏9克络石藤9克怀牛膝6克嫩桑枝9克冬瓜子9克活芦根1尺(去节)二诊：前进养肺阴清阳明之剂，已服10剂，咳呛内热，均见减轻，两足痿软不能任地，痿者萎也，如草木之萎，无雨露以灌溉，欲草木之荣茂，必得雨露之濡润，欲两足之不萎，必赖肺液以输布，能下荫于肝肾，肝得血则筋舒，肾得养则骨强，阴血充足，络热自清，治痿独取阳明，清阳明之热，滋肺金之阴以阳明能主润宗筋而流利机关也。大麦冬6克北沙参9克抱茯神9克淮山药9克细生地12克肥知母4．5克川贝母6克天花粉9克络石藤6克怀牛膝6克嫩桑枝9克三诊，五脏之热，皆能成痿，书有五痿之称，不独肺热叶焦也，然而虽有五，实则有二，热痿也，湿痿也。如草木久无雨露则萎，草木久被湿遏亦萎，两足痿躄，亦犹是也，今脉濡数，舌质红绛，此热痿也，叠进清阳明、滋肺阴以来，两足虽不能步履，已能自行举起之象，药病尚觉合宜，仍守原法，加入益精养血之品，徐图功效。北沙参9克大麦冬6克茯神9克怀山药9克川石斛9克小生地9克肥知母4．5克怀牛膝6克络石藤9克茺蔚子9克嫩桑枝9克猪脊髓两条(酒洗，入煎)虎潜丸9克，清晨淡盐汤送服。(《丁甘仁医案》)
例二赵，男，31岁，10月。湿热久蕴，营卫受阻，气血无以润养诸筋，胭内消瘦，筋骨痿软，下肢不能伸缩，脉象濡细，舌苔薄白，治拟气血并补，舒筋通络。清炙黄芪15克酒炒当归12克桂枝尖2．4克炙广地龙9克炒天虫9克老钩藤12克丝瓜络15克杜红花3克酒炒川断9克伸筋草12克千年健6克二诊：经云“气主煦之，血主濡之”。气血俱亏，不能温润肌肉筋脉，故渐而成痿。脉证如前，仍守原意出入。清炙黄芪15克酒炒当归9克大熟地15克杜红花3克清炙广地龙9克桂枝尖2．4克炒赤白芍各6克泽泻9克茯苓12克炒怀牛膝9克炒黄柏4．5克三诊：湿热浸淫，气血不充，无以濡养肌筋，两足痿软，肌肉消瘦，伸缩活动略有好转，苔薄黄，脉仍濡细，再仿丹溪加味二妙散法：炒黄柏6克炒苍术4．5克酒炒当归9克防己9克川萆薜9克怀牛膝9克炙龟板15克熟地15克炙黄芪15克炙甘草4．5克茯苓12克四诊：前方服后，湿热日渐清化，筋脉得气血之濡养，下肢软痿好转，尚能任地移行，伸缩已趋正常，再拟补气血填肝肾继之。米炒上潞参9克炙黄芪15克酒炒当归9克熟地24克怀牛膝9克炒黄柏4．5克酒炒川续断9克炒白芍9克炙甘草4．5克防己6克盐水炒杜仲15克健步虎潜丸12克(分吞)(《叶熙春医案》)[评按]痿证系指肢体筋脉弛缓，手足痿软的病证。一般分为肺热熏灼、肝肾虚亏、湿热浸淫等证型，其发病且与脾胃津液枯槁有关，故痿证大多属热、属虚。
例一证属阴液已伤，虚火灼金，肺热叶焦而致痿躄，遂取养肺阴、清阳明，下病治上之法，见效后，加入益精养血之品，此即张介宾所谓：“善补阴者，必于阳中求阴，则阴得阳升而源泉不竭”之义。丁氏将痿证分为热痿与湿痿，在临床上较易掌握。
例二系因气血不足，筋肉失于濡养而致痿。盖治痿之法，古有独取阳明之说。叶氏认为，病起中焦，独取阳明可也，病起厥阴，则应填补旰肾。而本例介于厥阴、太阴之间，故于补气血之中，增入化湿清热之味，可谓治痿之又一法。
附：重症肌无力
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)：2，981)
例二洪XX，男，34岁。初诊日期：1964年6月5日。患感冒已20多天。现证两足趾热痛，痛甚不可忍，不敢着地，夜卧必置于被外，面黄赤，口唇舌质紫红，舌苔白腻，根部微黄，午后发热，脉濡数。辨证：湿热闭阻经络。治法：清热祛湿，活血开痹。方药：苍术12克防己12克通草12克苡米24克地龙12克牛膝12克苏木9克蒲公英30克甘草6克水煎服外用桃仁12克，杏仁12克，薄荷9克，荆芥9克，栀子12克，上药为面加白面少许，白酒合调糊状，外敷痛处。内服外糊并用，翌日痛止，服3剂能走路，8剂痊愈。(《老中医经验汇编》第一集，郑桥医案)
例三蔡XX，女，30岁。于1961年因关节疼痛全身发热，肌肤灼热(体温380(3上下)，烦渴引饮，大便秘结，盗汗颇多，住院治疗。罹病二月，四肢关节疼痛剧烈，手足不能举动，甚至不能触摸。脉弦大数，舌质绛，苔黄腻少津，曾服白虎加桂枝汤、独活寄生汤等均未效。辨证：阴血虚极，阴伤热炽，热甚灼筋，筋脉失养。治法：滋阴清热，固表止汗。方药；当归六黄汤加减。黄芪24克生地15克当归9克黄连4．5克黄芩6克黄柏6克花粉9克桑枝15克秦艽9克连服4剂，热象盗汗大减，舌苔渐润，又进3剂，燥屎下，上肢关节疼痛渐有好转，自能持杯饮水吃饭。效不更方，再连服4剂，关节疼痛减轻。半月后能下床步履，同时配合针灸隔日一次，二旬之间，身凉脉静，诸证悉愈。(《席梁丞治验录》)[评按]热痹系因湿热痹阻经络，或因素体阳盛，风寒湿邪侵袭经络，郁而化热所致。一般发病较急，除关节灼热肿痛外，多兼有热病证候。治以清热疏风、祛湿通络为法。
例一证属热痹而热胜于湿，故以清热泻火为主，佐以疏风祛湿，待热退痛减，续服蠲痹汤，以加强活血通络之功。
例二病值湿盛之际，素有蕴热而复感湿邪，由于透发不力而湿热互结下注，经络阻滞，治以清热祛湿、活血开痹通络，内外兼治而奏效。
例三虽为热痹而证候殊异，发热盗汗肢节剧痛，历时二月之久，汗愈出阴愈伤，阴愈伤而热愈炽，热甚灼筋，筋脉失养，故关节疼剧，服白虎加桂枝汤而热不解，用风药而痛愈剧，乃阴血虚极不能濡筋之故，复用独活寄生汤以致“风假火威，火乘风势”，痛热反而增剧，改用当归六黄汤以矫妄，滋阴清热、固表止汗而告愈。(二十五)血痹赵XX，女，34岁，初诊日期：1975年7月半月前因洗衣被等物30余件，劳累出汗，当天晚上卧床后，即觉右肘至肩部沉重，麻木、怕冷，酸痛，尤以肩部疼痛较甚。次日右上肢抬举困难，活动受限，入夜疼甚。望之患者痛苦病容，面色咣白少华。脉沉细无力，舌淡白而润。右臂欠温。辨证：寒湿侵伤，血行不畅，阳气痹阻而致血痹。治法：温阳行痹。方药：黄芪桂枝五物汤加味。黄芪30克桂枝9克白芍9克生姜15克大枣10枚姜黄12克羌活6克5剂复诊：右臂麻木沉重大减，但怕冷仍如前，且肩疼仍甚，脉沉细，舌苔白润。原方加制附片9克，嘱服5剂。三诊，臂已不麻，肩部酸痛，抬肩举臂自如，但仍伯冷，沉重，脉舌如前，原方加苡仁15克，蚕砂12克，以增除湿之功，嘱服5剂。四诊时病已痊愈。(《窦伯清医案》)[评按]血痹系指“卧出而风吹之，血凝于肤者为痹”(《素问·五藏生成篇》)，与风寒湿所致痹证不同。血痹以肌肉麻痹无痛感，痹证则麻痛并见。正虚之体劳而汗出，则阳气更虚，风邪侵袭则血行不畅，故见肌肉麻痹，若风邪较重，也可发生疼痛，故曰“如风痹状”。本病在《金匮要略》记述较详。本案证状尚属典型，方用黄芪桂枝五物汤加羌活、附子等辛温之晶，药证相符，疗效卓著。治法在遵古的基础上有所变化。(二十六)瘘证附；重症肌无力
例一封X；女，温病后，阴液已伤，虚火灼金，肺热叶焦则生痿躄，两足不能任地，咳呛不爽，谷食减少，咽喉干燥，脉濡滑而数，舌质红，苔黄，延经数月，恙根已深，姑拟养肺阴、清阳明，下病治上，乃古之成法。南沙参9克川石斛9克天花粉9克生甘草1．5克川贝母9克肥知母4．5克瓜萎皮9克甜光杏9克络石藤9克怀牛膝6克嫩桑枝9克冬瓜子9克活芦根1尺(去节)二诊：前进养肺阴清阳明之剂，已服10剂，咳呛内热，均见减轻，两足痿软不能任地，痿者萎也，如草木之萎，无雨露以灌溉，欲草木之荣茂，必得雨露之濡润，欲两足之不萎，必赖肺液以输布，能下荫于肝肾，肝得血则筋舒，肾得养则骨强，阴血充足，络热自清，治痿独取阳明，清阳明之热，滋肺金之阴以阳明能主润宗筋而流利机关也。大麦冬6克北沙参9克抱茯神9克淮山药9克细生地12克肥知母4．5克川贝母6克天花粉9克络石藤6克怀牛膝6克嫩桑枝9克三诊，五脏之热，皆能成痿，书有五痿之称，不独肺热叶焦也，然而虽有五，实则有二，热痿也，湿痿也。如草木久无雨露则萎，草木久被湿遏亦萎，两足痿躄，亦犹是也，今脉濡数，舌质红绛，此热痿也，叠进清阳明、滋肺阴以来，两足虽不能步履，已能自行举起之象，药病尚觉合宜，仍守原法，加入益精养血之品，徐图功效。北沙参9克大麦冬6克茯神9克怀山药9克川石斛9克小生地9克肥知母4．5克怀牛膝6克络石藤9克茺蔚子9克嫩桑枝9克猪脊髓两条(酒洗，入煎)虎潜丸9克，清晨淡盐汤送服。(《丁甘仁医案》)
例二赵，男，31岁，10月。湿热久蕴，营卫受阻，气血无以润养诸筋，胭内消瘦，筋骨痿软，下肢不能伸缩，脉象濡细，舌苔薄白，治拟气血并补，舒筋通络。清炙黄芪15克酒炒当归12克桂枝尖2．4克炙广地龙9克炒天虫9克老钩藤12克丝瓜络15克杜红花3克酒炒川断9克伸筋草12克千年健6克二诊：经云“气主煦之，血主濡之”。气血俱亏，不能温润肌肉筋脉，故渐而成痿。脉证如前，仍守原意出入。清炙黄芪15克酒炒当归9克大熟地15克杜红花3克清炙广地龙9克桂枝尖2．4克炒赤白芍各6克泽泻9克茯苓12克炒怀牛膝9克炒黄柏4．5克三诊：湿热浸淫，气血不充，无以濡养肌筋，两足痿软，肌肉消瘦，伸缩活动略有好转，苔薄黄，脉仍濡细，再仿丹溪加味二妙散法：炒黄柏6克炒苍术4．5克酒炒当归9克防己9克川萆薜9克怀牛膝9克炙龟板15克熟地15克炙黄芪15克炙甘草4．5克茯苓12克四诊：前方服后，湿热日渐清化，筋脉得气血之濡养，下肢软痿好转，尚能任地移行，伸缩已趋正常，再拟补气血填肝肾继之。米炒上潞参9克炙黄芪15克酒炒当归9克熟地24克怀牛膝9克炒黄柏4．5克酒炒川续断9克炒白芍9克炙甘草4．5克防己6克盐水炒杜仲15克健步虎潜丸12克(分吞)(《叶熙春医案》)[评按]痿证系指肢体筋脉弛缓，手足痿软的病证。一般分为肺热熏灼、肝肾虚亏、湿热浸淫等证型，其发病且与脾胃津液枯槁有关，故痿证大多属热、属虚。
例一证属阴液已伤，虚火灼金，肺热叶焦而致痿躄，遂取养肺阴、清阳明，下病治上之法，见效后，加入益精养血之品，此即张介宾所谓：“善补阴者，必于阳中求阴，则阴得阳升而源泉不竭”之义。丁氏将痿证分为热痿与湿痿，在临床上较易掌握。
例二系因气血不足，筋肉失于濡养而致痿。盖治痿之法，古有独取阳明之说。叶氏认为，病起中焦，独取阳明可也，病起厥阴，则应填补旰肾。而本例介于厥阴、太阴之间，故于补气血之中，增入化湿清热之味，可谓治痿之又一法。
附：重症肌无力
Case 2 Gao XX, male, 56 years old, outpatient number 76/34981. First visit date: April 22, 1976. Suffered from rheumatoid arthritis for over three years, with swelling, pain, and deformity of the fingers and toes, aversion to cold, fatigue, deep and fine pulse, and thin white tongue coating. Syndrome differentiation: Wind-cold-dampness has long obstructed the collaterals, accompanied by blood stasis coagulation. Treatment method: It is appropriate to incorporate into Da Wutou Decoction (Great Aconite Decoction) herbs that resolve stasis and search out the collaterals. Prescription: Prepared Chuanwu and Caowu each 9g (decoct first), Raw Huangqi (Astragalus Root) 15g, Clean Mahuang (Ephedra Herba) 6g, Whole Danggui (Angelica Sinensis) 9g, Xixin (Asarum) 3g, Raw Gancao (Licorice Root) 9g, Chuan Guizhi (Cinnamon Twig) 9g, Stir-fried Chi Shaoyao (Red Peony Root) and Bai Shaoyao (White Peony Root) each 9g, Taoren (Peach Kernel) 9g, Honghua (Safflower) 6g, Qishe (Agkistrodon) 9g, Quanxie Powder (Scorpion Powder) 1.2g (swallow separately), Pure honey 15g (dissolve). With slight modifications, taken for over 30 doses. May 28 (Second visit): Swelling and pain of the toes greatly reduced, swelling and pain of the fingers also lightened, aversion to cold remains as before, deep and fine pulse, thin white tongue coating. The body is deficient in Yang, but there are signs of transformation in wind-cold-dampness and stasis. Still adhere to the previous method with additions and subtractions. Prepared Chuanwu and Caowu each 9g (decoct first), Raw Huangqi 18g, Clean Mahuang 6g, Chuan Guizhi 9g, Bei Xixin 3g, Stir-fried Chi Shaoyao and Bai Shaoyao each 9g, Shu Fupian (Prepared Aconite Slice) 9g (decoct first), Raw Gancao 9g, Whole Danggui 15g, Lufengfang (Honeycomb) 9g, Quanxie Powder 1.2g (swallow separately), Qishe 9g, Pure honey 15g. June 22 (Third visit): Toe swelling subsided and pain stopped, finger pain stopped, deformity improved, fine pulse, white tongue coating. Wind-cold-dampness and stasis are gradually resolving. Due to the chronic nature of the disease, Qi and Blood are depleted. Incorporate into the previous prescription herbs that tonify Qi and nourish Blood. Prepared Chuanwu and Caowu each 9g (decoct first), Shu Fupian 9g (decoct first), Whole Danggui 15g, Chuan Guizhi 9g, Bei Xixin 3g, Large Shudi (Rehmannia Root) 15g, Zhi Huangqi (Honey-fried Astragalus Root) 15g, Stir-fried Bai Shaoyao 9g, Stir-fried Chuanxiong (Ligusticum Rhizome) 6g, Lujiaopian (Deer Antler Slice) 9g, Quanxie Powder 1.2g (swallow separately), Qishe 9g, Pure honey 15g (dissolve), 14 doses. (From "Medical Cases of Zhang Boyu")
Case 3 Liu XX, male, 51 years old. Suffered from rheumatic arthritis for over twenty years. Recently exacerbated severely, especially swelling and pain in the right knee joint, requiring assistance to walk, lower back pain, severe aversion to cold, no thirst in mouth, loose stools easily, poor appetite, prone to catching colds, white and moist tongue coating, deep, fine, and weak pulse. Prescribed Guizhi Tang (Cinnamon Twig Decoction) plus Fuzi (Aconite) and Baizhu (Atractylodes Macrocephala Rhizome). Guizhi 10g, Shaoyao 30g, Zhi Gancao 10g, Shengjiang (Fresh Ginger) 3 slices, Dazao (Jujube) 5 pieces, Shu Fuzi 10g, Baizhu 24g, Raw Huangqi 24g, Fangfeng (Saposhnikovia Root) 10g, Danggui 15g, Sangjisheng (Taxillus Branch) 30g, Duzhong (Eucommia Bark) 15g, Xuduan (Dipsacus Root) 15g, Zhi Rushan and Moya (Processed Frankincense and Myrrh) each 15g. After taking 3 doses initially, waist and leg pain greatly reduced. After 5 doses, could walk alone on the street. After 10 doses, waist and knee pain basically resolved, returned to work. (Wan Yousheng: Clinical Experience with Guizhi Tang and its Modifications, *Jiangxi Traditional Chinese Medicine* 2:2, 1981)
Case 4 Wang XX, female, 35 years old, first visit date: September 20, 1977. Patient had a pale complexion, flabby obesity, and listlessness. Three years ago, pain occurred in the right sacral region and upper right thigh. Pain in limbs and joints was heavy and fixed, movement was inconvenient, skin often felt numb. Mouth was bland without thirst, diet and sleep were acceptable, bowel movements and urination were normal. Menstruation was irregular, often delayed, leukorrhea was abundant. Tongue coating was white and greasy, pulse was soggy and weak. Western medicine diagnosed as rheumatic arthritis. Syndrome differentiation: Dampness pathogen stagnates, blocking Qi and Blood, collaterals are not smooth. Treatment method: Resolve dampness and unblock collaterals, dispel wind and scatter cold. Prescription: Modified Yiyiren Tang (Coix Seed Decoction) from *Leizheng Zaicai*: Yiyiren (Coix Seed) 30g, Chuanxiong 7g, Danggui 10g, Guizhi (Cinnamon Twig) ?g, Duhuo (Angelica Pubescens) 7g, Dangshen (Codonopsis Root) 20g, Huangqi 20g, Chuanwu (Aconitum Carleiolii) 7g, Cangzhu (Atractylodes Lancea Rhizome) 10g, Mugua (Chaenomeles Fruit) 10g, Qinjiao (Gentiana Macrophylla Root) 10g. Decoct in water, take one dose daily. Combined with Xiaohuoluo Dan (Minor Collateral-Activating Pill), with adjustments as needed. Treated for two months, all symptoms improved. (Sheng Guorong: Discussion on Treatment of Bi Syndrome, *Fujian Traditional Chinese Medicine* 1(2):3, 1981) [Commentary]: Bi Syndrome refers to diseases caused by invasion of wind, cold, and dampness pathogens leading to obstruction of collaterals and blockage of Qi and Blood. As stated in *Jisheng Fang*, the occurrence of Bi syndrome is "due to body deficiency, empty and sparse interstices, resulting in Bi from wind-cold-dampness." External invasion of wind-cold-dampness usually occurs together, but one may predominate. Wind predominance leads to Moving Bi; Cold predominance leads to Painful Bi; Dampness predominance leads to Heaviness Bi.
Case 1 Wind predominance, treat with warming meridians and unblocking collaterals, assisted by wind-dispelling herbs.
Case 2 Diagnosed as rheumatoid arthritis, caused by wind-cold-dampness long obstructing collaterals with blood stasis coagulation, difficult to expel externally. Using general wind-dispelling or warming herbs is like scratching an itch through a boot. One must use Da Wutou Decoction, which is extremely pungent and hot, to warm meridians, drive out cold, and unblock collaterals, plus insect drugs that penetrate bone and search collaterals, to be effective. This case initially used Da Wutou Decoction added with Danggui Sini Tang (Angelica Decoction for Warming the Extremities) plus Taoren and Honghua to warm meridians, scatter cold, invigorate blood, and unblock collaterals, using Quanxie and Qishe to search and eliminate collaterals. Later, Fuzi and Lujiaopian were added to support healthy Qi and warm Yang, achieving good results.
Case 3 The course of disease is long. Mr. Wan believes that Taiyang and Shaoyin are exterior-interior related. Thus, when wind-cold-dampness invades Taiyang, it often damages Shaoyin Yang Qi. Also, since Taiyin dislikes dampness, excessive dampness easily injures Spleen Yang. Therefore, treating Taiyang wind-cold-damp Bi requires dispersing Taiyang wind-cold-dampness while simultaneously supporting Shaoyin and Taiyang Yang Qi. This formula functions to release the exterior and warm the interior, relieve urgency and pain, nourish blood and benefit sinews, invigorate blood and unblock collaterals. Its use in treating Bi syndrome is an extension of Guizhi Tang.
Case 4 Damp Bi is caused by dampness stagnation blocking Qi and Blood. The prescription uses Yiyiren Tang, focusing on resolving dampness and unblocking collaterals. All four cases above are Bi syndromes. Because the severity of wind-cold-dampness differs, treatment emphasis varies. However, the principle of treating blood runs throughout: unblock if there is blood stasis, replenish if there is blood deficiency. This deeply grasps the essence: "To treat wind, first treat blood; when blood moves, wind extinguishes itself."
(24) Heat Bi
Case 1 Lin XX, male, 34 years old. Visited in 1976. Patient had a flushed face, robust physique, fever with aversion to cold (temperature 38°C), thirst, redness and swelling of the right knee joint, difficulty moving for six days. Restlessness, insomnia, constipation, short and dark urine, red tongue body, yellow and dry coating, wiry and rapid pulse. Diagnosed as acute rheumatic arthritis. Syndrome differentiation: Damp-heat internal accumulation, pathogen transforming into heat. Treatment method: Clear heat and purge fire, assisted by dispersing wind and resolving dampness. Prescription: Modified Xuanbi Tang (Ventilating Bi Decoction) from *Wenbing Tiaobian*: Fangji (Stephania Root) 10g, Can Sha (Silkworm Excrement) 16g, Chixiaodou (Adzuki Bean) 20g, Huashi (Talcum) 20g, Lianqiao (Forsythia Fruit) 10g, Shanzhi (Gardenia Fruit) 10g, Huangqin (Scutellaria Root) 10g, Raw Shigao (Gypsum Fibrosum) 30g, Sangzhi (Mulberry Twig) 20g, Fangfeng 6g, Zhimu (Anemarrhena Rhizome) 10g. Decoct in water, take one dose daily. After taking 4 doses continuously, fever subsided, redness, swelling, and pain of the left knee joint also alleviated. Subsequently continued with modified Juanbi Tang (Dispel Bi Decoction), prescription as follows: Qinjiao 10g, Duhuo 6g, Jinteng (Honeysuckle Stem) 20g, Danggui 10g, Sangzhi 20g, Jixueteng (Spatholobus Stem) 16g, Chuanxiong 10g, Niuxi (Achyranthes Root) 14g, Bixie (Dioscorea Hypoglauca Rhizome) 10g, Yiren (Coix Seed) 30g. Decoct in water, take one dose daily. Combined with Xiaohuoluo Dan. Regulated for one month and cured. (Sheng Guorong: Discussion on Treatment of Bi Syndrome, *Fujian Traditional Chinese Medicine* 1(2):2, 1981)
Case 2 Hong XX, male, 34 years old. First visit date: June 5, 1964. Had a cold for over 20 days. Current symptoms: hot pain in both big toes, unbearable pain, afraid to step on ground, must place feet outside quilt at night, sallow and red face, purple-red lips and tongue body, white and greasy tongue coating with slightly yellow root, afternoon fever, soggy and rapid pulse. Syndrome differentiation: Damp-heat blocking collaterals. Treatment method: Clear heat and resolve dampness, invigorate blood and open Bi. Prescription: Cangzhu 12g, Fangji 12g, Tongcao (Tetrapanax Pith) 12g, Yimi (Coix Seed) 24g, Dilong (Earthworm) 12g, Niuxi 12g, Sumu (Sappan Wood) 9g, Gongying (Dandelion) 30g, Gancao 6g. Decoct in water for oral administration. External application: Taoren 12g, Xingren (Apricot Kernel) 12g, Bohe (Mint) 9g, Jingjie (Schizonepeta Spike) 9g, Zhizi 12g. Grind these herbs into powder, add a little white flour, mix with white wine to form a paste, apply externally to painful areas. Internal and external treatment combined. Pain stopped the next day, could walk after 3 doses, cured after 8 doses. (Compiled from *Experiences of Old TCM Doctors*, Vol. 1, Zheng Qiao Medical Cases)
Case 3 Cai XX, female, 30 years old. In 1961, due to joint pain and whole-body fever, burning skin (temperature around 38°C), irritability and thirst with desire to drink, constipation, and profuse night sweats, hospitalized. Sick for two months, severe pain in four limbs' joints, hands and feet unable to move, even unable to touch. Pulse wiry, large, and rapid, crimson tongue body, yellow and greasy coating with little fluid. Previously took Baihu Jia Guizhi Tang (White Tiger Plus Cinnamon Twig Decoction) and Duhuo Jisheng Tang (Angelica Pubescens and Taxillus Decoction) without effect. Syndrome differentiation: Extreme deficiency of Yin and Blood, Yin injury with fierce heat, heat scorching sinews, sinews and collaterals lacking nourishment. Treatment method: Nourish Yin and clear heat, secure exterior and stop sweating. Prescription: Modified Danggui Liuhuang Tang (Angelica Six Yellow Decoction). Huangqi 24g, Shengdi (Raw Rehmannia Root) 15g, Danggui 9g, Huanglian (Coptis Rhizome) 4.5g, Huangqin 6g, Huangbai (Phellodendron Bark) 6g, Huafen (Trichosanthes Root) 9g, Sangzhi 15g, Qinjiao 9g. Taken continuously for 4 doses, heat signs and night sweats greatly reduced, tongue coating gradually moistened. Took another 3 doses, dry stool passed, upper limb joint pain gradually improved, able to hold cup to drink and eat. Do not change formula upon efficacy, continue taking for 4 more doses, joint pain alleviated. Half a month later, able to get out of bed and walk. Simultaneously combined with acupuncture every other day. Within twenty days, body cooled, pulse quiet, all symptoms cured. (From *Records of Xi Liangcheng's Curative Experiences*) [Commentary]: Heat Bi is caused by damp-heat blocking collaterals, or due to constitutive Yang excess where wind-cold-dampness invades collaterals and stagnates transforming into heat. Generally onset is acute. Besides burning, swollen, and painful joints, there are often accompanying heat disease symptoms. Treatment method is clearing heat, dispersing wind, resolving dampness, and unblocking collaterals.
Case 1 Syndrome belongs to Heat Bi with heat exceeding dampness, so focus on clearing heat and purging fire, assisted by dispersing wind and resolving dampness. After heat subsides and pain reduces, continue taking Juanbi Tang to strengthen the function of invigorating blood and unblocking collaterals.
Case 2 Disease occurs during peak dampness season, with existing latent heat compounded by dampness pathogen. Due to ineffective venting, damp-heat binds and flows downward, blocking collaterals. Treat with clearing heat, resolving dampness, invigorating blood, opening Bi, and unblocking collaterals, combining internal and external treatment for effectiveness.
Case 3 Although Heat Bi, the syndrome is distinct. Fever, night sweats, severe joint pain lasting two months. Sweating increases Yin injury, Yin injury makes heat fiercer, heat scorches sinews, sinews lack nourishment, hence severe joint pain. Taking Baihu Jia Guizhi Tang did not resolve heat, using wind-dispelling herbs made pain worse. This is due to extreme Yin-Blood deficiency failing to moisten sinews. Reusing Duhuo Jisheng Tang led to "wind borrowing fire's might, fire riding wind's momentum," worsening pain and heat. Changed to Danggui Liuhuang Tang to correct the error, nourishing Yin, clearing heat, securing exterior, stopping sweat, and achieving cure.
(25) Blood Bi Zhao XX, female, 34 years old, first visit date: July 1975. Half a month prior, due to washing over 30 items like clothes and quilts, exertion and sweating, that night after lying in bed, felt heaviness, numbness, aversion to cold, and sore pain from right elbow to shoulder, especially severe shoulder pain. Next day, difficulty raising right upper limb, limited movement, severe pain at night. Observation showed patient in painful condition, sallow and lusterless complexion. Deep, fine, and powerless pulse, pale white and moist tongue. Right arm lacked warmth. Syndrome differentiation: Cold-dampness invading and injuring, blood flow not smooth, Yang Qi blocked leading to Blood Bi. Treatment method: Warm Yang and move Bi. Prescription: Modified Huangqi Guizhi Wuwu Tang (Astragalus and Cinnamon Twig Five Substance Decoction). Huangqi 30g, Guizhi 9g, Shaoyao 9g, Shengjiang 15g, Dazao 10 pieces, Jianghuang (Turmeric Rhizome) 12g, Qianghuo (Notopterygium Rhizome) 6g. 5 doses. Second visit: Right arm numbness and heaviness greatly reduced, but aversion to cold remained as before, and shoulder pain still severe, deep and fine pulse, white and moist tongue coating. Original formula plus Zhi Fupian 9g, instructed to take 5 doses. Third visit: Arm no longer numb, shoulder sore pain, raising shoulder and arm freely, but still afraid of cold and heaviness, pulse and tongue as before. Original formula plus Yiren 15g, Can Sha 12g to increase damp-resolving function, instructed to take 5 doses. Fourth visit: Disease cured. (From "Dou Boqing Medical Cases") [Commentary]: Blood Bi refers to "lying out and being blown by wind, blood coagulates in skin becoming Bi" (*Suwen: Chapter on Generation of Five Viscera*), different from Bi caused by wind-cold-dampness. Blood Bi presents with muscle paralysis without pain, whereas Bi presents with both numbness and pain. In a constitutionally deficient person, exertion and sweating make Yang Qi more deficient. Wind pathogen invasion causes blood flow not to be smooth, hence muscle paralysis. If wind pathogen is heavier, pain can occur, hence described as "like Feng Bi". This disease is recorded in detail in *Jingui Yaolue*. This case's symptoms are typical. Formula uses Huangqi Guizhi Wuwu Tang plus Qianghuo, Fuzi, and other acrid-warm herbs. Medicine matches syndrome,疗效 is outstanding. Treatment method changes slightly based on following ancient principles.
(26) Wei Syndrome Appendix: Myasthenia Gravis
Case 1 Feng X, female. After warm disease, Yin fluids already injured, deficient fire scorching Metal, Lung heat withering leaves leads to Wei Bi (paralysis), both legs unable to bear weight, coughing unpleasantly, reduced food intake, dry throat, soggy-slippery-rapid pulse, red tongue body, yellow coating. Persisted for months, root of illness deep. Tentatively prescribe nourishing Lung Yin, clearing Yangming. Treating lower disease from above is an ancient established method. Nan Shashen (Adenophora Root) 9g, Chuan Shihu (Dendrobium Stem) 9g, Tianhuafen (Trichosanthes Root) 9g, Raw Gancao 1.5g, Chuan Beimu (Fritillaria Cirrhosa Bulb) 9g, Fei Zhimu 4.5g, Gualoupi (Trichosanthes Peel) 9g, Tianguangxing (Sweet Apricot Kernel) 9g, Luoshteng (Trachelospermum Vine) 9g, Huainiu (Achyrathes Root) 6g, Nensangzhi (Young Mulberry Twig) 9g, Dongguazi (Winter Melon Seed) 9g, Huolugen (Live Reed Rhizome) 1 chi (remove nodes). Second visit: Previous dosage nourishing Lung Yin and clearing Yangming, taken 10 doses, coughing and internal heat both alleviated. Both legs flaccid and unable to bear weight. Wei means withering, like plants withering. Without rain and dew to irrigate, plants cannot flourish. To prevent legs from withering, must rely on Lung fluids to distribute, nourishing Liver and Kidney below. Liver gets blood then sinews relax, Kidney gets nourishment then bones strong. Yin and Blood sufficient, collateral heat clears. Treat Wei by exclusively selecting Yangming. Clear Yangming heat, nourish Lung Metal Yin because Yangming governs moistening Zongjin (major sinews) and facilitating joints. Damai Dong (Ophiopogon Tuber) 6g, Beishashen (Glehnia Root) 9g, Baofushen (Poria with Hostwood) 9g, Huaishanyao (Chinese Yam) 9g, Xi Shengdi 12g, Fei Zhimu 4.5g, Chuan Beimu 6g, Tianhuafen 9g, Luoshteng 6g, Huainiu 6g, Nensangzhi 9g. Third visit: Heat in five viscera can all cause Wei. Books mention five types of Wei, not just Lung heat withering leaves. However, although five, essentially two: Heat Wei and Damp Wei. Like plants withering from lack of rain/dew, or withering from damp suppression. Two legs Wei Bi is similar. Now pulse soggy-rapid, tongue crimson, this is Heat Wei. Since repeatedly advancing clearing Yangming and nourishing Lung Yin, although legs cannot walk, they can lift themselves. Medicine and disease seem appropriate. Still adhere to original method, add essence-nourishing and blood-supplementing herbs, slowly seek efficacy. Beishashen 9g, Damai Dong 6g, Fushen (Poria) 9g, Huaishanyao 9g, Chuan Shihu 9g, Xiao Shengdi 9g, Fei Zhimu 4.5g, Huainiu 6g, Luoshteng 9g, Chongwezi (Chervil Seed) 9g, Nensangzhi 9g, Zhu Suishui (Pig Spinal Cord) two strips (wash with wine, decoct), Hujian Wan (Tiger Hidden Pill) 9g, taken early morning with light salt soup. (From "Ding Ganren Medical Cases")
Case 2 Zhao, male, 31 years old, October. Damp-heat long accumulated, Ying and Wei blocked, Qi and Blood unable to moisten and nourish sinews. Popliteal area emaciated, sinews and bones flaccid, lower limbs unable to flex and extend, soggy-fine pulse, thin white tongue coating. Treatment plan: Tonify Qi and Blood together, relax sinews and unblock collaterals. Qing Zhi Huangqi (Clear Honey-fried Astragalus) 15g, Wine-fried Danggui 12g, Guizhi Jian (Cinnamon Twig Tip) 2.4g, Zhi Guang Dilong (Honey-fried Earthworm) 9g, Chao Tianchong (Stir-fried Cicada Slough) 9g, Lao Gouteng (Old Uncaria Ramulus) 12g, Sigualuo (Luffa Reticulate Fiber) 15g, Du Honghua (Du Red Safflower) 3g, Wine-fried Chuanduan (Dipsacus) 9g, Shenjincao (Lycopodium Herb) 12g, Qiannianjian (Cyrtandra Rhizome) 6g. Second visit: Classic says "Qi warms, Blood moistens." Qi and Blood both deficient, unable to warm and moisten muscles and sinews, thus gradually becoming Wei. Pulse and syndrome as before, still adhere to original intent with variations. Qing Zhi Huangqi 15g, Wine-fried Danggui 9g, Large Shudi 15g, Du Honghua 3g, Qing Zhi Guang Dilong 9g, Guizhi Jian 2.4g, Stir-fried Chi Shaoyao and Bai Shaoyao each 6g, Zexie (Alisma Rhizome) 9g, Fuling (Poria) 12g, Stir-fried Huainiu 9g, Stir-fried Huangbai 4.5g. Third visit: Damp-heat soaking, Qi and Blood not full, unable to nourish muscles and sinews. Both legs flaccid, muscle emaciation, flexion and extension slightly improved, thin yellow coating, pulse still soggy-fine. Again imitate Danxi's Modified Ermiao San Method: Stir-fried Huangbai 6g, Stir-fried Cangzhu 4.5g, Wine-fried Danggui 9g, Fangji 9g, Chuan Bixie 9g, Huainiu 9g, Zhi Guiban (Honey-fried Tortoise Shell) 15g, Shudi 15g, Zhi Huangqi 15g, Zhi Gancao 4.5g, Fuling 12g. Fourth visit: After taking previous formula, damp-heat gradually cleared and transformed. Sinews and collaterals receive Qi and Blood nourishment. Lower limb soft Wei improves, able to bear weight and move, flexion and extension approaching normal. Plan again to tonify Qi and Blood, fill Liver and Kidney subsequently. Rice-fried Shang Lushen (Codonopsis) 9g, Zhi Huangqi 15g, Wine-fried Danggui 9g, Shudi 24g, Huainiu 9g, Stir-fried Huangbai 4.5g, Wine-fried Chuan Xuduan 9g, Stir-fried Bai Shaoyao 9g, Zhi Gancao 4.5g, Fangji 6g, Salt-water fried Duzhong 15g, Jianbu Hujian Wan (Walking Tiger Hidden Pill) 12g (swallow separately). (From "Ye Xichun Medical Cases") [Commentary]: Wei Syndrome refers to diseases of flaccid sinews and collaterals in limbs, with flaccidity of hands and feet. Generally divided into Lung heat scorching, Liver-Kidney deficiency, Damp-heat soaking types. Onset is also related to exhaustion of Spleen-Stomach fluids. Thus Wei syndrome mostly belongs to Heat and Deficiency.
Case 1 Syndrome belongs to Yin fluid injury, deficient fire scorching Metal, Lung heat withering leaves causing Wei Bi. Thus adopt method of nourishing Lung Yin, clearing Yangming, treating lower disease from above. After efficacy, add essence-nourishing and blood-supplementing herbs. This is the meaning of Zhang Jiabin's saying: "Those good at tonifying Yin must seek Yin within Yang, so Yin rises with Yang and source does not exhaust." Mr. Ding divides Wei syndrome into Heat Wei and Damp Wei, easier to grasp clinically.
Case 2 Caused by Qi and Blood insufficiency, muscles and sinews lacking nourishment. Regarding treatment of Wei, ancient theory says "exclusively select Yangming." Mr. Ye believes, if disease originates in Middle Jiao, exclusively selecting Yangming is fine; if originating in Jueyin, should fill Liver and Kidney. This case is between Jueyin and Taiyin, thus among tonifying Qi and Blood, add damp-resolving and heat-clearing flavors. This can be considered another method of treating Wei.
Appendix: Myasthenia Gravis