【评按】乳癖由形寒饮冷，复加气郁，痰邪流渗乳络、积聚不散所致。此案的治疗方药从民间医生家属处而得。原治乳岩，黄氏以此方加减运用于乳癖颇见效验。方中柴胡、当归、香附理气和血，半夏配香附化痰散结，枸橘李、橘叶皮、公英、漏芦软坚通络，佐以二活升散、法风止痛。另用逍遥丸，小金丹以疏肝化痰、法瘀定痛。外敷皮硝，功能软坚消解。此案治法较之古代外科专著所载，有所改善提高。
（十四）乳疬张某某，女，34岁。月经前双侧乳房胀痛，触之有鸽蛋及蚕豆大小之包块数个，质略软、有轻压痛、推之可移动，月经后即缩小变软，患者精神紧张，怀疑为新生物，曾到各医院检查，诊断为“乳腺增生”、慢性乳腺囊性病”嘱定期观察及中医治疗。诊脉两关不调，舌质淡紫，有小瘀点，苔薄白，面色晦而不华。辨证：肝气不舒、气血失和，经脉瘀滞、结为乳疬。治法：舒肝理气、活血通络，散结软坚。方药，柴胡疏肝汤加味。柴胡9克白芍12克枳壳9克制香附9克郁金6克栝蒌壳9克青皮9克归尾15克生牡蛎18克夏枯草6克甘草3克每周3剂，连服一月。复诊：月经如常，乳房胀痛已止，包块只有黄豆大，质软。嘱每月复查一次，治疗基本方不变，治疗八月，包块已消散，追踪观察病未复发。（《李继昌医案》）
【评按】疬之生于乳部者、名为乳疬。此案由肝郁、气血失和，经脉瘀滞所致。李氏治以张介宾柴胡疏肝散加味方，着重疏肝理气，活血通络，软坚散结。此证甚易溃烂、古法有用土楝子（经霜者佳）、雄鼠屎、露蜂房各等分，俱煅存性为未，每服9克酒调服，间三日一服以治之者，功能排脓敛毒，聊备参考。
（十五）乳痨潘××，女，29岁。初诊日期：1973年9月10日。患者第二胎产后四个月，于二个月前左乳内侧肿胀。疼痛，发热，诊为急往乳腺炎，经抗菌素、服西药治疗无效，化脓自溃，溃后热渐退，疼痛等症也逐渐消失，但破口始终不愈，乳汁似有若无，全身无力，气短不眠，食欲不振，便溏。检查：慢性病容，形体消瘦，语言低微，二目无神，颜面无华，指甲苍白，左乳内侧可触及肿块，大小约占乳房内侧的3/4，表面不红，皮温不高，质硬。疮口塌陷，脓稀色灰，其味腥秽，用探针检查，斜行探入达7厘米深。舌苔薄白，脉沉而细。辩证：气血两亏，脾虚胃弱，继发乳痨。治法：气血双补，扶脾开胃。方药：生芪24克党参18克云苓15克白术12克当归12克赤芍9克扁豆15克山药12至陈皮6克鸡内金9克生谷稻芽18克外用甲字提毒粉干撒疮口，外贴痈疽膏。治疗经过：1973年10月2日复诊，服药20余剂，自觉体力好转，食欲增进：大便变稠，两日一解，量不多；左乳症状如故。拟以温化寒湿、补益气血为法，方药如下：麻黄6克甘草3克大熟地18克炮姜9克肉桂9克鹿角胶9克生芪24克党参18克白芥子12克云苓15克白术12克当归12克赤芍9克外贴阳和解凝膏。10月18日
（三诊）：服上方15剂，精神、气力均见好转，食欲、二便正常，乳汁已通，量已够喂养婴儿。左乳乳汁较少，其内侧硬块变软，疮口已有轻度疼痛感，疮口红活高起，有新生肉芽，漏管变浅（深5厘米），脓汁黄稠。上方加白芷9克，桔梗9克。外用甲字提毒粉，用棉捻上药，外贴阳和解凝膏。10月30日
（四诊）：疮口肉芽新鲜，漏管深1．5厘米，脓已少，左乳硬块范围已小，并继续变软。继以益气养血，健脾生肌。方药如下：生芪18克云苓15至白术12克当归12克赤芍9克太子参18克自芥子9克甘草3克11月27日
（五诊）：疮口肉芽已平，已有新生上皮。患者面色红润，全身情况良好，改为每早服八珍丸二丸，每晚服人参养荣丸二丸。外用粗生肌粉、吃疮粉各半，混匀干撒。12月5日，疮面愈合，临床痊愈。（《房芝董外科经验》）
【评按】乳痨系指乳部结核，或称“乳痰”。多伴有形瘦、阴虚，午后烦热，干嗽，颧红食少。此例属继发性乳痨，辨证属气血两亏，脾胃虚弱，治以气血双补、扶脾开胃为主。局部外用提毒消肿之剂，复诊时治法，在补益气血的同时，着重于温化寒湿，内服阳和汤加减方，外贴阳和解凝膏，此二方均属《外科全生集》方，乃治疗阴疽、阴毒之常用方。未以调补气血法收功。此案前后数诊，方治有条理，药物稳妥有效。须予指出的是，乳痨阴虚者颇多，当以六味地黄丸加减为主方，有肺结核者，必当兼治之。
（十六）肠痈
例一陆左。。初诊：痛在脐右斜下一寸，西医所谓盲肠炎也；脉大而实，当下之，用仲景法。生军15克芒硝9克桃仁15克冬瓜仁30克丹皮30克二诊：痛已略缓，右足拘急，不得屈伸，伸则牵腹中痛，宜芍药甘草汤。赤白芍各15克生甘草9克炙没药各9克。三诊：右足已伸，腹中剧痛如故。仍宜大黄牡丹汤以下之。生川军30克芒硝21克（冲）桃仁15克冬瓜仁30克丹皮30克
（曹颖甫《经方实验录》）
例二李××，女，65岁。住院号：39087。初诊日期：1959年12月19日。家属代诉：恶心、呕吐，发烧伴右下腹痛两周。患者两周前开始脐周围肿痛。并有恶心、不思饮食，纳后即吐，认为患胃痛而未予治疗。痛渐转移到右下腹部，隐隐作痛，右腿不能伸直起坐，屈身而卧。伴有发烧，朝轻暮重，连日不退，大使多日未解。曾诊为阑尾炎，经肌注青霉素3天，未见好转。入院检查：神志清楚，精神萎顿，痛舍面容，表情淡漠。右下腹可摸到一个9x7厘米大小之包块，腹壁紧张、压痛，有反跳痛，肌肤甲错，右下肢拳曲而卧，脉象沉细，舌尖光、苔根薄黄腻。体温38℃，白细胞总数18，600／立方毫米，中性81％，、血压3159／80毫米汞柱。辨证：湿热夹瘀、阻滞肠腑，营卫不和，热胜肉腐，证属肠痈（西医诊断：阑尾周围脓肿）。治法：和营化瘀，排毒消肿。方药：炒桃仁9克栝萎仁9克冬瓜子仁9克丹皮6克归、尾9克赤芍6克银花9克连翘9克炙甲片6克皂角刺9克伸筋草9克水煎服，外敷金黄膏。12月21日
（二诊）：两剂药后，大便得解，右小腹痛势见轻，腹壁紧张得缓，压痛减轻，热势已挫，略思纳食，舌苔根薄腻渐化，脉象弦滑。宗前方加败酱草9克苡仁12克3剂。12月24日
（三诊）：药后右下腹包块明显缩小，疼痛不甚，右足已能伸直，体温37．4℃，胃纳转馨，舌苔薄布，脉细滑。治宗前方加减。生苡仁12克冬瓜子仁9克当归9克赤芍9克栝萎仁9克丹皮9至败酱草9克陈皮6克银花9克水煎服。12月27日
（四诊）：3剂后包块已摸不到，治愈出院。（《朱仁康临床经验集》
【评按】肠痈相当于急性阑尾炎，仲景立大黄牡丹汤、薏苡附子败酱散，为后世所宗法。
例一即大黄牡丹汤证，此方功能泻热消瘀、散结消肿。曹氏抓住患者脉证俱实，故敢放胆施治，获得痊愈。
例二为肠痈合并周围脓肿，辨证为湿热挟瘀、阻滞肠腑，营卫不和，热胜肉腐，治以三仁汤为主，方用丹皮、桃仁、归尾、赤芍活血散瘀，冬瓜子、苡仁、败酱草排脓消肿，萎仁润燥通肠：银、翘清热解毒；并用山甲、憎371一皂刺以攻其坚，比二药有消、托两种作用，轻者能消，消之不可则托，促其自溃排服。总之，此案虽以三仁汤为主，实亦探合了大黄牡丹汤、薏苡附子贩酱散的多数药味，方治颇有精义。
（十七）肝痈邵某，右胁下硬隐痛，肿大如拳、寄予胁下，身体瘦弱，胁肋下皮肉菲薄，扪其皮外、缓力按之则累然大块，指下易得，诊为肝痈。穿刺为紫色血水，大便四五日未解，饮食少进，舌苔黄腻，小便黄赤。治以清肝热，凉血行瘀，泻火败毒。方药：粉丹皮15克生地黄15克青柴胡9克生黄芩12克夏枯草9克生大黄12克桃仁9克当归尾9克甘草梢9克净银花30克服药后，次日已能乘车来诊，面有笑容，患处肿胀已消其半，以手扶之疼痛减轻。原方药未变，药量各减3克，再服一剂。第三日，肿消痛减，前方去归尾、草梢，加云茯苓9克，焦白术9克，广陈皮9克，兼扶脾气。至第四日，肿消平复，改服调理脾胃之剂，兼清余邪，再进4剂，饮食渐加而愈。
（余无言：外科学中两个开刀问题和治疗报告，《新中医药》12：24，1955）
【评按】肝痈相当于肝脏肿。元·朱震亨认为；“肝痈始发，期门穴必隐痛”。此案治以清肝泻火、凉血行瘀为主，证方精契。如配合外治，可用芙蓉叶研极细末，凡士林调涂患部，外以消毒敷料盖贴，有消肿止痛作用。
（十八）肾痈柳姓，女。血分为湿热所郁，久而发为肾脏痈，腰肾及少腹左部胀痛，小溲时状若血淋，大便秘燥，舌黯无苔、边缘赤润，宜化瘀内消之。赤小豆（布包，煎）30克紫黄地丁冬12克生杜仲9克川芎4．5克炒丹皮9克生橘核12克当归尾12克炒二丑各6克乌药（土炒）9克生枳实4．5克栝蒌12克血余炭9克延胡索9克菟丝饼（盐水炒）4．5克犀黄丸4．5克（化服）黄土汤煎药，3剂。复诊：进服前方化瘀内消之剂，血少，腰痛减，少腹仍胀，小便浑浊，黄带颇盛，脉滑数，再加分清搜湿之味。原方加川萆薢12克、石苇12克，海金砂（布包煎）9克，西瓜翠衣用克（鲜），车前子（包煎）9克，去当归、川芎、栝蒌、血余炭、枳实。嘱服4剂。三诊：血止，溲清，腰痛已息。少腹微有下坠之意，颜面不似前苍黄，舌苔白薄，脉弦而沉。生牡蛎（包，先煎）24克子木通9克杜仲（盐水炒炭）9克阿胶珠3克紫丹参9克大腹绒45克川萆薢12克败龟板（包，先煎）6克桑寄生24克真血竭（包，先煎）6克甘草1．5克改用白水煎药，服6剂，并嘱常服猪肾。
（孔嗣伯整理：孔伯华医案，《中医杂志》8：547，1958）［评按］此案辨证，血分为湿热所郁。作为内痈之一，治当以内消为主，又须清除病理中的湿热和瘀滞，故于方中参入化瘀、清热、利湿诸法。分析前后数诊，可以看出孔氏治此病还借鉴了淋证治法，所拟诸方虽以祛邪为主，亦有顾护扶正之品。首诊方加用犀黄丸，意在消痈解毒；用黄土汤煎药者，寓有崇土制湿之意，方义颇堪玩味。
（十九）胆囊炎李某，女。患胆囊炎，右季肋部有自发痛与压痛感，常有微热，并出现恶心，食欲不振，腹部膨满，鼓肠暧气，脉弦大。投以大柴胡汤加味（柴胡12克，白芍9克，枳实6克，川军6克，黄芩9克，半夏9克，生姜15克，大枣4枚、擘，金钱草24克，滑石12克，鸡内金12克），连服7剂，食欲见佳，鼓肠、嗳气均大减。再进原方4剂，胁痛亦轻，唯微热来迟，改用小柴胡汤加鳖甲、青蒿、秦艽、郁金治之。（《岳美中医案集》）［评按］此例为慢性胆囊炎。大柴胡汤原治少阳热邪来解、阳明里热变盛的病理，岳氏以此方和解少阳，泻下热结。在用法上重用生姜以制呕恶；加金钱草以利胆清热，滑石利尿泄热，鸡内金克化积热，方药增损合宜。此方用以治阳实黄应及胆结石亦属对证。
（二十）胆结石
例一陈姓，男，旅苏，吴兴乡友，年约三十余，身体强壮。发病时突然寒战、发高热，剧痛、呕吐。初吐黄绿水，后无物可吐，痛时患者呈惊怖颜貌，甚至以指头探压舌根，促其呕吐，痛苦万状，脉弦滑数，黄症色鲜明，面目如装金，舌苔黄腻，便秘。断为阳明实症，用大柴胡汤，大黄加至12克，元明粉12克，开水泡浸顿服。另以熊胆1．2克分二次吞服，时值夏令，嘱多吃西瓜，小便增多，大便已通，黄疸稍减，一日服药后泻下稀粪，系下干搪磁痰盂内，忽听到一阵撒石子声，便后捡得结石20余颗，大者如黄豆，小者如绿豆，短圆形、菱形不等，外面黄色，剖视内面墨揭或兼灰白色。此后逐次以原方加减，服药两个月，比
【评按】乳癖（乳腺增生）是由于感受寒邪、饮食生冷，再加上气机郁滞，导致痰湿邪气流注并积聚在乳房络脉中，无法消散而引起的。这个案例的治疗方药是从民间医生家属那里获得的。原方用于治疗乳岩（乳腺癌），黄氏将此方加减后应用于治疗乳癖，效果非常显著。方中的柴胡、当归、香附能够理气和血；半夏配合香附可以化痰散结；枸橘李、橘叶皮、蒲公英、漏芦能够软坚通络；佐以羌活、独活升散风邪、祛风止痛。另外使用逍遥丸、小金丹来疏肝化痰、化瘀定痛。外敷皮硝，具有软坚消解的作用。此案的治法比古代外科专著中所记载的有所改善和提高。
（十四）乳疬（男性乳房发育症或女性乳腺异常肿块）张某某，女，34岁。月经前双侧乳房胀痛，触摸时有鸽蛋及蚕豆大小的数个包块，质地略软，有轻微压痛，推之可移动，月经结束后包块缩小变软。患者精神紧张，怀疑是新生物，曾到各家医院检查，诊断为“乳腺增生”、“慢性乳腺囊性病”，嘱咐定期观察及中医治疗。诊察发现两关脉不调，舌质淡紫，有小瘀点，苔薄白，面色晦暗无光泽。辨证：肝气不舒、气血失和，经脉瘀滞，结聚形成乳疬。治法：疏肝理气、活血通络，散结软坚。方药：柴胡疏肝汤加味。柴胡9克，白芍12克，枳壳9克，制香附9克，郁金6克，栝蒌壳9克，青皮9克，归尾15克，生牡蛎18克，夏枯草6克，甘草3克。每周3剂，连服一个月。复诊：月经恢复正常，乳房胀痛已停止，包块仅剩黄豆大小，质地变软。嘱咐每月复查一次，治疗基本方不变，治疗八个月后，包块已消散，追踪观察病情未复发。（《李继昌医案》）
【评按】发生在乳房部位的疬证，称为乳疬。此案由肝气郁结、气血失和，经脉瘀滞所致。李氏采用张介宾的柴胡疏肝散加味方进行治疗，着重于疏肝理气，活血通络，软坚散结。此证很容易溃烂，古法有用土楝子（经霜者为佳）、雄鼠屎、露蜂房各等分，全部煅烧至存性研为粉末，每次服用9克，酒调服，每隔三日服用一次以治疗，功能是排脓敛毒，仅供参考。
（十五）乳痨（乳房结核）潘××，女，29岁。初诊日期：1973年9月10日。患者第二胎产后四个月，两个月前左乳内侧出现肿胀、疼痛、发热，诊断为急性乳腺炎，经抗生素、西药治疗无效，化脓自溃，溃后热势渐退，疼痛等症状也逐渐消失，但破口始终不愈合，乳汁似有若无，全身无力，气短失眠，食欲不振，大便溏稀。检查：慢性病容，形体消瘦，语言低微，双目无神，颜面无华，指甲苍白，左乳内侧可触及肿块，大小约占乳房内侧的3/4，表面不红，皮温不高，质地硬。疮口塌陷，脓液稀薄色灰，气味腥秽，用探针检查，斜行探入达7厘米深。舌苔薄白，脉沉而细。辩证：气血两亏，脾虚胃弱，继发乳痨。治法：气血双补，扶脾开胃。方药：生黄芪24克，党参18克，云茯苓15克，白术12克，当归12克，赤芍9克，扁豆15克，山药12克，陈皮6克，鸡内金9克，生谷芽、生稻芽18克。外用甲字提毒粉干撒疮口，外贴痈疽膏。治疗经过：1973年10月2日复诊，服药20余剂，自觉体力好转，食欲增进，大便变稠，两日一解，量不多；左乳症状如故。拟以温化寒湿、补益气血为法，方药如下：麻黄6克，甘草3克，大熟地18克，炮姜9克，肉桂9克，鹿角胶9克，生黄芪24克，党参18克，白芥子12克，云茯苓15克，白术12克，当归12克，赤芍9克。外贴阳和解凝膏。10月18日
（三诊）：服上方15剂，精神、气力均见好转，食欲、二便正常，乳汁已通，量已够喂养婴儿。左乳乳汁较少，其内侧硬块变软，疮口已有轻度疼痛感，疮口红活高起，有新生肉芽，漏管变浅（深5厘米），脓汁黄稠。上方加白芷9克，桔梗9克。外用甲字提毒粉，用棉捻上药，外贴阳和解凝膏。10月30日
（四诊）：疮口肉芽新鲜，漏管深1.5厘米，脓已少，左乳硬块范围已小，并继续变软。继以益气养血，健脾生肌。方药如下：生黄芪18克，云茯苓15克，白术12克，当归12克，赤芍9克，太子参18克，白芥子9克，甘草3克。11月27日
（五诊）：疮口肉芽已平，已有新生上皮。患者面色红润，全身情况良好，改为每早服八珍丸二丸，每晚服人参养荣丸二丸。外用粗生肌粉、吃疮粉各半，混匀干撒。12月5日，疮面愈合，临床痊愈。（《房芝董外科经验》）
【评按】乳痨系指乳房部的结核，或称“乳痰”。多伴有形体消瘦、阴虚，午后烦热，干咳，颧红食少。此例属继发性乳痨，辨证属气血两亏，脾胃虚弱，治以气血双补、扶脾开胃为主。局部外用提毒消肿之剂，复诊时治法，在补益气血的同时，着重于温化寒湿，内服阳和汤加减方，外贴阳和解凝膏，此二方均属《外科全生集》方，乃治疗阴疽、阴毒之常用方。最终通过调补气血法收功。此案前后数诊，方治有条理，药物稳妥有效。须予指出的是，乳痨阴虚者颇多，当以六味地黄丸加减为主方，有肺结核者，必当兼治之。
例一陆左。初诊：疼痛在脐右斜下一寸，西医所谓盲肠炎也；脉大而实，当下之，用仲景法。生大黄15克，芒硝9克，桃仁15克，冬瓜仁30克，丹皮30克。二诊：疼痛已略缓，右足拘急，不得屈伸，伸则牵腹中痛，宜芍药甘草汤。赤芍、白芍各15克，生甘草9克，炙没药各9克。三诊：右足已伸，腹中剧痛如故。仍宜大黄牡丹汤以下之。生川军30克，芒硝21克（冲），桃仁15克，冬瓜仁30克，丹皮30克。
（曹颖甫《经方实验录》）
例二李××，女，65岁。住院号：39087。初诊日期：1959年12月19日。家属代诉：恶心、呕吐，发烧伴右下腹痛两周。患者两周前开始脐周围肿痛。并有恶心、不思饮食，纳后即吐，认为患胃痛而未予治疗。痛渐转移到右下腹部，隐隐作痛，右腿不能伸直起坐，屈身而卧。伴有发烧，朝轻暮重，连日不退，大便多日未解。曾诊为阑尾炎，经肌注青霉素3天，未见好转。入院检查：神志清楚，精神萎顿，痛苦面容，表情淡漠。右下腹可摸到一个9x7厘米大小之包块，腹壁紧张、压痛，有反跳痛，肌肤甲错，右下肢拳曲而卧，脉象沉细，舌尖光、苔根薄黄腻。体温38℃，白细胞总数18,600／立方毫米，中性81％，血压159／80毫米汞柱。辨证：湿热夹瘀、阻滞肠腑，营卫不和，热胜肉腐，证属肠痈（西医诊断：阑尾周围脓肿）。治法：和营化瘀，排毒消肿。方药：炒桃仁9克，栝萎仁9克，冬瓜子仁9克，丹皮6克，归尾9克，赤芍6克，银花9克，连翘9克，炙甲片6克，皂角刺9克，伸筋草9克。水煎服，外敷金黄膏。12月21日
（二诊）：两剂药后，大便得解，右小腹痛势见轻，腹壁紧张得缓，压痛减轻，热势已挫，略思纳食，舌苔根薄腻渐化，脉象弦滑。宗前方加败酱草9克，苡仁12克，3剂。12月24日
（三诊）：药后右下腹包块明显缩小，疼痛不甚，右足已能伸直，体温37.4℃，胃纳转馨，舌苔薄布，脉细滑。治宗前方加减。生苡仁12克，冬瓜子仁9克，当归9克，赤芍9克，栝萎仁9克，丹皮9克，败酱草9克，陈皮6克，银花9克。水煎服。12月27日
（四诊）：3剂后包块已摸不到，治愈出院。（《朱仁康临床经验集》）
【评按】肠痈相当于急性阑尾炎，仲景立大黄牡丹汤、薏苡附子败酱散，为后世所宗法。
例一即大黄牡丹汤证，此方功能泻热消瘀、散结消肿。曹氏抓住患者脉证俱实，故敢放胆施治，获得痊愈。
例二为肠痈合并周围脓肿，辨证为湿热挟瘀、阻滞肠腑，营卫不和，热胜肉腐，治以三仁汤为主，方用丹皮、桃仁、归尾、赤芍活血散瘀，冬瓜子、苡仁、败酱草排脓消肿，萎仁润燥通肠；银、翘清热解毒；并用山甲、皂刺以攻其坚，此二药有消、托两种作用，轻者能消，消之不可则托，促其自溃排脓。总之，此案虽以三仁汤为主，实亦探合了大黄牡丹汤、薏苡附子败酱散的多数药味，方治颇有精义。
（十七）肝痈（肝脏脓肿）邵某，右胁下硬隐痛，肿大如拳、触于胁下，身体瘦弱，胁肋下皮肉菲薄，扪其皮外、缓力按之则累然大块，指下易得，诊为肝痈。穿刺为紫色血水，大便四五日未解，饮食少进，舌苔黄腻，小便黄赤。治以清肝热，凉血行瘀，泻火败毒。方药：粉丹皮15克，生地黄15克，青柴胡9克，生黄芩12克，夏枯草9克，生大黄12克，桃仁9克，当归尾9克，甘草梢9克，净银花30克。服药后，次日已能乘车来诊，面有笑容，患处肿胀已消其半，以手扶之疼痛减轻。原方药未变，药量各减3克，再服一剂。第三日，肿消痛减，前方去归尾、草梢，加云茯苓9克，焦白术9克，广陈皮9克，兼扶脾气。至第四日，肿消平复，改服调理脾胃之剂，兼清余邪，再进4剂，饮食渐加而愈。
（余无言：外科学中两个开刀问题和治疗报告，《新中医药》12：24，1955）
【评按】肝痈相当于肝脏脓肿。元·朱震亨认为：“肝痈始发，期门穴必隐痛”。此案治以清肝泻火、凉血行瘀为主，证方精契。如配合外治，可用芙蓉叶研极细末，凡士林调涂患部，外以消毒敷料盖贴，有消肿止痛作用。
（十八）肾痈柳姓，女。血分为湿热所郁，久而发为肾脏痈，腰肾及少腹左部胀痛，小溲时状若血淋，大便秘燥，舌黯无苔、边缘赤润，宜化瘀内消之。赤小豆（布包，煎）30克，紫地丁、冬凌草12克，生杜仲9克，川芎4.5克，炒丹皮9克，生橘核12克，当归尾12克，炒二丑各6克，乌药（土炒）9克，生枳实4.5克，栝蒌12克，血余炭9克，延胡索9克，菟丝饼（盐水炒）4.5克，犀黄丸4.5克（化服）。黄土汤煎药，3剂。复诊：进服前方化瘀内消之剂，血少，腰痛减，少腹仍胀，小便浑浊，黄带颇盛，脉滑数，再加分清搜湿之味。原方加川萆薢12克、石苇12克，海金砂（布包煎）9克，西瓜翠衣若干克（鲜），车前子（包煎）9克，去当归、川芎、栝蒌、血余炭、枳实。嘱服4剂。三诊：血止，溲清，腰痛已息。少腹微有下坠之意，颜面不似前苍黄，舌苔白薄，脉弦而沉。生牡蛎（包，先煎）24克，木通9克，杜仲（盐水炒炭）9克，阿胶珠3克，紫丹参9克，大腹绒4.5克，川萆薢12克，败龟板（包，先煎）6克，桑寄生24克，真血竭（包，先煎）6克，甘草1.5克。改用白水煎药，服6剂，并嘱常服猪肾。
（孔嗣伯整理：孔伯华医案，《中医杂志》8：547，1958）［评按］此案辨证，血分为湿热所郁。作为内痈之一，治当以内消为主，又须清除病理中的湿热和瘀滞，故于方中参入化瘀、清热、利湿诸法。分析前后数诊，可以看出孔氏治此病还借鉴了淋证治法，所拟诸方虽以祛邪为主，亦有顾护扶正之品。首诊方加用犀黄丸，意在消痈解毒；用黄土汤煎药者，寓有崇土制湿之意，方义颇堪玩味。
（十九）胆囊炎李某，女。患胆囊炎，右季肋部有自发痛与压痛感，常有微热，并出现恶心，食欲不振，腹部膨满，鼓肠嗳气，脉弦大。投以大柴胡汤加味（柴胡12克，白芍9克，枳实6克，川军6克，黄芩9克，半夏9克，生姜15克，大枣4枚、擘，金钱草24克，滑石12克，鸡内金12克），连服7剂，食欲见佳，鼓肠、嗳气均大减。再进原方4剂，胁痛亦轻，唯微热来迟，改用小柴胡汤加鳖甲、青蒿、秦艽、郁金治之。（《岳美中医案集》）［评按］此例为慢性胆囊炎。大柴胡汤原治少阳热邪不解、阳明里热变盛的病理，岳氏以此方和解少阳，泻下热结。在用法上重用生姜以制呕恶；加金钱草以利胆清热，滑石利尿泄热，鸡内金克化积热，方药增损合宜。此方用以治阳实黄疸及胆结石亦属对证。
（二十）胆结石
例一陈姓，男，旅苏，吴兴乡友，年约三十余，身体强壮。发病时突然寒战、发高热，剧痛、呕吐。初吐黄绿水，后无物可吐，痛时患者呈惊怖颜貌，甚至以指头探压舌根，促其呕吐，痛苦万状，脉弦滑数，黄疸色鲜明，面目如装金，舌苔黄腻，便秘。断为阳明实证，用大柴胡汤，大黄加至12克，元明粉12克，开水泡浸顿服。另以熊胆1.2克分二次吞服，时值夏令，嘱多吃西瓜，小便增多，大便已通，黄疸稍减，一日服药后泻下稀粪，系下干搪瓷痰盂内，忽听到一阵撒石子声，便后捡得结石20余颗，大者如黄豆，小者如绿豆，短圆形、菱形不等，外面黄色，剖视内面墨黑或兼灰白色。此后逐次以原方加减，服药两个月，比例一直保持联系，三、四年来曾复发。（叶橘泉述，徐培记录：我对胆结石辨证治疗的体会，《江苏中医》3：38，1961）
[Commentary] Ruping (breast hyperplasia) is caused by cold pathogen invasion and consumption of cold food and drinks, compounded by qi stagnation, leading to the infiltration and accumulation of phlegm pathogens in the breast collaterals, which fail to dissipate. The prescription for this case was obtained from a folk doctor's family member. Originally used to treat Ruyan (breast cancer), Mr. Huang applied this modified prescription to treat Ruping with remarkable efficacy. In the formula, Chaihu (Bupleuri Radix), Danggui (Angelicae Sinensis Radix), and Xiangfu (Cyperi Rhizoma) regulate qi and nourish blood; Banxia (Pinelliae Rhizoma) combined with Xiangfu resolves phlegm and dissipates nodules; Goujuli (Aurantii Fructus Immaturus), Juyepi (Citri Reticulatae Pericarpium), Gongying (Taraxaci Herba), and Loulu (Euphorbiae Humifusae Herba) soften hardness and unblock collaterals; assisted by Qianghuo (Notopterygii Rhizoma et Radix) and Duhuo (Angelicae Pubescentis Radix) to ascend and disperse wind, relieving pain. Additionally, Xiaoyao Wan (Free and Easy Wanderer Pills) and Xiaojin Dan (Little Gold Pellets) are used to soothe the liver, resolve phlegm, remove stasis, and relieve pain. External application of Piao Xiao (Natrii Sulfas) functions to soften hardness and dissolve masses. This treatment method represents an improvement over those recorded in ancient surgical monographs.
(14) Ruli (abnormal breast mass) Zhang XX, female, 34 years old. Before menstruation, bilateral breast distending pain occurs, with several lumps palpable, sized like pigeon eggs or broad beans. They are slightly soft, have mild tenderness, and are movable. After menstruation, they shrink and soften. The patient is mentally tense, suspecting neoplasms, and has been examined at various hospitals, diagnosed with "breast hyperplasia" and "chronic cystic mastitis," advised regular observation and TCM treatment. Pulse examination shows discordant pulses at both Guan positions; tongue body is pale purple with small ecchymosis points, coating is thin and white; complexion is dull and lusterless. Syndrome differentiation: Liver qi stagnation, disharmony of qi and blood, collateral stasis, forming Ruli. Treatment method: Soothe the liver, regulate qi, invigorate blood, unblock collaterals, dissipate nodules, and soften hardness. Prescription: Chaihu Shugan Tang modified. Chaihu 9g, Baishao 12g, Zhike 9g, Zhi Xiangfu 9g, Yujin 6g, Gualouqiao 9g, Qingpi 9g, Guiwei 15g, Sheng Muli 18g, Xiakucao 6g, Gancao 3g. Three doses per week, taken continuously for one month. Follow-up: Menstruation normalized, breast distending pain ceased, lumps reduced to bean size and softened. Advised monthly re-examination, basic prescription unchanged. After eight months of treatment, lumps dissipated; follow-up observation showed no recurrence. (Li Jichang Medical Cases)
[Commentary] Lushi occurring in the breast region is called Ruli. This case is caused by liver depression, disharmony of qi and blood, and collateral stasis. Li treated it with Zhang Jiabin’s Chaihu Shugan San modified, focusing on soothing the liver, regulating qi, invigorating blood, unblocking collaterals, softening hardness, and dissipating nodules. This condition is prone to ulceration. Ancient methods used Tudianzi (best after frost), Xiong Shushi (male rat feces), and Lu Fengfang (honeycomb nest) in equal parts, calcined until carbonized but retaining efficacy, ground into powder, 9g per dose taken with wine, every three days, to drain pus and consolidate toxins, for reference only.
(15) Ru Lao (breast tuberculosis) Pan XX, female, 29 years old. First visit date: September 10, 1973. Four months postpartum after second delivery, swelling, pain, and fever appeared in the inner side of the left breast two months ago. Diagnosed as acute mastitis, treatment with antibiotics and Western medicine was ineffective. It suppurated and spontaneously ruptured; after rupture, fever subsided gradually, and pain symptoms disappeared, but the wound never healed. Milk secretion was scanty, general weakness, shortness of breath, insomnia, poor appetite, and loose stools. Examination: Chronic illness appearance, emaciated, low voice, dull eyes, lusterless face, pale nails. A hard lump palpable in the inner left breast, occupying about 3/4 of the inner breast area, surface not red, skin temperature normal. Wound collapsed, pus thin and gray with foul odor. Probe insertion reached 7 cm deep obliquely. Tongue coating thin white, pulse deep and fine. Differentiation: Deficiency of both qi and blood, spleen deficiency and stomach weakness, secondary Ru Lao. Treatment: Tonify both qi and blood, support spleen and open stomach. Prescription: Sheng Huangqi 24g, Dangshen 18g, Yunling 15g, Baizhu 12g, Danggui 12g, Chishao 9g, Biandou 15g, Shanyao 12g, Chenpi 6g, Jineijin 9g, Sheng Guya and Sheng Daoya 18g. Externally apply Jiazi Tidu Fen directly to the wound, cover with Yongju Gao. Treatment course: Follow-up on October 2, 1973, after taking more than 20 doses, felt improved energy and appetite; stool became formed, once every two days, small amount; left breast symptoms unchanged. Plan to warm and transform cold-dampness, tonify qi and blood. Prescription: Mahuang 6g, Gancao 3g, Shu Dihuang 18g, Pao Jiang 9g, Rougui 9g, Lujiao Jiao 9g, Sheng Huangqi 24g, Dangshen 18g, Baijiezi 12g, Yunling 15g, Baizhu 12g, Danggui 12g, Chishao 9g. Externally apply Yanghe Jiening Gao. October 18
(Third Visit): After 15 doses of the above prescription, spirit and strength improved, appetite and bowel/bladder functions normalized, milk flow established sufficient for infant feeding. Left breast milk production remains low, inner lump softened, wound has mild pain, red and raised with new granulation tissue, sinus tract shallower (5 cm deep), pus yellow and thick. Add Baizhi 9g, Jiegeng 9g to the prescription. Externally apply Jiazi Tidu Fen on cotton wicks, cover with Yanghe Jiening Gao. October 30
(Fourth Visit): Granulation tissue fresh, sinus tract depth 1.5 cm, pus decreased, left breast lump range reduced and continuing to soften. Continue to tonify qi and nourish blood, strengthen spleen and generate flesh. Prescription: Sheng Huangqi 18g, Yunling 15g, Baizhu 12g, Danggui 12g, Chishao 9g, Taizishen 18g, Baijiezi 9g, Gancao 3g. November 27
(Fifth Visit): Granulation tissue flat, new epithelium formed. Patient’s complexion ruddy, general condition good. Change to taking Bazhen Wan (Eight Treasures Pills) two pills every morning, and Renshen Yangrong Wan (Ginseng Nourishing Harmony Pills) two pills every night. Externally mix coarse Shengji Fen and Chifen (wound powder) half-and-half, sprinkle dry. December 5, wound healed, clinical cure. (Fang Zhidong Surgical Experience)
[Commentary] Ru Lao refers to tubercles in the breast, also called "Ru Tan." It is often accompanied by emaciation, yin deficiency, afternoon tidal fever, dry cough, malar flush, and poor appetite. This case is secondary Ru Lao, differentiated as deficiency of both qi and blood and spleen/stomach weakness, treated primarily with tonifying qi and blood and supporting the spleen/opening the stomach. Local external application of detoxifying and reducing swelling agents. At follow-up, while tonifying qi and blood, emphasis was placed on warming and transforming cold-dampness. Internally administered Yanghe Tang modified, externally applied Yanghe Jiening Gao. Both formulas are from *Waike Quansheng Ji* (Complete Book of External Medicine), commonly used for Yin abscesses and Yin toxins. Ultimately concluded with qi and blood regulation. The prescriptions across multiple visits were logical and drugs safe and effective. It must be pointed out that many Ru Lao cases involve yin deficiency, where Liuwei Dihuang Wan (Six-Ingredient Pill with Rehmannia) modified should be the main formula; if pulmonary tuberculosis exists, it must be treated concurrently.
(16) Chang Yong (Intestinal Abscess / Appendicitis)
Case 1 Lu Zuo. First visit: Pain located one cun diagonally below the right umbilicus, known in Western medicine as appendicitis; pulse is large and excess, requires purging, using Zhongjing’s method. Sheng Jun (Raw Rhubarb) 15g, Mangxiao 9g, Tao Ren 15g, Dongguaren 30g, Danpi 30g. Second visit: Pain slightly eased, right leg cramped, unable to flex or extend; extension pulls abdominal pain, suitable for Shaoyao Gancao Tang. Chi Shao and Bai Shao each 15g, Sheng Gancao 9g, Zhi Moyao each 9g. Third visit: Right leg can now extend, severe abdominal pain persists. Still suitable for Dahuang Mudan Tang to purge. Sheng Chuanjun (Sichuan Rhubarb) 30g, Mangxiao 21g (dissolved), Tao Ren 15g, Dongguaren 30g, Danpi 30g.
(Cao Yingfu *Jingfang Shiyan Lu*)
Case 2 Li XX, female, 65 years old. Hospital No.: 39087. First visit date: December 19, 1959. Family reported: nausea, vomiting, fever accompanied by right lower quadrant pain for two weeks. Two weeks ago, periumbilical swelling and pain began, with nausea, loss of appetite, immediate vomiting after eating, thought to be stomach pain and untreated. Pain gradually shifted to the right lower abdomen, dull ache, right leg cannot straighten to sit up, lies curled. Accompanied by fever, lighter in morning, heavier in evening, persistent for days, no bowel movement for many days. Previously diagnosed as appendicitis, treated with intramuscular penicillin for 3 days without improvement. Admission exam: Conscious, listless, painful expression, indifferent affect. Palpable 9x7 cm mass in right lower abdomen, abdominal wall tension, tenderness, rebound tenderness, xerosis cutis (skin resembling fish scales), right leg curled. Pulse deep and fine, tongue tip smooth, root coating thin yellow greasy. Temperature 38°C, WBC total 18,600/mm³, neutrophils 81%, BP 159/80 mmHg. Differentiation: Damp-heat with blood stasis obstructing the intestines, disharmony of Ying and Wei, heat exceeding causing flesh rot, syndrome belongs to Chang Yong (Western diagnosis: Periappendiceal abscess). Treatment method: Harmonize Ying, resolve stasis, detoxify, reduce swelling. Prescription: Chao Tao Ren 9g, Gualou Ren 9g, Donggua Zi Ren 9g, Danpi 6g, Guiwei 9g, Chishao 6g, Yinhua 9g, Lianqiao 9g, Zhi Jiapian 6g, Zaocis Spina 9g, Shenjincao 9g. Decoct in water, externally apply Jinhuang Gao. December 21
(Second Visit): After two doses, bowel movement achieved, right lower abdominal pain lightened, abdominal wall tension eased, tenderness reduced, fever broken, slight desire for food, root coating thin greasy gradually resolving, pulse string-slippery. Follow previous prescription adding Baijiangcao 9g, Yiren 12g, 3 doses. December 24
(Third Visit): After medication, right lower abdominal mass significantly shrunk, pain mild, right leg can straighten, temperature 37.4°C, appetite improved, tongue coating thin scattered, pulse fine-slippery. Treatment follows previous prescription modifications. Sheng Yiren 12g, Donggua Zi Ren 9g, Danggui 9g, Chishao 9g, Gualou Ren 9g, Danpi 9g, Baijiangcao 9g, Chenpi 6g, Yinhua 9g. Decoct in water. December 27
(Fourth Visit): After 3 doses, mass no longer palpable, cured and discharged. (Zhu Renkang Clinical Experience Collection)
[Commentary] Chang Yong corresponds to acute appendicitis. Zhongjing established Dahuang Mudan Tang and Yiyi Fuzi Baijiang San, which became models for later generations.
Case 1 is a Dahuang Mudan Tang syndrome; this formula functions to purge heat, eliminate stasis, dissipate nodules, and reduce swelling. Cao seized upon the patient’s excess pulse and symptoms, daring to administer boldly, achieving a cure.
Case 2 is Chang Yong complicated by periappendiceal abscess, differentiated as damp-heat with stasis obstructing intestines, disharmony of Ying and Wei, heat causing flesh rot. Treated primarily with Sanren Tang. Formula uses Danpi, Tao Ren, Guiwei, Chishao to invigorate blood and scatter stasis; Dongguazi, Yiren, Baijiangcao to drain pus and reduce swelling; Gualou Ren to moisten dryness and unblock intestines; Yin and Qiao clear heat and detoxify; Jiapian and Zaocis Spina attack hardness, possessing both "eliminate" and "support" functions—light cases can be eliminated, if elimination fails, support promotes spontaneous rupture and drainage. In summary, although this case primarily uses Sanren Tang, it actually incorporates most ingredients from Dahuang Mudan Tang and Yiyi Fuzi Baijiang San, showing profound prescription logic.
(17) Gan Yong (Liver Abscess) Shao Mou, hard dull pain under right hypochondrium, swelling like a fist, tender to touch, emaciated, subcostal muscles thin, palpation reveals large mass easily accessible, diagnosed as Gan Yong. Puncture yielded purple bloody fluid, no bowel movement for 4-5 days, poor intake, tongue coating yellow greasy, urine yellow-red. Treatment: Clear liver heat, cool blood and move stasis, purge fire and defeat toxin. Prescription: Fen Danpi 15g, Sheng Dihuang 15g, Qing Chaihu 9g, Sheng Huangqin 12g, Xiakucao 9g, Sheng Dahuang 12g, Tao Ren 9g, Dangguiwei 9g, Gancaoshao 9g, Jing Yinhua 30g. After taking medicine, next day able to ride to clinic, smiling, swelling at site reduced by half, less painful to touch. Original prescription unchanged, dosage reduced by 3g each, take one more dose. Third day, swelling and pain reduced, remove Guiwei and Gancaoshao from previous prescription, add Yunling 9g, Jiao Baizhu 9g, Guang Chenpi 9g, simultaneously supporting spleen qi. By fourth day, swelling resolved, change to spleen-stomach regulating agent, clearing residual pathogen, take 4 more doses, diet gradually increased and recovered.
(Yu Wu'yan: Two Surgical Problems and Treatment Reports in Surgery, *New Traditional Chinese Medicine* 12:24, 1955)
[Commentary] Gan Yong corresponds to liver abscess. Yuan dynasty Zhu Zhenheng believed: "At the onset of Gan Yong, Qimen acupoint must have dull pain." This case treated primarily with clearing liver fire, cooling blood, and moving stasis, matching syndrome and prescription precisely. If combined with external therapy, Furongye (Hibiscus Leaf) ground to fine powder mixed with vaseline applied to affected area, covered with sterile dressing, has effect of reducing swelling and relieving pain.
(18) Shen Yong (Kidney Abscess) Liu surname, female. Blood level constrained by damp-heat, long-term development into Kidney Yong, distending pain in lumbar/kidney and left lower abdomen, urination resembles blood strangury, constipation, tongue dark no coating, edges red and moist, suitable for internal resolution of stasis. Chixiaodou (wrapped in cloth, decocted) 30g, Zidi Dingdong 12g, Sheng Duzhong 9g, Chuanxiong 4.5g, Chao Danpi 9g, Sheng Juhe 12g, Dangguiwei 12g, Chao Erchou each 6g, Wuyao (earth-fried) 9g, Sheng Zhishi 4.5g, Gualou 12g, Xuyutan 9g, Yanhusuo 9g, Tusibing (salt-water fried) 4.5g, Xihuang Wan 4.5g (dissolved). Decoct medicine with Huangtu Tang, 3 doses. Follow-up: Taking previous stasis-resolving internal resolution agent, bleeding decreased, waist pain reduced, lower abdomen still distended, urine turbid, abundant yellow leukorrhea, pulse slip-numerous, add herbs for separating clarity and searching dampness. Original prescription add Chuan Bixie 12g, Shiwei 12g, Haijinsha (wrapped, decocted) 9g, Xigua Cuiyi [watermelon rind] some grams (fresh), Cheqianzi (wrapped, decocted) 9g, remove Danggui, Chuanxiong, Gualou, Xuyutan, Zhishi. Advise taking 4 doses. Third visit: Bleeding stopped, urine clear, waist pain ceased. Lower abdomen slight bearing-down sensation, complexion not previously sallow, tongue coating thin white, pulse string-deep. Sheng Muli (wrapped, decoct first) 24g, Mutong 9g, Duzhong (salt-water fried charcoal) 9g, Ejiaozhu 3g, Zidan Shen 9g, Dafurong 4.5g, Chuan Bixie 12g, Baiguiban (wrapped, decoct first) 6g, Sangjisheng 24g, Zhen Xuexie (wrapped, decoct first) 6g, Gancao 1.5g. Change to plain water decoction, take 6 doses, advise frequent consumption of pig kidneys.
(Kong Sibei compiled: Kong Bohua Medical Cases, *Chinese Journal of Traditional Medicine* 8:547, 1958) [Commentary] This case differentiates blood level constrained by damp-heat. As one type of internal Yong, treatment should focus on internal resolution, and must clear damp-heat and stasis in pathology, thus incorporating stasis-resolving, heat-clearing, and damp-draining methods. Analyzing multiple visits, Kong’s treatment of this disease also borrowed from Strangury treatment methods. Although proposed formulas mainly expel pathogens, they also contain supportive substances. First visit added Xihuang Wan, intending to resolve abscess and detoxify; using Huangtu Tang to decoct implies strengthening earth to control dampness, prescription meaning is worth pondering.
(19) Cholangitis Li Mou, female. Suffering from cholangitis, spontaneous pain and tenderness in right hypochondrium, frequent slight fever, nausea, poor appetite, abdominal distension, borborygmus, belching, pulse string-large. Administered Dachaihu Tang modified (Chaihu 12g, Baishao 9g, Zhishi 6g, Chuanjun 6g, Huangqin 9g, Banxia 9g, Shengjiang 15g, Dazao 4 pieces, split, Jinqiancao 24g, Huashi 12g, Jineijin 12g), taken continuously for 7 doses, appetite improved, borborygmus and belching greatly reduced. Take original prescription another 4 doses, hypochondriac pain also lightened, only slight fever delayed, change to Xiaochaihu Tang added Biejia, Qinghao, Qinjiao, Yujin for treatment. (*Yue Meiyi Medical Case Collection*) [Commentary] This case is chronic cholangitis. Dachaihu Tang originally treats Shaoyang heat pathogen unresolved and Yangming interior heat intensifying pathology. Yue used this formula to harmonize Shaoyang and purge heat accumulation. In usage, heavy Shengjiang controls nausea/vomiting; added Jinqiancao benefits gallbladder and clears heat, Huashi promotes urination and drains heat, Jineijin transforms accumulated heat, prescription modification appropriate. This formula is also indicated for Yang-excess jaundice and gallstones.
(20) Gallstones
Case 1 Chen surname, male, traveling in Russia, fellow villager from Wuxing, approx. 30s, strong constitution. Onset sudden chills, high fever, severe pain, vomiting. Initially vomited yellow-green water, later nothing to vomit, during pain patient showed terrified expression, even probing throat with finger to induce vomiting, extreme suffering, pulse string-slip-numerous, bright yellow jaundice, face like gold-plated, tongue coating yellow greasy, constipation. Judged as Yangming excess syndrome, used Dachaihu Tang, increased Dahuang to 12g, Yuanmingfen 12g, soaked in boiling water taken in one dose. Additionally, Xiongdan (Bear Bile) 1.2g taken in two doses. Summer season, advised eating much watermelon, urine increased, bowels opened, jaundice slightly reduced. One day after taking medicine, passed loose stool into dry enamel chamber pot, suddenly heard sound of scattering stones, collected over 20 stones after defecation, large ones like soybeans, small like mung beans, short round, rhomboid shapes, yellow outside, inside black or gray-white when cut. Thereafter successively modified original prescription, took medicine for two months, kept in contact, relapsed occasionally over three to four years. (Ye Juquan narrated, Xu Pei recorded: My Experience in Differential Diagnosis and Treatment of Gallstones, *Jiangsu Journal of Traditional Chinese Medicine* 3:38, 1961)