例二焦某，男，34岁。初诊日期：1973年9月9日。左足发凉麻痛三年，近四个月剧痛难忍。三年前，发现右足麻痛、发凉，不能远行，走路则疼痛加剧，左小腿胀麻、沉而酸。某医院诊为脉管炎，经治疗未见好转，症状日益加重，四个月前，左足1、2趾剧痛发黑，继而肿胀，五天前自行破溃，血水渗溢，剧痛难忍，昼夜难眠，食欲大减，五天来大便未解，小便短赤，遂来北京中医医院就医。检查：面色晦暗，痛苦表情。左足掀红肿胀，1、2趾已干枯坏死。趺阳脉、太溪脉均不能触及，足部皮温增高。舌质红绛，舌苔黄腻，脉弦滑数。辨证：郁热的阴，血瘀蕴毒（西医诊断：血栓闭塞性脉管炎皿期）治法：清热解毒，养阴活血镇痛。方药：元参30克石斛24克银花60克公英30克连翘30克地丁18克元胡9克当归18克赤芍12克红花12克桃仁9克川军3克白芷9克桔梗9克甘草9克牛膝9克生芪30克川楝子18克野菊花24克罂粟壳15克每日之剂，每六小时眼药一次。外治法：消毒后凡士林纱条包扎患趾。9月12日
（复诊）：按前方服药6付，大便已解，其他症状同前。上方去桃仁，加云苓15克继服。9月23日
（四诊）：仍有疼痛，左足1、2趾坏死，界限已分明。方药如下：元参30克石斛30克生地18克银花60克公英30克连翘30克当归15克地丁24克野菊24克牛膝9克生芪30克云苓15克赤芍12克党参18克红花9克元胡9克甘草9克罂粟壳15克9月28日
（五诊）：在局麻下，将左足1、2趾切除，术后情况良好，继服前方，外用止痛生肌散，于上截趾创面，纱布包扎。10月8日
（七诊）：疼痛已止，肿胀已消，左足焮红已退，皮温不高，伤口缩小，已有新肌生长，自觉腰痛。继服前方，改为一日一剂，煎三次，早、午、晚各服一次，外治法同前。10月15日
（八诊）：伤口继续缩小，新肌已平，自觉腰痛减轻，脉沉细，舌尖红。治以温补脾肾、通经活络。方药如下：元参30克生芪30克银花15克党参18克石斛18克云苓18克白术15克当归12克赤芍9克牛膝9克甘草3克菟丝子30克枸杞子30克10月31日
（九诊）：伤口已愈合，表面结薄痂，左小腿行路多则有酸沉感，腰痛已消失。11月17日
（十诊）：创面结痂已脱落，局部有轻度痒感，能走一，二站路，继服五子衍宗丸，每早服2丸，肾气丸每晚服2丸，以巩固疗效。（《房芝萱外科经验》
【评按】脱疽在《灵枢经·痈疽》名为“脱痈”相当于血栓闭塞性脉管炎。多由肢体感受寒湿所致。
例一由于寒湿郁久而化热毒，热甚阴伤，复有经络痹阻，气血凝滞，局部已现坏死，故治以养阴清热、和营活血为大法。此例在治法上有两个特点，其一、内服方是以四妙勇安汤（《验方新编》方）加减为基础，并吸取了民间草药，其二、外治方具有中西医结合的特点。方洽较为周密。
例二辨证为郁热的阴，血瘀蕴毒，内服方与例一大致相仿，因属Ⅲ期，足趾已坏死，故配合截趾，病程后期，以温补脾肾、通经活络为大法。此案源流俱澈，遣药标本兼到，可资临证参考。
（二十五）破伤风朱××，男，32岁。1951年左脚掌被锈钉刺入约4分深，但出血不多，是晚回家用草药敷包局部，并不十分疼痛。在第三日忽感咀嚼不便，吞咽困难，颈部亦觉不自由，当晚10点钟发生痉挛一次，至第四天，痉挛次数增多，颈部、脊、腰均呈强直状态，由人介绍来所求治，上下包车均需人扶持始能勉强行动。体温39．6℃，脉搏跳动甚速，大小便如常，神识清醒，不异常人。在诊察刚毕时又痉挛一次，但不严重，约三分钟即恢复正常。当将患部包扎草药除去，洗洁患部，见伤口呈肿硬状态，即以玉真散厚撒伤部，外用纱布绷带包扎，另给药散3包，每包重9克，命其回家时用热黄酒调服，每隔3小时一包。次日由人抬来复诊，揭示伤口肿硬较昨日初诊时减退约1/3，据称服药3包后，痉挛次数大减；洗净患部后，仍以玉真散撒布伤处包扎，仍给玉真散3包带回服用。至第三天来诊时伤部僵硬已完全软化平复，惟伤口尚未愈合，当即易以生肌收口药散，吞咽已恢复如常，痉挛次数大为减少，发作间隔延长，发作症势已转轻缓，内服玉真散如前，惟每包减量为6克，如此延续服用，计十二天而完全恢复正常。附方：玉真散：白附子320克生南星（姜汁炒）明天麻羌活防风白芷各30克蝉衣90克共研细未，贮瓶备用，不可泄气。
（张觉人：玉真散对破伤风的疔效，《中医杂志》8：421，1956）
【评按】玉真散（《外科正宗》方）为治疗破伤风常用方，功能祛风镇痉。张氏运用此方内服并配合外治，甚见功效。已故余无言氏在其《金匮要略新义》中介绍，用蝉衣（去净头足）为极细末，另以黄酒半斤，将蝉衣末15～30克放入酒内，文火多煮数沸，一次顿服。一般患者于服药后，周身淅淅汗出，其汗胶粘，其气腥臭，微汗颇久，一汗之后，邪去而病乃可愈。此方原见明·龚信《古今医鉴》，方名脱凡散，治破伤风良效。如患者有便结内热，再以承气汤下之。
（二十六）静脉炎马ｘ、女，28岁。初诊日期：1974年9月29日。患慢性痢疾了年余，住××医院治疗，曾静脉输液，出院已数天。近三天来左侧腕部疼痛，活动受限，左上肢起一条索，肿痛，睡眠不佳。检查：左前臂直至上臂，有一明显条索，长28．5厘米，质硬，触痛拒按，沿条索皮肤潮红，左前臂微肿，左腕及左时屈伸略受限。苔白，脉弦略数。辨证：湿热凝结，血瘀阻络（西医诊断：左上肢浅静脉炎）。治法：清热利湿，活血散结。方药：银花24克公英24克连翘18克茵陈30克条芩9克猪苓9克元参18克泽泻9克炒山甲15克赤芍9克归尾12克车前子9克红花9克元胡9克川楝子18克升麻9克甘草3克10月6日
（复诊）：药后肿消，痛轻，夜寐安，皮肤潮红已退，但局部条索同前。前方去黄芩，甘草，加地龙15克，泽兰叶12克继服。10月17日
（三诊）：疼痛已止，条索变软，无触痛，缩短至20厘米。方药如下：三棱9克赤芍9克莪术9克半夏9克元参18克炒山甲15克连翘15克生芪15克鸡血藤18克云苓12克红花9克炒僵蚕9克桃仁9克归尾9克酒军3克升麻9克10月31日
（四诊）：条索基本消失，按之已不明显。改服活血主力丸，每早服5丸，八珍丸，每晚服2丸，以巩固疗效。（《房芝萱外科经验》）
【评按】此案诊为左上肢浅静脉炎，局部条索状，皮肤潮红，左前臂微肿。中医辨证属湿热凝结，血瘀阻络。由于湿热证现于外，单用活血化瘀则病本难除，故治以双管齐下，清热利湿、活血散结并举。从方药分析，首诊时清热利湿居主导地位，其中银、翘、公英、茵陈等用量较大。俟痛止，肿消、潮红退，改用活血、调补气血法以竟全功。案中在掌握祛邪扶正的分寸和步骤方面，较为得体。
（二十七）手术后合并症
例一周××，男，74岁。病历号：2837。患者于1961年8月21日下午5时许，突感恶寒发热，随即伴有阵发性腹痛，局限于右上腹部，恶心呕吐，吐出物为食物残渣，鲜黄色稀软便一次，于次日下午皮肤出现明显黄疸，意识稍有朦胧，体温39．3℃，淋巴11％。大小便检查无异常。西医诊断为急性胆囊炎，于24日下午四时半在局麻下作胆囊造瘘术。术后至次晚八时，尿总量不到5毫升，患者处于半昏迷状态，呼吸深而速，脉搏70～80次／分。血压95～75/50毫米汞柱，巩膜发黄，心肺无特殊异常，腹略胀满，肠鸣正常，膀眈区呈鼓音，血液检查：白细胞20，900／立方毫米，中性89％，嗜酸性1％，淋巴10％，红细胞311万／立方毫米，血色素9．5克，血钠279．2毫克％，非蛋白氮112毫克％，二氧化碳结合力24．6容积％。白手术后即开始输液、输血，以纠正酸中毒及调整电解质平衡，但仍无排尿；又曾经二侧肾囊奴佛卡因封闭及针灸等治疗，均未见效果。自膀胱导尿，亦未排出尿液。乃于8月25日晚请中医会诊。会诊记录：患者神智时或昏沉，喃喃自语，周身及两目如橘黄色，口有秽味，身有微热，四肢发凉，全身浮肿，时出冷汗，小便已二日未解，大便不通，面色稍赤，口干舌燥，脉滑无力，舌苔白腻而垢、中心黄黑。辨证：肝胆湿热未清，因年迈体虚，以致湿热弥漫三焦，入窜心包，有正不抗邪之势。治法：养阴补血，滋肾通关。方药：西洋参麦冬当归各9克白芍30克大生地、天花粉各15克钗石斛、川贝、益元散（包）各12克炒知母、黄柏、枯芩、车前子（包）、全栝蒌、丹皮各9克茵陈、银花、赤苓各15克紫肉桂0．9克为引，煎服2剂。于当晚10时眼药后，至次日晨5时许，尿量达500毫升；至上午10时许，尿量达900毫升。尿常规：比重1．015，反应酸性，蛋白（＋），糖（一），镜检：上皮细胞少许，白细胞1～2／高倍，红细胞0～1／高倍。至8月27日晨尿量多达3600毫升／日，病人神智清醒，诉有饥饿感，要求进流质饮食，血液检查：非蛋白氮67毫克％，二氧化碳结合力32．3容积％，血钠290．8毫克％，病情有明显好转。8月27日下午复诊：发热已退，黄疸渐消，精神亦有好转；尿量正常，尿常规检查已无异常，脉滑数，舌苔稍黄。拟再进清热利湿，调补气血之品。在原方上去肉桂、黄柏、丹皮、车前、枯芩、益元散、栝蒌，加北沙参18克、地骨皮9克、蒲公英15克，再服二剂后，一般情况好转，尿量正常，血压120～130/70～80毫米汞柱，各项血液检查结果亦已接近正常。
（关幼波治验，危北海整理：医案选录——手术后无尿症一例，《中医杂志》7：27，1962）
例二李××，已婚，女，50岁。因上腹部疼痛4天，于1958年6月21日，急诊入北京××医院。患者十余年来，常有上腹疼痛，泛酸，服苏打后而缓解，疼痛多与饮食有关，近四日上腹部疼痛复作，以两肋缘为甚，入院前一日，疼痛加重，持续不解，大便两日未行，小便如常。既往史从略。一389一检查：急性病容，痛苦表情，皮肤无黄疸。头部器官阴性，颈软，心肺（一），腹壁普遍板硬，井有压痛，肝脾不易触及，膝反射存在。血压100／20毫米汞柱，血象正常。临床诊断为胃穿孔，合并腹膜炎。入院后施行手术，术后尿闭，呈半昏迷，肌肉抽动，非蛋白氮150毫克％，乃请中医会诊。患者神志欠清，时而躁动，手抽肉颤，尿闭，脉细肢凉，乃用真武汤加减，回阳利尿。药用西洋参、杭芍、白术、云苓、炮附片、生苡米。一剂后，能自排小便，四肢渐温，肉颤筋惕亦止。二诊时用红人参、白术、茯苓、车前子、牛膝、泽泻、苡米、玉竹，经过三诊之后，诸证好转，血压恢复正常，非蛋白氮降至37．5毫克％，后痊愈出院。（《岳美中医案集》）
例三孙××，女，52岁。因子宫颈癌，手术后发生呕吐不能食已五天，医院诊断为不全性肠梗阻，曾服中药微予通利，虽便泄数次，但呕吐仍不止，病清严重，西医施行输液及胃肠减压，未见好转。诊时患者头痛目眩，耳鸣口苦，心中疼热，呕吐涎沫，食不得入，渴不欲饮，大便先泄而后闭，肠鸣、不矢气，小便短黄，唇黯红，舌苔薄黄，脉弦。辨证：厥阴寒热夹杂，肝风扰胃，肝胃不和。治法：酸苦辛甘合剂，从乌梅丸化裁。方药：乌梅9克川连6克花椒3克西党9克当归6克黄柏9克干姜3克代储石15克橘皮4．5克竹茹4．5克水煎服。一剂呕吐即止，涎沫减少，能进饮食，心中疼热亦减，腑气得行，并下蛔虫一条。但仍口苦溺黄，脉细弦，苔黄舌质红，知其胃气渐降，而肝胃阴伤，余邪未清，再以原方去花椒、储石，加玉竹9克、丹参6克。四剂后，精神食欲好转，头晕耳鸣减轻，口苦除，但觉晚间腹部灼热，出汗后则渐舒，大便结，小便仍黄，脉细弦，舌苔根部薄黄，此乃肝胃渐和而气阴未复，最后仿炙甘草汤意调治：党参9克白芍9克丹参6克玉竹9克麦冬9克火麻仁9克炙甘草4．5克生姜6克四剂后，诸症大减，精神食欲均大有好转，呕吐从不再作。
（杨志一：医案扎记，《江西医药》9：29，1963）
【评按】
例一为手术后尿闭，神志时明时昧，口秽身黄，肢凉浮肿。患者年迈体虚，而肝胆湿热未清，弥漫三焦，入窜心包，以其正不抗邪，故治以养阴补血，滋肾通关，清热利湿法。药后尿闭得通，热退黄消。关氏对此案能细勘病机、斟酌虚实以疏邪扶正，其方药变化较有法度。
例二为手术后尿毒症，症见尿闭，半昏迷，肌肉抽动，脉细肢凉。肾为胃之关，肾阳因阳气式微而闭，故用真武汤加减以回阳利尿，肾关得阳则开，后以健脾气、利尿之剂投治，患者神清，排尿自如，岳氏以利尿法贯串全案，足见利尿在治疗尿毒症中之重要性。
例二 焦某，男性，34岁。初诊日期：1973年9月9日。左足发凉、麻木疼痛三年，近四个月剧痛难忍。三年前，发现右足麻木疼痛、发凉，不能远行，走路则疼痛加剧，左小腿胀麻、沉重而酸楚。某医院诊断为脉管炎，经治疗未见好转，症状日益加重。四个月前，左足第1、2趾剧痛发黑，继而肿胀；五天前自行破溃，血水渗溢，剧痛难忍，昼夜难眠，食欲大减，五天来大便未解，小便短赤，遂来北京中医医院就医。检查：面色晦暗，痛苦表情。左足掀红肿胀，第1、2趾已干枯坏死。趺阳脉、太溪脉均不能触及，足部皮温增高。舌质红绛，舌苔黄腻，脉弦滑数。辨证：郁热伤阴，血瘀蕴毒（西医诊断：血栓闭塞性脉管炎Ⅲ期）。治法：清热解毒，养阴活血镇痛。方药：元参30克，石斛24克，银花60克，公英30克，连翘30克，地丁18克，元胡9克，当归18克，赤芍12克，红花12克，桃仁9克，川军3克，白芷9克，桔梗9克，甘草9克，牛膝9克，生芪30克，川楝子18克，野菊花24克，罂粟壳15克。每日1剂，每六小时服药一次。外治法：消毒后凡士林纱条包扎患趾。
9月12日（复诊）：按前方服药6付，大便已解，其他症状同前。上方去桃仁，加云苓15克继服。
9月23日（四诊）：仍有疼痛，左足第1、2趾坏死，界限已分明。方药如下：元参30克，石斛30克，生地18克，银花60克，公英30克，连翘30克，当归15克，地丁24克，野菊24克，牛膝9克，生芪30克，云苓15克，赤芍12克，党参18克，红花9克，元胡9克，甘草9克，罂粟壳15克。
9月28日（五诊）：在局麻下，将左足第1、2趾切除，术后情况良好，继服前方，外用止痛生肌散，于上截趾创面，纱布包扎。
10月8日（七诊）：疼痛已止，肿胀已消，左足焮红已退，皮温不高，伤口缩小，已有新肌生长，自觉腰痛。继服前方，改为一日一剂，煎三次，早、午、晚各服一次，外治法同前。
10月15日（八诊）：伤口继续缩小，新肌已平，自觉腰痛减轻，脉沉细，舌尖红。治以温补脾肾、通经活络。方药如下：元参30克，生芪30克，银花15克，党参18克，石斛18克，云苓18克，白术15克，当归12克，赤芍9克，牛膝9克，甘草3克，菟丝子30克，枸杞子30克。
10月31日（九诊）：伤口已愈合，表面结薄痂，左小腿行路多则有酸沉感，腰痛已消失。
11月17日（十诊）：创面结痂已脱落，局部有轻度痒感，能走一、二站路，继服五子衍宗丸，每早服2丸，肾气丸每晚服2丸，以巩固疗效。（《房芝萱外科经验》）
【评按】脱疽在《灵枢经·痈疽》名为“脱痈”，相当于血栓闭塞性脉管炎。多由肢体感受寒湿所致。
例一由于寒湿郁久而化热毒，热甚阴伤，复有经络痹阻，气血凝滞，局部已现坏死，故治以养阴清热、和营活血为大法。此例在治法上有两个特点，其一、内服方是以四妙勇安汤（《验方新编》方）加减为基础，并吸取了民间草药；其二、外治方具有中西医结合的特点。方洽较为周密。
例二辨证为郁热伤阴，血瘀蕴毒，内服方与例一大致相仿，因属Ⅲ期，足趾已坏死，故配合截趾，病程后期，以温补脾肾、通经活络为大法。此案源流俱澈，遣药标本兼到，可资临证参考。
（二十五）破伤风 朱××，男，32岁。1951年左脚掌被锈钉刺入约4分深，但出血不多，是晚回家用草药敷包局部，并不十分疼痛。在第三日忽感咀嚼不便，吞咽困难，颈部亦觉不自由，当晚10点钟发生痉挛一次，至第四天，痉挛次数增多，颈部、脊、腰均呈强直状态，由人介绍来所求治，上下包车均需人扶持始能勉强行动。体温39.6℃，脉搏跳动甚速，大小便如常，神识清醒，不异常人。在诊察刚毕时又痉挛一次，但不严重，约三分钟即恢复正常。当将患部包扎草药除去，洗洁患部，见伤口呈肿硬状态，即以玉真散厚撒伤部，外用纱布绷带包扎，另给药散3包，每包重9克，命其回家时用热黄酒调服，每隔3小时一包。次日由人抬来复诊，揭示伤口肿硬较昨日初诊时减退约1/3，据称服药3包后，痉挛次数大减；洗净患部后，仍以玉真散撒布伤处包扎，仍给玉真散3包带回服用。至第三天来诊时伤部僵硬已完全软化平复，惟伤口尚未愈合，当即易以生肌收口药散，吞咽已恢复如常，痉挛次数大为减少，发作间隔延长，发作症势已转轻缓，内服玉真散如前，惟每包减量为6克，如此延续服用，计十二天而完全恢复正常。附方：玉真散：白附子320克，生南星（姜汁炒）、明天麻、羌活、防风、白芷各30克，蝉衣90克，共研细末，贮瓶备用，不可泄气。
（张觉人：玉真散对破伤风的疗效，《中医杂志》8：421，1956）
【评按】玉真散（《外科正宗》方）为治疗破伤风常用方，功能祛风镇痉。张氏运用此方内服并配合外治，甚见功效。已故余无言氏在其《金匮要略新义》中介绍，用蝉衣（去净头足）为极细末，另以黄酒半斤，将蝉衣末15～30克放入酒内，文火多煮数沸，一次顿服。一般患者于服药后，周身淅淅汗出，其汗胶粘，其气腥臭，微汗颇久，一汗之后，邪去而病乃可愈。此方原见明·龚信《古今医鉴》，方名脱凡散，治破伤风良效。如患者有便结内热，再以承气汤下之。
（二十六）静脉炎 马ｘ、女，28岁。初诊日期：1974年9月29日。患慢性痢疾了年余，住××医院治疗，曾静脉输液，出院已数天。近三天来左侧腕部疼痛，活动受限，左上肢起一条索，肿痛，睡眠不佳。检查：左前臂直至上臂，有一明显条索，长28.5厘米，质硬，触痛拒按，沿条索皮肤潮红，左前臂微肿，左腕及左肘屈伸略受限。苔白，脉弦略数。辨证：湿热凝结，血瘀阻络（西医诊断：左上肢浅静脉炎）。治法：清热利湿，活血散结。方药：银花24克，公英24克，连翘18克，茵陈30克，条芩9克，猪苓9克，元参18克，泽泻9克，炒山甲15克，赤芍9克，归尾12克，车前子9克，红花9克，元胡9克，川楝子18克，升麻9克，甘草3克。
10月6日（复诊）：药后肿消，痛轻，夜寐安，皮肤潮红已退，但局部条索同前。前方去黄芩，甘草，加地龙15克，泽兰叶12克继服。
10月17日（三诊）：疼痛已止，条索变软，无触痛，缩短至20厘米。方药如下：三棱9克，赤芍9克，莪术9克，半夏9克，元参18克，炒山甲15克，连翘15克，生芪15克，鸡血藤18克，云苓12克，红花9克，炒僵蚕9克，桃仁9克，归尾9克，酒军3克，升麻9克。
10月31日（四诊）：条索基本消失，按之已不明显。改服活血主力丸，每早服5丸，八珍丸，每晚服2丸，以巩固疗效。（《房芝萱外科经验》）
【评按】此案诊为左上肢浅静脉炎，局部条索状，皮肤潮红，左前臂微肿。中医辨证属湿热凝结，血瘀阻络。由于湿热证现于外，单用活血化瘀则病本难除，故治以双管齐下，清热利湿、活血散结并举。从方药分析，首诊时清热利湿居主导地位，其中银、翘、公英、茵陈等用量较大。俟痛止，肿消、潮红退，改用活血、调补气血法以竟全功。案中在掌握祛邪扶正的分寸和步骤方面，较为得体。
（二十七）手术后合并症
例一周××，男，74岁。病历号：2837。患者于1961年8月21日下午5时许，突感恶寒发热，随即伴有阵发性腹痛，局限于右上腹部，恶心呕吐，吐出物为食物残渣，鲜黄色稀软便一次，于次日下午皮肤出现明显黄疸，意识稍有朦胧，体温39.3℃，淋巴11％。大小便检查无异常。西医诊断为急性胆囊炎，于24日下午四时半在局麻下作胆囊造瘘术。术后至次晚八时，尿总量不到5毫升，患者处于半昏迷状态，呼吸深而速，脉搏70～80次／分。血压95～75/50毫米汞柱，巩膜发黄，心肺无特殊异常，腹略胀满，肠鸣正常，膀胱区呈鼓音，血液检查：白细胞20,900／立方毫米，中性89％，嗜酸性1％，淋巴10％，红细胞311万／立方毫米，血色素9.5克，血钠279.2毫克％，非蛋白氮112毫克％，二氧化碳结合力24.6容积％。自手术后即开始输液、输血，以纠正酸中毒及调整电解质平衡，但仍无排尿；又曾经二侧肾囊奴佛卡因封闭及针灸等治疗，均未见效果。自膀胱导尿，亦未排出尿液。乃于8月25日晚请中医会诊。会诊记录：患者神智时或昏沉，喃喃自语，周身及两目如橘黄色，口有秽味，身有微热，四肢发凉，全身浮肿，时出冷汗，小便已二日未解，大便不通，面色稍赤，口干舌燥，脉滑无力，舌苔白腻而垢、中心黄黑。辨证：肝胆湿热未清，因年迈体虚，以致湿热弥漫三焦，入窜心包，有正不抗邪之势。治法：养阴补血，滋肾通关。方药：西洋参、麦冬、当归各9克，白芍30克，大生地、天花粉各15克，钗石斛、川贝、益元散（包）各12克，炒知母、黄柏、枯芩、车前子（包）、全栝蒌、丹皮各9克，茵陈、银花、赤苓各15克，紫肉桂0.9克为引，煎服2剂。于当晚10时服药后，至次日晨5时许，尿量达500毫升；至上午10时许，尿量达900毫升。尿常规：比重1.015，反应酸性，蛋白（＋），糖（一），镜检：上皮细胞少许，白细胞1～2／高倍，红细胞0～1／高倍。至8月27日晨尿量多达3600毫升／日，病人神智清醒，诉有饥饿感，要求进流质饮食，血液检查：非蛋白氮67毫克％，二氧化碳结合力32.3容积％，血钠290.8毫克％，病情有明显好转。8月27日下午复诊：发热已退，黄疸渐消，精神亦有好转；尿量正常，尿常规检查已无异常，脉滑数，舌苔稍黄。拟再进清热利湿，调补气血之品。在原方上去肉桂、黄柏、丹皮、车前、枯芩、益元散、栝蒌，加北沙参18克、地骨皮9克、蒲公英15克，再服二剂后，一般情况好转，尿量正常，血压120～130/70～80毫米汞柱，各项血液检查结果亦已接近正常。
（关幼波治验，危北海整理：医案选录——手术后无尿症一例，《中医杂志》7：27，1962）
例二李××，已婚，女，50岁。因上腹部疼痛4天，于1958年6月21日，急诊入北京××医院。患者十余年来，常有上腹疼痛，泛酸，服苏打后而缓解，疼痛多与饮食有关，近四日上腹部疼痛复作，以两肋缘为甚，入院前一日，疼痛加重，持续不解，大便两日未行，小便如常。既往史从略。检查：急性病容，痛苦表情，皮肤无黄疸。头部器官阴性，颈软，心肺（一），腹壁普遍板硬，并有压痛，肝脾不易触及，膝反射存在。血压100／70毫米汞柱，血象正常。临床诊断为胃穿孔，合并腹膜炎。入院后施行手术，术后尿闭，呈半昏迷，肌肉抽动，非蛋白氮150毫克％，乃请中医会诊。患者神志欠清，时而躁动，手抽肉颤，尿闭，脉细肢凉，乃用真武汤加减，回阳利尿。药用西洋参、杭芍、白术、云苓、炮附片、生苡米。一剂后，能自排小便，四肢渐温，肉颤筋惕亦止。二诊时用红人参、白术、茯苓、车前子、牛膝、泽泻、苡米、玉竹，经过三诊之后，诸证好转，血压恢复正常，非蛋白氮降至37.5毫克％，后痊愈出院。（《岳美中医案集》）
例三孙××，女，52岁。因子宫颈癌，手术后发生呕吐不能食已五天，医院诊断为不全性肠梗阻，曾服中药微予通利，虽便泄数次，但呕吐仍不止，病情严重，西医施行输液及胃肠减压，未见好转。诊时患者头痛目眩，耳鸣口苦，心中疼热，呕吐涎沫，食不得入，渴不欲饮，大便先泄而后闭，肠鸣、不矢气，小便短黄，唇黯红，舌苔薄黄，脉弦。辨证：厥阴寒热夹杂，肝风扰胃，肝胃不和。治法：酸苦辛甘合剂，从乌梅丸化裁。方药：乌梅9克，川连6克，花椒3克，西党9克，当归6克，黄柏9克，干姜3克，代赭石15克，橘皮4.5克，竹茹4.5克，水煎服。一剂呕吐即止，涎沫减少，能进饮食，心中疼热亦减，腑气得行，并下蛔虫一条。但仍口苦溺黄，脉细弦，苔黄舌质红，知其胃气渐降，而肝胃阴伤，余邪未清，再以原方去花椒、赭石，加玉竹9克、丹参6克。四剂后，精神食欲好转，头晕耳鸣减轻，口苦除，但觉晚间腹部灼热，出汗后则渐舒，大便结，小便仍黄，脉细弦，舌苔根部薄黄，此乃肝胃渐和而气阴未复，最后仿炙甘草汤意调治：党参9克，白芍9克，丹参6克，玉竹9克，麦冬9克，火麻仁9克，炙甘草4.5克，生姜6克，四剂后，诸症大减，精神食欲均大有好转，呕吐从不再作。
（杨志一：医案扎记，《江西医药》9：29，1963）
【评按】
例一为手术后尿闭，神志时明时昧，口秽身黄，肢凉浮肿。患者年迈体虚，而肝胆湿热未清，弥漫三焦，入窜心包，以其正不抗邪，故治以养阴补血，滋肾通关，清热利湿法。药后尿闭得通，热退黄消。关氏对此案能细勘病机、斟酌虚实以疏邪扶正，其方药变化较有法度。
例二为手术后尿毒症，症见尿闭，半昏迷，肌肉抽动，脉细肢凉。肾为胃之关，肾阳因阳气式微而闭，故用真武汤加减以回阳利尿，肾关得阳则开，后以健脾气、利尿之剂投治，患者神清，排尿自如，岳氏以利尿法贯串全案，足见利尿在治疗尿毒症中之重要性。
Case 2 Jiao Mou, male, 34 years old. Initial visit date: September 9, 1973. Left foot coldness, numbness, and pain for three years; severe, unbearable pain in the past four months. Three years ago, right foot numbness, pain, and coldness were noticed; unable to walk long distances, walking exacerbated the pain; left lower leg distended, numb, heavy, and sore. Diagnosed with thromboangiitis obliterans (Thromboangiitis Obliterans) at a certain hospital; treatment was ineffective, symptoms worsened. Four months ago, severe pain and blackening of the left 1st and 2nd toes occurred, followed by swelling; five days ago, spontaneous ulceration occurred with bloody fluid exudate, unbearable severe pain, insomnia day and night, significantly reduced appetite, no bowel movement for five days, short and red urine, thus seeking medical attention at Beijing Hospital of Traditional Chinese Medicine. Examination: sallow complexion, painful expression. Left foot inflamed, red, swollen; left 1st and 2nd toes dry and necrotic. Dorsalis pedis pulse (Dorsalis Pedis Pulse) and Taixi pulse (Taixi Pulse) not palpable; increased skin temperature on the foot. Tongue body crimson, coating yellow and greasy; pulse wiry, slippery, and rapid. Syndrome differentiation: Stagnant heat injuring Yin, blood stasis accumulating toxin (Western diagnosis: Thromboangiitis Obliterans Stage III). Treatment principle: Clear heat and detoxify, nourish Yin, invigorate blood, and relieve pain. Prescription: Xuan Shen (Scrophulariae Radix) 30g, Shi Hu (Dendrobii Caulis) 24g, Yin Hua (Flos Lonicerae Japonicae) 60g, Gong Ying (Radix Taraxaci) 30g, Lian Qiao (Fructus Forsythiae) 30g, Di Ding (Herba Violae) 18g, Yuan Hu (Rhizoma Corydalis) 9g, Dang Gui (Radix Angelicae Sinensis) 18g, Chi Shao (Radix Paeoniae Rubra) 12g, Hong Hua (Flos Carthami) 12g, Tao Ren (Semen Persicae) 9g, Chuan Jun (Radix et Rhizoma Rhei) 3g, Bai Zhi (Radix Saposhnikoviae) 9g, Jie Geng (Radix Platycodonis) 9g, Gan Cao (Radix Glycyrrhizae) 9g, Niu Xi (Radix Achyranthis Bidentatae) 9g, Sheng Qi (Astragali Radix) 30g, Chuan Lian Zi (Fructus Meliae Toosendan) 18g, Ye Ju Hua (Flos Chrysanthemi Indici) 24g, Ying Su Ke (Capsule Papaveris) 15g. One dose per day, taken every six hours. External treatment: After disinfection, wrap the affected toes with Vaseline gauze strips.
September 12 (Follow-up): After taking 6 doses of the previous prescription, bowel movement has resumed, other symptoms remain the same. Remove Tao Ren from the previous prescription, add Yun Ling (Poria) 15g, continue taking.
September 23 (Fourth Visit): Pain persists; left 1st and 2nd toes are necrotic with clear boundaries. Prescription as follows: Xuan Shen 30g, Shi Hu 30g, Sheng Di (Rehmanniae Radix) 18g, Yin Hua 60g, Gong Ying 30g, Lian Qiao 30g, Dang Gui 15g, Di Ding 24g, Ye Ju 24g, Niu Xi 9g, Sheng Qi 30g, Yun Ling 15g, Chi Shao 12g, Dang Shen (Codonopsis Radix) 18g, Hong Hua 9g, Yuan Hu 9g, Gan Cao 9g, Ying Su Ke 15g.
September 28 (Fifth Visit): Under local anesthesia, the left 1st and 2nd toes were amputated; postoperative condition is good. Continue taking the previous prescription externally with Zhi Tong Sheng Ji San (Pain-relieving and Flesh-regenerating Powder), bandage the amputation wound with gauze.
October 8 (Seventh Visit): Pain has stopped, swelling has subsided, inflammation and redness of the left foot have receded, skin temperature is normal, wound has shrunk, new tissue is growing, self-reported lower back pain. Continue taking the previous prescription, change to one dose per day, decocted three times, taken once each morning, noon, and evening; external treatment remains the same.
October 15 (Eighth Visit): Wound continues to shrink, new tissue has flattened, self-reported lower back pain has decreased, pulse deep and fine, tongue tip red. Treatment principle: Warm and tonify Spleen and Kidney, unblock meridians and activate collaterals. Prescription as follows: Xuan Shen 30g, Sheng Qi 30g, Yin Hua 15g, Dang Shen 18g, Shi Hu 18g, Yun Ling 18g, Bai Zhu (Atractylodis Macrocephalae Rhizoma) 15g, Dang Gui 12g, Chi Shao 9g, Niu Xi 9g, Gan Cao 3g, Tu Si Zi (Cuscutae Semen) 30g, Gou Qi Zi (Lycii Fructus) 30g.
October 31 (Ninth Visit): Wound has healed, surface covered with thin scab; left lower leg feels sore and heavy after prolonged walking; lower back pain has disappeared.
November 17 (Tenth Visit): Scab has fallen off, local mild itching sensation, able to walk one or two stations. Continue taking Wu Zi Yan Zong Wan (Five Seeds for Procreation Pill), take 2 pills every morning, Shen Qi Wan (Kidney Qi Pill) 2 pills every night to consolidate therapeutic effect. (From "Collected Clinical Experiences of Fang Zhixuan in Surgery")
[Commentary] Tuo Ju (Gangrene of the extremities) is named "Tuo Yong" in *Ling Shu Jing: Congestion and Ulcer*, equivalent to thromboangiitis obliterans. It is mostly caused by limbs contracting cold-dampness.
Case 1 Due to cold-dampness stagnating for a long time transforming into heat-toxin, severe heat injuring Yin, accompanied by meridian obstruction and qi-blood stagnation, local necrosis has appeared. Therefore, the treatment principle is to nourish Yin, clear heat, harmonize nutritive level, and invigorate blood. This case has two characteristics in treatment: first, the internal prescription is based on modifications of Si Miao Yong An Tang (Four Marvels Preserving Life Decoction, from *Yan Fang Xin Bian*) and incorporates folk herbal medicines; second, the external treatment features integration of traditional Chinese and Western medicine. The treatment plan is relatively comprehensive.
Case 2 Syndrome differentiation is stagnant heat injuring Yin, blood stasis accumulating toxin. The internal prescription is similar to Case 1. Since it is Stage III with toe necrosis, toe amputation is combined. In the late stage of the disease, the treatment principle is warming and tonifying Spleen and Kidney, unblocking meridians and activating collaterals. This case has clear origins and thorough analysis, prescribing herbs addressing both root and branch, worthy of clinical reference.
(25) Tetanus Zhu Mou, male, 32 years old. In 1951, his left sole was pierced by a rusty nail about 4 fen deep, with little bleeding. That night, he went home and applied herbal compresses locally, feeling not much pain. On the third day, he suddenly felt difficulty chewing and swallowing, and neck stiffness. At 10 PM that night, one spasm occurred. By the fourth day, spasm frequency increased, neck, spine, and waist all showed rigidity. Introduced by someone, he came to seek treatment; required assistance even for getting on and off vehicles. Body temperature 39.6°C, pulse very rapid, bowel and bladder functions normal, consciousness clear, otherwise normal. Just after examination, another spasm occurred, but not severe, recovering normally after about three minutes. The herbal compress on the affected part was removed, the wound cleaned, showing swelling and hardness. Yu Zhen San (Jade True Powder) was thickly applied to the wound, wrapped with gauze bandages externally. Additionally, 3 packets of powder medicine were given, each weighing 9 grams, instructed to be mixed with hot yellow wine and taken at home, one packet every 3 hours. The next day, carried in for follow-up; wound swelling and hardness had decreased by about 1/3 compared to initial diagnosis yesterday. Claimed that after taking 3 packets, spasm frequency greatly reduced; after cleaning the wound, Yu Zhen San was still applied and wrapped, and 3 more packets of Yu Zhen San were given to take back. On the third day, wound stiffness had completely softened and flattened, only the wound had not yet healed. Immediately changed to Sheng Ji Shou Kou Yao San (Flesh-generating and Orifice-closing Powder); swallowing had recovered to normal, spasm frequency greatly reduced, attack intervals extended, severity turned mild. Internal Yu Zhen San as before, but each packet reduced to 6 grams. Continuing this regimen, fully recovered in twelve days. Attached Formula: Yu Zhen San: Bai Fu Zi (Typhonii Rhizoma Praeparatum) 320g, Sheng Nan Xing (Arisaematis Rhizoma cum Bile Praeparatum, stir-fried with ginger juice), Tian Ma (Gastrodiae Rhizoma), Qiang Huo (Notopterygii Rhizoma et Radix), Fang Feng (Saposhnikoviae Radix), Bai Zhi each 30g, Chan Yi (Bombyx Batryticatus) 90g. Grind into fine powder, store in bottle for future use, keep airtight.
(Zhang Jueren: Efficacy of Yu Zhen San in Treating Tetanus, *Chinese Journal of Traditional Medical Science and Technology* 8:421, 1956)
[Commentary] Yu Zhen San (from *Wai Ke Zheng Zong*) is a commonly used formula for treating tetanus, functioning to dispel wind and calm spasms. Mr. Zhang's application of this formula internally combined with external treatment showed significant efficacy. The late Mr. Yu Wu Yan introduced in his *New Interpretations of Jin Gui Yao Lue* using Chan Yi (cleaned of head and feet) ground into extremely fine powder, along with half a jin of yellow wine, putting 15-30g of Chan Yi powder into the wine, simmering gently for several boils, taking once in one dose. Generally, patients sweat profusely all over the body after taking the medicine, the sweat is sticky and smells fishy, slight sweating lasts quite long; after one sweat, pathogens leave and the disease can be cured. This formula originally appeared in Ming Dynasty Gong Xin's *Gu Jin Yi Jian*, named Tuo Fan San, effective for treating tetanus. If the patient has constipation and internal heat, use Cheng Qi Tang (Descending the Qi Decoction) to purge them.
(26) Phlebitis Ma x, female, 28 years old. Initial visit date: September 29, 1974. Suffered from chronic bacillary dysentery for over a year, treated in xx Hospital, received intravenous infusion, discharged for several days. For the past three days, left wrist pain, limited movement, a cord-like structure appeared on the left upper limb, swollen and painful, poor sleep. Examination: A distinct cord-like structure from left forearm to upper arm, length 28.5 cm, hard texture, tender to touch and refuses pressure, skin along the cord is flushed, left forearm slightly swollen, left wrist and elbow flexion and extension slightly limited. Coating white, pulse wiry and slightly rapid. Syndrome differentiation: Damp-heat coagulation, blood stasis blocking collaterals (Western diagnosis: Superficial phlebitis of left upper limb). Treatment principle: Clear heat and drain dampness, invigorate blood and dissipate nodules. Prescription: Yin Hua 24g, Gong Ying 24g, Lian Qiao 18g, Yin Chen (Artemisiae Scopariae Herba) 30g, Tiao Qin (Scutellariae Radix) 9g, Zhu Ling (Polyporus) 9g, Xuan Shen 18g, Ze Xie (Alismatis Rhizoma) 9g, Chao Shan Jia (Cassis Cortex Preparatus) 15g, Chi Shao 9g, Gui Wei (Angelicae Sinensis Cauda) 12g, Che Qian Zi (Plantaginis Semen) 9g, Hong Hua 9g, Yuan Hu 9g, Chuan Lian Zi 18g, Sheng Ma (Cimicifugae Rhizoma) 9g, Gan Cao 3g.
October 6 (Follow-up): After medication, swelling subsided, pain lightened, sleep peaceful, skin flushing receded, but local cord remains the same. Remove Huang Qin (Scutellariae Radix) and Gan Cao from previous prescription, add Di Long (Pheretima) 15g, Ze Lan Ye (Lycopus Herba) 12g, continue taking.
October 17 (Third Visit): Pain stopped, cord softened, no tenderness, shortened to 20 cm. Prescription as follows: San Leng (Sparganii Rhizoma) 9g, Chi Shao 9g, E Zhu (Curcumae Rhizoma) 9g, Ban Xia (Pinelliae Rhizoma Praeparatum) 9g, Xuan Shen 18g, Chao Shan Jia 15g, Lian Qiao 15g, Sheng Qi 15g, Ji Xue Teng (Spatholobi Caulis) 18g, Yun Ling 12g, Hong Hua 9g, Chao Jiang Can (Bombyx Batryticatus Preparatus) 9g, Tao Ren 9g, Gui Wei 9g, Jiu Jun (Rhei Radix et Rhizoma Preparatus with Wine) 3g, Sheng Ma 9g.
October 31 (Fourth Visit): Cord basically disappeared, not obvious upon palpation. Change to taking Huo Xue Zhu Li Wan (Blood-invigorating Main Force Pill), take 5 pills every morning, Ba Zhen Wan (Eight Treasures Pill) 2 pills every night to consolidate therapeutic effect. (From "Collected Clinical Experiences of Fang Zhixuan in Surgery")
[Commentary] This case diagnosed as superficial phlebitis of left upper limb, local cord-like structure, skin flushing, left forearm slightly swollen. TCM syndrome differentiation belongs to damp-heat coagulation, blood stasis blocking collaterals. Since damp-heat manifestation is external, using only blood-invigorating and stasis-resolving methods makes it difficult to eliminate the root cause. Therefore, treatment employs dual approach: clearing heat and draining dampness simultaneously with invigorating blood and dissipating nodules. From prescription analysis, in the first visit, clearing heat and draining dampness dominated, with large dosages of Yin, Qiao, Gong Ying, Yin Chen, etc. Once pain stops, swelling subsides, flushing recedes, switch to blood-invigorating and qi-blood tonifying methods to complete the cure. The case handles the balance and steps of expelling pathogens and supporting healthy qi appropriately.
(27) Postoperative Complications
Case 1 Zhou Mou Mou, male, 74 years old. Medical Record No.: 2837. Patient suddenly felt aversion to cold and fever around 5 PM on August 21, 1961, followed by paroxysmal abdominal pain localized to the right upper abdomen, nausea and vomiting, vomitus food residue, one episode of fresh yellow soft stool. Next afternoon, obvious jaundice appeared on skin, consciousness slightly hazy, body temperature 39.3°C, lymphocytes 11%. Urine and stool examinations normal. Western diagnosis: Acute cholecystitis. Underwent cholecystostomy under local anesthesia at 4:30 PM on the 24th. From surgery until 8 PM the next night, total urine output less than 5 ml, patient in semi-coma state, breathing deep and fast, pulse 70-80 beats/min. Blood pressure 95-75/50 mmHg, sclera yellow, heart and lungs no special abnormalities, abdomen slightly distended, bowel sounds normal, bladder area tympanic. Blood tests: White blood cells 20,900/cubic mm, neutrophils 89%, eosinophils 1%, lymphocytes 10%, red blood cells 3.11 million/cubic mm, hemoglobin 9.5g, sodium 279.2 mg%, non-protein nitrogen 112 mg%, carbon dioxide combining power 24.6 vol%. Intravenous fluids and blood transfusion started immediately after surgery to correct acidosis and adjust electrolyte balance, but still no urination; bilateral renal capsule Novocaine block and acupuncture treatments also ineffective. Catheterization from bladder also yielded no urine. Invited TCM consultation on the evening of August 25. Consultation record: Patient's consciousness sometimes drowsy, muttering to himself, whole body and eyes orange-yellow, foul breath, slight fever, cold limbs, generalized edema, occasional cold sweats, no urination for two days, no defecation, complexion slightly red, dry mouth and tongue, pulse slippery and weak, tongue coating white, greasy and dirty, center yellow-black. Syndrome differentiation: Liver and gallbladder damp-heat not cleared; due to advanced age and physical weakness, damp-heat diffused through Triple Burner, invading Pericardium, with healthy qi unable to resist pathogens. Treatment principle: Nourish Yin and tonify blood, moisten Kidney and open passages. Prescription: Xi Yang Shen (American Ginseng Radix et Rhizoma), Mai Dong (Ophiopogonis Radix), Dang Gui each 9g, Bai Shao (Paeoniae Radix Alba) 30g, Da Sheng Di (Rehmanniae Radix Preparata), Tian Hua Fen (Trichosanthis Radix) each 15g, Cha Shi Hu (Dendrobii Caulis), Chuan Bei (Fritillariae Cirrhosae Bulbus), Yi Yuan San (Benefit Origin Powder, wrapped) each 12g, Chao Zhi Mu (Anemarrhenae Rhizoma Preparatus), Huang Bo (Phellodendri Cortex), Ku Qin (Scutellariae Radix), Che Qian Zi (wrapped), Quan Gua Lou (Trichosanthis Fructus), Dan Pi (Moutan Cortex) each 9g, Yin Chen, Yin Hua, Chi Ling (Poria with Red Skin) each 15g, Zi Rou Gui (Cinnamomi Cortex) 0.9g as guide, decocted and taken, 2 doses. After taking medicine at 10 PM that night, by 5 AM next day, urine volume reached 500 ml; by 10 AM, urine volume reached 900 ml. Urine routine: specific gravity 1.015, reaction acidic, protein (+), sugar (-), microscopy: few epithelial cells, white blood cells 1-2/high power field, red blood cells 0-1/high power field. By 8 AM on August 27, urine volume up to 3600 ml/day, patient conscious, reported hunger, requested liquid diet. Blood tests: non-protein nitrogen 67 mg%, carbon dioxide combining power 32.3 vol%, sodium 290.8 mg%, condition significantly improved. Follow-up on afternoon of August 27: Fever gone, jaundice gradually fading, spirit improving; urine volume normal, urine routine no abnormalities, pulse slippery and rapid, tongue coating slightly yellow. Plan to further administer heat-clearing, damp-draining, qi-tonifying, and blood-nourishing items. Remove Rou Gui, Huang Bo, Dan Pi, Che Qian, Ku Qin, Yi Yuan San, Gua Lou from original prescription, add Bei Sha Shen (Glehniae Radix) 18g, Di Gu Pi (Lycii Cortex) 9g, Pu Gong Ying (Taraxaci Herba) 15g, take another 2 doses. General condition improved, urine volume normal, blood pressure 120-130/70-80 mmHg, various blood test results also approaching normal.
(Guan Youbo's Clinical Experience, compiled by Wei Beihai: Selected Medical Cases - One Case of Postoperative Anuria, *Chinese Journal of Traditional Medical Science and Technology* 7:27, 1962)
Case 2 Li Mou Mou, married, female, 50 years old. Due to upper abdominal pain for 4 days, admitted to emergency department of Beijing xx Hospital on June 21, 1958. For over ten years, often had upper abdominal pain, acid regurgitation, relieved after taking soda; pain mostly related to diet. Upper abdominal pain recurred in the past four days, especially at costal margins. Day before admission, pain intensified, continuous and unremitting, no bowel movement for two days, urine normal. Past history omitted. Examination: Acute ill appearance, painful expression, skin no jaundice. Head organs negative, neck soft, heart and lungs (-), abdominal wall generally board-like hard, with tenderness, liver and spleen not easily palpable, knee reflex present. Blood pressure 100/70 mmHg, blood picture normal. Clinical diagnosis: Gastric perforation, complicated by peritonitis. Surgery performed after admission, postoperative urinary retention, semi-coma, muscle twitching, non-protein nitrogen 150 mg%, invited TCM consultation. Patient consciousness unclear, sometimes restless, hand tremors and muscle twitching, urinary retention, pulse fine, limbs cold. Used Zhen Wu Tang (True Warrior Decoction) modified to restore Yang and promote diuresis. Medicines: Xi Yang Shen, Hang Shao (Paeoniae Radix Alba), Bai Zhu, Yun Ling, Pao Fu Pian (Prepared Aconiti Lateralis Radix), Sheng Yi Mi (Coicis Semen). After one dose, able to urinate spontaneously, limbs gradually warm, muscle twitching and tendon quivering stopped. Second visit used Hong Ren Shen (Red Ginseng Radix et Rhizoma), Bai Zhu, Fu Ling (Poria), Che Qian Zi, Niu Xi, Ze Xie, Yi Mi, Yu Zhu (Polygonati Odorati Rhizoma). After three visits, all symptoms improved, blood pressure returned to normal, non-protein nitrogen dropped to 37.5 mg%, subsequently discharged cured. (From "Collected Medical Cases of Yue Mei")
Case 3 Sun Mou Mou, female, 52 years old. Due to cervical cancer, vomiting and inability to eat for five days after surgery, hospital diagnosed incomplete intestinal obstruction. Took TCM medicine slightly promoting purgation; although had diarrhea several times, vomiting still did not stop, condition serious. Western medicine administered IV fluids and gastrointestinal decompression, no improvement seen. At diagnosis, patient had headache and dizziness, tinnitus, bitter taste, burning pain in chest, vomiting saliva and foam, unable to eat, thirsty but no desire to drink, stool first diarrhea then constipation, borborygmus, no flatus, short and yellow urine, lips dark red, tongue coating thin yellow, pulse wiry. Syndrome differentiation: Jueyin cold-heat complex, Liver wind disturbing Stomach, Liver-Stomach disharmony. Treatment principle: Sour-bitter-pungent-sweet combination, modified from Wu Mei Wan (Mume Pill). Prescription: Wu Mei (Mume Fructus) 9g, Chuan Lian (Coptidis Rhizoma) 6g, Hua Jiao (Zanthoxyli Pericarpium) 3g, Xi Dang (Codonopsis Radix) 9g, Dang Gui 6g, Huang Bo 9g, Gan Jiang (Zingiberis Rhizoma) 3g, Dai Zhe Shi (Hematitum) 15g, Ju Pi (Citri Reticulatae Pericarpium) 4.5g, Zhu Ru (Bambusae Caulis in Taenia) 4.5g, decocted in water and taken. After one dose, vomiting stopped, saliva foam reduced, able to eat, burning pain in chest also decreased, fu-organs qi moved, passed one roundworm. Still bitter taste and yellow urine, pulse fine-wiry, coating yellow, tongue body red, knowing stomach qi gradually descending, but Liver-Stomach Yin injured, residual pathogens not cleared. Again use original prescription remove Hua Jiao, Zhe Shi, add Yu Zhu 9g, Dan Shen (Salviae Miltiorrhizae Radix et Rhizoma) 6g. After four doses, spirit and appetite improved, dizziness and tinnitus reduced, bitter taste gone, but felt evening abdominal burning, gradually comfortable after sweating, stool constipated, urine still yellow, pulse fine-wiry, tongue coating root thin yellow, this is Liver-Stomach gradually harmonized but qi-Yin not restored. Finally imitate Zhi Gan Cao Tang (Honey-fried Licorice Decoction) idea for regulation: Dang Shen 9g, Bai Shao 9g, Dan Shen 6g, Yu Zhu 9g, Mai Dong 9g, Huo Ma Ren (Cannabis Semen) 9g, Zhi Gan Cao (Glycyrrhizae Radix et Rhizoma Preparata cum Melle) 4.5g, Sheng Jiang (Zingiberis Rhizoma Recens) 6g. After four doses, major symptoms greatly reduced, spirit and appetite greatly improved, vomiting never occurred again.
(Yang Zhiyi: Medical Case Notes, *Jiangxi Medicine* 9:29, 1963)
[Commentary]
Case 1 is postoperative urinary retention, consciousness fluctuating, foul breath and body yellow, cold limbs and edema. Patient elderly and physically weak, while liver-gallbladder damp-heat not cleared, diffusing through Triple Burner, invading Pericardium, because healthy qi cannot resist pathogens. Therefore, treatment uses nourishing Yin and tonifying blood, moistening Kidney and opening passages, clearing heat and draining dampness methods. After medication, urinary retention resolved, heat subsided, jaundice faded. Mr. Guan carefully analyzed pathogenesis, weighed deficiency and excess to disperse pathogens and support healthy qi; his prescription changes were methodical.
Case 2 is postoperative uremia, symptoms including urinary retention, semi-coma, muscle twitching, fine pulse and cold limbs. Kidney is the gate of Stomach; Kidney Yang closed due to declining Yang energy. Therefore, Zhen Wu Tang modified was used to restore Yang and promote diuresis; when Kidney gate receives Yang, it opens. Subsequently, formulas strengthening Spleen qi and promoting diuresis were administered. Patient became conscious, urinated freely. Mr. Yue贯穿ed diuretic method throughout the case, demonstrating the importance of diuresis in treating uremia.