猪苓(去皮) 茯苓 泽泻 滑石(碎) 阿胶(各一两)
上五味以水四升先煎四味取二升去滓内下阿胶烊消温服七合日三服
发汗多若重发汗者亡其阳谵语脉短者死脉自和者不死
汗多亡阳神败而发谵语脉短者阳绝乃死脉自和者阳复则生此申明上章发汗则躁心愦愦反谵语之义
直视谵语喘满者死下利者亦死
直视谵语阳亡而神败也喘满则胃逆而阳上脱下利则脾陷而阳下脱是以皆死
夫实则谵语虚则郑声郑声重语也
阳实则为谵语阳虚则为郑声郑声之义语之繁絮重复者实者上编之胃家实是也虚者本篇之胃中虚冷是也此申明上亡阳
谵语之义
阳明病下之其外有热手足温不结胸心中懊 饥不能食但头汗出者栀子豉汤主之(方在太阳八十九)
下伤中气阳浮于表故外有热而手足温胃中空虚客气动膈故成结胸(义在结胸)今不成结胸只觉心中懊 饥不能饮食
者膈下之阴与膈上之阳逼迫郁蒸而生瘀浊故也膈热薰腾故头上汗出此宜栀子豉汤吐瘀浊而清烦热也此申明六十五章若下
之胃中空虚客气动膈心中懊 舌上苔者栀子豉汤主之一段之义
三阳合病腹满身重难以转侧口不仁而面垢谵语遗尿发汗则谵语下之则额上生汗手足逆冷(此阳明入太阴去路)若自
汗者白虎汤主之(方在太阳三十七此阳明承气初证)
六十五章脉浮而紧为太阳证咽燥口干为少阳证发热汗出不恶寒反恶热为阳明证是三阳合病也而其腹满身重以至难以
转侧则太阴证脾窍于口阳虚湿盛开阖蹇涩故口不仁木主五色土湿木郁气色晦暗是以面垢神明不慧是以谵语膀胱失约是以
遗尿(此补六十五章未详之义也)若发汗则为郑声之谵语(此复申明若发汗则心愦愦反谵语一段)若下之则额上生汗手
足厥冷阳泄而土败(此复申明上章手足温头汗出之义而推展之头汗肢温是阳虚而上热额汗肢冷是阳泄而外寒也)若汗不
止头额而通身自汗者则津亡而土燥宜白虎汤泄热而清金也此复申六十五章白虎汤之义
猪苓(去皮) 茯苓 泽泻 滑石(打碎) 阿胶(各一两)
以上五味药,用水四升,先煎煮前四味药,取汁二升,去渣后加入阿胶,烊化溶解,每次温服七合,每日三次服用。
发汗过多,或者再次发汗的,会导致亡阳(阳气耗散),出现谵语(神志不清,胡言乱语)。脉象短的,预后不良;脉象平和的,不会死亡。
汗多导致亡阳,神气败坏而发出谵语。脉短说明阳气断绝,所以死亡;脉象自和说明阳气恢复,所以生存。这是为了阐明上一章“发汗则躁、心愦愦(心中烦闷)、反谵语”的道理。
眼睛直视、谵语、气喘胸满的,预后不良;腹泻的,也预后不良。
眼睛直视、谵语,是阳气亡失而神气败坏。气喘胸满,说明胃气上逆而阳气上脱;腹泻,说明脾气下陷而阳气下脱。因此这两种情况都会导致死亡。
实证会出现谵语,虚证会出现郑声(语言重复,声音低微)。郑声是指言语繁冗重复。
阳实就会发谵语,阳虚就会发郑声。“实”指的是《伤寒论》上篇所说的“胃家实”;“虚”指的是本篇所说的“胃中虚冷”。这是为了阐明前面关于亡阳谵语的道理。
阳明病经过攻下治疗后,体表仍有发热,手足温暖,没有形成结胸(邪热与痰水互结于胸膈),心中懊恼(烦闷不适),感觉饥饿但不能进食,只有头部出汗的,用栀子豉汤主治。(方剂在太阳篇第八十九节)
攻下损伤了中焦之气,阳气浮越于体表,所以体表有热而手足温暖。胃中空虚,客气(外邪或病理产物)扰动胸膈,所以会形成结胸(道理见结胸篇)。现在没有形成结胸,只是觉得心中懊恼,饥饿却不能饮食,这是因为膈下的阴气与膈上的阳气相互逼迫、郁蒸而生成的瘀浊所致。膈间的热气熏腾,所以头上出汗。这种情况适宜用栀子豉汤,以涌吐瘀浊并清除烦热。这是为了阐明第六十五章“若下之,胃中空虚,客气动膈,心中懊恼,舌上苔者,栀子豉汤主之”这一段的道理。
三阳合病(太阳、少阳、阳明三经同时发病),腹部胀满,身体沉重,难以翻身侧卧,口舌麻木不知滋味且面色垢秽,谵语,遗尿。如果发汗,则会加重谵语;如果攻下,则额头出汗,手足逆冷。(这是阳明病转入太阴病的途径)如果是全身自汗出的,用白虎汤主治。(方剂在太阳篇第三十七节,这是阳明承气汤证的初期表现)
第六十五章提到:脉浮紧是太阳证,咽燥口干是少阳证,发热汗出不恶寒反恶热是阳明证,这就是三阳合病。而其腹部胀满、身体沉重以至于难以转侧,则是太阴证的表现。脾开窍于口,阳虚湿盛,开阖功能涩滞,所以口舌麻木不知滋味。木主五色,土湿木郁,气色晦暗,所以面色垢秽。神明不聪慧,所以谵语。膀胱失去约束,所以遗尿。(这是对第六十五章未详细阐述的道理的补充)如果发汗,则会出现郑声样的谵语(这是再次阐明“若发汗则心愦愦反谵语”这一段的意思)。如果攻下,则额头出汗,手足厥冷,这是阳气泄越而脾土败坏(这是再次阐明上一章“手足温、头汗出”的道理并加以推展:头汗肢温是阳虚而上热,额汗肢冷是阳泄而外寒)。如果汗不止于头额,而是通身自汗,则是津液亡失而脾土干燥,适宜用白虎汤泄热并清肃肺气。这是再次申述第六十五章中白虎汤的道理。
Zhu Ling (Polyporus, with skin removed), Fu Ling (Poria), Ze Xie (Alisma), Hua Shi (Talcum, crushed), E Jiao (Donkey-hide Gelatin) (each one tael).
Take the above five herbs, add four sheng of water, first decoct the first four herbs to obtain two sheng of liquid, remove the dregs, then add the E Jiao and melt it. Take seven ge warm each time, three times a day.
If sweating is excessive, or if sweating is induced again after initial sweating, Yang collapse (collapse of Yang qi) occurs, accompanied by delirium (incoherent speech due to mental confusion). If the pulse is short, death ensues; if the pulse is harmonious, survival is possible.
Excessive sweating leads to Yang collapse and deterioration of Shen (spirit), resulting in delirium. A short pulse indicates the exhaustion of Yang qi, hence death; a self-harmonious pulse indicates the recovery of Yang qi, hence life. This clarifies the meaning of the previous chapter: "Sweating induces restlessness, mental confusion, and conversely, delirium."
Staring fixedly, delirium, and wheezing with chest fullness indicate death; diarrhea also indicates death.
Staring fixedly and delirium signify the loss of Yang qi and deterioration of Shen. Wheezing and chest fullness indicate rebellious Stomach qi and the upward collapse of Yang; diarrhea indicates sinking Spleen qi and the downward collapse of Yang. Therefore, both conditions lead to death.
Excess patterns manifest as delirium; deficiency patterns manifest as Zheng Sheng (repetitive, low-voiced muttering). Zheng Sheng refers to verbose and repetitive speech.
Yang excess results in delirium; Yang deficiency results in Zheng Sheng. "Excess" refers to what was described in the upper volume as "Stomach House Excess" (fullness in the Stomach); "deficiency" refers to what is described in this chapter as "Cold Deficiency in the Stomach." This clarifies the meaning of the preceding discussion on Yang collapse and delirium.
In Yangming disease, after purgation, if there is heat on the exterior, warmth of the hands and feet, no formation of Jie Xiong (chest binding), mental agitation (Ao Nao), hunger but inability to eat, and only sweating on the head, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should be administered. (Formula found in Taiyang Chapter 89).
Purgation damages Middle Qi, causing Yang to float to the exterior, hence external heat and warm hands and feet. The Stomach becomes empty, allowing hostile qi to disturb the diaphragm, which typically leads to Jie Xiong (see Jie Xiong section). However, since Jie Xiong has not formed here, but rather mental agitation, hunger without ability to eat, it is because Yin below the diaphragm and Yang above the diaphragm are forcing each other, leading to stagnation, steaming, and generation of turbid stasis. Heat steaming from the diaphragm causes sweating on the head. In this case, Zhi Zi Chi Tang is appropriate to induce vomiting of turbid stasis and clear烦热 (restless heat). This clarifies the meaning of the passage in Chapter 65: "If purged, the Stomach becomes empty, hostile qi disturbs the diaphragm, causing mental agitation and coating on the tongue; Zhi Zi Chi Tang should be administered."
San Yang He Bing (Concurrent disease of the Three Yang channels: Taiyang, Shaoyang, and Yangming): abdominal fullness, heaviness of the body, difficulty in turning over, numbness of the mouth (Kou Bu Ren) with a greasy facial appearance, delirium, and urinary incontinence. If sweating is induced, delirium worsens; if purgation is used, sweating appears only on the forehead with cold extremities (this is the pathway for Yangming disease transitioning to Taiyin). If there is spontaneous sweating of the whole body, Bai Hu Tang (White Tiger Decoction) should be administered. (Formula found in Taiyang Chapter 37; this is the initial stage of Yangming Cheng Qi Tang syndrome).
Chapter 65 states: Floating and tight pulse is a Taiyang syndrome; dry throat and mouth is a Shaoyang syndrome; fever, sweating, aversion to heat rather than cold is a Yangming syndrome. These constitute San Yang He Bing. The abdominal fullness and body heaviness, extending to difficulty in turning over, are Taiyin symptoms. The Spleen opens into the mouth; Yang deficiency with dampness abundance causes obstruction in opening and closing, leading to numbness of the mouth. Wood governs the five colors; Earth dampness stagnates Wood, causing dull complexion, hence the greasy face. Lack of clarity in Shen leads to delirium. Loss of control in the Bladder leads to urinary incontinence (this supplements the details omitted in Chapter 65). If sweating is induced, it results in Zheng Sheng-like delirium (reiterating "if sweated, mental confusion and delirium occur"). If purged, sweating on the forehead and cold extremities occur, indicating Yang leakage and failure of Earth (Spleen/Stomach) (reiterating and expanding upon the previous chapter's "warm hands/feet and head sweat": head sweat with warm limbs indicates Yang deficiency with upper heat; forehead sweat with cold limbs indicates Yang leakage with external cold). If sweating is not limited to the head and forehead but is spontaneous sweating of the entire body, it indicates loss of Jin Ye (body fluids) and dryness of Earth (Spleen/Stomach). Bai Hu Tang is suitable to drain heat and clear Metal (Lung). This reiterates the significance of Bai Hu Tang in Chapter 65.