喻嘉言治吴添官生母。时多暴怒。以致经行复止。秋间渐觉气逆上厥。如畏舟船之状。
动辄晕去。久久卧于床中。时若天翻地覆。不能强起。百般医治不效。因用人参三五分。略
宁片刻。最后日服五钱。家产费尽。病转凶危。大热引饮。脑间有如刀劈。食少泻多。已
治木。无他望矣。姑延喻诊。喻曰。可治。凡人怒甚。则血菀于上。而气不返于下。名曰厥
巅疾。厥者。逆也。气与血俱逆于高巅。故动辄眩晕也。又以上盛下虚者。过在少阳。少阳
者。足少阳胆也。胆之穴皆络于脑。郁怒之火。上攻于脑。得补而炽。其痛如劈。同为厥巅
之疾也。风火相煽。故振摇而热蒸。木土相凌。故艰食而多泻也。于是会内经铁落镇坠之意
以代赭石、龙胆草、芦荟、黄连之属。降其上逆之气。以蜀漆、丹皮、赤芍之属。行其
上菀之血。以牡蛎、龙骨、五味之属。敛其浮游之神。最要在每剂药中。生入猪胆汁二枚。
盖以少阳热炽。胆汁必干。亟以同类之物济之。资其持危扶颠之用。病者药一入口。便若神
返其舍。忘其苦口。连进十数剂。服猪胆二十余枚。热退身凉。饮食有加。便泻自止。始能
起床行动数步。然尚觉身轻如叶。不能久支。喻恐药味太苦。不宜多服。减去猪胆及芦、龙
等药。加入当归一钱。人参三分。姜、枣为引。平调数日而全愈。
喻嘉言诊金道宾之脉。左尺和平。右尺如控弦。如贯索。上冲甚锐。喻曰。是病枝叶未
有害。本实已先拨。必得之醉而使内也。曰诚有之。但已绝欲二年。服人参斤许。迄今诸无
所苦。惟闭目转盼。则身非己有。恍若离魂者然。不识可治与否。喻曰。夫人生之阴阳。相
抱而不脱。故阳欲上脱。阴下吸之则不脱。阴欲下脱。阳上吸之则不脱。惟大醉后大犯房劳
五脏翻覆。百脉动摇。二气乘之脱离。有顷刻殒于女身者。病之得有今日。犹幸也。但真
阳不能潜藏。常欲飞腾泄越耳。治之之法有三。以涩固脱。以重镇怯。以补理虚。更佐以介
类沉重下伏之物。引之潜降。使真阳复返其宅。凝然与真阴相恋。再用大封大固之法。可以
收功。经云。阳者亲上者也。阴者亲下者也。故凡上脱者。妄见妄闻。有如神灵。下脱者。
不见不闻。有如聋 。上脱者。身轻快而汗多淋漓。下脱者。身重着而肉多青紫。昔有新贵
人。马上扬扬得意。未及回寓。一笑而逝者。此上脱也。又有人寝而遭魇。身如被杖。九窍
出血者。此下脱也。是病始于溺情。继以纵欲。必须大夺其情。永积其精。再加千日之把特
乃不为倏然之上脱矣。
〔附〕一人忽觉自形作两。并卧。不别真假。不语。问亦无对。乃离魂也。用朱砂、人
参、茯苓浓煎服。真者气爽。假者即化。
松陵贡士吴友良。年逾古稀。头目眩晕。服补中益气汤。始用人参一钱。加至三钱。遂
痞满不食。坐不得卧。三昼夜喃喃不休。石顽往候。见其面赤。进退不常。左颊聂聂 动。
诊其六脉皆促。或七八至一歇。或三四至一歇。询其平昔起居。云是知命之年。便绝欲自保
饮啖自强。此壮火烁阴。而兼肝风上扰之兆。与生料六味。除去茱萸。易入钩藤。大剂煎
服。是夜即得酣寝。其后或加鳖甲。或加龙齿。或加枣仁。有时忘动怒火。达旦不宁。连宵
不已。则以秋石汤送灵砂丹。应如桴鼓。盛夏酷暑。则以小剂生脉散代茶。后与六味全料。
调理至秋而安。
震按眩晕有实有虚。如壮盛人实痰实火脉滑大有力者。二陈、芩、栀。不恶心者。用酒
制大黄二三钱。或加入。或为末茶调下。如肥白人痰多气虚脉濡大或细软者。六君加 、附
又内经谓诸风掉眩。皆属肝木。故因于外风者。二陈加荆、防、钩藤、天麻。因于内风者
即类中之渐。宜虎、膝、牡蛎、枸杞、首乌、桑叶、菊花、生地、人参。戴复庵曰。头脑
挟风。眩晕之甚。抬头则屋转。眼常黑花。如见有物飞动。或见物为两。宜大追风散。或秘
旨正元散加鹿茸。不效。一味鹿茸。每服五钱。酒煎去渣。入麝少许。盖鹿之阳气钟于头
故以类相从也。此即就风之一端而有虚实之分也。若在夏月有冒暑而眩晕者。又不得概从
风治。夫肝为风木之脏。故内经以眩晕专责之肝。若肾水亏少。肝枯木动。复挟相火。上踞
高巅而眩晕者。近时最多。董载臣曰。妇人患此更多。宜逍遥散为主。轻则合四物。重则合
六味加黄连。极有效验。他如晨晕属阳虚。昏晕属阴虚。亦辨证之大旨。未可据以为准。今
所选三案。原不越乎诸法。而议论卓荦。方药巧妙。实能驾乎诸法。原本类案所载者不及也
【医案一】
喻嘉言诊治吴添官的母亲。当时她经常暴怒，导致月经来潮后又停止。到了秋天，逐渐感到气逆上冲至头部，感觉像害怕乘船一样（眩晕欲仆）。动不动就晕倒，长时间卧床不起，时常感觉天翻地覆，无法勉强起身。各种治疗方法都无效，后来使用人参三五分，只能暂时稍微安宁片刻。最后每天服用五钱人参，家产耗尽，病情反而更加凶险危急。出现大热、引水自饮、头脑疼痛如刀劈一般、饮食减少、腹泻严重等症状，已经治疗了肝脏（木），没有其他希望了。姑且请喻嘉言诊脉。喻嘉言说：“可以治疗。”凡是人愤怒过度，血液就会郁积在头部上方，而气不能返回下方，这叫做“厥巅疾”。“厥”就是逆的意思。气和血都逆乱于头顶高处，所以动不动就发生眩晕。又因为这是上盛下虚的证候，病机在于少阳经。少阳指的是足少阳胆经。胆经的穴位都联络于脑，郁结愤怒产生的火邪，向上攻冲脑部，遇到补益药则火势更旺，所以头痛如刀劈。这也属于厥巅之疾。风与火相互煽动，所以身体震颤摇晃且热气蒸腾；肝木克制脾土，所以进食困难且多腹泻。于是结合《内经》中用铁落镇坠之意，使用代赭石、龙胆草、芦荟、黄连等药物，以降其上逆之气；使用蜀漆、丹皮、赤芍等药物，以行散其上郁之血；使用牡蛎、龙骨、五味子等药物，以收敛其浮游之神志。最关键的是每剂药中加入两个生猪胆汁。因为少阳热势炽盛，胆汁必然干枯，急需以同类之物来补救，起到扶持危局的作用。病人服药入口，便好像神灵返回体内，忘记了药的苦味。连续服用十几剂，吃了二十多个猪胆后，热退身凉，食欲增加，腹泻自然停止，才能起床走动几步。然而还觉得身体轻飘如叶子，不能久站支撑。喻嘉言担心药味太苦，不宜多服，于是减去猪胆及芦荟、龙骨等药，加入当归一钱、人参三分，以生姜、大枣为引子，平调数日后完全痊愈。
【医案二】
喻嘉言诊察金道宾的脉象，左尺脉平和，右尺脉像拉紧的弓弦，像贯穿的绳索，向上冲射非常锐利。喻嘉言说：“这个病的枝叶还没有受到损害，但根本已经先被拔除。这一定是因为醉酒之后进行房事所致。”患者说：“确实有过这种情况，但已经禁欲两年，服用了约一斤人参，至今没有任何痛苦，只是闭上眼睛转动眼珠时，就觉得身体不是自己的，恍惚好像离魂一样。不知道是否可以治疗？”喻嘉言说：“人的阴阳，互相抱持而不分离，所以阳气想要上脱，阴气在下吸引它就不会脱失；阴气想要下脱，阳气在上吸引它就不会脱失。只有在大醉后大犯房劳，导致五脏翻覆，百脉动摇，阴阳二气趁机脱离，甚至有顷刻间死在女子身边的情况。得病到现在还能存活，算是幸运了。但是真阳不能潜藏，常常想要飞腾泄越。治疗的方法有三种：一是用涩药固脱，二是用重镇药怯惊，三是用补药理虚。再辅助以介壳类沉重下伏的药物，引导阳气潜降，使真阳返回其宅邸，凝然地与真阴相恋。再用大封大固的方法，就可以收效。《内经》说：‘阳气亲上，阴气亲下。’所以上脱的人，妄见妄闻，好像有神灵附体；下脱的人，不见不闻，好像聋哑人。上脱的人，身体轻快而汗多淋漓；下脱的人，身体沉重而肌肉多青紫。以前有位新贵，骑马时扬扬得意，还没回到住所，一笑就去世了，这就是上脱。又有个人睡觉时被鬼压床（魇），身体像被杖打，九窍出血，这就是下脱。这个病开始于沉溺情欲，接着放纵欲望，必须大大抑制情欲，永远积蓄精气，再加上千日之久的调养，才不会突然发生上脱。”
【附案】
有一人忽然觉得自己的身体分成两个，并排躺着，分不清哪个是真哪个是假，不说话，问也不回答，这是离魂症。用朱砂、人参、茯苓浓煎服用。真的那个人精神清爽，假的那个随即消散。
【医案三】
松陵贡士吴友良，年龄超过七十岁，头目眩晕。服用补中益气汤，开始用人参一钱，加到三钱，于是出现痞满、不想吃东西、坐立不安、不能躺卧的症状，三天三夜喃喃自语不停。石顽前去探望，见他面色发红，进退无常，左脸颊微微跳动。诊察他的六部脉象都急促，有时七八次跳动歇止一次，有时三四次跳动歇止一次。询问他平时的起居习惯，他说从五十岁左右就开始绝欲自保，饮食方面力求自强。这是壮火灼烧阴液，兼有肝风上扰的征兆。给予生料六味地黄丸，去掉山茱萸，换入钩藤，大剂煎服。当天晚上就能熟睡。后来有时加入鳖甲，有时加入龙齿，有时加入酸枣仁。有时忘记控制怒火，通宵不宁，就用秋石汤送服灵砂丹，效果如击鼓应声般迅速。盛夏酷暑时，就用小剂量的生脉散代替茶水饮用。后来用六味地黄丸全方，调理到秋天才安定下来。
【按语】
俞震按：眩晕有实证也有虚证。如身体强壮的人，因实痰、实火导致脉象滑大有力者，可用二陈汤加黄芩、栀子；如果不恶心，可用酒制大黄二三钱，或研末用茶调服。如肥胖之人，痰多气虚，脉象濡大或细软者，可用六君子汤加白术、附子。另外，《内经》说“诸风掉眩，皆属肝木”，所以因外风引起的，可用二陈汤加荆芥、防风、钩藤、天麻；因内风引起的，即是中风的先兆，宜用虎骨、牛膝、牡蛎、枸杞、首乌、桑叶、菊花、生地、人参。戴复庵说：头脑挟风，眩晕严重，抬头则房屋旋转，眼睛常看到黑花，好像看见有物体飞动，或者看东西变成两个，宜用大追风散，或秘旨正元散加鹿茸。如果无效，单用一味鹿茸，每次服用五钱，酒煎去渣，加入少许麝香。因为鹿的阳气汇聚在头部，所以以类相从。这就是就“风”这一端而言，有虚实之分。如果在夏季因冒暑而眩晕，又不能一概从风论治。肝为风木之脏，所以《内经》将眩晕专门归责于肝。如果是肾水亏少，肝枯木动，又挟带相火，上踞高巅而导致眩晕的，近来最多。董载臣说：妇女患此病更多，宜以逍遥散为主，轻症合四物汤，重症合六味地黄丸加黄连，极有效验。其他的，如早晨眩晕属阳虚，黄昏眩晕属阴虚，也是辨证的大致原则，不可据此作为绝对标准。现在所选的三个医案，原本没有超出各种方法之外，但议论卓越，方药巧妙，实际上能超越各种方法，比原本类案中所记载的要好得多。
[Case 1]
Yu Jiayan treated the mother of Wu Tian Guan. At that time, she frequently experienced violent anger, which caused her menstruation to stop after it had started. In autumn, she gradually felt qi rebelling and rushing upward to the head, experiencing a sensation akin to seasickness (vertigo with a desire to fall). She would faint at every move and remained in bed for a long time, constantly feeling as if heaven and earth were overturning, unable to force herself to rise. Various treatments proved ineffective. Later, ginseng was used in doses of three to five fen, providing only brief, slight relief. Finally, she took five qian of ginseng daily, exhausting her family's wealth, yet her condition worsened critically. Symptoms included high fever, intense thirst, headache as if split by a knife, reduced food intake, and severe diarrhea. The liver (Wood) had already been treated, leaving no hope. Yu was consulted. Yu said, "It is treatable." When a person becomes extremely angry, blood stagnates in the upper part of the body, and qi fails to return to the lower part. This is called "Jue Dian Ji" (Rebellious Disease of the Vertex). "Jue" means rebellion. Both qi and blood rebel to the high vertex, causing frequent vertigo. Furthermore, this pattern of excess above and deficiency below involves the Shaoyang channel. Shaoyang refers to the Foot-Shaoyang Gallbladder channel. The acupoints of the gallbladder connect to the brain. Fire from郁怒 (depressive anger) attacks the brain upward; when tonified, the fire flares up, causing pain like splitting. This also belongs to Jue Dian disease. Wind and fire fan each other, causing tremors and steaming heat; Wood overacts on Earth (Liver overacting on Spleen), causing difficulty eating and frequent diarrhea. Thus, combining the meaning of using iron filings for sedation from the *Neijing*, he used Oyster Shell (Dai Zhe Shi), Gentian Root (Long Dan Cao), Aloe (Lu Hui), and Coptis Rhizome (Huang Lian) to descend the rebellious qi; Quinine Bark (Shu Qi), Moutan Cortex (Dan Pi), and Red Peony Root (Chi Shao) to circulate the stagnant blood; Oyster Shell (Mu Li), Dragon Bone (Long Gu), and Schisandra Berry (Wu Wei Zi) to gather the floating spirit. Most importantly, two raw pig bile sacs were added to each prescription. Since Shaoyang heat was blazing, the bile must have dried up; thus, similar substances were urgently needed to assist in supporting the critical situation. Upon taking the medicine, the patient felt as if her spirit returned, forgetting the bitter taste. After taking more than ten doses and over twenty pig bile sacs, the fever subsided, the body cooled, appetite increased, and diarrhea stopped spontaneously. She could then get up and walk a few steps, though her body still felt light as a leaf, unable to sustain standing for long. Yu feared the medicine was too bitter for prolonged use, so he removed the pig bile, Aloe, and Dragon Bone, adding one qian of Angelica Sinensis Root (Dang Gui) and three fen of Ginseng Radix et Rhizoma Rubra (Renshen), with Ginger and Jujube as guides. After several days of harmonizing treatment, she fully recovered.
[Case 2]
Yu Jiayan palpated the pulse of Jin Daobin. The left Chi pulse was peaceful, while the right Chi pulse resembled a taut bowstring or a rope passing through, shooting upward sharply. Yu said, "The branches of this disease are not yet damaged, but the root has already been uprooted. This must result from intercourse while drunk." The patient replied, "This is true, but I have abstained from sexual activity for two years and consumed about one jin of Ginseng Radix et Rhizoma Rubra (Renshen). To date, I suffer no discomfort. However, when I close my eyes and move them, I feel my body is not my own,恍惚 (huanghuo - trance-like) as if my soul has departed. I do not know if it is treatable." Yu said, "In humans, Yin and Yang embrace each other without separation. If Yang desires to escape upward, Yin吸 (xi - attracts/sucks) it from below, preventing escape; if Yin desires to escape downward, Yang吸 (xi) it from above, preventing escape. Only after heavy drunkenness and excessive sexual exertion, causing the five zang organs to overturn and all vessels to shake, can the two qi separate. There are cases where death occurs instantly in the presence of a woman. Surviving until now is fortunate. However, True Yang cannot hide and constantly seeks to fly and leak out. There are three methods of treatment: astringe to prevent collapse, use heavy sedatives to calm fright, and tonify to address deficiency. Additionally, assist with heavy shell-type minerals to guide the qi downward, allowing True Yang to return to its residence and cling firmly to True Yin. Then, use strong sealing and consolidating methods to achieve success. The *Neijing* states: 'Yang tends to ascend; Yin tends to descend.' Therefore, those with upper escape experience hallucinations and auditory delusions, as if possessed by spirits; those with lower escape are deaf and blind. Those with upper escape have light bodies and profuse sweating; those with lower escape have heavy bodies and purplish muscles. Previously, a newly elevated nobleman rode proudly and died laughing before returning to his residence; this was upper escape. Another person was sleep-paralyzed, feeling beaten, with bleeding from the nine orifices; this was lower escape. This disease began with indulgence in lust, followed by promiscuity. One must severely restrain emotions and permanently conserve essence. With thousand-day cultivation, sudden upper escape will be avoided."
[Attached Case]
A person suddenly felt their body split into two, lying side by side, unable to distinguish real from fake, silent, and unresponsive to questions. This is Soul Departure (Li Hun). They were administered a strong decoction of Cinnabar (Zhusha), Ginseng Radix et Rhizoma Rubra (Renshen), and Poria (Fuling). The real person regained clarity, and the fake form dissolved.
[Case 3]
Songling Gongshi Wu Youliang, over seventy years old, suffered from dizziness and vertigo. He took Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction), starting with one qian of Ginseng Radix et Rhizoma Rubra (Renshen) and increasing to three qian. This led to epigastric fullness, anorexia, inability to sit or lie down comfortably, and muttering incessantly for three days and nights. Shiwang visited and observed his red face, erratic movements, and twitching of the left cheek. His six pulses were all rapid (Cu), sometimes skipping after seven or eight beats, or after three or four beats. Asking about his lifestyle, he said that since age fifty, he had abstained from sex to preserve himself and forced himself to eat well. This indicated Zhuang Huo (Blazing Fire) scorching Yin, combined with Liver Wind harassing upward. A large dose of Shengliao Liuwei Wan (Raw Six-Ingredient Pill) was prescribed, with Cornus Fruit (Zhu Yu) removed and Uncaria Rhynchophylla (Gou Teng) added. That night, he slept soundly. Later, Turtle Shell (Bie Jia), Dragon Teeth (Long Chi), or Sour Jujube Seed (Suan Zao Ren) were added as needed. When he lost his temper and stayed awake all night, Qishi Tang (Ash Water Decoction) was used to administer Lingsha Dan (Cinnabar and Gold Pill), yielding immediate results. During the hot summer, a small dose of Shengmai San (Generate the Pulse Powder) was taken as tea. Finally, the complete Liuwei Dihuang Wan formula was used for conditioning until he stabilized in autumn.
[Commentary]
Yu Zhen comments: Vertigo can be excess or deficiency. For robust individuals with excess phlegm and fire, presenting with slippery, large, and forceful pulses, Erchen Tang (Two-Aged Decoction) plus Scutellaria Root (Huang Qin) and Gardenia Fruit (Zhi Zi) should be used. If there is no nausea, Rhubarb (Da Huang) processed with wine, 2-3 qian, can be used alone or as powder mixed with tea. For obese individuals with much phlegm, Qi deficiency, and soggy-large or fine-soft pulses, Liu Junzi Tang (Six-Gentlemen Decoction) plus Atractylodes Macrocephala Rhizome (Bai Zhu) and Prepared Aconite Root (Fu Zi) is appropriate. Additionally, the *Neijing* states, "All wind-induced tremors and vertigo belong to Liver Wood." Therefore, for exogenous wind, Erchen Tang plus Schizonepeta Spike (Jing Jie), Saposhnikovia Root (Fang Feng), Uncaria Rhynchophylla (Gou Teng), and Gastrodia Tuber (Tian Ma) is suitable. For endogenous wind, which is a precursor to stroke, Tiger Bone (Hu Gu), Achyranthes Root (Niu Xi), Oyster Shell (Mu Li), Goji Berry (Gou Qi), Polygonum Multiflorum Root (Shou Wu), Mulberry Leaf (Sang Ye), Chrysanthemum Flower (Ju Hua), Rehmannia Root (Sheng Di), and Ginseng Radix et Rhizoma Rubra (Renshen) are indicated. Dai Fu'an stated: Severe vertigo due to wind in the head causes the room to spin upon looking up, black spots in vision, flying objects, or diplopia. Dazhui Feng San (Great Wind-Chasing Powder) or Mizhi Zhengyuan San plus Deer Antler (Lurong) is suitable. If ineffective, Deer Antler alone, 5 qian per dose, decocted in wine, filtered, with a little Musk (She Xiang) added, is effective. This is because deer Yang energy concentrates in the head, utilizing the principle of similarity. This addresses the aspect of wind, distinguishing between excess and deficiency. If vertigo occurs in summer due to summerheat invasion, it cannot generally be treated as wind. The Liver is the organ of Wind-Wood, so the *Neijing* attributes vertigo specifically to the Liver. When Kidney Water is deficient, Liver Wood withers and moves, carrying Ministerial Fire to the high vertex causing vertigo, which is very common recently. Dong Zaichen stated: Women suffer from this more often. Xiaoyao San (Free and Easy Wanderer Powder) is primary; mild cases combine Siwu Tang (Four-Substance Decoction), severe cases combine Liuwei Dihuang Wan plus Coptis Rhizome (Huang Lian), with excellent efficacy. Others note that morning vertigo belongs to Yang deficiency, and evening vertigo belongs to Yin deficiency, which are general principles of differentiation, but should not be taken as absolute standards. The three selected cases herein do not exceed various methods, but their discussions are outstanding and prescriptions ingenious, truly surpassing other methods, superior to what was originally recorded in the category cases.