（附怫郁）
【纲】仲景曰。阳明病。脉浮而紧。咽燥口苦。腹满而喘。发热汗出。不恶寒。反恶热。身重。
若发汗。则躁。心愦愦而谵语。若加烧针。心怵惕。烦躁不得眠。若下之。则胃中空虚。客气动膈。
心中懊 。舌上苔者。栀子豉汤主之。
【目】成无己曰。内热曰烦。谓心中郁烦也。外热曰躁。谓气外热躁也。内热谓有根之火。故
但烦不躁。及先烦后躁者。皆可治。外热为无根之火。故但躁不烦。及先躁后烦者。皆不可治也。所
谓烦躁者。谓先烦渐至躁也。所谓躁烦者。谓先发躁。迤逦复烦也。从烦至躁为热。未有不渐烦
而躁者也。先躁后烦谓怫郁。怫然更作烦闷。此为阴盛格阳。大躁若欲于泥水中卧。水不得入口是
也。此气欲绝而争。如灯将灭而暴明。
黄仲理曰。烦躁者。懊 不得眠也。懊 者。郁闷不舒之貌。烦者。气也。火入于肺也。躁者。
血也。火入于肾也。
李 曰。心热则烦。肾热则躁。烦轻躁重。先烦渐躁为阳症。不烦便躁为阴症。烦主气。躁主血。肺主皮毛。气热
则烦。肾主津液。血热则躁。故仲景用栀子以治肺。豆豉以
治肾也。
【纲】仲景曰。伤寒下后。心烦腹满。起卧不安者。栀子浓朴汤主之。
【目】朱震亨曰。烦躁者。气随火而升也。
陶华曰。伤寒烦躁。有阴阳虚实之别。心热则烦。阳实阴虚。肾热则躁。阴实阳虚。烦乃热轻。
躁乃热重也。
【纲】仲景曰。得病二三日。脉弱。无太阳柴胡症。烦躁。心下硬。至四五日。虽能食。以小
承气少少与微和之。令小安。至六
日。与承气汤一升。若不大便。六七日小便少者。虽不能食。但初头硬。后必溏。未定成硬。攻之必
溏。须小便利。屎定硬。乃可攻之。宜大承气汤。
【目】李杲曰。栀子治肺烦。香豉治肾躁。少气虚满者。加甘草。呕哕者。加生姜、橘皮。下后
腹满而烦。栀子浓朴枳实汤。身热微烦。栀子甘草干姜汤。火入肺。烦也。火入肾。躁也。烦躁俱在
上者。肾子通于肺母也。发润如油。喘而不休。总言肺绝。鼻者。肺之外候。肺气通于鼻。鼻中气
出粗大。是肺热也。发者。血之余。肾气主之。发润如油。火迫肾水至高之分。是水将绝也。仲景
以发润喘大为肺绝。兼其肾而言之。发在高巅之上。虽属肾。肺为五脏之至高。故言肺绝兼肾也。大
抵肺肾相通。肺既已绝。肾不言而知其绝矣。或曰。烦者心为之烦。躁者心为之躁。何烦为肺躁为
肾耶。夫心者君火也。与邪热相接。上下通热。金以之而躁。水以之而亏。独存者火耳。故肺肾与
心合而为烦躁焉。此烦虽肺。躁虽肾。实心火为之也。若有宿食而烦躁者。栀子大黄汤。
陶华曰。有人伤寒八九日。无汗身热。时时谵语。因下后大便不通。已三日矣。非躁非烦。非寒
非痛。终夜不得卧。但心中无晓会处。许学士诊之曰。此懊 怫郁二症俱作也。胃中有燥屎。服承气
汤。下燥屎二十枚。得利而解。故仲景云。小便不利。大便难。时有微热怫郁。有燥屎也。怫郁者。
阳气蒸越。形于头面体肤之间。聚赤而不散也。其症有分别。如大便硬而气短燥渴者。实也。大柴胡
汤。汗下后有此症。饮水而哕者。胃虚也。桂苓人参汤加茯苓。初得病发汗不彻。并于阳明。续自
微汗出。面色赤者。阳气怫郁也。解肌汤。或汗不彻。其脉浮紧者。麻黄汤。或小便不利。时有微热。
大便作难。怫郁不得卧。此有燥屎作实也。承气汤。
(Attached: Fu Yu [Oppression and Stagnation])
[General Principle] Zhang Zhongjing stated: In Yangming disease, the pulse is floating and tight, with dryness in the throat and bitter taste in the mouth, abdominal fullness and wheezing, fever and sweating, aversion to cold absent but aversion to heat present, and heaviness of the body.
If diaphoresis (sweating therapy) is mistakenly applied, restlessness (Zao), mental confusion with delirious speech will occur; if burning needle therapy is mistakenly applied, fearfulness and palpitations with irritability (Fan Zao) and insomnia will occur; if purgation is mistakenly applied, the stomach becomes empty, pathogenic qi disturbs the diaphragm, causing inner frustration (Ao Nu), and if there is a coating on the tongue, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is the primary treatment.
[Commentary] Cheng Wuji stated: Internal heat is called Fan (Irritability/Mental Restlessness), referring to mental depression and vexation. External heat is called Zao (Physical Restlessness), referring to restless breathing and movement. Internal heat is fire with a root, so one may have only Fan without Zao, or Fan preceding Zao; both are treatable. External heat is fire without a root, so one may have only Zao without Fan, or Zao preceding Fan; both are untreatable. The term "Fan Zao" refers to Fan gradually progressing to Zao. The term "Zao Fan" refers to Zao occurring first, followed by Fan. Progression from Fan to Zao indicates Heat; there is no case of Zao occurring without preceding Fan. Zao preceding Fan is called "Fu Yu" (Oppression and Stagnation), characterized by sudden recurrence of vexation. This is Yin excess repelling Yang, manifesting as extreme restlessness desiring to lie in mud or water, yet unable to drink water. This indicates Qi about to perish struggling against itself, like a lamp flickering brightly before extinguishing.
Huang Zhongli stated: Fan Zao is frustration and inability to sleep. Ao Nu is the appearance of depression and discomfort. Fan belongs to Qi, representing Fire entering the Lung. Zao belongs to Blood, representing Fire entering the Kidney.
Li Xun stated: Heart heat causes Fan, Kidney heat causes Zao. Fan is mild, Zao is severe. Fan progressing to Zao is a Yang syndrome; Zao without Fan is a Yin syndrome. Fan governs Qi, Zao governs Blood. The Lung governs skin and hair; Qi heat causes Fan. The Kidney governs body fluids; Blood heat causes Zao. Therefore, Zhang Zhongjing uses Zhi Zi (Fructus Gardeniae) to treat the Lung, and Dou Chi (Semen Sojae Praeparatum) to treat the Kidney.
[General Principle] Zhang Zhongjing stated: After purgation for Cold Damage, if there is mental vexation, abdominal fullness, and restlessness in sitting and lying down, Zhi Zi Hou Po Tang (Gardenia and Magnolia Bark Decoction) is the primary treatment.
[Commentary] Zhu Zhenheng stated: Fan Zao is Qi rising along with Fire.
Tao Hua stated: Fan Zao caused by Cold Damage has distinctions of Yin/Yang and Deficiency/Excess. Heart heat causes Fan, indicating Excess of Yang and Deficiency of Yin. Kidney heat causes Zao, indicating Excess of Yin and Deficiency of Yang. Fan is mild heat, Zao is severe heat.
[General Principle] Zhang Zhongjing stated: On the second or third day of illness, with a weak pulse, absence of Taiyang or Shaoyang symptoms, presence of Fan Zao, and hardness below the heart. By the fourth or fifth day, even if the patient can eat, give Xiao Cheng Qi Tang (Minor Order the Qi Decoction) in small amounts to mildly harmonize, allowing slight relief. By the sixth day, give one sheng of Cheng Qi Tang. If there is no bowel movement, and on the sixth or seventh day urine output is low, even if the patient cannot eat, if the stool is hard at the beginning but loose at the end, it has not definitively become hard; purging will cause looseness. One must wait for free urination and definitive hardening of the stool before purging; Da Cheng Qi Tang (Major Order the Qi Decoction) is appropriate.
[Commentary] Li Gao stated: Zhi Zi treats Lung-related Fan, Xiang Chi treats Kidney-related Zao. For shortness of breath and deficiency-type fullness, add Gan Cao (Radix Glycyrrhizae). For vomiting and hiccups, add Sheng Jiang (Rhizoma Zingiberis Recens) and Ju Pi (Pericarpium Citri Reticulatae). For post-purgation abdominal fullness and vexation, use Zhi Zi Hou Po Zhi Shi Tang. For body heat and mild vexation, use Zhi Zi Gan Jiang Gan Jiang Tang. Fire entering the Lung causes Fan; Fire entering the Kidney causes Zao. When Fan and Zao are both located superiorly, it is because the Kidney (Water) connects to the Lung (Metal/Mother). Oily sweat on the head, continuous wheezing, generally indicates Lung Qi exhaustion. The nose is the external manifestation of the Lung; Lung Qi connects to the nose. Coarse breathing from the nose indicates Lung Heat. Hair is the surplus of Blood, governed by Kidney Qi. Oily sweat on the head indicates Fire forcing Kidney Water to the highest point, suggesting Water Qi is perishing. Zhang Zhongjing considers oily sweat and severe wheezing as signs of Lung exhaustion, also mentioning the Kidney. Although hair is at the crown (Kidney domain), the Lung is the highest of the five Zang organs, hence "Lung exhaustion" implies Kidney exhaustion as well. Generally, Lung and Kidney are connected; if the Lung is exhausted, the Kidney is implicitly exhausted. Some ask: Fan is Heart vexation, Zao is Heart restlessness, why attribute Fan to Lung and Zao to Kidney? The Heart is Ministerial Fire; when interacting with pathogenic heat, heat circulates up and down. Metal (Lung) becomes restless due to this, Water (Kidney) becomes deficient, leaving only Fire. Thus, Lung, Kidney, and Heart combine to produce Fan Zao. Although Fan involves the Lung and Zao involves the Kidney, the substance is Heart Fire. If Fan Zao is caused by retained food, Zhi Zi Da Huang Tang (Gardenia and Rhubarb Decoction) is used.
Tao Hua stated: A person suffered from Cold Damage for eight or nine days, with no sweat, body heat, and occasional delirium. After purgation, constipation persisted for three days. It was neither Zao nor Fan, neither Cold nor Pain. The patient could not lie down all night, feeling an indescribable discomfort in the chest. Physician Xu diagnosed this as simultaneous occurrence of Ao Nu and Fu Yu. There were dry feces in the stomach. Administration of Cheng Qi Tang resulted in the passage of twenty pieces of dry feces, leading to recovery through diarrhea. Thus, Zhang Zhongjing stated: Urinary difficulty, difficult defecation, occasional mild heat and Fu Yu indicate dry feces. Fu Yu is the steaming and overflowing of Yang Qi, manifesting as redness gathering on the head, face, and body without dissipating. Symptoms vary: Hard stool with shortness of breath and dry thirst indicates Excess; use Da Chai Hu Tang. Post-diaphoresis/purgation with this symptom, drinking water causing hiccups indicates Stomach Deficiency; use Gui Ling Ren Shen Tang plus Fu Ling. Initial illness with incomplete diaphoresis, pathogen merging into Yangming, subsequent spontaneous mild sweating, and red facial complexion indicate Yang Qi Fu Yu; use Jie Ji Tang. Or, incomplete diaphoresis with floating-tight pulse; use Ma Huang Tang. Or, urinary difficulty, occasional mild heat, difficult defecation, Fu Yu preventing sleep, indicating dry feces causing Excess; use Cheng Qi Tang.