昏冒，即昏愦不醒也。内伤而至昏冒，则死。伤寒热病至昏冒，亦重矣。方书皆言虚，误
也。仲景云∶太阳与少阳并病，头项强痛，或眩冒，当刺大椎、肺俞、肝俞。又曰∶阳明
病，小便不利，大便乍难乍易，时有热，喘冒不能卧，宜大承气汤。此言冒未至昏者，以下
乃言昏冒矣。海藏云∶伤寒传至五六日，渐变神昏不语，或睡中自语，目赤神焦，稀粥与之
则咽，不与则不思，此言热邪内传手少阴心经，心火上薰于肺，则神识昏迷，若脉浮数，热
在小肠，用导赤散；脉细数，热在心经，宜泻心汤；若浮沉皆数，两经皆热，导赤各半汤。
《伤寒直格》云∶邪热传内昏冒，脉应疾数。若热极内甚，脉反沉细欲绝，未明造化，误认阴
症。或有始得病时，阳热暴甚，初起便见昏冒者。或两感热甚，亦有昏沉者。或失下热极，
以至身冷脉微，昏冒将死。若急下之，则残阴暴绝而死，不下亦死，并宜凉膈散、黄连解毒
汤，待积热散则心胸暖，脉渐出。若有下症者，大承气汤。可见昏迷症，未可以虚概之。余
今酌定解表清里，化痰消导等法。若 痧疫毒，用升发；寒凉抑遏，用温散；热结大肠，用
下法∶汗下太过，脉空泻脱，用补元。
热入血室，《伤寒论》分四条。首条阳明病下血谵语，总论男女均有此病，故曰下血，不曰经
水，但头汗出，刺期门。少阳三条，则专言妇人矣。第一言经水适来，七八日热除身凉，胸
胁下满，如结胸状，言浑似太阳误下，身不发热，表邪乘虚入里，结胸症。但彼以误下，邪
热传入阳明肠胃，故成结胸。此以热邪自传厥阴血室，故刺期门。第二条言经水适断，发作
有时而寒热，浑似少阳似疟症，但彼以邪入少阳心胸之间，而成似疟，此以邪热入厥阴血室之
所，而成热入血室。二者病不同，而同用小柴胡汤，以其寒热发作，如疟状相同，肝胆同
治，故以小柴胡汤同和解。第三言虽有伤寒发热之表症，谵语见鬼之里症，然不用汗吐下等
法，以犯胃气，惟用刺期门，以泄里热，服小柴胡汤和解表里。大凡发热有气血之分。日间
发热为气热，夜间发热为血热。故昼安静，夜发热，名热入血室。然血热之症，又有虚实不
同。血虚发热，营血不足，如阴虚内热之症，故脉必细数，治以补血凉血，如海藏四物汤，
倍加柴胡，黄芩，以定寒热。血实发热，邪热入血，即热入血室等症，故脉必数大，治宜凉
血，不必补血，归芍柴胡汤、导赤各半汤，倍加柴胡、芍药、生地、黄芩、丹皮，引入血
分。然其症状，各有分别，血虚者，其人阴血素虚，渐渐夜间发热，日间仍能举动，其热也
缓，其脉细数无神；血实者，素无不足，偶因外有感冒，内有积热，表邪未散，里热未清，
或因早食浓味，或因早服补药，每夜发热，其热也甚，其脉数大有力。
阳明病，下血谵语者，此为热入血室。但头汗出者，刺期门，随其热而泻之， 然汗出则愈。
此条详注头汗下血门，宜互看。阳明表邪，传少阳内舍厥阴，不得外泄，上薰头汗出，刺
期门肝穴，经络宣通， 然汗出而愈。
妇人中风，发热恶寒，经水适来，得之七八日，热除，而脉迟身凉，胸胁下满，如结胸状，
谵语者，此为热入血室也，当刺期门，随其实而泻之。
中风发热恶寒七八日，热除脉迟身凉，当自愈矣。今反见胸胁下满，如结胸状，谵语者，
此因经水适来，血海正开，热邪乘虚入于厥阴藏血之室，肝主魂，热邪内乱神明，是以胁
满谵语，故刺期门厥阴所注之 ，泻其实热外泄。
妇人中风，七八日，续得寒热，发作有时，经水适断者，此为热入血室，其血必结，故使如
疟状，发作有时，小柴胡汤主之。
上条言身凉脉迟，不用发表，但刺期门；此条言七八日，续得寒热，发作有时，经水适断，
血室未闭，热入血结如疟状，宜用小柴胡汤。
妇人伤寒发热，经水适来，昼日明了，暮则谵语，如见鬼状者，此为热入血室，无犯胃气及
上二焦，必自愈。
上条一言结胸状，一言如疟状，此条又言如见鬼状，此互发热入血室，病形不一。两条言
刺期门，一条言小柴胡汤主之，此条言无犯胃气及上二焦，此总结上文热入血室，惟刺期
门、小柴胡汤二法。
小柴胡汤 见寒热头眩。
此方清血室之热，家秘加当归、芍药，则引入血分。立斋以此汤加生地、丹皮，亦是此意。
柴芩四物汤
柴胡 黄芩 生地 当归 白芍药 牡丹皮
此即海藏四物汤，家秘加入柴胡、黄芩治血虚发热，今用治热入血室最效。
归芍柴胡汤
归身 白芍 柴胡 生地 丹皮 地骨皮 秦艽 黄芩 广皮 甘草
此方凉血养血，家秘治血虚，夜发热，热入血室，阴虚骨蒸等症最效。
导赤各半汤
血藏于肝而生于心，故心火旺则血亦热。此方清心火，生心血，家秘加柴胡、归、芍，兼
肝热而治之矣。
昏冒，就是神志昏乱、不省人事的意思。内伤病发展到昏冒，就会死亡。伤寒热病发展到昏冒，病情也很严重了。医书中都说这是虚证，这是错误的。张仲景说：太阳病与少阳病同时发病，出现头项强痛，或者眩晕昏冒，应当针刺大椎穴、肺俞穴、肝俞穴。又说：阳明病，小便不通利，大便时而困难时而容易，偶尔有发热，气喘且昏冒不能平卧，适宜用大承气汤。这里说的是“冒”还没有发展到“昏”的程度，以下才讲到昏冒。李东垣（号海藏）说：伤寒传变到五六天，逐渐变为神志昏迷不说话，或者睡觉中说胡话，眼睛红赤、神情枯焦，给稀粥喝就吞咽，不给就不想吃，这是说热邪内传入手少阴心经，心火上熏于肺，导致神识昏迷。如果脉象浮数，热在小肠，用导赤散；脉象细数，热在心经，宜用泻心汤；如果浮取沉取都数，两经都有热，用导赤各半汤。《伤寒直格》说：邪热传入体内导致昏冒，脉象应该急数。如果热极深重，脉象反而沉细欲绝，如果不明白阴阳转化的道理，会误认为是阴证。有的病人刚开始得病时，阳热突然很盛，初起就出现昏冒的。或者有表里两感且热势很重的，也有昏沉的。或者因为该用下法而失治，热极，以至于身体冰冷、脉微细，昏冒快要死了。如果急忙用下法，残存的阴液会突然断绝而死；不用下法也会死，这种情况都适宜用凉膈散、黄连解毒汤，等到积热消散后心胸变暖，脉象逐渐显现。如果有可下的症状，用大承气汤。由此可见，昏迷症，不可以一概而论为虚证。我现在斟酌确定了解表清里、化痰消导等方法。如果是痧疫毒邪，用升发法；如果是寒凉药抑制遏伏了邪气，用温散法；如果是热结在大肠，用下法；如果是汗法和下法太过，导致脉空、腹泻脱证，用补元气法。
热入血室，《伤寒论》分为四条。第一条讲阳明病下血谵语，总括论述男女都有这个病，所以说“下血”，不说“经水”，只有头部出汗，针刺期门穴。接下来的三条，则专门讲妇人。第一条讲月经刚好来潮，七八天后热退身凉，胸胁下满，像结胸的样子，意思是好像太阳病误下后，身不发热，表邪乘虚入里，形成结胸证。但那是因误下，邪热传入阳明肠胃，所以结成结胸。这个是热邪自然传入厥阴血室，所以刺期门穴。第二条讲月经刚好结束，发作有时而忽冷忽热，好像少阳病似疟疾的症状，但那是邪气进入少阳心胸之间，而成似疟疾，这个是邪热进入厥阴血室所在之处，而成热入血室。两种病不同，但都用小柴胡汤，因为它们寒热发作像疟疾一样相同，肝胆同治，所以用小柴胡汤共同和解。第三条讲虽然有伤寒发热的表证，谵语见鬼的里证，然而不用汗、吐、下等法，以免损伤胃气，只用刺期门穴，以泄里热，服用小柴胡汤和解表里。大凡发热有气血之分。白天发热是气热，夜间发热是血热。所以白天安静，夜间发热，名叫热入血室。然而血热的症状，又有虚实不同。血虚发热，营血不足，像阴虚内热的症状，所以脉象必定细数，治疗以补血凉血为主，如海藏的四物汤，加倍加入柴胡、黄芩，以定寒热。血实发热，邪热入血，即热入血室等症状，所以脉象必定数大，治疗宜凉血，不必补血，用归芍柴胡汤、导赤各半汤，加倍加入柴胡、芍药、生地、黄芩、丹皮，引入血分。然而它们的症状，各有分别，血虚的人，其人阴血素来虚弱，渐渐在夜间发热，白天仍能活动，其热势缓和，脉象细数无神；血实的人，素来没有不足，偶然因为外有感冒，内有积热，表邪未散，里热未清，或者因为过早吃浓味食物，或者因为过早服用补药，每晚发热，其热势很盛，脉象数大有力。
阳明病，下血并谵语的，这是热入血室。只有头部出汗的，针刺期门穴，随着热势而泻之，周身汗出就好了。这一条详细注释在头汗下血门，宜互相参看。阳明表邪，传入少阳内舍于厥阴，不能向外宣泄，上熏导致头部出汗，针刺期门肝穴，经络宣通，周身汗出而痊愈。
妇人中风，发热恶寒，月经刚好来潮，得了七八天，热退，脉迟身凉，胸胁下满，像结胸的样子，谵语的，这是热入血室，应当针刺期门穴，随着其实证而泻之。
中风发热恶寒七八天，热退脉迟身凉，本该自愈了。现在反而出现胸胁下满，像结胸的样子，谵语，这是因为月经刚好来潮，血海正开，热邪乘虚进入厥阴藏血之室，肝主魂，热邪在内扰乱神明，所以胁满谵语，因此针刺期门穴，这是厥经所注的穴位，泻其实际的热邪使其外泄。
妇人中风，七八天，接着出现忽冷忽热，发作有时，月经刚好结束的，这是热入血室，其血液必定凝结，所以使身体像疟疾一样，发作有时，用小柴胡汤主治。
上一条讲身凉脉迟，不用发表，只刺期门；这一条讲七八天，接着出现忽冷忽热，发作有时，月经刚结束，血室未闭，热入血结像疟疾一样，适宜用小柴胡汤。
妇人伤寒发热，月经刚好来潮，白天神志清楚，晚上则谵语，像看见鬼怪一样的，这是热入血室，不要侵犯胃气及上二焦，必定自愈。
上一条一说像结胸状，一说像疟疾状，这一条又说像看见鬼怪状，这互相印证发热入血室，病形不一。两条讲刺期门，一条讲小柴胡汤主治，这一条讲不要侵犯胃气及上二焦，这是总结上文热入血室，只有刺期门、小柴胡汤两种方法。
小柴胡汤 见寒热头眩条目。
此方清除血室之热，家父秘传加当归、芍药，就能引入血分。薛立斋以此汤加生地、丹皮，也是这个意思。
这就是海藏的四物汤，家父秘传加入柴胡、黄芩治疗血虚发热，现在用来治疗热入血室最有效。
归芍柴胡汤
归身 白芍 柴胡 生地 丹皮 地骨皮 秦艽 黄芩 广皮 甘草
Hunmao (dizziness and confusion) refers to a state of mental confusion and unconsciousness. If internal injury progresses to Hunmao, death ensues. If cold-heat diseases progress to Hunmao, the condition is also severe. Medical texts all claim it is due to deficiency, which is mistaken. Zhang Zhongjing stated: "When Taiyang and Shaoyang diseases occur simultaneously, with stiffness and pain in the head and neck, or dizziness and confusion, one should needle the Dazhui (GV14), Feishu (BL13), and Ganshu (BL18) acupoints." He also said: "In Yangming disease, if urination is difficult, defecation alternates between difficulty and ease, there is occasional fever, panting, and confusion preventing lying down, Da Chengqi Tang (Major Order the Qi Decoction) is appropriate." This describes 'Mao' (dizziness/confusion) before it reaches 'Hun' (coma). The following text discusses Hunmao. Li Dongyuan (styled Haicang) said: "When cold-heat disease transmits to the fifth or sixth day, it gradually changes into mental confusion and silence, or talking in sleep, red eyes, and a withered spirit. Porridge is swallowed when offered, but not desired when not offered. This indicates that pathogenic heat has transmitted internally into the Hand-Shaoyin Heart Meridian. Heart fire steams upward to the Lung, causing mental confusion. If the pulse is floating and rapid, the heat is in the Small Intestine, use Daochi San (Guide Out Redness Powder); if the pulse is fine and rapid, the heat is in the Heart Meridian, use Xiexin Tang (Drain the Epigastrium Decoction); if both floating and deep pulses are rapid, indicating heat in both meridians, use Daochi Gehan Tang (Half-Half Guide Out Redness Decoction)." *Shanghan Zhi Ge* states: "When pathogenic heat transmits inward causing Hunmao, the pulse should be rapid. If heat is extreme and severe internally, the pulse may instead be deep, fine, and nearly imperceptible. Without understanding the transformation of life forces, this might be mistaken for a Yin syndrome. Some patients, upon initial onset, have sudden intense Yang heat and present with Hunmao from the start. Some with simultaneous exterior-interior contraction and intense heat also present with lethargy and confusion. Some, due to failure to purge when indicated, reach extreme heat, resulting in cold body and faint pulse, nearing death from Hunmao. If purged urgently, residual Yin fluids will abruptly perish, leading to death; if not purged, death also occurs. In such cases, Liangge San (Cool the Diaphragm Powder) and Huanglian Jiedu Tang (Coptis Detoxification Decoction) are suitable. Wait until accumulated heat dissipates, the chest and heart feel warm, and the pulse gradually emerges. If there are signs requiring purgation, use Da Chengqi Tang. Thus, coma symptoms cannot be generalized as deficiency. I have now determined methods such as releasing the exterior and clearing the interior, resolving phlegm and promoting digestion. For sha-yi (plague/toxin) pathogens, use ascending and dispersing methods; for suppression by cold-cooling herbs, use warming and dispersing methods; for heat binding in the Large Intestine, use purgative methods; for excessive sweating and purging leading to empty pulse and diarrhea/collapse, use tonifying Yuan Qi (Original Qi)."
Re entering the Blood Chamber, as divided into four clauses in *Shanghan Lun*. The first clause discusses Yangming disease with bleeding and delirium, generally stating that both men and women can suffer this disease, hence it says "bleeding" rather than "menstruation," with only sweat on the head, treated by needling Qimen (LR14). The subsequent three clauses specifically discuss women. The first discusses menstruation occurring just then. After seven or eight days, heat subsides and body cools, with fullness below the chest and hypochondrium resembling Jie Xiong (chest binding) syndrome. It implies a resemblance to Taiyang disease mishandled by purgation, where the body is no longer feverish, and exterior pathogens enter the interior due to deficiency, forming Jie Xiong. However, that case results from mishandled purgation transmitting heat to Yangming stomach and intestines, forming Jie Xiong. This case involves heat transmitting naturally to the Jueyin Blood Chamber, hence needling Qimen. The second clause discusses menstruation having just ceased, with paroxysmal chills and fever resembling Shaoyang malaria-like syndrome. However, that case involves pathogens entering the Shaoyang chest and heart region, forming a malaria-like state. This case involves pathogenic heat entering the Jueyin Blood Chamber, forming Re Ru Xue Shi (Heat Entering the Blood Chamber). Although the diseases differ, both use Xiao Chaihu Tang (Minor Bupleurum Decoction) because their chills and fever paroxysms resemble malaria identically, treating Liver and Gallbladder together, thus using Xiao Chaihu Tang for harmonization. The third clause discusses having exterior signs of Shanghan fever and interior signs of delirium seeing ghosts, yet not using sweating, vomiting, or purging methods to avoid damaging Stomach Qi, but only needling Qimen to drain interior heat, and taking Xiao Chaihu Tang to harmonize exterior and interior. Generally, fever has distinctions between Qi and Blood. Fever during the day is Qi heat; fever at night is Blood heat. Therefore, quietness by day and fever by night is named Heat Entering the Blood Chamber. However, Blood heat symptoms vary by deficiency and excess. Blood deficiency fever, due to insufficient Ying and Blood, resembles Yin deficiency internal heat, so the pulse must be fine and rapid; treatment involves tonifying Blood and cooling Blood, such as Haicang's Siwu Tang (Four Substances Decoction), with added Chai Hu (Bupleuri Radix) and Huang Qin (Scutellariae Radix) to stabilize chills and fever. Blood excess fever, where pathogenic heat enters Blood, i.e., Heat Entering the Blood Chamber, etc., so the pulse must be rapid and large; treatment should cool Blood without tonifying it, using Guishao Chaihu Tang (Angelica and Peony Bupleurum Decoction) or Daochi Gehan Tang, with increased Chai Hu, Shao Yao (Paeoniae Radix), Sheng Di Huang (Rehmanniae Radix), Huang Qin, and Mu Dan Pi (Moutan Cortex), guiding them into the Blood level. However, their symptoms differ. Those with Blood deficiency have inherent Yin-Blood deficiency, gradually developing night fever while remaining active during the day; their heat is mild, and pulse fine, rapid, and lacking spirit. Those with Blood excess have no inherent deficiency, occasionally contracting external cold with internal accumulated heat, unresolved exterior pathogens, and unclarified interior heat, or eating rich flavors too early, or taking tonics too early, resulting in nightly fever; their heat is severe, and pulse rapid, large, and forceful.
Yangming disease with bleeding and delirium is Heat Entering the Blood Chamber. With only head sweating, needle Qimen, draining according to the heat; general sweating leads to recovery. This clause details the Head Sweating and Bleeding section,宜互看 (should be cross-referenced). Yangming exterior pathogens transmit to Shaoyang and internally lodge in Jueyin, unable to vent outward, steaming upward causing head sweat. Needling Qimen, a Liver acupoint, unblocks meridians and collaterals, general sweating leads to recovery.
A woman with Fengzhong (Wind Strike), fever and aversion to cold, menstruation occurring just then, after seven or eight days, heat subsides, pulse becomes slow, body cools, fullness below chest and hypochondrium resembling Jie Xiong, and delirium, is Heat Entering the Blood Chamber. One should needle Qimen, draining according to its excess.
Fengzhong with fever and aversion to cold for seven or eight days, heat subsides, pulse slow, body cools, should heal spontaneously. Now instead presenting with fullness below chest and hypochondrium resembling Jie Xiong, and delirium, this is because menstruation occurred just then, the Sea of Blood was open, and pathogenic heat entered the Jueyin storage chamber of Blood due to deficiency. The Liver governs Hun (Ethereal Soul); heat disturbing internally confounds Shen Ming (Spiritual Consciousness), hence hypochondriac fullness and delirium. Therefore, needle Qimen, the Jing-River point of the Jueyin meridian, to drain its actual heat and allow it to vent outward.
A woman with Fengzhong, after seven or eight days, subsequently develops chills and fever occurring at times, menstruation having just ceased, is Heat Entering the Blood Chamber. Her blood must be bound, thus causing a malaria-like state occurring at times. Xiao Chaihu Tang (Minor Bupleurum Decoction) is the main treatment.
The previous clause discussed body cooling and slow pulse, not using exterior release, only needling Qimen; this clause discusses seven or eight days, subsequent chills and fever occurring at times, menstruation ceased, Blood Chamber not closed, heat entering and binding blood like malaria, suitable for Xiao Chaihu Tang.
A woman with Shanghan fever, menstruation occurring just then, clear-minded during the day, delirious at night as if seeing ghosts, is Heat Entering the Blood Chamber. Do not violate Stomach Qi or the Upper Two Jiaos; she will surely heal herself.
The previous clause mentioned resembling Jie Xiong, another resembling malaria; this clause mentions seeing ghosts, mutually confirming Heat Entering the Blood Chamber presents differently. Two clauses mention needling Qimen, one mentions Xiao Chaihu Tang; this clause mentions not violating Stomach Qi and Upper Two Jiaos, summarizing the above on Heat Entering the Blood Chamber, having only two methods: needling Qimen and Xiao Chaihu Tang.
Xiao Chaihu Tang (Minor Bupleurum Decoction) see Chills/Fever and Dizziness/Vertigo entries.
This formula clears heat from the Blood Chamber. My family secret adds Dang Gui (Angelicae Sinensis Radix) and Shao Yao (Paeoniae Radix) to guide it into the Blood level. Li Zhai used this formula with Sheng Di Huang (Rehmanniae Radix) and Mu Dan Pi (Moutan Cortex), sharing this intent.
Chaiqin Siwu Tang (Bupleurum and Scutellaria Four Substances Decoction)
Chai Hu (Bupleuri Radix) Huang Qin (Scutellariae Radix) Sheng Di Huang (Rehmanniae Radix) Dang Gui (Angelicae Sinensis Radix) Bai Shao Yao (White Paeonia Root) Mu Dan Pi (Moutan Cortex)
This is Haicang's Siwu Tang (Four Substances Decoction). My family secret adds Chai Hu and Huang Qin to treat Blood deficiency fever. Now used to treat Heat Entering the Blood Chamber, it is most effective.
Guishao Chaihu Tang (Angelica and Peony Bupleurum Decoction)
Gui Shen (Angelicae Sinensis Radix) Bai Shao (White Paeonia Root) Chai Hu (Bupleuri Radix) Sheng Di Huang (Rehmanniae Radix) Mu Dan Pi (Moutan Cortex) Di Gu Pi (Lycii Cortex) Qin Jiao (Gentianae Macrophyllae Radix) Huang Qin (Scutellariae Radix) Guang Pi (Citri Reticulatae Pericarpium) Gan Cao (Glycyrrhizae Radix et Rhizoma)
This formula cools Blood and nourishes Blood. My family secret uses it most effectively for Blood deficiency, night fever, Heat Entering the Blood Chamber, Yin deficiency bone-steaming, etc.
Daochi Gehan Tang (Half-Half Guide Out Redness Decoction)
Blood is stored in the Liver and generated by the Heart. Thus, when Heart Fire is vigorous, Blood is also hot. This formula clears Heart Fire and generates Heart Blood. My family secret adds Chai Hu, Dang Gui, and Shao Yao to concurrently treat Liver heat.