伤寒头眩。何以明之 非毛而见其毛。眩非玄而见其玄。 为眼花。眩为眼黑。眩
也运也冒也。三者形俱相近。有谓之眩运者有谓之眩冒者运为运转之运。世谓
之头旋者是矣。冒为蒙冒之冒世谓之昏迷者是矣少阳之为病口苦咽干目眩。
以少阳居表里之间表邪所传。渐行于里。表中阳虚故时时目眩也。二阳并病。头
项强痛。或眩运眩冒者。以少阳与太阳并病。故眩者责其虚也。伤寒有起则头眩
与眩冒者。皆发汗吐下后所致。是知其阳虚也故针经有曰上虚则眩。下虚则厥
眩虽为虚。而风家亦有眩者。盖风主运动故尔。伤寒阳明病。但头眩不恶寒。故能
食而咳。其人必咽痛。为阳明中风。是风亦主头眩也。诸如此者。皆非逆也。及其诸
逆。发汗剧者言。乱目眩者死。命将难全。呜呼。病势已成。可得半愈。及病势已深。虽
神医其能已之耶。
伤寒胸胁满。何以明之。胸胁满者。谓胸膈间气塞满闷也。非心下满者也。胁满者。
谓胁肋下气胀填满也。非腹满者也。邪气自表传里。必先自胸膈。已次经心胁而
入胃。邪气入胃。为入府也。是以胸满多带表症。胁满者。当半表半里症也。经曰。下
后脉促胸满者。桂枝去芍药汤主之。又曰。太阳与阳明合病。喘而胸满者不可下。
宜麻黄汤。是胸满属表。而须发汗者也。盖胸中至表犹近也。及胁者则更不言发
汗。但和解而已经曰。设胸满胁痛者。与小柴胡汤。又曰。胸满不去者。小柴胡汤主
之。本太阳病不解。传入少阳者。胁下硬满。干呕不能食。往来寒热。脉沉紧者。小柴
胡汤主之。是知胁满属半表半里明矣。大抵胸胁满。以邪气初入里。未停留为实。
气郁积而不行。致生满也。和解斯可矣。若邪气留于胸中。聚而为实者。非涌吐则
不可已。故华佗曰。四日在胸。吐之则愈。是邪气已收敛而不散漫者。则可吐之。内
经曰。其高者因而越之。病在胸膈之上为高。越之为吐也。经曰。病在胸中当吐之。
发汗若下之而烦热。胸中窒者。则以栀子豉汤吐之。若胸中痞硬。气上冲咽喉。不
得息者。此为胸中有寒也。则以瓜蒂散吐之。二者均是吐剂。栀子豉汤吐胸中虚
烦客热也。瓜蒂散吐胸中痰实宿寒也。若能审明药剂之轻重。辨别邪气之浅深。
对症投汤。不为效者。未之有也。
伤寒引起的头眩,该如何阐明呢?“眩”字并非指看见毛发(非毛而见其毛),“眩”也非指看见黑色(眩非玄而见其玄)。眼花称为“眩”,眼前发黑也称为“眩”。眩、运、冒这三种症状形态都非常相近。有的称为“眩运”,有的称为“眩冒”。“运”是运转之意,世人称之为“头旋”。“冒”是蒙蔽之意,世人称之为“昏迷”。《伤寒论》中说:少阳病(少阳经受邪所致的病证)的症状包括口苦、咽干、目眩。这是因为少阳位于表里之间,表邪传入,逐渐向里发展,导致表中的阳气虚弱,所以时常出现目眩。如果是二阳并病(太阳与阳明两经同时发病),出现头项强痛,或者伴有眩运、眩冒的情况,是因为少阳与太阳并病,所以对于眩晕应当责之于虚。伤寒病中,起身时感到头眩或眩冒的,都是由于发汗、催吐、泻下之后所致,由此可知这是阳气虚弱。所以《针经》说:“上虚则眩,下虚则厥。”虽然眩晕多因虚引起,但患风病的人也有眩晕的,因为风邪主运动,所以会导致眩晕。伤寒阳明病(阳明经受邪所致的病证),只表现为头眩而不恶寒,因此能进食且咳嗽,患者必然咽喉疼痛,这属于阳明中风(阳明经受风邪侵袭),说明风邪也会导致头眩。诸如此类的情况,都不是逆证。等到各种逆证出现,如发汗过度导致言语错乱、目眩的,就会死亡,生命难以保全。唉!当病势已经形成,尚可治愈一半;当病势已经深入,即使是神医又能治好它吗?
伤寒引起的胸胁满闷,该如何阐明呢?所谓“胸满”,是指胸膈间气机阻塞、满闷的感觉,并不是指心下(胃脘部)的满闷。所谓“胁满”,是指胁肋下方气胀填满的感觉,并不是指腹部的满闷。邪气从体表传入体内,必定先从胸膈开始,然后经过心胁进入胃腑。邪气进入胃腑,就是进入了六腑。因此,胸满多带有表证(表证指外感病初期,邪在肌表的证候),而胁满则属于半表半里证(半表半里证指邪既不在表也不在里的中间阶段证候)。经文说:误用下法后,脉象急促且胸满的,用桂枝去芍药汤主治。又说:太阳与阳明合病,出现气喘且胸满的,不可用下法,适宜用麻黄汤。这说明胸满属于表证,需要用发汗法治疗。因为胸中距离体表还近。至于胁部,则不再提及发汗,只是通过和解法来治疗。经文说:如果胸满且胁痛的,用小柴胡汤。又说:胸满不消退的,以小柴胡汤主治。原本患太阳病未解,传入少阳的,出现胁下硬满、干呕不能食、往来寒热(忽冷忽热)、脉象沉紧的,用小柴胡汤主治。由此可知,胁满属于半表半里证是很明确的。大抵而言,胸胁满闷,是因为邪气初入里,尚未停留成为实证,气机郁积而不运行,从而导致满闷。采用和解法就可以了。如果邪气停留在胸中,聚结成为实证,那么不用涌吐法就不能治愈。所以华佗说:“第四天邪气在胸,用吐法就可以治愈。”这是指邪气已经收敛而不散漫的情况,才可以采用吐法。《内经》说:“病位高的,就顺着向上的趋势使其越出。”病在胸膈之上称为高,“越之”就是指吐法。经文说:“病在胸中的,应当用吐法。”如果发汗或泻下后出现烦热、胸中窒塞感的,就用栀子豉汤进行吐治。如果胸中痞硬,气向上冲至咽喉,呼吸困难的,这是胸中有寒饮,就用瓜蒂散进行吐治。这两种都是吐剂。栀子豉汤用于吐出胸中的虚烦客热;瓜蒂散用于吐出胸中的痰实宿寒。如果能审明药剂的轻重,辨别邪气的浅深,对症投药,没有不见效的。
Head dizziness in Shanghan. How to clarify this? "Xuan" (dizziness) does not mean seeing hair (non-hair but seeing hair), nor does it mean seeing blackness (non-black but seeing blackness). Eye flickering is called "Xuan", and eyes going dark is also called "Xuan". Xuan, Yun (spinning), and Mao (clouding/obscuring) are three conditions with similar manifestations. Some are called "Xuan-Yun", others "Xuan-Mao". "Yun" refers to rotation/spinning; the world calls this "head spinning". "Mao" refers to being covered/obscured; the world calls this "coma/confusion". In Shaoyang disease (disease of the Shaoyang channel), symptoms include bitter taste in the mouth, dry throat, and dizzy eyes. This is because Shaoyang resides between the exterior and interior; pathogenic factors from the exterior transmit inward, gradually moving into the interior. Due to deficiency of Yang qi in the exterior, frequent eye dizziness occurs. In Er-Yang Bing (simultaneous involvement of Taiyang and Yangming channels), presenting with stiffness and pain in the head and neck, or accompanied by dizziness/spinning or clouding, it is because Shaoyang and Taiyang are involved simultaneously; thus, for dizziness, one should attribute it to deficiency. In Shanghan disease, those who experience head dizziness or clouding upon rising are caused by prior excessive sweating, vomiting, or purging; knowing this indicates Yang deficiency. Therefore, the *Zhen Jing* states: "Deficiency above causes dizziness, deficiency below causes cold extremities." Although dizziness is often due to deficiency, those suffering from Wind diseases also experience dizziness, as Wind primarily governs movement. In Yangming disease (disease of the Yangming channel), there is only head dizziness without aversion to cold; thus, the patient can eat and cough, and must have a sore throat. This is Yangming Zhongfeng (Wind invasion of the Yangming channel), indicating that Wind also causes head dizziness. Cases like these are not adverse conditions. However, when various adverse conditions arise, such as severe sweating leading to disordered speech and dizziness, death ensues, and life becomes difficult to preserve. Alas! When the disease pattern has formed, half recovery is possible; when the disease pattern has deepened, even a divine physician may not be able to cure it.
Chest and hypochondriac fullness in Shanghan. How to clarify this? "Chest fullness" refers to Qi obstruction and stuffiness in the chest and diaphragm area, not fullness in the epigastrium ("heart below"). "Hypochondriac fullness" refers to Qi distension and filling under the ribs, not abdominal fullness. Pathogenic factors transmitting from the exterior to the interior must first enter the chest and diaphragm, then pass through the heart and hypochondrium to enter the Stomach. When pathogenic factors enter the Stomach, they enter the Fu organs. Therefore, chest fullness is often accompanied by exterior syndrome (exterior syndrome refers to the initial stage of exogenous diseases where pathogens are on the body surface), while hypochondriac fullness belongs to the half-exterior half-interior syndrome (half-exterior half-interior syndrome refers to an intermediate stage where pathogens are neither in the exterior nor the interior). The classics state: After incorrect purgation, if the pulse is rapid and there is chest fullness, Guizhi Qu Shaoyao Tang (Decoction of Cinnamon Twig Decoction minus Peony) should be used. It also states: In simultaneous involvement of Taiyang and Yangming, with wheezing and chest fullness, purgation is contraindicated; Mahuang Tang (Ephedra Decoction) is suitable. This shows that chest fullness belongs to the exterior and requires sweating therapy. Because the chest is still close to the exterior. Regarding the hypochondrium, sweating is no longer mentioned; instead, harmonization therapy is used. The classics state: If there is chest fullness and hypochondriac pain, Xiaochaihu Tang (Minor Bupleurum Decoction) should be given. It also states: If chest fullness persists, Xiaochaihu Tang should be used. If original Taiyang disease does not resolve and transmits to Shaoyang, presenting with hardness and fullness under the hypochondrium, dry retching, inability to eat, alternating chills and fever, and a deep, tight pulse, Xiaochaihu Tang should be used. Thus, it is clear that hypochondriac fullness belongs to the half-exterior half-interior syndrome. Generally speaking, chest and hypochondriac fullness occur because pathogenic factors have just entered the interior and have not yet stagnated to form excess patterns; Qi stagnates and fails to circulate, causing fullness. Harmonization therapy suffices. If pathogenic factors remain in the chest, gathering to form excess, emesis therapy is required for cure. Thus, Hua Tuo said: "On the fourth day, if pathogens are in the chest, emesis will cure it." This applies when pathogens have condensed and are no longer diffuse, allowing for emesis. The *Nei Jing* states: "Where the pathology is high, use the method of ascending/vomiting." Pathology above the chest and diaphragm is considered "high"; "ascending/vomiting" refers to emesis. The classics state: "For pathology in the chest, emesis should be employed." If after sweating or purging, irritability and heat appear with a sensation of obstruction in the chest, Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) should be used to induce vomiting. If there is palpable hardness in the chest, Qi rushing up to the throat, and difficulty breathing, this indicates Cold-Phlegm in the chest; Gouti San (Melon Seed Powder) should be used to induce vomiting. Both are emetic formulas. Zhizi Chi Tang is used to expel empty irritability and guest-heat from the chest; Gouti San is used to expel phlegm-excess and chronic-cold from the chest. If one can accurately assess the weight of the medicinal agents and distinguish the depth of the pathogenic factors, and administer decoctions according to the syndrome, there will be no failure in efficacy.