伤寒筋惕肉 。何以明之。伤寒头痛身疼。恶寒发热者。必然之证也。其于筋惕肉
。非常有之者。必待发汗过汗多汗。则有之矣。内经曰。阳气者。精则养神柔则养
筋。发汗过多。津液枯少。阳气太虚。筋肉失所养。故惕惕然而跳。 然而动也。太
阳病脉微弱。汗出恶风者。不可服大青龙汤服之则厥逆。筋惕肉 。此为逆也。太
阳病发汗。汗出不解。其人仍发热。头眩身 动。振振欲擗地者。真武汤主之。动气
在左。不可发汗。发汗则头眩汗不止。筋惕肉 。即是观之。筋惕肉 。由发汗多亡
阳。阳虚可见矣。兹虽逆也。止于发汗亡阳而表虚。治以温经益阳则可矣。或因吐
下发汗。表里俱虚。而有此状者。又非若但发汗后所可同也。经曰。伤寒吐下后。发
汗虚烦。脉甚微。七八日。心下痞硬。胁下痛。气上冲咽喉。眩冒。筋脉动惕者。久而成
痿。此为逆之甚者也。太阳病发汗。复下之后。表里俱虚。复加烧针。因胸烦。面色青
黄。肤 者难治。兹为逆之甚者也。发汗吐下。庸可忽诸。
伤寒热入血室。何以明之。室者屋室也。谓可以停止之处。人身之血室者。荣血停
止之所。经脉留会之处。即冲脉是也。冲脉者。奇经八脉之一脉也。起于肾下。出于
气冲。并足阳明经。挟脐上行至胸中而散。为十二经脉之海。王 曰。冲为血海。言
诸经之血。朝会于此。男子则营运生精。女子则上为乳汁。下为月水。内经曰。任脉
通。冲脉盛。月事以时下者是也。王 曰。阴静海满而去血。谓冲脉盛。为海满也。即
是观之。冲是血室可知矣。伤寒之邪。妇人则随经而入。男子由阳明而传。以冲之
脉。与少阴之络起于肾。女子感邪。太阳随经。便得而入冲之经。并足阳明。男子阳
明内热。方得而入也。冲之得热。血必妄行。在男子则下血谵语。在妇人则月水适
来。阳明病下血谵语。此为热入血室者。斯盖言男子。不止谓妇人而言也。妇人伤
寒。经水适来。与经水适断者。皆以经气所虚。宫室不辟。邪得乘虚而入。针经有言
曰。邪气不得其虚。不能独伤人者是矣。妇人热入血室。有须治而愈者。有不须治
而愈者。又各不同也。妇人中风。发热恶寒。经水适来。得之七八日。热除而脉迟。身
凉和。胸胁下满。如结胸状。谵语者。此为热入血室。当刺期门。随其时经水适断者。
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。二者是须治而
愈是也。妇人伤寒发热。经水适来。昼则明了。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。是不须治而愈者也。谵语为病邪之甚者。何不须
治而愈耶。且胸胁满。如结胸谵语。是邪气留结于胸胁而不去者。必刺期门。随其
实而泻之。寒热如疟。发作有时者。是血结而不行者。须小柴胡汤散之。二者既有
留邪。必须治之可也。若发热经水适来。昼日明了。暮则谵语。此则经水既来。以里
无留邪。但不妄犯。热随血散。必自愈。经曰。血自下。下者愈。故无犯胃气。及上二焦。
必自愈。所谓妄犯者。谓恐以谵语为阳明内实。攻之犯其胃气也。此无胸胁之邪。
恐刺期门犯其中焦也。此无血结。恐与小柴胡汤犯其上焦也。小柴胡汤解散。则
动卫气。卫出上焦。动卫气是犯上焦也。刺期门则动荣气。荣出中焦。动荣气是犯
中焦也。脉经有曰。无犯胃气。及上二焦。岂谓药不谓针耶。此其是欤。
【伤寒筋惕肉瞤】
什么是“筋惕肉瞤”？需要加以阐明。伤寒病中，头痛、身体疼痛、恶寒、发热是必然出现的症状。而“筋惕肉瞤”（筋肉跳动），是非常见症状，必定是因为发汗过多、大汗淋漓才会出现。《内经》说：“阳气的作用，精微则滋养精神，柔和则滋养筋脉。”发汗过多，导致津液枯竭稀少，阳气极度虚弱，筋肉失去滋养，所以会出现惕惕然跳动的现象，“瞤”就是肌肉跳动的意思。
太阳病如果脉象微弱，出汗且怕风，不可服用大青龙汤；若误服，会导致四肢厥冷、筋惕肉瞤，这是治疗逆乱的表现。太阳病发汗后，汗出而病不解，患者仍然发热，头晕目眩，身体动摇，震颤得想要趴在地上，应用真武汤主治。如果动气在左侧，不可发汗；若发汗，会导致头晕、汗出不止、筋惕肉瞤。由此看来，筋惕肉瞤是由于发汗过多导致亡阳，阳气虚衰是显而易见的。虽然这是误治导致的逆证，但仅属于发汗亡阳引起的表虚，用温经益阳的方法治疗就可以了。也有因为吐下或发汗，导致表里俱虚而出现这种状况的，这就不能与单纯发汗后的情况等同看待了。《经》文说：“伤寒经过吐下之后，又发汗，导致虚烦，脉象非常微弱；过了七八天，心下痞塞坚硬，胁下疼痛，气向上冲咽喉，眩晕昏冒，筋脉跳动，时间久了会形成痿证。”这是误治非常严重的表现。太阳病发汗后，又用攻下法，导致表里俱虚，如果再加用烧针，因出现胸中烦闷，面色青黄，皮肤颤动的，难以治愈。这也是误治非常严重的表现。发汗、催吐、攻下，怎么可以忽视呢？
【热入血室】
什么是“热入血室”？需要加以阐明。“室”指屋室，是可以停留的地方。人体的“血室”，是营血停留之处，经脉汇聚之所，也就是冲脉。冲脉是奇经八脉之一，起于肾下，出于气冲穴，并足阳明经，挟脐上行至胸中而散开，为十二经脉之海。王冰说：“冲为血海”，意思是各经之血都朝会于此。男子靠它营运生精，女子则上化为乳汁，下变为月经。《内经》说：“任脉通畅，冲脉旺盛，月经就能按时来潮。”王冰说：“阴静海满而去血”，意思是冲脉旺盛，如同大海满溢。由此可知，冲脉就是血室。
伤寒邪气，妇人则是随经络传入，男子则由阳明经传变。因为冲脉与少阴之络起于肾，女子感受邪气，太阳经邪气随经传入，便进入冲脉，并与足阳明经相连。男子则是阳明内热，才能传入。冲脉受热，血液必然妄行。在男子表现为下血、谵语；在妇人表现为月经适来。阳明病出现下血、谵语，这就是热入血室的情况，这里说的是男子，并不只限于妇人而言。妇人患伤寒，月经适来或适断，都是因为经期气血虚弱，宫室不闭，邪气得以乘虚而入。《针经》说：“邪气不能在无虚的情况下单独伤人。”
妇人热入血室，有的需要治疗才能痊愈，有的不需要治疗也能痊愈，情况各不相同。妇人中风，发热恶寒，月经适来，患病七八天后，热退脉迟，身凉平和，胸胁下满，像结胸的样子，并有谵语，这是热入血室，应当针刺期门穴，根据病情泻实。若月经适断，这是热入血室，瘀血必结，所以出现像疟疾一样的症状，发作有时，用小柴胡汤主治。这两种情况是需要治疗才能痊愈的。
妇人伤寒发热，月经适来，白天神志清楚，晚上则谵语，如见鬼状，这是热入血室，不要侵犯胃气及上、中二焦，必定自愈。这是不需要治疗就能痊愈的情况。谵语是病邪严重的表现，为什么说不需治疗能痊愈呢？况且胸胁满，像结胸和谵语，是邪气留结于胸胁不去，必须针刺期门穴，随其实邪而泻之。寒热如疟，发作有时，是血结而不行，须用小柴胡汤解散。这两种情况既有留邪，必须治疗才行。如果是发热时月经适来，白天神清，晚上谵语，这是因为月经已来，体内没有留邪，只要不妄加干预，热随血散，必定自愈。《经》说：“血自下，下者愈。”所以不要侵犯胃气及上、中二焦，必定自愈。所谓“妄犯”，是指恐怕把谵语当作阳明腑实证而攻下，从而侵犯胃气。这里没有胸胁之邪，恐怕针刺期门穴会侵犯中焦。这里没有血结，恐怕用小柴胡汤会侵犯上焦。小柴胡汤具有解散作用，会扰动卫气，卫气出于上焦，扰动卫气就是侵犯上焦。针刺期门会扰动营气，营气出于中焦，扰动营气就是侵犯中焦。《脉经》说：“无犯胃气，及上二焦。”难道只指药物而不包括针灸吗？大概就是这个道理吧。
[Quivering of Muscles and Trembling of Flesh]
What is "quivering of muscles and trembling of flesh"? It needs to be elucidated. In cold damage disease, headache, body ache, aversion to cold, and fever are inevitable symptoms. However, "quivering of muscles and trembling of flesh" (muscle twitching) is a rare symptom that occurs only after excessive sweating or profuse sweating. The *Neijing* states: "The function of Yang Qi, when refined, nourishes the spirit; when soft, it nourishes the tendons." Excessive sweating leads to withered and scanty body fluids, extreme deficiency of Yang Qi, and loss of nourishment for muscles and tendons. Thus, there is a quivering sensation; "trembling" refers to muscle twitching.
In Taiyang disease, if the pulse is weak, there is sweating and aversion to wind, Da Qing Long Tang (Great Blue Dragon Decoction) must not be administered. If taken in error, it causes cold limbs, quivering of muscles, and trembling of flesh, which constitutes a therapeutic deviation. In Taiyang disease, after sweating, if the illness does not resolve despite sweating, and the patient still has fever, dizziness, body tremors, and feels as though they want to fall to the ground, Zhen Wu Tang (True Warrior Decoction) should be used. If there is pulsation on the left side, sweating is contraindicated; if sweating is induced, it leads to dizziness, incessant sweating, and quivering of muscles. From this, we see that quivering of muscles and trembling of flesh results from excessive sweating causing the loss of Yang Qi, making Yang deficiency evident. Although this is a deviation caused by mis-treatment, it belongs to exterior deficiency due to Yang loss from sweating, and can be treated by warming the meridians and benefiting Yang. There are also cases where vomiting, purging, or sweating cause both interior and exterior deficiency, leading to these symptoms; such cases cannot be equated with those resulting solely from excessive sweating. The Classics state: "After vomiting and purging in cold damage, followed by sweating, leading to empty irritability and a very faint pulse; after seven or eight days, epigastric fullness and hardness, pain under the ribs, Qi rushing up to the throat, dizziness, and tendon quivering, which eventually becomes flaccidity syndrome over time." This is a severe deviation. In Taiyang disease, after sweating and subsequent purging, causing both interior and exterior deficiency, if moxibustion (burning needle) is added, leading to chest irritability, greenish-yellow complexion, and skin tremors, it is difficult to treat. This is also a severe deviation. How can sweating, vomiting, and purging be neglected?
[Heat Entering the Blood Chamber]
What is "heat entering the blood chamber"? It needs to be elucidated. "Chamber" refers to a room, a place where things can stay. The human "blood chamber" is the place where Ying (Nutritive) blood stays and meridians converge, which is the Chong Mai (Penetrating Vessel). The Chong Mai is one of the Eight Extraordinary Vessels. It originates below the kidney, emerges at Qichong (ST30), runs alongside the Foot-Yangming Stomach Meridian, ascends flanking the navel to the chest where it disperses, and serves as the Sea of the Twelve Regular Meridians. Wang Bing stated: "The Chong is the Sea of Blood," meaning blood from all meridians converges here. In men, it circulates to generate essence; in women, it transforms upward into milk and downward into menstruation. The *Neijing* states: "When the Ren Mai is unobstructed and the Chong Mai is vigorous, menstruation arrives on time." Wang Bing said: "Yin is quiet; when the sea is full, blood flows out," meaning the Chong Mai is vigorous like a full sea. From this, it is clear that the Chong Mai is the blood chamber.
Pathogenic factors of cold damage enter women via the meridians, while in men, they transmit via the Yangming channel. Since the Chong Mai and the collaterals of Shaoyin originate in the kidney, when women contract pathogens, Taiyang pathogenic factors follow the meridians and enter the Chong Mai, connecting with the Foot-Yangming. In men, internal heat in Yangming allows entry. When the Chong Mai receives heat, blood will move recklessly. In men, this manifests as bleeding from below and delirium; in women, it manifests as the onset of menstruation. Yangming disease presenting with bleeding and delirium indicates heat entering the blood chamber; this refers to men, not just women. When women suffer from cold damage, whether menstruation is just beginning or has just ended, it is because Qi and Blood are deficient during the menstrual period, the uterine chamber is open, and pathogens take advantage of the deficiency to enter. The *Lingshu* states: "Pathogens cannot injure the body alone without existing deficiency."
In women, heat entering the blood chamber may require treatment to heal, or it may heal spontaneously; the situations vary. If a woman suffers from Wind Strike with fever and aversion to cold, and menstruation begins, after seven or eight days, the fever subsides, the pulse slows, the body feels cool and harmonious, but there is fullness under the chest and ribs resembling Jie Xiong (Chest Binding) syndrome, accompanied by delirium, this is heat entering the blood chamber. One should puncture Qi Men (LR14) to drain excess according to the timing. If menstruation has just ceased, this is heat entering the blood chamber, and the blood must be congealed, causing symptoms resembling malaria with periodic occurrences; Xiao Chai Hu Tang (Minor Bupleurum Decoction) should be used. These two cases require treatment to heal.
If a woman suffers from cold damage with fever, and menstruation begins, she is lucid during the day but delirious at night, seeing ghosts, this is heat entering the blood chamber. Do not violate the Stomach Qi or the Upper and Middle Jiao; it will heal spontaneously. This is a case that heals without treatment. Delirium indicates severe pathogenic factors, so why does it heal without treatment? Fullness under the chest and ribs, resembling Jie Xiong and delirium, indicates pathogenic factors lingering and binding in the chest and ribs; one must puncture Qi Men to drain the excess. Chills and fever resembling malaria with periodic occurrence indicate blood stagnation; Xiao Chai Hu Tang is needed to disperse it. Both cases have lingering pathogens and require treatment. However, if fever coincides with the onset of menstruation, with lucidity by day and delirium by night, since menstruation has started, there are no lingering pathogens inside. As long as one does not interfere recklessly, the heat dissipates with the blood, and it will heal spontaneously. The Classics state: "If blood flows down spontaneously, healing follows." Therefore, do not violate the Stomach Qi or the Upper and Middle Jiao; it will heal spontaneously. "Reckless interference" refers to mistakenly treating delirium as Yangming Interior Excess and using purgatives, thereby violating Stomach Qi. Here, there is no chest/rib pathology, so puncturing Qi Men would violate the Middle Jiao. Here, there is no blood congealment, so using Xiao Chai Hu Tang would violate the Upper Jiao. Xiao Chai Hu Tang has a dispersing action that disturves Wei (Defensive) Qi, which originates from the Upper Jiao; disturbing Wei Qi violates the Upper Jiao. Puncturing Qi Men disturbs Ying (Nutritive) Qi, which originates from the Middle Jiao; disturbing Ying Qi violates the Middle Jiao. The *Mai Jing* states: "Do not violate the Stomach Qi or the Upper and Middle Jiao." Does this refer only to herbs and not acupuncture? This is likely the reasoning.