三阳合病腹满身重难转侧口中不仁面垢谵语遗尿自汗者不可汗不可下宜少与白虎汤(详身重)
风温病脉浮自汗出体重多眠若下之则小便不利直视失溲(详风温)
杨士瀛曰膀胱潴水下焦不摄则亦遗溺经云邪中下焦阴气为栗足膝逆冷便溺妄出合用四逆汤下焦蓄血小腹结急小便
自利不禁轻者桃仁承气汤重者抵当汤
寸口脉微而涩微者卫气不行涩者荣气不逮荣卫不能相将三焦无所仰身体痹不仁荣气不足则烦疼口难言卫气虚则恶
寒数欠三焦不归其部上焦不归者噫而吞酢中焦不归者不能消谷引食下焦不归者则遗溺咳而小便利若失小便者不可发汗
汗出则四肢厥冷太阳病火熨其背大汗出谵语十余日振栗下利欲小便不得反呕而失溲者此为欲解也(详谵语)遗溲狂言目
反直视者此为肾绝
吴 凡遗尿者小便自出而不知也其热盛神昏遗尿者为可治若阴证下寒逆冷遗尿脉沉微者多难治宜附子汤加干姜益
智子以温其下也若厥阴囊缩厥冷脉微遗尿者四逆加吴茱萸汤温之阳不回者死凡伤寒汗下后热不解阴虚火动而遗尿者以
人参三白汤加知母黄柏或补中益气汤加知母黄柏麦门冬生地黄五味子之类主之若狂言直视谵语遗尿者此为肾绝内经言
膀胱不利为癃不约则遗溺又曰水泉不止者膀胱不藏也盖肾与膀胱为表里肾虚则膀胱之气不约故遗尿也要在滋补膀胱之
气也东垣谓溲便遗失为肺金虚又当补肺气也大抵肺虚肾虚热甚者皆可治惟肾绝遗尿则不可治此下焦气绝不归其部故也
三阳合病,出现腹部胀满、身体沉重难以翻身转侧、口中麻木不知滋味、面部污垢、胡言乱语、遗尿、自汗等症状的,不可使用发汗法,也不可使用泻下法,适宜少量给予白虎汤(详见“身重”条)。
风温病,脉象浮、自汗出、身体沉重、嗜睡,如果误用泻下法,则会导致小便不利、两眼直视、大小便失禁(详见“风温”条)。
杨士瀛说:膀胱内尿液潴留,下焦不能固摄,也会导致遗尿。《内经》说:邪气侵入下焦,阴气战栗,足膝逆冷,二便妄出,应当合用四逆汤。下焦蓄血证,小腹拘急结硬,小便自利且不禁,轻者用桃仁承气汤,重者用抵当汤。
寸口脉微而涩,微表示卫气运行不畅,涩表示营气到达不足,营卫不能相互协调,三焦无所依赖,身体麻痹不仁。营气不足则烦痛、口难言;卫气虚则恶寒、频繁呵欠。三焦之气不归其本部:上焦之气不归则嗳气、吞酸;中焦之气不归则不能消化谷物、牵引饮食停滞;下焦之气不归则遗尿、咳嗽而小便通利,若像失去控制一样小便失禁,则不可发汗,发汗则四肢厥冷。太阳病用火熨背部,大汗出后出现胡言乱语,十余日后出现颤抖、下利,想小便却不得,反而呕吐并大小便失禁的,这是正气来复欲解的表现(详见“谵语”条)。若遗尿、狂言、两眼反张直视的,这是肾气绝的表现。
吴崑说:遗尿是指小便自行流出而不知晓。如果是热盛神昏导致的遗尿,属于可治之症;如果是阴证下寒、逆冷导致的遗尿,脉象沉微的,大多难治,宜用附子汤加干姜、益智仁以温补下焦。如果是厥阴病,出现囊缩、厥冷、脉微、遗尿的,用四逆汤加吴茱萸汤温之,阳气不能回复的则死。凡是伤寒经过发汗或泻下后,热势不解,阴虚火动而致遗尿的,用人参三白汤加知母、黄柏,或者用补中益气汤加知母、黄柏、麦门冬、生地黄、五味子等为主治方。如果出现狂言、直视、胡言乱语、遗尿的,这是肾绝的表现。《内经》说:膀胱气化不利则为癃闭,约束失职则遗尿;又说:水泉不止(小便淋漓不断),是膀胱不能藏精气的表现。肾与膀胱互为表里,肾虚则膀胱之气不能约束,故导致遗尿,关键在于滋补膀胱之气。李东垣认为小便遗失是肺金虚弱,又应当补肺气。大抵肺虚、肾虚、热盛的遗尿皆可治疗,只有肾绝导致的遗尿才不可治疗,这是因为下焦气绝,气不归其本部的缘故。
In a combined disease of the three yang channels, presenting with abdominal fullness, heaviness of the body making turning difficult, numbness in the mouth (loss of taste sensation), facial greasiness, delirium, enuresis, and spontaneous sweating, sweating methods and purgative methods are contraindicated. It is appropriate to administer a small amount of Baihu Tang (White Tiger Decoction) (see "Heaviness of Body").
In Fengwen disease (Wind-Warmth disease), with floating pulse, spontaneous sweating, heavy body, and somnolence, if purgatives are mistakenly used, it will lead to difficulty in urination, staring fixedly, and loss of control over both urine and stool (see "Fengwen").
Yang Shiyin said: When urine stagnates in the bladder and the lower jiao fails to secure it, enuresis also occurs. The Classic states: When pathogenic factors attack the lower jiao, yin qi trembles, leading to coldness in the feet and knees and involuntary discharge of urine and feces. In such cases, Sini Tang (Frigid Extremities Decoction) should be used. For blood stasis accumulating in the lower jiao, characterized by urgency and tightness in the lower abdomen with free urination but incontinence, Tao Ren Chengqi Tang (Peach Kernel and Rhubarb Decoction) is used for mild cases, and Didang Tang (Definitely Invading Decoction) for severe cases.
The pulse at the cunkou (inch position) is faint and choppy. Faint indicates that Wei Qi (Defensive Qi) does not circulate freely; choppy indicates that Ying Qi (Nutritive Qi) fails to reach its destination. Ying and Wei cannot coordinate with each other, and the three jiao have no support, resulting in bodily numbness and insensitivity. Deficiency of Ying Qi causes irritability and pain, and difficulty in speaking; deficiency of Wei Qi causes aversion to cold and frequent yawning. When the Qi of the three jiao fails to return to its proper location: if the Upper Jiao Qi fails to return, belching and acid regurgitation occur; if the Middle Jiao Qi fails to return, inability to digest grain and food stagnation occur; if the Lower Jiao Qi fails to return, enuresis, coughing, and patent urination occur. If urination seems lost or uncontrollable, sweating methods are contraindicated; inducing sweat would lead to cold extremities. In Taiyang disease, if the back is scorched with hot irons causing profuse sweating, followed by delirium, and after more than ten days, trembling, diarrhea, desire to urinate but inability to do so, vomiting, and loss of control over urine and stool occur, this indicates that the disease is about to resolve (see "Delirium"). However, if enuresis, wild talking, and eyes staring fixedly upward occur, this indicates the exhaustion of Kidney Qi.
Wu Kun said: Enuresis refers to the involuntary leakage of urine without awareness. If enuresis is caused by excessive heat and confusion of the spirit, it is treatable. If it is caused by Yin syndrome with lower cold and reversed coldness, with a deep and faint pulse, it is mostly difficult to treat. One should use Fuzi Tang (Aconite Decoction) plus Ganjiang (Dried Ginger) and Yizhiren (Bitter Almond Seed) to warm the lower jiao. In Jueyin disease, presenting with retraction of the scrotum, cold extremities, faint pulse, and enuresis, Sini Tang plus Wuzhuyu Tang (Evodia Decoction) should be used to warm the body; if Yang Qi does not return, death ensues. Generally, after sweating or purging in Shanghan (Cold Damage), if heat persists due to Yin deficiency and hyperactive fire causing enuresis, Renshen Sanbai Tang (Ginseng Three Whites Decoction) plus Zhimu (Anemarrhena Rhizome) and Huangbai (Phellodendron Bark), or Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) plus Zhimu, Huangbai, Maidong (Ophiopogon Tuber), Shengdi Huang (Rehmannia Root), and Wuweizi (Schisandra Berry) should be used as the main treatment. If wild talking, staring, delirium, and enuresis occur, this indicates kidney exhaustion. The Inner Canon states: Obstruction of the bladder leads to strangury; lack of restraint leads to enuresis. It also states: Unceasing flow of water (urine) indicates the bladder's failure to store essence. The Kidney and Bladder are exterior-interior related; Kidney deficiency leads to the bladder's inability to constrain, thus causing enuresis. The key lies in tonifying the Qi of the bladder. Li Dongyuan stated that loss of urine and stool is due to deficiency of Lung Metal, and thus Lung Qi should be tonified. Generally, enuresis due to Lung deficiency, Kidney deficiency, or excessive heat is treatable. Only enuresis due to Kidney exhaustion is untreatable, because this results from the exhaustion of lower jiao Qi and its failure to return to its proper location.