宫XX，男，61岁，吉林省集安县人。1983年7月来诊。该患于半月前发病，始觉恶寒，发热，嗣后恶寒渐解而发热日重，体温达39．5℃左右，曾于当地医院治疗10余日，病势不减，且渐渐出现神志昏蒙，间有谵语之症。经人介绍，求为诊治。询其发病过程及证悄，言于20余日前，先感觉身体疲乏无力，身重肢倦，食欲不佳，于半月前，忽一日觉恶寒，头重而痛，全身酸痛，体温38．5℃o又有胸闷恶心，脘腹胀满，不饥不渴，即入院治疗。因患者本人即是老中医，当地县领导与医院都很重视，曾用各种中西药物治疗。西药以静脉给抗生素为主；中药大抵以清热解毒，养阴凉血之剂为主，虽一再用药，而病情不见好转。又细问其各种证情的变化，开始1-2日有恶寒，后即解除，而发热渐重，达39．5℃，上午较轻，下午加重，夜热更甚。发热虽高，但不觉燥热、口渴。每于体温升高时，可有汗出，汗后体温稍降，可致38℃左右，过2-3小时体温升高后，又有汗出，1日内能出几次汗。始觉全身酸痛，头部重痛，近些日疼痛大减，而头仍昏重。近三四日来于午后及夜间时有神识不清，谵语，曾用安宫牛黄丸数丸，每次服药后半小时左右，体温可下降至37℃左右，但2小时后体温反而更高；大便尚可，不燥不溏；小便量少而色黄；虽数日不欲食，而脘腹胀满犹不稍减。患者舌体淡胖，苔白黄而腻，脉象濡缓。据其发病过程，临床表现，所用药物及服药后之情况，特别是现有的症状、舌象、脉象等情况综合分析，此病属于湿温，证为湿热并重。拟以化湿清热之法为主，稍佐清心开窍之品。为其疏方：杏仁10g，厚朴15g，菊花10g，白蔻仁10g，半夏)5g，栀子15g，连翘15g，滑石15g，竹叶10g，郁金15g，菖蒲15g。水煎，日1剂，分3次服。2剂后体温下降至37．5℃，下午至38℃。各种证情均有明显好转，神志昏蒙，谵语减轻。又服前方2剂，体温降至36．5℃，下午37-37，5℃。舌苔已大体退净。病情基本好转，唯胃纳欠佳。用下方以善后：白蔻仁5g，藿香叶5g，薄荷叶5g，荷叶Ⅱ0g，芦根15g，竹叶5g。加温水适量浸泡1小时左右，放火上轻煎至有香气出为止，泌出药液，再加水煎1次。合并2次之药液，分3次服。2剂后，热退身和，胃中胀满全无，纳食渐加，舌象正常。于次日返回家乡。
医生甲请老师谈一下辨治此证之要点。
老师：对于温热病之治疗，首先要辨明其病是属于温热类温病，还是属于湿热类温病，其次是辨清其证的性质。温病中包括多种温病，区别开各种温病固然重要，而其中最为重要的还是辨明其为温热与湿热两类。因这两类温病从病因、病机、病位、病证及治则、用药等方面都有原则的区别，因而在诊治温热病时，这一点十分重要。从该患的证情来看，其病为湿热类温病无疑。更确切地讲，此病为湿温病，证属气分证。湿温的气分证，有湿有热，治疗时，当以辨明湿与热的孰多孰少为首务。即其证是属湿重于热，热重于湿，还是湿热并重，此患之证情，属于湿热并重，因而在治疗时采用化湿清热之法，从而收到了比较满意的效果。总之，首先辨明其为湿热类温病的湿温，证属气分，其次辨明其证为湿热并重，这是辨证上的要点。既然证属湿热并重，则应按湿热证之治疗法则用药，而不应以治疗温热之方法、药物来治疗湿热。
老师：此病发于7月份，正是夏暑(小暑在7月7日前后，大暑在7月23日前后)湿热偏盛之季。此时所患之温病，不是暑温(包括暑温类证)即是湿温。吴鞠通说，"暑兼湿热，其偏于暑之热者为暑温；偏于暑之湿者为湿温"。但暑温发病急剧，而湿温发病缓慢。暑温起病即以阳明燥热证为主，多无卫分证；而湿温始病以太阴湿热证为主，多有卫分证。此患者未病之前即已有数日身体不适，食欲不佳。发病后又有一二日之卫分证。当卫分证解除后，虽体温不断升高而热象并不显露，如不渴，不烦躁，面目不红赤，口唇不焦干，舌苔无燥裂起刺等都说明此病为湿温而非暑温。湿温邪在气分，其证有湿有热。若湿重于热者，虽热势稽留而外显一派湿象，如舌淡胖，苔白腻，小便不黄赤，若是热重于湿者，则又以阳明经热证为主。而此患之舌苔已变黄，小便短黄，则非湿重之证可知；而又无阳明燥热烦渴之象，故此证为湿热并重无疑。
医生丙：老师在前面讲，应按湿热证之治疗法则用药，而不应误以治疗温热之法来治疗湿热，能讲得详细些吗?
老师：湿热病之发热，为湿阻气机，湿热郁蒸而致。有时虽然体温很高，但却表现出一派气滞湿阻之象。所谓"湿处热外，热蕴湿中"，即形象地说明了这种状态。欲清此热，必先化湿。欲祛湿邪，必先畅气。欲畅气机，必开泄上焦，宣通中焦，渗利下焦之法同用。而药物必以辛温芳香，苦温燥湿，淡渗利湿之晶为主。如蔻仁、陈皮、半夏、藿香、菖蒲之辛香；杏仁、厚朴之苦温；苓、泽、通、滑、薏、竹之淡渗往往配合应用，使三焦之气机通畅，则水湿自无容留之地。湿邪去则热无所依而势孤，往往不清之而自退。此即治湿热蕴结，湿重于热之法。如病证已转化为湿热并重，则在此基础上，再加苦寒燥湿泄热之品，如黄芩、黄连、栀子等味，以泄热降火，即所谓"辛开苦泄"(或曰"辛开苦降")之法。既去其湿，又清其热，此治湿温气分证，湿热并重之法。若不识湿热郁于气分之机理，而一见高热，便直用寒凉。寒之而热不去，则用滋阴。或见脘腹胀满而用攻下，皆为误治。盖"热者寒之"，"治热以寒"，乃治阳热实火；之法。故温热类温病的气分证、邪热炽盛时，必以此法直折火势；热盛最易灼阴，或配阴柔，以济不足之阴；阴伤常易燥结，或伍泻下，以通燥热之结，皆为正治之法。但湿热类温病的气分证则不然，以上寒凉、滋阴、泻下等法皆不可用。盖因其发热乃由湿阻气机，气郁化热，湿热蕴结而致。湿为阴邪，粘腻淹滞，非用辛温刚燥宣散等阳药以畅之化之，则湿邪不去，湿邪不去则与热相结而愈郁愈热。若误用寒凉以清之，则是以阴寒之药治阴湿之邪，必有寒凉遏伏，气机郁阻，阴湿愈盛之患；若误用滋阴之晶，则为以湿助湿，而湿邪愈重；若误用泻下之晶，则脾阳受伤而湿邪愈留。此患者初时所用之药，大体不外此类，故病势渐至加重。
医生乙此患已出现神昏谵语，老师为何不用安宫丸、至宝丹等药?
老师：温病中出现神昏谵语，证情不同，治疗方法也因之而异，不能一见高热、神昏谵语便使用安宫牛黄丸、至宝丹等药。因为安宫牛黄丸与至宝丹等皆系凉开之晶。所谓凉开，是说这类药物具有芳香开窍之功，而性偏寒凉；又有清心解热之能，所以只适用于温热病中，由于热邪传入心包而致神昏窍闭之证。此患者之神识昏蒙，时有谵语，不属凉开药之适应证，故不用之。即或应用，也属药不对证。此患者曾服用过数丸安宫丸，不仅神昏谵语未见减轻，而发热等症反而加重，就说明了这一问题。
医生甲：老师说，温病中出现神昏谵语证情不同，能否讲一下这一问题。
老师：温病中出现神昏或谵语，大抵有以下几种情况，在温热类温病中有：热闭心包：为热邪上犯，煎津成痰，痰热阻闭心包，症见灼热，神昏谵语，或昏愤不语，舌蹇肢厥，舌绛鲜泽。治宜安宫、紫雪、至宝等清心开窍。热入营血：症见身热夜甚，心烦不寐，时有昏谵，舌绛无苔，为热入营分，若见失血或发斑，而见昏狂谵妄，则为热入血分。治宜清营泄热，或凉血散血，兼用清心开窍之品。胃热乘心：为阳明经、腑证而出现神昏谵语者，其舌苔或黄或灰或黑，必焦燥，或起刺，或有裂纹。宜白虎、承气辈清之、下之，则胃热去而神自清。蓄血证：即阳明腑实又兼肠内出血，不能顺利便出，蓄积而成。症见大便色黑而不易，小腹满硬，小便自利。宜桃仁承气之类泻燥结而化瘀血。又有热入血室，昼日明了，夜则谵妄之证。湿热病中出现昏谵，多为湿热郁蒸，上蒙心包而致，症见神识昏蒙，时清时昧，似清似昧，舌苔或黄或黄白相兼，而必垢腻，治宜化湿清热而开窍，常用菖蒲郁金汤之类。
暴吐、暴泻、虚脱
湖南中医学院教授熊继柏
男患，27岁，农民。病人大吐大泻，昏倒不起。由于病人家住边远山区，交通不便，且离医院较远，余遂急奔病人家中抢救。询其病情：家人诉患者当日下午冒着烈日酷暑在田间抢收早稻，因口渴之极，在田边水池中舀喝了2碗生水，须臾便觉腹中疼痛，旋即上吐下泻，竟昏倒在田间。该地乡村医生给服了半包人丹，l瓶十滴水，2瓶藿香正气水。入暮时，患者又复吐泻频频，上则呕吐如喷，下则泄水如注，请医生给予针剂注射、服药，可是不论药与水，下咽即吐，不能取效。察其病态：病人两目深陷，面部肌肉陷下，腹部凹陷瘪小，面色灰黯，口唇淡紫，声低息微，口张气短，时时呕逆，大便失禁，泄水不止。且全身冷汗淋漓，畏寒肢冷，舌色淡白，脉微细无力。析其脉证：乃阴液将竭，阳气欲脱之危侯。病人生命危在顷刻，已来不及抬送医院，当时又没有条件进行输液，只得完全依靠中药进行抢救，于是急拟2方。第一方：乌梅30g，干姜15g。第二方：高丽参30g，黑附片60g，炙甘草15g。首先用第一方的2味药煎成浓汁候冷，每次给病人喂服l汤匙，1小时之内连服5次，须臾呕吐之势稍定，药水已能入胃，旋即浓煎频饮第二方，半小时服1次，每次服3汤匙。约3小时左右，患者气色转佳，四肢转温，汗泻渐减，脉趋沉细，危机得到缓解。此时患者但觉口渴欲饮，气短不续。天明之后，改拟附子理中汤合生脉散治之。处方：吉林参15g，干姜15g，焦白术12g，附子15g，炙甘草10g，麦冬30g，五味子8g。水煎服3剂，日服1剂。次诊：3日后往视，患者吐泻均止，并已进粥。惟觉精神困倦，四肢乏力，食少，自汗。其舌色已转红润，脉象已趋细缓。乃拟参苓白术散3剂，善后收功。处方：台党参20g，焦白术10g，茯苓12g，炙甘草6g，山药15g，白莲肉10g，炒薏米15g，桔梗6g，砂仁6g，炒扁豆15g。服完3剂，病人即停进药，其病亦痊愈。
医生甲此病猝暴危急，请老师谈一谈在辨证时应把握住哪些关键?
老师：对此病的辨证，关键在于把握两点：此病发在炎暑季节，由于饮不洁净的生水所起。似此逢暑热燔炽而猝然饮冷者，最易造成两种病变，一是湿热壅遏肠胃，二是中焦阳气受损。而本患者身不发热，舌苔不见黄腻，脉不滑不数；却出现畏寒肢冷、舌淡、脉微。这显然不是湿热阻遏，而是中阳受损，脾胃失司所致的上吐下泻，此其一。上吐下泻，最应辨清虚实，凡"邪气盛则实，精气夺则虚"。实证必然表现实象，诸如发热恶寒、胸闷腹胀、腹痛拒按、呕吐酸苦、泻下腐臭、肛门灼热、小便黄赤、舌苔垢腻、脉象有力等。而本患者却见两目深陷、面颊瘦削、腹部凹陷、口张气短、声低息微，更兼自汗肢冷，脉微无力，已呈一派虚衰之象。且暴吐暴泻，谓之"上争下夺"，最易伤津耗气，产生危侯。《医宗金鉴》曾指出，"呕吐而见面色青，指甲黑，中痛不止，肢厥不回者凶；泄泻若见脉微细，手足寒，气短少，水浆不入，大便失禁者凶"。而本患所见即是虚脱凶险之象，此其二。当务之急，必须固气救脱，以挽生命于垂危。
医生乙请老师谈一谈，用中医中药抢救暴吐暴泻的虚脱证，应当注意哪些关键问题?
【背景信息】
书名：名师垂教 章节：正文(17/27) 类别：综合
宫某，男，61岁，吉林省集安县人。1983年7月来诊。该患于半月前发病，开始感觉恶寒（怕冷），发热，随后恶寒逐渐缓解而发热日益加重，体温达39.5℃左右，曾在当地医院治疗10余日，病势未减，且渐渐出现神志昏蒙（意识模糊不清），间有谵语（胡言乱语）的症状。经人介绍，求为诊治。询问其发病过程及证候情况，他说在20余日前，先感觉身体疲乏无力，身重肢倦，食欲不佳，于半月前，忽一日觉恶寒，头重而痛，全身酸痛，体温38.5℃。又有胸闷恶心，脘腹胀满，不饥不渴，即入院治疗。因患者本人即是老中医，当地县领导与医院都很重视，曾用各种中西药物治疗。西药以静脉给抗生素为主；中药大抵以清热解毒，养阴凉血之剂为主，虽一再用药，而病情不见好转。又细问其各种证情的变化，开始1-2日有恶寒，后即解除，而发热渐重，达39.5℃，上午较轻，下午加重，夜热更甚。发热虽高，但不觉燥热、口渴。每于体温升高时，可有汗出，汗后体温稍降，可致38℃左右，过2-3小时体温升高后，又有汗出，1日内能出几次汗。始觉全身酸痛，头部重痛，近些日疼痛大减，而头仍昏重。近三四日来于午后及夜间时有神识不清，谵语，曾用安宫牛黄丸数丸，每次服药后半小时左右，体温可下降至37℃左右，但2小时后体温反而更高；大便尚可，不燥不溏；小便量少而色黄；虽数日不欲食，而脘腹胀满犹不稍减。患者舌体淡胖，苔白黄而腻，脉象濡缓（浮而细软，慢）。据其发病过程，临床表现，所用药物及服药后之情况，特别是现有的症状、舌象、脉象等情况综合分析，此病属于湿温（一种由湿热病邪引起的急性外感热病），证为湿热并重（湿邪与热邪程度相当）。拟以化湿清热之法为主，稍佐清心开窍之品。为其疏方：杏仁10g，厚朴15g，菊花10g，白蔻仁10g，半夏15g，栀子15g，连翘15g，滑石15g，竹叶10g，郁金15g，菖蒲15g。水煎，日1剂，分3次服。2剂后体温下降至37.5℃，下午至38℃。各种证情均有明显好转，神志昏蒙，谵语减轻。又服前方2剂，体温降至36.5℃，下午37-37.5℃。舌苔已大体退净。病情基本好转，唯胃纳欠佳。用下方以善后：白蔻仁5g，藿香叶5g，薄荷叶5g，荷叶10g，芦根15g，竹叶5g。加温水适量浸泡1小时左右，放火上轻煎至有香气出为止，泌出药液，再加水煎1次。合并2次之药液，分3次服。2剂后，热退身和，胃中胀满全无，纳食渐加，舌象正常。于次日返回家乡。
医生甲请老师谈一下辨治此证之要点。
老师：对于温热病（一类急性外感热病）之治疗，首先要辨明其病是属于温热类温病，还是属于湿热类温病，其次是辨清其证的性质。温病中包括多种温病，区别开各种温病固然重要，而其中最为重要的还是辨明其为温热与湿热两类。因这两类温病从病因、病机、病位、病证及治则、用药等方面都有原则的区别，因而在诊治温热病时，这一点十分重要。从该患的证情来看，其病为湿热类温病无疑。更确切地讲，此病为湿温病，证属气分证（温热病发展过程中，邪入脏腑，正盛邪实，正邪剧争所表现的阶段）。湿温的气分证，有湿有热，治疗时，当以辨明湿与热的孰多孰少为首务。即其证是属湿重于热，热重于湿，还是湿热并重，此患之证情，属于湿热并重，因而在治疗时采用化湿清热之法，从而收到了比较满意的效果。总之，首先辨明其为湿热类温病的湿温，证属气分，其次辨明其证为湿热并重，这是辨证上的要点。既然证属湿热并重，则应按湿热证之治疗法则用药，而不应以治疗温热之方法、药物来治疗湿热。
老师：此病发于7月份，正是夏暑（小暑在7月7日前后，大暑在7月23日前后）湿热偏盛之季。此时所患之温病，不是暑温（包括暑温类证）即是湿温。吴鞠通说，“暑兼湿热，其偏于暑之热者为暑温；偏于暑之湿者为湿温”。但暑温发病急剧，而湿温发病缓慢。暑温起病即以阳明燥热证为主，多无卫分证（温热病初起，邪在肺卫所表现的阶段）；而湿温始病以太阴湿热证为主，多有卫分证。此患者未病之前即已有数日身体不适，食欲不佳。发病后又有一二日之卫分证。当卫分证解除后，虽体温不断升高而热象并不显露，如不渴，不烦躁，面目不红赤，口唇不焦干，舌苔无燥裂起刺等都说明此病为湿温而非暑温。湿温邪在气分，其证有湿有热。若湿重于热者，虽热势稽留而外显一派湿象，如舌淡胖，苔白腻，小便不黄赤，若是热重于湿者，则又以阳明经热证为主。而此患之舌苔已变黄，小便短黄，则非湿重之证可知；而又无阳明燥热烦渴之象，故此证为湿热并重无疑。
医生丙：老师在前面讲，应按湿热证之治疗法则用药，而不应误以治疗温热之法来治疗湿热，能讲得详细些吗?
老师：湿热病之发热，为湿阻气机，湿热郁蒸而致。有时虽然体温很高，但却表现出一派气滞湿阻之象。所谓“湿处热外，热蕴湿中”，即形象地说明了这种状态。欲清此热，必先化湿。欲祛湿邪，必先畅气。欲畅气机，必开泄上焦，宣通中焦，渗利下焦之法同用。而药物必以辛温芳香，苦温燥湿，淡渗利湿之品为主。如蔻仁、陈皮、半夏、藿香、菖蒲之辛香；杏仁、厚朴之苦温；苓、泽、通、滑、薏、竹之淡渗往往配合应用，使三焦之气机通畅，则水湿自无容留之地。湿邪去则热无所依而势孤，往往不清之而自退。此即治湿热蕴结，湿重于热之法。如病证已转化为湿热并重，则在此基础上，再加苦寒燥湿泄热之品，如黄芩、黄连、栀子等味，以泄热降火，即所谓“辛开苦泄”（或曰“辛开苦降”）之法。既去其湿，又清其热，此治湿温气分证，湿热并重之法。若不识湿热郁于气分之机理，而一见高热，便直用寒凉。寒之而热不去，则用滋阴。或见脘腹胀满而用攻下，皆为误治。盖“热者寒之”，“治热以寒”，乃治阳热实火之法。故温热类温病的气分证、邪热炽盛时，必以此法直折火势；热盛最易灼阴，或配阴柔，以济不足之阴；阴伤常易燥结，或伍泻下，以通燥热之结，皆为正治之法。但湿热类温病的气分证则不然，以上寒凉、滋阴、泻下等法皆不可用。盖因其发热乃由湿阻气机，气郁化热，湿热蕴结而致。湿为阴邪，粘腻淹滞，非用辛温刚燥宣散等阳药以畅之化之，则湿邪不去，湿邪不去则与热相结而愈郁愈热。若误用寒凉以清之，则是以阴寒之药治阴湿之邪，必有寒凉遏伏，气机郁阻，阴湿愈盛之患；若误用滋阴之品，则为以湿助湿，而湿邪愈重；若误用泻下之品，则脾阳受伤而湿邪愈留。此患者初时所用之药，大体不外此类，故病势渐至加重。
医生乙此患已出现神昏谵语，老师为何不用安宫丸、至宝丹等药?
老师：温病中出现神昏谵语，证情不同，治疗方法也因之而异，不能一见高热、神昏谵语便使用安宫牛黄丸、至宝丹等药。因为安宫牛黄丸与至宝丹等皆系凉开之品。所谓凉开，是说这类药物具有芳香开窍之功，而性偏寒凉；又有清心解热之能，所以只适用于温热病中，由于热邪传入心包而致神昏窍闭之证。此患者之神识昏蒙，时有谵语，不属凉开药之适应证，故不用之。即或应用，也属药不对证。此患者曾服用过数丸安宫丸，不仅神昏谵语未见减轻，而发热等症反而加重，就说明了这一问题。
医生甲：老师说，温病中出现神昏谵语证情不同，能否讲一下这一问题。
老师：温病中出现神昏或谵语，大抵有以下几种情况，在温热类温病中有：热闭心包：为热邪上犯，煎津成痰，痰热阻闭心包，症见灼热，神昏谵语，或昏愤不语，舌蹇肢厥，舌绛鲜泽。治宜安宫、紫雪、至宝等清心开窍。热入营血：症见身热夜甚，心烦不寐，时有昏谵，舌绛无苔，为热入营分，若见失血或发斑，而见昏狂谵妄，则为热入血分。治宜清营泄热，或凉血散血，兼用清心开窍之品。胃热乘心：为阳明经、腑证而出现神昏谵语者，其舌苔或黄或灰或黑，必焦燥，或起刺，或有裂纹。宜白虎、承气辈清之、下之，则胃热去而神自清。蓄血证：即阳明腑实又兼肠内出血，不能顺利便出，蓄积而成。症见大便色黑而不易，小腹满硬，小便自利。宜桃仁承气之类泻燥结而化瘀血。又有热入血室，昼日明了，夜则谵妄之证。湿热病中出现昏谵，多为湿热郁蒸，上蒙心包而致，症见神识昏蒙，时清时昧，似清似昧，舌苔或黄或黄白相兼，而必垢腻，治宜化湿清热而开窍，常用菖蒲郁金汤之类。
暴吐、暴泻、虚脱
湖南中医学院教授熊继柏
男患，27岁，农民。病人大吐大泻，昏倒不起。由于病人家住边远山区，交通不便，且离医院较远，余遂急奔病人家中抢救。询其病情：家人诉患者当日下午冒着烈日酷暑在田间抢收早稻，因口渴之极，在田边水池中舀喝了2碗生水，须臾便觉腹中疼痛，旋即上吐下泻，竟昏倒在田间。该地乡村医生给服了半包人丹，1瓶十滴水，2瓶藿香正气水。入暮时，患者又复吐泻频频，上则呕吐如喷，下则泄水如注，请医生给予针剂注射、服药，可是不论药与水，下咽即吐，不能取效。察其病态：病人两目深陷，面部肌肉陷下，腹部凹陷瘪小，面色灰黯，口唇淡紫，声低息微，口张气短，时时呕逆，大便失禁，泄水不止。且全身冷汗淋漓，畏寒肢冷，舌色淡白，脉微细无力。析其脉证：乃阴液将竭，阳气欲脱之危侯。病人生命危在顷刻，已来不及抬送医院，当时又没有条件进行输液，只得完全依靠中药进行抢救，于是急拟2方。第一方：乌梅30g，干姜15g。第二方：高丽参30g，黑附片60g，炙甘草15g。首先用第一方的2味药煎成浓汁候冷，每次给病人喂服1汤匙，1小时之内连服5次，须臾呕吐之势稍定，药水已能入胃，旋即浓煎频饮第二方，半小时服1次，每次服3汤匙。约3小时左右，患者气色转佳，四肢转温，汗泻渐减，脉趋沉细，危机得到缓解。此时患者但觉口渴欲饮，气短不续。天明之后，改拟附子理中汤合生脉散治之。处方：吉林参15g，干姜15g，焦白术12g，附子15g，炙甘草10g，麦冬30g，五味子8g。水煎服3剂，日服1剂。次诊：3日后往视，患者吐泻均止，并已进粥。惟觉精神困倦，四肢乏力，食少，自汗。其舌色已转红润，脉象已趋细缓。乃拟参苓白术散3剂，善后收功。处方：台党参20g，焦白术10g，茯苓12g，炙甘草6g，山药15g，白莲肉10g，炒薏米15g，桔梗6g，砂仁6g，炒扁豆15g。服完3剂，病人即停进药，其病亦痊愈。
医生甲此病猝暴危急，请老师谈一谈在辨证时应把握住哪些关键?
老师：对此病的辨证，关键在于把握两点：此病发在炎暑季节，由于饮不洁净的生水所起。似此逢暑热燔炽而猝然饮冷者，最易造成两种病变，一是湿热壅遏肠胃，二是中焦阳气受损。而本患者身不发热，舌苔不见黄腻，脉不滑不数；却出现畏寒肢冷、舌淡、脉微。这显然不是湿热阻遏，而是中阳受损，脾胃失司所致的上吐下泻，此其一。上吐下泻，最应辨清虚实，凡“邪气盛则实，精气夺则虚”。实证必然表现实象，诸如发热恶寒、胸闷腹胀、腹痛拒按、呕吐酸苦、泻下腐臭、肛门灼热、小便黄赤、舌苔垢腻、脉象有力等。而本患者却见两目深陷、面颊瘦削、腹部凹陷、口张气短、声低息微，更兼自汗肢冷，脉微无力，已呈一派虚衰之象。且暴吐暴泻，谓之“上争下夺”，最易伤津耗气，产生危侯。《医宗金鉴》曾指出，“呕吐而见面色青，指甲黑，中痛不止，肢厥不回者凶；泄泻若见脉微细，手足寒，气短少，水浆不入，大便失禁者凶”。而本患所见即是虚脱凶险之象，此其二。当务之急，必须固气救脱，以挽生命于垂危。
医生乙请老师谈一谈，用中医中药抢救暴吐暴泻的虚脱证，应当注意哪些关键问题?
[Background Information]
Book: Master's Teaching Chapter: Main Text (17/27) Category: Comprehensive
Patient Gong, male, 61 years old, from Ji'an County, Jilin Province. He sought medical treatment in July 1983. The illness began half a month prior, initially presenting with aversion to cold and fever. Subsequently, the aversion to cold gradually resolved while the fever intensified daily, reaching approximately 39.5°C. He had been treated at a local hospital for over ten days without improvement; his condition worsened, and he gradually developed clouding of consciousness and intermittent delirium. Introduced by others, he sought our diagnosis and treatment. Upon inquiring about the onset and clinical manifestations, he stated that more than twenty days ago, he first felt physical fatigue, heaviness in the body, weakness in the limbs, and poor appetite. Half a month ago, suddenly one day he experienced aversion to cold, heavy and painful head, generalized body aches, and a temperature of 38.5°C. He also suffered from chest tightness, nausea, abdominal distension, lack of hunger, and absence of thirst, leading to hospitalization. As the patient himself was an experienced traditional Chinese medicine practitioner, local county leaders and the hospital attached great importance to his case, employing various Western and Chinese medicines. Western treatment primarily involved intravenous antibiotics; Chinese medicine largely consisted of formulas for clearing heat and detoxifying, nourishing yin, and cooling blood. Despite repeated medication, there was no improvement. Further detailed inquiry into the changes in symptoms revealed that during the first 1-2 days, there was aversion to cold, which then resolved, followed by progressively worsening fever up to 39.5°C. The fever was milder in the morning, aggravated in the afternoon, and most severe at night. Although the fever was high, he did not feel dry heat or thirst. Each time the temperature rose, sweating occurred; after sweating, the temperature dropped slightly to around 38°C. Two to three hours later, the temperature rose again, accompanied by another bout of sweating, occurring several times a day. Initially, he felt generalized body aches and heavy head pain; in recent days, the pain decreased significantly, but the head remained heavy and cloudy. For the past three to four days, he experienced episodes of unclear consciousness and delirium in the afternoon and at night. He had taken several pills of Angong Niuhuang Wan (Calculus Bovis Pill); about half an hour after each dose, his temperature dropped to around 37°C, but two hours later, it rose even higher. Bowel movements were acceptable, neither dry nor loose; urine volume was low and yellowish. Although he had no desire to eat for several days, abdominal distension did not subside. The tongue was pale and swollen, with a white-yellow greasy coating; the pulse was soggy and slow. Based on the disease process, clinical manifestations, medications used, post-medication effects, and especially current symptoms, tongue appearance, and pulse, comprehensive analysis indicated this disease belongs to Damp-Warmth (an acute febrile disease caused by damp-heat pathogenic factors), with a syndrome pattern of equal dampness and heat. The treatment principle was primarily to resolve dampness and clear heat, supplemented by herbs to clear the heart and open the orifices. The prescription was: Almond Seed 10g, Magnolia Bark 15g, Chrysanthemum Flower 10g, White Cardamom Seed 10g, Pinellia Tuber 15g, Gardenia Fruit 15g, Forsythia Fruit 15g, Talcum 15g, Bamboo Leaf 10g, Curcuma Root 15g, Acorus Rhizome 15g. Decocted in water, one dose per day, divided into three doses. After two doses, the temperature dropped to 37.5°C, reaching 38°C in the afternoon. Various symptoms improved significantly, and clouding of consciousness and delirium lessened. After taking two more doses of the same prescription, the temperature dropped to 36.5°C, ranging from 37-37.5°C in the afternoon. The tongue coating had mostly disappeared. The condition basically improved, except for poor appetite. A follow-up prescription was used for recovery: White Cardamom Seed 5g, Pogostemon Leaf 5g, Mint Leaf 5g, Lotus Leaf 10g, Reed Rhizome 15g, Bamboo Leaf 5g. Soaked in warm water for about one hour, lightly decocted until fragrance emerged, the liquid was drained. Water was added for a second decoction. The two liquids were combined and divided into three doses. After two doses, the fever subsided, the body felt comfortable, gastric distension completely resolved, appetite gradually increased, and the tongue appearance normalized. He returned home the next day.
Doctor A asked the teacher to discuss the key points in differentiating and treating this syndrome.
Teacher: In the treatment of Warm Diseases (a category of acute exogenous febrile diseases), one must first distinguish whether the disease belongs to the Warm-Thermal type or the Damp-Heat type of Warm Disease, and secondly, clarify the nature of the syndrome. Warm Diseases include various types; while distinguishing between them is important, the most crucial distinction is between Warm-Thermal and Damp-Heat types. These two types have fundamental differences in etiology, pathogenesis, lesion site, syndrome characteristics, treatment principles, and medication usage, making this distinction vital in diagnosing and treating Warm Diseases. From this patient's condition, it is undoubtedly a Damp-Heat type Warm Disease. More precisely, it is Damp-Warmth, belonging to the Qi Level Syndrome (the stage where the pathogen enters the zang-fu organs, righteous qi is strong, pathogenic factor is substantial, and intense struggle occurs). In the Qi Level Syndrome of Damp-Warmth, both dampness and heat are present. Treatment should prioritize determining which is predominant: dampness predominating over heat, heat predominating over dampness, or equal dampness and heat. This patient's syndrome is characterized by equal dampness and heat; therefore, the treatment adopted was resolving dampness and clearing heat, yielding satisfactory results. In summary, the key to differentiation is first identifying it as Damp-Warmth within the Damp-Heat type, belonging to the Qi Level, and secondly, identifying the syndrome as equal dampness and heat. Since the syndrome is equal dampness and heat, one must follow the treatment rules for Damp-Heat syndromes and should not use methods or drugs intended for Warm-Thermal diseases to treat Damp-Heat.
Doctor B asked why the teacher diagnosed this as Damp-Warmth with equal dampness and heat, and what the basis was.
Teacher: This disease occurred in July, a season when summer heat and dampness are prevalent (Minor Heat around July 7th, Major Heat around July 23rd). Warm diseases contracted at this time are either Summerheat-Warmth (including Summerheat-like syndromes) or Damp-Warmth. Wu Jutong stated, "Summerheat combines with dampness and heat; those leaning towards summerheat heat are Summerheat-Warmth; those leaning towards summerheat dampness are Damp-Warmth." However, Summerheat-Warmth has an acute onset, whereas Damp-Warmth has a slow onset. Summerheat-Warmth begins mainly with Yangming Dry-Heat Syndrome, often lacking Wei Level Syndrome (the initial stage where the pathogen is in the lung and defensive level); Damp-Warmth begins mainly with Taiyin Damp-Heat Syndrome, often involving the Wei Level. Before falling ill, this patient had several days of discomfort and poor appetite. After onset, he had one to two days of Wei Level symptoms. Once the Wei Level symptoms resolved, although the temperature continued to rise, heat signs were not obvious: no thirst, no irritability, no redness of face and eyes, no dry lips, and no dry/cracked tongue coating. These indicate Damp-Warmth rather than Summerheat-Warmth. When the pathogen of Damp-Warmth is in the Qi Level, both dampness and heat are present. If dampness predominates, despite persistent fever, external signs show dampness, such as a pale swollen tongue, white greasy coating, and non-red/yellow urine. If heat predominates, it mainly presents as Yangming Meridian Heat Syndrome. In this patient, the tongue coating turned yellow, and urine was short and yellow, indicating it was not a damp-predominant syndrome; furthermore, there were no signs of Yangming dry-heat with irritability and thirst, confirming equal dampness and heat.
Doctor C asked the teacher to elaborate on using treatment rules for Damp-Heat syndromes and avoiding methods for Warm-Thermal diseases.
Teacher: Fever in Damp-Heat diseases is caused by dampness obstructing qi mechanism and damp-heat stagnating and steaming. Sometimes, despite high temperature, signs of qi stagnation and damp obstruction appear. The phrase "damp surrounds heat, heat is contained within damp" vividly describes this state. To clear this heat, one must first resolve dampness. To dispel dampness, one must first unblock qi. To unblock qi mechanism, methods to vent the Upper Jiao, circulate the Middle Jiao, and leach out dampness from the Lower Jiao must be used together. Medications should primarily be pungent-warm aromatic, bitter-warm drying-dampness, and bland-leaching dampness agents. Examples include the pungent-aromatic properties of Cardamom Seed, Tangerine Peel, Pinellia Tuber, Pogostemon, and Acorus; the bitter-warm properties of Almond Seed and Magnolia Bark; and the bland-leaching properties of Poria, Alisma, Smilax, Talcum, Coix Seed, and Bamboo Leaf. These are often combined to ensure smooth qi mechanism in the Three Jiaos, leaving no room for water-dampness retention. Once dampness is removed, heat loses its support and becomes isolated, often receding without direct clearing. This is the method for treating Damp-Heat accumulation with dampness predominating. If the syndrome transforms into equal dampness and heat, bitter-cold drying-dampness and draining-heat agents like Scutellaria Root, Coptis Rhizome, and Gardenia Fruit are added to drain heat and reduce fire, known as the "Pungent Opening and Bitter Draining" (or "Pungent Opening and Bitter Descending") method. This removes dampness and clears heat, the method for treating Damp-Warmth Qi Level Syndrome with equal dampness and heat. If one does not understand the mechanism of damp-heat stagnating in the Qi Level and sees high fever, directly using cold-cooling agents is a mistake. If cold fails to reduce fever, yin-nourishing is used. Or if abdominal distension is seen, purging is used. All these are mis-treatments. "Heat is treated with cold" applies to Yang-Heat Excess Fire. In the Qi Level of Warm-Thermal Warm Diseases, when pathogenic heat is vigorous, this method is used to directly suppress the fire; since excessive heat easily consumes yin, yin-nourishing is paired to supplement deficient yin; since yin injury often leads to dryness and constipation, purging is combined to unblock dry-heat accumulation. These are correct treatments. However, for the Qi Level of Damp-Heat Warm Diseases, these cold-cooling, yin-nourishing, and purging methods cannot be used. Because the fever is caused by dampness obstructing qi mechanism, qi stagnation transforming into heat, and damp-heat accumulation. Dampness is a Yin pathogen, sticky and stagnant. Without using pungent-warm, rigid-drying, dispersing Yang drugs to unblock and transform it, dampness will not leave. If dampness remains, it binds with heat, becoming more stagnant and hotter. Using cold-cooling agents mistakenly treats Yin-dampness with Yin-cold drugs, causing cold-cooling to trap and obstruct qi mechanism, worsening Yin-dampness. Using yin-nourishing agents mistakenly aids dampness with dampness, worsening the pathogen. Using purging agents mistakenly injures Spleen-Yang, causing dampness to remain. The medications initially used for this patient were largely of this type, hence the condition worsened.
Doctor B asked why the teacher did not use Angong Pills or Zhibao Dan given the patient's confusion and delirium.
Teacher: Confusion and delirium in Warm Diseases vary in syndrome, requiring different treatments. One cannot simply use Angong Niuhuang Wan or Zhibao Dan upon seeing high fever and delirium. Angong Niuhuang Wan and Zhibao Dan are Cold-Opening agents. "Cold-Opening" means these drugs have aromatic orifice-opening properties but are cold-cooling in nature, and can clear the heart and relieve heat. They are only suitable for Warm-Thermal diseases where heat pathogen enters the Pericardium causing orifice closure. This patient's clouding of consciousness and occasional delirium do not fit the indication for Cold-Opening agents, so they were not used. Even if used, it would be inappropriate. The patient had taken several pills of Angong Wan; not only did confusion and delirium not improve, but fever and other symptoms worsened, illustrating this point.
Doctor A asked the teacher to explain the different situations of confusion and delirium in Warm Diseases.
Teacher: Confusion or delirium in Warm Diseases generally falls into several categories. In Warm-Thermal Warm Diseases:
1. Heat Closing the Pericardium: Caused by heat pathogen attacking upward, scorching fluids into phlegm, blocking the Pericardium. Symptoms: burning heat, confusion and delirium, or stupor with muteness, stiff tongue, cold limbs, crimson bright tongue. Treatment: Clear heart and open orifices with Angong, Zixue, Zhibao, etc.
2. Heat Entering Ying and Blood Levels: Symptoms: worse fever at night, restlessness, insomnia, occasional confusion/delirium, crimson tongue without coating. This indicates Heat entering Ying Level. If bleeding or macules appear with wild confusion/delirium, it indicates Heat entering Blood Level. Treatment: Clear Ying and drain heat, or cool Blood and dissipate stasis, combined with clearing heart and opening orifices.
3. Stomach Heat Assailing the Heart: Confusion/delirium appearing in Yangming Meridian or Fu Organ syndromes. Tongue coating may be yellow, gray, or black, necessarily scorched/dry, prickly, or cracked. Treatment: Clear with Baihu Tang, purge with Chengqi Tang derivatives; once stomach heat is gone, spirit clears.
4. Blood Stasis Syndrome: Yangming Fu excess combined with intestinal bleeding, unable to pass smoothly, accumulating. Symptoms: black stool difficult to pass, full/hard lower abdomen, free urination. Treatment: Purge dryness and resolve blood stasis with Tao Ren Cheng Qi Tang derivatives.
5. Heat Entering Blood Chamber: Lucid during the day, delirious at night.
In Damp-Heat diseases, confusion/delirium is mostly due to damp-heat stagnating and steaming, misting the Pericardium. Symptoms: clouded consciousness, alternating clarity and obscurity, yellow or yellow-white mixed tongue coating, necessarily greasy/sticky. Treatment: Resolve dampness, clear heat, and open orifices, commonly using Changpu Yujin Tang derivatives.
Sudden Vomiting, Sudden Diarrhea, Collapse
Professor Xiong Jibo, Hunan College of Traditional Chinese Medicine
Male patient, 27 years old, farmer. The patient suffered sudden severe vomiting and diarrhea, collapsing and unable to rise. Due to living in a remote mountainous area with poor transportation and distance from the hospital, I rushed to his home for rescue. Inquiry into the condition: Family reported that in the afternoon, braving the scorching sun and heat, the patient was harvesting early rice in the field. Extremely thirsty, he drank two bowls of raw water from a pool by the field. Soon after, he felt abdominal pain, followed immediately by vomiting and diarrhea, eventually collapsing in the field. Local village doctors administered half a packet of Rendan, one bottle of Shidi Shui, and two bottles of Huoxiang Zhengqi Shui. By evening, vomiting and diarrhea became frequent again; vomiting was forceful like spraying, diarrhea watery like pouring. Doctors were called for injections and medication, but regardless of medicine or water, everything was vomited immediately upon swallowing, with no effect. Examination of the patient's state: Eyes sunken deep, facial muscles collapsed, abdomen concave and small, complexion gray-dark, lips pale-purple, voice low, breath faint, mouth open, shortness of breath, frequent retching, fecal incontinence, continuous watery diarrhea. Whole body covered in cold sweat, aversion to cold, cold limbs, pale white tongue, minute fine weak pulse. Analysis of pulse and syndrome: Critical sign of impending exhaustion of Yin fluids and collapse of Yang Qi. Life was in imminent danger, too late to transport to hospital, and IV fluids were unavailable. Rescue relied entirely on Chinese medicine. Two prescriptions were urgently formulated. Prescription 1: Mume Fruit 30g, Dried Ginger 15g. Prescription 2: Korean Ginseng 30g, Black Prepared Aconite Root 60g, Honey-fried Licorice Root 15g. First, decoct the two herbs of Prescription 1 into a concentrated juice, let cool. Administer 1 tablespoon per dose, five times within one hour. Soon, vomiting subsided slightly, allowing medicine to enter the stomach. Immediately, decoct Prescription 2 strongly and administer frequently, 1 dose every half hour, 3 tablespoons each time. After about 3 hours, the patient's complexion improved, limbs warmed, sweating and diarrhea gradually decreased, pulse became sinking and fine, crisis alleviated. At this point, the patient felt thirst wanting to drink, shortness of breath. After dawn, changed to Fuzi Lizhong Tang combined with Shengmai San. Prescription: Jilin Ginseng 15g, Dried Ginger 15g, Charred Atractylodes Macrocephala Rhizome 12g, Aconite Root 15g, Honey-fried Licorice Root 10g, Ophiopogon Tuber 30g, Schisandra Berry 8g. Decoct in water, take 3 doses, 1 dose per day. Second visit: Visited 3 days later. Vomiting and diarrhea stopped, patient could eat porridge. Only felt mental fatigue, limb weakness, poor appetite, spontaneous sweating. Tongue color turned rosy-red, pulse became fine and slow. Prescribed Shenling Baizhu San for 3 doses for recovery. Prescription: Codonopsis Root 20g, Charred Atractylodes Macrocephala Rhizome 10g, Poria 12g, Honey-fried Licorice Root 6g, Chinese Yam 15g, White Lotus Seed 10g, Stir-fried Coix Seed 15g, Platycodon Root 6g, Amomum Fruit 6g, Stir-fried Lablab Bean 15g. After finishing 3 doses, the patient stopped medication, and the disease was cured.
Doctor A asked the teacher to discuss the key points to grasp in differentiation for this sudden critical illness.
Teacher: The key to differentiating this disease lies in grasping two points: This disease occurred in the hot summer season, caused by drinking unclean raw water. Encountering blazing summer heat and suddenly drinking cold water easily causes two types of pathological changes: one is Damp-Heat congesting the intestines and stomach, the other is damage to Middle Jiao Yang Qi. This patient had no fever, no yellow-greasy tongue coating, no slippery-rapid pulse; instead, he presented with aversion to cold, cold limbs, pale tongue, minute pulse. This is obviously not Damp-Heat obstruction, but Upper-Temperature damage and Spleen-Stomach dysfunction causing vomiting and diarrhea, which is the first point. Vomiting and diarrhea require clear differentiation of Deficiency and Excess. "Excess of pathogenic factor is Excess; depletion of essential qi is Deficiency." Excess syndromes manifest as Excess signs, such as fever and aversion to cold, chest tightness and abdominal distension, abdominal pain refusing pressure, sour/bitter vomiting, foul diarrhea, burning anus, yellow-red urine, greasy tongue coating, forceful pulse. This patient, however, showed sunken eyes, thin cheeks, concave abdomen, open mouth, shortness of breath, low voice, faint breath, spontaneous sweating, cold limbs, minute weak pulse, presenting a picture of deficiency and decline. Moreover, sudden vomiting and diarrhea, termed "fighting above and losing below," easily injure fluids and deplete qi, producing critical signs. *Yizong Jinjian* pointed out, "Vomiting with blue complexion, black nails, unceasing mid-abdominal pain, and irreversible cold limbs is ominous; diarrhea with minute fine pulse, cold hands and feet, shortness of breath, inability to take fluids, and fecal incontinence is ominous." What this patient exhibited was the ominous image of collapse, which is the second point. The urgent task is to consolidate Qi and rescue from collapse to save life from peril.
Doctor B asked the teacher to discuss the key issues to note when using Chinese medicine to rescue sudden vomiting and diarrhea collapse syndromes.