（昏愦 旧以叉手冒心滥入今去之）
成 郁为郁结而气不舒冒为昏冒而神不清俗谓之昏迷是也皆因虚乘寒所致经曰诸虚乘寒者则为厥郁冒不仁此寒
气
乘虚中上也骆龙吉以附子汤倍人参川芎天麻干姜之类主之又曰太阳病先下之不解因复发汗以此表里俱虚其人因冒冒家
汗出自愈由表和也若不得汗不解者以人参三白汤加川芎天麻如下虚脉微者加附子以温肾经乃固本也经曰滋苗者必固本
伐下者枯其上此之谓也要略曰新产妇人有三病一茎二郁冒三大便难亡血复汗寒多郁冒又曰产妇郁冒其脉微弱不能食大
便坚者盖由血虚而厥厥而必冒冒家欲解必大汗出观此则郁冒为虚寒可知矣又少阴病下利止而头眩时时自冒者死以其虚
极而脱也
太阳 病先下之而不愈因复发汗以此表里俱虚其人因致冒冒家汗出自愈所以然者汗出表和故也里未和然后复下之
（成氏以郁训冒疑未莹按说文冒字从曰从目曰即小儿及蛮夷头衣也此致冒者谓若物蒙蔽其目也是昏迷之义今以冒为郁
不惟失六书之本旨且失病情及仲景之意也里未和时刻作得里和或增未字而不去得字则舛于文理今以宋本正之）诸乘寒者
则为厥郁冒不仁口急不能言战栗也
太阳与少阳并病头项强痛或眩冒时如结胸心下痞硬者当刺大椎肺俞肝俞（详项强）
阳明 病患小便不利大便乍难乍易时有微热喘冒不能卧有燥屎也宜大承气汤
少阴 病但欲寐下利止而头眩时时自冒者死
厥阴 下利清谷脉沉迟其人面赤身有微热必郁冒汗出而解（详下利）
伤寒吐下后虚烦脉其微八九日心下痞硬胁下痛气上冲咽喉眩冒经脉动惕者久而成痿
海 伤寒传至五六日间渐变神昏不语或睡中独语一二句目赤唇焦舌干不饮水稀粥与之则咽不与则不思六脉细数
而
不洪大心下无痞腹中不满大小便如常或传至十日以来形貌如醉医见神昏不已多用大承气汤下之则误矣盖不知此热传手
少阴心经也然又未知其何经而来答曰本太阳经伤风风为阳邪伤卫阴血自燥热结膀胱壬病逆传于丙丙丁兄妹由是传心心
火自上迫熏肺所以神昏也盖肺为清肃之脏内有火邪故令神昏宜栀子黄连黄芩汤若脉在丙者导赤散脉在丁者泻心汤若误
用凉膈散此乃气中之血药也如右手寸脉沉滑有力者则可用之或用犀角地黄汤近于是已本方所说若无犀角以升麻代之是
阳明经药也此解阳明经血中热药若脉浮沉俱有力者是丙丁俱有热可以导赤散泻心汤各半服之则宜矣此证膀胱传丙足传
手经者下传上也丙传丁者表传里也壬传丁者艮传离也越经传者又为腑传脏也活人云伤寒只传足经不传手经者此言不尽
意也有从足经而传手经者何以知之经云伤寒或止传一经或间传三经不可一途取之但视其脉与外证治之此活法也与食则
咽者邪不在胃也不与则不思者以其神昏故也邪热既不在里误用承气下之其死也必矣（脉在丙者脉浮也脉在丁者脉沉也脉
丙丁俱在有热者浮沉俱有力也）
余云衢太史形气充壮饮啖无人辛卯夏六月患热病肢体不甚热而间扬掷手足如躁扰状昏愦不知人事时发一二语不可
了而非谵也脉微细如欲绝有谓是阴证宜温者有谓当下者时座师陆葵曰先生与曾植斋冯琢庵二太史皆取决于余余谓是阳
病见阴脉在法为不治然素禀如此又值酷暑外烁酒灸内炎宜狂热如焚脉洪数有力而此何为者岂热气怫郁不得伸而然耶且
不大便七日矣姑以大柴胡汤下之时大黄止用二钱又熟煎而太医王雷庵力争以为太少不若用大承气余曰如此脉证岂宜峻
下待大柴胡不应而后用调胃承气调胃承气不应而后用小承气以及大承气未晚也已服药大便即行脉已出手足温矣余谓雷
庵曰设用大承气能免噬脐之悔哉继以黄连解毒汤数服而平七月初遂与陆先生同典试南京不复发矣明年余请告归里偶得
刘河间伤寒直格读之中有云蓄热内甚脉须疾数以其极热蓄甚而脉道不利反致脉沉细而欲绝俗未明造化之理反谓传为寒
极阴毒者或始得之阳热暴甚而便有此证候者或两感热甚者通宜解毒加大承气下之下后热稍退而未愈者黄连解毒汤调之
或微热未除者凉膈散调之或失下热极以至身冷脉微而昏冒将死若急下之则残阴暴绝而死盖阳气后竭而然也不下亦死宜
凉膈散或黄连解毒汤养阴退阳积热渐以宣散则心胸再暖而脉渐以生然后抚卷而叹曰古人先得我心矣余太史所患正失下
热极以至身冷脉微而昏冒欲绝者也下与不下大下与微下死生在呼吸间不容发呜乎可不慎哉因表而出之以为世鉴
（昏愦：旧版医书将“叉手冒心”的症状错误地归入此类，现已去除。）
成无己注：郁是指气机郁结而不得舒展，冒是指神志昏蒙而不清醒，也就是俗称的昏迷。这些症状都是因为正气虚弱，寒邪乘虚而入所致。《内经》说：“各种虚证遇到寒气侵袭，就会发生厥逆。”气机郁结、神志昏冒以及肢体麻木不仁，都是由于寒气乘虚侵入人体上部所致。骆龙吉主张用附子汤，并加倍使用人参，加入川芎、天麻、干姜等药物来主治。又说：太阳病先用了下法没有痊愈，接着又发汗，这样导致表里两虚。病人因此出现头目昏眩（冒）。凡是患“冒”证的病人，如果出汗，病就会自愈，这是因为表气调和的缘故。如果不出汗，病就不解，可以用人参三白汤加川芎、天麻治疗；如果是下焦虚损、脉象微弱的，加附子以温补肾经，这是巩固根本的方法。《内经》说：“滋润苗株必须稳固根本，砍伐树根则树梢枯死”，说的就是这个道理。《金匮要略》说：新产后的妇女有三种病：一是痉病，二是郁冒，三是大便难。亡血之后又出汗，感受寒邪较多，就会出现郁冒。又说：产妇患郁冒，脉象微弱，不能进食，大便坚硬，这是由于血虚导致厥逆，厥逆必然导致昏冒。患“冒”证的病人想要痊愈，必定会大汗出。看这些记载，就可以知道郁冒属于虚寒证了。另外，少阴病下利停止后出现头眩，时常感到昏冒的，是死证，因为正气极度虚弱而脱失。
太阳病：先用了下法而没有痊愈，接着又发汗，这样导致表里两虚，病人因此出现昏冒。患“冒”证的病人，如果出汗，病就会自愈。之所以这样，是因为出汗后表气调和的缘故。如果里气不和，然后再用下法。
（按语：成无己将“郁”解释为“冒”，认为含义不够透彻。查《说文解字》，“冒”字从曰从目，“曰”即小儿及蛮夷的头衣。这里所说的“致冒”，意思是像物体遮蔽眼睛一样，这是昏迷的含义。现在如果把“冒”解释为“郁”，不仅失去了六书造字的本义，也违背了病情及张仲景的原意。“里未和”三字在文中可能作“得里和”或增加“未”字但不去掉“得”字，这在文理上都有谬误，现以宋本为准。）各种受寒气侵袭的病症，就会发生厥逆、气机郁结、神志昏冒、肢体麻木、口唇拘急不能言语、战栗等症状。
太阳病与少阳病同时发病（并病）：头项强痛，或者眩晕昏冒，有时感觉像结胸证那样心下痞硬，应当针刺大椎穴、肺俞穴、肝俞穴。（关于项强的详细论述见相关章节）
阳明病：病人小便不利，大便时而困难时而容易，有时有轻微发热，气喘且昏冒，不能卧躺，这是体内有燥屎的表现，适宜用大承气汤。
少阴病：只想睡觉，下利停止后出现头眩，时常感到昏冒的，是死证。
厥阴病：下利排出未消化的食物（清谷），脉象沉迟，病人面部发红，身体有轻微发热，必定会出现气机郁结、神志昏冒，随后出汗而病愈。（关于下利的详细论述见相关章节）
伤寒经过吐法或下法治疗后，出现虚烦，脉象微弱。过了八九天，心下痞硬，胁下疼痛，气向上冲至咽喉，感到眩晕昏冒，经脉跳动惕动不安，时间久了会发展成痿证。
海藏（张元素/李东垣学派观点）：伤寒传变到五六日间，逐渐变为神志昏迷、不语，或者睡梦中独自说一两句话，眼睛发红，嘴唇焦裂，舌干但不想喝水，给喝稀粥能咽下，不给就不想吃。六脉细数而不洪大，心下没有痞块，腹中不胀满，大小便正常。或者传变到十天左右，神情面貌如同醉酒。医生见到神志昏迷不止，多用大承气汤攻下，这就错了。这是因为不知道此热邪传入手少阴心经。然而又不知道它从何经传来。回答是：原本太阳经受伤风，风为阳邪，损伤卫气，阴血自然干燥，热邪结聚膀胱。壬水之病逆传于丙火（小肠），丙丁相为兄妹，由此传入心脏。心火从上向下逼迫熏蒸肺脏，所以导致神志昏迷。因为肺是清肃之脏，内有火邪，所以令神志昏迷。适宜用栀子、黄连、黄芩汤。如果脉象显示病在丙（小肠），用导赤散；病在丁（心），用泻心汤。如果误用凉膈散，那是气分中的血药。如右手寸脉沉滑有力者，则可以使用。或者用犀角地黄汤，这也接近正确。原方所说如果没有犀角，可以用升麻代替，这是阳明经的药，是解除阳明经血分热的药。如果脉象浮沉都有力，说明丙丁二经都有热，可以各半服用导赤散和泻心汤，这样就适宜了。此证由膀胱传丙，足经传手经，是下传上；丙传丁，是表传里；壬传丁，是艮卦传离卦。越经传变，又是腑传脏。《活人书》说伤寒只传足经不传手经，这种说法不完全准确。也有从足经传到手经的，怎么知道呢？《内经》说伤寒有的只传一经，有的间传三经，不可拘泥于一途。只要观察其脉象和外证进行治疗，这才是灵活的方法。与食物能咽下，说明邪气不在胃；不给就不想吃，是因为神志昏迷的缘故。邪热既然不在里，误用承气汤攻下，死亡是必然的。（注：脉在丙指脉浮；脉在丁指脉沉；脉在丙丁俱有热指浮沉俱有力。）
余云衢太史：形体气质充盛壮实，饮食无人能比。辛卯年夏六月，患热病，肢体不是很热，但间歇性地扬掷手足，像烦躁扰乱的样子，昏愦不知人事，偶尔说一两句无法听懂的话，但不是谵语。脉象微细几乎要断绝。有人说这是阴证，宜用温法；有人说当下。当时的座师陆葵说：“先生曾与曾植斋、冯琢庵两位太史看病，都取决于你。”我说这是阳病出现阴脉，按照法则是不治之症。但他平素体质如此，又正值酷暑，外受热邪灼烁，内有酒毒艾灸之火炎上，应该表现为狂热如焚、脉象洪数有力，为什么反而这样呢？难道是热气怫郁不得伸展而造成的吗？而且已经七天不大便了。暂且用大柴胡汤攻下，其中大黄只用二钱，又熟煎。太医王雷庵极力争辩，认为不如用大承气汤。我说：“这样的脉证哪里适合峻下？等大柴胡汤无效后，再用调胃承气汤；调胃承气汤无效后，再用小承气汤，最后才用大承气汤，也不算晚。”服药后大便即行，脉象复出，手足温暖。我对雷庵说：“假如用了大承气汤，能不后悔莫及吗？”接着服用几剂黄连解毒汤而病愈。七月初，我与陆先生一同主持南京的考试，病未再复发。第二年我告老还乡，偶然读到刘河间的《伤寒直格》，其中有云：“蓄热内甚，脉须疾数，因其极热蓄积甚多，脉道不利，反而导致脉沉细而欲绝。”世俗之人不明白造化之理，反而认为是传变为寒极阴毒。有的是起初阳热暴甚就出现此证候；有的是两感热甚，通宜解毒加大承气汤攻下。下后热稍退但未愈者，用黄连解毒汤调理；或微热未除者，用凉膈散调理；或失于攻下，热极以至身冷脉微而昏冒将死，若急下之，则残存的阴液会暴绝而死，这是因为阳气后竭造成的。不下也会死，宜用凉膈散或黄连解毒汤养阴退阳，使积热渐渐宣散，则心胸再次温暖，脉象渐渐恢复。于是抚卷感叹说：“古人早已说出了我的心声！”余太史所患的正是失于攻下，热极以至身冷脉微而昏冒欲绝的证候。下与不下，大下与微下，生死就在呼吸之间，不容发丝之差。唉，怎么能不谨慎呢！因此记录下来，作为世人的借鉴。
(Confusion: In older texts, the symptom of "crossing hands over the heart" was incorrectly included here; it has now been removed.)
Cheng Wuji's Commentary: "Yu" (郁) refers to qi stagnation and inability to flow freely; "Mao" (冒) refers to mental cloudiness and lack of clarity, commonly known as coma. These conditions are caused by deficiency allowing cold pathogenic factors to invade. The *Neijing* states: "Various deficiencies encountering cold result in Jue (cold extremities/reversal)." Qi stagnation, mental cloudiness, and numbness are all due to cold qi invading the upper body while the interior is deficient. Luo Longji advocated using Fuzi Tang (Aconite Decoction), doubling the dosage of Renshen (Ginseng), and adding Chuanxiong (Sichuan Lovage Rhizome), Tianma (Gastrodia Rhizome), and Ganjiang (Dried Ginger). Furthermore, it is stated: In Taiyang disease, if purgation is used first without resolution, followed by sweating, this results in both exterior and interior deficiency. Consequently, the patient experiences Mao (dizziness/cloudiness). Patients with Mao will recover spontaneously upon sweating, because the exterior harmonizes. If sweating does not occur, the condition persists; Ren Shen San Bai Tang (Ginseng Three Whites Decoction) added with Chuanxiong and Tianma may be used. For those with lower jiao deficiency and a faint pulse, Fuzi (Aconite Root) should be added to warm the Kidney channel, which consolidates the root. The *Neijing* says: "To nourish the shoots, one must solidify the root; to chop the roots, the branches will wither." This is what is meant. The *Jin Gui Yao Lue* states: New postpartum women suffer from three diseases: one is Jing (spasm), two is Yu Mao (depression and cloudiness), and three is difficult defecation. After blood loss and sweating, with excessive cold exposure, Yu Mao occurs. It also states: Postpartum women with Yu Mao have a faint pulse, cannot eat, and have hard stools; this is due to blood deficiency leading to Jue, and Jue inevitably leads to Mao. Recovery from Mao requires profuse sweating. From this, we know that Yu Mao belongs to deficiency-cold patterns. Additionally, in Shaoyin disease, if diarrhea stops but dizziness occurs, accompanied by frequent episodes of cloudiness, it is a death sign, indicating extreme deficiency and collapse.
Taiyang Disease: Purgation was used first without resolution, followed by sweating, resulting in exterior and interior deficiency, causing the patient to experience Mao. Patients with Mao recover when they sweat, because sweating harmonizes the exterior. If the interior is not harmonized, purgation may be applied subsequently.
(Note: Cheng Wuji interpreted 'Yu' as 'Mao', which is considered insufficiently precise. According to *Shuowen Jiezi*, 'Mao' consists of 'Yue' (head covering) and 'Mu' (eye). Here, 'Zhi Mao' implies something obscuring the eyes, meaning coma. Interpreting 'Mao' merely as 'Yu' loses the etymological origin, the clinical reality, and Zhang Zhongjing's intent. The phrase 'Li Wei He' (interior not harmonized) might be textual corruption for 'De Li He' or similar; corrected here according to Song editions.) Various conditions involving cold invasion result in Jue, Qi Stagnation, Mao, numbness, oral rigidity, inability to speak, and shivering.
Taiyang and Shaoyang Bingbing (Combined Disease): Stiffness and pain in the head and neck, or dizziness and cloudiness, sometimes feeling like Jie Xiong (chest binding) with hardness below the heart. Acupuncture at Dazhui (GV14), Feishu (BL13), and Ganshu (BL18) is indicated. (See section on Neck Stiffness for details.)
Yangming Disease: Difficulty in urination, alternating difficulty and ease in defecation, occasional slight fever, panting, Mao (cloudiness/dizziness), and inability to lie down indicate dry stool accumulation. Da Chengqi Tang (Major Order the Qi Decoction) is appropriate.
Shaoyin Disease: Desire to sleep, cessation of diarrhea followed by dizziness and frequent episodes of cloudiness indicates a fatal prognosis.
Jueyin Disease: Diarrhea with undigested food, deep and slow pulse, red face, slight body heat, followed by Qi stagnation, cloudiness, and sweating indicates recovery. (See section on Diarrhea for details.)
After vomiting or purgation in Shanghan, restlessness with a faint pulse occurs. After eight or nine days, epigastric hardness, hypochondriac pain, qi rushing to the throat, dizziness, cloudiness, and twitching of meridians may lead to Wei syndrome (flaccidity) if prolonged.
Haizang (School of Zhang Yuansu/Li Dongyuan): When Shanghan transmits to the 5th or 6th day, it gradually changes into unconsciousness and aphasia, or muttering in sleep, red eyes, cracked lips, dry tongue without desire to drink. Porridge is swallowed if offered, but refused otherwise. The six pulses are fine and rapid, not surging. There is no epigastric fullness or abdominal distension, and urination/defecation are normal. By the 10th day, the appearance resembles drunkenness. Physicians often use Da Chengqi Tang for persistent unconsciousness, which is an error. This is because the heat has transmitted to the Hand-Shaoyin Heart Channel. However, its origin is unknown. Answer: Originally, Taiyang channel suffered wind attack. Wind is a yang pathogen damaging Wei qi, causing yin blood to dry. Heat accumulates in the Bladder. Ren water pathology reverses to transmit to Bing fire (Small Intestine). Bing and Ding are siblings, transmitting to the Heart. Heart fire presses down and steams the Lung, causing unconsciousness. Since the Lung is a clear and descending organ, internal fire causes cloudiness. Zhi Zi Huang Lian Huang Qin Tang (Gardenia, Coptis, and Scutellaria Decoction) is suitable. If the pulse indicates Bing (Small Intestine), Dao Chi San (Guide Out Red Powder) is used; if Ding (Heart), Xie Xin Tang (Drain the Epigastrium Decoction) is used. Misusing Liang Ge San (Cool the Terrace Powder), which acts on qi-level blood, is incorrect unless the right cun pulse is deep, slippery, and forceful. Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) is also close to correct. If Xi Jiao is unavailable, Sheng Ma (Cimicifuga Rhizome) can substitute, which is a Yangming channel herb clearing blood-heat. If floating and deep pulses are both forceful, indicating heat in both Bing and Ding, half doses of Dao Chi San and Xie Xin Tang together are appropriate. This transmission from Bladder to Bing involves Foot channels transmitting to Hand channels (lower to upper); Bing to Ding is exterior to interior; Ren to Ding is Gen trigram to Li trigram. Yue Jing Chuan (skipping channels) involves Fu organs transmitting to Zang organs. *Huo Ren Shu* claims Shanghan only transmits through Foot channels, not Hand channels, which is incomplete. Transmission from Foot to Hand channels does occur. As stated in the classics, Shanghan may transmit to one channel or skip to three; treatment must not be rigid but based on pulse and symptoms. Swallowing food indicates the pathogen is not in the Stomach; refusal indicates unconsciousness. If heat is not in the interior, using Chengqi decoctions for purgation leads to death. (Note: Pulse in Bing means floating; Pulse in Ding means deep; Pulse in both Bing and Ding with heat means both floating and deep pulses are forceful.)
Yu Yunqu, Grand Secretary: Possessed robust constitution and hearty appetite. In the summer of June in the Xinmao year, he contracted febrile disease. His limbs were not very hot, but he intermittently threw his limbs about as if restless. He was confused, unaware of his surroundings, occasionally uttering unintelligible words, but not delirious. His pulse was faint and thin, nearly imperceptible. Some suggested Yin pattern requiring warming; others suggested purgation. Lu Kui, his examiner, said: "You decided cases for Zeng Zhizhai and Feng Zhuo'an." I replied: "This is a Yang disease presenting with Yin pulse, which is untreatable by standard rules. However, given his constitution and the extreme summer heat externalizing, plus internal inflammation from wine and moxa, the pulse should be surging and rapid. Why is it so? Perhaps heat is constrained and unable to extend? Also, he has not had a bowel movement for seven days." I tentatively prescribed Da Chaihu Tang (Minor Bupleurum Decoction) for purgation, using only 2 qian of Dahuang (Rhubarb), well-decocted. Imperial Physician Wang Leian strongly argued against this, suggesting Da Chengqi Tang instead. I said: "With such pulse and signs, harsh purgation is inappropriate. Wait until Da Chaihu Tang fails, then try Tiao Wei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction); if that fails, Xiao Chengqi Tang (Minor Order the Qi Decoction); finally Da Chengqi Tang would not be too late." After medication, bowel movement occurred, pulse returned, and limbs warmed. I told Leian: "Had we used Da Chengqi Tang, would you not regret it?" Subsequently, several doses of Huang Lian Jie Du Tang (Coptis Decoction for Resolving Toxicity) cured him. In early July, I took the examination in Nanjing with Mr. Lu, and the illness did not recur. The following year, upon returning home, I read Liu Hejian's *Shanghan Zhi Ge*. It states: "Internal accumulation of severe heat requires rapid pulses; due to extreme heat obstructing the vessels, the pulse may become deep, fine, and nearly absent." Laypeople misunderstand this, thinking it is cold-toxic transmission. Some present with sudden severe heat initially; some with double-infection severe heat should use detoxification plus Da Chengqi Tang. If heat subsides slightly after purgation but remains, use Huang Lian Jie Du Tang. If slight heat remains, use Liang Ge San. If purgation was missed, leading to extreme heat, cold body, faint pulse, and impending coma/death, immediate purgation would cause sudden collapse of residual yin due to exhaustion of yang. Not purging also leads to death. Use Liang Ge San or Huang Lian Jie Du Tang to nourish yin, retreat yang, and gradually dissipate accumulated heat, warming the chest and restoring the pulse. I sighed: "The ancients anticipated my thoughts!" Yu Taishi suffered exactly from missed purgation leading to extreme heat, cold body, faint pulse, and coma. Life and death hung in the balance between purging and not purging, severely or mildly. Alas, how careful one must be! I record this as a warning for the world.