【荣斋按】急性热病热高邪壅，而刺激大脑，于是神经蒙昧，常有一时而知觉运动停止，这就是本
节所述的伤寒转闭。它的现证∶由于知觉神经蒙闭，则神识昏沉，如痴如醉；运动神经障碍，则不能
转侧，而目张口噤；呼吸窒塞，则痰气壅盛，喉中如水声。亦有心脏弛张一时停息而无脉者；膀胱括约
筋一时麻痹而遗尿者；而牙关紧急，两手握固。语言蹇塞，尤为主要的见证。俞氏归其原因于“热邪
传心”，“痰火所蒙”，“湿热所蔽”，而有“热闭”“痰闭”“湿蒙”等名目；其实乃是心、肺、脑
的生活机能遭遇了障碍，而一时知觉运动蒙闭罢了。叶天士所谓∶“邪热一陷，里络即闭”，王清臣所
说∶“脑髓中一时无气，不但无灵机，必死一时。”都帮助了“闭症”的意义。治闭须开∶苏合香、犀
角、蟾酥、西黄等药，有兴奋大脑，宣通闭窒的疗效，而麝香尤为开窍透络，壮脑强心之主药；若苏合
香丸、至宝丹，则更为闭症的良方。
喻嘉言云。人生之阴阳。本相抱而不脱。故阳欲上脱。阴必下吸之而不脱。阴欲下脱。阳必上吸之
而不脱。人病则阴阳偏胜。偏胜至极则脱矣。然脱有上下之分。上脱者。身轻快而汗淋漓。妄见妄闻。
如有神灵所附。下脱者。身重着而肉色青紫。不闻不见。如聋聩之形。且阳者亲上。所以汗多亡阳也。
阴者亲下。所以下多亡阴也。故回阳之中。必佐阴药（如真武汤、重用白芍、其义显然。）摄阴之内。
必顾阳气。（生脉散之义可见。）务使阳潜阴固。不致有偏胜之虞。至于内闭外脱之症。乃由藏府之窒塞。
而不尽关乎元气之虚脱。爰将致脱之原因证治。分列四例
于下。
（甲）汗下清消后大虚将脱例
【因】一因过汗误汗。以致自汗不止。几有亡阳气脱之虞。二因消伐攻下太过。下泻不止。以致
阴脱。三因多服寒冷药。致伤肠胃。命火式微。食减下利。脾阳下脱之症生矣。
【证】一因误汗气脱者。自汗不止。四肢厥冷。面色苍白。气少息促。二便通利。神识困倦而昏。
似寐非寐。呼之不应。二因妄下阴脱者。心中懊 。起卧不安。下泻不止。神志昏沉。肢冷息微。语
不接续。如痴如迷。舌色淡晦少神。三因凉药太过。脾阳下脱者。不喜食物。下利清谷。及下脓血。
或漏底不止。肢体厥冷。面色淡白。舌色淡红无神。动则出汗。独语如见鬼。声颤无力。喜向里卧。
似寐非寐。呼之不应。以上三症。皆属大虚将脱之候。
【脉】一气脱者。脉必沉细而软弱。二阴脱。及三脾阳脱者。脉必沉伏。或微弱无力。若脉阴阳俱盛。
重按无根。大汗出。是正气已脱。顷刻即死也。脉至乍疏乍数者。为脾败。阴阳散乱者亦死。凡大虚
欲脱之症。脉浮而洪。身汗如油。喘而不休。水浆不下。形体不仁。乍静乍乱。五脏之气皆脱。命根
已绝也。然未知何脏先绝。若汗出发润。喘而不休者。此为肺先绝也。阳反独留。形体如烟薰。直视摇
头者。此为心绝也。唇吻反青。四肢 极者。此为肝绝也。环口黧黑。柔汗发黄者。此为脾绝也。溲便
遗失狂言。目反直视者。此为肾绝也。
【治】一误汗气脱。凡过汗误汗。自汗不止者。宜卢氏桂枝参 煎。（桂枝、太子参、生 、白芍、
白术各二钱、新会皮八分、炙甘草五分、浮小麦五钱、麻黄根三钱醋炒。）若仍不止。几有亡阳者。
宜固汗屏风散。（生黄 、生
白术、防风、 牡蛎各三钱、浮小麦五钱、麻黄根四钱醋炒、五味子一钱。）阳虚自汗脉沉细者。宜回
阳正气饮。（人参、附子各一钱、生 三钱、生白术、当归、枣仁各二钱、炙甘草五分、麻黄根二钱醋炒）
二妄下阴脱。凡伤寒温热。攻下太过。脾胃受伤。心中懊 。起卧不安。下泻不止者。宜举陷参 煎。
（文元参、黄 各二钱、炒白术、茯苓、陈皮、柴胡、升麻各一钱、炙甘草五分、泽泻二钱、姜枣、灶
心土引）三寒凉过剂。伤脾损胃。下利清谷。及下脓血。漏底不止者。宜固下人参煎。（党参、炒白术、附子、
化龙骨、肉果霜各钱半、诃子炮姜、木香各一钱、陈粳米、大枣引。）
【荣斋按】伤寒过汗以致阳虚欲脱，镇江袁桂生有一个实验治例，足供参考。病者骆达三，素禀阳虚，新感
外寒，头痛恶寒，饮食无味，脉息小滑，舌苔滑白；初诊与葱豉二陈汤加荆芥苏叶疏散之剂，服后忽喘息不能
卧，头脑中觉热气上升，小腹左偏作痛，呕吐痰水，手指厥冷。脉息沉弱。乃与理中汤合六君子汤加味（别直
参一钱、炒白术二钱、炮姜一钱、炙甘草八分、茯苓三钱、姜半夏二钱、广橘皮一钱、上 桂八分、白芍三钱、
五味子六分。）服后喘呕俱平，腹痛亦止。但仍觉畏寒手冷，进理中汤加姜夏，两剂。后以六君子汤，资生丸
等药调养半月而痊（摘录《全国名医验案》）。廉臣先生对这类证候，有一个预防为主的医疗经验。他说∶“伤寒
当行发表者，必察其人本气阴阳无亏，方可径用。若真阳素亏，平日恶寒喜热，惯服辛温，大便溏滑者；此谓
阴脏。宜加附子、炮姜、黄 、白术于发表药中，助阳御表，庶免虚阳外越之弊。”这种防患未然的诊疗方法
和上面所述的一个治例，对我们有很大的启示。但古医学文献中，同样例子也有，摘录二则，以资参证。“滑
伯仁治一人，七月间，病发热，多服小柴胡汤，恶寒甚，肉 筋惕。滑诊之，脉细欲绝。曰∶‘此升发太过，
多汗亡阳，表虚极而恶寒甚也；肉 筋惕者，里虚极而阳不复也。’以真武汤进七八服，而愈。”“吴绶治
一人，伤寒十余日，曾三四次发汗过多，遂变肉 、身振摇、筋脉动惕；此汗多气血俱虚故也。与加味人参养
荣汤，二剂而愈。”此两条，一因多服小柴胡汤而遭致了肾阳外越，一因过汗而遭致了气血俱虚。在紧急措施
的救治下，总算都转危为安。然而许学士对于那些发汗有问题的病患，却有一个预见性的治例∶“乡人邱生，
病伤寒，发热、头痛、烦渴，脉虽浮数而无力，尺以下迟而弱。许曰∶‘虽麻黄证，而尺迟弱，仲景曰∶尺中
迟者，营气不足，未可发汗。’用建中汤加当归、黄 。至五日，尺部方应。遂投麻黄汤二服，发狂须臾，稍
定略睡，已得汗矣。”这是诊疗学上的宝贵经验，如果疏忽了脉诊，盲目发汗，当然也要酿成必然的病变。我
认为要深刻了解汗下清消的应用规律，则程钟龄的医门八法，应当熟读精思。
（乙）邪陷正虚内闭外脱例
【因】伤寒温热。已经汗下清透后。内伤气血精神。其人由倦而渐昏。由昏而渐沉。乃大虚将脱。邪热乘
虚内陷之兆。
【证】舌红燥起刺。欲伸无力。神昏谵语。或不语如尸。气短息促。手足厥冷。烦躁不得卧。冷汗自出。
扬手掷足。大便闭。在男子则囊缩。在妇人则乳缩。叶天士云。平时心虚有痰。外热一陷。里络就闭。人即昏厥发痉。
若不急开其闭。或开闭不得法。必致心气与肺气不相顺接。而其人肤冷汗出。躁扰不卧。脉细而急疾。便为气
脱之症矣。
【脉】内闭外脱之症。脉细而急疾。或沉细而数。
【治】急救之法。先宜开其内闭。固其外脱。如叶氏加减复脉汤去米仁、枇杷叶、加 皮五味子方。（炙甘
草、燕窝各一钱。真阿胶钱半、鲜生地四钱、麦冬三钱、吉林参五分、北沙参三钱、绵 皮钱半、五味子五分、
南枣二枚。）调入王氏牛黄清心丸。或神犀丹亦可酌用。
【荣斋按】俞氏引叶天士学说“平时心虚有痰，外热一陷，里络就闭。”这个阶段的症候，据虞阳徐
晓岑经验，谓应当“急清络热以开其闭。”药用∶“犀角、羚角、石决明、真玳瑁、制胆星、鲜生地、元参、
连翘、丹皮、生远志、川贝母、焦山栀，清心牛黄丸一粒。”到了“肤冷汗出，躁扰不卧，脉细而急疾，
便为气脱之症矣。”的一个阶段，徐晓岑认为是∶“亡阳脱证”，药用“真台参、北五味、麦冬、白术、
黄、熟地、制附子、肉桂、炙甘草、化龙骨、牡蛎。”（见陈根儒《温热论笺正》）附录于此，以
应“邪陷正虚内闭外脱”临床时的危急之变。
（丙）热深阳郁外闭内脱例
【因】凡伤寒温热病。多由兼风兼寒之候。不先祛风散寒以解表。早用苦寒直降。致表不解。而邪反
陷入内。外闭者。邪束阳郁之谓也。内脱者。阳盛阴涸之谓也。
【证】目 赤。或眼白现红丝。鼻干。唇红燥。耳聋心烦。渴喜凉饮。舌苔黄黑而燥。小便黄赤涩痛。
大便黄黑稠粘。或溏泻而极臭。或下鲜血。下时肛门热痛。胸至少腹热甚。按之灼手。一身肌表反不发热。
虽热亦微。恶寒无汗。反欲拥被向火。甚则四肢厥冷。指甲青紫。
【脉】浮虚兼数。重按濡数无力。
【治】先以轻扬发表解其外。而外不闭。如邵氏热郁汤。（苏薄荷一钱、青连翘、栝蒌皮、青子芩、
青蒿脑各钱半、焦山栀、广郁金各三钱、桔梗一钱、生甘草六分、鲜竹叶三十片。）五叶芦根汤。（藿香叶、
薄荷叶、佩兰叶、荷叶各钱半、先用枇杷叶一两、活水芦根一两二钱、鲜冬瓜二两、煎汤代水。）之类。
以撤热存阴者救其内。而内不
脱。如缪氏竹叶石膏汤。（生石膏五钱、苏薄荷、荆芥、蝉衣、炒牛蒡子、生葛根、知母、麦冬各
钱半。生甘草一钱、元参二钱、鲜西河柳五钱、竹叶三十片、冬米一撮。凡温毒痧疹、热壅于肺、
逆传心包、喘咳烦闷、躁乱狂越者、非此方不治。）加减竹叶石膏汤。（西洋参一钱、生石膏五钱、
生甘草八分、麦冬钱半、仙半夏一钱、青蔗浆三钱、生姜汁两滴、淡竹叶三十片、鲜茅根一两、鲜
稻穗三支。）皆可酌用以奏功。一方并治。表里双解。如《外台》三黄石膏汤。（麻黄六分、淡
豆豉三钱、小川连、生山栀、生川柏各一钱、青子芩二钱、生石膏五钱。）若表里三焦大热。五
心烦灼。两目如火。鼻干面赤。舌黄唇焦。形如涂朱。燥渴引饮。神昏谵语。宜杨氏增损三黄石膏汤。
（炒僵蚕三钱、蝉衣十只、苏薄荷二钱、知母二钱、生石膏五钱、小川连、生山栀、生川柏各一钱、
青子芩二钱）如热郁腠理。能内外分消。若胸腹胀满。痛而拒按。大便不通者。宜斟酌下之。
【荣斋按】本节（乙）（丙）两项之所谓“内闭外脱”，“外闭内脱”者，是表示着邪正交争
的极限。由于知觉运动神经既为邪热蒙闭而失其生活机能，机体抗病的力量，渐渐衰减；产生了“邪
与正势不两立”的尖锐斗争状态，结果与之外遁而俱脱──内闭外脱。另一方面∶邪热壅闭于表，
正气衰竭于里，如外不得汗解，则病毒内窜而转入阳盛阴涸之境。所谓“邪不达而正已夺”，结果逼
之内陷而偕脱──外闭内脱。总的来说，闭虽为邪盛，而骤转为脱的趋势，是应该密切注意的。
（丁）真阴下竭虚阳上脱例
【因】凡阴虚人。病伤寒温热。误用刚燥汗下药过量。缠绵日久。以致真阴虚极于下。致无根之
火。仓猝飞腾。气壅痰升。上蒙清窍。忽然痉厥。此属元阴告匮。真气不续。若厥而不回。其命遂倾。
【证】舌红短。面青。目合口开手不握固。音嘶气促。甚则冷汗淋漓。手足逆冷。二便自遗。
气息俱微。是为龙雷暴动之脱症。若兼有虚寒者。面色唇色多淡白无华。甚且青黯。必不红
润。亦有四肢清冷。而两颧独红。是为虚火上炎之戴阳症。非温补不可。
【脉】真元式微。龙雷暴动欲脱之际。脉必沉伏不见。或微弱无神。或不应指。
【治】急宜固扶元气。敛阴益液。摄纳真阴。镇潜虚阳。宜龙牡复脉汤。（吉林参一钱、陈阿胶钱半、
鸡子黄一枚包煎、生龟版、生牡蛎各八钱、化龙骨二钱、生鳖甲四钱、真玳瑁钱半、生白芍三钱、麦
冬三钱、大生地四钱、炙甘草钱半、大坎气一条酒洗、水两碗、煎至半碗服）若肢冷脉伏。自汗头汗。
汗出如油者。则阴亡而阳亦随亡。吉林参易别直参二钱。加淡附片钱半。若痰塞喉间。欲吐无力。药不能
下者。先用真猴枣末四分。煎鲜石菖蒲汤。先服。暂平其上逆之痰。继续服药。再用《局方》黑锡丹三钱、
煎服。以镇纳浮阳。温养下元。苟能痰涎一开。神醒气续。则育阴潜阳。固元摄纳之药。急急续进。
不可间断。必能元气渐回。形神渐振。神志清明。惟倦怠嗜卧。尤须照前方大剂投之。以固根基。而扶正
气。若确是热痰上涌之闭症。此方切不可用。反能阻凝痰涎于喉间。更速其死矣。
【秀按】内经云。阴平阳秘。精神乃治。阴阳离决。精气乃绝。夫至精气绝则真元脱矣。然脱之先。
必有形状也。《经》又云。精脱者耳聋。宜龟鹿二仙胶。气脱者目不明。宜生脉散、合保元汤。津脱者。腠理开。
汗大泄。宜人参固本汤、合生脉散。液脱者。骨属屈伸不利。色夭。脑髓消。胫 。耳数鸣。宜保阴煎。
斑龙丸之类。血脱者色白。夭然不泽。其脉空虚。宜归脾汤。人参养荣汤之类。《难经》又言、脱阳者见
【徐荣斋按语】急性热病中，若热势高涨、邪气壅盛并刺激大脑，导致神经功能蒙蔽，常出现一时性的知觉与运动停止，这就是本节所述的“伤寒转闭”。其临床表现：由于知觉神经被蒙蔽，则神志昏沉，如痴如醉；运动神经发生障碍，则身体不能转动侧身，且目睛直视、口噤不开；呼吸窒塞，则痰气壅盛，喉间发出如水鸡声。也有因心脏舒缩功能一时停息而无脉搏者；膀胱括约肌一时麻痹而遗尿者；以及牙关紧急、两手握固。语言蹇涩，更是主要的见证。俞氏将原因归结为“热邪传心”、“痰火所蒙”、“湿热所蔽”，因而有“热闭”、“痰闭”、“湿蒙”等名称；其实质乃是心、肺、脑的生命机能遭遇障碍，导致一时性的知觉与运动功能被蒙蔽罢了。叶天士所谓：“邪热一陷，里络即闭”，王清任所说：“脑髓中一时无气，不但无灵机，必死一时。”都佐证了“闭症”的含义。治疗闭症必须开窍：苏合香、犀角、蟾酥、西黄（麝香）等药物，具有兴奋大脑、宣通闭塞窒滞的疗效，而麝香尤为开窍透络、壮脑强心的主药；至于苏合香丸、至宝丹，则是治疗闭症的良方。
喻嘉言说：人生的阴阳，本应相互抱持而不分离。所以阳气欲上脱时，阴气必下吸以挽留之而不致脱离；阴气欲下脱时，阳气必上吸以挽留之而不致脱离。人患病后阴阳偏胜，偏胜至极则发生脱证。然而脱证有上下之分：上脱者，身体轻快而汗出淋漓，妄见妄闻，如有神灵附体；下脱者，身体沉重而肌肉颜色青紫，不闻不见，如聋哑痴呆之状。而且阳性亲上，所以汗多则亡阳；阴性亲下，所以下利多则亡阴。因此在回阳救逆之中，必须佐以阴药（如真武汤重用白芍，其义理显然）；在摄纳阴液之内，必须顾护阳气（生脉散之义可见）。务必使阳气潜藏、阴液坚固，不致使阴阳偏胜。至于内闭外脱之症，乃是由脏腑窒塞所致，并不完全关乎元气的虚脱。现将导致脱证的原因及证治，分列四例如下。
（甲）汗、下、清、消法后大虚将脱例
【病因】一因过汗或误汗，以致自汗不止，几乎有亡阳气脱的危险。二因攻下太过，下泻不止，以致阴液脱失。三因多服寒凉药物，损伤肠胃，命门之火微弱，食欲减退、下利，脾阳下脱之症由此产生。
【症状】一因误汗导致气脱者：自汗不止，四肢厥冷，面色苍白，气短息促，大小便通利，神志困倦而昏沉，似睡非睡，呼之不应。二因妄用攻下导致阴脱者：心中烦闷懊恼，起卧不安，下泻不止，神志昏沉，肢冷息微，言语断续，如痴如迷，舌色淡晦少神。三因寒凉药过量导致脾阳下脱者：不喜欢食物，下利清谷，甚至下脓血，或漏底不止，肢体厥冷，面色淡白，舌色淡红无神，动则出汗，独语如见鬼魅，声音颤抖无力，喜欢向里卧倒，似睡非睡，呼之不应。以上三种症状，皆属于大虚将脱的候象。
【脉象】一气脱者，脉必沉细而软弱。二阴脱及三脾阳脱者，脉必沉伏，或微弱无力。若脉象阴阳俱盛，重按无根，大汗出，这是正气已脱，顷刻即死。脉来乍疏乍数，为脾败；阴阳散乱者亦死。凡是大虚欲脱之症，脉浮而洪，身汗如油，喘促不停，水浆不进，形体麻木不仁，乍静乍乱，这是五脏之气皆脱，命根已绝。但不知何脏先绝：若汗出发润，喘促不停，此为肺先绝；阳气反独留，形体如烟熏，直视摇头，此为心绝；唇吻反青，四肢抽搐拘急者，此为肝绝；环口黧黑，柔汗发黄者，此为脾绝；小便大便失禁，狂言，目睛直视者，此为肾绝。
【治法】一误汗气脱：凡过汗误汗，自汗不止者，宜用卢氏桂枝参煎。（桂枝、太子参、生黄芪、白芍、白术各二钱，新会皮八分，炙甘草五分，浮小麦五钱，麻黄根三钱醋炒。）若仍不止，几有亡阳者，宜用固汗屏风散。（生黄芪、生白术、防风、煅牡蛎各三钱，浮小麦五钱，麻黄根四钱醋炒，五味子一钱。）阳虚自汗脉沉细者，宜用回阳正气饮。（人参、附子各一钱，生黄芪三钱，生白术、当归、枣仁各二钱，炙甘草五分，麻黄根二钱醋炒。）二妄下阴脱：凡伤寒温热病，攻下太过，脾胃受伤，心中懊恼，起卧不安，下泻不止者，宜用举陷参煎。（文元参、黄芪各二钱，炒白术、茯苓、陈皮、柴胡、升麻各一钱，炙甘草五分，泽泻二钱，姜枣、灶心土为引。）三寒凉过剂，伤脾损胃，下利清谷，及下脓血，漏底不止者，宜用固下人参煎。（党参、炒白术、附子、煅龙骨、肉果霜各钱半，诃子、炮姜、木香各一钱，陈粳米、大枣为引。）
【徐荣斋按语】伤寒过汗导致阳虚欲脱，镇江袁桂生有一个实验治例，足供参考。患者骆达三，素禀阳虚，新感外寒，头痛恶寒，饮食无味，脉息小滑，舌苔滑白；初诊给予葱豉二陈汤加荆芥、苏叶等疏散之剂，服后忽喘息不能卧，头脑中觉热气上升，小腹左偏作痛，呕吐痰水，手指厥冷。脉息沉弱。于是给予理中汤合六君子汤加味（别直参一钱，炒白术二钱，炮姜一钱，炙甘草八分，茯苓三钱，姜半夏二钱，广橘皮一钱，上肉桂八分，白芍三钱，五味子六分。）服后喘呕俱平，腹痛亦止。但仍觉畏寒手冷，进服理中汤加姜夏，两剂。后以六君子汤、资生丸等药调养半月而痊愈（摘录《全国名医验案》）。廉臣先生对这类证候，有一个预防为主的医疗经验。他说：“伤寒当行发表者，必察其人本气阴阳无亏，方可径用。若真阳素亏，平日恶寒喜热，惯服辛温，大便溏滑者；此谓阴脏。宜加附子、炮姜、黄芪、白术于发表药中，助阳御表，庶免虚阳外越之弊。”这种防患未然的诊疗方法和上面所述的一个治例，对我们有很大的启示。但古医学文献中，同样例子也有，摘录二则，以资参证。“滑伯仁治一人，七月间，病发热，多服小柴胡汤，恶寒甚，肉瞤筋惕。滑诊之，脉细欲绝。曰：‘此升发太过，多汗亡阳，表虚极而恶寒甚也；肉瞤筋惕者，里虚极而阳不复也。’以真武汤进七八服，而愈。”“吴绶治一人，伤寒十余日，曾三四次发汗过多，遂变肉瞤、身振摇、筋脉动惕；此汗多气血俱虚故也。与加味人参养荣汤，二剂而愈。”此两条，一因多服小柴胡汤而遭致了肾阳外越，一因过汗而遭致了气血俱虚。在紧急措施的救治下，总算都转危为安。然而许学士对于那些发汗有问题的病患，却有一个预见性的治例：“乡人邱生，病伤寒，发热、头痛、烦渴，脉虽浮数而无力，尺以下迟而弱。许曰：‘虽麻黄证，而尺迟弱，仲景曰：尺中迟者，营气不足，未可发汗。’用建中汤加当归、黄芪。至五日，尺部方应。遂投麻黄汤二服，发狂须臾，稍定略睡，已得汗矣。”这是诊疗学上的宝贵经验，如果疏忽了脉诊，盲目发汗，当然也要酿成必然的病变。我认为要深刻了解汗、下、清、消的应用规律，则程钟龄的《医门八法》，应当熟读精思。
（乙）邪陷正虚内闭外脱例
【病因】伤寒温热病，已经经过汗、下、清、透法治疗后，内伤气血精神。其人由疲倦而逐渐昏沉，由昏沉而逐渐昏迷，乃是大虚将脱、邪热乘虚内陷的征兆。
【症状】舌红燥起刺，想伸舌头却无力，神昏谵语，或不语如尸，气短息促，手足厥冷，烦躁不得卧，冷汗自出，扬手掷足，大便闭结。在男子则睾丸收缩，在妇人则乳房收缩。叶天士说：平时心虚有痰，外热一陷，里络就闭，人即昏厥发痉。若不急开其闭，或开闭不得法，必致心气与肺气不相顺接，而其人肤冷汗出，躁扰不卧，脉细而急疾，便为气脱之症矣。
【脉象】内闭外脱之症，脉细而急疾，或沉细而数。
【治法】急救之法，先宜开其内闭，固其外脱。如叶氏加减复脉汤去薏苡仁、枇杷叶，加陈皮、五味子方。（炙甘草、燕窝各一钱，真阿胶钱半，鲜生地四钱，麦冬三钱，吉林参五分，北沙参三钱，绵黄芪钱半，五味子五分，南枣二枚。）调入王氏牛黄清心丸，或神犀丹亦可酌用。
【徐荣斋按语】俞氏引叶天士学说“平时心虚有痰，外热一陷，里络就闭。”这个阶段的症候，据虞阳徐晓岑经验，谓应当“急清络热以开其闭。”药用：“犀角、羚角、石决明、真玳瑁、制胆星、鲜生地、元参、连翘、丹皮、生远志、川贝母、焦山栀，清心牛黄丸一粒。”到了“肤冷汗出，躁扰不卧，脉细而急疾，便为气脱之症矣。”的一个阶段，徐晓岑认为是：“亡阳脱证”，药用“真台参、北五味、麦冬、白术、黄芪、熟地、制附子、肉桂、炙甘草、煅龙骨、牡蛎。”（见陈根儒《温热论笺正》）附录于此，以应“邪陷正虚内闭外脱”临床时的危急之变。
（丙）热深阳郁外闭内脱例
【病因】凡伤寒温热病，多由兼风兼寒之候。不先祛风散寒以解表，早用苦寒直降，致表不解，而邪反陷入内。外闭者，指邪束阳郁；内脱者，指阳盛阴涸。
【症状】目赤，或眼白现红丝，鼻干，唇红燥，耳聋心烦，渴喜凉饮，舌苔黄黑而燥，小便黄赤涩痛，大便黄黑稠粘，或溏泻而极臭，或下鲜血，下时肛门热痛，胸至少腹热甚，按之灼手，一身肌表反不发热，虽热亦微，恶寒无汗，反欲拥被向火，甚则四肢厥冷，指甲青紫。
【脉象】浮虚兼数，重按濡数无力。
【治法】先以轻扬发表解其外，而外不闭。如邵氏热郁汤。（苏薄荷一钱，青连翘、栝蒌皮、青子芩、青蒿脑各钱半，焦山栀、广郁金各三钱，桔梗一钱，生甘草六分，鲜竹叶三十片。）五叶芦根汤。（藿香叶、薄荷叶、佩兰叶、荷叶各钱半，先用枇杷叶一两，活水芦根一两二钱，鲜冬瓜二两，煎汤代水。）之类。以撤热存阴者救其内，而内不脱。如缪氏竹叶石膏汤。（生石膏五钱，苏薄荷、荆芥、蝉衣、炒牛蒡子、生葛根、知母、麦冬各钱半，生甘草一钱，元参二钱，鲜西河柳五钱，竹叶三十片，冬米一撮。凡温毒痧疹、热壅于肺、逆传心包、喘咳烦闷、躁乱狂越者，非此方不治。）加减竹叶石膏汤。（西洋参一钱，生石膏五钱，生甘草八分，麦冬钱半，仙半夏一钱，青蔗浆三钱，生姜汁两滴，淡竹叶三十片，鲜茅根一两，鲜稻穗三支。）皆可酌用以奏功。一方并治，表里双解。如《外台》三黄石膏汤。（麻黄六分，淡豆豉三钱，小川连、生山栀、生川柏各一钱，青子芩二钱，生石膏五钱。）若表里三焦大热，五心烦灼，两目如火，鼻干面赤，舌黄唇焦，形如涂朱，燥渴引饮，神昏谵语，宜杨氏增损三黄石膏汤。（炒僵蚕三钱，蝉衣十只，苏薄荷二钱，知母二钱，生石膏五钱，小川连、生山栀、生川柏各一钱，青子芩二钱。）如热郁腠理，能内外分消，若胸腹胀满，痛而拒按，大便不通者，宜斟酌下之。
【徐荣斋按语】本节（乙）（丙）两项之所谓“内闭外脱”，“外闭内脱”者，是表示着邪正交争的极限。由于知觉运动神经既为邪热蒙闭而失其生活机能，机体抗病的力量，渐渐衰减；产生了“邪与正势不两立”的尖锐斗争状态，结果与之外遁而俱脱──内闭外脱。另一方面：邪热壅闭于表，正气衰竭于里，如外不得汗解，则病毒内窜而转入阳盛阴涸之境。所谓“邪不达而正已夺”，结果逼之内陷而偕脱──外闭内脱。总的来说，闭虽为邪盛，而骤转为脱的趋势，是应该密切注意的。
（丁）真阴下竭虚阳上脱例
【病因】凡阴虚之人，病伤寒温热，误用刚燥汗下药过量，缠绵日久，以致真阴虚极于下，致无根之火，仓猝飞腾，气壅痰升，上蒙清窍，忽然痉厥。此属元阴告匮，真气不续。若厥而不回，其命遂倾。
【症状】舌红短，面青，目合口开，手不握固，音嘶气促，甚则冷汗淋漓，手足逆冷，二便自遗，气息俱微，是为龙雷暴动之脱症。若兼有虚寒者，面色唇色多淡白无华，甚且青黯，必不红润。亦有四肢清冷，而两颧独红，是为虚火上炎之戴阳症，非温补不可。
【脉象】真元式微，龙雷暴动欲脱之际，脉必沉伏不见，或微弱无神，或不应指。
【治法】急宜固扶元气，敛阴益液，摄纳真阴，镇潜虚阳。宜龙牡复脉汤。（吉林参一钱，陈阿胶钱半，鸡子黄一枚包煎，生龟版、生牡蛎各八钱，煅龙骨二钱，生鳖甲四钱，真玳瑁钱半，生白芍三钱，麦冬三钱，大生地四钱，炙甘草钱半，大坎气一条酒洗，水两碗，煎至半碗服。）若肢冷脉伏，自汗头汗，汗出如油者，则阴亡而阳亦随亡。吉林参易别直参二钱，加淡附片钱半。若痰塞喉间，欲吐无力，药不能下者，先用真猴枣末四分，煎鲜石菖蒲汤，先服，暂平其上逆之痰。继续服药，再用《局方》黑锡丹三钱、煎服，以镇纳浮阳，温养下元。苟能痰涎一开，神醒气续，则育阴潜阳，固元摄纳之药，急急续进，不可间断。必能元气渐回，形神渐振，神志清明，惟倦怠嗜卧，尤须照前方大剂投之，以固根基，而扶正气。若确是热痰上涌之闭症，此方切不可用，反能阻凝痰涎于喉间，更速其死矣。
【秀按】《内经》云：阴平阳秘，精神乃治。阴阳离决，精气乃绝。夫至精气绝则真元脱矣。然脱之先，必有形状也。《经》又云：精脱者耳聋，宜龟鹿二仙胶。气脱者目不明，宜生脉散、合保元汤。津脱者，腠理开，汗大泄，宜人参固本汤、合生脉散。液脱者，骨属屈伸不利，色夭，脑髓消，胫痠，耳数鸣，宜保阴煎、斑龙丸之类。血脱者色白，夭然不泽，其脉空虚，宜归脾汤、人参养荣汤之类。《难经》又言：脱阳者见……
[Comment by Xu Rongzhai] In acute febrile diseases, when the heat is high and pathogenic factors are congested, stimulating the brain, neural functions become obscured. This often results in a temporary cessation of perception and movement, which is what this section refers to as "Shanghan Zhuan Bi" (Transformation of Cold Damage into Closure). Its clinical manifestations: due to the obscuration of sensory nerves, consciousness becomes lethargic, resembling intoxication or idiocy; due to motor nerve impairment, the body cannot turn or shift positions, eyes may be fixed open, and jaw clamped shut; due to respiratory obstruction, phlegm and qi are congested, producing sounds in the throat like water bubbling. There are also cases where cardiac systole and diastole temporarily cease, resulting in no pulse; or where the bladder sphincter muscle temporarily paralyzes, causing urinary incontinence; along with tightness of the jaw and clenched hands. Dysarthria is a particularly prominent sign. Yu attributed the cause to "heat pathogen transmitting to the Heart," "obscuration by phlegm-fire," and "covering by damp-heat," thus naming them "Heat Bi," "Phlegm Bi," and "Damp Obscuration." In reality, it is merely that the vital functions of the Heart, Lungs, and Brain have encountered obstacles, leading to a temporary obscuration of perception and movement. Ye Tianshi stated: "Once evil heat sinks inward, the interior collaterals immediately close." Wang Qingren said: "If there is no Qi in the brain marrow for a moment, not only will there be no spiritual activity, but death will occur instantly." Both statements support the meaning of "Bi Syndrome" (Closure Syndrome). Treatment of Bi requires opening: herbs such as Styrax Resin (Suhe Xiang), Rhinoceros Horn (Xijiao), Toad Venom (Chansu), and Musk (Xi Huang) have the efficacy of exciting the brain and unblocking closure and stagnation, among which Musk is the chief herb for opening orifices, penetrating collaterals, strengthening the brain, and fortifying the heart. Formulas such as Suhe Xiang Wan (Styrax Pill) and Zhibao Dan (Treasure Treasure Pill) are excellent prescriptions for treating Bi syndrome.
Yu Jiayan said: The Yin and Yang of human life naturally embrace each other without separation. Therefore, if Yang Qi desires to escape upward, Yin Qi must draw downward to retain it; if Yin Qi desires to escape downward, Yang Qi must draw upward to retain it. When people fall ill, Yin and Yang become biased toward excess. When this bias reaches its extreme, collapse occurs. However, collapse has upper and lower distinctions: Upper collapse presents with a light body and profuse sweating, hallucinations of seeing and hearing, as if possessed by spirits; Lower collapse presents with a heavy body and bluish-purple skin color, inability to hear or see, resembling deafness and dumbness. Furthermore, Yang nature tends upward, so excessive sweating leads to loss of Yang; Yin nature tends downward, so excessive diarrhea leads to loss of Yin. Therefore, in restoring Yang, one must assist with Yin herbs (such as using large doses of White Peony Root in Zhenwu Tang, the rationale being clear); within nourishing Yin, one must attend to Yang Qi (as seen in the rationale of Shengmai San). One must ensure that Yang is anchored and Yin is consolidated, avoiding any risk of imbalance. As for Internal Closure and External Collapse syndrome, it arises from the blockage of Zang-Fu organs and is not entirely related to the deficiency collapse of Yuan Qi. The causes and treatments leading to collapse are listed below in four examples.
(A) Example of Major Deficiency and Impending Collapse after Sweating, Purging, Cooling, and Eliminating Methods
[Etiology] 1. Excessive or mistaken sweating leading to continuous spontaneous sweating, risking the loss of Yang Qi and collapse. 2. Excessive purgation leading to continuous diarrhea, resulting in Yin collapse. 3. Overuse of cold medicines damaging the intestines and stomach, weakening the Mingmen Fire, reducing appetite, and causing diarrhea, giving rise to Spleen Yang sinking collapse.
[Symptoms] 1. Qi collapse due to mistaken sweating: Continuous spontaneous sweating, cold limbs, pale complexion, shortness of breath and rapid respiration, free urination and defecation, lethargic and confused consciousness, drowsy but not asleep, unresponsive to calling. 2. Yin collapse due to reckless purging: Restlessness and oppression in the chest, inability to lie still, continuous diarrhea, lethargic consciousness, cold limbs and faint breathing, interrupted speech, resembling idiocy or confusion, pale and dull tongue lacking spirit. 3. Spleen Yang sinking collapse due to excessive cooling medicine: Aversion to food, diarrhea with undigested food, or passage of pus and blood, or persistent watery diarrhea, cold limbs, pale complexion, pale red tongue lacking spirit, sweating upon movement, talking alone as if seeing ghosts, trembling voice and weakness, preference for lying facing inward, drowsy but not asleep, unresponsive to calling. All three conditions belong to the signs of major deficiency and impending collapse.
[Pulse] 1. In Qi collapse, the pulse must be deep, fine, weak, and soft. 2. In Yin collapse and Spleen Yang collapse, the pulse must be deep and hidden, or weak and forceless. If the pulse appears full and vigorous in both Yin and Yang positions but lacks root upon heavy pressing, accompanied by profuse sweating, this indicates that Zheng Qi (Upright Qi) has collapsed, and death will occur shortly. A pulse that alternates between slow and rapid indicates Spleen failure; scattered Yin and Yang also lead to death. In cases of major deficiency and impending collapse, if the pulse is floating and surging, sweat is like oil, panting does not cease, fluids cannot be taken in, the body feels numb, and there is alternating quietness and agitation, this indicates that the Qi of all five Zang organs has collapsed and the root of life is severed. However, knowing which Zang fails first: If hair is wet with sweat and panting does not cease, this is Lung failure first; if Yang remains alone while the body looks like smoke-stained, with fixed gaze and head shaking, this is Heart failure; if lips and corners of the mouth turn blue and limbs experience severe spasms, this is Liver failure; if the area around the mouth is dark black and sweat is yellowish, this is Spleen failure; if urine and stool are incontinent, with delirious speech and fixed gaze, this is Kidney failure.
[Treatment] 1. Qi collapse due to mistaken sweating: For those with continuous spontaneous sweating due to excessive or mistaken sweating, use Lu's Guizhi Shen Decoction (Cinnamon Twig, Pseudostellaria Root, Astragalus Root, White Peony Root, Atractylodes Macrocephala Rhizome each 2 qian, Tangerine Peel 0.8 qian, Honey-fried Licorice Root 0.5 qian, Fleeceflower Seed 5 qian, Ephedra Root 3 qian vinegar-fried). If it continues and approaches Yang collapse, use Guhan Pingfeng San (Sweat-Stopping Windscreen Powder) (Astragalus Root, Atractylodes Macrocephala Rhizome, Saposhnikovia Root, Calcined Oyster Shell each 3 qian, Fleeceflower Seed 5 qian, Ephedra Root 4 qian vinegar-fried, Schisandra Berry 1 qian). For Yang deficiency with spontaneous sweating and a deep, fine pulse, use Huiyang Zhengqi Yin (Restore Yang Upright Qi Decoction) (Ginseng, Aconite Root each 1 qian, Astragalus Root 3 qian, Atractylodes Macrocephala Rhizome, Angelica Sinensis, Ziziphus Seed each 2 qian, Honey-fried Licorice Root 0.5 qian, Ephedra Root 2 qian vinegar-fried). 2. Yin collapse due to reckless purging: For Shanghan or warm diseases where excessive purgation damages the Spleen and Stomach, causing restlessness in the chest, inability to lie still, and continuous diarrhea, use Juxian Shen Jian (Lift Sinking Ginseng Decoction) (Codonopsis Root, Astragalus Root each 2 qian, Stir-fried Atractylodes Macrocephala Rhizome, Poria, Tangerine Peel, Bupleurum Root, Cimicifuga Rhizome each 1 qian, Honey-fried Licorice Root 0.5 qian, Alisma Rhizome 2 qian, Ginger and Jujube as guides, Hearth Earth as guide). 3. Excessive cold and cool agents damaging Spleen and Stomach, causing diarrhea with undigested food, pus and blood, or persistent watery diarrhea, use Guxia Renshen Jian (Secure Lowering Ginseng Decoction) (Codonopsis Root, Stir-fried Atractylodes Macrocephala Rhizome, Aconite Root, Calcined Dragon Bone, Myristica Seed Frost each 1.5 qian, Chebula Fruit, Fried Ginger, Costus Root each 1 qian, Old Rice and Jujube as guides).
[Comment by Xu Rongzhai] Regarding Yang deficiency and impending collapse due to excessive sweating in Shanghan, there is an experimental case by Yuan Guisheng from Zhenjiang for reference. The patient, Luo Dasan, had inherent Yang deficiency, contracted external cold, suffered from headache and aversion to cold, loss of taste, small and slippery pulse, and slippery white tongue coating. The initial diagnosis prescribed Congchi Erchen Tang (Scallion and Soybean Decoction plus Two-Chen Formula) with Jingjie and Perilla Leaf for dispersal. After taking it, he suddenly developed wheezing unable to lie down, sensation of hot rising in the head, pain in the lower left abdomen, vomiting of phlegm-water, and cold fingers. The pulse was deep and weak. He was then given Lizhong Tang combined with Liujunzi Tang modified (Korean Ginseng 1 qian, Stir-fried Atractylodes Macrocephala Rhizome 2 qian, Fried Ginger 1 qian, Honey-fried Licorice Root 0.8 qian, Poria 3 qian, Ginger-processed Pinellia Tuber 2 qian, Tangerine Peel 1 qian, Cinnamon Bark 0.8 qian, White Peony Root 3 qian, Schisandra Berry 0.6 qian). After taking it, wheezing and vomiting ceased, and abdominal pain stopped. However, he still felt cold and had cold hands, so he took Lizhong Tang with Ginger and Pinellia for two doses. Later, he recovered after half a month of conditioning with Liujunzi Tang and Zisheng Wan (Excerpted from *National Famous Doctors' Verified Cases*). Mr. Lianchen had a preventive medical experience for such syndromes. He said: "When treating Shanghan requiring surface-releasing methods, one must observe whether the person's original Qi and Yin-Yang are intact before using them directly. If true Yang is inherently deficient, usually feeling cold and preferring warmth, accustomed to acrid-warm herbs, and having loose stools; this is called 'Yin Organ Constitution.' It is appropriate to add Aconite Root, Fried Ginger, Astragalus Root, and Atractylodes Macrocephala Rhizome to the surface-releasing herbs to assist Yang and defend the exterior, thereby avoiding the drawback of floating Yang escaping outward." This preventative diagnostic and treatment method, along with the case described above, offers great inspiration to us. Ancient medical literature also contains similar examples; two are excerpted here for reference. "Hua Bo Ren treated a person who, in July, had fever. After taking Xiao Chaihu Tang too much, he had severe aversion to cold and muscle twitching. Hua diagnosed a pulse fine and nearly absent. He said: 'This is due to excessive ascending and releasing, causing profuse sweating and loss of Yang, extreme exterior deficiency leading to severe aversion to cold; muscle twitching indicates extreme interior deficiency and Yang failing to return.' He administered Zhenwu Tang for seven or eight doses, and he recovered." "Wu Shou treated a person with Shanghan for over ten days, who had sweated excessively two or three times, subsequently developing muscle twitching, body tremors, and tendon spasms; this is because excessive sweating caused both Qi and Blood deficiency. He gave Modified Ginseng Yangrong Tang, and he recovered in two doses." These two cases, one due to excessive Xiao Chaihu Tang leading to Kidney Yang floating outward, and the other due to excessive sweating leading to Qi and Blood deficiency, were both saved from critical danger through emergency measures. However, Xu Xueshi had a predictive treatment case for patients with issues regarding sweating: "A villager named Qiu Sheng had Shanghan, with fever, headache, irritability, and thirst. Although his pulse was floating and rapid, it was forceless, and slow and weak below the chi position. Xu said: 'Although this resembles Ma Huang syndrome, the slow and weak chi position indicates insufficient Ying Qi. Zhongjing said: If the chi pulse is slow, Ying Qi is insufficient, and sweating should not be induced.' He used Jianzhong Tang added with Danggui and Astragalus Root. By the fifth day, the chi position responded. Then he administered two doses of Ma Huang Tang. The patient became manic for a moment, then settled slightly and slept, and finally sweated." This is a valuable experience in diagnostics. If pulse diagnosis is neglected and sweating is induced blindly, inevitable pathological changes will certainly result. I believe that to deeply understand the application rules of sweating, purging, cooling, and eliminating methods, one should read and ponder Cheng Zhongling's *Yimen Bafa* (Eight Methods of the Medical Gate) carefully.
(B) Example of Evil Sinking, Righteous Deficiency, Internal Closure, and External Collapse
[Etiology] After Shanghan or warm diseases have undergone sweating, purging, cooling, and penetrating methods, the interior Qi, Blood, and Spirit are damaged. The person progresses from fatigue to gradual drowsiness, and from drowsiness to gradual coma, indicating major deficiency and impending collapse, and the sign of evil heat sinking inward taking advantage of the deficiency.
[Symptoms] Red, dry tongue with prickles, inability to extend the tongue forcefully, delirium and confusion, or silence resembling a corpse, shortness of breath and rapid respiration, cold hands and feet, restlessness and inability to lie down, spontaneous cold sweat, throwing hands and feet about, constipation. In men, retraction of the testes; in women, retraction of the breasts. Ye Tianshi said: "If one normally has Heart deficiency with Phlegm, once external heat sinks inward, the interior collaterals close immediately, leading to fainting and convulsions. If one does not urgently open the closure, or opens it improperly, it will inevitably cause the Heart Qi and Lung Qi to fail to connect smoothly, resulting in cold sweaty skin, restlessness and inability to lie down, and a fine, rapid pulse, which constitutes Qi collapse."
[Pulse] In Internal Closure and External Collapse, the pulse is fine and rapid, or deep, fine, and rapid.
[Treatment] The emergency method is to first open the internal closure and secure the external collapse. Use Ye's Modified Fumai Tang removing Coix Seed and Loquat Leaf, adding Tangerine Peel and Schisandra Berry (Honey-fried Licorice Root and Bird's Nest each 1 qian, True Donkey-hide Gelatin 1.5 qian, Fresh Rehmannia Root 4 qian, Ophiopogon Tuber 3 qian, Jilin Ginseng 0.5 qian, North Glehnia Root 3 qian, Astragalus Root 1.5 qian, Schisandra Berry 0.5 qian, South Jujube 2 pieces). Mix in Wang's Niuhuang Qingxin Wan (Calculus Bovis Clearing Heart Pill) or Shenxi Dan can also be considered.
[Comment by Xu Rongzhai] Yu cited Ye Tianshi's theory: "If one normally has Heart deficiency with Phlegm, once external heat sinks inward, the interior collaterals close immediately." According to the experience of Xu Xiaocen from Yuyang, the symptoms at this stage should be treated by "urgently clearing collateral heat to open the closure." Herbs used: "Rhinoceros Horn, Antelope Horn, Halloysitum Rubrum, True Eretmochelys Carapax, Processed Arisaema Cum Bile, Fresh Rehmannia Root, Scrophularia Root, Forsythia Fruit, Moutan Cortex, Raw Polygala Root, Fritillaria Bulb, Charred Gardenia Fruit, one pill of Qingxin Niuhuang Wan." At the stage of "cold sweaty skin, restlessness and inability to lie down, fine and rapid pulse, constituting Qi collapse," Xu Xiaocen considers it "Yang Collapse Syndrome," using herbs: "True Taishan Ginseng, North Schisandra, Ophiopogon Tuber, Atractylodes Macrocephala Rhizome, Astragalus Root, Prepared Rehmannia Root, Prepared Aconite Root, Cinnamon Bark, Honey-fried Licorice Root, Calcined Dragon Bone, Oyster Shell." (See Chen Genru's *Jianzheng on Warmth Theory*) Appended here to address the critical changes of "Evil Sinking, Righteous Deficiency, Internal Closure, and External Collapse" in clinical practice.
(C) Example of Deep Heat, Yang Depression, External Closure, and Internal Collapse
[Etiology] Most Shanghan and warm diseases present with concurrent wind and cold. If wind and cold are not first dispelled to release the exterior, and bitter-cold descending herbs are used early, the exterior remains unresolved, and the pathogen sinks inward instead. External closure refers to pathogen binding and Yang depression; internal collapse refers to Yang excess and Yin exhaustion.
[Symptoms] Red eyes, or red veins visible in the whites of the eyes, dry nose, red and dry lips, deafness, irritability, thirst preferring cold drinks, yellow-black dry tongue coating, yellow-red painful urination, yellow-black sticky stool, or loose stool extremely foul-smelling, or passage of fresh blood, burning pain in the anus during defecation, intense heat from chest to lower abdomen, burning to touch, yet the body surface does not feel hot, or heat is slight, aversion to cold, no sweat, desire to wrap in blankets and face fire, even to the point of cold limbs and bluish-purple nails.
[Pulse] Floating, deficient, and rapid; heavy pressing reveals soggy, rapid, and forceless pulse.
[Treatment] First, use light and ascending herbs to release the exterior and resolve external closure. Such as Shao's Reyu Tang (Heat Stagnation Decoction) (Mint 1 qian, Green Forsythia Fruit, Trichosanthes Peel, Green Scutellaria Root, Green Artemisia Annua Head each 1.5 qian, Charred Gardenia Fruit, Curcuma Aromatica Rhizome each 3 qian, Platycodon Root 1 qian, Raw Licorice Root 0.6 qian, Fresh Bamboo Leaves 30 pieces.) Wuye Lugeng Tang (Five Leaves and Reed Root Decoction) (Agastache Leaf, Mint Leaf, Pogostemon Leaf, Lotus Leaf each 1.5 qian, decoct first with Loquat Leaf 1 liang, Living Reed Root 1.2 liang, Fresh Winter Melon 2 liang, use the decoction as water.) Such formulas. To save the interior and prevent internal collapse by withdrawing heat and preserving Yin, use Miao's Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction) (Raw Gypsum 5 qian, Mint, Schizonepeta, Cicada Slough, Stir-fried Arctii Fructus, Raw Kudzu Root, Anemarrhena Rhizome, Ophiopogon Tuber each 1.5 qian, Raw Licorice Root 1 qian, Scrophularia Root 2 qian, Fresh Tamarix Branch 5 qian, Bamboo Leaves 30 pieces, Rice grain a pinch. For warm toxins, rashes, heat congested in the Lungs, reverse transmission to the Pericardium, panting, cough, oppression, agitation, mania, and hyperactivity, this formula is essential.) Modified Zhuye Shigao Tang (American Ginseng 1 qian, Raw Gypsum 5 qian, Raw Licorice Root 0.8 qian, Ophiopogon Tuber 1.5 qian, Immature Pinellia Tuber 1 qian, Green Sugarcane Juice 3 qian, Ginger Juice 2 drops, Light Bamboo Leaves 30 pieces, Fresh Imperata Rhizome 1 liang, Fresh Rice Ear 3 branches.) All can be considered for efficacy. One formula treats both, resolving both exterior and interior. Such as Waitai Sanhuang Shigao Tang (External Classic Three-Yellow Gypsum Decoction) (Ephedra 0.6 fen, Fermented Soybean 3 qian, Small Coptis Rhizome, Raw Gardenia Fruit, Raw Phellodendron Bark each 1 qian, Green Scutellaria Root 2 qian, Raw Gypsum 5 qian.) If there is great heat in the exterior, interior, and Triple Burner, vexing heat in the five centers, eyes like fire, dry nose and red face, yellow tongue and scorched lips, body looking like painted vermilion, dry thirst craving drink, delirium and confusion, use Yang's Zengsun Sanhuang Shigao Tang (Increased and Reduced Three-Yellow Gypsum Decoction) (Stiff Silkworm 3 qian, Cicada Slough 10 pieces, Mint 2 qian, Anemarrhena Rhizome 2 qian, Raw Gypsum 5 qian, Small Coptis Rhizome, Raw Gardenia Fruit, Raw Phellodendron Bark each 1 qian, Green Scutellaria Root 2 qian.) If heat stagnates in the interstices and can be dispersed internally and externally, but there is chest and abdominal fullness, pain with refusal to press, and constipation, consider purging cautiously.
[Comment by Xu Rongzhai] The terms "Internal Closure and External Collapse" and "External Closure and Internal Collapse" in sections (B) and (C) represent the limit of the struggle between pathogenic factors and righteous Qi. Since the sensory and motor nerves are obscured by evil heat and lose their vital functions, the body's resistance gradually declines, creating a sharp struggle state where "evil and right cannot coexist." The result is a mutual escape outward—Internal Closure and External Collapse. On the other hand: Evil heat congests the exterior, while righteous Qi exhausts in the interior. If the exterior cannot be resolved by sweating, the virus invades inward, turning into a state of Yang excess and Yin exhaustion. So-called "evil not reaching and right already depleted," forcing it to sink inward and collapse together—External Closure and Internal Collapse. Generally speaking, although closure is due to excess evil, the sudden trend toward collapse should be closely monitored.
(D) Example of True Yin Exhaustion Below and Deficient Yang Escaping Above
[Etiology] In individuals with Yin deficiency, contracting Shanghan or warm diseases, and mistakenly using excessive acrid-dry sweating and purging drugs, lingering for a long time, leads to extreme deficiency of True Yin below. This causes rootless Fire to suddenly flare up, Qi congestion, Phlegm rising, obscuring the clear orifices, suddenly leading to convulsions and fainting. This belongs to the depletion of Primordial Yin and discontinuation of True Qi. If the cold extremities do not recover, life is lost.
[Symptoms] Short red tongue, blue face, eyes closed and mouth open, hands not clenched, hoarse voice and rapid breathing, even to the point of profuse cold sweat, inverted cold hands and feet, involuntary urination and defecation, faint breath and pulse, constituting the collapse syndrome of Dragon and Thunder violent movement. If accompanied by deficiency-cold, the face and lips are mostly pale and lusterless, even bluish-dark, definitely not red and moist. There are also cases of cold limbs but red cheeks alone, constituting the Daiyang syndrome (Floating Yang) of deficient Fire flaming upward, requiring warming and tonification.
[Pulse] When Primordial Qi is declining and Dragon and Thunder are violently moving towards collapse, the pulse must be deep and hidden, or weak and spiritless, or imperceptible.
[Treatment] Urgently solidify and support Yuan Qi, astringe Yin and benefit fluids, grasp True Yin, and anchor floating Deficient Yang. Use Longmu Fumai Tang (Dragon and Oyster Restore Pulse Decoction) (Jilin Ginseng 1 qian, Aged Donkey-hide Gelatin 1.5 qian, Chicken Egg Yolk wrapped and decocted 1 piece, Raw Tortoise Plastron and Raw Oyster Shell each 8 qian, Calcined Dragon Bone 2 qian, Raw Turtle Plastron 4 qian, True Eretmochelys Carapax 1.5 qian, Raw White Peony Root 3 qian, Ophiopogon Tuber 3 qian, Large Fresh Rehmannia Root 4 qian, Honey-fried Licorice Root 1.5 qian, Large Kappaqi [Fetal Membrane] washed with wine 1 strip, Water 2 bowls, decoct to half a bowl and take.) If there are cold limbs, hidden pulse, spontaneous head sweat, and sweat like oil, then Yin perishes and Yang follows. Replace Jilin Ginseng with Korean Ginseng 2 qian, add Pale Aconite Slice 1.5 qian. If Phlegm blocks the throat, wanting to vomit but with no strength, and medicine cannot go down, first use Zhen Houzao Mo (True Monkey Date Powder) 0.4 fen, decoct Fresh Acorus Rhizome Soup, take first to temporarily calm the rebellious Phlegm. Continue taking medicine, then use He Xi Dan (Black Tin Pill) from Ju Fang 3 qian, decoct and take, to anchor floating Yang and warm-nourish the Lower Origin. If Phlegm and saliva open, consciousness returns, and Qi resumes, then Yin-nourishing, Yang-anchoring, Yuan-solidifying, and grasping medicines should be continued urgently without interruption. Vital Qi will gradually return, form and spirit will gradually revive, and consciousness will become clear, though fatigue and desire to sleep remain. Especially in this case, large doses of the previous prescription must be administered to solidify the foundation and support righteous Qi. If it is indeed a Bi syndrome (closure) of hot Phlegm surging upward, this formula must absolutely not be used, as it will instead obstruct Phlegm and saliva in the throat, hastening death.
[Comment by Xiu] The *Neijing* states: "When Yin is balanced and Yang is secret, Spirit is governed. When Yin and Yang separate and decide, Essence and Qi perish." When Essence and Qi perish, Primordial Yuan collapses. However, before collapse, there must be manifestations. The *Classic* again states: "Essence collapse causes deafness, use Guilu Erxian Jiao (Tortoise and Deer Two-Immortal Glue)." "Qi collapse causes unclear vision, use Shengmai San combined with Baoyuan Tang." "Fluid collapse causes pores to open and profuse sweating, use Renshen Guben Tang combined with Shengmai San." "Liquid collapse causes difficulty in bending and extending bones, sallow complexion, diminished brain marrow, sore shins, and frequent tinnitus, use Baoyin Jian, Banlong Wan, etc." "Blood collapse causes pale color, sallow and lusterless appearance, empty pulse, use Guipi Tang, Renshen Yangrong Tang, etc." The *Nanjing* further states: "Those with Yang collapse see..."