病尸厥七日，僵卧于床，口噤，目瞪，神呆。医用香开，又服制雄丹，不效；皆云∶疾不可为也。先生为拟一方，
用∶牛黄、珠粉、牙皂、雄精、菖蒲等品，一剂神清能言，再剂而愈。”为治疗尸厥开辟了另一个法门，
是值得珍视的。
【因】其因有三。一热邪烁营。逆传心包而闭者。二痰因火动。蒙蔽神明而闭者。三湿热薰蒸。
上蒙心包如闭者。
【证】（一）身热口渴。烦躁而动。揭去衣被。扬手掷足。循衣摸床。撮空理线。便闭溲短。
舌质绛。苔黄焦。或黑糙。此因实热转闭。（二）面赤气粗。口噤目张。两手握固。语言蹇涩。身热便闭。
神志昏沉。舌苔黄腻。胖短。此因痰火转闭。（三）壮热口燥。不喜饮水。脘闷懊 。神识昏沉。
如痴如醉。嗜卧懒动。好向壁卧。懒与人言。或眼喜闭。或开目不欲见光明。此因湿蒙转闭。
【脉】由于热闭者。脉必沉实而数。有力者为实热。濡数者为暑热。由于痰闭者。脉必滑大。由于
湿蒙者。脉必濡数。或软弱无力。
【治】由于实热而闭。便闭者。宜服犀连承气汤。（犀角一钱、川水连一钱、生锦纹三钱、
小枳实钱半、元明粉二钱、真川朴五分。）加鲜生地六钱、连翘三钱主之。牛黄丸。紫雪丹。至宝丹。
临证酌加之。由于痰热而闭。口闭不语如厥者。宜先用卧龙丹。（西黄、金箔各四分、梅冰、荆芥、
闹羊花各二钱、麝香、辰砂各五分、牙皂角钱半、细辛一钱、灯心灰二钱四分、共研极细末。）搐鼻取嚏。以通肺窍。
次用导痰开关散。（见过玉书《治疔汇要》）开水调
服八分。以吐稠痰。再用雪羹汤。（陈海蛰漂淡二两、大荸荠五枚、去脐蒂。）煎汁。加萝卜汁、鸭梨汁
各一杯。鲜石菖蒲钱半捣汁。合调牛黄清心丸。徐徐灌下。分作两次服。由于湿蒙者。宜芳香逐秽汤。
（藿香、佩兰、蔻仁、白芥子、飞滑石、广郁金、真川朴、光杏仁、生苡仁。）加鲜芦根二两。紫金
片八分调冲。便闭者。加陆氏润字丸。（生锦纹一两、漂半夏、前胡、生楂肉、天花粉、广皮、白术、
枳实、槟榔各一钱二分半、晒干为末、神曲糊为丸。）三钱。另吞服。湿蒙偏于热重者。加叶氏神犀丹。
（犀角六钱磨汁、鲜石菖蒲六钱、鲜银花一两六钱、鲜生地四两、三味捣汁、青连翘一两、人中黄四钱、
上青黛九钱、青子芩六钱、淡香豉八钱、元参七钱、老紫草四钱、天花粉四钱、上药各生晒研细、
以各汁捣和、将豆豉煮烂为丸、每重三钱。）开水调服之。
【秀按】周澹然云。温邪初起。腰痛身疼。脉伏神昏。咽燥不语者。乃邪热内闭。治不合法。死期最
速。大凡邪来迅速。直传心胞。乃有内闭神昏之候。或热传胃府。与浊滞相合。亦令谵语神昏。湿与浊
最能昏人神智。往往温病初起。即能令人神识模糊。烦躁不知所苦。间有神清。而能自主者。梦寐亦多不
安。或闭目即有所见。有所见即谵妄之起蒂。若湿热甚。则薰蒸膻中。蒙蔽心胞。则神智昏沉。如醉如痴。
嗜卧懒动。渴不多饮。好向壁卧。闭目不欲见光明。宜芳香化浊。辛淡宣气。（全青蒿、佩兰、白蔻仁、
光杏仁、连翘、滑石、广郁金、鲜石菖蒲、生米仁、白薇、棉茵陈。）使气行浊化。加拨去云雾。即见青天。
此即湿蒙之治法也。若夫热邪传营。舌色必绛而无苔。其有舌绛中兼黄白苔者。及似苔非苔者。此气分遏
郁之热。非血分也。宜用辛润达邪。轻清泄热法。最忌苦寒冰伏。阴柔滋腻。致气分之邪。遏伏内陷。反成
纯绛无苔。其有不因冰伏。而舌纯绛鲜泽。神昏者。乃邪传包络。宜犀角、鲜生地、黄连、银花、连翘、
郁金、鲜石菖蒲、竹沥、姜汁等味。清化之中。佐以辛润开闭。若舌色紫黯。扪之且湿。乃其人胸膈中
素有宿瘀与热相搏。宜鲜生地、犀角、
丹皮、丹参、赤芍、郁金、花粉、桃仁、藕汁。凉血化瘀。否则瘀热为互。阻遏机窍。遂变如狂发狂之证。亦
有夏令新受暑热。昏迷若惊。此为暑厥。即热气闭塞孔窍所致。其邪入络。以牛黄丸、至宝丹。芳香利窍可
效。神苏已后。用清凉血分。如连翘心、竹叶心、元参、鲜生地、银花、绿豆衣、麦冬之属。此症初起时大忌
风药。暑火之邪。得风药而更炽矣。
【廉勘】邪热内闭。神昏谵语。必先辨其陷入之浅深。别其轻重以定方。如热初蒸及心之经。心烦多言。间
有糊涂语。其邪虽陷。尚浅而轻。但须丹溪清心汤。去硝黄。以泄卫透营可也。迨陷入心包。妄言妄见。疑鬼
疑神。其邪渐深而重。先以茶竹灯心汤（细芽茶五分、卷心竹叶三十片、灯心两帚。）调下万氏牛黄丸一二
颗。每多奏效。若厥后犹不清醒。反昏冒不语。全不省人事者。则邪热直陷心脏。极深而重。急用新定牛黄清
心丸。或安宫牛黄丸。甚或瓜霜紫雪丹。调入石氏犀地汤。（黑犀角、鲜生地、青连翘、银花、广郁金、鸭梨
汁、淡竹沥、姜汁、鲜石菖蒲、活水芦根、灯心。）以开透之。犹可十全一二。或用加减服蛮煎。（鲜生地五
钱、鲜金钗、知母、丹皮、辰茯神各二钱、麦冬、木通、广皮、鲜石菖蒲各一钱、犀角汁一瓢、西黄一分、
祝春渠《歌方集论》方。）调入厥症返魂丹四五丸。亦可幸全十中之一。如或不应。必至内闭外脱而毙。此热陷浅
深之次第。用药轻重之方法也。然昏虽系热深。却有夹痰浊、夹湿秽、夹胃实、夹血结、夹毒攻、夹冲逆之分。
而无不关系于神经。其分布于心肺胃三经者。即第十对迷走神经。主心肺胃之知觉运动。凡结邪在此神经。其
人知觉即昏迷。即肝肾冲督。亦有交感神经反射之作用。由是推之。肺主气。气闭而神昏迷者。由于痰浊迷漫
神经也。故曰痰迷。亦曰痰厥。治宜先用卧龙丹。（西牛黄、金箔各四分、梅冰、荆芥炭、闹羊花各二钱、麝
香、辰砂各五分、猪牙皂钱半、细辛一钱、灯心灰二钱五分、共研极细末。）搐鼻取嚏。以通肺窍。次用导痰
开关散（方载过玉书《治疔汇要》）开水调灌一钱。以吐稠痰。若痰虽吐。而神犹不醒。急用犀角二汁饮。（犀角汁
五匙、生萝卜汁半碗、梨汁两瓢、雪水三杯煮沸、和入三汁即服。）调入炼雄丹。（明雄黄一分、牙
硝六分、研细同入铜勺内、微火熔化拨匀、俟如水时、即滤清者于碗内、候其将凝、即印成锭。）三厘或五厘。
徐徐冷灌。一日三服。每见有吐出清痰粘涎数碗。而神识全清。终以枇杷叶饮子（《外台》方）调岩制
川贝（廉臣经验方）一二块。去余痰以整肃肺气。或用二陈汤善其后。此治痰迷重症之方法也。其夹湿秽而神
迷者。由于湿热郁蒸过极。迷蒙神经也。故曰湿蒙。治以芳香辟秽。辛淡开闭。藿朴夏苓汤去蔻朴。加细辛三
分、白芥子八分、芦笋一两、滑石五钱、煎汤代水。乘热即饮。蒙闭即开。甚则调入太乙紫金丹、一丸。投无不
效。若热势稍重者。宜以清凉透热。芳烈宣窍。清芳透邪汤。（鲜石菖蒲钱半、泽兰叶二钱、薄荷叶八分、青
蒿脑钱半、鲜茅根四十支、活水芦根一两、紫金片五分。）亦屡投辄验。樊师每用藿朴二陈汤。亦屡奏功。或
去本方中紫金片。磨冲苏合丸一颗。尤效。若夹胃实而神昏迷者。属胃热蒸脑。脑筋起炎。神即昏蒙。头摇目
瞪矣。延及脊髓筋亦发炎。则手足发痉。甚则角弓反张矣。盖胃为五脏六腑之海。其清气上注于目。其悍气上
冲于头。循咽喉。上走空窍。循眼系。入络脑。脑为元神之府。所以胃热蒸脑。无不发现神经诸病也。此为温
热病最多之候。其夹血结而神昏迷者。蓄血迷乱神经也。蓄血在上焦者。属心包络。证必脉细肢厥。胸痹痛厥。
故曰血结胸。法宜横开旁达。加味桂枝红花汤。（桂枝汤、加红花、桃仁、海蛤壳。）若舌红燥。脉弦数者。
陶氏用犀角地黄汤。加大黄、桃仁、红花、枳实。最为合法。蓄血在中焦者。属脾络。证必脘痛串胁。脉涩肢厥。
胀痛在左胁者居多。故名脾胀。和血逐邪汤。（鳖血柴胡、荆芥、制香附、嫩苏梗、秦艽各钱半、川朴、枳壳
各一钱、川芎八分、益母草、泽兰各三钱、绛通一钱、生姜皮五分。）甚效。五枝松针汤。（紫苏嫩枝钱半、
川桂枝五分、樟枝、桃枝各六钱、酒炒嫩桑枝二尺、青松针八钱、何氏验方。）亦验。重则加《金匮》鳖甲煎
丸四五钱、或加宽膨散（叶氏验方）一钱。奏效最捷。蓄血在下焦者。属肝络冲脉。证必左脉弦涩。手足厥冷。
大便溏黑。小
便自利。神昏如狂。治宜宣气解结。透络通瘀。叶氏加减小柴胡汤。（鳖血柴胡、黄芩、炙甘草、鲜生地、丹
皮、桃仁、楂肉、或犀角。）或舒氏增损小柴胡汤（舒驰远《伤寒集注》方）。随证酌用。延久而变肝胀血蛊。治
宜开郁通络。如新加绛复汤。（旋复花包煎、真新绛、原桃仁、柏子仁、当归须、乌贼骨、延胡、川楝子、茜
根、青葱管、徐氏医学举要方。）开郁通络饮。（陈香团、广郁金、延胡、远志、真新绛、宣木瓜、蜣螂虫、
通草、佛手片、丝瓜络、路路通、生米仁。）开郁正元散。（生白术、陈皮、青皮、香附、山楂、海粉、桔梗、
茯苓、砂仁、延胡、麦芽、甘草、神曲。）代抵当丸。（酒炒锦纹四两、桃仁三十粒、炒穿甲、醋炒莪术、归
尾、细生地、元明粉各一两、官桂三钱、为末、蜜为丸、如萝卜子大。如蓄血在上部者。黄昏去枕仰卧。以
津咽之。令停喉以搜逐瘀积。在中部食远服。下部空心服。俱丸如梧子。百劳水煎汤下之。如血老成积。攻之
不动。去归地。倍莪术官桂。）桃仁承气合逍遥散加味（原桃仁、全当归、赤苓各三钱、生锦纹钱半、赤芍二
钱、风化硝一钱、川柴胡、苏薄荷、炙甘草、官桂各五分、生晒术八分、细辛三分、蝼蛄十只、研末包煎。）
之类。临时对证选用可也。若夹毒攻而神昏迷者。血毒攻心也。名曰血闭。其症有三。一为温毒烁血。血毒攻
心。法当峻下。如桃仁承气汤、合抵当丸之类。二为产后积瘀。血毒攻心。宜回生至宝丹（华氏妇科方）最
灵。黑神丸。（百年陈京墨二锭、无根水磨成浓汁、倾入瓷盘中、晒燥刮下、研细、每料约用净墨粉四钱、陈
百草霜二钱、烧各种野草者佳、取灶门上积烟、明天麻二钱、淮小麦粉二钱、赤金箔五十张各研极细、称准
份量、再研匀、即将淮麦粉一钱、打糊为丸、金箔为衣、每丸约重一分、外用蜡封固、轻者服一丸、重者服二
三丸、童便陈酒合送下。）最稳而效。三为溺毒入血。血毒攻心。甚则血毒上脑。其症极危。急宜通窍开闭。
利溺逐毒。导赤泻心汤。（鲜生地、木通、甘草梢、淡竹叶、小川连、青子芩、山栀、知母、辰砂拌茯神、麦
冬、益元散。）调入犀珀至宝丹。或导赤、合加味虎杖散。（鲜生地一两、淡竹叶钱半、生甘梢、木通各一
钱、鲜杜牛膝一两、茺蔚子三钱、琥珀末五分冲、麝香一分冲。）调入局方《来复》丹二三钱。尚能幸全一二。此
皆治实闭之开透法也。
【炳章按】心为一身之主宰。心藏神。其体清虚。外衣膜络（即心包络）。乃神之宫室。即神气出入之里窍
也。上通于脑。盖神以心为宅。以囟为门。故心为藏神之脏。脑为元神之府。神明出焉。灵机发焉。若为痰火
所蒸。瘀热所闭。则心灵顿失。神明内乱。谵语如狂。或为痉为厥。急则内闭外脱。若不细辨明晰。焉能起死
回生。吴鞠通云。内闭谵语之由。载《伤寒论》中、已有八条。有被火劫谵语者。有汗出谵语者。有下利谵语者。
有燥屎在肠谵语者。有三阳合病谵语者。有过经谵语者。有亡阳谵语者。皆当色脉合参。详辨因证而救之。
至于叶案《温病论治》。尚有心阳素扰。神不安而谵语者。暑邪烁营。逆传心胞而谵语者。痰因火动。蒙蔽神
明而谵语者（以上俞何二公、已各有经验治法。）他如伤寒误遏。邪闭血管。变血结胸而谵语者。暑湿邪闭血
脉。热甚神昏谵语者。较伤寒为尤多。章虚谷云。如风寒等邪发表汗出。病仍不退。而又表之。反加神昏谵
语。于是更用凉泻。误而又误。以至于死。此因初起不明。或止用卫分之药。腠开汗泄。而营分之邪反陷。或
挟寒湿阴邪。应用辛温。而表药中。杂以凉药。既重虚其卫。而凉药闭其邪于血脉之中。心主营血。故亦神昏
谵语。若胃腑邪重热盛。心胞近心。心受胃热蒸逼。故其神昏。皆全然不知人事。若由邪闭血脉者。离心稍
远。故呼之即觉。与之言不知人事。若任其自睡而心放。即神昏谵语矣。其脉必兼涩滞。以邪闭血脉。使脉涩
滞也。此叶氏用桂枝红花汤。加海蛤壳、桃仁。以开邪闭。或佐归须、赤芍之类。以通血脉。如热甚略佐凉
味。无热必须温通。盖血得凉则愈闭也。又有暑湿邪盛。至下午晚间身热更甚。神昏谵语。至早上午前。则神
识清楚。身热亦微。此邪在三焦脾胃。因湿重遏热不得透发。湿为阴邪。旺于下午阴分。热不得外泄。则内扰
【病因】其病因主要有三种。一是热邪灼伤营阴，逆传心包导致闭证。二是痰浊因火热而动，蒙蔽神明导致闭证。三是湿热熏蒸，上蒙心包如同闭证。
【症状表现】（一）身体发热、口渴，烦躁不安且肢体躁动，掀开衣被，扬手掷足，循着衣物摸床，伸手抓空理线，大便不通，小便短少。舌质深红，苔黄焦或黑而粗糙。这是因实热导致的内闭。（二）面色红赤，呼吸气粗，口噤目张，两手握固，语言蹇涩，身体发热，大便不通，神志昏沉。舌苔黄腻，舌体胖短。这是因痰火导致的内闭。（三）高热，口燥，但不喜欢喝水，胃脘部闷胀懊恼，神志昏沉，像痴呆或醉酒一样，嗜睡懒动，喜欢面向墙壁躺卧，懒得与人说话，或者眼睛喜欢闭合，或者睁开眼却不喜欢见光亮。这是因湿浊蒙蔽导致的内闭。
【脉象】由于热闭引起的，脉象必定沉实而数，有力的是实热，濡数的是暑热。由于痰闭引起的，脉象必定滑大。由于湿蒙引起的，脉象必定濡数，或者软弱无力。
【治法】由于实热内闭且大便不通的，适宜服用犀连承气汤。（犀角一钱、川黄连一钱、生大黄三钱、枳实钱半、元明粉二钱、厚朴五分。）加入鲜生地六钱、连翘三钱为主药。牛黄丸、紫雪丹、至宝丹，临证时酌情加入使用。由于痰热内闭，口闭不语类似厥证的，适宜先用卧龙丹。（西黄、金箔各四分、梅冰、荆芥、闹羊花各二钱、麝香、辰砂各五分、牙皂角钱半、细辛一钱、灯心灰二钱四分，共研成极细末。）搐鼻取嚏，以通肺窍。接着用导痰开关散。（见于玉书《治疔汇要》）开水调服八分，以吐出稠痰。再用雪羹汤。（陈海蜇漂淡二两、大荸荠五枚，去脐蒂。）煎汁，加入萝卜汁、鸭梨汁各一杯，鲜石菖蒲钱半捣汁，调和牛黄清心丸，徐徐灌下，分两次服用。由于湿浊蒙蔽的，适宜用芳香逐秽汤。（藿香、佩兰、蔻仁、白芥子、飞滑石、广郁金、厚朴、光杏仁、生薏苡仁。）加入鲜芦根二两，紫金片八分冲调。大便不通的，加陆氏润字丸。（生大黄一两、漂半夏、前胡、生山楂肉、天花粉、陈皮、白术、枳实、槟榔各一钱二分半，晒干为末，神曲糊为丸。）三钱，另吞服。湿蒙偏于热重的，加叶氏神犀丹。（犀角六钱磨汁、鲜石菖蒲六钱、鲜银花一两六钱、鲜生地四两，三味捣汁；青连翘一两、人中黄四钱、上青黛九钱、青子芩六钱、淡香豉八钱、元参七钱、老紫草四钱、天花粉四钱，以上药物各生晒研细，以各汁捣和，将豆豉煮烂为丸，每丸重三钱。）开水调服。
【秀按】周澹然说：温邪初起，腰痛身疼，脉伏神昏，咽燥不语的，乃是邪热内闭，治疗不合法度，死期最快。大凡邪气来势迅速，直传心胞，才有内闭神昏的征候。或者热传胃府，与浊滞相合，也会令人谵语神昏。湿与浊最能昏乱人的神智，往往温病初起，就能令人神识模糊，烦躁不知痛苦。间或有神志清醒，能自主的，但梦寐也多不安，或者闭目即有所见，有所见即谵妄之始。若湿热甚，则熏蒸膻中，蒙蔽心胞，则神智昏沉，如醉如痴，嗜睡懒动，渴不多饮，喜欢面向墙壁躺卧，闭目不欲见光亮。适宜用芳香化浊，辛淡宣气的方法。（全青蒿、佩兰、白蔻仁、光杏仁、连翘、滑石、广郁金、鲜石菖蒲、生薏苡仁、白薇、棉茵陈。）使气行浊化，拨去云雾，即见青天。这就是湿蒙的治疗方法。至于热邪传营，舌色必定绛而无苔。如果有舌绛中兼黄白苔的，以及似苔非苔的，这是气分遏郁的热，不在血分。适宜用辛润达邪，轻清泄热法。最忌苦寒冰伏，阴柔滋腻，致使气分之邪，遏伏内陷，反成纯绛无苔。那些不因冰伏，而舌纯绛鲜泽，神昏的，乃是邪传包络，适宜用犀角、鲜生地、黄连、银花、连翘、郁金、鲜石菖蒲、竹沥、姜汁等味，在清化之中，佐以辛润开闭。如果舌色紫黯，摸上去湿润，那是其人胸膈中素有宿瘀与热相搏，适宜用鲜生地、犀角、丹皮、丹参、赤芍、郁金、花粉、桃仁、藕汁，凉血化瘀。否则瘀热互结，阻遏机窍，遂变成如狂发狂的证候。也有夏令新受暑热，昏迷若惊，此为暑厥，即热气闭塞孔窍所致。其邪入络，用牛黄丸、至宝丹，芳香利窍可效。神苏已后，用清凉血分的药，如连翘心、竹叶心、元参、鲜生地、银花、绿豆衣、麦冬之类。此症初起时大忌风药，暑火之邪，得风药而更炽烈了。
【廉勘】邪热内闭，神昏谵语，必须先辨别其陷入的浅深，区别轻重以确定方剂。如热初蒸及心之经，心烦多言，间有糊涂语，其邪虽陷，尚浅而轻，只需丹溪清心汤，去掉硝黄，以泄卫透营即可。等到陷入心包，妄言妄见，疑鬼疑神，其邪渐深而重，先用茶竹灯心汤（细芽茶五分、卷心竹叶三十片、灯心两帚）调下万氏牛黄丸一二颗，每多奏效。如果厥后仍不清醒，反昏冒不语，全不省人事的，则邪热直陷心脏，极深而重，急用新定牛黄清心丸，或安宫牛黄丸，甚或瓜霜紫雪丹，调入石氏犀地汤。（黑犀角、鲜生地、青连翘、银花、广郁金、鸭梨汁、淡竹沥、姜汁、鲜石菖蒲、活水芦根、灯心）以开透之，犹可十全一二。或用加减服蛮煎。（鲜生地五钱、鲜金钗、知母、丹皮、辰茯神各二钱、麦冬、木通、广皮、鲜石菖蒲各一钱、犀角汁一瓢、西黄一分，祝春渠《歌方集论》方）调入厥症返魂丹四五丸，亦可幸全十中之一。如果不应，必至内闭外脱而死。这是热陷浅深的次第，用药轻重的方法。然而昏虽系热深，却有夹痰浊、夹湿秽、夹胃实、夹血结、夹毒攻、夹冲逆之分，而无不关系于神经。其分布于心肺胃三经者，即第十对迷走神经，主心肺胃之知觉运动。凡结邪在此神经，其人知觉即昏迷。即肝肾冲督，亦有交感神经反射之作用。由是推之，肺主气，气闭而神昏迷者，由于痰浊迷漫神经也。故曰痰迷，亦曰痰厥，治宜先用卧龙丹。（西牛黄、金箔各四分、梅冰、荆芥炭、闹羊花各二钱、麝香、辰砂各五分、猪牙皂钱半、细辛一钱、灯心灰二钱五分，共研极细末）搐鼻取嚏，以通肺窍。次用导痰开关散（方载过玉书《治疔汇要》）开水调灌一钱，以吐稠痰。若痰虽吐，而神犹不醒，急用犀角二汁饮。（犀角汁五匙、生萝卜汁半碗、梨汁两瓢、雪水三杯煮沸，和入三汁即服）调入炼雄丹。（明雄黄一分、牙硝六分，研细同入铜勺内，微火熔化拨匀，俟如水时，即滤清者于碗内，候其将凝，即印成锭）三厘或五厘，徐徐冷灌，一日三服。每见有吐出清痰粘涎数碗，而神识全清，终以枇杷叶饮子（《外台》方）调岩制川贝（廉臣经验方）一二块，去余痰以整肃肺气。或用二陈汤善其后。这是治痰迷重症的方法。其夹湿秽而神迷者，由于湿热郁蒸过极，迷蒙神经也。故曰湿蒙，治以芳香辟秽，辛淡开闭。藿朴夏苓汤去蔻朴，加细辛三分、白芥子八分、芦笋一两、滑石五钱，煎汤代水，乘热即饮，蒙闭即开。甚则调入太乙紫金丹一丸，投无不效。若热势稍重者，宜以清凉透热，芳烈宣窍。清芳透邪汤。（鲜石菖蒲钱半、泽兰叶二钱、薄荷叶八分、青蒿脑钱半、鲜茅根四十支、活水芦根一两、紫金片五分）亦屡投辄验。樊师每用藿朴二陈汤，亦屡奏功。或去本方中紫金片，磨冲苏合丸一颗，尤效。若夹胃实而神昏迷者，属胃热蒸脑，脑筋起炎，神即昏蒙，头摇目瞪矣。延及脊髓筋亦发炎，则手足发痉，甚则角弓反张矣。盖胃为五脏六腑之海，其清气上注于目，其悍气上冲于头，循咽喉，上走空窍，循眼系，入络脑，脑为元神之府，所以胃热蒸脑，无不发现神经诸病也。此为温热病最多之候。其夹血结而神昏迷者，蓄血迷乱神经也。蓄血在上焦者，属心包络，证必脉细肢厥，胸痹痛厥，故曰血结胸，法宜横开旁达，加味桂枝红花汤。（桂枝汤、加红花、桃仁、海蛤壳）若舌红燥，脉弦数者，陶氏用犀角地黄汤，加大黄、桃仁、红花、枳实，最为合法。蓄血在中焦者，属脾络，证必脘痛串胁，脉涩肢厥，胀痛在左胁者居多，故名脾胀，和血逐邪汤。（鳖血柴胡、荆芥、制香附、嫩苏梗、秦艽各钱半、川朴、枳壳各一钱、川芎八分、益母草、泽兰各三钱、绛通一钱、生姜皮五分）甚效。五枝松针汤。（紫苏嫩枝钱半、川桂枝五分、樟枝、桃枝各六钱、酒炒嫩桑枝二尺、青松针八钱，何氏验方）亦验。重则加《金匮》鳖甲煎丸四五钱、或加宽膨散（叶氏验方）一钱，奏效最捷。蓄血在下焦者，属肝络冲脉，证必左脉弦涩，手足厥冷，大便溏黑，小便自利，神昏如狂，治宜宣气解结，透络通瘀。叶氏加减小柴胡汤。（鳖血柴胡、黄芩、炙甘草、鲜生地、丹皮、桃仁、楂肉、或犀角）或舒氏增损小柴胡汤（舒驰远《伤寒集注》方），随证酌用。延久而变肝胀血蛊，治宜开郁通络，如新加绛复汤。（旋复花包煎、真新绛、原桃仁、柏子仁、当归须、乌贼骨、延胡、川楝子、茜根、青葱管，徐氏医学举要方）开郁通络饮。（陈香团、广郁金、延胡、远志、真新绛、宣木瓜、蜣螂虫、通草、佛手片、丝瓜络、路路通、生薏苡仁）开郁正元散。（生白术、陈皮、青皮、香附、山楂、海粉、桔梗、茯苓、砂仁、延胡、麦芽、甘草、神曲）代抵当丸。（酒炒锦纹四两、桃仁三十粒、炒穿甲、醋炒莪术、归尾、细生地、元明粉各一两、官桂三钱，为末，蜜为丸，如萝卜子大。如蓄血在上部者，黄昏去枕仰卧，以津咽之，令停喉以搜逐瘀积，在中部食远服，下部空心服，俱丸如梧子，百劳水煎汤下之。如血老成积，攻之不动，去归地，倍莪术官桂）桃仁承气合逍遥散加味（原桃仁、全当归、赤苓各三钱、生锦纹钱半、赤芍二钱、风化硝一钱、川柴胡、苏薄荷、炙甘草、官桂各五分、生晒术八分、细辛三分、蝼蛄十只，研末包煎）之类，临时对证选用可也。若夹毒攻而神昏迷者，血毒攻心也，名曰血闭。其症有三。一为温毒烁血，血毒攻心，法当峻下，如桃仁承气汤、合抵当丸之类。二为产后积瘀，血毒攻心，宜回生至宝丹（华氏妇科方）最灵。黑神丸。（百年陈京墨二锭、无根水磨成浓汁，倾入瓷盘中，晒燥刮下，研细，每料约用净墨粉四钱、陈百草霜二钱，烧各种野草者佳，取灶门上积烟，明天麻二钱、淮小麦粉二钱、赤金箔五十张各研极细，称准份量，再研匀，即将淮麦粉一钱，打糊为丸，金箔为衣，每丸约重一分，外用蜡封固，轻者服一丸，重者服二三丸，童便陈酒合送下）最稳而效。三为溺毒入血，血毒攻心，甚则血毒上脑，其症极危，急宜通窍开闭，利溺逐毒。导赤泻心汤。（鲜生地、木通、甘草梢、淡竹叶、小川连、青子芩、山栀、知母、辰砂拌茯神、麦冬、益元散）调入犀珀至宝丹。或导赤、合加味虎杖散。（鲜生地一两、淡竹叶钱半、生甘梢、木通各一钱、鲜杜牛膝一两、茺蔚子三钱、琥珀末五分冲、麝香一分冲）调入局方《来复》丹二三钱，尚能幸全一二。此皆治实闭之开透法也。
【炳章按】心为一身之主宰，心藏神，其体清虚，外衣膜络（即心包络），乃神之宫室，即神气出入之里窍也。上通于脑，盖神以心为宅，以囟为门，故心为藏神之脏，脑为元神之府，神明出焉，灵机发焉。若为痰火所蒸，瘀热所闭，则心灵顿失，神明内乱，谵语如狂，或为痉为厥，急则内闭外脱。若不细辨明晰，焉能起死回生。吴鞠通云，内闭谵语之由，载《伤寒论》中，已有八条。有被火劫谵语者，有汗出谵语者，有下利谵语者，有燥屎在肠谵语者，有三阳合病谵语者，有过经谵语者，有亡阳谵语者，皆当色脉合参，详辨因证而救之。至于叶案《温病论治》，尚有心阳素扰，神不安而谵语者，暑邪烁营，逆传心胞而谵语者，痰因火动，蒙蔽神明而谵语者（以上俞何二公，已各有经验治法）。他如伤寒误遏，邪闭血管，变血结胸而谵语者，暑湿邪闭血脉，热甚神昏谵语者，较伤寒为尤多。章虚谷云，如风寒等邪发表汗出，病仍不退，而又表之，反加神昏谵语，于是更用凉泻，误而又误，以至于死。此因初起不明，或止用卫分之药，腠开汗泄，而营分之邪反陷，或挟寒湿阴邪，应用辛温，而表药中，杂以凉药，既重虚其卫，而凉药闭其邪于血脉之中，心主营血，故亦神昏谵语。若胃腑邪重热盛，心胞近心，心受胃热蒸逼，故其神昏，皆全然不知人事。若由邪闭血脉者，离心稍远，故呼之即觉，与之言不知人事，若任其自睡而心放，即神昏谵语矣。其脉必兼涩滞，以邪闭血脉，使脉涩滞也。此叶氏用桂枝红花汤，加海蛤壳、桃仁，以开邪闭，或佐归须、赤芍之类，以通血脉。如热甚略佐凉味，无热必须温通，盖血得凉则愈闭也。又有暑湿邪盛，至下午晚间身热更甚，神昏谵语，至早上午前，则神识清楚，身热亦微，此邪在三焦脾胃，因湿重遏热不得透发，湿为阴邪，旺于下午阴分，热不得外泄，则内扰
[Causes] There are three main causes. First, heat pathogen scorching the Ying (Nutrient) level and counter-flowing to the Pericardium causing closure. Second, phlegm stirred by fire clouding the Spirit causing closure. Third, damp-heat steaming upward, clouding the Pericardium like a closure syndrome.
[Symptoms] (1) Fever, thirst, irritability with restlessness, throwing off clothes and bedding, waving hands and kicking feet, grasping at clothing and bedrails, picking at empty air, constipation, and scanty urination. The tongue body is crimson, coating yellow and scorched or black and rough. This is internal closure due to excess heat. (2) Red face, coarse breathing, locked jaw, open eyes, clenched fists, slurred speech, fever, constipation, and deep coma. The tongue coating is yellow and greasy, and the tongue body is fat and short. This is internal closure due to phlegm-fire. (3) High fever, dry mouth without desire to drink, epigastric stuffiness and distress, deep coma, appearing dazed or drunk, lethargy, preference for lying facing the wall, reluctance to speak, or preferring closed eyes, or open eyes but aversion to light. This is internal closure due to dampness clouding the mind.
[Pulse] For heat closure, the pulse must be deep, solid, and rapid; forceful indicates excess heat, while soggy and rapid indicates summerheat. For phlegm closure, the pulse must be slippery and large. For dampness clouding, the pulse must be soggy and rapid, or weak and powerless.
[Treatment] For internal closure due to excess heat with constipation, Xili Chengqi Decoction (Rhino Horn and Coptis Purging Decoction) is suitable. (Rhinoceros Horn 1 qian, Coptis Chinensis Rhizome 1 qian, Raw Rheum Palmatum Root 3 qian, Immature Bitter Orange 1.5 qian, Mirabilite 2 qian, Magnolia Officinalis Bark 0.5 fen.) Add Fresh Rehmannia Root 6 qian and Forsythia Fruit 3 qian as the main ingredients. Niuhuang Wan (Calculus Bovis Pill), Zixue Dan (Purple Snow Elixir), and Zhibao Dan (Precious Treasure Elixir) should be added according to clinical judgment. For internal closure due to phlegm-heat, presenting with locked mouth and muteness similar to Jue syndrome, Wolong Dan (Sleeping Dragon Powder) should be used first. (Calculus Bovis and Gold Leaf each 4 fen, Borneol, Schizonepeta Spike, Datura Metel Flower each 2 qian, Musk and Cinnabar each 5 fen, Toothed Soap Pod 1.5 qian, Asarum Root 1 qian, Centipede Ash 2.4 fen, all ground into extremely fine powder.) Snuff into the nose to induce sneezing to open the Lung orifice. Then use Daotan Kaiguan San (Phlegm-Guiding Orifice-Opening Powder) (seen in Yushu's *Huiyao of Treating Carbuncles*). Take 8 fen mixed with boiled water to expectorate thick phlegm. Follow with Xuegang Soup (Snow Broth) (Aged Sea Cucumber washed bland 2 liang, Large Water Chestnut 5 pieces, remove umbilical stalk). Decoct, add Radish Juice and Pear Juice 1 cup each, and fresh Calamus Rhizome 1.5 qian crushed for juice. Mix with Niuhuang Qingxin Wan (Calculus Bovis Clearing Heart Pill) and administer slowly, divided into two doses. For dampness clouding, Fangxiang Zhuhui Tang (Fragrant Aromatic Eliminating Filth Decoction) is suitable. (Agastache Rugosus, Eupatorium Fortunei, Amomum Cardamom Seed, White Mustard Seed, Talcum, Curcuma Aromatica Rhizome, Magnolia Officinalis Bark, Apricot Kernel, Coix Seed). Add Fresh Reed Rhizome 2 liang and Taiyi Zijin Pian (Taiyi Purple Gold Tablet) 8 fen mixed in. For constipation, add Lu Shi Runzi Wan (Lu's Moistening Pill) (Raw Rheum Palmatum Root 1 liang, Washed Pinellia Tuber, Peucedanum Root, Raw Hawthorn Flesh, Pueraria Lobata Root, Tangerine Peel, Atractylodes Macrocephala Rhizome, Immature Bitter Orange, Areca Seed each 1.25 qian, dried and powdered, pillified with Qu paste). Take 3 qian separately swallowed. For dampness clouding with predominant heat, Ye's Shenxi Dan (Leaf's Divine Resonance Elixir) is added. (Rhinoceros Horn 6 qian crushed for juice, fresh Calamus Rhizome 6 qian, fresh Honeysuckle Flower 1.6 liang, fresh Rehmannia Root 4 liang, these three crushed for juice; Green Forsythia Fruit 1 liang, Human Waste Mound 4 qian, Indigo Naturalis 9 qian, Scutellaria Baicalensis Root 6 qian, Fermented Soybean 8 qian, Scrophularia Ningpoensis Root 7 qian, Old Arnebia Root 4 qian, Pueraria Lobata Root 4 qian, all sun-dried and finely powdered, mixed with juices, fermented soybeans boiled soft and pillified, each pill weighing 3 qian). Take mixed with boiled water.
[Xiu's Commentary] Zhou Danyan said: At the onset of warm pathogen, if there is lower back pain, body ache, hidden pulse, coma, dry throat, and muteness, it is internal closure by heat pathogen. If treatment is not appropriate, death comes quickly. Generally, when pathogen arrives rapidly and directly transmits to the Pericardium, internal closure and coma occur. Or if heat transmits to the Stomach Fu and combines with turbid stagnation, it also causes delirium and coma. Dampness and turbidity most easily confuse the spirit. Often, at the onset of warm disease, one can experience blurred consciousness and irritability without knowing the source of suffering. Occasionally, consciousness is clear and autonomous, but dreams are restless, or seeing things with closed eyes, which marks the beginning of delirium. If damp-heat is severe, it steams the Danzhong (Chest Center) and clouds the Pericardium, leading to deep coma, appearing drunk or dazed, lethargy, little thirst, preference for lying facing the wall, closed eyes, and aversion to light. It is suitable to use aromatic transformation of turbidity and pungent-light dispersal of Qi. (Full Artemisia Annua, Eupatorium Fortunei, Amomum Cardamom Seed, Apricot Kernel, Forsythia Fruit, Talcum, Curcuma Aromatica Rhizome, fresh Calamus Rhizome, Raw Coix Seed, Anemarrhena Asphodeloides Rhizome, Catharanthus Roseus). This allows Qi to move and turbidity to transform, clearing the mist to reveal the blue sky. This is the treatment method for dampness clouding. Regarding heat transmitting to the Ying level, the tongue color must be crimson without coating. If there is crimson tongue with yellow-white coating, or semi-coating, this is Qi-level constrained heat, not Blood level. It is suitable to use pungent-moistening to guide out pathogen and light-clearing to drain heat. One must strictly avoid bitter-cold ice-freezing and yin-nourishing cloying substances, which cause Qi-level pathogen to be constrained and sink inward, resulting in pure crimson no-coating tongue. Those who do not have ice-freezing but have pure crimson bright tongue and coma, this is pathogen transmitting to the Pericardium. It is suitable to use Rhinoceros Horn, fresh Rehmannia Root, Coptis Chinensis Rhizome, Honeysuckle Flower, Forsythia Fruit, Curcuma Aromatica Rhizome, fresh Calamus Rhizome, Bamboo Sap, Ginger Juice, etc. In clearing and transforming, assist with pungent-moistening to open closure. If the tongue color is purple-dark and moist to touch, it indicates old blood stasis in the chest and diaphragm clashing with heat. It is suitable to use fresh Rehmannia Root, Rhinoceros Horn, Moutan Cortex, Salvia Miltiorrhiza Root, Red Peony Root, Curcuma Aromatica Rhizome, Pueraria Lobata Root, Peach Kernel, Lotus Root Juice to cool blood and resolve stasis. Otherwise, stasis-heat intermingling obstructs the orifices, leading to manic-like symptoms. There are also cases of new summerheat received in summer, comatose and startled, called Summerheat Jue, caused by heat qi blocking the orifices. When pathogen enters the collaterals, Niuhuang Wan and Zhibao Dan, aromatic and opening orifices, can be effective. After consciousness returns, use cooling Blood level herbs such as Forsythia Heart, Bamboo Leaf Heart, Scrophularia Ningpoensis Root, fresh Rehmannia Root, Honeysuckle Flower, Mung Bean Coat, Ophiopogon Japonicus Rhizome. At the onset, wind-dispersing drugs are strictly contraindicated; summerheat-fire pathogen becomes more intense with wind drugs.
[Lian's Examination] Internal closure by heat pathogen, coma and delirium, requires first distinguishing the depth of invasion and severity to determine the formula. If heat initially steams the Heart Meridian, causing irritability and excessive talking, occasionally confused speech, although pathogen has sunk, it is still shallow and mild. Only Danxi Qingxin Tang (Danxi Clearing Heart Decoction) is needed, removing Mang Xiao and Da Huang, to vent Wei and penetrate Ying. When it sinks into the Pericardium, speaking wildly, seeing hallucinations, suspecting ghosts and gods, the pathogen is deeper and heavier. First use Chazhu Dengxin Tang (Tea Bamboo Centipede Decoction) (Fine Bud Tea 5 fen, Rolled Heart Bamboo Leaf 30 pieces, Centipede 2 bunches) to swallow Wanshi Niuhuang Wan (Wanshi Calculus Bovis Pill) 1-2 pills, often effective. If after Jue, still not clear,反而 (instead) comatose and mute, completely unconscious, then heat pathogen directly sinks into the Heart, extremely deep and heavy. Urgently use Xinding Niuhuang Qingxin Wan (Newly Formulated Calculus Bovis Clearing Heart Pill) or Angong Niuhuang Wan, or even Guashuang Zixue Dan (Melon Frost Purple Snow Elixir), mixed with Shishi Xidi Tang (Shi's Rhino Earth Decoction) (Black Rhinoceros Horn, fresh Rehmannia Root, Green Forsythia Fruit, Honeysuckle Flower, Curcuma Aromatica Rhizome, Duck Pear Juice, Light Bamboo Sap, Ginger Juice, fresh Calamus Rhizome, Living Reed Rhizome, Centipede) to open and penetrate. Still possible to save 1-2 out of 10. Or use Jiajian Fuman Jian (Modified Fuman Decoction) (fresh Rehmannia Root 5 qian, fresh Dendrobium Nobile Stem, Anemarrhena Asphodeloides Rhizome, Moutan Cortex, Cinnabar-Poria 2 qian each, Ophiopogon Japonicus Rhizome, Akebia Caulis, Tangerine Peel, fresh Calamus Rhizome 1 qian each, Rhinoceros Horn Juice 1 ladle, Calculus Bovis 1 fen, from Zhu Chunqu's *Ge Fang Ji Lun*) mixed with 4-5 Jue Syndrome Fanhun Dan (Jue Syndrome Soul-Returning Pills). Also possibly saving 1 out of 10. If ineffective, internal closure and external collapse will lead to death. This is the sequence of heat sinking depth and method of drug weight. However, although coma is due to deep heat, it may involve accompanying phlegm-turbidity, damp-filth, Stomach excess, blood stasis, toxin attack, or Chong-Meridian rebellion, all relating to the nervous system. Distributed in Heart, Lung, and Stomach meridians, i.e., the 10th pair Vagus Nerve, governing perception and movement of Heart, Lung, and Stomach. Pathogen knotting here causes coma. Liver, Kidney, Chong, and Du meridians also have sympathetic nerve reflex actions. From this, Lung governs Qi; Qi closure causing coma is due to phlegm-turbidity confusing the nerves. Thus called Phlegm Confusion or Phlegm Jue. Treatment should first use Wolong Dan (Calculus Bovis and Gold Leaf each 4 fen, Borneol, Charred Schizonepeta Spike, Datura Metel Flower each 2 qian, Musk and Cinnabar each 5 fen, Toothed Soap Pod 1.5 qian, Asarum Root 1 qian, Centipede Ash 2.5 fen, all ground fine). Snuff to sneeze to open Lung orifice. Then Daotan Kaiguan San (recorded in Yushu's *Huiyao*) 1 qian mixed with boiled water to expectorate thick phlegm. If phlegm is expelled but consciousness remains unclear, urgently use Xijiao Erzhi Yin (Rhino Horn Two Juices Drink) (Rhinoceros Horn Juice 5 spoons, Raw Radish Juice half bowl, Pear Juice 2 ladles, Snow Water 3 cups boiled, mix three juices and take immediately). Mixed with Lianxiong Dan (Refined Realgar Pill) (Realgar 1 fen, Natrii Sulfas 6 fen, ground fine together in copper spoon, melt gently over fire, stir evenly, when liquid, filter clear into bowl, wait to congeal, mold into ingot). 3 li or 5 li, slowly administer cold, three times a day. Often seen spitting several bowls of clear sticky phlegm, then consciousness fully clears. Finally use Pipaye Yinzi (Loquat Leaf Decoction) (*Waitai* formula) mixed with Yanzhi Chuanbei (Rock Processed Sichuan Fritillary Bulb) (Lianchen empirical formula) 1-2 pieces to remove residual phlegm and regulate Lung Qi. Or use Erchen Tang (Two-Aged Decoction) to conclude treatment. This is the method for severe Phlegm Confusion. For those with damp-filth confusion, due to extreme damp-heat constraint confusing nerves, called Damp Clouding. Treat with aromatic repelling filth and pungent-light opening closure. Huopo Xialing Tang (Magnolia Bark and Poria Decoction) remove Cardamom and Magnolia, add Asarum Root 3 fen, White Mustard Seed 8 fen, Reed Shoot 1 liang, Talcum 5 qian, decoct water substitute, drink hot, closure opens. Severe cases mix Taiyi Zijin Dan (Taiyi Purple Gold Pill) 1 pill, always effective. If heat is slightly heavier, use cooling penetrating heat and aromatic fierce opening orifices. Qingfang Touxie Tang (Clear Fragrant Penetrating Pathogen Decoction) (fresh Calamus Rhizome 1.5 qian, Landsberg Laurel Leaf 2 qian, Mint Leaf 8 fen, Artemisia Annua Brain 1.5 qian, fresh Imperata Rhizome 40 stalks, Living Reed Rhizome 1 liang, Zijin Pian 5 fen) also frequently effective. Master Fan often uses Huopo Erchen Tang, also frequently effective. Or remove Zijin Pian from this formula, grind and mix Suhe Wan (Styrax Pill) 1 pill, especially effective. For Stomach excess causing coma, it belongs to Stomach heat steaming the brain, brain inflammation, causing coma, head shaking, eye staring. Extending to spinal cord and tendons inflammation, limbs convulse, even opisthotonos. Stomach is the sea of five Zang and six Fu, its clear Qi ascends to eyes, its fierce Qi rushes to head, follows throat, ascends to orifices, follows eye system, enters brain network. Brain is the mansion of Original Spirit, so Stomach heat steaming brain inevitably manifests nervous diseases. This is the most common condition in warm-heat diseases. For blood stasis causing coma, accumulated blood confuses nerves. Accumulated blood in Upper Jiao belongs to Pericardium, pulse fine, limbs cold, chest bi pain and syncope, called Blood Knot Chest. Method should open horizontally and reach laterally, Jiawei Guizhi Honghua Tang (Modified Cinnamon Twig and Safflower Decoction) (Guizhi Tang plus Safflower, Peach Kernel, Clam Shell). If tongue red dry, pulse wiry rapid, Tao's Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction) plus Da Huang, Peach Kernel, Safflower, Immature Bitter Orange is most appropriate. Accumulated blood in Middle Jiao belongs to Spleen collaterals, epigastric pain radiating to hypochondrium, pulse choppy, limbs cold, distension pain mostly on left hypochondrium, named Spleen Distension. Hexie Zhuxie Tang (Blood Harmonizing Pathogen Expelling Decoction) (Bile-treated Bupleurum Root, Schizonepeta Spike, Processed Cyperus Rotundus Rhizome, Tender Perilla Stem, Gentiana Macrophylla Root each 1.5 qian, Magnolia Officinalis Bark, Immature Bitter Orange each 1 qian, Ligusticum Wallichii Rhizome 8 fen, Motherwort Herb, Landsberg Laurel Leaf each 3 qian, Jiangtong 1 qian, Ginger Skin 5 fen) very effective. Wuzhi Songzhen Tang (Five Branch Pine Needle Decoction) (Tender Perilla Branch 1.5 qian, Cinnamon Twig 5 fen, Camphor Branch, Peach Branch each 6 qian, Wine-fried Tender Mulberry Branch 2 chi, Green Pine Needle 8 qian, He's Empirical Formula) also effective. Severe cases add Jin Gui Biejia Jian Wan (Golden Cabinet Softshell Turtle Decoction Pill) 4-5 qian, or Kuanpeng San (Broad Distension Powder) (Ye's Empirical Formula) 1 qian, effect fastest. Accumulated blood in Lower Jiao belongs to Liver collaterals and Chong Meridian, left pulse wiry choppy, limbs cold, loose black stool, free urination, coma like mania. Treatment should disperse Qi, resolve knots, penetrate collaterals, unblock stasis. Ye's Jiajian Xiaochaihu Tang (Modified Minor Bupleurum Decoction) (Bile-treated Bupleurum Root, Scutellaria Baicalensis Root, Honey-fried Licorice Root, fresh Rehmannia Root, Moutan Cortex, Peach Kernel, Hawthorn Flesh, or Rhinoceros Horn) or Shu's Zengsun Xiaochaihu Tang (Shu Chi Yuan's *Shanghan Jizhu* formula), use according to syndrome. Prolonged leads to Liver Distension and Blood Gu, treat with opening depression and unblocking collaterals, e.g., Xinjia Jiangfu Tang (Newly Added Crimson Return Decoction) (Inula Flower wrapped decoct, True Xinjiang, Original Peach Kernel, Biota Seed, Angelica Sinensis Root Tip, Cuttlebone, Corydalis Yanhusuo, Toosendan Fruit, Rubia Cordifolia Root, Green Onion Tube, Xu's Medical Essentials Formula), Kaiyu Tongluo Yin (Depression-Opening Collateral-Unblocking Decoction) (Chen Xiang Tuan, Curcuma Aromatica Rhizome, Corydalis Yanhusuo, Polygala Tenuifolia Root, True Xinjiang,宣木瓜, Dung Beetle, Trogopterorus Faeces, Akebia Caulis, Bergamia Fruit Slice, Luffa Sponge Fiber, Liquidambar Fructus, Raw Coix Seed), Kaiyu Zhengyuan San (Depression-Opening Right Origin Powder) (Raw Atractylodes Macrocephala Rhizome, Tangerine Peel, Green Tangerine Peel, Cyperus Rotundus Rhizome, Hawthorn Fruit, Sea Flour, Platycodon Grandiflorus Root, Poria, Amomum Cardamom Seed, Corydalis Yanhusuo, Malt, Licorice Root, Medicated Leaven), Dai Dang Wan (Replace Dang Pill) (Wine-fried Rheum Palmatum Root 4 liang, Peach Kernel 30 grains, Stir-fried Softshell Turtle Carapace, Vinegar-fried Curcuma Zedoaria Rhizome, Angelica Sinensis Root Tail, Fine Rehmannia Root, Mirabilite each 1 liang, Cinnamon Twig 3 qian, powdered, honey pillified, size of radish seed. If accumulated blood in upper part, lie supine without pillow at dusk, swallow with saliva, let stop in throat to search and purge stasis accumulation, take far from meals for middle part, empty stomach for lower part, all pill-sized as mulberry seed, decoct with Bailao Water. If blood old and formed accumulation, attacking does not move, remove Angelica and Rehmannia, double Curcuma Zedoaria and Cinnamon). Taoren Chengqi He Xiaoyao San Jiawei (Peach Kernel Purging Qi Combined with Free Wanderer Powder Modified) (Original Peach Kernel, Whole Angelica Sinensis, Red Poria each 3 qian, Raw Rheum Palmatum Root 1.5 qian, Red Peony Root 2 qian, Weathered Niter 1 qian, Bupleurum Root, Mentha Haplocalyx, Honey-fried Licorice Root, Cinnamon Twig each 5 fen, Sun-dried Atractylodes Macrocephala Rhizome 8 fen, Asarum Root 3 fen, Mole 10, powdered wrapped decoct) etc., select temporarily according to syndrome. For toxin attack causing coma, blood toxin attacking Heart, named Blood Closure. Three syndromes. One is Warm Toxin scorching blood, blood toxin attacking Heart, method should purgatively descend, e.g., Taoren Chengqi Tang combined with Didang Wan. Two is postpartum accumulated stasis, blood toxin attacking Heart, suitable Huisheng Zhibao Dan (Hua's Gynecology Formula) most spiritual. Heishen Wan (Century-old Beijing Ink 2 sticks, rootless water ground to thick juice, poured into porcelain plate, sun-dried scraped down, ground fine, each dose approx 4 qian clean ink powder, Century-old Barn Smoke Dust 2 qian, burning various wild grasses best, taking smoke from stove door, Tian Mastax 2 qian, Huai Wheat Flour 2 qian, Red Gold Foil 50 sheets all ground fine, weigh accurately, grind uniformly, take 1 qian Huai Wheat Flour, make paste for pill, gold foil coat, each pill approx 1 fen, outer wax seal, mild case take 1 pill, severe case 2-3 pills, send down with child urine and aged wine) most stable and effective. Three is Uremic Toxin entering blood, blood toxin attacking Heart, even blood toxin ascending to brain, syndrome extremely critical, urgently need opening orifices, promoting urination and expelling toxin. Daochi Xiexin Tang (Guiding Outward Draining Heart Decoction) (Fresh Rehmannia Root, Akebia Caulis, Licorice Root Tip, Light Bamboo Leaf, Small Coptis Chinensis Rhizome, Green Scutellaria Baicalensis Root, Gardenia Jasminoides Fruit, Anemarrhena Asphodeloides Rhizome, Cinnabar-wrapped Poria, Ophiopogon Japonicus Rhizome, Yi Yuan San) mixed with Xipo Zhibao Dan (Rhino Amber Precious Treasure Elixir). Or Daochi combined with Jiawei Huzhang San (Modified Polygonum Multiflorum Powder) (Fresh Rehmannia Root 1 liang, Light Bamboo Leaf 1.5 qian, Raw Licorice Root Tip, Akebia Caulis each 1 qian, Fresh Achyranthes Bidentata Root 1 liang, Chrysanthemum Coronal Fruit 3 qian, Amber Powder 5 fen mixed, Musk 1 fen mixed) mixed with Ju Fang Laifu Dan (Bureau Formula Returning Life Pill) 2-3 qian, still possibly saving 1-2. These are all methods for opening and penetrating real closure.
[Bingzhang's Commentary] Heart is the master of the whole body, Heart stores Spirit, its substance is clear and empty, covered by membrane network (i.e., Pericardium), which is the palace of Spirit, the inner orifice of Spirit Qi entry and exit. Connects upward to Brain. Spirit takes Heart as residence, Fontanelle as gate, thus Heart is the organ storing Spirit, Brain is the mansion of Original Spirit, where Mingming emerges, Lingji develops. If steamed by Phlegm-Fire, closed by Stasis-Heat, then Heart Spirit suddenly lost, Mingming internally chaotic, delirious like mania, or becoming Jing or Jue, urgently internal closure and external collapse. Without careful differentiation, how can one revive the dead? Wu Jutong said, causes of internal closure delirium, recorded in *Shanghan Lun*, already eight items. Those delirious from Fire coercion, those delirious from sweating, those delirious from diarrhea, those delirious from dry feces in intestine, those delirious from Three Yang combined disease, those delirious after passing the meridian, those delirious from Yang exhaustion, all should combine color and pulse, detail differentiate cause and syndrome to rescue. As for Ye's *Wenbing Lunzhi*, there are also those with original Heart Yang disturbance, Spirit不安 (uneasy) causing delirium, Summerheat scorching Ying, counter-flowing to Pericardium causing delirium, Phlegm stirred by fire, clouding Spirit causing delirium (above Yu and He two masters, already have empirical treatment methods). Others like Shanghan mis-suppressed, pathogen closing vessels, changing to Blood Knot Chest causing delirium, Summer-Damp pathogen closing blood vessels, heat severe coma delirium, more numerous than Shanghan. Zhang Xugu said, like Wind-Cold etc. pathogen releasing surface sweating, disease still not retreating, yet again releasing surface,反而 (instead) adding coma delirium, then further using cold purging, mistake upon mistake, until death. This is because initial ignorance, or only using Wei level drugs, pores open sweat leaks, Ying level pathogen instead sinks, or carrying Cold-Damp Yin pathogen, should use pungent-warm, but in surface drugs, mix cold drugs, both heavily vacating Wei, and cold drugs closing pathogen in blood vessels, Heart governs Ying-Blood, thus also coma delirium. If Stomach Fu pathogen heavy heat severe, Pericardium near Heart, Heart receives Stomach heat steaming forcing, thus its coma, all completely unaware of human affairs. If due to pathogen closing vessels, distance from Heart slightly far, thus calling wakes, speaking to them unaware of human affairs, if letting self sleep and Heart releases, then coma delirium occurs. Pulse must additionally be choppy stagnant, because pathogen closing vessels makes pulse choppy stagnant. This Ye's use of Guizhi Honghua Tang, adding Clam Shell, Peach Kernel, to open pathogen closure, or assisting Angelica Root Tip, Red Peony Root etc., to unblock blood vessels. If heat severe slightly assist cold flavor, no heat must warm unblock, because Blood gets cold then more closed. Also Summer-Damp pathogen abundant, to afternoon evening body heat more severe, coma delirium, to morning before noon, then consciousness clear, body heat also slight, this pathogen in San Jiao Spleen Stomach, because damp heavy constrains heat cannot penetrate release, Damp is Yin pathogen, prosperous in afternoon Yin portion, heat cannot escape outward, then internally disturbs