保命集。顺气散。治中热在胃而能食。小便赤黄微利。至不欲食为效。不可多利。（即本方）
又三化汤。治中风邪气作实。二便不通。
于本方。加羌活。
拔萃方。顺气散。消中者。热在胃。而能饮食。小便赤黄。以此下之。不可多利。微微利。至不欲食而愈。
（即本方）
阳明病。潮热。大便微硬者。可与大承气汤。不硬者。不可与之。若不大便。六七日。恐有燥屎。欲知之
法。少与小承气汤。汤入腹中。转失气者。此有燥屎也。乃可攻之。若不转失气者。此但初头硬。后必溏。不
可攻之。攻之必胀满。不能食也。欲饮水者。与水则哕。其后发热者。必大便复硬而少也。以小承气汤和之。
不转失气者。慎不可攻也。（不可与之。成本。脱可字。玉函。作勿与之。此有燥屎也。成本。无也字。转失
气。玉函。并作转矢气。其后发热。玉函。作其后发潮热。周本。钱本。失。作矢。千金。下二转矢气作转气。）
〔成〕潮热者实。得大便微硬者。便可攻之。若不硬者。则热未成实。虽有潮热。亦未可攻。若不大便六
七日。恐有燥屎。当先与小承气赜（正脉。全书。作渍。汪校。作探。）之。如有燥屎。小承气汤。药势缓。
不能宣泄。必转气下失。若不转失气。是胃中无燥屎。但肠间少硬尔。止初头硬。后必溏。攻之则虚其胃气。
致腹胀满不能食也。胃中干燥。则欲饮水。水入胃中。虚寒相搏。气逆则哕。其后却发热者。则热气乘虚。还
复聚于胃中。胃燥得热。必大便复硬。而少与小承气汤微利。与（全书。作以。）和之。故以重云不转失气。
不可攻内。慎之至也。〔知〕上条曰。外欲解可攻里。曰外未解未可与承气。
曰可与小承气。微和胃气。勿令大泄下。此条曰可与。曰不可与。曰乃可攻之。不可攻之。曰少与小承气。曰
以小承气和之。慎不可攻。多少商量。慎重之意。故惟手足 然汗出。大便燥硬者。始主之以大承气。若小承
气。犹是微和胃气之法也。〔汪〕转失气。则知其人大便已硬。肠胃中燥热亢甚。故其气不外宣。时转而下。
不转失气。则肠胃中虽有热。而渗孔未至于燥。此但初头硬。后必溏也。
黄仲理曰。作五段看之。
钱氏云。其后发热句。当从不转矢气句落下为是。观末句复云不转矢气者。慎不可攻。则前后照应显然矣。
而注家谓攻后重复发热。胃热至此方炽。此必无之事。下笔详慎。智虑周密者。当不应若是。魏氏曰。欲饮水
者以下。细玩原文。明系另起一头脑。而注家含混。故文离愈甚。○案虚变为实。寒转为热。岂是必无之事。发
热即言潮热。玉函可证。成氏顺文注释。却觉允当。
舒氏云。案此条原文。止在攻之必胀满不能食也。文意已毕。其下数句。平空插入。亦后人之误。案转失
气。伤寒直格。谓动转失泄之气也。为是。条辨曰。黄氏曰。矢。汉书作屎。古屎矢通。失传写误。续医说。
医学全书曰。是下焦泄气。俗云去屁也。考之篇韵。屎矢通用。窃恐传写之误。矢为失耳。宜从转矢气为是。
且文理颇顺。若以失字。则于义为难训矣。舒氏云。案矢气二字。从前书中。皆云失气。此误也。缘矢字误写
出头耳。盖矢与屎同。矢气者屁。乃矢之气也。且失字之上。无转字之理。转乃转运也。以其气由转运而出。
若果失下。夫何转之有。确为矢字无疑。然考内经。有失气语。咳而失气。气与咳俱失之类。是也。乃改作矢
者。却釜矣。张兼善曰。或问伤寒论中。所言转失气
者。未审其气何如。若非腹中雷鸣滚动。转失气也。予曰。不然。凡泄泻之人。不能泻气。惟腹中雷鸣波动而
已。然滚动者。水势奔流则声响。泄气者。失气下趋。而为鼓泻。空虚则声响。充实则气泄。故腹滚与泄气。
为不同耳。其转失气。先硬后溏者。而气犹不能转也。况大便不实者乎。
夫实则谵语。虚则郑声。郑声者。重语也。直视谵语。喘满者死。下利者亦死。（也上。玉函。有是字。
外台。以郑声者重语也为细注。直视以下。成氏以降。分为别条。只志聪。锡驹。为一条。）
〔锡〕此章。统论谵语有虚实之不同。生死之各异也。实则谵语者。阳明燥热甚。而神昏气乱。故不避亲疏。
妄言骂詈也。虚则郑声者。神气虚而不能自主。故声音不正。而语言重复。即素问所谓。言而微。终日乃复言
者。是也。直视者。精不灌目。目系急而不转也。夫谵语当无死证。若喘满者。脾肺不交。而气脱于上。故死。
下利者。脾液不收。而气陷于下。亦死。郑声者。即谵语之声。聆其声有不正之声。轻微重复之语。即是郑声。
非谵语之中。别有一种郑声也。故止首提郑声。而后无郑声之证。〔张〕喘满者。邪乘阳位而上争。气从上脱。
故主死。下利者。邪聚阴位而下夺。气从下脱。亦死也。设谵语内结。下旁流清水者。又不可误认死证也。
〔钱〕喘则膻中迫促。而气不接。满则传化不通。而胃气绝。故死。
证治要诀曰。谵语者。颠倒错乱。言出无伦。常对空独语。如见鬼状。郑声者。郑重频繁。语虽谬而谆谆
重复不自已。年老之人。遇事则谇语不休。以阳气虚也。二者本不难辨。须以他证别之。大便秘小便赤。身热
烦渴。而妄言者。乃里实之谵语也。小便如常。大便洞下。或发躁。或反发热。而妄言者。乃阴隔阳之谵语也。
此谵语郑声。虚实所以不同也。
医学纲目曰。谵语者。谓乱语无次第。数数更端也。郑声者。谓郑重频烦也。只将一句旧言。重叠频言之。
终日殷勤。不换他声也。盖神有余。则能机变而乱语。数数更端。神不足则无机变。而只守一声也。成无己谓
郑声为郑卫之声。非是。
伤寒选录曰。郑声。说过又说也。
舒氏云。李肇夫曰。重字读平声。重语。当是絮絮叨叨。说了又说。纲语呢喃。声低息短。身重恶寒。与
谵语之声雄气粗。身轻恶热者迥别。
发汗多。若重发汗者。亡其阳。谵语。脉短者死。脉自和者不死。（玉函。重发汗下。无者字。有若已
下复发其汗七字句。多下。无若字。）
〔汪〕此系太阳病转属阳明谵语之证。本太阳经得病时。发汗多。转属阳明。重发其汗。汗多亡阳。汗本
血之液。阳亡则阴亦亏。津血耗竭。胃中燥实而谵语。谵语者。脉当弦实。或洪滑。为自和。自和者。言脉与
病不相背也。是病虽甚不死。若谵语脉短者。为邪热盛正气衰。乃阳证见阴脉也。以故主死。或以阳亡为脱阳。
脱阳者见鬼。故谵语。拟欲以四逆汤。急回其阳。大误之极。〔柯〕亡阳。即津液越出之互辞。
案方氏以此条。为太阳经错简。喻氏辨其误。是也。程氏锡驹。并以此条证。为脱阳。亦非是。
伤寒若吐若下后不解。不大便五六日。上至十余日。日晡所发潮热。不恶寒。独语如见鬼状。若剧者。
发则不识人。循衣摸床。惕而不安。（【原注】一云。顺衣妄撮。怵惕不安。）微喘直视。脉弦者生。涩者死。
微者。但发热谵语者。大承气汤主之。若一服利。则止后服。（成本。止上。脱则字。晡下所字。玉函。作时。
摸床。
玉函。作撮空。脉经。作妄撮。庞氏。亦作妄撮。注云。常见有此撮空候。故改之。惕而。玉函。脉经。作怵
惕。脉经。谵语下。无者字。是。五六日下。无上字。）
〔汪〕此条举谵语之势重者而言。伤寒若吐若下后。津液亡而邪未尽去。是为不解。邪热内结。不大便五
六日。上至十余日。此为可下之时。日晡所发潮热者。腑实燥甚。故当其王时。发潮热也。不恶寒者。表证罢
也。独语者。即谵语也。乃阳明腑实。而妄见妄闻。病剧则不识人。剧者。甚也。热气甚大。昏冒正气。故不
识人。循衣摸床者。阳热偏胜。而躁动于手也。惕而不安者。胃热冲膈。心神为之不宁也。又胃热甚。而气上
逆则喘。今者喘虽微。而直视。直视则邪干脏矣。故其死生之际。须于脉候决之。后条辨云以上见证。莫非阳
亢阴绝。孤阳无根据。而扰乱之象。弦涩皆阴脉。脉弦者为阴未绝。犹带长养。故可生。脉涩者为阴绝。已成涸
竭。以故云死。其热邪微。而未至于剧者。但发潮热谵语。宜以大承气汤。下胃中实热。肠中燥结。一服利止
后服者。盖大承气。虽能抑阳通阴。若利而再服。恐下多反亡其阴。必至危殆。可不禁之。〔钱〕伤寒法当先
汗。此但曰若吐若下后不解。明是当汗不汗。而误吐误下。以致外邪内陷。而不解也。〔柯〕如见鬼状独语。与
郑声谵语不同。潮热不恶寒。不大便。是可下证。目直视不识人。循衣摸床等症。是日晡发热时事。不发热自
安。故勿竟断为死症。凡直视谵语。喘满者死。此微喘而不满也。
伤寒准绳。赵嗣真云。此段当分作三截看。自伤寒云云。止如见鬼状。为上一截。是将潮热谵语。不恶
寒不大便。对为现证。下文又分作一截。以辨剧者微者之殊。微者但发热谵语。但字为义。以发热谵语之外。
别无他证。又云。弦者阳也。涩者阴也。阳病见阴脉者生。在仲景法中。弦涩者属
阴。不属阳。得无疑乎。金鉴曰。今观本文内。脉弦者生之弦字。当是滑字。若是弦字。弦为阴负之脉。岂有
必生之理。惟滑脉为阳。始有生理。滑者通。涩者塞。凡物理皆以通为生。塞为死。玩后条脉滑而疾者。小承
气主之。脉微涩者。里虚为难治。益见其误。○案辨脉。以弦为阴脉。故金鉴根据赵氏之言。有此说。然而弦与滑。
字形音韵迥别。决无相误之理。汪注原于成氏为允当。不复容他议也。弦义。详予所着脉学辑要。
本事方曰。有人病伤寒。大便不利。日晡发潮热。手循衣缝。两手撮空。直视喘急。更数医矣。见之皆
走。此诚恶候。得之者十中九死。仲景虽有证而无法。但云脉弦者生。涩者死。已经吐下。难以下药。谩且救
之。若大便得通。而脉弦者。庶可治也。与小承气汤一服。而大便利。诸疾渐退。脉且微弦。半月愈。予尝观
钱仲阳小儿直诀云。手寻衣领。及捻物者。肝热也。此证在玉函。列于阳明部。盖阳明者胃也。肝有热邪。淫
于胃经。故以承气泻之。且得弦脉。则肝平而胃不受克。此所谓有生之理。读仲景论。不能博通诸医书。以发
明其隐奥。吾未之见也。
张氏直解曰。丁巳秋。予治一妇人。伤寒九日。发狂面白。谵语不识人。循衣摸床。口目 动。肌肉抽
搐。遍身手足尽冷。六脉皆脱。死证悉具。诸医皆辞不治。予因审视良久。闻其声重而且长。句句有力。乃曰。
此阳明内实。热郁于内。故令脉道不通。非脱也。若真元败绝而脉脱。必气息奄奄。不久即死。安得有如许气
力。大呼疾声。久而不绝乎。遂用大承气汤。启齿而下。夜间解黑粪满床。脉出身热神清。舌燥而黑。更服小
陷胸汤。二剂而愈。因思此症大类四逆。若误投之立死。硝黄固不可以误投。参附又岂可以轻试也哉。
金鉴曰。循衣摸床。危恶之候也。大抵此证。多生于汗吐下后。阳气大虚。精神失守。经曰。四肢。诸阳
之本也。阳虚。故四肢扰乱。失所倚也。以独参汤救之。汗多者。以参 汤。厥冷者。以参附汤治之。愈者不
少。不可概谓阳极阴竭也。
阳明病。其人多汗。以津液外出。胃中燥。大便必硬。硬则谵语。小承气汤主之。若一服谵语止者。更莫
复服。（成本。止下。无者字。）
〔程〕阳明病法多汗。其人又属汗家。则不必发其汗。而津液外出。自致胃燥便硬而谵语。证在虚实之间。
故虽小承气汤。亦只一服为率。谵语止。更莫后服者。虽燥硬未全除。辄于实处防虚也。〔柯〕多汗。是胃燥
之因。便硬。是谵语之根。一服谵语止。大便虽未利。而胃濡可知矣。〔周〕经云。少阳不可发汗。发汗则谵语
者。今自汗亦如是耶。〔汪〕武陵陈氏（亮斯）云。大承气证。必如前条不大便五六日。或至十余日之久。渐渐
搏实。而后用之。今则汗多燥硬而谵语。其机甚速。此亡津液之故。而非渐渐搏实。虽坚而不大满。故止当用
小承气主之。且津液不足。非大承气所宜。服药后谵语虽止。即未大便。亦莫尽剂。恐过伤元气耳。
阳明病。谵语发潮热。脉滑而疾者。小承气汤主之。因与承气汤一升。腹中转气者。更服一升。若不转气
者。勿更与之。明日又不大便。脉反微涩者。里虚也。为难治。不可更与承气汤也。（转气。成本。并作转失
气。玉函。作转矢气。成本。脱勿上者字。及又字。千金翼。谵语下。有妄言二字。脉经。千金翼。无小承气
汤之小字。）
〔成〕阳明病。谵语发潮热。若脉沉实者。内实者也。则可下。若脉滑疾。为里热未实。则未可下。先与
小承气汤和之。汤入腹中。得失气者。中有燥屎。可更与小承气汤一升
以除之。若不转失气者。是无燥屎。不可更与小承气汤。至明日邪气传时。脉得沉实紧牢之类。是里实也。反
得微涩者。里气大虚也。若大便利后。脉微涩者。止为里虚而犹可。此不曾大便。脉反微涩。是正气内衰。为
The *Baoming Ji* (Collection for Preserving Life) contains the Shunqi San (Regulating Qi Powder), which treats heat in the stomach accompanied by the ability to eat. The patient presents with dark yellow urine and slight diarrhea. The treatment is considered effective when the patient loses their appetite; excessive diarrhea must be avoided. (This refers to the present formula.)
Additionally, there is the Sanhua Tang (Three Transformations Decoction), which treats excess conditions caused by wind-stroke pathogenic factors, presenting with obstruction of both urination and defecation.
(This formula is formed by adding Qianghuo (Notopterygii Rhizoma et Radix) to the aforementioned Shunqi San.)
The Shunqi San (Regulating Qi Powder) from the *Bacui Fang* (Extracts Formulas) treats Xiaozhong disease (a condition characterized by excessive hunger and eating). Its pathogenesis involves heat in the stomach, where the patient can eat normally but has dark yellow urine. A purgative method should be applied, but excessive diarrhea must be avoided. Only a slight loosening of the bowels is required, continuing until the patient loses their appetite, at which point the disease will be cured.
(This is the same formula as above.)
In Yangming disease, if tidal fever (fever that peaks in the late afternoon) occurs and the stool is slightly hard, Da Chengqi Tang (Major Order the Qi Decoction) may be administered. If the stool is not hard, it must not be given. If the patient has not had a bowel movement for six or seven days and one fears the presence of dry feces (hardened stool), the method to verify this is to administer a small amount of Xiao Chengqi Tang (Minor Order the Qi Decoction). After the decoction enters the abdomen, if the patient passes flatus (turning qi), this indicates the presence of dry feces, and purgation may proceed. If the patient does not pass flatus, it indicates that only the beginning of the stool is hard, while the rest will likely be loose; purgation must not be used. Improper purgation will inevitably lead to abdominal fullness and inability to eat. If the patient desires water and drinking causes hiccups, and if fever develops subsequently, the stool will likely become hard again but in smaller quantities. In such cases, Xiao Chengqi Tang should be used to harmonize the stomach and intestines. For patients who do not pass flatus, caution is essential, and purgation must not be attempted. (Note: The *Chengben* edition omits the character "ke" (may); the *Yuhan Jing* reads "wu zhi" (do not give). Regarding "this has dry feces," the *Chengben* lacks the particle "ye." "Zhuan shiqi" (turning qi) is read as "zhuan shiqi" (passing stool gas) in the *Yuhan Jing*. "Qi hou fa re" (subsequent fever) is read as "qi hou fa chaore" (subsequent tidal fever) in the *Yuhan Jing*. Zhou Ben and Qian Ben write "shi" instead of "shi." *Qianjin Fang* writes "zhuan qi" instead of "zhuan shiqi" in two instances.)
[Commentary by Cheng Wuji] Tidal fever indicates an excess pattern. When the stool is slightly hard, purgation can be performed. If the stool is not hard, the heat has not yet formed an excess pattern; even with tidal fever, purgation is contraindicated. If there is no bowel movement for six or seven days and dry feces are suspected, one should first probe with Xiao Chengqi Tang (the *Zhengmai* edition and *Quan Shu* read "zi"; Wang's correction reads "tan"). If dry feces are present, because Xiao Chengqi Tang has a mild effect and cannot fully purge, flatus will likely move downward. If there is no flatus, it means there are no dry feces in the stomach, only slight hardness in the intestines; specifically, the beginning is hard, but the rest will be loose. Purgation here would damage stomach qi, leading to abdominal fullness and inability to eat. Dryness in the stomach causes thirst; when water enters the stomach, it clashes with deficiency-cold, causing qi rebellion and hiccups. Subsequent fever occurs because heat pathogens take advantage of the deficiency and gather again in the stomach. The stomach becomes dry and heated, causing the stool to harden again in small amounts; a small dose of Xiao Chengqi Tang should be given to gently promote bowel movement and harmonize. Therefore, it is emphasized that those who do not pass flatus should not undergo internal purgation; utmost caution is required.
[Zhi's Commentary] The previous clause stated: "If exterior symptoms resolve, interior excess can be purged; if exterior symptoms persist, Chengqi formulas should not be given; Xiao Chengqi Tang may be given to gently harmonize stomach qi without causing severe diarrhea." This clause states: "may give," "may not give," "then may purge," "must not purge," "give a little Xiao Chengqi," "harmonize with Xiao Chengqi," "cautiously do not purge." The deliberation on dosage reflects extreme caution. Therefore, only when there is sweating around the hands and feet and dry, hard stool should Da Chengqi Tang be the primary treatment. Xiao Chengqi Tang, however, remains a method for gently harmonizing stomach qi.
[Wang's Commentary] Passing flatus indicates that the stool has hardened and intestinal-internal dry-heat is hyperactive, so qi cannot disperse outward but moves downward. Not passing flatus indicates that although there is heat in the intestines and stomach, the fluids have not dried out sufficiently; thus, only the beginning of the stool is hard, and the rest will be loose.
Huang Zhongli stated: This passage should be viewed in five segments.
Qian Shi said: The phrase "subsequent fever" should be understood as following the phrase "not passing stool gas." Observing the final sentence, "those who do not pass stool gas, cautiously do not purge," shows clear correspondence between the beginning and end. Commentators who claim that fever recurring after purgation indicates peak stomach heat are incorrect. Such statements lack the meticulousness expected of careful scholars. Wei Shi said: Starting from "desires water," the original text clearly shifts to a new topic, but commentators blur this distinction, further obscuring the meaning. ○ Analysis: It is not impossible for deficiency to transform into excess or cold to transform into heat. Fever becoming tidal fever is evidenced by the *Yuhan Jing*. Cheng Wuji’s linear interpretation seems appropriate.
Shu Shi commented: According to the original text, the meaning concludes at "purging will inevitably cause abdominal fullness and inability to eat." The subsequent sentences appear to be interpolated later and are likely errors by later authors. Regarding "zhuan shiqi," *Shanghan Zhige* explains it as the movement and discharge of qi, which is correct. *Tiaobian* cites Huang: "Shi" (arrow) was written as "Shi" (feces) in the *Han Shu*; in ancient texts, "Shi" and "Shi" were interchangeable, and "Shi" (loss) is a transcription error. *Xu Yishuo* and *Yixue Quan Shu* state this refers to lower jiao qi discharge, commonly known as passing gas. Examining *Pian Yun*, "Shi" and "Shi" are used interchangeably; I suspect "Shi" was mistakenly written as "Shi," so "zhuan shiqi" should be adopted. Moreover, the logic flows better this way; using "Shi" makes the meaning difficult to interpret. Shu Shi added: In earlier texts, "Shiqi" was always written as "Shiqi," which is an error caused by mistakenly adding a stroke to "Shi." Essentially, "Shi" is synonymous with "Shi" (feces); "Shiqi" is gas from feces. Furthermore, it makes no sense to have "Zhuan" (turn/rotate) before "Shi" (loss); "Zhuan" implies rotation, as the gas is expelled through rotation. If it were truly "Shi," what would be rotating? It is undoubtedly "Shi." However, examining the *Neijing*, there is mention of "Shiqi" (loss of qi), such as "coughing with loss of qi, qi lost along with coughing." Thus, changing it to "Shi" is superfluous. Zhang Jianshan asked: What kind of qi is referred to as "zhuan shiqi" in the *Shanghan Lun*? Is it rumbling in the abdomen? I replied: No. In diarrhea, qi cannot be discharged, only rumbling occurs. Rumbling is caused by flowing water creating sound; discharging qi involves qi moving downward, creating鼓胀 (drum-like distension). Emptiness creates sound, fullness allows qi discharge. Thus, abdominal rumbling and qi discharge are different. In cases of initial hardness followed by looseness, if qi cannot rotate, how much less so for those with unformed stool?
Excess leads to delirious speech (Zhanyu); deficiency leads to monotonous repetition (Zhengsheng). Zhengsheng refers to repetitive speech. Delirium with fixed gaze and panting/fullness indicates death; diarrhea also indicates death. (*Yuhan Jing* adds "Shi" before "Ye." *Waitai Mi Yao* treats "Zhengsheng refers to repetitive speech" as a sub-commentary. From "fixed gaze" onwards, Cheng Wuji and later editions split this into separate clauses, except for Zhi Cong and Xi Ju, who kept it as one clause.)
[Xi Ju's Commentary] This chapter discusses the differences in reality vs. deficiency and life vs. death regarding delirious speech. Excess delirium results from severe Yangming dry-heat confusing the spirit and disrupting qi, leading to inappropriate speech and cursing regardless of kinship. Deficiency Zhengsheng results from deficient spirit and qi lacking autonomy, causing abnormal voice and repetitive speech, as described in the *Suwen*: "speech is faint, repeated throughout the day." Fixed gaze occurs when essence fails to nourish the eyes, causing tension in the visual axis. Delirium itself does not typically indicate death; however, if accompanied by panting and fullness, it signifies failure of Spleen-Lung interaction and qi escaping upward, leading to death. Diarrhea indicates failure of Spleen fluids to retain and qi sinking downward, also leading to death. Zhengsheng is essentially the sound of delirium, characterized by abnormal, faint, repetitive speech; it is not a distinct type of delirium. Hence, Zhengsheng is mentioned only at the beginning, with no specific Zhengsheng syndromes listed later. [Zhang] Panting and fullness occur when pathogens attack the Yang positions and ascend, causing qi to escape upward, hence fatal. Diarrhea occurs when pathogens gather in Yin positions and descend, causing qi to escape downward, also fatal. Assuming delirium with internal binding and purging of clear water, one must not mistake this for a fatal sign.
[Qian's Commentary] Panting causes constriction in the Danzhong region and disconnects qi; fullness obstructs transmission and digestion, severing Stomach qi, hence fatal.
*Zhengzhi Yaojue* states: Delirium involves confused, illogical speech, often talking alone to empty space as if seeing ghosts. Zhengsheng involves earnest, frequent repetition; although erroneous, the speech is persistent and uncontrollable. Elderly people may chatter incessantly due to Yang deficiency. These two are easy to distinguish when combined with other signs. Constipation, dark urine, fever, thirst, and妄言 (wild speech) indicate interior-excess delirium. Normal urine, profuse diarrhea, irritability, or paradoxical fever with妄言 indicate Yin-intercepting-Yang delirium. This explains the difference in reality and deficiency between delirium and Zhengsheng.
*Yixue Gangmu* states: Delirium is chaotic speech without order, frequently changing topics. Zhengsheng is earnest and frequent, repeating old phrases continuously all day without changing tone. Abundant Spirit allows adaptability and chaotic speech; deficient Spirit lacks adaptability and sticks to one tone. Cheng Wuji’s claim that Zhengsheng refers to Zheng-Wei sounds is incorrect.
*Shanghan Xuanlu* states: Zhengsheng is speaking repeatedly.
Shu Shi cited Li Zhaofu: "Zhong" (heavy/repeated) is pronounced with the level tone. "Zhongyu" means chattering, saying the same thing over and over. The voice is low and breath short, with heavy body and aversion to cold, distinctly different from delirium, which features loud voice, rough breath, light body, and aversion to heat.
Excessive sweating, or re-sweating, leads to Yang collapse (Wangyang), resulting in delirium. A short pulse indicates death; a self-harmonious pulse indicates survival. (*Yuhan Jing* omits "Zhe" after "Zhong fahan"; includes "Ruo yi xia fu fa qi han" as a seven-character sentence; omits "Ruo" after "Duo".)
[Wang's Commentary] This describes delirium in Taiyang disease transferring to Yangming. Initially contracting Taiyang, excessive sweating transferred the disease to Yangming. Re-sweating caused Yang collapse. Sweat is the fluid of blood; Yang collapse implies Yin deficiency, leading to exhaustion of fluids and blood, dryness and excess in the Stomach, and delirium. The pulse in delirium should be wiry-solid or surging-slipping, indicating self-harmony (pulse matching the disease). Self-harmony means the pulse does not contradict the illness; despite severity, death is unlikely. A short pulse in delirium indicates strong pathogenic heat and weak righteous qi, an Yang syndrome showing Yin pulse, hence fatal. Some interpret Yang collapse as Tuoyang (collapse of Yang), where seeing ghosts causes delirium, suggesting immediate use of Sini Tang to restore Yang; this is a grave error. [Ke] Wangyang is synonymous with leakage of body fluids.
Analysis: Fang regarded this clause as a misplaced Taiyang clause; Yu corrected this error correctly. Cheng Xi Ju also viewed this as Tuoyang, which is incorrect.
If Shanghan is treated with vomiting or purgation and remains unresolved, with no bowel movement for five to six days up to ten-plus days, tidal fever occurs at dusk (ribu), without aversion to cold, and the patient speaks alone as if seeing ghosts. If severe, the patient may not recognize others, grasp at clothes and bedrails, and feel terrified and restless. (Original note: Alternatively, "shun yi wang cuo, chu ti bu an.") With slight panting and fixed gaze, a wiry pulse indicates survival, a choppy pulse indicates death. If mild, presenting only with fever and delirium, treat with Da Chengqi Tang. If one dose brings relief, stop subsequent doses. (*Chengben* omits "Ze" before "Zhi"; *Yuhan Jing* reads "Shi" for "Suo"; *Yuhan Jing* reads "Cuo kong" for "Mo chuang"; *Mai Jing* reads "Wang cuo"; Pang Shi also reads "Wang cuo," noting common occurrence of grasping at air; *Yuhan Jing* and *Mai Jing* read "Chu ti" for "Ti er"; *Mai Jing* omits "Zhe" after "Zhanyu," which is correct; *Chengben* omits "Shang" after "Wu liu ri".)
[Wang's Commentary] This clause describes severe delirium. After vomiting or purgation in Shanghan, fluids are depleted but pathogens remain, causing unresolved disease. Internal binding of pathogenic heat leads to constipation for five to six days or more, making this the time for purgation. Tidal fever at dusk indicates severe intestinal dry-heat peaking during its dominant time. Lack of aversion to cold indicates resolution of exterior symptoms. "Speaking alone" is delirium, caused by Yangming intestinal excess with hallucinations. Severe cases involve confusion due to overwhelming heat clouding the righteous qi. Grasping at clothes and bedrails results from excess Yang-heat causing hand agitation. Terror and restlessness result from Stomach-heat harassing the膈 (diaphragm) and disturbing the Shen. Severe Stomach-heat causes rebellious qi and panting. Although panting is slight, fixed gaze indicates pathogen invading the Zang organs. Survival depends on the pulse. Later commentaries suggest these signs reflect Yang hyperactivity and Yin exhaustion, with lone Yang lacking foundation. Wiry and choppy pulses are Yin pulses. A wiry pulse indicates Yin is not exhausted and retains nurturing capacity, suggesting survival. A choppy pulse indicates Yin exhaustion and depletion, suggesting death. For milder heat causing only tidal fever and delirium, Da Chengqi Tang should be used to purge Stomach excess and intestinal dryness. Stop dosing after one successful bowel movement because excessive purgation with Da Chengqi Tang may deplete Yin, leading to danger.
[Qian's Commentary] Shanghan treatment should begin with sweating. Here, "unresolved after vomiting/purgation" implies missed sweating and mistaken vomiting/purgation, causing exterior pathogens to sink inward.
[Ke] Speaking alone as if seeing ghosts differs from Zhengsheng/delirium. Tidal fever, no aversion to cold, and constipation indicate purgation is suitable. Fixed gaze, confusion, and grasbing behaviors occur during dusk fever; without fever, the patient is calm, so do not hastily diagnose as fatal. Fixed gaze with delirium and panting/fullness is fatal; here, panting is slight and there is no fullness.
Zhao Sizhen in *Shanghan Zhunseng* divided this section into three parts. Part 1 ends at "as if seeing ghosts," presenting current symptoms of tidal fever, delirium, no aversion to cold, and constipation. Part 2 distinguishes severe vs. mild cases. Mild cases have only fever and delirium. "Dan" (only) emphasizes absence of other symptoms. He questioned whether wiry/choppy pulses being Yin contradicts "Yang disease showing Yin pulse survives." *Jin Jian* argued "Wiry" should be "Slippery." A wiry pulse is Yin-deficient and unlikely to survive; slippery is Yang and suggests survival. Slippery means open, choppy means blocked; openness leads to life, blockage to death. Citing "slippery and rapid pulse -> Xiao Chengqi Tang" and "micro-choppy pulse -> interior deficiency difficult to treat" supports this error theory. ○ Analysis: *Bian Mai* considers wiry a Yin pulse, justifying *Jin Jian*'s view. However, "Wiry" and "Slippery" differ significantly in shape and sound, making error unlikely. Wang’s commentary based on Cheng is appropriate. See *Maixue Ji Yao* for details on wiry pulse.
*Benshi Fang* recorded a case: A patient with Shanghan had constipation, dusk tidal fever, grasping at seams, grasping at air, fixed gaze, and急促 panting. Physicians fled, recognizing it as a dire prognosis (90% mortality). Zhang Zhongjing provided no specific formula, only stating wiry pulse = survival, choppy = death. Given prior vomiting/purgation, harsh drugs were risky. If stool passed and pulse was wiry, treatment might succeed. One dose of Xiao Chengqi Tang resulted in bowel movement, symptom resolution, and a micro-wiry pulse; recovery in half a month. Observing Qian Zhongyang’s *Xiao'er Zhijue*, grasping at collars/items indicates Liver heat. This case is classified under Yangming in *Yuhan Jing*. Yangming is Stomach; Liver heat invading Stomach channel requires purgation via Chengqi. A wiry pulse indicates Liver equilibrium and protection of Stomach, explaining survival potential. Reading Zhang Zhongjing requires broad knowledge of medical texts to uncover hidden meanings.
Zhang’s Direct Explanation recounted treating a woman in autumn of Ding-Si year: Nine days of Shanghan, manic, pale face, delirious, unrecognized, grasping at clothes/bed, eye/mouth twitching, muscle spasms, cold limbs, absent pulses—all signs of death. Physicians refused treatment. Upon listening to her loud, sustained cries, Zhang diagnosed Yangming internal excess with trapped heat blocking pulse flow, not collapse. True collapse would show faint breathing and quick death, not sustained strength. He administered Da Chengqi Tang via mouth opening. Nighttime passage of black stool filled the bed; pulse returned, fever subsided, mind cleared, though tongue remained dry and black. Follow-up with Xiaoxianxiong Tang for two doses led to cure. He reflected that this resembles Sini Tang syndrome; mistaking it for Sini would be fatal. Bitter-cold purgatives like Rhubarb and Mirabilite must not be misused, nor should Ginseng and Aconite be tried lightly.
*Jin Jian* noted: Grasping at clothes/bed is a critical sign. Usually arising after sweating/vomiting/purgation, it stems from severe Yang deficiency and loss of spiritual control. The Classics state limbs are the root of Yang; deficiency causes limb agitation. Treat with Dushen Tang (Single Ginseng Decoction); for sweating, use ... Tang; for cold extremities, use Shenfu Tang. Many recover; do not assume it is solely Yang-extreme Yin-depletion.
In Yangming disease, excessive sweating causes fluid loss, Stomach dryness, hard stool, and delirium. Treat with Xiao Chengqi Tang. If delirium stops after one dose, do not continue. (*Chengben* omits "Zhe" after "Zhi".)
[Cheng] Yangming disease typically involves sweating. If the patient is prone to sweating, forcing sweat is unnecessary; external fluid loss naturally causes Stomach dryness, hard stool, and delirium. The syndrome lies between excess and deficiency; thus, even Xiao Chengqi Tang should be limited to one dose. Stopping after delirium ceases prevents damaging righteousness amidst excess. [Ke] Excessive sweating causes Stomach dryness; hard stool causes delirium. Cessation of delirium after one dose indicates Stomach moisture returns, even if stool hasn't moved. [Zhou] The Classics say Shaoyang should not be sweated; sweating causes delirium. Does spontaneous sweating act similarly? [Wang] Chen Liangsi of Wuling stated: Da Chengqi Tang is for prolonged constipation (5-6 days to 10+ days) with gradual solidification. Here, excessive sweating causes rapid dryness and delirium due to fluid loss, not gradual solidification. Though hard, it is not fully full, so Xiao Chengqi is appropriate. Large Chengqi is unsuitable for fluid deficiency. Even if delirium stops, do not finish the dose if stool hasn't passed, to avoid damaging Yuan Qi.
In Yangming disease, delirium with tidal fever and a slipping-rapid pulse indicates Xiao Chengqi Tang. Administer one sheng of Chengqi Tang. If qi turns in the abdomen, administer another sheng. If qi does not turn, do not give more. If tomorrow there is still no bowel movement and the pulse becomes micro-choppy, this indicates interior deficiency, making it difficult to treat; do not give Chengqi Tang again. ("Zhuan qi" in *Chengben* is "Zhuan shiqi"; *Yuhan Jing* is "Zhuan shiqi." *Chengben* omits "Zhe" before "Wu" and "You." *Qianjin Yi* adds "Wang yan" after "Zhanyu." *Mai Jing* and *Qianjin Yi* omit "Xiao" in "Xiao Chengqi Tang".)
[Cheng Wuji] Yangming disease with delirium and tidal fever: If the pulse is deep-solid, it is internal excess, suitable for purgation. If slipping-rapid, interior heat is not yet solidified, so purgation is premature. First give Xiao Chengqi Tang to harmonize. If flatus occurs after ingestion, dry feces are present; give another sheng of Xiao Chengqi Tang to remove them. If no flatus, there are no dry feces; do not give more. By the next day, if the pulse becomes deep-solid-tight-firm, it indicates interior excess. If it becomes micro-choppy, it indicates severe interior deficiency. If micro-choppy pulse appears after successful bowel movement, it is merely interior deficiency and manageable. Here, without bowel movement, the micro-choppy pulse indicates internal decline of righteous qi, constituting