大黄（四两酒洗） 浓朴（二两炙去皮） 枳实（三枚大者炙）
上三味。以水四升。煮取一升二合。去滓。分温二服。初服汤当更衣。不尔者尽饮之。若更衣者。勿再服。
成注云。大热结实者。与大承气汤。小热微结者。与小承气汤。以热不大甚。故于大承气汤。去芒硝。又以结不
至坚。故少减浓朴枳实也。
王海藏云。大黄泄实。浓朴去痞。必痞实全者。可用。琥按浓朴。乃泄胀满之药。其去痞者。当是枳实一味也。
吴院判云。或问承气汤。仲景有大小调胃之名。何也。然伤寒邪热。传变入里。谓之入府。府者。聚也。盖邪热与
糟粕。蕴而为实也。实则潮热谵语。手足 汗出者。此燥屎所为也。如人壮大热大实者。宜大承气汤下之。小热小实
者。与小承气汤下之。又热结不坚满者。减去浓朴枳实。加甘草而和缓之。故曰调胃承气也。若病大而以小承气攻之。
则邪气不伏。病小而以大承气攻之。则过伤正气。且不及。还可再攻。过则不能复救。可不谨哉。凡用攻法。必须妙算
料量合宜。则应手而效。若不料量。孟浪攻之。必至杀人。
武陵陈氏云。方名承气。殆即亢则害。承乃制之义乎。亢极反兼胜已之化。承者以下承上也。夫天地一理。万物一
气。故寒极生热。热极生寒。物穷则变。未有亢极而不变者。伤寒邪热入胃。津液耗。真阴虚。阳胜阴病。所谓阳盛阴
虚。汗之则死。下之则愈。急以苦寒胜热之剂。救将绝之阴。泻亢甚之阳。承气汤所以有挽回造化之功也。然不言承亢。
而言承气。何哉。夫寒热流转。不过一气之变迁而已。用药制方。彼气机之不可变者。力难矫之。亦第就气机之必变者。
而一承之耳。设其气有阳无阴。一亢而不可复。则为脉涩。直视喘满者死。何则。以其气机已绝。更无可承之气也。由
是言之。圣人虽尽人工之妙。止合乎天运之常耳。不云。承气而云何。
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。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。（此条
阳明病。以潮热失气。示人以可下之法也。阳明病潮热。虽属可攻。然亦必以大便之微硬不硬。以定大承气汤之与不与。
微硬者。犹言略硬也。若潮热不大便。已六七日。恐其腹中有燥屎。欲知之法。须少与小承气汤探之。汤入腹中。转失
气者。可攻。不转失气者。不可攻。转失气者。成注云转气下失也。转失气。则知其人大便已硬。肠胃中燥。热亢甚。
故其气时转而下。俗谓之屁气是也。不转失气。则肠胃中虽有热而未至于燥。犹挟水湿此但初头硬。后必溏薄也。故虽
六七日不大便。不可以大承气汤攻之。攻之。则其人肠胃受伤。必至胀满不能食也。欲饮水者。津液去。思欲得水以自
救也。与水则哕者。胃虚不能消水。以故气逆而作哕也。设其人于误攻之后。复发潮热。则虽有胀满不能食等证。不可
为虚。其大便。必当复硬。但溏者。既去则所留者。虽硬而甚少耳。止须复以小承气汤和之。足矣。和之者。以肠胃中
小热小实。用小承气汤下之。则实热去而胃气自和。然亦必转失气者。乃可攻之。若仍不失气。并小承气不可攻之。盖
慎之至也。）
夫实则谵语。虚则郑声。郑声重语也。（重平声。此一节辩郑声谵语之不同。以为下文诸节谵语之纲领。谵语者自言
也。注已见前郑声者。语声转而重复。故仲景以重语作郑声注脚也。夫谵语与郑声。有虚实之辩。成注引经云。邪气盛
则实。精气夺则虚。谵语由邪气盛。而神识昏。郑声由精气夺。而声不全。愚以神识昏。则妄。见妄闻其语诞妄。其声
高硕。而不以次。故谓之实邪。实则胃实。所以下文用大小承气。皆谵语证也。愚以声不全。则无妄。见妄闻之状。其
语倒乱。其声低微不正。故谓之虚。仲景恐人以谵语认作郑声。而以实证作虚证治。故其于郑声别无证治之条。可见伤
寒无虚证明矣。究竟郑声一候。亦由邪实而正虚。不可认以为真虚也。后人有以郑声为虚证。无邪可攻。而以温补法治
之者。大半皆死。可不审之。）
直视。谵语喘满者死。下利者亦死。（此先言谵语之死证也。经云。五脏六腑之气。皆上注于目。而为之精。直视者。
邪干于藏精。不荣于目也。夫谵语非死证。加之直视。则危矣。更加喘满者。及下利者成注云。喘满为气上脱。下利为
气下脱。是皆主死。为不治之证。）
发汗多。若重发汗者。亡其阳。谵语。脉短者死。脉自和者不死。（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。大诀之极。殊不知仲景云。亡阳者。
乃亡津液之通称。津液亡。而反用附桂等辛热之剂。吾恐脉虽和。亦必至死。条辩云。此疑太阳篇错简。）
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。止后服。（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。府实燥甚。故当其经气王时。发潮热也。不恶寒者。表证罢也。独语者。即谵语也。字释
云。病患自言为谵。则是独语如见鬼状。乃阳明府实而妄见妄闻。病剧。则不识人。剧者甚也。成注云热气甚大。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。则邪干藏矣。故其死生之机。须于脉候决之。后条辩云。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。通肠中燥结。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。）
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。更莫复服。（此条病并下
条。乃谵语宜用小承气汤之证。阳明病。指胃家实而言。其人多汗者。乃自汗出而多也。汗多。则津液外泄。胃亡津液。
则燥。肠与胃相通。胃中燥。则大便必硬。硬则热。邪不得下泄。阳明府实。因作谵语。治法。止须与小承气汤。下其
实热。若一服。实热得下。胃中稍空。则谵语止。更莫复服者。以亡津液。不堪过下故也。或问芒硝能润燥软坚。今者
胃中燥大便硬。何以不用大承气汤。余答云。武陵陈氏云。大承气汤证。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。斯言实得仲景之旨。）
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。腹中转失气者。更服一升。若不转失气。勿
更与之。明日不大便。脉反微涩者。里虚也。为难治。不可更与承气汤也。（阳明病至谵语发潮热。下证亦已审矣。本当
用大承气以攻之。只因脉滑而疾。滑者。往来流利。加之急疾。虽主有宿食内热。然成注云。脉未沉实者为里热。未实。
不可攻也。止须以小承气汤主之。然亦未敢多用。先与承气汤一升。视其失气与否。以为用药进退之法。设明日不大便。
前脉滑疾者。今反变而为微涩。乃正气内衰之诊。故曰里虚。此为难治。热邪虽盛。不可更与承气汤也。按后条辩云。
谵语潮热。脉反微涩。为里气大虚。并前此之脉滑疾。亦属虚阳泛上之假象。其言似是而非。愚以谵语潮热。脉滑疾者。
乃阳证见阳脉。其人邪气盛。而正气未衰也。故云可与承气汤。脉反微涩者。是阳证见阴脉。其人邪气盛。正气衰。故
云不可更与承气汤也。不转失气。并不大便。非肠中空虚而无物。乃胃家正气既衰。虽得汤药内助。其恶浊之物。仍然
不能下泄。故云。难治。后之人。议用补虚回阳之法。是与仲景初时用承气汤之意相反。补亡论常器之云。可用黄 人
参建中汤。亦与证不合。大抵此条病。但云难治。其非不治之证明矣。如欲用药。还宜补泻兼施之剂。）
阳明病。谵语。有潮热。反不能食者。胃中必有燥屎五六枚也。若能食者。但硬 。宜大承气汤下之。（ 与尔同自
此以下二条。乃谵语宜用大承气汤之证。谵语潮热。下证已具也。不能食。为肠胃皆实。故其屎既燥且硬。若能食为肠
实胃虚。故其屎但硬耳。俱宜大承气汤下之。尚论篇云。同一谵语潮热。故同一治法。至于药剂之大小。必有分矣。愚
按补亡论。宜大承气汤下之句。在若能食者之前。盖能食既异。治法必不相同。仲景法。宜另以调胃承气汤主之也。）
（附后例）阳明病。下血谵语者。此为热入血室。但头汗出者。刺期门。随其实而泻之。 然汗出。则愈（此条系
刺法。正文与注并穴图。详见后第十四卷刺热论中）
汗出谵语者。以其有燥屎在胃中。此为风也。须下者。过经乃可下之。下之若早。语言必乱。以表虚里实故也。下
之则愈。宜大承气汤。（此条系太阳阳明证。汗出者。本太阳经有风邪也。然汗出既多。则胃中燥实。必至谵语。所以汗
出之时。谵语者。主有燥屎在胃中。夫燥屎非胃中之物。要之胃实而至谵语。则肠中之屎必燥。此为风胜。故至燥也。
须下之者。然亦必邪过太阳经。至八九日之时。成注云。无表证。乃可下之。若下之早。则表邪乘虚。尽入于里。将向
之谵语者。至此必邪热更甚。而语言必乱。何也。以经中之邪虽罢。而表因虚。在府之热愈结。而里则实故也。皆须下
之则愈宜大承气汤。盖过经可下者。固宜用是汤。下早里实者。亦宜用是汤也。尚论篇云。必再一大下。庶大肠空。而
风邪得以并出。故自愈。此是下早里实。宜再下之义。补亡论以末二句。移之过经乃可下之句下。误矣。）
伤寒四五日。脉沉而喘满。沉为在里。而反发其汗。津液越出。大便为难表虚里实。久则谵语。（此条亦系太阳阳明
证。本太阳伤寒。至四五日。表邪入里。已非发汗之时。兼之脉沉而喘满。此喘非麻黄汤证之喘。乃胃府实热。胸膈满
而作喘。据脉沉而论。又为在里之证。医反发其汗致津液越出。越出者其出不顺。言津液由内而越于外也。津液既亡。
则胃中干燥。大便必难表虚里实义。注已见前条中。惟里实。故久则谵语。病至谵语。则下证已急。虽不出方。此承上
文之意。亦宜用大承气汤主之。以表虚里实既同。故同一治法也。补亡论用调胃承气汤。殊出不解。或问大便为难。何
至用大承气。余答云。既久而至谵语之时。则大便不惟难。而且硬。仲景法。还宜用大承气汤。的当无疑。）
（附例）二阳并病太阳证罢。但发潮热。手足 汗出大便难而谵语者。下之则愈。宜大承气汤（此条系并病谵语
之证。二阳并病者。乃太阳阳明。二经相并而病也。经病无可下之理。今者。太阳证。罢。已无恶寒头痛。在表之邪矣。
但发潮热。手足 汗出。大便难而谵语。是为阳明入府之证。故云下之则愈亦宜用大承气汤也。）
阳明病下之。心中懊 而烦。胃中有燥屎者。可攻。腹微满。初头硬。后必溏。不可攻之。若有燥屎者。宜大承气
汤（此条言阳明病下后。当再攻之证。阳明病既下之后。心中懊 而烦。似为虚烦。成注云。当与栀子豉汤。若胃中有
燥屎者。宜攻而不宜涌也。何以知之。下节云绕脐痛云云。此为辩燥屎之法。如病患腹微满而不痛。乃初硬后溏。不可
攻之。若有燥屎可攻者。还宜用大承气汤也。或问阳明病既下之矣。何以胃中犹有燥屎。余答云。病患痞满燥实证俱全。
本当用大承气。医人或止用小承气。为下之未尽。此即是上条证。）
病患不大便。五六日。绕脐痛。烦躁。发作有时者此有燥屎。故使不大便也。（此节承上文而辩有燥屎之法。阳明病
下之后。若病患不大便。又五六日绕脐痛。绕脐痛者。邪已入下脘。及肠中也。燥实。气不得通。则痛。烦躁者。邪热
Rhubarb (Four liang, washed with wine) Cinnamon Twig (Two liang, roasted and peeled) Immature Bitter Orange (Three large ones, roasted)
The above three herbs. Boil in four sheng of water. Reduce to one sheng and two he. Remove the dregs. Divide into two doses and take warm. After the first dose, bowel movement should occur. If not, drink the remaining medicine. If bowel movement has occurred, do not continue taking it.
Cheng Wuji's commentary states: For severe heat and solid accumulation, administer Da Chengqi Tang (Great Order the Qi Decoction). For mild heat and slight accumulation, administer Xiao Chengqi Tang (Minor Order the Qi Decoction). Because the heat is not severe, Mangxiao (Natrii Sulfas) is removed from Da Chengqi Tang. Furthermore, because the accumulation is not hard, the dosages of Cangzhu (Atractylodis Rhizoma) and Zhishi (Immature Bitter Orange) are reduced.
Wang Haicang says: Dahuang (Rhei Radix et Rhizoma) purges excess; Cangzhu (Atractylodis Rhizoma) eliminates fullness. It can only be used when both fullness and excess are present. My note states that Cangzhu (Atractylodis Rhizoma) is a herb for relieving distension. The herb that eliminates fullness should be Zhishi (Immature Bitter Orange) alone.
Wu Yuanpan says: Someone asks about Chengqi Tangs; Zhang Zhongjing has names for Da (Great), Xiao (Minor), and Tiaowei (Regulate Stomach). Why? However, when pathogenic heat from Shanghan (Cold Damage) transmits inward, it is called entering the Fu organs. Fu means gathering. Pathogenic heat and waste products accumulate to form excess. Excess manifests as tidal fever, delirious speech, and sweating on the hands and feet, caused by dry stool. If the person has strong heat and great excess, Da Chengqi Tang (Great Order the Qi Decoction) should be used to purge. If there is mild heat and slight excess, Xiao Chengqi Tang (Minor Order the Qi Decoction) should be used to purge. If heat accumulation is not hard or full, reduce Cangzhu (Atractylodis Rhizoma) and Zhishi (Immature Bitter Orange), add Gancao (Licorice Root) to moderate it. Hence it is called Tiaowei Chengqi Tang (Regulate Stomach Order the Qi Decoction). If the disease is severe but treated with Xiao Chengqi Tang (Minor Order the Qi Decoction), the pathogen will not be subdued. If the disease is mild but treated with Da Chengqi Tang (Great Order the Qi Decoction), healthy qi will be excessively damaged. If purging is insufficient, it can be repeated. If excessive, it cannot be rescued. Must one not be cautious? Whenever using purging methods, one must calculate precisely and dose appropriately to achieve immediate effect. Without calculation, reckless purging will inevitably kill.
Chen Shi of Wuling says: The name "Chengqi" probably implies the principle "Excess causes harm, subordination brings control." When extreme, it assumes the transformation of what controls it. "Cheng" means receiving from below. Heaven and Earth follow one principle; all things are generated by one Qi. Thus, extreme cold generates heat, extreme heat generates cold, and when things reach their limit, they change. Nothing remains extreme without changing. When Shanghan (Cold Damage) pathogenic heat enters the Stomach, body fluids are consumed, True Yin is deficient, Yang overcomes Yin. This is Yang excess and Yin deficiency. Sweating leads to death; purging leads to recovery. Urgently use bitter-cold agents to overcome heat, rescue nearly extinct Yin, and drain excessive Yang. Chengqi Tang thus has the merit of restoring vitality. But why say "Cheng Qi" instead of "Cheng Kang"? Cold and heat circulate, merely a transformation of one Qi. In prescribing herbs and formulas, for those aspects of Qi mechanism that cannot be changed, force struggles to correct them; one merely follows the Qi mechanism that must change and accommodates it. If its Qi has Yang without Yin, once extreme and irrecoverable, it results in choppy pulse, fixed gaze, wheezing, and fullness—death. Why? Because the Qi mechanism is exhausted, leaving no Qi to accommodate. Thus, although sages exhaust human ingenuity, they merely align with the constant course of Heaven. Why not say "Cheng Qi"?
Yangming disease with tidal fever and slightly hard stool may be given Da Chengqi Tang (Great Order the Qi Decoction). If not hard, do not give it. If no bowel movement for six or seven days, suspecting dry stool, the method to know is to give a small amount of Xiao Chengqi Tang (Minor Order the Qi Decoction). If after the decoction enters the abdomen, flatus occurs, this indicates dry stool, and purging may proceed. If no flatus occurs, the stool is only hard at the beginning and will likely be loose later; do not purge. Purging will cause abdominal fullness and inability to eat. If desiring water, giving water induces hiccups. Subsequent fever indicates stool will become hard again but in small quantity. Use Xiao Chengqi Tang (Minor Order the Qi Decoction) to harmonize. If no flatus occurs, strictly avoid purging. (This Yangming disease case uses tidal fever and flatus to indicate methods for purging. Although Yangming tidal fever suggests purgation is possible, one must determine whether to use Da Chengqi Tang (Great Order the Qi Decoction) based on whether the stool is slightly hard or not. "Slightly hard" means somewhat hard. If tidal fever and no bowel movement persist for six or seven days, suspecting dry stool in the abdomen, one must test with a small amount of Xiao Chengqi Tang (Minor Order the Qi Decoction). If flatus occurs after ingestion, purging is allowed; if not, it is forbidden. Flatus, as Cheng's commentary notes, is gas moving downward. Flatus indicates hardened stool and dry intestines due to excessive heat, causing gas to move down—commonly known as farting. No flatus indicates heat in the intestines without dryness, mixed with dampness, resulting in hard head and loose tail. Thus, even with no bowel movement for six or seven days, Da Chengqi Tang (Great Order the Qi Decoction) should not be used. Purging would damage the intestines and stomach, causing fullness and anorexia. Thirst for water indicates fluid loss; seeking water for self-rescue. Hiccups upon drinking indicate weak Stomach unable to transform fluids, causing rebellious Qi. If fever recurs after mistaken purging, despite fullness and anorexia, it is not deficiency; stool will harden again, though little remains. Only Xiao Chengqi Tang (Minor Order the Qi Decoction) is needed to harmonize. Harmonizing addresses minor heat and excess in the intestines; purging removes excess heat, restoring Stomach harmony. However, flatus must occur before purging. If no flatus, even Xiao Chengqi Tang (Minor Order the Qi Decoction) is contraindicated. This is utmost caution.)
Excess leads to delirious speech; deficiency leads to Zhengsheng (repetitive speech). Zhengsheng is repetitive speech. (Pronounced level tone. This section distinguishes Zhengsheng from Zhanyu (delirium) as a guideline for subsequent sections on delirium. Zhanyu refers to the patient speaking to themselves. Note seen previously. Zhengsheng involves voice changes and repetition, hence Zhang Zhongjing defines it as repetitive speech. There is a distinction between excess and deficiency in Zhanyu and Zhengsheng. Cheng's commentary cites classics: "Pathogenic excess constitutes Excess; Essence depletion constitutes Deficiency." Zhanyu arises from pathogenic excess causing mental confusion; Zhengsheng arises from essence depletion causing incomplete voice. I believe mental confusion leads to妄言 (wild speech); seeing hallucinations and hearing delusions, the speech is absurd, voice loud and irregular, thus termed Excess. Excess here refers to Stomach excess, hence Da and Xiao Chengqi Tangs are used for Zhanyu cases. I believe incomplete voice implies no wild speech; seeing hallucinations, the speech is disordered, voice low and improper, thus termed Deficiency. Zhang Zhongjing feared people mistaking Zhanyu for Zhengsheng and treating Excess as Deficiency, hence no separate treatment clauses for Zhengsheng, proving Shanghan (Cold Damage) lacks true deficiency patterns. Ultimately, Zhengsheng stems from pathogenic excess leading to healthy qi deficiency, not true deficiency. Later physicians treating Zhengsheng as deficiency without pathogenic excess, using warming tonification, mostly died. Must one not examine this carefully?)
Fixed gaze, delirious speech, wheezing, and fullness indicate death. Diarrhea also indicates death. (This first discusses fatal signs of delirium. Classics state: Qi of the five Zang and six Fu organs ascends to the eyes to nourish them. Fixed gaze indicates pathogen interfering with essence storage, failing to nourish the eyes. Delirium itself is not fatal, but combined with fixed gaze, it is critical. Adding wheezing/fullness or diarrhea, Cheng's commentary states: Wheezing/fullness is Qi escaping upward; diarrhea is Qi escaping downward. Both indicate death and untreatable conditions.)
Excessive sweating, or re-sweating, leads to Yang collapse, delirium. Pulse short indicates death. Pulse self-harmonized indicates survival. (This relates to Taiyang disease transforming into Yangming delirium. Initially contracting Taiyang disease, excessive sweating transforms it into Yangming. Re-sweating causes Yang collapse. Sweat is fluid of blood; Yang collapse implies Yin deficiency, consuming Jin-Ye (body fluids) and Blood, leading to dry Stomach excess and delirium. Delirium typically presents with wiry-solid or surging-slipping pulses, considered self-harmonized. Self-harmonized means pulse matches disease. Though severe, it is not fatal. If delirium presents with short pulse, it indicates pathogenic excess and healthy qi decline, Yang disease showing Yin pulse, thus fatal. Some interpret Yang collapse as Tuoyang (escaping Yang), where seeing ghosts causes delirium, suggesting Si Ni Tang (Frigid Extremities Decoction) to urgently restore Yang. This is a major error. Zhang Zhongjing states "Yang collapse" generally refers to fluid loss. Using acrid-hot herbs like Fuzi (Aconite Lateralis Radix Preparata) and Rougui (Cinnamomi Cortex) when fluids are lost, even if pulse harmonizes, will lead to death. Tiaobian suggests this might be a misplaced text in the Taiyang chapter.)
Shanghan (Cold Damage) after vomiting or purging remains unresolved, no bowel movement for five to six days, up to ten-plus days, tidal fever at dusk, aversion to cold absent, speaking alone as if seeing ghosts. If severe, losing recognition of others, grasping at clothes and bed, fearful and restless, slight wheezing, fixed gaze. Pulse wiry indicates survival; choppy indicates death. Mild cases with only fever and delirium are treated with Da Chengqi Tang (Great Order the Qi Decoction). If one dose produces bowel movement, stop subsequent doses. (This case describes severe delirium. After vomiting or purging in Shanghan (Cold Damage), fluids are lost but pathogens remain unresolved. Internal heat binding causes no bowel movement for five to six days, up to ten-plus days, indicating time for purging. Tidal fever at dusk indicates severe Fu organ dryness, occurring during peak meridian Qi time. Absence of aversion to cold means exterior syndrome has resolved. Speaking alone is delirium. Dictionary defines Zhanyu as patient speaking to self. Speaking alone as if seeing ghosts indicates Yangming Fu excess with hallucinations. Severe cases lose recognition. Cheng's commentary: Extreme heat confuses healthy Qi, causing loss of recognition. Grasping at clothes/bed indicates Yang heat dominance causing hand restlessness. Fearfulness indicates Stomach heat harassing膈 (Diaphragm), disturbing Shen (Spirit). Severe Stomach heat with rebellious Qi causes wheezing. Current slight wheezing with fixed gaze indicates pathogen affecting Zang organs. Survival depends on pulse. Tiaobian notes these signs reflect Yang hyperactivity and Yin exhaustion, lone Yang without foundation causing chaos. Wiry and choppy are Yin pulses. Wiry indicates Yin not yet exhausted, allowing growth, thus survival. Choppy indicates Yin exhaustion, dried up, thus death. Mild cases with only tidal fever and delirium should use Da Chengqi Tang (Great Order the Qi Decoction) to drain Stomach excess heat and unblock intestinal dryness. One dose producing bowel movement stops further use because although Da Chengqi Tang (Great Order the Qi Decoction) suppresses Yang and unblocks Yin, continued purging risks excessive fluid loss and danger. Must be prohibited!)
Yangming disease with profuse sweating leads to external fluid loss, dry Stomach, hard stool, and delirium. Treat with Xiao Chengqi Tang (Minor Order the Qi Decoction). If delirium ceases after one dose, do not administer more. (This case and the next describe indications for Xiao Chengqi Tang (Minor Order the Qi Decoction) in delirium. Yangming disease refers to Stomach excess. Profuse sweating indicates spontaneous sweating. Fluid loss dries the Stomach. Intestines connect to Stomach; Stomach dryness causes hard stool. Hardness generates heat, preventing pathogen excretion, leading to Yangming Fu excess and delirium. Treatment requires Xiao Chengqi Tang (Minor Order the Qi Decoction) to drain excess heat. If delirium stops after one dose, Stomach empties slightly, so stop administration to avoid damaging fluids from over-purging. Question: Mangxiao (Natrii Sulfas) moistens dryness and softens hardness; why not use Da Chengqi Tang (Great Order the Qi Decoction)? Answer: Chen Shi of Wuling states Da Chengqi Tang (Great Order the Qi Decoction) is for cases with no bowel movement for five to six days or more, gradually becoming solid. Here, profuse sweating causes rapid dryness and delirium due to fluid loss, not gradual solidification. Though hard, it is not fully full, so Xiao Chengqi Tang (Minor Order the Qi Decoction) is appropriate. Fluid insufficiency contraindicates Da Chengqi Tang (Great Order the Qi Decoction). Even if delirium stops, do not finish the dose if no bowel movement, to prevent excessive Qi damage. This aligns with Zhang Zhongjing's intent.)
Yangming disease with delirium and tidal fever, pulse slippery and rapid, is treated with Xiao Chengqi Tang (Minor Order the Qi Decoction). Administer one sheng of Chengqi Tang. If flatus occurs in the abdomen, administer another sheng. If no flatus, do not give more. If tomorrow still no bowel movement, pulse becomes faint and choppy, indicating interior deficiency, difficult to treat, do not give Chengqi Tang again. (In Yangming disease with delirium and tidal fever, purgative indications are clear. Da Chengqi Tang (Great Order the Qi Decoction) should theoretically be used, but slippery and rapid pulse suggests otherwise. Slippery means smooth flow; rapid indicates internal heat and retained food. Cheng's commentary: Pulse not deep-solid indicates interior heat but not sufficient excess for purging. Use Xiao Chengqi Tang (Minor Order the Qi Decoction). Do not use heavily; start with one sheng. Observe flatus to adjust dosage. If no bowel movement tomorrow and pulse changes from slippery-rapid to faint-choppy, it indicates internal healthy qi decline, termed interior deficiency. Difficult to treat. Despite excess heat, do not give Chengqi Tang. Tiaobian argues faint-choppy pulse in delirium/tidal fever indicates severe interior deficiency, and previous slippery-rapid pulse was false floating Yang. I disagree: Slippery-rapid pulse in delirium/tidal fever is Yang disease showing Yang pulse, indicating pathogenic excess with intact healthy qi, hence Chengqi Tang is suitable. Faint-choppy pulse is Yang disease showing Yin pulse, indicating pathogenic excess with declining healthy qi, hence Chengqi Tang is contraindicated. No flatus and no bowel movement do not mean empty intestines, but rather depleted Stomach Qi unable to expel turbid matter despite medication, hence difficult. Later suggestions for tonifying deficiency and restoring Yang contradict Zhang Zhongjing's initial use of Chengqi Tang. Chang Qizhi in Buwang Lun suggests Huangqi Ginseng Jianzhong Tang, which does not match the syndrome. Generally, "difficult to treat" implies not untreatable. Combination of tonification and purging is advisable.)
Yangming disease with delirium and tidal fever, yet unable to eat, indicates five or six pieces of dry stool in the Stomach. If able to eat, stool is only hard; treat with Da Chengqi Tang (Great Order the Qi Decoction) to purge. (These following two cases describe indications for Da Chengqi Tang (Great Order the Qi Decoction) in delirium. Delirium and tidal fever indicate purgative signs are present. Inability to eat indicates both intestines and Stomach are excess, so stool is both dry and hard. Ability to eat indicates intestinal excess but Stomach deficiency, so stool is only hard. Both require Da Chengqi Tang (Great Order the Qi Decoction). Shanglun Pian notes: Same delirium/tidal fever, same treatment, but dosage size differs. Buwang Lun places "treat with Da Chengqi Tang (Great Order the Qi Decoction)" before "if able to eat," implying different treatments. Zhang Zhongjing's method suggests using Tiaowei Chengqi Tang (Regulate Stomach Order the Qi Decoction) separately.)
(Attached Example) Yangming disease with bleeding and delirium is Heat entering the Blood Chamber. Only sweating on the head; puncture Qimen. Drain according to excess. Profuse sweating leads to recovery. (This case involves acupuncture. Text, commentary, and acupoint diagrams are detailed in Volume 14, Acupuncture for Heat Syndrome.)
Sweating with delirium indicates dry stool in the Stomach, caused by Wind. Purging is required, but only after the meridian stage passes. Premature purging causes chaotic speech due to exterior deficiency and interior excess. Purging leads to recovery; use Da Chengqi Tang (Great Order the Qi Decoction). (This case involves Taiyang-Yangming syndrome. Sweating indicates Wind pathogen in Taiyang. Profuse sweating dries the Stomach, causing excess and delirium. Sweating with delirium indicates dry stool in the Stomach. Dry stool is not in the Stomach proper, but Stomach excess leading to delirium implies dry intestinal stool. Wind dominance causes dryness. Purging is necessary, but only after the pathogen leaves the Taiyang meridian, around day eight or nine. Cheng's commentary: No exterior signs allow purging. Premature purging allows exterior pathogen to enter interior due to deficiency, worsening heat and causing chaotic speech. Exterior pathogen resolves, but exterior becomes deficient, while Fu heat consolidates and interior becomes excess. Purging cures both. Da Chengqi Tang (Great Order the Qi Decoction) is suitable for post-meridian purging and premature purging with interior excess. Shanglun Pian suggests a second heavy purge to empty the Large Intestine and expel Wind, ensuring recovery. This supports re-purging for premature interior excess. Buwang Lun incorrectly moves the last two sentences under "after meridian passes.")
Shanghan (Cold Damage) on day four or five, pulse deep with wheezing/fullness. Deep indicates interior. Reversely inducing sweating causes fluids to escape, making stool difficult. Exterior deficiency, interior excess, eventually leading to delirium. (This case involves Taiyang-Yangming syndrome. Initial Taiyang Shanghan (Cold Damage) on day four or five, exterior pathogen enters interior, no longer time for sweating. Pulse deep with wheezing/fullness indicates this wheezing is not Ma Huang Tang (Ephedra Decoction) type, but Stomach-Fu excess heat causing chest/diaphragm fullness and wheezing. Deep pulse confirms interior condition. Inducing sweating causes fluid escape (abnormal outward leakage). Fluid loss dries Stomach, making stool difficult. Interior excess leads to eventual delirium. Delirium indicates urgent purgative signs. Although no formula is listed, following the context, Da Chengqi Tang (Great Order the Qi Decoction) is appropriate due to matching exterior deficiency and interior excess. Buwang Lun suggests Tiaowei Chengqi Tang (Regulate Stomach Order the Qi Decoction), which is inexplicable. Question: Why use Da Chengqi Tang (Great Order the Qi Decoction) for difficult stool? Answer: By the time of delirium, stool is not only difficult but hard. Zhang Zhongjing's method dictates Da Chengqi Tang (Great Order the Qi Decoction). Undoubtedly correct.)
(Attached Example) Two Yangs concurrent disease, Taiyang signs resolved, only tidal fever, profuse sweating on hands and feet, difficult stool, and delirium. Purging leads to recovery; use Da Chengqi Tang (Great Order the Qi Decoction). (This case involves concurrent disease delirium. Two Yangs concurrent means Taiyang and Yangming meridems involved together. Meridian diseases cannot be purged. Now Taiyang signs have resolved, no aversion to cold or headache, exterior pathogen gone. Only tidal fever, profuse sweating on extremities, difficult stool, and delirium indicate Yangming entering Fu organs. Hence purging cures, using Da Chengqi Tang (Great Order the Qi Decoction).)
Yangming disease after purging, heart feels vexed and troubled, dry stool in Stomach may be purged. Abdominal slight fullness, hard head, loose tail, cannot be purged. If dry stool exists, use Da Chengqi Tang (Great Order the Qi Decoction). (This case discusses re-purging after Yangming purging. After purging Yangming disease, heart vexation resembles deficiency vexation. Cheng's commentary: Should use Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction). If dry stool exists, purging is indicated, not emesis. How to know? Next section mentions periumbilical pain. This distinguishes dry stool. If abdominal slight fullness without pain, hard head/loose tail, do not purge. If dry stool exists, use Da Chengqi Tang (Great Order the Qi Decoction). Question: Why dry stool remains after purging? Answer: Patient had full Pi-Man-Zao-Shi (fullness, obstruction, dryness, excess) syndrome, originally requiring Da Chengqi Tang (Great Order the Qi Decoction). Physician may have used only Xiao Chengqi Tang (Minor Order the Qi Decoction), resulting in incomplete purging, matching the previous case.)
Patient with no bowel movement for five to six days, periumbilical pain, irritability, occurring at times, indicates dry stool, hence no bowel movement. (This section continues distinguishing dry stool. After Yangming purging, if patient has no bowel movement for five to six days with periumbilical pain, pathogen has entered lower Wan and intestines. Dry excess blocks Qi, causing pain. Irrability is due to pathogenic heat.)