实也。虚则郑声，精神衰乏，不能自主，语言重覆，其声微短，正气虚也。
【集注】
戴元礼曰：谵语属阳，郑声属阴。经曰：实则谵语，虚则郑声。谵语者，颠倒错乱，
言出无伦，常对空独语，如见鬼状。郑声者，郑重频烦，语虽谬而谆谆不已，老年人
遇事则谇语不休，以阳气虚不精明也。此谵语、郑声虚实之所以不同也。二者本不难
辨，但阳盛里实，与阴盛格阳，皆能错语，须以他证别之，随证施治可也。
娄全善曰：余用参、耆、归、术等剂治谵语，得愈者甚多，岂可不分虚实，一概用黄
连解毒、大小承气等汤以治之乎？〔按〕其所云亦郑声也。
张锡驹曰：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，而语言重覆也。
@@@
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□语。
【注】
伤寒四、五日，入里之时也。脉沉而喘满，乃为在里之喘满，而反发其汗，津液越出
，则表虚也；汗出胃干，大便为难，则里实也。久则胃热炽盛，必发谵语也。
【集注】
方有执曰：越出谓枉道而出也。
张璐曰：伤寒四、五日，正邪热传里之时，况见脉沉在里之喘满，而反汗之，必致燥
结谵语矣。盖燥结□语，颇似大承气证，此以过汗伤津，而不致大实大满腹痛，祗宜
小承气为允当耳！
@@@
阳明病，其人多汗，以津液外出，胃中燥，大便必□，□则□语，小承气汤主之。若
一服□语止者，更莫复服。
【注】
此详上条以明其治也。阳明病其人多汗，以津液外出，胃中干燥，大便必□，久则□
语，宜以小承气汤主之，若一服利，□语止，慎不可更服也。
【集注】
张璐曰：多汗□语，下证急矣。以其人汗出既多，津液外耗，故不宜大下。但当略与
小承气汤，和其胃气，□语自止，若过服反伤津液也。
沈明宗曰：此汗多胃燥，非同实治也。
@@@
汗出□语者，以有燥屎在胃中，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。下之愈，宜大承气汤。
【注】
病自汗出而□语者，以素有燥屎在胃中，此为太阳风邪之所传也，须当下之。然必须
太阳之邪，已过阳明之经，而入阳明之府，乃可下之。若下之早，则里热未结，不但
热去不尽，且虚其中，热乘虚而上干于心，语言必乱。此表虚汗出，里实□语，所以
必待过经入府，而后下之则愈，宜大承气汤。
【集注】
方有执曰：过经，谓宁迟迟，非谓必待十三日后也。
程知曰：此言□语不当下早也。既出汗矣而□语，则必有燥屎在胃，此当属风。风为
阳邪，阳邪入里，故□语。然须六、七日乃可下之，下之早，则风邪未解于表，尽入
于里，里邪燥实，语言更乱也。
@@@
阳明病，□语有潮热，反不能食者，胃中必有燥屎五六枚也，若能食者，但□尔，宜
大承气汤下之。
【按】
「宜大承气汤下」之句，应在「必有燥屎五、六枚」之下，始合当用大承气汤下之之
义。若但便□而用大承气汤下之，殊失仲景顾虑误下、慎下之旨。
【注】
阳明病谵语有潮热反不能食者，知胃中必有燥屎已结实也，宜大承气汤下之。若能食
者，知胃将和，但大便□耳！当导之，不可下也。
【集注】
张璐曰：此以能食、不能食，辨燥结之微、甚也。潮热谵语，皆胃中热甚所致，胃热
则能消谷，今反不能食，此必热伤胃中津液，气化不能下行，燥屎逆攻于胃之故，宜
大承气汤，急祛亢极之阳，以救垂绝之阴。若能食者，胃中气化自行，热邪不盛，津
液不致大伤，大便虽□，不久自行，不必用药，反伤其气也。
@@@
下利谵语者，有燥屎也，宜小承气汤。
【注】
下利里虚，谵语里实，若脉滑大，证兼裹急，知其中必有宿食也。其下利之物，又必
稠粘臭秽，知热与宿食合而为之也，此可决其有燥屎也，宜以小承气汤下之。于此推
之，可知燥屎不在大便□与不□，而在里之急与不急，便之臭与不臭也。
【集注】
汪琥曰：下利者，肠胃之疾也。若谵语，则胃家实，与厥阴无与，乃肠中有燥屎不得
下也。治宜小承气汤者，此半利半结，祗须缓以攻之也。又曰：或问既下利矣，则热
气得以下泄，何由而致谵语有燥屎也？答曰：此系阳明府实大热之证，胃中糟粕为邪
所壅，留着于内，其未成□者，或时得下，其已成□者，终不得出，则燥屎为下利之
根，燥屎不得出，则邪热上乘于心，所以谵语。要之此证，须以手按脐腹当必坚痛，
方为有燥屎之征。
@@@
直视谵语，喘满者死，下利者亦死。
【注】
上条下利谵语为可治，此条下利谵语者死。要知谵语不死于下利，而死于直视也。直
视者，精不注乎目也；谵语者，神不守乎心也，已属恶候。加之喘满，阳上脱也，故
曰死。下利阴下脱也，故曰亦死也。
【集注】
方有执曰：直视，精不荣于目也；谵语，神不主乎心也。喘则阳争于上，利则阴争于
下，胃中土也，阴阳争夺于上下，而中气不守，故无法可治，而皆主死也。
@@@
发汗多，若重发汗者，亡其阳，□语。脉短者死；脉自和者不死。
【注】
太阳病，发汗过多不解，又复重发其汗，以致气液两亡，热邪乘燥传入阳明而生□语
。□语者，胃热阳也。脉短者，气衰阴也。阳病见阴脉，为阴胜于阳，故死也。若脉
不短，为阴阳自和，故不死也。
【集注】
喻昌曰：方注以此为太阳经脱简，不知太阳经无□语之例，必日久而兼阳明、少阳，
方有□语。故此言太阳经得病时，发汗过多，及传阳明时，重发其汗，因有亡阳而□
语之一证也。亡阳之人，所存者阴气耳，故神魂不定，而妄见妄闻，与热邪乘心之候
不同。脉短则阴阳不附，脉和则阴阳未离，其生死但从脉定耳。
汪琥曰：□语者，脉当大实或洪滑，为自和。自和者，言脉与病不相背也，病虽甚不
死。若谵语脉短，为邪热盛，正气衰乃阳证见阴脉也，无法可施。
@@@
发汗多，亡阳□语者，不可下，与柴胡桂枝汤和其荣卫，以通津液后自愈。
【注】
此又承上条以出其治也。谵语者，属阳明热实，可下之证也。若发汗过多，大亡气液
而发谵语者，乃津枯致燥之谵语，非热甚内实之谵语，不可下也。里有热，宜白虎加
人参汤。表不解，与柴胡桂枝汤和其荣卫，以通津液后自愈也。
【按】
发汗过多，亡阳□语，以无大便□满痛，故不可下；以无身寒汗出恶寒，故不可温。
于此可知发太阳汗出过多致谵语者，必无发热汗出恶寒也。发阳明汗出过多致谵语者
，必有潮热恶热不大便也。此则发少阳汗多致谵语者，即论中少阳不可发汗，发汗则
谵语是也。然舍小柴胡汤别无治法，若祗用柴胡又恐升散，非亡阳所宜，故合桂枝和
其荣卫，通其津液自可愈也。
@@@
阳明中风，脉弦浮大而短气，腹部满，□下及心痛，久按之气不通，鼻干，不得汗，
嗜卧，一身及目悉黄，小便难，有潮热，时时哕，耳前后肿，刺之小差，外不解，病
过十日，脉续浮者，与小柴胡汤。脉但浮，无余证者，与麻黄汤，若不尿，腹满加哕
者，不治。
【按】
续浮之「浮」字，当是「弦」字，始与文义相属，则可与小柴胡汤。若俱是「浮」字
，则上之浮，既宜用小柴胡汤，下之浮，又如何用麻黄汤耶？
【注】
中风传阳明，病太阳未罢，脉当浮缓。今脉弦浮大，弦，少阳脉也；浮，太阳脉也；
大，阳明脉也，脉既兼见，证亦如之。腹满，太阳阳明证也；□下及心痛，久按之气
不通快，少阳证也；鼻干，阳明证也；不得汗，太阳证也；嗜卧，少阴证也；面目悉
黄，太阴证也；小便难，太阳府证也；潮热，阳明里证也；哕逆，胃败证也；耳前后
肿，少阳证也；短气，气衰证也，凡仲景立法无方之条，皆是此等阴阳错杂，表里混
淆之证，但教人俟其病势所向，乘机而施治也。故用刺法，待其小差，若外病不解，
已成危候。如过十日，脉续弦不浮者，则邪机已向少阳，可与小柴胡汤和之，使阳明
之邪从少阳而解。若脉但浮不大，而无余证者，则邪机已向太阳，当与麻黄汤汗之，
使阳明之邪从太阳而解。若已过十余日，病势不减，又不归于胃而成实，更加不尿腹
满哕甚等逆，即有一、二可下之证，胃气已败，不可治也。
【集注】
程知曰：此条全是表证未解，而无汗出燥渴之证，故不可用白虎。虽有潮热，而无□
满谵语濈濈汗出之证，故不可用承气。不如俟气之自回，犹可渐引其邪从外出也。
程应旄曰：此条证以「不得汗」三字为主，故酌量于柴胡麻黄二汤间，以通其久闭，
总是要得汗耳！
@@@
脉浮而芤，浮为阳，芤为阴，浮芤相抟，胃气生热，其阳则绝。
【注】
脉浮而芤，浮为阳盛，芤为阴虚。阳盛则发热，阴虚则汗出，二者相抟，则胃气生热
愈盛，胃中津液立亡。其阳则绝者，言阳亡津液绝也。
【集注】
方有执曰：浮为气上行，故曰阳；芤为血内损，故曰阴。胃中生热者，阴不足以和阳
，津液干而成枯燥也。
张璐曰：此言脾约当下不下，则浮涩转为浮芤，津液竭而难下矣。其阳则绝，即阳绝
于里，亡津液之互辞也。
赵良曰：胃中阳热亢甚，脾无阴气以和之，孤阳无偶，不至燔灼竭绝不止耳。
沈明宗曰：此辨阳明津竭之脉也。浮为邪气强，芤为阴血虚，阳邪盛而阴血虚，为浮
芤相抟，胃气生热，故曰：其阳则绝。即亡津液之互词也。若见此脉，当养津液，不
可便攻也。
@@@
阳明病，反无汗，而小便利，二、三日呕而咳，手足厥者，必苦头痛，若不咳不呕，
手足不厥者，头不痛。
【注】
阳明病，法多汗，反无汗而小便利，是寒气内攻也；至二、三日呕而咳，寒邪上逆也
；手足厥者，寒气见于四肢也；气上逆，则咳而苦头痛矣。若不咳、不呕、不厥，则
头不痛。此证之头痛者标也，咳逆手足厥者本也。
【集注】
程知曰：无汗小便利，呕咳肢厥头痛，曷不谓太阳病？盖初起无头痛诸表证也，此头
痛是二、三日后呕咳而厥所致，非因头痛致呕咳而厥也。呕、咳二证，太阳、少阳俱
有之，其表证未解，则属太阳病；其寒热往来者，则谓之少阳病也。厥，则厥阴有之
，但无呕与咳也。
张璐曰：阳明无汗，呕咳手足厥者，得之荣卫俱伤而邪入深也。然小便利，则邪不在
内而在外，不在下而在上，故知必苦头痛，仍宜小青龙主之。若不呕、不咳、不厥而
小便利者，邪必顺水道而出，岂有逆攻巅顶之理哉！
林澜曰：须识阳明亦有手足厥证，胃主四肢，中虚气寒所致也。然头苦痛而咳，自与
阴寒但厥者异矣。此类数条最为难解。
吴人驹曰：呕咳手足厥头痛 ，皆由反无汗之故也。
@@@
阳明病，但头眩，不恶寒，故能食而咳，其人咽必痛，若不咳者，咽不痛。
【注】
阳明病，当恶热不恶寒，若从伤寒传来，则不能食，今从中风传来，故能食也。伤寒
挟寒邪，则有头痛证，今中风挟风邪，则有头眩证，理固然也。寒邪属阴，若兼饮则
咳而呕，今不呕而咽痛，则以风属阳邪，风病则兼火，故咳而咽痛，以类相从也。
【集注】
方有执曰：眩风旋而目运也，风故不恶寒能食。咳，逆气也。咽门，胃之系也。胃热
而气逆攻咽，则咳而咽伤也。
程知曰：阴邪下行，故无汗而小便利；阳邪上行，故不恶寒而头眩。寒则呕不能食，
风则能食；寒则头痛，风则咽痛，是风寒入胃之辨也。
程应旄曰：阳明以下行为顺，逆则上行，故中寒则有头痛证，中风则有头眩证。以不
恶寒而能食，知其郁热在里也。寒上攻能令咳，其咳兼呕，故不能食而手足厥；热上
攻亦令咳，其咳不呕，故能食而咽痛，以胃气上通于肺，而咽为胃府之门也。夫咽痛
惟少阴有之，今以咳伤致痛，若不咳则咽不痛，况更有头眩不恶寒之证，益可辨其为
阳明之郁热也。
@@@
病人有寒，复发汗，胃中冷，必吐蛔。
【注】
病人有寒，谓胃中寒也。复发汗，谓汗而复汗也。胃寒复汗，阳气愈微，胃中冷甚，
蛔不能安，故必吐蛔也，宜理中汤送乌梅丸可也。
【集注】
程应旄曰：汗生于谷精，胃中阳气所酿也。有寒复发汗，知胃阳不复存于内矣，蛔何
能安？
@@@
发汗后，水药不得入口为逆，若更发汗，必吐下不止。
【按】
必吐下不止之「下」字，当是衍文。
【注】
此承上条误而又误，必变而成逆也。胃中虚冷，本因误汗，水药不得入口，入口即吐
而为逆也。若更发其汗，则胃逆益甚，不能司纳，不特水药入口方吐，且必无时而不
吐逆也。
【集注】
This is an excess syndrome. If it is a deficiency syndrome, it manifests as Zhengsheng (repetitive speech due to mental exhaustion and confusion), caused by the depletion of spirit and essence, leading to an inability to control oneself, resulting in repetitive speech with a faint and short voice; this is due to the deficiency of healthy qi.
[Collected Annotations]
Dai Yuanli said: Chan Yu (delirious speech) belongs to Yang syndromes, while Zhengsheng belongs to Yin syndromes. The Classic states: Excess leads to Chan Yu, deficiency leads to Zhengsheng. Chan Yu is characterized by confused and disordered speech, lack of logic, often speaking alone to empty air, as if seeing ghosts. Zhengsheng is characterized by earnest and frequent repetition; although the words may be absurd, the patient continues incessantly. Elderly people often ramble when encountering events because their Yang qi is deficient and their mind is not clear. This is why Chan Yu and Zhengsheng differ in terms of excess and deficiency. These two are not difficult to distinguish, but both Yang excess with interior excess and Yin excess forcing Yang to float outward can cause disordered speech. One must differentiate them through other symptoms and treat according to the specific syndrome.
Lou Quanshan said: I have used formulas containing Ginseng Radix et Rhizoma (Renshen), Astragali Radix (Huangqi), Angelicae Sinensis Radix (Danggui), and Atractylodis Macrocephalae Rhizoma (Baizhu) to treat Chan Yu, with many recoveries. How can one indiscriminately use Huanglian Jiedu Tang (Coptis Decoction for Detoxification), Dachengqi Tang (Major Order the Qi Decoction), or Xiaochengqi Tang (Minor Order the Qi Decoction) without distinguishing between excess and deficiency? [Commentary]: What he treated was actually Zhengsheng.
Zhang Xiju said: Excess Chan Yu occurs when Yangming dryness-heat is severe, causing mental clouding and chaotic Qi mechanism, leading to speech that disregards social propriety and includes cursing. Deficiency Zhengsheng occurs when Shen Qi (spiritual energy) is deficient and cannot control itself, resulting in abnormal voice quality and repetitive speech.
@@@
In Cold Damage disease, after four or five days, if the pulse is deep and accompanied by wheezing and chest fullness, the deep pulse indicates the pathogen is in the interior. If sweating methods are incorrectly applied, fluids will leak out, making the stool difficult to pass. This results in exterior deficiency and interior excess. Over time, Chan Yu (delirious speech) will occur.
[Note]
Four or five days into Cold Damage is the time when pathogens enter the interior. A deep pulse with wheezing and chest fullness indicates interior involvement. Incorrectly applying sweating methods causes fluid leakage, leading to exterior deficiency. Sweating dries the stomach, making defecation difficult, leading to interior excess. Over time, stomach heat becomes blazing, inevitably causing Chan Yu.
[Collected Annotations]
Fang Youzhi said: "Leaking out" refers to fluids exiting improperly.
Zhang Lu said: Four or five days into Cold Damage is precisely when heat pathogens transmit to the interior. Given the deep pulse and interior wheezing/fullness, incorrect sweating will inevitably lead to dryness accumulation and Chan Yu. Although dryness-induced Chan Yu resembles Dachengqi Tang syndrome, this case arises from excessive sweating damaging fluids, without severe abdominal fullness and pain. Therefore, Xiaochengqi Tang (Minor Order the Qi Decoction) is appropriate.
@@@
In Yangming disease, if the patient sweats profusely, fluids exit the body, causing stomach dryness and inevitable constipation. Constipation leads to Chan Yu. The primary treatment is Xiaochengqi Tang (Minor Order the Qi Decoction). If Chan Yu stops after one dose, do not administer further doses.
[Note]
This elaborates on the previous clause to clarify treatment. In Yangming disease, profuse sweating depletes fluids, causing stomach dryness and constipation, which eventually leads to Chan Yu. Xiaochengqi Tang should be used. If bowel movement occurs and Chan Yu stops after one dose, it must not be taken again.
[Collected Annotations]
Zhang Lu said: Profuse sweating with Chan Yu indicates an urgent need for purgation. However, since fluids are already depleted by sweating, harsh purgation is unsuitable. A slight amount of Xiaochengqi Tang should be given to harmonize stomach Qi; Chan Yu will cease. Overdose would damage fluids.
Shen Mingzong said: This case involves profuse sweating and stomach dryness, differing from standard excess treatment.
@@@
Patients with sweating and Chan Yu have dry feces in the stomach (intestines); this is caused by Wind pathogen. Purging is required, but only after the pathogen has passed the Taiyang meridian. If purged too early, speech will become more chaotic due to exterior deficiency and interior excess. Recovery after purging is achieved with Dachengqi Tang (Major Order the Qi Decoction).
[Note]
Spontaneous sweating with Chan Yu indicates pre-existing dry feces in the stomach/intestines, transmitted from Taiyang Wind pathogen. Purging is necessary, but only after the Taiyang pathogen has passed the Yangming meridian and entered the Yangming fu-organs. Early purging means interior heat is not yet consolidated; not only will heat remain, but middle Qi will also be damaged. Heat will then attack the Heart vacuously, causing chaotic speech. Because of exterior deficiency with sweating and interior excess with Chan Yu, one must wait for the pathogen to pass the meridian and enter the fu-organ before purging to achieve recovery, using Dachengqi Tang.
[Collected Annotations]
Fang Youzhi said: "Passing the meridian" implies caution and delay, not necessarily waiting until the thirteenth day.
Cheng Zhi said: This clause states that Chan Yu should not be purged too early. Since sweating has occurred and Chan Yu is present, dry feces must exist in the stomach. This belongs to Wind. Wind is a Yang pathogen; entering the interior, it causes Chan Yu. However, purging should wait until the sixth or seventh day. Early purging leaves Wind pathogen unresolved in the exterior, driving it entirely into the interior, worsening chaos in speech due to interior dryness and excess.
@@@
In Yangming disease, Chan Yu accompanied by tidal fever, but with an inability to eat, indicates five or six pieces of dry feces in the stomach. If the patient can eat, it is merely constipation. Dachengqi Tang (Major Order the Qi Decoction) should be used to purge.
[Commentary]
The phrase "Yi Dachengqi Tang xia zhi" (Suitable to use Dachengqi Tang to purge) should follow "bi you zaoshi wu liu mei ye" (there must be five or six pieces of dry feces) to align with the indication for using Dachengqi Tang. Using Dachengqi Tang for mere constipation contradicts Zhongjing’s caution against erroneous and premature purging.
[Note]
Yangming disease with Chan Yu, tidal fever, and inability to eat indicates consolidated dry feces in the stomach; Dachengqi Tang is suitable for purging. If the patient can eat, it indicates the stomach Qi is recovering, and there is only constipation. Guiding methods (suppositories/enemas) should be used, not purgation.
[Collected Annotations]
Zhang Lu said: This distinguishes mild vs. severe dryness based on appetite. Tidal fever and Chan Yu result from severe stomach heat. Stomach heat usually digests food; inability to eat indicates heat damaging stomach fluids, preventing Qi transformation from descending, causing dry feces to attack the stomach. Dachengqi Tang is needed to urgently dispel extreme Yang heat to save declining Yin. If the patient can eat, stomach Qi transforms naturally, heat is not severe, fluids are not greatly damaged, and stool will pass soon without medication, avoiding damage to Qi.
@@@
Diarrhea accompanied by Chan Yu indicates the presence of dry feces; Xiaochengqi Tang (Minor Order the Qi Decoction) is suitable.
[Note]
Diarrhea suggests interior deficiency, while Chan Yu suggests interior excess. If the pulse is slippery and large, and the abdomen feels tight/painful,宿食 (retained food) is present. The diarrhea material is thick, sticky, and foul-smelling, indicating heat combined with retained food. This confirms the presence of dry feces. Xiaochengqi Tang should be used. From this, we learn that dry feces are determined not just by constipation, but by the urgency of interior symptoms and the odor of stool.
[Collected Annotations]
Wang Hu said: Diarrhea is a gastrointestinal issue. Chan Yu indicates Wei Jia Shi (Stomach/Home Excess), unrelated to Jueyin, but rather dry feces stuck in the intestines. Xiaochengqi Tang is used because it is half-purgative/half-consolidated, requiring gentle attacking. Question: If diarrhea allows heat to escape, how does Chan Yu and dry feces arise? Answer: This is a Yangming Fu-excess great heat syndrome. Waste is blocked by pathogens. Unformed waste may pass occasionally, but formed dry feces remain. Dry feces are the root of the diarrhea; trapped dry feces allow evil heat to ascend to the Heart, causing Chan Yu. Pressing the navel/abdomen will reveal hardness and pain, confirming dry feces.
@@@
Fixed gaze (Zhishi) with Chan Yu, accompanied by wheezing and chest fullness, indicates death. Diarrhea with Chan Yu also indicates death.
[Note]
The previous clause (diarrhea with Chan Yu) was treatable; this clause (diarrhea with Chan Yu) indicates death. Chan Yu does not kill via diarrhea, but via fixed gaze. Fixed gaze means Jing (essence) fails to nourish the eyes; Chan Yu means Shen (spirit) fails to guard the Heart. Both are ominous signs. Wheezing/fullness indicates Yang collapsing upward; thus, death. Diarrhea indicates Yin collapsing downward; thus, also death.
[Collected Annotations]
Fang Youzhi said: Fixed gaze means essence does not shine in the eyes; Chan Yu means spirit does not rule the heart. Wheezing is Yang struggling above; diarrhea is Yin struggling below. With Earth (Stomach) in the center, Yin and Yang struggle above and below, middle Qi cannot hold, so no cure exists, both indicate death.
@@@
Excessive sweating, or repeated sweating, leads to Wang Yang (collapse of Yang), resulting in Chan Yu. A short pulse indicates death; a harmonious pulse indicates survival.
[Note]
Taiyang disease with excessive sweating remains unresolved; repeated sweating causes Qi and fluids to perish. Heat pathogens enter Yangming due to dryness, causing Chan Yu. Chan Yu is Stomach Heat/Yang syndrome. Short pulse is Qi deficiency/Yin syndrome. Yang disease showing Yin pulse means Yin overcomes Yang, indicating death. If the pulse is not short, Yin and Yang are self-harmonized, indicating survival.
[Collected Annotations]
Yu Chang said: Fang Youzhi considers this a missing text from Taiyang chapter, noting Taiyang has no Chan Yu. It requires duration to involve Yangming/Shao Yang. Thus, this describes Taiyang onset with excessive sweating, then transmission to Yangming with repeated sweating, causing Wang Yang and Chan Yu. Those with Wang Yang retain Yin Qi, leading to unsettled spirit and hallucinations, distinct from Heat attacking the Heart. Short pulse means Yin/Yang detachment; harmonious pulse means they remain attached. Life/death depends on the pulse.
Wang Hu said: Chan Yu pulse should be large/excess or flooding/slippery, called "self-harmonious." Self-harmonious means pulse matches disease severity; severe disease but pulse matches, so survival. Chan Yu with short pulse means pathogen heat is excess, healthy Qi is deficient, Yang disease shows Yin pulse, untreatable.
@@@
Excessive sweating leading to Wang Yang and Chan Yu should not be purged. Use Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) to harmonize Ying and Wei, unblock fluids, and the patient will heal spontaneously.
[Note]
This follows the previous clause to propose treatment. Chan Yu usually belongs to Yangming Heat-Excess and is purgable. However, if Chan Yu arises from excessive sweating depleting Qi/fluids, it is dryness-induced Chan Yu, not Heat-Excess Chan Yu; it should not be purged. Interior heat warrants Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction). Exterior unresolved warrants Chaihu Guizhi Tang to harmonize Ying/Wei and unblock fluids for spontaneous healing.
[Commentary]
Excessive sweating/Wang Yang Chan Yu lacks constipation/abdominal pain, so no purging. Lacks cold/sweating/aversion to cold, so no warming. Taiyang excessive sweating Chan Yu lacks fever/sweating/aversion. Yangming excessive sweating Chan Yu has tidal fever/aversion to heat/constipation. This Shao Yang excessive sweating Chan Yu aligns with "Shao Yang cannot sweat; sweating causes Chan Yu." Xiao Chaihu Tang is the method, but pure Bupleurum may be too dispersing for Wang Yang. Combining with Cinnamon Twig harmonizes Ying/Wei and unblocks fluids for recovery.
@@@
Yangming Wind Strike presents with wiry-floating-large pulse and shortness of breath, abdominal fullness, hypochondriac/heart pain worsened by pressure, dry nose, inability to sweat, lethargy, jaundice of body and eyes, difficult urination, tidal fever, occasional hiccups, swelling around ears. Acupuncture brings slight relief. If exterior remains unresolved after ten days and pulse continues to float, give Chaihu Tang (Bupleurum Decoction). If pulse is only floating with no other symptoms, give Mahuang Tang (Ephedra Decoction). If urine ceases, abdominal fullness increases, and hiccups worsen, it is untreatable.
[Commentary]
"Xu Fu" (continues floating) likely contains a typo; "Fu" should be "Xian" (wiry). Then Chaihu Tang fits. If both are "floating," the logic for choosing Chaihu vs. Mahuang Tang is unclear.
[Note]
Wind Strike transmitting to Yangming with unresolved Taiyang typically has floating-slow pulse. Wiry-floating-large pulse combines Shao Yang (wiry), Taiyang (floating), and Yangming (large). Symptoms match: abdominal fullness (Taiyang/Yangming), hypochondriac pain (Shao Yang), dry nose (Yangming), no sweat (Taiyang), lethargy (Shaoyin), jaundice (Taiyin), difficult urination (Taiyang Fu), tidal fever (Yangming interior), hiccups (Stomach failure), ear swelling (Shao Yang), shortness of breath (Qi deficiency). These complex cases require observing disease trend. Acupuncture helps. If after ten days pulse is wiry (not floating), pathogen moves to Shao Yang; use Chaihu Tang to resolve via Shao Yang. If pulse is only floating without other symptoms, pathogen moves to Taiyang; use Mahuang Tang to resolve via Taiyang. If after ten days disease persists, does not consolidate in Stomach, and adds anuria/worsening fullness/hiccups, Stomach Qi is failed; untreatable.
[Collected Annotations]
Cheng Zhi said: Exterior unresolved, no dry-thirst, so no Baihu. Tidal fever but no fullness/delirium/sweating, so no Chengqi. Wait for Qi return to guide pathogen out.
Cheng Yingmao said: "Inability to sweat" is key. Choose between Chaihu/Mahuang to open blockage; goal is sweating.
@@@
Pulse is floating and Kou (hollow). Floating is Yang, Kou is Yin. Floating and Kou interacting, Stomach Qi generates heat, its Yang is severed.
[Note]
Floating-Kou pulse: Floating indicates Yang excess, Kou indicates Yin deficiency. Yang excess causes fever; Yin deficiency causes sweating. Interaction increases Stomach heat, instantly destroying Stomach fluids. "Yang is severed" means Yang perishes and fluids are exhausted.
[Collected Annotations]
Fang Youzhi said: Floating is Qi moving up (Yang); Kou is blood damaged inside (Yin). Stomach heat arises because Yin cannot harmonize Yang, drying fluids.
Zhang Lu said: This describes Splee Constriction where purgation is delayed, turning floating-choppy to floating-kou. Fluids exhaust, hard to purge. "Yang severed" is synonymous with interior Yang severance and fluid loss.
Zhao Liang said: Stomach Yang heat is extreme; Spleen lacks Yin to harmonize. Solitary Yang without partner burns until exhaustion.
Shen Mingzong said: Distinguishing Yangming fluid exhaustion pulse. Floating is strong pathogen; Kou is deficient Yin blood. Yang pathogen excess + Yin blood deficiency = interaction generating Stomach heat. "Yang severed" means fluid loss. See this pulse, nourish fluids, do not purge.
@@@
Yangming disease, paradoxically no sweat, but free urination. After 2-3 days, vomiting and coughing, cold extremities indicate severe headache. If no cough/vomiting/cold extremities, no headache.
[Note]
Yangming usually sweats. No sweat + free urination indicates internal Cold attack. Day 2-3 vomiting/coughing indicates Cold reversing upward. Cold extremities indicate Cold in limbs. Upward Qi reversal causes cough/headache. Absence of these means no headache. Headache is branch; cough/reversal/extremity cold is root.
[Collected Annotations]
Cheng Zhi said: Why not Taiyang? No initial exterior headache. Headache results from day 2-3 vomiting/coughing/cold extremities. Vomiting/coughing occur in Taiyang/Shao Yang. Taiyang if exterior unresolved; Shao Yang if alternating chills/fever. Jueyin has cold extremities but no vomiting/coughing.
Zhang Lu said: Yangming no sweat/vomiting/coughing/cold extremities due to Ying/Wei injury and deep pathogen. Free urination means pathogen is external/superior, not internal/inferior. Expect severe headache; Xiao Qinglong Tang is suitable. If no vomiting/coughing/cold extremities with free urination, pathogen exits via water pathway, unlikely to attack head.
Lin Lan said: Note Yangming has cold extremities due to Stomach governing limbs and middle deficiency/cold. But headache/cough differs from pure Yin-Cold extremity cold. Hard to interpret.
Wu Renju said: Vomiting/coughing/cold extremities/headache all stem from paradoxical no sweat.
@@@
Yangming disease, only vertigo, no aversion to cold, able to eat, coughing, sore throat. If no cough, no sore throat.
[Note]
Yangming dislikes heat, not cold. Transmitted from Cold Damage, unable to eat; from Wind Strike, able to eat. Cold Damage with Cold causes headache; Wind Strike with Wind causes vertigo. Cold is Yin; with fluid retention causes cough/vomiting. Here, no vomiting, but sore throat because Wind is Yang pathogen, combining with Fire, causing cough/sore throat.
[Collected Annotations]
Fang Youzhi said: Vertigo is wind spinning eyes. Wind causes no aversion to cold/ability to eat. Cough is reverse Qi. Throat is connection to Stomach. Stomach heat/reverse Qi attacks throat, causing cough/throat injury.
Cheng Zhi said: Yin pathogen descends (no sweat/free urine); Yang pathogen ascends (no aversion to cold/vertigo). Cold causes vomiting/inability to eat; Wind allows eating. Cold causes headache; Wind causes sore throat. Distinguishes Cold/Wind entering Stomach.
Cheng Yingmao said: Yangming prefers descending; reversal ascends. Cold causes headache; Wind causes vertigo. No aversion to cold/ability to eat indicates interior stagnant heat. Cold attacking up causes cough/vomiting/inability to eat/cold extremities. Heat attacking up causes cough/no vomiting/ability to eat/sore throat. Throat connects to Lung/Stomach. Sore throat usually Shaoyin, but here caused by cough injury. Combined with vertigo/no aversion to cold, confirms Yangming stagnant heat.
@@@
Patient has Cold, yet sweating is reapplied. Stomach becomes cold, inevitably vomiting roundworms.
[Note]
"Has Cold" means Stomach Cold. "Reapply sweating" means sweating repeatedly. Stomach Cold plus sweating makes Yang Qi weaker, Stomach colder, roundworms不安 (restless), causing vomiting. Lizhong Tang sending Wumei Wan (Mume Pill) is suitable.
[Collected Annotations]
Cheng Yingmao said: Sweat comes from grain essence, brewed by Stomach Yang Qi. Applying sweat to Cold means Stomach Yang is gone internally; how can roundworms rest?
@@@
After sweating, if water/medicine cannot enter mouth, it is adverse. If sweating is reapplied, vomiting and diarrhea will not stop.
[Commentary]
"Diarrhea" in "vomiting and diarrhea will not stop" is likely a superfluous character.
[Note]
Following previous error, becoming adverse. Stomach deficiency-cold from erroneous sweating prevents water/medicine entry; entering causes vomiting (adverse). Reapplying sweating worsens Stomach reversal, preventing intake. Not just upon entry, but constant vomiting/reversal.
[Collected Annotations]