于小柴胡汤方内。加芒硝六两。余根据前法。服不解。更服。
伤寒十三日不解。过经。谵语者。以有热也。当以汤下之。若小便利者。大盒饭硬。
而反下利。脉调和者。知医以丸药下之。非其治也。若自下利者。脉当微厥。今反和者。
此为内实也。调胃承气汤主之。
过经不解而谵语。其为热证明矣。以汤药下之。则热除垢净。以丸药下之。则热留肠
胃而下利不止。与调胃承气以荡涤余热。
伤寒十三日再传经尽。谓之过经。谵语者。阳明胃热也。当以诸承气汤下之。若小便
利者。津液偏渗。大盒饭硬。反下利者。知医以丸药下之也。下利脉微而厥者。虚寒也。
今脉调和。则非虚寒。由肠虚胃热。胁热而利也。与调胃承气汤。以下
胃热。
王宇泰云。经文内实之实。当作热。注偏渗。偏、当作漏。
又云。此 有五反一对。热与厥反。丸与汤反。便硬与下利反。脉微与脉和反。药
下与自利反。小便与大便硬为一对。读者宜细详之。
王三阳云。前条伤寒医下之续得下利。清谷不止。身疼痛者。急当救里。用四逆者。
观身有疼痛。则知邪全在表。大不当下。下之。则里虚之甚。略无分毫邪气在里。故元
气受损。清谷不止。急当用温药救里。况医下之。不云丸药。则必是承气汤。里之受病
多矣。可不急救乎。且外疼痛。亦须用桂枝可知。此证寒未变热。或寒中阴经之证。全
未热也。此条本柴胡证邪在半表半里。一半不当下。一半当下。况以丸药下之。表热不能
彻去。故邪热乘虚传里。为胁热利。且外证谵语。内有实邪可知。脉又调和。元气颇在。故
用承气汤后下之也。此二条。正宜参看用药。不可误也。
过经谵语。阳明胃热也。成注的甚。前条胸胁满而呕。日晡潮热下利。乃大柴胡症。过
经谵语。乃阳明症。不可不辨。
太阳病不解。热结膀胱。其人如狂。血自下。下者愈。其外不解者。尚未可攻。当
先解外。外解已。但少腹急结者。乃可攻之。宜桃核承气汤方。
太阳、膀胱经也。太阳经邪热不解。随经入腑。为热结膀胱。其人如狂者。为未至于
狂。但不宁尔。经曰。其人如狂者。以热在下焦。太阳多热。热在膀胱。必与血相搏。若
血不为蓄。为热迫之。则血自下。血下。则热随血出而愈。若血不下者。则血为热搏。蓄
积于下。而少腹急结。乃可攻之。与桃核承气汤。下热散血。内经曰。从外之内。而盛
于内者。先治其外。后调其内。此之谓也。
In the formula of Xiao Chai Hu Tang (Minor Bupleurum Decoction), add Liu Liang (six taels) of Mangxiao (Natrii Sulfas). Follow the previous methods for preparation and administration. If the condition does not resolve after taking the medicine, administer it again.
After thirteen days of Shanghan (Cold Damage) without resolution, and having passed through the meridians (Guojing), if delirium occurs, it is due to internal heat. One should use a decoction to purge. If urination is free, the stool should be hard; however, if diarrhea occurs instead, and the pulse is harmonious, it indicates that the physician used pill medicines to purge, which was incorrect treatment. If the patient had spontaneous diarrhea, the pulse should be faint or accompanied by cold extremities. The fact that the pulse is now harmonious indicates internal excess (Neishi). Tiaowei Chengqi Tang (Regulate the Stomach and Purge Yang Decoction) should be primarily administered.
When pathogenic factors pass through multiple meridians without resolving and delirium ensues, it proves to be a heat syndrome. Using decoctions for purging removes heat and clears accumulation; using pills for purging leaves heat in the intestines and stomach, causing persistent diarrhea. Administer Tiaowei Chengqi Tang to sweep away residual heat.
Shanghan lasting thirteen days with transmission completing another cycle is called "passing through the meridians" (Guojing). Delirium indicates Yangming Stomach heat. One should use various Chengqi Decoctions to purge. If urination is profuse, body fluids are diverted, and the stool should be hard. Diarrhea occurring contrary to this suggests the physician used pill medicines. Diarrhea with a faint pulse and cold extremities indicates deficiency-cold. A harmonious pulse here rules out deficiency-cold and points to intestinal deficiency with stomach heat, leading to diarrhea via gallbladder/intestinal heat. Administer Tiaowei Chengqi Tang to clear stomach heat.
Wang Yutai stated: The character "Shi" (solid/excess) in "internal excess" should be interpreted as "heat." In the annotation "pian shen" (diverted seepage), "pian" should be read as "lou" (leak).
He further stated: There are five reversals and one pair here. Heat vs. Cold extremities; Pill vs. Decoction; Hard stool vs. Diarrhea; Faint pulse vs. Harmonious pulse; Medicinal purging vs. Spontaneous diarrhea. Urination vs. Hard stool form a pair. Readers should examine these carefully.
Wang Sanyang stated: In the previous clause, after a physician incorrectly purged Shanghan, resulting in persistent diarrhea with undigested food and body pain, one must urgently rescue the interior using Si Ni Tang (Frigid Extremities Decoction). Observing body pain indicates the pathogen is entirely in the exterior, where purging is contraindicated. Incorrect purging causes severe interior deficiency, leaving no pathogen in the interior but damaging Yuan Qi (Original Qi), leading to persistent undigested diarrhea. Urgent warming therapy is required. Since the text does not specify pill medicines, it likely refers to Chengqi Decoctions. Interior diseases are complex; urgent rescue is necessary. Exterior pain also requires Guizhi Tang (Cinnamon Twig Decoction). This condition involves cold not yet transformed into heat, or cold invading Yin meridians without heat. This clause originally belongs to Chai Hu syndromes, where pathogens are half-exterior/half-interior; half is not suitable for purging, half is. Moreover, using pills failed to clear exterior heat, allowing pathogenic heat to enter the interior due to deficiency, causing diarrhea. Delirium indicates internal excess. A harmonious pulse shows Yuan Qi remains. Thus, Chengqi Decoction is used to purge. These two clauses should be compared to understand medication differences correctly.
Delirium after passing through meridians indicates Yangming Stomach heat. Cheng Wuji's annotation is accurate. The previous clause involving chest/flank fullness, vomiting, afternoon tidal fever, and diarrhea is Da Chai Hu Tang (Major Bupleurum Decoction) syndrome. Delirium after passing through meridians is Yangming syndrome; they must be distinguished.
If Taiyang disease does not resolve, heat binds to the Bladder. The patient appears manic-like. If blood discharges spontaneously, the patient heals. If exterior symptoms persist, attack is contraindicated; resolve the exterior first. Once the exterior is resolved, if only lower abdominal urgency and binding occur, attack may proceed. Taohe Chengqi Tang (Peach Kernel and Bupleurum Decoction) is indicated.
Taiyang meridian corresponds to the Bladder. Unresolved heat from the Taiyang meridian enters the fu-organ via the channels, causing heat binding in the Bladder. "Manic-like" means not fully manic, but restless. The Classics state: "Manic-like behavior is due to heat in the lower jiao." Taiyang is prone to heat; heat in the Bladder clashes with blood. If blood is not retained but forced by heat, it discharges spontaneously. Discharge allows heat to exit with blood, curing the disease. If blood does not discharge, it is clotted by heat and accumulates in the lower jiao, causing lower abdominal urgency and binding. Attack is then appropriate. Taohe Chengqi Tang is given to purge heat and dissipate blood stasis. The Inner Canon states: "When pathology moves from outside to inside and becomes excessive internally, treat the exterior first, then regulate the interior." This applies here.