【纲】仲景曰。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。发汗多。若重发汗者。亡其阳。谵语。脉短者死。脉自和者不死。
谵语直视。喘满者死。下利者亦死。
【目】李杲曰。问邪入阳明。为谵语。妄言错失。此果阳明乎。答曰。足阳明者。胃也。岂有
其言哉。伤寒始自皮毛入。是从肺中来。肺主声。入于心则为言。胃即戊也。戊为火化。下从肝肾。
王肯堂曰。谵语症。有补虚一法。如素问云。谵语者。气虚独言也。难经曰。脱阳者见鬼。仲
景谓亡阳谵语。即此义也。故楼英云。余用参、 、归、术等剂。治谵语得愈者百十数。岂可不分
虚实。一概用黄连解毒、大小承气等汤以治之乎。王海藏亦云。黄 汤。治伤寒或时悲哭。或时嘻
笑。或时太息。或语言错乱失次。世疑作谵语狂言者。非也。神不守舍耳。两手脉浮沉不一。举按
全无力。浮之损小。沉之亦损小。皆阴脉也。甚者调中丸。或理中丸。有阴症手足冷。脉细微而谵
语者。宜四逆汤。活人用白通汤。海藏用黄 加干姜汤。有人患此症。脉极沉细。外热内寒。肩背
胸胁斑出十数点。语言狂乱。或曰。发斑谵语。非热乎。余曰。非也。阳为阴逼。上入于肺。传之
皮毛。故斑出。神不守舍。故错语如狂。非谵语也。肌表虽热。以手按之。须臾。冷透如冰。与姜
附等药数日。约二十余两。得大汗而愈。后因再发。脉又沉迟。三四日不大便。与理中丸三日。其
病全愈。以是知此人之狂非阳狂之狂。乃失神之狂。即阴虚也。
柯琴曰。首条。谵语之由。二条。谵语之脉。脉短。是营卫不行。脏腑不通。故死也。二条。
言死脉。三条。言死症。盖谵语本胃实。则不是死症。若谵语而一见虚脉虚症。则是死症。而非胃家
实矣。
【纲】仲景曰。夫实则谵语。虚则郑声。郑声者。重语也。
【目】朱肱曰。病患有谵语郑声二症。郑声为虚。当用温药。白通汤主之。谵语为实。当调胃承
气汤。如服之而谵语止。或更衣者。止后服。不尔。再与之。仲景云。实则谵语。虚则郑声。世多
不别。然亦相似难辨。须凭外症与脉别之。若大小便利。手足冷。脉微细者。必郑声也。大便秘。
小便赤。手足温。脉洪数者。必谵语也。以此相参。然后用药。万全矣。大抵伤寒不应发汗者。汗
之必谵语。谵语属胃。和中则愈。不和则烦而躁。宜调胃承气汤。然亦有三阳合病谵语者。有胃实
谵语者。或汗多亡阳谵语者。有下利谵语者。有妇人热入血室谵语者。
成无己曰。郑声。不正之音也。汗后。或病久。人声转者是也。盖为正气虚而不全。故使转
而不正也。若以重语为重叠之语。与谵语混而莫辨。殊失仲景之旨。
李杲曰。狂言者。大开目与人语。语所未尝见之事也。谵语者。合目自言。言所日用常见常行
之事也。郑声者。声战无力。不相接续。造字出于喉中也。
吴绶曰。大都郑声。乃因内虚。正气将脱。而言皆不足之貌。如手足并冷。脉息沉细。口鼻气
息短少。所说言语。轻微无力。气少难以应息者。皆元气将脱也。或吃忒不止。神昏气促。不知人
事者死。或气息不促。手足颇温。其脉沉细而微者。急以附子汤倍人参主之。或以接气丹、黑锡丹
兼进一二服。以助其真气也。或浓煎人参。徐徐与之。或未可用附子者。以三白汤倍人参主之。
戴原礼曰。谵语属阳。郑声属阴。经云。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。年老人遇事则谇语不休。以阳气
虚故也。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。
须以他症别之。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。乃阴格阳之谵语也。里实宜下。调胃承气汤。热躁甚而妄言不休。大
渴喜饮。理中汤。阴格阳。宜温胆汤、四逆汤、附子理中汤。
又有不系正阳明。似困非困。间时有一二声郑语者。当随症施治。
外有已得汗。身和而妄言者。此是汗出后津液不和。慎不可下。乃非阳非阴者。宜小柴胡和建
中汤各半帖。和荣卫。通津液。若阳传入阴。自利。手足厥逆。语或错乱。此虽已自利。其中必有
燥屎。犹当下之。阴中之阳。宜调胃承气汤。瘀血在里。大便黑。小便利。小腹痛。其人如狂
谵语者。桃仁承气汤。妇人热入血室。亦能谵语。小柴胡汤。
病后血气未复。精神未全。多于梦寐中不觉失声如魇。此不系谵语郑声。宜温胆汤去竹茹。入人参五分。
或用六君子汤。
魏荔彤曰。阳明胃病。固多谵语矣。然谵语亦有虚实不同。不可概施攻下。夫谵语固谵语。惟
胃中实热。津液不足。方神明昏昧。而胡乱作语。此谵语也。若胃热不实。则神明不至甚乱而口语
亦不甚糊涂。但说了又说。繁言絮语。失其常度耳。盖其中虚气弱。词不达意。故语至再三。此真
为虚歉之象。不止伤寒症中有此。杂病气虚者多有之。以此为谵语而攻下。贼夫人之子矣。仲师必
详为立辨。令人认明谵语是胡言乱语。郑声是重言复语。故自解之曰。郑声重语也。重字当作平声。
张介宾曰。实则谵语。虚则郑声。此虚实之有不同也。夫二者总由神魂昏乱。而语言不正。又
何以分其虚实。但谵语者。狂妄之语也。郑声者。不正之声也。谵语为实。实者邪实也。如伤寒阳
明实热。上乘于心。心为热冒。则神魂昏乱而谵妄不休者。此实邪也。实邪为病。其声必高。其
气必壮。其色必厉。其脉必强。凡登高骂詈。狂呼跳扰之类。皆是也。此之为病。有由燥屎在胃者。
有由瘀血在脏者。有由火盛热极者。有由腹胀便秘口疮咽烂者。察其果实。即当以三承气。或白
虎汤、凉膈散之类治之。郑声为虚。虚者神虚也。如伤寒元神失守为邪所乘。神志昏沉而错乱不正
者。此虚邪也。虚邪为病。其声必低。其气必短。其色必萎。其脉必无力。凡其自言自语。喃喃不
全。或见鬼怪。或惊恐不休。或问之不应。答之不知之类。皆是也。此之为病。有因汗亡阳。因下
亡阴者。有因焦思抑郁。竭蹶心气者。有因劳力内伤。致损脾肾者。有因日用消耗。暗残中气者。
凡其病虽起。倒而遏之即止。终不若实邪之难制者。即虚邪也。察其果虚。最忌妄行攻伐。少有差谬。
无不即死。治此者。速宜察其精气。辨其阴阳。舍其外症。救其根本。稍迟犹恐不及。而况于误治乎。甚至有自利身
寒。或寻衣撮空。面壁啐啐者。尤为逆候。盖虚损之人。最忌谵妄。故凡身有微热。脉见洪滑者生。
心多烦躁。脉见微弱细急。而逆冷者死。
【纲】仲景曰。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。
妇人中风。发热恶寒。经水适来。得之七八日。热除而脉迟身凉。胸胁下满。如结胸状。谵语
者。此为热入血室也。当刺期门。随其实而泻之。
妇人伤寒。发热。经水适来。昼则明了。暮则谵语。如见鬼状。此为热入血室。无犯胃气。及
上二焦。必自愈。
【目】朱肱曰。问。仲景云无犯胃气。何也。答曰。热因经水适来。乘虚入室。故血室有热。
遂令谵语。当以小柴胡解之。却与胃实谵语不同。胃实有燥屎。故宜调胃承气下之。若血热有谵语。
非胃家实。仲景恐人作胃实攻之。故曰。无犯胃气也。大抵谵语是热。属阳。而反见阴症者逆。
刘完素曰。血病则肝伤。肝藏魂。肝伤则魂无所归。心神无主。此所以发谵语也。要之。此非
胃实。因热入血室而肝实也。肝热心亦热。肝与心相近也。热伤心气。既不能主血。亦不能作汗。
故但头有汗而不能遍身。
此三条。皆因谵语而发。不重热入血室。更不重在伤寒中风。须知谵语有不因于胃者。故不可
以谵语定为胃实之症。而犯其胃气。
【纲】仲景曰。三阳合病。腹满身重。难以转侧。口不仁而面垢。遗尿。发汗则谵语。下之则
额上出汗。手足冷。若自汗出者。白虎汤主之。
【目】寇宗 曰。谵语者。真气昏乱。神识不清之所致也。心藏神而主火。病则热气归焉。伤
寒胃中热盛。上乘于心。心为热冒。则神昏乱而语言多不知。所以言出无次而成谵妄之语。轻者睡
中呢喃。重者不睡亦语言错乱。有谵语者。有独语者。有狂语者。有语言不休者。有言乱者。此数
者皆因热之轻重也。谵语与独语。虽间有妄错。若与人言。犹有伦次。是热未至于极者也。经曰。独语
如见鬼状。若剧者。发则不识人。是独语。病犹未剧也。狂语者。热甚者也。由神昏而无所见。甚
则至于喊叫也。语言不休。则更甚矣。至于乱语者。妄言詈骂。不避亲疏。为神明乱极。经曰。诸
逆发汗。微
者难瘥。剧者言乱。是难可复制也。谵语之由。又自不同。有由火劫者。有由汗出者。有由下利者。
有由下血者。有由亡阳者。有由过经者。有由燥屎在胃者。如此条。则由三阳合病者。凡诸此类。
脉短则死。脉和则愈。又身微热。脉浮大生。逆冷脉沉细。不过一日死。实则谵语。收敛在内。
而实者本病也。或气上逆而喘满。或气下夺而自利者。皆为逆。经曰。直视谵语。喘满者死。下利
者亦死。谓其正气脱绝也。
鳌按。尿蓄于膀胱。故遗尿为太阳本病。少阳经行身之侧。故难以转侧为少阳病。其余口不仁。
面垢谵语。额上出汗。手足冷。自汗。皆属阳明。故虽三阳合病。实是阳明病。而略兼太少二经。
所以专从阳明主治。其用白虎汤者。以胃热而非胃实也。
【纲】仲景曰。若胃气不和。谵语者。少与调胃承气汤。
【目】王好古曰。治老幼及虚人伤寒。五六日昏冒言妄。小便或淋或涩。起卧无度。或烦而不
得眠。并宜白虎汤加山栀一钱。治热病及时疫。心躁。狂乱奔走。状似癫痫。言语不定。久不得汗。
及时疫不知人者。以人中黄不拘多少。入罐内。泥封固。武火 半日。放地。去盖半日。研细。
新汲水调下三钱。或未退。再服愈。
吴绶曰。治伤寒热甚。心烦有痰。神昏谵语者。以竹沥、生花粉汁各一盏服之。按此方内热不
禁下者可用。
【纲】仲景曰。伤寒十三日不解。过经谵语者。以有热故也。当以汤下之。若小便利者。大便
当硬而反下利。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。
【目】王肯堂曰。经文内实之实。当作热。
此段有五反一对。热与厥反。汤与丸反。硬与下利反。脉微与脉和反。药下与自利反。小便利
与大便硬为一对。读者详之。下利谵语。其曰脉调和。手足和。小便利者。阳也。故用承气下之。
其脉当微厥。及少阴但欲寐。被火气劫汗。谵语小便难者。阴也。故当用补剂和之。
【纲】仲景曰。阳明病。谵语。发潮热。脉滑而疾者。小承气汤主之。因与小承气汤一升。腹
中转失气者。更服一升。若不转失气者。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。
【目】朱肱曰。潮热脉滑疾者。必谵语也。小承气汤。大便秘。小便赤。手足温。脉洪数者。
必谵语也。调胃承气汤。谵语。不恶寒。反恶热。白虎汤。已得汗。身和谵语者。柴胡桂枝汤。火
迫而致谵语。亦白虎汤。
鳌按。此以里虚句为主。盖通节所言形症。皆是假有余。脉微涩。乃是真不足。故谵语潮热。
下症虽具。仲景于此。慎之又慎。只以小承气试之也。
【纲】仲景曰。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。大承气汤主之。若一服利。止后服。
【目】柯琴曰。微者。但发热谵语。是邪气实。当以下解。一服利。止后服。只攻其实。无乘
其虚也。
【纲】仲景曰。下利谵语者。有燥屎也。宜小承气汤。汗出谵语者。以有燥屎在胃中。此为风
也。须下之。过经乃可下之。下之若早。语言必乱。表虚里实故也。下之则愈。宜大承气汤。
阳明病。谵语。有潮热。反不能食者。胃中必有燥屎五六枚也。宜大承气汤下之。若能食者。
但硬耳。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。更莫后服。
【目】陶华曰。大热干呕。呻吟错语。不得眠。犀角解毒汤。得病无热。但狂言。烦躁不安。
精来不与人相当。新汲水调五苓散三钱探吐之。一法。用猪苓汤。瘀血狂言谵语。漱水。大便黑。
小便多。身黄腹满。此为当汗不汗。蓄热在里。轻者。犀角地黄汤。重者。桃仁承气汤、抵当丸。
【纲】张仲景说：伤寒病经过四五日，脉象沉而伴有气喘胸满。脉沉表示病邪在里，却反而使用发汗法治疗，导致津液外泄，大便因此变得困难。此时表虚里实，时间久了就会出现谵语（神志不清，胡言乱语）。如果发汗过多，或者再次误用发汗法，会导致亡阳（阳气耗散），出现谵语。若脉象短促的预后不良，脉象平和的则不死。谵语且目睛直视、伴有气喘胸满的预后不良；伴有下利的也预后不良。
【目】李杲说：有人问邪气进入阳明经，出现谵语、妄言错乱，这确实是阳明病吗？回答说：足阳明经属于胃，难道会有这种言语表现吗？伤寒病最初从皮毛侵入，是从肺开始传入的。肺主管声音，邪气入心则表现为言语。胃对应天干中的戊，戊属火化，下行关联肝肾。
王肯堂说：治疗谵语症，有一种补虚的方法。如《素问》所说：“谵语是由于气虚而独自说话。”《难经》说：“阳气脱失的人会看见鬼怪。”张仲景所说的亡阳谵语，就是这个意思。所以楼英说：“我用人参、白术、当归等药剂治疗谵语痊愈的患者有上百人，怎么能不分虚实，一概用黄连解毒汤、大承气汤或小承气汤来治疗呢？”王海藏也说：黄耆汤可以治疗伤寒时而悲伤哭泣，时而嬉笑，时而叹息，时而语言错乱无次序的情况。世人怀疑这是谵语狂言，其实不是，这是神不守舍的表现。两手脉象浮沉不一，举按都完全无力，轻取脉象损小，重取也损小，都是阴脉。严重的用调中丸，或者理中丸。如果有阴证手足冷、脉细微而谵语的，适宜用四逆汤。《活人书》用白通汤。王海藏用黄耆加干姜汤。有人患此症，脉极沉细，外热内寒，肩背胸胁发出十几点斑疹，语言狂乱。有人说：发斑谵语，不是热证吗？我说：不是。这是因为阳气被阴邪逼迫，向上进入肺，传至皮毛，所以出现斑疹。神不守舍，所以言语错乱如狂，这不是谵语。肌表虽然发热，用手按压片刻，感觉冷透如冰。给予姜、附等药物数日，大约二十多两，出大汗后痊愈。后来病情复发，脉象又沉迟，三四天不大便，给予理中丸三日，病全愈。由此可知这个人的狂乱不是阳狂，而是失神之狂，即阴虚。
柯琴说：第一条讲谵语的原因，第二条讲谵语的脉象。脉短，说明营卫运行不畅，脏腑不通，所以预后不良。第二条讲死脉，第三条讲死症。大概谵语本因胃实，就不是死症。如果谵语一见虚脉虚症，就是死症，而不是胃家实了。
【纲】张仲景说：实证会出现谵语，虚证会出现郑声（声音低微，重复啰嗦）。郑声，就是重复说话。
【目】朱肱说：患者有谵语和郑声两种症状。郑声属于虚证，应当用温药，以白通汤为主治。谵语属于实证，应当用调胃承气汤。如果服用后谵语停止，或者大便通畅，就停止服药。否则，再给服。张仲景说：实则谵语，虚则郑声。世人大多不能区分，但它们相似难以辨别。必须凭借外在症状和脉象来区别。如果大小便通畅，手足冷，脉微细的，一定是郑声。大便秘结，小便赤红，手足温，脉洪数的，一定是谵语。以此相互参照，然后用药，才万无一失。大致上，伤寒病不应当发汗的，发了汗必然导致谵语。谵语归属于胃，调和胃气则痊愈，不调和则烦躁躁动，适宜用调胃承气汤。然而也有三阳合病导致的谵语，有胃实导致的谵语，有发汗过多亡阳导致的谵语，有下利导致的谵语，有妇人热入血室导致的谵语。
成无己说：郑声，是不正常的声音。发汗后，或者病久，人声转变就是这种情况。大概是因为正气虚弱而不完整，所以使声音转变而不正常。如果把“重语”理解为重叠之语，与谵语混淆难以分辨，就大大失去了张仲景的本意。
李杲说：狂言，是睁大眼睛与人说话，谈论从未见过的事情。谵语，是闭着眼睛自言自语，谈论日常常见常行的事情。郑声，是声音颤抖无力，不相接续，字音出于喉中。
吴绶说：大抵郑声，是因为内虚，正气将要脱失，所说的言语都呈现不足的样子。如手足并冷，脉息沉细，口鼻气息短少，所说的言语轻微无力，气少难以应接呼吸的，都是元气将脱的表现。或者呃逆不止，神昏气促，不知人事的预后不良。或者气息不急促，手足颇温，脉沉细而微的，紧急用附子汤倍加人参主治。或者同时服用接气丹、黑锡丹一二服，以助其真气。或者浓煎人参，慢慢喂服。或者不能用附子的，用三白汤倍加人参主治。
戴原礼说：谵语属阳，郑声属阴。经文说：实则谵语，虚则郑声。谵语，是颠倒错乱，言语没有伦次，常常对着空气独自说话，像看见鬼怪一样。郑声，是郑重频繁，言语虽然谬误但谆谆不休。老年人遇到事情则谵语不休，是因为阳气虚的缘故。这就是谵语和郑声虚实不同的原因。这两者本来不难辨别，但阳盛里实，与阴盛格阳，都能导致错语。必须通过其他症状来区别。大便秘结，小便赤红，身热烦躁，口渴而胡乱说话的，是里实的谵语。小便如常，大便洞泻，或者烦躁，或者反发热而胡乱说话的，是阴格阳的谵语。里实适宜攻下，用调胃承气汤。热躁严重而胡乱说话不停，大渴喜饮的，用理中汤。阴格阳，适宜用温胆汤、四逆汤、附子理中汤。
又有不属于正阳明，似困非困，偶尔有一两声郑语的，应当随症施治。
另外有已经发过汗，身体平和而胡乱说话的，这是出汗后津液不和，千万不可攻下，这是非阳非阴的情况，适宜用小柴胡汤和建中汤各半帖，调和营卫，通利津液。如果阳传入阴，自利，手足厥逆，言语或错乱，这虽然已经自利，其中必有燥屎，仍然应当攻下。这是阴中之阳，适宜用调胃承气汤。瘀血在里，大便黑，小便利，小腹痛，其人如狂谵语的，用桃仁承气汤。妇人热入血室，也能导致谵语，用小柴胡汤。
病后血气未恢复，精神未完全，多于梦寐中不觉失声如魇，这不属于谵语郑声，适宜用温胆汤去竹茹，加入人参五分。或者用六君子汤。
魏荔彤说：阳明胃病，固然多有谵语，但谵语也有虚实不同，不可一概施用攻下法。夫谵语固然是谵语，只有胃中实热，津液不足，才会神明昏昧，而胡乱作语，这才是谵语。如果胃热不实，则神明不至甚乱，而口语也不甚糊涂，只是说了又说，繁言絮语，失去常度罢了。大概其中虚气弱，词不达意，所以语至再三，这真是虚歉的现象。不止伤寒症中有此，杂病气虚者多有之。以此为谵语而攻下，就是害人之子了。仲师必定详细设立辨别方法，让人认清谵语是胡言乱语，郑声是重言复语，所以自我解释曰：郑声重语也。“重”字当作平声。
张介宾说：实则谵语，虚则郑声，这是虚实有所不同。这两者总由神魂昏乱，而语言不正，又何以分其虚实？但谵语，是狂妄之语。郑声，是不正之声。谵语为实，实者是邪实也。如伤寒阳明实热，上乘于心，心被热蒙蔽，则神魂昏乱而谵妄不休的，这是实邪。实邪致病，其声音必高，其气必壮，其色必厉，其脉必强。凡是登高骂詈，狂呼跳扰之类的，都是如此。此病，有由燥屎在胃的，有由瘀血在脏的，有由火盛热极的，有由腹胀便秘口疮咽烂的。察其果实，就应当用三承气汤，或白虎汤、凉膈散之类治疗。郑声为虚，虚者是神虚也。如伤寒元神失守为邪所乘，神志昏沉而错乱不正的，这是虚邪。虚邪致病，其声音必低，其气必短，其色必萎，其脉必无力。凡其自言自语，喃喃不全，或见鬼怪，或惊恐不休，或问之不应，答之不知之类的，都是如此。此病，有因汗亡阳，因下亡阴的，有因焦思抑郁，竭蹶心气的，有因劳力内伤，致损脾肾的，有因日用消耗，暗残中气的。凡其病虽起，倒而遏之即止，终不如实邪之难制。即使是虚邪，察其果虚，最忌妄行攻伐，稍有差谬，无不立即死亡。治疗此病，速宜察其精气，辨其阴阳，舍其外症，救其根本，稍迟犹恐不及，何况误治呢。甚至有自利身寒，或寻衣撮空，面壁啐啐的，尤为逆候。大概虚损之人，最忌谵妄，所以凡身有微热，脉见洪滑的生存。心多烦躁，脉见微弱细急，而逆冷的预后不良。
【纲】张仲景说：阳明病，下血，谵语的，这是热入血室。只有头部出汗的，刺期门穴，随其实而泻之，自然汗出则愈。
妇人中风，发热恶寒，月经适来，得病七八日，热除而脉迟身凉，胸胁下满，如结胸状，谵语的，这是热入血室。应当刺期门穴，随其实而泻之。
妇人伤寒，发热，月经适来，昼则明了，暮则谵语，如见鬼状，这是热入血室。不要犯胃气，及上二焦，必自愈。
【目】朱肱说：问：张仲景说无犯胃气，为什么呢？答：热因月经适来，乘虚入室，所以血室有热，遂令谵语，应当用小柴胡汤解之。却与胃实谵语不同。胃实有燥屎，所以适宜用调胃承气汤下之。若血热有谵语，非胃家实，张仲景恐怕人作胃实攻之，所以说：无犯胃气也。大抵谵语是热，属阳，而反见阴症者逆。
刘完素说：血病则肝伤，肝藏魂，肝伤则魂无所归，心神无主，这就是发谵语的原因。总之，这不是胃实，因热入血室而肝实。肝热心亦热，肝与心相近。热伤心气，既不能主血，亦不能作汗，所以只有头部有汗而不能遍身。
这三条，都是因为谵语而发，不重在热入血室，更不重在伤寒中风。须知谵语有不因于胃的，所以不可以谵语定为胃实之症，而犯其胃气。
【纲】张仲景说：三阳合病，腹满身重，难以转侧，口不仁而面垢，遗尿，发汗则谵语，下之则额上出汗，手足冷。若自汗出的，白虎汤主治。
【目】寇宗奭说：谵语，是真气昏乱，神识不清所致。心藏神而主火，病则热气归焉。伤寒胃中热盛，上乘于心，心被热蒙蔽，则神昏乱而语言多不知，所以言出无次而成谵妄之语。轻者在睡中呢喃，重的不睡也语言错乱。有谵语的，有独语的，有狂语的，有语言不休的，有言乱的。这几者都是因为热的轻重不同。谵语与独语，虽然间有妄错，若与人言，犹有伦次，是热未至于极者也。经文说：独语如见鬼状，如果剧烈，发作时不识人，这是独语，病尚不剧烈。狂语，是热甚者也。由神昏而无所见，甚至至于喊叫。语言不休，则更甚矣。至于乱语，妄言詈骂，不避亲疏，为神明乱极。经文说：诸逆发汗，微者难瘥，剧者言乱，是难可复制也。谵语的原因，又自不同。有由火劫的，有由汗出的，有由下利的，有由下血的，有由亡阳的，有由过经的，有由燥屎在胃的。如此条，则由三阳合病。凡诸此类，脉短则死，脉和则愈。又身微热，脉浮大生，逆冷脉沉细，不过一日死。实则谵语，收敛在内，而实者本病也。或气上逆而喘满，或气下夺而自利的，皆为逆。经文说：直视谵语，喘满者死，下利者亦死。谓其正气脱绝也。
沈金鳌按：尿蓄于膀胱，故遗尿为太阳本病。少阳经行身之侧，故难以转侧为少阳病。其余口不仁，面垢谵语，额上出汗，手足冷，自汗，皆属阳明。故虽三阳合病，实是阳明病，而略兼太少二经。所以专从阳明主治。其用白虎汤者，以胃热而非胃实也。
【目】王好古说：治疗老幼及虚人伤寒，五六日昏冒言妄，小便或淋或涩，起卧无度，或烦而不得眠，并宜用白虎汤加山栀一钱。治疗热病及时疫，心躁，狂乱奔走，状似癫痫，言语不定，久不得汗，及时疫不知人的，以人中黄不拘多少，入罐内，泥封固，武火煅半日，放地，去盖半日，研细，新汲水调下三钱。或未退，再服愈。
吴绶说：治疗伤寒热甚，心烦有痰，神昏谵语的，以竹沥、生花粉汁各一盏服之。按此方内热不禁下者可用。
【纲】张仲景说：伤寒十三日不解，过经谵语的，因为有热，应当用汤药攻下。如果小便利，大便当硬而反下利，脉调和的，知道医生用丸药攻下，这不是正确的治法。如果自下利，脉当微厥，今反和的，此为内实，调胃承气汤主治。
【目】王肯堂说：经文内实之实，当作热。
此段有五反一对。热与厥反，汤与丸反，硬与下利反，脉微与脉和反，药下与自利反。小便利与大便硬为一对。读者详之。下利谵语，其曰脉调和，手足和，小便利者，阳也，故用承气下之。其脉当微厥，及少阴但欲寐，被火气劫汗，谵语小便难者，阴也，故当用补剂和之。
【纲】张仲景说：阳明病，谵语，发潮热，脉滑而疾的，小承气汤主治。因与小承气汤一升，腹中转失气的，更服一升。若不转失气的，勿更与之。明日不大便，脉反微涩的，里虚也，为难治，不可更与承气汤。
【目】朱肱说：潮热脉滑疾的，必谵语，用小承气汤。大便秘，小便赤，手足温，脉洪数的，必谵语，用调胃承气汤。谵语，不恶寒，反恶热的，用白虎汤。已得汗，身和谵语的，用柴胡桂枝汤。火迫而致谵语的，也用白虎汤。
沈金鳌按：此以里虚句为主。盖通节所言形症，皆是假有余，脉微涩，乃是真不足。故谵语潮热，下症虽具，张仲景于此，慎之又慎，只以小承气试之。
【纲】张仲景说：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，大承气汤主治。若一服利，止后服。
【目】柯琴说：微者，但发热谵语，是邪气实，当以下解。一服利，止后服，只攻其实，无乘其虚也。
【纲】张仲景说：下利谵语的，有燥屎也，宜小承气汤。汗出谵语的，以有燥屎在胃中，此为风也，须下之。过经乃可下之。下之若早，语言必乱，表虚里实故也。下之则愈，宜大承气汤。
阳明病，谵语，有潮热，反不能食的，胃中必有燥屎五六枚也，宜大承气汤下之。若能食的，但硬耳。
阳明病，其人多汗，以津液外出，胃中燥，大便必硬，硬则谵语，小承气汤主治。若一服谵语止，更莫后服。
【目】陶华说：大热干呕，呻吟错语，不得眠，犀角解毒汤。得病无热，但狂言，烦躁不安，精来不与人相当，新汲水调五苓散三钱探吐之。一法，用猪苓汤。瘀血狂言谵语，漱水，大便黑，小便多，身黄腹满，此为当汗不汗，蓄热在里。轻者，犀角地黄汤。重者，桃仁承气汤、抵当丸。
[Outline] Zhang Zhongjing said: In a cold damage disease, after four or five days, if the pulse is deep and accompanied by wheezing and chest fullness, it indicates that the pathogen is in the interior. If sweating methods are incorrectly applied, body fluids will leak out, causing difficulty in defecation. At this time, the exterior is deficient and the interior is excess; over time, delirium (confusion with incoherent speech) may occur. Excessive sweating, or re-applying sweating methods, leads to Yang collapse (loss of Yang energy), resulting in delirium. If the pulse is short, the prognosis is poor; if the pulse is harmonious, death is not imminent. Delirium accompanied by fixed staring, wheezing, and chest fullness indicates a poor prognosis; diarrhea also indicates a poor prognosis.
[Commentary] Li Gao said: Someone asked if delirium and incoherent speech caused by pathogen entering the Yangming channel belong to Yangming disease. The answer is: The Foot-Yangming channel belongs to the Stomach. Does the Stomach produce such speech? Cold damage begins at the skin and hair, entering from the Lung. The Lung governs sound; when the pathogen enters the Heart, it manifests as speech. The Stomach corresponds to Wu (Earth element in Five Phases theory), which transforms into Fire, descending to connect with the Liver and Kidney.
Wang Kentang said: There is a method of tonifying deficiency for treating delirium. As stated in *Su Wen*: "Delirium is due to Qi deficiency causing solitary speech." *Nan Jing* states: "Those whose Yang collapses see ghosts." Zhang Zhongjing's mention of delirium due to Yang collapse carries this meaning. Therefore, Lou Ying said: "I have cured over a hundred cases of delirium using formulas containing Ginseng, Atractylodes, Angelica, etc. How can one indiscriminately use Huanglian Jiedu Decoction, Da Chengqi Decoction, or Xiao Chengqi Decoction without distinguishing between excess and deficiency?" Wang Haizang also stated: Huangqi Tang treats cold damage where patients alternately weep, laugh, sigh, or speak incoherently. People suspect this is delirium or mania, but it is actually the Spirit failing to reside in its abode. The pulses in both hands vary in depth and strength, feeling weak upon both light and heavy pressure, indicating Yin pulses. For severe cases, Tiaozhong Wan or Lizhong Wan is used. For Yin syndrome with cold extremities, fine and minute pulse, and delirium, Sini Decoction is appropriate. *Huoren Shu* uses Baitong Decoction. Wang Haizang uses Huangqi Ganjiang Tang. A patient presented with extremely deep and fine pulses, external heat with internal cold, a few macules on shoulders/back/chest/ribs, and incoherent manic speech. Some argued that macules with delirium indicate heat. I replied: No. This is Yang being forced upward by Yin, entering the Lung and transmitting to the skin/hair, causing macules. The Spirit fails to reside, causing incoherent speech resembling mania, but this is not true delirium. Although the skin feels hot, pressing it reveals ice-coldness. Treatment with Ginger and Aconite preparations for several days (approx. 20 taels) resulted in profuse sweating and recovery. Upon recurrence with deep-slow pulse and constipation for 3-4 days, Lizhong Wan cured him. Thus, his mania was not Yang mania but Spirit loss, i.e., Yin deficiency.
Ke Qin said: The first paragraph discusses the cause of delirium; the second discusses the pulse. A short pulse indicates failure of Ying and Wei circulation and blockage of Zang-Fu, leading to death. The second paragraph mentions fatal pulses; the third mentions fatal symptoms. Generally, delirium due to Stomach excess is not fatal. However, if delirium presents with deficient pulses and symptoms, it is fatal and not due to Stomach excess.
[Outline] Zhang Zhongjing said: Excess conditions lead to delirium; deficiency conditions lead to Zhengsheng (repetitive, low-volume speech). Zhengsheng refers to repetitive speech.
[Commentary] Zhu Gong said: Patients present with two types of speech disorders: delirium and Zhengsheng. Zhengsheng is deficiency and should be treated with warming herbs, primarily using Baitong Decoction. Delirium is excess and should be treated with Tiaowei Chengqi Decoction. If delirium stops or bowel movements normalize after administration, stop the medication. Otherwise, continue. Zhang Zhongjing stated: Excess leads to delirium, deficiency leads to Zhengsheng. People often fail to distinguish them as they are similar. Differentiation must rely on external symptoms and pulses. If urination and defecation are normal, extremities are cold, and pulse is fine and minute, it is definitely Zhengsheng. If constipation, red urine, warm extremities, and surging-rapid pulse are present, it is definitely delirium. Cross-reference these to ensure safe treatment. Generally, if sweating is contraindicated in cold damage but applied, delirium ensues. Delirium relates to the Stomach; harmonizing the Stomach cures it, while disharmony causes irritability and restlessness, requiring Tiaowei Chengqi Decoction. However, delirium can also arise from combined diseases of the three Yang channels, Stomach excess, excessive sweating leading to Yang collapse, diarrhea, or Heat entering the Blood Chamber in women.
Cheng Wuji said: Zhengsheng is an abnormal voice. It occurs after sweating or prolonged illness when the voice changes. This is because Zheng Qi (Upright Qi) is deficient and incomplete, causing the voice to change abnormally. Interpreting "Zhong Yu" (repetitive speech) as merely overlapping words and confusing it with delirium misses Zhang Zhongjing's intent.
Li Gao said: Kuang Yan (Manic speech) involves open eyes and speaking about unseen events. Chan Yu (Delirium) involves closed eyes and speaking about daily routine matters. Zheng Sheng involves trembling, weak, discontinuous speech originating from the throat.
Wu Shou said: Generally, Zhengsheng results from internal deficiency and impending collapse of Zheng Qi, manifesting as insufficient speech. Symptoms include cold extremities, deep-fine pulse, short breath, weak speech, and difficulty keeping up with breathing, all indicating impending Yuan Qi collapse. Incontinence, coma, rapid breathing, and unconsciousness indicate death. If breathing is not rapid and extremities are warm, with deep-fine-micro pulse, Fuzi Tang with doubled Ren Shen is urgently indicated. Alternatively, Jieqi Dan or Heixi Dan may be given once or twice to support True Qi. Strongly decocted Ren Shen may be slowly administered. If Fuzi is contraindicated, Sanbai Tang with doubled Ren Shen is used.
Dai Yuanli said: Delirium belongs to Yang; Zhengsheng belongs to Yin. The classic states: Excess leads to delirium, deficiency leads to Zhengsheng. Delirium is chaotic, lacking order, often speaking to empty air as if seeing ghosts. Zhengsheng is earnest and frequent; although erroneous, the speech continues incessantly. Elderly people may ramble due to Yang deficiency. This explains the difference in excess/deficiency between the two. They are easy to distinguish: Yang excess with interior excess and Yin excess repelling Yang can both cause incoherent speech, differentiated by other symptoms. Constipation, red urine, fever, irritability, thirst, and wild speech indicate interior excess delirium. Normal urination, loose stools, irritability, or paradoxical fever with wild speech indicate Yin repelling Yang delirium. Interior excess requires purgation (Tiaowei Chengqi Decoction). Severe heat/restlessness with wild speech and intense thirst require Lizhong Tang. Yin repelling Yang requires Wendan Tang, Sini Tang, or Fuzi Lizhong Tang.
Occasional Zhengshyn-like utterances not strictly belonging to Yangming should be treated according to symptoms.
If a patient has sweated, feels comfortable, yet speaks incoherently, it is due to fluid imbalance post-sweating. Purging is forbidden. This is neither purely Yang nor Yin; use half doses of Xiaochaihu Tang and Jianzhong Tang to harmonize Ying/Wei and fluids. If Yang transmits to Yin, causing diarrhea and cold extremities with incoherent speech, despite diarrhea, dry feces may remain in the interior, requiring purgation (Yin containing Yang). Use Tiaowei Chengqi Decoction. Blood stasis in the interior presenting with black stool, clear urine, lower abdominal pain, and manic delirium requires Taoren Chengqi Decoction. Heat entering the Blood Chamber in women also causes delirium, treated with Xiaochaihu Tang.
Post-illness, when Qi/Blood and Spirit are not fully restored, patients may scream in sleep like night terrors. This is not delirium/Zhengsheng; use Wendan Tang minus Zhuru plus Ren Shen, or Liujunzi Tang.
Wei Litong said: While Yangming Stomach disease often causes delirium, it varies by excess/deficiency and should not always be purged. True delirium arises from Stomach excess-heat and fluid deficiency clouding the Spirit. If Stomach heat is not excessive, the Spirit is not severely confused, but speech may be repetitive due to Qi weakness and inability to express thoughts clearly. This deficiency pattern occurs in miscellaneous diseases too. Purging this would harm the patient. Zhang Zhongjing carefully distinguished delirium (wild speech) from Zhengsheng (repetitive speech), noting "Zhong" in Zhengsheng should be pronounced flat tone.
Zhang Jiebin said: Excess leads to delirium, deficiency leads to Zhengsheng. Both involve Spirit confusion and abnormal speech. Delirium is wild speech; Zhengsheng is abnormal voice. Delirium is excess pathogen (e.g., Yangming excess-heat ascending to Heart, clouding Spirit). Excess pathology features loud voice, strong Qi, harsh complexion, and strong pulse (e.g., climbing, cursing, jumping). Causes include dry feces in Stomach, blood stasis in Zang, extreme fire/heat, or abdominal distension/constipation/mouth ulcers. Treat with Three Chengqi Decoctions, Baihu Tang, or Liangge San. Zhengsheng is deficiency (Spirit deficiency). Caused by pathogen attacking lost Yuan Shen, leading to dull/confused Spirit. Deficiency pathology features low voice, short Qi, sallow complexion, and weak pulse (e.g., muttering, seeing ghosts, fear, unresponsiveness). Causes include sweating-induced Yang loss, purging-induced Yin loss, emotional stress damaging Heart Qi, labor injuring Spleen/Kidney, or daily depletion of Middle Qi. Deficiency symptoms stop abruptly if restrained, unlike persistent excess. Treating deficiency requires identifying Essence/Qi and Yin/Yang, ignoring external symptoms to save the root. Delay or error leads to death. Signs like spontaneous diarrhea, cold body, grasping at air, or muttering facing wall are adverse. Deficient patients fearing delirium survive if pulse is surging/sliding with slight heat; die if pulse is weak/fine/rapid with irritability and cold extremities.
[Outline] Zhang Zhongjing said: In Yangming disease, bleeding and delirium indicate Heat entering the Blood Chamber. If only the head sweats, puncture Qimen acupoint to drain excess. Natural sweating leads to recovery.
In women with Wind-stroke, fever/chills, during menstruation, after 7-8 days, with resolved fever, slow pulse, cool body, hypochondriac fullness resembling Chest Bind, and delirium, this is Heat entering the Blood Chamber. Puncture Qimen to drain excess.
In women with Cold Damage, fever, during menstruation, clear during day but delirious at night as if seeing ghosts, this is Heat entering the Blood Chamber. Do not violate Stomach Qi or Upper/Middle Jiao; it will self-resolve.
[Commentary] Zhu Gong said: Why "do not violate Stomach Qi"? Heat enters via menstruation, causing Heat in Blood Chamber and delirium. Treat with Xiaochaihu Tang. This differs from Stomach excess delirium (dry feces requiring Tiaowei Chengqi Decoction). Since Blood Heat delirium is not Stomach excess, Zhang Zhongjing warns against purging the Stomach. Generally, delirium is Heat/Yang; presenting with Yin symptoms is adverse.
Liu Wansu said: Blood disease injures Liver; Liver stores Hun (Ethereal Soul). Injury causes Hun to lose its home and Heart Spirit to lose mastery, causing delirium. This is not Stomach excess but Liver excess due to Heat entering Blood Chamber. Liver Heat affects Heart (adjacent organs). Heat damages Heart Qi, impairing blood control and sweat production, causing only head sweating.
These three paragraphs focus on delirium, not just Heat entering Blood Chamber or Cold/Wind stroke. Note that delirium does not always originate from Stomach; do not assume Stomach excess and violate Stomach Qi.
[Outline] Zhang Zhongjing said: Combined disease of Three Yang channels presents with abdominal fullness, heaviness, difficulty turning, oral insensitivity, facial grease, and enuresis. Sweating causes delirium; purging causes forehead sweating and cold extremities. If spontaneous sweating occurs, Baihu Tang is indicated.
[Commentary] Kou Zongshi said: Delirium results from confusion of True Qi and unclear Spirit. Heart stores Spirit and governs Fire; pathology attracts Heat. In cold damage, Stomach excess-heat ascends to Heart, clouding Spirit and causing incoherent speech. Mild cases murmur in sleep; severe cases speak incoherently awake. Types include delirium, solitary speech, manic speech, incessant speech, and chaotic speech, varying by heat severity. Delirium/solitary speech retain some logic when interacting, indicating heat not at extreme. Classic: Solitary speech like seeing ghosts; if severe, unrecognized person, still not extreme. Manic speech indicates severe heat, spirit loss, shouting. Incessant speech is worse. Chaotic speech (cursing, ignoring kin) is extreme Spirit disorder. Classic: Adverse sweating leads to difficult cure in mild cases, chaotic speech in severe cases. Causes of delirium vary: fire coercion, sweating, diarrhea, bleeding, Yang collapse, passing the stage, or dry feces. This case stems from Three Yang combined disease. Short pulse means death; harmonious pulse means recovery. Slight heat with floating-large pulse indicates survival; cold extremities with deep-fine pulse mean death within a day. Excess delirium is inward-contracted original disease. Qi rebelling upward (wheezing/fullness) or downward (diarrhea) are adverse signs. Classic: Fixed staring/delirium/wheezing/fullness/diarrhea indicate complete Zheng Qi collapse.
Shen Jin'ao notes: Enuresis relates to Bladder (Taiyang). Difficulty turning relates to Side of body (Shaoyang). Oral insensitivity, facial grease, delirium, forehead sweating, cold extremities, spontaneous sweating relate to Yangming. Thus, though Three Yang combined, it is primarily Yangming with minor Taiyang/Shaoyang involvement. Treatment focuses on Yangming. Baihu Tang is used because it is Stomach Heat, not Stomach Excess.
[Outline] Zhang Zhongjing said: If Stomach Qi is disharmonious and delirium occurs, administer a small amount of Tiaowei Chengqi Decoction.
[Commentary] Wang Haogu said: For elderly/children/deficient persons with cold damage, drowsiness/incoherence after 5-6 days, urinary issues, restlessness, insomnia, use Baihu Tang plus Gardenia. For heat diseases/epidemics with irritability, manic running, epilepsy-like state, unstable speech, lack of sweat, or epidemic coma, use Renzhonghuang (soot from human dung pit) sealed in jar, fired strongly for half day, cooled, powdered, mixed with fresh water, 3 qian dose. Repeat if needed.
Wu Shou said: For severe cold damage heat, irritability with phlegm, coma/delirium, use Bamboo Sap and Polygonatum juice (1 cup each). Suitable for internal heat intolerant of purging.
[Outline] Zhang Zhongjing said: After 13 days of unresolved cold damage, passing the stage with delirium indicates Heat; treat with decoction to purge. If urination is free, stool should be hard; if diarrhea occurs instead, and pulse is harmonious, it indicates previous incorrect pill-based purgation. If spontaneous diarrhea occurs, pulse should be micro/cold; if harmonious, it indicates interior excess. Tiaowei Chengqi Decoction is indicated.
[Commentary] Wang Kentang said: "Excess" in "Interior Excess" here implies Heat.
This passage contains five contrasts and one pair: Heat vs. Cold, Decoction vs. Pill, Hard vs. Diarrhea, Micro vs. Harmonious Pulse, Medication-induced vs. Spontaneous Diarrhea. Free urination vs. Hard stool is a pair. Read carefully. Diarrhea with delirium, harmonious pulse, warm extremities, free urination indicates Yang; thus use Chengqi to purge. Micro/cold pulse, Shaoyin lethargy, fire-coerced sweating with delirium/difficult urination indicates Yin; thus use tonifying/harmonizing formulas.
[Outline] Zhang Zhongjing said: Yangming disease with delirium and tidal fever, surging-slippery-fast pulse, indicates Xiao Chengqi Decoction. Administer 1 sheng. If flatus passes, give another 1 sheng. If no flatus, do not give. If next day still constipated but pulse becomes micro-slippery, it indicates interior deficiency; difficult to treat, do not give Chengqi Decoction again.
[Commentary] Zhu Gong said: Tidal fever with surging-slippery-fast pulse indicates delirium; use Xiao Chengqi Decoction. Constipation, red urine, warm extremities, surging-rapid pulse indicates delirium; use Tiaowei Chengqi Decoction. Delirium without aversion to cold, preferring heat, use Baihu Tang. Post-sweating comfort with delirium, use Chaihu Guizhi Tang. Fire-coercion induced delirium, use Baihu Tang.
Shen Jin'ao notes: The key is "interior deficiency." All described symptoms are false excess; micro-slippery pulse is true deficiency. Despite delirium/tidal fever/purgative indications, Zhang Zhongjing is cautious, testing only with Xiao Chengqi Decoction.
[Outline] Zhang Zhongjing said: After cold damage vomiting/purging, unresolved, constipation for 5-6 to 10+ days, tidal fever at dusk, no aversion to cold, solitary speech like seeing ghosts. Severe cases: unrecognized person, grasping clothes/bed, fearful/restless, slight wheezing, fixed staring. String-like pulse indicates survival; choppy pulse indicates death. Mild cases: only fever and delirium; Da Chengqi Decoction is indicated. If one dose relieves, stop subsequent doses.
[Commentary] Ke Qin said: Mild cases (fever/delirium) indicate excess pathogen; treat by purging. Stop after relief to avoid attacking deficiency.
[Outline] Zhang Zhongjing said: Diarrhea with delirium indicates dry feces; use Xiao Chengqi Decoction. Sweating with delirium indicates dry feces in Stomach due to Wind; purging is required. Wait until the stage passes before purging. Early purging causes chaotic speech due to exterior deficiency and interior excess. Purging cures; use Da Chengqi Decoction.
Yangming disease with delirium, tidal fever, inability to eat indicates 5-6 dry feces in Stomach; use Da Chengqi Decoction. Ability to eat indicates only hardness.
Yangming disease with profuse sweating loses fluids, drying Stomach, hardening stool, causing delirium; use Xiao Chengqi Decoction. If delirium stops after one dose, do not continue.
[Commentary] Tao Hua said: High fever, dry retching, groaning, incoherent speech, insomnia: Xijiao Jiedu Tang. Disease without fever, only manic speech, irritability, inappropriate behavior: induce vomiting with Wuling San mixed in fresh water. Alternative: Zhuling Tang. Blood stasis with manic delirium, rinsing mouth, black stool, frequent urination, jaundice, abdominal fullness (due to missed sweating retaining heat internally): Mild cases, Xijiao Dihuang Tang; Severe cases, Taoren Chengqi Tang or Didang Wan.