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
《保命集》中的顺气散，用于治疗胃中有热且能进食的病证。患者小便颜色赤黄，伴有轻微腹泻。服药以出现不想吃东西的感觉为见效标准，不可导致过度腹泻。（此处指的就是本方）
另外还有三化汤，用于治疗中风邪气导致的实证，症状表现为大小便不通。
（此方是在上述顺气散的基础上，加入羌活。）
《拔萃方》中的顺气散，用于治疗消中病（一种以多食易饥为主要特征的疾病）。其病机为胃中有热，患者能够正常饮食，小便赤黄。对此应用泻下法治疗，但不可导致过度腹泻，只需微微通利大便，直到患者出现不想吃东西的情况，病即可痊愈。
（即本方）
阳明病，出现潮热（每日下午定时发热），大便略微干硬者，可以给予大承气汤。如果大便不硬，则不可给予。若患者多日不大便，经过六七天，担心体内有燥屎（干结的粪便），想要确认的方法，是少量给予小承气汤。药汤进入腹中后，如果患者放屁（转失气），这说明体内有燥屎，才可以进行攻下治疗。如果不放屁，这说明只是大便开头硬，后面一定是稀溏的，不可攻下。如果误用攻下法，必然会导致腹胀满、不能进食。如果患者想喝水，给水喝则会出现呃逆（打嗝）。此后如果出现发热，大便一定会再次变得干硬且量少，此时应使用小承气汤调和胃肠。对于不放屁的患者，务必谨慎，不可攻下。（注：成本脱去“可”字，《玉函经》作“勿与之”。此处有燥屎，《成本》无“也”字。“转失气”，《玉函经》均作“转矢气”。其后发热，《玉函经》作“其后发潮热”。周本、钱本，“失”作“矢”。《千金方》在两个“转矢气”处写作“转气”。）
〔成无己注〕潮热属于实证，大便略微干硬的，就可以攻下。如果大便不硬，说明热邪尚未结成实邪，即使有潮热，也不可攻下。若多日不大便，担心有燥屎，应当先给予小承气汤试探（正脉本、全书本作“渍”，汪校本作“探”）。如果有燥屎，由于小承气汤药势缓和，不能宣泄，必然会出现气体向下排出的现象。如果不排气，说明胃中没有燥屎，只是肠道间稍微有些干硬，仅仅是开头硬，后面一定是稀溏的。此时攻下会损伤胃气，导致腹胀满、不能进食。胃中干燥，所以想喝水，水进入胃中，虚寒之气与水相搏结，气机上逆则发生呃逆。此后又出现发热，是因为热气乘虚而入，重新聚集在胃中，胃燥受热，大便必然会再次变硬且量少，此时少量给予小承气汤微微通利，予以调和。因此强调不要排气者，不可攻里，务必谨慎。
〔知〕上条说：表证已解才可攻里；表证未解不可与承气汤；可与小承气汤，微微调和胃气，不要让它剧烈泻下。本条说：可与、不可与、乃可攻之、不可攻之、少与小承气、以小承气和之、慎不可攻。通过多少剂量的斟酌，体现了慎重之意。因此只有手足濈然汗出、大便燥硬者，才主治以大承气汤。至于小承气汤，仍然是微微调和胃气的方法。
〔汪〕如果排气，就知道患者大便已经变硬，肠胃中燥热亢盛，所以气体不能向外宣散，时常转动并向下排出。如果不排气，说明肠胃中虽然有热，但津液渗孔尚未达到干燥程度，这仅仅是开头硬，后面一定是稀溏的。
黄仲理说：这段文字可以分为五段来看。
钱氏说：“其后发热”这一句，应当从“不转矢气”一句落下理解才是正确的。看最后一句又说“不转矢气者，慎不可攻”，前后照应非常明显。而注释家认为攻下后重复发热，胃热到这时才炽盛，这必定是不可能的情况。下笔详尽审慎、智虑周密的人，不应该像这样。魏氏说：“欲饮水者”以下，仔细玩味原文，明显是另起一个话题，而注释家含糊其辞，导致文意离析更甚。○按语：虚证变为实证，寒证转为热证，难道是绝对不可能的事吗？发热即称为潮热，《玉函经》可以证明。成氏顺着文意注释，反而觉得妥当。
舒氏说：案此条原文，止于“攻之必胀满不能食也”，文意已经结束，下面几句是平空插入的，也是后人的错误。案“转失气”，《伤寒直格》解释为动转排泄之气，这种说法是对的。《条辨》说：黄氏曰，“矢”在《汉书》中写作“屎”，古文中“屎”和“矢”通用，“失”是传写错误。《续医说》、《医学全书》说：这是下焦泄气，俗话叫放屁。考证《篇韵》，屎和矢通用，我怀疑是传写错误，把“矢”误写成了“失”，应该遵从“转矢气”的说法。而且文理颇为通顺，如果用“失”字，则在意义上难以训释。舒氏说：案“矢气”二字，以前的书中都写作“失气”，这是错误的。因为“矢”字误写多了出头。大概“矢”和“屎”同义，“矢气”就是屁，是屎的气体。而且“失”字上面没有“转”字的道理，“转”乃是转运的意思，因为气体由转运而出，如果真的是“失”下，哪里来的“转”呢？确凿无疑是“矢”字。然而考证《内经》，有“失气”的说法，如“咳而失气，气与咳俱失”之类，就是这个意思。于是改成“矢”字，却是画蛇添足了。张兼善说：有人问《伤寒论》中所说的“转失气”，不知道那气是什么样的？如果不是腹中雷鸣滚动，那就是转失气吗？我说：不是。凡是泄泻的人，不能泻气，只有腹中雷鸣波动而已。然而滚动的是水势奔流发出的声响，泄气是失气下趋，形成鼓胀泻下，空虚则发出声响，充实则气体排出，所以腹中滚动和泄气是不同的。那种先硬后溏的转失气，气尚且不能转动，何况大便不成形的人呢？
真实则谵语（胡言乱语），虚则郑声（语言重复低微）。郑声，是指重复说话。直视且谵语，伴有喘满的会死，伴有下利的也会死。（“也”字上，《玉函经》有“是”字。《外台秘要》将“郑声者重语也”作为小注。从“直视”以下，成无己以后的版本分为别条，只有志聪、锡驹将其作为一条。）
〔锡驹注〕这一章，总论谵语有虚实不同，生死各异。实证谵语，是阳明燥热严重，神志昏迷气机紊乱，所以不避亲疏，妄言骂人。虚证郑声，是神气虚弱不能自主，所以声音不正，语言重复，即《素问》所说的“言语细微，整天反复说”的情况。直视，是精气不能灌注眼睛，目系紧张不能转动。谵语本来没有死证，如果伴有喘满，是脾肺不交，气从上脱，所以死。伴有下利，是脾液不收，气陷于下，也死。郑声，就是谵语的声音，听其声音有不正之声，轻微重复的话语，这就是郑声，并不是在谵语之中另外有一种郑声。所以只首提郑声，而后没有郑声的证候。〔张〕喘满，是邪气乘阳位而上争，气从上脱，所以主死。下利，是邪聚阴位而下夺，气从下脱，也死。假设谵语内结，下利清水的，又不可误认为是死证。
〔钱〕喘则膻中迫促，气接不上；满则传化不通，胃气绝，所以死。
《证治要诀》说：谵语，是颠倒错乱，言出无伦常，常常对着空气独自说话，好像看见鬼的样子。郑声，是郑重频繁，话语虽然谬误但谆谆重复停不下来。年老的人，遇事则絮叨不休，是因为阳气虚。这两者本来不难辨别，必须结合其他证候来区分。大便秘结、小便赤、身热烦渴而妄言的，是里实证的谵语。小便如常、大便洞泻，或者烦躁，或者反发热而妄言的，是阴隔阳的谵语。这就是谵语和郑声虚实不同的原因。
《医学纲目》说：谵语，是说乱话没有次序，屡次更换话题。郑声，是说郑重频繁，只是将一句旧话重叠频繁地说，整天殷勤，不换其他声音。大概神有余，就能机变而乱语，屡次更换话题；神不足就没有机变，只守着一个声音。成无己说郑声是郑卫之声，是不对的。
《伤寒选录》说：郑声，是说过又说。
舒氏说：李肇夫说：“重”字读平声，“重语”应该是絮絮叨叨，说了又说。纲语呢喃，声音低气息短，身体沉重恶寒，与谵语声音雄壮气势粗猛、身体轻快恶热的截然不同。
发汗过多，如果再发汗，会导致亡阳（阳气耗损），出现谵语。脉短的会死，脉自和的不死。（《玉函经》在“重发汗”下没有“者”字，有“若已下复发其汗”七字句。在“多”下没有“若”字。）
〔汪〕这是太阳病转属阳明谵语的证候。原本太阳经得病时，发汗过多，转属阳明，再次发汗，汗多亡阳。汗本是血的津液，阳亡则阴也亏损，津血耗竭，胃中燥实而出现谵语。谵语者的脉应当弦实或洪滑，这叫自和。自和，是说脉象与病证不相违背，病情虽然严重但不会死。如果谵语脉短，是邪热盛正气衰，是阳证见阴脉，所以主死。有人将阳亡理解为脱阳，脱阳的人会看见鬼，所以谵语，打算用四逆汤急回阳气，这是极大的错误。〔柯〕亡阳，就是津液越出的互辞。
按：方氏将此条列为太阳经错简，喻氏辨析其误，是正确的。程氏锡驹也将此条证候视为脱阳，也不对。
伤寒如果经过吐法或下法后病不解，多日不大便，从五六天甚至十余天，每天傍晚发作潮热，不恶寒，独自说话好像看见鬼的样子。如果病情严重，发作时不认识人，手循摸衣被床沿，惊恐不安。（【原注】一说：顺衣妄撮，怵惕不安。）轻微气喘，直视。脉弦的生存，脉涩的死亡。病情轻微的，只是发热谵语，用大承气汤主治。如果服一次药后大便通利，就停止后面的服用。（《成本》在“止”上脱去“则”字。“晡”下“所”字，《玉函经》作“时”。“摸床”，《玉函经》作“撮空”，《脉经》作“妄撮”，庞氏也作“妄撮”，注云：常见有此撮空候，所以改之。“惕而”，《玉函经》、《脉经》作“怵惕”。《脉经》在“谵语”下没有“者”字，这是对的。“五六日”下没有“上”字。）
〔汪〕这条列举了谵语势重的情况。伤寒如果经过吐法或下法后病不解，说明津液亡失而邪气未尽去除。邪热内结，多日不大便，从五六天甚至十余天，这是可以攻下的时机。每天傍晚发作潮热，是腑实燥热严重，所以在其旺时发作潮热。不恶寒，说明表证已罢。独语，就是谵语，是阳明腑实，妄见妄闻。病剧则不认识人，“剧”意思是严重。热气盛大，昏冒正气，所以不认识人。循衣摸床，是阳热偏胜，躁动于手部。惕而不安，是胃热冲膈，心神为之不宁。另外胃热甚，气上逆则喘。现在喘虽轻微，但直视，直视说明邪气侵犯脏腑了。所以其生死之际，必须通过脉候来判断。后世条辨说：以上见证，无非是阳亢阴绝，孤阳无根据而扰乱的现象。弦涩都是阴脉，脉弦说明阴气未绝，还带有长养之气，所以可生。脉涩说明阴气已绝，已成枯竭，所以说死。热邪轻微，未达到严重的，只是发作潮热谵语，宜用大承气汤，下胃中实热，肠中燥结。服一次药通利后就停止后续服用，是因为大承气汤虽然能抑阳通阴，如果通利后再服，恐怕泻下过多反而亡阴，必定导致危殆，怎能不禁止呢？
〔钱〕伤寒治法应当先汗，这里只说如果吐如果下后病不解，明确是应当汗而未汗，误用吐下，导致外邪内陷而不解。
〔柯〕如见鬼状独语，与郑声谵语不同。潮热不恶寒，不大便，是可以攻下的证候。目直视不识人，循衣摸床等症状，是日晡发热时的事，不发热时自然安静，所以不要轻易断定为死症。凡直视谵语，喘满的会死，这里是微喘而不满。
《伤寒准绳》赵嗣真说：这一段应当分作三截看。从“伤寒”云云，止于“如见鬼状”，是第一截，是将潮热谵语、不恶寒不大便作为现证。下文又分作一截，以辨别剧者和微者的区别。微者只是发热谵语，“但”字意为义，即在发热谵语之外，没有其他证候。又说：弦是阳，涩是阴。阳病见阴脉者生，在仲景法中，弦涩属于阴，不属于阳，难道有疑问吗？《金鉴》说：现在看本文内，“脉弦者生”的“弦”字，应当是“滑”字。如果是“弦”字，弦是阴负之脉，哪里有必生的道理？只有滑脉为阳，才有生理。滑代表通，涩代表塞，凡物理都是以通为生，塞为死。玩味后条“脉滑而疾者，小承气主之”，“脉微涩者，里虚为难治”，更加印证这是错误。○按：《辨脉》以弦为阴脉，所以《金鉴》根据赵氏之言有此说法。然而“弦”与“滑”，字形音韵迥异，决无相误的道理。汪注源于成氏，颇为妥当，不容他议。关于弦义，详见我所著的《脉学辑要》。
《本事方》说：有人患伤寒，大便不利，每天傍晚发潮热，手循衣缝，两手撮空，直视气喘急促，换了好几个医生，见到的人都走开了，这确实是恶候，得此病的人十中九死。仲景虽然有证但没有方法，只说脉弦者生，涩者死。已经经过吐下，难以下药，姑且救之。如果大便得通，而脉弦的，或许可以治疗。给予小承气汤一服，大便通利，诸疾渐退，脉且微弦，半个月痊愈。我曾观察钱仲阳《小儿直诀》说：手寻衣领，及捻物的，是肝热。此证在《玉函经》列于阳明部，大概阳明就是胃，肝有热邪，淫溢于胃经，所以用承气汤泻之。且得到弦脉，则肝平而胃不受克，这就是所谓有生之理。读仲景论，不能博通诸医书以发明其隐奥，我没见过这样的人。
张氏直解说：丁巳年秋天，我治疗一位妇人，伤寒九天，发狂面白，谵语不认识人，循衣摸床，口眼抽动，肌肉抽搐，遍身手足尽冷，六脉皆脱，死证具备。众医都推辞不治。我审视良久，听到她声音重而且长，句句有力，就说：这是阳明内实，热郁于内，所以令脉道不通，不是脱证。如果真是元败绝而脉脱，必定气息奄奄，不久即死，怎么会有如此力气，大呼疾声，久而不绝呢？于是用大承气汤，撬开牙齿灌下。夜间解黑粪满床，脉出身热神清，舌燥而黑，再服小陷胸汤，两剂而愈。因而想到此症大类四逆，如果误投四逆汤立刻死亡。硝黄固不可以误投，参附又岂可以轻试呢？
《金鉴》说：循衣摸床，是危恶的候象。大抵此证，多生于汗吐下后，阳气大虚，精神失守。经说：四肢，是诸阳之本。阳虚，所以四肢扰乱，失去依托。用独参汤救治，汗多者，用参...汤，厥冷者，用参附汤治疗，痊愈者不少，不可一概说是阳极阴竭。
阳明病，患者多汗，因为津液外出，胃中干燥，大便必然干硬，硬则谵语，用小承气汤主治。如果服一次药谵语停止，不要再服用。（《成本》在“止”下没有“者”字。）
〔程〕阳明病法当多汗，此人又是汗家，则不必发其汗，而津液外出，自然导致胃燥便硬而谵语，证候在虚实之间，所以即使是小承气汤，也只以服一次为限度。谵语停止，不再服用，是因为虽然燥硬未全除，但在实处防止虚损。〔柯〕多汗，是胃燥的原因；便硬，是谵语的根源。服一次药谵语停止，大便虽未通利，但胃中湿润可知。〔周〕经云：少阳不可发汗，发汗则谵语，现在自汗也是这样吗？〔汪〕武陵陈氏（亮斯）说：大承气证，必须像前条那样多日不大便，或至十余天之久，渐渐搏实，然后使用。现在是汗多燥硬而谵语，病机很快，这是亡津液缘故，而不是渐渐搏实，虽然坚但不大满，所以只应当用小承气主治。且津液不足，不适合大承气。服药后谵语虽止，即使未大便，也不要服完一剂，恐怕过伤元气耳。
阳明病，谵语发潮热，脉滑而疾的，用小承气汤主治。于是给予承气汤一升，腹中转气的，再服一升。如果不转气的，不要再次给予。明天又不大便，脉反而微涩的，是里虚，为难治，不可再与承气汤。（“转气”，《成本》并作“转失气”，《玉函经》作“转矢气”。《成本》脱去“勿”上的“者”字及“又”字。《千金翼》在“谵语”下有“妄言”二字。《脉经》、《千金翼》没有“小承气汤”的“小”字。）
〔成无己注〕阳明病，谵语发潮热，如果脉沉实的，是内实，则可以攻下。如果脉滑疾，是里热未实，则不可攻下。先给予小承气汤调和。药汤进入腹中，如果排气，说明中有燥屎，可以再给予小承气汤一升以去除它。如果不转失气，是无燥屎，不可再给予小承气汤。到了第二天邪气传经之时，脉得沉实紧牢之类的，是里实。反而得微涩的，是里气大虚。如果大便利后，脉微涩的，仅为里虚还可以。这里不曾大便，脉反而微涩，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