【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（此便是狂）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】朱肱曰。脉弦者。阳也。涩者。阴也。阳症见阴脉者死。病患有阳症而脉涩者。慎不可
下。
下症悉具。服汤已。更衣者。止后服。不尔。方尽剂服之。下后。慎勿中服补药。孙真人云。
服大承气汤。得利瘥。慎不中服补药也。热气得补复盛。更复下之。是重困也。宜消息安养之。
仲景有宜下者。有微和其胃气者。盖伤寒里症。须看热气浅深。故仲景有宜下之症。如大承气
汤、小承气汤、十枣汤、大柴胡汤是也。有微和其胃气。如调胃承气汤、脾约丸、小承气。微和之
之类是也。金匮云。虚者十补勿一泻。强实者泻之。虚实等者泻勿大泻之。故叔和序伤寒有承气之
戒。
又问。转药孰紧。答曰。大承气最紧。小承气次之。调胃承气又次之。大柴胡又次之。仲景治
法。荡涤热积。皆用汤液。不得用丸子。不可不知也。大柴胡加大黄。小柴胡加芒硝。方为转药。
盖为病轻者设也。
鳌按。潮热谵狂俱见。症之极重者矣。阅仲景阳明症论中。有单言潮热者。有单言谵语者。有
单言发狂者。此条乃独举潮热谵狂而备言之。明乎其症之重。且凭脉以决其生死也。大约病至此。
其脉必弦者少。而涩者多。故弦者生句轻。看专重在涩者死句。欲医者于此。急审其脉。或犹见弦
象。则犹有下之一法以救之。不然。可勿药也。仲景特提此条以为世告。余亦因独摘此条。另立一
款。不杂入单言潮热单言谵语单言发狂款中也。
【纲】张仲景说：患伤寒病，如果经过催吐或泻下治疗后，病情仍未解除。出现连续五六天甚至十多天不大便，在傍晚时分（日晡所）定时发作潮热，不再怕冷。独自胡言乱语（这就是狂证），好像看见鬼怪一样。如果病情严重，发作时不认识人，手无意识地抓摸衣被和床沿，惊恐不安，轻微气喘，两眼直视。脉象弦的有生机，脉象涩的预后不良（主死）。症状较轻的，只是发热并伴有胡言乱语，用大承气汤主治。如果服用一次后大便通畅，就停止服用后面的药。
【目】朱肱说：脉象弦，属于阳脉；脉象涩，属于阴脉。阳证见到阴脉的会死亡。患者表现为阳证而脉象涩的，千万不可使用泻下法。
如果所有适合泻下的症状都具备，服药后大便通畅的，就停止服用后续药物。否则，就把整剂药服完。泻下之后，千万不要中途服用补药。孙思邈说：服用大承气汤后，若得利而病愈，切记不要中途服用补药。因为热气得到补益后会再次亢盛，导致需要再次泻下，这是使病人更加困顿的做法。应当仔细斟酌，安心调养。
张仲景对于适宜泻下的病症，也有轻微调和胃气的情况。大概是因为伤寒里的病症，必须观察热邪的深浅程度。所以张仲景有适宜峻下的病症，如大承气汤、小承气汤、十枣汤、大柴胡汤等；也有轻微调和胃气的情况，如调胃承气汤、脾约丸、小承气汤等微和之类的方剂。《金匮要略》说：虚证应当十次补益也不要一次泻下；实证应当泻下；虚实夹杂的，泻下时不要过于猛烈。所以王叔和在《伤寒论》序言中提出了关于承气汤使用的戒律。
又问：转换方药哪个更紧迫？回答说：大承气汤最峻猛，小承气汤次之，调胃承气汤再次之，大柴胡汤又次之。张仲景的治疗法则，荡涤热积，都用汤剂，不能用丸剂，这一点不可不知道。大柴胡汤加大黄，小柴胡汤加芒硝，这些方剂作为转换治疗的用药，大概是为病情较轻者设立的。
沈金鳌按语：潮热、谵语、发狂同时出现，是病情极其严重的表现。阅读张仲景关于阳明病的论述中，有单独提到潮热的，有单独提到谵语的，有单独提到发狂的。这一条唯独列举了潮热、谵语、发狂并详细论述，以明确其病情的严重性，并且通过脉象来判断生死。大概病情发展到这一步，脉象弦的少，而脉象涩的多。所以“脉弦者生”这句话语气较轻，重点在于强调“脉涩者死”。希望医生在此时，急切地审察脉象，如果还能看到弦象，那么还有使用泻下法来挽救的可能；不然，就不要用药了。张仲景特意提出这一条告诫世人，我也因此单独摘出这一条，另立一款，不混杂在单独提及潮热、谵语或发狂的条目中。
[General Principle] Zhang Zhongjing stated: In the case of Cold Damage (Shanghan), if after emesis or purgation, the condition remains unresolved. If there is no bowel movement for five to six days, extending up to ten or more days, tidal fever (Chao Re) occurs at dusk (Ri Bu Suo), without aversion to cold. The patient speaks alone (this constitutes mania/Kuang), appearing as if seeing ghosts. In severe cases, during episodes, the patient fails to recognize people, involuntarily grasps at clothing and bed rails, feels terrified and restless, has slight panting, and fixed staring. A wiry pulse (Xian Mai) indicates survival; a choppy pulse (Se Mai) indicates death. In milder cases, there is only fever accompanied by delirious speech (Chan Yu). Da Cheng Qi Tang (Major Order the Qi Decoction) is the primary treatment. If one dose results in relief (bowel movement), stop taking subsequent doses.
[Detailed Commentary] Zhu Gong said: A wiry pulse belongs to Yang; a choppy pulse belongs to Yin. When Yang symptoms present with a Yin pulse, it indicates death. If a patient exhibits Yang symptoms but has a choppy pulse, purgation must strictly be avoided.
If all indications for purgation are present, and after taking the decoction, normal defecation occurs, stop taking further doses. Otherwise, consume the entire prescribed amount. After purgation, strictly avoid administering tonifying medicines mid-course. Sun Simiao stated: After taking Da Cheng Qi Tang, if relief is achieved through bowel movement, one must strictly avoid taking tonics. Heat pathogens may become vigorous again upon receiving tonification, necessitating further purgation, which places the patient in a state of双重 distress (Zhong Kun). One should carefully assess and provide restful care.
Zhang Zhongjing addressed conditions suitable for purgation, as well as those requiring mild harmonization of Stomach Qi. Generally, in interior syndromes of Cold Damage, one must observe the depth of heat pathogens. Thus, Zhang Zhongjing indicated conditions suitable for strong purgation, such as Da Cheng Qi Tang (Major Order the Qi Decoction), Xiao Cheng Qi Tang (Minor Order the Qi Decoction), Shi Zao Tang (Ten Jujube Decoction), and Da Chai Hu Tang (Major Bupleurum Decoction). There are also conditions requiring mild harmonization of Stomach Qi, such as Tiao Wei Cheng Qi Tang (Regulate the Stomach Order the Qi Decoction), Pi Yue Wan (Splee Restriction Pill), and mild applications of Xiao Cheng Qi Tang. The *Jin Gui Yao Lue* states: For deficiency patterns, tonify ten times rather than purge once; for excess patterns, purge them; for mixed deficiency and excess, do not purge excessively. Therefore, Wang Shuhe issued warnings regarding the use of Cheng Qi formulas in his preface to *Shanghan Lun*.
Another question asked: Which formula conversion is most urgent? The answer is: Da Cheng Qi Tang is the most potent; Xiao Cheng Qi Tang is next; Tiao Wei Cheng Qi Tang follows; Da Chai Hu Tang is next. Zhang Zhongjing’s therapeutic principles for sweeping away heat accumulation utilize liquid decoctions, not pills. This must be known. Da Chai Hu Tang added with Rhubarb (Da Huang), and Xiao Chai Hu Tang added with Mirabilite (Mang Xiao), serve as transitional formulas, likely established for milder conditions.
Commentary by Shen Jin'ao: The simultaneous occurrence of tidal fever, delirium, and mania represents an extremely severe syndrome. In reading Zhang Zhongjing’s discussions on Yangming syndromes, there are mentions of tidal fever alone, delirium alone, or mania alone. This specific clause uniquely highlights tidal fever, delirium, and mania together, clarifying the severity of the syndrome and using the pulse to determine life or death. Generally, when the disease reaches this stage, a wiry pulse is rare, while a choppy pulse is common. Therefore, the statement "wiry pulse indicates survival" carries less weight, with the emphasis placed on "choppy pulse indicates death." Physicians should urgently examine the pulse here. If a wiry image is still visible, there remains a method of purgation to rescue the patient; otherwise, medication should be withheld. Zhang Zhongjing specifically raised this clause to warn the world. I have therefore extracted this clause separately, establishing it as a distinct category, not mixing it with clauses mentioning only tidal fever, delirium, or mania.