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。
在小柴胡汤的方剂组成中，加入芒硝六两。其余按照前面的煎服法操作。如果服药后病证未解，继续服用。
伤寒病程已过十三日仍未解除，且病邪已传入他经（过经），出现谵语（神志不清，胡言乱语）的症状，这是因为体内有热。应当用汤药进行攻下治疗。如果小便通畅，大便应当干硬，反而出现腹泻，且脉象调和，可知是医生使用了丸药进行攻下，这不是正确的治疗方法。如果是患者自行腹泻，脉象应当微弱或四肢厥冷，现在脉象反而调和，这说明体内有实邪结聚。应当用调胃承气汤主治。
病邪传变经过多经仍未解除而出现谵语，这证明是热证无疑。如果用汤药攻下，则热邪去除，积垢排净；如果用丸药攻下，则热邪滞留于肠胃，导致腹泻不止。此时给予调胃承气汤以荡涤残留的热邪。
伤寒病程十三日，病邪再传一遍经络，称为“过经”。出现谵语，是阳明胃热的表现。应当用各类承气汤进行攻下。如果小便通利，津液偏渗于膀胱，大便应当干硬。反而出现腹泻，是因为医生使用了丸药攻下。如果腹泻且脉象微弱、四肢厥冷，这是虚寒证。现在脉象调和，说明不是虚寒证，而是由于肠虚胃热、胁热导致的腹泻。给予调胃承气汤，以清除胃中的热邪。
王宇泰说：经文中的“内实”之“实”，应当解释为“热”。注释中的“偏渗”，“偏”字应当作“漏”字理解。
又说：此处有五组反常现象与一对对应关系。“热”与“厥”相反，“丸药”与“汤药”相反，“大便硬”与“下利”相反，“脉微”与“脉和”相反，“药物攻下”与“自行下利”相反。“小便”与“大便硬”为一对。读者应当仔细详察。
王三阳说：前一条文中，伤寒医生误用攻下法，随后出现腹泻，完谷不化且不止，身体疼痛的，应当紧急救治里证，使用四逆汤。观察其身有疼痛，可知邪气完全在表，本不应攻下。若误用攻下，会导致里气极度虚弱，毫无分毫邪气在里，因此元气受损，完谷不化不止，必须紧急使用温药救里。况且医生误下，并未说明是丸药，那必定是承气汤一类的方剂。里证受病情况复杂，怎能不急救呢？而且体表的疼痛，也应当使用桂枝汤来解表。此证寒邪尚未化热，或者是寒邪侵入阴经的证候，完全没有热象。这一条原本属于柴胡证，邪气在半表半里，一半不宜攻下，一半宜攻下。况且使用了丸药攻下，表热不能彻底去除，所以邪热乘虚传入里部，形成胁热利。且体表症状有谵语，可知内有实邪。脉象又调和，说明元气尚存，所以在用承气汤攻下之后，病情得以缓解。这两条条文，正适合参看用药区别，不可误判。
病邪过经后出现谵语，是阳明胃热所致。成无己的注解非常确切。前一条胸胁满闷且呕吐，日晡时潮热并伴有腹泻，那是大柴胡汤证。过经后出现谵语，则是阳明病证，不可不加以辨别。
太阳病未解除，热邪结聚于膀胱。患者神情恍惚，似狂非狂。如果瘀血自行排出，病就会痊愈。如果表证仍未解除，还不可以攻逐瘀血，应当先解表。表证解除后，如果仅见少腹急迫结痛，才可以攻逐瘀血。适宜使用桃核承气汤方。
太阳经即膀胱经。太阳经的邪热未解，随经脉进入腑脏，形成热结膀胱。患者神情恍惚似狂，是指还未达到真正发狂的程度，只是心神不宁罢了。经书说：“其人如狂者，是因为热在下焦。”太阳经多热，热在膀胱，必然与血相搏结。如果血液没有被蓄积，而是被热邪逼迫，就会自行下行出血。血下行后，热邪随血而出，病即痊愈。如果血不下行，则血液被热邪搏结，蓄积在下焦，导致少腹急迫结痛，这时才可以攻逐瘀血。给予桃核承气汤，以泻热散血。《内经》说：“病邪从外部传入内部，且在内部盛极的，先治其外，后调理其内。”说的就是这种情况。
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.