大便难。大便硬。燥矢。悉属里症。宜承气下之。然必候其舌苔黄浓焦刺。腹中硬满
胀痛。方可议下。
邵评∶用下须有真凭实据。
按承气症。后人以熟地、归、芍养阴之品。用代大黄。芒硝等药者非。盖伤寒热病。
每每不得大便。若腹中无痞满硬痛之状者。非承气症。外虽有潮热谵语自汗等症。亦只宜清火润燥养阴。
听其自然。不可攻下。所谓下不嫌迟也。必腹中痞满实而胀痛者。方是承气的症。斯时燥矢积垒胃底。
阳土亢极。肾水欲涸。若不急下。则地道不通而死。故以芒硝软坚。朴实推送。大黄达下。则燥矢得下。肠胃
通和而解。所谓土郁夺之也。养阴之品。惟宜施于汗后余热未退。二便虽秘。绝无硬满之苦者。此法方
为切当。附记于此。以俟临症者审察焉。
邵评∶辨津枯。热结与燥实。治法大异。最宜着眼。
卫气者。护卫皮肤腠理也。邪气干之。则卫气不能外固。而津液走泄。 然汗出矣。风与暑湿之邪。
皆令自汗。寒邪伤于营卫。则肤腠闭密。故无汗。及邪传里为热。则营卫通。腠理开。亦令汗自出矣。
邵评∶寒邪在表则无汗。风暑湿邪及邪传里。俱有自汗。
若汗出恶风。及微恶寒者。皆表未解。而为阳明表症。宜解肌。桂枝汤。至于漏不止
而恶风。及发汗后反恶寒者。此属表虚。宜温之。玉屏风加附子。
邵评∶表邪与阳虚自汗异治。
若身热汗出。不恶风寒者。此为表解。属里。为阳明本病。大热烦渴。白虎症。便硬谵语。承气症。
邵评∶自汗属阳明。有经热腑实之不同。
似阳明症 一曰柔痉。发热汗出。不恶寒。似阳明。而身反张为异。一曰风温。汗出身热。似阳明。
而脉浮身重多眠为异。（以上参准绳）
邵评∶柔痉与风温二症。俱有自汗。似属阳明。察其见症非阳明。恐人误认。故特揭出。
伤寒奥旨云。伤风则恶风自汗。伤湿则身重自汗。中暑则脉虚烦渴自汗。湿温则妄言自汗。风温则鼾
眠自汗。柔痉则搐搦自汗。阳明则潮热自汗。劳倦则身倦自汗。亡阳则漏不止自汗。
邵评∶自汗各有因。当分因施治。
大便困难。大便干硬。燥屎内结。都属于里证。适宜用承气汤类方剂攻下。然而必须等到舌苔黄厚、焦黑且生刺，腹部坚硬胀满疼痛时，才可以讨论使用下法。
邵评：使用下法必须有确凿的证据。
按语：承气汤证，后人用熟地黄、当归、白芍等养阴药物代替大黄、芒硝等药，这是错误的。因为伤寒热病，常常出现不大便的情况，如果腹部没有痞塞、胀满、坚硬、疼痛的症状，就不是承气汤证。即使外表有潮热、胡言乱语、自汗等症状，也只宜清热泻火、润燥养阴，听任其自然恢复，不可攻下。这就是所说的“下法不宜过早”。只有当腹部痞塞、胀满、坚实且疼痛时，才是承气汤的适应症。此时燥屎堆积在胃底，阳土亢盛至极，肾水将要枯竭，如果不紧急攻下，则肠道不通而死。所以用芒硝软化坚结，朴硝（此处原文为“朴实”，结合语境及承气汤组成，通常指厚朴或芒硝之软坚作用，但原文写“朴实推送”，疑为厚朴之误或特指其行气推荡之功，此处依原文直译并保留术语）推动输送，大黄通达下行，这样燥屎得以排出，肠胃通畅调和而病解。这就是所说的“土郁夺之”的治疗方法。养阴的药物，只适宜用于发汗后余热未退，二便虽然闭塞，但绝对没有坚硬胀满痛苦的患者，这种方法才恰当。附记在这里，以等待临症者仔细审察。
邵评：辨别津液枯涸、热邪结聚与燥实内结，治疗方法大不相同，最应着眼注意。
卫气，是护卫皮肤腠理的功能。邪气侵犯它，卫气就不能在外固守，导致津液外泄，于是出汗了。风邪与暑湿之邪，都会导致自汗。寒邪损伤营卫，则肌肤腠理闭合严密，所以无汗。等到邪气传入体内化为热邪，则营卫通行，腠理开泄，也会导致自然出汗。
邵评：寒邪在表则无汗，风、暑、湿邪以及邪气传入体内，都有自汗。
如果出汗且怕风，以及轻微怕冷的，都是表证未解，属于阳明表证，适宜用解肌法，方用桂枝汤。至于汗出如漏不止且怕风，以及发汗后反而怕冷的，这属于表虚，适宜温补，方用玉屏风散加附子。
如果身体发热、出汗，不怕风寒的，这是表证已解，病属里，是阳明本病。若见大热、烦躁、口渴，是白虎汤证；若见大便干硬、胡言乱语，是承气汤证。
类似阳明病的症状：一是柔痉，发热出汗，不怕冷，看似阳明病，但身体反张（角弓反张）是其不同之处。二是风温，出汗且身体发热，看似阳明病，但脉浮、身体沉重、多嗜睡是其不同之处。（以上参考《医宗必读》或相关典籍，原文注“参准绳”）
邵评：柔痉与风温两种病症，都有自汗，看似属于阳明病，但观察其表现并非阳明病，恐怕人们误认，所以特别提出。
《伤寒奥旨》说：伤风则怕风、自汗；伤湿则身体沉重、自汗；中暑则脉虚、烦躁、口渴、自汗；湿温则胡言乱语、自汗；风温则打鼾嗜睡、自汗；柔痉则抽搐、自汗；阳明病则潮热、自汗；劳倦则身体疲倦、自汗；亡阳则汗出不止、自汗。
Difficulty in defecation. Hard stool. Dry fecal impaction. All belong to interior syndromes (Interior Syndromes). It is appropriate to use Chengqi Decoction (Cassia Twig Decoction) variants for purgation. However, one must wait until the tongue coating is yellow, thick, scorched, and prickly, and the abdomen is hard, full, distended, and painful, before discussing the use of purgative methods.
Shao's Commentary: The use of purgatives requires solid evidence.
Note regarding Chengqi Syndrome: Later practitioners used Yin-nourishing herbs such as Shudi (Rehmanniae Radix Praeparata), Gui (Angelicae Sinensis Radix), and Shaoyao (Paeoniae Radix Alba/Rubra) to replace Dahuang (Rhei Radix et Rhizoma) and Mangxiao (Natrii Sulfas). This is incorrect. In Shanghan (Cold Damage) febrile diseases, constipation often occurs. If there are no symptoms of abdominal glomus, fullness, hardness, or pain, it is not a Chengqi syndrome. Even if exterior symptoms such as tidal fever, delirium, and spontaneous sweating are present, only clearing heat, draining fire, moistening dryness, and nourishing Yin should be employed, allowing nature to take its course; aggressive purgation is contraindicated. This is what is meant by "purgation should not be delayed." Only when the abdomen presents with glomus, fullness, solidity, and pain is it an indication for Chengqi Decoction. At this time, dry fecal matter accumulates at the bottom of the stomach, Yang Earth is hyperactive to the extreme, and Kidney Water is about to dry up. If urgent purgation is not performed, the pathway of the intestines will become blocked, leading to death. Therefore, Mangxiao (Natrii Sulfas) is used to soften hardness, Houpo (Magnoliae Officinalis Cortex) [Note: Text says 'Pushi', likely referring to Houpo's pushing action] pushes and transports, and Dahuang (Rhei Radix et Rhizoma) reaches downward. Thus, the dry feces are expelled, the intestines and stomach become smooth and harmonious, and the disease resolves. This is what is referred to as "draining the obstruction of Earth" (Tu Yu Duo Zhi). Yin-nourishing herbs are only suitable for cases where, after sweating, residual heat has not subsided, and although urination and defecation are obstructed, there is absolutely no suffering from hardness and fullness. This method is appropriate. It is recorded here for clinicians to examine carefully.
Shao's Commentary: Differentiating between fluid depletion, heat binding, and dry-solid accumulation reveals vastly different treatment methods; this deserves close attention.
Wei Qi (Defensive Qi) protects the skin and interstices (Cou Li). When pathogenic factors invade, Wei Qi cannot secure the exterior, causing body fluids to leak out, resulting in sweating. Wind, Summerheat, and Dampness pathogens all cause spontaneous sweating. Cold pathogens injure Ying Qi (Nutritive Qi) and Wei Qi, causing the skin and interstices to close tightly, thus resulting in no sweating. However, when pathogens transmit inward and transform into heat, Ying and Wei Qi circulate freely, the interstices open, and spontaneous sweating also occurs.
Shao's Commentary: Cold pathogens on the exterior result in no sweating; Wind, Summerheat, Dampness pathogens, and pathogens transmitting inward all involve spontaneous sweating.
If sweating is accompanied by aversion to wind and slight aversion to cold, the exterior is not yet resolved, constituting a Yangming exterior syndrome. It is appropriate to release the muscle layer using Guizhi Tang (Cinnamon Twig Decoction). If sweating continues like a leak and aversion to wind persists, or if aversion to cold appears after sweating, this belongs to exterior deficiency. It is appropriate to warm the exterior using Yupingfeng San (Jade Windscreen Powder) added with Fuzi (Aconiti Lateralis Radix Praeparata).
Shao's Commentary: Spontaneous sweating due to exterior pathogens and that due to Yang deficiency require different treatments.
If there is fever and sweating without aversion to wind or cold, the exterior is resolved, and the disease is interior, constituting the fundamental disease of Yangming. High fever, irritability, and thirst indicate Baihu Tang (White Tiger Decoction) syndrome. Hard stool and delirium indicate Chengqi Tang syndrome.
Shao's Commentary: Spontaneous sweating belongs to Yangming, differing between meridian heat and fu-organ excess.
Symptoms resembling Yangming include: First, Rou Jing (Soft Spasm), characterized by fever and sweating without aversion to cold. It resembles Yangming but differs by the backward arching of the body. Second, Feng Wen (Wind-Warmth), characterized by sweating and fever. It resembles Yangming but differs by floating pulse, heavy body, and excessive sleepiness. (Referenced from *Zhunsheng*)
Shao's Commentary: Both Rou Jing and Feng Wen involve spontaneous sweating and resemble Yangming, but their manifestations are not Yangming. They are highlighted to prevent misdiagnosis.
*Zanghan Aozhi* states: Wind injury causes aversion to wind and spontaneous sweating; Dampness injury causes heavy body and spontaneous sweating; Summerheat injury causes deficient pulse, irritability, thirst, and spontaneous sweating; Damp-Warmth causes incoherent speech and spontaneous sweating; Wind-Warmth causes snoring, sleepiness, and spontaneous sweating; Soft Spasm causes spasms and spontaneous sweating; Yangming disease causes tidal fever and spontaneous sweating; Labor fatigue causes tired body and spontaneous sweating; Collapse of Yang causes unceasing leakage of sweat and spontaneous sweating.
Shao's Commentary: Spontaneous sweating has various causes; treatment should be based on differentiation of etiology.