阳明病。脉迟。虽汗出不恶寒者。其身必重。短气。腹满而喘。有潮热者。此外欲解。可攻里
也。手足 然而汗出者。此大便已硬也。大承气汤主之。若汗多。微发热恶寒者。外未解也。其热
不潮。未可与承气汤。若腹大满不通者。可与小承气汤微和胃气。勿令大泄下。
伤寒以身热恶寒为在表。身热不恶寒为在里。而阳明病无表证者。可下。有表证者。则不可下
。此汗出不恶寒。身重短气。腹满而喘。潮热。皆里证也。脉虽迟。犹可攻之。以腹满便闭。里气
不行。故脉为之濡滞不利。非可比于迟则为寒之例也。若手足 然汗出者。阳明热甚。大便已硬。
欲攻其病。非大承气不为功矣。若汗多。微发热。恶寒。则表犹未解。其热不潮。则里亦未实。岂
可漫与大承气。遗其表而攻其里哉。
即腹大满不通。而急欲攻之者。亦宜与小承气微和胃气。而不可以大承气大泄大下。恐里虚邪
陷。变证百出。则难挽救矣。以下七条。于可攻证而更审其小便之多少。大便之溏硬。脉之实与不
实。经之过
与不过。热之潮与不潮。而后从而治之。故知下法不可不慎也。
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。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。
阳明病有潮热者。为胃实。热不潮者。为胃未
实。而大承气汤。有燥屎者。可与。初硬后溏者。则不可与。故欲与大承气。必先与小承气。恐胃
无燥屎。邪气未聚。攻之则病未必去。而正已大伤也。服汤后转失气者。便坚药缓。屎未能出。而
气先下趋也。故可更以大承气攻之。不转失气者。胃未及实。但初头硬后必溏。虽小承气已过其病
。况可以大承气攻之哉。胃虚无气。胀满不食。所必至矣。又阳明病能饮水者为实。不能饮水者为
虚。如虽欲饮。而与水则哕。所谓胃中虚冷。欲饮水者。与水则哕也。其后却发热者。知热气还入
于胃。则大便硬。而病从虚冷所变。故虽硬而仍少也。亦不可与大承气汤。但与小承气微和胃气而
已。盖大承气为下药之峻剂。仲景恐人不当下而误下。或虽当下而过下。故反复辨论如此。而又申
之曰。不转失气者。慎不可攻也。呜呼。仁人之心。可谓至矣。
阳明病。下之。心中懊 而烦。胃中有燥屎者。可攻。腹微满。初头硬。后必溏。不可攻之
。若有燥屎者。宜大承气汤。
阳明下后。心中懊 而烦。胃中有燥屎者。与阳明下后。心中懊 。饥不能食者有别矣。彼为
邪扰于上。此为热实于中也。热实则可攻。故宜大承气。若腹微满。初头硬。后必溏者。热而不实
。邪未及结。则不可攻。攻之必胀满不能食也。
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。腹中转失气者。更服
一升。若不转失气。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。
谵语发潮热。胃实之征也。脉滑而疾。则与滑而实者差异矣。故不与大承气。而与小承气也
。若服一升而转失气者。知有燥屎在胃中。可更服一升。若不转失气者。此必初硬后溏。不可更
与服之。一如前二条之意也。乃明日不大便。而脉反微涩。则邪气未去。而正气先衰。补则碍邪。
攻则伤正。故曰难治。便虽未通。岂可更以承气攻之哉。
得病二三日。脉弱。无太阳柴胡证。烦躁。心下硬。至四五日。虽能食。以小承气汤少少与微
和之。令小安。至六日。与承气汤一升。若不大便六七日。小便少者。虽不能食。但初头硬。后必溏
。未定成硬。攻之必溏。须小便利。屎定硬。乃可攻之。宜大承气汤。
伤寒能食者。为胃热而不实。不能食者。为胃热而实。而胃实之证。小便数者。可攻。小便少者
。则不可攻。得病二三日。脉不浮而弱。而又无太阳柴胡之证。知其病独在阳明之表也。烦躁心下
硬。至四五日不解。则里证复具。故虽能食。亦必以小承气微和胃气。至六日。热渐成实。当更与
大承气一升。以尽其病
也。若不大便六七日。于法当下。而小便少者。则水谷不分。知其初硬后溏。然虽不能食。亦不可
便与攻法。须俟其小便利。屎硬。然后以大承气与之。夫不大便而津液竭者。不可下。须俟其津液
还入胃中。而大便自行。不大便而小便少者。亦不可下。必俟其津液遍渗水道。而后可与下法。
盖津液已竭而强攻之。则正虚不复。大便未硬而辄攻之。则邪去不尽。学人不可不审。而轻用下药
也。
伤寒不大便六七日。头痛有热者。与承气汤。其小便清者。知不在里。仍在表也。当
须发汗。若头痛者。必衄。宜桂枝汤。
太阳风寒外束。令人头痛。阳明热气上冲。亦令人头痛。伤寒不大便六七日。头痛有热证者。
知其热盛于里。而气蒸于上。非风寒在表之谓矣。故可与承气汤下之。然热盛于里者。其小便必短
赤。若小便清者。知其热不在于里。而仍在于表。当以桂枝汤发其汗。而不可以承气汤攻其里也。
若头痛不除者。热留于经。必发鼻衄。宜桂枝汤四字。疑在当须发汗句下。此条从太阳篇中移入。
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。以表虚
里实故也。下之则愈。宜大承气汤。
汗出谵语。谓风未去表。而胃已成实也。故曰、有燥屎在胃中。又曰、此为风也。须下之。过
经乃可下之。见胃实须下。而风未去表。则必过经而后可下。不然。表间邪气。又将入里。胃益增
热。而语言错乱矣。表虚里实。即表和里病之意。言邪气入而并于里也。外台云、里病表和。下之则
愈。汗之则死。故宜大承气以
下里实。
阳明病。不能食。攻其热。必哕。所以然者。胃中虚冷故也。以其人本虚。故攻其热必哕。
天之邪气。中人则同。而人之脏气。虚实则不同。此下三条。乃为阳明病之中虚不足者设也。
阳明病当攻其热。而胃中虚冷不能食者。则不可攻其热。攻之则中寒益甚。而气乃上逆。故必作哕
。哕、呃逆也。以下不可攻之证。凡七条。
伤寒呕多。虽有阳明证。不可攻之。
夫阳明病。心下硬满者。不可攻之。攻之利遂不止者。死。利止者。愈。
阳明病。面合赤色。不可攻之。攻之必发热色黄。小便不利。
阳明虽有可下之例。然必表证全无。而热结在肠中者。方可攻之。若呕多者。邪在膈也。心下
硬满者。邪未下于胃也。面合赤色者。邪气怫郁在表也。故皆不可攻之。攻之则里虚而热入。
其淫溢于下者。则下利不止。其蓄聚于中者。则发热色黄。小便不利。其或幸而不死者。邪气竟从
下夺而愈耳。然亦难矣。
阳明病。脉迟。食难用饱。饱则微烦。头眩。必小便难。此欲作谷疸。虽下之。腹满如故。所以
然者。
脉迟故也。脉迟者。气弱而行不利也。气弱不行。则谷化不速。谷化不速。则谷气郁而生热
。其热上冲。则作头眩。气上冲者不下走。则小便难。而热之郁于中者。不得下行浊道。必将蒸积
为黄。故曰欲作谷疸。然以谷气郁而成热。而非胃有实热。故虽下之。而腹满不去。不得与脉数胃
实者同论也。
阳明病。本自汗出。医更重发汗。病已瘥。尚微烦不了了者。此大便必硬故也。以亡津液。胃
中干燥。故令大便硬。当问其小便日几行。若本小便日三四行。今日再行。故知大便不久出。今
为小便数少。以津液当还入胃中。故知不久必大便也。
阳明病不大便。有热结与津竭两端。热结者。可以寒下。可以咸软。津竭者。必津回燥释。而
后便可行也。兹已汗复汗。重亡津液。胃燥便硬。是当求之津液。而不可复行攻逐矣。小便本多而
今数少。则肺中所有之水精。不直输于膀胱。而还入于胃府。于是燥者得润。硬者得软。结者得通
。故曰不久必大便出。而不可攻之意。隐然言外矣。
阳明病。自汗出。若发汗。小便自利者。此为津液内竭。虽硬。不可攻之。当须自欲大便。宜
蜜煎导而通之。若土瓜根及大猪胆汁。皆可为导。
前条汗多复汗。亡津液大便硬者。已示不可攻之意。谓须其津液还入胃中。而大便自行。此条
复申不可攻之戒。而出蜜煎等润导之法。何虑之周而法之备也。总之、津液内竭之人。其不欲大便
者。静以需之。其自欲大便者。则因而导之。仲景成法。后人可以守之而无变也。
蜜煎导方
蜜七合。一味。内铜器中。微火煎之。稍凝似饧状。搅之。勿令焦着。欲可丸。并手捻作挺。
令头锐。大如指。长二寸许。当热时急作。冷则硬。以内谷道中。以手急抱。欲大便时。乃去之。
猪胆汁方
大猪胆一枚。泻汁。和醋少许。以灌谷道中。如一食顷。当大便出。
趺阳脉浮而涩。浮则胃气强。涩则小便数。浮涩相抟。大便则艰。其脾为约。麻仁丸主之。
浮者阳气多。涩者阴气少。而趺阳见之。是为胃强而脾弱。约、约束也。犹弱者受强之约束。
而气馁不用也。脾不用而胃独行。则水液并趋一处。而大便失其润矣。大黄、枳实、浓朴。所以泻
令胃弱。麻仁、杏仁、芍药。所以滋令脾浓。用蜜丸者。恐速下而伤其脾也。盖即取前条润导之意。
而少加之力。亦伤寒下药之变法也。
麻仁丸方
麻仁（二升） 芍药（半升） 枳实（半升） 大黄（一斤） 杏仁（一升） 浓朴（一尺炙
去皮）
上六味。为末。炼蜜为丸桐子大。饮服十丸。日三服。渐加以知为度。
阳明病，脉象迟缓，虽然出汗且不恶寒，但身体必定沉重，呼吸短促，腹部胀满且气喘。如果有潮热现象，说明表证即将解除，可以使用攻里法。如果手足濈然汗出，说明大便已经坚硬，应使用大承气汤主治。如果出汗多，伴有轻微发热和恶寒，说明表证尚未解除。如果发热没有潮热特征，不可使用承气汤。如果腹部显著胀满且不通畅，可以给予小承气汤轻微调和胃气，不要让它剧烈泻下。
伤寒病以身体发热、恶寒为表证，身体发热、不恶寒为里证。阳明病如果没有表证，可以攻下；如果有表证，则不可攻下。这里提到的出汗不恶寒、身体沉重、呼吸短促、腹部胀满气喘、潮热，都是里证的表现。脉象虽然迟缓，仍然可以攻下，因为腹部胀满、大便闭塞，里气运行不畅，所以脉象变得濡滞不利，这不能等同于“迟脉即为寒证”的常规例子。如果手足濈然汗出，说明阳明热盛，大便已经坚硬，想要攻治此病，非用大承气汤不可。如果出汗多，轻微发热、恶寒，说明表邪仍未解除；如果发热没有潮热特征，说明里实未成，怎么能随意使用大承气汤，遗留表邪而只攻里呢？
即使腹部显著胀满不通，急切想要攻下的情况，也应当给予小承气汤轻微调和胃气，不可以用大承气汤剧烈泻下。恐怕导致里虚邪陷，变证百出，那就难以挽救了。以下七条，在判断是否可攻时，进一步审查小便量的多少、大便的稀硬程度、脉象的虚实、病邪是否在经、发热的类型是否为潮热等，然后进行治疗。因此可知下法不可不谨慎。
阳明病，有潮热，大便轻微坚硬的，可以给予大承气汤；如果不坚硬，不可给予。如果六七天不大便，担心有燥屎，想知道是否有燥屎的方法，是少量给予小承气汤。服药后入腹中，如果转矢气（放屁），这是有燥屎，可以攻下；如果不转矢气，这只是开头硬，后面一定稀溏，不可攻下。攻下必然导致腹胀满、不能进食。想喝水的人，给水喝会出现呃逆。之后如果出现发热，大便一定会再次变硬但量少，应用小承气汤调和。不转矢气的，千万不可攻下。
阳明病有潮热的，属于胃实；没有潮热的，属于胃未实。大承气汤适用于有燥屎的情况；如果是开头硬后面稀溏的，则不可使用。所以想要使用大承气汤，必须先给予小承气汤试探，恐怕胃中没有燥屎，邪气未聚结，攻下则病未必去，正气已大伤。服用汤药后转矢气的，是因为大便坚硬而药力缓和，屎未能排出，而气先下行。所以可以再用大承气汤攻下。不转矢气的，说明胃未及实，只是开头硬后面必稀溏，即使小承气汤也已超过病情所需，何况用大承气汤攻下呢？胃虚无气，出现胀满不能食，是必然的结果。另外，阳明病能饮水的属实证，不能饮水的属虚证。如虽然想喝水，但给水喝就出现呃逆，这就是所谓的“胃中虚冷，欲饮水者，与水则哕”。之后却出现发热，知道热气还入于胃，则大便变硬，这是病从虚冷所变，所以虽然硬但也量少。也不可与大承气汤，只需与小承气汤轻微调和胃气即可。大承气汤是泻下药中的峻剂，张仲景恐怕人不在当下的情况下误下，或者虽当下而过下，所以反复辨析如此，又强调说：不转矢气的，千万不可攻下。唉，仁人的心肠，可谓到了极致。
阳明病，经过攻下后，心中懊恼烦乱，胃中有燥屎的，可以攻下；腹部轻微胀满，开头硬后面稀溏的，不可攻下。如果有燥屎的，适宜用大承气汤。
阳明病攻下后，心中懊恼烦乱，胃中有燥屎的，与阳明病攻下后心中懊恼、饥饿但不能进食是不同的。后者是邪气扰动在上部，前者是热实在中部。热实则可以攻下，所以适宜用大承气汤。如果腹部轻微胀满，开头硬后面稀溏，是热而不实，邪气未结聚，则不可攻下。攻下必然导致腹胀满不能进食。
阳明病，谵语，发潮热，脉象滑而疾速的，用小承气汤主治。于是给予承气汤一升，腹中转矢气的，再服一升；如果不转矢气，不要再给。明天仍不大便，脉象反而微涩的，是里虚，属于难治，不可再给承气汤。
谵语发潮热，是胃实的征象。脉象滑而疾速，则与滑而有力的脉象不同。所以不给大承气汤，而给小承气汤。如果服一升后转矢气，知道胃中有燥屎，可以再服一升；如果不转矢气，这一定是开头硬后面稀溏，不可再给服用。这与前两条的意思一样。到了第二天仍不大便，而脉象反而微涩，则邪气未去，正气先衰。补益则碍邪，攻下则伤正，所以说难治。大便虽未通，难道还可以再用承气汤攻下吗？
得病二三天，脉弱，没有太阳病或少阳病的证候，烦躁，心下硬，到四五天，虽然能进食，用小承气汤少量给予轻微调和，令其稍安。到第六天，给予承气汤一升。如果六七天不大便，小便少的，虽然不能进食，但开头硬，后面必稀溏，未确定成硬，攻下必然导致稀溏。必须等到小便利，大便确定变硬，才可以攻下，适宜用大承气汤。
伤寒病能进食的，是胃热但不实；不能进食的，是胃热且实。而胃实的证候，小便频数的，可以攻下；小便少的，则不可攻下。得病二三天，脉不浮而弱，又没有太阳病或少阳病的证候，知道病独在阳明之表。烦躁心下硬，到四五天不解，则里证又具备。所以虽然能进食，也必须用小承气汤轻微调和胃气。到第六天，热渐成实，应当再给大承气汤一升，以尽除病邪。如果六七天不大便，按法应当攻下，但小便少的，则水谷不分，知道开头硬后面稀溏。然而虽然不能进食，也不可立即用攻法。必须等到小便利，大便硬，然后用大承气汤给予。不大便而津液枯竭的，不可攻下，必须等到津液回归胃中，大便自行排出。不大便而小便少的，也不可攻下，必须等到津液遍渗水道，然后才可运用下法。大概津液已竭而强行攻下，则正气虚弱无法恢复；大便未硬而辄行攻下，则邪气去不尽。学者不可不审慎，轻率使用下药。
伤寒病六七天不大便，头痛且有发热的，给予承气汤。如果小便清长的，知道病不在里，仍在表，应当须发汗。如果头痛不止，必然流鼻血，适宜用桂枝汤。
太阳风寒外束，令人头痛；阳明热气上冲，也令人头痛。伤寒病六七天不大便，有头痛发热证的，知道热盛于里，气蒸腾于上，不是风寒在表的意思。所以可以与承气汤攻下。然而热盛于里的，小便必短赤。如果小便清长，知道热不在于里，而仍在表，应当用桂枝汤发汗，不可以用承气汤攻里。如果头痛不除，热留于经脉，必然发生鼻衄。宜桂枝汤四字，怀疑应在“当须发汗”句下。此条从太阳篇中移入。
出汗且谵语的，是因为胃中有燥屎，这是风邪所致。须攻下，但要过经（表解）后才可攻下。攻下如果过早，语言必错乱，因为表虚里实。攻下后则愈，适宜用大承气汤。
出汗谵语，是指风邪未去表，而胃已成实。所以说“有燥屎在胃中”，又说“此为风也”，“须下之，过经乃可下之”。见胃实须下，而风邪未去表，则必须过经后才可攻下。不然，表间邪气又将入里，胃热更增，而语言错乱。表虚里实，即表和里病的意思，指邪气入而并于里。《外台秘要》说：“里病表和，下之则愈，汗之则死。”所以适宜用大承气汤攻下里实。
阳明病，不能进食，攻其热，必然出现呃逆。之所以这样，是因为胃中虚冷。因为病人本身体虚，所以攻其热必然出现呃逆。
天之邪气中人则相同，而人的脏气虚实不同。这三条，是为阳明病中虚不足者设立的。阳明病应当攻其热，而胃中虚冷不能进食的，则不可攻其热。攻之则中寒更甚，气机上逆，所以必然作呃逆。哕，就是呃逆。以下关于不可攻的证候，共有七条。
伤寒呕吐多的，虽然有阳明证，不可攻下。
夫阳明病，心下硬满的，不可攻下。攻下后利不止的，死；利止的，愈。
阳明病，面部全面发红（合赤色），不可攻下。攻下必然发热色黄，小便不利。
阳明病虽有可下的例子，但必须表证全无，而热结在肠中，方可攻下。如果呕吐多，邪在膈部；心下硬满，邪未下到胃；面合赤色，邪气怫郁在表。所以都不可攻下。攻下则里虚而热入。其淫溢于下的，则下利不止；其蓄聚于中的，则发热色黄，小便不利。其或幸而不死的，邪气竟从下夺而愈罢了。然而也很难了。
阳明病，脉迟，饮食难以吃饱，饱则轻微心烦，头眩，必然小便难，这是将要发作谷疸。虽然攻下，腹部胀满依旧。之所以这样，是因为脉迟的缘故。脉迟，是气弱而行不利。气弱不行，则谷物消化不迅速。谷物消化不迅速，则谷气郁而生热。其热上冲，则作头眩。气上冲不下走，则小便难。而热郁于中，不得下行浊道，必将蒸积为黄。所以说欲作谷疸。然而因谷气郁而成热，而非胃有实热，所以虽然攻下，腹满不去，不得与脉数胃实者同论。
阳明病，本来自汗出，医生更重发汗，病已好转，尚轻微烦闷不适的，这大便一定硬，是因为亡失津液，胃中干燥，所以令大便硬。应当问其小便一天几次。如果原本小便一天三四次，今天两次，故知大便不久会排出。现在小便次数减少，因为津液应当回归胃中，故知不久必大便排出。
阳明病不大便，有热结与津竭两端。热结的，可以用寒下，可以用咸软。津竭的，必须津回燥释，而后便可行。此处已汗复汗，重亡津液，胃燥便硬，是应当求之于津液，而不可再行攻逐。小便本多而今少，则肺中所有的水精，不直输于膀胱，而还入于胃府。于是燥者得润，硬者得软，结者得通。所以说不久必大便出，而不可攻之意，隐然言外矣。
阳明病，自汗出，若发汗，小便自利的，这是津液内竭，虽然硬，不可攻下。应当等待其自欲大便，适宜用蜜煎导法通之。如果土瓜根及大猪胆汁，都可以作为导法。
前条汗多复汗，亡津液大便硬者，已示不可攻之意，谓须其津液还入胃中，而大便自行。此条重申不可攻的戒律，而出蜜煎等润导之法，考虑多么周密而方法完备啊。总之，津液内竭之人，其不欲大便的，静以需之；其自欲大便的，则因而导之。张仲景的成法，后人可以守之而无变。
蜜煎导方
蜂蜜七合，一味，放入铜器中，微火煎之，稍凝似饴糖状，搅动它，不要让焦着。想要做成丸状，并用手捻作挺状，令头部尖锐，大如手指，长约二寸许。应当在热时急做，冷则硬。纳入肛门中，用手紧抱，欲大便时，再去掉它。
猪胆汁方
大猪胆一枚，取汁，和少许醋，灌入肛门中。如一顿饭的时间，大便应当排出。
趺阳脉浮而涩，浮则胃气强，涩则小便数。浮涩相搏，大便则艰涩，其脾为约，麻仁丸主治。
浮者是阳气多，涩者是阴气少，而在趺阳脉见到，是为胃强而脾弱。约，约束也。犹弱者受强之约束，而气馁不用。脾不用而胃独行，则水液并趋一处，而大便失其润。大黄、枳实、厚朴，所以泻令胃弱；麻仁、杏仁、芍药，所以滋令脾浓。用蜜丸者，恐速下而伤其脾。大概是取前条润导之意，而稍加之力，也是伤寒下药的变法。
麻仁丸方
麻仁（二升） 芍药（半升） 枳实（半升） 大黄（一斤） 杏仁（一升） 厚朴（一尺炙去皮）
以上六味，为末，炼蜜为丸桐子大，饮服十丸，日三服，渐加以知为度。
Yangming disease. The pulse is slow. Although there is sweating and no aversion to cold, the body must be heavy, shortness of breath occurs, abdominal fullness with wheezing. If there is tidal fever (Tidal Fever), this indicates that the exterior syndrome is about to resolve, and internal purgation can be used. If there is continuous sweating on the hands and feet, this indicates that the stool has already hardened; Da Cheng Qi Tang (Major Order the Qi Decoction) should be primarily administered. If there is profuse sweating with slight fever and aversion to cold, the exterior has not yet resolved. If the fever is not tidal, Cheng Qi Tangs should not be used. If the abdomen is significantly full and obstructed, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) may be given to gently harmonize the stomach qi; do not allow severe purgation.
In Shanghan (Cold Damage), fever with aversion to cold indicates an exterior syndrome, while fever without aversion to cold indicates an interior syndrome. In Yangming disease, if there are no exterior symptoms, purgation is permissible; if there are exterior symptoms, purgation is contraindicated. Here, sweating without aversion to cold, body heaviness, shortness of breath, abdominal fullness with wheezing, and tidal fever are all interior syndromes. Although the pulse is slow, it can still be treated with purgation because abdominal fullness and constipation indicate that interior qi circulation is obstructed, causing the pulse to become soggy and sluggish. This cannot be compared to the general rule that a slow pulse indicates cold. If there is continuous sweating on the hands and feet, Yangming heat is excessive, and the stool has hardened; to treat this condition, only Da Cheng Qi Tang will suffice. If there is profuse sweating, slight fever, and aversion to cold, the exterior pathogen has not yet been resolved. If the fever is not tidal, the interior is not yet solid. How could one casually use Da Cheng Qi Tang, leaving the exterior pathogen behind while attacking the interior?
Even if the abdomen is significantly full and obstructed, and there is an urgent desire to purge, one should give Xiao Cheng Qi Tang to gently harmonize the stomach qi, rather than using Da Cheng Qi Tang for severe purgation. Otherwise, interior deficiency with pathogen sinking may occur, leading to myriad complications that would be difficult to rescue. The following seven clauses further examine the amount of urine, the consistency of the stool (loose or hard), the excess or deficiency of the pulse, whether the disease has passed through the meridians, and whether the fever is tidal before deciding on treatment. Thus, it is known that purgative methods must be applied with caution.
In Yangming disease, with tidal fever and slightly hard stool, Da Cheng Qi Tang may be given; if the stool is not hard, it should not be given. If there has been no bowel movement for six or seven days and dry fecal matter (Dry Stool) is suspected, the method to determine its presence is to give a small amount of Xiao Cheng Qi Tang. If, after ingestion, flatus (passing gas) is heard in the abdomen, this indicates the presence of dry fecal matter, and purgation is permissible. If no flatus occurs, the stool is merely hard at the beginning and will likely be loose later; purgation is contraindicated. Purgation would inevitably cause abdominal fullness and inability to eat. If the patient desires water and drinking water induces hiccups (Hiccup), and subsequent fever occurs, the stool will likely become hard again but in small quantities; Xiao Cheng Qi Tang should be used to harmonize. If no flatus occurs, purgation must absolutely be avoided.
In Yangming disease, the presence of tidal fever indicates stomach excess (Stomach Excess); the absence of tidal fever indicates the stomach is not yet solid. Da Cheng Qi Tang is suitable for cases with dry fecal matter; it is contraindicated for cases where the stool is hard at the beginning and loose later. Therefore, before administering Da Cheng Qi Tang, one must first try Xiao Cheng Qi Tang. It is feared that if there is no dry fecal matter and the pathogen has not gathered, purgation will fail to eliminate the disease while severely damaging the healthy qi. If flatus occurs after taking the decoction, it is because the stool is hard and the medicine's action is mild; the stool cannot be expelled, but the qi moves downward first. Thus, Da Cheng Qi Tang can be used again to purge. If no flatus occurs, the stomach has not reached a state of excess; the stool is merely hard at the beginning and will surely be loose later. Even Xiao Cheng Qi Tang exceeds the necessary treatment; how much more so Da Cheng Qi Tang? Gastric deficiency with lack of qi leads inevitably to abdominal fullness and inability to eat. Furthermore, in Yangming disease, the ability to drink water indicates excess, while the inability to drink indicates deficiency. For example, if the patient desires to drink but hiccups upon drinking water, this is "cold deficiency in the stomach, where desiring water and giving water causes hiccups." Subsequent fever indicates heat returning to the stomach, causing the stool to harden; this is a change from cold deficiency. Thus, although the stool is hard, it is scanty. Da Cheng Qi Tang should not be given; only Xiao Cheng Qi Tang should be used to gently harmonize the stomach qi. Da Cheng Qi Tang is a harsh purgative. Zhang Zhongjing repeatedly discusses these points to prevent inappropriate or excessive purgation, emphasizing: "If no flatus occurs, purgation must absolutely be avoided." Alas, the benevolent heart is truly perfect.
In Yangming disease, after purgation, if there is inner restlessness (Inner Restlessness) and irritability, and dry fecal matter exists in the stomach, purgation is permissible. If the abdomen is slightly full, with stool hard at the beginning and loose later, purgation is contraindicated. If dry fecal matter exists, Da Cheng Qi Tang is appropriate.
Post-purgation inner restlessness and irritability with dry fecal matter in the stomach differs from post-purgation inner restlessness accompanied by hunger but inability to eat. The latter is due to pathogen disturbing the upper jiao; the former is due to heat-solidity in the middle jiao. Heat-solidity allows for purgation, hence Da Cheng Qi Tang is appropriate. If the abdomen is slightly full, with stool hard at the beginning and loose later, the heat is not solid, and the pathogen has not coagulated; purgation is contraindicated. Purgation would inevitably cause abdominal fullness and inability to eat.
In Yangming disease, with delirium (Delirium) and tidal fever, and a slippery and rapid pulse, Xiao Cheng Qi Tang is primarily administered. One sheng of the decoction is given initially. If flatus occurs in the abdomen, another sheng may be given. If no flatus occurs, do not administer more. If the next day there is still no bowel movement and the pulse becomes faint and choppy, this indicates interior deficiency; it is difficult to treat, and Cheng Qi Tang should not be given again.
Delirium and tidal fever are signs of stomach excess. A slippery and rapid pulse differs from a slippery and forceful pulse. Therefore, Da Cheng Qi Tang is not given, but Xiao Cheng Qi Tang is. If flatus occurs after one sheng, it confirms dry fecal matter in the stomach, and another sheng may be given. If no flatus occurs, the stool is likely hard at the beginning and loose later; it should not be given again. This aligns with the meaning of the previous two clauses. If the next day there is still no bowel movement and the pulse becomes faint and choppy, the pathogen remains while the healthy qi declines. Tonification would hinder the pathogen, while purgation would damage the healthy qi; thus, it is said to be difficult to treat. Even if the bowels are not open, how can Cheng Qi Tang be used to purge?
Two or three days after contracting the disease, with a weak pulse, no Taiyang or Shaoyang symptoms, irritability, and hardness below the heart: by the fourth or fifth day, even if the patient can eat, give a small amount of Xiao Cheng Qi Tang to gently harmonize and provide slight relief. By the sixth day, give one sheng of Cheng Qi Tang. If there has been no bowel movement for six or seven days and urine output is low, even if the patient cannot eat, the stool is likely hard at the beginning and loose later, not yet definitively hardened. Purgation would cause loose stools. One must wait until urination is normal and the stool is definitely hard before purging; Da Cheng Qi Tang is appropriate.
In Shanghan, the ability to eat indicates stomach heat without excess; inability to eat indicates stomach heat with excess. In cases of stomach excess, frequent urination permits purgation, while infrequent urination contraindicates it. Two or three days after contracting the disease, a pulse that is not floating but weak, along with the absence of Taiyang or Shaoyang symptoms, indicates the disease is solely in the exterior of Yangming. Irritability and hardness below the heart persisting into the fourth or fifth day indicate that interior symptoms have appeared. Thus, even if the patient can eat, Xiao Cheng Qi Tang must be used to gently harmonize the stomach qi. By the sixth day, as heat gradually solidifies, one sheng of Da Cheng Qi Tang should be given to fully resolve the disease. If there has been no bowel movement for six or seven days, purgation is indicated by law, but if urine output is low, water and grain are not separated properly, indicating the stool is hard at the beginning and loose later. Even if the patient cannot eat, immediate purgation is contraindicated. One must wait for normal urination and hardening of the stool before administering Da Cheng Qi Tang. Constipation with exhausted fluids is not suitable for purgation; one must wait for fluids to return to the stomach for spontaneous defecation. Constipation with low urine output is also not suitable for purgation; one must wait for fluids to permeate the water passages before applying purgative methods. Generally, forcibly purging when fluids are exhausted leads to irreversible healthy qi deficiency; purging before the stool is hard leaves pathogens behind. Scholars must be cautious and not lightly use purgatives.
Shanghan with constipation for six or seven days, headache, and fever: give Cheng Qi Tang. If the urine is clear, the disease is not in the interior but remains in the exterior; sweating therapy is required. If the headache persists, nasal bleeding (Epistaxis) will likely occur; Gui Zhi Tang (Cinnamon Twig Decoction) is appropriate.
Taiyang wind-cold constraining the exterior causes headache; Yangming heat rushing upward also causes headache. In Shanghan with constipation for six or seven days and headache with fever, the heat is excessive in the interior, steaming upward, which is not wind-cold in the exterior. Thus, Cheng Qi Tang can be used to purge. However, in cases of excessive interior heat, urine is typically scanty and red. If urine is clear, the heat is not in the interior but remains in the exterior; Gui Zhi Tang should be used to induce sweating, and Cheng Qi Tang should not be used to purge the interior. If the headache does not resolve, heat remains in the meridians, likely causing epistaxis. The phrase "Gui Zhi Tang" is suspected to belong under the sentence "when sweating is required." This clause was moved from the Taiyang chapter.
Sweating with delirium indicates dry fecal matter in the stomach; this is due to wind. Purging is required, but only after the disease has passed through the meridians (Exterior Resolution). Premature purging will cause language confusion due to exterior deficiency and interior excess. After purging, recovery occurs; Da Cheng Qi Tang is appropriate.
Sweating and delirium indicate that the wind pathogen has not left the exterior, but the stomach has become solid. Hence, "dry fecal matter in the stomach" and "this is wind" are stated. Purging is required, but only after the meridians have passed through. If the stomach is solid and requires purging, but the wind pathogen remains in the exterior, purging must wait until the exterior resolves. Otherwise, exterior pathogens will enter the interior, increasing gastric heat and causing confused speech. "Exterior deficiency and interior excess" means the exterior is harmonious while the interior is diseased, indicating pathogens have entered and consolidated in the interior. *Wai Tai Mi Yao* states: "Interior disease with exterior harmony: purging cures, sweating kills." Therefore, Da Cheng Qi Tang is appropriate to purge interior excess.
In Yangming disease, inability to eat, and attacking the heat will inevitably cause hiccups. This is because of cold deficiency in the stomach. Since the patient is originally deficient, attacking the heat will cause hiccups.
Heavenly pathogens affect humans similarly, but human organ qi varies in deficiency and excess. These three clauses are designed for patients with Yangming disease who have interior deficiency and insufficiency. Yangming disease usually requires attacking the heat, but if the stomach is cold-deficient and unable to eat, attacking the heat is contraindicated. Doing so worsens middle-jiao cold and causes qi to rebel upward, inevitably causing hiccups. Hiccups refer to hiccupping. There are seven clauses regarding conditions where purgation is contraindicated below.
In Shanghan, if vomiting is frequent, even if Yangming symptoms exist, purgation is contraindicated.
In Yangming disease, if hardness and fullness are below the heart, purgation is contraindicated. If purgation is performed and diarrhea continues uncontrollably, death ensues; if diarrhea stops, recovery occurs.
In Yangming disease, if the face is completely red, purgation is contraindicated. Purgation will inevitably cause fever, yellow complexion, and difficulty in urination.
Although Yangming disease has examples of purgation, it is only permissible when exterior symptoms are completely absent and heat is bound in the intestines. If vomiting is frequent, the pathogen is in the diaphragm; if hardness and fullness are below the heart, the pathogen has not descended to the stomach; if the face is red, the pathogen is constrained in the exterior. Thus, purgation is contraindicated in all these cases. Purgation leads to interior deficiency and heat entry. Pathogens overflowing downward cause uncontrollable diarrhea; pathogens accumulating in the middle cause fever, yellow complexion, and urinary difficulty. Those who survive by chance recover as pathogens exit downward, but this is rare and difficult.
In Yangming disease, a slow pulse, difficulty eating to satiety, slight irritability after eating, dizziness, and difficulty in urination indicate impending Grain Jaundice (Grain Jaundice). Even with purgation, abdominal fullness remains. This is due to the slow pulse. A slow pulse indicates weak qi and poor circulation. Weak qi fails to move, slowing grain digestion. Undigested grain generates heat. Rising heat causes dizziness. Upward-moving qi fails to descend, causing urinary difficulty. Heat constrained in the middle cannot descend through turbid pathways and steams into jaundice. Thus, it is said to be impending Grain Jaundice. However, since the heat arises from grain stagnation rather than stomach excess heat, purgation will not remove abdominal fullness. This differs from cases with a rapid pulse and stomach excess.
In Yangming disease, originally with spontaneous sweating, if the physician induces heavy sweating again, and although the illness has improved, slight irritability and discomfort persist, the stool must be hard due to fluid exhaustion and dryness in the stomach. One should ask about daily urine frequency. If the patient normally urinates three or four times a day but now only twice, it is known that the stool will pass soon. Now, with reduced urine frequency, fluids are returning to the stomach; thus, it is known that defecation will occur soon.
Constipation in Yangming disease involves either heat binding or fluid exhaustion. Heat binding can be treated with cold purgation or saline softening. Fluid exhaustion requires fluid restoration to resolve dryness before defecation is possible. Here, repeated sweating has severely depleted fluids, causing gastric dryness and hard stool. Treatment should focus on fluids, not further purgation. Reduced urine frequency indicates lung fluids are returning to the stomach instead of going directly to the bladder. Thus, dryness is moistened, hardness is softened, and binding is unblocked. The implication is that purgation is unnecessary.
In Yangming disease, with spontaneous sweating or induced sweating, and free urination, this indicates internal fluid exhaustion. Even if the stool is hard, purgation is contraindicated. One should wait for the natural urge to defecate and use Honey Suppository (Honey Suppository) to guide passage. Radix Trichosanthis (Tu Gua Gen) or large pig bile can also be used as guiding agents.
The previous clause regarding heavy sweating depleting fluids and hardening stool indicated that purgation is contraindicated, waiting for fluids to return for spontaneous defecation. This clause reiterates the prohibition against purgation and offers moistening guiding methods like honey suppositories, showing thorough consideration and comprehensive methods. In summary, for those with internal fluid exhaustion who do not desire defecation, wait quietly; for those who desire defecation, guide them accordingly. Zhang Zhongjing's established methods can be followed without alteration.
**Honey Suppository Formula**
Seven he of honey. Single ingredient. Place in a copper vessel and simmer over low heat until slightly thickened like malt syrup. Stir constantly to avoid burning. When moldable, shape into suppositories by hand, sharpening the tip, about the thickness of a finger and two inches long. Make while warm, as they harden when cool. Insert into the anus and hold tightly with hand. Remove when the urge to defecate arises.
**Pig Bile Formula**
One large pig gallbladder. Extract juice, mix with a little vinegar. Instill into the anus. After the time of one meal, the stool should pass.
At the foot-yang pulse, floating and choppy. Floating indicates strong stomach qi; choppy indicates frequent urination. Floating and choppy combined lead to difficult defecation. The spleen is constrained (Spleen Constraint). Ma Ren Wan (Hemp Seed Pill) is primarily administered.
Floating indicates abundant yang qi; choppy indicates scarce yin qi. Seen at the foot-yang pulse, this indicates strong stomach and weak spleen. "Constraint" means restriction. Just as the weak is restricted by the strong, the spleen's qi is inhibited. With the spleen inactive and the stomach acting alone, fluids converge in one place, and the stool loses moisture. Rhubarb, Immature Bitter Orange, and Magnolia Bark reduce stomach strength; Hemp Seed, Apricot Kernel, and White Peony Root nourish spleen density. Using honey pills prevents rapid purgation from damaging the spleen. This takes the meaning of the previous moistening guidance and adds slight force, representing a variation in Shanghan purgative methods.
**Ma Ren Wan Formula**
Hemp Seed (2 sheng), White Peony Root (0.5 sheng), Immature Bitter Orange (0.5 sheng), Rhubarb (1 jin), Apricot Kernel (1 sheng), Magnolia Bark (1 chi, processed, peeled).
These six ingredients are powdered. Refined honey is used to form pills the size of tung seeds. Take ten pills with water, three times daily. Gradually increase until effective.