舌见黄而涩。有隔瓣者。热已入胃。邪毒深矣。心火烦渴。急宜大承气汤下。若身发黄者。用茵陈蒿汤。下血。用
抵当汤。水在胁内。十枣汤。结胸甚者。大陷胸汤。痞用大黄泻心汤。
\r纯黄隔瓣舌图\pt101a28.bmp\r
【介按】黄苔起瓣。系是脏腑实热已极。或因温暑热邪。灼烁胃液。或因温燥之药。误投劫津。致热毒熏蒸而现此
舌。外证必大热、大渴。面赤、唇红。甚则谵语、神昏。治宜大承气汤。以急下而救液。至于发黄之证。有湿热与蓄血
之异。如阳明热胜挟湿而发黄者。外证遍身无汗。但头汗出而小便不利。渴欲饮水。此系热不得越。郁蒸为黄也。治宜
茵陈蒿汤。苦寒通泄。使内瘀之热下趋。则黄从大便而解。如发黄而小便清利。或大便反易。脉象沉细而结。此是蓄血
之发黄也。治宜抵当汤。以消瘀而退黄。更有悬饮之病。脉象沉弦而细。因其水饮。凝结，悬于胸胁之间。以致咳引内
痛。照此证状。不得误认为结胸。治宜十枣汤。直达病所。使水饮下趋而无结痛之患。又有结胸之症。因病初在太阳。
医者失表而误下之。则邪热入里与内蓄之水饮结于胸中。脉象沉紧。心下痛而按之石硬。此系热实而致结胸。治宜大陷
胸汤。使其软坚破积而导去热邪。夫病在于阳而反下之，热入而为结胸，既已述其病状与治法，然亦有病发于阴而反下
之。因而作痞者。不可不知也。但痞与结胸。同为硬满之症。当以痛与不痛而辨明之。如满而硬痛。是谓结胸。满而不
痛。是谓痞满。凡治伤寒。大下之后而复汗之。则正虚邪入。心下成痞。外证如有恶寒、身热。先宜治以解表之剂。待
其表解之后。再进大黄泻心汤。以攻痞而涤热。此言舌苔纯黄起瓣。固宜大承气汤之峻下。然须详审病证。仔细诊察。
否则如发黄有湿热与蓄血之别。又有悬饮与结胸之辨。倘若误用承气。更有结胸与痞满之变也。
大承气汤
浓朴（姜制三钱） 枳实（麸炒二钱） 大黄（二钱） 芒硝（二钱）
每服一两。水一钟半。先煎枳实。候热，方入大黄。再煎数沸。入芒硝。煎三五沸。去渣热服。
【介按】大承气汤之功用。取其急下之义。如阳明证之谵语、潮热。及二阳并病以致潮热。或阳明下后。心中懊
而烦。腹满痛。本有宿食。又如少阴证之口燥、舌干。或自利清水。色纯青等证。皆因胃中热极而燥矢为患，故用大黄
之苦寒。涤腐秽而清热毒。芒硝苦咸而化燥矢。又有枳朴以消留滞之气。夫大肠为传导之官。变化出焉。然则大承气者。
所以通泄大肠。而承制胃中之热气者也。
茵陈汤
茵陈（五钱） 大黄（三钱） 山栀子（七枚）
上每服一两。水一盏半。先煎茵陈半熟。次入二味。再煎去渣。通口热服。
【介按】柯韵伯曰。茵陈禀北方之气。经冬不凋。傲霜凌雪。遍受大寒之气。故能除热邪留结。率栀子以通水源。
大黄以调胃实。令一身内外瘀热。悉从小便而出。腹满自减，肠中无伤。乃合引而竭之之法。此阳明利水之圣剂也。
抵当汤
水蛭（糯米炒七个） 虻虫（炒去羽足七个） 大黄（三钱）
上作一服，水一盏半，煎一钟，去渣，通口服。
【介按】张仲景先生之抵当汤。尚有桃仁一味。今无桃仁。谅系原书失载所致。至于方义。先哲柯韵伯已甚详晰。
爰述其言曰。蛭虫之善饮血者，而利于水。虻虫之善吮血者，而猛于陆。并取水陆之善取血者以攻之。同气相求。更佐
桃仁之苦甘。推陈致新。大黄之苦寒。荡涤邪热。故名抵当也。若热虽盛而未狂。少腹满而未硬。宜小其制为丸以缓治
之。
十枣汤
芫花（醋浸炒） 大戟 甘遂（煨各等分）
上每服二钱。弱人减半。以水一钟半。大枣十枚。劈碎。煎取八分。去渣。通口服。
【介按】柯韵伯曰。甘遂、芫花、大戟。三味皆辛苦气寒而禀性最毒。并举而用之。气味合。相济相须。故可交相
去邪之巢穴。决其渎而大之。一举而水患可平也。然水利所凑。其元气已虚。而毒药攻邪。必脾胃反弱。使无健脾、调
胃之品为主宰。邪气尽而大命亦随之矣。故选十枣之大而肥者以君之。以培脾土之虚，一以制水气之横。一以解诸药之
毒。得一物而三善备。即不使邪气之盛而不制。又不使元气之虚而不支。此仲景立法之尽善也。昧者惑于甘能中满之说
而不敢用。岂知承制之理乎。
大陷胸汤
大黄（七钱） 芒硝（三钱） 甘遂末（四分）
上用水二钟。先煎大黄至一钟。去渣。下芒硝。煎三五沸。再用甘遂末。温服取利。
【介按】大黄、芒硝。善涤肠胃之实热。但病在胸中。而亦以此为君者。因热淫于内。治以苦寒。借以涤胸中之热。
又任甘遂之苦辛。直攻胸间之饮邪。则不专荡胃中之邪秽矣。此系邪留胸间而及于胃。胸胃俱病。而致结胸之专剂也。
大黄泻心汤
大黄（五钱） 黄连 黄芩（各二钱五分）
上作一服。水二钟。煎一钟。去渣。通口服。若有宿食痰饮者。加半夏曲二钱。
【介按】心下痞。按之濡而不硬。是内陷之邪。与无形之气。抟聚不散而为热痞。故用苦寒能降之品。以泄无形之
热。不用枳朴者。非荡实热之剂也。若兼宿食、痰饮为患者。再用半夏曲以开痞而蠲饮也。
舌象呈现黄色且干燥涩滞。若舌苔出现隔瓣，说明热邪已传入胃腑，邪毒深重。患者伴有心火亢盛、烦躁口渴等症状，应当紧急使用大承气汤（Da Chengqi Tang, Cinnamon Twig and Rhubarb Decoction）进行攻下治疗。如果身体出现发黄症状，则使用茵陈蒿汤（Yinchen Hao Tang, Yinchen Artemisia Decoction）。若有下血症状，使用抵当汤（Didang Tang, Didang Pill/Decoction）。若水饮停聚于胁肋内部，使用十枣汤（Shizao Tang, Ten Jujube Decoction）。结胸证严重的，使用大陷胸汤（Daxiexiong Tang, Major Xiexiong Decoction）。痞证使用大黄泻心汤（Dahuang Xiexin Tang, Rhubarb Heart-Draining Decoction）。
【介按】黄苔起瓣，属于脏腑实热达到极点的表现。这可能是由于温病或暑热邪气，灼伤胃中津液；或者是误用了温燥的药物，劫夺津液，导致热毒熏蒸而显现出这种舌象。外在症状必然有大热、大渴、面红、唇红，严重时甚至出现胡言乱语、神志昏迷。治疗适宜用大承气汤，通过急下来保存阴液。至于发黄的病症，有湿热与蓄血的区别。如果是阳明热盛挟带湿邪而发黄，外在症状是遍身无汗，只有头部出汗，小便不利，想喝水。这是热邪无法外越，郁蒸发黄所致。治疗适宜用茵陈蒿汤，苦寒通泄，使内部的瘀热向下排出，黄疸就会随大便解除。如果是发黄且小便清利，或者大便反而容易，脉象沉细而结，这是蓄血导致的发黄。治疗适宜用抵当汤，以消除瘀血从而退黄。更有悬饮的病证，脉象沉弦而细，因为水饮凝结，悬挂在胸胁之间，导致咳嗽牵引内部疼痛。根据这些症状，不能误认为是结胸。治疗适宜用十枣汤，直达病所，使水饮下行而没有结痛的危害。又有结胸的症候，因为病初在太阳经，医生失于解表而误用下法，导致邪热入里与体内蓄积的水饮结于胸中。脉象沉紧，心下疼痛且按压如石头般坚硬。这是热实导致的结胸。治疗适宜用大陷胸汤，使其软坚破积并引导热邪出去。疾病在阳经却反用下法，热邪内入成为结胸，这已经叙述了病状与治法，然而也有病发于阴经却反用下法，因而形成痞证的，不可不知道。但痞证与结胸，都有硬满的症状，应当通过疼痛与否来辨别。如果胀满且硬痛，称为结胸；胀满但不痛，称为痞满。凡是治疗伤寒，在大下之后又发汗，会导致正气虚弱邪气内入，心下形成痞证。外在症状如有恶寒、身热，先适宜用解表的药剂治疗，等到表证解除后，再进服大黄泻心汤，以攻逐痞满并清除热邪。这里说舌苔纯黄起瓣，固然适宜用大承气汤峻猛攻下，但是必须详细审察病证，仔细诊断，否则像发黄有湿热与蓄血的区别，又有悬饮与结胸的辨别，倘若误用承气汤，更会有结胸与痞满的变化。
大承气汤
厚朴（姜制三钱） 枳实（麸炒二钱） 大黄（二钱） 芒硝（二钱）
每次服用一两。用水一钟半，先煎枳实，待沸腾后，才放入大黄。再煎几滚，放入芒硝，煎三五滚，去渣，趁热服用。
【介按】大承气汤的功效，取其急下的意义。如阳明证的谵语、潮热，以及两阳合病导致的潮热，或者阳明病下法之后，心中懊恼而烦，腹部胀满疼痛，本有宿食。又如少阴证的口燥、舌干，或者自利清水、颜色纯青等证，都是因为胃中热极而燥屎为患，所以用大黄之苦寒，涤除腐秽并清热毒。芒硝苦咸而软化燥屎。又有枳实、厚朴来消除滞留的气机。大肠是传导之官，变化由此产生。那么大承气汤，就是用来通泄大肠，并制约胃中热气的方法。
茵陈蒿汤
茵陈（五钱） 大黄（三钱） 山栀子（七枚）
以上每服一两。用水一盏半，先煎茵陈至半熟，其次放入另外两味药，再煎去渣，通口服，趁热服用。
【介按】柯韵伯说：茵陈禀受北方之气，经过冬天不凋谢，傲霜凌雪，遍受大寒之气，所以能除去热邪留结。率领栀子以通水源，大黄以调理胃实，令一身内外的瘀热，全部从小便而出，腹满自然减轻，肠中没有损伤，这是符合“引而竭之”的方法。这是阳明病利水的圣剂。
抵当汤
水蛭（糯米炒七个） 虻虫（炒去羽足七个） 大黄（三钱）
以上作一服，用水一盏半，煎取一钟，去渣，通口服。
【介按】张仲景先生的抵当汤，还有桃仁一味药，现在没有桃仁，推测是原书失载所致。至于方义，先哲柯韵伯已经非常详细清晰。于是引述他的话说道：水蛭善于吸血，且利于在水中活动；虻虫善于吮血，且猛烈于陆地。同时选取水陆之中善于取血的动物来攻击病邪，同气相求，再加上桃仁的苦甘，推陈致新，大黄之苦寒，荡涤邪热，所以名叫抵当。如果热势虽盛但未发狂，少腹胀满但未坚硬，适宜减小剂量制成丸药以缓治之。
十枣汤
芫花（醋浸炒） 大戟 甘遂（煨各等分）
以上每服二钱，体弱者减半。用水一钟半，大枣十枚，劈碎，煎取八分，去渣，通口服。
【介按】柯韵伯说：甘遂、芫花、大戟，这三味药都辛苦气寒且禀性最毒，并举而用之，气味相合，相互辅助，所以可以交互去除邪气的巢穴，决其水道而扩大之，一举而水患可平。然而水利汇聚之处，元气已经虚弱，而毒药攻邪，必然使脾胃更加虚弱，如果没有健脾、调胃的药物作为主宰，邪气尽除而性命也随之终结了。所以选择十个大而肥的大枣作为君药，以培补脾土之虚，一方面制约水气的横逆，一方面解诸药的毒性，得到这一物而三善具备，既不让邪气盛而不制，也不让元气虚而不支，这是仲景立法的尽善尽美。愚昧的人被“甘能中满”的说法迷惑而不敢使用，哪里知道承制的道理呢？
大陷胸汤
大黄（七钱） 芒硝（三钱） 甘遂末（四分）
以上用水二钟，先煎大黄至一钟，去渣，下芒硝，煎三五滚，再用甘遂末，温服取利。
【介按】大黄、芒硝，善于涤荡肠胃的实热，但病在胸中，也以此作为君药，是因为热淫于内，用苦寒治疗，借以涤荡胸中之热。又任用甘遂之苦辛，直攻胸间的水饮邪气，就不专门荡涤胃中的邪秽了。这是邪气留滞胸间而波及于胃，胸胃俱病，而导致结胸的专剂。
大黄泻心汤
大黄（五钱） 黄连 黄芩（各二钱五分）
以上作一服，用水二钟，煎取一钟，去渣，通口服。如果有宿食痰饮者，加半夏曲二钱。
【介按】心下痞，按之柔软而不硬，是内陷的邪气，与无形之气，抟聚不散而成为热痞。所以用苦寒能降的药物，以泄无形之热。不用枳实、厚朴，不是因为它是荡涤实热的药剂。如果兼有宿食、痰饮为患者，再用半夏曲来开痞并祛除水饮。
The tongue appears yellow and dry with a rough texture. If the coating presents with septal partitions (geographic tongue-like fissures), it indicates that heat has entered the Stomach (Wei, stomach) and the pathogenic toxin is deep-seated. The patient suffers from Heart fire (Xin huo, hyperactivity of heart fire) causing irritability and thirst; urgent administration of Da Chengqi Tang (Cinnamon Twig and Rhubarb Decoction) for purgation is required. If jaundice (huang, yellowing of skin and eyes) manifests, use Yinchen Hao Tang (Artemisia Capillaris and Rhubarb Decoction). For hematochezia (xia xue, bleeding from the rectum), use Didang Tang (Didang Decoction). For fluid retention in the hypochondrium (shui zai xie nei, water accumulating within the ribs), use Shizao Tang (Ten Jujube Decoction). For severe chest binding (jie xiong shen zhe, severe phlegm-fluid and heat binding in the chest), use Daxiexiong Tang (Major Chest-Binding Decoction). For fullness obstruction (pi, epigastric fullness without pain), use Dahuang Xiexin Tang (Rhubarb Heart-Draining Decoction).
[Commentary by Jie] Yellow coating with septal partitions signifies extreme excess heat in the Zang-Fu organs. This may result from warm or summerheat pathogens scorching Stomach fluids, or from the erroneous administration of warm-drying herbs that deplete fluids, leading to steaming by toxic heat. Externally, there must be high fever, intense thirst, red face, and red lips; severely, delirium (shen hun, loss of consciousness) and coma may occur. Treatment should employ Da Chengqi Tang to urgently purge and preserve fluids. Regarding jaundice, there is a distinction between damp-heat and blood stasis. If Yangming heat excess combined with dampness causes jaundice, external signs include absence of sweat over the body, sweating only on the head, difficulty urinating, and desire to drink water. This is due to heat unable to vent outward, stagnating and steaming into jaundice. Treatment requires Yinchen Hao Tang, using bitter-cold properties to unblock and drain, allowing internal stagnant heat to descend, so jaundice resolves via the stool. If jaundice presents with clear urine or easy bowel movements, and the pulse is deep, fine, and knotted, this is jaundice caused by blood stasis (xu xue). Treatment requires Didang Tang to eliminate stasis and resolve jaundice. Furthermore, there is the disease of hanging fluid (xuan yin, pleural effusion), where the pulse is deep, wiry, and fine. Due to fluid retention condensing and hanging between the chest and hypochondrium, coughing draws internal pain. Based on these symptoms, it must not be mistaken for chest binding. Treatment requires Shizao Tang to reach the disease site directly, causing fluid to descend without binding pain. There is also the syndrome of chest binding (jie xiong), which occurs when a disease begins in the Taiyang channel, but the physician fails to release the exterior and erroneously uses purgation. Pathogenic heat enters the interior and binds with accumulated fluids in the chest. The pulse is deep and tight, pain exists below the heart (xin xia, epigastrium) and feels hard like stone upon pressure. This is chest binding caused by heat excess. Treatment requires Daxiexiong Tang to soften hardness, break accumulation, and guide out pathogenic heat. When a disease in the Yang channels is treated with purgation, heat enters and forms chest binding; this pathology and treatment have been described. However, one must also know that when a disease in the Yin channels is treated with purgation, it can lead to pi (fullness obstruction). Although both pi and chest binding present with hardness and fullness, they are distinguished by pain: if full, hard, and painful, it is chest binding; if full but not painful, it is pi-fullness. In treating cold damage, after severe purgation followed by sweating, righteous qi becomes deficient and pathogens enter, forming pi in the epigastrium. External signs such as aversion to cold and body heat require initial treatment with exterior-releasing formulas. After the exterior is resolved, administer Dahuang Xiexin Tang to attack pi and clear heat. Thus, while a pure yellow septal tongue warrants the strong purgation of Da Chengqi Tang, careful examination of symptoms and diagnosis is essential. Otherwise, distinctions such as damp-heat versus blood stasis in jaundice, or hanging fluid versus chest binding, may be confused. Erroneous use of Chengqi formulas could lead to complications of chest binding or pi-fullness.
Da Chengqi Tang
Houpo (Magnolia Bark, ginger-processed, 3 qian)
Zhishi (Immature Bitter Orange, bran-fried, 2 qian)
Dahuang (Rhubarb Root, 2 qian)
Mangxiao (Mirabilite, 2 qian)
Take 1 liang per dose. Use 1.5 zhong of water. First decoct Zhishi. Once boiling, add Dahuang. Boil a few more times, then add Mangxiao. Boil for three to five boils, strain, and take hot.
[Commentary by Jie] The function of Da Chengqi Tang lies in its meaning of urgent purgation. It applies to Yangming syndrome with delirium and tidal fever, or two-Yang combined disease causing tidal fever, or post-purgation Yangming syndrome with mental restlessness, abdominal fullness and pain, and existing food retention. It also applies to Shaoyin syndrome with dry mouth and tongue, or spontaneous diarrhea of clear water with pure green color. These are all caused by extreme heat in the Stomach and dry feces. Therefore, the bitter-cold Dahuang is used to cleanse filth and clear toxic heat. Mangxiao, bitter and salty, softens dry feces. Zhishi and Houpo eliminate stagnant Qi. The Large Intestine is the official of transmission and transformation. Thus, Da Chengqi Tang unblocks and drains the Large Intestine to control heat in the Stomach.
Yinchen Hao Tang
Yinchen (Artemisiae Scopariae Herba, 5 qian)
Dahuang (Rhubarb Root, 3 qian)
Shanzhizi (Gardeniae Fructus, 7 pieces)
Take 1 liang per dose. Use 1.5 zhong of water. First decoct Yinchen until half-cooked, then add the other two herbs. Decoct further, strain, and take hot orally.
[Commentary by Jie] Ke Yunbo stated: Yinchen inherits the Qi of the North, does not wither in winter, braves frost and snow, and absorbs great cold. Thus, it can remove lingering heat pathogens. Guided by Zhizi to open the water source, and assisted by Dahuang to regulate Stomach excess, it allows internal and external stagnant heat to exit via urination. Abdominal fullness decreases naturally, and the intestines remain undamaged. This aligns with the method of "drawing out and exhausting." It is the sacred formula for draining water in Yangming syndrome.
Didang Tang
Shuizhi (Leech, fried with glutinous rice, 7 pieces)
Mengchong (Dragonfly Larva, fried, wings and feet removed, 7 pieces)
Dahuang (Rhubarb Root, 3 qian)
Prepare as one dose. Use 1.5 zhong of water, decoct to 1 zhong, strain, and take orally.
[Commentary by Jie] Zhang Zhongjing's original Didang Tang included Taoren (Peach Kernel). Its absence here is likely due to omission in the original text. Regarding the formula's rationale, Ke Yunbo explained it clearly: Leeches are good at drinking blood and thrive in water; dragonfly larvae suck blood and are fierce on land. Using these aquatic and terrestrial blood-suckers attacks the pathogen through sympathetic resonance. Assisted by Taoren's bitter-sweetness to push out the old and generate the new, and Dahuang's bitter-coldness to scour pathogenic heat, it is named Didang. If heat is severe but without mania, and lower abdomen is full but not hard, reduce the dosage and make pills for slow treatment.
Shizao Tang
Yuanhua (Genkwa Flos, vinegar-soaked and fried)
Daji (Euphorbiae Pekinensis Radix)
Gansui (Kansui Radix, roasted, equal parts)
Take 2 qian per dose (half for weak persons). Use 1.5 zhong of water and 10 large jujubes (dazao), split and crushed. Decoct to obtain 0.8 zhong, strain, and take orally.
[Commentary by Jie] Ke Yunbo stated: Gansui, Yuanhua, and Daji are all pungent-bitter, cold in nature, and highly toxic. Used together, their flavors combine and mutually assist, allowing them to attack the pathogen's nest, open the waterways, and extinguish water disaster in one stroke. However, where water accumulates, righteous Qi is already deficient. Toxic drugs attacking pathogens weaken the Spleen and Stomach further. Without Spleen-tonifying and Stomach-regulating agents as masters, eliminating pathogens would also kill the patient. Therefore, ten large, plump jujubes are chosen as the sovereign herb to tonify deficient Spleen Earth, restrain rampant Water Qi, and detoxify the harsh herbs. One ingredient achieves three benefits: controlling excess pathogens without damaging deficient righteous Qi. This is the perfection of Zhang Zhongjing's legislation. Ignorant people, confused by the saying "sweetness causes fullness," dare not use it, failing to understand the principle of restraint and control.
Daxiexiong Tang
Dahuang (Rhubarb Root, 7 qian)
Mangxiao (Mirabilite, 3 qian)
Gansui Mo (Kansui Radix Powder, 4 fen)
Use 2 zhong of water. First decoct Dahuang to 1 zhong, strain. Add Mangxiao, boil for three to five boils. Add Gansui powder, take warm to induce evacuation.
[Commentary by Jie] Dahuang and Mangxiao are excellent at cleansing excess heat in the intestines and stomach. Although the disease is in the chest, they serve as sovereign herbs because heat invading the interior is treated with bitter-cold substances to cleanse chest heat. Combined with Gansui's pungent-bitterness to directly attack fluid pathogens in the chest, it no longer solely targets gastric filth. This is a specialized formula for chest binding caused by pathogen retention in the chest affecting the Stomach, resulting in simultaneous disease of the chest and Stomach.
Dahuang Xiexin Tang
Dahuang (Rhubarb Root, 5 qian)
Huanglian (Coptidis Rhizoma, 2.5 qian)
Huangqin (Scutellariae Radix, 2.5 qian)
Prepare as one dose. Use 2 zhong of water, decoct to 1 zhong, strain, and take orally. If there is food retention or phlegm-fluid, add Banxia Qu (Pinellia Fermented Paste, 2 qian).
[Commentary by Jie] Epigastric pi feels soft upon pressure and is not hard. This is internalized pathogens combining with formless Qi, stagnating to form heat-pi. Therefore, bitter-cold descending herbs are used to drain formless heat. Zhishi and Houpo are not used because this is not a formula for scouring excess heat. If complicated by food retention or phlegm-fluid, Banxia Qu is added to open pi and dispel fluid.