程知曰∶言有燥屎，即可大攻下也。下后心中懊 而烦者，虚烦也，当与栀子豉汤。
若胃有燥屎，则非虚烦，故可攻。腹不甚满，则无必攻之法，有燥屎则非先硬后溏者也，故
可攻。又曰∶便硬与燥屎不同。便硬者，大便实满而硬；燥屎者，胃中宿食，因胃热而
结为燥丸之屎也。故便硬，犹有用小承气者；若燥屎，则无不用芒硝之咸寒也。
程应旄曰∶未句乃申可攻句，以决治法。
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。
【注】得病二三日，无太阳、少阳证，烦躁心下硬，至四五日，不大便，若脉大，属
正阳阳明，胃实之证也，下之无疑。今脉弱，虽胃和能食，不可轻下，只可与小承气汤，少
少与而微和之，令其小安。次日仍不大便，继
与小承气汤促之。若六七日竟不大便而小便少者，即不能食，亦属胃中尚未干燥，屎未
定硬，如大攻之，初见硬复必溏也。须待小便利，知屎定硬，乃可攻之，宜大承气汤。
【集注】方有执曰∶太阳不言药，以有桂枝、麻黄之同也；少阳言药，以专主柴胡也。
凡以此为文者，皆互发也。以无太、少二经证，故知此属阳明，以脉弱，故宜微和，至
六日以下，乃历叙可攻、不可攻之节度也。
程应旄曰∶能食以结在肠间，而胃火自盛也。先以小承气汤少少与之，和胃中之火，
令少安后，以前药增至一升，去肠中之结。既用小承气矣，而又减去分数，接续投之，以
脉弱之胃，其禀素虚，而为日又未久也。
张璐曰∶此段之能食、不能食，全与辨风寒强弱无涉。言能食者，不可以为胃强而
轻下；不能食者，不可以为胃中有燥屎而轻下也。
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。
【注】阳明病脉迟，虽汗出不恶寒，外证欲解而脉不实，尚未可攻也。若其人身重，热
困于体也；短气而喘，热壅于上也；腹满潮热，热聚于中也，手足 然汗出，大便已硬，
热结于下也，斯为外邪已解，内实已成，始可攻之，主以大承气汤可也。若汗出，微发
热恶寒者，则外犹未解也，其热不潮者，里犹未实也，不可与承气汤。即有里急、腹大
满、不通等证，亦只宜与小承气汤微和胃气，勿令大泄下，盖以脉迟故也。
【集注】方有执曰∶潮热，阳明旺于申酉戌，故热作于此时，如潮之有信也。手足
然而汗出者，脾主四肢而胃为之合，胃中燥实而蒸蒸腾达于四肢，故曰∶大便已硬也。
林澜曰∶此节辨脉迟内结之，或宜大承气攻之，或但可以小承气微和之也。阳明病
脉迟证，兼汗出不恶寒，身重短气，腹满而喘，似属可攻。然必有潮热者，为外证已解，
里证已具，手足 然汗出者，为大便已硬，主以大承气汤攻之奚疑！若汗出虽多，犹见发
热恶寒，则表尚在也，其热不潮，汗亦非手足 然之汗，安可与承气以攻之乎！即腹大
满不通，亦只可与小承气微和，勿令大泄下。此何以故？脉迟便非必下之脉，虽内结亦岂
大承气所宜哉！
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，转矢气者，此有燥屎也，乃可攻之；若
不转矢气者，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。不转矢气者，慎不可攻也。
【注】阳明病，潮热大便微硬者，可与大承气汤；不硬者，不可与之也。若不大便六
七日，恐有燥屎，欲知之法，少与小承气汤，汤入腹中转矢秽气，则为有燥屎，乃可攻之。
若不转矢秽气，此但初头硬后必溏，是尚未成硬也，不可攻之，攻之必寒气乘虚上逆，胀
满不能食也。欲饮水者，得水则哕，亦由虚寒之气上逆，不能化水而下输也。若其后所
发潮热不退，必是大便再硬，但已经下后，所硬者无多，只以小承气汤和之可也。故凡服
承气汤不转矢气者，慎不可攻也。此盖仲景戒人不可轻下之意。
【集注】方有执曰∶此以潮热、转矢气次第而详言之，以决当下之候也。转矢气，反
屁出也。胀满，药寒之过也。哕，亦寒伤胃也。复硬而少者，重下故也。末句重致叮咛之意。
喻昌曰∶若腹中气仍不转，则不但用大
承气大差，即小承气亦差矣。
程知曰∶上条曰∶外欲解，可攻里；曰∶外未解，未可与承气；曰∶可与小承气，微
和胃气，勿令大泄下。此条曰∶可与；曰∶不可与；曰∶乃可攻之，不可攻之；曰∶少与
小承气；曰∶以小承气和之，慎不可攻。多少商量慎重之意。故惟手足 然汗出，大便
燥硬者，始主之以大承气，若小承气，犹是微和胃气之法也。
汪琥曰∶转矢气，则知其人大便已硬，肠胃中燥热之甚，故其气不外宣，时转而下；不
转矢气，则肠胃中虽有热，而渗孔未至于燥，此但初头硬，后必溏也。
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，若不转矢气者，勿更与之。明日又不大便，脉反微涩者，里虚也，为难治，
不可更与承气汤也。
【注】阳明病，谵语，潮热，脉滑而疾者，是可攻之证脉也。然无 然之汗出，与小
便数、大便硬燥实等证，则不可骤然攻之，宜先与小承气汤一升试之。若腹中转矢秽气，则
知肠中燥屎已硬，以药少未能遽下，所转下者，但屎之气耳！可更服一升促之，自可下
也。若不转矢气，则勿更与服，俟明日仍不大便，诊其脉仍滑疾，则更服之。今脉反见
微涩，则是里虚无气，不能承送，故为难治，所以不可更与承气汤也。
【集注】方有执曰∶滑以候食，故为大便硬之诊。疾者，属里热也。微者，阳气不充，
无以营运。涩者，阴血不足，无以润送。故曰∶阳微不可下，无血不可下。此之谓也。
张璐曰∶此条脉滑而疾，有谵语、潮热，而无硬满实证，只宜以小承气汤下之，下之
而脉反微涩，证变里虚，故为难治。
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
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、谵语者，大承气汤主之。若一服利，则止后服。
【按】赵嗣真曰∶《活人书》去∶弦者，阳也；涩者，阴也。阳病见阳脉者生，在仲景
脉法中，弦涩属阴不属阳得无疑乎？今观本文内，脉弦者生之“弦”字，当是“滑”字。
若是“弦”字，弦为阴负之脉，岂有必生之理？惟滑脉为阳，始有生理。滑者通，涩者
塞，凡物理皆以通为生，塞为死。玩上条脉滑而疾者小承气主之，脉微涩者，里虚为难治，益见其误。
【注】伤寒，若吐、若下后，津液已亡，而表不解，邪因入里，不大便五六日，上至
十余日仍不大便，日晡所发潮热，不恶寒者，此乃表邪悉罢，里热渐深也，仍宜大承汤，荡
尽余邪，以存阴液，自可愈也。若因循失下，以致独语如见鬼状，病势剧者，则不识人，循
衣摸床，惊惕不安，微喘直视，见一切阳亢阴微，孤阳无根据，神明扰乱之象。当此之际，
惟诊其脉滑者为实，堪下则生；涩者为虚，难下则死。若病势微者，但见潮热、谵语、不
大便之证，而无前神昏等剧者，宜以大承气汤下之，若一服利，即止后服，盖恐其过也。
【按】循衣摸床，危恶之候也。一以阴气未竭为可治，如太阳中风，火劫变逆，捻衣
摸床，小便利者生，不利者死是也。一以阳热之极为可攻，如阳明里热成实，循衣摸床，
脉滑者生，涩者死是也。大抵此证，多生于汗、吐、下后，阳气大虚，精神失守。经曰∶
四肢者，诸阳之本也。阳虚故四肢扰乱失所倚也，以独参汤救之；汗多者，以参 汤；厥
冷者，以参附汤治之。愈者不少，不可概谓阳极阴竭也。
【集注】喻昌曰∶此条举谵语之势重者为言。而势重之中，复分二等∶剧者主死；微
者主生。故以大承气汤下之。
程知曰∶娄全善治循衣摸床，每以补益
得愈，亦因其脉证之不足也。刘守真每以承气治热病，法虽祖于仲景，而辨证其未能如
此详悉，故开后人卤莽之端。又曰∶喘则气欲上脱；微喘者邪实于内，而又不能大喘也。
不识人循衣摸床，心欲绝也；动惕不安，肝欲绝也；微喘，肺欲绝也；直视，肾欲绝也。
《内经》所谓三阴三阳，五脏六腑皆受病，荣卫不行，脏腑不通，故脉涩者死也。
汪琥曰∶日晡所发潮热者，腑实燥甚，故当其经气王时发潮热也。独语者，即谵语也。
病患自言为谵，独语如见鬼状，乃阳明腑实而妄见妄闻。剧者，甚也。成注云∶热甚昏
冒正气，故不识人。循衣摸床者，阳热偏胜而躁动于手也。惕而不安者，胃热冲膈，心
神为之不宁也。又胃热甚而气上逆则喘，直视则邪干脏矣。故其生死之机，须于脉候决之。
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。
【注】阳明病，本应自汗出，医误以为风邪，更重发汗，病已瘥，尚微烦不了了者，此
大便必硬故也。然无或满、或痛之苦者，以重汗亡津，胃中干燥，故大便硬，本无宿食
也。则当问其小便日几行，若本一日三四行，今日只再行，可知大便不久则出。盖小便数
少，则津液当还胃中，故知不久必大便自出，不须药也。
【集注】方有执曰∶水谷入胃，其精者为津液，粗者成渣滓。水精渗出肠胃之外，清
者为津液，浊者外而为汗，下而为小便。故汗与小便过多者，皆能夺乎津液，所以渣滓
之为大便者，干燥结硬而难出也。然二便者，水谷分行之道路，此通则彼塞，此塞则彼通，
小便出少，则津液还停胃中，必大便润而自出也。
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。
【注】此承上条详其义以明其治也。阳明病，自汗出，或发汗、小便自利者，此为津
液内竭，虽大便硬而无满痛之苦，不可攻之，当待津液还胃，自欲大便，燥屎已至直肠，难
出肛门之时，则用蜜煎润窍滋燥，导而利之。或土瓜根宣气通燥，或猪胆汁清热润燥，皆
可为引导法，择而用之可也。
【集注】成无己曰∶津液内竭，肠胃干燥，大便因硬，此非结热，故不可攻，宜以润药
外治而导引之。
张璐曰∶凡系多汗伤津，及屡经汗下不解，或尺中脉迟弱，元气素虚之人，当攻而
不可攻者，并宜导法。
程应旄曰∶小便自利者，津液未还入胃中，津液内竭而硬，故自欲大便，但苦不能
出耳。须有此光景时，方可从外导法，渍润其肠，肠润则水流就湿，津液自归还于胃，故
不但大便通，而小便亦从内转矣。
蜜煎导方
蜜七合，一味纳铜器中，微火煎之，稍凝似饴状，搅之勿令焦着，欲可丸，并手捻
作挺子，令头锐大如指，长二寸许。当热时急作，冷则硬，以纳谷道中，以手急抱，欲
大便时乃去之。
《内台方》用蜜五合，煎凝时，加皂角末五钱，蘸捻作挺，以猪胆汁或油润谷道，纳之。
猪胆汁方
大猪胆一枚，泻汁和法醋少许，以灌谷
道内，如一食顷，当大便，出宿食恶物甚效。
《内台方》不用醋，以小竹管插入胆口，留一头用油润，纳入谷道中，以手将胆捻之，
其汁自入内，此方用之甚便。
土瓜根方（缺）
【按】土瓜，即俗名赤雹也。《肘后方》治大便不通，采根捣汁，用筒吹入肛门内。此
与上猪胆汁方同义。《内台方》用土瓜根削如挺，纳入谷道中，误矣。盖蜜挺入谷道能烊
化而润大便，土瓜根不能烊化，如削挺用之，恐失仲景制方之义。
伤寒六七日，目中不了了，睛不和，无表里证，大便难，身微热者，此为实也。急
下之，宜大承气汤。
【注】少阴病，得之二三日，口燥咽干，急下之，宜大承气汤者，乃因热势甚速，消
灼肾水，津液不能到咽，故不必待其有可下之证而急下之，是下其热，以救将绝之水；缓
则肾水干竭，阳必无根据，躁冒自焚而死也。目中不了了而睛和者，阴证也；睛不和者，阳
证也。今伤寒六七日，目中不了了，睛不和者，是肾水为胃阳所竭，水既不能制火，则
程知说：只要存在燥屎，就可以使用峻下法攻逐。如果攻下之后心中烦闷懊恼，这是虚烦证，应当给予栀子豉汤。
如果胃中有燥屎，那就不是虚烦，所以可以攻下。腹部胀满不严重，就没有必须攻下的指征；如果有燥屎，就不是先干硬后稀溏的情况，所以可以攻下。又说：大便干硬与燥屎不同。大便干硬，是指大便结实、充满且坚硬；燥屎，是指胃中留宿的食物，因为胃热而凝结成干燥丸状的粪便。所以大便干硬时，还有可能用小承气汤；如果是燥屎，则没有不用芒硝这种咸寒药物的情况。
程应旄说：最后一句是重申“可攻”的意思，以此决定治疗方法。
患病两三天，脉象弱，没有太阳病或少阳病的柴胡证，出现烦躁、心下部硬满，到了第四五天，虽然能进食，但只给少量小承气汤，微微调和胃气，使病人稍微安宁。到了第六天，给一升承气汤。如果六七天不大便，小便量少，虽然不能进食，但大便开头硬，后面一定稀溏，说明尚未完全形成干硬，此时攻下必然导致腹泻。必须等到小便通畅，确定大便是干硬的，才可以攻下，适宜用大承气汤。
【注】患病两三天，没有太阳病、少阳病的证候，烦躁、心下部硬满，到了第四五天，不大便，如果脉象大，属于正阳阳明，是胃实证的范畴，攻下无疑。现在脉象弱，虽然胃气调和能进食，不可轻易攻下，只可以给小承气汤，少量给予以微微调和，使其稍微安宁。第二天仍然不大便，继续给予小承气汤以催促排便。如果六七天竟然不大便且小便少，即使不能进食，也属于胃中尚未干燥，大便未定形为干硬，如果大力攻下，初见干硬随后必定稀溏。必须等待小便通畅，知道大便确实干硬，才可以攻下，适宜用大承气汤。
【集注】方有执说：太阳病篇不讲具体用药，是因为有桂枝汤、麻黄汤的通用性；少阳病篇讲用药，是因为专门主用柴胡汤。凡是这样行文的地方，都是互相阐发。因为没有太阳、少阳二经的证候，所以知道这属于阳明病；因为脉象弱，所以适宜微微调和，到了第六天以下，是详细叙述可以攻下和不可以攻下的节度。
程应旄说：能进食是因为结滞在于肠间，而胃火自然旺盛。先用小承气汤少量给予，调和胃中的火热，让病情稍安后，将前药量增加至一升，以去除肠间的结滞。既然已经用了小承气汤，却又减少剂量，连续投服，是因为脉弱的胃，其体质素来虚弱，而且病程又不久。
张璐说：这段文中提到的能食、不能食，完全与辨别风寒强弱无关。说能食的，不可以认为是胃强而轻率攻下；说不能食的，不可以认为是胃中有燥屎而轻率攻下。
阳明病，脉象迟，虽然出汗但不恶寒，身体一定沉重，短气，腹部胀满且喘，有潮热的，这是表证将要解除，可以攻里的标志；手足濈然汗出的，这是大便已经干硬，主用大承气汤。如果汗出多，微发热恶寒的，表证尚未解除，热势没有潮热特点，不可给予承气汤；如果腹部显著胀满不通的，可以给予小承气汤，微微调和胃气，不要让它剧烈泄下。
【注】阳明病脉象迟，虽然出汗但不恶寒，表证欲解但脉象不实，尚不可攻下。如果身体沉重，是热邪困阻于体表；短气而喘，是热邪壅塞于上焦；腹部胀满、潮热，是热邪聚集于中焦；手足濈然汗出，是大便已经干硬，是热邪结聚于下焦。这才是外邪已解，内实已成，才可以攻下，主用大承气汤是可以的。如果汗出，微发热恶寒，那么表证仍未解除；热势没有潮热特点，里证仍未充实，不可给予承气汤。即使有里急、腹部显著胀满、不通等证候，也只适宜给予小承气汤微微调和胃气，不要让它剧烈泄下，这是因为脉象迟的缘故。
【集注】方有执说：潮热，阳明经旺于申、酉、戌时，所以热势在此时发作，像潮水一样有信期。手足濈然汗出，脾主四肢而胃与之相合，胃中燥实蒸腾达于四肢，所以说大便已经干硬。
林澜说：这一节辨析脉象迟伴有内结的，有的适宜用大承气汤攻下，有的只能用小承气汤微微调和。阳明病脉象迟的证候，兼见汗出不恶寒、身重短气、腹满而喘，似乎属于可以攻下的情况。然而必须有潮热，才是表证已解，里证具备；手足濈然汗出，才是大便已经干硬，主用大承气汤攻下有什么可疑的呢！如果汗出虽多，仍见发热恶寒，那么表证尚在；热势没有潮热特点，汗也不是手足濈然之汗，怎么可以给予承气汤攻下呢！即使腹部显著胀满不通，也只可给予小承气汤微微调和，不要让它剧烈泄下。这是什么原因？脉迟便不是必须攻下的脉象，虽然有内结，难道是大承气汤所适宜的吗！
阳明病，有潮热，大便微硬的，可以给予大承气汤；不硬的，不可给予。如果六七天不大便，担心有燥屎，想要知道的方法，是少量给予小承气汤，汤药进入腹中，转放屁的，这是有燥屎，才可以攻下；如果不转放屁的，这只是开头硬，后面一定稀溏，不可攻下，攻下必然导致胀满不能进食。想喝水的，给水则发生呃逆，其后再次发热的，大便一定会再次变硬且量少，用小承气汤调和它。不转放屁的，千万不要攻下。
【注】阳明病，有潮热且大便微硬的，可以给予大承气汤；不硬的，不可给予。如果六七天不大便，担心有燥屎，想要知道的方法，是少量给予小承气汤，汤药进入腹中转放秽气，则为有燥屎，才可以攻下。如果不转放秽气，这只是开头硬后面一定稀溏，是尚未形成干硬，不可攻下，攻下必然导致寒气乘虚上逆，出现胀满不能进食。想喝水的，得水则呃逆，也是由于虚寒之气上逆，不能化水而下输。如果其后所发的潮热不退，一定是大便再次变硬，但已经攻下过，所形成的硬便不多，只以小承气汤调和即可。所以凡是服用承气汤不转放屁的，千万不要攻下。这是仲景告诫人们不可轻率攻下的意思。
【集注】方有执说：这里按潮热、转放屁的顺序详细论述，以此决定当下攻下的时机。转矢气，就是反常地放屁。胀满是药物寒凉过度的过错。呃逆，也是寒邪损伤胃气。再次变硬且量少，是因为再次攻下的缘故。最后一句重在致意叮咛。
喻昌说：如果腹中气机仍然不转动，那么不仅用大承气汤差误，即使用小承气汤也是差误。
程知说：上一条说：表证欲解，可以攻里；说：表证未解，不可给予承气汤；说：可以给予小承气汤，微微调和胃气，不要让它剧烈泄下。这一条说：可以给予；说：不可给予；说：才可以攻下，不可攻下；说：少量给予小承气；说：用小承气调和，千万不要攻下。多少商量，慎重之意。所以只有手足濈然汗出，大便燥硬的，才主用大承气汤，至于小承气汤，仍然是微微调和胃气的方法。
汪琥说：转放屁，就知道此人大便已经干硬，肠胃中燥热非常严重，所以气不外散，时常转动而下；不转放屁，则肠胃中虽有热，但渗孔未至于干燥，这只是开头硬，后面一定稀溏。
阳明病，谵语，发潮热，脉象滑而疾速的，主用小承气汤。因此给予承气汤一升，腹中转放屁的，再服一升；如果不转放屁的，不要再给予。第二天又不大便，脉象反而微涩的，是里虚，属于难治，不可再给予承气汤。
【注】阳明病，谵语，潮热，脉象滑而疾速的，这是可以攻下的证候脉象。然而如果没有濈然汗出，以及小便频数、大便硬燥实等证候，则不可骤然攻下，适宜先给予小承气汤一升试探。如果腹中转放秽气，就知道肠中燥屎已经干硬，因为药量少未能立即下行，所转下的，只是屎的气罢了！可以再服一升以催促，自然可以下行。如果不转放屁，就不要再给予，等到明天仍然不大便，诊察脉象仍滑疾，则再给予。现在脉象反而见微涩，则是里虚无气，不能承送，所以为难治，因此不可再给予承气汤。
【集注】方有执说：滑脉以候食积，所以是大便硬的诊断。疾速，属于里热。微，是阳气不充，无法营运。涩，是阴血不足，无法润送。所以说：阳微不可下，无血不可下。说的就是这个道理。
张璐说：这一条脉象滑而疾速，有谵语、潮热，但没有硬满实证，只适宜用小承气汤攻下，攻下后脉象反而微涩，证候变为里虚，所以为难治。
伤寒经过吐法或下法后病不解，五到六天甚至十几天不大便，傍晚时分发潮热，不恶寒，独自说话好像看见鬼怪一样。如果病情严重的，发作时不认识人，抓衣摸床，惊恐不安，轻微气喘，直视。脉象弦的预后好（生），脉象涩的预后坏（死）。病情轻微的，只是发热、谵语的，主用大承气汤。如果一次服药后通便，就停止后面的服药。
【按】赵嗣真说：《活人书》删去了“弦者”二字。弦，是阳脉；涩，是阴脉。阳病见到阳脉者生，在仲景脉法中，弦、涩属阴不属阳，难道没有疑问吗？现在看本文内，“脉弦者生”的“弦”字，应当是“滑”字。如果是“弦”字，弦是阴负之脉，哪里有必生的道理？只有滑脉为阳，才有生机。滑代表通，涩代表塞，凡物理皆以通为生，塞为死。玩味上一条“脉滑而疾者小承气主之，脉微涩者，里虚为难治”，更加证明此处有误。
【注】伤寒，经过吐法或下法后，津液已亡，而表证未解，邪气因而入里，五到六天甚至十几天仍不大便，傍晚时分发潮热，不恶寒，这是表邪全部罢除，里热逐渐加深，仍宜用大承气汤，荡尽余邪，以保存阴液，自然可以痊愈。如果因循延误攻下，以致独自说话好像看见鬼怪，病势严重的，则不认识人，抓衣摸床，惊惕不安，轻微气喘，直视，出现一切阳亢阴微，孤阳无依，神明扰乱的现象。当此之际，只有诊察脉象滑者为实证，堪攻下则生；涩者为虚证，难攻下则死。如果病势轻微，只见潮热、谵语、不大便的证候，而没有前面神昏等严重的症状，适宜用大承气汤攻下，如果一次服药后通便，就停止后面的服药，大概是恐怕攻下过度。
【按】抓衣摸床，是危重的征候。一种是以阴气未竭为可治，如太阳中风，用火劫法导致变逆，捻衣摸床，小便利的生，不利的死。一种是以阳热极盛为可攻，如阳明里热成实，抓衣摸床，脉滑的生，脉涩的死。大抵这个证候，多产生于汗、吐、下之后，阳气大虚，精神失守。经文说：四肢，是诸阳之本。阳虚所以四肢扰乱失去依靠，用独参汤救治；汗多的，用人参汤；四肢厥冷的，用人参附子汤治疗。治愈的不少，不可一概说是阳极阴竭。
【集注】喻昌说：这一条举谵语势头重的来说明。而在势头重之中，又分二等：严重的预后死；轻微的预后生。所以用大承气汤攻下。
程知说：娄全善治疗抓衣摸床，每每通过补益得以痊愈，也是因为其脉证不足。刘守真每每用承气汤治疗热病，方法虽然效法仲景，但在辨证方面未能如此详尽，所以开启了后人鲁莽的开端。又说：气喘则是气欲上脱；微喘是邪实于内，而又不能大喘。不认识人、抓衣摸床，是心气欲绝；惊恐不安，是肝气欲绝；微喘，是肺气欲绝；直视，是肾气欲绝。《内经》所谓三阴三阳，五脏六腑都受病，营卫不行，脏腑不通，所以脉涩的预后死。
汪琥说：傍晚时分发潮热，是腑实燥热严重，所以在其经气旺盛时发潮热。独语，就是谵语。病患自言自语为谵，独自说话好像看见鬼怪，乃阳明腑实而妄见妄闻。剧者，就是严重。成无己注云：热势严重昏冒正气，所以不认识人。抓衣摸床，是阳热偏胜而躁动于手部。惊恐不安，是胃热冲膈，心神为之不宁。又胃热甚而气上逆则喘，直视则是邪气侵犯脏气。所以其生死的关键，必须在脉候上决断。
阳明病，本来自己出汗，医生更重重发汗，病已好转，还轻微烦闷不舒畅的，这大便一定干硬。因为津液亡失，胃中干燥，所以令大便干硬，应当询问他一天小便几次，如果原本一天小便三四次，今天只两次，所以知道大便不久就会排出。现在小便次数减少，因为津液应当回归胃中，所以知道不久一定大便通畅。
【注】阳明病，本来应当自汗出，医生误以为风邪，更重重发汗，病已好转，还轻微烦闷不舒畅的，这大便一定干硬。然而没有胀满、疼痛的痛苦，因为重汗亡失津液，胃中干燥，所以大便干硬，本无宿食。则应当询问他一天小便几次，如果原本一天三四次，今天只两次，可知大便不久则排出。盖小便次数少，则津液应当回归胃中，所以知道不久一定大便自行排出，不需要药物。
【集注】方有执说：水谷进入胃，其中精华部分成为津液，粗糙部分成为渣滓。水精渗出肠胃之外，清的部分成为津液，浊的部分外泄为汗，下行为小便。所以汗和小便过多者，都能剥夺津液，所以渣滓形成的大便，干燥结硬而难排出。然而大小便，是水谷分行的道路，此通则彼塞，此塞则彼通，小便出得少，则津液还停胃中，必然大便润而自行排出。
阳明病，自汗出，或者发汗，小便自利（频数）的，这是津液内部枯竭，虽然大便干硬也不可攻下，应当等待病人自己想大便，适宜用蜜煎导法通便。如果用土瓜根及大猪胆汁，都可以作为导法。
【注】这是承接上一条详细说明其义以明确治疗方法。阳明病，自汗出，或者发汗、小便自利，这是津液内部枯竭，虽然大便硬但没有胀满痛苦，不可攻下，应当等待津液回归胃中，病人自己想大便，燥屎已到直肠，难以排出肛门之时，则用蜜煎润窍滋燥，引导而利之。或者土瓜根宣气通燥，或者猪胆汁清热润燥，都可以作为引导法，择而用之即可。
【集注】成无己说：津液内部枯竭，肠胃干燥，大便因此干硬，这不是结热，所以不可攻下，适宜用润药外治而引导。
张璐说：凡是属于多汗伤津，以及屡次经过汗下病不解，或者尺中脉迟弱，元气素来虚弱的人，应当攻下而不可攻下的，都适宜用导法。
程应旄说：小便自利（频数），津液未回归胃中，津液内部枯竭而干硬，所以自己想大便，只是苦于不能排出。必须有这种情景时，才可以从外部用导法，浸渍滋润其肠道，肠润则水流就湿，津液自然归还于胃，所以不但大便通，而且小便也从内转了。
蜜煎导方
蜂蜜七合，一味药放入铜器中，用微火煎煮，稍微凝固像饴糖状，搅拌它不要让锅底烧焦，想要做成丸状，用手捏作挺子，头部尖锐粗大如手指，长约二寸左右。趁热赶紧制作，冷了就硬，纳入肛门中，用手紧紧抱住，想大便时才去掉。
《内台方》用蜂蜜五合，煎凝时，加皂角末五钱，蘸取捏作挺，用猪胆汁或油润滑肛门，纳入。
猪胆汁方
大猪胆一枚，挤出汁液混合少许醋，灌入肛门内，一顿饭的功夫，应当大便，排出宿食恶物非常有效。
《内台方》不用醋，用小竹管插入胆口，留一头用油润滑，纳入肛门中，用手将胆挤压，其汁液自然流入内，此方使用很方便。
土瓜根方（缺）
【按】土瓜，就是俗名赤雹。《肘后方》治疗大便不通，采集根捣汁，用筒吹入肛门内。这与上面猪胆汁方意义相同。《内台方》用土瓜根削成挺子，纳入肛门中，是错误的。大概蜜挺入肛门能熔化而润大便，土瓜根不能熔化，如削成挺子使用，恐怕违背仲景制方的本义。
伤寒六七天，眼睛看不清楚，眼球运动不灵活，没有表证也没有里证，大便困难，身体微热的，这是实证。紧急攻下，适宜用大承气汤。
【注】少阴病，得病两三天，口燥咽干，紧急攻下，适宜用大承气汤的，是因为热势非常迅速，消灼肾水，津液不能到达咽喉，所以不必等到有可下的证候而紧急攻下，这是下其热，以救将绝之水；迟缓则肾水干竭，阳气必无依托，躁冒自焚而死。眼睛看不清楚而眼球灵活的，是阴证；眼球不灵活的，是阳证。现在伤寒六七天，眼睛看不清楚，眼球不灵活的，是肾水被胃阳所耗尽，水既不能制约火，则
Cheng Zhi stated: As long as dry feces (dry stool) are present, a vigorous purgative method can be used to attack and purge. If after purging one experiences mental restlessness and vexation (vexation with a sense of oppression), this is deficiency vexation (vexation due to deficiency of Yin and accumulation of heat), and Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) should be administered.
If there are dry feces in the stomach/intestines, it is not deficiency vexation, so attacking is permissible. If abdominal fullness is not severe, there is no absolute indication for purging; if dry feces are present, it is not the case of stool being initially hard and later loose, so attacking is permissible. It is also said that hard stool differs from dry feces. Hard stool refers to stool that is solid, full, and hard; dry feces refer to retained food in the stomach that has condensed into dry, pill-like masses due to stomach heat. Therefore, when stool is merely hard, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) may still be used; but if dry feces are present, Mangxiao (Natrii Sulfas) must invariably be included due to its salty-cold nature.
Cheng Yingmao stated: The final sentence reiterates the "permissible to attack" point to determine the treatment method.
Two or three days after contracting the disease, if the pulse is weak, and there are no Shaoyang syndrome symptoms requiring Chaihu (Bupleuri Radix), but rather irritability and hardness in the epigastrium, by the fourth or fifth day, even if the patient can eat, administer a small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to slightly harmonize the Stomach Qi, allowing for slight relief. By the sixth day, administer one sheng (a unit of volume) of Chengqi Tang. If there has been no bowel movement for six or seven days, and urine output is scanty, even if the patient cannot eat, if the stool is only hard at the beginning and likely loose later, it indicates that hardness has not yet fully formed; attacking now will inevitably cause loose stools. One must wait until urination becomes normal and the stool is definitely hard before attacking, using Da Cheng Qi Tang (Major Order the Qi Decoction).
[Annotation] Two or three days after contracting the disease, without Taiyang or Shaoyang syndrome symptoms, with irritability and epigastric hardness, and constipation by the fourth or fifth day: if the pulse is large, it belongs to Zheng Yang Yangming (True Yang Yangming), a Stomach Excess syndrome, and purging is unquestionably indicated. Now, since the pulse is weak, although the Stomach Qi is harmonious and the patient can eat, light purging should not be attempted. Only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) should be given in small amounts to slightly harmonize, bringing slight relief. If constipation persists the next day, continue with Xiao Cheng Qi Tang to promote defecation. If there is no bowel movement for six or seven days and urine is scanty, even if the patient cannot eat, it indicates the Stomach is not yet dry and the stool is not definitively hard; aggressive purging would result in initial hardness followed by looseness. One must wait for normal urination to confirm definite hardness before attacking, using Da Cheng Qi Tang (Major Order the Qi Decoction).
[Collected Annotations] Fang Youzhi stated: The Taiyang chapter does not specify medicines because Guizhi Tang (Cinnamon Twig Decoction) and Mahuang Tang (Ephedra Decoction) are standard; the Shaoyang chapter specifies medicine because Chaihu Tang (Bupleurum Decoction) is the primary formula. Such writing styles mutually elaborate on each other. Since there are no Taiyang or Shaoyang meridian syndromes, it is known to belong to Yangming; because the pulse is weak, slight harmonization is appropriate. From the sixth day onwards, the text details the degrees of when to attack and when not to.
Cheng Yingmao stated: The ability to eat indicates stagnation is in the intestines while Stomach fire is naturally abundant. First, give a small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to harmonize Stomach fire and bring slight peace; then increase the dose to one sheng to remove intestinal stagnation. After using Xiao Cheng Qi Tang, reducing the dosage and administering it continuously is because the Stomach with a weak pulse is constitutionally deficient, and the disease duration is short.
Zhang Lu stated: The mentions of ability to eat and inability to eat in this section have nothing to do with distinguishing the strength of Wind-Cold. Saying "can eat" does not mean Stomach strength is high enough for light purging; saying "cannot eat" does not necessarily mean dry feces are in the Stomach justifying light purging.
In Yangming disease, if the pulse is slow, and although there is sweating and no aversion to cold, the body is heavy, there is shortness of breath, abdominal fullness with wheezing, and tidal fever, this indicates the exterior is resolving, and the interior can be attacked. Sweating from the hands and feet indicates the stool has hardened; Da Cheng Qi Tang (Major Order the Qi Decoction) is the main formula. If there is profuse sweating, slight fever, and aversion to cold, the exterior has not resolved; if the fever is not tidal, Chengqi Tang should not be given. If abdominal distension and obstruction are severe, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) may be given to slightly harmonize Stomach Qi, avoiding drastic purgation.
[Annotation] In Yangming disease with a slow pulse, although there is sweating and no aversion to cold, the exterior signs are resolving but the pulse is not solid, so purging is not yet appropriate. Body heaviness indicates heat trapping the body; shortness of breath and wheezing indicate heat obstructing the upper jiao; abdominal fullness and tidal fever indicate heat gathering in the middle jiao; sweating from the hands and feet indicates the stool has hardened, with heat binding in the lower jiao. Only when external pathogens are resolved and internal excess is established can one attack, primarily using Da Cheng Qi Tang (Major Order the Qi Decoction). If there is sweating, slight fever, and aversion to cold, the exterior remains unresolved; if the fever is not tidal, the interior is not yet full, so Chengqi Tang should not be given. Even with urgent internal symptoms like severe abdominal distension and obstruction, only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) should be used to slightly harmonize Stomach Qi, avoiding drastic purgation, due to the slow pulse.
[Collected Annotations] Fang Youzhi stated: Tidal fever occurs in Yangming during the Shen, You, and Xu hours (3 PM - 9 PM), rising like the tide. Sweating from the hands and feet: Spleen governs the four limbs and combines with the Stomach; dryness and excess in the Stomach steam towards the limbs, hence "the stool has hardened."
Lin Lan stated: This section distinguishes between slow pulse with internal binding, where some cases suit Da Cheng Qi Tang (Major Order the Qi Decoction) for attack, while others suit only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) for slight harmonization. Yangming disease with slow pulse, accompanied by sweating, no aversion to cold, body heaviness, shortness of breath, abdominal fullness, and wheezing, seems suitable for purging. However, tidal fever must be present to confirm exterior resolution and interior establishment; sweating from hands and feet confirms hardened stool, making Da Cheng Qi Tang (Major Order the Qi Decoction) the clear choice. If sweating is profuse but fever and aversion to cold persist, the exterior remains; if fever is not tidal and sweat is not from the extremities, how can Chengqi Tang be used? Even with severe abdominal distension, only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) for slight harmonization is appropriate, avoiding drastic purgation. Why? A slow pulse is not an indication for mandatory purging; even with internal binding, is Da Cheng Qi Tang (Major Order the Qi Decoction) suitable?
In Yangming disease, with tidal fever and slightly hard stool, Da Cheng Qi Tang (Major Order the Qi Decoction) may be given; if not hard, it should not be given. If there is no bowel movement for six or seven days, and one fears dry feces, the method to verify is to give a small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If, after ingestion, flatus (passing gas) occurs, this indicates dry feces, and attacking is permissible; if no flatus occurs, the stool is only hard at the beginning and likely loose later, so attacking is forbidden, as it will cause abdominal fullness and inability to eat. Thirst for water resulting in hiccups upon drinking indicates subsequent fever will lead to slightly hard, scanty stool; treat with Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to harmonize. If no flatus occurs, strictly avoid attacking.
[Annotation] In Yangming disease, with tidal fever and slightly hard stool, Da Cheng Qi Tang (Major Order the Qi Decoction) may be given; if not hard, it should not be given. If no bowel movement for six or seven days, fearing dry feces, the verification method is to give a small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If flatus occurs after ingestion, dry feces are present, and attacking is permissible. If no flatus occurs, the stool is only hard at the beginning and likely loose later, meaning hardness has not yet formed; attacking is forbidden, as cold qi will rise against empty defenses causing abdominal fullness and inability to eat. Thirst for water leading to hiccups indicates deficiency-cold qi rising, unable to transform and transport water downward. If subsequent tidal fever persists, the stool will harden again, but since purging has already occurred, the amount of hard stool is small; treat with Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to harmonize. Thus, for those taking Chengqi Tang who do not pass flatus, attacking must be strictly avoided. This is Zhongjing's warning against light purging.
[Collected Annotations] Fang Youzhi stated: This details tidal fever and flatus sequentially to decide the timing for purging. Flatus means passing gas abnormally. Abdominal fullness is an error of cold medicine. Hiccups are cold damaging the Stomach. Hardening again with small amount is due to repeated purging. The final sentence emphasizes caution.
Yu Chang stated: If abdominal qi does not move, using Da Cheng Qi Tang (Major Order the Qi Decoction) is a major error, and even Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is erroneous.
Cheng Zhi stated: The previous clause said: Exterior resolving, interior can be attacked; Exterior unresolved, Chengqi Tang not to be given; Can give Xiao Cheng Qi Tang, slightly harmonize Stomach Qi, avoid drastic purgation. This clause says: Can give; Cannot give; Can attack, Cannot attack; Give small amount of Xiao Cheng Qi Tang; Use Xiao Cheng Qi Tang to harmonize, strictly avoid attacking. The discussion of quantity reflects prudence. Therefore, only when hands and feet sweat profusely and stool is dry and hard is Da Cheng Qi Tang (Major Order the Qi Decoction) the primary choice; Xiao Cheng Qi Tang (Minor Order the Qi Decoction) remains a method for slight harmonization.
Wang Hu stated: Passing flatus indicates hardened stool due to severe dry-heat in the intestines, causing qi to turn and descend; not passing flatus indicates heat exists but pores are not dry, so stool is only hard at the beginning and likely loose later.
In Yangming disease, with delirium and tidal fever, if the pulse is slippery and rapid, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is the main formula. Administer one sheng of Chengqi Tang. If flatus occurs in the abdomen, administer another sheng; if no flatus occurs, do not give more. If the next day there is still no bowel movement, and the pulse becomes faint and choppy, this indicates interior deficiency, making it difficult to treat; do not give Chengqi Tang again.
[Annotation] In Yangming disease, delirium, tidal fever, and a slippery, rapid pulse are indications for purging. However, without profuse sweating, frequent urination, or definitely hard/dry stool, sudden purging is inappropriate. First, test with one sheng of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If flatus occurs, dry feces in the intestines are confirmed hard; the small dose was insufficient to immediately purge, so the passed flatus is merely gas. Administer another sheng to promote purging. If no flatus occurs, do not give more. Wait until the next day; if still no bowel movement and the pulse remains slippery and rapid, then give it. Now, if the pulse becomes faint and choppy, it indicates interior deficiency and lack of qi to transport, making it difficult to treat, so Chengqi Tang should not be given again.
[Collected Annotations] Fang Youzhi stated: Slippery pulse indicates food retention, thus diagnosing hard stool. Rapid indicates interior heat. Faint indicates insufficient Yang qi for circulation. Choppy indicates insufficient Yin blood for lubrication. Hence: "Faint Yang cannot be purged, Blood deficiency cannot be purged." This refers to that.
Zhang Lu stated: This clause has a slippery, rapid pulse with delirium and tidal fever, but no hard/full excess syndrome. Only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) should be used. If the pulse becomes faint and choppy after purging, the syndrome changes to interior deficiency, making it difficult to treat.
After Shanghan (Cold Damage) treated with vomiting or purging, if the disease persists, with no bowel movement for five to six days up to ten-plus days, tidal fever occurring at dusk (You hour), no aversion to cold, and solitary speech as if seeing ghosts: if severe, the patient may become unresponsive, grasp at clothes and bedrails, feel terrified and restless, with slight wheezing and fixed gaze. If the pulse is string-taut (Xian), survival is possible; if choppy (Se), death is likely. If mild, presenting only with fever and delirium, Da Cheng Qi Tang (Major Order the Qi Decoction) is the main formula. If one dose results in relief, stop subsequent doses.
[Note] Zhao Sizhen stated: *Huoren Shu* removed "string-taut". String-taut is Yang; choppy is Yin. Yang disease showing Yang pulse indicates life; in Zhongjing's pulse methods, Xian and Se belong to Yin, not Yang, raising doubt. In "pulse string-taut implies life," the character "Xian" should likely be "Hua" (slippery). If "Xian," it is a Yin-deficient pulse, lacking reason for guaranteed life. Only "Hua" (slippery) is Yang, indicating vitality. Hua means open/unobstructed; Se means blocked/stagnant. Physics dictates openness leads to life, blockage to death. Comparing with the previous clause "slippery and rapid pulse uses Xiao Cheng Qi Tang, faint and choppy pulse indicates interior difficulty," proves the error.
[Annotation] After Shanghan treated with vomiting or purging, fluids are depleted, exterior unresolved, pathogen enters interior. No bowel movement for five to six days up to ten-plus days, tidal fever at dusk, no aversion to cold: exterior pathogens are gone, interior heat deepens. Da Cheng Qi Tang (Major Order the Qi Decoction) should still be used to sweep away residual pathogens and preserve Yin fluids, leading to recovery. If purging is delayed, leading to solitary speech as if seeing ghosts, severe cases involve unresponsiveness, grasping at clothes/bedrails, terror/restlessness, slight wheezing, and fixed gaze. These are signs of extreme Yang rising, Yin declining, lone Yang without foundation, and disturbed spirit. At this time, diagnose slippery pulse as excess (purgeable, life possible); choppy pulse as deficiency (hard to purge, death likely). If mild, showing only tidal fever, delirium, and constipation without severe confusion, use Da Cheng Qi Tang (Major Order the Qi Decoction). If one dose brings relief, stop further doses to avoid over-purging.
[Note] Grasping at clothes and bedrails is a critical sign. One perspective: treatable if Yin is not exhausted (e.g., Taiyang Wind Strike treated with fire therapy causing reversal, grasping clothes, urinary flow determines life/death). Another: treatable by attacking if Yang heat is extreme (e.g., Yangming interior excess, grasping clothes, slippery pulse life, choppy pulse death). Generally, this syndrome arises after excessive sweating, vomiting, or purging, causing great Yang deficiency and loss of spirit. The Classic states: Limbs are the root of all Yang. Yang deficiency causes limb disturbance. Treat with Du Shen Tang (Single Ginseng Decoction); for profuse sweating, use Renshen Tang (Ginseng Decoction); for cold limbs, use Renshen Fuzi Tang (Ginseng and Aconite Decoction). Many recover; do not一概 (uniformly) attribute it to extreme Yang and exhausted Yin.
[Collected Annotations] Yu Chang stated: This clause discusses severe delirium. Within severity, two grades: severe implies death; mild implies life. Hence, use Da Cheng Qi Tang (Major Order the Qi Decoction) to purge.
Cheng Zhi stated: Lou Quanshan treated grasping at clothes/bedrails with tonics, often achieving recovery, due to deficient pulse/syndrome. Liu Shouzhen often used Chengqi Tang for febrile diseases. While based on Zhongjing, his differentiation was less detailed, opening doors for later recklessness. Also: Wheezing indicates qi about to escape upward; slight wheezing indicates interior excess preventing full wheezing. Unresponsiveness/grasbing indicates Heart qi failing; terror/restlessness indicates Liver qi failing; slight wheezing indicates Lung qi failing; fixed gaze indicates Kidney qi failing. *Neijing* states: When Three Yin and Three Yang, Five Zang and Six Fu are diseased, Ying and Wei cease moving, Zang and Fu cease communicating, hence choppy pulse implies death.
Wang Hu stated: Tidal fever at dusk indicates severe fu-organ excess and dryness, occurring during the meridian's prosperous time. Solitary speech is delirium. Patient speaking alone as if seeing ghosts is Yangming fu-excess with hallucinations. Severe means serious. Cheng Wuji notes: Heat confuses righteous qi, causing unresponsiveness. Grasping at clothes/bedrails is Yang heat dominance causing hand agitation. Terror/restlessness is Stomach heat rushing膈 (diaphragm), disturbing Heart spirit. Severe Stomach heat causes upward qi rebellion (wheezing); fixed gaze indicates pathogen invading Zang organs. Life/death depends on pulse diagnosis.
In Yangming disease, originally with spontaneous sweating, if the doctor induces heavy sweating, and although the illness has improved, slight vexation and discomfort remain, the stool must be hard. This is due to fluid depletion and dry Stomach causing hard stool. Ask about daily urination frequency. If originally urinating 3-4 times daily, but only twice today, know that stool will soon pass. Now, with reduced urination, fluids should return to the Stomach, so know that stool will soon pass naturally.
[Annotation] In Yangming disease, originally with spontaneous sweating, if the doctor mistakenly treats for Wind and induces heavy sweating, and although improved, slight vexation remains, the stool must be hard. However, without pain or fullness, the heaviness of sweating depleted fluids, drying the Stomach and hardening stool, without retained food. Ask about daily urination. If originally 3-4 times, now only twice, stool will soon pass. Reduced urination means fluids return to the Stomach, so stool will pass naturally without medication.
[Collected Annotations] Fang Youzhi stated: Food/water in Stomach: essence becomes Jin-Ye (fluids), dregs become waste. Fluids seeping out of intestines: clear becomes Jin-Ye, turbid becomes sweat externally or urine internally. Excessive sweat/urine depletes Jin-Ye, making stool dry, hard, and difficult to pass. Intestines/bladder are paths for water/food separation; open here, blocked there; blocked here, open there. Less urine means fluids stay in Stomach, moistening stool for natural passage.
In Yangming disease, with spontaneous sweating, or sweating induced, and frequent urination, this indicates internal exhaustion of Jin-Ye (body fluids). Although stool is hard, it cannot be purged. Wait until the patient feels the urge to defecate; use Honey Suppository (Mi Jian Dao) to guide passage. Radix Trichosanthis Kirilowii (Tugua Gen) or large Pig Bile (Da Zhu Dan Zhi) can also be used as guiding agents.
[Annotation] This elaborates on the previous clause to clarify treatment. In Yangming disease, with spontaneous sweating, induced sweating, or frequent urination, this indicates internal exhaustion of Jin-Ye. Although stool is hard, without fullness/pain, purging is forbidden. Wait for fluids to return to Stomach and urge to defecate, when dry stool reaches rectum and struggles to exit anus. Use Honey Suppository to moisten orifices and guide passage. Or use Tugua Gen to promote qi and unblock dryness, or Pig Bile to clear heat and moisten dryness. Choose appropriately.
[Collected Annotations] Cheng Wujie stated: Internal exhaustion of Jin-Ye causes dry intestines and hard stool. This is not heat binding, so purging is forbidden. Use external moistening suppositories to guide.
Zhang Lu stated: For cases of excessive sweating damaging fluids, or persistent disease despite multiple sweating/purging, or slow/weak chi pulse, or constitutionally weak patients who need purging but cannot tolerate it, guiding methods are appropriate.
Cheng Yingmao stated: Frequent urination means fluids have not returned to Stomach; internal exhaustion causes hardness. Patient feels urge but cannot pass. Only at this stage should external guiding methods be used to moisten intestines. Moistened intestines attract water/fluids, returning Jin-Ye to Stomach. Thus, not only does stool pass, but urination also regulates internally.
Honey Suppository Formula
Seven he of honey, single ingredient, place in copper vessel, simmer gently until slightly thick like malt syrup, stir constantly to prevent burning. When moldable, shape into suppositories by hand, sharp head, thick as finger, approx. two cun long. Shape while hot; hardens when cold. Insert into anus, hold tightly with hand, remove when urge to defecate arises.
*Neitai Fang*: Use five he of honey, add five qian of Gleditsiae Sinensis (Zaojiao) powder when thickened, shape into suppository, lubricate anus with Pig Bile or oil, insert.
Pig Bile Formula
One large Pig Gallbladder, extract juice, mix with small amount of Vinegar,灌 (instill) into anus. Within one meal time, bowel movement should occur, expelling old food and foul matter effectively.
*Neitai Fang*: Do not use vinegar. Insert small bamboo tube into gallbladder neck, leave one end, lubricate with oil, insert into anus. Squeeze gallbladder with hand to inject juice. This method is very convenient.
Radix Trichosanthus Kirilowii Formula (Missing)
[Note] Tugua is commonly known as Chibao. *Zhouhou Fang* treats constipation by crushing root, extracting juice, and blowing into anus via tube. Same principle as Pig Bile Formula. *Neitai Fang* suggests cutting root into suppository shape for insertion, which is incorrect. Honey suppositories melt and moisten stool; Tugua Gen does not melt. Cutting into suppository form likely violates Zhongjing's formulation intent.
After six or seven days of Shanghan, if vision is unclear and eye movements are stiff, without exterior or interior syndromes, difficulty defecating, and slight body heat, this is an Excess syndrome. Urgently purge, using Da Cheng Qi Tang (Major Order the Qi Decoction).
[Annotation] In Shaoyin disease, two to three days after onset, with dry mouth/throat, urgently purge using Da Cheng Qi Tang (Major Order the Qi Decoction) because heat rapidly consumes Kidney Water, preventing fluids from reaching throat. Purge heat to save impending water exhaustion; delay leads to dry Kidney Water, unsupported Yang, restlessness, self-burning death. Unclear vision with flexible eyes is Yin syndrome; unclear vision with stiff eyes is Yang syndrome. Now, after six/seven days of Shanghan, unclear vision with stiff eyes indicates Kidney Water exhausted by Stomach Yang. Water fails to control Fire, so...