蜜煎方附：豬膽汁導法（校補）
食蜜七合上一味，於銅器內，微火煎，當須凝如飴狀，攪之勿令焦著，欲可丸，並手撚作梃，令頭銳，大如指，長二寸許。當熱時急作，冷則鞕。以內穀道中，以手急抱，欲大便時，乃去之（疑非仲景意，已試甚良）。
又大豬膽汁一枚，瀉汁，和少許法醋，以灌穀道內，如一食頃，當大便出宿食惡物，甚效。
【方解及其應用範圍】這是兩種通導大便的法，適用於多汗傷津，尺脈遲弱，元氣素虛，想大便而便不出的病人。一般津液枯的用蜜導，邪熱盛的用膽汁導。現西醫用灌腸法，此法遂廢而不用。
八、陽明病脈遲，雖汗出不惡寒者，其身必重，短氣、腹滿而喘，有潮熱者，此外欲解，可攻裏也。手足濈然（而）汗出者，此大便已鞕也，大承氣湯主之，若汗多，微發熱惡寒者，外未解也，其熱不潮，未可與承氣湯，若腹大滿不通者，可與小承氣湯，微和胃氣，勿令至大泄下。原文208
鄭論：陽明主脈大，脈遲者，裏有寒也。雖汗出不惡寒，因屬內熱之征，而汗出與身重、短氣、腹滿而喘觀之，證屬少陰，而非陽明，即汗出不惡寒一端，務要果有舌黃、乾渴、飲冷、大熱，方可稱陽明的證，再加以日晡潮熱，與手足濈然汗出，大便已鞕，則大承氣乃為的候。若汗多、微發熱、惡寒，則又屬太陽之邪未解，又當表之，故曰其熱不潮，未可與承氣，足以見用藥之大有分寸，即腹滿大便不通，又當審其輕重而斟酌於大小之間，勿令大泄，可見用藥之非易易也
【闡釋】鄭氏論此條著重在辨析太陽、陽明、少陰的疑似證。若汗多，微發熱惡寒者，太陽證也，若汗出與身重，短氣，腹滿而喘者，少陰證也，汗出不惡寒一端，需參以舌黃、乾渴、飲冷、大熱，乃陽明的證，再加以日晡潮熱，手足濈然汗出，大便燥實，則為大承氣證。即腹滿大便不通，鄭氏亦告誡“當審其輕重而斟酌於大小之間，勿令大泄。”示人辨證用藥時宜慎之。
大承氣湯方（校補）
大黃四兩（酒洗）厚樸半斤（炙去皮）枳實五枚（炙）芒硝三合上四味，以水一鬥，先煮二物，取五升，去渣，內大黃，更煮取二升，去渣，內芒硝，更上微火一二沸，分溫再服，得下，餘勿服。
【方解及其應用範圍】按《傷寒論》有大、小、調胃承氣湯之別。大承氣湯治正陽陽明，小承氣湯治少陽陽明，調胃承氣湯治太陽陽明。蓋陽明病者，胃腸熱病也。大承氣為攻下重劑，治傷寒陽明腑證，陽邪入裏，胃實不大便，發熱譫語，自汗出。不惡寒，痞滿燥實堅全見。《內經》謂：“熱淫於內，治以鹹寒，火淫於內，治以苦寒。”
芒硝之鹹寒，以潤燥軟堅，配合大黃之苦寒，瀉實滯，清結熱。再加枳實苦寒，厚朴苦溫，下氣破結而除痞滿，實滿。唐容川謂：“三承氣不但藥力有輕重之分，而其主治亦各有部位之差別。大承氣湯，仲景提出大便已鞕四字，是專指大腸而言，大腸居下，欲其藥力直達，不欲其留于中宮，故不用甘草；大腸與胃同稟燥氣，故同用硝、黃，以潤降其燥；用枳、樸者，取木氣疏泄，助其速降也。”本方煎煮時，大黃必須後下，後下則氣銳行速，能充分發揮藥之效力。本方在《傷寒論》中用於陽明病者有十一條，用於少陰病者有三條，大都有熱結裏實，宜急下存陰的病症。鄭氏專就陽明裏症立說，故特別提出“胃家實”三字提綱，必須審察的確，如大、小便不通，大便鞕、腹滿、狂亂奔走叫駡，不避親疏，潮熱、譫語種種病象，務宜斟酌不可猛浪誤用。又指出吳又可《溫疫論》中用此方者有三十餘症，教人宜明圓通應用之妙。鄭氏在《醫法圓通》中，推廣應用以治咳嗽聲如洪鐘、食入即吐及頭暈神昏無主三症。此三症俱非應下之症，但審其俱由邪火熾甚而致，故用本方治之而愈，實屬善用成方。筆者曾用此方治傷熱咳嗽，所投輒效；又用治臌脹病，患者腹脹如鼓，胸脅滿悶，皮膚蒼黃，肌肉變硬。大便秘結，所下如羊矢，舌質深紅，苔黃燥，脈沉實有力，精神不衰，口渴飲冷。此屬陽明腑症，痞滿燥實俱備，大承氣湯下之而愈。現加減化裁，能治多種腸梗阻及闌尾炎，亦治流行性乙型腦炎，於通下後即能熱退神清，抽搐停止。
九、病人不大便五六日，繞臍痛，煩躁，發作有時者，此有（躁）〔燥〕屎，故使不大便也。原文239
鄭論：按大便五六日不便，繞臍而痛，非有熱結，必係（躁）〔燥〕屎阻滯氣機，不得流通暢，故有此等病形也。
【闡釋】此條係腸中燥屎內結的主要證狀，繞臍痛，煩躁，發作有時，其原因在於腸中燥屎不得出，矢氣攻沖，時而發作，時而停止，可用大承氣湯攻下之。
十、大下後，六七日不大便，煩不解，腹滿〔痛〕者，此有（躁）〔燥〕屎也，所以然者，本有宿食故也，宜大承氣湯。原文241
鄭論：按既經下後，應當通暢，複見六七日不大便，反煩不解，腹滿，定是下時，而邪未泄盡，複又閉塞耳。果係泄盡，又雲有複閉塞之理乎？此條稱有屎宿積，亦是正論。
【闡釋】患陽明腑證，大下之後，六七日又不大便，煩不解，則熱未退可知，腹滿脹痛，此腸中有燥屎宿食積聚。下之未盡，仍當下之。
十一、病人小便不利，大便乍難乍易，時有微熱，喘冒不能臥者①，有（躁）〔燥〕屎也，宜大承氣湯。原文242
鄭論：此條總緣（躁）〔燥〕矢不行，隔塞於中，而各經氣機不得舒暢，氣阻于前陰，則小便不利，氣阻於膽，則夜不能眠，氣逆於肺，則喘證生，氣阻于衛，則微熱作，大便之乍難乍易者，皆氣機之時開時闔所致也。急以大承氣湯治之，去其（躁）〔燥〕矢，（躁）〔燥〕矢一去，氣機立通，則諸證自釋矣。
【闡釋】小便不利，喘冒不能臥，微熱，大便乍難乍易，如鄭氏所說總緣燥矢不行，隔塞於中，各經氣機不得舒暢所致。用大承氣湯內攻燥屎，燥屎除則諸證自愈。
十二、陽明病，潮熱，大便微鞕者，可與大承氣湯，不鞕者，不可與之。若不大便六七日，恐有（躁）〔燥〕屎，欲（和）〔知〕之法，少與小承氣湯，湯入腹中，轉失氣者①，此有（躁）〔燥〕矢，乃可攻之。若不轉失氣〔者〕，此但初頭鞕，後必溏，不可攻之，攻之必脹滿不能食也。欲飲水者，與水則噦。其後發熱者，必大便複鞕而少也，以小承氣湯和之。不轉失氣者，慎不可攻也。原文209
①轉失氣：腸中屎氣下趨，俗言放屁。
鄭論：按鞕與不鞕，指邪熱之輕重，而定可攻與不可攻之意也。轉失氣與不轉失氣，乃決有（躁）〔燥〕屎無（躁）〔燥〕屎之真偽也。若攻之脹滿不食，法宜溫中，又非承氣可了也。
【闡釋】本條是反復說明運用承氣湯的辨證。具體說可分為三段看，從開首至不可與之為第一段，辨識大承氣湯的應用；若不大便至與水則噦為第二段，從失氣不失氣來辨識小承氣湯的應用；其後發熱至文末為第三段，從發熱和失氣的機轉來決定是否應用小承氣湯。若鄭氏所論“攻之脹滿不食，法宜溫中。”則當用理中湯加半夏、砂仁主之。
十三、陽明病，下之，心中懊憹而煩，胃中有燥屎者，可攻。腹微滿，初頭鞕，後必溏，不可攻之。若有燥屎者，宜大承氣湯。原文238
鄭論：按陽明下後，而懊憹心煩者，熱邪未去，而擾攘太甚也。胃中尚有燥矢者，下之而結熱未淨也。燥者可攻，裏實也；先鞕後溏者，不可攻，裏虛也。此處就是認證眼目，用藥法竅，學者宜細求之。
【闡釋】攻下是陽明腑實證的正治方法，現攻下後，病者心中有懊憹而煩的見證，可見邪氣還沒有盡除。但是下後心煩懊憹，有熱邪不除留於胸隔的梔豉湯證；有燥屎未去積滯內陰的大承氣湯證。原文指出胃中有燥屎者，即辨證的要點，可用大承氣湯再下之。
十四、得病二三日，脈弱，無（少）〔太〕陽柴胡證，煩〔燥〕，心下鞕，至四五日，雖能食，以小承氣湯，少少與微和之，令小安。至六、七日，與承氣湯一升。若不大便六七日，小便少者，雖不（能）〔受〕食，但初頭鞕，後必溏，未定成鞕，攻之必溏，須小便利，屎定鞕，乃可攻之，宜大承氣湯（主之）。原文251
鄭論：按此條既稱脈弱，無（少）〔太〕陽柴胡證，即見煩躁，心下鞕，焉知非寒結，而成心下鞕乎？況條中並無陽明熱證實據，只憑屎定鞕一語，而斷為大承氣湯證，於理法誠有未當，尚祈高明證之。
【闡釋】鄭氏對此條之按，與歷代注家不同，持否定之意見。先提出“焉知非寒結而成心下鞕”質疑。繼又說：“條文中並無陽明熱證實據，只憑屎定鞕一語，而斷為大承氣湯證，於理法誠有未當”。筆者遍閱成無己、柯韻伯、陳修園等十餘家之注，都牽強附會，反不若從鄭氏存疑之說為當。
鄭論：按邪至陽明，未經吐下，但心煩者，此以承氣湯主之，是以為熱伏於內也。餘謂心煩故似熱象，有胃液被奪，不能輸津液於心腎者，不得一例論之，統以承氣為是。
【闡釋】陽明病必至腹滿、便秘、潮熱、譫語，乃可大攻下。此條邪熱在胃，未經吐下而心煩，為邪熱鬱蒸也，可與調胃承氣湯微溏之，以解其熱，則心煩自愈。鄭氏更進一層曰：“心煩故似熱象，有胃液被奪，不能輸津液於心腎者”，則調胃承氣湯不可用，法當養陰益胃，以竹葉石膏湯加沙參、玉竹、生地治之。
十六、陽明病，譫語發潮熱，脈滑而疾者①，小承氣湯主之。因與承氣湯一升，腹中轉（矢）氣者②，更服一升；若不轉（矢）氣〔者〕，勿更與之。明日又不大便，脈反微澀者③，裏虛也，為難治，不可更與承氣湯也。原文214
①脈滑而疾：脈象圓滑流利，應指快速。
②轉氣：即前21條轉失氣之意。
③微澀：脈象微而無力，蹇澀而不流利。
鄭論：按譫語發熱，本可下之證，仲師斟酌，轉矢氣與不轉矢氣，以定可攻與不可攻之分。但轉矢氣而下之，複見脈微澀，此又正氣之虛，此刻欲攻之，則恐正氣不勝，不攻之，又慮邪氣複熾，故曰難治，不可更與承氣湯也。
【闡釋】原文雲：“明日又不大便，脈反微澀者，裏虛也，為難治”。微為陽虛，澀為液竭，是陰陽兩虛的表現，攻邪則傷正，扶正則礙邪，所以斷為難治。所謂難治，並不等於不治，而邪實需攻，正虛宜扶，自以攻補兼施為宜。筆者認為可用四逆湯以補陽，加參、歸、地以助陰，合承氣湯而治之，則難治者不難矣。
十七、夫實則譫語①，虛則鄭聲②，鄭聲者重語也。原文210前段
①譫語：是神志昏亂，語言沒有倫次，聲音粗壯。
②鄭聲：是說過又說，語言重複，細語呢喃，聲低息短。
鄭論：此條舉虛實，以明陰陽現證之異。異者何？聲厲、聲低是也；有神、無神是也；張目、瞑目是也；安靜、不寧是也。學者不可粗心，務要將譫語、鄭聲情形實據，熟習於胸，臨證分辨，庶不誤人。
【闡釋】譫語屬陽，鄭聲屬陰，有如鄭氏所言，“以明陰陽現證之異”。
是實是虛，當從全面證狀來確定。然譫語中亦有虛證，不可不知。實證大多見於陽明熱實之證，由於燥實內結，濁氣上幹，神明受熱熏灼，以致發生神志昏亂的狀態。虛證是心神將脫，譫語時而昏亂，時而清澈者，或獨自譫語，呼問則清楚等是也。實證治以承氣湯，虛證仍當用溫法治療。鄭聲者，精神衰乏，不能自主，語言重複，其聲微短，正氣虛也，法當回陽以治之，如四逆加人參湯是也。
鄭論：按直視、譫語、喘滿者，明是胃火灼盡陰精，此條專舉胃火旺極者言也。更有少陰真陽衰極，真精不能上榮於目亦直視，危亡已在瞬息之間。直視而見喘滿者，陰精將盡，而又下利，更竭其液，不死何待？
【闡釋】直視譫語，是陽熱亢極，陰精告竭的現象，火熱上亢，神明受擾故作譫語。熱甚傷陰，五臟之精氣，被邪熱所劫，不能上榮於目，故直視不動，如果再見喘滿，則陰精竭絕，陽失依附，而氣從上脫；若見到下利的證狀，是中氣亦敗，邪實正虛，且利複傷陰。兩者皆是死候。鄭氏更論及少陰真陽衰極，真精不能上榮於目之直視，危亡已在瞬息之間，法當大劑回陽以救之。
十九、發（熱）〔汗〕多，若重發汗者，亡其陽①，譫語脈短者死②，脈自和者不死③原文211
①亡其陽：汗液出得太多，致有虛脫的現象。
②脈短：是上不至寸，下不至尺，只有關脈搏動。
③脈自和：與脈短相對而說，也就是脈無敗象的意思。
鄭論：按陽明發（熱）〔汗〕，多屬有餘，陽旺陰必虧，若重發汗，陰必亡，陰亡陽亦與之俱亡，譫語、脈短，陰陽兩不相互之候，不死何待？若脈尚自和者，陰血未盡滅也，故斷其不死。
【闡釋】本條指出虛證譫語的成因是汗多重發汗，不但津液更傷，而陽氣隨汗外泄，有亡陽之慮，屬大虛之候，脈短，這是氣血津液消耗殆盡，行將陰陽離絕，故為死候。脈自和，則知陰陽尚未脫離地步，用藥治療得當，可以不死。
[Appendix: Honey Suppository Method and Pig Bile Guiding Method]
Take seven *he* (a traditional Chinese unit of volume) of edible honey, this single ingredient, place it in a copper vessel, and simmer over low heat. It must be boiled until it condenses to a consistency like malt syrup (*yi*). Stir constantly to prevent it from burning or sticking to the bottom. When it can be molded into pills, while still hot, roll it by hand into a stick shape with a pointed head, about as thick as a finger and two *cun* (approx. 6-7 cm) long. It must be made while warm; if it cools, it will harden. Insert it into the anus, hold the buttocks tightly with your hand, and remove it only when there is an urge to defecate (This method is suspected not to be Zhang Zhongjing’s original intent, but practical trials show it to be very effective).
Alternatively, take the bile from one large pig gallbladder, extract the juice, mix it with a small amount of vinegar, and instill it into the anus. After approximately the time it takes to eat one meal, the accumulated food and foul matter should be expelled. This is highly effective.
[Formula Analysis and Scope of Application] These are two methods for promoting bowel movement, applicable to patients with excessive sweating damaging body fluids, a slow and weak chi pulse, inherent deficiency of primal qi, and the desire to defecate but inability to do so. Generally, for dryness due to fluid depletion, honey guidance is used; for excess pathogenic heat, bile guidance is used. With the modern Western medical use of enemas, these methods have been abandoned.
8. In Yangming disease, if the pulse is slow, although there is sweating without aversion to cold, the body will certainly feel heavy, accompanied by shortness of breath, abdominal fullness, and wheezing. If there is tidal fever, it indicates that the exterior syndrome is resolving, and interior purgation may be performed. If there is continuous sweating on the hands and feet, this indicates that the feces have hardened; Da Cheng Qi Tang (Major Order the Qi Decoction) is the primary formula. If there is profuse sweating, slight fever, and aversion to cold, the exterior has not resolved; since the fever is not tidal, Cheng Qi Tang formulas should not be given. 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, avoiding severe purgation. Original Text 208
Zheng Qin’an’s Commentary: Yangming disease typically presents with a large pulse; a slow pulse indicates cold in the interior. Although there is sweating without aversion to cold, suggesting internal heat, observing the combination of sweating with body heaviness, shortness of breath, abdominal fullness, and wheezing, the syndrome belongs to Shaoyin, not Yangming. Even regarding the specific sign of "no aversion to cold," one must definitively observe yellow tongue coating, dry mouth with thirst, preference for cold drinks, and high fever before diagnosing a Yangming syndrome. Only when supplemented by afternoon tidal fever and continuous sweating on the extremities, indicating hardened feces, is Da Cheng Qi Tang the appropriate prescription. If there is profuse sweating, slight fever, and aversion to cold, it indicates unresolved Taiyang exterior pathogens, requiring exterior resolution. Thus, "if the fever is not tidal, do not give Cheng Qi Tang." This demonstrates the precision required in medication. Even with abdominal fullness and constipation, one must assess the severity and deliberate between Major and Minor Cheng Qi Tangs, avoiding drastic purgation, showing that prescribing is not easy.
[Interpretation] Zheng’s commentary focuses on differentiating between similar syndromes of Taiyang, Yangming, and Shaoyin. Profuse sweating with slight fever and aversion to cold indicates a Taiyang syndrome. Sweating accompanied by body heaviness, shortness of breath, abdominal fullness, and wheezing indicates a Shaoyin syndrome. The sign of "sweating without aversion to cold" requires reference to yellow tongue coating, dry mouth/thirst, preference for cold drinks, and high fever to confirm a Yangming syndrome. Combined with afternoon tidal fever, continuous sweating on extremities, and dry-hard feces, it becomes a Da Cheng Qi Tang syndrome. Even with abdominal fullness and constipation, Zheng warns to "assess severity and deliberate between Major and Minor Cheng Qi Tangs, avoiding drastic purgation," advising caution in pattern differentiation and treatment.
Da Cheng Qi Tang Formula (Corrected Supplement)
Da Huang (Rhei Radix et Rhizoma) 4 liang (washed with wine), Hou Po (Magnoliae Officinalis Cortex) 8 liang (stir-fried, skin removed), Zhi Shi (Immature Bitter Orange) 5 pieces (stir-fried), Mang Xiao (Natrii Sulfas) 3 he. The above four ingredients are decocted in 10 dou of water. First boil Hou Po and Zhi Shi, reduce to 5 sheng, strain, add Da Huang, boil again to reduce to 2 sheng, strain, add Mang Xiao, and boil briefly over low heat for one or two boils. Divide into two warm doses. If defecation occurs, do not consume the remainder.
[Formula Analysis and Scope of Application] According to *Shanghan Lun*, there are distinctions among Da Cheng Qi Tang, Xiao Cheng Qi Tang, and Tiao Wei Cheng Qi Tang. Da Cheng Qi Tang treats Zheng Yang Yangming; Xiao Cheng Qi Tang treats Shao Yang Yangming; Tiao Wei Cheng Qi Tang treats Tai Yang Yangming. Yangming disease refers to heat pathology of the stomach and intestines. Da Cheng Qi Tang is a heavy purgative formula treating Yangming Fu-organ syndrome of cold damage, where yang pathogens enter the interior causing gastric excess, constipation, fever, delirium, spontaneous sweating, and absence of aversion to cold, presenting with all signs of stagnation, fullness, dryness, excess, and hardness. The *Neijing* states: "For heat rampant within, treat with salty-cold; for fire rampant within, treat with bitter-cold."
Mang Xiao’s salty-cold nature moistens dryness and softens hardness, combined with Da Huang’s bitter-cold nature to purge excess stagnation and clear consolidated heat. Added are Zhi Shi (bitter-cold) and Hou Po (bitter-warm) to direct qi downward, break stagnation, and eliminate distension and fullness. Tang Rongchuan stated: "The three Cheng Qi Tangs differ not only in potency but also in their therapeutic targets. Da Cheng Qi Tang, as highlighted by Zhang Zhongjing’s phrase 'feces already hardened,' specifically targets the Large Intestine. Located inferiorly, it aims for direct drug action, avoiding retention in the Middle Jiao, hence no Gan Cao is used. Since the Large Intestine and Stomach share dryness qi, Xiao and Huang are used together to moisten and descend dryness; Zhi and Hou Po are used to leverage the dispersing and draining properties of Wood qi to assist rapid descent." During decoction, Da Huang must be added later; late addition preserves its sharp, rapid action, maximizing efficacy. This formula appears in eleven clauses for Yangming disease and three for Shaoyin disease in *Shanghan Lun*, mostly indicating heat-consolidated interior excess requiring urgent purgation to preserve yin. Zheng focused on Yangming interior symptoms, highlighting "Stomach House Excess" as the outline. One must verify accurately: cases of constipation and urinary difficulty, hard feces, abdominal fullness, manic behavior, shouting, tidal fever, and delirium require careful deliberation to avoid rash misuse. He also noted Wu Keyi’s *Wenyi Lun* used this formula for over thirty cases, teaching the art of flexible application. Zheng extended its use in *Yifa Yuantong* for cough with resonant voice, immediate vomiting after eating, and dizziness with mental confusion. Though not typical purgative indications, these were caused by intense pathogenic fire, cured by this formula, demonstrating skillful use. The author has used this formula successfully for heat-damage cough and for鼓胀 (drum-like distension), where the patient had drum-like abdominal distension, chest/hypochondriac fullness, sallow skin, hardened muscles, sheep-dung-like constipation, deep red tongue with dry yellow coating, deep-solute-forceful pulse, unimpaired spirit, and thirst for cold drinks. This is a Yangming Fu syndrome with complete stagnation, fullness, dryness, and excess; purged with Da Cheng Qi Tang, the patient recovered. Modified, it treats various intestinal obstructions and appendicitis, and epidemic cerebrospinal meningitis, clearing heat and calming convulsions post-purgation.
9. If a patient has not defecated for five to six days, experiences periumbilical pain, irritability, and paroxysmal symptoms, this indicates dry feces, causing constipation. Original Text 239
Zheng Qin’an’s Commentary: Constipation for five to six days with periumbilical pain, if not due to heat consolidation, must be dry feces obstructing qi mechanism, preventing smooth flow, thus producing these symptoms.
[Interpretation] This clause describes main symptoms of dry feces consolidating in the intestines: periumbilical pain, irritability, and paroxysmal onset. The cause is dry feces unable to exit, with flatus attacking and rushing, causing intermittent symptoms. Da Cheng Qi Tang should be used for purgation.
10. After severe purgation, if the patient does not defecate for six to seven days, remains irritable, and has abdominal fullness/pain, this indicates dry feces. The reason is pre-existing retained food; Xiao Cheng Qi Tang is indicated. Original Text 241
Zheng Qin’an’s Commentary: After purgation, patency should ensue. Recurrence of constipation for six to seven days with persistent irritability and abdominal fullness implies pathogens were not fully expelled during purgation and re-obstructed. If truly fully expelled, why would re-obstruction occur? This clause’s mention of retained feces is correct.
[Interpretation] In Yangming Fu syndrome, after severe purgation, recurrence of constipation after six to seven days with persistent irritability indicates residual heat. Abdominal fullness and pain indicate accumulation of dry feces and retained food in the intestines. Since purgation was incomplete, further purgation is necessary.
11. If a patient has difficult urination, alternating difficulty and ease of defecation, occasional slight fever, wheezing, vertigo, and inability to lie down, this indicates dry feces; Da Cheng Qi Tang is indicated. Original Text 242
Zheng Qin’an’s Commentary: This clause results from dry feces obstructing the middle, preventing smooth qi mechanism in all meridians. Qi obstruction at the anterior yin causes difficult urination; obstruction at the Gallbladder causes insomnia; rebellion at the Lung causes wheezing; obstruction at the Wei level causes slight fever. Alternating defecation difficulty is due to the opening and closing of the qi mechanism. Urgently treat with Da Cheng Qi Tang to remove dry feces; once removed, qi mechanism flows freely, and symptoms resolve.
① Wheezing and Vertigo: Wheezing results from severe abdominal fullness causing shortness of breath resembling asthma. Vertigo refers to dizziness from intense heat.
[Interpretation] Difficult urination, wheezing/vertigo/inability to lie down, slight fever, and alternating defecation difficulty, as Zheng stated, result from dry feces obstructing the middle and impeding qi mechanism in all meridians. Use Da Cheng Qi Tang to attack dry feces internally; removal cures all symptoms.
12. In Yangming disease with tidal fever and slightly hardened feces, Da Cheng Qi Tang may be given; if not hardened, do not give. If no defecation for six to seven days and suspicion of dry feces, to test, give a small amount of Xiao Cheng Qi Tang. If passing gas after ingestion, dry feces are present, and purgation is allowed. If no passing of gas, the feces are likely hard at the beginning but loose later; do not purge, as it will cause bloating and anorexia. Thirst for water leading to hiccups upon drinking indicates contraindication. Subsequent fever suggests recurrent hardening with scanty stool; harmonize with Xiao Cheng Qi Tang. If no passing of gas, absolutely do not purge. Original Text 209
① Passing Gas: Intestinal gas moving downward, commonly known as flatulence.
Zheng Qin’an’s Commentary: Hard vs. soft feces indicates the severity of pathogenic heat, determining purgation eligibility. Passing gas vs. not passing gas determines the authenticity of dry feces. Purging when bloating/anorexia occur requires warming the middle; Cheng Qi Tang is insufficient.
[Interpretation] This clause repeatedly explains differentiation for using Cheng Qi Tangs. It can be divided into three parts: From start to "do not give" is Part 1, identifying Da Cheng Qi Tang application; From "no defecation" to "hiccups from water" is Part 2, identifying Xiao Cheng Qi Tang via gas passage; From subsequent fever to end is Part 3, deciding Xiao Cheng Qi Tang use based on fever and gas mechanisms. Regarding Zheng’s note "purging causes bloating/anorexia, treat with warming middle," Li Zhong Tang plus Ban Xia and Sha Ren should be used.
13. In Yangming disease, after purgation, if there is inner restlessness and irritability, and dry feces in the stomach, purgation is allowed. If mild abdominal fullness with hard initial stool but loose later, do not purge. If dry feces are present, Da Cheng Qi Tang is indicated. Original Text 238
Zheng Qin’an’s Commentary: After purgation in Yangming disease, inner restlessness and irritability indicate lingering heat causing severe disturbance. Remaining dry feces mean consolidated heat is not cleared. Dry/stubborn stool allows purging (Interior Excess); hard-then-loose stool prohibits purging (Interior Deficiency). This is the key to diagnosis and prescription technique; students must study carefully.
[Interpretation] Purgation is the standard treatment for Yangming Fu-excess syndrome. Post-purgation inner restlessness and irritability indicate incomplete pathogen elimination. However, post-purgation irritability/restlessness can indicate either residual heat in the chest/diaphragm (Zhi Zi Chi Tang syndrome) or remaining dry feces in the interior (Da Cheng Qi Tang syndrome). The text specifies "dry feces in the stomach" as the diagnostic key, allowing further purgation with Da Cheng Qi Tang.
14. Two to three days after illness, with weak pulse, no Taiyang Chai Hu syndrome, irritability, and epigastric hardness, progressing to day four or five, even if able to eat, give Xiao Cheng Qi Tang sparingly to gently harmonize and provide relief. By day six or seven, give one sheng of Cheng Qi Tang. If no defecation for six to seven days and scanty urine, even if unable to eat, if initial stool is hard but later loose, not yet definitively hardened, purging will cause loose stools. Wait for free urination and definitive hardening of stool before purging with Da Cheng Qi Tang. Original Text 251
Zheng Qin’an’s Commentary: Given weak pulse and no Taiyang Chai Hu syndrome, yet irritability and epigastric hardness, how do we know it is not cold consolidation causing epigastric hardness? Moreover, lacking evidence of Yangming heat-excess, relying solely on "definitive hardening of stool" to diagnose Da Cheng Qi Tang syndrome is theoretically flawed. I request verification from experts.
[Interpretation] Zheng’s commentary differs from previous commentators, holding a negative view. He questions "how do we know it is not cold consolidation?" and notes the lack of Yangming heat-excess evidence, arguing that judging Da Cheng Qi Tang syndrome solely on "hard stool" is theoretically inappropriate. Having reviewed over ten commentaries by Cheng Wuji, Ke Yunbo, Chen Xiuyuan, etc., all seem forced; Zheng’s skeptical approach is more appropriate.
15. In Yangming disease, without vomiting or purgation, if there is heart irritation/irritability, Tiao Wei Cheng Qi Tang may be given. Original Text 207
Zheng Qin’an’s Commentary: Pathogens reaching Yangming without prior vomiting/purgation, presenting only with heart irritation, treated with Cheng Qi Tang, assumes heat concealed within. I argue that while heart irritation resembles heat, cases where stomach fluids are depleted, failing to transport fluids to Heart/Kidney, cannot be uniformly treated with Cheng Qi Tang.
[Interpretation] Yangming disease typically requires major purgation only when abdominal fullness, constipation, tidal fever, and delirium are present. Here, pathogenic heat is in the Stomach, causing heart irritation without prior vomiting/purgation due to heat constraint. Tiao Wei Cheng Qi Tang can be given to mildly purge and clear heat, resolving irritation. Zheng adds: "Heart irritation resembles heat; if stomach fluids are depleted, failing to transport to Heart/Kidney," Tiao Wei Cheng Qi Tang is contraindicated. Treatment should nourish yin and benefit the stomach, using Zhu Ye Shi Gao Tang plus Sha Shen, Yu Zhu, and Di Gu Pi.
16. In Yangming disease with delirium and tidal fever, if the pulse is slippery and rapid, Xiao Cheng Qi Tang is indicated. Give one sheng of Cheng Qi Tang; if passing gas, give another sheng. If no gas, do not give more. If no defecation the next day and pulse becomes faint and choppy, this indicates interior deficiency, making it difficult to treat; do not give Cheng Qi Tang again. Original Text 214
① Slippery and Rapid Pulse: Pulse is round, smooth, and fast.
② Passing Gas: Same meaning as "passing wind" in Clause 21.
③ Faint and Choppy: Pulse is faint/weak and sluggish/not smooth.
Zheng Qin’an’s Commentary: Delirium and fever are indications for purgation. Zhang Zhongjing deliberates based on passing gas vs. not, determining purgation eligibility. If purging after passing gas leads to faint/choppy pulse, it indicates righteous qi deficiency. Purging now risks overwhelming righteous qi; not purging risks pathogen resurgence. Hence, "difficult to treat," do not give Cheng Qi Tang.
[Interpretation] The text states: "Next day no defecation, pulse faint/choppy, interior deficiency, difficult to treat." Faint indicates yang deficiency; choppy indicates fluid exhaustion, representing yin-yang dual deficiency. Attacking pathogens harms righteous qi; supporting righteous qi hinders pathogen expulsion. Thus, "difficult to treat." This does not mean untreatable; since pathogen excess requires attack and righteous deficiency requires support, combining attack and tonification is appropriate. The author suggests using Si Ni Tang to tonify yang, adding Ren Shen, Dang Gui, and Shu Di to assist yin, combined with Cheng Qi Tang, making difficult cases manageable.
17. Excess leads to delirium; deficiency leads to Zheng Sheng (repetitive speech). Zheng Sheng is repetitive speech. Original Text 210 (First part)
① Delirium: Mental confusion, incoherent speech, loud voice.
② Zheng Sheng: Repetitive speech, murmuring, low voice, short breath.
Zheng Qin’an’s Commentary: This clause contrasts excess and deficiency to clarify differences in yin-yang manifestations. Differences include: loud vs. low voice; presence vs. absence of spirit; open vs. closed eyes; calm vs. restless. Students must not be careless; thoroughly memorize the characteristics of delirium and Zheng Sheng to differentiate clinically and avoid errors.
[Interpretation] Delirium belongs to Yang; Zheng Sheng belongs to Yin, as Zheng stated, "clarifying yin-yang manifestation differences." Determining excess vs. deficiency requires comprehensive symptom analysis. Note that delirium can also occur in deficiency. Excess delirium usually appears in Yangming heat-excess due to dry-excess consolidation, turbid qi ascending, and mind scorched by heat, causing mental confusion. Deficiency delirium involves impending collapse of the mind, with intermittent clarity/confusion or solitary muttering, becoming clear when addressed. Excess is treated with Cheng Qi Tang; deficiency requires warming methods. Zheng Sheng indicates spiritual depletion, loss of autonomy, repetitive speech, low/short voice, and righteous qi deficiency; treatment should restore yang, e.g., Si Ni Tang plus Ren Shen.
18. Fixed gaze with delirium, wheezing/fullness indicates death; diarrhea also indicates death. Original Text 210 (Second part)
Zheng Qin’an’s Commentary: Fixed gaze, delirium, and wheezing/fullness clearly indicate stomach fire consuming yin essence. This clause highlights extreme stomach fire. Additionally, in Shaoyin, extreme decline of true yang and failure of true essence to nourish the eyes also causes fixed gaze, with danger imminent. Fixed gaze with wheezing/fullness indicates yin essence nearly exhausted; with diarrhea, fluids are further depleted; death is inevitable.
[Interpretation] Fixed gaze and delirium represent extreme yang heat and exhaustion of yin essence. Fire rising disturbs the mind, causing delirium. Heat injuring yin deprives the five zang organs of essence, preventing nourishment of the eyes, causing fixed gaze. If accompanied by wheezing/fullness, yin essence is exhausted, yang loses its anchor, and qi escapes upward. If accompanied by diarrhea, central qi fails, pathogen excess and righteous deficiency coexist, and diarrhea further injures yin. Both are fatal signs. Zheng also discussed fixed gaze in Shaoyin due to extreme true yang decline and failure of essence to nourish eyes, with imminent danger, requiring large doses of yang-restoring herbs.
19. Excessive sweating, or repeated sweating, leads to loss of yang. Delirium with short pulse indicates death; pulse self-harmonious indicates survival. Original Text 211
① Loss of Yang: Excessive sweating leading to collapse.
② Short Pulse: Pulse does not reach Cun (inch) superiorly or Chi (cubit) inferiorly; only Guan (bar) pulse beats.
③ Self-Harmonious Pulse: Opposite of short pulse, meaning no signs of deterioration.
Zheng Qin’an’s Commentary: Yangming sweating is often excess; strong yang inevitably depletes yin. Repeated sweating destroys yin; yin destruction leads to yang destruction. Delirium with short pulse indicates mutual non-interaction of yin and yang; death is inevitable. If pulse is self-harmonious, yin-blood is not completely extinguished, so survival is predicted.
[Interpretation] This clause identifies the cause of deficiency-type delirium as excessive/repeated sweating, further damaging fluids and allowing yang to escape with sweat, risking yang collapse, a major deficiency state. Short pulse indicates exhaustion of qi, blood, and fluids, approaching yin-yang separation, hence fatal. Self-harmonious pulse indicates yin-yang not yet separated; with proper treatment, survival is possible.