阳明之为病。胃家实是也。
邪自太阳传来。或本经自受。皆属在经之邪。可更传少阳。亦可传入三阴。或邪欲自解。亦可还表。仍入太阳。所
谓传
经之邪也。其在经之时。可以此传彼。故曰转属阳明。又曰属阳明也。若此者。未可即谓之阳明胃实也。
唯经邪内入阳明之里。邪热实于胃腑。方可谓之胃实。夫阳明居中。土也。万物所归。至无所复传之地。
而成可下之证。故曰阳明之为病。胃家实是也。
伤寒三日。阳明脉大。
邪在太阳。则有浮缓浮紧之脉。而不言脉大。在少阳则有弦细弦数之脉。而亦不言大。即太阳阳明
及少阳阳明。亦不言大。唯邪气独在阳明。无太少两经之兼证者。为正阳阳明胃实之症。乃两阳合明之经。
水谷之海。多气多血。且邪并于阳。故恶热而脉大也。阳明伤寒。必至三日而脉大者。盖得之一日。尚不
发热而恶寒。邪犹在表也。二日恶寒自罢。即自汗出而恶热。则阳明证已见矣。三日阳明之里热盛。故脉
大也。惟大则为阳明胃家实热之脉。不大不足以言胃实也。若阳明病而脉不大者。即脉迟及浮缓浮紧
浮弦之类。皆太少兼证之脉也。
正阳阳明者。胃家实是也。
凡邪自太阳传来。虽阳明见证居多。若略见太阳症有未罢者。尚当解散太阳邪气。未可攻下。若已传
少阳。才见少阳一二证。阳明症虽多。汗下在所必禁。故仲景谓伤寒中风。有柴胡证。但见一证便是。
不必悉具。即使邪入阳明。适太阳证已罢。少阳证未见而热不潮者。亦尚未可与承气。以邪气尚在阳明之经。
胃邪未实。故犹未可下。必邪入阳明之里。胃实而发潮热者。知其大便已硬。当亟用攻下。以逐外入之邪。
存胃中之津液。而病却如失矣。此所谓无所复传之地。当下之候。故胃实为正阳阳明也。
太阳病。三日。发汗不解。蒸蒸发热者。属胃也。调胃承气汤主之。
蒸蒸发热。犹釜甑之蒸物。热气蒸腾。从内达外。气蒸湿润之状。非若翕翕发热之在皮肤也。邪在太阳
已三日。表证未解。发热恶寒无汗之候。发汗则当热退身凉而解矣。乃邪气仍不解。反蒸蒸然发热。
则其身热汗出不恶寒之阳明证已现。邪不在太阳可知矣。而蒸蒸之热。又为热气自内而出。并不在阳明之经。
已入阳明之腑。故曰属胃也。邪既入胃。必致热耗津液。故当调和其胃气。谓之调胃者。盖以大黄去胃热。
而以甘草和胃也。其所以止用调胃者。以未至潮热便硬。故不须攻下。既无潮热便硬等胃实之证。而三日即
用调胃者。以邪既入里。必损胃中之津液。且无太阳表证。故不以为早也。
阳明病。不吐不下。心烦者。可与调胃承气汤。
心烦者。胸中烦 也。然烦有虚实之不同。此以阳明病而未经吐下。则胃中之津液元气无损。为热邪在
胃之烦可知。但不若潮热便硬之胃实。所以不必攻下。而可与调胃承气汤也。
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。转矢气者。此有燥屎。乃可攻之。若不转矢气。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。必大便硬而少也。以小承气汤和之。不转矢气
者。慎不可攻也。
此以下四条。皆示人以用承气之法。若认证未的。不可轻投峻剂。当先以小承气探其虚实。以为进止。不可忽遽以
致误也。言病在阳明。因潮热而知其大便微硬者。可与大承气汤。不硬者不可与之。若不大便已六七日。
惟恐其有燥屎。然犹未知其燥与不燥。欲知之法。当先少与小承气汤。汤入腹中转矢气者。此有燥屎欲出也。
乃可攻之。若不转矢气。则知胃无实热。大约但初头硬。后必溏。故不可攻之。攻之则胃阳败损。中气
虚寒而胀满不能食也。欲饮水者。胃热未甚。不可与也。若与水。则水寒伤胃而哕矣。哕者。呃忒也。若服小
承气。虽不转矢气。而其后又复发热者。乃潮热之类也。以此测之。则胃邪虽非大实。而未尽全空。
必大便虽硬而少也。少则仍不必攻。当以小承气汤和之足矣。不可用大承气汤。故又缴云。不转矢气者。
慎不可攻也。
辨误 其后发热句。当从不转矢气句落下为是。观末句复云不转矢气者。慎不可攻。则前后照应显然矣。
而注家谓攻后重复发热。胃热至此方炽。误矣。若既攻之后。胀满不能食。又至饮水则哕。胃气已是虚冷。
岂能重复发热。使大便复硬乎。此必无之事。下笔详慎。智虑周密者。当不应若是。
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。
二三日。邪未深入之时也。脉弱。虚寒之候。非可小之脉也。无太阳柴胡证。邪气已在正阳阳明矣。烦躁
心下硬。胃实之征也。以日数尚少。恐胃邪未实。延至四五日。胃邪当实矣。虽能食者。盖能食则为中风之阳邪。
且能食又疑其胃未实满。似不当攻下。又以脉弱之故。未可遽下。故用小承气汤少少与之。以微和其胃气。
使胃邪稍缓。令得小安。至
六日量其胃邪果实。方与承气汤一升。以尽其邪。若初病至六七日不大便者。其胃气当实。而其小便少者。
乃下焦无火。气化不行也。虽不能食。似乎胃中实满。而不知不能食者为阳明中寒。胃无热邪。其大便
但初头硬。后出者必溏。恐未必一定皆成硬。所以攻之必溏也。须。待也。言当待其三焦之阳气流行。
则膀胱之气化能出而小便分利。阳气旺而水谷分消。屎定成硬。乃可攻之。以六七日不大便。又待其小
便利而屎已硬。故宜用大承气汤。
辨误 注谓胃弱而膀胱气化之源窒。恐未必然。若膀胱气化。岂可责之于胃乎。经云。膀胱者。州都
之官。津液藏焉。气化则能出矣。又云。三焦者。决渎之官。水道出焉。膀胱虽藏津液。非三焦之火气营运。
则不能气化而出。盖三焦为命门之用。乃先天真阳之气也。又何关乎后天之胃弱乎。又谓此段之虽能食。
虽不能食。全与辨风寒无涉。云另有二义。岂仲景立法。理无一贯。又令后人二三其说邪。
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。腹中转矢气者。更服一升。若不转
矢气。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。
邪在阳明而谵语发潮热。则邪热当实于胃。而为可下之证矣。脉滑则食停于胃。疾则热邪过甚。躁动已极。
其变态有不可测者。以未见实大之脉。不可轻下。故不用大承气汤。而以小承气汤主之。因与承气汤一升。
若腹中行动而转矢气者。此胃中有实热也。更服一升。以去其热邪宿滞。若不转矢气者。是胃无实邪也。勿
更与之。至明日而竟不大便。其脉反微涩者。知其内无真气矣。脉微则真阳衰。涩则阴气竭。阴阳俱虚。故
曰里虚也。里气既虚。以滑疾之脉而反变微涩。是邪盛正虚。所以为难治。如此者。正气将败。断不可更虚其虚。
是以不可更与承气汤也。
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。
前阳明上编。有下之而胃中空虚。客气动膈。心中懊 。舌上苔者。不用攻下。而以栀子豉汤主之。
及下之不结胸。心中懊 。饥不能食。亦以栀子豉汤主之者。一以脉尚浮紧。发热汗出。一以其外有热但
头汗出。此皆表未解而误下所致。虽未结胸。而邪已入膈。乘其将陷未陷之时。故用高者越之之法。
以涌出其邪耳。此以阳明病而不言外证。是已无表邪也。既无外证而下之。心中懊 而烦者。当是热邪
在里也。察其脉症。若舌苔黄黑。按之而痛者。或脉大沉实者。乃胃中有燥屎。可攻之证也。若腹微满。
则知证兼太阴。里无大热可知。若攻之。必初头硬。后必溏泄。故不可攻之也。若上截所谓胃中有燥屎者。
乃胃实之证。宜大承气汤。
病患不大便五六日。绕脐痛。烦躁。发作有时者。此有燥屎。故使不大便也。
不大便五六日而绕脐痛者。燥屎在肠胃也。烦躁。实热郁闷之所致也。发作有时者。日晡潮热之类
也。阳明胃实之里证悉备。是以知其有燥屎。故使不大便也。
病患小便不利。大便乍难乍易。时有微热。喘冒不能卧者。有燥屎也。宜大承气汤。
凡小便不利。皆由三焦不运。气化不行所致。惟此条小便不利。则又不然。因肠胃壅塞。大气不行。
热邪内瘀。津液枯燥。故清道皆涸也。乍难。大便燥结也。乍易。旁流时出也。时有微热。潮热之余也。
喘者。中满而气急也。冒者。热邪不得下泄。气蒸而郁冒也。胃邪实满。喘冒不宁。故不得卧。经所谓
胃不和则卧不安也。若验其舌苔黄黑。按之痛而脉实
大者。有燥屎在内故也。宜大承气汤。
大下后。六七日不大便。烦不解。腹满痛者。此有燥屎也。宜大承气汤。
阳明胃实而大下之。邪食皆可去矣。下后又六七日不大便。其烦闷终不解。反腹满而痛者。此尚有
燥屎未尽也。非更为攻下不可。故宜大承气汤。
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。
阳明外证。本已自汗出。而中风亦汗自出。然谵语而汗出。则胃家实热也。所以有燥屎在胃中。风者。
阳邪也。此因太阳中风之阳邪。传入阳明胃腑之所致。故曰此为风也。但胃中之燥屎须下之。然必过
经乃可下之。过经者。非所谓过经十余日。及十三日方谓之过经。言太阳之表邪已罢。邪气已过阳明之经。
入里而胃实。乃可下之。若有太阳证未罢。固不可下。即阳明之经邪。尚未入里。亦不可遽下。下之若早。
则胃气一虚。外邪必陷。必至热甚神昏。语言必乱。盖以表间之邪气。皆陷入于里。表空无邪。邪皆在里。
故谓之表虚里实也。邪既尽入于里。则邪热实于胃中。故下之则愈。宜大承气汤。
阳明病。谵语。有潮热。反不能食者。胃中必有燥屎五六枚也。若能食者。但硬耳。宜大承气汤。
此条示人以机宜活法。未可以能食不能食。执泥其法。以为中风中寒而致误也。阳明病而谵语潮热。
邪热已实于胃矣。反似阳明中寒之不能食。故曰反也。然所以不能食者。何也。若果中于寒。必有如中寒
条内胃中虚冷之变矣。
今谵语潮热。乃因胃中实满。故不能食。是以知必有燥屎五六枚也。若能食者。胃中未至实满之极。
但屎硬耳。然硬亦在所当下。故皆宜大承气汤。
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。止后服。
伤寒法当先汗。此但曰若吐若下后不解。明是当汗不汗而误吐误下。以致外邪内陷而不解也。邪既入里。
而不大便五六日。则热邪郁结于内。再上至十余日。郁蒸愈久。热邪愈深矣。日晡。未后申酉之间。
阳明气旺之时也。潮热为阳明里证。当下之候也。不恶寒。阳明之本证。言无外邪也。独语。谵言妄语也。
如见鬼状。邪热炽盛。不得下泄。浊邪上迫。目昧神昏而妄见也。剧者。病之甚也。发。发作之时也。言病
之剧者。其发作之时。邪热肆虐。蔽塞清道。夺人聪明。乱人心志。故令不识人也。循衣。遇衣则扪而
循之也。摸床。摸其所卧之床也。言两手无措。撮空之状也。惕而不安。动惕不能安卧。即经所谓病则
恶人与火。闻木声则惕然而惊也。微喘。气短促而呼吸无力也。直视。目光直而睛不转动也。素问解精微论云。
夫心者。五脏之专精也。目者其窍也。华色者。其荣也。有德则气和于目。王太仆云。神内守则外鉴明。
盖热邪壅盛。神志俱夺而不守也。金匮真言论云。东方青色。入通于肝。开窍于目。故直视又为肝气将
绝也。弦脉属肝。弦则少阳之生气未绝。三焦之真气尚行。且弦脉气旺而有力。故生。若如新张弓弦。
则亦真脏之绝脉。未必生矣。涩脉属阴。涩则阴气虚竭。阳邪迫烁。精枯髓涸。故死也。病之剧者则然。
若邪之轻微者。但发热谵语而已。当以
大承气汤主之。邪热既微。若一服即利。止后服。
阳明病。发热汗多者。急下之。宜大承气汤。
潮热自汗。阳明胃实之本证也。此曰汗多。非复阳明自汗可比矣。汗多则津液尽泄。卫阳随之而外走。
顷刻有亡阳之祸。故当急下。庶可以留阳气而存津液。故宜大承气汤。然必以脉症参之。若邪气在
经而发热汗多。胃邪未实。舌苔未干浓而黄黑者。未可下也。
发汗不解。腹满痛者。急下之。宜大承气汤。
The manifestation of Yangming disease is "Stomach-Fu Excess" (Wei Jia Shi, 胃家实).
When pathogenic factors transmit from the Taiyang (Greater Yang) channel, or are directly contracted by the Yangming channel itself, they belong to pathogenic factors in the channels. Such pathogenic factors can further transmit to Shaoyang (Lesser Yang), or enter the Three Yin channels. Alternatively, if the pathogenic factors wish to resolve spontaneously, they may return to the exterior and re-enter Taiyang. This is referred to as "transmitting-channel pathogenic factors" (Chuan Jing Zhi Xie, 传经之邪). While the pathogenic factors are in the channels, they can transmit from one channel to another; hence it is called "transferring to Yangming" (Zhuan Shu Yangming, 转属阳明) or "belonging to Yangming" (Shu Yangming, 属阳明). In such cases, it cannot yet be termed Yangming Stomach-Fu Excess. Only when the channel pathogenic factors penetrate internally into the interior of Yangming, and pathogenic heat becomes excess in the Stomach-Fu, can it be termed Stomach-Fu Excess. Yangming resides in the center and corresponds to the Earth element; it is where all things gather, a place where there is no further transmission, leading to syndromes suitable for purgation. Therefore, it is said that the manifestation of Yangming disease is Stomach-Fu Excess.
In cold damage diseases, after three days, the Yangming pulse is large (Da Mai, 脉大).
When pathogenic factors are in Taiyang, the pulse presents as Floating-Slow (Fu Huan, 浮缓) or Floating-Tight (Fu Jin, 浮紧), but is not described as large. When in Shaoyang, the pulse presents as Wiry-Fine (Xian Xi, 弦细) or Wiry-Rapid (Xian Shu, 弦数), also not described as large. Even in combined Taiyang-Yangming or Shaoyang-Yangming cases, the pulse is not described as large. Only when pathogenic factors exist solely in Yangming, without concurrent symptoms of Taiyang and Shaoyang, does it constitute the syndrome of Zheng Yang Yangming (Zheng Yang Yangming, 正阳阳明) Stomach-Fu Excess. This is the channel of the combination of two Yangs, the sea of water and grain, abundant in Qi and Blood. Since pathogenic factors merge with Yang, there is aversion to heat and a large pulse. In Yangming cold damage, the pulse only becomes large on the third day because: on the first day, there is still no fever but aversion to cold, indicating the pathogen is still at the exterior; on the second day, aversion to cold ceases spontaneously, followed by spontaneous sweating and aversion to heat, marking the appearance of Yangming symptoms; on the third day, interior heat in Yangming is vigorous, hence the large pulse. Only a large pulse characterizes the heat-excess of Yangming Stomach-Fu Excess; a non-large pulse is insufficient to indicate Stomach-Fu Excess. If Yangming disease presents with a non-large pulse, such as Slow (Chi, 迟), Floating-Slow, Floating-Tight, or Floating-Wiry pulses, these are pulses of concurrent Taiyang and Shaoyang syndromes.
Zheng Yang Yangming refers to Stomach-Fu Excess.
Whenever pathogenic factors transmit from Taiyang, although Yangming symptoms are predominant, if even slight Taiyang symptoms remain unresolved, one should first dissipate the Taiyang pathogenic factors and not proceed immediately with purgation. If the pathogen has transmitted to Shaoyang and only one or two Shaoyang symptoms appear, even if Yangming symptoms are numerous, both diaphoresis and purgation are strictly contraindicated. Thus, Zhang Zhongjing stated that in cold damage or wind-strike, if there are Chaihu (Bupleurum) syndrome signs, observing just one sign is sufficient; it is not necessary for all signs to be present. Even if the pathogen enters Yangming, provided Taiyang symptoms have ceased and Shaoyang symptoms are absent, but the fever is not tidal fever (Chao Re, 潮热), Chengqi Decoctions should not yet be used, because the pathogen remains in the Yangming channels and the Stomach pathogen is not yet excess, so purgation is not yet indicated. One must wait until the pathogen enters the Yangming interior, the Stomach becomes excess, and tidal fever appears, indicating hard stool, before urgently employing purgation to expel the invading pathogen, preserve Stomach fluids, and cause the illness to vanish like lost goods. This is the "place of no further transmission," the timing for purgation; thus, Stomach Excess constitutes Zheng Yang Yangming.
In Taiyang disease, after three days, if sweating fails to resolve the condition and steaming-hot fever (Zheng Zheng Fa Re, 蒸蒸发热) appears, the pathogen belongs to the Stomach. Tiao Wei Cheng Qi Tang (Regulate the Stomach and Purge Heat Decoction) should be administered.
Steaming-hot fever resembles steam rising from a pot; the heat vaporizes and rises from the interior to the exterior, presenting a moist, steaming quality, unlike Xi Xi Fa Re (翕翕发热), which is confined to the skin. After three days in Taiyang, if exterior symptoms remain unresolved, presenting with fever, aversion to cold, and anhidrosis, sweating should result in the cessation of fever and cooling of the body. However, if the pathogen persists and steaming-hot fever emerges, the Yangming symptoms of body heat, sweating, and absence of aversion to cold become apparent, confirming the pathogen is no longer in Taiyang. Furthermore, this steaming heat originates from within, indicating the pathogen has entered the Yangming Fu (Organs) rather than remaining in the channels; hence, it is said to "belong to the Stomach." Once the pathogen enters the Stomach, it consumes fluids through heat; therefore, the Stomach Qi must be harmonized. The term "Tiao Wei" (Regulate the Stomach) implies using Da Huang (Rhubarb Root and Rhizome) to clear Stomach heat and Gan Cao (Licorice Root) to harmonize the Stomach. Tiao Wei Cheng Qi Tang is used specifically because tidal fever and hard stool have not yet developed, making strong purgation unnecessary. Although typical Stomach Excess signs like tidal fever and hard stool are absent, administering this formula on the third day is justified because the interior pathogen damages Stomach fluids, and the absence of Taiyang exterior signs means it is not too early.
In Yangming disease, if there is mental irritability (Xin Fan, 心烦) without prior emesis or purgation, Tiao Wei Cheng Qi Tang may be given.
Mental irritability refers to vexation in the chest. Vexation can be due to deficiency or excess. Here, since Yangming disease has not undergone emesis or purgation, Stomach fluids and Yuan Qi (Original Qi) are undamaged, indicating the vexation is caused by pathogenic heat in the Stomach. However, it lacks the severity of tidal fever and hard stool characteristic of full Stomach Excess, so strong purgation is not required; Tiao Wei Cheng Qi Tang is appropriate.
In Yangming disease, if there is tidal fever and slightly hard stool, Da Cheng Qi Tang (Major Order the Qi Decoction) 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 (Zao Shi, 燥屎) is suspected, the method to verify this is to administer a small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If, after ingestion, flatus occurs (Zhuan Shi Qi, 转矢气), dry fecal matter is present, and purgation may proceed. If no flatus occurs, the stool is likely hard only at the beginning and loose thereafter; purgation is contraindicated. Purgation would cause abdominal fullness and inability to eat. A patient desiring water who is given water may experience hiccups (Yue, 哕). If fever recurs later, the stool will likely be hard but scanty; Xiao Cheng Qi Tang should be used to harmonize. If no flatus occurs, purgation must be strictly avoided.
The following four clauses demonstrate the methods for using Chengqi Decoctions. If diagnosis is uncertain, harsh formulas should not be lightly administered. One should first use Xiao Cheng Qi Tang to probe for excess or deficiency to guide treatment decisions, avoiding haste and error. It states that in Yangming disease, tidal fever indicates slightly hard stool, warranting Da Cheng Qi Tang; if not hard, it is contraindicated. If no bowel movement occurs for six or seven days and dry fecal matter is feared, but its presence is unconfirmed, one should first give a small dose of Xiao Cheng Qi Tang. If flatus occurs, dry fecal matter is present and ready to pass, allowing for purgation. If no flatus occurs, it indicates no excess heat in the Stomach; the stool is likely hard initially and loose subsequently, so purgation is contraindicated. Purgation would damage Stomach Yang, causing Middle Qi deficiency and cold, leading to abdominal fullness and anorexia. Thirst indicates mild Stomach heat; giving water may cause cold-induced hiccups. Hiccups refer to spasmodic expiration. If Xiao Cheng Qi Tang is taken without flatus, but fever recurs later (a form of tidal fever), it suggests the Stomach pathogen is not fully excess nor completely empty, but results in hard, scanty stool. Scanty stool does not require purgation; harmonizing with Xiao Cheng Qi Tang suffices. Da Cheng Qi Tang should not be used. Hence, it concludes: if no flatus occurs, purgation must be strictly avoided.
[Correction of Misinterpretations] The phrase "fever recurs later" should follow the clause "no flatus occurs." The final sentence reiterates "if no flatus occurs, purgation must be strictly avoided," showing clear correspondence. Commentators who argue that fever recurs after purgation because Stomach heat peaks at this stage are mistaken. If purgation has already occurred, leading to abdominal fullness, anorexia, and hiccups upon drinking water, the Stomach Qi is deficient and cold; it cannot generate recurrent fever or re-harden the stool. This is impossible. A meticulous author would not write thus.
If, two or three days after contracting the disease, the pulse is weak, there are no Taiyang or Chaihu (Shaoyang) signs, but there is irritability and hardness below the heart, progressing to four or five days: even if the patient can eat, administer a small amount of Xiao Cheng Qi Tang to mildly harmonize the Stomach Qi and provide slight relief. By the sixth day, administer one sheng of Cheng Qi Decoction. 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 only at the beginning and loose thereafter, not yet definitively hardened; purgation would cause diarrhea. Wait until urination is free and the stool is definitely hard before purging, using Da Cheng Qi Tang.
Two or three days represent the time before the pathogen deeply penetrates. A weak pulse indicates deficiency-cold, not a pulse to be disregarded. Absence of Taiyang and Chaihu signs indicates the pathogen is in Zheng Yang Yangming. Irritability and hardness below the heart are signs of Stomach Excess. Since the duration is short, the Stomach pathogen may not yet be fully excess; by four or five days, it should be. The ability to eat suggests Wind-Strike (Yang pathogen); however, eating capacity raises doubt about full Stomach excess, suggesting purgation might be premature. Coupled with the weak pulse, immediate purgation is contraindicated. Thus, a small dose of Xiao Cheng Qi Tang is given to mildly harmonize the Stomach, alleviating the pathogen slightly and providing comfort. By the sixth day, if the Stomach pathogen is confirmed excess, one sheng of Cheng Qi Decoction is given to eliminate the pathogen. If no bowel movement occurs from onset to six or seven days, the Stomach Qi should be excess. However, low urine output indicates lack of fire in the Lower Jiao and failure of Qi transformation. Inability to eat might seem to indicate Stomach fullness, but it actually signifies Yangming Cold-Damp with no Stomach heat; the stool is hard initially but loose subsequently, unlikely to be fully hardened. Purgation would cause diarrhea. "Xu" (须) means to wait. One must wait for the circulation of San Jiao (Triple Burner) Yang Qi, allowing Bladder Qi transformation and free urination. When Yang Qi is robust and water/grain separate, the stool will definitely harden, permitting purgation with Da Cheng Qi Tang.
[Correction of Misinterpretations] Commentators suggest that Stomach weakness obstructs the source of Bladder Qi transformation; this is likely incorrect. How can Bladder Qi transformation be blamed on the Stomach? The Classic states: "The Bladder is the Officer of the Metropolis, storing fluids; Qi transformation allows them to exit." It also states: "The San Jiao is the Officer of Ditches, governing water passages." Although the Bladder stores fluids, without the operational fire of the San Jiao, Qi transformation cannot occur. The San Jiao is the function of the Gate of Life (Ming Men), representing innate True Yang Qi, unrelated to postnatal Stomach weakness. Others claim that "can eat" and "cannot eat" in this passage are irrelevant to distinguishing Wind-Cold, proposing alternative meanings. Does Zhang Zhongjing’s legislation lack consistency, confusing future generations?
In Yangming disease, if delirium (Chan Yu, 谵语) and tidal fever occur with a slippery and rapid pulse, Xiao Cheng Qi Tang should be administered. Give one sheng of Cheng Qi Decoction. 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 (Wei Se, 微涩), this indicates interior deficiency, a difficult case to treat; do not administer Cheng Qi Decoction again.
Delirium and tidal fever in Yangming indicate pathogenic heat excess in the Stomach, suitable for purgation. A slippery pulse indicates food stagnation in the Stomach; a rapid pulse indicates excessive heat and extreme agitation, with unpredictable changes. Without a large/excess pulse, light purgation is contraindicated; thus, Da Cheng Qi Tang is not used, but Xiao Cheng Qi Tang is. Administer one sheng. If flatus occurs, it confirms Stomach excess-heat; administer another sheng to remove heat and stagnation. If no flatus occurs, there is no Stomach excess pathogen; do not give more. If the next day brings no bowel movement and the pulse turns faint and choppy, it indicates depletion of true Qi. Faint pulse indicates decline of True Yang; choppy pulse indicates exhaustion of Yin Qi. Both Yin and Yang are deficient, hence "interior deficiency." With interior deficiency, a shift from slippery/rapid to faint/choppy indicates excess pathogen and deficient righteous Qi, making it difficult to treat. Righteous Qi is failing; one must not further deplete deficiency. Thus, Cheng Qi Decoction is contraindicated.
In Yangming disease, after purgation, if there is profound discomfort (Ao Nu, 懊憹) and irritability: if dry fecal matter exists in the Stomach, purgation is indicated; if there is mild abdominal fullness with stool hard initially and loose subsequently, purgation is contraindicated. If dry fecal matter is present, Da Cheng Qi Tang is appropriate.
In the preceding Yangming section, purgation leading to an empty Stomach, disturbing guest Qi in the Diaphragm, causing Ao Nu and tongue coating, was treated with Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) rather than purgation. Similarly, purgation failing to form Jie Xiong (Chest Binding), with Ao Nu and hunger without desire to eat, was also treated with Zhi Zi Chi Tang. These cases involved floating-tight pulses, fever, and sweating, or exterior heat with only head sweating, resulting from erroneous purgation while exterior signs persisted. Although Jie Xiong had not formed, the pathogen had entered the Diaphragm; using the "high and venting" method, the pathogen was expelled via vomiting. In the current case, Yangming disease presents without exterior signs, indicating no exterior pathogen. Purgation performed without exterior signs, resulting in Ao Nu and irritability, suggests interior pathogenic heat. Observing pulse and signs: yellow-black tongue coating with tenderness on pressure, or large/deep/excess pulse, indicates dry fecal matter in the Stomach, warranting purgation. Mild abdominal fullness suggests concurrent Taiyin involvement and lack of severe interior heat; purgation would cause initial hardness and subsequent diarrhea, so it is contraindicated. If dry fecal matter is present as mentioned earlier, it is a Stomach Excess syndrome, requiring Da Cheng Qi Tang.
If a patient has no bowel movement for five or six days, experiences periumbilical pain, irritability, and periodic exacerbation, this indicates dry fecal matter causing the constipation.
No bowel movement for five or six days with periumbilical pain indicates dry fecal matter in the intestines and stomach. Irritability is caused by excess-heat stagnation. Periodic exacerbation refers to afternoon tidal fever. All interior signs of Yangming Stomach Excess are present, confirming dry fecal matter and causing constipation.
If a patient has difficulty urinating, intermittent difficulty and ease in defecation, occasional mild fever, wheezing, dizziness, and inability to lie down, this indicates dry fecal matter. Da Cheng Qi Tang is appropriate.
Difficulty urinating generally results from San Jiao dysfunction and failed Qi transformation. However, in this clause, it is different. Intestinal and gastric obstruction prevents the movement of Great Qi; internal heat stasis and fluid dryness cause the clear pathways to dry up. "Intermittent difficulty" refers to dry fecal binding; "intermittent ease" refers to paroxysmal leakage. Occasional mild fever is residual tidal fever. Wheezing indicates fullness in the middle and urgent Qi; dizziness indicates heat pathogen unable to descend, causing Qi steaming and oppression. Stomach pathogen excess and fullness cause restless wheezing and dizziness, preventing lying down, as stated in the Classic: "When the Stomach is not harmonious, sleep is disturbed." If the tongue shows yellow-black coating, tenderness on pressure, and a large/excess pulse, dry fecal matter is present internally; Da Cheng Qi Tang is appropriate.
After severe purgation, if there is no bowel movement for six or seven days, persistent irritability, and abdominal fullness/pain, this indicates dry fecal matter. Da Cheng Qi Tang is appropriate.
Severe purgation in Yangming Stomach Excess should remove pathogenic factors and food residue. If, after purgation, six or seven days pass without bowel movement, persistent irritability, and new abdominal fullness/pain, it indicates residual dry fecal matter. Further purgation is necessary; thus, Da Cheng Qi Tang is appropriate.
Sweating accompanied by delirium indicates dry fecal matter in the Stomach, caused by Wind. Purgation is required, but only after the pathogen has passed the channel (Guo Jing, 过经). Purgating too early will cause speech confusion due to exterior deficiency and interior excess. Purgation will cure the disease; Da Cheng Qi Tang is appropriate.
Yangming exterior signs naturally include sweating; Wind-Strike also involves spontaneous sweating. However, delirium with sweating indicates Stomach-Fu Excess-Heat, implying dry fecal matter in the Stomach. Wind is a Yang pathogen. This results from Taiyang Wind-Strike Yang pathogen transmitting to the Yangming Stomach-Fu, hence "this is Wind." Dry fecal matter in the Stomach requires purgation, but only after "passing the channel." "Passing the channel" does not mean waiting ten-plus days or thirteen days; it means Taiyang exterior pathogen has ceased, and the pathogen has passed the Yangming channel, entering the interior with Stomach Excess. If Taiyang signs persist, purgation is contraindicated; even if Yangming channel pathogen has not entered the interior, immediate purgation is contraindicated. Early purgation weakens Stomach Qi, allowing exterior pathogen to sink inward, causing severe heat, coma, and speech confusion. Exterior pathogen sinks entirely into the interior, leaving the exterior empty and interior full of pathogen, termed "Exterior Deficiency, Interior Excess." Once the pathogen fully enters the interior and heat excesses in the Stomach, purgation cures the disease; Da Cheng Qi Tang is appropriate.
In Yangming disease, if delirium and tidal fever occur with an inability to eat, there must be five or six pieces of dry fecal matter in the Stomach. If the patient can eat, the stool is merely hard. Da Cheng Qi Tang is appropriate.
This clause illustrates flexible application; one should not rigidly judge based on appetite to avoid misdiagnosing Wind-Strike vs. Cold-Damage. Yangming disease with delirium and tidal fever indicates heat excess in the Stomach. The inability to eat resembles Yangming Cold-Damp, hence "reversely" (Fan, 反). Why the inability to eat? If truly Cold-Damage, there would be signs of Stomach deficiency-cold as described in Cold-Damage clauses. Here, delirium and tidal fever result from Stomach fullness/excess, causing anorexia, indicating five or six pieces of dry fecal matter. If the patient can eat, the Stomach has not reached extreme fullness; the stool is merely hard. However, hardness still warrants purgation; thus, Da Cheng Qi Tang is appropriate for both.
In cold damage, if emesis or purgation fails to resolve the condition, and there is no bowel movement for five or six days, extending to ten-plus days, with afternoon tidal fever, absence of aversion to cold, and solitary muttering as if seeing ghosts: if severe, the patient may lose recognition, grasp at clothes, rub the bed, feel terrified and uneasy, have mild wheezing, and fixed staring eyes. A wiry (Xian, 弦) pulse indicates survival; a choppy (Se, 涩) pulse indicates death. If mild, only fever and delirium occur; Da Cheng Qi Tang is appropriate. If one dose causes bowel movement, stop subsequent doses.
Cold damage protocol dictates initial diaphoresis. The text mentions resolution failure after emesis/purgation, indicating missed diaphoresis and erroneous emesis/purgation, causing exterior pathogen to sink inward. Entering the interior with no bowel movement for five-six days traps heat internally; extending to ten-plus days deepens the heat. "Ri Bu" (Afternoon) refers to Shen/You hours (3-7 PM), when Yangming Qi is vigorous. Tidal fever is a Yangming interior sign, indicating the need for purgation. Absence of aversion to cold is a Yangming fundamental sign, indicating no exterior pathogen. Solitary muttering is delirious speech. "Seeing ghosts" results from intense heat blocking downward flow, turbid pathogen pressing upward, clouding the eyes and spirit, causing hallucinations. "Severe" means critical illness. "Fa" (Attack/Onset) refers to发作 times. During critical onset, pathogenic heat rages, blocking clear orifices, depriving intelligence, and disturbing the mind, causing loss of recognition. "Xun Yi" (Grasping clothes) and "Mo Chuang" (Rubbing bed) describe aimless hand movements. "Ti Er Bu An" (Terrified and uneasy) matches the Classic: "Illness makes one dislike people and fire; hearing wood sounds causes terror." "Mild wheezing" is shortness of breath with weak respiration. "Fixed staring" is immobile gaze. *Su Wen* states: "The Heart is the essence of the Five Zang; the Eye is its orifice... Spirit guards inward, vision clarifies outward." Heat excess deprives the spirit. *Jin Gui Zhen Yan Lun* states: "East, Green, connects to Liver, opens to Eyes." Fixed staring indicates impending Liver Qi exhaustion. Wiry pulse belongs to Liver; wiry indicates surviving Shaoyang life Qi and functioning San Jiao true Qi, with vigorous force, indicating survival. If wiry like a newly strung bow, it is a True Zang pulse of extinction, possibly fatal. Choppy pulse belongs to Yin; choppy indicates Yin exhaustion, Yang pathogen burning essence and marrow, indicating death. Critical cases present thus. Mild cases involve only fever and delirium; Da Cheng Qi Tang is appropriate. If heat is mild and one dose induces bowel movement, stop subsequent doses.
In Yangming disease, if there is fever and profuse sweating, urgent purgation is required; Da Cheng Qi Tang is appropriate.
Tidal fever and spontaneous sweating are fundamental Yangming Stomach Excess signs. "Profuse sweating" exceeds normal Yangming sweating. Profuse sweating exhausts fluids and drives Wei Yang outward, risking Yang collapse instantly. Urgent purgation preserves Yang Qi and fluids; thus, Da Cheng Qi Tang is appropriate. However, pulse and signs must be correlated. If pathogen is in the channel with fever/profuse sweating, but Stomach pathogen is not excess and tongue coating is not dry/thick/yellow-black, purgation is contraindicated.
If diaphoresis fails to resolve the condition and abdominal fullness/pain occurs, urgent purgation is required; Da Cheng Qi Tang is appropriate.