曰可攻。不过用小承气调胃承气法耳。必手足 然汗出。方可验胃实便硬外邪尽解。而当从大承气
急下之法也。申酉戌间独热。余时不热者。为潮热。若汗出微发热恶寒。是阳明症尚兼太阳。纵腹
大满。胃终不实。只可微和胃气以从权而已。
【纲】仲景曰。阳明病。谵语。发潮热。脉滑而疾者。小承气汤主之。因与承气汤一升。腹中
转失气者。更服一升。若不转失气者。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。
【目】柯琴曰。脉滑而疾。有宿食也。明日仍不大便。脉反微涩。微则无阳。涩则少血。此为
里虚。故阳症反见阴脉也。然
胃家未实。阴脉尚多。故脉迟脉弱者。始可和而久可下。阳脉而变为阴脉者。不惟不可下。更不可
和。脉滑者生。脉涩者死。故为难治。然滑有不同。又当详明。夫脉弱而滑。是有胃气。此脉来滑
疾。是失其常度。重阳必阴。仲景早有成见。故少与小承气试之。若据谵语潮热而与大承气。阴盛
已亡矣。此脉症之假有余。小试之而即见真不足。凭脉辨症。可不慎哉。
【纲】仲景曰。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。大承气汤主之。若一服利。止后服。
【目】张兼善曰。此本坏病也。但不可不辨其微剧。微者是邪气实。当以下解。一服利者止后
服。只攻其实。毋乘其虚也。剧者。邪正交争也。当以脉断其虚实。弦者是邪气实。不失为下症。
故生。涩者是正气虚。不可更下。故死。
【纲】仲景曰。脉滑而数者。有宿食也。当下之。宜大承气汤。
【目】龚信曰。数为在腑。故滑为有食。数以至数言。是本来面目。疾以体状言。在谵语潮热
时见。故为失度。
【纲】仲景曰。病患烦热。汗出则解。又如疟状。日晡所发热者。属阳明也。脉实者。宜下之。
与承气汤。
【目】柯琴曰。烦热自汗。似桂枝症。寒热如疟。似柴胡症。然日晡潮热。则属阳明。而脉已
沉实。确为可下。是承气主症主脉也。
【纲】仲景曰。得病二三日。脉弱。无太阳柴胡症。烦躁心下硬。至四五日。虽能食。以小承气
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。
【目】王肯堂曰。二三日尚在三阳之界。脉弱者。无阳故也。无阳者。无太阳桂枝症。无少阳
柴胡症也。如是则病不在
表。而阳邪入阴。病在阳明之里也。七日后乃可攻者。以脉弱是太阳中风。能食是阳明中风。以此
为风也。
If it is stated that purgation can be used, it merely involves the methods of Xiao Cheng Qi Tang (Minor Order the Intestines Decoction) or Tiao Wei Cheng Qi Tang (Regulate the Stomach Order the Intestines Decoction). Only when there is continuous sweating on the hands and feet can one verify that the stomach is full of heat, the stool is hard, and the external pathogens have completely resolved; at this point, the method of urgent purgation with Da Cheng Qi Tang (Major Order the Intestines Decoction) should be adopted. If fever occurs exclusively between Shen, You, and Xu hours (3 PM to 9 PM) but not at other times, this is termed tidal fever (Chao Re). If accompanied by sweating, slight fever, and aversion to cold, it indicates that the Yangming syndrome still coexists with Taiyang syndrome. Even if the abdomen is severely distended, the stomach has ultimately not formed excess heat; one can only slightly harmonize the stomach qi as a temporary measure.
[Gang] Zhang Zhongjing said: In Yangming disease, if there is delirium (Dan Yu), tidal fever, and a slippery and rapid pulse, Xiao Cheng Qi Tang (Minor Order the Intestines Decoction) is the primary treatment. Therefore, administer one sheng of Cheng Qi Tang. If gas moves in the abdomen after taking the medicine, administer another sheng; if there is no movement of gas, 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, which is difficult to treat, and Cheng Qi Tang should not be administered again.
[Mu] Ke Qin said: A slippery and rapid pulse indicates the presence of retained food stagnation. If there is still no bowel movement the next day and the pulse becomes faint and choppy, a faint pulse indicates lack of yang, and a choppy pulse indicates scant blood; this constitutes interior deficiency, hence an yang syndrome presents with yin pulses. However, if the stomach house is not yet solid and yin pulses are still predominant, then when the pulse is slow or weak, gentle harmonization may be used, and purgation may be considered for chronic conditions. If yang pulses transform into yin pulses, not only is purgation contraindicated, but gentle harmonization is also contraindicated. A slippery pulse indicates survival, while a choppy pulse indicates death; thus, it is described as difficult to treat. Nevertheless, "slippery" pulses vary and must be clarified in detail. A weak yet slippery pulse indicates the presence of stomach qi; however, a pulse that comes in a slippery and rapid manner has lost its normal rhythm. Extreme yang transforms into yin, and Zhang Zhongjing had this insight early on. Therefore, a small amount of Xiao Cheng Qi Tang (Minor Order the Intestines Decoction) is given as a test. If one were to administer Da Cheng Qi Tang (Major Order the Intestines Decoction) based solely on delirium and tidal fever, yin excess would lead to yang exhaustion. This represents a false appearance of excess in pulse and symptoms, which reveals true deficiency upon minor testing. Relying on pulse to differentiate symptoms, how can one not be cautious?
[Gang] Zhang Zhongjing said: After Shanghan (Cold Damage) has been treated with emesis or purgation, if the condition remains unresolved, with no bowel movement for five to six days up to ten-plus days, tidal fever occurs during Dubu time (3 PM to 5 PM), without aversion to cold, and the patient speaks alone as if seeing ghosts. If severe, the patient may become unrecognizable during episodes, grasp clothing and bed rails, feel terrified and uneasy, exhibit slight panting, and stare fixedly. A string-like (Xian) pulse indicates survival, while a choppy (Se) pulse indicates death. In mild cases, there is only fever and delirium, treated with Da Cheng Qi Tang (Major Order the Intestines Decoction). If relief occurs after one dose, stop subsequent doses.
[Mu] Zhang Jianshan said: This originally belongs to Huai Bing (complicated disease due to mismanagement). However, one must distinguish between mild and severe cases. Mild cases involve excess pathogenic factors, which should be resolved through purgation. Stopping after one dose of relief prevents further damage to deficiency while attacking excess. Severe cases involve struggle between pathogenic factors and healthy qi; the pulse should be used to determine deficiency or excess. A string-like pulse indicates excess pathogenic factors, making it suitable for purgation, hence survival. A choppy pulse indicates deficiency of healthy qi, making further purgation contraindicated, hence death.
[Gang] Zhang Zhongjing said: When the pulse is slippery and rapid, it indicates retained food stagnation, which should be purged using Da Cheng Qi Tang (Major Order the Intestines Decoction).
[Mu] Gong Xin said: "Rapid" refers to frequency, describing its fundamental nature; "swift" refers to the physical quality. Seeing these pulses during delirium and tidal fever indicates loss of normal rhythm.
[Gang] Zhang Zhongjing said: If patients experience vexatious heat, relief follows sweating, yet symptoms resemble malaria with alternating chills and fever, and fever occurs at Dubu time, it belongs to Yangming. If the pulse is excess (Shi), purgation is appropriate, administering Cheng Qi Tang.
[Mu] Ke Qin said: Vexatious heat with spontaneous sweating resembles Guizhi Tang (Cinnamon Twig Decoction) syndrome; chills and fever resembling malaria resembles Chaihu Tang (Bupleurum Decoction) syndrome. However, tidal fever at Dubu time belongs to Yangming, and the pulse is already deep and excess, confirming suitability for purgation; these are the main symptoms and pulses for Cheng Qi Tang.
[Gang] Zhang Zhongjing said: Two to three days after contracting disease, if the pulse is weak, without Taiyang or Shaoyang symptoms, but with restlessness and hardness in the epigastrium, progressing to four to five days, even if the patient can eat, give Xiao Cheng Qi Tang (Minor Order the Intestines Decoction) in small amounts frequently to mildly harmonize the stomach qi, allowing slight comfort. By the sixth day, administer one sheng of Cheng Qi Tang. If there is still no bowel movement, and from the sixth to seventh day urine output is low, even if the patient cannot eat, if the stool is hard at the beginning but loose later, it has not definitively hardened; purging will cause loose stools. One must wait for free urination and definitive hardening of the stool before purging, using Da Cheng Qi Tang (Major Order the Intestines Decoction).
[Mu] Wang Kentang said: Two to three days after onset is still within the realm of the Three Yang meridians. A weak pulse indicates absence of yang. Absence of yang means absence of Taiyang Guizhi Tang (Cinnamon Twig Decoction) syndrome and Shaoyang Chaihu Tang (Bupleurum Decoction) syndrome. Thus, the disease is not in the exterior, but yang pathogens have entered the interior, residing in the interior of Yangming. Purging can only be done after seven days because a weak pulse suggests Taiyang wind-stroke, and ability to eat suggests Yangming wind-stroke, identifying the pathogen as wind.