阳明病。不吐不下心烦者。可与调胃承气汤（此条言阳明病。亦胃家实之证。不吐不下者。谓热邪上不得越下不得
泄也。热郁胃府之中。其气必上熏于膈。则心烦。烦闷而热也。阳明病。但心烦。为下证未全具。故以调胃承气汤。下
其实热。和其胃气。）
（此方自原论中第二卷移附于此）
大黄（四两去皮。清酒浸） 甘草（二两炙） 芒硝（半升）
上三味。 咀。以水三升。煮取一升。去滓。内芒硝。更上火。微煮令沸。少少温服之。
成注引内经曰。热淫于内。治以咸寒。佐以苦甘。芒硝咸寒以除热。大黄苦寒以荡实。甘草甘平。助二物推陈而缓
中。承气汤方义。注见后汤方下。
王海藏云。大黄泄实芒硝软坚。甘草和中。上汤必燥实坚三证全者。可用。愚按和中二字。即是调胃之意。
内台方议问曰诸下泄方中。皆不用甘草。独此汤中。复用甘草何也。答曰。诸下泄方。乃下大实大热之证。速如星
火。甘草能缓诸药。是以去也。独此方中。乃调和胃气。故用甘草以缓其中也。或问云。胃喜温暖。故凡温暖之药。可
称调胃。上方中用硝黄咸苦大寒。止炙甘草一味温暖。反少用之。何也。余答云。胃以温暖。为适中。所以胃犯大热之
气。则太过而不调。犯大寒之气。则不及而亦不调。今者。胃有郁热而烦。是太过也。故方中专藉甘草。引硝黄泻胃中。
有余之热。调和其气而使之平。调胃之名。正以此也。今医于上方中。甘草多用生者。此亦是泻有余之义。
（附例）发汗后恶寒者。虚故也。不恶寒但热者。实也。当和胃气。与调胃承气汤。（此条病。系太阳伤寒发汗之后。
恶寒之证当解。其不解者。乃汗多亡阳。表气虚故也。汗后不恶寒而但热者。此为邪已离表。尽入于里。胃气燥热。乃
里实之证也。成注引经云。汗出不恶寒者。此表解里未和。与调胃承气汤。以和胃气。按此条论言虚证。补亡论郭白云
云。宜芍药甘草附子汤。此因原论中。前条。有发汗病不解。反恶寒者。为营卫俱虚。乃阴寒之证。误发其汗所致。仲
景法。用芍药甘草附子汤主之。今者发汗恶寒。证虽相同。未必是真寒证。此汤恐不宜用。当以黄 建中汤主之。）
伤寒十三日不解。过经谵语者。以有热也。当以汤下之。若小便利者。大盒饭硬。而反下利。脉调和者。知医以丸
药下之。非其治也。若自下利者。脉当微厥。今反和者。此为内实也。调胃承气汤主之。（此条病本系太阳伤寒。延至十
三日不解是为过经。过经者谓六经传。尽病已过而不愈也。有如太阳病。一日受者。六日当解。传至厥阴。六日受病。
当十二日解。所以伤寒家。相传十三日不解者。不论病自何经而起。曾传变六经与否。统谓之过经也。成注云。再传经
尽。谓之过经。余于太阳上编。已辩其非。谵语者。自言也。寒邪郁里。胃中有热。热气熏膈。则神昏而自言也。谵语
有热。法当以汤荡涤之。若小便利者。津液偏渗。大盒饭坚硬而不出。今反下利。及诊其脉。又调和而非自利之脉。知
医非其治。而以丸药下之也。若其人不因误下而自利者。其脉当微而手足见厥。此为内虚。不可下也。今脉反和。反和
者。言其脉与阳明府证不相背之意。若脉果调和。则无病矣。此为内实。故见谵语下利等证。与调胃承气汤者。以下胃
中之实热也。或问既下利矣。则大便未必燥坚。何以汤中复用芒硝。余答云。谵语有热。是有燥屎。医用丸药。下之太
缓。肠中坚实之物不能去。所下者。旁流溏垢耳。据仲景法。下利谵语者。有燥屎也。宜小承气汤。今改用调胃者。以
医误下之故。内实不去。胃气徒伤。故于小承气汤。去浓朴枳实。而加甘草。以调和之也。因大便坚实。以故复加芒硝。）
太阳病过经十余日。心下温温欲吐。而胸中痛。大便反溏。腹微满。郁郁微烦。先此时自极吐下者。与调胃承气汤。
若不尔者。不可与。但欲呕胸中痛。微溏者。此非柴胡证。以呕故知极吐下也。（此条病。亦系太阳伤寒。至十余日。病
为过经。心下温温欲吐。温温者热气泛沃之状。欲吐而不能吐。则其为干呕。可知矣。胸中痛者。膈以内实也。胸痛当
责邪热。结于胃中。而大便应硬。今则反溏。大便溏。则气下泄。腹不应满。今则微满。郁郁微烦者。腹满热聚而冲于
膈也。以上见证。殆有故焉。必先其时极吐极下所致。极吐。则胃脘受伤。故胸中痛。极下。则直肠不禁。故大便溏。
既吐且下。而心中温温然。仍欲吐。腹仍微满。郁郁然生烦。此为胃气虽伤。邪热结实。不因吐下而去也。法宜与调胃
承气汤下之。若不因极吐下者。则欲吐胸痛等候。邪犹在经。承气汤不可与也。要之病邪在经。此亦非柴胡汤证。以柴
胡证之呕。必口苦。此不口苦。是太阳风气上壅也。柴胡证之胸痛。必连胁。此不胁痛。是阳明郁热留经也。其微溏而
下利者。乃太阳阳明合病。当是葛根汤证。其非柴胡证明矣。今以呕甚。故知胃中实热。自极吐下而作呕。其当与调胃
承气。的确无疑。按上云。此非柴胡证。则是但呕胸痛微溏者。仲景法还宜用葛根加半夏汤也。补亡论郭白云云。宜大
半夏加橘皮汤。或问云。极吐。则胃气受伤。固宜用调胃承气矣。极下而大便溏。何以不去芒硝。余答云。极吐。则胃
中水去而津液亡。大便溏。则旁流之物已尽。肠中燥屎愈坚。焉得不用芒硝。所以调胃承气。为不可易之剂。上三条证
自太阳中篇移附于此。）
太阳病三日。发汗不解蒸蒸发热者属胃也。调胃承气汤主之。（上数条言太阳病。皆过经不解而后下之。此条言太阳
病。不可拘以日数。但见属胃之证。即可下也。有如太阳病方三日。曾发过汗矣。其不解者。非表邪不解。乃病热不能
解也。太阳病止翕翕发热。明知其热在外。今变而为蒸蒸发热。蒸者。熏也。炊也。火气上升之貌。条辩云。其热自内。
腾达于外。如蒸炊然。此系太阳之邪。转属于胃。经云。已入于府者。可下而已与调胃承气汤者。以下证。未全具。故
大承气中止用硝黄。复加甘草。以调其中而下其实热也。或问太阳病暂三日。胃中何由而实。大便何由而硬。余答云。
尚论篇云。其热蒸蒸。势必至其汗 。汗出过多。则胃中燥实。大便必硬。但下证未急。故用调胃承气汤。缓以攻之
也。）
伤寒吐后。腹胀满者。与调胃承气汤。（此条承上文而言。伤寒虽不指何经。大都是太阳病。既吐之后。则胸中热邪
得越。表证亦随之而解。以吐中有发散之义故也。今者。既吐之后。腹复胀满。是邪热不因吐解。留结于胃。而为里实
之证。无疑矣。与调胃承气汤者。以吐后胃气受伤。不得不调之。以缓下其实也。或问治胀满。莫如浓朴枳实。何以不
用大小承气。今者。调胃承气中去枳朴。反加甘草。经云。中满者。勿食甘。其汤不与病相左邪。余曰。不然。伤寒既
经吐后。则胸中之实已去。其腹胀满者。实热在胃之下脘也。若用枳朴。与病无与。徒伤其上焦之阳气。且甘草虽能作
满。亦能引泻满之药。直至胀满之所。以导去其实热。所以调胃承气汤中用甘草者。其佐硝黄。而泻满之功更神。非俗
医所能拟议也。上二条证自本篇麻仁丸后移附于。此总按上五条证。皆系太阳病。今入阳明篇者。以其病自太阳经起。
转属阳明。胃府实热。乃太阳阳明也。故俱入阳明篇中。）
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 然而汗出
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。（阳明病脉当大。或长。今则脉迟。脉迟义。注见前。脉迟。虽汗出。惟不恶寒
者。此为外欲解。盖汗出。与下汗多相照应。汗出为表已解。然汗出多。亦有表未解者。故云。虽汗出。必以不恶寒为
表证罢也。身必重者。阳明主肌肉。邪在表之阳。则身轻易以转侧。入里之阴。则身重也。短气者。气实促急也。腹满
而喘。此因满而致喘。皆里实可攻之证。然亦必有潮热者。为外证确乎欲解。里证确乎可攻。否则虽汗出身重。短气。
腹满而喘。据脉迟而言。恐非实热之证。不可攻也。其热既潮。手足又 然而汗出。手足汗出者。胃中郁热亢甚。蒸发
于四肢之间。汗去则津液燥。此大便已硬也。成注云。与大承气汤。以下胃热。若其人汗出多。肌表间微发热而恶寒者。
外未解也。不可攻里。即不恶寒而热不潮者。胃未全实。大便未硬。虽可攻里。未可与大承气汤。若其人腹大满。大便
不通者。止可与小承气汤。微和胃气。而使之平。勿令大泄下者。盖言病有缓急。治有轻重。医者当知通变之法也。）
Yangming disease. If there is mental restlessness (xin fan, irritability and vexation) without prior emesis or purgation, Tiaowei Chengqi Decoction (Stomach-Regulating Purging Decoction) may be administered. (This clause discusses Yangming disease, which also belongs to the syndrome of "stomach house excess" (weijia shi, accumulation of heat and dryness in the stomach and intestines). The phrase "without emesis or purgation" means that the pathogenic heat cannot escape upward through vomiting nor downward through diarrhea. The heat stagnates within the stomach fu organ, and its qi necessarily steams upward to the diaphragm, causing mental restlessness, characterized by vexation and heat. In Yangming disease, if only mental restlessness is present, it indicates that the indications for purgation are not yet fully established; therefore, Tiaowei Chengqi Decoction is used to purge the excess heat and harmonize the stomach qi.)
(This formula was moved from Volume II of the original treatise and attached here.)
Dahuang (Rhei Radix et Rhizoma, 4 liang, peeled, soaked in clear wine)
Gancao (Glycyrrhizae Radix et Rhizoma, 2 liang, honey-fried)
Mangxiao (Natrii Sulfas, half sheng)
The above three ingredients are coarsely crushed. Boil with three sheng of water to obtain one sheng of decoction. Strain out the dregs, add Mangxiao, and boil gently over fire until boiling. Take warm in small amounts frequently.
Cheng Wuji's commentary cites the *Neijing*: "When heat invades internally, treat with salty-cold substances, assisted by bitter-sweet ones." Mangxiao is salty and cold to eliminate heat; Dahuang is bitter and cold to sweep away excess; Gancao is sweet and neutral, assisting the other two to push out the old and generate the new while moderating the middle jiao. The rationale of the Chengqi Decoctions is noted under the subsequent formulas.
Wang Haicang stated: Dahuang purges excess, Mangxiao softens hardness, and Gancao harmonizes the middle. The aforementioned decoction should only be used when all three syndromes of dryness, excess, and hardness are present. My analysis notes that the term "harmonizing the middle" (he zhong) is precisely the meaning of "regulating the stomach" (tiao wei).
*Neitai Fangyi* asks: Among purgative formulas, Gancao is generally omitted, yet it is used again in this formula. Why? The answer is: The various purgative formulas address severe excess and heat syndromes where urgency is like a spark; Gancao can delay the action of other herbs, hence it is removed. Only in this formula is it used to harmonize stomach qi, thus employing Gancao to moderate the middle. One might ask: The stomach prefers warmth, so warming herbs are called "stomach-regulating." This formula uses Xiaohuang (Mangxiao and Dahuang), which are salty, bitter, and greatly cold, using only one warming herb, Gancao, in a small amount. Why? I reply: The stomach's ideal state is warmth. When invaded by excessive heat, it becomes too much and unharmonious; when invaded by excessive cold, it becomes too little and also unharmonious. Now, with stagnant heat in the stomach causing vexation, this represents excess. Therefore, the formula relies specifically on Gancao to guide Mangxiao and Dahuang to drain the excess heat from the stomach, harmonizing its qi to achieve balance. The name "Regulating Stomach" derives from this principle. Modern physicians often use raw Gancao in this formula, which also aligns with the principle of draining excess.
(Attached Example) After sweating therapy, if chills occur, it is due to deficiency; if there are no chills but only fever, it is due to excess. One should harmonize the stomach qi and administer Tiaowei Chengqi Decoction. (This condition arises after sweating therapy for Taiyang cold damage. The chills should have resolved; if they persist, it is due to excessive sweating leading to loss of yang qi and deficiency of exterior qi. If after sweating there are no chills but only fever, it indicates the pathogen has left the exterior and entered the interior, resulting in dry-heat in the stomach, a interior excess syndrome. Cheng Wuji cites the classic: "Sweating without chills indicates the exterior is resolved but the interior is not harmonized"; administer Tiaowei Chengqi Decoction to harmonize stomach qi. Regarding the discussion of deficiency syndromes, Guo Baiyun in *Buwang Lun* suggests Shaoyao Gancao Fuzi Decoction. This is because the preceding clause mentions "sweating therapy fails to resolve the disease, with recurring chills," indicating dual deficiency of ying and wei, a yin-cold syndrome caused by erroneous sweating. Zhang Zhongjing's method uses Shaoyao Gancao Fuzi Decoction. Although the current presentation of chills after sweating appears similar, it may not be a true cold syndrome; this formula is likely inappropriate. Huangqi Jianzhong Decoction should be used instead.)
Cold damage persists for thirteen days without resolution. If delirium (zanyu, confused speech) occurs after passing through the meridians, it is due to heat, and a decoction should be used to purge. If urination is free, the stool should be hard; if diarrhea occurs instead, and the pulse is harmonious, it indicates the physician erroneously used pill-based purgatives, which is incorrect treatment. If the patient has spontaneous diarrhea, the pulse should be faint or extremities cold; if the pulse is now harmonious, it indicates internal excess, treated with Tiaowei Chengqi Decoction. (This condition originally belonged to Taiyang cold damage. Persisting for thirteen days without resolution is termed "passing through the meridians" (guojing). "Passing through the meridians" means the six meridians have completed their transmission cycle, and the disease has passed its expected duration without healing. For example, Taiyang disease contracted on day one should resolve by day six; if transmitted to Jueyin, contracted on day six, it should resolve by day twelve. Thus, in cold damage literature, persistence beyond thirteen days is termed "passing through the meridians" regardless of the starting meridian or transmission status. Cheng Wuji notes: Completing the transmission twice is called "passing through the meridians." I have refuted this in the Taiyang section. Delirium refers to incoherent speech. Cold pathogens stagnate internally, generating heat in the stomach; this heat steams to the diaphragm, causing mental confusion and self-talk. Delirium with heat requires purgation with decoctions. If urination is free, fluids are diverted, and stool should be hard. If diarrhea occurs instead, and the pulse is harmonious rather than indicative of spontaneous deficiency-diarrhea, it reveals the physician's error in using pill purgatives. If the patient had spontaneous diarrhea without erroneous purgation, the pulse would be faint with cold extremities, indicating internal deficiency, contraindicating purgation. The current "harmonious" pulse means it does not contradict the Yangming fu syndrome. A truly harmonious pulse implies health; here, it signifies internal excess, manifesting as delirium and diarrhea. Tiaowei Chengqi Decoction is given to purge gastric excess heat. One asks: If diarrhea has occurred, stool need not be dry-hard; why add Mangxiao? I reply: Delirium with heat indicates dry fecal impaction. The physician's pill purgative acted too slowly, failing to remove solid matter from the intestines; what was expelled was merely paralytic loose stool. According to Zhang Zhongjing's method, diarrhea with delirium indicates dry fecal impaction, warranting Xiao Chengqi Decoction. The switch to Tiaowei Chengqi Decoction here is due to the physician's erroneous purgation failing to remove internal excess while damaging stomach qi. Thus, Houpo and Zhishi are removed from Xiao Chengqi Decoction, and Gancao is added to harmonize. Due to the firm stool, Mangxiao is re-added.)
Taiyang disease lasting over ten days, with epigastric nausea, chest pain, loose stools, slight abdominal fullness, and mild vexation. If these symptoms followed extreme emesis or purgation, administer Tiaowei Chengqi Decoction. If not, do not administer. Mere desire to vomit, chest pain, and loose stools do not constitute Chaihu syndrome; the vomiting indicates prior extreme emesis or purgation. (This condition is Taiyang cold damage persisting over ten days, termed "passing through the meridians." Epigastric nausea ("wun wun") describes the sensation of heat surging; the inability to vomit indicates dry heaving. Chest pain indicates internal excess at the diaphragm. Chest pain is attributed to pathogenic heat knotting in the stomach; stool should be hard, but is now loose. Loose stool implies descending qi, so abdominal fullness should not occur, yet it is present. Mild vexation results from heat accumulation in the abdomen steaming to the diaphragm. These signs suggest a cause: prior extreme emesis and purgation. Extreme emesis injures the stomach wall, causing chest pain; extreme purgation causes rectal incontinence, leading to loose stool. Despite emesis and purgation, persistent epigastric nausea, slight abdominal fullness, and vexation indicate that although stomach qi is injured, pathogenic heat remains entrenched and was not expelled by emesis or purgation. The method warrants Tiaowei Chengqi Decoction to purge. If not caused by extreme emesis/purgation, the symptoms suggest the pathogen remains in the meridians, and Chengqi Decoctions are contraindicated. Ultimately, with pathogen in the meridians, this is not Chaihu syndrome either. Chaihu syndrome vomiting accompanies bitter taste; absence of bitter taste indicates Taiyang wind-qi rising. Chaihu syndrome chest pain radiates to the flanks; absence of flank pain indicates Yangming stagnant heat lingering in the meridians. The loose stool/diarrhea suggests Taiyang-Yangming combined disease, warranting Gegen Decoction, clearly ruling out Chaihu syndrome. Given severe vomiting, gastric excess heat arising from prior extreme emesis/purgation is confirmed, making Tiaowei Chengqi Decoction undoubtedly appropriate. As stated earlier, "not Chaihu syndrome," mere vomiting, chest pain, and loose stools should technically be treated with Gegen Banxia Decoction per Zhang Zhongjing. Guo Baiyun in *Buwang Lun* suggests Banxia Tianma Decoction variant. One asks: Extreme emesis injures stomach qi, justifying Tiaowei Chengqi Decoction; extreme purgation leads to loose stool, why keep Mangxiao? I reply: Extreme emesis depletes stomach fluids and body fluids; loose stool indicates paralytic discharge is exhausted, leaving dry fecal impaction harder in the intestines. How can Mangxiao be omitted? Thus, Tiaowei Chengqi Decoction is an irreplaceable formula. The above three clauses were moved from the Taiyang middle section.)
Taiyang disease for three days, unresolved after sweating, with continuous fever (zhengzheng re) belongs to the stomach; Tiaowei Chengqi Decoction governs. (The previous clauses discuss Taiyang disease requiring purgation only after passing through meridians. This clause states Taiyang disease purgation depends on symptoms, not days. If stomach syndromes appear, purgation is indicated. For instance, Taiyang disease for three days, post-sweating, unresolved: this is not failure to resolve exterior pathogens, but inability to resolve pathological heat. Taiyang disease typically presents with mild fever (xixi re), known to be exterior. Transformation into continuous fever (zhengzheng re)—"zheng" means steaming/cooking, heat rising—is pathogen transferring from Taiyang to the stomach. The classic states: "Once entered the fu organs, purgation is possible." Tiaowei Chengqi Decoction is used because the purgative indications are not fully established; unlike Da Chengqi Decoction which uses only Mangxiao and Dahuang, this adds Gancao to harmonize the middle while purging excess heat. One asks: How can the stomach become excess and stool hard after only three days of Taiyang disease? I reply: *Shanglun Pian* states: Continuous fever inevitably leads to sweating; excessive sweating causes gastric dryness and excess, making stool hard. However, since the purgative urgency is low, Tiaowei Chengqi Decoction is used to attack gently.)
After cold damage emesis, if abdominal fullness occurs, administer Tiaowei Chengqi Decoction. (This follows the previous context. Although "cold damage" doesn't specify the meridian, it is mostly Taiyang. After emesis, thoracic heat escapes, and exterior symptoms resolve, as emesis has a dispersing nature. Now, post-emesis, abdominal fullness indicates pathogenic heat did not resolve with emesis but remained knotted in the stomach as an interior excess syndrome. Tiaowei Chengqi Decoction is given because emesis injures stomach qi, necessitating regulation to gently purge excess. One asks: For fullness, Houpo and Zhishi are best; why not use Da or Xiao Chengqi Decoction? Why remove Zhishi/Houpo and add Gancao? The classic says "fullness in the middle prohibits sweet foods"; does this formula contradict the pathology? I say: No. Post-emesis, thoracic excess is gone; abdominal fullness indicates excess-heat in the lower stomach. Using Houpo/Zhishi would be irrelevant and damage upper jiao yang qi. Although Gancao can cause fullness, it also guides purgative herbs to the site of fullness to drain excess heat. Thus, Gancao in Tiaowei Chengqi Decoction assists Mangxiao/Dahuang in resolving fullness more effectively, a insight beyond common physicians. The above two clauses were moved from the Mahuang Wan section. Summarizing the five clauses: all originate from Taiyang disease but are placed in the Yangming chapter because they start in Taiyang and transfer to Yangming, involving stomach fu excess-heat (Taiyang-Yangming). Hence, they are included in the Yangming chapter.)
Yangming disease with slow pulse (chi), sweating, and aversion to cold absent, will present with heavy body, shortness of breath, abdominal fullness, and wheezing. If tidal fever (chao re) is present, the exterior is resolving, and interior purgation is permissible. If sweat flows continuously from hands and feet, stool is hard; Da Chengqi Decoction governs. If sweating is profuse with slight fever and aversion to cold, the exterior is unresolved; if fever is not tidal, Chengqi Decoctions are contraindicated. If abdominal distension and obstruction are severe, Xiao Chengqi Decoction may be used to mildly harmonize stomach qi, avoiding drastic purgation. (Yangming pulse should be large or long; a slow pulse is noted here, see previous explanation. Slow pulse with sweating and no aversion to cold indicates exterior resolution. Sweating corresponds to the later mention of profuse sweating; sweating indicates exterior resolution, though profuse sweating can sometimes leave exterior unresolved. Thus, "sweating" alone is insufficient; absence of aversion to cold confirms exterior resolution. Heavy body: Yangming governs muscles; exterior pathogen allows easy movement, while interior pathogen causes heaviness. Shortness of breath: excess qi causing急促 breathing. Abdominal fullness and wheezing result from fullness causing respiratory distress; these are interior excess indications. However, tidal fever must be present to confirm exterior resolution and interior readiness for purgation. Otherwise, despite sweating, heaviness, shortness of breath, and fullness, the slow pulse suggests non-excess-heat, contraindicating purgation. With tidal fever and continuous hand/foot sweating, stomach heat is intense, evaporating to limbs; fluid loss leads to hard stool. Cheng Wuji notes: Da Chengqi Decoction purges gastric heat. If profuse sweating with slight fever/chills, exterior is unresolved, contraindicating interior purgation. If no chills but non-tidal fever, stomach is not fully excess, stool not hard; although interior purgation is possible, Da Chengqi Decoction is premature. If severe abdominal distension and obstruction, Xiao Chengqi Decoction is appropriate to mildly harmonize stomach qi. "Avoid drastic purgation" emphasizes that disease severity varies, requiring flexible treatment strategies.)