太阳病。若吐若下若发汗。微烦。小便数。大便因硬者。与小承气汤和之愈。
若与或同。病在太阳。或吐或下或汗。邪仍不解。而兼微烦。邪气不之表而之里也。小便数。
大便因硬者。热气不之太阳之本而之阳明之腑。可与小承气。和胃除热为主。不取大下者。以津液
先亡。不欲更伤其阴耳。
小承气汤方
大黄（四两） 浓朴（二两去皮炙） 枳实（三枚炙）
上三味。以水四升。煮取一升二合。去滓。分温二服。初服汤。当更衣。不尔者。尽饮之。若更
衣者。勿服之。阳明病。其人多汗。以津液外出。胃中燥。大便必硬。硬则谵语。小承气汤主之。
若一服谵语止。更莫复服。汗生于津液。津液资于谷气。故阳明多汗。则津液外出也。津液出于阳明
。而阳明亦藉养于津液。故阳明多汗。则胃中无液而燥也。胃燥则大便硬。大便硬则谵语。是宜小
承气汤。以和胃而去实。若一服谵
语止。更莫复服者。以津液先亡。不欲多下。以竭其阴。亦如上条之意也。
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
下之。伤寒胃热而虚者。能食。胃寒而实者。则不能食。而阳明病有燥屎者。可攻。无燥屎者。则不
可攻。谵语潮热。胃之热也。是当能食。而反不能食者。中有燥屎。气窒而不行。法当大承气下
之者也。若能食者。屎未成燥而但硬耳。设欲攻之。则必以小承气和之。如上二条所云而已。本文
宜大承气汤下之七字。当在胃中有燥屎句下。
大承气汤方
大黄（四两酒洗） 浓朴（半斤炙去皮） 枳实（五枚炙） 芒硝（二合）
上四味。以水一斗。先煮二物。取五升。去滓。纳大黄。煮取二升。去滓。纳芒硝。更上微火
一两沸。分温再服。得下。余勿服。
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。小便不
利者。其大便必溏。而有燥屎者。水液虽还入胃。犹不足以润之。故大便乍有难时。而亦乍有易
时也。若时有微热。喘冒不得卧。则热气外攻内扰。而复上逆。知其聚于中者。盛也。故曰有燥屎
也。大便
虽有易时。亦必以大承气为主矣。
大下后。六七日。不大便。烦不解。腹满痛者。此有燥屎也。所以然者。本有宿食故也。宜大
承气汤。
大下之后。胃气复实。烦满复增者。以其人本有宿食未去。邪气复得而据之也。不然。下后
胃虚。岂得更与大下哉。盖阳明病实则邪易聚而不传。虚则邪不得聚而传。是以虽发潮热而大便溏
者。邪气转属少阳。为胸胁满不去。虽经大下而有宿食者。邪气复集胃中。为不大便烦满。腹痛有
燥屎。而彼与小柴胡。此宜大承气。一和一下。天然不易之法也。小柴胡证见本篇四十一条。宜互
参。
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。
吐下之后。邪气不从外解而仍内结。热入胃腑。聚而成实。致不大便五六日。或十余日也。阳
明内实。则日晡所发潮热。盖申酉为阳明王时。而日晡为申酉时也。表和里病。则不恶寒。伤寒以
恶热为里。而恶寒为表也。热气熏心。则独语如见鬼状。盖神藏于心。而阳明之络通于心也。若热
甚而剧者。发则不识人。循衣摸床。惕而不安。微喘直视。是不特邪盛而正亦衰矣。若脉弦。则阴
未绝而犹可治。脉涩。则阴已绝而不可治。所谓伤寒阳胜而阴绝者。死也。其热微而未至于剧者。
则但发热。谵语。不大便而已。是可以大承气下之而愈也。一服利。止后服者。以热未至剧。故不
可过下。以伤其正耳。
二阳并病。太阳证罢。但发潮热。手足 汗出。大便难而谵语者。下之则愈。宜大承气汤。
此太阳并于阳明之证。然并病有并而未罢之证。虽入阳明。未离太阳。则可汗而不可下。如本
篇第三十九条之证是也。此条为并而已罢之证。虽曰并病。实为阳明。故可下而不可汗。潮热
。手足 汗出。大便难。谵语。皆胃实之征。故曰下之则愈。宜大承气汤。
阳明少阳合病。必下利。其脉不负者。顺也。负者。失也。互相克贼。名为负也。脉滑而数者。
有宿食也。当下之。宜大承气汤。
阳明少阳合病。视太阳阳明合病为尤深矣。故必下利。而阳明为土。少阳为木。于法又有互
相克贼之机。故须审其脉。不负者为顺。其有负者为失也。负者。少阳王而阳明衰。谓木胜乘土也
。若脉滑而数。则阳明王而少阳负。以有宿食在胃。故邪气得归阳明。而成可下之证。不然。胃虚
风动。其下利宁有止期耶。
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。
目中不了了者。目光不精而视物不明也。睛不和者。目直视而不圆转也。六七日。热盛而阴伤
。故其证如此。无表里证。无头痛恶寒。而又无腹满谵语等证也。然而大便难。身微热。则实证已
具。合之目中不了了。睛不和。其为热极阴伤无疑。故虽无大满大实。亦必以大承气汤急下。见稍迟。
则阴竭不复而死耳。
阳明病。发热汗多者。急下之。宜大承气汤。
发热汗多者。热盛于内。而津迫于外也。不下则热不除。不除则汗不止。而阴乃亡矣。故宜急
下。然必有实满之证。而后可下。不然。则是阳明白虎汤证。宜清而不宜下矣。学人辨诸。
发汗不解。腹满痛者。急下之。宜大承气汤。
发汗不解。腹满痛者。病去表之里而盛于里矣。夫正气与邪气相击则痛。治之者。如救斗
然。迟则正被伤矣。故亦宜急下。
以上下法共十五条。然其间或曰和。或曰下。或曰急下。或一服利止后服。各随病之大小缓急
而异其治。学人所当明辨也。
合论三承气汤方
承者。顺也。顺而承者。地之道也。故天居地上。而常卑而下行。地处天下。而常顺承乎天。
人之脾胃。犹地之上也。乃邪热入之。与糟粕结。于是燥而不润。刚而不柔。滞而不行。而失其地
之道矣。岂复能承天之气哉。大黄、芒硝、枳、朴之属。涤荡脾胃。使糟粕一行。则热邪毕出。
地道既平。天气乃降。清宁复旧矣。曰大。曰小。曰调胃。则各因其制而异其名耳。盖以硝黄之润下
。而益以枳、朴之推逐。则其力颇猛。故曰大。其无芒硝。而但有枳、朴者。则下趋之势缓。故曰
小。其去枳、朴之苦辛。而加甘草之甘缓。则其力尤缓。但取和调胃气。使归于平而已。故曰调胃
。
Taiyang disease. If, after emesis, purgation, or diaphoresis, the patient presents with slight restlessness (Wei Fan), frequent urination, and consequently hard stool, administer Xiao Chengqi Tang to harmonize the stomach, leading to recovery.
If the aforementioned treatments fail, the pathogen remains in the Taiyang stage. Following emesis, purgation, or diaphoresis, if the pathogenic factor is not resolved and is accompanied by slight restlessness, it indicates that the pathogen has moved from the exterior to the interior. Frequent urination leads to hard stool because the heat does not remain at the root of the Taiyang channel but enters the Yangming Fu organs. Xiao Chengqi Tang may be given to harmonize the stomach and clear heat, rather than employing drastic purgation, because the body fluids have already been depleted, and further injury to Yin should be avoided.
Formula: Xiao Chengqi Tang (Minor Order the Qi Decoction)
Rhubarb (Da Huang, 4 liang), Magnolia Bark (Hou Po, 2 liang, peeled and stir-fried), Immature Bitter Orange (Zhi Shi, 3 pieces, stir-fried).
Boil the above three ingredients in 4 sheng of water until reduced to 1.2 sheng. Strain. Divide into two warm doses. After the first dose, defecation should occur. If not, consume the remaining liquid. If defecation has occurred, do not take the remainder.
Yangming disease. The patient sweats profusely; as body fluids exit externally, the Stomach becomes dry, and the stool must become hard. Hard stool leads to delirium (Chan Yu). Treat with Xiao Chengqi Tang. If delirium ceases after one dose, do not administer further doses. Sweat is generated from body fluids, which are nourished by Gu Qi (Grain Qi). Thus, in Yangming disease, profuse sweating causes external loss of body fluids. Since body fluids originate from Yangming, and Yangming relies on them for nourishment, profuse sweating depletes fluids in the Stomach, causing dryness. Dry Stomach leads to hard stool, and hard stool leads to delirium. In such cases, Xiao Chengqi Tang is appropriate to harmonize the Stomach and remove excess heat. If delirium stops after one dose, cease administration because body fluids are already depleted; excessive purgation would exhaust Yin. This follows the principle of the previous clause.
In Yangming disease, delirium accompanied by tidal fever (Chao Re), yet the patient cannot eat, indicates the presence of five or six pieces of dry feces (Zao Shi) in the Stomach. If the patient can eat, the stool is merely hard. Da Chengqi Tang is indicated for purgation. In cold damage, a patient with Stomach heat and deficiency can eat; one with Stomach cold and excess cannot eat. However, in Yangming disease with dry feces, purgation is permissible; without dry feces, it is contraindicated. Delirium and tidal fever indicate Stomach heat, which typically allows eating. The inability to eat suggests obstruction by dry feces, blocking Qi movement. According to the method, Da Chengqi Tang should be used for purgation. If the patient can eat, the feces are not yet dry but merely hard. If purgation is desired, Xiao Chengqi Tang should be used to harmonize, as stated in the previous two clauses. The phrase "Yi Da Chengqi Tang xia zhi" (Suitable to use Da Chengqi Tang for purgation) in the text should follow the sentence "Wei zhong bi you zao shi wu liu mei ye" (There must be dry feces in the Stomach).
Formula: Da Chengqi Tang (Major Order the Qi Decoction)
Rhubarb (Da Huang, 4 liang, washed with wine), Magnolia Bark (Hou Po, 0.5 jin, peeled and stir-fried), Immature Bitter Orange (Zhi Shi, 5 pieces, stir-fried), Mirabilite (Mang Xiao, 2 he).
Boil the four ingredients in 1 dou of water. First boil Magnolia Bark and Immature Bitter Orange to obtain 5 sheng. Strain. Add Rhubarb and boil to obtain 2 sheng. Strain. Add Mirabilite and boil briefly over low fire. Divide into two warm doses. If bowel movement occurs, stop taking the remainder.
If the patient has difficulty urinating, intermittent difficulty and ease in defecation, occasional slight fever, wheezing, dizziness, and inability to lie down, this indicates the presence of dry feces. Da Chengqi Tang is indicated. Difficulty urinating usually implies loose stool. However, with dry feces, although some fluid returns to the Stomach, it is insufficient to moisten the intestines, resulting in alternating difficulty and ease in defecation. Occasional slight fever, wheezing, and dizziness preventing lying down indicate that heat is attacking outwardly and disturbing inwardly, rising upward. This signifies intense accumulation of heat in the center, confirming the presence of dry feces. Even if defecation is sometimes easy, Da Chengqi Tang remains the primary treatment.
After drastic purgation, if six or seven days pass without defecation, unresolved irritability, and abdominal fullness and pain, this indicates dry feces. This occurs because there was originally retained food (Su Shi). Da Chengqi Tang is indicated.
After drastic purgation, if Stomach Qi recovers and becomes replete, leading to increased irritability and fullness, it is because the patient originally had retained food that was not cleared, allowing pathogenic factors to re-occupy the area. Otherwise, post-purgation Stomach deficiency would preclude further drastic purgation. Generally, in Yangming disease, excess conditions allow pathogens to aggregate without transmitting, while deficiency conditions prevent aggregation and promote transmission. Thus, even with tidal fever and loose stool, if the pathogen transfers to Shaoyang, chest and hypochondriac fullness persists. If, despite drastic purgation, retained food exists, pathogens re-aggregate in the Stomach, causing constipation, irritability, fullness, abdominal pain, and dry feces. The former requires Xiao Chaihu Tang (Minor Bupleurum Decoction); the latter requires Da Chengqi Tang. One harmonizes, the other purges; this is an immutable natural method. Refer to Clause 41 of this chapter for Xiao Chaihu Tang patterns.
Following cold damage treated with emesis or purgation, if the condition remains unresolved and there is no defecation for five to six days, up to ten or more days, with tidal fever occurring at dusk (Ribang Suo), absence of aversion to cold, and solitary muttering as if seeing ghosts, severe cases may present with unconsciousness, picking at bedclothes and sheets (Xun Yi Mo Chuang), palpitations and restlessness, slight wheezing, and fixed gaze. A wiry pulse indicates survival; a choppy pulse indicates death. In milder cases presenting only with fever and delirium, Da Chengqi Tang is indicated. If one dose results in relief, discontinue subsequent doses.
After emesis and purgation, if pathogens do not resolve from the exterior but remain internally bound, heat enters the Stomach Fu, aggregating into excess, causing constipation for several days. Yangming internal excess leads to tidal fever at dusk, as Shen and You hours correspond to the peak of Yangming. With the exterior resolved and interior affected, there is no aversion to cold. In cold damage, aversion to heat indicates interior syndrome, while aversion to cold indicates exterior syndrome. Heat steaming the Heart causes solitary muttering, as Spirit resides in the Heart, and Yangming collaterals connect to the Heart. In severe heat, unconsciousness, picking behaviors, palpitations, slight wheezing, and fixed gaze indicate both excess pathogen and deficient Zheng Qi. A wiry pulse suggests Yin is not exhausted and treatability remains; a choppy pulse suggests Yin is exhausted and untreatability. This refers to death from Yang excess and Yin exhaustion. In milder heat, presenting only with fever, delirium, and constipation, Da Chengqi Tang can cure via purgation. Discontinuing after one dose prevents excessive purgation from damaging Zheng Qi when heat is not yet critical.
In Er Yang Bing (Combined Disease of Two Yangs), if Taiyang symptoms cease and only tidal fever, continuous sweating of the hands and feet, difficult defecation, and delirium remain, purgation leads to recovery. Da Chengqi Tang is indicated.
This represents Taiyang merging into Yangming. Combined diseases may have lingering Taiyang symptoms; if entering Yangming but still connected to Taiyang, diaphoresis is permitted but purgation is not (see Clause 39). This clause describes combined disease where Taiyang has ceased; although called combined, it is essentially Yangming. Thus, purgation is permitted, and diaphoresis is not. Tidal fever, hand/foot sweating, difficult defecation, and delirium are signs of Stomach excess. Hence, purgation cures, and Da Chengqi Tang is indicated.
In Yangming-Shaoyang Combined Disease, diarrhea inevitably occurs. A pulse that does not show "Fu" (defeat/subjugation) indicates a favorable prognosis; "Fu" indicates unfavorable prognosis due to mutual overcoming. A slippery and rapid pulse indicates retained food requiring purgation. Da Chengqi Tang is indicated.
Yangming-Shaoyang combined disease is deeper than Yangming-Taiyang combined disease, hence diarrhea. Yangming corresponds to Earth, Shaoyang to Wood, creating potential for mutual overcoming. Pulse assessment is crucial. Non-Fu indicates favorability. Fu indicates Shaoyang dominance over Yangming weakness (Wood overcoming Earth). A slippery and rapid pulse indicates Yangming dominance over Shaoyang weakness, due to retained food in the Stomach allowing pathogens to converge into Yangming, forming a purgable condition. Otherwise, Stomach deficiency with wind movement would cause indefinite diarrhea.
In cold damage, after six or seven days, if vision is unclear (Mu Zhong Liao Liao Bu Le) and eye movements are stiff (Jing Bu He), without exterior or interior signs, but with difficult defecation and slight body heat, this is an excess condition requiring urgent purgation. Da Chengqi Tang is indicated.
"Mu Zhong Liao Liao Bu Le" means blurred vision. "Jing Bu He" means fixed gaze with limited rotation. After six or seven days, intense heat injures Yin, causing these signs. Absence of headache/aversion to cold (exterior) and abdominal fullness/delirium (interior) defines "no exterior/interior signs." However, difficult defecation, slight heat, and ocular signs confirm extreme heat and Yin injury. Even without major fullness/excess, urgent purgation with Da Chengqi Tang is necessary; delay leads to Yin exhaustion and death.
In Yangming disease, fever with profuse sweating requires urgent purgation. Da Chengqi Tang is indicated.
Fever and profuse sweating indicate internal heat forcing fluids outward. Without purgation, heat persists, sweating continues, and Yin perishes. Urgent purgation is required, provided there are signs of excess fullness. Otherwise, it is Bai Hu Tang Syndrome (White Tiger Decoction Pattern), requiring clearing rather than purging. Scholars must distinguish this.
After diaphoresis, if the condition remains unresolved with abdominal fullness and pain, urgent purgation is required. Da Chengqi Tang is indicated.
Unresolved condition post-diaphoresis with abdominal fullness/pain indicates pathogen moving from exterior to interior and intensifying. Pain results from Zheng Qi clashing with pathogens. Treatment is like stopping a fight; delay harms Zheng Qi. Urgent purgation is thus required.
The above fifteen clauses concern purgation methods. Some prescribe "harmonizing," others "purgation," "urgent purgation," or "stop after one dose if relieved." Treatments vary according to the severity and urgency of the disease. Scholars must discern these distinctions clearly.
General Discussion on the Three Chengqi Formulas
"Cheng" means to follow or succeed. Following and succeeding is the way of the Earth. Heaven resides above Earth, humbly descending; Earth resides below Heaven, obediently receiving. Human Spleen and Stomach are like the Earth. When pathogenic heat enters and binds with waste, it becomes dry, rigid, stagnant, and loses its earthly nature, failing to receive Heavenly Qi. Rhubarb, Mirabilite, Immature Bitter Orange, and Magnolia Bark cleanse the Spleen and Stomach. Once waste moves, heat exits completely. Earthly order is restored, Heavenly Qi descends, and clarity returns. They are named Large, Small, and Harmonizing Stomach based on their formulations. Using Mirabilite and Rhubarb for moist purgation plus Immature Bitter Orange and Magnolia Bark for pushing creates strong force, hence "Large." Without Mirabilite, relying only on Immature Bitter Orange and Magnolia Bark creates slower downward momentum, hence "Small." Removing the bitter/acrid properties of Immature Bitter Orange and Magnolia Bark and adding Sweet Licorice (Gan Cao) for mildness creates gentle force, aiming only to harmonize Stomach Qi to balance, hence "Harmonizing Stomach."