攻之。与三十六节言欲与大承气汤。即以小承气汤为试。其义相通。详于浅注。若大便硬。忽见外便数
少。以津液当还入胃中。不久自下。不必攻之。详于二十五节。当细味之。三十九节言汗出谵语。以燥屎
在胃中。此为风也。过经乃可下之。下之若早。语言必乱。无非谆谆然不可轻下不可早下之意。陶节庵
云。痞满燥实坚五者全具。方可用之。此语虽曰未粹。亦堪为卤莽者脑后下一金针也。然论中急下三
条。却不在痞满燥实坚五证。第七十节云。伤寒六七日。目中不了了。睛不和。无表里证。大便难。无里证。
故大便不硬。但觉其难。身微热者。无表证。故身无大热。而止微热。此为实也。急下之。宜大承气汤。此言
悍热之气上走空窍也。七十一节云。阳明病。发热汗多者。急下之。止发热汗出无燥渴硬实之证。而亦
急下之者。病在悍气无疑矣。宜大承气汤。此言悍热之气内出。而迫其津液外亡也。七十二节云。发汗
不解。腹满痛者。急下之。宜大承气汤。此言悍热不上走于空窍。而下循于脐腹也。三者之外。虽无急下
之明文。亦有不可姑缓者。七十三节云。腹满不减。减不足言。当下之。宜大承气汤。言在阳明无形之悍
气。从肓膜而聚有形之胸腹。又与阳明之本气不同也。盖此证初患。皆为病不甚重。病家医家。往往不
甚留意。若读过薛立斋张景岳。及老村学先生多阅八家书者。为之主方。其死定矣。阳明篇此证甚为
难治。其余各症。皆可于本篇按法而施方治。自无难事。善读者当自领之。不能以笔楮罄也。
门人问曰。时贤柯韵伯谓阳明表证。身热自汗。不恶寒反恶热。此因内热外发。以栀子豉汤因势吐之。
后人认不出阳明表证。既不敢用麻桂。又不知用栀豉。必待热深热极。始以白虎承气投之。是不知仲
景治阳明之初法。遂废仲景之吐法。立说甚超。夫子以为何如。曰。栀子豉汤。治心烦胸中懊 不眠等
证。堪为阳明证初患未实者之要药。善用之。自有左宜右有之妙。但云因势吐之。是因前人之误。反失
栀子豉汤立方之本旨。且以瓜蒂散之涌吐。亦移入阳明篇中。更失之远矣。其自撰出上越中清下夺
为治阳明三大法。试问阳明篇何尝有涌吐之条乎。门人又问曰。发汗利小便为阳明之大禁。然乎否
乎。曰。此为正论。但不可泥矣。五十二节五十三节。麻黄桂枝二汤。已有明文。且五十八节。桂枝汤与大
承气汤。为一表一里之对峙。以脉实宜下。脉浮虚宜汗。六十二节。病患不恶寒而渴者。此转属阳明也。
小便数者。大便必硬。不更衣十日。无所苦也。渴欲饮水。少少与之。但以法救之。渴者宜五苓散。意者十
日无所苦。承气汤既不可用。饮水亦不至数升。白虎加人参汤又非所宜。惟以五苓散助脾气以转输。
多饮暖水以出汗。则内外俱松矣。读此可知禁汗为正治之法。而发汗原为除热以存津液起见。亦为
权宜之法也。四十三节云。若脉浮发热。渴欲饮水。小便不利者。猪苓汤主之。意者利水之中寓以育阴。
不失阳明之治法。而后半节又云。阳明病。汗出多而渴者。不可与猪苓汤。以汗多胃中燥。猪苓汤复利
其小便故也。读此。可知利水原为清火以存津液起见。是为权宜之妙用。若汗出不多者可与。汗出多
者不可与。以汗之与溺。同出而异归。权宜中仍以正治之法为重也。
攻下法。第三十六节提到想要使用大承气汤，这里先用小承气汤进行试探。其义理是相通的，详细解释见浅注。如果大便坚硬，忽然发现小便次数减少，这是因为津液应当回归胃中，不久后大便自然会排出，不需要攻下。详细解释见第二十五节，应当仔细体味。第三十九节说汗出且谵语，是因为燥屎在胃中，这是风邪所致。必须经过传经之后才可以攻下。如果攻下过早，语言必然错乱。这无非是谆谆告诫不可轻易攻下、不可过早攻下的意思。陶节庵说，痞、满、燥、实、坚五者全部具备，才可以使用（大承气汤）。这句话虽然说不够精粹，但也足以给鲁莽的人脑后敲一记警钟。然而，《伤寒论》中提到的急下三条，并不在痞、满、燥、实、坚五证之中。第七十节说：伤寒六七天，眼睛视物不清，眼球转动不灵活，没有表证也没有里证，大便困难，并没有里实证（指大便不硬），只是觉得排便困难。身体微热，因为没有表证，所以身体没有大热，只是微热。这是实证，应当急下，宜用大承气汤。这是说悍热之气向上走窜空窍。第七十一节说：阳明病，发热且汗多，应当急下。只有发热出汗，没有燥渴、硬、实的证候，却也要急下的，病位肯定在悍气。宜用大承气汤。这是说悍热之气向内外出，逼迫津液外亡。第七十二节说：发汗后病不解，腹部胀满疼痛，应当急下，宜用大承气汤。这是说悍热之气不向上走窜空窍，而是向下循行于脐腹。在这三种情况之外，虽然没有明确说要急下，但也有不可姑且延缓的情况。第七十三节说：腹部胀满不减，即使有减轻也不足挂齿，应当攻下，宜用大承气汤。这是说在阳明无形之悍气，从肓膜聚集到有形的胸腹，这与阳明之本气不同。大概这个病症初起时，往往病情不重，病人和医生往往不太留意。如果让读过薛立斋、张景岳以及老村学究先生们多读八家书的人来主方治疗，病人一定会死。阳明篇中这个病症非常难治，其余各症，都可以在本篇中按照方法施以方药治疗，自然没有难事。善于读书的人应当自己领会，无法用笔墨完全穷尽。
门人问：当代贤者柯韵伯认为阳明表证，表现为身热自汗，不恶寒反而恶热，这是因为内热外发，应该用栀子豉汤因势利导通过呕吐来治疗。后人认不出阳明表证，既不敢用麻黄汤、桂枝汤，又不知道用栀子豉汤，一定要等到热深热极，才开始用白虎汤或承气汤投治。这是不知道仲景治疗阳明的初始方法，于是废弃了仲景的吐法，立论很高超，老师您认为怎么样？回答说：栀子豉汤，治疗心烦、心中懊憹、失眠等证，可以作为阳明证初患尚未成实者的要药。善于使用它，自有左右逢源的妙处。但说“因势吐之”，是沿袭前人的错误，反而失去了栀子豉汤立方原本的宗旨。而且把瓜蒂散的涌吐法也移入阳明篇中，更是失之千里。他自己撰写的“上越、中清、下夺”作为治疗阳明的三大法，试问阳明篇中何曾有涌吐的条文呢？门人又问：发汗和利小便为阳明病的大禁忌，是这样吗？回答说：这是正确的理论，但不可以拘泥。第五十二节、五十三节，麻黄汤、桂枝汤二方已有明文记载。而且第五十八节，桂枝汤与大承气汤，是一表一里的对峙关系，脉实适宜攻下，脉浮虚适宜发汗。第六十二节说：病人不恶寒而口渴，这是转属阳明。小便频数的人，大便必定坚硬，十天不大便，也没有痛苦。想喝水，少量给予，只按方法救治他。口渴者宜用五苓散。意思是十天无所苦，承气汤既然不可用，饮水也不会达到几升，白虎加人参汤又不适宜。只有用五苓散帮助脾气转输，多喝暖水以出汗，那么内外都松解了。读到这里可知，禁止发汗是正治之法，而发汗原本是为了除热以保存津液起见，也是权宜之法。第四十三节说：如果脉浮发热，想喝水，小便不利，用猪苓汤主治。意思是利水中蕴含育阴之意，不失阳明治法。而后半节又说：阳明病，汗出多且口渴，不可与猪苓汤，因为汗多导致胃中干燥，猪苓汤再次利其小便的缘故。读到这里，可知利水原本是为了清火以保存津液起见，这是权宜的妙用。若汗出不多的可以与，汗出多的不可与。因为汗与溺，同源而异归，权宜之中仍以正治之法为重。
Attack with purgation. In Section 36, it is mentioned that one wishes to use Da Cheng Qi Tang (Major Order the Qi Decoction), so here Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is used as a test. The principles are interconnected; detailed explanations can be found in the *Qian Zhu* (Light Annotations). If the stool is hard, but suddenly the frequency of urination decreases, this indicates that body fluids should return to the stomach, and the stool will naturally pass soon; no purgation is necessary. Detailed explanations can be found in Section 25; one should savor this carefully. Section 39 states that sweating and delirious speech occur because dry feces are in the stomach, which is due to Wind pathogen. One may only purge after the disease has passed through its stages. If purged too early, speech will surely become chaotic. This is nothing but earnest admonition against light-minded or premature purgation. Tao Jie'an said: "Only when all five conditions—fullness (Pi), distension (Man), dryness (Zao), excess (Shi), and hardness (Jian)—are present can [Da Cheng Qi Tang] be used." Although this statement is not entirely refined, it serves as a warning needle for the rash. However, the three urgent purgation cases in the *Lun* do not fall under these five syndromes. Section 70 says: "In Cold Damage after six or seven days, if the eyes cannot see clearly and the pupils are unresponsive, without exterior or interior syndromes, with difficult defecation but no interior excess syndrome (meaning the stool is not hard, only felt to be difficult), and with slight fever (without exterior syndrome, so there is no high fever, only slight fever), this is an Excess syndrome. Urgent purgation is required; Da Cheng Qi Tang (Major Order the Qi Decoction) is appropriate." This refers to the vigorous heat qi moving upward into the orifices. Section 71 says: "Yangming Disease, with fever and profuse sweating, requires urgent purgation." There is only fever and sweating, without dryness, thirst, hardness, or excess syndromes, yet urgent purgation is still indicated; this undoubtedly involves the vigorous qi. Da Cheng Qi Tang (Major Order the Qi Decoction) is appropriate. This refers to vigorous heat qi moving inward and outward, forcing body fluids to escape externally. Section 72 says: "After sweating, the disease does not resolve, and abdominal fullness and pain occur; urgent purgation is required. Da Cheng Qi Tang (Major Order the Qi Decoction) is appropriate." This refers to vigorous heat qi not moving upward to the orifices, but descending along the navel and abdomen. Outside of these three cases, although there is no explicit text on urgent purgation, there are situations where delay is inadvisable. Section 73 says: "Abdominal fullness that does not decrease, even if slightly reduced, is negligible; purgation is required. Da Cheng Qi Tang (Major Order the Qi Decoction) is appropriate." This refers to formless vigorous qi of Yangming gathering from the epigastrium into the tangible chest and abdomen, which differs from the original qi of Yangming. Generally, at the onset of this syndrome, the disease is often not severe, and patients and physicians often pay little attention. If treated by those who have read Xue Lizhai, Zhang Jingyue, and old village scholars who have extensively studied the Eight Masters, death is certain. This syndrome in the Yangming Chapter is very difficult to treat; other symptoms can be treated according to the methods in this chapter, making it easy. Those who read well should understand this themselves; it cannot be fully exhausted by pen and paper.
A disciple asked: "Contemporary scholar Ke Yunbo states that Yangming exterior syndrome presents with body heat, spontaneous sweating, aversion to cold being absent and aversion to heat appearing, because internal heat emits outward. One should use Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) to induce vomiting according to the trend. Later generations fail to recognize Yangming exterior syndrome; they dare not use Ma Huang Tang (Ephedra Decoction) or Gui Zhi Tang (Cinnamon Twig Decoction), nor do they know to use Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction). They wait until the heat is deep and extreme before administering Bai Hu Tang (White Tiger Decoction) or Cheng Qi Tangs. This shows ignorance of Zhongjing's initial method for treating Yangming, thereby abandoning Zhongjing's vomiting method. His theory is quite advanced; what does your lord think?" I replied: "Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) treats syndromes such as vexation, mental restlessness (Ao Nao), and insomnia. It is an essential medicine for early-stage Yangming syndromes that have not yet become solid. Used skillfully, it yields versatile benefits. However, saying 'induce vomiting according to the trend' follows previous errors and loses the original intent of the formula. Moreover, transferring Gua Di San (Melon Tip Powder) for inducing vomiting into the Yangming Chapter is even more erroneous. He proposed 'upper dispersing, middle clearing, lower purging' as the three major methods for treating Yangming. Let me ask: Does the Yangming Chapter ever contain clauses on inducing vomiting?" The disciple asked again: "Is it true that sweating and promoting urination are great taboos in Yangming?" I replied: "This is correct theory, but one must not be dogmatic. Sections 52 and 53 explicitly mention Ma Huang Tang (Ephedra Decoction) and Gui Zhi Tang (Cinnamon Twig Decoction). Furthermore, in Section 58, Gui Zhi Tang (Cinnamon Twig Decoction) and Da Cheng Qi Tang (Major Order the Qi Decoction) stand as exterior and interior counterparts: if the pulse is solid, purgation is suitable; if floating and deficient, sweating is suitable. Section 62 states: 'If the patient does not fear cold but feels thirsty, this has transferred to Yangming.' If urination is frequent, the stool will surely be hard. Even if ten days pass without defecation, there is no distress. If thirsty and desiring water, give small amounts, and rescue according to the method. For thirst, Wu Ling San (Five-Ingredient Powder with Poria) is appropriate. The meaning is that since there is no distress after ten days, Da Cheng Qi Tang (Major Order the Qi Decoction) is contraindicated, and drinking several liters of water is unlikely. Bai Hu Jia Ren Shen Tang (White Tiger Decoction plus Ginseng) is also unsuitable. Only Wu Ling San (Five-Ingredient Powder with Poria) helps the spleen qi transform and transport; drinking warm water induces sweating, thus relaxing both interior and exterior. Reading this reveals that prohibiting sweating is the standard treatment, while sweating is originally intended to remove heat and preserve body fluids, serving as an expedient method. Section 43 states: 'If the pulse is floating, there is fever, thirst, and difficulty in urination, Zhu Ling Tang (Polyporus Decoction) governs.' The meaning is that promoting uritation contains the principle of nourishing yin, adhering to Yangming treatment methods. However, the latter half adds: 'In Yangming Disease, if sweating is profuse and there is thirst, Zhu Ling Tang (Polyporus Decoction) must not be given, because profuse sweating causes dryness in the stomach, and Zhu Ling Tang (Polyporus Decoction) would further promote urination.' Reading this, we know that promoting urination is originally intended to clear fire and preserve body fluids, representing a skillful expedient use. It may be used if sweating is not profuse, but not if sweating is profuse. Since sweat and urine share the same source but have different destinations, among expedients, the standard treatment remains paramount."