【纲】仲景曰。病患无表里症。发热。七八日不大便。虽脉浮数者。可下之。假令已下。脉数不
解。合热则消谷善饥。至六七日不大便者。有瘀血也。宜抵当汤。若脉数不解。而下利不止。必协
热而便脓血也。
【目】鳌按。热利不止。必大便脓血。由于素有蓄血。内外俱热。阳盛阴虚。而阴络受伤故也。
此因下后协热便脓血。热气下流故也。
【纲】仲景曰。阳明病。下血谵语。此热入血室。但头汗者。当刺期门。
【目】王肯堂曰。冲脉为血海。即血室也。男女均有之。男子下血谵语。女人寒热似疟。皆为
热入血室。迫血下行。则为协热而利。挟血之脉。乍涩乍数。或沉或伏。血热交并。则脉洪盛。大
抵男多在左手。女多在右手见之也。又有阴寒为病。下利脓血者。乃下焦虚寒。肠胃不固。清浊不
分。而便下脓血也。二者一为血热。一为血寒。临病审之。
【纲】仲景曰。阳明病。潮热。大便硬者。可与大承气汤。不硬者。不可与之。若不便六七日。
恐有燥屎。欲知之法。少与小承气汤。汤入腹中。转失气者。此有燥屎。乃可攻之。若不转失气
者。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。
必大便硬而少也。以小承气汤和之。不转失气者。慎不可攻也。阳明病。下之。心中懊
而烦。胃中有燥屎者。可攻之。宜大承气汤。腹微满。初头硬。后必溏。不可攻之。阳明病。若
中寒。不能食。小便不利。手足 然汗出。此欲作痼瘕。必大便初硬后溏。所以然者。以胃中冷。
水谷不别故也。
得病二三日。脉弱。无太阳柴胡症。烦燥。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】许叔微曰。仲景论中言先硬后溏者四症。前二症不言及小便。第三症言小便不利。第四
症言小便少。其不言小便二条。首则因胃中邪热未作热实。次则因虚。烦热在上。胃中无燥屎。其
小便不利条。则以胃中水谷不别之故。其言小便少条。则又以胃中未可定其硬不硬。而必候小便之
利。是知仲景测大便法。皆以小便觇之。如小便清。知不在里。利不止者。利其小便。小便数少。
津液当还入胃中。必大便。皆可验者。然小便利。屎定硬。固为可攻。亦有小便自利。大便硬。不
可攻者。何哉。阳明自汗。或发汗。小便自利。此为津液内竭。虽硬不可攻之。当须自欲大便时。
用蜜煎导法。盖非里实。故不可攻也。又太阳一症云。若吐若发汗。微烦。小便数。大便硬。与小
承气汤和之。此两症。汗后大便硬。小便利。皆同。而治法不同者。后症为有传邪。故微烦。又因
发汗吐下后。小便数。内亡津液。大便硬。是热邪入里。故以小承气利之。至若前症小便自利。以
无传邪。故无烦症。大便虽硬。不得为里实。但肠头干燥。止可用蜜导也。读仲景书者。宜详究焉。
柯琴曰。痼瘕。即初硬后溏之谓。肛门虽固结。而肠中不全干也。溏即水谷不别之象。以 瘕
作解者谬矣。按大小肠俱属于胃。欲知胃之虚实。必于二便验之。小便利。屎定硬。小便不利。必
大便初硬后溏。今人但知不大便、大便难、大便硬者。为阳明病。亦知小便难、小便不利、小便数
少、或不尿者。皆阳明病乎。
【纲】张仲景说：患者没有表证和里证的典型症状，出现发热，七八天不大便。即使脉象浮数，也可以使用攻下法。假如已经使用了攻下法，但脉数仍未解除，体内热邪与胃气相合，导致消化食物过快、容易饥饿。到了六七天仍然不大便的，说明体内有瘀血。适宜使用抵当汤（破血逐瘀方剂）。如果脉数仍未解除，反而出现腹泻不止的情况，必定是伴随热邪而排出脓血。
【目】沈金鳌按语：热性腹泻不止，必然导致大便中夹杂脓血。这是由于患者素有瘀血蓄积，内外俱热，阳气盛而阴液虚，导致阴络受损的缘故。这种情况是因为攻下之后，热邪随之下行，导致便脓血，这是热气下流所致。
【纲】张仲景说：阳明病，出现便血和胡言乱语的症状，这是热邪侵入血室。只有头部出汗的，应当针刺期门穴。
【目】王肯堂说：冲脉是血海，也就是血室。男女都有。男子出现便血和胡言乱语，女子出现寒热往来像疟疾一样的症状，都是因为热邪侵入血室，逼迫血液下行，从而形成伴随热邪的腹泻。挟带血液的脉象，时而涩滞时而数急，或者沉伏。血与热相互搏结，脉象就会洪大旺盛。大概来说，男性多在左手脉象上显现，女性多在右手脉象上显现。又有因阴寒致病，出现腹泻脓血的，这是下焦虚寒，肠胃不坚固，清浊不分，从而导致大便排出脓血。这两种情况，一种是血热，一种是血寒，临证时需要仔细审察。
【纲】张仲景说：阳明病，出现潮热，大便硬的，可以给予大承气汤（峻下热结方剂）。大便不硬的，不可给予。如果不大便六七天，担心有燥屎。想要确认的方法，少量给予小承气汤（轻下热结方剂）。药汤进入腹中，如果转放屁，这说明有燥屎，才可以攻下。如果不转放屁的，这仅仅是开头硬，后面一定稀溏，不可攻下。如果攻下，必定会导致腹胀满，不能进食。想喝水的人，给水喝则会发生呃逆。此后如果出现发热，必定是大便变硬且量少。用小承气汤调和即可。不转放屁的，千万不可攻下。阳明病，经过攻下后，心中烦闷懊恼，胃中有燥屎的，可以攻下。适宜使用大承气汤。腹部轻微胀满，开头硬，后面一定稀溏的，不可攻下。阳明病，如果中寒，不能进食，小便不利，手足濈然汗出，这是将要形成痼瘕（积聚性疾病），必定是大便开头硬后面稀溏。之所以这样，是因为胃中寒冷，水谷不分的原因。
患病二三天，脉弱，没有太阳病或少阳病的症状，烦躁，心下硬满。到了四五天，虽然能进食，也要少量多次给予小承气汤，微微调和，使其稍微安宁。到了第六天，给予一升承气汤。如果仍然不大便，六七天小便少的，虽然不能进食，但只是开头硬，后面一定稀溏，尚未完全结成硬块，攻下必定导致腹泻。必须等到小便通利，大便确定变硬，才可以攻下。适宜使用大承气汤。
【目】许叔微说：张仲景的论述中提到先硬后溏的情况有四症。前两个症状没有提及小便，第三个症状提到小便不利，第四个症状提到小便少。那两个未提及小便的条文，第一条是因为胃中的邪热尚未形成实热，第二条是因为虚证，烦热在上，胃中没有燥屎。关于小便不利的条文，是因为胃中水谷不分的原因。关于小便少的条文，是因为胃中尚不能确定大便是否变硬，必须等待小便通利来验证。由此可知，张仲景判断大便的方法，都是通过观察小便来推测的。如小便清长，知道病不在里；如果腹泻不止，应利其小便；小便次数少，津液应当回归胃中，大便自然会变硬，这些都是可以验证的。然而，小便利，大便确定变硬，固然可以攻下；也有小便自利，大便硬，却不可攻下的情况，为什么呢？如果是阳明病自汗，或者发汗后，小便自利，这是因为津液在内枯竭，虽然大便硬也不可用攻下法。应当等到患者自己想排便时，使用蜜煎导法（外用栓剂）。因为这不是里实证，所以不可攻下。另外太阳病有一条说：如果呕吐或发汗后，轻微烦躁，小便频数，大便硬，给予小承气汤调和。这两个症状，都是汗后大便硬，小便利，但治法不同。后面的症状因为有传变的邪气，所以轻微烦躁；又因为发汗、吐、下之后，小便频数，内部津液亡失，大便变硬，这是热邪入里，所以用小承气汤通利它。至于前面的症状，小便自利，因为没有传变的邪气，所以没有烦躁症状，大便虽然硬，但不能算作里实证，只是肠道前端干燥，只可用蜜导法。读张仲景书籍的人，应该详细探究。
柯琴说：痼瘕，就是指开头硬后面稀溏的意思。肛门虽然固结，但肠中并不完全干燥。稀溏就是水谷不分的现象。把痼瘛解释为其他含义是错误的。按大小肠都归属于胃，想要了解胃的虚实，必须通过二便来验证。小便利，大便一定硬；小便不利，大便一定开头硬后面稀溏。现在的人只知道不大便、大便难、大便硬的是阳明病，难道也知道小便难、小便不利、小便次数少、或不排尿的，也都是阳明病吗？
[General Principle] Zhang Zhongjing stated: If a patient presents with no typical exterior or interior syndromes, but has fever and has not had a bowel movement for seven to eight days, even if the pulse is floating and rapid, purgation may be used. If purgation has already been administered but the rapid pulse persists, the internal heat combines with stomach qi, leading to excessive digestion and hunger. If there is still no bowel movement after six or seven days, it indicates the presence of blood stasis. The Dandang Tang (Dang Gui Decoction) is appropriate. If the rapid pulse persists and diarrhea becomes unceasing, it is likely accompanied by heat resulting in pus and blood in the stool.
[Commentary] Shen Jin'ao noted: Unceasing heat-type diarrhea inevitably leads to pus and blood in the stool. This occurs because the patient previously had accumulated blood stasis, resulting in both internal and external heat, excess Yang and deficient Yin, causing injury to the Yin collaterals. This condition arises from heat flowing downward following purgation, leading to pus and blood in the stool.
[General Principle] Zhang Zhongjing stated: In Yangming disease, bleeding from the anus accompanied by delirium indicates that heat has entered the Blood Chamber (Xue Shi). If only the head sweats, the Qimen acupoint should be needled.
[Commentary] Wang Kentang stated: The Chong Mai (Penetrating Vessel) is the Sea of Blood, also known as the Blood Chamber. Both men and women possess it. In men, bleeding and delirium; in women, alternating chills and fever resembling malaria, are all caused by heat entering the Blood Chamber, forcing blood downward, resulting in heat-accompanied diarrhea. The pulse carrying blood may be intermittent and rapid, or deep and hidden. When blood heat intertwines, the pulse becomes surging and vigorous. Generally, this manifests more often on the left hand in men and the right hand in women. There are also cases of diarrhea with pus and blood caused by Yin-cold pathology, which results from deficiency-cold in the Lower Jiao, instability of the intestines and stomach, and failure to separate the clear from the turbid, leading to pus and blood in the stool. These two conditions represent one of Blood Heat and one of Blood Cold; they must be carefully distinguished during clinical practice.
[General Principle] Zhang Zhongjing stated: In Yangming disease, if tidal fever and hard stool are present, Da Chengqi 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 feces are suspected, the method to confirm is to administer a small amount of Xiao Chengqi Tang (Minor Order the Qi Decoction). If gas passes after the decoction enters the abdomen, dry feces are present, and purgation can proceed. If gas does not pass, the stool is merely hard at the beginning and loose at the end; purgation is contraindicated. Purgation would lead to abdominal fullness and inability to eat. If the patient desires water, giving it may cause hiccups. Subsequent fever will likely result in hard but scanty stool; Xiao Chengqi Tang should be used to harmonize. If gas does not pass, purgation must be strictly avoided. In Yangming disease, after purgation, if there is inner restlessness and agitation indicating dry feces in the stomach/intestines, purgation is indicated, preferably with Da Chengqi Tang. If the abdomen is slightly full, with stool hard at the beginning and loose at the end, purgation is contraindicated. In Yangming disease, if cold affects the middle, causing inability to eat, difficulty urinating, and continuous sweating on the hands and feet, this suggests the impending formation of a Gujia (stubborn mass/accumulation), and the stool will likely be hard at the beginning and loose at the end. This is due to cold in the stomach and the failure to distinguish between water and grain.
Two to three days after contracting the disease, if the pulse is weak, without Taiyang or Shaoyang symptoms, and the patient is irritable with hardness below the heart, by the fourth or fifth day, even if they can eat, give small amounts of Xiao Chengqi Tang frequently to gently harmonize and bring slight relief. By the sixth day, administer one sheng of Chengqi Tang. If there is still no bowel movement, and urine output is low over six or seven days, even if they cannot eat, the stool is likely hard at the beginning and loose at the end, not yet fully hardened. Purgation will cause diarrhea. One must wait for free urination and confirmation of hard stool before purging, using Da Chengqi Tang.
[Commentary] Xu Shuwei stated: In Zhang Zhongjing's treatise, there are four instances mentioning stool that is hard at the beginning and loose at the end. The first two do not mention urination; the third mentions difficulty urinating, and the fourth mentions scanty urination. In the two cases not mentioning urination, the first is because the pathogenic heat in the stomach has not yet formed a heat-excess syndrome, and the second is due to deficiency, with irritant heat above and no dry feces in the stomach. Regarding the case of difficulty urinating, it is due to the failure to separate water and grain in the stomach. Regarding the case of scanty urination, it is because it is undetermined whether the stool is hard, so one must wait for urination to become free to verify. Thus, Zhang Zhongjing's method of assessing stool involves observing urination. If urine is clear, the disease is not in the interior; if diarrhea persists, promote urination; if urination is frequent and scanty, body fluids should return to the stomach, and the stool will naturally harden—all of which are verifiable. However, while free urination and confirmed hard stool indicate purgation is suitable, there are cases where urination is spontaneous and stool is hard, yet purgation is contraindicated. Why? If Yangming disease involves spontaneous sweating or post-sweating, with spontaneous urination, this indicates depletion of internal body fluids. Although the stool is hard, purgation is contraindicated. One should wait for the urge to defecate and use Honey Suppositories (Mi Jian Dao). This is not an interior excess syndrome, so purgation is inappropriate. Another Taiyang syndrome states: After vomiting or sweating, if there is mild irritability, frequent urination, and hard stool, give Xiao Chengqi Tang to harmonize. In these two cases, both involve hard stool and free urination after sweating, but the treatments differ. The latter case involves transmitted pathogenic factors, hence mild irritability; after sweating, vomiting, and purging, frequent urination leads to fluid loss and hard stool, indicating heat entering the interior, so Xiao Chengqi Tang is used to drain it. In the former case, spontaneous urination occurs without transmitted pathogens, hence no irritability; although the stool is hard, it is not an interior excess, merely dryness at the intestinal entrance, so only honey suppositories are applicable. Readers of Zhang Zhongjing's works should investigate this in detail.
Ke Qin stated: Gujia refers to stool that is hard at the beginning and loose at the end. Although the anus is constricted, the intestines are not completely dry. Loose stool is the sign of failing to separate water and grain. Interpreting Gujia otherwise is erroneous. The large and small intestines belong to the stomach. To determine the deficiency or excess of the stomach, one must examine the bowels and urine. Free urination indicates hard stool; difficulty urinating indicates stool hard at the beginning and loose at the end. Nowadays, people know that infrequent bowel movements, difficult defecation, and hard stool constitute Yangming disease. Do they also recognize that difficult urination, difficulty urinating, frequent/scanty urination, or anuria are also Yangming diseases?