【纲】仲景曰。阳明病。脉浮而紧者。必潮热。发作有时。但浮者。必盗汗出。
【目】刘完素曰。潮热属阳明。必于日晡时发者。乃为潮热。若日三五发者。则是发热。非潮
热也。
王好古曰。脉浮而紧。是恶寒将自罢。将发潮热时之脉也。此紧反入里之谓。不得拘紧则为寒
之说。
【纲】仲景曰。阳明中风。脉弦浮大而短气。腹部满。胁下及心痛。久按之。气不通。鼻干不
得汗。嗜卧。一身及面目悉黄。小便难。有潮热。时时哕。耳前后肿。刺之小瘥。外不解。病过十
日。脉弦浮者。与小柴胡汤。脉但浮。无余症者。与麻黄汤。若不尿腹满。加哕者难治。
【目】鳌按。本条不言发热。但曰有潮热。是明兼少阳矣。故可与小柴胡汤。
【纲】仲景曰。阳明病。脉迟。微汗出。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。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。可与小承气微和胃气。勿令大泄下。阳明
病。潮热。大便硬者。可与大承气汤。不硬者。不可与之。若不大便六七日。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。其后发热者。必大便硬而少也。以小
承气汤和之。不转失气者。慎不可攻也。
【目】朱肱曰。潮热者。大率当下。仲景云。潮热者实也。大承气汤症。云其热不潮。未可与
也。则知潮热当下无疑矣。虽然。更看脉与外症。脉若弦若浮。及外症恶寒。犹有表症。且与小柴
胡汤以解之。若腹大满不通者。可与小承气微和
其胃气。勿令大泄。纵使潮热当行大承气。亦须先少与小承气。若不转失气。不可攻之。后发热复
硬者。大柴胡汤下之。若胸胁满而呕。日晡发潮热者。小柴胡加芒硝。又有日晡发潮热。已有微利
者。又有微发潮热而大便溏者。或潮热而咳逆者。皆当用小柴胡也。冬阳明潮热。当行黄芩汤。阳
明病俱宜下。惟恶寒中寒。为病在经。与太阳合病。属表。发其汗耳。若吐若下后。七八日不解。
热结在里。表里俱热。时时恶寒者。白虎症也。
柯琴曰。胃实诸症。以手足汗出为可据。而潮热尤为亲切。以四肢为诸阳之本。而日晡潮热为
阳明主时也。后条。必因脉之迟弱。即潮热尚不足据。故又立试法。以小承气汤为和。即以小承气
汤为试。仍与小承气汤为和。总是慎用大承气耳。
【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】鳌按。此潮热而又不大便。不恶寒。俱是可下症也。
【纲】仲景曰。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。
【目】魏荔彤曰。能食不能食二者。俱知津必立枯。屎必尽燥。日久愈耗液伤正。自宜大承气
汤。此于不能食而辨其已有燥屎。于能食而辨其将来必有燥屎。俱宜攻下也。
他条言虽能食。虽不能食。俱应斟酌。不可大为攻下。此条又言反不能食者。若能食者。俱应
直捷而大为攻下。非自体认能得仲师之心。从孰问津乎。
凡伤寒论中。仲师既恐人不应下而下。又恐人应当下而下之太早太甚。今且恐人应下而不下。
或不敢大下。故就燥屎以示之。令人既知详慎。又忌迟疑。中庸所以不易能也夫。
【纲】仲景曰。二阳并病。太阳症罢。但发潮热。手足 汗出。大便难而谵语者。下之则愈。
宜大承气汤。
【目】方中行曰。太阳症罢。分明全属阳明。首必先言二阳并病者。见未下时便有可下之症。
见得太阳一罢。其余皆可下之症矣。
【纲】仲景曰。阳明病。谵语发潮热。脉滑而疾者。小承气主之。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。里症也。为难治。不可
更与承气也。
【目】魏荔彤曰。脉滑而疾。滑者大之渐。而疾者数之称。病由太阳转属阳明。必在表之邪。
变热入里。脉之浮者必变大。其紧与缓者。必俱变疾。疾数也。数热也。非变热入里。无以致成阳
明也。凡病邪入经。脉必变紧缓为数。病邪入腑。脉又易数疾稍迟。
【纲】张仲景说：阳明病，脉象浮而紧的，必定出现潮热，发作有定时；若脉象仅见浮象，必定在夜间盗汗。
【目】刘完素说：潮热属于阳明病，必须在日晡时（下午3点至5点）发作的，才称为潮热。如果一天发作三五次，那是发热，不是潮热。
王好古说：脉象浮而紧，是恶寒即将停止、将要发生潮热时的脉象。这就是“紧脉反入里”的意思，不能拘泥于“紧脉主寒”的说法。
【纲】张仲景说：阳明中风，脉象弦、浮、大且短气，腹部胀满，胁下及心口疼痛，长时间按压后气机不通，鼻干无汗，嗜睡，全身及面目都发黄，小便困难，伴有潮热，时常呃逆，耳前耳后肿胀。针刺后症状稍缓解，但表证未解。病程超过十天，脉象仍见弦浮的，给予小柴胡汤；若脉象仅见浮，没有其他症状的，给予麻黄汤。若不排尿且腹部胀满，加上呃逆的，难以治疗。
【目】沈金鳌按语：本条没有提到发热，只说有潮热，这是明确兼有少阳病证。所以可以给予小柴胡汤。
【纲】张仲景说：阳明病，脉象迟，微汗出，不恶寒，身体必定沉重，短气，腹部胀满且喘，有潮热的，这是表证将解，可以攻里。手足濈然汗出的，说明大便已经硬结，以大承气汤为主治方。若汗多，微发热恶寒的，说明表证未解，其热不呈潮热状，不可给予承气汤。若腹部显著胀满不通的，可给予小承气汤轻微调和胃气，不要令其剧烈泻下。阳明病，出现潮热，大便硬的，可给予大承气汤；大便不硬的，不可给予。若六七天不大便，担心有燥屎，想要确认的方法，少量给予小承气汤。汤药进入腹中，若转矢气（放屁），这是有燥屎，才可以攻下。若不转矢气的，这仅是开头大便硬，后面必定溏薄，不可攻下。攻下必导致胀满不能进食。想喝水的，给水则会导致呃逆。其后发热的，必定大便硬而量少，以小承气汤调和。不转矢气的，千万不可攻下。
【目】朱肱说：潮热者，大体上应当用下法。张仲景说：“潮热者实也。”大承气汤证中提到“其热不潮，未可与也”，由此可知潮热当下无疑。虽然如此，更要看脉象和外部症状。若脉象弦或浮，以及外部症状有恶寒，仍有表证，暂且给予小柴胡汤以解除表邪。若腹部显著胀满不通的，可给予小承气汤轻微调和胃气，不要令其剧烈泻下。即使潮热应当使用大承气汤，也必须先少量给予小承气汤试探。若不转矢气，不可攻下。后来发热且大便复硬的，用大柴胡汤攻下。若胸胁胀满且呕吐，日晡时发潮热的，用小柴胡汤加芒硝。又有日晡时发潮热，已有轻微腹泻的；又有轻微潮热而大便溏薄的；或潮热而咳嗽气逆的，都应当使用小柴胡汤。冬季阳明病潮热，应当使用黄芩汤。阳明病大多适宜用下法，只有恶寒、中寒，病在经脉，与太阳合病，属于表证，应当发汗。若在吐下之后，七八天病不解，热结在里，表里俱热，时时恶寒的，是白虎汤证。
柯琴说：胃实诸症，以手足汗出为依据，而潮热尤为确切。因为四肢为诸阳之本，而日晡时潮热是阳明经主时的表现。后一条文中，必定因为脉象迟弱，即潮热尚不足以作为依据，所以又设立试探法，用小承气汤来调和，即以之作为试探，仍然以小承气汤调和，总是慎用大承气汤罢了。
【纲】张仲景说：伤寒经过吐法或下法治疗后，病未解，不大便，从五六天到十余天，日晡时发潮热，不恶寒，独自说话如同看见鬼怪一样。若病情严重的，发作时不认识人，循衣摸床，惊恐不安，微喘直视。脉象弦的预后良好，脉象涩的预后不良。病情较轻的，只是发热谵语，以大承气汤主治。若服用一次后大便通利，停服后面的药。
【目】沈金鳌按语：此条既有潮热又不大便，且不恶寒，都是可以使用下法的指征。
【纲】张仲景说：阳明病，谵语，有潮热，反而不能进食的，胃中必定有燥屎五六枚。若能进食的，仅仅是大便硬罢了，宜用大承气汤。
【目】魏荔彤说：能食与不能食两种情况，都知道津液必然枯竭，粪便必然完全干燥。日久更会耗伤津液损伤正气，自然适宜用大承气汤。这里通过不能食来辨别已有燥屎，通过能食来辨别将来必有燥屎，都适宜攻下。其他条文说无论能食还是不能食，都应斟酌，不可大为攻下。此条又说“反不能食者”，若是能食者，都应直截了当地大为攻下。若不是亲身体悟，谁能领会张仲师的心意呢？
凡是《伤寒论》中，张仲师既担心人们不该下而下，又担心人们该下而下得太早太甚。现在又担心人们该下而不下，或不敢大下，所以通过燥屎的情况来示警，让人既知道详细谨慎，又忌讳迟疑不决。中庸之道之所以不易做到，大概就是这样吧。
【纲】张仲景说：二阳并病，太阳证已罢，只发潮热，手足汗出，大便难且谵语的，用下法即可痊愈，宜用大承气汤。
【目】方中行说：太阳证已罢，分明全属阳明病。开头必先言二阳并病，是为了显示在未下之前就有可下的症状，表明太阳一经证候一罢，其余都可下的症状就显现了。
【纲】张仲景说：阳明病，谵语发潮热，脉象滑而疾数的，以小承气汤为主治。因此给予承气汤一升，腹中转矢气的，再服一升。若不转矢气的，不要再给。第二天，仍不大便，脉象反而微涩的，这是里虚证，为难治，不可再给予承气汤。
【目】魏荔彤说：脉象滑而疾数，滑是大的渐象，疾是数的称呼。病由太阳转属阳明，必定是表邪变热入里。脉象浮的必定变大，紧与缓的，必定都变为疾。疾就是数，数代表热。若非变热入里，无法形成阳明病。凡病邪入经，脉象必定由紧缓变为数；病邪入腑，脉象又由数疾稍变为迟。
[Outline] Zhang Zhongjing stated: In Yangming disease, if the pulse is floating and tight, tidal fever (Chao Re) will certainly occur, with regular onset times. If the pulse is merely floating, night sweats (Dao Han) will certainly occur.
[Commentary] Liu Wansu stated: Tidal fever belongs to Yangming disease. It must occur during the Shen hour (15:00-17:00) to be termed tidal fever. If it occurs three to five times a day, it is merely fever (Fa Re), not tidal fever.
Wang Haogu stated: A floating and tight pulse indicates that aversion to cold (E Han) is about to cease and tidal fever is about to erupt. This refers to the "tight pulse turning inward." One should not rigidly adhere to the theory that "a tight pulse indicates cold."
[Outline] Zhang Zhongjing stated: In Yangming wind-strike, the pulse is wiry, floating, and large, accompanied by shortness of breath, abdominal fullness, pain in the hypochondrium and heart region, obstruction of Qi upon prolonged pressure, dry nose without sweat, lethargy, complete yellowing of the body and face, difficulty in urination, tidal fever, frequent hiccups (Yue), and swelling around the ears. After acupuncture, symptoms improve slightly, but the exterior syndrome remains unresolved. If the disease persists for more than ten days and the pulse remains wiry and floating, administer Xiao Chai Hu Tang (Minor Bupleurum Decoction). If the pulse is merely floating without other symptoms, administer Ma Huang Tang (Ephedra Decoction). If there is no urination, abdominal fullness, and hiccups, the condition is difficult to treat.
[Commentary] Shen Jin'ao noted: This clause does not mention fever, only tidal fever, clearly indicating an involvement of Shaoyang disease. Therefore, Xiao Chai Hu Tang can be administered.
[Outline] Zhang Zhongjing stated: In Yangming disease, with a slow pulse, slight sweating, and no aversion to cold, the body will certainly feel heavy, accompanied by shortness of breath, abdominal fullness and wheezing. If there is tidal fever, this indicates the exterior is resolving, and interior purgation can be performed. Profuse sweating on the hands and feet indicates hardened stool; Da Cheng Qi Tang (Major Order the Qi Decoction) is indicated. If there is profuse sweating, slight fever, and aversion to cold, the exterior is not yet resolved, and the fever is not tidal; thus, Cheng Qi Tangs should not be given. If there is significant abdominal fullness and obstruction, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) may be given to mildly harmonize Stomach Qi, avoiding severe purgation. In Yangming disease, if there is tidal fever and hardened stool, Da Cheng Qi Tang may be given; if the stool is not hardened, it should not be given. If there has been no bowel movement for six or seven days and dry feces (Zao Shi) are suspected, the method to verify is to give a small amount of Xiao Cheng Qi Tang. If, after ingestion, intestinal gas (Shi Qi) is passed, this indicates dry feces, and purgation can proceed. If no intestinal gas is passed, the stool is likely hard at the beginning but loose later; do not purge. Purging will cause abdominal fullness and inability to eat. Thirst followed by water intake leading to hiccups indicates further complications. Subsequent fever suggests hard, scanty stool, which should be harmonized with Xiao Cheng Qi Tang. If no intestinal gas is passed, absolutely do not purge.
[Commentary] Zhu Gong stated: Tidal fever generally indicates the need for purgation. Zhang Zhongjing said, "Tidal fever indicates excess." In the Da Cheng Qi Tang syndrome description, it states, "If the fever is not tidal, do not give it," confirming that tidal fever warrants purgation. However, one must also examine the pulse and external symptoms. If the pulse is wiry or floating, and there is aversion to cold, an exterior syndrome persists; use Xiao Chai Hu Tang to resolve it first. If there is significant abdominal fullness and obstruction, use Xiao Cheng Qi Tang to mildly harmonize Stomach Qi, avoiding severe purgation. Even if tidal fever suggests Da Cheng Qi Tang, one must first test with a small dose of Xiao Cheng Qi Tang. If no intestinal gas is passed, do not purge. If fever recurs and stool becomes hard again, use Da Chai Hu Tang (Major Bupleurum Decoction) to purge. If there is chest and hypochondriac fullness with vomiting and tidal fever at the Shen hour, use Xiao Chai Hu Tang plus Mang Xiao (Mirabilite). If there is tidal fever at the Shen hour with mild diarrhea, or mild tidal fever with loose stool, or tidal fever with cough and counterflow Qi, Xiao Chai Hu Tang is appropriate. In winter, for Yangming tidal fever, Huang Qin Tang (Scutellaria Decoction) should be used. Yangming diseases generally suit purgation, except when there is aversion to cold or cold damage, where the pathogen is in the meridians, combining with Taiyang as an exterior syndrome, requiring diaphoresis. After emesis or purgation, if the disease persists for seven to eight days with heat结 (Jie) in the interior, exterior and interior both hot, and occasional aversion to cold, it is a Bai Hu Tang (White Tiger Decoction) syndrome.
Ke Qin stated: For various Stomach excess syndromes, sweating on the hands and feet is a reliable sign, while tidal fever is particularly indicative. Since the four limbs are the root of all Yang meridians, and tidal fever at the Shen hour corresponds to the time dominated by the Yangming meridian. In subsequent clauses, if the pulse is slow and weak, tidal fever alone is insufficient evidence, hence the testing method using Xiao Cheng Qi Tang for harmonization and testing, always exercising caution with Da Cheng Qi Tang.
[Outline] Zhang Zhongjing stated: After emesis or purgation in Shang Han (Cold Damage), if the disease is unresolved, with no bowel movement from five to six days up to ten-plus days, tidal fever occurs at the Shen hour, without aversion to cold. The patient speaks alone as if seeing ghosts. In severe cases, they become disoriented, grasp at clothes and beds, are terrified and restless, have slight wheezing and fixed gaze. A wiry pulse indicates survival; a choppy pulse indicates death. In milder cases, there is only fever and delirious speech (Chan Yu), treated with Da Cheng Qi Tang. If one dose results in relief, stop taking the remaining doses.
[Commentary] Shen Jin'ao noted: This case presents tidal fever, constipation, and no aversion to cold, all indicating indications for purgation.
[Outline] Zhang Zhongjing stated: In Yangming disease, with delirious speech and tidal fever, if the patient cannot eat, there must be dry feces (Zao Shi) in the stomach/intestines. If they can eat, the stool is merely hard; Da Cheng Qi Tang is appropriate.
[Commentary] Wei Litong stated: Whether the patient can eat or not, fluid depletion and complete drying of feces are inevitable. Prolonged illness consumes fluids and damages healthy Qi, making Da Cheng Qi Tang suitable. Here, inability to eat distinguishes existing dry feces, while ability to eat predicts future dry feces; both warrant purgation. Other clauses advise caution regardless of eating ability, avoiding excessive purgation. This clause emphasizes that "inability to eat" warrants direct, strong purgation, while "ability to eat" also warrants it. Only through personal insight can one understand Zhang Zhongjing's intent.
In the Shang Han Lun, Zhang Zhongjing fears both inappropriate purgation and premature/excessive purgation. Now he fears failure to purge when indicated or hesitation to purge strongly. Thus, he illustrates the presence of dry feces to warn patients to be cautious yet decisive. This reflects the difficulty of achieving the Doctrine of the Mean.
[Outline] Zhang Zhongjing stated: In Er Yang Bing Bing (Dual Yang Concurrent Disease), once Taiyang symptoms cease, only tidal fever remains, with sweating on hands and feet, difficulty in defecation, and delirious speech. Purging will cure it; Da Cheng Qi Tang is indicated.
[Commentary] Fang Zhongxing stated: With Taiyang symptoms ceased, it fully belongs to Yangming. Mentioning "Dual Yang" initially shows that purgative indications existed even before treatment, demonstrating that once Taiyang resolves, the remaining symptoms are all purgable.
[Outline] Zhang Zhongjing stated: In Yangming disease, with delirious speech and tidal fever, if the pulse is slippery and rapid, Xiao Cheng Qi Tang is indicated. Administer one Sheng of the decoction. If intestinal gas is passed in the abdomen, administer another Sheng. If no intestinal gas is passed, do not administer more. The next day, if there is still no bowel movement and the pulse becomes faint and choppy, this indicates interior deficiency, making it difficult to treat; do not administer Cheng Qi Tang again.
[Commentary] Wei Litong stated: A slippery and rapid pulse indicates the progression toward excess (slippery) and heat (rapid). When the disease transfers from Taiyang to Yangming, exterior pathogens transform into heat and enter the interior. Floating pulses become larger; tight and slow pulses become rapid. Rapidity indicates heat. Without heat transforming and entering the interior, Yangming disease would not form. Generally, when pathogens enter meridians, pulses change from tight/slow to rapid; when entering fu organs, pulses change from rapid to slightly slower.