曰可攻。不过用小承气调胃承气法耳。必手足 然汗出。方可验胃实便硬外邪尽解。而当从大承气
急下之法也。申酉戌间独热。余时不热者。为潮热。若汗出微发热恶寒。是阳明症尚兼太阳。纵腹
大满。胃终不实。只可微和胃气以从权而已。
【纲】仲景曰。阳明病。谵语。发潮热。脉滑而疾者。小承气汤主之。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。里虚也。为难治。不
可更与承气汤也。
【目】柯琴曰。脉滑而疾。有宿食也。明日仍不大便。脉反微涩。微则无阳。涩则少血。此为
里虚。故阳症反见阴脉也。然
胃家未实。阴脉尚多。故脉迟脉弱者。始可和而久可下。阳脉而变为阴脉者。不惟不可下。更不可
和。脉滑者生。脉涩者死。故为难治。然滑有不同。又当详明。夫脉弱而滑。是有胃气。此脉来滑
疾。是失其常度。重阳必阴。仲景早有成见。故少与小承气试之。若据谵语潮热而与大承气。阴盛
已亡矣。此脉症之假有余。小试之而即见真不足。凭脉辨症。可不慎哉。
【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】张兼善曰。此本坏病也。但不可不辨其微剧。微者是邪气实。当以下解。一服利者止后
服。只攻其实。毋乘其虚也。剧者。邪正交争也。当以脉断其虚实。弦者是邪气实。不失为下症。
故生。涩者是正气虚。不可更下。故死。
【纲】仲景曰。脉滑而数者。有宿食也。当下之。宜大承气汤。
【目】龚信曰。数为在腑。故滑为有食。数以至数言。是本来面目。疾以体状言。在谵语潮热
时见。故为失度。
【纲】仲景曰。病患烦热。汗出则解。又如疟状。日晡所发热者。属阳明也。脉实者。宜下之。
与承气汤。
【目】柯琴曰。烦热自汗。似桂枝症。寒热如疟。似柴胡症。然日晡潮热。则属阳明。而脉已
沉实。确为可下。是承气主症主脉也。
【纲】仲景曰。得病二三日。脉弱。无太阳柴胡症。烦躁心下硬。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】王肯堂曰。二三日尚在三阳之界。脉弱者。无阳故也。无阳者。无太阳桂枝症。无少阳
柴胡症也。如是则病不在
表。而阳邪入阴。病在阳明之里也。七日后乃可攻者。以脉弱是太阳中风。能食是阳明中风。以此
为风也。
如果说可以使用攻下法，也不过是运用小承气汤或调胃承气汤的方法罢了。必须等到手足濈然汗出，才能验证胃中实热、大便干硬且外邪已完全解除的情况，此时才应当采用大承气汤急下的治法。如果在申时、酉时、戌时（下午3点至晚上9点）之间单独出现发热，而其他时间不发热，这称为潮热。如果伴有出汗、轻微发热和恶寒，说明阳明病证候仍然兼有太阳病证候。即使腹部胀满严重，胃中也终究没有形成实热，只能稍微调和胃气以权宜处理而已。
【纲】张仲景说：阳明病，出现谵语（神志不清，胡言乱语），发潮热，脉象滑而疾速的，用小承气汤主治。因此给予承气汤一升。如果服药后腹中转动排气（放屁），可以再服一升；如果不转失气，就不要继续给予。到了第二天仍然不大便，脉象反而变得微细涩滞，这是里虚的表现，属于难治之症，不可再给予承气汤。
【目】柯琴说：脉象滑而疾速，说明体内有宿食积滞。如果第二天仍然不大便，脉象反而变得微涩，微脉表示阳气不足，涩脉表示阴血亏少，这是里虚的表现，所以阳证反而出现了阴脉。然而，如果胃家尚未结实，阴脉表现还较多，那么脉迟或脉弱时，才可以温和地调理，久病方可攻下。如果阳脉转变为阴脉，不仅不可攻下，更不可温和调理。脉滑者生，脉涩者死，所以说难治。然而“滑”脉也有不同情况，应当详细阐明。脉弱而滑，是有胃气的表现；此处的脉来滑疾，是失去了正常的节度。重阳必转为阴，张仲景早有定见，所以少量给予小承气汤试探。如果依据谵语、潮热就直接给予大承气汤，阴盛阳亡的情况就会发生。这是脉症表现为假性的有余，经过小试后即显露出真正的不足。凭借脉象辨别症状，能不谨慎吗？
【纲】张仲景说：伤寒病，经过吐法或下法治疗后，病情未解，依然不大便，从五六天到十余天，在日晡时分（下午3-5点）发作潮热，不恶寒，独自说话如同看见鬼怪一样。如果病情严重，发作时不认识人，手抓衣被床沿，惊恐不安，轻微气喘，两眼直视，脉象弦长的可以生存，脉象涩滞的会死亡。病情较轻的只是发热、谵语，用大承气汤主治。如果服用一次后大便通畅，就停止后续服用。
【目】张兼善说：这原本是属于坏病（因误治导致的复杂病变）。但不可不辨别其轻微与严重。轻微的是邪气实，应当通过攻下法解除。服用一次后大便通畅就停止后续服用，只攻其实邪，不要乘其正气虚弱之时进一步损伤。严重的，是邪气与正气交争，应当通过脉象判断虚实。脉弦表示邪气实，不失为可攻下的指征，所以能生存。脉涩表示正气虚，不可再攻下，所以会导致死亡。
【纲】张仲景说：脉象滑而数的，说明有宿食积滞，应当攻下，适宜使用大承气汤。
【目】龚信说：“数”是指脉搏频率快，是从至数（次数）而言，是其本来面目；“疾”是指脉动形态急促，是从体状而言。在出现谵语、潮热时见到这种脉象，说明脉律失常。
【纲】张仲景说：病人感到烦热，出汗后症状缓解，但又像疟疾一样寒热往来，在日晡时分发热的，属于阳明病。脉象实的，适宜攻下，给予承气汤。
【目】柯琴说：烦热自汗，看似桂枝汤证；寒热如疟，看似柴胡汤证。但是日晡潮热，则归属于阳明，而且脉象已经沉实，确凿无疑是可以攻下的，这是承气汤的主症主脉。
【纲】张仲景说：得病两三天，脉象弱，没有太阳病或少阳病的证候，烦躁，心下部硬满，到了四五天，虽然能进食，应少量多次给予小承气汤以轻微调和胃气，使病人稍感安宁。到了第六天，给予承气汤一升。如果仍然不大便，六七天期间小便量少，虽然不能进食，但大便开头硬，后面必然稀溏，尚未完全结成硬块，如果攻下必然导致腹泻。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】王肯堂说：得病两三天还在三阳经的界限内。脉弱，是因为无阳（表阳不足）。无阳，是指没有太阳病的桂枝汤证，也没有少阳病的柴胡汤证。如果是这样，那么病不在表，而是阳邪入里，病在阳明之里。七天后才可以攻下，是因为脉弱提示可能是太阳中风，能进食提示可能是阳明中风，以此判断为风邪致病。
If it is stated that purgation can be used, it merely involves the methods of Xiao Cheng Qi Tang (Minor Order the Intestines Decoction) or Tiao Wei Cheng Qi Tang (Regulate the Stomach Order the Intestines Decoction). Only when there is continuous sweating on the hands and feet can one verify that the stomach is full of heat, the stool is hard, and the external pathogens have completely resolved; at this point, the method of urgent purgation with Da Cheng Qi Tang (Major Order the Intestines Decoction) should be adopted. If fever occurs exclusively between Shen, You, and Xu hours (3 PM to 9 PM) but not at other times, this is termed tidal fever (Chao Re). If accompanied by sweating, slight fever, and aversion to cold, it indicates that the Yangming syndrome still coexists with Taiyang syndrome. Even if the abdomen is severely distended, the stomach has ultimately not formed excess heat; one can only slightly harmonize the stomach qi as a temporary measure.
[Gang] Zhang Zhongjing said: In Yangming disease, if there is delirium (Dan Yu), tidal fever, and a slippery and rapid pulse, Xiao Cheng Qi Tang (Minor Order the Intestines Decoction) is the primary treatment. Therefore, administer one sheng of Cheng Qi Tang. If gas moves in the abdomen after taking the medicine, administer another sheng; if there is no movement of gas, do not give more. If the next day there is still no bowel movement and the pulse becomes faint and choppy, this indicates interior deficiency, which is difficult to treat, and Cheng Qi Tang should not be administered again.
[Mu] Ke Qin said: A slippery and rapid pulse indicates the presence of retained food stagnation. If there is still no bowel movement the next day and the pulse becomes faint and choppy, a faint pulse indicates lack of yang, and a choppy pulse indicates scant blood; this constitutes interior deficiency, hence an yang syndrome presents with yin pulses. However, if the stomach house is not yet solid and yin pulses are still predominant, then when the pulse is slow or weak, gentle harmonization may be used, and purgation may be considered for chronic conditions. If yang pulses transform into yin pulses, not only is purgation contraindicated, but gentle harmonization is also contraindicated. A slippery pulse indicates survival, while a choppy pulse indicates death; thus, it is described as difficult to treat. Nevertheless, "slippery" pulses vary and must be clarified in detail. A weak yet slippery pulse indicates the presence of stomach qi; however, a pulse that comes in a slippery and rapid manner has lost its normal rhythm. Extreme yang transforms into yin, and Zhang Zhongjing had this insight early on. Therefore, a small amount of Xiao Cheng Qi Tang (Minor Order the Intestines Decoction) is given as a test. If one were to administer Da Cheng Qi Tang (Major Order the Intestines Decoction) based solely on delirium and tidal fever, yin excess would lead to yang exhaustion. This represents a false appearance of excess in pulse and symptoms, which reveals true deficiency upon minor testing. Relying on pulse to differentiate symptoms, how can one not be cautious?
[Gang] Zhang Zhongjing said: After Shanghan (Cold Damage) has been treated with emesis or purgation, if the condition remains unresolved, with no bowel movement for five to six days up to ten-plus days, tidal fever occurs during Dubu time (3 PM to 5 PM), without aversion to cold, and the patient speaks alone as if seeing ghosts. If severe, the patient may become unrecognizable during episodes, grasp clothing and bed rails, feel terrified and uneasy, exhibit slight panting, and stare fixedly. A string-like (Xian) pulse indicates survival, while a choppy (Se) pulse indicates death. In mild cases, there is only fever and delirium, treated with Da Cheng Qi Tang (Major Order the Intestines Decoction). If relief occurs after one dose, stop subsequent doses.
[Mu] Zhang Jianshan said: This originally belongs to Huai Bing (complicated disease due to mismanagement). However, one must distinguish between mild and severe cases. Mild cases involve excess pathogenic factors, which should be resolved through purgation. Stopping after one dose of relief prevents further damage to deficiency while attacking excess. Severe cases involve struggle between pathogenic factors and healthy qi; the pulse should be used to determine deficiency or excess. A string-like pulse indicates excess pathogenic factors, making it suitable for purgation, hence survival. A choppy pulse indicates deficiency of healthy qi, making further purgation contraindicated, hence death.
[Gang] Zhang Zhongjing said: When the pulse is slippery and rapid, it indicates retained food stagnation, which should be purged using Da Cheng Qi Tang (Major Order the Intestines Decoction).
[Mu] Gong Xin said: "Rapid" refers to frequency, describing its fundamental nature; "swift" refers to the physical quality. Seeing these pulses during delirium and tidal fever indicates loss of normal rhythm.
[Gang] Zhang Zhongjing said: If patients experience vexatious heat, relief follows sweating, yet symptoms resemble malaria with alternating chills and fever, and fever occurs at Dubu time, it belongs to Yangming. If the pulse is excess (Shi), purgation is appropriate, administering Cheng Qi Tang.
[Mu] Ke Qin said: Vexatious heat with spontaneous sweating resembles Guizhi Tang (Cinnamon Twig Decoction) syndrome; chills and fever resembling malaria resembles Chaihu Tang (Bupleurum Decoction) syndrome. However, tidal fever at Dubu time belongs to Yangming, and the pulse is already deep and excess, confirming suitability for purgation; these are the main symptoms and pulses for Cheng Qi Tang.
[Gang] Zhang Zhongjing said: Two to three days after contracting disease, if the pulse is weak, without Taiyang or Shaoyang symptoms, but with restlessness and hardness in the epigastrium, progressing to four to five days, even if the patient can eat, give Xiao Cheng Qi Tang (Minor Order the Intestines Decoction) in small amounts frequently to mildly harmonize the stomach qi, allowing slight comfort. By the sixth day, administer one sheng of Cheng Qi Tang. If there is still no bowel movement, and from the sixth to seventh day urine output is low, even if the patient cannot eat, if the stool is hard at the beginning but loose later, it has not definitively hardened; purging will cause loose stools. One must wait for free urination and definitive hardening of the stool before purging, using Da Cheng Qi Tang (Major Order the Intestines Decoction).
[Mu] Wang Kentang said: Two to three days after onset is still within the realm of the Three Yang meridians. A weak pulse indicates absence of yang. Absence of yang means absence of Taiyang Guizhi Tang (Cinnamon Twig Decoction) syndrome and Shaoyang Chaihu Tang (Bupleurum Decoction) syndrome. Thus, the disease is not in the exterior, but yang pathogens have entered the interior, residing in the interior of Yangming. Purging can only be done after seven days because a weak pulse suggests Taiyang wind-stroke, and ability to eat suggests Yangming wind-stroke, identifying the pathogen as wind.