也。又云。今人病热。大渴引饮。饮愈多则渴愈甚。所饮之水既多。一时小便岂能尽去。况人既病热。则气必
偏胜。水自趋下。火自炎上。此即是水湿停而燥渴之征。故猪苓汤。润燥渴而利湿热也。
猪苓汤方
猪苓（去皮） 滑石（碎各一两○外台。有绵裹二字。） 茯苓 阿胶（○外台。有炙字。） 泽泻
上五味。以水四升。先煮四味。取二升。去滓。纳阿胶烊消。温服七合。日三服。（成本。纳下。有下
字。烊消。玉函。作消尽。）
〔鉴〕赵羽皇曰。仲景制猪苓汤。以行阳明少阴二经水热。然其旨全在益阴。不专利水。盖伤寒表虚。最
忌亡阳。而里虚又患亡阴。亡阴者。亡肾中之阴。与胃家之津液也。故阴虚之人。不但大便不可轻动。即小水
亦忌下通。倘阴虚过于渗利。则津液反致竭。方中阿胶质膏。养阴而滋燥。滑石性滑。去热而利水。佐以二苓
之渗泻。既疏浊热。而不留其壅瘀。亦润真阴。而不苦其枯燥。是利水而不伤阴之善剂也。故利水之法。于太
阳用五苓。加桂者。温之以行水也。于阳明少阴。用猪苓。加阿胶滑石者。润之以滋养无形。以行有
形也。利水虽同。寒温迥别。惟明者知之。
医方考曰。四物皆渗利。则又有下多亡阴之惧。故用阿胶佐之。以存津液于决渎尔。
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。
〔成〕针经曰。水谷入于口。输于肠胃。其液别为五。天寒衣薄则为溺。天热衣浓则为汗。是汗溺一液也。
汗多为津液外泄。胃中干燥。故不可与猪苓汤利小便也。（案针经文。出五癃津液别论。）〔柯〕汗多而渴。
当白虎汤。胃中燥。当承气汤。具在言外。
案魏氏云。若见虚。则炙甘草之证。实则调胃承气之证。炙甘草。盖为不对矣。
脉浮而迟。表热里寒。下利清谷者。四逆汤主之。
〔钱〕此与少阴厥阴。里寒外热。同义。若风脉浮而表热。则浮脉必数。今表虽热而脉迟。则知阴寒在里。
阴盛格阳于外。而表热也。虚阳在外。故脉浮。阴寒在里。故脉迟。所以下利清谷。此为真寒假热。故以四逆
汤。祛除寒气。恢复真阳也。若以为表邪。而汗之则殆矣。〔魏〕此虽有表证。且不治表而治里。则虽有阳明
假热之证。宁容不治真寒。而治假热乎。是皆学人所宜明辨。而慎出之者也。
案此其实少阴病。而假现汗出恶热等。阳明外证者。故特揭出斯篇。方氏云。此疑三阴篇错简。恐不然也。
若胃中虚冷。不能食者。饮水则哕。（玉函。冷下。有其人二字。千金翼。无若字。脉经。若上。有阳明
病三字。冷下。有其人二字。是。）
〔锡〕此论阳明中焦虚冷也。若者。承上文而言也。言不特下焦生阳不启。而为虚寒。即中焦火土衰微。
而亦虚冷也。夫胃气壮。则谷消而水化。若胃中虚冷。则谷不消。而不能
食。夫既不能食。则水必不化。两寒相得。是以发哕。〔汪〕武陵陈氏云。法当大温。上节已用四逆。故不更
言治法。愚案常器之云。宜温中汤。然不若用茯苓四逆汤。即四逆汤中。加人参以补虚。茯苓以利水也。〔鉴〕
宜理中汤。加丁香吴茱萸。温而降之可也。
脉浮发热。口干鼻燥。能食者。则衄。（王肯堂校千金翼。鼻。作舌。）
〔魏〕脉浮发热。太阳病尚有存者。而口干鼻燥能食。虽阳明里证未全成。阳明内热已太盛。热盛则上逆。
上逆则引血。血上则衄。此又气足阳亢之故。热邪亦随之而泄。〔锡〕能食者则衄。言病不在胃。非因能食而
致衄也。
〔汪〕常器之云。可与黄芩汤。愚云。宜犀角地黄汤。
案舒氏云。热病得衄则解。能食者。胃气强。邪当自解。故曰能食者则衄。俗谓红衣伤寒。不治之证。何
其陋也。太阳发衄者。曰衄乃解。曰自衄者愈。以火劫致变者。亦云邪从衄解。即以阴邪。激动营血者。尚有
四逆汤可救。安见衄证。皆为不可治乎。大抵俗医见衄。概以寒凉。冰凝生变。酿成不治。故创此名色。以欺
世而逃其责耳。
阳明病下之。其外有热。手足温不结胸。心中懊 。饥不能食。但头汗出者。栀子豉汤主之。（脉经。千
金翼。饥上。有若字。）
〔汪〕此亦阳明病误下之变证。阳明误下。邪热虽应内陷。不比太阳病误下之深。故其身外犹有余热。手
足温。不结胸。手足温者。征其表和而无大邪。不结胸者。征其里和而无大邪。表里已无大邪。其邪但在胸膈
之间。以故心中懊 。饥不能食者。言懊 之甚。则似饥非饥。嘈杂不能食也。但头汗出者。成注云。热自胸
中。熏蒸于上。故但头汗出。而身无汗也。〔志〕栀豉汤。解心中之虚热。以下交则上下调和。
而在外之热。亦清矣。
阳明病。发潮热。大便溏。小便自可。胸胁满不去者。与小柴胡汤。（成本。无与字。汤下。有主之二字。
玉函同。胸上。有而字。千金翼同。）
〔王〕阳明为病。胃实是也。今便溏。而言阳明病者。谓阳明外证。身热汗出。不恶寒。反恶热之病也。
〔成〕阳明病潮热。为胃实。大便硬而小便数。今大便溏。小便自可。则胃热未实。而水谷不别也。大便溏者。
应气降而胸胁满去。今反不去者。邪气犹在半表半里之间。与小柴胡汤。以去表里之邪。〔钱〕盖阳明虽属主
病。而仲景已云伤寒中风。有柴胡证。但见一证便是。不必悉具。故凡见少阳一证。便不可汗下。惟宜以小柴
胡汤。和解之也。
阳明病。胁下硬满。不大便而呕。舌上白苔者。可与小柴胡汤。上焦得通。津液得下。胃气因和。身
然汗出而解。（成本。解下。有也字。）
〔成〕阳明病。腹满不大便。舌上苔黄者。为邪热入腑。可下。若胁下硬满。虽不大便而呕。舌上白苔者。
为邪未入腑。在表里之间。与小柴胡汤。以和解之。上焦得通。则呕止。津液得下。则胃气因和。汗出而解。
〔钱〕不大便。为阳明里热。然呕则又少阳证也。若热邪实于胃。则舌苔非黄即黑。或干硬。或芒刺矣。舌上白
苔。为舌苔之初现。若夫邪初在表。舌尚无苔。既有白苔。邪虽未必全在于表。然犹未尽入于里。故仍为半表
半里之证。〔方〕津液下。大便行也。〔程〕胁下硬痛。不大便而呕。自是大柴胡汤证。其用小柴胡汤者。以
舌上白苔。犹带表寒故也。若苔不滑而涩。则所谓舌上干燥而烦。欲饮水数升之谓。热已耗及津液。此汤不可
主矣。〔锡〕不大便者。下焦不通。津液不得下也。呕者。中
焦不治。胃气不和也。舌上白苔者。上焦不通。火郁于上也。可与小柴胡汤。调和三焦之气。上焦得通。而白
苔去。津液得下。而大便利。胃气因和。而呕止。三焦通畅。气机旋转。身 然汗出而解也。
阳明中风。脉弦浮大。而短气。腹都满。胁下及心痛。久按之气不通。鼻干不得汗。嗜卧。一身及目悉黄。
小便难。有潮热。时时哕。耳前后肿。刺之小瘥。外不解。病过十日。脉续浮者。与小柴胡汤。脉但浮。无余
证者。与麻黄汤。若不尿。腹满加哕者。不治。（成本。玉函。目上。有面字。脉经注云。按之气不通。一作
按之不痛。正脉。腹都。作腹部。）
〔方〕弦。少阳。浮。太阳。大。阳明。胁下痛。少阳也。小便难。太阳之膀胱不利也。腹满。鼻干。嗜
卧。一身及面目悉黄。潮热。阳明也。时时哕。三阳具见。而气逆甚也。耳前后肿。阳明之脉。出大迎。循颊
车。上耳前。太阳之脉。其支者。从巅至耳。少阳之脉。下耳后。其支者。从耳后。入耳中。出走耳前也。然
则三阳俱见证。而曰阳明者。以阳明居多。而任重也。〔钱〕久按之。气不通者。言不按已自短气。若久按之。
则气愈不通。盖言其邪气充斥也。嗜卧。阳明里邪也。小便难者。邪热闭塞。三焦气化不行也。若小便利。则
不能发黄矣。〔程〕此条证。以不得汗三字为主。盖风热两壅。阳气重矣。怫郁不得越。欲出不得出。欲入不
得入。经缠被扰。无所不至。究竟无宣泄处。故见证如此。刺法。从经脉中。泄其热耳。其风邪被缠者固未去
也。故纡而缓之。乃酌量于柴胡麻黄二汤间。以通其久闭。总是要得汗耳。不尿腹满加哕。胃气已竭。而三焦
不复流通。邪永无出路矣。〔柯〕本条不言发热。看中风二字。便藏表热在内。外不解。即指表热而言。即暗
伏内已解句。病过十日。是内已解之互
文也。当作外不解句上。无余证句。接外不解句来。刺之。是刺足阳明。随其实而泻之。少瘥句。言内能俱减。
但外证未解耳。非刺耳前后。其肿少瘥之谓也。脉弦浮者。向之浮大减小。而弦尚存。是阳明之证已罢。惟少
阳之表邪尚存。故可用小柴胡以解外。若脉但浮。而不弦大。则非阳明少阳脉。无余证。则上文诸证悉罢。是
无阳明少阳证。惟太阳之表邪未散。故可与麻黄汤以解外。若不尿腹满加哕。是接耳前后肿来。此是内不解。
故小便难者竟不尿。腹部满者竟不减。时时哕者。更加哕矣。非刺后所致。亦非用柴胡麻黄后变证也。〔志〕
耳前后肿。即伤寒中风之发颐证。但发颐之证。有死有生。阴阳并逆者死。气机旋转者生。朱氏曰。此与太阳
篇中。十日以去。胸满胸痛者。与小柴胡汤。脉但浮者。与麻黄汤。同一义也。（案出第三十七条中篇。）
金鉴云。此等阴阳错杂。表里混淆之证。但教人俟其病势所向。乘机而施治也。故用刺法。待其小瘥。案
金鉴云。续浮之浮字。当是弦字。始与文义相属。则可与小柴胡汤。若俱是浮字。则上之浮。既宜用小柴胡汤。
下之浮。又如何用麻黄汤耶。此说近是。
阳明病。自汗出。若发汗。小便自利者。此为津液内竭。虽硬不可攻之。当须自欲大便。宜蜜煎导而通之。
若土瓜根。及大猪胆汁。皆可为导。（成本。及下。有与字。玉函。脉经。猪上。无大字。）
〔成〕津液内竭。肠胃干燥。大便因硬。此非结热。故不可攻。宜以药外治。而导引之。〔鉴〕阳明病自
汗出。或发汗。小便自利者。此为津液内竭。虽大便硬。而无满痛之苦。不可攻之。当待津液还胃。自欲大便。
燥屎已至直肠。难出肛门之时。则用蜜煎。润窍滋燥。导而利之。或土瓜根。宣气通燥。或猪胆汁。清热润燥。
皆可为引导法。择而用之可也。
〔柯〕连用三自字。见胃实而无变证者。当任其自然。而不可妄治。更当探苦欲之情。于欲大便时。因其势而
利导之。不欲便者。宜静以俟之矣。
案方氏云。虽上或下。当有大便二字。可谓拘矣。
汪氏云。或问。小便自利大便硬。何以不用麻仁丸。余答云。麻仁丸。治胃热尿结于回肠以内。兹者。
胃无热证。屎已近肛门之上。直肠之中。故云因其势而导之也。
蜜煎方（成本。作蜜煎导。）
食蜜（七合○成本。玉函。千金翼。无食字。）
上一味。于铜器内。微火煎。当须凝如饴状。搅之勿令焦着。欲可丸。并手捻作挺。令头锐。大如指。
长二寸许。当热时急作。冷则硬。以纳谷道中。以手急抱。欲大便时乃去之。疑非仲景意。已试甚良。○又大
猪胆一枚。泻汁。和少许法醋。以灌谷道内。如一食顷。当大便出宿食恶物。甚效。（成本。玉函。于铜器内。
作纳铜器中。当须。作之稍。如。作似。无疑以下九字。和少许法醋。作和醋少许。谷道内。作谷道中。无宿
以下六字。正脉。搅。作扰。玉函。欲可丸。作俟可丸。成本。大猪胆上。无又字。方本。挺下。有子字。王
本。并手。作以手。抱字。作捺住二字。）
〔汪〕内台方。用蜜五合。煎凝时。加皂角末五钱。蘸捻作挺。以猪胆汁或油。润谷道纳之。猪胆汁方。
不用醋。以小竹管。插入胆口留一头。用油润。纳入谷道中。以手将胆捻之。其汁自入内。此法。用之甚便。
土瓜根方缺。肘后方。治大便不通。土瓜根。采根捣汁。筒吹入肛门内。取通。此与上猪胆方同义。内台方。
用土瓜根。削如挺。纳入谷道中。误矣。盖蜜挺。入谷道。能烊化而润大便。土瓜根。不能烊化。如削挺用之。
恐失仲景制方之义。
志聪本。蜜煎后。有或用土瓜根捣汁。竹管灌入谷道十
三字。盖据肘后补添者。钱本。蜜煎。及猪胆汁法。与原文异。今录下。蜜煎导法。白蜜七合。一味。入铜铫
中。微火煎老。试其冷则硬。勿令焦。入猪牙皂角末少许。热时手捻作挺。令头锐根凹。长寸半者三枚。待冷
硬。蘸油少许。纳谷道中。其次以锐头顶凹。而入三枚尽。以布着手指抵定。若即欲大便。勿轻去。俟先入者
已化大便急甚。有旁流者出。方去手。随大便出。猪胆导法。极大猪胆一枚。用芦管长三寸余通之。磨光一头。
以便插入谷道。用尖锋刀。刺开胆口。以管插入胆中。用线扎定管口。抹油。捻入谷道。插尽芦管。外以布衬
手。用力捻之。则胆汁尽入。方去之。少顷大便即出。
伤寒准绳曰。凡多汗伤津。或屡汗不解。或尺中脉迟弱。元气素虚人。便欲下而不能出者。并宜导法。但
也。又说：现在人患热病，大渴引饮，喝得越多则渴越厉害。所喝的水既然很多，一时之间小便怎么能全部排出去呢？况且人既患热病，那么阳气必然偏胜，水自然趋下，火自然炎上。这就是水湿停聚而燥渴的征象。所以猪苓汤，能润燥止渴并利湿热。
猪苓汤方
猪苓（去皮） 滑石（打碎，各一两，《外台秘要》有“绵裹”二字。） 茯苓 阿胶（《外台秘要》有“炙”字。） 泽泻
以上五味药，用水四升，先煮前四味药，取二升药液，去渣，加入阿胶使其烊化溶解。每次温服七合，每日三次。（《成本》本，“纳”下有“下”字。“烊消”，《玉函经》作“消尽”。）
〔鉴〕赵羽皇说：张仲景制定猪苓汤，是为了运行阳明、少阴二经的水热之邪。然而其主旨全在于益阴，并不专门利尿。大概伤寒表虚，最忌讳亡阳；而里虚又担心亡阴。亡阴，就是肾中的阴气和胃家的津液耗亡。所以阴虚之人，不但大便不可轻易攻动，即使小便也忌讳过度通利。倘若阴虚之人过度使用渗利药物，那么津液反而会导致枯竭。方中阿胶质地膏润，养阴而滋润燥渴；滑石性质滑利，清热而利水。佐以猪苓、茯苓的渗泻作用，既能疏通浊热，又不留滞壅瘀；也能滋润真阴，而不致过于苦燥。这是利水而不伤阴的良好方剂。所以利水的方法，在太阳病用五苓散，加桂枝，是用温性来行水；在阳明、少阴病用猪苓汤，加阿胶、滑石，是用润性来滋养无形之阴，从而推动有形之水。虽然都是利水，但寒温截然不同，只有明理的人才能知晓。
《医方考》说：四方皆属渗利之品，则有因利下过多而亡阴的担忧，所以用阿胶来佐助，以保存津液于决渎之道。
阳明病，汗出多而且口渴的，不可给予猪苓汤。因为汗多导致胃中干燥，猪苓汤再次利其小便的缘故。
〔成〕《针经》说：水谷进入口中，输送到肠胃，其中的液体分为五种。天气寒冷衣服单薄时就化为尿；天气炎热衣服厚重时就化为汗。这说明汗和尿是同一种液体转化而来的。汗出多则是津液外泄，胃中干燥，所以不可用猪苓汤利小便。（按：《针经》此文出自《五癃津液别论》。）〔柯〕汗多而渴，应当用白虎汤。胃中干燥，应当用承气汤。意思都在言外。
案：魏氏说：如果见到虚证，则是炙甘草汤的适应证；如果是实证，则是调胃承气汤的适应证。用炙甘草汤就不对了。
〔钱〕这与少阴、厥阴病的里寒外热，意义相同。如果是风邪所致脉浮而表热，那么浮脉必定数急。现在虽然表热但脉迟，就知道阴寒在里。阴盛格拒阳气于外，所以出现表热。虚阳在外，所以脉浮；阴寒在里，所以脉迟。因此出现下利清谷。这是真寒假热，所以用四逆汤祛除寒气，恢复真阳。如果认为是表邪而发汗，那就危险了。〔魏〕这虽然有表证，但不治表而治里，那么虽然有阳明假热的证候，难道可以不顾真寒而去治疗假热吗？这都是学者应当明辨，并且谨慎施治的地方。
案：这其实是少阴病，而虚假地表现出汗、恶热等阳明外证，所以特意揭示在这一篇中。方氏说：这怀疑是三阴篇的错简，恐怕不是这样。
如果胃中虚冷，不能进食的，喝水就会呃逆。（《玉函经》，“冷”下有“其人”二字。《千金翼方》无“若”字。《脉经》，“若”上有“阳明病”三字。“冷”下有“其人”二字，是正确的。）
〔锡〕这是论述阳明中焦虚冷。这里的“若”，是承接上文来说的。意思是不仅下焦生阳不启而为虚寒，就连中焦的火土衰微，也是虚冷的。胃气壮实，则谷物消化而水液运化。如果胃中虚冷，则谷物不消化，而不能进食。既然不能进食，那么水液必然不化。两寒相合，所以发生呃逆。〔汪〕武陵陈氏说：治法应当大温。上一节已经用了四逆汤，所以不再说明治法。我按：常器之说：宜用温中汤。然而不如用茯苓四逆汤，即在四逆汤中加入人参以补虚，茯苓以利水。〔鉴〕宜用理中汤，加丁香、吴茱萸，温降即可。
脉浮发热，口干鼻燥，能进食的，则会鼻衄。（王肯堂校勘《千金翼方》，将“鼻”改为“舌”。）
〔魏〕脉浮发热，太阳病还有残留，而口干鼻燥能食，虽然阳明里证尚未完全形成，但阳明内热已经太盛。热盛则气机上逆，气机上逆则引动血液，血上行则鼻衄。这又是气足阳亢的缘故，热邪也随之而泄。〔锡〕“能食者则衄”，是说病不在胃，不是因为能食而导致鼻衄。
案：舒氏说：热病得鼻衄则解。能食者，胃气强，邪气应当自行解除，所以说能食者则衄。世俗称为“红衣伤寒”，是不可治之证，多么浅陋啊！太阳病发鼻衄的，说“衄乃解”，说“自衄者愈”。因火劫导致变证的，也说“邪从衄解”。即使是阴邪激动营血，尚有四逆汤可救，怎见得衄血证都是不可治的呢？大抵庸医见衄，一概用寒凉药，冰凝而生变，酿成不治之症，所以创立这个名目，来欺骗世人逃避责任罢了。
阳明病，经过攻下后，体表仍有热，手足温暖，没有结胸，心中懊恼，饥饿但不能进食，仅头部出汗的，用栀子豉汤主治。（《脉经》、《千金翼方》，“饥”上有“若”字。）
〔汪〕这也是阳明病误下后的变证。阳明病误下，邪热虽然应该内陷，但不比太阳病误下那样深重，所以身体外部仍有残余热邪。手足温暖，证明表和无大邪；没有结胸，证明里和无大邪。表里已无大邪，邪气只在胸膈之间。因此心中懊恼。所谓“饥不能食”，是说懊恼得很厉害，则似饥非饥，嘈杂不能进食。仅头部出汗，成无己注解说：热自胸中熏蒸于上，所以仅头部出汗，而身体无汗。〔志〕栀豉汤，解开心中的虚热，以下交则上下调和，而在外的热邪，也就清除了。
阳明病，发潮热，大便溏，小便正常，胸胁满闷不去的，给予小柴胡汤。（《成本》本，无“与”字。“汤”下有“主之”二字。《玉函经》同。“胸”上有“而”字。《千金翼方》同。）
〔王〕阳明为病，胃实是主要特征。现在大便溏，却说阳明病，是指阳明外证，即身热汗出，不恶寒，反恶热的病。〔成〕阳明病潮热，是胃实，大便硬而小便频数。现在大便溏，小便正常，则胃热未实，而水谷不分。大便溏，应当气降而胸胁满消除。现在反而不去，说明邪气还在半表半里之间，给予小柴胡汤，以去除表里之邪。〔钱〕大概阳明虽属主病，但仲景已说伤寒中风，有柴胡证，只要见到一个柴胡证即可，不必具备所有症状。所以凡见到少阳一证，就不可汗下，只宜用小柴胡汤和解。
阳明病，胁下硬满，不大便而呕，舌上白苔的，可给予小柴胡汤。上焦通畅，津液下行，胃气因而调和，身体微微汗出而解。（《成本》本，“解”下有“也”字。）
〔成〕阳明病，腹满不大便，舌上苔黄的，是邪热入腑，可攻下。如果胁下硬满，虽然不大便而呕，舌上白苔的，是邪未入腑，在表里之间，给予小柴胡汤，以和解。上焦通畅，则呕止；津液下行，则胃气因而调和；汗出而解。〔钱〕不大便，是阳明里热。然而呕又是少阳证。如果热邪实于胃，则舌苔非黄即黑，或干硬，或有芒刺。舌上白苔，是舌苔初现。如果邪气初在表，舌尚无苔。既有白苔，邪气虽然未必全在表，但也未尽入于里，所以仍为半表半里之证。〔方〕津液下行，大便通行。〔程〕胁下硬痛，不大便而呕，本是大柴胡汤证。其用小柴胡汤的，是因为舌上白苔，还带有表寒。如果苔不滑而涩，那就是所谓的“舌上干燥而烦，欲饮水数升”。热已耗及津液，此汤不可主了。〔锡〕不大便，是下焦不通，津液不得下行。呕，是中焦不治，胃气不和。舌上白苔，是上焦不通，火郁于上。可给予小柴胡汤，调和三焦之气。上焦通畅，而白苔去；津液下行，而大便通；胃气因而调和，而呕止。三焦通畅，气机旋转，身体微微汗出而解。
阳明中风，脉弦浮大，而短气，腹部都胀满，胁下及心痛，久按之气不通，鼻干不得汗，嗜卧，全身及眼睛都发黄，小便难，有潮热，时时呃逆，耳前后肿，针刺后稍好转，表证仍未解。病过十天，脉继续浮的，给予小柴胡汤。脉只浮，没有其他余证的，给予麻黄汤。如果不排尿，腹满加重且呃逆的，是不治之证。（《成本》本、《玉函经》，“目”上有“面”字。《脉经》注云：“按之气不通”，一作“按之不痛”。《正脉》，“腹都”作“腹部”。）
〔方〕弦，属少阳；浮，属太阳；大，属阳明。胁下痛，属少阳。小便难，是太阳膀胱不利。腹满、鼻干、嗜卧、全身及面目悉黄、潮热，属阳明。时时呃逆，是三阳俱见，而气逆很严重。耳前后肿，阳明的经脉，出于大迎，循颊车，上耳前；太阳的经脉，其支者，从巅至耳；少阳的经脉，下耳后，其支者，从耳后，入耳中，出走耳前。既然如此，三阳俱见证候，而说阳明，是因为阳明居多，而任重。〔钱〕久按之，气不通，是说不按已经短气，如果久按，则气更不通。大概是说邪气充斥。嗜卧，是阳明里邪。小便难，是邪热闭塞，三焦气化不行。如果小便利，就不能发黄了。〔程〕这条证候，以“不得汗”三字为主。大概风热两壅，阳气重了。怫郁不得发散，想出不出来，想入进不去，经络缠绕被扰，无所不至。终究没有宣泄之处，所以见证如此。刺法，是从经脉中泄其热而已。那风邪被缠绕的固然没去掉。所以迂回缓慢地处理，于是斟酌于柴胡、麻黄二汤之间，以通其久闭。总是要得汗罢了。不尿、腹满加哕，是胃气已竭，而三焦不复流通，邪气永远没有出路了。〔柯〕本条不言发热，看“中风”二字，便藏表热在内。“外不解”，即指表热而言。即暗伏“内已解”句。“病过十日”，是“内已解”的互文。应当放在“外不解”句上。“无余证”句，接“外不解”句来。“刺之”，是刺足阳明，随其实而泻之。“少瘥”句，是说内部能俱减，但外证未解罢了。不是刺耳前后，其肿少瘥的意思。脉弦浮者，向之浮大减小，而弦尚存，是阳明之证已罢，惟少阳之表邪尚存，故可用小柴胡以解外。若脉但浮，而不弦大，则非阳明少阳脉。无余证，则上文诸证悉罢。是无阳明少阳证，惟太阳之表邪未散，故可与麻黄汤以解外。若不尿、腹满加哕，是接“耳前后肿”来。这是内不解，故小便难者竟不尿，腹部满者竟不减，时时哕者，更加哕矣。这不是刺后所致，也不是用柴胡麻黄后变证。〔志〕耳前后肿，即伤寒中风之发颐证。但发颐之证，有死有生，阴阳并逆者死，气机旋转者生。朱氏说：这与太阳篇中，“十日以去，胸满胸痛者，与小柴胡汤。脉但浮者，与麻黄汤。”同一义理。（案：出自第三十七条中篇。）
金鉴说：这些阴阳错杂、表里混淆的证候，只是教人等待病势所向，乘机而施治。所以用刺法，待其稍好转。案金鉴说：“续浮”的“浮”字，应当是“弦”字，才与文义相属，则可与小柴胡汤。如果俱是“浮”字，则上面的“浮”，既宜用小柴胡汤，下面的“浮”，又如何用麻黄汤呢？这种说法接近正确。
阳明病，自汗出，如果发汗，小便自利的，这是津液内竭。虽然大便硬，不可攻下。应当等到患者自欲大便时，宜用蜜煎导而通之。如果用土瓜根，以及大猪胆汁，都可以作为导法。（《成本》本，“及”下有“与”字。《玉函经》、《脉经》，“猪”上无“大”字。）
〔成〕津液内竭，肠胃干燥，大便因此变硬。这不是结热，所以不可攻下。宜用药外治，而引导它。〔鉴〕阳明病自汗出，或发汗，小便自利的，这是津液内竭。虽然大便硬，而无满痛之苦，不可攻下。应当等待津液还胃，自欲大便，燥屎已至直肠，难出肛门之时，则用蜜煎，润窍滋燥，导而利之。或用土瓜根，宣气通燥；或猪胆汁，清热润燥。都可以作为引导法，择而用之即可。
〔柯〕连用三个“自”字，见胃实而无变证者，当任其自然，而不可妄治。更当探求苦欲之情，于欲大便时，因其势而利导之。不欲便者，宜静以俟之。
案：方氏说：虽然上或下，应当有“大便”二字，可谓拘泥。
汪氏说：有人问：小便自利大便硬，为什么不用麻仁丸？我回答：麻仁丸，治胃热尿结于回肠以内。此时，胃无热证，屎已近肛门之上，直肠之中，所以说因其势而导之。
蜜煎方（《成本》本，作“蜜煎导”。）
食蜜（七合○《成本》本、《玉函经》、《千金翼方》，无“食”字。）
以上一味药，在铜器内，微火煎。应当等到凝固如饴糖状，搅动它不要让它焦着。想要做成丸状，用手捻作挺条，令头尖，大约一指粗，长二寸左右。应当在热时急做，冷了就硬。纳入肛门中，用手紧紧抱住，想大便时才去掉。怀疑不是张仲景的本意，已经试验很有效。○又一大猪胆一枚，泻汁，和少许法醋，以灌肛门内。一顿饭功夫，应当大便排出宿食恶物，很有效。（《成本》本、《玉函经》，“于铜器内”，作“纳铜器中”。“当须”，作“之稍”。“如”，作“似”。“无疑”以下九字。“和少许法醋”，作“和醋少许”。“谷道内”，作“谷道中”。无“宿”以下六字。《正脉》，“搅”，作“扰”。《玉函经》，“欲可丸”，作“俟可丸”。《成本》本，“大猪胆”上，无“又”字。《方本》，“挺”下，有“子”字。《王本》，“并手”，作“以手”。“抱”字，作“捺住”二字。）
〔汪〕《内台方》用蜜五合，煎凝时，加皂角末五钱，蘸捻作挺，用猪胆汁或油，润谷道纳之。猪胆汁方，不用醋，以小竹管，插入胆口留一头，用油润，纳入谷道中，用手将胆捻之，其汁自入内。此法，用之甚便。土瓜根方缺。《肘后方》，治大便不通，土瓜根，采根捣汁，筒吹入肛门内，取通。这与上猪胆方同义。《内台方》用土瓜根，削如挺，纳入谷道中，错误了。大概蜜挺，入谷道，能烊化而润大便。土瓜根，不能烊化，如削挺用之，恐怕失去张仲景制方之义。
志聪本，蜜煎后，有“或用土瓜根捣汁，竹管灌入谷道”十三字，大概是据《肘后方》补添的。钱本，蜜煎及猪胆汁法，与原文异，今录如下。蜜煎导法：白蜜七合，一味，入铜铫中，微火煎老，试其冷则硬，勿令焦。入猪牙皂角末少许，热时手捻作挺，令头锐根凹，长寸半者三枚，待冷硬，蘸油少许，纳谷道中。其次以锐头顶凹，而入三枚尽，以布着手指抵定。若即欲大便，勿轻去，俟先入者已化大便急甚，有旁流者出，方去手，随大便出。猪胆导法：极大猪胆一枚，用芦管长三寸余通之，磨光一头，以便插入谷道。用尖锋刀，刺开胆口，以管插入胆中，用线扎定管口，抹油，捻入谷道，插尽芦管，外以布衬手，用力捻之，则胆汁尽入，方去之。少顷大便即出。
Also. It is further stated: When people currently suffer from heat disease, they experience intense thirst and crave drinking. The more they drink, the more severe their thirst becomes. Since the amount of water consumed is substantial, how can urine excrete it all at once? Moreover, when a person suffers from heat disease, Yang Qi must be in excess, causing Water to naturally flow downward and Fire to naturally flare upward. This is the sign of dampness and fluid retention accompanied by dryness and thirst. Therefore, Zhu Ling Tang (Polyporus Decoction) moistens dryness and relieves thirst while promoting the drainage of damp-heat.
Zhu Ling Tang Formula
Zhu Ling (Polyporus, with skin removed), Hua Shi (Talcum, crushed, each 1 liang; *Wai Tai Mi Yao* adds "wrapped in cotton gauze"), Fu Ling (Poria), E Jiao (Donkey-hide Gelatin; *Wai Tai Mi Yao* adds "roasted"), Ze Xie (Alisma).
Take the above five herbs. Add four sheng of water. First decoct the first four herbs, reduce to two sheng of liquid, remove the dregs, add E Jiao, and melt it until dissolved. Take seven he of warm decoction orally, three times daily. (*Cheng Ben* edition has "xia" [down] after "na" [add]. *Yu Han Jing* reads "xiao jin" [dissolve completely] for "yang xiao" [melt and dissolve].)
[Jian] Zhao Yuhuang said: Zhang Zhongjing formulated Zhu Ling Tang to regulate water and heat in the Yangming and Shaoyin meridians. However, its main purport lies entirely in nourishing Yin, not merely in promoting diuresis. Generally, in exterior deficiency of cold damage, one must most avoid the loss of Yang Qi; whereas in interior deficiency, one must fear the loss of Yin Qi. Loss of Yin refers to the depletion of Kidney Yin and the fluids of the Stomach House. Thus, in persons with Yin deficiency, not only should the bowels not be lightly purged, but even urination should be avoided if it involves excessive draining. If Yin-deficient patients undergo excessive diuresis, body fluids will instead become exhausted. In this formula, E Jiao has a gelatinous texture that nourishes Yin and moistens dryness; Hua Shi has a slippery nature that clears heat and promotes urination. Assisted by the draining actions of Zhu Ling and Fu Ling, it disperses turbid heat without retaining stagnation, and also moistens True Yin without being overly bitter or drying. This is an excellent agent that promotes urination without damaging Yin. Therefore, regarding methods of promoting urination: in Taiyang disease, Wu Ling San (Five-Ingredient Poria Decoction) is used, adding Gui Zhi (Cinnamon Twig) to warm and move water; in Yangming and Shaoyin diseases, Zhu Ling Tang is used, adding E Jiao and Hua Shi to moisten and nourish the formless (Yin) to move the formed (water/fluids). Although both promote urination, their cold and warm natures are vastly different; only those who understand clearly can perceive this.
*Yi Fang Kao* states: Since all four ingredients are draining and diuretic, there is a fear of losing Yin due to excessive downward purging. Therefore, E Jiao is added as an assistant to preserve body fluids in the Du Shu (water passages).
In Yangming disease, if sweating is profuse and accompanied by thirst, Zhu Ling Tang should not be administered. This is because profuse sweating causes dryness in the Stomach, and administering Zhu Ling Tang would further drain urine.
[Cheng] *Zhen Jing* states: Food and drink enter the mouth and are transported to the intestines and stomach. Their fluids differentiate into five types. In cold weather with thin clothing, they become urine; in hot weather with thick clothing, they become sweat. Thus, sweat and urine are derived from the same fluid. Profuse sweating indicates external leakage of body fluids and dryness in the Stomach; therefore, Zhu Ling Tang should not be used to promote urination. (Note: This text from *Zhen Jing* comes from the chapter "On Five Obstructions and Fluids".) [Ke] If there is profuse sweating and thirst, Bai Hu Tang (White Tiger Decoction) should be used. If there is dryness in the Stomach, Cheng Qi Tang (Order the Qi Decoction) should be used. These implications are evident in the text.
Commentary: Wei Shi stated: If deficiency signs are seen, it is an indication for Zhi Gan Cao Tang (Honey-Fried Licorice Decoction); if excess signs are seen, it is an indication for Tiao Wei Cheng Qi Tang (Regulate the Stomach Order the Qi Decoction). Using Zhi Gan Cao Tang would be inappropriate.
If the pulse is floating and slow, with exterior heat and interior cold, and diarrhea with undigested food, Si Ni Tang (Frigid Extremities Decoction) is the primary treatment.
[Qian] This shares the same meaning as interior cold with exterior heat in Shaoyin and Jueyin diseases. If the condition were wind-induced with floating pulse and exterior heat, the floating pulse would necessarily be rapid. Now, although there is exterior heat, the pulse is slow, indicating Cold-Yin in the interior. Excess Yin repels Yang to the exterior, causing exterior heat. Deficient Yang resides on the exterior, hence the floating pulse; Cold-Yin resides in the interior, hence the slow pulse. Consequently, diarrhea with undigested food occurs. This is true cold presenting as false heat; therefore, Si Ni Tang is used to dispel cold pathogens and restore True Yang. If mistaken for an exterior pathogen and treated with sweating, it would be perilous. [Wei] Although there are exterior signs here, treating the interior rather than the exterior means that even if there are signs of false heat in Yangming, one certainly cannot neglect true cold to treat false heat. These are matters scholars must distinguish clearly and handle with caution.
Commentary: This is essentially a Shaoyin disease manifesting falsely with sweating and aversion to heat, which are Yangming exterior signs. Hence, it is specifically highlighted in this chapter. Fang Shi suggested this might be a misplaced passage from the Three Yin chapters, which is likely incorrect.
If the Stomach is deficient and cold, unable to accept food, drinking water will induce hiccups. (*Yu Han Jing* has "qi ren" [this person] under "leng" [cold]. *Qian Jin Yi Fang* omits "ruo" [if]. *Mai Jing* has "Yangming bing" [Yangming disease] before "ruo". "Leng" has "qi ren", which is correct.)
[Xi] This discusses deficiency-cold in the Middle Jiao of Yangming. The word "ruo" [if] connects to the preceding context. It means that not only is the Lower Jiao's generating Yang not activating, leading to deficiency-cold, but the Fire and Earth of the Middle Jiao are also deficient and cold. When Stomach Qi is strong, grain is digested and water is transformed. If the Stomach is deficient and cold, grain is not digested, and eating is impossible. Since eating is impossible, water is not transformed. The combination of two colds leads to hiccups. [Wang] Chen Wuling stated: The method should involve strong warming. The previous section already used Si Ni Tang, so no further treatment method was mentioned. My commentary: Chang Qizhi stated: Use Wen Zhong Tang (Warm the Middle Decoction). However, using Fu Ling Si Ni Tang (Poria and Frigid Extremities Decoction) is better, which is Si Ni Tang plus Ren Shen (Ginseng) to tonify deficiency and Fu Ling (Poria) to drain dampness. [Jian] Li Zhong Tang (Regulate the Middle Decoction) plus Ding Xiang (Clove) and Wu Zhu Yu (Evodia) for warming and descending would be appropriate.
If the pulse is floating with fever, dry mouth and nose, and the patient can eat, epistaxis (nosebleed) will occur. (Wang Kentang, in his collation of *Qian Jin Yi Fang*, changed "bi" [nose] to "she" [tongue].)
[Wei] Floating pulse and fever indicate residual Taiyang disease. Dry mouth, nose, and ability to eat suggest that although the Yangming interior syndrome is not fully formed, the internal heat of Yangming is already excessive. Excessive heat causes Qi to rebel upward; upward rebellion draws blood upward, resulting in epistaxis. This is due to sufficient Qi and hyperactive Yang. The heat pathogen is also released along with the blood. [Xi] "Ability to eat leads to epistaxis" means the pathology is not in the Stomach, nor is the epistaxis caused by the ability to eat.
[Wang] Chang Qizhi stated: Huang Qin Tang (Scutellaria Decoction) may be given. I state: Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) is appropriate.
Commentary: Shu Shi stated: In heat diseases, resolution occurs via epistaxis. Ability to eat indicates strong Stomach Qi, so the pathogen should resolve spontaneously; hence, "ability to eat leads to epistaxis." Laypeople call this "Red-Clothing Cold Damage," claiming it is incurable. How vulgar! In Taiyang disease, epistaxis is described as "resolution upon bleeding" or "spontaneous healing." Even changes induced by fire therapy are said to resolve via epistaxis. Even when Yin pathogens agitate Ying Blood, Si Ni Tang can still save the patient. How can one claim all epistaxis cases are incurable? Generally, mediocre physicians see epistaxis and indiscriminately use cold-cooling herbs, causing ice-like stagnation and complications, leading to incurable conditions. Thus, they created this label to deceive the world and evade responsibility.
After purgation in Yangming disease, if there is exterior heat, warm hands and feet, no chest binding (Jie Xiong), mental restlessness (Ao Nu), hunger but inability to eat, and only sweating on the head, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is the primary treatment. (*Mai Jing*, *Qian Jin Yi Fang* have "ruo" [if] before "ji" [hunger].)
[Wang] This is also a complication of erroneous purgation in Yangming disease. In Yangming, erroneous purgation causes pathogenic heat to sink inward, but not as deeply as in Taiyang. Thus, residual heat remains on the exterior. Warm hands and feet indicate the exterior is harmonious without major pathogenic factors; absence of chest binding indicates the interior is harmonious without major pathogenic factors. With no major pathogenic factors in the exterior or interior, the pathogen resides only between the chest and diaphragm. Hence, mental restlessness. "Hunger but inability to eat" means the restlessness is so severe that it feels like hunger but is not, causing discomfort preventing eating. "Only sweating on the head": Cheng Wuji noted: Heat steams upward from the chest, causing only head sweating and no body sweating. [Zhi] Zhi Zi Chi Tang resolves empty heat in the heart. By facilitating communication between upper and lower, harmony is achieved, and the exterior heat is also cleared.
In Yangming disease, if tidal fever occurs, stool is loose, urination is normal, and fullness in the chest and hypochondrium persists, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is given. (*Cheng Ben* omits "yu" [give]. *Yu Han Jing* adds "zhu zhi" [mainly treats] after "tang". *Qian Jin Yi Fang* adds "er" [and] before "xiong" [chest].)
[Wang] Yangming disease typically involves Stomach excess. Here, stool is loose, yet it is called Yangming disease, referring to Yangming exterior signs: fever, sweating, aversion to neither cold nor heat, but aversion to heat. [Cheng] Tidal fever in Yangming indicates Stomach excess, hard stool, and frequent urination. Now, stool is loose and urination is normal, indicating Stomach heat is not yet solidified, and water and grain are not separated. Loose stool should lead to descending Qi and resolution of chest/hypochondriac fullness. Since it persists, the pathogen remains in the half-exterior, half-interior stage. Xiao Chai Hu Tang is given to resolve pathogenic factors in both exterior and interior. [Qian] Although Yangming is the primary disease, Zhongjing stated: In cold damage and wind strike, if Chai Hu signs are present, seeing just one sign is sufficient; all need not be present. Thus, whenever a Shaoyang sign appears, sweating and purgation are contraindicated; only Xiao Chai Hu Tang for harmonization is suitable.
In Yangming disease, if hardness and fullness in the hypochondrium occur, constipation with vomiting, and a white coating on the tongue, Xiao Chai Hu Tang may be given. Once the Upper Jiao is unblocked, fluids descend, Stomach Qi harmonizes, and the body sweats slightly to resolve. (*Cheng Ben* adds "ye" [particle] after "jie" [resolve].)
[Cheng] In Yangming disease, abdominal fullness, constipation, and yellow tongue coating indicate pathogenic heat entering the Fu organs, warranting purgation. If, however, there is hardness/fullness in the hypochondrium, constipation with vomiting, and a white tongue coating, the pathogen has not entered the Fu organs but remains between exterior and interior. Xiao Chai Hu Tang is given for harmonization. Unblocking the Upper Jiao stops vomiting; descending fluids harmonize Stomach Qi; sweating resolves the condition. [Qian] Constipation indicates Yangming interior heat. Vomiting is a Shaoyang sign. If heat pathogen were solid in the Stomach, the tongue coating would be yellow or black, dry/hard, or prickly. A white coating indicates early appearance. If the pathogen were initially in the exterior, there would be no coating. The presence of a white coating suggests the pathogen is not entirely in the exterior nor fully in the interior, thus remaining in the half-exterior, half-interior stage. [Fang] Descending fluids lead to bowel movement. [Cheng] Hard pain in the hypochondrium, constipation, and vomiting are indications for Da Chai Hu Tang (Major Bupleurum Decoction). The use of Xiao Chai Hu Tang here is because the white coating still carries exterior cold. If the coating were not slippery but rough/dry, it would correspond to "dry tongue with irritability, desiring several sheng of water," indicating heat has consumed fluids, making this decoction unsuitable. [Xi] Constipation indicates Lower Jiao blockage, preventing fluid descent. Vomiting indicates Middle Jiao dysfunction and disharmonious Stomach Qi. White tongue coating indicates Upper Jiao blockage and trapped Fire. Xiao Chai Hu Tang harmonizes the Qi of the Three Jiao. Unblocking the Upper Jiao removes the white coating; descending fluids facilitate bowel movement; harmonizing Stomach Qi stops vomiting. With open Three Jiao and rotating Qi mechanism, slight sweating resolves the condition.
In Yangming wind-strike, if the pulse is wiry, floating, and large, with shortness of breath, generalized abdominal fullness, pain in the hypochondrium and chest that does not relieve upon prolonged pressing, dry nose with inability to sweat, lethargy, jaundice of the whole body and eyes, difficult urination, tidal fever, occasional hiccups, and swelling around the ears: acupuncture provides slight relief, but the exterior condition remains unresolved. If ten days pass and the pulse continues to float, give Xiao Chai Hu Tang. If the pulse is only floating without other residual signs, give Ma Huang Tang (Ephedra Decoction). If there is no urination, increased abdominal fullness, and worsening hiccups, it is incurable. (*Cheng Ben*, *Yu Han Jing* add "mian" [face] before "mu" [eye]. *Mai Jing* note: "an zhi qi bu tong" [pressing makes Qi blocked] is alternatively read as "an zhi bu tong" [pressing is not painful]. *Zheng Mai*: "fu du" [abdomen all] is read as "fu bu" [abdomen region].)
[Fang] Wiry indicates Shaoyang; floating indicates Taiyang; large indicates Yangming. Hypochondriac pain belongs to Shaoyang. Difficult urination indicates Taiyang Bladder dysfunction. Abdominal fullness, dry nose, lethargy, jaundice of body/eyes, and tidal fever belong to Yangming. Occasional hiccups indicate involvement of all three Yang meridians with severe Qi rebellion. Swelling around the ears: Yangming meridian emerges at Daying, follows Jiache, goes up to the front of the ear; Taiyang meridian branch goes from vertex to the ear; Shaoyang meridian goes down behind the ear, branch enters the ear, exits to the front. Thus, although signs of all three Yang appear, it is termed Yangming because Yangming is predominant and bears the burden. [Qian] "Pressing makes Qi blocked" means shortness of breath exists even without pressing; prolonged pressing worsens it, indicating pathogenic factors fill the space. Lethargy is Yangming interior pathogen. Difficult urination is due to pathogenic heat blocking, stopping Three Jiao Qi transformation. If urination were free, jaundice would not occur. [Cheng] This clause focuses on "inability to sweat." Wind and heat are both obstructed, Yang Qi is heavy. Depressed and unable to vent, unable to exit or enter, meridians are tangled and disturbed everywhere. Ultimately, there is no outlet for release, hence these signs. Acupuncture drains heat from the meridians. The wind pathogen entangled remains. Thus, handling it slowly involves weighing between Chai Hu and Ma Huang decoctions to open long-standing closure. The goal is always to induce sweating. No urination, increased abdominal fullness, and hiccups indicate Stomach Qi exhaustion and failure of Three Jiao circulation, leaving no exit for pathogens. [Ke] The clause does not mention fever; the term "wind-strike" implies interior exterior heat. "Exterior unresolved" refers to this exterior heat, implicitly hinting at "interior resolved." "Disease passes ten days" is a parallel construction for "interior resolved." It should follow "exterior unresolved." "No residual signs" connects to "exterior unresolved." "Acupuncture" refers to puncturing Foot Yangming to drain excess. "Slight improvement" means internal symptoms decrease, but exterior signs remain; it does not mean swelling around ears improves slightly. Wiry-floating pulse: previously large-floating decreased, but wiry remains. Yangming signs have ceased; only Shaoyang exterior pathogen remains, so Xiao Chai Hu Tang can resolve the exterior. If pulse is only floating, not wiry/large, it is not Yangming/Shaoyang pulse. "No residual signs" means previous signs have ceased. No Yangming/Shaoyang signs remain; only Taiyang exterior pathogen lingers, so Ma Huang Tang can resolve the exterior. "No urination, increased abdominal fullness, and hiccups" connect to "swelling around ears." This indicates interior unresolved: difficult urination becomes no urination; abdominal fullness does not decrease; hiccups worsen. This is not caused by acupuncture nor subsequent use of Chai Hu/Ma Huang. [Zhi] Swelling around ears is the "Fa Yi" (parotitis) syndrome of cold damage/wind-strike. Fa Yi can be fatal or curable; death occurs with Yin-Yang reversal, life with Qi rotation. Zhu Shi stated: This shares the same principle as Taiyang chapter: "Ten days later, chest fullness/pain -> Xiao Chai Hu Tang; pulse only floating -> Ma Huang Tang." (From Chapter 37 middle section.)
Jin Jian stated: For such complex Yin-Yang and mixed interior-exterior conditions, one should wait for the disease trend and treat accordingly. Hence, acupuncture is used, waiting for slight improvement. Jin Jian also noted: The "floating" in "xu fu" [continues floating] should be "wiry" to fit the context, allowing Xiao Chai Hu Tang. If both are "floating," the upper floating suits Xiao Chai Hu Tang, but how could the lower floating suit Ma Huang Tang? This view is plausible.
In Yangming disease, with spontaneous sweating, if sweating is induced and urination is free, this indicates internal exhaustion of body fluids. Although stool is hard, it cannot be purged. One must wait for the patient's desire to defecate, then use Honey Suppository (Mi Jian Dao) to guide passage. Radix Trichosanthes Kirilowii (Tu Gua Gen) and large pig bile can also serve as guiding agents. (*Cheng Ben* adds "yu" [with] after "ji" [and]. *Yu Han Jing*, *Mai Jing* omit "da" [large] before "zhu" [pig].)
[Cheng] Internal exhaustion of body fluids leads to dry intestines and hard stool. This is not accumulated heat, so purgation is contraindicated. External medication should be used to guide passage. [Jian] Spontaneous sweating in Yangming, or induced sweating with free urination, indicates internal exhaustion of body fluids. Although stool is hard, without fullness/pain suffering, purgation is contraindicated. Wait for fluids to return to the Stomach and natural desire to defecate. When dry feces reach the rectum and struggle to exit the anus, use honey suppository to moisten orifices and dryness, guiding passage. Or Tu Gua Gen to promote Qi and unblock dryness; or pig bile to clear heat and moisten dryness. Any can be used as a guiding method, chosen appropriately.
[Ke] The repetition of "zi" [self/spontaneous] shows that for Stomach excess without complicated signs, one should let nature take its course and not treat rashly. One must probe the patient's desires. When the desire to defecate arises, guide according to the momentum. If no desire, wait quietly.
Commentary: Fang Shi stated: Adding "da bian" [stool] either above or below would be pedantic.
Wang Shi stated: Question: Why not use Ma Ren Wan (Hemp Seed Pill) for free urination and hard stool? Answer: Ma Ren Wan treats Stomach heat with fluid accumulation in the ileum. Here, there is no Stomach heat sign, and feces are near the anus/rectum. Hence, "guide according to momentum."
Honey Suppository Formula (*Cheng Ben* reads "Mi Jian Dao").
Shi Mi (Food-grade Honey, 7 he; *Cheng Ben*, *Yu Han Jing*, *Qian Jin Yi Fang* omit "shi" [food]).
Take the single ingredient. Simmer gently in a copper vessel until it congeals like malt syrup. Stir constantly to prevent burning. When moldable, shape by hand into suppositories, pointed at one end, about one finger thick and two cun long. Form while hot; it hardens when cold. Insert into the anal canal. Hold firmly with hand. Remove when defecation is desired. Suspected not to be Zhongjing's original intent, but tested and effective. ○ Also, one large pig gallbladder. Extract juice, mix with a little vinegar, and灌 (irrigate) into the anal canal. After one meal time, old food and foul matter should be expelled. Very effective. (*Cheng Ben*, *Yu Han Jing*: "yu tong qi nei" [in copper vessel] reads "na tong qi zhong" [put into copper vessel]; "dang xu" [should] reads "zhi shao"; "ru" [like] reads "si" [similar]; nine characters "wu yi yi xia" [no doubt below] omitted; "he shao xu fa cu" [mix little method vinegar] reads "he cu shao xu" [mix little vinegar]; "gu dao nei" [in anal canal] reads "gu dao zhong" [in anal canal]; six characters "su shi yi xia" [old food below] omitted. *Zheng Mai*: "jiao" [stir] reads "rao" [disturb]. *Yu Han Jing*: "yu ke wan" [want can pill] reads "si ke wan" [wait can pill]. *Cheng Ben*: "da zhu dan" [large pig gallbladder] omits "you" [again]. *Fang Ben*: "ting" [suppository] adds "zi" [child/sub]. *Wang Ben*: "bing shou" [together hand] reads "yi shou" [with hand]; "bao" [embrace] reads "na zhu" [press hold].)
[Wang] *Nei Tai Fang* uses 5 he honey, simmered until congealed, adding 5 qian Saponaria powder, shaped into suppositories, lubricated with pig bile or oil before insertion. Pig bile formula: no vinegar. Use small bamboo tube inserted into gallbladder neck, lubricated with oil, inserted into anal canal. Squeeze gallbladder with hand to inject juice. This method is very convenient. Tu Gua Gen formula is missing. *Zhou Hou Fang* for constipation: harvest Tu Gua Gen roots, crush to juice, blow into anus via tube to achieve passage. Same principle as pig bile. *Nei Tai Fang* shapes Tu Gua Gen into suppository and inserts it; this is error. Honey suppository melts and moistens stool; Tu Gua Gen does not melt. Shaping it risks losing Zhongjing's formulation intent.
Zhi Cong edition adds after Honey Suppository: "Or use Tu Gua Gen crushed juice, irrigate into anal canal via bamboo tube" (13 characters), likely added based on *Zhou Hou Fang*. Qian edition differs from original text for Honey and Pig Bile methods, recorded below.
Honey Guiding Method: White honey 7 he. Single ingredient. Enter copper pot. Simmer gently until old/concentrated. Test: hardens when cold. Do not burn. Add little pig tooth gourd powder. Shape into suppositories while hot: pointed tip, concave root, 1.5 cun long, three pieces. Wait until cold/hard. Dip in little oil. Insert into anal canal. Next, insert concave end first, all three. Press firmly with cloth-wrapped finger. If immediate urge to defecate, do not remove lightly. Wait until first piece melts, urgency increases, peripheral flow appears, then remove hand, following stool out.
Pig Bile Guiding Method: Large pig gallbladder one. Insert 3+ cun reed tube. Grind one end smooth for insertion. Pierce gallbladder neck with sharp knife. Insert tube. Tie tube opening with thread. Smear oil. Twist into anal canal. Insert reed fully. Support hand with cloth outside. Twist forcefully until bile enters completely. Remove. Stool exits shortly after.
*Shang Han Zhun Sheng* states: For cases of excessive sweating injuring fluids, repeated sweating failing to resolve, or chi pulse slow/weak in constitutionally deficient persons with urge to defecate but inability, guiding methods are appropriate. But