内盛也。发作有时者。邪乘未申之时。阳明经气王。故当其时。则烦躁发作。此是有燥屎之征。故使不大便也。愚按仲
景用大承气汤证。必辩其有燥屎。则是前言潮热谵语。手足汗出转失气。其法可谓备矣。此条复云。绕脐痛。可见证候
多端。医者所当通变而延医之也。）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。脉浮
虚者。宜发汗下之。与大承气汤。发汗宜桂枝汤。（此条系太阳阳明证。病患烦热者。此太阳经风邪犹未尽也。汗出者。
自汗出也。自汗出。则其热暂解。至明日又烦。故云。有如疟状。乃表证仍在也。日晡所发热者。热传阳明。邪已入府
而发潮热。乃里证已具也。然亦当审其脉。如脉实者。里证已的。宜下之。故云与大承气汤。如脉虚浮者。为表证未解。
虽日晡发热。不过是烦热而非潮热。其邪未全入府。犹在于经。故云宜桂枝汤以透发其汗俟。表证罢。然后斟酌下药。
或问病如疟状。则脉实者。何以不用大柴胡汤。余答云。上云。如疟状者。乃烦热时。得汗则解。有如疟。非云。寒热
如疟也。但脉虚浮者。宜发汗。愚以此必是太阳阳明经证。仲景法。还宜用桂枝加葛根汤方也。）
大下后。六七日。不大便。烦不解。腹满痛者。此有燥屎也。所以然者。本有宿食故也。宜大承气汤。（此条乃大下
后。府实未尽。更当大下之证。不大便烦满腹痛者。下证具也。因有下证。故大下之。今者。大下之后。又六七日。不
大便。烦仍不解。腹中满而作痛者。此有燥屎也。夫既经大下。何以里实如是。所以然者。以其人本有宿食。故下之而
犹未尽也。成注云。与大承气汤以下除之。或问大下后。六七日不大便。此是下证否。余答云。大下之后。胃中虚。新
谷未入。虽六七日不大便。亦非下证。惟烦不解。腹满痛。此是有燥屎之征。故宜复与大承气汤。下除之也。）
病患小便不利。大便乍难乍易。时有微热。喘冒不能卧者。有燥屎也。宜大承气汤。（此条病。未经下而有燥屎。乃
医人不易识之证。成注云。小便利。则大便硬此有燥屎。乃理之常。今者。病患小便不利。大便乍难乍易。何以知其有
燥屎邪。盖大实大满之证。则前后便皆不通。大便为燥屎壅塞。其未坚结者。或有时而并出。故乍易。其极坚结者。终
着于大肠之中。故乍难。燥屎结积于下。浊气攻冲于上。以故时有微热。微热者热伏于内。不得发泄。此比潮热。则更
深矣。后条辩云。浊气乘于心肺。故既冒且喘。不得卧者。胃家为燥热所扰。即经云。胃不和。则卧不安也。凡此者。
皆是有燥屎之征。故云。宜大承气汤。陈亮斯云。此为识燥屎之变法。医人不可以不知也。）
太阳病若吐。若下。若发汗微烦。小便数。大便因硬者。与小承气汤和之。愈（此条系太阳阳明证。太阳病既经汗
吐下。其邪为已减矣。所未解者内入于胃。胃府实热。必不大甚。故曰微烦。微烦者。大便未必能硬。其硬者。只因小
便数故也。此非大满大实之证。故云与小承气汤。和之则愈。愚按此条病。乃汗吐下不解。非误汗吐下之比。故成注止
云。损津液。而非亡津液也。大便因硬。乃大便略觉硬。非大便坚结而难出。成注以脾约作解。大误之极。）
得病二三日。脉弱无太阳柴胡证。烦躁心下硬。至四五日。虽能食。以小承气汤。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。（此条乃申言大小承气。不可多用。及骤用之。意得病二三日。不言伤寒与中风者。乃风
寒之邪皆有。不须分辩之病也。脉弱者。谓无浮紧等在表之脉也。无太阳柴胡证。谓无恶寒发热。或往来寒热。在表及
半表半里之证也。烦躁。心下硬者。全是阳明府热邪实。至四五日。则足阳明胃府实热者。下而传于手阳明。当大肠之
府实热也。经云。肠实则胃虚。故能食。能食者。其人不痞不满。为下证未急。非阳明胃强。发狂能食比也。故云虽能
食。止须以小承气汤。少少与。微和之。因其人烦躁。必不大便。欲令其小安也。至六日。仍烦躁不安。而不大便者。
前用小承气汤。可加至一升。使得大便而止。此言小承气汤。不可多用之意。若不大便句。承上文烦躁心下硬而言。至
六七日不大便。为可下之时。但小便少。乃小水不利。此系胃中之水谷不厘清。故不能食。非谵语潮热。有燥屎之不能
食也。故云。虽不能食。但初头硬。后必溏。未定成硬而攻之。并硬者。必化而为溏矣。须待小便利。屎定成硬。乃可
用大承气汤攻之。此言大承气。亦不可骤用之意。条辩云。太阳不言药。以有桂枝麻黄之不同也。柴胡不言证。以专少
阳也。此等文。皆是互相发明之义。后条辩云。能食者。结在肠间而胃火自盛。故烦躁。不能食者。胃弱不能布水。水
渍胸中。以故脉弱。愚以心下硬此是二三日之见证。至四五日。六七日之时。其硬当更下矣。或问脉弱。则胃气亦弱。
何以用大承气。余答云。大承气汤中有芒硝。直走大肠。攻其硬屎。斯邪去而胃不伤。如未定成硬。而遽攻之。斯邪不
能去。徒伤胃气耳。医人不可不知。）伤寒六七日。目中不了了。睛不和。无表里证。大便难身微热者。此为实也。急下
之宜大承气汤。（无表里证。里字当是传写错误。宜从删。此条系邪热侵藏。急当下之之证。伤寒至六七日。为邪气入里
之时。目中不了了。不了了者。病患之目。视物不明了也。睛不和者。乃医者视病患之睛光。或昏暗。或散乱。是为不
和。为阳明热邪亢盛。土来乘水。肾水将绝。瞳子不能照物故也。当其时已无表证。但大便难者。里实也。身微热者。
里热也。里实热盛。故于身外候之。亦微热。非在表发热也。此为里实。当下。兼之目睛不和。此为里实热盛。当急下。
宜大承气汤。以泻土之郁。救水之涸。不可迟也。按此条系阳明府病。条辩以阳明经脉络目作解。大谬之极。）
阳明病发热。汗多者。急下之。宜大承气汤。（此条病。亦当急下。以救胃涸之证。邪热入府。里热盛而蒸发于外。
故云发热汗多。成注云。热迫津液将竭。急与大承气汤。以下其府热。存其津液也。）
发汗不解。腹满痛者。急下之。宜大承气汤（此条病。乃正阳阳明。宜急下之证。发汗不解者。此发阳明经中之汗。
表证罢而邪不解也。不解。则邪热传入于府。府中大实。腹满而痛。成注云。传之迅者也。惟传之迅。故宜大承气汤急
下之。以通其在里之实热。）
腹满不减。减不足言。当下之。宜大承气汤（此承上条而申言之。腹中满痛。急用大承气汤下之后。腹满不减。言
胀满之形。不因下之而减。成注云。邪气仍实也。减不足言者。言下之后。纵减一二分尚论篇云。不足以杀其势也。故
云。当复下之。宜大承气汤。）
阳明少阳合病必下利其脉不负者。顺也。负者失也。互相克贼。名为负也。脉滑而数者。有宿食也。当下之。宜大
承气汤。（此条系合病。然亦必俟少阳之邪。总归阳明。故为当下之证。条辩云。阳明属土其主水谷。少阳属木。其主风。
风主飧泄。以故二阳合病。必至下利也。阳明脉大。少阳脉弦。其脉不负者。谓阳明大脉。与少阳弦脉相敌。乃为顺候
也。若少阳脉胜而弦。阳明脉负而不大。乃阳明之正气。失而其候不顺也。木为土之贼。土受木克。其名为负。此下利
不治之证也。若其脉滑而数者。滑主食数主热。乃有宿食也。此为少阳之邪。尽归阳明之府。而成府实证。成注云。与
大承气汤以下除之。以上十三条证。即从本篇之后移附于此）
下利谵语者。有燥屎也。宜小承气汤。（此条自厥阴篇移附于此。下利者。肠胃之疾也。若谵语则胃家实。与厥阴无
与。主肠中有燥屎。不得下也。治宜小承气汤者。此半利半结。止须缓以攻之也。或问既下利矣。则热气得以下泄。何
由而致谵语有燥屎也。余答云。此系阳明府实。大热之证。胃中糟粕。为热邪所壅。留着于内。其未成硬者。或时得下
其已成硬者。终不得出。则此燥屎者。为下利之根也。燥屎不得出。则邪热上乘于心。以故谵语。要之此证。须以手按
脐腹。当必坚痛。此为有燥屎之征。）
三阳合病。腹满。身重。难以转侧。口不仁而面垢。谵语。遗尿。发汗则谵语。下之。则额上生汗手足逆冷。若自
汗出者。白虎汤主之。（此条虽系合病。实则阳明经与府气分热极之证。三阳合病者阳证多热。病合三阳。其热甚矣。热
甚。则肢体倦怠而神昏。以故身重。难以转侧。口不仁而谵语。不仁者。不正也。条辩云。饮食不利。便无口之知觉也。
凡此者。皆是阳明主证。经云。少阳病甚。则面微尘。垢亦尘也。面垢者。少阳热而青黯之色不泽也。遗尿者。太阳热
而膀胱之府不约也。成注云。三者以阳明证多。故出阳明篇中。三阳合病为表里有邪。医因身重而误发其汗。则邪并阳
明胃中燥热。故谵语益甚。复因谵语而误下之。则肠胃之阴受伤。阳无根据而上越。故额上生汗。手足逆冷者。胃虚热极
而见厥。乃热深厥亦深也。若不因发汗。而自汗出者。成注虽云。三阳热甚。终是阳明气分燥热。以故肌肉之间。自汗
时出也。成注复云。与白虎汤以解内外之热。此是合经与府俱治之义。或问白虎汤何以能解三阳之热。余答云。病至自
汗出。则太少之邪。总归阳明矣。安得不从阳明而专治之。或又问云。既从阳明而治之。何以下之而不愈。余又答云。
腹满谵语。似乎可下。要之阳明胃府气分燥热亢极者。亦致谵语。其腹满者气滞也。身重者。气困也。口不仁者。气不
和也。面垢者。气不舒也。遗屎者。气不摄也。自汗出者。气不敛也。凡此者。皆气分燥热所致也。气燥热而反用大小
承气等血药以攻之。故见头汗手足冷等变证也。白虎汤能清阳明气分热。滋肠胃中之燥。故为上证必用之药。）
体内邪热炽盛。发作有定时，是因为邪气在申时（下午3-5点）和未时（下午1-3点）乘虚而入，此时阳明经气旺盛，所以到了这个时间，烦躁就会发作。这是有燥屎的征象，因此导致不大便。我按语：张仲景在使用大承气汤的证候中，必定辨别是否有燥屎，那么前面提到的潮热、谵语、手足出汗、转失气（放屁），其治法可以说是完备了。这一条又说绕脐痛，可见证候多种多样，医生应当灵活变通并延请医家诊治。）
病人烦热，出汗后症状缓解，又像疟疾一样发作，每天傍晚（日晡所，即下午3-7点）发热，这属于阳明病。脉象实的，适宜用攻下法；脉象浮虚的，适宜用发汗法。若用攻下法，给予大承气汤；若用发汗法，适宜用桂枝汤。（这一条属于太阳阳明合病。病人烦热，是因为太阳经的风邪还没有完全清除。出汗，是指自汗出。自汗出，则热势暂时缓解，到第二天又烦躁，所以说像疟疾一样，这是表证仍在。每天傍晚发热，是热邪传入阳明，邪气已经入腑而引发潮热，这是里证已具备。然而也应当审察脉象，如果脉实，说明里证确切，适宜攻下，所以说给予大承气汤。如果脉虚浮，说明表证未解，虽然傍晚发热，不过是烦热而不是潮热，邪气没有完全入腑，还在经脉，所以说适宜用桂枝汤来透发汗液，等待表证解除后，再斟酌使用下药。有人问：病情像疟疾一样，脉象实的，为什么不用大柴胡汤？我回答说：上面说的“像疟疾一样”，是指烦热时，得到汗出就缓解，好像疟疾，并不是说寒热往来像疟疾。只是脉象虚浮的，适宜发汗。我认为这一定是太阳阳明经证，张仲景的法度，还适宜用桂枝加葛根汤方。）
经过猛烈攻下之后，过了六七天，仍然不大便，烦躁不解除，腹部胀满疼痛，这是有燥屎。之所以这样，是因为原本就有积食。适宜用大承气汤。（这一条是在猛烈攻下之后，腑实未尽，更应当再次猛攻的证候。不大便、烦躁、腹部胀满疼痛，是下法的指征具备。因为有下法的指征，所以用了猛攻。现在，猛攻之后，又过了六七天，仍然不大便，烦躁仍不解除，腹中胀满且疼痛，这是有燥屎。既然已经经过猛攻，为什么里实还是这样？之所以这样，是因为这个人原本就有积食，所以攻下后仍未排尽。成无己注解说：给予大承气汤以攻下除去它。有人问：猛烈攻下后，六七天不大便，这是下法的指征吗？我回答说：猛攻之后，胃中虚弱，新谷尚未进入，即使六七天不大便，也不是下法的指征。只有烦躁不解除，腹部胀满疼痛，这才是有燥屎的征象，所以适宜再次给予大承气汤，攻下除去它。）
病人小便不利，大便有时难有时易，偶尔有轻微发热，气喘且头昏目眩不能平卧，这是有燥屎。适宜用大承气汤。（这一条病，未经过攻下而有燥屎，是医生不容易识别的证候。成无己注解说：小便利，则大便硬，这是有燥屎，是常理。现在，病人小便不利，大便有时难有时易，怎么知道是有燥屎呢？大概是大实大满的证候，前后二便都不通。大便被燥屎壅塞，其中未坚结的部分，有时可能会一起排出，所以有时容易（乍易）；那些极度坚结的，始终附着在大肠中，所以有时困难（乍难）。燥屎结积在下部，浊气攻冲于上部，因此偶尔有轻微发热。微热，是因为热伏在内，不得发泄，这比潮热更深一层。后面的条文辨析说：浊气侵犯心肺，所以既头昏又气喘，不能平卧，是因为胃家被燥热扰乱，正如经文所说：胃不和，则卧不安。凡是这些情况，都是有燥屎的征象，所以说适宜用大承气汤。陈亮斯说：这是识别燥屎的变法，医生不可以不知道。）
太阳病，如果用吐法，如果用下法，如果发汗后出现轻微烦躁，小便频数，大便因此变硬，给予小承气汤调和它，就能痊愈。（这一条属于太阳阳明合病。太阳病既然经过汗、吐、下治疗，邪气已经减轻。没有解除的是邪气内入于胃，胃腑实热，一定不是很严重，所以说轻微烦躁。轻微烦躁，大便未必能硬，变硬的原因，只是因为小便频数所致。这不是大满大实的证候，所以说给予小承气汤，调和它就能痊愈。我按语：这一条病，是汗、吐、下后不解，不是误用汗、吐、下的情况，所以成无己只说是损伤津液，而不是亡失津液。大便因此变硬，是大便略微觉硬，不是大便坚结而难以排出。成无己将其解释为脾约，错误极大。）
得病两三天，脉弱，没有太阳病和少阳病的证候，烦躁，心下硬，到了四五天，虽然能吃，用小承气汤，少量给予，微微调和它，让它稍微安宁。到了第六天，给予承气汤一升。如果六七天不大便，小便少的，虽然不能吃，但大便开头硬，后面一定稀溏，不一定完全变硬，攻下它一定会拉稀。必须等到小便通利，大便确定变硬，才可以攻下，适宜用大承气汤。（这一条是进一步说明大小承气汤不可多用，也不可骤用。意谓得病两三天，不说伤寒与中风，是因为风寒之邪都有，不需要分辨的病。脉弱，是指没有浮紧等在表的脉象。没有太阳和少阳病的证候，是指没有恶寒发热，或寒热往来的在表及半表半里的证候。烦躁，心下硬，完全是阳明腑热邪实。到了四五天，足阳明胃腑的实热，下行传于手阳明大肠腑，当是大肠腑的实热。经文说：肠实则胃虚，所以能吃。能吃的人，他不痞不满，是下法的指征不紧急，不是阳明胃强、发狂能食的情况。所以说虽然能吃，只需用小承气汤，少量给予，微微调和它，因为这个人烦躁，必然不大便，想要让他稍微安宁。到了第六天，仍然烦躁不安，且不大便，之前用小承气汤，可以加至一升，使得大便通畅就停止。这是说小承气汤不可多用的意思。“若不大便”一句，承接上文“烦躁心下硬”而言。到了六七天不大便，是可以下的时候。但小便少，是小水不利，这是因为胃中的水谷不能分清，所以不能吃，不是谵语潮热、有燥屎的那种不能吃。所以说虽然不能吃，但大便开头硬，后面一定稀溏，不一定完全变硬而攻下它，连同硬的也会化为稀溏。必须等待小便通利，大便确定成硬，才可用大承气汤攻下。这是说大承气汤也不可以骤用的意思。条辩说：太阳病不言药，因为有桂枝汤和麻黄汤的不同。少阳病不言证，因为专主少阳。这些文字，都是互相阐发的意义。后面的条辩说：能吃的，结滞在肠间而胃火自盛，所以烦躁；不能吃的，胃弱不能布散水液，水渍胸中，所以脉弱。我认为“心下硬”是二三天的见证，到了四五天、六七天的时候，其硬应当更靠下了。有人问：脉弱，则胃气也弱，为什么用大承气汤？我回答说：大承气汤中有芒硝，直走大肠，攻下硬屎，这样邪去而胃不伤。如果大便未定成硬，而贸然攻下，这样邪不能去，徒然损伤胃气罢了。医生不可以不知道。）
伤寒六七天，眼睛看不清楚，眼球转动不灵活，没有表证也没有典型的里证，大便难，身体微热，这是实证，急当下之，适宜用大承气汤。（“无表里证”的“里”字应该是传写错误，适宜删去。这一条是邪热侵扰脏腑，急需攻下的证候。伤寒到了六七天，是邪气入里的时间。眼睛看不清楚，“不了了”是指病人的眼睛视物不明了。眼球转动不灵活，是医生观察病人的眼球光泽，或昏暗，或散乱，这叫不和。这是阳明热邪亢盛，土来乘水，肾水将绝，瞳孔不能照物的缘故。这个时候已经没有表证，只是大便难，是里实。身体微热，是里热。里实热盛，所以在身体外部表现也是微热，不是在表的发热。这是里实，当下。加上目睛不和，这是里实热盛，当急下，适宜用大承气汤，以泻土之郁，救水之涸，不可以迟缓。按：这一条属于阳明腑病，条辩将其解释为阳明经络目，错误极大。）
阳明病发热，汗多的，急当下之，适宜用大承气汤。（这一条病，也应当急下，以救胃中津液枯竭的证候。邪热入腑，里热盛而蒸发于外，所以说发热汗多。成无己注解说：热迫津液将竭，急与大承气汤，以下除其腑热，存留其津液。）
发汗后病不解，腹部胀满疼痛的，急当下之，适宜用大承气汤。（这一条病，是正阳阳明，适宜急下的证候。发汗后病不解，这是发阳明经中之汗，表证解除而邪气不解。不解，则邪热传入于腑，腑中大实，腹部胀满而疼痛。成无己注解说：传变迅速。正因为传变迅速，所以适宜用大承气汤急下，以通其在里的实热。）
腹部胀满不减，即使减少也不值得一提的，当下之，适宜用大承气汤。（这一条承接上一条而进一步说明。腹部满痛，急用大承气汤攻下后，腹部胀满不减，是说胀满的形状，不因攻下而减少。成无己注解说：邪气仍然实。减不足言，是说攻下之后，纵然减少一二分，《尚论篇》说不足以消除其势头。所以说应当再次攻下，适宜用大承气汤。）
阳明病和少阳病合病，必然下利。其脉象不负者，是顺证。负者，是逆证。互相克贼，名为负。脉滑而数的，有宿食，当下之，适宜用大承气汤。（这一条属于合病，但也必须等到少阳之邪，总归阳明，才是当下之证。条辩说：阳明属土，主司水谷；少阳属木，主司风。风主飧泄，所以二阳合病，必然导致下利。阳明脉大，少阳脉弦。其脉不负，是说阳明的大脉，与少阳的弦脉相敌，才是顺候。如果少阳脉胜而弦，阳明脉负而不大，是阳明的正气失守，而其候不顺。木是土的贼，土受木克，名为负。这是下利的不治之证。如果脉滑而数，滑主食，数主热，是有宿食。这是少阳之邪，全部归入阳明之腑，而成腑实证。成无己注解说：给予大承气汤以攻下除去它。以上十三条证候，是从本篇之后移附于此的。）
下利且谵语的，有燥屎，适宜用小承气汤。（这一条从厥阴篇移附于此。下利，是肠胃的疾病。如果谵语，则是胃家实，与厥阴无关。主因肠中有燥屎，不得下。治宜小承气汤，是因为此证半利半结，只需缓以攻之。有人问：既然下利，则热气得以下泄，怎么会致谵语且有燥屎呢？我回答说：这是阳明腑实，大热的证候。胃中糟粕，被热邪壅滞，留着于内，其中未成硬的部分，有时得以排出；已成硬的部分，终究不得排出，那么这个燥屎，就是下利的根源。燥屎不得出，则邪热上乘于心，所以谵语。总之此证，须用手按压脐腹，必然坚硬疼痛，这是有燥屎的征象。）
三阳合病，腹部胀满，身体沉重，难以翻身，口不知味且面部污垢，谵语，遗尿。发汗则谵语加重；攻下则额上出汗，手足逆冷。如果自汗出的，白虎汤主之。（这一条虽然是合病，实际上是阳明经与腑气分热极的证候。三阳合病，阳证多热，病合三阳，热势很盛。热甚，则肢体倦怠而神志昏迷，所以身体沉重，难以翻身。口不知味且谵语，“不仁”是不正常的意思。条辩说：饮食不利，便没有口的知觉。凡是这些，都是阳明的主证。经文说：少阳病甚，则面微尘。“垢”也是尘的意思。面垢，是少阳热而青黯之色不泽。遗尿，是太阳热而膀胱之腑不约束。成无己注解说：这三者以阳明证多，所以出自阳明篇中。三阳合病为表里有邪，医生因为身体沉重而误发其汗，则邪并入阳明胃中燥热，所以谵语更甚。又因为谵语而误下之，则肠胃之阴受伤，阳无根据而上越，所以额上出汗。手足逆冷，是胃虚热极而见厥，乃热深厥亦深。如果不因发汗，而自汗出，成无己虽说是三阳热甚，终归是阳明气分燥热，所以在肌肉之间，自汗时时而出。成无己又说：给予白虎汤以解内外之热。这是合经与腑俱治的意义。有人问：白虎汤怎么能解三阳之热？我回答说：病到了自汗出的程度，则太阴、少阳之邪，总归阳明了，怎能不从阳明而专治之呢？又有人问：既然从阳明而治，为什么用下法而不愈？我又回答说：腹满谵语，似乎可下。要之，阳明胃腑气分燥热亢极者，也致谵语。其腹满是气滞，身重是气困，口不仁是气不和，面垢是气不舒，遗尿是气不摄，自汗出是气不敛。凡是这些，都是气分燥热所致。气燥热而反用大小承气等血药以攻之，所以出现头汗、手足冷等变证。白虎汤能清阳明气分热，滋肠胃中之燥，所以是上证必用的药。）
Heat is abundant within the interior. The symptoms occur at specific times because the pathogenic factor takes advantage of the Shen (3-5 PM) and Wei (1-3 PM) hours, when the Qi of the Yangming channel is prosperous. Therefore, at these times, irritability occurs. This is a sign of dry stool (hardened feces), which causes constipation. My commentary: When Zhang Zhongjing uses Da Chengqi Tang (Major Order the Qi Decoction) for syndromes, he must differentiate whether there is dry stool. Thus, the previously mentioned tidal fever, delirium, sweating of the hands and feet, and passing flatus constitute a comprehensive treatment method. This clause further mentions periumbilical pain, showing that syndromes can be diverse; physicians should adapt flexibly and seek medical advice.)
The patient suffers from vexation and heat. Symptoms resolve after sweating, yet recur like malaria. Fever occurring in the late afternoon (Ribu, 3-7 PM) indicates involvement of the Yangming channel. If the pulse is excess (Shi), purgation is indicated; if the pulse is floating and deficient (Xu), diaphoresis is indicated. For purgation, administer Da Chengqi Tang (Major Order the Qi Decoction); for diaphoresis, Guizhi Tang (Cinnamon Twig Decoction) is appropriate. (This clause pertains to a Taiyang-Yangming combined syndrome. The patient's vexation and heat indicate that wind-pathogens in the Taiyang channel have not been fully cleared. Spontaneous sweating temporarily alleviates the heat, but vexation returns the next day, hence the comparison to malaria, indicating the exterior syndrome persists. Late afternoon fever signifies heat transmitting to Yangming, with pathogens entering the Fu organs and causing tidal fever, indicating interior syndromes are established. However, the pulse must be assessed. An excess pulse confirms interior syndromes, warranting purgation with Da Chengqi Tang (Major Order the Qi Decoction). A floating and deficient pulse indicates unresolved exterior syndromes; despite afternoon fever, it is merely vexation and heat rather than tidal fever, meaning pathogens have not fully entered the Fu organs but remain in the channels. Thus, Guizhi Tang (Cinnamon Twig Decoction) is suitable to induce sweating. Wait for the exterior syndrome to resolve before considering purgatives. Question: If the condition resembles malaria and the pulse is excess, why not use Chaihu Xiaocheng Tang (Bupleurum Minor Order the Qi Decoction)? Answer: The "resembling malaria" mentioned earlier refers to vexation and heat resolving with sweat, mimicking malaria patterns, not alternating chills and fever. With a floating and deficient pulse, diaphoresis is indicated. I believe this is a Taiyang-Yangming channel syndrome. According to Zhang Zhongjing's methods, Guizhi Jia Gegen Tang (Cinnamon Twig Decoction plus Pueraria Decoction) would be appropriate.)
After severe purgation, six or seven days pass without bowel movement. Vexation remains unresolved, accompanied by abdominal fullness and pain. This indicates the presence of dry stool. The reason is pre-existing food stagnation. Da Chengqi Tang (Major Order the Qi Decoction) is indicated. (This clause describes a case where, after severe purgation, interior excess has not been fully resolved, necessitating another round of strong purgation. Constipation, vexation, abdominal fullness, and pain indicate that purgative indications are present. Having used severe purgation, yet six or seven days later, there is still no bowel movement, unresolved vexation, and abdominal fullness with pain, this confirms dry stool. Why is interior excess so pronounced after severe purgation? Because the patient originally had food stagnation, which was not fully cleared. Cheng Wuji notes: Administer Da Chengqi Tang (Major Order the Qi Decoction) to purge and eliminate it. Question: After severe purgation, is constipation for six or seven days an indication for purgation? Answer: After severe purgation, the Stomach is deficient, and new food has not entered. Even without bowel movements for six or seven days, it is not necessarily an indication for purgation. Only unresolved vexation and abdominal fullness/pain signify dry stool, warranting repeated administration of Da Chengqi Tang (Major Order the Qi Decoction) to purge it.)
The patient has difficult urination, intermittent difficulty and ease in defecation, occasional slight fever, wheezing, dizziness, and inability to lie down. This indicates dry stool. Da Chengqi Tang (Major Order the Qi Decoction) is indicated. (This case involves dry stool without prior purgation, a syndrome difficult for physicians to recognize. Cheng Wuji notes: Normal urine flow leads to hard stools, a common sign of dry stool. Here, difficult urination and intermittent defecation suggest dry stool because in cases of severe excess and fullness, both urination and defecation are blocked. Dry stool obstructs the intestines; unhardened parts may occasionally pass, causing intermittent ease (Zha Yi), while extremely hardened parts remain stuck, causing intermittent difficulty (Zha Nan). Dry stool accumulates below, turbid Qi attacks above, causing occasional slight fever. Slight fever indicates heat trapped inside, unable to vent, deeper than tidal fever. Later commentaries state: Turbid Qi invades the Heart and Lungs, causing dizziness and wheezing, preventing lying down. The Stomach is disturbed by dry-heat, as stated in the classics: "When the Stomach is disharmonious, sleep is restless." These are all signs of dry stool, hence Da Chengqi Tang (Major Order the Qi Decoction) is indicated. Chen Liangsi says: This is a variant method for identifying dry stool; physicians must know it.)
In a Taiyang syndrome, if emesis, purgation, or diaphoresis results in slight vexation, frequent urination, and consequently hard stools, Xiao Chengqi Tang (Minor Order the Qi Decoction) should be given to harmonize, leading to recovery. (This clause pertains to a Taiyang-Yangming combined syndrome. After diaphoresis, emesis, and purgation in Taiyang syndrome, pathogens are reduced. Residual pathogens enter the Stomach, causing mild interior excess-heat, hence "slight vexation." Slight vexation does not necessarily mean hard stools; hardness here is due to frequent urination depleting fluids. This is not a severe excess-fullness syndrome, so Xiao Chengqi Tang (Minor Order the Qi Decoction) is given to harmonize. My commentary: This case represents failure to resolve after diaphoresis, emesis, and purgation, distinct from misapplication. Cheng Wuji attributes it to fluid damage, not depletion. Hard stools here mean slightly hard, not firmly impacted. Cheng Wuji's interpretation as Pi Yue (Spleen Confinement) is highly erroneous.)
Two or three days after contracting disease, the pulse is weak, with no Taiyang or Shaoyang syndromes. There is vexation and hardness in the epigastrium. By the fourth or fifth day, even if the patient can eat, give Xiao Chengqi Tang (Minor Order the Qi Decoction) in small amounts to mildly harmonize, allowing slight relief. By the sixth day, administer one Sheng of Chengqi Tang. If there is no bowel movement for six or seven days and urine output is scanty, even if the patient cannot eat, if the stool is hard at the beginning but loose at the end, it is not definitively hard; purging will cause diarrhea. Wait until urination is normal and stool is definitely hard before purging; Da Chengqi Tang (Major Order the Qi Decoction) is then indicated. (This clause elaborates that Da and Xiao Chengqi Tangs should not be overused or used abruptly. Not specifying Cold Damage or Wind Strike implies mixed wind-cold pathogens requiring no differentiation. Weak pulse indicates absence of exterior pulses like floating-tight. Absence of Taiyang/Shaoyang syndromes means no chills/fever or alternating chills/fever. Vexation and epigastric hardness indicate full Yangming Fu organ excess-heat. By day four or five, heat transmits from Foot Yangming Stomach to Hand Yangming Large Intestine. As stated, "When the Intestines are excess, the Stomach is deficient," explaining the ability to eat. Ability to eat implies no bloating/fullness, indicating purgation is not urgent, unlike Yangming Stomach strength with mania. Thus, Xiao Chengqi Tang (Minor Order the Qi Decoction) is given in small amounts to mildly harmonize and relieve vexation/constipation. By day six, if vexation persists and no bowel movement occurs, increase to one Sheng to facilitate defecation. This warns against overusing Xiao Chengqi Tang. "If no bowel movement..." continues from "vexation and epigastric hardness." Days six-seven without bowel movement is the time for purgation. Scanty urine indicates fluid metabolism issues in the Stomach, preventing eating, distinct from delirium/tidal fever cases where dry stool prevents eating. Thus, even if unable to eat, initial hard stool followed by loose stool indicates incomplete hardening; purging now causes diarrhea. Wait for normal urination and definitive hard stool before using Da Chengqi Tang (Major Order the Qi Decoction). This warns against abrupt use of Da Chengqi Tang. Commentaries note: Taiyang specifies herbs due to Guizhi/Mahuang differences; Shaoyang specifies syndromes due to its exclusive nature. These texts mutually clarify meanings. Regarding eating: Ability to eat suggests blockage in intestines with strong Stomach fire causing vexation; inability to eat suggests weak Stomach failing to distribute fluids, causing fluid accumulation in the chest and weak pulse. I consider epigastric hardness a symptom of days two-three, shifting lower by days four-five/seven. Question: If pulse is weak, Stomach Qi is also weak; why use Da Chengqi Tang? Answer: Mangxiao (Natrii Sulfas) in Da Chengqi Tang targets the Large Intestine directly to purge hard stool, removing pathogens without damaging the Stomach. Premature purging fails to remove pathogens and damages Stomach Qi. Physicians must know this.)
Six or seven days into Cold Damage, vision is unclear ("liao liao bu liao"), eyes are unresponsive ("jing bu he"). With no exterior or typical interior syndromes, difficult defecation, and slight body fever, this is an Excess syndrome. Urgent purgation is required; Da Chengqi Tang (Major Order the Qi Decoction) is indicated. (The character "Li" (Interior) in "no exterior or interior syndromes" is likely a transcription error and should be deleted. This clause describes pathogenic heat invading viscera, requiring urgent purgation. By day six-seven, pathogens enter the interior. Unclear vision means the patient sees poorly. Unresponsive eyes mean dim or scattered pupil light, indicating disharmony. This is hyperactive Yangming heat, where Earth overacts on Water, threatening Kidney Water exhaustion, causing pupils to fail to focus. At this stage, no exterior syndrome exists; difficult defecation indicates interior excess. Slight body fever indicates interior heat. Interior excess-heat manifests externally as slight fever, not exterior fever. This is interior excess requiring purgation. Combined with unresponsive eyes, it signifies severe interior excess-heat requiring urgent purgation with Da Chengqi Tang (Major Order the Qi Decoction) to drain Earth depression and save Water exhaustion. Delay is unacceptable. Note: This is a Yangming Fu syndrome; interpreting it via Yangming channel connecting to the eyes is highly erroneous.)
Yangming syndrome with fever and profuse sweating requires urgent purgation; Da Chengqi Tang (Major Order the Qi Decoction) is indicated. (This syndrome also requires urgent purgation to rescue depleted Stomach fluids. Pathogenic heat enters the Fu organs, interior heat becomes excessive and evaporates outward, causing fever and profuse sweating. Cheng Wuji notes: Heat forces fluids toward depletion; urgently administer Da Chengqi Tang (Major Order the Qi Decoction) to purge Fu heat and preserve fluids.)
Diaphoresis fails to resolve the condition; abdominal fullness and pain require urgent purgation; Da Chengqi Tang (Major Order the Qi Decoction) is indicated. (This is Zheng Yang Yangming, requiring urgent purgation. Failure to resolve after diaphoresis indicates sweating targeted Yangming channel pathogens; exterior syndrome resolves, but pathogens persist. Pathogenic heat transmits to Fu organs, causing severe interior excess, abdominal fullness, and pain. Cheng Wuji notes: Transmission is rapid. Due to rapid transmission, Da Chengqi Tang (Major Order the Qi Decoction) is urgently needed to purge interior excess-heat.)
Abdominal fullness does not decrease, or any decrease is negligible. Purge; Da Chengqi Tang (Major Order the Qi Decoction) is indicated. (This continues the previous clause. After urgent purgation with Da Chengqi Tang for abdominal fullness/pain, if fullness persists, it means bloating does not reduce after purgation. Cheng Wuji notes: Pathogens remain excess. "Decrease is negligible" means even a slight reduction is insufficient to curb the pathogen's momentum, as noted in Shang Lun Pian. Thus, repeat purgation with Da Chengqi Tang (Major Order the Qi Decoction) is indicated.)
Combined syndromes of Yangming and Shaoyang必然 result in diarrhea. If the pulse is "not negative" (Fu), it is favorable (Shun). If "negative," it is unfavorable (Shi). Mutual overcoming is called "negative." A slippery and rapid pulse indicates food stagnation; purge; Da Chengqi Tang (Major Order the Qi Decoction) is indicated. (This is a combined syndrome, but purgation is only warranted when Shaoyang pathogens consolidate in Yangming. Commentaries state: Yangming belongs to Earth, governing water/grain; Shaoyang belongs to Wood, governing wind. Wind causes undigested diarrhea. Thus, combined Yang-Shao syndromes lead to diarrhea. Yangming pulse is large; Shaoyang pulse is string-like. "Not negative" means Yangming's large pulse matches Shaoyang's string-like pulse, a favorable sign. If Shaoyang pulse dominates (string-like) and Yangming pulse is weak/not large, Yangming righteous Qi is lost, indicating unfavorable prognosis. Wood is the thief of Earth; Earth overcome by Wood is "negative." This is an untreatable diarrhea. However, a slippery-rapid pulse indicates food stagnation (Slippery governs food, Rapid governs heat). This means Shaoyang pathogens have fully entered Yangming Fu organs, forming Fu excess. Cheng Wuji notes: Administer Da Chengqi Tang (Major Order the Qi Decoction) to purge. The above thirteen clauses were moved here from the end of the original chapter.)
Diarrhea accompanied by delirium indicates dry stool; Xiao Chengqi Tang (Minor Order the Qi Decoction) is indicated. (Moved from Jueyin chapter. Diarrhea is an intestinal issue. Delirium indicates Stomach excess, unrelated to Jueyin. The primary cause is dry stool in the intestines blocking passage. Xiao Chengqi Tang (Minor Order the Qi Decoction) is used because the condition is half-diarrhea, half-blockage, requiring gentle purgation. Question: If diarrhea allows heat to escape downward, how does delirium and dry stool arise? Answer: This is Yangming Fu excess with intense heat. Fecal matter in the Stomach is congested by heat, remaining inside. Unhardened parts may pass occasionally; hardened parts never exit. This dry stool is the root of the diarrhea. Blocked dry stool allows pathogenic heat to ascend to the Heart, causing delirium. Generally, pressing the umbilical/abdominal area will reveal hardness and pain, confirming dry stool.)
Combined syndromes of the Three Yang present with abdominal fullness, heavy body, difficulty turning, insensitivity in the mouth, facial grime, delirium, and urinary incontinence. Diaphoresis worsens delirium; purgation causes sweating on the forehead and cold extremities. If spontaneous sweating occurs, Baihu Tang (White Tiger Decoction) governs. (Although a combined syndrome, this is actually extreme heat in the Yangming Channel and Fu organ Qi levels. Combined Three Yang syndromes involve many Yang heat syndromes, resulting in intense heat. Intense heat causes limb fatigue and confusion, leading to heaviness and difficulty turning. Mouth insensitivity and delirium: "Insensitivity" means abnormality. Commentaries state: Inability to taste/eat leads to lack of oral sensation. These are Yangming main syndromes. Classics state: Severe Shaoyang disease causes facial dust. "Grime" is dust. Facial grime indicates Shaoyang heat with dull, dark complexion. Urinary incontinence indicates Taiyang heat with bladder loss of control. Cheng Wuji notes: Since Yangming syndromes predominate, this appears in the Yangming chapter. Combined Three Yang syndromes involve exterior-interior pathogens. Misdiagnosing heaviness as needing diaphoresis drives pathogens into Yangming Stomach dry-heat, worsening delirium. Subsequent misdiagnosis of delirium as needing purgation injures Yin of intestines/stomach, leaving Yang unanchored and floating upward, causing forehead sweating. Cold extremities indicate Stomach deficiency with extreme heat leading to Jue (cold limbs), i.e., deep heat causes deep Jue. If spontaneous sweating occurs without prior diaphoresis, Cheng Wuji attributes it to extreme Three Yang heat, specifically Yangming Qi-level dry-heat causing muscle sweating. He adds: Baihu Tang (White Tiger Decoction) resolves interior-exterior heat, treating both Channel and Fu. Question: How does Baihu Tang resolve Three Yang heat? Answer: Spontaneous sweating indicates Taiyin/Shaoyang pathogens have consolidated in Yangming; thus, treat exclusively via Yangming. Question: If treating Yangming, why doesn't purgation work? Answer: Abdominal fullness and delirium seem purgable. However, extreme Yangming Stomach Qi-level dry-heat also causes delirium. Fullness is Qi stagnation; heaviness is Qi distress; mouth insensitivity is Qi disharmony; facial grime is Qi constraint; incontinence is Qi failure to secure; spontaneous sweating is Qi failure to contain. All result from Qi-level dry-heat. Using blood-invigorating purgatives like Da/Xiao Chengqi Tangs for Qi-level dry-heat causes side effects like head sweating and cold limbs. Baihu Tang (White Tiger Decoction) clears Yangming Qi-level heat and moistens intestinal dryness, making it essential for this syndrome.)