大猪胆一枚，泻汁和法醋少许，以灌谷道内，如一食顷，当大便，出宿食恶物甚效。
『内台方』不用醋，以小竹管插入胆口，留一头用油润，内入谷道中，以手将胆捻之
，其汁自入内，此方用之甚便。
（缺）
【按】
土瓜，即俗名赤雹也。『肘后方』治大便不通，采根捣汁，用筒吹入肛门内。此与上
猪胆汁方同义。『内台方』用土瓜根削如挺，内入谷道中误矣。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。
@@@
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。
【注】
少阴病，得之二、三日，口燥咽干，急下之，宜大承气汤者，乃因热势甚速，消灼肾
水，津液不能到咽，故不必待其有可下之证而急下之，是下其热，以救将绝之水，缓
则肾水干竭，阳必无根据，躁冒自焚而死也。目中不了了而睛和者，阴证也，睛不和者
，阳证也。今伤寒六、七日，目中不了了，睛不和者，是肾水为胃阳所竭，水既不能
制火，则火上熏于目，而眸子朦胧，为之不了了也，此热结神昏之渐，危恶之候也。
虽外无阳证，惟身微热，内无满痛，祗大便难，亦为热实，故曰：此为实也。急以大
承气汤下之，泻阳救阴，以全未竭之水可也。睛不和者，谓睛不活动也。
【集注】
方有执曰：了了，犹了了也。『素问』曰：阳明主肉，其脉侠鼻络于目。『灵枢』曰
：足阳明之脉，上循咽出于口，还系目系合于阳明也。又曰：足阳明之筋，其支者，
上颈上侠口合于頄，下结于鼻，上合于太阳。太阳为目上纲，阳明为目下纲；所以目
中不了了，睛不和，知胃实也。急下者，任脉循面入目，督脉上系两目中央，诸脉皆
属于目，而人之精神注焉，是以宜急下也。
喻昌曰：少阴有急下三法以救肾水：一本经水竭，一木邪涌水，一土邪凌水。阳明亦
有急下三法以救津液：一汗多津越于外，一腹满津结于内，一目睛不慧，津枯于中。
合两经下法以观病情生理，如身在冰壶腹饮上池矣。
张锡驹曰：阳火亢极，阴水欲枯，故使目中不了了而睛不和，急下之，所以抑亢极之
阳火，而救垂绝之阴水也。
魏荔彤曰：阳明燥屎应下，胃实应下，俱详考其脉证矣。乃有表里无他证，独于阳明
胃脉所发见端倪处，体认其证，如伤寒六、七日，太阳已罢，阳明已成，其目昏暗朦
昧，若隔云雾而不了了明白者，此证名为睛不和也。阳明热盛，循经络而发其昏朦之
象，以致睛失其光，此内热盛而为实，其机已兆，兼以大便□而难，身有微热者，则
胃实已真，故曰：此为实也，急下之，宜大承气汤。
@@@
病人小便不利，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。
【注】
阳明病之人，小便自利，大盒饭□，小便不利，大便不□，是知□不□，不在热不热
，而在液之竭与不竭也。今小便不利，而大便乍难乍易者，盖热将欲作结，而液未竭
也。有时微热者热入里也，喘者热乘肺也，冒者热乘心也，不能卧者热并阳也，此皆
一派热结便□之征，神昏谵狂之渐，虽无满痛，亦必有燥屎，宜大承气汤下之自愈也
。
【集注】
王三阳曰：此证不宜妄动，必以手按之脐腹有□块，喘冒不能卧，方可攻之，何也？
乍难乍易故也。
林澜曰：既微热时作，喘冒不能卧，则有燥屎已得。自宜下逐里实为急，安可复以小
便利、屎定□，始可攻之常法拘哉！
汪琥曰：此条病未经下而有燥屎，乃医人不易识之证。成无已云：小便利则大便□，
此有燥屎乃理之常。今病人小便不利，大便乍难乍易，何以知其有燥屎耶？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，热伏于内不得发泄也。后条辨云：浊气乘于心肺，故既冒且喘也，
不得卧者，胃有燥屎所扰，即胃不和则卧不安也。凡此者，皆是有燥屎之征，故云：
宜大承气汤。
@@@
病人不大便五、六日，绕脐痛，烦躁，发作有时者，此有燥屎，故使不大便也。
【注】
病人不大便五、六日，绕脐痛者，是肠胃中燥屎结无去路，故绕脐痛也。烦躁发作有
时者，是燥屎秽热上攻则烦躁，不攻则不烦躁，故发作有时也。不须以小承气汤试之
，直以大承气汤下其燥屎，大便利自可愈也。
【集注】
方有执曰：病人，谓凡有病之人，而证犯如此者，则皆当如此治之。此示人辨凡百胃
实之大旨也。
程应旄曰：攻法，必待有燥屎，方不为误攻。所以验燥屎之法，不可不备，无恃转失
气之一端也。病人虽不大便五、六日，屎之燥与不燥未可知也。但绕脐痛，则知肠胃
干，屎无去路，滞涩在一处而作痛；烦躁发作有时者，因屎气攻动，则烦躁发作；又
有时伏而不动，亦不烦躁，而有绕脐痛者，断其不大盒饭无差矣，何大承气汤之不可
攻耶！
@@@
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。
【注】
此承上条以明其治也。下之未尽，仍当下之。乃大下之后，六、七日后不大便，烦亦
不解，腹仍满痛者，此有燥屎下之未尽也。所以然者，本有宿食故也，宜大承气汤复
下之自愈也。
【集注】
程知曰：大下之后，宜乎病解矣，乃复六、七日不大便，烦不解而腹满痛，此必有燥
屎未尽而然。盖宿食因热复为之结□也。
@@@
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。
【注】
阳明经病下之，身热未除，手足温，不结胸者，是所陷之邪浅也。心中懊□，饥不能
食，但头汗出者，是阳邪蒸郁于胸膈间也。故宜栀子豉汤涌其热也。
【集注】
程知曰：其外有热者，经邪未解也；手足温者，热入未深也。
程应旄曰：懊□扰胃，故饥不能食。热郁气蒸，故但头汗出。
魏荔彤曰：表邪未全入里，乃即以为胃实而遽下之，则其外仍有热，究不能随下药而
荡涤也。于是虽热而不潮，手足虽温而无濈然之汗出，则是在表者，仍在表而下之，
徒伤其里耳！即不至于全在太阳者，误下成结胸，而心下懊□，饥不能食，但头汗出
，其阳明蒸蒸之热，为阴寒之药所郁，俱凝塞于胸膈之上，其证已昭然矣。但病仍带
表，既不可再下，且已入里，又不可复发汗，惟有主以栀子豉汤，仍从太阳治也。
@@@
伤寒呕多，虽有阳明证，不可攻之。
【注】
伤寒三阳多有呕证，以其风寒之表未除，胸中阳气为寒所郁，故皆不可攻下也。其干
呕而恶寒发热者，属太阳也。喜呕而寒热往来者，属少阳也。今虽祗有恶寒、不恶寒
、大便□之阳明证，而呕多亦不可攻之，其气逆在上而未敛，为实也。
【集注】
沈明宗曰：恶寒发热之呕属太阳，寒热往来之呕属少阳，但恶热不恶寒之呕属阳明。
然呕多则气已上逆，邪气偏侵上脘，或带少阳，故虽有阳明证，慎不可攻也。
@@@
阳明中风，口苦咽干，腹满微喘，发热恶寒，脉浮而紧，若下之，则腹满小便难也。
【注】
阳明，谓阳明里证。中风，谓太阳表证也。口苦咽干，少阳热证也。腹满，阳明热证
也。微喘，发热恶寒，太阳伤寒证也。脉浮而紧，伤寒脉也。此为风寒兼伤表里同病
之证，当审表里施治：太阳、阳明病多，则以桂枝加大黄汤两解之。少阳、阳明病多
，则以大柴胡汤和而下之。若惟从里治，而遽以腹满一证，为热入阳明而下之，则表
邪乘虚复陷，故腹更满也；里热愈竭其液，故小便难也。
【集注】
程知曰：此言阳明兼有太阳、少阳表邪，即不可攻也。阳明中风，热邪也，腹满而喘
，热入里矣。然喘而微，则未全入里也。发热恶寒，脉浮而紧，皆太阳未除之证，口
苦咽干，为有少阳之半表半里，若误下之，则表邪乘虚内陷，而腹益满矣。兼以重亡
津液，故小便难也。
程应旄曰：此条与太阳大青龙证同。太阳以风寒持其荣卫，故有烦躁证而无腹满证；
此以风寒持住阳明，故有腹满证而无烦躁证。然口苦、咽干，实与烦躁同其机兆也。
@@@
阳明病，脉浮而紧，咽燥口苦，腹满而喘，发热汗出，不恶寒反恶热，身重。若发汗
则躁，心愦愦反□语。若加温针，必怵惕烦躁不得眠。若下之，则胃中空虚，客气动
膈，心中懊□，舌上胎者，栀子豉汤主之。若渴欲饮水，口干舌燥者，白虎加人参汤
主之。若脉浮发热，渴欲饮水，小便不利者，猪苓汤主之。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。
【注】
此承前条互发其义，以明其治也。前条表证居多，戒不可误下；此条表里混淆，脉证
错杂，不但不可误下，亦不可误汗也。若以脉浮而紧，误发其汗，则夺液伤阴。或加
烧针，必益助阳邪，故□语烦躁，怵惕愦乱不眠也。或以证之腹满，恶热，而误下之
，则胃中空虚，客气邪热，扰动胸膈，心中懊□，舌上生胎，是皆误下之过，宜以栀
子豉汤一涌而可安也。若脉浮不紧，证无懊□，惟发热，渴欲饮水，口干舌燥者，为
太阳表邪已衰，阳明燥热正甚，宜白虎加人参汤，滋液以生津。若发热渴欲饮水，小
便不利者，是阳明饮热并盛，宜猪苓汤利水以滋干。然阳明病，法当多汗，因汗出多
，致小便少而渴者，不可与猪苓汤。盖以汗多胃燥，无水不能下行，乃水涸之小便少
，非水蓄之小便不利也，恐猪苓汤更利其小便，则益竭津液而助燥矣。
【按】
太阳病，烦热无汗而渴，小便利者，大青龙汤证也；小便不利者，小青龙汤去半夏加
花粉、茯苓证也。太阳病，烦热有汗而渴，小便利者，桂枝合白虎汤证也；小便不利
者，五芩散证。阳明病，烦热无汗而渴，小便利者，宜葛根汤加石膏主之；小便不利
者，以五芩散加石膏、寒水石、滑石主之。阳明病，烦热有汗而渴，小便利者，宜白
虎汤；小便不利者，以猪苓汤。少阳病寒热无汗而渴，小便利者，当以小柴胡汤去半
夏加花粉；小便不利者，当以小柴胡汤加茯苓。太阴无渴。少阴阳邪，烦呕小便赤而
渴者，以猪苓汤；少阴阴邪下利，小便白而渴者，以真武汤。厥阴阳邪消渴者，白虎
加人参汤；厥阴阴邪，转属阳明，渴欲饮水者，少少与之则愈。证既不同，法亦各异
，当详审而明辨之。
【集注】
喻昌曰：发热以上与前条同，而汗出，不恶寒，反恶热，身重，四者皆阳明之见证，
所以汗、下、烧针俱不可用。舌上胎，则膈热甚，故涌以栀子鼓而微去其膈热，斯治
太阳而无碍阳明矣。若前证更加口干舌燥，则宜用白虎汤以解热生津；更加小便不利
，则宜以猪苓汤，以导热滋干也。其汗多而渴，不可与猪苓汤者，以热邪传入阳明，
必先耗其津液；加以汗多复夺之于外，又利小便更夺之于下，则津液有立亡之患，故
示戒也。
程应旄曰：热在上焦，故用栀子豉汤；热在中焦，故用白虎加人参汤；热在下焦，故
用猪苓汤。
大猪胆一个，挤出胆汁，加入少量米醋，灌入肛门内，大约一顿饭的工夫，应当排出大便，排出积存的宿食和污物，效果显著。
《内台方》不用醋，用一根小竹管插入胆口，留一头用油润滑，插入肛门中，用手将胆挤压，胆汁自然流入体内，此法使用非常方便。
（此处原文缺失）
【按语】
土瓜，就是俗称的赤雹。《肘后备急方》治疗大便不通，采集土瓜根捣取汁液，用筒状工具吹入肛门内。这与上面的猪胆汁方意义相同。《内台方》将土瓜根削成棒状，插入肛门中是错误的。因为蜜制的栓剂插入肛门能融化并润滑大便。土瓜根不能融化，如果削成棒状使用，恐怕违背了张仲景制方的本意。
@@@
伤寒病六七天，眼睛视物不清，眼球转动不灵活，没有表证也没有典型的里实证，大便困难，身体微热，这是里实热证，必须紧急攻下，适宜用大承气汤。
【注解】
少阴病，得病两三天，出现口干咽燥，必须紧急攻下，适宜用大承气汤，这是因为热势迅猛，消灼肾水，津液不能上达咽喉，所以不必等到有可下的典型症状就紧急攻下，这是通过泻下来清热，以挽救即将枯竭的肾水，如果迟缓，肾水干竭，阳气无所依附，病人会因烦躁神昏、自焚而死。眼睛视物不清但眼球转动灵活的，是阴证；眼球转动不灵活的，是阳证。现在伤寒六七天，眼睛视物不清，眼球转动不灵活，这是肾水被胃阳所耗竭，水既不能制约火，则火上熏于目，导致瞳孔朦胧，视物不清，这是热结导致神志昏蒙的开端，是危险恶劣的征候。虽然体表没有明显的阳证，只是身体微热，体内没有胀满疼痛，仅仅大便困难，也属于热实，所以说：这是里实证。必须紧急用大承气汤攻下，泻阳救阴，以保全尚未枯竭的阴液。所谓眼球转动不灵活，是指眼球活动不灵活。
【集注】
方有执说：了了，就是清楚的意思。《素问》说：阳明经主肌肉，其经脉夹鼻络于目。《灵枢》说：足阳明经脉，上行沿咽喉出于口，回环联系目系，合于阳明经。又说：足阳明经筋，其分支，上行颈部夹口合于颧部，下行结于鼻，上行合于太阳经。太阳经为目上纲，阳明经为目下纲；所以眼睛视物不清，眼球转动不灵活，可知是胃家实。必须紧急攻下，因为任脉循行面部进入目内，督脉上行联系两眼中央，诸脉都归属于目，人的精神灌注于此，所以宜紧急攻下。
喻昌说：少阴病有急下三法以救肾水：一是本经肾水枯竭，二是肝木邪气涌盛凌水，三是脾土邪气凌水。阳明病也有急下三法以救津液：一是汗多津液外越，二是腹满津液结聚于内，三是眼睛视物不明，津液枯涸于中。综合两条经的下法来观察病情和生理机制，就像身在冰壶中饮用上池之水一样透彻。
张锡驹说：阳火亢盛到了极点，阴水将要枯竭，所以使眼睛视物不清且眼球转动不灵活，紧急攻下，是为了抑制亢盛的阳火，而挽救垂绝的阴水。
魏荔彤说：阳明燥屎应当攻下，胃家实应当攻下，都在详细考证其脉证之后。然而有表里没有其他证候，唯独在阳明胃脉所显现的端倪处，体认其证，如伤寒六七天，太阳病已罢，阳明病已成，眼睛昏暗朦胧，像隔着云雾一样看不清楚明白，这种证候名叫睛不和。阳明热盛，循经络发作昏蒙之象，导致眼睛失去光泽，这是内热盛而为实，病机已经显露，兼有大便难解，身体有微热，那么胃实已经确凿，所以说：这是里实证，必须紧急攻下，适宜用大承气汤。
@@@
病人小便不利，大便有时难解有时易解，时常有微热，气喘头昏不能平卧的，是有燥屎，适宜用大承气汤。
【注解】
患阳明病的人，如果小便通利，大便应当干燥；如果小便不利，大便就不干燥，由此可知大便干与不干，不在于热与不热，而在于津液的枯竭与否。现在小便不利，而大便有时难解有时易解，大概是热邪将要结聚，而津液尚未枯竭。有时出现微热，是热邪入里；气喘，是热邪犯肺；头昏，是热邪犯心；不能平卧，是热邪并入阳分，这都是一派热结便硬的征象，神志昏乱谵语的开端，虽然没有胀满疼痛，但也一定有燥屎，适宜用大承气汤攻下，自愈。
【集注】
王三阳说：此证不宜妄动，必须用手按压脐腹部有硬块，气喘头昏不能平卧，才可以攻下，为什么呢？因为大便乍难乍易的缘故。
林澜说：既然微热时作，气喘头昏不能平卧，说明已有燥屎。自然应当急下以逐除里实，怎么可以拘泥于常法，一定要等小便通利、大便确定干燥，才可以攻下呢！
汪琥说：这一条病症未经攻下而有燥屎，是医生不易识别的证候。成无己说：小便利则大便干燥，这是有燥屎的道理之常情。现在病人小便不利，大便乍难乍易，怎么知道有燥屎呢？大概大实、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，有时一并排出，所以乍易；其中极坚结的部分，始终留在大肠之中，所以乍难。燥屎结积于下，浊气攻冲于上，所以时有微热；微热，是因为热伏于内不得发泄。后条辨析说：浊气乘袭心肺，所以既头昏又气喘；不能平卧，是因为胃中有燥屎扰乱，即胃不和则卧不安。凡是这些情况，都是有燥屎的征象，所以说：适宜用大承气汤。
@@@
病人不大便五、六天，绕脐疼痛，烦躁，发作有定时的，这是有燥屎，所以导致不大便。
【注解】
病人不大便五、六天，绕脐疼痛，是肠胃中燥屎结聚没有出路，所以绕脐疼痛。烦躁发作有定时，是燥屎秽热上攻则烦躁，不上攻则不烦躁，所以发作有定时。不需要用小承气汤试探，直接用大承气汤攻下燥屎，大便通畅自然痊愈。
【集注】
方有执说：病人，指凡是患病的人，而证候符合上述情况的，都应当这样治疗。这是向人展示辨别各种胃家实的大旨。
程应旄说：攻下法，必须确认有燥屎，才不是误攻。所以验证燥屎的方法，不可不周全，不能只依赖转失气这一端。病人虽然不大便五、六天，屎的干燥与否还不可知。但只要绕脐痛，就知道肠胃干燥，屎无去路，滞涩在一处而作痛；烦躁发作有定时，是因为屎气攻动，则烦躁发作；又有时伏而不攻动，也不烦躁，但有绕脐痛，断定其不大便无误，为什么不可以用大承气汤攻下呢！
@@@
大攻下之后，六、七天不大便，烦躁不解，腹部胀满疼痛的，这是有燥屎，之所以这样，是因为本来就有宿食，适宜用大承气汤。
【注解】
这是承接上一条来说明治法。攻下未尽，仍然应当攻下。在大攻下之后，六、七日后又不大便，烦躁也不解，腹部仍然胀满疼痛，这是有燥屎攻下未尽。之所以这样，是因为本来就有宿食，适宜用大承气汤再次攻下，自愈。
【集注】
程知说：大攻下之后，病应当解除，却又六、七天不大便，烦躁不解且腹部胀满疼痛，这必定是有燥屎未尽所致。大概宿食因热复结而成燥屎。
@@@
阳明病，经过攻下治疗后，体表仍有发热，手足温暖，没有结胸，心中烦闷懊恼，饥饿但不能进食，只有头部出汗的，用栀子豉汤主治。
【注解】
阳明经病经过攻下，身热未除，手足温暖，没有结胸，说明陷入体内的邪气较浅。心中烦闷懊恼，饥饿但不能进食，只有头部出汗，是阳邪蒸郁于胸膈之间。所以适宜用栀子豉汤涌吐其热。
【集注】
程知说：体表仍有发热，是经邪未解；手足温暖，说明热邪入里不深。
程应旄说：懊恼扰动胃气，所以饥饿但不能进食。热郁气蒸，所以只有头部出汗。
魏荔彤说：表邪未完全入里，就认为是胃实而急于攻下，那么体表仍有热，终究不能随下药而荡涤干净。于是虽然有热但不潮热，手足虽然温暖但没有濈然汗出，那么在表的邪气仍在表，攻下徒伤里气！即使不至于全在太阳经，误下形成结胸，而出现心下懊恼，饥饿不能进食，只有头部出汗，其阳明蒸蒸之热，被阴寒药物所郁遏，都凝塞于胸膈之上，其证候已经明显。但病仍带表证，既然不能再攻下，且已入里，又不能重新发汗，唯有用栀子豉汤，仍从太阳经治法处理。
@@@
伤寒呕吐多，即使有阳明证，也不可攻下。
【注解】
伤寒三阳病多有呕吐证候，因为其风寒表邪未除，胸中阳气被寒邪郁遏，所以都不可攻下。干呕而恶寒发热的，属太阳病。喜欢呕吐且寒热往来的，属少阳病。现在虽然有恶寒或不恶寒、大便干燥的阳明证，但呕吐多也不可攻下，因为气逆在上而未收敛，属实证。
【集注】
沈明宗说：恶寒发热的呕吐属太阳，寒热往来的呕吐属少阳，但恶热不恶寒的呕吐属阳明。然而呕吐多则气已上逆，邪气偏侵上脘，或带有少阳病机，所以虽有阳明证，务必不可攻下。
@@@
阳明中风，口苦咽干，腹部胀满微喘，发热恶寒，脉浮而紧，如果攻下，则腹部胀满加重，小便困难。
【注解】
阳明，指阳明里证。中风，指太阳表证。口苦咽干，是少阳热证。腹部胀满，是阳明热证。微喘，发热恶寒，是太阳伤寒证。脉浮而紧，是伤寒脉象。这是风寒同时伤害表里的同病证候，应当审查表里施治：太阳、阳明病多，就用桂枝加大黄汤表里双解。少阳、阳明病多，就用大柴胡汤和解攻下。如果只从里治，就仅凭腹部胀满一证，认为热入阳明而攻下，则表邪乘虚再次陷入，所以腹部更胀满；里热进一步耗竭津液，所以小便困难。
【集注】
程知说：这说明阳明兼有太阳、少阳表邪，就不可攻下。阳明中风，是热邪，腹部胀满而喘，热邪入里了。但喘而轻微，则未完全入里。发热恶寒，脉浮而紧，都是太阳未除的证候，口苦咽干，是有少阳半表半里之邪，如果误用攻下，则表邪乘虚内陷，而腹部更加胀满。加上重伤津液，所以小便困难。
程应旄说：这一条与太阳大青龙汤证相同。太阳病以风寒束缚营卫，所以有烦躁证而无腹部胀满证；此条以风寒束缚阳明，所以有腹部胀满证而无烦躁证。然而口苦、咽干，实际上与烦躁有相同的病机兆示。
@@@
阳明病，脉浮而紧，咽燥口苦，腹部胀满而喘，发热汗出，不恶寒反恶热，身体沉重。如果发汗，则出现烦躁，心中烦乱反而谵语。如果加用温针，必定惊恐烦躁不得睡眠。如果攻下，则胃中空虚，客气动膈，心中烦闷懊恼，舌上有苔的，用栀子豉汤主治。如果口渴想喝水，口干舌燥的，用白虎加人参汤主治。如果脉浮发热，口渴想喝水，小便不利的，用猪苓汤主治。阳明病，汗出多而口渴的，不可给猪苓汤，因为汗多胃中干燥，猪苓汤再次利其小便的缘故。
【注解】
这是承接前条互相发挥其义，以说明治法。前条表证居多，告诫不可误下；此条表里混淆，脉证错杂，不但不可误下，也不可误汗。如果凭脉浮而紧，误用发汗，则夺液伤阴。或者加用烧针，必定助长阳邪，所以谵语烦躁，惊恐烦乱不眠。或者凭腹部胀满、恶热的证候，误用攻下，则胃中空虚，客气邪热，扰动胸膈，心中烦闷懊恼，舌上生苔，这都是误下的过错，适宜用栀子豉汤涌吐即可安宁。如果脉浮不紧，证无懊恼，只有发热，口渴想喝水，口干舌燥的，是太阳表邪已衰，阳明燥热正盛，适宜用白虎加人参汤，滋液生津。如果发热口渴想喝水，小便不利的，是阳明饮热并盛，适宜用猪苓汤利水以滋润干燥。然而阳明病，法当多汗，因汗出多，导致小便少而口渴的，不可给猪苓汤。因为汗多胃燥，无水不能下行，这是水枯竭的小便少，而非水蓄积的小便不利，恐怕猪苓汤更利其小便，则更加竭尽津液而助长燥热。
【按语】
太阳病，烦热无汗而口渴，小便通利的，是大青龙汤证；小便不利的，是小青龙汤去半夏加花粉、茯苓证。太阳病，烦热有汗而口渴，小便通利的，是桂枝合白虎汤证；小便不利的，是五苓散证。阳明病，烦热无汗而口渴，小便通利的，适宜葛根汤加石膏主治；小便不利的，用五苓散加石膏、寒水石、滑石主治。阳明病，烦热有汗而口渴，小便通利的，适宜白虎汤；小便不利的，用猪苓汤。少阳病寒热无汗而口渴，小便通利的，应当用小柴胡汤去半夏加花粉；小便不利的，应当用小柴胡汤加茯苓。太阴病无口渴。少阴阳邪，烦呕小便赤而口渴的，用猪苓汤；少阴阴邪下利，小便清白而口渴的，用真武汤。厥阴阳邪消渴的，用白虎加人参汤；厥阴阴邪，转属阳明，口渴想喝水的，少量给予则愈。证候既然不同，治法也各异，应当详细审察而明确辨别。
【集注】
喻昌说：发热以上与前条相同，而汗出，不恶寒，反恶热，身体沉重，这四者都是阳明见证，所以汗、下、烧针都不可用。舌上有苔，则膈热甚，所以用栀子豉汤涌吐以微去其膈热，这样治疗太阳而无碍阳明。如果前证加上口干舌燥，则适宜用白虎汤以解热生津；加上小便不利，则适宜用猪苓汤，以导热滋润干燥。其汗多而口渴，不可给猪苓汤的，是因为热邪传入阳明，必先耗损津液；加上汗多又从外部夺取，又利小便再从下部夺取，则津液有立即亡失的隐患，所以示以警戒。
程应旄说：热在上焦，所以用栀子豉汤；热在中焦，所以用白虎加人参汤；热在下焦，所以用猪苓汤。
One large pig gallbladder, express the juice and mix with a small amount of rice vinegar, pour into the anus. After about the time it takes to eat one meal, bowel movement should occur; expelling retained food and foul matter is very effective.
The *Neitai Fang* does not use vinegar. Insert a small bamboo tube into the mouth of the gallbladder, leave one end lubricated with oil, insert it into the anus, and squeeze the gallbladder by hand so that the juice flows in naturally. This method is very convenient.
(Missing)
[Commentary]
Tugua (Trichosanthes kirilowii root), commonly known as Chibao. The *Zhouhou Fang* treats constipation by collecting the root, crushing it to extract juice, and blowing it into the anus with a tube. This has the same meaning as the above Pig Gallbladder Decoction. The *Neitai Fang* carving Tugua root into a suppository shape and inserting it into the anus is incorrect. Because honey suppositories inserted into the anus can melt and lubricate the stool. Tugua root cannot melt; if used carved into a stick, it may violate the original intent of Zhang Zhongjing's prescription formulation.
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In Shaoyang disease lasting six or seven days, if the eyes fail to see clearly and the eyeballs move stiffly, without exterior or interior syndromes, difficulty in defecation, and slight fever, this is an excess syndrome. Urgent purgation is required, and Da Chengqi Tang (Major Order the Qi Decoction) is appropriate.
[Annotation]
In Shaoyin disease, two or three days after onset, if dry mouth and throat appear, urgent purgation is required, using Da Chengqi Tang (Major Order the Qi Decoction). This is because the heat pathogen advances rapidly, consuming Kidney Water (Jing/Essence fluids), preventing body fluids from reaching the throat. Therefore, one should not wait for typical signs of stagnation requiring purgation but must purge urgently to clear heat and rescue the nearly exhausted Yin fluids. Delaying will lead to the exhaustion of Kidney Water, leaving Yang without foundation, resulting in death due to restlessness, delirium, and internal burning. If the eyes fail to see clearly but the eyeballs move freely, it is a Yin syndrome; if the eyeballs move stiffly, it is a Yang syndrome. Now, in Shaoyang disease lasting six or seven days, with unclear vision and stiff eyeballs, this indicates that Kidney Water is depleted by Stomach Yang. Since Water cannot control Fire, Fire flares up to the eyes, causing blurred vision and unclear sight. This is the beginning of heat accumulation leading to spirit confusion, a critical and ominous sign. Although there are no obvious exterior Yang signs, only slight fever, and internally no fullness or pain, merely difficulty in defecation, it is still considered Heat Excess. Thus it says: "This is an excess syndrome." Urgently purge with Da Chengqi Tang (Major Order the Qi Decoction) to drain Yang and save Yin, preserving the unexhausted Yin fluids. "Stiff eyeballs" refers to lack of mobility in the eyeballs.
[Collected Commentaries]
Fang Youzhi states: "Liaoliao" means clear. The *Suwen* states: "Yangming governs flesh, its meridian runs alongside the nose and connects to the eyes." The *Lingshu* states: "The Foot-Yangming meridian ascends along the throat, emerges at the mouth, and loops back to connect with the eye system, merging with Yangming." It also states: "The branch of the Foot-Yangming sinew ascends the neck, runs alongside the mouth, and merges at the cheekbone; descends to knot at the nose, and ascends to merge with Taiyang." Taiyang is the upper border of the eye, Yangming is the lower border; thus, unclear vision and stiff eyeballs indicate Stomach Excess. Urgent purgation is needed because the Ren Mai (Conception Vessel) runs through the face into the eyes, the Du Mai (Governing Vessel) ascends to connect the center of both eyes, and all meridians belong to the eyes where the spirit resides; hence, urgent purgation is suitable.
Yu Chang states: Shaoyin disease has three methods for urgent purgation to rescue Kidney Water: one is depletion of the kidney water itself, one is Liver Wood pathogen surging against water, and one is Spleen Earth pathogen overwhelming water. Yangming disease also has three methods for urgent purgation to rescue body fluids: one is excessive sweating causing fluid loss externally, one is abdominal fullness causing fluid binding internally, and one is unclear vision indicating fluid exhaustion centrally. Observing the pathology and physiology through these purgative methods of both meridians provides profound insight.
Zhang Xiju states: When Yang Fire reaches extreme hyperactivity and Yin Water is about to dry up, causing unclear vision and stiff eyeballs, urgent purgation is used to suppress the extreme Yang Fire and rescue the dying Yin Water.
Wei Litong states: Yangming dry feces should be purged, and Stomach Excess should be purged, after careful examination of pulse and symptoms. However, in cases with no other exterior or interior signs, one must recognize the syndrome at the manifestation point of the Yangming Stomach meridian. For example, in Shaoyang disease lasting six or seven days, when the Taiyang stage has passed and Yangming is established, if the eyes are dim and blurred, appearing unclear like looking through fog, this syndrome is called "stiff eyeballs" (Jing Bu He). Severe Yangming heat follows the meridians to cause this blurring, depriving the eyes of their luster. This indicates severe internal heat and excess, with the mechanism already manifesting. Coupled with difficult defecation and slight fever, Stomach Excess is confirmed. Thus it says: "This is an excess syndrome," requiring urgent purgation with Da Chengqi Tang (Major Order the Qi Decoction).
@@@
If a patient has dysuria, intermittent difficulty and ease in defecation, occasional slight fever, wheezing, dizziness, and inability to lie down, there are dry feces. Da Chengqi Tang (Major Order the Qi Decoction) is appropriate.
[Annotation]
In Yangming disease, if urination is free, stools should be dry; if urination is difficult, stools should not be dry. Thus, whether stools are dry depends not on heat or cold, but on the depletion or preservation of fluids. Now, with dysuria and intermittent difficulty/ease in defecation, it suggests heat is about to bind but fluids are not yet exhausted. Occasional slight fever indicates heat entering the interior. Wheezing indicates heat affecting the Lungs. Dizziness indicates heat affecting the Heart. Inability to lie down indicates heat merging with Yang. These are all signs of heat binding and stool hardening, precursors to spirit confusion and delirium. Even without fullness or pain, dry feces must exist. Da Chengqi Tang (Major Order the Qi Decoction) should be used to purge, leading to self-healing.
[Collected Commentaries]
Wang Sanyang states: This syndrome should not be treated recklessly. One must press the umbilical and abdominal area to feel hardness, accompanied by wheezing, dizziness, and inability to lie down, before attacking. Why? Because of the intermittent nature of the stool.
Lin Lan states: With occasional slight fever, wheezing, dizziness, and inability to lie down, dry feces are already present. Urgent purgation to remove interior excess is indicated. How can one be bound by the common rule of waiting for free urination and confirmed dry stool before attacking?
Wang Hu states: This case involves dry feces without prior purgation, a syndrome difficult for physicians to identify. Cheng Wuji said: Free urination leads to dry stool; having dry feces is the norm. Now, with dysuria and intermittent stool, how do we know there are dry feces? In severe excess and fullness, both urine and stool are blocked. Dry feces block the bowels; the unhardened parts may pass occasionally, causing intermittent ease; the extremely hardened parts remain in the large intestine, causing intermittent difficulty. Dry feces accumulate below, turbid qi attacks upward, causing occasional slight fever (heat trapped inside). The later commentary explains: Turbid qi affects Heart and Lungs, causing dizziness and wheezing. Inability to lie down is due to disturbance by dry feces in the Stomach ("When the Stomach is disharmonious, sleep is restless"). All these are signs of dry feces, hence Da Chengqi Tang (Major Order the Qi Decoction) is appropriate.
@@@
If a patient has not had a bowel movement for five or six days, experiences periumbilical pain, restlessness, and periodic发作 (attacks), there are dry feces causing the constipation.
[Annotation]
No bowel movement for five or six days with periumbilical pain indicates dry feces bound in the intestines and stomach with no exit, causing pain around the navel. Restlessness occurring periodically indicates that turbid heat from dry feces attacks upward causing restlessness; when it does not attack, there is no restlessness. There is no need to test with Xiao Chengqi Tang (Minor Order the Qi Decoction); directly use Da Chengqi Tang (Major Order the Qi Decoction) to purge the dry feces. Once bowels move freely, healing will follow.
[Collected Commentaries]
Fang Youzhi states: "Patient" refers to any sick person presenting such symptoms, who should all be treated this way. This illustrates the general principle for identifying all Stomach Excess syndromes.
Cheng Yingmao states: Purgative methods require confirmation of dry feces to avoid mistaken purgation. Verification methods must be comprehensive, not relying solely on passing gas. Although no bowel movement for five or six days, the dryness of stool is unknown. But periumbilical pain indicates intestinal dryness and blocked exit, stagnating in one spot causing pain. Periodic restlessness occurs when stool qi moves and attacks; when it lies dormant, there is no restlessness, only periumbilical pain. This confirms constipation without error. Why not attack with Da Chengqi Tang (Major Order the Qi Decoction)?
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After severe purgation, if six or seven days pass without a bowel movement, restlessness persists, and abdominal fullness and pain occur, there are dry feces. This is because there was originally retained food. Da Chengqi Tang (Major Order the Qi Decoction) is appropriate.
[Annotation]
This continues the previous section to clarify treatment. If purgation was incomplete, it must be repeated. After severe purgation, if six or seven days pass without a bowel movement, restlessness persists, and abdominal fullness/pain remains, this indicates residual dry feces from incomplete purgation. This happens because there was originally retained food. Da Chengqi Tang (Major Order the Qi Decoction) should be used again to purge, leading to self-healing.
[Collected Commentaries]
Cheng Zhi states: After severe purgation, the illness should resolve. Yet, six or seven days pass without a bowel movement, with persistent restlessness and abdominal fullness/pain. This must be due to residual dry feces. Retained food re-binds due to heat.
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In Yangming disease, after purgation, if there is external heat, warm hands and feet, no Jie Xiong (Chest Binding), mental depression and vexation (Ao Nao), hunger but inability to eat, and only head sweating, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is the primary treatment.
[Annotation]
In Yangming Meridian disease, after purgation, if body heat remains, hands and feet are warm, and there is no Chest Binding, the pathogen sinking inward is shallow. Mental depression/vexation, hunger but inability to eat, and only head sweating indicate Yang pathogen steaming and obstructing the chest and diaphragm. Therefore, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is suitable to induce vomiting/emetic action to clear heat.
[Collected Commentaries]
Cheng Zhi states: External heat indicates meridian pathogen unresolved; warm hands and feet indicate heat has not penetrated deeply.
Cheng Yingmao states: Vexation disturbs the Stomach, causing hunger but inability to eat. Heat obstruction and qi steaming cause only head sweating.
Wei Litong states: If exterior pathogen has not fully entered the interior, and one mistakenly considers it Stomach Excess and purges hastily, external heat remains and cannot be cleared by the purgative. Thus, although hot, there is no tidal fever; although hands/feet are warm, there is no continuous sweating. The exterior pathogen remains exterior, and purgation only injures the interior! Even if not entirely Taiyang, mistaken purgation leading to Chest Binding presents with epigastric vexation, hunger/inability to eat, and head sweating. The steaming heat of Yangming is constrained by cold medicines, condensing in the upper chest/diaphragm. The syndrome is evident. Since the disease still carries exterior characteristics, it cannot be purged again, nor can it be induced to sweat as it has entered the interior. Only Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should be used, treating it according to Taiyang methods.
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In Shaoyang disease with frequent vomiting, even if Yangming signs exist, purgation is contraindicated.
[Annotation]
Shaoyang diseases often present with vomiting because the Wind-Cold exterior pathogen is not resolved, and Yang qi in the chest is constrained by Cold. Thus, purgation is contraindicated. Dry retching with aversion to cold and fever belongs to Taiyang. Frequent vomiting with alternating chills and fever belongs to Shaoyang. Now, even if there are only Yangming signs like aversion to cold or lack thereof, and dry stool, frequent vomiting precludes purgation. The rebellious Qi is above and not gathered, constituting an Excess pattern.
[Collected Commentaries]
Shen Mingzong states: Vomiting with chills/fever belongs to Taiyang; alternating chills/fever belongs to Shaoyang; only heat aversion without cold aversion belongs to Yangming. However, frequent vomiting indicates rebellious Qi and pathogen invading the Upper Jiao or involving Shaoyang. Thus, even with Yangming signs, caution against purgation is essential.
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Yangming Wind Strike, with bitter taste in the mouth, dry throat, abdominal fullness, slight wheezing, fever, aversion to cold, floating and tight pulse. If purged, abdominal fullness will worsen and urination will become difficult.
[Annotation]
"Yangming" refers to Yangming interior syndrome. "Wind Strike" refers to Taiyang exterior syndrome. Bitter taste and dry throat are Shaoyang Heat signs. Abdominal fullness is Yangming Heat sign. Slight wheezing, fever, and aversion to cold are Taiyang Cold Damage signs. Floating and tight pulse is a Cold Damage pulse. This is a syndrome of simultaneous Wind-Cold attacking both exterior and interior. Treatment must assess exterior and interior: If Taiyang and Yangming dominate, use Guizhi Jiadahuang Tang (Cinnamon Twig Decoction plus Rhubarb) to resolve both. If Shaoyang and Yangming dominate, use Dachaihu Tang (Major Bupleurum Decoction) to harmonize and purge. If treating only the interior, and hastily purging based solely on abdominal fullness as Heat entering Yangming, the exterior pathogen will sink deeper due to deficiency, worsening fullness. Interior heat further depletes fluids, causing difficult urination.
[Collected Commentaries]
Cheng Zhi states: This indicates that if Yangming is combined with Taiyang and Shaoyang exterior pathogens, purgation is contraindicated. Yangming Wind Strike is Heat pathogen. Abdominal fullness and wheezing indicate heat entering the interior. But slight wheezing means it hasn't fully entered. Fever, aversion to cold, floating/tight pulse are Taiyang signs. Bitter taste/dry throat indicate Shaoyang half-exterior/half-interior. Mistaken purgation causes exterior pathogen to sink inward, increasing fullness. Heavy loss of fluids causes difficult urination.
Cheng Yingmao states: This line is similar to the Taiyang Da Qinglong Tang syndrome. Taiyang constrains Ying and Wei with Wind-Cold, causing restlessness but no abdominal fullness. This constrains Yangming with Wind-Cold, causing abdominal fullness but no restlessness. However, bitter taste and dry throat share the same mechanistic indication as restlessness.
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Yangming disease, floating and tight pulse, dry throat, bitter taste, abdominal fullness, wheezing, fever, sweating, aversion to heat rather than cold, heavy body. If sweated, restlessness ensues, heart feels confused, and delirium occurs. If moxibustion/warm needle is added, terror, restlessness, and insomnia result. If purged, the Stomach becomes empty, guest pathogen agitates the diaphragm, mental depression/vexation occurs, and coating appears on the tongue. Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is primary. If thirsty for water, dry mouth and tongue, Baihu Jiarenshen Tang (White Tiger Decoction plus Ginseng) is primary. If floating pulse, fever, thirst for water, and dysuria, Zhuling Tang (Polyporus Decoction) is primary. In Yangming disease, if sweating is profuse and thirst exists, Zhuling Tang (Polyporus Decoction) is contraindicated because profuse sweating causes Stomach dryness, and Zhuling Tang (Polyporus Decoction) promotes urination, further depleting fluids.
[Annotation]
This expands on the previous lines to clarify treatment. The previous line emphasized avoiding mistaken purgation due to predominant exterior signs; this line highlights mixed exterior-interior signs and complex pulses/symptoms, warning against both mistaken purgation and mistaken sweating. Sweating based on floating/tight pulse depletes fluids and injures Yin. Adding burning needles aids Yang pathogen, causing delirium, restlessness, terror, and insomnia. Purging based on abdominal fullness and heat aversion empties the Stomach, allowing guest pathogen/heat to disturb the diaphragm, causing vexation and tongue coating—errors of mistaken purgation. Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) clears this via emesis. If pulse is floating not tight, no vexation, only fever/thirst/dry mouth/tongue, Taiyang exterior pathogen is fading while Yangming dry-heat is strong. Baihu Jiarenshen Tang (White Tiger Decoction plus Ginseng) nourishes fluids. If fever/thirst/dysuria, Yangming Fluid-Heat is abundant. Zhuling Tang (Polyporus Decoction) drains water to moisten dryness. However, Yangming disease typically involves profuse sweating. If profuse sweating leads to low urine and thirst, Zhuling Tang (Polyporus Decoction) is contraindicated. Profuse sweating causes Stomach dryness; lack of water prevents downward flow. This is oliguria due to fluid depletion, not fluid retention. Using Zhuling Tang (Polyporus Decoction) would further drain fluids and aggravate dryness.
[Commentary]
Taiyang disease with vexation/heat, no sweat, thirst, and free urination is Da Qinglong Tang (Major Green Dragon Decoction) syndrome; dysuria is Xiao Qinglong Tang (Minor Green Dragon Decoction) minus Banxia plus Huafen and Fuling. Taiyang disease with vexation/heat, sweat, thirst, and free urination is Guizhi He Baihu Tang (Cinnamon Twig Combined with White Tiger Decoction); dysuria is Wuling San (Five-Ingredient Powder with Poria). Yangming disease with vexation/heat, no sweat, thirst, and free urination requires Gegen Tang (Kudzu Decoction) plus Shigao; dysuria requires Wuling San plus Shigao, Hanshuishi, and Huashi. Yangming disease with vexation/heat, sweat, thirst, and free urination requires Baihu Tang (White Tiger Decoction); dysuria requires Zhuling Tang (Polyporus Decoction). Shaoyang disease with chills/fever, no sweat, thirst, and free urination requires Xiaochaihu Tang (Minor Bupleurum Decoction) minus Banxia plus Huafen; dysuria requires Xiaochaihu Tang plus Fuling. Taiyin disease has no thirst. Shaoyin Yang pathogen with vexation/vomiting, red urine, and thirst uses Zhuling Tang (Polyporus Decoction); Shaoyin Yin pathogen with diarrhea, white urine, and thirst uses Zhenwu Tang (True Warrior Decoction). Jueyin Yang pathogen with polydipsia uses Baihu Jiarenshen Tang (White Tiger Decoction plus Ginseng); Jueyin Yin pathogen transferring to Yangming with thirst for water heals with small sips. Since syndromes differ, methods vary; careful differentiation is required.
[Collected Commentaries]
Yu Chang states: Fever matches the previous line, but sweating, aversion to heat, and heavy body are Yangming signs. Thus, sweating, purgation, and needles are all contraindicated. Tongue coating indicates severe diaphragmatic heat; Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) clears this slightly, treating Taiyang without harming Yangming. If dry mouth/tongue adds, Baihu Tang (White Tiger Decoction) resolves heat and generates fluids. If dysuria adds, Zhuling Tang (Polyporus Decoction) guides heat out and moistens dryness. Profuse sweating and thirst contraindicate Zhuling Tang (Polyporus Decoction) because Yangming heat consumes fluids; profuse sweating loses them externally, and diuretics lose them internally, risking immediate fluid collapse. Hence the warning.
Cheng Yingmao states: Heat in the Upper Jiao uses Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction); Heat in the Middle Jiao uses Baihu Jiarenshen Tang (White Tiger Decoction plus Ginseng); Heat in the Lower Jiao uses Zhuling Tang (Polyporus Decoction).