大黄（四两苦寒酒洗） 浓朴（半斤苦温炙去皮） 枳实（五枚味苦寒炙） 芒硝
（三合味咸寒）
上四味。以水一斗。先煮二物。取五升。去滓。内大黄。煮取二升。去滓。内芒硝。
更上火。微一两沸。分温再服。得下。余勿服。
内经曰。燥淫所胜。以苦下之。大黄枳实之苦。以润燥除热。又曰。燥淫于内。治
以苦温。浓朴之苦。下结燥。又曰。热淫所胜。治以咸寒。芒硝之咸。以攻蕴热。王海
藏
云。浓朴去痞。枳实泄满。芒硝软坚。大黄泄实。必痞满燥。实四证全者。方可用之。
张卿子云。干阳亢极于上。而曰有悔。悔字。即阴承于下。五行家所谓阴生于午。
坤象所谓顺承天。亢害承制之义爽然。此汤不曰制火。不曰生阴。曰承气。仲景真法天
而为方者也。
大黄（四两） 浓朴（二两炙去皮） 枳实（三枚大者炙）
以上三味。以水四升。煮取一升二合。去滓。分温二服。初服汤。当更衣。不尔者。
尽饮之。若更衣者。勿服之。
大热结实者。与大承气汤。小热微结者。与小承气汤。以热不大甚。故于大承气汤
去芒硝。又以结不至坚。故亦减浓朴枳实也。
吴氏云。或问承气汤。仲景有大小调胃之名。何也。伤寒传变入里。邪热与糟粕蕴
而为实。实则潮热。谵语。手心 汗出者。此燥屎所为也。如人壮大热大实者。宜大
承气汤下之。小热小实者。与小承气汤下之。又热结不坚满者。故减去浓朴枳实。加甘
草而和缓之。故曰调胃承气也。若病大而以小承气攻之。则邪
气不伏。病小而以大承气攻之。则过伤正气。且不及还可再攻。过则不能复救。可不慎
哉。
阳明病潮热。大便微硬者。可与大承气汤。不硬者。不与之。若不大便六七日。恐
有燥屎。欲知之。法少与小承气汤。汤入腹中。转失气者。此有燥屎。乃可攻之。若不
转失气者。此但初头硬。后必溏。不可攻之。攻之。必胀满不能食也。欲饮水者。与水
则哕。其后发热者。必大便复硬而少也。以小承气汤和之。不转失气者。慎不可攻也。
潮热者实。得大便微硬者。便可攻之。若便不硬者。则热未成实。微有潮热。亦未
可攻。若不大便六七日。恐有燥屎。当先与小承气汤渍之。如有燥屎。小承气汤药势缓。
不能宣泄。必转气下失。若不转失气。是胃中无燥屎。但肠间少硬尔。止初头硬。后必
溏。攻之则虚其胃气。致腹胀满不能食也。胃中干燥。则欲饮水。水入胃中。虚寒相搏。
气逆则哕。其后却发热者。则热气乘虚。还复聚于胃中。胃燥得热。必大便复硬。而少与
小承气汤。微利以和之。故重云不转失气不可攻。慎之至也。
夫实则谵语。虚则郑声。郑声、重语也。
内经曰。邪气盛则实。精气夺则虚。谵语由邪气盛而神识昏也。郑声由精气夺而声
不全也。谵语者。言语不次也。郑声者。郑音不正也。论语也。恶郑声之乱雅乐。又云。
放郑声。远佞人。郑声淫。佞人殆。言郑声不正也。今新瘥气虚。人声转者是。所谓重
语者也。若声重亦声转之。
王宇泰云。谵语者。谓乱言无次。数数更端也。郑声者。谓郑重频烦也。只将一句
旧言。重叠频言之。终日殷勤。不换他声也。盖神有余。则能机变而乱语。数数更端。神不
足。则无机变而只守一声也。成氏谓郑卫之声非是。
娄氏云。谵语者。气虚独语也。素问云。脱阳者见鬼。余用参 温补。活者数百十
人。不可概以谵语为实。
直视。谵语。喘满者死。下利者亦死。
直视谵语。邪胜也。喘满为气上脱。下利为气下脱。是皆主死。
发汗多。若重发汗者。亡其阳。谵语。脉短者死。脉自和者不死。
亡阳胃燥谵语者。脉短。津液已绝。不可复治。脉自和。为正气未衰而犹可生也。
伤寒。若吐若下后。不解。不大便。五六日。上至十余日。日晡所发潮热。不恶寒。独
语。
如见鬼状。若剧者。发则不识人。循衣摸床。惕而不安。微喘。直视。脉弦者生。涩者
死。微者。但发热谵语者。大承气汤主之。若一服利。止后服。
若吐若下。皆伤胃气。不大便。五六日。上至十余日者。亡津液。胃气虚。邪热内
结也。阳明王于申酉戌。日晡所发潮热者。阳明热甚也。不恶寒者。表证罢也。独语如见
鬼状者。阳明内实也。以为热气有余。若剧者。是热气甚大也。热大甚于内。昏冒正气。
使不识人。至于循衣摸床。惕而不安。微喘直视。伤寒阳胜而阴绝者死。阴胜而阳绝者
死。热剧者为阳胜。脉弦为阴有余。涩为阴不足。阳热虽剧。脉弦。知阴未绝而犹可生。
脉涩。则绝阴。故不可治。其邪热微而未至于剧者。但发热。谵语。可与大承气汤以下
胃中热。经曰。凡服下药。中病即止。不必尽剂。此以热未剧。故云若一服利。则止后
服。
阳明病。其人多汗。以津液外出。胃中燥。大便必硬。硬则谵语。小承气汤主之。
若一服。谵语止。更莫复服。
亡津液。胃燥。大便硬而谵语。虽无大热内结。亦须与小承气汤。和其胃气。得一
服。谵语止。则胃燥以润。更莫复与承气汤。以本无实热故也。
阳明病。谵语。发潮热。脉滑而疾者。小承气汤主之。因与承气汤一升。腹中转失
气者。更服一升。若不转失气。勿更与之。明日不大便。脉反微涩者。里虚也。为难治。
不可更与承气汤也。
阳明病。谵语。发潮热。若脉沉实者。内实者也。则可下。若脉滑疾。为里热未实。则
未可下。先与小承气汤和之。汤入腹中。得失气者。中有燥屎。可更与小承气汤一升以
除之。若不转失气者。是无燥屎。不可更与小承气汤。至明日。邪气传时。脉得沉实紧
牢之类。是里实也。反得微涩者。里气大虚也。若大便利后。脉微涩者。止为里虚而犹
可。此不曾大便。脉反微涩。是正气内衰。为邪气所胜。故云难治。
阳明病。谵语。有潮热。反不能食者。胃中必有燥屎五六枚也。若能食者。但硬尔。
宜大承气汤下之。
谵语。潮热。为胃热。当消谷引食。反不能食者。胃中有燥屎而胃中实也。若能食
者。胃中虚热。虽硬不得为有燥屎。杂病。虚为不欲食。实为欲食。伤寒则胃实热甚者
不能食。胃中虚热甚者能食。与杂病为异也。大承气汤。以下燥屎。逐结热。
阳明病。下血谵语者。此为热入血室。但头汗出者。刺期门。随其实而泻之。 然汗出
则愈。
阳明病。热入血室。迫血下行。使下血谵语。阳明病法多汗。以夺血者无汗。故但
头汗出也。刺期门。以散血室之热也。随其实而泻之。以除阳明之邪热。散邪除热。荣
卫得通。津液得复。 然汗出而解。
王三阳云。此男子亦有之。不比太阳少阳证也。热邪入腑中。故迫血下行。亦刺期
门者。期门。肝之募。肝主血。刺之以泻实也。
汗出谵语者。以有燥屎在胃中。此为风也。须下之。过经乃可下之。下之若早。语言
必乱。以表虚里实故也。下之则愈。宜大承气汤。
胃中有燥屎。则谵语。以汗出为表未罢。故云风也。燥屎在胃。则当下。以表未和。
则未可下。须过太阳经。无表证。乃可下之。若下之早。燥屎虽除。则表邪乘虚。复陷
于里。为表虚里实。胃虚热甚。语言必乱。与大承气汤。却下胃中邪热则止。
王三阳云。阳明多汗。况有谵语。故又当下。但风家有汗。恐汗出则表未罢。故须
过经可下。若早。燥屎虽除。表邪乘虚复陷。又将为表虚里实矣。下之则愈二句。
又申明乃可下之一句耳。
伤寒四五日。脉沉而喘满。沉为在里。而反发其汗。津液越出。大便为难。表虚里
实。久则谵语。
邪气入内之时。得脉沉而喘满。里证具也。则当下之。反发其汗。令津液越出。胃
中干燥。大便必难。久则屎燥胃实。必发谵语。
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。
腹满身重。难以反侧。口不仁。谵语者。阳明也。针经曰。少阳病甚则面微尘。此
面垢者。少阳也。遗尿者。太阳也。三者以阳明证多。故出阳明篇中。三阳合病。为表
里有邪。若发汗攻表。则燥热益甚。必愈谵语。若下之攻里。表热乘虚内陷。必额上汗
出。手足逆冷。其自汗出者。三阳经热甚也。内经曰。热则腠理开。荣卫通。汗大泄。
与白虎汤。以解内外之热。
二阳并病。太阳证罢。但发潮热。手足 汗出。大便难而谵语者。下之则愈。宜
大承气汤。
本太阳病。并于阳明。名曰并病。太阳证罢。是无表证。但发潮热。是热并阳明。一
身汗出。为热越。今手足 汗出。是热聚于胃也。必大便难而谵语。经曰。手足 然
而汗出者。必大便已硬也。与大承气汤。以下胃中实热。
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。
若发汗则燥。心愦愦。反谵语。若加烧针。必怵惕烦躁。不得眠。若下之。则胃中空虚。
客气动膈。心中懊 。舌上苔者。栀子豉汤主之。
脉浮发热。为邪在表。咽燥口苦。为热在经。脉紧。腹满而喘。汗出。不恶寒。反
恶热。身重。为邪在里。此表里俱有邪。犹当双解之。若发汗攻表。表热虽除。而内热
益甚。故燥而愦愦。反谵语。愦愦者。心乱。经曰。荣气微者。加烧针。则血不行。更
发热而躁烦。此表里有热。若加烧针。则损动阴气。故怵惕烦躁不得眠也。若下之。里
热虽去。则胃中空虚。表中客邪之气。乘虚陷于上焦。烦动于膈。使心中懊 而不了了
也。舌上苔黄者。热气客于胃中。舌上苔白。知热气客于胸中。与栀子豉汤。以吐胸中
之邪。
娄氏云。栀子豉汤。专指下后心中懊 者设。
若渴欲饮水。口干舌燥者。白虎加人参汤主之。
若下后。邪热客于上焦者。为虚烦。此下后。邪热不客于上焦。而客于中焦者。是
为干燥烦渴。与白虎加人参汤。散热润燥。
若脉浮。发热。渴欲饮水。小便不利者。猪苓汤主之。
此下后客热客于下焦者也。邪气自表入里。客于下焦。三焦俱带热也。脉浮发热者。
上焦热也。渴欲饮水者。中焦热也。小便不利者。邪客下焦。津液不得下通也。与猪苓
汤利小便。以泻下焦之热也。
张兼善云。脉浮发热。上焦也。渴欲饮水。中焦也。小便不利。下焦也。津液不得
下通也。但邪热客于下焦。则津液亦不得上升。故亦有作渴者。泻下焦之热。热不得阻
塞中焦。肺与膀胱。津液流通。而病自愈矣。
【大承气汤方第七十三】
大黄（四两，味苦性寒，用酒洗） 浓朴（半斤，味苦性温，炙后去皮） 枳实（五枚，味苦性寒，炙） 芒硝（三合，味咸性寒）
以上四味药。用水一斗。先煮浓朴和枳实两味药。取药液五升。滤去药渣。加入大黄。再煮取药液二升。滤去药渣。加入芒硝。再次放在火上加热。微沸一两滚即可。分两次温服。如果大便通下。剩下的药液不要服用。
《内经》说：燥邪过胜，用苦味药攻下。大黄、枳实的苦味，能润燥除热。又说：燥邪在内，用苦温药治疗。浓朴的苦味，能下结燥。又说：热邪过胜，用咸寒药治疗。芒硝的咸味，能攻逐蕴积之热。王海藏说：浓朴去除痞满，枳实泄除胀满，芒硝软化坚结，大黄攻泻实邪。必须痞、满、燥、实四证俱全者，方可使用此方。
张卿子说：阳气亢极于上，而曰“有悔”。“悔”字，即指阴气承接于下。五行家所谓“阴生于午”，《易经》坤卦象辞所谓“顺承天”，这正是亢害承制的道理清晰明了。此汤不叫“制火汤”，不叫“生阴汤”，而叫“承气汤”。这是张仲景真正效法天道来组方的体现。
【小承气汤方第七十四】
大黄（四两） 浓朴（二两，炙后去皮） 枳实（三枚，大的，炙）
以上三味药。用水四升。煮取药液一升二合。滤去药渣。分两次温服。初次服药后，应当排便。如果不排便，就把药全部喝完。如果已经排便了，就不要继续服用。
大热结实者，给予大承气汤。小热微结者，给予小承气汤。因为热势不是特别大，所以在大承气汤中去掉芒硝。又因为结滞不至于坚硬，所以也减少浓朴和枳实的用量。
吴氏说：有人问承气汤，张仲景有大、小、调胃三种名称，为什么呢？伤寒传变入里，邪热与糟粕蕴结而成实邪。实邪则出现潮热、谵语、手心出汗等症状，这是燥屎造成的。如人体壮热大实者，宜用大承气汤攻下。小热小实者，用小承气汤攻下。又因热结不坚满，所以减去浓朴、枳实，加入甘草以缓和药性，所以叫调胃承气汤。如果病重而用小承气汤攻之，则邪气不能伏灭；病轻而用大承气汤攻之，则会过度损伤正气。而且不及还可以再攻，过了则无法补救，能不谨慎吗？
阳明病，出现潮热，大便微硬者，可给予大承气汤。大便不硬者，不给。如果六七天不大便，担心有燥屎。想要知道是否有燥屎，方法是小量给予小承气汤。汤药进入腹中，如果转矢气（放屁），这是有燥屎，才可以攻下。如果不转矢气，这只是开头硬，后面一定稀溏，不可攻下。如果攻下，必然导致腹胀满不能进食。想喝水的人，给水喝则会发生呃逆。其后如果出现发热，大便一定会再次变硬且量少。用小承气汤调和。如果不转矢气，千万不可攻下。
潮热说明是实证。大便微硬者，就可以攻下。如果大便不硬，说明热未成实。即使有轻微潮热，也不可攻下。如果六七天不大便，担心有燥屎，应当先给予小承气汤试探。如果有燥屎，由于小承气汤药势缓和，不能宣泄，必然会转矢气。如果不转矢气，说明胃中没有燥屎，只是肠间稍微有点硬。只是开头硬，后面一定稀溏。攻下则会虚其胃气，导致腹胀满不能进食。胃中干燥，则想喝水。水进入胃中，虚寒相搏，气逆则发生呃逆。其后却出现发热，则是热气乘虚，重新聚于胃中。胃燥得热，大便必然再次变硬。少量给予小承气汤，微利以调和它。所以反复强调不转矢气不可攻下，这是非常谨慎的态度。
实证则谵语，虚证则郑声。郑声，是指重复言语。
《内经》说：邪气盛则实，精气夺则虚。谵语是由于邪气盛而导致神识昏乱。郑声是由于精气夺而导致声音不全。谵语，是指言语没有次序。郑声，是指声音不正。出自《论语》：“恶郑声之乱雅乐。”又说：“放郑声，远佞人。郑声淫，佞人殆。”是说郑声不正。现在新病愈后气虚，人说话声音转变，这就是所谓的重复言语。如果声音沉重也是声音转变的表现。
王宇泰说：谵语，是指胡言乱语没有次序，频繁更换话题。郑声，是指郑重频繁。只将一句旧话，重叠频繁地说，终日殷勤，不换其他声音。大概神气有余，则能机变而乱语，频繁更换话题；神气不足，则无机变而只守着一句话。成无己认为郑卫之声不对。
娄氏说：谵语，是气虚独语。《素问》说：脱阳者见鬼。我用人参温补，救活了几百人，不可一概把谵语当作实证。
直视谵语，是邪气胜。喘满是气上脱，下利是气下脱。这些都是主死的征象。
发汗多，或者重发汗的，亡其阳气。出现谵语，脉短者死，脉自和者不死。
亡阳导致胃燥谵语的，脉短，津液已绝，不可复治。脉自和，说明正气未衰，还有生机。
伤寒，如果用吐法或下法后，病不解，不大便，从五六天到十余天，日晡时（下午3-5点）出现潮热，不恶寒，独自说话，像看见鬼怪一样。如果病情严重，发作时不认识人，循衣摸床，惊恐不安，微喘，直视，脉弦者生，脉涩者死。病情轻微的，只是发热谵语，以大承气汤主治。如果一次服药后大便通利，停止后面的服药。
如果用吐法或下法，都损伤胃气。不大便，从五六天到十余天，是亡失津液，胃气虚，邪热内结。阳明旺于申、酉、戌时。日晡时发潮热，是阳明热甚。不恶寒，说明表证已罢。独自说话像看见鬼怪，是阳明内实。认为是热气有余。如果病情严重，是热气甚大。热大甚于内，昏冒正气，使人不认识人。至于循衣摸床，惊恐不安，微喘直视。伤寒阳胜而阴绝者死，阴胜而阳绝者死。热剧者为阳胜。脉弦为阴有余，脉涩为阴不足。阳热虽剧，但脉弦，知道阴未绝，还有生机。脉涩，则绝阴，故不可治。其邪热微而未至于严重的，只是发热、谵语，可给予大承气汤以下胃中热。经书说：凡服用下药，中病即止，不必尽剂。这是因为热未剧，所以说如果一次服药后通利，就停止后面的服药。
阳明病，病人多汗，因为津液外出，胃中干燥，大便必硬。硬则谵语，以小承气汤主治。如果一次服药后，谵语停止，不要再服用。
亡津液，胃燥，大便硬而谵语，虽然没有大热内结，也必须给予小承气汤，调和胃气。得到一次服药后谵语停止，则胃燥得以滋润，不要再给承气汤，因为本来就没有实热。
阳明病，谵语，发潮热，脉滑而疾者，以小承气汤主治。因此给予承气汤一升，腹中转矢气的，再服一升。如果不转矢气，不要再次给予。明天不大便，脉反而微涩的，是里虚，为难治，不可再给承气汤。
阳明病，谵语，发潮热，如果脉沉实，是内实，则可以攻下。如果脉滑疾，是里热未实，则不可攻下。先给予小承气汤调和。汤药进入腹中，如果转矢气，说明中有燥屎，可以再给予小承气汤一升以除去它。如果不转矢气，是没有燥屎，不可再给小承气汤。到了明天，邪气传经之时，脉得沉实紧牢之类的，是里实。反而得微涩的，是里气大虚。如果大便通利后，脉微涩的，只是里虚还可以。这里是大便不通，脉反而微涩，是正气内衰，被邪气所胜，所以说难治。
阳明病，谵语，有潮热，反而不能食的，胃中必有燥屎五六枚。如果能食，只是大便硬罢了。宜用大承气汤攻下。
谵语、潮热，是胃热，应当消谷引食。反而不能食的，是胃中有燥屎而胃中实。如果能食的，是胃中虚热，虽然硬也不能算是有燥屎。杂病中，虚为不欲食，实为欲食。伤寒则胃实热甚者不能食，胃中虚热甚者能食，这与杂病不同。大承气汤，用以攻下燥屎，驱逐结热。
阳明病，下血谵语的，这是热入血室。只有头汗出的，刺期门穴。随其实而泻之。周身汗出则痊愈。
阳明病，热入血室，迫血下行，使下血谵语。阳明病法多汗，但以夺血者无汗，所以只有头汗出。刺期门，以散血室之热。随其实而泻之，以除阳明之邪热。散邪除热，营卫得通，津液得复，周身汗出而解。
王三阳说：这男子也有这种情况，不像太阳少阳证那样。热邪入腑中，所以迫血下行。也刺期门，期门是肝之募穴，肝主血，刺之以泻实。
汗出谵语的，因为有燥屎在胃中，这是风邪。需要攻下。须过经（表证解除）才可攻下。攻下如果过早，语言必乱。因为表虚里实。攻下则愈。宜用大承气汤。
胃中有燥屎，则谵语。因为汗出为表未罢，所以叫风。燥屎在胃，则当下。但因为表未和，则未可下。须过太阳经，无表证，才可攻下。如果攻下过早，燥屎虽除，则表邪乘虚，复陷于里，成为表虚里实。胃虚热甚，语言必乱。给予大承气汤，却下胃中邪热则止。
王三阳说：阳明多汗，况且有谵语，所以又当下。但风家有汗，恐汗出则表未罢，所以须过经才可下。如果早，燥屎虽除，表邪乘虚复陷，又将变为表虚里实了。“下之则愈”两句，又是申明“乃可下之一句”罢了。
伤寒四五日，脉沉而喘满。沉为在里，而反发其汗，津液越出，大便为难，表虚里实，久则谵语。
邪气入内之时，得脉沉而喘满，里证具备。则当下之。反发其汗，令津液越出，胃中干燥，大便必难。久则屎燥胃实，必发谵语。
三阳合病，腹满身重，难以转侧，口不仁而面垢，谵语，遗尿。发汗则谵语加重，下之则额上生汗，手足逆冷。若自汗出者，白虎汤主治。
腹满身重，难以反侧，口不仁，谵语，是阳明证。《针经》说：少阳病甚则面微尘，这面垢的是少阳证。遗尿的是太阳证。三者以阳明证多，所以出在阳明篇中。三阳合病，为表里有邪。若发汗攻表，则燥热益甚，必加重谵语。若下之攻里，表热乘虚内陷，必额上汗出，手足逆冷。其自汗出者，是三阳经热甚。《内经》说：热则腠理开，荣卫通，汗大泄。给予白虎汤，以解内外之热。
二阳并病，太阳证罢，但发潮热，手足濈然汗出，大便难而谵语者，下之则愈。宜用大承气汤。
本太阳病，并于阳明，名曰并病。太阳证罢，是无表证。但发潮热，是热并阳明。一身汗出，为热越。今手足濈然汗出，是热聚于胃。必大便难而谵语。经书说：手足濈然而汗出者，必大便已硬也。给予大承气汤，以下胃中实热。
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。若发汗则燥，心愦愦，反谵语。若加烧针，必怵惕烦躁，不得眠。若下之，则胃中空虚，客气动膈，心中懊憹，舌上苔者，栀子豉汤主治。
脉浮发热，为邪在表。咽燥口苦，为热在经。脉紧，腹满而喘，汗出，不恶寒，反恶热，身重，为邪在里。此表里俱有邪，犹当双解之。若发汗攻表，表热虽除，而内热益甚，故燥而愦愦。愦愦者，心乱。经书说：荣气微者，加烧针，则血不行，更发热而躁烦。此表里有热，若加烧针，则损动阴气，故怵惕烦躁不得眠也。若下之，里热虽去，则胃中空虚，表中客邪之气，乘虚陷于上焦，烦动于膈，使心中懊憹而不了了也。舌上苔黄者，热气客于胃中。舌上苔白，知热气客于胸中。给予栀子豉汤，以吐胸中之邪。
若渴欲饮水，口干舌燥者，白虎加人参汤主治。
若下后，邪热客于上焦者，为虚烦。此下后，邪热不客于上焦，而客于中焦者，是为干燥烦渴。给予白虎加人参汤，散热润燥。
此下后客热客于下焦者也。邪气自表入里，客于下焦，三焦俱带热也。脉浮发热者，上焦热也。渴欲饮水者，中焦热也。小便不利者，邪客下焦，津液不得下通也。给予猪苓汤利小便，以泻下焦之热也。
张兼善说：脉浮发热，是上焦热。渴欲饮水，是中焦热。小便不利，是下焦热。津液不得下通也。但邪热客于下焦，则津液亦不得上升，故亦有作渴者。泻下焦之热，热不得阻塞中焦，肺与膀胱，津液流通，而病自愈矣。
[Prescription of Dachengqi Decoction, Formula 73]
Rhubarb (4 liang, bitter and cold in nature, washed with wine)
Coptis Rhizome (half jin, bitter and warm in nature, processed by stir-frying, skin removed)
Immature Bitter Orange (5 pieces, bitter and cold in nature, processed by stir-frying)
Mirabilite (3 he, salty and cold in nature)
The above four herbs. Use one dou of water. First decoct Coptis Rhizome and Immature Bitter Orange. Obtain five sheng of liquid. Remove the dregs. Add Rhubarb. Decoct to obtain two sheng of liquid. Remove the dregs. Add Mirabilite. Heat again over fire until it boils slightly for one or two rolls. Divide into two doses and take warm. If bowel movement occurs, do not consume the remaining medicine.
The *Neijing* states: When dryness pathogen prevails excessively, use bitter purgatives. The bitterness of Rhubarb and Immature Bitter Orange moistens dryness and eliminates heat. It also states: When dryness is internal, treat with bitter-warm methods. The bitterness of Coptis Rhizome descends dryness accumulation. It further states: When heat pathogen prevails excessively, treat with salty-cold methods. The salinity of Mirabilite attacks accumulated heat. Wang Haicang said: Coptis Rhizome removes distension; Immature Bitter Orange drains fullness; Mirabilite softens hardness; Rhubarb purges excess. Only when all four syndromes—distension (pi), fullness (man), dryness (zao), and excess (shi)—are present can this formula be used.
Zhang Qingzi stated: When Yang qi reaches extreme hyperactivity upwards, it is termed "regret" (hui). The character "hui" implies Yin receiving/supporting from below. As the Five Elements theory states, "Yin is born at Wu," and the Kun hexagram image says "following and supporting Heaven." This clearly illustrates the principle of hyperactivity causing harm and being controlled by reception. This decoction is not named "Fire-Restraining Decoction" nor "Yin-Generating Decoction," but "Chengqi Decoction" (Receiving Qi Decoction). Zhang Zhongjing truly formulated this based on the Way of Heaven.
[Prescription of Xiaochengqi Decoction, Formula 74]
Rhubarb (4 liang)
Coptis Rhizome (2 liang, processed by stir-frying, skin removed)
Immature Bitter Orange (3 large pieces, processed by stir-frying)
The above three herbs. Use four sheng of water. Decoct to obtain one sheng and two he of liquid. Remove the dregs. Divide into two doses and take warm. After the first dose, defecation should occur. If not, drink the entire amount. If defecation has occurred, do not continue taking it.
For severe heat and solid accumulation, administer Dachengqi Decoction. For mild heat and slight accumulation, administer Xiaochengqi Decoction. Because the heat is not extreme, Mirabilite is omitted from Dachengqi Decoction. Furthermore, because the accumulation is not hard, the dosages of Coptis Rhizome and Immature Bitter Orange are reduced.
Wu Shi said: One may ask why there are names for Large, Small, and Stomach-Regulating Chengqi Decoctions in Zhang Zhongjing's work. When Shaoyang disease transmits inward, pathogenic heat combines with fecal matter to form excess. Excess leads to tidal fever, delirious speech, and sweating of the palms, caused by dry stool. For patients with strong heat and great excess, Dachengqi Decoction should be used to purge. For mild heat and slight excess, Xiaochengqi Decoction should be used. Since the heat accumulation is not hard and full, Coptis Rhizome and Immature Bitter Orange are removed, and Licorice Root is added to moderate the action, hence it is called Tiaowei Chengqi Decoction (Stomach-Regulating Chengqi Decoction). If the disease is severe but treated with Xiaochengqi Decoction, the pathogen will not subside. If the disease is mild but treated with Dachengqi Decoction, healthy Qi will be excessively damaged. Moreover, if the attack is insufficient, it can be repeated; if excessive, it cannot be rescued. How can one not be cautious?
In Yangming disease, with tidal fever and slightly hard stool, Dachengqi Decoction may be given. If the stool is not hard, it should not be given. If there is no bowel movement for six or seven days, suspecting dry stool, the method is to give a small amount of Xiaochengqi Decoction. If, after the decoction enters the abdomen, flatulence occurs, this indicates dry stool, and purging may proceed. If flatulence does not occur, the stool is only hard at the beginning and will likely be loose later; purging must not be performed. Purging will inevitably cause abdominal fullness and inability to eat. If the patient desires water and is given water, hiccups may occur. If fever develops subsequently, the stool will become hard again but scanty. Treat with Xiaochengqi Decoction to harmonize. If flatulence does not occur, strictly avoid purging.
Tidal fever indicates excess. If the stool is slightly hard, purging is permissible. If the stool is not hard, the heat has not formed excess. Even with mild tidal fever, purging is not allowed. If there is no bowel movement for six or seven days, suspecting dry stool, first administer Xiaochengqi Decoction as a test. If dry stool exists, due to the mild potency of Xiaochengqi Decoction, it may not fully expel it, but flatulence will likely occur. If flatulence does not occur, there is no dry stool in the stomach, only slight hardness in the intestines. The stool is hard at the beginning and loose later. Purging will weaken Stomach Qi, leading to abdominal fullness and inability to eat. Dryness in the Stomach causes thirst. Water entering the Stomach interacts with deficiency-cold, causing Qi rebellion and hiccups. Subsequent fever indicates heat taking advantage of deficiency to reaccumulate in the Stomach. Stomach dryness combined with heat causes the stool to become hard again. Administer a small amount of Xiaochengqi Decoction to mildly promote bowel movement and harmonize. Hence, it is repeatedly emphasized that purging must not be done if flatulence does not occur; this is utmost caution.
Excess leads to delirious speech; deficiency leads to Zhengsheng (repetitive speech). Zhengsheng refers to repetitive utterances.
The *Neijing* states: Pathogenic excess constitutes Excess; Essence depletion constitutes Deficiency. Delirious speech arises from pathogenic excess confusing the Shen (Spirit). Zhengsheng arises from essence depletion causing incomplete voice. Delirious speech means speech without order. Zhengsheng means improper tone. It originates from the *Analects*: "Detest Zheng music as it disrupts elegant music." It also says: "Discard Zheng music, distance flatterers. Zheng music is licentious; flatterers are dangerous." This indicates Zhengsheng is improper. In cases of recent recovery with Qi deficiency, the change in voice is what is meant by repetitive speech. Heavy voice is also a sign of voice change.
Wang Yutai said: Delirious speech refers to chaotic, unordered speech, frequently changing topics. Zhengsheng refers to earnest repetition. Repeating an old phrase frequently throughout the day without changing tone. Generally, abundant Shen allows for variability and chaotic speech, frequently changing topics. Insufficient Shen lacks variability and sticks to one sound. Cheng Wuji incorrectly interpreted Zhengsheng as referring to Zheng and Wei music.
Lou Shi said: Delirious speech is solitary talking due to Qi deficiency. The *Suwen* states: Those losing Yang see ghosts. I have saved hundreds using Ginseng for warming and tonifying. One must not generalize all delirious speech as excess.
Fixed gaze, delirious speech, and wheezing/fullness indicate death. Diarrhea also indicates death.
Fixed gaze and delirious speech indicate pathogen victory. Wheezing and fullness indicate Qi escaping upward; diarrhea indicates Qi escaping downward. All are signs of impending death.
Excessive sweating, or repeated sweating, leads to loss of Yang Qi. Delirious speech with a short pulse indicates death; a normal pulse indicates survival.
Loss of Yang causing Stomach dryness and delirious speech with a short pulse means fluids are exhausted and incurable. A normal pulse indicates healthy Qi is not yet depleted, and survival is possible.
In Cold Damage, after vomiting or purging, if the condition remains unresolved, with no bowel movement for five to six days up to ten-plus days, tidal fever occurs at dusk (You hour), without aversion to cold, speaking alone as if seeing ghosts. If severe, the patient becomes unrecognizable, grasps at clothes and beds, feels terrified and uneasy, has slight wheezing, fixed gaze. A wiry pulse indicates survival; a choppy pulse indicates death. Mild cases presenting only with fever and delirious speech are treated with Dachengqi Decoction. If one dose results in relief, stop subsequent doses.
Vomiting and purging both damage Stomach Qi. No bowel movement for five to six days up to ten-plus days indicates fluid loss, Stomach Qi deficiency, and internal binding of pathogenic heat. Yangming peaks at Shen, You, and Xu hours. Tidal fever at dusk indicates severe Yangming heat. Lack of aversion to cold indicates the exterior syndrome has resolved. Speaking alone as if seeing ghosts indicates Yangming interior excess. This is considered surplus heat. Severe cases indicate extreme heat. Extreme internal heat confuses healthy Qi, causing unrecognizability. Grasping at clothes/beds, terror, slight wheezing, and fixed gaze represent death from Yang excess and Yin exhaustion, or Yin excess and Yang exhaustion. Severe heat is Yang excess. A wiry pulse indicates Yin surplus; a choppy pulse indicates Yin deficiency. Although Yang heat is severe, a wiry pulse shows Yin is not exhausted, so survival is possible. A choppy pulse indicates exhausted Yin, making it incurable. For mild pathogenic heat not reaching severity, presenting only with fever and delirious speech, Dachengqi Decoction may be used to purge Stomach heat. The classics state: Stop purgatives once the disease is addressed; do not necessarily finish the dose. Since the heat is not severe, it says if one dose brings relief, stop subsequent doses.
In Yangming disease, with profuse sweating, fluids exit externally, causing Stomach dryness and hard stool. Hard stool leads to delirious speech, treated with Xiaochengqi Decoction. If delirium stops after one dose, do not administer further.
Fluid loss, Stomach dryness, hard stool, and delirious speech, even without severe internal heat binding, require Xiaochengqi Decoction to harmonize Stomach Qi. Once delirium stops after one dose, Stomach dryness is moistened; do not give Chengqi formulas again as there was no true excess heat originally.
In Yangming disease, with delirious speech and tidal fever, if the pulse is slippery and rapid, Xiaochengqi Decoction is indicated. Administer one sheng of Chengqi Decoction. If flatulence occurs in the abdomen, administer another sheng. If no flatulence occurs, do not give more. If there is no bowel movement the next day and the pulse becomes faint and choppy, this is interior deficiency, making it difficult to treat; do not give Chengqi Decoction again.
In Yangming disease, with delirious speech and tidal fever, if the pulse is deep and solid, it is interior excess, and purging is permitted. If the pulse is slippery and rapid, interior heat is not yet solidified, so purging is not permitted. First give Xiaochengqi Decoction to harmonize. If flatulence occurs after ingestion, dry stool is present, and another sheng of Xiaochengqi Decoction may be given to remove it. If no flatulence occurs, there is no dry stool, and Xiaochengqi Decoction should not be given. By the next day, during the time of pathogen transmission, if the pulse becomes deep, solid, tight, or firm, this is interior excess. If it becomes faint and choppy instead, this is severe interior Qi deficiency. If the pulse is faint and choppy after bowel movement, it is merely interior deficiency and still manageable. Here, without bowel movement, the pulse is faint and choppy, indicating internal decline of healthy Qi overcome by pathogen, hence "difficult to treat."
In Yangming disease, with delirious speech and tidal fever, if the patient cannot eat, there are likely five or six pieces of dry stool in the Stomach. If the patient can eat, the stool is merely hard. Dachengqi Decoction should be used to purge.
Delirious speech and tidal fever indicate Stomach heat, which should digest food and stimulate appetite. Inability to eat indicates dry stool and Stomach excess. Ability to eat indicates Stomach deficiency-heat; although hard, it is not dry stool. In miscellaneous diseases, deficiency means lack of appetite, excess means desire to eat. In Cold Damage, severe Stomach excess-heat causes inability to eat, while severe Stomach deficiency-heat causes ability to eat, differing from miscellaneous diseases. Dachengqi Decoction purges dry stool and drives out accumulated heat.
In Yangming disease, with bleeding and delirious speech, this is Heat entering the Blood Chamber. With sweating only on the head, puncture Qimen (LR14). Drain according to excess. Generalized sweating indicates recovery.
Yangming disease, Heat entering the Blood Chamber, forcing blood downward, causing bleeding and delirious speech. Yangming disease typically involves sweating, but blood loss prevents sweating, hence only head sweating. Puncturing Qimen dissipates Heat in the Blood Chamber. Draining according to excess removes Yangming pathogenic heat. Dissipating pathogen and clearing heat allows Ying and Wei to flow freely and fluids to restore, leading to resolution through generalized sweating.
Wang Sanyang noted: This also occurs in men, unlike Taiyang and Shaoyang syndromes. Heat pathogen enters the Fu organs, forcing blood downward. Puncturing Qimen, the Front-Mu point of the Liver, which governs blood, drains excess.
Sweating with delirious speech indicates dry stool in the Stomach, attributed to Wind. Purging is required. However, purging is only permissible after the meridian stage passes (exterior syndrome resolves). Premature purging will cause chaotic speech due to exterior deficiency and interior excess. Purging will lead to recovery. Dachengqi Decoction is appropriate.
Dry stool in the Stomach causes delirious speech. Sweating indicates the exterior is not yet resolved, hence termed Wind. Dry stool in the Stomach requires purging, but since the exterior is not harmonized, purging is delayed. One must wait for the Taiyang meridian stage to pass and the exterior syndrome to resolve before purging. Premature purging removes dry stool but allows exterior pathogen to sink inward due to deficiency, creating exterior deficiency and interior excess. Severe Stomach deficiency-heat causes chaotic speech. Dachengqi Decoction clears Stomach pathogenic heat, stopping the symptoms.
Wang Sanyang stated: Yangming involves much sweating, plus delirious speech, so purging is needed. However, wind patterns involve sweating, suggesting the exterior may not be resolved. Thus, waiting for the meridian stage to pass is necessary. Premature purging removes dry stool but allows exterior pathogen to sink inward, recreating exterior deficiency and interior excess. The statement "purging leads to recovery" reiterates the condition "only then can purging be done."
In Cold Damage, around the fourth or fifth day, a deep pulse with wheezing and fullness. Deep indicates interior location. Counterproductively inducing sweating causes fluids to escape, making bowel movement difficult. Exterior deficiency and interior excess develop, eventually leading to delirious speech.
When pathogen enters internally, a deep pulse with wheezing and fullness indicates complete interior syndrome, requiring purging. Inducing sweating instead causes fluid loss, Stomach dryness, and difficult bowel movements. Over time, dry stool and Stomach excess lead to delirious speech.
In Three-Yang Combined Disease, with abdominal fullness, body heaviness, difficulty turning, oral insensitivity, facial grease, delirious speech, and urinary incontinence. Inducing sweating worsens delirious speech; purging causes sweating on the forehead and cold extremities. If spontaneous sweating occurs, Baihu Tang (White Tiger Decoction) is indicated.
Abdominal fullness, body heaviness, difficulty turning, oral insensitivity, and delirious speech indicate Yangming. The *Zhenjing* states: Severe Shaoyang disease presents with a dusty face; facial grease indicates Shaoyang. Urinary incontinence indicates Taiyang. Since Yangming symptoms predominate, this is listed in the Yangming chapter. Three-Yang Combined Disease involves exterior and interior pathogens. Inducing sweating to attack the exterior increases dryness-heat, worsening delirious speech. Purging to attack the interior allows exterior heat to sink inward due to deficiency, causing forehead sweating and cold extremities. Spontaneous sweating indicates severe heat in all three Yang meridians. The *Neijing* states: Heat opens pores, allows Ying and Wei to flow, and causes profuse sweating. Baihu Tang is given to resolve interior and exterior heat.
In Two-Yang Concurrent Disease, after Taiyang symptoms cease, only tidal fever, continuous sweating of hands and feet, difficult bowel movement, and delirious speech remain. Purging leads to recovery. Dachengqi Decoction is appropriate.
Original Taiyang disease merging into Yangming is called Concurrent Disease. Ceased Taiyang symptoms mean no exterior syndrome. Tidal fever indicates heat merging into Yangming. Whole-body sweating indicates heat dispersing. Continuous hand and foot sweating indicates heat gathering in the Stomach. This必然 leads to difficult bowel movement and delirious speech. The classics state: Continuous hand and foot sweating indicates hard stool. Dachengqi Decoction is given to purge Stomach excess heat.
In Yangming disease, with a floating and tight pulse, dry throat, bitter taste, abdominal fullness, wheezing, fever, sweating, no aversion to cold, aversion to heat, and body heaviness. Inducing sweating causes dryness, mental confusion, and delirious speech. Adding moxibustion causes fear, restlessness, and insomnia. Purging empties the Stomach, allowing guest pathogen to disturb the diaphragm, causing inner vexation (Aonao). With tongue coating, Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) is indicated.
Floating pulse and fever indicate exterior pathogen. Dry throat and bitter taste indicate heat in the channels. Tight pulse, abdominal fullness, wheezing, sweating, no aversion to cold, aversion to heat, and body heaviness indicate interior pathogen. Both exterior and interior have pathogens, requiring dual resolution. Inducing sweating to attack the exterior removes exterior heat but intensifies interior heat, causing dryness and confusion. Confusion means mental disorder. The classics state: With deficient Ying Qi, adding moxibustion stops blood flow, causing fever and irritability. Interior-exterior heat combined with moxibustion damages Yin Qi, causing fear, restlessness, and insomnia. Purging removes interior heat but empties the Stomach, allowing exterior guest pathogen to sink into the Upper Jiao, disturbing the diaphragm and causing inner vexation. Yellow tongue coating indicates heat in the Stomach; white coating indicates heat in the Chest. Zhizi Chi Tang is given to vomit chest pathogens.
Lou Shi noted: Zhizi Chi Tang is specifically designed for inner vexation after purging.
If thirsty for water with dry mouth and tongue, Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) is indicated.
After purging, if pathogenic heat resides in the Upper Jiao, it is empty vexation. Here, post-purging, pathogenic heat resides in the Middle Jiao, causing dryness, vexation, and thirst. Baihu Jia Renshen Tang is given to clear heat and moisten dryness.
If floating pulse, fever, thirst for water, and difficult urination occur, Zhuling Tang (Polyporus Decoction) is indicated.
This is guest heat residing in the Lower Jiao after purging. Pathogen moves from exterior to interior, lodging in the Lower Jiao, affecting all three Jiaos with heat. Floating pulse and fever indicate Upper Jiao heat. Thirst indicates Middle Jiao heat. Difficult urination indicates pathogen in Lower Jiao blocking fluid passage. Zhuling Tang promotes urination to drain Lower Jiao heat.
Zhang Jianshan stated: Floating pulse and fever indicate Upper Jiao heat. Thirst indicates Middle Jiao heat. Difficult urination indicates Lower Jiao heat. Fluids fail to descend. Guest heat in the Lower Jiao also prevents fluids from ascending, causing thirst. Draining Lower Jiao heat prevents blockage of the Middle Jiao. Lung and Bladder fluids circulate, and the disease heals.