硬甚明。伤寒发太阳膀胱经之汗，即当顾虑阳气，以膀胱主气化故也。发阳明胃经之汗，
即当顾虑阴津，以胃中藏津液故也。所以阳明多有热越之证，谓胃中津液随热而尽越于
外，汗出不止耳。然则阳明病，不论中风，伤寒，脉微，脉实，汗出少而邪将自解，汗出
多则阴津易致竭绝也。
阳明病法多汗，反无汗，其身如虫行皮中状者，此以久虚故也。
【注】阳明病法当汗多，反无汗，其身如虫行皮中状者，以其人胃气久虚，邪郁于太
阳之表，阳明肌腠不能宣发作汗故也。宜葛根汤小剂微汗，和其肌表，自可愈也。
【集注】汪琥曰∶按此条论仲景无治法。常器之云∶可用桂枝加黄 汤。郭雍云∶宜
用桂枝麻黄各半汤。不知上二汤，皆太阳经药，今系阳明无汗证，仍宜用葛根汤主之。
魏荔彤曰∶阳明病法应多汗，今反无汗，但见身如虫行皮中状者，此邪热欲出表作汗，
而正气衰弱不能达之也。
阳明病，初欲食，小便反不利，大便自调，其人骨节疼，翕翕如有热状，奄然发狂，
然汗出而解者，此水不胜谷气，与汗共并，脉紧则愈。
【注】阳明病，初欲食，知其从中风热邪传来也，阳明受邪，当小便数，大便硬，今
小便反不利，大便自调，知津未伤而胃自和，不成里实也。既不成实，则在经之邪本轻，可
自愈也。若其人骨节疼，翕翕如有热状，是太阳之表未除也。奄，忽也。忽然发狂，
然汗出而解者，盖以太阳传来之邪本轻，阳明所受之邪自浅，津未伤而胃自和，仍当还
表作解也。然必待发狂而解者，此胃中水气不胜，初欲食之谷气，谷气长阳化热，水不
胜热，酿汗共并而出，所以发狂作解也。凡将汗解，脉必先浮，今言脉紧则愈者，亦邪
还于表，欲解应见之脉也。
伤寒发热无汗，呕不能食，而反汗出 然者，是转属阳明也。
【注】伤寒发热无汗，呕不能食，为太阳之邪欲传也。若无汗，为太阳阳明之表尚在，
汗之可也。今反汗出 然者，是邪已转属阳明之腑，可下不可汗也。
【集注】成无己曰∶伤寒发热无汗，呕不能食者，太阳受病也。若反汗出 然者，是
太阳之邪转属阳明也。故经曰∶阳明病法多汗。
方有执曰∶呕不能食，热入胃也。反汗出者，肌肉着热，肤腠反开也。
程应旄曰∶太阳本证现下，而反汗出 然者，虽表证未罢，已是转属阳明也。
，连绵之意，即俗云汗一身不了又一身是也。
伤寒脉浮，发热无汗，其表不解，不可与白虎汤；渴欲饮水，无表证者，白虎加人参汤主之。
【注】伤寒之邪，传入阳明，脉浮，发热无汗，其表不解者，虽有燥渴，乃大青龙汤
证，不可与白虎汤。即有阳明渴欲饮水热证，应与白虎者，亦必审其无太阳表证，始可与
也。加人参者，以其脉浮不滑，非有余也；且欲于大解热中，速生其津液也。
【集注】郑重光曰∶此申明用白虎汤之法。以白虎但能解热而不解表，若稍带外感，有
无汗、恶寒、身痛、头疼之表证，慎不可用也。
白虎加人参汤方
于白虎汤方内加人参三两，余根据白虎汤方。
伤寒脉浮滑，此以表有热里有寒，白虎汤主之。
【按】王三阳云∶经文“寒”字，当“邪”字解，亦热也。其说甚是。若是“寒”
字，非白虎汤证矣。
【注】此言伤寒太阳证罢，邪传阳明，表里俱热，而未成胃实之病也。脉浮滑者，浮
为表有热之脉，阳明表有热，当发热汗出；滑为里有热之脉，阳明里有热，当烦渴引饮。故
曰∶表有热里有热也，此为阳明表里俱热之证，白虎乃解阳明表里俱热之药，故主之也。
不加人参者，以其未经汗、吐、下，不虚故也。
【集注】程知曰∶滑则里热，云浮滑则表里俱热矣。大热之气，得辛凉而解，犹之暑
之令，得金风而爽，故清凉之剂，以白虎名之。又曰∶厥阴条中有伤寒，脉滑而厥者，
里有热也，白虎汤主之，可证此条之非里有寒矣。
魏荔彤曰∶此里尚为经络之里，非脏腑之里，亦如卫为表，营为里，非指脏腑而言也。
白虎汤方
知母（六两） 石膏（碎，一斤） 甘草（炙，二两） 粳米（六合）
上四味，以水一斗，煮米熟，汤成去滓，温服一升，日三服。
【集解】柯琴曰∶阳明邪从热化，故不恶寒而恶热；热蒸外越，故热汗出，热烁胃中，
故渴欲饮水；邪盛而实，故脉滑，然犹在经，故兼浮也。盖阳明属胃，外主肌肉，虽内外
大热而未实，终非苦寒之味所宜也。石膏辛寒，辛能解肌热，寒能胜胃火，寒能沉内，辛
能走外，此味两擅内外之能，故以为君；知母苦润，苦以泻火，润以滋燥，故用为臣；甘
草、粳米调和于中宫，且能土中泻火，稼穑作甘，寒剂得之缓其寒，苦剂得之平其苦，使
二味为佐，庶大寒大苦之品，无伤损脾胃之虑也。煮汤入胃，输脾归肺，水精四布，大
烦大渴可除矣。白虎为西方金神，取以名汤，秋金得令，而炎暑自解。方中有更加人参者，
亦补中益气而生津也。用以协和甘草、粳米之补，承制石膏、知母之寒，泻火而土不伤，
乃操万全之术者也。
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。
【注】病患，谓病太阳经中风、伤寒之人也。太阳病烦热，汗出则应解矣。今又寒热
如疟状，每至日晡所即发潮热。日晡者，乃申酉阳明旺时，故曰属阳明也。证虽如此，当
审其果尽归阳明耶，抑或尚兼太阳也？故又当以脉辨之。若脉实者，邪已入里，则汗出
潮热，为阳明下证，宜与大承气汤下之；若脉浮虚者，邪尚在表，则寒热如疟，仍属太
阳当汗之证也，宜与桂枝汤汗之。
【集注】程知曰∶病患得汗后，烦热解，太阳之邪，将尽未尽，其人复如疟状，日晡
时发热，则邪入阳明审矣。然虽已入阳明，尚恐未离太阳，故必重辨其脉。脉实者可下；若
脉浮虚者，仍是阳明兼太阳，便宜汗而不宜下也。
太阳病，若吐、若下、若发汗后，微烦小便数，大便因硬者，与小承气汤和之愈。
【注】太阳病，若吐、若下、若发汗后不解，入里微烦者，乃栀子豉汤证也。今小便
数，大便因硬，是津液下夺也，当与小承气汤和之。以其结热未甚，入里未深也。
【集注】喻昌曰∶微烦小便数，大便因硬，皆是邪渐入里之机，故用小承气汤和之。
程应旄曰∶吐、下、汗后而见烦证，征之于大便硬，固非虚烦者比。然烦既微而小
便数，当由胃家失润，燥气客之使然，胃虽实非大实也。以小承气汤取其和也，非大攻也。
小承气汤方
大黄（四两） 浓朴（去皮，炙，二两） 枳实（大者，炙，三枚）
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。
趺阳脉浮而涩，浮则胃气强，涩则小便数，浮涩相搏，大便则硬，其脾为约，麻仁丸主之。
【注】趺阳，胃经脉也。趺阳脉浮而涩，阳浮则胃气强，阴涩则小便数，阴阳相搏，则
热盛而液竭矣，故大便则硬也。其名为约者，
谓脾为邪所约束，不能为胃行其津液，故名脾约也。以麻仁丸主之，养液润燥，清热通
幽，其不敢恣行承气者，以脉涩故也。
【集注】程知曰∶言胃脉浮涩，不可大攻，宜用麻仁丸润法也。趺阳，胃脉也。在足跗
上，动脉应手。浮则阳热盛而胃强，涩则阴津少而小便数。脾主为胃行其津液者也，胃
阳强则脾阴弱，不能为胃行其津液，故约其食物，如一二弹丸也。此不当下而当润之。
程应旄曰∶麻仁丸润燥通幽，伤寒不可恣行大承气可知矣。所以然者，以其为太阳
阳明，非正阳阳明胃家实者比也。推之少阳阳明，其不可以正阳明胃家实之法治之，更可知矣。
汪琥曰∶以胃强脾弱为脾约作解，盖以胃中之邪热盛为阳强，故脉浮；脾家之津液
少为阴弱，故脉涩。用麻仁丸者，以泻胃中之阳而扶脾之阴也。
麻仁丸方
麻仁（二升） 芍药（半斤） 枳实（半斤） 大黄（去皮，一斤） 浓朴（去皮，一斤） 杏仁
（去皮尖，熬，别作脂，一升）
上六味，蜜合丸，如桐子大。饮服十丸，日三服，渐加，以和为度。
【集解】方有执曰∶麻子、杏仁能润干燥之坚，枳实、浓朴能导固结之滞，芍药敛液
以辅润，大黄推陈以致新，脾虽为约，此能疏之。
伤寒吐后，腹胀满者，与调胃承气汤。
【注】伤寒吐后，胸不胀满而腹胀满者，是表邪已尽，胃中壅热故也。宜与调胃承气
汤，下其热而和之。以无硬痛，故不用大小承气也。
【集注】程知曰∶言吐后腹胀满宜调胃也，热在上焦则吐，吐后腹胀满，则邪不在胸，其
为里实可知。然胀满而不硬痛，自不宜用急下之法，但与调胃承气，和其胃热可耳！《内
经》云∶诸胀腹大，皆属于热也。
程应旄曰∶吐伤津液，燥气不能下达，遂成土郁，是以腹胀满，用调胃承气，一夺其郁可耳！
调胃承气汤方
大黄（去皮，酒浸，四两） 甘草（炙，二两） 芒硝（半升）
上三味，以水三升，煮取一升，去滓，纳芒硝，更煮两沸，少少温服之。
【方解】方名调胃承气者，有调和承顺胃气之义，非若大小承气专攻下也。经曰∶热
淫于内，治以咸寒；火淫于内，治以苦寒。君大黄之苦寒，臣芒硝之咸寒，二味并举，攻
热泻火之力备矣。恐其速下，故佐甘草之缓；又恐其过下，故少少温服之，其意在不峻而和也。
阳明病，不吐不下，心烦者，可与调胃承气汤。
【注】阳明病，谓已传阳明，不吐、不下，心烦者，谓未经吐、下而心烦也，其为热盛
实烦可知。故与调胃承气汤泻热，而烦自除也。
【集注】成无己曰∶吐后心烦谓之内烦，下后心烦谓之虚烦，今阳明病不吐不下心烦，
则是胃有郁热也，与调胃承气汤以下其郁热。
喻昌曰∶胃气及津液，既不由吐、下而伤，则心烦明系胃中热炽，故可与调胃承气汤。
阳明发热汗多者，急下之，宜大承气汤。
【注】阳明病，不大便，发热汗多不止者，虽无内实，亦当急下之。盖因阳气大蒸于内，
恐致阴液暴亡于外，故以全津液为急务也，宜大承气汤下之。
【集注】喻昌曰∶汗多则津液外渗，加以发热，则津液尽随热势，蒸蒸腾达于外，更
无他法以止其汗，惟有急下一法，引热势从
大肠而出，庶津液不致尽越于外耳。
程应旄曰∶此等之下，皆为救阴而设，不在夺实。夺实之下可缓，救阴之下不可缓。
沈明宗曰∶阳明里实，以潮热微汗为正。兹见发热汗多，乃里热炽盛之极，蒸腾胃中
津液，尽越于外，非亟夺其邪以救津液不可，故宜大承气汤急下也。
大承气汤方
大黄（酒洗，四两） 浓朴（炙，去皮，半斤） 枳实（炙，五枚） 芒硝（三合）
上四味，以水一斗，先煮二物，取五升去滓，纳大黄更煮；取二升去滓，纳芒硝，更
上微火一两沸。分温再服，得下，余勿服。
【方解】诸积热结于里而成满痞燥实者，均以大承气汤下之也。满者，腹胁满急 胀，
故用浓朴以消气壅；痞者，心下痞塞硬坚，故用枳实以破气结；燥者，肠中燥屎干结，故
用芒硝润燥软坚；实者，腹痛大便不通，故用大黄攻积泻热。然必审四证之轻重，四药
之多少适其宜，始可与也。若邪重剂轻，则邪气不服；邪轻剂重，则正气转伤，不可不慎也。
【集解】柯琴曰∶诸病皆因于气，秽物之不去，由于气之不顺也，故攻积之剂，必用
气分之药，因以承气名汤。方分大小有二义焉。浓朴倍大黄，是气药为君，名大承气；大
黄倍浓朴，是气药为臣，名小承气。味多性猛，制大其服，欲令大泻下也，因名曰大；味
寡性缓，制小其服，欲微和胃气也，因名曰小。且煎法更有妙义，大承气用水一斗煮朴、
枳，取五升去滓，纳大黄，再煮取二升，纳芒硝，何哉？盖生者气锐而先行，熟者气纯
而和缓，仲景欲使芒硝先化燥屎，大黄继通地道，而后枳、朴除其痞满。若小承气，以
三味同煎，不分次第，同一大黄而煎法不同，此可见仲景微和之意也。
程知曰∶调胃承气，大黄用酒浸；大承气，大黄用酒洗，皆为芒硝之咸寒而以酒制
之。若小承气，不用芒硝，则亦不事酒浸洗矣。
阳明病，下之，心中懊 而烦，胃中有燥屎者，可攻，腹微满，初头硬，后必溏，不
可攻之。若有燥屎者，宜大承气汤。
【注】阳明病，下之后，心中懊 而烦者，若腹大满，不大便，小便数，知胃中未尽之
燥屎复硬也，乃可攻之。若腹微满，不可攻也。误攻必变胀满不能食，饮水则哕等，逆
矣。若果有燥屎，宜下者，以大承气汤下之。
【集注】方有执曰∶可攻以上，以转矢气言。懊 ，悔 痛恨之意。盖药力不足以胜
病，燥硬欲行而不能，故曰∶可攻。言当更服汤以促之也。腹微满以下，以不转矢气言。
头硬后溏里热轻也，故曰∶不可攻之。言当止汤勿服也。
这段文字论述得非常明确。治疗太阳膀胱经的伤寒，发汗时应当顾虑阳气，因为膀胱主管气化功能。治疗阳明胃经的伤寒，发汗时应当顾虑阴津，因为胃中贮藏津液。所以阳明病多有热邪外越的症状，意思是胃中的津液随着热势完全向外发散，导致出汗不止。既然如此，阳明病不论属于中风还是伤寒，脉象微弱或实大，如果出汗少而邪气将自行解除；如果出汗多，则阴津容易导致枯竭。
阳明病通常应当多汗，反而无汗，身体像有虫子在皮肤里爬行一样，这是因为久病体虚的缘故。
【注】阳明病本应多汗，反而无汗，身体像有虫子在皮肤里爬行一样，是因为此人胃气长期虚弱，邪气郁结在太阳之表，阳明肌腠不能宣发作汗的缘故。适宜用小剂量的葛根汤（Kegen Tang, Pueraria Decoction）微微发汗，调和肌表，自然可以痊愈。
【集注】汪琥说：按此条论述张仲景没有给出治法。常器之说：可用桂枝加黄芪汤（Guizhi Jia Huangqi Tang, Cinnamon Twig and Astragalus Decoction）。郭雍说：宜用桂枝麻黄各半汤（Guizhi Mahuang Ban Tang, Half-and-Half Decoction of Cinnamon Twig and Ephedra）。不知道上述两种汤剂都是太阳经的药物，现在是阳明病无汗证，仍适宜用葛根汤主治。魏荔彤说：阳明病本应多汗，现在反而无汗，只见到身体像有虫子在皮肤里爬行，这是邪热想要出表作汗，而正气衰弱不能达到的缘故。
阳明病，起初想进食，小便反而不利，大便正常，这个人骨节疼痛，轻微发热，突然发狂，随后出汗而病解的，这是因为水湿不胜谷气，与汗一起排出，脉紧则病愈。
【注】阳明病，起初想进食，知道是从中风热邪传过来的，阳明受邪，应当小便频数，大便干硬，现在小便反而不利，大便正常，知道津液未伤而胃气和顺，不成里实证。既然不成里实，那么在经之邪本来轻浅，可自行痊愈。如果这个人骨节疼痛，轻微发热，是太阳之表证未除。奄，忽也。忽然发狂，随后出汗而病解的，大概是因为从太阳传来的邪气本轻，阳明所受的邪气自浅，津液未伤而胃气和顺，仍然应当还表作解。但是必须等到发狂而解的，这是胃中水气不胜，起初想吃的谷气，谷气长养阳气化为热，水不胜热，酿成汗一起排出，所以发狂而病解。凡是将要汗解，脉必先浮，现在说脉紧则愈的，也是邪气还于表，欲解时应见的脉象。
伤寒发热无汗，呕吐不能进食，反而汗出连绵不断的，是转属阳明病。
【注】伤寒发热无汗，呕吐不能进食，是太阳之邪欲传变。如果无汗，为太阳阳明之表证尚在，可以发汗。现在反而汗出连绵不断，是邪气已转属阳明之腑，可下不可汗。
【集注】成无己说：伤寒发热无汗，呕吐不能进食，是太阳受病。如果反汗出连绵不断，是太阳之邪转属阳明。所以经文说：阳明病本应多汗。
方有执说：呕吐不能进食，是热入胃中。反汗出，是肌肉着热，肤腠反而开泄。
程应旄说：太阳本证现下，而反汗出连绵不断，虽表证未罢，已是转属阳明。
“然”，连绵之意，即俗话说的汗一身不了又一身。
伤寒脉浮，发热无汗，其表证不解，不可给予白虎汤（Baihu Tang, White Tiger Decoction）；口渴想喝水，无表证的，由白虎加人参汤（Baihu Jia Renshen Tang, White Tiger with Ginseng Decoction）主治。
【注】伤寒之邪，传入阳明，脉浮，发热无汗，其表证不解的，虽有燥渴，乃大青龙汤（Daqinglong Tang, Major Blue Green Dragon Decoction）证，不可给予白虎汤。即使有阳明口渴想喝水的热证，应与白虎汤者，也必须审查其无太阳表证，才可以给予。加人参的，是因为其脉浮不滑，非有余；且想在大幅清热中，迅速生津液。
【集注】郑重光说：此申明用白虎汤的方法。白虎只能解热而不解表，如果稍带外感，有无汗、恶寒、身痛、头疼的表证，千万不可用。
伤寒脉浮滑，这是因为表有热里有寒，由白虎汤主治。
【按】王三阳说：经文“寒”字，当“邪”字解，也是热。这种说法很对。如果是“寒”字，就不是白虎汤证了。
【注】此言伤寒太阳证罢，邪传阳明，表里俱热，而未成胃实之病。脉浮滑者，浮为表有热的脉，阳明表有热，当发热汗出；滑为里有热的脉，阳明里有热，当烦渴引饮。所以说：表有热里有热，此为阳明表里俱热之证，白虎乃解阳明表里俱热之药，故主治。不加人参的，是因为未经汗、吐、下，不虚的缘故。
【集注】程知说：滑则里热，云浮滑则表里俱热矣。大热之气，得辛凉而解，犹如暑令，得金风而爽，所以清凉之剂，以白虎名之。又说：厥阴条中有伤寒，脉滑而厥者，里有热也，白虎汤主之，可证此条之非里有寒矣。
魏荔彤说：此里尚为经络之里，非脏腑之里，亦如卫为表，营为里，非指脏腑而言也。
白虎汤方
知母（六两） 石膏（碎，一斤） 甘草（炙，二两） 粳米（六合）
以上四味，以水一斗，煮米熟，汤成去滓，温服一升，日三服。
【集解】柯琴说：阳明邪从热化，故不恶寒而恶热；热蒸外越，故热汗出，热烁胃中，故渴欲饮水；邪盛而实，故脉滑，然犹在经，故兼浮也。盖阳明属胃，外主肌肉，虽内外大热而未实，终非苦寒之味所宜也。石膏辛寒，辛能解肌热，寒能胜胃火，寒能沉内，辛能走外，此味两擅内外之能，故以为君；知母苦润，苦以泻火，润以滋燥，故用为臣；甘草、粳米调和于中宫，且能土中泻火，稼穑作甘，寒剂得之缓其寒，苦剂得之平其苦，使二味为佐，庶大寒大苦之品，无伤损脾胃之虑也。煮汤入胃，输脾归肺，水精四布，大烦大渴可除矣。白虎为西方金神，取以名汤，秋金得令，而炎暑自解。方中有更加人参者，亦补中益气而生津也。用以协和甘草、粳米之补，承制石膏、知母之寒，泻火而土不伤，乃操万全之术者也。
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（Dachengqi Tang, Major Order the Qi Decoction），发汗宜桂枝汤（Guizhi Tang, Cinnamon Twig Decoction）。
【注】病患，谓病太阳经中风、伤寒之人也。太阳病烦热，汗出则应解矣。今又寒热如疟状，每至日晡所即发潮热。日晡者，乃申酉阳明旺时，故曰属阳明也。证虽如此，当审其果尽归阳明耶，抑或尚兼太阳也？故又当以脉辨之。若脉实者，邪已入里，则汗出潮热，为阳明下证，宜与大承气汤下之；若脉浮虚者，邪尚在表，则寒热如疟，仍属太阳当汗之证也，宜与桂枝汤汗之。
【集注】程知说：病患得汗后，烦热解，太阳之邪，将尽未尽，其人复如疟状，日晡时发热，则邪入阳明审矣。然虽已入阳明，尚恐未离太阳，故必重辨其脉。脉实者可下；若脉浮虚者，仍是阳明兼太阳，便宜汗而不宜下也。
太阳病，若吐、若下、若发汗后，微烦小便数，大便因硬者，与小承气汤（Xiaochengqi Tang, Minor Order the Qi Decoction）和之愈。
【注】太阳病，若吐、若下、若发汗后不解，入里微烦者，乃栀子豉汤（Zhizi Chi Tang, Gardenia and Fermented Soybean Decoction）证也。今小便数，大便因硬，是津液下夺也，当与小承气汤和之。以其结热未甚，入里未深也。
【集注】喻昌说：微烦小便数，大便因硬，皆是邪渐入里之机，故用小承气汤和之。
程应旄说：吐、下、汗后而见烦证，征之于大便硬，固非虚烦者比。然烦既微而小便数，当由胃家失润，燥气客之使然，胃虽实非大实也。以小承气汤取其和也，非大攻也。
小承气汤方
大黄（四两） 浓朴（去皮，炙，二两） 枳实（大者，炙，三枚）
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。
趺阳脉浮而涩，浮则胃气强，涩则小便数，浮涩相搏，大便则硬，其脾为约，麻仁丸（Maren Wan, Hemp Seed Pill）主之。
【注】趺阳，胃经脉也。趺阳脉浮而涩，阳浮则胃气强，阴涩则小便数，阴阳相搏，则热盛而液竭矣，故大便则硬也。其名为约者，谓脾为邪所约束，不能为胃行其津液，故名脾约也。以麻仁丸主之，养液润燥，清热通幽，其不敢恣行承气者，以脉涩故也。
【集注】程知说：言胃脉浮涩，不可大攻，宜用麻仁丸润法也。趺阳，胃脉也。在足跗上，动脉应手。浮则阳热盛而胃强，涩则阴津少而小便数。脾主为胃行其津液者也，胃阳强则脾阴弱，不能为胃行其津液，故约其食物，如一二弹丸也。此不当下而当润之。
程应旄说：麻仁丸润燥通幽，伤寒不可恣行大承气可知矣。所以然者，以其为太阳阳明，非正阳阳明胃家实者比也。推之少阳阳明，其不可以正阳明胃家实之法治之，更可知矣。
汪琥说：以胃强脾弱为脾约作解，盖以胃中之邪热盛为阳强，故脉浮；脾家之津液少为阴弱，故脉涩。用麻仁丸者，以泻胃中之阳而扶脾之阴也。
麻仁丸方
麻仁（二升） 芍药（半斤） 枳实（半斤） 大黄（去皮，一斤） 浓朴（去皮，一斤） 杏仁（去皮尖，熬，别作脂，一升）
上六味，蜜合丸，如桐子大。饮服十丸，日三服，渐加，以和为度。
【集解】方有执说：麻子、杏仁能润干燥之坚，枳实、浓朴能导固结之滞，芍药敛液以辅润，大黄推陈以致新，脾虽为约，此能疏之。
伤寒吐后，腹胀满者，与调胃承气汤（Tiaoweichengqi Tang, Regulate the Stomach and Order the Qi Decoction）。
【注】伤寒吐后，胸不胀满而腹胀满者，是表邪已尽，胃中壅热故也。宜与调胃承气汤，下其热而和之。以无硬痛，故不用大小承气也。
【集注】程知说：言吐后腹胀满宜调胃也，热在上焦则吐，吐后腹胀满，则邪不在胸，其为里实可知。然胀满而不硬痛，自不宜用急下之法，但与调胃承气，和其胃热可耳！《内经》云：诸胀腹大，皆属于热也。
程应旄说：吐伤津液，燥气不能下达，遂成土郁，是以腹胀满，用调胃承气，一夺其郁可耳！
调胃承气汤方
大黄（去皮，酒浸，四两） 甘草（炙，二两） 芒硝（半升）
上三味，以水三升，煮取一升，去滓，纳芒硝，更煮两沸，少少温服之。
【方解】方名调胃承气者，有调和承顺胃气之义，非若大小承气专攻下也。经曰：热淫于内，治以咸寒；火淫于内，治以苦寒。君大黄之苦寒，臣芒硝之咸寒，二味并举，攻热泻火之力备矣。恐其速下，故佐甘草之缓；又恐其过下，故少少温服之，其意在不峻而和也。
阳明病，不吐不下，心烦者，可与调胃承气汤。
【注】阳明病，谓已传阳明，不吐、不下，心烦者，谓未经吐、下而心烦也，其为热盛实烦可知。故与调胃承气汤泻热，而烦自除也。
【集注】成无己说：吐后心烦谓之内烦，下后心烦谓之虚烦，今阳明病不吐不下心烦，则是胃有郁热也，与调胃承气汤以下其郁热。
喻昌说：胃气及津液，既不由吐、下而伤，则心烦明系胃中热炽，故可与调胃承气汤。
阳明发热汗多者，急下之，宜大承气汤。
【注】阳明病，不大便，发热汗多不止者，虽无内实，亦当急下之。盖因阳气大蒸于内，恐致阴液暴亡于外，故以全津液为急务也，宜大承气汤下之。
【集注】喻昌说：汗多则津液外渗，加以发热，则津液尽随热势，蒸蒸腾达于外，更无他法以止其汗，惟有急下一法，引热势从大肠而出，庶津液不致尽越于外耳。
程应旄说：此等之下，皆为救阴而设，不在夺实。夺实之下可缓，救阴之下不可缓。
沈明宗说：阳明里实，以潮热微汗为正。兹见发热汗多，乃里热炽盛之极，蒸腾胃中津液，尽越于外，非亟夺其邪以救津液不可，故宜大承气汤急下也。
大承气汤方
大黄（酒洗，四两） 浓朴（炙，去皮，半斤） 枳实（炙，五枚） 芒硝（三合）
上四味，以水一斗，先煮二物，取五升去滓，纳大黄更煮；取二升去滓，纳芒硝，更上微火一两沸。分温再服，得下，余勿服。
【方解】诸积热结于里而成满痞燥实者，均以大承气汤下之也。满者，腹胁满急胀，故用浓朴以消气壅；痞者，心下痞塞硬坚，故用枳实以破气结；燥者，肠中燥屎干结，故用芒硝润燥软坚；实者，腹痛大便不通，故用大黄攻积泻热。然必审四证之轻重，四药之多少适其宜，始可与也。若邪重剂轻，则邪气不服；邪轻剂重，则正气转伤，不可不慎也。
【集解】柯琴说：诸病皆因于气，秽物之不去，由于气之不顺也，故攻积之剂，必用气分之药，因以承气名汤。方分大小有二义焉。浓朴倍大黄，是气药为君，名大承气；大黄倍浓朴，是气药为臣，名小承气。味多性猛，制大其服，欲令大泻下也，因名曰大；味寡性缓，制小其服，欲微和胃气也，因名曰小。且煎法更有妙义，大承气用水一斗煮朴、枳，取五升去滓，纳大黄，再煮取二升，纳芒硝，何哉？盖生者气锐而先行，熟者气纯而和缓，仲景欲使芒硝先化燥屎，大黄继通地道，而后枳、朴除其痞满。若小承气，以三味同煎，不分次第，同一大黄而煎法不同，此可见仲景微和之意也。
程知说：调胃承气，大黄用酒浸；大承气，大黄用酒洗，皆为芒硝之咸寒而以酒制之。若小承气，不用芒硝，则亦不事酒浸洗矣。
阳明病，下之，心中懊恼而烦，胃中有燥屎者，可攻，腹微满，初头硬，后必溏，不可攻之。若有燥屎者，宜大承气汤。
【注】阳明病，下之后，心中懊恼而烦者，若腹大满，不大便，小便数，知胃中未尽之燥屎复硬也，乃可攻之。若腹微满，不可攻也。误攻必变胀满不能食，饮水则哕等，逆矣。若果有燥屎，宜下者，以大承气汤下之。
【集注】方有执说：可攻以上，以转矢气言。懊恼，悔痛恨之意。盖药力不足以胜病，燥硬欲行而不能，故曰：可攻。言当更服汤以促之也。腹微满以下，以不转矢气言。头硬后溏里热轻也，故曰：不可攻之。言当止汤勿服也。
This discussion is very clear. When treating cold damage (Shanghan) affecting the Taiyang Bladder meridian and inducing sweating, one must consider Yang Qi, because the Bladder governs Qi transformation. When treating cold damage affecting the Yangming Stomach meridian and inducing sweating, one must consider Yin Jin (Body Fluids), because the Stomach stores Body Fluids. Therefore, Yangming diseases often present with symptoms of heat venting outward, meaning that the Body Fluids in the Stomach are completely dispersed outward along with the heat, resulting in continuous sweating. In this regard, for Yangming disease, regardless of whether it is wind-stroke or cold damage, and whether the pulse is faint or full/excess, if sweating is slight and the pathogen will resolve spontaneously; however, if sweating is excessive, Yin Jin is prone to exhaustion.
Yangming disease typically presents with profuse sweating; conversely, if there is no sweating, and the body feels as though insects are crawling under the skin, this is due to long-standing deficiency.
[Annotation] Yangming disease should normally present with profuse sweating; conversely, if there is no sweating, and the body feels as though insects are crawling under the skin, it is because this person's Stomach Qi has been deficient for a long time, causing the pathogen to stagnate at the Taiyang exterior, preventing the Yangming muscle layer from dispersing and producing sweat. It is appropriate to use a small dose of Ge Gen Tang (Pueraria Decoction) to induce slight sweating, harmonizing the muscle layer, which will naturally lead to recovery.
[Collected Annotations] Wang Hu said: According to this clause, Zhang Zhongjing did not provide a treatment method. Chang Qizhi said: Guizhi Jia Huangqi Tang (Cinnamon Twig and Astragalus Decoction) can be used. Guo Yong said: Guizhi Mahuang Ban Tang (Half-and-Half Decoction of Cinnamon Twig and Ephedra) is suitable. These two decoctions are medicines for the Taiyang meridian; now that this is a case of Yangming disease without sweating, Ge Gen Tang (Pueraria Decoction) should still be used as the primary treatment. Wei Litong said: Yangming disease should normally present with profuse sweating; now conversely there is no sweating, only seeing the sensation of insects crawling under the skin. This indicates that the pathogenic heat desires to exit the exterior through sweating, but the healthy Qi is too weak to reach it.
In Yangming disease, if initially there is an appetite, but urination is instead obstructed, and stool is normal, and the person experiences joint pain, slight fever, sudden mania, followed by sweating and resolution, this is because water dampness cannot overcome grain Qi, which combines with sweat to be expelled. If the pulse is tight, the disease will resolve.
[Annotation] In Yangming disease, if initially there is an appetite, it is known to have transmitted from wind-stroke pathogenic heat. When Yangming is affected, urination should be frequent and stool hard. Now, urination is obstructed and stool is normal, indicating that Body Fluids are not injured and the Stomach is harmonious, so interior excess syndrome does not form. Since interior excess does not form, the pathogen in the meridian is light and can resolve spontaneously. If the person has joint pain and slight fever, it means the Taiyang exterior syndrome has not been eliminated. "Yan" means suddenly. Sudden mania followed by sweating and resolution suggests that the pathogen transmitted from Taiyang was originally light, and the pathogen received by Yangming was shallow. With Body Fluids uninjured and the Stomach harmonious, it should still return to the exterior for resolution. However, why must it resolve after mania? This is because the water Qi in the Stomach cannot overcome the Grain Qi desired initially. Grain Qi nourishes Yang and transforms into heat; water cannot overcome heat, brewing sweat to be expelled together, thus causing mania and resolution. Generally, when resolving via sweating, the pulse must first become floating. The statement here that a tight pulse indicates resolution also refers to the pathogen returning to the exterior, where a tight pulse is expected upon resolution.
Cold damage presenting with fever, no sweating, vomiting, inability to eat, but conversely with continuous sweating, indicates transmission to Yangming.
[Annotation] Cold damage with fever, no sweating, vomiting, and inability to eat indicates that the Taiyang pathogen is about to transmit. If there is no sweating, the Taiyang-Yangming exterior remains, and sweating therapy is applicable. Now, conversely, there is continuous sweating, indicating that the pathogen has transmitted to the Yangming Fu organs. Purging is indicated, not sweating.
[Collected Annotations] Cheng Wuji said: Cold damage with fever, no sweating, vomiting, and inability to eat indicates Taiyang disease. If conversely there is continuous sweating, it means the Taiyang pathogen has transmitted to Yangming. Hence the classic states: Yangming disease should normally present with profuse sweating.
Fang Youzhi said: Vomiting and inability to eat indicate heat entering the Stomach. Conversely sweating indicates that muscles are affected by heat, and the skin pores open.
Cheng Yingmao said: Although the Taiyang primary symptoms are present, conversely having continuous sweating means that although the exterior syndrome has not ceased, it has already transmitted to Yangming.
"Ran" implies continuity, colloquially meaning sweat that does not stop on one part of the body before appearing on another.
In cold damage, if the pulse is floating, with fever and no sweating, and the exterior syndrome is unresolved, Baihu Tang (White Tiger Decoction) should not be given; if there is thirst desire to drink water, and no exterior syndrome, Baihu Jia Renshen Tang (White Tiger with Ginseng Decoction) is the primary treatment.
[Annotation] When cold damage pathogens transmit to Yangming, presenting with a floating pulse, fever, and no sweating, if the exterior syndrome is unresolved, even if there is dryness and thirst, it is a Da Qinglong Tang (Major Blue Green Dragon Decoction) syndrome, and Baihu Tang should not be given. Even if there is a Yangming heat syndrome with thirst desire to drink water requiring Baihu Tang, one must verify the absence of Taiyang exterior syndrome before administering it. Ginseng is added because the pulse is floating and not slippery, indicating deficiency rather than excess; furthermore, it aims to rapidly generate Body Fluids amidst significant heat clearance.
[Collected Annotations] Zheng Zhongguang said: This clarifies the method for using Baihu Tang. Baihu can only clear heat but does not release the exterior. If there is any external contraction accompanied by exterior symptoms such as no sweating, aversion to cold, body ache, or headache, it must strictly not be used.
Formula for Baihu Jia Renshen Tang
Add three liang of Renshen (Ginseng Root) to the Baihu Tang formula; follow the rest of the Baihu Tang formula.
In cold damage, if the pulse is floating and slippery, this is because there is heat on the exterior and cold on the interior; Baihu Tang is the primary treatment.
[Commentary] Wang Sanyang stated: The character "cold" in the text should be interpreted as "pathogen," which is also heat. This interpretation is correct. If it were truly "cold," it would not be a Baihu Tang syndrome.
[Annotation] This discusses the cessation of Taiyang cold damage symptoms, with the pathogen transmitting to Yangming, presenting with heat on both the exterior and interior, but without forming Stomach excess. A floating pulse indicates heat on the exterior; Yangming exterior heat presents with fever and sweating. A slippery pulse indicates heat on the interior; Yangming interior heat presents with irritability, thirst, and desire to drink. Thus, it is stated: heat on the exterior and heat on the interior. This is a Yangming syndrome of heat on both exterior and interior. Baihu Tang clears heat on both exterior and interior of Yangming, hence it is the primary treatment. Ginseng is not added because there has been no sweating, vomiting, or purging, so there is no deficiency.
[Collected Annotations] Cheng Zhi said: Slippery indicates interior heat; floating and slippery indicates heat on both exterior and interior. Great heat is resolved by acrid-cool properties, just as summer heat is refreshed by autumn winds. Therefore, cooling agents are named Baihu (White Tiger). He further stated: In the Jueyin chapter, there is cold damage with a slippery pulse and cold limbs, indicating interior heat, treated with Baihu Tang. This proves that this clause does not indicate interior cold.
Wei Litong said: The "interior" here refers to the interior of the meridians, not the Zang-Fu organs. Similarly, Wei (Defensive Qi) is exterior, and Ying (Nutritive Qi) is interior; this does not refer to Zang-Fu organs.
Formula for Baihu Tang
Zhimu (Anemarrhena Rhizome, six liang), Shigao (Gypsum Fibrosum, crushed, one jin), Gancao (Licorice Root, honey-fried, two liang), Jingmi (Oryza Sativa, six he).
These four ingredients are boiled in ten dou of water until the rice is cooked. Strain the decoction. Take one sheng warm, three times a day.
[Collected Exegesis] Ke Qin said: Pathogens in Yangming transform from heat, hence there is no aversion to cold but aversion to heat. Heat steams outward, causing hot sweating; heat scorches the Stomach, causing thirst desire to drink. Pathogen excess and excess result in a slippery pulse, yet since it remains in the meridian, it is accompanied by floating. Yangming belongs to the Stomach and governs the muscles externally. Although there is great internal and external heat without interior excess, bitter-cold flavors are ultimately not suitable. Shigao is acrid and cold; acridity resolves muscle heat, coldness overcomes Stomach fire. Cold sinks internally, acridity moves externally; this herb possesses both internal and external capabilities, thus serving as the Sovereign herb. Zhimu is bitter and moist; bitterness drains fire, moisture nourishes dryness, thus serving as the Minister herb. Gancao and Jingmi harmonize the Middle Jiao, draining fire within the Earth element. Sweetness arises from sowing and reaping; cold formulas gain moderation from sweetness, bitter formulas gain balance from sweetness. Using these two as Assistant herbs prevents the great cold and bitterness from damaging the Spleen and Stomach. Boiled into a decoction and entering the Stomach, it distributes fluids to the Spleen and Lungs, spreading essence throughout the body, removing great irritability and thirst. Baihu (White Tiger) is the Metal Spirit of the West; naming the decoction after it signifies that when Autumn Metal gains command, summer heat resolves naturally. Adding Ginseng in some variations supplements the Middle, boosts Qi, and generates fluids, coordinating with the tonifying effects of Gancao and Jingmi, restraining the cold of Shigao and Zhimu, draining fire without injuring Earth, ensuring complete safety.
Patients experiencing irritability and heat, resolving with sweating, resembling malaria, with tidal fever occurring in the late afternoon (You hour), belong to Yangming. If the pulse is excess, purging is indicated; if the pulse is floating and deficient, sweating is indicated. For purging, use Dachengqi Tang (Major Order the Qi Decoction); for sweating, use Guizhi Tang (Cinnamon Twig Decoction).
[Annotation] "Patient" refers to those suffering from wind-stroke or cold damage of the Taiyang meridian. In Taiyang disease, irritability and heat should resolve with sweating. Now, if chills and fever resemble malaria, with tidal fever occurring specifically during the Shen-You hours (late afternoon), this indicates Yangming dominance, hence belonging to Yangming. Although the symptoms appear thus, one must determine if they fully belong to Yangming or still involve Taiyang. Therefore, differentiation by pulse is necessary. If the pulse is excess, the pathogen has entered the interior; sweating, tidal fever, and constipation constitute a Yangming purgative syndrome, requiring Dachengqi Tang. If the pulse is floating and deficient, the pathogen remains on the exterior; chills and fever resembling malaria still belong to Taiyang sweating syndrome, requiring Guizhi Tang.
[Collected Annotations] Cheng Zhi said: After the patient sweats, irritability and heat resolve. The Taiyang pathogen is nearly exhausted but not entirely gone. If the person again resembles malaria with fever during the You hour, the pathogen has definitively entered Yangming. However, fearing it has not left Taiyang, the pulse must be carefully differentiated. An excess pulse allows purging; a floating-deficient pulse indicates Yangming combined with Taiyang, warranting sweating rather than purging.
In Taiyang disease, after vomiting, purging, or sweating, if there is slight irritability, frequent urination, and consequently hard stool, give Xiaochengqi Tang (Minor Order the Qi Decoction) to harmonize and cure.
[Annotation] In Taiyang disease, if unresolved after vomiting, purging, or sweating, and interior slight irritability occurs, it is a Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) syndrome. Now, frequent urination and consequent hard stool indicate depletion of Body Fluids downward. Xiaochengqi Tang should be given to harmonize. Because the accumulated heat is not severe and the pathogen has not deeply entered the interior.
[Collected Annotations] Yu Chang said: Slight irritability, frequent urination, and hard stool are signs of the pathogen gradually entering the interior; thus, Xiaochengqi Tang is used to harmonize.
Cheng Yingmao said: Irritability after vomiting, purging, or sweating, coupled with hard stool, is certainly different from deficiency-induced irritability. However, since the irritability is slight and urination is frequent, it is likely due to the Stomach losing moisture and dryness invading. Although the Stomach is excess, it is not major excess. Xiaochengqi Tang is chosen for its harmonizing effect, not for major attack.
Formula for Xiaochengqi Tang
Dahuang (Rhubarb Root and Rhizome, four liang), Houpo (Magnolia Bark, peeled, honey-fried, two liang), Zhishi (Immature Bitter Orange, large ones, honey-fried, three pieces).
Boil these three ingredients in four sheng of water to obtain one sheng and two he. Strain. Divide into two warm doses. After the first dose, if bowel movement occurs, do not take the remainder. If not, consume the entire amount. If bowel movement occurs, do not take the remainder.
If the Fuyang pulse is floating and choppy, floating indicates strong Stomach Qi, and choppy indicates frequent urination. The interaction of floating and choppy pulses results in hard stool. The Spleen is constrained, termed "Spleen Constraint"; Maren Wan (Hemp Seed Pill) is the primary treatment.
[Annotation] Fuyang is the pulse point of the Stomach meridian. A floating and choppy Fuyang pulse indicates that floating Yang means strong Stomach Qi, and choppy Yin means frequent urination. The interaction of Yin and Yang leads to excessive heat and exhaustion of fluids, resulting in hard stool. It is called "Constraint" because the Spleen is constrained by the pathogen and cannot transport Body Fluids for the Stomach, hence named Spleen Constraint. Maren Wan is used to nourish fluids, moisten dryness, clear heat, and unblock the bowels. One dares not recklessly use Chengqi formulas due to the choppy pulse.
[Collected Annotations] Cheng Zhi said: Floating and choppy Stomach pulse indicates that major purging is inappropriate; moistening with Maren Wan is suitable. Fuyang is the Stomach pulse, located on the dorsum of the foot where the artery is palpable. Floating indicates abundant Yang heat and strong Stomach; choppy indicates scarce Yin fluids and frequent urination. The Spleen governs transporting fluids for the Stomach. Strong Stomach Yang weakens Spleen Yin, preventing fluid transport, thus constraining food intake like one or two pellets. This requires moistening, not purging.
Cheng Yingmao said: Maren Wan moistens dryness and unblocks the bowels; thus, one knows that Dachengqi Tang should not be used recklessly in cold damage. This is because it involves Taiyang-Yangming, not the true Yangming Stomach excess. By extension, Shaoyang-Yangming cannot be treated with true Yangming methods.
Wang Hu said: Interpreting Spleen Constraint as strong Stomach and weak Spleen: pathogenic heat in the Stomach is strong Yang, hence floating pulse; scant fluids in the Spleen are weak Yin, hence choppy pulse. Maren Wan is used to drain Stomach Yang and support Spleen Yin.
Formula for Maren Wan
Maren (Hemp Seed, two sheng), Shaoyao (Peony Root, half jin), Zhishi (Immature Bitter Orange, half jin), Dahuang (Rhubarb Root and Rhizome, peeled, one jin), Houpo (Magnolia Bark, peeled, one jin), Xingren (Apricot Seed, peeled and tipped, roasted, processed separately into paste, one sheng).
These six ingredients are mixed with honey and formed into pills the size of tung seeds. Take ten pills with water, three times a day, gradually increasing the dose until harmony is achieved.
[Collected Exegesis] Fang Youzhi said: Hemp seed and apricot seed moisten dry hardness; Zhishi and Houpo guide stuck accumulation; Shaoyao collects fluids to assist moistening; Dahuang eliminates the old to bring forth the new. Although the Spleen is constrained, this formula can relieve it.
After cold damage induces vomiting, if abdominal distension and fullness occur, give Tiaoweichengqi Tang (Regulate the Stomach and Order the Qi Decoction).
[Annotation] After cold damage vomiting, if chest is not distended but abdomen is, it means exterior pathogens are exhausted and heat accumulates in the Stomach. Tiaoweichengqi Tang should be given to purge heat and harmonize. Because there is no hardness or pain, neither Dachengqi nor Xiaochengqi is used.
[Collected Annotations] Cheng Zhi said: Abdominal distension after vomiting requires regulating the Stomach. Heat in the Upper Jiao causes vomiting; post-vomiting abdominal distension indicates the pathogen is not in the chest but constitutes interior excess. However, distension without hardness/pain makes urgent purging inappropriate; Tiaoweichengqi is sufficient to harmonize Stomach heat. The *Neijing* states: All abdominal distensions and enlargements belong to heat.
Cheng Yingmao said: Vomiting injures fluids; dryness cannot descend, leading to Earth stagnation, causing abdominal distension. Tiaoweichengqi releases this stagnation.
Formula for Tiaoweichengqi Tang
Dahuang (Rhubarb Root and Rhizome, peeled, wine-soaked, four liang), Gancao (Licorice Root, honey-fried, two liang), Mangxiao (Mirabilite, half sheng).
Boil these three ingredients in three sheng of water to obtain one sheng. Strain, add Mangxiao, boil twice more. Take small amounts warm.
[Formula Explanation] The name "Regulate the Stomach and Order the Qi" implies harmonizing and accommodating Stomach Qi, unlike Dachengqi and Xiaochengqi which focus solely on purging. The classic states: Treat internal heat excess with salty-cold; treat internal fire excess with bitter-cold. Dahuang (bitter-cold) is Sovereign; Mangxiao (salty-cold) is Minister. Together, they prepare power to attack heat and drain fire. To prevent rapid purging, Gancao (mild) is added as Assistant; to prevent excessive purging, small warm doses are taken. The intent is mild harmonization, not harsh action.
In Yangming disease, without prior vomiting or purging, if irritability occurs, Tiaoweichengqi Tang may be given.
[Annotation] Yangming disease refers to transmission to Yangming. Irritability without prior vomiting or purging indicates heat excess causing real irritability. Thus, Tiaoweichengqi Tang is given to drain heat, removing irritability.
[Collected Annotations] Cheng Wuji said: Irritability after vomiting is internal irritability; irritability after purging is deficiency irritability. Now, Yangming irritability without vomiting or purging indicates stagnant heat in the Stomach; Tiaoweichengqi Tang drains this stagnant heat.
Yu Chang said: Since Stomach Qi and fluids are not injured by vomiting or purging, irritability clearly stems from blazing Stomach heat; thus, Tiaoweichengqi Tang is appropriate.
In Yangming disease, if there is fever and profuse sweating, urgent purging is required, preferably with Dachengqi Tang.
[Annotation] In Yangming disease, if there is constipation, fever, and continuous profuse sweating, even without interior excess, urgent purging is required. This is because Yang Qi steams excessively internally, risking sudden loss of Yin fluids externally. Preserving Body Fluids is the urgent priority; Dachengqi Tang is used for purging.
[Collected Annotations] Yu Chang said: Profuse sweating causes fluid leakage; combined with fever, fluids evaporate outward with heat. No other method stops this sweating except urgent purging to draw heat out through the Large Intestine, preventing total fluid loss.
Cheng Yingmao said: Such purging is designed to save Yin, not to seize excess. Purging for excess can be delayed; purging to save Yin cannot be delayed.
Shen Mingzong said: Yangming interior excess typically presents with tidal fever and slight sweating. Here, fever and profuse sweating indicate extreme interior heat steaming Stomach fluids outward. Urgently seizing the pathogen to save fluids is necessary; thus, Dachengqi Tang is urgently indicated.
Formula for Dachengqi Tang
Dahuang (Rhubarb Root and Rhizome, wine-washed, four liang), Houpo (Magnolia Bark, honey-fried, peeled, half jin), Zhishi (Immature Bitter Orange, honey-fried, five pieces), Mangxiao (Mirabilite, three he).
Boil these four ingredients in ten dou of water. First boil Houpo and Zhishi to obtain five sheng, strain. Add Dahuang and boil further to obtain two sheng, strain. Add Mangxiao and boil briefly over low heat. Divide into two warm doses. If purging occurs, do not take the remainder.
[Formula Explanation] Accumulated heat binding in the interior causing fullness, stuffiness, dryness, and excess are all treated with Dachengqi Tang. Fullness (abdominal/flank distension) uses Houpo to dissipate Qi stagnation; Stuffiness (epigastric blockage/hardness) uses Zhishi to break Qi knots; Dryness (dry fecal impaction) uses Mangxiao to moisten and soften hardness; Excess (abdominal pain/constipation) uses Dahuang to attack accumulation and drain heat. One must assess the severity of the four symptoms and the dosage of the four herbs appropriately. If the pathogen is heavy and the dose light, the pathogen will not submit; if the pathogen is light and the dose heavy, healthy Qi will be damaged. Caution is essential.
[Collected Exegesis] Ke Qin said: All diseases stem from Qi; retained waste remains due to Qi obstruction. Thus, purgatives must use Qi-moving herbs, hence the name "Chengqi" (Ordering Qi). There are two reasons for Major and Minor distinctions. In Dachengqi, Houpo doubles Dahuang, making Qi herbs Sovereign; in Xiaochengqi, Dahuang doubles Houpo, making Qi herbs Ministers. Many flavors and potent nature with large doses aim for major purging, hence "Major." Few flavors and mild nature with small doses aim for mild Stomach harmonization, hence "Minor." The decoction method is also subtle: Dachengqi boils Houpo and Zhishi first, then adds Dahuang, then Mangxiao. Raw herbs act sharply and quickly; cooked herbs act purely and mildly. Zhongjing intended Mangxiao to dissolve dry feces first, Dahuang to open the intestinal pathway next, and Houpo/Zhishi to remove stuffiness/fullness last. Xiaochengqi boils all three together without sequence, showing Zhongjing's intent for mild harmonization.
Cheng Zhi said: In Tiaoweichengqi, Dahuang is wine-soaked; in Dachengqi, Dahuang is wine-washed, both to moderate the salty-cold of Mangxiao. Xiaochengqi uses no Mangxiao, hence no wine processing.
In Yangming disease, after purging, if there is inner distress and irritability, and dry feces exist in the Stomach, purging may be attempted. If the abdomen is slightly full, with hard stool at the beginning and loose stool later, purging is contraindicated. If dry feces are confirmed, Dachengqi Tang is appropriate.
[Annotation] In Yangming disease, after purging, if there is inner distress and irritability, and if the abdomen is greatly full, constipated, and urinating frequently, it indicates remaining dry feces in the Stomach have hardened again; purging may be attempted. If the abdomen is only slightly full, purging is contraindicated. Mistaken purging will cause distension, inability to eat, and hiccups upon drinking water, leading to adverse outcomes. If dry feces are indeed present and purging is indicated, Dachengqi Tang is used.
[Collected Annotations] Fang Youzhi said: The section above "may purge" refers to passing flatus. "Ao Nao" implies regret and frustration. The medicine's strength is insufficient to overcome the disease; dry hardness wants to move but cannot. Thus, "may purge" means taking more decoction to promote it. The section below "slightly full" refers to lack of flatus. Hard beginning and loose later indicate light interior heat; thus, "purging is contraindicated" means stopping the decoction.