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Constipation, in the category of miscellaneous diseases, is divided into excess constipation (Shi Mi), deficiency constipation (Xu Mi), wind constipation (Feng Mi), cold constipation (Leng Mi), heat constipation (Re Mi), qi constipation (Qi Mi), and blood depletion constipation (Xue Ku). In the category of external contraction diseases, symptoms are divided into unresolved exterior syndrome (Biao Wei Jie), half-exterior half-interior syndrome (Ban Biao Ban Li), resolved exterior syndrome (Biao Yi Jie), and exterior pathogen transmitting to interior (Biao Xie Chuan Li). Treatments are divided into should purge (Ying Xia), urgently purge (Ji Xia), mildly purge (Wei Xia), heavily purge (Da Xia), can purge (Ke Xia), cannot purge (Wei Ke Xia), absolutely cannot purge (Bu Ke Xia), and waiting with honey suppository methods (Si Zhi Mi Dao). If the exterior sweat has not been released, and the exterior syndrome still exists, with the disease located in the chest, floating pulse with body fever, fine and non-rapid pulse, or hidden pulse not emerging, red face with irritability, food stagnation in the chest, prolonged illness with excessive sweating, exhausted blood and depleted fluids, purging is contraindicated. If there is no significant body heat, excessive sweating on hands and feet, hard stool with abdominal distension, no exterior pathogen, desire to defecate but inability, frequent passage of foul gas, dry mouth and throat, thirst with rapid water consumption, long-term constipation, frequent fullness, yellow and scorched tongue coating, and abdominal pain, urgent purging is indicated, using Da Cheng Qi Tang (Major Order the Qi Decoction). However, Zhang Zhongjing's purging methods are detailed not only in this section but also in the spontaneous sweating chapter, primarily because purging is most feared when the exterior pathogen has not dispersed and exterior sweat is not thorough; only after spontaneous and excessive sweating does the exterior pathogen resolve. Cross-referencing these sections prevents errors. If bowel obstruction occurs with umbilical and abdominal distension and pain, where the exterior syndrome exists but the interior syndrome is particularly urgent, requiring purging, use only Xiao Chai Hu Tang (Minor Order the Gallbladder Decoction) to simultaneously resolve the exterior and interior. If heat is mild with little accumulation, fluids are dried up, constipation is present without significant abdominal distension, and no flatus passes, mild purging is appropriate, using only Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If there is bowel obstruction without abdominal distension, no urge to defecate, even if stools are bound, wait for signs of heat without accumulation and no flatus; waiting is appropriate. For insufficient fluids, dry hard stools, blood depletion with mild heat, nourishing fluids and blood with external honey suppositories is suitable. If there is no heat in the upper chest and stomach, making the patient intolerant to the bitter-cold nature of Cheng Qi formulas, but there is heat accumulation in the lower large intestine, bile suppositories can be used externally. Thus, for bowel obstruction, one distinguishes between purgative and non-purgative, mild and urgent purging, and waiting or guiding methods based on whether the exterior pathogen is resolved, whether interior heat is accumulated, the amount of sweating, presence of body heat, urgency of purgative indications, hardness of stool, dryness of fluids, presence of abdominal pain, and rapidity of pulse.

In Shanghan (Cold Damage), a weak Yang pulse with scant sweating indicates self-harmony. Excessive sweating indicates excess. A solid Yang pulse followed by excessive sweating due to diaphoresis also indicates excess. Excess leads to Yang exhaustion internally and loss of body fluids, causing the stool to become hard.

This section explains that excessive sweating causes Yang fluids to be exhausted internally, termed "loss of body fluids," leading to hard stools, not referring to Yang fire deficiency or cold.

In Taiyang disease, if diaphoresis, purging, or promoting urination is performed, it results in loss of body fluids, dryness of the stomach, and transformation into Yangming disease. Failure to defecate, internal excess, and difficulty in defecation constitute Yangming disease.

This clarifies that previous chapters' sweating and purging causing fluid loss, stomach dryness, internal excess, and difficulty defecating constitute Yangming interior syndrome.

In Taiyang disease, if vomiting, purging, or sweating is performed, resulting in slight irritability, frequent urination, and consequently hard stools, administer Xiao Cheng Qi Tang to harmonize and cure.

This clarifies that after vomiting and purging, although Yangming purgative indications exist, since fluids are exhausted, only Xiao Cheng Qi Tang should be used to harmonize.

If the patient is not aversed to cold but feels thirsty, this indicates transformation into Yangming disease. Frequent urination implies hard stools; ten days without defecation without discomfort is possible. If thirsty for water, give small amounts frequently to treat according to principles.

This clarifies that lack of defecation without distension or discomfort is not an indication for purging. Detailed notes on thirst follow.

In Yangming disease, originally characterized by spontaneous sweating, if the physician induces heavy sweating again, and although the illness has improved, slight irritability and malaise persist, this is because the stool must be hard. Due to loss of body fluids and stomach dryness, the stool becomes hard. One should ask about daily urine frequency; if originally three to four times daily but now only twice, it indicates stool will soon pass. Now, due to frequent urination and reduced fluids, fluids should return to the stomach, so stool will likely pass soon.

This reiterates that excessive sweating causing fluid loss and hard stool contraindicates purging; waiting is appropriate. Zhang Zhongjing often uses urine availability to determine stool hardness. Here, reduced urine indicates water returning to the large intestine, ensuring spontaneous defecation.

In Yangming disease, with spontaneous sweating, induced sweating, and free urination, this indicates internal exhaustion of body fluids. Although the stool is hard, it cannot be attacked; one must wait for the patient's urge to defecate, using honey suppositories to guide passage. Radix Trichosanthis (Tu Gua Gen) and pig bile can also serve as guides.

This continues from the previous text on severe fluid loss; even with hard stool and purgative indications, external guidance is appropriate.

In Yangming disease, a slow pulse, despite sweating and aversion to cold being absent, implies heaviness of the body, shortness of breath, abdominal fullness, and wheezing. With tidal fever, the exterior is resolving, and interior attack is possible. Continuous sweating on hands and feet indicates hard stool; use Da Cheng Qi Tang. If sweating is profuse with slight fever and aversion to cold, the exterior is unresolved; without tidal fever, do not give Cheng Qi Tang. If abdominal distension and blockage are severe, Xiao Cheng Qi Tang may be given to mildly harmonize stomach Qi, avoiding drastic purging.

A Yangming pulse is typically surging and large; a slow pulse here is not a floating-tight exterior pulse. Generally, sweating without aversion to cold lacks body heaviness. Here, despite heaviness, shortness of breath, and wheezing, tidal fever allows interior attack. However, continuous hand-foot sweating confirms hard stool, warranting Da Cheng Qi Tang. Profuse sweating with fever and aversion to cold, without tidal fever, contraindicates purging. Severe abdominal distension and blockage warrant only Xiao Cheng Qi Tang to mildly harmonize stomach Qi.

If the patient has not defecated for five to six days, experiences periumbilical pain, irritability, and periodic发作, this indicates dry fecal matter causing obstruction.

After severe purging, if there is no defecation for six to seven days, accompanied by irritability and abdominal fullness, this indicates dry fecal matter. This is due to retained food residue; Da Cheng Qi Tang is appropriate.

The above sections caution against inappropriate use of purging and external guidance. These two sections warn against missing indications for purging; thus, abdominal distension/pain, periodic irritability, and constipation indicate dry feces requiring urgent purging.

In Yangming disease with tidal fever and slightly hard stool, Da Cheng Qi Tang may be given. If not hard, do not give. If no defecation for six to seven days and dry feces are suspected, test by giving a small dose of Xiao Cheng Qi Tang. Passage of flatus indicates dry feces amenable to attack. If no flatus, the stool is likely hard at the beginning and loose later; attacking it will cause distension and anorexia. Thirst with water intake causing hiccups, followed by fever, indicates hard but scant stool; treat with Xiao Cheng Qi Tang to harmonize. If no flatus, cautiously avoid attacking.

These two sections explain the key to major purging, while subsequent sections caution against attacking without confirmed dry feces. For example, in Yangming disease with tidal fever and interior signs plus slightly hard stool, Da Cheng Qi Tang is suitable. If not hard, do not give. If no defecation for six to seven days suspecting dry feces, use Xiao Cheng Qi Tang. If flatus with foul odor passes after ingestion, dry feces are present and can be attacked. If no foul flatus, only the beginning is hard and the rest loose; attacking causes distension and anorexia. Thirst with water causes stomach cold and hiccups. Subsequent fever and irritability with hard stool imply scant dry feces; only Xiao Cheng Qi Tang should harmonize. If no flatus, cautiously avoid attacking.

Two to three days after onset, with a weak pulse, absence of Taiyang or Shaoyang symptoms, irritability, and epigastric hardness, progressing to day four or five: even if the patient can eat, give a small amount of Xiao Cheng Qi Tang to mildly harmonize and provide relief. By day six, administer Cheng Qi Tang. If no defecation for six to seven days and urine is scant, even if unable to eat, the stool is likely hard initially and loose later, not definitively hard; attacking will cause diarrhea. Wait until urine is abundant and stool is definitely hard before attacking with Da Cheng Qi Tang.

The first part states that with a weak pulse and absence of Taiyang/Shaoyang exterior signs, but presence of irritability and epigastric hardness indicating purgative need, even with appetite, Xiao Cheng Qi Tang should mildly harmonize. The second part states that scant urine suggests stool may not be hard; even with anorexia, do not attack. Wait for abundant urine and definitive hard stool before attacking.

In Yangming disease, delirium with tidal fever and a slippery, rapid pulse is treated with Xiao Cheng Qi Tang. Administer one sheng of Xiao Cheng Qi Tang; if flatus passes, give another sheng. If no flatus, do not give more. If no defecation the next day and the pulse becomes faint and choppy, this indicates interior deficiency, making treatment difficult; do not give Cheng Qi Tang again.

This section states that if, after taking Cheng Qi Tang, there is no foul flatus and no defecation, do not continue administration. Refer to notes on tidal fever for cross-reference.

In Yangming disease, if the patient sweats excessively, fluids exit externally, causing stomach dryness and hard stool, leading to delirium. Xiao Cheng Qi Tang is indicated. If delirium ceases after one dose, do not administer further.

Excessive sweating causes massive fluid loss and stomach dryness, leading to hard stool. Upper heat cannot descend, causing delirium. Xiao Cheng Qi Tang clears stomach heat and stops delirium without necessarily purging dry feces; thus, stop administration once delirium ceases.

In Shanghan, on day four or five, a deep pulse with wheezing and fullness indicates interior involvement. Inducing sweating in error causes fluids to escape, making defecation difficult, resulting in exterior deficiency and interior excess, eventually leading to delirium.

This reiterates that erroneous sweating causes fluid loss, making defecation difficult and eventually causing delirium. A deep pulse with wheezing/fullness indicates interior heat wheezing; mistaking it for exterior pathogen and inducing sweating makes defecation difficult, preventing interior heat discharge and causing delirium.

In Shanghan, after vomiting or purging, if the condition remains unresolved, with no defecation for five to six days up to ten-plus days, tidal fever at dusk, no aversion to cold, and hallucinations (seeing ghosts): in severe cases, confusion, grasping at clothes and bed, fearfulness, slight wheezing, and fixed gaze occur. A wiry pulse indicates survival; a choppy pulse indicates death. In mild cases, only fever and delirium occur, treated with Da Cheng Qi Tang. If one dose relieves, stop subsequent doses.

The first paragraph summarizes unresolved conditions after vomiting/purging, no defecation, dusk tidal fever, no aversion to cold, and hallucinations. The second paragraph details severe cases: confusion, grasping, fear, wheezing, fixed gaze; wiry pulse is good, choppy is bad. The final paragraph addresses mild cases with only fever and delirium, treatable with Da Cheng Qi Tang; stop after one relieving dose.

In Yangming disease, delirium with tidal fever and inability to eat indicates five or six pieces of dry feces in the stomach. If able to eat, the stool is merely hard; Da Cheng Qi Tang is appropriate.

This section corrects ancient misinterpretations. Yangming disease implies absence of Taiyang/Shaoyang exterior signs. Delirium and tidal fever confirm interior heat. Yangming stomach heat normally allows eating. Inability to eat indicates dry feces occupying space in the intestines/stomach, requiring Da Cheng Qi Tang. Ability to eat indicates remaining space for food; hard stool does not necessarily mean dry feces, so Da Cheng Qi Tang is contraindicated. Previous scholars noted Da Cheng Qi Tang at the end of the sentence and assumed uniform application, which is illogical.

In Shanghan, on day six or seven, unclear vision and unfocused eyes, absence of exterior/interior signs, difficulty defecating, and slight body heat indicate excess; urgent purging with Da Cheng Qi Tang is required.

Unfocused eyes are an exterior sign. On day six or seven, transmission to interior occurs. Absence of exterior/interior signs, difficulty defecating, and slight heat indicate not Yangming exterior pathogen but Yangming interior excess heat, hence urgent purging. Zhang Zhongjing lists six urgent purging indications: three in Yangming channel, all saving fluids (excessive sweating, tidal fever with internal fluid exhaustion, unfocused eyes with upper fluid exhaustion); three in Shaoyin channel, all saving kidney water (true water exhaustion, wood dryness/water depletion, earth dryness/water drying). Humans rely on fluids for life; stagnation causes disease, binding causes danger, exhaustion causes death. Pathogens in Taiyang bind muscles and block pores, requiring exterior release to dissipate binding. Pathogens in Shaoyang bind half-exterior/half-interior, causing chest/flank fullness and vomiting, requiring harmonization to open binding. Pathogens in Yangming interior bind intestines/stomach, causing constipation, requiring purging to unblock binding.

In Yangming disease, hardness and fullness in the hypochondrium, constipation, vomiting, and white tongue coating indicate Xiao Chai Hu Tang (Minor Order the Gallbladder Decoction). Once the upper jiao is unblocked, fluids descend, stomach Qi harmonizes, and sweating resolves the condition.

Yangming disease with hypochondriac hardness/fullness, constipation, vomiting, and white tongue coating represents Shaoyang half-exterior/half-interior syndrome, requiring harmonization and sweating via Xiao Chai Hu Tang. This clarifies that harmonization can unblock fluids and induce sweating.

Taiyang-Yangming refers to Spleen Constraint (Pi Yue). Zhengyang-Yangming refers to Stomach Excess (Wei Shi). Shaoyang-Yangming refers to agitation, irritability, excess, and difficulty defecating after sweating and promoting urination.

Taiyang-Yangming: Taiyang exterior pathogen transmits to Yangming interior; Yangming interior heat further transmits to Taiyin, constraining hard stool, hence "Spleen Constraint." Zhengyang-Yangming: Yangming heat pathogen transmits directly to Large Intestine dry-heat without passing through Taiyin. Shaoyang-Yangming: After sweating and diuresis, transmission to Yangming intestines/stomach causes agitation and difficulty defecating. This section distinguishes the three Yang channels transmitting to interior with constipation.

In Shanghan, a floating and slow pulse with warm hands and feet indicates attachment to Taiyin. Taiyin disease typically presents with jaundice; however, if urination is free, jaundice does not develop. By day seven or eight, if stool becomes hard, it is Yangming disease.

This follows the previous line on Yangming heat transmitting to Taiyin causing dry-heat Spleen Constraint, treated with Pi Yue Wan. If Shaoyin re-transmits to Yangming with hard stool and a large, deep, rapid pulse, Cheng Qi Tang is still used, unlike the damp-heat Taiyin section involving foul discharge.

In Shaoyin disease, abdominal distension and constipation after six or seven days require urgent purging with Da Cheng Qi Tang.

The previous line discussed Taiyin heat transmitting outward to Yangming. This line discusses Shaoyin heat transmitting outward to Yangming, presenting with abdominal distension requiring urgent purging with Da Cheng Qi Tang.

Diarrhea with delirium indicates dry feces; Xiao Cheng Qi Tang is appropriate.

The previous chapter discussed abdominal distension/constipation requiring urgent purging. This chapter discusses diarrhea with delirium without abdominal distension/constipation; even if dry feces exist, only Xiao Cheng Qi Tang is appropriate.

In combined disease of two Yang channels, after Taiyang disease resolves, only tidal fever, sweating on hands/feet, difficulty defecating, and delirium remain. Purging cures; Da Cheng Qi Tang is appropriate.

With Taiyang symptoms resolved, exterior signs are gone. Tidal fever, excessive hand/foot sweating, difficulty defecating, and delirium indicate Yangming purgative indications.

Xiao Cheng Qi Tang (Minor Order the Qi Decoction)
Zhi Qiao (Immature Bitter Orange), Hou Po (Magnolia Bark), Da Huang (Rhubarb).
This is a mild purgative formula. Add Chai Hu (Bupleurum) and Ge Gen (Kudzu Root) for exterior pathogens; add Ren Shen (Ginseng), Chen Pi (Tangerine Peel), and Gan Cao (Licorice) for middle Qi deficiency; add Mu Tong (Akebia Stem) for difficult urination.

Da Cheng Qi Tang (Major Order the Qi Decoction)
Zhi Qiao (Immature Bitter Orange), Hou Po (Magnolia Bark), Da Huang (Rhubarb), Mang Xiao (Mirabilite).
For痞满 (stifling fullness) and abdominal distension requiring urgent purging, use this formula.

Da Chai Hu Tang (Major Order the Gallbladder Decoction) - See Fever and Chills.
When purgative indications are present but accompanied by Shaoyang exterior signs, use this formula to simultaneously resolve exterior and interior.

Ma Ren Wan (Hemp Seed Pill)
Ma Ren (Hemp Seed), Bai Shao Yao (White Peony Root), Zhi Shi (Immature Bitter Orange), Da Huang (Rhubarb), Xing Ren (Apricot Seed), Hou Po (Magnolia Bark).
For heat accumulation in Yangming Qi level, use Cheng Qi Tang. For heat accumulation in Taiyin Blood level, use this formula.