忌攻下者,有表邪未解,未可攻下者,有里气虚寒,不可攻下者,有津竭血燥,忌攻下者;
有阳明不实,不必攻下者,有无一下症,不犯攻下者,有虽热无结,本非攻下者;有身热脉
大,禁攻下者,有 痧未透,攻下则内伏者;有邪汗未透,攻下则邪伏者;有手足不温,攻
下则脉伏不出者。故曰∶恶寒身痛,太阳症未罢,不可下。结胸症,脉浮大,不可下。阳明
病,面赤色,表症也,不可下。服小承气汤不失臭气者,无燥屎也,不可攻下。脉浮数者,
表脉也,不可攻下。脉虚细者,正气虚也,不可攻下。伤寒热久,津液干枯,自汗复发其
汗,津液重伤,不可攻下。与厥冷、虚家、久病、新产、脉微,并不可攻下也。是以仲景攻
下真诀,惟以表症之解与不解,腹中气之转失与不转失,脐腹之痛与不痛,脉之浮与不浮。
实与不实,汗之多与不多,小便之利与不利,里热之甚与不甚,津液之干与不干,屎之硬与
不硬、溏与不溏,以消悉大下、微下、和之,俟之,导之之法,示后人临症斟酌,庶无早下
误下之患。
消导一法,《伤寒》未有条目,然细玩之,有云胸中邪气,胃中有燥粪五六枚,又以川连泻心汤
消痞满,以栀子豆豉加枳壳治食复,比例而推,则伤寒夹食者,亦可拟以消导之治矣。余尝
治外感兼有食滞者,用发表之药,汗不出,表不解,后用消导之法而汗出病愈者。又尝用清
里之药而里热不除,后用消导而热退者。又尝治谵妄,用清热之味不效,后用消导而热退谵
妄止者。更有 痧内伏,连用升提而不出,用消导而 现邪解者。 痧不化,服化 凉解之
药,愈见昏沉,用消导而 化神清者。如是则外感门汗、下、和、解温、清、之外,余又不
得不补消导一法。仲景有下法,治下部大肠之实。余今补消导法,治上部胃家之实。夫大肠
之实,在下部,行之即是消之。胃家之实,在上部,消之即是行之也。总之,发热不解,胸
前饱闷,右关脉滑,宜消导;谵妄,口不干渴不消水,脉大不数者,此食滞中焦也,宜消
导;发狂奔走,强壮有力者,宜消导;口噤不语,如醉如痴,脉滑不数,口不干渴,此痰饮
食滞也,宜消导。然消导之法,必要详明所伤何物,如谷食则用神曲、麦芽,肉食则用楂
肉、三棱,面食用莱菔子。气食相凝,多加枳实。甘寒停食,平胃保和散加白豆蔻等,辛温以散之。
The term "contraindication for purgation" refers to several conditions: when exterior pathogenic factors have not yet been resolved, purgation is inadvisable; when interior qi is deficient and cold, purgation is contraindicated; when body fluids are exhausted and blood is dry, purgation is prohibited; when Yangming disease presents without excess accumulation (non-excess), purgation is unnecessary; when there are no specific indications for a single purgative action, one should avoid violating the principle of purgation; when there is heat but no accumulation, it does not belong to the indications for purgation; when there is fever and a large pulse, purgation is forbidden; when miasma (sha) has not fully erupted, purgation will cause the pathogen to lie latent within; when pathogenic factors have not been thoroughly released through sweating, purgation will cause the pathogen to become trapped inside; when the hands and feet are not warm, purgation will cause the pulse to become deep and hidden. Therefore, it is said: if there is aversion to cold and body pain, indicating that Taiyang disease (a syndrome caused by pathogenic invasion of the Taiyang channel) has not ceased, downward purging must not be used. In Jie Xiong syndrome (a syndrome characterized by water-heat binding in the chest and diaphragm), if the pulse is floating and large, downward purging must not be used. In Yangming disease, if the face is red, this indicates an exterior syndrome, and downward purging must not be used. If after administering Xiao Cheng Qi Tang (Minor Chengqi Decoction) foul odor is still detectable, it indicates the absence of dry feces, and aggressive purgation is contraindicated. A floating and rapid pulse indicates an exterior pulse pattern, so purgation is contraindicated. A deficient and fine pulse indicates deficiency of healthy qi, so purgation is contraindicated. In Shanghan (Cold Damage) with prolonged heat, if body fluids are already dry, inducing sweat again will severely damage body fluids, making purgation contraindicated. For patients with cold limbs, those with constitutional weakness, chronic illness, recent postpartum status, or a faint pulse, purgation is strictly contraindicated. Thus, Zhang Zhongjing's true principles regarding purgation focus solely on whether the exterior syndrome has resolved, whether abdominal gas passes, whether there is pain around the navel and abdomen, whether the pulse is floating or not, whether the condition is excess or not, the amount of sweating, the patency of urination, the severity of interior heat, the state of body fluids (dry or moist), and the consistency of stool (hard or soft, formed or loose). These factors guide the choice between strong purgation, mild purgation, harmonizing treatment, waiting, or guiding methods, instructing later practitioners to exercise judgment in clinical practice to avoid the dangers of premature or erroneous purgation.
The method of digestion-promoting and stagnation-resolving is not explicitly categorized in the *Shanghan Lun*, but careful study reveals instances such as treating evil qi in the chest and dry feces in the stomach with Chuan Lian Xie Xin Tang (Coptis Decoction to Drain the Heart) to resolve fullness, and using Zhi Zi Chi Shi Jia Zhi Qiao (Gardenia, Fermented Soybean, and Aurantium Decoction with Added Aurantium) to treat recurrence due to dietary indiscretion. By analogy, Shanghan complicated by food stagnation can also be treated with digestion-promoting methods. I once treated a patient with external contraction complicated by food stagnation; initial exterior-releasing herbs failed to induce sweat or resolve the exterior syndrome, but subsequent use of digestion-promoting methods induced sweating and cured the disease. I once treated interior heat that did not subside with interior-clearing herbs, but it resolved after switching to digestion-promoting methods. I once treated delirium where heat-clearing herbs were ineffective, but delirium ceased and heat subsided after using digestion-promoting methods. Furthermore, in cases of latent miasma that failed to erupt despite repeated lifting and ascending therapies, digestion-promoting methods allowed the pathogen to manifest and resolve. When miasma failed to transform and cooling-resolving herbs led to increased lethargy, digestion-promoting methods facilitated the transformation of miasma and clarity of spirit. Thus, beyond the sweating, purging, harmonizing, warming, and clearing methods in the external contraction category, I feel compelled to supplement the digestion-promoting method. Zhang Zhongjing's purgative method treats excess in the lower portion (large intestine). My supplemented digestion-promoting method treats excess in the upper portion (stomach). Excess in the large intestine is in the lower part; promoting movement constitutes resolving stagnation. Excess in the stomach is in the upper part; resolving stagnation constitutes promoting movement. In summary: if fever persists accompanied by chest fullness and a slippery pulse at the right Guan position, digestion-promoting methods are indicated; if delirium occurs with no dry mouth or thirst and a large but not rapid pulse, this indicates food stagnation in the middle jiao, and digestion-promoting methods are indicated; if the patient runs wildly with robust strength, digestion-promoting methods are indicated; if the jaw is locked, speech is absent, the patient appears intoxicated or dazed, with a slippery but not rapid pulse and no dry mouth or thirst, this indicates phlegm-fluid and food stagnation, and digestion-promoting methods are indicated. However, the digestion-promoting method requires detailed identification of the ingested substance: for grain food, use Shen Qu (Medicated Leaven) and Mai Ya (Malt); for meat, use Zha Rou (Hawthorn Fruit) and San Leng (Burreed Rhizome); for flour-based foods, use Lai Fu Zi (Radish Seed). If qi and food are congealed together, add Zhi Shi (Immature Bitter Orange). For stagnation due to sweet and cold substances, modify Ping Wei Bao He San (Pingwei and Harmony Powder) with Bai Dou Kou (Cardamom) and others, using acrid-warm herbs to disperse.