大黄（酒洗）四两 厚朴（炙，去皮）半筋 枳实（炙）五枚 芒硝三合
右四味，以水一斗，先煮二物，取五升去滓，内大黄更煮，取二升去滓，内芒硝，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□满急□胀，故用厚
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。厚朴倍大黄，是气药为君，名大承气；大
黄倍厚朴，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，内大黄，再煮取二升，内芒硝，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□，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□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，以转失气言。懊□，悔□痛恨之意。盖药力不足以胜病，燥□
欲行而不能，故曰：可攻，言当更服汤以促之也。腹微满以下，以不转失气言。头□
后溏里热轻也，故曰：不可攻之，言当止汤勿服也。
程知曰：言有燥屎，即可大攻下也。下后心中懊□而烦者，虚烦也，当与栀子豉汤。
若胃有燥屎，则非虚烦，故可攻。腹不甚满，则无必攻之法，有燥屎则非先□后溏者
也，故可攻。又曰：便□与燥屎不同。便□者，大便实满而□；燥屎者，胃中宿食，
因胃热而结为燥丸之屎也。故便□，犹有用小承气者；若燥屎、则无不用芒硝之咸寒
也。
程应旄曰：末句乃申可攻句，以决治法。
@@@
得病二、三日，脉弱，无太阳柴胡证，烦躁心下□，至四、五日，虽能食，以小承气
汤，少少与微和之，令小安。至六日，与承气汤一升，若不大便六、七日，小便少者
，虽不能食，但初头□，后必溏，未定成□，攻之必溏，须小便利，屎定□，乃可攻
之，宜大承气汤。
【注】
得病二、三日，无太阳、少阳证，烦躁心下□，至四、五日，不大便。若脉大，属正
阳阳明，胃实之证也，下之无疑。今脉弱，虽胃和能食，不可轻下，只可与小承气汤
，少少与而微和之，令其小安。次日仍不大便，继与小承气汤促之。若六、七日竟不
大便而小便少者，即不能食，亦属胃中尚未干燥，屎未定□，如大攻之，初见□复必
溏也。须待小便利，知屎定□，乃可攻之，宜大承气汤。
【集注】
方有执曰：太阳不言药，以有桂枝、麻黄之不同也；少阳言药，以专主柴胡也。凡以
此为文者，皆互发也。以无太、少二经证，故知此属阳明，以脉弱，故宜微和，至六
日以下，乃历叙可攻、不可攻之节度也。
程应旄曰：能食以结在肠间，而胃火自盛也。先以小承气汤少少与之，和胃中之火，
令小安后，以前药增至一升，去肠中之结。既用小承气矣？而又减去分数，接续投之
，以脉弱之胃，其禀素虚，而为日又未久也。
张璐曰：此段之能食、不能食，全与辨风寒强弱无涉。言能食者，不可以为胃强而轻
下；不能食者，不可以为胃中有燥屎而轻下也。
@@@
阳明病，脉迟，虽汗出，不恶寒者，其身必重，短气腹满而喘，有潮热者，此外欲解
，可攻里也，手足濈然汗出者，此大便已□也，大承气汤主之。若汗多，微发热恶寒
者，外未解也，其热不潮，未可与承气汤。若腹大满不通者，可与小承气汤，微和胃
气，勿令大泄下。
【注】
阳明病脉迟，虽汗出不恶寒，外证欲解而脉不实，尚未可攻也。若其人身重，热困于
体也；短气而喘，热壅于上也；腹满潮热，热聚于中也，手足濈然汗出，大便已□，
热结于下也，斯为外邪已解，内实已成，始可攻之，主以大承气汤可也。若汗出，微
发热恶寒者，则外犹未解也，其热不潮者，里犹未实也，不可与承气汤。即有里急、
腹大满、不通等证，亦只宜与小承气汤微和胃气，勿令大泄下，盖以脉迟故也。
【集注】
方有执曰：潮热，阳明王于申酉戌，故热作于此时，如潮之有信也。手足濈然而汗出
者，脾主四肢而胃为之合，胃中燥实而蒸蒸腾达于四肢，故曰：大便已□也。
林澜曰：此节辨脉迟内结之，或宜大承气攻之，或但可以小承气微和之也。阳明病脉
迟证，兼汗出不恶寒，身重短气，腹满而喘，似属可攻。然必有潮热者，为外证已解
，里证已具，手足濈然汗出者，为大便已□，主以大承气汤攻之奚疑！若汗出虽多，
犹见发热恶寒，则表尚在也，其热不潮，汗亦非手足濈然之汗，安可与承气以攻之乎
？即腹大满不通，亦只可与小承气微和，勿令大泄下。此何以故？脉迟便非必下之脉
，虽内结亦岂大承气所宜哉！
@@@
阳明病，潮热，大便微□者，可与大承气汤，不□者，不可与之。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，此有燥屎也，乃可攻
之。若不转失气者，此但初头□，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□而少也，以小承气汤和之，不转失气者，慎
不可攻也。
【注】
阳明病，潮热大便微□者，可与大承气汤，不□者，不可与之也。若不大便六、七日
，恐有燥屎，欲知之法，少与小承气汤，汤入腹中转失哕气，则为有燥屎，乃可攻之
。若不转失秽气，此但初头□后必溏，是尚未成□也，不可攻之。攻之必寒气乘虚上
逆，胀满不能食也。欲饮水者，得水则哕，亦由虚寒之气上逆，不能化水而下输也。
若其后所发潮热不退，必是大便再□，但已经下后，所□者无多，只以小承气汤和之
可也。故凡服承气汤不转失气者，慎不可攻也。此盖仲景戒人不可轻下之意。
【集注】
方有执曰：此以潮热、转失气次第而详言之，以决当下之候也。转失气，反屁出也。
胀满，药寒之过也。哕，亦寒伤胃也。复□而少者，重下故也。末句重致叮咛之意。
喻昌曰：若腹中气仍不转，则不但用大承气大差，即小承气亦差矣。
程知曰：上条曰：外欲解，可攻里。曰：外未解，未可与承气。曰：可与小承气，微
和胃气，勿令大泄下。此条曰：可与。曰：不可与。曰：乃可攻之，不可攻之。曰：
少与小承气。曰：以小承气和之，慎不可攻。多少商量慎重之意。故惟手足濈然汗出
，大便燥□者，始主之以大承气，若小承气，犹是微和胃气之法也。
汪琥曰：转失气，则知其人大便已□，肠胃中燥热之甚，故其气不外宣，时转而下；
不转失气，则肠胃中虽有热，而渗孔未至于燥，此但初头□，后必溏也。
@@@
阳明病，□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，若不转失气者，勿更与之。明日又不大便，脉反微涩者，里虚也，为
难治，不可更与承气汤也。
【注】
阳明病，□语，潮热，脉滑而疾者，是可攻之证脉也。然无濈濈然之汗出，与小便数
、大便□燥实等证，则不可骤然攻之，宜先与小承气汤一升试之，若腹中转失秽气，
则知肠中燥屎已□，以药少未能遽下，所转下者，但屎之气耳！可更服一升促之，自
可下也。若不转失气，则勿更与服，俟明日仍不大便，诊其脉仍滑疾，则更服之。今
脉反见微涩，则是里虚无气，不能承送，故为难治，所以不可更与承气汤也。
【集注】
方有执曰：滑以候食，故为大便□之诊。疾者，属里热也。微者，阳气不充，无以运
行。涩者，阴血不足，无以润送。故曰：阳微不可下，无血不可下。此之谓也。
张璐曰：此条脉滑而疾，有□语、潮热，而无□满实证，只宜以小承气汤下之，下之
而脉反微涩，证变里虚，故为难治。
@@@
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，循衣摸床，惕而不安，微喘直视，脉弦者生，涩者
死。微者但发热□语者，大承气汤主之，若一服利，则止后服。
【按】
赵嗣真曰：『活人书』云：弦者阳也，涩者阴也。阳病见阳脉者生，在仲景脉法中，
弦涩属阴不属阳得无疑乎？今观本文内，脉弦者生之「弦」字，当是「滑」字。若是
「弦」字，弦为阴负之脉，岂有必生之理，惟滑脉为阳，始有生理。滑者通，涩者塞
，凡物理皆以通为生，塞为死。玩上条脉滑而疾者小承气主之，脉微涩者，里虚为难
治，益见其误。
【注】
伤寒，若吐、若下后，津夜已亡，而表不解，邪因入里，不大便五、六日，上至十余
日仍不大便，日晡所发潮热，不恶寒者，此乃表邪悉罢，里热渐深也，仍宜大承气汤
，荡尽余邪，以存阴液，自可愈也。若因循失下，以致独语如见鬼状。病势剧者，则
不识人，循衣摸床，惊惕不安，微喘直视，见一切阳亢阴微，孤阳无根据，神明扰乱之
象。当此之际，惟诊其脉滑者为实，堪下则生；涩者为虚，难下则死。若病势微者，
但见潮热、谵语、不大便之证，而无前神昏等剧者，宜以大承气汤下之。若一服利，
即止后服，盖恐其过也。
【按】
循衣摸床，危恶之候也。一以阴气未竭为可治，如太阳中风，火劫变逆，捻衣摸床，
小便利者生，不利者死是也。一以阳热之极为可攻，如阳明里热成实，循衣摸床，脉
滑者生，涩者死是也。大抵此证，多生于汗、吐、下后，阳气大虚，精神失守。经曰
：四肢者，诸阳之本也。阳虚故四肢扰乱失所倚也，以独参汤救之；汗多者，以参耆
汤；厥冷者，以参附汤治之。愈者不少，不可概谓阳极阴竭也。
【集注】
喻昌曰：此条举谵语之势重者为言。而势重之中，复分二等，剧者主死，微者主生，
故以大承气汤下之。
程知曰：娄全善治循衣摸床，每以补益得愈，亦因其脉证之不足也。刘守真每以承气
治热病，法虽祖于仲景，而其辨证未能如此详悉，故开后人卤莽之端。又曰：喘则气
欲上脱，微喘者邪实于内，而又不能大喘也。不识人循衣摸床，心欲绝也；动惕不安
，肝欲绝也；微喘，肺欲绝也；直视，肾欲绝也。『内经』所谓三阴三阳，五藏六府
皆受病，荣卫不行，藏府不通，故脉涩者死也。
汪琥曰：日晡所发潮热者，府实燥甚，故当其经气王时发潮热也。独语者，即谵语也
。病人自言为谵，独语如见鬼状，乃阳明府实而妄见妄闻，剧者甚也。成注云：热甚
昏冒正气，故不识人。循衣摸床者，阳热偏胜而躁动于手也。惕而不安者，胃热冲膈
，心神为之不宁也。又胃热甚而气上逆则喘，直视则邪干藏矣。故其生死之机，须于
脉候决之。
@@@
阳明病，本自汗出，医更重发汗，病已差，尚微烦不了了者，此大便必□故也。以亡
津液，胃中干燥，故令大便□，当问其小便日几行，若本小便日三、四行，今日再行
，故知大便不久出。今为小便数少，以津液当还入胃中，故知不久必大便也。
【注】
阳明病，本应自汗出，医误以为风邪，更重发汗，病已差，尚微烦不了了者，此大便
必□故也。然无或满、或痛之苦者，以重汗亡津，胃中干燥，故大便□，本无宿食也
。则当问其小便日几行，若本一日三、四行，今日祗再行，可知大便不久则出。盖小
便数少，则津液当还胃中，故知不久必大便自出，不须药也。
【集注】
方有执曰：水谷入胃，其精者为津液，粗者成楂滓。水精渗出肠胃之外，清者为津液
，浊者外而为汗，下而为小便。故汗与小便过多者，皆能夺乎津液，所以楂滓之为大
便者，干燥结□而难出也。然二便者，水谷分行之道路，此通则彼塞，此塞则彼通，
小便出少，则津液还停胃中，必大便润而自出也。
@@@
[Formula Analysis]
For various accumulations of heat binding in the interior, resulting in the four symptoms of fullness (Man), stuffiness (Pi), dryness (Zao), and excess (Shi), Da Cheng Qi Tang (Great Order the Qi Decoction) should be used to purge. "Fullness" refers to abdominal distension that is urgent and swollen; therefore, Houpo (Magnolia Bark) is used to dissipate qi stagnation. "Stuffiness" refers to a sensation of blockage and hardness in the epigastrium; therefore, Zhishi (Immature Bitter Orange) is used to break up qi knots. "Dryness" refers to dry, hard feces in the intestines; therefore, Mangxiao (Mirabilite) is used to moisten dryness and soften hardness. "Excess" refers to abdominal pain and constipation; therefore, Dahuang (Rhubarb Root and Rhizome) is used to attack accumulation and purge heat. However, one must carefully examine the severity of these four syndromes and ensure the dosages of the four herbs are appropriate before administering the formula. If the pathogen is severe but the medication is weak, the pathogen will not be subdued; if the pathogen is mild but the medication is too strong, healthy qi will be damaged. Caution is essential.
[Ji Jie - Collected Explanations]
Ke Qin stated: All diseases originate from qi dysfunction. The inability to expel filth is due to qi not flowing smoothly. Therefore, purgative agents must use herbs that regulate the qi level, hence the name "Cheng Qi" (Ordering Qi). There are two reasons for dividing the formula into Da Cheng Qi Tang (Great Order the Qi Decoction) and Xiao Cheng Qi Tang (Minor Order the Qi Decoction). In Da Cheng Qi Tang, the dosage of Houpo (Magnolia Bark) is double that of Dahuang (Rhubarb Root and Rhizome); since the qi-regulating herb is the sovereign herb, it is named Da Cheng Qi Tang. In Xiao Cheng Qi Tang, the dosage of Dahuang (Rhubarb Root and Rhizome) is double that of Houpo (Magnolia Bark); since the qi-regulating herb is the minister herb, it is named Xiao Cheng Qi Tang. The former has many ingredients and potent properties, with larger dosages intended to induce severe purgation, hence "Da" (Great). The latter has fewer ingredients and milder properties, with smaller dosages intended to mildly harmonize stomach qi, hence "Xiao" (Minor). Furthermore, the decoction method holds profound meaning. Da Cheng Qi Tang uses one dou of water to first boil Houpo (Magnolia Bark) and Zhishi (Immature Bitter Orange), reducing to five sheng, filtering out the dregs, adding Dahuang (Rhubarb Root and Rhizome), boiling again to reduce to two sheng, filtering out the dregs, and finally adding Mangxiao (Mirabilite), heating slightly for one or two boils. Why? Because raw herbs have sharp qi and act quickly, while cooked herbs have pure qi and act gently. Zhang Zhongjing intended for Mangxiao (Mirabilite) to first dissolve the dry feces, followed by Dahuang (Rhubarb Root and Rhizome) to unblock the intestinal tract, and finally by Zhishi (Immature Bitter Orange) and Houpo (Magnolia Bark) to eliminate stuffiness and fullness. In contrast, Xiao Cheng Qi Tang boils all three herbs together without sequence. Although Dahuang (Rhubarb Root and Rhizome) is used in both, the decoction methods differ, revealing Zhang Zhongjing's intent to mildly harmonize stomach qi.
Cheng Zhi stated: In Tiao Wei Cheng Qi Tang (Regulate the Stomach Order the Qi Decoction), Dahuang (Rhubarb Root and Rhizome) is soaked in wine; in Da Cheng Qi Tang (Great Order the Qi Decoction), Dahuang (Rhubarb Root and Rhizome) is washed in wine. Both utilize the salty-cold nature of Mangxiao (Mirabilite) and control it with wine. For Xiao Cheng Qi Tang (Minor Order the Qi Decoction), which does not use Mangxiao (Mirabilite), there is no need for wine soaking or washing.
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In Yangming disease, after purgation, if there is mental restlessness and discomfort (Ao Nao) with dry feces in the stomach/intestines, purgation is permissible. If there is only slight abdominal fullness, with stool that is hard at the beginning but loose at the end, purgation is contraindicated. If dry feces are indeed present, Da Cheng Qi Tang (Great Order the Qi Decoction) is indicated.
[Note]
In Yangming disease, after purgation, mental restlessness and discomfort (Ao Nao): If the abdomen is significantly full, there is constipation, and frequent urination, indicating that residual dry feces in the stomach have re-aggregated, purgation may be performed. If the abdomen is only slightly full, purgation is contraindicated. Incorrect purgation will inevitably lead to adverse conditions such as abdominal distension, inability to eat, and hiccups upon drinking water. If dry feces are truly present and purgation is indicated, Da Cheng Qi Tang (Great Order the Qi Decoction) should be used.
[Ji Zhu - Collected Annotations]
Fang Youzhi stated: The section above "permissible to purge" is based on the passage of flatus. "Ao Nao" implies regret and intense distress. It means the medicinal power is insufficient to overcome the disease, and the dry feces wish to move but cannot. Thus, "permissible to purge" means one should continue taking the decoction to promote defecation. The section below "slight abdominal fullness" is based on the absence of flatus. Hard stool at the beginning and loose at the end indicates mild interior heat; thus, "contraindicated to purge" means one should stop taking the decoction.
Cheng Zhi stated: If dry feces are present, vigorous purgation can be used. Mental restlessness and discomfort after purgation indicate empty irritability, for which Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) should be given. If there are dry feces in the stomach, it is not empty irritability, so purgation is allowed. If the abdomen is not very full, there is no absolute indication for purgation; however, if dry feces are present, the stool would not be hard at the beginning and loose at the end, so purgation is allowed. Furthermore, hard stool differs from dry feces. Hard stool refers to solid, full, and dry bowel movements; dry feces refer to retained food in the stomach that has formed hard pellets due to stomach heat. Therefore, for hard stool, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) might still be used; for dry feces, the salty-cold property of Mangxiao (Mirabilite) is always necessary.
Cheng Yingmao stated: The final sentence reiterates the "permissible to purge" clause to determine the treatment method.
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Two to three days after contracting the disease, if the pulse is weak, and there are no Taiyang or Shaoyin Chaihu syndrome signs, but there is irritability and epigastric stuffiness, by the fourth or fifth day, even if the patient can eat, give Xiao Cheng Qi Tang (Minor Order the Qi Decoction) in small amounts to mildly harmonize the stomach qi, allowing for slight relief. By the sixth day, administer one sheng of Cheng Qi Tang. If there has been no bowel movement for six or seven days and urine output is scanty, even if the patient cannot eat, as long as the stool is hard at the beginning and loose at the end, indicating it has not yet fully formed dry feces, purgation will cause diarrhea. One must wait until urine flows freely and the stool is definitely hard before purging, using Da Cheng Qi Tang (Great Order the Qi Decoction).
[Note]
Two to three days after contracting the disease, without Taiyang or Shaoyang syndromes, with irritability and epigastric stuffiness, progressing to constipation by the fourth or fifth day. If the pulse is large, it belongs to Zheng Yang Yangming (True Yang Yangming), a syndrome of stomach excess, and purgation is unquestionably indicated. Now, with a weak pulse, although the stomach is harmonious and the patient can eat, light purgation is not permitted. Only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) should be given in small amounts to mildly harmonize the stomach qi, providing slight comfort. If there is still no bowel movement the next day, continue with Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to promote defecation. If there is no bowel movement for six or seven days and urine is scanty, even if the patient cannot eat, it indicates the stomach is not yet dry and the stool is not firmly hardened. Vigorous purgation will result in initial hardness followed by looseness. One must wait for free urination to confirm the stool is firmly hardened before purging, using Da Cheng Qi Tang (Great Order the Qi Decoction).
[Ji Zhu - Collected Annotations]
Fang Youzhi stated: Taiyang disease does not specify herbs because of differences between Guizhi Tang (Cinnamon Twig Decoction) and Mahuang Tang (Ephedra Decoction); Shaoyang disease specifies herbs because it primarily focuses on Chaihu Tang (Bupleurum Decoction). Such writing styles mutually elaborate. Since there are no Taiyang or Shaoyang meridian syndromes, this is known to belong to Yangming. Due to the weak pulse, mild harmonization is suitable. From the sixth day onwards, the limits of permissible and impermissible purgation are narrated in detail.
Cheng Yingmao stated: The ability to eat is due to accumulation in the intestines causing spontaneous stomach fire. First, give Xiao Cheng Qi Tang (Minor Order the Qi Decoction) in small amounts to harmonize stomach fire, allowing slight comfort, then increase the dose to one sheng to remove intestinal accumulation. Why reduce the fraction and administer continuously after using Xiao Cheng Qi Tang (Minor Order the Qi Decoction)? Because patients with weak pulses have constitutionally deficient stomachs, and the disease duration is short.
Zhang Lu stated: The mention of ability or inability to eat in this section is unrelated to distinguishing the strength of wind-cold. Saying "can eat" does not mean stomach strength allows for light purgation; saying "cannot eat" does not mean dry feces in the stomach allow for light purgation.
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In Yangming disease, if the pulse is slow, and although there is sweating, there is no aversion to cold, the body will necessarily feel heavy, accompanied by shortness of breath, abdominal fullness, and wheezing. If there is tidal fever, this indicates the exterior is resolving, and the interior can be attacked. If hands and feet sweat continuously, this indicates the stool has hardened; Da Cheng Qi Tang (Great Order the Qi Decoction) should govern. If there is profuse sweating, slight fever, and aversion to cold, the exterior has not resolved; if the fever is not tidal, Cheng Qi Tang should not be given. If the abdomen is significantly full and obstructed, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) may be given to mildly harmonize stomach qi, avoiding severe purgation.
[Note]
In Yangming disease, a slow pulse, sweating without aversion to cold, suggests the exterior syndrome is resolving but the pulse is not solid, so purgation is not yet appropriate. If the body feels heavy, heat is trapping the body; shortness of breath and wheezing indicate heat obstructing the upper jiao; abdominal fullness and tidal fever indicate heat gathering in the middle jiao; continuous sweating of hands and feet indicates the stool has hardened and heat is binding in the lower jiao. Only when external pathogens are resolved and internal excess is established can purgation be performed, governed by Da Cheng Qi Tang (Great Order the Qi Decoction). If there is sweating, slight fever, and aversion to cold, the exterior remains unresolved. If the fever is not tidal, the interior is not yet solid, and Cheng Qi Tang should not be given. Even with symptoms like urgency, significant abdominal fullness, and obstruction, only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) should be given to mildly harmonize stomach qi, avoiding severe purgation, due to the slow pulse.
[Ji Zhu - Collected Annotations]
Fang Youzhi stated: Tidal fever occurs when Yangming is prosperous at Shen, You, and Xu hours (3 PM–9 PM), so the fever arises at this time, reliable as the tide. Continuous sweating of hands and feet occurs because the spleen governs the four limbs and combines with the stomach; stomach dryness and excess cause steaming heat to reach the limbs, hence "stool has hardened."
Lin Lan stated: This section differentiates slow-pulse interior binding syndromes, determining whether to use Da Cheng Qi Tang (Great Order the Qi Decoction) for purgation or Xiao Cheng Qi Tang (Minor Order the Qi Decoction) for mild harmonization. Yangming disease with slow pulse, sweating, no aversion to cold, heaviness, shortness of breath, abdominal fullness, and wheezing seems purgable. However, tidal fever must be present to confirm exterior resolution and interior establishment. Continuous sweating of hands and feet confirms hardened stool, making Da Cheng Qi Tang (Great Order the Qi Decoction) the clear choice. If sweating is profuse but fever and aversion to cold persist, the exterior remains. If the fever is not tidal and sweating is not continuous on extremities, how can Cheng Qi Tang be used for purgation? Even with significant abdominal fullness and obstruction, only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) should be used for mild harmonization, avoiding severe purgation. Why? A slow pulse is not an indication for mandatory purgation; even with interior binding, is Da Cheng Qi Tang (Great Order the Qi Decoction) appropriate?
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In Yangming disease, with tidal fever and slightly hardened stool, Da Cheng Qi Tang (Great Order the Qi Decoction) may be given; if not hardened, it should not be given. If there has been no bowel movement for six or seven days and dry feces are suspected, the method to verify is to give a small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If, after the decoction enters the abdomen, flatus passes, this indicates dry feces are present, and purgation is permissible. If flatus does not pass, this indicates only initial hardness with subsequent looseness, and purgation is contraindicated; purging will cause abdominal fullness and inability to eat. Thirst for water results in hiccups upon drinking. If fever develops later, the stool will likely become hard again but in small quantity; treat with Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to harmonize. If flatus does not pass, absolutely do not purge.
[Note]
In Yangming disease, with tidal fever and slightly hardened stool, Da Cheng Qi Tang (Great Order the Qi Decoction) may be given; if not hardened, it should not be given. If there has been no bowel movement for six or seven days and dry feces are suspected, the verification method is to give a small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If flatus passes after ingestion, dry feces are present, and purgation is permissible. If flatus does not pass, this indicates only initial hardness with subsequent looseness, meaning dry feces have not yet formed, and purgation is contraindicated. Purging will cause cold qi to counterflow due to deficiency, leading to abdominal fullness and inability to eat. Thirst for water resulting in hiccups is also due to counterflow of deficient cold qi, preventing water transformation and downward transmission. If subsequent tidal fever persists, the stool will likely become hard again, but since purgation has already occurred, the amount expelled is small; treat with Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to harmonize. Therefore, for anyone taking Cheng Qi Tang who does not pass flatus, absolutely do not purge. This is Zhang Zhongjing's warning against light purgation.
[Ji Zhu - Collected Annotations]
Fang Youzhi stated: This explains tidal fever and passing flatus in sequence to decide the timing for purgation. Passing flatus refers to abnormal gas release. Abdominal fullness is an error caused by cold medicine. Hiccups are also caused by cold injuring the stomach. Hard stool in small quantity later is due to heavy purgation. The final sentence emphasizes caution.
Yu Chang stated: If qi in the abdomen still does not move, using Da Cheng Qi Tang (Great Order the Qi Decoction) is a major error, and even Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is incorrect.
Cheng Zhi stated: The previous article said: Exterior resolving, interior can be attacked. Exterior not resolved, do not give Cheng Qi Tang. Give Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to mildly harmonize stomach qi, avoid severe purgation. This article says: May give. Do not give. Then may purge, do not purge. Give small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). Use Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to harmonize, strictly do not purge. This reflects careful deliberation. Therefore, only when hands and feet sweat continuously and stool is dry/hard should Da Cheng Qi Tang (Great Order the Qi Decoction) be used. Using Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is still a method to mildly harmonize stomach qi.
Wang Hu stated: Passing flatus indicates hardened stool and severe dry-heat in the intestines, so qi does not disperse outward but turns and moves downward. Not passing flatus indicates that although there is heat in the intestines, the pores are not yet dry; this is only initial hardness with subsequent looseness.
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In Yangming disease, with delirium (Zhou Yu), tidal fever, and a slippery and rapid pulse, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) should govern. Administer one sheng of Cheng Qi Tang. If flatus passes in the abdomen, administer another sheng. If flatus does not pass, do not give more. If there is no bowel movement the next day and the pulse becomes faint and choppy, this indicates interior deficiency, which is difficult to treat, and Cheng Qi Tang should not be given again.
[Note]
In Yangming disease, delirium, tidal fever, and a slippery and rapid pulse are indications for purgation. However, without continuous sweating, frequent urination, and dry/hard/stool excess, sudden purgation is not appropriate. It is suitable to first test with one sheng of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If flatus passes, it indicates intestinal dry feces have hardened; the small dose was insufficient to immediately expel them, so the passed flatus is merely gas from the stool. Another sheng can be administered to promote defecation, which will naturally occur. If flatus does not pass, do not administer more. Wait until the next day; if there is still no bowel movement and the pulse remains slippery and rapid, administer again. Now, if the pulse becomes faint and choppy, it indicates interior deficiency and lack of qi to transport, making it difficult to treat, so Cheng Qi Tang should not be given again.
[Ji Zhu - Collected Annotations]
Fang Youzhi stated: Slippery pulse indicates food retention, hence a diagnosis of hardened stool. Rapid pulse indicates interior heat. Faint pulse indicates insufficient yang qi to transport. Choppy pulse indicates insufficient yin blood to moisten and transport. Thus, "Yang faint, do not purge; Blood absent, do not purge." This is what is meant.
Zhang Lu stated: This article shows slippery and rapid pulse with delirium and tidal fever, but without Pi-Man (stuffiness-fullness) excess syndrome. Only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) should be used for purgation. If the pulse becomes faint and choppy after purgation, the syndrome changes to interior deficiency, making it difficult to treat.
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In Shanghan (Cold Damage), if vomiting or purgation fails to resolve the condition, and there is no bowel movement for five or six days, extending to ten-plus days, with tidal fever at dusk, no aversion to cold, and solitary speech as if seeing ghosts. If severe, during attacks, the patient does not recognize people, grasps at clothes and bedrails, is terrified and uneasy, has slight wheezing and fixed gaze. If the pulse is string-taut (Xian), survival is possible; if choppy (Se), death is likely. If mild, with only fever and delirium, Da Cheng Qi Tang (Great Order the Qi Decoction) should govern. If one dose relieves symptoms, stop subsequent doses.
[Commentary]
Zhao Sizhen stated: *Huo Ren Shu* (Book of Living People) says: String-taut pulse is Yang, choppy pulse is Yin. Yang disease showing Yang pulse indicates survival. In Zhang Zhongjing's pulse methodology, Xian and Se belong to Yin, not Yang, raising doubt. Looking at the text "Pulse Xian indicates survival," the character "Xian" should be "Hua" (Slippery). If it were "Xian," a Yin-deficient pulse, how could it guarantee survival? Only Hua (Slippery) pulse is Yang and indicates life. Hua means flow, Se means blockage. Physics dictates flow is life, blockage is death. Reviewing the previous article "Slippery and rapid pulse, Xiao Cheng Qi Tang governs; faint and choppy pulse, interior deficiency, difficult to treat," further proves this error.
[Note]
In Shanghan (Cold Damage), after vomiting or purgation, fluids are depleted, exterior remains unresolved, and pathogens enter the interior. No bowel movement for five or six days, extending to ten-plus days, with tidal fever at dusk and no aversion to cold, indicates exterior pathogens have ceased and interior heat deepens. Da Cheng Qi Tang (Great Order the Qi Decoction) should still be used to sweep away residual pathogens and preserve yin fluids, ensuring recovery. If purgation is delayed, solitary speech as if seeing ghosts may occur. In severe cases, the patient does not recognize people, grasps at clothes and bedrails, is terrified and uneasy, has slight wheezing and fixed gaze, showing signs of extreme yang and deficient yin, lone yang without foundation, and disturbed spirit. At this moment, only diagnose the pulse: slippery indicates excess, purgation is viable, and survival is possible; choppy indicates deficiency, purgation is difficult, and death is likely. If the condition is mild, showing only tidal fever, delirium, and constipation without severe confusion, Da Cheng Qi Tang (Great Order the Qi Decoction) should be used for purgation. If one dose relieves symptoms, stop subsequent doses to avoid over-purgation.
[Commentary]
Grasping at clothes and bedrails is a critical sign. One perspective considers survivability based on uninhausted yin qi, e.g., Taiyang wind-strike transformed by fire therapy, grasping at clothes/bedrails, survival if urine is free, death if obstructed. Another perspective considers survivability based on extreme yang-heat being purgable, e.g., Yangming interior heat forming excess, grasping at clothes/bedrails, survival if pulse is slippery, death if choppy. Generally, this syndrome often arises after excessive sweating, vomiting, or purgation, causing great yang deficiency and loss of spirit. The Classics state: The four limbs are the root of all yang. Yang deficiency causes limb disturbance and loss of support; treat with Du Shen Tang (Single Ginseng Decoction). For profuse sweating, use Renshen Qitang (Ginseng and Astragalus Decoction). For cold extremities, use Shenfu Tang (Ginseng and Aconite Decoction). Many recover; one cannot generally attribute it to extreme yang exhaustion and yin depletion.
[Ji Zhu - Collected Annotations]
Yu Chang stated: This article discusses severe delirium. Within severe cases, two levels are distinguished: severe leads to death, mild leads to survival, hence purging with Da Cheng Qi Tang (Great Order the Qi Decoction).
Cheng Zhi stated: Lou Quanshan treated grasping at clothes/bedrails with tonification, achieving recovery due to deficient pulse and syndrome. Liu Shouzhen frequently used Cheng Qi formulas for febrile diseases. Although his methods originated from Zhang Zhongjing, his differentiation was not detailed enough, opening the door for later recklessness. Also, wheezing indicates qi attempting to escape upward; slight wheezing means pathogenic excess internally prevents severe wheezing. Not recognizing people and grasbing at bedrails indicates heart qi failing; terror and unease indicate liver qi failing; slight wheezing indicates lung qi failing; fixed gaze indicates kidney qi failing. As stated in *Neijing*, when all three yin and three yang meridians and five zang and six fu organs are diseased, and ying and wei qi do not circulate, and organs do not communicate, a choppy pulse indicates death.
Wang Hu stated: Tidal fever at dusk indicates severe fu-organ excess and dryness, occurring when the meridian qi is prosperous. Solitary speech is delirium. Patient speaking alone is delirium; solitary speech as if seeing ghosts is Yangming fu-excess with hallucinations; severe cases are critical. Cheng Wuji notes: Heat confuses righteous qi, causing unrecognized persons. Grasping at clothes/bedrails is yang-heat excess causing hand agitation. Terror and unease is stomach heat rushing to the diaphragm, disturbing the mind. Severe stomach heat causes qi counterflow and wheezing; fixed gaze indicates pathogen interfering with organs. Thus, the key to life and death must be determined by pulse diagnosis.
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In Yangming disease, originally with spontaneous sweating, if the doctor induces heavy sweating, the illness improves, but slight irritability and discomfort remain. This indicates the stool must be hardened. Due to fluid depletion and stomach dryness, the stool becomes hard. One should ask about daily urine frequency. If originally urinating three or four times a day, but only twice today, it is known that stool will be expelled soon. Now, with reduced urine frequency, fluids should return to the stomach, so it is known that stool will likely pass naturally soon.
[Note]
In Yangming disease, originally prone to spontaneous sweating, if the doctor mistakenly treats it as wind-pathogen and induces heavy sweating, the illness improves, but slight irritability and discomfort remain. This indicates the stool must be hardened. However, without pain or fullness, heavy sweating depleted fluids, causing stomach dryness and hardened stool, but there is no retained food. One should ask about daily urine frequency. If originally urinating three or four times a day, but only twice today, it is known that stool will be expelled soon. Since urine frequency decreases, fluids should return to the stomach, so it is known that stool will likely pass naturally soon, requiring no medication.
[Ji Zhu - Collected Annotations]
Fang Youzhi stated: When food and water enter the stomach, the essence becomes jin-yey (body fluids), and the coarse residue becomes dregs. Fluid essence seeps outside the intestines and stomach; the clear part becomes jin-yey, the turbid part exits as sweat externally or urine downwards. Therefore, excessive sweating or urination depletes jin-yey, causing the dreg-formed stool to become dry, hard, and difficult to pass. However, the two excretions are pathways for water and grain separation; if one flows, the other blocks, and vice versa. Reduced urine output means fluids return and stay in the stomach, ensuring the stool becomes moist and passes naturally.