大黄（四两，酒浸） 浓朴（半升，姜汤炒） 枳实（五枚，麸炒） 芒硝（三合）
伤寒，阳邪入里，痞、满、燥、实、坚全俱者，急以此方主之。
调胃承气汤不用枳、朴者，以其不作痞、满，用之恐伤上焦虚无氤氲之元气也。小承气
汤不用芒硝者，以其实而未坚，用之恐伤下焦血分之真阴，谓不伐其根也，此则上、中、下
三焦皆病，痞、满、燥、实、坚皆全，故主此方以治之。浓朴苦温以去痞，枳实苦寒以泄满，
芒硝咸寒以润燥软坚，大黄苦寒以泄实去热。虽然，仲景言急下之证，亦有数条。如少阴属
肾水，病则口燥舌干而渴，乃热邪内炎，肾水将绝，宜急下之，以救将绝之水。又如腹胀不
大便，土胜水也，宜急下之；阳明属土，汗出热盛，急下以存津液；腹满痛者，为土实，急
当下之；热病，目不明，热不已者死。此肾水将竭，不能照物，则已危矣，须急下之，此皆
大承气证也。若病未危急而早下之，或虽危急而下药过之，则又有寒中之患。寒中者，急温
之，宜与理中汤。
桃仁（五十枚，去皮尖） 桂枝（二两，洗净，妊娠用炒） 大黄（四两，酒浸） 芒
硝（二
伤寒，外证已解，小腹急，大便黑，小便利，其人如狂者，有蓄血也，此方主之。
无头痛、发热恶寒者，为外证已解。小腹急者，邪在下焦也；大便黑者，瘀血渍之也；
小便利者，血病而气不病也。上焦主阳，下焦主阴。阳邪居上焦者，名曰重阳，重阳则狂。
今瘀热客于下焦，下焦不行，则干上部清阳之分，而天君弗宁矣，故其证如狂。桃仁，润物
也，能泽肠而滑血；大黄，行药也，能推陈而致新；芒硝，咸物也，能软坚而润燥；甘草，
平剂也，能调胃而和中；桂枝，辛物也，能利血而行滞。又曰∶血寒则止，血热则行。桂枝
之辛热，君以桃仁、硝、黄，则入血而助下行之性矣，斯其制方之意乎！
Da Huang (Rhei Radix et Rhizoma, 4 liang, soaked in wine) Hou Po (Magnoliae Officinalis Cortex, half sheng, stir-fried with ginger juice) Zhi Shi (Aurantii Fructus Immaturus, 5 pieces, stir-fried with bran) Mang Xiao (Natrii Sulfas, 3 he)
In Shaoyang disease (Shaoyang syndrome), when yang pathogenic factors penetrate inward and symptoms of pi (stagnation/fullness sensation), man (distension), zao (dryness), shi (excess/firmness), and jian (hardness) are all fully present, this formula should be urgently administered as the primary treatment.
Tiaowei Chengqi Tang (Regulate the Stomach and Bear Down Decoction) does not use Zhi Shi or Hou Po because these symptoms of pi and man are not produced; using them might damage the ethereal primordial qi (Yunyuan Zhi Yuanqi) of the Upper Jiao (Upper Burner). Xiaochengqi Tang (Minor Bear Down Decoction) does not use Mang Xiao because the excess is firm but not yet hard; using it might damage the true yin (Zhenyin) of the blood aspect in the Lower Jiao (Lower Burner), which is referred to as "not felling the root." In contrast, the condition treated by this formula involves pathology in the Upper, Middle, and Lower Jiao, with all symptoms of pi, man, zao, shi, and jian fully present; therefore, this formula is used as the main treatment. Hou Po, being bitter and warm, eliminates pi; Zhi Shi, being bitter and cold, drains man; Mang Xiao, being salty and cold, moistens dryness and softens hardness; Da Huang, being bitter and cold, drains excess and clears heat.
Nevertheless, Zhang Zhongjing mentions several conditions requiring urgent purgation. For instance, Shaoyin disease (Shaoyin syndrome) belongs to Kidney Water. When diseased, it presents with dry mouth, dry tongue, and thirst, indicating internal flaming of heat pathogens and impending exhaustion of Kidney Water; urgent purgation is indicated to save the nearly exhausted water. Similarly, abdominal distension with constipation indicates Earth overcoming Water; urgent purgation is indicated. Yangming disease (Yangming syndrome) belongs to Earth; profuse sweating with intense heat requires urgent purgation to preserve body fluids. Abdominal fullness and pain indicate Earth excess, requiring urgent purgation. In febrile diseases, if vision is unclear and heat persists without abating, death ensues. This signifies that Kidney Water is nearly exhausted and cannot reflect objects, a critical state requiring urgent purgation. All these constitute indications for Dachengqi Tang (Major Bear Down Decoction). However, if purgation is performed prematurely when the condition is not critical, or if the dosage is excessive even when critical, complications of Cold-Middle (Han Zhong) may arise. Cold-Middle should be urgently warmed with Lizhong Tang (Regulate the Middle Decoction).
Tao Ren (Persicae Semen, 50 pieces, skin and tip removed) Guizhi (Cinnamomi Ramulus, 2 liang, washed clean; stir-fried for pregnant women) Da Huang (Rhei Radix et Rhizoma, 4 liang, soaked in wine) Mang Xiao (Natrii Sulfas, 2 he)
In Shaoyang disease, when external syndromes have resolved, there is urgency in the lower abdomen, black stools, free urination, and the patient exhibits a manic-like state (ru kuang); this indicates Blood Stasis (Xu Xue), and this formula is the primary treatment.
The absence of headache, fever, and aversion to cold indicates that external syndromes have resolved. Urgency in the lower abdomen indicates pathogenic factors in the Lower Jiao. Black stools indicate infiltration by blood stasis. Free urination indicates pathology in the blood aspect while the qi aspect remains unaffected. The Upper Jiao governs Yang, and the Lower Jiao governs Yin. When Yang pathogens reside in the Upper Jiao, it is called "Double Yang" (Chong Yang), leading to mania due to Double Yang. Currently, stasis-heat lodges in the Lower Jiao; when the Lower Jiao fails to circulate properly, it interferes with the clear Yang portion of the upper body, causing the Heavenly Ruler (Heart/Mind) to be unsettled, hence the symptom resembling mania. Tao Ren is a moistening substance that nourishes the intestines and lubricates blood; Da Huang is an active agent that pushes out the old and brings forth the new; Mang Xiao is a salty substance that softens hardness and moistens dryness; Gan Cao (Licorice Root) is a neutralizing agent that harmonizes the stomach and middle; Guizhi is a pungent substance that promotes blood circulation and moves stagnation. It is said: "Cold in blood causes stagnation, heat in blood causes movement." The pungent and hot nature of Guizhi, combined with Tao Ren, Mang Xiao, and Da Huang, enters the blood aspect and assists the descending action, which is the intent behind this prescription's formulation!