【纲】仲景曰。阳明病。心下硬满者。不可攻之。攻之。利遂不止者死。利止者愈。
伤寒呕家。虽有阳明症。不可攻之。阳明病。自汗出。若发汗。小便自利。此为津液内竭。大
便虽硬。不可攻之。当须自欲大便。宜蜜煎导而通之。若土瓜根。及与大猪胆汁。皆可为导。
【目】张云岐曰。非阳明之本病不可下。阳明本病。胃家实也。非痞满燥实。不可下。非潮热
发渴。不可下。非詈骂亲疏。不可下。非脉沉数。不可下。非弃衣登高。目见鬼。不可下。
李 曰。可下者。脉症全在里也。若太早。若过。则水谷脱而变生焉。不可下者。诸虚咽肿。
呕吐厥逆。结胸。不转失气。脐中左右上下动气。脉浮细、浮虚、浮涩、带迟。恶寒等症。下之则危。随
宜以温热药救之。
【纲】仲景曰。阳明中风。口苦咽干。腹满微喘。发热恶寒。脉浮而紧。若下之。则腹满小便
难也。
【目】朱肱曰。脉浮不可下。脉虚不可下。恶寒不可下。呕吐不可下。小便清不可下。不转
失气不可下。大便坚小便数。不可用承气汤。（乃脾约丸症也）大便硬小便少者。不可攻。
柯琴曰。此中风伤寒。胃实转胃虚。初能食而致反不能食之机也。
【纲】仲景曰。阳明病。脉浮而紧。咽燥口苦。腹满而喘。发热汗出。不恶寒。反恶热。身
重。若下之。则胃中空虚。客气动膈。心中懊 。舌上胎者。栀子豉汤主之。
【目】朱肱曰。大抵伤寒最慎于下。若表未罢。不可乱投汤剂。虚其胃气。仲景云。表解而内
不消。非大满。犹生寒热。则病不除也。表已解而内不消。大满大实。坚有燥屎。乃可下之。虽四
五日不能为祸。若不宜下而攻之。内虚热入。协热遂利。烦躁。诸变不可胜数。轻者困。重者死。
古人所以伤寒有承气之戒。脉浮不可下。其病在表。宜发汗。下之则为懊 。为痞。为结胸。脉虚
细。不可下。恶寒不可下。以恶寒为表之虚。虽是阳明症。尚恶寒。即与太阳合病。属表。但可发
汗。少阴恶寒。当温之。呕吐者不可下。宜与小柴胡和解。不转失气不可下。与小柴胡。明日又不大便。
脉反微涩。里虚也。为难治。姑与黄 建中汤。
程郊倩曰。阳明中风。病在气分。故不可妄下。
【纲】仲景曰。发汗。若下之。而发烦热。胸中窒者。栀子豉汤主之。
【目】吴绶曰。凡有恶寒恶风者。凡腹满时减时满者。凡腹胀满可揉可按虚软者。凡阴虚劳倦
者。凡手足逆冷尺脉弱者。凡脉在表者。俱不可下。凡脉沉。不实不疾。按之无力者。凡亡血。虚
家。及妇人经水适来适断。热入血室。与夫胎前产后崩漏等症。及小便频数。小便清而大便秘者。
俱不可下也。
鳌按。此热伤君主。心气不足而然也。故不可下。
【纲】仲景曰。少阴病。饮食入口则吐。心中温温欲吐。复不能吐。始得之。手足寒。脉弦迟
者。此胸中实。不可下也。当吐之。
【目】魏荔彤曰。胸中实见不惟少阴寒邪为病。且兼痰饮积实于胸次为病也。邪在上。自当顺
其势而治之。不可下而可吐。
【纲】仲景曰。三阳合病。腹满身重。难以辗侧。口不仁而面垢。遗尿。发汗则谵语。下之。
则额上汗出。手足冷。若自汗出者。白虎汤主之。
【目】戴原礼曰。阳明下症悉具。其人喘嗽。或微恶寒。为太阳阳明。或往来寒热。为少阳阳
明。于阳明症中而有太阳少阳症。此非正阳明也。不可遽下。所以古注阳明有三。常须识此。
【纲】仲景曰。伤寒发汗已。身目为黄。所以然者。寒湿在里不解故也。不可下。于寒湿中求
之。
【目】鳌按。寒湿在里。与瘀热在里不同。且既由寒湿。则非属阳明病矣。故不可下。
【纲】仲景曰。阳明病。脉迟。微汗出。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 然而汗出者。此大便已硬也。大承气汤主之。若汗出。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。可与小承气微和胃气。勿令大泄下。
【目】黄仲理曰。阳明之为病。胃家实是也。谓之正阳阳明。属下症。轻则大柴胡。重则大小
承气。此邪自阳明经传入腑者。故可下。但亦有在经未入腑者。纵大满大实不通。亦不过小承气微
下之以和胃气。入胃在经。尤宜两审也。其阳明一症。少有自病者。多因太阳传入。兼与太阳阳明
合病。用葛根汤者是也。少阳阳明合病。用黄芩芍药汤者是也。自少阳传入阳明。及未合并病者亦
然。
鳌按。勿令大泄下者。以脉迟也。脉迟者。为无阳。为在脏也。故不可下。
【纲】仲景曰。脉浮而大。心下反硬。有热属脏者。攻之。不令发汗。属腑者。不令溲数。溲
数则大便硬。汗多则热愈。汗少则便难。脉迟尚未可攻。
【目】柯琴曰。脉迟。便非热实。是浮大皆为虚脉矣。仲景特出此句。正发明心下硬一症。有
无热属脏者为妄攻其热者戒也。
【总纲】张仲景说：阳明病，如果心下（胃脘部）感觉硬满的，不可使用攻下法。如果误用攻下法，导致腹泻不止的，预后不良，可能死亡；如果腹泻能自行停止的，则病情会痊愈。
患有呕吐症状的伤寒患者，即使出现阳明的证候，也不可使用攻下法。阳明病患者，如果自汗出，或者经过发汗治疗后，小便自然通畅，这说明体内的津液已经枯竭。此时虽然大便干硬，但不可使用攻下法。应当等待患者有便意时，适宜使用蜜煎导法来通便。也可以使用土瓜根，或者给予大猪胆汁作为导引剂。
【注释】张云岐说：只有符合阳明本病的证候才可攻下。阳明的本病是“胃家实”（胃肠燥热结实）。如果不是痞、满、燥、实四种证候具备，不可攻下；如果没有潮热和口渴，不可攻下；如果没有骂人不避亲疏的神志症状，不可攻下；如果脉象不是沉数有力，不可攻下；如果没有脱衣登高、看见鬼怪等狂躁症状，不可攻下。
李姓医家说：可以攻下的情况，其脉象和症状都完全在里。如果攻下过早或过度，会导致水谷精微耗脱而产生变证。不可以攻下的情况包括：各种虚证引起的咽肿、呕吐、四肢厥冷、结胸证、不转矢气、脐周上下左右动气、脉象浮细、浮虚、浮涩或带迟、恶寒等症状。如果对这些情况误用攻下法，会造成危险。此时应根据具体情况，用温热药进行救治。
【总纲】张仲景说：阳明中风，出现口苦、咽干、腹部胀满、轻微气喘、发热、恶寒、脉象浮而紧的症状。如果误用攻下法，会导致腹部胀满加重和小便困难。
【注释】朱肱说：脉象浮的不可攻下；脉象虚的不可攻下；恶寒的不可攻下；呕吐的不可攻下；小便清长的不可攻下；不转矢气的不可攻下。大便坚硬而小便频数的，不可使用承气汤（这属于脾约丸的证候）。大便硬而小便少的，不可攻下。
柯琴说：这是中风或伤寒导致胃实转化为胃虚，从起初能进食转变为不能进食的关键机制。
【总纲】张仲景说：阳明病，脉象浮而紧，咽燥口苦，腹部胀满且气喘，发热汗出，不恶寒反而恶热，身体沉重。如果误用攻下法，会导致胃中空虚，客气（邪气）扰动膈肌，心中烦闷懊恼，舌苔厚腻者，主治方剂为栀子豉汤。
【注释】朱肱说：大致上，治疗伤寒最谨慎于攻下法。如果表证未解，不可乱投汤剂，以免损伤胃气。张仲景说：表证解除后，如果内部仍有积滞但未达到“大满”的程度，仍然会产生寒热，病就不能去除。表证已解而内部积滞未消，出现大满大实、坚硬且有燥屎的情况，才可以攻下。即使病程已有四五天，只要不对症，也不会造成祸害。如果不该攻下而强行攻之，会导致内虚热入，协热下利，烦躁不安，各种变证不可胜数。轻者困顿，重者死亡。古人因此对伤寒使用承气汤有所告诫。脉象浮的不可攻下，因为病在表，适宜发汗。误下则会导致心中懊恼、痞证或结胸证。脉象虚细的不可攻下。恶寒的不可攻下，因为恶寒表示表虚，即使是阳明证，只要还恶寒，就属于与太阳合病，属表证，只可发汗。少阴病恶寒，应当温补。呕吐的不可攻下，适宜用小柴胡汤和解。不转矢气的不可攻下，可给予小柴胡汤。如果第二天仍不大便，脉象反而微弱涩滞，说明里虚，属于难治之症。暂且给予黄芪建中汤。
【总纲】张仲景说：经过发汗或攻下治疗后，出现心烦发热、胸中窒塞感的，主治方剂为栀子豉汤。
【注释】吴绶说：凡是有恶寒恶风症状的，凡是腹部胀满有时减轻有时加重的，凡是腹胀满可按揉且感觉虚软的，凡是阴虚劳倦的，凡是手足逆冷且尺脉弱的，凡是脉象在表的，都不可攻下。凡是脉象沉，不实不疾，按之无力的，凡是失血者、虚损之人，以及妇女月经适来或适断、热入血室，还有产前产后崩漏等症状，以及小便频数、小便清长而大便秘结的，都不可攻下。
沈金鳌按语：这是因为热邪损伤了君主（心），心气不足所致，所以不可攻下。
【总纲】张仲景说：少阴病，饮食入口即吐，心中感觉温温欲吐却又吐不出来。刚发病时，手足寒冷，脉象弦迟的，这是胸中有实邪，不可攻下，应当采用涌吐法。
【注释】魏荔彤说：胸中实邪不仅见于少阴寒邪致病，也兼有痰饮积实在胸中致病。邪气在上，自然应当顺应其势而治疗，不可攻下而应采用涌吐法。
【总纲】张仲景说：三阳合病，出现腹部胀满、身体沉重、难以翻身侧卧、口舌不知味而面部污垢、遗尿等症状。如果误用发汗法，会出现谵语；如果误用攻下法，会出现额头出汗、手足冰冷。如果是自汗出的，主治方剂为白虎汤。
【注释】戴原礼说：阳明证的攻下指征全部具备，但如果病人伴有喘嗽，或轻微恶寒，属于太阳阳明合病；或伴有往来寒热，属于少阳阳明合病。在阳明证中夹杂太阳和少阳的症状，这不是纯正的阳明病，不可急于攻下。所以古代注解说阳明有三种情况，必须认识这一点。
【总纲】张仲景说：伤寒经过发汗治疗后，身体和眼睛发黄。之所以这样，是因为寒湿在体内未能解除的缘故。不可攻下，应当在寒湿证中寻找治疗方法。
【注释】沈金鳌按语：寒湿在里，与瘀热在里不同。而且既然由寒湿引起，就不属于阳明病了，所以不可攻下。
【总纲】张仲景说：阳明病，脉象迟缓，微微汗出，不恶寒，身体必然沉重，短气，腹部胀满且气喘。如果有潮热的，说明表证即将解除，可以攻里。如果手足濈然汗出，说明大便已经干硬，主治方剂为大承气汤。如果汗出，伴有轻微发热恶寒的，说明表证未解。如果热势没有达到潮热的程度，不可给予承气汤。如果腹部显著胀满不通的，可以给予小承气汤轻微调和胃气，不要让它剧烈泻下。
【注释】黄仲理说：阳明病的本质是“胃家实”，称为正阳阳明，属于攻下证。轻症用大柴胡汤，重症用大、小承气汤。这是邪气从阳明经传入腑脏的情况，所以可以攻下。但也有邪气在经而未入腑的情况，即使是大满大实不通，也不过是用小承气汤轻微攻下以调和胃气。邪气在经或在胃，尤其需要仔细审察。阳明这一类病症，很少是自发的，多因太阳病传入，兼有太阳阳明合病，使用葛根汤的就是这种情况。少阳阳明合病，使用黄芩芍药汤的就是这种情况。从少阳传入阳明，以及尚未合并其他病的，也是如此。
沈金鳌按语：“勿令大泄下”的原因，是因为脉象迟缓。脉迟缓，表示阳气不足，病在脏，所以不可攻下。
【总纲】张仲景说：脉象浮而大，心下反而硬满，如果有热邪归属于脏的，可以攻之，但不要令其发汗；如果热邪归属于腑的，不要令其小便频数。小便频数则大便干硬。汗多则热势更盛，汗少则排便困难。脉象迟缓的，尚不可攻下。
【注释】柯琴说：脉象迟缓，就不是热实证，那么浮大的脉象都是虚脉了。张仲景特意提出这句话，正是为了阐明心下硬满这一症状，有无热邪归属脏腑的区别，以此警告那些妄图攻下热邪的错误做法。
[General Principle] Zhang Zhongjing stated: In Yangming disease, if there is hardness and fullness in the epigastrium (heart below), purgation must not be used. If purgation is mistakenly applied and diarrhea persists without stopping, the prognosis is poor and death may ensue; if the diarrhea stops spontaneously, the patient will recover.
In typhoid patients who suffer from vomiting, even if Yangming symptoms are present, purgation must not be used. In Yangming disease, if there is spontaneous sweating, or after diaphoresis treatment, urination occurs naturally, this indicates that body fluids (Jin Ye) are internally exhausted. Although the stool may be hard, purgation must not be used. One should wait for the patient's urge to defecate and use Honey Suppository (Mi Jian Dao) to facilitate passage. Alternatively, Trichosanthes root (Tugua Gen) or large pig bile can be used as suppositories.
[Commentary] Zhang Yunqi stated: Purgation is only indicated for the fundamental disease of Yangming. The fundamental disease of Yangming is "Stomach House Excess" (Wei Jia Shi - gastrointestinal dry-heat accumulation). Purgation is contraindicated unless Pi (stagnation), Man (fullness), Zao (dryness), and Shi (excess) syndromes are all present. It is contraindicated without tidal fever and thirst. It is contraindicated without manic behavior such as cursing relatives and strangers indiscriminately. It is contraindicated if the pulse is not deep and rapid. It is contraindicated without delirious behaviors like discarding clothes, climbing high, or seeing ghosts.
Li stated: Purgation is indicated when both pulse and symptoms indicate a interior syndrome. If purgation is too early or excessive, it leads to the depletion of water and grain essence and generates complications. Purgation is contraindicated in cases of various deficiency syndromes causing throat swelling, vomiting, cold limbs, Jie Xiong (chest binding), inability to pass flatus, pulsations around the umbilicus in any direction, floating-thin, floating-empty, floating-choppy, or slow pulses, and aversion to cold. Mistaken purgation in these cases is dangerous. Treatment should follow appropriate warming methods using warm-tonifying herbs.
[General Principle] Zhang Zhongjing stated: In Yangming wind-stroke, presenting with bitter taste in the mouth, dry throat, abdominal fullness, slight wheezing, fever, aversion to cold, and a floating-tight pulse, mistaken purgation will lead to worsened abdominal fullness and difficulty in urination.
[Commentary] Zhu Gong stated: Purgation is contraindicated with a floating pulse, a deficient pulse, aversion to cold, vomiting, clear urine, and inability to pass flatus. For hard stool with frequent urination, Chengqi Decoction is contraindicated (this belongs to Pi Yue Wan syndrome). For hard stool with scanty urination, purgation is contraindicated.
Ke Qin stated: This describes the mechanism where wind-stroke or typhoid transforms stomach excess into stomach deficiency, shifting from initial ability to eat to subsequent inability to eat.
[General Principle] Zhang Zhongjing stated: In Yangming disease, with a floating-tight pulse, dry throat, bitter taste, abdominal fullness with wheezing, fever, sweating, absence of aversion to cold but presence of aversion to heat, and heavy body, mistaken purgation leads to an empty stomach, disturbance of pathogenic qi in the diaphragm, mental restlessness and oppression (Ao Nu), and thick tongue coating. The primary formula is Gardenia and Fermented Soybean Decoction (Zhizi Chi Tang).
[Commentary] Zhu Gong stated: Generally, one must be most cautious regarding purgation in typhoid. If the exterior syndrome is not resolved, decoctions must not be administered recklessly to avoid damaging Stomach Qi. Zhang Zhongjing said: If the exterior is resolved but internal stagnation remains without reaching "great fullness," chills and fever will persist, and the disease will not be cured. Only when the exterior is resolved, internal stagnation is severe ("great fullness and excess"), and hard dry feces are present, can purgation be used. Even if four or five days have passed, inappropriate purgation causes no harm if correctly indicated. However, if purgation is used inappropriately, internal deficiency allows heat to enter, leading to heat-collateral diarrhea, irritability, and numerous complications. Mild cases become difficult; severe cases result in death. Hence, ancient texts warn against using Chengqi formulas in typhoid. Floating pulse indicates exterior syndrome, suitable for diaphoresis; mistaken purgation causes Ao Nu, Pi syndrome, or Jie Xiong. Deficient-thin pulse indicates contraindication for purgation. Aversion to cold indicates contraindication because it signifies exterior deficiency; even in Yangming disease, if aversion to cold persists, it involves Taiyang combination and belongs to the exterior, requiring only diaphoresis. Shaoyin disease with aversion to cold requires warming. Vomiting contraindicates purgation; Xiao Chai Hu Decoction is suitable for harmonization. Inability to pass flatus contraindicates purgation; Xiao Chai Hu Decoction may be given. If constipation persists the next day with a weak-choppy pulse, it indicates interior deficiency and is difficult to treat; temporarily provide Huangqi Jianzhong Decoction.
Cheng Jiaoqian stated: Yangming wind-stroke affects the Qi level, so reckless purgation is contraindicated.
[General Principle] Zhang Zhongjing stated: After diaphoresis or purgation, if vexation and heat appear with chest oppression, the primary formula is Gardenia and Fermented Soybean Decoction (Zhizi Chi Tang).
[Commentary] Wu Shou stated: Cases with aversion to cold or wind, intermittent abdominal fullness, soft abdominal distension palpable on pressure, yin deficiency with fatigue, cold limbs with weak chi pulse, superficial pulse, deep pulse that is neither solid nor rapid and weak upon pressure, blood loss, deficiency constitutions, women with irregular menstruation, heat entering the blood chamber, pre/post-partum metrorrhagia, frequent urination, clear urine with constipation—all contraindicate purgation.
Shen Jin'ao noted: This results from heat injuring the Monarch (Heart) and insufficient Heart Qi, thus purgation is contraindicated.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease, if food is vomited immediately upon entry, there is a sensation of warmth and urge to vomit but inability to do so. At onset, with cold limbs and a string-tight slow pulse, this indicates excess in the chest. Purgation is contraindicated; emesis (vomiting therapy) should be used.
[Commentary] Wei Litong stated: Chest excess is seen not only in Shaoyin cold pathogen disease but also in diseases involving phlegm-fluid retention and accumulation in the chest. Since the pathogen is superior, treatment should follow its upward trend; purgation is contraindicated while emesis is indicated.
[General Principle] Zhang Zhongjing stated: In combined disease of the three yangs, presenting with abdominal fullness, body heaviness, difficulty turning over, insensitivity of the mouth and face, and urinary incontinence, mistaken diaphoresis leads to delirium; mistaken purgation leads to sweating on the forehead and cold limbs. If there is spontaneous sweating, the primary formula is White Tiger Decoction (Baihu Tang).
[Commentary] Dai Yuanli stated: When all Yangming purgation indications are present, but accompanied by wheezing/cough or slight aversion to cold, it is Taiyang-Yangming combined disease; or with alternating chills and fever, it is Shaoyang-Yangming combined disease. Yangming disease with Taiyang and Shaoyang symptoms is not pure Yangming disease and should not be hastily purged. Ancient commentaries mention three types of Yangming; this distinction must be recognized.
[General Principle] Zhang Zhongjing stated: After diaphoresis in typhoid, if the body and eyes turn yellow, it is because cold-dampness remains unresolved internally. Purgation is contraindicated; treatment should seek methods for cold-dampness.
[Commentary] Shen Jin'ao noted: Cold-dampness in the interior differs from blood stasis-heat in the interior. Furthermore, since it arises from cold-dampness, it does not belong to Yangming disease, thus purgation is contraindicated.
[General Principle] Zhang Zhongjing stated: In Yangming disease, with a slow pulse, slight sweating, absence of aversion to cold, inevitable body heaviness, shortness of breath, abdominal fullness with wheezing, and tidal fever, the exterior is resolving, and interior purgation is permissible. If hands and feet sweat continuously, stool is hardened, and the primary formula is Da Chengqi Decoction. If sweating occurs with slight fever and aversion to cold, the exterior is unresolved. Without tidal fever, Chengqi Decoction is contraindicated. If abdominal distension and obstruction are significant, Xiao Chengqi Decoction may be used to mildly harmonize Stomach Qi, avoiding drastic purgation.
[Commentary] Huang Zhongli stated: Yangming disease is defined by "Stomach House Excess," termed Zheng Yang Yangming, belonging to purgation syndromes. Mild cases use Da Chaihu Decoction; severe cases use Da or Xiao Chengqi Decoctions. This applies when pathogen transmits from Yangming channel to fu organs, allowing purgation. However, if pathogen remains in the channel without entering the fu organ, even with great fullness and obstruction, only Xiao Chengqi Decoction should be used mildly to harmonize Stomach Qi. Pathogen in the channel or stomach requires careful examination. Yangming disease rarely occurs spontaneously; it often transmits from Taiyang, forming Taiyang-Yangming combined disease treated with Gegen Decoction. Shaoyang-Yangming combined disease is treated with Huangqin Shaoyao Decoction. Transmission from Shaoyang to Yangming or uncombined cases follow similar principles.
Shen Jin'ao noted: "Avoid drastic purgation" is due to the slow pulse. A slow pulse indicates lack of Yang and involvement of zang organs, thus purgation is contraindicated.
[General Principle] Zhang Zhongjing stated: With a floating-large pulse and paradoxical hardness in the epigastrium, if heat belongs to the zang organ, attack it but do not induce sweating; if heat belongs to the fu organ, do not allow frequent urination. Frequent urination leads to hard stool. Excessive sweating increases heat; scanty sweating leads to difficult defecation. If the pulse is slow, attack is not yet permissible.
[Commentary] Ke Qin stated: A slow pulse indicates it is not a heat-excess syndrome; thus, floating-large pulses are deficiency pulses. Zhang Zhongjing highlights this sentence to clarify that epigastric hardness varies by presence or absence of heat-zang involvement, warning against reckless purgation of heat.