【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】朱肱曰。伤寒固有始得病。便变阳盛之症。须便下之。又有腠理寒。一二日便成少阴病
者。须急温之。阳明里症者。内热是也。宜下之。伤寒始发热。恶寒。今汗后不恶寒。但倍发热而
躁。始脉浮大。今脉洪实。或沉细数。始惺静。今狂语。此为胃实阳盛。再汗即死。须下即愈。更
有心胸连脐腹大段疰闷。腹中疼。坐卧不安。冒闷喘急极者。亦不候他症。便下之。但大便妨闷。
恐尚有表症者。亦须少少与小承气汤微解之。不可过多。令大泄也。
失下。则气血不通。四肢便厥。医人不知。反疑是阴厥。进热药。祸如反掌。不可不察。
问。三阴有可下者乎。三阴大约可温。然须有积症方可也。何谓积症。太阴腹满时痛。桂枝加
芍药汤。甚者桂枝加大黄汤。少阴口燥咽干。或腹满不大便。或下利清谷。心下痛。皆积症也。下
症悉具。服汤已更衣者。止后服。不尔。尽剂与之。
王肯堂曰。大法秋宜下。凡可下者。用汤胜丸散。中病便止。不必尽剂也。
【纲】仲景曰。病患烦热。汗出则解。又如疟状。日晡所发热者。属阳明也。脉实者。宜下之。
与承气汤。
【目】王好古曰。大承气。治大实大满。满则胸腹填胀。状若合瓦。大实则不大便也。痞满燥
实四症俱备。则用之。杂病
则进退用之。小承气。治痞实而微满。状若饥人食饱饭。腹中无转失气。心下痞。大便或通。热甚。
须可下。宜此方。调胃承气。治实而不满者。腹如仰瓦。腹中有转失气。有燥屎。不大便而谵语
坚实之症。以上三法不可瘥。假令调胃承气症。用大承气下之。则愈后元气不复。以其气药犯之也。
大承气症。用调胃承气下之。则愈后神痴不清。以其无气药也。小承气症。用芒硝下之。则或利
不止。变而成虚矣。又曰。伤寒外症。全是下症。而脉反细不可下者。泻心汤主之。脉有力者。黄连
泻心汤。无力者。半夏泻心汤。
鳌按。承气症甚多。不全采录。单有急下之。急攻之字样者。录之。盖以着此字样者。皆有急
当攻下之故。其余承气症。未尽若是也。
【纲】仲景曰。得病二三日。脉弱。无太阳柴胡症。烦躁。心下硬。至四五日。虽能食。以小承
气少少与微和之。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
头硬。后必溏。未定成硬。攻之必溏。须小便利。屎定硬。乃可攻之。宜大承气汤。
【目】吴绶曰。经言太阳病。发热汗出不解。其人蒸蒸热者。属胃也。调胃承气汤。凡潮热腹
满者。大柴胡加浓朴。凡阳明病汗多。胃中必燥。大便必硬。硬则谵语。小承气汤。若谵语脉滑而
疾。发潮热者。大柴胡汤。凡谵语潮热不食者。胃中必有燥屎五六枚。小承气汤。若能食大便硬者。
大承气汤。
【纲】仲景曰。汗出。谵语者。以有燥屎在胃中。此为风也。须下之。过经乃可下之。下之若
早。语言必乱。表虚里实故也。下之则愈。宜大承气汤。
【目】成无己曰。胃实不大便。或难或硬。燥屎悉属里症。宜下者多矣。然而有表未解。风湿
相搏。尤宜先解表已而下之。可也。如经言不大便六七日。头痛有热者。小便清和。不在表仍在里
是也。其症多见于阳明。盖胃土万物所归。无
所复传。自太少阳传入者。众所共知。而于三阴传入者。鲜或能识。若能熟视其微。则三阴有急下之
症多矣。岂非仲景之微意欤。
陶华曰。有宜急下者两症。少阴症口燥咽干。谓之肾汁干。宜急下。阳明症发热汗多。谓之胃
汁干。亦宜急下。此所谓急下两症也。
汪昂曰。少阴病。得之二三日。口燥咽干者。急下之。邪入未深。便作口燥。此肾水将干。宜
急下以救欲绝之本。少阴病。六七日。腹胀。不大便者。急下之。此少阴邪热入胃腑也。土胜则水
干。宜急下以救肾水。少阴病。自利清水。色纯青。心中必痛。口中燥者。急下。青为肝色。肝邪
乘肾。故下利。阳邪上攻。故口燥。此亦少阴传入阳明腑病也。厥阴症。舌卷囊缩。宜急下之。此
症仲景无治法。按舌卷囊缩。有寒极者。宜附子四逆加吴萸。并灸关元气海。或葱熨法。又有阳明
之热。陷入厥阴经。阳明主润宗筋。宗筋为热所攻。弗荣而急。引舌与睾丸。故舌卷囊缩。此为热
极。当泻阳以救阴。以上皆大承气症也。张兼善曰。胃为水谷之海。四旁有病。皆能传入胃土。燥
则肾水干。故阳明与少阴。皆有急下之症。症虽不同。其入腑之理则一。故皆用大承气。有病循衣
摸床撮空者。此胃热也。钱仲阳小儿直诀云。此肝热也。亦承气汤主之。
王肯堂曰。胃家实不大便。虽三尺之童。亦知可下也。殊不知仲景之法。虽有胃实症。若表未
解。及有半表者。亦先用桂枝、柴胡以解外。然后视虚实消息之可也。凡胃家不大便等症。其或
胃实有表者。必先解表。其或口苦咽干脉浮紧者。宜和解。其或便硬无所苦者。且候之。其或胃实
表解有症者。急随症攻之。其或胃实表解无症者。忌攻。大便硬者导之。盖以阳明病。身汗出。若发
汗。小便自利者。此津液内竭。虽硬不可攻之。当须自欲大便时。蜜导之。
鳌按。王氏有症攻之。无症忌攻云者。症即阳明实症。如潮热谵语是也。有此等症。方可攻。无此
等症。虽不大便。皆由津液不足。当须详审。勿妄攻也。
经言过经乃可下者。言已过七日。行经已尽。此时阳邪入阴。乃可下也。
【纲】仲景曰。阳明病。下之。心中懊 而烦。胃中有燥屎者。可攻之。宜大承气汤。腹微满。
初头硬。后必溏。不可攻之。
【目】李 曰。里症具而脉沉实者。宜下。若下后热不退。脉未和者。犹当量虚实再下。若失
下。则邪无从出。又或应下而反汗之。则津液内竭。变为动悸等症。
鳌按。腹大满不通。是胃中燥屎上攻也。故可攻。
【纲】仲景曰。脉滑而数者。有宿食也。宜大承气汤。腹满不减。减不足言。当下之。宜大承
气汤。发汗不解。腹满痛者。急下之。宜大承气汤。阳明病。发热。汗多者。急下之。宜大承气汤。
【目】鳌按。数为在腑。故滑而数。为有食。为当下之症。二条。腹满如故。乃下之。虽当减
而未尽。故更当下也。三条。表虽未解而邪甚于里。故当急攻。四条。汗多亡阳。又当急下以存津
液。
【纲】仲景曰。伤寒六七日。目中不了了。睛不和。无表里症。大便难。身热者。此为热也。
急下之。宜大承气汤。
【目】李 曰。伤寒热气入脏。流于少阴之经。咽焦。口燥渴。肾水干也。热病热不已。目睛
不和。亦肾水干也。皆急下以救肾水。阳明发热汗多。或已汗不解。腹满痛。及谵狂。不大便者。
皆急下以存胃液。伤寒脉弦而迟。弦为寒。迟为脏。脉大而紧。大为阳。紧为寒。俱谓之阳中伏阴。
急下以分阴阳。又下利。旦部脉平。心下硬者。内实也。下利脉迟而滑。或浮大。按之反涩。恶食
者。皆胃有宿食也。但宿食忌巴豆。只宜用大黄荡涤。
刘完素曰。下后热不退。再下之。热愈盛。脉微。气虚。力弱。不加以法。则无可生之理。若
辍而不下。则邪热极盛。阴气极衰。脉息断绝。必不可救。如此之症。下亦死。不下亦死。
经云。三下而热不退者死。后人有三四次。至十数次而生者。此乃偶中。不可为法。但用解毒
汤合凉膈散调之。庶不失人命。
汗下后热不退。不问有汗无汗。宜白虎加人参、苍
术以解之。
陶华曰。凡言急下者。盖病热已迫。将有变也。非若他病。尚可稍缓。
【总纲】张仲景说：脉象浮而大，心窝部反而坚硬，有热邪内结于脏的，应当用攻下法，不要发汗。热邪属于腑的，不要使小便频数。小便频数就会导致大便干硬。汗出多则热势更盛，汗出少则排便困难。脉象迟缓的，暂时还不可以攻下。
【细目】朱肱说：伤寒病中，确实有刚得病就转变为阳热亢盛症状的，必须立即攻下。也有因腠理受寒，一两天就变成少阴病的，必须紧急温补。阳明里证，就是体内发热，适宜用攻下法。伤寒开始发热、恶寒，现在发汗后不再恶寒，只是发热更加严重且烦躁，起初脉象浮大，现在脉象洪实，或者沉细数，起初神志清醒安静，现在胡言乱语，这是胃气实、阳气亢盛的表现。再发汗就会致死，必须攻下才能痊愈。还有心胸连及脐腹部严重胀闷，腹中疼痛，坐卧不安，头昏闷、气喘急促到极点的情况，也不等待其他症状出现，直接攻下。但如果只是大便不畅闷塞，担心还有表证的，也只需少量给予小承气汤轻微疏通即可，不可过多，导致剧烈腹泻。
如果该攻下而未攻下，气血就会不通畅，四肢就会厥冷。医生不知道这一点，反而怀疑是阴寒厥逆，进服热性药物，灾祸就在顷刻之间，不可不仔细辨别。
问：三阴病中有可以攻下的吗？三阴病大体上适宜温补，但必须有积滞症状才可以攻下。什么是积滞症状？太阴病腹部胀满、时而疼痛，用桂枝加芍药汤；严重的用桂枝加大黄汤。少阴病口燥咽干，或者腹部胀满不大便，或者下利清谷（泻下未消化的食物），心窝部疼痛，都是积滞症状。如果下证全部具备，服药后大便通畅的，停止服用后面的药；如果不通，就把整剂药服完。
王肯堂说：一般原则是秋季适宜攻下。凡是可下的病症，用汤剂胜过丸剂和散剂。药力到达病处就停止，不必服完整个剂量。
【总纲】张仲景说：病人烦热，出汗后缓解，又像疟疾一样发作，每天傍晚发热的，属于阳明病。脉象实的，适宜攻下，给予承气汤。
【细目】王好古说：大承气汤，治疗大实大满之证。“满”指胸腹填塞胀满，形状像合在一起的瓦片；“大实”指不大便。痞、满、燥、实四种症状都具备，才使用它。治疗杂病时，根据病情进退使用。小承气汤，治疗痞实而轻微胀满，感觉像饥饿的人吃饱了饭，腹中没有排气，心下痞塞，大便有时通畅，热势很重，需要攻下的，适宜用此方。调胃承气汤，治疗实而不满的，腹部像仰放的瓦片，腹中有排气，有燥屎，不大便且胡言乱语等坚实症状。以上三种方法不能混淆。假如是调胃承气汤证，却用大承气汤攻下，那么病愈后元气无法恢复，因为其中含有行气药损伤了正气。如果是大承气汤证，却用调胃承气汤攻下，那么病愈后神志痴呆不清醒，因为缺乏行气药。如果是小承气汤证，却用芒硝攻下，那么可能导致腹泻不止，转变为虚证。又说：伤寒外症，全是下证，但脉象反而细弱不可攻下的，用泻心汤主治。脉有力的，用黄连泻心汤；脉无力的，用半夏泻心汤。
沈金鳌按：承气汤证很多，这里不全收录，只摘录有“急下”、“急攻”字样的条文。大概是因为标有这些字样的，都有急需攻下的原因。其余承气汤证，并不都像这样紧急。
【总纲】张仲景说：得病二三天，脉象弱，没有太阳病和柴胡汤证，烦躁，心窝部坚硬，到了四五天，虽然能吃饭，也要少量给予小承气汤轻微调和，使其稍微安宁。到了六天，给予承气汤一升。如果不大便，六七天小便少的，虽然不能吃饭，但大便开头硬，后面一定稀溏，尚未完全成硬块，攻下必然导致腹泻。必须等到小便通利，大便确定变硬，才可以攻下，适宜用大承气汤。
【细目】吴绶说：经文说太阳病，发热汗出不解，其人蒸蒸发热的，属于胃家实证，用调胃承气汤。凡是潮热、腹部胀满的，用大柴胡汤加厚朴。凡是阳明病汗多，胃中必定干燥，大便必定硬，硬了就会胡言乱语，用小承气汤。如果胡言乱语，脉滑而快，发潮热的，用大柴胡汤。凡是胡言乱语、潮热、不能进食的，胃中一定有燥屎五六枚，用小承气汤。如果能吃饭、大便硬的，用大承气汤。
【总纲】张仲景说：出汗，胡言乱语的，是因为胃中有燥屎，这是风邪所致。必须攻下。但要过了经界之后才可以攻下。攻下如果过早，语言必定错乱，这是因为表虚里实的缘故。攻下后就会痊愈，适宜用大承气汤。
【细目】成无己说：胃实不大便，或者难解或者干硬，燥屎都属于里证，适宜攻下的情况很多了。然而如果有表证未解，风湿相搏，尤其应该先解表然后再攻下。如经文所说不大便六七天，头痛有热的，小便清长平和，说明病不在表仍在里，这种情况多见于阳明病。因为胃土是万物所归，无所复传。从太阳、少阳传入的，大家共知，而从三阴传入的，很少人能识别。如果能仔细观察其细微之处，那么三阴病也有许多急下证，这难道不是张仲景的微意吗？
陶华说：有适宜急下的两种症状。少阴病口燥咽干，称为肾汁干枯，适宜急下。阳明病发热汗多，称为胃汁干枯，也适宜急下。这就是所说的急下两症。
汪昂说：少阴病，得病二三天，口燥咽干的，急下之。邪气入体未深，就出现口燥，这是肾水将要干枯，宜急下以挽救将绝的根本。少阴病，六七天，腹胀，不大便的，急下之。这是少阴邪热传入胃腑。土胜则水干，宜急下以救肾水。少阴病，自利清水，颜色纯青，心中必定痛，口中干燥的，急下。青色为肝色，肝邪乘袭肾脏，所以下利。阳邪上攻，所以口燥。这也是少阴传入阳明腑病。厥阴病，舌卷缩、睾丸收缩，宜急下之。此症张仲景没有治法，按舌卷囊缩，有寒极的，宜用附子四逆汤加吴茱萸，并灸关元、气海穴，或用葱熨法。又有阳明热邪陷入厥阴经的，阳明主润宗筋，宗筋被热邪攻击，不能荣养而拘急，牵引舌头和睾丸，所以舌卷囊缩。此为热极，当泻阳以救阴。以上都是大承气汤证。张兼善说：胃是水谷之海，四周有病，都能传入胃土。燥则肾水干，所以阳明与少阴，都有急下证。症状虽然不同，其入腑的道理是一样的，所以都用大承气汤。有病见循衣摸床、撮空理的，这是胃热。钱仲阳《小儿直诀》说，这是肝热，也用承气汤主治。
王肯堂说：胃家实、不大便，即使是三岁小孩，也知道可以攻下。殊不知张仲景的法度，虽然有胃实症，如果表证未解，以及有半表半里证的，也先用桂枝汤、柴胡汤来解外，然后视虚实斟酌处理。凡是胃家不大便等症状，如果胃实而有表证的，必须先解表；如果口苦咽干脉浮紧的，宜和解；如果大便硬而没有痛苦的，暂且观察；如果胃实、表解且有症的，急随症攻之；如果胃实、表解而无症的，忌攻。大便硬的用导法。因为阳明病，身体出汗，如果再发汗，小便自利的，这是津液内竭，虽然大便硬也不可攻下。应当等到患者想大便时，用蜜导法。
沈金鳌按：王氏说“有症攻之，无症忌攻”，这里的“症”即阳明实症，如潮热、谵语等。有此等症，方可攻下。无此等症，虽不大便，都是由津液不足引起的，应当详细审察，不要妄用攻下。
经文说“过经乃可下”，意思是已过七日，行经已尽，此时阳邪入阴，才可攻下。
【总纲】张仲景说：阳明病，攻下后，心中懊恼而烦，胃中有燥屎的，可攻下，适宜用大承气汤。腹部微满，开头硬，后面一定稀溏的，不可攻下。
【细目】李梴说：里证具备而脉象沉实的，宜攻下。如果攻下后热不退，脉象不和的，还应当衡量虚实再次攻下。如果失于攻下，则邪气无处排出。又或者应当攻下反而发汗的，则津液内竭，变为动悸等症状。
【总纲】张仲景说：脉象滑而数的，有宿食，适宜用大承气汤。腹部胀满不减，即使减轻也不足挂齿的，当下之，适宜用大承气汤。发汗后病不解，腹部胀痛的，急下之，适宜用大承气汤。阳明病，发热，汗多的，急下之，适宜用大承气汤。
【细目】沈金鳌按：数为在腑，所以滑而数是有食积，是当下之症。第二条，腹部胀满如故，是下之，虽然减轻但未除尽，所以更要攻下。第三条，表证虽未解但邪气甚于里，所以当急攻。第四条，汗多亡阳，又当急下以保存津液。
【总纲】张仲景说：伤寒六七天，眼睛看不清楚，眼球转动不灵活，没有表里证，大便难，身体热的，这是热邪内结，急下之，适宜用大承气汤。
【细目】李梴说：伤寒热气入脏，流于少阴经，咽喉焦枯，口燥渴，是肾水干枯。热病热势不退，眼睛不和，也是肾水干枯。都需急下以救肾水。阳明发热汗多，或者已经发汗但热不解，腹部胀满痛，以及谵语狂躁，不大便的，都需急下以存胃液。伤寒脉弦而迟，弦为寒，迟为脏病；脉大而紧，大为阳，紧为寒，都称为阳中伏阴，急下以分阴阳。又如下利，早晨脉平，心窝部坚硬的，是内实。下利脉迟而滑，或浮大，按之反涩，厌恶食物的，都是胃有宿食。但宿食忌用巴豆，只宜用大黄荡涤。
刘完素说：攻下后热不退，再攻下，热势更盛，脉微，气虚，力弱，不加以恰当方法，就没有生存的道理。如果停止攻下，则邪热极盛，阴气极衰，脉息断绝，必不可救。这样的病症，攻下也死，不攻下也死。经文说：“三次攻下而热不退者死。”后人有三四次，甚至十几次而活的，这只是偶然中的，不能作为法则。但用解毒汤合凉膈散调理，或许不失人命。
发汗攻下后热不退，不问有汗无汗，宜用白虎加人参汤、苍术以解之。
陶华说：凡说急下的，是因为病热已经逼迫，将有变化发生。不像其他病，还可以稍作缓和。
[General Principle] Zhang Zhongjing stated: When the pulse is floating and large, and the epigastrium is conversely hard, if heat belongs to the Zang organs, attack it with purgation; do not induce sweating. If heat belongs to the Fu organs, do not cause frequent urination. Frequent urination leads to hard stools. Excessive sweating intensifies heat, while insufficient sweating makes defecation difficult. If the pulse is slow, purgation should not yet be performed.
[Detailed Commentary] Zhu Gong said: In Shanghan (Cold Damage) disease, there are indeed cases where Yang-excess symptoms appear immediately upon onset, requiring immediate purgation. There are also cases where cold in the interstices transforms into Shaoyin disease within one or two days, requiring urgent warming. Yangming interior syndrome refers to internal heat, which is suitable for purgation. In Shanghan, initially presenting with fever and aversion to cold, after sweating, if aversion to cold ceases but fever increases significantly accompanied by irritability, and the pulse changes from initially floating and large to now surging and solid, or deep, thin, and rapid; if the patient changes from being alert and quiet to delirious speech, this indicates Stomach excess and Yang hyperactivity. Another sweat will cause death; purgation is required for recovery. Additionally, in cases of severe distension and oppression connecting the chest, heart, umbilicus, and abdomen, abdominal pain, restlessness in sitting and lying, extreme dizziness, oppression, and panting, purgation should be administered without waiting for other symptoms. However, if there is only difficulty and oppression in defecation, suspecting residual exterior syndrome, administer Xiao Chengqi Tang (Minor Order the Qi Decoction) in small amounts to gently resolve it. Do not administer too much to avoid severe diarrhea.
Failure to purge when indicated results in blocked Qi and Blood, leading to cold extremities. Physicians who do not understand this may mistakenly diagnose Yin-cold reversal and administer hot herbs, causing disaster instantly. This must be carefully distinguished.
Question: Are there cases in the Three Yin diseases suitable for purgation? Generally, Three Yin diseases are suitable for warming, but purgation is only appropriate if there are accumulation symptoms. What are accumulation symptoms? In Taiyin disease, abdominal fullness with intermittent pain is treated with Guizhi Ji Shaoyao Tang (Cinnamon Twig Decoction Augmented with Peony Root). Severe cases use Guizhi Jia Dahuang Tang (Cinnamon Twig Decoction Augmented with Rhubarb). In Shaoyin disease, dry mouth and throat, or abdominal fullness with constipation, or diarrhea with undigested food, and epigastric pain, are all accumulation symptoms. If all purgation indications are present, and bowel movement occurs after taking the decoction, stop the remaining dose; otherwise, administer the entire dose.
Wang Kentang stated: The general rule is that autumn is suitable for purgation. For conditions suitable for purgation, decoctions are superior to pills and powders. Stop medication once the pathogen is addressed; it is not necessary to finish the entire dose.
[General Principle] Zhang Zhongjing stated: If a patient has vexatious heat, relief follows sweating. If it resembles malaria with fever occurring at dusk, it belongs to Yangming. If the pulse is solid, purgation is suitable. Administer Chengqi Tang (Order the Qi Decoction).
[Detailed Commentary] Wang Haogu stated: Dachengqi Tang (Major Order the Qi Decoction) treats severe excess and fullness. "Fullness" refers to chest and abdominal distension resembling joined tiles; "severe excess" refers to constipation. It is used when Pi (blockage), Man (fullness), Zao (dryness), and Shi (excess) syndromes are all present. For miscellaneous diseases, it is used according to the progression of the condition. Xiaochengqi Tang (Minor Order the Qi Decoction) treats Pi and Shi with mild fullness, feeling like a hungry person who has eaten their fill, with no flatus in the abdomen and epigastric blockage, though stool may pass. It is suitable when heat is severe and purgation is needed. Tiaowei Chengqi Tang (Regulate the Stomach Order the Qi Decoction) treats excess without fullness, where the abdomen feels like an inverted tile, with flatus, dry feces, constipation, and delirious speech—symptoms of solidity. These three methods must not be confused. If Tiaowei Chengqi Tang syndrome is treated with Dachengqi Tang, post-recovery vitality will not recover due to the harsh Qi-moving herbs. If Dachengqi Tang syndrome is treated with Tiaowei Chengqi Tang, post-recovery mental clarity will be impaired due to the lack of Qi-moving herbs. If Xiaochengqi Tang syndrome is treated with Mangxiao (Natrii Sulfas), it may cause unceasing diarrhea, transforming into deficiency. Furthermore, although exterior symptoms of Shanghan often indicate purgation, if the pulse is fine and purgation is contraindicated, Xiexin Tang (Drain the Epigastrium Decoction) is the primary treatment. If the pulse is forceful, use Huanglian Xiexin Tang (Coptis Drain the Epigastrium Decoction); if weak, use Banxia Xiexin Tang (Pinellia Drain the Epigastrium Decoction).
Shen Jin'ao noted: Chengqi Tang syndromes are numerous; not all are recorded here. Only those with "urgent purgation" or "urgent attack" labels are included, as these indicate an immediate need for purgation. Other Chengqi Tang syndromes are not always so urgent.
[General Principle] Zhang Zhongjing stated: On the second or third day of illness, if the pulse is weak, without Taiyang or Chaihu syndrome symptoms, but with irritability and hardness in the epigastrium, progressing to the fourth or fifth day, even if the patient can eat, administer Xiaochengqi Tang (Minor Order the Qi Decoction) in small amounts to gently harmonize and provide slight relief. By the sixth day, administer one sheng of Chengqi Tang. If there is no bowel movement, and on the sixth or seventh day urine is scanty, even if the patient cannot eat, if the stool is hard at the beginning but loose at the end, it has not definitively become hard. Purgation will cause loose stools. Wait until urine flows freely and stool is definitely hard before purging, using Dachengqi Tang (Major Order the Qi Decoction).
[Detailed Commentary] Wu Shou stated: The classic text says that in Taiyang disease, if fever and sweating do not resolve and the patient has a steaming heat sensation, it belongs to the Stomach; treat with Tiaowei Chengqi Tang (Regulate the Stomach Order the Qi Decoction). For tidal fever and abdominal fullness, use Daichaihu Tang (Greater Bupleurum Decoction) augmented with Houpo (Magnolia Bark). In Yangming disease, excessive sweating causes dryness in the Stomach and hard stool, leading to delirium; treat with Xiaochengqi Tang (Minor Order the Qi Decoction). If delirium is accompanied by a slippery and rapid pulse and tidal fever, use Daichaihu Tang (Greater Bupleurum Decoction). If delirium, tidal fever, and anorexia occur, there are likely five or six pieces of dry feces in the Stomach; treat with Xiaochengqi Tang (Minor Order the Qi Decoction). If the patient can eat and stool is hard, use Dachengqi Tang (Major Order the Qi Decoction).
[General Principle] Zhang Zhongjing stated: Sweating accompanied by delirious speech indicates dry feces in the Stomach, caused by Wind. Purgation is required. However, wait until the meridian cycle has passed before purging. Premature purgation will cause language disorder due to exterior deficiency and interior excess. After purgation, the condition will resolve; use Dachengqi Tang (Major Order the Qi Decoction).
[Detailed Commentary] Cheng Wuji stated: Stomach excess with constipation, whether difficult or hard, involves dry feces belonging to interior syndrome, often requiring purgation. However, if the exterior is unresolved and wind-dampness is interacting, it is better to resolve the exterior first before purging. As stated in the classic: constipation for six or seven days with headache and fever, but clear urine, indicates the pathogen is in the interior, not the exterior. This syndrome is common in Yangming because the Stomach Earth is the destination of all pathogens and does not transmit further. Transmission from Taiyang and Shaoyang is well known, but transmission from the Three Yin is rarely recognized. Careful observation reveals many urgent purgation cases in Three Yin diseases, reflecting Zhang Zhongjing's subtle intent.
Tao Hua stated: There are two conditions suitable for urgent purgation. Shaoyin disease with dry mouth and throat indicates dried kidney fluids and requires urgent purgation. Yangming disease with fever and excessive sweating indicates dried stomach fluids and also requires urgent purgation. These are the two urgent purgation conditions.
Wang Ang stated: In Shaoyin disease, if dry mouth and throat appear within two or three days, urgent purgation is needed. The pathogen has not penetrated deeply, but mouth dryness indicates impending kidney water depletion; urgent purgation saves the root. In Shaoyin disease, if abdominal fullness and constipation appear on the sixth or seventh day, urgent purgation is needed. This is Shaoyin heat entering the Stomach Fu. Earth excess depletes Water; urgent purgation saves kidney water. In Shaoyin disease, spontaneous diarrhea with pure green fluid, heart pain, and mouth dryness require urgent purgation. Green corresponds to Liver; Liver pathogen attacking Kidney causes diarrhea. Yang pathogen attacking upward causes mouth dryness. This is Shaoyin transmitting to Yangming Fu disease. In Jueyin disease, tongue retraction and testicular contraction require urgent purgation. Zhang Zhongjing did not provide a treatment for this. Tongue retraction and testicular contraction can be caused by extreme cold, treated with Fuzi Sini Tang (Aconite Decoction Reversing Collapse) plus Wuzhuyu (Evodia Fruit), moxa on Guanyuan and Qihai, or scallion warming. Alternatively, Yangming heat sinking into Jueyin meridian causes the sinews to contract due to heat damaging nourishment, pulling the tongue and testes. This is extreme heat; purge Yang to save Yin. All these are Dachengqi Tang (Major Order the Qi Decoction) indications. Zhang Jianshan stated: The Stomach is the sea of water and grain; diseases from all directions can transmit to Stomach Earth. Dryness depletes kidney water, so both Yangming and Shaoyin have urgent purgation indications. Although symptoms differ, the principle of entering the Fu is the same, hence Dachengqi Tang is used. For patients picking at clothes or reaching into empty space, this is Stomach heat. Qian Zhongyang's *Xiao'er Zhijue* states this is Liver heat, also treated with Chengqi Tang.
Wang Kentang stated: Stomach excess with constipation is known even by children to require purgation. However, Zhang Zhongjing's method dictates that even with Stomach excess, if the exterior is unresolved or there is a half-exterior/half-interior condition, use Guizhi Tang (Cinnamon Twig Decoction) or Chaihu Tang (Bupleurum Decoction) to resolve the exterior first, then assess deficiency and excess. For Stomach excess with constipation: if exterior symptoms exist, resolve the exterior first; if bitter taste, dry throat, and tight floating pulse exist, use harmonizing methods; if hard stool without discomfort, observe; if Stomach excess with resolved exterior and specific symptoms, attack urgently based on symptoms; if Stomach excess with resolved exterior but no specific symptoms, avoid purgation. Use suppositories for hard stool. In Yangming disease, if sweating and diuresis occur, this indicates internal depletion of fluids; even with hard stool, do not purge. Wait for the urge to defecate and use honey suppositories.
Shen Jin'ao noted: Wang's statement "attack if symptoms exist, avoid if none" refers to Yangming excess symptoms like tidal fever and delirium. Only with these symptoms is purgation appropriate. Without them, constipation is due to fluid deficiency; examine carefully and do not purge recklessly. "Passing the meridian before purging" means waiting until the seventh day when the meridian cycle is complete, allowing Yang pathogen to enter Yin before purging.
[General Principle] Zhang Zhongjing stated: In Yangming disease, after purgation, if there is inner vexation and irritability with dry feces in the Stomach, purgation is suitable; use Dachengqi Tang (Major Order the Qi Decoction). If the abdomen is slightly full, with hard stool at the beginning and loose at the end, do not purge.
[Detailed Commentary] Li Chen stated: When interior symptoms are present and the pulse is deep and solid, purgation is suitable. If heat persists after purgation and the pulse remains irregular, reassess deficiency and excess for further purgation. Failure to purge allows the pathogen no exit. Conversely, purging when sweating is indicated depletes fluids, leading to palpitations.
Shen Jin'ao noted: Severe abdominal fullness and obstruction indicate ascending dry feces from the Stomach, warranting purgation.
[General Principle] Zhang Zhongjing stated: A slippery and rapid pulse indicates retained food; use Dachengqi Tang (Major Order the Qi Decoction). Abdominal fullness that does not decrease, or decreases insignificantly, requires purgation; use Dachengqi Tang (Major Order the Qi Decoction). If sweating fails to resolve the condition and abdominal fullness/pain occurs, urgent purgation is needed; use Dachengqi Tang (Major Order the Qi Decoction). In Yangming disease, fever with excessive sweating requires urgent purgation; use Dachengqi Tang (Major Order the Qi Decoction).
[Detailed Commentary] Shen Jin'ao noted: Rapid pulse indicates pathology in the Fu organs; slippery and rapid indicates food retention, a sign for purgation. In the second case, persistent fullness indicates incomplete resolution, requiring further purgation. In the third case, although the exterior is unresolved, interior pathogen is severe, necessitating urgent attack. In the fourth case, excessive sweating depletes Yang; urgent purgation preserves fluids.
[General Principle] Zhang Zhongjing stated: In Shanghan, after six or seven days, if vision is unclear and eyes are unresponsive, without exterior/interior symptoms, but with difficult defecation and body heat, this is heat; urgent purgation is needed; use Dachengqi Tang (Major Order the Qi Decoction).
[Detailed Commentary] Li Chen stated: Shanghan heat entering Zang organs and flowing into Shaoyin meridian causes scorched throat, dry mouth/thirst, indicating dried kidney water. Unresolved heat with unresponsive eyes also indicates dried kidney water; urgent purgation saves kidney water. Yangming fever with excessive sweating, or unresolved sweating, abdominal fullness/pain, delirium/rage, and constipation all require urgent purgation to preserve stomach fluids. In Shanghan, a string-taut and slow pulse indicates cold and organ disease; a large and tight pulse indicates Yang and cold, termed "Yin hidden within Yang"; urgent purgation differentiates Yin and Yang. Diarrhea with normal morning pulse and hard epigastrium indicates interior excess. Diarrhea with slow/slippery or floating/large pulse,涩 (choppy) upon pressure, and food aversion indicate retained food in the Stomach. Retained food contraindicates Bidou (Croton Seed); use Dahuang (Rhubarb) to cleanse.
Liu Wansu stated: If heat persists after purgation, further purgation increases heat. With faint pulse, Qi deficiency, and weakness, without proper method, survival is impossible. Ceasing purgation allows extreme heat and Yin depletion, leading to pulse cessation and death. Such cases die whether purged or not. The classic states death if heat persists after three purgations. Rare survivals after four to ten purgations are coincidental and not standard practice. Use Jiedu Tang (Detoxification Decoction) combined with Liangge San (Cool the Chest Powder) to manage, potentially saving lives. After sweating and purging, if heat persists regardless of sweating, use Baihu Jia Renshen Cangzhu Tang (White Tiger Plus Ginseng and Atractylodes Decoction) to resolve it.
Tao Hua stated: "Urgent purgation" implies the disease heat is pressing and complications are imminent, unlike other diseases where delay is possible.