邪在表宜汗，邪入里宜下。人之一身，元气周流，不能容纤芥之邪。稍有滞碍，则壅塞
经络，隔遏阴阳而为病矣，或寒或热，或气或血，或痰或食，为证不一。轻则消而导之，重
必攻
须
者
（仲景）
治伤寒阳明腑证，阳邪入里，胃实不大便，发热谵语，自汗出，不恶寒，痞满燥实坚全
见；杂病三焦大热，脉沉实者（阳明外证，身热汗出不恶寒反恶热是也，此为在经，仍当汗
散。若热邪已入胃腑，痞满燥实坚全见者，为当下。实则谵语乱言无次也。虚则郑声一语频
言也。阳明多血多气，法多自汗，过汗亡液，无水以制火，胃有燥粪，结而不下，故妄见妄
言也；燥粪在大肠不在于胃，伤寒传胃不传大肠，然治病必求其本，且胃与大肠同为阳明燥
金也。经曰∶何缘得阳明病，曰∶太阳病若下、若汗、若利小便，此亡津液，胃中干燥，因
转属阳明，胃实大便难也。又曰∶太阳初病发其汗，汗先出不彻，因转属阳明。阳明证，能
食为中风，风，阳邪，能消谷；不能食，为中寒，寒，阴邪，不能消谷，以此为辨。胸闷不
食为痞，胸腹膨胀为满，大便枯少为燥，腹满痛不大便为实，按之 硬为坚。亦治阳明刚痉
此太阳兼阳明证。其症胸满口噤，卧不着席，挛足， 齿而无汗，谓之刚痉。宜下之者，以
阳明主润宗筋，风寒湿热伤阳明胃，津液不行，筋失所养，故以此汤下湿热、行津液。喻嘉
言曰∶伤寒腹满可下，胸满不可下，谓热邪尚在表也，此证入里之热，极深极重，阳热既极，
阴血立至消亡，小小下之，尚不能胜，必大下之，以承领其一线之阴，阴气不尽，为阳所劫，
因而得生者多矣。既有下多亡阴之大戒，复有急下救阴之活法，学人深造，端在斯矣。胃为
水谷之海，四旁有病，皆传入胃，已入胃腑，则不复传他经，如太阳传入胃，则不更传阳明；
阳明传入胃，则不传少阳；少阳传入胃，则不传三阴。经曰∶阳明居中土也，万物所归，无
所
大黄（四两酒洗。王海藏曰∶邪气居高，非酒不到，大黄若用生者，则遗高分之邪热，
病愈后变生目赤、喉痹、头肿，膈上热疾也） 芒硝（三合） 浓朴（半斤） 枳实（五枚。）
先煎朴、实将熟，内大黄，煮二三沸，倾碗内，和芒硝服，得利则止（陶节庵曰∶去实热用
大黄，无枳实不通；温经用附子，无干姜不热；发表用麻黄，无葱白不发；吐痰用瓜蒂，无
淡豉不通；竹沥无姜
此正阳阳明药也（东垣曰∶太阳、阳明药）。热淫于内，治以咸寒，气坚者以咸软之，
热盛者以寒消之，故用芒硝之咸寒，以润燥软坚；大黄之苦寒，以泻热去瘀，下燥结，泄胃
强；枳实、浓朴之苦降，泻痞满实满，经所谓土郁夺之也（阳明属土。大黄治大实，芒硝治
大燥大坚，二味治有形血药，浓朴治大满，枳实治痞，二味治无形气药）。然非大实大满，
不可轻投，恐有寒中结胸痞气之变（此大小陷胸汤之由所也。承，顺也；十剂曰∶通可去滞，
泄可去闭。使塞者利而闭者通，正气得舒，故曰承气。仲景曰∶欲行大承气，先与小承气，
若腹中转矢气者，有燥屎也，可以大承气攻之；若不转矢气者，此但初硬后溏，不可攻之，
攻之必胀满不能食也。又曰∶阳明病脉迟、汗出多、微恶寒者，表未解也，可发汗，宜桂枝
汤；阳明病应发汗，医反下之，此为大逆，皆仲景慎于攻下之意也。喻嘉言曰∶阳明以胃实
为正，则皆下证也，阳明之邪，其来路则由太阳，凡阳明证见八九，而太阳有一二未罢，仍
从太阳而不从阳明，可汗而不可下也，其去路则趋少阳；凡阳明证虽见八九，而少阳证略见
一二，即从少阳而不从阳明，汗下两不可用也；惟风寒之邪，已离太阳，未接少阳，恰在阳
明界内，亟为攻下，则不再传他经，津液元气，两无亏损矣。庸愚无识，必待七日传经已尽，
方敢议下，不知太阳有十余日不解者，若不辨经，而但计日，其误下仍在太阳，至阳明二三
日内即显下证，反以计日当面错过，及阳明已入少阳，又以计日妄行攻下，轻者重，而重者
死矣。仲景法日数虽多，但有表证而脉浮者，犹宜发汗，日数虽少，若有里证而脉沉者，即
宜下之。昂按∶阳明必已入腑，方敢议下，非云界内便属可下，嘉言之言，尚有未当，古人
有治恶寒战栗，用大承气下燥屎而愈者，此阳邪入里；热结于里，表虚无阳，故恶寒战栗，
此阳盛格阴，乃热病，非寒证，误投热药则死矣。朱丹溪曰∶初下痢腹痛，不可用参术；然
气虚、胃虚者，可用。初得之，亦可用大承气、调胃承气下之，看其气病血病，然后加减用
药。尝治叶先生患滞下，后甚逼迫，正合承气证，但气日虚，形虽实而面黄白，此必平昔过
食伤胃，宁忍二三日辛苦，遂与参术陈芍药十余帖，至三日后，胃气稍完，与承气二帖而安，
苟不先补，完胃气
本方加甘草等分，名三一承气汤∶治大承气证腹满实痛，调胃证谵语下利，小承气证内
热不便，一切伤寒杂病，蓄热内甚，燥实坚胀（谓合三承气为一方也。成无己曰∶若大承气
证，反用小承气，则邪不服；若小承气证，反用大承气，则过伤元气，而腹满不能食；仲景
所以分而治之。后人以三药合而为一，云通治三药证，及伤寒杂病、内外一切所伤，与仲景
之方甚相违戾，失轩岐缓急之旨，使病患暗受其弊，将谁咎哉）。本方加柴胡、黄芩、甘草，
入铁锈水三匙，坠热开结，名六一顺气汤（节庵谓合三承气、三一承气、大柴胡、大陷胸六
方而为一方也）∶治潮热自汗，发渴，谵语狂妄，斑黄，腹满便实，正阳明腑病。本方加人
参、甘草、当归、桔梗，姜枣煎，名黄龙汤∶治热邪传里，胃有燥屎，心下硬痛，身热口渴，
谵语，下利纯清水（有燥屎何以又下清水，陶节庵曰∶此非内寒而利，乃曰饮汤药而下渗也，
名热结利；庸医妄谓漏底伤寒，以热药止之，杀人多矣。年老气血虚者去芒硝）。本方去芒
硝，加麻仁、杏仁、芍药，蜜丸，名麻仁丸（仲景）∶治趺阳脉浮而涩，浮则胃气强，涩则
小便数，浮涩相搏，大便则难，其脾为约（趺阳，胃脉也。经曰∶饮食入胃，游溢精气，上
输于脾，脾气散精，上归于肺，通调水道，下输膀胱，水精四布，五经并行，是脾土为胃行
其津液者也。今胃火乘脾，约束精液，但输膀胱，致小便数而大便难故名脾约，与此汤润燥
通肠。此太阳传入阳明之证，故仲景曰太阳阳明，脾约是也。按成氏释此证谓脾弱胃强，然
本文但云脾约，未尝云脾弱也。喻嘉言曰∶脾弱即当补矣，何为反用大黄朴实乎，此脾土过
燥，使肠胃津液枯槁，致中消便难；使脾胃弱，非溏则泻，焉能反约少胃中之谷食乎，阳明
证中凡宜攻下者，惟恐邪未入胃，大便弗硬，又恐初硬后溏，未可妄攻，故先与小承气试其
转矢气，方可攻之，皆是虑夫脾气之弱也。若脾约证在太阳，即当下矣，何待阳明耶。朱丹
溪曰∶此由久病大汗大下之后，阴血枯槁，内火燔灼，热伤元气，又伤于脾而成。肺金受
火，气无所摄，肺为脾子，肺耗则液亏，金耗则木寡于畏，土欲不伤，其可得乎。肺失传送，
脾失转输，故大便秘而小便数也，理宜滋养阴血，使火不炽而金化行，木有制而脾土运，津
液乃能入胃肠润而通矣。此方施之热盛而气实者则安，若热盛而气血不实者，勿胶柱而鼓瑟
也）。
当下诸证（发汗不解，腹满痛者急下之；下利，三部脉皆平，按之心下硬者，急下之；
脉滑而数者，有宿食也，宜下之。《脉经》曰∶滑为食病。仲景曰∶滑则谷气实。又曰∶寸
脉浮大，按之反涩，尺中亦微而涩，知有宿食，宜下之。伤寒六七日，目中不了了，晴不和，
无表里证，大便难，身微热者，此为实也，急下之。《内经》曰∶诸脉皆属于目。《针经》曰∶
热病目不明，热不已者，此肾水将绝，不能照物也。阳明病发热汗多者，急下之；汗多则亡
津液而内燥，宜急下以存津液。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，宜急下救欲绝之水。少阴证六七日，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，色纯清，心中必痛，口中燥
者，急下之；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证也。厥
阴证舌卷囊缩，宜急下之；此证仲景无治法，按∶舌卷囊缩，有寒极而缩者，宜附子四逆加
吴茱萸汤，并灸关元、气海、葱熨等法；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。以上皆大承气证
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
急下之条，证虽不同，其入腑之理则一，故皆用大承气。有病循衣摸床、两手撮空者，此胃
热也，钱仲阳《小儿直诀》云∶此肝热也，亦承气汤主之。楼全善曰∶尝治循衣摸床数人，
皆用大补气血之剂，唯一人兼振 ，脉代，遂于补剂中加桂二分，亦振止脉和而愈。按∶谵
语亦有因气虚阳脱而然者，皆当用参附补剂）。
忌下诸证太阳病外证未解，不可下；脉浮大，不可下，浮大为在表；恶寒不可下，恶寒
为邪在表。呕多，虽有阳明证，不可下，呕为邪在上焦；阳明病不能食，攻其热必哕，胃中
虚冷
肺气
之则
不
邪气在表应当用发汗法，邪气入里应当用攻下法。人体的元气周身循环流动，不能容许丝毫的邪气存在。稍有阻滞阻碍，就会壅塞经络，阻隔阴阳而导致疾病，或者表现为寒证或热证，或者涉及气分或血分，或者为痰饮或食积，证候表现不一。轻症的用消导法治疗，重症必须用攻下法（出自张仲景）。
治疗伤寒阳明腑实证，阳热邪气入里，胃中实热导致大便不通，发热、说胡话，自汗出，不恶寒，痞、满、燥、实、坚五种症状全部出现；以及杂病中三焦大热，脉象沉实的患者。（注：阳明外证，表现为身体发热、出汗、不恶寒反而恶热，这是邪气在经，仍应当用发汗散邪的方法。如果热邪已经传入胃腑，痞、满、燥、实、坚五种症状全部出现，这是应当用攻下法的情况。实证表现为胡言乱语、语无伦次。虚证表现为郑声，即反复重复同一句话。阳明经多血多气，法度上容易自汗，如果发汗过度导致津液亡失，没有水来制约火，胃中有干燥的粪便，结聚而不下行，所以会出现妄见妄言的情况；干燥的粪便在大肠而不在胃，伤寒传变只传胃而不传大肠，然而治病必须探究根本，且胃与大肠同属阳明燥金。经文说：为什么会得阳明病？回答说：太阳病如果被误用下法、发汗法或利小便法，这会导致津液亡失，胃中干燥，因此转属阳明，出现胃实大便难的情况。又说：太阳初起病时发汗，汗出得不透彻，因此转属阳明。阳明证中，能进食的是中风，风是阳邪，能消化谷物；不能进食的是中寒，寒是阴邪，不能消化谷物，以此作为辨别依据。胸闷不想吃东西叫作痞，胸腹部膨胀叫作满，大便干枯量少叫作燥，腹部胀满疼痛且不大便叫作实，按压时感觉坚硬叫作坚。也治疗阳明刚痉，这是太阳兼阳明证。其症状为胸部胀满、牙关紧闭、睡觉时背部不能着席、脚部挛急、磨牙且无汗，称为刚痉。适宜用攻下法的理由在于：阳明主润养宗筋，风寒湿热邪气伤害阳明胃，导致津液运行不畅，筋脉失去滋养，所以用此汤攻下湿热、通行津液。喻嘉言说：伤寒腹满可以攻下，胸满不可攻下，是因为热邪还在表。此证是入里的热邪，极深极重，阳热已经至极，阴血立刻面临消亡，轻微攻下尚且不能胜任，必须大剂量攻下，以承接保留一线之阴，如果阴气不被阳气劫夺，因而得以生存的人就多了。既然有攻下过多导致亡阴的大戒律，又有紧急攻下以救阴的活方法，学者深入钻研，关键在于此。胃是水谷之海，四周有病，都会传入胃，一旦进入胃腑，就不再传变到其他经，如太阳传入胃，则不再传阳明；阳明传入胃，则不传少阳；少阳传入胃，则不传三阴。经文说：阳明居中属土，是万物归附之所，无所不纳。大黄（四两，酒洗。王海藏说：邪气位置高，不用酒不到达，大黄如果用生的，会遗留高处的邪热，病愈后变生目赤、喉痹、头肿等膈上热疾） 芒硝（三合） 浓朴（半斤） 枳实（五枚。） 先煎浓朴、枳实，将熟时，加入大黄，煮二三个沸，倒入碗中，调和芒硝服用，得利则停服（陶节庵说：去除实热用大黄，没有枳实则不通畅；温经用附子，没有干姜则不热；发表用麻黄，没有葱白则不发散；吐痰用瓜蒂，没有淡豆豉则不通畅；竹沥没有生姜……） 这是正阳阳明的药物（东垣说：太阳、阳明药）。热邪淫溢于内，用咸寒之法治疗，气机坚结的用咸味软之，热盛的用寒凉消之，所以用芒硝的咸寒，以润燥软坚；大黄的苦寒，以泻热去瘀，下燥结，泄胃强；枳实、浓朴的苦降，泻痞满实满，经文所谓“土郁夺之”（阳明属土。大黄治大实，芒硝治大燥大坚，这两味药治有形的血分病，浓朴治大满，枳实治痞，这两味药治无形的气分病）。然而如果不是大实大满，不可轻易投用，恐怕有寒中、结胸、痞气的变证（这是大小陷胸汤产生的缘由。承，顺也；十剂说：通可去滞，泄可去闭。使堵塞者通畅，闭塞者通达，正气得以舒展，所以叫承气。仲景说：欲行大承气汤，先与小承气汤，如果腹部有转矢气，说明有燥屎，可以用大承气攻之；如果不转矢气，这只是开头硬后面稀，不可攻之，攻之必然胀满不能进食。又说：阳明病脉迟、汗出多、微恶寒，表证未解，可发汗，宜桂枝汤；阳明病应当发汗，医生反而用下法，这是大逆，都是仲景谨慎使用攻下法的意思。喻嘉言说：阳明以胃实为正，那么都是下证，阳明的邪气，其来路由太阳，凡是阳明证见到八九成，而太阳有一二成未罢，仍从太阳而不从阳明，可汗而不可下；其去路则趋向少阳；凡是阳明证虽见八九成，而少阳证略见一二成，即从少阳而不从阳明，汗下两法都不可用；只有风寒邪气，已离太阳，未接少阳，恰在阳明界内，亟需攻下，则不再传变其他经，津液元气，两无亏损。庸俗愚昧之人，必定等到七日传经已尽，才敢议论攻下，不知道太阳有十余日不解的，如果不辨经脉，而只计算日期，其误下仍在太阳，到了阳明二三日内即显现下证，反而因为计算日期当面错过，等到阳明已入少阳，又以计算日期妄行攻下，轻者变重，重者致死。仲景的法度中日数虽多，但有表证而脉浮的，仍宜发汗；日数虽少，若有里证而脉沉的，即宜下之。汪昂按：阳明必须已入腑，才敢议论攻下，不是说在界内就属于可下，喻嘉言之言，尚有不当之处。古人有治疗恶寒战栗，用大承气攻下燥屎而痊愈的，这是阳邪入里；热结于里，表虚无阳，所以恶寒战栗，这是阳盛格阴，乃是热病，非寒证，误投热药则会死。朱丹溪说：初患痢疾腹痛，不可用人参白术；然而气虚、胃虚者，可用。初得的，也可用大承气、调胃承气攻下，看其是气病还是血病，然后加减用药。曾治疗叶先生患滞下，后来非常逼迫，正合承气证，但气日渐虚弱，形体虽实而面色黄白，这必定是平素过食伤胃，宁可忍受二三日辛苦，遂与人参白术陈皮芍药十余帖，到三日后，胃气稍恢复，给承气二帖而安，如果不先补，完不成胃气…… 本方加甘草等分，名三一承气汤：治疗大承气证腹满实痛，调胃证谵语下利，小承气证内热不便，一切伤寒杂病，蓄热内甚，燥实坚胀（谓合三承气为一方的意思。成无己说：如果是大承气证，反用小承气，则邪气不服；如果是小承气证，反用大承气，则过伤元气，而腹满不能进食；仲景所以分而治之。后人将三药合而为一，说通治三药证，及伤寒杂病、内外一切所伤，这与仲景的方剂非常违背，失去了轩岐缓急的宗旨，使病患暗中受其弊，怪罪谁呢）。本方加柴胡、黄芩、甘草，入铁锈水三匙，坠热开结，名六一顺气汤（节庵说合三承气、三一承气、大柴胡、大陷胸六方而为一方）：治疗潮热自汗，发渴，谵语狂妄，斑黄，腹满便实，正阳明腑病。本方加人参、甘草、当归、桔梗，姜枣煎，名黄龙汤：治疗热邪传里，胃有燥屎，心下硬痛，身热口渴，谵语，下利纯清水（有燥屎为何又下清水，陶节庵说：这不是内寒而利，而是说喝汤药而下渗，名叫热结利；庸医妄称漏底伤寒，用热药止之，杀人很多了。年老气血虚者去芒硝）。本方去芒硝，加麻仁、杏仁、芍药，蜜丸，名麻仁丸（仲景）：治疗趺阳脉浮而涩，浮则胃气强，涩则小便数，浮涩相搏，大便则难，其脾为约（趺阳，胃脉也。经文说：饮食入胃，游溢精气，上输于脾，脾气散精，上归于肺，通调水道，下输膀胱，水精四布，五经并行，是脾土为胃行其津液者也。现在胃火乘脾，约束精液，只输膀胱，致小便数而大便难，故名脾约，与此汤润燥通肠。这是太阳传入阳明之证，所以仲景说太阳阳明，脾约是也。按成氏解释此证谓脾弱胃强，然而本文只说脾约，未曾说脾弱。喻嘉言说：脾弱就当补了，为什么反而用大黄枳实呢？这是脾土过燥，使肠胃津液枯槁，致中消便难；如果脾胃弱，不是溏就是泻，怎么能反而约束少胃中的谷食呢？阳明证中凡宜攻下者，惟恐邪未入胃，大便不硬，又恐初硬后溏，未可妄攻，所以先与小承气试其转矢气，方可攻之，都是顾虑脾气的弱。如果脾约证在太阳，就当下矣，何待阳明耶。朱丹溪说：这是由于久病大汗大下之后，阴血枯槁，内火燔灼，热伤元气，又伤于脾而成。肺金受火，气无所摄，肺为脾子，肺耗则液亏，金耗则木寡于畏，土欲不伤，其可得乎。肺失传送，脾失转输，故大便秘而小便数也，理宜滋养阴血，使火不炽而金化行，木有制而脾土运，津液乃能入胃肠润而通矣。此方施之热盛而气实者则安，若热盛而气血不实者，勿胶柱而鼓瑟也）。
当下诸证（发汗不解，腹满痛者急下之；下利，三部脉皆平，按之心下硬者，急下之；脉滑而数者，有宿食也，宜下之。《脉经》说：滑为食病。仲景说：滑则谷气实。又说：寸脉浮大，按之反涩，尺中亦微而涩，知有宿食，宜下之。伤寒六七日，目中不了了，睛不和，无表里证，大便难，身微热者，此为实也，急下之。《内经》说：诸脉皆属于目。《针经》说：热病目不明，热不已者，此肾水将绝，不能照物也。阳明病发热汗多者，急下之；汗多则亡津液而内燥，宜急下以存津液。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，宜急下救欲绝之水。少阴证六七日，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，色纯清，心中必痛，口中燥者，急下之；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证也。厥阴证舌卷囊缩，宜急下之；此证仲景无治法，按：舌卷囊缩，有寒极而缩者，宜附子四逆加吴茱萸汤，并灸关元、气海、葱熨等法；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。以上皆大承气证也。张兼善说：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条，证虽不同，其入腑之理则一，故皆用大承气。有病循衣摸床、两手撮空者，此胃热也，钱仲阳《小儿直诀》云：此肝热也，亦承气汤主之。楼全善说：曾治疗循衣摸床数人，皆用大补气血之剂，唯一人兼振颤，脉代，遂于补剂中加桂二分，亦振止脉和而愈。按：谵语亦有因气虚阳脱而然者，皆当用参附补剂）。
忌下诸证太阳病外证未解，不可下；脉浮大，不可下，浮大为在表；恶寒不可下，恶寒为邪在表。呕多，虽有阳明证，不可下，呕为邪在上焦；阳明病不能食，攻其热必哕，胃中虚冷肺气……之则不……
When pathogenic factors are in the exterior, sweating should be used; when they have entered the interior, purgation should be used. The Yuan Qi (Original Qi) of the human body circulates throughout, allowing no room for even the slightest pathogen. Any slight obstruction will block the meridians and collaterals, obstructing Yin and Yang and causing disease. It may manifest as cold or heat, affecting Qi or Blood, phlegm or food retention, with various syndromes. Mild cases are treated with resolution and guidance methods, while severe cases must be treated with aggressive purgation (from Zhang Zhongjing).
This formula treats Yangming Fu-organ syndrome in Shanghan (Cold Damage), where Yang pathogenic factors enter the interior, causing stomach excess and constipation, accompanied by fever, delirium, spontaneous sweating, aversion to cold absent, and the simultaneous presence of five symptoms: Pi (stifling sensation), Man (fullness), Zao (dryness), Shi (excess), and Jian (hardness). It is also indicated for miscellaneous diseases involving excessive heat in the San Jiao (Triple Burner) with a deep and solid pulse. (Note: Yangming Exterior Syndrome presents with fever, sweating, absence of aversion to cold, and preference for cold; this indicates the pathogen is in the channels, and sweating dispersal is still appropriate. If heat pathogens have entered the Stomach Fu-organ, presenting with all five symptoms of Pi, Man, Zao, Shi, and Jian, purgation is required. Excess syndromes present with incoherent speech. Deficiency syndromes present with Zheng Sheng (repetitive murmuring). The Yangming channel has abundant Qi and Blood, making spontaneous sweating common. Excessive sweating leads to fluid loss; without water to control fire, dry feces accumulate in the stomach, leading to hallucinations and incoherent speech. Dry feces reside in the Large Intestine, not the Stomach. Shanghan transmission affects the Stomach but not directly the Large Intestine; however, treating disease requires addressing the root. The Stomach and Large Intestine both belong to Yangming Dry Metal. The Classic states: "Why does one contract Yangming disease?" Answer: "If Taiyang disease is incorrectly treated with purgation, sweating, or diuresis, fluids are lost, the Stomach becomes dry, and it transfers to Yangming, resulting in stomach excess and difficult defecation." It also states: "If sweating is induced early in Taiyang disease but is incomplete, it transfers to Yangming." In Yangming syndromes, ability to eat indicates Wind Strike (Wind is a Yang pathogen that digests grain); inability to eat indicates Cold Strike (Cold is a Yin pathogen that fails to digest grain), which serves as a differentiation criterion. Chest tightness and anorexia constitute Pi (stifling); chest and abdominal distension constitute Man (fullness); dry and scant stool constitutes Zao (dryness); abdominal fullness, pain, and constipation constitute Shi (excess); hardness upon palpation constitutes Jian (hardness). It also treats Yangming Gang Jing (Stiff Spasm), a combination of Taiyang and Yangming. Symptoms include chest fullness, trismus, inability to lie flat (back touching the bed), leg spasms, teeth grinding, and anhidrosis, termed Gang Jing. Purgation is indicated because Yangming moistens the Zong Jin (Major Tendons). When Wind-Cold-Damp-Heat pathogens injure the Yangming Stomach, fluid dynamics fail, and tendons lose nourishment; thus, this decoction purges damp-heat and promotes fluid circulation. Yu Jiayan stated: Abdominal fullness in Shanghan can be purged, but chest fullness cannot, as heat remains in the exterior. This case involves deep, severe interior heat. Extreme Yang heat immediately threatens Yin blood depletion. Mild purgation is insufficient; massive purgation is required to preserve the last thread of Yin. If Yin is not robbed by Yang, survival is likely. Despite the warning against excessive purgation causing Yin collapse, there is a vital method of urgent purgation to save Yin. Scholars must master this principle. The Stomach is the Sea of Water and Grain; diseases from surrounding areas transmit to it. Once in the Stomach Fu-organ, it does not transmit further: Taiyang transmitting to Stomach does not go to Yangming; Yangming to Stomach does not go to Shaoyang; Shaoyang to Stomach does not go to the Three Yin channels. The Classic states: "Yangming resides in the center, belonging to Earth, the destination of all things, accepting nothing outside." Da Huang (Cortex Rhei Rhizoma et Radix, 4 liang, washed with wine). Wang Haicang said: "Pathogens located high require wine to reach them. Raw Da Huang leaves high heat pathogens, causing post-recovery red eyes, throat bi, head swelling, and upper jiao heat disorders." Mang Xiao (Natrii Sulfas, 3 he) Hou Po (Cortex Magnoliae Officinalis, 8 liang) Zhi Shi (Fructus Aurantii Immaturus, 5 pieces). First decoct Hou Po and Zhi Shi until nearly done, add Da Huang, boil for two or three boils, pour into a bowl, mix with Mang Xiao, and take. Stop once bowel movement occurs. Tao Jian'an said: "To remove excess heat, use Da Huang; without Zhi Shi, unblocking fails. To warm meridians, use Fu Zi; without Gan Jiang, warming fails. To release the exterior, use Ma Huang; without Cong Bai, dispersion fails. To induce vomiting of phlegm, use Gua Di; without Dan Chi, unblocking fails. Zhu Li (Bamboo Sap) needs Ginger..." This is the correct formula for Zheng Yang Yangming (Dong Yuan: Taiyang/Yangming formulas). For heat rampant within, treat with salty-cold. Solidify Qi with salty softening; eliminate excessive heat with cold. Thus, Mang Xiao's salty-cold moistens dryness and softens hardness; Da Huang's bitter-cold purges heat, removes stasis, descends dry accumulation, and drains stomach excess. Zhi Shi and Hou Po's bitter descent purges Pi, Man, and Shi excess, corresponding to the Classic's "Earth stagnation requires seizure" (Yangming belongs to Earth. Da Huang treats great excess; Mang Xiao treats great dryness and hardness; these two treat tangible blood-pathology. Hou Po treats great fullness; Zhi Shi treats Pi; these two treat intangible Qi-pathology). However, do not use lightly unless there is great excess and fullness, lest cold injury, Jie Xiong (Chest Binding), or Pi Qi complications arise (Origin of Xiao/Da Xie Xiong Tangs. Cheng means to inherit/continue. Ten Agents states: "Tong (Unblocking) removes stagnation; Xie (Draining) removes closure." Making blocked passages clear and closed passages open allows Zheng Qi to relax, hence "Cheng Qi". Zhongjing said: "To administer Da Cheng Qi Tang, first give Xiao Cheng Qi Tang. If intestinal gas passes, dry feces exist, and Da Cheng Qi can attack; if no gas passes, only the beginning is hard and the end loose, do not attack, or bloating and anorexia will result." Also: "Yangming disease with slow pulse, much sweating, and slight aversion to cold indicates unresolved exterior; sweating with Gui Zhi Tang is appropriate. Yangming disease requiring sweating but treated with purgation is a major error," showing Zhongjing's caution. Yu Jiayan said: "Yangming considers stomach excess as standard, so all are purgation indications. Yangming pathogens come from Taiyang. If Yangming signs appear at 80-90% but Taiyang signs remain at 10-20%, follow Taiyang, not Yangming; sweat, do not purge. The exit route trends toward Shaoyang. If Yangming signs are 80-90% but Shaoyang signs appear slightly, follow Shaoyang; neither sweat nor purge. Only when wind-cold has left Taiyang but not reached Shaoyang, residing strictly within Yangming, is urgent purgation necessary to prevent transmission to other channels, preserving fluids and Yuan Qi. Ignorant practitioners wait for seven days of transmission to complete before daring to purge, unaware that Taiyang may persist over ten days. Not differentiating channels but counting days leads to erroneous purgation in Taiyang. Conversely, missing purgation indications in Yangming (days 2-3) due to day-counting, or wrongly purging when entering Shaoyang based on days, turns mild cases severe and severe cases fatal. Zhongjing's rule: many days with exterior signs and floating pulse require sweating; few days with interior signs and deep pulse require purgation. Ang notes: Purge only after entering the Fu-organ, not merely being in the 'zone'. Yu's statement is imperfect. Ancients cured chills/shivering with Da Cheng Qi to purge dry feces; this is Yang pathogen entering interior, heat binding interior, exterior void of Yang, causing chills/shivering—Yang excess repelling Yin, a heat disease, not cold. Misusing hot herbs causes death. Zhu Danxi said: Initial dysentery with abdominal pain forbids Ren Shen/Bai Zhu; but for Qi/Stomach deficiency, they are usable. Initially, Da Cheng Qi or Tiao Wei Cheng Qi may be used to purge, then adjust based on Qi or Blood pathology. I treated Mr. Ye with severe dysentery fitting Cheng Qi pattern, but his Qi was daily declining, though his form seemed solid, his face was yellow-white, indicating past dietary injury to the Stomach. I endured his suffering for two days, giving Ren Shen, Bai Zhu, Chen Pi, Shao Yao for ten doses. After three days, Stomach Qi recovered slightly, then gave Cheng Qi for two doses, resulting in peace. Without prior tonification, Stomach Qi would not recover... Adding Gan Jiang in equal parts creates San Yi Cheng Qi Tang: treats Da Cheng Qi abdominal fullness/pain, Tiao Wei Cheng Qi delirium/diarrhea, Xiao Cheng Qi internal heat/constipation, and all Shanghan/miscellaneous diseases with severe internal heat accumulation, dryness, excess, hardness, and distension (Combining the three Cheng Qi formulas. Cheng Wuji said: Using Xiao Cheng Qi for Da Cheng Qi syndrome fails to subdue pathogens; using Da Cheng Qi for Xiao Cheng Qi syndrome over-injures Yuan Qi, causing bloating/anorexia. Zhongjing separates them for specific treatment. Later practitioners combined them, claiming universal efficacy for all injuries, violating Zhongjing's intent and Xuandi's principles of urgency/moderation, harming patients silently. Who is to blame?). Adding Chai Hu, Huang Qin, Gan Jiang, and 3 spoons of Iron Rust Water creates Liu Yi Shun Qi Tang (Jie'an: Combines three Cheng Qi, San Yi Cheng Qi, Da Chai Hu, Da Xie Xiong six formulas): treats tidal fever, spontaneous sweating, thirst, delirium/madness, macules/jaundice, abdominal fullness, and solid stool; correct Yangming Fu-organ disease. Adding Ren Shen, Gan Cao, Dang Gui, Jie Geng, Decocted with Jiang/Zao creates Huang Long Tang: treats heat transmission to interior, dry feces in stomach, epigastric hardness/pain, fever/thirst, delirium, and diarrhea of pure clear water (Why diarrhea with dry feces? Tao Jian'an: Not internal cold diarrhea, but liquid seeping around dry feces due to herbal intake, named Re Jie Li (Heat-Binding Diarrhea). Quacks call it Lou Di Shang Han and use hot herbs, killing many. Remove Mang Xiao for elderly/Qi-Blood deficient). Removing Mang Xiao, adding Ma Ren, Xing Ren, Shao Yao, Honey Pills create Ma Ren Wan (Zhongjing): treats Fuyang pulse floating and choppy; floating indicates strong Stomach Qi, choppy indicates frequent urination; floating-choppy interaction causes difficult defecation, termed Pi Yue (Spleen Contraction) (Fuyang is Stomach pulse. Classic: Food enters Stomach, essence floats up to Spleen, Spleen scatters essence to Lung, regulates water passages to Bladder, fluids distribute, five channels run together; Spleen Earth moves fluids for Stomach. Now Stomach Fire attacks Spleen, contracting fluids to Bladder, causing frequent urination and difficult defecation, hence Pi Yue. This formula moistens dryness and unblocks intestines. This is Taiyang transferring to Yangming, hence Zhongjing calls it Taiyang Yangming Pi Yue. Cheng Shi interpreted this as weak Spleen/strong Stomach, but text only says Pi Yue, not weak Spleen. Yu Jiayan: If Spleen were weak, tonify it; why use Da Huang/Zhi Shi? This is excessive dryness of Spleen Earth, drying gut fluids, causing middle Xiao and difficulty. If Spleen-Stomach were weak, stool would be loose/liquid, how could it contract grain? In Yangming purgation indications, fear is pathogen not in Stomach/stool not hard, or hard-beginning/loose-end, preventing reckless purgation. Hence testing with Xiao Cheng Qi for gas passage before attacking shows concern for weak Spleen Qi. If Pi Yue occurred in Taiyang, purge immediately; why wait for Yangming? Zhu Danxi: Caused by prolonged illness, heavy sweating/purgation, depleting Yin Blood, internal fire blazing, injuring Yuan Qi and Spleen. Lung Metal受 Fire, Qi uncontrolled. Lung is Spleen's child; Lung consumption depletes fluids; Metal exhaustion reduces Wood's restraint; Earth cannot remain uninjured. Lung loses transport, Spleen loses transformation, hence constipation and frequent urination. Ideally nourish Yin Blood, extinguish fire, promote Metal transformation, restrain Wood, move Spleen Earth, allowing fluids to moisten intestines. This formula works for excess heat/Qi; avoid in heat excess with deficient Qi/Blood).
Urgent Purgation Syndromes (Sweating fails, abdominal fullness/pain: urgent purge. Diarrhea, all three pulses level, pressing epigastrium hard: urgent purge. Slippery-numerous pulse indicates retained food, purge. Mai Jing: Slippery indicates food disease. Zhongjing: Slippery indicates grain Qi excess. Also: Cun pulse floating-large, pressing choppy, Chi pulse micro-choppy indicates retained food, purge. Shanghan 6-7 days, unclear vision, eyes unresponsive, no exterior/interior signs, difficult defecation, slight fever: this is excess, urgent purge. Nei Jing: All pulses relate to eyes. Zhen Jing: Heat disease with unclear vision, if heat persists, Kidney Water is failing, unable to illuminate. Yangming fever with much sweating: urgent purge. Much sweating loses fluids, causing internal dryness; purge urgently to preserve fluids. Shaoyin disease 2-3 days, dry mouth/throat: urgent purge. Pathogen not deep yet causes dry mouth; Kidney Water is drying; purge urgently to save impending water loss. Shaoyin 6-7 days, abdominal fullness, constipation: urgent purge. Shaoyin heat enters Stomach Fu; Earth excess dries Water; purge urgently to save Kidney Water. Shaoyin spontaneous diarrhea of pure clear water, green color, heart pain, dry mouth: urgent purge. Green is Liver color; Liver pathogen attacks Kidney causing diarrhea; Yang pathogen attacks upward causing dry mouth; this is Shaoyin transmitting to Yangming Fu. Jueyin tongue curling and testicular retraction: urgent purge. Zhongjing has no treatment for this. Note: Tongue curling/testicular retraction can be extreme cold (use Fu Zi Si Ni plus Wu Zhu Yu, moxibustion Guan Yuan/Qi Hai, ginger compression); or Yangming heat sinking into Jueyin. Yangming moistens Zong Jin; heat attacks Zong Jin, failing to nourish, pulling tongue and testes tightly. This is extreme heat; drain Yang to save Yin. All above are Da Cheng Qi indications. Zhang Jianshan: Stomach is Sea of Water/Grain; surrounding diseases transmit to it; Earth dryness dries Kidney Water; thus both Yangming and Shaoyin have urgent purge clauses. Syndromes differ, but mechanism of entering Fu is same, hence both use Da Cheng Qi. Patients tracing clothes, grasping at air: Stomach heat. Qian Zhongyang's Xiao'er Zhijue: Liver heat; also treat with Cheng Qi Tang. Lou Quanshan: Treated several such patients with major Qi/Blood tonics; one with tremors and intermittent pulse added 2 fen Gui Zhi to tonic, stopping tremors and harmonizing pulse. Note: Delirium can also stem from Qi deficiency/Yang collapse, requiring Ren Shen/Fu Zi tonics).
Contraindications for Purgation (Taiyang exterior unresolved: do not purge. Floating-large pulse: do not purge, indicates exterior. Aversion to cold: do not purge, indicates exterior pathogen. Frequent vomiting: even with Yangming signs, do not purge; vomiting indicates pathogen in Upper Jiao. Yangming inability to eat: attacking heat causes hiccups; Stomach deficiency-cold... Lung Qi... then not...)