大便秘结，杂症门有实秘、虚秘、风秘、冷秘、热秘、气秘、血枯之分；外感门，症分表未
解、半表半里、表已解、表邪传里，治分应下、急下、微下、大下、可下、未可下、不可
下、俟之蜜导等法。如表汗未出，表症尚在，病在胸前，脉浮身热，脉细不数，脉伏不出，
面赤烦躁，胸前食滞，久病多汗，血竭津竭者，不可下。身无大热，手足多汗，便硬腹胀，
身无表邪，欲便而不得便，时转臭气下，口燥咽干，渴而消水，大便久结，常胀满，舌苔黄
焦，腹中作痛，应急下，皆用大承气汤。然仲景下法，既详此条之中，复详于自汗门内，良
以下法最怕表邪未散，表汗未彻，必自汗多汗表邪方解，互注参玩，庶不差误。若大便不通，
脐腹胀痛，表症在而里症尤急，不得不下者，止用大柴胡汤，双解表里。如热轻结少，津液
干涸，便闭不通，腹胀未满，不转臭气者，宜微下，止用小承气汤。若大便不通，腹不胀
满，未欲大便，即大便闭结，俟之有热无结，不转矢气者，宜俟之。津液不足，大便干结，血枯
热微者，宜生津养血，外用蜜导。上部胸胃无热，不耐承气苦寒，下部大肠热结，下用胆汁
外导。是以大便闭结，惟以表邪之解与未解，里热之结与不结，汗之多与不多，身表之热与
不热，下症之急与不急，屎之硬与不硬，津液之干与不干，脐腹之痛与不痛，脉之数与不
数，以别可下、不可下、微下、急下、俟之导之之法也。
伤寒脉阳微而汗少，为自和也。汗出多者，为太过。阳脉实，因发其汗出多者，亦为太过。
太过，阳绝于里，亡津液，大便因硬。
此条言汗出太多，则阳液竭绝于里，名亡津液，大便因硬，非言阳火虚寒也。
太阳病，若发汗，若下，若利小便，此亡津液，胃中干燥，因转属阳明。不更衣，内实，大
便难者，此名阳明也。
此申明上章汗下亡津液，胃中干燥，内实，大便难，此名阳明里症也。
太阳病，若吐，若下，若发汗，微烦，小便数，大便因硬者，与小承气汤和之愈。
此申明上章吐下后，虽有阳明可下之症，但津液耗尽，止与小承气汤和之。
病患不恶寒而渴，此转属阳明也。小便数者，大便必硬，不更衣十日，无所苦也。渴欲饮
水，少少与之，以法救之。
此申明不大便，无所胀苦，非下症也。详注口渴。
阳明病，本自汗出，医更重发汗，病已瘥，尚微烦不了了者，此大便必硬故也。以亡津液，
胃中干燥，故令大便硬。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，少津液，当还入胃，故不久必大便也。
此重申多汗亡津液，大便硬不可下，宜俟之。仲景常以小便利不利，以定屎之硬不硬。今
又以小便减少，以定水液还入大肠，而必大便之自行。
阳明病，自汗出，若发汗，小便自利者，此为津液内竭，虽硬不可攻之，当须自欲大便，宜
蜜煎导而通之，若土瓜根及猪胆汁，皆可为导也。
此承上文重亡津液，即大便硬，有下症者，止宜用外导。
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
矣。手足 然而汗出者，此大便已硬也，大承气汤。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。
阳明脉洪大，今反迟，非浮紧之表脉。大凡汗出不恶寒者，无身重，今虽身重，短气而
喘，因有潮热，则可攻里矣。然必手足 汗出，则大便已硬，宜用大承气。若汗多而见
发热恶寒，其热不潮，未可下也。若腹大满不通，只可小承气汤，微和胃气。
病患不大便五六日，绕脐痛，烦躁，发作有时者，此有燥屎故使大便也。
大下后，六七日不大便，烦而不解腹满者，此有燥屎也。所以然者，本有宿食故也，宜大承气汤。
以上诸条，关防未可下外导等法。此二条又恐应下失下，故曰腹满痛，烦躁发作有时，不
大便，即是有燥屎，急宜下者。
阳明病潮热，大便微硬者，可与大承气汤。不硬者，不可与之。若不大便六七日，恐有燥
屎，欲知之法，少与小承气汤入腹中，转矢气者，此有燥屎，乃可攻。若不转矢气，此但初
硬而后必溏，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，必大便硬
而少也，以小承气汤和之。不转矢气者，慎不可攻也。
上二条申明大下的诀，以下又关防若未见燥粪，尚宜探讨。例如阳明病，见潮热里证，又
见大便微硬，可与大承气汤。若不硬者，切勿与之。若不大便六七日，恐有燥屎，当以小
承气汤。若汤入腹，有臭气下矢，此有燥屎可攻。若不矢臭气，但初头硬，后必溏，攻之
必胀满不能食。欲饮水者，与水则胃寒而哕。其后虽发热烦躁，即大便硬，然结粪必少，
止可以小承气汤和之。若不转矢气，慎不可攻。
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，以小承气汤，少少
微和之，令小安，至六日与承气汤。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。
上半节，以脉弱无太阳少阳表症，而有烦躁心下硬应下之症，故即能食，亦宜以小承气汤
微和之。下半节，以小便少别粪未必硬，即不能食，未可攻，须待小便多屎定硬方可攻。
阳明病，谵语发潮热，脉滑而疾者，小承气汤主之。因与小承气汤一升，腹中转矢气者，更
复一升。若不转矢气，勿更与之。明日不大便，脉反微涩者，里虚也，为难治，不可更与承气汤也。
此条言服承气汤，不转臭气，又不大便，不可再服。详注潮热，宜互看。
阳明病，其人多汗，以津液外出，胃中燥，大便必硬，硬则谵语，小承气汤主之。若一服谵
语止，更莫复服。
多汗则津液大泄，胃中必干，大便必硬，上热不得下泄，故谵语。然用小承气汤，清胃
热，止谵语，不求必下结粪，故谵语止，勿再服。
伤寒四五日，脉沉而喘满，沉为在里，而反发其汗，津液越出，大便为难，表虚里实，久则谵语。
此重申误汗亡津液，大便必难，久则谵语。如脉沉喘满，乃里热之喘，误认表邪，反发其
汗，大便必难，里热不得下泄，久则谵语。
伤寒若吐若下后，不解，不大便五六日，上至十余日，日晡发潮热，不恶寒，独如见鬼状。
若剧者，发则不识人，循衣摸床，惕则不安，微喘直视，脉弦者生，涩者死。微者，但发热
谵语者，大承气汤主之。若一服利，止后服。
首段总言吐下不解，不大便，日晡发潮热，不恶寒，如见鬼状之病。第二段分剧者不识
人，循衣摸床，惕而不安，微喘直视，脉弦者生，若脉涩者则死。后段言症之微者，但发
热谵语，可以大承气汤。大便一利，不可再服。
阳明病，谵语有潮热，反不能食者，胃中必有燥屎五六枚也。若能食者，但硬耳，宜大承气汤。
此章千古误注。曰阳明病，则无太阳少阳表症。谵语潮热，乃里热无疑。阳明胃热，本能
食。今反不能食，乃是肠胃有燥屎，内无容物之地，当用大承气汤。若能食者，胃虽热，
尚有容物之地，但硬大便未必有燥屎，不可用大承气汤。前贤见大承气汤，在末句，皆注
曰同用此方，岂理也哉。
伤寒六七日，目中不了了，睛不和，无表里症，大便难，身微热者，此为实也，急下之，宜大承气。
目睛不和，表症也。今六七日传里日期，无表里症，大便难，身微热，非阳明表邪，乃是
阳明里症实热，故急下之。按仲景用急下有六条，阳明经三条，皆救津液。一日汗多，津
越于外；一曰潮热，便结津竭于内；一曰目睛不和，津竭于上。少阴经三条，皆救肾水。
一曰真水自竭；一曰木燥水枯；一曰土燥水干。夫人以津液养生，停聚则病，泥结则危，
干竭则死。邪在太阳，则结聚肌肉，而毛窍不通，故用发表，以散结聚。邪在少阳，则结
聚半表半里，而胸胁满呕，故用和解，以开结聚。邪在阳明之里，则结聚肠胃，而大便
不通，故用下法，以通结聚。
阳明病，胁下硬满，不大便而呕，舌上白苔者，可与小柴胡汤。上焦得通，津液得下，胃气
因和， 然汗出而解矣。
阳明病，胁下硬满，不大便而呕，舌上白苔，少阳半表半里，和解发汗之症，故宜小柴胡
汤。此申明和解，可以通津液发汗也。
太阳阳明者，脾约也。正阳阳明者，胃实也。少阳阳明者，发汗利小便已，胃中躁烦实，大
便难是也。
言太阳阳明者，太阳表邪，后归阳明之里，阳明里热，又内传太阴，约束大便坚结，故曰
脾约也。正阳阳明者，阳明热邪，不传太阴而传大肠燥热也。少阳阳明者，发汗利小便
后，传阳明肠胃，烦燥而大便难也。此章分别三阳传里，大便结硬也。
伤寒脉浮而缓，手足自温者，是为系在太阴。太阴者，身当发黄，若小便自利者，不能发
黄，至七八日大便硬者，为阳明病也。
此承明上条阳明之热，内传太阴而为燥热脾约者，当用脾约丸。若少阴复传阳明，大便
硬，脉大沉数者，仍用承气汤，不比太阴篇湿热系在太阴而下秽腐之条。
少阴病，六七日腹胀不大便者，急下之，宜大承气汤。
上条言太阴热邪，外传阳明。此条言少阴热邪，外传阳明，有便腹胀急下之症，宜用大承气汤。
下利谵语者，有燥屎也，宜小承气汤。
上章言腹胀满不大便，宜急下；此章言下利谵语，无腹胀不大便，即有燥屎亦止，宜小承气汤。
二阳并病，太阳病罢，但发汗潮热，手足 出，大便难而谵语者，下之则愈，宜大承气汤。
太阳症罢，则表症全无。但发潮热，手足多汗，大便难，谵语者，此阳明应下之症。
小承气汤
枳壳 浓朴 大黄
此方下剂之轻者。表有邪，加柴胡、葛根；中气虚，加人参、广皮、甘草；小便不利，加木通。
大承气汤
枳壳 浓朴 大黄 芒硝
痞满腹胀，应急下症，则用此方。
大柴胡汤 见寒热。
下症虽见，尚带少阳表症者，则以此方双解表里。
麻仁丸
麻仁 白芍药 枳实 大黄 杏仁 浓朴
热结阳明气分者，则用承气汤。热结太阴血分者，则此方。
大便秘结，在杂病门类中有实秘、虚秘、风秘、冷秘、热秘、气秘、血枯之分；在外感病门类中，病症分为表证未解、半表半里证、表证已解、表邪传入里证，治疗分为应当攻下、紧急攻下、轻微攻下、大力攻下、可以攻下、不可以攻下、不可攻下、等待并使用蜜导等方法。如果表汗尚未发出，表证依然存在，病位在胸前，脉象浮而身体发热，或脉细而不数，或脉伏隐不出，面色红赤烦躁，胸前有食积停滞，久病多汗，血液枯竭津液耗尽的情况，不可攻下。身体没有大热，手足多汗，大便干硬腹胀，身体没有表邪，想排便却排不出来，时常有臭气从肛门排出，口燥咽干，口渴且饮水即消，大便长期结滞，经常感到胀满，舌苔黄焦黑，腹中疼痛，应当紧急攻下，均使用大承气汤。然而张仲景的攻下法，既在此条中详细论述，又在自汗门内详细论述，良因攻下法最怕表邪未散，表汗未透，必须待自汗多汗后表邪才解除，互相参照研读，才不会出错误。如果大便不通，脐腹部胀痛，表证存在而里证尤其急迫，不得不攻下的，仅用大柴胡汤，双解表里。如果热势轻结聚少，津液干涸，便秘不通，腹胀未满，不转矢气（放屁）的，宜轻微攻下，仅用小承气汤。如果大便不通，腹部不胀满，没有想大便的感觉，即使大便闭结，等待其有热无结，不转矢气的，宜等待。津液不足，大便干结，血枯热微的，宜生津养血，外用蜜导。上部胸胃无热，不耐受承气汤的苦寒，下部大肠热结，用胆汁外导。因此大便闭结，只以表邪是否解除、里热是否结聚、汗出多少、体表是否有热、下证是否急迫、粪便是否干硬、津液是否干枯、脐腹是否疼痛、脉搏是否数急，来辨别可下、不可下、微下、急下、等待及导引的方法。
伤寒脉象阳部微弱而汗少，这是自身调和的表现。汗出过多的，属于太过。阳脉实，因发汗导致汗出过多的，也属于太过。太过，则阳气绝于体内，亡失津液，大便因此变硬。
此条说明汗出太多，则阳液竭绝于体内，名为亡津液，大便因此变硬，并非指阳火虚寒。
太阳病，如果发汗，如果攻下，如果利小便，这会导致亡失津液，胃中干燥，因而转属阳明病。不排便，内实，大便困难的，这名叫阳明病。
此条申述上章汗下导致亡津液，胃中干燥，内实，大便难，这名叫阳明里证。
太阳病，如果吐，如果攻下，如果发汗，出现轻微心烦，小便频数，大便因此变硬的，给予小承气汤调和即可痊愈。
此条申述上章吐下之后，虽有阳明可下之症，但津液耗尽，仅给予小承气汤调和。
病患不恶寒而口渴，这是转属阳明病。小便频数的，大便必定干硬，十天不排便，也没有痛苦。口渴想喝水，少量给予，依法救治。
此条申述不大便，没有胀苦，不是攻下之症。详细注解口渴。
阳明病，本来就有汗出，医生又重发汗，病虽好转，尚且轻微心烦不适的，这是因为大便必定干硬的缘故。因为亡失津液，胃中干燥，所以使大便变硬。应当询问他每天小便几次，如果原本每天小便三四次，今天只有两次，所以知道大便不久会排出。现在因为小便频数，津液减少，应当回流进入胃中，所以不久必定大便通畅。
此条重申多汗亡津液，大便硬不可攻下，宜等待。张仲景常以小便利与不利，来判断粪便干硬与否。现在又以小便减少，来判断水液回流大肠，而必定大便自行排出。
阳明病，自汗出，如果发汗，小便自利的，这是津液内竭，虽然大便硬也不可攻伐，应当等待病人自己想大便时，宜用蜜煎导通大便，或者土瓜根及猪胆汁，都可以作为导引。
此条承接上文重亡津液，即使大便硬，有下症的，仅适宜用外导法。
阳明病，脉迟，虽然有汗出不恶寒，身体必定沉重，短气腹满而喘，有潮热的，这是表证欲解，可以攻里了。手足濈然汗出的，这是大便已经硬了，用大承气汤。如果汗多，微发热恶寒的，表证未解，其热不潮，不可给予承气汤。如果腹大满不通的，可给予小承气汤。轻微调和胃气，不要令其大泄下。
阳明脉洪大，现在反而迟，这不是浮紧的表脉。大凡汗出不恶寒的，没有身重，现在虽然有身重，短气而喘，因为有潮热，则可以攻里了。然而必须手足汗出，则大便已硬，宜用大承气。如果汗多而见发热恶寒，其热不潮，不可攻下。如果腹大满不通，只可用小承气汤，轻微调和胃气。
病患不大便五六天，绕脐痛，烦躁，发作有定时的，这是有燥屎致使大便不通。
大攻下之后，六七天不大便，烦闷不解腹满的，这是有燥屎。之所以这样，是因为本有宿食，宜用大承气汤。
以上诸条，关防不可用下法和外导法等。这两条又恐应下而未下，所以说腹满痛，烦躁发作有时，不大便，就是有燥屎，急需攻下的。
阳明病潮热，大便微硬的，可给予大承气汤。不硬的，不可给予。如果不大便六七天，恐怕有燥屎，想知道的方法，少量给予小承气汤入腹中，转矢气的，这是有燥屎，才可攻伐。如果不转矢气，这只是初头硬而后必溏，不可攻伐，攻伐必定胀满不能进食。想喝水的，给水则哕逆，其后发热，必定大便硬而量少，用小承气汤调和。不转矢气的，谨慎不可攻伐。
上两条申述大下的诀窍，以下又关防若未见燥粪，尚宜探讨。例如阳明病，见潮热里证，又见大便微硬，可与大承气汤。若不硬者，切勿给予。若不大便六七天，恐怕有燥屎，当给予小承气汤。若汤入腹，有臭气下矢，这是有燥屎可攻。若不矢臭气，但初头硬，后必溏，攻伐必定胀满不能进食。想喝水的，给水则胃寒而哕逆。其后虽发热烦躁，即大便硬，然结粪必少，只可以用小承气汤调和。若不转矢气，谨慎不可攻伐。
得病二三日，脉弱，无太阳柴胡症、烦躁，心下硬，至四五日，虽然能食，以小承气汤，少量轻微调和，令其稍安，至六日给予承气汤。如果不大便六七天，小便少的，虽然不能食，但初头硬，后必溏，未定成硬，攻伐必定溏泄。须小便利，屎定硬，才可攻伐，宜用大承气汤。
上半节，以脉弱无太阳少阳表症，而有烦躁心下硬应下之症，故即使能食，也宜以小承气汤微和之。下半节，以小便少别粪未必硬，即使不能食，不可攻伐，须待小便多屎定硬方可攻伐。
阳明病，谵语发潮热，脉滑而疾的，小承气汤主治。因给予小承气汤一升，腹中转矢气的，再给一升。如果不转矢气，不要再给予。明天不大便，脉反微涩的，是里虚，为难治，不可再给予承气汤。
此条言服承气汤，不转臭气，又不大便，不可再服。详细注解潮热，宜互看。
阳明病，其人汗多，以津液外出，胃中燥，大便必硬，硬则谵语，小承气汤主治。如果一服谵语止，更不要再服。
多汗则津液大泄，胃中必干，大便必硬，上热不得下泄，故谵语。然用小承气汤，清胃热，止谵语，不求必下结粪，故谵语止，勿再服。
伤寒四五日，脉沉而喘满，沉为在里，而反发其汗，津液越出，大便为难，表虚里实，久则谵语。
此重申误汗亡津液，大便必难，久则谵语。如脉沉喘满，乃里热之喘，误认表邪，反发其汗，大便必难，里热不得下泄，久则谵语。
伤寒如果吐如果攻下后，病不解，不大便五六日，上至十余日，日晡发潮热，不恶寒，独如见鬼状。如果严重的，发作时不识人，循衣摸床，惕而不安，微喘直视，脉弦者生，涩者死。轻微的，但发热谵语的，大承气汤主治。如果一服利，停止后服。
首段总言吐下不解，不大便，日晡发潮热，不恶寒，如见鬼状之病。第二段分剧者不识人，循衣摸床，惕而不安，微喘直视，脉弦者生，若脉涩者则死。后段言症之微者，但发热谵语，可以大承气汤。大便一利，不可再服。
阳明病，谵语有潮热，反不能食的，胃中必有燥屎五六枚也。若能食的，但硬耳，宜大承气汤。
此章千古误注。曰阳明病，则无太阳少阳表症。谵语潮热，乃里热无疑。阳明胃热，本能食。今反不能食，乃是肠胃有燥屎，内无容物之地，当用大承气汤。若能食者，胃虽热，尚有容物之地，但硬大便未必有燥屎，不可用大承气汤。前贤见大承气汤，在末句，皆注曰同用此方，岂理也哉。
伤寒六七日，目中不了了，睛不和，无表里症，大便难，身微热者，此为实也，急下之，宜大承气。
目睛不和，表症也。今六七日传里日期，无表里症，大便难，身微热，非阳明表邪，乃是阳明里症实热，故急下之。按仲景用急下有六条，阳明经三条，皆救津液。一日汗多，津越于外；一曰潮热，便结津竭于内；一曰目睛不和，津竭于上。少阴经三条，皆救肾水。一曰真水自竭；一曰木燥水枯；一曰土燥水干。夫人以津液养生，停聚则病，泥结则危，干竭则死。邪在太阳，则结聚肌肉，而毛窍不通，故用发表，以散结聚。邪在少阳，则结聚半表半里，而胸胁满呕，故用和解，以开结聚。邪在阳明之里，则结聚肠胃，而大便不通，故用下法，以通结聚。
阳明病，胁下硬满，不大便而呕，舌上白苔的，可给予小柴胡汤。上焦得通，津液得下，胃气因和，漐然汗出而解矣。
阳明病，胁下硬满，不大便而呕，舌上白苔，少阳半表半里，和解发汗之症，故宜小柴胡汤。此申明和解，可以通津液发汗也。
太阳阳明者，脾约也。正阳阳明者，胃实也。少阳阳明者，发汗利小便已，胃中躁烦实，大便难是也。
言太阳阳明者，太阳表邪，后归阳明之里，阳明里热，又内传太阴，约束大便坚结，故曰脾约也。正阳阳明者，阳明热邪，不传太阴而传大肠燥热也。少阳阳明者，发汗利小便后，传阳明肠胃，烦燥而大便难也。此章分别三阳传里，大便结硬也。
伤寒脉浮而缓，手足自温者，是为系在太阴。太阴者，身当发黄，若小便自利者，不能发黄，至七八日大便硬者，为阳明病也。
此承明上条阳明之热，内传太阴而为燥热脾约者，当用脾约丸。若少阴复传阳明，大便硬，脉大沉数者，仍用承气汤，不比太阴篇湿热系在太阴而下秽腐之条。
上条言太阴热邪，外传阳明。此条言少阴热邪，外传阳明，有便腹胀急下之症，宜用大承气汤。
上章言腹胀满不大便，宜急下；此章言下利谵语，无腹胀不大便，即有燥屎亦止，宜小承气汤。
二阳并病，太阳病罢，但发汗潮热，手足 出，大便难而谵语者，下之则愈，宜大承气汤。
太阳症罢，则表症全无。但发潮热，手足多汗，大便难，谵语者，此阳明应下之症。
小承气汤
枳壳 浓朴 大黄
此方下剂之轻者。表有邪，加柴胡、葛根；中气虚，加人参、广皮、甘草；小便不利，加木通。
大承气汤
枳壳 浓朴 大黄 芒硝
痞满腹胀，应急下症，则用此方。
Constipation, in the category of miscellaneous diseases, is divided into excess constipation (Shi Mi), deficiency constipation (Xu Mi), wind constipation (Feng Mi), cold constipation (Leng Mi), heat constipation (Re Mi), qi constipation (Qi Mi), and blood depletion constipation (Xue Ku). In the category of external contraction diseases, symptoms are divided into unresolved exterior syndrome (Biao Wei Jie), half-exterior half-interior syndrome (Ban Biao Ban Li), resolved exterior syndrome (Biao Yi Jie), and exterior pathogen transmitting to interior (Biao Xie Chuan Li). Treatments are divided into should purge (Ying Xia), urgently purge (Ji Xia), mildly purge (Wei Xia), heavily purge (Da Xia), can purge (Ke Xia), cannot purge (Wei Ke Xia), absolutely cannot purge (Bu Ke Xia), and waiting with honey suppository methods (Si Zhi Mi Dao). If the exterior sweat has not been released, and the exterior syndrome still exists, with the disease located in the chest, floating pulse with body fever, fine and non-rapid pulse, or hidden pulse not emerging, red face with irritability, food stagnation in the chest, prolonged illness with excessive sweating, exhausted blood and depleted fluids, purging is contraindicated. If there is no significant body heat, excessive sweating on hands and feet, hard stool with abdominal distension, no exterior pathogen, desire to defecate but inability, frequent passage of foul gas, dry mouth and throat, thirst with rapid water consumption, long-term constipation, frequent fullness, yellow and scorched tongue coating, and abdominal pain, urgent purging is indicated, using Da Cheng Qi Tang (Major Order the Qi Decoction). However, Zhang Zhongjing's purging methods are detailed not only in this section but also in the spontaneous sweating chapter, primarily because purging is most feared when the exterior pathogen has not dispersed and exterior sweat is not thorough; only after spontaneous and excessive sweating does the exterior pathogen resolve. Cross-referencing these sections prevents errors. If bowel obstruction occurs with umbilical and abdominal distension and pain, where the exterior syndrome exists but the interior syndrome is particularly urgent, requiring purging, use only Xiao Chai Hu Tang (Minor Order the Gallbladder Decoction) to simultaneously resolve the exterior and interior. If heat is mild with little accumulation, fluids are dried up, constipation is present without significant abdominal distension, and no flatus passes, mild purging is appropriate, using only Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If there is bowel obstruction without abdominal distension, no urge to defecate, even if stools are bound, wait for signs of heat without accumulation and no flatus; waiting is appropriate. For insufficient fluids, dry hard stools, blood depletion with mild heat, nourishing fluids and blood with external honey suppositories is suitable. If there is no heat in the upper chest and stomach, making the patient intolerant to the bitter-cold nature of Cheng Qi formulas, but there is heat accumulation in the lower large intestine, bile suppositories can be used externally. Thus, for bowel obstruction, one distinguishes between purgative and non-purgative, mild and urgent purging, and waiting or guiding methods based on whether the exterior pathogen is resolved, whether interior heat is accumulated, the amount of sweating, presence of body heat, urgency of purgative indications, hardness of stool, dryness of fluids, presence of abdominal pain, and rapidity of pulse.
In Shanghan (Cold Damage), a weak Yang pulse with scant sweating indicates self-harmony. Excessive sweating indicates excess. A solid Yang pulse followed by excessive sweating due to diaphoresis also indicates excess. Excess leads to Yang exhaustion internally and loss of body fluids, causing the stool to become hard.
This section explains that excessive sweating causes Yang fluids to be exhausted internally, termed "loss of body fluids," leading to hard stools, not referring to Yang fire deficiency or cold.
In Taiyang disease, if diaphoresis, purging, or promoting urination is performed, it results in loss of body fluids, dryness of the stomach, and transformation into Yangming disease. Failure to defecate, internal excess, and difficulty in defecation constitute Yangming disease.
This clarifies that previous chapters' sweating and purging causing fluid loss, stomach dryness, internal excess, and difficulty defecating constitute Yangming interior syndrome.
In Taiyang disease, if vomiting, purging, or sweating is performed, resulting in slight irritability, frequent urination, and consequently hard stools, administer Xiao Cheng Qi Tang to harmonize and cure.
This clarifies that after vomiting and purging, although Yangming purgative indications exist, since fluids are exhausted, only Xiao Cheng Qi Tang should be used to harmonize.
If the patient is not aversed to cold but feels thirsty, this indicates transformation into Yangming disease. Frequent urination implies hard stools; ten days without defecation without discomfort is possible. If thirsty for water, give small amounts frequently to treat according to principles.
This clarifies that lack of defecation without distension or discomfort is not an indication for purging. Detailed notes on thirst follow.
In Yangming disease, originally characterized by spontaneous sweating, if the physician induces heavy sweating again, and although the illness has improved, slight irritability and malaise persist, this is because the stool must be hard. Due to loss of body fluids and stomach dryness, the stool becomes hard. One should ask about daily urine frequency; if originally three to four times daily but now only twice, it indicates stool will soon pass. Now, due to frequent urination and reduced fluids, fluids should return to the stomach, so stool will likely pass soon.
This reiterates that excessive sweating causing fluid loss and hard stool contraindicates purging; waiting is appropriate. Zhang Zhongjing often uses urine availability to determine stool hardness. Here, reduced urine indicates water returning to the large intestine, ensuring spontaneous defecation.
In Yangming disease, with spontaneous sweating, induced sweating, and free urination, this indicates internal exhaustion of body fluids. Although the stool is hard, it cannot be attacked; one must wait for the patient's urge to defecate, using honey suppositories to guide passage. Radix Trichosanthis (Tu Gua Gen) and pig bile can also serve as guides.
This continues from the previous text on severe fluid loss; even with hard stool and purgative indications, external guidance is appropriate.
In Yangming disease, a slow pulse, despite sweating and aversion to cold being absent, implies heaviness of the body, shortness of breath, abdominal fullness, and wheezing. With tidal fever, the exterior is resolving, and interior attack is possible. Continuous sweating on hands and feet indicates hard stool; use Da Cheng Qi Tang. If sweating is profuse with slight fever and aversion to cold, the exterior is unresolved; without tidal fever, do not give Cheng Qi Tang. If abdominal distension and blockage are severe, Xiao Cheng Qi Tang may be given to mildly harmonize stomach Qi, avoiding drastic purging.
A Yangming pulse is typically surging and large; a slow pulse here is not a floating-tight exterior pulse. Generally, sweating without aversion to cold lacks body heaviness. Here, despite heaviness, shortness of breath, and wheezing, tidal fever allows interior attack. However, continuous hand-foot sweating confirms hard stool, warranting Da Cheng Qi Tang. Profuse sweating with fever and aversion to cold, without tidal fever, contraindicates purging. Severe abdominal distension and blockage warrant only Xiao Cheng Qi Tang to mildly harmonize stomach Qi.
If the patient has not defecated for five to six days, experiences periumbilical pain, irritability, and periodic发作, this indicates dry fecal matter causing obstruction.
After severe purging, if there is no defecation for six to seven days, accompanied by irritability and abdominal fullness, this indicates dry fecal matter. This is due to retained food residue; Da Cheng Qi Tang is appropriate.
The above sections caution against inappropriate use of purging and external guidance. These two sections warn against missing indications for purging; thus, abdominal distension/pain, periodic irritability, and constipation indicate dry feces requiring urgent purging.
In Yangming disease with tidal fever and slightly hard stool, Da Cheng Qi Tang may be given. If not hard, do not give. If no defecation for six to seven days and dry feces are suspected, test by giving a small dose of Xiao Cheng Qi Tang. Passage of flatus indicates dry feces amenable to attack. If no flatus, the stool is likely hard at the beginning and loose later; attacking it will cause distension and anorexia. Thirst with water intake causing hiccups, followed by fever, indicates hard but scant stool; treat with Xiao Cheng Qi Tang to harmonize. If no flatus, cautiously avoid attacking.
These two sections explain the key to major purging, while subsequent sections caution against attacking without confirmed dry feces. For example, in Yangming disease with tidal fever and interior signs plus slightly hard stool, Da Cheng Qi Tang is suitable. If not hard, do not give. If no defecation for six to seven days suspecting dry feces, use Xiao Cheng Qi Tang. If flatus with foul odor passes after ingestion, dry feces are present and can be attacked. If no foul flatus, only the beginning is hard and the rest loose; attacking causes distension and anorexia. Thirst with water causes stomach cold and hiccups. Subsequent fever and irritability with hard stool imply scant dry feces; only Xiao Cheng Qi Tang should harmonize. If no flatus, cautiously avoid attacking.
Two to three days after onset, with a weak pulse, absence of Taiyang or Shaoyang symptoms, irritability, and epigastric hardness, progressing to day four or five: even if the patient can eat, give a small amount of Xiao Cheng Qi Tang to mildly harmonize and provide relief. By day six, administer Cheng Qi Tang. If no defecation for six to seven days and urine is scant, even if unable to eat, the stool is likely hard initially and loose later, not definitively hard; attacking will cause diarrhea. Wait until urine is abundant and stool is definitely hard before attacking with Da Cheng Qi Tang.
The first part states that with a weak pulse and absence of Taiyang/Shaoyang exterior signs, but presence of irritability and epigastric hardness indicating purgative need, even with appetite, Xiao Cheng Qi Tang should mildly harmonize. The second part states that scant urine suggests stool may not be hard; even with anorexia, do not attack. Wait for abundant urine and definitive hard stool before attacking.
In Yangming disease, delirium with tidal fever and a slippery, rapid pulse is treated with Xiao Cheng Qi Tang. Administer one sheng of Xiao Cheng Qi Tang; if flatus passes, give another sheng. If no flatus, do not give more. If no defecation the next day and the pulse becomes faint and choppy, this indicates interior deficiency, making treatment difficult; do not give Cheng Qi Tang again.
This section states that if, after taking Cheng Qi Tang, there is no foul flatus and no defecation, do not continue administration. Refer to notes on tidal fever for cross-reference.
In Yangming disease, if the patient sweats excessively, fluids exit externally, causing stomach dryness and hard stool, leading to delirium. Xiao Cheng Qi Tang is indicated. If delirium ceases after one dose, do not administer further.
Excessive sweating causes massive fluid loss and stomach dryness, leading to hard stool. Upper heat cannot descend, causing delirium. Xiao Cheng Qi Tang clears stomach heat and stops delirium without necessarily purging dry feces; thus, stop administration once delirium ceases.
In Shanghan, on day four or five, a deep pulse with wheezing and fullness indicates interior involvement. Inducing sweating in error causes fluids to escape, making defecation difficult, resulting in exterior deficiency and interior excess, eventually leading to delirium.
This reiterates that erroneous sweating causes fluid loss, making defecation difficult and eventually causing delirium. A deep pulse with wheezing/fullness indicates interior heat wheezing; mistaking it for exterior pathogen and inducing sweating makes defecation difficult, preventing interior heat discharge and causing delirium.
In Shanghan, after vomiting or purging, if the condition remains unresolved, with no defecation for five to six days up to ten-plus days, tidal fever at dusk, no aversion to cold, and hallucinations (seeing ghosts): in severe cases, confusion, grasping at clothes and bed, fearfulness, slight wheezing, and fixed gaze occur. A wiry pulse indicates survival; a choppy pulse indicates death. In mild cases, only fever and delirium occur, treated with Da Cheng Qi Tang. If one dose relieves, stop subsequent doses.
The first paragraph summarizes unresolved conditions after vomiting/purging, no defecation, dusk tidal fever, no aversion to cold, and hallucinations. The second paragraph details severe cases: confusion, grasping, fear, wheezing, fixed gaze; wiry pulse is good, choppy is bad. The final paragraph addresses mild cases with only fever and delirium, treatable with Da Cheng Qi Tang; stop after one relieving dose.
In Yangming disease, delirium with tidal fever and inability to eat indicates five or six pieces of dry feces in the stomach. If able to eat, the stool is merely hard; Da Cheng Qi Tang is appropriate.
This section corrects ancient misinterpretations. Yangming disease implies absence of Taiyang/Shaoyang exterior signs. Delirium and tidal fever confirm interior heat. Yangming stomach heat normally allows eating. Inability to eat indicates dry feces occupying space in the intestines/stomach, requiring Da Cheng Qi Tang. Ability to eat indicates remaining space for food; hard stool does not necessarily mean dry feces, so Da Cheng Qi Tang is contraindicated. Previous scholars noted Da Cheng Qi Tang at the end of the sentence and assumed uniform application, which is illogical.
In Shanghan, on day six or seven, unclear vision and unfocused eyes, absence of exterior/interior signs, difficulty defecating, and slight body heat indicate excess; urgent purging with Da Cheng Qi Tang is required.
Unfocused eyes are an exterior sign. On day six or seven, transmission to interior occurs. Absence of exterior/interior signs, difficulty defecating, and slight heat indicate not Yangming exterior pathogen but Yangming interior excess heat, hence urgent purging. Zhang Zhongjing lists six urgent purging indications: three in Yangming channel, all saving fluids (excessive sweating, tidal fever with internal fluid exhaustion, unfocused eyes with upper fluid exhaustion); three in Shaoyin channel, all saving kidney water (true water exhaustion, wood dryness/water depletion, earth dryness/water drying). Humans rely on fluids for life; stagnation causes disease, binding causes danger, exhaustion causes death. Pathogens in Taiyang bind muscles and block pores, requiring exterior release to dissipate binding. Pathogens in Shaoyang bind half-exterior/half-interior, causing chest/flank fullness and vomiting, requiring harmonization to open binding. Pathogens in Yangming interior bind intestines/stomach, causing constipation, requiring purging to unblock binding.
In Yangming disease, hardness and fullness in the hypochondrium, constipation, vomiting, and white tongue coating indicate Xiao Chai Hu Tang (Minor Order the Gallbladder Decoction). Once the upper jiao is unblocked, fluids descend, stomach Qi harmonizes, and sweating resolves the condition.
Yangming disease with hypochondriac hardness/fullness, constipation, vomiting, and white tongue coating represents Shaoyang half-exterior/half-interior syndrome, requiring harmonization and sweating via Xiao Chai Hu Tang. This clarifies that harmonization can unblock fluids and induce sweating.
Taiyang-Yangming refers to Spleen Constraint (Pi Yue). Zhengyang-Yangming refers to Stomach Excess (Wei Shi). Shaoyang-Yangming refers to agitation, irritability, excess, and difficulty defecating after sweating and promoting urination.
Taiyang-Yangming: Taiyang exterior pathogen transmits to Yangming interior; Yangming interior heat further transmits to Taiyin, constraining hard stool, hence "Spleen Constraint." Zhengyang-Yangming: Yangming heat pathogen transmits directly to Large Intestine dry-heat without passing through Taiyin. Shaoyang-Yangming: After sweating and diuresis, transmission to Yangming intestines/stomach causes agitation and difficulty defecating. This section distinguishes the three Yang channels transmitting to interior with constipation.
In Shanghan, a floating and slow pulse with warm hands and feet indicates attachment to Taiyin. Taiyin disease typically presents with jaundice; however, if urination is free, jaundice does not develop. By day seven or eight, if stool becomes hard, it is Yangming disease.
This follows the previous line on Yangming heat transmitting to Taiyin causing dry-heat Spleen Constraint, treated with Pi Yue Wan. If Shaoyin re-transmits to Yangming with hard stool and a large, deep, rapid pulse, Cheng Qi Tang is still used, unlike the damp-heat Taiyin section involving foul discharge.
In Shaoyin disease, abdominal distension and constipation after six or seven days require urgent purging with Da Cheng Qi Tang.
The previous line discussed Taiyin heat transmitting outward to Yangming. This line discusses Shaoyin heat transmitting outward to Yangming, presenting with abdominal distension requiring urgent purging with Da Cheng Qi Tang.
Diarrhea with delirium indicates dry feces; Xiao Cheng Qi Tang is appropriate.
The previous chapter discussed abdominal distension/constipation requiring urgent purging. This chapter discusses diarrhea with delirium without abdominal distension/constipation; even if dry feces exist, only Xiao Cheng Qi Tang is appropriate.
In combined disease of two Yang channels, after Taiyang disease resolves, only tidal fever, sweating on hands/feet, difficulty defecating, and delirium remain. Purging cures; Da Cheng Qi Tang is appropriate.
With Taiyang symptoms resolved, exterior signs are gone. Tidal fever, excessive hand/foot sweating, difficulty defecating, and delirium indicate Yangming purgative indications.
Xiao Cheng Qi Tang (Minor Order the Qi Decoction)
Zhi Qiao (Immature Bitter Orange), Hou Po (Magnolia Bark), Da Huang (Rhubarb).
This is a mild purgative formula. Add Chai Hu (Bupleurum) and Ge Gen (Kudzu Root) for exterior pathogens; add Ren Shen (Ginseng), Chen Pi (Tangerine Peel), and Gan Cao (Licorice) for middle Qi deficiency; add Mu Tong (Akebia Stem) for difficult urination.
Da Cheng Qi Tang (Major Order the Qi Decoction)
Zhi Qiao (Immature Bitter Orange), Hou Po (Magnolia Bark), Da Huang (Rhubarb), Mang Xiao (Mirabilite).
For痞满 (stifling fullness) and abdominal distension requiring urgent purging, use this formula.
Da Chai Hu Tang (Major Order the Gallbladder Decoction) - See Fever and Chills.
When purgative indications are present but accompanied by Shaoyang exterior signs, use this formula to simultaneously resolve exterior and interior.
Ma Ren Wan (Hemp Seed Pill)
Ma Ren (Hemp Seed), Bai Shao Yao (White Peony Root), Zhi Shi (Immature Bitter Orange), Da Huang (Rhubarb), Xing Ren (Apricot Seed), Hou Po (Magnolia Bark).
For heat accumulation in Yangming Qi level, use Cheng Qi Tang. For heat accumulation in Taiyin Blood level, use this formula.