字。玉函。必上。更有攻之二字。案无者字。为是。）
〔成〕合。通也。阳明病面色通赤者。热在经也。不可下之。下之虚其胃气。耗其津液。经中之热。乘虚
入胃。必发热色黄。小便不利也。〔柯〕面色正赤者。阳气怫郁在表。当以汗解。而反下之。热不得越。故复发
热。而赤转为黄也。总因津液枯涸。不能通调水道而然。须栀子柏皮。滋化源而致津液。非渗泄之剂所宜矣。
汪氏云。郭白云曰。既不可攻。但茵陈蒿汤。调五苓散
服之。太谬之极。此与二阳并病。面色缘缘正赤相同。可小发汗。宜桂枝加葛根汤。以微汗之。
案张璐云。下虚之人。才感外邪。则挟虚火。而面色通红。总由真阳素虚。无根之火。随表药之性上升。
云云。世素有此证。然与本条之义。不相干焉。
阳明病。不吐不下。心烦者。可与调胃承气汤。（玉函。千金翼。作不吐下而烦。脉经同。无调胃二字。）
〔柯〕言阳明病。则身热汗出。不恶寒反恶热矣。若吐下后而烦。为虚邪。宜栀子豉汤。〔汪〕不吐不下
者。热邪上不得越。下不得泄。郁胃腑之中。其气必上熏于膈则心烦。烦。闷而热也。〔钱〕但心烦。不若潮
热便硬之胃实。所以不必攻下。而可与调胃承气汤也。〔张〕可与者。欲人临病裁酌。不可竟行攻击也。〔舒〕
案心烦一证。阴阳互关。宜加细察。而后用药。调胃承气。不可轻试。
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。可攻里也。手足 然
汗出者。此大便已硬也。大承气汤主之。若汗多。微发热恶寒者。外未解也。（【原注】一法。与桂枝汤。）
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。勿令至大泄下。（攻里间。玉函。
脉经。有其字。 然下。成本。有而字。汗多间。玉函。有出字。外未解也下。千金。外台。有桂枝汤主之五
字。不通。脉经。千金作不大便。勿令下。成本。无至字。外台。至。作致。）
〔魏〕汗出。太阳所有。而不恶寒。则太阳所无也。身疼体痛。太阳所有。而身重则太阳所无也。兼以短
气腹满。喘而潮热。纯见里证。而不见表证。知此外之太阳病。欲解而非解也。乃转属阳明。而阳明之胃实将
成也。考验于此八者。乃可攻里。无疑矣。但攻里又非一途。更必于汗于热辨之。
如手足 然。而汗出者。胃热盛而逼汗于四末。津液知其内亡矣。大便必已干硬。胃实之成。确乎不易。大承
气汤。荡积通幽。何容缓乎。若汗虽多。而发热反微。且带恶寒。仍存于表可知矣。再谛之于热。汗出虽多。
热却不潮。则阳明之病未尽全。仍当从太阳表治可也。或病患患腹大满不通者。则胃家已有闷塞之征。小承气。
调和胃气。下而非下。勿令大泄下。以伤正气也。〔张〕仲景既言脉迟尚未可攻。而此证首言脉迟。复言可攻者。
何也。夫所谓脉迟。尚未可攻者。以腹中热尚未甚。燥结未定。故尚未宜攻下。攻之必胀满不食。而变结胸痞
满等证。须俟脉实结定。后方可攻之。此条虽云脉迟。而按之必实。且其证一一尽显胃实。故当攻下无疑。若
以脉迟。妨碍一切下证。则大陷胸之下证最急者。亦将因循缩手待毙乎。〔程〕身重者。经脉有所阻也。表里
邪盛。皆能令经脉阻。邪气在表而喘者。满或在胸。而不在腹。此则腹满而喘。知外欲解。可攻里也。
案程氏以脉迟。为尚未可攻之迟脉。柯氏钱氏。为中寒无阳之迟脉。并与经旨左矣。
钱氏云。热邪归胃。邪气根据附于宿食粕滓。而郁蒸煎迫。致胃中之津液枯竭。故发潮热。而大便硬也。
若不以大承气汤下之。必至热邪败胃。谵语狂乱。循衣摸床等变而至不救。
锡驹云。四肢皆禀气于胃。手足汗出者。阳明胃气盛也。
舒氏云。吾家有时宗者。三月病热。予与仲远同往视之。身壮热而谵语。苔刺满口。秽气逼人。少腹硬
满。大便闭。小便短。脉实大而迟。仲远谓热结在里。其人发狂。小腹硬满。胃实而兼蓄血也。法以救胃为急。
但此人年已六旬。证兼蓄血。下药中宜重加生地黄。一以保护元阴。一以破瘀行
血。予然其言。主大承气汤。硝黄各用八钱。加生地一两。捣如泥。先 数十沸。乃纳诸药同煎。连进五剂。
得大下数次。人事贴然。少进米饮。一二口辄不食。呼之不应。欲言不言。但见舌苔干燥异常。口内喷热如火。
则知里燥尚未衰减。复用犀角地黄汤加大黄。三剂又下胶滞二次。色如败酱。臭恶无状。于是口臭乃除。里燥
仍盛。三四日无小便。忽自取夜壶。小便一回。予令其子取出视之。半壶鲜血。观者骇然。经言血自下。下者
愈。亦生地之功也。复诊之。脉转浮矣。此溃邪有向表之机。合以柴胡汤。迎其机而导之。但此时表里俱还热
极。阴津所存无几。柴胡亦非所宜。惟宜白虎汤。加生地黄芩以救里。倍用石膏之质重气轻。专达肌表。而兼
解外也。如是二剂。得微汗。而脉静身凉。舌苔退。而人事清矣。再用清燥养荣汤。二十剂而痊愈。
大承气汤方
浓朴（半斤炙去皮） 枳实（五枚炙） 芒硝（三合） 大黄（四两酒洗○外台。无酒洗字。）
上四味。以水一斗。先煮二物。取五升。去滓。纳大黄。更煮取二升。去滓。纳芒硝。更上微火一两沸。
分温再服。得下余勿服。（成本。煮上。无更字。微火。作火微。非也。）
〔鉴〕诸积热结于里。而成满痞燥实者。均以大承气汤下之也。满者。腹胁满急 胀。故用浓朴。以消
气壅。痞者。心下痞塞硬坚。故用枳实。以破气结。燥者。肠中燥屎干结。故用芒硝。润燥软坚。实者。腹痛
大便不通。故用大黄。攻积泻热。然必审四证之轻重。四药之多少适其宜。始可与也。若邪重剂轻。则邪气不
服。邪轻剂重。则正气转伤。不可不慎也。〔柯〕诸病皆因于气。秽物之不去。由气之不顺也。故攻积之剂。
必用气分之药。故以承气名汤。煎法更有妙义。
大承气用水一斗。煮朴枳取五升。去滓。纳大黄。再煮取二升。纳芒硝。何哉。盖生者气锐而先行。熟者气纯
而和缓。仲景欲使芒硝先化燥屎。大黄继通地道。而后枳朴除其痞满。若小承气。以三味同煎。不分次第。同
一大黄。而煎法不同。此可见仲景微和之意也。〔知〕调胃承气。大黄用酒浸。大承气。大黄用酒洗。皆为芒
硝之咸寒。而以酒制之。若小承气。不用芒硝。则亦不事酒浸洗矣。
明理论曰。承。顺也。伤寒邪气入胃者。谓之入腑。腑之为言。聚也。胃为水谷之海。营卫之源。水谷会
聚于胃。变化而为营卫。邪气入于胃也。胃中气郁滞。糟粕秘结。壅而为实。是正气不得舒顺也。本草曰。通
可去滞。泄可去邪。塞而不利。闭而不通。以汤荡涤。使塞者利而闭者通。正气得以舒顺。是以承气名之。
总病论。凡脉沉细数。为热在里。又兼腹满咽干。或口燥舌干而渴者。或六七日不大便。小便自如。或目
中瞳子不明。无外证者。或汗后脉沉实者。或下利三部脉皆平。心下坚者。或连发汗已。不恶寒者。或已经下。
其脉浮沉按之有力者。宜大承气汤。
医垒元戎曰。大承气汤。治大实大满。满则胸腹胀满。状若合瓦。大实。则不大便也。痞满燥实。四证俱
备则用之。杂病则进退用之。○案王叔和伤寒例云。若表已解。而内不消。大满大实坚有燥屎。自可除下之。虽
四五日。不能为祸也。好古之说。盖原于此。
内台方议曰。仲景所用大承气者。二十五证。虽曰各异。然即下泄之法也。其法虽多。不出大满大热大
实。其脉沉实滑者之所当用也。
伤寒蕴要曰。大抵下药。必切脉沉实。或沉滑沉疾有力者。
可下也。再以手按脐腹。硬者。或叫痛不可按者。则下之无疑也。凡下后不解者。再按脐腹。有无硬处。如有
手不可按。下未尽也。复再下之。若下后腹中虚软。脉无力者。此为虚也。
外台。崔氏承气丸。疗十余日不大便者。
于本方。去浓朴。加杏仁二两。蜜和丸如弹子。以生姜汤六合。研一丸。服之。须臾即通。
卫生宝鉴。治发狂因触冒寒邪。失于解利。因转属阳明证。胃实谵语。本方加黄连。
理伤续断方。大成汤。一名大承气汤。治伤损瘀血不散。腹肚膨胀。大小便不通。上攻心腹。闷乱至死
者。急将此药。通下瘀血。后方可服损药。
于大承气汤。加甘草陈皮红花当归苏木木通。○损药。乃本方小承气汤。
医经会解。加味承气汤。治痢疾邪毒在里。
于本方。加黄连木香皂角刺。
本草汇言。嘉 方。治伤寒热实结胸。铁锈磨水。入承气汤。服之极验。
医学正传。治一人。六月投渊取鱼。至深秋雨凉。半夜小腹痛甚。大汗。脉沉弦细实。重取如循刀责责
然。夫腹痛脉沉弦细实。如循刀责责然。阴邪固结之象。便不当有汗。今大汗出。此必瘀血留结。营气不能内
守。而渗泄于外也。且弦脉亦肝血受伤之候。与大承气加桂。二服微利痛减。连日于未申时。复坚硬不可近。
与前药。加桃仁泥。下紫血升余。痛止。脉虽稍减。而责责然犹在。又以前药。加川附子。下大便四五行。有
紫黑血如破絮者。二升而愈。
吴勉学汇聚单方。余治一少年。腹痛目不见人。阴茎缩入。喊声彻天。医方灸脐愈痛。欲得附子理中汤。余偶过其
门。诸亲友邀入。余曰。非阴症也。主人曰。晚于他处有失。已审侍儿矣。余曰。阴症声低少。止呻吟耳。今
高厉有力。非也。脉之伏而数且弦。肝为甚。外肾为筋之会。肝主筋。肝火盛也。肝脉绕阴茎。肝开窍于目。
故目不明。用承气汤。一服立止。知有结粪在下故也。凡痛须审察寒热虚实。诸症皆然。久腹痛。多有积。宜消之。
医方集解曰。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。初下利腹痛。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。
正合承气症。但气口虚。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。苟不先补完胃气之伤。而遽行承气。宁免后患乎。此先补后下。例之变也。
伤寒直格曰。活人书。大承气最紧。小承气次之。调胃承气又次之。而缓下急下。善开发而难郁结。可通
用者。大承气汤。最为妙也。故今加甘草。名曰三一承气汤。通治三承气汤。于效甚速。而无加害也。儒门事
亲曰。大承气汤。刘河间加甘草。以为三一承气。以甘和其中。余尝以大承气。改作调中汤。加以姜枣煎。俗
见姜枣。以为补脾胃而喜服。卫生宝鉴曰。若大承气证。反用调胃承气治之。则邪气不散。小承气汤证。反以
大承气汤下之。则过伤正气。此仲景所以分而治之。后之学人。以此三药。合而为一。且云通治三药之证。及
伤寒杂病内外一切所伤。与仲景之方。甚相违背。失轩岐缓急之旨。使病患暗受其弊。将谁咎哉。
小承气汤方
大黄（四两） 浓朴（二两炙去皮） 枳实（三枚大者炙）
上三味。以水四升。煮取一升二合。去滓。分温二服。初服汤当更衣。不尔者尽饮之。若更衣者。勿服
之。（千金翼。作初服谵语即止。服汤当更衣。不尔尽服之。外台。作若一服得利谵语止。勿服之。）
〔钱〕小承气者。即大承气。而小其制也。大邪大热之实于胃者。以大承气汤下之。邪热轻者。及无大热。
但胃中津液干燥。而大便难者。以小承气微利之。以和其胃气。胃和则止。非大攻大下之 剂也。以无大坚实。
故于大承气中。去芒硝。又以邪气未大结满。故减浓朴枳实也。创法立方。惟量其缓急轻重。而增损之。使无
太过不及。适中病情耳。
案钱氏云。大黄四两。既名之曰小。当是二两。汉之二两。即宋之五钱外。分二次服耳。此说无明证。
唯外台崔氏承气汤。即本方。用浓朴大黄各三两。枳实六片。庞氏用大黄二两。而减浓朴一两。枳实一枚。
吴有性瘟疫论曰。案三承气汤。功用仿佛。热邪传里。但上焦痞满者。宜小承气汤。中有坚结者。加芒
硝。软坚而润燥。病久失下。虽无结粪。然多粘腻结臭恶物。得芒硝。则大黄有荡涤之能。设无痞满。惟存宿
结。而有瘀热者。调胃承气宜之。三承气。功效俱在大黄。余皆治标之品也。不耐药汤者。或呕或畏。当为细
末蜜丸汤下。医垒元戎。小承气汤。治痞实而微满。状若饥人。食饱腹中无转失气。即大承气。只去芒硝。心
下痞大便或通。热甚。宜此方。
金匮要略。治腹满痛而闭者。浓朴三物汤。（即本方。用浓朴八两。枳实五枚。）
又治支饮胸满。浓朴大黄汤。（即本方。用浓朴一尺。大黄六两。枳实四枚。）
直指方。枳壳锉散。治热证胀满。
于本方。加桔梗甘草乌梅姜枣。
【原文】（前文残缺，接上文）字。玉函。必上。更有攻之二字。案无者字。为是。）
〔成无己注〕合，通也。阳明病面色通赤的，是热邪在经络。不可用泻下法。如果误用泻下，会损伤胃气，耗竭津液。经络中的热邪便会乘虚进入胃腑，必然出现发热、面色发黄、小便不利等症状。
〔柯琴注〕面色正红的，是阳气怫郁在肌表，应当用发汗法解表。如果反而用泻下法，热邪无法向外发散，所以再次发热，且红色转为黄色。这总归是因为津液枯竭，不能通调水道所致。此时需用栀子柏皮汤，以滋养化源并恢复津液，而不是使用渗湿泄利的药物。汪氏引用郭白云的话说：“既然不可攻下，只用茵陈蒿汤调和五苓散服用。”这种说法极其荒谬。此证与“二阳并病，面色缘缘正赤”相同，可以轻微发汗，宜用桂枝加葛根汤，以微汗解之。
按语：张璐说：“体质虚弱的人，刚感受外邪，就会挟带虚火，导致面色通红。这总归是真阳素来虚弱，无根之火随着解表药的药性上升。”云云。世间确实有这种病症，但与本条经文的原意无关。
阳明病，没有经过催吐或泻下治疗，却出现心烦症状的，可以给予调胃承气汤。（《玉函经》、《千金翼方》作“不吐下而烦”，《脉经》同，无“调胃”二字。）
〔柯琴注〕说是阳明病，那么就有身热、汗出、不恶寒反恶热的症状。如果是经过吐下治疗后出现的心烦，属于虚邪，适宜用栀子豉汤。
〔汪琥注〕所谓“不吐不下”，是指热邪向上不能宣越，向下不能排泄，郁结在胃腑之中，其热气必然上熏于膈膜，从而导致心烦。烦，就是闷而且热的感觉。
〔钱潢注〕仅仅心烦，不像潮热、大便干硬那样属于胃家实证的典型表现，所以不必用猛烈的攻下法，但可以与调胃承气汤。
〔张锡驹注〕“可与”二字，意在让人根据病情斟酌处理，不可以盲目地进行猛烈攻伐。
〔舒驰远注〕按语：心烦这一症状，与阴阳互相关联，应当仔细诊察，然后用药。调胃承气汤不可轻易尝试。
阳明病，脉象迟缓，虽然出汗，但不恶寒的，身体必然沉重，呼吸短促，腹部胀满且气喘。如果有潮热现象，说明表证将要解除，可以攻治里证。如果手足濈然汗出，这说明大便已经坚硬，应用大承气汤主治。如果汗出多，伴有轻微发热和恶寒，说明表证尚未解除。（【原注】另一种方法，给予桂枝汤。）如果发热不呈潮热状，不可给予承气汤。如果腹部显著胀满不通畅，可以给予小承气汤，轻微调和胃气，不要让它导致剧烈腹泻。（关于“攻里”之间，《玉函经》、《脉经》有“其”字；“然下”之间，《成本》有“而”字；“汗多”之间，《玉函经》有“出”字；“外未解也”之下，《千金方》、《外台秘要》有“桂枝汤主之”五字；“不通”之间，《脉经》、《千金方》作“不大便”；“勿令至大泄下”之下，《成本》无“至”字；《外台秘要》中，“至”作“致”。）
〔魏荔彤注〕汗出，是太阳病的表现，而不恶寒，则是太阳病所没有的。身体疼痛，是太阳病的表现，而身体沉重则是太阳病所没有的。再加上短气、腹满、气喘和潮热，纯粹见到里证，而不见表证，可知这是太阳表证欲解而非已解。这是转属阳明病，且阳明胃实证即将形成。通过考察这八个方面，才可以攻治里证，毫无疑问了。但是攻治里证并非只有一条途径，还必须从汗出和发热情况来辨别。
如果是手足濈然汗出的，这是胃热炽盛逼迫汗液出于四肢末端，津液知道已经在体内亡失，大便必定已经干硬，胃实证的形成，确凿无疑，大承气汤荡涤积滞、通达幽隐，哪里容得迟疑呢？如果汗虽多，但发热反而轻微，且带有恶寒，说明邪气仍然停留在表，可以知晓。再审视发热情况，虽然汗出多，但热却不呈潮热状，则阳明病并未完全形成，仍应当从太阳表证治疗。或者病人腹部显著胀满不通的，则胃家已有闷塞的迹象，用小承气汤调和胃气，下法而非峻下，不要让它导致剧烈腹泻，以免损伤正气。
〔张锡驹注〕仲景既说脉迟时尚未可攻，而此条首先说脉迟，接着又说可攻，为什么呢？所谓脉迟尚未可攻，是因为腹中热势尚不严重，燥结未定，所以还不适宜攻下。如果攻下，必然导致胀满不食，并变生结胸、痞满等证。必须等到脉象实而结定后，才可以攻下。此条虽然也说脉迟，但按之必然有力，且症状一一显露出胃实，所以当攻下无疑。如果因为脉迟就妨碍一切下证的应用，那么大陷胸汤证中最危急的下证，也将因循守旧、缩手待毙吗？
〔程知注〕身体沉重，是因为经脉有所阻滞。表里邪气盛，都能令经脉阻滞。邪气在表而气喘的，胀满可能在胸部，而不在腹部。此处则是腹满而喘，可知表证欲解，可以攻治里证。
按语：程氏将脉迟理解为尚未可攻的迟脉，柯氏、钱氏将其理解为中寒无阳的迟脉，都与经旨相左。
钱潢说：热邪归入胃腑，邪气依附于宿食糟粕，郁蒸煎迫，导致胃中津液枯竭，所以发生潮热，大便坚硬。如果不以大承气汤攻下，必然导致热邪败坏胃气，出现谵语、狂乱、循衣摸床等变证，直至无法救治。
舒驰远说：我家有位宗姓患者，三月患热病，我与仲远一同前往诊治。他身体壮热且谵语，舌苔刺满口腔，秽气逼人，少腹硬满，大便闭结，小便短少，脉象实大而迟。仲远认为热结在里，其人发狂，小腹硬满，这是胃实兼蓄血。治疗方法应以救胃为急务。但此人年已六十，证候兼有蓄血，下药中应重加生地黄，一方面保护元阴，一方面破瘀行血。我赞同他的意见，主方用大承气汤，芒硝、大黄各用八钱，加生地一两，捣成泥状，先煮数十沸，然后纳入诸药同煎。连续服用五剂，得到多次大幅度的腹泻，人事逐渐清醒。稍进米饮，一二口就不能进食，呼叫不应，想说话却不说话，只见舌苔干燥异常，口中喷热如火，就知道里燥尚未衰减。又复用犀角地黄汤加大黄，三剂后又排出胶滞物两次，颜色如败酱，臭恶难闻，于是口臭才消除。里燥仍然旺盛，三四天没有小便，忽然自己取来夜壶，排了一次尿。我让他儿子取出查看，半壶鲜血，旁观者惊骇。经书说“血自下，下者愈”，这也是生地的功效。复诊时，脉象转为浮象。这是溃散的邪气有向表透发的机转，合用柴胡汤，顺应机转而引导它。但此时表里俱还热极，阴津所剩无几，柴胡汤也不适宜。只宜用白虎汤，加生地黄、黄芩以救里，倍用石膏，因其质重气轻，专达肌表，兼解外热。如此两剂，得到微汗，脉静身凉，舌苔退去，人事清明。再用清燥养荣汤，二十剂而痊愈。
大承气汤方
浓朴（半斤，炙，去皮） 枳实（五枚，炙） 芒硝（三合） 大黄（四两，酒洗○《外台秘要》无“酒洗”二字。）
以上四味，用水一斗，先煮浓朴、枳实两味，取五升，去滓，纳人大黄，再煮取二升，去滓，纳入芒硝，再上火微煮一两沸。分温两次服用。得到腹泻后，剩下的药不要服。（《成本》中，“煮”上有“更”字；“微火”作“火微”，不对。）
〔赵良鉴注〕各种积热结于里，而成满、痞、燥、实的，均用大承气汤攻下。满，指腹胁满急胀，所以用浓朴，以消气壅。痞，指心下痞塞硬坚，所以用枳实，以破气结。燥，指肠中燥屎干结，所以用芒硝，润燥软坚。实，指腹痛大便不通，所以用大黄，攻积泻热。然而必须审察四证的轻重，四药的数量适中适宜，才可以给予。如果邪重剂轻，则邪气不服；邪轻剂重，则正气反伤，不可不谨慎。
〔柯琴注〕各种病都因于气，秽物之不去，是由于气的不顺。所以攻积的药剂，必须用气分的药，因此以“承气”名汤。煎法更有妙义。
大承气汤用水一斗，煮朴、枳取五升，去滓，纳大黄，再煮取二升，纳芒硝。为什么呢？大概生者气锐利而先行，熟者气纯正而和缓。仲景想让芒硝先化解燥屎，大黄继而在后通利地道，而后枳、朴消除痞满。如果是小承气汤，将三味药同煎，不分次第，同样是重用大黄，但煎法不同，这可见仲景微微调和之意。
〔知友注〕调胃承气汤，大黄用酒浸；大承气汤，大黄用酒洗，都是为了配合芒硝的咸寒，而以酒制之。如果是小承气汤，不用芒硝，也就不需要酒浸洗了。
《明理论》说：承，顺也。伤寒邪气入胃，称为入腑。腑的意思，是聚。胃是水谷之海，营卫之源。水谷汇聚于胃，变化而为营卫。邪气入于胃，胃中气机郁滞，糟粕秘结，壅塞而成实证，这是正气不得舒展顺畅。本草说：通可去滞，泄可去邪。塞而不利，闭而不通，用汤药荡涤，使塞者利而闭者通，正气得以舒展顺畅，因此以“承气”命名。
《总病论》说：凡是脉沉细数，为热在里。又兼腹满咽干，或口燥舌干而渴的，或六七日不大便，小便自如的，或眼中瞳子不明，无外证的，或汗后脉沉实的，或下利三部脉皆平，心下坚的，或连发汗已，不恶寒的，或已经下后，其脉浮沉按之有力的，适宜用大承气汤。
《医垒元戎》说：大承气汤，治大实大满。满则胸腹胀满，状若合瓦。大实，则不大便。痞、满、燥、实四证具备则用之。杂病则进退使用。○按语：王叔和《伤寒例》说：如果表已解，而内不消，大满大实坚有燥屎，自可除下之，即使四五日，也不能成为祸害。好古的说法，大概源于此。
《内台方议》说：仲景所用大承气的，共二十五证，虽然各异，然而都是下泄之法。其法虽多，不出大满、大热、大实，其脉沉实滑者所当用也。
《伤寒蕴要》说：大抵下药，必须切脉沉实，或沉滑、沉疾有力的，才可下。再以手按脐腹，硬的，或叫痛不可按的，则下之无疑。凡下后不解者，再按脐腹，有无硬处。如有手不可按，下未尽也，复再下之。若下后腹中虚软，脉无力者，此为虚也。
《外台秘要》载崔氏承气丸，疗十余日不大便者。
在本方基础上，去浓朴，加杏仁二两，蜜和丸如弹子大小，以生姜汤六合，研一丸服用。须臾即通。
《卫生宝鉴》治发狂因触冒寒邪，失于解利，因转属阳明证，胃实谵语。本方加黄连。
《理伤续断方》大成汤，一名大承气汤。治伤损瘀血不散，腹肚膨胀，大小便不通，上攻心腹，闷乱至死者。急将此药，通下瘀血，后方可服损药。
于大承气汤，加甘草、陈皮、红花、当归、苏木、木通。○损药，乃本方小承气汤。
《医经会解》加味承气汤，治痢疾邪毒在里。
于本方，加黄连、木香、皂角刺。
《本草汇言》嘉靖方，治伤寒热实结胸。铁锈磨水，入承气汤，服之极验。
《医学正传》治一人，六月投渊取鱼，至深秋雨凉，半夜小腹痛甚，大汗，脉沉弦细实，重取如循刀责责然。夫腹痛脉沉弦细实，如循刀责责然，阴邪固结之象。便不当有汗，今大汗出，此必瘀血留结，营气不能内守，而渗泄于外也。且弦脉亦肝血受伤之候。与大承气加桂，二服微利痛减。连日于未申时，复坚硬不可近。与前药，加桃仁泥，下紫血升余，痛止。脉虽稍减，而责责然犹在。又以前药，加川附子，下大便四五行，有紫黑血如破絮者，二升而愈。
吴勉学汇聚单方：余治一少年，腹痛目不见人，阴茎缩入，喊声彻天。医方灸脐愈痛，欲得附子理中汤。余偶过其门，诸亲友邀入。余曰：非阴症也。主人曰：晚于他处有失，已审侍儿矣。余曰：阴症声低少，止呻吟耳。今高厉有力，非也。脉之伏而数且弦，肝为甚。外肾为筋之会，肝主筋，肝火盛也。肝脉绕阴茎，肝开窍于目，故目不明。用承气汤，一服立止。知有结粪在下故也。凡痛须审察寒热虚实，诸症皆然。久腹痛，多有积，宜消之。
《医方集解》说：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。朱丹溪说：初下利腹痛，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，正合承气症。但气口虚，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。苟不先补完胃气之伤，而遽行承气，宁免后患乎？此先补后下，例之变也。
《伤寒直格》说：《活人书》认为，大承气最紧，小承气次之，调胃承气又次之。而缓下急下，善开发而难郁结，可通用者，大承气汤，最为妙也。故今加甘草，名曰三一承气汤，通治三承气汤，于效甚速，而无加害也。
《儒门事亲》说：大承气汤，刘河间加甘草，以为三一承气，以甘和其中。余尝以大承气，改作调中汤，加以姜枣煎。俗见姜枣，以为补脾胃而喜服。《卫生宝鉴》说：若大承气证，反用调胃承气治之，则邪气不散；小承气汤证，反以大承气汤下之，则过伤正气。此仲景所以分而治之。后之学人，以此三药，合而为一，且云通治三药之证，及伤寒杂病内外一切所伤，与仲景之方，甚相违背，失轩岐缓急之旨，使病患暗受其弊，将谁咎哉？
小承气汤方
大黄（四两） 浓朴（二两，炙，去皮） 枳实（三枚大者，炙）
以上三味，用水四升，煮取一升二合，去滓，分温两次服用。初服汤应当排便，如果不排便，则喝完所有药。如果排便了，就不要服剩下的药。（《千金翼方》作“初服谵语即止，服汤当更衣，不尔尽服之”。《外台秘要》作“若一服得利谵语止，勿服之”。）
〔钱潢注〕小承气汤，就是大承气汤，而缩小其剂量。大邪大热之实于胃者，以大承气汤下之。邪热轻者，及无大热，但胃中津液干燥，而大便难者，以小承气微利之，以和其胃气，胃和则止，不是大攻大下的药剂。因为没有大坚实，所以在大承气中去掉芒硝。又因为邪气未大结满，所以减少浓朴、枳实。创法立方，惟量其缓急轻重，而增损之，使无太过不及，适中病情罢了。
按语：钱氏说，大黄四两，既名之曰小，当是二两。汉之二两，即宋之五钱，外分二次服耳。此说无明证。唯《外台秘要》崔氏承气汤，即本方，用浓朴、大黄各三两，枳实六片。庞氏用大黄二两，而减浓朴一两，枳实一枚。
吴有性《瘟疫论》说：案三承气汤，功用仿佛。热邪传里，但上焦痞满者，宜小承气汤。中有坚结者，加芒硝，软坚而润燥。病久失下，虽无结粪，然多粘腻结臭恶物，得芒硝，则大黄有荡涤之能。设无痞满，惟存宿结，而有瘀热者，调胃承气宜之。三承气，功效俱在大黄，余皆治标之品也。不耐药汤者，或呕或畏，当为细末蜜丸汤下。
《医垒元戎》：小承气汤，治痞实而微满，状若饥人食饱，腹中无转失气，即大承气，只去芒硝。心下痞大便或通，热甚，宜此方。
《金匮要略》：治腹满痛而闭者，浓朴三物汤。（即本方，用浓朴八两，枳实五枚。）
又治支饮胸满，浓朴大黄汤。（即本方，用浓朴一尺，大黄六两，枳实四枚。）
[Text continues from previous context] ...character. *Yuhan Jing* (Classic of Jade Cabinet). There must be added above the characters "gong" (attack/purge) two more characters. Case analysis: The absence of the character "zhe" (this/that) is correct.)
[Cheng Wuji's Commentary] "He" means "tong" (connected/unobstructed). In Yangming disease, if the face is uniformly red, it indicates heat in the meridians. Purging should not be used. If purging is mistakenly applied, it will weaken stomach qi and consume body fluids. The heat in the meridians will then enter the stomach via the deficiency, inevitably causing fever, yellowish complexion, and difficult urination.
[Ke Qin's Commentary] A uniformly red face indicates yang qi being constrained at the exterior. Sweating should be used to resolve the exterior. If purging is instead applied, the heat cannot vent outward, resulting in recurrent fever and a change of color from red to yellow. This is fundamentally due to the exhaustion of body fluids, which fails to regulate water passages. Zizhi Bopi Tang (Gardenia and Phellodendron Decoction) is required to nourish the source of transformation and restore fluids; it is not suitable to use diuretic and draining agents. Wang Shi quotes Guo Baiyun: "Since attacking is contraindicated, one should only use Yinchen Hao Tang (Artemisiae Scopariae Decoction) to harmonize with Wuling San (Five-Ingredient Powder with Poria)." This view is extremely absurd. This condition is similar to "Two-Yang concurrent disease, with the face uniformly and completely red." Mild sweating may be employed, using Guizhi Jia Gegen Tang (Cinnamon Twig Decoction plus Kudzu Root) to induce slight perspiration.
Case Note: Zhang Lu states, "In persons with deficiency constitution, upon contracting external pathogens, deficient fire is carried along, leading to a flushed red face. This is invariably due to inherent deficiency of true yang, where rootless fire rises following the nature of exterior-resolving herbs." Such cases exist in the world, but they are irrelevant to the meaning of this specific clause.
In Yangming disease, without prior emesis or purging, if restlessness occurs, Tuiwei Chengqi Tang (Stomach-Harmonizing Purging Decoction) may be given. (*Yuhan Jing* and *Qianjin Yi Fang* read "restlessness without emesis or purging"; *Mai Jing* agrees, omitting "Tuiwei".)
[Ke Qin's Commentary] Stating "Yangming disease" implies symptoms of bodily heat, sweating, aversion to cold being absent, and preference for heat. If restlessness occurs after emesis or purging, it belongs to deficient evil, and Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) is appropriate.
[Wang Hu's Commentary] "Without emesis or purging" means the pathogenic heat cannot vent upward nor drain downward, becoming stagnant in the stomach fu. Its qi must ascend to熏 (smoke/permeate) the diaphragm, causing mental restlessness. "Fan" (restlessness) denotes a sensation of stuffiness and heat.
[Qian Huang's Commentary] Mere mental restlessness differs from tidal fever and hard stool characteristic of fullness in the stomach. Therefore, aggressive purging is not necessary, but Tuiwei Chengqi Tang can be administered.
[Zhang Xiju's Commentary] "May be given" implies that the physician should exercise judgment based on the clinical presentation; blind aggressive attack should be avoided.
[Shu Chiyuan's Commentary] Case Note: Mental restlessness is interrelated with yin and yang. Careful examination is required before prescribing. Tuiwei Chengqi Tang should not be tried lightly.
In Yangming disease, with a slow pulse, although sweating occurs, there is no aversion to cold. The body will necessarily feel heavy, breathing short, abdomen full, and panting. If tidal fever is present, the exterior is about to resolve, and the interior can be attacked. If sweat oozes continuously from the hands and feet, the feces have already hardened. Da Chengqi Tang (Major Order the Qi Decoction) is the primary treatment. If sweating is profuse, accompanied by slight fever and aversion to cold, the exterior has not yet resolved. [Original Note: One method suggests giving Guizhi Tang.] If the fever is not tidal, Chengqi Decoctions should not be given. If the abdomen is significantly full and obstructed, Xiao Chengqi Tang (Minor Order the Qi Decoction) may be given to mildly harmonize stomach qi, preventing excessive diarrhea. (Regarding the phrase "attack the interior", *Yuhan Jing* and *Mai Jing* include the character "qi" [its]; regarding "ran xia" [oozing down], *Cheng Ben* includes "er" [and]; regarding "han duo" [sweating much], *Yuhan Jing* includes "chu" [out]; below "wai wei jie ye" [exterior not resolved], *Qianjin Fang* and *Waitai Mi Yao* add "Guizhi Tang zhu zhi" [Cinnamon Twig Decoction is the main treatment"]; regarding "bu tong" [not unobstructed], *Mai Jing* and *Qianjin Fang* read "bu da bian" [no large bowel movement]; below "wu ling zhi da xie xia" [do not let it cause large purgation], *Cheng Ben* omits "zhi" [to/reach]; *Waitai Mi Yao* reads "zhi" as "zhi" [cause].)
[Wei Litong's Commentary] Sweating is a symptom of Taiyang disease, but lack of aversion to cold is not. Body pain is a symptom of Taiyang, but heaviness of the body is not. Combined with shortness of breath, abdominal fullness, panting, and tidal fever, these purely indicate interior signs without exterior signs. This shows that the Taiyang exterior disease is resolving, though not fully resolved. It is transferring to Yangming, and the stomach-fullness of Yangming is about to form. By examining these eight aspects, one can confidently treat the interior. However, treating the interior is not a single path; differentiation must be made based on sweating and fever.
If sweat oozes from the hands and feet, it indicates flourishing stomach heat forcing sweat to the four extremities, knowing that body fluids are depleted internally. The feces must be dry and hard, and the formation of stomach-fullness is certain. Da Chengqi Tang sweeps away accumulation and opens the pathways; why hesitate? If sweating is profuse but fever is slight and accompanied by aversion to cold, it is evident that the pathogen remains at the exterior. Re-examining the fever: although sweating is profuse, if the fever is not tidal, the Yangming disease is not fully established, and treatment should still follow the Taiyang exterior approach. Or, if the patient has significant abdominal fullness and obstruction, the stomach house already shows signs of blockage. Xiao Chengqi Tang harmonizes stomach qi; it is a purging method but not harsh purging, avoiding excessive diarrhea to prevent damaging righteous qi.
[Zhang Xiju's Commentary] Zhang Jingyue stated that when the pulse is slow, purging is not yet indicated. Yet this clause mentions a slow pulse first, then says purging is indicated. Why? When it says "pulse slow, not yet ready to purge," it means the internal heat is not severe, and dryness/consolidation is not fixed, so purging is premature. Purging would cause bloating and anorexia, leading to complications like chest binding and epigastric fullness. One must wait for the pulse to become solid and consolidation to fix before purging. Although this clause mentions a slow pulse, palpation reveals solidity, and all symptoms manifest stomach-fullness, so purging is undoubtedly indicated. If one lets a slow pulse hinder all purging indications, would one also hesitate in the most urgent cases requiring Daxiexiong Tang (Major Draining the Chest Decoction), waiting passively for death?
[Cheng Zhi's Commentary] Heaviness of the body indicates obstruction in the meridians. Excess pathogenic factors in the interior and exterior can both cause meridian obstruction. When pathogen is at the exterior causing panting, fullness may be in the chest, not the abdomen. Here, abdominal fullness with panting indicates the exterior is resolving and the interior can be attacked.
Case Note: Cheng Shi interpreted the slow pulse as indicating purging is not yet ready. Ke Shi and Qian Shi interpreted it as a slow pulse due to cold in the middle and lack of yang. Both interpretations deviate from the classic intent.
Qian Huang states: Heat pathogen enters the stomach, adhering to retained food and dregs, steaming and pressing, depleting stomach fluids, causing tidal fever and hard stool. If not purged with Da Chengqi Tang, heat will damage the stomach, leading to delirium, mania, grasping at bedclothes, and other transformations, ultimately incurable.
Xiju states: The four limbs receive qi from the stomach. Sweat on hands and feet indicates flourishing Yangming stomach qi.
Shu Chiyuan states: A relative of mine, surnamed Zong, suffered from heat disease in March. I visited him with Zhongyuan. He had high fever and delirium, prickly coating covering the tongue, foul odor offensive to the nose, hardness and fullness in the lower abdomen, constipation, scanty urine, and a solid, large, yet slow pulse. Zhongyuan believed heat was consolidated internally, causing mania, lower abdominal hardness, and stomach-fullness combined with blood stasis. The urgent method is to save the stomach. However, since he was sixty years old and the syndrome involved blood stasis, raw Rehmanniae Radix (Sheng Dihuang) should be heavily added to the purging formula to protect primordial yin and break stasis/move blood. I agreed, prescribing Da Chengqi Tang with Mangxiao (Natrii Sulfas) and Dahuang (Rhei Radix et Rhizoma) each at 8 qian, plus 1 liang of Sheng Dihuang, pounded into paste. Boiled first for dozens of boils, then other herbs added and decocted together. Five doses were taken consecutively, resulting in several large purgations, and consciousness gradually cleared. Small amounts of rice drink were taken, but after one or two mouthfuls, eating stopped, calling yielded no response, wanting to speak but unable, with abnormally dry tongue coating and breath hot as fire. Knowing internal dryness had not subsided, Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) with added Dahuang was used for three doses, again expelling sticky matter twice, resembling spoiled sauce, foul and indescribable. Only then did bad breath cease. Internal dryness remained intense. For three to four days without urination, he suddenly took a chamber pot and urinated once. I asked his son to examine it; half a pot of fresh blood, shocking to observers. The Classic says "blood comes out spontaneously, those who come out are healed," which is also the merit of Sheng Dihuang. On re-examination, the pulse became floating. This indicated disorganized pathogen having a tendency to move outward. Chaihu Tang (Bupleurum Decoction) was combined to guide it according to this trend. But at this time, interior and exterior were still extremely hot, with very little yin fluid remaining; Chaihu Tang was not suitable. Instead, Baihu Tang (White Tiger Decoction) with added Sheng Dihuang and Huangqin (Scutellariae Radix) was used to save the interior. Shigao (Gypsum Fibrosum) was doubled for its heavy quality and light qi, reaching the muscle layer specifically and resolving the exterior. After two doses, slight sweating occurred, pulse calmed, body cooled, tongue coating receded, and consciousness cleared. Qingzao Yangrong Tang (Clear Dryness and Nourish Ying Decoction) was used for twenty doses, resulting in recovery.
Da Chengqi Tang Formula
Cortex Magnoliae Officinalis Prepared (Ban Zhi, roasted, bark removed)
Fructus Trichosanthis Preparatus (Wu Mei, roasted)
Natrii Sulfas (San He)
Radix et Rhizoma Rhei Preparated (Si Liang, washed with wine [Waitai Mi Yao omits "washed with wine"])
The above four ingredients: Use one dou of water. First decoct Cortex Magnoliae Officinalis and Fructus Trichosanthis Preparatus, obtain five sheng, remove dregs. Add Radix et Rhizoma Rhei Preparated, decoct further to obtain two sheng, remove dregs. Add Natrii Sulfas, heat slightly for one or two boils. Divide into two warm doses. If bowel movement occurs, do not take the remainder. ([Cheng Ben]: "Geng" [further] is missing before "zhu" [decoct]; "Wei huo" [slight fire] is written as "Huo wei" [fire slight], which is incorrect.)
[Jian's Commentary] Various accumulations of heat consolidating in the interior, resulting in fullness, oppression, dryness, and excess, are all treated with Da Chengqi Tang to purge. "Man" (fullness) refers to abdominal and hypochondriac urgency and distension; thus Cortex Magnoliae Officinalis is used to dissipate qi stagnation. "Pi" (oppression) refers to epigastric oppression, hardness, and firmness; thus Fructus Trichosanthis Preparatus is used to break qi knots. "Zao" (dryness) refers to dry feces stuck in the intestines; thus Natrii Sulfas is used to moisten dryness and soften hardness. "Shi" (excess) refers to abdominal pain and constipation; thus Radix et Rhizoma Rhei Preparated is used to attack accumulation and drain heat. However, the severity of the four symptoms and the dosage of the four herbs must be assessed appropriately before administration. If pathogen is heavy and dose is light, the pathogen will not yield; if pathogen is light and dose is heavy, righteous qi will be damaged. Caution is essential.
[Ke Qin's Commentary] All diseases stem from qi. The inability to eliminate filth is due to unsmooth qi. Therefore, formulas attacking accumulation must use qi-moving herbs, hence named "Chengqi" (Ordering the Qi). The decoction method holds profound meaning.
Da Chengqi Tang uses one dou of water, decocts Magnolia and Trichosanthes to five sheng, removes dregs, adds Rhubarb, decocts again to two sheng, adds Mirabilite. Why? Raw herbs have sharp qi and act first; cooked herbs have pure qi and act gently. Zhang Jingyue intended Mirabilite to first dissolve dry feces, Rhubarb to subsequently open the intestinal pathway, and then Magnolia and Trichosanthes to remove oppression and fullness. In Xiao Chengqi Tang, the three herbs are decocted together without sequence. Although Rhubarb is used heavily in both, the decoction methods differ, revealing Zhang Jingyue's intention of mild harmonization.
[Zhi's Commentary] In Tuiwei Chengqi Tang, Rhubarb is soaked in wine; in Da Chengqi Tang, Rhubarb is washed with wine. This is to counteract the salty-cold nature of Mirabilite using wine preparation. In Xiao Chengqi Tang, Mirabilite is not used, so wine soaking/washing is unnecessary.
*Ming Li Lun* states: "Cheng" means to obey/follow. When cold-damage pathogen enters the stomach, it is called entering the fu organ. "Fu" means gathering. The stomach is the sea of water and grain, the source of ying and wei. Water and grain gather in the stomach, transforming into ying and wei. When pathogen enters the stomach, stomach qi becomes stagnant, waste products bind, blocking into excess, preventing righteous qi from flowing smoothly. Materia Medica states: "Unblocking removes stagnation, draining removes evil." Blocked and ununblocked, using decoctions to sweep clean, making blocked things unblocked and closed things open, allowing righteous qi to flow smoothly. Hence named "Chengqi".
*Zong Bing Lun* states: Whenever the pulse is deep, fine, and rapid, heat is in the interior. If accompanied by abdominal fullness, dry throat, or dry mouth/tongue and thirst; or no bowel movement for six to seven days with normal urination; or unclear vision in the eyes without exterior signs; or deep, solid pulse after sweating; or diarrhea with flat pulses in all three positions but hardness under the heart; or continuous sweating followed by lack of aversion to cold; or after purging, pulses deep or superficial but forceful upon pressure, Da Chengqi Tang is appropriate.
*Yi Lei Yuan Rong* states: Da Chengqi Tang treats major excess and major fullness. Fullness causes chest and abdominal distension, resembling joined tiles. Major excess causes constipation. It is used when pi (oppression), man (fullness), zao (dryness), and shi (excess) are all present. For miscellaneous diseases, it is used with adjustment. ○ Case Note: Wang Shuhe's *Shanghan Li* states: If the exterior is resolved but internal stagnation remains, with major fullness, major excess, firmness, and dry feces, purging can naturally be used. Even if four or five days have passed, it will not cause disaster. Haogou's theory likely originates from this.
*Nei Tai Fang Yi* states: Zhang Jingyue used Da Chengqi for twenty-five cases. Although varied, they all employ purging methods. Though many methods exist, they do not exceed major fullness, major heat, and major excess, indicated for deep, solid, slippery pulses.
*Shanghan Yun Yao* states: Generally, purging requires checking for deep, solid pulses, or deep, slippery, or deep, rapid, and forceful pulses. Only then can purging be used. Pressing the umbilical and abdominal area: if hard, or painful/crying upon touch, purging is undoubtedly indicated. If unresolved after purging, press again. If hard areas remain and are untouchable, purging is incomplete; purge again. If the abdomen becomes soft and weak post-purging with a powerless pulse, this indicates deficiency.
*Waitai Mi Yao* records Cui Shi's Chengqi Pill for ten-plus days of constipation.
From the base formula, remove Cortex Magnoliae Officinalis, add Almond (Xingren) 2 liang. Mix with honey into pills the size of quail eggs. Take one pill ground in 6 he of ginger juice. Passage occurs shortly.
*Weisheng Baojian* treats mania caused by cold invasion, failure to resolve, transferring to Yangming, stomach-fullness with delirium. Add Coptidis Rhizoma (Huanglian) to the base formula.
*Lishang Xuduan Fang* Dacheng Tang, also known as Da Chengqi Tang. Treats traumatic injury with un-dispersed blood stasis, abdominal distension, constipation and urinary retention, ascending to attack heart and abdomen, causing extreme distress nearing death. Urgently use this medicine to purge blood stasis before administering trauma medicines.
To Da Chengqi Tang, add Glycyrrhizae Radix (Gancao), Citri Reticulatae Pericarpium (Chenpi), Carthami Flos (Honghua), Angelicae Sinensis Radix (Danggui), Swietenia Wood (Sumu), and Akebia Caulis (Mutong). ○ Trauma medicine refers to Xiao Chengqi Tang derived from this formula.
*Yijing Huijie* Jiawei Chengqi Tang (Modified Chengqi Decoction) treats dysentery with pathogenic toxins in the interior.
To the base formula, add Coptidis Rhizoma (Huanglian), Aucklandiae Radix (Muxiang), and Gleditsiae Spina (Zaojiaoci).
*Benzhong Huiyan* Jiajing Formula treats cold-damage heat-excess chest binding. Grind iron rust into water, add to Chengqi Tang. Extremely effective.
*Yixue Zhengchuan* Treating a patient who fished in June, exposed to cool autumn rain in September, suffering severe lower abdominal pain at midnight, profuse sweating, deep, string-taut, fine, and solid pulse, feeling like touching a sword blade upon heavy pressure. Abdominal pain with deep, string-taut, fine, solid pulse, feeling like a sword blade, indicates congealed yin evil. Sweating should not occur; profuse sweating here indicates blood stasis retention, defensive qi failing to stay inside, leaking outward. String-taut pulse also indicates liver blood injury. Prescribe Da Chengqi Tang plus Cinnamon Twig (Guizhi). Two doses brought slight relief and reduced pain. Days later, at Wei/Shen hours, hardness returned, untouchable. Given previous medicine plus Peach Kernel Paste (Taoren Ni), expelled over a sheng of purple blood, pain ceased. Pulse slightly decreased, but sword-like feeling remained. Given previous medicine plus Sichuan Aconite Root (Chuan Fuzi), expelled four to five stools containing purple-black blood like broken cotton, totaling two sheng, resulting in cure.
Wu Mianxue's Collection of Single Prescriptions: I treated a youth with abdominal pain, blindness, retracted penis, and screaming to the heavens. Acupuncture on the navel worsened pain; he desired Fuzi Lizhong Tang. Passing by, relatives invited me in. I said: Not a yin syndrome. Owner said: Mistake made elsewhere, maid already examined. I said: Yin syndromes have low voices, only groaning. Now voice is loud and forceful, not yin. Pulse is hidden, rapid, and string-taut, especially in the liver. External genitalia are the meeting of sinews; liver governs sinews; liver fire is flourishing. Liver meridian wraps around the penis; liver opens into the eyes; hence blindness. Use Chengqi Tang. One dose stopped symptoms immediately. Knowing impacted feces were below. All pains require examining cold/heat and deficiency/excess. Chronic abdominal pain often involves accumulation; should be dispersed.
*Yifang Jijie* states: Ancients treated chills and trembling with Da Chengqi Tang, purging dry feces to cure. This is yang pathogen entering the interior, heat consolidating internally, exterior lacking yang, causing chills and trembling. This is yang excess repelling yin, a heat disease not a cold syndrome. Misusing hot medicines leads to death. Zhu Danxi said: Initial diarrhea with abdominal pain should not use Ginseng and Atractylodes. However, for qi-deficient and stomach-deficient persons, they can be used. Initially, Da Chengqi or Tuiwei Chengqi can be used to purge. Observe whether it is qi or blood pathology, then adjust. I once treated Mr. Ye with dysentery, severe urgency, fitting Chengqi syndrome. But the qi-kou pulse was deficient, shape solid but face yellow-white, indicating past overeating damaging the stomach. Endured hardship for two or three days, then gave Ginseng, Atractylodes, and aged Chenpi/Paeonia for over ten doses. After three days, stomach qi recovered somewhat, then gave two doses of Chengqi, resulting in peace. Had we not first replenished stomach qi damage before abruptly using Chengqi, how could we avoid later troubles? This is a variation of the "tonify first, purge later" principle.
*Shanghan Zhi Ge* states: *Huoren Shu* considers Da Chengqi the strongest, Xiao Chengqi next, Tuiwei Chengqi weakest. For gentle vs. urgent purging, opening vs. stagnation, universally applicable, Da Chengqi Tang is most excellent. Thus, adding Licorice creates Sanyi Chengqi Tang (Three-One Chengqi Decoction), treating all three Chengqi syndromes, acting fast without harm.
*Rumen Shiqin* states: Liu Hejian added Licorice to Da Chengqi Tang to create Sanyi Chengqi Tang, using sweet flavor to harmonize the center. I once modified Da Chengqi Tang into Tiaozhong Tang, adding Ginger and Jujube for decoction. Laypeople see Ginger and Jujube, believe they tonify spleen/stomach, and prefer taking them. *Weisheng Baojian* states: If Da Chengqi syndrome is treated with Tuiwei Chengqi, pathogen will not disperse; if Xiao Chengqi syndrome is treated with Da Chengqi Tang, righteous qi is excessively damaged. This is why Zhang Jingyue treated them separately. Later scholars combined these three medicines into one, claiming universal application for all three syndromes and all cold-damage/miscellaneous disease injuries, contradicting Zhang Jingyue's formulas and losing Xuanyuan/Qibo's principles of urgency and moderation, causing patients hidden harm. Who is to blame?
Xiao Chengqi Tang Formula
Radix et Rhizoma Rhei Preparated (Si Liang)
Cortex Magnoliae Officinalis Prepared (Liang Er, roasted, bark removed)
Fructus Trichosanthis Preparatus (San Mei Da Zhe, roasted)
The above three ingredients: Use four sheng of water, decoct to obtain one sheng and two he, remove dregs. Divide into two warm doses. After the first dose, bowel movement should occur. If not, drink the rest. If bowel movement occurs, do not take the rest. (*Qianjin Yi Fang*: "After first dose, delirium stops, should have bowel movement; if not, drink all." *Waitai Mi Yao*: "If one dose brings benefit and delirium stops, do not take.")
[Qian Huang's Commentary] Xiao Chengqi Tang is essentially Da Chengqi Tang but with reduced dosage. For major evil and major heat excess in the stomach, Da Chengqi Tang is used to purge. For lighter pathogenic heat, or no major heat, but dry stomach fluids causing difficult defecation, Xiao Chengqi Tang is used to mildly promote bowel movement and harmonize stomach qi. Once stomach is harmonized, stop. It is not a major attacking/purging agent. Because there is no major solidity, Mirabilite is removed from Da Chengqi Tang. Also, because pathogen is not massively consolidated/full, Cortex Magnoliae Officinalis and Fructus Trichosanthis Preparatus are reduced. Creating methods and formulas depends on measuring urgency and severity, increasing or decreasing accordingly, avoiding excess or deficiency, fitting the condition perfectly.
Case Note: Qian Shi said Rhubarb is 4 liang; since it is named "Small", it should be 2 liang. Han dynasty 2 liang equals Song dynasty 5 qian, divided into two doses. This claim lacks clear evidence. Only *Waitai Mi Yao*'s Cui Shi Chengqi Tang, which is this formula, uses 3 liang each of Cortex Magnoliae Officinalis and Rhubarb, and 6 pieces of Fructus Trichosanthis Preparatus. Pang Shi used 2 liang Rhubarb, reducing Cortex Magnoliae Officinalis by 1 liang and Fructus Trichosanthis Preparatus by 1 piece.
Wu Youxing's *Wenyi Lun* states: Case note: The three Chengqi Tangs have similar functions. When heat pathogen transmits to the interior, if only upper jiao oppression/fullness exists, Xiao Chengqi Tang is appropriate. If there is hard consolidation in the middle, add Mirabilite to soften hardness and moisten dryness. If illness is prolonged and purging was missed, even without formed feces, there are often sticky, foul-smelling accumulated matters. With Mirabilite, Rhubarb gains sweeping ability. If no oppression/fullness, only retained consolidation with stasis-heat, Tuiwei Chengqi Tang is appropriate. The efficacy of all three Chengqi Tangs lies primarily in Rhubarb; the others are symptomatic treatments. For those intolerant to liquid medicine, vomiting or aversion may occur; grind into fine powder, mix with honey into pills, take with decoction.
*Yi Lei Yuan Rong*: Xiao Chengqi Tang treats oppression-excess with slight fullness, feeling like a hungry person after eating, with no flatus in the abdomen. This is Da Chengqi Tang minus Mirabilite. Epigastric oppression with possible bowel movement, severe heat, this formula is appropriate.
*Jingui Yaolue*: Treats abdominal fullness, pain, and closure with Houpo Sanwu Tang (Magnolia Three-Ingredient Decoction). (This is the base formula using 8 liang Cortex Magnoliae Officinalis and 5 pieces Fructus Trichosanthis Preparatus.)
Also treats fluid retention in the chest with fullness, Houpo Dahuang Tang (Magnolia and Rhubarb Decoction). (This is the base formula using 1 chi Cortex Magnoliae Officinalis, 6 liang Radix et Rhizoma Rhei Preparated, and 4 pieces Fructus Trichosanthis Preparatus.)
*Zhizhi Fang*: Zhiqiao Cu San (Crushed Immature Bitter Orange Powder) treats heat-syndrome distension/fullness.
To the base formula, add Platycodonis Radix (Jiegeng), Glycyrrhizae Radix (Gancao), Mume Fructus (Wumei), Ginger, and Jujube.