大法秋宜下凡可下者用汤胜丸散中病便止不必尽剂也
下利三部脉皆平按之心下硬者急下之下利脉迟而滑者内实也利未欲止当下之少阴病得之二三日口燥咽干者急下之
少阴病六七日腹满不大便者急下之阳明少阳合病必下利其脉不负者为顺也负者失也互相克贼名为负也脉滑而数者有宿
食当下之问曰人病有宿食何以别之师曰寸口脉浮而大按之反涩尺中亦微而涩故知有宿食当下之下利不欲食者以有宿食
故也当下之下利瘥至其年日月时复发者以病不尽故也当下之下利脉反滑当有所去下乃愈脉双弦而迟者必心下硬脉大而
紧者阳中有阴也可下之阳明病谵语有潮热反不能食者胃中有燥屎五六枚也若饮食者但硬耳得病二三日脉弱无太阳柴胡
证烦躁心下痞至四五日虽能食以承气汤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大便但
初头硬后必溏此未定成硬也攻之必溏须小便利屎定硬乃可攻之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二阳并病太阳证罢但发潮热手足 汗出大便难而谵语者下之则
愈病患小便不利大便乍难乍易时有微热喘胃不能卧者有燥屎也大下后六七日不大便烦不解腹满痛者此有燥屎也所以然
者本有宿食故也以上俱属大承气汤证
阳明病发热汗多者急下之伤寒后脉沉沉者内实也下之解太阳病未解脉阴阳俱停必先振栗汗出而解但尺脉实者下之
而解病患无表里证发热七八日虽脉浮数者可下之伤寒发热汗出不解心中痞硬呕吐而下利者伤寒十余日热结在里复往来
寒热者以上俱属大柴胡汤证
少阴病下利清水色纯青心下必痛口干燥者可下之病腹中满痛者此为实也当下之腹满不减减不足言当下之伤寒六七
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汗出谵语者以有燥屎在胃中此为风也须下者过经乃可下
之下之若早者语言必乱以表虚里实故也下之愈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可下之以上俱
属大柴胡大承气证
下利谵语者有燥屎也阳明病其人多汗以津液外出胃中燥大便必硬硬则谵语以上俱属小承气汤证阳明病脉迟虽汗出
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出多微发
热恶寒者外未解也桂枝汤主之其热不潮未可与承气汤若腹大满不通者与小承气汤微和胃气勿令至大泄下阳明病潮热大
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汤入腹中转失气者此有燥屎也
乃可攻之若不转失气者此但初头硬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者大便必复硬而少
也宜以小承气汤和之不转失气者慎不可攻也阳明病谵语发潮热脉滑而疾者小承气汤主之因与承气汤一升腹中转气者更
服一升若不转气者勿更与之明日又不大便脉反微涩者里虚也为难治不可更与承气汤
阳明病不吐不下心烦者属调胃承气汤
太阳病不解热结膀胱其人如狂血自下者愈其外未解者尚未可攻当先解其外外解已但少腹急结者乃可攻之宜桃核承
气汤
太阳病六七日表证仍在脉微而沉反不结胸其人发狂者以热在下焦少腹当硬满而小便自利者下血乃愈所以然者以太
阳随经瘀热在里故也宜下之太阳病身黄脉沉结少腹硬满小便不利者为无血也小便自利其人如狂者血证也阳明证其人喜
忘者必有蓄血所以然者本有久瘀血故令喜忘屎虽硬大便反易其色必黑以上俱抵当汤证伤寒有热少腹满应小便不利今反
利者为有血也当下之宜抵当丸
阳明病发热汗出者此为热越不能发黄也但头汗出身无汗剂颈而还小便不利渴引水浆者以瘀热在里身必发黄宜下之
以茵陈蒿汤伤寒七八日身黄如橘子色小便不利腹微满者亦属茵陈蒿汤证
但结胸无大热者以水结在胸胁也但头微汗出者伤寒六七日结胸热实脉沉而紧心下痛按之石硬者俱属大陷胸汤结胸
者项亦强如柔痉状下之则和大陷胸丸
太阳病中风下利呕逆表解者乃可攻之其人 汗出发作有时头痛心下痞硬满引胁下痛干呕则短气汗出不恶寒者此
表解里未和也属十枣汤
吴 经言太阳病发热汗出不解其人蒸蒸发热者属胃也调胃承气汤下之凡潮热腹痛者大柴胡加浓朴下之凡阳明病
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有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凡汗出谵语必有燥屎调胃承气汤凡潮热手足 然汗出大便难而谵语者大承气汤凡五
六日不大便绕脐痛烦躁发作有时者此有燥屎也调胃承气汤凡曾经下后又六七日不大便烦热不解腹满痛者此有燥屎也大
承气汤病患小便不利大便乍难乍易时有微热喘满不能卧者有燥屎也大承气汤凡吐后腹胀满者调胃承气汤凡汗吐下后微
烦小便数而大便硬者小承气汤凡腹满不减者小承气汤凡下利脉滑而数者有宿食也小承气汤凡病腹中满痛者有宿食也小
承气汤凡脉沉有力内实潮热不解者大柴胡汤大抵下药必切脉沉实或沉滑沉疾有力者方可以下再以手按脐腹硬或叫痛不
可按者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
以参胡三白汤和之若发热或潮热或往来寒热不解者宜小柴胡汤增损和之若烦热不得眠者宜竹叶石膏汤或十味温胆汤
活 伤寒里证须看热气浅深故仲景有宜下之者如大小承气十枣大柴胡汤是也有微和其胃气者如调胃承气汤脾约
丸少与小承气微和之之类是也虚者十补勿一泻强实者泻之虚实等者虽泻勿大泄之此金匮语也故王叔和序伤寒有承气之戒
垣 药用大承气汤最紧小承气汤次之调胃承气又次之大柴胡汤又次之
海 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
大黄（治大实） 芒硝（治大燥此二味治有形血药也） 浓朴（治大满） 枳实（治痞此二味治无形气药也）
小承气汤治痞实而微满状若饥人食饱饭腹中无转失气即大承气只去芒硝心下痞大便或通热甚须可下宜此方调胃承
气汤治实而不满者腹如仰瓦腹中有转失气有燥粪不大便而谵语坚实之证宜用之
上以上三法不可差差则无者生之有者遗
之假令调胃承气证用大承气下之则愈后元气不复以其气药犯之也若大承气证用调胃承气下之则愈后神痴不清以其无气
药也小承气证若用芒硝下之则或利不止变而成虚矣
垣 三一承气汤辨实则泻之人所共知如缓急轻重之剂则临时消息焉如不恶寒反恶热发渴谵语腹满而喘手足 然
汗出急下之宜大承气汤如邪未深恐有燥粪少腹痛小承气汤试之腹中转失气者有燥粪也乃可攻之不转失气者初硬后溏尚未
可攻攻之则腹满不能食若腹不通止与小承气汤微和胃气勿令大泄如发汗不恶寒但实者胃实也当和胃气调胃承气汤主之
成 大热结实者与大承气汤小热微结者与小承气汤以热不大甚故于大承气汤中去芒硝又以结不至坚故减浓朴枳
实如不至大坚然邪热已甚而须攻下者亦未可投大承气汤必以轻缓之剂攻之于大承气汤中减浓朴枳实加甘草乃轻缓之剂以
调胃也设若大承气汤证反用调胃承气汤下之则邪气不伏小承气汤证反用大承气汤下之则过伤正气而腹满不能食故有勿
大泄之戒此仲景所以分而治之未尝越圣人之制度后之医者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
伤若如此说与仲景之方甚相背戾且失轩岐缓急之旨由是红紫乱失迷惑世人一唱百和使病者暗受其弊将何所咎哉倘有公
心审是者当于内经仲景方中求之责使药证相对以圣贤之心为心则方之真伪自可得而知矣
海 伤寒外证全是下证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
治疗原则：秋季适宜使用下法。凡是属于可下证的，用汤剂的效果优于丸剂和散剂。服药后病愈即止，不必服完全部剂量。
如果腹泻但寸、关、尺三部脉象都平和，按压心下部感觉坚硬者，应当紧急使用下法。如果腹泻且脉象迟而滑，说明体内有实邪积滞，腹泻不会自行停止，应当使用下法。少阴病发病两三天，出现口干燥、咽喉干者，应当紧急使用下法。
少阴病六七天，腹部胀满且大便不通者，应当紧急使用下法。阳明病与少阳病合病，必然出现腹泻。如果脉象没有相克（即脉象符合病情顺逆规律），为顺证；所谓“负”，就是失义，指脉象互相克制贼害。如果脉象滑而数，说明体内有宿食停滞，应当使用下法。问：人患有宿食，如何辨别？答曰：寸口脉浮大，按之反而涩，尺中脉也微而涩，因此知道有宿食停滞，应当使用下法。腹泻而不想吃东西的，是因为有宿食，应当使用下法。腹泻痊愈后，到了原来的年、月、日、时复发，是因为病根未除尽，应当使用下法。腹泻而脉象反滑，说明体内有积滞需要去除，下之后才能痊愈。脉象双弦而迟的，必定心下部坚硬；脉象大而紧的，是阳中有阴（表里同病或寒热错杂中的实证表现），可以使用下法。
阳明病出现谵语（胡言乱语）、潮热（定时发热），反而不能进食的，说明胃中有燥结的粪便五六枚。如果能进食，只是大便硬而已。患病二三日，脉象弱，没有太阳病或少阳病的证候，出现烦躁，心下部痞塞，到四五天虽然能进食，也应少量给予承气汤，微微调和胃气，使其稍微安宁。到第六天，给予承气汤一升。如果六七天不大便，小便量少，虽然不大便，但大便开头硬后面稀溏，这是尚未完全结成硬便。攻下会导致腹泻，必须等到小便通利，大便确定变硬后才可以攻下。
阳明病脉象迟，虽然出汗但不怕冷，身体必定沉重，气短，腹部胀满而喘，有潮热的，这是表证将要解除，可以攻里的征象。手足濈然汗出（持续出汗）的，说明大便已经变硬。两阳并病（太阳与阳明并病），太阳证已罢，只发潮热，手足出汗，大便困难且谵语的，使用下法即可痊愈。患者小便不利，大便时而难解时而易解，时常有轻微发热，气喘，胃气不和不能平卧的，说明有燥屎。大下之后六七天不大便，烦躁不解除，腹部胀满疼痛的，这是有燥屎。之所以这样，是因为原本就有宿食。以上情况都属于大承气汤证。
阳明病发热、汗多者，应当紧急使用下法。伤寒后脉象沉伏有力的，说明内里有实邪，使用下法可以解除。太阳病未解，脉象阴阳俱停（指脉搏暂时隐伏不见），必须先出现战栗，然后出汗而解；但如果尺脉实，则使用下法而解。患者没有表证和里证，发热七八天，虽然脉象浮数，也可以使用下法。伤寒发热，出汗后病不解，心中痞塞坚硬，呕吐且腹泻的，伤寒十余天，热邪结聚在里，又出现往来寒热的，以上情况都属于大柴胡汤证。
少阴病腹泻排出清水，颜色纯青，心下部必定疼痛，口干燥的，可以使用下法。病腹中胀满疼痛的，这是实证，应当使用下法。腹部胀满不减，即使减轻也不足挂齿的，应当使用下法。伤寒六七天，眼睛视物不清，眼球转动呆滞无神，没有明显的表证和里证，大便困难，身体微热的，这是实证，应当紧急使用下法。出汗且谵语的，是因为胃中有燥屎，这是风邪所致。需要下法的，必须等表证经过（表解）之后才可以下。如果下得过早，语言必定错乱，因为表虚里实的原因。下法后可以痊愈。患者烦热，出汗后缓解。又如疟疾状，傍晚时分发热，属于阳明病。脉象实的，可以使用下法。以上情况都属于大柴胡汤和大承气汤证。
腹泻且谵语的，是有燥屎。阳明病患者多汗，津液外泄，胃中干燥，大便必定变硬，硬则谵语。以上情况都属于小承气汤证。
阳明病脉象迟，虽然出汗但不怕冷，身体必定沉重，气短，腹部胀满而喘，有潮热的，这是表证将要解除，可以攻里的征象。手足濈然汗出的，说明大便已经变硬，以大承气汤主治。如果出汗多，微发热，怕冷的，说明表证未解，以桂枝汤主治。如果热势不呈潮热状，不可给予承气汤。如果腹部大满不通，给予小承气汤，微微调和胃气，不要让它导致剧烈腹泻。阳明病潮热，大便微硬的，可以给予大承气汤；如果不硬，不可给予。如果六七天不大便，担心有燥屎，想知道是否有燥屎的方法，是少量给予小承气汤。汤药入腹后，如果转矢气（放屁），这是有燥屎，才可以攻下。如果不转矢气，这仅仅是开头硬后面必稀溏，不可攻下。攻下必定导致腹胀满，不能进食。想要喝水的，给水则会呃逆。其后再次发热的，大便必定再次变硬而且量少，宜用小承气汤调和。不转矢气的，千万不可攻下。阳明病谵语，发潮热，脉象滑而急数的，以小承气汤主治。因给予承气汤一升，腹中转气的，再服一升；如果不转气，不要再次给予。第二天又不大便，脉象反而微涩的，是里虚，为难治，不可再给予承气汤。
太阳病不解，热邪结聚在膀胱，其人如狂（神情恍惚似疯癫），瘀血自行下出的，病会自愈。其表证未解的，尚不可攻下，应当先解其表。表解之后，仅见少腹急结（拘急胀痛）的，才可以攻下，宜用桃核承气汤。
太阳病六七天，表证仍在，脉象微而沉，反而不形成结胸，其人发狂的，是因为热邪在下焦，少腹部应当硬满，而小便自利的，通过下血可以痊愈。之所以这样，是因为太阳经邪热随经入里，瘀热在里，所以应当使用下法。太阳病身黄，脉象沉结，少腹硬满，小便不利的，是无瘀血；小便自利，其人如狂的，是血证。阳明证中人喜欢健忘的，必定有蓄血。之所以这样，是因为本有久瘀血，所以令其健忘。大便虽然硬，但大便反而容易排出，颜色必定黑。以上情况都属于抵当汤证。伤寒有热，少腹满，应当小便不利，现在反而利，说明有瘀血，当下之，宜用抵当丸。
阳明病发热出汗的，这是热邪向外发散，不能发黄。如果只有头部出汗，身上无汗，汗止于颈部而还，小便不利，口渴想喝水浆的，是因为瘀热在里，身体必定发黄，宜用下法，以茵陈蒿汤主治。伤寒七八天，身黄如橘子色，小便不利，腹部微满的，也属于茵陈蒿汤证。
只有结胸而没有大热的，是水饮结聚在胸胁。只有头部微微出汗的，伤寒六七天，结胸热实证，脉象沉而紧，心下部疼痛，按之像石头一样硬的，都属于大陷胸汤证。结胸病患者项部也强直，像柔痉的样子，使用下法可以和解，用大陷胸丸。
太阳病中风，腹泻，呕吐逆气，表证已解的，才可以攻下。其人漐漐汗出，发作有时，头痛，心下部痞塞坚硬满闷，牵引胁下疼痛，干呕，短气，出汗不怕冷的，这是表解里未和，属于十枣汤证。
吴又可说：太阳病发热出汗，病不解，其人蒸蒸发热（热气由内向外透发）的，属于胃家实，用调胃承气汤下之。凡是潮热腹痛的，用大柴胡汤加浓朴下之。凡是阳明病汗多，胃中必定干燥，大便必定变硬，硬则谵语，用小承气汤。如果谵语，脉滑而疾，发潮热的，用大柴胡汤。凡是谵语有潮热，不能食的，胃中必有燥屎五六枚，用小承气汤。如果能食，大便硬，用大承气汤。凡是出汗谵语的，必有燥屎，用调胃承气汤。凡是潮热，手足濈然汗出，大便难而谵语的，用大承气汤。凡是五六天不大便，绕脐痛，烦躁，发作有时的，这是有燥屎，用调胃承气汤。凡是曾经下过，后又六七天不大便，烦热不解，腹满痛的，这是有燥屎，用大承气汤。患者小便不利，大便乍难乍易，时有微热，喘满不能卧的，有燥屎，用大承气汤。凡是吐后腹胀满的，用调胃承气汤。凡是汗、吐、下后微烦，小便数而大便硬的，用小承气汤。凡是腹满不减的，用小承气汤。凡是下利，脉滑而数的，有宿食，用小承气汤。凡是病腹中满痛的，有宿食，用小承气汤。凡是脉沉有力，内实，潮热不解的，用大柴胡汤。
大抵使用下药，必须切脉见沉实，或沉滑、沉疾有力者，才可以下。再以手按压脐腹，如果有硬块或者叫痛不可按的，则下之无疑。凡是下后病不解的，再按脐腹有无硬处。如果有，手不可按下，说明未尽，再下之。如果下后腹中虚软，脉无力，此为虚证，用参胡三白汤调和。如果发热，或潮热，或往来寒热不解的，宜用小柴胡汤加减调和。如果烦热不得眠的，宜用竹叶石膏汤或十味温胆汤。
活人书说：伤寒里证须看热气浅深，所以仲景有宜下之的方剂，如大小承气汤、十枣汤、大柴胡汤等。也有微微和其胃气的，如调胃承气汤、脾约丸、少量给予小承气汤微和之等。虚者，十分补勿要一分泻；强实者，泻之；虚实等者，虽泻勿要大泄。这是《金匮要略》的话。所以王叔和在《伤寒序例》中有承气汤使用的戒律。
李东垣说：药用大承气汤最紧要，小承气汤次之，调胃承气汤又次之，大柴胡汤又次之。
张元素说：大承气汤治疗大实大满。满，则胸腹胀满，状如合瓦；大实，则不大便。痞、满、燥、实四证俱备，则用之。杂病则进退使用。大黄（治疗大实），芒硝（治疗大燥，此二味治疗有形之血分药也）；浓朴（治疗大满），枳实（治疗痞，此二味治疗无形之气分药也）。
小承气汤治疗痞实而微满，状若饥人食饱饭，腹中无转矢气，即大承气汤只去芒硝。心下痞，大便或通，热甚须可下的，宜此方。调胃承气汤治疗实而不满，腹如仰瓦，腹中有转矢气，有燥粪，不大便而谵语，坚实之证宜用之。
以上三种方法不可差错，差错则无者生之，有者遗之。假令调胃承气汤证，用大承气汤下之，则愈后元气不复，因为其气药（破气药）犯之也。若大承气汤证，用调胃承气汤下之，则愈后神志痴钝不清，因为其无气药也。小承气汤证，若用芒硝下之，则或利不止，变而成虚矣。
李东垣又说：三一承气汤辨析。实则泻之，人所共知。如缓急轻重之剂，则临时斟酌。如不恶寒反恶热，发渴，谵语，腹满而喘，手足濈然汗出，急下之，宜大承气汤。如邪未深，恐有燥粪，少腹痛，用小承气汤试之。腹中转矢气者，有燥粪也，乃可攻之。不转矢气者，初硬后溏，尚未可攻，攻之则腹满不能食。若腹不通，只与小承气汤微和胃气，勿令大泄。如发汗不恶寒，但实者，胃实也，当和胃气，调胃承气汤主之。
成无己说：大热结实者，与大承气汤。小热微结者，与小承气汤。以热不大甚，故于大承气汤中去芒硝。又以结不至坚，故减浓朴、枳实。如不至大坚，然邪热已甚而须攻下者，亦未可投大承气汤，必以轻缓之剂攻之，于大承气汤中减浓朴、枳实，加甘草，乃轻缓之剂以调胃也。设若大承气汤证，反用调胃承气汤下之，则邪气不伏；小承气汤证，反用大承气汤下之，则过伤正气而腹满不能食。故有“勿大泄之”的戒律。这是仲景所以分而治之，未尝越圣人之制度。后之医者，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。若如此说，与仲景之方甚相背戾，且失轩岐（黄帝与岐伯）缓急之旨。由是红紫乱目，迷惑世人，一唱百和，使病者暗受其弊，将何所咎哉！倘有公心审是者，当于《内经》、仲景方中求之，责使药证相对，以圣贤之心为心，则方之真伪自可得而知矣。
General Principle: Autumn is suitable for the purgative method. For all cases indicating the use of purgatives, decoctions are more effective than pills and powders. Stop medication once the illness is cured; there is no need to finish the entire dose.
If diarrhea occurs but the pulse at the cun, guan, and chi positions on both wrists is peaceful, and palpation of the epigastrium reveals hardness, urgent purgation is indicated. If diarrhea is accompanied by a slow and slippery pulse, it indicates internal excess accumulation; the diarrhea will not stop spontaneously, so purgation is indicated. In Shaoyin disease, if oral dryness and throat dryness appear within two or three days of onset, urgent purgation is indicated.
In Shaoyin disease, if abdominal distension and constipation persist for six or seven days, urgent purgation is indicated. When Yangming and Shaoyang diseases occur together, diarrhea is inevitable. If the pulse does not show mutual overcoming (indicating a favorable progression), it is considered a smooth course. "Fu" (negative/overcoming) refers to the loss of harmony where pulses mutually overcome each other. A slippery and rapid pulse indicates retained food stagnation, warranting purgation. Question: How can retained food be distinguished? Answer: The pulse at the cun position is floating and large, but feels rough upon pressure; the chi position is also slightly rough. This indicates retained food stagnation, requiring purgation. Diarrhea accompanied by anorexia is due to retained food and requires purgation. If diarrhea resolves but recurs at the same time of year, month, day, or hour, it is because the root cause was not fully eliminated, necessitating purgation. If diarrhea presents with a slippery pulse, it suggests internal retention that needs to be expelled; recovery follows purgation. A double-stringy and slow pulse indicates epigastric hardness; a large and tight pulse indicates yang containing yin (excess pattern amidst mixed cold-heat), allowing for purgation.
Yangming disease presenting with delirium and tidal fever, yet inability to eat, indicates five or six pieces of dry stool in the stomach. If the patient can eat, only the stool is hard. Two or three days after onset, if the pulse is weak, without Taiyang or Shaoyang signs, but with irritability and epigastric stuffiness, even if the patient can eat by the fourth to fifth day, give a small amount of Chengqi Decoction to mildly harmonize the stomach qi and bring slight relief. By the sixth day, administer one sheng of Chengqi Decoction. If there is no bowel movement for six or seven days and urine output is scant, although there is constipation, the stool may be hard at the beginning and loose at the end, indicating it has not fully hardened. Purging would cause loose stools; wait until urination is normal and the stool is confirmed hard before purging.
In Yangming disease, a slow pulse despite sweating and aversion to cold absent indicates the body will feel heavy, with shortness of breath, abdominal fullness, and wheezing. Tidal fever indicates the exterior syndrome is resolving and interior attack is permissible. Continuous sweating on the hands and feet indicates hardened stool. In combined Taiyang and Yangming disease, if Taiyang signs have ceased, presenting only with tidal fever, hand and foot sweating, difficult defecation, and delirium, purgation leads to recovery. If the patient has difficulty urinating, alternating difficulty and ease in defecation, occasional mild fever, wheezing, and inability to lie down due to stomach disharmony, dry stool is present. After severe purgation, if constipation persists for six or seven days with unresolved irritability and abdominal fullness/pain, dry stool is present because of prior retained food. These cases all belong to Da Chengqi Tang Syndrome.
In Yangming disease, fever and profuse sweating indicate urgent purgation. After Shanghan, a deep and forceful pulse indicates internal excess, resolved by purgation. If Taiyang disease is unresolved and the pulse at both cun and chi positions temporarily stops, chills followed by sweating indicate resolution; however, if the chi pulse is excess, purgation resolves it. If a patient has neither exterior nor interior signs but has fever for seven or eight days, even with a floating and rapid pulse, purgation may be used. In Shanghan, if fever and sweating do not resolve the condition, accompanied by epigastric stuffiness/hardness, vomiting, and diarrhea, or if after ten-plus days of Shanghan, heat is bound internally with alternating chills and fever, these cases all belong to Da Chaihu Tang Syndrome.
In Shaoyin disease, diarrhea of clear green water, epigastric pain, and oral dryness indicate purgation is possible. Abdominal fullness and pain indicate excess, requiring purgation. Persistent abdominal fullness that does not significantly reduce requires purgation. In Shanghan, if after six or seven days the eyes appear dull and unresponsive, without obvious exterior/interior signs, with difficult defecation and mild fever, this is excess requiring urgent purgation. Sweating with delirium indicates dry stool in the stomach due to wind pathogen; purgation should only be performed after the exterior stage has passed. Premature purgation causes speech confusion due to deficient exterior and excess interior. Recovery follows purgation. Irritability and fever resolving with sweating resemble malaria; evening fever belongs to Yangming. A solid pulse allows purgation. These cases belong to Da Chaihu Tang and Da Chengqi Tang Syndromes.
Diarrhea with delirium indicates dry stool. In Yangming disease, profuse sweating depletes fluids, drying the stomach and hardening the stool, leading to delirium. These cases belong to Xiao Chengqi Tang Syndrome.
Yangming disease with a slow pulse, sweating without aversion to cold, heavy body, shortness of breath, abdominal fullness, wheezing, and tidal fever indicates the exterior is resolving and interior attack is permissible. Hand and foot sweating indicates hardened stool; treat with Da Chengqi Tang. If sweating is profuse with mild fever and aversion to cold, the exterior is unresolved; treat with Guizhi Tang. If fever is not tidal, do not give Chengqi Decoction. If abdominal fullness and obstruction are severe, give Xiao Chengqi Tang to mildly harmonize stomach qi, avoiding excessive purgation. In Yangming disease, tidal fever with slightly hard stool allows Da Chengqi Tang; if not hard, do not give it. If no bowel movement for six or seven days and concern exists for dry stool, give a small amount of Xiao Chengqi Tang as a test. If gas passes after ingestion, dry stool is present, and purgation is allowed. If no gas passes, the stool is likely hard at the start and loose at the end; do not purge, as it causes abdominal fullness and anorexia. Thirst satisfied by water may cause hiccups. Subsequent fever indicates recurrent hard, scant stool; harmonize with Xiao Chengqi Tang. Do not purge if no gas passes. Yangming disease with delirium, tidal fever, and slippery-rapid pulse is treated with Xiao Chengqi Tang. After administering one sheng of Chengqi Decoction, if gas passes, administer another sheng; if not, do not repeat. If the next day shows constipation with a faint and rough pulse, interior deficiency makes it difficult to treat; do not give Chengqi Decoction again.
Yangming disease with irritability without prior vomiting or purgation belongs to Tiaowei Chengqi Tang Syndrome.
Taiyang disease unresolved with heat binding in the Bladder causing manic behavior resolves if blood discharges spontaneously. If the exterior remains, do not attack; resolve the exterior first. Once the exterior is resolved, if only lower abdominal urgency and binding exist, attack with Taohe Chengqi Tang.
Taiyang disease lasting six or seven days with persistent exterior signs, but a faint and sinking pulse without Jie Xiong (Chest Binding), and manic behavior, indicates heat in the lower jiao. Lower abdominal hardness/fullness with free urination indicates blood stasis; purging blood resolves it. This is because Taiyang pathogen enters the channels, binding heat and stasis internally. Treat with purgation. Taiyang disease with jaundice, sinking-knotted pulse, lower abdominal hardness/fullness, and urinary difficulty indicates no blood stasis. Free urination with manic behavior indicates blood syndrome. In Yangming disease, forgetfulness indicates blood retention due to long-standing blood stasis. Stool may be hard but passage is easy and color black. These cases belong to Didang Tang Syndrome. In Shanghan with heat, lower abdominal fullness usually implies urinary difficulty; if urination is free, blood stasis is present, requiring purgation with Didang Wan.
Yangming disease with fever and sweating indicates heat dispersing outward, preventing jaundice. Head-only sweating, no body sweat stopping at the neck, urinary difficulty, and thirst for fluids indicate internal damp-heat, causing jaundice; treat with purgation using Yinchen Hao Tang. In Shanghan lasting seven or eight days, yellow skin like orange peel, urinary difficulty, and mild abdominal fullness also belong to Yinchen Hao Tang Syndrome.
Jie Xiong without significant heat indicates water binding in the chest and hypochondrium. Only slight head sweating in Shanghan after six or seven days, with Jie Xiong heat-excess syndrome, sinking-tight pulse, epigastric pain, and stone-hard palpation, belongs to Daxiexiong Tang. Jie Xiong patients may have stiff necks resembling Rou Jing (Soft Spasm); purgation harmonizes via Daxiexiong Wan.
Taiyang Wind Strike with diarrhea and vomiting, after exterior resolution, allows purgation. Profuse sweating occurring intermittently, headache, epigastric stuffiness/fullness radiating to hypochondriac pain, dry heaves, shortness of breath, sweating without aversion to cold, indicates resolved exterior and disharmonious interior, belonging to Shizao Tang.
Wu Ji stated: Taiyang disease with fever/sweating unresolved and steaming heat indicates Stomach excess; purge with Tiaowei Chengqi Tang. Tidal fever with abdominal pain uses Da Chaihu Tang plus Houpo. Yangming disease with profuse sweating causes stomach dryness and hard stool/delirium; treat with Xiao Chengqi Tang. Delirium with slippery-rapid pulse and tidal fever uses Da Chaihu Tang. Delirium with tidal fever and anorexia indicates dry stool; treat with Xiao Chengqi Tang. Anorexia with hard stool uses Da Chengqi Tang. Sweating with delirium indicates dry stool; treat with Tiaowei Chengqi Tang. Tidal fever, hand/foot sweating, difficult defecation, and delirium use Da Chengqi Tang. Constipation for five-six days with periumbilical pain, intermittent irritability indicates dry stool; treat with Tiaowei Chengqi Tang. Post-purgation constipation for six-seven days with unresolved irritability and abdominal pain indicates dry stool; treat with Da Chengqi Tang. Urinary difficulty, alternating stool consistency, mild fever, wheezing, and inability to lie down indicate dry stool; treat with Da Chengqi Tang. Abdominal fullness post-vomiting uses Tiaowei Chengqi Tang. Post-sweat/vomit/purgation with mild irritability, frequent urination, and hard stool uses Xiao Chengqi Tang. Persistent abdominal fullness uses Xiao Chengqi Tang. Diarrhea with slippery-rapid pulse indicates retained food; use Xiao Chengqi Tang. Abdominal fullness/pain indicates retained food; use Xiao Chengqi Tang. Deep-forceful pulse, internal excess, unresolved tidal fever uses Da Chaihu Tang. Generally, purgatives require a deep-solid, deep-slippery, or deep-rapid-strong pulse. Palpate the umbilical/abdominal area for hardness or tenderness; if present, purgation is certain. If purgation fails, re-palpate; if hardness persists, purge again. If abdomen becomes soft and pulse weak post-purgation, it is deficiency; harmonize with Shenhu Sanbai Tang. If fever, tidal fever, or alternating chills/fever persist, harmonize with Xiaochaihu Tang. Irritability and insomnia use Zhuye Shigao Tang or Shiwei Wendan Tang.
Huozhe Shu states: Interior Shanghan patterns depend on heat depth. Zhang Zhongjing prescribed purgatives like Da/Xiao Chengqi Tang, Shizao Tang, and Da Chaihu Tang for excess. He also prescribed mild stomach harmonizers like Tiaowei Chengqi Tang, Pi Yue Wan, and small doses of Xiao Chengqi Tang. For deficiency, nourish ten parts, purge none; for excess, purge; for equal excess/deficiency, purge moderately without excessive depletion. This reflects Jin Gui principles. Wang Shuhe warned against Chengqi misuse.
Li Dongyuan ranked formulas: Da Chengqi Tang is most critical, followed by Xiao Chengqi Tang, Tiaowei Chengqi Tang, and Da Chaihu Tang.
Zhang Yuansu stated: Da Chengqi Tang treats major excess and fullness (chest/abdominal distension like joined tiles) and major solidity (constipation). Use when Pi, Man, Zao, and Shi syndromes coexist. It is used flexibly in miscellaneous diseases. Dahuang treats major excess; Mangxiao treats major dryness (these two treat tangible blood/stasis). Houpo treats major fullness; Zhishi treats Pi (these two treat intangible qi). Xiao Chengqi Tang treats Pi and Shi with mild fullness (like a hungry person feeling full); if no gas passes, it is essentially Da Chengqi Tang minus Mangxiao. Use for epigastric Pi, open bowels, high heat needing purgation. Tiaowei Chengqi Tang treats Shi without Man (abdomen like an inverted tile); gas passes, dry stool present, constipation with delirium/solidity.
These three methods must not be confused; error leads to harm. Using Da Chengqi Tang for Tiaowei Chengqi indications exhausts Yuan Qi due to qi-moving herbs. Using Tiaowei Chengqi Tang for Da Chengqi indications leaves spirit clouded due to lack of qi-moving herbs. Using Mangxiao for Xiao Chengqi indications causes uncontrollable diarrhea and deficiency.
Li Dongyuan further clarified: Excess requires purging. Adjust severity based on symptoms. No aversion to cold, preference for heat, thirst, delirium, abdominal fullness/wheezing, hand/foot sweating: urgent Da Chengqi Tang. Mild pathogen, suspected dry stool, lower abdominal pain: trial Xiao Chengqi Tang. Gas passage confirms dry stool for purgation. No gas passage means initial hardness/loose end; do not purge. If obstruction persists, use Xiao Chengqi Tang to mildly harmonize. Post-sweat non-aversion to cold but excess Stomach heat: harmonize with Tiaowei Chengqi Tang.
Cheng Wuji stated: Major heat/excess uses Da Chengqi Tang. Minor heat/mild binding uses Xiao Chengqi Tang (removes Mangxiao from Da Chengqi due to less heat; reduces Houpo/Zhishi due to less hardness). If heat is severe but hardness is not extreme, avoid Da Chengqi Tang; use a milder agent by reducing Houpo/Zhishi and adding Gancao to Tiaowei Chengqi Tang to harmonize the Stomach. Using Tiaowei Chengqi Tang for Da Chengqi indications fails to subdue pathogens. Using Da Chengqi Tang for Xiao Chengqi indications damages healthy qi, causing abdominal fullness/anorexia. Hence the warning against excessive purging. Zhang Zhongjing separated these treatments strictly. Later physicians merged them, claiming universal efficacy for Shanghan and miscellaneous diseases, contradicting Zhang Zhongjing and Huangdi/Qibo’s principles of urgency. This confuses people and harms patients. Seek truth in Nei Jing and Zhang Zhongjing’s formulas, ensuring symptom-formula correspondence.
Zhang Yuansu added: For Shanghan exterior signs mimicking purgative indications but with fine pulses (contraindicating purgation), use Xiexin Tang. Forceful pulse: Huanglian Xiexin Tang. Weak pulse: Banxia Xiexin Tang.