（大便难 大便硬 燥屎）
成 不大便大便难大便硬燥屎悉属里证宜下者多矣然而有表未罢风湿相搏尤宜先解表已而下之可也如经曰伤寒
不
大便六七日头疼有热者小便清知不在里仍在表是也其证多见于阳明盖胃土万物所归无所复传自太阳少阳传入者众所共
知而于三阴传入者鲜或能识若能熟视其微则三阴有急下之证多矣岂非仲景之微意欤
胃实有表者先解表
伤寒（兼太阳）不大便六七日（有汗桂枝）头痛有热者与承气汤其小便清者知不在里仍在表也
须当发汗若头痛者必衄宜桂枝汤（三时羌活汤 成 不大便六七日头痛有热者故宜当下若小便清者知里无热则不可下经
曰小便数者大便必硬不更衣十日无所苦也况此不大便六七日小便清者不可责邪在里是仍在表也与桂枝汤以解外若头痛
不已为表不罢郁甚于经迫血妄行上为衄也 丹 谨按外证未解不可下下为逆今头痛有热宜解表反与承气正是责其妄下
之过也故下文又言小便清者知其无里邪不当行承气又继之曰当须发汗日头痛必衄血宜桂枝汤反复告戒论意甚明而注反
直曰故当宜下想因六七日不大便尔虽不大便他无所苦候表解然后攻之正仲景法也注意似未莹）阳明病（无汗麻黄）脉浮
无汗而喘者发汗则愈宜麻黄汤 阳明病（兼少阳）胁下硬满大便不利而呕舌上白苔者可与小柴胡汤上焦得通津液得下胃
气因和身 然汗出而解也（阳明病腹满不大便舌上苔黄者为邪热入腑可下若胁下硬满虽不大便而呕舌上白苔者为邪未入
腑在表里之间与小柴胡汤以和解之上焦得通则呕止津液得下则胃气因和汗出而解）阳明中风脉弦浮大而短气腹都满胁下
及心痛久按之气不通鼻干不得汗嗜卧一身及面目悉黄小便难有潮热时时哕耳前后肿刺之小瘥外不解病过十日脉续浮者
与小柴胡汤脉但浮无余证者与麻黄汤若不尿腹满加哕者不治（成 脉浮大为阳风在表也弦则为阴风在里也短气腹满胁下
及心痛风热壅于腹中而不通也若寒客于内而痛者按之则寒气散而痛止此以风热内壅故虽久按而气亦不通阳明病鼻干不
得卧自汗出者邪在表也此鼻干不得汗而嗜卧者风热内攻不于里也一身及面目悉黄小便难有潮热时时哕者风热攻于胃也
阳明之脉出大迎循颊车上耳过客主人热胜则肿此风热在经故耳前后肿刺之经气通肿则小瘥如此者外证罢则可攻若外证
不解虽过十日脉续浮者邪气犹在半表半里与小柴胡汤若其脉但浮而不弦又无诸里证者是邪但在表也可与麻黄汤如发其
汗若不尿腹满加哕者关格之疾也故云不治难经曰关格者不得尽其命而死）
口苦咽干脉浮紧宜和
阳明中风口苦咽干腹满微喘发热恶寒脉浮而紧若下之则腹满小便难也（发热恶寒表未解也而误下之则亡阴无阴则阳
无以化故腹满小便难也许学士云宜小柴胡汤）阳明腹满脉浮紧口苦咽干而喘若发热汗出不恶寒
反恶热身重者忌发汗忌加烧针忌下（论见自汗）阳明病脉浮而紧者潮热作有时但浮者必盗汗出
上胃家实不大便虽三尺之童亦知可下也殊不知仲景之法虽有胃实证若表未解及有半表者亦先用桂枝柴胡以解外
然后视虚实消息之也
胃实表解无证者忌攻大便硬者导之
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时
宜用蜜煎导而通之若土瓜根及入猪胆汁皆可导之
蜜煎导法
用蜜七合入铜器中微火熬稍凝似饴状搅之勿令焦候可丸以手捻作挺子令头锐大如指长二寸许乘热急作之纳谷道中
用手急捺住欲大便时乃去之
又猪胆汁方
用大猪胆一个泻汁和醋少许和匀灌入谷道中如饭时顷大便自去
便硬无所苦者俟之
太阳病寸缓关浮尺弱其人发热汗出复恶寒不呕但心下痞者此以医下之也如其不下者病患不恶
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但以法救之渴者宜五苓散（成 太阳病脉
阳浮阴弱为邪在表今寸缓关浮尺弱邪气渐传里则发热汗出复恶寒者表未解也传经之邪入里里不和者必呕此不呕但心下
痞者医下之早邪气留于心下也如其不下者必渐不恶寒而渴太阳之邪转属阳明也若吐若下若发汗后小便数大便硬者当与
小承气汤和之此不因吐下发汗后小便数大便硬者是无满实虽不更衣十日无所苦也候津液还入胃中小便数少大便必自出
也渴欲饮水者少少与之以润胃气但审邪气所在以法救之如渴不止与五苓散是也 张 或问上条云小便数者大便必硬不
更衣十数日无所苦也尝有四五日六七日不大便者即为攻之今言十日不更衣而不用攻伐何也曰此非结热乃津液不足虽十
日不更衣亦无所苦也经曰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本小便日三四行今日再行故知大便不久为出不便数少以津液当还胃中故知不久大便也夫不便者
若有潮热谵语可下之证者然后可以攻之其不大便而无诸下证者此津液不足当须自审慎勿以日数久而辄为攻下也）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以津液当还入胃中故知不久必大便也
胃实表解有证者随证攻之
阳明病潮热不大便六七日恐有燥粪欲知之法少与小承气汤转失气者有燥屎可攻若不转
失气者无燥屎不可攻（方论见潮热）阳明病汗出大便硬而谵语者宜小承气汤（方见谵语）不大便腹满者宜下之若但绕脐
痛者则为燥屎宜承气汤 若心下至小腹满痛者则为结胸宜陷胸汤（论见腹痛）阳明病不吐不下心烦者可与调胃承气汤（成
注吐后心烦谓之内烦下后心烦谓之虚烦今阳明病不吐不下心烦则是胃有郁热也与调胃承气汤以下郁热 按阳明一证分
为太阳正阳少阳三等而以调胃大小承气下之者按本草曰大黄酒浸入太阳经酒洗入阳明经浸久于洗得酒气为多故能引之
于至高之分若物在山巅人迹不及必射以取之也故仲景以调胃承气收入太阳门而大黄下注曰酒浸及详其用本汤一则曰少
少温服二则曰当和胃气与调胃承气汤又详本汤之证则曰不吐不下心烦者又发汗不解蒸蒸发热又吐后腹胀满是太阳阳明
去表未远其病在上不当攻下故宜缓剂以调和之也及至正阳阳明则皆曰急下之与大承气汤而大承气汤中大黄下注曰酒洗
是洗轻于浸微升其走下之性以治其中也至少阳阳明则去正阳而逼太阴其分为下故小承气汤中大黄不用酒制少阳不宜下
故又曰少与曰微溏之勿令大泄下此仲景之妙法也东垣不审胃之云者乃仲景置调胃承气于太阳篇太阳不宜下故又称胃以
别之却踵成氏之谬以小承气治太阳脾约之证以调胃承气治正阳阳明大承气之证余故不能无辨）小便不利大便乍难乍易有
微热喘冒不卧者宜大承气汤（论见不得卧）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宜大
承气汤（成 诸脉皆属于目伤寒六七日邪气入里之时目中不了了睛不和者邪热内甚上熏于目也无表里证大便难者里实也
身大热者表热也身微热者里热也针经曰热病目不明热不已者死此目中不了了睛不和则证近危恶也须急与大承气汤下
之）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麻仁丸主之（成 趺阳者脾胃之脉诊浮为阳知胃气
强涩为阴知脾为约约者俭约之约又约束之约内经曰饮入于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主为胃行其津液者也今胃强脾弱约束津液不得四布但输膀胱致小便数大便难与脾约丸通肠润燥）
麻仁丸方
麻子仁（二升） 芍药（半斤） 枳实（半斤炒） 大黄（去皮一斤） 浓朴（去粗皮炙一尺） 杏仁（一斤去皮
尖别熬作脂）上六味为末炼蜜丸如桐子大饮服十丸日三服渐加以愈为度（成 内经曰脾欲缓急食甘以缓之麻子杏仁之甘
缓脾而润燥津液不足以酸收之芍药之酸以敛津液肠燥胃强以苦泄之枳实浓朴大黄之苦下燥结而泄胃强也）
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（去声）其色必黑宜抵当汤主之（方见蓄
血）无表里证下后脉数不解消谷易饥六七日不大便者有瘀血宜抵当汤
许 有一士家病者二人皆旬日矣一则身热无汗大便不通小便如涩神昏而睡诊其脉长大而实予用承气下之而愈一
则
阳明自汗大便不通小便利津液少口干燥其脉亦大而虚作蜜煎三进之下燥粪得溏利而解其家曰皆大便不通何以治之异予
曰二证虽相似然自汗小便利者不可荡涤五脏为无津液也然则伤寒大证相似两证稍有不同宜予细斟酌正如格局看命虽年
月日时皆同而贵贱穷通不相侔者于一时中有浅深故知不可不谨
便初硬后溏
仲景论中有四证内有二证不言小便一证言小便不利一证言小便少其二证不言小便者阳明病潮热不大
便六七日与小承气汤不转失气者此但初硬后必溏不可攻之此胃中邪热未作实者也又太阳病下之心中懊 而烦腹满者初
硬后必溏此虚烦热在上胃中无燥屎者也其一证小便不利者阳明病中寒不能食小便不利手足 然汗出此欲作痼瘕必大便
初硬后溏所以然者以胃中水谷不别故也又一证言小便少者服承气汤一升若不大便六七日小便少者虽不能食但初硬后必
溏未定成硬攻之必溏须小便利屎定硬乃可攻之是知仲景测大便法皆以小便觇之如小便清知不在里利不止者利其小便小
便数少津液当还入胃中必大便皆可验者然小便利屎定硬固为可攻亦有小便自利大便硬而不可攻者何哉阳明病自汗或发
汗小便自利此为津液内竭虽硬不可攻之当须自欲大便宜蜜煎导盖非里实故不可攻也太阳病又一证云若吐若下若发汗微
烦小便数大便硬与小承气汤和之此两证汗后大便硬小便利皆同而治法不同者后证为有传邪故微烦又因发汗吐下后小便
数内亡津液大便硬是热邪入里故以小承气利之至若前证小便自利以无传邪故无烦证大便虽硬不得为里热但肠头干燥正
可用蜜导也读仲景书者宜详究焉
成无己注：不大便、大便难、大便硬、燥屎，都属于里证，大多适宜用下法。然而，如果有表证未解，风湿相搏的情况，尤其应当先解表，待表解后再攻下才是正确的。正如经文所说：“伤寒，不大便六七日，头痛有热者，小便清，知不在里，仍在表也。”这种证候多见于阳明病。因为胃属土，是万物所归之处，病邪传入后不再传变，这是众所周知的；而病邪从太阳、少阳传入的也是大家共知的，但从三阴经传入的情况却很少有人能识别。如果能仔细审视其细微之处，就会发现三阴病也有急下的证候，这难道不是张仲景的微意吗？
伤寒（兼太阳病），不大便六七日（若有汗出用桂枝汤），头痛有发热，给予承气汤。如果小便清长，说明病不在里，仍在表。此时应当发汗。如果头痛不止，必然会导致鼻衄，适宜用桂枝汤。（成无己注：不大便六七日，头痛有发热，所以适宜当下。但如果小便清长，说明里没有热邪，则不可下。经文说：“小便频数的人，大便一定硬，即使十天不排便也没有痛苦。”何况这里不大便六七日，小便清长，不能指责邪气在里，这说明邪气仍在表。给予桂枝汤以解表邪。如果头痛不已，说明表邪未解，郁滞严重于经脉，逼迫血液妄行，向上导致鼻衄。）丹波元简按：谨按外证未解不可下，下之为逆。现在头痛有发热，应当解表，反而给予承气汤，这正是责备其妄下的过错。所以下文又说小便清长，知道没有里邪，不应当用承气汤，接着又说应当发汗，若头痛必致衄血，适宜桂枝汤。反复告诫，论意非常明确，而注释却直接说“故当宜下”，可能是因为有六七日不大便的缘故。虽然不大便，但其他没有痛苦，等待表解后再攻之，这才是张仲景的法度。注意似乎不够透彻。）阳明病（无汗用麻黄汤），脉浮，无汗而喘，发汗则愈，适宜麻黄汤。阳明病（兼少阳病），胁下硬满，大便不利且呕，舌上白苔，可以给予小柴胡汤。上焦得通，津液得下，胃气因和，身体濈然汗出而解。（阳明病腹满不大便，舌上苔黄，是邪热入腑，可下。若胁下硬满，虽不大便但呕，舌上白苔，是邪未入腑，在半表半里之间，与小柴胡汤以和解。上焦得通则呕止，津液得下则胃气因和，汗出而解。）阳明中风，脉弦浮大而短气，腹部胀满，胁下及心痛，久按之气不通，鼻干不得汗，嗜睡，一身及面目悉黄，小便难，有潮热，时时呃逆，耳前后肿，刺之稍愈。外证不解，病过十日，脉续浮者，与小柴胡汤。脉但浮无余证者，与麻黄汤。若不排尿，腹满加重呃逆者，不治。（成无己注：脉浮大为阳，风在表；弦则为阴，风在里。短气腹满，胁下及心痛，是风热壅于腹中而不通。若是寒邪客于内而痛，按之则寒气散而痛止。此乃风热内壅，故虽久按而气亦不通。阳明病鼻干不得卧，自汗出，是邪在表。此处鼻干不得汗而嗜卧，是风热内攻，不在里。一身及面目悉黄，小便难，有潮热，时时呃逆，是风热攻于胃。阳明之脉出大迎，循颊车，上耳前，过客主人穴，热胜则肿。此风热在经，故耳前后肿，刺之经气通，肿则小愈。像这样的情况，若外证罢则可攻。若外证不解，虽过十日，脉续浮，邪气犹在半表半里，与小柴胡汤。若其脉但浮而不弦，又无诸里证，是邪但在表，可与麻黄汤。如发其汗，若不尿，腹满加哕，是关格之疾，所以说难治。《难经》说：关格者不得尽其命而死。）
阳明中风口苦咽干，腹满微喘，发热恶寒，脉浮而紧，若误下之，则腹满小便难也。（发热恶寒，表未解也，而误下之，则亡阴，无阴则阳无以化，故腹满小便难。许学士云：宜小柴胡汤。）阳明腹满，脉浮紧，口苦咽干而喘，若发热汗出不恶寒，反恶热，身重者，忌发汗，忌加烧针，忌下（论见自汗）。阳明病，脉浮而紧者，潮热发作有时；但浮者，必盗汗出。
上胃家实不大便，虽三尺之童亦知可下也。殊不知仲景之法，虽有胃实证，若表未解及有半表半里证者，亦先用桂枝、柴胡以解外，然后视虚实消息之也。
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，当须自欲大便时，宜用蜜煎导而通之。若土瓜根及人猪胆汁皆可导之。
蜜煎导法：
用蜜七合，入铜器中，微火熬，稍凝似饴状，搅之勿令焦。候可丸，以手捻作挺子，令头锐，大如指，长二寸许。乘热急作之，纳谷道中，用手急捺住，欲大便时乃去之。
又猪胆汁方：
用大猪胆一个，泻汁，和醋少许，和匀，灌入谷道中，如饭时顷，大便自去。
便硬无所苦者，俟之
太阳病，寸缓关浮尺弱，其人发热汗出，复恶寒，不呕，但心下痞者，此以医下之也。如其不下者，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，但以法救之。渴者，宜五苓散。（成无己注：太阳病，脉阳浮阴弱，为邪在表。今寸缓关浮尺弱，邪气渐传里，则发热汗出，复恶寒者，表未解也。传经之邪入里，里不和者必呕。此不呕但心下痞者，医下之早，邪气留于心下也。如其不下者，必渐不恶寒而渴，太阳之邪转属阳明也。若吐若下若发汗后，小便数，大便硬者，当与小承气汤和之。此不因吐下发汗后，小便数大便硬者，是无满实，虽不更衣十日，无所苦也。候津液还入胃中，小便数少，大便必自出也。渴欲饮水者，少少与之，以润胃气。但审邪气所在，以法救之。如渴不止，与五苓散是也。）张元素或问：上条云“小便数者，大便必硬，不更衣十数日，无所苦也”。尝有四五日、六七日不大便者，即为攻之。今言十日不更衣而不用攻伐，何也？曰：此非结热，乃津液不足。虽十日不更衣，亦无所苦也。经曰：“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，本小便日三四行，今日再行，故知大便不久为出。不便数少，以津液当还胃中，故知不久大便也。”夫不便者，若有潮热谵语，可下之证者，然后可以攻之。其不大便而无诸下证者，此津液不足，当须自审慎，勿以日数久而辄为攻下也。）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，以津液当还入胃中，故知不久必大便也。
胃实表解有证者，随证攻之
阳明病，潮热，不大便六七日，恐有燥粪。欲知之法，少与小承气汤，转失气者，有燥屎，可攻；若不转失气者，无燥屎，不可攻。（方论见潮热）阳明病，汗出，大便硬而谵语者，宜小承气汤。（方见谵语）不大便，腹满者，宜下之。若但绕脐痛者，则为燥屎，宜承气汤。若心下至小腹满痛者，则为结胸，宜陷胸汤（论见腹痛）。阳明病，不吐不下，心烦者，可与调胃承气汤。（成注：吐后心烦谓之内烦，下后心烦谓之虚烦。今阳明病不吐不下，心烦，则是胃有郁热也，与调胃承气汤以下郁热。按：阳明一证，分为太阳、正阳、少阳三等，而以调胃、大小承气下之者。按本草曰：大黄酒浸，入太阳经；酒洗，入阳明经。浸久于洗，得酒气为多，故能引之于至高之分。若物在山巅，人迹不及，必射以取之也。故仲景以调胃承气收入太阳门，而大黄下注曰“酒浸”。及详其用，本汤一则曰“少少温服”，二则曰“当和胃气，与调胃承气汤”。又详本汤之证，则曰“不吐不下，心烦者”，又“发汗不解，蒸蒸发热”，又“吐后腹胀满”，是太阳阳明，去表未远，其病在上，不当攻下，故宜缓剂以调和之也。及至正阳阳明，则皆曰“急下之”，与大承气汤。而大承气汤中大黄下注曰“酒洗”，是洗轻于浸，微升其走下之性，以治其中也。至少阳阳明，则去正阳而逼太阴，其分为下，故小承气汤中大黄不用酒制。少阳不宜下，故又曰“少与”、“曰微溏之”，勿令大泄下。此仲景之妙法也。东垣不审胃之云者，乃仲景置调胃承气于太阳篇，太阳不宜下，故又称胃以别之。却踵成氏之谬，以小承气治太阳脾约之证，以调胃承气治正阳阳明大承气之证。余故不能无辨。）小便不利，大便乍难乍易，有微热，喘冒不卧者，宜大承气汤（论见不得卧）。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，宜大承气汤。（成注：诸脉皆属于目。伤寒六七日，邪气入里之时，目中不了了，睛不和者，邪热内甚，上熏于目也。无表里证，大便难者，里实也。身大热者，表热也。身微热者，里热也。《针经》曰：“热病目不明，热不已者死。”此目中不了了，睛不和，则证近危恶也，须急与大承气汤下之。）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，麻仁丸主之。（成注：趺阳者，脾胃之脉诊。浮为阳，知胃气强；涩为阴，知脾为约。约者，俭约之约，又约束之约。《内经》曰：“饮入于胃，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，是脾主为胃行其津液者也。”今胃强脾弱，约束津液，不得四布，但输膀胱，致小便数，大便难。与脾约丸，通肠润燥。）
麻仁丸方：
麻子仁（二升）、芍药（半斤）、枳实（半斤炒）、大黄（去皮一斤）、浓朴（去粗皮炙一尺）、杏仁（一斤去皮尖，别熬作脂）。上六味为末，炼蜜丸如桐子大，饮服十丸，日三服，渐加以愈为度。（成注：《内经》曰：“脾欲缓，急食甘以缓之。”麻子、杏仁之甘，缓脾而润燥。津液不足，以酸收之，芍药之酸以敛津液。肠燥胃强，以苦泄之，枳实、浓朴、大黄之苦，下燥结而泄胃强也。）
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（去声），其色必黑，宜抵当汤主之（方见蓄血）。无表里证，下后脉数不解，消谷易饥，六七日不大便者，有瘀血，宜抵当汤。
许叔微有一士家病者二人，皆旬日矣。一则身热无汗，大便不通，小便如涩，神昏而睡。诊其脉长大而实，予用承气下之而愈。一则阳明自汗，大便不通，小便利，津液少，口干燥，其脉亦大而虚。作蜜煎三进之下，燥粪得溏利而解。其家曰：皆大便不通，何以治之异？予曰：二证虽相似，然自汗小便利者，不可荡涤五脏，为无津液也。然则伤寒大证相似，两证稍有不同，宜予细斟酌。正如格局看命，虽年月日时皆同，而贵贱穷通不相侔者，于一时中有浅深。故知不可不谨。
便初硬后溏
仲景论中有四证，内有二证不言小便，一证言小便不利，一证言小便少。其二证不言小便者：阳明病潮热，不大便六七日，与小承气汤，不转失气者，此但初硬，后必溏，不可攻之，此胃中邪热未作实者也。又太阳病下之，心中懊憹而烦，腹满者，初硬后必溏，此虚烦热在上，胃中无燥屎者也。其一证小便不利者：阳明病中寒，不能食，小便不利，手足濈然汗出，此欲作痼瘕，必大便初硬后溏。所以然者，以胃中水谷不别故也。又一证言小便少者：服承气汤一升，若不大便六七日，小便少者，虽不能食，但初硬后必溏，未定成硬，攻之必溏。须小便利，屎定硬，乃可攻之。是知仲景测大便法，皆以小便觇之。如小便清，知不在里；利不止者，利其小便；小便数少，津液当还入胃中，必大便皆可验者。然小便利，屎定硬，固为可攻，亦有小便自利，大便硬而不可攻者，何哉？阳明病自汗，或发汗，小便自利，此为津液内竭，虽硬，不可攻之，当须自欲大便，宜蜜煎导。盖非里实，故不可攻也。太阳病又一证云：若吐若下若发汗，微烦，小便数，大便硬，与小承气汤和之。此两证汗后大便硬，小便利皆同，而治法不同者，后证为有传邪，故微烦，又因发汗吐下后，小便数，内亡津液，大便硬，是热邪入里，故以小承气利之。至若前证，小便自利，以无传邪，故无烦证，大便虽硬，不得为里热，但肠头干燥，正可用蜜导也。读仲景书者，宜详究焉。
(Difficult Defecation, Hard Stool, Dry Feces)
Cheng Wuji's Commentary: Inability to defecate, difficult defecation, hard stool, and dry feces all belong to Interior Syndromes (Interior Syndromes: syndromes caused by pathogenic factors invading the interior of the body), and most are suitable for purgative treatment. However, if the Exterior Syndrome (Exterior Syndromes: syndromes caused by pathogenic factors attacking the exterior of the body) has not resolved, and Wind-Dampness is struggling, it is especially appropriate to first release the Exterior, and only after the Exterior is resolved should one proceed with purgation. As stated in the classic text: "In Cold Damage (Cold Damage: diseases caused by cold pathogenic factors), if there is an inability to defecate for six or seven days, accompanied by headache and fever, but the urine is clear, it indicates that the pathogen is not in the Interior but remains in the Exterior." This syndrome is often seen in Yangming Disease (Yangming Disease: a stage of Cold Damage characterized by heat and excess in the Stomach and Intestines). This is because the Stomach belongs to Earth, which is the destination for all things, and once pathogens enter, they do not transmit further; this is widely known. It is also commonly known that pathogens transmit from the Taiyang (Taiyang: the initial stage of Cold Damage involving the bladder and small intestine meridians) and Shaoyang (Shaoyang: the second stage of Cold Damage involving the gallbladder and triple burner meridians) channels. However, few can recognize when pathogens transmit from the three Yin channels (Three Yin channels: Taiyin, Shaoyin, and Jueyin channels). If one carefully observes the subtle signs, one will find that there are many cases of urgent purgation required in Three Yin diseases. Is this not the profound intention of Zhang Zhongjing?
For Yangming Excess with Exterior Symptoms, Release the Exterior First
In Cold Damage (complicated by Taiyang disease), if there is an inability to defecate for six or seven days (if sweating is present, use Guizhi Tang/Cinnamon Twig Decoction), headache, and fever, administer Chengqi Tang (Bowel-Regulating Decoction). If the urine is clear, it indicates the pathogen is not in the Interior but remains in the Exterior. At this time, diaphoresis (sweating therapy) should be employed. If the headache persists, nasal bleeding (epistaxis) will inevitably occur, and Guizhi Tang (Cinnamon Twig Decoction) is appropriate. (Cheng Wuji's Commentary: Inability to defecate for six or seven days, with headache and fever, suggests that purgation is indicated. However, if the urine is clear, it indicates no heat in the Interior, so purgation is contraindicated. The classic states: "Those with frequent urination will have hard stools; even if they do not defecate for ten days, they will feel no discomfort." How much more so here, where there is an inability to defecate for six or seven days and clear urine; one cannot blame the pathogen for being in the Interior, indicating it remains in the Exterior. Administer Guizhi Tang (Cinnamon Twig Decoction) to resolve the Exterior. If the headache persists, it indicates the Exterior pathogen has not resolved; severe stagnation in the meridians forces blood to move recklessly, leading upward to epistaxis.) Danbo Yuanjian notes: According to principles, if Exterior symptoms are unresolved, purgation is contraindicated; doing so is adverse. Now, with headache and fever, one should release the Exterior, yet Chengqi Tang (Bowel-Regulating Decoction) is given instead, which is precisely the error of reckless purgation. Therefore, the text later states that clear urine indicates no Interior pathogen, and Chengqi Tang (Bowel-Regulating Decoction) should not be used. Instead, it follows with "diaphoresis should be employed"; if headache persists, epistaxis will occur, and Guizhi Tang (Cinnamon Twig Decoction) is appropriate. The repeated warnings make the intent very clear, whereas the commentary directly says "therefore purgation is indicated," likely due to the six or seven days of constipation. Although there is constipation, if there are no other complaints, waiting for the Exterior to resolve before attacking is the correct method of Zhang Zhongjing. The attention seems insufficiently thorough.) In Yangming Disease (without sweating, use Mahuang Tang/Ephedra Decoction), if the pulse is floating, there is no sweating, and wheezing, diaphoresis leads to recovery, and Mahuang Tang (Ephedra Decoction) is appropriate. In Yangming Disease (complicated by Shaoyang disease), if there is hardness and fullness under the hypochondrium, difficulty in defecation, vomiting, and a white coating on the tongue, Xiaochaihu Tang (Minor Bupleurum Decoction) may be administered. When the Upper Jiao (Upper Jiao: the upper part of the Sanjiao, primarily involving the Heart and Lungs) is unblocked, fluids descend, the Stomach Qi harmonizes, and the body sweats slightly, leading to resolution. (In Yangming Disease, abdominal fullness and inability to defecate with a yellow tongue coating indicate Heat Pathogen entering the Fu organs, warranting purgation. If there is hardness and fullness under the hypochondrium, though unable to defecate, with vomiting and a white tongue coating, the pathogen has not entered the Fu organs but is between the Exterior and Interior. Administer Xiaochaihu Tang (Minor Bupleurum Decoction) to harmonize. Unblocking the Upper Jiao stops vomiting; descending fluids harmonize Stomach Qi; sweating resolves the condition.) In Yangming Wind Strike, if the pulse is wiry, floating, and large, with shortness of breath, abdominal fullness, pain in the hypochondrium and heart region that does not relieve upon long pressure, dry nose, inability to sweat, drowsiness, jaundice of the whole body and face, difficult urination, tidal fever, occasional hiccups, and swelling around the ears, acupuncture may provide slight relief. If Exterior symptoms remain unresolved and the disease lasts over ten days, and the pulse continues to float, administer Xiaochaihu Tang (Minor Bupleurum Decoction). If the pulse is merely floating without other symptoms, administer Mahuang Tang (Ephedra Decoction). If there is no urination, increased abdominal fullness, and added hiccups, it is untreatable. (Cheng Wuji's Commentary: A floating and large pulse indicates Yang, with Wind at the Exterior; wiry indicates Yin, with Wind in the Interior. Shortness of breath and abdominal fullness, along with pain in the hypochondrium and heart, indicate Wind-Heat congesting the abdomen and blocking flow. If pain were caused by Cold invading internally, pressing would disperse the Cold and stop the pain. Here, Wind-Heat is internally congested, so even long pressure does not relieve the Qi blockage. In Yangming Disease, a dry nose, inability to sleep, and spontaneous sweating indicate the pathogen is at the Exterior. Here, a dry nose, inability to sweat, and drowsiness indicate Wind-Heat attacking internally, not in the Interior. Jaundice of the whole body and face, difficult urination, tidal fever, and hiccups indicate Wind-Heat attacking the Stomach. The Yangming meridian emerges from Daying, follows the cheekbone, ascends to the ear, passes through the Guest Master point; excessive heat causes swelling. This Wind-Heat in the meridian causes swelling around the ears; acupuncture unblocks the meridian Qi, and the swelling subsides slightly. In such cases, if Exterior symptoms resolve, purgation is possible. If Exterior symptoms remain unresolved, even after ten days, if the pulse continues to float, the pathogen is still in the Half-Exterior Half-Interior, and Xiaochaihu Tang (Minor Bupleurum Decoction) is appropriate. If the pulse is merely floating, wiry, and lacks Interior symptoms, the pathogen is solely at the Exterior, and Mahuang Tang (Ephedra Decoction) may be given. If diaphoresis is induced and results in no urination, increased abdominal fullness, and hiccups, it is Guan Ge (Guan Ge: a critical condition involving obstruction of both ascending and descending functions), hence described as untreatable. The Classic of Difficulties states: "Those with Guan Ge will not live out their natural lifespan.")
Bitter Taste in Mouth, Dry Throat, Floating-Tight Pulse, Suitable for Harmonizing
In Yangming Wind Strike, with bitter taste in the mouth, dry throat, abdominal fullness, slight wheezing, fever, aversion to cold, and a floating-tight pulse, if purgation is mistakenly used, it will result in abdominal fullness and difficult urination. (Fever and aversion to cold indicate the Exterior is unresolved; mistaken purgation consumes Yin fluids. Without Yin, Yang cannot transform, resulting in abdominal fullness and difficult urination. Xu Xueshi states: Xiaochaihu Tang (Minor Bupleurum Decoction) is appropriate.) In Yangming, with abdominal fullness, floating-tight pulse, bitter taste, dry throat, and wheezing, if there is fever, sweating, no aversion to cold, but aversion to heat, and heaviness of the body, diaphoresis is contraindicated, moxibustion with burning needles is contraindicated, and purgation is contraindicated (see Self-Sweating discussion). In Yangming Disease, if the pulse is floating and tight, tidal fever occurs at specific times; if the pulse is merely floating, night sweating will occur.
Regarding Stomach Excess with Inability to Defecate: Even a child knows purgation is indicated. However, one must not ignore Zhang Zhongjing's method: even with Stomach Excess, if the Exterior is unresolved or there are Half-Exterior/Half-Interior symptoms, one must first use Guizhi Tang (Cinnamon Twig Decoction) or Chaihu Tang (Bupleurum Decoction) to release the Exterior, and then assess deficiency and excess to decide on treatment.
For Stomach Excess with Resolved Exterior and No Specific Symptoms, Avoid Attack; For Hard Stool, Use Guiding Methods
In Yangming Disease, if there is spontaneous sweating, or if sweating was induced and urination is free, this indicates internal depletion of Body Fluids (Body Fluids: normal fluids in the body). Even if the stool is hard, it cannot be attacked with purgatives. One must wait until the patient feels the urge to defecate, then use Honey Suppositories (Honey Suppositories: a suppository made of honey for local lubrication) to guide and relieve it. Radish root (Tugua Gen) or human pig bile can also be used for guiding.
Method for Honey Suppositories:
Take seven he of honey, place in a copper vessel, simmer gently over low fire until slightly thickened like malt syrup. Stir constantly to prevent burning. When it can be molded, shape it by hand into a cone, sharp at the head, about the thickness of a finger and two cun long. While hot, quickly insert it into the rectum. Hold it firmly with the hand; remove it when the urge to defecate arises.
Another Pig Bile Formula:
Use one large pig gallbladder, extract the juice, mix with a little vinegar, and instill into the rectum. After the time it takes to eat a meal, the stool will pass naturally.
For Hard Stool Without Discomfort, Wait
In Taiyang Disease, if the Cun position is slow, Guan is floating, Chi is weak, the person has fever, sweating, and recurrent aversion to cold, no vomiting, but only epigastric stuffiness, this is due to the physician mistakenly using purgation. If purgation was not used, and the patient is not averse to cold but thirsty, this indicates transmission to Yangming. Frequent urination leads to hard stool; even if one does not defecate for ten days, there is no discomfort. If thirsty and desiring water, give small amounts frequently, and treat according to the method. For thirst, Wuling San (Five-Ingredient Powder with Poria) is appropriate. (Cheng Wuji's Commentary: In Taiyang Disease, a floating pulse at Yang positions and weak at Yin positions indicates pathogen at the Exterior. Now, slow at Cun, floating at Guan, weak at Chi, indicates pathogen gradually transmitting to the Interior. Fever, sweating, and recurrent aversion to cold mean the Exterior is unresolved. Pathogen transmitting to the Interior causing Interior disharmony usually leads to vomiting. Here, no vomiting but only epigastric stuffiness indicates premature purgation by the physician, leaving pathogen lingering in the epigastrium. If not purged, the patient will gradually lose aversion to cold and become thirsty, indicating Taiyang pathogen transmitting to Yangming. After vomiting, purgation, or sweating, if urination becomes frequent and stool hard, Xiao Chengqi Tang (Minor Bowel-Regulating Decoction) should be given to harmonize. Here, without prior vomiting/purgation/sweating, frequent urination and hard stool indicate no fullness/excess; even without defecating for ten days, there is no discomfort. Wait for fluids to return to the Stomach; as urination decreases, stool will pass naturally. For thirst, give small amounts of water to moisten Stomach Qi. Assess the pathogen's location and treat accordingly. If thirst persists, use Wuling San (Five-Ingredient Powder with Poria).) Zhang Yuansu asks: The previous clause states "frequent urination leads to hard stool; not defecating for ten-plus days causes no discomfort." Yet, I have treated patients with four, five, six, or seven days of constipation with purgation. Why now say ten days without purgation? Answer: This is not accumulated heat, but insufficient fluids. Even without defecating for ten days, there is no discomfort. The classic states: "In Yangming Disease, originally with spontaneous sweating, if the physician induces heavy sweating again, and although the illness has improved, slight vexation remains, this indicates hard stool. Due to loss of fluids and dryness in the Stomach, stool becomes hard. Ask how many times the patient urinates daily. Originally three or four times, now twice, indicating stool will pass soon. Less frequent urination means fluids are returning to the Stomach, so stool will pass soon." Only if there are symptoms like tidal fever and delirium indicating purgation is needed should one attack. If there is constipation without these purgative indications, it is fluid deficiency; one must be cautious and not purge simply because days have passed.) In Yangming Disease, originally with spontaneous sweating, if the physician induces heavy sweating again, and although the illness has improved, slight vexation remains, this indicates hard stool. Due to loss of fluids and dryness in the Stomach, stool becomes hard. Ask how many times the patient urinates daily. If originally three or four times, now twice, it indicates stool will pass soon. Now, with decreased urination, fluids are returning to the Stomach, so stool will pass soon.
For Stomach Excess with Resolved Exterior and Present Symptoms, Attack According to Syndrome
In Yangming Disease, with tidal fever and inability to defecate for six or seven days, suspecting dry feces: To verify, give a small amount of Xiao Chengqi Tang (Minor Bowel-Regulating Decoction). If gas passes, there are dry feces, and purgation is possible; if gas does not pass, there are no dry feces, and purgation is contraindicated. (Formula discussion see Tidal Fever) In Yangming Disease, with sweating, hard stool, and delirium, Xiao Chengqi Tang (Minor Bowel-Regulating Decoction) is appropriate. (See Delirium) With inability to defecate and abdominal fullness, purgation is indicated. If there is only periumbilical pain, it indicates dry feces, and Chengqi Tang (Bowel-Regulating Decoction) is appropriate. If there is fullness and pain from the epigastrium to the lower abdomen, it indicates Jie Xiong (Jie Xiong: Chest Binding, a syndrome of pain and fullness in the chest/abdomen), and Xianxiong Tang (Chest-Unbinding Decoction) is appropriate. (See Abdominal Pain) In Yangming Disease, if there is mental irritability without prior vomiting or purgation, Tiaowei Chengqi Tang (Stomach-Harmonizing Bowel-Regulating Decoction) may be given. (Cheng's Note: Irritability after vomiting is Internal Vexation; after purgation, it is Deficiency Vexation. Here, in Yangming Disease, without vomiting or purgation, irritability indicates stagnant Heat in the Stomach; administer Tiaowei Chengqi Tang (Stomach-Harmonizing Bowel-Regulating Decoction) to drain the stagnant Heat. Analysis: Yangming syndrome is divided into Taiyang, Zhengyang, and Shaoyang categories, treated with Tiaowei, Da, and Xiao Chengqi Tangs. According to Materia Medica: Rhubarb soaked in wine enters Taiyang channel; washed in wine enters Yangming channel. Soaking longer than washing extracts more wine essence, allowing it to reach high locations. Like objects on a mountain peak unreachable by foot, they must be shot down. Thus, Zhang Zhongjing places Tiaowei Chengqi Tang (Stomach-Harmonizing Bowel-Regulating Decoction) in the Taiyang chapter, noting Rhubarb is "soaked in wine." Detailed usage: "Take small amounts, warm, and drink"; "Harmonize Stomach Qi with Tiaowei Chengqi Tang." Indications include "no vomiting/purgation, irritability," "post-sweating unremitting steaming fever," and "post-vomiting abdominal fullness." These are Taiyang-Yangming transitions, close to the Exterior, with pathology above, unsuitable for strong purgation; thus, mild agents are used to harmonize. For Zhengyang Yangming, "urgent purgation" with Da Chengqi Tang (Major Bowel-Regulating Decoction) is stated, noting Rhubarb is "washed in wine." Washing is lighter than soaking, slightly enhancing its downward movement to treat the Middle. For Shaoyang Yangming, moving away from Zhengyang towards Taiyin, the location is lower, so Rhubarb in Xiao Chengqi Tang (Minor Bowel-Regulating Decoction) is not wine-treated. Shaoyang is unsuitable for purgation, hence "give small amounts," "induce slight diarrhea," avoiding severe purging. This is Zhang Zhongjing's subtle method. Dongyuan failed to understand why "Stomach" is mentioned; Zhang Zhongjing placed Tiaowei Chengqi Tang (Stomach-Harmonizing Bowel-Regulating Decoction) in the Taiyang chapter because Taiyang is unsuitable for purgation, hence adding "Stomach" to distinguish it. Chengshi erroneously used Xiao Chengqi Tang (Minor Bowel-Regulating Decoction) for Taiyang Pi Yue (Spleen Constriction) and Tiaowei Chengqi Tang (Stomach-Harmonizing Bowel-Regulating Decoction) for Zhengyang Yangming Da Chengqi Tang (Major Bowel-Regulating Decoction) cases. I cannot but dispute this.) If there is difficult urination, alternating hard and soft stool, slight fever, wheezing, vertigo, and inability to lie down, Da Chengqi Tang (Major Bowel-Regulating Decoction) is appropriate. (See Inability to Lie Down) In Cold Damage, after six or seven days, if the eyes appear unclear and pupils are unresponsive, with no Exterior or Interior symptoms, difficult defecation, and slight body heat, this is Excess; urgent purgation with Da Chengqi Tang (Major Bowel-Regulating Decoction) is required. (Cheng's Note: All meridians connect to the eyes. In Cold Damage, after six or seven days, when pathogen enters the Interior, unclear vision and unresponsive pupils indicate severe Internal Heat steaming upwards. No Exterior/Interior symptoms and difficult defecation indicate Interior Excess. High body heat indicates Exterior Heat; slight body heat indicates Interior Heat. The Needle Classic states: "In Heat diseases, if vision is impaired and heat persists, death ensues." Unclear vision and unresponsive pupils indicate a critical, dangerous condition; urgent purgation with Da Chengqi Tang (Major Bowel-Regulating Decoction) is necessary.) If the Yuyang pulse is floating and choppy, floating indicates strong Stomach Qi, choppy indicates frequent urination. Floating and choppy interacting leads to difficult defecation; this is Pi Yue (Pi Yue: Spleen Constriction, where the Spleen fails to distribute fluids), treated with Maren Wan (Hemp Seed Pill). (Cheng's Note: Yuyang pulse diagnoses the Spleen and Stomach. Floating is Yang, indicating strong Stomach Qi; choppy is Yin, indicating Spleen Constriction. "Yue" means restraint or constraint. The Inner Classic states: "Fluids enter the Stomach, essence floats up, transmits to the Spleen; Spleen scatters essence to the Lungs; regulates water passages, transmits to Bladder; fluids distribute four ways, meridians circulate together. The Spleen governs distributing fluids for the Stomach." Now, strong Stomach and weak Spleen constrain fluids, preventing distribution, sending them only to the Bladder, causing frequent urination and difficult defecation. Administer Pi Yue Pill to unblock intestines and moisten dryness.)
Maren Wan (Hemp Seed Pill) Formula:
Hemp Seed (Er Sheng), Peony Root (Ban Jin), Immature Bitter Orange (Ban Jin, stir-fried), Rhubarb (Qu Pi, Yi Jin), Magnolia Bark (Qu Cu Pi, roasted, Yi Chi), Apricot Kernel (Yi Jin, qu pi jian, separately boiled to paste). Grind the above six herbs into powder, refine honey, and make pills the size of wu zi seeds. Take ten pills with water, three times daily, gradually increasing until recovery. (Cheng's Note: The Inner Classic states: "The Spleen desires relaxation; urgently feed sweet flavors to relax it." Hemp seed and apricot kernel are sweet, relaxing the Spleen and moistening dryness. Insufficient fluids are gathered with sour flavors; Peony root is sour, gathering fluids. Intestinal dryness and strong Stomach are drained with bitter flavors; Immature Bitter Orange, Magnolia Bark, and Rhubarb are bitter, draining dryness and reducing strong Stomach Qi.)
In Yangming Syndrome, if the patient suffers from forgetfulness, there must be Blood Stasis (Blood Stasis: stagnant blood). The reason is pre-existing long-standing Blood Stasis, causing forgetfulness. Although stool is hard, defecation is surprisingly easy, and the color is black; Dandang Tang (Resolute Elimination Decoction) is appropriate. (See Blood Stasis) With no Exterior or Interior symptoms, if after purgation the rapid pulse persists, digestion is rapid with easy hunger, and there is no defecation for six or seven days, this indicates Blood Stasis; Dandang Tang (Resolute Elimination Decoction) is appropriate.
Xu Shumi reports: Two scholars in one family were ill for ten days. One had fever, no sweating, inability to defecate, difficult urination, confusion, and sleepiness. The pulse was large, long, and solid. I used Chengqi Tang (Bowel-Regulating Decoction) to purge, and he recovered. The other had Yangming spontaneous sweating, inability to defecate, free urination, scant fluids, dry mouth, and a large, empty pulse. I administered Honey Suppositories three times; dry feces passed as loose stool, and he recovered. The family asked: Both had constipation, why different treatments? I replied: Though similar, the one with sweating and free urination cannot undergo harsh purgation of the Five Zang organs due to fluid deficiency. Thus, although major Cold Damage syndromes are similar, slight differences require careful consideration. Just as in destiny reading, same year/month/day/hour can yield different fortunes based on subtle depths within the hour. Thus, caution is essential.
Stool Initially Hard, Then Loose
Zhang Zhongjing discusses four syndromes. Two do not mention urination; one mentions difficult urination; one mentions scant urination. Regarding the two not mentioning urination: In Yangming Disease with tidal fever and inability to defecate for six or seven days, if after giving Xiao Chengqi Tang (Minor Bowel-Regulating Decoction) gas does not pass, the stool is initially hard but will subsequently be loose; purgation is contraindicated, as the pathogenic heat in the Stomach has not formed Excess. Also, in Taiyang Disease, after purgation, if there is inner vexation and abdominal fullness, the stool is initially hard but will subsequently be loose; this is Empty Vexation with Heat above, and no dry feces in the Stomach. Regarding the case with difficult urination: In Yangming Disease with Cold invasion, inability to eat, difficult urination, and continuous sweating on hands and feet, this indicates impending Guo Zha (Guo Zha: chronic accumulation/mass), and stool will be initially hard then loose. This is because food and water are not separated in the Stomach. Regarding the case with scant urination: After taking one sheng of Chengqi Tang (Bowel-Regulating Decoction), if there is no defecation for six or seven days and urination is scant, even if unable to eat, the stool is initially hard but will subsequently be loose. It is not yet definitely hard; purging will cause loose stool. One must wait for free urination and definite hard stool before purging. Thus, Zhang Zhongjing's method for assessing stool relies on observing urination. Clear urine indicates pathogen not in Interior; if diarrhea persists, benefit the urination; if urination is less, fluids return to Stomach, and stool will pass. However, even with free urination and hard stool (indicating purgation is possible), there are cases with free urination and hard stool where purgation is contraindicated. Why? In Yangming Disease with spontaneous sweating, or induced sweating, with free urination, this indicates internal depletion of fluids; even if hard, purgation is contraindicated. Wait for the urge to defecate and use Honey Suppositories. This is not Interior Excess, hence purgation is contraindicated. Another Taiyang case states: After vomiting, purgation, or sweating, if there is slight vexation, frequent urination, and hard stool, give Xiao Chengqi Tang (Minor Bowel-Regulating Decoction) to harmonize. In these two cases, post-sweating hard stool and free urination are the same, but treatments differ. The latter has transmitting pathogen, hence slight vexation; post-sweating/vomiting/purgation, frequent urition depletes internal fluids, hardening stool due to Heat entering Interior; thus, Xiao Chengqi Tang (Minor Bowel-Regulating Decoction) is used to promote movement. In the former case, free urination indicates no transmitting pathogen, hence no vexation; although stool is hard, it is not Interior Heat, but merely dryness at the rectal entrance; Honey Suppositories are appropriate. Readers of Zhang Zhongjing's works should investigate this in detail.