Source 出处 · Jingui Yaolüe · Doses are not given here: they are set by a licensed practitioner for the individual.
Safety. This is the formula that establishes the category of the warm purge, and the reason it is interesting is that on the face of it the combination is a contradiction. Purging is the method for heat bound in the interior; warming is what one does when there is cold. Putting a cold-natured purgative and a hot-natured emergency poison into three ingredients looks less like a prescription than like an argument, and the tradition has never entirely stopped having that argument. What the Jingui Yaolüe describes is pain under the ribs spreading to the side, with fever, and a pulse that is tight and wiry; its reading is that this is cold accumulating in the interior, and that the treatment is to warm it and move it out rather than to clear heat. The later textbook category that grew around the formula is the warm purge, and it is small: this is the type case and there are not many others.
Whether the condition corresponds to anything one would recognise now is worth saying carefully, because the overlap is suggestive rather than tidy. The picture most often mapped onto it in modern terms includes severe constipation with colicky pain, faecal impaction, postoperative or opioid-induced ileus, and - the one that gets people into trouble - the right clinical presentations that look like constipation and are not. It is also worth noting that the source itself pairs this with a neighbouring line on what to do when the pain is accompanied by a pulse picture indicating something else entirely, which is the text again writing its own boundary.
The sequencing point has to come before the formula, as it does everywhere in this knowledge base. Abdominal pain with a distended abdomen and no stool or wind passing is a same-day assessment, because the two branches are obstruction and non-obstruction and their treatments are opposite. Stimulant laxatives, enemas and anything that increases peristalsis are withheld in an undiagnosed acute abdomen for a reason that has nothing to do with caution as a disposition: if there is a mechanical obstruction or a distended, ischaemic or friable bowel, forcing it is one of the dependable ways to produce perforation and peritonitis. In older adults the presentation that mimics simple constipation most convincingly is faecal impaction, which can present as overflow diarrhoea and is therefore regularly misread.
And then the materials, which is where this entry has to be uncompromising. Two of the three ingredients are the two most serious hazard stories in ordinary Chinese materia medica.
Aconite is first. Aconitum is the single most hazardous item in routine use and it has a poisoning literature to match: aconitine and the related diester alkaloids hold voltage-gated sodium channels open, and poisoning presents with numbness and tingling of the mouth and limbs, nausea and vomiting, a slow or erratic ventricular rhythm, and arrest. Reported cases cluster around inadequately processed material, decoctions not boiled long enough, self-medication, and misuse of raw material or alcoholic extracts. Practice answers with two requirements and neither is negotiable: only processed accessory root is used, and it is boiled for a long time, which hydrolyses the diester alkaloids into far less toxic products. Several jurisdictions restrict or have restricted the sale of aconite-containing material.
Asarum is second and it is serious for a quieter reason that accumulates rather than announces itself. It belongs to the birthwort family, Aristolochiaceae, whose members contain aristolochic acid; the nephropathy and upper urinary tract urothelial carcinoma associated with that compound class come from cumulative exposure for which no safe threshold has been established. This is why the Chinese pharmacopoeia restricts the medicinal part of asarum to root and rhizome rather than the aerial parts, and why the part used is not a technicality. Anything containing asarum is, for this knowledge base, a reason for a reader to want the source of the material named.
Rhubarb is the mildest of the three and it is still an anthraquinone stimulant laxative, with dependence, fluid and potassium loss, and melanosis coli on long repeated use.
So: a formula that works by putting the most dangerous herb in common use next to a purgative, in order to purge what cold has bound. It is worth understanding as a piece of reasoning. It is not something to assemble at home, and the abdominal picture it is aimed at is, first and always, a question for an emergency department.
这一首方确立了「温下」这个类别，而它有意思的地方在于：表面上看，这个组合本身就是一个矛盾。攻下是对里热的方法；温是面对寒的时候做的事。把一味寒性的泻药和一味热性的急救级毒物放进三味药里，看起来与其说是一张方，不如说是一场争论——而传统自己也从未完全停止这场争论。《金匮要略》描写的是胁下偏痛、发热、脉紧弦；它的读法是寒积在里，治法是温而散之，不是清热。后世围绕此方长出来的教科书类别就是温下法，而这个类别很小：它是样本方，别的成员不多。
至于它今天对应什么，值得谨慎地说，因为那种重合是启发性的而不是严丝合缝的。现代最常被对上去的画面包括：严重便秘伴绞痛、粪便嵌塞、术后或阿片类所致的肠麻痹，以及——恰恰是最让人出事的那一类——看起来像便秘而并不是便秘的那些临床表现。也值得一提的是，原书自己在旁边写了一句「脉象另是一回事时应当怎么处理」的文字，那是文本又一次在写自己的边界。
顺序问题必须放在方子前面，正如本站处处所做的那样。腹痛、腹胀、不排便也不排气，是当日就诊的事，因为两条分支是梗阻与非梗阻，而它们的处理正好相反。对一个尚未判明的急腹症不给泻药、不给灌肠、不给任何增加肠蠕动的手段，理由与「谨慎」这种性格无关：如果存在机械性梗阻，或一段已经胀大、缺血、发脆的肠管，逼它动是把可活的病推进穿孔与腹膜炎的可靠办法之一。在老年人身上，把「普通便秘」模仿得最像的其实是粪便嵌塞，而它可以表现为溢液性腹泻，因此经常被读错。
接下来是单味药，这也正是本条不能退让的地方：三味里有两味是常用中药中最严重的两段风险故事。
第一是附子。乌头属是常规使用里危险性最高的一味，也有与之相称的中毒文献：乌头碱及相关双酯型生物碱使电压门控钠通道持续开放，中毒表现为口唇与四肢麻木刺痛、恶心呕吐、心率慢或不齐的室性心律，直至停搏。报道的病例集中在炮制不足的药材、煎煮时间不够的汤剂、自行用药，以及生品或醇提物的滥用。常规做法用两条来回应，而两条都不可以商量：只用炮制过的附子，并且久煎——久煎会把双酯型生物碱水解成毒性低得多的一串产物。若干司法辖区对含乌头类药材的销售有限制或曾经有限制。
第二是细辛，它严重的原因更安静，是一条累积而不是当场宣告的线。它属马兜铃科，该科植物含马兜铃酸；与这一类化合物相关的肾病与上尿路上皮癌来自累积暴露，而没有确定过任何安全阈值。这也是为什么《中国药典》把细辛的药用部位限定为根及根茎而不是地上部分，也是为什么「用哪个部位」不是技术细节。对本站来说，任何含细辛的东西都构成读者应当要求标明来源的理由。
大黄是三味里最缓的，但它仍然是蒽醌类刺激性泻药，反复久服会带来依赖、水与钾的丢失和结肠黑变病。
于是：一首靠把最常用的最危险的药与一味泻药放在一起、去攻下被寒所结之物的方。作为一个推理它是值得理解的。它不是可以在家里配出来的东西，而它所对的那幅腹部画面，首先并且永远是一个急诊问题。