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[General Principle] Zhang Zhongjing stated: When the pulse is floating and large, and the epigastrium is conversely hard, if heat belongs to the Zang organs, attack it with purgation; do not induce sweating. If heat belongs to the Fu organs, do not cause frequent urination. Frequent urination leads to hard stools. Excessive sweating intensifies heat, while insufficient sweating makes defecation difficult. If the pulse is slow, purgation should not yet be performed.

[Detailed Commentary] Zhu Gong said: In Shanghan (Cold Damage) disease, there are indeed cases where Yang-excess symptoms appear immediately upon onset, requiring immediate purgation. There are also cases where cold in the interstices transforms into Shaoyin disease within one or two days, requiring urgent warming. Yangming interior syndrome refers to internal heat, which is suitable for purgation. In Shanghan, initially presenting with fever and aversion to cold, after sweating, if aversion to cold ceases but fever increases significantly accompanied by irritability, and the pulse changes from initially floating and large to now surging and solid, or deep, thin, and rapid; if the patient changes from being alert and quiet to delirious speech, this indicates Stomach excess and Yang hyperactivity. Another sweat will cause death; purgation is required for recovery. Additionally, in cases of severe distension and oppression connecting the chest, heart, umbilicus, and abdomen, abdominal pain, restlessness in sitting and lying, extreme dizziness, oppression, and panting, purgation should be administered without waiting for other symptoms. However, if there is only difficulty and oppression in defecation, suspecting residual exterior syndrome, administer Xiao Chengqi Tang (Minor Order the Qi Decoction) in small amounts to gently resolve it. Do not administer too much to avoid severe diarrhea.

Failure to purge when indicated results in blocked Qi and Blood, leading to cold extremities. Physicians who do not understand this may mistakenly diagnose Yin-cold reversal and administer hot herbs, causing disaster instantly. This must be carefully distinguished.

Question: Are there cases in the Three Yin diseases suitable for purgation? Generally, Three Yin diseases are suitable for warming, but purgation is only appropriate if there are accumulation symptoms. What are accumulation symptoms? In Taiyin disease, abdominal fullness with intermittent pain is treated with Guizhi Ji Shaoyao Tang (Cinnamon Twig Decoction Augmented with Peony Root). Severe cases use Guizhi Jia Dahuang Tang (Cinnamon Twig Decoction Augmented with Rhubarb). In Shaoyin disease, dry mouth and throat, or abdominal fullness with constipation, or diarrhea with undigested food, and epigastric pain, are all accumulation symptoms. If all purgation indications are present, and bowel movement occurs after taking the decoction, stop the remaining dose; otherwise, administer the entire dose.

Wang Kentang stated: The general rule is that autumn is suitable for purgation. For conditions suitable for purgation, decoctions are superior to pills and powders. Stop medication once the pathogen is addressed; it is not necessary to finish the entire dose.

[General Principle] Zhang Zhongjing stated: If a patient has vexatious heat, relief follows sweating. If it resembles malaria with fever occurring at dusk, it belongs to Yangming. If the pulse is solid, purgation is suitable. Administer Chengqi Tang (Order the Qi Decoction).

[Detailed Commentary] Wang Haogu stated: Dachengqi Tang (Major Order the Qi Decoction) treats severe excess and fullness. "Fullness" refers to chest and abdominal distension resembling joined tiles; "severe excess" refers to constipation. It is used when Pi (blockage), Man (fullness), Zao (dryness), and Shi (excess) syndromes are all present. For miscellaneous diseases, it is used according to the progression of the condition. Xiaochengqi Tang (Minor Order the Qi Decoction) treats Pi and Shi with mild fullness, feeling like a hungry person who has eaten their fill, with no flatus in the abdomen and epigastric blockage, though stool may pass. It is suitable when heat is severe and purgation is needed. Tiaowei Chengqi Tang (Regulate the Stomach Order the Qi Decoction) treats excess without fullness, where the abdomen feels like an inverted tile, with flatus, dry feces, constipation, and delirious speech—symptoms of solidity. These three methods must not be confused. If Tiaowei Chengqi Tang syndrome is treated with Dachengqi Tang, post-recovery vitality will not recover due to the harsh Qi-moving herbs. If Dachengqi Tang syndrome is treated with Tiaowei Chengqi Tang, post-recovery mental clarity will be impaired due to the lack of Qi-moving herbs. If Xiaochengqi Tang syndrome is treated with Mangxiao (Natrii Sulfas), it may cause unceasing diarrhea, transforming into deficiency. Furthermore, although exterior symptoms of Shanghan often indicate purgation, if the pulse is fine and purgation is contraindicated, Xiexin Tang (Drain the Epigastrium Decoction) is the primary treatment. If the pulse is forceful, use Huanglian Xiexin Tang (Coptis Drain the Epigastrium Decoction); if weak, use Banxia Xiexin Tang (Pinellia Drain the Epigastrium Decoction).

Shen Jin'ao noted: Chengqi Tang syndromes are numerous; not all are recorded here. Only those with "urgent purgation" or "urgent attack" labels are included, as these indicate an immediate need for purgation. Other Chengqi Tang syndromes are not always so urgent.

[General Principle] Zhang Zhongjing stated: On the second or third day of illness, if the pulse is weak, without Taiyang or Chaihu syndrome symptoms, but with irritability and hardness in the epigastrium, progressing to the fourth or fifth day, even if the patient can eat, administer Xiaochengqi Tang (Minor Order the Qi Decoction) in small amounts to gently harmonize and provide slight relief. By the sixth day, administer one sheng of Chengqi Tang. If there is no bowel movement, and on the sixth or seventh day urine is scanty, even if the patient cannot eat, if the stool is hard at the beginning but loose at the end, it has not definitively become hard. Purgation will cause loose stools. Wait until urine flows freely and stool is definitely hard before purging, using Dachengqi Tang (Major Order the Qi Decoction).

[Detailed Commentary] Wu Shou stated: The classic text says that in Taiyang disease, if fever and sweating do not resolve and the patient has a steaming heat sensation, it belongs to the Stomach; treat with Tiaowei Chengqi Tang (Regulate the Stomach Order the Qi Decoction). For tidal fever and abdominal fullness, use Daichaihu Tang (Greater Bupleurum Decoction) augmented with Houpo (Magnolia Bark). In Yangming disease, excessive sweating causes dryness in the Stomach and hard stool, leading to delirium; treat with Xiaochengqi Tang (Minor Order the Qi Decoction). If delirium is accompanied by a slippery and rapid pulse and tidal fever, use Daichaihu Tang (Greater Bupleurum Decoction). If delirium, tidal fever, and anorexia occur, there are likely five or six pieces of dry feces in the Stomach; treat with Xiaochengqi Tang (Minor Order the Qi Decoction). If the patient can eat and stool is hard, use Dachengqi Tang (Major Order the Qi Decoction).

[General Principle] Zhang Zhongjing stated: Sweating accompanied by delirious speech indicates dry feces in the Stomach, caused by Wind. Purgation is required. However, wait until the meridian cycle has passed before purging. Premature purgation will cause language disorder due to exterior deficiency and interior excess. After purgation, the condition will resolve; use Dachengqi Tang (Major Order the Qi Decoction).

[Detailed Commentary] Cheng Wuji stated: Stomach excess with constipation, whether difficult or hard, involves dry feces belonging to interior syndrome, often requiring purgation. However, if the exterior is unresolved and wind-dampness is interacting, it is better to resolve the exterior first before purging. As stated in the classic: constipation for six or seven days with headache and fever, but clear urine, indicates the pathogen is in the interior, not the exterior. This syndrome is common in Yangming because the Stomach Earth is the destination of all pathogens and does not transmit further. Transmission from Taiyang and Shaoyang is well known, but transmission from the Three Yin is rarely recognized. Careful observation reveals many urgent purgation cases in Three Yin diseases, reflecting Zhang Zhongjing's subtle intent.

Tao Hua stated: There are two conditions suitable for urgent purgation. Shaoyin disease with dry mouth and throat indicates dried kidney fluids and requires urgent purgation. Yangming disease with fever and excessive sweating indicates dried stomach fluids and also requires urgent purgation. These are the two urgent purgation conditions.

Wang Ang stated: In Shaoyin disease, if dry mouth and throat appear within two or three days, urgent purgation is needed. The pathogen has not penetrated deeply, but mouth dryness indicates impending kidney water depletion; urgent purgation saves the root. In Shaoyin disease, if abdominal fullness and constipation appear on the sixth or seventh day, urgent purgation is needed. This is Shaoyin heat entering the Stomach Fu. Earth excess depletes Water; urgent purgation saves kidney water. In Shaoyin disease, spontaneous diarrhea with pure green fluid, heart pain, and mouth dryness require urgent purgation. Green corresponds to Liver; Liver pathogen attacking Kidney causes diarrhea. Yang pathogen attacking upward causes mouth dryness. This is Shaoyin transmitting to Yangming Fu disease. In Jueyin disease, tongue retraction and testicular contraction require urgent purgation. Zhang Zhongjing did not provide a treatment for this. Tongue retraction and testicular contraction can be caused by extreme cold, treated with Fuzi Sini Tang (Aconite Decoction Reversing Collapse) plus Wuzhuyu (Evodia Fruit), moxa on Guanyuan and Qihai, or scallion warming. Alternatively, Yangming heat sinking into Jueyin meridian causes the sinews to contract due to heat damaging nourishment, pulling the tongue and testes. This is extreme heat; purge Yang to save Yin. All these are Dachengqi Tang (Major Order the Qi Decoction) indications. Zhang Jianshan stated: The Stomach is the sea of water and grain; diseases from all directions can transmit to Stomach Earth. Dryness depletes kidney water, so both Yangming and Shaoyin have urgent purgation indications. Although symptoms differ, the principle of entering the Fu is the same, hence Dachengqi Tang is used. For patients picking at clothes or reaching into empty space, this is Stomach heat. Qian Zhongyang's *Xiao'er Zhijue* states this is Liver heat, also treated with Chengqi Tang.

Wang Kentang stated: Stomach excess with constipation is known even by children to require purgation. However, Zhang Zhongjing's method dictates that even with Stomach excess, if the exterior is unresolved or there is a half-exterior/half-interior condition, use Guizhi Tang (Cinnamon Twig Decoction) or Chaihu Tang (Bupleurum Decoction) to resolve the exterior first, then assess deficiency and excess. For Stomach excess with constipation: if exterior symptoms exist, resolve the exterior first; if bitter taste, dry throat, and tight floating pulse exist, use harmonizing methods; if hard stool without discomfort, observe; if Stomach excess with resolved exterior and specific symptoms, attack urgently based on symptoms; if Stomach excess with resolved exterior but no specific symptoms, avoid purgation. Use suppositories for hard stool. In Yangming disease, if sweating and diuresis occur, this indicates internal depletion of fluids; even with hard stool, do not purge. Wait for the urge to defecate and use honey suppositories.

Shen Jin'ao noted: Wang's statement "attack if symptoms exist, avoid if none" refers to Yangming excess symptoms like tidal fever and delirium. Only with these symptoms is purgation appropriate. Without them, constipation is due to fluid deficiency; examine carefully and do not purge recklessly. "Passing the meridian before purging" means waiting until the seventh day when the meridian cycle is complete, allowing Yang pathogen to enter Yin before purging.

[General Principle] Zhang Zhongjing stated: In Yangming disease, after purgation, if there is inner vexation and irritability with dry feces in the Stomach, purgation is suitable; use Dachengqi Tang (Major Order the Qi Decoction). If the abdomen is slightly full, with hard stool at the beginning and loose at the end, do not purge.

[Detailed Commentary] Li Chen stated: When interior symptoms are present and the pulse is deep and solid, purgation is suitable. If heat persists after purgation and the pulse remains irregular, reassess deficiency and excess for further purgation. Failure to purge allows the pathogen no exit. Conversely, purging when sweating is indicated depletes fluids, leading to palpitations.

Shen Jin'ao noted: Severe abdominal fullness and obstruction indicate ascending dry feces from the Stomach, warranting purgation.

[General Principle] Zhang Zhongjing stated: A slippery and rapid pulse indicates retained food; use Dachengqi Tang (Major Order the Qi Decoction). Abdominal fullness that does not decrease, or decreases insignificantly, requires purgation; use Dachengqi Tang (Major Order the Qi Decoction). If sweating fails to resolve the condition and abdominal fullness/pain occurs, urgent purgation is needed; use Dachengqi Tang (Major Order the Qi Decoction). In Yangming disease, fever with excessive sweating requires urgent purgation; use Dachengqi Tang (Major Order the Qi Decoction).

[Detailed Commentary] Shen Jin'ao noted: Rapid pulse indicates pathology in the Fu organs; slippery and rapid indicates food retention, a sign for purgation. In the second case, persistent fullness indicates incomplete resolution, requiring further purgation. In the third case, although the exterior is unresolved, interior pathogen is severe, necessitating urgent attack. In the fourth case, excessive sweating depletes Yang; urgent purgation preserves fluids.

[General Principle] Zhang Zhongjing stated: In Shanghan, after six or seven days, if vision is unclear and eyes are unresponsive, without exterior/interior symptoms, but with difficult defecation and body heat, this is heat; urgent purgation is needed; use Dachengqi Tang (Major Order the Qi Decoction).

[Detailed Commentary] Li Chen stated: Shanghan heat entering Zang organs and flowing into Shaoyin meridian causes scorched throat, dry mouth/thirst, indicating dried kidney water. Unresolved heat with unresponsive eyes also indicates dried kidney water; urgent purgation saves kidney water. Yangming fever with excessive sweating, or unresolved sweating, abdominal fullness/pain, delirium/rage, and constipation all require urgent purgation to preserve stomach fluids. In Shanghan, a string-taut and slow pulse indicates cold and organ disease; a large and tight pulse indicates Yang and cold, termed "Yin hidden within Yang"; urgent purgation differentiates Yin and Yang. Diarrhea with normal morning pulse and hard epigastrium indicates interior excess. Diarrhea with slow/slippery or floating/large pulse,涩 (choppy) upon pressure, and food aversion indicate retained food in the Stomach. Retained food contraindicates Bidou (Croton Seed); use Dahuang (Rhubarb) to cleanse.

Liu Wansu stated: If heat persists after purgation, further purgation increases heat. With faint pulse, Qi deficiency, and weakness, without proper method, survival is impossible. Ceasing purgation allows extreme heat and Yin depletion, leading to pulse cessation and death. Such cases die whether purged or not. The classic states death if heat persists after three purgations. Rare survivals after four to ten purgations are coincidental and not standard practice. Use Jiedu Tang (Detoxification Decoction) combined with Liangge San (Cool the Chest Powder) to manage, potentially saving lives. After sweating and purging, if heat persists regardless of sweating, use Baihu Jia Renshen Cangzhu Tang (White Tiger Plus Ginseng and Atractylodes Decoction) to resolve it.

Tao Hua stated: "Urgent purgation" implies the disease heat is pressing and complications are imminent, unlike other diseases where delay is possible.