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Yangming disease. The pulse is slow. Although there is sweating and no aversion to cold, the body must be heavy, shortness of breath occurs, abdominal fullness with wheezing. If there is tidal fever (Tidal Fever), this indicates that the exterior syndrome is about to resolve, and internal purgation can be used. If there is continuous sweating on the hands and feet, this indicates that the stool has already hardened; Da Cheng Qi Tang (Major Order the Qi Decoction) should be primarily administered. If there is profuse sweating with slight fever and aversion to cold, the exterior has not yet resolved. If the fever is not tidal, Cheng Qi Tangs should not be used. If the abdomen is significantly full and obstructed, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) may be given to gently harmonize the stomach qi; do not allow severe purgation.

In Shanghan (Cold Damage), fever with aversion to cold indicates an exterior syndrome, while fever without aversion to cold indicates an interior syndrome. In Yangming disease, if there are no exterior symptoms, purgation is permissible; if there are exterior symptoms, purgation is contraindicated. Here, sweating without aversion to cold, body heaviness, shortness of breath, abdominal fullness with wheezing, and tidal fever are all interior syndromes. Although the pulse is slow, it can still be treated with purgation because abdominal fullness and constipation indicate that interior qi circulation is obstructed, causing the pulse to become soggy and sluggish. This cannot be compared to the general rule that a slow pulse indicates cold. If there is continuous sweating on the hands and feet, Yangming heat is excessive, and the stool has hardened; to treat this condition, only Da Cheng Qi Tang will suffice. If there is profuse sweating, slight fever, and aversion to cold, the exterior pathogen has not yet been resolved. If the fever is not tidal, the interior is not yet solid. How could one casually use Da Cheng Qi Tang, leaving the exterior pathogen behind while attacking the interior?

Even if the abdomen is significantly full and obstructed, and there is an urgent desire to purge, one should give Xiao Cheng Qi Tang to gently harmonize the stomach qi, rather than using Da Cheng Qi Tang for severe purgation. Otherwise, interior deficiency with pathogen sinking may occur, leading to myriad complications that would be difficult to rescue. The following seven clauses further examine the amount of urine, the consistency of the stool (loose or hard), the excess or deficiency of the pulse, whether the disease has passed through the meridians, and whether the fever is tidal before deciding on treatment. Thus, it is known that purgative methods must be applied with caution.

In Yangming disease, with tidal fever and slightly hard stool, Da Cheng Qi Tang may be given; if the stool is not hard, it should not be given. If there has been no bowel movement for six or seven days and dry fecal matter (Dry Stool) is suspected, the method to determine its presence is to give a small amount of Xiao Cheng Qi Tang. If, after ingestion, flatus (passing gas) is heard in the abdomen, this indicates the presence of dry fecal matter, and purgation is permissible. If no flatus occurs, the stool is merely hard at the beginning and will likely be loose later; purgation is contraindicated. Purgation would inevitably cause abdominal fullness and inability to eat. If the patient desires water and drinking water induces hiccups (Hiccup), and subsequent fever occurs, the stool will likely become hard again but in small quantities; Xiao Cheng Qi Tang should be used to harmonize. If no flatus occurs, purgation must absolutely be avoided.

In Yangming disease, the presence of tidal fever indicates stomach excess (Stomach Excess); the absence of tidal fever indicates the stomach is not yet solid. Da Cheng Qi Tang is suitable for cases with dry fecal matter; it is contraindicated for cases where the stool is hard at the beginning and loose later. Therefore, before administering Da Cheng Qi Tang, one must first try Xiao Cheng Qi Tang. It is feared that if there is no dry fecal matter and the pathogen has not gathered, purgation will fail to eliminate the disease while severely damaging the healthy qi. If flatus occurs after taking the decoction, it is because the stool is hard and the medicine's action is mild; the stool cannot be expelled, but the qi moves downward first. Thus, Da Cheng Qi Tang can be used again to purge. If no flatus occurs, the stomach has not reached a state of excess; the stool is merely hard at the beginning and will surely be loose later. Even Xiao Cheng Qi Tang exceeds the necessary treatment; how much more so Da Cheng Qi Tang? Gastric deficiency with lack of qi leads inevitably to abdominal fullness and inability to eat. Furthermore, in Yangming disease, the ability to drink water indicates excess, while the inability to drink indicates deficiency. For example, if the patient desires to drink but hiccups upon drinking water, this is "cold deficiency in the stomach, where desiring water and giving water causes hiccups." Subsequent fever indicates heat returning to the stomach, causing the stool to harden; this is a change from cold deficiency. Thus, although the stool is hard, it is scanty. Da Cheng Qi Tang should not be given; only Xiao Cheng Qi Tang should be used to gently harmonize the stomach qi. Da Cheng Qi Tang is a harsh purgative. Zhang Zhongjing repeatedly discusses these points to prevent inappropriate or excessive purgation, emphasizing: "If no flatus occurs, purgation must absolutely be avoided." Alas, the benevolent heart is truly perfect.

In Yangming disease, after purgation, if there is inner restlessness (Inner Restlessness) and irritability, and dry fecal matter exists in the stomach, purgation is permissible. If the abdomen is slightly full, with stool hard at the beginning and loose later, purgation is contraindicated. If dry fecal matter exists, Da Cheng Qi Tang is appropriate.

Post-purgation inner restlessness and irritability with dry fecal matter in the stomach differs from post-purgation inner restlessness accompanied by hunger but inability to eat. The latter is due to pathogen disturbing the upper jiao; the former is due to heat-solidity in the middle jiao. Heat-solidity allows for purgation, hence Da Cheng Qi Tang is appropriate. If the abdomen is slightly full, with stool hard at the beginning and loose later, the heat is not solid, and the pathogen has not coagulated; purgation is contraindicated. Purgation would inevitably cause abdominal fullness and inability to eat.

In Yangming disease, with delirium (Delirium) and tidal fever, and a slippery and rapid pulse, Xiao Cheng Qi Tang is primarily administered. One sheng of the decoction is given initially. If flatus occurs in the abdomen, another sheng may be given. If no flatus occurs, do not administer more. If the next day there is still no bowel movement and the pulse becomes faint and choppy, this indicates interior deficiency; it is difficult to treat, and Cheng Qi Tang should not be given again.

Delirium and tidal fever are signs of stomach excess. A slippery and rapid pulse differs from a slippery and forceful pulse. Therefore, Da Cheng Qi Tang is not given, but Xiao Cheng Qi Tang is. If flatus occurs after one sheng, it confirms dry fecal matter in the stomach, and another sheng may be given. If no flatus occurs, the stool is likely hard at the beginning and loose later; it should not be given again. This aligns with the meaning of the previous two clauses. If the next day there is still no bowel movement and the pulse becomes faint and choppy, the pathogen remains while the healthy qi declines. Tonification would hinder the pathogen, while purgation would damage the healthy qi; thus, it is said to be difficult to treat. Even if the bowels are not open, how can Cheng Qi Tang be used to purge?

Two or three days after contracting the disease, with a weak pulse, no Taiyang or Shaoyang symptoms, irritability, and hardness below the heart: by the fourth or fifth day, even if the patient can eat, give a small amount of Xiao Cheng Qi Tang to gently harmonize and provide slight relief. By the sixth day, give one sheng of Cheng Qi Tang. If there has been no bowel movement for six or seven days and urine output is low, even if the patient cannot eat, the stool is likely hard at the beginning and loose later, not yet definitively hardened. Purgation would cause loose stools. One must wait until urination is normal and the stool is definitely hard before purging; Da Cheng Qi Tang is appropriate.

In Shanghan, the ability to eat indicates stomach heat without excess; inability to eat indicates stomach heat with excess. In cases of stomach excess, frequent urination permits purgation, while infrequent urination contraindicates it. Two or three days after contracting the disease, a pulse that is not floating but weak, along with the absence of Taiyang or Shaoyang symptoms, indicates the disease is solely in the exterior of Yangming. Irritability and hardness below the heart persisting into the fourth or fifth day indicate that interior symptoms have appeared. Thus, even if the patient can eat, Xiao Cheng Qi Tang must be used to gently harmonize the stomach qi. By the sixth day, as heat gradually solidifies, one sheng of Da Cheng Qi Tang should be given to fully resolve the disease. If there has been no bowel movement for six or seven days, purgation is indicated by law, but if urine output is low, water and grain are not separated properly, indicating the stool is hard at the beginning and loose later. Even if the patient cannot eat, immediate purgation is contraindicated. One must wait for normal urination and hardening of the stool before administering Da Cheng Qi Tang. Constipation with exhausted fluids is not suitable for purgation; one must wait for fluids to return to the stomach for spontaneous defecation. Constipation with low urine output is also not suitable for purgation; one must wait for fluids to permeate the water passages before applying purgative methods. Generally, forcibly purging when fluids are exhausted leads to irreversible healthy qi deficiency; purging before the stool is hard leaves pathogens behind. Scholars must be cautious and not lightly use purgatives.

Shanghan with constipation for six or seven days, headache, and fever: give Cheng Qi Tang. If the urine is clear, the disease is not in the interior but remains in the exterior; sweating therapy is required. If the headache persists, nasal bleeding (Epistaxis) will likely occur; Gui Zhi Tang (Cinnamon Twig Decoction) is appropriate.

Taiyang wind-cold constraining the exterior causes headache; Yangming heat rushing upward also causes headache. In Shanghan with constipation for six or seven days and headache with fever, the heat is excessive in the interior, steaming upward, which is not wind-cold in the exterior. Thus, Cheng Qi Tang can be used to purge. However, in cases of excessive interior heat, urine is typically scanty and red. If urine is clear, the heat is not in the interior but remains in the exterior; Gui Zhi Tang should be used to induce sweating, and Cheng Qi Tang should not be used to purge the interior. If the headache does not resolve, heat remains in the meridians, likely causing epistaxis. The phrase "Gui Zhi Tang" is suspected to belong under the sentence "when sweating is required." This clause was moved from the Taiyang chapter.

Sweating with delirium indicates dry fecal matter in the stomach; this is due to wind. Purging is required, but only after the disease has passed through the meridians (Exterior Resolution). Premature purging will cause language confusion due to exterior deficiency and interior excess. After purging, recovery occurs; Da Cheng Qi Tang is appropriate.

Sweating and delirium indicate that the wind pathogen has not left the exterior, but the stomach has become solid. Hence, "dry fecal matter in the stomach" and "this is wind" are stated. Purging is required, but only after the meridians have passed through. If the stomach is solid and requires purging, but the wind pathogen remains in the exterior, purging must wait until the exterior resolves. Otherwise, exterior pathogens will enter the interior, increasing gastric heat and causing confused speech. "Exterior deficiency and interior excess" means the exterior is harmonious while the interior is diseased, indicating pathogens have entered and consolidated in the interior. *Wai Tai Mi Yao* states: "Interior disease with exterior harmony: purging cures, sweating kills." Therefore, Da Cheng Qi Tang is appropriate to purge interior excess.

In Yangming disease, inability to eat, and attacking the heat will inevitably cause hiccups. This is because of cold deficiency in the stomach. Since the patient is originally deficient, attacking the heat will cause hiccups.

Heavenly pathogens affect humans similarly, but human organ qi varies in deficiency and excess. These three clauses are designed for patients with Yangming disease who have interior deficiency and insufficiency. Yangming disease usually requires attacking the heat, but if the stomach is cold-deficient and unable to eat, attacking the heat is contraindicated. Doing so worsens middle-jiao cold and causes qi to rebel upward, inevitably causing hiccups. Hiccups refer to hiccupping. There are seven clauses regarding conditions where purgation is contraindicated below.

In Shanghan, if vomiting is frequent, even if Yangming symptoms exist, purgation is contraindicated.

In Yangming disease, if hardness and fullness are below the heart, purgation is contraindicated. If purgation is performed and diarrhea continues uncontrollably, death ensues; if diarrhea stops, recovery occurs.

In Yangming disease, if the face is completely red, purgation is contraindicated. Purgation will inevitably cause fever, yellow complexion, and difficulty in urination.

Although Yangming disease has examples of purgation, it is only permissible when exterior symptoms are completely absent and heat is bound in the intestines. If vomiting is frequent, the pathogen is in the diaphragm; if hardness and fullness are below the heart, the pathogen has not descended to the stomach; if the face is red, the pathogen is constrained in the exterior. Thus, purgation is contraindicated in all these cases. Purgation leads to interior deficiency and heat entry. Pathogens overflowing downward cause uncontrollable diarrhea; pathogens accumulating in the middle cause fever, yellow complexion, and urinary difficulty. Those who survive by chance recover as pathogens exit downward, but this is rare and difficult.

In Yangming disease, a slow pulse, difficulty eating to satiety, slight irritability after eating, dizziness, and difficulty in urination indicate impending Grain Jaundice (Grain Jaundice). Even with purgation, abdominal fullness remains. This is due to the slow pulse. A slow pulse indicates weak qi and poor circulation. Weak qi fails to move, slowing grain digestion. Undigested grain generates heat. Rising heat causes dizziness. Upward-moving qi fails to descend, causing urinary difficulty. Heat constrained in the middle cannot descend through turbid pathways and steams into jaundice. Thus, it is said to be impending Grain Jaundice. However, since the heat arises from grain stagnation rather than stomach excess heat, purgation will not remove abdominal fullness. This differs from cases with a rapid pulse and stomach excess.

In Yangming disease, originally with spontaneous sweating, if the physician induces heavy sweating again, and although the illness has improved, slight irritability and discomfort persist, the stool must be hard due to fluid exhaustion and dryness in the stomach. One should ask about daily urine frequency. If the patient normally urinates three or four times a day but now only twice, it is known that the stool will pass soon. Now, with reduced urine frequency, fluids are returning to the stomach; thus, it is known that defecation will occur soon.

Constipation in Yangming disease involves either heat binding or fluid exhaustion. Heat binding can be treated with cold purgation or saline softening. Fluid exhaustion requires fluid restoration to resolve dryness before defecation is possible. Here, repeated sweating has severely depleted fluids, causing gastric dryness and hard stool. Treatment should focus on fluids, not further purgation. Reduced urine frequency indicates lung fluids are returning to the stomach instead of going directly to the bladder. Thus, dryness is moistened, hardness is softened, and binding is unblocked. The implication is that purgation is unnecessary.

In Yangming disease, with spontaneous sweating or induced sweating, and free urination, this indicates internal fluid exhaustion. Even if the stool is hard, purgation is contraindicated. One should wait for the natural urge to defecate and use Honey Suppository (Honey Suppository) to guide passage. Radix Trichosanthis (Tu Gua Gen) or large pig bile can also be used as guiding agents.

The previous clause regarding heavy sweating depleting fluids and hardening stool indicated that purgation is contraindicated, waiting for fluids to return for spontaneous defecation. This clause reiterates the prohibition against purgation and offers moistening guiding methods like honey suppositories, showing thorough consideration and comprehensive methods. In summary, for those with internal fluid exhaustion who do not desire defecation, wait quietly; for those who desire defecation, guide them accordingly. Zhang Zhongjing's established methods can be followed without alteration.

**Honey Suppository Formula**
Seven he of honey. Single ingredient. Place in a copper vessel and simmer over low heat until slightly thickened like malt syrup. Stir constantly to avoid burning. When moldable, shape into suppositories by hand, sharpening the tip, about the thickness of a finger and two inches long. Make while warm, as they harden when cool. Insert into the anus and hold tightly with hand. Remove when the urge to defecate arises.

**Pig Bile Formula**
One large pig gallbladder. Extract juice, mix with a little vinegar. Instill into the anus. After the time of one meal, the stool should pass.

At the foot-yang pulse, floating and choppy. Floating indicates strong stomach qi; choppy indicates frequent urination. Floating and choppy combined lead to difficult defecation. The spleen is constrained (Spleen Constraint). Ma Ren Wan (Hemp Seed Pill) is primarily administered.
Floating indicates abundant yang qi; choppy indicates scarce yin qi. Seen at the foot-yang pulse, this indicates strong stomach and weak spleen. "Constraint" means restriction. Just as the weak is restricted by the strong, the spleen's qi is inhibited. With the spleen inactive and the stomach acting alone, fluids converge in one place, and the stool loses moisture. Rhubarb, Immature Bitter Orange, and Magnolia Bark reduce stomach strength; Hemp Seed, Apricot Kernel, and White Peony Root nourish spleen density. Using honey pills prevents rapid purgation from damaging the spleen. This takes the meaning of the previous moistening guidance and adds slight force, representing a variation in Shanghan purgative methods.

**Ma Ren Wan Formula**
Hemp Seed (2 sheng), White Peony Root (0.5 sheng), Immature Bitter Orange (0.5 sheng), Rhubarb (1 jin), Apricot Kernel (1 sheng), Magnolia Bark (1 chi, processed, peeled).
These six ingredients are powdered. Refined honey is used to form pills the size of tung seeds. Take ten pills with water, three times daily. Gradually increase until effective.