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When pathogenic factors are in the exterior, sweating should be used; when they have entered the interior, purgation should be used. The Yuan Qi (Original Qi) of the human body circulates throughout, allowing no room for even the slightest pathogen. Any slight obstruction will block the meridians and collaterals, obstructing Yin and Yang and causing disease. It may manifest as cold or heat, affecting Qi or Blood, phlegm or food retention, with various syndromes. Mild cases are treated with resolution and guidance methods, while severe cases must be treated with aggressive purgation (from Zhang Zhongjing).

This formula treats Yangming Fu-organ syndrome in Shanghan (Cold Damage), where Yang pathogenic factors enter the interior, causing stomach excess and constipation, accompanied by fever, delirium, spontaneous sweating, aversion to cold absent, and the simultaneous presence of five symptoms: Pi (stifling sensation), Man (fullness), Zao (dryness), Shi (excess), and Jian (hardness). It is also indicated for miscellaneous diseases involving excessive heat in the San Jiao (Triple Burner) with a deep and solid pulse. (Note: Yangming Exterior Syndrome presents with fever, sweating, absence of aversion to cold, and preference for cold; this indicates the pathogen is in the channels, and sweating dispersal is still appropriate. If heat pathogens have entered the Stomach Fu-organ, presenting with all five symptoms of Pi, Man, Zao, Shi, and Jian, purgation is required. Excess syndromes present with incoherent speech. Deficiency syndromes present with Zheng Sheng (repetitive murmuring). The Yangming channel has abundant Qi and Blood, making spontaneous sweating common. Excessive sweating leads to fluid loss; without water to control fire, dry feces accumulate in the stomach, leading to hallucinations and incoherent speech. Dry feces reside in the Large Intestine, not the Stomach. Shanghan transmission affects the Stomach but not directly the Large Intestine; however, treating disease requires addressing the root. The Stomach and Large Intestine both belong to Yangming Dry Metal. The Classic states: "Why does one contract Yangming disease?" Answer: "If Taiyang disease is incorrectly treated with purgation, sweating, or diuresis, fluids are lost, the Stomach becomes dry, and it transfers to Yangming, resulting in stomach excess and difficult defecation." It also states: "If sweating is induced early in Taiyang disease but is incomplete, it transfers to Yangming." In Yangming syndromes, ability to eat indicates Wind Strike (Wind is a Yang pathogen that digests grain); inability to eat indicates Cold Strike (Cold is a Yin pathogen that fails to digest grain), which serves as a differentiation criterion. Chest tightness and anorexia constitute Pi (stifling); chest and abdominal distension constitute Man (fullness); dry and scant stool constitutes Zao (dryness); abdominal fullness, pain, and constipation constitute Shi (excess); hardness upon palpation constitutes Jian (hardness). It also treats Yangming Gang Jing (Stiff Spasm), a combination of Taiyang and Yangming. Symptoms include chest fullness, trismus, inability to lie flat (back touching the bed), leg spasms, teeth grinding, and anhidrosis, termed Gang Jing. Purgation is indicated because Yangming moistens the Zong Jin (Major Tendons). When Wind-Cold-Damp-Heat pathogens injure the Yangming Stomach, fluid dynamics fail, and tendons lose nourishment; thus, this decoction purges damp-heat and promotes fluid circulation. Yu Jiayan stated: Abdominal fullness in Shanghan can be purged, but chest fullness cannot, as heat remains in the exterior. This case involves deep, severe interior heat. Extreme Yang heat immediately threatens Yin blood depletion. Mild purgation is insufficient; massive purgation is required to preserve the last thread of Yin. If Yin is not robbed by Yang, survival is likely. Despite the warning against excessive purgation causing Yin collapse, there is a vital method of urgent purgation to save Yin. Scholars must master this principle. The Stomach is the Sea of Water and Grain; diseases from surrounding areas transmit to it. Once in the Stomach Fu-organ, it does not transmit further: Taiyang transmitting to Stomach does not go to Yangming; Yangming to Stomach does not go to Shaoyang; Shaoyang to Stomach does not go to the Three Yin channels. The Classic states: "Yangming resides in the center, belonging to Earth, the destination of all things, accepting nothing outside." Da Huang (Cortex Rhei Rhizoma et Radix, 4 liang, washed with wine). Wang Haicang said: "Pathogens located high require wine to reach them. Raw Da Huang leaves high heat pathogens, causing post-recovery red eyes, throat bi, head swelling, and upper jiao heat disorders." Mang Xiao (Natrii Sulfas, 3 he) Hou Po (Cortex Magnoliae Officinalis, 8 liang) Zhi Shi (Fructus Aurantii Immaturus, 5 pieces). First decoct Hou Po and Zhi Shi until nearly done, add Da Huang, boil for two or three boils, pour into a bowl, mix with Mang Xiao, and take. Stop once bowel movement occurs. Tao Jian'an said: "To remove excess heat, use Da Huang; without Zhi Shi, unblocking fails. To warm meridians, use Fu Zi; without Gan Jiang, warming fails. To release the exterior, use Ma Huang; without Cong Bai, dispersion fails. To induce vomiting of phlegm, use Gua Di; without Dan Chi, unblocking fails. Zhu Li (Bamboo Sap) needs Ginger..." This is the correct formula for Zheng Yang Yangming (Dong Yuan: Taiyang/Yangming formulas). For heat rampant within, treat with salty-cold. Solidify Qi with salty softening; eliminate excessive heat with cold. Thus, Mang Xiao's salty-cold moistens dryness and softens hardness; Da Huang's bitter-cold purges heat, removes stasis, descends dry accumulation, and drains stomach excess. Zhi Shi and Hou Po's bitter descent purges Pi, Man, and Shi excess, corresponding to the Classic's "Earth stagnation requires seizure" (Yangming belongs to Earth. Da Huang treats great excess; Mang Xiao treats great dryness and hardness; these two treat tangible blood-pathology. Hou Po treats great fullness; Zhi Shi treats Pi; these two treat intangible Qi-pathology). However, do not use lightly unless there is great excess and fullness, lest cold injury, Jie Xiong (Chest Binding), or Pi Qi complications arise (Origin of Xiao/Da Xie Xiong Tangs. Cheng means to inherit/continue. Ten Agents states: "Tong (Unblocking) removes stagnation; Xie (Draining) removes closure." Making blocked passages clear and closed passages open allows Zheng Qi to relax, hence "Cheng Qi". Zhongjing said: "To administer Da Cheng Qi Tang, first give Xiao Cheng Qi Tang. If intestinal gas passes, dry feces exist, and Da Cheng Qi can attack; if no gas passes, only the beginning is hard and the end loose, do not attack, or bloating and anorexia will result." Also: "Yangming disease with slow pulse, much sweating, and slight aversion to cold indicates unresolved exterior; sweating with Gui Zhi Tang is appropriate. Yangming disease requiring sweating but treated with purgation is a major error," showing Zhongjing's caution. Yu Jiayan said: "Yangming considers stomach excess as standard, so all are purgation indications. Yangming pathogens come from Taiyang. If Yangming signs appear at 80-90% but Taiyang signs remain at 10-20%, follow Taiyang, not Yangming; sweat, do not purge. The exit route trends toward Shaoyang. If Yangming signs are 80-90% but Shaoyang signs appear slightly, follow Shaoyang; neither sweat nor purge. Only when wind-cold has left Taiyang but not reached Shaoyang, residing strictly within Yangming, is urgent purgation necessary to prevent transmission to other channels, preserving fluids and Yuan Qi. Ignorant practitioners wait for seven days of transmission to complete before daring to purge, unaware that Taiyang may persist over ten days. Not differentiating channels but counting days leads to erroneous purgation in Taiyang. Conversely, missing purgation indications in Yangming (days 2-3) due to day-counting, or wrongly purging when entering Shaoyang based on days, turns mild cases severe and severe cases fatal. Zhongjing's rule: many days with exterior signs and floating pulse require sweating; few days with interior signs and deep pulse require purgation. Ang notes: Purge only after entering the Fu-organ, not merely being in the 'zone'. Yu's statement is imperfect. Ancients cured chills/shivering with Da Cheng Qi to purge dry feces; this is Yang pathogen entering interior, heat binding interior, exterior void of Yang, causing chills/shivering—Yang excess repelling Yin, a heat disease, not cold. Misusing hot herbs causes death. Zhu Danxi said: Initial dysentery with abdominal pain forbids Ren Shen/Bai Zhu; but for Qi/Stomach deficiency, they are usable. Initially, Da Cheng Qi or Tiao Wei Cheng Qi may be used to purge, then adjust based on Qi or Blood pathology. I treated Mr. Ye with severe dysentery fitting Cheng Qi pattern, but his Qi was daily declining, though his form seemed solid, his face was yellow-white, indicating past dietary injury to the Stomach. I endured his suffering for two days, giving Ren Shen, Bai Zhu, Chen Pi, Shao Yao for ten doses. After three days, Stomach Qi recovered slightly, then gave Cheng Qi for two doses, resulting in peace. Without prior tonification, Stomach Qi would not recover... Adding Gan Jiang in equal parts creates San Yi Cheng Qi Tang: treats Da Cheng Qi abdominal fullness/pain, Tiao Wei Cheng Qi delirium/diarrhea, Xiao Cheng Qi internal heat/constipation, and all Shanghan/miscellaneous diseases with severe internal heat accumulation, dryness, excess, hardness, and distension (Combining the three Cheng Qi formulas. Cheng Wuji said: Using Xiao Cheng Qi for Da Cheng Qi syndrome fails to subdue pathogens; using Da Cheng Qi for Xiao Cheng Qi syndrome over-injures Yuan Qi, causing bloating/anorexia. Zhongjing separates them for specific treatment. Later practitioners combined them, claiming universal efficacy for all injuries, violating Zhongjing's intent and Xuandi's principles of urgency/moderation, harming patients silently. Who is to blame?). Adding Chai Hu, Huang Qin, Gan Jiang, and 3 spoons of Iron Rust Water creates Liu Yi Shun Qi Tang (Jie'an: Combines three Cheng Qi, San Yi Cheng Qi, Da Chai Hu, Da Xie Xiong six formulas): treats tidal fever, spontaneous sweating, thirst, delirium/madness, macules/jaundice, abdominal fullness, and solid stool; correct Yangming Fu-organ disease. Adding Ren Shen, Gan Cao, Dang Gui, Jie Geng, Decocted with Jiang/Zao creates Huang Long Tang: treats heat transmission to interior, dry feces in stomach, epigastric hardness/pain, fever/thirst, delirium, and diarrhea of pure clear water (Why diarrhea with dry feces? Tao Jian'an: Not internal cold diarrhea, but liquid seeping around dry feces due to herbal intake, named Re Jie Li (Heat-Binding Diarrhea). Quacks call it Lou Di Shang Han and use hot herbs, killing many. Remove Mang Xiao for elderly/Qi-Blood deficient). Removing Mang Xiao, adding Ma Ren, Xing Ren, Shao Yao, Honey Pills create Ma Ren Wan (Zhongjing): treats Fuyang pulse floating and choppy; floating indicates strong Stomach Qi, choppy indicates frequent urination; floating-choppy interaction causes difficult defecation, termed Pi Yue (Spleen Contraction) (Fuyang is Stomach pulse. Classic: Food enters Stomach, essence floats up to Spleen, Spleen scatters essence to Lung, regulates water passages to Bladder, fluids distribute, five channels run together; Spleen Earth moves fluids for Stomach. Now Stomach Fire attacks Spleen, contracting fluids to Bladder, causing frequent urination and difficult defecation, hence Pi Yue. This formula moistens dryness and unblocks intestines. This is Taiyang transferring to Yangming, hence Zhongjing calls it Taiyang Yangming Pi Yue. Cheng Shi interpreted this as weak Spleen/strong Stomach, but text only says Pi Yue, not weak Spleen. Yu Jiayan: If Spleen were weak, tonify it; why use Da Huang/Zhi Shi? This is excessive dryness of Spleen Earth, drying gut fluids, causing middle Xiao and difficulty. If Spleen-Stomach were weak, stool would be loose/liquid, how could it contract grain? In Yangming purgation indications, fear is pathogen not in Stomach/stool not hard, or hard-beginning/loose-end, preventing reckless purgation. Hence testing with Xiao Cheng Qi for gas passage before attacking shows concern for weak Spleen Qi. If Pi Yue occurred in Taiyang, purge immediately; why wait for Yangming? Zhu Danxi: Caused by prolonged illness, heavy sweating/purgation, depleting Yin Blood, internal fire blazing, injuring Yuan Qi and Spleen. Lung Metal受 Fire, Qi uncontrolled. Lung is Spleen's child; Lung consumption depletes fluids; Metal exhaustion reduces Wood's restraint; Earth cannot remain uninjured. Lung loses transport, Spleen loses transformation, hence constipation and frequent urination. Ideally nourish Yin Blood, extinguish fire, promote Metal transformation, restrain Wood, move Spleen Earth, allowing fluids to moisten intestines. This formula works for excess heat/Qi; avoid in heat excess with deficient Qi/Blood).

Urgent Purgation Syndromes (Sweating fails, abdominal fullness/pain: urgent purge. Diarrhea, all three pulses level, pressing epigastrium hard: urgent purge. Slippery-numerous pulse indicates retained food, purge. Mai Jing: Slippery indicates food disease. Zhongjing: Slippery indicates grain Qi excess. Also: Cun pulse floating-large, pressing choppy, Chi pulse micro-choppy indicates retained food, purge. Shanghan 6-7 days, unclear vision, eyes unresponsive, no exterior/interior signs, difficult defecation, slight fever: this is excess, urgent purge. Nei Jing: All pulses relate to eyes. Zhen Jing: Heat disease with unclear vision, if heat persists, Kidney Water is failing, unable to illuminate. Yangming fever with much sweating: urgent purge. Much sweating loses fluids, causing internal dryness; purge urgently to preserve fluids. Shaoyin disease 2-3 days, dry mouth/throat: urgent purge. Pathogen not deep yet causes dry mouth; Kidney Water is drying; purge urgently to save impending water loss. Shaoyin 6-7 days, abdominal fullness, constipation: urgent purge. Shaoyin heat enters Stomach Fu; Earth excess dries Water; purge urgently to save Kidney Water. Shaoyin spontaneous diarrhea of pure clear water, green color, heart pain, dry mouth: urgent purge. Green is Liver color; Liver pathogen attacks Kidney causing diarrhea; Yang pathogen attacks upward causing dry mouth; this is Shaoyin transmitting to Yangming Fu. Jueyin tongue curling and testicular retraction: urgent purge. Zhongjing has no treatment for this. Note: Tongue curling/testicular retraction can be extreme cold (use Fu Zi Si Ni plus Wu Zhu Yu, moxibustion Guan Yuan/Qi Hai, ginger compression); or Yangming heat sinking into Jueyin. Yangming moistens Zong Jin; heat attacks Zong Jin, failing to nourish, pulling tongue and testes tightly. This is extreme heat; drain Yang to save Yin. All above are Da Cheng Qi indications. Zhang Jianshan: Stomach is Sea of Water/Grain; surrounding diseases transmit to it; Earth dryness dries Kidney Water; thus both Yangming and Shaoyin have urgent purge clauses. Syndromes differ, but mechanism of entering Fu is same, hence both use Da Cheng Qi. Patients tracing clothes, grasping at air: Stomach heat. Qian Zhongyang's Xiao'er Zhijue: Liver heat; also treat with Cheng Qi Tang. Lou Quanshan: Treated several such patients with major Qi/Blood tonics; one with tremors and intermittent pulse added 2 fen Gui Zhi to tonic, stopping tremors and harmonizing pulse. Note: Delirium can also stem from Qi deficiency/Yang collapse, requiring Ren Shen/Fu Zi tonics).

Contraindications for Purgation (Taiyang exterior unresolved: do not purge. Floating-large pulse: do not purge, indicates exterior. Aversion to cold: do not purge, indicates exterior pathogen. Frequent vomiting: even with Yangming signs, do not purge; vomiting indicates pathogen in Upper Jiao. Yangming inability to eat: attacking heat causes hiccups; Stomach deficiency-cold... Lung Qi... then not...)