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If purgation (a treatment method using laxatives to remove excess pathogens from the body) should have been applied but was neglected, symptoms such as dry mouth, dry tongue, and thirst will occur. The body heat may paradoxically decrease, while the limbs experience periodic coldness (cold extremities), leading the patient to desire proximity to fire and thick coverings; this indicates the entrapment of Yang Qi within.

After purgation has been administered and the cold extremities resolve, if removing the heat source and reducing coverings results in a large and rapid pulse, moisture on the tongue, and a lack of desire for water or drinks, this signifies that the internal pathogens have been expelled and the constrained Yang Qi is suddenly extending. In such cases, Chaihu Qingzao Tang (Bupleurum Decoction to Clear Dryness) with Huafen (Trichosanthis Radix) and Zhimu (Anemarrhenae Rhizoma) removed, and Gegen (Puerariae Lobatae Radix) added, is appropriate to ascend and vent the pathogenic factors according to their nature. This syndrome resembles Baihu Tang syndrome; however, since the heat and thirst have already subsided, Baihu Tang is no longer suitable.

In patients with warm pestilence who have undergone purgation, if thorny moss-like coating reappears on the tongue within two or three days, or even one or two days after treatment, it indicates that the pathogens are not yet fully cleared. Purgation should be repeated. Although the thorny coating may persist, it will lose its sharpness and become soft. If heat and thirst remain unrelieved, further purgation should be administered. As heat and thirst diminish and the thorny coating sheds, fever may recur later with the reappearance of the thorny coating, necessitating continued purgation. My patient Zhou Yuli suffered from this condition for over a month due to pestilence. His tongue exhibited thorny coatings that changed three times, and he consumed a total of twenty taels of Dahuang (Rhei Radix et Rhizoma) before the fever ceased to recur, after which other pulse and symptom manifestations gradually receded. Therefore, when employing purgation, one should not count the number of doses; rather, administer the appropriate medicine for the presenting syndrome. Physicians who lack deep understanding or clinical experience often hesitate midway, causing delays in treating such cases. However, regimens vary: some require purgation every other day, some require consecutive purgation for three or four days, and others require consecutive purgation for two days followed by a one-day interval. During these intervals, Chaihu Qingzao Tang may be indicated in some cases, while Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction) may be indicated in others. Regarding the administration of Chengqi Tang formulas, determining whether to increase or decrease the dosage on specific days requires skill that cannot be fully conveyed through words; it depends on flexible judgment at the time of treatment.

Zhu Haichou, aged forty-five, contracted pestilence and presented with indications for purgation. His limbs were immobile, his body lay rigid like a statue, his eyes were closed, and his mouth was open. A thorny coating appeared on his tongue. Unable to answer questions about his discomfort, his son reported that he had taken three doses of Chengqi Tang over two or three days, with approximately one tael of Dahuang per dose, without effect. With no other options, they could only wait, but unwilling to stand by idly, they sought another consultation. Upon examination, I found his pulse still possessed "Shen" (spirit/vitality), and all indications for purgation were present, suggesting the medication had been too mild for the depth of the disease. I initially administered one tael and five qian of Dahuang. Afterward, his eyes occasionally moved slightly. Upon subsequent administration, the sharpness of the thorny coating on his tongue disappeared, and his mouth gradually opened, allowing him to speak. After three doses, the tongue coating partially receded, and his mental clarity improved slightly. On the fourth day, he took Chaihu Qingzao Tang. On the fifth day, thorny spines reappeared, and irritability and heat intensified, requiring further purgation. On the seventh day, Chengqi Yangrong Tang (Chengqi Decoction to Nourish Ying) was administered, resulting in slight reduction of heat. On the eighth day, Da Chengqi Tang (Major Chengqi Decoction) was used again, enabling slight movement of the limbs. Over half a month, he consumed a total of twelve taels of Dahuang and recovered. Several days later, he resumed consuming congee and underwent conditioning for two months until full recovery. Among the thousand patients I treated, only three or four presented with such conditions. This case record is preserved here for reference.