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Examining the Zhidang Tang (Resolute Decoction) syndrome, there are manifestations of mania; in the Taoheshengqi Tang (Peach Kernel and Magnolia Bark Decoction) syndrome, there is a state resembling mania. These are clear evidence that blood heat affects the brain nerves. Therefore, the medication generally does not depart from Dahuang (Rhubarb Rhizome), but rather derives from the Chengqi (Assist to Enter the Qi) decoctions, which is worthy of deep reflection. However, regarding intestinal heat easily invading the brain versus not easily invading it, whether a person's nerves are fragile or not is a major factor; indeed, those with fragile nerves are more easily affected, as shown in this case, which makes the principle very clear. Furthermore, children have fragile nerves, so convulsive diseases are particularly common.

Cao Yingfu said: In Yangming syndrome headache, it initially occurs at the Yintang area (between the eyebrows), and in severe cases, the entire head hurts. This is not only seen in Chengqi Tang syndromes but also in Baihu Tang (White Tiger Decoction) syndromes. Moreover, in Yangming Fu-organ excess syndrome, dryness qi rushing upward often causes confusion of the brain nerves, leading to delirium and headache. Or, conversely, after defecation, rootless heat toxins rush upward; for example, if the bowels have moved but the head suddenly becomes painful, this can be proven. Only when there is damp-heat accumulating and steaming in the intestines does its qi easily invade the brain, similar to how water vapor flows easily. Just as boiling water below sends steam rising above, unlike dry fecal matter which must wait for purgation before its qi rushes upward. In this syndrome, simply purging turbid water can prove that warm-heat pathogens are accumulating in the Yangming. Otherwise, why should the treatment method for symptoms such as unclear vision ("mu zhong le le bu liao"), absence of exterior or interior signs, difficulty in defecation, and slight fever be urgent purgation?

**Case Three of Dachengqi Tang Syndrome**

I once treated a woman surnamed Wu from a butcher shop on Jiangyin Street. She had been ill for six or seven days, presenting with high fever, sweating only on the head, a large pulse, constipation, and no bowel movement for seven days. Her body was not yellow, her chest was not stiff, and her abdomen was not distended. She suffered only from severe headache all over her head, did not speak, kept her eyes open, her pupils could not blink, and she could not recognize people approaching her. The condition was quite critical. I said: "Unclear vision and inflexible eyeballs indicate dry-heat rushing upward. This is the first of the three urgent purgation syndromes in the Yangming Chapter. If not treated quickly, the disease will become incurable." I then prescribed Dachengqi Tang (Major Order the Qi Decoction).

Dahuang (Rhubarb Rhizome) 4 qian, Zhishi (Immature Bitter Orange) 3 qian, Chuanpu (Aucklandiae Radix) 1 qian, Mangxiao (Mirabilite) 3 qian. I instructed the family to decoct and administer it quickly. Remarkably, one dose resulted in a cure. Because Yangming dryness qi rushed upward to the vertex, causing head sweating, severe headache, clouded consciousness, and inability to recognize people, the situation was critical in an instant. Now, with one dose, it is like removing firewood from under the cauldron; stomach heat is drained. Once stomach heat is pacified, the rushing dryness qi, having no further support from below, descends together with it. Thus, the head and eyes become clear, and the illness vanishes instantly. This differs from cases with retained food stagnation, abdominal distension and pain, high fever, and delirium, which require several doses to take effect. This distinguishes the slow from the urgent. Therefore, one must distinguish between formless qi and formed accumulation to avoid confusion during clinical practice.

[Note] I once saw a male patient with fluctuating consciousness, spasms and cold extremities in the four limbs, holding his forehead with his left hand and his genitals with his right, his legs bent inward and raised. Despite great effort by bystanders, he could not be straightened. His eyes were open and red, and he closed them tightly near light. His pulse was chaotic and faint. He had not defecated for many days and had suffered headaches recently. The illness began only seven or eight days ago, and after taking medicine for five or six days, he reached this state. It was said he previously contracted a venereal disease from visiting prostitutes, which was cured externally. I said: "This is a Dachengqi Tang syndrome that was neglected." However, due to trismus (lockjaw), medicine could not be swallowed. An assistant used a simple method, inserting glycerin suppositories into the anus three times, with no effect. Unfortunately, no relative was present to authorize the use of a gallbladder-based cathartic method (Dan Dao Fa). The next day, he sweated and died at night; it was truly pitiable. Another male patient fell ill for a few days with mild abdominal pain. A doctor gave him Sini San (Frigid Extremities Powder) as a decoction. The pain improved slightly, but his unclear vision worsened significantly. When spoken to, he answered half correctly and half incorrectly, and died that night.

Based on the above experimental verification, "unclear vision and inflexible eyeballs" are indeed extremely critical and urgent conditions. Even if Shanghan (Cold Damage) has lasted only six or seven days, with no exterior or interior signs, only slight fever, and difficult but unformed stool, if it is a excess syndrome, urgent purgation is indicated, and Dachengqi Tang is appropriate.

Zhong Jing wrote about this clearly in his treatise. If treated with proper methods, efficacy is also swift, as demonstrated in this case.

"Unclear vision and inflexible eyeballs" are external signs of brain disease. External eye pathology indicates internal brain pathology. Compared to the previous case mentioning only severe headache, this condition is more severe and more urgent, requiring heavier dosages. There is no second method of treatment other than Dachengqi Tang. Nevertheless, the Great Treatise also states: "In Shanghan, if vomiting or purgation fails to resolve the condition, and there is no bowel movement for five to six days, up to ten or more days, tidal fever occurs at dusk, without aversion to cold, with solitary muttering as if seeing ghosts. If severe, the patient may not recognize people, grasp at clothes and bedrails, feel terrified and uneasy, breathe slightly short, stare fixedly. If the pulse is wiry, life is possible; if choppy, death ensues. If mild, merely fever and delirium occur, Dachengqi Tang governs." This shows that even when brain nerve disease progresses to not recognizing people, muttering alone as if seeing ghosts, grasping at objects, or a choppy pulse, if mild, Dachengqi Tang can still be used. If severe, even administering this decoction will be ineffective. Let us deduce the reason for ineffectiveness: Dachengqi Tang can only treat the source of intestinal heat, not the location of nerve damage. Although the source is removed, the blaze at the site has already spread, scorching all nerves, leading to various adverse external manifestations and ultimately fatal outcomes. So, what medicine can save the patient at this time? Answer: There is one, namely Lingyangjiao (Antelope Horn). *Bencao Gangmu* states: "This product soothes the liver, relaxes sinews, stabilizes wind, calms the soul, disperses blood, expels wind, wards off evil, detoxifies, and treats infantile convulsions and spasms." What is called "evil" and "toxin" arises from heat. What is called "liver" and "sinew" refers to nerves. When heat-toxicity scorches nerves, spasms and convulsions appear, which is what is meant by "Liver Wind stirring Yang." Lingyangjiao can cool and harmonize nerves, making them calm. Therefore, if used properly and in correct dosage, it can treat conditions that Dachengqi Tang cannot. Other herbs such as Shijueming (Concha Haliotidis), Gouxi (Uncariae Ramulus cum Uncis), Quanxie (Buthus), and Wugong (Scolopendra) can serve as assistants.

Cao Yingfu said: Yun Tieqiao treated Wang Luping's son with meningitis using Lingyangjiao (Antelope Horn) and Xijiao (Rhino Horn) with success. Wang Luping's son told me this personally. Corroborating Zuo Jing's statements, this is highly credible. It shows that treating critical conditions often requires remedies not covered by classical formulas, borrowing from the innovations of later experts. Thus, medical treatment values comprehensive understanding.

**Case Four of Dachengqi Tang Syndrome**

A young man surnamed Chen lived in a small house on Wuxi Road. At sixteen, he lost his father early and relied solely on his mother. Working hard all year, he barely managed to eat his fill. During the New Year, he sold fireworks hoping for a small profit. Due to irregular diet, eating cold rice when hungry, and exposure to wind-cold, he developed abdominal pain that refused pressure, frequent diarrhea with pure black stool, no fever, and a slippery, large pulse with thirst. His family was poor and could not afford a doctor. After more than ten days, he came for consultation. Observing his symptoms, I knew it was diarrhea due to stagnation. I prescribed Dachengqi Tang, but out of pity for his poverty, omitted Houpo (Magnolia Bark). The prescription consisted of Dahuang 4 qian, Zhishi 4 qian, and Mangxiao 2 qian. After writing it, I told his mother: "If after taking the medicine you experience violent diarrhea worse than before, the old disease will be cured." His mother asked strangely: "Instead of stopping the diarrhea, you accelerate it? Why?" I replied: "You will know after taking it." Indeed, after one dose, he had three large bowel movements consisting of black stool, mixed wet and dry. The diarrhea stopped, and he was cured. This is the example cited in *Jingui Yaolue*: "Diarrhea due to retained food should be treated by removing the retention; purgation leads to cure, suitable for Dachengqi Tang."

[Note] The Great Treatise states: "Shaoyin syndrome with spontaneous diarrhea of clear water, pure green color,必定 pain in the epigastrium, dry mouth, and dry throat, requires urgent purgation. Dachengqi Tang is suitable." This can corroborate each other. *Wenyi Lun* states: "Heat binding with lateral flow occurs because of Stomach excess and internal heat blockage. Initially constipation follows by diarrhea of pure foul-smelling water, completely devoid of feces, occurring three to four times or more than ten times a day. Dachengqi Tang is suitable. Cure occurs when solid feces are expelled and diarrhea stops. If after taking the decoction, solid feces are not expelled, and diarrhea of foul water and ingested medicine continues, it is because the large intestine's pathogenic excess has caused loss of its transportation function, indicating the pathogen remains. The disease will not decrease; another purgation is needed." The late scholar Wu Youke of Yanling spoke thus, truly deserving to be called a direct disciple of Zhong Jing.

A guest asked: "Zhong Jing discusses Shanghan, while Youke discusses Wenyi. How can you mix them?" I replied: "Alas! What kind of words are these? Zhong Jing said: 'Observe the pulse and symptoms, understand what deviation has occurred, and treat according to the syndrome.' The strength of our TCM lies precisely in recognizing this 'syndrome' character. If we observe that the patient presents a Dachengqi Tang syndrome, we administer Dachengqi Tang; if they present a Sini Tang syndrome, we administer Sini Tang. If the effect responds like an echo after administration, then the name of the preceding disease need not be rigidly adhered to."

**Case Five of Dachengqi Tang Syndrome**

The *Shanghan Lun* states: "Jue (cold extremities) syndromes should be treated with purgation; if sweating is used instead, oral ulcers and redness will certainly occur." Cold constrained externally and heat trapped internally means the syndrome should wait for yang heat to gradually return before purging, allowing heat pathogens to vent from the lower part, curing the disease. If sweating is induced, stomach fluids are depleted, Gallbladder fire generates dryness, transforming into a Yangming heat syndrome, resulting in oral ulcers and redness. This is analogous to abnormal sweating leading to sore throat and bi-syndrome in the throat, caused by excessive sweating leading to excessive yang qi ascending. I personally witnessed this case at Siming Hospital. I did not see the initial illness, but when I consulted, the mouth was fully ulcerated and red. Checking the previous prescription, it was the lightest dosage of Guizhi Tang, with the record noting aversion to cold. Using Guizhi Tang for a Taiyang disease might not be entirely accurate, but it is close enough. Later, the disease transformed into Yangming. After taking Baihu Tang for five doses, the previous doctor deemed it incurable. My old friend Zhou Xiaopeng asked me to consult together. Asking about the condition: clear during the day, high fever at dusk, unable to sleep all night. Ying qi travels through yang at night; fever at dusk belongs to the blood level. Clarity by day and confusion by night is similar to women's heat entering the blood chamber. Heat entering the blood chamber uses Taoheshengqi Tang; thus, this syndrome involves Jueyin combined with Yangming dryness transformation. The patient stated that after Western doctors administered Epsom salts for one bowel movement, he could sleep slightly better in the middle of the night. His pulse was deep, slippery, and forceful. I therefore used Dachengqi Tang, one dose daily. Fever subsided after five days. Xiaopeng followed up with Suanzaoren Tang, and recovery occurred in seven days.

[Note] The Great Treatise states: "The deeper the jue, the deeper the heat; the milder the jue, the milder the heat. Jue should be treated with purgation; if sweating is used instead, oral ulcers and redness will occur." Since oral ulcers and redness are now present, investigating the cause reveals fault in sweating, so purgation should be employed even more. This is the first basis from the text for using Chengqi. Yangming syndrome features tidal fever at dusk, frequently mentioned in the Great Treatise. The current patient is clear by day and has high fever at dusk, which matches perfectly. This is the second basis. Further examination of the pulse reveals it is deep, slippery, and forceful, indicating excess. This is the third basis from the pulse image. Western doctors previously used Epsom salts for mild purgation, allowing slight rest at midnight. This is the fourth basis from previous treatment. With these four indications, one can claim carefulness; if one still cannot boldly administer the formula, can one be called a physician? Cao Yingfu said: "Oral ulcers and redness indicate stomach heat; dry fecal impaction indicates intestinal heat. Both Hand-Yangming and Foot-Yangming are hot. If not urgently purged, how can the disease be eliminated?"

**Xiaochengqi Tang Syndrome**

Patient Shi experienced pain at the Yintang area. Qi mechanism in the stomach was not smooth. Previous treatment with Pingwei San was ineffective. There must be stagnant retained food, leading to decreased appetite. I proposed Xiaochengqi Tang (Minor Order the Qi Decoction) to harmonize.

Sheng Chuanjun (Raw Rhubarb) 3 qian (added later), Zhong Chuanpu (Aucklandia) 2 qian, Zhishi 4 qian. Zhu Chao's Note: Effect is immediate upon ingestion.

**Tiaowei Chengqi Tang Syndrome**

Patient Shen Baobao became ill on the Si Day of the Spring month, lasting over forty days. No bowel movement, dry mouth and thirst. This is clear evidence that Yangming dominates the central earth and transmission ceases. Previously, using Senna leaves led to hard stool followed by loose stool, and slightly better sleep. This is a turning point in the disease. After purgation, abdominal pain persists, residual stagnation is not cleared, and the pulse remains slippery and rapid. Tiaowei Chengqi Tang (Regulate the Stomach Assist to Enter Qi Decoction) should be used gently to harmonize.

Sheng Chuanjun (Raw Rhubarb) 2 qian (added later), Sheng Gancao (Raw Licorice) 3 qian, Mangxiao (Mirabilite) 1 qian (dissolved).

[Note] Tiaowei Chengqi Tang, Xiaochengqi Tang, and the aforementioned Dachengqi Tang constitute the three Chengqi Decoctions. Their ingredients differ, dosages vary, decoction methods are distinct, and administration methods differ. Zhong Jing divided them in great detail and applied them with precision. Among commentators throughout history, Ke Yunbo distinguished them most thoroughly and explained them most clearly. Students should study them carefully. However, I wish to supplement a few minor points: Zhong Jing often mentions "dry feces in the stomach." The term "Wei Zhong" (Stomach Middle) here should be read as a single noun, meaning "Intestine," not literally inside the stomach. Therefore, the "Wei" in Tiaowei Chengqi Tang and the "Wei" in harmonizing stomach qi can both be interpreted as "stomach middle" or directly as "intestine." This is point one. Ke claimed Tiaowei Chengqi Tang is a harmonizing formula for concurrent Taiyang and Yangming disease, stating that exterior unresolved status is due to interior obstruction. Thus, although Taiyang neck stiffness remains, Yangming fever without aversion to cold appears externally. Ignoring that Yangming also has headaches, specifically at Yintang, not Taiyang acupoints, and Yangming also has fever, specifically steaming heat, not fluttering heat. Hence, the Great Treatise says: "Taiyang disease, three days, sweating fails to resolve, steaming heat occurs, belonging to the Stomach, Tiaowei Chengqi Tang governs." Here, "unresolved" does not mean exterior unresolved, but rather Taiyang heat gone, Yangming heat succeeding, also termed "unresolved." Ke forcibly added "no headache," which contradicts the text. This is point two. Ke suggested Houpo doubled with Dahuang makes Qi herb the sovereign, and Dahuang doubled with Houpo makes Qi herb the minister. Calling them "Qi" seems vague. Houpo is an intestinal herb that reaches the intestine directly, widening the intestinal wall. In severe intestinal binding, dry feces adhere tightly to the intestinal wall. Even if Xiaoming and Dahuang enter, they cannot exert their effect. Thus, Houpo must be used to widen the intestinal wall and drive out flatus, so that dry feces can be attacked and expelled. This is point three.

Nevertheless, I still have doubts regarding Dachengqi Tang. Zhong Jing used Houpo up to half a jin in this formula. Converting to my teacher's one-tenth method, this would be eight qian. But my teacher rarely used it up to eight qian. Wu Yi can be considered an expert on Chengqi formulas, yet his Dachengqi Tang used Dahuang up to five qian, while Houpo was only one qian. Wu Jutong was bolder, using Dahuang six qian and Houpo only half that amount, up to three qian. Wu argued that for treating primary Shanghan, heavy Houpo should be used; for treating primary Warm Disease, reduced Houpo should be used. This is mere embellishment, not the view of a knowledgeable person. Viewing this strictly and calculating dosage ratios, there is no true Dachengqi Tang in the world. Erudite readers, have you ever commonly used the true Dachengqi Tang and understood its essence?

Having concluded the discussion of nine syndromes from Guizhi Tang to Tiaowei Chengqi Tang, we can compile a table as follows:

Mahuang Tang Syndrome — Maxing Shigan Tang Syndrome — Chengqi Tang Syndrome
— Xiaochengqi Tang Syndrome
Guizhi Tang Syndrome — Baihu Tang Syndrome — — Dachengqi Tang Syndrome
Gegen Tang Syndrome — Gegen Qinlian Tang Syndrome — — Tiaowei Chengqi Tang Syndrome

The meaning of this table is: Mahuang Tang syndrome transforms heat entering the interior to become Maxing Shigan Tang syndrome. Guizhi Tang syndrome transforms heat entering the interior to become Baihu Tang syndrome. Gegen Tang syndrome transforms heat entering the interior to become Gegen Qinlian Tang syndrome. After Gegen Qinlian Tang, Baihu Tang, and Maxing Shigan Tang syndromes transform heat, they all become Chengqi Tang syndromes. For mild intestinal binding, attack and tonification can be combined; this "harmonizing" approach is Tiaowei Chengqi Tang syndrome. For moderate intestinal binding, the harmonizing method is also used, which is Xiaochengqi Tang syndrome. For severe intestinal binding, the purgative method, also called urgent purgation or attacking method, is Dachengqi Tang syndrome. In reality, the three Chengqi formulas, compared to the sweating methods of Mahuang, Guizhi, and Gegen, and the clearing method of Baihu Tang, can all be called purgative methods.

The transmission of Maxing Shigan Tang syndrome to Chengqi Tang syndrome seems not yet described in the above experimental medical cases. In fact, although such cases are fewer than Baihu Tang transforming into Chengqi Tang, they are not rare. The classics state that the Lung and Large Intestine are exterior-interior related. Intestinal heat can transfer to the Lung, and Lung heat can affect the Intestine. What is called "Warm pathogens received from above, first attacking the Lung, reversely transmitting to the Pericardium" refers to severe Maxing Shigan Tang syndrome. Unable to resolve with Sangju Yin or Yinqiao San, it transmits to intestinal heat. Unchecked intestinal heat scorches the nerves, causing coma and delirium, which is then labeled as reverse transmission to the Pericardium. Based on my clinical experience, after Lung heat transfers to intestinal heat, the Lung heat often does not dissipate. At this time, if only treating Lung heat, even with extremely heavy doses of Maxing Shigan Tang, it will inevitably be useless. One must urgently use Chengqi methods to remove intestinal heat. If one worries that Chengqi harms the Lung, punishing the innocent, then the Guiding Method (Dao Fa, detailed in the middle volume) is excellent. I have used it repeatedly with success. Once intestinal heat is removed, continuing with Maxing Shigan Tang to treat Lung heat yields results. Hence, the Great Treatise states: "After purgation, do not use Guizhi Tang again. If sweating and wheezing occur without significant heat, Maxing Gan Shi Tang can be given." This clause seems redundant and should be deleted, yet clinically this example exists. How strange? Very often, after purgation, Lung qi opens naturally, and coughing clears. I have encountered this repeatedly. A child surnamed Yu suffered from sore throat, redness and swelling, accompanied by white spots and chest discomfort on the 3rd day of a certain month. On the 4th day, fine spots like hemp appeared on the skin. Doctor Jia diagnosed the need to clear blood and protect the throat, using Shengdi, Huanglian, Heizhizi, Danqin, etc. That night, the child's throat swelled, he muttered deliriously, ground his teeth, and his eyes were red. On the 5th day, Doctor Jia used Xuanshen, Shengdi, Shanzhizi, Zuojin Wan, etc. Doctor Yi changed the prescription to muscle-releasing and rash-expelling agents like Douchi, Bohe, Gegen, Niubangzi, etc. On the 6th day, Doctor Yi emphasized expelling rash for throat scarlet fever, heavily prescribing rash-expelling medicines. On the 7th day, the rash was dense, mixed with white patches, temperature higher, muttering in dreams at night. Worried about fluid injury, Doctor Yi used fluid-nourishing and heat-clearing methods like Lianqiao, Yinhua, Zhuye, Daihe San, etc. By the evening of the 11th day, although the rash receded, fever persisted. Coughing was rough, nasal flaring, mouth breathing, chest discomfort, clouded consciousness, plus abdominal pain refusing pressure, and diffuse swelling below the ears. Doctor Bing, who had insight, said: "One should unblock the fu organs." Directly using Sheng Dahuang 3 qian and Yuanmingfen 1 qian, combined with rash-expelling medicines to eliminate remaining pathogens. That night, bowel movements occurred frequently, mental agitation settled, nasal flaring and ear swelling gradually receded.

On follow-up, Xiaoming and Dahuang were continued until stool color turned yellow, then conditioning therapy was given for peace. From this case, it is evident that for Lung heat transforming into intestinal heat, if one does not attempt to remove intestinal heat binding, but only knows how to release the exterior and generate fluids, what benefit is there? Thus, Maxing Shigan, Baihu, and Gegen Qinlian three tang syndromes can all transform heat into Chengqi Tang syndromes. Regarding the disease location, the three tang syndromes' locations are relatively upper, while Chengqi Tang syndrome's location leans toward the intestine, which is relatively lower. From this, we derive the third principle of exogenous disease transmission: from upper to lower. The Great Treatise states: "Yangming resides in the center, governing Earth. All things return to it, and transmission ceases." Is this what is meant? In studying the nine formulas listed above, one thing deserves attention: among these nine formulas, seven contain Gancao (Licorice Root).

The upper three formulas (Mahuang, Guizhi, Gegen) do not leave out Gancao. The middle three formulas do not detach from Gancao. The lower Tiaowei Chengqi Tang also uses Gancao.