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Cheng Zhi stated: As long as dry feces (dry stool) are present, a vigorous purgative method can be used to attack and purge. If after purging one experiences mental restlessness and vexation (vexation with a sense of oppression), this is deficiency vexation (vexation due to deficiency of Yin and accumulation of heat), and Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) should be administered.
If there are dry feces in the stomach/intestines, it is not deficiency vexation, so attacking is permissible. If abdominal fullness is not severe, there is no absolute indication for purging; if dry feces are present, it is not the case of stool being initially hard and later loose, so attacking is permissible. It is also said that hard stool differs from dry feces. Hard stool refers to stool that is solid, full, and hard; dry feces refer to retained food in the stomach that has condensed into dry, pill-like masses due to stomach heat. Therefore, when stool is merely hard, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) may still be used; but if dry feces are present, Mangxiao (Natrii Sulfas) must invariably be included due to its salty-cold nature.

Cheng Yingmao stated: The final sentence reiterates the "permissible to attack" point to determine the treatment method.

Two or three days after contracting the disease, if the pulse is weak, and there are no Shaoyang syndrome symptoms requiring Chaihu (Bupleuri Radix), but rather irritability and hardness in the epigastrium, by the fourth or fifth day, even if the patient can eat, administer a small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to slightly harmonize the Stomach Qi, allowing for slight relief. By the sixth day, administer one sheng (a unit of volume) of Chengqi Tang. If there has been no bowel movement for six or seven days, and urine output is scanty, even if the patient cannot eat, if the stool is only hard at the beginning and likely loose later, it indicates that hardness has not yet fully formed; attacking now will inevitably cause loose stools. One must wait until urination becomes normal and the stool is definitely hard before attacking, using Da Cheng Qi Tang (Major Order the Qi Decoction).

[Annotation] Two or three days after contracting the disease, without Taiyang or Shaoyang syndrome symptoms, with irritability and epigastric hardness, and constipation by the fourth or fifth day: if the pulse is large, it belongs to Zheng Yang Yangming (True Yang Yangming), a Stomach Excess syndrome, and purging is unquestionably indicated. Now, since the pulse is weak, although the Stomach Qi is harmonious and the patient can eat, light purging should not be attempted. Only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) should be given in small amounts to slightly harmonize, bringing slight relief. If constipation persists the next day, continue with Xiao Cheng Qi Tang to promote defecation. If there is no bowel movement for six or seven days and urine is scanty, even if the patient cannot eat, it indicates the Stomach is not yet dry and the stool is not definitively hard; aggressive purging would result in initial hardness followed by looseness. One must wait for normal urination to confirm definite hardness before attacking, using Da Cheng Qi Tang (Major Order the Qi Decoction).

[Collected Annotations] Fang Youzhi stated: The Taiyang chapter does not specify medicines because Guizhi Tang (Cinnamon Twig Decoction) and Mahuang Tang (Ephedra Decoction) are standard; the Shaoyang chapter specifies medicine because Chaihu Tang (Bupleurum Decoction) is the primary formula. Such writing styles mutually elaborate on each other. Since there are no Taiyang or Shaoyang meridian syndromes, it is known to belong to Yangming; because the pulse is weak, slight harmonization is appropriate. From the sixth day onwards, the text details the degrees of when to attack and when not to.

Cheng Yingmao stated: The ability to eat indicates stagnation is in the intestines while Stomach fire is naturally abundant. First, give a small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to harmonize Stomach fire and bring slight peace; then increase the dose to one sheng to remove intestinal stagnation. After using Xiao Cheng Qi Tang, reducing the dosage and administering it continuously is because the Stomach with a weak pulse is constitutionally deficient, and the disease duration is short.

Zhang Lu stated: The mentions of ability to eat and inability to eat in this section have nothing to do with distinguishing the strength of Wind-Cold. Saying "can eat" does not mean Stomach strength is high enough for light purging; saying "cannot eat" does not necessarily mean dry feces are in the Stomach justifying light purging.

In Yangming disease, if the pulse is slow, and although there is sweating and no aversion to cold, the body is heavy, there is shortness of breath, abdominal fullness with wheezing, and tidal fever, this indicates the exterior is resolving, and the interior can be attacked. Sweating from the hands and feet indicates the stool has hardened; Da Cheng Qi Tang (Major Order the Qi Decoction) is the main formula. If there is profuse sweating, slight fever, and aversion to cold, the exterior has not resolved; if the fever is not tidal, Chengqi Tang should not be given. If abdominal distension and obstruction are severe, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) may be given to slightly harmonize Stomach Qi, avoiding drastic purgation.

[Annotation] In Yangming disease with a slow pulse, although there is sweating and no aversion to cold, the exterior signs are resolving but the pulse is not solid, so purging is not yet appropriate. Body heaviness indicates heat trapping the body; shortness of breath and wheezing indicate heat obstructing the upper jiao; abdominal fullness and tidal fever indicate heat gathering in the middle jiao; sweating from the hands and feet indicates the stool has hardened, with heat binding in the lower jiao. Only when external pathogens are resolved and internal excess is established can one attack, primarily using Da Cheng Qi Tang (Major Order the Qi Decoction). If there is sweating, slight fever, and aversion to cold, the exterior remains unresolved; if the fever is not tidal, the interior is not yet full, so Chengqi Tang should not be given. Even with urgent internal symptoms like severe abdominal distension and obstruction, only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) should be used to slightly harmonize Stomach Qi, avoiding drastic purgation, due to the slow pulse.

[Collected Annotations] Fang Youzhi stated: Tidal fever occurs in Yangming during the Shen, You, and Xu hours (3 PM - 9 PM), rising like the tide. Sweating from the hands and feet: Spleen governs the four limbs and combines with the Stomach; dryness and excess in the Stomach steam towards the limbs, hence "the stool has hardened."

Lin Lan stated: This section distinguishes between slow pulse with internal binding, where some cases suit Da Cheng Qi Tang (Major Order the Qi Decoction) for attack, while others suit only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) for slight harmonization. Yangming disease with slow pulse, accompanied by sweating, no aversion to cold, body heaviness, shortness of breath, abdominal fullness, and wheezing, seems suitable for purging. However, tidal fever must be present to confirm exterior resolution and interior establishment; sweating from hands and feet confirms hardened stool, making Da Cheng Qi Tang (Major Order the Qi Decoction) the clear choice. If sweating is profuse but fever and aversion to cold persist, the exterior remains; if fever is not tidal and sweat is not from the extremities, how can Chengqi Tang be used? Even with severe abdominal distension, only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) for slight harmonization is appropriate, avoiding drastic purgation. Why? A slow pulse is not an indication for mandatory purging; even with internal binding, is Da Cheng Qi Tang (Major Order the Qi Decoction) suitable?

In Yangming disease, with tidal fever and slightly hard stool, Da Cheng Qi Tang (Major Order the Qi Decoction) may be given; if not hard, it should not be given. If there is no bowel movement for six or seven days, and one fears dry feces, the method to verify is to give a small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If, after ingestion, flatus (passing gas) occurs, this indicates dry feces, and attacking is permissible; if no flatus occurs, the stool is only hard at the beginning and likely loose later, so attacking is forbidden, as it will cause abdominal fullness and inability to eat. Thirst for water resulting in hiccups upon drinking indicates subsequent fever will lead to slightly hard, scanty stool; treat with Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to harmonize. If no flatus occurs, strictly avoid attacking.

[Annotation] In Yangming disease, with tidal fever and slightly hard stool, Da Cheng Qi Tang (Major Order the Qi Decoction) may be given; if not hard, it should not be given. If no bowel movement for six or seven days, fearing dry feces, the verification method is to give a small amount of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If flatus occurs after ingestion, dry feces are present, and attacking is permissible. If no flatus occurs, the stool is only hard at the beginning and likely loose later, meaning hardness has not yet formed; attacking is forbidden, as cold qi will rise against empty defenses causing abdominal fullness and inability to eat. Thirst for water leading to hiccups indicates deficiency-cold qi rising, unable to transform and transport water downward. If subsequent tidal fever persists, the stool will harden again, but since purging has already occurred, the amount of hard stool is small; treat with Xiao Cheng Qi Tang (Minor Order the Qi Decoction) to harmonize. Thus, for those taking Chengqi Tang who do not pass flatus, attacking must be strictly avoided. This is Zhongjing's warning against light purging.

[Collected Annotations] Fang Youzhi stated: This details tidal fever and flatus sequentially to decide the timing for purging. Flatus means passing gas abnormally. Abdominal fullness is an error of cold medicine. Hiccups are cold damaging the Stomach. Hardening again with small amount is due to repeated purging. The final sentence emphasizes caution.

Yu Chang stated: If abdominal qi does not move, using Da Cheng Qi Tang (Major Order the Qi Decoction) is a major error, and even Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is erroneous.

Cheng Zhi stated: The previous clause said: Exterior resolving, interior can be attacked; Exterior unresolved, Chengqi Tang not to be given; Can give Xiao Cheng Qi Tang, slightly harmonize Stomach Qi, avoid drastic purgation. This clause says: Can give; Cannot give; Can attack, Cannot attack; Give small amount of Xiao Cheng Qi Tang; Use Xiao Cheng Qi Tang to harmonize, strictly avoid attacking. The discussion of quantity reflects prudence. Therefore, only when hands and feet sweat profusely and stool is dry and hard is Da Cheng Qi Tang (Major Order the Qi Decoction) the primary choice; Xiao Cheng Qi Tang (Minor Order the Qi Decoction) remains a method for slight harmonization.

Wang Hu stated: Passing flatus indicates hardened stool due to severe dry-heat in the intestines, causing qi to turn and descend; not passing flatus indicates heat exists but pores are not dry, so stool is only hard at the beginning and likely loose later.

In Yangming disease, with delirium and tidal fever, if the pulse is slippery and rapid, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is the main formula. Administer one sheng of Chengqi Tang. If flatus occurs in the abdomen, administer another sheng; if no flatus occurs, do not give more. If the next day there is still no bowel movement, and the pulse becomes faint and choppy, this indicates interior deficiency, making it difficult to treat; do not give Chengqi Tang again.

[Annotation] In Yangming disease, delirium, tidal fever, and a slippery, rapid pulse are indications for purging. However, without profuse sweating, frequent urination, or definitely hard/dry stool, sudden purging is inappropriate. First, test with one sheng of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). If flatus occurs, dry feces in the intestines are confirmed hard; the small dose was insufficient to immediately purge, so the passed flatus is merely gas. Administer another sheng to promote purging. If no flatus occurs, do not give more. Wait until the next day; if still no bowel movement and the pulse remains slippery and rapid, then give it. Now, if the pulse becomes faint and choppy, it indicates interior deficiency and lack of qi to transport, making it difficult to treat, so Chengqi Tang should not be given again.

[Collected Annotations] Fang Youzhi stated: Slippery pulse indicates food retention, thus diagnosing hard stool. Rapid indicates interior heat. Faint indicates insufficient Yang qi for circulation. Choppy indicates insufficient Yin blood for lubrication. Hence: "Faint Yang cannot be purged, Blood deficiency cannot be purged." This refers to that.

Zhang Lu stated: This clause has a slippery, rapid pulse with delirium and tidal fever, but no hard/full excess syndrome. Only Xiao Cheng Qi Tang (Minor Order the Qi Decoction) should be used. If the pulse becomes faint and choppy after purging, the syndrome changes to interior deficiency, making it difficult to treat.

After Shanghan (Cold Damage) treated with vomiting or purging, if the disease persists, with no bowel movement for five to six days up to ten-plus days, tidal fever occurring at dusk (You hour), no aversion to cold, and solitary speech as if seeing ghosts: if severe, the patient may become unresponsive, grasp at clothes and bedrails, feel terrified and restless, with slight wheezing and fixed gaze. If the pulse is string-taut (Xian), survival is possible; if choppy (Se), death is likely. If mild, presenting only with fever and delirium, Da Cheng Qi Tang (Major Order the Qi Decoction) is the main formula. If one dose results in relief, stop subsequent doses.

[Note] Zhao Sizhen stated: *Huoren Shu* removed "string-taut". String-taut is Yang; choppy is Yin. Yang disease showing Yang pulse indicates life; in Zhongjing's pulse methods, Xian and Se belong to Yin, not Yang, raising doubt. In "pulse string-taut implies life," the character "Xian" should likely be "Hua" (slippery). If "Xian," it is a Yin-deficient pulse, lacking reason for guaranteed life. Only "Hua" (slippery) is Yang, indicating vitality. Hua means open/unobstructed; Se means blocked/stagnant. Physics dictates openness leads to life, blockage to death. Comparing with the previous clause "slippery and rapid pulse uses Xiao Cheng Qi Tang, faint and choppy pulse indicates interior difficulty," proves the error.

[Annotation] After Shanghan treated with vomiting or purging, fluids are depleted, exterior unresolved, pathogen enters interior. No bowel movement for five to six days up to ten-plus days, tidal fever at dusk, no aversion to cold: exterior pathogens are gone, interior heat deepens. Da Cheng Qi Tang (Major Order the Qi Decoction) should still be used to sweep away residual pathogens and preserve Yin fluids, leading to recovery. If purging is delayed, leading to solitary speech as if seeing ghosts, severe cases involve unresponsiveness, grasping at clothes/bedrails, terror/restlessness, slight wheezing, and fixed gaze. These are signs of extreme Yang rising, Yin declining, lone Yang without foundation, and disturbed spirit. At this time, diagnose slippery pulse as excess (purgeable, life possible); choppy pulse as deficiency (hard to purge, death likely). If mild, showing only tidal fever, delirium, and constipation without severe confusion, use Da Cheng Qi Tang (Major Order the Qi Decoction). If one dose brings relief, stop further doses to avoid over-purging.

[Note] Grasping at clothes and bedrails is a critical sign. One perspective: treatable if Yin is not exhausted (e.g., Taiyang Wind Strike treated with fire therapy causing reversal, grasping clothes, urinary flow determines life/death). Another: treatable by attacking if Yang heat is extreme (e.g., Yangming interior excess, grasping clothes, slippery pulse life, choppy pulse death). Generally, this syndrome arises after excessive sweating, vomiting, or purging, causing great Yang deficiency and loss of spirit. The Classic states: Limbs are the root of all Yang. Yang deficiency causes limb disturbance. Treat with Du Shen Tang (Single Ginseng Decoction); for profuse sweating, use Renshen Tang (Ginseng Decoction); for cold limbs, use Renshen Fuzi Tang (Ginseng and Aconite Decoction). Many recover; do not一概 (uniformly) attribute it to extreme Yang and exhausted Yin.

[Collected Annotations] Yu Chang stated: This clause discusses severe delirium. Within severity, two grades: severe implies death; mild implies life. Hence, use Da Cheng Qi Tang (Major Order the Qi Decoction) to purge.

Cheng Zhi stated: Lou Quanshan treated grasping at clothes/bedrails with tonics, often achieving recovery, due to deficient pulse/syndrome. Liu Shouzhen often used Chengqi Tang for febrile diseases. While based on Zhongjing, his differentiation was less detailed, opening doors for later recklessness. Also: Wheezing indicates qi about to escape upward; slight wheezing indicates interior excess preventing full wheezing. Unresponsiveness/grasbing indicates Heart qi failing; terror/restlessness indicates Liver qi failing; slight wheezing indicates Lung qi failing; fixed gaze indicates Kidney qi failing. *Neijing* states: When Three Yin and Three Yang, Five Zang and Six Fu are diseased, Ying and Wei cease moving, Zang and Fu cease communicating, hence choppy pulse implies death.

Wang Hu stated: Tidal fever at dusk indicates severe fu-organ excess and dryness, occurring during the meridian's prosperous time. Solitary speech is delirium. Patient speaking alone as if seeing ghosts is Yangming fu-excess with hallucinations. Severe means serious. Cheng Wuji notes: Heat confuses righteous qi, causing unresponsiveness. Grasping at clothes/bedrails is Yang heat dominance causing hand agitation. Terror/restlessness is Stomach heat rushing膈 (diaphragm), disturbing Heart spirit. Severe Stomach heat causes upward qi rebellion (wheezing); fixed gaze indicates pathogen invading Zang organs. Life/death depends on pulse diagnosis.

In Yangming disease, originally with spontaneous sweating, if the doctor induces heavy sweating, and although the illness has improved, slight vexation and discomfort remain, the stool must be hard. This is due to fluid depletion and dry Stomach causing hard stool. Ask about daily urination frequency. If originally urinating 3-4 times daily, but only twice today, know that stool will soon pass. Now, with reduced urination, fluids should return to the Stomach, so know that stool will soon pass naturally.

[Annotation] In Yangming disease, originally with spontaneous sweating, if the doctor mistakenly treats for Wind and induces heavy sweating, and although improved, slight vexation remains, the stool must be hard. However, without pain or fullness, the heaviness of sweating depleted fluids, drying the Stomach and hardening stool, without retained food. Ask about daily urination. If originally 3-4 times, now only twice, stool will soon pass. Reduced urination means fluids return to the Stomach, so stool will pass naturally without medication.

[Collected Annotations] Fang Youzhi stated: Food/water in Stomach: essence becomes Jin-Ye (fluids), dregs become waste. Fluids seeping out of intestines: clear becomes Jin-Ye, turbid becomes sweat externally or urine internally. Excessive sweat/urine depletes Jin-Ye, making stool dry, hard, and difficult to pass. Intestines/bladder are paths for water/food separation; open here, blocked there; blocked here, open there. Less urine means fluids stay in Stomach, moistening stool for natural passage.

In Yangming disease, with spontaneous sweating, or sweating induced, and frequent urination, this indicates internal exhaustion of Jin-Ye (body fluids). Although stool is hard, it cannot be purged. Wait until the patient feels the urge to defecate; use Honey Suppository (Mi Jian Dao) to guide passage. Radix Trichosanthis Kirilowii (Tugua Gen) or large Pig Bile (Da Zhu Dan Zhi) can also be used as guiding agents.

[Annotation] This elaborates on the previous clause to clarify treatment. In Yangming disease, with spontaneous sweating, induced sweating, or frequent urination, this indicates internal exhaustion of Jin-Ye. Although stool is hard, without fullness/pain, purging is forbidden. Wait for fluids to return to Stomach and urge to defecate, when dry stool reaches rectum and struggles to exit anus. Use Honey Suppository to moisten orifices and guide passage. Or use Tugua Gen to promote qi and unblock dryness, or Pig Bile to clear heat and moisten dryness. Choose appropriately.

[Collected Annotations] Cheng Wujie stated: Internal exhaustion of Jin-Ye causes dry intestines and hard stool. This is not heat binding, so purging is forbidden. Use external moistening suppositories to guide.

Zhang Lu stated: For cases of excessive sweating damaging fluids, or persistent disease despite multiple sweating/purging, or slow/weak chi pulse, or constitutionally weak patients who need purging but cannot tolerate it, guiding methods are appropriate.

Cheng Yingmao stated: Frequent urination means fluids have not returned to Stomach; internal exhaustion causes hardness. Patient feels urge but cannot pass. Only at this stage should external guiding methods be used to moisten intestines. Moistened intestines attract water/fluids, returning Jin-Ye to Stomach. Thus, not only does stool pass, but urination also regulates internally.

Honey Suppository Formula
Seven he of honey, single ingredient, place in copper vessel, simmer gently until slightly thick like malt syrup, stir constantly to prevent burning. When moldable, shape into suppositories by hand, sharp head, thick as finger, approx. two cun long. Shape while hot; hardens when cold. Insert into anus, hold tightly with hand, remove when urge to defecate arises.

*Neitai Fang*: Use five he of honey, add five qian of Gleditsiae Sinensis (Zaojiao) powder when thickened, shape into suppository, lubricate anus with Pig Bile or oil, insert.

Pig Bile Formula
One large Pig Gallbladder, extract juice, mix with small amount of Vinegar,灌 (instill) into anus. Within one meal time, bowel movement should occur, expelling old food and foul matter effectively.

*Neitai Fang*: Do not use vinegar. Insert small bamboo tube into gallbladder neck, leave one end, lubricate with oil, insert into anus. Squeeze gallbladder with hand to inject juice. This method is very convenient.

Radix Trichosanthus Kirilowii Formula (Missing)

[Note] Tugua is commonly known as Chibao. *Zhouhou Fang* treats constipation by crushing root, extracting juice, and blowing into anus via tube. Same principle as Pig Bile Formula. *Neitai Fang* suggests cutting root into suppository shape for insertion, which is incorrect. Honey suppositories melt and moisten stool; Tugua Gen does not melt. Cutting into suppository form likely violates Zhongjing's formulation intent.

After six or seven days of Shanghan, if vision is unclear and eye movements are stiff, without exterior or interior syndromes, difficulty defecating, and slight body heat, this is an Excess syndrome. Urgently purge, using Da Cheng Qi Tang (Major Order the Qi Decoction).

[Annotation] In Shaoyin disease, two to three days after onset, with dry mouth/throat, urgently purge using Da Cheng Qi Tang (Major Order the Qi Decoction) because heat rapidly consumes Kidney Water, preventing fluids from reaching throat. Purge heat to save impending water exhaustion; delay leads to dry Kidney Water, unsupported Yang, restlessness, self-burning death. Unclear vision with flexible eyes is Yin syndrome; unclear vision with stiff eyes is Yang syndrome. Now, after six/seven days of Shanghan, unclear vision with stiff eyes indicates Kidney Water exhausted by Stomach Yang. Water fails to control Fire, so...