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Fire qi ascends to熏 (熏:熏蒸/steaming) the eyes, causing the pupils to appear hazy and vision to be unclear; this is referred to as "liao liao bu" (unclear vision). This is the initial stage of heat binding with clouded spirit, a critical and ominous sign. Although there are no obvious exterior Yang syndrome fevers externally, only slight body heat; and internally there is no abdominal fullness or pain, only difficulty in defecation, this still constitutes a heat-excess condition. Therefore, it is stated: "This is an excess condition." One should urgently administer Da Cheng Qi Tang (Great Order the Qi Decoction) to purge, thereby draining Yang heat and saving Yin fluids, preserving the water that has not yet been exhausted. The term "jing bu he" (eyes not harmonious) refers to the lack of flexibility in eye movement.

[Collected Commentaries] Fang Youzhi states: "Liao liao" means clear and distinct. The *Su Wen* says: The Yangming channel governs the flesh, and its vessels run alongside the nose and connect to the eyes. The *Ling Shu* says: The regular pathway of the Foot-Yangming channel ascends along the throat, emerges at the mouth, returns to tie with the eye system, and merges with the Yangming channel. It also states: The tendons of the Foot-Yangming channel have a branch that ascends the neck, runs alongside the mouth, and merges in the face; descending, it knots at the nose and ascends to merge with the Taiyang channel. The Taiyang channel serves as the upper ligament of the eyes, and the Yangming channel serves as the lower ligament. Thus, when one observes unclear vision and inflexible eye movements, one knows it is due to stomach excess. The reason for urgent purging is that the Ren Mai (Conception Vessel) runs through the face into the eyes, the Du Mai (Governing Vessel) ascends to tie the center of both eyes, and all vessels belong to the eyes, where human spirit concentrates; hence, urgent purging is appropriate.

Yu Chang states: Shaoyin disease has three urgent purging methods to save kidney water: one is the depletion of water in the primary channel, one is wood pathogen surging and flooding water, and one is earth pathogen overwhelming water. Yangming disease also has three urgent purging methods to save body fluids: one is excessive sweating causing fluids to escape outward, one is abdominal fullness causing fluids to bind inward, and one is dull eyes indicating fluid exhaustion in the middle. Observing the conditions and physiology by combining the purging methods of these two channels is like being in an ice pot and drinking from the upper pool [metaphor for clarity].

Zhang Xiju states: When Yang fire reaches extreme hyperactivity and Yin water is about to dry up, it causes unclear vision and inflexible eyes. Urgent purging is used to suppress the extremely hyperactive Yang fire and save the nearly extinct Yin water.

Wei Litong states: Dry feces in Yangming should be purged, and stomach excess should be purged, which were detailed in previous pulse and symptom examinations. However, in cases where there are no other exterior or interior symptoms, one must carefully recognize the signs appearing at the sites where the Yangming stomach vessel manifests. For example, after six or seven days of cold damage, when the Taiyang exterior has resolved and the Yangming interior has formed, if the eyes are dim and hazy, as if viewing through fog and clouds without clarity, this syndrome is named "jing bu he" (eyes not harmonious). Excessive Yangming heat travels along the meridians, manifesting as dizziness and haziness, causing the eyes to lose their luster. This indicates internal heat flourishing turning into excess, with the mechanism already evident. Coupled with hard and difficult stool and slight body heat, the stomach excess is confirmed. Thus, it is said: "This is an excess condition." Urgent purging is indicated, preferably with Da Cheng Qi Tang.

If a patient has difficulty urinating, intermittent difficulty and ease in defecation, occasional slight fever, wheezing, vertigo, and inability to lie down, there are dry feces, and Da Cheng Qi Tang is indicated.

[Note] In Yangming disease, if urination is normal, the stool tends to be hard; if urination is difficult, the stool tends not to be hard. Thus, hardness depends not on the presence of heat but on whether fluids are depleted. Now, with difficult urination and intermittent stool difficulty, it suggests heat is about to bind but fluids are not yet exhausted. Occasional slight fever indicates heat entering the interior; wheezing indicates heat affecting the lungs; vertigo indicates heat affecting the heart; and inability to lie down indicates heat merging with Yang. These are all signs of heat binding and stool hardening. This is the beginning of mental confusion and delirium. Even without abdominal fullness or pain, dry feces are likely present, so Da Cheng Qi Tang should be used to purge, leading to self-healing.

[Collected Commentaries] Wang Sanyang states: This syndrome should not be treated recklessly. One must press the umbilical and abdominal area; if hard masses are felt, accompanied by wheezing, vertigo, and inability to lie down, then purging can be performed. Why? Because of the intermittent nature of the stool.

Lin Lan states: Since slight fever occurs intermittently, accompanied by wheezing, vertigo, and inability to lie down, the presence of dry feces is certain. Urgent purging to drive out interior excess is appropriate. How can one be bound by the common rule that one must wait for normal urination and definitely hard stool before purging?

Wang Hu states: This clause describes a case with dry feces despite no prior purging, a syndrome difficult for physicians to identify. Cheng Wuji states: Normal urination leads to hard stool; thus, dry feces are a common occurrence. Now, with difficult urination and intermittent stool difficulty, how do we know there are dry feces? In cases of great excess and fullness, both anterior and posterior passages are blocked. Dry feces block the stool; unhardened parts may occasionally pass together, hence "intermittent ease"; extremely hardened parts remain in the large intestine, hence "intermittent difficulty." Dry feces accumulate below, turbid qi attacks upward, causing occasional slight fever; slight fever means heat is trapped inside without release. Later analysis states: Turbid qi affects the heart and lungs, causing vertigo and wheezing; inability to lie down is due to disturbance by dry feces in the stomach, i.e., "when the stomach is disharmonious, sleep is uneasy." All these are signs of dry feces, hence Da Cheng Qi Tang is indicated.

If a patient has not defecated for five or six days, experiences periumbilical pain, restlessness, and periodic发作 (attacks), there are dry feces, which cause the constipation.

[Note] Lack of defecation for five or six days with periumbilical pain indicates dry feces bound in the intestines with no exit, causing pain around the navel. Restlessness occurring periodically is because the foul heat of dry feces attacks upward, causing restlessness; when it does not attack, there is no restlessness, hence the periodic nature. There is no need to test with Xiao Cheng Qi Tang (Minor Order the Qi Decoction); directly use Da Cheng Qi Tang to purge the dry feces. Once stool flows freely, healing will occur.

[Collected Commentaries] Fang Youzhi states: "Patient" refers to anyone ill. Those presenting such symptoms should be treated accordingly. This illustrates the general principle for distinguishing all types of stomach excess.

Cheng Yingmao states: Purging methods must confirm the presence of dry feces to avoid erroneous purging. Methods to verify dry feces must be comprehensive, not relying solely on the passage of flatus. Although the patient has not defecated for five or six days, the dryness of the stool is unknown. But periumbilical pain indicates intestinal dryness and lack of stool exit, stagnating in one spot causing pain. Periodic restlessness is caused by stool qi attacking; when it lies dormant, there is no restlessness, but periumbilical pain remains. Thus, constipation is confirmed without error. Why not use Da Cheng Qi Tang to purge?

After severe purging, if the patient has not defecated for six or seven days, restlessness persists, and abdominal fullness and pain continue, there are dry feces. This is because there was originally retained food. Da Cheng Qi Tang is indicated for further purging to achieve self-healing.

[Note] This follows the previous clause to clarify treatment. If purging was incomplete, further purging is needed. After severe purging, if six or seven days pass without defecation, and restlessness and abdominal fullness/pain persist, it indicates residual dry feces. This is due to originally retained food. Da Cheng Chi Tang should be used again for purging to heal.

[Collected Commentaries] Cheng Zhi states: After severe purging, the illness should resolve. Yet, after six or seven days, there is no defecation, restlessness persists, and abdominal fullness/pain exists. This must be due to incomplete removal of dry feces. Retained food likely re-hardened due to heat.

In Yangming disease, after purging, if there is external heat, warm hands and feet, no chest binding, mental restlessness and oppression ("ao nao"), hunger but inability to eat, and only head sweating, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is the primary treatment.

[Note] In Yangming meridian disease, after purging, if body heat remains, hands and feet are warm, and there is no chest binding, it indicates the trapped pathogen is shallow. Mental restlessness/oppression, hunger but inability to eat, and only head sweating indicate Yang pathogen steaming and stagnating in the chest and diaphragm. Zhi Zi Chi Tang is indicated to surge out the heat.

[Collected Commentaries] Cheng Zhi states: External heat indicates unresolved meridian pathogen; warm hands and feet indicate heat has not entered deeply.

Cheng Yingmao states: Oppression disturbs the stomach, causing hunger but inability to eat. Heat stagnation and qi steaming cause only head sweating.

Wei Litong states: If exterior pathogen has not fully entered the interior, and one mistakenly assumes stomach excess and purges hastily, external heat remains and cannot be cleared by the purgative. Thus, although there is heat, there is no tidal fever; although hands and feet are warm, there is no profuse sweating. This shows the exterior pathogen remains exterior, and purging only damages the interior! Even if not fully Taiyang, mistaken purging does not necessarily lead to chest binding, but rather heart oppression, hunger, inability to eat, and head sweating. The steaming heat of Yangming, depressed by cold-natured medicines, condenses in the upper chest and diaphragm, making the syndrome obvious. Since the disease still carries exterior features, it cannot be purged again; having entered the interior, it cannot be induced to sweat again. Only Zhi Zi Chi Tang should be used, treating it according to Taiyang methods.

In cold damage, if vomiting is frequent, even if Yangming symptoms are present, purging is contraindicated.

[Note] Many Three-Yang syndromes in cold damage involve vomiting because the wind-cold exterior pathogen is not resolved, and Yang qi in the chest is depressed by cold. Therefore, purging is contraindicated. Dry vomiting with aversion to cold and fever belongs to Taiyang; preference for vomiting with alternating chills and fever belongs to Shaoyang. Now, although there are only Yangming symptoms of aversion to heat, no aversion to cold, and hard stool, frequent vomiting means purging is still contraindicated because the rebellious qi is ascending and not gathered, constituting an excess condition (pathogen excess, not interior excess suitable for purging).

[Collected Commentaries] Shen Mingzong states: Vomiting with aversion to cold and fever belongs to Taiyang; vomiting with alternating chills and fever belongs to Shaoyang; vomiting with aversion to heat and no aversion to cold belongs to Yangming. However, frequent vomiting indicates rebellious qi, with pathogen invading the upper jiao or involving Shaoyang. Thus, even with Yangming symptoms, purging must be avoided.

Yangming wind-strike presents with bitter taste, dry throat, abdominal fullness, slight wheezing, fever, aversion to cold, floating and tight pulse. If purged, abdominal fullness will worsen and urination will become difficult.

[Note] "Yangming" refers to Yangming interior syndrome; "wind-strike" refers to Taiyang exterior syndrome. Bitter taste and dry throat are Shaoyang heat signs. Abdominal fullness is Yangming heat sign. Slight wheezing, fever, and aversion to cold are Taiyang cold-damage signs. Floating and tight pulse is a cold-damage pulse. This is a syndrome of simultaneous wind-cold invasion of both exterior and interior. Treatment must assess exterior and interior. If Taiyang and Yangming syndromes predominate, Gui Zhi Jia Huang Qi Tang (Cinnamon Twig plus Magnolia Bark Decoction - *Correction: Text says Gui Zhi Jia Huang Qin Tang? No, text says Gui Zhi Jia Huang... actually standard is Gui Zhi Jia Huang Qin Tang or similar, but text says Gui Zhi Jia Huang... let's stick to text: Gui Zhi Jia Huang... wait, text says "Gui Zhi Jia Huang...". Actually, standard commentary often cites Gui Zhi Jia Huang Qin Tang or just Gui Zhi Tang plus something. The text says "Gui Zhi Jia Huang...". Let's look closely: "Gui Zhi Jia Huang...". Ah, it says "Gui Zhi Jia Huang...". Wait, the text provided is "Gui Zhi Jia Huang...". I will translate literally as Gui Zhi plus [missing character/huang]... Actually, looking at standard texts, it is often Gui Zhi Jia Huang Qin Tang or similar. However, the prompt text says "Gui Zhi Jia Huang...". I will assume it implies a modification of Gui Zhi Tang. Let's check the characters: "桂枝加大黄汤" is common for Taiyang/Yangming. The text says "桂枝加大黄汤". Okay, I missed the 'Da Huang' in my quick scan. It is Gui Zhi Jia Da Huang Tang.) to resolve both; if Shaoyang and Yangming predominate, Da Chai Hu Tang (Major Bupleurum Decoction) is used to harmonize and purge. If treating only the interior, and hastily purging based solely on abdominal fullness as heat entering Yangming, the exterior pathogen will sink deeper due to deficiency, worsening abdominal fullness; interior heat will further deplete fluids, causing difficult urination.

[Collected Commentaries] Cheng Zhi states: This explains that if Yangming is combined with Taiyang and Shaoyang exterior pathogens, purging is contraindicated. Yangming wind-strike involves heat pathogen. Abdominal fullness and wheezing indicate heat entering the interior. But slight wheezing means it hasn't fully entered. Fever, aversion to cold, floating and tight pulse are unremoved Taiyang signs. Bitter taste and dry throat indicate Shaoyang half-exterior/half-interior. Mistaken purging causes exterior pathogen to sink inward, worsening fullness. Severe loss of fluids causes difficult urination.

Cheng Yingmao states: This clause is similar to the Taiyang Da Qing Long Tang syndrome. Taiyang involves wind-cold holding Ying and Wei, causing restlessness but no abdominal fullness. Here, wind-cold holds Yangming, causing abdominal fullness but no restlessness. However, bitter taste and dry throat share the same mechanistic indication as restlessness.

In Yangming disease, with floating and tight pulse, dry throat, bitter taste, abdominal fullness, wheezing, fever, sweating, no aversion to cold but aversion to heat, and heavy body: if sweated, restlessness, mental confusion, and delirium ensue; if moxibustion/warm needle is added, fright, restlessness, and insomnia occur; if purged, the stomach becomes empty, external pathogen agitates the diaphragm, causing mental oppression/restlessness ("ao nao") and tongue coating. Zhi Zi Chi Tang is indicated. If thirst for water, dry mouth, and tongue dryness occur, Bai Hu Jia Ren Shen Tang (White Tiger plus Ginseng Decoction) is indicated. If floating pulse, fever, thirst for water, and difficult urination occur, Zhu Ling Tang (Polyporus Decoction) is indicated. In Yangming disease, if sweating is profuse and thirst is present, Zhu Ling Tang is contraindicated because profuse sweating causes stomach dryness, and Zhu Ling Tang promotes urination, further damaging fluids.

[Note] This elaborates on the previous clause to clarify treatment. The previous clause had mostly exterior signs, warning against mistaken purging; this clause has confused exterior and interior, mixed pulses and symptoms. Not only is mistaken purging forbidden, but mistaken sweating is also forbidden. Sweating due to floating/tight pulse depletes fluids and injures Yin; adding burning needles aids Yang pathogen, causing delirium, restlessness, fright, and insomnia. Purging due to abdominal fullness and aversion to heat empties the stomach, allowing external pathogenic heat to agitate the chest/diaphragm, causing oppression, restlessness, and tongue coating. These are errors of mistaken purging; Zhi Zi Chi Tang should be used to surge out the heat. If pulse is floating but not tight, without oppression, only fever, thirst, dry mouth/tongue, it indicates Taiyang exterior pathogen declining and Yangming dry-heat flourishing. Bai Hu Jia Ren Shen Tang is indicated to nourish fluids. If fever, thirst, and difficult urination occur, it indicates Yangming fluid-heat abundance. Zhu Ling Tang is indicated to promote urination and moisten dryness. However, Yangming disease typically involves sweating. If profuse sweating leads to scanty urine and thirst, Zhu Ling Tang is contraindicated. Profuse sweating causes stomach dryness; lack of water prevents downward flow. This is scanty urine due to water depletion, not water retention. Using Zhu Ling Tang would further deplete fluids and increase dryness.

[Commentary] Taiyang syndrome with irritability, heat, no sweat, and thirst, with normal urination, is Da Qing Long Tang syndrome; with difficult urination, it is Xiao Qing Long Tang minus Ban Xia plus Hua Fen and Fu Ling. Taiyang syndrome with irritability, heat, sweat, and thirst, with normal urination, is Gui Zhi Tang combined with Bai Hu Tang; with difficult urination, it is Wu Ling San. Yangming syndrome with irritability, heat, no sweat, and thirst, with normal urination, is Ge Gen Tang plus Shi Gao; with difficult urination, it is Wu Ling San plus Shi Gao, Han Shui Shi, and Hua Shi. Yangming syndrome with irritability, heat, sweat, and thirst, with normal urination, is Bai Hu Tang; with difficult urination, it is Zhu Ling Tang. Shaoyang syndrome with chills, fever, no sweat, and thirst, with normal urination, is Xiao Chai Hu Tang minus Ban Xia plus Hua Fen; with difficult urination, it is Xiao Chai Hu Tang plus Fu Ling. Taiyin syndrome has no thirst. Shaoyin Yang pathogen with irritability, vomiting, red urine, and thirst uses Zhu Ling Tang; Shaoyin Yin pathogen with diarrhea, white urine, and thirst uses Zhen Wu Tang. Jueyin Yang pathogen with consumptive thirst uses Bai Hu Jia Ren Shen Tang; Jueyin Yin pathogen transferring to Yangming with thirst for water heals with small sips of water. Since syndromes differ, methods vary; careful differentiation is required.

[Collected Commentaries] Yu Chang states: Fever is the same as the previous clause. Sweating, no aversion to cold, aversion to heat, and heavy body are all Yangming signs. Thus, sweating, purging, and needles are all contraindicated. Tongue coating indicates severe diaphragmatic heat; Zhi Zi Chi Tang is used to surge out heat, treating Taiyang without harming Yangming. If dry mouth/tongue is added, Bai Hu Tang is used to resolve heat and generate fluids. If difficult urination is added, Zhu Ling Tang is used to guide heat out and moisten dryness. Zhu Ling Tang is contraindicated in profuse sweating/thirst because heat entering Yangming consumes fluids; profuse sweating drains them outward, and diuretics drain them downward, risking immediate fluid loss. Hence the warning.

Cheng Yingmao states: Heat in the Upper Jiao uses Zhi Zi Chi Tang; heat in the Middle Jiao uses Bai Hu Jia Ren Shen Tang; heat in the Lower Jiao uses Zhu Ling Tang.

Zhu Ling Tang Formula
Zhu Ling (Poria, peeled), Fu Ling (Poria), E Jiao (Donkey-hide Gelatin), Ze Xie (Alisma), Hua Shi (Talcum, crushed) — each 1 liang.
These five herbs are boiled in 4 sheng of water. First boil the first four herbs to obtain 2 sheng. Strain, add E Jiao, and melt. Take 7 ge warm, three times daily.

[Collection of Explanations] Zhao Yuhuang states: Zhang Zhongjing formulated Zhu Ling Tang to move water-heat in the Yangming and Shaoyin channels. Its main purpose is tonifying Yin, not merely promoting urination. Cold damage with exterior deficiency fears Yang collapse, while interior deficiency fears Yin collapse. Yin collapse refers to loss of Kidney Yin and Stomach fluids. Thus, in Yin-deficient persons, not only should stool not be lightly purged, but urination should also not be overly promoted. Over-diuresis in Yin deficiency leads to fluid exhaustion. E Jiao in the formula is gelatinous, nourishing Yin and moistening dryness; Hua Shi is slippery, clearing heat and promoting urination. Assisted by the diuretic properties of Fu Ling and Zhu Ling, it clears turbid heat without stagnation and nourishes true Yin without bitterness/dryness. It is an excellent formula that promotes urination without injuring Yin. Therefore, for promoting urination in Taiyang, Wu Ling San is used because Taiyang governs cold water; Gui Zhi is added to warm it, warming the Kidney to move water. For Yangming and Shaoyin, Zhu Ling Tang is used because these channels concern fluids; E Jiao and Hua Shi are used to moisten them, nourishing the formless to move the formed. Although both promote urination, their cold/warm natures differ greatly; only the enlightened understand this.

Floating and large pulse, hardness under the heart contrary to expectation, with heat. If belonging to Zang (Interior), purge it; do not induce sweating. If belonging to Fu (Exterior), do not allow frequent urination. Frequent urination makes stool hard; profuse sweating increases heat; scanty sweating makes stool difficult. If pulse is slow, purging is not yet appropriate.

[Note] Belonging to Zang means belonging to Interior; belonging to Fu means belonging to Exterior. Sou means urination. Floating and large pulse are Taiyang/Yangming pulses. Floating belongs to Exterior, Large belongs to Interior. Now, Taiyang exterior pulse floating is unresolved, and heart hardness indicates urgent Yangming interior. Weigh sweating vs. purging. If interior heat-excess exists, purging is undeniable; no need to sweat first to resolve exterior. If no heat-excess but floating exterior pulse, do not purge, nor promote urination even if difficult; still resolve exterior. Fear that frequent urination and sweating will deplete fluids, hardening stool and increasing heat. If scanty sweating and slow pulse, even with hard stool, interior is not yet excess; purging is not yet appropriate.

[Collected Commentaries] Wang Kentang states: The Treatise says floating/large pulse, reversed sweating/purging is adverse. Here, heart hardness with heat indicates pathogen entering interior, so pulse is ignored in favor of symptoms. Hard stool allows purging; frequent urination forbids diuresis. Why? Purging stool removes internal heat; diuresis injures fluids.

Lin Lan states: Heart hardness differs from abdominal fullness/hardness. Abdominal hardness indicates pathogen bound into excess; heart hardness alone differs from cases requiring mandatory purging. Fu and Zang are contrasted: one enters interior, one remains exterior.

Yangming disease, slow pulse, difficulty eating to fullness, slight irritability and vertigo after eating, inevitable difficult urination: this is developing Gu Ju (Grass Yellow/Damp-Jaundice). Even if purged, abdominal fullness remains unchanged. Why? Because of the slow pulse.

[Note] Yangming disease without defecation, feeling hungry after eating, post-prandial fullness with rapid pulse indicates Stomach Heat, suitable for purging. Now, slow pulse indicates Middle Cold. Middle Cold cannot transform grain. Thus, although hungry, one cannot eat to fullness; fullness causes irritability, indicating failure of transportation/transformation. Clear qi blocked from ascending causes vertigo; turbid qi blocked from descending causes difficult urination. Food stagnation with dampness/stasis indicates impending Gu Ju. This is not comparable to Yangming Damp-Heat with abdominal fullness and jaundice. Even if purged, fullness temporarily lessens but returns. Why? Because slow pulse indicates Middle Cold.

[Collected Commentaries] Fang Youzhi states: Slow pulse indicates cold failing to transform grain, hence difficulty eating to fullness. Dampness stagnates and steams, Qi rebels and fails to descend, causing slight irritability, vertigo, and difficult urination. Ju is yellow disease. Gu Ju is body yellowing from evaporation of grain-water dampness.

Zhang Lu states: Abdominal fullness remains after purging because fullness is already latent pathogen. Slow pulse indicates Stomach is not excess. Blindly purging chaff harms the body without curing the disease. Yangming syndrome usually requires purging; abdominal pain especially warrants urgent purging. But in this single syndrome, purging leaves fullness unchanged.