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If purgation is mistakenly applied, this constitutes a major violation of treatment principles. Since improper purgation has already occurred, the so-called "floating" pulse indicates internal emptiness and blood deficiency; the so-called "large" pulse transforms into interior deficiency with cold. The interplay of deficiency and cold leads to borborygmus (intestinal rumbling). If the physician observes a large pulse and assumes the presence of heat, administering cold water to induce sweating by overcoming heat with cold will fail, as the interior is already deficient and cold. The interaction between the existing interior cold-deficiency and the ingested cold water causes cold to coagulate in the upper jiao, inevitably resulting in dysphagia (choking sensation in the throat) and rebellious qi.

In Shaoyang disease presenting with hiccups (yue) and abdominal fullness, one should examine the anterior and posterior orifices to determine which is obstructed; relieving the obstruction will lead to recovery.

[Annotation] In Shaoyang disease, hiccups without abdominal fullness indicate deficiency of healthy qi and correspond to the Wuzhuyu Tang syndrome. Hiccups accompanied by abdominal fullness indicate excess of pathogenic factors; observing which part of the bowel movements is obstructed and relieving it will result in cure.

[Collected Annotations] Cheng Wuji stated: Hiccups with abdominal fullness signify qi rebelling upward without descending. Observing obstruction in the anterior (urine) or posterior (stool) orifices and relieving it will subdue the rebellious qi.

Cheng Zhi stated: Obstruction in the anterior orifice (urine) is treated by later generations with Wuling San; obstruction in the posterior orifice (stool) is treated with Chengqi Decoctions. This is the correct approach.

Shen Mingzong stated: When pathogens transmit to the stomach, stomach qi becomes stagnant and obstructed. The conflict between these two qi mechanisms causes rebellious qi to rush upward, resulting in hiccups.

Zhang Xiju stated: When Shaoyang disease progresses to hiccups, it indicates either the failure of stomach qi or cold in the stomach. However, there are cases where interior excess prevents qi from descending, causing it to rebel upward and produce hiccups; these must be carefully differentiated.

Excess conditions manifest as delirious speech (zhanyu), while deficiency conditions manifest as monotonous repetition (zhengsheng). Zhengsheng refers to repetitive speech.

[Annotation] Delirious speech can be either excess or deficiency. Excess delirious speech results from extreme Yangming heat ascending to disturb the heart, causing incoherent speech with a loud voice, indicating pathogenic excess. Deficient zhengsheng results from spiritual depletion and lack of self-control, characterized by repetitive speech with a weak and short voice, indicating healthy qi deficiency.

[Collected Annotations] Dai Yuanli stated: Delirious speech belongs to Yang, while zhengsheng belongs to Yin. The Classic states: Excess manifests as delirious speech, deficiency as zhengsheng. Those with delirious speech speak incoherently and disorderly, often talking to empty air as if seeing ghosts. Those with zhengsheng speak earnestly and frequently; although their words may be erroneous, they continue incessantly. Elderly people who ramble about events do so due to deficient Yang qi and lack of clarity. This explains the difference between delirious speech and zhengsheng. Although these two are not difficult to distinguish, both Yang excess with interior excess and Yin excess with repelling Yang can cause confused speech; differentiation through other symptoms and appropriate treatment based on the syndrome is required.

Lou Quanshan stated: I have used formulas containing Ginseng Radix et Rhizoma [text missing], Angelicae Sinensis Radix, and Atractylodis Macrocephalae Rhizoma to treat delirious speech with many recoveries. How can one indiscriminately use Huanglian Jiedu Tang or Da/Xiao Chengqi Tangs without distinguishing between excess and deficiency? (Note: What he described was actually zhengsheng.)

Zhang Xiju stated: Excess delirious speech occurs when Yangming dry-heat is severe, confusing the spirit and disrupting qi, leading to inappropriate speech regardless of kinship or cursing. Deficient zhengsheng occurs when spiritual qi is weak and lacks autonomy, resulting in abnormal voice and repetitive speech.

In Shaoyang disease lasting four to five days, if the pulse is deep and accompanied by asthma and chest fullness, the deep pulse indicates the disease is in the interior. Mistakenly inducing sweat in this case causes body fluids to escape excessively, leading to exterior deficiency. Sweating dries the stomach, making defecation difficult, resulting in interior excess. Prolonged heat blazing in the stomach will eventually cause delirious speech.

[Annotation] Four to five days into Shaoyang disease marks the time for pathogens to enter the interior. A deep pulse with asthma and chest fullness indicates interior involvement. Mistakenly inducing sweat causes body fluids to escape, resulting in exterior deficiency. Sweating dries the stomach and causes constipation, resulting in interior excess. Prolonged intense stomach heat will inevitably trigger delirious speech.

[Collected Annotations] Fang Youzhi stated: "Escaping excessively" means fluids leaving via an incorrect pathway.

Zhang Lu stated: At four to five days of Shaoyang disease, it is precisely when pathogenic heat transmits to the interior. Given the deep pulse and interior asthma/fullness, mistaken sweating will certainly lead to dryness, accumulation, and delirium. Although dryness-accumulation delirium resembles Da Chengqi Tang syndrome, this case involves fluid damage from excessive sweating without severe fullness and abdominal pain. Therefore, Xiao Chengqi Tang is more appropriate.

In Yangming disease, if the patient sweats profusely, body fluids exit externally, causing dryness in the stomach and hardening of the stool, which leads to delirious speech. Xiao Chengqi Tang is indicated. If delirium ceases after one dose, do not administer further doses.

[Annotation] This clarifies the treatment for the previous clause. In Yangming disease, profuse sweating depletes body fluids, drying the stomach and hardening the stool, eventually causing delirium. Xiao Chengqi Tang is indicated. If bowel movement occurs and delirium stops after one dose, further administration must be strictly avoided.

[Collected Annotations] Zhang Lu stated: Profuse sweating with delirium indicates an urgent need for purgation. However, since body fluids are already depleted through sweating, drastic purgation is unsuitable. A small dose of Xiao Chengqi Tang should be given to harmonize stomach qi, stopping delirium naturally. Overuse would damage fluids further.

Shen Mingzong stated: This case of profuse sweating and stomach dryness differs from standard excess treatment.

When sweating accompanies delirious speech, it indicates the presence of dry feces in the stomach, caused by Wind pathogen. Purging is required but must wait until the pathogen has passed through the meridians into the fu organs. Premature purging will cause language confusion because the exterior is deficient and the interior is excess. Recovery after purging requires Da Chengqi Tang.

[Annotation] Spontaneous sweating with delirium indicates pre-existing dry feces in the stomach, transmitted from Taiyang Wind pathogen. Purging is necessary but must wait until the Taiyang pathogen has passed the Yangming meridian and entered the Yangming fu organs. Premature purging fails to clear residual heat and damages the interior, allowing heat to harass the heart and confuse speech. Because the exterior is deficient (sweating) and the interior is excess (delirium), one must wait for the pathogen to pass the meridian and enter the fu organ before purging with Da Chengqi Tang.

[Collected Annotations] Fang Youzhi stated: "Passing the meridian" implies caution and delay, not necessarily waiting ten to thirteen days.

Cheng Zhi stated: This clause warns against premature purging for delirium. Since sweating has occurred and delirium is present, dry feces must exist in the stomach, attributed to Wind. Wind is a Yang pathogen; entering the interior, it causes delirium. However, purging should wait until the sixth or seventh day. Premature purging allows unresolved Wind pathogen to fully enter the interior, worsening dryness, excess, and speech confusion.

In Yangming disease, delirium with tidal fever and inability to eat indicates the presence of five or six pieces of dry feces in the stomach. If the patient can eat, the stool is merely hard. Da Chengqi Tang is indicated for purging.

[Note] The phrase "Da Chengqi Tang is indicated for purging" should follow "presence of five or six pieces of dry feces" to align with the indication for using Da Chengqi Tang. Using Da Chengqi Tang solely for hard stool contradicts Zhongjing's caution against improper purging.

[Annotation] Yangming disease with delirium, tidal fever, and anorexia indicates solidified dry feces in the stomach; Da Chengqi Tang is indicated for purging. If the patient can eat, stomach qi is recovering, and the stool is merely hard; guiding methods (suppositories/enemas) should be used instead of purging.

[Collected Annotations] Zhang Lu stated: This distinguishes the severity of dryness based on appetite. Tidal fever and delirium result from severe stomach heat. Normally, stomach heat aids digestion, but inability to eat indicates heat damaging stomach fluids and blocking downward qi flow, causing dry feces to rebel against the stomach. Da Chengqi Tang is needed urgently to dispel extreme Yang and save declining Yin. If the patient can eat, stomach qi functions normally, heat is mild, fluids are preserved, and hard stool will pass naturally without medication, avoiding damage to qi.

Diarrhea accompanied by delirious speech indicates the presence of dry feces; Xiao Chengqi Tang is indicated.

[Annotation] Diarrhea suggests interior deficiency, while delirium suggests interior excess. If the pulse is slippery and large, accompanied by tenesmus,宿食 (retained food) is present. The diarrhea material is thick, sticky, and foul-smelling, indicating a combination of heat and retained food. This confirms the presence of dry feces, warranting Xiao Chengqi Tang for purging. From this, we infer that dry feces are determined not by stool hardness alone, but by the presence of tenesmus and foul odor.

[Collected Annotations] Wang Hu stated: Diarrhea is an intestinal/colonic issue. Delirium indicates stomach excess, unrelated to Jueyin, but signifies dry feces trapped in the intestines. Xiao Chengqi Tang is used because this is a mixed condition of partial diarrhea and partial constipation, requiring gentle purging. Furthermore, if diarrhea occurs, heat should dissipate downward; why does delirium and dry feces occur? This is a severe Yangming fu-excess heat syndrome. Waste products in the stomach are blocked by pathogens. Unformed waste may pass occasionally, but formed hard feces remain trapped. These dry feces are the root of the diarrhea. Trapped dry feces allow pathogenic heat to ascend to the heart, causing delirium. Clinically, pressing the umbilical region should reveal hardness and pain, confirming dry feces.

Fixed gaze (direct staring) with delirious speech, accompanied by asthma and chest fullness, indicates a fatal prognosis. Fixed gaze with delirious speech and diarrhea also indicates death.

[Annotation] The previous clause described curable diarrhea with delirium; this clause describes fatal diarrhea with delirium. Delirium itself is not fatal due to diarrhea, but due to fixed gaze. Fixed gaze indicates essence failing to nourish the eyes; delirium indicates spirit failing to guard the heart. Both are ominous signs. Asthma and chest fullness indicate Yang escaping upward, hence death. Diarrhea indicates Yin escaping downward, hence also death.

[Collected Annotations] Fang Youzhi stated: Fixed gaze means essence fails to nourish the eyes; delirium means spirit fails to govern the heart. Asthma represents Yang struggling upward; diarrhea represents Yin struggling downward. With Earth (Stomach) in the center, Yin and Yang struggle above and below, causing central qi to collapse, rendering treatment impossible, hence both indicate death.

Excessive sweating, or repeated sweating, leads to loss of Yang. Delirium with a short pulse indicates death; delirium with a harmonious pulse indicates survival.

[Annotation] In Taiyang disease, excessive sweating without resolution, followed by repeated sweating, causes simultaneous loss of qi and fluids. Heat pathogens, taking advantage of dryness, transmit to Yangming, causing delirium. Delirium reflects Stomach heat (Yang); a short pulse reflects qi decline (Yin). An Yang disease presenting with a Yin pulse indicates Yin overcoming Yang, leading to death. If the pulse is not short, indicating Yin-Yang harmony, survival is expected.

[Collected Annotations] Yu Chang stated: Previous annotations considered this a lost text from the Taiyang chapter, noting Taiyang disease rarely presents with delirium unless prolonged and involving Yangming or Shaoyang. Thus, this refers to Taiyang disease where excessive initial sweating, compounded by repeated sweating during transmission to Yangming, causes Yang loss and delirium. Patients with Yang loss retain only Yin, leading to unsettled spirit and hallucinations, distinct from heat harassing the heart. A short pulse indicates Yin-Yang detachment; a harmonious pulse indicates Yin-Yang connection. Prognosis depends on the pulse.

Wang Hu stated: Delirium typically presents with a large, solid, or surging-slippery pulse, termed "harmonious." Harmonious means the pulse matches the disease severity; even if severe, the patient survives. A short pulse with delirium indicates excessive pathogenic heat and deficient healthy qi (Yang disease with Yin pulse), making treatment futile.

Excessive sweating causing Yang loss and delirium should not be treated with purgation. Instead, Chaihu Guizhi Tang should be administered to harmonize Ying and Wei, promoting fluid circulation, after which the patient will recover spontaneously.

[Annotation] This continues the previous clause by providing treatment. Delirium usually indicates Yangming heat-excess, suitable for purging. However, delirium caused by excessive sweating and severe fluid/qi loss is due to fluid exhaustion causing dryness, not severe internal heat-excess. Therefore, purging is contraindicated. If interior heat exists, Baihu Jia Renshen Tang is indicated. If exterior symptoms persist, Chaihu Guizhi Tang harmonizes Ying and Wei to restore fluids, leading to spontaneous recovery.

[Note] Delirium from excessive sweating and Yang loss cannot be purged due to absence of hard, full, painful abdomen. It cannot be warmed due to absence of cold limbs, sweating, and aversion to cold. Thus, Taiyang excessive sweating causing delirium lacks fever, sweating, and aversion to cold. Yangming excessive sweating causing delirium includes tidal fever, aversion to heat, and constipation. This Shaoyang excessive sweating causing delirium aligns with the principle that Shaoyang disease forbids sweating; sweating causes delirium. Since Xiaochaihu Tang is the primary remedy, but Chaihu alone may be too dispersing for Yang loss, combining it with Guizhi harmonizes Ying and Wei, restoring fluids and ensuring recovery.

Yangming Wind-strike presents with a string-taut, floating, and large pulse, shortness of breath, generalized abdominal fullness, hypochondriac and cardiac pain unrelieved by pressure, nasal dryness, inability to sweat, lethargy, jaundice of the whole body and face, difficulty urinating, tidal fever, frequent hiccups, and swelling around the ears. Acupuncture provides slight relief. If exterior symptoms persist beyond ten days and the pulse remains floating, Chaihu Tang is indicated. If the pulse is only floating without other symptoms, Mahuang Tang is indicated. If the patient cannot urinate, abdominal fullness worsens, and hiccups increase, the condition is incurable.

[Note] The character "floating" in "pulse remains floating" should likely be "string-taut" to match the context for Chaihu Tang. If both were "floating," the logic for using Mahuang Tang for the second instance would be flawed.

[Annotation] Wind-strike transmitting to Yangming with unresolved Taiyang typically presents with a floating-slow pulse. Here, the pulse is string-taut, floating, and large. String-taut indicates Shaoyang; floating indicates Taiyang; large indicates Yangming. Symptoms correspond: abdominal fullness (Taiyang/Yangming); hypochondriac/cardiac pain unrelieved by pressure (Shaoyang); nasal dryness (Yangming); no sweat (Taiyang); lethargy (Shaoyin); jaundice (Taiyin); difficult urination (Taiyang Fu); tidal fever (Yangming Interior); hiccups (Stomach failure); ear swelling (Shaoyang); shortness of breath (Qi deficiency). Zhang Zhongjing’s clauses without specific formulas address such complex Yin-Yang and interior-exterior mixtures, advising physicians to observe the disease trajectory and intervene opportunistically. Acupuncture is used first for slight relief. If exterior symptoms persist and the condition becomes critical, and after ten days the pulse remains string-taut (not floating), the pathogen is shifting to Shaoyang; Chaihu Tang harmonizes the interior, allowing Yangming pathogens to resolve via Shaoyang. If the pulse is only floating without other symptoms, the pathogen shifts to Taiyang; Mahuang Tang induces sweating, resolving Yangming pathogens via Taiyang. If after ten-plus days the condition worsens without forming Fu-excess, and presents with anuria, worsening abdominal fullness, and severe hiccups, the Stomach qi has failed, and the condition is incurable despite any purgative indications.

[Collected Annotations] Cheng Zhi stated: This clause shows unresolved exterior symptoms without sweating, dryness, or thirst, ruling out Baihu Tang. Despite tidal fever, there is no hard-fullness, delirium, or sweating, ruling out Chengqi Tangs. Waiting for qi to recover allows gradual expulsion of pathogens outward.

Cheng Yingmao stated: The key symptom here is "inability to sweat." Treatment oscillates between Chaihu and Mahuang Tangs to open long-standing closure, aiming ultimately to induce sweating.

A floating and hollow (kou) pulse: Floating indicates Yang, hollow indicates Yin. The interaction of floating and hollow pulses generates heat in the Stomach qi, leading to the extinction of Yang.

[Annotation] A floating and hollow pulse indicates Yang excess and Yin deficiency. Yang excess causes fever; Yin deficiency causes sweating. Their interaction intensifies Stomach heat, rapidly depleting Stomach fluids. "Extinction of Yang" refers to the loss of Yang and depletion of fluids.

[Collected Annotations] Fang Youzhi stated: Floating indicates ascending Qi (Yang); hollow indicates internal blood damage (Yin). Heat in the Stomach arises because Yin cannot harmonize Yang, leading to dryness and desiccation.

Zhang Lu stated: This describes Spleen-constraint where purgation is delayed; the pulse changes from floating-choppy to floating-hollow. Fluid exhaustion makes purgation difficult. "Extinction of Yang" is synonymous with interior Yang extinction and fluid loss.

Zhao Liang stated: Extreme Yang-heat in the Stomach without Yin to harmonize it leaves solitary Yang unpaired, burning until exhaustion.

Shen Mingzong stated: This differentiates the pulse of Yangming fluid exhaustion. Floating indicates strong pathogenic qi; hollow indicates deficient Yin-blood. Yang-pathogen excess combined with Yin-blood deficiency creates the floating-hollow interaction, generating Stomach heat, hence "extinction of Yang," synonymous with fluid loss. Upon seeing this pulse, fluids must be nourished; aggressive purging is contraindicated.

In Yangming disease, paradoxically no sweating occurs, yet urination is free. After two to three days, vomiting and coughing appear, along with cold extremities. The patient suffers from headache. If there is no coughing, vomiting, or cold extremities, there is no headache.

[Annotation] Yangming disease typically involves sweating. Paradoxical absence of sweating with free urination indicates internal Cold attack. By day two or three, vomiting and coughing indicate Cold pathogen rebelling upward. Cold extremities indicate Cold manifesting in the limbs. Upward rebellious qi causes coughing and severe headache. Absence of coughing, vomiting, or cold extremities means no headache. Headache is the branch symptom; coughing/rebellion and cold extremities are the root.

[Collected Annotations] Cheng Zhi stated: Why not diagnose Taiyang given no sweat, free urination, vomiting, coughing, cold limbs, and headache? Because initial onset lacked typical Taiyang headache/exterior symptoms. This headache results from vomiting/coughing/cold limbs occurring two to three days later, not vice versa. Vomiting and coughing occur in both Taiyang and Shaoyang. Unresolved exterior symptoms indicate Taiyang; alternating chills and fever indicate Shaoyang. Cold limbs occur in Jueyin but without vomiting/coughing.

Zhang Lu stated: Yangming no sweat with vomiting, coughing, and cold limbs results from severe Ying-Wei damage and deep pathogen penetration. Free urination indicates the pathogen is external rather than internal, superior rather than inferior, thus predicting severe headache. Xiaolongtan Tang is still appropriate. Without vomiting, coughing, or cold limbs, free urination allows pathogens to exit via the urinary tract, preventing upward rebellion to the head.

Lin Lan stated: Note that Yangming can also present with cold extremities, as the Stomach governs the limbs, and middle deficiency/Cold causes this. However, headache with coughing differs from pure Yin-Cold cold limbs. These clauses are particularly difficult to interpret.

Wu Renju stated: Vomiting, coughing, cold limbs, and headache all stem from the paradoxical absence of sweating.

In Yangming disease, if there is only vertigo, no aversion to cold, ability to eat, and coughing, the throat will surely hurt. If there is no coughing, the throat will not hurt.

[Annotation] Yangming disease typically involves aversion to heat, not cold. Transmission from Shaoyang Cold-disease implies inability to eat; transmission from Wind-strike implies ability to eat. Shaoyang Cold-disease with Cold pathogen causes headache; Wind-strike with Wind pathogen causes vertigo. Cold is Yin; combined with fluid retention, it causes coughing and vomiting. Here, absence of vomiting but presence of sore throat indicates Wind (Yang pathogen) combined with Fire, causing coughing and sore throat due to similarity attraction.

[Collected Annotations] Fang Youzhi stated: Vertigo is spinning dizziness caused by Wind, explaining lack of aversion to cold and ability to eat. Coughing is rebellious qi. The pharynx is connected to the Stomach. Stomach heat and rebellious qi attacking the pharynx cause coughing and throat injury.

Cheng Zhi stated: Yin pathogens descend, causing no sweat and free urination; Yang pathogens ascend, causing no aversion to cold and vertigo. Cold causes vomiting/anorexia; Wind allows eating. Cold causes headache; Wind causes sore throat. This distinguishes Cold vs. Wind entering the Stomach.

Cheng Yingmao stated: Yangming favors downward movement; rebellion moves upward. Cold invasion causes headache; Wind invasion causes vertigo. Lack of aversion to cold and ability to eat indicate constrained heat in the interior. Cold rebelling upward causes coughing with vomiting (anorexia/cold limbs); Heat rebelling upward causes coughing without vomiting (anorexia absent/sore throat), as Stomach qi connects to the Lungs and the pharynx is the gate of the Stomach. While sore throat is typical of Shaoyin, here it results from cough-induced injury. No cough means no sore throat. Combined with vertigo and lack of aversion to cold, this confirms Yangming constrained heat.

For a patient with Cold symptoms, subsequent sweating causes Cold in the Stomach, inevitably leading to vomiting of roundworms.