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General Principle: Autumn is suitable for the purgative method. For all cases indicating the use of purgatives, decoctions are more effective than pills and powders. Stop medication once the illness is cured; there is no need to finish the entire dose.

If diarrhea occurs but the pulse at the cun, guan, and chi positions on both wrists is peaceful, and palpation of the epigastrium reveals hardness, urgent purgation is indicated. If diarrhea is accompanied by a slow and slippery pulse, it indicates internal excess accumulation; the diarrhea will not stop spontaneously, so purgation is indicated. In Shaoyin disease, if oral dryness and throat dryness appear within two or three days of onset, urgent purgation is indicated.

In Shaoyin disease, if abdominal distension and constipation persist for six or seven days, urgent purgation is indicated. When Yangming and Shaoyang diseases occur together, diarrhea is inevitable. If the pulse does not show mutual overcoming (indicating a favorable progression), it is considered a smooth course. "Fu" (negative/overcoming) refers to the loss of harmony where pulses mutually overcome each other. A slippery and rapid pulse indicates retained food stagnation, warranting purgation. Question: How can retained food be distinguished? Answer: The pulse at the cun position is floating and large, but feels rough upon pressure; the chi position is also slightly rough. This indicates retained food stagnation, requiring purgation. Diarrhea accompanied by anorexia is due to retained food and requires purgation. If diarrhea resolves but recurs at the same time of year, month, day, or hour, it is because the root cause was not fully eliminated, necessitating purgation. If diarrhea presents with a slippery pulse, it suggests internal retention that needs to be expelled; recovery follows purgation. A double-stringy and slow pulse indicates epigastric hardness; a large and tight pulse indicates yang containing yin (excess pattern amidst mixed cold-heat), allowing for purgation.

Yangming disease presenting with delirium and tidal fever, yet inability to eat, indicates five or six pieces of dry stool in the stomach. If the patient can eat, only the stool is hard. Two or three days after onset, if the pulse is weak, without Taiyang or Shaoyang signs, but with irritability and epigastric stuffiness, even if the patient can eat by the fourth to fifth day, give a small amount of Chengqi Decoction to mildly harmonize the stomach qi and bring slight relief. By the sixth day, administer one sheng of Chengqi Decoction. If there is no bowel movement for six or seven days and urine output is scant, although there is constipation, the stool may be hard at the beginning and loose at the end, indicating it has not fully hardened. Purging would cause loose stools; wait until urination is normal and the stool is confirmed hard before purging.

In Yangming disease, a slow pulse despite sweating and aversion to cold absent indicates the body will feel heavy, with shortness of breath, abdominal fullness, and wheezing. Tidal fever indicates the exterior syndrome is resolving and interior attack is permissible. Continuous sweating on the hands and feet indicates hardened stool. In combined Taiyang and Yangming disease, if Taiyang signs have ceased, presenting only with tidal fever, hand and foot sweating, difficult defecation, and delirium, purgation leads to recovery. If the patient has difficulty urinating, alternating difficulty and ease in defecation, occasional mild fever, wheezing, and inability to lie down due to stomach disharmony, dry stool is present. After severe purgation, if constipation persists for six or seven days with unresolved irritability and abdominal fullness/pain, dry stool is present because of prior retained food. These cases all belong to Da Chengqi Tang Syndrome.

In Yangming disease, fever and profuse sweating indicate urgent purgation. After Shanghan, a deep and forceful pulse indicates internal excess, resolved by purgation. If Taiyang disease is unresolved and the pulse at both cun and chi positions temporarily stops, chills followed by sweating indicate resolution; however, if the chi pulse is excess, purgation resolves it. If a patient has neither exterior nor interior signs but has fever for seven or eight days, even with a floating and rapid pulse, purgation may be used. In Shanghan, if fever and sweating do not resolve the condition, accompanied by epigastric stuffiness/hardness, vomiting, and diarrhea, or if after ten-plus days of Shanghan, heat is bound internally with alternating chills and fever, these cases all belong to Da Chaihu Tang Syndrome.

In Shaoyin disease, diarrhea of clear green water, epigastric pain, and oral dryness indicate purgation is possible. Abdominal fullness and pain indicate excess, requiring purgation. Persistent abdominal fullness that does not significantly reduce requires purgation. In Shanghan, if after six or seven days the eyes appear dull and unresponsive, without obvious exterior/interior signs, with difficult defecation and mild fever, this is excess requiring urgent purgation. Sweating with delirium indicates dry stool in the stomach due to wind pathogen; purgation should only be performed after the exterior stage has passed. Premature purgation causes speech confusion due to deficient exterior and excess interior. Recovery follows purgation. Irritability and fever resolving with sweating resemble malaria; evening fever belongs to Yangming. A solid pulse allows purgation. These cases belong to Da Chaihu Tang and Da Chengqi Tang Syndromes.

Diarrhea with delirium indicates dry stool. In Yangming disease, profuse sweating depletes fluids, drying the stomach and hardening the stool, leading to delirium. These cases belong to Xiao Chengqi Tang Syndrome.

Yangming disease with a slow pulse, sweating without aversion to cold, heavy body, shortness of breath, abdominal fullness, wheezing, and tidal fever indicates the exterior is resolving and interior attack is permissible. Hand and foot sweating indicates hardened stool; treat with Da Chengqi Tang. If sweating is profuse with mild fever and aversion to cold, the exterior is unresolved; treat with Guizhi Tang. If fever is not tidal, do not give Chengqi Decoction. If abdominal fullness and obstruction are severe, give Xiao Chengqi Tang to mildly harmonize stomach qi, avoiding excessive purgation. In Yangming disease, tidal fever with slightly hard stool allows Da Chengqi Tang; if not hard, do not give it. If no bowel movement for six or seven days and concern exists for dry stool, give a small amount of Xiao Chengqi Tang as a test. If gas passes after ingestion, dry stool is present, and purgation is allowed. If no gas passes, the stool is likely hard at the start and loose at the end; do not purge, as it causes abdominal fullness and anorexia. Thirst satisfied by water may cause hiccups. Subsequent fever indicates recurrent hard, scant stool; harmonize with Xiao Chengqi Tang. Do not purge if no gas passes. Yangming disease with delirium, tidal fever, and slippery-rapid pulse is treated with Xiao Chengqi Tang. After administering one sheng of Chengqi Decoction, if gas passes, administer another sheng; if not, do not repeat. If the next day shows constipation with a faint and rough pulse, interior deficiency makes it difficult to treat; do not give Chengqi Decoction again.

Yangming disease with irritability without prior vomiting or purgation belongs to Tiaowei Chengqi Tang Syndrome.

Taiyang disease unresolved with heat binding in the Bladder causing manic behavior resolves if blood discharges spontaneously. If the exterior remains, do not attack; resolve the exterior first. Once the exterior is resolved, if only lower abdominal urgency and binding exist, attack with Taohe Chengqi Tang.

Taiyang disease lasting six or seven days with persistent exterior signs, but a faint and sinking pulse without Jie Xiong (Chest Binding), and manic behavior, indicates heat in the lower jiao. Lower abdominal hardness/fullness with free urination indicates blood stasis; purging blood resolves it. This is because Taiyang pathogen enters the channels, binding heat and stasis internally. Treat with purgation. Taiyang disease with jaundice, sinking-knotted pulse, lower abdominal hardness/fullness, and urinary difficulty indicates no blood stasis. Free urination with manic behavior indicates blood syndrome. In Yangming disease, forgetfulness indicates blood retention due to long-standing blood stasis. Stool may be hard but passage is easy and color black. These cases belong to Didang Tang Syndrome. In Shanghan with heat, lower abdominal fullness usually implies urinary difficulty; if urination is free, blood stasis is present, requiring purgation with Didang Wan.

Yangming disease with fever and sweating indicates heat dispersing outward, preventing jaundice. Head-only sweating, no body sweat stopping at the neck, urinary difficulty, and thirst for fluids indicate internal damp-heat, causing jaundice; treat with purgation using Yinchen Hao Tang. In Shanghan lasting seven or eight days, yellow skin like orange peel, urinary difficulty, and mild abdominal fullness also belong to Yinchen Hao Tang Syndrome.

Jie Xiong without significant heat indicates water binding in the chest and hypochondrium. Only slight head sweating in Shanghan after six or seven days, with Jie Xiong heat-excess syndrome, sinking-tight pulse, epigastric pain, and stone-hard palpation, belongs to Daxiexiong Tang. Jie Xiong patients may have stiff necks resembling Rou Jing (Soft Spasm); purgation harmonizes via Daxiexiong Wan.

Taiyang Wind Strike with diarrhea and vomiting, after exterior resolution, allows purgation. Profuse sweating occurring intermittently, headache, epigastric stuffiness/fullness radiating to hypochondriac pain, dry heaves, shortness of breath, sweating without aversion to cold, indicates resolved exterior and disharmonious interior, belonging to Shizao Tang.

Wu Ji stated: Taiyang disease with fever/sweating unresolved and steaming heat indicates Stomach excess; purge with Tiaowei Chengqi Tang. Tidal fever with abdominal pain uses Da Chaihu Tang plus Houpo. Yangming disease with profuse sweating causes stomach dryness and hard stool/delirium; treat with Xiao Chengqi Tang. Delirium with slippery-rapid pulse and tidal fever uses Da Chaihu Tang. Delirium with tidal fever and anorexia indicates dry stool; treat with Xiao Chengqi Tang. Anorexia with hard stool uses Da Chengqi Tang. Sweating with delirium indicates dry stool; treat with Tiaowei Chengqi Tang. Tidal fever, hand/foot sweating, difficult defecation, and delirium use Da Chengqi Tang. Constipation for five-six days with periumbilical pain, intermittent irritability indicates dry stool; treat with Tiaowei Chengqi Tang. Post-purgation constipation for six-seven days with unresolved irritability and abdominal pain indicates dry stool; treat with Da Chengqi Tang. Urinary difficulty, alternating stool consistency, mild fever, wheezing, and inability to lie down indicate dry stool; treat with Da Chengqi Tang. Abdominal fullness post-vomiting uses Tiaowei Chengqi Tang. Post-sweat/vomit/purgation with mild irritability, frequent urination, and hard stool uses Xiao Chengqi Tang. Persistent abdominal fullness uses Xiao Chengqi Tang. Diarrhea with slippery-rapid pulse indicates retained food; use Xiao Chengqi Tang. Abdominal fullness/pain indicates retained food; use Xiao Chengqi Tang. Deep-forceful pulse, internal excess, unresolved tidal fever uses Da Chaihu Tang. Generally, purgatives require a deep-solid, deep-slippery, or deep-rapid-strong pulse. Palpate the umbilical/abdominal area for hardness or tenderness; if present, purgation is certain. If purgation fails, re-palpate; if hardness persists, purge again. If abdomen becomes soft and pulse weak post-purgation, it is deficiency; harmonize with Shenhu Sanbai Tang. If fever, tidal fever, or alternating chills/fever persist, harmonize with Xiaochaihu Tang. Irritability and insomnia use Zhuye Shigao Tang or Shiwei Wendan Tang.

Huozhe Shu states: Interior Shanghan patterns depend on heat depth. Zhang Zhongjing prescribed purgatives like Da/Xiao Chengqi Tang, Shizao Tang, and Da Chaihu Tang for excess. He also prescribed mild stomach harmonizers like Tiaowei Chengqi Tang, Pi Yue Wan, and small doses of Xiao Chengqi Tang. For deficiency, nourish ten parts, purge none; for excess, purge; for equal excess/deficiency, purge moderately without excessive depletion. This reflects Jin Gui principles. Wang Shuhe warned against Chengqi misuse.

Li Dongyuan ranked formulas: Da Chengqi Tang is most critical, followed by Xiao Chengqi Tang, Tiaowei Chengqi Tang, and Da Chaihu Tang.

Zhang Yuansu stated: Da Chengqi Tang treats major excess and fullness (chest/abdominal distension like joined tiles) and major solidity (constipation). Use when Pi, Man, Zao, and Shi syndromes coexist. It is used flexibly in miscellaneous diseases. Dahuang treats major excess; Mangxiao treats major dryness (these two treat tangible blood/stasis). Houpo treats major fullness; Zhishi treats Pi (these two treat intangible qi). Xiao Chengqi Tang treats Pi and Shi with mild fullness (like a hungry person feeling full); if no gas passes, it is essentially Da Chengqi Tang minus Mangxiao. Use for epigastric Pi, open bowels, high heat needing purgation. Tiaowei Chengqi Tang treats Shi without Man (abdomen like an inverted tile); gas passes, dry stool present, constipation with delirium/solidity.

These three methods must not be confused; error leads to harm. Using Da Chengqi Tang for Tiaowei Chengqi indications exhausts Yuan Qi due to qi-moving herbs. Using Tiaowei Chengqi Tang for Da Chengqi indications leaves spirit clouded due to lack of qi-moving herbs. Using Mangxiao for Xiao Chengqi indications causes uncontrollable diarrhea and deficiency.

Li Dongyuan further clarified: Excess requires purging. Adjust severity based on symptoms. No aversion to cold, preference for heat, thirst, delirium, abdominal fullness/wheezing, hand/foot sweating: urgent Da Chengqi Tang. Mild pathogen, suspected dry stool, lower abdominal pain: trial Xiao Chengqi Tang. Gas passage confirms dry stool for purgation. No gas passage means initial hardness/loose end; do not purge. If obstruction persists, use Xiao Chengqi Tang to mildly harmonize. Post-sweat non-aversion to cold but excess Stomach heat: harmonize with Tiaowei Chengqi Tang.

Cheng Wuji stated: Major heat/excess uses Da Chengqi Tang. Minor heat/mild binding uses Xiao Chengqi Tang (removes Mangxiao from Da Chengqi due to less heat; reduces Houpo/Zhishi due to less hardness). If heat is severe but hardness is not extreme, avoid Da Chengqi Tang; use a milder agent by reducing Houpo/Zhishi and adding Gancao to Tiaowei Chengqi Tang to harmonize the Stomach. Using Tiaowei Chengqi Tang for Da Chengqi indications fails to subdue pathogens. Using Da Chengqi Tang for Xiao Chengqi indications damages healthy qi, causing abdominal fullness/anorexia. Hence the warning against excessive purging. Zhang Zhongjing separated these treatments strictly. Later physicians merged them, claiming universal efficacy for Shanghan and miscellaneous diseases, contradicting Zhang Zhongjing and Huangdi/Qibo’s principles of urgency. This confuses people and harms patients. Seek truth in Nei Jing and Zhang Zhongjing’s formulas, ensuring symptom-formula correspondence.

Zhang Yuansu added: For Shanghan exterior signs mimicking purgative indications but with fine pulses (contraindicating purgation), use Xiexin Tang. Forceful pulse: Huanglian Xiexin Tang. Weak pulse: Banxia Xiexin Tang.