（阳明主里。外候肌肉。内候胃中。）
何谓阳明经症。曰。身热目痛。鼻干不得眠。反恶热是也。有未罢太阳已罢太阳之辨。
若兼见头痛恶寒。是太阳症未罢。自汗脉缓。宜桂枝汤。项背强KT KT 。桂枝加葛根汤主之。无汗脉浮。宜
麻黄汤。项背强KT KT 。葛根汤主之。
若无头痛恶寒。但见壮热口渴。是已罢太阳。为阳明经之本症。宜白虎汤主之。
何谓阳明腑症。曰。潮热谵语。手足腋下 然汗出。腹满大便硬。是也。有太阳阳明少阳阳明正阳阳明之辨。
本太阳病。治之失法。亡其津液。致太阳之热。乘胃燥而转属阳明。其症小便数。大便硬。伤寒论谓之脾
约。宜麻仁丸。以上言太阳阳明之症也。
本少阳病。治之失法。亡其津液。致少阳之邪。乘胃燥而转属阳明。为大便结燥。伤寒论谓为大便难。以
蜜煎胆汁导之。以上言少阳阳明之症也。
病患阳气素盛。或有宿食外邪传入。遂归于胃腑。伤寒论谓为胃家实。宜以三承气汤下之。以上言
正阳阳明之症也。
阳明在经。未离太阳。宜汗之。既离太阳。宜清之。在腑。审其轻重。宜下之。若在经络之界。汗之不可。清之
不可。下之不可。宜用吐法。柯韵伯云。除胃实症。其余如虚热咽干。口干口苦。舌苔。腹满烦燥。不得卧。消
渴而小便不利。凡在胃之外者。悉是阳明表症。仲景制汗剂。是开太阳表邪之出路。制吐剂。是引阳明
表邪之出路。使心腹之浊邪。上出于口。一吐则心腹得舒。表里之烦热悉除矣。烦热既除。则胃外清。自
不致胃中之实。所以为阳明解表之圣剂。
内经云。阳明之上。燥气治之。所谓本也。本之下。中之见也。见之下。气之标也。又曰。阳明不从标本。从乎中
见。从中见者。以中气从化也。又曰。阳明为阖。又热病论曰。二日阳明受之。阳明主肉。其脉挟鼻。络于目。故
身热目痛。而鼻干不得卧也。伤寒多发热。而此独身热者。盖阳明主肌肉。身热尤甚也。邪热在胃则烦。故
不得舒卧也。
伤寒论云。问曰。病有太阳阳明。有正阳阳明。有少阳阳明。何谓也。答曰。太阳阳明者。脾约是也。本太阳病
不解。太阳之标热。合阳明之燥热。以致脾之津液。为其所灼而穷约。正阳阳明者。胃家实是也。燥为阳明
之本气。燥气太过。无中见湿土之化而实。少阳阳明者。发汗利小便。胃中燥。烦而实。大便难是也。少阳之上。相火
治之。少阳病误发汗。误利小便。则津液竭。而相火炽盛。胃中燥实。而大便难矣。
阳明之为病。胃家实也。言阳明病虽有三者之分。而其为胃家实则一也。此节为阳明病之提纲。沈尧封
云。胃家实言以手按胃中实硬也。柯韵伯云。不大便利便。是胃家实。尤在泾云。凡伤寒腹满。便闭。潮热。转
失气。手足 汗出等证。皆是胃家实。三说不同。均存之以互参。
问曰。阳明外证云何。答曰。身热。肌肉蒸蒸然热达于外。与太阳表热不同。汗自出。热气内盛。
然汗溢于外。与太阳之自汗不同。不恶寒。外寒已解。反恶热。里热已盛也。沈尧封云。此节合上一节。为阳
明证一内一外之提纲。只因有胃家实之病根。即现热盛汗出之病证。不恶寒反恶热之病情。必内外俱备。方是
阳明之的证。
阳明本燥而标阳。若不得中见太阴之湿化。其燥气阳热太盛。则为胃家实之病。故仲景以胃家实为
此证提纲。虽有太阳阳明正阳阳明少阳阳明之分。而其为胃家实则一也。且更合之外证。自热汗自
出。不恶寒反恶热。便知胃家实证。有诸中而见诸外。愈可定其为真阳明也。其证虽有在表宜从汗解
者。须知汗出多。脉微。宜桂枝汤。无汗而喘。脉浮。宜麻黄汤。二者俱太阳证而属之阳明者。以其不头痛
项强故也。若恶寒已罢。二方必不可用。且阳明提纲。重在里证。所以论中以此条别作一章也。
至于阳明本证。有自受证。有转属证。有邪盛证。有正虚证。有能食不能食证。有寒冷燥热证。有从枢从
开证。有名同而实异。源一而流分证。治之者不得其绪。如治丝而棼之也。
何谓自受。病起于阳明本经自为之病。其外证身热汗自出。不恶寒反恶热。为阳明病自内达外之表
证。其有得之一日。不待解散。而二日恶寒自罢。即自汗出而发热。为风寒入于阳明本经之表证。此阳
明自受之大略也。
何调转属。凡太阳病。过汗亡其津液。致胃中干燥而转属者固多。亦有本太阳病。初得时发汗不彻。太
阳标热之气。不能随汗而泄。即与阳明燥气。混为一家而转属者。亦有发热无汗。呕不能食。其时即伏
胃不和之病机。不因发汗。而自 然汗出为转属者。更有误下而转属者。此阳明病转属之大略也。
何以谓正虚。本篇第十六节云。阳明病。不能食。胃中虚冷。攻其热必哕。言胃腑之虚也。第十七节云。脉
迟。食难用饱。饱则微烦。头眩。必小便难。此欲作谷瘅。虽下之。腹满如故。此言经脉之虚也。第十八节云。
无汗。身如虫行皮中状者。虚故也。此言皮腠之虚也。论虽无方。大抵不外温补之法。第二十六节云。伤
寒呕多。虽有阳明证。不可攻之。以呕则胃气虚。虽有阳明实热之证。不可误攻而致死。此言胃气虚不
可下也。第二十七节云。心下硬满者。不可攻之。攻之利遂不止者死。论止言心下。而不及腹。止言硬满。
而不兼痛。且心下为阳明之膈。膈实者腹必虚。腹中之虚气闭于阳明之部。若误攻之。则谷气尽而下
利死矣。此言真虚假实者不可下也。第十八节云。面合赤色。不可攻之。攻之必发热色黄。小便不利。以
阳明之脉。上循于面。不知熏解之法而误攻之。则变为发热色黄。小便不利等症。此言外实内虚不可
下也。须知阳明证。虽以胃家实为提纲。惟不得中见太阴之湿化。阳明愈实。而中见愈虚。前此注家。不
知从此发挥。以致患阳明证者。以白虎承气枉死几千万人也。
何谓邪实。论中阳明腑证。皆热邪为病。然热邪散漫于内外。大渴大汗。宜用白虎逐热而生液。热邪结
聚于肠胃。潮热谵语。宜用承气逐热而荡实。二方均为阳明腑病而设。误用之。便致杀人。第四十一节。
三阳合病。末一句云。若自汗出者。主用白虎汤。可以得其大要。而三承气汤各有所主。阳明证不吐不
下。虽胃气不虚。而胃络上通于心。可因其心烦一证。而知其胃气不和。可与调胃承气汤。二十九节已
有明文也。至于大承气证。于其脉迟。则知其阳邪尽入于里阴。又于其汗出不恶寒。身重。短气。腹满而
喘。五者之中。更取出里证最确者。曰。不恶寒而潮热。言热邪尽入于胃。必变身热为潮热也。且于里证
中。而知其大便硬之最确者。曰。手足 然而汗出。言胃主四肢。若大便已硬者。必通身热蒸之汗。自敛
而变为手足 然之汗。方为大承气之的证。否则不过燥屎不行。只为小承气证耳。然而小承气亦不
可以轻用也。不大便六七日。欲知其有燥屎与否。少与小承气汤试之。汤入腹中而转失气者。可再用
之。若不转失气者。此为胃气之虚。初硬后溏。必致不能食而胀满。不能饮而作哕矣。论中二十九节。三
十节。三十一节。当潜心体玩。至于谵语。诸家皆谓邪实。然论中三十二节。有实则谵语虚则郑声之分。
本节直视为精气已夺。喘满为脾肺不交。下利为脾肾不固。此皆谵语虚脱之死候。其余自三十三节
至四十三节。实邪固多。而亦不可概认为实邪之为病也。张隐庵云。凡谵语乃心主神气内虚。言主于
心。非关于胃。胃燥谵语而用承气。乃胃络不能上通于心。胃气清而脉络能通之义。仲景示以法。不可
泥于法也。
何谓能食不能食。若中风则能食。以风能鼓动阳明之气也。若中寒则不能食。以寒能拒闭阳明之气
也。中寒之旨。详于第十九节。中风之旨。详于第二十节。意以寒为阴邪而下行。故无汗而小便利。风为
阳邪而上行。故不恶寒而头眩。寒则呕不能食。风则能食。寒则头痛。风则咽痛。此阳明有风寒之别也。
何谓寒冷燥热之分。本篇第四十四节云。脉浮而迟。虚寒之脉也。其云表热者。阳明戊土。不能下合少
阴癸水。而独主乎外也。其云里寒者。少阴癸水。不能上合阳明戊土。而独主乎内也。其云下利清谷者。
戊癸不合。而下焦生阳不升也。以四逆汤为主治。第四十五节云。胃中虚冷者。言中焦土气虚冷也。其
云不能食者。中焦虚冷。夫其消谷之用也。其云饮水则哕者。两寒相得而为哕也。论中未出方。而理中
汤堪为主治。推之第六十节云。食谷欲呕者。属阳明也。吴茱萸汤主之。与此节亦互相发明也。第四十
六节云。脉浮发热者。阳明燥热在于经脉也。其云口干鼻燥者。热循经脉而乘于上焦也。其云能食则
衄者。热在经脉。不伤中焦之胃气。此证正于能食。而得热在经脉之确证。经脉热甚。得衄则热有出路而解
矣。推之第六十节。食谷欲呕。后半节云。得汤反剧者。属上焦也。上焦主火热而言。与此节亦互相发明也。
何谓从枢从开。内经云。太阳为开。阳明为阖。少阳为枢。三经者。不得相失也。使阳明而终于阖则死矣。
然则何法以致其开。一则从少阳之枢以转之。四十七节云。下之后。外热。手足温。不结胸。心中懊 。饥
不能食。但头汗出者。是阳明阖。其气不交于上下也。以栀子豉汤主之。四十八节云。发潮热。大便溏。小
便自可。胸胁满不去者。是阳明阖。其气不涉于大小二便。止逆于胸胁之间。以小柴胡汤主之。且小柴
胡汤时医止知为少阳之方。而不知为阳明之要方也。四十九节云。阳明病。胁下硬满。言不得少阳之
枢。则下焦不通而为不大便。中焦不治。胃气不和而为呕。上焦不和。火郁于上。其舌上现有白苔。可与
小柴胡汤。上焦得通。津液得下。胃气因和。身 然汗出而解。所以从枢以转之者此也。一则从太阳之
开以出之。五十节。阳明中风。脉弦浮大而短气。共九十三字。解详浅注。病过十日。又当三阴受邪。若脉
续浮者。知其不涉于阴。仍欲从少阳之枢而出。若脉但浮而别无余症者。是病机欲从太阳之开。可与
麻黄汤以助之。若不尿。腹满加哕者。是不从少阳之枢。太阳之开。逆于三阴。为不治之证。所谓从开以
出者此也。
何谓名同而实异。内经云。人之伤于寒也。则为热病。二日阳明受之。其脉挟鼻。络于目。所云身热目痛。
鼻干不得眠。是止就阳明经病之一端而言。仲景以胃家实提纲。是该内外证治之全法而立论也。后
人妄用升麻葛根汤。反发阳明之汗。上而鼻衄。下而便难。是引贼破家矣。此所谓名同而实则异也。
何谓源一而流分。阳明原主气。而蓄血证则主血。阳明原主燥。而发黄证则合温。五十五节云。阳明证。
其人喜忘。必有蓄血。屎虽硬。大便反易。其色必黑。抵当汤主之。七十五节云。病患无表里证。发热七八
日。虽脉浮数者。可下之。言病在阳明之络。络则无涉于表里也。发热而不恶寒。下之所以泄其热也。假
令已下。脉浮已解。而数不解。知其热不在气而在血。不在阳明之经而在阳明之络。论名合热。其合有
二．一合于中。则为消谷善饥。至六七日不大便。其血必瘀于中。宜抵当汤以攻之。一合于下。则为下利
不止。必协热而便脓血。虽未出方。大抵温剂不外桃花汤。寒剂不外白头翁汤之类。同一阳明证。而又
有发黄者。第二十一节云。阳明病。无汗小便不利。心中懊 者。身必发黄。二十二节云。阳明病被火。额
上微汗出。小便不利者。必发黄。此言湿热郁于中土也。七十六节云。伤寒发汗已。身目为黄。为寒湿在
里。意者湿热之黄可下。而寒湿之黄不可下。虽未出方。大抵五苓散加茵陈蒿为近是。七十七节云。伤
寒七八日。身黄如橘子色。小便不利。腹微满者。茵陈蒿汤主之。此言湿热郁于里而为黄。以大黄合茵
陈蒿导之从小便出也。七十八节云。伤寒身黄发热者。栀子柏皮汤主之。言湿热已发于外。全无里证。
取柏皮以走皮。以三味色黄以治黄也。七十九节云。伤寒瘀热在里。身必发黄。麻黄连翘赤小豆汤主
之。此言伤寒表证未解。而湿热瘀于里而形于外。藉麻黄以取微汗也。此所谓源一而流则分也。
至于治法。阖者恐其终阖。实者虑其大实。故以三承气汤之重剂为主。麻仁尤为润下之轻剂也。蜜煎
导为外取之尤轻者也。其调胃承气汤。方中芒硝。上承火气。大黄下通地道。不用朴实之破泄。而用甘
草之和中。所以名为调胃也。其小承气汤。专取通其燥屎。故不用芒硝之上承火气。配不炙之枳朴。而
疏达壅滞。多与为攻。少与为和。故名之曰小也。若夫大承气汤。乃大无不该。主承通体之火热而下行。
凡血气瘀滞。聚邪宿食。无不一扫而净。为下剂之最重者。用之得法。可以起死回生。倘若一误。则邪去
而正亦亡矣。所以二十一节言欲与大承气汤。先少与小承气汤。若转失气为有燥屎。方以大承气汤
( The Yangming channel governs the interior. Its external manifestation is on the muscles, and its internal reflection is in the stomach.)
What is called Yangming channel syndrome? Answer: Body heat, eye pain, nasal dryness, inability to sleep, and aversion to heat are what is meant. There is a distinction between Taiyang syndrome that has not yet resolved and Taiyang syndrome that has resolved.
If accompanied by headache and aversion to cold, it indicates that Taiyang syndrome has not yet resolved. If there is spontaneous sweating and a slow pulse, Guizhi Tang (Cinnamon Twig Decoction) is appropriate. If the neck and back feel stiff and uncomfortable, Guizhi Jia Gegen Tang (Cinnamon Twig Decoction with Pueraria Root) should be used. If there is no sweating and a floating pulse, Mahuang Tang (Ephedra Decoction) is appropriate. If the neck and back feel stiff and uncomfortable, Gegen Tang (Pueraria Root Decoction) should be used.
If there is no headache or aversion to cold, but only high fever and thirst are seen, it indicates that Taiyang syndrome has resolved. This is the primary syndrome of the Yangming channel, and Baihu Tang (White Tiger Decoction) is appropriate.
What is called Yangming fu-organ syndrome? Answer: Tidal fever, delirium, continuous sweating on the hands, feet, and axillae, abdominal fullness, and hard stool are what is meant. There is a distinction between Taiyang-Yangming, Shaoyang-Yangming, and Zhengyang-Yangming.
Originally a Taiyang disease, if treated improperly, leading to loss of body fluids, the heat of Taiyang may take advantage of the dryness in the stomach to transfer to Yangming. The symptoms are frequent urination and hard stool. Shanghan Lun refers to this as "Pi Yue" (Spleen Constraint), and Maren Wan (Hemp Seed Pill) is appropriate. This above describes the syndrome of Taiyang-Yangming.
Originally a Shaoyang disease, if treated improperly, leading to loss of body fluids, the pathogen of Shaoyang may take advantage of the dryness in the stomach to transfer to Yangming, resulting in hard and difficult defecation. Shanghan Lun refers to this as "Da Bian Nan" (Difficulty in Defecation), and honey suppositories or bile can be used as a guiding agent for evacuation. This above describes the syndrome of Shaoyang-Yangming.
The patient's yang qi is inherently strong, or there is retained food or external pathogens entering, eventually settling in the stomach organ. Shanghan Lun refers to this as "Wei Jia Shi" (Stomach Organ Excess), and the three Chengqi Decoctions (San Chengqi Tang) are appropriate for purging. This above describes the syndrome of Zhengyang-Yangming.
When Yangming disease is in the channel and has not yet left the Taiyang category, diaphoresis (sweating method) is appropriate. Since it has left Taiyang, clearing heat is appropriate. In the fu-organ, one must assess the severity, and purging is appropriate. If it is at the boundary of the channels, neither diaphoresis, clearing heat, nor purging is appropriate; vomiting therapy is appropriate. Ke Yunbo said: Except for stomach excess syndromes, other conditions such as deficiency heat with dry throat, dry and bitter mouth, abnormal tongue coating, abdominal fullness and irritability, inability to lie down, thirst with dysuria, etc., all located outside the stomach, are Yangming exterior syndromes. Zhang Zhongjing formulated diaphoretic agents to provide an exit for Taiyang exterior pathogens; he formulated emetic agents to provide an exit for Yangming exterior pathogens, allowing turbid pathogens in the heart and abdomen to exit through the mouth. After one vomit, the heart and abdomen relax, and all exterior-interior irritability and heat are eliminated. Once irritability and heat are eliminated, the exterior of the stomach becomes clear, naturally preventing stomach excess. Therefore, the emetic method is the supreme remedy for resolving Yangming exterior syndromes.
Neijing states: Above Yangming, dryness qi governs; this is the root. Below the root is the intermediate manifesting qi. Below the intermediate manifesting qi is the marked qi. It also says: Yangming does not follow the root or mark but follows the intermediate manifesting qi. Following the intermediate manifesting qi means transforming according to the middle qi. It also says: Yangming is the closing mechanism. Relian Lun states: On the second day, Yangming receives the pathogen. Yangming governs the flesh, its vessels run along the nose, and connect to the eyes. Hence, body heat, eye pain, nasal dryness, and inability to sleep occur. Shuhan often involves fever, but here body heat is emphasized because Yangming governs the muscles, making body heat particularly severe. Pathogenic heat in the stomach causes irritability, hence the inability to lie comfortably.
Shanghan Lun states: Question: Diseases include Taiyang-Yangming, Zhengyang-Yangming, and Shaoyang-Yangming. What does this mean? Answer: Taiyang-Yangming is Pi Yue (Spleen Constraint). Originally, Taiyang disease did not resolve; the marked heat of Taiyang combined with the dryness heat of Yangming, burning up the spleen's fluids until they were exhausted and constrained. Zhengyang-Yangming is Wei Jia Shi (Stomach Organ Excess). Dryness is the root qi of Yangming. When dryness qi is excessive, without the transformation of the intermediate damp earth, it becomes excess. Shaoyang-Yangming is caused by improper sweating and diuresis, leading to dryness in the stomach, irritability, excess, and difficult defecation. Above Shaoyang, ministerial fire governs. Improper sweating and diuresis in Shaoyang disease deplete fluids, causing ministerial fire to blaze, leading to dryness and excess in the stomach and difficult defecation.
The general outline of Yangming disease is: Wei Jia Shi (Stomach Organ Excess). Although Yangming disease is divided into the three types mentioned above, its essence is always Stomach Organ Excess. This section serves as the outline for Yangming disease. Shen Yaofeng said: "Wei Jia Shi" refers to the feeling of hardness and excess when pressing the stomach with the hand. Ke Yunbo said: Infrequent bowel movements constitute Wei Jia Shi. You Zaijing said: Any shuhan presenting with abdominal fullness, constipation, tidal fever, passing gas, and sweating on the hands and feet constitutes Wei Jia Shi. These three views differ; all are preserved for mutual reference.
Question: What are the exterior signs of Yangming? Answer: Body heat, with muscles steaming hot reaching the exterior, which differs from the exterior heat of Taiyang. Spontaneous sweating, where internal heat is abundant and sweat overflows externally, which differs from the spontaneous sweating of Taiyang. No aversion to cold, because the exterior cold has resolved; instead, aversion to heat, because interior heat is abundant. Shen Yaofeng said: This section, combined with the previous one, forms the interior-exterior outline of Yangming syndrome. Because there is the pathological root of Wei Jia Shi, symptoms of abundant heat and sweating appear, along with the condition of no aversion to cold but aversion to heat. Only when both interior and exterior signs are present is it a definitive Yangming syndrome.
Yangming is fundamentally dry and marked by yang. If it does not receive the moistening transformation of the intermediate Taiyin, its dryness and yang heat become too excessive, forming the disease of Wei Jia Shi. Therefore, Zhang Zhongjing uses Wei Jia Shi as the outline for this syndrome. Although there are distinctions of Taiyang-Yangming, Zhengyang-Yangming, and Shaoyang-Yangming, their essence is all Wei Jia Shi. Furthermore, combining with the exterior signs—self-heat, spontaneous sweating, no aversion to cold but aversion to heat—one knows that Wei Jia Shi manifests internally and appears externally, further confirming it as true Yangming disease. Among these syndromes, although some in the exterior should be resolved via sweating, one must know that if sweating is profuse and the pulse is faint, Guizhi Tang is appropriate; if there is no sweating and wheezing with a floating pulse, Mahuang Tang is appropriate. Both belong to Taiyang syndromes but are attributed to Yangming because they lack headache and neck stiffness. If aversion to cold has ceased, these two formulas must absolutely not be used. Moreover, the Yangming outline emphasizes interior syndromes, so this clause is treated as a separate chapter in the treatise.
Regarding the primary syndromes of Yangming, there are self-received syndromes, transferred syndromes, pathogen-excess syndromes, deficiency syndromes, syndromes of ability/inability to eat, cold/heat syndromes, syndromes following pivot/opening mechanisms, syndromes with same names but different realities, and syndromes with same sources but different flows. A practitioner who cannot sort them out will find themselves tangled like silk threads.
What is self-received? Disease originating from the Yangming channel itself. Its exterior signs are body heat, spontaneous sweating, no aversion to cold but aversion to heat, representing the exterior syndrome of Yangming disease moving from interior to exterior. Some cases, on the first day, do not require resolution; by the second day, aversion to cold ceases spontaneously, followed immediately by spontaneous sweating and fever. This represents the exterior syndrome of wind-cold entering the Yangming channel. This is the general overview of self-received Yangming.
What is transferred? In many cases of Taiyang disease, excessive sweating depletes fluids, leading to dryness in the stomach and transfer to Yangming. Also, originally Taiyang disease, if initial sweating was incomplete, the marked heat of Taiyang could not escape with the sweat, mixing with Yangming dryness and transferring. Also, cases with fever, no sweating, vomiting, and inability to eat harbor a mechanism of stomach disharmony; even without sweating, spontaneous sweating occurs, leading to transfer. Also, improper purging can lead to transfer. This is the general overview of transferred Yangming.
What is deficiency? Section 16 states: Yangming disease, inability to eat, cold deficiency in the stomach; attacking the heat will cause hiccups. This refers to stomach organ deficiency. Section 17 states: Slow pulse, difficulty eating to fullness, slight irritability and dizziness after eating, inevitable difficulty in urination; this desires to become grain jaundice. Even if purged, abdominal fullness remains. This refers to channel deficiency. Section 18 states: No sweating, sensation of insects crawling under the skin; this is due to deficiency. This refers to skin and pore deficiency. Although no formulas are listed, the method is generally warming and tonifying. Section 26 states: Shuhan with frequent vomiting; even if Yangming signs exist, do not purge. Vomiting indicates weak stomach qi; even with Yangming excess heat, do not mistakenly purge to death. This refers to insufficient stomach qi for purging. Section 27 states: Hardness and fullness in the epigastrium should not be purged. Purging leads to uncontrolled diarrhea and death. The text mentions only the epigastrium, not the abdomen; only hardness and fullness, not pain. The epigastrium is the diaphragm of Yangming; diaphragmatic excess implies abdominal deficiency. Deficient qi in the abdomen closes off in the Yangming region; mistaken purging exhausts grain qi, leading to fatal diarrhea. This refers to true deficiency mimicking excess, which should not be purged. Section 18 (Note: likely referring to another section regarding facial redness) states: Facial redness should not be purged. Purging leads to fever, yellow complexion, and dysuria. Yangming vessels ascend to the face; failing to use fumigation/resolving methods and mistakenly purging leads to these symptoms. This refers to exterior excess with interior deficiency, which should not be purged. One must know that although Yangming syndrome outlines with Wei Jia Shi, without the moistening transformation of intermediate Taiyin, the more Yangming excess, the more intermediate deficiency. Previous commentators failed to elaborate on this, causing millions to die wrongly using Baihu Tang and Chengqi Tang.
What is pathogen excess? In the treatise, Yangming fu-organ syndromes are all caused by heat pathogens. However, if heat pathogens are scattered inside and outside, with great thirst and sweating, Baihu Tang is appropriate to drive out heat and generate fluids. If heat pathogens cluster in the intestines and stomach, with tidal fever and delirium, Chengqi Tang is appropriate to drive out heat and purge excess. Both formulas are designed for Yangming fu-disease; misuse kills. Section 41, San Yang He Bing, last sentence: If there is spontaneous sweating, Baihu Tang is the main formula, grasping the key point. The three Chengqi Decoctions each have specific indications. For Yangming syndrome without vomiting or purging, even if stomach qi is not deficient, the stomach vessel connects to the heart; based on irritability, one knows stomach qi is disharmonious, and Tiaowei Chengqi Tang can be given. Section 29 has explicit text. Regarding Da Chengqi Tang syndrome, a slow pulse indicates yang pathogen has fully entered yin interior; spontaneous sweating, no aversion to cold, heaviness, shortness of breath, abdominal fullness, and wheezing—among these five, the most certain interior sign is selected: no aversion to cold but tidal fever, indicating heat pathogen fully enters the stomach, changing body heat to tidal fever. Among interior signs, the most certain sign of hard stool is: sweating on hands and feet continuously. Stomach governs the four limbs; if stool is already hard, whole-body steaming sweat converges into continuous sweating on hands and feet, which is the definitive sign for Da Chengqi Tang. Otherwise, it is merely dry feces retention, suitable only for Xiao Chengqi Tang. However, Xiao Chengqi Tang should not be used lightly. If no bowel movement for six or seven days, to determine if there is dry feces, give a small amount of Xiao Chengqi Tang as a test. If passing gas after ingestion, it can be used again. If no passing gas, this indicates weak stomach qi; initially hard then loose stool will lead to inability to eat and bloating, inability to drink and hiccups. Sections 29, 30, and 31 should be studied carefully. As for delirium, experts consider it pathogen excess. However, Section 32 distinguishes "excess causes delirium, deficiency causes Zhengsheng." This section directly views it as exhaustion of essence and qi; wheezing and fullness indicate spleen-lung disharmony; diarrhea indicates spleen-kidney insecurity. These are all fatal signs of delirium due to deficiency collapse. From Section 33 to 43, although excess pathogens are common, one cannot generally assume all are pathogen excess diseases. Zhang Yinan said: Delirium is essentially deficiency of the heart master's spirit qi. Speech is governed by the heart, not the stomach. Using Chengqi for stomach-dryness delirium is because the stomach vessel fails to connect to the heart; clearing stomach qi allows vessels to connect. Zhang Zhongjing provides methods; one must not stick rigidly to them.
What is ability/inability to eat? If struck by wind, one can eat, because wind stirs Yangming qi. If struck by cold, one cannot eat, because cold blocks Yangming qi. The principle of cold strike is detailed in Section 19. The principle of wind strike is detailed in Section 20. Generally, cold is yin pathogen descending, hence no sweating and free urination; wind is yang pathogen ascending, hence no aversion to cold but dizziness. Cold causes vomiting and inability to eat; wind allows eating. Cold causes headache; wind causes sore throat. This is the distinction between wind and cold in Yangming.
What is the distinction between cold and dryness/heat? Section 44 states: Floating and slow pulse is a pulse of deficiency cold. The stated exterior heat is because Yangming Wu Earth cannot descend to combine with Shaoyin Gui Water, governing solely externally. The stated interior cold is because Shaoyin Gui Water cannot ascend to combine with Yangming Wu Earth, governing solely internally. The stated diarrhea with undigested food is because Wu and Gui do not combine, and lower jiao generating yang fails to ascend. Sini Tang is the main treatment. Section 45 states: Cold deficiency in the stomach refers to deficiency cold of middle jiao earth qi. Inability to eat is because middle jiao deficiency cold loses its function of digesting grain. Drinking water causes hiccups because two colds combine. No formula is given, but Lizhong Tang is suitable. Extending to Section 60: Desire to vomit after eating belongs to Yangming, treated with Wuzhuyu Tang. This mutually illuminates the previous section. Section 46 states: Floating pulse and fever indicate Yangming dryness-heat in the channel. Dry mouth and nose indicate heat traveling along the channel to attack the upper jiao. Ability to eat with epistaxis indicates heat in the channel, not damaging middle jiao stomach qi. This case, precisely because of ability to eat, confirms heat in the channel. Severe channel heat resolves through epistaxis as an exit. Extending to Section 60, latter part: Worsening after taking medicine belongs to upper jiao. Upper jiao governs fire-heat, mutually illuminating this section.
What is following pivot/opening? Neijing states: Taiyang is opening, Yangming is closing, Shaoyang is pivot. The three channels must not lose connection. If Yangming ends in closing, death ensues. So how to achieve opening? First, transform via Shaoyang pivot. Section 47: After purging, exterior heat, warm hands and feet, no chest binding, mental restlessness, hunger but inability to eat, only head sweating—this is Yangming closing, qi not connecting up and down. Zhi Zi Chi Tang is indicated. Section 48: Tidal fever, loose stool, normal urination, persistent chest/hypochondriac fullness—this is Yangming closing, qi not involving large/small intestines, reversing in chest/hypochondrium. Xiao Chai Hu Tang is indicated. Moreover, contemporary physicians only know Xiao Chai Hu Tang as a Shaoyang formula, not knowing it is a crucial Yangming formula. Section 49: Yangming disease, hardness/fullness under hypochondrium. Without Shaoyang pivot, lower jiao不通 leads to constipation; middle jiao untreated leads to stomach disharmony and vomiting; upper jiao disharmonious, fire stagnates upward, white coating on tongue. Xiao Chai Hu Tang can be given. Upper jiao opens, fluids descend, stomach qi harmonizes, body sweats slightly and resolves. This is why transforming via pivot works. Second, export via Taiyang opening. Section 50: Yangming wind strike, stringy-floating-large pulse, shortness of breath. Explained in shallow notes. Disease over ten days, three yin channels may receive pathogen. If pulse continues to float, it does not involve yin, still wanting to exit via Shaoyang pivot. If pulse is only floating with no other symptoms, disease mechanism wants to exit via Taiyang opening; Mahuang Tang can assist. If no urination, abdominal fullness plus hiccups, it does not follow Shaoyang pivot or Taiyang opening, reverses into three yin, untreatable. This is exporting via opening.
What is same name but different reality? Neijing states: Injury by cold becomes heat disease. Second day Yangming receives it. Vessels run along nose, connect to eyes. Stated body heat, eye pain, nasal dryness, inability to sleep refers only to one aspect of Yangming channel disease. Zhang Zhongjing outlines with Wei Jia Shi, covering the complete method of interior/exterior diagnosis and treatment. Later people wrongly used Shengma Gengen Tang,反而 inducing Yangming sweating, leading to upper epistaxis and lower difficulty defecating, inviting thieves to destroy the home. This is same name but different reality.
What is same source but different flow? Yangming originally governs qi, but blood stasis syndrome governs blood. Yangming originally governs dryness, but jaundice syndrome combines with warmth. Section 55: Yangming syndrome, forgetfulness,必有 blood stasis. Stool hard but defecation easy, color black. Didang Tang is indicated. Section 75: Patient without exterior-interior signs, fever for 7-8 days, even if floating-numerous pulse, can be purged. Disease in Yangming collaterals, collaterals do not involve exterior-interior. Fever without aversion to cold, purging drains heat. If purged, floating pulse resolves but numerous pulse persists, heat is in blood not qi, in Yangming collateral not channel. Treatise calls it combined heat, two types: Combined in middle, excessive hunger, after 6-7 days no bowel movement, blood stasis in middle, Didang Tang to attack. Combined in lower, unceasing diarrhea, heat-coupled pus-blood stool. No formula given, generally warm agents like Taohua Tang, cold agents like Baitouweng Tang. Same Yangming syndrome, yet jaundice occurs. Section 21: Yangming disease, no sweating, dysuria, mental restlessness, body will turn jaundiced. Section 22: Yangming disease subjected to fire, slight sweat on forehead, dysuria, will turn jaundiced. Heat-dampness stagnating in central earth. Section 76: Shuhan after sweating, body and eyes yellow, cold-dampness in interior. Heat-damp jaundice can be purged, cold-damp jaundice cannot. No formula given, Wuling San plus Yinchen Hao is close. Section 77: Shuhan 7-8 days, body yellow like orange peel, dysuria, slight abdominal fullness. Yinchen Hao Tang is indicated. Heat-dampness stagnating in interior turning yellow, guided out via urine by Dahuang and Yinchen Hao. Section 78: Shuhan body yellow with fever. Zhizi Baipi Tang is indicated. Heat-dampness emitted externally, no interior signs, using Baipi to reach skin, three yellow-colored herbs to treat yellow. Section 79: Shuhan stagnant heat in interior, body will turn yellow. Mahlian Qiaochi Xiaodou Tang is indicated. Exterior syndrome unresolved, heat-dampness stagnant in interior manifesting externally, using Mahuang to induce slight sweat. This is same source but different flow.
Regarding treatment methods: Closing ones fear final closure, excess ones worry about great excess, so heavy agents of the three Chengqi Decoctions are primary. Maren Wan is a light moistening purgative. Honey suppository is the lightest external method. Tiaowei Chengqi Tang: Mangxiao承接 fire qi upwards, Dahuang conducts downwards; avoids harsh breaking agents, uses Gancao to harmonize middle, hence named "Regulating Stomach". Xiao Chengqi Tang: Specifically targets dry feces, thus omits Mangxiao, uses unroasted Zhishi and Houpo to disperse stagnation, more for attacking, less for harmonizing, hence named "Small". Da Chengqi Tang: Comprehensive,承接 whole-body fire-heat downward, sweeping away blood/qi stasis, accumulated pathogens, and retained food, the heaviest purgative. Used correctly, it rescues the dying; once mistaken, pathogen leaves and righteous qi perishes. Thus, Section 21 says: intending to give Da Chengqi Tang, first give a little Xiao Chengqi Tang. If passing gas indicates dry feces, then give Da Chengqi Tang.