【闡釋】鼻衄，有解病佳兆者。口幹鼻燥，能食，雖陽明裏證未全成，陽明內熱已太盛，熱甚則上逆，上逆則引血，血上則衄，熱邪亦隨之而泄。近世醫家以衄為紅汗者，正以其泄鬱熱故也。鬱熱泄則自愈。
三十二、陽明病，發熱汗出者，此為熱越①不能發黃也；但頭汗出，身無汗，劑頸而還，小便不利，渴飲水漿者，此為瘀熱在裏②身必發黃，茵陳蒿湯主之。原文236
①熱越：裏熱發越於外之意。
②瘀熱：即邪熱鬱滯的意思。
鄭論：條中所言熱外越者，不發黃，是因汗出，知其表氣通，而熱得外泄故也。若頭汗出，身無汗，小便不利，渴欲飲水者，此是熱伏於內，抑鬱太甚，而邪無由路出，故成陽黃之候，茵陳蒿湯主之，實為的證之方，妥切之甚者也。
【闡釋】此節乃陽明濕熱郁蒸發黃的證狀。若但頭汗出，周身沒有汗，則熱不得越；小便不利，由濕無出路，邪熱既不能外達，水濕又無從下泄，水濕與熱邪相蒸不解，郁而不達，身心發黃，治以茵陳蒿湯，苦寒通泄，使濕熱之邪從小便而出，濕去熱清，則發黃自愈。
茵陳蒿湯方（校補）
茵陳蒿六兩梔子十四枚（擘）大黃二兩（去皮）上三味，以水一鬥二升，先煮茵陳，減六升，內二味，煮取三升，去渣，分三服。小便當利，尿如皂莢汁狀，色正赤，一宿腹減，黃從小便去也。
【方解及其應用範圍】濕熱瘀裏，蒸發而外見黃色，用茵陳苦寒清濕而解鬱熱，佐梔子清利三焦，以通水道，以大黃除胃熱，導火下行兼清血分中之熱。三味合用，使瘀熱濕濁，從小便而出，濕熱一泄、則發黃自愈。《傷寒》《金匱》二書中，分黃疸為陰陽兩綱，敍述簡略，僅根據皮膚黃染情況來辨陰陽。凡身目俱黃，黃如橘子色澤鮮明，小便不利，色黃赤而短少，腹脹食少，厭油食，舌苔黃膩，脈滑數者，為陽黃。
無論其為現代醫學所稱之急性黃疸型傳染肝炎，濕熱偏盛的慢性肝炎，肝膽道感染，膽道結石等病見陽黃證者，都可用本方加減治療。
三十三、陽明病，面合色赤①，不可攻之。（攻之則）必發熱，色黃〔者〕，小便不利也。原文206
①面合色赤：即面色通赤。
鄭論：據陽明而面赤色，又當察其可攻與不可攻，如氣粗面赤，唇焦，飲冷甚者，宜攻之；若雖面赤而無熱象足征，又不可攻，攻之則必發熱者，是真陽因攻而浮於上，浮於上，即不能化下焦之陰，小便亦見不利。學者切勿執一陽明病，而定為熱證，妄施攻下也。此條所謂不可攻，攻之則必發熱，焉知非（帶）〔戴〕陽而何？
【闡釋】邪熱怫鬱在經，禁用攻下，誤攻下，必然發熱，肌膚發黃而且小便不利。因誤攻而見此證，欲救其失，茵陳五苓散可用。鄭氏更論及“雖面赤而無熱象足征，又不可攻，攻之則必發熱者，是真陽因攻而浮於上，……焉知非戴陽而何？”戴陽乃危證，救逆之法，非大劑回陽不可。
三十四、陽明病，無汗，小便不利，心中懊憹者，身必發黃。原文199
鄭論：邪至陽明而從熱化，無汗者，邪不得外泄，小便不利者，邪不得下泄，抑鬱於中而懊憹，懊憹者，心不安之謂，所以斷其必發黃也。
【闡釋】陽明病沒有汗出，是濕熱不能外散；小便不利，幾水濕不能下行。
濕與熱蒸於內，則身體發黃。原文未出方劑，似宜麻黃連翹赤小豆湯外發內利；或梔子豉湯以清裏而達表，則身黃自退。
三十五、陽明病，被火，額上微汗出，而小便不利者，必發黃。原文200
鄭論：陽明本屬（躁）〔燥〕地，又得陽邪，又複被火，火勢內攻，小便不通，熱邪無從下泄，遏熱太甚，是以決其必發黃也。
【闡釋】陽明病，無汗，本應以葛根湯發其汗，今竟以火劫取汗，則熱邪愈熾，津液被束，無複外布與下滲矣，其身必發黃。原文未出方治，根據辨證，必須清熱利濕，梔子柏皮湯主之。
三十六、陽明病，下血譫語者，此為熱入血室。①但頭汗出者，刺期門，隨其實而瀉之，濈然汗出則愈。原文216
①血室：各家見解不一，有的認為是沖脈，有的認為是肝臟，有的認為是子宮，所說都均有一定理由，顧名思義，要不外血液儲留之處，三者均有連帶關係，不需強分。又少陽篇18條所指“血室”即子宮。
鄭論：據陽明而稱下血，必是胃中有熱，逼血下行耳。譫語者，熱氣乘心，神無所主也。茲雲熱入血室，夫膀胱之外，乃為血海，又稱血室，此病係在陽明大腸，何得直指之為血室乎？何得刺期門穴乎？但下血一（等）〔證〕，有果係熱逼血下行者，必有熱象可征。譫語一證，有陽虛、陰虛、脾虛之異。更有下血、譫語而將脫者，不得總統言之，學者務宜細心探求則得矣。
【闡釋】本證由於邪熱熾盛，血為熱擾，故便血；內熱蒸騰，故頭汗出；熱氣乘心，神無所主，故譫語。鄭氏按稱：“此病係在陽明大腸，何得直指之為血室乎？何得刺期門穴乎？……務宜細心探求則得矣，”筆者信而從之。
三十七、陽明證，其人（善）〔喜〕忘者①，必有畜血②，所以然者，本有久瘀血，故令（善）〔喜〕忘，糞雖（難）〔鞕〕，（而）大便反易，其色必黑〔者〕，宜抵當湯（主）〔下〕之。原文237
①喜忘：喜作善字解，言語動靜隨過隨忘，即健忘之意。
②畜血：畜與蓄字同，瘀血停留叫蓄血。
鄭論：據善忘緣因瘀血所致，瘀滯不行，氣血不得流通，神明寓於氣血之中，為氣血之主。今為瘀血所阻，氣血不得流通，神明每多昏憒，所以善忘而斷之瘀血，確乎不爽。但蓄血在太陽，驗之於小便，其人如狂；蓄血在陽明，驗之於大腸，其色必黑，大便色黑者，蓄血之驗也。
【闡釋】太陽蓄血證是太陽之邪熱隨經入腑與血相結，以致出現少腹急結，或鞕滿，小便利，如狂、發狂等證候。陽明蓄血證是陽明邪熱與宿有的瘀血相結，故令善忘。二者證狀不同，因蓄血擾亂神志則一。辨太陽蓄血證在小便之利與不利，辨陽明蓄血證在大便之黑與不黑、難與不難。兩者的病理機轉都是屬於邪熱與血相結，所以都可用抵當湯下之。
三十八、病人無表裏證，發熱七八日，雖脈浮數者，可下之。假令已下，脈數不解，合熱則消穀善饑，至六七日，不大便者，有瘀血（也），宜抵當湯。若脈數不解，而下（利）不止，必協熱（而）便膿血也。原文257、258
鄭論：既稱無表裏證，即不在發表之例，即不在攻下之例，雖脈浮數，總要有風熱病情足征，庶可相機施治。所雲發熱七八日，然發熱有由外入之發熱，有由內而出之發熱，大有涇渭之分，若只憑脈之浮數而攻之，則由外入者，有內陷之變，由內而出者，有亡陽之逆，假令下之脈數不解，合熱則消穀善饑，此是為果有外邪致發熱者言之，而非為內出之發熱者言之也。迨至六七日，不大便者有瘀血，何以知其必有瘀血也？況熱結而不大便者亦多，此以抵當湯治之，似不恰切，仲師未必果有是說也。
【闡釋】鄭注此條與歷代注家不同，發熱有外入與內出之分，若只憑發熱而攻之，則有邪熱內陷與亡陽之虞。假令已下脈數不解，合熱消穀善饑，不大便者，何以辨之，並無征驗，況熱結而不大便亦多，提出質疑。最後歸結為“此以抵當湯治之，似不恰切，仲師未必果有是說也。”
三十九、病人煩熱，汗出則解，又如瘧狀，日晡所發熱者，屬陽明也。脈實者，宜下之；脈浮虛者，宜發汗。下之與大承氣湯；發汗宜桂枝湯。原文240
鄭論：此條以脈實、脈虛，而定為可汗、可下，似未必盡善。
論脈實而要有胃實病形足征，方可言下，脈浮虛而要有風邪足征，始可言發汗，若專以日晡發熱，而定為陽明證，即下之，決不妥切。
【闡釋】本條係太陽陽明並病，即表裏俱病，必先解表而後攻裏。但不能僅根據脈象虛實來決定汗、下，而應結合證狀來辨別太陽之表邪是否已解，或陽明之裏實是否已成，然後先表後裏，解表用桂枝湯，下之與大承氣湯，方為合法。
伤寒恒论下
清·鄭欽安
闡釋·唐步祺
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傷寒恒論卷五
陽明中篇
凡外邪盡入胃腑，謂之正陽陽明，列於此篇，計三十一法（據舒本校增）
一、陽明之為病，胃家實〔是也〕。原文180
鄭論：陽明乃多氣多血之府，邪至陽明（躁）〔燥〕地，與胃合成一家，其邪易實，故病見邪盛者極多，故曰胃家實。
【闡釋】“胃家實”三字是陽明病的提綱。胃家包括腸、胃而言，“實”字有廣義和狹義的區別，廣義包括經腑兩證，狹義就是單指陽明腑證而言。《內經》所說“邪氣盛則實”並不僅指有形結滯而言。食物積滯而實者，承氣證；熱邪積滯而實者，白虎證。
二、傷寒三日，陽明脈大。原文186
鄭論：一日太陽，二日陽明，三日少陽，乃傳經之次第。今三日而見脈大，可知其邪未傳少陽，而仍在陽明也，何以知之，浮為太陽，大為陽明，弦為少陽故也。
【闡釋】陽明病的脈大，必然大而有力，假使大而無力，或浮大無根，那就不一定全屬於陽明病。此雲三日陽明脈大者，謂不兼太陽陽明之浮大，亦不兼少陽陽明之弦大，而正見正陽陽明之大脈也。
三、傷寒發熱無汗，嘔不能食，而反汗出濈濈然者，是轉屬陽明也。原文185後段
鄭論：按發熱無汗，寒傷營也，嘔不能食，太陽有寒也，汗出濈濈然者，寒邪外出也。此曰轉屬陽明，果何所見而然乎？餘甚不解。
【闡釋】鄭氏將《傷寒論》185條分作兩條，前段列入陽明上篇9條，本條即後段。傷寒發熱無汗，嘔不能食，是少陽小柴胡證，不因發汗而反汗出濈濈然者，此由少陽轉屬陽明也，如此注釋，鄭氏之不解可解矣。
四、傷寒轉（屬）〔係〕陽明者，〔其人〕濈然微汗出也。原文188
鄭論：按轉屬陽明，必有陽明證足征，或見肌肉之間大熱，而又見口渴飲冷，氣粗口熱，蒸蒸汗出，如此言之，則曰轉屬陽明，方可無疑。而此只憑一濈濈然汗出，而即謂之轉屬陽明，實不恰切。
【闡釋】凡傷寒轉屬陽明，不論由太陽、少陽、少陰等轉係陽明，其人必見濈濈然連綿不已之微汗出也。此其裏熱亢盛，將水分外薰而為汗，腸中始得結實，而成鞕滿便難之陽明證。鄭氏曰：“而此只憑一濈濈然汗出，而即謂之轉屬陽明，實不恰切。”舒馳遠曰：“此條但據汗出濈濈一端，便是轉屬陽明，恐不能無疑。若熱退身涼，飲食有味，豈非病自解之汗耶？必其人惡熱、不惡寒，腹滿、按痛、譫語諸證錯見，方為有據，否則不足憑也。”故臨床不能憑一證以定寒熱虛實，須四診合參乃可。
五、太陽病三日，發汗不解①，蒸蒸發熱②者，屬胃也，調胃承氣湯主之。原文248
①發汗不解：指發汗後熱病不愈，不是太陽病不解。
②蒸蒸發熱：有如蒸籠中熱氣，從內向外蒸騰一樣，熱面潮潤。
鄭論：按三日，乃少陽主氣之期。今太陽發汗而不解，是邪入陽明，而未傳經也。觀其蒸蒸發熱者，陽明內熱之征，可以無疑矣。故以調胃承氣湯治之，其病自愈。
【闡釋】發汗以後，太陽表證雖解，而邪氣反化熱傳裏，轉為陽明腑實。當時證狀，除了蒸蒸發熱以外，一定還有腹滿、便秘、或心下鞕，鬱鬱微煩等腑實見證，才能使用調胃承氣湯。設若沒有上述證狀，僅憑蒸蒸發熱，就使用下法，是不恰當的。
六、陽明病，本自汗出，醫更重發汗，病已差，尚微煩不了了者，此〔必〕大便（已）鞕故也。以亡津液，胃中乾燥，故令大便鞕。當問其小便日幾行，若本小便日三四行，今日再行，故知大便不久出，今為小便數少，以津液當還入胃中，故知不久必大便也。原文203
鄭論：此由過汗傷及津液，已致胃燥失潤，問其小便尚利，津液未竭，故知其不久必便也。
【闡釋】陽明病大便鞕而難出，有熱結與津液不足兩端。熱結者可以攻下，承氣湯之類。津液不足者，必腸中津液增加，大便鞕得濡潤，無需攻下，亦必然不久自出。至於小便多的，大便必鞕；大便溏泄的，小便必少，是診斷大便鞕與溏泄的主要關鍵。今小便少，則津液還停胃中，胃中津液足，則大便潤，潤則軟滑，此其所以必出也。
七、陽明病，自汗出（者），若發汗，小便自利者，此為津液內竭，雖鞕不可攻之。當須自欲大便，宜蜜煎導而通之，若土瓜根及（與）大豬膽汁，皆可為導。原文233
鄭論：按汗自出，與小便自利，二者皆是大傷津液，故大便雖鞕者，不可攻之，俟其津液自回，亦可自便。此以蜜導法治之，亦切要之法，此又與熱結者，不可同法也。
【闡釋】本條大便鞕，是因自汗出，小便自利而大傷津液，腸中津液枯竭，與陽明中篇31條津液不行的脾約證，燥熱結實的承氣證，即鄭氏所說熱結皆不同，須詳辨之，必俟其津液自回，用蜜煎因勢利導之。
[Explanation] Epistaxis (nosebleed) can be a favorable sign of disease resolution. Dry mouth and nose, ability to eat, although the Yangming interior syndrome is not fully formed, the internal heat in Yangming is already excessive. When heat is severe, it reverses upward; when it reverses upward, it draws blood upward; when blood flows upward, epistaxis occurs, and the pathogenic heat is discharged along with it. Modern physicians refer to epistaxis as "red sweat," precisely because it discharges stagnant heat. When stagnant heat is discharged, the disease heals spontaneously.
32. In Yangming disease, if there is fever and sweating, this indicates that the heat is venting outward①, and jaundice will not occur; if there is only sweating on the head, no sweating on the body, the sweat stops at the neck, difficulty in urination, and thirst for drinking fluids, this indicates stagnant heat in the interior②, and jaundice will certainly develop. Yinchen Hao Tang (Yin Chen Hao Decoction) should be used to treat it. Original Text 236
① Heat venting outward: Refers to the meaning of interior heat venting to the exterior.
② Stagnant heat: Refers to the stagnation of pathogenic heat.
Zheng's Commentary: The text mentions that when heat vents outward, jaundice does not occur, because sweating indicates that the exterior qi is unobstructed, allowing heat to escape outward. If there is sweating on the head, no sweating on the body, difficulty in urination, and thirst for water, this indicates that heat is concealed within, excessively stagnant, with no pathway for the pathogen to exit, thus forming the pattern of Yang Jaundice. Yinchen Hao Tang (Yin Chen Hao Decoction) is indeed an appropriate formula for this specific pattern.
[Explanation] This section describes the symptoms of jaundice caused by damp-heat stagnation and steaming in Yangming. If there is only sweating on the head and no sweating on the body, the heat cannot vent outward; difficulty in urination means dampness has no outlet. Since pathogenic heat cannot reach the exterior and water-dampness cannot drain downward, water-dampness and pathogenic heat steam each other without resolving, becoming stagnant and obstructed, leading to yellowing of the body and mind. Treatment uses Yinchen Hao Tang (Yin Chen Hao Decoction), which is bitter and cold to unblock and drain, allowing the damp-heat pathogen to exit via urination. When dampness is removed and heat is cleared, jaundice heals spontaneously.
Yinchen Hao Tang Formula (Corrected and Supplemented)
Artemisiae Scopariae Herba (Yin Chen) 6 liang, Gardeniae Fructus (Zhi Zi) 14 pieces (broken), Rheae Radix et Rhizoma (Da Huang) 2 liang (bark removed). These three ingredients are boiled in 12 sheng of water. First boil Artemisiae Scopariae Herba (Yin Chen) until the volume reduces by 6 sheng, then add the other two ingredients, boil to obtain 3 sheng of liquid, remove dregs, and divide into three doses. Urination should become profuse, urine resembling soap pod juice, reddish in color. After one night, abdominal distension decreases, and yellow pigment is eliminated through urination.
[Formula Analysis and Scope of Application] When damp-heat stagnates in the interior and steams outward manifesting as yellow skin, use Artemisiae Scopariae Herba (Yin Chen) for its bitter-cold nature to clear dampness and resolve stagnant heat. Assist with Gardeniae Fructus (Zhi Zi) to clear and promote the San Jiao (Triple Burner) to unblock water passages, and use Rheae Radix et Rhizoma (Da Huang) to eliminate stomach heat, guide fire downward, and clear heat from the blood level. The combination of these three herbs allows stagnant heat and turbid dampness to exit via urination. Once damp-heat is drained, jaundice heals spontaneously. In the *Shanghan Lun* and *Jingui Yaolue*, jaundice is categorized into Yin and Yang types based briefly on skin discoloration. If the whole body and eyes are yellow, bright orange-yellow in color, with difficult urination, dark red scanty urine, abdominal distension, poor appetite, aversion to grease, yellow greasy tongue coating, and slippery rapid pulse, it is classified as Yang Jaundice.
Whether diagnosed in modern medicine as acute icteric infectious hepatitis, chronic hepatitis with predominant damp-heat, hepatobiliary tract infection, or biliary calculi, if presenting with Yang Jaundice patterns, this formula can be modified for treatment.
33. In Yangming disease, if the face is entirely red①, purgation must not be used. (If purged,) fever will inevitably arise, the complexion will turn yellow [if present], and urination will be difficult. Original Text 206
① Face entirely red: Refers to the entire face being flushed red.
Zheng's Commentary: Based on Yangming disease presenting with facial redness, one must observe whether purgation is indicated or contraindicated. If there is coarse breathing, facial redness, cracked lips, and extreme preference for cold drinks, purgation is suitable. However, if there is facial redness without sufficient evidence of heat, purgation is contraindicated. Purging would inevitably cause fever, indicating that True Yang floats upward due to improper purgation. Floating upward prevents transformation of Yin in the Lower Jiao, leading to difficult urination. Scholars must not rigidly assume all Yangming diseases are heat patterns and recklessly apply purgation. Regarding this clause stating purgation is contraindicated and causes fever, how do we know it is not Dai Yang (Floating Yang) syndrome?
[Explanation] Pathogenic heat constrained in the meridians prohibits the use of purgation. Mistaken purgation inevitably causes fever, yellowing of the skin, and difficult urination. To remedy this error, Yinqin Wuling San (Yin Chen Wu Ling Powder) may be used. Zheng further discusses, "Although the face is red without sufficient heat signs, purgation is contraindicated; causing fever implies True Yang floating upward... could it not be Dai Yang (Floating Yang)?" Dai Yang (Floating Yang) is a critical condition requiring large doses of Yang-restoring herbs for rescue.
34. In Yangming disease, with no sweating, difficult urination, and mental restlessness (Ao Nao), jaundice will certainly develop. Original Text 199
Zheng's Commentary: When pathogens enter Yangming and transform into heat, lack of sweating prevents external discharge, and difficult urination prevents downward discharge. Stagnation in the middle causes mental restlessness (Ao Nao), which refers to inner unease, hence predicting certain development of jaundice.
[Explanation] Lack of sweating in Yangming disease indicates damp-heat cannot scatter externally; difficult urination indicates water-dampness cannot descend. Steaming of dampness and heat internally leads to bodily yellowing. Although no formula is provided in the original text, Mahuang Lianqiao Chixiaodou Tang (Ephedra, Forsythia, and Red Bean Decoction) might be considered for external release and internal drainage, or Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) to clear interior heat and reach the exterior, thereby resolving jaundice.
35. In Yangming disease, after fire therapy, slight sweating on the forehead but difficult urination results in certain jaundice. Original Text 200
Zheng's Commentary: Yangming belongs to dryness. Experiencing Yang pathogens and undergoing fire therapy drives fire inward. With blocked urination, heat has no downward exit, causing excessive suppression of heat, thus predicting certain jaundice.
[Explanation] In Yangming disease with no sweating, Ge Gen Tang (Kudzu Decoction) should have been used to induce sweating. Instead, fire therapy was used to force sweating, intensifying heat and binding fluids, preventing external distribution and downward infiltration, leading to certain jaundice. No formula is given in the original text; based on differentiation, clearing heat and promoting diuresis is required, using Zhizi Bopi Tang (Gardenia and Phellodendron Bark Decoction).
36. In Yangming disease, bleeding from the lower orifices accompanied by delirium indicates heat entering the Blood Chamber.① If there is only sweating on the head, puncture Qimen (LR14), draining excess according to the pattern. Profuse sweating follows, and recovery ensues. Original Text 216
① Blood Chamber: Interpretations vary; some consider it the Chong Mai (Penetrating Vessel), others the Liver, and still others the Uterus. All have merit. Etymologically, it refers to a place where blood accumulates; the three are interconnected and need not be strictly distinguished. Note that in Shaoyang Chapter 18, "Blood Chamber" refers specifically to the Uterus.
Zheng's Commentary: Bleeding in Yangming disease suggests stomach heat forcing blood downward. Delirium indicates heat attacking the Heart, leaving the Spirit unanchored. Claiming heat enters the Blood Chamber here is problematic since the pathology lies in the Yangming Large Intestine, not the Blood Chamber, making puncture of Qimen (LR14) inappropriate. While bleeding may result from heat forcing blood down, showing heat signs, delirium varies by deficiency types (Yang, Yin, Spleen). Cases involving bleeding and delirium with impending collapse require careful distinction. Scholars must investigate meticulously.
[Explanation] This pattern arises from intense pathogenic heat disturbing blood, causing bleeding; internal heat steaming causes head sweating; heat attacking the Heart causes delirium. Zheng argues against locating this pathology in the Blood Chamber or using Qimen (LR14) puncture, advocating careful investigation instead. I follow his view.
37. In Yangming patterns, if the patient suffers from forgetfulness①, there must be accumulated blood②. This is because pre-existing long-standing blood stasis causes forgetfulness. Although stool is hard, it passes easily, and its color is definitely black [indicative]. Diding Tang (Di Dang Decoction) should be used to purge. Original Text 237
① Forgetfulness: "Xi" (likes) is interpreted as "Shan" (prone to), meaning prone to forgetting words and actions immediately after they occur.
② Accumulated Blood: "Chu" is synonymous with "Xu" (store/accumulate); retained blood stasis is called accumulated blood.
Zheng's Commentary: Forgetfulness stems from blood stasis obstructing flow, preventing Qi and Blood circulation. Spirit resides in Qi and Blood. Obstruction by blood stasis causes mental confusion and forgetfulness, confirming blood stasis accurately. Sun Tai accumulated blood is verified by urinary issues and manic behavior; Yangming accumulated blood is verified by bowel movements and black stool color. Black stool confirms accumulated blood.
[Explanation] Sun Tai accumulated blood involves pathogenic heat entering the Fu organs via meridians, binding with blood, causing lower abdominal urgency/fullness, normal urination, and manic behavior. Yangming accumulated blood involves Yangming heat binding with existing blood stasis, causing forgetfulness. Both involve heat-blood binding affecting the spirit, treated with Diding Tang (Di Dang Decoction). Differentiation relies on urination status for Sun Tai and stool color/consistency for Yangming.
38. A patient presents without exterior or interior syndromes, with fever for seven to eight days. Even if the pulse is floating and rapid, purgation may be used. If purgation has been applied and the rapid pulse persists, combined heat causes efficient digestion and frequent hunger. By the sixth or seventh day, if constipation occurs, blood stasis is present, and Diding Tang (Di Dang Decoction) is indicated. If the rapid pulse persists and diarrhea continues, heat-collaborating dysentery with pus and blood in stool will occur. Original Texts 257, 258.
Zheng's Commentary: Without exterior or interior syndromes, neither releasing the exterior nor purging is indicated. Despite a floating-rapid pulse, sufficient evidence of wind-heat is needed before treatment. Fever lasting seven to eight days distinguishes between external invasion and internal emergence. Relying solely on pulse for purgation risks internal sinking of external pathogens or Yang collapse from internal heat. If purgation fails to resolve the rapid pulse and heat causes hunger, this applies to external pathogen-induced fever, not internal fever. Constipation at six to seven days suggests blood stasis, but heat accumulation also causes constipation. Using Diding Tang (Di Dang Decoction) here seems inappropriate; Zhang Zhongjing likely did not intend this literally.
[Explanation] Zheng’s note differs from previous commentators, distinguishing external vs. internal fever. Blind purgation risks heat sinking or Yang collapse. Persistent rapid pulse post-purgation with hunger and constipation lacks clear verification, as heat accumulation also causes constipation. Zheng questions the literal application of Diding Tang (Di Dang Decoction) here.
39. Patients experience irritability and heat, resolving with sweating. Symptoms resemble malaria, with afternoon fever, indicating Yangming involvement. If the pulse is excess, purgation is suitable; if floating and deficient, sweating induction is suitable. Use Dachengqi Tang (Major Order the Qi Decoction) for purgation; Guizhi Tang (Cinnamon Twig Decoction) for sweating. Original Text 240.
Zheng's Commentary: Determining sweating or purgation based solely on excess or deficient pulses is not entirely sound. Pulse excess requires sufficient evidence of stomach excess to justify purgation; pulse floating-deficient requires sufficient wind-pathogen evidence for sweating. Relying solely on afternoon fever to diagnose Yangming and purge is inappropriate.
[Explanation] This clause describes concurrent Taiyang-Yangming disease (exterior and interior involvement). Exterior must be resolved first. Pulse alone is insufficient; clinical signs must determine if Taiyang exterior is resolved or Yangming interior excess is formed. Resolve exterior with Guizhi Tang (Cinnamon Twig Decoction), then purge interior with Dachengqi Tang (Major Order the Qi Decoction).
Shanghan Henglun Volume 5
Middle Chapter of Yangming
When external pathogens fully enter the Stomach Fu organs, it is called Zheng Yang Yangming (True Yang Yangming). This chapter lists thirty-one methods (added according to Shu's edition).
1. The essence of Yangming disease is Wei Jia Shi (Stomach Family Excess) [is it]. Original Text 180.
Zheng's Commentary: Yangming is a reservoir of abundant Qi and Blood. When pathogens reach the dryness terrain of Yangming, they merge with the Stomach, easily becoming excess. Thus, many cases show strong pathogens, hence "Wei Jia Shi" (Stomach Family Excess).
[Explanation] "Wei Jia Shi" (Stomach Family Excess) is the guiding principle of Yangming disease. "Wei Jia" includes intestines and stomach. "Shi" (Excess) has broad and narrow meanings: broadly including Jing and Fu syndromes, narrowly referring only to Yangming Fu syndrome. *Neijing* states "excess of pathogen is Shi," not limited to tangible obstruction. Food stagnation causing excess is Chengqi pattern; heat stagnation causing excess is Baihu pattern.
2. After three days of Shanghan, the Yangming pulse is large. Original Text 186.
Zheng's Commentary: Day 1 Taiyang, Day 2 Yangming, Day 3 Shaoyang represents transmission sequence. Seeing a large pulse on Day 3 indicates pathogens have not transmitted to Shaoyang but remain in Yangming. How do we know? Floating is Taiyang, Large is Yangming, Wiry is Shaoyang.
[Explanation] Yangming large pulse must be large and forceful. If large but weak, or floating-large rootless, it may not belong entirely to Yangming. "Three days, Yangming large pulse" refers to the pure large pulse of Zheng Yang Yangming, not mixed with Taiyang floating-large or Shaoyang wiry-large.
3. Shanghan with fever, no sweating, vomiting, inability to eat, yet suddenly sweating continuously (Jie Jie Ran) indicates transmission to Yangming. Original Text 185 (second half).
Zheng's Commentary: Fever and no sweating indicate Cold injuring Ying; vomiting and inability to eat indicate Taiyang Cold. Continuous sweating indicates Cold pathogen exiting. Why call this transmission to Yangming? I am confused.
[Explanation] Zheng divides Text 185. The first part is in Yangming Upper Chapter 9. This second half: Fever, no sweating, vomiting, inability to eat resembles Shaoyang Xiaochaihu Tang (Minor Chai Hu Decoction) pattern. Sudden continuous sweating after not inducing sweat indicates transmission from Shaoyang to Yangming. This clarifies Zheng's confusion.
4. Shanghan transmitting [to] Yangming manifests as [the person having] continuous slight sweating. Original Text 188.
Zheng's Commentary: Transmission to Yangming requires sufficient Yangming signs, such as significant heat in muscles, thirst for cold drinks, coarse breath, hot mouth, and steaming sweating. Only then can we confidently say transmission to Yangming. Relying solely on continuous sweating is inadequate.
[Explanation]: Any Shanghan transmitting to Yangming, regardless of origin (Taiyang, Shaoyang, Shaoyin), presents with continuous slight sweating. This indicates intense interior heat steaming fluids outward as sweat, leading to intestinal drying, hardness, fullness, and difficult defecation—Yangming Fu syndrome. Zheng criticizes relying solely on sweating. Shu Chi Yuan notes doubt, suggesting additional signs like aversion to heat, abdominal fullness/tenderness, and delirium are necessary for confirmation. Clinical diagnosis requires Four Examinations, not single signs.
5. Taiyang disease for three days, sweating fails to resolve①, steaming fever② indicates involvement of the Stomach. Tiaowei Chengqi Tang (Regulate the Stomach Order the Qi Decoction) should be used. Original Text 248.
① Sweating fails to resolve: Heat illness persists after sweating, not unresolved Taiyang disease.
② Steaming fever: Heat steams outward from inside like a steamer, with moist heat surface.
Zheng's Commentary: Three days is the Shaoyang ruling period. Taiyang sweating failing to resolve indicates pathogen entered Yangming without further transmission. Steaming fever confirms interior Yangming heat. Tiaowei Chengqi Tang (Regulate the Stomach Order the Qi Decoction) cures it.
[Explanation]: After sweating, Taiyang exterior resolves, but pathogen transforms into heat entering interior, becoming Yangming Fu excess. Besides steaming fever, signs like abdominal fullness, constipation, epigastric hardness, and mild vexation must exist to use Tiaowei Chengqi Tang (Regulate the Stomach Order the Qi Decoction). Using purgation solely for steaming fever is inappropriate.
6. Yangming disease, originally sweating, doctor induces heavy sweating again. Disease improves, but slight vexation remains unresolved. This [certainly] means stool is [already] hard due to loss of Body Fluids, drying the Stomach. Ask about daily urination frequency. If originally 3-4 times daily, now twice, expect stool soon as fluids return to Stomach. If urination decreases significantly, fluids return to Stomach, ensuring soft stool passage. Original Text 203.
Zheng's Commentary: Over-sweating injured fluids, causing Stomach dryness. Urination remains adequate, fluids not exhausted, so stool will pass soon.
[Explanation]: Yangming hard stool has two causes: Heat accumulation (treatable with purgation like Chengqi formulas) or Fluid deficiency (requires fluid restoration, spontaneous passage). Frequent urination leads to hard stool; loose stool implies scanty urination. Scanty urination means fluids return to Stomach, moistening stool for easy passage.
7. Yangming disease, spontaneous sweating (or induced sweating), with spontaneous profuse urination, indicates internal exhaustion of Body Fluids. Even if stool is hard, do not purge. Wait for natural urge to defecate, use Honey Suppository to guide passage. Tu Gua Gen (Radix Trichosanthis Kirilowii) or large pig bile can also be used as guides. Original Text 233.
Zheng's Commentary: Spontaneous sweating and profuse urination both severely injure fluids. Hard stool should not be purged; wait for fluid recovery. Honey suppository is a crucial method, distinct from treating heat accumulation.
[Explanation]: Hard stool here results from fluid exhaustion due to sweating and diuresis, differing from Pi Yue Syndrome (Spleen Constraint) or heat-stagnation Chengqi patterns. Must distinguish carefully. Wait for fluid recovery and use honey suppository to guide passage顺势.