二十、陽明病，其人多汗，以津液外（亡）〔出〕，胃中（躁）〔燥〕，大便必鞕，鞕則譫語，小承氣湯主之；若一服譫語止〔者〕，更莫〔複〕服。原文213
鄭論：按因汗出以致譫語，大便鞕者，胃（躁）〔燥〕也，血液外亡也，今既下之，而大便不鞕，不譫語者，胃得潤而和，故令其勿更服，恐再下之，而別生他病也。
【闡釋】譫語由於便鞕，便鞕由胃燥，胃燥由於津液少，津液少為熱實於裏而汗液外泄。因為大便鞕結。腑氣不通，則穢濁之氣上攻，心神不擾，所以發生譫語。小承氣湯以去實熱而和胃，則譫語自止。
二十一、傷寒四五日，脈沉而喘滿，沉為在裏，而反發其汗，津液越出，大便〔為〕難，表虛裏實，久則譫語。原文218
鄭論：按邪原在裏，而反汗之，其誤已甚，汗出則津液外越，津液外行，自然胃（躁）〔燥〕而大便亦與之俱（躁）〔燥〕，（更）〔便〕所以難也，裏分邪實，無怪乎譫語也。
【闡釋】表證之喘滿，其滿在胸部，其脈必浮；裏證之喘滿，其滿在腹部，其脈必沉。前者可用麻黃湯之類發其汗則愈；後者發汗則誤，以致津液外越，燥實結於內，久則譫語。此以過汗傷津，而不致大實滿痛，宜少與小承氣治之。
二十二、傷寒若吐若下後不解，不大便五六日，上至十餘日，日晡所發潮熱，不惡寒，獨語如見鬼狀。若劇者，發則不識人，循衣摸床，惕而不安，微喘直視。脈弦者生，澀者死。微者，但發熱，譫語者，大承氣湯主之；若一服利，〔則〕止後服。原文212
鄭論：按既經吐下後不解，延至如見鬼狀，循衣摸床，微喘直視者，乃將死之征。但脈弦者，弦為陰象，是陰尚未盡也，故曰生。
若脈見澀，澀為血枯，枯則陰竭，不死何待？病形若但發熱譫語，而無直視可據，故以大承氣湯主之。
【闡釋】傷寒表證，應汗之使邪從外解，反治以吐下，以致津傷化燥，邪陷成實，不惡寒，發潮熱，便秘，都是胃腸燥實之征，延至獨語如見鬼狀，循衣摸床，惕而不安，微喘直視，此不僅陽明腑實自病，且已波及厥少二陰，危之甚矣。脈弦為正氣尚存，陰精未竭，故曰脈弦者生；脈澀是營血衰竭，陽亢陰絕，故曰脈澀者死。若但見發熱譫語之腑實證，可用大承氣湯蕩滌其燥結，然此峻下之劑，必須中病即止，以免過劑傷正。
二十三、汗出譫語者，以有（躁）〔燥〕屎在胃中，此為風也。須下（之）〔者〕，過經乃可下之①。下之若早，語言必亂，以表虛裏實故也。下之（則）愈，宜大承氣湯。原文217
①過經：這裏是太陽表證解除之意思。成無己注：須過太陽經無表證。
鄭論：按既稱汗出譫語，明是內熱胃（躁）〔燥〕而有（躁）〔燥〕屎也。何得以風名之乎？又曰下之早，而語言必亂，亂亦譫語之屬也，何必強名之乎？總之此病乃為裏實證，故下之可愈。
【闡釋】此條鄭氏不隨文注釋，亦不牽強附會，而提出質疑，最後歸結為：此病乃為裏實證，故下之可愈。可啟迪後學深思之。
二十四、陽膽病，譫語有潮熱，反不能食者，胃中必有（躁）〔燥〕屎五六枚也，若能食者，但鞕爾，宜大承氣湯（主）〔下〕之。原文215
鄭論：按（躁）〔燥〕屎與但鞕，二者有輕重之分，其間譫語、潮熱、不能食，皆胃中熱結阻滯也。
【闡釋】以能食不能食，來辨別腑實內結的微甚。重則燥屎阻結，輕則僅僅便鞕。已結者開其結，未結者滌其熱，不令更結。譫語潮熱雖相同，但腑實的程度有輕有重，原文俱主以大承氣湯。筆者認為能食者，只用小承氣微和胃氣即可。若不能食，是燥屎已成之確據，則可用大承氣湯下之。
二十五、陽明病，發熱汗多者，急下之，宜大承氣湯。原文253
鄭論：按陽明發熱汗多，而急下之者，何也？恐血液外越過盛，而胃中反生（躁）〔燥〕結等證，下之正所〔以〕存津液以安胃也。但此證，只憑一發熱汗多而定為急下，況人參白虎證，亦大熱汗出，尚未急下。當時大約為陽亢已極者而言之也，若但發熱汗出，而定為急下，不能無疑。
【闡釋】鄭氏謂：“若但發熱無汗，而定為急下，不能無疑”。蓋陽明病發熱汗多，不論陽明經證、腑證都有，如屬經症熱熾，則白虎人參湯即可清熱救陰。故此條當有其他腑實證狀，如腹滿痛，不大便、潮熱、譫語等證，方能急下存陰。
二十六、發汗不解，腹滿痛者，急下之，宜大承氣湯。原文254
鄭論：按此條為陽明胃實者言之，而非為胃虛者言之，學者宜詳辨虛實。
【闡釋】汗為陰液，發汗則傷津而熱邪更熾，與糟粕相結而成燥屎，陰梗於中，氣機窒塞，不通則痛，故宜大承氣湯急下之。
二十七、腹滿不減㈠，減不足言，當下之，宜大承氣湯。原文255㈠腹滿豈無虛實（頂批）。
鄭論：按此條未指出當下實據，不能無疑，姑錄之。
【闡釋】按此節承上條，蓋謂下後腹痛雖減腹滿未減，或減十分之一二，言不甚減也。所以然者，悍熱太甚，非一下可盡除也。此下之未盡，故仍以大承氣湯再次攻之。前條曰急下之，本條曰當下之，用法自亦有微劇之分矣。又腹滿有虛實之別，太陰虛寒的腹滿，裏無實邪，其腹滿，常有緩解之時；本證腹滿，乃是裏有燥屎，有形的實邪，腹滿無減輕之時。《金匱》“腹滿時減，複如故，此為寒，當與溫藥”。虛、實之間，最宜詳辨，治法亦迥異。
二十八、傷寒六七日，目中不了了①，睛不和②，無表裏證③，大便難，身微熱〔者〕，此為實也，急下之，宜大承氣湯。原文252
①目中不了了：即視物不明。
②睛不和：是眼珠轉動不靈活。
③無表裏證：指既無頭痛惡寒表證，也無腹滿譫語等裏證。也有認為是無少陽的半表半裏證。
鄭論：按目睛不了了者，皆緣內有伏熱傷及津液，津液暗耗，不能上榮於目，故不了了，觀其大便難，身微熱，其內之伏熱，亦可慨見矣。故宜急下之，正以救津液，恐遲緩則熬幹陰精也。
【闡釋】《內經》雲：“五臟六腑之精，皆上注於目，熱邪內灼，津液枯燥，則精神不得上注於目，故目中不了了，睛不和也”。燥屎內阻，則大便不通，此為裏實證，謂無表證則可，無裏證則不可，無裏證安能下之耶？正如鄭氏所說：“故宜急下之，正以救津液，恐遲緩則熬幹陰精也”。
二十九、陽明病欲解時，從申至戌上。原文193
④芤（kōu摳）：脈之一，脈輕按浮大，重按中空，有如蔥管，是陰血不足，陽氣浮盛之征。
鄭論：按申、酉、戌，乃陽明之旺時，邪衰者于旺時可以潛消，邪盛者于此時更盛，觀日晡潮熱之人，則得解與不解之道也。
【闡釋】此條所論涉及時間醫學，按照祖國醫學理論，申、酉、戌時，（即現在的下午三時至八時）日晡時也。陽明潮熱，發於日晡，陽明病解，亦於日晡，為陽明經氣當旺的時候，欲解說法也。
三十、脈浮而芤④，浮為陽，芤為陰，浮芤相搏，胃氣生熱，其陽則絕。原文246
【闡釋】此節但言脈而不言證者。蓋指平素陽旺陰虛之人，故感邪即從陽熱而化也。浮則氣分之陽熱盛，芤則血分之津液虛，浮芤相搏，則胃中合相搏之勢，而愈生火熱矣。曰其陽則絕，並不是說陽氣的敗絕，與陽明上篇4條一樣，為津液不足，裏熱亢盛的意思。亦即太陽膀膠之津液，不能還入胃中，有斷絕不續之現象也（鄭書原無三十、三十一條，據舒本校補）。
三十一、趺陽脈浮而澀⑤，浮則胃氣強，澀則小便數，浮澀相搏，大便則鞕，其脾為約，麻子仁丸主之。原文247
⑤趺（fū膚）陽：即沖陽穴，在足背第二第三蹠（zhí）骨間，屬足陽明胃經，古人常用跌陽脈診察脾胃疾病。
【闡釋】此節乃太陽陽明之脾約證也。獨診之足者，蓋邪熱從足而上，太陽膀胱之津液先虛，故脾被熱灼，而津液澀約，胃被熱蒸，而火氣強盛，故不用承氣之速下，而用麻仁丸之緩攻，以和之也。
又上二條，舒馳遠《再重訂傷寒集注》具載，鄭氏《傷寒恒論》缺之。但舒氏亦疑此兩條非仲景原文，而為叔和錄入，有矛盾。或為鄭氏不錄此二條之原因。
麻子仁丸方（校補）
麻子仁二升芍藥半斤枳實半斤（炙）大黃一斤（去皮）厚樸一尺（炙去皮）杏仁一升（去皮尖熬，別作脂）上六味，蜜和丸，如梧桐子大，飲服十丸，日三服，漸加，以知為度。
【方解及其應用範圍】本方有滋腸潤燥緩瀉作用，方中麻仁杏仁潤腸肅肺，因肺與大腸相表裏，肺氣降有助於通便作用。枳實、厚樸破氣行滯，芍藥養陰，大黃攻下清熱。所以成其潤腸緩下劑，但仍兼攻下破氣。現有中成藥出售，為有效的潤下劑，用於虛弱體質便秘者多效。
傷寒恒論卷六
陽明下篇
外邪已趨少陽，未離陽明，謂之少陽陽明，列於此篇，計八法（據舒本校補）。
一、陽明病，發潮熱，大便溏，小便自可，胸脅滿不去者，〔與〕小柴胡湯（主之）。原文229
鄭論：按大便溏，胃虛而不實也；小便自可，內無熱也；胸脅滿者，濁陰閉塞也；發潮熱者，陽氣浮也。此際正當溫中，又非柴胡湯所宜也。此條意著重在兩脅上，究其端倪，故以小柴胡湯主之。
【闡釋】此節乃少陽陽明二陽合病。邪熱陷於大腸，故發潮熱；如胃家實，當大便鞭而小便數，今大便溏，小便自可，知非實熱之證。鄭氏謂：“大便溏、發潮熱等諸證，正當溫中，又非柴胡湯所宜”。當用理中湯加砂仁半夏治之。然就胸脅滿不去一證，仍宜從胸脅而達之外，可從轉樞而出。因陽明經病輕，少陽經病重，用小柴胡湯治少陽，解其主症。
二、陽明病，（而）脅下鞭滿，不大便而嘔，舌上白苔者，可與小柴胡湯（主之）。上焦得通，津液得下，胃氣因和①，身濈然汗出而解（也）。原文230
①胃氣因和：指胃的正常機能得到恢復。
鄭論：按此證，乃陽明而兼少陽也。夫兩脅者，少陽之地界也。今兩脅鞭滿，是少陽氣機不舒之候，不大便者，胃實之征，舌上白苔色者，寒也，嘔時而作，少陽喜嘔也。餘意此證，可小柴胡內重加大黃，俾土木之氣舒則內暢，而津液通，胃氣自和，只用小柴胡湯而不用大黃，似不恰切。
【闡釋】本條與前條亦少陽陽明二陽合病，較上節為重。前節係邪陷於大腸，此節係陷於胸胃之間。曰脅下鞭滿，不大便而嘔，舌上白苔者，正氣不得上升下降，故使不大便也。用小柴胡湯以轉其樞，則諸證自愈。但鄭氏則主“小柴胡湯重加大黃，俾土木之氣舒則內暢，而津液通，胃氣自和”，似較僅用小柴胡湯原方為對證。
三、間曰：病有太陽陽明，有正陽〔陽〕明，有少陽陽明，何謂也？答曰：太陽陽明者，脾約是也①正陽〔陽〕明者，胃家實是也②；少陽陽明者，發汗利小便〔已〕，胃中（躁）〔燥〕煩實，大便難是也。原文179
①脾約：脾約以胃中之津液言。胃無津液，脾氣無以轉輸，故如窮約而不能舒展也。即是由於津液虧少而引起便秘。
②胃家實：指腸胃中有熱邪積滯。
鄭論：按太陽之邪未盡，而傳至陽明，如桂枝湯加葛根之屬，與脾約湯之屬是也。正陽〔陽〕明者，太陽之邪傳至陽明，隨（躁）〔燥〕而化為熱邪，絕無一毫太陽寒氣，而胃獨受其邪，則為之正陽〔陽〕明，所雲胃家實是也。少陽陽明者，是陽明之邪半入少陽地界，兩經之提綱病情互見，故為少陽陽明，如兩脅滿而不大便是也。
【闡釋】此條採取問答形式，鄭氏所注分別說明三類陽明府證的成因和來路，較為全面。太陽陽明由於津虧，其證狀較輕；正陽陽明由於陽旺，不大便，內實滿痛，名胃家實，其證狀最重。少陽陽明由於誤治，其證狀較太陽陽明為重。三者病因雖有別，而皆熱盛於裏致腸胃成實，則理無二致。
附：少陽轉陽明二證（據舒本校補）
四、少陽陽明〔者〕，發汗利小便〔已〕，胃中（躁）〔燥〕煩實，大便難是也。原文179後段
③此條與上條第三小節重複，不識何故，為保存原書面貌，姑存之。
鄭論：按此證，前已申明，茲不復敘③
五、服柴胡湯已，渴者屬陽陰，以法治之。原文97後段
鄭論：接此條，本有少陽證，故服柴胡湯已而口渴者，胃有熱而傷及津液也，仍以陽明口渴法治之。餘細思口渴一證，有胃熱太甚，口臭氣粗，身熱汗出，渴飲冷者，仲師以人參白虎湯治之。有陽衰不能薰騰津液於上而亦口渴，但飲滾飲冷不同，仲師以回陽治之，如此用藥，方不誤人。
【闡釋】本條明言“渴者屬陽明也，以法治之”。鄭氏主以人參白虎湯治之，于理於法皆合。至有陽衰不能薰騰津液於上，而亦口渴，其非陽明證明甚，當屬少陰證之口渴，自當以回陽法治之。
附：太陰轉陽明一證（據舒本校補）
六、傷寒脈浮而緩，手足自溫者，是為係在太陰。太陰者，身當發黃。若小便自利者，不能發黃，至七八日，大便鞭者，為陽明〔病〕也。原文187
20. Yangming disease, where the patient sweats profusely, causes the body fluids to escape outward, leading to dryness in the stomach and hardening of the stool. Hardening of the stool inevitably leads to delirium (altered mental status with incoherent speech). Xiao Chengqi Tang (Minor Order the Qi Decoction) is the primary treatment; if one dose stops the delirium, do not administer further doses. Original Text 213
Zheng's Commentary: Regarding cases where sweating leads to delirium and hard stools, this indicates stomach dryness and the loss of blood and fluids externally. Now that purgation has been used and the stool is no longer hard nor is there delirium, it shows the stomach has been moistened and harmonized. Therefore, it advises against further administration, fearing that repeated purgation might induce other diseases.
[Explanation]: Delirium arises from hardened stool, which results from stomach dryness, caused by a deficiency of body fluids due to internal heat excess and external leakage of sweat. Because the stool is hardened, the fu-organ qi is obstructed, allowing turbid qi to attack upward and disturb the heart-mind, thus causing delirium. Xiao Chengqi Tang removes excess heat and harmonizes the stomach, so delirium ceases naturally.
21. In Shaoyang disease lasting four or five days, if the pulse is deep and there is wheezing and fullness, a deep pulse indicates an interior condition. If sweating is incorrectly induced, body fluids escape outward, making defecation difficult. This results in exterior deficiency and interior excess; over time, delirium may occur. Original Text 218
Zheng's Commentary: The pathogen was originally in the interior, yet sweating was incorrectly induced, a grave error. Sweating causes body fluids to escape outward; as fluids move outward, the stomach naturally becomes dry, and the intestines follow suit, becoming dry, hence the difficulty in defecation. With interior excess of pathogens, it is no wonder that delirium occurs.
[Explanation]: Exterior syndrome wheezing and fullness manifest as distension in the chest with a floating pulse; interior syndrome wheezing and fullness manifest as distension in the abdomen with a deep pulse. The former can be cured by inducing sweat with formulas like Mahuang Tang (Ephedra Decoction); the latter is a misdiagnosis if treated with sweating, leading to outward escape of fluids and internal binding of dryness and excess, eventually causing delirium. Since excessive sweating injures fluids without causing severe fullness and pain, a small amount of Xiaochengqi Tang should be used for treatment.
22. After Shanghan (Cold Damage) is treated with emesis or purgation and remains unresolved, if there is no bowel movement for five to six days, or even ten-plus days, tidal fever (fever worsening in the late afternoon) occurs at dusk, accompanied by aversion to cold absence, and the patient speaks alone as if seeing ghosts. In severe cases, upon onset, the patient does not recognize people, grasps at clothes and bedsheets, feels terrified and uneasy, has slight panting, and stares fixedly. A wiry pulse indicates survival; a choppy pulse indicates death. In mild cases, only fever and delirium occur; Dachengqi Tang (Major Order the Qi Decoction) is the primary treatment. If one dose results in bowel movement, stop subsequent doses. Original Text 212
Zheng's Commentary: After emesis and purgation fail to resolve the condition, progressing to symptoms like seeing ghosts, grasping at objects, slight panting, and fixed staring, these are signs of impending death. However, if the pulse is wiry, indicating a yin characteristic, it means yin energy has not completely exhausted, hence survival is possible.
If the pulse is choppy, indicating blood exhaustion and yin depletion, death is inevitable. If the presentation is merely fever and delirium without fixed staring, Dachengqi Tang is indicated.
[Explanation]: For exterior Shanghan, sweating should be used to release pathogens from the exterior. Using emesis or purgation instead injures fluids, leading to dryness transformation and pathogen sinking into excess. Absence of aversion to cold, tidal fever, and constipation are signs of gastrointestinal dryness and excess. Progression to solitary speech resembling hallucinations, grasping behaviors, terror, slight panting, and fixed staring indicates not only Yangming fu-excess but also involvement of Jueyin and Shaoyin, representing extreme danger. A wiry pulse suggests righteous qi remains and yin essence is not exhausted, hence survival. A choppy pulse indicates failure of Ying-blood and extreme yang with yin exhaustion, hence death. For mild fu-excess presenting only with fever and delirium, Dachengqi Tang can purge dryness accumulation, but as a harsh purgative, it must be stopped once effective to avoid damaging righteous qi.
23. Cases with sweating and delirium indicate dry feces in the stomach, attributed to wind. Purging is required, but only after the meridian stage has passed.① If purged too early, language will become chaotic due to exterior deficiency and interior excess. Upon successful purging, recovery occurs; Dachengqi Tang is appropriate. Original Text 217
① Passing the meridian: Here refers to the resolution of Taiyang exterior syndrome. Cheng Wuji noted: One must pass the Taiyang meridian stage without exterior syndrome.
Zheng's Commentary: Given sweating and delirium, it clearly indicates internal heat and stomach dryness with dry feces. Why attribute this to wind? It states that early purging causes chaotic speech, which is a form of delirium. Why force the name "wind"? Ultimately, this disease is an interior excess syndrome, so purging leads to cure.
[Explanation]: Zheng did not annotate this clause literally nor forced interpretations, but raised questions, concluding that this is an interior excess syndrome treatable by purging. This encourages deep reflection among students.
24. In Yangming disease, delirium with tidal fever, yet inability to eat, indicates five or six pieces of dry feces in the stomach. If able to eat, the stool is merely hard; Dachengqi Tang should be used to purge. Original Text 215
Zheng's Commentary: There is a difference in severity between dry feces and merely hard stool. Delirium, tidal fever, and inability to eat all result from heat binding and stagnation in the stomach.
[Explanation]: Ability or inability to eat distinguishes the severity of interior fu-binding. Severe cases involve dry feces obstruction; mild cases involve merely hard stool. Bound feces require opening the blockage; unbound heat requires clearing, preventing re-accumulation. Although delirium and tidal fever are similar, the degree of fu-excess varies. The original text recommends Dachengqi Tang for both. The author believes that for those who can eat, Xiaochengqi Tang (Minor Order the Qi Decoction) to mildly harmonize stomach qi suffices. For those unable to eat, confirming formed dry feces, Dachengqi Tang is appropriate for purging.
25. In Yangming disease, with fever and profuse sweating, urgent purging is required; Dachengqi Tang is indicated. Original Text 253
Zheng's Commentary: Why urgently purge Yangming fever with profuse sweating? To prevent excessive outward escape of blood and fluids, which could lead to stomach dryness and binding. Purging preserves body fluids to calm the stomach. However, basing urgent purging solely on fever and sweating is questionable, as Ren Shen Bai Hu Tang (Ginseng and White Tiger Decoction) cases also present with high fever and sweating without requiring urgent purging. This likely referred to extreme yang hyperactivity. Merely fever and sweating warrant doubt regarding urgent purging.
[Explanation]: Zheng stated, "If merely fever without sweating warrants urgent purging, it is doubtful." Yangming fever with profuse sweating applies to both Jing (Channel) and Fu (Organ) syndromes. If it is a Jing syndrome with intense heat, Baizhu Renshen Tang (White Tiger and Ginseng Decoction) clears heat and saves yin. Thus, this clause implies other fu-excess symptoms like abdominal fullness/pain, constipation, tidal fever, and delirium are necessary for urgent purging to save yin.
26. After sweating fails to resolve the condition, if abdominal fullness and pain occur, urgent purging is required; Dachengqi Tang is indicated. Original Text 254
Zheng's Commentary: This clause refers to Yangming stomach excess, not deficiency. Students must carefully distinguish deficiency from excess.
[Explanation]: Sweat is yin fluid; sweating injures fluids and intensifies heat pathogens, which bind with waste to form dry feces. Yin obstruction blocks middle jiao qi mechanism, causing pain due to lack of free flow. Hence, urgent purging with Dachengqi Tang is appropriate.
27. Abdominal fullness that does not decrease, or decreases insignificantly, requires purging; Dachengqi Tang is indicated. Original Text 255 ①Abdominal fullness: Is there no distinction between deficiency and excess? (Marginal note).
Zheng's Commentary: This clause lacks clear evidence for purging, raising doubts. Recorded tentatively.
[Explanation]: Following the previous clause, this implies that after purging, abdominal pain may decrease but fullness remains, or decreases only slightly. This is because fierce heat is too severe to be removed by a single purgation. This represents incomplete purging, necessitating repeated use of Dachengqi Tang. The previous clause said "urgent purging," while this says "purge," indicating differences in intensity. Furthermore, abdominal fullness differs by deficiency/excess. Taiyin deficiency-cold fullness lacks interior excess pathogens and often relieves intermittently; this case involves interior dry feces (solid excess), so fullness never relieves. *Jin Gui* states: "Abdominal fullness that comes and goes is cold, treat with warming herbs." Distinguishing deficiency and excess is crucial, as treatments differ significantly.
28. In Shanghan lasting six or seven days, if vision is unclear① and eye movements are stiff②, with no exterior or interior syndrome signs③, difficulty defecating, and slight body heat, this is excess; urgent purging is required; Dachengqi Tang is indicated. Original Text 252
① Vision unclear: Poor eyesight/blurred vision.
② Stiff eyes: Inflexible eye movement.
③ No exterior/interior syndrome: Refers to absence of headache/aversion-to-cold (exterior) and abdominal fullness/delirium (interior). Some interpret this as absence of Shaoyang half-exterior/half-interior syndrome.
Zheng's Commentary: Unclear vision and stiff eyes result from latent heat injuring fluids, which are secretly consumed and cannot nourish the eyes. Observing difficulty defecating and slight heat reveals internal latent heat. Urgent purging is needed to save fluids, fearing delay will boil away yin essence.
[Explanation]: *Nei Jing* states: "Essence of all zang-fu organs ascends to the eyes." Internal burning heat and dry fluids prevent spirit from ascending to the eyes, causing unclear vision and stiffness. Dry feces blocking internally cause constipation, constituting an interior excess syndrome. Saying there is no exterior syndrome is acceptable, but saying there is no interior syndrome is incorrect; how can one purge without interior syndrome? As Zheng said: "Urgent purging saves fluids, fearing delay boils yin essence."
29. Yangming disease tends to resolve from Shen hour to Xu hour. Original Text 193
④ Kong (Hollow) pulse: A pulse felt floating and large on light pressure but hollow on heavy pressure, resembling a scallion stalk, indicating insufficient yin-blood and floating excess yang.
Zheng's Commentary: Shen, You, and Xu hours are peak times for Yangming. When pathogens are weak, they dissipate during peak times; when strong, they intensify. Observing patients with tidal fever at dusk illustrates the principles of resolution versus non-resolution.
[Explanation]: This clause involves temporal medicine. According to traditional theory, Shen, You, and Xu hours (3 PM to 8 PM) correspond to Ri Bu (late afternoon). Yangming tidal fever occurs at Ri Bu, and Yangming disease resolution also occurs then, coinciding with the peak of Yangming channel qi. This explains the concept of "tendency to resolve."
30. Pulse is floating and kong (hollow). Floating indicates yang; kong indicates yin. When floating and kong interact, stomach qi generates heat, leading to yang extinction. Original Text 246
[Explanation]: This clause mentions only pulse, not symptoms. It likely refers to individuals with inherent yang excess and yin deficiency, whose pathogens transform into heat upon infection. Floating indicates excess yang heat in the qi level; kong indicates fluid deficiency in the blood level. Their interaction increases fire-heat in the stomach. "Yang extinction" does not mean collapse of yang qi, but rather fluid insufficiency and extreme interior heat, similar to Clause 4 in the Yangming chapter. It signifies that bladder fluids cannot return to the stomach, showing a discontinuation phenomenon (Clauses 30 and 31 were added based on Shu's edition, absent in Zheng's original).
31. Fuyang pulse is floating and choppy. Floating indicates strong stomach qi; choppy indicates frequent urination. Interaction of floating and choppy pulses leads to hard stool; the spleen is constrained. Maziren Wan (Hemp Seed Pill) is the primary treatment. Original Text 247
⑤ Fuyang: Chongyang acupoint, located between the second and third metatarsal bones on the dorsum of the foot, belonging to the Foot-Yangming Stomach Channel. Ancient physicians frequently used the Fuyang pulse to diagnose spleen/stomach diseases.
[Explanation]: This describes the Spleen Constraint syndrome of Taiyang-Yangming. Diagnosing the foot specifically is because pathogenic heat rises from below; Taiyang bladder fluids are first depleted. Heat scorches the spleen, constraining fluids; heat steams the stomach, strengthening fire qi. Thus, fast purging with Chengqi formulas is avoided in favor of the slow attacking action of Maziren Wan to harmonize.
The above two clauses are fully recorded in Shu Chi Yuan's *Revised Commentary on Shanghan*, missing from Zheng's *Shanghan Heng Lun*. Shu doubted these were Zhang Zhongjing's original texts, possibly inserted by Wang Shuhe, creating contradictions, which may explain Zheng's omission.
Maziren Wan Formula (Supplemented)
Hemp Seed (Semen Cannabis) 2 sheng, Peony Root (Radix Paeoniae Alba) 0.5 jin, Immature Bitter Orange (Fructus Aurantii Immaturus) 0.5 jin (stir-fried), Rhubarb (Radix et Rhizoma Rhei) 1 jin (peeled), Magnolia Bark (Cortex Magnoliae Officinalis) 1 chi (stir-fried, peeled), Apricot Kernel (Semen Armeniacae Amarum) 1 sheng (peeled, tip removed, roasted separately to extract oil). Six ingredients. Mix with honey to make pills the size of wax tree seeds. Take 10 pills with water, three times daily, gradually increasing until effect is achieved.
[Formula Analysis and Application Scope]: This formula moistens intestines, clears dryness, and gently purges. Hemp seed and apricot kernel moisten intestines and regulate lungs; since lung and large intestine are exterior-interior pairs, descending lung qi aids bowel movement. Immature bitter orange and magnolia bark break qi stagnation; peony nourishes yin; rhubarb purges and clears heat. Thus, it forms a gentle laxative that also moves qi and purges. Commercial preparations exist as effective moistening laxatives, particularly effective for constipation in weak constitutions.
Shanghan Heng Lun Volume 6
Yangming Lower Chapter
When external pathogens have moved toward Shaoyang but not left Yangming, it is called Shaoyang-Yangming, listed in this chapter, totaling eight methods (supplemented per Shu's edition).
1. Yangming disease with tidal fever, loose stools, normal urination, and persistent chest-hypochondriac fullness: Xiao Chaihu Tang (Minor Bupleurum Decoction) is indicated. Original Text 229
Zheng's Commentary: Loose stools indicate deficient, non-excess stomach; normal urination indicates no interior heat; chest-hypochondriac fullness indicates turbid yin obstruction; tidal fever indicates floating yang. At this stage, warming the center is appropriate, not Xiao Chaihu Tang. However, focusing on the hypochondriac region, analyzing its origin, Xiao Chaihu Tang is used.
[Explanation]: This is a combined Shaoyang-Yangming syndrome. Pathogenic heat sinks into the large intestine, causing tidal fever. If stomach excess existed, stools would be hard and urination frequent. Here, loose stools and normal urination indicate non-excess heat. Zheng stated: "Loose stools and tidal fever require warming the center, not suitable for Chaihu Tang." Lizhong Tang (Regulate the Middle Decoction) with Amomum and Pinellia should be used. However, regarding persistent chest-hypochondriac fullness, resolving via the hypochondrium allows exit through pivot transformation. Since Yangming channel disease is mild and Shaoyang is severe, Xiao Chaihu Tang treats Shaoyang, resolving main symptoms.
2. Yangming disease with hardness/fullness under the ribs, constipation, vomiting, and white tongue coating: Xiao Chaihu Tang is indicated. Once the upper jiao opens, fluids descend, stomach qi harmonizes, and the body breaks out in continuous sweat, resolving the condition. Original Text 230
① Stomach qi harmonizes: Restoration of normal stomach function.
Zheng's Commentary: This is Yangming combined with Shaoyang. The hypochondrium is the domain of Shaoyang. Hardness/fullness here indicates stagnant Shaoyang qi mechanism. Constipation indicates stomach excess. White tongue coating indicates cold. Vomiting is characteristic of Shaoyang. I suggest adding Rhubarb to Xiao Chaihu Tang to soothe wood-earth qi, ensuring internal smoothness, fluid flow, and stomach harmony. Using only Xiao Chaihu Tang without Rhubarb seems inappropriate.
[Explanation]: Like the previous clause, this is combined Shaoyang-Yangming syndrome, heavier than the prior section. Previous section involved heat sinking into large intestine; this involves sinking between chest and stomach. Hardness/fullness under ribs, constipation, vomiting, and white coating indicate qi failing to ascend and descend, causing constipation. Xiao Chaihu Tang turns the pivot, healing all symptoms. Zheng advocated adding heavy Rhubarb to Xiao Chaihu Tang to soothe wood-earth qi, facilitating fluid flow and stomach harmony, which seems more accurate than using the original formula alone.
3. Question: What are Taiyang-Yangming, Zhengyang-Yangming, and Shaoyang-Yangming? Answer: Taiyang-Yangming is Spleen Constraint. Zhengyang-Yangming is Stomach Excess. Shaoyang-Yangming results from sweating and promoting urination, leading to stomach dryness, irritability, excess, and difficult defecation. Original Text 179
① Spleen Constraint: Refers to stomach fluids. Without stomach fluids, spleen qi cannot transport, appearing constrained and unable to expand. It is constipation caused by fluid deficiency.
② Stomach Excess: Heat pathogen accumulation in intestines/stomach.
Zheng's Commentary: If Taiyang pathogen is incomplete and transmits to Yangming, such as Guizhi Tang plus Ge Gen, or Spleen Constraint formulas, it is Taiyang-Yangming. Zhengyang-Yangming occurs when Taiyang pathogen transmits to Yangming, transforming into heat via dryness, with no residual Taiyang cold, affecting only the stomach, constituting Stomach Excess. Shaoyang-Yangming is when Yangming pathogen partially enters Shaoyang territory, showing mixed提纲 (outline) symptoms of both meridians, such as hypochondriac fullness and constipation.
[Explanation]: Using Q&A format, Zheng's notes comprehensively explain the causes and origins of three Yangming fu syndromes. Taiyang-Yangming due to fluid deficiency has milder symptoms. Zhengyang-Yangming due to yang excess presents with constipation, internal excess, fullness, and pain, named Stomach Excess, with the heaviest symptoms. Shaoyang-Yangming due to mistreatment has symptoms heavier than Taiyang-Yangming. Though etiologies differ, all involve heat excess in the interior forming intestinal/stomach excess, sharing the same principle.
Appendix: Two Cases of Shaoyang Transforming to Yangming (Supplemented per Shu's edition)
4. Shaoyang-Yangming results from sweating and promoting urination, leading to stomach dryness, irritability, excess, and difficult defecation. Original Text 179 latter part
③ This repeats the third subsection of the previous clause; reason unknown. Preserved to maintain original text appearance.
Zheng's Commentary: This case was previously explained; not repeated here.③
5. After taking Chaihu Tang, if thirst occurs, it belongs to Yangming; treat according to method. Original Text 97 latter part
Zheng's Commentary: This clause originally had Shaoyang symptoms. Post-Chaihu Tang thirst indicates stomach heat injuring fluids; treat Yangming thirst accordingly. Considering thirst: severe stomach heat with bad breath, coarse breathing, fever, sweating, and cold drink preference is treated by Zhang Zhongjing with Ren Shen Bai Hu Tang. Yang decline failing to vaporize fluids upward also causes thirst, but drinking preferences differ; Zhang uses Yang-restoring methods. Such differentiation prevents medication errors.
[Explanation]: This clause explicitly states "thirst belongs to Yangming; treat accordingly." Zheng advocates Ren Shen Bai Hu Tang, consistent with theory and method. Thirst due to yang decline failing to vaporize fluids is clearly not Yangming syndrome but Shaoyin syndrome thirst, requiring Yang-restoring methods.
Appendix: One Case of Taiyin Transforming to Yangming (Supplemented per Shu's edition)
6. In Shanghan, if pulse is floating and slow, and hands/feet are warm, it relates to Taiyin. Taiyin typically presents with jaundice. If urination is normal, jaundice does not develop. By day seven or eight, if stool becomes hard, it becomes Yangming disease. Original Text 187