阳明病。脉迟。食难用饱。饱则微烦。头眩。必小便难。欲作谷疸。虽下之。腹满如故。所以然者。脉迟故也。
脉迟。中寒也。食难用饱。饱则微烦者。胃寒不化。强饱则满闷而烦也。头眩者。谷不腐化而浊气郁蒸也。
必小便难者。寒邪在里。下焦无火。气化不行也。食既不化。小便又难。则水谷壅滞。所以欲作谷疸。谓之欲作。盖将
作未作之时也。
谷疸者。寒在中焦。胃不能化。脾不能运。谷食壅滞。中满发黄也。通评虚实论云。黄胆暴痛。五脏不平。
六腑闭塞之所生也。此虽下之。腹满如故。不为少减者。皆以脉迟而寒邪在里。所以寒下无效也。
阴阳应象论云。寒气生浊。热气生清。又云。浊气在上。则生 胀。若不温中散寒。徒下无益也。
阳明病。若中寒不能食。小便不利。手足 然汗出。此欲作固瘕。必大便初硬后溏。所以然者。以胃中冷。
水谷不别故也。
若字不必作如字解。若中寒不能食者。言阳明若为寒邪所中而不能食者。即前不能食者为中寒之义也。
小便不利者。寒邪在里。三焦之气化不行也。 然汗出。邪入阳明之本证也。手足 然汗出。则又不同矣。
阳明脉解云。四肢者。诸阳之本也。灵枢终始篇云。阳受气于四末。太阴阳明论云。四肢皆禀气于胃。如下
文阳明脉迟。有潮热而手足 然汗出者。为大便已硬。此胃气实而手足 然汗出也。此所谓手足 然汗出者。
以寒邪在胃。欲作固瘕。致四肢不能禀气于胃。阳气不达于四肢。卫气不固。故手足亦 然而冷汗出也。
寒邪固结。中气不行。所以欲作固瘕。固瘕者。寒聚腹坚。虽非石瘕肠覃。月令所谓水泽腹坚之意也。初硬
后溏者。胃未中寒之时。中州温暖。尚能坚实。自中寒之后。胃寒无火化之功。三焦无气化之用。水谷不分。
胃气不得坚实而溏也。故又申明其旨曰。所以然者。以胃中冷。水谷不别故也。
辨误 注家以前人坚固积聚为谬。而曰大便初硬后溏。因成瘕泄。瘕泄。即溏泄也。久而不止。则为固
瘕。愚以固瘕二字推之。其为坚凝固结之寒积可知。岂可但以溏泄久而不止为解。况初硬后溏。乃欲作固瘕
之征。非谓已作固
瘕。然后初硬后溏也。观欲作二字。及必字之义。皆逆料之词。未可竟以为然也。
阳明病。初欲食。小便反不利。大便自调。其人骨节疼。翕然如有热状。奄然发狂。 然汗出而解者。
此水不胜。谷气与汗共并。脉紧则愈。
初者。阳明本经受病之初也。欲食。非能食也。仲景原云能食为中风。不能食为中寒。曰初欲食者。
谓阳明受病之初。寒邪在经。尚未深入。胃气犹在。故欲食也。胃无邪热。小盒饭利。今小便不利。故曰反也。
寒邪固闭。三焦不运。气化不行。故小便反不利也。若阳明热邪归里。大盒饭硬。今反自调。尤知无里热也。
骨节疼者。在经之寒邪未解也。翕翕如有热状。寒气衰而阳欲复也。奄然发狂。郁伏之阳迅发。汗欲出而烦
躁如狂也。翕然有热。奄然发狂。则阳回气润。阳蒸阴而为汗。故 然汗出而寒邪得解也。水不胜。谷气与汗俱并。
未详其义。或曰水者。津液也。谷气者。胃气也。水不胜者。津液不足以作汗也。脉紧则愈者。在太阳则紧
为寒邪在表。在阳明则紧为里气充实。脉浮为邪气在经。紧则浮去而里气充实也。原其所以然之故。皆由寒邪
郁滞。无阳气以蒸腾。则津液不得外达而为汗。故曰水不胜也。胃阳之谷气。既不能蒸津液而为汗。故谷气与汗
共并而不得发泄也。素问评热论云。人之所以汗出者。皆生于谷。谷生于精。今邪气交争于骨肉而得汗者。是邪
却而精胜也。精胜则当能食而不复热。复热者。邪气也。汗者。精气也。以此推之。则人身之汗。皆生于胃中
之谷气。精者。津液之谓也。谷生于精者。言津液乃谷气所化也。谷气者。胃中之阳气也。阳气胜。则能蒸
津液而为汗。故为邪却而精胜。若寒邪胜。阳气不能蒸津液而为汗。故谓之水不胜也。（谷气说见太阳
上编火劫第四条）
阳明病。不能食。攻其热必哕。所以然者。胃中虚冷故也。以其人本虚。故攻其热必哕。
不能食。阳明中寒也。攻其热者。以寒药治之也。哕。呃逆也。其所以然者。盖以阳明中寒。胃中虚冷故也。
以其人平素胃气本属虚寒。而粗工浅智。妄拟为热。而以寒下之药攻之。致苦寒伤胃。令胃阳败绝而成呃逆
难治之证也。
若胃中虚冷不能食者。饮水则哕。
言胃中虚冷而不能食者。胃脘之阳大衰。非但以寒攻热而致哕也。即以冷水饮之。则哕矣。
脉浮而迟。表热里寒。下利清谷。四逆汤主之。
此与少阴厥阴里寒外热同义。若风脉浮而表热。则浮脉必数。今表虽热而脉迟。则知阴寒在里。阴盛格阳
于外而表热也。虚阳在外。故脉浮。阴寒在里。故脉迟。所以下利清谷。此为真寒假热。故以四逆汤祛除寒气。
恢复真阳也。若以为表邪而汗之。则殆矣。
阳明病。反无汗而小便利。二三日呕而咳。手足厥者。必苦头痛。若不咳不呕。手足不厥者。头不痛。
阳明本经受病。固当自汗出。即从太阳转入阳明者。亦当 然汗出矣。此以无汗。故曰反也。其所以无汗者。
寒在阳明之经也。小便利者。里无热邪也。二三日呕而咳。则知无汗在二三日之前矣。二三日前。即称阳明病。
尤知其为阳明本经自入之邪。非太阳传经之邪矣。然邪由营卫而入。必假道于太阳而入。所以无汗也。一日无
汗而小便利。至二三日呕咳手足厥者。寒邪入里也。呕者。寒邪深入而犯胃也。咳者。有声无痰之称。阴盛迫阳于上。
肺气上逆而咳也。四肢为诸阳之本。太阴阳明论云。四肢皆禀气于胃。寒邪入胃。则阳气不充于四肢。致阴阳
不相顺接而厥也。呕
咳而厥。则阴邪纵肆。格阳于上。故虚火上浮而必苦头痛也。若不呕不咳不厥。则无阴盛格阳之病。故头
亦不痛也。
辨误 此条与阳明中风之但头眩不恶寒。故能食而咳。其人必咽痛。若不咳者咽不痛之条。一寒一热。
恰相对待。盖示人以辨证之法也。奈何注家以为无汗呕咳。手足厥者。得之寒因而邪热深也。不知厥阴条
内之厥者必热。前热者后必厥。因是阴阳相半之经。故有厥深热亦深。厥微热亦微之论。所以又云反发其汗者。
必有口伤烂赤之患。此条虽属阳明。实阳明中寒之证。并无热邪在里。岂可亦作此论。且又云若不咳不呕
不厥而小便利者。邪热必顺水道而出。窃恐既有邪热在里。小便未必顺利。即使能利。邪热亦未必肯从小便而出。
若曰不从汗少。偏从水道而出。吾不信也。成氏以伤寒寒邪内攻立论。方氏以寒胜为解。当亦不甚相远也。
阳明病。法多汗。反无汗。其身如虫行皮中状者。此以久虚故也。
邪在阳明。于法当多自汗。今反无汗。而身如虫行皮中状者。皆由寒邪郁于肌腠之间。不得发泄故也。此无
他。不过因元气素虚。无阳气以鼓泄其阴液以为汗。使邪气欲出而不得之所致也。
食谷欲呕者。属阳明也。吴茱萸汤主之。得汤反剧者。属上焦也。
此所以辨太阳阳明之疑似也。食谷欲呕。似乎阳明中寒之不能食。故曰属阳明也。胃寒不纳。故以吴茱萸汤
温胃。若得汤反剧者。非胃寒也。仍是太阳之表邪在胸而呕。犹未入胃。故为属上焦也。娄氏谓得汤反剧者。
火也。当用生姜黄连治之。其意因得热反剧。故以苦寒为治。而加生姜止呕。不知仍是太阳呕逆。尚属表邪。仲景
虽未立方。若发热无汗。尚未发表。外邪将次入胃而呕者。邪犹在胸。当以栀子豉汤涌之。庶几近似。
吴茱萸汤方
吴茱萸（一升洗） 人参（三两） 生姜（六两） 大枣（十二枚）
上四味。以水七升。煮取二升。去滓。温服七合。日三服。
吴茱萸一升。当是一合。即今之二勺半。人参三两。当是一两。即宋之二钱七分。生姜六两。当是二两。
即宋之五钱余。大枣当是四五枚。水七升。亦当是三升。观小承气汤止用水四升。调胃承气只用水三升。
此方以辛热补剂。而用之于表里疑似之间。岂反过之。大约出之后人之手。非仲景本来升合分两。学人当因
时酌用。铢两升合法见卷首。
阳明病。脉迟。虽汗出不恶寒者。其身必重。短气腹满而喘。有潮热者。此外欲解。可攻里也。手足 然而
汗出者。此大便已硬也。大承气汤主之。若汗多微发热恶寒者。外未解也。其热不潮。未可与承气汤。若
腹大满不通者。可与小承气汤微和胃气。勿令大泄下。
脉迟。阳明中寒之脉也。表邪未解。当恶寒而无汗。今虽汗出而不恶寒者。是邪气已入阳明之里。然终是脉迟。
为阴寒邪气。脾胃以膜相连。故有其身必重。短气腹满之太阴兼症也。邪实中焦。所以腹满身重。满则胃中填胀。
故短气而喘也。既汗出不恶寒而又潮热。乃外证欲解。邪已入胃。可以攻里之候也。然四肢皆禀气于胃。胃气实则
手足 然汗出。此为大便已硬。然后可以大承气汤主之。若其人汗多微发热而恶寒者。则又不然。汗多则知邪
气已在阳明。发微热恶寒。则又知太阳之表症未罢。故曰外未解也。凡邪实于胃。至申酉阳明气旺之时。必发潮热。
若其热不潮。则阳明里邪未实。大便犹未硬也。故未可与承气汤。然虽未可下。若腹大满不通者。不得已而欲下之。可
与小
承气汤。微和其胃气。勿令大泄下。何也。终以脉迟之故。胃中无大实热。所以不可大下也。
大承气汤方
大黄（四两酒洗） 浓朴（四两炙去皮） 枳实（五枚） 芒硝（三合）
上四味。以水一斗。先煮二物取五升。去滓。内大黄。煮取二升。去滓。内芒硝。更上火微一两沸。
分温再服。得下余勿服。
热邪归胃。邪气根据附于宿食粕滓而郁蒸煎迫。致胃中之津液枯竭。故发潮热而大便硬也。若不以大
承气汤下之。必致热邪败胃。谵语狂乱。循衣摸床等变而至不救。故必咸寒苦泄之药。逐使下出。则热邪随宿
垢而泄。犹釜底抽薪。薪去则火亦随薪而出矣。然非必宿垢满实而泄之也。胃中之热邪盛者。亦在所必
用。古人所谓用之以逐热邪。非下糟粕也。其制以苦寒下泄之大黄为君。咸寒软坚下走之芒硝为臣。又以辛温
下气之浓朴为佐。破气泄满之枳实为使。而后可以攻坚泻热也。若脉弱气馁。热邪不甚者。未可轻用也。
辨误 成氏谓承。顺也。邪气入胃。胃气郁滞。糟粕秘结。壅而为实。是正气不得舒顺也。以汤荡涤。
使塞者利而闭者通。正气得以舒顺。故曰承气也。愚谓此解犹未足以发仲景立方之义。谓之承气者。盖承其邪
盛气实。而以咸寒苦泄。荡涤攻下之也。但热实气盛者可用。无实热而正气虚馁者。不可攻也。若胃气已败。
正气将绝。虽力攻之。亦不得下矣。此无气可承之故也。即内经亢则害。承乃制之义。谓热邪亢害。而以咸寒苦
泄承制之。非舒顺其正气之谓也。观太阳阳明脾约之治。以无大实热。但胃中津液枯燥。故仅以小承气及麻仁丸
和润其胃燥。不令大泄下。则晓然
矣。
小承气汤方
大黄（四两，既名之曰小当是二两汉之二两即宋之五钱外分二次服耳） 浓朴（二两当是一两） 枳实（三枚）
以上三味。以水四升。煮取一升二合。分温二服。初服汤当更衣。不尔者尽饮之。若更衣者勿服之。
小承气者。即大承气而小其制也。大邪大热之实于胃者。以大承气汤下之。邪热轻者。及无大热。但胃中津
液干燥而大便难者。以小承气微利之。以和其胃气。胃和则止。非大攻大下之 剂也。以无大坚实。故于大承气
中去芒硝。又以邪气未大结满。故减浓朴枳实也。创法立方。惟量其缓急轻重而增损之。使无太过不及。适中病情
已耳。若不量虚实。不揆轻重。不及则不能祛除邪气。太过则大伤元气矣。临证审之。
Yangming disease. The pulse is slow. It is difficult to eat until full. If one eats until full, slight irritability and dizziness will occur, and there will inevitably be difficulty in urination. This indicates that "Grain Jaundice" (Gu Dan, jaundice caused by food stagnation) is about to develop. Even if purgatives are used, abdominal fullness remains unchanged. The reason for this is the slow pulse (indicating internal cold).
A slow pulse indicates cold in the middle jiao. Difficulty eating until full, and slight irritability after eating, is due to stomach cold failing to transform food; forcing oneself to eat leads to distension and irritability. Dizziness occurs because grains fail to rot and transform, leading to the stagnation and steaming of turbid qi.
The inevitable difficulty in urination is due to cold pathogen in the interior, lack of fire in the lower jiao, and failure of qi transformation. Since food is not transformed and urination is difficult, water and grain become stagnant and obstructed, hence it is said that Grain Jaundice is "about to develop" (yu zuo), meaning at the time when it is about to manifest but has not yet fully developed.
Grain Jaundice refers to cold in the middle jiao where the stomach cannot transform and the spleen cannot transport, causing grain and food to stagnate, leading to middle jiao fullness and yellowing. The *Tong Ping Xu Shi Lun* states: "Sudden pain in jaundice arises from dysfunction of the five zang organs and obstruction of the six fu organs." Although purgatives are used here, abdominal fullness remains as before without any reduction. This is all because of the slow pulse and cold pathogen in the interior, rendering cold purgation ineffective.
The *Yin Yang Ying Xiang Lun* states: "Cold qi generates turbidity; heat qi generates clarity." It also states: "If turbid qi stays in the upper part, distension occurs." Without warming the middle and dispersing cold, purgation alone is of no benefit.
In Yangming disease, if one is struck by cold and cannot eat, with difficulty in urination and continuous sweating on the hands and feet, this indicates that "Gu Jia" (solid mass due to cold) is about to form. There will inevitably be stool that is initially hard and later loose. The reason is cold in the stomach, where water and grain are not separated.
The word "ruo" (if/whether) here should not be interpreted literally. "Ruo zhong han bu neng shi" means if Yangming disease is struck by cold pathogen and cannot eat, which aligns with the previous meaning that "cannot eat" signifies middle cold.
Difficulty in urination is due to cold pathogen in the interior and failure of qi transformation in the three jiao. Continuous sweating is a primary manifestation of pathogen entering Yangming. However, continuous sweating on the hands and feet is different.
The *Yangming Mai Jie* states: "The four limbs are the root of all yang meridians." The *Ling Shu · Zhong Shi Pian* states: "Yang receives qi at the extremities." The *Tai Yin Yang Ming Lun* states: "The four limbs all receive qi from the stomach." As mentioned below, if Yangming disease presents with a slow pulse, tidal fever, and continuous sweating on the hands and feet, it indicates that the stool has hardened; this is continuous sweating due to excess stomach qi. The continuous sweating mentioned here, however, is because cold pathogen is in the stomach, about to form Gu Jia, preventing the four limbs from receiving qi from the stomach. Yang qi fails to reach the four limbs, and defensive qi is insecure, causing cold sweat on the hands and feet.
Cold pathogen is firmly bound, and middle qi fails to circulate, hence Gu Jia is about to form. Gu Jia refers to cold accumulation making the abdomen hard. Although not Stone Fibroma or Intestinal Polyp, it resembles the meaning of "water and marshes freezing solid in the belly" described in the *Monthly Ordinances*. Stool that is initially hard and later loose occurs because before the stomach was struck by cold, the middle jiao was warm and capable of maintaining solidity. After being struck by cold, stomach cold lacks the function of yang transformation, and the three jiao lack qi transformation, so water and grain are not separated, and stomach qi fails to maintain solidity, resulting in loose stool. Thus, it reiterates: The reason is cold in the stomach, where water and grain are not separated.
[Correction of Misinterpretations] Commentators considered the previous interpretation of solid accumulation as erroneous, stating that initial hardness followed by looseness leads to "Jia Diarrhea" (Xia Xie), which is loose diarrhea. If prolonged, it becomes Gu Jia. I argue that inferring from the term "Gu Jia," it must refer to solidified cold accumulation. How can it be explained merely as prolonged loose diarrhea? Moreover, "initial hardness followed by looseness" is a sign of "Gu Jia about to form," not that Gu Jia has already formed and then presents with initial hardness followed by looseness. Observing the terms "about to form" and "inevitably," these are predictive words and should not be taken as established facts.
In Yangming disease, if initially desiring to eat, but urination is unexpectedly difficult, and stool is normal, and the person experiences joint pain, a mild feverish sensation, sudden madness, and continuous sweating leading to recovery, this is because fluids are insufficient to overcome the pathogen, and grain qi combines with sweat. A tight pulse indicates recovery.
"Chu" (initially) refers to the beginning of the disease in the Yangming proper meridian. "Yu shi" (desiring to eat) does not mean able to eat significantly. Zhang Zhongjing originally stated that "able to eat" indicates Wind Strike, while "unable to eat" indicates Cold Strike. Saying "initially desiring to eat" means at the beginning of Yangming disease, the cold pathogen is in the meridian and has not deeply penetrated; stomach qi still exists, hence the desire to eat. With no pathogenic heat in the stomach, urination should be unobstructed. Now, since urination is difficult, it is called "unexpectedly." Cold pathogen is firmly closed, the three jiao do not circulate, and qi transformation fails, hence urination is unexpectedly difficult. If Yangming heat pathogen entered the interior, stool would likely be hard. Now that it is normal, it confirms the absence of interior heat.
Joint pain indicates that the cold pathogen in the meridian has not resolved. A mild feverish sensation indicates that cold qi is receding and yang qi is recovering. Sudden madness indicates that suppressed yang qi suddenly erupts, and sweat desires to exit, causing irritability resembling madness. Mild fever and sudden madness indicate yang recovery and qi moistening. Yang steams yin to produce sweat, hence continuous sweating allows the cold pathogen to resolve. "Water is insufficient" refers to grain qi combining with sweat; its precise meaning is unclear. Some say: Water refers to body fluids; grain qi refers to stomach qi. "Water is insufficient" means body fluids are inadequate to generate sweat. A tight pulse indicates recovery: in Taiyang disease, a tight pulse means cold pathogen in the exterior; in Yangming disease, it means interior qi is substantial. A floating pulse means pathogen in the meridian; a tight pulse means the floating quality disappears and interior qi becomes substantial. Investigating the reason, it is because cold pathogen is stagnant, lacking yang qi to steam and ascend, so body fluids cannot reach the exterior to become sweat. Hence, "water is insufficient." Stomach yang's grain qi, unable to steam body fluids into sweat, causes grain qi and sweat to combine and fail to dissipate. The *Su Wen · Ping Re Lun* states: "Human sweating originates from grain qi, and grain qi is generated from essence. Now, when pathogen contends between flesh and bones and sweat is produced, it means pathogen retreats and essence prevails. When essence prevails, one should be able to eat and not have recurrent fever. Recurrent fever is pathogen; sweat is essence." Inferring from this, human sweat is generated from grain qi in the stomach. Essence refers to body fluids. "Grain qi generates essence" means body fluids are transformed from grain qi. Grain qi is the yang qi in the stomach. When yang qi prevails, it steams body fluids into sweat, thus representing pathogen retreat and essence victory. If cold pathogen prevails, yang qi cannot steam body fluids into sweat, hence it is called "water is insufficient." (See discussion on grain qi in Taiyang Upper Volume, Fire Coercion Item 4).
In Yangming disease, inability to eat, if one attacks the heat,必将 result in hiccups. The reason is deficiency-cold in the stomach. Because the person is fundamentally deficient, attacking the heat will inevitably cause hiccups.
Inability to eat indicates Yangming middle cold. Attacking the heat means treating it with cold herbs. Hiccups (yue) refer to hiccuping. The reason is Yangming middle cold and deficiency-cold in the stomach. Because the person's stomach qi is inherently deficient and cold, ignorant physicians mistakenly diagnose heat and use cold purgatives, damaging stomach yang with bitter-cold herbs, causing stomach yang to collapse and resulting in refractory hiccups.
If deficiency-cold in the stomach prevents eating, drinking water will cause hiccups.
This means that for those with deficiency-cold in the stomach unable to eat, the yang qi of the stomach chamber is severely depleted. Not only will attacking heat with cold herbs cause hiccups, but even drinking cold water will induce them.
Pulse is floating and slow, exterior heat and interior cold, with diarrhea of undigested food. Treat with Si Ni Tang (Four Counterflow Decoction).
This shares the same principle as Shaoyin and Jueyin diseases presenting with interior cold and exterior heat. If wind pulse were floating with exterior heat, the floating pulse would be rapid. Now, although there is exterior heat, the pulse is slow, indicating interior yin-cold. Yin excess repels yang to the exterior, causing exterior heat. Deficient yang is outside, hence the pulse floats; yin-cold is inside, hence the pulse is slow. Thus, diarrhea of undigested food occurs. This is true cold with false heat, so Si Ni Tang is used to dispel cold and restore true yang. If mistaken for exterior pathogen and treated with sweating, it would be dangerous.
In Yangming disease, unexpectedly no sweat, but clear urination. After two or three days, vomiting and coughing occur, with cold hands and feet. Such a person will surely suffer from headache. If there is no cough, no vomiting, and no cold hands and feet, the head will not hurt.
When the Yangming proper meridian is diseased, spontaneous sweating should naturally occur. Even if transferring from Taiyang to Yangming, continuous sweating should occur. Here, because there is no sweat, it is called "unexpectedly." The reason for no sweat is cold pathogen in the Yangming meridian. Clear urination indicates no heat pathogen in the interior. Vomiting and coughing after two or three days indicate that the lack of sweat occurred before two or three days ago. Referring to it as Yangming disease two or three days prior confirms that this is pathogen entering directly from the Yangming proper meridian, not transmitted from Taiyang. However, pathogen enters via Ying and Wei, passing through Taiyang first, hence no sweat. One day of no sweat and clear urination, progressing to two or three days of vomiting, coughing, and cold hands and feet, indicates cold pathogen entering the interior. Vomiting indicates cold pathogen deeply invading the stomach. Coughing, defined as sound without phlegm, occurs because yin excess forces yang upward, causing lung qi to rebel and cough. The four limbs are the root of all yang. The *Tai Yin Yang Ming Lun* states: "The four limbs all receive qi from the stomach." Cold pathogen entering the stomach prevents yang qi from filling the four limbs, causing yin and yang to fail to connect smoothly, resulting in cold limbs. Vomiting, coughing, and cold limbs indicate yin pathogen running rampant, repelling yang upward, causing deficient fire to float up and resulting in severe headache. If there is no vomiting, coughing, or cold limbs, there is no yin excess repelling yang, hence no headache.
[Correction of Misinterpretations] This clause contrasts with the Yangming Wind Strike clause: "Only dizziness, no aversion to cold, hence able to eat and cough, person will surely have sore throat; if no cough, no sore throat." One is cold, one is heat, exactly opposing each other, demonstrating differentiation methods. Why do commentators think that no sweat, vomiting, coughing, and cold limbs result from cold pathogen causing deep heat? They ignore the Jueyin clause stating "cold limbs must involve heat, prior heat leads to subsequent cold limbs," because Jueyin is a half-yin half-yang meridian, hence the theory "deeper cold limbs mean deeper heat, milder cold limbs mean milder heat." Thus, they add that reversing sweating will cause mouth ulcers. Although this clause belongs to Yangming, it is actually Yangming middle cold, with no heat pathogen in the interior. How can it be interpreted this way? Furthermore, they state that if no cough, vomiting, or cold limbs, but clear urination, heat pathogen must exit via the water pathway. I fear that if there were heat pathogen in the interior, urination might not be smooth. Even if smooth, heat pathogen might not willingly exit via urine. To say pathogen exits via water instead of sweat, I do not believe it. Cheng Wuji based his theory on cold pathogen attacking internally; Fang Youzhi explained it as cold prevailing. Their views are likely not far apart.
In Yangming disease, according to method, there should be much sweat. Unexpectedly no sweat, and the body feels like insects crawling in the skin. This is due to long-standing deficiency.
Pathogen in Yangming should naturally have much sweating. Now unexpectedly no sweat, and the body feels like insects crawling, all due to cold pathogen stagnating between muscle and cutaneous layers, unable to dissipate. This is simply because primordial qi is inherently deficient, lacking yang qi to鼓动 (stimulate) and release yin fluids as sweat, causing pathogen to desire exit but fail to do so.
Desire to vomit after eating grain belongs to Yangming disease. Treat with Wu Zhu Yu Tang (Evodia Decoction). If symptoms worsen after taking the decoction, it belongs to the upper jiao.
This distinguishes between suspected Taiyang and Yangming diseases. Desire to vomit after eating seems like Yangming middle cold inability to eat, hence "belongs to Yangming." Stomach cold fails to accept, so Wu Zhu Yu Tang warms the stomach. If worsening after taking the decoction, it is not stomach cold, but rather Taiyang exterior pathogen in the chest causing vomiting, not yet entering the stomach, hence "belongs to upper jiao." Lou believed that worsening after taking the decoction indicates fire, suggesting Ginger and Coptis treatment. His reasoning was that worsening with heat implies using bitter-cold herbs plus ginger for vomiting. He did not realize this is still Taiyang vomiting due to exterior pathogen. Although Zhang Zhongjing did not prescribe a formula, if fever and no sweat exist, exterior has not been released, and exterior pathogen is about to enter the stomach causing vomiting, the pathogen is still in the chest. Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should be used to induce vomiting, which would be approximately correct.
Wu Zhu Yu Tang Formula
Wu Zhu Yu (Evodiae Fructus, 1 sheng, washed) Renshen (Ginseng Radix et Rhizoma, 3 liang) Shengjiang (Zingiberis Rhizoma Recens, 6 liang) Dazao (Jujubae Fructus, 12 pieces)
These four ingredients, with 7 sheng of water, boil to obtain 2 sheng, remove dregs, take 7 ge warm, three times daily.
One sheng of Wu Zhu Yu should be one he, i.e., two and a half spoons today. Three liang of Renshen should be one liang, i.e., 2.7 qian in Song dynasty. Six liang of Shengjiang should be two liang, i.e., over 5 qian in Song dynasty. Dates should be 4-5 pieces. Seven sheng of water should be three sheng. Looking at Xiao Cheng Qi Tang using only 4 sheng of water, and Tiao Wei Cheng Qi Tang using only 3 sheng, this formula, being a pungent-warm tonic used between exterior-interior suspicions, could it be excessive? It likely originated from later hands, not Zhang Zhongjing's original measurements. Scholars should adjust dosages according to times. See volume preface for conversion.
Yangming disease, pulse slow, although sweating and no aversion to cold, the body will surely feel heavy, short of breath, abdominal fullness, and wheezing. If there is tidal fever, the exterior is about to resolve, and interior can be attacked. Continuous sweating on hands and feet indicates stool has hardened. Treat with Da Cheng Qi Tang (Major Order the Qi Decoction). If sweating is profuse with slight fever and aversion to cold, exterior has not resolved. If fever is not tidal, do not give Cheng Qi Tang. If abdominal distension is severe and unblocked, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) may be given to mildly harmonize stomach qi, avoiding drastic purgation.
Slow pulse is the pulse of Yangming middle cold. Exterior pathogen unresolved should present with aversion to cold and no sweat. Now, although sweating and no aversion to cold, pathogen has entered Yangming interior. But ultimately the pulse is slow, indicating yin-cold pathogen. Spleen and stomach are connected by membranes, hence there are Taiyin concomitant symptoms like heavy body, shortness of breath, and abdominal fullness. Pathogen excess in middle jiao causes abdominal fullness and heaviness. Fullness fills the stomach, causing shortness of breath and wheezing. Having sweated, no aversion to cold, and tidal fever indicates exterior resolving and pathogen entering stomach, ready for interior attack. However, four limbs receive qi from stomach. When stomach qi is excess, hands and feet sweat continuously, indicating stool has hardened. Only then can Da Cheng Qi Tang be used. If the person sweats profusely with slight fever and aversion to cold, it is different. Profuse sweating indicates pathogen in Yangming; slight fever and aversion to cold indicate Taiyang exterior syndrome has not ceased. Hence "exterior not resolved." Whenever pathogen excess in stomach, during Shen-You hours (3-7 PM, peak Yangming qi), tidal fever must occur. If fever is not tidal, Yangming interior pathogen is not excess, and stool is not hardened. Hence Cheng Qi Tang cannot be given. Although drastic purgation is not indicated, if abdominal distension is severe and unblocked, out of necessity, Xiao Cheng Qi Tang may be given to mildly harmonize stomach qi, avoiding drastic purgation. Why? Ultimately due to the slow pulse, there is no major excess-heat in the stomach, so drastic purgation is contraindicated.
Da Cheng Qi Tang Formula
Dahuang (Rhei Radix et Rhizoma, 4 liang, wine-washed) Nongpo (Magnoliae Officinalis Cortex, 4 liang, roasted, peeled) Zhishi (Aurantii Fructus Immaturus, 5 pieces) Mangxiao (Natrii Sulfas, 3 he)
These four ingredients, with 1 dou of water, first boil Nongpo and Zhishi to obtain 5 sheng, remove dregs, add Dahuang, boil to obtain 2 sheng, remove dregs, add Mangxiao, heat slightly for one or two boils. Divide into two warm doses. If bowel movement occurs, do not consume the remainder.
Heat pathogen entering the stomach attaches to retained food and fecal matter, steaming and pressing, depleting stomach fluids, causing tidal fever and hardened stool. If not purged with Da Cheng Qi Tang, heat pathogen will damage stomach qi, leading to delirium, mania, grasping at bedclothes, etc., unto death. Hence, salty-cold and bitter-purgative drugs are necessary to force expulsion. Heat pathogen exits with old filth, like removing firewood from under the cauldron; when wood is gone, fire goes with it. However, it is not only for full retention of filth; if stomach heat pathogen is abundant, it is also necessary. Ancients said this drug is used to purge heat pathogen, not just feces. The formulation uses bitter-cold purgative Dahuang as Sovereign, salty-cold softening Mangxiao as Minister, pungent-warm qi-descending Nongpo as Assistant, and qi-breaking fullness-relieving Zhishi as Envoy, thereby enabling hard-drilling and heat-clearing. If pulse is weak and qi deficient, with mild heat, it should not be used lightly.
[Correction of Misinterpretations] Cheng Wuji said: Cheng means to obey/smooth. Pathogen enters stomach, stomach qi stagnates, feces bind, becoming excess, preventing righteous qi from smoothing. The decoction cleanses, making blocked passages smooth and closed ones open, allowing righteous qi to smooth, hence "Cheng Qi." I believe this explanation is insufficient to reveal Zhang Zhongjing's intent. Calling it "Cheng Qi" likely means accommodating the excess pathogen and substantial qi, using salty-cold and bitter-purgative methods to cleanse and purge. It is usable only for heat-excess and qi-substantial cases; for non-excess-heat and righteous qi-deficient cases, purgation is contraindicated. If stomach qi has failed and righteous qi is about to perish, even strong purgation will not work. This is the case of "no qi to accommodate." It aligns with the *Nei Jing* principle "Excess causes harm, accommodation brings control," meaning heat pathogen excess is controlled by salty-cold and bitter-purgatives, not merely smoothing righteous qi. Observing the treatment of Taiyang-Yangming Spleen Constraint, due to lack of major excess-heat and only dry stomach fluids, only Xiao Cheng Qi Tang and Ma Ren Wan are used to moisten stomach dryness, avoiding drastic purgation, which clarifies this point.
Xiao Cheng Qi Tang Formula
Dahuang (Rhei Radix et Rhizoma, 4 liang, though named "Small," should be 2 liang; Han 2 liang equals Song 5 qian, divided into two doses) Nongpo (Magnoliae Officinalis Cortex, 2 liang, should be 1 liang) Zhishi (Aurantii Fructus Immaturus, 3 pieces)
These three ingredients, with 4 sheng of water, boil to obtain 1 sheng 2 he, divide into two warm doses. First dose should result in bowel movement. If not, drink the rest. If bowel movement occurs, do not take the rest.
Xiao Cheng Qi Tang is Da Cheng Qi Tang with reduced dosage and strength. For major pathogen and major heat excess in stomach, Da Cheng Qi Tang is used. For mild heat pathogen, or no major heat, only dry stomach fluids and difficult stool, Xiao Cheng Qi Tang mildly promotes bowel movement to harmonize stomach qi. Stop when stomach harmonizes; it is not a drastic purgative. Because there is no major hardness, Mangxiao is removed from Da Cheng Qi Tang. Because pathogen is not greatly knotted and full, Nongpo and Zhishi are reduced. Creating methods and formulas involves adjusting based on urgency and severity, avoiding excess or deficiency, fitting the condition. If one does not assess deficiency/excess or weigh severity, insufficiency fails to expel pathogen, while excess severely damages primordial qi. Exercise caution in clinical practice.