阳明病。脉迟。汗出多。微恶寒者。表未解也。可发汗。宜桂枝汤。
邪在太阳。则以浮缓为中风。阳明已在肌肉之分。与太阳稍异。故不曰缓而曰迟。所谓迟者。非寒脉之迟。
乃缓脉之变称也。又非中寒之阳明脉迟也。若阳明脉迟。即不能食矣。下文阳明中风者皆能食。但此条
以风邪在太阳之表。仍是风伤卫分。故不言能食而亦以桂枝汤主之也。汗出多者。太阳中风。已是阴弱而汗自出矣。
而阳明证又法当多汗。二证兼并。故汗出多也。太阳中风本恶寒。邪入阳明。当不恶寒而反恶热矣。今风邪尚
在太阳卫分。故仍恶寒。但邪气已属阳明。故虽恶寒而亦微也。然汗出已多。邪气当解而不恶寒矣。以汗多而仍恶寒。
是以知太阳之表证尚未解也。故云可发汗。宜桂枝汤。
太阳病。项背强。KT KT 。反汗出恶风者。桂枝加葛根汤主之。
旧注云。KT KT 。伸颈之貌。动则伸颈摇身而行。项背强者。动则如之。此成氏之说也。夫项背已强缩而
不得伸。又安能伸颈摇身而行乎。KT KT 。按字义本属象形。言鸟之短羽者。飞则KT KT 然。所以形容病患之
颈项俱病。俯首不能自如
之貌。盖因太阳之经。自头而行于背。故项强。阳明之经。自面而行于身之前。故颈病。灵枢脉经篇云。足太阳之脉。
其
直者从巅入络脑。还出别下项。挟脊抵腰中。足阳明之脉。旁约太阳。循颐后。出大迎。循颊车。过客主人。
循发际。其支者下人迎。循喉咙。入缺盆。以二经并皆受邪。故颈项皆病。所以不得引伸而KT KT 然也。此条与阳
明
伤寒之KT KT 无汗恶风者。互相对待。彼以太阳寒邪初入阳明。其无汗恶风之太阳表证仍在。故以有麻黄之葛根汤
主之。
此以太阳风邪初入阳明。其汗出恶风之太阳表证仍在。故以桂枝加葛根汤主之。盖无汗恶风及汗出恶风。皆太阳中风
伤寒之见证。惟KT KT 为颈病。故属阳明。以太阳证多。阳明证少。故仍谓之太阳病。而各以伤寒之麻黄。中风之
桂枝
为主治。而加入葛根以解阳明初入之邪也。夫阳明本多汗。太阳中风亦自汗出。此以太阳中风传入阳明。本当汗出而
谓之反者。非阳明中风。不应汗出而曰反也。盖因阳明伤寒条下。有KT KT 无汗恶风。故此曰反汗出也。
桂枝加葛根汤方
葛根（四两） 桂枝（三两） 芍药（二两） 生姜（三两） 大枣（十二枚擘） 甘草（二两）
上六味。以水一斗。煮取三升。去滓。温服一升。如桂枝汤法。
于桂枝汤方内。加葛根三两。余根据桂枝汤法。
辨误 按太阳阳明KT KT 证二条。其治反汗出恶风。既名之曰桂枝加葛根矣。无汗恶风者。乃伤寒初入阳明。
故仍
用麻黄汤之汗泄。而加入葛根。以解阳明初入之经邪。本当名之曰麻黄加葛根汤。两方并峙。则风寒各异。自无交
互舛错之病矣。不意但名之曰葛根汤。其名义稍觉模糊。致后之昧于理者。搅乱错杂。以桂枝汤中之芍药。误入有
麻黄之葛根汤中。芍药乃敛阴收汗之药。岂宜用之于无汗恶风之伤寒。至以葛根汤中之麻黄。误入桂枝加葛根
汤中。岂反汗出者之所宜。况太阳中风本自汗出。阳明又多自汗。宁可更用麻黄又发其汗乎。恐不止于
津液枯竭。而有亡阳之祸矣。前注皆失于觉察。相沿传习。其害有不可胜言者。故特拈出。以辨千载之误。
阳明病。脉浮而紧者。必潮热。发作有时。但浮者。必盗汗出。
邪在太阳。以浮紧为寒。浮缓为风。在阳明则紧为在里。浮为在表。脉浮而紧者。言浮而且紧也。谓邪
虽在经。大半已入于里也。邪入于里。必发潮热。其发作有时者。阳明气旺于申酉。故日晡时潮热也。
潮热则已成可下之证矣。但脉尚兼浮。则为表邪未尽。犹未可下也。若但浮者。风邪未全入里。其在经之
邪未解。必盗汗出也。阳明本多汗多眠。故有盗汗。然不必阳明始有盗汗。如太阳上编脉浮而动数。因自汗出
之中风。即有盗汗。盖由目瞑则卫气内入。皮肤不阖。则盗汗出矣。此示人当以脉症辨认表里。未可因
潮热而轻用下法也。
阳明病。但头眩。不恶寒。故能食而咳。其人必咽痛。若不咳者。咽不痛。
但头眩者。热在上也。不恶寒。即阳明篇首所谓不恶寒反发热之义也。能食。阳明中风也。咳者。热
在上焦而肺气受伤也。中风之阳邪壅于上焦。故咽门必痛也。若不咳者。上焦之邪热不甚。故咽亦不痛。此条纯
是热邪。当与阳明中寒之不咳不呕。手足不厥。头不痛一条。两相对待。盖示人以风寒之辨也。
脉浮发热。口干鼻燥。能食者则衄。
脉浮发热。邪在表也。口干鼻燥。阳明之脉。起于鼻之交 中。下循鼻外。上入齿中。还出挟口环唇。下循
喉咙。入缺盆。
热论云。阳明主肉。其脉挟鼻络于目。故身热目疼。而鼻干不得卧也。能食者。阳明中风。热邪能杀谷也。
阳明郁甚。不得汗泄。逼血妄行而出于上焦清窍也。
阳明病。口燥。但欲漱水不欲咽。此必衄。
口燥者。热在上也。但欲漱水不欲咽者。邪热未入于胃也。若热邪入胃。则必渴欲饮水。今但漱而不欲咽。
是邪未入里。阳邪独盛于上。故迫血妄行而上溢。所以必衄也。
若渴欲饮水。口干舌燥。白虎加人参汤主之。
承上文言不但口燥。若口干舌燥。且渴欲饮水者。方是邪热归胃。胃中热燥而津液枯涸也。当清胃热而滋养
其津液。故以白虎加人参汤主之。
若脉浮发热。渴欲饮水。小便不利者。猪苓汤主之。
脉浮发热。太阳表邪犹未解也。渴欲饮水。当属胃热。若渴欲饮水而小便不利者。仍是足太阳膀胱之里证。
非胃中热燥也。盖膀胱为州都之官。津液藏焉。太阳热邪归腑。则热聚膀胱。气化失常。下焦之气液不得上腾。
故渴欲饮水。下焦之地气既不得升。则上焦之肺气不降。是无高源之水矣。水热穴论云。肾为本而肺为末。膀胱者。
肾之腑也。本末不相通。故渴而小便不利也。若邪气止在太阳一经而内犯膀胱者。仲景必以五苓散治之矣。
若太阳上编之中风发热。六七日不解而烦。渴欲饮水。水入则吐者。又如太阳中篇发汗已。脉浮数烦渴者。又如
本以下之故。心下痞。与泻心汤痞不解。其人渴而口燥烦。小便不利者。皆以五苓散主之。此条因是太阳阳明兼证。
且阳明乃两阳合明。
至阳之腑。又中风而非中寒。故不宜用桂。但以猪苓汤渗泄膀胱之热邪。使阴阳升降。气液通行。邪可分消矣。
猪苓汤方
猪苓（去皮） 茯苓 阿胶 滑石（嫩者研细） 泽泻（以上各一两）
上五味。以水四升。先煮四味取二升。去滓。内下阿胶。烊消。温服七合。日三服。
猪苓及茯苓泽泻。义见五苓散论中。滑石者。十剂中之通剂也。李时珍曰。滑石利窍。不独小便也。
上能利毛腠之窍。下能利精溺之窍。盖甘淡之味。先入于胃。渗走经络。游溢精气。上输于脾。肺为水之上源。
下通膀胱。津液藏焉。气化则出。故滑石上能发表。下利小便。为荡热燥湿之剂。阿胶乃济水之伏流。阴水也。
能清肺益阴。用此水以搅浊水则清。盖济水质清而性重。其性趋下故也。成氏谓阿胶之滑以利水道。不知何
所考据。
阳明病。汗出多而渴者。不可与猪苓汤。以汗多胃中燥。猪苓汤复利其小便故也。
阳明病。法当多汗。若汗出多。则胃中之津液已外泄矣。其渴固所宜然。且又无小便不利之证。故不可与
猪苓汤。何也。以汗出既多。则胃中之津液枯燥。若更与猪苓汤复利其小便。是又下竭其津液矣。焉得不为脾约乎。
当滋其津液。渴自止矣。
病患烦热。汗出则解。又如疟状。日晡所发热者。属阳明也。脉实者宜下之。脉浮虚者宜发汗。下之与大
承气汤。发汗宜桂枝汤。
此亦太阳入阳明之辨证法也。言病患烦热。至汗出而后解者。又或如疟状。必至日晡时发热者。即潮热也。如此。
则
邪气已属阳明矣。然表里之分。当以脉辨之。若按其脉而实大有力者。为邪在阳明之里而胃实。宜攻下之。
若脉浮虚者。即浮缓之义。为风邪犹在太阳之表而未解。宜汗解之。谓之浮虚者。言浮脉按之本空。非虚弱之虚也。
若虚弱则不宜于发汗矣。宜详审之。脉实者下之。以其胃热。故宜与大承气汤。浮虚者汗之。以其风邪未解。
故宜与桂枝汤。
阳明病。脉浮而紧。咽干口苦。腹满而喘。发热汗出。不恶寒。反发热。身重。若发汗则燥。心愦愦。反谵语。
若加烧针。必怵惕烦躁不得眠。若下之。胃中空虚。客气动膈。心中懊 。舌上苔者。栀子豉汤主之。
脉浮为邪在阳明之经。紧则入于里矣。解见上文第十三条。胃开窍于口。咽则胃之门户也。邪热在胃。故咽燥
口苦而腹满也。喘者。腹满而胀。气不得息。非肺家之痰喘。即阴阳应象论所谓身热喘粗也。发热汗出。阳明表证也。
不恶寒反恶热。邪入阳明之本症也。腹满身重。本属太阴。经云。脾胃以膜相连。邪热在胃。阳明胃腑受病。则太
阴脾土亦病。故身重也。表里皆有邪。若治其表。而以辛温发汗。则亡津液而胃中热燥。必使心神愦愦。反增谵语。
若以烧针取汗。则阳邪受火。愈增煽动。故心神为之怵惕惊恐。阳盛而烦。阴虚而躁。故不得眠也。若下之。则表邪
未解。里邪未实。徒伤胃气。曰胃中空虚者。非谓胃中之水谷尽出。乃胃中之阳气空虚也。正气虚而客邪动于膈间。
故心中懊 。懊 者。若有所忧闷悔恨然也。但言舌上苔而不言其色与状者。以意揆之。当是邪初入里。胃邪未实。
其色犹未至于黄黑焦紫。必是白中微黄耳。邪气初入。既不可汗下。而烧针又非阳邪所宜。邪在膈间。治无他法。
不得已而用高者越之之法。故以栀子豉汤主之。
阳明病下之。其外有热。手足温。不结胸。心中懊 。饥不欲食。但头汗出者。栀子豉汤主之。
虽误下之。而外仍有热。是邪气犹在外也。四肢为诸阳之本。而禀气于胃。误下之而手足尚温。是胃气未伤而邪未
入阴也。不结胸。邪未尽陷也。心中懊 。饥不能食。但头汗出者。热客胸中。虚邪搅扰于膈间也。头为诸阳之
会。阳邪郁蒸于上。阴阳之脉络不得相输。故但头汗出而身无汗。所谓剂颈而还也。当用栀子豉汤以吐胸中之邪。
吐则并可得汗而解外也。
阳明中风。口苦咽干。腹满微喘。发热恶寒。脉浮而紧。若下之。则腹满小便难也。
口苦咽干。腹满微喘。即上文咽燥口苦。腹满而喘也。脉浮而紧。亦与上条同义。上文发热汗出。不恶寒而反恶热。
邪入阳明已深。以其经邪未解。故不可下。此条尚发热恶寒。则知太阳之经邪亦未解也。庸可下乎。若早下之。则胃气
空虚。表邪陷入而腹更满。阳气虚损。三焦不运。气化不行。津液不流而小便难矣。
阳明中风。脉弦浮大而短气。腹都满。胁下及心痛。久按之。气不通。鼻干不得汗。嗜卧。一身及面目悉黄。小便
难。
有潮热。时时哕。耳前后肿。刺之小瘥。外不解。病过十日。脉续浮者。与小柴胡汤。脉但浮无余证者。与麻黄汤。
若不尿腹满加哕者。不治。
脉弦。少阳风木之邪也。浮为风邪在表。大则阳明热邪在里矣。腹满。阳明里证也。腹都满。言遍腹皆满也。满甚
而气
不得通。故短气也。胁下及心痛。即少阳篇所谓胸胁满痛也。少阳之脉合缺盆。下胸中。贯膈络肝属胆。循胁里。故胁
下及
心胸间皆痛也。久按之气不通者。言不按已自短气。若久按之。则气愈不通。盖言其邪气充斥也。鼻干。阳明之脉络于
鼻也。
邪入阳明。法多汗。不得汗。则阳明之经邪。愈不得泄矣。嗜卧。阳明里邪也。盖邪在阳明之表。则不得卧。
邪在阳明之里。则嗜卧也。一身及面目悉黄。因不得汗泄。热邪不能发越。而阳明瘀热在里故也。小便难者。
邪热闭塞。三焦不用。气化不行也。若小便利。则不能发黄矣。潮热。阳明里实也。时时哕者。邪热伤胃。
胃气不通。气逆而作呃忒也。耳前后肿。虽三阳之脉络皆至耳。阳明之脉。已见前第十二条。然少阳之脉起
于目锐 。上抵头角。下耳后。其支者从耳后入耳中。出走耳前。风热上壅。故前后皆肿也。刺之小瘥者。
刺少阳阳明之络。则热邪暂泄。经气稍通。故肿处小瘥也。里证如此深重。则外证亦可以已矣。若外证犹
未解者。是邪未尽入也。病情至此。其脉当不浮矣。既有外证未解。病过十日。而其脉续见浮者。则阳明里邪。
有向外复出之机。重归少阳之经。故与小柴胡汤和解之。以引出其半表半里之邪。若脉但浮。浮为邪气在表。
且从前诸余症悉无者。是邪尽还表。复出太阳营卫之间矣。治之无难。一汗而愈矣。故重与麻黄汤。然治中
风而以麻黄汤者。以邪气重大深入。致腹满发黄。潮热不得汗小便难之剧证。非复桂枝汤可啜粥汗解之症矣。
况阳明本应多汗。今不得汗而脉浮。故以麻黄汤发其汗。经所谓开腠理。致津液。通气也。若邪不复外出而
Yangming disease. The pulse is slow, there is profuse sweating, and slight aversion to cold; this indicates that the exterior syndrome has not yet resolved. Sweating may be induced, and Guizhi Tang (Cinnamon Twig Decoction) is appropriate.
When pathogenic factors are in the Taiyang (Greater Yang) meridian, a floating and moderate pulse indicates Wind Strike (Zhong Feng). In Yangming disease, the pathogen is already at the muscle level, which differs slightly from Taiyang; therefore, "moderate" is not used, but "slow". Here, "slow" does not refer to the cold-type slow pulse, nor is it the slow pulse of Yangming caused by Cold Strike. It is rather a variant term for a moderate pulse. If it were the slow pulse of Yangming due to Cold Strike, the patient would be unable to eat. As mentioned later regarding Yangming Wind Strike, patients can eat. However, in this clause, because the wind pathogen remains at the exterior of Taiyang, it is still Wind damaging the Wei (Defensive) level; thus, the ability to eat is not mentioned, and Guizhi Tang is still prescribed. Profuse sweating occurs because Taiyang Wind Strike inherently involves weak Yin leading to spontaneous sweating, and Yangming syndromes typically involve excessive sweating; the combination of these two conditions results in profuse sweating. Taiyang Wind Strike inherently involves aversion to cold. When pathogens enter Yangming, one should no longer be averse to cold but instead averse to heat. Currently, since the wind pathogen is still in the Taiyang Wei level, aversion to cold persists. However, because the pathogen belongs to Yangming, the aversion to cold is slight. Although sweating is profuse and the pathogen should theoretically resolve without aversion to cold, the persistence of aversion to cold despite profuse sweating indicates that the Taiyang exterior syndrome has not yet resolved. Therefore, it is stated that sweating may be induced, and Guizhi Tang is appropriate.
Taiyang disease characterized by stiffness and discomfort in the nape and back, difficulty extending the neck, accompanied by spontaneous sweating and aversion to wind, is primarily treated with Guizhi Jia Gegen Tang (Guizhi Decoction plus Pueraria Root).
Old annotations describe "KT KT" as the appearance of extending the neck, moving by extending the neck and shaking the body. Those with stiff nape and back move in this manner when active; this is Cheng Wuji's explanation. However, if the nape and back are already stiff and contracted, unable to extend, how can one extend the neck and shake the body? "KT KT" is originally an ideogram depicting short-winged birds flying. It describes the posture of a patient suffering from both neck and nape ailments, unable to lift their head freely. This is because the Taiyang meridian runs from the head down the back, causing nape stiffness; the Yangming meridian runs from the face down the front of the body, causing neck ailments. The *Ling Shu: Mai Jing* states: The straight branch of the Foot-Taiyang Bladder Meridian enters the brain from the vertex, emerges separately to descend the nape, and reaches the waist along the spine. The Foot-Yangming Stomach Meridian runs alongside the Taiyang, follows behind the jaw, emerges at Daying, follows the cheekbone, passes through Jiache, travels along the hairline, its branch descends to Renying, follows the throat, and enters the Supraclavicular Fossa. Since both meridians are affected by pathogens, both the neck and nape are diseased, resulting in the inability to extend and presenting the "KT KT" appearance. This clause contrasts with the Yangming Cold Strike clause featuring "KT KT", absence of sweating, and aversion to wind. In the latter, Taiyang Cold Pathogens have just entered Yangming, and the Taiyang exterior syndrome of no sweating and aversion to wind persists; thus, Gegen Tang containing Mahuang (Ephedra) is used. In this clause, Taiyang Wind Pathogens have just entered Yangming, and the Taiyang exterior syndrome of sweating and aversion to wind persists; thus, Guizhi Jia Gegen Tang is used. Generally, absence of sweating with aversion to wind and sweating with aversion to wind are manifestations of Taiyang Wind Strike and Cold Strike. Only "KT KT" relates to neck ailments, hence belonging to Yangming. Since Taiyang symptoms predominate over Yangming symptoms, it is still called Taiyang disease. Treatment primarily uses Mahuang for Cold Strike and Guizhi for Wind Strike, adding Gegen (Pueraria Root) to resolve pathogens newly entering Yangming. Yangming naturally involves more sweating, and Taiyang Wind Strike also involves spontaneous sweating. This clause involves Taiyang Wind Strike transmitting to Yangming; although sweating is expected, it is termed "reverse" not because Yangming Wind Strike shouldn't sweat, but because the Yangming Cold Strike clause mentions "KT KT", no sweating, and aversion to wind, making the presence of sweating here appear "reverse".
**Guizhi Jia Gegen Tang Formula**
Gegen (Puerariae Radix) - 4 liang
Guizhi (Cinnamomi Ramulus) - 3 liang
Shaoyao (Paeoniae Radix Alba) - 2 liang
Shengjiang (Zingiberis Rhizoma Recens) - 3 liang
Dazao (Jujubae Fructus) - 12 pieces, split
Gancao (Glycyrrhizae Radix et Rhizoma) - 2 liang
Take the above six ingredients, decoct in 10 dou of water until 3 sheng remain, remove the dregs, and take 1 sheng warm, following the method of Guizhi Tang.
Add 3 liang of Gegen to the Guizhi Tang formula; follow the rest of the Guizhi Tang method.
**Correction of Misconceptions:** Regarding the two clauses on Taiyang-Yangming "KT KT" syndrome, the treatment addresses sweating and aversion to wind. Since it is named Guizhi Jia Gegen Tang, the case of no sweating and aversion to wind represents Cold Strike newly entering Yangming. Thus, the sweating-inducing action of Mahuang in Gegen Tang is retained, adding Gegen to resolve pathogens newly entering the Yangming meridian. It should properly be named Mahuang Jia Gegen Tang. With both formulas standing side by side, Wind and Cold would be distinct, preventing confusion. Regrettably, naming it merely "Gegen Tang" created ambiguity, leading later practitioners ignorant of principles to mix them up. They mistakenly included Shaoyao (which astringes Yin and stops sweating) into the Mahuang-containing Gegen Tang, which is inappropriate for no-sweating Cold Strike. Conversely, they mistakenly included Mahuang into Guizhi Jia Gegen Tang, which is unsuitable for patients with sweating. Moreover, Taiyang Wind Strike inherently involves spontaneous sweating, and Yangming involves excessive spontaneous sweating; using Mahuang again to induce sweating could lead not only to exhaustion of Jin-Ye (Body Fluids) but also to the disaster of collapse of Yang Qi. Previous annotations failed to notice this, perpetuating the error with dire consequences. This is highlighted to correct a millennium-old mistake.
In Yangming disease, a floating and tight pulse indicates tidal fever occurring at specific times. If the pulse is only floating, night sweats will occur.
When pathogens are in Taiyang, a floating-tight pulse indicates Cold, and floating-moderate indicates Wind. In Yangming, tight indicates interior involvement, and floating indicates exterior involvement. A floating-tight pulse means both floating and tight, indicating that although the pathogen is in the meridian, most has entered the interior. Interior pathogens cause tidal fever. The timing is due to Yangming Qi being vigorous during Shen and You hours (3 PM–7 PM), hence tidal fever occurs in the late afternoon (ribu). Tidal fever signifies a condition suitable for purgation. However, since the pulse still floats, exterior pathogens remain unresolved, and purgation is premature. If the pulse is only floating, Wind pathogens have not fully entered the interior, and exterior pathogens remain unresolved, leading to night sweats. Yangming naturally involves more sweating and sleepiness, hence night sweats. However, night sweats are not exclusive to Yangming; in the earlier Taiyang section, a floating and rapid-moving pulse with spontaneous sweating (Wind Strike) also presents night sweats. This occurs because when eyes close, Wei Qi enters internally, and if the skin pores do not close, night sweats occur. This illustrates that one must distinguish exterior and interior based on pulse and symptoms, and not lightly use purgation due to tidal fever alone.
In Yangming disease, isolated dizziness, no aversion to cold, ability to eat, and cough indicate that the person will definitely suffer from sore throat. If there is no cough, the throat will not hurt.
Isolated dizziness indicates heat in the upper jiao. No aversion to cold aligns with the opening statement of the Yangming chapter: "no aversion to cold, but aversion to heat." Ability to eat indicates Yangming Wind Strike. Cough indicates heat in the upper jiao injuring Lung Qi. Yang pathogens from Wind Strike congesting the upper jiao cause sore throat. If there is no cough, upper jiao heat is mild, so the throat does not hurt. This clause involves pure heat pathogens and should be contrasted with Yangming Cold Strike involving no cough, no vomiting, cold limbs, and no headache, to illustrate the differentiation between Wind/Cold and Heat.
Floating pulse, fever, dry mouth, and dry nose, with the ability to eat, indicate epistaxis (nosebleed).
Floating pulse and fever indicate pathogens in the exterior. Dry mouth and nose relate to the Yangming meridian, which starts at the nose, crosses the midline, descends along the outside of the nose, enters the teeth, emerges beside the mouth encircling the lips, descends along the throat, and enters the supraclavicular fossa. The *Re Lun* states: Yangming governs flesh; its meridian flanks the nose and connects to the eyes. Hence, body heat, eye pain, and dry nose preventing sleep. Ability to eat indicates Yangming Wind Strike, where heat pathogens digest food effectively. Severe Yangming stagnation prevents sweating, forcing blood to act recklessly and exit through the clear orifices of the upper jiao.
In Yangming disease, dry mouth with desire to rinse water but not swallow indicates inevitable epistaxis.
Dry mouth indicates heat in the upper jiao. Desire to rinse but not swallow indicates heat pathogens have not entered the Stomach. If heat entered the Stomach, thirst and desire to drink water would occur. Rinsing without swallowing shows pathogens have not entered the interior; Yang pathogens dominate the upper jiao, forcing blood upward, hence epistaxis.
If there is thirst and desire to drink water, with dry mouth and tongue, Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) is indicated.
Continuing from the previous text, if there is not just dry mouth but also dry mouth/tongue and thirst/desire to drink, this indicates heat pathogens returning to the Stomach, causing Stomach heat-dryness and fluid exhaustion. One must clear Stomach heat and nourish fluids, hence Baihu Jia Renshen Tang.
If there is a floating pulse, fever, thirst/desire to drink water, and difficult urination, Zhuling Tang (Polyporus Decoction) is indicated.
Floating pulse and fever indicate unresolved Taiyang exterior pathogens. Thirst/desire to drink suggests Stomach heat. However, thirst with difficult urination indicates an interior syndrome of the Foot-Taiyang Bladder, not Stomach heat-dryness. The Bladder is the official of storage, housing fluids. When Taiyang heat pathogens enter the fu-organ, heat gathers in the Bladder, disrupting qi transformation. Lower jiao qi and fluids cannot ascend, causing thirst. Since lower jiao earth qi cannot rise, upper jiao Lung qi cannot descend, lacking high-source water. The *Shui Re Xue Lun* states: Kidney is root, Lung is tip; Bladder is the Fu of Kidney. Disconnection between root and tip causes thirst and difficult urination. If pathogens remained only in Taiyang and invaded the Bladder, Zhang Zhongjing would use Wuling San (Five-Ingredient Powder with Poria). Cases like Taiyang Wind Strike fever unresolved for 6-7 days with vexation/thirst/water rejection, or post-sweating floating/rapid pulse/vexation/thirst, or heart-fullness after mis-purgation with vexation/thirst/difficult urination, are all treated with Wuling San. This clause involves Taiyang-Yangming combined syndrome. Yangming is the fusion of two Yangs, the extreme Yang fu. Since it is Wind Strike, not Cold Strike, Guizhi is inappropriate. Instead, Zhuling Tang drains Bladder heat, allowing yin-yang ascent/descent and qi-fluid circulation, dispersing pathogens.
**Zhuling Tang Formula**
Zhuling (Polypori Umbilicati Sclerotium, peeled)
Fuling (Poria)
Ejiao (Colla Corii Asini)
Huashi (Talcum, fine powder of tender variety)
Zexie (Alismatis Rhizoma)
(Above each 1 liang)
Take the above five ingredients, decoct in 4 sheng of water. First decoct the first four until 2 sheng remain, remove dregs, add Ejiao, melt, and take 7 he warm, three times daily.
Zhuling, Fuling, and Zexie meanings are seen in the Wuling San discussion. Huashi is a "Slippery Agent" among the Ten Categories. Li Shizhen said: Huashi opens orifices, not just for urination. It opens cutaneous orifices above and essence/urine orifices below. Its sweet-bland flavor enters the Stomach, permeates collaterals, circulates essence, uploads to Spleen. Lung is the upper source of water, connecting downward to Bladder. Qi transformation releases fluids. Thus, Huashi releases the exterior above and promotes urination below, acting as a agent to wash away heat and dry dampness. Ejiao is the hidden flow of Ji River, Yin Water. It clears Lung and benefits Yin; mixing this clear water with turbid water clarifies it. Ji River water is clear and heavy, tending downward. Cheng Wuji claimed Ejiao's slipperiness benefits water passages, but his evidence is unknown.
In Yangming disease, if there is profuse sweating and thirst, Zhuling Tang must not be given. Because profuse sweating causes Stomach dryness, and Zhuling Tang further promotes urination.
Yangming disease naturally involves profuse sweating. If sweating is profuse, Stomach fluids are already lost externally. Thirst is expected. Without difficult urination, Zhuling Tang is contraindicated. Why? Profuse sweating dries Stomach fluids; using Zhuling Tang to promote urination further depletes fluids, leading to Pi Yue (Spleen Constraint). One must nourish fluids, and thirst will cease.
Patients with vexatious heat find relief after sweating, resembling malaria. Fever occurring at ribu (late afternoon) indicates Yangming. If the pulse is solid, purgation is indicated; if floating and deficient, sweating is indicated. For purgation, Da Chengqi Tang (Major Order the Qi Decoction) is used. For sweating, Guizhi Tang is used.
This is the differentiation method for Taiyang entering Yangming. Vexatious heat resolving after sweating, resembling malaria, with fever at ribu (tidal fever), indicates pathogens belong to Yangming. Exterior/Interior distinction depends on pulse. Solid, large, forceful pulse indicates interior excess in Yangming/Stomach, requiring purgation. Floating-deficient pulse implies floating-moderate, indicating Wind pathogens still in Taiyang exterior unresolved, requiring sweating. "Floating-deficient" means the floating pulse feels empty upon pressure, not deficiency weakness. Weakness would contraindicate sweating. Carefully examine. Solid pulse requires purgation due to Stomach heat, hence Da Chengqi Tang. Floating-deficient pulse requires sweating due to unresolved Wind pathogens, hence Guizhi Tang.
Yangming disease with floating-tight pulse, dry throat/bitter taste, abdominal fullness with panting, fever with sweating, no aversion to cold but aversion to heat, and body heaviness. If sweating is induced, agitation ensues, mind becomes confused, and delirium appears. If fire needle therapy is added, fright, vexation, and insomnia result. If purgation is used, Stomach becomes empty, guest pathogens disturb the diaphragm, causing mental depression (Ao Nao). With coating on the tongue, Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) is indicated.
Floating pulse indicates pathogens in Yangming meridian; tight indicates entry into interior (see Clause 13). Mouth opens to Stomach; throat is Stomach gate. Heat in Stomach causes dry throat, bitter taste, and abdominal fullness. Panting is due to abdominal distension blocking qi, not Lung phlegm-panting, but "body heat and rough breathing" from *Yin Yang Ying Xiang Da Lun*. Fever with sweating is Yangming exterior syndrome. No aversion to cold but aversion to heat is the fundamental Yangming symptom. Abdominal fullness and body heaviness belong to Taiyin. Spleen and Stomach are connected by membranes; Stomach heat affects Spleen Earth, causing body heaviness. With exterior and interior pathogens, treating exterior with acrid-warm sweating depletes fluids, causing Stomach heat-dryness, leading to confused mind and delirium. Fire needle adds fire to Yang pathogens, increasing agitation, causing fright and insomnia (Yang excess causes vexation, Yin deficiency causes restlessness). Purgation when exterior is unresolved and interior is not solid injures Stomach Qi. "Stomach empty" refers to deficiency of Stomach Yang Qi, not lack of food. Deficient righteous Qi allows guest pathogens to disturb the diaphragm, causing Ao Nao (mental depression/regret). Tongue coating color/states omitted imply early interior entry, not yet solid, likely white with slight yellow. Early interior pathogens cannot be treated with sweating/purgation or fire needle. For pathogens in diaphragm, the only method is "vomiting high pathogens," hence Zhizi Chi Tang.
After purgation in Yangming disease, if exterior heat remains, hands/feet are warm, no Jie Xiong (Chest Binding), mental depression (Ao Nao), hunger but no desire to eat, and only head sweating, Zhizi Chi Tang is indicated.
Despite mistaken purgation, exterior heat remains, indicating pathogens still outside. Limbs are root of Yang Qi, receiving Qi from Stomach. Warm hands/feet post-purgation show Stomach Qi intact and pathogens not entering Yin. No Jie Xiong shows pathogens not fully sinking. Mental depression, hunger without eating, and head-only sweating indicate heat lodging in chest, disturbing diaphragm. Head is gathering of Yang; Yang pathogens steaming upward block yin-yang meridian connection, causing head-only sweating ("stopping at neck"). Use Zhizi Chi Tang to vomit chest pathogens; vomiting induces sweating to resolve exterior.
Yangming Wind Strike with bitter taste, dry throat, abdominal fullness, slight panting, fever with aversion to cold, floating-tight pulse. If purged, abdominal fullness and difficult urination result.
Bitter taste, dry throat, abdominal fullness, slight panting match previous clause. Floating-tight pulse same meaning. Previous clause had fever/sweating/no aversion to cold/aversion to heat, deep Yangming entry, but meridian pathogens unresolved, so no purgation. This clause has fever/aversion to cold, showing Taiyang meridian pathogens unresolved. How can purgation be used? Early purgation empties Stomach Qi, traps exterior pathogens increasing fullness, damages Yang Qi, disrupts San Jiao transport, stops qi transformation/fluid flow, causing difficult urination.
Yangming Wind Strike with wiry-floating-large pulse, shortness of breath, generalized abdominal fullness, hypochondriac and heart pain, qi obstruction upon prolonged pressing, dry nose, inability to sweat, lethargy, jaundice of whole body/face, difficult urination, tidal fever, frequent hiccups, swelling before/behind ears. Acupuncture brings slight relief. Exterior unresolved. Disease past ten days, pulse continues floating: give Xiao Chaihu Tang (Minor Bupleurum Decoction). Pulse only floating without other symptoms: give Mahuang Tang (Ephedra Decoction). If no urination, abdominal fullness increases with hiccups: untreatable.
Wiry pulse indicates Shaoyang Wind-Wood pathogen. Floating indicates exterior Wind. Large indicates interior Yangming Heat. Abdominal fullness is Yangming interior syndrome. Generalized fullness blocks qi, causing shortness of breath. Hypochondriac/heart pain matches Shaoyang chest-hypochondriac fullness. Shaoyang meridian connects to supraclavicular fossa, descends chest, pierces diaphragm, connects Liver/Gallbladder, follows ribs, causing pain. Prolonged pressing worsening qi obstruction indicates pathogen congestion. Dry nose relates to Yangming meridian connecting to nose. Yangming pathogens normally sweat; inability to sweat prevents pathogen release. Lethargy indicates Yangming interior pathogen (exterior prevents sleep, interior causes lethargy). Jaundice results from trapped heat failing to vent, accumulating in Yangming. Difficult urination due to heat blocking San Jiao/qi transformation. Clear urination prevents jaundice. Tidal fever indicates Yangming interior excess. Frequent hiccups indicate heat injuring Stomach, blocking Qi reversal. Swelling before/behind ears: Shaoyang meridian starts at outer eye corner, goes to temple, behind ear, branch enters/exits ear. Wind-heat congestion causes swelling. Acupuncture provides slight relief by temporarily draining heat/passing meridian qi. Deep interior symptoms suggest exterior should resolve. If exterior persists, pathogens haven't fully entered. Pulse should not float. But if disease lasts >10 days and pulse remains floating, Yangming interior pathogens have opportunity to exit outward, returning to Shaoyang meridian. Give Xiao Chaihu Tang to harmonize and draw out half-exterior/half-interior pathogens. If pulse only floating without other symptoms, pathogens returned entirely to exterior/Taiyang Ying-Wei. Easy to treat with one sweating episode. Hence, Mahuang Tang is given again. Using Mahuang Tang for Wind Strike is justified because severe/deep pathogens caused fullness/jaundice/no-sweating/difficult urination, too severe for Guizhi Tang + porridge sweating. Yangming should sweat; now no sweat with floating pulse, so Mahuang Tang induces sweating. Classic says: open pores, deliver fluids, unblock qi. If pathogens do not exit outward...