约。岂能尽合仲景通篇立名之义乎。至若太阳阳明之脾约。与少阳阳明之胃中燥烦实。大便难者。实为相近。盖太
阳以误汗误下。且利其小便。故令胃中干燥空虚而邪气入胃。虽无大热实。而亦必以小承气和之麻仁丸润之也。
少阳亦禁汗下。若妄汗下之。且利其小便。故令胃中燥烦实。大便难。亦是邪气入胃。仲景不言治。而其法可类推矣。
奈何尚论必以为不可触类而推。又设难以为热邪必自太阳而阳明。阳明而少阳。必待日久而后津液受烁。大便
方难。其邪在太阳。未入于胃。何得津液即便消耗。持论如此。是太少毕竟不相连属。则太少两经之合病并病何来。
太阳之邪未入胃。则太阳阳明之名义安在。若曰津液不当即耗。岂忘却篇首之若汗若下若利小便之亡津液。胃
中干燥之语邪。又谓脾约之症。乃未感之先。其人素惯脾约。故邪未入胃而胃已先实。此论尤为背理。仲景为天下
后世立法。安肯因平素燥结之人。遂立伤寒误治之太阳阳明脾约一例邪。总因但晓浮涩相搏之一症为脾约。犹
未协通篇立法之旨耳。
阳明病。脉浮无汗而喘者。发汗则愈。宜麻黄汤。
邪在太阳之表。则脉有浮缓浮紧之分。病有风寒营卫之别。若阳明之经。已在肌肉之分。营卫之内。以胃腑为里。
故前以能食不能食辨别风寒。此亦不以紧缓为辨。但见脉浮。则知初入之邪。犹在太阳。无汗而喘。则知与太阳中卷
之首条无异矣。故曰发汗则愈。宜麻黄汤。然此条脉证治法。皆寒伤营也。若无阳明病三字。不几列之太阳中篇。而
仲景何故以阳明病冠之耶。盖以太阳中篇之第一条曰。恶寒体痛。脉阴阳俱紧者。名曰伤寒。其次条又曰。
恶风无汗而喘者。麻黄汤主之。此条虽亦无汗而喘。然无恶风恶寒之证。即阳明所谓不恶寒反恶热之意。
是以谓之阳明病也。
太阳病。项背强KT KT 。无汗恶风者。葛根汤主之。
此与前阳明中风第十二条反汗出恶风相对待。前为中风之邪初入阳明而设。此因伤寒邪气初入阳明而设也。
义在阳明中风条下。然项背强。无汗恶风。皆太阳经寒伤营之本证也。以才见KT KT 一证。便是太阳
寒邪已入阳明之经矣。以邪气初入阳明之一二。故以葛根汤主之。
葛根汤方
葛根（四两） 麻黄（三两） 桂枝（二两） 芍药（二两后人误入） 甘草（一两） 生姜（三两）
大枣（十二枚）
上七味。 咀。以水一斗。先煮麻黄葛根减二升。去沫。内诸药。煮取三升。去滓。温服一升。覆取微似汗。不
须啜粥。余如桂枝法将息。及禁忌。
葛根汤。即麻黄汤加入葛根也。因项背强。无汗恶风。纯是太阳伤寒表证。故仍以麻黄汤汗解其寒邪。然较之麻黄
汤证不喘。故去杏仁。但以KT KT 为颈项俱病。项虽属太阳。而颈已属阳明。是以知太阳寒邪。已经透入阳明疆界。
故入葛根以解阳明初入之经邪也。李时珍曰。本草十剂云。轻可去实。麻黄葛根之属。盖麻黄为肺经专药。肺主皮毛。
故可以发太阳之汗。葛根乃阳明经药。兼入脾经。脾主肌肉。故能解肌。二药皆轻扬发散。而所入则迥然不同也。
（辨误见前桂枝加葛根汤下）
伤寒呕多。虽有阳明症。不可攻之。
呕者。邪在胸膈。胸属太阳。故伤寒首条云。太阳病。恶寒体痛呕逆。脉阴阳俱紧者。名曰伤寒。若伤寒呕多。
则太阳表证未罢。虽有阳明见证。未可轻下。下之必有变逆之患。故曰不可攻之。
阳明病。心下硬满者。不可攻之。攻之利遂不止者死。利止者愈。
见证虽属阳明。而心下尚硬满。心下者。心之下。胃之上也。邪未入胃。尚结于胸膈之间。即太阳结胸之类也。
虽属阳明。犹未离乎太阳也。故不可攻之。攻之则里虚邪陷。随其误下之势。利遂不止者。正气不守。真元暴亡。
所以死也。即太阳篇之结胸证。脉浮大者不可下。下之则死。其义一也。若利止者。中气足以自守。真元不致骤脱。
故邪去而能愈也。
脉阳微而汗出少者。为自和也。汗出多者为太过。
阳脉实。因发其汗。出多者亦为太过。太过为阳绝于里。亡津液。大便因硬也。
浮候为脉之阳。沉候为脉之阴。微则经邪衰而表气虚。实则经邪盛而表气实。阳明证本多汗。中风又汗自出。故浮
候之阳脉既微。则邪气已衰而汗出自少。少则津液不耗。正气不虚。故为自和也。若脉阳微。则表气已虚。若汗出多
者。必亡津液而虚正气。故为太过。阳明证虽多汗。而伤寒亦可无汗。风邪盛者亦可发微汗。所以太阳阳明证中。
有项背强KT KT 。反汗出恶风者。用桂枝加葛根汤。无汗恶风者。以用麻黄之葛根汤主之。是皆发微似汗以解之也。
故阳脉实者。因发其微似汗而邪气得解。足矣。若令汗出多者。亦为太过。凡此二太过者。皆足以泄卫阳而
丧津液者也。何也。谷入于胃。胃中阳气。蒸腐水谷。其精华之清气。化而为营。行于脉中。变赤化血。所以滋
养一身。谷之浊气。降于下焦。下焦之真阳。蒸腾其浊中之清气。是谓清阳之气。直达皮肤而为卫气。所以捍
卫风寒。固密皮毛者也。汗出则阳气鼓动。阴液外泄。太过则胃中之阳气孤绝。故曰阳绝于里。阳亢而津液消亡。
使肠胃枯槁而大便因硬也。
伤寒四五日。脉沉而喘满。沉为在里。而反发其汗。津液越出。大便为难。表虚里实。久则谵语。
四五日。邪气入里之时也。在太阳则四五日。亦有表未解者。若脉沉则邪已内入而归里矣。故喘满也。满者。
邪入于胃也。喘者。满而气促。非肺病也。所谓满则必喘也。脉沉既为在里。而反发其汗。是病在里而反攻其表也。
表既无邪。发汗则徒使津液外越。胃中干燥。遂成脾约。故大便难也。妄发其汗。则表气愈虚。津竭便难。则里邪
更实。所以久则谵语也。谵语皆由胃实。仲景虽未立方。推其汗后津枯。表虚里实。大约亦如下文小承气和之而已。
伤寒十三日不解。过经谵语者。以有热也。当以汤下之。若小便利者。大盒饭硬而反下利。脉调和者。知
医以丸药下之。非其治也。若自下利者。脉当微厥。今反和者。此为内实也。调胃承气汤主之。
邪气在表。至七日而六经已尽。至十三日而再经亦尽。故谓之过经。过经而谵语者。以邪入阳明之里。胃中
有实热也。故当以汤下之。曰汤而不曰承气者。以上四句是起下文语。乃借客形主之词。故在所忽也。若小便利者。
其水谷自别。津液下渗。大盒饭硬矣。而反下利。下利则脉不当调。今脉自调和者。非变症使然。知医以丸药误下
所致也。以
理推之。上截谵语而胃中有热。故当以汤下之。此因小便利。则里无大热可知。大便虽硬。无热不须峻下。当以调胃
承气汤和胃。令大便微溏。足矣。不然。胆导蜜导法可耳。岂容以峻厉丸药下之邪。故曰非其治也。若不
因误下而自下利者。脉当微厥。微厥者。忽见微细也。微厥则正气虚衰。真阳欲亡。乃虚寒之脉证也。今下利而脉
反和者。此为内实。内实者。胃中本有实邪也。然内实则脉象亦当实大。而脉反和者。何也。盖不下利之内实。
脉方实大。此以丸药误下。气已下泄。故脉仅得调和而不能实大也。内虽实而脉和。且小便自利。则里无大热。不须
攻下。故以调胃承气汤主之。调胃本云少少温服。以平胃实。胃和则愈矣。
太阳病。若吐。若下。若发汗。微烦。小便数。大便因硬者。与小承气汤和之。愈。
邪在太阳。无论桂枝麻黄。皆取微似汗而已。凡吐下发汗。皆足以伤胃气而损津液。令胃气空虚。虚邪入胃。故微
烦
也。微烦则里无大热。故小便频数。数则津液又从下竭。而气液不能上腾还胃。故大便因硬而成脾约也。以汗吐下
后。胃气已虚。津液已竭。且无大热。不必攻下。故与小承气汤。令微溏以和之。则愈矣。
(Previous discussion) How could it possibly fully conform to the principle of naming established by Zhang Zhongjing throughout his entire work? As for the Pi Yue (Spleen Constriction, a condition characterized by constipation due to fluid deficiency) in Taiyang Yangming disease, and the dryness, irritability, excess, and difficulty in defecation in Shaoyang Yangming disease, they are actually quite similar. This is because Taiyang disease, after mistaken sweating or purging, along with diuresis, leads to dryness and emptiness in the stomach, allowing pathogenic factors to enter the stomach. Although there is no significant heat or excess syndrome, it is still necessary to harmonize it with Xiaochengqi Tang (Minor Order the Yellow Emperor Decoction) and moisten it with Maziren Wan (Hemp Seed Pill).
Shaoyang disease also prohibits sweating and purging. If one recklessly induces sweating or purges, and promotes urination, it results in dryness, irritability, and excess in the stomach, causing difficulty in defecation. This is also due to pathogenic factors entering the stomach. Although Zhang Zhongjing did not explicitly state the treatment method, the therapeutic principles can be inferred by analogy.
Why do some argue that one cannot infer by analogy? They raise objections claiming that heat pathogens must transmit from Taiyang to Yangming, and then from Yangming to Shaoyang, requiring time for body fluids to be scorched before defecation becomes difficult. If the pathogen is still in the Taiyang channel and has not entered the stomach, how can body fluids be consumed immediately? Holding such a view implies that Taiyang and Shaoyang are fundamentally unrelated; thus, where would combined diseases (He Bing) and concurrent diseases (Bing Bing) of these two channels come from? If Taiyang pathogens do not enter the stomach, on what basis does the name "Taiyang Yangming" exist? If one argues that body fluids should not be consumed immediately, have they forgotten the statements at the beginning of the chapter regarding "if sweating, if purging, if promoting urination" leading to loss of body fluids and dryness in the stomach?
Furthermore, some claim that the symptoms of Pi Yue occur because the patient was predisposed to Pi Yue before contracting the disease, so the stomach became full/excess before the pathogen entered. This argument is particularly illogical. Zhang Zhongjing established laws for future generations; would he create a specific case of Taiyang Yangming Pi Yue resulting from mistreatment of cold damage simply because a patient had a chronic tendency towards dryness and constipation? Ultimately, this stems from understanding only the symptom of "floating and choppy pulse interacting" as Pi Yue, without grasping the comprehensive intent of the book's legislative principles.
Yangming disease, presenting with a floating pulse, absence of sweat, and wheezing, will resolve with sweating therapy; Mahuang Tang (Ephedra Decoction) is indicated.
When pathogens are in the exterior of Taiyang, pulses may be floating-slow or floating-tight, corresponding to wind-cold and differences in Ying and Wei levels. However, in the Yangming channel, which is located in the muscle layer, inside the Ying and Wei, with the Stomach Fu organ as the interior, differentiation relies on whether the patient can eat or not, rather than pulse tightness or slowness. Here, seeing a floating pulse indicates the newly arrived pathogen is still in the Taiyang channel. Absence of sweat and wheezing indicate this is identical to the first clause of the Taiyang chapter. Thus, it is said that inducing sweating will cure it, and Mahuang Tang is appropriate. However, the pulse, symptoms, and treatment here all pertain to Cold injuring the Ying level. Without the three characters "Yangming Disease," this would seemingly belong in the Taiyang chapter. Why did Zhang Zhongjing title it "Yangming Disease"? Presumably because the first clause of the Taiyang chapter states: "Aversion to cold, body pain, and pulses both Yin and Yang being tight is named Shanghan (Cold Damage)." The second clause states: "Aversion to wind, absence of sweat, and wheezing are treated with Mahuang Tang." Although this clause also presents absence of sweat and wheezing, it lacks aversion to wind and cold, aligning with the Yangming concept of "no aversion to cold but aversion to heat." Hence, it is called Yangming Disease.
Taiyang disease, presenting with stiffness and discomfort in the nape and back (Jiang Bei Qiang Ji Ji), absence of sweat, and aversion to wind, is treated with Gegen Tang (Kudzu Root Decoction).
This contrasts with Clause 12 of Yangming Wind Strike ("reverse sweating and aversion to wind"). The former addresses Wind Strike pathogens newly entering Yangming; this addresses Shanghan (Cold Damage) pathogens newly entering Yangming. The rationale lies under the Yangming Wind Strike clause. However, stiffness in the nape and back, absence of sweat, and aversion to wind are primary syndromes of Cold damaging the Ying level in the Taiyang channel. The appearance of stiffness in the nape and back alone indicates that Taiyang Cold pathogens have entered the Yangming channel. Because the pathogen has just begun to enter Yangming, Gegen Tang is used.
Gegen Tang Formula
Gegen (Puerariae Lobatae Radix, 4 liang)
Mahuang (Ephedrae Herba, 3 liang)
Guizhi (Cinnamomi Ramulus, 2 liang)
Shaoyao (Paeoniae Radix Alba, 2 liang - erroneously added by later authors)
Gancao (Glycyrrhizae Radix et Rhizoma, 1 liang)
Shengjiang (Zingiberis Rhizoma Recens, 3 liang)
Dazao (Ziziphi Jujubae Fructus, 12 pieces)
The above seven ingredients are crushed. Boil in one dou of water. First decoct Mahuang and Gegen until reduced by two sheng, skim off the foam, then add the remaining herbs. Decoct to obtain three sheng of liquid, remove dregs, and take one sheng warm. Cover to induce slight perspiration. No hot porridge is needed. Rest and dietary precautions follow those of Guizhi Tang.
Gegen Tang is essentially Mahuang Tang with the addition of Gegen. Since stiffness in the nape and back, absence of sweat, and aversion to wind are purely Taiyang Shanghan exterior syndromes, Mahuang Tang is used to release the Cold via sweating. However, unlike Mahuang Tang syndrome which involves wheezing, Xingren (Apricot Seed) is removed here. The term "Qiang Ji Ji" refers to illness affecting both the neck and nape. While the nape belongs to Taiyang, the neck belongs to Yangming. Thus, it is known that Taiyang Cold pathogens have penetrated into the Yangming boundary. Therefore, Gegen is added to resolve the pathogen newly entering the Yangming channel. Li Shizhen stated in *Bencao Shiji*: "Light substances can remove excess," referring to Mahuang and Gegen. Mahuang is a specific herb for the Lung channel; the Lung governs skin and hair, so it can induce sweating from Taiyang. Gegen is an herb for the Yangming channel, also entering the Spleen channel; the Spleen governs muscles, so it can release the muscles. Both herbs are light and dispersing, yet their target channels are distinctly different. (See correction notes under Guizhi Jia Gegen Tang).
In Shanghan, if there is frequent vomiting, even if Yangming symptoms are present, purging must not be used.
Vomiting indicates pathogens in the chest and diaphragm. The chest belongs to Taiyang. Thus, the first clause of Shanghan states: "Taiyang disease, aversion to cold, body pain, vomiting, and reversal, with pulses both Yin and Yang being tight, is named Shanghan." If Shanghan presents with frequent vomiting, the Taiyang exterior syndrome has not resolved. Even if Yangming signs appear, gentle purging should not be attempted. Purging would inevitably lead to adverse changes. Hence, it is said that purging is contraindicated.
In Yangming disease, if the epigastrium is hard and full, purging is contraindicated. If purged and diarrhea persists unceasingly, death ensues; if diarrhea stops, recovery occurs.
Although the signs belong to Yangming, hardness and fullness in the epigastrium remain. The epigastrium is below the heart and above the stomach. Pathogens have not entered the stomach but are knotted in the chest and diaphragm, resembling Taiyang Jie Xiong (Constraint Chest) syndrome. Although classified as Yangming, it has not yet departed from Taiyang. Therefore, purging is contraindicated. Purging causes interior deficiency and pathogen collapse. Following the momentum of mistaken purging, unceasing diarrhea indicates failure of righteous Qi to maintain itself and sudden loss of True Yuan, leading to death. This shares the same principle as the Jie Xiong syndrome in the Taiyang chapter: "If the pulse is floating and large, downward therapy is contraindicated; purging leads to death." If diarrhea stops, the Middle Qi is sufficient to defend itself, and True Yuan does not suddenly escape, allowing the pathogen to depart and recovery to occur.
If the Yang pulse is faint and sweating is scant, this indicates self-harmonization. Excessive sweating indicates excessiveness.
If the Yang pulse is solid/full, and sweating is induced, excessive sweating is also considered excessiveness. Excessiveness leads to Yang isolation in the interior, loss of body fluids, and consequent hardening of feces.
Floating palpation represents the Yang aspect of the pulse; deep palpation represents the Yin aspect. Faintness indicates declining channel pathogens and deficient exterior Qi; fullness indicates abundant channel pathogens and strong exterior Qi. Yangming syndromes typically involve profuse sweating, and Wind Strike involves spontaneous sweating. Therefore, if the floating Yang pulse is faint, pathogens have declined, and sweating is naturally scant. Scant sweating preserves body fluids and righteous Qi, hence termed "self-harmonization." If the Yang pulse is faint, exterior Qi is already deficient; if sweating is excessive, body fluids are lost and righteous Qi weakened, hence termed "excessiveness." Although Yangming syndromes often feature sweating, Shanghan may present without sweat, and strong Wind pathogens may cause slight sweating. Thus, in Taiyang-Yangming syndromes, cases with stiffness in the nape/back, reverse sweating, and aversion to wind use Guizhi Jia Gegen Tang (Guizhi Tang plus Kudzu Root); cases with no sweat and aversion to wind use Gegen Tang containing Mahuang. All these induce slight perspiration to resolve the pathogen. Therefore, for those with a solid Yang pulse, inducing slight perspiration resolves the pathogen sufficiently. Inducing excessive sweating is excessiveness. Both types of excessiveness deplete Wei Yang and consume body fluids. Why? Grain enters the stomach; Stomach Yang qi steams and rots the grain. Its essence and clear Qi transform into Ying (Nutritive Qi), circulating within vessels, turning red to form Blood, nourishing the whole body. The turbid Qi of grain descends to the Lower Jiao. The True Yang of the Lower Jiao steams the clear Qi within the turbidity, creating Clear Yang Qi, which reaches the skin to become Wei (Defensive) Qi, protecting against wind-cold and securing the pores. Sweating moves Yang Qi and expels Yin fluids. Excessiveness isolates Stomach Yang Qi, hence "Yang isolation in the interior." Yang hyperactivity consumes body fluids, drying the intestines and stomach, causing hard stools.
In Shanghan, on the fourth or fifth day, if the pulse is deep and accompanied by wheezing and fullness: Deep indicates interior location. Mistakenly inducing sweating causes body fluids to leak out, making defecation difficult. Exterior deficiency and interior excess develop; over time, delirium occurs.
The fourth or fifth day is when pathogens enter the interior. In Taiyang, even on the fourth or fifth day, the exterior may not be resolved. However, a deep pulse indicates pathogens have moved inward to the interior. Hence, wheezing and fullness. Fullness signifies pathogens entering the stomach. Wheezing is shortness of breath due to fullness, not lung pathology. It is said that fullness necessitates wheezing. Since a deep pulse indicates interior location, inducing sweating attacks the exterior while the disease is interior. With no exterior pathogen, sweating merely drives body fluids outward, causing stomach dryness, forming Pi Yue (Spleen Constriction), and resulting in difficult defecation. Reckless sweating further weakens exterior Qi; exhausted fluids and difficult defecation strengthen interior pathogens. Thus, delirium occurs over time. Delirium arises from Stomach excess. Although Zhang Zhongjing did not prescribe a formula here, inferring from post-sweat fluid depletion, exterior deficiency, and interior excess, it likely resembles using Xiaochengqi Tang (Minor Order the Yellow Emperor Decoction) to harmonize, as mentioned later.
If Shanghan remains unresolved for thirteen days, and delirium occurs after passing through the meridians (Guo Jing), it is due to heat; downward therapy with decoction is indicated. If urine is free-flowing, stool should be hard, yet diarrhea occurs instead. If the pulse is harmonious, it indicates the physician mistakenly used pill-based purgatives, which is incorrect treatment. If diarrhea occurred spontaneously, the pulse should be faint and thready (Wei Jue). Since the pulse is now harmonious, this indicates interior excess. Tiaowei Chengqi Tang (Harmonize the Stomach Order the Yellow Emperor Decoction) is indicated.
Pathogens in the exterior complete the six meridians cycle in seven days. By thirteen days, the second cycle is complete, hence "passing through the meridians." Delirium after this period indicates pathogens have entered the Yangming interior, creating excess heat in the stomach. Downward therapy with decoction is required. The text says "decoction" rather than specifying "Chengqi" because the preceding four sentences introduce the following context, serving as a rhetorical device. If urine flows freely, water and grain separate, and body fluids seep downward, stool should be hard. Yet diarrhea occurs. Diarrhea usually precludes a harmonious pulse. A harmonious pulse here indicates the condition resulted from mistaken purging with pills, not a natural transformation. Logically, the earlier delirium indicated stomach heat requiring decoction purging. However, free-flowing urine suggests no major heat in the interior. Although stool is hard, without significant heat, harsh purging is unnecessary. Tiaowei Chengqi Tang should be used to harmonize the stomach, aiming for slightly loose stools. Alternatively, enema methods could be used. Harsh pill purgatives are inappropriate, hence "incorrect treatment." If diarrhea were spontaneous (not caused by mistaken purging), the pulse would be faint and thready, indicating deficiency-cold. A harmonious pulse during diarrhea indicates interior excess (pathogenic excess in the stomach). Typically, interior excess presents with a large, solid pulse. Here, the pulse is merely harmonious because the pill purgative drained Qi downward, preventing it from becoming large and solid. Despite interior excess and a harmonious pulse, plus free-flowing urine indicating no major heat, aggressive purging is not needed. Tiaowei Chengqi Tang is used. It should be taken in small amounts, warm, to pacify Stomach excess. When the Stomach harmonizes, recovery occurs.
In Taiyang disease, if vomiting, purging, or sweating were performed, resulting in slight irritability, frequent urination, and consequently hard stool, Xiaochengqi Tang (Minor Order the Yellow Emperor Decoction) should be given to harmonize, leading to recovery.
For pathogens in Taiyang, whether using Guizhi or Mahuang, the goal is slight perspiration. Vomiting, purging, and sweating all damage Stomach Qi and consume body fluids, leaving Stomach Qi empty and allowing deficient pathogens to enter, causing slight irritability. Slight irritability indicates no major heat in the interior, hence frequent urination. Frequent urination exhausts body fluids downward, preventing Qi and fluids from ascending back to the stomach, resulting in hard stool and Pi Yue. After sweating, vomiting, and purging, Stomach Qi is deficient, body fluids are depleted, and there is no major heat. Aggressive purging is unnecessary. Xiaochengqi Tang is given to induce slight looseness and harmonize the interior, leading to recovery.