少阳阳明者。发汗利小便已。胃中燥烦实。大便难是也。
此言少阳入阳明之由也。少阳阳明之证。有阳明之经邪传入少阳者。有少阳之经邪归入阳明胃腑者。
皆可称少阳阳明。虽两经之兼证。然论中已有明训曰。伤寒中风。有柴胡证。但见一证便是。不必悉具。
又申之以禁例曰。少阳不可发汗。不可吐下。若此。则凡见少阳一症。汗吐下三法。皆在所禁矣。若以
少阳证而发其汗。且利其小便。令胃中之津液干燥而烦。是少阳之邪。并归于胃。故曰燥烦实。实则大
便难也。盖以少阳胆经。内藏精汁。不出不纳。无本经里证。既不内入三阴。故复归阳明中土而大便难。
既归阳明。则邪气已离少阳。而汗下之禁已弛。其治当与太阳阳明之脾约不远矣。仲景虽不言治法。
而但曰胃中燥烦实。大便难。则是与前太阳阳明之亡津液。胃中干燥。大便难之证无异。其和胃之法。
从可推矣。
服柴胡汤已。渴者。属阳明也。以法治之。
此亦邪自少阳入阳明也。服柴胡汤者。邪在少阳故也。无论他经传入。或本经自感。但见少阳证。
即当用之以和解
半表半里之邪。无他法也。服已而渴。非复少阳证之或渴或不渴矣。夫少阳之渴。热犹在经而未入里。
故虽渴不甚。但以小柴胡加栝蒌根治之而已。至服汤之后。当邪解而渴止矣。乃服已而渴。知邪已入胃。
胃中津液枯燥。即前渴欲饮水之渴。故曰属阳明也。但云以法治之而不言法者。盖法无定法也。倘虽
属阳明。而少阳证尚有未罢。犹未可轻犯少阳之禁。若竟归阳明。即当以治阳明法治之。不必更拘少
阳法也。邪热既以归胃。当审其虚实而治之可也。假令无形之热邪在胃。烁其津液。则有白虎汤之法
以解之。若津竭胃虚。又有白虎加人参之法以救之。若有形之实邪。则有小承气及调胃承气汤和胃之法。
若大实满而潮热谵语。大便硬者。则有大承气攻下之法。若胃气已实而身热未除者。则有大柴胡汤两
解之法。若此之类。机变无穷。当随时应变。因证便宜耳。岂有一定之法可立。又岂因久远遗亡之所
致哉。
辨误 夫邪之入少阳也。或从太阳与阳明传来。或本经自受。盖太阳主外而居表。邪气由此假途而入。
在所不免。然未必一定从阳明传入也。虽云太阳总营卫而主第一层。阳明主肌肉而为第二层。少阳主
躯壳之里而为第三层。而其经脉。则太阳之脉行身之背。阳明之脉行身之前。少阳之脉行身之侧。虽各
有支别。行度而不乱。然其交互盘错。则有不能必相离异者。故其受邪必不能按次循序。先后不紊。
若云必由太阳而传阳明。阳明而传少阳。挨次轮传。则太少有所间隔。何谓两阳合明乎。且合病并病条中。
不当有太少合并之病矣。更曷为有柴胡桂枝汤之太少两解。及柴胡桂枝干姜汤乎。注家谓风寒皆从阳
明而传少阳。此又云少阳重转阳明。则邪还阳明。岂知阳明传少阳者。乃在表之经邪也。故谓之传经。
少阳属阳明者。乃入胃之腑邪也。为自经入里。非惟三阳之邪自经归里。皆
必入胃。胃实而后可下。即三阴证中如太阴症之腹满时痛至大实痛者。即以桂枝大黄汤主之。及腐秽当
去之类。又如少阴症中之承气汤急下三条。厥阴证中之下利谵语。有燥屎者以小承气汤。皆邪气入胃。
所谓阳明中土。万物所归。无所复传之地也。惟此三阴下证。然后可称重转阳明。邪还阳明。以既入三阴。
理难再返。故曰重转。若在三阳。不过邪气入里。谓之转属阳明而已。岂宜胶固其层次之说。而又茫
然混称其为重转阳明也哉。
阳明病。发潮热。大便溏。小便自可。胸胁满不去者。小柴胡汤主之。
此阳明兼少阳之证也。邪在阳明而发潮热。为胃实可下之候矣。而大便反溏。则知邪虽入而胃未实也。
小便自可。尤知热邪未深。故气化无乖而经邪尚未尽入也。胸胁满者。邪在少阳之经也。少阳之脉循胁里。
其支者合缺盆。下胸中。胸胁之满未去。其邪犹在半表半里之间。故为少阳阳明。然既曰阳明病。而独以
少阳法治之者。盖阳明虽属主病。而仲景已云伤寒中风。有柴胡证。但见一证便是。不必悉具。故凡见少阳
一证。便不可汗下。惟宜以小柴胡汤和解之也。
阳明病。胁下硬满。不大便而呕。舌上白苔者。可与小柴胡汤。上焦得通。津液得下。胃气因和。身 然而
汗出解也。
此亦阳明兼少阳之证也。上文虽潮热而大便反溏。小便自可。此虽不大便而未见潮热。皆为阳明热邪未实于胃
之证。前云胸胁满未去。此云胁下硬满而呕。皆为少阳见证。而似瘥有轻重。以致后人有少阳为多之解。然仲
景之意。不过互相发明。初无少异。但训人以见证虽有不同。其理本无二致也。言证见阳明而又胁下硬满。此证兼少阳
也。少阳之脉行身之侧。循胁里。邪气入经。故硬满也。不大便为阳明里热。然呕则又少阳证也。少阳
之支脉。合缺盆。下胸中。邪在胸中。故呕也。舌苔之状。虽各有不同。而寒热虚实。及邪之浅深。
证之表里。无不毕现。智者明睿所照。自是纤毫无爽。若热邪实于胃。则舌苔非黄即黑。或干硬。或芒
刺矣。舌上白苔。为舌苔之初现。若夫邪初在表。舌尚无苔。既有白苔。邪虽未必全在于表。然犹未尽
入于里。故仍为半表半里之证。邪在半里。则不可汗。邪在半表。则不可下。故可与小柴胡汤以和解之。
少阳之经邪得解。则胸邪去而其呕自止。胁邪平而硬满自消。无邪气间隔于中。则上焦之气得以通行无
滞。故胃中之津液得以下流。而大便自通。胃气因此而和。遂得表里畅达。通身 然汗出而解矣。
上焦得通。津液得下。胃气因和三句。成氏未悟其旨。故不能解。方氏已知津液得下为大便行矣。
喻氏因之。故曰既云津液得下。则大便自行。亦可知矣。而犹未知上焦得通。胃气因和之义。故有风寒
之邪。协津液而上聚膈中之说。又多一篇泛论。盖小柴胡非上焦之药。因少阳之脉络循胸胁。邪入其
经。故胁硬满而呕。胸胁如此。所以上下不通。既得和解。而少阳之经脉流通。硬满已消。一无障碍。故
上焦之气得以通行。而胃中之津液。亦随气下走。燥去而大便通矣。胃气因和者。因大便通而胃气得和也。
即前太阳阳明证中小承气和胃之义也。前以汗吐下后。又利其小便。虽无大热。奈胃中之津液枯涸。故成
脾约。胃中既无津液。无以流通。故不得已而以小承气和胃。及麻仁丸润燥。令胃和则愈。此以未经汗下。
津液无损。故不必小承气而后和。但得和解而气通津下。大便自通。胃气自和矣。仲景之文。虽未显言。
然推其词气。已无余蕴矣。若但举其所知而遗其所不知。是终未得其全旨。恐于后学。终无益也。
Shaoyang-Yangming disease refers to the condition where, after undergoing sweating and diuresis treatments, the stomach becomes dry, irritable, and full of excess heat, resulting in difficult defecation.
This explains the mechanism by which Shaoyang disease transitions into Yangming disease. The syndrome of Shaoyang-Yangming includes cases where pathogenic factors from the Yangming channel transmit to Shaoyang, as well as cases where pathogenic factors from the Shaoyang channel enter the Yangming Stomach organ. Both can be termed Shaoyang-Yangming. Although this is a combined syndrome of two channels, the *Shanghan Lun* (Treatise on Cold Damage) explicitly states: In cases of cold damage or wind strike, if there are Chaihu Syndrome (the main formula syndrome for Shaoyang disease) signs, observing just one symptom is sufficient; it is not necessary for all symptoms to be present. Furthermore, contraindications are reiterated: Shaoyang disease should not be treated with sweating, emesis, or purging. Thus, whenever even one sign of Shaoyang is observed, the three methods of sweating, emesis, and purging are all prohibited. If sweating is applied to a Shaoyang syndrome, along with promoting urination, the body fluids in the stomach will dry up, causing irritability and heat. This means the Shaoyang pathogen has converged into the stomach, hence described as "dryness, irritability, and excess." Excess leads to difficult defecation. Since the Gallbladder channel of Shaoyang stores essence juice (bile) and neither excretes nor absorbs internally, lacking interior syndromes of its own channel, and since it does not transmit inward to the Three Yin channels, it returns to the Yangming Earth (Spleen and Stomach), causing difficult defecation. Once the pathogen has entered Yangming, it has left Shaoyang, and the previous prohibitions against sweating and purging for Shaoyang are lifted. The treatment method should not differ significantly from the Pi Yue (Spleen Restriction) syndrome of Taiyang-Yangming (constipation due to fluid depletion). Although Zhang Zhongjing did not explicitly state the treatment, merely saying "stomach dryness, irritability, excess, and difficult defecation," this is identical to the earlier Taiyang-Yangming syndrome characterized by loss of body fluids, dry stomach, and difficult defecation. The method of harmonizing the stomach can thus be inferred.
If thirst occurs after taking Chaihu Tang, it belongs to Yangming disease. Treat according to the methods for Yangming disease.
This also represents the transmission of pathogen from Shaoyang to Yangming. Taking Chaihu Tang indicates the pathogen was in Shaoyang. Whether transmitted from other channels or directly contracted by the channel itself, whenever Shaoyang signs appear, Chaihu Tang should be used to harmonize and resolve pathogens in the half-exterior, half-interior; there is no other method. Thirst appearing after medication is no longer the intermittent thirst characteristic of Shaoyang disease. In Shaoyang disease, thirst arises because heat remains in the channel without entering the interior; thus, although thirsty, the sensation is mild, and it can be treated with Xiao Chai Hu Tang (Minor Bupleurum Decoction) plus Gualou Gen (Trichosanthes Root). After taking the decoction, the pathogen should resolve and thirst cease. Now, if thirst persists or appears after taking the medicine, it indicates the pathogen has entered the stomach, drying the stomach fluids. This is the same thirst desiring water mentioned previously, hence stated as belonging to Yangming. The text says "treat according to the method" without specifying it because there is no fixed method. If, although belonging to Yangming, Shaoyang signs have not yet resolved, one must still avoid violating Shaoyang contraindications. If it completely belongs to Yangming, then Yangming treatment methods should be used, without being constrained by Shaoyang methods. Since the pathogenic heat has returned to the stomach, one must examine its deficiency or excess to treat accordingly. If formless heat exists in the stomach, scorching fluids, Bai Hu Tang (White Tiger Decoction) can be used to resolve it. If fluids are exhausted and Stomach Qi is deficient, Bai Hu Jia Ren Shen Tang (White Tiger Plus Ginseng Decoction) is used to rescue. If there is substantial excess pathogen, Xiao Cheng Qi Tang (Minor Order the Qi Decoction) or Tiao Wei Cheng Qi Tang (Regulate the Stomach Order the Qi Decoction) are used to harmonize the stomach. If there is severe fullness and hardness accompanied by tidal fever, delirium, and hard stool, Da Cheng Qi Tang (Major Order the Qi Decoction) is used for purging. If Stomach Qi is excessive but external fever remains, Da Chai Hu Tang (Major Bupleurum Decoction) is used for simultaneous exterior-interior resolution. Such variations are infinite; one must adapt to changes according to circumstances and adjust flexibly based on the syndrome. Is there a fixed rule? Is this due to loss over long ages?
[Correction of Misunderstandings]
When pathogens enter Shaoyang, they may come from Taiyang and Yangming, or be directly contracted by the channel itself. Taiyang governs the exterior and resides on the surface; pathogens borrowing this route to enter are inevitable. However, they do not necessarily transmit from Yangming. Although it is said that Taiyang governs Ying and Wei and occupies the first layer, Yangming governs muscles and occupies the second layer, and Shaoyang governs the interior of the body shell occupying the third layer, regarding their meridians: Taiyang meridians run along the back, Yangming along the front, and Shaoyang along the sides. Although each has branches running orderly, they interweave and cannot always be strictly separated. Therefore, contracting pathogens does not necessarily follow a sequential order without deviation. If one claims transmission must go from Taiyang to Yangming, then to Shaoyang, sequentially, there would be a gap between Taiyang and Shaoyang, contradicting the concept of "Two Yangs Combining to Brighten." Moreover, in sections on Combined Diseases and Concurrent Diseases, there would be no mention of Taiyang-Shaoyang concurrent diseases, nor the existence of formulas like Chai Hu Gui Zhi Tang (Bupleurum and Cinnamon Twig Decoction) for resolving both Taiyang and Shaoyang, or Chai Hu Gui Zhi Gan Jiang Tang (Bupleurum, Cinnamon Twig, and Dried Ginger Decoction). Commentators claim wind-cold transmits from Yangming to Shaoyang, and here it says Shaoyang turns to Yangming, calling it "pathogen returning to Yangming." They fail to realize that Yangming transmitting to Shaoyang involves exterior channel pathogens, termed "transmission." Shaoyang belonging to Yangming involves interior organ pathogens entering the stomach, termed "entering from channel to interior." Not only do Three Yang pathogens entering from channels to interior must enter the stomach before purging can occur, but even in Three Yin syndromes, such as Taiyin syndrome with abdominal fullness and pain ranging to severe pain, Guizhi Dahuang Tang (Cinnamon Twig and Rhubarb Decoction) is used, or for eliminating foul matter; similarly, the three urgent purging indications using Cheng Qi Tang in Shaoyin syndrome, and dysentery with delirium and dry feces in Jueyin syndrome treated with Xiao Cheng Qi Tang, all indicate pathogens entering the stomach—the so-called "Yangming Central Earth, where all things return, having nowhere else to transmit." Only these Three Yin purging indications can be called "re-turning to Yangming" or "pathogen returning to Yangming," because once entering Three Yin, it is theoretically difficult to return, hence "re-turning." In the Three Yang, it is merely pathogen entering the interior, termed "turning to belong to Yangming." One should not rigidly adhere to hierarchical layers and vaguely confuse them with "re-turning to Yangming."
In Yangming disease, if there is tidal fever, loose stools, normal urination, and persistent chest-hypochondriac fullness, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is indicated.
This is a Yangming syndrome combined with Shaoyang. Pathogen in Yangming causing tidal fever suggests stomach excess suitable for purging. However, stools are loose, indicating that although the pathogen has entered, the stomach is not yet solid. Normal urination further indicates shallow heat, unimpaired Qi transformation, and that channel pathogens have not fully entered the interior. Chest-hypochondriac fullness indicates pathogen in the Shaoyang channel. Shaoyang meridians circulate through the hypochondrium; branch meridians converge at the Clavicle (Quepen) and descend into the chest. Persistent chest-hypochondriac fullness indicates the pathogen remains in the half-exterior, half-interior, hence termed Shaoyang-Yangming. Although termed Yangming disease, treating solely with Shaoyang methods is because Zhang Zhongjing stated: in cold damage or wind strike, if Chaihu signs exist, observing one is sufficient. Thus, whenever one Shaoyang sign appears, sweating and purging are prohibited; only Xiao Chai Hu Tang should be used to harmonize.
In Yangming disease, if there is hardness and fullness under the hypochondrium, constipation, vomiting, and a white coating on the tongue, Xiao Chai Hu Tang (Minor Bupleurum Decoction) may be given. When the Upper Jiao becomes free, body fluids descend, Stomach Qi harmonizes, and the patient sweats slightly, the disease resolves.
This is also a Yangming syndrome combined with Shaoyang. Previously, tidal fever with loose stools and normal urination indicated Yangming heat not yet solid in the stomach. Here, constipation without tidal fever also indicates Yangming heat not solid in the stomach. Previous chest-hypochondriac fullness and current hypochondriac hardness with vomiting are both Shaoyang signs, differing only in severity, leading some later commentators to believe Shaoyang signs predominate. However, Zhang Zhongjing's intent was mutual clarification, with no fundamental difference, teaching that while signs vary, the principle is consistent. Yangming signs with hypochondriac hardness indicate combined Shaoyang. Shaoyang meridians run along the side and hypochondrium; pathogen entering the channel causes hardness. Constipation indicates Yangming interior heat, but vomiting is a Shaoyang sign. Shaoyang branch meridians converge at Quepen and descend into the chest; pathogen in the chest causes vomiting. Tongue coating varies, revealing cold-heat, deficiency-excess, pathogen depth, and exterior-interior status. A wise observer sees clearly. If heat is solid in the stomach, the coating is yellow or black, dry/hard, or prickly. A white coating is an initial manifestation. If pathogen is initially in the exterior, there is no coating; presence of white coating means pathogen is not entirely in the exterior nor fully in the interior, remaining half-exterior, half-interior. Pathogen in half-interior prohibits sweating; pathogen in half-exterior prohibits purging. Thus, Xiao Chai Hu Tang is used to harmonize. Resolution of Shaoyang channel pathogens removes chest pathogens (stopping vomiting) and calms hypochondriac pathogens (resolving hardness). With no pathogen obstructing the middle, Upper Jiao Qi flows freely, allowing stomach fluids to descend and bowels to open naturally. Stomach Qi harmonizes, interior-exterior flow is smooth, slight sweating occurs, and the disease resolves.
Regarding the phrases "Upper Jiao becomes free, body fluids descend, Stomach Qi harmonizes," Cheng Wuji failed to grasp the meaning and could not explain. Fang Youzhi understood "body fluids descend" implies bowel movement, and Yu Jiayan followed him, stating that if fluids descend, bowel movement follows. However, they missed the meaning of "Upper Jiao becomes free, Stomach Qi harmonizes," proposing instead that wind-cold pathogens combine with fluids gathering in the Diaphragm, adding unnecessary generalizations. Xiao Chai Hu Tang is not specifically an Upper Jiao drug; rather, Shaoyang meridians traverse the chest and hypochondrium. Pathogen entering the channel causes hypochondriac hardness and vomiting. Obstruction in chest-hypochondrium blocks upper-lower communication. Upon harmonization, Shaoyang meridians flow freely, hardness resolves, and obstacles clear. Thus, Upper Jiao Qi flows, and stomach fluids follow the Qi downward. Dryness clears, bowels open. "Stomach Qi harmonizes" means Stomach Qi harmonizes due to opened bowels. This aligns with the harmonizing stomach meaning of Xiao Cheng Qi Tang in earlier Taiyang-Yangming cases. Previously, after sweating, emesis, purging, and diuresis, despite lack of major heat, stomach fluids were depleted, forming Pi Yue. With no fluids to circulate, Xiao Cheng Qi Tang and Ma Ren Wan (Hemp Seed Pill) were used to moisten dryness and harmonize the stomach. Here, without prior sweating/purging, fluids are intact, so Xiao Cheng Qi Tang is unnecessary. Harmonization allows Qi flow and fluid descent, naturally opening bowels and harmonizing Stomach Qi. Although Zhang Zhongjing did not explicitly state this, analyzing his wording reveals complete meaning. Listing only what is known while omitting the unknown fails to capture the full intent, ultimately offering little benefit to future students.