问曰。病有太阳阳明。有正阳阳明。有少阳阳明。何谓也。答曰。太阳阳明者。脾约是也。正阳阳明者。胃家
实是也。少阳阳明者。发汗利小便已。胃中燥烦实。大便难是也。
此又设问以明邪入阳明之证治。各有不同。有太阳之邪。初入阳明境界。仍当用太阳治表之法者。如用桂枝汤麻
黄汤及葛根汤桂枝加葛根汤者是也。有邪虽深入阳明。太阳症犹未罢而不可下者。有邪在太阳。误汗吐下。更利
其小便。致胃中亡津液而干燥。大便难而为脾约者。是为太阳阳明。有邪入阳明之里。既无太阳未罢之证。又无传
入少阳之兼证。乃阳明中土。万物所归。无所复传。而为胃实攻下之证者。是谓正阳阳明。有阳明之邪。或太阳之邪
传入少阳。但见少阳一症。便不可汗吐下。止以小柴胡汤和之者。有邪气既在少阳。因误发其汗。利其小便。令胃中
津液干燥烦实。乃邪气复归阳明而大便难者。皆谓之少阳阳明。此三节乃阳明三篇之纲领。今即以此三节。分置
三篇之前。以三节之所属。分隶其下。以便检阅。其解各见本条之下。
阳明病。能食者为中风。不能食者为中寒。
能食为中风者。风性虽温而客热不能杀谷。然合胃热。则能消谷善饥。故能食也。不能食为中寒者。
寒邪在胃。则不化不纳。故不能食也。前太阳以营卫分风寒。此以能食不能食为辨者。何也。岂阳明本经自
受之邪。不由营卫乎。曰。非也。前得之一日。不发热而恶寒。非营卫而何。且有阳明病而用麻黄汤桂枝汤者。
非由营卫而入乎。灵枢邪气脏腑病形篇云。诸阳之会。皆在于面。方乘虚时及新用力。若饮食汗出。腠理开
而中于邪。中于面则下阳明。中于项则下太阳。中于颊则下少阳。阳明居身之前。虽主肌肉。亦必待腠理开而中于邪。
邪气由外而入。安得不由营卫乎。然仲景不以营卫立辨。而以能食不以食为别者。因太阳居身之表。为最外一层。
脉证疑似。表里参错。千蹊万径。变幻无穷。最难察识。非营卫无以为辨。故不得已而用之。至邪入阳明。内关胃气。
即以能食不能食证之。风寒判然。何等明白。何等显易。一言破惑。智愚尽晓。何快如之。又何必喋喋于极难
辨别之营卫乎。此仲景立法之所以妙也。
辨误 此条本所以别阳明本经自感之风寒。而条辨谓是太阳传来之辨验。非阳明自中而然也。不知太阳有经。
阳明亦有经。若果自太阳传来。则仲景已有明训曰。太阳得病时。汗先出不彻。因转属阳明。又曰伤寒发热无汗。呕
不能食。而反汗出 然者。是转属阳明也。又曰伤寒转系阳明者。其人 然汗出也。观此条之语气。以能食不能
食辨别风寒。犹为初症。岂非阳明经之自感乎。至于中风中寒之称。方氏又谓中寒即伤寒之互词。中
伤二字之于风寒。亦从来之通称。通篇虽无伤风一说。然以中寒论之。则中风得称伤风。亦可推也。此
说虽近似有理。然仲景立法垂训。宁肯模糊笼统。使后人于暗中摸影邪。愚考之论中。自太阳篇中至三
阴诸证。凡寒邪为病。无不称伤寒者。此条为阳明纲领。独有中寒二字。已自不同。后节条目中。更有
阳明病若中寒不能食。及阳明病不能食。攻其热必哕。胃中虚冷故也。阳明脉迟。食难用饱。诸证。
皆阳明中寒也。盖伤则邪入犹浅。中则邪入较深。所以即能伤犯胃气而不能食也。试观太阳误治。乘虚
陷入。不痞结于胸中。即入里而伤胃。何况阳明本经受邪。入胃尤为易便。故有得之一日。不发热而
恶寒。二日恶寒自罢。即便汗出而恶热。从可推矣。盖风之中人也。仅伤于卫。寒之伤人也。已伤其
营。俱为在表之邪而已。至失治误治。方得入里。若寒邪之中。气已达内。非复风邪之中人可比。是以
六经条下。风必称中者。风本阳邪。性温而缓。必待中而后能伤卫。若伤风。不过鼻塞声重咳嚏而已。
岂得与伤寒并峙乎。寒本阴邪。其性锋锐。伤之则透卫入营。中之则内犯胃气而不能食矣。至三阴证中。
仲景虽不言中。而太阴之呕吐自利。腹满而痛。少阴脉沉足冷。吐利烦躁。身蜷四逆。厥阴之呕吐涎沫。
下利清谷。以至囊缩等证。岂非后人之所谓直中乎。然则中伤二字。方氏既有箭中刀伤之喻。而又谓
之通称之互词。然欤否欤。
Question: In disease, there are Taiyang Yangming (Taiyang-Yangming syndrome), Zhengyang Yangming (True Yang-Yangming syndrome), and Shaoyang Yangming (Shaoyang-Yangming syndrome). What does this mean?
Answer: Taiyang Yangming refers to Pi Yue (Spleen Constraint, a condition where spleen qi constrains fluids leading to dry stool); Zhengyang Yangming refers to Wei Jia Shi (Stomach House Excess, an excess syndrome of dry-heat accumulation in the stomach and intestines); Shaoyang Yangming refers to the situation after sweating or promoting urination has been performed, resulting in dryness, irritability, and excess heat in the stomach, leading to difficult defecation.
This section uses questions to clarify that the syndromes and treatments for pathogenic factors entering the Yangming channel differ. In some cases, pathogenic factors from the Taiyang channel have just entered the realm of the Yangming channel, and methods for treating Taiyang exterior syndromes should still be used, such as applying Guizhi Tang (Cinnamon Twig Decoction), Mahuang Tang (Ephedra Decoction), Gegen Tang (Kudzu Decoction), or Guizhi Jia Gegen Tang (Cinnamon Twig plus Kudzu Decoction). In other cases, although the pathogen has deeply entered the Yangming channel, Taiyang symptoms have not yet ceased, and purgative methods cannot be used. In some cases, while the pathogen was in the Taiyang channel, improper use of sweating, vomiting, or purging, combined with excessive promotion of urination, caused the depletion of fluids in the stomach, leading to dryness and difficult defecation, forming Pi Yue; this is called Taiyang Yangming. In some cases, the pathogen has entered the interior of the Yangming channel, without any lingering Taiyang symptoms or concurrent Shaoyang symptoms; instead, it follows the nature of Yangming (Earth element) where all things return and no further transmission occurs, forming a Stomach Excess syndrome requiring purgation; this is called Zhengyang Yangming. In some cases, pathogenic factors from the Yangming channel, or those transmitted from Taiyang to Shaoyang, present with even one Shaoyang symptom; in such cases, sweating, vomiting, or purging are contraindicated, and only Xiao Chaihu Tang (Minor Bupleurum Decoction) should be used to harmonize. In some cases, the pathogen is already in the Shaoyang channel, but due to improper sweating or diuresis, causing dryness, irritability, and excess heat in the stomach, the pathogen returns to the Yangming channel, leading to difficult defecation; these are all called Shaoyang Yangming. These three sections serve as the outline for the Upper, Middle, and Lower chapters on Yangming. They are now placed before each respective chapter, categorized under their respective headings for easy reference. Detailed explanations can be found under each specific clause.
In Yangming disease, the ability to eat indicates Zhong Feng (Wind Strike/Attack by Wind Pathogen), while the inability to eat indicates Zhong Han (Cold Strike/Attack by Cold Pathogen).
The reason why the ability to eat corresponds to Zhong Feng is that although wind nature is warm, the external heat alone cannot digest food. However, when combined with stomach heat, it promotes digestion and causes hunger, hence the patient can eat. The reason why the inability to eat corresponds to Zhong Han is that cold pathogens in the stomach prevent digestion and intake, hence the patient cannot eat. Previously, in the Taiyang stage, Wind and Cold were distinguished by Ying and Wei (Nutritive and Defensive levels). Why distinguish here by the ability to eat? Is it because the Yangming channel receives pathogens independently of Ying and Wei? The answer is no. As mentioned earlier, on the first day of illness, without fever but with aversion to cold, this relates to Ying and Wei. Moreover, cases of Yangming disease treated with Mahuang Tang or Guizhi Tang imply transmission via Ying and Wei. The *Ling Shu: Pathogenic Qi, Zang-Fu Organs, and Disease Manifestations* chapter states: "The meeting point of all Yang channels is on the face." When the body is deficient or after exertion, if sweating occurs during eating or drinking, the pores open, allowing pathogens to strike. Striking the face leads downward into the Yangming channel; striking the nape leads downward into the Taiyang channel; striking the cheek leads downward into the Shaoyang channel. The Yangming channel is located at the front of the body; although it governs muscles, it requires open pores to receive pathogens. Since pathogens enter from the exterior, how could they not pass through Ying and Wei? However, Zhang Zhongjing did not use Ying and Wei for differentiation here, but rather used the ability to eat or not as the distinction. This is because the Taiyang channel is at the most superficial level of the body. Its pulse and symptoms are often ambiguous, with interior and exterior signs mixed, making it extremely difficult to identify; thus, Ying and Wei differentiation was necessary. Once the pathogen enters the Yangming channel and affects the Stomach Qi, the distinction between Wind and Cold becomes clear based on appetite, which is straightforward and simple. One statement dispels confusion, understandable to both wise and foolish. How satisfying! Why bother discussing the highly complex Ying and Wei differentiation? This is the subtlety of Zhang Zhongjing's legislative method.
Clarification of Misconceptions: This clause originally aimed to differentiate Wind and Cold directly affecting the Yangming channel itself. Some commentaries claim it differentiates transmission from Taiyang, not direct Yangming infection. However, Taiyang has channel syndromes, and so does Yangming. If it were indeed transmitted from Taiyang, Zhang Zhongjing would have explicitly stated: "When Taiyang disease begins, if sweating is incomplete, it may transform into Yangming." He also said: "In Shanghan (Cold Damage) with fever, no sweat, vomiting, and inability to eat, but with continuous sweating (Ji Ran Han Chu), it transforms into Yangming." And again: "When Shanghan transforms into Yangming, the person sweats continuously." The tone of this clause, distinguishing Wind and Cold by appetite, suggests early-stage symptoms, implying direct Yangming channel infection. Regarding the terms Zhong Feng and Zhong Han, Fang Yi suggested that Zhong Han is synonymous with Shanghan, and "Zhong" and "Shang" are interchangeable terms for Wind and Cold. Although the text rarely uses "Shang Feng" (Injured by Wind), inferring from "Zhong Han," "Zhong Feng" could be equated to "Shang Feng." While this argument seems plausible, Zhang Zhongjing’s legislative principles are precise, not vague, preventing later generations from guessing blindly. Examining his work, from Taiyang to the Three Yin stages, all cold-pathogen diseases are termed Shanghan. This clause, serving as the Yangming outline, uniquely uses "Zhong Han," indicating a difference. Subsequent clauses mention "Yangming disease, if Zhong Han, cannot eat," "Yangming disease, inability to eat, attacking heat will cause hiccups due to cold deficiency in the stomach," and "Yangming pulse is slow, difficulty in eating until full." All these are manifestations of Yangming Zhong Han. Generally, "Shang" implies shallow pathogen entry, while "Zhong" implies deeper entry, thus damaging Stomach Qi and causing anorexia. Consider Taiyang mismanagement: pathogens sinking due to deficiency either cause chest stagnation or enter the interior to damage the Stomach. How much easier is it for pathogens to enter the Stomach when directly infecting the Yangming channel? Thus, on day one, aversion to cold without fever; on day two, aversion to cold ceases, followed by sweating and aversion to heat, which can be inferred. Wind striking the human body typically injures only the Wei (Defensive) level; Cold striking injures the Ying (Nutritive) level; both are exterior pathogens. Only upon mismanagement do they enter the interior. Cold striking reaches the interior quickly, unlike Wind. Therefore, in the Six Channels, Wind is always termed "Zhong" (Strike) because Wind is a Yang pathogen, warm and mild, requiring "striking" to injure Wei. "Shang Feng" (Injured by Wind) merely causes nasal congestion, heavy voice, cough, and sneezing; it cannot stand alongside Shanghan. Cold is a Yin pathogen, sharp and penetrating; "Shang" penetrates Wei into Ying, while "Zhong" invades the interior, damaging Stomach Qi and causing anorexia. In the Three Yin syndromes, although Zhang Zhongjing does not use the term "Zhong," conditions like Taiyin vomiting and diarrhea, abdominal fullness and pain; Shaoyin deep pulse, cold feet, vomiting, diarrhea, irritability, curled body, and four extremities cold; Jueyin vomiting of saliva/froth, clear watery diarrhea, and testicular retraction—are these not what later generations call "Zhi Zhong" (Direct Strike)? Given Fang Yi’s metaphor of being hit by an arrow or knife, yet calling these terms interchangeable, is this correct or not?