问曰。阳明病外证云何。答曰。身热汗自出。不恶寒。反恶热也。
此设为问答。以别阳明之外证。与太阳不同也。如太阳中风。则发热汗出而必恶风恶寒。若阳明中风。
虽同一身热汗自出。即不恶寒而反恶热矣。反恶热者。以邪入阳明之经也。灵枢阴阳系日月篇云。辰为左足
之阳明。巳为右足之阳明。此两阳合明于前。故曰阳明。盖辰巳之前。午居离位。乃至阳之地。邪并于阳。
阳盛则热也。故阴阳别论以胃脘之阳为二十五阳之主。所以能运化腐熟。而为水谷之海也。邪气入之。则阳
邪炽盛。故不恶寒而反恶热也。以后凡称阳明病者。皆必有此等证。然后可称阳明病也。
问曰。病有一日得之。不发而恶寒者。何也。答曰。虽得之一日。恶寒将自罢。即自汗出而恶热也。
此又设问以辨阳明本经自感之表邪。与太少二阳经之表证迥异也。夫寒邪之在太少二阳经也。有六七日表证
仍在者。有八九日不解表证仍在者。有四五日身热恶风项强胁满者。五六日往来寒热者。惟阳明本经
自感之寒邪。亦由营卫而入。营卫属太阳。故有一日得之。不发热而恶寒者。然一日之后。邪入阳明肌肉之分。
由渐入里。故不待解散。其恶寒将自罢。即自汗出而反恶热矣。不似太阳传经之邪。必待误汗误下及利小便。
或汗不彻。然后转属阳明也。
问曰。恶寒何故自罢。答曰。阳明居中。土也。万物所归。无所复传。始虽恶寒。二日自止。此为阳明病也。
此又以明阳明伤寒入里而不恶寒之故也。曰恶寒何故自罢。曰阳明之经。在太少二阳之间。胃为阳明之腑。
又在心肺之下。肝肾之上而居中。与脾脏以膜相连而为表里。犹大地居天之中。故为中央土也。土为万物之所归。
邪气入胃。不比在经之邪。而能游行传遍。至此而无所复传。惟有攻下之法而已。经所谓土郁则夺之也。故始初
之一日。尚在表而恶寒。至二日渐入阳明之里而自止。此为阳明之里证也。然邪气初到阳明。何以即入里乎。
曰若分而言之。则太阳有经。故外以经脉为表。内以膀胱为里。是以里证少而表证多。阳明亦有经。故亦以经脉为表。
而以胃腑为里。里证多而表证少。所以太阳治表之法居多。其治里之法。惟五苓散而已。阳明治里之法居多。其治
表之法。惟葛根汤而已。然葛根汤之治表。亦必藉太阳之麻黄桂枝。方能发表。以邪从营卫而入。必由太阳故也。
若以大概言之。则太阳专主乎表。必因误治而入里。阳明专主乎里。六经之邪皆可归入。入则无所复传。而成阳明
下证。故谓之万物所归也。二日自止者。即内经热论所云。一日巨阳受之。二日阳明受之之谓也。然此亦阳明之大意。
立法之常
经。犹未尽其变也。若在经之邪。至入里之候。或迟或速。其不齐正未可量也。
问曰。何缘得阳明病。答曰。太阳病。若发汗。若下。若利小便。此亡津液。胃中干燥。因转属阳明。
不更衣。内实大便难者。此名阳明病也。
此又以明邪在太阳。因误治而传入阳明之里也。曰因何缘故而得阳明病乎。曰太阳病。若误发其汗。
或早下之。及利其小便。皆足以丧胃中之津液。损胃阳之真气。使热邪乘虚入里。故为亡津液而胃中干燥。
因热邪转属阳明胃经。故使不更衣。更衣者。凡贵人大便后。必更换所服之衣。故称大便曰更衣。不更衣
则内实而大便难。此名阳明病也。不曰不大便有燥屎。而曰不更衣大便难者。缓词也。言此不过无津液
而大便难。非若正阳阳明之热邪实于胃。有燥屎而谵语潮热不大便也。故一以小承气和之。一以大承气
攻下之也。不大便则绝不能大便。今曰大便难。则犹欲大便而但觉难也。
本太阳初得病时。发其汗。汗先出不彻。因转属阳明也。
言寒邪初入太阳。因邪气在表而发其汗。汗多固嫌于太过。然汗少亦为不及。不及则汗不彻而留邪内入。
由太阳转属阳明矣。此示人以太阳传入阳明之故也。
伤寒转系阳明者。其人 然微汗出也。
转者。以此转属于彼。即传经之谓也。系。连属也。 然。 然微汗润湿之貌。言以无汗之伤寒。
才入阳明。即 然微汗而现阳明经证矣。此示人以验邪入阳明之候也。
伤寒发热无汗。呕不能食。而反汗出 然者。是转属阳明也。
寒邪在表。则发热无汗。寒邪在胸。则呕不能食。皆太阳寒伤营之表证也。以无汗之伤寒。而反汗出 然者。
是太阳之经邪。失治而转属阳明。以阳明病法多汗。故反 然汗出也。
阳明病。欲解时。从申至戌上。
此概言阳明病欲解之愈时也。阳明者。两阳合明也。至真要大论。帝曰。愿闻阴阳之有三也何谓。岐伯曰。
气有多少异用也。帝曰。阳明何谓也。曰。两阳合明也。曰。厥阴何谓也。曰。两阴交尽也。天元纪大论云。
帝曰。何谓气有多少。鬼臾区曰。阴阳之气。各有多少。故曰。三阴三阳也。以愚意测之。庖牺氏之作易也。
阴阳各一太少耳。惟人身之经脉有三。故帝亦不知而有此问也。其所以谓之多少异用者。盖以少为阴阳之初生。
故谓之少。太为阴阳之盛极。故谓之多。少则其气必盈。阴盈则阳必亏。阳盈则阴必亏。故其用异。太则其气必亏。
阴亏则阳必盈。阳亏则阴必盈。故其用亦异也。是故阳明者。太少两阳合明之盈气。厥阴者。太少两阴交尽
之盈气也。若以经脉言之。阴阳离合论云。少阴之上。名曰太阳。太阴之前。名曰阳明。厥阴之表。名曰少阳。
盖以三阳居三阴之上而在外。阳明又在二阳之间。居身之前。其太少之气。各有多少。至阳明两阳并合而为盛阳。
故曰阳明。又云。中则为阴。其冲在下。名曰太阴。太阴之后。名曰少阴。少阴之前。名曰厥阴。三阴居三阳
之下而在内。厥阴又在二阴之中。居身之下。其太少之气。亦各有多少。至厥阴两阴交尽而为至阴。故曰厥阴。
灵枢阴阳系日月篇云。足之十二经。应十二月。合之于脉。则辰者三月。主左足之阳明。巳者四月。主右足之阳明。
此两阳合于前。以上半年为三阳之所属。而阳明又居于太阳少阳之中。故曰两
阳合明也。又曰戌者九月。主右足之厥阴。亥者十月。主左足之厥阴。为两阴之尽。以下半年为三阴之所属。
而厥阴又居于太阴少阴之间。故曰两阴交尽。而仲景以从申至戌为阳明之旺时者。是不以经脉言。而以阳气之生旺言
也。夫寅卯为阳气初出而发生。故为少阳。巳午为阳气盛长而畅达。故为太阳。至申酉而阴已长成。收气虽至。正阳
极之时。如初秋之收气已至。而炎暑未除。热气犹盛。此正太少两阳之所归。故胃虽六月之未土。而大肠又兼谓之
阳明燥金也。至戌而为阴盛剥阳之时。一日之气亦同。故其气不能更旺于戌。故曰戌上。
Q: What are the external manifestations of Yangming disease?
A: The body is hot, sweating occurs spontaneously, there is no aversion to cold, but rather an aversion to heat.
This is a hypothetical Q&A designed to distinguish the external manifestations of Yangming disease from those of Taiyang disease. For instance, in Taiyang Wind Strike syndrome, fever and sweating occur accompanied by aversion to wind and cold. In Yangming Wind Strike syndrome, although the presentation includes fever and spontaneous sweating, there is no aversion to cold, but rather an aversion to heat. The reason for this aversion to heat is that the pathogenic factor has entered the Yangming channel. The *Ling Shu: Yin Yang Xi Ri Yue* chapter states: "Chen corresponds to the Yangming channel of the left foot, and Si corresponds to the Yangming channel of the right foot." These two Yang channels converge and illuminate the front of the body, hence the name Yangming (Two Yangs Combined Brightness). Prior to Chen and Si, Wu occupies the Li trigram position, which is the realm of extreme Yang. When pathogens merge with Yang, Yang excess generates heat. Therefore, the *Su Wen: Yin Yang Bie Lun* regards the Yang Qi of the stomach as the master of the twenty-five Yangs, because it can transform and ripen water and grain, serving as the Sea of Water and Grain. When pathogenic factors invade, Yang pathogens become rampant, leading to no aversion to cold but rather an aversion to heat. Henceforth, any condition termed Yangming disease must present with these symptoms to be classified as such.
Q: Some diseases acquired one day prior do not manifest fever but instead show aversion to cold. What is the cause?
A: Even if acquired one day prior, the aversion to cold will cease spontaneously, followed immediately by spontaneous sweating and an aversion to heat.
This further hypothetical question distinguishes the exterior pathogens directly affecting the Yangming primary channel from the exterior syndromes of Shaoyang and Taiyang. Pathogenic cold in the Shaoyang and Taiyang channels may persist as an exterior syndrome for six or seven days, or even eight or nine days without resolution. It may present four to five days after onset with fever, aversion to wind, stiffness of the neck and back, and fullness in the hypochondrium; or five to six days after onset with alternating chills and fever. However, pathogenic cold directly contracting the Yangming primary channel enters via Ying and Wei (Nutritive and Defensive Qi). Since Ying and Wei belong to Taiyang, there may be a case where, upon acquisition one day prior, there is no fever but only aversion to cold. Yet, after one day, the pathogen enters the muscle layer of Yangming and gradually moves inward. Thus, without needing dispersal treatment, the aversion to cold ceases spontaneously, followed by spontaneous sweating and an aversion to heat. This differs from pathogens transmitted from Taiyang, which require misapplication of diaphoresis, purgation, or diuresis, or incomplete diaphoresis, before transferring to Yangming.
Q: Why does the aversion to cold cease spontaneously?
A: Yangming resides in the center and belongs to Earth. It is the destination of all things, and once pathogens enter here, they do not transmit further. Although aversion to cold occurs initially, it stops spontaneously on the second day. This constitutes Yangming disease.
This clarifies why Yangming Cold Damage moving inward does not present with aversion to cold. The Yangming channel lies between Taiyang and Shaoyang. The Stomach, as the Fu organ of Yangming, is located below the Heart and Lungs and above the Liver and Kidneys, residing centrally. It connects via membranes with the Spleen, forming interior-exterior pairs, much like Earth resides within Heaven, thus called Central Earth. Earth is the gathering place of all things. Once pathogens enter the Stomach, unlike pathogens in the channels that circulate and transmit, they stop here and do not transmit further; only purgative methods apply. As the classics state, "When Earth is depressed, it must be liberated." Thus, on the first day, the pathogen is still at the exterior causing aversion to cold; by the second day, it moves deeper into the Yangming interior, and the aversion to cold stops. This represents a Yangming interior syndrome. However, why do pathogens entering Yangming immediately move inward?
If analyzed separately: Taiyang has its channel, so externally the channel is the exterior and internally the Bladder is the interior; thus, interior syndromes are few and exterior syndromes are many. Yangming also has its channel, so externally the channel is the exterior and internally the Stomach Fu is the interior; thus, interior syndromes are many and exterior syndromes are few. Consequently, Taiyang treatment focuses mostly on the exterior, with Wuling San being the sole method for the interior. Yangming treatment focuses mostly on the interior, with Gegen Tang being the sole method for the exterior. However, Gegen Tang's exterior treatment relies on Mahuang and Guizhi from the Taiyang channel to release the exterior, because pathogens enter via Ying and Wei, necessarily passing through Taiyang.
Generally speaking: Taiyang exclusively governs the exterior, requiring mismanagement to move inward; Yangming exclusively governs the interior, receiving pathogens from all six channels. Once received, they do not transmit further, forming Yangming purge-able syndromes, hence called "the destination of all things." The cessation of aversion to cold on the second day refers to the *Nei Jing: Re Lun*: "On the first day, Juyang receives the pathogen; on the second day, Yangming receives it." This is the general principle and standard legislation of Yangming, though it does not exhaust its variations. If pathogens in the channel reach the interior stage, their timing varies—some late, some early—and cannot be precisely quantified.
Q: What causes Yangming disease?
A: In Taiyang disease, if diaphoresis, purgation, or diuresis are used, fluid and essence are depleted, the Stomach becomes dry, and the condition transfers to Yangming. Failure to defecate, internal solidity, and difficulty in bowel movements constitute Yangming disease.
This explains how pathogens in Taiyang transfer to the Yangming interior due to mismanagement. How is Yangming disease obtained? If Taiyang disease is mistakenly treated with diaphoresis, premature purgation, or diuresis, it depletes Stomach fluids and damages Stomach Yang Qi. Heat pathogens then enter the deficiency, causing fluid depletion and Stomach dryness. The heat pathogen transfers to the Yangming Stomach channel, resulting in failure to defecate. "Gengyi" (changing clothes) refers to the ancient custom where nobles changed clothes after defecation; thus, defecation was euphemistically called "changing clothes." Failure to "change clothes" leads to internal solidity and difficulty in bowel movements, termed Yangming disease. The text says "failure to change clothes and difficulty in bowel movements" rather than "no bowel movement with dry feces" to soften the description. It indicates that this is merely difficulty due to fluid deficiency, unlike Zheng Yang Yangming where heat pathogens solidify in the Stomach with dry feces, causing delirium, tidal fever, and constipation. Therefore, Xiao Chengqi Tang is used to harmonize the former, while Da Chengqi Tang is used to purge the latter. Complete inability to pass stool is "no bowel movement"; "difficulty in bowel movement" implies the desire to pass stool but encountering resistance.
Originally, when Taiyang disease was just acquired, diaphoresis was applied, but the sweat was not thorough, leading to a transfer to Yangming.
This describes initial Taiyang contraction where, due to exterior pathogens, diaphoresis was induced. Excessive sweating is excessive, but insufficient sweating is inadequate. Inadequate sweating means incomplete release, allowing residual pathogens to enter inward, transferring from Taiyang to Yangming. This illustrates the mechanism of Taiyang transmitting to Yangming.
In Cold Damage transferring to Yangming, the patient exhibits Ji Ran (continuous slight sweating).
"Zhuan" means transferring to another channel, i.e., transmission. "Xi" means connection. "Ji Ran" describes a state of continuous, slight, moist sweating. It means that Cold Damage, originally without sweat, upon entering Yangming, presents with Ji Ran slight sweating, manifesting Yangming channel symptoms. This illustrates the signs verifying pathogen entry into Yangming.
In Cold Damage with fever, no sweat, vomiting, inability to eat, but presenting with Ji Ran sweating, it is a transfer to Yangming.
Pathogenic cold at the exterior causes fever and no sweat; cold in the chest causes vomiting and inability to eat. These are Taiyang Cold damaging Ying blood exterior syndromes. Originally having no sweat, the appearance of Ji Ran sweating indicates that Taiyang channel pathogens, due to lack of proper treatment, have transferred to Yangming. Since Yangming disease typically involves sweating, Ji Ran sweating appears.
Yangming disease tends to resolve from Shen hour to Xu hour.
This generally states the time when Yangming disease tends to resolve. Yangming means Two Yangs Combined Brightness. In *Su Wen: Zhi Zhen Yao Da Lun*, the Yellow Emperor asks about the tripartite division of Yin and Yang. Qibo replies that Qi has varying degrees and functions. Regarding Yangming, it is defined as Two Yangs Combined Brightness. Regarding Jueyin, it is Two Yins Exhausted. *Tian Yuan Ji Da Lun* states that Yin and Yang Qi have different quantities, hence Three Yin and Three Yang. Analyzing this, Fuxi's *I Ching* had only Shao (Less) and Tai (Greater) Yin/Yang. Human meridians have three, prompting the Emperor's question. "Shao" denotes initial generation; "Tai" denotes peak abundance. Shao Qi is full; Yin fullness implies Yang deficiency, and vice versa, hence different functions. Tai Qi is deficient; Yin deficiency implies Yang abundance, and vice versa, hence different functions. Thus, Yangming is the abundant Qi of combined Shaoyang and Taiyang; Jueyin is the abundant Qi of exhausted Shaoyin and Taiyin.
From a meridian perspective, *Yin Yang Li He Lun* states: Above Shaoyin is Taiyang; before Taiyin is Yangming; exterior to Jueyin is Shaoyang. Three Yangs reside above Three Yins externally; Yangming is between the two Yangs, anteriorly. Its Shao and Tai Qi vary in quantity, merging at Yangming into盛 Yang. "Middle is Yin, its surge is lower, named Taiyin; behind Taiyin is Shaoyin; before Shaoyin is Jueyin." Three Yins reside below Three Yangs internally; Jueyin is between the two Yins, inferiorly. Its Shao and Tai Qi vary, merging at Jueyin into Extreme Yin.
*Ling Shu: Yin Yang Xi Ri Yue* links foot meridians to months: Chen (3rd month) governs Left Yangming; Si (4th month) governs Right Yangming. These Two Yangs combine anteriorly, belonging to the first half of the year (Three Yangs), with Yangming between Taiyang and Shaoyang. Xu (9th month) governs Right Jueyin; Hai (10th month) governs Left Jueyin. These Two Yins exhaust, belonging to the second half (Three Yins), with Jueyin between Taiyin and Shaoyin. Zhang Zhongjing identifies Shen to Xu hours as the prosperous time for Yangming, not based on meridians but on the growth and prosperity of Yang Qi. Yin and Mao hours see initial Yang emergence (Shaoyang); Si and Wu hours see peak Yang expansion (Taiyang). By Shen and You hours, Yin has grown, and收敛 (receiving/contracting) Qi arrives, yet Yang is at its peak, like early autumn where cooling air arrives but heat remains. This is the return of Shaoyang and Taiyang. The Stomach is Wei Earth (6th month), but Large Intestine is Yangming Dry Metal. By Xu hour, Yin peaks and strips Yang; daily Qi mirrors this, so Yang cannot prosper further in Xu, hence "Xu Shang" (up to Xu).