【纲】仲景曰。阳明病。脉浮而紧。咽燥口苦。腹满而喘。发热汗出。不恶寒反恶热。身重。
若发汗。则躁。心愦愦而谵语。若加烧针。心怵惕。烦躁不得眠。若下之。则胃中空虚。客气动膈。
心中懊 。舌上苔者。栀子豉汤主之。
【目】成无己曰。懊者懊恼。 者郁闷。郁郁然不舒畅。愦愦然无可奈。比之烦闷而甚者也。
由下后。表中阳邪乘虚内陷。郁而不发。结伏于心胸之间。故如是也。本条之胃中空虚。客气动膈。
心中懊 。及下之益烦。心中懊 如饥。即是阳气内陷。为诸懊 也。其治法或吐之。或下之。
【纲】仲景曰。发汗吐下后。虚烦不得眠。若剧者。必反复颠倒。心中懊 。栀子豉汤主之。
若少气者。栀子甘草豉汤主之。若呕者。栀子生姜豉汤主之。
【目】成无己曰。此条是邪热郁于胸中。当须吐之。以涌其结热者也。
柯琴曰。虚烦。阳明之坏病也。便从栀豉汤随症治之。犹太阳坏病。多用桂枝汤加减也。首句
虽兼汗吐下。而大意单指下后言。以阳明病多误在早下也。反复二句。切肖不得眠之状。为虚烦二
字传神。此火性摇动。心无依着故也。心居胃上。即阳明之表。凡心病皆阳明表邪。故制栀豉汤以
越之。
鳌按。因虚烦故不得眠。因不得眠。故反复颠倒。因反复颠倒故心中益觉懊 。数语形容尽致。
当作一气读。总由阳明火热之邪上炎。摇动心君也。
【纲】仲景曰。阳明病。下之。其外有热。手足温。不结胸。心中懊 。饥不能食。但头汗出
者。栀子豉汤主之。
【目】魏荔彤曰。胃之实不实。仍以热之在里在外为验也。如阳明表邪所变之热。已全入里。
而潮热。 然汗出。此宜作胃实而言下。如所变热。未全入里。乃以为胃实而遽下。则其外仍热。
究不能随下药而荡涤。于是虽热而不潮。手足虽温而无汗。即不致如太阳误下成结胸。而懊 不
食。但头汗出。其郁热之气。为阴寒之药所格。俱凝塞于胸膈之上。病症昭然矣。但病仍带表。既
不可再下。且已入里。又不可复发汗。故用栀豉表里兼治也。
鳌按。此与上条。皆下后变症。上焦之热未除。故心中懊 也。
【纲】仲景曰。阳明病。无汗。小便不利。心中懊 者。必发黄。阳明病。下之。心中懊 而
烦。胃中有燥屎者。可攻之。腹微满。初头硬。后必溏。不可攻之。若有燥屎者。宜大承气汤。
【目】许叔微曰。此二条。是邪热结于胃中。当须攻之以涤其内热者也。
魏荔彤曰。前既以小承气试之。又懊 而烦。胃中有燥屎明矣。可用大承气攻之。勿疑懊 而烦。
为胃虚而不敢用。以坐误也。
[Outline] Zhang Zhongjing stated: In Yangming disease, the pulse is floating and tight; there is dryness in the throat and bitterness in the mouth; abdominal fullness with panting; fever accompanied by sweating; aversion to cold is absent, but there is an aversion to heat; and a sense of heaviness in the body.
If diaphoresis (sweating-inducing treatment) is mistakenly applied, restlessness ensues, accompanied by mental confusion and delirious speech. If cauterization (burning needle therapy) is mistakenly applied, the patient experiences fright and palpitations, irritability, and inability to sleep. If purgation is mistakenly applied, the stomach becomes empty and deficient, allowing pathogenic qi to disturb the diaphragm. If the patient feels "Ao Nu" (a sensation of profound inner vexation and regret) in the chest and heart, and there is a coating on the tongue, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is the primary formula.
[Commentary] Cheng Wuji explained: "Ao" refers to a state of inner vexation and regret; "Nu" refers to depression and gloominess. It is characterized by a stifling discomfort, a feeling of helplessness ("Kui Kui"), which is more severe than ordinary irritability. This occurs because, following purgation, yang pathogenic factors from the exterior sink inward due to deficiency, becoming stagnant and unable to disperse, thus knotting between the heart and chest. The phrases "stomach empty," "pathogenic qi disturbing the diaphragm," and "inner vexation in the heart/chest" mentioned in this article, as well as "increased irritability after purgation" and "vexation resembling hunger," all indicate the sinking of yang qi into the interior, constituting various forms of "Ao Nu." The treatment methods may involve emesis or purgation.
[Outline] Zhang Zhongjing stated: After undergoing diaphoresis, emesis, or purgation, if deficiency-heat causes irritability and insomnia, and if the condition worsens, the patient will inevitably toss and turn restlessly, experiencing profound inner vexation ("Ao Nu") in the chest and heart. Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is the primary formula.
If shortness of breath is present, Zhi Zi Gan Cao Chi Tang (Gardenia, Licorice, and Fermented Soybean Decoction) is indicated. If vomiting is present, Zhi Zi Sheng Jiang Chi Tang (Gardenia, Ginger, and Fermented Soybean Decoction) is indicated.
[Commentary] Cheng Wuji stated: This clause describes pathogenic heat stagnating in the chest; it requires the use of emesis to purge the knotted heat.
Ke Qin stated: Deficiency-heat is a deteriorated condition (bad outcome due to mismanagement) of Yangming disease. One should treat it according to symptoms using modifications of Zhi Chi Tang, similar to how deteriorated conditions of Taiyang disease are often treated with modifications of Gui Zhi Tang. Although the first sentence mentions diaphoresis, emesis, and purgation, the main point refers specifically to erroneous purgation, as Yangming disease is frequently mishandled by premature purgation. The descriptions of "tossing and turning" vividly depict the state of insomnia, capturing the essence of "deficiency-heat." This is because fire-nature is agitating, leaving the heart spirit without support. The heart resides above the stomach, which corresponds to the exterior of Yangming. Therefore, any heart disease is attributed to exterior pathogenic factors of Yangming, hence the formulation of Zhi Chi Tang to vent the stagnation.
Shen Jin'ao noted: Due to deficiency-heat, one cannot sleep; due to lack of sleep, one tosses and turns; due to tossing and turning, the inner vexation ("Ao Nu") intensifies. These sentences describe the situation perfectly and should be read as a continuous flow. Ultimately, it is caused by the flaming upward of Yangming fire-heat pathogenic factors, agitating the Heart Sovereign (Heart Spirit).
[Outline] Zhang Zhongjing stated: In Yangming disease, after purgation, if there is residual heat on the exterior, warmth in the hands and feet, no formation of Jie Xiong (chest binding), inner vexation ("Ao Nu") in the chest and heart, a sensation of hunger but inability to eat, and only sweating on the head, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is the primary formula.
[Commentary] Wei Litong stated: Whether the stomach contains excess depends on whether the heat is in the interior or exterior. If the heat transformed from Yangming exterior pathogenic factors has fully entered the interior, manifesting as tidal fever and continuous sweating, it should be treated as a stomach-excess condition requiring purgation. However, if the transformed heat has not fully entered the interior, yet purgation is hastily applied under the assumption of stomach-excess, the exterior heat remains. Consequently, the heat cannot be cleared by the purgative drugs. Thus, although there is fever, it is not tidal; the hands and feet are warm but there is no sweating. Even if it does not develop into Jie Xiong (chest binding) as seen in erroneous Taiyang purgation, symptoms such as vexation, inability to eat, and only head-sweating occur. This is because the stagnant heat is rejected by the yin-cold nature of the drugs and condenses in the upper chest and diaphragm, making the pathology clear. Since the disease still carries exterior characteristics, further purgation is contraindicated; since it has entered the interior, re-diaphoresis is also contraindicated. Therefore, Zhi Chi Tang is used to treat both exterior and interior simultaneously.
Shen Jin'ao noted: Both this clause and the previous one are post-purgation complications where the heat in the upper jiao remains unresolved, causing inner vexation ("Ao Nu").
[Outline] Zhang Zhongjing stated: In Yangming disease, if there is no sweating, difficulty in urination, and inner vexation ("Ao Nu") in the chest and heart, jaundice will certainly develop. In Yangming disease, after purgation, if there is inner vexation ("Ao Nu") and irritability, and dry fecal matter exists in the stomach/intestines, attack with purgation is permissible. However, if the abdomen is only slightly full, and stool is hard at the beginning but loose later, purgation is forbidden. If dry fecal matter is confirmed, Da Cheng Qi Tang (Major Order the Qi Decoction) is appropriate.
[Commentary] Xu Shuwei stated: These two clauses indicate that pathogenic heat is knotted in the stomach; purgation must be used to cleanse the internal heat.
Wei Litong stated: Having previously tested with Xiao Cheng Qi Tang (Minor Order the Qi Decoction), and now presenting with vexation and irritability, the presence of dry fecal matter in the stomach is evident. Da Cheng Qi Tang (Major Order the Qi Decoction) can be used for attack. Do not hesitate to use it due to fear that vexation indicates stomach deficiency, lest you miss the opportunity and cause delay.