【纲】仲景曰。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。
【目】成无己曰。此条舌苔。是邪气在半表半里者也。
舌者心之苗。本红而泽。伤寒三四日。舌上有膜。白滑如苔。甚者或燥或涩。或黄或黑。是数
者热气浅深之谓也。邪气在表者。舌上即无苔。邪传里。津液抟结。则舌上生苔也。
张云岐曰。舌上白苔。邪未入肝。属半表半里。以小柴胡和解之。若舌生黄。热已入胃。调胃
承气汤。舌上黑苔。或生芒刺。是肾水克心火。急以大承气下之。此热已极也。
【纲】仲景曰。舌上如苔者。以丹田有热。胸中有寒也。
【目】成无己曰。此条是邪气初传入里者也。
王履曰。胸中有寒者。谓寒气初传入里也。舌乃心苗。应南方。色本红。邪在表。舌无苔。邪
在里。津液抟结。舌生苔而滑。
热渐深。舌苔燥而涩。热聚胃。舌苔黄。承气汤下之。热极深。病极笃。舌苔黑。经曰。热病口干。
舌黑者死。水刑火也。
张介宾曰。邪在表。则无苔。及传里。则津液干燥而舌苔生。若邪犹未深。在半表里间。或邪
客胸中者。其苔不黑不涩。止宜小柴胡和之。若阳邪传里。胃中有热。则舌苔涩。宜栀子豉汤清之。
若烦躁欲饮水数升者。白虎加人参汤。大都舌上黄苔而焦色者。胃腑有邪热也。或清之。或微下
之。然必大便燥实。脉沉有力。而大渴者。方可下。若微渴而脉不实。便不坚。苔不干燥芒刺者。
不可下也。
【纲】仲景曰。阳明病。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。此条是邪气客于胸中者也。
魏荔彤曰。此症既汗之不可。烧针之不可。若以为里症而当下。然热未积深。胃未成实。若下
之。胃中正气空虚于中脘。客邪动冲于上焦。心中懊 。阳为阴寒所陷。舌上生苔。热为阴寒所迫。
此误治阳明之变。又其一也。盖本条汗针下三者皆误。惟其不明涌越之一法也。今其人虽表邪尚
在。而咽燥口苦腹满而喘。纯是表邪变热。壅逆上焦之象。邪在上。自应从上达之。以栀子豉汤主
之。仍是太阳香豉治表。栀子泄热之法。而阳明一治于五苓。再治于栀子豉。可见非拘拘专治阳明
者。可愈阳明病也。
【纲】仲景曰。脏结。无阳症。不往来寒热。其人反静。舌上苔滑者。不可攻也。
【目】成无己曰。此条是邪未全成热。犹带表寒者也。及其邪传为热。则舌上之苔。不滑而涩
也。
鳌按。脏结者。渐积凝结而为阴。五脏之阳尽已竭绝也。然舌苔虽滑。犹不至黄黑芒刺。故尚
未可攻。
[General Principle] Zhang Zhongjing stated: In Yangming disease, if there is hardness and fullness in the hypochondrium, constipation accompanied by vomiting, and a white coating on the tongue, Xiao Chai Hu Tang (Minor Bupleurum Decoction) may be administered. Once the Qi mechanism of the Upper Jiao (Upper Burner) is unblocked, body fluids descend, Stomach Qi harmonizes, sweat emerges naturally from the body, and the pathogenic factor is resolved.
[Detailed Commentary] Cheng Wuji stated: The description of the tongue coating in this clause indicates that the pathogenic factor is located at the half-exterior and half-interior level.
The tongue is the sprout of the Heart; its natural color is red and lustrous. After three or four days of Taiyang cold damage, a membrane appears on the tongue, white and slippery like moss. In severe cases, it becomes dry or rough, yellow, or black. These variations reflect the depth of heat pathogens. When the pathogen is at the exterior, there is no coating on the tongue. When the pathogen transmits to the interior, body fluids condense and coagulate, resulting in the formation of a tongue coating.
Zhang Yunqi stated: A white coating on the tongue indicates that the pathogen has not yet entered the Liver channel and belongs to the half-exterior and half-interior syndrome. It should be harmonized with Xiao Chai Hu Tang (Minor Bupleurum Decoction). If the tongue develops a yellow coating, the heat has entered the Stomach, and Tiao Wei Cheng Qi Tang (Regulate the Gastric Power Decoction) should be used. If the tongue has a black coating or develops prickles, it signifies Kidney Water overcoming Heart Fire, requiring urgent purgation with Da Cheng Qi Tang (Major Order the Qi Decoction). This indicates extreme heat.
[General Principle] Zhang Zhongjing stated: A tongue that appears to have a coating indicates heat in the Dantian (Lower Jiao/Lower Burner) and cold in the chest.
[Detailed Commentary] Cheng Wuji stated: This clause describes the initial transmission of the pathogen into the interior.
Wang Lü stated: "Cold in the chest" refers to cold qi initially transmitting into the interior. The tongue is the sprout of the Heart, corresponding to the South, with a natural red color. When the pathogen is at the exterior, there is no coating. When the pathogen is at the interior, body fluids condense, leading to a slippery tongue coating. As heat deepens, the coating becomes dry and rough. Heat gathering in the Stomach results in a yellow coating, treated with Cheng Qi Tang (Order the Qi Decoctions) for purgation. Extreme heat leads to critical illness and a black coating. The Classics state: In heat diseases, if the mouth is dry and the tongue is black, death ensues. This represents Water overcoming Fire.
Zhang Jiebin stated: When the pathogen is at the exterior, there is no coating. Upon transmission to the interior, body fluids dry up, and a coating forms. If the pathogen is not yet deep, remaining between the half-exterior and half-interior, or lodging in the chest, the coating will not be black or rough; only Xiao Chai Hu Tang (Minor Bupleurum Decoction) for harmonization is suitable. If Yang pathogens transmit to the interior and heat exists in the Stomach, the tongue coating becomes rough, and Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should be used to clear the heat. If restlessness and intense thirst for several liters of water occur, Bai Hu Jia Ren Shen Tang (White Tiger Decoction plus Ginseng) is indicated. Generally, a yellow coating that is scorched indicates pathogenic heat in the Stomach Fu organ. Treatment may involve clearing heat or mild purgation. However, purgation is only appropriate when stool is dry and solid, the pulse is deep and forceful, and there is intense thirst. If thirst is slight, the pulse is not solid, stool is not hard, and the coating is not dry or prickle-like, purgation must not be used.
[General Principle] Zhang Zhongjing stated: In Yangming disease, if purgation is mistakenly applied, the Stomach becomes empty and deficient, rebellious Qi disturbs the Diaphragm, causing mental restlessness and stifling oppression (Ao Nu), and a coating appears on the tongue. Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is the primary treatment.
[Detailed Commentary] Cheng Wuji stated: This clause describes pathogenic factors lodging in the chest.
Wei Litong stated: For this syndrome, neither sweating nor burning needle therapy is applicable. If one mistakes it for an interior syndrome requiring purgation, but the heat has not accumulated deeply and the Stomach has not formed excess, purgation will cause righteous Qi in the Middle Jiao to become deficient. Rebellious pathogens will surge upward to the Upper Jiao, causing mental restlessness. Yang Qi is trapped by Yin-cold, leading to tongue coating; heat is forced by Yin-cold. This is a complication arising from mismanagement of Yangming disease. Essentially, sweating, burning needles, and purgation are all errors here due to ignorance of the method of inducing emesis to vent pathogens. Although exterior pathogens remain, symptoms such as dry throat, bitter taste, abdominal fullness, and wheezing indicate that exterior pathogens have transformed into heat, obstructing and reversing upward in the Upper Jiao. Since the pathogen is above, it should be vented from above using Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction). This still employs the method of using fermented soybeans to treat the exterior and gardenia to clear heat, originally from Taiyang disease protocols. The treatment of Yangming disease first utilized Wu Ling San (Five-Ingredient Poria Powder) and subsequently Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction), demonstrating that curing Yangming disease does not rely solely on methods specific to Yangming.
[General Principle] Zhang Zhongjing stated: In Zang-Jie (Organ Knotting) syndrome, without Yang signs, without alternating chills and fever, with the patient appearing unusually quiet, and with a slippery coating on the tongue, purgation is contraindicated.
[Detailed Commentary] Cheng Wuji stated: This clause describes a pathogen that has not fully transformed into heat and still retains exterior cold. When the pathogen transmits and transforms into heat, the tongue coating changes from slippery to rough.
Shen Jin'ao's Note: Zang-Jie (Organ Knotting) is a gradual accumulation and coagulation forming a Yin syndrome, where the Yang Qi of the Five Zang organs is completely exhausted. Although the tongue coating is slippery, it has not yet turned yellow or black, nor developed prickles; therefore, purgation is not yet appropriate.