柯琴曰。首条。下利是大肠虚。谵语是胃气实。胃实肠虚。宜大黄以濡胃。无庸芒硝以润肠。
末条。阳明主津液所生病。故阳明病多汗。多汗是胃燥之因。便硬是谵语之根。一服谵语止。虽未利而胃濡可知矣。
【纲】仲景曰。二阳并病。太阳症罢。但发潮热。手足 汗出。大便难。而谵语者。下之则
愈。宜大承气汤。
【目】鳌按。本条全属阳明可下之症。故本二阳并病。而开手即揭清太阳症罢句也。
【纲】仲景曰。阳明病。头痛。不恶寒。反恶热。大便实。宜调胃承气汤。阳明病。反无汗而
小便利。二三日呕而咳。手足厥者。必苦头痛。若不咳不呕。手足不厥者。头不痛。
【目】王肯堂曰。内经云。巨阳受邪。少阴为里。得热则往从之。从之则厥也。太阳与少阴为
合。此症当是太阳未全罢耳。经又云。阳明病则喘而 。 则恶人。小便利者。寒邪内攻。肢厥头
痛者。寒邪外攻也。
喻昌曰。阳明病。本不头痛。若无汗。呕咳。手足厥者。得里因而邪热深也。然小便利。则邪热
不在内而在外。不在下而在上。故知必苦头痛也。
魏荔彤曰。此手足之厥。与头痛互见。非少阴之手足厥也。故呕而汗出。与反无汗亦不同。正
见少阴之手足厥冷。有汗而不头痛。呕而不咳。与阳明之呕咳而无汗。头痛而手足厥有别。
此阳明病有类少阴。而又微带太阳。后学皆茫然不知下手处。故仲师苦心标出。
问。少阴亦有咳。何以辨。曰。少阴所云。咳而下利谵语者。被火气劫故也。原文详之矣。不然。
何能上炎而咳。其言或咳而呕。渴不得眠者。则必兼呕渴不得眠。而见少阴之阴躁。不与阳明之
呕咳兼头痛类也。其言或咳或悸。或小便不利。或腹中痛。或泄利下重。然必兼四者。诸症虽有似
阳明。而头痛一症。必非少阴所有也。此少阴之咳。与阳明所以不同也。故太阳之头痛。入于阳明
之小便利呕咳厥逆中。总属阳症。又见阳
能统阴。一阳存而群阴悉化为阳。在病气亦如此。正气之在人身者可识矣。
【纲】仲景曰。阳明病。表里大热。烦渴引饮。头痛如破者。竹叶石膏汤。阳明病。身热头痛。
漱水不欲咽。必发衄。
【目】杨士瀛曰。将发衄而脉数者。宜犀角地黄汤。茅花汤亦可。
吴绶曰。阳明头痛额前。目疼鼻干。脉长也。无汗者。葛根加葱白、白芷汗之。有汗。曾经发
汗。头痛不解者。葛根葱白汤。若不恶风而反恶热。自汗烦渴。脉洪数。饮水头疼者。白虎加白芷
汤。内有燥屎。蒸蒸发热头痛者。调胃承气汤。凡阳明头痛无汗者。葛根、麻黄、葱白、白芷、石
膏之类也。有汗。则白芷、石膏、葛根、川芎汤也。
【纲】仲景曰。阳明病。脉迟。食难用饱。饱则微烦。头眩。必小便难。欲作谷疸。须下之。
腹满如故。所以然者。脉迟故也。
【目】魏荔彤曰。本条之上条云。食谷欲呕者。属阳明也。吴茱萸汤主之。得汤反剧者。属上
焦也。与本条俱言胃虚。然虚寒与虚热又迥不同。虚固不可作实而攻下。热可遽作寒而温补乎。故
仲师就上条食谷欲呕中。又示人以推类详义之法。如阳明病脉迟。似属虚寒。但寒则不能食。此能
食而但难用饱。饱则微烦头眩者。胃惟不寒故能食。胃惟气虚故不用饱。不用饱者。不受饱也。微
烦头眩。俱虚而兼热之象。以此辨胃之虚。与食谷欲呕条同。而热则本条独异。夫迟为寒脉。何云
是热。不知此乃兼涩之迟。非沉迟之迟。谓之虚而兼湿热则可。谓之虚寒则大不可也。故又见小便
难一症。虚则气不充而湿不除。湿则气不化而热不消。胃中谷气不能化正养身。却蕴酿湿热。蒸作
疸黄之兆。如不清热除湿。培土消疸。而妄下之。将湿愈增而虚愈甚。腹满如故。胃累及脾。表里
受病。而发黄身肿矣。故又曰。脉迟故也。言迟则濡涩而不滑利。虚而湿之义为主。而热副之。主
治者以除湿培土补中为君。以清热消疸为臣佐之用。斯为得仲师心法者。
【纲】仲景曰。阳明病。但头眩。不恶寒。故能食而咳。其人必咽痛。若不咳者。咽不痛。
【目】王肯堂曰。阳明病。身不重。但头眩而不恶寒者。阳明中风而风内攻也。经曰。阳明病。
若能食。名中风。风邪攻胃。胃气上逆则咳。咽门者。胃之系。咳甚则咽伤。故咽痛。若胃气不逆
则不咳。其咽亦不痛也。
鳌按。此与前头痛款中反无汗一条。俱是阳明病而有类少阴者。然彼条之呕咳而无汗。头痛而
手足厥。所以异于少阴之手足厥冷有汗而不头痛。及呕而不咳。此条之咳而咽痛。亦所以异于少阴
之咽痛为不咳而痛也。
Ke Qin stated. The first clause indicates that diarrhea is a manifestation of large intestine deficiency-cold, and delirium is a manifestation of stomach qi excess-heat. With an excess stomach and a deficient intestine, it is appropriate to use Rhubarb (Da Huang) to moisten the stomach, without the need for Mirabilite (Mang Xiao) to lubricate the intestines.
The last clause indicates that the Yangming channel governs diseases arising from body fluids; therefore, Yangming disease often presents with excessive sweating. Excessive sweating is the cause of stomach dryness, and hard stool is the root of delirium. After one dose, if delirium ceases, although bowel movement has not yet occurred, it can be known that the stomach has been moistened.
[Gang] Zhang Zhongjing said. In concurrent Taiyang and Yangming disease (Liang Yang Bing), when Taiyang symptoms have resolved, but tidal fever occurs, sweat appears on the hands and feet, difficulty in defecation arises, and delirium is present, purgation therapy will cure it. Da Cheng Qi Tang (Great Order the Qi Decoction) is indicated.
[Mu] Shen Jin'ao commented: This clause entirely belongs to Yangming disease patterns suitable for purgation. Although it is concurrent Taiyang and Yangming disease, it explicitly states "Taiyang symptoms have resolved" at the outset to clarify the distinction.
[Gang] Zhang Zhongjing said. In Yangming disease, headache occurs, there is no aversion to cold, but rather an aversion to heat, and the stool is solid. Tiao Wei Cheng Qi Tang (Regulate the Stomach Order the Qi Decoction) is indicated. In Yangming disease, if there is absence of sweat and free urination, and after two or three days vomiting accompanied by coughing occurs, along with cold extremities, the patient must suffer from headache. If there is no cough or vomiting, and the extremities are not cold, the head will not hurt.
[Mu] Wang Kentang stated: The *Neijing* says, when Juyang (Taiyang) is affected by pathogenic factors, Shaoyin serves as the interior. When heat enters, it follows the pathogen, leading to Jue (cold extremities). Taiyang and Shaoyin are exterior-interior paired channels. This pattern likely indicates that Taiyang disease has not completely resolved. The classic also states, in Yangming disease, there is panting and restlessness; restlessness leads to aversion to people. Free urination indicates internal attack by cold pathogens; cold extremities and headache indicate external attack by cold pathogens.
Yu Chang stated: Yangming disease typically does not present with headache. However, if there is absence of sweat, vomiting, coughing, and cold extremities, it is because an internal condition causes deep penetration of pathogenic heat. Yet, free urination indicates that pathogenic heat is not in the interior but in the exterior, not below but above. Thus, we know the patient must suffer from headache.
Wei Litong stated: The cold extremities and headache appearing together here are not Shaoyin cold extremities. Therefore, vomiting with sweating differs from absence of sweating. This precisely distinguishes Shaoyin cold extremities (which have sweating but no headache, vomiting but no cough) from Yangming disease (which has vomiting, coughing, absence of sweating, headache, and cold extremities). This shows Yangming disease having features resembling Shaoyin, while slightly involving Taiyang. Later students were confused about how to approach treatment, so Master Zhongjing painstakingly highlighted this distinction.
Question: Shaoyin also involves coughing; how to differentiate? Answer: What Shaoyin refers to as "coughing with diarrhea and delirium" is caused by fire coercion. The original text details this. Otherwise, how could it flare upward causing coughing? Statements regarding "coughing or vomiting, thirst preventing sleep" must involve vomiting, thirst, and insomnia, presenting Shaoyin Yin restlessness, distinct from Yangming's vomiting/coughing combined with headache. Statements regarding "coughing or palpitations, or difficult urination, or abdominal pain, or heavy sensation during diarrhea" must involve combinations of these four. Although these symptoms may resemble Yangming, headache is certainly not a Shaoyin symptom. This is why Shaoyin cough differs from Yangming. Thus, Taiyang headache entering the context of Yangming's free urination, vomiting, coughing, and cold extremities all belong to Yang patterns, demonstrating that Yang can command Yin; with one Yang qi preserved, all Yins transform into Yang. This applies to disease qi as well, allowing us to recognize the state of righteous qi in the human body.
[Gang] Zhang Zhongjing said. In Yangming disease, with intense heat in both exterior and interior, irritability, thirst with desire to drink, and severe headache feeling like bursting, Zhu Ye Shi Gao Tang (Bamboo Leaf and Gypsum Decoction) is used. In Yangming disease, with body heat and headache, rinsing the mouth with water but no desire to swallow, epistaxis (nosebleed) will inevitably occur.
[Mu] Yang Shiyin stated: For impending epistaxis with a rapid pulse, Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) is appropriate. Mao Hua Tang (Thistle Flower Decoction) may also be used.
Wu Shou stated: Yangming headache is located in the forehead, accompanied by eye pain and nasal dryness, with a long pulse. For absence of sweat, use Ge Gen plus Cong Bai (Scallion Juice) and Bai Zhi (Angelica Dahurica) to induce sweating. For presence of sweat, where previous sweating failed to resolve headache, use Ge Gen Cong Bai Tang. If there is no aversion to wind but rather aversion to heat, spontaneous sweating, irritability, thirst, surging-rapid pulse, and headache worsened by drinking water, use Bai Hu Jia Bai Zhi Tang (White Tiger Decoction plus Angelica Dahurica). For internal dry feces causing steaming heat and headache, use Tiao Wei Cheng Qi Tang. Generally, for Yangming headache with absence of sweat, use Ge Gen, Ma Huang (Ephedra), Cong Bai, Bai Zhi, Shi Gao (Gypsum). For presence of sweat, use Bai Zhi, Shi Gao, Ge Gen, Chuan Xiong (Sichuan Lovage Root) decoction.
[Gang] Zhang Zhongjing said. In Yangming disease, with a slow pulse, difficulty eating until full, mild vexation after eating, dizziness, and inevitable difficulty in urination, Gu Dan Jaundice (Grain Jaundice) is developing. Purging is required. If abdominal fullness remains unchanged after purging, it is due to the slow pulse.
[Mu] Wei Litong stated: The preceding clause states: "Desire to vomit after eating belongs to Yangming," treated with Wu Zhu Yu Tang. Worsening after taking the medicine indicates Upper Jiao involvement. Both clauses discuss stomach deficiency, but deficiency-cold and deficiency-heat are vastly different. Deficiency should not be treated as excess with purgatives; can heat be immediately treated as cold with warming tonics? Thus, Master Zhongjing uses the "desire to vomit after eating" clause to demonstrate analogical reasoning. For example, Yangming disease with a slow pulse seems like deficiency-cold, but cold patterns cannot eat; here, eating is possible but difficult to tolerate fullness. Mild vexation and dizziness after eating indicate the stomach is not cold (hence able to eat) but qi-deficient (hence unable to tolerate fullness). Mild vexation and dizziness are signs of deficiency combined with heat. This identifies stomach deficiency similarly to the "vomit after eating" clause, but the heat aspect is unique to this clause. Slow pulse usually indicates cold; why call it heat? This is a slow pulse combined with choppy quality, not a deep-slow pulse. It can be called deficiency combined with damp-heat, but calling it deficiency-cold is a major error. The symptom of difficult urination further confirms this: deficiency means qi fails to充盈 (fill) and dampness persists; dampness prevents qi transformation and heat dissipation. Grain qi in the stomach fails to transform into healthy nourishment, instead brewing damp-heat, steaming into jaundice. Without clearing heat, removing dampness, strengthening Earth, and resolving jaundice, reckless purging will increase dampness and worsen deficiency, leaving abdominal fullness unchanged. The stomach affects the spleen, invading both interior and exterior, leading to yellowing and edema. Hence, "due to the slow pulse." This means the pulse is soggy-choppy and not slippery, emphasizing deficiency and dampness primarily, with heat secondarily. The correct treatment prioritizes removing dampness, strengthening Earth, and tonifying the center as the sovereign herb, using heat-clearing and jaundice-resolving herbs as ministers and assistants. This truly masters Master Zhongjing's method.
[Gang] Zhang Zhongjing said. In Yangming disease, only dizziness occurs, with no aversion to cold, ability to eat, and coughing; the person must have a sore throat. If there is no coughing, the throat will not hurt.
[Mu] Wang Kentang stated: In Yangming disease, the body is not heavy, only dizzy with no aversion to cold, indicating Yangming Wind-stroke with internal attack of wind. The classic says: In Yangming disease, ability to eat is named Wind-stroke. Wind pathogen attacks the stomach, stomach qi rebels upward causing coughing. The pharynx is connected to the stomach; severe coughing injures the pharynx, causing sore throat. If stomach qi does not rebel, there is no coughing, and thus no sore throat.
Shen Jin'ao commented: This clause and the "absence of sweat" clause in the previous headache section both show Yangming disease resembling Shaoyin. However, that clause's vomiting/coughing without sweat and headache with cold extremities differs from Shaoyin's cold extremities with sweat but no headache, and vomiting without coughing. This clause's coughing with sore throat differs from Shaoyin's sore throat without coughing.