【纲】仲景曰。伤寒三日。阳明脉大。
【目】朱肱曰。足阳明胃之经。从鼻起。挟于鼻。络于目。下分为四道。并正别脉六道。上下
行腹。纲维于身。盖诸阳在表。阳阴主肌肉。络于鼻。故病患身热目疼。鼻干不得卧。其脉尺寸俱
长者。知阳明经受病也。
戴原礼曰。脉大者。两阳合明。内外皆阳之象也。阳明受病之初。病为在表。脉但浮而未大。
与太阳同。故亦有麻黄桂枝症也。至二日恶寒自止而反恶热。三日热大盛。故脉亦应其象而洪大。
此为胃家实之正脉。若小而不大。便属少阳。内经云。阳明之至短而涩。此指秋金司令之时脉言也。
又曰。阳明脉象大浮也。此指两阳合明之病脉言也。
喻昌曰。伤寒一日太阳。二日阳明。三日少阳。乃传经之次第。其实不以日拘。此三日阳明脉大。
正见二日之阳明传自太阳。必兼乎浮紧浮缓。未定是正阳阳明也。若正阳阳明。气血俱多。其脉
必大。而与太阳别矣。言外见三日。症连少阳。则其脉必大而弦。又不得为正阳阳明也。
魏荔彤曰。阳明之为病。胃家实。何以验之。验之于脉。如其人本太阳伤寒。三日之久。表邪
不解。致变热传里。入阳明。成胃家实。则其脉浮紧浮缓者。忽变为大。浮与紧缓。俱不见矣。既不
浮。则沉可知也。既云大。则沉而兼滑又可知也。向者太阳之浮。候于寸者既多。今者阳明之沉。候
于关者必多也。关脉大而沉滑。恰是中脘为病。则胃家之实。可决也。
【纲】仲景曰。脉浮而大。心下反硬。有热属脏者。攻之。不令发汗。属腑者。不令溲数。溲
数则大便硬。汗多则热愈。汗少则
便难。脉迟尚未可攻。（以上论胃实）
【目】柯琴曰。此治阳明之大法也。夫脉之浮而紧。浮而缓。浮而数。浮而迟者。皆不可攻而
可汗。此浮而反不可汗而可攻者。以阳明三日之脉。当知大为病进。不可拘浮为在表也。又曰。脉
迟尚未可攻者。以症有虚实。脉有真假。假令脉迟。便非脏实。是浮大皆为虚症矣。特为妄攻其实
者禁也。
朱肱曰。问。伤寒何以须诊冲阳脉。答曰。冲阳脉。是足阳明胃之经。人受气于谷。谷入于胃。
乃传与五脏六腑。脏腑皆受气于胃。其清者为营。浊者为卫。营行脉中。卫行脉外。阴阳相贯。
如环无端。胃为水谷之海。主禀四时。皆以胃气为本。是谓四时之变病。死生之要会。故伤寒必诊
冲阳。以察其胃之有无也。冲阳二穴。一名会源。在足跗上五寸骨间动脉上。去陷骨三寸。
【纲】仲景曰。阳脉微而汗出少者。为自和也。汗出多者。为太过。阳脉实。因汗出多者。亦
为太过。太过为阳实于里。亡津液。大便因硬也。
【目】危亦林曰。此虽指太阳转属。然阳明表症亦有之。
【纲】仲景曰。太阳病。寸缓关浮尺弱。其人发汗出。复恶寒不呕。但心下痞者。此以医下之
也。如不下者。病患不恶寒而渴者。此转属阳明也。小便数者。大便必硬。不大便十日无所苦也。
渴欲饮水。少少与之。但以法救之。宜五苓散。伤寒脉浮缓。手足自温者。系在太阴。太阴者。身
当发黄。若小便自利者。不能发黄。至七八日。大便硬者。为阳明病也。（以上论他经转属）
【目】柯琴曰。上条病机。在渴欲饮水。利水是胃家实而脉弱之正治。不用猪苓汤而用五苓散
者。以表热未除故耳。此为太阳阳明之并病。下条病机。在小便。太阴受病。转属阳明。以阳明为
燥土。故非经络表里相关所致。总因亡津液而致也。
【纲】仲景曰。问曰。脉有阳结阴结。何以别之。答曰。其脉浮而数。能食不大便者。此为实。
名曰阳结也。期十七日当剧。其脉沉而迟。不能食。身体重。大便反硬。名曰阴结也。期十四日
当剧。（以上论阴阳结症）
【目】张云岐曰。此条。本为阴结发论。阳结即是胃实。为阴结作伴耳。阴结无表症。当属之
少阴。不可以身重不能食为阳明应有之症。沉迟为阳明当见之脉。便硬为胃家实。而不敢用温补也。
【纲】仲景曰。阳明病。脉迟。汗出多。微恶寒者。表未解也。可发汗。宜桂枝汤。阳明病。
脉浮。无汗而喘者。发汗则愈。宜麻黄汤。阳明病。脉浮而紧者。必潮热。发作有时。但浮者。必
盗汗出。脉浮而迟。面热赤而战惕者。六七日当汗出而解。迟为无阳。不能作汗。其身为痒也。
【目】魏荔彤曰。太阳中风伤寒。解肌肌不尽解。发汗汗不尽出。外邪气变热。内正阳生热。
阴燥阳绝。太阳病已转属阳明矣。然病有已入阳明而未离太阳者。则中风伤寒二条。尚在表而未尽
除也。岂可遽舍太阳表治。而从阳明里治乎。故仲师特举此首条二条以立法也。盖此乃太阳阳明之
症。入阳明未深。故令其邪仍自表出。不致归于胃而无所复传。是解肌发汗二法。始终井井者也。
三条。乃阳明病仍带太阳。深恐阳明病去太阳渐远而成阳明渐多。非就脉症以明之。不审也。
脉浮紧。由太阳伤寒而成。为寒伤营而致成阳明之脉症者。脉但浮。由太阳中风而成。为风伤卫而
致成阳明之脉症者。阳明病至此。已将离太阳八九矣。而尚有一二太阳在主治者。犹当以下之太
早为戒。而防结胸与痞也。四条。乃阳明之虚脉虚症也。汗者阳气。迟者阴脉。无阳不能作汗。又
当助阳发汗者也。
【纲】仲景曰。脉浮发热。口干鼻燥。能食者。则衄。（以上论阳明在表症）
【目】楼全善曰。此条主治。宜桃仁承气汤、犀角地黄汤之类也。
【纲】仲景曰。伤寒四五日。脉沉而喘满。沉为在里。而反发其汗。津液越出。大便为难。表
虚里实。久则谵语。发汗多。若
重发汗者。亡其阳。谵语脉短者死。脉自和者不死。（以上论阳明谵语症）
【目】朱 曰。表虚里实。谵语之由也。谵语脉短。谵语之脉也。汗多则津脱营虚。故脉短。
若津虽脱而不甚脱。营虽虚而不甚虚。则脉自和。
【纲】仲景曰。阳明中风。口苦咽干。腹满微喘。发热恶寒。脉浮而紧。若下之。则腹满。小
便难也。
【目】鳌按。脉浮而紧。潮热有时之候。此为阳明初病在里之表也。
【纲】仲景曰。阳明中风。脉弦浮大而短气。腹部满。胁下及心痛。久按之。气不通。鼻干不
得汗。嗜卧。一身及面目悉黄。小便难。有潮热。时时哕。耳前后肿。刺之小瘥。外不解。病过十日。
脉弦紧者。与小柴胡汤。脉但浮。无余症者。与麻黄汤。若不尿。腹满。加哕者不治。（以上论
阳明中风）
【目】朱肱曰。问。十二经皆一。而阳明有三。何也。有太阳阳明。有少阳阳明。有正阳阳明也。
太阳阳明者。本太阳病。若发汗。若下。若利小便。此亡津液。胃中干燥。因转属阳明也。少阳阳
明者。本传到少阳。因发汗。利小便已。胃中燥实。大便难也。正阳阳明者。病患本风盛气实也。
三阳明俱宜下。惟恶寒及中寒为病在经。与太阳合病属表。可发其汗。盖太阳与阳明合病。脉必浮
大而长。症必头疼腰痛。肌热目痛鼻干也。脉浮大者。太阳也。长者。阳明也。头疼腰痛者。太阳
也。肌热目痛鼻干者。阳明也。尚恶寒者。可升麻汤汗之。若不恶寒反恶热。大便不秘者。可白虎
汤解利之。不恶寒反恶热。大便秘。或谵语者。属胃家实也。可调胃承气汤下之。身热汗出 然
者。属阳明也。
张介宾曰。太阳阳明者。邪自太阳传入于胃。其名脾约。以其小便数。大便硬也。正阳阳明者。
邪自阳明本经传入于腑。而邪实于胃也。少阳阳明者。邪自少阳传入于胃也。胃本属土。为万物
所归。邪入于胃。则无所复传。郁而为热。此由耗亡津液。胃中干燥。或三阳热邪不解。自经而腑。
热结所成。故邪入阳明胃腑者。谓之实邪。土气为邪。王于申未。
所以日晡潮热者。属阳明也。论曰。潮热者。实也。是为可下之症。然虽可下。若脉浮而紧。或小
便难大便溏。身热无汗。此热邪未全入腑。犹属表症。仍当和解。若邪热在表而妄攻之。则祸不旋
踵。
【纲】仲景曰。阳明病。脉迟腹满。食难用饱。饱则微烦。头眩。必小便难。此欲作谷疸。虽
下之。腹满如故。所以然者。脉迟故也。
【目】鳌按。阳明中风。其脉则浮而弦大。今脉则迟。是中寒。且无阳矣。
【纲】仲景曰。伤寒脉迟。六七日而反与黄芩汤彻其热。脉迟为寒。今与黄芩汤复除其热。腹
中虚冷。当不能食。今反能食。此名除中。必死。若脉迟。至六七日不欲食。此为晚发。水停中故
也。为未解。食自可者。为欲解。（以上论阳明中寒）
【目】陈士铎曰。伤寒脉迟。自然是寒。误与黄芩汤。则益加寒矣。寒盛宜不能食。今反能食。
病名除中。仲景谓是死症者何也。夫能食是胃气有余。如何反曰死症。不知胃寒而加之寒药。反
致能食者。此胃气欲绝。转见假食之象。不过一时能食。病名除中者。正言胃中之气。除去而不可
留也。虽是死症。犹有生机。终以其能食。胃气将除而未除。可用药以留其胃气也。方用加减参苓
汤。
王履曰。凡言阳明病者。必身热汗出不恶寒反恶热也。今但言伤寒。则恶寒可知。非不恶寒者
也。况脉迟为无阳。必其里寒特甚。
【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。若脉浮发热。渴欲饮水。小便不利者。猪苓汤主之。
【目】吴绶曰。细绎脉浮而紧一条。乃阳明半表里症也。邪已入腹。不在营卫之间。脉虽浮。
不得以为在表而发汗。脉
虽紧。不得以其身重而加温针。胃家初实。尚未燥硬。不得以其喘满恶热而攻下。阳明栀子豉汤。
犹太阳桂枝汤。既可驱邪。亦可攻误。
虞抟曰。上条。是不肯令胃燥。下条。是不肯令水浸入胃。总为胃家惜津液也。
【纲】仲景曰。病如桂枝症。头不痛。项不强。寸脉微浮。胸中痞硬。气上冲咽喉不得息者。
此为胸有寒也。当吐之。宜瓜蒂散。
【目】鳌按。寸脉微浮。尚是阳明之表脉。用瓜蒂散。即是阳明之表剂。
【纲】仲景曰。病患手足厥冷。脉乍紧者。邪结在胸中。心下满而烦。饥不能食者。病在胸中。
当吐之。宜瓜蒂散。
【目】鳌按。紧本为寒。今言乍紧者。正与厥应。不厥时未必紧。是寒结胸中之脉症也。
【纲】仲景曰。太阳病。当恶寒发热。今自汗出。不恶寒发热。关上脉细数者。以医吐之过也。
此为小逆。一二日吐之者。腹中饥。口不能食。三四日吐之者。不喜糜粥。欲食冷食。朝食暮吐。
以医吐之所致也。
【目】柯琴曰。言太阳病。头项强痛可知。以脉辨之。关上者。阳明之脉。细弦数而不洪大。
虽自汗而不恶热。则不是与阳明并病。不口干烦满而自汗出。自不与少阴两感。原其故。乃庸医妄吐
所致。则自汗为表虚。脉细数为里热也。
【纲】仲景曰。伤寒脉浮。发热无汗。其表不解者。不可与白虎汤。渴欲饮水。无表症者。白
虎加人参汤主之。服桂枝汤。大汗出后。大烦。渴不解。脉洪大者。白虎加人参汤主之。
【目】黄仲理曰。此二条。必合看乃得。盖前条。症也。后条。脉也。脉浮发热无汗。本麻黄
症尚存。即是表不解。更兼渴欲饮水。又是热入于里。此谓有表里症。当用五苓散。
【纲】仲景曰。三阳合病。脉浮大在关上。但欲睡眠。合目则汗。
【目】程郊倩曰。脉而浮大。阳脉也。关上阳所治。是为重阳矣。与少阴脉沉细而但欲寐者自
异。
【纲】仲景曰。伤寒脉浮滑。此表有热。里有邪。白虎汤主之。伤寒脉滑而厥者。里有热也。
白虎汤主之。
【目】柯琴曰。此条论脉而不及症。因有白虎症而推及其脉也。切勿据脉而不审其症。脉浮而
滑为阳。阳主热。内经云。脉缓而滑曰热中。是浮为在表。滑为在里。此虽表里并言。而重在里热。
所谓结热在里。表里俱热者也。脉微而厥为寒厥。脉滑而厥为热厥。阳极似阴之症。全凭脉以辨
之。
【纲】仲景曰。伤寒十三日不解。过经谵语者。以有热故也。当以汤下之。若小便秘者。大便
当硬。而反下利。脉调和者。知医以丸药下之。非其治也。若自下利者。脉当微。今反和者。此为
内实也。调胃承气汤主之。
【目】张云岐曰。脉调和而不微。是脉有胃气也。内实者。胃实也。胃实则肠虚。故必以调胃
承气汤调其胃也。
【纲】仲景曰。阳明病。脉迟微汗出。不恶寒者。其身必重。短气腹满而喘。有潮热者。此外
欲解。可攻里也。手足 然而汗出者。此大便已硬也。大承气汤主之。若汗多。微发热恶寒者。外
未解也。其热不潮。未可与承气汤。若腹大满不通者。可与小承气汤。微和胃气。勿令大泄下。
【目】方中行曰。脉迟汗出等八症。乃阳明之外邪欲解。可以攻里而不为大误也。然曰欲解。
[Outline] Zhang Zhongjing said: In the course of a cold damage disease, after three days, the pulse of the Yangming channel manifests as large (Da).
[Commentary] Zhu Gong said: The Foot-Yangming Stomach channel originates from beside the nose, runs along both sides of the nose, connects with the eyes, and divides downward into four pathways. Together with the main and divergent channels, there are six pathways in total, traveling up and down the abdomen to support the body. Generally, all Yang channels are on the exterior, while Yangming governs the muscles and connects to the nose. Therefore, patients present with fever, eye pain, dry nose, and inability to lie down comfortably. If the pulses at both the Cun (inch) and Chi (cubit) positions are long, it indicates that the Yangming channel is affected.
Dai Yuanli said: A large pulse indicates the convergence of two Yang energies, manifesting as Yang within and without. At the beginning of Yangming disease, the pathogen is still on the exterior; the pulse is merely floating but not yet large, similar to Taiyang disease. Thus, symptoms of Mahuang Tang or Guizhi Tang may also appear. By the second day, aversion to cold ceases and is replaced by aversion to heat. By the third day, heat becomes intense, so the pulse becomes surging and large accordingly. This is the characteristic pulse for "Stomach Fullness-Excess" (Wei Jia Shi). If the pulse is small rather than large, it belongs to Shaoyang. The *Neijing* states: "When Yangming prevails, the pulse is short and choppy." This refers to the normal pulse during the season when Metal rules (Autumn). It also states: "The Yangming pulse is large and floating," which refers to the pathological pulse when two Yangs combine.
Yu Chang said: Cold damage transmits from Taiyang on the first day, Yangming on the second, and Shaoyang on the third; this is the sequence of transmission. However, one should not be rigidly bound by days. The statement "on the third day, the Yangming pulse is large" implies that the Yangming condition on the second day transmitted from Taiyang and must still carry floating-tight or floating-slow characteristics, indicating it has not yet become "Zheng Yang Yangming" (True Yang Yangming). If it were Zheng Yang Yangming, with abundant Qi and Blood, the pulse would necessarily be large, distinguishing it from Taiyang. Implicitly, if by the third day symptoms involve Shaoyang, the pulse would be large and wiry, thus not constituting Zheng Yang Yangming.
Wei Litong said: The hallmark of Yangming disease is "Stomach Fullness-Excess" (Wei Jia Shi). How is this verified? Through the pulse. If a patient originally had Taiyang cold damage, and after three days the exterior pathogen remains unresolved, transforming into heat and transmitting inward to Yangming to form Stomach Fullness-Excess, the previously floating-tight or floating-slow pulse will suddenly become large. The floating and tight/slow qualities disappear. Since it is no longer floating, sinking is implied; since it is large, sinking combined with slippery is inferred. Previously, the Taiyang floating pulse was prominent at the Cun position; now, the Yangming sinking pulse will be prominent at the Guan position. A large, sinking, and slippery Guan pulse corresponds precisely to pathology at the Zhongwan point, confirming Stomach Fullness-Excess.
[Outline] Zhang Zhongjing said: When the pulse is floating and large, and the epigastrium feels hard contrary to expectation, if the heat belongs to the Zang organs, use purgation; do not induce sweating. If the heat belongs to the Fu organs, do not promote frequent urination. Frequent urination leads to hard stool; excessive sweating increases heat; insufficient sweating leads to difficult defecation. If the pulse is slow, purgation is not yet indicated. (Above discusses Stomach Excess patterns)
[Commentary] Ke Qin said: This outlines the general treatment principle for Yangming disease. Pulses that are floating-tight, floating-slow, floating-rapid, or floating-slow are generally not suitable for purgation but can be treated with diaphoresis. However, in the case of a floating pulse here, diaphoresis is contraindicated, and purgation is indicated. This is because in the third day of Yangming disease, a "large" pulse indicates disease progression; one cannot rigidly assume "floating" always means the exterior. Furthermore, "if the pulse is slow, purgation is not yet indicated" exists because symptoms have deficiency/excess distinctions and pulses have true/false variations. If the pulse is slow, it is not internal excess; thus, floating and large pulses here indicate deficiency. This clause specifically prohibits reckless purgation.
Zhu Gong said: Question: Why must Chongyang pulse be examined in cold damage? Answer: Chongyang is the Yuan-source point of the Foot-Yangming Stomach channel. Humans derive Qi from grain; grain enters the stomach and distributes to the Zang and Fu organs. All organs rely on Stomach Qi. The clear part becomes Ying (Nutritive) Qi, circulating inside the vessels; the turbid part becomes Wei (Defensive) Qi, circulating outside the vessels. Yin and Yang interconnect like an endless circle. The Stomach is the sea of water and grain, adapting to the four seasons, rooted in Stomach Qi. This is the key to seasonal variations and life/death. Therefore, examining Chongyang assesses the presence of Stomach Qi. There are two Chongyang points, also called Huiyuan, located 5 cun above the foot dorsum between the bones on the arterial pulse, 3 cun from Xangu.
[Outline] Zhang Zhongjing said: If the Yang pulse is faint and sweating is slight, it indicates self-recovery. If sweating is excessive, it indicates excess. If the Yang pulse is full/excessive and sweating is profuse, it also indicates excess. Excess leads to Yang stagnating in the interior, loss of Body Fluids, and consequently hard stool.
[Commentary] Wei Yilin said: Although this refers to transmission from Taiyang, such patterns occur in Yangming exterior conditions as well.
[Outline] Zhang Zhongjing said: In Taiyang disease, with a slow Cun pulse, floating Guan pulse, and weak Chi pulse, if the patient sweats after treatment, continues to have aversion to cold, does not vomit, but experiences epigastric stuffiness, this is due to erroneous purgation by the physician. If purgation was not performed, and the patient is not averse to cold but is thirsty, this indicates transmission to Yangming. Frequent urination leads to hard stool; even if no bowel movement occurs for ten days without discomfort, it is acceptable. If thirsty for water, give small amounts frequently, treating according to principles, using Wuling San. In cold damage with a floating-slow pulse and warm hands/feet, the disease is associated with Taiyin. Taiyin patients typically develop jaundice; however, if urination is free, jaundice will not develop. By the seventh or eighth day, if stool becomes hard, it becomes a Yangming disease. (Above discusses transmission from other channels to Yangming)
[Commentary] Ke Qin said: The mechanism of the previous clause lies in thirst for water; promoting urination is the correct treatment for Stomach Fullness-Excess with a weak pulse. Wuling San is used instead of Zhuling Tang because the exterior heat is not yet resolved. This is a concurrent disease of Taiyang and Yangming. The mechanism of the next clause lies in urination. Transmission from Taiyin to Yangming occurs because Yangming is Dry Earth; it is not merely due to meridian interior-exterior relationships but primarily due to the loss of Body Fluids.
[Outline] Zhang Zhongjing said: Question: How to distinguish between Yang Constriction (Yang Jie) and Yin Constriction (Yin Jie) pulses? Answer: A floating and rapid pulse with ability to eat but inability to pass stool indicates Excess, named Yang Constriction. Expect worsening on the seventeenth day. A sinking and slow pulse with inability to eat, heavy body, and conversely hard stool indicates Yin Constriction. Expect worsening on the fourteenth day. (Above discusses Yin-Yang Constriction patterns)
[Commentary] Zhang Yunqi said: This clause primarily discusses Yin Constriction. Yang Constriction is essentially Stomach Excess, accompanying Yin Constriction. Yin Constriction lacks exterior symptoms and belongs to Shaoyin; one should not interpret heavy body and inability to eat as typical Yangming symptoms, nor sinking-slow pulse as typical Yangming pulse. Hard stool indicates Stomach Excess, precluding the use of warming tonification.
[Outline] Zhang Zhongjing said: In Yangming disease, with a slow pulse, profuse sweating, and slight aversion to cold, the exterior is unresolved; diaphoresis is permissible, using Guizhi Tang. In Yangming disease, with a floating pulse, no sweating, and wheezing, diaphoresis leads to recovery; use Mahuang Tang. In Yangming disease, with a floating-tight pulse, tidal fever will definitely occur at specific times; if only floating, night sweats will occur. With a floating-slow pulse, facial flushing, and trembling/fear, resolution via sweating should occur around the sixth or seventh day. Slow pulse indicates lack of Yang, inability to sweat, leading to itching.
[Commentary] Wei Litong said: In Taiyang wind-strike or cold damage, if muscle-relieving methods fail to fully resolve the exterior, or sweating fails to fully expel pathogens, external evil transforms into heat, and internal Zheng Yang generates heat. With Yin dryness and Yang exhaustion, Taiyang disease has transmitted to Yangming. However, some cases have entered Yangming but not left Taiyang entirely. Thus, the wind-strike and cold damage clauses remain relevant for residual exterior pathogens. One cannot abruptly abandon Taiyang exterior treatment for Yangming interior treatment. Zhongjing highlights these first two clauses to establish legal principles. These are Taiyang-Yangming concurrent symptoms where entry into Yangming is shallow, allowing pathogens to exit via the exterior, preventing them from settling in the Stomach and transmitting further. Muscle-relieving and sweating methods are applied systematically. The third clause involves Yangming disease retaining Taiyang features; fearing Yangming moves away from Taiyang and dominates, one must examine pulses and symptoms carefully. Floating-tight arises from Taiyang cold damage injuring Ying, becoming Yangming pulse/symptoms; floating alone arises from Taiyang wind-strike injuring Wei, becoming Yangming pulse/symptoms. By this stage, Yangming is nearly separated from Taiyang, yet some Taiyang remains. Caution against premature purgation to prevent chest binding and epigastric痞 (Pi). The fourth clause describes Yangming deficiency pulse and symptoms. Sweat is Yang Qi; slow is Yin pulse. Lack of Yang prevents sweating, requiring assistance of Yang to induce sweat.
[Outline] Zhang Zhongjing said: With floating pulse, fever, dry mouth, and dry nose, if the patient can eat, nasal hemorrhage (Xu) will occur. (Above discusses Yangming exterior patterns)
[Commentary] Lou Quanshan said: Treatment for this clause should utilize formulas like Taoren Chengqi Tang or Xijiao Dihuang Tang.
[Outline] Zhang Zhongjing said: In cold damage, on the fourth or fifth day, with sinking pulse and wheezing/fullness. Sinking indicates interior location. Erroneous sweating causes fluids to escape, making stool difficult. Exterior deficiency and interior excess lead to delirium over time. Excessive sweating, or repeated sweating, causes loss of Yang. Delirium with a short pulse indicates death; delirium with a harmonious pulse indicates survival. (Above discusses Yangming delirium patterns)
[Commentary] Zhu Gong said: Exterior deficiency and interior excess cause delirium. Delirium with short pulse is the corresponding pulse. Profuse sweating leads to fluid depletion and Ying deficiency, hence the short pulse. If fluid depletion and Ying deficiency are mild, the pulse remains harmonious.
[Outline] Zhang Zhongjing said: In Yangming wind-strike, with bitter taste, dry throat, abdominal fullness, slight wheezing, fever, aversion to cold, and floating-tight pulse. Erroneous purgation leads to abdominal fullness and difficulty urinating.
[Commentary] Shen Jin'ao notes: Floating-tight pulse with periodic tidal fever indicates early Yangming disease involving the interior's exterior aspect.
[Outline] Zhang Zhongjing said: In Yangming wind-strike, with wiry-floating-large pulse and shortness of breath, abdominal fullness, pain in the hypochondrium and heart region, obstruction of Qi upon prolonged pressing, dry nose, inability to sweat, lethargy, generalized and facial jaundice, difficulty urinating, tidal fever, frequent hiccups, and swelling before/behind the ears. Acupuncture provides slight relief, but exterior symptoms persist. After ten days, if the pulse is wiry-tight, administer Xiaochaihu Tang. If the pulse is merely floating with no other symptoms, administer Mahuang Tang. If urine stops, abdominal fullness worsens, and hiccups increase, it is untreatable. (Above discusses Yangming wind-strike)
[Commentary] Zhu Gong said: Question: Why are there three types of Yangming? Answer: Taiyang-Yangming, Shaoyang-Yangming, and Zheng Yang Yangming. Taiyang-Yangming results from Taiyang disease treated with sweating, purgation, or diuresis, causing fluid loss, dry stomach, and transmission to Yangming. Shaoyang-Yangming results from Shaoyang disease treated with sweating/diuresis, causing dry/stagnant stomach and difficult stool. Zheng Yang Yangming results from patients with inherent strong Wind and robust Qi. All three benefit from purgation, except when aversion to cold or interior cold indicates pathogen in the channel (exterior), treatable with sweating. Concurrent Taiyang-Yangming presents with floating-large-long pulse, headache, lower back pain, muscle heat, eye pain, dry nose. Floating-large is Taiyang; Long is Yangming; headache/back pain is Taiyang; muscle heat/eye pain/dry nose is Yangming. If aversion to cold persists, use Shengma Tang. If no aversion to cold but aversion to heat, with non-obstipated stool, use Baihu Tang. If no aversion to cold, aversion to heat, constipation, or delirium, it is Stomach Excess; use Tiaowei Chengqi Tang. Generalized heat with continuous sweating indicates Yangming.
Zhang Jiabin said: Taiyang-Yangming is pathogen transferring from Taiyang to Stomach, named Pi Yue (Spleen Restriction), characterized by frequent urination and hard stool. Zheng Yang Yangming is pathogen transferring from Yangming channel to Fu organ, creating Stomach Excess. Shaoyang-Yangming is pathogen transferring from Shaoyang to Stomach. Stomach belongs to Earth, the destination of all pathogens. Once entering Stomach, transmission stops, stagnating into heat due to fluid loss or unresolved Three-Yang heat. Pathogens entering Yangming Stomach Fu are called Excess Pathogens. Earth energy peaks at Shen/Wei hours (3-7 PM). Hence, afternoon tidal fever belongs to Yangming. Tidal fever indicates Excess, warranting purgation. However, if floating-tight pulse, difficult urination/loose stool, or heat/no sweat exist, pathogen is not fully in Fu; treat with harmonizing. Premature purgation of exterior heat brings disaster.
[Outline] Zhang Zhongjing said: In Yangming disease, with slow pulse and abdominal fullness, inability to eat much, slight vexation after eating, dizziness, and difficulty urinating, this suggests impending Grain Jaundice. Purging will not relieve abdominal fullness because of the slow pulse.
[Commentary] Shen Jin'ao notes: Yangming wind-strike pulse should be floating-wiry-large; a slow pulse indicates Interior Cold and lack of Yang.
[Outline] Zhang Zhongjing said: In cold damage with slow pulse, if Huangqin Tang is erroneously given on days 6-7 to clear heat, the slow pulse indicates Cold. Giving cooling herbs further damages the interior, causing cold deficiency and inability to eat. If the patient suddenly eats, it is named Chu Zhong (Elimination of the Middle), indicating death. If slow pulse persists to day 6-7 with anorexia, it is late onset due to water retention in the middle; the disease is unresolved. Spontaneous desire to eat indicates recovery. (Above discusses Yangming Interior Cold)
[Commentary] Chen Shiduo said: Slow pulse in cold damage indicates Cold. Erroneous Huangqin Tang exacerbates Cold. Severe Cold should cause anorexia; sudden appetite is Chu Zhong. Zhongjing calls it fatal because apparent appetite is a false sign of failing Stomach Qi trying to survive briefly. Though fatal, there is hope if Stomach Qi is not completely gone; use modified Shenling Tang to preserve Stomach Qi.
Wang Lü said: Yangming disease typically presents with heat, sweating, no aversion to cold, but aversion to heat. Mentioning only "cold damage" implies aversion to cold exists. Slow pulse indicates lack of Yang and severe Interior Cold.
[Outline] Zhang Zhongjing said: In Yangming disease, with floating-tight pulse, dry throat, bitter taste, abdominal fullness, wheezing, fever, sweating, no aversion to cold but aversion to heat, and heavy body. Erroneous sweating causes restlessness, mental confusion, and delirium. Moxibustion causes fear, irritability, and insomnia. Erroneous purgation leaves Stomach empty, allowing hostile Qi to disturb the Diaphragm, causing stifled sensation in the chest. With tongue coating, Zhizi Chi Tang is indicated. If floating pulse, fever, thirst, and difficulty urinating occur, Zhuling Tang is indicated.
[Commentary] Wu Shou said: The floating-tight clause represents a half-exterior/half-interior Yangming pattern. Pathogen is in the abdomen, not Ying/Wei. Floating pulse does not mean exterior; do not sweat. Tight pulse does not justify moxibustion despite heaviness. Initial Stomach Excess is not yet dry/hard; do not purge despite wheezing/heat. Zhizi Chi Tang acts like Guizhi Tang in Taiyang, dispelling pathogen and correcting errors.
Yu Tuan said: The first clause prevents Stomach dryness; the second prevents Water invading Stomach. Both aim to protect Stomach fluids.
[Outline] Zhang Zhongjing said: Symptoms resemble Guizhi Tang pattern, but without headache or stiff neck. Cun pulse is slightly floating, epigastrium is stuffy/hard, Qi rushes to throat obstructing breathing. This is Phlegm-Fluid in the Chest; induce vomiting with Goudi San.
[Commentary] Shen Jin'ao notes: Slightly floating Cun pulse is still a Yangming exterior pulse; Goudi San is a Yangming exterior formula.
[Outline] Zhang Zhongjing said: Patients with cold hands/feet and suddenly tight pulse have pathogen constrained in the Chest. Epigastric fullness/vexation, hunger but inability to eat indicates pathology in the Chest; induce vomiting with Goudi San.
[Commentary] Shen Jin'ao notes: Tight pulse indicates Cold. "Suddenly tight" correlates with cold limbs. When limbs are warm, pulse is not tight. This is Cold constraining the Chest.
[Outline] Zhang Zhongjing said: Taiyang disease should have aversion to cold and fever. Now, spontaneous sweating, no aversion to cold/fever, and thin-rapid Guan pulse result from erroneous vomiting by the physician. This is a minor error. Vomiting on days 1-2 causes hunger but inability to eat. Vomiting on days 3-4 causes dislike of congee, craving cold food, and morning-eating/evening-vomiting, caused by erroneous vomiting.
[Commentary] Ke Qin said: Taiyang disease implies headache/stiff neck. Guan pulse is Yangming; thin-wiry-rapid without large quality, plus sweating without heat aversion, excludes concurrent Yangming. No dry mouth/vexation excludes Shaoyin involvement. Cause is physician's erroneous vomiting. Sweating indicates exterior deficiency; thin-rapid pulse indicates interior heat.
[Outline] Zhang Zhongjing said: In cold damage with floating pulse, fever, and no sweating, if exterior is unresolved, Baihu Tang is contraindicated. If thirsty for water with no exterior signs, Baihu Jia Renshen Tang is indicated. After taking Guizhi Tang, if profuse sweating leads to severe vexation/thirst unrelieved by large pulse, Baihu Jia Renshen Tang is indicated.
[Commentary] Huang Zhongli said: These two clauses must be read together. The first addresses symptoms; the second addresses pulse. Floating fever/no sweating indicates Mahuang Tang pattern persists (exterior unresolved). Thirst indicates heat entering interior. This is exterior-interior complex; Wuling San is appropriate.
[Outline] Zhang Zhongjing said: In Three-Yang concurrent disease, pulse is floating-large at Guan. Patient desires sleep; sweating occurs when closing eyes.
[Commentary] Cheng Jiaoqian said: Floating-large is Yang pulse. Guan is governed by Yang, representing Double Yang. This differs from Shaoyin's sinking-thin pulse and desire to sleep.
[Outline] Zhang Zhongjing said: In cold damage, floating-slippery pulse indicates exterior heat and interior pathogen; Baihu Tang is indicated. In cold damage, slippery pulse with cold limbs indicates interior heat; Baihu Tang is indicated.
[Commentary] Ke Qin said: This clause discusses pulse based on Baihu Tang syndrome. Do not judge solely by pulse. Floating-slippery is Yang, governing Heat. *Neijing* says: "Slow-slippy pulse indicates Heat in Middle." Floating is exterior, Slippery is interior. Emphasis is on Interior Heat, i.e., Heat knotting in interior with exterior-interior heat. Micro-cold limbs is Cold Jue; Slippery-cold limbs is Heat Jue (Extreme Yang resembling Yin). Pulse differentiation is crucial.
[Outline] Zhang Zhongjing said: After thirteen days of unresolved cold damage, if delirium occurs post-transmission, it is due to Heat; treat with decoction purgation. If urine is scant, stool should be hard; if diarrhea occurs instead, and pulse is harmonious, it indicates physician used pill purgatives incorrectly. If spontaneous diarrhea, pulse should be micro; if harmonious, it indicates Internal Excess. Tiaowei Chengqi Tang is indicated.
[Commentary] Zhang Yunqi said: Harmonious pulse without micro quality indicates Stomach Qi. Internal Excess is Stomach Excess. When Stomach is excess, Intestines are deficient; thus, Tiaowei Chengqi Tang regulates the Stomach.
[Outline] Zhang Zhongjing said: In Yangming disease, with slow pulse, slight sweating, no aversion to cold, heavy body, shortness of breath, abdominal fullness, wheezing, and tidal fever, the exterior is resolving, and interior purgation is permissible. Continuous sweating on hands/feet indicates hard stool; Dachengqi Tang is indicated. If profuse sweating, slight fever/aversion to cold, exterior is unresolved; if no tidal fever, do not use Chengqi Tang. If severe abdominal fullness/obstruction, Xiao Chengqi Tang may be used to mildly harmonize Stomach Qi, avoiding drastic purgation.
[Commentary] Fang Zhongxing said: The eight symptoms (slow pulse, sweating, etc.) indicate exterior pathogen resolving, allowing interior purgation without major error. However, "resolving" implies...