邪气所胜。故云难治。〔魏〕滑虽热盛于里之兆。而疾则热未成实之征。热之初传入腑。脉又变沉大。而兼带
迟滞之象。迟乃疾之对。向之滑疾。今乃沉大而迟滞。斯见胃以成实矣。今脉见滑疾。是犹带数。热变而传入。
尚未坚凝结聚。小承气汤主之。消熟调津。足以已病矣。〔柯〕虚甚者。与四逆汤。阴得阳则解矣。
汪氏云。案后条辨云。谵语潮热。脉反微涩。为里气大虚。并前此之脉滑疾。亦属虚阳泛上之假象。其
言似是而非。愚以谵语潮热。脉滑疾者。乃阳证见阳脉。其人邪气盛。而正气未衰也。故云可与承气汤。脉反
微涩者。是阳证见阴脉。其人邪气盛。正气衰。故云不可更与承气汤也。不转失气。并不大便。非肠中空虚。
而无物。乃胃家正气既衰。虽得汤药。内助其恶浊之物。仍然不能下泄。故云难治。后之人议用补虚回阳之法。
是与仲景初时用承气之意相反。补亡论。常器之云。可用黄 人参建中汤。亦与论不合。大抵此条病。但云难
治。其非不治之证明矣。如欲用药。还宜补泻兼施之剂。
案白虎证脉滑。方氏以降。多以宿食解之。盖原于脉诀。不可从也。
阳明病。谵语有潮热。反不能食者。胃中必有燥屎五六枚也。若不能食者。但硬耳。宜大承气汤下之。
（耳。成本。作尔。反上。玉函。脉经。有而字。玉函。无宜字。脉经。无大承气之大。宜大承气汤主之七字。
柯本。移在若能食者上。张本同。周氏义同。金鉴以为错误。非也。）
〔张〕此以能食不能食。辨燥结之微甚也。详仲景言。病
人潮热谵语。皆胃中热盛所致。胃热则能消谷。今反不能食。此必热伤胃中津液。气化不能下行。燥屎逆攻于
胃之故。宜大承气汤。急祛亢极之阳。以救垂绝之阴。若能食者。胃中气化自行。热邪原不为盛。津液不致大
伤。大便虽硬。而不久自行。不必用药反伤其气也。若以能食便硬。而用承气。殊失仲景平昔顾虑津液之旨。
〔汪〕补亡论。宜大承气汤下之句。在若能食者之前。盖能食既异。治法必不相同。仲景法。宜另以调胃承气汤
主之也。〔周〕案大承气汤。宜单承燥屎五六枚来。何者至于不能食。为患已深。故宜大下。若能食但硬。未
必燥屎五六枚口气。原是带说。只宜小承气汤可耳。
此事难知曰。胃实者。非有物也。地道塞而不通也。难经云。胃上口为贲门。胃下口为幽门。幽门接小肠
上口。小肠下口。即大肠上口也。大小二肠相会。为阑门。水渗泄入于膀胱。粗滓入于大肠。结广肠。广肠者。
地道也。地道不通。土壅塞也。则火逆上行至胃。名曰胃实。所以言阳明当下者。言上下阳明经不通也。言胃
中有燥屎五六枚者。非在胃中也。言胃是连及大肠也。○案魏氏云。胃中必有燥屎五六枚。阻塞于胃底肠间。
此言得之。
徐灵胎云。案燥屎当在肠中。今云胃中。何也。盖邪气结成糟粕。未下则在胃中。欲下则在肠中。已续者
即谓之燥屎。言胃。则肠已该矣。
又云。不能食者。客热不能消谷。能食。非真欲食。不过粥饮犹入口耳。不能食。则谷气全不近肠胃。实
极故也。案阳明病。谵语潮热。燥结甚者。皆不能食。而今下一反字。为可疑矣。注家消谷之说。乃是热中消
瘅证。邪热不杀谷。伤寒家之常。何言之反。顺文解释。往往有如是者。又案程氏钱氏志聪锡驹。不论不能食
与能食。并以大承气汤为主。
非也。
阳明病。下血谵语者。此为热入血室。但头汗出者。刺期门。随其实而写之。 然汗出则愈。（写。成
本。作泻。玉函。千金翼。刺上。有当字。则上。有者字。脉经同。金匮要略。妇人杂病篇。有此条。刺上。
有当字。则。作者。）
〔汪〕案此条。当亦是妇人病。邪热郁于阳明之经。迫血从下而行。血下则经脉空虚。热得乘虚而入其室。
亦作谵语。后条辨云。血室。虽冲脉所属。而心君实血室之主。室被热扰。其主必昏故也。但头汗出者。血下
夺则无汗。热上扰则汗蒸也。刺期门以泻经中之实。则邪热得除。而津液回复。遂 然汗出而解矣。或问此条
病。仲景不言是妇人。所以尚论诸家。直指为男子。今子偏以妇人论之。何也。余答云。仲景于太阳篇中。一
则曰。妇人中风。云云。经水适来。此为热入血室。再则曰。妇人中风。云云。经水适断。此为热入血室。三
则曰。妇人伤寒。云云。经水适来。此为热入血室。则是热入血室。明系妇人之证。至此实不待言而可知矣。
且也此条。言下血。当是经水及期。而交错妄行。以故血室有亏。而邪热得以乘之。故成热入血室之证。考之
灵枢海论云。冲脉为十二经之海。注云。此即血海也。冲脉起于胞中。又考素问天真论云。女子二七而天癸至。
任脉通。太冲脉盛。月事以时下。夫任也。冲也。其经脉皆行于腹。故其血必由前阴而下。斯血室有亏。邪热
方得而入。则是仲景云下血。乃经水交错妄行。又不问而自明矣。
金鉴曰。血已止。其热不去。蓄于阳明。不得外越而上蒸。故但头汗出也。
钱氏云。肝为藏血之脏。邪既入血。则热邪实满于经脉。故刺之以泄其实邪。然不以桃仁承气及抵当等
汤治之者。仲
景原云。毋犯胃气及上二焦。盖以此也。
案此条证。喻氏断为男子病。方氏三阳志聪锡驹柯氏周氏皆为男女俱有之证。金鉴则与喻同。特汪氏以
妇人论之。可谓超卓之见矣。然不知血室即是胞。殊可惜耳。程氏魏氏钱氏并无男女之说。疑是疑而不决欤。
汗出（【原注】汗。一作卧。）谵语者。以有燥屎在胃中。此为风也。须下者。过经乃可下之。下之若早。
语言必乱。以表虚里实故也。下之愈。宜大承气汤。（【原注】一云。大柴胡汤。○成本。玉函。下者。作下
之。愈上。有则字。）
〔成〕胃中有燥屎。则谵语。以汗出为表未罢。故云风也。燥屎在胃。则当下。以表未和。则未可下。须
过太阳经无表证。乃可下之。〔三〕阳明多汗。况有谵语。故又当下。但风家有汗。恐汗出则表未罢。故头过
经可下。若早燥屎虽除。表邪乘虚复陷。又将为表虚里实矣。下之则愈二句。又申明乃可下之一句耳。
钱氏云。若下早。则胃气一虚。外邪内陷。必至热盛神昏。语言必乱。盖以表间之邪气。皆陷入于里。表
空无邪。邪皆在里。故谓之表虚里实也。
汪氏云。补亡论。以末二句。移之过经乃可下之句下。误矣。○案补亡论。移原文者。固误矣。然而经旨
必当如此耳。
又案魏氏以此条证。为内经所谓胃风肠风。汪氏则为风燥症。并非也。
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。
〔张〕伤寒四五日。正热邪传里之时。况见脉沉喘满。里证已具。而反汗之。必致燥结谵语矣。盖燥结谵语。
颇似大
承气证。此以过汗伤津。而不致大实大满腹痛。止宜小承气。为允当耳。〔舒〕脉沉而喘满。则知为阳明宿燥
阻滞。浊气上干而然也。故曰。沉为在里。明非表也。而反发其汗。则津越便难。而成实矣。至久则谵语者。
自宜大承气汤。此因夺液而成燥者。原非大热入胃者比。故仲景不出方。尚有微甚之斟酌耳。〔方〕越出。谓
枉道而出也。
三阳合病。腹满身重。难以转侧。口不仁面垢。（【原注】又作枯。一云向经。）谵语遗尿。发汗则谵语。
下之则额上生汗。手足逆冷。若自汗出者。白虎汤主之。（口下。脉经。有中字。成本。玉函。面上。有而字。
面垢二字。千金翼。作言语向经四字。则谵语。玉函。作则谵语甚。逆冷。作厥冷。千金翼同。）
〔鉴〕三阳合病者。必太阳之头痛发热。阳明之恶热不眠。少阳之耳聋寒热等证。皆具也。太阳主背。阳
明主腹。少阳主侧。今一身尽为三阳热邪所困。故身重难以转侧也。胃之窍出于口。热邪上攻。故口不仁也。
阳明主面。热邪蒸越。故面垢也。热结于里。则腹满。热盛于胃。故谵语也。热迫膀胱。则遗尿。热蒸肌腠。
故自汗也。证虽属于三阳。而热皆聚胃中。故当从阳明热证主治也。若从太阳之表发汗。则津液愈竭。而胃热
愈深。必更增谵语。若从阳明之里下之。则阴益伤。而阳无根据则散。故额汗肢冷也。要当审其未经汗下。而身
热自汗出者。始为阳明的证。宜主以白虎汤。大清胃热。急救津液。以存其阴可也。〔柯〕里热而非里实。故
当用白虎。而不当用承气。若妄汗则津竭。而谵语。误下则亡阳。而额汗出。手足厥也。此自汗出。为内热甚
者言耳。接遗尿句来。若自汗。而无大烦大渴证。无洪大浮滑脉。当从虚治。不得妄用白虎。若额上汗出。手
足冷者。见烦渴谵语等证。与洪滑之脉。亦可用白虎汤。〔方〕口不仁。谓不正而
饮食不利便。无口之知觉也。
钱云。灵枢曰。胃和则口能知五味矣。此所云口不仁。是亦阳明胃家之病也。
方云。生汗。生不流也。
案手足逆冷。成氏程氏魏氏汪氏宗印。皆为热厥。误矣。周氏以此条。移于温病热病篇。亦非也。○又案
玉函。则谵语下。有甚字。文意尤明矣。
三阳并病。太阳证罢。但发潮热。手足 汗出。大便难而谵语者。下之则愈。宜大承气汤。
〔成〕本太阳病。并于阳明。名曰并病。太阳证罢。是无表证。但发潮热。是热并阳明。一身汗出为热
越。今手足 汗出。是热聚于胃也。必大便难而谵语。经曰。手足 然而汗出者。必大便已硬也。与大承气
汤。以下胃中实热。〔柯〕太阳症罢。是全属阳明矣。先揭二阳并病者。见未罢时便有可下之症。今太阳一罢。
则种种皆下症。
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。心愦愦反谵
语。若加温针。必怵惕烦躁不得眠。若下之则胃中空虚。客气动膈。心中懊 。舌上胎者。栀子豉汤主之。若
渴欲饮水。口干舌燥者。白虎加人参汤主之。若脉浮。发热。渴欲饮水。小便不利者。猪苓汤主之。（反恶热。
脉经。千金翼。作反偏恶热。心下。千金翼。有中字。温针。成本。作烧针。舌上胎。总病论。作苔生舌上。
玉函。千金翼。无加人参三字。）
〔鉴〕此条。表里混淆。脉证错杂。不但不可误下。亦不可误汗也。若以脉浮而紧。误发其汗。则夺液
伤阴。或加烧针。必益助阳邪。故谵语烦躁。怵惕愦乱不眠也。或以证之腹满恶热。而误下之。则胃中空虚。
客气邪热。扰动胸膈。
心中懊 。舌上生苔。是皆误下之过。宜以栀子豉汤。一涌而可安也。若脉浮不紧。证无懊 。惟发热。渴欲
饮水。口干舌燥者。为太阳表邪已衰。阳明燥热正甚。宜白虎加人参汤。滋液以生津。若发热。渴欲饮水。小
便不利者。是阳明饮热并盛。宜猪苓汤。利水以滋干。〔成〕舌上苔黄者。热气客于胃中。舌上苔白。知热气
客于胸中。与栀子豉汤。以吐胸中之邪。〔柯〕连用五若字。见仲景设法御病之详。栀豉汤所不及者。白虎汤
继之。白虎汤不及者。猪苓汤继之。此阳明起手之三法。所以然者。总为胃家惜津液。既不肯令胃燥。亦不肯
令水渍入胃耳。〔程〕热在上焦。故用栀子豉汤。热在中焦。故用白虎加人参汤。热在下焦。故用猪苓汤。〔汪〕
陈亮斯云。案本文。汗下烧针。独详言误下治法者。以阳明一篇。所重在下。故辨之独深悉焉。
喻云。汗出。不恶寒。反恶热。身重。四端。则皆阳明之见症。钱云。舌上苔。当是邪初入里。胃邪未实。
其色犹未至于黄黑焦紫。必是白中微黄耳。
案若脉浮之浮。其义未详。魏氏钱氏锡驹并云。表邪未尽。果然。则与五苓散证何别。汪氏云。非风邪在
表之脉浮。乃热邪伤气之脉浮也。此亦未见经中有其说。张氏乃以此条。编入温热病篇云。伤寒小便不利。以
脉浮者属气分。五苓散。脉沉者。属血分。猪苓汤。而温热病之小便不利。脉浮者属表证。猪苓汤。脉沉者。
属里证。承气汤。此说亦是臆造。经无明文。不可从也。特活人书。若伤寒引饮。下焦有热。小便不通。脉浮
者。五苓散。脉沉者。猪苓汤。王氏则云。此条浮字。误也。若脉字下。脱一不字矣。成氏直以脉浮释之。而
朱氏却以脉沉言之。胥失之矣。若曰脉浮者五苓散。不浮者。猪苓汤。则得仲景之意矣。盖其作沉。作不浮。未
知本经旧文果然否。然推之于处方之理。极觉明确。故姑从其说焉。○汪昂云。改脉浮。为不浮。方书中。无
此文法。
案喻氏云。四段。总顶首段。医学纲目。引本条云。阳明病脉浮紧。咽燥口苦。腹满发热。汗出不恶寒。
若下后。脉浮发热。渴欲饮水。小便不利者。猪苓汤主之。正与喻意符矣。
汪氏云。白虎汤证。即或有小便不利者。但病患汗出多。水气得以外泄。今观下条云。汗出多。不可与
猪苓汤。乃知此证。其汗亦少。汗与溺俱无。则所饮之水。安得不停。故用猪苓汤。上以润燥渴。下以利湿热
Pathogenic factors prevail, hence it is said to be difficult to treat. [Wei] A slippery and rapid pulse is a sign of heat flourishing in the interior, but the rapidity indicates that the heat has not yet formed excess (Shi). When heat initially transmits to the Fu organs, the pulse changes to deep and large, accompanied by a sluggish quality. "Sluggish" (Chi) is the opposite of "rapid". Previously slippery and rapid, now deep, large, and sluggish; this reveals that the Stomach has formed excess. Now that the pulse is slippery and rapid, it still carries a frequent quality, indicating that the heat has transformed and transmitted, but has not yet hardened and coagulated. Xiao Cheng Qi Tang should be administered. It eliminates accumulated food/stagnation and harmonizes body fluids, which is sufficient to cure the disease. [Ke] For those with severe deficiency, Si Ni Tang should be given. Yin resolves when it receives Yang.
Wang states: In the commentary on subsequent clauses, it says: "Delirium and tidal fever with a pulse that is faint and choppy indicate severe deficiency of interior Qi." Combining this with the previous slippery and rapid pulse, it also belongs to the false appearance of deficient Yang floating upwards. This statement seems plausible but is actually incorrect. I believe that delirium, tidal fever, and a slippery and rapid pulse represent a Yang syndrome presenting with a Yang pulse. The person has abundant pathogenic factors but unimpaired righteous Qi, hence it is said that Cheng Qi Tang can be used. A pulse that is faint and choppy represents a Yang syndrome presenting with a Yin pulse; the person has abundant pathogenic factors but depleted righteous Qi, hence it is said that Cheng Qi Tang should not be used again. If there is no passage of flatus and no bowel movement, it is not because the intestines are empty and devoid of matter, but because the righteous Qi of the Stomach-Chang system has declined. Even after taking herbal decoctions, the internal accumulation of turbid pathogens cannot be discharged. Hence it is said to be difficult to treat. Later physicians discussed using methods to tonify deficiency and restore Yang, which contradicts Zhang Zhongjing's original intent of using Cheng Qi Tang. Chang Qizhi in *Bu Wang Lun* suggests Huang Qi Ren Shen Jian Zhong Tang, which also conflicts with the canonical meaning. Generally, this clause states only that it is difficult to treat, proving it is not an incurable condition. If medication is desired, a formula combining tonification and purgation is appropriate.
Regarding Bai Hu Tang syndrome, the pulse is slippery. From Fang Youzhi onwards, many have interpreted this as due to retained food. This likely stems from *Mai Jue* and should not be accepted.
Yangming disease presents with delirium and tidal fever. If the patient cannot eat, there must be dry fecal balls (Zao Shi) numbering five or six in the Stomach. If the patient cannot eat, the stool is merely hard. Da Cheng Qi Tang should be used to purge. ("Er" in *Cheng Ben* is read as "Er". "Fan" has "Er" before it in *Yu Han* and *Mai Jing*. *Yu Han* lacks "Yi". *Mai Jing* lacks "Da" in "Da Cheng Qi Tang" and the seven characters "Yi Da Cheng Qi Tang Zhu Zhi". *Ke Ben* moves this sentence above "If able to eat", same as Zhang Yin'an and Zhou Yangjun. *Yi Zong Jin Jian* considers it an error, which is incorrect.)
[Zhang] This distinguishes the severity of dryness and accumulation based on the ability to eat or not. Examining Zhang Zhongjing's words: patients with tidal fever and delirium all suffer from excessive heat in the Stomach. Stomach heat digests grain; now, unable to eat, this must be due to heat damaging Stomach fluids, preventing Qi transformation from descending, causing dry feces to attack the Stomach inversely. Da Cheng Qi Tang should be used to urgently dispel extreme Yang heat to save nearly exhausted Yin. If able to eat, Stomach Qi transformation functions naturally, heat is not severe, fluids are not greatly damaged. Although stool is hard, it will pass spontaneously soon; medication is unnecessary as it would damage Qi. Using Cheng Qi Tang for those who can eat and have hard stool violates Zhang Zhongjing's principle of protecting fluids.
[Wang] In *Bu Wang Lun*, "Yi Da Cheng Qi Tang Xia Zhi" is placed before "If able to eat". Since eating ability differs, treatment must differ. Following Zhang Zhongjing's method, Tiao Wei Cheng Qi Tang should be used.
[Zhou] Regarding Da Cheng Qi Tang, it should follow "dry fecal balls numbering five or six". Why? Inability to eat indicates deep pathology, requiring strong purgation. If able to eat but stool is hard, there may not be five or six dry fecal balls. The mention of breath was incidental; Xiao Cheng Qi Tang is sufficient.
*Cishi Nan Zhi* states: "Stomach excess" does not mean physical matter exists, but that the pathway is blocked. *Nan Jing* says: The upper opening of the Stomach is Fen Men; the lower opening is You Men. You Men connects to the upper opening of the Small Intestine; the lower opening of the Small Intestine is the upper opening of the Large Intestine. They meet at Lan Men. Water seeps into the Bladder; coarse residue enters the Large Intestine and accumulates in Guang Chang (the pathway). If the pathway is blocked, Earth stagnates, Fire rebels upward to the Stomach, named "Stomach Excess". Thus, "Yangming should be purged" means the Upper and Lower Yangming meridians are obstructed. Saying "five or six dry fecal balls in the Stomach" implies connection to the Large Intestine, not literally inside the Stomach. ○ Wei states: "Five or six dry fecal balls blocking the bottom of the Stomach and intestinal space" is correct.
Xu Lingtai states: Dry feces should be in the intestines; why say Stomach? Pathogenic factors form waste; before descending, it is in the Stomach; when descending, it is in the intestines. Once formed, it is called dry feces. Mentioning Stomach includes the intestines.
Also: Inability to eat means external heat cannot digest grain. Ability to eat does not mean true desire for food, only that porridge/drinks can enter. Inability to eat means grain qi does not approach the stomach/intestines at all, due to extreme excess. Note: Yangming disease with delirium, tidal fever, and severe dryness results in inability to eat. The use of "fan" (reverse/opposite) here is suspicious. Commentators' explanation of "digesting grain" refers to Heat Zhong Xiao Dan syndrome. Pathogenic heat failing to digest grain is common in Shang Han; why call it "reverse"? Literal interpretation often leads to such contradictions. Also, Cheng, Qian Zhicong, and Xiju use Da Cheng Qi Tang regardless of eating ability, which is incorrect.
In Yangming disease, bleeding from below with delirium indicates Heat entering the Blood Chamber. If only the head sweats, puncture Qi Men, draining the excess according to its reality. General sweating leads to recovery. ("Xie" in *Cheng Ben* is "Xie". *Yu Han*, *Qian Jin Yi* add "Dang" before "Ci". "Ze" has "Zhe" before it. *Mai Jing* agrees. *Jin Gui Yao Lue · Fu Ren Za Bing Pian* has this clause, adding "Dang" before "Ci", "Zhe" instead of "Ze".)
[Wang] This clause likely concerns women. Pathogenic heat stagnates in the Yangming meridian, forcing blood downward. Downward bleeding empties the meridians, allowing heat to enter the chamber vacuously, causing delirium. Subsequent commentary states: The Blood Chamber belongs to the Chong Mai, but the Heart Sovereign is its master. Heat disturbing the chamber confuses the master. Only head sweats because downward blood loss prevents general sweating, while upward heat steams sweat. Puncturing Qi Men drains meridian excess, clearing heat, restoring fluids, leading to general sweating and resolution. Question: Zhang Zhongjing does not specify gender here, so Shang Lun scholars point to men. Why do you argue for women? Answer: In the Taiyang chapter, Zhang mentions "Woman with Wind Strike... menses just started... Heat entering Blood Chamber"; "Woman with Wind Strike... menses just ended... Heat entering Blood Chamber"; "Woman with Cold Damage... menses just started... Heat entering Blood Chamber". Thus, Heat entering Blood Chamber is clearly a female condition. Here, "bleeding from below" implies irregular menstruation, causing Blood Chamber deficiency, allowing heat invasion. *Ling Shu · Hai Lun* states: Chong Mai is the Sea of Twelve Meridians, i.e., the Sea of Blood. Chong Mai originates in the Bao Zhong. *Su Wen · Tian Zhen Lun* states: At age 14, women's Tian Gui arrives, Ren Mai opens, Tai Chong Mai flourishes, menstruation occurs regularly. Ren and Chong meridians run through the abdomen, so blood exits via the anterior yin. Thus, Blood Chamber deficiency allows heat entry. Zhang's "bleeding from below" refers to irregular menstruation, self-evident.
*Yi Zong Jin Jian* states: After bleeding stops, heat remains, accumulating in Yangming, unable to vent outward, steaming upward, causing only head sweat.
Qian states: Liver stores blood. Once pathogen enters blood, heat fills the meridians, so puncture to drain excess. Tao Ren Cheng Qi Tang and Di Dang Tang are not used because Zhang Zhongjing stated "Do not violate Stomach Qi and the Upper/Middle Jiao," which applies here.
Note: Yu Jiayuan diagnosed this as male disease. Fang Youzhi, San Yang, Zhicong, Xiju, Ke Qin, Zhou Yangjun considered it applicable to both sexes. *Yi Zong Jin Jian* agreed with Yu. Only Wang argued for women, a superior view, though failing to recognize Blood Chamber equals Uterus is regrettable. Cheng, Wei, Qian had no gender distinction, perhaps undecided.
Sweating with delirium indicates dry feces in the Stomach, caused by Wind. Purging is required, but only after the exterior stage passes. Premature purging causes chaotic speech due to exterior deficiency and interior excess. Purging cures; Da Cheng Qi Tang is indicated. ([Original note] One version says Da Chai Hu Tang. ○ *Cheng Ben*, *Yu Han*: "Xia Zhe" is "Xia Zhi". "Yu" has "Ze" before it.)
[Cheng] Dry feces in Stomach cause delirium. Sweating indicates exterior not resolved, hence "Wind". Dry feces require purging, but since exterior is not harmonized, purging is delayed until Taiyang exterior signs resolve. [San] Yangming has much sweating; with delirium, purging is needed. But wind patients sweat, fearing exterior unresolved. Only after passing the meridian stage can one purge. Early purging removes feces but allows exterior pathogen to sink inward, creating exterior deficiency/interior excess. "Purging cures" reiterates "only then can one purge".
Qian states: Early purging weakens Stomach Qi, allowing external pathogen to sink inward, causing heat excess, spirit confusion, and chaotic speech. Exterior pathogen sinks to interior; exterior is empty, interior full, hence "exterior deficiency, interior excess".
Wang states: *Bu Wang Lun* moved the last two sentences under "pass meridian then purge", which is wrong. ○ Moving the text is wrong, but the canonical meaning supports this order.
Also: Wei interprets this as Nei Jing's Stomach Wind/Intestinal Wind; Wang interprets as Wind-Dryness, both incorrect.
Cold damage for four to five days, pulse deep with wheezing/fullness. Deep indicates interior. Purging incorrectly depletes fluids, causing difficult defecation, exterior deficiency, interior excess, eventually delirium.
[Zhang] Four to five days is when heat transmits to interior. Pulse deep, wheezing, fullness confirm interior syndrome. Incorrect sweating leads to dryness, constipation, delirium. Though resembling Da Cheng Qi Tang syndrome, excessive sweating damages fluids without severe abdominal fullness/pain. Xiao Cheng Qi Tang is appropriate.
[Shu] Deep pulse with wheezing/fullness indicates Yangming chronic dryness obstruction, turbid Qi attacking upward. "Deep indicates interior" confirms non-exterior. Incorrect sweating depletes fluids, causing difficulty and excess. Eventually delirium requires Da Cheng Qi Tang. This dryness results from fluid depletion, unlike severe heat invading Stomach, so Zhang omitted a formula, allowing for judgment of severity.
[Fang] "Yue Chu" means exiting wrongly.
Three Yang combined disease: Abdominal fullness, body heaviness, difficulty turning, mouth dysfunction, facial dirtiness. Delirium, urinary incontinence. Sweating worsens delirium. Purging causes forehead sweating and cold limbs. If spontaneous sweating occurs, Bai Hu Tang governs. ("Kou" has "Bu" in *Mai Jing*. "Mian shang" has "Er" in *Cheng Ben*, *Yu Han*. *Qian Jin Yi* reads "Mian Gu" as "Yan Yu Xiang Jing". *Yu Han* reads "Ze Chan Yu" as "Ze Chan Yu Shen". "Ni Leng" is "Jue Leng", same in *Qian Jin Yi*.)
[Jian] Three Yang combined disease includes Taiyang headache/fever, Yangming aversion to heat/insomnia, Shaoyang deafness/chills-fever. Taiyang governs back, Yangming abdomen, Shaoyao sides. All three Yang heat pathogens confine the body, causing heaviness/difficulty turning. Mouth is Stomach orifice; heat attacks upward causing mouth dysfunction. Yangming governs face; heat steams causing facial dirtiness. Heat knots interior causing abdominal fullness. Heat flourishes Stomach causing delirium. Heat forces Bladder causing incontinence. Heat steams muscle/cutaneous causing spontaneous sweating. Though involving Three Yang, heat gathers in Stomach, so treat as Yangming heat. Sweating from Taiyang exterior depletes fluids, deepening Stomach heat, worsening delirium. Purging from Yangming interior injures Yin, leaving Yang unrooted, causing forehead sweat/cold limbs. Examine if untreated, with fever/spontaneous sweating, confirming Yangming syndrome. Use Bai Hu Tang to clear Stomach heat, rescue fluids, preserve Yin.
[Ke] Interior heat without interior excess requires Bai Hu, not Cheng Qi. Wrong sweating depletes fluids, causing delirium. Wrong purging loses Yang, causing forehead sweat/cold limbs. Spontaneous sweating indicates severe internal heat. Connecting to incontinence: If sweating without great vexation/thirst or洪大 pulse, treat deficiency, do not use Bai Hu blindly. If forehead sweat/cold limbs with vexation/thirst/delirium and洪滑 pulse, Bai Hu Tang can be used.
[Fang] Mouth dysfunction means improper taste perception and difficulty eating.
Qian states: *Ling Shu* says harmonious Stomach perceives five tastes. Mouth dysfunction is a Yangming Stomach disease.
Fang states: Sheng Han means sweat does not flow.
Note: Cold limbs were diagnosed as Heat Jue by Cheng, Cheng, Wei, Wang, Zongyin, which is wrong. Zhou moved this to Warm Disease chapter, also wrong. ○ *Yu Han* adds "Shen" after "Chan Yu", clarifying meaning.
Three Yang concurrent disease: Taiyang signs cease, only tidal fever, continuous sweating on hands/feet, difficult defecation, delirium. Purging cures; Da Cheng Qi Tang is indicated.
[Cheng] Originally Taiyang disease merging into Yangming is concurrent disease. Taiyang cessation means no exterior. Tidal fever indicates heat merging into Yangming. General sweating vents heat; continuous hand/foot sweating indicates heat gathering in Stomach. Must have difficult defecation/delirium. Classic says: Continuous hand/foot sweating implies hard stool. Give Da Cheng Qi Tang to purge Stomach excess heat.
[Ke] Taiyang cessation means fully Yangming. Mentioning Two Yang concurrent shows purgable symptoms existed before cessation. Now Taiyang ceases, all symptoms indicate purgation.
Yangming disease, pulse floating/tight, dry throat, bitter taste, abdominal fullness/wheezing, fever/sweating, no aversion to cold but aversion to heat, body heaviness. Sweating causes agitation, mental confusion, delirium. Moxibustion causes fear, restlessness, insomnia. Purging empties Stomach, guest Qi disturbs Diaphragm, heart feels vexed, tongue has coating; Zi Chi Tang governs. Thirst for water, dry mouth/tongue; Bai Hu Jia Ren Shen Tang governs. Pulse floating, fever, thirst, difficult urination; Zhu Ling Tang governs. ("Fan E Re" is "Fan Pian E Re" in *Mai Jing*, *Qian Jin Yi*. "Xin xia" has "Zhong" in *Qian Jin Yi*. "Wen Zhen" is "Shao Zhen" in *Cheng Ben*. "She shang tai" is "Tai Sheng She Shang" in *Zong Bing Lun*. *Yu Han*, *Qian Jin Yi* lack "Jia Ren Shen".)
[Jian] This clause mixes exterior/interior, pulse/symptoms. Do not mistake purging or sweating. Floating/tight pulse mistaken for sweating depletes fluids/Yin. Moxibustion aids Yang pathogen, causing delirium/restlessness/fear/confusion. Abdominal fullness/heat mistaken for purging empties Stomach, guest heat disturbs chest/diaphragm, causing vexation/tongue coating. These are errors of premature purging. Zi Chi Tang induces vomiting to settle. Floating pulse without tightness/vexation, only fever/thirst/dry mouth indicates declining Taiyang exterior, flourishing Yangming dry-heat. Bai Hu Jia Ren Shen Tang moistens fluids. Fever/thirst/difficult urination indicates Yangming fluid-heat abundance. Zhu Ling Tang promotes urination to nourish dryness.
[Cheng] Yellow tongue coating indicates heat in Stomach. White coating indicates heat in Chest. Zi Chi Tang vomits chest pathogen.
[Ke] Five "Ruo" (if) show Zhang's detailed disease management. Where Zi Chi fails, Bai Hu follows; where Bai Hu fails, Zhu Ling follows. These are the first three Yangming methods. Purpose: protect Stomach fluids, avoid drying Stomach or flooding with water.
[Cheng] Heat in Upper Jiao uses Zi Chi Tang. Heat in Middle Jiao uses Bai Hu Jia Ren Shen Tang. Heat in Lower Jiao uses Zhu Ling Tang.
[Wang] Chen Liangsi notes: Text details errors of sweating/purging/moxibustion, emphasizing purging importance in Yangming chapter.
Yu states: Sweating, no aversion to cold, aversion to heat, body heaviness are Yangming signs.
Qian states: Tongue coating indicates early interior entry, Stomach pathogen not excess, color not yellow/black/scorched, but white with slight yellow.
Note: Meaning of "floating" pulse is unclear. Wei, Qian, Xiju say exterior pathogen remains. If so, how different from Wu Ling San? Wang says: Not wind-pathogen exterior floating, but heat damaging Qi floating. Unfound in classics. Zhang Yin'an places this in Warm Diseases: Cold damage difficult urination, floating pulse Qi aspect Wu Ling San, sinking pulse Blood aspect Zhu Ling Tang. Warm disease difficult urination, floating pulse exterior Zhu Ling Tang, sinking pulse interior Cheng Qi Tang. This is fabrication, unsupported by classics. *Huo Ren Shu* says: Cold damage drinking, lower jiao heat, no urination, floating pulse Wu Ling San, sinking pulse Zhu Ling Tang. Wang Shi says: "Floating" is error, missing "Bu" after "Mai". Cheng explains floating; Zhu argues sinking. Both wrong. If floating pulse Wu Ling San, non-floating Zhu Ling Tang, it fits Zhang's intent. Whether original text was "sinking" or "non-floating" is unknown, but logic supports it. So tentatively accept. ○ Wang Ang states: Changing "floating" to "non-floating" lacks precedent in medical texts.
Note: Yu states: Four paragraphs summarize the first. *Yi Xue Gang Mu* cites: Yangming disease floating/tight pulse, dry throat/bitter taste, abdominal fullness/fever, sweating/no aversion to cold. Post-purging, floating pulse/fever/thirst/difficult urination, Zhu Ling Tang governs. Matches Yu's intent.
Wang states: Bai Hu Tang syndrome may have difficult urination, but heavy sweating vents water qi. Next clause says: Heavy sweating, do not give Zhu Ling Tang. Thus, this case has little sweating. No sweat, no urine, ingested water stagnates. Zhu Ling Tang moistens upper dryness, drains lower damp-heat.