须分津液枯者。用蜜导。邪热盛者。用胆导。湿热痰饮固结。姜汁麻油。浸栝蒌根导。惟下旁流水者。导之无
益。非诸承气汤攻之不效。以实结在内。而不在下也。至于阴结便闭者。宜于蜜煎中。加姜汁生附子末。或削
陈酱姜导之。凡此皆善于推展仲景之法者也。
外台秘要。崔氏。胃中有燥粪。令人错语。正热盛。令人错语。宜服承气汤。亦应外用生姜兑。（读作锐。
下同。）使必去燥粪。姜兑法。削生姜。如小指长二寸。盐涂之。纳下部中立通。
三因方。蜜兑法。蜜三合。盐少许。煎如饧。出冷水中。捏如指大。长三寸许。纳下部。立通。
得效方。蜜兑法。蜜三合。入猪胆汁两枚在内。煎如饴。以井水出冷。候凝捻如指大。长三寸许。纳下部。
立通。活人书。单用蜜。一法。入皂角末。在人斟酌用。一法。入薄
荷末。代皂角用。尤好。又或偶无蜜。只嚼薄荷。以津液调。作挺用之。亦妙。
丹溪心法。凡诸 。服药不通。或兼他证。又或老弱虚极。不可用药者。用蜜熬。入皂角末少许。作兑以
导之。冷 。生姜兑亦可。丹溪纂要。蜜导方。以纸捻为骨。便。
医学入门。白蜜半盏。于铜杓内。微火熬。令滴水不散。入皂角末二钱搅匀。捻成小枣大。长寸。两头锐。
蘸香油。推入谷道中。大便即急而去。如不通。再易一条。外以布掩肛门。须忍住蜜。待粪至。方放开布。
吴仪洛方论。海藏法。用蜜煎盐相合。或草乌头末相合。亦可。盖盐。能软坚润燥。草乌。能化寒消结。
可随证阴阳所宜而用之。
阳明病。脉迟。汗出多。微恶寒者。表未解也。可发汗。宜桂枝汤。（玉函。千金翼。脉上。有其字。多
下。有而字。）
〔汪〕此条言阳明病。非胃家实之证。乃太阳病。初传阳明。经中有风邪也。脉迟者。太阳中风缓脉之所
变。传至阳明。邪将入里。故脉变迟。汗出多者。阳明热而肌腠疏也。微恶寒者。太阳在表之风邪。未尽解也。
治宜桂枝汤。以解肌发汗。以其病从太阳经来。故仍从太阳经例治之。
金鉴曰。汗出多之下。当有发热二字。若无此二字。脉迟汗出多微恶寒。乃是表阳虚。桂枝附子汤证也。岂
有用桂枝汤。发汗之理乎。必是传写之遗。○案揭以阳明病三字。其发热。可不须言而知也。金鉴之说。却非是也。
阳明病脉浮。无汗而喘者。发汗则愈。宜麻黄汤。（而字。玉函。千金翼。作其人必三字。无者字。）
〔鉴〕是太阳之邪。未悉入阳明。犹在表也。当仍从太阳伤寒治之。发汗则愈。〔钱〕此条脉证治法。皆
寒伤营也。若
无阳明病三字。不几列之太阳篇中。而仲景何故以阳明病冠之邪。盖以太阳篇曰。恶寒体痛。脉阴阳俱紧者。
名曰伤寒。其次条又曰。恶风无汗而喘者。麻黄汤主之。此条虽亦无汗而喘。然无恶风恶寒之证。即阳明所谓
不恶寒。反恶热之意。是以谓之阳明病也。
阳明病。发热汗出者。此为热越。不能发黄也。但头汗出。身无汗。剂颈而还。小便不利。渴引水浆者。
此为瘀热在里。身必发黄。茵陈蒿汤主之。（汗出上。玉函。有而字。无汗出者之者字。成本同。身无汗之汗。
千金翼。外台。作有。剂。玉函。千金翼。作齐。玉函。成本。千金翼。无蒿字。程本。剂。作跻。金鉴同。
方本。引。作饮。喻程诸本。并同。）
〔成〕但头汗出。身无汗。剂颈而还者。热不得越也。小便不利。渴饮水浆者。热甚于胃。津液内竭也。
胃为土而色黄。胃为热蒸。则色夺于外。必发黄也。与茵陈汤。逐热退黄。〔程〕无汗而小便利者属寒。无汗
而小便不利者。属湿热。两邪交郁。不能宣泄。故 而发黄。解热除郁。何黄之不散也。〔柯〕身无汗。小便
不利。不得用白虎。瘀热发黄。内无津液。不得用五苓。故制茵陈汤。以佐栀子承气之所不及也。
汪昂云。热外越而表不郁。湿下渗而里不停。今小便既不利。身又无汗。故郁而为黄。
茵陈蒿汤方
茵陈蒿（六两） 大黄（二两去皮） 栀子（十四枚擘○千金。作四十枚。）
上三味。以水一斗二升。先煮茵陈。减六升。纳二味。煮取三升。去滓。分三服。小盒饭利。尿如皂荚
汁状。色正赤。一宿腹减。黄从小便去也。（一斗二升。金匮。及玉函。成本。作一斗。六升下。肘后。千金。
外台。有去滓二字。分下。金匮。及玉函。成本。有温字。汁。千金。并翼。作沫。一宿二字。千金作当一字。
千金翼。无腹减二字。）
〔钱〕茵陈。性虽微寒。而能治湿热黄胆。及伤寒滞热。
通身发黄。小便不利。栀子苦寒。泻三焦火。除胃热时疾黄病。通小便。解消渴心烦懊 。郁热结气。更入血
分。大黄苦寒下泄。逐邪热通肠胃。三者皆能蠲湿热。去郁滞。故为阳明发黄之首剂云。
金匮要略。谷疸之为病。寒热不食。食即头眩。心胸不安。久久发黄为谷疸。茵陈蒿汤主之。
千金方注。范汪疗谷疸。短剧方。用石膏一斤。
阳明证。其人喜忘者。必有蓄血。所以然者。本有久瘀血。故令喜忘。屎虽硬。大便反易。其色必黑者。
宜抵当汤下之。（喜忘。外台。作善忘。成本。黑下。无者字。玉函。下。作主。）
〔钱〕喜忘者。语言动静。随过随忘也。言所以喜忘者。以平日本有积久之瘀血在里故也。前太阳证中。因
郁热之表邪不解。故随经之瘀热。内结膀胱。所以有如狂发狂之证。此无瘀热。故但喜忘耳。素问调经论云。
血气未并。五脏安定。血并于下。气并于上。乱而喜忘者。是也。〔锡〕喜忘。犹善忘也。〔程〕血蓄于下。则
心窍易塞。而识智昏。故应酬问答。必失常也。病属阳明。故屎硬。血与粪并。故易而黑。
伤寒准绳曰。案邪热燥结。色未尝不黑。但瘀血则溏。而黑粘如漆。燥结则硬。而黑晦如煤。此为明辨也。
又海藏云。初便褐色者重。再硬深褐色者愈重。三便黑色者为尤重。色变者。以其火燥也。如羊血在日色中。
须臾变褐色。久则渐变而为黑色。即此意也。
阳明病下之。心中懊 而烦。胃中有燥屎者。可攻。腹微满。初头硬。后必溏。不可攻之。若有燥屎者。
宜大承气汤。（玉函。脉经。千金翼。腹上。有其人二字。初头硬后必溏。作头坚后溏。）
〔成〕下后心中懊 。而烦者。虚烦也。当与栀子豉汤。若胃中有燥屎者。非虚烦也。可与大承气汤下之。
其腹微满。
初硬后溏。是无燥屎。此热不在胃。而在上也。故不可攻。〔鉴〕阳明病。下之后。心中懊 而烦者。若腹大
满。不大便。小便数。知胃中未尽之燥屎复硬也。乃可攻之。〔程〕末句。乃申可攻句。以决治法。〔柯〕腹微
满。犹是栀子浓朴汤证。
病患不大便五六日。绕脐痛。烦躁。发作有时者。此有燥屎。故使不大便也。
〔钱〕不大便五六日。而绕脐痛者。燥屎在肠胃也。烦躁。实热郁闷之所致也。发作有时者。日晡潮热之
类也。阳明胃实之里证悉备。是以知其有燥屎。故使不大便也。〔程〕绕脐痛。则知肠胃干屎无去路。故滞涩
在一处而作痛。〔志〕不言大承气汤者。省文也。上文云。若有燥屎者。宜大承气汤。此接上文而言。此有燥屎。
则亦宜大承气汤明矣。〔汪〕仲景用大承气汤。证必辨其有燥屎。则是前言潮热谵语。手足汗出。转失气。其
法可谓备矣。此条复云绕脐痛。可见证候多端。医者所当通变而延医之也。
病患烦热。汗出则解。又如疟状。日晡所发热者。属阳明也。脉实者宜下之。脉浮虚者宜发汗。下之与大
承气汤。发汗宜桂枝汤。（玉函。又。作复。上二宜字。并作当字。与。作宜。）
〔鉴〕病患。谓病太阳经中风伤寒之人也。〔钱〕言病患烦热。至汗出而后解者。又或如疟状。必至日晡时
发热者。即潮热也。如此则邪气已属阳明矣。然表里之分。当以脉辨之。若按其脉。而实大有力者。为邪在阳
明之里而胃实。宜攻下之。若脉浮虚者。即浮缓之义。为风邪犹在太阳之表而未解。宜汗解之。谓之浮虚者。
言浮脉按之本空。非虚弱之虚也。若虚弱则不宜于发汗矣。宜详审之。脉实者下之。以其胃热。故宜与大承气
汤。浮虚者汗之。以其风邪未解。故宜与桂枝汤。〔印〕此章。与太阳并病章。伤寒不大便六七日。头痛有
热者。与承气汤。（太阳中篇五十六条）大意相同。
大下后。六七日不大便。烦不解。腹满痛者。此有燥屎也。所以然者。本有宿食故也。宜大承气汤。
〔程〕烦不解。指大下后之证。腹满痛。指六七日不大便后之证。从前宿食。经大下而栖泊于回肠曲折之处。
胃中尚有此。故烦不解。久则宿食结成燥屎。挡住去路。新食之浊秽。总蓄于腹。故满痛。下后亡津液。亦能
令不大便。然烦有解时。腹满不痛可验。〔锡〕此证着眼。全在六七日上。以六七日不大便。则六七日内所食之
物。又为宿食。所以用得大承气。然今人本虚质弱。大下后得此者。亦什不得一耳。
舒氏云。此证虽经大下。而宿燥隐匿未去。是以大便复闭。热邪复集。则烦不解。而腹为满为痛也。所言
有宿食者。即胃家实之互辞。乃正阳阳明之根因也。若其人本有宿食。下后隐匿不去者。固有此证。且三阴寒
证。胃中隐匿宿燥。温散之后。而传实者。乃为转属阳明也。予内弟以采者。患腹痛作泄。逾月不愈。姜附药。
服过无数。其人禀素盛善啖肉。因自恃强壮。病中不节饮食。而酿胃实之变。则大便转闭。自汗出。昏愦不省
人事。谵语狂乱。心腹胀满。舌苔焦黄。干燥开裂。反通身冰冷。脉微如丝。寸脉更微。殊为可疑。予细察之。
见其声音烈烈。扬手掷足。渴欲饮冷。而且夜不寐。参诸腹满舌苔等证。则胃实确无疑矣。于是更察其通身冰
冷者。厥热亢极。隔阴于外也。脉微者。结热阻截中焦。营气不达于四末也。正所谓阳极似阴之候。宜急下之。
作大承气汤一剂投之。无效。再投一剂。又无效。服至四剂。竟无效矣。予因忖道。此证原从三阴而来。想有
阴邪未尽。观其寸脉。其事着矣。竟于大承气汤中。加附子三钱。以破其阴。使各行其用。而共成其功。服一
剂。得大下。寸脉即
出。狂反大发。予知其阴已去矣。附子可以不用。乃单投承气一剂。病势略杀。复连进四剂。其前计十剂矣。
硝黄各服过半斤。诸证以渐而愈。可见三阴寒证。因有宿食。转属阳明。而反结燥者。有如是之可畏也。
病患小便不利。大便乍难乍易。时有微热。喘冒（【原注】一作息。）不能卧者。有燥屎也。宜大承气汤。
〔钱〕凡小便不利。皆由三焦不运。气化不行所致。惟此条小便不利。则又不然。因肠胃壅塞。大气不行。
热邪内瘀。津液枯燥。故清道皆涸也。乍难。大便燥结也。乍易。旁流时出也。时有微热。潮热之余也。喘者。
中满而气急也。冒者。热邪不得下泄。气蒸而郁冒也。胃邪实满。喘冒不宁。故不得卧。经所谓胃不和。则卧
不安也。若验其舌苔黄黑。按之痛。而脉实大者。有燥屎在内故也。宜大承气汤。〔程〕易者。新屎得润而流
利。难者。燥屎不动而阻留。
〔王〕此证不宜妄动。必以手按之。大便有硬块。喘冒不能卧。方可下之。何也。乍难乍易故也。
食谷欲呕。属阳明也。吴茱萸汤主之。得汤反剧者。属上焦也。（玉函。成本。呕。下。有者字。）
〔程〕食谷欲呕者。纳不能纳之象。属胃气虚寒。不能消谷使下行也。曰属阳明者。别其少阳喜呕之兼半
表。太阳干呕不呕食之属表者不同。温中降逆为主。〔汪〕得汤反剧者。成注云。以治上焦法治之。而无其方。
准绳云。葛根半夏汤。误矣。尚论篇云。仍属太阳热邪。而非胃寒。条辨云。上焦以膈言。戒下之意。此又泥
于伤寒呕多。虽有阳明证。不可攻之。皆大谬之极。穷思先贤用药。岂如今医之鲁莽。误以胃家虚寒。为实热
证。但虚寒在膈以上。不与胃腑之中溷同一治。上条证。治以吴茱萸汤。寒热虚实。原无误也。其有
得汤反剧者。补亡论。常器之云。宜橘皮汤。注云。类要方。用橘皮二两。甘草一两。生姜四两。人参三两。
水煎服。斯言庶得之矣。
魏氏云。何以得汤反剧耶。不知者。以为胃热而非胃寒矣。仲师示之曰。此固有热也。而热不在胃脘之中
焦。乃在胸膈之上焦。惟其中焦有寒。所以上焦有热。吴茱萸人参之辛温。本宜于中焦之寒者。先乖于上焦之
热。此吴茱萸之所以宜用而未全宜耳。主治者。见兹上热下寒之证。则固有黄连炒吴茱萸。生姜易干姜一法。
似为温中而不僭上。一得之愚。不知当否。喻谓得汤转剧。属太阳。谬矣。程谓仍与吴茱萸。亦胶柱之见也。
热因寒用。以猪胆为引。如用于理中汤之法。或亦有当乎。○案柯氏云。服汤反剧者。以痰饮在上焦为患。呕
尽自愈。非谓不宜服也。钱氏云。得汤反剧者。邪犹在胸。当以栀子豉汤涌之。庶几近似。二氏并失经旨矣。
吴茱萸汤方
One must distinguish between cases of fluid depletion and those of excess pathogenic heat. For fluid depletion, use honey suppositories (Mi Dao). For excess pathogenic heat, use gallbladder bile suppositories (Dan Dao). For conditions where damp-heat, phlegm-fluids are firmly consolidated, soak Trichosanthis Radix (Gualou Gen) in ginger juice and sesame oil to make a suppository. Only in cases of "sluicing" (Pang Liu Shui), where only clear watery stool passes around impactions, is the use of suppositories of no benefit; one must employ the various Chengqi Decoctions (Chengqi Tang) for purgation to be effective, because the solid accumulation is internal, not located in the lower part. As for constipation due to Yin binding (Yin Jie Bian Bi), one should add ginger juice and powdered raw Aconite Root (Sheng Fuzi) to honey suppositories, or carve aged soy sauce pickled ginger into a suppository shape. All these methods are employed by those who skillfully extend the therapeutic principles of Zhang Zhongjing.
*Waitai Miyao* records: Cui Shi stated that dry feces in the stomach cause delirious speech (Cuo Yu); likewise, intense heat causes delirious speech. It is appropriate to administer Chengqi Decoction (Chengqi Tang). Additionally, external application of fresh ginger suppositories (Sheng Jiang Dui) should be used ("Dui" is pronounced as "Rui", same below). The method for ginger suppositories: slice fresh ginger to the length of two cun (approx. 6 cm) and thickness of a little finger, coat with salt, insert into the anus, and bowel movement will immediately become unobstructed.
*Sanyin Fang* records: Honey suppository method. Take three he of honey and a small amount of salt, boil until thick like malt syrup, remove and place in cold water, mold into a cylinder the size of a finger and about three cun long, insert into the anus, and bowel movement will immediately become unobstructed.
*De Xiao Fang* records: Honey suppository method. Take three he of honey, add two pig gallbladders, boil until like malt syrup, remove from well water to cool, wait until it solidifies, mold into a cylinder the size of a finger and about three cun long, insert into the anus, and bowel movement will immediately become unobstructed.
*Huoren Shu* records: A method using only honey. One variation adds powder of Gleditsia Sinensis Fruit (Zao Jiao Mo), to be used according to judgment. Another variation adds powder of Mentha Haplocalyx (Bo He Mo) to replace Gleditsia Sinensis Fruit, which is particularly good. Alternatively, if honey is unavailable, chew Mentha Haplocalyx (Bo He), mix with saliva, and form into a suppository, which is also excellent.
*Danxi Xin Fa* records: In all cases of constipation where medication fails to induce bowel movement, or when accompanied by other syndromes, or in elderly/weak patients with extreme deficiency who cannot tolerate medication, boil honey, add a small amount of Gleditsia Sinensis Fruit (Zao Jiao Mo) powder, and form a suppository to guide the bowels. For cold constipation, ginger suppositories can also be used. *Danxi Zuan Yao* records: Honey suppository formula. Use paper twists as a core for convenience.
*Yixue Rumen* records: Take half a zhan of white honey, simmer gently in a copper spoon until it does not disperse when dropped in water, add two qian of Gleditsia Sinensis Fruit (Zao Jiao Mo) powder and stir evenly, mold into a shape the size of a small jujube, one cun long, with pointed ends, dip in sesame oil, and push into the rectum. Bowel movement will urgently follow. If still obstructed, replace with another. Cover the anus with cloth externally, retain the honey until the stool arrives, then release the cloth.
Wu Yiluo's *Fang Lun* records: Haizang's method. Combine boiled honey with salt, or combine with powder of Aconitum Kusnezoffii (Caowutou Mo), both are acceptable. Salt softens hardness and moistens dryness; Aconitum Kusnezoffii resolves cold and dissipates accumulation. Choose according to the suitability of yin or yang in the syndrome.
Yangming disease, with slow pulse, profuse sweating, and slight aversion to cold, indicates the exterior is not yet resolved. Sweating may be induced, preferably with Guizhi Tang (Cinnamon Twig Decoction). (*Yuhan Jing* and *Qianjin Yi Fang*: add "Qi" before "Mai" [pulse], and "Er" [and] after "Duo" [profuse].)
Wang's commentary: This clause describes Yangming disease, but not the "stomach house excess" (Wei Jia Shi) syndrome; rather, it is Taiyang disease initially transmitting to Yangming, with wind pathogen in the meridians. The slow pulse is a variation of the slow pulse of Taiyang wind-strike; upon transmission to Yangming, as pathogen enters interior, the pulse becomes slow. Profuse sweating occurs because Yangming heat causes skin pores to open. Slight aversion to cold indicates the wind pathogen at the Taiyang exterior has not fully resolved. Treatment should use Guizhi Tang (Cinnamon Twig Decoction) to resolve the muscle layer and induce sweating. Since the disease originated from the Taiyang meridian, it is treated according to Taiyang meridian principles.
*Yizong Jinjian* states: After "profuse sweating," the characters "fa re" [fever] should likely exist. Without these two characters, slow pulse, profuse sweating, and slight aversion to cold indicate exterior yang deficiency, which is the indication for Guizhi Fuzi Tang (Cinnamon Twig and Aconite Decoction). How could Guizhi Tang (Cinnamon Twig Decoction) be used to induce sweating? It must be a transcription omission. ○ Note: Since the text begins with "Yangming disease," fever is implied and need not be explicitly stated. Jinjian's view is incorrect.
Yangming disease, with floating pulse, no sweating, and wheezing, resolves with sweating; Ma Huang Tang (Ephedra Decoction) is indicated. (*Yuhan Jing*, *Qianjin Yi Fang*: "Er" [and] is written as "Ren Bi" [the person necessarily]; "Wu" [no] is written as "You" [have].)
Jian's commentary: This is Taiyang pathogen not fully entering Yangming, remaining at the exterior. It should still be treated as Taiyang cold damage; inducing sweating leads to recovery. Qian's commentary: The pulse, symptoms, and treatment method here all pertain to cold damaging the Ying level. If not for the three characters "Yangming Bing" [Yangming Disease], would this not be listed in the Taiyang chapter? Why did Zhongjing prefix it with "Yangming Disease"? Presumably because the Taiyang chapter states: "Aversion to cold, body pain, and pulse tight at both yin and yang positions is named Cold Damage." The next clause states: "Aversion to wind, no sweating, and wheezing are treated with Ma Huang Tang (Ephedra Decoction)." Although this clause also presents no sweating and wheezing, it lacks aversion to wind and cold, aligning with the Yangming principle of "no aversion to cold, but aversion to heat." Hence, it is called Yangming Disease.
Yangming disease, with fever and sweating, indicates heat venting outward, preventing jaundice. However, if there is sweating only on the head, no sweating on the body, stopping at the neck, combined with difficult urination and thirst prompting intake of fluids, this indicates stagnant heat in the interior, leading to jaundice. Yinchen Hao Tang (Artemisiae Scopariae and Gardeniae Decoction) is indicated. (*Yuhan Jing*: adds "Er" [and] before "Han Chu" [sweating], removes "Zhe" [particle] from "Han Chu Zhe". Cost edition same. *Qianjin Yi Fang*, *Waitai Mi Yao*: change "Han" [sweat] in "Shen Wu Han" to "You" [have]. *Yuhan Jing*, *Qianjin Yi Fang*: change "Ji" [to the extent of] to "Qi" [even]. *Yuhan Jing*, Cost edition, *Qianjin Yi Fang*: omit "Hao" [seed]. Cheng edition: change "Ji" to "Ji" [ascend]. Jinjian agrees. Fang edition: change "Yin" to "Yin" [drink]. Yu Jiayan, Cheng Zhi, and others agree.)
Cheng's commentary: Sweating only on the head, no sweating on the body, stopping at the neck, indicates heat cannot vent. Difficult urination and thirst for fluids indicate heat severe in the stomach and exhaustion of internal fluids. Stomach belongs to Earth and its color is yellow; steamed by heat, the yellow color manifests externally, causing jaundice. Administer Yinchen Tang to purge heat and resolve jaundice. Cheng's commentary: No sweating with free urination indicates cold; no sweating with difficult urination indicates damp-heat. Two pathogens intertwine, unable to vent, thus causing jaundice. Resolve heat and dissipate stagnation, and what jaundice would remain? Ke's commentary: No sweating and difficult urination preclude Baihu Tang; stagnant heat with jaundice and internal fluid exhaustion preclude Wuling San. Thus, Yinchen Hao Tang (Artemisiae Scopariae and Gardeniae Decoction) was formulated to supplement the deficiencies of Zhizi Chengqi Tang (Gardenia and Major Purgative Decoction).
Wang Ang stated: Heat vents outward without exterior constraint; dampness seeps downward without interior retention. Now, since urination is difficult and there is no sweating, stagnation results in jaundice.
Yinchen Hao Tang Formula
Yin Chen Hao (Six liang) Da Huang (Two liang, peeled) Zhi Zi (Fourteen seeds, broken open *Qianjin Fang* uses forty seeds).
The above three ingredients: Boil in twelve sheng of water, first decoct Yin Chen Hao until reduced by six sheng, then add the other two ingredients, decoct to obtain three sheng, remove dregs, divide into three doses. Urination should become smooth; urine will resemble soap pod juice, bright red. After one night, abdominal fullness decreases, and yellow drains via urination. (*Jinkui Yaolue*, *Yuhan Jing*, Cost edition: "Twelve sheng" is "Ten sheng". *Zhouhou Beiji Fang*, *Qianjin Fang*, *Waitai Mi Yao*: add "Qu Za" [remove dregs] after "Liu Sheng". *Jinkui Yaolue*, *Yuhan Jing*, Cost edition: add "Wen" [warm] after "Fen" [divide]. *Qianjin Fang*, *Qianjin Yi Fang*: change "Zhi" [juice] to "Mo" [foam]. *Qianjin Fang*: change "Yi Su" [one night] to "Dang" [should]. *Qianjin Yi Fang*: omits "Fu Jian" [abdomen reduces].)
Qian's commentary: Yin Chen Hao, though slightly cold, treats damp-heat jaundice and stagnant heat from cold damage causing whole-body jaundice and difficult urination. Zhi Zi is bitter and cold, clears Triple Burner fire, removes stomach heat and epidemic jaundice, promotes urination, relieves thirst, vexation, restlessness, and stagnant heat qi condensation, enters the blood level. Da Huang is bitter and cold, purges downward, expels pathogenic heat, and unblocks intestines/stomach. All three eliminate damp-heat and dissipate stagnation, making this the primary formula for Yangming jaundice.
*Jinkui Yaolue* records: Gu Dan (Grain Jaundice) presents with chills, fever, anorexia, dizziness upon eating, chest/heart discomfort, and eventual jaundice after prolonged time. Yinchen Hao Tang (Artemisiae Scopariae and Gardeniae Decoction) is indicated.
*Qianjin Fang Zhu* records: Fan Wang treated Gu Dan; *Duan Ju Fang* used Shi Gao (Gypsum Fibrosum) one jin.
Yangming syndrome, where the patient suffers from forgetfulness (Xi Wang),必有蓄血 (must have accumulated blood). The reason is that chronic blood stasis existed previously, causing forgetfulness. Stool may be hard, but defecation is surprisingly easy, and the color must be black. Didang Tang (Di Dang Decoction) is indicated for purgation. (*Waitai Mi Yao*: changes "Xi Wang" to "Shan Wang". Cost edition: removes "Zhe" after "Hei". *Yuhan Jing*: changes "Xia" [down/purge] to "Zhu" [main/treat].)
Qian's commentary: Forgetfulness refers to forgetting words and actions immediately after they occur. The reason for forgetfulness is the presence of chronic blood stasis in the interior. In previous Taiyang syndromes, unresolved heat-pathogen from the exterior follows the meridians to bind internally in the Bladder, causing manic behavior. Here, there is no heat-pathogen binding, hence only forgetfulness. *Suwen: Tiao Jing Lun* states: "When blood and qi are not disturbed, five zang are stable; when blood binds below and qi binds above, confusion and forgetfulness occur." Xi's commentary: Forgetfulness is akin to being prone to forgetting. Cheng's commentary: Blood accumulating below blocks heart orifices, dulling intellect, causing失常 in social interactions. The disease belongs to Yangming, so stool is hard; blood mixes with feces, making it easy to pass and black.
*Shanghan Zhunsheng* states: Regarding heat-dryness accumulation, color is not always black. But blood stasis is loose, black and sticky like lacquer. Dryness accumulation is hard, black and dull like coal. This is a clear distinction. Also, Haizang stated: First stool brownish is heavy; second stool hard dark brown is heavier; third stool black is most severe. Color changes due to fire-dryness. Like sheep blood in sunlight, it turns brown quickly, then gradually black. This illustrates the point.
After purgation in Yangming disease, if there is inner annoyance (Ao Nao) and irritability, and dry feces in the stomach, purgation is permissible. If abdomen is slightly full, stool hard at beginning but loose later, purgation is forbidden. If dry feces are present, Da Chengqi Tang (Major Order the Qi Decoction) is indicated. (*Yuhan Jing*, *Maijing*, *Qianjin Yi Fang*: add "Qi Ren" [this person] before "Fu" [abdomen]. "Chu Tou Ying Hou Bi Tang" is written as "Tou Jian Hou Tang".)
Cheng's commentary: Annoyance and irritability after purgation constitute empty irritability; Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) should be given. If dry feces are in the stomach, it is not empty irritability; Da Chengqi Tang (Major Order the Qi Decoction) can be used for purgation. Slight abdominal fullness with hard initial and loose later stool indicates no dry feces; heat is not in the stomach but above, so purgation is forbidden. Jian's commentary: After purgation in Yangming disease, if annoyance and irritability persist, and abdomen is greatly full, no bowel movement, frequent urination, indicating residual dry feces in stomach have hardened again, then purgation is permissible. Cheng's commentary: The final sentence reiterates the permission to purge, determining the treatment. Ke's commentary: Slight abdominal fullness is still an indication for Zhizi Houpo Tang (Gardenia and Magnolia Bark Decoction).
If a patient has not had a bowel movement for five to six days, experiences periumbilical pain, irritability, and periodic exacerbations, this indicates dry feces, causing the lack of bowel movement.
Qian's commentary: No bowel movement for five to six days with periumbilical pain indicates dry feces in intestines/stomach. Irritability is caused by excess heat and depression. Periodic exacerbation refers to afternoon tidal fever. All interior signs of Yangming stomach excess are present, confirming dry feces, hence no bowel movement. Cheng's commentary: Periumbilical pain indicates dry feces in intestines/stomach have no exit, stagnating in one place causing pain. Zhi's commentary: Omission of "Da Chengqi Tang" is elliptical. The preceding text says: "If dry feces, Da Chengqi Tang is indicated." Connecting to this, "This has dry feces" implies Da Chengqi Tang is also indicated. Wang's commentary: Zhongjing uses Da Chengqi Tang (Major Order the Qi Decoction) only after distinguishing dry feces. Previous mentions of tidal fever, delirium, sweaty hands/feet, and passing gas show comprehensive methodology. This clause adds periumbilical pain, showing diverse symptoms; physicians must adapt accordingly.
If a patient has vexing heat, resolving with sweating, resembling malaria, with afternoon fever, it belongs to Yangming. If pulse is excess, purgation is indicated; if pulse is floating and deficient, sweating is indicated. Purge with Da Chengqi Tang (Major Order the Qi Decoction); induce sweating with Guizhi Tang (Cinnamon Twig Decoction). (*Yuhan Jing*: "You" [again] is "Fu" [repeat]. Both "Yi" [suitable] are "Dang" [should]. "Yu" [give] is "Yi" [suitable].)
Jian's commentary: "Patient" refers to those suffering from wind-strike or cold damage of Taiyang meridian. Qian's commentary: Vexing heat resolving with sweating, or resembling malaria, specifically afternoon fever (tidal fever), indicates pathogen belongs to Yangming. Differentiation of exterior/interior depends on pulse. Excess-large forceful pulse indicates pathogen in Yangming interior/stomach excess, requiring purgation. Floating-deficient pulse implies floating-slow, indicating wind pathogen still at Taiyang exterior, requiring diaphoresis. "Floating-deficient" means pulse is hollow upon pressure, not true deficiency. True deficiency contraindicates sweating. Careful examination is needed. Excess pulse requires purgation due to stomach heat, hence Da Chengqi Tang (Major Order the Qi Decoction). Floating-deficient pulse requires sweating due to unresolved wind pathogen, hence Guizhi Tang (Cinnamon Twig Decoction). Yin's commentary: This chapter parallels the Taiyang concurrent disease clause: "Cold damage, no bowel movement for 6-7 days, headache with fever, give Chengqi Tang" (Taiyang Middle Chapter, Clause 56), with similar intent.
After severe purgation, if six to seven days pass without bowel movement, irritability persists, and abdominal fullness/pain occurs, this indicates dry feces. The reason is pre-existing retained food. Da Chengqi Tang (Major Order the Qi Decoction) is indicated.
Cheng's commentary: Persistent irritability refers to post-purgation state. Abdominal fullness/pain refers to state after 6-7 days without bowel movement. Retained food, after severe purgation, lodges in convolutions of ileum, remaining in stomach, causing persistent irritability. Over time, retained food forms dry feces, blocking passage, causing accumulation of new turbid waste, leading to fullness/pain. Purgation depletes fluids, also causing no bowel movement. However, irritability eventually resolves, and absence of abdominal pain/fullness verifies this. Xi's commentary: Key is the "six to seven days." Six to seven days without bowel movement means food eaten during this period becomes retained food, justifying Da Chengqi Tang (Major Order the Qi Decoction). However, modern patients often have underlying deficiency; obtaining this after severe purgation is rare (1 in 10).
Shu stated: Although severe purgation occurred, retained dryness remained hidden, causing recurrent constipation and heat accumulation, leading to persistent irritability and abdominal fullness/pain. "Retained food" is synonymous with "Stomach House Excess," the root cause of Zheng Yang Yangming. If retained food exists and remains hidden after purgation, this syndrome occurs. Also, in Three Yin cold syndromes, if retained dryness in stomach is warmed/dispersed and transforms into excess, it transfers to Yangming. My brother-in-law, Yi Cai, suffered abdominal pain and diarrhea for over a month, taking numerous Ginger/Aconite medicines. He had strong constitution and loved meat. Assuming strength, he disregarded diet during illness,酿成胃实 (brewing stomach excess), leading to constipation, spontaneous sweating, coma, delirium, mania, abdominal distension, scorched yellow cracked tongue coating, yet whole body cold, pulse faint as silk, especially at Cun position. Upon careful observation, his voice was loud, he threw limbs about, desired cold drinks, insomnia. Combined with abdominal fullness and tongue coating, stomach excess was certain. Whole body cold indicated extreme heat reversal, isolating yin externally. Faint pulse indicated heat knot blocking middle jiao, preventing Ying qi reaching extremities. This is "Extreme Yang resembling Yin." Urgent purgation was required. One dose of Da Chengqi Tang (Major Order the Qi Decoction) failed. Second dose failed. Four doses failed. I reasoned: Originating from Three Yin, lingering yin pathogen likely exists, evident in Cun pulse. I added three qian of Fu Zi (Prepared Aconiti Lateralis Radix) to Da Chengqi Tang (Major Order the Qi Decoction) to break yin, allowing mutual action. One dose produced severe purgation, Cun pulse emerged, mania intensified. I knew yin was gone, Fu Zi unnecessary. Single dose of Chengqi followed. Condition slightly improved. Four more doses administered, total ten doses. Half a jin each of Xiaoshi (Natrii Sulfas) and Da Huang (Rhei Radix et Rhizoma) consumed. Symptoms gradually resolved. This shows Three Yin cold syndromes with retained food transferring to Yangming and forming dryness can be terrifyingly severe.
If patient has difficult urination, alternating difficulty/ease of bowel movement, occasional mild fever, wheezing and vertigo (Note: original note says "Yi" [rest]), inability to lie down, this indicates dry feces. Da Chengqi Tang (Major Order the Qi Decoction) is indicated.
Qian's commentary: Generally, difficult urination results from Triple Burner dysfunction and qi transformation failure. Here, however, it is different. Intestinal/stomach blockage prevents qi movement, internal heat stasis, fluid dryness, drying clear pathways. "Alternating difficulty" means dry feces obstruction; "alternating ease" means sluicing discharge. "Occasional mild fever" is residual tidal fever. "Wheezing" is central fullness causing breath urgency. "Vertigo" is heat pathogen unable to descend, steaming causing oppression. Stomach pathogen excess/fullness causes restless wheezing/vertigo, preventing lying down. Classic states: "Stomach disharmony leads to restless sleep." If tongue coating is yellow/black, tender on pressure, pulse excess-large, dry feces are internal. Da Chengqi Tang (Major Order the Qi Decoction) is indicated. Cheng's commentary: "Ease" means new stool flows smoothly due to moisture; "difficulty" means dry feces remain blocked.
Wang's commentary: Do not act rashly. Press abdomen; if hard stool mass exists, plus wheezing/vertigo/inability to lie down, then purge. Why? Because of alternating difficulty/ease.
Food intake triggering vomiting belongs to Yangming; Wuzhuyu Tang (Evodia Decoction) is indicated. If condition worsens after taking medicine, it belongs to Upper Jiao. (*Yuhan Jing*, Cost edition: adds "Zhe" [particle] after "Ou" [vomit].)
Cheng's commentary: Vomiting after eating indicates inability to receive food, belonging to stomach qi deficiency-cold, unable to digest and descend grain. "Belongs to Yangming" distinguishes it from Shaoyang vomiting (half-exterior/half-interior) and Taiyang dry retching (exterior). Primary treatment is warming middle and descending rebellion. Wang's commentary: Worsening after medicine: Cheng's annotation says treat Upper Jiao method, but no formula given. *Zhunsheng* suggests Gegen Banxia Tang (Pueraria and Pinellia Decoction), which is erroneous. *Shanglun Pian* says still Taiyang heat pathogen, not stomach cold. *Tiaobian* says Upper Jiao refers to diaphragm, warning against purgation. Clinging to "Many vomits in cold damage, even with Yangming signs, do not purge" is extremely erroneous. Reflecting on sages' medication, how could it be as reckless as modern doctors mistaking stomach deficiency-cold for excess heat? Deficiency-cold above diaphragm is not treated identically to stomach fu organ. Previous clause treated with Wuzhuyu Tang (Evodia Decoction), correctly addressing cold/heat/deficiency/excess. For those worsening after medicine, *Buwang Lun* Chang Qizhi says: Orange Peel Decoction (Jupi Tang) is suitable. Annotation: *Leiyao Fang* uses Jupi (Citri Reticulatae Pericarpium) two liang, Gancao (Glycyrrhizae Radix et Rhizoma) one liang, Shengjiang (Zingiberis Rhizoma Recens) four liang, Renshen (Ginseng Radix) three liang, decoct in water. This seems correct.
Wei stated: Why worsen after medicine? Ignorants think stomach heat, not cold. Zhongshi showed: There is heat, but not in stomach/middle jiao, but in chest/diaphragm/upper jiao. Middle jiao has cold, hence upper jiao has heat. Acrid-warm Evodia/Ginseng suit middle jiao cold but conflict with upper jiao heat, explaining why Evodia is partially suitable. Physicians seeing upper-heat/lower-cold might use Huanglian (Coptidis Rhizoma) fried Evodia, replacing dried ginger with fresh ginger, warming middle without rushing upward. Is this valid? Yu claimed worsening indicates Taiyang, which is wrong. Cheng claimed continuing Evodia is rigid thinking. Using heat with cold method, using pig gallbladder as guide, like in Lizhong Tang (Regulate the Middle Decoction), might be appropriate? ○ Note: Ke Qin said: Worsening after medicine is due to phlegm-fluids in Upper Jiao; vomiting resolves it naturally, not implying unsuitability. Qian Huang said: Worsening means pathogen still in chest, should use Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) to induce vomiting, approximating truth. Both lost classic intent.
Wuzhuyu Tang Formula