伤寒三日。阳明脉大。
邪气并于太阳则浮。并于阳明则大。云三日者。举传经次第之大凡也。又阳明之脉。人迎趺阳
皆是。伤寒三日。邪入阳明。则是二脉当大。不得独诊于右手之附上也。
本太阳病。初得时。发其汗。汗先出不彻。因转属阳明也。
彻、达也。汗虽欲出。而不达于皮肤。则邪不外出。而反内入。此太阳之邪传阳明之经。与汗下
后入腑者不同也。
阳明病。脉浮而紧者。必潮热。发作有时。但浮者，必盗汗出。
太阳脉紧。为寒在表。阳明脉紧。为实在里。里实则潮热。发作有时也。若脉但浮而不紧者。
为里未实而经有热。经热则盗汗出。盖杂病盗汗。为热在脏。外感盗汗。为邪在经。易简方用防风
治盗汗不止。此之
谓也。
阳明病。反无汗而小便利。二三日。呕而咳。手足厥者。必苦头痛。苦不咳不呕。手足不
厥者。头不痛。
无汗而小便利。邪不外散。而气但下趋也。二三日。呕而咳者。邪复从上行也。手足厥者。气仍
不外达也。
故必苦头痛。所以然者。下趋而极。势必上行。外达无由。上攻必猛也。若不咳不呕。则气且
下行。手足不厥。则气得四达。何至上逆而头痛哉。读此可以知阳明邪气上下进退之机。
阳明病。口燥。但欲漱水不欲咽者。此必衄。
阳明口燥。欲饮水者。热在气而属腑。口燥但欲漱水不欲咽者。热在血而属经。经中热甚。血
被热迫。必妄行为衄也。
脉浮发热。口干鼻燥。能食者则衄。
脉浮发热。口干鼻燥。亦热邪壅盛于经之证。能食者。风多热迫。安得不胜阴血被衄耶。
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。
此二条乃风寒国中阳明之证。其见证与太阳中风伤寒相类。而阳明比太阳稍深。故中风之脉。
不浮而迟。伤寒之脉。不紧而浮。以风寒之气。入肌肉之分。则闭固之力少。而壅遏之力多也。而
其治法。则必与太阳少异。见有汗而恶寒者。必桂枝可解。无汗而喘者。非麻黄不发矣。
二阳并病。太阳初得病时。发其汗。汗先出不彻。因转属阳明。续自微汗出。不恶寒。若太阳
病证不罢者。不可下。下之为逆。如此可小发汗。设面色缘缘正赤者。阳气怫郁在表。当解之熏之
。若发汗不彻。不足言。阳气怫郁不得越。当汗不汗。其人躁烦。不知痛处。乍在腹中。乍在四肢。
按之不可得。其人短气。但坐以汗出不彻故也。更发汗则愈。何以知汗出不彻。以脉涩。故知也
。此篇从太阳篇移入。
二阳并病者。太阳病未罢。而并于阳明也。太阳得病时。发汗不彻。则邪气不得外。出而反内
走阳明。此并之由也。续自微汗出。不恶寒。此阳明证续见。乃并之证也。若太阳证不罢者。不可
下。下之为逆。所谓本当发汗而反下之。此为逆是也。如是者。可小发汗。以病兼阳明。故不可大
汗而可小发。此并病之治也。若发其小汗已。面色缘缘正赤者。阳气怫郁在表而不得越散。当解之
熏之。以助其散。又并病之治也。发汗不彻下。疑脱一彻字。谓发汗不彻。虽彻而不足云彻。犹腹
满不减。减不足言之文。汗出不彻。则阳气怫郁不得越。阳不得越。则当汗而不得汗。于是邪无从
出。攻走无常。其人躁烦。不知痛处。乍在腹中。乍在四肢。按之而不可得也。短气者。表不得泄
。肺气不宣也。坐、犹缘也。言躁烦短气等证。但缘汗出不彻所致。故当更发其汗。则邪气外达而愈
。非特熏解所能已其疾矣。以面色缘缘正赤者。邪气怫郁躯壳之表。躁烦短气者。邪气怫郁躯壳之
里也。按内经云、脉滑者多汗。又曰、脉涩者。阴气少阳气多也。夫汗出于阳而生于阴。因诊其脉
涩。而知其汗出不彻也。此又并病之治也。
阳明病。发潮热。大便溏。小便自可。胸胁满不去者。小柴胡汤主之。
潮热者。胃实也。胃实则大便硬。乃大便溏。小便自可。胸胁满不去。知其邪不在于阳明之腑。
而入于少阳之经。由胃实而肠虚。是以邪不得聚而复传也。是宜小柴胡以解少阳邪气。
阳明病。胁下硬满。不大便而呕。舌上白苔者。可与小柴胡汤。上焦得通。津液得下。胃气因
和。身 然而汗出解也。
此亦阳明传入少阳之证。胁下硬满而呕。舌上苔白。皆少阳经病见证。虽不大便。不可攻之。
亦宜小柴胡和解少阳邪气而已。夫胁下满痛而呕。则邪方上壅。而津液不得下行。与小柴胡和散其
邪。则上焦得通。而胁不满硬矣。津液得下。而呕不作矣。气通津下。胃气因和。便从里出。汗从
表出。而邪自涣然冰释矣。是以胃中硬满。不大便。而无少阳证者可攻。其有少阳证者。虽不大便
。亦不可攻而可和也。
After three days of contracting a cold injury (Shanghan), the pulse characteristic of Yangming disease appears: a large pulse.
When pathogenic qi merges into the Taiyang meridian, the pulse is floating; when it merges into the Yangming meridian, the pulse is large. The mention of "three days" generally illustrates the sequence of disease transmission. Furthermore, regarding the Yangming meridian, pulses at both the Renying (ST9) and Zufuyang (ST42) acupoints are relevant. Three days after contracting a cold injury, if pathogenic qi enters the Yangming meridian, these pulses should both become large; one cannot rely solely on palpating the radial artery at the wrist (Cunkou).
In a case originally presenting as Taiyang disease, upon initial onset, diaphoresis (sweating therapy) was administered, but the sweat was not thorough. Consequently, the condition transferred to belong to the Yangming stage.
"Thorough" means reaching or penetrating. Although sweating was intended, if the sweat did not reach the skin surface, the pathogen would not exit outwardly but instead enter inwardly. This represents the transmission of Taiyang pathogen into the Yangming meridian, which differs from cases where pathogens enter the Fu organs after sweating or purgation therapies.
In Yangming disease, if the pulse is floating and tight, tidal fever (fever that peaks at specific times) must occur, with regular timing of episodes. If the pulse is merely floating without tightness, night sweats (sweating during sleep) must occur.
A tight pulse in Taiyang indicates cold pathogen in the exterior. A tight pulse in Yangming indicates excess pathogen in the interior. Interior excess leads to tidal fever with regular timing. If the pulse is only floating and not tight, it indicates that interior excess has not yet formed, but heat exists in the meridians. Heat in the meridians causes night sweats. Generally, night sweats in miscellaneous diseases indicate heat in the Zang organs, whereas night sweats in external contraction indicate pathogen in the meridians. The *Yijian Fang* uses Fangfeng (Radix Saposhnikoviae) to treat persistent night sweats, referring to this mechanism.
In Yangming disease, if there is a lack of sweat despite dry mouth, and urination is free, after two or three days, if vomiting and coughing occur accompanied by cold extremities, the patient will certainly suffer from headache. If there is no cough or vomiting, and the extremities are not cold, the head will not hurt.
Lack of sweat with free urination indicates that pathogen cannot scatter via the exterior, and Qi trends downward. After two or three days, vomiting and coughing indicate that pathogen moves upward again. Cold extremities indicate that Qi still fails to reach the exterior.
Therefore, headache is inevitable. The reason is that when downward trending reaches its extreme, it inevitably reverses upward; since there is no outlet for outward dispersion, the upward attack becomes fierce. If there is no cough or vomiting, Qi continues to descend; if extremities are not cold, Qi can reach the four limbs. How could it reverse upward to cause headache? Reading this allows one to understand the mechanism of pathogen advancement and retreat in the Yangming meridian.
In Yangming disease, if the mouth is dry and the patient desires to rinse water in the mouth but does not wish to swallow, epistaxis (nosebleed) will certainly occur.
Dry mouth in Yangming disease with desire to drink water indicates heat in the Qi level belonging to the Fu organs. Dry mouth with desire to rinse but not swallow indicates heat in the Blood level belonging to the meridians. When heat in the meridians is severe, blood is forced by heat to move recklessly, resulting in epistaxis.
If the pulse is floating, there is fever, dry mouth, dry nose, and the patient can eat, epistaxis will occur.
Floating pulse, fever, dry mouth, and dry nose are also signs of excessive heat pathogen congesting in the meridians. The ability to eat suggests wind-heat predominance; under such heat pressure, Yin blood cannot withstand it, leading to epistaxis.
In Yangming disease, if the pulse is slow, there is abundant sweating, and slight aversion to cold, the exterior pattern remains unresolved. Diaphoresis may be used, preferably Guizhi Tang (Cinnamon Twig Decoction).
In Yangming disease, if the pulse is floating, there is no sweat, and wheezing occurs, diaphoresis will lead to recovery, preferably using Mahuang Tang (Ephedra Decoction).
These two clauses describe patterns of Wind-Cold invading the Yangming meridian. The manifestations are similar to Taiyang Zhongfeng (Wind Strike) and Shanghan (Cold Damage), but slightly deeper than Taiyang. Thus, the pulse for Zhongfeng is slow rather than floating; the pulse for Shanghan is floating rather than tight. This is because Wind-Cold qi enters the muscle layer, where its closing and consolidating power is less, but its obstructing and stagnating power is greater. The treatment method must differ slightly from Taiyang. For those with sweat and aversion to cold, Guizhi Tang is required to resolve the exterior; for those without sweat and with wheezing, Mahuang Tang is necessary to induce sweating.
In concurrent disease of the Two Yangs (Taiyang and Yangming), when Taiyang disease first began, diaphoresis was administered, but the sweat was not thorough, causing the condition to transfer to Yangming. Subsequently, there is continuous mild sweating and no aversion to cold. If Taiyang symptoms have not ceased, purgation is contraindicated; using purgation here is an error (Ni). In such cases, mild diaphoresis may be used. If the face is persistently red, this indicates Yang Qi being constrained and depressed in the exterior; it should be resolved through fumigation or steaming. If diaphoresis was not thorough, it is insufficient to call it thorough. Constrained Yang Qi cannot vent; when sweating should occur but does not, the person becomes restless and irritable, unable to locate pain, which shifts between the abdomen and limbs, and cannot be pinpointed by pressure. The person experiences shortness of breath, solely due to incomplete sweating. Re-administering diaphoresis will lead to recovery. How do we know sweating was incomplete? By observing a choppy pulse. This section was moved from the Taiyang chapter.
Concurrent disease of the Two Yangs means Taiyang disease has not resolved and has merged into Yangming. When Taiyang disease began, if diaphoresis was not thorough, pathogen cannot exit outwardly but moves inward to Yangming; this is the origin of the merger. Continuous mild sweating and no aversion to cold are subsequent Yangming symptoms, representing the signs of the merger. If Taiyang symptoms persist, purgation is forbidden; purgation here is erroneous, meaning "when one should have induced sweat but instead used purgation." In such cases, mild diaphoresis is appropriate. Because the disease involves Yangming, heavy sweating is contraindicated; mild sweating is suitable. This is the treatment for concurrent disease. If, after mild diaphoresis, the face remains persistently red, this indicates Yang Qi constrained in the exterior unable to disperse; resolution and fumigation should be used to assist dispersion. This is another aspect of treating concurrent disease. (The text likely omits a character "che" [thorough] after "fa han bu che," implying that even if sweating occurred, it was not truly thorough, similar to the phrase "abdominal fullness does not decrease, so a slight decrease is not worth mentioning.") Incomplete sweating causes constrained Yang Qi to fail to vent. Since Yang Qi cannot vent, sweating should occur but does not; thus, pathogen has no exit and wanders unpredictably. The person becomes restless and irritable, unable to locate pain, shifting between abdomen and limbs, unresponsive to pressure. Shortness of breath occurs because exterior pathogen cannot vent and Lung Qi is not diffusing. "Zuo" (sit) implies "due to" or "because of"; restlessness and shortness of breath are caused by incomplete sweating. Therefore, further diaphoresis is needed to drive pathogen outward and achieve recovery. Fumigation and resolution alone cannot cure this, as facial redness indicates pathogen constrained in the exterior shell, while restlessness and shortness of breath indicate pathogen constrained within the interior shell. As stated in the *Neijing*: a slippery pulse indicates profuse sweating; a choppy pulse indicates deficient Yin and excess Yang. Sweat originates from Yang but is generated from Yin. By diagnosing a choppy pulse, we know sweating was incomplete. This is another principle of treating concurrent disease.
In Yangming disease, if there is tidal fever, loose stools, normal urination, and persistent chest and hypochondriac fullness, Xiao Chaihu Tang (Minor Bupleurum Decoction) is the primary treatment.
Tidal fever usually indicates Stomach Excess (Wei Shi). Stomach Excess leads to hard stools. Here, stools are loose and urination is normal, with persistent chest/hypochondriac fullness, indicating the pathogen is not in the Yangming Fu organs but has entered the Shaoyang meridian. Due to the transition from Stomach Excess to Intestine Deficiency, the pathogen cannot accumulate and transmits again. It is appropriate to use Xiao Chaihu Tang to resolve Shaoyang pathogen.
In Yangming disease, if there is hardness and fullness below the ribs, constipation, vomiting, and a white coating on the tongue, Xiao Chaihu Tang may be given. Once the Upper Jiao is unblocked, fluids descend, Stomach Qi harmonizes, and the body breaks out in continuous sweat, resolving the disease.
This is also a pattern of Yangming transmitting to Shaoyang. Hardness/fullness below the ribs with vomiting and a white tongue coating are all signs of Shaoyang meridian disease. Although there is constipation, purgation is not indicated. Xiao Chaihu Tang should be used to harmonize and resolve Shaoyang pathogen. Fullness/pain below the ribs with vomiting indicates pathogen obstructing upward, preventing fluids from descending. Administering Xiao Chaihu Tang to harmonize and disperse pathogen unblocks the Upper Jiao, relieving rib hardness. Fluids descend, stopping vomiting. With unblocked Qi and descending fluids, Stomach Qi harmonizes, stool exits from the interior, sweat exits from the exterior, and pathogen dissipates like melting ice. Therefore, if there is Stomach hardness/fullness and constipation without Shaoyang signs, purgation is possible; if Shaoyang signs are present, even with constipation, purgation is contraindicated, and harmonization is preferred.