阳明之为病。胃家实也。
胃者。汇也。水谷之海。为阳明之腑也。胃家实者。邪热入胃。与糟粕相结而成。实非胃气自
盛也。凡伤寒腹满便闭。潮热。转失气。手足 汗出等证。皆是阳明胃实之证也。
问曰、病有太阳阳明。有正阳阳明。有少阳阳明。何谓也。答曰、太阳阳明者。脾约是也。
正阳阳明者。胃家实是也。少阳阳明者。发汗。利小便已。胃中燥。烦实。大便难是也。
太阳阳明者。病在太阳。而兼阳明内实。以其人胃阳素盛。脾阴不布。屎小而硬。病成脾约。
于是太阳方受邪气。而阳明已成内实也。正阳阳明者。邪热入胃。糟粕内结。为阳明自病。活人所
谓病患本谷盛。气实是也。少阳阳明者。病从少阳。而转属阳明得之。发汗。利小便。津液去。而胃
燥实。如本论所谓伤寒十余日。热结在里。复往来寒热者。与大柴胡汤是也。此因阳明之病。有是
三者之异。故设为问答以明之。而其为胃家实则一也。
问曰、阳明病。外证云何。答曰、身热。汗自出。不恶寒。反恶热也。
问曰、病有得之一日。不发热而恶寒者。何也。答曰、虽得之一日。恶寒将自罢。即自汗出
而恶热也。
问曰、恶寒何故自罢。答曰、阳明居中。土也。万物所归。无所复传。始虽恶寒。二日自止。
此为阳明病也。
经邪未变。故恶寒入腑则变热而不寒。经邪不能聚。故传入腑。则聚而不传。曰万物所归者。
谓邪气离经入腑。聚而不行。如万物之归于土也。是以恶寒为伤寒在表之的证。恶热为阳明入腑之
的证。始虽恶寒。不久即止。岂若太阳始终有寒者哉。此三条并论阳明受病之证也。
问曰、何缘得阳明病。答曰、太阳病发汗若下若利小便。此亡津液。胃中干燥。因转属阳明。
不更衣。内实。大便难者。此名阳明也。
胃者。津液之腑也。汗下利小便。津液外亡。胃中干燥。此时寒邪已变为热。热、犹火也。火
必就燥。所以邪气转属阳明也。而太阳转属阳明。其端有二。太阳初得病时。发其汗。汗先出不彻
。因转属阳明者。为邪气未尽。而传其病在经。此太阳病若汗若下若利小便。亡津液。胃中干燥。
因转属阳明者。为邪气变热。而传其病在腑也。此阳明受病之因也。
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。
脉沉、病在里也。喘满、因满而为喘。病之实也。伤寒四五日。病在里而成实。法当攻里而反
发其汗。津液外亡。肠胃内燥。大便为难。所必然矣。表虚里实。亦即表和里病之意。久则谵语者
。热气乘虚。必归阳明而成胃实也。
脉阳微而汗出少者。为自和也。汗出多者。为太过。阳脉实。因发其汗出多者。亦为太过。太
过为阳绝于里。亡津液。大便因硬也。
脉阳微者。诸阳脉微。即正之虚也。故汗出少者。邪适去而正不伤。为自和。汗出多者。邪虽
却而正亦衰。为太过也。阳脉实者。邪之实也。然发其汗出多者。亦为太过。为其津亡于外。而阳
绝于里也。夫阳为津液之源。津液为阳之根。汗出过多。津液竭矣。阳气虽存。根本则离。故曰
阳绝。阳绝津亡。大便焉得不硬
耶。
脉浮而芤。浮为阳。芤为阴。浮芤相搏。胃气生热。其阳则绝。
脉浮为盛于外。脉芤为歉于内。浮为阳。谓阳独盛也。芤为阴。调阴不足也。浮芤相搏。阳有
余而阴不足也。胃液枯竭。内虚生热。虽有阳气。无与为偶。亦如上条之意也。故曰其阳则绝。
以上三条。乃因阳明受病之因而申言之。其下三条。则申言阳明受病之证也。
伤寒发热无汗。呕不能食。而反汗出 然者。是转属阳明也。
伤寒转系阳明者。其人 然微汗出也。
发热无汗。为太阳病在表。呕不能食者。邪欲入里而正气拒之也。至汗出 。则太阳之邪。
阳明已受之矣。故曰转系阳明。太阳寒在皮毛。腠理闭塞。故无汗。阳明热在肌肉。腠开液泄。故
然汗自出也。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。
热结阳明。为不大便五六日。为绕脐痛。烦躁。发作有时。皆燥屎在胃之征。有时、谓阳明王
时。为日晡也。阳明燥结。不得大便。意非大承气不为功矣。
The general principle of Yangming disease is: Excess in the Stomach organ system (Wei Jia Shi).
The Stomach (Wei), meaning "gathering," is the sea of water and grain, belonging to the Fu organs of the Yangming channel. "Excess in the Stomach organ system" refers to pathogenic heat entering the Stomach and binding with fecal matter to form excess. This "excess" is not due to natural hyperactivity of Stomach Qi. Symptoms such as abdominal fullness, constipation, tidal fever, passing flatus, and continuous sweating on the hands and feet are all manifestations of Yangming Stomach excess.
Question: There are three types of Yangming disease: Taiyang-Yangming, Zhengyang-Yangming, and Shaoyang-Yangming. What do these mean? Answer: Taiyang-Yangming refers to the Pi Yue (Spleen Constraint) syndrome. Zhengyang-Yangming refers to Wei Jia Shi (Excess in the Stomach organ system). Shaoyang-Yangming refers to a condition where, after sweating or promoting urination, the Stomach becomes dry, causing irritability and solidification, leading to difficult defecation.
Taiyang-Yangming occurs when the disease is in the Taiyang stage but simultaneously involves internal excess in the Yangming stage. This happens because the patient's Stomach Yang is naturally robust, preventing the Spleen Yin from distributing properly, resulting in small and hard stools, forming Pi Yue (Spleen Constraint). At this point, while the Taiyang channel is just receiving pathogenic factors, the Yangming stage has already developed internal excess. Zhengyang-Yangming occurs when pathogenic heat directly enters the Stomach and binds with internal fecal matter, constituting a primary Yangming disease, as described in the *Huo Ren Shu* (Book of Life-Preserving Physicians): the patient originally had abundant food intake and robust Qi. Shaoyang-Yangming arises when the disease transfers from the Shaoyang stage to the Yangming stage. After sweating or promoting urination, body fluids are depleted, leading to dryness and excess in the Stomach. For example, as stated in the main text, if ten days have passed since the onset of cold damage, heat is bound internally, accompanied by alternating chills and fever, the Da Chai Hu Tang (Major Bupleurum Decoction) is indicated. These three variations illustrate different causes for Yangming disease, yet their essence remains Wei Jia Shi (Excess in the Stomach organ system).
Question: What are the external manifestations of Yangming disease? Answer: Fever, spontaneous sweating, aversion to cold is absent, and there is an aversion to heat.
Question: In some cases, on the first day of illness, there is no fever but aversion to cold. Why? Answer: Although it is only the first day, the aversion to cold will cease spontaneously, followed by spontaneous sweating and aversion to heat.
Question: Why does the aversion to cold cease spontaneously? Answer: Yangming resides in the center and corresponds to Earth; it is where all things return, and pathogens do not transmit further. Initially, there may be aversion to cold, but it stops by the second day. This constitutes Yangming disease.
Pathogens in the exterior channels remain unchanged, hence aversion to cold; upon entering the Fu organs, they transform into heat, losing the aversion to cold. Exterior pathogens cannot accumulate, so upon entering the Fu organs, they gather and stop transmitting. Saying "where all things return" means that pathogens leave the channels and enter the Fu organs, gathering without moving, similar to how all things return to the earth. Therefore, aversion to cold is the definitive sign of cold damage in the exterior, while aversion to heat is the definitive sign of Yangming disease entering the Fu organs. Although aversion to cold may occur initially, it ceases shortly thereafter, unlike Taiyang disease which persists with chills throughout. These three passages collectively discuss the manifestations of Yangming disease acquisition.
Question: How does one contract Yangming disease? Answer: If Taiyang disease is treated incorrectly with sweating, purging, or promoting urination, body fluids are lost, the Stomach becomes dry, and the condition transforms into Yangming disease. Failure to pass stool, internal excess, and difficulty in defecation characterize this as Yangming disease.
The Stomach is the Fu organ of body fluids. Sweating, purging, or promoting urination causes body fluids to escape externally, leading to dryness in the Stomach. At this stage, cold pathogens have transformed into heat. Heat behaves like fire, which naturally moves toward dryness; thus, pathogens transfer to the Yangming stage. The transformation from Taiyang to Yangming has two origins: First, during the initial Taiyang stage, incomplete sweating leaves residual pathogens, causing transmission while the disease remains in the channels. Second, incorrect treatment (sweating, purging, diuresis) depletes body fluids, dries the Stomach, transforms pathogens into heat, and transmits the disease into the Fu organs. These are the causes of Yangming disease acquisition.
In cold damage lasting four to five days, if the pulse is deep and accompanied by wheezing and fullness, a deep pulse indicates interior involvement. Incorrectly inducing sweating causes body fluids to leak out, making defecation difficult, resulting in exterior deficiency and interior excess. Prolonged, this leads to delirious speech.
A deep pulse indicates interior disease; wheezing and fullness result from abdominal distension causing breathlessness, indicating excess. In cold damage of four to five days, with interior excess, purgation should be used. Inducing sweating instead causes fluid loss and intestinal dryness, inevitably leading to difficult defecation. "Exterior deficiency and interior excess" implies harmony at the exterior but pathology within. Delirium develops over time as heat exploits the deficiency, converging on Yangming to form Stomach excess.
If the radial pulse is superficial and fine, with slight sweating, the condition is self-regulating. Profuse sweating indicates excessiveness. If the pulse is superficial and firm, and profuse sweating follows induction, this is also excessive. Excessiveness leads to Yang exhaustion in the interior and fluid depletion, causing hard stools.
A superficial and fine pulse indicates weak Yang Qi. Slight sweating means pathogens are departing without damaging healthy Qi, representing self-regulation. Profuse sweating indicates that although pathogens retreat, healthy Qi declines, representing excessiveness. A superficial and firm pulse indicates pathogenic excess. However, profuse sweating after induction is excessive because fluids are lost externally, leading to Yang exhaustion in the interior. Yang is the source of fluids, and fluids are the root of Yang. Profuse sweating exhausts fluids; although Yang Qi remains, its root is severed, termed "Yang exhaustion." With exhausted Yang and depleted fluids, stools inevitably become hard.
A floating and knifelike (Kou) pulse: Floating indicates Yang, Kou indicates Yin. When floating and Kou interact, Stomach Qi generates heat, leading to Yang exhaustion.
A floating pulse indicates abundance in the exterior; a Kou pulse indicates deficiency in the interior. Floating represents exclusive Yang abundance; Kou represents Yin insufficiency. Their interaction signifies Yang excess and Yin deficiency. Depletion of Stomach fluids causes internal heat generation. Although Yang Qi exists, it lacks Yin to pair with, similar to the previous passage. Hence, "Yang exhaustion."
The above three passages elaborate on the causes of Yangming disease. The following three passages elaborate on its manifestations.
In cold damage, if there is fever, no sweat, vomiting, inability to eat, yet continuous sweating occurs, the disease is transferring to Yangming.
When cold damage transfers to Yangming, the patient exhibits continuous, slight sweating.
Fever and no sweat indicate Taiyang disease in the exterior. Vomiting and inability to eat indicate pathogens attempting to enter the interior while healthy Qi resists. Once continuous sweating occurs, it signifies that the Taiyang pathogen has been accepted by Yangming. Thus, it is called "transferring to Yangming." Taiyang cold binds in the skin and hair follicles, closing the pores, hence no sweat. Yangming heat resides in the muscles, opening the pores and leaking fluids, hence continuous sweating.
If a patient has not defecated for five to six days, experiences periumbilical pain, irritability, and periodic exacerbations, this indicates dry feces causing the constipation.
Heat binding in Yangming causes constipation for five to six days, periumbilical pain, irritability, and periodic symptoms, all signs of dry feces in the Stomach. "Periodic" refers to the peak time of Yangming, which is Shen hour (3-5 PM). With Yangming dryness and obstruction preventing defecation, unless Da Cheng Qi Tang (Major Order the Qi Decoction) is used, efficacy is unlikely.