大猪胆一枚，泻汁和法醋少许，以灌谷道内，如一食顷，当大便，出宿食恶物甚效。
『内台方』不用醋，以小竹管插入胆口，留一头用油润，内入谷道中，以手将胆捻之
，其汁自入内，此方用之甚便。
（缺）
【按】
土瓜，即俗名赤雹也。『肘后方』治大便不通，采根捣汁，用筒吹入肛门内。此与上
猪胆汁方同义。『内台方』用土瓜根削如挺，内入谷道中误矣。盖蜜挺入谷道能烊化
而润大便。土瓜根不能烊化，如削挺用之，恐失仲景制方之义。
@@@
伤寒六、七日，目中不了了，睛不和，无表里证，大便难，身微热者，此为实也，急
下之，宜大承气汤。
【注】
少阴病，得之二、三日，口燥咽干，急下之，宜大承气汤者，乃因热势甚速，消灼肾
水，津液不能到咽，故不必待其有可下之证而急下之，是下其热，以救将绝之水，缓
则肾水干竭，阳必无根据，躁冒自焚而死也。目中不了了而睛和者，阴证也，睛不和者
，阳证也。今伤寒六、七日，目中不了了，睛不和者，是肾水为胃阳所竭，水既不能
制火，则火上熏于目，而眸子朦胧，为之不了了也，此热结神昏之渐，危恶之候也。
虽外无阳证，惟身微热，内无满痛，祗大便难，亦为热实，故曰：此为实也。急以大
承气汤下之，泻阳救阴，以全未竭之水可也。睛不和者，谓睛不活动也。
【集注】
方有执曰：了了，犹了了也。『素问』曰：阳明主肉，其脉侠鼻络于目。『灵枢』曰
：足阳明之脉，上循咽出于口，还系目系合于阳明也。又曰：足阳明之筋，其支者，
上颈上侠口合于頄，下结于鼻，上合于太阳。太阳为目上纲，阳明为目下纲；所以目
中不了了，睛不和，知胃实也。急下者，任脉循面入目，督脉上系两目中央，诸脉皆
属于目，而人之精神注焉，是以宜急下也。
喻昌曰：少阴有急下三法以救肾水：一本经水竭，一木邪涌水，一土邪凌水。阳明亦
有急下三法以救津液：一汗多津越于外，一腹满津结于内，一目睛不慧，津枯于中。
合两经下法以观病情生理，如身在冰壶腹饮上池矣。
张锡驹曰：阳火亢极，阴水欲枯，故使目中不了了而睛不和，急下之，所以抑亢极之
阳火，而救垂绝之阴水也。
魏荔彤曰：阳明燥屎应下，胃实应下，俱详考其脉证矣。乃有表里无他证，独于阳明
胃脉所发见端倪处，体认其证，如伤寒六、七日，太阳已罢，阳明已成，其目昏暗朦
昧，若隔云雾而不了了明白者，此证名为睛不和也。阳明热盛，循经络而发其昏朦之
象，以致睛失其光，此内热盛而为实，其机已兆，兼以大便□而难，身有微热者，则
胃实已真，故曰：此为实也，急下之，宜大承气汤。
@@@
病人小便不利，大便乍难乍易，时有微热，喘冒不能卧者，有燥屎也，宜大承气汤。
【注】
阳明病之人，小便自利，大盒饭□，小便不利，大便不□，是知□不□，不在热不热
，而在液之竭与不竭也。今小便不利，而大便乍难乍易者，盖热将欲作结，而液未竭
也。有时微热者热入里也，喘者热乘肺也，冒者热乘心也，不能卧者热并阳也，此皆
一派热结便□之征，神昏谵狂之渐，虽无满痛，亦必有燥屎，宜大承气汤下之自愈也
。
【集注】
王三阳曰：此证不宜妄动，必以手按之脐腹有□块，喘冒不能卧，方可攻之，何也？
乍难乍易故也。
林澜曰：既微热时作，喘冒不能卧，则有燥屎已得。自宜下逐里实为急，安可复以小
便利、屎定□，始可攻之常法拘哉！
汪琥曰：此条病未经下而有燥屎，乃医人不易识之证。成无已云：小便利则大便□，
此有燥屎乃理之常。今病人小便不利，大便乍难乍易，何以知其有燥屎耶？盖大实、
大满之证，则前、后便皆不通。大便为燥屎壅塞，其未坚结者，或有时而并出，故乍
易；其极坚结者，终着于大肠之中，故乍难。燥屎结积于下，浊气攻冲于上，以故时
有微热；微热者，热伏于内不得发泄也。后条辨云：浊气乘于心肺，故既冒且喘也，
不得卧者，胃有燥屎所扰，即胃不和则卧不安也。凡此者，皆是有燥屎之征，故云：
宜大承气汤。
@@@
病人不大便五、六日，绕脐痛，烦躁，发作有时者，此有燥屎，故使不大便也。
【注】
病人不大便五、六日，绕脐痛者，是肠胃中燥屎结无去路，故绕脐痛也。烦躁发作有
时者，是燥屎秽热上攻则烦躁，不攻则不烦躁，故发作有时也。不须以小承气汤试之
，直以大承气汤下其燥屎，大便利自可愈也。
【集注】
方有执曰：病人，谓凡有病之人，而证犯如此者，则皆当如此治之。此示人辨凡百胃
实之大旨也。
程应旄曰：攻法，必待有燥屎，方不为误攻。所以验燥屎之法，不可不备，无恃转失
气之一端也。病人虽不大便五、六日，屎之燥与不燥未可知也。但绕脐痛，则知肠胃
干，屎无去路，滞涩在一处而作痛；烦躁发作有时者，因屎气攻动，则烦躁发作；又
有时伏而不动，亦不烦躁，而有绕脐痛者，断其不大盒饭无差矣，何大承气汤之不可
攻耶！
@@@
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。
【注】
此承上条以明其治也。下之未尽，仍当下之。乃大下之后，六、七日后不大便，烦亦
不解，腹仍满痛者，此有燥屎下之未尽也。所以然者，本有宿食故也，宜大承气汤复
下之自愈也。
【集注】
程知曰：大下之后，宜乎病解矣，乃复六、七日不大便，烦不解而腹满痛，此必有燥
屎未尽而然。盖宿食因热复为之结□也。
@@@
阳明病，下之，其外有热，手足温，不结胸，心中懊□，饥不能食，但头汗出者，栀
子豉汤主之。
【注】
阳明经病下之，身热未除，手足温，不结胸者，是所陷之邪浅也。心中懊□，饥不能
食，但头汗出者，是阳邪蒸郁于胸膈间也。故宜栀子豉汤涌其热也。
【集注】
程知曰：其外有热者，经邪未解也；手足温者，热入未深也。
程应旄曰：懊□扰胃，故饥不能食。热郁气蒸，故但头汗出。
魏荔彤曰：表邪未全入里，乃即以为胃实而遽下之，则其外仍有热，究不能随下药而
荡涤也。于是虽热而不潮，手足虽温而无濈然之汗出，则是在表者，仍在表而下之，
徒伤其里耳！即不至于全在太阳者，误下成结胸，而心下懊□，饥不能食，但头汗出
，其阳明蒸蒸之热，为阴寒之药所郁，俱凝塞于胸膈之上，其证已昭然矣。但病仍带
表，既不可再下，且已入里，又不可复发汗，惟有主以栀子豉汤，仍从太阳治也。
@@@
伤寒呕多，虽有阳明证，不可攻之。
【注】
伤寒三阳多有呕证，以其风寒之表未除，胸中阳气为寒所郁，故皆不可攻下也。其干
呕而恶寒发热者，属太阳也。喜呕而寒热往来者，属少阳也。今虽祗有恶寒、不恶寒
、大便□之阳明证，而呕多亦不可攻之，其气逆在上而未敛，为实也。
【集注】
沈明宗曰：恶寒发热之呕属太阳，寒热往来之呕属少阳，但恶热不恶寒之呕属阳明。
然呕多则气已上逆，邪气偏侵上脘，或带少阳，故虽有阳明证，慎不可攻也。
@@@
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。
【注】
阳明，谓阳明里证。中风，谓太阳表证也。口苦咽干，少阳热证也。腹满，阳明热证
也。微喘，发热恶寒，太阳伤寒证也。脉浮而紧，伤寒脉也。此为风寒兼伤表里同病
之证，当审表里施治：太阳、阳明病多，则以桂枝加大黄汤两解之。少阳、阳明病多
，则以大柴胡汤和而下之。若惟从里治，而遽以腹满一证，为热入阳明而下之，则表
邪乘虚复陷，故腹更满也；里热愈竭其液，故小便难也。
【集注】
程知曰：此言阳明兼有太阳、少阳表邪，即不可攻也。阳明中风，热邪也，腹满而喘
，热入里矣。然喘而微，则未全入里也。发热恶寒，脉浮而紧，皆太阳未除之证，口
苦咽干，为有少阳之半表半里，若误下之，则表邪乘虚内陷，而腹益满矣。兼以重亡
津液，故小便难也。
程应旄曰：此条与太阳大青龙证同。太阳以风寒持其荣卫，故有烦躁证而无腹满证；
此以风寒持住阳明，故有腹满证而无烦躁证。然口苦、咽干，实与烦躁同其机兆也。
@@@
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□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。阳明病，汗出多而渴者，
不可与猪苓汤，以汗多胃中燥，猪苓汤复利其小便故也。
【注】
此承前条互发其义，以明其治也。前条表证居多，戒不可误下；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□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□，舌上生胎，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。然阳明病，法当多汗，因汗出多
，致小便少而渴者，不可与猪苓汤。盖以汗多胃燥，无水不能下行，乃水涸之小便少
，非水蓄之小便不利也，恐猪苓汤更利其小便，则益竭津液而助燥矣。
【按】
太阳病，烦热无汗而渴，小便利者，大青龙汤证也；小便不利者，小青龙汤去半夏加
花粉、茯苓证也。太阳病，烦热有汗而渴，小便利者，桂枝合白虎汤证也；小便不利
者，五芩散证。阳明病，烦热无汗而渴，小便利者，宜葛根汤加石膏主之；小便不利
者，以五芩散加石膏、寒水石、滑石主之。阳明病，烦热有汗而渴，小便利者，宜白
虎汤；小便不利者，以猪苓汤。少阳病寒热无汗而渴，小便利者，当以小柴胡汤去半
夏加花粉；小便不利者，当以小柴胡汤加茯苓。太阴无渴。少阴阳邪，烦呕小便赤而
渴者，以猪苓汤；少阴阴邪下利，小便白而渴者，以真武汤。厥阴阳邪消渴者，白虎
加人参汤；厥阴阴邪，转属阳明，渴欲饮水者，少少与之则愈。证既不同，法亦各异
，当详审而明辨之。
【集注】
喻昌曰：发热以上与前条同，而汗出，不恶寒，反恶热，身重，四者皆阳明之见证，
所以汗、下、烧针俱不可用。舌上胎，则膈热甚，故涌以栀子鼓而微去其膈热，斯治
太阳而无碍阳明矣。若前证更加口干舌燥，则宜用白虎汤以解热生津；更加小便不利
，则宜以猪苓汤，以导热滋干也。其汗多而渴，不可与猪苓汤者，以热邪传入阳明，
必先耗其津液；加以汗多复夺之于外，又利小便更夺之于下，则津液有立亡之患，故
示戒也。
程应旄曰：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。
One large pig gallbladder, express the juice and mix with a small amount of rice vinegar, pour into the anus. After about the time it takes to eat one meal, bowel movement should occur; expelling retained food and foul matter is very effective.
The *Neitai Fang* does not use vinegar. Insert a small bamboo tube into the mouth of the gallbladder, leave one end lubricated with oil, insert it into the anus, and squeeze the gallbladder by hand so that the juice flows in naturally. This method is very convenient.
(Missing)
[Commentary]
Tugua (Trichosanthes kirilowii root), commonly known as Chibao. The *Zhouhou Fang* treats constipation by collecting the root, crushing it to extract juice, and blowing it into the anus with a tube. This has the same meaning as the above Pig Gallbladder Decoction. The *Neitai Fang* carving Tugua root into a suppository shape and inserting it into the anus is incorrect. Because honey suppositories inserted into the anus can melt and lubricate the stool. Tugua root cannot melt; if used carved into a stick, it may violate the original intent of Zhang Zhongjing's prescription formulation.
@@@
In Shaoyang disease lasting six or seven days, if the eyes fail to see clearly and the eyeballs move stiffly, without exterior or interior syndromes, difficulty in defecation, and slight fever, this is an excess syndrome. Urgent purgation is required, and Da Chengqi Tang (Major Order the Qi Decoction) is appropriate.
[Annotation]
In Shaoyin disease, two or three days after onset, if dry mouth and throat appear, urgent purgation is required, using Da Chengqi Tang (Major Order the Qi Decoction). This is because the heat pathogen advances rapidly, consuming Kidney Water (Jing/Essence fluids), preventing body fluids from reaching the throat. Therefore, one should not wait for typical signs of stagnation requiring purgation but must purge urgently to clear heat and rescue the nearly exhausted Yin fluids. Delaying will lead to the exhaustion of Kidney Water, leaving Yang without foundation, resulting in death due to restlessness, delirium, and internal burning. If the eyes fail to see clearly but the eyeballs move freely, it is a Yin syndrome; if the eyeballs move stiffly, it is a Yang syndrome. Now, in Shaoyang disease lasting six or seven days, with unclear vision and stiff eyeballs, this indicates that Kidney Water is depleted by Stomach Yang. Since Water cannot control Fire, Fire flares up to the eyes, causing blurred vision and unclear sight. This is the beginning of heat accumulation leading to spirit confusion, a critical and ominous sign. Although there are no obvious exterior Yang signs, only slight fever, and internally no fullness or pain, merely difficulty in defecation, it is still considered Heat Excess. Thus it says: "This is an excess syndrome." Urgently purge with Da Chengqi Tang (Major Order the Qi Decoction) to drain Yang and save Yin, preserving the unexhausted Yin fluids. "Stiff eyeballs" refers to lack of mobility in the eyeballs.
[Collected Commentaries]
Fang Youzhi states: "Liaoliao" means clear. The *Suwen* states: "Yangming governs flesh, its meridian runs alongside the nose and connects to the eyes." The *Lingshu* states: "The Foot-Yangming meridian ascends along the throat, emerges at the mouth, and loops back to connect with the eye system, merging with Yangming." It also states: "The branch of the Foot-Yangming sinew ascends the neck, runs alongside the mouth, and merges at the cheekbone; descends to knot at the nose, and ascends to merge with Taiyang." Taiyang is the upper border of the eye, Yangming is the lower border; thus, unclear vision and stiff eyeballs indicate Stomach Excess. Urgent purgation is needed because the Ren Mai (Conception Vessel) runs through the face into the eyes, the Du Mai (Governing Vessel) ascends to connect the center of both eyes, and all meridians belong to the eyes where the spirit resides; hence, urgent purgation is suitable.
Yu Chang states: Shaoyin disease has three methods for urgent purgation to rescue Kidney Water: one is depletion of the kidney water itself, one is Liver Wood pathogen surging against water, and one is Spleen Earth pathogen overwhelming water. Yangming disease also has three methods for urgent purgation to rescue body fluids: one is excessive sweating causing fluid loss externally, one is abdominal fullness causing fluid binding internally, and one is unclear vision indicating fluid exhaustion centrally. Observing the pathology and physiology through these purgative methods of both meridians provides profound insight.
Zhang Xiju states: When Yang Fire reaches extreme hyperactivity and Yin Water is about to dry up, causing unclear vision and stiff eyeballs, urgent purgation is used to suppress the extreme Yang Fire and rescue the dying Yin Water.
Wei Litong states: Yangming dry feces should be purged, and Stomach Excess should be purged, after careful examination of pulse and symptoms. However, in cases with no other exterior or interior signs, one must recognize the syndrome at the manifestation point of the Yangming Stomach meridian. For example, in Shaoyang disease lasting six or seven days, when the Taiyang stage has passed and Yangming is established, if the eyes are dim and blurred, appearing unclear like looking through fog, this syndrome is called "stiff eyeballs" (Jing Bu He). Severe Yangming heat follows the meridians to cause this blurring, depriving the eyes of their luster. This indicates severe internal heat and excess, with the mechanism already manifesting. Coupled with difficult defecation and slight fever, Stomach Excess is confirmed. Thus it says: "This is an excess syndrome," requiring urgent purgation with Da Chengqi Tang (Major Order the Qi Decoction).
@@@
If a patient has dysuria, intermittent difficulty and ease in defecation, occasional slight fever, wheezing, dizziness, and inability to lie down, there are dry feces. Da Chengqi Tang (Major Order the Qi Decoction) is appropriate.
[Annotation]
In Yangming disease, if urination is free, stools should be dry; if urination is difficult, stools should not be dry. Thus, whether stools are dry depends not on heat or cold, but on the depletion or preservation of fluids. Now, with dysuria and intermittent difficulty/ease in defecation, it suggests heat is about to bind but fluids are not yet exhausted. Occasional slight fever indicates heat entering the interior. Wheezing indicates heat affecting the Lungs. Dizziness indicates heat affecting the Heart. Inability to lie down indicates heat merging with Yang. These are all signs of heat binding and stool hardening, precursors to spirit confusion and delirium. Even without fullness or pain, dry feces must exist. Da Chengqi Tang (Major Order the Qi Decoction) should be used to purge, leading to self-healing.
[Collected Commentaries]
Wang Sanyang states: This syndrome should not be treated recklessly. One must press the umbilical and abdominal area to feel hardness, accompanied by wheezing, dizziness, and inability to lie down, before attacking. Why? Because of the intermittent nature of the stool.
Lin Lan states: With occasional slight fever, wheezing, dizziness, and inability to lie down, dry feces are already present. Urgent purgation to remove interior excess is indicated. How can one be bound by the common rule of waiting for free urination and confirmed dry stool before attacking?
Wang Hu states: This case involves dry feces without prior purgation, a syndrome difficult for physicians to identify. Cheng Wuji said: Free urination leads to dry stool; having dry feces is the norm. Now, with dysuria and intermittent stool, how do we know there are dry feces? In severe excess and fullness, both urine and stool are blocked. Dry feces block the bowels; the unhardened parts may pass occasionally, causing intermittent ease; the extremely hardened parts remain in the large intestine, causing intermittent difficulty. Dry feces accumulate below, turbid qi attacks upward, causing occasional slight fever (heat trapped inside). The later commentary explains: Turbid qi affects Heart and Lungs, causing dizziness and wheezing. Inability to lie down is due to disturbance by dry feces in the Stomach ("When the Stomach is disharmonious, sleep is restless"). All these are signs of dry feces, hence Da Chengqi Tang (Major Order the Qi Decoction) is appropriate.
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If a patient has not had a bowel movement for five or six days, experiences periumbilical pain, restlessness, and periodic发作 (attacks), there are dry feces causing the constipation.
[Annotation]
No bowel movement for five or six days with periumbilical pain indicates dry feces bound in the intestines and stomach with no exit, causing pain around the navel. Restlessness occurring periodically indicates that turbid heat from dry feces attacks upward causing restlessness; when it does not attack, there is no restlessness. There is no need to test with Xiao Chengqi Tang (Minor Order the Qi Decoction); directly use Da Chengqi Tang (Major Order the Qi Decoction) to purge the dry feces. Once bowels move freely, healing will follow.
[Collected Commentaries]
Fang Youzhi states: "Patient" refers to any sick person presenting such symptoms, who should all be treated this way. This illustrates the general principle for identifying all Stomach Excess syndromes.
Cheng Yingmao states: Purgative methods require confirmation of dry feces to avoid mistaken purgation. Verification methods must be comprehensive, not relying solely on passing gas. Although no bowel movement for five or six days, the dryness of stool is unknown. But periumbilical pain indicates intestinal dryness and blocked exit, stagnating in one spot causing pain. Periodic restlessness occurs when stool qi moves and attacks; when it lies dormant, there is no restlessness, only periumbilical pain. This confirms constipation without error. Why not attack with Da Chengqi Tang (Major Order the Qi Decoction)?
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After severe purgation, if six or seven days pass without a bowel movement, restlessness persists, and abdominal fullness and pain occur, there are dry feces. This is because there was originally retained food. Da Chengqi Tang (Major Order the Qi Decoction) is appropriate.
[Annotation]
This continues the previous section to clarify treatment. If purgation was incomplete, it must be repeated. After severe purgation, if six or seven days pass without a bowel movement, restlessness persists, and abdominal fullness/pain remains, this indicates residual dry feces from incomplete purgation. This happens because there was originally retained food. Da Chengqi Tang (Major Order the Qi Decoction) should be used again to purge, leading to self-healing.
[Collected Commentaries]
Cheng Zhi states: After severe purgation, the illness should resolve. Yet, six or seven days pass without a bowel movement, with persistent restlessness and abdominal fullness/pain. This must be due to residual dry feces. Retained food re-binds due to heat.
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In Yangming disease, after purgation, if there is external heat, warm hands and feet, no Jie Xiong (Chest Binding), mental depression and vexation (Ao Nao), hunger but inability to eat, and only head sweating, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is the primary treatment.
[Annotation]
In Yangming Meridian disease, after purgation, if body heat remains, hands and feet are warm, and there is no Chest Binding, the pathogen sinking inward is shallow. Mental depression/vexation, hunger but inability to eat, and only head sweating indicate Yang pathogen steaming and obstructing the chest and diaphragm. Therefore, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is suitable to induce vomiting/emetic action to clear heat.
[Collected Commentaries]
Cheng Zhi states: External heat indicates meridian pathogen unresolved; warm hands and feet indicate heat has not penetrated deeply.
Cheng Yingmao states: Vexation disturbs the Stomach, causing hunger but inability to eat. Heat obstruction and qi steaming cause only head sweating.
Wei Litong states: If exterior pathogen has not fully entered the interior, and one mistakenly considers it Stomach Excess and purges hastily, external heat remains and cannot be cleared by the purgative. Thus, although hot, there is no tidal fever; although hands/feet are warm, there is no continuous sweating. The exterior pathogen remains exterior, and purgation only injures the interior! Even if not entirely Taiyang, mistaken purgation leading to Chest Binding presents with epigastric vexation, hunger/inability to eat, and head sweating. The steaming heat of Yangming is constrained by cold medicines, condensing in the upper chest/diaphragm. The syndrome is evident. Since the disease still carries exterior characteristics, it cannot be purged again, nor can it be induced to sweat as it has entered the interior. Only Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) should be used, treating it according to Taiyang methods.
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In Shaoyang disease with frequent vomiting, even if Yangming signs exist, purgation is contraindicated.
[Annotation]
Shaoyang diseases often present with vomiting because the Wind-Cold exterior pathogen is not resolved, and Yang qi in the chest is constrained by Cold. Thus, purgation is contraindicated. Dry retching with aversion to cold and fever belongs to Taiyang. Frequent vomiting with alternating chills and fever belongs to Shaoyang. Now, even if there are only Yangming signs like aversion to cold or lack thereof, and dry stool, frequent vomiting precludes purgation. The rebellious Qi is above and not gathered, constituting an Excess pattern.
[Collected Commentaries]
Shen Mingzong states: Vomiting with chills/fever belongs to Taiyang; alternating chills/fever belongs to Shaoyang; only heat aversion without cold aversion belongs to Yangming. However, frequent vomiting indicates rebellious Qi and pathogen invading the Upper Jiao or involving Shaoyang. Thus, even with Yangming signs, caution against purgation is essential.
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Yangming Wind Strike, with bitter taste in the mouth, dry throat, abdominal fullness, slight wheezing, fever, aversion to cold, floating and tight pulse. If purged, abdominal fullness will worsen and urination will become difficult.
[Annotation]
"Yangming" refers to Yangming interior syndrome. "Wind Strike" refers to Taiyang exterior syndrome. Bitter taste and dry throat are Shaoyang Heat signs. Abdominal fullness is Yangming Heat sign. Slight wheezing, fever, and aversion to cold are Taiyang Cold Damage signs. Floating and tight pulse is a Cold Damage pulse. This is a syndrome of simultaneous Wind-Cold attacking both exterior and interior. Treatment must assess exterior and interior: If Taiyang and Yangming dominate, use Guizhi Jiadahuang Tang (Cinnamon Twig Decoction plus Rhubarb) to resolve both. If Shaoyang and Yangming dominate, use Dachaihu Tang (Major Bupleurum Decoction) to harmonize and purge. If treating only the interior, and hastily purging based solely on abdominal fullness as Heat entering Yangming, the exterior pathogen will sink deeper due to deficiency, worsening fullness. Interior heat further depletes fluids, causing difficult urination.
[Collected Commentaries]
Cheng Zhi states: This indicates that if Yangming is combined with Taiyang and Shaoyang exterior pathogens, purgation is contraindicated. Yangming Wind Strike is Heat pathogen. Abdominal fullness and wheezing indicate heat entering the interior. But slight wheezing means it hasn't fully entered. Fever, aversion to cold, floating/tight pulse are Taiyang signs. Bitter taste/dry throat indicate Shaoyang half-exterior/half-interior. Mistaken purgation causes exterior pathogen to sink inward, increasing fullness. Heavy loss of fluids causes difficult urination.
Cheng Yingmao states: This line is similar to the Taiyang Da Qinglong Tang syndrome. Taiyang constrains Ying and Wei with Wind-Cold, causing restlessness but no abdominal fullness. This constrains Yangming with Wind-Cold, causing abdominal fullness but no restlessness. However, bitter taste and dry throat share the same mechanistic indication as restlessness.
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Yangming disease, floating and tight pulse, dry throat, bitter taste, abdominal fullness, wheezing, fever, sweating, aversion to heat rather than cold, heavy body. If sweated, restlessness ensues, heart feels confused, and delirium occurs. If moxibustion/warm needle is added, terror, restlessness, and insomnia result. If purged, the Stomach becomes empty, guest pathogen agitates the diaphragm, mental depression/vexation occurs, and coating appears on the tongue. Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is primary. If thirsty for water, dry mouth and tongue, Baihu Jiarenshen Tang (White Tiger Decoction plus Ginseng) is primary. If floating pulse, fever, thirst for water, and dysuria, Zhuling Tang (Polyporus Decoction) is primary. In Yangming disease, if sweating is profuse and thirst exists, Zhuling Tang (Polyporus Decoction) is contraindicated because profuse sweating causes Stomach dryness, and Zhuling Tang (Polyporus Decoction) promotes urination, further depleting fluids.
[Annotation]
This expands on the previous lines to clarify treatment. The previous line emphasized avoiding mistaken purgation due to predominant exterior signs; this line highlights mixed exterior-interior signs and complex pulses/symptoms, warning against both mistaken purgation and mistaken sweating. Sweating based on floating/tight pulse depletes fluids and injures Yin. Adding burning needles aids Yang pathogen, causing delirium, restlessness, terror, and insomnia. Purging based on abdominal fullness and heat aversion empties the Stomach, allowing guest pathogen/heat to disturb the diaphragm, causing vexation and tongue coating—errors of mistaken purgation. Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) clears this via emesis. If pulse is floating not tight, no vexation, only fever/thirst/dry mouth/tongue, Taiyang exterior pathogen is fading while Yangming dry-heat is strong. Baihu Jiarenshen Tang (White Tiger Decoction plus Ginseng) nourishes fluids. If fever/thirst/dysuria, Yangming Fluid-Heat is abundant. Zhuling Tang (Polyporus Decoction) drains water to moisten dryness. However, Yangming disease typically involves profuse sweating. If profuse sweating leads to low urine and thirst, Zhuling Tang (Polyporus Decoction) is contraindicated. Profuse sweating causes Stomach dryness; lack of water prevents downward flow. This is oliguria due to fluid depletion, not fluid retention. Using Zhuling Tang (Polyporus Decoction) would further drain fluids and aggravate dryness.
[Commentary]
Taiyang disease with vexation/heat, no sweat, thirst, and free urination is Da Qinglong Tang (Major Green Dragon Decoction) syndrome; dysuria is Xiao Qinglong Tang (Minor Green Dragon Decoction) minus Banxia plus Huafen and Fuling. Taiyang disease with vexation/heat, sweat, thirst, and free urination is Guizhi He Baihu Tang (Cinnamon Twig Combined with White Tiger Decoction); dysuria is Wuling San (Five-Ingredient Powder with Poria). Yangming disease with vexation/heat, no sweat, thirst, and free urination requires Gegen Tang (Kudzu Decoction) plus Shigao; dysuria requires Wuling San plus Shigao, Hanshuishi, and Huashi. Yangming disease with vexation/heat, sweat, thirst, and free urination requires Baihu Tang (White Tiger Decoction); dysuria requires Zhuling Tang (Polyporus Decoction). Shaoyang disease with chills/fever, no sweat, thirst, and free urination requires Xiaochaihu Tang (Minor Bupleurum Decoction) minus Banxia plus Huafen; dysuria requires Xiaochaihu Tang plus Fuling. Taiyin disease has no thirst. Shaoyin Yang pathogen with vexation/vomiting, red urine, and thirst uses Zhuling Tang (Polyporus Decoction); Shaoyin Yin pathogen with diarrhea, white urine, and thirst uses Zhenwu Tang (True Warrior Decoction). Jueyin Yang pathogen with polydipsia uses Baihu Jiarenshen Tang (White Tiger Decoction plus Ginseng); Jueyin Yin pathogen transferring to Yangming with thirst for water heals with small sips. Since syndromes differ, methods vary; careful differentiation is required.
[Collected Commentaries]
Yu Chang states: Fever matches the previous line, but sweating, aversion to heat, and heavy body are Yangming signs. Thus, sweating, purgation, and needles are all contraindicated. Tongue coating indicates severe diaphragmatic heat; Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) clears this slightly, treating Taiyang without harming Yangming. If dry mouth/tongue adds, Baihu Tang (White Tiger Decoction) resolves heat and generates fluids. If dysuria adds, Zhuling Tang (Polyporus Decoction) guides heat out and moistens dryness. Profuse sweating and thirst contraindicate Zhuling Tang (Polyporus Decoction) because Yangming heat consumes fluids; profuse sweating loses them externally, and diuretics lose them internally, risking immediate fluid collapse. Hence the warning.
Cheng Yingmao states: Heat in the Upper Jiao uses Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction); Heat in the Middle Jiao uses Baihu Jiarenshen Tang (White Tiger Decoction plus Ginseng); Heat in the Lower Jiao uses Zhuling Tang (Polyporus Decoction).