者，缘脉迟则胃气空虚，津液不充，其满不过虚热内壅，非结热当下之比也。可见脉迟
胃虚，不但下之无益，即发汗利小便之法，亦不可用，惟当用和法，如甘草干姜汤，先温
其中，然后少与调胃微和胃气可也。
程应旄曰∶热蓄成黄之腹满，下之可去。此则谷气不得宣泄，属胃气虚寒使然，下之
益虚其虚矣。故腹满如故。
阳明病，若中寒者，不能食，小便不利，手足 然汗出，此欲作固瘕，必大便初硬后
溏，所以然者，以胃中冷，水谷不别故也。
【注】阳明病内热，则不大便，能食，小便利，手足 然汗出，是可下之证也。今中
寒不能食，小便不利，虽手足 然汗出，不可下也，此为中寒欲作固瘕。何以知之？以
大便必初硬而后溏也。所以然者，胃中虚冷，水谷不分，故小便不利而大便必溏也。
【按】不能食与上条食难用饱，同一不能腐熟水谷也。小便不利与上条小便难，同一
不能下输膀胱也。惟手足 然汗出，与上条饱则微烦、头眩不同，彼欲作谷疸，此欲作
固瘕，皆胃中寒冷。一以微烦头眩，阳在中上，故不病泻而病疸；一以手足汗出，阳在
四肢，故不病疸而病泻也。再上条中寒食难用饱，无汗小便难，欲作谷疸，以其尚能少
食微烦，犹有阳气故也。此条中寒不能食，手足冷汗，小便不利，欲作固瘕，则是寒湿不
化，纯阴故也。固瘕者，大瘕泻也，俗谓之溏泻。固者，久而不止之谓也。
【按】人之汗以天地之雨名之，阴阳和而后有雨，阳亢则热而雨少，阴盛则寒而雨多，
人之汗亦若是也。四肢手足属土，土主脾胃，若脉大，其汗蒸蒸而热，则为阳盛可下之证
也；若脉迟，其汗 而寒，则为阴盛可温之证也。
【集注】程应旄曰∶水谷不别，属湿热偏渗者多。此点出胃中冷，欲人知病本于寒，宜
从寒治，不在小便也。
太阳病，寸缓关浮尺弱，其人发热汗出。复恶寒不呕，但心下痞者，此以医下之也；如
其不下者，病患不恶寒而渴者，此转属阳明也。小便数者，大便必硬，不更衣十日，无
所苦也，渴欲饮水，少少与之，但以法救之，渴者，宜五苓散。
【按】“但以法救之”五字，当是“若小便不利”方与上文小便数、下文“渴者”之
义相合。此条病势不急救之之文，殊觉无谓，必有遗误。王三阳亦云∶此处五苓散难用，不
然经文“渴者？之下，当有阙文也。
【注】太阳病脉浮缓而弱，中风脉也；发热汗出恶寒，中风证也。不呕则里气和，缘
何而有心下痞证？此必以医下之故也。如其不经医下，邪热自传于里，病患不恶寒而渴
者，此邪去太阳，已转属阳明也。若小便数者，大便必硬，然使不更衣十余日，而无或
满或痛之苦，是仍属虚燥不实之硬，不可议下，俟之可也。如或渴欲饮水，必是胃中干
燥，当少少与之以滋其胃可耳。其或小便不利而渴者，是又为水停不化，宜五苓散以导
其所停之水矣。盖病在膀胱，故仍治太阳而不治阳明也。
【集注】张兼善曰∶十日不更衣，而不用攻伐何也？曰∶此非结热，虽不大便，而无
潮热、谵语可下之证，当须审慎，勿以日数久而辄为攻下也。
喻昌曰∶寸缓、关浮、尺弱，发热汗出恶寒，纯是太阳中风未罢之证，设非误下，何
得心下痞结耶？如不误下，而太阳证必渐传经，乃至不恶寒而渴，邪入阳明审矣。然阳
明津液既偏渗于小便，则大肠失其润而大便硬，与肠中热结自是不同，所以旬日不更衣无所苦也。
汪琥曰∶小便数大便硬，仲景论中何以无治法耶？盖此正是仲景不须用药处，俟其
阴阳自和，则小便渐少，大便必自出也。
阳明病，心下硬满者，不可攻之；攻之利遂不止者死，利止者愈。
【注】此申上条痞硬不更衣十日无所苦，误攻之变也。阳明病非胃家实，而心下硬满
者，不可攻之。若攻之，其人利不止者，则正脱而死。其人利自止者，邪退则犹可愈也。
【集注】汪琥曰∶或问结胸证同是心下硬满，又属可下何也？盖结胸证，心下硬满而
痛者，为胃中实，故可下；此证不痛，当是
虚硬虚满，与半夏泻心汤之心下痞硬略同，故云不可攻也。
诸虚者，不可下，下之则大渴，求水者易愈，恶水者剧。
【注】虚者下之，是为重虚，阴津消亡，自然大渴。其求水者，阳气犹存，故易愈；若
恶水者，阳气已绝，则难愈矣。
【集注】程应旄曰∶诸虚者，阳津阴液，必有所亡，故下之则大渴；求水者亡阴，恶
水者亡阳，故有愈剧之分。观此知仲景虑误下之助阴，甚于虑误下之亡阴矣。
大下之后，复发汗，小便不利者，亡津液故也。勿治之，得小便利，必自愈。
【注】大下之后，复发其汗，重亡津液，小盒饭少，以水液内竭故也。勿治之，言勿
利其小便也。须俟津液回而小便利，必自愈矣。
【集注】程知曰∶言下后复发汗，有俟津液自回之法。若强责其小便，则膀胱之气化
不行，有增硬满喘胀者矣。故宜以不治治之。
阳明病，下血谵语者，此为热入血室。但头汗出者，刺期门，随其实而泻之， 然汗出则愈。
【注】妇人病伤寒，经血适至，则有热入血室之证，宜刺期门；男子病伤寒，有下血
谵语者，亦为热入血室也。若热随血去，必通身汗出而解矣。若血已止，其热不去，蓄
于阳明，不得外越而上蒸，但头汗出而不解者，亦当刺期门，随其实而泻之，则亦必通
身然汗出而愈也。
【集注】方有执曰∶血室、头汗、期门，注皆见太阳篇中。阳明之脉其直者，从缺盆
下乳内廉下，侠脐入气街中。血室之脉起于气街，上行至胸中而散。所以妇人经来，热
入血室，则似结胸而谵语，从阳明里也。男子下血，热入血室，但头汗出亦谵语，从阳
明外也，故并宜刺期门。
程应旄曰∶下血则经脉空虚，热得乘虚而入血室，谵语以血室虽冲脉所属，而心经
实血室之主，室被热扰，故心神不清也。但头汗出者，血下夺则无汗，热上扰则汗蒸也。
刺期门者，热入阴分，实在阴，随其实而泻之，则荣气和而心气下通，故 然汗出而解。
阳明病，口燥，但欲漱水不欲咽者，此必衄。
【注】阳明属胃，开窍于口，阳明有热，故口燥也。但欲漱水不欲咽者，虽燥而不渴，
知热在经而不在腑，在血而不在气也。热在经血，迫血妄行，必致衄也。
【集注】喻昌曰∶口中干燥与渴异，漱水不欲咽，知不渴也。阳明病，口燥但漱水不
欲咽，知邪入血分，阳明之脉起于鼻，故知血得热而妄行，必由鼻而出也。
沈阳宗曰∶阳明病，口燥漱水而不欲咽，乃邪郁于经，未入于腑也。
脉浮发热，口干鼻燥，能食者，则衄。
【注】此承上条详出脉证，以互发其义也。阳明病，脉浮发热，口鼻干燥，热在经也。若
其人能食，则为胃和，胃和则邪当还表作解也。然还表作解，不解于卫，则解于营，汗
出而解者，从卫解也；衄血而解者，从营解也。今既能食、衄血，则知欲从营解也。
【集注】张锡驹曰∶此论阳明经脉燥热也。夫热在经脉，故脉浮发热，热循阳明经脉而
上，故口干鼻燥，不伤胃气，故能食。能食者则衄，言病不在胃腑，非因能食而致衄也。
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。
【注】经曰∶血并于下，乱而喜忘。喜忘者，好忘前言往事也。今阳明病，其人喜忘
者，本有久瘀之血，与热上并于心，故令喜
忘也。蓄血之屎虽硬，然大便反易，其色必黑，盖以血与糟粕共并，故反易而色黑也。不
用桃仁承气汤，而用抵当汤大下之者，以其人本有久瘀之血故也。
【集注】张志聪曰∶太阳蓄血在膀胱，故验其小便之利与不利；阳明蓄血在肠胃，故
验其大便之黑与不黑。
张璐曰∶大便色黑，虽曰瘀血，而燥结亦黑，但瘀血则粘如漆，燥结则晦如煤，此为明辨也。
郑重光曰∶太阳热结膀胱证，轻者如狂，重者发狂。如狂者血自下，故用桃仁承气汤，
因势而利导之；发狂者血不下，须用抵当汤。此条喜忘差减于狂，乃用发狂之重剂，何也？
盖太阳经少血，阳明经多血，所以宜用抵当汤峻攻。太阳云主之，乃确然不易之法，此
云宜用，则证有轻重，在于临时酌量耳。
病患无表里证，发热七八日，虽脉浮数者，可下之。假令已下，脉数不解，合热则
消谷善饥，至六七日不大便者，有瘀血，宜抵当汤。若脉数不解，而下不止，必协热便脓血也。
【注】此承上条言蓄血喜忘，热结而无表里证者，当下之义也。病患无表里证，是无
太阳表、阳明里证也。但发热而无恶寒，七八日，虽脉浮数不可汗也。若屎硬可下之，假
令已下，脉不浮而数不解，是表热去里热未去也。至六七日又不大便，若不能消谷善饥，
是胃实热也，以大承气汤下之。今既能消谷善饥，是胃和合热，非胃邪合热，故屎虽硬
色必黑，乃有瘀血热结之不大便也，宜有抵当汤下之。若脉数不解，不大便硬而下利不
止，必有久瘀，协热腐化而便脓血也，则不宜用抵当汤下之矣。
【集注】张璐曰∶病虽七八日，尚发热脉浮数，仍属太阳表证。因误下引邪内入，所
以脉数不解，内外合邪而见消谷善饥。谷入既多，反至六七日不大便，且不烦渴，是知
其证非热结在胃，乃热结在血。以其表证误下，尚兼太阳随经之热未尽，故以抵当为至
当也。若脉数不解而下利不止，又当随其下血与不下血而异治之，倘血分之热邪不除，必协热而便脓血也。
伤寒发汗已，身目为黄。所以然者，以寒湿在里不解故也，以为不可下也，于寒湿中求之。
【注】伤寒发汗已，身目为黄。所以然者，以表有寒里有湿未解也。夫表寒里湿，郁而
发黄，自非热湿内瘀，郁而成黄者比，故不可下。惟当于表寒里湿中求其治法，宜发其
表寒，利其里湿可也。
【集注】喻昌曰∶伤寒发汗已，热邪解矣，何由反蒸身目为黄？所以然者，寒湿抟聚，适
在躯壳之里，故尔发黄也。里者，在内之通称，非谓寒湿深入在里，盖身目正属躯壳，与
脏腑无关也。于寒湿中求之，求其寒湿中之治法也。
程应旄曰∶其人素有湿邪在里，表寒虽经发汗，而其为里湿所持者，终在里而无从
解散也。发汗后之寒，与湿郁蒸为热，非实热也，故不可下。仍当于寒湿中，责其或浅
或深而治之可也。
伤寒瘀热在里，身必发黄，麻黄连轺赤小豆汤主之。
【注】伤寒表邪未解，适遇其人阳明素有湿邪，热入里而与湿合，湿热蒸瘀，外薄肌
表，身必发黄也。若其人头有汗，小便不利，大便硬，则或清、或下、或利小便，自可愈
也。今乃无汗小便利，是里之瘀热未深，表之郁遏犹甚，故用麻黄连轺赤小豆汤，外发
其表，内逐其湿也。
【集注】喻昌曰∶伤寒之邪，得湿而不行，所以热瘀身中而发黄，设泥“里”字，岂有
邪在里而反治其表之理哉！
程应旄曰∶凡伤寒瘀热在里者，由湿蒸
而来，故身必发黄。此之瘀热未深，只从表一边开其郁滞，而散除湿热，麻黄连轺赤小豆汤是其主也。
林澜曰∶麻黄连轺一证，虽曰在里，必因邪气在表之时，有失解散，今虽发黄，犹宜兼汗解以治之也。
汪琥曰∶夫寒邪自外而来，若挟内湿瘀于经络之中，则郁而变热，故令其人身目发
黄也。此条乃是太阳经传来者，太阳伤寒，理宜用麻黄汤，只因邪传阳明，热瘀于里，里非胃腑，以阳明经
居太阳之里，即《尚论篇》所云躯壳之里是也。惟其里有热，所以方中用麻黄汤而去桂枝之辛热，更加赤小
豆、姜、枣之甘辛，以祛散在表之寒湿，复加连轺、生梓白皮之苦寒，以清解肌里之瘀热也。
麻黄连轺赤小豆汤方
麻黄（去节，二两） 赤小豆（一升） 杏仁（去皮尖，四十枚） 生姜（切，二两） 大枣（擘，十二枚）
甘草（炙，二两） 生梓白皮（切，一升） 连轺（二两）
以上八味，以潦水一斗，先煮麻黄，再沸去上沫，纳诸药，煮取三升，分温三服，半日则尽。
【方解】湿热发黄无表里证，热盛者清之，小便不利者利之，里实者下之，表实者汗之，
皆无非为病求去路也。用麻黄汤以开其表，使黄从外而散。去桂枝者，避其热也；佐姜、枣
者，和其营卫也；加连轺、梓皮以泻其热，赤小豆以利其湿，共成治表实发黄之效也。连
轺，即连翘根。无梓皮以茵陈代之。
【集解】周扬俊曰∶此亦两解表里法也，故用外汗之药，必兼渗湿之味。伤寒发黄者，
必其人太阴素有湿热，更兼寒邪未散，两邪相合，因而蒸郁为黄也。
伤寒七八日，身黄如橘子色，小便不利，腹微满者，茵陈蒿汤主之。
【注】身黄湿热之为病也，湿盛于热，则黄色晦，热盛于湿，则黄色明。如橘子色者，
谓黄色明也。伤寒七八日，身黄色明，小便不利，其腹微满，此里热深也。故以茵陈蒿
The term "slow pulse" (Chi Mai) arises because a slow pulse indicates emptiness of Stomach Qi and insufficient filling of Body Fluids. The abdominal fullness in this case is merely due to the internal obstruction of deficient heat, which is not comparable to excess heat accumulation requiring purgation. Thus, it can be seen that when the pulse is slow and Stomach Qi is deficient, not only is purgation ineffective, but methods such as inducing sweating or promoting urination are also contraindicated. One should only employ harmonizing methods, such as using Gancao Ganjiang Tang (Licorice and Dried Ginger Decoction) to first warm the Middle Jiao, followed by administering small amounts of Tiaowei Chengqi Tang (Regulate the Stomach and Direct Downward Decoction) to slightly harmonize Stomach Qi.
Cheng Yingmao stated: Abdominal fullness accompanied by jaundice resulting from accumulated heat can be treated with purgation. However, the condition described here involves the inability of Grain Qi to diffuse and descend, caused by deficiency-cold of the Stomach. Purgation would further deplete the deficiency, leaving the abdominal fullness unchanged.
In Yangming disease, if one contracts cold (Zhong Han), the patient cannot eat, experiences difficulty in urination, and has continuous sweating on the hands and feet. This indicates an impending formation of Gujia (a chronic diarrhea or mass). The stool will likely be hard initially and loose later. The reason for this is cold in the Stomach, leading to the failure to separate Water and Grain.
[Annotation] In Yangming disease characterized by internal heat, symptoms include constipation, ability to eat, free urination, and continuous sweating on the hands and feet; these are indications for purgation. However, in the current case of contracting cold with inability to eat and difficult urination, despite continuous sweating on the hands and feet, purgation is contraindicated. This represents cold contracting cold, leading to impending Gujia. How do we know this? Because the stool will be hard initially and loose later. This occurs because of deficiency-cold in the Stomach, causing Water and Grain to mix, resulting in difficult urination and loose stools.
[Commentary] The inability to eat mentioned here is similar to "difficulty eating until full" in the previous clause, both indicating the Spleen and Stomach's failure to rot and ripen Food and Fluids. Difficult urination here is similar to "difficult urination" in the previous clause, both indicating the failure to transport fluids downward to the Bladder. The difference lies in "continuous sweating on the hands and feet" versus "mild irritability and dizziness after eating." The former leads to Gutanic Jaundice (Gu Danja) because Yang Qi is in the upper-middle Jiao, causing jaundice rather than diarrhea. The latter leads to Gujia because Yang Qi is in the four limbs, causing diarrhea rather than jaundice. Regarding the previous clause, contracting cold with difficulty eating until full, no sweating, and difficult urination, leading to Gutanic Jaundice, implies that some Yang Qi remains, evidenced by the ability to eat slightly and mild irritability. In contrast, this clause describes contracting cold with inability to eat, cold sweating on the hands and feet, and difficult urition, leading to Gujia, indicating untransformed cold-dampness and a pure Yin syndrome. Gujia refers to severe diarrhea, commonly known as loose stool. "Gu" means persistent and unceasing.
[Commentary] Human sweat can be likened to rain from heaven and earth. Rain occurs when Yin and Yang harmonize; excessive Yang leads to heat and little rain, while excessive Yin leads to cold and much rain. Similarly, human sweat reflects this balance. The four limbs and hands/feet belong to Earth, which governs the Spleen and Stomach. If the pulse is large and sweat is profuse and hot, it indicates excess Yang suitable for purgation. If the pulse is slow and sweat is clear and cold, it indicates excess Yin suitable for warming.
[Collected Notes] Cheng Yingmao stated: Failure to separate Water and Grain is mostly due to damp-heat shifting abnormally. Here, the focus is on cold in the Stomach to remind practitioners that the root cause is cold, requiring treatment based on cold, rather than focusing on urination.
In Taiyang disease, with a slow pulse at the Cun position, floating at Guan, and weak at Chi, the patient presents with fever, sweating, aversion to cold, no vomiting, but epigastric stuffiness. This results from a physician's erroneous use of purgation. If purgation was not used, and the patient is not averse to cold but feels thirsty, the pathogen has transferred to Yangming. Frequent urination leads to hard stool. Even if ten days pass without defecation, there is no discomfort. If thirsty and desiring water, give small amounts frequently. Rescue according to the method. For thirst, Wuling San (Five-Ingredient Powder with Poria) is indicated.
[Commentary] The phrase "rescue according to the method" should likely read "if urination is difficult" to align with the preceding "frequent urination" and following "thirst." The current text seems superfluous given the non-urgent nature of the condition, suggesting a textual error. Wang Sanyang also noted the difficulty in applying Wuling San here, suggesting missing text after "thirst."
[Annotation] Taiyang disease with floating-slow and weak pulses is the pulse of Wind Strike. Fever, sweating, and aversion to cold are Wind Strike symptoms. No vomiting indicates harmonious interior Qi. Why is there epigastric stuffiness? It must be due to erroneous purgation by a physician. If not purged, and heat transfers internally, causing thirst without aversion to cold, the pathogen has left Taiyang and transferred to Yangming. Frequent urination causes hard stool. However, if there is no discomfort after ten days without defecation, it is still deficiency-dryness hardness, not suitable for purgation; waiting is appropriate. If thirsty for water, it indicates dryness in the Stomach; give small amounts to moisten the Stomach. If urination is difficult and thirsty, it indicates water retention and transformation failure; Wuling San is indicated to guide out the retained water. Since the disease is in the Bladder, treat Taiyang, not Yangming.
[Collected Notes] Zhang Jianshan asked: Why not use attacking methods for ten days without defecation? Answer: This is not excess heat accumulation. Although there is constipation, there are no signs like tidal fever or delirium suitable for purgation. Caution is required; do not purge simply because time has passed.
Yu Chang stated: Slow Cun, floating Guan, weak Chi, fever, sweating, aversion to cold are all Taiyang Wind Strike signs unresolved. Without erroneous purgation, how could epigastric stuffiness arise? Without purgation, Taiyang signs would gradually transmit, leading to no aversion to cold and thirst, confirming entry into Yangming. Since Yangming fluids shift to urination, the Large Intestine loses moisture, causing hard stool. This differs from intestinal heat accumulation, hence no discomfort after ten days.
Wang Hu asked: Why is there no treatment method for frequent urination and hard stool in Zhongjing's discussion? This is precisely where Zhongjing deemed medication unnecessary. Wait for Yin-Yang self-harmonization; urination will decrease, and stool will pass naturally.
In Yangming disease, epigastric hardness and fullness are contraindications for purgation. If purged and diarrhea persists, death ensues; if diarrhea stops, recovery occurs.
[Annotation] This reiterates the previous clause regarding epigastric stuffiness/hardness and ten days without defecation without discomfort, illustrating the consequences of erroneous purgation. In Yangming disease, if it is not Stomach Excess but presents with epigastric hardness/fullness, purgation is contraindicated. Purging leads to persistent diarrhea and Qi collapse (death). If diarrhea stops spontaneously, the pathogen retreats, and recovery is possible.
[Collected Notes] Wang Hu asked: Jie Xiong (Chest Binding) also presents with epigastric hardness/fullness and is treatable with purgation. Why? Jie Xiong involves pain, indicating Stomach excess, thus purgable. This case lacks pain, indicating deficiency hardness/fullness, similar to Banxia Xiexin Tang's epigastric stuffiness/hardness, hence purgation is contraindicated.
All deficiency syndromes are contraindications for purgation. Purging causes severe thirst. Those seeking water recover easily; those rejecting water worsen.
[Annotation] Purging deficiency causes double deficiency, consuming Yin fluids, leading to severe thirst. Those seeking water have residual Yang Qi, facilitating recovery. Those rejecting water have exhausted Yang Qi, making recovery difficult.
[Collected Notes] Cheng Yingmao stated: In all deficiencies, Yang fluids and Yin liquids are lost. Purging causes severe thirst. Seeking water indicates Yin loss; rejecting water indicates Yang loss, explaining the difference in outcomes. This shows Zhongjing feared purging aiding Yin more than harming Yin.
After severe purgation followed by sweating, if urination is difficult, it is due to fluid exhaustion. Do not treat it; when urination becomes normal, it will heal spontaneously.
[Annotation] Severe purgation followed by sweating doubly exhausts fluids, reducing urine output due to internal fluid depletion. "Do not treat" means do not promote diuresis. Wait for fluid restoration and normal urination for spontaneous healing.
[Collected Notes] Cheng Zhi stated: This indicates a method of waiting for fluid restoration after purgation and sweating. Forcing diuresis impairs Bladder Qi transformation, potentially worsening hardness, fullness, and wheezing. Thus, non-treatment is the appropriate approach.
In Yangming disease, hematochezia (blood in stool) with delirium indicates Heat entering the Blood Chamber (Xue Shi). If only the head sweats, puncture Qimen (LR14) to drain excess. Generalized sweating indicates recovery.
[Annotation] In women with Shanghan, menstruation coinciding with illness leads to Heat entering the Blood Chamber, treated by puncturing Qimen. In men with Shanghan, hematochezia with delirium also indicates Heat entering the Blood Chamber. If heat leaves with blood, generalized sweating resolves the condition. If bleeding stops but heat remains, accumulating in Yangming and steaming upward, causing only head sweating, puncture Qimen to drain excess. Generalized sweating then indicates recovery.
[Collected Notes] Fang Youzhi stated: Blood Chamber, head sweating, and Qimen are explained in the Taiyang chapter. The straight branch of the Yangming meridian descends from the clavicle, passes the breast, enters the abdomen. The Blood Chamber meridian originates in the groin, ascends to the chest. In women during menstruation, heat entering the Blood Chamber resembles Jie Xiong with delirium, originating from the Yangming interior. In men, hematochezia with head sweating and delirium originates from the Yangming exterior. Both require puncturing Qimen.
Cheng Yingmao stated: Hematochezia empties the meridians, allowing heat to enter the Blood Chamber. Delirium occurs because although the Blood Chamber belongs to the Chong Mai, the Heart governs it; heat disturbing the chamber clouds the Spirit. Head sweating occurs because blood loss prevents body sweating, while heat steaming upward causes head sweating. Puncturing Qimen drains heat from the Yin aspect. Draining excess harmonizes Ying Qi and allows Heart Qi to descend, resulting in generalized sweating and resolution.
In Yangming disease, dry mouth with desire to rinse but not swallow indicates impending nasal hemorrhage (Bi Nu).
[Annotation] Yangming corresponds to the Stomach, opening into the mouth. Yangming heat causes dry mouth. Desire to rinse but not swallow indicates dryness without thirst, meaning heat is in the channels, not the Fu organs, and in the Blood, not Qi. Heat in the Blood channels forces blood to move recklessly, causing nasal hemorrhage.
[Collected Notes] Yu Chang stated: Dry mouth differs from thirst. Rinsing without swallowing indicates no thirst. In Yangming disease, dry mouth with rinsing but no swallowing indicates pathogen entering the Blood level. The Yangming meridian starts at the nose; thus, heat forcing blood recklessly causes nasal hemorrhage.
Shenyang Zong stated: Dry mouth with rinsing but no swallowing in Yangming disease indicates pathogen stagnating in the channels, not yet entering the Fu organs.
Floating pulse, fever, dry mouth, and nasal dryness with ability to eat indicate nasal hemorrhage.
[Annotation] This elaborates on the previous clause's pulse and symptoms to clarify their meaning. Floating pulse, fever, and dry mouth/nose in Yangming disease indicate heat in the channels. Ability to eat suggests harmonious Stomach Qi, implying the pathogen should return to the surface for resolution. Resolution can occur via Wei (defensive) layer through sweating or Ying (nutritive) layer through hemorrhage. Since the patient eats and bleeds, resolution is expected via the Ying layer.
[Collected Notes] Zhang Xiju stated: This discusses Yangming channel dryness-heat. Heat in channels causes floating pulse and fever. Heat ascending along the Yangming channel causes dry mouth and nose. Unharmed Stomach Qi allows eating. "Able to eat leads to hemorrhage" means the disease is not in the Stomach Fu, nor caused by eating.
In Yangming syndrome, forgetfulness (Xi Wang) indicates Blood Stasis (Xu Xue). The reason is pre-existing long-standing Blood Stasis causing forgetfulness. Stool may be hard but passes easily and is black. Didang Tang (Di Dang Decoction) is indicated for purgation.
[Annotation] The Classics state: Blood pooling below disturbs the mind, causing forgetfulness. Forgetfulness means forgetting past words and deeds. In Yangming disease, forgetfulness arises from pre-existing Blood Stasis combining with heat and ascending to the Heart, causing forgetfulness. Although stool in Blood Stasis is hard, it passes easily and is black because blood mixes with feces. Didang Tang is used instead of Taoren Chengqi Tang because of the pre-existing long-standing Blood Stasis.
[Collected Notes] Zhang Zhicong stated: Taiyang Blood Stasis is in the Bladder, verified by urination. Yangming Blood Stasis is in the intestines, verified by black stool.
Zhang Lu stated: Black stool indicates Blood Stasis, but dryness also causes black stool. Blood Stasis is sticky like lacquer; dryness is dull like coal. This distinguishes them clearly.
Zheng Zhongguang stated: Taiyang Heat Binding in the Bladder presents as mania-like or mania. Mania-like allows spontaneous blood discharge, treated with Taoren Chengqi Tang to guide the pathogen. Mania requires Didang Tang as blood does not discharge spontaneously. Forgetfulness is less severe than mania, yet Didang Tang is used. Why? Taiyang channels have less blood; Yangming channels have more blood, justifying strong purgation. Taiyang chapter uses "mainly treats," a fixed rule. Yangming chapter uses "suitable for," allowing adjustment based on severity.
Patients with no exterior or interior signs, fever for seven to eight days, even with floating-rapid pulse, may be purged. If purged and rapid pulse persists, combined heat causes efficient digestion and hunger. After six to seven days without defecation, Blood Stasis is present; Didang Tang is indicated. If rapid pulse persists with uncontrolled diarrhea, heat-collicative pus and blood in stool will occur.
[Annotation] This continues the discussion on Blood Stasis and forgetfulness, addressing heat binding without exterior/interior signs requiring purgation. "No exterior/interior signs" means no Taiyang exterior or Yangming interior signs. Fever without aversion to cold for seven to eight days, even with floating-rapid pulse, contraindicates sweating. If stool is hard, purgation is possible. If purged and pulse is rapid but not floating, exterior heat is gone, interior heat remains. Six to seven days without defecation: if unable to digest food efficiently, it is Stomach excess heat, treated with Dachengqi Tang. If able to digest food efficiently, it is Stomach harmony with combined heat, not Stomach pathogen heat. Stool may be hard and black due to Blood Stasis heat binding, requiring Didang Tang. If rapid pulse persists with hard stool and uncontrolled diarrhea, long-standing Blood Stasis mixed with heat causes pus and blood in stool; Didang Tang is contraindicated.
[Collected Notes] Zhang Lu stated: Despite seven to eight days, fever and floating-rapid pulse suggest Taiyang exterior signs. Erroneous purgation drew the pathogen inward, causing persistent rapid pulse. Exterior-interior pathogen combination causes efficient digestion. Excessive food intake leads to constipation after six to seven days without irritability/thirst, indicating heat binding in Blood, not Stomach. Due to erroneous purgation of exterior signs, residual Taiyang channel heat remains, making Didang Tang appropriate. If rapid pulse persists with uncontrolled diarrhea, treatment depends on bleeding. If Blood-level heat is not removed, heat-collicative pus and blood in stool will result.
After Shanghan sweating, yellowing of body and eyes occurs. This is due to unresolved Cold-Dampness in the interior. Purgation is contraindicated; seek treatment within the context of Cold-Dampness.
[Annotation] After Shanghan sweating, yellowing of body and eyes occurs due to unresolved exterior cold and interior dampness. Exterior cold and interior dampness obstructing and transforming into yellowing differ from interior damp-heat accumulation. Thus, purgation is contraindicated. Seek treatment by dispersing exterior cold and draining interior dampness.
[Collected Notes] Yu Chang stated: After Shanghan sweating, heat pathogen resolves. Why does yellowing occur? Cold-Dampness aggregates in the "interior" (body shell), causing yellowing. "Interior" here refers generally to the body shell, not deep visceral interior. Yellowing affects the body shell, unrelated to Zang-Fu. "Seek within Cold-Dampness" means finding treatment methods for Cold-Dampness.
Cheng Yingmao stated: Pre-existing interior dampness persists despite sweating resolving exterior cold. The post-sweat cold combines with dampness to generate heat, but it is not excess heat, so purgation is contraindicated. Treat based on the depth of Cold-Dampness.
Shanghan with stagnant heat in the interior causes yellowing. Mahuang Lianqiao Chixiaodou Tang (Ephedra, Forsythia, and Red Bean Decoction) is indicated.
[Annotation] Shanghan exterior pathogen unresolved, combined with pre-existing Yangming dampness, heat enters the interior and combines with dampness. Steaming and stagnation of damp-heat on the muscle surface causes yellowing. If head sweating, difficult urination, and hard stool occur, clearing, purging, or promoting urination may resolve it. Currently, no sweating and free urination indicate shallow interior heat and severe exterior constraint. Mahuang Lianqiao Chixiaodou Tang disperses the exterior and eliminates interior dampness.
[Collected Notes] Yu Chang stated: Shanghan pathogen combined with dampness stagnates, causing heat accumulation and yellowing. Clinging to the word "interior" wrongly suggests treating the exterior for interior pathogens!
Cheng Yingmao stated: Stagnant heat in the interior in Shanghan arises from dampness steaming, causing yellowing. Since heat is not deep, open the exterior constraint to dissipate damp-heat. Mahuang Lianqiao Chixiaodou Tang is the main formula.
Lin Lan stated: Although Mahuang Lianqiao syndrome is termed "interior," it originates from failure to resolve exterior pathogen. Even with yellowing, sweating/resolving is appropriate.
Wang Hu stated: Cold pathogen from outside, carrying interior dampness stagnating in collaterals, transforms into heat, causing yellowing. This transmits from Taiyang. Taiyang Shanghan typically uses Mahuang Tang. However, pathogen transmitting to Yangming causes heat stagnation in the interior. This interior is not the Stomach Fu but the Yangming channel, located inside Taiyang, referred to as the "shell interior" in Shanglun Pian. Due to interior heat, Mahuang Tang is modified: remove Guizhi (Cinnamon Twig) for its acrid-warmth; add Chixiaodou (Red Bean), Shengjiang (Fresh Ginger), and Dazao (Jujube) for sweet-acrid properties to disperse exterior cold-dampness; add Lianqiao (Forsythia) and Shengzi Bapi (Raw Catalpa Bark) for bitter-cold properties to clear interior stagnant heat.
Mahuang Lianqiao Chixiaodou Tang Formula
Mahuang (Ephedrae Herba, removed nodes, 2 liang)
Chixiaodou (Phaseoli Semen Rubrum, 1 sheng)
Xingren (Armeniacae Semen Amarum, peeled tips, 40 pieces)
Shengjiang (Zingiberis Rhizoma Recens, sliced, 2 liang)
Dazao (Ziziphi Jujubae Fructus, split, 12 pieces)
Gancao (Glycyrrhizae Radix et Rhizoma, honey-fried, 2 liang)
Shengzi Bapi (Catalpae Cortex, sliced, 1 sheng)
Lianqiao (Forsythiae Fructum, 2 liang)
Boil these eight ingredients in 1 dou of rainwater. First boil Mahuang, skim foam upon boiling, add remaining herbs. Boil to obtain 3 sheng. Divide into three warm doses. Finish within half a day.
[Formula Analysis] For damp-heat yellowing without distinct exterior/interior signs: clear excess heat, promote urination for difficult urination, purge interior excess, sweat for exterior excess. All aim to provide an exit for the pathogen. Mahuang Tang opens the exterior to scatter yellow externally. Guizhi is removed to avoid heat. Ginger and Jujube harmonize Ying and Wei. Lianqiao and Catalpa Bark drain heat. Chixiaodou promotes dampness drainage. Together, they treat exterior-excess yellowing. Lianqiao here refers to Forsythia Root. If Catalpa Bark is unavailable, Yinchen (Artemisiae Scopariae Herba) substitutes.
[Collected Explanation] Zhou Yangjun stated: This is a method resolving both exterior and interior. Sweating herbs must be combined with damp-draining agents. Shanghan yellowing occurs when Taiyin pre-existing damp-heat combines with unresolved cold pathogen, steaming and郁stagnating to cause yellowing.
After seven to eight days of Shanghan, yellowing like orange peel color, difficult urination, and slight abdominal fullness are treated with Yinchenshao Tang (Artemisia Scoparia Decoction).
[Annotation] Yellowing is a damp-heat disease. Dampness exceeding heat causes dull yellow; heat exceeding dampness causes bright yellow. "Orange peel color" denotes bright yellow. After seven to eight days of Shanghan, bright yellow body, difficult urination, and slight abdominal fullness indicate deep interior heat. Yinchenshao Tang is indicated.