【纲】仲景曰。阳明之为病。胃家实也。
【目】朱肱曰。不恶寒。反恶热。手掌心并胁下 汗出。胃中干燥结聚。潮热。大便闭。
小便如常。腹满而喘。或谵语。脉浮而滑者。里症也。里症者。内热也。内热属阳明。下之。
李 曰。里症。始焉脉浮而大。今则沉而数。始焉惺而静。今则躁而动。始焉头疼发热恶寒。
今则不恶寒反恶热。烦躁倍加。胸连脐腹满痛。胁下掌心自汗 。以致胃干。屎燥秘结。小便赤
涩。口干。发狂谵语。掀衣揭被。扬手掷足。六脉有力。即是传经热症。又谓阳盛误汗即死。或有
初病即见此症者。不拘日数多少。便宜通利。失下。则血气不通而发厥矣。抑又有说。纯乎表而里
无一毫病者。当解表时勿攻里。纯乎里而表无一毫病者。当攻里时勿解表。如表里俱见。或表多里
少。表急里缓。则先治表。后攻里。或里多表少。里急表缓。则先攻里。后救表。又表虚里实。药
宜辛凉。里虚表实。药宜辛热。皆以里为主。内气正而后可以治表。虽莫急于内。表亦不可缓也。
表里虚实。而医之大分明矣。
鳌按。阳明虽亦有表病。其根总在胃家实。提纲是揭其根。非意不在表也。
【纲】仲景曰。伤寒四五日。脉沉而喘满。沉为里。而反发其汗。津液越出。大便为难。表虚
里实。久则谵语。
渴欲饮水。无表症者。白虎加人参汤主之。伤寒发汗已。身目为黄。所以然者。以寒湿在里。不
解故也。不可下。于寒湿中求之。阳明病。谵语。发潮热。脉滑而疾者。小承气汤主之。因与承气汤
一升。腹中转失气者。更服一升。若不转失气者。勿更与之。
明日不大便。脉反微涩者。里虚也。为难治。不可更与承气汤也。汗出谵语者。以有燥屎在胃中。
此为风也。须下之。过经乃可下之。下之若早。语言必乱。表虚里实故也。下之则愈。宜大承气汤。
【目】朱肱曰。伤寒始发热恶寒。今汗后不恶寒。但倍发热而躁。始脉浮大。今洪实。或沉细
数。始惺静。今狂语。此为胃实阳盛。再汗即死。须下之愈。
发汗后不敢再表者。为脉沉实耳。脉若浮者。须再汗也。发汗后不恶寒。只发热。脉沉实。或
狂语。此为胃实阳盛。即不可再汗。须下之。设令下后又不解。表里邪亦衰矣。阳明病。头疼。不
恶寒。反恶热。胃实故也。阳明气实。故攻头也。调胃承气汤。病患无表里症。发热。八九日。脉
虽浮数。宜大柴胡汤下之。大便秘。加大黄。
亦有始得病。便变阳盛之症。便须下。勿拘日数。
更有心胸连脐腹大段疰闷。腹中疼。坐卧不安。冒闷喘急极者。亦不候他症。便下之。凡大便
秘。妨闷。尚有表症者。亦须少少饮小承气汤解之。不可过多。令大泄也。失下。则气血不通。
四肢便厥。医人不知。反认是阴厥。复进热药。祸如反掌。不可不察也。
刘完素曰。凡里症。脉实而不浮。不恶风寒。身不疼。自汗谵语。不大便。或咽干腹满者。可
下不可汗也。宜三承气汤选用。又不问风寒暑湿。或表里症俱不见。但无表症而有可下者。三一承
气汤。此药虽峻攻。使无表热入里。而无结胸或痞之象也。或热结极深。而诸药数下。毕竟不能通
利以致将死者。宜大承气加甘遂一钱下之。病在里。脉沉细者。不问风寒暑湿。或表里症俱不见。
或内外诸邪所伤。有汗无汗。心腹痛满。谵妄烦躁。蓄热内盛。但是脉沉者。皆宜三一承气汤合解
毒汤下之。解毒调胃汤及承气汤。皆能泻大热。
魏荔彤曰。脉滑而疾。滑虽热盛于里之兆。而疾则热未成实之征。盖热初传入腑。或由浮而变
沉大。兼迟滞。方可攻下。今脉滑疾。是犹带数。热变而传入。尚未坚凝结聚。小承气汤消热调津。
足以已病矣。以下尤斟酌尽善之处。
鳌按。里症。有虚、有实、有寒、有湿、有热。其邪之入里者。皆为里症。不专指邪实阳盛一
边说也。
【纲】仲景曰。伤寒脉浮滑者。此表有热。里有邪。白虎汤主之。
【目】张介宾曰。阳邪在表则表热。阴邪在表则表寒。阳邪在里则里热。阴邪在里则里寒。邪
在半表半里间而无定处。则寒热往来。邪在表。则心腹不满。邪在里。则心腹胀痛。邪在表。则呻
吟不安。邪在里。则躁烦闷乱。邪在表。则能食。邪在里。则不食。邪在半表里。则不欲食。未至
于不能食也。邪在表。则不烦不呕。邪在里。则烦满而呕。凡初见心烦喜呕。及胸膈渐生痞闷者。
邪自表方传里也。不可攻下。凡病本在表。外症悉具。脉反沉微者。以元阳不足不能外达也。但当
救里。以助阳散阴为上策。
柯琴曰。此论脉而不及症。因有白虎汤症而推及其脉。只据脉而不审其症。虽表里并言。而重
在里热。所谓热结在里。表里俱热者也。
鳌按。发热无汗。口燥渴。心烦。舌上干燥。欲饮水数升。大便秘。皆白虎汤症也。皆应得此
脉。
【纲】仲景曰。伤寒脉滑而厥者。里有热也。白虎汤主之。
【目】鳌按。脉滑而厥者。阳厥也。所谓阳极似阴也。然必烦渴引饮。能食而大便难。乃为里
有热。
【提纲】张仲景说：阳明病的特征，是胃家实（胃肠邪热炽盛、燥屎内结的实证）。
【注解】朱肱说：不恶寒，反而恶热，手心及胁下出汗，胃中干燥结聚，出现潮热（定时发热），大便闭塞，小便正常，腹部胀满且气喘，或者胡言乱语，脉象浮而滑的，属于里证。所谓里证，就是内热。内热归属于阳明经。治疗应当用攻下法。
李氏说：里证，起初脉象浮大，现在则变为沉而数；起初神志清醒安静，现在则烦躁躁动；起初头痛、发热、恶寒，现在则不恶寒反而恶热，烦躁加倍加重，胸部连及脐腹满痛，胁下和手心自汗，导致胃干，粪便干燥秘结，小便赤涩，口干，发狂胡言乱语，掀开衣服被子，扬手掷足，六脉有力，这就是传经的热证。又说，如果是阳盛之体误用发汗法就会致死。也有初得病就出现这些症状的，不拘泥于患病天数的多少，应当及时通利大便。如果失于攻下，就会导致气血不通而发生厥逆。此外还有一种说法：如果完全是表证而里证毫无病态的，在解表时不要攻里；如果完全是里证而表证毫无病态的，在攻里时不要解表。如果表里证同时出现，或者表证多里证少，表证急迫里证缓和，则先治表证，后攻里证；或者里证多表证少，里证急迫表证缓和，则先攻里证，后救表证。还有表虚里实的，用药宜辛凉；里虚表实的，用药宜辛热。都以调理里气为主，体内正气恢复后才能治疗表证。虽然内证最为紧急，但表证也不可迟缓。表里虚实的情况，医生的诊疗原则就非常明确了。
沈金鳌按语：阳明病虽然也有表证，但其根本总在于胃家实。提纲是为了揭示其根本，并非意指不在表证方面考虑。
【提纲】张仲景说：伤寒四五日，脉象沉而气喘胸满。沉脉主里，却反而给他发汗，导致津液外越，大便因而困难，日久会出现胡言乱语。
口渴想喝水，没有表证的，用白虎加人参汤主治。伤寒发汗后，身体和眼睛发黄。之所以这样，是因为寒湿在里，不能解除的缘故。不可用攻下法，应当在寒湿证中寻找治疗方法。阳明病，胡言乱语，发潮热，脉象滑而疾速的，用小承气汤主治。因此给予小承气汤一升，如果腹中有肠鸣排气（转失气）的，再服一升；如果不排气的，不要再给他服用。
明天仍然不大便，脉象反而微弱涩滞的，这是里虚，难以治疗，不可再给承气汤了。出汗且胡言乱语的，是因为胃中有燥屎，这属于风邪所致。必须用攻下法。待经过本经之后才可以攻下。如果攻下过早，语言必定错乱，这是因为表虚里实的缘故。攻下后就会痊愈，宜用大承气汤。
【注解】朱肱说：伤寒开始发热恶寒，现在发汗后不恶寒，只是发热加倍且烦躁，起初脉象浮大，现在变为洪实，或者沉细数；起初神志清醒安静，现在胡言乱语，这是胃实阳盛。再发汗就会致死，必须用攻下法才能痊愈。
发汗后不敢再用解表法的，是因为脉象沉实。脉象如果浮的，需要再次发汗。发汗后不恶寒，只发热，脉象沉实，或者胡言乱语，这是胃实阳盛，就不可再发汗，必须攻下。假如攻下后病仍不解，说明表里邪气也都衰落了。阳明病，头痛，不恶寒，反恶热，是因为胃实。阳明经气实，所以攻击头部（引起头痛）。用调胃承气汤。患者没有表里证，发热，持续八九天，脉象虽然浮数，宜用大柴胡汤攻下。大便秘结的，加大黄。
更有心胸连及脐腹严重痞闷，腹中疼痛，坐卧不安，头昏闷喘急极度的，也不等待其他症状，直接攻下。凡是便秘，痞闷难受，尚有表证的，也须少量饮用小承气汤来解除它，不可过多，以免导致剧烈腹泻。如果失于攻下，则气血不通，四肢就会厥冷。医生不知道这一点，反而认为是阴厥，又进服热药，祸患如反掌之间发生，不可不仔细考察。
刘完素说：凡是里证，脉象实而不浮，不恶风寒，身体不疼，自汗胡言乱语，不大便，或者咽干腹满的，可以攻下不可发汗。宜在三承气汤中选择使用。又不问是风寒暑湿，或者表里证都不见，只要没有表证而有可下之症的，用三一承气汤。此药虽然峻猛攻下，但只要没有表热入里，就不会出现结胸或痞证的征象。或者热结极深，各种药物多次攻下，终究不能通利以致濒临死亡的，宜在大承气汤中加入甘遂一钱攻下。病在里，脉象沉细的，不问风寒暑湿，或者表里证都不见，或者被内外各种邪气所伤，有汗无汗，心腹痛满，胡言乱语烦躁，蓄热内盛，只要是脉沉的，都宜用三一承气汤合解毒汤攻下。解毒调胃汤及承气汤，都能泻除大热。
魏荔彤说：脉象滑而疾速，滑虽然是热盛于里的征兆，但疾速则是热尚未成实的迹象。大概热初入腑，或由浮脉变为沉大，兼带迟滞，才可以攻下。现在脉象滑疾，还是带有数象，热邪变化传入，尚未坚硬凝结聚积，用小承气汤消热调津，足以治愈疾病了。以下论述更是斟酌尽善之处。
沈金鳌按语：里证，有虚、有实、有寒、有湿、有热。那些邪气入里的，都称为里证，并不专指邪实阳盛一方面来说。
【提纲】张仲景说：伤寒脉象浮滑的，这是表有热，里有邪，用白虎汤主治。
【注解】张介宾说：阳邪在表则表热，阴邪在表则表寒；阳邪在里则里热，阴邪在里则里寒。邪在半表半里间而无定处，则寒热往来。邪在表，则心腹不满；邪在里，则心腹胀痛。邪在表，则呻吟不安；邪在里，则躁烦闷乱。邪在表，则能食；邪在里，则不食。邪在半表里，则不欲食，但未至于不能食。邪在表，则不烦不呕；邪在里，则烦满而呕。凡初见心烦喜呕，及胸膈逐渐产生痞闷的，是邪气从表方传入里。不可攻下。凡病本在表，外症具备，脉象反而沉微的，是因为元阳不足不能外达。只应当救里，以助阳散阴为上策。
柯琴说：这里论述脉象而未提及症状，是因为有白虎汤证而推及其脉象。只依据脉象而不审察症状，虽然表里并言，但重在里热，所谓“热结在里，表里俱热”。
沈金鳌按语：发热无汗，口燥渴，心烦，舌上干燥，想喝几升水，大便秘，都是白虎汤证。都应该出现这种脉象。
[Outline] Zhang Zhongjing stated: The defining characteristic of Yangming disease is "Wei Jia Shi" (Stomach-Fullness Excess, referring to an excess syndrome characterized by intense heat in the stomach and intestines and accumulation of dry stool).
[Commentary] Zhu Gong stated: Absence of aversion to cold, but presence of aversion to heat; sweating from the palms and hypochondrium; dryness and aggregation in the stomach; tidal fever (fever occurring at specific times); constipation; normal urination; abdominal fullness with panting; or delirium. If the pulse is floating and slippery, it is a Interior Syndrome. An Interior Syndrome refers to internal heat. Internal heat belongs to the Yangming channel. Treatment requires purgation.
Li stated: In an Interior Syndrome, initially the pulse is floating and large, but now it has become deep and rapid; initially the spirit is clear and quiet, but now it is irritable and restless; initially there is headache, fever, and aversion to cold, but now there is no aversion to cold, only aversion to heat; irritability is doubled; chest pain extending to the umbilicus and abdomen; spontaneous sweating from the hypochondrium and palms, leading to stomach dryness; dry and constipated stool; dark and scanty urine; dry mouth; mania and delirium; throwing off clothes and blankets; waving hands and kicking feet; all six pulses are forceful. This is a Heat Syndrome transmitted through the meridians. It is also said that if a patient with Yang Excess is mistakenly treated with diaphoresis (sweating method), death will ensue. There are cases where these symptoms appear immediately upon onset of illness, regardless of the number of days passed; timely purgation should be employed. Failure to purge will lead to obstruction of Qi and Blood, resulting in Jue (cold extremities/collapse). Furthermore, another view holds: If the condition is purely Exterior with no trace of Interior pathology, when resolving the Exterior, do not attack the Interior; if the condition is purely Interior with no trace of Exterior pathology, when attacking the Interior, do not resolve the Exterior. If both Exterior and Interior signs are present, or if Exterior signs predominate over Interior signs, or if the Exterior is urgent while the Interior is slow, treat the Exterior first, then attack the Interior. Conversely, if Interior signs predominate over Exterior signs, or if the Interior is urgent while the Exterior is slow, attack the Interior first, then rescue the Exterior. Additionally, for Exterior Deficiency and Interior Excess, medications should be pungent and cool; for Interior Deficiency and Exterior Excess, medications should be pungent and hot. In all cases, regulating the Interior is primary; only after the internal Qi is rectified can the Exterior be treated. Although internal conditions are most urgent, the Exterior cannot be neglected. The distinction between Exterior/Interior and Deficiency/Excess clarifies the physician's principles significantly.
Shen Jin'ao's Note: Although Yangming disease may also involve Exterior pathology, its root always lies in Wei Jia Shi (Stomach-Fullness Excess). The outline highlights this root, implying that consideration of the Exterior is not absent.
[Outline] Zhang Zhongjing stated: In Cold Damage (Shanghan) lasting four or five days, if the pulse is deep and accompanied by panting and chest fullness, the deep pulse indicates an Interior condition. However, if one mistakenly induces sweating, body fluids will leak out, making defecation difficult. Over time, this leads to delirium.
If there is thirst desire to drink water and no Exterior signs, Baihu Jia Renshen Tang (White Tiger Decoction plus Ginseng) is the primary treatment. After treating Cold Damage with sweating, if the body and eyes turn yellow, this occurs because cold-dampness remains in the Interior unresolved. Purgation is contraindicated; instead, seek treatment within the framework of cold-dampness syndromes. For Yangming disease presenting with delirium and tidal fever, and a pulse that is slippery and rapid, Xiao Chengqi Tang (Minor Order the Qi Decoction) is indicated. Administer one sheng of Xiao Chengqi Tang. If bowel sounds indicating gas passage (zhuan shiqi) occur, administer another sheng. If no gas passage occurs, do not administer more.
If the patient does not have a bowel movement the next day and the pulse becomes faint and choppy, this indicates Interior Deficiency. It is difficult to treat, and Chengqi decoctions should not be administered again. If sweating accompanies delirium, it is due to dry feces retained in the stomach, attributed to Wind pathogen. Purging is required. However, purging should only be performed after the pathogen has passed through the current meridian stage. Premature purging will cause confused speech due to Exterior Deficiency and Interior Excess. Proper purging will lead to recovery; Da Chengqi Tang (Major Order the Qi Decoction) is appropriate.
[Commentary] Zhu Gong stated: In early Cold Damage, fever and aversion to cold are present. After sweating, if aversion to cold ceases but fever intensifies with restlessness, and the pulse changes from floating-large to surging-forceful, or deep-thin-rapid; if the mental state changes from clear-quiet to manic-delirious, this indicates Stomach Excess and Yang Hyperactivity. Another dose of sweating will cause death; purging is necessary for recovery.
After sweating, if further exterior-resolving treatment is avoided, it is because the pulse is deep and forceful. If the pulse is floating, further sweating is required. If after sweating, there is no aversion to cold, only fever, with a deep-forceful pulse or delirium, this indicates Stomach Excess and Yang Hyperactivity; sweating is contraindicated, and purging is required. If the condition persists after purging, it implies that both Exterior and Interior pathogens have weakened. In Yangming disease, headache without aversion to cold but with aversion to heat is caused by Stomach Excess. Yangming Qi Excess attacks the head. Tiaowei Chengqi Tang (Regulate the Stomach Order the Qi Decoction) is used. If a patient presents with fever for eight or nine days without Exterior or Interior signs, and the pulse is floating and rapid, Da Chaihu Tang (Major Bupleurum Decoction) should be used to purge. Add Dahuang (Rhubarb Root) if constipation is present.
There are cases where Yang Excess symptoms appear immediately upon onset of illness; purging is required without adhering strictly to the number of days.
In cases of severe stagnation and oppression from the heart/chest down to the umbilicus and abdomen, abdominal pain, inability to sit or lie comfortably, dizziness, oppression, and extreme panting, purging should be administered immediately without waiting for other symptoms. For constipation with oppressive discomfort but still retaining some Exterior signs, small doses of Xiao Chengqi Tang should be given to relieve it, avoiding excessive dosage that causes severe diarrhea. Failure to purge leads to obstruction of Qi and Blood, resulting in cold extremities. Physicians who fail to recognize this may misdiagnose Yin Jue (Yin Collapse) and administer warming herbs, causing disaster swiftly. Careful examination is essential.
Liu Wansu stated: For Interior Syndromes, if the pulse is forceful but not floating, with no aversion to wind/cold, no body ache, spontaneous sweating, delirium, constipation, or dry throat/abdominal fullness, purging is indicated while sweating is contraindicated. Choose among the three Chengqi Decoctions. Regardless of whether the pathogen is Wind-Cold, Summerheat, or Dampness, or if neither Exterior nor Interior signs are obvious, provided there is no Exterior sign but indications for purging exist, Sanyi Chengqi Tang (Three-One Order the Qi Decoction) is suitable. Although this medicine is strongly purgative, as long as Exterior Heat does not enter the Interior, complications like Jie Xiong (Chest Binding) or Pi (Glomus) will not occur. In cases of extreme heat binding where multiple purgations fail to relieve the condition and the patient is near death, add Gansui (Kansui Root) to Da Chengqi Tang. For Interior diseases with deep-thin pulses, regardless of pathogen type or presence of Exterior/Interior signs, or injury from various internal/external pathogens, with or without sweating, with heart/abdominal pain/fullness, delirium, irritability, and accumulated internal heat, any case with a deep pulse should be treated with Sanyi Chengqi Tang combined with Jiedu Tang (Detoxification Decoction). Both Jiedu Tiaowei Tang and Chengqi Decoctions can purge intense heat.
Wei Litong stated: A slippery and rapid pulse indicates that while slipperiness suggests heat excess in the Interior, rapidity indicates that the heat has not yet formed solid excrement. Generally, when heat first enters the Fu organs, transforming from floating to deep-large with sluggishness, purging is appropriate. However, a slippery-rapid pulse suggests the heat is still moving rapidly and has not yet hardened into a mass. Xiao Chengqi Tang, which clears heat and regulates fluids, is sufficient. The subsequent discussion demonstrates careful deliberation.
Shen Jin'ao's Note: Interior Syndromes include Deficiency, Excess, Cold, Dampness, and Heat. Any pathogen entering the Interior constitutes an Interior Syndrome, not solely referring to Pathogenic Excess and Yang Hyperactivity.
[Outline] Zhang Zhongjing stated: In Cold Damage, if the pulse is floating and slippery, this indicates Heat on the Exterior and Pathogen in the Interior. Baihu Tang (White Tiger Decoction) is the primary treatment.
[Commentary] Zhang Jiabin stated: When Yang pathogens are on the Exterior, there is Exterior Heat; when Yin pathogens are on the Exterior, there is Exterior Cold. When Yang pathogens are in the Interior, there is Interior Heat; when Yin pathogens are in the Interior, there is Interior Cold. When pathogens are in the Half-Exterior/Half-Interior region without fixed location, alternating chills and fever occur. When pathogens are on the Exterior, the heart and abdomen are not full; when in the Interior, the heart and abdomen are painful and full. When on the Exterior, patients moan uncomfortably; when in the Interior, they are restless, irritable, and chaotic. When on the Exterior, appetite is preserved; when in the Interior, appetite is lost. In the Half-Exterior/Half-Interior, appetite is diminished but not completely absent. On the Exterior, there is no irritability or vomiting; in the Interior, there is irritability, fullness, and vomiting. Initial signs of heart irritability, preference for vomiting, and gradual epigastric glomus indicate transmission from Exterior to Interior. Purging is contraindicated. If the disease originates in the Exterior with complete external symptoms but the pulse is faint and micro, it is due to insufficiency of Primordial Yang failing to reach the exterior. Rescue the Interior by assisting Yang and dispersing Yin is the superior strategy.
Ke Qin stated: This section discusses the pulse without detailing symptoms, inferring the pulse from the Baihu Tang syndrome. Relying solely on the pulse without examining symptoms, although mentioning both Exterior and Interior, emphasizes Interior Heat, described as "Heat binding in the Interior, with Heat manifesting in both Exterior and Interior."
Shen Jin'ao's Note: Symptoms such as fever without sweat, dry mouth/thirst, heart irritability, dry tongue coating, desire to drink several liters of water, and constipation constitute Baihu Tang syndrome. These symptoms correspond to the aforementioned pulse.
[Outline] Zhang Zhongjing stated: In Cold Damage, if the pulse is slippery and accompanied by cold extremities (Jue), this indicates Heat in the Interior. Baihu Tang is the primary treatment.
[Commentary] Shen Jin'ao's Note: A slippery pulse with cold extremities indicates Yang Jue (Yang Collapse/Jue). This is known as "Extreme Yang resembling Yin." However, this diagnosis requires accompanying signs of irritability, thirst with desire to drink, ability to eat, and difficulty in defecation to confirm Interior Heat.