阴盛则结。故谓之结阴也。代。替代也。气血虚惫。真气衰微。力不支给。如欲求代也。动而中止句。与结脉
同。不能自还。因而复动者。前因中止之后。更来小数。随即有还者反动。
故可言自还。此则止而未即复动。若有不复再动之状。故谓之不能自还。又略久复动。故曰因而复动。本从缓
脉中来。为阴盛之脉。故谓之代阴也。上文虽云脉结代者。皆以炙甘草汤主之。然结为病脉。代为危候。故又
有得此脉者。必难治句。以申明其义。
案脉来动之动。周氏。柯氏。志聪。并以为阴阳相搏之动脉。非也。
脉经曰。代脉来数。中止不能自还。因而复动。脉结者生。代者死。
诊家正眼曰。结脉之止。一止即来。代脉之止。良久方至。内经。以代脉之见。为脏气衰微。脾气脱绝之
诊也。惟伤寒心悸。怀胎三月。或七情太过。或跌仆重伤。及风家痛家。俱不忌。代脉未可断其必死。
案方氏云。本条结代。下文无代。而有代阴。中间疑漏代一节。金鉴云。脉按之来缓。时一止至。名曰结
阴也。数语。文义不顺。且前论促结之脉已明。当是衍文。二书所论如是。要之此条实可疑尔。
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。（【原注】一云
络）是也。正阳阳明者。胃家实。是也。少阳阳明者。发汗利小便已。胃中躁烦实。大便难。是也。（玉函。
二少阳字。并作微阳。无烦实字。云。脾约。一作脾结。千金翼同。柯氏删此条。○案玉函。无烦实二字。似
甚允当。）
〔鉴〕阳明可下之证。不止于胃家实也。其纲有三。故又设问答。以明之也。太阳之邪。乘胃燥热。传
入阳明。谓之太阳阳明。不更衣无所苦。名脾约者。是也。太阳之邪。乘胃宿食。与燥热结。谓之正阳阳明。
不大便内实满痛。名胃家实者。是也。太阳之邪。已到少阳。法当和解。而反发汗利小便伤其津液。少阳之邪。
复乘胃燥。转属阳明。谓之少阳阳明。大便涩而难出。名大便难者。是也。〔钱〕太阳阳明者。太阳证犹未罢
者。若发汗。若下。若利小便。亡津液。而胃中干燥。大便难者。遂为脾约也。脾约以胃中之津液言。胃无津
液。脾气无以转输。故如穷约。而不能舒展也。所以有和胃润燥之法。正阳阳明。乃热邪宿垢。实满于胃。而
有荡涤之剂。少阳阳明。以少阳证。而发其汗。且利其小便。令胃中之津液干燥而烦。是少阳之邪。并归于胃。
故曰躁烦实。实则大便难也。其治当与太阳阳明之脾约不远矣。〔汪〕愚以大抵太阳阳明。宜桂枝加大黄汤。正
阳阳明。宜三承气汤选用。少阳阳明。宜大柴胡汤。此为不易之法。
阳明之为病。胃家实（【原注】一作寒。）是也。（玉函。以此条冠本篇之首。是也。成本。无是字。）
〔柯〕阳明为传化之腑。当更实更虚。食入胃实而肠虚。食下肠实而胃虚。若但实不虚。斯为阳明之病
根矣。胃实不是阳明病。而阳明之为病。悉从胃实上得来。故以胃家实。为阳明一经之总纲也。然致实之由。
最宜详审。有实于未病之先者。有实于得病之后者。有风寒外束。热不得越而实者。有妄汗吐下。重亡津液而
实者。有从本经热盛而实者。有从他经转属而实者。此只举其病根在实耳。案阳明提纲。与内经热论不同。热
论重在经络。病为在表。此经里证为主。里不和。即是阳明病。是二经所由分也。〔方〕实者。大便结为硬满。
而不得出也。作于迟早不同。非日数所可拘。
问曰。何缘得阳明病。答曰。太阳病。若发汗。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。（玉函。也上。有病字。千金翼。衣下。有而字。）
〔成〕本太阳病不解。因汗利小便亡津液。胃中干燥。太阳之邪入腑。转属阳明。古人登厕必更衣。不更
衣者。通为不大便。不更衣。则胃中物不得泄。故为内实。胃无津液。加之蓄热。大便则难。为阳明里实也。
〔汪〕或问。太阳病若下。则胃中之物已去。纵亡津液。胃中干燥。未必复成内实。余答云。方其太阳初病时。
下之不当。徒亡津液。胃中之物。依然不泄。必转属阳明。而成燥粪。故成内实之证。
总病论曰。更衣。即登厕也。非颜师古注汉书更衣之义。集验方。痔有更衣挺出。妨于更衣。更衣出清
血。故以知之。○集验方之说。今见外台五痔论。
问曰。阳明病外证云何。答曰。身热汗自出。不恶寒。反恶热也。（玉函。千金翼。反上。有但字。）
〔汪〕上言阳明病。系胃家内实。其外见证。从未言及。故此条又设为问答。夫身热与发热异。以其热在
肌肉之分。
非若发热之翕翕然。仅在皮肤以外也。汗自出者。胃中实热。则津液受其蒸迫。故其汗自出。与太阳中风。汗
虽出而不能透。故其出甚少。亦有异。此条病。则汗由内热蒸出。其出必多。而不能止也。不恶寒者。邪不在
表也。反恶热者。明其热在里也。伤寒当恶寒。故以恶热为反。夫恶热虽在内之证。其状必见于外。或扬手掷
足。迸去覆盖。势所必至。因外以征内。其为阳明胃实证无疑矣。尚论篇。以此条病。辨阳明中风证兼太阳。
若以其邪犹在于经。大误之极。大抵此条病。乃承气汤证。〔柯〕四证。是阳明外证之提纲。故胃中虚冷。亦
得称阳明病者。因其外证如此也。
案方氏魏氏金鉴。并以此条证。为阳明病由太阳中风而传入者。非也。
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。（发
热。玉函。作恶热。千金翼。发上。无不字。）
〔周〕案承上言。虽云反恶热。亦有得之一日而恶寒者。曰此尚在太阳居多耳。若至转阳明。未有不罢而
恶热者。〔程〕阳明恶寒终是带表。至于腑病。不唯不恶寒。且恶热。表罢不罢。须于此验之。故从反诘以辨出。
案无热恶寒发于阴。此云不发热而恶寒。恐不得为阳明内实之证。玉函作恶热。似极是。
问曰。恶寒何故自罢。答曰。阳明居中。主土也。万物所归。无所复传。始虽恶寒。二日自止。此为阳明
病也。（成本。玉函。千金翼。无主字。）
〔鉴〕此释上条阳明恶寒自罢之义。阳明属胃。居中。土也。土为万物所归。故邪热归胃。则无所复传。
亦万物归土之义。阳明初病一日。虽仍恶寒。是太阳之表未罢也。至二
日恶寒自止。则是太阳之邪。已悉归并阳明。此为阳明病也。〔柯〕太阳病八九日。尚有恶寒证。若少阳寒热往
来。三阴恶寒转甚。非发汗温中。何能自罢。惟阳明恶寒。未经表散。即能自止。与他经不同。始虽恶寒二句。
语意在阳明居中句上。夫知阳明之恶寒易止。便知阳明为病之本矣。胃为戊土。位处中州。表里寒热之邪。无
所不归。无所不化。皆从燥化而为实。实则无所复传。此胃家实。所以为阳明之病根也。
本太阳初得病时。发其汗。汗先出不彻。因转属阳明也。
〔方〕彻。除也。言汗发不对。病不除也。此言由发太阳汗不如法。致病入胃之大意。〔程〕汗出不透。
则邪未尽出。而辛热之药性反内留。而助动燥邪。因转属阳明。辨脉篇所云。汗多则热愈。汗少则便难。是也。
〔魏〕太阳初受风寒之时。发其汗。而汗终出不彻者。则在表之邪。亦可以日久变热于外。内郁之热日久。耗
津于内。汗难出未太过。而津已坐耗为多。其阳盛津亡。大便因硬。转属阳明。无二也。
案太阳中篇。第四十八条。二阳并病。太阳初得病时发其汗。汗先出不彻。因转属阳明。云云。正与此条同义。
伤寒发热。无汗。呕不能食。而反汗出 然者。是转属阳明也。（伤寒二字。玉函。千金翼。作病一字。）
〔成〕伤寒发热无汗。呕不能食者。太阳受病也。若反汗出 然者。太阳之邪。转属阳明也。经曰。阳
明病法多汗。〔钱〕寒邪在表。则发热无汗。寒邪在胸。则呕不能食。皆太阳寒伤营之表证也。〔程〕反汗出
然者。知大便已燥结于内。虽表证未罢。已是转属阳明也。 。连绵之意。俗云汗一身不了。又一身也。
伤寒三日。阳明脉大。
〔鉴〕伤寒一日太阳。二日阳明。三日少阳。乃内经言传经之次第。非必以日数拘也。此云三日阳明脉大者。
谓不兼太阳阳明之浮大。亦不兼少阳阳明之弦大。而正见正阳阳明之大脉也。盖由去表传里。邪热入胃。而成
内实之诊。故其脉象有如此者。
伤寒脉浮而缓。手足自温者。是为系在太阴。太阴者。身当发黄。若小便自利者。不能发黄。至七八日。
大便硬者。为阳明病也。
〔程〕脉浮而缓。是为表脉。然无头痛发热恶寒等外证。而只手足温。是邪不在表而在里。但入里有阴阳
之分。须以小便别之。小便不利者。湿蒸瘀热而发黄。以其人胃中原来无燥气也。小便自利者。胃干便硬而成
实。以其人胃中本来有燥气也。病虽成于八九日。而其始证。却脉浮而缓。手足自温。则实是太阴病转属来也。
既已转系阳明。其脉之浮缓者。转为沉大。不必言矣。而手足之温。不止温已也。必 然微汗出。盖阴证无汗。
汗出者。必阳气充于内。而后溢于外。其大便之实可知也。
案太阴篇云。伤寒脉浮而缓。手足自温者。系在太阴。太阴当发身黄。若小便自利者。不能发黄。至七八
日。虽暴烦下利日十余行。必自止。以脾家实腐秽当去故也。当与此条互考。
伤寒转系阳明者。其人 然微汗出也。（玉函。作 然。千金翼。转。作传。方本。喻本。魏本。亦作
然。程本。此条。接上为一条。）
〔汪〕此承上文。而申言之。上言伤寒系在太阴。要之既转而系于阳明。其人外证。不但小便利。当 然微
汗出。盖热蒸于内。汗润于外。汗虽微而腑实之证的矣。
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。
〔知〕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。表邪乘
虚内陷。而腹益满矣。兼以重亡津液。故小便难也。
案下条云。阳明病能食者。为中风。金鉴则云。阳明谓阳明里证。中风谓太阳表证。非也。
案此条。常器之云。可桂枝麻黄各半汤。又小柴胡汤。汪氏云。以葛根汤为主。加黄芩等凉药以治之。
金鉴云。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。
阳明病。若能食名中风。不能食名中寒。（二名字。玉函。千金翼。作为。）
〔程〕本因有热。则阳邪应之。阳化谷。故能食。就能食者。名之曰中风。其实乃瘀热在里证也。本因
有寒。则阴邪应之。阴不化谷。故不能食。就不能食者。名之曰中寒。其实乃胃中虚冷证也。〔柯〕此不特以
能食不能食别风寒。更以能食不能食。审胃家虚实也。要知风寒本一体。随人胃气而别。〔方〕名。犹言为也。
中寒。即伤寒之互词。
案程氏云。论中总无中寒字。独此处见之。犹云风与寒。自内得也。此解恐未允。
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。（成本。寒下。无者字。玉函。千金翼。无若字。食下。有而字。固。作坚。）
〔周〕此条。阳明中之变证。着眼只在中寒不能食句。此
系胃弱素有积饮之人。兼膀胱之气不化。故邪热虽入。未能实结。况小便不利。则水并大肠。故第手足汗出。
不若潮热之遍身 有汗。此欲作固瘕也。其大便始虽硬。后必溏者。岂非以胃中阳气向衰。不能蒸腐水谷。
尔时。急以理中温胃。尚恐不胜。况可误以寒下之药乎。仲景惧人于阳明证中。但知有下法。及有结未定俟日
而下之法。全不知有不可下反用温之法。故特揭此以为戒。〔程〕此之手足 然汗出者。小便不利所致。水溢
非胃蒸也。固瘕者。固而成癖。水气所结。其腹必有响声。特以结在胸。为水结胸。结在腹为固瘕。阴阳冷热
攸别。〔钱〕注家。以前人坚固积聚为谬。而大便初硬后溏。因成瘕泄。瘕泄。即溏泄也。久而不止。则为固
瘕。（案此喻注。后柯氏张氏志聪金鉴。并宗其说。）愚以固瘕二字推之。其为坚凝固结之寒积可知。岂可但
以溏泄久而不止为解。况初硬后溏。乃欲作固瘕之征。非谓已作固瘕。然后初硬后溏也。观欲作二字。及必字
之义。皆逆料之词。未可竟以为然也。
阳明病。初欲食。小便反不利。大便自调。其人骨节疼。翕翕如有热状。奄然发狂。 然汗出。而解者。
此水不胜谷气。与汗共并。脉紧则愈。（成本。无初字。不利。玉函。作不数。并。成本。玉函。作并。脉紧。
千金翼。作坚一字。喻本。程本。有初字。）
阴气过盛则脉气凝结，所以称为“结阴”。代脉的“代”，意为替代。当气血极度虚弱，真气衰微，脉搏无力接续，就像想要寻求替代一样。所谓“动而中止”，与结脉相同，但区别在于：结脉在停止后能自行恢复跳动（不能自还，因而复动），是指前一次中止之后，紧接着来了一组细小的搏动，随即恢复正常跳动，所以说能“自还”；而代脉则是停止后并不立即恢复跳动，似乎有不再跳动的样子，所以叫“不能自还”。虽然隔了一段时间才再次跳动，所以称为“因而复动”。代脉原本是从缓脉中发展而来的，属于阴气过盛的脉象，所以称为“代阴”。上文虽然说过出现结脉或代脉都用炙甘草汤主治，然而结脉是病脉，代脉则是危重的征候，所以又有“得到这种脉象的人，一定难以治疗”的说法，以此来阐明其中的道理。
按语：关于脉来跳动的“动”字，周氏、柯氏、志聪都认为是阴阳相搏产生的动脉，这是错误的。
《脉经》说：代脉跳动快速，中途停止且不能自行恢复，随后又跳动。脉象呈结脉的预后良好，呈代脉的预后不良甚至死亡。
《诊家正眼》说：结脉的停止，停一下随即就来；代脉的停止，要过很久才再来。《内经》认为见到代脉，是脏气衰微、脾气脱绝的诊断表现。只有在伤寒导致心悸、怀孕三个月、或者七情过度、跌打重伤，以及患风病或痛病的情况下，才不忌讳代脉，此时不能断定代脉必然主死。
按语：方氏说：本条提到结脉和代脉，下文没有代脉，却有“代阴”，中间怀疑遗漏了关于代脉的一节内容。《医宗金鉴》说：脉象按之来势缓慢，偶尔有一次停顿，叫做结阴。这几句话文义不通顺，而且前面论述促脉和结脉已经很明确了，这应该是衍文（多余的文字）。两本书的论述如此，总之这一条确实值得怀疑。
问：病有太阳阳明、正阳阳明、少阳阳明，这是什么意思？答：太阳阳明，是指脾约证。（【原注】一说为“络”）正阳阳明，是指胃家实证。少阳阳明，是指发汗或利小便后，胃中干燥烦躁且实，大便困难的情况。（《玉函经》中两个“少阳”字都作“微阳”，没有“烦实”二字，说“脾约”一作“脾结”，《千金翼方》相同。柯氏删去了这一条。○按《玉函经》，没有“烦实”二字，似乎非常恰当。）
〔鉴〕阳明病可以攻下的证候，不仅仅局限于胃家实。其纲领有三点，所以又设立问答来阐明它。太阳的邪气，趁着胃中的燥热，传入阳明，称为太阳阳明。如果不排便也没有痛苦，称为脾约，就是这种情况。太阳的邪气，趁着胃中宿食，与燥热结合，称为正阳阳明。如果不大便，腹部内部坚实胀满疼痛，称为胃家实，就是这种情况。太阳的邪气，已经传到少阳，按理应当和解，却反而发汗利小便损伤津液，少阳的邪气，又趁着胃中燥热，转属阳明，称为少阳阳明。大便涩滞难出，称为大便难，就是这种情况。
〔钱〕太阳阳明，是指太阳证还没有完全解除的情况。如果发汗、攻下或利小便，导致津液亡失，胃中干燥，大便困难，这就成为脾约。脾约是从胃中津液的角度来说的，胃中没有津液，脾气无法转输，所以像受穷困约束一样，不能舒展。因此有调和胃气、润燥的方法。正阳阳明，是热邪和宿垢实在地充满于胃，需要用荡涤的药剂。少阳阳明，是因为有少阳证，却发汗且利小便，使胃中津液干燥而烦躁，这是少阳的邪气并归于胃，所以说“躁烦实”。实就会导致大便困难。其治疗方法应该与太阳阳明的脾约不远。
〔汪〕我认为大抵上，太阳阳明宜用桂枝加大黄汤，正阳阳明宜选用三承气汤，少阳阳明宜用大柴胡汤，这是不变的方法。
阳明病的特征，是胃家实。（【原注】一作寒。）（《玉函经》将此条放在本篇之首，是正确的。宋成本，没有“是”字。）
〔柯〕阳明是传化之腑，应当虚实交替。食物进入胃，胃实而肠虚；食物下行到肠，肠实而胃虚。如果只实不虚，这就是阳明病的病根。胃实不是阳明病的全部，但阳明病的所有表现都从胃实而来，所以以“胃家实”作为阳明一经的总纲。然而导致实的原因，最应详细审察。有在未病之前就已经实的，有在得病之后才实的，有因风寒外束，热气不得宣泄而实的，有因误用汗、吐、下法，严重亡失津液而实的，有因本经热盛而实的，有从他经转属而实的。这里只举出其病根在于“实”罢了。按语：阳明提纲与《内经·热论》不同，《热论》重在经络，病在表；此经以里证为主，里不和就是阳明病，这是两经的区别所在。
〔方〕实，是指大便结聚成硬块且胀满，排不出来。发生的时间早晚不同，不能用日数来拘泥。
问：为什么会得阳明病？答：太阳病，如果发汗、攻下或利小便，这会亡失津液，导致胃中干燥，因而转属阳明。如果不排便，内部坚实且大便困难，这就名叫阳明病。（《玉函经》在“也”字上有“病”字。《千金翼方》在“衣”字下有“而”字。）
〔成〕原本是太阳病未解，因为发汗、利小便亡失津液，胃中干燥，太阳的邪气入腑，转属阳明。古人上厕所必须换衣服，不更衣就是指通称的不大便。不更衣，则胃中的东西得不到排泄，所以成为内实。胃中没有津液，加上蓄积的热，大便就困难，这是阳明里实证。
〔汪〕有人问：太阳病如果攻下，那么胃中的东西已经去除了，即使亡失津液，胃中干燥，未必会再次形成内实。我回答：在太阳病初起时，不当攻下而攻下，白白亡失津液，胃中的东西依然没有排泄，必定转属阳明，形成燥粪，所以成为内实证。
《总病论》说：更衣，就是上厕所的意思，不是颜师古注释《汉书》中更换衣服的意义。《集验方》说痔疮患者有大便时挺出，妨碍更衣，更衣时流出清血，所以知道是痔疮。○《集验方》的说法，现在见于《外台秘要》五痔论。
问：阳明病的外证是什么？答：身体发热，自然出汗，不恶寒，反而恶热。（《玉函经》、《千金翼方》在“反”字上有“但”字。）
〔汪〕上面说的阳明病，是指胃家内实，其外在见证，从未提及，所以这一条又设立问答。身热与发热不同，因为热在肌肉的分野，不像发热那样仅在皮肤表面。汗自出，是因为胃中实热，津液受到蒸迫，所以汗自然流出，这与太阳中风不同，太阳中风虽然出汗但不能透达，所以出的很少。这一条的病，汗是由内热蒸腾而出，出的量一定很多，而且不能停止。不恶寒，说明邪气不在表。反恶热，明确说明热在里。伤寒通常应当恶寒，所以以恶热为反常。恶热虽然是内部的证候，但其状态一定会表现在外部，比如扬手掷足，掀开覆盖物，这是势所必至的。通过外部表现来推断内部，这无疑是阳明胃实证。《尚论篇》用这一条病来辨别阳明中风证兼有太阳证，如果认为邪气还在经络，那是极大的错误。大抵这一条病，是承气汤证。
〔柯〕这四个证候，是阳明外证的提纲。所以胃中虚冷，也能称为阳明病，因为其外证如此。
按语：方氏、魏氏、《医宗金鉴》都认为这一条证候，是阳明病由太阳中风传入的，这是错误的。
问：有的病得病一天，不发热而恶寒，为什么呢？答：虽然得病一天，恶寒将会自行停止，随即就会自汗出而恶热。（发热，《玉函经》作恶热。《千金翼方》在“发”字上没有“不”字。）
〔周〕按上述所说，虽然说是反恶热，也有得病一天而恶寒的情况，说这大多还在太阳经。如果转到阳明，没有不罢除恶寒而转为恶热的。
〔程〕阳明恶寒终究带有表证的特点，至于腑病，不仅不恶寒，而且恶热。表证是否解除，必须从这里验证。所以用反问来辨析。
按语：无热恶寒发于阴，这里说不发热而恶寒，恐怕不能算是阳明内实证。《玉函经》作恶热，似乎非常正确。
问：恶寒为什么自行停止？答：阳明居中，属土，万物所归，无所复传。开始虽然恶寒，第二天自行停止，这就是阳明病。（宋成本、《玉函经》、《千金翼方》没有“主”字。）
〔鉴〕这是解释上一条阳明恶寒自停止的道理。阳明属胃，位居中央，属土。土是万物所归，所以邪热归胃，就无所复传，也是万物归土的意思。阳明初病第一天，虽然仍然恶寒，这是太阳的表证未解除。到了第二天恶寒自行停止，则是太阳的邪气已经完全归并到阳明，这就是阳明病。
〔柯〕太阳病八九天，还有恶寒证，如果是少阳寒热往来，三阴恶寒加重，不是发汗温中，怎么能自行停止。只有阳明恶寒，未经过表散，就能自行停止，与其他经不同。“始虽恶寒”两句，语意重点在“阳明居中”上。知道阳明的恶寒容易停止，就知道阳明为病的根本了。胃为戊土，位处中州，表里寒热的邪气，无所不归，无所不化，都从燥化而为实。实了就无所复传，这就是“胃家实”所以成为阳明病根的原因。
原本是太阳病刚得病的时候，发汗，汗先出不透彻，因而转属阳明。
〔方〕彻，是除尽的意思。说发汗不对，病不除尽。这是说由发太阳汗不如法，导致病入胃的大意。
〔程〕汗出不透，则邪气未尽出，而辛热药物的药性反而内留，助动燥邪，因而转属阳明。《辨脉篇》所说“汗多则热愈，汗少则便难”，就是这个意思。
〔魏〕太阳刚受风寒的时候，发汗，但汗始终出不透彻，那么在表的邪气，也可以日久在外部变热，内部郁积的热日久，耗伤内部的津液，汗难出且不过多，但津液已经坐耗很多。其阳盛津亡，大便因此变硬，转属阳明，没有第二种情况。
按语：太阳中篇第四十八条，“二阳并病，太阳初得病时发其汗，汗先出不彻，因转属阳明”，与此条意义相同。
伤寒发热，无汗，呕吐不能进食，反而汗出连绵不断的，是转属阳明。
〔成〕伤寒发热无汗，呕吐不能进食，是太阳受病。如果反而汗出连绵不断，是太阳的邪气转属阳明。经上说：阳明病法多汗。
〔钱〕寒邪在表，则发热无汗。寒邪在胸，则呕吐不能进食，都是太阳寒伤营的表证。
〔程〕反而汗出连绵不断，知道大便已经在内部燥结，虽然表证未解除，已经是转属阳明了。“ 然”是连绵的意思，俗语说汗一身不了，又一身也。
伤寒三日，阳明脉大。
〔鉴〕伤寒一日太阳，二日阳明，三日少阳，是《内经》传言经的次第，不一定拘泥于日数。这里说三日阳明脉大，是指不兼太阳阳明的浮大脉，也不兼少阳阳明的弦大脉，而正见正阳阳明的大脉。大概是因为由表传里，邪热入胃，而成内实之诊，所以脉象有这样的表现。
伤寒脉浮而缓，手足自然温暖的，这是病系在太阴。太阴病，身体应当发黄，如果小便自利，就不能发黄。到了七八天，大便硬的，就是阳明病。
〔程〕脉浮而缓，是表脉，但没有头痛、发热、恶寒等外证，只是手足温，说明邪气不在表而在里。但入里有阴阳之分，须以小便来辨别。小便不利的，湿蒸瘀热而发黄，因为此人胃中原来没有燥气。小便自利的，胃干便硬而成实，因为此人胃中本来有燥气。病虽然成于八九日，而其初始证候，却是脉浮而缓，手足自温，则实际上是太阴病转属而来的。既然已经转系阳明，其脉的浮缓者，转为沉大，不用说矣，而手足的温，不止于温而已，必定微微汗出。盖阴证无汗，汗出者，必定阳气充于内，而后溢于外，其大便的实可知也。
按语：太阴篇说：伤寒脉浮而缓，手足自温者，系在太阴。太阴当发身黄。若小便自利者，不能发黄。至七八日，虽暴烦下利日十余行，必自止，以脾家实腐秽当去故也。应当与此条互相参考。
伤寒转系阳明者，其人微微汗出。（《玉函经》作“濈然”，《千金翼方》“转”作“传”，方本、喻本、魏本，也作“濈然”，程本，此条接上为一条。）
〔汪〕这是承接上文，申述其意。上面说伤寒系在太阴，总之既然转而系于阳明，其人的外证，不但小便利，当濈然微汗出。盖热蒸于内，汗润于外，汗虽微而腑实之证确矣。
阳明中风，口苦咽干，腹满微喘，发热恶寒，脉浮而紧。
如果攻下，则腹满小便难。
〔知〕这是说阳明兼有太阳少阳表邪，即不可攻下。阳明中风，是热邪。腹满而喘，是热入里了。但喘而轻微，则未全入里。发热恶寒，脉浮而紧，都是太阳未除之证。口苦咽干，是有少阳的半表半里。如果误用下法，表邪乘虚内陷，而腹更满了。兼以重亡津液，所以小便难。
按语：下一条说：阳明病能食者，为中风。《医宗金鉴》则说：阳明谓阳明里证，中风谓太阳表证，这是错误的。
按语：此条，常器之说：可用桂枝麻黄各半汤，或小柴胡汤。汪氏说：以葛根汤为主，加黄芩等凉药来治它。《医宗金鉴》说：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。若只从里治，而遽然攻下，则表邪乘虚复陷，所以腹更满。里热愈竭其液，所以小便难。
阳明病，如果能食名叫中风，不能食名叫中寒。（“名”字，《玉函经》、《千金翼方》作“为”。）
〔程〕本因有热，则阳邪应之，阳化谷，故能食，就能食者，名之曰中风。其实乃是瘀热在里证。本因有寒，则阴邪应之，阴不化谷，故不能食，就不能食者，名之曰中寒。其实乃是胃中虚冷证。
〔柯〕这不仅以能食不能食来辨别风寒，更以能食不能食来审察胃家的虚实。要知道风寒本是一体，随人胃气而分别。
〔方〕名，犹言为也。中寒，即伤寒的互词。
按语：程氏说：《伤寒论》中总无中寒字，独此处见之，犹云风与寒，自内得也。此解恐未允。
阳明病如果中寒者，不能食，小便不利，手足濈然汗出，这是欲作固瘕，必定大便初硬后溏。之所以这样，是因为胃中冷，水谷不别故也。（宋成本，寒下，无“者”字。《玉函经》、《千金翼方》，无“若”字。食下，有“而”字。固，作坚。）
〔周〕此条，是阳明中的变证，着眼点只在中寒不能食句。这是胃弱素有积饮之人，兼膀胱之气不化，故邪热虽入，未能实结。况小便不利，则水并大肠，故第手足汗出，不像潮热之遍身濈然有汗。这是欲作固瘕。其大便始虽硬，后必溏者，难道不是因为胃中阳气向衰，不能蒸腐水谷吗？那时，急用理中温胃，尚恐不胜，何况可误用寒下之药呢？仲景惧人于阳明证中，但知有下法，及有结未定俟日而下之法，全不知有不可下反用温之法，故特揭此以为戒。
〔程〕此之手足濈然汗出者，是小便不利所致。水溢非胃蒸也。固瘕者，固而成癖，水气所结，其腹必有响声。特以结在胸，为水结胸，结在腹为固瘕，阴阳冷热攸别。
〔钱〕注家，以前人坚固积聚为谬，而大便初硬后溏，因成瘕泄。瘕泄，即溏泄也。久而不止，则为固瘕。（按此喻注，后柯氏、张氏、志聪、金鉴，并宗其说。）愚以固瘕二字推之，其为坚凝固结之寒积可知，岂可但以溏泄久而不止为解。况初硬后溏，乃欲作固瘕之征，非谓已作固瘕，然后初硬后溏也。观欲作二字，及必字之义，皆逆料之词，未可竟以为然也。
阳明病，初欲食，小便反不利，大便自调，其人骨节疼，翕翕如有热状，奄然发狂，濈然汗出，而解者，此水不胜谷气，与汗共并，脉紧则愈。（宋成本，无“初”字。不利，《玉函经》作不数。并，宋成本、《玉函经》作并。脉紧，《千金翼方》作坚一字。喻本、程本，有“初”字。）
Excessive Yin leads to knotting (Jie). Hence it is called "Knotting Yin" (Jie Yin). Dai pulse (Intermittent Pulse) refers to substitution. When Qi and Blood are extremely deficient and exhausted, and the True Qi is withered and weak, the force cannot sustain itself, as if seeking a substitute. The phrase "beating then stopping" is similar to the Jie pulse. However, in the case of the Dai pulse, it "cannot return on its own, hence beats again later." This means that after the previous pause, a few small beats come, followed by a return to normal beating, which allows one to say it "returns on its own." In contrast, the Dai pulse stops and does not immediately resume beating, appearing as if it will not beat again; thus it is called "unable to return on its own." Although it resumes beating after a slight delay, it is therefore described as "hence beats again later." The Dai pulse originates from the Huan (Slow) pulse and is a pulse of excessive Yin, hence called "Dai Yin." Although the preceding text states that both Jie and Dai pulses should be treated primarily with Zhigancao Tang (Prepared Licorice Decoction), Jie is a pathological pulse, whereas Dai is a critical sign. Therefore, there is also the statement that "those who obtain this pulse will certainly be difficult to treat," to elucidate this meaning.
Commentary: Regarding the "beat" in the description of the pulse coming and beating, Zhou Shi, Ke Shi, and Zhi Cong all considered it to be the Dong (Agitated) pulse caused by the struggle between Yin and Yang, which is incorrect.
The Mai Jing (Pulse Classic) states: "The Dai pulse beats rapidly, stops midway, cannot return on its own, and then beats again. A Jie pulse indicates survival; a Dai pulse indicates death."
Zhenjia Zhengyan (Correct Eyes of Pulse Diagnosis) states: "The pause of the Jie pulse comes immediately after one stop; the pause of the Dai pulse arrives only after a long time." The Nei Jing (Inner Canon) holds that the appearance of the Dai pulse is a diagnosis of衰竭 of Zang Qi and exhaustion of Pi Qi (Spleen Qi). However, in cases of palpitations due to Shanghan (Cold Damage), pregnancy at three months, excessive emotional agitation, severe falls or trauma, and in patients suffering from Wind diseases or Pain diseases, the Dai pulse is not taboo, and one cannot definitively judge it as fatal.
Commentary: Fang Shi says: This clause mentions Jie and Dai pulses, but the following text has no mention of Dai pulse, only "Dai Yin." It is suspected that a section regarding the Dai pulse was omitted in the middle. Yizong Jinjian (Golden Mirror of Medical Tradition) states: "When pressing the pulse, it comes slowly and occasionally stops once, this is called Knotting Yin." These sentences do not flow logically in meaning, and since the Cu (Rapid-interrupted) and Jie pulses were already clearly discussed previously, this must be an interpolations (derivative text). Both books discuss it thus; ultimately, this clause is indeed questionable.
Question: There are Taiyang Yangming, Zhengyang Yangming, and Shaoyang Yangming. What do these mean? Answer: Taiyang Yangming refers to Pi Yue (Spleen Constraint). [Original Note: Alternatively read as 'Luo'.] Zhengyang Yangming refers to Wei Jia Shi (Stomach House Excess). Shaoyang Yangming refers to the condition where, after sweating or promoting urination, the Stomach becomes dry, restless, excess, and defecation is difficult. [Yuhan Jing reads both instances of 'Shaoyang' as 'Wei Yang', omits 'Fan Shi', and states 'Pi Yue' is alternatively 'Pi Jie'; Qianjin Yi Fang agrees. Ke Shi deleted this clause. ○ According to Yuhan Jing, omitting 'Fan Shi' seems very appropriate.]
[Jian]: The indications for purgative therapy in Yangming disease are not limited to Wei Jia Shi. Its principles have three aspects, so questions and answers are set up to clarify them. When Taiyang pathogenic factors take advantage of Stomach dryness-heat and transmit to Yangming, it is called Taiyang Yangming. If one does not change clothes (defecate) and feels no discomfort, it is called Pi Yue, which is this situation. When Taiyang pathogenic factors take advantage of retained food in the Stomach and combine with dryness-heat, it is called Zhengyang Yangming. If there is constipation, internal fullness, hardness, and pain, it is called Wei Jia Shi, which is this situation. When Taiyang pathogenic factors have reached Shaoyang, reconciliation should be the method, but instead, sweating and diuresis damage fluids. Shaoyang pathogenic factors then take advantage of Stomach dryness and transfer to Yangming, called Shaoyang Yangming. If stool is astringent and difficult to pass, it is called Da Bian Nan (Difficult Defecation), which is this situation.
[Qian]: Taiyang Yangming occurs when Taiyang symptoms have not yet ceased. If sweating, purging, or diuresis causes fluid loss and Stomach dryness leading to difficult defecation, it becomes Pi Yue. Pi Yue refers to the perspective of Stomach fluids; without fluids, Pi Qi (Spleen Qi) cannot transport, thus being constrained like poverty, unable to expand. Therefore, methods to harmonize the Stomach and moisten dryness are used. Zhengyang Yangming involves heat pathogens and retained filth filling the Stomach, requiring purgatives to scour and wash. Shaoyang Yangming arises because, having Shaoyang symptoms, one sweats and promotes urination, drying Stomach fluids and causing restlessness; Shaoyang pathogenic factors merge into the Stomach, hence described as 'Zao Fan Shi' (Dryness, Restlessness, Excess). Excess leads to difficult defecation. Its treatment should not differ much from Taiyang Yangming's Pi Yue.
[Wang]: Generally, Taiyang Yangming is suitable for Guizhi Jiadahuang Tang (Cinnamon Twig Decoction plus Rhubarb), Zhengyang Yangming is suitable for selecting among the Three Chengqi Decoctions, and Shaoyang Yangming is suitable for Dachaihu Tang (Greater Bupleurum Decoction). This is an unchanging method.
Yangming disease is characterized by Wei Jia Shi (Stomach House Excess). [Original Note: Alternatively Cold.] [Yuhan Jing places this clause at the beginning of this chapter, which is correct. Song Ben edition lacks the character 'Shi'.]
[Ke]: Yangming is a fu organ of transmission and transformation; it should alternate between fullness and emptiness. When food enters the Stomach, the Stomach is full and the Intestines empty; when food moves to the Intestines, the Intestines are full and the Stomach empty. If it is only full and never empty, this is the root cause of Yangming disease. Stomach fullness itself is not Yangming disease, but all manifestations of Yangming disease arise from Stomach fullness. Thus, 'Wei Jia Shi' serves as the general outline for the Yangming channel. However, the causes of fullness require careful examination. Fullness may exist before illness onset or develop after. It can result from external wind-cold binding, preventing heat dispersion; from mistaken sweating, vomiting, or purging causing severe fluid loss; from excessive heat in the primary channel; or from transmission from other channels. Here, only the root cause of 'fullness' is mentioned. Commentary: The Yangming outline differs from Re Lun (Heat Treatise) in Nei Jing. Re Lun focuses on meridians and exterior pathology; this text focuses on interior pathology. Interior disharmony constitutes Yangming disease; this is the distinction between the two.
[Fang]: 'Shi' (Excess) refers to hard, full stools that cannot be passed. The timing varies and cannot be restricted by days.
Question: How does one contract Yangming disease? Answer: In Taiyang disease, if sweating, purging, or diuresis causes fluid loss and Stomach dryness, the condition transfers to Yangming. If one does not defecate, has internal excess, and difficult stools, this is named Yangming disease. [Yuhan Jing adds 'Bing' (disease) after 'Ye'. Qianjin Yi Fang adds 'Er' (and) after 'Yi'.]
[Cheng]: Originally Taiyang disease unresolved, due to sweating and diuresis causing fluid loss and Stomach dryness, Taiyang pathogens enter the Fu organs and transfer to Yangming. Ancients changed clothes when using the toilet; 'bu geng yi' (not changing clothes) generally means constipation. Not defecating means stomach contents cannot be discharged, resulting in internal excess. Without Stomach fluids and with accumulated heat, stools become difficult, constituting Yangming interior excess syndrome.
[Wang]: One might ask: If Taiyang disease is purged, stomach contents are removed; even with fluid loss and dryness, internal excess shouldn't reform. I answer: If inappropriate purging is done during early Taiyang disease, fluids are lost while stomach contents remain undischarged. They inevitably transfer to Yangming, forming dry feces, thus creating internal excess.
Zong Bing Lun (General Discussion of Diseases) states: 'Geng yi' (changing clothes) means going to the toilet, not the meaning of changing clothes in Yan Shigu's commentary on Han Shu. Ji Yan Fang states: Hemorrhoids may protrude during defecation, hindering 'geng yi'; clear blood flows out during 'geng yi', allowing identification. ○ Ji Yan Fang's view is found in Wai Tai Mi Yao's discussion on hemorrhoids.
Question: What are the external manifestations of Yangming disease? Answer: Body heat, spontaneous sweating, aversion to cold ceases, and aversion to heat increases. [Yuhan Jing and Qianjin Yi Fang add 'Dan' (only) before 'Fan' (reverse/instead).]
[Wang]: The previous mention of Yangming disease referred to internal Stomach excess; external signs were not discussed. Hence this clause sets up Q&A. 'Shen re' (body heat) differs from 'Fa re' (fever); the heat is in the muscle layer, unlike 'Fe re' (floating fever) which is merely on the skin. Spontaneous sweating occurs because Stomach excess-heat steams and forces fluids out. This differs from Taiyang Wind Strike, where sweat is scanty and fails to penetrate. In this condition, sweat is steamed from internal heat, abundant and unstoppable. 'Bu e han' (no aversion to cold) indicates pathogens are not in the exterior. 'Fan e re' (instead aversion to heat) confirms heat is in the interior. Shanghan typically involves aversion to cold; thus aversion to heat is 'fan' (contrary). Although aversion to heat is an internal sign, its state manifests externally, such as tossing hands and feet or removing coverings. Inferring internal from external, this is undoubtedly Yangming Stomach excess syndrome. Shanglun Pian uses this clause to distinguish Yangming Wind Strike combined with Taiyang; believing the pathogen remains in the meridian is a major error. Generally, this clause describes a Chengqi Tang syndrome.
[Ke]: These four signs are the outline of Yangming external manifestations. Therefore, even Stomach deficiency-cold can be called Yangming disease because its external signs resemble this.
Commentary: Fang Shi, Wei Shi, and Yizong Jinjian believe this clause describes Yangming disease transmitted from Taiyang Wind Strike, which is incorrect.
Question: Some diseases present on the first day with no fever but aversion to cold. Why? Answer: Although presenting on the first day, aversion to cold will cease spontaneously, followed by spontaneous sweating and aversion to heat. [Fever, Yuhan Jing reads 'Aversion to Heat'. Qianjin Yi Fang omits 'Bu' (no) before 'Fa' (emit).]
[Zhou]: Based on the above, although it says 'aversion to heat', there are cases of aversion to cold on the first day. This mostly remains in Taiyang. Once transferring to Yangming, aversion to cold ceases and aversion to heat begins.
[Cheng]: Yangming aversion to cold retains exterior characteristics. Once it becomes Fu organ disease, there is not only no aversion to cold but also aversion to heat. Whether the exterior resolves depends on verifying this. Hence the rhetorical question clarifies this.
Commentary: 'No fever and aversion to cold' arises from Yin. Saying 'no fever but aversion to cold' here likely does not constitute Yangming internal excess. Yuhan Jing reading 'Aversion to Heat' seems very correct.
Question: Why does aversion to cold cease spontaneously? Answer: Yangming resides in the center and governs Earth; it is the destination of all things and has nowhere further to transmit. Initially there may be aversion to cold, but it stops by the second day; this is Yangming disease. [Song Ben, Yuhan Jing, Qianjin Yi Fang omit 'Zhu' (govern).]
[Jian]: This explains why Yangming aversion to cold ceases. Yangming belongs to the Stomach, resides in the center, and corresponds to Earth. Earth is the destination of all things; thus, when pathogenic heat returns to the Stomach, it has nowhere else to transmit, mirroring the concept of all things returning to Earth. On the first day of Yangming onset, aversion to cold persists because Taiyang exterior is not yet resolved. By the second day, aversion to cold ceases spontaneously, indicating Taiyang pathogens have fully merged into Yangming; this is Yangming disease.
[Ke]: Taiyang disease lasting eight or nine days may still have aversion to cold. Shaoyang features alternating chills and fever; Yin channels have worsening chills. None resolve spontaneously without sweating or warming. Only Yangming aversion to cold resolves spontaneously without prior exterior resolution, differing from other channels. The phrase 'initially aversion to cold' emphasizes 'Yangming resides in the center.' Knowing Yangming aversion to cold stops easily reveals the essence of Yangming disease. The Stomach is Wu Earth, located in the Central Region. Exterior, interior, cold, and heat pathogens all gather here and transform. All transform via dryness into excess. Once excess, there is no further transmission. This is why 'Wei Jia Shi' is the root of Yangming disease.
When Taiyang disease is first contracted, if sweating is induced but the sweat is incomplete ('bu che'), the condition transfers to Yangming.
[Fang]: 'Che' means removal/completion. It means improper sweating fails to remove the disease. This describes how improper sweating in Taiyang leads to disease entering the Stomach.
[Cheng]: Incomplete sweating leaves pathogens unresolved, and acrid-warm drug properties remain inside, aiding dryness pathogens, thus transferring to Yangming. As stated in Bian Mai Pian: 'Excessive sweating increases heat; insufficient sweating leads to difficult defecation.'
[Wei]: When Taiyang first contracts wind-cold, if sweating is induced but remains incomplete, exterior pathogens may turn hot over time externally, while internal郁 heat consumes fluids internally. Sweat is difficult to produce and not excessive, yet fluids are significantly depleted. Yang excess and fluid depletion lead to hard stools, transferring to Yangming without exception.
Commentary: Taiyang Middle Chapter, Clause 48, discusses 'Two-Yang concurrent disease... initial sweating incomplete... transfers to Yangming,' which has the same meaning as this clause.
Shanghan (Cold Damage) presents with fever, no sweat, vomiting, inability to eat, but instead continuous sweating; this indicates transfer to Yangming. [Shanghan, Yuhan Jing and Qianjin Yi Fang read 'Bing' (disease).]
[Cheng]: Fever, no sweat, vomiting, and inability to eat indicate Taiyang involvement. Continuous sweating indicates Taiyang pathogens transferring to Yangming. The Classics state: Yangming disease typically involves profuse sweating.
[Qian]: Cold pathogens in the exterior cause fever and no sweat. Cold pathogens in the chest cause vomiting and inability to eat. These are all Taiyang cold damaging Ying (Nutrient) exterior signs.
[Cheng]: Continuous sweating indicates dry feces have formed internally in the intestines. Even if exterior signs persist, it has transferred to Yangming. 'Ji ran' implies continuity; colloquially, sweat covers one part of the body, then another.
On the third day of Shanghan, the Yangming pulse is large.
[Jian]: Day 1 Taiyang, Day 2 Yangming, Day 3 Shaoyang represents the sequence of channel transmission in Nei Jing, not a rigid daily count. 'Third day Yangming pulse is large' means it is neither the floating-large pulse of Taiyang Yangming nor the string-large pulse of Shaoyang Yangming, but specifically the large pulse of Zhengyang Yangming. This results from pathogens moving from exterior to interior, heat entering the Stomach, and forming internal excess, hence the pulse appears thus.
In Shanghan, if the pulse is floating and slow, and hands and feet are naturally warm, the disease is tied to Taiyin. Taiyin disease typically presents with jaundice. If urination is free, jaundice will not occur. By the seventh or eighth day, if stools become hard, it is Yangming disease.
[Cheng]: Floating and slow pulse indicates exterior, but without headache, fever, or aversion to cold, only hand-foot warmth suggests pathogens are interior, not exterior. Interior transmission has Yin-Yang distinctions, distinguished by urination. If urination is obstructed, dampness steams turbid heat causing jaundice, because the person originally lacked Stomach dryness. If urination is free, Stomach dryness and hard stools form excess, because the person originally had Stomach dryness. Though manifesting on days 7-8, the initial signs of floating-slow pulse and hand-foot warmth indicate transmission from Taiyin. Having transferred to Yangming, the floating-slow pulse transforms to deep-large, and hand-foot warmth extends to slight sweating. Yin syndromes lack sweat; sweating indicates sufficient Yang Qi internally overflowing externally, confirming intestinal excess.
Commentary: Taiyin Chapter states: 'Shanghan floating-slow pulse, hand-foot warmth, tied to Taiyin. Taiyin should develop jaundice. If urination is free, no jaundice. By days 7-8, even if sudden irritability and diarrhea occur ten-plus times daily, it will stop spontaneously because Spleen excess expels rotting filth.' This should be cross-referenced with this clause.
When Shanghan transfers to tie with Yangming, the person exhibits slight continuous sweating. [Yuhan Jing reads 'Ji ran'. Qianjin Yi Fang reads 'Zhuan' as 'Chuan'. Fang Ben, Yu Ben, Wei Ben also read 'Ji ran'. Cheng Ben connects this to the previous clause.]
[Wang]: This elaborates on the previous text. Previously, Shanghan tied to Taiyin; now transferring to Yangming, external signs include not just free urination but also slight continuous sweating. Heat steams internally, moisture moistens externally. Though sweat is slight, Fu organ excess is confirmed.
Yangming Fengzhong (Wind Strike), with bitter taste, dry throat, abdominal fullness, slight panting, fever, aversion to cold, floating-tight pulse.
If purged, abdominal fullness and difficult urination result.
[Zhi]: This states that Yangming combined with Taiyang and Shaoyang exterior pathogens cannot be purged. Yangming Fengzhong is heat pathogen. Abdominal fullness and panting indicate heat entering the interior. But slight panting means not fully interior. Fever, aversion to cold, floating-tight pulse are Taiyang signs not yet resolved. Bitter taste and dry throat indicate Shaoyang half-exterior/half-interior. Mistaken purging allows exterior pathogens to sink inward due to deficiency, increasing abdominal fullness. Combined with severe fluid loss, urination becomes difficult.
Commentary: Next clause states: 'Yangming disease, able to eat is Fengzhong.' Yizong Jinjian claims: Yangming refers to Yangming interior syndrome, Fengzhong refers to Taiyang exterior syndrome, which is incorrect.
Commentary: For this clause, Chang Qizhi suggests Guizhi Mahuang Ge Ban Tang or Xiaochaihu Tang. Wang Shi suggests Gegen Tang as main formula, adding Huangqin and cooling herbs. Yizong Jinjian states: If Taiyang Yangming predominates, use Guizhi Jiadahuang Tang to resolve both; if Shaoyang Yangming predominates, use Dachaihu Tang to harmonize and purge. Treating only the interior and hastily purging allows exterior pathogens to sink, increasing fullness. Interior heat depletes fluids, causing difficult urination.
Yangming disease, if able to eat is named Fengzhong (Wind Strike); if unable to eat is named Zhonghan (Cold Strike). ['Ming' (named), Yuhan Jing and Qianjin Yi Fang read 'Wei' (is).]
[Cheng]: Originally having heat, Yang pathogens respond; Yang transforms grain, hence able to eat. Able to eat is named Fengzhong. Actually, it is stagnant heat in the interior. Originally having cold, Yin pathogens respond; Yin does not transform grain, hence unable to eat. Unable to eat is named Zhonghan. Actually, it is Stomach deficiency-cold.
[Ke]: This distinguishes not only wind vs. cold by eating ability, but also assesses Stomach deficiency vs. excess by eating ability. Know that wind and cold are essentially one entity, differentiated by the person's Stomach Qi.
[Fang]: 'Ming' means 'is'. Zhonghan is a synonym for Shanghan.
Commentary: Cheng Shi says: The Treatise rarely uses 'Zhonghan', appearing only here, implying wind and cold originate internally. This interpretation is likely unsatisfactory.
In Yangming disease, if contracting cold, one cannot eat, urination is obstructed, and hands and feet exhibit continuous sweating. This desires to form Gu Jia (Solid Mass), and stools will initially be hard then loose. The reason is Stomach cold failing to separate water and grain. [Song Ben omits 'Zhe' after 'Han'. Yuhan Jing and Qianjin Yi Fang omit 'Ruo' (if). Qianjin Yi Fang adds 'Er' (and) after 'Shi'. 'Gu' reads 'Jian' (hard).]
[Zhou]: This clause is a variant syndrome in Yangming. The key point is 'Zhonghan unable to eat.' This applies to persons with weak Stomach and chronic fluid retention, combined with Bladder Qi failure to transform. Thus, although heat pathogens enter, they do not form solid excess. Moreover, with obstructed urination, water merges into the Large Intestine, causing only hand-foot sweating, unlike tidal fever with whole-body continuous sweating. This desires to form Gu Jia. Stools starting hard then becoming loose occur because Stomach Yang Qi is declining, unable to steam and rot water and grain. At this time, urgently using Lizhong Tang to warm the Stomach might still be insufficient, let alone mistakenly using cold purgatives. Zhang Zhongjing fears people only know purgative methods in Yangming syndromes, including waiting for fixed knots to purge, lacking knowledge of non-purgative warming methods. Thus, he highlights this as a warning.
[Cheng]: Hand-foot continuous sweating here is caused by obstructed urination. Water overflows, not steamed by Stomach. Gu Jia means solidified masses formed by water qi accumulation, likely causing abdominal rumbling. Chest binding is Water Binding Chest; abdominal binding is Gu Jia, distinguishing Yin/Yang and Cold/Heat.
[Qian]: Commentators consider previous interpretations of solid accumulations erroneous. Hard-then-loose stools form Xia Xie (Mass Diarrhea), which is loose diarrhea. Prolonged unresolved loose diarrhea becomes Gu Jia. (Commentator Yu's view was adopted by Ke Shi, Zhang Shi, Zhi Cong, and Yizong Jinjian.) I deduce from 'Gu Jia' that it indicates solidified cold accumulation. How can it be interpreted merely as prolonged loose diarrhea? Furthermore, hard-then-loose stools are signs of *desiring* to form Gu Jia, not that Gu Jia has already formed. The words 'yu zuo' (desires to form) and 'bi' (must) imply prediction, not certainty.
In Yangming disease, initially desiring to eat, urination is unexpectedly obstructed, stools are self-regulated, the person experiences bone joint pain, feels slightly hot, suddenly becomes delirious, sweats continuously, and resolves. This is because Water cannot overcome Grain Qi; they combine with sweat. If the pulse is tight, recovery occurs. [Song Ben omits 'Chu' (initial). Yuhan Jing reads 'Bu Li' as 'Bu Shu' (not frequent). Song Ben and Yuhan Jing read 'Bing' as 'Bing'. Qianjin Yi Fang reads 'Mai Jin' (pulse tight) as 'Jian' (hard). Yu Ben and Cheng Ben include 'Chu'.]