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，只大便难，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 也。《素问》曰∶阳明主肉，其脉侠鼻络于目。
《灵枢》曰∶足阳明之正，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 ，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，兼以大便硬而难，身有微热者，则胃实已真，故
曰∶此为实也，急下之，宜大承气汤。
病患小便不利，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，大盒饭硬，小便不利，大便不硬。是知硬不硬，不在热
不热，而在液之竭与不竭也。今小便不利，而大便乍难乍难易者，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，此皆一派热结便硬之征。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，必以手按之脐腹有硬块，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，则有燥屎已的。自宜下逐里实为急，安可复以
小便利、屎定硬，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。成无己云∶小便利则大便硬，此有燥屎乃理之常。今病患小便不利，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。
病患不大便五六日，绕脐痛，烦躁，发作有时者，此有燥屎，故使不大便也。
【注】病患不大便五六日，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∶病患，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
矢气之一端也。病患虽不大便五六日，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，烦不解面腹满痛，此必
有燥屎未尽而然。盖宿食因热复为之结硬也。
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。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 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。今虽只有恶热、不恶
寒、大便硬之阳明证，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。太阳以风寒持其营卫，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，心愦愦反谵语；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 ，舌上苔者，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，故谵语烦躁，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 ，舌上生苔，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，五苓散证。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，
以五苓散加石膏、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。舌上苔，则膈热甚，故涌以栀子豉而彻去其膈热，
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。
猪苓汤方
猪苓（去皮） 茯苓 阿胶 泽泻 滑石（碎，各一两）
上五味，以水四升，先煮四味，取二升，去滓，纳阿胶烊消，温服七合，日三服。
【集解】赵羽皇曰∶仲景制猪苓一汤，以行阳明、少阴二经水热。然其旨全在益阴，不
专利水。盖伤寒表虚，最忌亡阳，而里虚又患亡阴。亡阴者，亡肾中之阴，与胃家之津
液也。故阴虚之人，不但大便不可轻动，即小水亦忌下通，倘阴虚过于渗利，则津液反
致耗竭。方中阿胶质膏，养阴而滋燥；滑石性滑，去热而利水；佐以二苓之渗泻，既疏
浊热而不留其壅瘀，亦润真阴而不苦其枯燥，是利水而不伤阴之善剂也。故利水之法，于
太阳用五苓者，以太阳职司寒水，故加桂以温之，是暖肾以行水也；于阳明、少阴用猪
苓者，以二经两关津液，特用阿胶、滑石以润之，是滋养无形以行有形也。利水虽同，寒
温迥别，惟明者知之。
脉浮而大，心下反硬，有热。属脏者攻之，不令发汗；属腑者不令溲数。溲数则大
便硬，汗多则热愈，汗少则便难，脉迟尚未可攻。
【注】属脏，谓属里也；属腑，谓属表也。溲，谓小便也。脉浮而大，太阳、阳明脉也。
浮属表，大属里，今太阳脉浮之表未解，而心下反硬，阳明之里又急，权乎汗、下可也。
设里有热实，攻之无疑，不须先汗以解外也。如无热实，而有脉浮之表，不但不令攻之，即
小便不利，亦不令利小便，仍当解外也。盖恐溲数汗多，亡其津液，致大便硬，则热愈
实也。若汗少脉迟，即有便硬，里尚未实，亦未可攻也。
【集注】王肯堂曰∶论言脉浮大，反发汗反下之为逆。此以心下硬有热，知传邪入里，
故舍脉而从证也。大便则许攻之，小便则不许利何也？曰∶攻大便则内热除，利小便则津液伤也。
林澜曰∶心下硬与腹硬满不同。腹硬邪已结聚成实，此但在心下，自与非下不可者
异矣。腑与脏对举而言，见一为入里，一犹属表之义也。
阳明病，脉迟，食难用饱，饱则微烦头眩，必小便难，此欲作谷疽。虽下之，腹满
如故，所以然者，脉迟故也。
【注】阳明病不更衣，已食如饥，食辄腹满脉数者，则为胃热，可下证也。今脉迟，迟
为中寒，中寒不能化谷，所以虽饥欲食，食难用饱，饱则烦闷，是健运失度也。清者阻
于上升，故头眩，浊者阻于下降，故小便难。食郁湿瘀，此欲作谷疽之征，非阳明热湿，腹
满发黄者比。虽下之腹满暂减，顷复如故，所以然者，脉迟中寒故也。
【集注】方有执曰∶迟为寒不化谷，故食难用饱。湿郁而蒸，气逆而不下行，故微烦
头眩，小便难也，疽黄病也。谷疽，水谷之湿蒸发而身黄也。
张璐曰∶下之腹满如故，盖腹满已是邪隐，脉迟则胃不实，徒下其糟粕，病既不除，
而反害之耳！夫阳明证本当下，阳明而至腹痛，尤当急下。独此一证下之，腹满必如故
火气上熏于眼部，导致瞳孔视物模糊不清，这就是所谓的“不了了”。这是热邪内结、神志昏蒙的初期表现，属于危险凶险的证候。虽然体表没有明显的阳证发热，仅有身体微热；体内没有腹部胀满疼痛，仅有大便困难，这也属于热实之证，所以说：“这是实证。”应当紧急使用大承气汤攻下，以泻除阳热、拯救阴液，保全尚未枯竭的阴精。所谓“睛不和”，是指眼球转动不灵活。
【集注】方有执说：了了，就是清楚明白的意思。《素问》说：阳明经主司肌肉，其经脉夹鼻旁联络于目。《灵枢》说：足阳明经的正脉，上行沿咽喉出于口，回绕联系目系，与阳明经相合。又说：足阳明经的筋，其分支，上行颈部夹口旁会合于面部，向下结聚于鼻旁，向上与太阳经相合。太阳经是眼睑的上纲（主管），阳明经是眼睑的下纲（主管），所以出现眼睛视物模糊不清、眼球转动不灵活，可以判断为胃家实热。需要急下的原因，是因为任脉循行面部进入目内，督脉上行联系两眼中央，诸条经脉都归属于目，人的精神意识汇聚于此，所以适宜急下以救阴。
喻昌说：少阴病有急下三法来挽救肾水：一是本经肾水枯竭，二是肝木邪气上涌凌犯肾水，三是脾土邪气凌犯肾水。阳明病也有急下三法来挽救津液：一是发汗过多，津液外越；二是腹部胀满，津液内结；三是眼睛神采不明，津液枯涸于中。综合观察这两经的攻下法，以了解病情和生理机制，就像身处冰壶之中、饮用上池之水一样清凉透彻。
张锡驹说：阳火亢盛到了极点，阴水即将枯竭，所以导致眼中视物模糊、眼球转动不灵活。急用攻下法，是为了抑制亢盛的阳火，挽救垂危的阴水。
魏荔彤说：阳明病的燥屎应当攻下，胃家实热应当攻下，这些都在前面的脉证中详细考证过了。然而有的病例表里没有其他证候，唯独在阳明胃脉所表现的端倪处，仔细体认其证候，比如伤寒六七天，太阳表证已罢，阳明里证已成，眼睛昏暗朦胧，好像隔着云雾不能看清，这种证候名叫“睛不和”。阳明热盛，沿着经络发作出昏蒙的现象，导致眼睛失去光泽，这是内热盛而转为实证，病机已经显现，加上大便干硬困难，身体有微热，那么胃实就已经确凿无疑，所以说：“这是实证。”应当急下，适宜用大承气汤。
病人小便不利，大便时而困难时而容易，偶尔有轻微发热，气喘且头昏目眩不能平卧的，说明体内有燥屎，适宜用大承气汤。
【注】患阳明病的人，通常小便自利，大便就会干硬；如果小便不利，大便就不会干硬。由此可知，大便是否干硬，不在于热势的大小，而在于津液的枯竭与否。现在小便不利，而大便时而困难时而容易，这是因为热邪将要凝结，但津液尚未完全枯竭。有时出现轻微发热，是热邪入里；气喘，是热邪侵犯肺脏；头昏目眩，是热邪侵犯心脏；不能平卧，是热邪并入阳分。这些都是热邪内结、大便干硬的征象。这是神志昏乱、胡言乱语的初期，虽然腹部没有胀满疼痛，但也一定有燥屎，适宜用大承气汤攻下，自然痊愈。
【集注】王三阳说：这个证候不宜妄动攻下，必须用手按压脐腹部，如果有硬块，且伴有气喘、头昏不能平卧，才可以攻下。为什么呢？因为大便乍难乍易的缘故。
林澜说：既然微热时作，气喘头昏不能平卧，那么有燥屎就是确定的。自然应当急用攻下法驱逐里实，怎么可以被“小便利、大便一定硬才可攻下”的常规法则所拘泥呢！
汪琥说：这一条病症未经攻下而有燥屎，是医生不容易识别的证候。成无己说：小便利则大便硬，这是有燥屎常理。现在病人小便不利，大便乍难乍易，怎么知道有燥屎呢？大概是大实、大满的证候，前后二便都不通。大便被燥屎壅塞，其中未坚结的部分，有时可能会一起排出，所以叫“乍易”；其中极度坚结的部分，始终留在大肠中，所以叫“乍难”。燥屎结积在下部，浊气攻冲于上部，因此偶尔有轻微发热；微热，是因为热伏在内不得发泄。后文辨析说：浊气乘袭心肺，所以既头昏又气喘；不能平卧，是因为胃中有燥屎扰乱，即“胃不和则卧不安”。凡此种种，都是有燥屎的征象，所以说：适宜用大承气汤。
病人不大便五六天，绕脐疼痛，烦躁，定时发作的，这是有燥屎，所以导致不大便。
【注】病人不大便五六天，绕脐疼痛，是因为肠胃中的燥屎结聚，没有出路，所以绕脐疼痛。烦躁定时发作，是因为燥屎的秽热上攻则烦躁，不上攻则不烦躁，所以发作有时。不需要用小承气汤试探，直接以大承气汤攻下燥屎，大便通畅自然可以痊愈。
【集注】方有执说：病患，指所有患病的人。而出现这种证候的，都应当按照这种方法治疗。这是向人们展示辨别各种胃家实热的大旨。
程应旄说：攻下法，必须确认有燥屎，才不会误攻。所以验证燥屎的方法，不可不周全，不能只依赖转矢气这一种方法。病人虽然不大便五六天，屎的干燥与否还不可知。但只要绕脐痛，就知道肠胃干燥，屎无去路，滞涩在一处而作痛；烦躁发作有时，是因为屎气攻动则烦躁发作；又有时伏而不攻动，也不烦躁，但有绕脐痛，断定其不大便无误。为什么不可以用大承气汤攻下呢！
大攻下之后，六七天不大便，烦躁不解，腹部胀满疼痛的，这是有燥屎。之所以这样，是因为原本就有宿食，适宜用大承气汤再次攻下，自然痊愈。
【注】这是承接上一条来说明治法。攻下未尽，仍然应该攻下。这是在大攻下之后，六七天后又不大便，烦躁也不解，腹部仍然胀满疼痛，这是有燥屎没有被攻下干净。之所以这样，是因为原本就有宿食，适宜用大承气汤再次攻下，自然痊愈。
【集注】程知说：大攻下之后，病应该解除了，却又六七天不大便，烦躁不解且腹部胀满疼痛，这必定是有燥屎未尽才这样。大概是宿食因热邪再次凝结变硬。
阳明病，经过攻下治疗后，体表仍有发热，手足温暖，没有形成结胸，心中烦闷懊恼，感觉饥饿但不能进食，只有头部出汗的，主治用栀子豉汤。
【注】阳明经病经过攻下，身热未除，手足温暖，没有形成结胸，说明陷入体内的邪气较浅。心中烦闷懊恼，感觉饥饿但不能进食，只有头部出汗，说明阳热邪气蒸腾郁结在胸膈之间。适宜用栀子豉汤涌吐其热邪。
【集注】程知说：体表仍有发热，是经邪未解；手足温暖，说明热邪入里不深。
程应旄说：懊恼扰动胃气，所以感觉饥饿但不能进食。热邪郁结，气机蒸腾，所以只有头部出汗。
魏荔彤说：表邪未完全入里，就误认为是胃实而急于攻下，那么体表仍有热邪，终究不能随下药而荡涤干净。于是虽然有热但不潮热，手足虽温但没有濈然汗出，这说明在表的邪气仍在表，攻下只会徒然损伤里气！即使不像全在太阳经那样，误下形成结胸，而是心下懊恼，饥饿不能进食，只有头部出汗，这是阳明蒸蒸之热，被阴寒性质的药物郁遏，全部凝塞在胸膈之上，其证候已经非常明显。但病仍带有表证，既然不能再攻下，且已入里，也不能再发汗，只有用栀子豉汤，仍然从太阳经的方法治疗。
【注】伤寒病的三阳经多有呕吐证候，因为风寒表邪未除，胸中阳气被寒邪郁遏，所以都不可攻下。那些干呕且恶寒发热的，属于太阳病；喜欢呕吐且寒热往来的，属于少阳病。现在虽然有恶热、不恶寒、大便硬的阳明证，但呕吐频繁也不可攻下，因为气机上逆在上部而未收敛，属于实证（此处指邪气盛实，非里实可下）。
【集注】沈明宗说：恶寒发热的呕吐属于太阳，寒热往来的呕吐属于少阳，但恶热不恶寒的呕吐属于阳明。然而呕吐频繁则气已上逆，邪气偏侵上脘，或者兼带少阳，所以即使有阳明证，也千万不可攻下。
阳明中风，口苦咽干，腹部胀满微喘，发热恶寒，脉浮而紧，如果误用攻下法，就会导致腹部胀满加重、小便困难。
【注】阳明，指阳明里证。中风，指太阳表证。口苦咽干，是少阳热证。腹部胀满，是阳明热证。微喘，发热恶寒，是太阳伤寒证。脉浮而紧，是伤寒的脉象。这是风寒同时侵袭表里的同病证候，应当审查表里情况施治。如果是太阳、阳明病多，就用桂枝加大黄汤表里双解；如果是少阳、阳明病多，就用大柴胡汤和解攻下。如果只从里治，就仅仅根据腹部胀满一证，认为热入阳明而攻下，那么表邪就会乘虚再次陷入，所以腹部更加胀满；里热进一步耗竭津液，所以小便困难。
【集注】程知说：这是说阳明兼有太阳、少阳表邪，就不可以攻下。阳明中风，是热邪。腹部胀满而喘，是热邪入里。但喘得轻微，说明未完全入里。发热恶寒，脉浮而紧，都是太阳表证未除的表现，口苦咽干，说明有少阳半表半里之邪，如果误用攻下，表邪就会乘虚内陷，腹部更加胀满。再加上严重耗伤津液，所以小便困难。
程应旄说：这一条与太阳病的大青龙汤证相同。太阳病因为风寒束缚营卫，所以有烦躁证而没有腹部胀满证；此条因为风寒束缚住阳明，所以有腹部胀满证而没有烦躁证。然而口苦、咽干，其实与烦躁有相同的病机征兆。
阳明病，脉浮而紧，咽喉干燥口苦，腹部胀满而喘，发热汗出，不恶寒反而恶热，身体沉重，如果误用发汗法，就会出现烦躁、心中昏乱反而胡言乱语；如果加用温针，一定会惊恐不安、烦躁无法入睡；如果误用攻下法，会导致胃中空虚，客气（邪气）扰动胸膈，心中烦闷懊恼，舌上有苔的，主治用栀子豉汤。如果口渴想喝水，口干舌燥的，主治用白虎加人参汤。如果脉浮发热，口渴想喝水，小便不利的，主治用猪苓汤。阳明病，出汗多且口渴的，不可给予猪苓汤，因为出汗多导致胃中干燥，猪苓汤又会利尿，从而进一步损伤津液。
【注】这是承接前一条互相阐发其义，以说明治法。前一条表证居多，告诫不可误下；这一条表里混淆，脉证错杂，不但不可误下，也不可误汗。如果因为脉浮而紧，误用发汗，就会夺液伤阴；或者加用烧针，必然助长阳邪，所以出现胡言乱语、烦躁、惊恐昏乱不眠；或者因为腹部胀满、恶热的症状而误用攻下，就会导致胃中空虚，客气邪热扰动胸膈，心中烦闷懊恼，舌上生苔，这都是误下的过错，适宜用栀子豉汤涌吐热邪即可安宁。如果脉浮不紧，证候没有懊恼，只是发热，口渴想喝水，口干舌燥的，是太阳表邪已衰，阳明燥热正盛，适宜用白虎加人参汤，滋润津液以生津。如果发热口渴想喝水，小便不利的，是阳明饮热并盛，适宜用猪苓汤利水以滋润干燥。然而阳明病，法当多汗，因为出汗多，导致小便少而口渴的，不可给予猪苓汤。因为出汗多导致胃燥，无水不能下行，这是水枯竭导致的小便少，而不是水蓄积导致的小便不利，恐怕猪苓汤更利小便，则会进一步枯竭津液而助长燥热。
【按】太阳病，烦热无汗而口渴，小便利的，是大青龙汤证；小便不利的，是小青龙汤去掉半夏，加天花粉、茯苓的证候。太阳病，烦热有汗而口渴，小便利的，是桂枝汤合白虎汤证；小便不利的，是五苓散证。阳明病，烦热无汗而口渴，小便利的，适宜用葛根汤加石膏主治；小便不利的，用五苓散加石膏、寒水石、滑石主治。阳明病，烦热有汗而口渴，小便利的，适宜用白虎汤；小便不利的，用猪苓汤。少阳病，寒热无汗而口渴，小便利的，应当用小柴胡汤去掉半夏加天花粉；小便不利的，应当用小柴胡汤加茯苓。太阴病无口渴。少阴阳邪，烦呕小便赤而口渴的，用猪苓汤；少阴阴邪下利，小便色白而口渴的，用真武汤。厥阴阳邪消渴的，用白虎加人参汤；厥阴阴邪，转属阳明，口渴想喝水的，少量给予饮水则痊愈。证候既然不同，治法也各异，应当详细审察并明确辨别。
【集注】喻昌说：发热以上面与前一条相同，而汗出，不恶寒，反恶热，身体沉重，这四者都是阳明病的见证，所以汗法、下法、烧针都不可用。舌上有苔，说明膈间热甚，所以用栀子豉汤涌吐以去除膈热，这样治疗太阳就不会妨碍阳明。如果前证再加上口干舌燥，就适宜用白虎汤以解热生津；再加上小便不利，就适宜用猪苓汤，以导热滋润干燥。那些出汗多而口渴，不可给予猪苓汤的原因，是因为热邪传入阳明，必先耗伤津液；加上出汗多又从外部夺走津液，再用利小便的方法从下部夺走津液，那么津液就有立即亡失的危险，所以示以警戒。
程应旄说：热在上焦，所以用栀子豉汤；热在中焦，所以用白虎加人参汤；热在下焦，所以用猪苓汤。
猪苓汤方
猪苓（去皮） 茯苓 阿胶 泽泻 滑石（捣碎，各一两）
以上五味药，用水四升，先煮前四味药，取二升药液，去掉药渣，加入阿胶使其溶化，每次温服七合，每日三次服用。
【集解】赵羽皇说：仲景制定猪苓汤这一方剂，用来通行阳明、少阴二经的水热之邪。然而其主旨全在于益阴，不仅仅专利水。大概伤寒表虚，最忌讳亡阳，而里虚又担心亡阴。亡阴，是指肾中之阴和胃家的津液亡失。所以阴虚之人，不但大便不可轻易攻动，就连小便也忌讳过度通利，倘若阴虚之人过度渗利，津液反而会耗竭。方中阿胶质地膏润，能养阴滋润燥热；滑石性质滑利，能清热利水；佐以茯苓、猪苓的渗泄作用，既能疏通浊热而不留滞瘀阻，又能滋润真阴而不使其枯燥，这是利水而不伤阴的良好方剂。所以利水的方法，在太阳病用五苓散的，是因为太阳职司寒水，所以加桂枝以温之，这是暖肾以行水；在阳明、少阴病用猪苓汤的，是因为这两经关乎津液，特意用阿胶、滑石来滋润，这是滋养无形之气以推动有形之水。利水虽然相同，但寒温迥异，只有明理者才知道。
脉浮而大，心下反而硬满，有热邪。属于脏（里）的应当攻下，不让发汗；属于腑（表）的不让小便频数。小便频数则大便干硬，出汗多则热邪更盛，出汗少则大便困难，脉迟则尚不可攻下。
【注】属脏，指属于里；属腑，指属于表。溲，指小便。脉浮而大，是太阳、阳明的脉象。浮属于表，大属于里。现在太阳脉浮的表证未解，而心下反而硬满，阳明之里又急迫，权衡汗、下之法即可。假设里有热实，攻下无疑，不需要先发汗以解表。如果没有热实，而有脉浮的表证，不仅不可以攻下，就连小便不利，也不可以用利小便的方法，仍然应当解表。大概是因为担心小便频数、出汗多，亡失津液，导致大便干硬，那么热邪会更加实盛。如果出汗少、脉迟，即使有大便干硬，里证尚未实，也不可攻下。
【集注】王肯堂说：论中说脉浮大，反用发汗、反用攻下是错误的。这里因为心下硬且有热，知道邪气传入了里，所以舍脉而从证。大便干硬则允许攻下，小便频数则不允许利小便，为什么呢？回答说：攻下大便则内热消除，利小便则损伤津液。
林澜说：心下硬满与腹部硬满不同。腹部硬满是邪气已经结聚成实，这里仅在心下，自然与非攻下不可的情况不同。腑与脏对举而言，见其一为入里，其一仍属表的意义。
阳明病，脉迟，进食难以吃饱，吃饱了就轻微烦躁、头晕目眩，一定小便困难，这是将要发生谷疸。即使攻下，腹部胀满依然如故，之所以这样，是因为脉迟的缘故。
【注】阳明病如果不排便，吃完饭后像饿了一样想吃，进食后腹部胀满、脉数的，则是胃热，是可以攻下的证候。现在脉迟，迟脉主中寒，中寒不能消化谷物，所以虽然饥饿想吃，但进食难以吃饱，吃饱了就烦闷，这是脾胃健运功能失调。清气阻滞不能上升，所以头晕目眩；浊气阻滞不能下降，所以小便困难。食物郁滞湿瘀，这是将要发生谷疸的征象，不是阳明湿热、腹部胀满发黄的证候可比。即使攻下，腹部胀满暂时减轻，一会儿又恢复原状，之所以这样，是因为脉迟主中寒的缘故。
【集注】方有执说：迟脉主寒，不能消化谷物，所以进食难以吃饱。湿气郁结而蒸腾，气机上逆而不能下行，所以轻微烦躁、头晕目眩、小便困难，疽是黄病。谷疸，是水谷之湿蒸发而导致身体发黄。
张璐说：攻下后腹部胀满依然如故，大概腹部胀满已经是邪气潜伏，脉迟则胃不实，白白地攻下其糟粕，病既不除，反而伤害身体！阳明证本来应当攻下，阳明病出现腹痛，尤其应当急下。唯独这一个证候攻下，腹部胀满必然如故。
Fire qi ascends to熏 (熏:熏蒸/steaming) the eyes, causing the pupils to appear hazy and vision to be unclear; this is referred to as "liao liao bu" (unclear vision). This is the initial stage of heat binding with clouded spirit, a critical and ominous sign. Although there are no obvious exterior Yang syndrome fevers externally, only slight body heat; and internally there is no abdominal fullness or pain, only difficulty in defecation, this still constitutes a heat-excess condition. Therefore, it is stated: "This is an excess condition." One should urgently administer Da Cheng Qi Tang (Great Order the Qi Decoction) to purge, thereby draining Yang heat and saving Yin fluids, preserving the water that has not yet been exhausted. The term "jing bu he" (eyes not harmonious) refers to the lack of flexibility in eye movement.
[Collected Commentaries] Fang Youzhi states: "Liao liao" means clear and distinct. The *Su Wen* says: The Yangming channel governs the flesh, and its vessels run alongside the nose and connect to the eyes. The *Ling Shu* says: The regular pathway of the Foot-Yangming channel ascends along the throat, emerges at the mouth, returns to tie with the eye system, and merges with the Yangming channel. It also states: The tendons of the Foot-Yangming channel have a branch that ascends the neck, runs alongside the mouth, and merges in the face; descending, it knots at the nose and ascends to merge with the Taiyang channel. The Taiyang channel serves as the upper ligament of the eyes, and the Yangming channel serves as the lower ligament. Thus, when one observes unclear vision and inflexible eye movements, one knows it is due to stomach excess. The reason for urgent purging is that the Ren Mai (Conception Vessel) runs through the face into the eyes, the Du Mai (Governing Vessel) ascends to tie the center of both eyes, and all vessels belong to the eyes, where human spirit concentrates; hence, urgent purging is appropriate.
Yu Chang states: Shaoyin disease has three urgent purging methods to save kidney water: one is the depletion of water in the primary channel, one is wood pathogen surging and flooding water, and one is earth pathogen overwhelming water. Yangming disease also has three urgent purging methods to save body fluids: one is excessive sweating causing fluids to escape outward, one is abdominal fullness causing fluids to bind inward, and one is dull eyes indicating fluid exhaustion in the middle. Observing the conditions and physiology by combining the purging methods of these two channels is like being in an ice pot and drinking from the upper pool [metaphor for clarity].
Zhang Xiju states: When Yang fire reaches extreme hyperactivity and Yin water is about to dry up, it causes unclear vision and inflexible eyes. Urgent purging is used to suppress the extremely hyperactive Yang fire and save the nearly extinct Yin water.
Wei Litong states: Dry feces in Yangming should be purged, and stomach excess should be purged, which were detailed in previous pulse and symptom examinations. However, in cases where there are no other exterior or interior symptoms, one must carefully recognize the signs appearing at the sites where the Yangming stomach vessel manifests. For example, after six or seven days of cold damage, when the Taiyang exterior has resolved and the Yangming interior has formed, if the eyes are dim and hazy, as if viewing through fog and clouds without clarity, this syndrome is named "jing bu he" (eyes not harmonious). Excessive Yangming heat travels along the meridians, manifesting as dizziness and haziness, causing the eyes to lose their luster. This indicates internal heat flourishing turning into excess, with the mechanism already evident. Coupled with hard and difficult stool and slight body heat, the stomach excess is confirmed. Thus, it is said: "This is an excess condition." Urgent purging is indicated, preferably with Da Cheng Qi Tang.
If a patient has difficulty urinating, intermittent difficulty and ease in defecation, occasional slight fever, wheezing, vertigo, and inability to lie down, there are dry feces, and Da Cheng Qi Tang is indicated.
[Note] In Yangming disease, if urination is normal, the stool tends to be hard; if urination is difficult, the stool tends not to be hard. Thus, hardness depends not on the presence of heat but on whether fluids are depleted. Now, with difficult urination and intermittent stool difficulty, 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; vertigo indicates heat affecting the heart; and inability to lie down indicates heat merging with Yang. These are all signs of heat binding and stool hardening. This is the beginning of mental confusion and delirium. Even without abdominal fullness or pain, dry feces are likely present, so Da Cheng Qi Tang 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; if hard masses are felt, accompanied by wheezing, vertigo, and inability to lie down, then purging can be performed. Why? Because of the intermittent nature of the stool.
Lin Lan states: Since slight fever occurs intermittently, accompanied by wheezing, vertigo, and inability to lie down, the presence of dry feces is certain. Urgent purging to drive out interior excess is appropriate. How can one be bound by the common rule that one must wait for normal urination and definitely hard stool before purging?
Wang Hu states: This clause describes a case with dry feces despite no prior purging, a syndrome difficult for physicians to identify. Cheng Wuji states: Normal urination leads to hard stool; thus, dry feces are a common occurrence. Now, with difficult urination and intermittent stool difficulty, how do we know there are dry feces? In cases of great excess and fullness, both anterior and posterior passages are blocked. Dry feces block the stool; unhardened parts may occasionally pass together, hence "intermittent ease"; extremely hardened parts remain in the large intestine, hence "intermittent difficulty." Dry feces accumulate below, turbid qi attacks upward, causing occasional slight fever; slight fever means heat is trapped inside without release. Later analysis states: Turbid qi affects the heart and lungs, causing vertigo and wheezing; inability to lie down is due to disturbance by dry feces in the stomach, i.e., "when the stomach is disharmonious, sleep is uneasy." All these are signs of dry feces, hence Da Cheng Qi Tang is indicated.
If a patient has not defecated for five or six days, experiences periumbilical pain, restlessness, and periodic发作 (attacks), there are dry feces, which cause the constipation.
[Note] Lack of defecation for five or six days with periumbilical pain indicates dry feces bound in the intestines with no exit, causing pain around the navel. Restlessness occurring periodically is because the foul heat of dry feces attacks upward, causing restlessness; when it does not attack, there is no restlessness, hence the periodic nature. There is no need to test with Xiao Cheng Qi Tang (Minor Order the Qi Decoction); directly use Da Cheng Qi Tang to purge the dry feces. Once stool flows freely, healing will occur.
[Collected Commentaries] Fang Youzhi states: "Patient" refers to anyone ill. Those presenting such symptoms should be treated accordingly. This illustrates the general principle for distinguishing all types of stomach excess.
Cheng Yingmao states: Purging methods must confirm the presence of dry feces to avoid erroneous purging. Methods to verify dry feces must be comprehensive, not relying solely on the passage of flatus. Although the patient has not defecated for five or six days, the dryness of the stool is unknown. But periumbilical pain indicates intestinal dryness and lack of stool exit, stagnating in one spot causing pain. Periodic restlessness is caused by stool qi attacking; when it lies dormant, there is no restlessness, but periumbilical pain remains. Thus, constipation is confirmed without error. Why not use Da Cheng Qi Tang to purge?
After severe purging, if the patient has not defecated for six or seven days, restlessness persists, and abdominal fullness and pain continue, there are dry feces. This is because there was originally retained food. Da Cheng Qi Tang is indicated for further purging to achieve self-healing.
[Note] This follows the previous clause to clarify treatment. If purging was incomplete, further purging is needed. After severe purging, if six or seven days pass without defecation, and restlessness and abdominal fullness/pain persist, it indicates residual dry feces. This is due to originally retained food. Da Cheng Chi Tang should be used again for purging to heal.
[Collected Commentaries] Cheng Zhi states: After severe purging, the illness should resolve. Yet, after six or seven days, there is no defecation, restlessness persists, and abdominal fullness/pain exists. This must be due to incomplete removal of dry feces. Retained food likely re-hardened due to heat.
In Yangming disease, after purging, if there is external heat, warm hands and feet, no chest binding, mental restlessness and oppression ("ao nao"), hunger but inability to eat, and only head sweating, Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) is the primary treatment.
[Note] In Yangming meridian disease, after purging, if body heat remains, hands and feet are warm, and there is no chest binding, it indicates the trapped pathogen is shallow. Mental restlessness/oppression, hunger but inability to eat, and only head sweating indicate Yang pathogen steaming and stagnating in the chest and diaphragm. Zhi Zi Chi Tang is indicated to surge out the heat.
[Collected Commentaries] Cheng Zhi states: External heat indicates unresolved meridian pathogen; warm hands and feet indicate heat has not entered deeply.
Cheng Yingmao states: Oppression disturbs the stomach, causing hunger but inability to eat. Heat stagnation and qi steaming cause only head sweating.
Wei Litong states: If exterior pathogen has not fully entered the interior, and one mistakenly assumes stomach excess and purges hastily, external heat remains and cannot be cleared by the purgative. Thus, although there is heat, there is no tidal fever; although hands and feet are warm, there is no profuse sweating. This shows the exterior pathogen remains exterior, and purging only damages the interior! Even if not fully Taiyang, mistaken purging does not necessarily lead to chest binding, but rather heart oppression, hunger, inability to eat, and head sweating. The steaming heat of Yangming, depressed by cold-natured medicines, condenses in the upper chest and diaphragm, making the syndrome obvious. Since the disease still carries exterior features, it cannot be purged again; having entered the interior, it cannot be induced to sweat again. Only Zhi Zi Chi Tang should be used, treating it according to Taiyang methods.
In cold damage, if vomiting is frequent, even if Yangming symptoms are present, purging is contraindicated.
[Note] Many Three-Yang syndromes in cold damage involve vomiting because the wind-cold exterior pathogen is not resolved, and Yang qi in the chest is depressed by cold. Therefore, purging is contraindicated. Dry vomiting with aversion to cold and fever belongs to Taiyang; preference for vomiting with alternating chills and fever belongs to Shaoyang. Now, although there are only Yangming symptoms of aversion to heat, no aversion to cold, and hard stool, frequent vomiting means purging is still contraindicated because the rebellious qi is ascending and not gathered, constituting an excess condition (pathogen excess, not interior excess suitable for purging).
[Collected Commentaries] Shen Mingzong states: Vomiting with aversion to cold and fever belongs to Taiyang; vomiting with alternating chills and fever belongs to Shaoyang; vomiting with aversion to heat and no aversion to cold belongs to Yangming. However, frequent vomiting indicates rebellious qi, with pathogen invading the upper jiao or involving Shaoyang. Thus, even with Yangming symptoms, purging must be avoided.
Yangming wind-strike presents with bitter taste, 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.
[Note] "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 invasion of both exterior and interior. Treatment must assess exterior and interior. If Taiyang and Yangming syndromes predominate, Gui Zhi Jia Huang Qi Tang (Cinnamon Twig plus Magnolia Bark Decoction - *Correction: Text says Gui Zhi Jia Huang Qin Tang? No, text says Gui Zhi Jia Huang... actually standard is Gui Zhi Jia Huang Qin Tang or similar, but text says Gui Zhi Jia Huang... let's stick to text: Gui Zhi Jia Huang... wait, text says "Gui Zhi Jia Huang...". Actually, standard commentary often cites Gui Zhi Jia Huang Qin Tang or just Gui Zhi Tang plus something. The text says "Gui Zhi Jia Huang...". Let's look closely: "Gui Zhi Jia Huang...". Ah, it says "Gui Zhi Jia Huang...". Wait, the text provided is "Gui Zhi Jia Huang...". I will translate literally as Gui Zhi plus [missing character/huang]... Actually, looking at standard texts, it is often Gui Zhi Jia Huang Qin Tang or similar. However, the prompt text says "Gui Zhi Jia Huang...". I will assume it implies a modification of Gui Zhi Tang. Let's check the characters: "桂枝加大黄汤" is common for Taiyang/Yangming. The text says "桂枝加大黄汤". Okay, I missed the 'Da Huang' in my quick scan. It is Gui Zhi Jia Da Huang Tang.) to resolve both; if Shaoyang and Yangming predominate, Da Chai Hu Tang (Major Bupleurum Decoction) is used 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 abdominal fullness; interior heat will further deplete fluids, causing difficult urination.
[Collected Commentaries] Cheng Zhi states: This explains that if Yangming is combined with Taiyang and Shaoyang exterior pathogens, purging is contraindicated. Yangming wind-strike involves 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 and tight pulse are unremoved Taiyang signs. Bitter taste and dry throat indicate Shaoyang half-exterior/half-interior. Mistaken purging causes exterior pathogen to sink inward, worsening fullness. Severe loss of fluids causes difficult urination.
Cheng Yingmao states: This clause is similar to the Taiyang Da Qing Long Tang syndrome. Taiyang involves wind-cold holding Ying and Wei, causing restlessness but no abdominal fullness. Here, wind-cold holds Yangming, causing abdominal fullness but no restlessness. However, bitter taste and dry throat share the same mechanistic indication as restlessness.
In Yangming disease, with floating and tight pulse, dry throat, bitter taste, abdominal fullness, wheezing, fever, sweating, no aversion to cold but aversion to heat, and heavy body: if sweated, restlessness, mental confusion, and delirium ensue; if moxibustion/warm needle is added, fright, restlessness, and insomnia occur; if purged, the stomach becomes empty, external pathogen agitates the diaphragm, causing mental oppression/restlessness ("ao nao") and tongue coating. Zhi Zi Chi Tang is indicated. If thirst for water, dry mouth, and tongue dryness occur, Bai Hu Jia Ren Shen Tang (White Tiger plus Ginseng Decoction) is indicated. If floating pulse, fever, thirst for water, and difficult urination occur, Zhu Ling Tang (Polyporus Decoction) is indicated. In Yangming disease, if sweating is profuse and thirst is present, Zhu Ling Tang is contraindicated because profuse sweating causes stomach dryness, and Zhu Ling Tang promotes urination, further damaging fluids.
[Note] This elaborates on the previous clause to clarify treatment. The previous clause had mostly exterior signs, warning against mistaken purging; this clause has confused exterior and interior, mixed pulses and symptoms. Not only is mistaken purging forbidden, but mistaken sweating is also forbidden. Sweating due to floating/tight pulse depletes fluids and injures Yin; adding burning needles aids Yang pathogen, causing delirium, restlessness, fright, and insomnia. Purging due to abdominal fullness and aversion to heat empties the stomach, allowing external pathogenic heat to agitate the chest/diaphragm, causing oppression, restlessness, and tongue coating. These are errors of mistaken purging; Zhi Zi Chi Tang should be used to surge out the heat. If pulse is floating but not tight, without oppression, only fever, thirst, dry mouth/tongue, it indicates Taiyang exterior pathogen declining and Yangming dry-heat flourishing. Bai Hu Jia Ren Shen Tang is indicated to nourish fluids. If fever, thirst, and difficult urination occur, it indicates Yangming fluid-heat abundance. Zhu Ling Tang is indicated to promote urination and moisten dryness. However, Yangming disease typically involves sweating. If profuse sweating leads to scanty urine and thirst, Zhu Ling Tang is contraindicated. Profuse sweating causes stomach dryness; lack of water prevents downward flow. This is scanty urine due to water depletion, not water retention. Using Zhu Ling Tang would further deplete fluids and increase dryness.
[Commentary] Taiyang syndrome with irritability, heat, no sweat, and thirst, with normal urination, is Da Qing Long Tang syndrome; with difficult urination, it is Xiao Qing Long Tang minus Ban Xia plus Hua Fen and Fu Ling. Taiyang syndrome with irritability, heat, sweat, and thirst, with normal urination, is Gui Zhi Tang combined with Bai Hu Tang; with difficult urination, it is Wu Ling San. Yangming syndrome with irritability, heat, no sweat, and thirst, with normal urination, is Ge Gen Tang plus Shi Gao; with difficult urination, it is Wu Ling San plus Shi Gao, Han Shui Shi, and Hua Shi. Yangming syndrome with irritability, heat, sweat, and thirst, with normal urination, is Bai Hu Tang; with difficult urination, it is Zhu Ling Tang. Shaoyang syndrome with chills, fever, no sweat, and thirst, with normal urination, is Xiao Chai Hu Tang minus Ban Xia plus Hua Fen; with difficult urination, it is Xiao Chai Hu Tang plus Fu Ling. Taiyin syndrome has no thirst. Shaoyin Yang pathogen with irritability, vomiting, red urine, and thirst uses Zhu Ling Tang; Shaoyin Yin pathogen with diarrhea, white urine, and thirst uses Zhen Wu Tang. Jueyin Yang pathogen with consumptive thirst uses Bai Hu Jia Ren Shen Tang; Jueyin Yin pathogen transferring to Yangming with thirst for water heals with small sips of water. Since syndromes differ, methods vary; careful differentiation is required.
[Collected Commentaries] Yu Chang states: Fever is the same as the previous clause. Sweating, no aversion to cold, aversion to heat, and heavy body are all Yangming signs. Thus, sweating, purging, and needles are all contraindicated. Tongue coating indicates severe diaphragmatic heat; Zhi Zi Chi Tang is used to surge out heat, treating Taiyang without harming Yangming. If dry mouth/tongue is added, Bai Hu Tang is used to resolve heat and generate fluids. If difficult urination is added, Zhu Ling Tang is used to guide heat out and moisten dryness. Zhu Ling Tang is contraindicated in profuse sweating/thirst because heat entering Yangming consumes fluids; profuse sweating drains them outward, and diuretics drain them downward, risking immediate fluid loss. Hence the warning.
Cheng Yingmao states: Heat in the Upper Jiao uses Zhi Zi Chi Tang; heat in the Middle Jiao uses Bai Hu Jia Ren Shen Tang; heat in the Lower Jiao uses Zhu Ling Tang.
Zhu Ling Tang Formula
Zhu Ling (Poria, peeled), Fu Ling (Poria), E Jiao (Donkey-hide Gelatin), Ze Xie (Alisma), Hua Shi (Talcum, crushed) — each 1 liang.
These five herbs are boiled in 4 sheng of water. First boil the first four herbs to obtain 2 sheng. Strain, add E Jiao, and melt. Take 7 ge warm, three times daily.
[Collection of Explanations] Zhao Yuhuang states: Zhang Zhongjing formulated Zhu Ling Tang to move water-heat in the Yangming and Shaoyin channels. Its main purpose is tonifying Yin, not merely promoting urination. Cold damage with exterior deficiency fears Yang collapse, while interior deficiency fears Yin collapse. Yin collapse refers to loss of Kidney Yin and Stomach fluids. Thus, in Yin-deficient persons, not only should stool not be lightly purged, but urination should also not be overly promoted. Over-diuresis in Yin deficiency leads to fluid exhaustion. E Jiao in the formula is gelatinous, nourishing Yin and moistening dryness; Hua Shi is slippery, clearing heat and promoting urination. Assisted by the diuretic properties of Fu Ling and Zhu Ling, it clears turbid heat without stagnation and nourishes true Yin without bitterness/dryness. It is an excellent formula that promotes urination without injuring Yin. Therefore, for promoting urination in Taiyang, Wu Ling San is used because Taiyang governs cold water; Gui Zhi is added to warm it, warming the Kidney to move water. For Yangming and Shaoyin, Zhu Ling Tang is used because these channels concern fluids; E Jiao and Hua Shi are used to moisten them, nourishing the formless to move the formed. Although both promote urination, their cold/warm natures differ greatly; only the enlightened understand this.
Floating and large pulse, hardness under the heart contrary to expectation, with heat. If belonging to Zang (Interior), purge it; do not induce sweating. If belonging to Fu (Exterior), do not allow frequent urination. Frequent urination makes stool hard; profuse sweating increases heat; scanty sweating makes stool difficult. If pulse is slow, purging is not yet appropriate.
[Note] Belonging to Zang means belonging to Interior; belonging to Fu means belonging to Exterior. Sou means urination. Floating and large pulse are Taiyang/Yangming pulses. Floating belongs to Exterior, Large belongs to Interior. Now, Taiyang exterior pulse floating is unresolved, and heart hardness indicates urgent Yangming interior. Weigh sweating vs. purging. If interior heat-excess exists, purging is undeniable; no need to sweat first to resolve exterior. If no heat-excess but floating exterior pulse, do not purge, nor promote urination even if difficult; still resolve exterior. Fear that frequent urination and sweating will deplete fluids, hardening stool and increasing heat. If scanty sweating and slow pulse, even with hard stool, interior is not yet excess; purging is not yet appropriate.
[Collected Commentaries] Wang Kentang states: The Treatise says floating/large pulse, reversed sweating/purging is adverse. Here, heart hardness with heat indicates pathogen entering interior, so pulse is ignored in favor of symptoms. Hard stool allows purging; frequent urination forbids diuresis. Why? Purging stool removes internal heat; diuresis injures fluids.
Lin Lan states: Heart hardness differs from abdominal fullness/hardness. Abdominal hardness indicates pathogen bound into excess; heart hardness alone differs from cases requiring mandatory purging. Fu and Zang are contrasted: one enters interior, one remains exterior.
Yangming disease, slow pulse, difficulty eating to fullness, slight irritability and vertigo after eating, inevitable difficult urination: this is developing Gu Ju (Grass Yellow/Damp-Jaundice). Even if purged, abdominal fullness remains unchanged. Why? Because of the slow pulse.
[Note] Yangming disease without defecation, feeling hungry after eating, post-prandial fullness with rapid pulse indicates Stomach Heat, suitable for purging. Now, slow pulse indicates Middle Cold. Middle Cold cannot transform grain. Thus, although hungry, one cannot eat to fullness; fullness causes irritability, indicating failure of transportation/transformation. Clear qi blocked from ascending causes vertigo; turbid qi blocked from descending causes difficult urination. Food stagnation with dampness/stasis indicates impending Gu Ju. This is not comparable to Yangming Damp-Heat with abdominal fullness and jaundice. Even if purged, fullness temporarily lessens but returns. Why? Because slow pulse indicates Middle Cold.
[Collected Commentaries] Fang Youzhi states: Slow pulse indicates cold failing to transform grain, hence difficulty eating to fullness. Dampness stagnates and steams, Qi rebels and fails to descend, causing slight irritability, vertigo, and difficult urination. Ju is yellow disease. Gu Ju is body yellowing from evaporation of grain-water dampness.
Zhang Lu states: Abdominal fullness remains after purging because fullness is already latent pathogen. Slow pulse indicates Stomach is not excess. Blindly purging chaff harms the body without curing the disease. Yangming syndrome usually requires purging; abdominal pain especially warrants urgent purging. But in this single syndrome, purging leaves fullness unchanged.