反下之，此为大逆。既经妄下，则所谓浮者，至于内空而无血；所谓大者，变为里虚而有
寒，虚寒相抟，则为肠鸣。医见脉大，以为有热，饮以冷水，欲以水寒胜热而作汗，里
先虚寒，又得冷水与之相抟，则冷结上焦，必至咽噎塞而气逆矣。
伤寒哕而腹满，视其前后，知何部不利，利之则愈。
【注】伤寒哕而不腹满者，为正气虚，吴茱萸汤证也。哕而腹满者，为邪气实，视其
二便何部不利，利之则愈也。
【集注】成无己曰∶哕而腹满，气上而不下也。视其前后有不利者，即利之以降其气。
前部小便也，后部大便也。
程知曰∶前部不利，后人治以五苓；后部不利，后人治以承气是也。
沈明宗曰∶邪传于胃，胃气壅遏，两气相抟，气逆上冲，则为哕矣。
张锡驹曰∶伤寒至哕，非胃气败，即胃中寒。然亦有里实不通，气不得下泄，反上逆而为哕者，当详辨之。
夫实则谵语，虚则郑声。郑声者，重语也。
【注】谵语一证，有虚有实。实则谵语，阳明热甚，上乘于心，乱言无次，其声高朗，邪气实也。虚则郑
声，精神衰乏，不能自主，语言重复，其声微短，正气虚也。
【集注】戴元礼曰∶谵语属阳，郑声属阴。经曰∶实则谵语，虚则郑声。谵语者，颠倒错乱，言出无伦，
常对空独语，如见鬼状。郑声者，郑重频烦，语虽谬而谆谆不已，老年人遇事则谇语不休，以阳气虚不精明也。
此谵语、郑声虚实之所以不同也。二者本不难辨，但阳盛里实，与阴盛格阳，皆能错语，须以他证别之，随证
施治可也。
娄全善曰∶余用参、 、归、术等剂治谵语，得愈者甚多，岂可不分虚实，一概用黄连解毒、大小承气等
汤以治之乎？（按∶其所云亦郑声也。）
张锡驹曰∶实则谵语者，阳明燥热甚而神昏气乱，故不避亲疏，妄言骂詈也。虚则郑声者，神气虚而不能
自主，故声音不正，而语言重复也。
伤寒四五日，脉沉而喘满，沉为在里，而反发其汗，津液越出，大便为难，表虚里实，久则谵语。
【注】伤寒四五日，入里之时也。脉沉而喘满，乃为在里之喘满，而反发其汗，津液越出，则表虚也，汗
出胃干，大便为难，则里实也。久则胃热炽盛，必发谵语也。
【集注】方有执曰∶越出谓枉道而出也。
张璐曰∶伤寒四五日，正邪热传里之时，况见脉沉在里之喘满，而反汗之，必致燥结谵语矣。盖燥结谵
语，颇似大承气证，此以过汗伤津，而不致大实大满腹痛，只宜小承气为允当耳！
阳明病，其人多汗，以津液外出，胃中燥，大便必硬，硬则谵语，小承气汤主之。若一服谵语止者，更
莫复服。
【注】此详上条以明其治也。阳明病其人多汗，以津液外出，胃中干燥，大便必硬，久则谵语，宜以小
承气汤主之，若一服利，谵语止，慎不可更服也。
【集注】张璐曰∶多汗谵语，下证急矣。以其人汗出既多，津液外耗，故不宜大下。但当略与小承气汤，
和其胃气，谵语自止，若过服反伤津液也。
沈明宗曰∶此汗多胃燥，非同实治也。
汗出谵语者，以有燥屎在胃中，此为风也。须下者，过经乃可下之。下之若早，语言必乱，以表虚里实
故也。下之愈，宜大承气汤。
【注】病自汗出而谵语者，以素有燥屎在胃中，此为太阳风邪之所传也，须当下之。然必须太阳之邪，
已过阳明之经，而入阳明之腑，乃可下之。若下之早，则里热未结，不但热去不尽，且虚其中，热乘虚而上干
于心，语言必乱。此表虚汗出，里实谵语，所以必待过经入腑，而后下之则愈，宜大承气汤。
【集注】方有执曰∶过经，谓宁迟迟，非谓必待十三日后也。
程知曰∶此言谵语不当下早也。既出汗矣而谵语，则必有燥屎在胃，此当属风。风为阳邪，阳邪入里，
故谵语。然须六七日乃可下之，下之早，则风邪未解于表，尽入于里，里邪燥实，语言更乱也。
阳明病，谵语有潮热，反不能食者，胃中必有燥屎五六枚也；若能食者，但硬尔。宜大承气汤下之。
【按】“宜大承气汤下之”句，应在“必有燥屎五六枚”之下，始合当用大承气汤下之之义。若但便硬
而用大承气汤下之，殊失仲景顾虑误下、慎下之旨。
【注】阳明病谵语有潮热，反不能食者，知胃中必有燥屎已结实也，宜大承气汤下之。若能食者，知胃
将和，但大便硬耳！当导之，不可下也。
【集注】张璐曰∶此以能食、不能食辨燥结之微甚也。潮热谵语，皆胃中热甚所致。胃热则能消谷，今
反不能食，此必热伤胃中津液，气化不能下行，燥屎逆攻于胃之故，宜大承气汤，急祛亢极之阳，以救垂绝之
阴。若能食者，胃中气化自行，热邪不盛，津液不致大伤，大便虽硬，不久自行，不必用药，反伤其气也。
下利谵语者，有燥屎也，宜小承气汤。
【注】下利里虚，谵语里实，若脉滑大，证兼里急，知其中必有宿食也。其下利之物，又必稠粘臭秽，
知热与宿食合而为之也，此可决其有燥屎也，宜以小承气汤下之。于此推之，可知燥屎不在大便硬与不硬，而
在里之急与不急，便之臭与不臭也。
【集注】汪琥曰∶下利者，肠胃之疾也。若谵语，则胃家实，与厥阴无与，乃肠中有燥屎不得下也。治
宜小承气汤者，此半利半结，只须缓以攻之也。又曰∶或问既下利矣，则热气得以下泄，何由而致谵语有燥屎
也？答曰∶此系阳明腑实大热之证，胃中糟粕为邪所壅，留着于内，其未成硬者，或时得下，其已成硬者，终
不得出，则燥屎为下利之根，燥屎不得出，则邪热上乘于心，所以谵语。要之此证，须以手按脐腹当必坚痛，
方为有燥屎之征。
直视谵语，喘满者死，下利者亦死。
【注】上条下利谵语为可治，此条下利谵语者死。要知谵语不死于下利，而死于直视也。直视者，精不注
乎目也；谵语者，神不守乎心也，已属恶候。加之喘满，阳上脱也，故曰死。下利阴下脱也，故曰亦死也。
【集注】方有执曰∶直视，精不荣于目也；谵语，神不主乎心也。喘则阳争于上，利则阴争于下，胃中土
也，阴阳争夺于上下，而中气不守，故无法可治，而皆主死也。
发汗多，若重发汗者，亡其阳。谵语，脉短者死；脉自和者不死。
【注】太阳病，发汗过多，不解，又复重发其汗，以致气液两亡，热邪乘燥传入阳明而生谵语。谵语者，
胃热阳也；脉短者，气衰阴也。阳病见阴脉，为阴胜于阳，故死也。若脉不短，为阴阳自和，故不死也。
【集注】喻昌曰∶方注以此为太阳经脱简，不知太阳经无谵语之例，必日久而兼阳明、少阳，方有谵语。
故此言太阳经得病时，发汗过多，及传阳明时，重发其汗，因有亡阳而谵语之一证也。亡阳之人，所存者阴气
耳，故神魂不定，而妄见妄闻，与热邪乘心之候不同。脉短则阴阳不附。脉和则阴阳未离，其生死但从脉定耳。
汪琥曰∶谵语者，脉当大实或洪滑，为自和。自和者，言脉与病不相背也，病虽甚不死。若谵语脉短，为
邪热盛，正气衰，乃阳证见阴脉也，无法可施。
发汗多，亡阳谵语者，不可下，与柴胡桂枝汤和其营卫，以通津液后自愈。
【注】此又承上条以出其治也。谵语者，属阳明热实，可下之证也。若发汗过多，大亡气液而发谵语者，
乃津枯致燥之谵语，非热甚内实之谵语，不可下也。里有热，宜白虎加人参汤。表不解，与柴胡桂枝汤和其营
卫，以通津液后自愈也。
【按】发汗过多，亡阳谵语，以无大便硬满痛，故不可下；以无身寒汗出恶寒，故不可温。于此可知发太
阳汗出过多致谵语者，必无发热汗出恶寒也。发阳明汗出过多致谵语者，必有潮热恶热不大便也。此则发少阳
汗多致谵语者，即论中少阳不可发汗，发汗则谵语是也。然舍小柴胡汤别无治法，若只用柴胡又恐升散，非亡
阳所宜，故合桂枝和其营卫，通其津液自可愈也。
阳明中风，脉弦浮大而短气，腹都满，胁下及心痛，久按之气不通，鼻干，不得汗，嗜卧，一身及面目悉
黄，小便难，有潮热，时时哕，耳前后肿，刺之小瘥，外不解，病过十日，脉续浮者，与小柴胡汤。脉但浮，
无余证者，与麻黄汤。若不尿，腹满加哕者，不治。
【按】续浮之“浮”字，当是“弦”字，始与文义相属，则可与小柴胡汤。若俱是“浮”字，则上之浮，
既宜用小柴胡汤，下之浮又如何用麻黄汤耶？
【注】中风传阳明，病太阳未罢，脉当浮缓。今脉弦浮大，弦，少阳脉也；浮，太阳脉也；大，阳明脉也，
脉既兼见，证亦如之。腹满，太阳阳明证也；胁下及心痛，久按之不通快，少阳证也；鼻干，阳明证也；不得
汗，太阳证也；嗜卧，少阴证也；面目悉黄，太阴证也；小便难，太阳腑证也；潮热，阳明里证也；哕逆，胃
败证也；耳前后肿，少阳证也；短气，气衰证也，凡仲景立法无方之条，皆是此等阴阳错杂，表里混淆之证，
但教人俟其病势所向，乘机而施治也。故用刺法，待其小瘥，若外病不解，已成危候。如过十日，脉续弦不浮
者，则邪机已向少阳，可与小柴胡汤和之，使阳明之邪从少阳而解。若脉但浮不大，而无余证者，则邪机已向
太阳，当与麻黄汤汗之，使阳明之邪从太阳而解。若已过十余日，病势不减，又不归于胃而成实，更加不尿腹
满哕甚等逆，即有一二可下之证，胃气已败，不可治也。
【集注】程知曰∶此条全是表证未解，而无汗出燥渴之证，故不可用白虎。虽有潮热，而无硬满谵语
汗出之证，故不可用承气。不如俟气之自回，犹可渐引其邪从外出也。
程应旄曰∶此条证以“不得汗”三字为主，故酌量于柴胡、麻黄二汤间，以通其久闭，总是要得汗耳！
脉浮而芤，浮为阳，芤为阴，浮芤相搏，胃气生热，其阳则绝。
【注】脉浮而芤，浮为阳盛，芤为阴虚。阳盛则发热，阴虚则汗出，二者相搏，则胃气生热愈盛，胃中津
液立亡。其阳则绝者，言阳亡津液绝也。
【集注】方有执曰∶浮为气上行，故曰阳；芤为血内损，故曰阳。胃中生热者，阴不足以和阳，津液干而
成枯燥也。
张璐曰∶此言脾约当下不下，则浮涩转为浮芤，津液竭而难下矣。其阳则绝，即阳绝于里，亡津液之互辞也。
赵良曰∶胃中阳热亢甚，脾无阴气以和之，孤阳无偶，不至燔灼竭绝不止耳。
沈明宗曰∶此辨阳明津竭之脉也。浮为邪气强，芤为阴血虚，阳邪盛而阴血虚，为浮芤相搏，胃气生热，
故曰∶其阳则绝。即亡津液之互词也。若见此脉，当养津液，不可便攻也。
阳明病，反无汗，而小便利，二三日呕而咳，手足厥者，必苦头痛，若不咳不呕，手足不厥者，头不痛。
【注】阳明病，法多汗，反无汗而小便利，是寒气内攻也。至二三日呕而咳，寒邪上逆也；手足厥者，寒
气见于四肢也；气上逆，则咳而苦头痛矣。若不咳、不呕、不厥，则头不痛。此证之头痛者标也，咳逆、手足
厥者本也。
【集注】程知曰∶无汗小便利，呕咳肢厥头痛，曷不谓太阳病？盖初起无头痛诸表证也。此头痛是二三日
后呕咳而厥所致，非因头痛致呕咳而厥也。呕、咳二证，太阳、少阳俱有之，其表证未解，则属太阳病；其寒
热往来者，则谓之少阳病也。厥，则厥阴有之，但无呕与咳也。
张璐曰∶阳明无汗，呕咳手足厥者，得之荣卫俱伤而邪入深也。然小便利，则邪不在内而在外，不在下而
在上，故知必苦头痛，仍宜小青龙主之。若不呕、不咳、不厥而小便利者，邪必顺水道而出，岂有逆攻巅顶之理哉！
林澜曰∶须识阳明亦有手足厥证，胃主四肢，中虚气寒所致也。然头苦痛而咳，自与阴寒但厥者异矣。此
类数条最为难解。
吴人驹曰∶呕咳手足厥头痛，皆由反无汗之故也。
阳明病，但头眩，不恶寒，故能食而咳，其人咽必痛；若不咳者，咽不痛。
【注】阳明病，当恶热不恶寒，若从伤寒传来，则不能食，今从中风传来，故能食也。伤寒挟寒邪，则有
头痛证，今中风挟风邪，则有头眩证，理固然也。寒邪属阴，若兼饮则咳而呕，今不呕而咽痛，则以风属阳邪，
风病则兼火，故咳而咽痛，以类相从也。
【集注】方有执曰∶眩，风旋而目运也，风，故不恶寒能食。咳，逆气也。咽门，胃之系也。胃热而气逆
攻咽，则咳而咽伤也。
程知曰∶阴邪下行，故无汗而小便利；阳邪上行，故不恶寒而头眩。寒则呕不能食，风则能食；寒则头
痛，风则咽痛，是风寒入胃之辨也。
程应旄曰∶阳明以下行为顺，逆则上行，故中寒则有头痛证，中风则有头眩证。以不恶寒而能食，知其
郁热在里也。寒上攻能令咳，其咳兼呕，故不能食而手足厥；热上攻亦令咳，其咳不呕，故能食而咽痛，以胃气
上通于肺，而咽为胃腑之门也。夫咽痛惟少阴有之，今以咳伤致痛，若不咳则咽不痛，况更有头眩不恶寒之证，
益可辨其为阳明之郁热也。
病患有寒，复发汗，胃中冷，必吐蛔。
如果误用攻下法，这是严重的错误。既然已经妄用攻下，那么所谓的“浮”脉，是因为内部空虚而无血；所谓的“大”脉，变成了里虚而有寒，虚与寒相互搏结，就会导致肠鸣。医生见到脉大，认为是有热，便给病人喝冷水，想用冷水的寒气来战胜体内的热以出汗，但体内原本就虚寒，又得到冷水与之相搏结，导致冷气凝结在上焦，必然会导致咽喉噎塞、气逆上冲。
伤寒病中出现呃逆（哕）并且腹部胀满，应当观察前阴和后阴，知道哪一部分不通利，通利那部分就可以痊愈。
【注】伤寒出现呃逆而不腹满的，是正气虚弱，属于吴茱萸汤证。呃逆且腹满的，是邪气实盛，观察二便哪一部分不通利，通利它就可以痊愈。
【集注】成无己说：呃逆且腹满，是气向上冲而不能下行。观察前后二阴有不通利的，就通利它以降下其气。前部指小便，后部指大便。
程知说：前部（小便）不通利，后人用五苓散治疗；后部（大便）不通利，后人用承气汤治疗，就是这个道理。
沈明宗说：邪气传入胃中，胃气壅滞遏阻，两股气机相互搏结，气逆上冲，就会发生呃逆。
张锡驹说：伤寒发展到呃逆，不是胃气败绝，就是胃中有寒。但也有因为里实不通，气不能向下排泄，反而向上逆冲而导致呃逆的，应当详细辨别。
【注】谵语这一症状，有虚证也有实证。实证谵语，是阳明热势极盛，上乘于心，胡言乱语没有次序，声音高亢洪亮，这是邪气实盛。虚证郑声，是精神衰败匮乏，不能自主控制，语言重复，声音微弱短促，这是正气虚弱。
【集注】戴元礼说：谵语属阳，郑声属阴。经书说：实证谵语，虚证郑声。谵语的人，颠倒错乱，说话没有条理，常常对着空气独自说话，好像看见鬼怪一样。郑声的人，郑重频繁，话语虽然谬误但喋喋不休不停止，老年人遇到事情则啰嗦不休，这是因为阳气虚弱不精明所致。这就是谵语和郑声虚实不同的原因。这两者本来不难辨别，只是阳盛里实，与阴盛格阳，都能导致言语错乱，必须通过其他症状来区别，随证施治即可。
娄全善说：我用人参、[缺字]、当归、白术等方剂治疗谵语，痊愈的很多，怎么能不分虚实，一概用黄连解毒汤、大小承气汤等来治疗呢？（按：他所说的这种情况也是郑声。）
张锡驹说：实证谵语，是阳明燥热极盛而神志昏乱、气机紊乱，所以不顾及亲疏关系，胡言乱语甚至骂人。虚证郑声，是神气虚弱而不能自主，所以声音不正，语言重复。
伤寒病四五日，脉象沉而气喘胸满，沉脉主病在里，却反而发汗，导致津液外泄，大便变得困难，表虚里实，时间久了就会发生谵语。
【注】伤寒病四五日，是病邪入里的时期。脉沉而气喘胸满，是为在里的喘满，却反而发汗，津液外泄，这就导致表虚；汗出导致胃中干燥，大便困难，这就导致里实。时间久了胃热炽盛，必然会发生谵语。
张璐说：伤寒病四五日，正是邪热传里的时期，况且见到脉沉在里的喘满，却反而发汗，必然导致燥结谵语。大概燥结谵语，很像大承气汤证，此条是因为过汗伤津，而没有达到大实大满腹痛的程度，只宜用小承气汤才妥当！
阳明病，病人多汗，因为津液外泄，胃中干燥，大便必然硬结，硬结就会谵语，主治用小承气汤。如果服一次药后谵语停止，不要再服用。
【注】此条详细说明上一条的治疗方法。阳明病病人多汗，因为津液外泄，胃中干燥，大便必然硬结，时间久了就会谵语，宜用小承气汤主治，如果服一次药后大便通利，谵语停止，千万不可再服用。
【集注】张璐说：多汗谵语，下法的指征已经很急迫了。因为此人汗出既多，津液外耗，所以不宜峻下。只应当略与小承气汤，调和胃气，谵语自然停止，如果过服反而损伤津液。
汗出且谵语的，是因为胃中有燥屎，这是风邪所致。需要攻下的，必须等到病邪经过经络传入腑脏之后才可以攻下。如果攻下过早，语言必然混乱，这是因为表虚里实的缘故。攻下后痊愈的，宜用大承气汤。
【注】病自汗出而谵语的，是因为素有燥屎在胃中，这是太阳风邪所传变而来，必须攻下。然而必须等到太阳之邪，已过阳明之经，而入阳明之腑，才可以攻下。如果攻下过早，则里热未结实，不但热去不尽，而且会使其内部虚弱，热邪乘虚上扰于心，语言必然混乱。此条表虚汗出，里实谵语，所以必须等待病邪过经入腑，然后攻下才能痊愈，宜用大承气汤。
【集注】方有执说：过经，意思是宁可迟缓，并不是说一定要等到十三日后。
程知说：此条说的是谵语不应当过早攻下。既然已经出汗而谵语，那么胃中必有燥屎，这应当属于风邪。风为阳邪，阳邪入里，所以谵语。然而必须等到六七日才可以攻下，攻下过早，则风邪未在表解尽，全部入里，里邪燥实，语言更加混乱。
阳明病，谵语伴有潮热，反而不能进食的，胃中一定有燥屎五六枚；如果能进食的，仅仅是大便硬罢了。宜用大承气汤攻下。
【按】“宜大承气汤下之”这句话，应该在“必有燥屎五六枚”之下，才符合当用大承气汤攻下的意义。如果只是大便硬就用大承气汤攻下，非常违背仲景顾虑误下、谨慎攻下的宗旨。
【注】阳明病谵语伴有潮热，反而不能进食的，知道胃中一定有已结实的燥屎，宜用大承气汤攻下。如果能进食的，知道胃气将要调和，仅仅是大便硬罢了！应当用导法，不可攻下。
【集注】张璐说：此条通过能食、不能食来辨别燥结的轻重。潮热谵语，都是胃中热盛所致。胃热则能消化食物，现在反而不能进食，这一定是热邪损伤了胃中津液，气化不能下行，燥屎逆冲于胃的缘故，宜用大承气汤，急祛亢极之阳，以救垂绝之阴。如果能进食的，胃中气化自行，热邪不盛，津液不至于大伤，大便虽硬，不久会自行排出，不必用药，反而损伤正气。
【注】下利属里虚，谵语属里实，如果脉象滑大，证候兼有里急后重，知道其中必有宿食。其下利的物质，又必定稠粘臭秽，知道是热与宿食结合而成的，由此可以断定有燥屎，宜用小承气汤攻下。由此推之，可知燥屎不在于大便硬或不硬，而在于里急与否，大便臭与不臭。
【集注】汪琥说：下利，是肠胃的疾病。如果谵语，则是胃家实，与厥阴无关，是肠中有燥屎不得排出。治疗宜用小承气汤，这是半利半结的情况，只需缓攻即可。又说：有人问既然下利了，热气得以向下排泄，怎么会导致谵语和有燥屎呢？回答说：这是阳明腑实大热的证候，胃中糟粕被邪气壅塞，留滞在体内，那些未成硬的，有时能排出；那些已成硬的，终究排不出，所以燥屎成为下利的根源，燥屎排不出，邪热就上乘于心，所以谵语。总之此证，必须用手按压脐腹部一定坚硬疼痛，才是有燥屎的征象。
眼睛直视且谵语，气喘胸满的预后不良（死），下利的也预后不良（死）。
【注】上一条的下利谵语是可治的，此条的下利谵语是死证。要知道谵语不死于下利，而死于直视。直视，是精气不能灌注于目；谵语，是神志不能守于心，已属恶候。加上气喘胸满，是阳气上脱，所以说死。下利是阴气下脱，所以说也死。
【集注】方有执说：直视，是精气不能荣养于目；谵语，是神志不能主宰于心。气喘则阳气争于上，下利则阴气争于下，胃居中土，阴阳在上下争夺，而中气不守，所以无法可治，都主死证。
发汗过多，或者再次发汗的，会导致亡阳。出现谵语，脉象短的预后不良（死）；脉象平和的不预后不良（不死）。
【注】太阳病，发汗过多，病不解，又再次发汗，导致气液两亡，热邪乘燥传入阳明而生谵语。谵语，是胃热属阳；脉短，是气衰属阴。阳病见阴脉，为阴胜于阳，所以死。如果脉不短，为阴阳自和，所以不死。
【集注】喻昌说：前面的注解将此条视为太阳经脱简，不知道太阳经没有谵语的病例，必须日久兼涉阳明、少阳，才有谵语。所以此条说的是太阳经得病时，发汗过多，及传到阳明时，再次发汗，因此有亡阳而谵语这一证候。亡阳的人，存留的是阴气，所以神魂不定，而妄见妄闻，与热邪乘心的证候不同。脉短则阴阳不相依附。脉和则阴阳未分离，其生死只从脉象而定。
汪琥说：谵语，脉应当大实或洪滑，这叫自和。自和，是说脉与病不相违背，病虽重但不死。如果谵语脉短，为邪热盛，正气衰，乃阳证见阴脉，无法施治。
发汗过多，亡阳而谵语的，不可攻下，给予柴胡桂枝汤调和营卫，以通津液，之后自愈。
【注】此条又承接上一条以提出治疗方法。谵语，属阳明热实，是可攻下的证候。如果发汗过多，大伤气液而发谵语的，乃是津枯致燥的谵语，不是热甚内实的谵语，不可攻下。里有热，宜用白虎加人参汤。表不解，给予柴胡桂枝汤调和营卫，以通津液后自愈。
【按】发汗过多，亡阳谵语，因为没有大便硬满痛，所以不可攻下；因为没有身寒汗出恶寒，所以不可温补。由此可知发太阳汗出过多致谵语者，必无发热汗出恶寒。发阳明汗出过多致谵语者，必有潮热恶热不大便。此条是发少阳汗多致谵语者，即论中少阳不可发汗，发汗则谵语是也。然而除了小柴胡汤别无治法，若只用柴胡又恐升散，不适合亡阳，故合桂枝调和营卫，通其津液自可痊愈。
阳明中风，脉弦浮大而短气，腹部全面胀满，胁下及心痛，久按之气不通畅，鼻干，无汗，嗜睡，全身及面目悉黄，小便难，有潮热，时时呃逆，耳前后肿胀，针刺后稍好转，表证仍未解，病过十日，脉继续浮的，给予小柴胡汤。脉仅浮，没有其他证候的，给予麻黄汤。如果不排尿，腹满加重呃逆的，预后不良（不治）。
【按】续浮之“浮”字，应当是“弦”字，才与文义相属，则可与小柴胡汤。如果都是“浮”字，则上面的浮，既宜用小柴胡汤，下面的浮又如何用麻黄汤呢？
【注】中风传入阳明，病在太阳未罢，脉应当浮缓。现在脉弦浮大，弦，是少阳脉；浮，是太阳脉；大，是阳明脉，脉既兼见，证候也是如此。腹满，是太阳阳明证；胁下及心痛，久按之不通快，是少阳证；鼻干，是阳明证；无汗，是太阳证；嗜卧，是少阴证；面目悉黄，是太阴证；小便难，是太阳腑证；潮热，是阳明里证；呃逆，是胃败证；耳前后肿，是少阳证；短气，是气衰证，凡是仲景立法无方的条文，都是这种阴阳错杂，表里混淆的证候，只是教人等待病势所向，乘机而施治。所以用刺法，待其稍好转，如果外病不解，已成危候。如过十日，脉续弦不浮的，则邪机已向少阳，可与小柴胡汤和解，使阳明之邪从少阳而解。如果脉仅浮不大，而无其他证候的，则邪机已向太阳，当给予麻黄汤发汗，使阳明之邪从太阳而解。如果已过十余日，病势不减，又不归于胃而成实，更加不尿腹满哕甚等逆证，即使有一二可下之证，胃气已败，不可治也。
【集注】程知说：此条全是表证未解，而无汗出燥渴之证，所以不可用白虎汤。虽有潮热，而无硬满谵语汗出之证，所以不可用承气汤。不如等待气机自回，还可以逐渐引导邪气从外出。
程应旄说：此条证候以“不得汗”三字为主，所以在柴胡、麻黄二汤间斟酌，以通其久闭，总是要得汗而已！
【注】脉浮而芤，浮为阳盛，芤为阴虚。阳盛则发热，阴虚则汗出，二者相搏，则胃气生热愈盛，胃中津液立即亡失。其阳则绝，是说阳亡津液绝。
【集注】方有执说：浮为气上行，故曰阳；芤为血内损，故曰阴。胃中生热，是阴不足以和阳，津液干而成枯燥。
张璐说：此条说脾约当下不下，则浮涩转为浮芤，津液竭而难下矣。其阳则绝，即阳绝于里，亡津液的互辞。
赵良说：胃中阳热亢甚，脾无阴气以和之，孤阳无偶，不至燔灼竭绝不止。
沈明宗说：此条辨别阳明津竭之脉。浮为邪气强，芤为阴血虚，阳邪盛而阴血虚，为浮芤相搏，胃气生热，所以说：其阳则绝。即亡津液的互词。若见此脉，当养津液，不可便攻也。
阳明病，反而无汗，而小便通利，二三日呕吐而咳嗽，手足厥冷的，必然苦于头痛，如果不咳不呕，手足不厥冷的，头不痛。
【注】阳明病，法度上多汗，反而无汗而小便通利，是寒气内攻。到了二三日呕吐而咳嗽，是寒邪上逆；手足厥冷，是寒气见于四肢；气上逆，则咳而苦于头痛。如果不咳、不呕、不厥，则头不痛。此证的头痛是标，咳逆、手足厥是本。
【集注】程知说：无汗小便利，呕咳肢厥头痛，为什么不说是太阳病？因为初起没有头痛等表证。此头痛是二三日后的呕咳而厥所致，不是因头痛致呕咳而厥。呕、咳二证，太阳、少阳都有，其表证未解，则属太阳病；其寒热往来的，则称为少阳病。厥，则厥阴有，但没有呕与咳。
张璐说：阳明无汗，呕咳手足厥，是由于营卫俱伤而邪入深。然而小便利，则邪不在内而在外，不在下而在上，所以知道必然苦于头痛，仍宜用小青龙汤主治。如果不呕、不咳、不厥而小便利的，邪必顺水道而出，哪有逆攻巅顶的道理呢！
林澜说：须认识阳明也有手足厥证，胃主四肢，中虚气寒所致。然而头苦痛而咳，自然与阴寒但厥者不同。此类数条最为难解。
阳明病，仅仅头眩，不恶寒，所以能进食而咳嗽，其人咽喉必然痛；如果不咳嗽的，咽喉不痛。
【注】阳明病，应当恶热不恶寒，如果从伤寒传来，则不能进食，现在从中风传来，所以能进食。伤寒挟寒邪，则有头痛证，现在中风挟风邪，则有头眩证，道理固然如此。寒邪属阴，若兼饮则咳而呕，现在不呕而咽痛，则以风属阳邪，风病则兼火，所以咳而咽痛，以类相从。
【集注】方有执说：眩，是风旋而目运，风，所以不恶寒能食。咳，是逆气。咽门，是胃之系。胃热而气逆攻咽，则咳而咽伤。
程知说：阴邪下行，所以无汗而小便利；阳邪上行，所以不恶寒而头眩。寒则呕不能食，风则能食；寒则头痛，风则咽痛，这是风寒入胃的辨别。
程应旄说：阳明以下行为顺，逆则上行，所以中寒则有头痛证，中风则有头眩证。以不恶寒而能食，知其郁热在里。寒上攻能令咳，其咳兼呕，所以不能食而手足厥；热上攻亦令咳，其咳不呕，所以能食而咽痛，以胃气上通于肺，而咽为胃腑之门。夫咽痛惟少阴有之，今以咳伤致痛，若不咳则咽不痛，况更有头眩不恶寒之证，更可以辨别其为阳明之郁热。
If purgation is mistakenly applied, this constitutes a major violation of treatment principles. Since improper purgation has already occurred, the so-called "floating" pulse indicates internal emptiness and blood deficiency; the so-called "large" pulse transforms into interior deficiency with cold. The interplay of deficiency and cold leads to borborygmus (intestinal rumbling). If the physician observes a large pulse and assumes the presence of heat, administering cold water to induce sweating by overcoming heat with cold will fail, as the interior is already deficient and cold. The interaction between the existing interior cold-deficiency and the ingested cold water causes cold to coagulate in the upper jiao, inevitably resulting in dysphagia (choking sensation in the throat) and rebellious qi.
In Shaoyang disease presenting with hiccups (yue) and abdominal fullness, one should examine the anterior and posterior orifices to determine which is obstructed; relieving the obstruction will lead to recovery.
[Annotation] In Shaoyang disease, hiccups without abdominal fullness indicate deficiency of healthy qi and correspond to the Wuzhuyu Tang syndrome. Hiccups accompanied by abdominal fullness indicate excess of pathogenic factors; observing which part of the bowel movements is obstructed and relieving it will result in cure.
[Collected Annotations] Cheng Wuji stated: Hiccups with abdominal fullness signify qi rebelling upward without descending. Observing obstruction in the anterior (urine) or posterior (stool) orifices and relieving it will subdue the rebellious qi.
Cheng Zhi stated: Obstruction in the anterior orifice (urine) is treated by later generations with Wuling San; obstruction in the posterior orifice (stool) is treated with Chengqi Decoctions. This is the correct approach.
Shen Mingzong stated: When pathogens transmit to the stomach, stomach qi becomes stagnant and obstructed. The conflict between these two qi mechanisms causes rebellious qi to rush upward, resulting in hiccups.
Zhang Xiju stated: When Shaoyang disease progresses to hiccups, it indicates either the failure of stomach qi or cold in the stomach. However, there are cases where interior excess prevents qi from descending, causing it to rebel upward and produce hiccups; these must be carefully differentiated.
Excess conditions manifest as delirious speech (zhanyu), while deficiency conditions manifest as monotonous repetition (zhengsheng). Zhengsheng refers to repetitive speech.
[Annotation] Delirious speech can be either excess or deficiency. Excess delirious speech results from extreme Yangming heat ascending to disturb the heart, causing incoherent speech with a loud voice, indicating pathogenic excess. Deficient zhengsheng results from spiritual depletion and lack of self-control, characterized by repetitive speech with a weak and short voice, indicating healthy qi deficiency.
[Collected Annotations] Dai Yuanli stated: Delirious speech belongs to Yang, while zhengsheng belongs to Yin. The Classic states: Excess manifests as delirious speech, deficiency as zhengsheng. Those with delirious speech speak incoherently and disorderly, often talking to empty air as if seeing ghosts. Those with zhengsheng speak earnestly and frequently; although their words may be erroneous, they continue incessantly. Elderly people who ramble about events do so due to deficient Yang qi and lack of clarity. This explains the difference between delirious speech and zhengsheng. Although these two are not difficult to distinguish, both Yang excess with interior excess and Yin excess with repelling Yang can cause confused speech; differentiation through other symptoms and appropriate treatment based on the syndrome is required.
Lou Quanshan stated: I have used formulas containing Ginseng Radix et Rhizoma [text missing], Angelicae Sinensis Radix, and Atractylodis Macrocephalae Rhizoma to treat delirious speech with many recoveries. How can one indiscriminately use Huanglian Jiedu Tang or Da/Xiao Chengqi Tangs without distinguishing between excess and deficiency? (Note: What he described was actually zhengsheng.)
Zhang Xiju stated: Excess delirious speech occurs when Yangming dry-heat is severe, confusing the spirit and disrupting qi, leading to inappropriate speech regardless of kinship or cursing. Deficient zhengsheng occurs when spiritual qi is weak and lacks autonomy, resulting in abnormal voice and repetitive speech.
In Shaoyang disease lasting four to five days, if the pulse is deep and accompanied by asthma and chest fullness, the deep pulse indicates the disease is in the interior. Mistakenly inducing sweat in this case causes body fluids to escape excessively, leading to exterior deficiency. Sweating dries the stomach, making defecation difficult, resulting in interior excess. Prolonged heat blazing in the stomach will eventually cause delirious speech.
[Annotation] Four to five days into Shaoyang disease marks the time for pathogens to enter the interior. A deep pulse with asthma and chest fullness indicates interior involvement. Mistakenly inducing sweat causes body fluids to escape, resulting in exterior deficiency. Sweating dries the stomach and causes constipation, resulting in interior excess. Prolonged intense stomach heat will inevitably trigger delirious speech.
[Collected Annotations] Fang Youzhi stated: "Escaping excessively" means fluids leaving via an incorrect pathway.
Zhang Lu stated: At four to five days of Shaoyang disease, it is precisely when pathogenic heat transmits to the interior. Given the deep pulse and interior asthma/fullness, mistaken sweating will certainly lead to dryness, accumulation, and delirium. Although dryness-accumulation delirium resembles Da Chengqi Tang syndrome, this case involves fluid damage from excessive sweating without severe fullness and abdominal pain. Therefore, Xiao Chengqi Tang is more appropriate.
In Yangming disease, if the patient sweats profusely, body fluids exit externally, causing dryness in the stomach and hardening of the stool, which leads to delirious speech. Xiao Chengqi Tang is indicated. If delirium ceases after one dose, do not administer further doses.
[Annotation] This clarifies the treatment for the previous clause. In Yangming disease, profuse sweating depletes body fluids, drying the stomach and hardening the stool, eventually causing delirium. Xiao Chengqi Tang is indicated. If bowel movement occurs and delirium stops after one dose, further administration must be strictly avoided.
[Collected Annotations] Zhang Lu stated: Profuse sweating with delirium indicates an urgent need for purgation. However, since body fluids are already depleted through sweating, drastic purgation is unsuitable. A small dose of Xiao Chengqi Tang should be given to harmonize stomach qi, stopping delirium naturally. Overuse would damage fluids further.
Shen Mingzong stated: This case of profuse sweating and stomach dryness differs from standard excess treatment.
When sweating accompanies delirious speech, it indicates the presence of dry feces in the stomach, caused by Wind pathogen. Purging is required but must wait until the pathogen has passed through the meridians into the fu organs. Premature purging will cause language confusion because the exterior is deficient and the interior is excess. Recovery after purging requires Da Chengqi Tang.
[Annotation] Spontaneous sweating with delirium indicates pre-existing dry feces in the stomach, transmitted from Taiyang Wind pathogen. Purging is necessary but must wait until the Taiyang pathogen has passed the Yangming meridian and entered the Yangming fu organs. Premature purging fails to clear residual heat and damages the interior, allowing heat to harass the heart and confuse speech. Because the exterior is deficient (sweating) and the interior is excess (delirium), one must wait for the pathogen to pass the meridian and enter the fu organ before purging with Da Chengqi Tang.
[Collected Annotations] Fang Youzhi stated: "Passing the meridian" implies caution and delay, not necessarily waiting ten to thirteen days.
Cheng Zhi stated: This clause warns against premature purging for delirium. Since sweating has occurred and delirium is present, dry feces must exist in the stomach, attributed to Wind. Wind is a Yang pathogen; entering the interior, it causes delirium. However, purging should wait until the sixth or seventh day. Premature purging allows unresolved Wind pathogen to fully enter the interior, worsening dryness, excess, and speech confusion.
In Yangming disease, delirium with tidal fever and inability to eat indicates the presence of five or six pieces of dry feces in the stomach. If the patient can eat, the stool is merely hard. Da Chengqi Tang is indicated for purging.
[Note] The phrase "Da Chengqi Tang is indicated for purging" should follow "presence of five or six pieces of dry feces" to align with the indication for using Da Chengqi Tang. Using Da Chengqi Tang solely for hard stool contradicts Zhongjing's caution against improper purging.
[Annotation] Yangming disease with delirium, tidal fever, and anorexia indicates solidified dry feces in the stomach; Da Chengqi Tang is indicated for purging. If the patient can eat, stomach qi is recovering, and the stool is merely hard; guiding methods (suppositories/enemas) should be used instead of purging.
[Collected Annotations] Zhang Lu stated: This distinguishes the severity of dryness based on appetite. Tidal fever and delirium result from severe stomach heat. Normally, stomach heat aids digestion, but inability to eat indicates heat damaging stomach fluids and blocking downward qi flow, causing dry feces to rebel against the stomach. Da Chengqi Tang is needed urgently to dispel extreme Yang and save declining Yin. If the patient can eat, stomach qi functions normally, heat is mild, fluids are preserved, and hard stool will pass naturally without medication, avoiding damage to qi.
Diarrhea accompanied by delirious speech indicates the presence of dry feces; Xiao Chengqi Tang is indicated.
[Annotation] Diarrhea suggests interior deficiency, while delirium suggests interior excess. If the pulse is slippery and large, accompanied by tenesmus,宿食 (retained food) is present. The diarrhea material is thick, sticky, and foul-smelling, indicating a combination of heat and retained food. This confirms the presence of dry feces, warranting Xiao Chengqi Tang for purging. From this, we infer that dry feces are determined not by stool hardness alone, but by the presence of tenesmus and foul odor.
[Collected Annotations] Wang Hu stated: Diarrhea is an intestinal/colonic issue. Delirium indicates stomach excess, unrelated to Jueyin, but signifies dry feces trapped in the intestines. Xiao Chengqi Tang is used because this is a mixed condition of partial diarrhea and partial constipation, requiring gentle purging. Furthermore, if diarrhea occurs, heat should dissipate downward; why does delirium and dry feces occur? This is a severe Yangming fu-excess heat syndrome. Waste products in the stomach are blocked by pathogens. Unformed waste may pass occasionally, but formed hard feces remain trapped. These dry feces are the root of the diarrhea. Trapped dry feces allow pathogenic heat to ascend to the heart, causing delirium. Clinically, pressing the umbilical region should reveal hardness and pain, confirming dry feces.
Fixed gaze (direct staring) with delirious speech, accompanied by asthma and chest fullness, indicates a fatal prognosis. Fixed gaze with delirious speech and diarrhea also indicates death.
[Annotation] The previous clause described curable diarrhea with delirium; this clause describes fatal diarrhea with delirium. Delirium itself is not fatal due to diarrhea, but due to fixed gaze. Fixed gaze indicates essence failing to nourish the eyes; delirium indicates spirit failing to guard the heart. Both are ominous signs. Asthma and chest fullness indicate Yang escaping upward, hence death. Diarrhea indicates Yin escaping downward, hence also death.
[Collected Annotations] Fang Youzhi stated: Fixed gaze means essence fails to nourish the eyes; delirium means spirit fails to govern the heart. Asthma represents Yang struggling upward; diarrhea represents Yin struggling downward. With Earth (Stomach) in the center, Yin and Yang struggle above and below, causing central qi to collapse, rendering treatment impossible, hence both indicate death.
Excessive sweating, or repeated sweating, leads to loss of Yang. Delirium with a short pulse indicates death; delirium with a harmonious pulse indicates survival.
[Annotation] In Taiyang disease, excessive sweating without resolution, followed by repeated sweating, causes simultaneous loss of qi and fluids. Heat pathogens, taking advantage of dryness, transmit to Yangming, causing delirium. Delirium reflects Stomach heat (Yang); a short pulse reflects qi decline (Yin). An Yang disease presenting with a Yin pulse indicates Yin overcoming Yang, leading to death. If the pulse is not short, indicating Yin-Yang harmony, survival is expected.
[Collected Annotations] Yu Chang stated: Previous annotations considered this a lost text from the Taiyang chapter, noting Taiyang disease rarely presents with delirium unless prolonged and involving Yangming or Shaoyang. Thus, this refers to Taiyang disease where excessive initial sweating, compounded by repeated sweating during transmission to Yangming, causes Yang loss and delirium. Patients with Yang loss retain only Yin, leading to unsettled spirit and hallucinations, distinct from heat harassing the heart. A short pulse indicates Yin-Yang detachment; a harmonious pulse indicates Yin-Yang connection. Prognosis depends on the pulse.
Wang Hu stated: Delirium typically presents with a large, solid, or surging-slippery pulse, termed "harmonious." Harmonious means the pulse matches the disease severity; even if severe, the patient survives. A short pulse with delirium indicates excessive pathogenic heat and deficient healthy qi (Yang disease with Yin pulse), making treatment futile.
Excessive sweating causing Yang loss and delirium should not be treated with purgation. Instead, Chaihu Guizhi Tang should be administered to harmonize Ying and Wei, promoting fluid circulation, after which the patient will recover spontaneously.
[Annotation] This continues the previous clause by providing treatment. Delirium usually indicates Yangming heat-excess, suitable for purging. However, delirium caused by excessive sweating and severe fluid/qi loss is due to fluid exhaustion causing dryness, not severe internal heat-excess. Therefore, purging is contraindicated. If interior heat exists, Baihu Jia Renshen Tang is indicated. If exterior symptoms persist, Chaihu Guizhi Tang harmonizes Ying and Wei to restore fluids, leading to spontaneous recovery.
[Note] Delirium from excessive sweating and Yang loss cannot be purged due to absence of hard, full, painful abdomen. It cannot be warmed due to absence of cold limbs, sweating, and aversion to cold. Thus, Taiyang excessive sweating causing delirium lacks fever, sweating, and aversion to cold. Yangming excessive sweating causing delirium includes tidal fever, aversion to heat, and constipation. This Shaoyang excessive sweating causing delirium aligns with the principle that Shaoyang disease forbids sweating; sweating causes delirium. Since Xiaochaihu Tang is the primary remedy, but Chaihu alone may be too dispersing for Yang loss, combining it with Guizhi harmonizes Ying and Wei, restoring fluids and ensuring recovery.
Yangming Wind-strike presents with a string-taut, floating, and large pulse, shortness of breath, generalized abdominal fullness, hypochondriac and cardiac pain unrelieved by pressure, nasal dryness, inability to sweat, lethargy, jaundice of the whole body and face, difficulty urinating, tidal fever, frequent hiccups, and swelling around the ears. Acupuncture provides slight relief. If exterior symptoms persist beyond ten days and the pulse remains floating, Chaihu Tang is indicated. If the pulse is only floating without other symptoms, Mahuang Tang is indicated. If the patient cannot urinate, abdominal fullness worsens, and hiccups increase, the condition is incurable.
[Note] The character "floating" in "pulse remains floating" should likely be "string-taut" to match the context for Chaihu Tang. If both were "floating," the logic for using Mahuang Tang for the second instance would be flawed.
[Annotation] Wind-strike transmitting to Yangming with unresolved Taiyang typically presents with a floating-slow pulse. Here, the pulse is string-taut, floating, and large. String-taut indicates Shaoyang; floating indicates Taiyang; large indicates Yangming. Symptoms correspond: abdominal fullness (Taiyang/Yangming); hypochondriac/cardiac pain unrelieved by pressure (Shaoyang); nasal dryness (Yangming); no sweat (Taiyang); lethargy (Shaoyin); jaundice (Taiyin); difficult urination (Taiyang Fu); tidal fever (Yangming Interior); hiccups (Stomach failure); ear swelling (Shaoyang); shortness of breath (Qi deficiency). Zhang Zhongjing’s clauses without specific formulas address such complex Yin-Yang and interior-exterior mixtures, advising physicians to observe the disease trajectory and intervene opportunistically. Acupuncture is used first for slight relief. If exterior symptoms persist and the condition becomes critical, and after ten days the pulse remains string-taut (not floating), the pathogen is shifting to Shaoyang; Chaihu Tang harmonizes the interior, allowing Yangming pathogens to resolve via Shaoyang. If the pulse is only floating without other symptoms, the pathogen shifts to Taiyang; Mahuang Tang induces sweating, resolving Yangming pathogens via Taiyang. If after ten-plus days the condition worsens without forming Fu-excess, and presents with anuria, worsening abdominal fullness, and severe hiccups, the Stomach qi has failed, and the condition is incurable despite any purgative indications.
[Collected Annotations] Cheng Zhi stated: This clause shows unresolved exterior symptoms without sweating, dryness, or thirst, ruling out Baihu Tang. Despite tidal fever, there is no hard-fullness, delirium, or sweating, ruling out Chengqi Tangs. Waiting for qi to recover allows gradual expulsion of pathogens outward.
Cheng Yingmao stated: The key symptom here is "inability to sweat." Treatment oscillates between Chaihu and Mahuang Tangs to open long-standing closure, aiming ultimately to induce sweating.
A floating and hollow (kou) pulse: Floating indicates Yang, hollow indicates Yin. The interaction of floating and hollow pulses generates heat in the Stomach qi, leading to the extinction of Yang.
[Annotation] A floating and hollow pulse indicates Yang excess and Yin deficiency. Yang excess causes fever; Yin deficiency causes sweating. Their interaction intensifies Stomach heat, rapidly depleting Stomach fluids. "Extinction of Yang" refers to the loss of Yang and depletion of fluids.
[Collected Annotations] Fang Youzhi stated: Floating indicates ascending Qi (Yang); hollow indicates internal blood damage (Yin). Heat in the Stomach arises because Yin cannot harmonize Yang, leading to dryness and desiccation.
Zhang Lu stated: This describes Spleen-constraint where purgation is delayed; the pulse changes from floating-choppy to floating-hollow. Fluid exhaustion makes purgation difficult. "Extinction of Yang" is synonymous with interior Yang extinction and fluid loss.
Zhao Liang stated: Extreme Yang-heat in the Stomach without Yin to harmonize it leaves solitary Yang unpaired, burning until exhaustion.
Shen Mingzong stated: This differentiates the pulse of Yangming fluid exhaustion. Floating indicates strong pathogenic qi; hollow indicates deficient Yin-blood. Yang-pathogen excess combined with Yin-blood deficiency creates the floating-hollow interaction, generating Stomach heat, hence "extinction of Yang," synonymous with fluid loss. Upon seeing this pulse, fluids must be nourished; aggressive purging is contraindicated.
In Yangming disease, paradoxically no sweating occurs, yet urination is free. After two to three days, vomiting and coughing appear, along with cold extremities. The patient suffers from headache. If there is no coughing, vomiting, or cold extremities, there is no headache.
[Annotation] Yangming disease typically involves sweating. Paradoxical absence of sweating with free urination indicates internal Cold attack. By day two or three, vomiting and coughing indicate Cold pathogen rebelling upward. Cold extremities indicate Cold manifesting in the limbs. Upward rebellious qi causes coughing and severe headache. Absence of coughing, vomiting, or cold extremities means no headache. Headache is the branch symptom; coughing/rebellion and cold extremities are the root.
[Collected Annotations] Cheng Zhi stated: Why not diagnose Taiyang given no sweat, free urination, vomiting, coughing, cold limbs, and headache? Because initial onset lacked typical Taiyang headache/exterior symptoms. This headache results from vomiting/coughing/cold limbs occurring two to three days later, not vice versa. Vomiting and coughing occur in both Taiyang and Shaoyang. Unresolved exterior symptoms indicate Taiyang; alternating chills and fever indicate Shaoyang. Cold limbs occur in Jueyin but without vomiting/coughing.
Zhang Lu stated: Yangming no sweat with vomiting, coughing, and cold limbs results from severe Ying-Wei damage and deep pathogen penetration. Free urination indicates the pathogen is external rather than internal, superior rather than inferior, thus predicting severe headache. Xiaolongtan Tang is still appropriate. Without vomiting, coughing, or cold limbs, free urination allows pathogens to exit via the urinary tract, preventing upward rebellion to the head.
Lin Lan stated: Note that Yangming can also present with cold extremities, as the Stomach governs the limbs, and middle deficiency/Cold causes this. However, headache with coughing differs from pure Yin-Cold cold limbs. These clauses are particularly difficult to interpret.
Wu Renju stated: Vomiting, coughing, cold limbs, and headache all stem from the paradoxical absence of sweating.
In Yangming disease, if there is only vertigo, no aversion to cold, ability to eat, and coughing, the throat will surely hurt. If there is no coughing, the throat will not hurt.
[Annotation] Yangming disease typically involves aversion to heat, not cold. Transmission from Shaoyang Cold-disease implies inability to eat; transmission from Wind-strike implies ability to eat. Shaoyang Cold-disease with Cold pathogen causes headache; Wind-strike with Wind pathogen causes vertigo. Cold is Yin; combined with fluid retention, it causes coughing and vomiting. Here, absence of vomiting but presence of sore throat indicates Wind (Yang pathogen) combined with Fire, causing coughing and sore throat due to similarity attraction.
[Collected Annotations] Fang Youzhi stated: Vertigo is spinning dizziness caused by Wind, explaining lack of aversion to cold and ability to eat. Coughing is rebellious qi. The pharynx is connected to the Stomach. Stomach heat and rebellious qi attacking the pharynx cause coughing and throat injury.
Cheng Zhi stated: Yin pathogens descend, causing no sweat and free urination; Yang pathogens ascend, causing no aversion to cold and vertigo. Cold causes vomiting/anorexia; Wind allows eating. Cold causes headache; Wind causes sore throat. This distinguishes Cold vs. Wind entering the Stomach.
Cheng Yingmao stated: Yangming favors downward movement; rebellion moves upward. Cold invasion causes headache; Wind invasion causes vertigo. Lack of aversion to cold and ability to eat indicate constrained heat in the interior. Cold rebelling upward causes coughing with vomiting (anorexia/cold limbs); Heat rebelling upward causes coughing without vomiting (anorexia absent/sore throat), as Stomach qi connects to the Lungs and the pharynx is the gate of the Stomach. While sore throat is typical of Shaoyin, here it results from cough-induced injury. No cough means no sore throat. Combined with vertigo and lack of aversion to cold, this confirms Yangming constrained heat.
For a patient with Cold symptoms, subsequent sweating causes Cold in the Stomach, inevitably leading to vomiting of roundworms.