【闡釋】鼻衄，有解病佳兆者。口幹鼻燥，能食，雖陽明裏證未全成，陽明內熱已太盛，熱甚則上逆，上逆則引血，血上則衄，熱邪亦隨之而泄。近世醫家以衄為紅汗者，正以其泄鬱熱故也。鬱熱泄則自愈。
三十二、陽明病，發熱汗出者，此為熱越①不能發黃也；但頭汗出，身無汗，劑頸而還，小便不利，渴飲水漿者，此為瘀熱在裏②身必發黃，茵陳蒿湯主之。原文236
①熱越：裏熱發越於外之意。
②瘀熱：即邪熱鬱滯的意思。
鄭論：條中所言熱外越者，不發黃，是因汗出，知其表氣通，而熱得外泄故也。若頭汗出，身無汗，小便不利，渴欲飲水者，此是熱伏於內，抑鬱太甚，而邪無由路出，故成陽黃之候，茵陳蒿湯主之，實為的證之方，妥切之甚者也。
【闡釋】此節乃陽明濕熱郁蒸發黃的證狀。若但頭汗出，周身沒有汗，則熱不得越；小便不利，由濕無出路，邪熱既不能外達，水濕又無從下泄，水濕與熱邪相蒸不解，郁而不達，身心發黃，治以茵陳蒿湯，苦寒通泄，使濕熱之邪從小便而出，濕去熱清，則發黃自愈。
茵陳蒿湯方（校補）
茵陳蒿六兩梔子十四枚（擘）大黃二兩（去皮）上三味，以水一鬥二升，先煮茵陳，減六升，內二味，煮取三升，去渣，分三服。小便當利，尿如皂莢汁狀，色正赤，一宿腹減，黃從小便去也。
【方解及其應用範圍】濕熱瘀裏，蒸發而外見黃色，用茵陳苦寒清濕而解鬱熱，佐梔子清利三焦，以通水道，以大黃除胃熱，導火下行兼清血分中之熱。三味合用，使瘀熱濕濁，從小便而出，濕熱一泄、則發黃自愈。《傷寒》《金匱》二書中，分黃疸為陰陽兩綱，敍述簡略，僅根據皮膚黃染情況來辨陰陽。凡身目俱黃，黃如橘子色澤鮮明，小便不利，色黃赤而短少，腹脹食少，厭油食，舌苔黃膩，脈滑數者，為陽黃。
無論其為現代醫學所稱之急性黃疸型傳染肝炎，濕熱偏盛的慢性肝炎，肝膽道感染，膽道結石等病見陽黃證者，都可用本方加減治療。
三十三、陽明病，面合色赤①，不可攻之。（攻之則）必發熱，色黃〔者〕，小便不利也。原文206
①面合色赤：即面色通赤。
鄭論：據陽明而面赤色，又當察其可攻與不可攻，如氣粗面赤，唇焦，飲冷甚者，宜攻之；若雖面赤而無熱象足征，又不可攻，攻之則必發熱者，是真陽因攻而浮於上，浮於上，即不能化下焦之陰，小便亦見不利。學者切勿執一陽明病，而定為熱證，妄施攻下也。此條所謂不可攻，攻之則必發熱，焉知非（帶）〔戴〕陽而何？
【闡釋】邪熱怫鬱在經，禁用攻下，誤攻下，必然發熱，肌膚發黃而且小便不利。因誤攻而見此證，欲救其失，茵陳五苓散可用。鄭氏更論及“雖面赤而無熱象足征，又不可攻，攻之則必發熱者，是真陽因攻而浮於上，……焉知非戴陽而何？”戴陽乃危證，救逆之法，非大劑回陽不可。
三十四、陽明病，無汗，小便不利，心中懊憹者，身必發黃。原文199
鄭論：邪至陽明而從熱化，無汗者，邪不得外泄，小便不利者，邪不得下泄，抑鬱於中而懊憹，懊憹者，心不安之謂，所以斷其必發黃也。
【闡釋】陽明病沒有汗出，是濕熱不能外散；小便不利，幾水濕不能下行。
濕與熱蒸於內，則身體發黃。原文未出方劑，似宜麻黃連翹赤小豆湯外發內利；或梔子豉湯以清裏而達表，則身黃自退。
三十五、陽明病，被火，額上微汗出，而小便不利者，必發黃。原文200
鄭論：陽明本屬（躁）〔燥〕地，又得陽邪，又複被火，火勢內攻，小便不通，熱邪無從下泄，遏熱太甚，是以決其必發黃也。
【闡釋】陽明病，無汗，本應以葛根湯發其汗，今竟以火劫取汗，則熱邪愈熾，津液被束，無複外布與下滲矣，其身必發黃。原文未出方治，根據辨證，必須清熱利濕，梔子柏皮湯主之。
三十六、陽明病，下血譫語者，此為熱入血室。①但頭汗出者，刺期門，隨其實而瀉之，濈然汗出則愈。原文216
①血室：各家見解不一，有的認為是沖脈，有的認為是肝臟，有的認為是子宮，所說都均有一定理由，顧名思義，要不外血液儲留之處，三者均有連帶關係，不需強分。又少陽篇18條所指“血室”即子宮。
鄭論：據陽明而稱下血，必是胃中有熱，逼血下行耳。譫語者，熱氣乘心，神無所主也。茲雲熱入血室，夫膀胱之外，乃為血海，又稱血室，此病係在陽明大腸，何得直指之為血室乎？何得刺期門穴乎？但下血一（等）〔證〕，有果係熱逼血下行者，必有熱象可征。譫語一證，有陽虛、陰虛、脾虛之異。更有下血、譫語而將脫者，不得總統言之，學者務宜細心探求則得矣。
【闡釋】本證由於邪熱熾盛，血為熱擾，故便血；內熱蒸騰，故頭汗出；熱氣乘心，神無所主，故譫語。鄭氏按稱：“此病係在陽明大腸，何得直指之為血室乎？何得刺期門穴乎？……務宜細心探求則得矣，”筆者信而從之。
三十七、陽明證，其人（善）〔喜〕忘者①，必有畜血②，所以然者，本有久瘀血，故令（善）〔喜〕忘，糞雖（難）〔鞕〕，（而）大便反易，其色必黑〔者〕，宜抵當湯（主）〔下〕之。原文237
①喜忘：喜作善字解，言語動靜隨過隨忘，即健忘之意。
②畜血：畜與蓄字同，瘀血停留叫蓄血。
鄭論：據善忘緣因瘀血所致，瘀滯不行，氣血不得流通，神明寓於氣血之中，為氣血之主。今為瘀血所阻，氣血不得流通，神明每多昏憒，所以善忘而斷之瘀血，確乎不爽。但蓄血在太陽，驗之於小便，其人如狂；蓄血在陽明，驗之於大腸，其色必黑，大便色黑者，蓄血之驗也。
【闡釋】太陽蓄血證是太陽之邪熱隨經入腑與血相結，以致出現少腹急結，或鞕滿，小便利，如狂、發狂等證候。陽明蓄血證是陽明邪熱與宿有的瘀血相結，故令善忘。二者證狀不同，因蓄血擾亂神志則一。辨太陽蓄血證在小便之利與不利，辨陽明蓄血證在大便之黑與不黑、難與不難。兩者的病理機轉都是屬於邪熱與血相結，所以都可用抵當湯下之。
三十八、病人無表裏證，發熱七八日，雖脈浮數者，可下之。假令已下，脈數不解，合熱則消穀善饑，至六七日，不大便者，有瘀血（也），宜抵當湯。若脈數不解，而下（利）不止，必協熱（而）便膿血也。原文257、258
鄭論：既稱無表裏證，即不在發表之例，即不在攻下之例，雖脈浮數，總要有風熱病情足征，庶可相機施治。所雲發熱七八日，然發熱有由外入之發熱，有由內而出之發熱，大有涇渭之分，若只憑脈之浮數而攻之，則由外入者，有內陷之變，由內而出者，有亡陽之逆，假令下之脈數不解，合熱則消穀善饑，此是為果有外邪致發熱者言之，而非為內出之發熱者言之也。迨至六七日，不大便者有瘀血，何以知其必有瘀血也？況熱結而不大便者亦多，此以抵當湯治之，似不恰切，仲師未必果有是說也。
【闡釋】鄭注此條與歷代注家不同，發熱有外入與內出之分，若只憑發熱而攻之，則有邪熱內陷與亡陽之虞。假令已下脈數不解，合熱消穀善饑，不大便者，何以辨之，並無征驗，況熱結而不大便亦多，提出質疑。最後歸結為“此以抵當湯治之，似不恰切，仲師未必果有是說也。”
三十九、病人煩熱，汗出則解，又如瘧狀，日晡所發熱者，屬陽明也。脈實者，宜下之；脈浮虛者，宜發汗。下之與大承氣湯；發汗宜桂枝湯。原文240
鄭論：此條以脈實、脈虛，而定為可汗、可下，似未必盡善。
論脈實而要有胃實病形足征，方可言下，脈浮虛而要有風邪足征，始可言發汗，若專以日晡發熱，而定為陽明證，即下之，決不妥切。
【闡釋】本條係太陽陽明並病，即表裏俱病，必先解表而後攻裏。但不能僅根據脈象虛實來決定汗、下，而應結合證狀來辨別太陽之表邪是否已解，或陽明之裏實是否已成，然後先表後裏，解表用桂枝湯，下之與大承氣湯，方為合法。
伤寒恒论下
清·鄭欽安
闡釋·唐步祺
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傷寒恒論卷五
陽明中篇
凡外邪盡入胃腑，謂之正陽陽明，列於此篇，計三十一法（據舒本校增）
一、陽明之為病，胃家實〔是也〕。原文180
鄭論：陽明乃多氣多血之府，邪至陽明（躁）〔燥〕地，與胃合成一家，其邪易實，故病見邪盛者極多，故曰胃家實。
【闡釋】“胃家實”三字是陽明病的提綱。胃家包括腸、胃而言，“實”字有廣義和狹義的區別，廣義包括經腑兩證，狹義就是單指陽明腑證而言。《內經》所說“邪氣盛則實”並不僅指有形結滯而言。食物積滯而實者，承氣證；熱邪積滯而實者，白虎證。
二、傷寒三日，陽明脈大。原文186
鄭論：一日太陽，二日陽明，三日少陽，乃傳經之次第。今三日而見脈大，可知其邪未傳少陽，而仍在陽明也，何以知之，浮為太陽，大為陽明，弦為少陽故也。
【闡釋】陽明病的脈大，必然大而有力，假使大而無力，或浮大無根，那就不一定全屬於陽明病。此雲三日陽明脈大者，謂不兼太陽陽明之浮大，亦不兼少陽陽明之弦大，而正見正陽陽明之大脈也。
三、傷寒發熱無汗，嘔不能食，而反汗出濈濈然者，是轉屬陽明也。原文185後段
鄭論：按發熱無汗，寒傷營也，嘔不能食，太陽有寒也，汗出濈濈然者，寒邪外出也。此曰轉屬陽明，果何所見而然乎？餘甚不解。
【闡釋】鄭氏將《傷寒論》185條分作兩條，前段列入陽明上篇9條，本條即後段。傷寒發熱無汗，嘔不能食，是少陽小柴胡證，不因發汗而反汗出濈濈然者，此由少陽轉屬陽明也，如此注釋，鄭氏之不解可解矣。
四、傷寒轉（屬）〔係〕陽明者，〔其人〕濈然微汗出也。原文188
鄭論：按轉屬陽明，必有陽明證足征，或見肌肉之間大熱，而又見口渴飲冷，氣粗口熱，蒸蒸汗出，如此言之，則曰轉屬陽明，方可無疑。而此只憑一濈濈然汗出，而即謂之轉屬陽明，實不恰切。
【闡釋】凡傷寒轉屬陽明，不論由太陽、少陽、少陰等轉係陽明，其人必見濈濈然連綿不已之微汗出也。此其裏熱亢盛，將水分外薰而為汗，腸中始得結實，而成鞕滿便難之陽明證。鄭氏曰：“而此只憑一濈濈然汗出，而即謂之轉屬陽明，實不恰切。”舒馳遠曰：“此條但據汗出濈濈一端，便是轉屬陽明，恐不能無疑。若熱退身涼，飲食有味，豈非病自解之汗耶？必其人惡熱、不惡寒，腹滿、按痛、譫語諸證錯見，方為有據，否則不足憑也。”故臨床不能憑一證以定寒熱虛實，須四診合參乃可。
五、太陽病三日，發汗不解①，蒸蒸發熱②者，屬胃也，調胃承氣湯主之。原文248
①發汗不解：指發汗後熱病不愈，不是太陽病不解。
②蒸蒸發熱：有如蒸籠中熱氣，從內向外蒸騰一樣，熱面潮潤。
鄭論：按三日，乃少陽主氣之期。今太陽發汗而不解，是邪入陽明，而未傳經也。觀其蒸蒸發熱者，陽明內熱之征，可以無疑矣。故以調胃承氣湯治之，其病自愈。
【闡釋】發汗以後，太陽表證雖解，而邪氣反化熱傳裏，轉為陽明腑實。當時證狀，除了蒸蒸發熱以外，一定還有腹滿、便秘、或心下鞕，鬱鬱微煩等腑實見證，才能使用調胃承氣湯。設若沒有上述證狀，僅憑蒸蒸發熱，就使用下法，是不恰當的。
六、陽明病，本自汗出，醫更重發汗，病已差，尚微煩不了了者，此〔必〕大便（已）鞕故也。以亡津液，胃中乾燥，故令大便鞕。當問其小便日幾行，若本小便日三四行，今日再行，故知大便不久出，今為小便數少，以津液當還入胃中，故知不久必大便也。原文203
鄭論：此由過汗傷及津液，已致胃燥失潤，問其小便尚利，津液未竭，故知其不久必便也。
【闡釋】陽明病大便鞕而難出，有熱結與津液不足兩端。熱結者可以攻下，承氣湯之類。津液不足者，必腸中津液增加，大便鞕得濡潤，無需攻下，亦必然不久自出。至於小便多的，大便必鞕；大便溏泄的，小便必少，是診斷大便鞕與溏泄的主要關鍵。今小便少，則津液還停胃中，胃中津液足，則大便潤，潤則軟滑，此其所以必出也。
七、陽明病，自汗出（者），若發汗，小便自利者，此為津液內竭，雖鞕不可攻之。當須自欲大便，宜蜜煎導而通之，若土瓜根及（與）大豬膽汁，皆可為導。原文233
鄭論：按汗自出，與小便自利，二者皆是大傷津液，故大便雖鞕者，不可攻之，俟其津液自回，亦可自便。此以蜜導法治之，亦切要之法，此又與熱結者，不可同法也。
【闡釋】本條大便鞕，是因自汗出，小便自利而大傷津液，腸中津液枯竭，與陽明中篇31條津液不行的脾約證，燥熱結實的承氣證，即鄭氏所說熱結皆不同，須詳辨之，必俟其津液自回，用蜜煎因勢利導之。
【阐释】鼻出血，有作为病愈佳兆的情况。口干鼻燥，能进食，虽然阳明里证尚未完全形成，但阳明内热已经过于旺盛，热势严重则向上逆乱，向上逆乱则牵引血液上行，血液上溢则发生鼻衄，热邪也随之而泄出。近代医家将鼻衄称为“红汗”，正是因为它能泄出郁积的热邪。郁积的热邪得以泄出，疾病自然痊愈。
三十二、阳明病，发热汗出的，这是热邪向外发散①，不会发黄；如果只有头部出汗，身上无汗，汗水仅到颈部即止，小便不利，口渴想喝水浆的，这是瘀热在体内②，身体一定会发黄，用茵陈蒿汤主治。原文236
①热越：指里热向外发散的意思。
②瘀热：即邪热郁滞的意思。
郑钦安论述：条文中所说的热向外发散，不发黄，是因为汗出，说明表气通畅，热邪得以向外泄出。如果头部出汗，身上无汗，小便不利，渴欲饮水，这是热邪伏于体内，郁滞太甚，邪气没有出路，所以形成阳黄的证候，用茵陈蒿汤主治，确实是针对确证的方剂，非常妥帖恰当。
【阐释】这一节讲的是阳明湿热郁蒸发黄的证状。如果只有头部出汗，周身没有汗，那么热邪就不能向外发散；小便不利，是因为湿气没有出路，邪热既然不能向外达表，水湿又无法从下焦泄出，水湿与热邪相互蒸腾不解，郁结而不能通达，导致身心发黄，治疗用茵陈蒿汤，苦寒通泄，使湿热之邪从小便排出，湿去热清，则发黄自愈。
茵陈蒿汤方（校补）
茵陈蒿六两 栀子十四枚（掰开） 大黄二两（去皮） 以上三味药，用水一斗二升，先煮茵陈，水量减少六升，再加入另外两味药，煮取三升药液，去掉药渣，分三次服用。小便应当通利，尿液像皂荚汁一样，颜色正红，过一夜腹部胀满减轻，黄色从小便去除。
【方解及其应用范围】湿热瘀积在体内，蒸腾外现黄色，用茵陈苦寒清除湿气并解除郁热，佐以栀子清利三焦，以通调水道，用大黄清除胃热，引导火气下行兼清血分之热。三味药合用，使瘀热湿浊从小便排出，湿热一泄，则发黄自愈。《伤寒》《金匮》两书中，将黄疸分为阴阳两纲，叙述简略，仅根据皮肤黄染情况来辨别阴阳。凡是全身和眼睛都发黄，黄色如橘子色色泽鲜明，小便不利，颜色黄赤且短少，腹胀食少，厌油腻食物，舌苔黄腻，脉滑数的，为阳黄。
无论是现代医学所称的急性黄疸型传染性肝炎、湿热偏盛的慢性肝炎、肝胆道感染、胆道结石等疾病见到阳黄证者，都可以用本方加减治疗。
三十三、阳明病，面色通红①，不可攻下。（若攻下则）必然发热，面色发黄〔者〕，小便不利。原文206
①面合色赤：即面色全部发红。
郑钦安论述：依据阳明病而见面赤色，又应当观察其可攻与不可攻，如气粗面赤，嘴唇焦裂，极度喜冷饮的，适宜攻下；如果虽然面赤但没有足够的热象证据，又不可攻下，攻下则必然发热，这是真阳因误攻而浮越于上，浮越于上，就不能化生下焦之阴，小便也会见不利。学者切勿固执地认为阳明病就是热证，妄施攻下法。此条所谓不可攻，攻下则必发热，怎知不是戴阳证呢？
【阐释】邪热怫郁在经络，禁用攻下法，误用攻下，必然发热，肌肤发黄而且小便不利。因误攻而出现此证，想要补救其过失，可用茵陈五苓散。郑氏更论及“虽然面赤但没有足够的热象证据，又不可攻下，攻下则必然发热，这是真阳因误攻而浮越于上，……怎知不是戴阳证呢？”戴阳乃是危重证候，救逆的方法，非大剂量回阳不可。
三十四、阳明病，无汗，小便不利，心中烦闷懊恼的，身体一定会发黄。原文199
郑钦安论述：邪气传入阳明而从热化，无汗，则邪气不得向外泄出，小便不利，则邪气不得向下泄出，郁滞于中而感到懊恼，懊恼，是指心中不安的意思，所以断定其必然发黄。
【阐释】阳明病没有汗出，是湿热不能向外散发；小便不利，是水湿不能下行。
湿与热在体内蒸腾，则身体发黄。原文未出方剂，似乎宜用麻黄连翘赤小豆汤外发内利；或用栀子豉汤以清里热而透达表邪，则身黄自退。
三十五、阳明病，被火疗，额头微汗出，而小便不利的，必然发黄。原文200
郑钦安论述：阳明本属燥土，又感受阳邪，又再受火疗，火势向内攻冲，小便不通，热邪无从向下泄出，遏阻热邪太甚，所以断定其必然发黄。
【阐释】阳明病，无汗，本应以葛根汤发其汗，现在竟用火劫迫取汗，则热邪更加炽盛，津液被束缚，不再向外布散与向下渗透了，其身体必然发黄。原文未出方治，根据辨证，必须清热利湿，用栀子柏皮汤主治。
三十六、阳明病，下血谵语的，这是热入血室。①只有头部出汗的，刺期门穴，随其实证而泻之，濈然汗出则痊愈。原文216
①血室：各家见解不一，有的认为是冲脉，有的认为是肝脏，有的认为是子宫，所说都均有一定理由，顾名思义，不外乎血液储留之处，三者均有连带关系，不需强行区分。又少阳篇第18条所指的“血室”即子宫。
郑钦安论述：依据阳明病而下血，必然是胃中有热，逼迫血液下行。谵语，是热气乘袭心神，神志无所主司。这里说热入血室，膀胱之外，即为血海，又称血室，此病系在阳明大肠，怎能直指之为血室呢？怎能刺期门穴呢？只是下血一证，有果真是热逼血下行的，必有热象可征。谵语一证，有阳虚、阴虚、脾虚的不同。更有下血、谵语而将脱的，不能一概而论，学者务必细心探求才能得之。
【阐释】本证由于邪热炽盛，血为热扰，故便血；内热蒸腾，故头汗出；热气乘袭心神，神志无所主司，故谵语。郑氏按语称：“此病系在阳明大肠，怎能直指之为血室呢？怎能刺期门穴呢？……务必细心探求才能得之，”笔者信从他的观点。
三十七、阳明证，其人健忘者①，必有蓄血②，之所以这样，是因为原本就有久瘀血，所以令其健忘，大便虽然坚硬，反而容易排出，其颜色必定黑〔者〕，宜用抵当汤攻下。原文237
①喜忘：喜作善字解，言语动静随过随忘，即健忘之意。
②畜血：畜与蓄字同，瘀血停留叫蓄血。
郑钦安论述：据健忘缘由因瘀血所致，瘀滞不行，气血不得流通，神明寓于气血之中，为气血之主。如今为瘀血所阻，气血不得流通，神明每多昏愦，所以健忘而断定为瘀血，确实无误。但蓄血在太阳，验之于小便，其人如狂；蓄血在阳明，验之于大肠，其色必黑，大便色黑者，是蓄血的验证。
【阐释】太阳蓄血证是太阳之邪热随经入腑与血相结，以致出现少腹急结，或硬满，小便利，如狂、发狂等证候。阳明蓄血证是阳明邪热与宿有的瘀血相结，所以令其健忘。二者证状不同，因蓄血扰乱神志则一。辨太阳蓄血证在于小便之利与不利，辨阳明蓄血证在于大便之黑与不黑、难与不难。两者的病理机转都是属于邪热与血相结，所以都可用抵当汤攻下。
三十八、病人无表里证，发热七八日，虽脉浮数者，可下之。假如已下，脉数不解，合热则消谷善饥，至六七日，不大便者，有瘀血〔也〕，宜抵当汤。若脉数不解，而下利不止，必协热而便脓血也。原文257、258
郑钦安论述：既称无表里证，即不在发表之列，也不在攻下之列，虽脉浮数，总要有风热病情足够证据，方可相机施治。所说发热七八日，然而发热有由外入的发热，有由内而出的发热，大有泾渭之分，如果只凭脉之浮数而攻之，则由外入者，有内陷之变，由内而出者，有亡阳之逆，假如下之后脉数不解，合热则消谷善饥，这是为果有外邪致发热者而言的，而非为内出之发热者而言的。等到六七日，不大便者有瘀血，怎么知道其必有瘀血呢？况且热结而不大便者也很多，此处用抵当汤治之，似乎不恰切，仲师未必果有此说也。
【阐释】郑注此条与历代注家不同，发热有外入与内出之分，若只凭发热而攻之，则有邪热内陷与亡阳之虞。假如已下脉数不解，合热消谷善饥，不大便者，如何辨别，并无征验，况且热结而不大便亦多，提出质疑。最后归结为“此处用抵当汤治之，似乎不恰切，仲师未必果有此说也。”
三十九、病人烦热，汗出则解，又如疟状，日晡所发热者，属阳明也。脉实者，宜下之；脉浮虚者，宜发汗。下之与大承气汤；发汗宜桂枝汤。原文240
郑钦安论述：此条以脉实、脉虚，而定为可汗、可下，似乎未必尽善。
论脉实而要有胃实病形足够证据，方可言下，脉浮虚而要有风邪足够证据，始可言发汗，若专以日晡发热，而定为阳明证，即下之，决不妥切。
【阐释】本条系太阳阳明并病，即表里俱病，必先解表而后攻里。但不能仅根据脉象虚实来决定汗、下，而应结合证状来辨别太阳之表邪是否已解，或阳明之里实是否已成，然后先表后里，解表用桂枝汤，下之与大承气汤，方为合法。
伤寒恒论下
清·郑钦安
阐释·唐步祺
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伤寒恒论卷五
阳明中篇
凡外邪尽入胃腑，谓之正阳阳明，列于此篇，计三十一法（据舒本校增）
一、阳明之为病，胃家实〔是也〕。原文180
郑钦安论述：阳明乃多气多血之府，邪至阳明〔燥〕地，与胃合成一家，其邪易实，故病见邪盛者极多，故曰胃家实。
【阐释】“胃家实”三字是阳明病的提纲。胃家包括肠、胃而言，“实”字有广义和狭义的区别，广义包括经腑两证，狭义就是单指阳明腑证而言。《内经》所说“邪气盛则实”并不仅指有形结滞而言。食物积滞而实者，承气证；热邪积滞而实者，白虎证。
郑钦安论述：一日太阳，二日阳明，三日少阳，乃传经之次第。今三日而见脉大，可知其邪未传少阳，而仍在阳明也，何以知之，浮为太阳，大为阳明，弦为少阳故也。
【阐释】阳明病的脉大，必然大而有力，假使大而无力，或浮大无根，那就不一定全属于阳明病。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。
三、伤寒发热无汗，呕不能食，而反汗出濈濈然者，是转属阳明也。原文185后段
郑钦安论述：按发热无汗，寒伤营也，呕不能食，太阳有寒也，汗出濈濈然者，寒邪外出也。此曰转属阳明，果何所见而然乎？余甚不解。
【阐释】郑氏将《伤寒论》185条分作两条，前段列入阳明上篇第9条，本条即后段。伤寒发热无汗，呕不能食，是少阳小柴胡证，不因发汗而反汗出濈濈然者，此由少阳转属阳明也，如此注释，郑氏之不解可解矣。
郑钦安论述：按转属阳明，必有阳明证足够证据，或见肌肉之间大热，而又见口渴饮冷，气粗口热，蒸蒸汗出，如此言之，则曰转属阳明，方可无疑。而此只凭一濈濈然汗出，而即谓之转属阳明，实不恰切。
【阐释】凡伤寒转属阳明，不论由太阳、少阳、少阴等转系阳明，其人必见濈濈然连绵不已之微汗出也。此其里热亢盛，将水分外熏而为汗，肠中始得结实，而成硬满便难之阳明证。郑氏曰：“而此只凭一濈濈然汗出，而即谓之转属阳明，实不恰切。”舒驰远曰：“此条但据汗出濈濈一端，便是转属阳明，恐不能无疑。若热退身凉，饮食有味，岂非病自解之汗耶？必其人恶热、不恶寒，腹满、按痛、谵语诸证错见，方为有据，否则不足凭也。”故临床不能凭一证以定寒热虚实，须四诊合参乃可。
五、太阳病三日，发汗不解①，蒸蒸发热②者，属胃也，调胃承气汤主之。原文248
②蒸蒸发热：有如蒸笼中热气，从内向外蒸腾一样，热面潮润。
郑钦安论述：按三日，乃少阳主气之期。今太阳发汗而不解，是邪入阳明，而未传经也。观其蒸蒸发热者，阳明内热之征，可以无疑矣。故以调胃承气汤治之，其病自愈。
【阐释】发汗以后，太阳表证虽解，而邪气反化热传里，转为阳明腑实。当时证状，除了蒸蒸发热以外，一定还有腹满、便秘、或心下硬，郁郁微烦等腑实见证，才能使用调胃承气汤。设若没有上述证状，仅凭蒸蒸发热，就使用下法，是不恰当的。
六、阳明病，本自汗出，医更重发汗，病已差，尚微烦不了了者，此〔必〕大便（已）硬故也。以亡津液，胃中干燥，故令大便硬。当问其小便日几行，若本小便日三四行，今日再行，故知大便不久出，今为小便数少，以津液当还入胃中，故知不久必大便也。原文203
郑钦安论述：此由过汗伤及津液，已致胃燥失润，问其小便尚利，津液未竭，故知其不久必便也。
【阐释】阳明病大便硬而难出，有热结与津液不足两端。热结者可以攻下，承气汤之类。津液不足者，必肠中津液增加，大便硬得濡润，无需攻下，亦必然不久自出。至于小便多的，大便必硬；大便溏泄的，小便必少，是诊断大便硬与溏泄的主要关键。今小便少，则津液还停胃中，胃中津液足，则大便润，润则软滑，此其所以必出也。
七、阳明病，自汗出（者），若发汗，小便自利者，此为津液内竭，虽硬不可攻之。当须自欲大便，宜蜜煎导而通之，若土瓜根及（与）大猪胆汁，皆可为导。原文233
郑钦安论述：按汗自出，与小便自利，二者皆是大伤津液，故大便虽硬者，不可攻之，俟其津液自回，亦可自便。此以蜜导法治之，亦切要之法，此又与热结者，不可同法也。
【阐释】本条大便硬，是因自汗出，小便自利而大伤津液，肠中津液枯竭，与阳明中篇第31条津液不行的脾约证，燥热结实的承气证，即郑氏所说热结皆不同，须详辨之，必俟其津液自回，用蜜煎因势利导之。
[Explanation] Epistaxis (nosebleed) can be a favorable sign of disease resolution. Dry mouth and nose, ability to eat, although the Yangming interior syndrome is not fully formed, the internal heat in Yangming is already excessive. When heat is severe, it reverses upward; when it reverses upward, it draws blood upward; when blood flows upward, epistaxis occurs, and the pathogenic heat is discharged along with it. Modern physicians refer to epistaxis as "red sweat," precisely because it discharges stagnant heat. When stagnant heat is discharged, the disease heals spontaneously.
32. In Yangming disease, if there is fever and sweating, this indicates that the heat is venting outward①, and jaundice will not occur; if there is only sweating on the head, no sweating on the body, the sweat stops at the neck, difficulty in urination, and thirst for drinking fluids, this indicates stagnant heat in the interior②, and jaundice will certainly develop. Yinchen Hao Tang (Yin Chen Hao Decoction) should be used to treat it. Original Text 236
① Heat venting outward: Refers to the meaning of interior heat venting to the exterior.
② Stagnant heat: Refers to the stagnation of pathogenic heat.
Zheng's Commentary: The text mentions that when heat vents outward, jaundice does not occur, because sweating indicates that the exterior qi is unobstructed, allowing heat to escape outward. If there is sweating on the head, no sweating on the body, difficulty in urination, and thirst for water, this indicates that heat is concealed within, excessively stagnant, with no pathway for the pathogen to exit, thus forming the pattern of Yang Jaundice. Yinchen Hao Tang (Yin Chen Hao Decoction) is indeed an appropriate formula for this specific pattern.
[Explanation] This section describes the symptoms of jaundice caused by damp-heat stagnation and steaming in Yangming. If there is only sweating on the head and no sweating on the body, the heat cannot vent outward; difficulty in urination means dampness has no outlet. Since pathogenic heat cannot reach the exterior and water-dampness cannot drain downward, water-dampness and pathogenic heat steam each other without resolving, becoming stagnant and obstructed, leading to yellowing of the body and mind. Treatment uses Yinchen Hao Tang (Yin Chen Hao Decoction), which is bitter and cold to unblock and drain, allowing the damp-heat pathogen to exit via urination. When dampness is removed and heat is cleared, jaundice heals spontaneously.
Yinchen Hao Tang Formula (Corrected and Supplemented)
Artemisiae Scopariae Herba (Yin Chen) 6 liang, Gardeniae Fructus (Zhi Zi) 14 pieces (broken), Rheae Radix et Rhizoma (Da Huang) 2 liang (bark removed). These three ingredients are boiled in 12 sheng of water. First boil Artemisiae Scopariae Herba (Yin Chen) until the volume reduces by 6 sheng, then add the other two ingredients, boil to obtain 3 sheng of liquid, remove dregs, and divide into three doses. Urination should become profuse, urine resembling soap pod juice, reddish in color. After one night, abdominal distension decreases, and yellow pigment is eliminated through urination.
[Formula Analysis and Scope of Application] When damp-heat stagnates in the interior and steams outward manifesting as yellow skin, use Artemisiae Scopariae Herba (Yin Chen) for its bitter-cold nature to clear dampness and resolve stagnant heat. Assist with Gardeniae Fructus (Zhi Zi) to clear and promote the San Jiao (Triple Burner) to unblock water passages, and use Rheae Radix et Rhizoma (Da Huang) to eliminate stomach heat, guide fire downward, and clear heat from the blood level. The combination of these three herbs allows stagnant heat and turbid dampness to exit via urination. Once damp-heat is drained, jaundice heals spontaneously. In the *Shanghan Lun* and *Jingui Yaolue*, jaundice is categorized into Yin and Yang types based briefly on skin discoloration. If the whole body and eyes are yellow, bright orange-yellow in color, with difficult urination, dark red scanty urine, abdominal distension, poor appetite, aversion to grease, yellow greasy tongue coating, and slippery rapid pulse, it is classified as Yang Jaundice.
Whether diagnosed in modern medicine as acute icteric infectious hepatitis, chronic hepatitis with predominant damp-heat, hepatobiliary tract infection, or biliary calculi, if presenting with Yang Jaundice patterns, this formula can be modified for treatment.
33. In Yangming disease, if the face is entirely red①, purgation must not be used. (If purged,) fever will inevitably arise, the complexion will turn yellow [if present], and urination will be difficult. Original Text 206
① Face entirely red: Refers to the entire face being flushed red.
Zheng's Commentary: Based on Yangming disease presenting with facial redness, one must observe whether purgation is indicated or contraindicated. If there is coarse breathing, facial redness, cracked lips, and extreme preference for cold drinks, purgation is suitable. However, if there is facial redness without sufficient evidence of heat, purgation is contraindicated. Purging would inevitably cause fever, indicating that True Yang floats upward due to improper purgation. Floating upward prevents transformation of Yin in the Lower Jiao, leading to difficult urination. Scholars must not rigidly assume all Yangming diseases are heat patterns and recklessly apply purgation. Regarding this clause stating purgation is contraindicated and causes fever, how do we know it is not Dai Yang (Floating Yang) syndrome?
[Explanation] Pathogenic heat constrained in the meridians prohibits the use of purgation. Mistaken purgation inevitably causes fever, yellowing of the skin, and difficult urination. To remedy this error, Yinqin Wuling San (Yin Chen Wu Ling Powder) may be used. Zheng further discusses, "Although the face is red without sufficient heat signs, purgation is contraindicated; causing fever implies True Yang floating upward... could it not be Dai Yang (Floating Yang)?" Dai Yang (Floating Yang) is a critical condition requiring large doses of Yang-restoring herbs for rescue.
34. In Yangming disease, with no sweating, difficult urination, and mental restlessness (Ao Nao), jaundice will certainly develop. Original Text 199
Zheng's Commentary: When pathogens enter Yangming and transform into heat, lack of sweating prevents external discharge, and difficult urination prevents downward discharge. Stagnation in the middle causes mental restlessness (Ao Nao), which refers to inner unease, hence predicting certain development of jaundice.
[Explanation] Lack of sweating in Yangming disease indicates damp-heat cannot scatter externally; difficult urination indicates water-dampness cannot descend. Steaming of dampness and heat internally leads to bodily yellowing. Although no formula is provided in the original text, Mahuang Lianqiao Chixiaodou Tang (Ephedra, Forsythia, and Red Bean Decoction) might be considered for external release and internal drainage, or Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) to clear interior heat and reach the exterior, thereby resolving jaundice.
35. In Yangming disease, after fire therapy, slight sweating on the forehead but difficult urination results in certain jaundice. Original Text 200
Zheng's Commentary: Yangming belongs to dryness. Experiencing Yang pathogens and undergoing fire therapy drives fire inward. With blocked urination, heat has no downward exit, causing excessive suppression of heat, thus predicting certain jaundice.
[Explanation] In Yangming disease with no sweating, Ge Gen Tang (Kudzu Decoction) should have been used to induce sweating. Instead, fire therapy was used to force sweating, intensifying heat and binding fluids, preventing external distribution and downward infiltration, leading to certain jaundice. No formula is given in the original text; based on differentiation, clearing heat and promoting diuresis is required, using Zhizi Bopi Tang (Gardenia and Phellodendron Bark Decoction).
36. In Yangming disease, bleeding from the lower orifices accompanied by delirium indicates heat entering the Blood Chamber.① If there is only sweating on the head, puncture Qimen (LR14), draining excess according to the pattern. Profuse sweating follows, and recovery ensues. Original Text 216
① Blood Chamber: Interpretations vary; some consider it the Chong Mai (Penetrating Vessel), others the Liver, and still others the Uterus. All have merit. Etymologically, it refers to a place where blood accumulates; the three are interconnected and need not be strictly distinguished. Note that in Shaoyang Chapter 18, "Blood Chamber" refers specifically to the Uterus.
Zheng's Commentary: Bleeding in Yangming disease suggests stomach heat forcing blood downward. Delirium indicates heat attacking the Heart, leaving the Spirit unanchored. Claiming heat enters the Blood Chamber here is problematic since the pathology lies in the Yangming Large Intestine, not the Blood Chamber, making puncture of Qimen (LR14) inappropriate. While bleeding may result from heat forcing blood down, showing heat signs, delirium varies by deficiency types (Yang, Yin, Spleen). Cases involving bleeding and delirium with impending collapse require careful distinction. Scholars must investigate meticulously.
[Explanation] This pattern arises from intense pathogenic heat disturbing blood, causing bleeding; internal heat steaming causes head sweating; heat attacking the Heart causes delirium. Zheng argues against locating this pathology in the Blood Chamber or using Qimen (LR14) puncture, advocating careful investigation instead. I follow his view.
37. In Yangming patterns, if the patient suffers from forgetfulness①, there must be accumulated blood②. This is because pre-existing long-standing blood stasis causes forgetfulness. Although stool is hard, it passes easily, and its color is definitely black [indicative]. Diding Tang (Di Dang Decoction) should be used to purge. Original Text 237
① Forgetfulness: "Xi" (likes) is interpreted as "Shan" (prone to), meaning prone to forgetting words and actions immediately after they occur.
② Accumulated Blood: "Chu" is synonymous with "Xu" (store/accumulate); retained blood stasis is called accumulated blood.
Zheng's Commentary: Forgetfulness stems from blood stasis obstructing flow, preventing Qi and Blood circulation. Spirit resides in Qi and Blood. Obstruction by blood stasis causes mental confusion and forgetfulness, confirming blood stasis accurately. Sun Tai accumulated blood is verified by urinary issues and manic behavior; Yangming accumulated blood is verified by bowel movements and black stool color. Black stool confirms accumulated blood.
[Explanation] Sun Tai accumulated blood involves pathogenic heat entering the Fu organs via meridians, binding with blood, causing lower abdominal urgency/fullness, normal urination, and manic behavior. Yangming accumulated blood involves Yangming heat binding with existing blood stasis, causing forgetfulness. Both involve heat-blood binding affecting the spirit, treated with Diding Tang (Di Dang Decoction). Differentiation relies on urination status for Sun Tai and stool color/consistency for Yangming.
38. A patient presents without exterior or interior syndromes, with fever for seven to eight days. Even if the pulse is floating and rapid, purgation may be used. If purgation has been applied and the rapid pulse persists, combined heat causes efficient digestion and frequent hunger. By the sixth or seventh day, if constipation occurs, blood stasis is present, and Diding Tang (Di Dang Decoction) is indicated. If the rapid pulse persists and diarrhea continues, heat-collaborating dysentery with pus and blood in stool will occur. Original Texts 257, 258.
Zheng's Commentary: Without exterior or interior syndromes, neither releasing the exterior nor purging is indicated. Despite a floating-rapid pulse, sufficient evidence of wind-heat is needed before treatment. Fever lasting seven to eight days distinguishes between external invasion and internal emergence. Relying solely on pulse for purgation risks internal sinking of external pathogens or Yang collapse from internal heat. If purgation fails to resolve the rapid pulse and heat causes hunger, this applies to external pathogen-induced fever, not internal fever. Constipation at six to seven days suggests blood stasis, but heat accumulation also causes constipation. Using Diding Tang (Di Dang Decoction) here seems inappropriate; Zhang Zhongjing likely did not intend this literally.
[Explanation] Zheng’s note differs from previous commentators, distinguishing external vs. internal fever. Blind purgation risks heat sinking or Yang collapse. Persistent rapid pulse post-purgation with hunger and constipation lacks clear verification, as heat accumulation also causes constipation. Zheng questions the literal application of Diding Tang (Di Dang Decoction) here.
39. Patients experience irritability and heat, resolving with sweating. Symptoms resemble malaria, with afternoon fever, indicating Yangming involvement. If the pulse is excess, purgation is suitable; if floating and deficient, sweating induction is suitable. Use Dachengqi Tang (Major Order the Qi Decoction) for purgation; Guizhi Tang (Cinnamon Twig Decoction) for sweating. Original Text 240.
Zheng's Commentary: Determining sweating or purgation based solely on excess or deficient pulses is not entirely sound. Pulse excess requires sufficient evidence of stomach excess to justify purgation; pulse floating-deficient requires sufficient wind-pathogen evidence for sweating. Relying solely on afternoon fever to diagnose Yangming and purge is inappropriate.
[Explanation] This clause describes concurrent Taiyang-Yangming disease (exterior and interior involvement). Exterior must be resolved first. Pulse alone is insufficient; clinical signs must determine if Taiyang exterior is resolved or Yangming interior excess is formed. Resolve exterior with Guizhi Tang (Cinnamon Twig Decoction), then purge interior with Dachengqi Tang (Major Order the Qi Decoction).
Shanghan Henglun Volume 5
Middle Chapter of Yangming
When external pathogens fully enter the Stomach Fu organs, it is called Zheng Yang Yangming (True Yang Yangming). This chapter lists thirty-one methods (added according to Shu's edition).
1. The essence of Yangming disease is Wei Jia Shi (Stomach Family Excess) [is it]. Original Text 180.
Zheng's Commentary: Yangming is a reservoir of abundant Qi and Blood. When pathogens reach the dryness terrain of Yangming, they merge with the Stomach, easily becoming excess. Thus, many cases show strong pathogens, hence "Wei Jia Shi" (Stomach Family Excess).
[Explanation] "Wei Jia Shi" (Stomach Family Excess) is the guiding principle of Yangming disease. "Wei Jia" includes intestines and stomach. "Shi" (Excess) has broad and narrow meanings: broadly including Jing and Fu syndromes, narrowly referring only to Yangming Fu syndrome. *Neijing* states "excess of pathogen is Shi," not limited to tangible obstruction. Food stagnation causing excess is Chengqi pattern; heat stagnation causing excess is Baihu pattern.
2. After three days of Shanghan, the Yangming pulse is large. Original Text 186.
Zheng's Commentary: Day 1 Taiyang, Day 2 Yangming, Day 3 Shaoyang represents transmission sequence. Seeing a large pulse on Day 3 indicates pathogens have not transmitted to Shaoyang but remain in Yangming. How do we know? Floating is Taiyang, Large is Yangming, Wiry is Shaoyang.
[Explanation] Yangming large pulse must be large and forceful. If large but weak, or floating-large rootless, it may not belong entirely to Yangming. "Three days, Yangming large pulse" refers to the pure large pulse of Zheng Yang Yangming, not mixed with Taiyang floating-large or Shaoyang wiry-large.
3. Shanghan with fever, no sweating, vomiting, inability to eat, yet suddenly sweating continuously (Jie Jie Ran) indicates transmission to Yangming. Original Text 185 (second half).
Zheng's Commentary: Fever and no sweating indicate Cold injuring Ying; vomiting and inability to eat indicate Taiyang Cold. Continuous sweating indicates Cold pathogen exiting. Why call this transmission to Yangming? I am confused.
[Explanation] Zheng divides Text 185. The first part is in Yangming Upper Chapter 9. This second half: Fever, no sweating, vomiting, inability to eat resembles Shaoyang Xiaochaihu Tang (Minor Chai Hu Decoction) pattern. Sudden continuous sweating after not inducing sweat indicates transmission from Shaoyang to Yangming. This clarifies Zheng's confusion.
4. Shanghan transmitting [to] Yangming manifests as [the person having] continuous slight sweating. Original Text 188.
Zheng's Commentary: Transmission to Yangming requires sufficient Yangming signs, such as significant heat in muscles, thirst for cold drinks, coarse breath, hot mouth, and steaming sweating. Only then can we confidently say transmission to Yangming. Relying solely on continuous sweating is inadequate.
[Explanation]: Any Shanghan transmitting to Yangming, regardless of origin (Taiyang, Shaoyang, Shaoyin), presents with continuous slight sweating. This indicates intense interior heat steaming fluids outward as sweat, leading to intestinal drying, hardness, fullness, and difficult defecation—Yangming Fu syndrome. Zheng criticizes relying solely on sweating. Shu Chi Yuan notes doubt, suggesting additional signs like aversion to heat, abdominal fullness/tenderness, and delirium are necessary for confirmation. Clinical diagnosis requires Four Examinations, not single signs.
5. Taiyang disease for three days, sweating fails to resolve①, steaming fever② indicates involvement of the Stomach. Tiaowei Chengqi Tang (Regulate the Stomach Order the Qi Decoction) should be used. Original Text 248.
① Sweating fails to resolve: Heat illness persists after sweating, not unresolved Taiyang disease.
② Steaming fever: Heat steams outward from inside like a steamer, with moist heat surface.
Zheng's Commentary: Three days is the Shaoyang ruling period. Taiyang sweating failing to resolve indicates pathogen entered Yangming without further transmission. Steaming fever confirms interior Yangming heat. Tiaowei Chengqi Tang (Regulate the Stomach Order the Qi Decoction) cures it.
[Explanation]: After sweating, Taiyang exterior resolves, but pathogen transforms into heat entering interior, becoming Yangming Fu excess. Besides steaming fever, signs like abdominal fullness, constipation, epigastric hardness, and mild vexation must exist to use Tiaowei Chengqi Tang (Regulate the Stomach Order the Qi Decoction). Using purgation solely for steaming fever is inappropriate.
6. Yangming disease, originally sweating, doctor induces heavy sweating again. Disease improves, but slight vexation remains unresolved. This [certainly] means stool is [already] hard due to loss of Body Fluids, drying the Stomach. Ask about daily urination frequency. If originally 3-4 times daily, now twice, expect stool soon as fluids return to Stomach. If urination decreases significantly, fluids return to Stomach, ensuring soft stool passage. Original Text 203.
Zheng's Commentary: Over-sweating injured fluids, causing Stomach dryness. Urination remains adequate, fluids not exhausted, so stool will pass soon.
[Explanation]: Yangming hard stool has two causes: Heat accumulation (treatable with purgation like Chengqi formulas) or Fluid deficiency (requires fluid restoration, spontaneous passage). Frequent urination leads to hard stool; loose stool implies scanty urination. Scanty urination means fluids return to Stomach, moistening stool for easy passage.
7. Yangming disease, spontaneous sweating (or induced sweating), with spontaneous profuse urination, indicates internal exhaustion of Body Fluids. Even if stool is hard, do not purge. Wait for natural urge to defecate, use Honey Suppository to guide passage. Tu Gua Gen (Radix Trichosanthis Kirilowii) or large pig bile can also be used as guides. Original Text 233.
Zheng's Commentary: Spontaneous sweating and profuse urination both severely injure fluids. Hard stool should not be purged; wait for fluid recovery. Honey suppository is a crucial method, distinct from treating heat accumulation.
[Explanation]: Hard stool here results from fluid exhaustion due to sweating and diuresis, differing from Pi Yue Syndrome (Spleen Constraint) or heat-stagnation Chengqi patterns. Must distinguish carefully. Wait for fluid recovery and use honey suppository to guide passage顺势.