此为危恶之候。阳明里热之极。脉弦者生。脉涩者死。以弦长胃气尚存。可下承气故也。然亦危
极矣。盖生者未必尽生。而死者断无可生之理。
邵评∶此症胃气不虚者。尚可救治。然亦危险。虚者必死无疑。
若见于三法之后。乃大虚之兆。不必辨其阴阳虚实。当以独参汤六味饮时时与
之。每有生者。
经云。病患不恶寒而渴者。此转属阳明也。故渴列阳明门。然六经皆有渴病者。（参准绳）
邵评∶渴虽属阳明。然六经皆有渴症。
渴病多因三法伤其津液。胃中干燥。故渴。阳邪往乘三阴。太阴则嗌干。少阴则口燥。厥阴则消渴。
亦属热伤津液也。太阳之渴。用五苓散者。以水停下焦。小便不便也。阳明之渴。用白虎汤者。以胃
热饮水不已也。少阳症具。心烦渴。而用小柴胡汤和解。去半夏加花粉者。避燥以生津液也。（以上参金鉴）
凡渴欲饮水者。当少与之。以滋胃燥。则胃和而愈。若恣意饮之。必致停水为病。
江苏闽浙。天气温暖。地势卑湿。乃天下湿热之区。阳明气盛血热。容纳水谷。亦人
身湿热之薮。若感风温风热之邪。病都不由太阳而入阳明者。（口鼻吸入）或从太阳而
即入阳明者。（皮毛传入）阳明内热之邪。与外邪风热相搏。凝滞成毒。每多发 发疹。若
不辨明热与寒邪之异。概用太阳经药发表。汗不得出。 不得透。温热内燔。烁干胃中津液。而成坏症。
死者多矣。用将阳明热病诸条胪列于后。惟在临症者之圆机焉。
凡遇发热身痛。口渴唇燥。或初起微寒。即发热不已。舌苔中黄边白。或黄燥如刺。
脉来洪滑。此阳明内热。为外感新邪引动而发也。宜犀角、连翘、牛蒡、薄荷、黄芩、葛根、防风、木通之类。清解之。
若见烦闷呕恶。足冷耳聋。脉沉伏。或浮躁者。此 疹欲透也。亦用此方透 解毒。渴而干呕者。加芦根一
握。如遇脉象沉郁。不可认为寒。此必 透不快也。如关上见伏脉。此必热毒凝滞。 不得出也。若右关脉
伏。而兼胸痛气急。或咳者。此必有伏痰也。又当以治痰为主。总以舌苔黄燥为实热之凭。
勿以脉象沉迟为虚寒之验也。阳明以胃实为病。故大便不通。然热邪外无出路。每每下逼大肠。而下黄黑稠粘
之粪。下时肛门必有热气。此因外不得解。而邪从下泄。虽通仍作不通论。勿止之。或从下泄之后。反能得
汗而解。即不能得汗。亦只清火解毒。兼养阴液。其邪自能渐解身凉。或从养阴之后。阴液外溢。反得大汗而
解。或有热毒内结。 疹不得外透。反从下泄之后。 疹始出。或用透发不应。只用清火解毒。 疹反透。
此皆热毒内结使然。（以舌苔黄燥者论阳明内热引发）
邵评∶伤寒与温热。本自不同。伤寒大便溏。为邪已尽。温热大便溏。为邪未尽。必大便硬。乃为无湿。
斯不可再攻耳。惟热毒总以舌苔黄燥为凭。若新邪外触内发。伏邪重而新邪轻。势所必然。
如 疹已透。只宜清解毒火。微兼养阴。柴葛升提之品。俱不可投。宜连翘、赤芍、元参、花粉、知
母、黄芩、银花、鲜生地、人中黄之类。 毒自化矣。
邵评∶余毒未清。禁用升提。
若见舌绛如朱。目赤如火。口燥唇裂。汗出津津。此阳明血热。邪从内发。已遍三焦。
即阳明热病也。切忌风药升散。宜凉膈散。去芒硝、大黄。加石膏、牛蒡、赤芍、鲜生地、
牡丹皮主之。大便秘者。去硝留黄。（阳明血分热病）
邵评∶阳明血分热病。忌用升提。
若见发热自汗。舌自如刺。或黄燥口渴。不恶寒。反恶热。此阳明气分之热。宜栀子
豉汤。加连翘、黄芩、淡竹叶、芦根之类清之。（阳明气分热病）
邵评∶此阳明气分热病正治法。
化 解毒之后。或汗解之后。尚有余热未退。大便虽闭。腹中调和者。只宜养阴退
阳。甘露饮加减妙。阴液复。余邪自退。大便自通矣。
有身热已退。独额热未除者。此胃中有余邪也。宜清疏阳明。如连翘、黄芩、生楂、麦
芽、枳壳、金斛之类。如已身凉。独腹热未退。此脾家有火也。加生白芍清之。
这是极其危重的证候。阳明里热达到极点。脉象弦的有生机，脉象涩的预后不良。因为弦长之脉表示胃气尚存，可以使用承气汤类方剂攻下，所以可生。然而病情也极为危险了。大概有生机的人未必都能痊愈，而脉涩无胃气者断无生还的道理。
邵评：此症如果胃气不虚，还可以救治，但也十分危险。若胃气已虚，则必定死亡无疑。
如果这种症状出现在汗、吐、下三法治疗之后，那是正气大虚的征兆，不必辨别是阴证还是阳证、虚证还是实证，应当用独参汤和六味地黄汤频繁给予服用，常常能挽救生命。
经书说：病人不恶寒而口渴的，这是病邪转入阳明经的表现。所以将口渴列在阳明篇中。然而六经都有出现口渴病症的情况。（参考《医宗必读》）
口渴病症多因汗、吐、下三法损伤津液，导致胃中干燥，因而口渴。阳热之邪乘袭三阴经，侵犯太阴经则咽喉干燥，侵犯少阴经则口燥，侵犯厥阴经则消渴。这也属于热邪损伤津液所致。太阳病的口渴，使用五苓散，是因为水饮停聚在下焦，小便不利。阳明病的口渴，使用白虎汤，是因为胃热炽盛，饮水不止。少阳病具备相应症状，心烦且口渴，使用小柴胡汤进行和解，去掉半夏加入天花粉，是为了避免半夏的燥性以生津液。（以上参考《医宗金鉴》）
凡是想要喝水的病人，应当少量给予饮水，以滋润胃中的燥热，胃气和顺即可痊愈。如果肆意大量饮水，必然导致水饮停聚成为疾病。
江苏、福建、浙江等地，气候温暖，地势低洼潮湿，是天下的湿热区域。阳明经气盛而血热，负责容纳水谷，也是人身湿热聚集之处。如果感受风温或风热邪气，病邪都不从太阳经传入而直接入阳明经。（通过口鼻吸入）或者从太阳经迅速传入阳明经。（通过皮毛传入）阳明内部的火热邪气，与外来的风热邪气相互搏结，凝结成毒，经常多发斑疹。如果不辨明热邪与寒邪的区别，一概使用太阳经的药物发表解表，汗不得出，斑疹不得透发，温热之邪在内焚烧，灼干胃中的津液，从而形成坏病（变证），死亡的很多。现将阳明热病的各种条文列举在后面，全凭临证医生的灵活变通。
凡是遇到发热身痛，口渴唇燥，或者初起时轻微恶寒，随即持续发热，舌苔中间黄边缘白，或者黄燥如刺，脉象洪滑，这是阳明内部的热邪，被外感的新邪引动而发作。适宜使用犀角、连翘、牛蒡子、薄荷、黄芩、葛根、防风、木通等药物，进行清热解表。
如果见到烦闷呕恶，足冷耳聋，脉象沉伏，或者浮躁，这是斑疹欲透发的表现。也使用上述方剂来透发解毒。如果口渴且干呕，加芦根一把。如果遇到脉象沉郁，不可认为是寒证，这一定是斑疹透发不畅。如果关部脉象伏匿，这一定是热毒凝滞，斑疹不能透出。如果右关脉伏，兼有胸痛气急，或者咳嗽，这一定是有伏痰存在。又应当以治痰为主。总之以舌苔黄燥作为实热的依据，不要以脉象沉迟作为虚寒的证据。阳明病以胃实为特点，所以大便不通。然而热邪向外没有出路，往往向下逼迫大肠，排出黄黑稠粘的大便。排便时肛门必有热气冒出。这是因为邪气向外不得解散，而从下面泄出，虽然通了仍当作不通来处理，不要止泻。或者在排泄之后，反而能出汗而痊愈。即使不能出汗，也只是清火解毒，兼养阴液，邪气自然能逐渐解除，身体变凉。或者在滋养阴液之后，阴液外溢，反而大汗淋漓而痊愈。或者有热毒内结，斑疹不能向外透发，反而在排泄之后，斑疹才出来。或者使用透发方法无效，只用清火解毒，斑疹反而透发。这都是热毒内结造成的。（根据舌苔黄燥来判断阳明内热引发）
邵评：伤寒与温热病，本来不同。伤寒大便溏薄，说明邪气已尽；温热病大便溏薄，说明邪气未尽。必须到大便坚硬，才是没有湿邪，这时才不能再攻下。只有热毒总是以舌苔黄燥为依据。如果是新邪外触内发，伏邪重而新邪轻，这是势所必然的。
如果斑疹已经透发，只宜清解毒火，微微兼以养阴。柴胡、葛根、升麻等升提的药物，都不可投用。适宜使用连翘、赤芍、玄参、天花粉、知母、黄芩、金银花、鲜生地、人中黄等药物，毒邪自然化解。
如果见到舌色红绛如朱砂，眼睛红赤如火，口燥唇裂，汗出津津，这是阳明血分热盛，邪气从内部发出，已经遍布三焦。这就是阳明热病。切忌使用风药升散。适宜使用凉膈散，去掉芒硝、大黄，加入石膏、牛蒡子、赤芍、鲜生地、牡丹皮为主药。大便秘结的，去掉芒硝保留大黄。（这是阳明血分热病）
如果见到发热自汗，舌面如刺状，或者黄燥口渴，不恶寒，反恶热，这是阳明气分的热邪。适宜使用栀子豉汤，加入连翘、黄芩、淡竹叶、芦根等药物来清热。（这是阳明气分热病）
邵评：这是治疗阳明气分热病的正治法。
化解毒邪之后，或者汗解之后，尚有余热未退，大便虽然闭塞，但腹中调和舒适的，只宜养阴退阳，甘露饮加减效果奇妙。阴液恢复，余邪自然消退，大便自然通畅。
有身体热势已退，唯独额头热度未除的，这是胃中有余邪。适宜清疏阳明经，如使用连翘、黄芩、生山楂、麦芽、枳壳、金钗石斛等药物。如果已经身体凉爽，唯独腹部热度未退，这是脾家有火，加入生白芍来清之。
This is a critical and ominous syndrome. The interior heat of the Yangming channel has reached its extreme. A wiry (Xian) pulse indicates survival, while a choppy (Se) pulse indicates death. This is because a long and wiry pulse suggests that the Stomach Qi remains intact, allowing for the use of Chengqi Tang (Cassia Twig Decoction) to purge, thus offering a chance of life. However, the condition is extremely perilous. Generally, those with a chance of survival may not all recover, whereas those with no Stomach Qi have absolutely no hope of recovery.
Shao's Commentary: If the Stomach Qi is not deficient in this syndrome, it can still be treated, but it remains dangerous. If the Stomach Qi is already deficient, death is inevitable.
If this symptom appears after the application of the sweating, vomiting, or purging methods, it signifies a severe deficiency of Zheng Qi (Upright Qi). There is no need to distinguish between Yin/Yang or Deficiency/Excess syndromes. One should frequently administer Dushen Tang (Single Ginseng Decoction) and Liuwei Dihuang Wan (Six-Ingredient Rehmannia Pill) to nourish the body, which often leads to recovery.
The Classics state: "When a patient does not feel aversion to cold but experiences thirst, the pathogen has transferred to the Yangming channel." Therefore, thirst is categorized under the Yangming section. However, thirst can occur in all six channels. (Referenced from *Yi Zong Bi Du*)
Shao's Commentary: Although thirst is predominantly associated with Yangming, it can manifest in all six channels.
Thirst syndromes are mostly caused by damage to Jin Ye (Body Fluids) due to sweating, vomiting, or purging, leading to dryness in the Stomach. When Yang-pathogenic heat attacks the Three Yin channels, it causes dryness of the throat in Taiyin, dry mouth in Shaoyin, and Xiao Ke (Wasting-Thirst) in Jueyin. These also result from heat damaging body fluids. For thirst in Taiyang syndrome, Wuling San (Five-Ingredient Powder with Poria) is used because water retention in the Lower Jiao impedes urination. For thirst in Yangming syndrome, Baihu Tang (White Tiger Decoction) is used because excessive Stomach heat drives constant drinking. For Shaoyang syndrome presenting with irritability and thirst, Xiaochaihu Tang (Minor Bupleurum Decoction) is used for harmonization; Banxia (Pinellia Rhizome) is removed and Huafen (Trichosanthes Root) added to avoid dryness and generate fluids. (Referenced from *Yi Zong Jin Jian*)
For patients desiring water, small amounts should be given to moisten Stomach dryness; once the Stomach harmonizes, the disease resolves. Indiscriminate large-volume drinking will inevitably lead to water retention pathology.
Jiangsu, Fujian, and Zhejiang regions are warm and humid, being areas of damp-heat in the world. The Yangming channel possesses abundant Qi and hot Blood, responsible for receiving and digesting food and water, making it a reservoir for damp-heat in the human body. If one contracts Wind-Warmth or Wind-Heat pathogens, the disease may enter Yangming directly without passing through Taiyang (via inhalation through nose and mouth), or rapidly transfer from Taiyang to Yangming (via skin and hair pores). The internal heat of Yangming combats with external Wind-Heat, condensing into toxicity, often causing macules and papules (Zhen). If the difference between Heat and Cold pathogens is not distinguished, and Taiyang-releasing herbs are indiscriminately used, sweat will not emerge, and rashes will not erupt. Warm-heat burns internally, scorching Stomach fluids, resulting in complicated diseases (Huai Zheng), with many deaths. The following sections detail various Yangming heat syndromes, relying on the clinician's flexibility.
Whenever encountering fever, body pain, thirst, dry lips, or initial mild aversion to cold followed by persistent fever, with a tongue coating yellow in the center and white at the edges, or yellow and dry like thorns, and a surging (Hong) and slippery (Hua) pulse, this indicates Yangming internal heat triggered by new external pathogens. It is suitable to use Xijiao (Rhinoceros Horn - *Note: Substitute with Buffalo Horn in modern practice*), Lianqiao (Forsythia Fruit), Niubangzi (Arctium Fruit), Bohe (Mint), Huangqin (Scutellaria Root), Gegen (Kudzu Root), Fangfeng (Saposhnikovia Root), Mutong (Akebia Stem), etc., to clear and resolve.
If irritability, nausea, cold feet, deafness, a deep (Chen) or floating-restless pulse appear, this indicates the rash is about to erupt. Use the same formula to promote eruption and resolve toxicity. If there is thirst with dry retching, add a handful of Lugen (Reed Rhizome). If the pulse is deep and depressed, do not mistake it for cold; this indicates poor eruption. If the Guan position pulse is hidden (Fu), it indicates heat-toxin stagnation preventing eruption. If the Right Guan pulse is hidden with chest pain, shortness of breath, or cough, it indicates latent Phlegm; treatment should focus on resolving phlegm. Overall, rely on yellow and dry tongue coating as evidence of Excess-Heat, and do not interpret a deep-slow pulse as Deficiency-Cold. Yangming disease is characterized by Stomach excess, leading to constipation. However, when heat pathogens have no exit, they often press downward into the Large Intestine, expelling yellow-black, thick, sticky stool. Hot air must escape from the anus during defecation. This occurs because the pathogen cannot be resolved externally and exits downward. Even if bowel movements occur, treat it as obstruction; do not stop diarrhea. Sometimes, after defecation, sweating occurs leading to resolution. If sweating does not occur, only clear fire, resolve toxicity, and nourish Yin fluids; the pathogen will gradually resolve, and the body will cool. Alternatively, after nourishing Yin, if fluids overflow externally, profuse sweating may occur leading to resolution. If heat-toxin is internally bound, preventing rash eruption, the rash may only appear after defecation. If eruption-promoting methods fail, using only fire-clearing and detoxifying methods may cause the rash to erupt. All these are caused by internally bound heat-toxin. (Determine Yangming internal heat based on yellow-dry tongue coating.)
Shao's Commentary: Shanghan (Cold Damage) and Wenre (Warm Disease) are fundamentally different. In Shanghan, loose stools indicate the pathogen is exhausted; in Warm Disease, loose stools indicate the pathogen is not exhausted. Only when stools become hard is it confirmed that there is no dampness, and only then should purgatives be avoided. Heat-toxin is always judged by yellow-dry tongue coating. If new pathogens trigger internal latent pathogens, where latent pathogens are heavy and new ones light, this is inevitable.
Once the rash has erupted, only clear toxic fire and slightly nourish Yin. Herbs that lift and ascend, such as Chaihu (Bupleurum Root), Gegen (Kudzu Root), and Shengma (Cimicifuga Rhizome), must not be used. Suitable herbs include Lianqiao (Forsythia Fruit), Chishao (Red Peony Root), Xuanshen (Scrophularia Root), Huafen (Trichosanthes Root), Zhimu (Anemarrhena Rhizome), Huangqin (Scutellaria Root), Yinhua (Honeysuckle Flower), Xianshengdi (Fresh Rehmannia Root), Renzhonghuang (Human Midden Yellow), etc. The toxin will naturally transform.
Shao's Commentary: With residual toxins uncleaned, lifting herbs are contraindicated.
If the tongue is crimson red like cinnabar, eyes are red like fire, mouth and lips are dry and cracked, and there is continuous sweating, this indicates Yangming Blood-Heat, with pathogens emerging internally and spreading throughout the Three Jiao. This is Yangming Heat Disease. Wind-dispersing herbs must be strictly avoided. Liangge San (Cool the Upper Jiao Powder) is suitable, removing Mangxiao (Mirabilite) and Dahuang (Rhubarb Root), adding Shigao (Gypsum), Niubangzi (Arctium Fruit), Chishao (Red Peony Root), Xianshengdi (Fresh Rehmannia Root), and Mudanpi (Moutan Cortex). If constipated, remove Mangxiao but keep Dahuang. (This is Yangming Blood-Heat Disease).
Shao's Commentary: Yangming Blood-Heat Disease contraindicates lifting herbs.
If fever, spontaneous sweating, a prickly tongue surface, or yellow-dry thirst, aversion to heat rather than cold are observed, this is Heat in the Qi level of Yangming. Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) is suitable, adding Lianqiao (Forsythia Fruit), Huangqin (Scutellaria Root), Danzhuye (Lophatherum Leaf), and Lugen (Reed Rhizome) to clear heat. (This is Yangming Qi-Level Heat Disease).
Shao's Commentary: This is the standard treatment for Yangming Qi-Level Heat Disease.
After resolving toxicity or achieving resolution through sweating, if residual heat remains and although stools are closed, the abdomen feels comfortable, only nourish Yin and retreat Yang. Ganlu Yin (Sweet Dew Drink) modified is excellent. Once Yin fluids are restored, residual pathogens recede, and bowels open naturally.
If body heat has subsided but forehead heat persists, this indicates residual pathogens in the Stomach. Clear and disperse Yangming using Lianqiao (Forsythia Fruit), Huangqin (Scutellaria Root), Shengzha (Raw Hawthorn Seed), Maiya (Barley Sprout), Zhike (Aurantii Fructus), and Jinhu (Dendrobium Stem). If the body is cool but abdominal heat persists, this indicates Fire in the Spleen; add Baishao (White Peony Root) to clear it.