按阳明提纲。以里症为主。虽有表症。仲景意不在表。为有诸中而形诸外之谓也。或兼经病。仲景意不在经。
为表在经而根于胃也。太阴阳明同处中州。而太阴为开。阳明为合。故阳明必以 病为主。不大便固 也。不小便亦合
也。不能食。食难用饱。初欲食。反不能食。皆 也。自汗盗汗。表开而里 也。反无汗。内外皆 也。种种 病。或
然或否。故提纲独以胃实为正。胃实不是竟指燥粪坚硬。只对下利言。下利是胃家不实矣。故汗出解后。胃中不和。而
下利者。不称阳明病。如胃中虚而不下利者。便属阳明。即初硬后溏。水谷不别。虽死而不下利者。总为阳明病也。盖
阳明太阴同为仓廪之官。而所司各别。胃司纳。故以阳明主实。脾司输。故太阴主利。同一胃腑。而分治如此。是二经
所由分也。按阳明为传化之府。当更实更虚。食入胃实而肠虚。食下肠实而胃虚。若但实不虚。则为阳明之病根矣。
胃实不是阳明病。而阳明之为病。悉从胃实上得来。故以胃家实为阳明一经总纲也。然致实之由。是宜详审。有实于未
病之先者。有实于得病之后者。有风寒外来。热不得越而实者。有妄汗吐下。重亡津液而实者。有从本经热盛而实者。
有从他经转属而实者。此只举其病根在实。而勿得以胃实即为可下之症。
身热汗自出。不恶寒。反恶热。是阳明表症之提纲。故胃中虚冷。亦得称阳明病者。因其表症如此也。然此为内热
达外之表。非中风伤寒之表。此时表寒已散。故不恶寒。里热闭结。故反恶热。只因有胃家实之病根。即见此身热自汗
出之外症。不恶寒反恶热之病情。然此但言病机发现。非即可下之症也。必 语潮热烦躁胀痛。诸症兼见。才可下耳。
太阳总纲。示人以正面。阳明总纲。反示人以底板。其正面与太阳之表同。又当看出阳明之表。与太阳不同矣。如
阳明病。脉迟汗出多。微恶寒者。是阳明之桂枝症。阳明病脉浮无汗而喘者。是阳明之麻黄症。本论云。病得之一日。
不发热而恶寒者。即此是已。后人见太阳已得此脉症。便道阳明不应有此脉症。故有尚在太阳。将入阳明之说。不知仲
景书。多有本条不见。而他条中发见者。若始虽恶寒。与反无汗等句是也。以阳明表症。本是汗出不恶寒。故加反无字
耳。有本经未宣。而他经发现者。若太阳之头项强痛。少阳之脉弦细者是也。然头痛而项不强。脉大而不弦细。便是阳
明之表矣。夫太阳行身之后。阳明行身之前。所受风寒。俱在营卫之表。太阳营卫有虚实。阳明营卫亦有虚实。虚则桂
枝。实则麻黄。是仲景治表邪之定局也。仲景之方。因症而设。非因经而设。见此症。便与此方。是仲景之活法。后人
妄以方分经络。非惟阳明不敢用二方。即太阳亦弃之久矣。
阳明之表有二。有外邪初伤之表。有内热达外之表。外邪之表。只在一二日间。其症微恶寒。汗出多。或无汗而喘
者是也。内热之表在一二日后。其症身热汗自出。不恶寒。反恶热是也。表因风寒外来。故仲景亦用麻黄桂枝二汤汗之。
表因内热外发。故仲景更制栀子豉汤。因其热而吐之。后人认不出阳明表症。一二日既不敢用麻黄。二三日来又不知用
栀子豉汤。不识仲景治阳明之初法。所以废弃阳明之吐法。必待热深实极。以白虎承气投之。是养虎遗患也。
六经伤寒。惟阳明最轻者。以阳明为水谷之海。谷气足以胜邪气。阳明为十二经脉之长。气血足以御寒气。阳明居
两阳合明之地。阳气足以御阴气也。阳明受邪。一日恶寒。与太阳同。二日便不恶寒。反恶热。故内经曰。二日阳明受
之。以阳明之症。在二日见。非谓阳明之病。在太阳交也。仲景曰。伤寒三日阳明脉大。要知阳明伤寒。祗在一日二日
即寒去而热生。三日见阳明之脉大。则全无寒气。便是阳明之病热。而非复前日之伤寒。始虽由于伤寒。今不再称伤寒。
以伤寒之剂治之矣。
阳明之恶寒。二日自止。固与他经不同。其恶寒微。又不若太阳之甚。阳明在肌肉中蒸蒸发热。但热无寒。与太阳
翕翕发热。寒束于皮毛之上者不同。阳明自汗。亦异于太阳中风之自汗。太阳虽自汗。而出之不利。有执持之意。故其
状曰。 。阳明自汗。多有波澜摇动之状。故名之曰 。太阳之脉浮而紧者。必潮热。太阳之脉但浮者。必无汗。
阳明脉但浮者。必盗汗出。二经表症。表脉。不同如此。
今伤寒书。以头痛分三阳。阳明之痛在额。理固然也。然阳明主里。头痛非其本症。内经曰。伤寒一日。巨阳受之。
以其脉连风府。故头项痛也。七日太阳病衰。头痛少愈也。二日阳明受之。其脉夹鼻络于目。故身热目疼。鼻干不得卧。
是内经以头痛属太阳。不属阳明矣。仲景有阳明头痛症二条。一日阳明病。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。此头痛在二三日。而不在得病之一日。且因于呕咳。而不因于外邪
也。一日伤寒不大便。六七日头痛不热者。与承气汤。此头痛反在太阳衰时。而因于不大便。即内经所云。 胀而头痛。
非因于风寒也。其中风伤寒诸条。俱不及头痛症。则阳明头痛。又与太阳迥别矣。本论云。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。此处当直接栀子豉汤主之句。若发汗三段。因不用此方。而妄治所致。仍
当栀子豉汤主之。仲景但于结句一见。是省文法也。后人竟认栀豉汤。为汗下后救逆之剂。请问未汗下前。仲景何法以
治之乎。要知咽燥。口苦。腹满而喘。是阳明里热。发热汗出。不恶寒。反恶热。是阳明表热。因阳明之热。自内达表。
则里症为重。故此条叙症。以里症列表症之前。任栀子以清里热。而表热亦解。用香豉以泻腹满。而身重亦除。后人不
能于仲景书中。寻出阳明之表。而远引内经热府论之目痛鼻干。不得卧以当之。不得仲景阳明治表之法。妄引痘科中葛
根升麻以主之。不知内经因论热病。而只发阳明经病之一端。仲景立阳明一经。是该内外症治之全法。又不知目痛鼻干。
是阳盛阴虚。法当滋阴清火。而反发阳明之汗。若上而鼻衄。下而便难。是引贼破家矣。要知是风寒之表。则用麻黄而
治。如是内热之表。即荆防薄荷皆足以亡津液。而成胃实。在用者如何耳。治阳明内热之表有三法。如热在上焦者。用
栀子豉汤吐之。上焦得通。津液得下。胃家不实矣。热在中焦者。用白虎汤清之。胃火得清。胃家不实矣。热陷下焦者。
用猪苓汤利之。火从下泄。胃家不实矣。要知阳明之治表热。即是预治其里。三方皆是润剂。所以存津液。而不令胃家
实也。后人因循升麻葛根之谬竟不察仲景治阳明表症之法。
太阳以心胸为里。故用辛甘发散之剂。助心胸之阳。而开玄府之表。不得用苦寒之剂。以伤上焦之阳也。所以宜汗
而不宜吐。阳明以心胸为表。当用酸苦涌泄之剂。引胃脘之阳。而开胸中之表。不得用温散之剂。以伤中宫之津液也。
故法当吐。而不当汗。阳明当吐。而反行汗下温针等法。以致心中愦愦。怵惕。懊 。烦躁。 语。舌苔。等症。然仍
不离阳明之表。太阳当汗而反吐。便见自汗出而不恶寒。饥不能食。朝食暮吐。不欲近衣。欲食冷食等症。此为太阳转
属阳明之表。皆是栀子豉汤症。盖阳明以胃实为里。不特发热恶寒汗出身重目疼鼻干谓之表。一切虚烦。虚热。如口苦。
咽干。舌苔。喘满。不得卧。消渴。而小便不利。凡在胃之外者。悉属阳明之表。但除胃口之热。便解胃家之实。此
栀子豉汤。为阳明解表和里之圣剂也。
按伤寒脉浮。自汗出。淅淅恶寒。是阳明表症。心烦小便数。脚挛急。是阳明里之表症。斯时用栀子豉汤吐之。则
胃阳得升。恶寒自罢。心烦得止。汗不自出矣。上焦得通。津液得下。小便自利。其脚自伸矣。反用桂枝发汗。所以亡
阳。其咽中干。烦躁。吐逆。是栀子生姜豉汤症。 以亡阳而厥。急当回阳。故改用甘草干姜汤。服之后。仍作芍药甘
草以和阴。少与调胃承气以和里。皆因先时失用栀豉。如此挽回费力耳。
按仲景云。病如桂枝症。则便不得鉴定为太阳中风。凡恶风。恶寒。发热。而汗自出者。无论太阳阳明中风伤寒皆
是桂枝症矣。太阳病头项强痛。而此云头不痛。项不强。便非太阳症。内经曰。邪中于肤。则入阳明。此云。胸中疼
硬。气上冲。咽喉不得息。是阳明受病无疑也。虽外症象桂枝。而病在胸中。不在营卫。便不是桂枝症。故立瓜蒂散。
所谓在上者。因而越之也。此与前条本阳明病。仲景不冠以阳明者。以不关于胃实。而未见不恶寒之病情耳。
上越中清下夺。是治阳明三大法。发汗利小便。是阳明经两大禁。然风寒初入阳明之表。即用麻黄桂枝发汗者。是
急于除热而存津液。与急下之法同。若脉浮。烦渴。小便不利。用猪苓汤利小便者。亦以清火而存津液。而又曰。汗多
者不可与猪苓汤。要知发汗利小便。是治阳明权巧法门。非正治法。
阳明之病在热实。宜无温补法矣。而食谷欲呕者。是胃口虚寒。故不主内热也。然胃口虽虚。胃中犹实。仍不失为
阳明病。与吴茱萸汤。散胃口之寒。上焦得通。津液得下。胃气因和。则温补又阳明之从治法。若胃口虚热者。用白虎
加人参。是阳明又有凉补法也。此二义。又是治阳明权巧法门。
本论云。伤寒三日。三阳为尽。三阴当受邪。其人反能食。不呕。此为三阴不受矣。盖阳明为三阴之表。故三阴皆
看阳明之转施。三阴之不受邪。藉胃为之蔽其外也。胃气和。则能食不呕。故邪自解。而三阴不病。胃阳虚邪始。得入
三阴。故太阳受邪。腹满而吐。食不下。少阴受邪。欲吐不吐。厥阴受邪。饥不欲食。食即吐蛔。若胃阳亡。则水浆不
入而死。要知三阴受邪。关系不在少阳太阳。而全关系阳明。
阳明以太阴为里。是指牝脏言。太阴亦以阳明为里。是指转属言也。肾者胃之关。木者土之贼。故三阴亦得以阳明
为里。三阴为三阳之里。而三阴反得转属阳明为里。故三阴皆得从阳明而下。则阳明又是三阴实邪之出路也。既为三
阴之表以御邪。又为三阴之里以逐邪。阳明之关系三阴重矣。
按照阳明病的提纲，以里证为主。即使有表证，张仲景的意图也不在解表，这是因为“有诸内而形诸外”的道理。如果兼有经病（经络层面的病变），张仲景的意图也不在治经，因为表证虽在经络，但根源在于胃腑。太阴与阳明同处中焦，太阴主开，阳明主合，所以阳明病必须以里实为主。不大便固然是里实，不小便也是里实（气机闭塞）。不能进食、进食难以吃饱、起初想吃后来反而不能吃，都是里实的表现。自汗或盗汗，是表开而里实。反而出汗少或无汗，则是内外皆实。种种里实证，或有或无，所以提纲独以“胃家实”为正。所谓“胃实”，并不是仅仅指燥屎坚硬，而是相对于下利而言的；下利说明胃家不实。所以，出汗后病解，但胃中不和而下利的，不称为阳明病。如果是胃中虚寒但不下利的，就属于阳明病。即使是初头硬后溏、水谷不分，虽然严重甚至致死但不下利的，总归为阳明病。大概因为阳明和太阴同为仓廪之官，但职能不同：胃主受纳，所以阳明主实；脾主运化输布，所以太阴主利。同样是胃腑，却这样分工治疗，这就是这两条经脉区分的原因。
按阳明是传化之腑，应当更替虚实。食物进入胃中，胃实而肠虚；食物下行入肠，肠实而胃虚。如果只有实而没有虚，那就是阳明病的病根了。“胃实”本身不是阳明病，但阳明病的产生，全部是从“胃实”发展而来的，所以以“胃家实”作为阳明一经的总纲。然而导致实邪的原因，应当详细审察。有的实邪是在发病之前就已经存在的；有的在发病之后形成的；有的是风寒外来，热邪无法发散而致实；有的是误用汗、吐、下法，重伤津液而致实；有的是本经热盛而致实；有的是从他经转属而来而致实。这里只列举了病根在于“实”，但不要认为“胃实”就是可以攻下的症状。
身热、汗自出、不恶寒、反恶热，这是阳明表证的提纲。所以，胃中虚冷也能称为阳明病，是因为它的表证表现如此。但这属于内热达于体表的表证，不同于中风或伤寒的表证。此时表寒已散，所以不恶寒；里热闭结，所以反恶热。只因有“胃家实”的病根，才出现身热自汗出的外症，以及不恶寒反恶热的病情。然而这仅说明病机显现，并不是就可以攻下的症状。必须等到谵语、潮热、烦躁、胀痛等症状兼见时，才可以攻下。
太阳病的总纲，展示给人看的是正面；阳明病的总纲，反过来展示给人看的是底板。其正面与太阳病的表证相同，但也应当看出阳明的表证与太阳病是不同的。例如，阳明病，脉迟、汗出多、微恶寒的，这是阳明病的桂枝汤证；阳明病，脉浮、无汗而喘的，这是阳明病的麻黄汤证。《伤寒论》原文说：“病得之一日，不发热而恶寒者”，指的就是这种情况。后人见到太阳病已有这些脉症，就说阳明病不应有此脉症，因此有了“尚在太阳，将入阳明”的说法。不知道张仲景的书，有很多在本条不见而在其他条文中发现的例子，比如开始虽恶寒，以及“反无汗”等语句。因为阳明表证本是汗出不恶寒，所以加上“反”字罢了。有的本经未宣发，而其他经发现症状，比如太阳病的头项强痛，少阳病的脉弦细。然而头痛而不项强，脉大而不弦细，便是阳明病的表证了。太阳行于身之后，阳明行于身之前，所受的风寒，都在营卫之表。太阳营卫有虚实，阳明营卫也有虚实。虚则用桂枝汤，实则用麻黄汤，这是张仲景治疗表邪的定局。张仲景的方剂，是因症而设，不是因经而设。见此症，便与此方，这是张仲景的活法。后人妄以方剂分属经络，不仅不敢在阳明病中使用这两个方子，就连太阳病也废弃很久了。
阳明病的表证有两种：有外邪初伤的表证，有内热达外的表证。外邪的表证，只在一二日间，症状是微恶寒、汗出多，或者无汗而喘。内热的表证在一二日后，症状是身热汗自出、不恶寒、反恶热。表证因风寒外来，所以张仲景也用麻黄汤、桂枝汤发汗。表证因内热外发，所以张仲景另外制定栀子豉汤，因其热而用涌吐法。后人认不出阳明表证，一二日时不敢用麻黄汤，二三日来又不知用栀子豉汤，不识张仲景治疗阳明病的初法，所以废弃了阳明病的吐法。一定要等到热深实极，才用白虎汤、承气汤投之，这是养虎遗患啊。
六经伤寒中，唯有阳明病最轻，因为阳明是水谷之海，谷气足以胜邪气；阳明是十二经脉之长，气血足以御寒气；阳明居两阳合明之地，阳气足以御阴气。阳明受邪，第一天恶寒，与太阳相同；第二天便不恶寒，反恶热。所以《内经》说：“二日阳明受之。”这是以阳明病的症状在第二天出现为依据，不是说阳明病是在太阳病交接时才产生的。张仲景说：“伤寒三日，阳明脉大。”要知道阳明伤寒，只在第一二天就寒去热生。第三天见到阳明脉大，就全无寒气，便是阳明病的病热，而不是前日的伤寒了。开始时虽然由于伤寒，现在不再称伤寒，不能用治伤寒的方剂来治疗了。
阳明病的恶寒，第二天自然停止，这与其他经不同。其恶寒轻微，又不像太阳病那么严重。阳明病在肌肉中蒸蒸发热，但热无寒，与太阳病翕翕发热、寒束于皮毛之上不同。阳明病自汗，也异于太阳中风病的自汗。太阳病虽然自汗，但出汗不利，有拘执之意，所以其状曰“濈濈然”。阳明病自汗，多有波澜摇动之状，故名之曰“汗出濈濈”。太阳病脉浮紧的，必有潮热；太阳病脉但浮的，必无汗。阳明病脉但浮的，必盗汗出。这两经的表证、表脉，不同如此。
现在的伤寒书，以头痛分三阳，阳明病的头痛在额部，道理固然如此。然而阳明主里，头痛不是它的本证。《内经》说：“伤寒一日，巨阳受之。”因为其脉连风府，所以头项痛。“七日太阳病衰，头痛少愈也。”“二日阳明受之。”其脉夹鼻络于目，所以身热、目疼、鼻干、不得卧。这是《内经》以头痛归属于太阳，不归属于阳明。张仲景有两条阳明头痛症：一条是“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。”此头痛在二三日，而不在得病的第一天，且因于呕咳，而不因于外邪。另一条是“伤寒不大便，六七日头痛不热者，与承气汤。”此头痛反在太阳病衰时，而因于不大便，即《内经》所说的“腹满而头痛”，非因于风寒。其中风伤寒诸条，都不涉及头痛症，则阳明头痛，又与太阳迥别了。《伤寒论》原文说：“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。”此处应当直接接“栀子豉汤主之”一句。若发汗三段，是因为不用此方而妄治所致，仍当用栀子豉汤主之。张仲景只在结尾处一见，是省文法。后人竟认栀豉汤为汗下后的救逆之剂，请问未汗下前，张仲景用什么法治它呢？要知道咽燥、口苦、腹满而喘，是阳明里热；发热汗出、不恶寒、反恶热，是阳明表热。因阳明之热，自内达表，则里症为重，所以此条叙述症状，以里症列表症之前。任栀子以清里热，而表热亦解；用香豉以泻腹满，而身重亦除。后人不能在仲景书中寻出阳明之表，而远引《内经·热论》中的目痛、鼻干、不得卧来当之，不懂仲景治阳明表证的方法，妄引痘科中的葛根、升麻来主治。不知道《内经》因论述热病，只发阳明经病的一端；仲景立阳明一经，是该内外症治的全法。又不知道目痛鼻干，是阳盛阴虚，法当滋阴清火，反而发阳明之汗，若上而鼻衄，下而便难，这是引贼破家了。要知道是风寒之表，则用麻黄汤治疗；如是内热之表，即荆芥、防风、薄荷都足以亡津液而成胃实。关键在于使用者如何把握。治疗阳明内热之表有三法：如热在上焦者，用栀子豉汤吐之，上焦得通，津液得下，胃家不实矣；热在中焦者，用白虎汤清之，胃火得清，胃家不实矣；热陷下焦者，用猪苓汤利之，火从下泄，胃家不实矣。要知道阳明之治表热，即是预治其里。三方皆是润剂，所以存津液，而不令胃家实。后人因循升麻葛根的谬误，竟不考察仲景治阳明表证的方法。
太阳病以心胸为里，所以用辛甘发散之剂，助心胸之阳，而开玄府之表，不得用苦寒之剂以伤上焦之阳。所以宜汗而不宜吐。阳明病以心胸为表，当用酸苦涌泄之剂，引胃脘之阳，而开胸中之表，不得用温散之剂以伤中宫之津液。故法当吐，而不当汗。阳明病当吐，而反行汗、下、温针等法，以致心中愦愦、怵惕、懊憹、烦躁、谵语、舌苔等症。然而仍不离阳明之表。太阳病当汗而反吐，便见自汗出而不恶寒、饥不能食、朝食暮吐、不欲近衣、欲食冷食等症。此为太阳转属阳明之表，皆是栀子豉汤证。盖阳明以胃实为里，不特发热、恶寒、汗出、身重、目疼、鼻干谓之表，一切虚烦、虚热，如口苦、咽干、舌苔、喘满、不得卧、消渴而小便不利，凡在胃之外的，悉属阳明之表。只要除去胃口之热，便解胃家之实。此栀子豉汤，为阳明解表和里之圣剂。
按伤寒脉浮、自汗出、淅淅恶寒，是阳明表证；心烦、小便数、脚挛急，是阳明里之表证。此时用栀子豉汤吐之，则胃阳得升，恶寒自罢，心烦得止，汗不自出矣。上焦得通，津液得下，小便自利，其脚自伸矣。反用桂枝汤发汗，所以亡阳。其咽中干、烦躁、吐逆，是栀子生姜豉汤证。因亡阳而厥，急当回阳，故改用甘草干姜汤。服用之后，仍作芍药甘草汤以和阴，少与调胃承气汤以和里，皆因先时失用栀豉汤，如此挽回费力耳。
按仲景说：“病如桂枝症”，则便不得鉴定为太阳中风。凡恶风、恶寒、发热而汗自出者，无论太阳、阳明中风伤寒皆是桂枝汤证矣。太阳病头项强痛，而此云头不痛、项不强，便非太阳症。《内经》说：“邪中于肤，则入阳明。”此云胸中疼硬、气上冲、咽喉不得息，是阳明受病无疑也。虽外症象桂枝，而病在胸中，不在营卫，便不是桂枝汤证。故立瓜蒂散，所谓“在上者，因而越之”也。此与前条本阳明病，仲景不冠以阳明者，以不关于胃实，而未见不恶寒之病情耳。
上越、中清、下夺，是治阳明三大法。发汗、利小便，是阳明经两大禁。然风寒初入阳明之表，即用麻黄、桂枝发汗者，是急于除热而存津液，与急下之法同。若脉浮、烦渴、小便不利，用猪苓汤利小便者，亦以清火而存津液。而又曰：“汗多者不可与猪苓汤。”要知发汗、利小便，是治阳明权巧法门，非正治法。
阳明之病在热实，宜无温补法矣。而食谷欲呕者，是胃口虚寒，故不主内热也。然胃口虽虚，胃中犹实，仍不失为阳明病。与吴茱萸汤，散胃口之寒，上焦得通，津液得下，胃气因和，则温补又是阳明之从治法。若胃口虚热者，用白虎加人参汤，是阳明又有凉补法也。此二义，又是治阳明权巧法门。
《伤寒论》原文说：“伤寒三日，三阳为尽，三阴当受邪。其人反能食，不呕，此为三阴不受矣。”盖阳明为三阴之表，故三阴皆看阳明之转施。三阴之不受邪，藉胃为之蔽其外也。胃气和，则能食不呕，故邪自解，而三阴不病。胃阳虚邪始得入三阴，故太阳受邪，腹满而吐，食不下；少阴受邪，欲吐不吐；厥阴受邪，饥不欲食，食即吐蛔。若胃阳亡，则水浆不入而死。要知三阴受邪，关系不在少阳太阳，而全关系阳明。
阳明以太阴为里，是指牝脏言。太阴亦以阳明为里，是指转属言也。肾者胃之关，木者土之贼，故三阴亦得以阳明为里。三阴为三阳之里，而三阴反得转属阳明为里，故三阴皆得从阳明而下，则阳明又是三阴实邪之出路也。既为三阴之表以御邪，又为三阴之里以逐邪，阳明之关系三阴重矣。
According to the outline of Yangming disease, the focus is on interior syndromes. Even if exterior syndromes exist, Zhang Zhongjing's intention is not to treat the exterior, based on the principle that "internal conditions manifest externally." If there are concurrent meridian diseases (pathological changes at the level of meridians), Zhang Zhongjing's intention is not to treat the meridians, because although the exterior syndrome resides in the meridians, its root lies in the Stomach organ. Taiyin and Yangming both reside in the Middle Jiao; Taiyin governs opening, while Yangming governs closing. Therefore, Yangming disease must prioritize interior excess. Constipation is certainly interior excess, as is oliguria (closure of Qi mechanism). Inability to eat, difficulty in consuming large meals, initial desire to eat followed by inability to eat—all are manifestations of interior excess. Spontaneous sweating or night sweats indicate an open exterior but interior excess. Conversely, scanty sweating or anhidrosis indicates interior excess both inside and outside. Various interior excess syndromes may or may not be present; thus, the outline uniquely identifies "Stomach Excess" (Wei Shi) as the standard. "Stomach Excess" does not merely refer to dry, hard feces, but is defined in contrast to diarrhea; diarrhea indicates that the Stomach is not excess. Therefore, after sweating resolves the illness, if there is disharmony in the Stomach accompanied by diarrhea, it is not called Yangming disease. If there is deficiency-cold in the Stomach without diarrhea, it belongs to Yangming disease. Even if the stool is initially hard and later loose, with undigested food and fluid separation, as long as there is no diarrhea despite severe condition or death, it is generally classified as Yangming disease. This is because Yangming and Taiyin are both officials of the granary, yet their functions differ: the Stomach governs reception, so Yangming governs excess; the Spleen governs transport and transformation, so Taiyin governs diarrhea. Although they share the same Fu organ, this division in treatment explains why these two meridians are distinguished.
Yangming is a transmitting and transforming Fu organ, which should alternate between fullness and emptiness. When food enters the Stomach, the Stomach is full and the Intestines are empty; when food moves into the Intestines, the Intestines are full and the Stomach is empty. If there is only fullness without emptiness, this becomes the root cause of Yangming disease. "Stomach Excess" itself is not Yangming disease, but all Yangming diseases arise from "Stomach Excess"; therefore, "Stomach Home Excess" (Wei Jia Shi) serves as the general outline for the Yangming meridian. However, the causes leading to excess should be carefully examined. Some excess exists prior to the onset of illness; some develops after the illness begins. Some result from external wind-cold where heat cannot disperse, causing excess. Some result from improper use of sweating, vomiting, or purging methods, which severely deplete body fluids, leading to excess. Some arise from intense heat within the originating meridian. Others transfer from other meridians. Here, only the root cause being "excess" is listed; one must not assume that "Stomach Excess" automatically indicates a condition suitable for purgation.
Body heat, spontaneous sweating, aversion to cold absent, and aversion to heat constitute the outline of Yangming exterior syndromes. Therefore, even cold-deficiency in the Stomach can be termed Yangming disease because its exterior presentation matches this description. However, this represents an exterior syndrome caused by internal heat reaching the surface, distinct from exterior syndromes of Wind-Stroke or Cold Damage. At this stage, exterior cold has dissipated, hence no aversion to cold; interior heat is constrained, hence aversion to heat. Due to the root cause of "Stomach Home Excess," external symptoms like body heat and spontaneous sweating appear, along with the clinical picture of no aversion to cold but aversion to heat. Yet, this merely indicates the manifestation of pathogenesis and does not immediately justify purgation. Purgation is only appropriate when symptoms such as delirium, tidal fever, irritability, and distending pain coexist.
The general outline of Taiyang disease shows people the "frontal aspect," whereas the general outline of Yangming disease shows the "base plate." Its frontal aspect is similar to the exterior of Taiyang, yet one must recognize that Yangming's exterior differs from Taiyang's. For instance, in Yangming disease, if the pulse is slow, sweating is profuse, and there is slight aversion to cold, this is the Gui Zhi Tang (Cinnamon Twig Decoction) pattern of Yangming. If the pulse is floating, there is no sweating, and wheezing occurs, this is the Ma Huang Tang (Ephedra Decoction) pattern of Yangming. The *Shanghan Lun* states: "On the first day of illness, without fever but with aversion to cold," referring to this situation. Later scholars, seeing these pulse and symptom patterns in Taiyang disease, argued that Yangming should not exhibit them, leading to the theory that the disease remains in Taiyang before transitioning to Yangming. They fail to realize that Zhang Zhongjing's text often presents conditions in one chapter that are described elsewhere, such as initial aversion to cold or "reverse anhidrosis." Since Yangming exterior syndromes typically involve sweating without aversion to cold, the character "reverse" (fan) is added. Some conditions originate from one meridian but manifest through another, such as head and nape stiffness in Taiyang or wiry-thin pulses in Shaoyang. However, headache without nape stiffness and a large rather than wiry-thin pulse indicate Yangming exterior syndrome. Taiyang runs along the posterior body, while Yangming runs along the anterior body. The wind-cold they receive affects the Ying and Wei levels at the exterior. Both Taiyang and Yangming Ying-Wei levels have deficiency and excess patterns. Deficiency calls for Gui Zhi Tang; excess calls for Ma Huang Tang. This is Zhang Zhongjing's fixed approach for treating exterior pathogens. Zhang Zhongjing's formulas are designed based on symptoms, not meridians. Seeing a symptom and prescribing the corresponding formula is his flexible method. Later scholars erroneously assigned formulas to specific meridians, refusing to use these two formulas for Yangming and abandoning them even for Taiyang.
There are two types of Yangming exterior syndromes: exterior caused by initial external pathogen invasion, and exterior caused by internal heat reaching the surface. The former occurs within one to two days, presenting with slight aversion to cold, profuse sweating, or anhidrosis with wheezing. The latter appears after one to two days, presenting with body heat, spontaneous sweating, absence of aversion to cold, and presence of aversion to heat. Because the exterior is due to external wind-cold, Zhang Zhongjing uses Ma Huang Tang and Gui Zhi Tang to induce sweating. Because the exterior is due to internal heat erupting outward, he devised Zhi Zi Chi Tang (Gardenia and Fermented Soybean Decoction) to induce vomiting based on the heat. Later scholars failed to recognize Yangming exterior syndromes; they dared not use Ma Huang Tang in the first two days and did not know to use Zhi Zi Chi Tang thereafter. Ignoring Zhang Zhongjing's initial treatment methods for Yangming, they abandoned the vomiting method for Yangming. They waited until heat was deep and excess extreme before using Bai Hu Tang (White Tiger Decoction) or Cheng Qi Tang (Order the Qi Decoctions), which is nurturing the tiger and leaving trouble for later.
Among the Six Meridians' Cold Damage, Yangming is considered the mildest because Yangming is the sea of water and grain, where grain Qi suffices to overcome pathogenic Qi; Yangming is the leader of the twelve meridians, where Qi and Blood suffice to resist cold Qi; Yangming resides in the place of combined Yang brightness, where Yang Qi suffices to resist Yin Qi. Upon contracting Yangming, there is aversion to cold on the first day, identical to Taiyang. On the second day, aversion to cold ceases, replaced by aversion to heat. Thus, the *Neijing* states: "On the second day, Yangming receives it." This refers to the appearance of Yangming symptoms on the second day, not that Yangming disease arises only upon the transition from Taiyang. Zhang Zhongjing said: "Three days of Cold Damage, Yangming pulse is large." One must understand that in Yangming Cold Damage, cold dissipates and heat arises within the first two days. Seeing a large Yangming pulse on the third day means all cold has vanished, indicating Yangming heat disease, not the previous Cold Damage. Although initially caused by Cold Damage, it is no longer termed Cold Damage, nor should Cold Damage treatments be used.
Yangming's aversion to cold stops naturally on the second day, differing from other meridians. It is mild, unlike the severe aversion to cold in Taiyang. Yangming features steaming heat radiating from the muscles, with heat only and no cold, differing from Taiyang's fluttering heat where cold binds the skin and hair pores. Yangming's spontaneous sweating also differs from Taiyang Wind-Stroke's spontaneous sweating. In Taiyang, although sweating occurs, it is difficult and feels constrained, described as "ji ji ran" (continuous dripping). Yangming's spontaneous sweating often has a rolling, wave-like quality, hence named "ji ji ran" (rolling/swaying). In Taiyang, a floating-tight pulse必然 leads to tidal fever; a merely floating pulse必然 leads to anhidrosis. In Yangming, a merely floating pulse必然 leads to night sweats. The exterior syndromes and pulses of these two meridians differ thusly.
Modern Shanghan texts divide headache among the Three Yang meridians; Yangming headache is located in the forehead, which is logical. However, Yangming governs the interior, and headache is not its primary symptom. The *Neijing* states: "On the first day of Cold Damage, Juyang (Taiyang) receives it." Because its meridian connects to Fengfu, there is head and nape pain. "On the seventh day, Taiyang disease declines, and headache lessens." "On the second day, Yangming receives it." Its meridian flanks the nose and connects to the eyes, causing body heat, eye pain, nasal dryness, and inability to sleep. Thus, the *Neijing* attributes headache to Taiyang, not Yangming. Zhang Zhongjing describes two Yangming headache patterns: 1. "Yangming disease, reverse anhidrosis, frequent urination, vomiting and coughing on days 2-3, cold extremities—must suffer headache. If no vomiting/coughing and warm extremities, no headache." This headache occurs on days 2-3, not day 1, and is caused by vomiting/coughing, not external pathogens. 2. "Cold damage with constipation, headache without fever on days 6-7—administer Cheng Qi Tang." This headache occurs during Taiyang decline, caused by constipation, i.e., "abdominal fullness and headache" mentioned in the *Neijing*, not caused by wind-cold. Other Wind-Cold and Cold Damage sections do not mention headache, distinguishing Yangming headache sharply from Taiyang. The *Shanghan Lun* states: "Yangming disease, floating-tight pulse, dry throat, bitter taste, abdominal fullness, wheezing, fever, sweating, no aversion to cold, reverse aversion to heat, heaviness of body." Here, it should directly follow with "Zhi Zi Chi Tang governs." The subsequent three paragraphs on sweating are results of mismanagement due to not using this formula; it should still be governed by Zhi Zi Chi Tang. Zhang Zhongjing mentions it only at the end as an ellipsis. Later scholars mistakenly viewed Zhi Zi Chi Tang solely as a rescue formula post-sweating/purging. Before sweating/purging, what method did Zhang Zhongjing use? Dry throat, bitter taste, abdominal fullness, and wheezing are Yangming interior heat; fever, sweating, no aversion to cold, and reverse aversion to heat are Yangming exterior heat. Because Yangming heat reaches the exterior from the interior, interior symptoms are heavier. Thus, this section lists interior symptoms before exterior ones. Gardenia clears interior heat, resolving exterior heat; Fermented Soybean drains abdominal fullness, relieving body heaviness. Later scholars failed to find Yangming exterior treatment in Zhang Zhongjing's work, instead citing the *Neijing*'s Eye Pain, Nasal Dryness, and Insomnia from the Heat Disease Chapter. Misapplying Ge Gen Sheng Ma Tang (Kudzu and Cimicifuga Decoction) from smallpox therapy, they ignored that the *Neijing* only covered one aspect of Yangming meridian disease regarding heat, while Zhang Zhongjing established a comprehensive method for Yangming. Furthermore, Eye Pain and Nasal Dryness indicate Excess Yang and Deficient Yin, requiring nourishment of Yin and clearing of fire; inducing sweat in Yangming would cause epistaxis and constipation, inviting disaster. If it is a wind-cold exterior, use Ma Huang Tang. If it is an internal heat exterior, even Jing Jie, Fang Feng, or Bo He can deplete fluids and create Stomach excess. Treatment depends on the practitioner. There are three methods for treating Yangming internal heat exterior: If heat is in the Upper Jiao, use Zhi Zi Chi Tang to vomit; once the Upper Jiao opens, fluids descend, and Stomach Home avoids excess. If heat is in the Middle Jiao, use Bai Hu Tang to clear; once Stomach fire clears, Stomach Home avoids excess. If heat sinks to the Lower Jiao, use Zhu Ling Tang to promote urination; once fire drains downward, Stomach Home avoids excess. Treating Yangming exterior heat is essentially preemptive treatment of the interior. All three formulas are moistening agents to preserve fluids and prevent Stomach Home excess. Later scholars blindly followed the error of Ge Gen and Sheng Ma, failing to examine Zhang Zhongjing's methods for Yangming exterior syndromes.
Taiyang disease considers the Heart and Chest as the interior, using pungent-sweet dispersing agents to assist Heart-Chest Yang and open the Xuan-Fu (pores) exterior, avoiding bitter-cold agents that damage Upper Jiao Yang. Thus, sweating is preferred over vomiting. Yangming disease considers the Heart and Chest as the exterior, using sour-bitter rising-and-draining agents to guide Stomach-Wan Yang and open the Chest exterior, avoiding warm-dispersing agents that damage Middle Jiao fluids. Thus, vomiting is the method, not sweating. If Yangming disease requires vomiting but instead undergoes sweating, purging, or moxibustion, it leads to mental confusion, fearfulness, restlessness, irritability, delirium, and tongue coating issues. These remain within Yangming exterior. If Taiyang disease requires sweating but undergoes vomiting, it presents with spontaneous sweating, no aversion to cold, hunger without appetite, morning eating evening vomiting, dislike of warmth, and desire for cold food. This is Taiyang transferring to Yangming exterior, all Zhi Zi Chi Tang patterns. Since Yangming defines Stomach Excess as interior, anything besides fever, aversion to cold, sweating, body heaviness, eye pain, and nasal dryness—such as all deficiency vexation, deficiency heat, bitter taste, dry throat, tongue coating, wheezing/fullness, insomnia, thirst with insufficient urination—is considered Yangming exterior if outside the Stomach. Removing heat from the Stomach Wan resolves Stomach Home excess. Thus, Zhi Zi Chi Tang is the supreme agent for harmonizing the exterior and interior in Yangming.
In Cold Damage, a floating pulse, spontaneous sweating, and chilly aversion to cold are Yangming exterior syndromes; irritability, frequent urination, and leg cramps are Yangming interior-exterior syndromes. Using Zhi Zi Chi Tang to vomit at this time raises Stomach Yang, eliminating aversion to cold, stopping irritability, and halting sweating. Opening the Upper Jiao allows fluids to descend, regulating urination and extending the legs. Using Gui Zhi Tang to sweat instead causes Yang collapse. Dry throat, irritability, and vomiting indicate Zhi Zi Sheng Jiang Chi Tang (Gardenia, Fresh Ginger, and Fermented Soybean Decoction) pattern. Due to Yang collapse and cold extremities, urgent restoration of Yang is needed, so Gan Cao Gan Jiang Tang (Licorice and Dried Ginger Decoction) is used. Afterwards, Shao Yao Gan Cao Tang (Peony and Licorice Decoction) harmonizes Yin, and a small amount of Tiao Wei Cheng Qi Tang (Regulate the Waist and Order the Qi Decoction) harmonizes the interior. These measures are necessary due to the earlier failure to use Zhi Zi Chi Tang, making recovery laborious.
Zhang Zhongjing stated: "Illness resembling Gui Zhi pattern" cannot be definitively diagnosed as Taiyang Wind-Stroke. Any case with aversion to wind/cold, fever, and spontaneous sweating is a Gui Zhi Tang pattern, regardless of Taiyang or Yangming origin. Taiyang disease involves head and nape stiffness; here, the absence of headache and nape stiffness rules out Taiyang. The *Neijing* says: "Pathogens striking the skin enter Yangming." Here, chest pain/hardness, Qi rushing upward, and difficulty breathing confirm Yangming disease. Although external symptoms resemble Gui Zhi, the pathology is in the Chest, not Ying-Wei, so it is not a Gui Zhi Tang pattern. Hence, Gua Di San (Melon Seed Powder) is prescribed, following the principle "those above, induce vomiting." Unlike previous Yangming cases, Zhang Zhongjing did not label this "Yangming disease" because it does not concern Stomach Excess and lacks the hallmark of no aversion to cold.
Upward expulsion, middle clearing, and downward purging are the three major methods for treating Yangming. Sweating and promoting urination are the two major prohibitions for Yangming meridians. However, if wind-cold initially invades Yangming exterior, using Ma Huang or Gui Zhi to sweat is urgently removing heat to preserve fluids, similar to emergency purging. If pulse is floating, with irritability/thirst and insufficient urination, Zhu Ling Tang promotes urination to clear fire and preserve fluids. Yet, it warns: "Do not give Zhu Ling Tang if sweating is profuse." Sweating and promoting urination are expedient methods for Yangming, not standard treatments.
Yangming disease involves heat-excess, seemingly precluding warming-tonifying methods. However, desire to vomit after eating indicates deficiency-cold at the Stomach Wan, not internal heat. Although the Wan is deficient, the Stomach interior remains excess, still qualifying as Yangming disease. Wu Zhu Yu Tang (Evodia Decoction) disperses Wan cold; once the Upper Jiao opens, fluids descend, and Stomach Qi harmonizes, warming-tonification becomes a compliant treatment method for Yangming. For deficiency-heat at the Wan, Bai Hu Jia Ren Shen Tang (White Tiger Plus Ginseng Decoction) is used, representing a cooling-tonifying method. These two principles are expedient methods for treating Yangming.
The *Shanghan Lun* states: "Three days of Cold Damage, Three Yang are exhausted, Three Yin should receive pathogens. If the person can eat and does not vomit, this means Three Yin are unaffected." Yangming is the exterior of Three Yin, so Three Yin transitions depend on Yangming. Three Yin avoiding pathogens relies on the Stomach shielding the exterior. Harmonized Stomach Qi allows eating without vomiting, resolving pathogens and protecting Three Yin. Only when Stomach Yang is deficient do pathogens enter Three Yin: Taiyang receiving pathogens causes abdominal fullness, vomiting, and inability to eat; Shaoyin receiving pathogens causes desire to vomit but inability; Jueyin receiving pathogens causes hunger without appetite and vomiting roundworms upon eating. If Stomach Yang perishes, intake of fluids ceases, leading to death. Thus, the impact of Three Yin pathogen reception depends entirely on Yangming, not Shaoyang or Taiyang.
Yangming regards Taiyin as interior, referring to the Yin organs. Taiyin regards Yangming as interior, referring to transmission/transition. The Kidney is the gate of the Stomach; Wood is the thief of Earth. Thus, Three Yin also regard Yangming as interior. While Three Yin are the interior of Three Yang, they can also transition to Yangming as interior. Therefore, Three Yin can drain downward through Yangming, making Yangming the exit route for Three Yin excess pathogens. Acting as both the exterior of Three Yin to resist pathogens and the interior to expel them, Yangming's relationship with Three Yin is profound.