柯琴曰。首条。下利是大肠虚。谵语是胃气实。胃实肠虚。宜大黄以濡胃。无庸芒硝以润肠。
末条。阳明主津液所生病。故阳明病多汗。多汗是胃燥之因。便硬是谵语之根。一服谵语止。虽未利而胃濡可知矣。
【纲】仲景曰。二阳并病。太阳症罢。但发潮热。手足 汗出。大便难。而谵语者。下之则
愈。宜大承气汤。
【目】鳌按。本条全属阳明可下之症。故本二阳并病。而开手即揭清太阳症罢句也。
【纲】仲景曰。阳明病。头痛。不恶寒。反恶热。大便实。宜调胃承气汤。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。
【目】王肯堂曰。内经云。巨阳受邪。少阴为里。得热则往从之。从之则厥也。太阳与少阴为
合。此症当是太阳未全罢耳。经又云。阳明病则喘而 。 则恶人。小便利者。寒邪内攻。肢厥头
痛者。寒邪外攻也。
喻昌曰。阳明病。本不头痛。若无汗。呕咳。手足厥者。得里因而邪热深也。然小便利。则邪热
不在内而在外。不在下而在上。故知必苦头痛也。
魏荔彤曰。此手足之厥。与头痛互见。非少阴之手足厥也。故呕而汗出。与反无汗亦不同。正
见少阴之手足厥冷。有汗而不头痛。呕而不咳。与阳明之呕咳而无汗。头痛而手足厥有别。
此阳明病有类少阴。而又微带太阳。后学皆茫然不知下手处。故仲师苦心标出。
问。少阴亦有咳。何以辨。曰。少阴所云。咳而下利谵语者。被火气劫故也。原文详之矣。不然。
何能上炎而咳。其言或咳而呕。渴不得眠者。则必兼呕渴不得眠。而见少阴之阴躁。不与阳明之
呕咳兼头痛类也。其言或咳或悸。或小便不利。或腹中痛。或泄利下重。然必兼四者。诸症虽有似
阳明。而头痛一症。必非少阴所有也。此少阴之咳。与阳明所以不同也。故太阳之头痛。入于阳明
之小便利呕咳厥逆中。总属阳症。又见阳
能统阴。一阳存而群阴悉化为阳。在病气亦如此。正气之在人身者可识矣。
【纲】仲景曰。阳明病。表里大热。烦渴引饮。头痛如破者。竹叶石膏汤。阳明病。身热头痛。
漱水不欲咽。必发衄。
【目】杨士瀛曰。将发衄而脉数者。宜犀角地黄汤。茅花汤亦可。
吴绶曰。阳明头痛额前。目疼鼻干。脉长也。无汗者。葛根加葱白、白芷汗之。有汗。曾经发
汗。头痛不解者。葛根葱白汤。若不恶风而反恶热。自汗烦渴。脉洪数。饮水头疼者。白虎加白芷
汤。内有燥屎。蒸蒸发热头痛者。调胃承气汤。凡阳明头痛无汗者。葛根、麻黄、葱白、白芷、石
膏之类也。有汗。则白芷、石膏、葛根、川芎汤也。
【纲】仲景曰。阳明病。脉迟。食难用饱。饱则微烦。头眩。必小便难。欲作谷疸。须下之。
腹满如故。所以然者。脉迟故也。
【目】魏荔彤曰。本条之上条云。食谷欲呕者。属阳明也。吴茱萸汤主之。得汤反剧者。属上
焦也。与本条俱言胃虚。然虚寒与虚热又迥不同。虚固不可作实而攻下。热可遽作寒而温补乎。故
仲师就上条食谷欲呕中。又示人以推类详义之法。如阳明病脉迟。似属虚寒。但寒则不能食。此能
食而但难用饱。饱则微烦头眩者。胃惟不寒故能食。胃惟气虚故不用饱。不用饱者。不受饱也。微
烦头眩。俱虚而兼热之象。以此辨胃之虚。与食谷欲呕条同。而热则本条独异。夫迟为寒脉。何云
是热。不知此乃兼涩之迟。非沉迟之迟。谓之虚而兼湿热则可。谓之虚寒则大不可也。故又见小便
难一症。虚则气不充而湿不除。湿则气不化而热不消。胃中谷气不能化正养身。却蕴酿湿热。蒸作
疸黄之兆。如不清热除湿。培土消疸。而妄下之。将湿愈增而虚愈甚。腹满如故。胃累及脾。表里
受病。而发黄身肿矣。故又曰。脉迟故也。言迟则濡涩而不滑利。虚而湿之义为主。而热副之。主
治者以除湿培土补中为君。以清热消疸为臣佐之用。斯为得仲师心法者。
【纲】仲景曰。阳明病。但头眩。不恶寒。故能食而咳。其人必咽痛。若不咳者。咽不痛。
【目】王肯堂曰。阳明病。身不重。但头眩而不恶寒者。阳明中风而风内攻也。经曰。阳明病。
若能食。名中风。风邪攻胃。胃气上逆则咳。咽门者。胃之系。咳甚则咽伤。故咽痛。若胃气不逆
则不咳。其咽亦不痛也。
鳌按。此与前头痛款中反无汗一条。俱是阳明病而有类少阴者。然彼条之呕咳而无汗。头痛而
手足厥。所以异于少阴之手足厥冷有汗而不头痛。及呕而不咳。此条之咳而咽痛。亦所以异于少阴
之咽痛为不咳而痛也。
柯琴说。首条指出，下利是大肠虚寒的表现，谵语是胃气实热的表现。胃实而肠虚，适宜用大黄来润养胃腑，不需要用芒硝来润肠通便。
末条指出，阳明经主管津液所生的疾病，所以阳明病多汗。多汗是导致胃燥的原因，大便干硬是谵语的根源。服用一次药后谵语停止，虽然大便尚未通利，但可知胃腑已经得到濡润了。
【纲】张仲景说。两阳并病（太阳与阳明同时发病），太阳病症候已罢，只出现潮热，手足出汗，大便困难，并且出现谵语的情况，采用攻下法治疗就会痊愈，适宜使用大承气汤。
【目】沈金鳌按：本条完全属于阳明病可攻下的证候。既然是两阳并病，但在开头就明确指出“太阳症罢”这一句，以资辨别。
【纲】张仲景说。阳明病，头痛，不恶寒，反而恶热，大便结实，适宜使用调胃承气汤。阳明病，反而无汗且小便通畅，两三天后出现呕吐兼咳嗽，手足厥冷的人，必定痛苦于头痛。如果不咳嗽、不呕吐，手足也不厥冷，头就不会痛。
【目】王肯堂说：《内经》说，巨阳（太阳）受邪，少阴为里，得热则随之而化热，随之则发生厥逆。太阳与少阴互为表里合经，此症应当是太阳病未完全解除罢了。经文又说，阳明病则气喘且躁扰不安，躁扰则厌恶见人。小便通利的，是寒邪内攻；四肢厥冷、头痛的，是寒邪外攻。
喻昌说：阳明病本来不头痛，如果无汗、呕吐咳嗽、手足厥冷，是因为里有原因导致邪热深入。然而小便通利，说明邪热不在内而在外，不在下而在上，所以知道必定痛苦于头痛。
魏荔彤说：此处的四肢厥冷与头痛互见，并非少阴病的四肢厥冷。所以呕吐而汗出，与反无汗也不同。这正是为了显示少阴病的四肢厥冷，是有汗而不头痛，呕吐而不咳嗽，这与阳明病的呕吐咳嗽而无汗、头痛而手足厥冷是有区别的。这是阳明病有类似少阴的地方，而又微带太阳的特点，后世学者都茫然不知从何下手，所以仲景先生苦心标出以示区别。
问：少阴也有咳嗽，如何辨别？答：少阴所说的“咳嗽而下利谵语”，是被火劫所致。原文已有详细说明。不然，怎么会向上炎盛而咳嗽？文中说的或咳嗽或呕吐，口渴不得安眠的，则必定兼有呕吐、口渴、不得安眠，并出现少阴的阴躁症状，不与阳明病的呕吐咳嗽兼头痛相类似。文中说的或咳嗽或心悸，或小便利不利，或腹中痛，或泄利下重，但必须兼有四者中的几种。这些症状虽然有类似阳明的，但头痛一症，必定不是少阴病所有的。这就是少阴之咳与阳明不同的原因。所以太阳的头痛，进入阳明的小便利、呕咳、厥逆之中，总属阳证，又见到阳能统阴，只要有一阳之气存在，群阴都会化为阳，在病气上也如此，人身正气的情况就可以认识了。
【纲】张仲景说。阳明病，表里大热，烦躁口渴想喝水，头痛剧烈如破裂感，使用竹叶石膏汤。阳明病，身体发热头痛，漱口但不想咽下，必定会发生鼻衄。
【目】杨士瀛说：将要发生鼻衄而脉象数的，适宜使用犀角地黄汤。茅花汤也可以使用。
吴绶说：阳明头痛在前额，眼睛疼痛，鼻子干燥，脉象长。无汗的，用葛根加葱白、白芷发汗。有汗的，曾经发过汗，头痛不解的，用葛根葱白汤。如果不恶风反而恶热，自汗、烦躁口渴，脉象洪数，饮水时头疼的，用白虎加白芷汤。内有燥屎，蒸蒸发热伴头痛的，用调胃承气汤。凡是阳明头痛无汗的，用葛根、麻黄、葱白、白芷、石膏之类。有汗的，用白芷、石膏、葛根、川芎汤。
【纲】张仲景说。阳明病，脉迟，吃饭难以吃饱，饱了就轻微心烦，头晕目眩，必定小便困难，想要形成谷疸。需要攻下。如果攻下后腹部胀满依旧，之所以这样，是因为脉迟的缘故。
【目】魏荔彤说：本条的上条说：“吃食物就想呕吐的，属于阳明病”，用吴茱萸汤主治。喝了药反而加剧的，属于上焦。与本条都讲的是胃虚，但是虚寒与虚热又截然不同。虚证固然不能当作实证而攻下，热证可以立刻当作寒证而温补吗？所以仲景先生在上一条“吃食物就想呕吐”的基础上，又向人们展示类推详辨义理的方法。比如阳明病脉迟，似乎属于虚寒，但寒证就不能进食，这里却能进食只是难以吃饱，吃饱后就轻微心烦头晕的，胃只有不寒才能进食，胃只有气虚才不耐饱。“不用饱”就是不能承受饱食的意思。轻微心烦和头晕，都是虚而兼热的征象。以此辨别胃的虚，与“吃食物就想呕吐”那条相同，但热证则是本条独有的不同。迟脉通常主寒，为什么说这是热呢？不知道这是兼有涩象的迟脉，而不是沉迟的迟脉。称之为虚而兼湿热是可以的，称之为虚寒就大错特错了。所以又见到小便困难这一症状，虚则气不充而湿不去，湿则气不化而热不消。胃中的谷气不能化生正气滋养身体，却蕴酿湿热，蒸腾成为黄疸的征兆。如果不清热除湿、培土消疸，而妄用攻下法，将使湿气更增而虚证更甚，腹部胀满依旧，胃累及脾，表里受病，从而发黄身肿。所以又说“脉迟故也”。意思是脉迟则濡涩而不滑利，以虚和湿的意义为主，热为辅。主治者应以除湿培土补中为君药，以清热消疸为臣佐之用，这才是深得仲景心法的人。
【纲】张仲景说。阳明病，只是头晕目眩，不恶寒，所以能进食且咳嗽，其人必定咽喉痛。如果不咳嗽，咽喉就不痛。
【目】王肯堂说：阳明病，身体不沉重，只是头晕目眩且不恶寒的，是阳明中风而风邪内攻。经文说：阳明病，如果能进食，名叫中风。风邪攻胃，胃气上逆则咳嗽。咽门是胃的系联，咳嗽厉害则咽喉受伤，所以咽喉痛。如果胃气不逆则不咳嗽，其咽喉也不痛。
沈金鳌按：此条与前文头痛款中“反无汗”一条，都是阳明病而有类似少阴的情况。然而彼条的呕吐咳嗽而无汗、头痛而手足厥冷，所以不同于少阴的手足厥冷有汗而不头痛，以及呕吐而不咳嗽。此条的咳嗽而咽喉痛，也所以不同于少阴的不咳嗽而咽喉痛。
Ke Qin stated. The first clause indicates that diarrhea is a manifestation of large intestine deficiency-cold, and delirium is a manifestation of stomach qi excess-heat. With an excess stomach and a deficient intestine, it is appropriate to use Rhubarb (Da Huang) to moisten the stomach, without the need for Mirabilite (Mang Xiao) to lubricate the intestines.
The last clause indicates that the Yangming channel governs diseases arising from body fluids; therefore, Yangming disease often presents with excessive sweating. Excessive sweating is the cause of stomach dryness, and hard stool is the root of delirium. After one dose, if delirium ceases, although bowel movement has not yet occurred, it can be known that the stomach has been moistened.
[Gang] Zhang Zhongjing said. In concurrent Taiyang and Yangming disease (Liang Yang Bing), when Taiyang symptoms have resolved, but tidal fever occurs, sweat appears on the hands and feet, difficulty in defecation arises, and delirium is present, purgation therapy will cure it. Da Cheng Qi Tang (Great Order the Qi Decoction) is indicated.
[Mu] Shen Jin'ao commented: This clause entirely belongs to Yangming disease patterns suitable for purgation. Although it is concurrent Taiyang and Yangming disease, it explicitly states "Taiyang symptoms have resolved" at the outset to clarify the distinction.
[Gang] Zhang Zhongjing said. In Yangming disease, headache occurs, there is no aversion to cold, but rather an aversion to heat, and the stool is solid. Tiao Wei Cheng Qi Tang (Regulate the Stomach Order the Qi Decoction) is indicated. In Yangming disease, if there is absence of sweat and free urination, and after two or three days vomiting accompanied by coughing occurs, along with cold extremities, the patient must suffer from headache. If there is no cough or vomiting, and the extremities are not cold, the head will not hurt.
[Mu] Wang Kentang stated: The *Neijing* says, when Juyang (Taiyang) is affected by pathogenic factors, Shaoyin serves as the interior. When heat enters, it follows the pathogen, leading to Jue (cold extremities). Taiyang and Shaoyin are exterior-interior paired channels. This pattern likely indicates that Taiyang disease has not completely resolved. The classic also states, in Yangming disease, there is panting and restlessness; restlessness leads to aversion to people. Free urination indicates internal attack by cold pathogens; cold extremities and headache indicate external attack by cold pathogens.
Yu Chang stated: Yangming disease typically does not present with headache. However, if there is absence of sweat, vomiting, coughing, and cold extremities, it is because an internal condition causes deep penetration of pathogenic heat. Yet, free urination indicates that pathogenic heat is not in the interior but in the exterior, not below but above. Thus, we know the patient must suffer from headache.
Wei Litong stated: The cold extremities and headache appearing together here are not Shaoyin cold extremities. Therefore, vomiting with sweating differs from absence of sweating. This precisely distinguishes Shaoyin cold extremities (which have sweating but no headache, vomiting but no cough) from Yangming disease (which has vomiting, coughing, absence of sweating, headache, and cold extremities). This shows Yangming disease having features resembling Shaoyin, while slightly involving Taiyang. Later students were confused about how to approach treatment, so Master Zhongjing painstakingly highlighted this distinction.
Question: Shaoyin also involves coughing; how to differentiate? Answer: What Shaoyin refers to as "coughing with diarrhea and delirium" is caused by fire coercion. The original text details this. Otherwise, how could it flare upward causing coughing? Statements regarding "coughing or vomiting, thirst preventing sleep" must involve vomiting, thirst, and insomnia, presenting Shaoyin Yin restlessness, distinct from Yangming's vomiting/coughing combined with headache. Statements regarding "coughing or palpitations, or difficult urination, or abdominal pain, or heavy sensation during diarrhea" must involve combinations of these four. Although these symptoms may resemble Yangming, headache is certainly not a Shaoyin symptom. This is why Shaoyin cough differs from Yangming. Thus, Taiyang headache entering the context of Yangming's free urination, vomiting, coughing, and cold extremities all belong to Yang patterns, demonstrating that Yang can command Yin; with one Yang qi preserved, all Yins transform into Yang. This applies to disease qi as well, allowing us to recognize the state of righteous qi in the human body.
[Gang] Zhang Zhongjing said. In Yangming disease, with intense heat in both exterior and interior, irritability, thirst with desire to drink, and severe headache feeling like bursting, Zhu Ye Shi Gao Tang (Bamboo Leaf and Gypsum Decoction) is used. In Yangming disease, with body heat and headache, rinsing the mouth with water but no desire to swallow, epistaxis (nosebleed) will inevitably occur.
[Mu] Yang Shiyin stated: For impending epistaxis with a rapid pulse, Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) is appropriate. Mao Hua Tang (Thistle Flower Decoction) may also be used.
Wu Shou stated: Yangming headache is located in the forehead, accompanied by eye pain and nasal dryness, with a long pulse. For absence of sweat, use Ge Gen plus Cong Bai (Scallion Juice) and Bai Zhi (Angelica Dahurica) to induce sweating. For presence of sweat, where previous sweating failed to resolve headache, use Ge Gen Cong Bai Tang. If there is no aversion to wind but rather aversion to heat, spontaneous sweating, irritability, thirst, surging-rapid pulse, and headache worsened by drinking water, use Bai Hu Jia Bai Zhi Tang (White Tiger Decoction plus Angelica Dahurica). For internal dry feces causing steaming heat and headache, use Tiao Wei Cheng Qi Tang. Generally, for Yangming headache with absence of sweat, use Ge Gen, Ma Huang (Ephedra), Cong Bai, Bai Zhi, Shi Gao (Gypsum). For presence of sweat, use Bai Zhi, Shi Gao, Ge Gen, Chuan Xiong (Sichuan Lovage Root) decoction.
[Gang] Zhang Zhongjing said. In Yangming disease, with a slow pulse, difficulty eating until full, mild vexation after eating, dizziness, and inevitable difficulty in urination, Gu Dan Jaundice (Grain Jaundice) is developing. Purging is required. If abdominal fullness remains unchanged after purging, it is due to the slow pulse.
[Mu] Wei Litong stated: The preceding clause states: "Desire to vomit after eating belongs to Yangming," treated with Wu Zhu Yu Tang. Worsening after taking the medicine indicates Upper Jiao involvement. Both clauses discuss stomach deficiency, but deficiency-cold and deficiency-heat are vastly different. Deficiency should not be treated as excess with purgatives; can heat be immediately treated as cold with warming tonics? Thus, Master Zhongjing uses the "desire to vomit after eating" clause to demonstrate analogical reasoning. For example, Yangming disease with a slow pulse seems like deficiency-cold, but cold patterns cannot eat; here, eating is possible but difficult to tolerate fullness. Mild vexation and dizziness after eating indicate the stomach is not cold (hence able to eat) but qi-deficient (hence unable to tolerate fullness). Mild vexation and dizziness are signs of deficiency combined with heat. This identifies stomach deficiency similarly to the "vomit after eating" clause, but the heat aspect is unique to this clause. Slow pulse usually indicates cold; why call it heat? This is a slow pulse combined with choppy quality, not a deep-slow pulse. It can be called deficiency combined with damp-heat, but calling it deficiency-cold is a major error. The symptom of difficult urination further confirms this: deficiency means qi fails to充盈 (fill) and dampness persists; dampness prevents qi transformation and heat dissipation. Grain qi in the stomach fails to transform into healthy nourishment, instead brewing damp-heat, steaming into jaundice. Without clearing heat, removing dampness, strengthening Earth, and resolving jaundice, reckless purging will increase dampness and worsen deficiency, leaving abdominal fullness unchanged. The stomach affects the spleen, invading both interior and exterior, leading to yellowing and edema. Hence, "due to the slow pulse." This means the pulse is soggy-choppy and not slippery, emphasizing deficiency and dampness primarily, with heat secondarily. The correct treatment prioritizes removing dampness, strengthening Earth, and tonifying the center as the sovereign herb, using heat-clearing and jaundice-resolving herbs as ministers and assistants. This truly masters Master Zhongjing's method.
[Gang] Zhang Zhongjing said. In Yangming disease, only dizziness occurs, with no aversion to cold, ability to eat, and coughing; the person must have a sore throat. If there is no coughing, the throat will not hurt.
[Mu] Wang Kentang stated: In Yangming disease, the body is not heavy, only dizzy with no aversion to cold, indicating Yangming Wind-stroke with internal attack of wind. The classic says: In Yangming disease, ability to eat is named Wind-stroke. Wind pathogen attacks the stomach, stomach qi rebels upward causing coughing. The pharynx is connected to the stomach; severe coughing injures the pharynx, causing sore throat. If stomach qi does not rebel, there is no coughing, and thus no sore throat.
Shen Jin'ao commented: This clause and the "absence of sweat" clause in the previous headache section both show Yangming disease resembling Shaoyin. However, that clause's vomiting/coughing without sweat and headache with cold extremities differs from Shaoyin's cold extremities with sweat but no headache, and vomiting without coughing. This clause's coughing with sore throat differs from Shaoyin's sore throat without coughing.