宗印云。此直中之寒邪。不能胜谷精之正气。与汗共并而出。故其脉亦如蛇之纡回而欲出也。魏氏云。紧者。
缓之对言。脉紧者。言不若病脉之缓而已。非必如伤寒之紧也。钱氏云。紧则浮去。而里气充实也。○案以上数
说。未审孰是。姑从成注。
阳明病。欲解时。从申至戌上。
〔成〕四月为阳。土旺于申酉戌。向旺时。是为欲解。〔柯〕申酉为阳明主时。即日晡也。
阳明病。不能食。攻其热必哕。所以然者。胃中虚冷故也。以其人本虚。攻其热必哕。
〔魏〕阳明病不能食。即使有手足 然汗出等证之假热。见于肤表面目之间。一考验之于不能食。自不
可妄言攻下。若以为胃实之热而攻之。则胃阳愈陷而脱。寒邪愈盛而冲。必作哕证。谷气将绝矣。再明其所以
然。确为胃中虚冷之故。以其人本属胃冷而虚。并非胃热之实。误加攻下。下陷上逆。则医不辨寒热虚实。而
概为阳明病。必当下之之过也。〔志〕高子曰。遍阅诸经。止有哕而无呃。则哕之为呃也。确乎不易。诗云。銮
声哕哕。谓呃之发声有序。如车銮声之有节奏也。凡经论之言哕者。俱作呃解无疑。〔钱〕胃阳败绝。而成
呃逆。难治之证也。
〔汪〕愚谓宜用附子理中汤。
阳明病脉迟。食难用饱。饱则微烦头眩。必小便难。此欲作谷瘅。虽下之。腹满如故。所以然者。脉迟故
也。（瘅。成本。作疸。微。玉函。作发。柯本。脉迟下。补腹满二字。金匮。迟食间。有者字。微。作发。
必小便难。作小便必难。）
〔程〕脉迟为寒。寒则不能宣行胃气。故非不能饱。特难用饱耳。饥时气尚流通。饱则填滞。以故上焦不
行。而有微烦头眩证。下脘不通。而有小便难证。小便难中。包有腹满证在内。欲作谷疸者。中焦升降失职。
则水谷之气不行。郁黩而成黄也。曰谷疸者。明非邪热也。下之。兼前后部言。茵陈蒿汤。五苓散之类也。曰
腹满如故。则小便仍难。而疸不得除。可知。再出脉迟。欲人从脉上悟出胃中冷来。热蓄成黄之腹满。下之可
去。此则谷气不得宣泄。属胃气虚寒使然。下之益虚其虚矣。故腹满如故。〔印〕案金匮。谷疸有二证。此则
虚寒而冷HT 者也。〔钱〕谓之欲作。盖将作未作之时也。阴阳应象论云。寒气生浊。热气生清。又云。浊气在
上。则生 胀。若不温中散寒。徒下无益也。
案汪氏云。补亡论。常器之云。宜猪苓汤。五苓散。愚以上二方。未成谷疸时。加减出入。可随证选用。
郭白云云。已发黄者。茵陈蒿汤。此为不可易之剂。张氏云。脉迟胃虚。下之无益。则发汗利小便之法。用之
无益。惟当用和法。如甘草干姜汤。先温其中。然后少与调胃。微和胃气。是也。以上二说。似未妥帖。当考。
阳明病。法多汗。反无汗。其身如虫行皮中状者。此以久虚故也。（玉函。千金翼。作阳明病久久而坚者
阳明当多汗而反无汗云云。）
〔成〕胃为津液之本。气虚津液少。病则反无汗。胃候身
之肌肉。其身如虫行皮中者。知胃气久虚也。〔程〕阳明病。阳气充盛之候也。故法多汗。今反无汗。胃阳不足。
其人不能食可知。盖汗生于谷精。阳气所宣发也。胃阳既虚。不能透出肌表。故怫郁皮中。如虫行状。虚字指
胃言。兼有寒。久字指未病时言。〔柯〕此又当益津液和营卫。使阴阳自和。而汗出也。
案汪氏云。常器之云。可桂枝加黄 汤。郭白云云。桂枝麻黄各半汤。愚以还当用葛根汤主之。金鉴云。
宜葛根汤小剂。微汗和其肌表。自可愈也。魏氏云。补虚清热。人参白虎汤之类。并似与经旨相畔矣。
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。
（【原注】一云。冬阳明。○玉函。作各阳明病。千金翼。作冬阳明病。）
〔成〕阳明病法多汗。反无汗。而小便利者。阳明伤寒。而寒气内攻也。至二三日。呕咳而支厥者。寒邪
发于外也。必苦头痛。若不咳不呕。手足不厥者。是寒邪但攻里。而不外发。其头亦不痛也。
案此条难解。录数说于下。方氏云。此亦寒胜。故小便利。呕。手足厥。喻氏云。得之寒因。而邪热深
也。然小便利。则邪热不在内而在外。不在下而在上。故苦头痛也。程氏云。胃中独治之寒。厥逆上攻。故头
痛者标。咳呕手足厥者本。张璐注与喻同。云。仍宜小青龙主之。汪氏云。此阳明经伤寒。热气上攻。必苦头
痛。当用葛根汤。类要。用小建中汤。常氏用小柴胡汤。并非也。钱氏云。其所以无汗者。寒在阳明之经。而
小便不利者。里无热邪也。柯氏云。此胃阳不敷布于四肢。故厥。不上升于额颅。故痛。缘邪中于膺。结在胸
中。致呕咳而伤阳也。当用瓜蒂散吐之。呕咳止。厥
痛自除矣。两者字。作时看更醒。
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。（【原注】一云。冬阳明。○玉
函。作各阳明病。千金翼。作冬阳明病。）
〔钱〕但头眩者。热在上也。不恶寒。即阳明篇首。所谓不恶寒反恶热之义也。能食。阳明中风也。咳
者。热在上焦。而肺气受伤也。中风之阳邪。壅于上焦。故咽门必痛也。若不咳者。上焦之邪热不甚。故咽亦
不痛。此条纯是热邪。当与前条之不咳不呕。手足不厥头不痛一条。两相对待。示人以风寒之辨也。〔程〕夫
咽痛。惟少阴有之。今此以咳伤致痛。若不咳则咽不痛。况更有头眩不恶寒。以证之。不难辨其为阳明之郁热也。
案此条证。常器之张璐并云。茯苓桂枝白术甘草汤。常氏又云。咽痛者。桔梗汤。柯氏云。此邪结胸中。
而胃家未实也。当从小柴胡加减法。
阳明病。无汗。小便不利。心中懊 者。身必发黄。
〔成〕阳明病无汗。而小便不利者。热蕴于内。而不得越。心中懊 者。热气郁蒸。欲发于外而为黄也。
〔志〕阳明之气。不行于表里上下。则内逆于心中。而为懊 。阳热之气留中。入胃之饮不布。则湿热窨HT 。而身必
发黄。〔柯〕口不渴。腹不满。非茵陈汤所宜。与栀子柏皮汤。黄自解矣。
案金鉴云。心中懊 。湿瘀热郁于里也。宜麻黄连轺赤小豆汤。若经汗吐下后。或小便利。而心中懊
者。热郁也。便硬者。宜调胃承气汤。便软者。宜栀子豉汤。视之柯注。却似于经旨不切矣。
阳明病。被火。额上微汗出。而小便不利者。必发黄。（成本。无而字。玉函同。）
〔喻〕阳明病。湿停热郁。而烦渴有加。势必发黄。然汗出。热从外越。则黄可免。小便多。热从下泄。
则黄可免。若误攻之。其热邪愈陷。清液愈伤。而汗与小便。愈不可得矣。误火之。则热邪愈炽。津液上奔。
额虽微汗。而周身之汗与小便。愈不可得矣。发黄之变。安能免乎。〔柯〕非栀子柏皮汤。何以挽津液于涸竭
之余耶。
案常氏云。可与茵陈蒿汤。汪氏云。五苓散。去桂枝加葛根。白术当改用苍术。金鉴云。若小便利。则从
燥化。必烦渴。宜白虎汤。小便不利。则从湿化。必发黄。茵陈蒿汤。并于经旨未妥。
阳明病。脉浮而紧者。必潮热发作有时。但浮者。必盗汗出。（玉函。千金翼。作其热必潮。）
〔钱〕邪在太阳。以浮紧为寒。浮缓为风。在阳明。则紧为在里。浮为在表。脉浮而紧者。言浮而且紧也。
谓邪虽在经。太半已入于里也。邪入于里。必发潮热。其发作有时者。阳明气旺于申酉。故日晡时潮热也。潮
热则已成可下之证矣。若但脉浮者。风邪全未入里。其在经之邪未解。必盗汗出。犹未可下也。阳明本多汗多
眠。故有盗汗。然不必阳明始有盗汗。如太阳上编。脉浮而动数。因自汗出之中风。即有盗汗。盖由目瞑则卫
气内入。皮肤不阖。则盗汗出矣。此示人当以脉证辨认表里。未可因潮热而轻用下法也。〔锡〕睡中汗出。如
盗贼乘人之不觉而窃去也。
案补亡论。与柴胡桂枝汤。汪氏及金鉴云。桂枝加葛根汤。补亡论为是。
案程氏云。脉浮而紧者。缘里伏阴寒。系阳于外故也。阴盛阳不敢争。仅乘旺时而一争。故潮热发作有时
也。但浮者。胃阳虚。而中气失守也。睡则阴气盛。阳益不能入。而
盗汗出也。夫潮热汗出。皆阳明里实证。而今属之虚寒。则于其脉辨之。更可互参及能食不能食之内法也。此
亦一说。故表而出。又集注。金氏曰。无病之人。则日有潮而不觉。病则随潮外现矣。此说太奇。故附于此。
金鉴曰。自汗。是阳明证。盗汗。是少阳证。盗汗。当是自汗。文义始属。○案此说太误。
阳明病。口燥。但欲漱水。不欲咽者。此必衄。（ 。千金翼。作咽。）
〔喻〕口中干燥与渴异。漱水不欲咽。知不渴也。阳明气血俱多。以漱水不欲咽。知邪入血分。阳明之
脉。起于鼻。故知血得热而妄行。必由鼻而出也。
魏氏云。漱水。非渴也。口中粘也。
周氏云。使此时以葛根汤汗之。不亦可以夺汗而无血乎。此必衄者。仲景正欲人之早为治。不致衄后更
问成流与否也。汪氏云。常器之曰。可黄芩芍药地黄汤。一云。当作黄芩芍药甘草汤。愚以此二汤。乃衄后之
药。于未衄时。还宜用葛根等汤加减主之。柯氏云。宜桃仁承气。犀角地黄辈。○案本条。下一必字。宜衄前
防衄。犀角地黄之类。盖为的对矣。
阳明病。本自汗出。医更重发汗。病已瘥。尚微烦不了了者。此必大便硬故也。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。（此必大便硬。成本。作此大便必硬。津液。玉函。作精液。汪氏云。当还二字。
作还当。其义乃顺。非也。○案据柯注。数。如字。）
〔柯〕胃者。津液之本也。汗与溲。皆本于津液。本自出汗。本小便利。其人胃家之津液本多。仲景揭
出亡津液句。为世之不惜津液者告也。病瘥。指身热汗出言。烦即恶热之
谓。烦而微。知恶热将自罢。以尚不了。故大便硬耳。数少。即再行之谓。大便硬。小便少。皆因胃亡津液所
致。不是阳盛于里也。因胃中干燥。则饮入于胃。不能上输于肺。通调水道。下输膀胱。故小便反少。而游溢
之气。尚能输精于脾。津液相成。还归于胃。胃气因和。则大便自出。更无用导法矣。以此见津液素盛者。虽
亡津液。而津液终自还。正以见胃家实者。每踌躇顾虑。示人以勿妄下与妄汗也。历举治法。脉迟不可攻。心
下满不可攻。呕多不可攻。小便自利。与小便数少。不可攻。总见胃家实不是可攻证。〔方〕盖水谷入胃。其
清者为津液。粗者成渣滓。津液之渗而外出者。则为汗。潴而下行者。为小便。故汗与小便出多。皆能令人亡
津液。所以渣滓之为大便者。干燥结硬而难出也。然二便者。水谷分行之道路。此通则彼塞。此塞则彼通。小便
出少。则津液还停胃中。胃中津液足。则大便软滑。此其所以必出可知也。〔汪〕病家如欲用药。宜少与麻仁丸。
伤寒呕多。虽有阳明证。不可攻之。
〔沈〕呕多则气已上逆。邪气偏侵上脘。或带少阳。故虽有阳明证。慎不可攻也。〔方〕虽字当玩味。
〔柯〕呕多。是水气在上焦。虽有胃实证。只宜小柴胡以通液。攻之恐有利遂不止之祸。要知阳明病。津液未
亡者。慎不可攻。盖腹满呕吐。是太阴阳明相关证。胃实胃虚。是阳明太阴分别处。胃家实。虽变证百出。不
失为生阳。下利不止。参附不能挽回。便是死阴矣。
常氏云。宜小柴胡汤。汪氏云。兼有阳明证。宜用葛根加半夏汤。案汪以葛根为阳明药。不可从。
喻氏云。呕多。诸病不可攻下。不特伤寒也。
阳明病。心下硬满者。不可攻之。攻之利遂不止者死。
利止者愈。（玉函。千金翼。作遂利。）
〔成〕阳明病腹满者。为邪气入腑。可下之。心下硬满。则邪气尚浅。未全入腑。不可便下之。得利止者。
为邪气去正气安。正气安则愈。若因下利不止者。为正气脱而死。〔魏〕言阳明病。则发热汗出之证具。若胃实
者。硬满在中焦。今阳明病。而见心下硬满。非胃实可知矣。虽阳明。亦可以痞论也。主治者。仍当察其虚实
寒热。于泻心诸方中求治法。〔汪〕结胸证。心下硬满而痛。此为胃中实。故可下。此证不痛。当是虚硬虚满。
故云不可攻也。常器之云。未攻者。可与生姜泻心汤。利不止者。四逆汤。愚以须理中汤救之。
程氏云。心下硬满者。邪聚阳明之膈。膈实者腹必虚。气从虚闭。亦见阳明假实证。攻之是为重虚。锡驹
云。心下硬满者。胃中水谷空虚。胃无所仰。虚气上逆。反硬满也。故太阳篇曰。此非结热。但以胃中空虚。
客气上逆。故使硬也。○案以上二说。以心下硬满。为虚满假证。此证世多有之。然今考经文。唯云心下硬满。
并不拈出虚候。故难信据焉。
阳明病。面合色赤。不可攻之。必发热色黄者。小便不利也。（玉函。成本。色赤。作赤色。黄下。无者
宗印说：这是直中（寒邪直接侵入脏腑）的寒邪，不能胜过谷精（饮食水谷化生的精气）的正气，与汗液一起并出。所以脉象也像蛇一样迂回曲折，想要外出。魏氏说：“紧”是相对于“缓”而言的。脉紧，是说它不像病脉那样舒缓罢了，并不一定像伤寒那样紧束。钱氏说：紧脉则浮去，而里气充实。○按语：以上几种说法，不清楚哪一种是正确的，暂且遵从成无己的注解。
阳明病，欲解时（病情可能缓解的时间段），从申时到戌时上。
〔成〕四月为阳，土旺于申、酉、戌三个时辰。趋向旺盛的时候，就是欲解之时。〔柯〕申、酉是阳明主时的时刻，也就是日晡（下午3点到7点）。
阳明病，不能进食，如果攻其热（使用清热或泻下法），必定会发生哕（呃逆）。之所以这样，是因为胃中虚冷。因为病人本来虚弱，攻其热必定导致哕。
〔魏〕阳明病不能进食，即使有手足濈然汗出等假热的症状，表现在皮肤表面和面目之间，一旦检验到不能进食，自然不可以妄言攻下。如果认为是胃实之热而攻之，那么胃阳就会更加陷入而脱失，寒邪更加旺盛而冲逆，必定出现哕证，谷气将要断绝了。再说明其中的原因，确确实实是胃中虚冷的缘故。因为这个人本来属于胃冷而虚，并不是胃热之实。误加攻下，下陷上逆，这是医生不辨别寒热虚实，一概认为阳明病必须用下法的过错。〔志〕高子说：遍阅各种经典，只有哕而没有呃，那么哕就是呃，确凿无疑。《诗经》说：“銮声哕哕”，是说呃的声音有序，像车銮声有节奏一样。凡是经论中说的哕，都作呃解无疑。〔钱〕胃阳败绝，而成呃逆，是难治的病证。
〔汪〕我认为应该用附子理中汤。
阳明病，脉迟，吃东西难以吃饱，饱了就轻微心烦、头眩，必定小便难，这是将要发生谷瘅（因饮食不当引起的黄疸）。虽然用下法，腹满依然如故。之所以这样，是因为脉迟的缘故。（瘅，成本本作疸。微，玉函本作发。柯本在脉迟下补了腹满二字。金匮要略中，迟食间，有者字。微，作发。必小便难，作小便必难。）
〔程〕脉迟为寒，寒则不能宣行胃气，所以不是不能饱，只是难以吃得过饱。饥饿时气尚流通，饱了就填滞，所以上焦不行，而有轻微心烦、头眩的症状；下脘不通，而有小便难的证候。在小便难中，包涵有腹满证在内。将要发生谷疸的，是中焦升降失职，那么水谷之气不行，郁积而成黄。叫谷疸，说明不是邪热。下法，兼前后部来说，指茵陈蒿汤、五苓散之类的方剂。说腹满如故，那么小便仍然难，而疸不得除，可以知道了。再次提出脉迟，想让人从脉象上悟出胃中冷来。热蓄成黄的腹满，用下法可以去掉，这则是谷气不得宣泄，属于胃气虚寒使然。用下法更加虚其虚了，所以腹满如故。〔印〕按语：金匮要略中，谷疸有二种证候，这则是虚寒而冷的。〔钱〕称为“欲作”，大概是即将发作还未发作的时候。《阴阳应象大论》说：寒气生浊，热气生清。又说：浊气在上，则生䐜胀。如果不温中散寒，徒然用下法没有益处。
按语：汪氏说：《补亡论》中，常器之说：宜用猪苓汤、五苓散。我认为以上两个方剂，在未形成谷疸时，加减出入，可随证选用。郭白云说：已经发黄的，用茵陈蒿汤，这是不可改变的方剂。张氏说：脉迟胃虚，用下法没有益处，那么发汗利小便的方法，用之也没有益处。只应当用和法，如甘草干姜汤，先温其中，然后少与调胃，微微调和胃气，就是这样。以上两种说法，似乎不太妥当，应当考证。
阳明病，法当多汗，反而无汗，身体像虫行皮中状（感觉皮肤中有虫子爬行），这是因为久虚的缘故。（玉函、千金翼作：阳明病久久而坚者，阳明当多汗而反无汗云云。）
〔成〕胃为津液之本，气虚津液少，生病则反而无汗。胃候身之肌肉，身体像虫行皮中，知道胃气久虚。〔程〕阳明病，是阳气充盛的征候，所以法当多汗。现在反而无汗，可知胃阳不足，其人不能进食。大概汗生于谷精，由阳气宣发。胃阳既虚，不能透出肌表，所以怫郁在皮中，像虫行状。“虚”字指胃而言，兼有寒；“久”字指未病时而言。〔柯〕这又应当益津液、和营卫，使阴阳自和，而汗出。
按语：汪氏说：常器之说：可用桂枝加黄芪汤。郭白云说：桂枝麻黄各半汤。我认为还应当用葛根汤主治。《医宗金鉴》说：宜用小剂葛根汤，微汗和其肌表，自然可以痊愈。魏氏说：补虚清热，用人参白虎汤之类，都与经旨相违背了。
阳明病，反而无汗，而小便利，二三天后呕而咳，手足厥冷的人，必定苦头痛。如果不咳不呕，手足不厥冷的，头不痛。
（【原注】一说：冬阳明。○玉函作：各阳明病。千金翼作：冬阳明病。）
〔成〕阳明病法当多汗，反而无汗，而小便利的，是阳明伤寒，寒气内攻。到了二三天，呕咳而四肢厥冷的，是寒邪发于外。必定苦头痛。如果不咳不呕，手足不厥冷的，是寒邪但攻里，而不外发，其头也不痛。
按语：这一条很难理解，录几种说法在下面。方氏说：这也是寒胜，所以小便利。呕、手足厥。喻氏说：得之于寒因，而邪热深也。然而小便利，则邪热不在内而在外，不在下而在上，所以苦头痛。程氏说：胃中独治之寒，厥逆上攻，所以头痛者是标，咳呕手足厥是本。张璐注与喻同，说：仍宜用小青龙汤主治。汪氏说：这是阳明经伤寒，热气上攻，必定苦头痛，当用葛根汤。《类要》用小建中汤，常氏用小柴胡汤，都不对。钱氏说：其所以无汗的，是寒在阳明之经，而小便不利的，是里无热邪。柯氏说：这是胃阳不敷布于四肢，所以厥；不上升于额颅，所以痛。缘邪中于膺，结在胸中，致呕咳而伤阳。当用瓜蒂散吐之，呕咳止，厥痛自除矣。将“两者”二字，当作“时”字看更醒目。
阳明病，但头眩，不恶寒，所以能食而咳，其人咽必痛。若不咳者，咽不痛。
（【原注】一说：冬阳明。○玉函作：各阳明病。千金翼作：冬阳明病。）
〔钱〕但头眩的，是热在上。不恶寒，即阳明篇首所说的不恶寒反恶热的意思。能食，是阳明中风。咳的，是热在上焦，而肺气受伤。中风的阳邪，壅于上焦，所以咽门必痛。如果不咳，上焦的邪热不甚，所以咽也不痛。这一条纯是热邪，应当与前条的不咳不呕、手足不厥、头不痛一条，两相对待，示人以风寒的辨别。〔程〕夫咽痛，只有少阴病有。现在这是以咳伤致痛，如果不咳则咽不痛，况且更有头眩不恶寒，来验证它，不难辨明其为阳明的郁热。
按语：这一条证候，常器之、张璐都说：茯苓桂枝白术甘草汤。常氏又说：咽痛的，桔梗汤。柯氏说：这是邪结胸中，而胃家未实。应当从小柴胡加减法治疗。
阳明病，无汗，小便不利，心中懊憹的，身必发黄。
〔成〕阳明病无汗，而小便不利的，热蕴于内，而不得越。心中懊憹的，热气郁蒸，欲发于外而为黄。〔志〕阳明之气，不行于表里上下，则内逆于心中，而为懊憹。阳热之气留中，入胃之饮不布，则湿热窨酿，而身必发黄。〔柯〕口不渴，腹不满，非茵陈汤所宜。与栀子柏皮汤，黄自解矣。
按语：《医宗金鉴》说：心中懊憹，湿瘀热郁于里。宜麻黄连轺赤小豆汤。若经过汗、吐、下后，或小便利，而心中懊憹的，是热郁。便硬的，宜调胃承气汤。便软的，宜栀子豉汤。看来与柯注相比，却似乎与经旨不切。
阳明病，被火（误用火疗），额上微汗出，而小便不利的，必发黄。
〔喻〕阳明病，湿停热郁，而烦渴有加，势必发黄。然而汗出，热从外越，则黄可免。小便多，热从下泄，则黄可免。如果误攻之，其热邪愈陷，清液愈伤，而汗与小便，愈不可得了。误用火疗，则热邪愈炽，津液上奔，额虽微汗，而周身之汗与小便，愈不可得了。发黄的变证，怎么能避免呢？〔柯〕不用栀子柏皮汤，怎么能在津液涸竭之余挽回津液呢？
按语：常氏说：可与茵陈蒿汤。汪氏说：五苓散，去桂枝加葛根，白术当改用苍术。《医宗金鉴》说：若小便利，则从燥化，必烦渴，宜白虎汤。小便不利，则从湿化，必发黄，茵陈蒿汤。这些都与经旨未妥。
阳明病，脉浮而紧的，必潮热，发作有时。但浮的，必盗汗出。（玉函、千金翼作：其热必潮。）
〔钱〕邪在太阳，以浮紧为寒，浮缓为风。在阳明，则紧为在里，浮为在表。脉浮而紧的，是说浮而且紧。谓邪虽然在经，太半已入于里。邪入于里，必发潮热。其发作有时的，阳明气旺于申、酉，所以日晡时潮热。潮热则已成可下的证候了。若但脉浮的，风邪全未入里，其在经之邪未解，必盗汗出。犹未可下。阳明本多汗多眠，故有盗汗。然而不必阳明始有盗汗，如太阳上编，脉浮而动数，因自汗出之中风，即有盗汗。盖由目瞑则卫气内入，皮肤不阖，则盗汗出。这是示人应当以脉证辨认表里，未可因潮热而轻用下法。〔锡〕睡中汗出，如盗贼乘人之不觉而窃去。
按语：《补亡论》用柴胡桂枝汤，汪氏及《金鉴》说：桂枝加葛根汤。《补亡论》是对的。
按语：程氏说：脉浮而紧的，缘里伏阴寒，系阳于外。阴盛阳不敢争，仅乘旺时而一争，所以潮热发作有时。但浮的，胃阳虚，而中气失守。睡则阴气盛，阳益不能入，而盗汗出。夫潮热汗出，皆阳明里实证，而今属之虚寒，则于其脉辨之，更可互参及能食不能食的内法。这也是一种说法，所以表而出之。又集注，金氏说：无病之人，则日有潮而不觉，病则随潮外现。此说太奇，所以附于此。《金鉴》说：自汗，是阳明证；盗汗，是少阳证。盗汗，应当是自汗，文义始属。○按语：此说太误。
阳明病，口燥，但欲漱水，不欲咽的，此必衄（鼻出血）。（ 。千金翼作：咽。）
〔喻〕口中干燥与渴异。漱水不欲咽，知不渴。阳明气血俱多，以漱水不欲咽，知邪入血分。阳明之脉，起于鼻，故知血得热而妄行，必由鼻而出。
魏氏说：漱水，非渴，是口中粘。
周氏说：使此时以葛根汤汗之，不也可以夺汗而无血乎？此必衄者，仲景正欲人之早为治，不致衄后更问成流与否。汪氏说：常器之说：可黄芩芍药地黄汤。一说：当作黄芩芍药甘草汤。我认为这两汤，是衄后的药，在未衄时，还宜用葛根等汤加减主治。柯氏说：宜桃仁承气、犀角地黄辈。○按语：本条下一“必”字，宜在衄前防衄，犀角地黄之类，盖为的对。
阳明病，本自汗出，医更重发汗，病已瘥，尚微烦不了了者，此必大便硬。以亡津液胃中干燥，故令大便硬。应当问其小便日几行。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。（此必大便硬，成本作：此大便必硬。津液，玉函作：精液。汪氏说：当还二字，作还当，其义乃顺，不对。○按语：据柯注，数，如字。）
〔柯〕胃是津液之本。汗与溲，皆本于津液。本自出汗，本小便利，其人胃家之津液本多。仲景揭出亡津液句，为世之不惜津液者告也。病瘥，指身热汗出言。烦即恶热之谓。烦而微，知恶热将自罢，以尚不了，故大便硬耳。数少，即再行之谓。大便硬，小便少，皆因胃亡津液所致，不是阳盛于里。因胃中干燥，则饮入于胃，不能上输于肺，通调水道，下输膀胱，故小便反少，而游溢之气，尚能输精于脾，津液相成，还归于胃，胃气因和，则大便自出，更无用导法。以此见津液素盛者，虽亡津液，而津液终自还，正以见胃家实者，每踌躇顾虑，示人以勿妄下与妄汗。历举治法，脉迟不可攻，心下满不可攻，呕多不可攻，小便自利，与小便数少，不可攻。总见胃家实不是可攻证。〔方〕盖水谷入胃，其清者为津液，粗者成渣滓。津液之渗而外出者，则为汗；潴而下行者，为小便。故汗与小便出多，皆能令人亡津液，所以渣滓之为大便者，干燥结硬而难出。然而二便者，水谷分行之道路，此通则彼塞，此塞则彼通。小便出少，则津液还停胃中，胃中津液足，则大便软滑，此其所以必出可知。〔汪〕病家如欲用药，宜少与麻仁丸。
伤寒呕多，虽有阳明证，不可攻之。
〔沈〕呕多则气已上逆，邪气偏侵上脘，或带少阳，故虽有阳明证，慎不可攻。〔方〕虽字当玩味。〔柯〕呕多，是水气在上焦，虽有胃实证，只宜小柴胡以通液，攻之恐有利遂不止之祸。要知阳明病，津液未亡者，慎不可攻。盖腹满呕吐，是太阴阳明相关证，胃实胃虚，是阳明太阴分别处。胃家实，虽变证百出，不失为生阳；下利不止，参附不能挽回，便是死阴。
常氏说：宜小柴胡汤。汪氏说：兼有阳明证，宜用葛根加半夏汤。按语：汪以葛根为阳明药，不可从。
喻氏说：呕多，诸病不可攻下，不特伤寒。
阳明病，心下硬满者，不可攻之。攻之利遂不止者死。利止者愈。
〔成〕阳明病腹满的，为邪气入腑，可下。心下硬满，则邪气尚浅，未全入腑，不可便下。得利止的，为邪气去正气安，正气安则愈。若因下利不止的，为正气脱而死。〔魏〕言阳明病，则发热汗出之证具。若胃实者，硬满在中焦。今阳明病，而见心下硬满，非胃实可知。虽阳明，亦可以痞论也。主治者，仍当察其虚实寒热，于泻心诸方中求治法。〔汪〕结胸证，心下硬满而痛，此为胃中实，故可下。此证不痛，当是虚硬虚满，故云不可攻。常器之说：未攻者，可与生姜泻心汤。利不止者，四逆汤。我认为须理中汤救之。
程氏说：心下硬满者，邪聚阳明之膈，膈实者腹必虚，气从虚闭，亦见阳明假实证。攻之是为重虚。锡驹说：心下硬满者，胃中水谷空虚，胃无所仰，虚气上逆，反硬满。故太阳篇曰：此非结热，但以胃中空虚，客气上逆，故使硬。○按语：以上两种说法，以心下硬满为虚满假证，此证世多有之。然而今考经文，唯云心下硬满，并不拈出虚候，故难信据。
Zong Yin said: This is cold pathogenic factors directly invading (Zhizhong, cold pathogens directly entering the zang-fu organs), which cannot overcome the righteous qi of grain essence (Gu Jing, the vital energy derived from food and drink). It emerges together with sweat. Therefore, the pulse is also like a snake winding back and forth, attempting to exit. Mr. Wei stated: "Tight" (Jin) is spoken of in contrast to "slow" (Huan). A tight pulse means it is not as relaxed as a pathological pulse; it does not necessarily mean as tight as in Cold Damage (Shanghan). Mr. Qian stated: When the pulse is tight, the floating aspect departs, and the interior qi becomes full. ○ Commentary: Among the above several theories, it is unclear which is correct. For now, we follow Cheng Wuji's annotation.
Yangming disease, the time when it may resolve (Yujie Shi), is from Shen hour to Xu hour.
[Cheng] The fourth month belongs to Yang. Earth flourishes at Shen, You, and Xu hours. Approaching its flourishing time is considered the time of resolution. [Ke] Shen and You are the times governed by Yangming, i.e., Ribusha (late afternoon, roughly 3 PM to 7 PM).
In Yangming disease, if the patient cannot eat, attacking the heat (using heat-clearing or purgative methods) will inevitably cause hiccups (Yue, hiccup/eructation). The reason for this is deficiency-cold in the stomach. Because the person is originally deficient, attacking the heat will inevitably lead to hiccups.
[Wei] In Yangming disease, inability to eat indicates that even if there are signs of false heat, such as continuous sweating on the hands and feet, appearing on the skin surface and face, once tested against the inability to eat, one must not rashly speak of purging. If one considers it excess heat in the stomach and attacks it, the Stomach Yang will sink further and collapse, and cold pathogenic factors will become more abundant and surge upward, inevitably resulting in hiccups, and the Qi of grain will be nearly exhausted. To clarify the reason, it is indeed due to deficiency-cold in the stomach. Because this person originally has cold and deficiency in the stomach, not excess heat in the stomach. Mistakenly applying purgatives causes sinking downward and counterflow upward. This is the fault of physicians who do not differentiate between cold, heat, deficiency, and excess, and generally assume all Yangming diseases require purgation. [Zhi] Gao Zi said: Reviewing various classics, only Yue is mentioned, not E (hiccup). Thus, Yue refers to E, which is indisputable. The Book of Songs says: "The sound of bells is Yue-yue," meaning the sound of hiccup is orderly, like the rhythm of carriage bells. All mentions of Yue in the classics should undoubtedly be interpreted as E. [Qian] When Stomach Yang fails and perishes, leading to hiccup, it is a difficult-to-treat condition.
[Wang] I suggest using Fuzi Lizhong Tang (Aconite Decoction for Regulating the Middle).
In Yangming disease, if the pulse is slow (Chi), the patient finds it difficult to eat until full. After eating until full, they experience slight irritability and dizziness, and invariably have difficulty urinating. This is about to develop into Grain Jaundice (Gu Dan, jaundice caused by dietary mishandling). Even if purged, abdominal fullness remains unchanged. The reason is due to the slow pulse. (Dan, in Bencao, is written as Dan. Wei, in Yuhan, is written as Fa. Keben adds two characters "abdominal fullness" after Chi pulse. Jingui Yaolue has "you" character between Chi and Shi. Wei is written as Fa. Bi Xiaobian Nan is written as Xiaobian Bi Nan.)
[Cheng] A slow pulse indicates cold. Cold cannot circulate Stomach Qi freely. Therefore, it is not that they cannot feel full, but rather it is difficult to eat until full. When hungry, Qi flows smoothly; when full, it becomes stagnant. Hence, Upper Jiao does not circulate, leading to symptoms of slight irritability and dizziness; Lower Wan does not unblock, leading to symptoms of difficulty urinating. Within the symptom of difficulty urinating, abdominal fullness is included. Regarding the impending Grain Jaundice, when the ascending and descending functions of the Middle Jiao fail, the Qi of water and grain cannot circulate, stagnating and transforming into yellow. Calling it Grain Jaundice clarifies that it is not due to pathogenic heat. Purging, speaking of both anterior and posterior orifices, refers to formulas like Yinchen Hao Tang (Artemisia Capillaris Decoction) and Wuling San (Five-Ingredient Powder with Poria). Saying abdominal fullness remains unchanged implies urine difficulty persists and jaundice is not resolved, which can be known. Reiterating the slow pulse aims to make people realize cold in the stomach from the pulse. Abdominal fullness from heat accumulation causing jaundice can be removed by purging; this case involves grain Qi failing to vent, caused by Stomach Qi deficiency and cold. Purging further depletes the deficiency, so abdominal fullness remains unchanged. [Yin] Commentary: In Jingui Yaolue, there are two types of Grain Jaundice; this one is deficiency-cold and cold. [Qian] Called "about to develop," implying the time just before onset. The Treatise on Corresponding Influences states: Cold generates turbidity, heat generates clarity. It also states: Turbid Qi residing above leads to distension. If one does not warm the middle and dissipate cold, purging alone is of no benefit.
Commentary: Wang Shi said: Buchuang Lun records Chang Qizhi stating: Zhu Ling Tang and Wuling San are suitable. I believe these two formulas, used before Grain Jaundice forms, can be selected according to symptoms with modifications. Guo Baiyun said: For those already yellowed, Yinchen Hao Tang is the indispensable formula. Zhang Shi said: Slow pulse indicates Stomach deficiency; purging is of no benefit. Thus, diaphoresis and promoting urination are also of no benefit. One should use harmonizing methods, such as Gancao Ganjiang Tang (Licorice and Dried Ginger Decoction), first warming the middle, then giving small amounts to gently regulate Stomach Qi. The above two opinions seem inappropriate and require verification.
In Yangming disease, according to the method, there should be much sweating. Conversely, if there is no sweating, and the body feels like insects crawling under the skin, this is due to long-standing deficiency. (Yuhan and Qianjin Yiyan state: In Yangming disease lasting long and becoming firm, Yangming should have much sweating but conversely has none...)
[Cheng] The Stomach is the root of Jin-Ye (body fluids). Qi deficiency and scanty Jin-Ye cause the disease to present with no sweating. The Stomach corresponds to the muscles of the body. Feeling like insects crawling under the skin indicates long-standing Stomach Qi deficiency. [Cheng] Yangming disease is a sign of abundant Yang Qi, so according to the method, there should be much sweating. Now, conversely, there is no sweating, indicating insufficient Stomach Yang and the person's inability to eat. Sweat is generated from grain essence and disseminated by Yang Qi. Since Stomach Yang is deficient, it cannot penetrate the muscle layer, thus stagnating under the skin like insects crawling. The word "deficiency" refers to the Stomach, combined with cold; "long-standing" refers to the pre-disease state. [Ke] This situation requires replenishing Jin-Ye and harmonizing Ying and Wei, allowing Yin and Yang to self-harmonize, resulting in sweating.
Commentary: Wang Shi said: Chang Qizhi stated: Guizhi Jia Huangqi Tang (Cinnamon Twig Decoction plus Astragalus) can be used. Guo Baiyun stated: Guizhi Mahuang Banban Tang (Half-and-Half Decoction of Cinnamon Twig and Ephedra). I believe Gegen Tang (Kudzu Decoction) should still be used as the main treatment. Yizong Jinjian stated: Small dose of Gegen Tang is suitable, inducing mild sweating to harmonize the muscle layer, leading to recovery. Wei Shi said: Tonifying deficiency and clearing heat, using Renshen Baibu Tang (Ginseng and White Tiger Decoction), etc., deviates from the classic intent.
In Yangming disease, conversely, there is no sweating, but urination is free. After two or three days, vomiting and coughing occur, and the hands and feet are cold. Such a person must suffer from headache. If there is no coughing or vomiting, and the hands and feet are not cold, the head does not hurt.
([Original Note] One version says: Winter Yangming. ○ Yuhan reads: Each Yangming disease. Qianjin Yiyan reads: Winter Yangming disease.)
[Cheng] Yangming disease usually involves much sweating. Conversely, no sweating but free urination indicates Yangming Cold Damage, with cold pathogenic factors attacking internally. By the second or third day, vomiting, coughing, and limb cold indicate cold pathogenic factors manifesting externally. Headache must be suffered. If there is no coughing or vomiting, and limbs are not cold, it means cold pathogenic factors attack only the interior without manifesting externally, so the head does not hurt.
Commentary: This clause is difficult to interpret. Several theories are recorded below. Fang Shi said: This is also due to excessive cold, hence free urination. Vomiting and limb cold. Yu Shi said: Caused by cold etiology, with deep pathogenic heat. However, free urination means pathogenic heat is not inside but outside, not below but above, hence suffering headache. Cheng Shi said: Independent cold in the Stomach, counterflow cold attacking upward, so headache is the branch, while coughing, vomiting, and limb cold are the root. Zhang Lu's annotation agrees with Yu, stating: Still suitable to use Xiao Qinglong Tang (Minor Green Dragon Decoction) as the main treatment. Wang Shi said: This is Cold Damage of the Yangming Meridian, with hot Qi attacking upward, inevitably causing headache. Gegen Tang should be used. Lei Yao uses Xiaojianzhong Tang (Minor Construct the Middle Decoction), Chang Shi uses Xiaochaihu Tang (Minor Bupleurum Decoction), neither is correct. Qian Shi said: The reason for no sweating is cold in the Yangming Meridian, while difficulty urinating indicates no heat pathogen in the interior. Ke Shi said: Stomach Yang does not distribute to the four limbs, hence cold limbs; does not ascend to the forehead, hence headache. Pathogens strike the chest, knotting in the Chest Jiao, causing vomiting and coughing and damaging Yang. Genti San (Throatwort Powder) should be used to induce vomiting. Once vomiting and coughing stop, cold limbs and headache naturally cease. Reading "liang zhe" (both) as "shi" (time) makes it clearer.
In Yangming disease, only dizziness occurs, without aversion to cold. Therefore, the patient can eat and cough, and their throat must hurt. If there is no cough, the throat does not hurt.
([Original Note] One version says: Winter Yangming. ○ Yuhan reads: Each Yangming disease. Qianjin Yiyan reads: Winter Yangming disease.)
[Qian] Only dizziness indicates heat in the upper part. No aversion to cold aligns with the beginning of the Yangming chapter, meaning no aversion to cold but aversion to heat. Ability to eat indicates Yangming Wind Strike. Coughing indicates heat in the Upper Jiao injuring Lung Qi. The Yang pathogen of wind strike congests the Upper Jiao, so the pharynx must hurt. If there is no cough, the heat pathogen in the Upper Jiao is not severe, so the throat does not hurt. This clause involves purely heat pathogen. It should be contrasted with the previous clause of no coughing/vomiting, no limb cold, and no headache, to show differentiation between wind-cold. [Cheng] Throat pain is found only in Shaoyin disease. Here, it is caused by injury from coughing. If no cough, then no throat pain. Moreover, with dizziness and no aversion to cold, it is easy to identify as Yangming constrained heat.
Commentary: For this syndrome, Chang Qizhi and Zhang Lu both stated: Fuling Guizhi Baizhu Gancao Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala, and Licorice Decoction). Chang Shi further stated: For throat pain, Jiegeng Tang (Platycodon Decoction). Ke Shi said: Pathogens knot in the Chest Jiao, while the Stomach house is not solid. Treatment should follow modifications of Xiaochaihu Tang.
In Yangming disease, with no sweating and difficulty urinating, and feeling stifled and restless (Ao Nao) in the heart, the body will surely turn yellow.
[Cheng] In Yangming disease, no sweating and difficulty urinating mean heat accumulates internally and cannot vent. Feeling stifled and restless in the heart indicates heat Qi stagnating and steaming, attempting to emerge externally as jaundice. [Zhi] Yangming Qi does not circulate in the exterior, interior, upper, and lower, reversing internally into the heart, causing stifled restlessness. Yang heat Qi stays in the middle, and drinks entering the stomach are not distributed, causing damp-heat to brew, leading to bodily yellowing. [Ke] If the mouth is not thirsty and the abdomen is not full, Yinchen Tang is not suitable. Using Zhizi Bopi Tang (Gardenia and Phellodendron Bark Decoction) will resolve the yellow naturally.
Commentary: Yizong Jinjian stated: Stifled restlessness in the heart indicates dampness, blood stasis, and heat郁 (constrained) in the interior. Mian Lian Ye Chi Xiao Dou Tang (Mahuang, Red Bean, and Other Ingredients Decoction) is suitable. If after sweating, vomiting, or purging, or if urination is free but stifled restlessness persists, it is heat constraint. If stool is hard, Tiaowei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction) is suitable. If stool is soft, Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) is suitable. Compared to Ke's annotation, this seems less aligned with the classic intent.
In Yangming disease, subjected to fire therapy (Huoliao), with slight sweating on the forehead and difficulty urinating, jaundice will inevitably occur.
[Yu] In Yangming disease, dampness stops and heat constrains, increasing irritability and thirst, inevitably leading to jaundice. However, if sweating occurs, heat vents externally, jaundice can be avoided. If urination is frequent, heat drains downward, jaundice can be avoided. If mistakenly purged, pathogenic heat sinks deeper, clear fluids are damaged further, and sweating and urination become impossible. If mistakenly subjected to fire therapy, pathogenic heat becomes fiercer, fluids rush upward. Although slight sweating occurs on the forehead, whole-body sweating and urination become impossible. How can changes of jaundice be avoided? [Ke] Without Zhizi Bopi Tang, how can fluids be salvaged from exhaustion?
Commentary: Chang Shi said: Yinchen Hao Tang can be given. Wang Shi said: Wuling San, remove Guizhi, add Gegen, replace Baizhu with Cangzhu. Yizong Jinjian stated: If urination is free, transformation follows dryness, inevitably irritability and thirst, suitable for Baihu Tang (White Tiger Decoction). If urination is difficult, transformation follows dampness, inevitably jaundice, suitable for Yinchen Hao Tang. These are not fully consistent with the classic intent.
In Yangming disease, if the pulse is floating and tight, tidal fever (Chaore) must occur at specific times. If only floating, night sweats (Daohan) must occur. (Yuhan and Qianjin Yiyan read: Its heat must be tidal.)
[Qian] Pathogens in Taiyang, floating-tight indicates cold, floating-slow indicates wind. In Yangming, tight indicates interior, floating indicates exterior. Floating and tight pulse means both floating and tight. It means although pathogens are in the meridian, most have entered the interior. Pathogens entering the interior inevitably cause tidal fever. The specificity of timing is because Yangming Qi flourishes at Shen and You hours, hence tidal fever at Ribusha. Tidal fever indicates a condition ready for purging. If only floating, wind pathogens have not entered the interior at all, pathogens in the meridian are unresolved, night sweats must occur. Purging is still not indicated. Yangming naturally involves much sweating and sleepiness, hence night sweats. However, night sweats are not exclusive to Yangming. As in the Taiyang section, floating and moving-numerous pulse due to spontaneous sweating in wind strike also has night sweats. This is because when eyes close, Wei Qi enters internally, skin pores do not close, leading to night sweats. This shows people should distinguish exterior and interior via pulse and symptoms, and not lightly use purgatives just because of tidal fever. [Xi] Sweating during sleep is like thieves stealing while one is unaware.
Commentary: Buchuang Lun uses Chaihu Guizhi Tang. Wang Shi and Yizong Jinjian state: Guizhi Jia Gegen Tang (Cinnamon Twig Decoction plus Kudzu). Buchuang Lun is correct.
Commentary: Cheng Shi said: Floating and tight pulse is due to latent Yin-cold in the interior, binding Yang externally. Yin excess, Yang dares not contend, only contends when flourishing, hence tidal fever at specific times. Only floating indicates Stomach Yang deficiency and loss of Middle Qi control. Sleep increases Yin Qi, Yang cannot enter, leading to night sweats. Tidal fever and sweating are all Yangming interior excess syndromes, but here attributed to deficiency-cold. Differentiation via pulse allows mutual reference to methods regarding ability/inability to eat. This is another theory, so it is presented. Ji Zhu, Jin Shi said: Healthy people have daily tides unconsciously; illness manifests with tides. This theory is too strange, so attached here. Yizong Jinjian stated: Spontaneous sweating is Yangming syndrome; night sweats are Shaoyang syndrome. Night sweats should be spontaneous sweating for textual coherence. ○ Commentary: This theory is too erroneous.
In Yangming disease, dry mouth, desiring only to rinse water in the mouth without swallowing, this must result in epistaxis (nosebleed). ( . Qianjin Yiyan reads: Swallow.)
[Yu] Dry mouth differs from thirst. Rinsing water without swallowing indicates no thirst. Yangming has abundant Qi and Blood. Rinsing without swallowing indicates pathogens entered the Blood level. Yangming meridian starts at the nose, so knowing blood heated moves recklessly, it must exit through the nose.
Wei Shi said: Rinsing water is not thirst, but sticky mouth.
Zhou Shi said: If at this time one induces sweating with Gegen Tang, would it not deprive fluids and cause bleeding? "Must result in epistaxis" means Zhang Zhongjing intends for early treatment to prevent questioning later whether bleeding flows. Wang Shi said: Chang Qizhi said: Huangqin Shaoyao Dihuang Tang (Scutellaria, Peony, and Rehmannia Decoction) is suitable. Another version says: Should be Huangqin Shaoyao Gancao Tang. I believe these two decoctions are post-epistaxis medicines. Before epistaxis, Gegen Tang and similar formulas with modifications should be used. Ke Shi said: Tao Ren Chengqi Tang (Peach Kernel and Magnolia Bark Decoction) or Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) are suitable. ○ Commentary: The word "must" in this clause suggests preventing epistaxis beforehand. Xijiao Dihuang Tang is precisely appropriate.
In Yangming disease, originally having spontaneous sweating, the physician induces heavy sweating again. The disease has improved, yet slight irritability and incompleteness remain. This must be due to hard stool. Due to loss of Jin-Ye and dryness in the stomach, stool becomes hard. One should ask how many times they urinate per day. If originally urinating three or four times a day, and now only twice, one knows stool will pass soon. Now, since urination frequency is reduced, Jin-Ye should return to the stomach, so one knows stool will pass soon. (This must be hard stool, Bencao reads: This stool must be hard. Jin-Ye, Yuhan reads: Jing-Ye. Wang Shi said: "Dang Huan" should be "Huan Dang", making sense, incorrect. ○ Commentary: According to Ke's note, Shu is read as is.)
[Ke] The Stomach is the root of Jin-Ye. Sweat and urination both originate from Jin-Ye. Originally spontaneous sweating and free urination mean the person's Stomach Jin-Ye was originally abundant. Zhang Zhongjing highlights "loss of Jin-Ye" to warn those who disregard fluids. Disease improvement refers to cessation of fever and sweating. Irritability means aversion to heat. Slight irritability indicates aversion to heat will subside. Incompleteness indicates hard stool. Reduced frequency means twice a day. Hard stool and reduced urination are caused by Stomach loss of Jin-Ye, not Yang excess in the interior. Due to stomach dryness, drinks entering the stomach cannot upload to the Lung, regulate water passages, and drain to the Bladder, hence urination decreases. However, overflowing Qi can still transport essence to the Spleen. Jin-Ye forms mutually and returns to the Stomach. Stomach Qi harmonizes, stool passes naturally, no need for guiding methods. This shows that those with abundant Jin-Ye, even if lost, will eventually recover. It warns those with Stomach Excess to hesitate, showing not to blindly purge or sweat. Listing treatments: Slow pulse cannot be purged, Epigastric fullness cannot be purged, Frequent vomiting cannot be purged, Free urination and reduced urination cannot be purged. Overall, Stomach Excess is not a purgable condition. [Fang] Food and water entering the stomach, clear parts become Jin-Ye, coarse parts become residue. Jin-Ye seeping out externally becomes sweat; accumulating and flowing down becomes urine. Hence, excessive sweat and urine lead to Jin-Ye loss, making residue hard and difficult to pass. However, the two excretions are paths for water and grain separation. If one opens, the other closes; if one closes, the other opens. Reduced urine means Jin-Ye stays in the stomach. Sufficient Stomach Jin-Ye makes stool soft and slippery, explaining why it must pass. [Wang] If the patient desires medication, small doses of Maren Wan (Hemp Seed Pill) are suitable.
Cold Damage with frequent vomiting, even with Yangming symptoms, cannot be purged.
[Shen] Frequent vomiting means Qi is counterflowing upward, pathogens invade the Upper Wan, or involve Shaoyang. Thus, even with Yangming symptoms, purging must be cautious. [Fang] The word "even" should be pondered. [Ke] Frequent vomiting indicates Water Qi in the Upper Jiao. Even with Stomach Excess, only Xiaochaihu Tang should be used to circulate fluids. Purging risks endless diarrhea. Know that in Yangming disease, if Jin-Ye is not lost, purging must be cautious. Abdominal fullness and vomiting are related Taiyin-Yangming syndromes. Stomach Excess and Deficiency are distinctions between Yangming and Taiyin. Stomach Excess, despite hundred transformations, preserves Life Yang; endless diarrhea, unrecoverable by Shenfu, is Dead Yin.
Chang Shi said: Xiaochaihu Tang is suitable. Wang Shi said: Combined with Yangming symptoms, Gegen Jia Banxia Tang (Kudzu Decoction plus Pinellia) is suitable. Commentary: Wang considers Gegen a Yangming herb, which is incorrect.
Yu Shi said: Frequent vomiting, all diseases cannot be purged, not just Cold Damage.
In Yangming disease, hardness and fullness in the epigastrium (Xinxia) cannot be purged. If purged and diarrhea continues endlessly, death results. If diarrhea stops, recovery occurs.
[Cheng] Yangming disease with abdominal fullness indicates pathogens entered the Fu organs, purging is possible. Epigastric hardness and fullness mean pathogens are shallow, not fully in Fu organs, purging is not immediately indicated. Diarrhea stopping means pathogens leave and Zheng Qi rests; resting Zheng Qi leads to recovery. Endless diarrhea from purging means Zheng Qi collapses, leading to death. [Wei] Speaking of Yangming disease implies fever and sweating are present. If Stomach Excess, hardness/fullness is in the Middle Jiao. Now, Yangming disease presents with epigastric hardness/fullness, indicating non-Stomach Excess. Though Yangming, it can be discussed as Pi (glomus). Physicians should examine deficiency/excess and cold/heat, seeking treatment among Xiexin (Drain the Epigastrium) formulas. [Wang] Jie Xiong (Knotted Chest) syndrome involves painful epigastric hardness/fullness, indicating Stomach Excess, hence purging is possible. This case is painless, likely deficiency-hardness and deficiency-fullness, hence cannot be purged. Chang Qizhi said: Before purging, Shengjiang Xiexin Tang (Fresh Ginger Drain the Epigastrium Decoction) can be given. If diarrhea continues, Sini Tang (Four Counterflow Decoction). I believe Lizhong Tang (Regulate the Middle Decoction) is needed to save.
Cheng Shi said: Epigastric hardness/fullness means pathogens gather at Yangming Diaphragm. Diaphragm excess implies abdominal deficiency. Qi closes from deficiency, presenting as Yangming false excess. Purging causes double deficiency. Xi Ju said: Epigastric hardness/fullness means Stomach water/grain is empty, Stomach lacks support, deficient Qi counterflows upward, causing apparent hardness/fullness. Thus, Taiyang chapter says: This is not accumulated heat, but empty Stomach allowing hostile Qi to counterflow, causing hardness. ○ Commentary: The above two theories view epigastric hardness/fullness as deficiency-fullness false syndrome, common in the world. However, examining the classic text, it only mentions epigastric hardness/fullness, not highlighting deficiency signs, so these are hard to trust.
In Yangming disease, face appears red (He Se Chi), cannot be purged. If fever and yellowing occur, it is due to difficulty urinating.