〔成〕发汗不解。邪热传入腑。而成腹满痛者。传之迅也。是须急下之。〔程〕发汗不解。津液已经外夺。
腹满痛者。胃热遂尔迅攻。邪阳盛实而弥漫。不急下之。热毒熏蒸。糜烂速及肠胃矣。阴虚不任阳填也。
柯氏云。表虽不解。邪甚于里。急当救里。里和而表自
解矣。○案太阳中篇。八十九条云。本先下之。而反汗之。为逆。若先下之。治不为逆。柯氏盖据此条为解。然
而考经文。不解。邪气不解也。非谓表不解也。故其说难凭。
腹满不减。减不足言。当下之。宜大承气汤。
〔成〕腹满不减。邪气实也。经曰。大满大实。自可除下之。大承气汤。下其满实。若腹满时减。非内实
也。则不可下。金匮要略曰。腹满时减。复如故。此为寒。当与温药。是减不足言也。〔喻〕减不足言四字。
形容腹满如绘。见满至十分。即减去一二分。不足杀其势也。〔钱〕然有下之而脉症不为少减者。死症也。
舒氏云。案以上二条。俱未言其病之来由。又未明其所以当急之理。令人不无余憾。
案玉函经。此下有一条。云。伤寒腹满。按之不痛者为虚。痛者为实。当下之。舌黄未下者。下之黄自去。
宜大承气汤。金匮要略。亦载此条。恐此经遗脱之。
阳明少阳合病。必下利。其脉不负者。为顺也。负者。失也。互相克贼。名为负也。脉滑而数者。有宿食
也。当下之。宜大承气汤。（成本。顺上。无为字。负也之也。玉函。作若。脉经。当下之以下。作属大柴胡
承气汤证。柯本。删此条。）
〔成〕阳明土。少阳木。二经合病。气不相和。则必下利。少阳脉不胜。阳明不负。是不相克。为顺也。
若少阳脉胜。阳明脉负者。是鬼贼相克。为正气失也。脉经曰。脉滑者。为病食也。又曰。滑数则胃气实。下
利者脉当微厥冷。脉滑数。知胃有宿食。与大承气汤。以下之。〔程〕见滑数之脉。为不负。为顺。见弦直之
脉。为负为失。
案金匮要略曰。脉数而滑者。实也。此有宿食也。当下之。宜大承气汤。乃知脉滑以下。正是别条。与阳明少阳合
病不相干。
病患无表里证。发热七八日。虽脉浮数者。可下之。假令已下。脉数不解。合热则消谷喜饥。至六七日。
不大便者。有瘀血。宜抵当汤。若脉数不解。而下不止。必协热便脓血也。（玉函。虽脉。作脉虽。协。作挟。
若脉以下。原本为别条。今根据玉函千金翼。合而为一条。喻本。魏本。周本。柯本。程本。并同玉函。）
〔鉴〕病患无表里证。是无太阳表。阳明里证也。但发热而无恶寒。七八日虽脉浮数。不可汗也。若屎硬。
可下之。假令已下。脉不浮。而数不解。是表热去。里热未去也。至六七日。又不大便。若不能消谷善饥。是
胃实热也。以大承气汤下之。今既能消谷善饥。是胃和合热。非胃邪合热。故屎虽硬。色必黑。乃有瘀血热结
之不大便也。宜用抵当汤下之。若脉数不解。不大便硬。而下利不止。必有久瘀。协热腐化。而便脓血也。则
不宜用抵当汤下之矣。
〔周〕伤寒一书。凡太阳表证未尽者。仲景戒不可攻。今发热七八日。太阳表证也。脉浮数。太阳表证
也。此仲景自言者也。七八日中。未尝更衣。阳明腑证也。此仲景言外者也。何云病患无表里证。乃至自为矛
盾耶。必始先发热。至七八日。则热势已杀。且热不潮。七八日虽不更衣。未尝实满。则里不为急。故曰无表
里证。然脉尚浮数。仲景以为可下者。正以浮虽在外。而数且属腑。不一两解。恐内外之邪。相持而不去也。
尔时以大柴胡议下。不亦可乎。〔柯〕七八日下。当有不大便句。故脉虽浮数。有可下之理。热利不止。必太
阳瘀血。宜黄连阿胶汤。〔汪〕成注云。可下之。与大承气汤。以为清涤阳明里热也。尚论编云。可下之。如
大柴胡汤之类。误矣。便脓血者。仲景无治法。补亡论。常器之云。可白头翁汤。
程氏云。今之医者。不论病患表罢不罢。里全未全。但
见发热七八日。虽脉浮数者。以为可下之。不知发热脉浮。邪浑在表。岂可计日妄下。故一下而变证各出。○案
根据程说。下则为误治。然观文脉殊不尔。第此条亦是不明核。姑举数说俟后考。
伤寒发汗已。身目为黄。所以然者。以寒湿（【原注】一作温。）在里不解故也。以为不可下也。于寒湿
中求之。（玉函。寒湿下。有相搏二字。以为下。有非瘀热而四字。也于间。有当字。）
〔汪〕伤寒发汗已。热气外越。何由发黄。今者发汗已。身目为黄。所以然者。以其人在里素有寒湿。在
表又中寒邪。发汗已。在表之寒邪虽去。在里之寒湿未除。故云不解也。且汗为阳液。乃中焦阳气所化。汗后
中气愈虚。寒湿愈滞。脾胃受寒湿所伤。而色见于外。此与湿热发黄不同。故云不可下。或问云。湿挟热则郁
蒸。故发黄。今挟寒。何以发黄。余答云。寒湿发黄。譬之秋冬阴雨。草木不应黄者亦黄。此冷黄也。王海藏
云。阴黄。其证身冷汗出。脉沉。身如熏黄色黯。终不如阳黄之明如橘子色。治法。小便利者。术附汤。小便
不利。大便反快者。五苓散。
伤寒七八日。身黄如橘子色。小便不利。腹微满者。茵陈蒿汤主之。（玉函。腹上。有少字。千金方。身
上。有内实瘀。结五字。微下。有胀字。）
〔钱〕此言阳明发黄之色状。与阴黄如烟熏之不同也。伤寒至七八日。邪气入里已深。身黄如橘子色者。
湿热之邪在胃。独伤阳分。故发阳黄也。小便不利。则水湿内蓄。邪食壅滞。而腹微满也。以湿热实于胃。故
以茵陈蒿汤主之。
伤寒身黄发热。栀子柏皮汤主之。（热下。成本。有者字。）
〔成〕伤寒身黄。胃有瘀热。须当下去之。此以发热。为热未实。与栀子柏皮汤解之。〔汪〕武林陈氏
曰。发热身黄者。
乃黄证中之发热。而非麻黄桂枝证之发热也。热既郁而为黄。虽表而非纯乎表证。但当清其郁以退其黄。则发
热自愈。〔鉴〕伤寒身黄发热者。设有无汗之表。宜用麻黄连轺赤小豆。汗之可也。若有成实之里。宜用茵陈
蒿汤下之亦可也。今外无可汗之表证。内无可下之里证。故惟宜以栀子柏皮汤清之也。
栀子柏皮汤方
肥栀子（十五个擘○成本。无肥字。玉函同。作十四枚） 甘草（一两炙） 黄柏（二两）
上三味。以水四升。煮取一升半。去滓。分温再服。（一升半。千金翼。作二升。）
〔钱〕栀子苦寒。泻三焦火。除胃热时疾黄病。通小便。治心烦懊 。郁热结气。柏皮苦寒。治五脏肠胃
中结热黄胆。故用之以泻热邪。又恐苦寒伤胃。故以甘草。和胃保脾。而为调剂之妙也。
案金鉴云。此方之甘草。当是茵陈蒿。必传写之误也。此说太谬。不可从焉。
伤寒瘀热在里。身必黄。麻黄连轺赤小豆汤主之。（必下。成本。有发字。千金。并翼。轺。作翘。）
〔钱〕瘀。留蓄壅滞也。言伤寒郁热。与胃中之湿气。互结湿蒸。如淖泽中之淤泥。水土粘泞而不分也。
经云。湿热相交。民多病瘅。盖以湿热胶固。壅积于胃。故曰瘀热在里。身必发黄也。麻黄连轺赤小豆汤。治
表利小便。解郁热。故以此主之。〔澜〕此证虽曰在里。必因邪气在表之时。有失解散。今虽发黄。犹宜兼汗
解以治之。
麻黄连轺赤小豆汤方
麻黄（二两去节） 连轺（二两连翘根是○千金。并翼。轺。作翘。程柯同。） 杏仁（四十个去皮尖）
赤小豆（一升） 大枣（十二枚擘） 生姜（二两切） 甘草（二两炙
○成本。作一两。） 生梓白皮（一升切）
上八味。以潦水一斗。先煮麻黄再沸。去上沫。纳诸药。煮取三升。去滓。分温三服。半日服尽。（上字。
成本。作已上二字。再沸。玉函。作一二沸。成本。脱去滓二字。潦。千金。作劳。盖此涝字之讹。）
〔钱〕麻黄汤。麻黄桂枝杏仁甘草也。皆开鬼门而泄汗。汗泄则肌肉腠理之郁热湿邪皆去。减桂枝而不用
者。恐助瘀热也。赤小豆除湿散热。下水肿而利小便。梓白皮。性苦寒。能散温热之邪。其治黄。无所考据。
连翘根。陶弘景云。方药不用。人无识者。王好古云。能下热气。故仲景治伤寒瘀热用之。李时珍云。潦水。
乃雨水所积。韩退之诗云。潢潦无根源。朝灌夕已除。盖谓其无根而易涸。故成氏谓其味薄。不助湿气。而利
热也。〔方〕轺。本草作翘。翘本鸟尾。以草子拆开。其间片片相比如翘得名。轺。本使者小车乘马者。无义。
疑误。以上四条。疑太阳中篇错简。当移。
伤寒类方曰。连轺。即连翘根。气味相近。今人不采。即以连翘代可也。
案内台方议曰。潦水。又曰甘澜水。误也。医学正传曰。潦水。又名无根水。山谷中无人迹去处。新上
科臼中之水也。取其性不动摇。而有土气内存。乃与时珍有少异。当考。
【成无己注】发汗后病证未解，邪热传入腑，导致腹部胀满疼痛的，这是传变迅速的表现。此时必须紧急攻下。
【程知注】发汗后病证未解，津液已经因汗出而外泄耗夺。出现腹部胀满疼痛，说明胃中热势随即迅猛攻冲，邪气阳盛且实，弥漫全身。若不紧急攻下，热毒熏蒸，会迅速腐蚀糜烂肠胃。这是因为阴液亏虚，无法承受阳热的填塞。
柯琴认为：虽然表证未解，但邪气在里更甚，应当紧急救治里证。里气调和，表证自然解除。
○按语：《伤寒论·太阳病篇》第八十九条说：“本应先攻下，却反而用发汗法，这是逆治；如果先攻下，治疗就不算逆治。”柯氏大概是依据这一条来解释的。然而考察经文，“不解”指的是邪气未解，并非指表证未解。所以柯氏的说法难以采信。
腹部胀满持续不减，即使有轻微减轻也不足挂齿，应当攻下，适宜使用大承气汤。
【成无己注】腹部胀满持续不减，是邪气实盛的表现。经书说：“大满大实，自然可以攻下。”大承气汤能攻下腹部的胀满和实邪。如果腹部胀满有时减轻，就不是内实，则不可攻下。《金匮要略》说：“腹部胀满有时减轻，过后又像以前一样，这是寒证，应当给予温药。”这就是所谓的“减不足言”。
【喻嘉言注】“减不足言”这四个字，生动地形容了腹部胀满的情况。见到胀满到了十分的程度，即使减去一二分，也不足以削弱其势头。
【钱潢注】然而，如果有攻下之后，脉象和症状仍没有明显减轻的，这是死症。
舒驰远说：案以上两条，都没有说明疾病的由来，也没有明确阐明之所以必须紧急治疗的道理，让人不免感到遗憾。
按语：《玉函经》在此处有一条补充，说：“伤寒腹部胀满，按压不痛的属于虚证，痛的属于实证，应当攻下。舌苔发黄尚未攻下的，攻下后黄苔自去，适宜大承气汤。”《金匮要略》也记载了这一条，恐怕是此经文中遗漏脱失的。
阳明病与少阳病合病，必然出现下利。脉象不负（即脉象不现相克之象）的，为顺证。所谓“负”，就是失的意思。互相克制贼害，称为“负”。脉象滑而数的，是有宿食积滞，应当攻下，适宜大承气汤。（成本：顺上，无为字，负也之也。玉函：作若。脉经：当下之以下，作属大柴胡承气汤证。柯本：删此条。）
【成无己注】阳明属土，少阳属木，两经合病，气机不相调和，则必然下利。若少阳脉不胜（弱于阳明），阳明不负（不被克），这是不相克，为顺证。若少阳脉胜（强于阳明），阳明脉负（受克），这是鬼贼相克，为正气的丧失。《脉经》说：脉滑，主病食积。又说：滑数则胃气实。下利的脉象应当微厥冷，现脉滑数，可知胃中有宿食，给予大承气汤以攻下。
【程知注】见到滑数之脉，是不负，为顺；见到弦直之脉，是负，为失。
按语：《金匮要略》说：“脉数而滑的，是实证，这里有宿食，应当攻下，适宜大承气汤。”由此可知，从“脉滑以下”正是另一条的内容，与阳明少阳合病无关。
病患没有表证和里证，发热七八天，即使脉象浮数，也可以攻下。假如已经攻下，脉数仍未解除，合并热邪则消谷善饥，到了六七天，不大便的，是有瘀血，适宜抵当汤。如果脉数仍未解除，而下利不止，必然协热便脓血。（玉函：虽脉，作脉虽。协，作挟。若脉以下，原本为别条，今根据玉函千金翼，合而为一条。喻本、魏本、周本、柯本、程本，并同玉函。）
【尤在泾注】病患没有表里证，是指没有太阳表证和阳明里证。只是发热而没有恶寒，七八天即使脉象浮数，也不可发汗。如果大便硬，可以攻下。假如已经攻下，脉不浮而数仍未解除，说明表热已去，里热未去。到了六七天，又不大便，如果不能消谷善饥，是胃实热，以大承气汤攻下。现在既能消谷善饥，是胃气和合热，非胃邪合热，所以大便虽硬，颜色必黑，乃是有瘀血热结导致的不大便，适宜用抵当汤攻下。如果脉数未解除，不大便硬，而下利不止，必有久瘀，协热腐化，而便脓血，则不宜用抵当汤攻下了。
【周扬俊注】《伤寒论》一书，凡是太阳表证未尽者，仲景告诫不可攻下。现在发热七八天，是太阳表证；脉浮数，也是太阳表证。这是仲景自己说的。七八天中，未曾排便，是阳明腑证。这是仲景言外之意。怎可以说病患无表里证？这岂不是自相矛盾吗？必定是起初发热，到了七八天，热势已衰，且热不潮，七八天即使不排便，也未尝实满，则里不为急，所以说无表里证。然而脉尚浮数，仲景认为可下的，正是因为浮虽在外，而数且属腑，不一两解，恐内外之邪，相持不去。当时如果用大柴胡汤议下，不也可以吗？
【柯琴注】“七八日下”当有“不大便”句，故脉虽浮数，有可下之理。热利不止，必有太阳瘀血，宜黄连阿胶汤。
【汪琥注】成无己注云：可下之，与大承气汤，以为清涤阳明里热也。《尚论编》云：可下之，如大柴胡汤之类，误矣。便脓血者，仲景无治法，《补亡论》常器之说：可白头翁汤。
程氏说：现在的医者，不论病患表证是否罢除，里证是否全备，只见发热七八天，即使脉象浮数，就认为是可下的。不知道发热脉浮，邪气完全在表，岂可计日妄下？所以下一次治疗就变证百出。○按语：根据程氏的说法，下法则为误治。然而观文脉殊非如此。只是这一条也不明确确切，暂举几种说法供以后考证。
伤寒发汗后，身体眼睛发黄，之所以这样，是因为寒湿在里不解的缘故。认为不可攻下，应当在寒湿中求治。（玉函：寒湿下，有相搏二字。以为下，有非瘀热而四字。也于间，有当字。）
【汪琥注】伤寒发汗后，热气外越，为何发黄？现在发汗后，身体眼睛发黄，之所以这样，是因为此人里素有寒湿，在表又中寒邪。发汗后，在表的寒邪虽去，在里的寒湿未除，所以说不解。且汗为阳液，乃中焦阳气所化。汗后中气愈虚，寒湿愈滞，脾胃受寒湿所伤，而色见于外。这与湿热发黄不同，所以说不可下。有人问：湿挟热则郁蒸，故发黄。现在挟寒，何以发黄？我回答说：寒湿发黄，譬如秋冬阴雨，草木不应黄的也黄了，这是冷黄。王海藏说：阴黄，其证身冷汗出，脉沉，身如熏黄色黯，终不如阳黄之明如橘子色。治法：小便利者，术附汤；小便不利，大便反快者，五苓散。
伤寒七八天，身黄如橘子色，小便不利，腹部微满的，茵陈蒿汤主治。（玉函：腹上，有少字。千金方：身上，有内实瘀结五字。微下，有胀字。）
【钱潢注】这是说阳明发黄的色状，与阴黄如烟熏的不同。伤寒至七八天，邪气入里已深，身黄如橘子色的，是湿热之邪在胃，独伤阳分，故发阳黄。小便不利，则水湿内蓄，邪食壅滞，而腹微满。因为湿热实于胃，所以以茵陈蒿汤主治。
【成无己注】伤寒身黄，胃有瘀热，须当下去之。这里因为发热，说明热未实，给予栀子柏皮汤解之。
【汪琥注】武林陈氏说：发热身黄者，乃黄证中之发热，而非麻黄桂枝证之发热也。热既郁而为黄，虽表而非纯乎表证，但当清其郁以退其黄，则发热自愈。
【尤在泾注】伤寒身黄发热者，设有无汗之表，宜用麻黄连轺赤小豆汤汗之可也。若有成实之里，宜用茵陈蒿汤下之亦可也。现在外无可汗之表证，内无可下之里证，所以惟宜以栀子柏皮汤清之。
栀子柏皮汤方
肥栀子（十五个擘。成本：无肥字。玉函同。作十四枚） 甘草（一两炙） 黄柏（二两）
上三味，以水四升，煮取一升半，去滓，分温再服。（一升半，千金翼，作二升。）
【钱潢注】栀子苦寒，泻三焦火，除胃热时疾黄病，通小便，治心烦懊憹，郁热结气。柏皮苦寒，治五脏肠胃中结热黄疸，故用之以泻热邪。又恐苦寒伤胃，故以甘草，和胃保脾，而为调剂之妙。
按语：《医宗金鉴》说：此方的甘草，应当是茵陈蒿，必是传写之误。这种说法太荒谬，不可听从。
伤寒瘀热在里，身体必然发黄，麻黄连轺赤小豆汤主治。（必下，成本，有发字。千金、并翼，轺，作翘。）
【钱潢注】瘀，留蓄壅滞也。说伤寒郁热，与胃中的湿气，互结湿蒸，如淖泽中的淤泥，水土粘泞而不分。经书说：湿热相交，民多病瘅。盖因湿热胶固，壅积于胃，所以说瘀热在里，身体必然发黄。麻黄连轺赤小豆汤，治表利小便，解郁热，所以以此主治。
【吴谦注】此证虽曰在里，必因邪气在表之时，有失解散。现在虽发黄，犹宜兼汗解以治之。
麻黄连轺赤小豆汤方
麻黄（二两去节） 连轺（二两连翘根是。千金、并翼，轺，作翘。程柯同。） 杏仁（四十个去皮尖）
赤小豆（一升） 大枣（十二枚擘） 生姜（二两切） 甘草（二两炙。成本，作一两。） 生梓白皮（一升切）
上八味，以潦水一斗，先煮麻黄再沸，去上沫，纳诸药，煮取三升，去滓，分温三服。半日服尽。（上字，成本，作已上二字。再沸，玉函，作一二沸。成本，脱去滓二字。潦，千金，作劳。盖此涝字之讹。）
【钱潢注】麻黄汤，由麻黄、桂枝、杏仁、甘草组成。皆开鬼门而泄汗，汗泄则肌肉腠理之郁热湿邪皆去。减桂枝而不用者，恐助瘀热也。赤小豆除湿散热，下水肿而利小便。梓白皮，性苦寒，能散温热之邪，其治黄，无所考据。连翘根，陶弘景说：方药不用，人无识者。王好古说：能下热气，故仲景治伤寒瘀热用之。李时珍说：潦水，乃雨水所积。韩退之诗云：潢潦无根源，朝灌夕已除。盖谓其无根而易涸，故成氏谓其味薄，不助湿气，而利热也。
【方有执注】轺，本草作翘。翘本鸟尾，以草子拆开，其间片片相比如翘得名。轺，本使者小车乘马者，无义，疑误。以上四条，疑太阳中篇错简，当移。
《伤寒类方》说：连轺，即连翘根，气味相近，今人不采，即以连翘代可也。
《案内台方议》说：潦水，又曰甘澜水，误也。《医学正传》说：潦水，又名无根水，山谷中无人迹去处，新上科臼中之水也。取其性不动摇，而有土气内存，乃与时珍有少异，当考。
[Cheng Wuji's Commentary] After sweating, the disease condition remains unresolved. The pathogenic heat has transmitted to the fu organs, resulting in abdominal fullness and pain; this indicates rapid transmission. In such cases, urgent purgation is required.
[Cheng Zhi's Commentary] After sweating, the disease condition remains unresolved, and body fluids have already been depleted externally through sweat. The occurrence of abdominal fullness and pain indicates that stomach heat is swiftly attacking with urgency. The pathogenic yang is excessive and solid, spreading diffusely throughout the body. If purgation is not performed urgently, the heat toxin will fumigate and steam, rapidly corroding and ulcerating the intestines and stomach. This occurs because yin deficiency cannot withstand the filling of yang.
Ke Qin stated: Although the exterior syndrome remains unresolved, the pathogen is more severe in the interior. Urgent treatment should focus on the interior. Once the interior harmonizes, the exterior will resolve spontaneously.
○ Note: In Chapter 89 of the *Taiyang* section of the *Shanghan Lun*, it states: "If purgation should have been used first but sweating was used instead, this is a contraindication (ni). If purgation had been used first, the treatment would not be considered a contraindication." Ke likely based his explanation on this clause. However, examining the original text, "unresolved" refers to the unresolved pathogen, not an unresolved exterior syndrome. Therefore, Ke's interpretation is difficult to rely upon.
Abdominal fullness that does not decrease, or decreases insignificantly, requires purgation. Da Cheng Qi Tang (Major Order the Qi Decoction) is appropriate.
[Cheng Wuji's Commentary] Abdominal fullness that does not decrease indicates excess of pathogenic factors. The Classics state: "When there is great fullness and great excess, purgation can naturally be employed." Da Cheng Qi Tang (Major Order the Qi Decoction) purges the fullness and excess. If abdominal fullness decreases intermittently, it is not internal excess, and purgation should not be used. The *Jingui Yaolue* states: "Abdominal fullness that decreases intermittently and returns to its previous state is due to cold; warm medicines should be administered." This is what is meant by "decrease is insignificant."
[Yu Jiayan's Commentary] The phrase "decrease is insignificant" vividly describes abdominal fullness. Even if fullness reaches ten parts and decreases by one or two parts, it is insufficient to diminish its momentum.
[Qian Huang's Commentary] However, if after purgation the pulse and symptoms do not show significant reduction, it is a fatal sign.
Shu Chiyuan said: Regarding the above two clauses, neither explains the origin of the disease nor clearly elucidates the rationale for urgent treatment, leaving one somewhat dissatisfied.
Note: The *Yuhan Jing* contains an additional clause here stating: "In typhoid fever, abdominal fullness that is non-tender upon pressure indicates deficiency; tender fullness indicates excess, requiring purgation. If the tongue coating is yellow and purgation has not yet been performed, purgation will cause the yellow coating to disappear. Da Cheng Qi Tang (Major Order the Qi Decoction) is appropriate." The *Jingui Yaolue* also records this clause, suggesting it may have been omitted from this text.
When Yangming disease and Shaoyang disease occur simultaneously (hebing), diarrhea is inevitable. A pulse that does not show "fu" (defeat/loss) indicates a favorable prognosis. "Fu" means loss. Mutual overcoming and harming are termed "fu". A slippery and rapid pulse indicates retained food stagnation. Purgation is indicated, and Da Cheng Qi Tang (Major Order the Qi Decoction) is appropriate. (Cheng Ben: "Shun" above, no "wei" character, "fu ye zhi ye". Yuhan: reads "ruo". Maijing: below "xia zhi", reads "shu Da Chaihu Chengqi Tang zheng". Ke Ben: deletes this clause.)
[Cheng Wuji's Commentary] Yangming belongs to Earth, and Shaoyang belongs to Wood. When these two meridians suffer simultaneous disease, qi fails to harmonize, inevitably leading to diarrhea. If the Shaoyang pulse is weaker than Yangming, and Yangming is not overcome ("bu fu"), they do not overcome each other, constituting a favorable pattern. If the Shaoyang pulse is stronger than Yangming, and Yangming is overcome ("fu"), this represents mutual overcoming by ghost thieves, indicating the loss of righteous qi. The *Maijing* states: A slippery pulse indicates food disease. It also states: Slippery and rapid pulses indicate excess stomach qi. Diarrhea typically presents with a faint, cold pulse. A slippery and rapid pulse indicates retained food in the stomach. Da Cheng Qi Tang (Major Order the Qi Decoction) should be given to purge.
[Cheng Zhi's Commentary] Observing a slippery and rapid pulse indicates no defeat ("bu fu") and a favorable pattern. Observing a string-like and straight pulse indicates defeat and loss.
Note: The *Jingui Yaolue* states: "A number and slippery pulse indicates excess; this involves retained food. Purgation is indicated, and Da Cheng Qi Tang (Major Order the Qi Decoction) is appropriate." From this, we know that the content following "slippery pulse" belongs to a different clause and is unrelated to Yangming-Shaoyang simultaneous disease.
In a patient without exterior or interior syndromes, who has had fever for seven to eight days, purgation may be used even if the pulse is floating and rapid. If purgation has already been performed but the rapid pulse persists, combined heat will cause increased appetite and hunger. By the sixth or seventh day, if there is no bowel movement, blood stasis is present. Shui Dang Tang (Di Dang Tang) is appropriate. If the rapid pulse persists but diarrhea continues incessantly, heat-collateral pus and blood stool will occur. (Yuhan: "sui mai" reads "mai sui". "Xie" reads "jia". Below "ruo mai", originally a separate clause, now combined into one clause according to Yuhan and Qianjin Yi. Yu Ben, Wei Ben, Zhou Ben, Ke Ben, Cheng Ben all follow Yuhan.)
[You Zaijing's Commentary] "No exterior or interior syndromes" means absence of Taiyang exterior syndrome and Yangming interior syndrome. There is only fever without aversion to cold. Even if the pulse is floating and rapid for seven to eight days, sweating is contraindicated. If feces are hard, purgation is permissible. If purgation has been performed and the pulse is no longer floating but remains rapid, it indicates that exterior heat has gone but interior heat remains. By the sixth or seventh day, if there is no bowel movement and the patient cannot digest food easily (xiao gu shan ji), it is stomach excess heat, treated with Da Cheng Qi Tang (Major Order the Qi Decoction). Now, since the patient can digest food easily and feels hungry, it is stomach harmony combined heat, not stomach pathogen combined heat. Thus, although feces are hard, their color must be black, indicating blood stasis and heat knot causing constipation. Shui Dang Tang (Di Dang Tang) is appropriate. If the rapid pulse persists, feces are hard, but diarrhea continues incessantly, there must be long-standing blood stasis, rotting due to combined heat, resulting in pus and blood in stool. Shui Dang Tang (Di Dang Tang) should not be used.
[Zhou Yangjun's Commentary] In the *Shanghan Lun*, whenever Taiyang exterior syndrome is not fully resolved, Zhang Zhongjing warns against using attack/purgation methods. Now, fever for seven to eight days is a Taiyang exterior syndrome; a floating and rapid pulse is also a Taiyang exterior syndrome. This is what Zhang Zhongjing explicitly states. Seven to eight days without defecation is a Yangming fu syndrome. This is implied by Zhang Zhongjing. How can one say the patient has no exterior or interior syndrome? Is this not self-contradictory? It must be that initially there was fever, which subsided by the seventh or eighth day, and the heat was not tidal. Even without defecation for seven to eight days, there was no true fullness, so the interior was not urgent. Hence, it is said there are no exterior or interior syndromes. However, the pulse is still floating and rapid. Zhang Zhongjing considers purgation appropriate because although floating indicates the exterior, rapid indicates the fu organ. Without resolving both, the exterior and interior pathogens may persist mutually. At that time, using Da Chai Hu Tang (Minor Order the Gallbladder Decoction) for purgation would also have been acceptable.
[Ke Qin's Commentary] Below "seven to eight days," the phrase "no bowel movement" should exist. Therefore, even if the pulse is floating and rapid, there is a rationale for purgation. If heat-induced diarrhea continues incessantly, there must be Taiyang blood stasis. Huang Lian E Jiao Tang (Coptis and Donkey-Hide Gelatin Decoction) is appropriate.
[Wang Hu's Commentary] Cheng's commentary states: "Purgation is appropriate, using Da Cheng Qi Tang (Major Order the Qi Decoction) to clear and wash away Yangming interior heat." The *Shanglun Bian* states: "Purgation is appropriate, such as Da Chai Hu Tang (Minor Order the Gallbladder Decoction)," which is incorrect. For pus and blood in stool, Zhang Zhongjing provides no treatment method. Chang Qizhi in *Bu Wang Lun* states: Bai Tou Weng Tang (Pulsatilla Decoction) is appropriate.
Cheng stated: Current physicians, regardless of whether the patient's exterior syndrome has resolved or the interior syndrome is complete, seeing fever for seven to eight days and a floating and rapid pulse, assume purgation is appropriate. They do not realize that fever with a floating pulse means the pathogen is entirely in the exterior. How can one blindly use purgation based on days? Consequently, one purgation leads to various transformed syndromes. ○ Note: According to Cheng's view, purgation constitutes mis-treatment. However, observing the textual context, this is not the case. This clause is indeed unclear; several interpretations are listed here for future verification.
After typhoid fever induces sweating, the body and eyes turn yellow. The reason is that cold-dampness remains unresolved in the interior. It is considered that purgation is contraindicated; treatment should seek resolution within the context of cold-dampness. (Yuhan: below "han shi," adds "xiang bo" [struggle]. Below "yi wei," adds "fei yu re er" [not due to stagnant heat]. Between "ye" and "yu," adds "dang" [should].)
[Wang Hu's Commentary] After typhoid fever induces sweating, heat qi escapes outward. Why does jaundice appear? Now, after sweating, the body and eyes turn yellow. The reason is that the person inherently has cold-dampness in the interior and contracted cold pathogens in the exterior. After sweating, the exterior cold pathogens are expelled, but the interior cold-dampness remains unremoved, hence "unresolved." Sweat is yang fluid, transformed from middle jiao yang qi. After sweating, middle qi becomes more deficient, and cold-dampness becomes more stagnant. The spleen and stomach are injured by cold-dampness, and the color manifests externally. This differs from damp-heat jaundice, hence purgation is contraindicated. Someone asked: Dampness combined with heat causes stagnation and steaming, leading to jaundice. How does cold lead to jaundice? I answer: Cold-damp jaundice is like autumn and winter rainy seasons, where grass and trees turn yellow despite normally not doing so; this is cold jaundice. Wang Haicang stated: Yin jaundice presents with cold limbs and sweating, deep pulse, and a dark, smoked-yellow body color, never as bright orange-red as yang jaundice. Treatment: If urination is free, Zhu Fu Tang (Atractylodes and Aconite Decoction); if urination is difficult and stool is loose, Wu Ling San (Five-Ingredient Powder with Poria).
By the seventh or eighth day of typhoid fever, if the body turns yellow like an orange peel, with difficult urination and slight abdominal fullness, Yin Chen Hao Tang (Artemisiae Scopariae Decoction) is the primary treatment. (Yuhan: above "fu," adds "shao" [slight]. Qianjin Fang: above "shen," adds "nei shi yu jie" [interior excess and knot]. Below "wei," adds "zhang" [distension].)
[Qian Huang's Commentary] This describes the color manifestation of Yangming jaundice, differing from yin jaundice which looks like smoke. By the seventh or eighth day of typhoid fever, the pathogen has entered deeply into the interior. Body yellow like an orange peel indicates damp-heat pathogen in the stomach, injuring only the yang aspect, thus causing yang jaundice. Difficult urination causes water-dampness to accumulate internally, and pathogenic food stagnates, causing slight abdominal fullness. Because damp-heat is excess in the stomach, Yin Chen Hao Tang (Artemisiae Scopariae Decoction) is used.
Typhoid fever with body jaundice and fever is primarily treated with Zhi Zi Bai Pi Tang (Gardenia and Phellodendron Bark Decoction). (Below "re," Cheng Ben adds "zhe" [particle].)
[Cheng Wuji's Commentary] Typhoid fever with body jaundice involves stagnant heat in the stomach, which must be purged downward. Here, because of fever, the heat is not yet solidified. Zhi Zi Bai Pi Tang (Gardenia and Phellodendron Bark Decoction) is used to resolve it.
[Wang Hu's Commentary] Mr. Chen from Wulin stated: Fever with jaundice is fever within the jaundice syndrome, not the fever of Mahuang Guizhi syndrome. Since heat is constrained and transforms into jaundice, although it involves the exterior, it is not purely an exterior syndrome. One should only clear the constraint to reduce jaundice, and the fever will resolve spontaneously.
[You Zaijing's Commentary] In typhoid fever with body jaundice and fever, if there is a non-sweating exterior syndrome, Ma Huang Lian Qiao Chi Xiao Dou Tang (Ephedra, Forsythia, and Red Bean Decoction) should be used to induce sweating. If there is a solidified interior syndrome, Yin Chen Hao Tang (Artemisiae Scopariae Decoction) can be used for purgation. Currently, there is no exterior syndrome suitable for sweating, nor an interior syndrome suitable for purgation. Therefore, only Zhi Zi Bai Pi Tang (Gardenia and Phellodendron Bark Decoction) should be used to clear.
Zhi Zi Bai Pi Tang (Gardenia and Phellodendron Bark Decoction) Formula
Fei Zhi Zi (15 pods, split. Cheng Ben: no "fei" character. Yuhan same. Reads 14 pieces.) Gan Cao (1 liang, honey-fried.) Huang Bo (2 liang.)
The above three ingredients are boiled in four sheng of water to obtain one and a half sheng. Strain the dregs. Divide into two warm doses. (One and a half sheng, Qianjin Yi, reads two sheng.)
[Qian Huang's Commentary] Zhi Zi is bitter and cold, draining fire from the triple burner, removing stomach heat and epidemic jaundice, promoting urination, treating mental restlessness and depression, and resolving stagnant heat and qi. Bai Pi (Phellodendron bark) is bitter and cold, treating clustered heat and jaundice in the five zang and six fu organs and intestines. Thus, it is used to drain pathogenic heat. Fearing that bitter cold damages the stomach, Gan Cao (Licorice) is added to harmonize the stomach and protect the spleen, serving as a wonderful adjustment.
Note: *Yizong Jinjian* states: The Gan Cao in this formula should be Yin Chen Hao (Artemisiae Scopariae Herba); it must be a transcription error. This view is too absurd and should not be followed.
Typhoid fever with stagnant heat in the interior inevitably causes body jaundice. Ma Huang Lian Qiao Chi Xiao Dou Tang (Ephedra, Forsythia, and Red Bean Decoction) is the primary treatment. (Below "bi," Cheng Ben adds "fa" [develop]. Qianjin and Yi, "Yao" reads "Qiao".)
[Qian Huang's Commentary] "Yu" means retention, accumulation, and obstruction. It refers to typhoid fever constrained heat interacting with dampness in the stomach, steaming together like mud in a marsh, where water and soil stick together indistinguishably. The Classics state: "When dampness and heat intersect, people often suffer from dan disease." Because damp-heat is cemented and accumulates in the stomach, it is called "stagnant heat in the interior," inevitably causing body jaundice. Ma Huang Lian Qiao Chi Xiao Dou Tang (Ephedra, Forsythia, and Red Bean Decoction) treats the exterior and promotes urination, resolving constrained heat; thus, it is the primary treatment.
[Wu Qian's Commentary] Although this syndrome is said to be in the interior, it must originate from a failure to release the pathogen when it was in the exterior. Even though jaundice has appeared, sweating and releasing should still be combined in treatment.
Ma Huang Lian Qiao Chi Xiao Dou Tang (Ephedra, Forsythia, and Red Bean Decoction) Formula
Ma Huang (2 liang, nodes removed.) Lian Yao (2 liang, root of Forsythia. Qianjin and Yi, "Yao" reads "Qiao". Cheng and Ke same.) Xing Ren (40 seeds, skin and tips removed.) Chi Xiao Dou (1 sheng.) Da Zao (12 pieces, split.) Sheng Jiang (2 liang, sliced.) Gan Cao (2 liang, honey-fried. Cheng Ben, reads 1 liang.) Sheng Zi Bai Pi (1 sheng, sliced.)
The above eight ingredients are boiled in one dou of liao water. First boil Ma Huang until it boils again, remove the foam on top, then add the remaining herbs. Boil to obtain three sheng. Strain the dregs. Divide into three warm doses. Take all within half a day. (Above character, Cheng Ben, reads "yi shang" [above]. Boil again, Yuhan, reads "one or two boils". Cheng Ben, omits "strain dregs". Liao, Qianjin, reads "Lao". Likely an error for "Lao" [floodwater].)
[Qian Huang's Commentary] Mahuang Tang consists of Ma Huang, Gui Zhi, Xing Ren, and Gan Cao. All open the pores to induce sweating. Sweating removes constrained heat and damp pathogens from muscle tissue and interstices. Gui Zhi is reduced and not used to avoid assisting stagnant heat. Chi Xiao Dou removes dampness and drains heat, reducing edema and promoting urination. Zi Bai Pi is bitter and cold, able to disperse warm-heat pathogens; its efficacy in treating jaundice lacks documentation. Lian Qiao Gen (Forsythia root): Tao Hongjing stated it is not used in prescriptions, and few recognize it. Wang Haogu stated it can descend heat qi, which is why Zhang Zhongjing used it for typhoid fever stagnant heat. Li Shizhen stated: Liao water is accumulated rainwater. Han Yutu's poem says: "Rivers and pools have no source, morning irrigation is dried up by evening." This implies it is rootless and easily dries up. Thus, Cheng Shi stated it has thin flavor, does not assist dampness, and promotes heat drainage.
[Fang Youzhi's Commentary] "Yao" is written as "Qiao" in Bencao. "Qiao" originally refers to bird tails; named so because split grass seeds look like tail feathers. "Yao" originally refers to a messenger's small carriage pulled by horses, having no meaning here, suspected to be an error. The above four clauses are suspected to be misplaced slips from the Taiyang section and should be moved.
*Shanghan Leifang* states: Lian Yao is the root of Forsythia. Their flavors and properties are similar. Modern practitioners do not harvest it; Forsythia fruit can be used as a substitute.
*Annei Taifangyi* states: Liao water is also called Ganlan Water, which is incorrect. *Yixue Zhengchuan* states: Liao water is also called Wugen Water, collected from new mortars in mountain valleys where no humans tread. Its nature is stable and retains earth qi internally, differing slightly from Shizhen's view, requiring verification.