去谓热不为汗衰。盖言寒气外泄。寒邪独盛。表虚邪盛。势必失和。有内拘急四肢疼之证。再见下利厥
逆。阴寒内盛。恶寒。阳气大虚。故用四逆汤温经复阳。以消阴翳。大汗身热。四肢疼。皆是热邪为患。而仲
师便用四逆汤者。以外有厥热恶寒之证。内有拘急下利之候。阴寒毕露。则知汗出为阳气外亡。身热
由虚阳外泄。肢冷为阳气内脱。其辨证又只在恶寒下利。总之仲师辨阳症。以恶热不便为里实。上节
阳虚有假热。此节阳虚无假热。大汗若大下利而厥冷者。四逆汤主之。汗而云大。阳气亡于表。下利云
大。阳气亡于里。加以厥冷。何不列于死证。玩本文不言五六日六七日。可知乃阴寒骤中。邪气虽盛。正
气初伤。急温正气。犹能自复。故用四逆汤胜寒毒于濒危。回阳气于将绝。汗利止。厥回。可望生全。不因
汗下而厥冷。用当归四逆汤。因汗下而厥冷。用四逆汤。此缓急之机权也。此证无外热相错。为阴寒之
证易明。然云大汗大下。则阴津亦亡。此际救阳为急。阳回亦当徐救其阴也。亦有因痰水而致厥者。病
人无他证。手足厥冷。四肢受气于胸中。因痰饮结聚。斯气不能通贯于四肢。脉乍紧者。痰脉怪变无常。
不紧而忽紧。忽紧而又不紧。邪结在胸中。胸者心主之宫城。心为邪碍。心下满而烦。饥不欲食。病在胸
中。当须吐之，宜瓜蒂散。即内经所谓高者引而越之之意。再言水厥。伤寒厥而心下悸。宜先治水。当服
茯苓甘草汤。却治其厥。不尔水渍入胃。必作利也。此厥阴病预防下利之法。病至厥阴。以阳升为欲愈。
邪陷为危机。厥而下利。则中气不守。邪愈内陷。此条厥而心下悸。水邪乘心。心阳失御。见此则治厥为
缓。而治水为急。何也。厥犹可从发热之多少。以审进退之机。水必趋于下。而力能牵阳下坠故也。伤寒
六七日大下后。寸脉沉而迟。手足厥冷。下部脉不至。咽喉不利。唾脓血。泄利不止。为难治。麻黄升麻汤
主之。寸脉。气口也。气口独为五脏主。胃阳衰而寸脉沉迟也。四肢为诸阳之本。阳虚故手足厥冷。下后
阳虚。故下部脉不至。下寒则热迫于上。故咽喉不利而吐脓血也。即前所谓厥后热不除者。必便脓血。
热气有余。必口伤烂赤。泄利不止。寒邪在下。正虚邪实。阴盛阳衰。寒多热胜。表里舛错。治寒则遗其热。
治热则遗其寒。补虚必助其实。泻实必助其虚。诚为难治。
六章十八节。皆统论厥阴下利。有寒热虚实阴阳生死之不同。伤寒四五日腹中痛。若转气下趋少腹
者。厥阴阴寒。内合太阴。由太阴而仍归厥阴。下而不上。此欲自利也。伤寒本自寒下。医复吐下。寒格更
逆吐下。若食入口即吐。干姜黄连黄芩人参汤主之。其人本从于寒而下利。复吐下之。下因下而愈寒。
上因吐而愈热。寒热相阻而成格症。非寒热相结而成痞症。不食则不吐。是心下无水。故不用姜夏。以
干姜辛温除寒下。而辛烈又能开格纳食也。下利。有微热而渴。脉弱者。今自愈。此言得中见之化也。下
利脉数。有微热。汗出。今自愈。设复紧。得厥阴之气矣。故为未解。下利手足厥冷。无脉者。阳陷下。不得横
行于手足。又不能充达于经脉也。灸之不温。若脉不还。反微喘。是根气绝于下。阳气脱于上。故死。少阴
负趺阳者为顺也。负。承也。趺阳乃阳明胃脉。言少阴之气。得上承阳明。则阴气生而脉还。阳气复而得
温。故为顺也。下利阳气下陷。其脉当沉。阴气内盛。其脉当迟。今不沉迟而寸脉反浮数。是热伤心包。尺
中自涩者。下利阴血虚也。阳盛血虚。迫血下行。必清脓血。上节言阴盛伤阳。此节言阳盛伤阴。下利清
谷。藏气虚寒。不可攻表。汗出则表阳外虚。里阴内结。故必胀满。经云。脏寒生满病。下利脉沉弦。则少阳
初之气下陷。下重是火邪下逼。若阳热甚而脉大。而非初阳之脉象。为未止。脉微弱为阴。数为阳。乃阴
中有阳。为欲自止。内经有身热则死之说。而此得少阳中见之化。为阴出阳。虽发热不死。厥阴阴寒下
利。脉沉而迟。其人面少赤。三阳之气。上循头面阳格于上。喜得少阳之热化。身有微热。然而下利清谷
者。厥阴之标阴。全陷于下。阳热在上。阴寒在下。两不相接。惟取少阴篇大方救之。从阴出阳。必郁冒汗
出而解。病患必微厥。所以然者。其面戴阳。下虚故也。下利脉数而渴者。今自愈。设不瘥。必清脓血。以有
热故也。言当愈不愈。必热伤心包络而便脓血。申明所以便脓血者。以脉数而渴。内有热故也。下利后
脉绝。下焦生气不升。手足厥冷。中焦土气不和。 时环转一周。脉还手足温者。中土之气将复。复能从
中焦而注于手太阴。故生。脉不还者。中土已败。生气已绝。虽手足不逆冷。亦主死。此言生死之机。全凭
脉息。而脉之根。又藉于中土也。诸节皆言下利。此节独言下利后。则与少阴下利。而头时时自冒者同
意。利后似乎邪去。殊不知正气与邪气俱脱之故。 时脉还。手足温。阳气尚存一线。犹可用四逆白通
等法。以救将绝之阳也。伤寒下利。日十余行。病在厥阴。而三阳三阴之气皆虚。脉反实者。无胃气柔和
之脉。乃真元下脱。故死。谷入于胃。藉中土之气。变糟粕。犹奉心化赤。厥阴标阴气盛。入胃不能变化精
微。蒸津液而泌糟粕。清浊不分。下利清谷。里寒外热。汗出而厥者。通脉四逆汤主之。此言里不通于外。
而阴寒内拒。外不通于里。而孤阳外越。非急用大温之剂。必不能通阴阳之气于顷刻。厥阴标阴病。则
为下利清谷。厥阴中见得病。则为热利。下重者。白头翁汤主之。内经所谓暴注下迫。皆属于热也。下重
者。厥阴经邪热入下于大肠之间。肝性急速。邪热甚则气滞壅塞。其恶浊之物。急欲出而不得。故下重
也。下利腹满。身体疼痛。先温其里。乃攻其表。温里宜四逆汤。攻表宜桂枝汤。脏寒生满病。水谷之气下
行。阴寒之气上逆。故先温其里寒。后去其表寒也。下利欲饮水者。以有热故也。白头翁汤主之。此申明
白头翁汤。能清火热以下降。而引阴液以上升也。下利 语者。中是火化。与阳明燥气相合。胃气不和
有燥屎也。厥阴忌下。有燥屎不得不下。宜小承气汤微和胃气。下利后更烦。水液下竭。火热上盛。按之
心下濡者。非上焦君火充盛之烦。乃下焦水阴不得上济之烦。此为虚烦。宜栀子豉汤。
呕家有痈脓者。热伤包络。血化为脓也。腐秽欲去而呕。不可以辛散之品治呕。反逆其机。热邪内壅。无
所泄矣。俟脓尽则热随脓去而自愈。此章四节。俱厥阴之呕。有血气寒热虚实之不同也。呕而脉弱。里
气大虚。小便复利。气机下泄。身有微热。见厥者。阴阳之气不相顺接。上者自上。下者自下。有出无入。故
为难治。四逆汤主之。干呕吐涎沫。头痛者。吴茱萸汤主之。此言厥阴阴寒极盛。津液为寒气绊迎而上。
所呕皆涎沫。而无饮食痰饮。而且逆行巅顶而作头痛。非大剂不能治此暴剧之证。方中无治头痛之
药。以头因气逆上冲。止呕即所以治头痛也。呕而发热者。小柴胡汤主之。厥阴与少阳为表里。邪在厥
阴。惟恐厥逆下利。若见呕而发热。是脏邪还腑。自阴出阳。无阴邪变逆之患矣。故当从少阳之枢而治
之。伤寒以胃气为本。不独厥阴然也。厥阴不治。取之阳明。尤为要法。伤寒大吐大下之。极虚复极汗出。
则外亦极虚。虚则气少不能交通于内。其人外气怫郁。恰似外来之邪怫郁于表。误认为邪热。复与之
水以发其汗。因得哕。所以然者。胃中寒冷故也。伤寒哕而腹满。视其前后。知何部不利。利之则愈。哕既
有虚寒之症。亦有实热之症。厥阴之经。抵少腹。挟胃。上入颃颡。凡哕呃之气。必从少腹而起。由胃而上
升于咽嗌故也。夫伤寒至哕。非中土败绝。即胃中寒冷。然亦有里实不通。气不得下泄。反上逆而为哕
者。玉机真藏论云。脉盛、皮热、腹胀、前后不通、闷瞀、此谓五实。身汗得后利。则实者活。今哕而腹满。前后
不利。五实之二实也。实者泻之。视其前后二部。利之则气得通。下泄而不上逆。哕即愈矣。夫以至虚至
寒之哕症。亦有实者存焉。凡实热之证。亦有虚者在矣。视其寒热虚实。而施温凉补泻。则人无夭扎之患矣。
所谓“去谓热不为汗衰”，意思是说发热并没有因为出汗而减轻。这是因为寒气向外发散，但寒邪依然强盛，导致表虚而邪气盛，身体必然失去调和，出现内部拘急、四肢疼痛的症状。如果再见到下利（腹泻）和四肢厥冷（手脚冰凉），说明阴寒在体内强盛，恶寒，阳气极度虚弱，所以使用四逆汤来温通经脉、恢复阳气，以消除阴寒之邪。大汗后身热、四肢疼痛，这些通常都是热邪为患的表现，但张仲景却使用四逆汤，是因为患者外有厥冷、发热、恶寒的症状，内有拘急、下利的表现，阴寒之象完全显露。由此可知，汗出是阳气外亡，身热是虚阳外泄，肢冷是阳气内脱。其辨证的关键只在于恶寒和下利。总之，张仲景辨别阳证，是以怕热、大便不通作为里实的标准；上一节讲的是阳虚伴有假热，这一节讲的是阳虚没有假热。如果大汗或大下利且出现四肢厥冷，就用四逆汤主治。说“大汗”，意味着阳气亡失于体表；说“大下利”，意味着阳气亡失于体内。再加上四肢厥冷，为什么不列为死证呢？细读原文，文中没有提及发病经过五六天或六七天的过程，可知这是阴寒突然中伤人体，虽然邪气强盛，但正气刚刚受损，急需温补正气，正气尚能自行恢复。所以用四逆汤在濒危之际战胜寒毒，在阳气将绝之时挽回阳气。如果汗止、利止，四肢回暖，就有望保全生命。如果不因汗下而导致四肢厥冷，则用当归四逆汤；如果因汗下而导致四肢厥冷，则用四逆汤。这就是处理缓急问题的权变方法。此证没有外热夹杂，属于阴寒证，容易辨明。然而提到大汗和大下利，说明阴津也耗伤了，此时急救阳气为当务之急，待阳气回复后，再慢慢救治阴液。也有因为痰水导致四肢厥冷的情况。病人没有其他症状，只是手足厥冷。四肢的气血来源于胸中，因为痰饮结聚，导致气机不能贯通到四肢。脉象时而紧，是因为痰脉变化无常，不紧的时候忽然变紧，忽紧之后又不紧。邪气结聚在胸中，胸是心主的宫城，心被邪气阻碍，所以心下胀满且烦闷，感觉饥饿但不想吃东西。病位在胸中，应当采用涌吐法治疗，适宜用瓜蒂散。这正如《内经》所说的“高者引而越之”的意思。再谈谈水厥：伤寒出现四肢厥冷且心下悸动，应当先治疗水饮，服用茯苓甘草汤，然后再治疗四肢厥冷。如果不这样做，水气浸渍入胃，必然会导致腹泻。这是预防厥阴病发生下利的方法。病至厥阴，以阳气上升为欲愈，邪气内陷为危机。如果出现四肢厥冷并伴有下利，则中气不能固守，邪气进一步内陷。这一条讲到四肢厥冷且心下悸动，是水邪乘袭心脏，导致心阳失去统御，见此症状则治疗四肢厥冷为缓，而治疗水饮为急。为什么呢？四肢厥冷还可以根据发热的多少来判断病势的进退，而水饮必然趋向于下，且力量能牵引阳气下坠。
伤寒病程六七天，经过猛烈攻下后，寸脉沉而迟，手足厥冷，尺部脉搏摸不到，咽喉不利，唾吐脓血，腹泻不止，这种情况难以治疗，用麻黄升麻汤主治。寸脉即气口，气口独主五脏，胃阳衰弱所以寸脉沉迟。四肢是诸阳之本，阳虚故手足厥冷。攻下后阳虚，所以下部脉象不至。下焦寒盛则热气被迫上行，所以咽喉不利且吐脓血。这就是前文所说的厥冷后热不退的人，必然会出现便脓血的情况。热气有余，必然导致口腔损伤、红肿溃烂。腹泻不止，是因为寒邪在下，正气虚弱而邪气实，阴盛阳衰，寒多热胜，表里错杂。治疗寒邪会遗漏热邪，治疗热邪会遗漏寒邪，补虚必助长邪实，泻实必加重正虚，确实难以治疗。
第六章第十八节，总论厥阴病的下利，有寒热虚实、阴阳生死的不同。伤寒四五日，腹中疼痛，如果有肠鸣气向下走窜至小腹的情况，这是厥阴阴寒，内合太阴，由太阴又回归厥阴，气机下行而不能上行，这是想要自发的下利。伤寒本来就有寒性下利，医生又误用吐法和下法，导致寒邪格拒，更加逆乱引起呕吐和下利。如果食物入口立即吐出，用干姜黄连黄芩人参汤主治。其人本来因寒而下利，医生又用吐下法，下法使下部更寒，吐法使上部更热。寒热相互阻隔形成格症，而不是寒热互结形成的痞症。不吃东西就不吐，说明心下没有停水，所以不用生姜、半夏。用干姜辛温以祛除下焦之寒，其辛烈之性又能开通格拒、纳受饮食。
下利，伴有微热且口渴，脉象弱的，现在将会自愈。这是得到了中见之气转化的结果。下利，脉数，伴有微热，汗出的，现在将会自愈。如果脉象再次变得紧，说明获得了厥阴之气，所以病未解除。下利，手足厥冷，无脉，是阳气下陷，不能横行通达于手足，也不能充盈达于经脉。艾灸后不温暖，如果脉搏不还复，反而轻微气喘，这是肾根之气绝于下，阳气脱逸于上，所以死亡。少阴脉弱于趺阳脉的为顺证。“负”意为承继、不及。趺阳脉是阳明胃脉，意思是少阴之气能够上承于阳明，则阴气生而脉象恢复，阳气复而肢体得温，所以为顺证。
下利阳气下陷，脉象应当沉；阴气内盛，脉象应当迟。现在不沉不迟，反而寸脉浮数，这是热邪伤害心包；尺中脉涩，是下利导致阴血亏虚。阳盛血虚，迫血下行，必然出现便脓血。上一节讲阴盛伤阳，这一节讲阳盛伤阴。下利完谷不化，是脏腑之气虚寒，不可攻表。如果发汗，则表阳外虚，里阴内结，必然导致腹胀满。经云：“脏寒生满病”。下利脉沉弦，是少阳初生之气下陷；下重感是火邪下逼。如果阳热甚盛而脉大，就不是初生阳气的脉象，说明病不会停止。脉微弱属阴，数属阳，这是阴中有阳，说明下利将要自止。《内经》有身热则死的说法，但此处得到少阳中见之气的转化，属于阴出阳，虽然发热也不会死。
厥阴阴寒下利，脉沉而迟，病人面部稍微发红，这是三阳之气上循头面，阳气格拒于上，喜欢得到少阳的热化，身上有微热。然而下利完谷不化，是因为厥阴的标阴之气完全陷于下，阳热在上，阴寒在下，两者不相交接，只有取用《少阴篇》的大方来救治，从阴出阳，必然会出现郁冒、汗出而解的情况。病人必然会有轻微厥冷。之所以这样，是因为病人面部戴阳，下部虚弱的缘故。
下利，脉数且口渴的，现在将会自愈。如果不好转，必然便脓血，因为有热邪的缘故。这是在说应当痊愈而未痊愈时，必然热伤心包络而便脓血。申明之所以便脓血，是因为脉数且口渴，体内有热邪的缘故。下利后脉象消失，下焦生气不升，手足厥冷，中焦土气不和。经过一个时辰左右，脉搏还复，手足温暖的，说明中土之气将要恢复，随后能从中焦注入手太阴肺经，所以能生。脉搏不还复的，说明中土已败，生气已绝，即使手足不逆冷，也主死。这是在说生死的关键全凭脉息，而脉的根基，又依赖于中土。各节都在讲下利，这一节单独讲下利后，与少阴病下利且头部时时昏蒙的意思相同。下利后似乎邪气已去，殊不知是正气与邪气一同脱失的缘故。经过一个时辰脉搏还复，手足温暖，说明阳气尚存一线，还可以用四逆汤、白通汤等方法，来挽救将绝的阳气。
伤寒下利，一天十几次，病在厥阴，但三阳三阴之气都虚弱，脉象反而实，这是没有胃气柔和之脉，乃真元下脱，所以死亡。谷物进入胃中，依靠中土之气，转化为糟粕，犹如奉心化赤。厥阴标阴气盛，进入胃中不能变化精微，蒸腾津液而分泌糟粕，清浊不分，导致下利完谷不化。里寒外热，汗出且四肢厥冷，用通脉四逆汤主治。这是说里气不通于外，阴寒在内抗拒；外气不通于里，孤阳在外越脱。不是紧急使用大温的药剂，一定不能顷刻间通调阴阳之气。厥阴标阴病，表现为下利完谷不化；厥阴中见得病，表现为热利。如果有下重感，用白头翁汤主治。《内经》所谓“暴注下迫，皆属于热”。下重感，是厥阴经邪热深入大肠之间，肝性急速，邪热甚则气滞壅塞，那些恶浊之物急于排出却排不出，所以下重。
下利伴腹部胀满，身体疼痛，应当先温其里，然后攻其表。温里适宜用四逆汤，攻表适宜用桂枝汤。脏寒生满病，水谷之气下行，阴寒之气上逆，所以先温里寒，后去表寒。下利想喝水的，是因为有热邪，用白头翁汤主治。这是申明白头翁汤能清降火热，并引导阴液上升。下利伴谵语的，是中焦火化，与阳明燥气相合，胃气不和且有燥屎。厥阴病忌用下法，但有燥屎不得不下的，适宜用小承气汤微微调和胃气。下利后更加烦躁，是因为水液下竭，火热上盛。按压心下柔软的，这不是上焦君火充盛的烦躁，而是下焦水阴不能上济的烦躁，此为虚烦，适宜用栀子豉汤。
呕吐家有痈脓的，是热邪损伤心包络，血液化为脓液。腐秽之物欲去而呕吐，不可以用辛散的药物治呕，否则会违背病机，导致热邪内壅，无处宣泄。等到脓尽，则热随脓去而自愈。本章第四节，都是厥阴病的呕吐，有血气寒热虚实等不同。
呕吐而脉弱，是里气大虚；小便又通利，是气机下泄；身体有微热，出现厥冷，是阴阳之气不相顺接，上的往上，下的往下，有出无入，所以为难治，用四逆汤主治。干呕，吐涎沫，头痛的，用吴茱萸汤主治。这是说厥阴阴寒极盛，津液被寒气绊迎而上，所呕吐的都是涎沫，而没有饮食痰饮，而且逆行至巅顶引起头痛，非大剂量药物不能治疗这种暴剧的病症。方中没有治头痛的药，因为头痛是因气逆上冲所致，止呕即所以治头痛。
呕吐而发热的，用小柴胡汤主治。厥阴与少阳互为表里，邪在厥阴，惟恐出现厥逆下利。如果见到呕吐而发热，说明脏邪还腑，自阴出阳，没有阴邪变逆的祸患了。所以应当从少阳的枢机来治疗。伤寒以胃气为本，不仅厥阴病如此。厥阴病不治，取法于阳明，尤为重要的法则。
伤寒经过大吐大下，极度虚弱，又极度出汗，则体表也极度虚弱。虚则气少，不能交通于内。病人外表气机怫郁，恰似外来的邪气怫郁于体表，误认为是邪热，又给水以发其汗，因此导致呃逆（哕）。之所以这样，是因为胃中寒冷的缘故。
伤寒呃逆且腹部胀满，观察前后二阴，知道哪一部不利，通利它则痊愈。呃逆既有虚寒的症状，也有实热的症状。厥阴经脉，抵少腹，挟胃，上入颃颡。凡是呃逆之气，必然从少腹而起，由胃而上升至咽喉。伤寒到了呃逆的地步，如果不是中土败绝，就是胃中寒冷。然而也有里实不通，气不得下泄，反而上逆而为呃逆的情况。《玉机真藏论》说：脉盛、皮热、腹胀、前后不通、闷瞀，这叫五实。身汗且大小便通利，则实证者可活。如今呃逆且腹部胀满，前后不利，这是五实中的两个实证。实证应当泻之，观察前后两部，通利它们则气得通，下泄而不向上逆，呃逆即愈。以至虚至寒的呃逆症，也有实证存在。凡实热的证候，也有虚的情况存在。观察其寒热虚实，而施以温凉补泻之法，则人没有夭折的祸患了。
It is said that "heat does not diminish with sweating," meaning that fever does not subside due to perspiration. This indicates that while cold qi disperses outward, the cold pathogen remains vigorous, resulting in exterior deficiency and excess pathogen, inevitably causing disharmony. Symptoms include internal constraint and pain in the four limbs. If diarrhea (Li) and cold extremities (Jue Ni) are also observed, it signifies excessive Yin-cold within, aversion to cold, and severe Yang deficiency. Therefore, Sini Tang (Four Reversal Decoction) is used to warm the meridians and restore Yang, thereby dispelling Yin pathogens. Profuse sweating followed by body heat and limb pain are typically signs of Heat pathogen affliction; however, Zhang Zhongjing employs Sini Tang because the patient presents externally with Jue (reversal), heat, and aversion to cold, and internally with constraint and diarrhea, fully exposing the Yin-cold syndrome. From this, we understand that sweating represents the loss of Yang Qi to the exterior, body heat represents the leakage of deficient Yang, and cold limbs represent the internal collapse of Yang. The key to differentiation lies in the aversion to cold and diarrhea. In summary, when distinguishing Yang syndromes, Zhang Zhongjing considers aversion to heat and constipation as indicators of interior excess. The previous section discussed Yang deficiency with false heat; this section discusses Yang deficiency without false heat. If profuse sweating or severe diarrhea leads to cold extremities, Sini Tang is indicated. "Profuse sweating" implies Yang loss at the exterior; "severe diarrhea" implies Yang loss at the interior. Combined with cold extremities, why is this not listed as a fatal condition? Examining the text, which lacks mentions of days five through seven, reveals that this is a sudden attack by Yin-cold. Although the pathogen is strong, the healthy Qi is only initially damaged. Urgent warming of the healthy Qi can allow for self-recovery. Thus, Sini Tang is used to overcome cold toxicity at the brink of danger and restore Yang Qi on the verge of extinction. If sweating and diarrhea cease and extremities warm, survival is possible. If cold extremities do not result from sweating or purging, Danggui Sini Tang (Angelica Sinensis Decoction for Reversal Cold) is used; if they do result from these treatments, Sini Tang is used. This illustrates the principle of managing urgency and slackness. This syndrome lacks mixed exterior heat, making it an easily identifiable Yin-cold syndrome. However, since profuse sweating and severe purging deplete Yin fluids, restoring Yang is the immediate priority; once Yang is restored, Yin should be slowly nourished.
There are cases of Jue caused by Phlegm-Fluids. The patient has no other symptoms, only cold extremities. The Qi of the four limbs originates from the chest. Due to the accumulation of Phlegm-Fluids, Qi cannot circulate to the limbs. The pulse may suddenly become tight, as Phlegm pulses vary unpredictably—tight then loose, loose then tight. The pathogen is knotted in the chest, the palace of the Heart Master. Obstruction by the pathogen causes fullness and irritability below the heart, hunger without desire to eat. Since the disease is in the chest, emesis is required, using Gengti San (Thistle Powder). This aligns with the Nei Jing's principle: "For high positions, induce vomiting." Regarding Water-induced Jue: In Shanghan, Jue accompanied by palpitations below the heart requires treating the water first with Fuling Gancao Tang (Poria and Licorice Decoction), before addressing the Jue. Otherwise, water infiltrating the stomach will cause diarrhea. This is a preventive method for diarrhea in Jueyin diseases. At the Jueyin stage, rising Yang indicates recovery, while sinking pathogens indicate crisis. Jue with diarrhea means Middle Qi fails to hold, allowing further pathogen invasion. Here, Jue with palpitations below the heart indicates Water pathogen attacking the Heart, causing Heart Yang to lose control. Thus, treating Jue is secondary, while treating Water is urgent. Why? Jue can be assessed by the degree of fever to determine progression or regression, whereas Water tends downward and drags Yang down.
After six or seven days of Shanghan, following severe purging, the Cun pulse is deep and slow, extremities are cold, the lower pulse is absent, throat is obstructed, expectoration of pus and blood occurs, and diarrhea persists. This is difficult to treat; Mahuang Shengma Tang (Ephedra and Asparagus Root Decoction) is indicated. The Cun pulse, or Qi Kou, governs the five Zang organs. Stomach Yang decline causes the deep, slow Cun pulse. The four limbs are the root of all Yang; Yang deficiency causes cold extremities. Post-purging Yang deficiency results in the absence of the lower pulse. Lower cold forces heat upward, causing throat obstruction and pus-blood expectoration. This refers to the previously mentioned case where heat persists after Jue, leading to pus-blood stool. Excess heat causes oral lesions. Persistent diarrhea indicates lower cold, deficiency of Zheng Qi, excess of pathogen, Yin excess and Yang decline, more cold than heat, and complex exterior-interior contradictions. Treating cold neglects heat; treating heat neglects cold. Tonifying deficiency aids excess; draining excess harms deficiency. Indeed, this is difficult to treat.
Chapter 6, Section 18, generally discusses Jueyin diarrhea, noting differences in cold/heat, deficiency/excess, Yin/Yang, and life/death. After four or five days of Shanghan, abdominal pain with gas moving downward to the lower abdomen indicates Jueyin Yin-cold merging with Taiyin, returning to Jueyin, descending without ascending, indicating impending spontaneous diarrhea. If Shanghan, originally characterized by cold diarrhea, is mistreated with vomiting and purging, cold rejection worsens the reversal of vomiting and purging. If food is vomited immediately upon entry, Ganjiang Huanglian Huangqin Renshen Tang (Dried Ginger, Coptis, Scutellaria, and Ginseng Decoction) is used. The patient originally had cold diarrhea; vomiting and purging made the lower part colder and the upper part hotter. Cold and heat block each other, forming a Ge (rejection) syndrome, not a Pi (glomus) syndrome. Absence of vomiting when fasting indicates no water retention below the heart, hence no Ginger or Pinellia. Dried Ginger warms the lower cold and its pungency opens rejection to accept food.
Diarrhea with slight heat and thirst, and a weak pulse, indicates self-healing due to the transformation of the Zhongjian (middle-exposed) Qi. Diarrhea with a rapid pulse, slight heat, and sweating also indicates self-healing. If the pulse becomes tight again, it reflects Jueyin Qi, indicating unresolved disease. Diarrhea with cold extremities and no pulse signifies Yang sinking, unable to reach the limbs or meridians. If moxibustion fails to warm and the pulse does not return, but slight panting occurs, it indicates root Qi exhaustion below and Yang escape above, leading to death. If Shaoyin is weaker than Duyang, it is favorable. "Fu" means yielding or supporting. Duyang is the Yangming Stomach pulse; if Shaoyin Qi supports Yangming, Yin generates, pulses return, Yang recovers, and warmth returns, which is favorable.
Yang sinking in diarrhea suggests a deep pulse; Yin excess suggests a slow pulse. A floating, rapid Cun pulse indicates Heat injuring the Pericardium; a choppy Chi pulse indicates Yin blood deficiency from diarrhea. Yang excess and blood deficiency force blood downward, causing pus-blood stool. The previous section discussed Yin injuring Yang; this section discusses Yang injuring Yin. Diarrhea with undigested food indicates organ deficiency and cold; exterior release is contraindicated. Sweating causes exterior Yang deficiency and interior Yin knotting, leading to abdominal fullness. The Classics state: "Cold in organs generates fullness." Diarrhea with a deep-string pulse indicates sinking of Shaoyang's initial Qi; heaviness in defecation is forced by Fire pathogen. If Yang heat is severe with a large pulse, it is not the pulse of initial Yang, and diarrhea will not stop. A weak pulse is Yin; a rapid pulse is Yang. Yin containing Yang suggests diarrhea will stop. Although Nei Jing states fever leads to death, here the transformation of Shaoyang's Zhongjian Qi allows Yin to emerge into Yang; thus, fever does not lead to death.
In Jueyin Yin-cold diarrhea with deep-slow pulse, slight facial redness indicates Three Yang Qi ascending to the head, Yang rejection above, seeking Shaoyang heat transformation, with slight body heat. However, diarrhea with undigested food shows Jueyin Biao-Yin completely sunk below, with Yang heat above and Yin cold below, disconnected. Treatment requires large formulas from the Shaoyin chapter to rescue, transitioning from Yin to Yang, likely resulting in Yu Mao (depression and dizziness) and sweating for resolution. Patients may have slight Jue due to Dai Yang (face red like wearing yang) and lower deficiency.
Diarrhea with rapid pulse and thirst indicates self-healing; if unresolved, pus-blood stool will occur due to Heat. This clarifies that unresolved heat injures the Pericardium meridian. Diarrhea followed by absent pulse, lower Sheng Qi failing to rise, and cold extremities, with Disharmony of Middle Earth Qi, may recover after one cycle (Shichen). If the pulse returns and extremities warm, Middle Earth Qi is recovering and injecting into Hand-Taiyin Lung, indicating life. If the pulse does not return, Middle Earth has failed and Sheng Qi is extinct; even without cold extremities, death is indicated. Life and death depend on the pulse, rooted in Middle Earth. This section differs from others by focusing on post-diarrhea, similar to Shaoyin diarrhea with frequent dizziness. Post-diarrhea seems like pathogen departure, but actually involves simultaneous loss of Zheng Qi and pathogen. Pulse return and warm extremities indicate surviving Yang, treatable with Sini Tang or Baitong Tang.
Shanghan diarrhea occurring ten-plus times daily, located in Jueyin, with deficiency of all Three Yang and Three Yin Qi, yet a "Shi" (excess) pulse, indicates lack of gentle Stomach Qi pulse, true Yuan Qi sinking, leading to death. Grain enters the stomach, transformed by Middle Earth Qi into waste, akin to Heart transforming blood. Jueyin Biao-Yin excess prevents proper transformation of essence and separation of clear/turbid, causing undigested food diarrhea. Interior cold with exterior heat, sweating, and Jue require Tongmai Sini Tang (Pulse-Rescuing Sini Tang). This describes interior Yang blocked by Yin cold and exterior Yang escaping due to interior isolation. Only urgent strong warming can instantly harmonize Yin and Yang. Jueyin Biao-Yin disease causes undigested food diarrhea; Jueyin Zhongjian disease causes Heat diarrhea. Heaviness in defecation requires Baitouweng Tang (Pulsatilla Decoction), as stated in Nei Jing: "Sudden diarrhea with straining belongs to Heat." Heaviness results from Jueyin Heat pathogen entering the Large Intestine; Liver's swift nature combined with severe Heat causes Qi stagnation, making foul matter eager to exit but blocked.
Diarrhea with abdominal fullness and body pain requires warming the interior first, then releasing the exterior. Warm interior with Sini Tang; release exterior with Guizhi Tang (Cinnamon Twig Decoction). Organ cold causes fullness; Water-Grain Qi descends while Yin-cold ascends, necessitating interior warming before exterior release. Thirst for water during diarrhea indicates Heat; use Baitouweng Tang. This decoction clears Heat downward and raises Yin fluids. Diarrhea with delirium indicates Middle Fire combining with Yangming Dryness, causing Stomach Disharmony and dry feces. Jueyin forbids purging, but dry feces require mild purgation with Xiaochengqi Tang (Minor Order the Yellow Decoction) to harmonize Stomach Qi. Diarrhea followed by increased irritability, due to fluid depletion and rising Fire, with soft epigastrium upon pressure, indicates deficiency irritability (Xu Fan) from lower Yin failing to ascend, treated with Zhizi Chidao Tang (Gardenia and Fermented Soybean Decoction).
Vomiting with pus in patients with abscesses indicates Heat injuring the Pericardium, turning blood to pus. Vomiting expels foul matter;辛散 (pungent-dispersing) anti-emetics should be avoided as they reverse the mechanism, trapping Heat. Once pus is exhausted, Heat leaves with it, and healing occurs. This section covers Jueyin vomiting, varying by Blood/Qi, Cold/Heat, Deficiency/Excess.
Vomiting with weak pulse indicates severe interior deficiency; frequent urination indicates Qi leaking downward; slight body heat with Jue indicates failure of Yin-Yang connection, with Qi exiting without entering, making it difficult to treat. Use Sini Tang. Dry retching with salivary foam and headache requires Wuzhuyu Tang (Evodia Decoction). This indicates extreme Jueyin Yin-cold binding fluids upward. Vomiting is only saliva, no food/phlegm, ascending to the vertex causing headache. Large doses are needed. The formula treats headache by stopping vomiting, as headache stems from rebellious Qi. Vomiting with fever requires Xiao Chaihu Tang (Minor Bupleurum Decoction). Jueyin and Shaoyang are exterior-interior pairs. Pathogen in Jueyin fears Jue and diarrhea. Vomiting with fever indicates脏邪还腑 (Zang pathogen returning to Fu), emerging from Yin to Yang, avoiding Yin rebellion. Treat via Shaoyang pivot. Shanghan prioritizes Stomach Qi. For Jueyin, treating Yangming is crucial.
Severe vomiting and purging cause extreme deficiency; extreme sweating causes extreme exterior deficiency. Qi deficiency prevents internal communication. Exterior Qi stagnation mimics exterior pathogen stagnation. Mistaking this for Heat and giving water to induce sweating causes Hiccups (Yue). This is due to Cold in the Stomach.
Hiccups with abdominal fullness require examining the anterior and posterior orifices to identify obstruction; relieving it cures hiccups. Hiccups can be Cold-Deficiency or Heat-Excess. Jueyin meridian passes the lower abdomen, flanks the Stomach, and enters the nasopharynx. Hiccup Qi rises from the lower abdomen through the Stomach to the throat. Severe hiccups indicate either Middle Earth collapse or Stomach Cold, or sometimes interior excess blocking Qi descent, forcing it upward. Nei Jing's Yuji Zhenzang Lun lists Five Excesses: full pulse, hot skin, abdominal fullness, blocked bowels/bladder, and mental clouding. Sweat and bowel movement resolve excess. Hiccups with fullness and blocked bowels/bladder represent two of the five excesses. Drain excess; relieve anterior/posterior obstruction to allow Qi descent, curing hiccups. Even extreme Cold-Deficiency hiccups may have Excess components. Conversely, Heat-Excess may have Deficiency aspects. Differentiate Cold/Heat, Deficiency/Excess, and apply warming/cooling, tonifying/draining methods to prevent premature death.