【纲】仲景曰。尺寸脉微缓者。厥阴受病也。当六七日发。其症少腹烦满而囊缩。
【目】朱肱曰。厥阴病。其脉微浮为欲愈。不浮为未愈。宜小建中汤。脉微缓者。必囊不缩。
外症必发热恶寒似疟。为欲愈。宜桂枝麻黄合半汤。尺寸俱沉短者。必囊缩。表气入腹。宜承气汤
下之。大抵伤寒脏腑传变。阳经先受病。次传入阴经。以阳主生。阴主杀也。若六七日传厥阴。脉得
微缓微浮。为脾胃脉也。故知土气不受克。邪无所容。荣卫将复。水升火降。则寒热作而大汗出矣。
王好古曰。厥阴病者。烦满囊缩。大小便不通。发热引饮腹满。尺寸脉俱微缓。烦者。火也。
满者。木也。虽不吐蛔囊缩。但急者。亦木也。火木相合。四肢厥逆。而爪甲青。大小便不通。地
道塞也。发热引饮。邪气在里。宜温之下之。
有以上诸症。大小便俱通。地道不塞。不发渴引饮。邪不在里。则宜温之灸之。则里外相接。
以复阳气。宜正阳散。
【纲】仲景曰。伤寒一二日。至四五日。厥者。必发热。前热者后必厥。厥深者热亦深。厥微
者热亦微。厥应下之。而反发汗者。必口伤烂赤。脉滑而厥者。里有热也。白虎汤主之。
【目】朱肱曰。手足逆冷。此名厥也。厥者。逆也。阴阳不相顺接。故手足逆冷也。阳气衰。
阴气盛。阴胜于阳。故阳脉为之逆。不通于手足。所以逆冷也。伤寒热多厥少者。其病当愈。
厥多热少者。其病为进。然有冷厥。有热厥。当仔细辨认。冷厥者。初得病日。便四肢逆冷。脉沉
微而数。足多蜷卧而恶寒。或自引衣盖覆。不饮水。或下利清谷。或清便自调。或小便数。外症多
惺惺而静。脉虽沉实。按之迟而弱者。知其冷厥也。四逆汤、理中汤、通脉四逆汤、当归四逆汤、
当归四逆加吴萸生姜汤、白通加猪胆汁汤选用。热厥者。初病必身热头痛。别有阳症。二三日至四
五日。乃发厥兼热。厥至半日。却身热。盖热气深方发厥。须在二三日后也。若微厥即发热者。热
厥故也。脉虽沉伏。按之而滑。为里有热。其人或畏热。或饮水。或扬手掷足。烦躁不得卧。大
便秘。小便赤。外症多昏愦者。知其热厥也。白虎承气随症用之。本条云。厥应下之。以热厥当下。
若反发汗。必口伤烂赤也。又有下症悉具而见四逆者。是失下后血气不通。四肢便厥。医人不识。
疑是阴厥。反进热药。祸如反掌。大抵热厥。须脉沉伏而滑。头汗。手虽冷。爪甲时温。须承气下之。
勿拘忌。
诸手足逆冷。皆属厥阴。不可汗下。然有须汗须下者。谓虽逆冷。时有温时。手足掌心暖。非
正厥逆也。当消息之。若寒热而厥。面色。不泽。冒昧。两手忽无脉。或一手无脉者。必是有正汗
也。多用绵衣包手足令暖。急用五味子汤。或兼与麻黄细辛甘草汤。服之 时。必大汗解。或厥逆
怔忡者。宜先治水。茯苓甘草汤。然后治厥不然。水浸入胃。必下利。又有手足厥冷。脉乍结者。
邪结在胸也。心下满而烦。饥不能食者。病在胸中。吐之。瓜蒂散。盖病在胸中。亦令人手足厥。
但认脉乍结是也。脉阴虚则结。脉来缓。时一止。复来。曰结。主胸满烦躁。太阴少阴脉俱不至头。
俱无头疼症。仲景只有厥阴一症。吴茱萸汤治干呕吐涎沫头疼而已。大抵属三阳者。头疼为多也。若非次头疼。胸中满。
及发寒热。脉紧而不大者。即是膈上有痰。瓜蒂末一钱水调下。吐涎立愈。重阳必阴。重阴必阳。寒暑之变也。假令手
足逆冷。大便秘。小便赤。或大便黑。脉沉而滑。阳症似阴也。轻则白虎。重则承气。
伤寒失下。血气不通。令四肢逆冷。此是伏热
深。故厥亦深。急用大承气加分剂下之。汗出立瘥。仲景所谓厥宜下之者此也。
热厥与阴厥。自不同。热厥者。微厥即发热。阴厥即不发热。四肢逆冷。恶寒脉细。大小便滑
泄矣。
王好古曰。仲景言四逆与厥者非一。或曰四逆。或曰厥逆、厥冷、厥寒。或曰厥。或曰手足逆
冷、手足厥逆、手足厥冷、手足厥逆冷。俱是言寒冷耳。故厥逆二字。每每互言。未尝分逆为不温。
厥为冷也。既曰不温。则为冷矣。何异乎。然四肢与手足却有分。以四字加逆字上。是通指手足
臂胫以上言也。以手足字加厥逆等字上。及无手足字。是独指手足言也。虽然。厥冷俱为寒冷。却
有阴阳之殊。热极而厥逆。阳极似阴也。以四逆散寒药治之。寒极而厥逆。独阴无阳也。
仲景虽无四逆汤热药治四逆之条。但四逆汤之名。由四肢之冷而立。今以四逆汤治手足厥冷。
岂非逆厥之不异乎。成氏既谓四逆为热邪。至少阴病四逆条下。又谓四逆为寒甚。不自悖乎。是知
四肢冷。犹厥之有寒
有热。但四肢通冷。比之手足独冷则异耳。故仲景曰。少阴病吐利烦躁四逆者
死。又曰。少阴病四逆恶寒而蜷。脉不至烦而躁者死。又曰。少阴病吐利手足厥冷烦躁欲死者。吴
茱萸汤。此三条。二为死。一为可治。虽通由诸症兼见而然。然死者以逆言。可治者以厥冷言。可
见四逆重于厥冷矣。成氏谓厥甚于逆。岂不谬耶。
王肯堂曰。凡言四逆。或言厥言逆者。皆为重症。皆言四肢耳。言指头寒。言手足厥与逆与冷
者。皆为厥微。盖手之上为腕。腕上为臂。足之上为踝。踝上为胫也。其病之轻重浅深。皆寓于
书法中。宜审。
自热至温。自温至厥。乃传经之邪。四逆散主之。厥逆。大便秘。小便赤。或大便黑。脉沉而
滑。此为阳症似阴。白虎汤。重者大承气。不可误也。
张介宾曰。厥有二症。曰阳厥。曰阴厥。阳厥者。热厥也。必其先自三阳传入阴分。故初起必
头疼发热。自浅入深。然后及于三阴。变为四肢逆冷。或时乍温。其症必便结躁烦。谵语发渴。
不恶寒。反恶热。脉沉有力。此以传经热邪所化。外虽手足厥冷。内则因于热邪。阳症发厥。故为阳
厥。乃阳极似阴也。其症由邪热内结。或伏阳失下之所致也。凡厥微
热亦微。宜四逆散之类。厥甚热亦甚。宜大承气之类。阴厥者。寒厥也。初无三阳传经实热等症。
而真寒直入三阴。则畏寒厥冷。腹痛吐泻。战栗不渴。脉沉无力。此阴寒厥逆。独阴无阳也。故为
阴厥。轻则理中汤。重则四逆汤。回阳汤。主之。按阳厥阴厥。其辨如此。此先哲之大法也。然愚
则犹有辨。如厥阴一症。既无阳症阳脉。而病寒若此。明是阴症。今人但曰中寒者。即其病也。然
犯此者无几。知此者无难。治宜温中。无待辨也。惟是阳厥则有不得不辨者矣。夫厥由三阳所传。
为阳厥固矣。即以传经者言之。又岂尽无阴症乎。故凡病真阳不足者。即阳中之阴厥也。脉弱无神
者。即阳中之阴厥也。攻伐清凉太过者。即阳中之阴厥也。四肢为诸阳之本。使非有热结烦渴胀实
等症。而见厥逆者。皆由阳气不足也。成无己曰。大抵厥逆为阴所主。寒者多矣。又曰。厥为阴之
盛也。故凡属挟虚伤寒。则虽自阳经传入者。是亦阳中之阴厥也。阴中之阴者。宜温。阳中之阴者。
果宜凉乎。勿谓其先有头疼发热。但自三阳传至者。便为阳厥。而寒因热用之。则为害不小矣。
柯琴曰。首条。明热厥之理。二条。明热厥之脉与方。脉滑以弱。是有胃气。缓而滑。名热中。
与寒厥之。脉微欲绝不同。
【纲】仲景曰。伤寒病。厥五日。热亦五日。设六日当复厥。不厥者自愈。厥终不过五日。以热
五日。故知自愈。
【目】喻昌曰。厥终不过五日。即上句之注脚。见热与厥相应。阴阳一胜一复。恰恰相当。故
可勿药自愈。
魏荔彤曰。此与上一二日至四五日条。乃申解厥阴病厥热互见。以明其阳陷入阴之深浅。均应
理其热邪。毋伤阴分。不可误见阳陷为厥。即以为寒。亦不可见阳升发热。即为可汗。而妄治也。
上条言一二日至四五日。夫久病非寒。故知其为传经之热。阳陷于阴而得厥也。厥者必发热。是因
后之必发热。知为热厥而非寒厥也。前热者后必厥。正见传经热邪。入于厥阴。升降不能。故发为厥
热互见之症也。厥深。为日多也。热入阴分之深也。故厥后必热。热亦因深而久也。厥微。为日少也。热入阴分微也。
故厥后必热。热亦因浅而暂也。推之热后必厥者亦如之。总为阳陷之故
也。阳气亦热邪。热邪即阳气也。然热微则陷者浅。可以升举。热深则陷者深。不可升举。乘其陷
入之势。与以荡涤之施。是厥阴无下法。又未尝无下法也。喻氏用小承气。下热邪而净阴分也。然
大柴胡尤为对症。不然。热入之深而反发汗。并失其升举之道矣。若妄施之。邪热愈炽。口伤烂赤。
必矣。试就其厥与热互见之日明之。如本条厥五日。阳入也。热亦五日。阳出也。设六日当复厥。阳
又入也。不厥。则阳不入而直出透表矣。所以知其能自愈。倘复厥。其日亦不过五。以前阳出之数
计之。知阳入又必五日而出也。更推之。凡阳入几日。厥几日。必阳出几日。热几日也。
均应理热邪。亦未能尽。如渐厥多热少。则又当理其寒邪。勿伤阳分矣。然厥多热少。渐致有
厥无热。自各有专条也。
【纲】仲景曰。伤寒热少厥微。指头寒。默默不欲食。烦躁。数日。小便利。色白者。此热除
也。欲得食。其病为愈。若厥而呕。胸胁烦满者其后必便血。
【目】张云岐曰。热少厥微。即热微厥亦微之症也。但曰指头寒。不言手足逆冷。其为热亦有
限矣。
【纲】仲景曰。伤寒脉微而厥。至七八日。肤冷。其人躁无暂安时者。此为脏厥。非蛔厥也。
蛔厥者。其人当吐蛔。今病者静而复时烦者。此为脏寒。蛔上入其膈。故烦。须臾复止。得食而呕。
又烦者。蛔闻食臭出。其人当自吐蛔。蛔厥者。乌梅丸主之。又主久利。
【目】成无己曰。脏厥者死。阳气绝也。蛔厥虽厥而烦。吐蛔已则静。不若脏厥而躁无临时安
也。
【纲】仲景曰。伤寒发热四日。厥反五日。复热四日。厥少热多。其病当愈。四日至七日。热
不除者。必便脓血。伤寒厥。四日。热反三日。复厥五日。其病为进。寒多热少。阳气退。故为进也。
【目】喻昌曰。以阴阳进退之义互举。其旨跃然。
【纲】仲景曰。伤寒先厥。后发热而利者。必自止。见厥。复利。伤寒先厥。后发热下利。必
自止。而反汗出。咽中痛者。其喉为
痹。发热无汗而利。必自止。若不止。必便脓血。便脓血者。其喉不痹。
【目】魏荔彤曰。此与上发热四日厥反三日条。申明热厥互见。并详其传经之热邪。上冲下注
不同。即此可知阳气升陷之几。而病势之进退决焉。盖传经之邪。其有深浅升降固已。然就深浅言。
此热原为传经之邪。就升降言。此热又为正阳之气。非阳气升透。则热入既深。漫无出路。其患非
上冲。即下注。岂能遽言愈哉。
厥阴病。总宜升阳于阴分。散热于表分也。此与上条。又在厥阴中辨病势吉凶之大关键也乎。
【纲】仲景曰。伤寒始发热六日。厥反九日而利。凡厥利者。当不能食。今反能食者。恐为除
中。食以索饼。不发热者。知胃气尚在。必愈。恐暴热来出而复去也。后三日脉之。其热续在者。
期之旦日夜半愈。所以然者。本发热六日。厥反九日。复发热三日。并前六日。亦为九日。与厥相
应。故期之旦日夜半愈。后三日脉之。而脉数。其热不罢者。此为热气有余。必发痈脓也。
【目】魏荔彤曰。凡仲景言日。如他条一二日四五日。及五日六日四日三日。与本条九日。皆
设以为验之辞。俱不可拘。如算法设为问答。以明其数。使人得较量其亏盈也。
【纲】仲景曰。伤寒六七日。大下后。寸脉沉而迟。手足厥逆。下部脉不至。咽喉不利。吐脓
血。泄利不止者。为难治。麻黄升麻汤主之。
【目】王好古曰。厥阴症。四肢厥冷。爪甲青。脉沉疾。按之有力者。为阳。则当下。宜大承
气汤。如脉沉。按之无力者。为阴。则当温。宜四逆汤。
喻昌曰。寸脉沉而迟。明是阳去入阴之故。非阳气衰微可拟。故虽手足厥逆。下部脉不至。泄
利不止。其不得为纯阴无阳可知。况咽喉不利。唾脓血。又阳邪搏阴。上逆之征验。所以仲景特于
阴中提出其阳得汗出。而错杂之邪尽解也。
魏荔彤曰。寸。上焦之部位。阳分之脉也。而见沉迟。寒格于热。上热伏于寒下可知。手足厥冷。阳陷入阴。寒格
热伏又
可知。下部尺脉不至。平日之寒下肾虚又可知。是肾阳素弱。阳陷于阴。热格于寒之故。如绘目前。
何可任阳澌灭乎。但阳毕竟在阴中。虽弱。未尝无也。热毕竟伏寒下。惟郁。故反能为害也。咽喉
不利。唾脓血者。热邪不肯屈伏而上冲于肺为患也。泄利不止。热邪既不能上达。不得不随阴气。
而为挟热之利也。即是热邪伏郁阴中。阳气必勃动于阴分。固极难为升举。不易致透表散邪。治之
得愈矣。然非有阴无阳。厥去不还之死症也。仍当以破阴升阳为主治。用麻黄升麻汤。与乌梅丸。
【纲领】张仲景说：寸口和尺部的脉搏都呈现微缓之象，这是厥阴经受邪所致。通常在发病后的第六或第七天发作。其症状表现为小腹部烦闷胀满，以及阴囊收缩。
【注释】朱肱说：厥阴病，如果脉搏微带浮象，说明病情即将痊愈；如果不浮，则说明尚未痊愈。适宜使用小建中汤（Minor Construct the Middle Decoction）。如果脉搏微缓，那么阴囊就不会收缩。外在症状必定是发热、恶寒，类似疟疾的样子，这是将要痊愈的征兆，适宜使用桂枝麻黄各半汤（Guizhi Mahuang Half Combination Decoction）。如果寸部和尺部脉搏都沉而短，必然会出现阴囊收缩。这是因为表邪内陷入腹，适宜用承气汤（Chengqi Decoction）攻下。大抵伤寒病的脏腑传变规律，阳经先受病邪，然后传入阴经，因为阳主生发，阴主肃杀。如果经过六七天传入厥阴，脉搏出现微缓或微浮，这是脾胃脉象的表现，因此知道土气（脾胃之气）没有受到克制，邪气无处容身，营卫之气即将恢复，水火既济（水升火降），于是会出现寒热交替并大汗出的情况。
王好古说：厥阴病的症状包括烦闷、胀满、阴囊收缩、大小便不通、发热且想喝水、腹部胀满，寸尺脉搏都微缓。烦，属于火邪；满，属于木邪。即使不吐蛔虫且有阴囊收缩，只要感到急迫，也属于木邪。火与木邪相合，导致四肢厥逆，指甲青紫，大小便不通，这是地道（肠道/下焦通道）堵塞。发热且想喝水，说明邪气在体内，适宜采用温法兼以攻下。
如果有上述各种症状，但大小便通畅，地道没有堵塞，且不口渴想喝水，说明邪气不在体内深处，则适宜用温法配合艾灸，使里外阳气相接，从而恢复阳气，适宜使用正阳散（Zhengyang Powder）。
【纲领】张仲景说：患伤寒病一两天，到四五天，出现四肢厥冷的，必定会发热。先前发热的，后来必然出现厥冷。厥冷严重的，体内的热邪也深重；厥冷轻微的，体内的热邪也轻微。厥冷证应当用攻下法，如果反而使用发汗法，必然会导致口腔损伤、红肿溃烂。脉搏滑利而四肢厥冷的，是体内有热邪，由白虎汤（Baihu Decoction）主治。
【注释】朱肱说：手足逆冷，这叫做“厥”。厥，就是逆乱的意思。阴阳之气不能顺接，所以手足逆冷。阳气衰弱，阴气旺盛，阴胜于阳，所以阳脉发生逆乱，不能通达于手足，因此出现逆冷。伤寒病中，发热多而厥冷少的，病情应当痊愈；厥冷多而发热少的，病情为进展。然而有冷厥（寒厥）和热厥之分，应当仔细辨认。冷厥者，刚得病时，四肢就逆冷，脉搏沉微而数，双脚多蜷缩卧倒且怕冷，或者自己拉衣服遮盖，不想喝水，或者下利清谷（大便中有未消化的食物），或者大便正常，或者小便频数。外在症状大多神志清醒而安静，虽然脉搏沉实，但按之迟而弱，可以知道这是冷厥。可选用四逆汤（Sini Decoction）、理中汤（Lizhong Decoction）、通脉四逆汤（Tongmai Sini Decoction）、当归四逆汤（Danggui Sini Decoction）、当归四逆加吴茱萸生姜汤（Danggui Sini plus Evodia and Ginger Decoction）、白通加猪胆汁汤（Baitong plus Pig Bile Decoction）中的一种。热厥者，初起必定身体发热、头痛，有别于阳证的症状，二三天到四五天，才出现厥冷兼有热象。厥冷持续半天后，又身体发热，这是因为热气深伏才引发厥冷，通常要在两三天后才出现。如果轻微厥冷随即发热，这就是热厥。脉搏虽然沉伏，但按之滑利，说明体内有热。患者可能怕热，或者想喝水，或者扬手掷足，烦躁无法躺卧，大便干结，小便赤红。外在症状大多昏沉糊涂，可以知道这是热厥。白虎汤或承气汤随证选用。本条文中说“厥应下之”，是指热厥应当用攻下法。如果反而发汗，必然导致口腔损伤红肿溃烂。又有具备所有攻下指征却出现四肢逆冷的，这是失于攻下后气血不通，四肢因而厥冷。医生不认识此症，怀疑是阴厥，反而进服热药，灾祸如反掌之间就会发生。大抵热厥，必须脉搏沉伏而滑，头部出汗，手虽然冷，但指甲时常温暖，必须用承气汤攻下，不要拘泥禁忌。
所有的手足逆冷，都属于厥阴经病变，一般不可发汗或攻下。然而有必须发汗或必须攻下的情况，说的是虽然逆冷，但有时温暖，手足掌心暖，这不是真正的厥逆。应当斟酌处理。如果有寒热往来且厥冷，面色无光泽，头目昏眩，两手突然摸不到脉搏，或者一手无脉的，必定会有正常的汗出。多用绵衣包裹手足使其温暖，紧急时使用五味子汤（Wuweizi Decoction），或者兼用麻黄细辛甘草汤（Mahuang Xixin Gancao Decoction）。服药时，必定大汗而解。如果出现厥逆伴随心悸怔忡，适宜先治疗水饮，用茯苓甘草汤（Fuling Gancao Decoction），然后再治厥逆。否则，水气浸入胃中，必然导致下利。又有手足厥冷，脉搏偶尔结代的，是邪气结聚在胸中。心下胀满而烦，饥饿却不能进食，病位在胸中，应用吐法，用瓜蒂散（Gudui Powder）。病在胸中，也会让人手足厥冷，只要认定脉搏偶尔结代即可。脉阴虚则结，脉搏来势缓慢，偶尔停止一下，然后又来，叫做结脉，主胸满烦躁。太阴、少阴经脉的气都不上达头部，都没有头痛症状。张仲景只有厥阴病的一条症状，用吴茱萸汤（Wuzhuyu Decoction）治疗干呕吐涎沫和头痛罢了。大抵属于三阳经的，头痛较多。如果不是经常性的头痛，伴有胸中胀满，以及发寒热，脉搏紧而不大的，就是膈上有痰，用瓜蒂末一钱，水调服下，吐出涎液立即痊愈。重阳必转化为阴，重阴必转化为阳，这是寒暑的变化。假如有手足逆冷，大便秘结，小便赤红，或者大便黑色，脉搏沉而滑，这是阳证似阴证。轻的用白虎汤，重的用承气汤。
伤寒失于攻下，气血不通，导致四肢逆冷，这是伏热深重，所以厥冷也深重。紧急时用加大剂量的大承气汤（Da Chengqi Decoction）攻下，汗出后立即痊愈。这就是张仲景所说的“厥宜下之”的情况。
热厥与阴厥（寒厥），自然不同。热厥者，轻微厥冷随即发热；阴厥者，不发热，四肢逆冷，怕冷，脉搏细，大小便滑泄。
王好古说：张仲景提到的四逆和厥，说法不一。有的说四逆，有的说厥逆、厥冷、厥寒，有的单说厥，有的说手足逆冷、手足厥逆、手足厥冷、手足厥逆冷，都是指寒冷而言。所以“厥逆”二字，常常互用，未曾区分“逆”为不温，“厥”为冷。既然说不温，那就是冷了，有什么区别呢？然而四肢与手足却有区别。在“逆”字上加四字（指四肢），是通指手臂和小腿以上而言。在手足字上加厥逆等字，以及没有手足字，是独指手足而言。虽然如此，厥冷都指寒冷，却有阴阳的区别。热极而导致厥逆，是阳极似阴。用四逆散（Sini San）等寒凉药治疗。寒极而导致厥逆，是独阴无阳。张仲景虽然没有用四逆汤等热药治疗四逆的条文记载，但四逆汤这个名字，是由四肢冷而立的。现在用四逆汤治疗手足厥冷，难道不是逆和厥没有区别吗？成无己既说四逆是热邪，到了少阴病四逆条下，又说四逆是寒甚，这不矛盾吗？由此可知，四肢冷，就像厥分寒热一样，只是四肢通冷，与手足独冷有所不同。所以张仲景说：“少阴病，吐利，烦躁，四逆者死。”又说：“少阴病，四逆，恶寒而蜷，脉不至，烦而躁者死。”又说：“少阴病，吐利，手足厥冷，烦躁欲死者，吴茱萸汤主之。”这三条中，两条为死证，一条可治。虽然都是因为诸症兼见所致，但死证用“逆”言，可治者用“厥冷”言，可见四逆重于厥冷。成无己说厥甚于逆，难道不荒谬吗？
王肯堂说：凡是说四逆，或者说厥、说逆的，都是重症，都指四肢而言。说指头寒，说手足厥、逆、冷的，都是厥证轻微。手的上面是腕，腕上是臂；足的上面是踝，踝上是胫。病的轻重浅深，都蕴含在书法（文字表述）之中，应当审慎。
从热到温，从温到厥，这是传经之邪，用四逆散主治。厥逆，大便秘结，小便赤红，或大便黑色，脉搏沉而滑，此为阳证似阴证，用白虎汤，重的用大承气汤，不可误治。
张介宾说：厥有两种症状，叫阳厥，叫阴厥。阳厥者，就是热厥。必定是先从三阳传入阴分，所以初起必定头疼发热，由浅入深，然后波及三阴，变为四肢逆冷，有时暂时转温。其症状必定是大便干结、躁动烦闷、谵语、发渴，不怕冷，反而怕热，脉搏沉而有力。这是由传经的热邪转化而来，外面虽然手足厥冷，内部是因为热邪，阳证发厥，所以叫阳厥，这是阳极似阴。其症状由邪热内结，或伏阳失于攻下所致。凡厥冷轻微，热也轻微，适宜用四逆散之类；厥冷严重，热也严重，适宜用大承气汤之类。阴厥者，就是寒厥。初起没有三阳传经的实热等症状，而是真寒直接侵入三阴，则畏寒厥冷，腹痛吐泻，战栗不渴，脉搏沉而无力。这是阴寒厥逆，独阴无阳，所以叫阴厥。轻的用理中汤，重的用四逆汤、回阳汤主治。按阳厥和阴厥，辨别方法如此，这是先哲的大法。然而我仍有辨析。如厥阴这一症，既然没有阳证阳脉，而病寒如此，明明是阴证。今人只说中寒，就是它的病。然而犯此病的人很少，知道这一点并不难，治疗适宜温中，无需辨别。只有阳厥是有不得不辨别的。夫厥由三阳传来，定为阳厥固然正确。即以传经者来说，又岂尽无阴证乎？所以凡是真阳不足的人，就是阳中之阴厥。脉搏弱无神的，就是阳中之阴厥。攻伐清凉太过的人，就是阳中之阴厥。四肢是诸阳之本，如果不是有热结、烦渴、胀实等症状，而出现厥逆的，都是由阳气不足引起。成无己说：大抵厥逆由阴所主，多为寒证。又说：厥是阴气盛也。所以凡是属于挟虚伤寒，即使是自阳经传入的，也是阳中之阴厥。阴中之阴者，适宜温补；阳中之阴者，果真适宜凉润吗？不要认为先前有头疼发热，只要是自三阳传至的，就认为是阳厥，而用寒因热用的方法，危害就不小了。
柯琴说：首条，阐明热厥的道理。二条，阐明热厥的脉象和方剂。脉滑而弱，是有胃气的表现，缓而滑，名叫热中，与寒厥的脉微欲绝不同。
【纲领】张仲景说：患伤寒病，厥冷五天，发热也五天。假设第六天应当再次厥冷，如果不厥冷，就会自愈。厥冷终不超过五天，因为发热五天，所以知道能自愈。
【注释】喻昌说：厥冷终不超过五天，就是上一句的注脚，显示热与厥相应，阴阳一进一退，恰恰相当，所以可以不药而愈。
魏荔彤说：这与上一条一二日至四五日条，乃是申解厥阴病厥热互见的情况，以说明阳气陷入阴分的深浅，都应该调理热邪，不要损伤阴分，不可错误地见到阳陷入阴导致厥冷，就以为是寒证；也不可见到阳气上升发热，就以为是可发汗，而妄加治疗。上一条说一二日至四五日，久病非寒，所以知道是传经之热。阳陷入阴而得厥。厥冷必定伴随发热，是因为后来必然发热，知道是热厥而非寒厥。前热者后必厥，正是显示传经热邪，进入厥阴，升降失常，所以发为厥热互见的症状。厥深，是因为日子多，热入阴分深，所以厥后必热，热也因为深而持久。厥微，是因为日子少，热入阴分浅，所以厥后必热，热也因为浅而短暂。推之热后必厥者也是如此，总归是阳陷入阴的缘故。阳气也就是热邪，热邪即阳气。然而热微则陷入浅，可以升举；热深则陷入深，不可升举。乘其陷入之势，给予荡涤的方法，这是厥阴并非无下法，也未尝无下法。喻氏用小承气汤，攻下热邪而洁净阴分。然而大柴胡汤更为对症。不然，热入已深而反而发汗，并失去了升举之道。如果妄加施用，邪热更炽盛，必然导致口腔损伤红肿溃烂。试从其厥与热互见的天数来阐明。如本条厥五日，是阳入；热亦五日，是阳出。假设六日应当再次厥冷，是阳又入。不厥，则阳不入而直接透出体表，所以知道能自愈。倘若再次厥冷，其天数也不过五，以前阳出的天数计算，知道阳入又必五日而出。再推之，凡阳入几日，厥几日，必阳出几日，热几日。都应调理热邪，但也未能穷尽。如渐次厥多热少，则又当调理寒邪，不要损伤阳分了。然而厥多热少，渐致有厥无热，自有各自的专条论述。
【纲领】张仲景说：伤寒病热少厥微，仅指头寒，沉默不想吃东西，烦躁。几天后，小便通利，颜色白的，这是热除去了，想吃东西，病就会痊愈。如果厥冷且呕吐，胸胁烦满的，其后必然便血。
【注释】张云岐说：热少厥微，就是热微厥亦微的症状。只说指头寒，不说手足逆冷，说明其热也是有限的。
【纲领】张仲景说：伤寒脉搏微而厥冷，到七八天，皮肤冷，其人躁动没有片刻安宁的时候，这叫脏厥，不是蛔厥。蛔厥者，其人应当吐蛔虫。现在病人安静而又时不时心烦的，这是脏寒，蛔虫上行进入膈部，所以心烦，一会儿又停止，吃饭后呕吐，又心烦的，是蛔虫闻到食物气味而出，其人应当自行吐蛔虫。蛔厥者，用乌梅丸（Wumei Pill）主治。又主治久痢。
【注释】成无己说：脏厥者死，因为阳气绝灭。蛔厥虽然厥冷且心烦，但吐蛔后就安静了，不像脏厥那样躁动没有片刻安宁。
【纲领】张仲景说：伤寒发热四天，厥冷反而五天，又发热四天，厥少热多，病应当痊愈。从第四天到第七天，热不退的，必然便脓血。伤寒厥冷四天，发热反而三天，又厥冷五天，病为进展。寒多热少，阳气衰退，所以为进展。
【纲领】张仲景说：伤寒先厥冷，后发热而下利的，必定自行停止。见到厥冷，下利又发作。伤寒先厥冷，后发热下利，必定自行停止，而反而汗出，咽喉痛的，喉部会成为痹证。发热无汗而下利，必定自行停止，如果不停止，必然便脓血。便脓血的，喉部不会痹阻。
【注释】魏荔彤说：这与上一条发热四天厥冷反而三天条，申明热厥互见，并详细阐述传经热邪上冲和下注的不同。由此可知阳气升陷的机枢，而病势的进退也就决定了。大概传经之邪，其深浅升降固已存在。然就深浅而言，此热原为传经之邪；就升降而言，此热又是正阳之气。若非阳气升透，则热入既深，漫无出路，其患不是上冲，就是下注，怎能遽然说痊愈呢？厥阴病，总宜升阳于阴分，散热于表分。这与上一条，又在厥阴中辨别病势吉凶的大关键啊。
【纲领】张仲景说：伤寒开始发热六天，厥冷反而九天而下利。凡厥冷下利的，应当不能食。现在反而能食的，恐怕是除中（胃气将绝的回光返照）。给吃索饼（面条），如果不发热，知道胃气尚在，必定痊愈。担心暴热来去匆匆。后三天诊脉，如果热度持续存在，预期在第二天半夜痊愈。之所以这样，本来发热六天，厥冷反而九天，又发热三天，加上前面的六天，也为九天，与厥冷相应，所以预期在第二天半夜痊愈。后三天诊脉，如果脉搏数，热度不消退的，这是热气有余，必然发生痈脓。
【注释】魏荔彤说：凡是仲景说的天数，如其他条的一二日、四五日，及五日、六日、四日、三日，与本条的九日，都是设为验证的说法，都不可拘泥。如同数学题设问，以明确其数，使人得以较量盈亏。
【纲领】张仲景说：伤寒六七天，经过大力攻下后，寸脉沉而迟，手足厥逆，下部脉摸不到，咽喉不利，吐脓血，泄利不止的，为难治。用麻黄升麻汤（Mahuang Shengma Decoction）主治。
【注释】王好古说：厥阴症，四肢厥冷，指甲青紫，脉搏沉疾，按之有力的，属阳，则应当攻下，宜用大承气汤。如脉搏沉，按之无力的，属阴，则应当温补，宜用四逆汤。
喻昌说：寸脉沉而迟，明是阳气离去进入阴分的原因，不是阳气衰微所能比拟的。所以虽然手足厥逆，下部脉不至，泄利不止，其不得为纯阴无阳是显而易见的。何况咽喉不利，唾脓血，又是阳邪搏结阴分，上逆的征验。所以张仲景特意在阴证中提出其阳，得汗出，而错杂之邪尽解。
魏荔彤说：寸脉，是上焦的部位，阳分之脉。却见沉迟，是寒格于热，上热伏于寒下可知。手足厥冷，阳陷入阴，寒格热伏又可知。下部尺脉不至，平日之寒下肾虚又可知。是肾阳素弱，阳陷于阴，热格于寒的缘故。如绘目前，怎能让阳气消亡呢？但阳毕竟在阴中，虽弱，未尝没有。热毕竟伏于寒下，惟郁，所以反能为害。咽喉不利，唾脓血，是热邪不肯屈伏而上冲于肺为患。泄利不止，热邪既不能上达，不得不随阴气，而为挟热之利。即是热邪伏郁阴中，阳气必勃动于阴分，固极难为升举，不易致透表散邪，治疗得当才能痊愈。然而并非有阴无阳、厥去不还的死症。仍当以破阴升阳为主治，用麻黄升麻汤，与乌梅丸。
[Outline] Zhang Zhongjing said: When the pulse at both the Cun (inch) and Chi (cubit) positions is slightly slow and moderate (Wei Huan), it indicates that the Jueyin meridian is affected. This typically manifests on the sixth or seventh day of illness. The symptoms include a sensation of vexation and fullness in the lower abdomen, and retraction of the scrotum.
[Commentary] Zhu Gong said: In Jueyin disease, if the pulse is slightly floating, recovery is imminent; if not floating, the disease has not yet resolved. Xiao Jianzhong Tang (Minor Construct the Middle Decoction) is appropriate. If the pulse is slightly slow and moderate, the scrotum will not retract. The external symptoms must include fever and aversion to cold resembling malaria, which indicates impending recovery. Guizhi Mahuang Ban Tang (Guizhi and Mahuang Half-Combination Decoction) is appropriate. If the pulses at both Cun and Chi are deep and short, scrotal retraction will certainly occur. This is due to exterior pathogens penetrating into the interior. Chengqi Tang (Purgative Decoction) should be used to purge. Generally, in Shanghan (Cold Damage) diseases, transmission follows the zang-fu organs: Yang meridians are affected first, then transmitted to Yin meridians, because Yang governs generation and Yin governs destruction. If transmission reaches Jueyin after six or seven days, and the pulse becomes slightly slow/moderate or slightly floating, this reflects the spleen-stomach pulse. Thus, one knows that Earth Qi (Spleen/Stomach energy) is not being overcome, pathogens have no place to reside, and Ying and Wei (Nutritive and Defensive) energies are about to recover. With Water ascending and Fire descending, alternating chills and fever will occur followed by profuse sweating.
Wang Haogu said: Symptoms of Jueyin disease include vexation, fullness, scrotal retraction, obstruction of urination and defecation, fever with thirst, and abdominal distension, with pulses at Cun and Chi being slightly slow/moderate. Vexation belongs to Fire; fullness belongs to Wood. Even without vomiting roundworms, if there is scrotal retraction accompanied by a sense of urgency, it also relates to Wood. The combination of Fire and Wood leads to cold limbs (Jue Ni), cyanosis of the fingernails, and obstruction of urination and defecation, indicating blockage of the "Earthly Path" (lower jiao/intestines). Fever with thirst indicates pathogens in the interior; warm methods combined with purging are appropriate.
If the aforementioned symptoms are present but urination and defecation are unobstructed, and there is no thirst, the pathogen is not deeply entrenched in the interior. Warm methods combined with moxibustion should be used to connect interior and exterior Yang Qi and restore it. Zhengyang San (Zhengyang Powder) is appropriate.
[Outline] Zhang Zhongjing said: In Shanghan, from the first or second day to the fourth or fifth day, if cold limbs (Jue) appear, fever will inevitably follow. If fever preceded cold limbs, cold limbs will follow. The deeper the cold limbs, the deeper the internal heat; the milder the cold limbs, the milder the internal heat. Cold limb syndromes should be treated with purging. If sweating is induced instead, oral ulcers and redness will certainly result. If the pulse is slippery with cold limbs, there is heat in the interior, treated by Baihu Tang (White Tiger Decoction).
[Commentary] Zhu Gong said: Cold reversal of the hands and feet is called "Jue". Jue means reversal. Because Yin and Yang Qi fail to connect smoothly, the hands and feet become cold. When Yang Qi is weak and Yin Qi is strong, Yin overcomes Yang, causing Yang pulses to reverse and fail to reach the extremities, resulting in coldness. In Shanghan, if fever predominates over cold limbs, the disease will heal; if cold limbs predominate over fever, the disease progresses. However, one must distinguish between Cold Jue (Han Jue) and Heat Jue (Re Jue). In Cold Jue, from the onset, limbs are cold, the pulse is deep, fine, and rapid, legs are curled up with aversion to cold, the patient may pull clothes over themselves, refuse water, suffer from diarrhea with undigested food, or have normal stool or frequent urination. Externally, the patient is usually alert and quiet. Although the pulse may feel deep and solid, pressing reveals it as slow and weak, indicating Cold Jue. Options include Sini Tang, Lizhong Tang, Tongmai Sini Tang, Danggui Sini Tang, Danggui Sini plus Wuzhuyu and Shengjiang Decoction, and Baitong plus Zhu Danzhi Decoction.
In Heat Jue, initial symptoms include body fever and headache, distinct from typical Yang syndrome patterns. On the second to fifth day, cold limbs appear accompanied by heat. After half a day of cold limbs, fever returns because deep heat triggers cold limbs, usually appearing after two to three days. If mild cold limbs are quickly followed by fever, it is Heat Jue. The pulse may be deep and hidden but feels slippery upon pressure, indicating internal heat. Patients may fear heat, desire water, toss about restlessly, suffer constipation, and have dark urine. Externally, they may appear confused. This indicates Heat Jue. Baihu Tang or Chengqi Tang should be selected based on symptoms. The text states "Jue should be purged," referring to Heat Jue requiring purgation. Inducing sweat instead causes oral damage. If all purgative indications are present but cold limbs appear, it is due to blood and Qi stagnation from missed purgation. Misdiagnosing this as Yin Jue and administering hot medicines causes disaster. Heat Jue requires a deep, hidden, slippery pulse, head sweating, and warm nail beds despite cold hands. Purge with Chengqi Tang without hesitation.
All cold reversals of hands and feet belong to Jueyin, generally prohibiting sweating or purging. However, exceptions exist where sweating or purging is needed if the cold is intermittent and palms are warm, indicating it is not true Jue Ni. One must exercise judgment. If accompanied by chills and fever, pale complexion, dizziness, and absent radial pulses, normal sweating will likely occur. Keep limbs warm with cotton; urgently use Wuweizi Decoction or combine with Mahuang Xixin Gancao Decoction. Profuse sweating will resolve the condition. If cold reversal is accompanied by palpitations, treat fluid retention first with Fuling Gancao Decoction, then address Jue. Otherwise, fluid invading the stomach causes diarrhea. If cold limbs are accompanied by an intermittent pulse (Jie Mai), pathogens are knotted in the chest. Fullness and vexation below the heart, hunger without appetite, indicate pathology in the chest; induce vomiting with Gudi San. Chest pathology can cause cold limbs; identify by the intermittent pulse. A deficient pulse knots; a slow pulse with occasional stops is called Jie, indicating chest fullness and vexation. Taiyin and Shaoyin pulses do not reach the head, so no headache occurs. Zhang Zhongjing mentions only one Jueyin symptom for headache with dry vomiting and saliva, treated by Wuzhuyu Tang. Headaches are common in Yang meridians. Non-routine headaches with chest fullness, chills/fever, and tight/large-inadequate pulses indicate phlegm in the diaphragm; administer Gudi powder mixed with water to vomit saliva and cure. Extreme Yang transforms to Yin, extreme Yin transforms to Yang, reflecting seasonal changes. For example, cold limbs, constipation, dark urine or black stool, with deep/slippery pulses, indicate Yang syndrome resembling Yin. Mild cases use Baihu Tang; severe cases use Chengqi Tang.
Missed purgation in Shanghan causes Qi/Blood stagnation and cold limbs due to deep latent heat, hence deep cold limbs. Urgently purge with a larger dose of Da Chengqi Tang; sweating resolves it. This is what Zhang Zhongjing meant by "Jue should be purged."
Heat Jue and Yin Jue differ. Heat Jue features mild cold limbs followed by fever; Yin Jue features no fever, cold limbs, aversion to cold, fine pulse, and loose stools.
Wang Haogu noted that Zhang Zhongjing uses various terms for cold limbs: Si Ni, Jue Ni, Jue Leng, Jue Han, Jue, Shou Zu Ni Leng, etc., all denoting cold. "Jue Ni" is often used interchangeably. There is no distinction between "Ni" (not warm) and "Jue" (cold); both imply cold. However, "Si Zhi" (four limbs) differs from "Shou Zu" (hands and feet). Adding "Si Zhi" before "Ni" refers to arms and calves; using "Shou Zu" specifies hands and feet. Although both denote cold, they differ in Yin/Yang nature. Extreme heat causing Jue Ni is "Extreme Yang resembling Yin," treated with cooling herbs like Sini San. Extreme cold causing Jue Ni is "Yin alone without Yang." Although Zhang Zhongjing lacks explicit texts on using hot medicines like Sini Tang for Si Ni, the name implies treating cold limbs. Using Sini Tang for hand/foot coldness suggests no difference between Ni and Jue. Cheng Wuji stated Si Ni is heat pathogen, yet later called it severe cold in Shaoyin context, which seems contradictory. Thus, limb coldness, like Jue, has cold and heat types. General limb coldness differs from isolated hand/foot coldness. Zhang Zhongjing stated: "Shaoyin disease with vomiting, diarrhea, irritability, and Si Ni is fatal." And "Shaoyin disease with Si Ni, aversion to cold, curling up, absent pulse, irritability, and restlessness is fatal." But "Shaoyin disease with vomiting, diarrhea, cold limbs, and severe irritability" is treatable with Wuzhuyu Tang. Two are fatal, one treatable. Fatal cases use "Ni"; treatable cases use "Jue Leng." Thus, Si Ni is more severe than Jue Leng. Cheng Wuji's claim that Jue is worse than Ni is erroneous.
Wang Kentang said: Terms like Si Ni, Jue, or Ni indicate severe conditions affecting four limbs. Mentioning cold fingertips or specific hand/foot coldness indicates mild Jue. Anatomy matters: wrist above hand, arm above wrist; ankle above foot, calf above ankle. Severity is encoded in terminology.
Transition from heat to warmth to cold limbs indicates transmitted pathogenic heat, treated with Sini San. Cold reversal with constipation, dark urine/stool, and deep/slippery pulse is Yang syndrome resembling Yin, treated with Baihu Tang or Da Chengqi Tang.
Zhang Jiebin said: Jue has two types: Yang Jue and Yin Jue. Yang Jue is Heat Jue, originating from Yang meridians transmitting to Yin. Initial symptoms include headache and fever, progressing to cold limbs with intermittent warmth. Symptoms include constipation, irritability, delirium, thirst, aversion to heat, and deep/forceful pulse. Internal heat causes external cold limbs; this is Yang Jue (Extreme Yang resembling Yin), caused by internal heat knotting or missed purgation. Mild Jue/heat uses Sini San; severe uses Da Chengqi Tang. Yin Jue is Cold Jue, lacking Yang meridian heat signs, with true cold entering Yin meridians directly. Symptoms include aversion to cold, cold limbs, abdominal pain, vomiting/diarrhea, shivering, no thirst, and deep/weak pulse. This is Yin cold reversal (Yin alone without Yang), treated with Lizhong Tang (mild) or Sini Tang/Huiyang Tang (severe).
I offer further clarification. Jueyin disease without Yang signs/pulses is clearly Yin. Modern practitioners call this "Zhong Han" (Cold Strike), but it is rare and easily treated with warming the middle. Differentiation is crucial for Yang Jue. While Yang Jue stems from Yang meridians, transmitted cases can involve Yin patterns. Those with deficient True Yang suffer from "Yin within Yang." Weak pulses indicate "Yin within Yang." Overuse of cooling/purging drugs causes "Yin within Yang." Limbs are the root of Yang; without heat knots/thirst/distension, cold limbs stem from Yang deficiency. Cheng Wuji stated Jue is governed by Yin and is mostly cold. He also said Jue represents盛 (abundance) of Yin. Thus, even transmitted cases with deficiency are "Yin within Yang." Should "Yin within Yin" be warmed? Yes. Should "Yin within Yang" be cooled? No. Do not assume all transmitted cases are Yang Jue simply due to initial fever/headache; using cold for heat here causes harm.
Ke Qin said: The first clause explains the principle of Heat Jue. The second clause explains its pulse and formula. A slippery yet weak pulse indicates Stomach Qi; slow and slippery indicates "Heat in the Middle." This differs from the faint/almost absent pulse of Cold Jue.
[Outline] Zhang Zhongjing said: In Shanghan, five days of cold limbs followed by five days of fever. If the sixth day brings recurrent cold limbs, the disease heals if cold limbs do not recur. Cold limbs last no more than five days; since fever lasts five days, self-healing is expected.
[Commentary] Yu Chang explained: The limit of five days for cold limbs notes the previous sentence, showing correspondence between fever and cold limbs. Yin and Yang advance and retreat equally, allowing spontaneous recovery without medication.
Wei Litong stated: This clarifies the alternating nature of Jue and Re in Jueyin disease, indicating the depth of Yang sinking into Yin. One must regulate heat pathogens without damaging Yin. Do not mistake Yang sinking for cold, nor assume fever allows for sweating. The previous clause (days 1-2 to 4-5) indicates long-standing illness is not cold but transmitted heat. Yang sinks into Yin causing Jue; subsequent fever confirms Heat Jue. Preceding fever leading to Jue shows heat entering Jueyin, disrupting ascent/descent, causing alternating Jue/Re. Deep Jue implies many days and deep heat entry, leading to prolonged post-Jue fever. Mild Jue implies few days and shallow heat entry, leading to brief post-Jue fever. Conversely, post-fever Jue follows similar logic. All result from Yang sinking. Yang Qi is heat pathogen. Mild heat sinks shallowly and can be lifted; deep heat sinks deeply and cannot. Utilizing the sinking momentum to purge is valid; thus, Jueyin is not devoid of purgation. Yu Chang used Xiao Chengqi Tang to purge heat and cleanse Yin. Da Chaihu Tang is also suitable. Mistaken sweating deepens heat, blocking lifting pathways, causing oral ulcers. Analyzing days: 5 days Jue (Yang enters), 5 days Re (Yang exits). Day 6 recurrence of Jue means Yang re-enters. No Jue means Yang exits directly to surface, ensuring healing. If Jue recurs, it lasts 5 days, predicting another 5-day exit. Generally, days of Yang entry equal days of Jue, which equal days of Yang exit and Re. Regulate heat, but if Jue increases while Re decreases, regulate cold to protect Yang. Specific clauses cover Jue-dominant cases.
[Outline] Zhang Zhongjing said: In Shanghan, mild heat and mild Jue manifest as cold fingertips, silence, anorexia, and irritability. After several days, clear urine indicates heat removal. Desire for food signals recovery. If Jue is accompanied by vomiting and chest/hypochondriac fullness, hematochezia will follow.
[Commentary] Zhang Yunqi noted: Mild heat/Jue implies limited heat. Specifying only cold fingertips, rather than full limb coldness, confirms limited heat.
[Outline] Zhang Zhongjing said: In Shanghan, a faint pulse with cold limbs persisting to the 7th-8th day, with cold skin and constant restlessness (no respite), indicates Zang Jue (Visceral Cold), not Huo Jue (Roundworm Jue). Huo Jue patients vomit roundworms. Current patient is quiet but intermittently vexed due to visceral cold causing roundworms to ascend to the diaphragm. Vexation ceases briefly. Eating induces vomiting and vexation as roundworms smell food and emerge; patient vomits roundworms. Huo Jue is treated with Wumei Wan (Dark Plum Pill), also for chronic dysentery.
[Commentary] Cheng Wuji stated: Zang Jue is fatal due to Yang exhaustion. Huo Jue involves Jue and vexation, but settles after vomiting roundworms, unlike the constant restlessness of Zang Jue.
[Outline] Zhang Zhongjing said: In Shanghan, fever for 4 days, then cold limbs for 5 days, then fever for 4 days. Less Jue, more Re indicates healing. If fever persists from day 4 to 7, pus and blood in stool will occur. If Shanghan presents with 4 days Jue, then 3 days Re, then 5 days Jue, the disease progresses. More cold, less heat indicates Yang decline.
[Commentary] Yu Chang noted: The interplay of Yin/Yang advancement/retreat makes the intent clear.
[Outline] Zhang Zhongjing said: In Shanghan, initial Jue followed by fever and diarrhea leads to spontaneous cessation. Recurrence of Jue restarts diarrhea. If initial Jue is followed by fever and diarrhea cessation, but sweating occurs with throat pain, Bi Syndrome (throat obstruction) results. If fever, no sweating, and diarrhea cease spontaneously but continue, pus/blood in stool occurs. If pus/blood occurs, throat Bi does not.
[Commentary] Wei Litong stated: This clarifies alternating Heat/Jue and details how transmitted heat ascends or descends. This reveals the mechanism of Yang rising/sinking and determines disease progression. Transmitted pathogens have depth and direction. Heat is both pathogen and Zheng Yang. Without Yang lifting, deep heat has no outlet, causing upper or lower complications. Jueyin treatment requires lifting Yang in Yin and dispersing heat in the exterior. This distinguishes auspicious/inauspicious trends in Jueyin.
[Outline] Zhang Zhongjing said: In Shanghan, initial fever for 6 days, then Jue for 9 days with diarrhea. Typically, Jue/diarrhea patients cannot eat. If able to eat, suspect Chu Zhong (stomach Qi returning falsely). Feed Suo Bing (noodles). If no fever ensues, Stomach Qi remains, and healing is expected. Fear sudden transient heat. Three days later, if pulse shows sustained heat, expect healing by midnight of the next day. Reason: 6 days fever + 3 days recent fever = 9 days, matching 9 days of Jue. If pulse is rapid and heat persists after three days, excess heat will cause abscesses/pus.
[Commentary] Wei Litong stated: Zhang Zhongjing's day counts (e.g., 9 days) are hypothetical calculations to illustrate balance/imbalance, not rigid timelines.
[Outline] Zhang Zhongjing said: In Shanghan, after severe purgation on days 6-7, if Cun pulse is deep/slow, limbs are cold, lower pulses are absent, throat is obstructed, pus/blood is vomited/spit, and diarrhea is unceasing, it is difficult to treat. Mahuang Shengma Decoction is indicated.
[Commentary] Wang Haogu said: Jueyin symptoms with cold limbs, cyanotic nails, and deep/rapid forceful pulse indicate Yang; purge with Da Chengqi Tang. Deep/weak pulse indicates Yin; warm with Sini Tang.
Yu Chang stated: Deep/slow Cun pulse indicates Yang retreating into Yin, not mere Yang deficiency. Despite cold limbs and absent lower pulses/diarrhea, it is not pure Yin without Yang. Throat obstruction and spitting pus/blood show Yang pathogen attacking Yin and reversing upward. Zhang Zhongjing extracts Yang from Yin to induce sweating and resolve complex pathogens.
Wei Litong stated: Cun pulse (upper jiao/Yang) being deep/slow indicates cold blocking heat, with upper heat trapped by lower cold. Cold limbs show Yang sinking into Yin. Absent Chi pulse indicates kidney Yang deficiency from prior cold purgation. Kidney Yang is weak, Yang sinks into Yin, heat blocked by cold. Throat obstruction and pus/blood show heat attacking lungs. Unceasing diarrhea shows heat following Yin qi as heat-induced diarrhea. Heat is trapped in Yin; Yang struggles to rise and disperse. Treatment must break Yin and lift Yang using Mahuang Shengma Decoction and Wumei Wan.