伯曰∶四肢者，诸阳之本也。阳盛则四肢实，实则能登高也。帝曰∶其弃衣而走者何也？岐伯曰∶热盛于身，故弃衣欲
走也。帝曰∶其妄言骂詈，不避亲疏，而不欲食，不欲食，故妄走也。
章虚谷曰∶四肢禀气于脾胃，胃为脏腑之海，而阳明行气于三阳，故四肢为诸阳之本也。邪盛于胃，气实于四肢，
则能登高也。热盛于身，故弃衣欲走，邪乱神明，怒气冲动，故妄言骂詈。胃中邪实，不欲饮食，四肢多力，则妄走也，
是大承气汤之证。其邪连经，脉必滑大，下之可生。其邪连脏，脉必沉细。仲景云∶阳病见阴脉者死，则虽有下证，不
可用下法矣。
雄按∶温证误投热药补剂，亦有此候。经证亦有可用白虎汤者，沉细之脉，亦有因热邪闭塞使然。形证实者，下之
可生，未可概以阴脉见而断其必死。凡热邪壅遏，脉多细软迟涩，按证清解，自形滑数，不比内伤病服凉药而脉加数者
为虚也。
汪按∶大承气证，仲圣谓∶脉弦者生，涩者死。洄溪则云∶弦则尚有可生之机，未必尽生，涩则断无不死者也。余
所见滑大者，固下之不必顾忌，亦有弦而兼涩，下之而愈者。若大汗淋漓者，可用白虎也。
《生气通天论》曰∶因于暑汗，烦则喘喝，静则多言。
吴鞠通曰∶暑为火邪，与心同气，心受邪迫，汗出而烦。烦从火、从页，谓心气不安，而面若火铄也。喘喝者，火
克金故喘。遏郁胸中清廓之气，故欲喝而伸之。其或邪不外张，而内藏于心则静。心主言，暑邪在心，虽静亦欲自言不
休也。略参拙意。
《刺志论》曰∶气盛身寒，得之伤寒；气虚身热，得之伤暑。
林观子曰∶虽云身寒，实指身发热言也。要以意得之。
雄按∶虽发热而仍恶寒，不似伤暑之恶热，故曰身寒。
吴鞠通曰∶此伤寒暑之辨也，经语分明如此，奈何世人悉以治寒法治温暑哉！
雄按∶不但寒伤形，暑伤气，截然分明，而寒为阴邪（虽有红炉暖阁、羔酒狐裘而患火病者，不可谓寒是阳邪，寒
必兼火也），暑为阳邪（虽有袭凉饮冷夹杂阴寒之证，亦人事之兼伤，非天气之本然也），亦如水火之不相射。经云∶天
寒地冻，天暑地热。又云∶阴阳之升降，寒暑彰其兆。理极明显，奈后贤道在迩而求诸远，遂不觉其立言之失，而用药
之非也。
淦按∶云得之者，推原受病之始，厘清证因也。伤寒伤暑，为《内经》两大纲，是从对待说。若春伤于风，夏生飧
泄云云，则从四序说。喻氏于《内经》中又补伤燥，可见诸气感人，皆能为病，先圣后贤，论极昭析，何今人治感，不
论何证，但以伤寒药治之，而不知有温、暑、燥、湿之病，陋矣！
《热论篇》帝曰∶热病已愈，时有所遗者，何也？岐伯曰∶诸病遗者，热甚而强食之，故有所遗也。若此者，皆病
已衰而热有所藏，因其谷气相薄，两热相合，故有所遗也。帝曰∶治遗奈何？岐伯曰∶视其虚实，调其逆从，可使必已
也。帝曰∶病热常何禁之？岐伯曰∶病热少愈，食肉则复，多食则遗，此其禁也。
叶香岩曰∶因食复、劳复、女劳复而发汗必致亡阳而死。
章虚谷曰∶此言病初愈，余热留藏于经络血气中而未净，因食助气，则两热相合而复炽，故食肉病必复发，多食谷
则邪遗留，必淹缠难愈。故当戒口，清淡稀粥渐为调养也。
《论疾诊尺篇》曰∶尺肤热甚，脉盛躁者，病温也。其脉盛而滑者，病且出也。
吴鞠通曰∶经之辨温病，分明如是，何世人悉谓伤寒，而悉以伤寒足三阴经温法治之哉！张会卿作《类经》，割裂经
文，蒙混成章，由未细心 绎也。尺肤热甚，火烁精也。脉盛躁，精被火煎沸也。脉盛而滑，邪机向外也。
此节以下诊温病之法。
《平人气象论》曰∶人一呼脉三动，一吸脉三动而躁。尺热曰病温，尺不热脉滑曰病风，脉涩曰痹。
吴鞠通曰∶呼吸俱三动，是六七至脉矣，而气象又躁急。若尺部肌肤热，则为病温。盖温病必伤金水二脏之津液，
尺之脉属肾，尺之穴属肺也。此处肌肉热，故知为病温。其不热而脉兼滑者，则为病风。风之伤人也，阳先受之。尺为
阴，故不热也。如脉动躁而兼涩，是气有余而血不足，病则为痹矣。
《玉版论要》曰∶病温虚甚，死。
吴鞠通曰∶病温之人，精血虚甚，则无阴以胜温热，故死。
《热病篇》曰∶热病三日，而气口静、人迎躁者，取之诸阳，五十九刺，以泻其热，而出其汗，实其阴，以补其不
足者。
吴鞠通曰∶人迎躁，邪在上焦，故取之诸阳，以泄其阳邪，阳气通则汗随之；实其阴，以补其不足者，阳盛则阴衰，
泻阳则阴得安其位，故曰实其阴。泻阳之有余，即所以补阴之不足，故曰补其不足也。
雄按∶用药之道亦如此。
又曰∶实其阴以补其不足，此一句实治温热之吃紧大纲。盖热病未有不耗阴者，其耗之未尽则生，尽则阳无留恋，
必脱而死也。真能体味斯言，思过半矣。
雄按∶耗之未尽者，尚有一线之生机可望；若耗尽而阴竭，如旱苗之根已枯矣。
沛然下雨，亦曷济耶？
汪按∶叶氏必以保津液为要，细考经文此条，可知其理。奈何恣用升提温燥，重伤其津耶？
身热甚，阴阳皆静者，勿刺也。其可刺者，急取之，不汗出则泄。所谓勿刺者，有死征也。
吴鞠通曰∶阳证阴脉，故曰勿刺。
热病七日八日，动喘而弦者，急刺之，汗且自出，浅刺手大指间。
吴鞠通曰∶喘为肺气实，弦为风火鼓荡，故浅刺手大指间，以泄肺热。肺之热痹开则汗出。大指间，肺之少商穴也。
热病七日八日，脉微小，病者溲血，口中干，一日半而死，脉代者，一日死。
吴鞠通曰∶邪气深入下焦，逼血从小便出，故溲血。肾精告竭，阴液不得上潮，故口中干。脉至微小，不惟阴精竭，
阳气亦从而竭矣，死象自明。倘脉实者可治。
热病已得汗出，而脉尚躁，喘且复热，勿刺肤，喘甚者死。
吴鞠通曰∶热不为汗衰，金受火克，喘而化源欲绝，故死。然间有可治者。
热病不知所痛，耳聋，不能自收，口干，阳热甚，阴颇有寒者，热在骨髓，死，不可治。
吴鞠通曰∶不知所痛，正衰不与邪争也。耳聋，阴伤精欲脱也。不能自收，正气惫也。口干、热甚，阳邪独盛也。
阴颇有寒，热邪深入阴分，外虽似寒，而热在骨髓也。故曰死，不治。其有阴精未至涸竭者，间可侥幸得生。略参拙意。
热病已得汗，而脉尚躁甚，此阴脉之极也，死；其得汗，而脉静者，生。
吴鞠通曰∶汗后脉躁，阴虚之极，故曰死。然虽不可刺，能以甘凉药沃之得法，亦有得生者。
热病者脉尚躁盛，而不得汗者，此阳脉之极也，死；脉盛躁，得汗，静者，生。
吴鞠通曰∶脉躁无汗，阳盛之极，阳盛而至于极，阴无容留之地，故亦曰死。虽然较前阴阳俱静有差。此证犹可大
剂急急救阴，亦有活者。即已得汗而阳脉躁盛，邪强正弱，正尚能与邪争，若留得一分津液，便有一分生理，贵在留之
得法耳！至阴阳俱静，邪气深入下焦阴分，正无捍邪之意，直听邪之所为，不死何待？
热病不可刺者有九∶一曰∶汗不出，大颧发赤，杨按∶阴虚劳损，两颧必赤，可与此比类而观。哕者，死。
雄按∶汗不出，大颧赤，似属阳盛。哕者，呃忒也。肺胃之气不降，杨按∶此是实证，必颜赤，不仅两颧赤。则呃
呃而上逆也。治以轻清肃化之剂，病似可瘳，何以经文即断为不可刺之死候？殆谓热邪方炽，而肾阳欲匮，阳已无根，
病深声哕之证欤！杨按∶大颧属肾。发赤是伏藏之阳上脱也，加以哕，则证与色合，顷刻而脱，故不治。则其哕必自下
焦而升，病由冬不藏精所致。更察其脉，亦必与上焦阳盛之病有别也。
二曰∶泄而腹满甚者，死。
雄按∶腹满者当泄之，既泄而满甚，是邪尚踞而阴下脱，犹之乎热不为汗衰也，故死。又陈远公云∶喘满直视，谵
语下利，一齐同见者不治；若有一证未见者，或可望生。宜用∶人参、麦冬、白芍各一两，石膏五钱、竹茹三钱，名挽
脱汤，欲脱未脱时亟服之，庶几可挽。
三曰∶目不明，热不已者，死。
吴鞠通曰∶目不明，精散而气脱也。经曰∶精散视歧。又曰∶气脱者目不明。热犹未已，仍烁其精而伤其气，不死
得乎！
汪按∶此目不明，乃《难经》所谓脱阴者目盲也。阴竭而热犹不已，安得不死？
四曰∶老人婴儿，热而腹满者，死。
雄按∶腹满者宜泄之，老人婴儿，不任大泄，既不任泄，热无出路，老弱阴液不充之体，涸可立待，故曰死。
五曰∶汗不出，呕，下血者，死。
雄按∶汗不出，热内逼，上乾清道以为呕，迫铄于营而下血，阴液两夺，是为死征。
六曰∶舌烂，热不已者，死。
吴鞠通曰∶阳邪深入，则一阴一阳之火结于血分，肾水不得上济，故舌本烂。热退犹可生，热仍不止，故曰死也。
汪按∶此舌烂乃由肾中虚阳，故断为死候，与肺胃热炽、大热、口舌糜腐者大异。
七曰∶咳而衄，汗不出，出不至足者，死。
吴鞠通曰∶咳而衄，邪闭肺络，上行清道，汗出邪泄可生，不然则化源绝矣。
雄按∶汗出不至足者，肺气不能下及，亦是化源欲绝之征也。
八曰∶髓热者，死。九曰∶热而痉者，死。腰折，螈 ，齿噤 也。
吴鞠通曰∶髓热者，邪入至深，至于肾部也。热而痉，邪入至深，至于肝部也。
○此节历叙热病之死征，以禁人之刺，为刺则必死也。然刺固不可，亦有可药而愈者，盖刺法能泄能通，开热邪之
闭结最速。至于益阴以存津。杨云∶二语乃治温要领。实刺法之所短，而汤药之所长也。
汪按∶统观死候九条，大抵由于阴竭者为多，吴氏语破的。
岐伯说：四肢是诸阳经的根本。阳气亢盛则四肢充实有力，因此能够登上高处。黄帝问：那些脱掉衣服奔跑的人是怎么回事？岐伯说：因为体内热势炽盛，所以想要脱衣并四处奔走。黄帝说：那些胡言乱语、骂人、不分亲疏，并且不想吃东西，因为不想吃东西而胡乱奔走，这是怎么回事？
章虚谷说：四肢的气血禀受于脾胃，胃是脏腑之海，阳明经将气行于三阳经，所以四肢是诸阳经的根本。邪气盛于胃，气实于四肢，所以能登高。热势盛于身体，所以脱衣欲走；邪气扰乱神明，怒气冲动，所以胡言乱语、骂人。胃中邪气壅实，不想饮食，但四肢多力，所以胡乱奔走，这是大承气汤证的病机。如果邪气连及经络，脉象必定滑大，用下法可以生还。如果邪气连及脏腑，脉象必定沉细。张仲景说：阳病见到阴脉者死，那么即使有可下的证候，也不可用下法了。
王士雄按：温病误投热性补药，也会出现这种证候。如果是经证，也有可用白虎汤的情况；脉象沉细，也有因热邪闭塞导致的。形体壮实、证候属实者，用下法可以生还，不能一概以见到阴脉就断定必死。凡是热邪壅遏，脉象多细软迟涩，根据证候清热解表后，脉象自然会变为滑数，这不同于内伤病服用凉药后脉象反而加数的情况（后者为虚证）。
汪氏按：大承气汤证，张仲景说：脉弦者生，脉涩者死。洄溪先生则说：脉弦还有可生的生机，未必都能生还；脉涩则断无不死的可能。我所见到的滑大脉，固然可以直接下法而不必顾忌，也有脉弦兼涩，用下法治愈的。如果有大汗淋漓的情况，可以用白虎汤。
《素问·生气通天论》说：感受暑邪出汗，心烦则喘息有声，安静时则多言多语。
吴鞠通说：暑为火邪，与心同气，心受邪气逼迫，汗出且心烦。“烦”字从火、从页，指心气不安，面部像被火烤一样。喘喝，是因为火克金导致气喘。暑邪遏郁胸中清廓之气，所以想长吁短叹来舒展它。如果邪气不外张，而是内藏于心，则表现为安静。心主言语，暑邪在心，虽然安静也忍不住自言自语。略参拙见。
《素问·刺志论》说：气盛身寒，是伤寒所致；气虚身热，是伤暑所致。
林观子说：虽然说身寒，实际上是指身体发热而言。要用心意去领会。
王士雄按：虽然发热但仍然恶寒，不像伤暑那样恶热，所以说身寒。
吴鞠通说：这是区分伤寒和暑病的依据，经文讲得如此分明，为什么世人全都用治寒的方法来治疗温暑病呢！
王士雄按：不仅寒伤形、暑伤气截然分明，而且寒是阴邪（虽然有红炉暖阁、羔酒狐裘等环境却患火病的人，不能说寒是阳邪，寒邪往往兼夹火邪），暑是阳邪（虽然有贪凉饮冷夹杂阴寒的证候，也是人事不慎造成的兼伤，并非天气的本然属性），这也像水火不相容一样。经文说：天寒地冻，天暑地热。又说：阴阳的升降，寒暑显示出征兆。道理极其明显，无奈后世贤者舍近求远，不觉其立论和用药的错误。
淦氏按：“得之”是推究发病的起始，厘清病因的意思。伤寒和伤暑是《内经》的两大纲领，是从对立面来说的。如果是“春伤于风，夏生飧泄”之类，则是从四季顺序来说的。喻嘉言在《内经》中又补充了伤燥，可见各种邪气感人，都能致病。先圣后贤，论述极为清晰，为什么现在的人治病，不论什么证候，只用伤寒药治疗，而不知道有温、暑、燥、湿这些疾病，真是浅陋啊！
《素问·热论篇》黄帝问：热病已经痊愈，但有时还有余热遗留，是怎么回事？岐伯说：所有病后余热遗留的情况，都是因为热势很盛时勉强进食，所以有余热遗留。像这种情况，都是病情已经衰退但热邪有所潜藏，因为食物之气与残留的热邪相互搏结，两热相合，所以有余热遗留。黄帝问：治疗余热遗留该怎么办？岐伯说：观察虚实，调理逆顺，就可以使病必愈。黄帝问：患热病有什么禁忌？岐伯说：热病稍有好转，吃肉就会复发，多吃就会遗留余热，这就是禁忌。
章虚谷说：这里说的是病初愈，余热留藏在经络气血中未净，因为进食助长正气（或谷气），则两热相合而再次炽盛，所以吃肉病必复发，多吃谷物则邪气遗留，必然缠绵难愈。所以应当忌口，清淡稀粥逐渐调养。
《素问·论疾诊尺篇》说：尺部皮肤灼热，脉象盛大躁急的，是温病。脉象盛大而滑利的，病邪将要外出。
吴鞠通说：经文辨别温病，分明如此，为什么世人全说是伤寒，全都用治疗足三阴经伤寒的方法来治疗呢！张介宾作《类经》，割裂经文，蒙混成章，是因为没有细心推演。尺肤热甚，是火热灼伤精液。脉盛躁，是精气被火热煎熬沸腾。脉盛而滑，是邪气机转向外。
这一节以下是诊断温病的方法。
《素问·平人气象论》说：人一呼脉跳动三次，一吸脉跳动三次且躁急。尺部肌肤热的，是温病；尺部不热而脉滑的，是风病；脉涩的是痹证。
吴鞠通说：呼吸各跳动三次，就是六到七至的脉象，而且气象又躁急。如果尺部肌肤热，就是温病。因为温病必然损伤肺金和肾水二脏的津液，尺脉属肾，尺穴属肺。此处肌肉热，所以知道是温病。如果不热而脉兼滑，就是风病。风邪伤人，阳分先受邪。尺部属阴，所以不热。如果脉动躁急而兼涩，是气有余而血不足，病则为痹证。
《素问·玉版论要》说：患温病而精气极度虚弱的，死。
吴鞠通说：患温病的人，如果精血极度虚弱，就没有阴液来制约温热邪气，所以死。
《素问·热病篇》说：热病三天，气口脉静、人迎脉躁动的，取诸阳经穴位，用五十九刺法，以泻其热，使其出汗，充实阴液，以补其不足。
吴鞠通说：人迎脉躁动，说明邪气在上焦，所以取诸阳经穴位，以泄阳邪，阳气通畅则汗随之而出；充实阴液以补其不足，是因为阳盛则阴衰，泻阳则阴得以安守其位，所以叫充实阴液。泻阳之有余，就是补阴之不足，所以叫补其不足。
王士雄按：用药的道理也是如此。
又说：充实阴液以补其不足，这一句确实是治疗温热病的关键大纲。因为热病没有不耗伤阴液的，耗伤未尽就能生还，耗尽则阳气无所留恋，必然脱失而死。真正能体味这句话，思虑就过半了。
王士雄按：耗伤未尽者，尚有一线生机可望；如果耗尽而阴竭，就像旱季禾苗的根已经枯死，沛然下雨，又有什么帮助呢？
汪氏按：叶天士必定以保津液为要务，仔细考证经文这一条，可知其道理。为什么恣意使用升提温燥的药物，严重损伤津液呢？
身体高热，但寸关尺三部脉都平静的，不要针刺。可以针刺的，要急取穴位，不出汗就用泄法。所谓不要针刺的，是有死征。
热病七天八天，出现气喘且脉弦的，急刺穴位，汗将会自然流出，浅刺手大指间（少商穴）。
吴鞠通说：气喘是肺气实，脉弦是风火鼓荡，所以浅刺手大指间，以泄肺热。肺的热痹开通则汗出。大指间，是肺经的少商穴。
热病七天八天，脉微小，病人尿血，口中干燥，一天半会死；脉代绝的，一天死。
吴鞠通说：邪气深入下焦，逼迫血液从小便出，所以尿血。肾精告竭，阴液不能上潮，所以口中干燥。脉至微小，不仅阴精竭，阳气也随之竭尽，死象自然明显。如果脉实则可以治疗。
热病已经出汗，但脉仍然躁动，气喘且再次发热，不要刺皮肤，气喘严重的会死。
吴鞠通说：热不为汗所减，金受火克，气喘且化源欲绝，所以死。然而间或有可治的。
热病不知疼痛，耳聋，不能自主收摄，口干，阳热甚，阴分颇有寒意的，热在骨髓，死，不可治。
吴鞠通说：不知疼痛，是正气衰弱不与邪气抗争。耳聋，是阴伤精欲脱。不能自主收摄，是正气疲惫。口干、热甚，是阳邪独盛。阴颇有寒，是热邪深入阴分，外虽似寒，而热在骨髓。所以说死，不治。其中有阴精未至涸竭的，间或侥幸得生。略参拙见。
热病已经出汗，但脉仍然躁动得很厉害，这是阴脉的极期，死；如果出汗后脉象平静的，生。
吴鞠通说：汗后脉躁，是阴虚之极，所以说死。然而虽然不可针刺，如果能用甘凉药物浇灌得当，也有得生的。
热病患者脉仍然躁盛，但不能出汗的，这是阳脉的极期，死；脉盛躁，出汗后平静的，生。
吴鞠通说：脉躁无汗，是阳盛之极，阳盛至于极，阴无容留之地，所以也说死。虽然比前文阴阳俱静稍有差别。此证还可以用大剂量的药物急救救阴，也有活着的。即使已经出汗而阳脉躁盛，邪强正弱，正气尚能与邪气抗争，如果留得一分津液，便有一分生理，贵在留之得当！至于阴阳俱静，邪气深入下焦阴分，正气没有抵御邪气的意愿，直接听任邪气所为，不死还等什么？
热病不可针刺的有九种情况：一曰：不出汗，两颧发赤，呃逆的，死。
王士雄按：不出汗，两颧赤，似乎属于阳盛。呃逆，就是打嗝。肺胃之气不降，杨氏按：这是实证，必然颜面赤，不仅两颧赤，则呃呃而上逆。用轻清肃化的药物治疗，病似乎可愈，为什么经文即断定为不可针刺的死候？大概是说热邪正炽盛，而肾阳欲匮乏，阳已无根，病深声音呃逆的证候吧！杨氏按：两颧属肾。发赤是伏藏的阳气上脱，加上呃逆，则证与色合，顷刻而脱，所以不治。那么他的呃逆必然自下焦而升，病由冬天不藏精所致。再察其脉，也必然与上焦阳盛的病有别。
二曰：腹泻且腹部胀满严重的，死。
王士雄按：腹满者应当用泄法，既然已经腹泻而胀满更甚，是邪气尚踞守而阴气下脱，就像热不为汗所减一样，所以死。另外陈远公说：喘满直视，谵语下利，一齐同时出现的，不治；如果有一个证候未见到的，或许有望生还。宜用人参、麦冬、白芍各一两，石膏五钱、竹茹三钱，名为挽脱汤，在欲脱未脱时紧急服用，或许可以挽回。
三曰：眼睛看不见，热势不止的，死。
吴鞠通说：眼睛看不见，是精气涣散而气脱。经文说：精散视歧。又说：气脱者目不明。热势仍未停止，仍在灼伤精气而损伤气，不死还能怎样！
汪氏按：这个目不明，是《难经》所说的脱阴者目盲。阴竭而热仍不止，怎么能不死？
四曰：老人婴儿，发热且腹部胀满的，死。
王士雄按：腹满者适宜用泄法，老人婴儿，承受不住大的泄法，既然不能泄，热无出路，老弱阴液不充的身体，枯竭可以立刻等待，所以说死。
王士雄按：不出汗，热邪内逼，上干清道导致呕吐，迫灼营血导致下血，阴液两夺，这是死征。
六曰：舌烂，热势不止的，死。
吴鞠通说：阳邪深入，则一阴一阳之火结于血分，肾水不得上济，所以舌本烂。热退犹可生，热仍不止，所以说死。
汪氏按：这个舌烂是由肾中虚阳引起的，所以断为死候，与肺胃热炽、大热、口舌糜腐的大不相同。
七曰：咳嗽且鼻出血，不出汗，出汗不到足的，死。
吴鞠通说：咳嗽且鼻出血，是邪闭肺络，上行清道，出汗邪气发泄可生，不然则化源绝矣。
八曰：髓热的，死。九曰：发热且痉挛的，死。腰背反折，抽搐，牙关紧闭。
吴鞠通说：髓热，是邪气入至深处，至于肾部。发热且痉挛，是邪气入至深处，至于肝部。
○这一节历数热病的死征，禁止人们针刺，因为针刺必死。然而针刺固然不可，也有可用药物治愈的，大概针刺法能泄能通，开热邪闭结最快。至于益阴以存津液，杨氏云：这两句话是治疗温病的关键。这是针刺法的短处，而汤药的长处。
汪氏按：统观死候九条，大多由于阴竭，吴氏的话切中要害。
Qibo said: The four limbs are the root of all Yang meridians. When Yang Qi is excessive, the four limbs become solid and strong, thus enabling one to climb high. The Yellow Emperor asked: What causes those who discard their clothes and run? Qibo replied: Because heat is rampant in the body, they wish to discard clothes and run about. The Yellow Emperor asked: What causes those who speak nonsensically, curse, show no respect for kinship or strangers, and do not desire food, leading them to run wildly?
Zhang Xugu stated: The four limbs receive their Qi from the Spleen and Stomach. The Stomach is the sea of the Zang-Fu organs, and the Yangming Meridian circulates Qi through the three Yang meridians; therefore, the four limbs are the root of all Yang meridians. When pathogenic factors are excessive in the Stomach and Qi is solid in the four limbs, one can climb high. Heat rampant in the body causes discarding clothes and running; pathogenic factors disturb the Shen (Spirit), causing anger and impulse, leading to nonsensical speech and cursing. Excess pathogenic factors in the Stomach cause lack of desire for food, while excess strength in the four limbs leads to wild running. This is the syndrome of Dachengqi Tang (Major Order the Qi Decoction). If the pathogen involves the meridians, the pulse will be slippery and large; purgation can lead to survival. If the pathogen involves the Zang organs, the pulse will be deep and fine. Zhang Zhongjing stated: In Yang diseases, if Yin pulses are seen, death occurs. Thus, even if there are indications for purgation, it should not be used.
Wang Shixiong noted: Misadministration of hot tonic medicines in warm diseases can also produce these symptoms. For meridian-stage syndromes, Baihu Tang (White Tiger Decoction) may be applicable; a deep and fine pulse may also result from heat pathogen obstruction. If the physique is robust and the syndrome is excess, purgation can lead to survival; one cannot generally judge inevitable death solely based on the presence of Yin pulses. Whenever heat pathogen is obstructed, the pulse is often fine, soft, slow, or choppy. After clearing heat according to the syndrome, the pulse naturally becomes slippery and rapid. This differs from deficiency cases in internal injuries where taking cooling medicines causes the pulse to become more rapid.
Wang commented: For Dachengqi Tang syndrome, Zhang Zhongjing stated: A wiry pulse indicates survival; a choppy pulse indicates death. Huixi stated: A wiry pulse still holds a chance of survival, though not guaranteed; a choppy pulse implies certain death. I have observed slippery and large pulses where purgation could be used without hesitation, and also wiry pulses combined with choppy qualities that were cured by purgation. In cases of profuse sweating, Baihu Tang (White Tiger Decoction) can be used.
The *Suwen* (Basic Questions), "Shengqi Tongtian Lun" states: Affected by summerheat sweating, vexation leads to panting and loud breathing; in quietness, there is excessive talking.
Wu Jutong explained: Summerheat is a Fire pathogen, sharing the same Qi as the Heart. When the Heart is forced by pathogen, sweating and vexation occur. The character "vexation" (Fan) contains Fire and Page, indicating Heart Qi unrest and a face resembling smelting fire. Panting and loud breathing occur because Fire overcomes Metal (Lung). Summerheat obstructs the clear Qi in the chest, causing a desire to sigh and stretch. If the pathogen does not expand outward but hides internally in the Heart, the patient appears quiet. The Heart governs speech; with summerheat in the Heart, even in quietness, the patient desires to talk incessantly.
The *Suwen*, "Cizhi Lun" states: Qi excess with cold body results from Cold Damage (Shanghan); Qi deficiency with hot body results from Summerheat Damage (Shangshu).
Lin Guanzi stated: Although it says "cold body," it actually refers to fever. One must grasp this through mental comprehension.
Wang Shixiong noted: Although there is fever, there is still aversion to cold, unlike Shangshu which features aversion to heat; hence it is called "cold body."
Wu Jutong stated: This distinguishes Shanghan from Shangshu. The classic text is so clear; why do people treat warm and summerheat diseases with methods for cold diseases?
Wang Shixiong noted: Not only is it distinct that Cold damages the Form and Summerheat damages the Qi, but Cold is a Yin pathogen (even with red stoves, warm rooms, lamb wine, and fox furs, contracting fire disease proves Cold is not a Yang pathogen; Cold often combines with Fire), while Summerheat is a Yang pathogen (even with conditions involving cooling off and drinking cold liquids mixed with Yin-Cold, these are human-caused combined injuries, not the natural state of weather). This is like water and fire not射 (clashing/complementing). The classic states: Heaven is cold, earth freezes; Heaven is hot, earth is warm. It also states: The rise and fall of Yin and Yang manifest in Cold and Summerheat. The logic is extremely clear, yet later scholars seek far when the way is near, unaware of errors in theory and medication.
Gan commented: "Obtained from" traces the origin of illness to clarify etiology. Shanghan and Shangshu are two major outlines in the *Neijing*, discussed from a perspective of opposition. Cases like "Wind damage in Spring generates loose stools in Summer" discuss the four seasons. Yu Jia Yan added "Dryness damage" to the *Neijing*, showing that all Qi pathogens can cause disease. Ancient sages and later scholars have analyzed this clearly. Why do modern practitioners treat all infections with Shanghan medicines, ignoring Warm, Summerheat, Dryness, and Damp diseases? This is ignorant!
The *Suwen*, "Relun Pian" asks: After heat disease subsides, why does residual heat sometimes remain? Qibo replies: Residual heat in all diseases occurs because one forces eating when heat is severe. In such cases, although the disease has declined, heat is hidden. The Qi of grain conflicts with residual heat, combining two heats, causing residual heat. How to treat residual heat? Observe deficiency and excess, regulate reversal and normalcy, and the disease will surely heal. What are the dietary prohibitions for heat disease? When heat disease slightly improves, eating meat causes relapse; overeating causes residual heat. These are the prohibitions.
Ye Tianshi stated: Sweating due to food relapse, labor relapse, or sexual activity relapse will inevitably lead to collapse of Yang Qi and death.
Zhang Xugu explained: This refers to early recovery where residual heat remains in meridians and blood/Qi uncleaned. Food aids Qi, combining with residual heat to reignite. Eating meat causes disease relapse; overeating grains leaves pathogen lingering, making cure difficult. One must guard the mouth, using light, bland, thin porridge for gradual nourishment.
The *Suwen*, "Lunji Chichi Pian" states: Skin at the Chi position is very hot, and the pulse is vigorous and restless; this is Wenbing (Warm Disease). If the pulse is vigorous and slippery, the pathogen is about to exit.
Wu Jutong stated: The classic distinction of Wenbing is clear. Why do people call it Shanghan and treat it with methods for the three Yin meridians of foot Shanghan? Zhang Huiqing's *Leijing* fragmented the classic text, confusing chapters, due to lack of careful deduction. Very hot Chi skin indicates Fire scorching Essence. Vigorous and restless pulse indicates Essence boiling under Fire. Vigorous and slippery pulse indicates pathogen mechanism moving outward.
The following section describes methods for diagnosing Wenbing.
The *Suwen*, "Pingren Qixiang Lun" states: Three beats per exhalation and three beats per inhalation, with restlessness. Hot Chi skin indicates Wenbing; non-hot Chi skin with slippery pulse indicates Fengbing (Wind Disease); choppy pulse indicates Bi Syndrome.
Wu Jutong explained: Six to seven beats per breath cycle with restless imagery. If Chi skin is hot, it is Wenbing. Wenbing injures Jin (Fluids) of Lung Metal and Kidney Water. Chi pulse belongs to Kidney; Chi acupoint belongs to Lung. Heat here indicates Wenbing. Non-hot with slippery pulse indicates Wind. Wind attacks Yang first. Chi is Yin, so it is not hot. Restless and choppy pulse indicates excess Qi and deficient Blood, resulting in Bi Syndrome.
The *Suwen*, "Yuban Lunyao" states: Wenbing with extreme deficiency leads to death.
Wu Jutong explained: In Wenbing, if Jing and Blood are extremely deficient, there is no Yin to overcome Heat, leading to death.
The *Suwen*, "Rebing Pian" states: On the third day of heat disease, if the Qi Kou pulse is calm and the Ren Ying pulse is restless, treat the various Yang meridians using the Fifty-Nine Acupoints needling method to drain heat and induce sweating. Solidify Yin to supplement insufficiency.
Wu Jutong explained: Restless Ren Ying pulse indicates pathogen in the Upper Jiao. Treating Yang meridians drains Yang pathogen;畅通 Yang Qi induces sweating. Solidifying Yin supplements insufficiency because Yang excess leads to Yin decline. Draining Yang allows Yin to settle, thus "solidifying Yin." Draining Yang excess supplements Yin insufficiency.
Wang Shixiong noted: The principle of medication is the same.
It further states: "Solidify Yin to supplement insufficiency" is the crucial outline for treating warm-heat diseases. Heat diseases always consume Yin. If consumption is incomplete, life is possible; if complete, Yang has no attachment and collapses, leading to death. Truly understanding this phrase covers half the treatment logic.
Wang Shixiong noted: If consumption is incomplete, there is a glimmer of hope. If exhausted and Yin is depleted, it is like dry seedlings with dead roots. Even heavy rain would not help.
Wang commented: Ye Tianshi emphasized preserving Jin (Fluids). Examining this classic passage reveals the rationale. Why use ascending, warming, and drying drugs recklessly, severely injuring fluids?
If body heat is severe but both Yin and Yang pulses are calm, do not needle. For those suitable for needling, act quickly; if no sweat, use draining methods. "Do not needle" indicates signs of death.
Wu Jutong stated: Yang syndrome with Yin pulse means do not needle.
On the seventh or eighth day of heat disease, if panting and wiry pulse appear, urgently needle; sweat will self-emerge. Superficially needle between the thumb and index finger.
Wu Jutong explained: Panting indicates Lung Qi excess; wiry pulse indicates Wind and Fire agitation. Superficial needling between the thumb (Shaoshang point) drains Lung heat. Opening Lung heat-bi induces sweating.
On the seventh or eighth day, if pulse is minute and small, urine blood occurs, and mouth is dry, death occurs within 1.5 days. If the pulse is intermittent (Dai), death occurs in one day.
Wu Jutong explained: Pathogen enters Lower Jiao, forcing blood out via urine (hematuria). Kidney Essence is exhausted, Yin fluids cannot ascend, causing dry mouth. Minute/small pulse indicates not only Yin Essence exhaustion but also Yang Qi depletion, clearly indicating death. If the pulse is solid, it is treatable.
After sweating in heat disease, if the pulse remains restless, panting recurs, and fever returns, do not needle the skin. Severe panting indicates death.
Wu Jutong explained: Heat not reduced by sweat indicates Metal受克 by Fire. Panting suggests source of transformation is failing, leading to death. However, some cases are treatable.
In heat disease, if the patient feels no pain, is deaf, cannot control movements, has a dry mouth, intense Yang heat, yet significant Yin cold sensation, the heat is in the marrow. This is incurable and fatal.
Wu Jutong explained: No pain indicates weak Zheng Qi unable to fight pathogen. Deafness indicates Yin injury and Essence depletion. Inability to control movements indicates exhausted Zheng Qi. Dry mouth and intense heat indicate solitary Yang pathogen excess. Significant Yin cold indicates pathogen deeply entered Yin division; external cold is apparent, but heat is in marrow. Hence, death/incurable. Cases where Yin Essence is not completely depleted may rarely survive.
If after sweating, the pulse remains extremely restless, this is the extreme of Yin pulse, indicating death. If pulse becomes calm after sweating, survival is indicated.
Wu Jutong explained: Restless pulse after sweat indicates extreme Yin deficiency, hence death. Although needling is contraindicated, proper administration of sweet-cool medicines may save the patient.
If pulse is vigorous and restless without sweat in heat disease, this is the extreme of Yang pulse, indicating death. If pulse is vigorous/restful but becomes calm after sweating, survival is indicated.
Wu Jutong explained: Restless pulse without sweat indicates extreme Yang excess. Extreme Yang leaves no room for Yin, hence death. This differs slightly from Yin-Yang both calm. This condition can still be treated with large doses of urgent Yin-nourishing medicine, potentially saving the patient. Even with sweat, if Yang pulse is vigorous, pathogen is strong and Zheng Qi weak, but Zheng Qi still fights. Retaining one part of fluid retains one part of life. Crucial is retaining fluids properly. If Yin-Yang are both calm, pathogen enters Lower Jiao Yin division, Zheng Qi has no defense intent, leaving fate to pathogen; death is inevitable.
There are nine conditions in heat disease where needling is contraindicated:
1. No sweat, red cheeks, and hiccups indicate death.
Wang Shixiong noted: No sweat and red cheeks suggest Yang excess. Hiccups (E'ni) result from failure of Lung and Stomach Qi to descend. Yang commentary: This is an excess syndrome, causing facial redness, not just cheeks, leading to upward rebellion. Light, clear, resolving agents might cure it, yet the classic deems it incurable. Perhaps it means Heat pathogen is blazing while Kidney Yang is failing, Yang has no root, and deep disease manifests as hiccups. Yang commentary: Cheeks belong to Kidney. Redness indicates floating Yang escaping upward. Combined with hiccups, syndrome and color match, indicating imminent collapse, hence incurable. Hiccups likely rise from Lower Jiao, caused by Winter failure to store Essence. Pulse would differ from Upper Jiao Yang excess.
2. Diarrhea with severe abdominal fullness indicates death.
Wang Shixiong noted: Abdominal fullness requires draining. If diarrhea occurs but fullness worsens, pathogen remains while Yin collapses downward, similar to heat not reducing with sweat, hence death. Chen Yuan Gong stated: Panting, fullness, fixed gaze, delirium, and diarrhea appearing together are incurable. If any symptom is absent, survival is possible. Use Renshen (Ginseng Root), Maidong (Ophiopogon Tuber), Baishao (White Peony Root) each 30g, Shigao (Gypsum Fibrosum) 15g, Zhuru (Bambusae Caulis in Recens) 9g, named Wantuo Tang (Rescue Collapse Decoction). Administer urgently when collapse is impending.
3. Blindness with persistent heat indicates death.
Wu Jutong explained: Blindness indicates scattered Essence and collapsing Qi. Classic states: Scattered Essence causes diplopia. Collapsing Qi causes blindness. Persistent heat continues to scorch Essence and injure Qi, leading to death.
Wang commented: This blindness corresponds to "Depletion of Yin causes blindness" in *Nanjing*. Yin exhaustion with persistent heat leads to death.
4. Elderly and infants with heat and abdominal fullness indicate death.
Wang Shixiong noted: Abdominal fullness requires draining. Elderly and infants cannot tolerate strong draining. Without drainage, heat has no outlet. Bodies lacking Yin fluids in old age/weakness will dry up immediately, hence death.
5. No sweat, vomiting, and lower bleeding indicate death.
Wang Shixiong noted: No sweat forces heat inward. Upward invasion of clear pathways causes vomiting. Pressing/scorching Ying Blood causes lower bleeding. Dual loss of Yin fluids indicates death.
6. Tongue ulceration with persistent heat indicates death.
Wu Jutong explained: Deep Yang pathogen causes Fire of Yin and Yang to knot in Blood division. Kidney Water fails to ascend, causing tongue base ulceration. If heat subsides, survival is possible; persistent heat indicates death.
Wang commented: This tongue ulceration stems from deficient Yang in Kidney, deemed incurable, differing greatly from Lung/Stomach blazing heat with oral ulcers.
7. Cough with epistaxis, no sweat, or sweat not reaching feet indicates death.
Wu Jutong explained: Cough and epistaxis indicate pathogen closing Lung collaterals, invading clear pathways. Sweat allowing pathogen exit leads to survival; otherwise, source of transformation fails.
Wang Shixiong noted: Sweat not reaching feet indicates Lung Qi failing to descend, also a sign of failing source of transformation.
8. Marrow heat indicates death.
9. Heat with spasms indicates death. Back arching, convulsions, and teeth grinding.
Wu Jutong explained: Marrow heat indicates pathogen entering deepest level, reaching Kidney. Heat with spasms indicates pathogen entering deepest level, reaching Liver.
This section lists death signs of heat disease to prohibit needling, as needling ensures death. However, while needling is contraindicated, drug therapy may cure. Needling drains and unblocks, opening heat closure fastest. Nourishing Yin to preserve fluids is key. Yang commentary: These two phrases are the essence of treating warmth. This is the weakness of needling and the strength of decoctions.
Wang commented: Reviewing the nine death conditions, most stem from Yin exhaustion. Wu Shi's words hit the mark.