半里。或问曰∶阳明亦有寒热往来者,何意?曰∶若阳明经病,邪在肌肉则身发热,
焉有寒热往来。已传阳明之腑,郁热熏蒸,结粪在内,故寒热或往或来,是阳明之腑,
非阳明之经,当用调胃承气汤攻之。(调胃承气硝黄草,甘暖微和将胃保,不用朴实伤上焦,中焦燥
实服之好。)故云∶阳明内实,故寒热往来耳。
头汗 或问头汗为半表半里者,盖以诸阳经脉络上至头则有汗,诸阴经脉络系
背至颈而还,焉得有头汗,故一见头汗即属半表半里。或问曰∶既诸阳脉上至头,今
汗出当云表证,何以为半表半里?曰∶若表证尚有寒邪闭塞,焉能有汗,今既有汗,
是寒邪将化为热。名曰里证,则头有汗,名曰表证,则头无汗;故云半表半里。又曰∶
瘀血水气发黄,亦有头汗者何也?夫瘀血头汗,小便自利;水气头汗,胸满咳呕;发
黄头汗,小便不利。若半表半里头汗,必往来寒热也。然三证头汗,皆未离乎阳,可见头汗属半表半里也。
盗汗 或问盗汗何为半表半里?曰∶夫热邪熏灼腠理,使人有汗,寒则腠理闭密,
无汗是里,当出汗不止,今汗在睡而出,觉而收,乃邪将旺于阴分,独未深入于阴,亦
属半表半里。又问曰∶杂证盗汗亦作半表半里治乎?曰∶杂证盗汗,乃阴虚至极,血
分亏损,名劳怯之证。今伤寒盗汗,乃有
余之邪,名曰外感,非杂证一例论也。
目眩口苦 或问目眩口苦,何以是半表半里?曰∶目者肝之窍,胆汁藏于肝,病
在少阳胆经,故目眩口苦者,胆之汁也,热泄胆汁故口苦,二者是少阳胆经病。半表
半里,法宜和解,至于他经,便无此证。
以上俱邪在半表半里,当和解。
脉沉有力 或问脉沉有力,何以是传经里证?曰∶夫脉存则生,脉绝则死,太
过不及则病,内实则脉实,内虚则脉虚。今沉者病脉也,主病在里,有力者实也,主
病为热,今脉沉有力,是里实且热也。
下利清黄水 或问下利清黄水,何为里证?曰∶盖肠胃因久失下,致燥粪结实
成块,则清黄水下漏魄门,如物之聚而结实者,水液不能渗漏,物坚如磊石者,沃
之水必渗漏矣。今病者下利清黄水,粪结如磊石在内,此水从结粪旁流走而出,急
下之无疑。往往以直中下利清谷者,为漏底伤寒,若误认此证为漏底,投以四逆,如
抱薪救火,殆哉!故下利清黄水,是里证,当急下之。
小腹满 小腹满者胡为里证?曰∶夫胸膈属清阳之分,虽胀满是邪气而非有物,
小腹乃糟粕之区,若胀满非邪气也,故知有物急下之。又曰∶瘀血证及溺涩证者,亦
少腹胀满,何以别之?凡小便自利,小腹硬满而痛者,此瘀血证也。小便不利而少
腹胀满者,即溺涩不通也。若小便短赤,大便秘结,致小腹硬者,乃内有燥粪,故尔
满也。即瘀血溺涩,皆是里证。
谵语发狂 谵语发狂为里证者,盖热实于胃,热极故发狂,轻则令人谵语,皆
是传经里证。《难经》曰∶发狂谵语,乃实热阳盛所使。经言有虚有实何也?曰∶惊
狂属虚。或当汗不得汗,火迫致狂,名曰火邪惊狂,当用柴胡龙骨牡蛎之类。非若实热发狂可下也。
发斑 或问发斑亦里证耶?曰∶斑有温毒,有热毒,有胃烂。温毒者,即冬受
寒,至春阳与阴气相搏而发者是也。热毒者,是暑气伏胃,因遇寒而发者是也。胃
烂者,或误下而热乘虚入胃,或失下而热不得外泄,毒瓦斯入胃深极也。故斑者毒也,
毒者乖戾失常,偏阴偏阳之至也。外因六气相感,胃有热毒熏蒸,胃主肌肉,热甚
伤血,里实表虚,故令周匝遍体,状如蚊啮。红赤者生,紫黑者死,以热极而胃烂
也。舌苔唇裂者不治,治当解毒清凉,不可表药取汗。盖表虚里实,发汗则益令开
泄,更增斑烂矣。又问阴证,亦有发斑者何也?曰∶或因汗吐下后,中气虚乏,或
因俗事耗损真阳,或因过服凉药,遂成阴证,寒伏于下,逼其无根失守之火,上熏
肺胃而发斑点,其色淡红,隐隐见于肌表,与阳证发斑色紫赤者不同,此胃气极虚,若
服凉药立见危殆。吴鹤皋曰∶以参 桂附而治斑,法之变也,医不达权安足语此。又
问曰∶内伤亦有发斑者,何也?曰∶内伤元气不足之病,因气血两虚,亦身痛心烦
作热,但脉虚大,懒于言动,倦怠自汗为异耳。若妄作外感有余治,立见倾危。速
进补中益气汤,熟眠热止自愈。丹溪曰∶内伤发斑者,胃气极虚,一身之火,游行于
外,宜补以降之,大建中汤最佳。(参 归芍炙草,半夏桂附加姜枣,水煎服。)若内有伏阴,误服
凉药,逼其虚阳浮散于外,而为阴斑。脉虽洪大,按之无力,或手足逆冷过肘膝者,
先用炮姜理中汤,以复其阳,次随证治,不应加附子。
转矢气 或问转矢气,何以是里证?曰∶言其气下泄也,观无病患将欲大便,必
先气泄,病者内有燥粪,结而不通,则气必下失。阳明篇云∶若不转矢气者,不可
投承气汤,是知转矢气属里矣。
头痛发热俱止 头痛发热俱止,是里也。邪之国中,始于太阳,太阳为表之表,
头痛发热,俱多少阳、阳明,为表之中,亦头痛发热。若邪入里,必表证尽除,焉得头痛发热乎?
自汗 自汗何为里证?经云∶寒则腠理闭塞,热则腠理开疏,太阳始受寒邪,未
化为热,腠理致密无汗,当用麻黄汤。始无汗忽变为有汗者,知热已入腑,熏蒸鼎
沸,故自汗为里证。假寒在表,焉有汗乎?或问自汗为里,有用桂枝汤又何故?盖自
汗用桂枝汤者,乃太阳伤风证,夫里证自汗为阳盛,孰敢用桂枝。仲景云∶桂枝下
咽,阳盛则毙。别之奈何?淅淅然恶风,头痛发热,悉具者,太阳伤风自汗也;烦躁
恶热,不恶风寒者,里证自汗也。
小便多 或问小便多者,何为里证?曰∶盖饮食入胃,由胃传于小肠。经曰∶小
肠者受盛之官,胃司水谷,清浊不分,一概混受,由小肠而下,则有膀胱与大肠,清
者从溺渗入膀胱,糟粕从胃之下口传于大肠,膀胱窍闭,水入大肠,必作泄泻。若
大便坚闭,津液走前,则小便频数。今小便多者,大便闭结,故证属里也。小便若
少,大便虽闭,水液不久浸入大肠,当先硬满而后溏泄矣。仲景云∶小便少者不可攻,以其不久,当自便也。
潮热 或问潮热,何以是里证?曰∶潮热者,如潮水之汛,不失其期。如今日发
于未申,至明日仍发于未申,盖未申时属阴,今见潮热,是邪居阴分,热结在里,熏
灼结粪当下之。又问曰∶潮热属里故当下,犹有表证,何以治之?曰∶已有潮热尚兼表证未退,必先解表,
然后攻里,乃为当耳。
下利肠垢 或问下利肠垢,何以是里?曰∶下利出于肠胃,若表有邪则里和,焉
得下利!因邪入腑,热灼肠胃,致有此证。又曰∶表证亦下利否?曰∶三阳合病则有
下利,或少阳阳明合病,阳明者内主胃腑,故有下利。三阳合病,若不入腑,又无下
利,何者为辨?但有发热及诸表证耳,下利固为里证,又当分传中,传经则肠垢,直
中则清谷,二者下利以肠垢清谷为异耳。
恶热 或问恶热,何以是里证?曰∶热
传脏腑,熏蒸烦冤,揭去衣被,扬手露体,此热传里也。若有寒在内则恶寒,焉有恶热之理。
目不明 或疑目不明以为里者,何解?曰∶目系五脏精华,五脏属阴,阴居于里,
故云在里。况瞳人属肾,内热灼极,则肾水枯涸,不能照物,譬之炎天热甚,致目
昏蔽,当速下之,以救肾家将绝之水。设谓此证属虚,误投热药,害岂浅鲜哉。
腹痛 或问腹痛,何以属里?曰∶尝考坤为腹,乃纯阴也,谓之曰阴,则腹痛
非表明甚。若腹未痛而胸前痛者,邪未深入,尚作半表半里证。今腹痛知邪已传腑
矣。曰∶既腹痛属里,当投大黄,又用桂枝者何意?曰∶或太阳证误下致腹痛,尚
有微表未解,或太阴里证而脉带浮者,故用桂枝大黄,令表里两解,然腹痛虽属里,
又有传经直中之分,须慎之。
不眠 或问不眠,何以见里证?曰∶盖热邪入腑,令人烦躁不安。若寒盛为直中,
则属阴,阴主静,静则多眠,又岂能不眠。又问∶不得眠固属传经里证,有投寒药愈
盛者何故?此乃汗、吐、下后证也。名曰∶津液内竭不得眠,必心蕴虚烦,脉未浮弱
者,当用真武汤及酸枣仁汤。而里证不眠者,则烦躁口渴不已,脉必有力,故知之。
手足心腋下有汗 手足心及腋下出汗为里证者,盖人身诸背属阳,诸腹属阴,手
足掌心腋下皆属阴地,五脏经络所系,热邪熏蒸脏腑,致掌中腋下汗出。若掌中腋
下未滋润者,邪尚在表,未入里,即谓之表病里和。今掌心腋下有汗,知大便已硬,当急下之,为里证无疑。
嗌干齿燥 或问嗌干齿燥,何以属里?曰∶夫咽为胃之路,齿乃骨之余,今嗌干
者腑热盛也,齿燥者热灼骨也,骨与胃非里乎?或问曰∶内热甚当咽痛,寒证亦咽
痛何也?盖直中之寒为咽痛,必下利清谷,四肢厥逆,此乃寒极而成反致咽痛,与之
水则不欲咽,不若传经嗌干齿燥,极喜饮
水耳。
以上俱传经里证当攻里。
脉沉细无力 或问脉沉细无力,何以是直中寒证?曰∶盖元气固于一身,畅于
四肢,热则脉数,寒则脉迟定理也。沉者阴也,无力者虚也,是寒中阴经,阳气衰
微,故脉不能有力。假内有热,脉必实而且滑,安得无力?若脉无力,即为寒为虚
为直中耳。外虽有表证,或大热之证,不敢用攻里及发表药,若不凭脉而概投麻黄,令重虚其虚,欲救晚矣。
背恶寒 或问背恶寒,如何是直中?曰∶阴邪入于阳分,阴盛阳衰,当用附子
理中汤。或曰∶阳明腑病,背亦恶寒何也?曰∶夫阳明腑病背恶寒者,外无寒证,必
见口渴烦躁,背属阳,阳热内陷入腑,则背空虚,致微恶寒,故用白虎汤。若口中
和者正属直中寒证,又孰敢用白虎耶!总之,渴则内有热,不渴则内有寒也。
呕吐清涎沫 或问呕吐涎沫,何以为直中?曰∶胃腑有寒热,必先现涎沫。《内
经》云∶诸呕吐酸水及水液混浊者,皆属于热;诸病吐涎及澄沏清冷者,皆属于寒。
如天寒则水清,天热则水浊之意,若有热有火在胃脘之间,自烧耗津液,以致口渴,化为酸浊之水,又安得有清涎沫乎!
四肢厥逆 或问四肢厥逆,何为直中寒证?曰∶盖四肢属阳,寒邪属阴,阳衰
阴盛,故发厥过乎肘膝,况肘膝乃人之四关,今寒过之是为直中。脉沉迟无力者,急
温之。或问又有阳厥者何也?此物极则反,虽厥指甲尚温,不似寒厥冷极,外证必口
渴烦躁恶热,小便短赤,大便或闭或下利肠垢,脉必沉实有力,但有一证,即以为别。
多眠 或问多眠何以属直中?曰∶阴盛则静,静则使人多眠。若传经热证则属
阳,阳主动,焉得多眠。又云∶表证亦有多眠者何说?曰∶表证是感邪深重,必头
痛发热,方为表证多眠,若传经里证,则
烦躁恶热,揭去衣被,甚则谵语发狂,又何能多眠也!总之,多眠非直中寒证,即是表证矣。
干呕 或问干呕,何以是阴寒证?曰∶盖寒郁中脘,阳气不舒,欲吐不吐,名曰
干呕。若有热在内,则吐出物或呕酸苦水,便无此证。或谓太阳、少阳、水气亦令人
干呕何也?曰∶太阳干呕,头痛发热,少阳干呕,胸满胁痛,水气干呕,咳引胁下
痛,惟直中干呕,则外无一毫表证,必见下利清谷,面惨洒淅,及诸寒证。然太阳、少阳、水气三者干呕,究未
离乎寒也。
下利清谷 或问下利清谷,何以是直中寒证?夫寒邪居内则水谷不化。经云∶食
下即化腐臭而出者,是有火也,食下不化完谷而出者,是有寒也。又云∶天寒则水
清,天热则水浊。《病机》云∶诸水液澄沏清冷者,皆属乎寒。今下利清谷,非寒而
何?若传经热证,便下利肠垢,而不下利清谷矣。
吐蛔 或问吐蛔,何为直中?曰∶蛔得热则安,遇寒则泛吐蛔,必膈上有寒也。
投以凉药则逆,当急温之。又问曰∶倘外大热证而吐蛔,亦禁用寒凉药否?曰∶如
乌梅理中丸,系安蛔药也。皆用附子、干姜,虽有热证,必先安蛔而后可治。他证不然,膈上虚寒,犯之必危。
蜷卧 或问蜷卧何为直中?曰∶热则舒畅流通,何有蜷卧,试观常人冬月独卧,
寒极必蜷卧,天气稍暖,则手足伸舒,卧便自如。曰∶阳经表证,亦有蜷卧者,寒
耶?热耶?曰∶阳经蜷卧,表中寒深故也。须大发表,分别在有头痛发热及诸表证,乃
是阳经蜷卧。盖阴经蜷卧,则无一毫表证。
囊缩 或问囊缩,何以属直中者?曰∶盖热主流通,寒则敛缩,且直中寒证,乃
阴盛阳衰,不能温其下,故令阴囊收缩。如常人遇冬,睾丸反隐于上,此寒盛也;遇
夏睾丸下垂,此阳盛也。然《指掌》以囊缩用承气者何意?曰∶厥阴者肝也,肝主
筋膜,若次第传至厥阴,六经已尽,邪气盛者,致筋急舌卷如中风状,而囊为之敛
搐,以筋聚于阴器故也。非似直中曰隐曰缩。夫《指掌》以囊缩当下者,必口渴烦
半表半里。有人问:阳明病也有寒热往来的情况,这是什么意思?回答说:如果是阳明经病,邪气在肌肉层面,身体会发热,怎么会有寒热往来呢?如果已经传入阳明的腑(六腑之一,指胃、大肠、小肠等),郁积的热气熏蒸,燥屎结聚在肠道内,所以出现寒热交替往来的症状。这是阳明的腑病,而不是阳明经病,应当使用调胃承气汤来攻下。(调胃承气汤由芒硝、大黄、甘草组成,药性甘温微和,能保护胃气,不用厚朴、枳实以免损伤上焦,中焦燥实证服用效果良好。)所以说:因为阳明内部结实,所以出现寒热往来。
头汗。有人问:为什么头汗属于半表半里?大概是因为所有阳经的脉络都上行至头部,所以有汗出;而所有阴经的脉络系于背部,上行至颈部即返回,怎么会有头汗呢?所以一见头汗就归属于半表半里。又问:既然诸阳脉都上行至头,现在出汗应该说是表证,为什么说是半表半里?回答说:如果是表证,还有寒邪闭塞腠理,怎么能有汗出?现在既有汗出,说明寒邪将要化为热邪。如果命名为里证,则头部有汗;如果命名为表证,则头部无汗;所以说属于半表半里。又说:瘀血、水气发黄,也有出现头汗的情况,为什么呢?瘀血导致的头汗,小便通畅自如;水气导致的头汗,胸部胀满、咳嗽呕吐;发黄导致的头汗,小便不利。如果是半表半里的头汗,必然伴有寒热往来。然而这三种情况的头汗,都没有脱离阳证的范畴,可见头汗属于半表半里。
盗汗。有人问:盗汗为什么属于半表半里?回答说:热邪熏灼腠理,使人出汗,寒冷时腠理闭密,不出汗,这属于里证。现在汗出是在睡觉时发生,醒来后停止,这是因为邪气将在阴分旺盛,但尚未深入阴分,也属于半表半里。又问:杂病中的盗汗也按照半表半里来治疗吗?回答说:杂病的盗汗,是阴虚到了极点,血分亏损,称为劳怯之证。现在的伤寒盗汗,是有余的邪气,称为外感,不能与杂病一例而论。
目眩口苦。有人问:目眩口苦,为什么是半表半里?回答说:眼睛是肝的窍道,胆汁藏于肝,病在少阳胆经,所以目眩口苦,是胆液外泄的表现,热邪迫使胆汁外泄所以口苦,这两者都是少阳胆经的病。半表半里,治法适宜和解,至于其他经络,就没有这种症状。
以上都属于邪在半表半里,应当采用和解法。
脉沉有力。有人问:脉象沉而有力,为什么是传经入里的证候?回答说:脉象存在则生,脉象断绝则死,太过或不及都会生病,内部充实则脉实,内部虚弱则脉虚。现在脉沉是病脉,主病在里,脉有力表示实证,主病为热。现在脉沉有力,说明里实且热。
下利清黄水。有人问:下利排出清稀黄水,为什么是里证?回答说:肠胃因为久未通下,导致燥屎结块成团,于是清稀黄水从肛门漏出。就像物体聚集结实一样,水液无法渗透;如果物体坚硬如磊石,浇灌水液必然会渗漏。现在病人下利清黄水,粪结如磊石在内,这是水液从结粪旁边流走而出,必须急下,毫无疑问。往往有人将直中寒证的下利清谷,误认为是漏底伤寒,如果错误地将此证认作漏底,投用四逆汤,如同抱薪救火,危险啊!所以下利清黄水,是里证,应当急下。
小腹满。小腹满胀,为什么是里证?回答说:胸膈属于清阳之分,虽然胀满是邪气而非有形之物;小腹乃糟粕积聚的区域,如果胀满不是邪气,而是有形之物,所以知道有物积聚,应当急下。又说:瘀血证及小便涩滞证,也会出现少腹胀满,如何区别它们?凡是小便自利的,小腹硬满且疼痛的,这是瘀血证。小便不利而少腹胀满的,就是小便涩滞不通。如果小便短赤,大便秘结,导致小腹硬满的,乃是内有燥屎,所以胀满。即使是瘀血和小便涩滞,也都属于里证。
谵语发狂。谵语发狂属于里证,是因为热邪结实于胃,热极所以发狂,轻则让人说胡话(谵语),这都是传经入里的证候。《难经》说:发狂谵语,是由实热阳盛引起的。经文说有虚有实,为什么呢?回答说:惊狂属于虚证。或者应当发汗却未能发汗,用火疗逼迫导致发狂,称为火邪惊狂,应当使用柴胡龙骨牡蛎汤之类。不像实热发狂可以用攻下法。
发斑。有人问:发斑也是里证吗?回答说:斑有温毒、热毒、胃烂三种。温毒,是指冬天感受寒邪,到春天阳气与阴气相搏激而发作的。热毒,是指暑气伏留于胃,因遇到寒气而发作的。胃烂,或者是误用下法导致热邪乘虚进入胃中,或者是失于攻下导致热邪不得外泄,毒瓦斯深入胃中至极点。所以斑就是毒,毒就是乖戾失常,偏阴偏阳至极的状态。外因六气相感,胃有热毒熏蒸,胃主肌肉,热甚伤血,里实表虚,所以令周身遍体,状如蚊虫叮咬。红色者生,紫黑色者死,因为热极而导致胃烂。舌苔干裂、嘴唇破裂的不治,治疗应当解毒清凉,不可用解表药取汗。因为表虚里实,发汗则会更加开泄,更增加斑烂。又问:阴证,也有发斑的情况,为什么呢?回答说:或者是因为汗、吐、下之后,中气虚乏,或者因为世俗琐事耗损真阳,或者因为过服凉药,遂成阴证,寒邪伏于下部,逼迫其无根失守之火,向上熏蒸肺胃而发斑点,颜色淡红,隐隐见于肌表,与阳证发斑色紫赤者不同,这是胃气极虚,如果服用凉药立刻就会见到危殆。吴鹤皋说:用人参、肉桂、附子来治疗斑,是治法的变通,医生如果不通达权变,怎么能够谈论这个。又问:内伤也有发斑的情况,为什么呢?回答说:内伤是元气不足的病,因为气血两虚,也会身体疼痛、心烦发热,只是脉象虚大,懒于言语动作,倦怠自汗作为区别罢了。如果妄自作外感有余来治疗,立刻就会见到倾覆危险。迅速进服补中益气汤,熟睡后热止自愈。丹溪说:内伤发斑,是胃气极虚,一身之火游行于外,应当补益以降火,大建中汤最佳。(人参、当归、白芍、炙甘草,半夏、肉桂、附子加生姜、大枣,水煎服。)如果内有伏阴,误服凉药,逼迫其虚阳浮散于外,而为阴斑。脉象虽洪大,按之无力,或者手足逆冷超过肘膝的,先用炮姜理中汤,以恢复其阳气,其次随证治疗,无效再加附子。
转矢气。有人问:转矢气(放屁),为什么是里证?回答说:说的是气体向下排泄。观察没有病患想要大便时,必定先排气,病人内有燥屎,结聚不通,那么气必定向下流失。阳明篇说:如果不转矢气的,不可以投用承气汤,由此可知转矢气属于里证。
头痛发热俱止。头痛发热同时停止,说明病在里。邪气在国中(体内),始于太阳,太阳为表之表,头痛发热,多少涉及少阳、阳明,为表之中,也见头痛发热。如果邪气入里,必然表证全部消除,哪里还会有头痛发热呢?
自汗。自汗为什么是里证?经文说:寒冷则腠理闭塞,热则腠理开疏。太阳刚开始受寒邪,未化为热,腠理致密无汗,应当用麻黄汤。开始无汗忽然变为有汗的,知道热已入腑,熏蒸鼎沸,所以自汗为里证。假如有寒在表,哪里有汗呢?有人问:自汗属于里证,有用桂枝汤的,又是什么缘故?回答说:自汗用桂枝汤的,乃是太阳伤风证。里证自汗为阳盛,谁敢用桂枝?仲景说:桂枝下咽,阳盛则毙。如何区别呢?淅淅然恶风,头痛发热,全都具备的,是太阳伤风自汗;烦躁恶热,不恶风寒的,是里证自汗。
小便多。有人问:小便多的,为什么是里证?回答说:饮食进入胃,由胃传导至小肠。经文说:小肠是受盛之官,胃主管水谷,清浊不分,一概混受,从小肠而下,则有膀胱与大肠,清者从溺渗入膀胱,糟粕从胃之下口传于大肠,如果膀胱窍闭,水进入大肠,必然造成泄泻。如果大便坚闭,津液走前阴,则小便频数。现在小便多的,是大便闭结,所以证属里。如果小便少,大便虽闭,水液不久浸入大肠,应当先硬满而后溏泄了。仲景说:小便少的不可攻下,因为不久,应当自行排便。
潮热。有人问:潮热,为什么是里证?回答说:潮热,像潮水的涨落,不失其期。比如今天发生在未时申时,到明天仍然发生在未时申时,盖未申时属阴,现在见到潮热,是邪气居于阴分,热结在里,熏灼结粪,应当攻下。又问:潮热属于里故当攻下,如果还有表证,怎么治疗?回答说:已有潮热尚兼表证未退,必须先解表,然后攻里,才是恰当的。
下利肠垢。有人问:下利肠垢,为什么是里证?回答说:下利出于肠胃,如果表有邪气则里气和,怎么会有下利!因为邪气入腑,热灼肠胃,导致有此证。又说:表证也有下利吗?回答说:三阳合病则有下利,或者少阳阳明合病,阳明者内主胃腑,所以有下利。三阳合病,如果不入腑,又没有下利,如何辨别?只要有发热及诸表证而已,下利固然是里证,又应当分传中和直中,传经则下利肠垢,直中则下利清谷,这两种下利以肠垢和清谷为区别。
恶热。有人问:恶热,为什么是里证?回答说:热邪传脏腑,熏蒸烦冤,揭去衣被,扬手露体,这是热邪传里。如果有寒在内则恶寒,哪有恶热的道理。
目不明。有人怀疑目不明以为里证,怎么解释?回答说:眼睛汇聚五脏精华,五脏属阴,阴居于里,所以说在里。况且瞳人属肾,内热灼极,则肾水枯涸,不能照物,譬如炎天热甚,导致目昏蔽,应当速下,以救肾家将绝之水。如果说此证属虚,误投热药,害处难道浅显吗?
腹痛。有人问:腹痛,为什么属里?回答说:曾经考证坤为腹,乃纯阴也,称之为阴,则腹痛非表明甚矣。如果腹部未痛而胸前痛,邪气未深入,尚作半表半里证。现在腹痛,知道邪气已传腑了。说:既然腹痛属里,应当投用大黄,又用桂枝是什么意思?回答说:或者太阳证误下导致腹痛,尚有微表未解,或者太阴里证而脉带浮者,所以用桂枝大黄,令表里两解,然而腹痛虽属里,又有传经直中之分,须谨慎。
不眠。有人问:不眠,为什么能见到里证?回答说:热邪入腑,令人烦躁不安。如果寒盛为直中,则属阴,阴主静,静则多眠,又岂能不眠。又问:不得眠固属传经里证,有投寒药愈盛者何故?此乃汗、吐、下后证也。名曰:津液内竭不得眠,必心蕴虚烦,脉未浮弱者,当用真武汤及酸枣仁汤。而里证不眠者,则烦躁口渴不已,脉必有力,故知之。
手足心腋下有汗。手足心及腋下出汗为里证者,盖人身诸背属阳,诸腹属阴,手足掌心腋下皆属阴地,五脏经络所系,热邪熏蒸脏腑,致掌中腋下汗出。若掌中腋下未滋润者,邪尚在表,未入里,即谓之表病里和。今掌心腋下有汗,知大便已硬,当急下之,为里证无疑。
嗌干齿燥。有人问:嗌干齿燥,为什么属里?回答说:夫咽为胃之路,齿乃骨之余,今嗌干者腑热盛也,齿燥者热灼骨也,骨与胃非里乎?或问曰:内热甚当咽痛,寒证亦咽痛何也?盖直中之寒为咽痛,必下利清谷,四肢厥逆,此乃寒极而成反致咽痛,与之水则不欲咽,不若传经嗌干齿燥,极喜饮水耳。
以上俱传经里证当攻里。
脉沉细无力。有人问:脉沉细无力,为什么是直中寒证?回答说:盖元气固于一身,畅于四肢,热则脉数,寒则脉迟定理也。沉者阴也,无力者虚也,是寒中阴经,阳气衰微,故脉不能有力。假内有热,脉必实而且滑,安得无力?若脉无力,即为寒为虚为直中耳。外虽有表证,或大热之证,不敢用攻里及发表药,若不凭脉而概投麻黄,令重虚其虚,欲救晚矣。
背恶寒。有人问:背恶寒,如何是直中?回答说:阴邪入于阳分,阴盛阳衰,当用附子理中汤。或曰:阳明腑病,背亦恶寒何也?回答说:夫阳明腑病背恶寒者,外无寒证,必见口渴烦躁,背属阳,阳热内陷入腑,则背空虚,致微恶寒,故用白虎汤。若口中和者正属直中寒证,又孰敢用白虎耶!总之,渴则内有热,不渴则内有寒也。
呕吐清涎沫。有人问:呕吐涎沫,何以为直中?回答说:胃腑有寒热,必先现涎沫。《内经》云:诸呕吐酸水及水液混浊者,皆属于热;诸病吐涎及澄沏清冷者,皆属于寒。如天寒则水清,天热则水浊之意,若有热有火在胃脘之间,自烧耗津液,以致口渴,化为酸浊之水,又安得有清涎沫乎!
四肢厥逆。有人问:四肢厥逆,何为直中寒证?回答说:盖四肢属阳,寒邪属阴,阳衰阴盛,故发厥过乎肘膝,况肘膝乃人之四关,今寒过之是为直中。脉沉迟无力者,急温之。或问又有阳厥者何也?此物极则反,虽厥指甲尚温,不似寒厥冷极,外证必口渴烦躁恶热,小便短赤,大便或闭或下利肠垢,脉必沉实有力,但有一证,即以为别。
多眠。有人问:多眠何以属直中?回答说:阴盛则静,静则使人多眠。若传经热证则属阳,阳主动,焉得多眠。又云:表证亦有多眠者何说?回答说:表证是感邪深重,必头痛发热,方为表证多眠,若传经里证,则烦躁恶热,揭去衣被,甚则谵语发狂,又何能多眠也!总之,多眠非直中寒证,即是表证矣。
干呕。有人问:干呕,何以是阴寒证?回答说:盖寒郁中脘,阳气不舒,欲吐不吐,名曰干呕。若有热在内,则吐出物或呕酸苦水,便无此证。或谓太阳、少阳、水气亦令人干呕何也?回答说:太阳干呕,头痛发热,少阳干呕,胸满胁痛,水气干呕,咳引胁下痛,惟直中干呕,则外无一毫表证,必见下利清谷,面惨洒淅,及诸寒证。然太阳、少阳、水气三者干呕,究未离乎寒也。
下利清谷。有人问:下利清谷,何以是直中寒证?回答说:夫寒邪居内则水谷不化。经云:食下即化腐臭而出者,是有火也,食下不化完谷而出者,是有寒也。又云:天寒则水清,天热则水浊。《病机》云:诸水液澄沏清冷者,皆属乎寒。今下利清谷,非寒而何?若传经热证,便下利肠垢,而不下利清谷矣。
吐蛔。有人问:吐蛔,何为直中?回答说:蛔得热则安,遇寒则泛吐蛔,必膈上有寒也。投以凉药则逆,当急温之。又问曰:倘外大热证而吐蛔,亦禁用寒凉药否?回答说:如乌梅理中丸,系安蛔药也。皆用附子、干姜,虽有热证,必先安蛔而后可治。他证不然,膈上虚寒,犯之必危。
蜷卧。有人问:蜷卧何为直中?回答说:热则舒畅流通,何有蜷卧,试观常人冬月独卧,寒极必蜷卧,天气稍暖,则手足伸舒,卧便自如。曰:阳经表证,亦有蜷卧者,寒耶?热耶?回答说:阳经蜷卧,表中寒深故也。须大发表,分别在有头痛发热及诸表证,乃是阳经蜷卧。盖阴经蜷卧,则无一毫表证。
囊缩。有人问:囊缩,何以属直中者?回答说:盖热主流通,寒则敛缩,且直中寒证,乃阴盛阳衰,不能温其下,故令阴囊收缩。如常人遇冬,睾丸反隐于上,此寒盛也;遇夏睾丸下垂,此阳盛也。然《指掌》以囊缩用承气者何意?回答说:厥阴者肝也,肝主筋膜,若次第传至厥阴,六经已尽,邪气盛者,致筋急舌卷如中风状,而囊为之敛搐,以筋聚于阴器故也。非似直中曰隐曰缩。夫《指掌》以囊缩当下者,必口渴烦
Shaobyang (Half-Exterior, Half-Interior). A question was asked: "Yangming disease also presents with alternating chills and fever; what is the meaning of this?" The answer was: "If it is a Yangming channel disease, where the pathogen is in the muscles, the body will be feverish. How could there be alternating chills and fever? If the pathogen has already transmitted to the Yangming fu organs (the six hollow organs, specifically referring to the stomach, large intestine, small intestine, etc.), the stagnant heat steams and steeps, and dry feces are knotted inside. Therefore, alternating chills and fever occur. This is a Yangming fu organ disease, not a Yangming channel disease. It should be treated with Tiaowei Chengqi Decoction (Stomach-Regulating Purging Decoction) to purge [the accumulation]. (Tiaowei Chengqi Decoction consists of Mangxiao, Dahuang, and Gancao; its nature is sweet, warm, and mildly harmonizing, protecting the Stomach Qi without using Houpo or Zhishi which might damage the Upper Jiao; it is effective for Middle Jiao dryness and excess.) Thus it is said: Because of internal fullness in Yangming, alternating chills and fever occur."
Head Sweating. A question was asked: "Why is head sweating considered Shaobyang (Half-Exterior, Half-Interior)? Roughly speaking, all Yang channels ascend to the head, hence sweating occurs there; whereas all Yin channels connect to the back and return at the neck. How could there be head sweating? Therefore, upon seeing head sweating, it is attributed to Shaobyang (Half-Exterior, Half-Interior)." Another question: "Since all Yang channels ascend to the head, and now sweating occurs, shouldn't this be called an Exterior Syndrome? Why call it Shaobyang (Half-Exterior, Half-Interior)?" The answer was: "If it were an Exterior Syndrome, cold pathogens would still be closing the interstices (pores), so how could there be sweating? Now that there is sweating, it indicates that the cold pathogen is transforming into heat. If named an Interior Syndrome, there is head sweating; if named an Exterior Syndrome, there is no head sweating; thus it is called Shaobyang (Half-Exterior, Half-Interior)." It was further said: "Blood stasis, fluid retention causing jaundice, can also present with head sweating. Why? Head sweating due to blood stasis presents with free urination; head sweating due to fluid retention presents with chest fullness, coughing, and vomiting; head sweating due to jaundice presents with difficult urination. If it is head sweating from Shaobyang (Half-Exterior, Half-Interior), there must be alternating chills and fever. However, these three types of head sweating do not depart from Yang syndromes, confirming that head sweating belongs to Shaobyang (Half-Exterior, Half-Interior)."
Night Sweats. A question was asked: "Why are night sweats considered Shaobyang (Half-Exterior, Half-Interior)?" The answer was: "Heat pathogens scorch the interstices, causing sweating. Cold causes the interstices to close tightly, resulting in no sweating, which is an Interior Syndrome. Now, sweating occurs during sleep and stops upon waking. This means the pathogen is about to flourish in the Yin aspect but has not yet deeply penetrated the Yin. It also belongs to Shaobyang (Half-Exterior, Half-Interior)." Another question: "Are night sweats in miscellaneous diseases also treated as Shaobyang (Half-Exterior, Half-Interior)?" The answer was: "Night sweats in miscellaneous diseases indicate extreme Yin deficiency and depletion of the Blood aspect, known as consumptive weakness syndromes. Night sweats in Shanghan (Cold Damage) are caused by surplus pathogens, known as external contraction, and cannot be discussed in the same category as miscellaneous diseases."
Dizziness and Bitter Taste in the Mouth. A question was asked: "Why are dizziness and bitter taste in the mouth considered Shaobyang (Half-Exterior, Half-Interior)?" The answer was: "The eyes are the orifices of the Liver. Bile is stored in the Liver. When the disease is in the Shaoyang Gallbladder channel, dizziness and bitter taste in the mouth result from the leakage of bile juice. Heat forces the bile juice out, causing bitterness in the mouth. Both are diseases of the Shaoyang Gallbladder channel. For Shaobyang (Half-Exterior, Half-Interior), the appropriate method is harmonization. Other channels do not present these symptoms."
All the above involve pathogens in Shaobyang (Half-Exterior, Half-Interior) and should be treated with harmonization methods.
Deep and Forceful Pulse. A question was asked: "Why does a deep and forceful pulse indicate a transmitted Interior Syndrome?" The answer was: "Where the pulse exists, there is life; where it is absent, there is death. Excess or deficiency leads to disease. Internal fullness results in a forceful pulse; internal deficiency results in a deficient pulse. Now, a deep pulse is a pathological pulse indicating disease in the Interior. Forcefulness indicates excess, signifying heat. A deep and forceful pulse indicates Interior excess and heat."
Diarrhea of Clear Yellow Water. A question was asked: "Why is diarrhea of clear yellow water an Interior Syndrome?" The answer was: "Because the intestines and stomach have long been un-purged, dry feces have knotted into masses. Consequently, clear yellow water leaks from the anus. Just as when substances accumulate and harden, water cannot penetrate; if the substance is hard like a rock, pouring water on it will cause seepage. Now, the patient has diarrhea of clear yellow water, with fecal matter knotted inside like rocks. This water flows out from around the knotted feces. Urgent purging is undoubtedly required. Often, people mistake direct transmission cold syndrome diarrhea of undigested food for 'leaky bottom' Shanghan. If this condition is mistakenly identified as leaky bottom and Sini Decoction is administered, it is like adding firewood to a fire—dangerous! Therefore, diarrhea of clear yellow water is an Interior Syndrome and requires urgent purging."
Fullness in the Lower Abdomen. A question was asked: "Why is fullness in the lower abdomen an Interior Syndrome?" The answer was: "The chest and diaphragm belong to the realm of clear Yang. Although they may feel full, it is due to pathogenic qi, not tangible matter. The lower abdomen is the area for waste products. If there is fullness here, it is not just pathogenic qi but tangible matter. Thus, knowing there is matter, urgent purging is indicated." It was added: "Blood stasis syndromes and dysuria syndromes also present with lower abdominal fullness. How to distinguish them? If urination is free, and the lower abdomen is hard, full, and painful, this is a blood stasis syndrome. If urination is difficult and the lower abdomen is full, this is dysuria. If urine is scanty and dark, stool is constipated, leading to hardness in the lower abdomen, it is due to internal dry feces. Thus, both blood stasis and dysuria are Interior Syndromes."
Delirium and Mania. Delirium and mania are Interior Syndromes because heat is excessive in the Stomach. Extreme heat causes mania; mild heat causes delirium. All are transmitted Interior Syndromes. The *Nanjing* states: "Mania and delirium are caused by excess heat and flourishing Yang." The classics mention both deficiency and excess. Why? The answer is: Startled mania is deficiency. Or, if sweating should have been induced but wasn't, and moxibustion forced the condition, causing mania, it is called Fire Pathogen Startled Mania, treated with Chaihu Longgu Muli Tang (Bupleurum, Dragon Bone, and Oyster Shell Decoction). This differs from mania due to excess heat, which can be purged.
Eruption of Macules. A question was asked: "Is eruption of macules also an Interior Syndrome?" The answer was: "Macules arise from Warm Toxicity, Heat Toxicity, or Rotting of the Stomach. Warm Toxicity refers to cold contracted in winter, manifesting in spring when Yang and Yin qi contend. Heat Toxicity refers to summer heat latent in the Stomach, triggered by cold. Rotting of the Stomach occurs either from erroneous purging allowing heat to enter the empty Stomach, or from failure to purge, preventing heat from escaping, so toxic vapors penetrate deeply into the Stomach. Thus, macules represent toxicity. Toxicity is deviation from normalcy, reaching extremes of Yin or Yang. External factors of the Six Qi interact; heat toxicity steams the Stomach. The Stomach governs muscles. Extreme heat injures blood. Interior excess and Exterior deficiency cause macules to cover the entire body, resembling mosquito bites. Red macules indicate survival; purple-black macules indicate death, due to extreme heat causing rotting of the Stomach. Dry tongue coating and cracked lips indicate untreatability. Treatment should detoxify and cool; exterior-releasing drugs to induce sweating must not be used. Because Exterior is deficient and Interior is excess, sweating increases openness and worsens the macule erosion. Another question: "Can Yin Syndromes also present with macules?" The answer was: "This may occur after sweating, vomiting, or purging, depleting Middle Qi; or due to lifestyle draining True Yang; or from overuse of cooling drugs, forming a Yin Syndrome. Cold lurks below, forcing rootless, unanchored fire upward to steam the Lungs and Stomach, causing faint red spots hidden under the skin. This differs from Yang Syndrome macules which are purple-red. This indicates extreme Stomach Qi deficiency. Administering cooling drugs will lead to immediate danger. Wu Hegao said: Using Renshen (Ginseng), Rougui (Cinnamon Bark), and Fuzi (Aconite Root) to treat macules is a variation of method. Physicians who do not understand flexibility cannot discuss this." Another question: "Can Internal Injury also cause macules?" The answer was: "Internal injury is a disease of insufficient Yuan Qi. Due to dual deficiency of Qi and Blood, the body may ache, feel irritable, and have fever. However, the pulse is large and deficient, speech and movement are reluctant, and fatigue with spontaneous sweating distinguishes it. Mistaking this for an Exterior Excess syndrome leads to immediate peril. Rapidly administer Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction). After sound sleep, the fever stops and health returns naturally. Danxi said: Internal injury macules indicate extreme Stomach Qi deficiency, with the fire of the whole body wandering externally. Tonification is needed to descend the fire. Dajianzhong Tang (Great Construct the Middle Decoction) is best. (Renshen, Danggui, Baishao, Zhi Gancao, Banxia, Rougui, Fuzi, plus Shengjiang and Dazao, decocted in water.) If there is latent Yin internally, and cooling drugs are mistakenly taken, forcing deficient Yang to float outward, Yin macules form. The pulse may be surging but weak upon pressure, or limbs may be cold past elbows and knees. First use Paosheng Jiang Lizhong Tang (Roasted Ginger, Cinnamon, and Central-Regulating Decoction) to restore Yang, then treat according to symptoms. If ineffective, add Fuzi."
Passing Gas. A question was asked: "Why is passing gas an Interior Syndrome?" The answer was: "It refers to gas escaping downward. Observing healthy people, before defecation, gas must escape first. Patients with internal dry feces, knotted and blocked, will inevitably lose gas downward. The Yangming chapter states: 'If there is no passing of gas, Chengqi Decoction should not be administered.' Thus, passing gas indicates an Interior Syndrome."
Cessation of Headache and Fever. Cessation of both headache and fever indicates the disease is in the Interior. Pathogens in the body start in Taiyang. Taiyang is the outermost layer of the Exterior. Headache and fever occur here. Shaoyang and Yangming are the middle of the Exterior, also presenting with headache and fever. If pathogens enter the Interior, all Exterior symptoms must disappear. How could headache and fever remain?
Spontaneous Sweating. Why is spontaneous sweating an Interior Syndrome? The classics state: Cold closes the interstices; heat opens them. When Taiyang first receives cold pathogens, before transformation into heat, the interstices are tight, and there is no sweating. Mahuang Tang (Ephedra Decoction) should be used. If initially no sweating suddenly turns to sweating, it indicates heat has entered the Fu organs, steaming fiercely. Thus, spontaneous sweating is an Interior Syndrome. If there were cold in the Exterior, how could there be sweating? A question arose: "Spontaneous sweating is an Interior Syndrome, yet Guizhi Tang (Cinnamon Twig Decoction) is sometimes used. Why?" The answer was: "When Guizhi Tang is used for spontaneous sweating, it is for a Taiyang Wind Strike syndrome. Spontaneous sweating in Interior Syndromes is due to Yang excess; who would dare use Guizhi Tang? Zhongjing said: 'Once Guizhi enters the throat, if Yang is in excess, death ensues.' How to distinguish? With chilliness, aversion to wind, headache, and fever all present, it is Taiyang Wind Strike spontaneous sweating. With irritability, aversion to heat, and no aversion to wind or cold, it is Interior Syndrome spontaneous sweating."
Frequent Urination. A question was asked: "Why is frequent urination an Interior Syndrome?" The answer was: "Food enters the Stomach and transmits to the Small Intestine. The classics say: The Small Intestine is the official of reception and transformation. The Stomach manages food and drink. If clear and turbid are not separated, they mix. From the Small Intestine, it goes to the Bladder and Large Intestine. Clear fluids seep into the Bladder via urination; residue passes from the lower Stomach to the Large Intestine. If the Bladder orifice is closed, water enters the Large Intestine, causing diarrhea. If stool is hard and blocked, fluids go forward, causing frequent urination. Now, frequent urination indicates constipation, so the syndrome belongs to the Interior. If urination is scanty, even with constipation, fluids do not immediately soak into the Large Intestine; the stool will first become hard and full, then loose. Zhongjing said: 'Do not purge if urination is scanty, as defecation will occur soon naturally.'"
Tidal Fever. A question was asked: "Why is tidal fever an Interior Syndrome?" The answer was: "Tidal fever, like the tide, arrives on time. For example, if it occurs at Wei and Shen hours today, it occurs at the same hours tomorrow. Wei and Shen hours belong to Yin. Seeing tidal fever now indicates the pathogen resides in the Yin aspect, with heat knotted in the Interior, steaming dry feces that require purging." Another question: "Tidal fever belongs to the Interior and requires purging. What if there is still an Exterior Syndrome?" The answer was: "If tidal fever exists alongside an unresolved Exterior Syndrome, one must first resolve the Exterior, then purge the Interior. This is correct."
Diarrhea of Intestinal Mucus. A question was asked: "Why is diarrhea of intestinal mucus an Interior Syndrome?" The answer was: "Diarrhea comes from the intestines and stomach. If there is a pathogen in the Exterior, the Interior is harmonious; how could there be diarrhea? Because the pathogen enters the Fu organs, heat scorches the intestines and stomach, causing this symptom." It was added: "Can Exterior Syndromes also present with diarrhea?" The answer was: "San Yang (Three Yang) combined diseases can present with diarrhea. Or Shaoyang-Yangming combined diseases. Yangming internally governs the Stomach Fu, hence diarrhea occurs. In San Yang combined diseases, if the pathogen does not enter the Fu organs, there is no diarrhea. How to distinguish? By the presence of fever and other Exterior symptoms. Diarrhea is indeed an Interior Syndrome, but one must distinguish between transmission and direct transmission. Transmission results in diarrhea of intestinal mucus; direct transmission results in diarrhea of undigested food. These two types of diarrhea differ by mucus versus undigested food."
Aversion to Heat. A question was asked: "Why is aversion to heat an Interior Syndrome?" The answer was: "Heat transmitting to the Zang and Fu organs causes steaming and oppression. Removing clothes and blankets, waving hands, and exposing the body indicates heat transmitting to the Interior. If there were cold inside, there would be aversion to cold. How could there be aversion to heat?"
Blurred Vision. Doubt arises: Why is blurred vision considered an Interior Syndrome? The answer is: The eyes gather the essence of the Five Zang organs. The Five Zang belong to Yin, and Yin resides in the Interior. Thus, it is said to be in the Interior. Moreover, the pupils belong to the Kidney. Extreme internal heat scorches, drying up Kidney Water, rendering it unable to illuminate objects. Like intense heat in summer causing visual obstruction, urgent purging is needed to save the nearly exhausted Kidney Water. If this syndrome is mistaken for deficiency and hot drugs are administered, the harm would be severe.
Abdominal Pain. A question was asked: "Why does abdominal pain belong to the Interior?" The answer was: "Kun represents the abdomen, which is pure Yin. Calling it Yin makes it clear that abdominal pain is definitely Interior. If the chest hurts but the abdomen does not, the pathogen has not deeply penetrated, and it is still a Shaobyang (Half-Exterior, Half-Interior) syndrome. Now, abdominal pain indicates the pathogen has transmitted to the Fu organs." It was asked: "Since abdominal pain belongs to the Interior, why use Dahuang and also Guizhi?" The answer was: "If Taiyang syndrome was erroneously purged causing abdominal pain, a slight Exterior may remain. Or, in a Taiyin Interior syndrome with a floating pulse, Guizhi and Dahuang are used to resolve both Exterior and Interior. However, although abdominal pain belongs to the Interior, one must distinguish between transmission and direct transmission. Caution is required."
Insomnia. A question was asked: "How does insomnia reveal an Interior Syndrome?" The answer was: "Heat pathogens entering the Fu organs cause irritability and restlessness. If cold is excessive (direct transmission), it belongs to Yin. Yin governs stillness; stillness leads to much sleep. How could there be insomnia?" Another question: "Inability to sleep certainly belongs to transmitted Interior Syndrome. Why does administering cold drugs sometimes worsen it?" The answer was: "This occurs after sweating, vomiting, or purging. It is named: Exhaustion of Body Fluids leading to insomnia. There must be internal emptiness and irritability. If the pulse is not floating and weak, Zhenwu Tang (True Warrior Decoction) and Suanzaoren Tang (Sour Jujube Seed Decoction) should be used. For Interior Syndrome insomnia, there is incessant irritability and thirst, and the pulse is certainly forceful, thus distinguishing it."
Sweating in Palms, Soles, and Axillae. Sweating in the palms, soles, and axillae indicates an Interior Syndrome. The back belongs to Yang; the abdomen belongs to Yin. The palms, soles, and axillae are Yin areas connected to the meridians of the Five Zang organs. Heat pathogens steam the Zang and Fu, causing sweating in the palms and axillae. If the palms and axillae are not moist, the pathogen is still in the Exterior, not having entered the Interior; this is called Exterior disease with Interior harmony. Now, sweating in the palms and axillae indicates the stool has hardened. Urgent purging is required; it is undoubtedly an Interior Syndrome.
Dry Throat and Dry Teeth. A question was asked: "Why do dry throat and dry teeth belong to the Interior?" The answer was: "The throat is the pathway of the Stomach; teeth are the surplus of bones. Now, a dry throat indicates excessive heat in the Fu organs; dry teeth indicate heat scorching the bones. Are bones and the Stomach not Interior?" Another question: "Severe internal heat should cause sore throat. Why do cold syndromes also cause sore throat?" The answer was: "Direct transmission cold causing sore throat must present with diarrhea of undigested food and cold limbs. This is extreme cold causing reverse sore throat. Such patients do not desire to swallow water. This differs from transmitted dry throat and dry teeth, where patients strongly desire to drink water."
All the above are transmitted Interior Syndromes requiring purging of the Interior.
Deep, Fine, and Weak Pulse. A question was asked: "Why does a deep, fine, and weak pulse indicate Direct Transmission Cold Syndrome?" The answer was: "Yuan Qi consolidates the body and flows freely through the limbs. Heat causes a rapid pulse; cold causes a slow pulse. This is a fixed principle. Deep indicates Yin; weakness indicates deficiency. This is cold invading the Yin channels, with declining Yang Qi, hence the pulse cannot be forceful. If there were internal heat, the pulse would be solid and slippery; how could it be weak? If the pulse is weak, it indicates cold, deficiency, or direct transmission. Even if there are Exterior symptoms or great heat externally, one dares not use purging or exterior-releasing drugs. If one ignores the pulse and indiscriminately administers Mahuang, causing double deficiency in the deficient, rescue will be too late."
Aversion to Cold in the Back. A question was asked: "How is aversion to cold in the back Direct Transmission?" The answer was: "Yin pathogens enter the Yang aspect; Yin is excess and Yang is deficient. Fuzi Lizhong Tang (Aconite and Central-Regulating Decoction) should be used." Someone said: "In Yangming Fu disease, why is there also aversion to cold in the back?" The answer was: "In Yangming Fu disease with aversion to cold in the back, there are no external cold signs. Instead, thirst and irritability must be present. The back belongs to Yang. When Yang heat sinks internally into the Fu organs, the back feels empty, causing slight aversion to cold. Hence, Baihu Tang (White Tiger Decoction) is used. If the mouth is harmonious (no thirst), it is truly Direct Transmission Cold Syndrome; who would dare use Baihu Tang! In summary, thirst indicates internal heat; lack of thirst indicates internal cold."
Vomiting of Clear Saliva and Foam. A question was asked: "Why is vomiting saliva and foam Direct Transmission?" The answer was: "Whether the Stomach Fu has cold or heat, saliva and foam must appear first. The *Neijing* states: 'All vomiting of sour water and turbid fluids belongs to heat; all vomiting of saliva and clear, cold fluids belongs to cold.' As cold weather makes water clear and hot weather makes it turbid: if there is heat and fire in the Stomach, consuming fluids leads to thirst, transforming into sour and turbid water. How could there be clear saliva and foam!"
Cold Extremities. A question was asked: "Why are cold extremities Direct Transmission Cold Syndrome?" The answer was: "The limbs belong to Yang; cold pathogens belong to Yin. Yang decline and Yin excess cause cold extremities extending past the elbows and knees. Since elbows and knees are the four gates of the body, cold surpassing them indicates direct transmission. If the pulse is deep, slow, and weak, urgent warming is required." Another question: "What about Yang Cold Extremities?" The answer was: "This is reversal due to extremity. Although the fingertips remain warm, unlike extreme cold extremities, external signs must include thirst, irritability, aversion to heat, scanty dark urine, and either constipation or diarrhea of intestinal mucus. The pulse must be deep, solid, and forceful. The presence of any one of these signs distinguishes it."
Excessive Sleep. A question was asked: "Why does excessive sleep belong to Direct Transmission?" The answer was: "Yin excess leads to stillness; stillness causes excessive sleep. Transmitted heat syndromes belong to Yang; Yang governs movement. How could there be excessive sleep?" It was also said: "Can Exterior Syndromes also present with excessive sleep?" The answer was: "Exterior syndromes involve deep pathogen invasion, necessarily presenting with headache and fever to be considered Exterior Syndrome excessive sleep. If it is a transmitted Interior Syndrome, there is irritability, aversion to heat, removal of clothes and blankets, and possibly delirium and mania. How could there be excessive sleep! In summary, excessive sleep is either Direct Transmission Cold Syndrome or an Exterior Syndrome."
Dry Retching. A question was asked: "Why is dry retching a Yin-Cold Syndrome?" The answer was: "Cold stagnates in the Middle Jiao, obstructing Yang Qi. The desire to vomit without success is called dry retching. If there is heat inside, vomitus may contain sour or bitter water, so this symptom would not occur." Some ask: "Do Taiyang, Shaoyang, and Water-Qi also cause dry retching?" The answer was: "Taiyang dry retching presents with headache and fever. Shaoyang dry retching presents with chest fullness and hypochondriac pain. Water-Qi dry retching presents with cough pulling pain in the hypochondrium. Only Direct Transmission dry retching has absolutely no Exterior signs, but must present with diarrhea of undigested food, pale and shivering face, and other cold signs. However, dry retching from Taiyang, Shaoyang, and Water-Qi ultimately does not depart from cold."
Diarrhea of Undigested Food. A question was asked: "Why is diarrhea of undigested food Direct Transmission Cold Syndrome?" The answer was: "When cold pathogens reside inside, food and drink are not digested. The classics state: 'Food transformed into foul-smelling decay and expelled indicates Fire; food expelled undigested indicates Cold.' Also: 'Cold weather makes water clear; hot weather makes it turbid.' The *Pathogenesis* states: 'All clear, cold, and transparent fluids belong to Cold.' Now, diarrhea of undigested food—if not cold, what else? If it were a transmitted heat syndrome, it would present with diarrhea of intestinal mucus, not undigested food."
Vomiting Roundworms. A question was asked: "Why is vomiting roundworms Direct Transmission?" The answer was: "Roundworms are calm with heat and restless/vomit with cold. There must be cold above the diaphragm. Administering cooling drugs will cause rebellion; urgent warming is required." Another question: "If there is a major Exterior Heat Syndrome with vomiting roundworms, are cooling drugs also contraindicated?" The answer was: "Wumei Lizhong Wan (Mume Pill for Regulating the Middle) is a worm-calming medicine. It uses Fuzi and Ganjiang. Even with heat signs, one must first calm the worms before treating other conditions. Other conditions are different. Deficient cold above the diaphragm, if violated, leads to danger."
Curled Posture. A question was asked: "Why is curled posture Direct Transmission?" The answer was: "Heat allows smooth flow; how could there be curled posture? Observe ordinary people sleeping alone in winter; extreme cold causes curling. When weather warms slightly, limbs extend, and sleeping becomes natural." Asked: "Do Yang Channel Exterior Syndromes also present with curled posture? Is it cold or heat?" The answer was: "Yang Channel curled posture is due to deep cold in the Exterior. Major exterior-releasing methods are needed. Distinction lies in the presence of headache, fever, and other Exterior signs. This is Yang Channel curled posture. Yin Channel curled posture has absolutely no Exterior signs."
Retraction of Testicles. A question was asked: "Why does retraction of testicles belong to Direct Transmission?" The answer was: "Heat promotes flow; cold causes retraction. Direct Transmission Cold Syndrome involves Yin excess and Yang deficiency, failing to warm the lower part, causing testicular retraction. Like ordinary people in winter, testes retract upward due to cold excess; in summer, they hang down due to Yang excess. However, *Zhangzhi* suggests using Chengqi Decoction for retraction. Why?" The answer was: "Jueyin is the Liver. The Liver governs sinews. If transmission proceeds sequentially to Jueyin, exhausting the Six Channels, and pathogens are strong, sinews tighten, the tongue curls like stroke, and the scrotum contracts because sinews gather at the genitalia. This is not like Direct Transmission described as hiding or shrinking. Those in *Zhangzhi* who advocate purging for retraction must have thirst and irritability...