腹满，胺之痛也。论中有少腹满，按之痛，小便自利者，是血结膀胱证；小便不利者，是水结膀胱证；手足热，
小便赤涩者，是热结膀胱证。此则手足冷，小便数而白，知是冷结膀胱证也。
【集注】成无己曰∶手足厥，不结胸者，无热也。小腹满，按之痛，下焦冷结也。
程知曰∶阳邪结于上，阴邪结于下，手足厥冷，小腹满，按之痛，其为阴邪下结可知。此当用温、用灸。
关元，穴名，在脐下三寸，为极阴之位，足三阴、任脉之会，膀胱所居也。
程应旄曰∶发厥，虽不结胸，而小腹满实作痛结，则似乎可下。然下焦之结多冷，不比上焦之结多热也。
况手足厥，上焦不结，惟结膀胱关元之处，故曰∶冷结也。
凡厥者，阴阳气不相顺接，便为厥。厥者，手足逆冷者是也。诸四逆厥者，不可下
之。虚家亦然。
【注】此详诸条致厥之由，慎不可下也。盖厥虽阴经俱有，然所属者厥阴也，故厥阴一病，不问寒热皆有
厥，若无厥，则非厥阴也。太阴寒微，故手足温而无厥冷；少阴寒甚，故有寒厥而无热厥；厥阴阴极生阳，故
寒厥热厥均有之也。凡厥者，谓阴阳寒热之厥也，阴阳不相顺接者，谓阴阳之气不相顺接交通也。不相顺接交
通，则阳自阳而为热，阴自阴而为寒，即为厥病也。厥者之证，手足逆冷是也。诸四逆厥者，谓诸病四逆厥冷
者也。然厥病阴阳已不相顺接交通，慎不可下，虚家见厥，尤不可下，故曰∶虚家亦然也。
【集注】成无己曰∶手之三阴三阳，相接于手之十指；足之三阴三阳，相接于足之十指。阳气内陷，不与
阴相顺接，故手足为之厥冷也。
喻昌曰∶厥阴证，仲景总不欲下，无非欲邪还于表，使阴从阳解也。此但举最不可下之二端，以严其戒。
伤寒五六日，不结胸，腹濡，脉虚，复厥者，不可下。此亡血，下之死。
【按】“结胸”二字，当是“大便”二字。不结胸，腹濡，脉虚，复厥，皆无可下之理，而曰不可下，何
所谓耶？
【注】此承上条详申不可下之义也。伤寒五六日，邪至厥阴之时，不大便似可下也。若腹濡、脉虚、复厥
者，此为亡血虚躁，更不可下也，下之则蹈虚虚之戒而死矣。大病汗后，产妇亡血之家，多有此证。
【集注】张璐曰∶伤寒五六日，邪入厥阴，其热深矣。今脉虚而复厥，则非热深当下之可比。以其亡血伤
津，大便枯涩，恐人误认五六日热入阳明之燥结，故有不可下之之戒。盖脉虚、腹濡，知内外无热。厥则阴气
用事，即当同亡血例治。若其人阴血更亏于阳，或阴中稍挟阳邪，不能胜辛热者，又属当归四逆证矣。
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。
【注】伤寒邪传厥阴，阴阳错杂为病，若阳交于阴，是阴中有阳，则不厥冷；阴交于阳，是阳中有阴，则
不发热。惟阴盛不交于阳，阴自为阴，则厥冷也；阳亢不交于阴，阳自为阳，则发热也。盖厥热相胜则逆，逆
则病进；厥热相平则顺，顺则病愈。今厥与热日相等，气自平，故知阴阳和而病自愈也。
【集注】方有执曰∶厥五日，热亦五日，阴阳胜复无偏也，当复厥不厥，阳气胜也。阳主生，故自愈可知也。
张璐曰∶此云厥终不过五日，言厥之常；后云厥反九日而利，言厥之变。盖常则易治，变则难复也。
林澜曰∶三阴经伤寒，太阴为始，则手足温；少阴则手足冷；厥阴则手足厥逆。然病至厥阴，阴之极也，
反有发热之理？盖阳极而生阴，故阳病有厥冷之证；阴极而生阳，故厥逆有发热之条。
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。
【注】伤寒热少厥微，所以手足不冷，而但指头寒，寒邪浅也。默默，阴也。烦躁，阳也。不欲食，胃不
和也。此厥阴阴阳错杂之轻病，即论中热微厥亦微之证也。若数日小便利，其色白者，此邪热已去也；欲得食，
其胃已和也；热去胃和，阴阳自平，所以其病为愈也。若小便不利而色赤，厥不微而甚，不惟默默而且烦，不
但不欲食，更呕而胸胁满，此热未除而且深也，即论中厥深热亦深之证也。热深不除，久持阴分，后必便血也，
所谓数日者，犹曰连日也。
【集注】王肯堂曰∶设未欲食，宜干姜甘草汤。呕而胸胁烦满者，少阳证也。少阳与厥阴为表里，邪干其
腑，故呕而胸胁烦满，肝主血，故后必便血。
方有执曰∶热少厥微，邪浅也，所以手足不冷，而但指头寒。默默，谓无言也。不欲食，厥阴之脉挟胃也。
烦躁则内热，故以小便辨之。欲食，邪退而胃回也。厥而呕、胸胁烦满者，厥阴脉挟胃贯膈布胁肋也。便血，
阴邪必走下窍也。
林澜曰∶于热厥，言指头寒。于寒厥微者，言手足寒。甚者，言四逆。厥逆轻重浅深，当细味之。
汪琥曰∶按此条论，仲景无治法。郭雍云∶热不除而便血，可用犀角地黄汤。
伤寒一二日至四五日而厥者，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。
【注】伤寒一二日即厥，四五日仍厥不已者，是阴盛阳衰之寒厥也。寒厥者，即脏厥也。若一二日厥，至
四五日而热；或一二日热，至四五日而厥，前厥后热，前热后厥，是阴阳互为胜复之热厥也。热厥者，即阳厥
也。厥深者，热亦深；厥微者，热亦微，此厥乃应下之热厥，非当温散之寒厥也。若误为寒厥而反温散之，则
助其热上攻，必口伤烂赤也。
【集注】成无已曰∶经云∶诸四逆者不可下之。至此又云“应下”，最宜详审。先贤谓热厥手足虽厥冷，
而或有温时，手足虽逆冷，而手足掌心必暖。戴元礼又以指甲之暖冷、红青，别厥证之寒热，皆慎之至也。
汪琥曰∶此条乃传经邪热，阳极似阴之证。伤寒一二日至四五日而厥者，言伤寒在一二日之时本发热，至
四五日后而厥者，乃邪传厥阴之候也。必发热者，言病患四肢及肌表虽厥，而躯壳以内必发热也。前热者后
必厥，乃申明一二日为前，四五日为后，以见热极必发厥也。阳邪深伏，应须以苦寒之药下去其热，使阴气得
伸，则阴阳平，四肢和顺而不厥矣。粗工见厥，认以为寒，而反用辛温之药，辛温皆升，引热上行，必口伤
烂赤，以厥阴之脉循颊里环唇内故也。
病患手足厥冷，脉乍紧劲，邪结在胸中。心下满而烦，饥不能食者，病在胸中，当须吐之，宜瓜蒂散。
【注】病患手足厥冷，其脉微而细，是寒虚也。寒虚者可温可补。今脉乍紧劲，是寒实也。寒实者宜温
宜吐也。时烦吐蛔，饥不能食，乃病在胃中也；今心中烦满，饥不能食，是病在胸中也。寒饮实邪壅塞胸中，
则胸中阳气为邪所遏，不能外达四肢，是以手足厥冷，胸满而烦，饥不能食也。当吐之，宜瓜蒂散涌其在上之
邪，则满可消，而厥可回矣。
【集注】喻昌曰∶此与太阳之结胸迥殊，其脉乍紧，其邪亦必乍结，故用瓜蒂散涌载其邪而出，斯阳邪
仍从阳解耳！
程应旄曰∶手足厥冷，邪气内阻。脉乍紧，紧而不常，往来中倏忽一见也。
伤寒脉滑而厥者，里有热，白虎汤主之。
【注】伤寒脉微细，身无热，小便清白而厥者，是寒虚厥也，当温之。脉乍紧，身无热，胸满而烦厥者，
是寒实厥也，当吐之。脉实，大小便闭，腹满硬痛而厥者，热实厥也，当下之。今脉滑而厥，滑为阳脉，里热
可知，是热厥也。然内无腹满痛不大便之证，是虽有热而里未实，不可下而可清，故以白虎汤主之。
【集注】程应旄曰∶脉滑而厥，乃阳实拒阴之厥，白虎汤凉能清里，而辛可解表，故当舍证而从脉也。
林澜曰∶热厥亦有不同，如传邪入腑，秘结不通，燥矢在内，非下不可者，以承气治之之证是也。若火
极似水，里有大热，而大
便不闭，无燥粪可除者，滑则里热已深，厥则邪陷已极，非以白虎涤其极热，则亢甚之阳，何以清耶！
吴人驹曰∶厥，因阳气不相顺接，其脉当见阴象。脉滑为气有余，是阳盛于内，格阴于外，内则实热，外
而假寒者也。白虎以清解实热，则厥自解矣。辨之之法，冷必不甚，浮而近之则冷，按之肌骨之下，则反热矣。
伤寒脉促，手足厥逆，可灸之。
【注】伤寒阴证见阳脉者，虽困无害，无宁俟之也。今伤寒脉促，手足厥逆，而曰可灸之者，盖以欲温则
有阳脉之疑，欲清则有阴厥之碍也。夫证脉无寒热之确据，设以促之一阳脉清之，惟恐有误于脉，或以厥之一
阴证温之，又恐有误于证，故设两可之灸法，斯通阳而不助热，回厥而不伤阴也。
【集注】喻昌曰∶伤寒脉促，则阳气 可知，更加手足厥逆，其阳必为阴所格拒而不能返，故宜灸以通阳也。
张璐曰∶手足厥逆，本当用四逆汤，以其脉促，知为阳气内阻，而非阳虚，故但用灸以通其阳，不用温经
以助阳也。
伤寒发热四日，厥反三日，复热四日，厥少热多者，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。
【注】伤寒邪在厥阴，阳邪则发热，阴邪则厥寒，阴阳错杂，互相胜复，故或厥或热也。伤寒发热四日，
厥亦四日，是相胜也。今厥反三日，复热四日，是热多厥少，阳胜阴退，故其病当愈也。当愈不愈，热仍不止，
则热郁于阴，其后必便脓血也。若厥四日，热反三日，则厥多热少，阴胜阳退，故为病进也。
【集注】程知曰∶此即厥热往复之机。知阴阳进退之义，明厥证所重在阳，则厥阴之大旨昭然矣。
张璐曰∶太阳以恶寒发热为病进，恐其邪气传里也；厥阴以厥少热多为病退，喜其阴尽阳复也。
程应旄曰∶厥阴、少阳，一脏一腑。少阳在三阳为尽，阳尽则阴生，故有寒热之往来；厥阴在三阴为尽，
阴尽则阳生，故有厥热之胜复。凡遇此证，不必论其来自三阳、起自三阴，只论厥与热之多少。热多厥少，知
为阳胜，阳胜病当愈；厥多热少，知为阴胜，阴胜病日进。热在后而不退，则为阳过胜，过胜而阴不能复，遂
有便血诸热证；厥在后而不退，则为阴过胜，过胜而阳不能复，遂有亡阳诸死证。所以调停二者治法，须合乎
阴阳进退之机，阳胜宜下，阴胜宜温。若不图之于早，坐令阴竭阳亡，其死必矣。
吴人驹曰∶《内经》言，人之伤于寒也，则为病热。热虽甚不死，是伤寒以热为贵也。然热不及者病，太
过者亦病。故此二节，论寒热之多少，以明不可太过与不及也。
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。
【按】不发热者之“不”字，当是“若”字。若是“不”字，即是除中，何以下接“恐暴热来出而复去”
之文也？
【注】热而不厥为阳，厥而不热为阴。伤寒始发热六日，厥亦六日，至七日仍发热而不厥者，是阳来复，
当自愈也。今厥九日，较
热多三日，是阴胜阳，故下利也。凡厥利者，中必寒，当不能食，今反能食，恐是阴邪除去胃中阳气，而为除
中之病也。恐者，疑而未定之辞也。故以索饼试之∶食后不发热，则为除中；若发热，知胃气尚在，则非除中，
可必愈也。若食后虽暴发热，恐热暂出而复去，仍是除中，故必俟之三日，其热续在不去，与厥相应，始可期
之旦日夜半愈也。若俟之三日后，虽热不罢而亦不愈，且脉犹数者，此为热气有余，留连营卫，必发痈脓也。
【集注】方有执曰∶食，饲也。索，常也。谓以素常所食之饼饲之也。一说无肉曰索，谓不令犯食禁也。
旦日，明日平旦，朝而阳长之时也；夜半，阴尽阳生之时也，数以候热。痈脓者，厥阴主血，血热持久则壅瘀，
壅瘀则腐化，故可必也。
吴人驹曰∶除者，去也；中者，中气也。乃中气除去，欲引外食以自救也。
伤寒脉迟，六七日，而反黄芩汤彻其热，脉迟为寒，今与黄芩汤复除其热，腹中应冷，当不能食，今反能
食，此名除中，必死。
【按】“伤寒脉迟，六七日”之下，当有“厥而下利”四字，若无此四字，则非除中证矣。有此四字，始
与下文反与黄芩汤之义相属。
【注】伤寒脉数，六七日，厥而下利，热厥下利也，当与黄芩汤彻其热。今伤寒脉迟，六七日，厥而下利，
寒厥下利也，当与理中汤温其寒。而反与黄芩汤复除其热，腹中应冷，当不能食，今反能食，此名除中。乃胃
气将绝，求食以救，终无补于胃也，故曰必死。
【集注】方有执曰∶反者，言不顺于道也。黄芩汤，寒药也。彻，亦除也。应，亦当也。反能食者，胃欲
腹部胀满，按压时疼痛。《伤寒论》原文中提到：少腹胀满，按压疼痛，小便通畅的，是血结膀胱证；小便不利的，是水结膀胱证；手足发热，小便短赤涩痛的，是热结膀胱证。此处则是手足发冷，小便频数且色白，可知是冷结膀胱证。
【集注】成无己说：手足厥冷，若不结胸，说明体内没有热邪。小腹胀满，按压疼痛，这是下焦冷结。
程知说：阳邪结聚于上部，阴邪结聚于下部，出现手足厥冷、小腹胀满、按压疼痛，这显然是阴邪在下部结聚所致。此时应当使用温法，或者施以艾灸。关元，是穴位名称，位于脐下三寸，是极阴之位，为足三阴经与任脉交会之处，也是膀胱所在之地。
程应旄说：发生厥逆，虽然不结胸，但小腹胀满坚实作痛且有结滞感，似乎可以用攻下法。然而下焦的结滞多为寒冷，不像上焦的结滞多为热邪。况且手足厥冷，上焦并无结滞，只有膀胱和关元处有结滞，所以说这是冷结。
凡是厥证，都是由于阴阳之气不能顺接贯通，就会形成厥证。所谓厥，就是手足逆冷的表现。各种四肢逆冷厥证的病人，不可用攻下法。身体虚弱的患者也是如此。
【注】此处详细阐述各种导致厥证的原因，强调绝不可使用攻下法。虽然厥证在阴经中都有出现，但归属于厥阴经，所以只要是厥阴病，无论寒证热证都会出现厥逆；如果没有厥逆，那就不是厥阴病了。太阴病寒气轻微，所以手足温暖而没有厥冷；少阴病寒气极重，所以只有寒厥而没有热厥；厥阴病阴极则生阳，所以寒厥和热厥都有可能出现。所谓的厥，是指阴阳寒热性质的厥逆；阴阳不相顺接，是指阴阳之气不能相互顺接交通。如果不能相互顺接交通，那么阳气独自为阳而表现为热，阴气独自为阴而表现为寒，这就形成了厥病。厥病的症状，就是手足逆冷。所谓的“诸四逆厥者”，是指各种患有四肢逆冷厥证的病人。然而厥病已经阴阳不相顺接交通，千万不可攻下，虚弱的患者见到厥逆，更加不可攻下，所以说“虚家亦然”。
【集注】成无己说：手部的三条阴经和三条阳经，交接于手部的十个手指；足部的三条阴经和三条阳经，交接于足部的十个脚趾。阳气内陷，不与阴气顺接，所以手足会因此厥冷。
喻昌说：厥阴证，张仲景总体上不希望使用攻下法，无非是想让邪气回归体表，使阴邪从阳分化解。这里只列举了最不可攻下的两种情况，以严格警示后人。
伤寒病经过五六天，不结胸，腹部柔软，脉象虚弱，再次出现厥逆的，不可攻下。这是因为亡血（失血），如果误用攻下法会导致死亡。
【按】这里的“结胸”二字，应该是“大便”二字。如果不结胸，腹部柔软，脉象虚弱，再次厥逆，都没有可以攻下的理由，却说“不可下”，这是什么意思呢？
【注】此处承接上一条，详细申述不可攻下的道理。伤寒病经过五六天，邪气传入厥阴之时，虽然不大便似乎可以用攻下法。但如果腹部柔软、脉象虚弱、再次厥逆的，这是亡血导致的虚躁，更不可攻下，如果攻下就会触犯“虚虚之戒”（使虚者更虚）而导致死亡。大病发汗后，以及产妇失血的病人，多有这种证候。
【集注】张璐说：伤寒病经过五六天，邪气进入厥阴，热势已经很深了。现在脉象虚弱又出现厥逆，这就不是热势深重应当攻下的情况可比了。因为这是亡血伤津，导致大便枯涩，恐怕人们误认为是五六天热入阳明腑实的燥结，所以有不可攻下的告诫。通过脉象虚弱、腹部柔软，可知内外没有热邪。出现厥逆说明阴气用事，就应当按照亡血的例子来治疗。如果病人的阴血比阳气亏损更严重，或者阴中稍微夹杂阳邪，不能耐受辛热药物的，又属于当归四逆汤证的范畴了。
伤寒病，厥逆五天，发热也五天，假设第六天应当再次厥逆，结果没有厥逆的，病会自愈。厥逆的时间不超过五天，因为发热也有五天，所以知道病会自愈。
【注】伤寒邪气传入厥阴，阴阳错杂致病，如果阳气交合于阴分，就是阴中有阳，就不会厥冷；阴气交合于阳分，就是阳中有阴，就不会发热。只有阴气盛极而不交合于阳，阴气独自为阴，就会厥冷；阳气亢盛而不交合于阴，阳气独自为阳，就会发热。大概厥与热互相胜负就会导致逆乱，逆乱则病情进展；厥与热平衡则顺遂，顺遂则病愈。现在厥与热的天数相等，气机自然平和，所以知道阴阳调和而病会自愈。
【集注】方有执说：厥逆五天，发热也五天，阴阳胜负没有偏颇，应当再次厥逆却没有厥逆，说明阳气胜了。阳气主生发，所以知道病会自愈。
张璐说：这里说厥逆终归不超过五天，说的是厥逆的常理；后面说厥逆反而九天并伴有下利，说的是厥逆的变局。常理容易治疗，变局难以恢复。
林澜说：三阴经伤寒，太阴经开始发病，则手足温暖；少阴经则手足冷；厥阴经则手足厥逆。然而病至厥阴，是阴气的极点，怎么会有发热的道理呢？大概阳极而生阴，所以阳病会有厥冷的证候；阴极而生阳，所以厥逆会有发热的条文。
伤寒病热势轻浅，厥逆轻微，仅指尖发凉，神情沉默不想吃东西，烦躁几天，小便通利，颜色白的，这是热邪已除。想要吃东西，病就会痊愈。如果出现厥逆并且呕吐，胸胁烦闷胀满的，其后必定会出现便血。
【注】伤寒病热势轻浅，厥逆轻微，所以手足不冷，只是指尖发凉，说明寒邪浅表。默默不语，属阴。烦躁，属阳。不想吃东西，是胃气不和。这是厥阴阴阳错杂的轻症，也就是《伤寒论》中热微厥亦微的证候。如果几天后小便通利，颜色白的，这是邪热已去；想要吃东西，说明胃气已和；热去胃和，阴阳自然平和，所以病会痊愈。如果小便不利且颜色红赤，厥逆不轻微反而严重，不仅沉默而且烦躁，不仅不想吃东西，反而呕吐且胸胁满闷，这是热邪未除而且深入，也就是《伤寒论》中厥深热亦深的证候。热邪深入不除，长久滞留阴分，后来必定便血，所说的“数日”，意思是连日。
【集注】王肯堂说：如果尚未想吃东西，适宜用干姜甘草汤。呕吐且胸胁烦闷胀满的，是少阳证。少阳与厥阴互为表里，邪气侵犯其腑，所以呕吐且胸胁烦闷胀满，肝主血，所以后来必定便血。
方有执说：热势轻浅，厥逆轻微，说明邪气浅表，所以手足不冷，只是指尖发凉。默默，指不说话。不想吃东西，是因为厥阴经脉挟行于胃。烦躁则内有热，所以用小便来辨别。想要吃东西，说明邪气退去而胃气恢复。出现厥逆、呕吐、胸胁烦闷胀满，是因为厥阴经脉挟胃贯穿膈肌散布于胁肋。便血，是因为阴邪必然向下窍走窜。
林澜说：对于热厥，提到指尖发凉。对于轻微的寒厥，提到手足发凉。严重的，称为四逆。厥逆的轻重深浅，应当仔细体味。
汪琥说：按此条论述，张仲景没有给出治法。郭雍说：热邪不除而便血，可用犀角地黄汤。
伤寒病一二天到四五天出现厥逆的，必定会发热。先前发热的，后来必定厥逆；厥逆深的，热势也深；厥逆轻的，热势也轻。厥逆（热厥）应当用攻下法，如果反而用发汗法，必定会导致口腔损伤溃烂发红。
【注】伤寒病一两天就出现厥逆，四五天仍然厥逆不止的，这是阴盛阳衰的寒厥。寒厥，就是脏厥。如果一两天厥逆，到四五天发热；或者一两天发热，到四五天厥逆，前厥后热，前热后厥，这是阴阳互相胜负交替的热厥。热厥，就是阳厥。厥逆深，热势也深；厥逆轻，热势也轻，这种厥逆是应当攻下的热厥，不是应当温散治疗的寒厥。如果误认为是寒厥而反而用温散法，就会助长热邪向上攻冲，必定导致口腔损伤溃烂发红。
【集注】成无己说：经文说：各种四肢逆冷的不可攻下。到这里又说“应当攻下”，最应当详细审慎。先贤认为热厥虽然手足厥冷，但有时会有温暖的时候，虽然手足逆冷，但手心必定温暖。戴元礼又以指甲的温暖寒冷、红润青紫，来区别厥证的寒热，都是极其谨慎的态度。
汪琥说：此条乃是传经邪热，阳极似阴的证候。伤寒病一两天到四五天出现厥逆，是说伤寒在一两天时本来发热，到四五天之后才出现厥逆的，这是邪气传入厥阴的征候。必定发热，是说病患四肢及肌表虽然厥冷，但躯壳内部必定发热。前热后必厥，是申明一两天为前，四五天为后，以显示热极必发厥逆。阳邪深伏，应当用苦寒的药物下去其热，使阴气得以上升伸展，则阴阳平和，四肢和顺而不厥逆了。粗劣的医生见到厥逆，误认为是寒证，而反而用辛温药物，辛温药性皆上升，引热上行，必定导致口腔损伤溃烂发红，因为厥阴经脉循行于面颊内部环绕嘴唇内侧的缘故。
病患手足厥冷，脉象突然变得紧而有力，邪气结聚在胸中。心下胀满且烦躁，饥饿但不能吃东西的，病在胸中，应当用吐法，适宜用瓜蒂散。
【注】病患手足厥冷，如果脉象微弱而细，这是寒虚证。寒虚证可以用温法或补法。现在脉象突然紧而有力，这是寒实证。寒实证适宜用温法或吐法。时常烦躁吐蛔虫，饥饿但不能吃东西，是病在胃中；现在是心中烦闷胀满，饥饿但不能吃东西，是病在胸中。寒饮实邪壅塞胸中，则胸中阳气被邪气遏制，不能外达四肢，所以手足厥冷，胸满而烦躁，饥饿但不能吃东西。应当用吐法，适宜用瓜蒂散涌吐在上部的邪气，则胀满可消，而厥逆可回。
【集注】喻昌说：这与太阳病的结胸截然不同，其脉象突然紧，其邪气也必然是突然结聚，所以用瓜蒂散涌吐载着邪气排出，这样阳邪仍从阳分化解啊！
程应旄说：手足厥冷，邪气内阻。脉象突然紧，紧而不恒定，在往来中忽然一见。
伤寒病脉象滑利而手足厥冷的，里有热邪，用白虎汤主治。
【注】伤寒病脉象微细，身体无热，小便清白而厥冷的，是寒虚厥，应当用温法。脉象突然紧，身体无热，胸满而烦躁厥冷的，是寒实厥，应当用吐法。脉象实，大小便闭塞，腹部胀满硬痛而厥冷的，是热实厥，应当用攻下法。现在脉象滑利而厥冷，滑是阳脉，可知里有热，这是热厥。然而内部没有腹部胀满疼痛不大便的证候，这是虽然有热但里未结实，不可攻下而可以清解，所以用白虎汤主治。
【集注】程应旄说：脉滑而厥，是阳实拒绝阴气的厥逆，白虎汤凉性能清里热，而辛性能解表邪，所以应当舍证而从脉。
林澜说：热厥也有不同，如传邪入腑，秘结不通，燥屎在内，非攻下不可的，用承气汤治疗的证候就是这类。如果是火极似水，里有大热，而大便不闭，没有燥粪可除的，脉滑说明里热已深，厥逆说明邪气陷入已极，不用白虎汤涤荡极热，那亢盛的阳气，用什么来清解呢！
吴人驹说：厥逆，是因为阳气不相顺接，脉象应当见阴象。脉滑说明气有余，是阳盛于内，格拒阴气于外，内部是实热，外部是假寒。用白虎汤清解实热，则厥逆自然解除。辨别的方法，寒冷必定不严重，浮取感觉冷，重按至肌肉骨骼之下，反而热了。
伤寒病脉象急促，手足厥逆，可以用艾灸治疗。
【注】伤寒阴证出现阳脉的，虽然病重也无害，不必等待它自行好转。现在伤寒脉象急促，手足厥逆，却说可以用艾灸的，大概是因为如果想用温法，则有阳脉的疑虑；如果想用清法，则有阴厥的阻碍。既然证候和脉象没有寒热的确切依据，如果用急促这一阳脉来清解，唯恐误判脉象；或者用厥逆这一阴证来温补，又恐误判证候，所以设立两可的灸法，这样既能通阳而不助热，回阳救逆而不伤阴。
【集注】喻昌说：伤寒脉象急促，则阳气可知，再加上手足厥逆，其阳气必定被阴气格拒而不能返回，所以适宜用艾灸来通阳。
张璐说：手足厥逆，本应当用四逆汤，但因为脉象急促，知道是阳气内阻，而不是阳虚，所以只用艾灸来通阳，不用温经药来助阳。
伤寒发热四天，厥逆反而三天，再次发热四天，厥少热多的，病应当痊愈；从第四天到第七天热势不退的，必定便脓血。伤寒厥逆四天，发热反而三天，再次厥逆五天，病势为进展。寒多热少，阳气衰退，所以病势进展。
【注】伤寒邪气在厥阴，阳邪则发热，阴邪则厥寒，阴阳错杂，互相胜负交替，所以或厥或热。伤寒发热四天，厥逆也四天，是互相胜负。现在厥逆反而三天，再次发热四天，是热多厥少，阳胜阴退，所以病应当痊愈。应当痊愈却不愈，热势仍不止，则热郁于阴分，后来必定便脓血。如果厥逆四天，发热反而三天，则厥多热少，阴胜阳退，所以病势进展。
【集注】程知说：这就是厥热往复的机理。懂得阴阳进退的意义，明白厥证重在阳气，则厥阴的大旨就昭然若揭了。
张璐说：太阳病以恶寒发热为病进，是担心邪气传入里；厥阴病以厥少热多为病退，是喜欢阴尽阳复。
程应旄说：厥阴与少阳，一脏一腑。少阳在三阳经中为尽头，阳尽则阴生，所以有寒热往来的症状；厥阴在三阴经中为尽头，阴尽则阳生，所以有厥热胜负交替的症状。凡是遇到这种证候，不必讨论它是来自三阳还是起自三阴，只讨论厥与热的多少。热多厥少，知道是阳胜，阳胜病当愈；厥多热少，知道是阴胜，阴胜病日进。热在后面而不退，则为阳过胜，过胜而阴不能复，于是有便血等各种热证；厥逆在后面而不退，则为阴过胜，过胜而阳不能复，于是有亡阳等各种死证。所以调停二者的治法，必须合乎阴阳进退的机理，阳胜宜下，阴胜宜温。如果不尽早谋划，坐视阴竭阳亡，其死亡是必然的。
吴人驹说：《内经》说，人受寒邪侵袭，就会得热病。热势即使很重也不会死，这说明伤寒以热为贵。然而热不及会生病，太过也会生病。所以这两节内容，论述寒热的多少，是为了说明不可太过与不及。
伤寒开始发热六天，厥逆反而九天并伴有下利，凡是厥逆下利的病人，应当不能吃东西，现在反而能吃东西的，恐怕是除中（胃气将绝的回光返照），给吃面条饼，如果不发热，就知道胃气尚在，病必痊愈。担心是暴热来临，出来后又消失，三天后诊察脉象，如果热势持续存在，预期在第二天半夜痊愈。之所以这样，是因为本来发热六天，厥逆反而九天，再次发热三天，加上前面的六天，也是九天，与厥逆的天数相应，所以预期在第二天半夜痊愈。三天后诊察脉象如果脉数，热势不消退的，这是热气有余，必定会发生痈脓。
【按】“不发热者”的“不”字，应当是“若”字。如果是“不”字，那就是除中，怎么下面接着写“恐暴热来出而复去”的文字呢？
【注】热而不厥为阳，厥而不热为阴。伤寒开始发热六天，厥逆也六天，到第七天仍然发热而不厥逆的，是阳气来复，应当自愈。现在厥逆九天，比发热多三天，是阴胜阳，所以下利。凡是厥逆下利的，中焦必定寒，应当不能吃东西，现在反而能吃东西，恐怕是阴邪除去胃中阳气，而形成除中的病证。“恐”字，是怀疑而未定的说法。所以用面条饼试探：进食后不发热，就是除中；如果发热，就知道胃气尚在，就不是除中，可以断定病会痊愈。如果进食后虽然暴发热，担心热暂时出来后又消失，仍是除中，所以必须等待三天，如果热势持续不去，与厥逆的天数相应，才可以预期在第二天半夜痊愈。如果等待三天后，虽然热势不消退也不痊愈，而且脉象仍然数，这是热气有余，留连于营卫之间，必定发生痈脓。
【集注】方有执说：食，喂的意思。索，常的意思。谓用素常所吃的饼来喂他。另一种说法是无肉曰索，谓不让犯饮食禁忌。旦日，明日清晨，早晨阳气生长的时候；夜半，阴尽阳生的时候，用数来候察热势。痈脓，是因为厥阴主血，血热持久则壅滞瘀积，壅滞瘀积则腐化，所以可以断定。
吴人驹说：除，去除的意思；中，中气的意思。乃中气除去，想要借助外食来自救。
伤寒病脉迟，六七天，却反而用黄芩汤清除其热，脉迟为寒，现在给予黄芩汤又清除其热，腹中应当冷，应当不能吃东西，现在反而能吃东西，这名叫除中，必定死亡。
【按】“伤寒脉迟，六七日”之下，应当有“厥而下利”四字，如果没有这四字，就不是除中证了。有了这四字，才开始与下文反用黄芩汤的意义相联系。
【注】伤寒病脉数，六七天，厥逆并下利，是热厥下利，应当给予黄芩汤清除其热。现在伤寒病脉迟，六七天，厥逆并下利，是寒厥下利，应当给予理中汤温其寒。却反而给予黄芩汤又清除其热，腹中应当冷，应当不能吃东西，现在反而能吃东西，这名叫除中。这是胃气将绝，寻求食物以自救，终究对胃没有补益，所以说必定死亡。
【集注】方有执说：反，指不合于正道。黄芩汤，是寒药。彻，也是除的意思。应，也是当的意思。反能食者，胃欲……
Abdominal fullness, with pain upon pressure. In the *Shanghan Lun* (Treatise on Cold Damage), it is stated: If there is fullness in the lower abdomen, pain upon pressure, and free urination, this is a syndrome of Blood Stagnation in the Bladder (Xue Jie Pang Guang Zheng); if urination is difficult, it is a syndrome of Water Stagnation in the Bladder (Shui Jie Pang Guang Zheng); if the hands and feet are hot, and urination is scanty, dark, and painful, it is a syndrome of Heat Stagnation in the Bladder (Re Jie Pang Guang Zheng). Here, however, the hands and feet are cold, and urination is frequent and pale; thus, we know this is a syndrome of Cold Stagnation in the Bladder (Leng Jie Pang Guang Zheng).
[Collected Commentaries] Cheng Wuji said: Cold extremities without chest binding indicate the absence of heat. Fullness in the lower abdomen with pain upon pressure indicates Cold Stagnation in the Lower Jiao (Xia Jiao Leng Jie).
Cheng Zhi said: When Yang pathogens accumulate above and Yin pathogens accumulate below, resulting in cold extremities, lower abdominal fullness, and pain upon pressure, it is evident that Yin pathogens are accumulating in the lower part. In such cases, warming methods or moxibustion should be employed. Guanyuan (CV4) is an acupoint located three cun below the umbilicus. It is the seat of extreme Yin and the convergence point of the Foot Three Yin meridians and the Ren Mai (Conception Vessel), and it is the residence of the Bladder.
Cheng Yingmao said: Although cold extremities occur without chest binding, the lower abdominal fullness, firmness, pain, and stagnation seem to suggest the use of purgatives. However, stagnation in the Lower Jiao is mostly cold, unlike stagnation in the Upper Jiao which is mostly heat. Moreover, since the upper Jiao has no stagnation and only the Bladder and Guanyuan area have stagnation, it is termed Cold Stagnation.
In all cases of Jue (Cold Extremities), it is because the Yin and Yang Qi fail to connect smoothly, leading to Jue. Jue refers to the condition of cold extremities. For patients with various forms of Si Ni (Four Coldness) and Jue, purgatives must not be used. This also applies to patients with deficiency constitutions.
[Annotation] This section details the causes of various types of Jue, emphasizing that purgatives must absolutely not be used. Although Jue can occur in all Yin meridians, it belongs specifically to the Jueyin Meridian. Therefore, any Jueyin disease presents with Jue, regardless of whether it is cold or heat; without Jue, it is not a Jueyin disease. In Taiyin disease, the cold is mild, so the hands and feet are warm without Jue; in Shaoyin disease, the cold is severe, so there is only Cold Jue without Hot Jue; in Jueyin disease, where extreme Yin generates Yang, both Cold Jue and Hot Jue may occur. "Jue" refers to Jue caused by Yin/Yang and Cold/Heat imbalances. "Failure of Yin and Yang to connect smoothly" means the Qi of Yin and Yang fails to communicate and connect. When they fail to connect, Yang acts independently as Yang and manifests as heat, while Yin acts independently as Yin and manifests as cold, forming the Jue disease. The symptom of Jue is cold extremities. "Various Si Ni Jue" refers to diseases characterized by cold extremities. Since the Yin and Yang Qi in Jue disease have failed to connect, purgatives must be strictly avoided. For deficient patients presenting with Jue, purgatives are even more contraindicated, hence the statement "deficient patients are the same."
[Collected Commentaries] Cheng Wuji said: The Three Hand Yin and Three Hand Yang meridians connect at the ten fingers of the hands; the Three Foot Yin and Three Foot Yang meridians connect at the ten toes of the feet. When Yang Qi sinks inward and fails to connect smoothly with Yin, the hands and feet become cold.
Yu Chang said: Regarding Jueyin syndromes, Zhang Zhongjing generally avoids purgatives, aiming instead to return pathogens to the exterior and resolve Yin pathogens through Yang. Here, only two extreme cases where purgatives are forbidden are cited to strictly warn practitioners.
After five or six days of Shanghan, if there is no chest binding, the abdomen is soft, the pulse is weak, and Jue recurs, purgatives must not be used. This is due to loss of blood (Wang Xue); using purgatives here would lead to death.
[Note] The term "chest binding" (Jie Xiong) here should likely be "stool" (Da Bian). If there is no chest binding, the abdomen is soft, the pulse is weak, and Jue recurs, there is no rationale for purgation. Why then say "do not purge"?
[Annotation] This follows the previous clause to elaborate on the principle against purgation. After five or six days of Shanghan, when pathogens reach the Jueyin stage, constipation might seem to warrant purgation. However, if the abdomen is soft, the pulse is weak, and Jue recurs, this indicates blood loss and deficiency restlessness; purgation is even more contraindicated. Purgation would violate the rule against further weakening the deficient, leading to death. This pattern is common after profuse sweating in major illnesses or in postpartum women who have lost blood.
[Collected Commentaries] Zhang Lu said: After five or six days of Shanghan, pathogens enter Jueyin, and heat is profound. Now, with a weak pulse and Jue, this is not comparable to cases where profound heat requires purgation. Due to blood loss and fluid injury causing dry stool, people might mistakenly recognize this as the dry accumulation of Yangming heat entering after five or six days. Hence, the warning against purgation. A weak pulse and soft abdomen indicate no heat inside or outside. Jue indicates Yin Qi is dominant, so it should be treated like blood loss cases. If the patient's Yin blood is more deficient than Yang, or if slight Yang pathogen is mixed within Yin, making them unable to tolerate pungent-warm herbs, it falls under the Danggui Sini Tang (Angelica Decoction for Nourishing Blood and Unblocking Collaterals) syndrome.
In Shanghan disease, if Jue lasts five days and fever lasts five days, and on the sixth day Jue should recur but does not, the disease will heal spontaneously. Since Jue does not exceed five days and fever lasts five days, we know it will heal.
[Annotation] When Shanghan pathogens transmit to Jueyin, the disease involves complex Yin-Yang interactions. If Yang connects with Yin, there is Yang within Yin, so there is no cold extremity; if Yin connects with Yang, there is Yin within Yang, so there is no fever. Only when Yin is excessive and does not connect with Yang does Yin act alone as Yin, causing cold extremities; when Yang is hyperactive and does not connect with Yin, Yang acts alone as Yang, causing fever. Generally, when Jue and Heat contend, reversal occurs, and the disease progresses; when Jue and Heat are balanced, harmony occurs, and the disease heals. Now, since the days of Jue and Heat are equal, the Qi naturally balances, indicating Yin-Yang harmony and spontaneous healing.
[Collected Commentaries] Fang Youzhi said: Five days of Jue and five days of Heat indicate no bias in Yin-Yang contention. If Jue should recur but does not, it shows Yang has prevailed. Since Yang governs life, spontaneous healing is known.
Zhang Lu said: Here, saying Jue does not exceed five days refers to the normal course of Jue; later, saying Jue lasts nine days with diarrhea refers to the variation. Normal courses are easier to treat; variations are harder to recover from.
Lin Lan said: In Three Yin Shanghan, Taiyin starts with warm hands and feet; Shaoyin has cold hands and feet; Jueyin has cold extremities. However, reaching Jueyin, the extreme of Yin, why is there fever? Because extreme Yang generates Yin, Yang diseases present with cold extremities; extreme Yin generates Yang, so Jue presents with fever lines.
In Shanghan, if heat is slight and Jue is mild, with only cold fingertips, silence, anorexia, and irritability for several days, if urination is free and white, this indicates heat has resolved. Desire to eat indicates the disease will heal. If Jue occurs with vomiting and chest/hypochondriac fullness and irritability, bloody stools will follow later.
[Annotation] Slight heat and mild Jue mean the hands and feet are not cold, only the fingertips are cold, indicating shallow cold pathogens. Silence is Yin; irritability is Yang. Anorexia indicates stomach disharmony. This is a mild case of Jueyin complex Yin-Yang disorder, corresponding to the "slight heat, slight Jue" syndrome in the text. If after several days urination is free and white, heat has gone; desire to eat indicates stomach harmony; with heat gone and stomach harmonized, Yin-Yang naturally balances, so the disease heals. If urination is difficult and red, Jue is severe rather than mild, accompanied by irritability instead of silence, and vomiting with chest/hypochondriac fullness instead of just anorexia, this indicates heat remains and has deepened, corresponding to the "deep Jue, deep heat" syndrome. If deep heat persists and lingers in the Yin aspect, bloody stools will eventually occur. "Several days" implies consecutive days.
[Collected Commentaries] Wang Kentang said: If the patient does not yet desire food, Ganjiang Gancao Tang (Dried Ginger and Licorice Decoction) is suitable. Vomiting with chest/hypochondriac fullness and irritability is a Shaoyang syndrome. Shaoyang and Jueyin are interior-exterior pairs; pathogens invading the Fu organ cause vomiting and fullness. Since the Liver governs blood, bloody stools will follow.
Fang Youzhi said: Slight heat and mild Jue indicate shallow pathogens, so hands and feet are not cold, only fingertips. Silence means speechlessness. Anorexia occurs because the Jueyin meridian accompanies the stomach. Irritability indicates internal heat, distinguished by urination. Desire to eat indicates pathogen retreat and stomach recovery. Jue with vomiting and chest/hypochondriac fullness occurs because the Jueyin meridian accompanies the stomach, pierces the diaphragm, and spreads to the hypochondrium. Bloody stools occur because Yin pathogens move downward through the lower orifices.
Lin Lan said: For Heat Jue, cold fingertips are mentioned. For mild Cold Jue, cold hands and feet are mentioned. For severe cases, Si Ni (four extremities cold) is mentioned. The severity and depth of Jue should be carefully appreciated.
Wang Hu said: According to this clause, Zhang Zhongjing provides no treatment method. Guo Yong states: If heat persists and causes bloody stools, Xijiao Dihuang Tang (Rhino Horn and Rehmannia Decoction) can be used.
If Shanghan presents with Jue between one or two days up to four or five days, fever must follow. If fever preceded Jue, Jue will follow; the deeper the Jue, the deeper the heat; the milder the Jue, the milder the heat. Jue [of the heat type] should be treated with purgation, but if sweating is induced instead, mouth sores and redness will result.
[Annotation] Jue occurring on day one or two and persisting until day four or five indicates Cold Jue due to Yin excess and Yang deficiency. Cold Jue is also called Zang Jue (Visceral Jue). If Jue occurs on day one or two, followed by fever on day four or five; or fever on day one or two, followed by Jue on day four or five, alternating Jue and heat indicates Hot Jue due to mutual Yin-Yang contention. Hot Jue is also called Yang Jue. Deep Jue corresponds to deep heat; mild Jue corresponds to mild heat. This Jue requires purgation (as it is Hot Jue), not warming dispersion (as it is not Cold Jue). Mistaking it for Cold Jue and using warming dispersion will aggravate heat ascending, causing mouth sores and redness.
[Collected Commentaries] Cheng Wuji said: The classic states, "Do not purge various Si Ni." Yet here it says "should purge," requiring careful scrutiny. Ancients noted that although Hot Jue has cold extremities, they may occasionally be warm; although cold, the palms are always warm. Dai Yuanli distinguished cold vs. heat Jue by the warmth/cold and color (red/purple) of the nails, showing utmost caution.
Wang Hu said: This clause describes transmitted heat pathogens, a condition of extreme Yang resembling Yin. Shanghan presenting with Jue on days one to five implies that while it originally febrile on days one-two, Jue on days four-five indicates transmission to Jueyin. "Must have fever" means although limbs and skin feel cold, the interior trunk is hot. "Preceding heat leads to subsequent Jue" clarifies that days one-two are prior, days four-five are posterior, showing extreme heat leads to Jue. Deeply lodged Yang pathogens require bitter-cold purgatives to clear heat, allowing Yin Qi to rise, balancing Yin-Yang and harmonizing limbs. Crude physicians see Jue, mistake it for cold, and use pungent-warm drugs. Pungent-warm drugs ascend, drawing heat upward, causing mouth sores and redness because the Jueyin meridian circles the lips.
If a patient has cold extremities, sudden tight and forceful pulse, and pathogens stuck in the chest, with epigastric fullness, irritability, hunger but inability to eat, the disease is in the chest and requires emesis, preferably Gouti San (Melon Sepal Powder).
[Annotation] Cold extremities with a faint, thin pulse indicate Cold Deficiency, treatable with warming or tonifying. A sudden tight, forceful pulse indicates Cold Excess, treatable with warming or emesis. Frequent irritability and vomiting of roundworms, hunger but inability to eat, indicate disease in the stomach. Current epigastric fullness, irritability, hunger but inability to eat indicate disease in the chest. Cold-fluid excess blocking the chest suppresses Chest Yang, preventing it from reaching the limbs, causing cold extremities, chest fullness, irritability, and anorexia. Emesis is required; Gouti San should be used to vomit out upper pathogens, resolving fullness and reversing Jue.
[Collected Commentaries] Yu Chang said: This differs significantly from Taiyang Chest Binding. The sudden tight pulse indicates sudden pathogen accumulation, so Gouti San is used to vomit out pathogens, allowing Yang pathogens to resolve via Yang.
Cheng Yingmao said: Cold extremities indicate internal pathogen obstruction. Sudden tight pulse means tightness is intermittent, appearing suddenly during pulse flow.
If Shanghan presents with a slippery pulse and Jue, there is internal heat, treated with Baihu Tang (White Tiger Decoction).
[Annotation] Faint/thin pulse, no fever, clear urine, and Jue indicate Cold Deficiency Jue, treated with warming. Sudden tight pulse, no fever, chest fullness, irritability, and Jue indicate Cold Excess Jue, treated with emesis. Forceful pulse, constipation, abdominal fullness/hardness/pain, and Jue indicate Heat Excess Jue, treated with purgation. Now, a slippery pulse with Jue: Slippery is a Yang pulse, indicating internal heat, i.e., Hot Jue. However, without abdominal fullness/pain/constipation, the interior is not solid despite heat. Purging is contraindicated; clearing is appropriate. Thus, Baihu Tang is used.
[Collected Commentaries] Cheng Yingmao said: Slippery pulse with Jue is Yang excess rejecting Yin. Baihu Tang clears interior heat with its cool nature and resolves exterior with its pungent nature, so one should follow the pulse over the symptoms.
Lin Lan said: Hot Jue varies. If pathogens transmit to Fu organs, causing blockage and dry feces, purgation with Chengqi Tang is necessary. If fire extreme resembles water, with intense internal heat but no constipation/dry feces, a slippery pulse indicates deep internal heat, and Jue indicates extreme pathogen sinking. Without Baihu Tang to cleanse extreme heat, how can hyperactive Yang be cleared?
Wu Renju said: Jue results from failure of Yang Qi connection, typically showing Yin pulses. A slippery pulse indicates Qi excess, meaning Yang excess internally repelling Yin externally—internal real heat, external false cold. Baihu Tang clears real heat, resolving Jue. Differentiation: Cold is not severe; superficial touch feels cold, but deep pressure reveals heat.
If Shanghan presents with a rapid pulse and cold extremities, moxibustion may be used.
[Annotation] Yin syndromes showing Yang pulses are not fatal and need not wait for spontaneous resolution. Here, rapid pulse with cold extremities suggests moxibustion because warming is doubted by the Yang pulse, and clearing is hindered by Yin Jue. With no clear evidence of cold/heat in symptoms/pulse, using the rapid Yang pulse for clearing risks misinterpreting the pulse; using the Yin Jue for warming risks misinterpreting the syndrome. Thus, moxibustion offers a middle way, unblocking Yang without aiding heat, restoring extremities without injuring Yin.
[Collected Commentaries] Yu Chang said: Rapid pulse indicates Yang presence. With cold extremities, Yang is likely rejected by Yin and cannot return, so moxibustion is suitable to unblock Yang.
Zhang Lu said: Cold extremities usually require Si Ni Tang. However, the rapid pulse indicates internal Yang obstruction, not Yang deficiency. Thus, only moxibustion is used to unblock Yang, avoiding warm-meridian tonics.
If Shanghan features four days of fever, followed by three days of Jue, then four more days of fever, with less Jue and more heat, the disease should heal. If fever persists from day four to seven, bloody pus stools will occur. If Shanghan features four days of Jue, followed by three days of fever, then five more days of Jue, the disease progresses. More cold than heat indicates Yang decline, hence progression.
[Annotation] In Jueyin Shanghan, Yang pathogens cause fever, Yin pathogens cause Jue/cold, creating complex Yin-Yang alternation. Four days fever, four days Jue indicates contention. Now, three days Jue, four days fever indicates more heat, less Jue, Yang prevailing over Yin, so healing is expected. If healing fails and heat persists, heat stagnates in Yin, leading to bloody pus stools. If four days Jue, three days fever, then five days Jue, more Jue less heat indicates Yin prevailing over Yang, hence progression.
[Collected Commentaries] Cheng Zhi said: This is the mechanism of Jue-Heat alternation. Understanding Yin-Yang advance-retreat clarifies that Jue focuses on Yang, revealing the essence of Jueyin.
Zhang Lu said: Taiyang disease progression is marked by aversion to cold and fever (fear of transmission to interior). Jueyin disease retreat is marked by less Jue and more heat (joy of Yin exhaustion and Yang recovery).
Cheng Yingmao said: Jueyin and Shaoyang are a Zang-Fu pair. Shaoyang ends the Three Yang; Yang end generates Yin, causing cold-heat alternation. Jueyin ends the Three Yin; Yin end generates Yang, causing Jue-heat contention. Regardless of origin, focus on Jue vs. Heat quantity. More heat/less Jue = Yang prevails = healing. More Jue/less heat = Yin prevails = progression. Persistent late heat = Yang excess, Yin cannot recover, leading to bleeding/heat syndromes. Persistent late Jue = Yin excess, Yang cannot recover, leading to Yang collapse/death. Treatment must balance Yin-Yang dynamics: Yang excess needs purging, Yin excess needs warming. Delay leads to Yin exhaustion/Yang collapse and death.
Wu Renju said: *Neijing* states cold invasion causes heat. Even severe heat is not fatal, valuing heat in Shanghan. However, insufficient heat causes illness, and excess heat also causes illness. These sections discuss heat/cold quantities to show neither excess nor deficiency is acceptable.
If Shanghan starts with six days of fever, followed by nine days of Jue with diarrhea, patients with Jue/diarrhea normally cannot eat. If the patient now eats, suspect Chu Zhong (Stomach Qi extinction/rebound). Feed noodle cakes; if no fever ensues, Stomach Qi remains, and healing is certain. Fear is that sudden heat comes and goes. Check pulse after three days; if heat persists, expect healing at dawn/midnight next day. Reason: Originally 6 days fever, 9 days Jue. Plus 3 days new fever equals 9 days total, matching Jue days, hence expectation of healing at dawn/midnight. If pulse is rapid after three days and heat persists, this is excess heat, likely causing carbuncles/pus.
[Note] The character "bu" (not) in "no fever" should be "ruo" (if). If it were "not," it would be Chu Zhong, contradicting the following text about fearing sudden heat.
[Annotation] Heat without Jue is Yang; Jue without heat is Yin. Six days fever, six days Jue, then fever without Jue on day seven indicates Yang recovery and healing. Now, nine days Jue (three more than fever) indicates Yin prevailing over Yang, causing diarrhea. Normally, Jue/diarrhea implies middle cold and anorexia. Eating suggests Yin pathogens destroying Stomach Yang, forming Chu Zhong. "Suspect" implies uncertainty. Testing with noodles: No fever after eating = Chu Zhong. Fever after eating = Stomach Qi remains, not Chu Zhong, healing certain. If sudden fever occurs, fear it is transient Chu Zhong. Wait three days; if heat persists and matches Jue duration, expect healing at dawn/midnight. If after three days heat persists without healing and pulse is rapid, this is excess heat lingering in Ying/Blood, likely causing carbuncles/pus.
[Collected Commentaries] Fang Youzhi said: "Shi" means feed. "Suo" means common/plain. Feed plain noodles. Another view: "Suo" means meatless, avoiding dietary taboos. "Dan ri" is tomorrow morning, time of Yang growth. "Ye ban" is midnight, Yin end/Yang birth. Carbuncles/pus occur because Jueyin governs blood; prolonged blood heat causes stasis and putrefaction.
Wu Renju said: "Chu" means remove; "Zhong" means Middle Qi. Middle Qi is removed, seeking external food for self-rescue.
If Shanghan presents with a slow pulse for six-seven days, and Huangqin Tang (Scutellaria Decoction) is wrongly used to clear heat, knowing slow pulse indicates cold, giving Huangqin Tang again clears heat. The abdomen should be cold, and the patient should not eat. If the patient now eats, this is named Chu Zhong, and death is certain.
[Note] Under "Shanghan slow pulse, six-seven days," the characters "Jue and diarrhea" should be inserted. Without them, it is not Chu Zhong. With them, it aligns with the subsequent wrong use of Huangqin Tang.
[Annotation] If Shanghan has a rapid pulse for six-seven days with Jue and diarrhea, it is Heat Jue diarrhea, treated with Huangqin Tang to clear heat. Now, Shanghan has a slow pulse for six-seven days with Jue and diarrhea, it is Cold Jue diarrhea, treated with Lizhong Tang to warm cold. Instead, giving Huangqin Tang clears heat, causing abdominal cold and anorexia. If the patient eats, this is Chu Zhong. Stomach Qi is nearly extinct, seeking food for rescue, offering no benefit to the stomach, hence death is certain.
[Collected Commentaries] Fang Youzhi said: "Fan" means contrary to the Dao. Huangqin Tang is a cold medicine. "Che" also means clear/remove. "Ying" also means should. "Fan neng shi" (contrary ability to eat) means the stomach desires...