（四逆 尸厥附）
四逆者四肢不温厥者手足冷夫邪在三阳则手足热传到太阴则手足温至少阴则逆而不温至厥阴则为之厥甚于逆也盖
自热至温而四逆至厥者传经之邪也四逆散主之始得之便厥是阴经受邪阳气不足四逆汤主之
王 仲景言四逆与厥者非一或曰四逆或曰厥或曰厥逆厥冷厥寒或曰手足逆冷手足厥逆手足厥冷手足厥逆冷俱是
言
寒冷耳故厥逆二字每每互言未尝分逆为不温厥为冷也既曰不温则为冷矣尚何异乎然四肢与手足却有所分以四字加逆字
之上者是通指手足臂胫以上言也以手足字加厥逆厥冷等上及无手足字者是独指手足言也虽然厥逆俱为寒冷却有阴阳之
殊热极而成厥逆者阳极似阴也仲景以四逆散寒药治之是也寒极而成厥逆者独阴无阳也仲景虽无四逆汤热药治四逆之条
但四逆汤之名由四肢之冷而立今以四逆汤治手足厥冷岂非逆厥之不异乎成氏既谓四逆为热邪至少阴病死证二条下又谓
四逆为寒甚不自悖其说乎是知四逆亦犹厥之有寒有热但四肢通冷比之手足独冷则有间耳故仲景曰少阴病吐利烦躁四逆
者死又曰少阴病四逆恶寒而蜷脉不至不烦而躁者死又曰少阴病吐利手足厥冷烦躁欲死者吴茱萸汤此三条二为死一为可
治虽通由诸证兼见而然然死者以四逆言可治者以厥冷言可见四逆重于厥冷矣成氏谓厥甚于逆岂不谬耶
按凡言四逆或言厥言逆者皆为重证若举四肢而言耳言指头寒言手足厥与逆与冷者皆为厥微盖手之上为腕腕上为臂
足之上为踝踝之上为胫也其病之轻重浅深皆寓于书法之中不可不审自热至温自温至厥乃传经之邪四逆散主之厥逆大便
秘小便赤或大便黑脉沉而滑此为阳证似阴白虎汤甚者大承气汤不可误也
太阳 伤寒脉浮自汗出小便数心烦微恶寒脚挛急反与桂枝汤欲攻其表此误也得之便厥咽中干烦躁吐逆者作甘草干
姜汤与之太阳中风脉浮紧发热恶寒身疼痛不汗出而烦躁者大青龙汤主之若脉微弱汗出恶风者不可服 服之则厥逆筋惕肉
此为逆也（真武汤方见下利太阳止有二证皆误发表所致汗多亡阳故温之）
甘草干姜汤方
甘草（炙四两） 干姜（二两炮）上 咀以水三升煮取一升五合去滓分温再服（内经曰辛甘发散为阳甘草干姜相合
以复阳气）
阳明 病反无汗而小便利二三日呕而咳手足厥者必苦头痛若不咳不呕手足不厥者头不痛伤寒脉滑而厥者里有热也
白虎汤主之三阳合病腹满身重难以转侧口不仁而面垢谵语遗尿发汗则谵语下之则额上生汗手足逆冷若自汗出者白虎汤
主之
少阴 病吐利手足厥冷烦躁欲死者吴茱萸汤（方见吐）少阴病下利脉微者与白通汤利不止厥逆无脉干呕烦者白通加
猪胆汁汤脉暴出者死微续者生少阴病下利清谷里寒外热手足厥逆脉微欲绝身反不恶寒其人面色赤或腹痛或干呕或咽痛
或利止脉不出者通脉四逆汤（俱见下利）少阴病四逆其人或咳或悸或小便不利或腹中痛或泄利下重者四逆散（方见少阴
病按言四者四肢之省文也四肢者自指至肘足至膝是也其邪为深凡言手足者自指至腕足至踝而已其邪为浅仲景下字不苟
得之则轻重浅深一览了然矣赵仲景上文但云少阴病四逆活人第八十问中改作四肢厥逆设遇寒厥下利腹痛而咳者根据其言
而用四逆散之凉剂可乎夫邪自阳经入里而厥者是热极而厥也是或可用若直入阴经之寒邪而欲厥者是为以水济水尤当戒
之学人宜详究焉）
少阴病恶寒身蜷而利手足逆冷者不治 少阴病吐利烦躁四逆者死少阴病四逆恶寒而身蜷脉不至不烦而躁者死少阴
病但厥无汗而强发之必动其血未知从何道出或从口鼻或从目出是名下厥上竭为难治（但厥无汗热入里而外寒甚也当温之
而强发其汗则卫寒甚而汗不能出必内伤其荣血而妄行也诸厥者皆属下但厥为下厥血亡于上为上竭）
厥阴 伤寒先厥后发热而利者必自止见厥复利（四逆散张 或云三阴经伤寒太阴为始则手足温少阴则手足清厥阴则
手足厥逆然病至厥阴乃阴之极也何故反有发热之理盖阳极则阴生阴极则阳生此阴阳推荡必然之理也易云穷则变穷者至
极之谓也阳至极而生阴故阳病有厥冷之证阴至极而生阳则厥逆者有发热之条凡言厥深热亦深者乃事之极而变之常经曰
亢则害承乃制是也）伤寒厥而心下悸者宜先治水当服茯苓甘草汤却治其厥不尔水渍入胃必作利也（成 金匮要略曰水停
心下甚者则悸厥虽寒胜然以心下悸为水饮内甚先与茯苓甘草汤治其厥而后治其水若先治厥则水饮浸渍入胃必作下利）
茯苓甘草汤方
茯苓 桂枝（去粗皮各二两） 生姜（三两切） 甘草（炙一两）上四味以水四升煮取二升去滓分温三服（茯苓甘
草之甘益津而和卫桂枝生姜之辛助阳气而解表）
伤寒六七日大下后寸脉沉而迟手足厥逆下部脉不至咽喉不利吐脓血泄利不止者为难治麻黄升麻汤主之（方见下利）
手足厥寒脉细欲绝者当归四逆汤主之（成 手足厥寒者阳气外虚不温四末脉细欲绝者阴血内弱脉行不利与当归四逆汤助
阳生阴也）
当归四逆汤方
当归 桂枝（去粗皮） 芍药 细辛（各三两） 甘草（炙） 通草（各二两） 大枣（二十五枚擘）上七味以水
八升煮取三升去滓温服一升日三服（内经曰脉者血之腑也诸血者皆属心通脉者必先补心益血苦先入心当归之苦以助心血
心苦缓急食酸以收之芍药之酸以收心气肝苦急急食甘以缓之大枣甘草通草之甘以缓阴血）
下利脉沉而迟其人面少赤身有微热下利清谷者必郁冒汗出而解病患必微厥所以然者其面戴阳下虚故也
下利后脉绝手足厥冷 时脉还手足温者生脉不还者死下利清谷里寒外热汗出而厥者通脉四逆汤大汗出热不去内拘
急四肢疼又下利厥逆而恶寒者四逆汤（吐）病患手足厥冷脉乍紧者邪结在胸中心中满而烦饥不能食者病在胸中当须吐之
宜瓜蒂散（方见气上冲心）伤寒（下）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（伤寒一二日至四五日而厥者必发热是传经之邪前热后厥者亦传经之邪当以厥之微甚辨热之深浅
若厥热入腑而实者须下去之若反发汗则胃中津液愈燥竭而热故必口伤烂赤然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院使又以指甲之暖冷别热寒二厥临病之工慎之）诸
四逆厥者（禁）不可下虚家亦然伤寒五六日不结胸腹濡脉虚复厥者不可下此为亡血下之必死伤寒（灸）脉促手足厥逆者
可灸之
诊 凡厥者阴阳气不相顺接便为厥厥者手足逆冷是也（成手之三阴三阳相接于手十指足之三阴三阳相接于足十
指阳
气内陷阳不与阴相顺接故手足为之厥冷也）伤寒发热四日厥反三日复热四日厥少热多其病当愈四日至七日热不除者其后
必便脓血（成 先热后厥者阳邪传里也发热为邪气在表至四日后厥者传之阴也后三日复传阳经则复热厥少则邪微热多为
阳胜其病为愈至七日传经尽热除则愈热不除者为热气有余内搏厥阴之血其后必大便脓血）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（成 始发热
邪在表也至六日邪传厥阴阴气胜者作厥而利厥反九日阴寒气多当不能食而反能食者恐为除中除去也中胃气也言邪气太
甚除去胃气胃欲引食自救故暴能食此邪胜也食以索饼试之若胃气绝得面则必发热若不发热者胃气尚在也恐是寒极变热
因暴热来而复去使之能食非除中也金匮要略曰病患索不能食而反暴思之必发热后三日脉之其热续在者阳气胜也期之旦
日夜半愈若旦日不愈后三日脉数而热不罢者为热气有余必发痈脓经曰数脉不时则生恶疮）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（成 阴胜则厥阳胜则热先厥五日为阴胜至六日阳复胜热亦五日后复
厥者阴复胜若不厥为阳全胜故自愈经曰发热四日厥反三日复热四日厥少热多其病为愈）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（指头寒者是厥微热少也默默不欲食烦
躁者邪热初传里也数日之后小便色白里热去欲得食为胃气已和其病为愈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府故呕而胸胁烦满也肝主血故后必便血）少腹满痛而厥为冷结关元（详少腹满痛）发热（不
治）而厥七日下利者为难治伤寒六七日脉微手足厥冷烦躁灸厥阴厥不还者死（厥阴六穴岂按四时灸井荣俞经合耶）
伤寒发热下利厥逆躁不得卧者死伤寒发热下利至甚厥不止者死下利手足厥冷无脉者灸之不温若脉不还反微喘者死
附
活 冷厥者初得病日便四肢逆冷脉沉微而不数足多挛卧时恶寒或自引衣盖覆不饮水或下利清谷或清便自调或小
便
数外证多惺惺而静脉虽沉实按之迟而弱者知其为冷厥也四逆汤理中汤通脉四逆汤当归四逆汤当归四逆加吴茱萸生姜汤
白通加猪胆汁汤随证用之
热厥者国中病必身热头痛外别有阳证二三日至四五日方发厥兼热厥者厥至半日却身热盖热气深方能发厥须在二三
日后也若微厥却发热者热深故也其脉虽伏按之而滑者为里热其人或畏热或饮水或扬手掷足烦躁不得眠大便秘小便赤外
证多昏愦者知其热厥也白虎承气汤随证用之
又有下证悉具而见四逆者是失下后血气不通四肢便厥医人不识却疑阴厥复进热药祸如反掌大抵热厥须脉沉伏而滑
头上有汗其手虽冷时复指爪温须用承气汤下之不可拘忌也
诸手足逆冷皆属厥阴不可汗下然有须汗须下者正谓手足虽逆冷时有温时手足掌心必暖非正厥逆也当消息之
海 厥阴证四肢厥冷爪甲青脉沉疾按之有力者为阳则当下宜大承气汤如脉沉迟按之无力者为阴则当温宜四逆汤
更须速灸之
罗 省掾曹德裕男妇二月初病伤寒八九日请予治之脉得沉细而微四肢逆冷自利腹痛目不欲开两手常抱腋下昏昏
嗜卧口舌干燥乃曰前医者留白虎加人参汤可服否予曰白虎虽云治口燥舌干若只此一句亦未然今此证不可服白虎者有三伤
寒证云立夏以前立秋以下不可妄用一也太阳证无汗而渴者不可用二也况病患阴证悉具其时春气尚寒三也仲景云下利清谷
急当救里宜四逆汤五两人参一两生姜十余片连须葱白九茎水五大盏同煎至三盏去滓分三服一日服之至夜则止手足温翌
日大汗而解继之以理中汤数服而愈孙真人习业论云凡欲为太医必须精读甲乙素问黄帝针经明堂流注十二经络三候九部
本草药性仲景叔和并须精熟如此方为太医不则犹无目夜游动致颠陨执此用药者再思可矣
阳证治验 真定府赵吉夫年三十三至元五月间因劳役饮食失节伤损脾胃时发烦躁而渴又食冷物过度遂病身体困
倦头痛四肢逆冷呕吐而心下痞医人不察见其四肢逆冷呕吐而心下痞乃用桂枝末三钱匕热酒调下仍以绵衣覆之作阴毒伤寒
施治须臾汗大出汗后即加口干舌涩眼白时红项强硬肢体不柔和小便淋赤大便秘涩循衣摸床如发狂状问之则言语错乱视
其舌则赤而欲裂朝轻暮剧凡七八日家人辈悉谓危殆不望生全邻人吉仲完举予治之诊其脉七八至知其热证明矣遂用大承
气汤苦辛大寒之剂一两作一服服之利下三行折其胜势翌日以黄连解毒汤大苦寒之剂二两徐徐服之以去其热三日后病十
分中减五六更与白虎加人参汤约半斤服之泻热补气前证皆退戒以慎起居节饮食月余渐得平复内经曰凡用药者无失天时
无逆气宜无翼其胜无赞其复是谓至治又云必先岁气无伐天和当暑气方盛之时圣人以寒凉急救肾水之原补肺金之不足虽
有客寒伤人仲景云用麻黄汤内加黄芩知母石膏之类恐发黄发斑又用桂枝汤之戒况医以桂末熟酒调服所谓差之毫厘谬以
千里逆仲景之治法经云不伐天和不赞其复不翼其胜不失气宜不然故疾未已新病起矣
用热远热从乎中治 友人刘巨源年六十五岁至正夏月因劳役饮食失节又伤冷冻饮料得疾医者往往以为四时证治之不
愈
逮十日请予治诊之右手三部脉沉细而微太阴证也左手三部脉微浮而弦虚阳在表也大抵阴多而阳少今所苦身体沉重四肢
逆冷自利清谷引衣自覆气难布息懒言语此脾受寒湿中气不足故也仲景言下利清谷急当救里宜四逆汤温之内经有用热远
热之戒口干但漱水不咽早晨身凉而肌生粟午后烦躁不欲去衣昏昏睡而面赤隐隐红斑见于皮肤此表实里虚故也内虚则外
证随时而变详内外之证乃饮食劳倦寒伤于脾胃非四时之证明矣治病必察其下今适当大暑之时而得内寒之病以标本论之
时为标也病为本也用寒药则顺时而违本用热药则从本而逆时此乃寒热俱伤必当从乎中治中治者温之是也遂以钱氏白术
（四逆 附尸厥）
所谓四逆，是指四肢不温暖；所谓厥，是指手足冰冷。邪气在太阳、阳明、少阳三阳经时，手足发热；传到太阴经时，手足温和；传到少阴经时，则逆而不温；传到厥阴经时，就发展为厥，比“逆”更严重。
从热到温，再到四逆，最后到厥，这是传经的邪气所致，用四逆散主治。如果刚得病就出现厥冷，这是阴经受邪，阳气不足，用四逆汤主治。
王肯堂按：张仲景所说的四逆与厥的情况不止一种。有人说四逆，有人说厥，有人说厥逆，有人说厥冷，有人说厥寒，还有人说手足逆冷、手足厥逆、手足厥冷、手足厥逆冷，这些都是指寒冷罢了。所以“厥逆”二字常常互用，并没有把“逆”解释为不温、“厥”解释为冷的区别。既然说不温，那就是冷了，还有什么不同呢？然而，“四肢”和“手足”却有所区分。在“逆”字前加四字（如“四逆”），是通指手、足、臂、胫以上而言；在“厥逆”、“厥冷”等词前加“手足”二字，或者没有“手足”二字的，是独指手和足而言。虽然“厥”和“逆”都是寒冷，但有阴阳的区别。热极而导致的厥逆，是阳极似阴，张仲景用四逆散这种寒凉药治疗，是正确的。寒极而导致的厥逆，是独阴无阳，张仲景虽然没有专门写用热药治疗四逆的条文，但四逆汤这个名字就是根据四肢寒冷而立名的，现在用四逆汤治疗手足厥冷，难道不是说明“逆”和“厥”没有区别吗？成无己既说四逆是热邪，又在少阴病死证两条下说四逆是寒甚，这不是自相矛盾吗？由此可知，四逆也像厥一样，有寒有热，只是四肢普遍寒冷与仅手足单独寒冷之间略有区别罢了。所以张仲景说：“少阴病，吐利，烦躁，四逆者死。”又说：“少阴病，四逆，恶寒而蜷卧，脉不至，不烦而躁者死。”又说：“少阴病，吐利，手足厥冷，烦躁欲死者，吴茱萸汤主之。”这三条中，两条是死证，一条是可治证。虽然都是因为各种症状兼见所致，但以“四逆”言的是死证，以“厥冷”言的是可治证，可见“四逆”重于“厥冷”。成无己说“厥甚于逆”，难道不是错误吗？
按：凡是说四逆，或者说厥，或者说逆，都是指重证，如果是举四肢而言的话。如果说指头寒，或者说手足厥、逆、冷，都是指厥轻。盖手之上为腕，腕上为臂；足之上为踝，踝上为胫。病的轻重浅深都蕴含在文字的用法之中，不可不仔细审察。从热到温，从温到厥，这是传经的邪气，用四逆散主治。如果厥逆伴有便秘、小便赤，或者大便黑、脉沉而滑，这是阳证似阴，用白虎汤；严重的用大承气汤，不可误治。
太阳伤寒，脉浮，自汗出，小便频数，心烦，轻微恶寒，脚挛急，反而给予桂枝汤想要攻表，这是误治。得此误治后立刻出现厥冷、咽干、烦躁、呕吐逆气的，制作甘草干姜汤给予服用。
太阳中风，脉浮紧，发热，恶寒，身体疼痛，无汗且烦躁的，用大青龙汤主治。如果脉微弱，出汗，恶风的，不可服用。服用了就会引起厥逆、筋惕肉瞤，这是逆证。（真武汤方见下利篇。太阳病只有这两种情况，都是误用发汗法所致，汗多亡失阳气，所以用温法。）
甘草干姜汤方
甘草（炙，四两） 干姜（二两，炮制）。上药切碎，用水三升，煮取一升五合，去渣，分两次温服。（《内经》说：辛甘发散为阳。甘草与干姜相合，可以恢复阳气。）
阳明病，反而无汗而小便通利，两三天后出现呕吐、咳嗽、手足厥冷的，必定头痛。如果不咳嗽、不呕吐、手足不厥冷的，头就不痛。伤寒脉滑而厥冷的，是里有热，用白虎汤主治。三阳合病，腹部胀满，身体沉重，难以翻身侧卧，口不知味，面垢，谵语，遗尿。发汗则谵语加重；攻下则额上出汗，手足逆冷。如果自汗出的，用白虎汤主治。
少阴病，吐利，手足厥冷，烦躁欲死的，用吴茱萸汤主治（方见吐利篇）。少阴病下利，脉微弱的，给予白通汤。如果利不止，厥逆，无脉，干呕，烦躁的，用白通加猪胆汁汤。如果脉搏突然出现的，死；脉搏微微续出的，生。少阴病下利清谷，里寒外热，手足厥逆，脉微欲绝，身体反而不恶寒，其人面色发红，或者腹痛，或者干呕，或者咽痛，或者利止但脉不出者，用通脉四逆汤主治（俱见下利篇）。少阴病四逆，其人或者咳嗽，或者心悸，或者小便不利，或者腹中痛，或者泄利下重的，用四逆散主治（方见少阴病篇。按：文中说“四”是“四肢”的省文。四肢是从手指到肘、从脚趾到膝。其邪气较深。凡是说“手足”的，是从手指到腕、从脚趾到踝而已，其邪气较浅。张仲景用字严谨，得知其意则轻重浅深一目了然。赵嗣真在《活人书》第八十问中将上文改为“四肢厥逆”，如果遇到寒厥、下利、腹痛而咳的人，根据其言论使用四逆散的凉剂，可以吗？邪气从阳经入里而致厥的，是热极而厥，这或许可以用。如果是直入阴经的寒邪而欲致厥的，这是以水济水，尤其应当戒除。学者应当详细研究。）
少阴病，恶寒，身体蜷缩而下利，手足逆冷的，不治。少阴病，吐利，烦躁，四逆的，死。少阴病，四逆，恶寒而身蜷，脉不至，不烦而躁的，死。少阴病，但厥无汗，强行发汗的，必定动血，不知道血液从哪条道流出，或者从口鼻，或者从眼睛流出，这叫下厥上竭，为难治。（但厥无汗，是热入里而外寒甚。应当温之而强行发汗，则卫气寒甚而汗不能出，必定内伤营血而妄行。所有的厥都属于下，但厥为下厥，血亡于上为上竭。）
厥阴伤寒，先厥冷后发热而下利的，必定自行停止；见到厥冷又复现下利。（四逆散。张元素云：三阴经伤寒，以太阴为始，则手足温；少阴则手足清冷；厥阴则手足厥逆。然而病至厥阴乃是阴之极，为何反而有发热的道理？盖阳极则阴生，阴极则阳生，这是阴阳推移激荡必然的道理。《易经》说：穷则变。穷是至极的意思。阳至极而生阴，所以阳病有厥冷的证候；阴至极而生阳，所以厥逆者有发热的条文。凡是说“厥深热亦深”的，是事物的极端变化之常理。《内经》说：亢则害，承乃制，就是这个道理。）伤寒厥冷而心下悸的，应当先治水，当服用茯苓甘草汤，然后再治其厥。否则，水气浸渍入胃，必定导致下利。（成无己注：《金匮要略》说：水停心下甚者则悸。厥虽然是寒胜，但以心下悸为水饮内盛，先给茯苓甘草汤治其厥，然后治其水。如果先治厥，则水饮浸渍入胃，必定导致下利。）
茯苓甘草汤方
茯苓 桂枝（去粗皮，各二两） 生姜（三两，切） 甘草（炙，一两）。上四味，用水四升，煮取二升，去渣，分三次温服。（茯苓、甘草的甘味益津液而调和卫气；桂枝、生姜的辛味助阳气而解表。）
伤寒六七天，经过大力攻下后，寸脉沉而迟，手足厥逆，下部脉摸不到，咽喉不利，吐脓血，泄利不止的，为难治，用麻黄升麻汤主治（方见下利篇）。手足厥寒，脉细欲绝的，用当归四逆汤主治（成无己注：手足厥寒，是阳气外虚，不能温煦四肢末端；脉细欲绝，是阴血内弱，脉行不利。给予当归四逆汤，助阳生阴。）
当归四逆汤方
当归 桂枝（去粗皮） 芍药 细辛（各三两） 甘草（炙） 通草（各二两） 大枣（二十五枚，掰开）。上七味，用水八升，煮取三升，去渣，温服一升，每日三次。（《内经》说：脉是血的府库，所有的血都属于心。通脉必须先补心益血。苦味先入心，当归的苦味以助心血；心苦缓，急食酸味以收敛之，芍药的酸味以收心气；肝苦急，急食甘味以缓之，大枣、甘草、通草的甘味以缓阴血。）
下利，脉沉而迟，其人面部稍微发红，身体有微热，下利清谷的，必定郁冒出汗而解。病患必定轻微厥冷。之所以这样，是因为其面戴阳，下虚的缘故。
下利后，脉绝，手足厥冷，过了一会儿脉搏回复，手足温暖的，生；脉搏不回复的，死。下利清谷，里寒外热，出汗而厥冷的，用通脉四逆汤。大汗出，热不退，内部拘急，四肢疼痛，又下利，厥逆而恶寒的，用四逆汤（吐利篇）。病患手足厥冷，脉搏突然紧实的，邪气结在胸中，心中胀满而烦，饥饿但不能进食的，病在胸中，应当用吐法，宜用瓜蒂散（方见气上冲心篇）。伤寒一二日至四五日而出现厥冷的，必定发热。先前发热的，后来必厥冷。厥深的，热也深；厥微的，热也微。厥应当用下法，而反用发汗法的，必定口腔受伤溃烂发红。（伤寒一二日至四五日而厥的，必定发热，这是传经的邪气。前热后厥的，也是传经的邪气，应当根据厥的轻重辨别热的深浅。如果厥热入腑而实，须用下法。如果反用发汗，则胃中津液更加燥竭而热，所以必定口伤烂赤。然而经文说：所有的四逆者不可下。到这里又说应下，最宜详审。先贤说：热厥手足虽然厥冷，但有时会有温暖的时候。手足虽然逆冷，但手心足心必定暖。戴元礼又以指甲的冷暖来区别热寒两种厥。临证的医生谨慎对待。）诸四逆厥者（禁）不可下，虚家亦然。伤寒五六日，不结胸，腹部柔软，脉虚，又复厥的，不可下，这是亡血。下之必死。伤寒（灸）脉促，手足厥逆的，可灸之。
诊法：凡是厥，是阴阳之气不相顺接，便成为厥。厥是指手足逆冷。（成无己注：手之三阴三阳相接于手十指，足之三阴三阳相接于足十指。阳气内陷，阳不与阴相顺接，所以手足为之厥冷。）伤寒发热四天，厥反三天，又发热四天。厥少热多，其病应当痊愈。第四天到第七天热不退的，其后必定便脓血。（成无己注：先热后厥，是阳邪传里。发热为邪气在表，至第四日后厥，是传至阴经。后三日又传阳经则复热。厥少则邪微，热多为阳胜，其病为愈。至七日传经尽，热除则愈。热不除，是热气有余，内搏厥阴之血，其后必大便脓血。）伤寒厥四天，热反三天，又厥五天，其病为进展。寒多热少，阳气退，故为进也。伤寒开始发热六天，厥反九天而下利。凡是厥利的，应当不能食，现在反而能食的，恐怕是除中。吃索饼（面条），如果不发热，知道胃气尚在，必定痊愈。恐怕是暴热来出而复去。后三天诊脉，如果热持续存在，预期在旦日夜半痊愈。之所以这样，本来发热六天，厥反九天，又发热三天，加上前面的六天，也为九天，与厥相应，所以预期在旦日夜半痊愈。后三天诊脉，如果脉数，热不罢的，这是热气有余，必定发痈脓。（成无己注：开始发热，邪在表。至六日邪传厥阴，阴气胜者作厥而利。厥反九天，阴寒气多，当不能食，而反能食，恐怕是除中。除去也，指胃气。言邪气太甚，除去胃气，胃欲引食自救，故暴能食，此邪胜也。吃索饼试探，如果胃气绝，得面则必发热；如果不发热，胃气尚在。恐怕是寒极变热，因暴热来而复去使之能食，非除中也。《金匮要略》说：病患素不能食而反暴思之，必发热。后三天诊脉，如果热持续存在，是阳气胜，预期在旦日夜半愈。如果旦日不愈，后三天脉数而热不罢，是热气有余，必发痈脓。经文说：数脉不时则生恶疮。）伤寒病厥五天，热亦五天。设第六天应当复厥，不厥的自愈。厥终不过五天，以热五天，故知自愈。（成无己注：阴胜则厥，阳胜则热。先厥五日为阴胜，至六日阳复胜，热亦五天。后复厥者，阴复胜。若不厥，为阳全胜，故自愈。经文说：发热四天，厥反三天，复热四天，厥少热多，其病为愈。）伤寒热少厥微，指头寒，默默不欲食，烦躁，数日后小便利，色白的，这是热除。想吃饭，其病为愈。如果厥而呕，胸胁烦满的，其后必定便血。（指头寒，是厥微热少。默默不欲食，烦躁，是邪热初传里。数日之后小便色白，里热去，想吃饭为胃气已和，其病为愈。设未想食，宜干姜甘草汤。呕而胸胁烦满，是少阳证。少阳与厥阴为表里，邪干其府，故呕而胸胁烦满。肝主血，故后必便血。）少腹满痛而厥，为冷结关元（详见少腹满痛）。发热（不治）而厥七天，下利的，为难治。伤寒六七天，脉微，手足厥冷，烦躁，灸厥阴穴，厥不还的，死。（厥阴六穴岂是按四时灸井荥俞经合耶？）伤寒发热，下利，厥逆，躁不得卧的，死。伤寒发热，下利至甚，厥不止的，死。下利，手足厥冷，无脉的，灸之不温，如果脉不还，反微喘的，死。
附：
活人书：冷厥者，初得病日便四肢逆冷，脉沉微而不数，足多挛卧，时恶寒，或自引衣覆盖，不饮水，或下利清谷，或清便自调，或小便数。外证多惺惺（清醒），静脉虽沉实，按之迟而弱者，知其为冷厥也。四逆汤、理中汤、通脉四逆汤、当归四逆汤、当归四逆加吴茱萸生姜汤、白通加猪胆汁汤，随证用之。
热厥者，国中病（此处疑为“固”或泛指），必身热头痛，外别有阳证。二三日至四五日方发厥。兼热厥者，厥至半日却身热。盖热气深方能发厥，须在二三日后也。若微厥却发热者，热深故也。其脉虽伏，按之而滑者为里热。其人或畏热，或饮水，或扬手掷足，烦躁不得眠，大便秘，小便赤。外证多昏愦者，知其热厥也。白虎汤、承气汤，随证用之。
又有下证悉具而见四逆的，是失下后血气不通，四肢便厥。医人不识，却疑阴厥，复进热药，祸如反掌。大抵热厥须脉沉伏而滑，头上有汗，其手虽冷，时复指爪温，须用承气汤下之，不可拘忌也。
诸手足逆冷皆属厥阴，不可汗下。然有须汗须下者，正谓手足虽逆冷，时有温时，手足掌心必暖，非正厥逆也。当消息之。
海藏：厥阴证，四肢厥冷，爪甲青，脉沉疾，按之有力者为阳，则当下，宜大承气汤。如脉沉迟，按之无力者为阴，则当温，宜四逆汤。更须速灸之。
罗谦甫：省掾曹德裕男妇，二月初病伤寒八九日，请予治之。脉得沉细而微，四肢逆冷，自利腹痛，目不欲开，两手常抱腋下，昏昏嗜卧，口舌干燥。乃曰：前医者留白虎加人参汤可服否？予曰：白虎虽云治口燥舌干，若只此一句，亦未然。今此证不可服白虎者有三：伤寒证云立夏以前，立秋以下，不可妄用，一也；太阳证无汗而渴者，不可用，二也；况病患阴证悉具，其时春气尚寒，三也。仲景云：下利清谷，急当救里，宜四逆汤五两人参一两生姜十余片连须葱白九茎水五大盏同煎至三盏去滓分三服一日服之。至夜则止，手足温。翌日大汗而解。继之以理中汤数服而愈。孙真人习业论云：凡欲为太医，必须精读甲乙素问黄帝针经明堂流注十二经络三候九部本草药性仲景叔和并须精熟如此方为太医不则犹无目夜游动致颠陨执此用药者再思可矣。
阳证治验：真定府赵吉夫年三十三，至元五月间，因劳役饮食失节，伤损脾胃，时发烦躁而渴，又食冷物过度，遂病身体困倦，头痛，四肢逆冷，呕吐而心下痞。医人不察，见其四肢逆冷，呕吐而心下痞，乃用桂枝末三钱匕，热酒调下，仍以绵衣覆之，作阴毒伤寒施治。须臾汗大出，汗后即加口干舌涩，眼白时红，项强硬，肢体不柔，小便淋赤，大便秘涩，循衣摸床，如发狂状。问之则言语错乱。视其舌则赤而欲裂，朝轻暮剧。凡七八日，家人辈悉谓危殆，不望生全。邻人吉仲完举予治之。诊其脉七八至，知其热证明矣。遂用大承气汤，苦辛大寒之剂一两，作一服，服之利下三行，折其胜势。翌日以黄连解毒汤，大苦寒之剂二两，徐徐服之，以去其热。三日后病十分中减五六，更与白虎加人参汤约半斤服之，泻热补气，前证皆退。戒以慎起居，节饮食，月余渐得平复。内经曰：凡用药者，无失天时，无逆气宜，无翼其胜，无赞其复，是谓至治。又云：必先岁气，无伐天和。当暑气方盛之时，圣人以寒凉急救肾水之原，补肺金之不足。虽有客寒伤人，仲景云：用麻黄汤内加黄芩知母石膏之类，恐发黄发斑。又用桂枝汤之戒。况医以桂末熟酒调服，所谓差之毫厘谬以千里，逆仲景之治法。经云：不伐天和，不赞其复，不翼其胜，不失气宜，不然故疾未已，新病起矣。
用热远热，从乎中治：友人刘巨源年六十五岁，至正夏月，因劳役饮食失节，又伤冷冻饮料得疾。医者往往以为四时证，治之不愈。逮十日，请予治。诊之右手三部脉沉细而微，太阴证也。左手三部脉微浮而弦，虚阳在表也。大抵阴多而阳少。今所苦身体沉重，四肢逆冷，自利清谷，引衣自覆，气难布息，懒言语。此脾受寒湿，中气不足故也。仲景言下利清谷，急当救里，宜四逆汤温之。内经有用热远热之戒。口干但漱水不咽，早晨身凉而肌生粟，午后烦躁不欲去衣，昏昏睡而面赤，隐隐红斑见于皮肤。此表实里虚故也。内虚则外证随时而变。详内外之证，乃饮食劳倦，寒伤于脾胃，非四时之证明矣。治病必察其下。今适当大暑之时而得内寒之病，以标本论之，时为标也，病为本也。用寒药则顺时而违本，用热药则从本而逆时。此乃寒热俱伤，必当从乎中治。中治者，温之是也。遂以钱氏白术...
(Asiatic Cold Extremities [Sini], with Corpse Cold [Shijue] attached)
What is called "Sini" (Asiatic Cold Extremities) refers to the limbs not being warm; what is called "Jue" (Cold Extremities) refers to the hands and feet being cold. When pathogenic factors are in the three Yang meridians (Taiyang, Yangming, Shaoyang), the hands and feet are hot; when transmitted to the Taiyin meridian, the hands and feet are warm; when transmitted to the Shaoyin meridian, they become reversed and not warm; when transmitted to the Jueyin meridian, it develops into "Jue," which is more severe than "Sini."
The progression from heat to warmth, then to Sini, and finally to Jue represents pathogenic factors transmitted through the meridians, treated primarily with Sini San (Four Counterflow Powder). If cold extremities appear immediately upon onset, it indicates pathogenic factors affecting the Yin meridians with insufficient Yang Qi, treated primarily with Sini Tang (Four Counterflow Decoction).
Weng Kentang's Commentary: Zhang Zhongjing mentions various conditions of Sini and Jue. Some refer to Sini, some to Jue, some to Jue-Ni (reversed cold), some to Jue-Leng (cold extremities), some to Jue-Han (cold reversal), and others to Shou-Zu Ni-Leng (hands and feet reversed cold), Shou-Zu Jue-Ni (hands and feet cold and reversed), Shou-Zu Jue-Leng (hands and feet cold and chilled), or Shou-Zu Jue-Ni-Leng (hands and feet cold, reversed, and chilled). All these terms refer to coldness. Thus, "Jue-Ni" are often used interchangeably, without distinguishing "Ni" as merely not warm and "Jue" as cold. Since "not warm" implies cold, what is the difference? However, there is a distinction between "four limbs" (sì zhī) and "hands and feet" (shǒu zú). Adding the character "four" before "Ni" (e.g., Sini) generally refers to the hands, feet, arms, and shins above. Adding "hands and feet" before terms like "Jue-Ni" or "Jue-Leng," or omitting "hands and feet," refers specifically to the hands and feet alone. Although both "Jue" and "Ni" indicate coldness, there is a distinction between Yin and Yang. Jue-Ni caused by extreme heat is "Yang extreme resembling Yin," correctly treated by Zhang Zhongjing with Sini San, a cooling formula. Jue-Ni caused by extreme cold is "Yin extreme without Yang." Although Zhang Zhongjing did not explicitly write a section on using heating medicines for Sini, the name Sini Tang is derived from cold limbs. Using Sini Tang to treat cold hands and feet now suggests that "Ni" and "Jue" are not different. Cheng Wuji stated that Sini is due to heat pathogens, yet also described Sini as extreme cold in two death cases of Shaoyin disease, which seems contradictory. Therefore, Sini, like Jue, can be either cold or heat; the difference lies between general coldness of the four limbs versus isolated coldness of the hands and feet. Thus, Zhang Zhongjing said: "In Shaoyin disease, if there is vomiting, diarrhea, irritability, and Sini, it is fatal." He also said: "In Shaoyin disease, if there is Sini, aversion to cold, curling up, absence of pulse, no irritability but restlessness, it is fatal." He also said: "In Shaoyin disease, vomiting, diarrhea, cold hands and feet, and severe irritability are treated with Wuzhuyu Tang." Among these three cases, two are fatal, and one is treatable. Although all involve combined symptoms, those described as "Sini" are fatal, while those described as "cold extremities" are treatable, indicating that "Sini" is more severe than "cold extremities." Cheng Wuji’s statement that "Jue is more severe than Ni" is erroneous.
Note: Whenever "Sini," "Jue," or "Ni" is mentioned, it refers to a severe condition involving the four limbs. If only the tips of the fingers/toes are cold, or if "Jue," "Ni," or "cold" is specified for hands and feet, it refers to mild Jue. The upper hand is the wrist, above the wrist is the arm; the upper foot is the ankle, above the ankle is the shin. The severity and depth of the disease are embedded in the terminology and must be carefully examined. Progression from heat to warmth, then to Jue, indicates transmitted pathogenic factors, treated with Sini San. If Jue-Ni is accompanied by constipation, red urine, or black stool with a deep and slippery pulse, it is a Yang syndrome resembling Yin, treated with Baihu Tang; severe cases are treated with Dachengqi Tang. Do not mistake this.
In Taiyang Cold Damage, with floating pulse, spontaneous sweating, frequent urination, vexation, slight aversion to cold, and cramped legs, administering Guizhi Tang (Cinnamon Twig Decoction) to attack the exterior is an error. This leads to immediate cold extremities, dry throat, vexation, and vomiting/reversal of Qi. Treat with Gancao Ganjiang Tang (Licorice and Dried Ginger Decoction).
In Taiyang Wind Strike, with tight floating pulse, fever, aversion to cold, body pain, anhidrosis, and vexation, treat with Daqinglong Tang (Major Blue-Green Dragon Decoction). If the pulse is weak, with sweating and aversion to wind, do not administer. Administration causes reversed cold, twitching of sinews, and trembling of flesh, which is a counter-indication. (Zhenwu Tang is found under Diarrhea. These two Taiyang cases result from erroneous sweating, leading to loss of Yang Qi; thus, warming methods are used.)
Gancao Ganjiang Tang Formula:
Gancao (Honey-fried, 4 liang), Ganjiang (Pao-processed, 2 liang). Coarsely crush the herbs, boil in 3 sheng of water to obtain 1.5 sheng, strain, and divide into two warm doses. (*Neijing* states: Pungent and sweet disperse and generate Yang. The combination of Gancao and Ganjiang restores Yang Qi.)
Yangming Disease presenting with anhidrosis but free urination, followed after two to three days by vomiting, coughing, and cold hands and feet, will necessarily involve headache. If there is no vomiting, no coughing, and no cold hands/feet, there is no headache. In Cold Damage, a slippery pulse with cold extremities indicates internal heat, treated with Baihu Tang (White Tiger Decoction). In a combination of the three Yang meridians, with abdominal fullness, heavy body, difficulty turning over, insensitivity of the mouth, greasy facial complexion, delirium, and urinary incontinence: sweating worsens delirium; purgation causes sweating on the forehead and reversed cold hands/feet. If there is spontaneous sweating, treat with Baihu Tang.
Shaoyin Disease with vomiting, diarrhea, cold hands and feet, and severe irritability is treated with Wuzhuyu Tang (Evodia Decoction). Shaoyin Disease with diarrhea and weak pulse is given Baitong Tang (White Passage Decoction). If diarrhea persists, with reversed cold, absent pulse, dry heaving, and vexation, use Baitong Jia Zhu Danzhi Tang (White Passage Decoction plus Pig Gallbladder Bile). If the pulse suddenly appears, it is fatal; if it slowly returns, there is life. Shaoyin Disease with clear undigested food in diarrhea, internal cold with external heat, reversed cold hands/feet, and faint-to-absent pulse, yet the body does not feel cold, and the face is red, or with abdominal pain, dry heaving, sore throat, or cessation of diarrhea with absent pulse, is treated with Tongmai Sini Tang (Pulse-Returning Four Counterflow Decoction). Shaoyin Disease with Sini, where the patient may have cough, palpitations, difficult urination, abdominal pain, or feeling of heaviness in defecation, is treated with Sini San (Four Counterflow Powder). Note: "Si" is an abbreviation for "Si Zhi" (four limbs). Four limbs extend from fingers to elbows and toes to knees, indicating deeper pathology. "Hands and feet" extend from fingers to wrists and toes to ankles, indicating shallower pathology. Zhang Zhongjing’s terminology is precise; understanding it reveals the severity and depth at a glance. Zhao Tizhen in *Huoren Shu* changed the text to "Si Zhi Jue Ni." For patients with cold Jue, diarrhea, abdominal pain, and cough, using the cooling Sini San would be inappropriate. Pathogenic factors entering from Yang meridians causing Jue are due to extreme heat, where this might apply. However, for direct invasion of Yin meridians by cold pathogens causing Jue, this is adding water to water and must be avoided. Scholars should investigate this carefully.
Shaoyin Disease with aversion to cold, curling up, diarrhea, and reversed cold hands/feet is untreatable. Shaoyin Disease with vomiting, diarrhea, irritability, and Sini is fatal. Shaoyin Disease with Sini, aversion to cold, curling up, absent pulse, no irritability but restlessness is fatal. Shaoyin Disease with only Jue and no sweat, forcibly induced sweating will cause blood disturbance, bleeding from mouth/nose or eyes, known as Lower Jue and Upper Exhaustion, which is difficult to treat. (Jue without sweat indicates heat entering interior with severe exterior cold. Warming is indicated; forced sweating makes Wei Qi cold, preventing sweat release, injuring Ying Blood internally. All Jue belong to Lower Jue; blood loss upwards is Upper Exhaustion.)
Jueyin Cold Damage: Initially cold extremities, then fever with diarrhea, which will stop spontaneously; if cold extremities return, diarrhea returns. (Sini San. Zhang Yuansu stated: In Three Yin Cold Damage, starting with Taiyin, hands/feet are warm; Shaoyin, hands/feet are cold/clear; Jueyin, hands/feet are reversed cold. However, Jueyin is the extreme of Yin, so why is there fever? Because Yang extreme generates Yin, and Yin extreme generates Yang, following the law of Yin-Yang transformation. *I Ching* says: At the limit, change occurs. Yang extreme generates Yin, hence Yang diseases have cold extremities; Yin extreme generates Yang, hence Jue diseases have fever. "Deep Jue means deep heat" is the normal change at extremes. *Neijing* says: Hyperactivity causes harm, succession brings regulation.) In Cold Damage, Jue with palpitation below the heart requires treating water first with Fuling Ganjiang Tang (Poria and Ginger Decoction) before treating Jue. Otherwise, water infiltrates the stomach, causing diarrhea. (Cheng Wuji notes: *Jinkui Yaolue* states severe water retention below the heart causes palpitation. Although Jue is due to cold excess, palpitation indicates internal water abundance. Treat Jue with Fuling Ganjiang Tang first, then water. Treating Jue first allows water to infiltrate the stomach, causing diarrhea.)
Fuling Ganjiang Tang Formula:
Fuling, Guizhi (bark removed, 2 liang each), Shengjiang (sliced, 3 liang), Gancao (fried, 1 liang). Boil four ingredients in 4 sheng of water to obtain 2 sheng, strain, and divide into three warm doses. (Sweetness of Fuling and Gancao benefits fluids and harmonizes Wei Qi; pungency of Guizhi and Shengjiang assists Yang Qi and releases the exterior.)
Cold Damage after six or seven days, following severe purgation, presents with deep and slow Cun pulse, reversed cold hands/feet, absent Chi pulse, blocked throat, vomiting of pus/blood, and unceasing diarrhea. This is difficult to treat, managed with Mahuang Shengma Tang (Ephedra and Ma Huang Shen Decoction). Cold hands/feet with fine, nearly absent pulse is treated with Danggui Sini Tang (Angelica Sinensis Four Counterflow Decoction). (Cheng Wuji notes: Cold hands/feet indicates deficient exterior Yang failing to warm extremities; fine/almost absent pulse indicates deficient interior Yin-Blood obstructing pulse flow. Danggui Sini Tang assists Yang to generate Yin.)
Danggui Sini Tang Formula:
Danggui, Guizhi (bark removed), Shaoyao, Xixin (3 liang each), Gancao (fried), Tongcao (2 liang each), Dazao (25 pieces, split). Boil seven ingredients in 8 sheng of water to obtain 3 sheng, strain, take 1 sheng warm, three times daily. (*Neijing* states: Pulse is the house of Blood; all Blood belongs to the Heart. To unblock pulses, one must tonify Heart and benefit Blood. Bitter enters Heart first; Danggui’s bitterness aids Heart Blood. Heart suffers from laxity, requiring sour to astringe; Shaoyao’s sourness astringes Heart Qi. Liver suffers from urgency, requiring sweet to relax; Dazao, Gancao, Tongcao sweetness relaxes Yin-Blood.)
Diarrhea with deep/slow pulse, slightly red face, slight body heat, and clear undigested food in diarrhea leads to dizziness, sweating, and resolution. The patient likely has mild Jue because the red face indicates "Dai Yang" (floating Yang) and lower deficiency.
After diarrhea, if pulse disappears and hands/feet are cold, but pulse returns and hands/feet warm, there is life; if pulse does not return, death. Clear undigested food in diarrhea, internal cold with external heat, sweating, and Jue are treated with Tongmai Sini Tang. Profuse sweating, persistent heat, internal cramping, limb pain, diarrhea, Jue, and aversion to cold are treated with Sini Tang. Cold hands/feet with sudden tight pulse indicates pathogen knotting in the chest, chest fullness, vexation, hunger but inability to eat. The disease is in the chest, requiring emesis with Gouti San (Melon Seed Powder). Cold Damage progressing from one-two days to four-five days with Jue will have fever. Previous heat followed by Jue indicates transmission. Deep Jue means deep heat; mild Jue means mild heat. Jue should be treated with purgation; if sweating is used instead, mouth ulcers and redness occur. (One-two to four-five days with Jue implies transmitted pathogen. Heat precedes Jue, also transmitted. Assess heat depth by Jue severity. If Jue-heat enters Fu organs and becomes excess, purgation is needed. Sweating dries Stomach fluids, increasing heat, causing mouth ulcers. Although texts say "do not purge Sini," here purgation is appropriate. Ancestors note: In Heat Jue, hands/feet may be warm occasionally; palms/soles are warm. Dai Yuanli distinguished Heat/Cold Jue by nail temperature. Physicians must be cautious.) All Sini/Jue cases (contraindicated) should not be purged; this applies to deficient patients too. Cold Damage after five-six days, no Chest Binding, soft abdomen, empty pulse, and recurrence of Jue should not be purged; this is Blood exhaustion. Purging leads to death. Cold Damage with rapid pulse and reversed cold hands/feet can be moxa-ed.
Diagnosis: Jue occurs when Yin and Yang Qi fail to connect smoothly, resulting in cold extremities. (Cheng Wuji notes: Hand/Foot Three Yin/Yang meridians connect at ten fingers/toes. Internal sinking of Yang Qi prevents smooth connection with Yin, causing cold extremities.) Cold Damage with fever for four days, Jue for three, then fever for four days. Less Jue, more heat indicates recovery. If heat persists from day four to seven, pus-blood in stool follows. (Cheng Wuji notes: Heat then Jue is Yang pathogen transmitting inward. Fever is exterior; Jue on day four is transmission to Yin. Recovery of heat after three days is transmission back to Yang. Less Jue/more heat means pathogen weak/Yang strong, indicating recovery. By day seven, transmission ends, heat clears. Persistent heat means excess heat attacking Jueyin Blood, causing pus-blood in stool.) Cold Damage with Jue for four days, heat for three, then Jue for five days indicates progression. More cold, less heat means Yang retreats, so disease advances. Cold Damage starting with fever for six days, Jue for nine days with diarrhea. Normally, Jue/diarrhea patients cannot eat. If eating, suspect "Chu Zhong" (Elimination of Middle). Feeding Suobing (noodles): if no fever, Stomach Qi remains, recovery expected. Fear is sudden heat coming and going. After three days, if pulse shows continuous heat, recovery expected at dawn/midnight. Originally fever 6 days + Jue 9 days + fever 3 days = 9 days, matching Jue duration. If pulse is rapid and heat persists after three days, excess heat causes abscess/pus. (Cheng Wuji notes: Initial fever is exterior. Day six transmission to Jueyin, Yin dominance causes Jue/diarrhea. Nine days Jue means much Yin-Cold, should not eat. Eating suggests Chu Zhong (elimination of Stomach Qi). Excess pathogen forces Stomach to seek food. Test with noodles: if Stomach Qi exhausted, fever ensues with flour; if no fever, Stomach Qi remains. Fear is cold extreme transforming to heat, sudden heat enabling eating, not Chu Zhong. *Jinkui*: inability to eat but sudden craving causes fever. Continuous heat after three days means Yang dominance, recovery at dawn/midnight. No recovery, rapid pulse, persistent heat means excess heat, causing abscess. Text: Irregular rapid pulse causes sores.) Cold Damage with Jue five days, heat five days. If sixth day should recur Jue but doesn't, self-heals. Jue does not exceed five days; heat five days confirms self-healing. (Cheng Wuji notes: Yin dominance causes Jue, Yang dominance causes heat. Five days Jue is Yin dominance. Day six Yang recovers, heat five days. Recurrence of Jue means Yin returns. No Jue means Yang complete dominance, self-healing. Text: Fever 4 days, Jue 3 days, fever 4 days, less Jue more heat, recovery.) Cold Damage with little heat, mild Jue, cold finger tips, silence, anorexia, vexation. After several days, clear urine, white color indicates heat removal. Desire to eat indicates recovery. If Jue with vomiting and chest/hypochondriac fullness/vexation, blood in stool follows later. (Cold fingertips mean mild Jue/little heat. Silence/anorexia/vexation means pathogen heat entering interior. Clear urine/white color later means interior heat gone. Desire to eat means Stomach Qi harmonized. If no desire to eat, Gancao Ganjiang Tang is suitable. Vomiting/chest fullness is Shaoyang syndrome. Shaoyang and Jueyin are exterior-interior pairs; pathogen affects Fu organ, causing vomiting/fullness. Liver governs Blood, hence blood in stool later.) Fullness/pain in lower abdomen with Jue indicates Cold Knotting at Guanyuan (see Lower Abdomen Pain). Fever (untreatable) with Jue for seven days and diarrhea is difficult. Cold Damage six-seven days, faint pulse, cold hands/feet, vexation. Moxa Jueyin points; if Jue does not reverse, death. (Are the six Jueyin points moxa-ed according to seasons/Well-Spring-Stream-River-Sea?) Cold Damage with fever, diarrhea, reversed cold, restlessness unable to lie down is fatal. Fever, severe diarrhea, persistent Jue is fatal. Diarrhea, cold hands/feet, absent pulse. Moxa but not warm; if pulse doesn't return and slight panting occurs, fatal.
Appendix:
*Huoren Shu*: Cold Jue begins with cold extremities, deep/faint/non-rapid pulse, curled legs, aversion to cold, covering with clothes, no thirst, clear undigested diarrhea, or normal stool, or frequent urination. Exterior signs are alert/conscious. Pulse deep/solid but slow/weak on pressure indicates Cold Jue. Use Sini Tang, Lizhong Tang, Tongmai Sini Tang, Danggui Sini Tang, Danggui Sini Jia Wuzhuyu Shengjiang Tang, Baitong Jia Zhu Danzhi Tang as indicated.
Heat Jue involves fever/headache and other Yang signs. Jue appears after two-three to four-five days. With Heat Jue, Jue lasts half a day then heat returns. Deep heat causes Jue, appearing after two-three days. Mild Jue with returning heat indicates deep heat. Pulse hidden but slippery on pressure indicates interior heat. Patient fears heat, drinks water, throws limbs, vexation, insomnia, constipation, red urine. Exterior signs include confusion. This is Heat Jue. Use Baihu Tang or Chengqi Tang as indicated.
If all purgation signs exist but Sini appears, it is due to missed purgation causing Qi/Blood blockage and cold limbs. Misdiagnosing as Yin Jue and giving heating drugs causes disaster. Heat Jue requires deep/hidden/slipping pulse, sweat on head, cold hands but warm nails occasionally. Use Dachengqi Tang to purge; do not hesitate.
All reversed cold hands/feels belong to Jueyin, contraindicating sweating/purging. However, sweating/purging may be needed if hands/feet are cold but occasionally warm, especially palms/soles, indicating non-standard Jue. Analyze carefully.
Haizang: Jueyin syndrome with cold extremities, blue nails, deep/rapid pulse, forceful on pressure is Yang; purge with Dachengqi Tang. If deep/slow pulse, weak on pressure is Yin; warm with Sini Tang. Moxa quickly.
Luo Qianfu: A woman of official Cao Deyu fell ill with Cold Damage for eight-nine days in early spring. Pulse deep/fine/faint, cold extremities, spontaneous diarrhea, abdominal pain, eyes closed, arms hugging armpits, drowsy, dry mouth/tongue. Asked if Baibu Jia Renshen Tang could be used. I said: Although Baibu treats dry mouth/tongue, it is inappropriate here for three reasons: 1. Before Lixia/After Liqiu, do not use rashly. 2. Taiyang syndrome with anhidrosis and thirst should not use it. 3. Patient has all Yin signs, and spring air is still cold. Zhang Zhongjing says: Clear undigested diarrhea requires urgent interior rescue with Sini Tang (5 liang), Renshen (1 liang), Shengjiang (10+ slices), Congbai (9 stalks), Water (5 large cups). Boil to 3 cups, strain, divide into three doses. By night, hands/feet warm. Next day, profuse sweat resolves disease. Follow with Lizhong Tang. Sun Simiao’s thesis: Great physicians must master *Jia Yi*, *Suwen*, *Huangdi Zhenjing*, *Mingtang*, *Liuzu*, meridians, *Bencao*, *Shennong*, *Zhang Zhongjing*, *He Hu*. Without this, it is wandering blind. Reconsider such medication.
Yang Syndrome Case Study: Zhao Jifu, 33, in May (Zhiyuan era), suffered spleen/stomach damage from labor/diet, causing irritability/thirst. Overconsumption of cold food led to fatigue, headache, cold extremities, vomiting, epigastric fullness. Doctor misdiagnosed as Yin Toxic Cold Damage due to cold extremities/vomiting/fullness, gave Guizhi powder in hot wine, covered with cotton. Suddenly profuse sweat, followed by dry mouth/tongue, red eyes, stiff neck, rigid limbs, red painful urination, constipation, picking at bedclothes, delirium. Tongue red/cracked, better morning/worse evening. Family despaired. Neighbor Ji Zhongwan consulted me. Pulse 7-8 beats per breath confirmed Heat Syndrome. Used Dachengqi Tang (pungent/bitter/great cold, 1 liang). Three bowel movements reduced excess. Next day, Huanglian Jiedu Tang (great bitter/cold, 2 liang) slowly to remove heat. After three days, 50-60% improvement. Given Baibu Jia Renshen Tang (~0.5 jin) to clear heat/tonify Qi. Symptoms resolved. Advised lifestyle/diet control. Recovered in a month. *Neijing*: Do not miss seasonal timing, oppose Qi suitability, assist excess, or aid recovery. This is perfect treatment. Must respect annual Qi, not harm Heaven-Harmony. In summer heat, sages use cold to save Kidney Water source and supplement Lung Metal. Even with external cold, Zhang Zhongjing adds Huangqin/Zhimu/Shigao to Mahuang Tang to prevent yellow spots/rashes, and warns against Guizhi Tang. Using Guizhi in hot wine deviates from method. Error of a hair leads to mile deviation. Text: Not harming harmony, not assisting excess/recovery, not missing Qi suitability prevents new diseases.
Use Heat Far From Heat, Treat from the Middle: Friend Liu Juyuan, 65, in summer (Zhengtong era), fell ill from labor/diet/cold drinks. Doctors treated as seasonal illness without success. Ten days later, I examined him. Right hand pulse deep/fine/faint (Taiyin syndrome). Left hand pulse slightly floating/string-like (deficient Yang on exterior). Yin excess, Yang deficiency. Symptoms: heavy body, cold extremities, clear undigested diarrhea, covering self, short breath, reluctance to speak. Spleen cold-damp, middle Qi deficiency. Zhang Zhongjing: Clear undigested diarrhea requires urgent interior rescue with Sini Tang. *Neijing* warns: Use heat far from heat. Dry mouth, rinses but doesn't swallow. Morning cool with gooseflesh; afternoon vexation,不愿 remove clothes, drowsy red face, faint red spots on skin. Exterior excess, interior deficiency. Interior deficiency changes exterior signs with time. Detailed analysis shows diet/labor/cold damaged spleen/stomach, not seasonal. Treat based on root/branch. Time is branch, disease is root. Cold medicine follows time but violates root; heat medicine follows root but violates time. Both cold and heat injure; must treat from the "Middle." Middle treatment means warming. Used Qian Shi Baizhu...