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It is said that "heat does not diminish with sweating," meaning that fever does not subside due to perspiration. This indicates that while cold qi disperses outward, the cold pathogen remains vigorous, resulting in exterior deficiency and excess pathogen, inevitably causing disharmony. Symptoms include internal constraint and pain in the four limbs. If diarrhea (Li) and cold extremities (Jue Ni) are also observed, it signifies excessive Yin-cold within, aversion to cold, and severe Yang deficiency. Therefore, Sini Tang (Four Reversal Decoction) is used to warm the meridians and restore Yang, thereby dispelling Yin pathogens. Profuse sweating followed by body heat and limb pain are typically signs of Heat pathogen affliction; however, Zhang Zhongjing employs Sini Tang because the patient presents externally with Jue (reversal), heat, and aversion to cold, and internally with constraint and diarrhea, fully exposing the Yin-cold syndrome. From this, we understand that sweating represents the loss of Yang Qi to the exterior, body heat represents the leakage of deficient Yang, and cold limbs represent the internal collapse of Yang. The key to differentiation lies in the aversion to cold and diarrhea. In summary, when distinguishing Yang syndromes, Zhang Zhongjing considers aversion to heat and constipation as indicators of interior excess. The previous section discussed Yang deficiency with false heat; this section discusses Yang deficiency without false heat. If profuse sweating or severe diarrhea leads to cold extremities, Sini Tang is indicated. "Profuse sweating" implies Yang loss at the exterior; "severe diarrhea" implies Yang loss at the interior. Combined with cold extremities, why is this not listed as a fatal condition? Examining the text, which lacks mentions of days five through seven, reveals that this is a sudden attack by Yin-cold. Although the pathogen is strong, the healthy Qi is only initially damaged. Urgent warming of the healthy Qi can allow for self-recovery. Thus, Sini Tang is used to overcome cold toxicity at the brink of danger and restore Yang Qi on the verge of extinction. If sweating and diarrhea cease and extremities warm, survival is possible. If cold extremities do not result from sweating or purging, Danggui Sini Tang (Angelica Sinensis Decoction for Reversal Cold) is used; if they do result from these treatments, Sini Tang is used. This illustrates the principle of managing urgency and slackness. This syndrome lacks mixed exterior heat, making it an easily identifiable Yin-cold syndrome. However, since profuse sweating and severe purging deplete Yin fluids, restoring Yang is the immediate priority; once Yang is restored, Yin should be slowly nourished.

There are cases of Jue caused by Phlegm-Fluids. The patient has no other symptoms, only cold extremities. The Qi of the four limbs originates from the chest. Due to the accumulation of Phlegm-Fluids, Qi cannot circulate to the limbs. The pulse may suddenly become tight, as Phlegm pulses vary unpredictably—tight then loose, loose then tight. The pathogen is knotted in the chest, the palace of the Heart Master. Obstruction by the pathogen causes fullness and irritability below the heart, hunger without desire to eat. Since the disease is in the chest, emesis is required, using Gengti San (Thistle Powder). This aligns with the Nei Jing's principle: "For high positions, induce vomiting." Regarding Water-induced Jue: In Shanghan, Jue accompanied by palpitations below the heart requires treating the water first with Fuling Gancao Tang (Poria and Licorice Decoction), before addressing the Jue. Otherwise, water infiltrating the stomach will cause diarrhea. This is a preventive method for diarrhea in Jueyin diseases. At the Jueyin stage, rising Yang indicates recovery, while sinking pathogens indicate crisis. Jue with diarrhea means Middle Qi fails to hold, allowing further pathogen invasion. Here, Jue with palpitations below the heart indicates Water pathogen attacking the Heart, causing Heart Yang to lose control. Thus, treating Jue is secondary, while treating Water is urgent. Why? Jue can be assessed by the degree of fever to determine progression or regression, whereas Water tends downward and drags Yang down.

After six or seven days of Shanghan, following severe purging, the Cun pulse is deep and slow, extremities are cold, the lower pulse is absent, throat is obstructed, expectoration of pus and blood occurs, and diarrhea persists. This is difficult to treat; Mahuang Shengma Tang (Ephedra and Asparagus Root Decoction) is indicated. The Cun pulse, or Qi Kou, governs the five Zang organs. Stomach Yang decline causes the deep, slow Cun pulse. The four limbs are the root of all Yang; Yang deficiency causes cold extremities. Post-purging Yang deficiency results in the absence of the lower pulse. Lower cold forces heat upward, causing throat obstruction and pus-blood expectoration. This refers to the previously mentioned case where heat persists after Jue, leading to pus-blood stool. Excess heat causes oral lesions. Persistent diarrhea indicates lower cold, deficiency of Zheng Qi, excess of pathogen, Yin excess and Yang decline, more cold than heat, and complex exterior-interior contradictions. Treating cold neglects heat; treating heat neglects cold. Tonifying deficiency aids excess; draining excess harms deficiency. Indeed, this is difficult to treat.

Chapter 6, Section 18, generally discusses Jueyin diarrhea, noting differences in cold/heat, deficiency/excess, Yin/Yang, and life/death. After four or five days of Shanghan, abdominal pain with gas moving downward to the lower abdomen indicates Jueyin Yin-cold merging with Taiyin, returning to Jueyin, descending without ascending, indicating impending spontaneous diarrhea. If Shanghan, originally characterized by cold diarrhea, is mistreated with vomiting and purging, cold rejection worsens the reversal of vomiting and purging. If food is vomited immediately upon entry, Ganjiang Huanglian Huangqin Renshen Tang (Dried Ginger, Coptis, Scutellaria, and Ginseng Decoction) is used. The patient originally had cold diarrhea; vomiting and purging made the lower part colder and the upper part hotter. Cold and heat block each other, forming a Ge (rejection) syndrome, not a Pi (glomus) syndrome. Absence of vomiting when fasting indicates no water retention below the heart, hence no Ginger or Pinellia. Dried Ginger warms the lower cold and its pungency opens rejection to accept food.

Diarrhea with slight heat and thirst, and a weak pulse, indicates self-healing due to the transformation of the Zhongjian (middle-exposed) Qi. Diarrhea with a rapid pulse, slight heat, and sweating also indicates self-healing. If the pulse becomes tight again, it reflects Jueyin Qi, indicating unresolved disease. Diarrhea with cold extremities and no pulse signifies Yang sinking, unable to reach the limbs or meridians. If moxibustion fails to warm and the pulse does not return, but slight panting occurs, it indicates root Qi exhaustion below and Yang escape above, leading to death. If Shaoyin is weaker than Duyang, it is favorable. "Fu" means yielding or supporting. Duyang is the Yangming Stomach pulse; if Shaoyin Qi supports Yangming, Yin generates, pulses return, Yang recovers, and warmth returns, which is favorable.

Yang sinking in diarrhea suggests a deep pulse; Yin excess suggests a slow pulse. A floating, rapid Cun pulse indicates Heat injuring the Pericardium; a choppy Chi pulse indicates Yin blood deficiency from diarrhea. Yang excess and blood deficiency force blood downward, causing pus-blood stool. The previous section discussed Yin injuring Yang; this section discusses Yang injuring Yin. Diarrhea with undigested food indicates organ deficiency and cold; exterior release is contraindicated. Sweating causes exterior Yang deficiency and interior Yin knotting, leading to abdominal fullness. The Classics state: "Cold in organs generates fullness." Diarrhea with a deep-string pulse indicates sinking of Shaoyang's initial Qi; heaviness in defecation is forced by Fire pathogen. If Yang heat is severe with a large pulse, it is not the pulse of initial Yang, and diarrhea will not stop. A weak pulse is Yin; a rapid pulse is Yang. Yin containing Yang suggests diarrhea will stop. Although Nei Jing states fever leads to death, here the transformation of Shaoyang's Zhongjian Qi allows Yin to emerge into Yang; thus, fever does not lead to death.

In Jueyin Yin-cold diarrhea with deep-slow pulse, slight facial redness indicates Three Yang Qi ascending to the head, Yang rejection above, seeking Shaoyang heat transformation, with slight body heat. However, diarrhea with undigested food shows Jueyin Biao-Yin completely sunk below, with Yang heat above and Yin cold below, disconnected. Treatment requires large formulas from the Shaoyin chapter to rescue, transitioning from Yin to Yang, likely resulting in Yu Mao (depression and dizziness) and sweating for resolution. Patients may have slight Jue due to Dai Yang (face red like wearing yang) and lower deficiency.

Diarrhea with rapid pulse and thirst indicates self-healing; if unresolved, pus-blood stool will occur due to Heat. This clarifies that unresolved heat injures the Pericardium meridian. Diarrhea followed by absent pulse, lower Sheng Qi failing to rise, and cold extremities, with Disharmony of Middle Earth Qi, may recover after one cycle (Shichen). If the pulse returns and extremities warm, Middle Earth Qi is recovering and injecting into Hand-Taiyin Lung, indicating life. If the pulse does not return, Middle Earth has failed and Sheng Qi is extinct; even without cold extremities, death is indicated. Life and death depend on the pulse, rooted in Middle Earth. This section differs from others by focusing on post-diarrhea, similar to Shaoyin diarrhea with frequent dizziness. Post-diarrhea seems like pathogen departure, but actually involves simultaneous loss of Zheng Qi and pathogen. Pulse return and warm extremities indicate surviving Yang, treatable with Sini Tang or Baitong Tang.

Shanghan diarrhea occurring ten-plus times daily, located in Jueyin, with deficiency of all Three Yang and Three Yin Qi, yet a "Shi" (excess) pulse, indicates lack of gentle Stomach Qi pulse, true Yuan Qi sinking, leading to death. Grain enters the stomach, transformed by Middle Earth Qi into waste, akin to Heart transforming blood. Jueyin Biao-Yin excess prevents proper transformation of essence and separation of clear/turbid, causing undigested food diarrhea. Interior cold with exterior heat, sweating, and Jue require Tongmai Sini Tang (Pulse-Rescuing Sini Tang). This describes interior Yang blocked by Yin cold and exterior Yang escaping due to interior isolation. Only urgent strong warming can instantly harmonize Yin and Yang. Jueyin Biao-Yin disease causes undigested food diarrhea; Jueyin Zhongjian disease causes Heat diarrhea. Heaviness in defecation requires Baitouweng Tang (Pulsatilla Decoction), as stated in Nei Jing: "Sudden diarrhea with straining belongs to Heat." Heaviness results from Jueyin Heat pathogen entering the Large Intestine; Liver's swift nature combined with severe Heat causes Qi stagnation, making foul matter eager to exit but blocked.

Diarrhea with abdominal fullness and body pain requires warming the interior first, then releasing the exterior. Warm interior with Sini Tang; release exterior with Guizhi Tang (Cinnamon Twig Decoction). Organ cold causes fullness; Water-Grain Qi descends while Yin-cold ascends, necessitating interior warming before exterior release. Thirst for water during diarrhea indicates Heat; use Baitouweng Tang. This decoction clears Heat downward and raises Yin fluids. Diarrhea with delirium indicates Middle Fire combining with Yangming Dryness, causing Stomach Disharmony and dry feces. Jueyin forbids purging, but dry feces require mild purgation with Xiaochengqi Tang (Minor Order the Yellow Decoction) to harmonize Stomach Qi. Diarrhea followed by increased irritability, due to fluid depletion and rising Fire, with soft epigastrium upon pressure, indicates deficiency irritability (Xu Fan) from lower Yin failing to ascend, treated with Zhizi Chidao Tang (Gardenia and Fermented Soybean Decoction).

Vomiting with pus in patients with abscesses indicates Heat injuring the Pericardium, turning blood to pus. Vomiting expels foul matter;辛散 (pungent-dispersing) anti-emetics should be avoided as they reverse the mechanism, trapping Heat. Once pus is exhausted, Heat leaves with it, and healing occurs. This section covers Jueyin vomiting, varying by Blood/Qi, Cold/Heat, Deficiency/Excess.

Vomiting with weak pulse indicates severe interior deficiency; frequent urination indicates Qi leaking downward; slight body heat with Jue indicates failure of Yin-Yang connection, with Qi exiting without entering, making it difficult to treat. Use Sini Tang. Dry retching with salivary foam and headache requires Wuzhuyu Tang (Evodia Decoction). This indicates extreme Jueyin Yin-cold binding fluids upward. Vomiting is only saliva, no food/phlegm, ascending to the vertex causing headache. Large doses are needed. The formula treats headache by stopping vomiting, as headache stems from rebellious Qi. Vomiting with fever requires Xiao Chaihu Tang (Minor Bupleurum Decoction). Jueyin and Shaoyang are exterior-interior pairs. Pathogen in Jueyin fears Jue and diarrhea. Vomiting with fever indicates脏邪还腑 (Zang pathogen returning to Fu), emerging from Yin to Yang, avoiding Yin rebellion. Treat via Shaoyang pivot. Shanghan prioritizes Stomach Qi. For Jueyin, treating Yangming is crucial.

Severe vomiting and purging cause extreme deficiency; extreme sweating causes extreme exterior deficiency. Qi deficiency prevents internal communication. Exterior Qi stagnation mimics exterior pathogen stagnation. Mistaking this for Heat and giving water to induce sweating causes Hiccups (Yue). This is due to Cold in the Stomach.

Hiccups with abdominal fullness require examining the anterior and posterior orifices to identify obstruction; relieving it cures hiccups. Hiccups can be Cold-Deficiency or Heat-Excess. Jueyin meridian passes the lower abdomen, flanks the Stomach, and enters the nasopharynx. Hiccup Qi rises from the lower abdomen through the Stomach to the throat. Severe hiccups indicate either Middle Earth collapse or Stomach Cold, or sometimes interior excess blocking Qi descent, forcing it upward. Nei Jing's Yuji Zhenzang Lun lists Five Excesses: full pulse, hot skin, abdominal fullness, blocked bowels/bladder, and mental clouding. Sweat and bowel movement resolve excess. Hiccups with fullness and blocked bowels/bladder represent two of the five excesses. Drain excess; relieve anterior/posterior obstruction to allow Qi descent, curing hiccups. Even extreme Cold-Deficiency hiccups may have Excess components. Conversely, Heat-Excess may have Deficiency aspects. Differentiate Cold/Heat, Deficiency/Excess, and apply warming/cooling, tonifying/draining methods to prevent premature death.