厥阴篇中次第不一有纯阳无阴之证。有纯阴无阳之证有阴阳差多差少之证。有阳进欲愈之证有阴进未愈之症。大率
阳脉阳证当从三阳经治法阴脉阴证合用少阴经治法厥阴见阳为逆愈见阴为难愈。其阴阳错杂不分有必先温其里。后解其
表。设见咽喉不利。咳唾脓血。则温法不可用仍当先解其表矣。世医遇厥阴诸证。如涉大洋。茫无边际是以动手即错耳。
以类相聚。分为五截庶学人易于入室也。
厥阴之为病消渴气上撞心。心中疼热饥而不欲食。食则吐 下之利不止。（ 蛔同）
消渴者饮水多而小便少也。厥阴邪热盛。则肾水为之消。故消而且渴其渴不为水止也。气上撞心。心中疼热者。肝
火上乘。肝气通于心也。饥不欲食者。木邪横肆胃土受制也。食则吐 者胃中饥。 臭食则出也。下之利不止者。邪在
厥阴下之徒伤阳明。木益乘其所胜是以食则吐 。下之利不止耳。○按厥阴原无下法故首先示戒。云下之利不止。盖厥
多主下利。下利中伏有死证。中间虽有小承气一法因胃有燥屎。微攻其下非攻厥阴之邪也。厥阴与少阳表里邪在少阳已
有三禁。岂厥阴反宜下乎。虽有厥应下之一语乃对发汗而言谓厥应内解其热。不当外发其汗。岂可泥应下。二字。遂犯
厥阴之大戒耶。今人每谓伤寒六七日当下。此特指阳邪入腑。而言未尝言邪传厥阴可下也。○张卿子曰。尝见厥阴消渴
数症舌尽红赤。厥冷脉微渴甚服白虎黄连等汤皆不救。盖厥阴消渴皆是寒热错杂之邪。非纯阳亢热之证岂白虎黄连等药
所能治乎。
伤寒脉微而厥。至七八日肤冷其入躁无暂安时者。此为脏厥。非 厥也。 厥者。其人尝吐 。今病者静而复时烦。
此为胃寒。 上入膈。故烦须臾复止。得食而呕又烦者。 闻食臭出。其人当自吐 。 厥者。乌梅主之。又主久利。
脏厥者。其人阳气素虚。肾脏之真阳衰极。 厥者。始本寒邪因发汗吐下太过。或寒饮蓄积胃中寒热在胃。 不能
安而上膈也。脉微而厥。则阳气衰微可知然未定其脏厥 厥也。惟肤冷而躁无暂安时。加以趺阳脉不出乃为脏厥。脏厥
用附子理中汤及灸法其厥不回者死若是 厥则时烦时止未为死候。但因此而驯至胃中无阳则死也。乌梅丸中酸苦辛温互
用以治阴阳错乱之邪。胃中之寒热和而 自安矣厥阴多主下利厥逆。所以久利而变脓血亦不出此主治也。
病患有寒复发汗。胃中冷必吐 。
病患素有寒饮复发其汗则大损胸中阳气胃中寒饮愈逆致 不安而上出也。后人以理中丸加乌梅治之仍不出仲景之成
则耳。
伤寒本自寒下医复吐下之寒格更逆吐下若食入口即吐干姜黄连黄芩人参汤主之。
伤寒本自寒下其人下虚也医复吐下之损其胸中阳气内为格拒则阴阳不通食入即吐也寒格更逆吐下。言医不知。又复
吐下。是为重虚。故用干姜散逆气而调其阳。辛以散之也。芩连通寒格而调其阴。苦以泄之也。人参益胃气而调其中甘
以缓之也。
伤寒四五日。腹中痛。若转气下趋少腹者此欲自利也。
腹证多属虚寒与实满不同若更转气下趋少腹必因痛而致下利明眼见此自当图功于未着也。○按腹痛亦有属火者。其
痛必自下逆攻而上。若痛自上而下趋者。定属寒痛无疑。
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。
太阳阳明并病面色缘缘正赤者。为阳气怫郁宜解其表。此下利脉沉迟而面见少赤身见微热者。阴寒格阳于外则身微
热。格阳于上则面少赤。仲景以为阳虚者。谓下。无其阳。而反在外在上。故云虚也。虚阳虚于外越上出危候已彰。或
其人阳尚有根。或用温药以胜阴助阳阳得复返而与阴争。差可恃以无恐盖阳返虽阴不能格。然阴尚盛亦未肯降必郁冒少
顷。然后阳胜。而阴出为汗。邪从外解。自不下利矣。
下利清谷里寒外热。汗出而厥者。通脉四逆汤主之。
上条辨证。此条用药两相互发。然不但此也。少阴病下利清谷面色赤者。已用其法矣。要之通之正。所以收之也。
不然。岂有汗出而反加葱之理哉。
下利腹胀满。身体疼痛者。先温其里乃攻其表。温里四逆汤。攻表桂枝汤。
此与太阳篇中下利身疼。先里后表之法无异。彼因误下而致下利。此因下利而致腹胀。总之温里为急也。身疼痛。
有表有里。必清便已调其痛仍不减方属于表。太阳条中已悉。故此不赘。
下利清谷不可攻表。汗出必胀满。
此条重举下利清谷。不可攻表。以示戒。正互明上条所以必先温里。然后攻表之义。见误表其汗。则阳出。而阴气
弥塞。胸腹必致胀满而酿变耳。合用浓朴生姜半夏甘草人参汤以温胃消胀为务也。
干呕吐涎沫头痛者。吴茱萸汤主之。
凡用吴茱萸汤有三证。一为阳明食谷欲呕。一为少阴吐利手足厥冷。烦燥欲死。此则干呕吐涎沫头痛经络证候各殊
而治则一者。总之下焦浊阴之气上乘于胸中清阳之界。真气反郁在下。不得安其本位。有时欲上不能。但冲动浊气。所
以干呕吐涎沫也。头痛者。厥阴之经与督脉会于巅也。食谷欲呕者。浊气在上也。吐利者清气在下也。手足厥冷者。阴
寒内盛也。烦燥欲死者。虚阳扰乱也。故主吴茱萸汤以茱萸专主开豁胸中逆气。兼人参姜枣以助胃中之清阳。共襄祛浊
之功。由是清阳得以上升。而浊阴自必下降矣。
呕而脉弱。小便复利身有微热见厥者难治四逆汤主之。
呕与微热似有表也。脉弱则表邪必不盛。小便利则里邪必不盛可见其呕为阴邪。主干之呕热为阳邪外散之热见厥则
阳遭阴掩。其势 危。故为难治非用四逆汤莫可救也。
以上阴进未愈证。
大汗出热不去。内拘急四肢疼。又下利厥逆而恶寒者四逆汤主之。
大汗出而热反不去。正恐阳气越出。若内拘急四肢疼。更加下利厥逆恶寒。则在里先是阴寒。急用四逆汤以回其阳
而阴邪自散耳。
大汗若大下利而厥冷者。四逆汤主之。
此证较上条无外热相错。其为阴寒易明。然既云大汗大下利则阴津亦亡。但此际不得不以救阳为急。俟阳回尚可徐
救其阴。所以不当牵制也。
伤寒六七日不利。便发热而利。其人汗出不止者死有阴无阳故也。
六七日不利忽发热而利浑是内阴外阳之象。盖发热而利。里虚而外邪内入也。故曰有阴。汗出不止表虚而内阳外出
也故曰外阳此中伏有危机。所以仲景早为回护用温用炙以安其阳。若俟汗出不止乃始图之。则无及矣可见邪乱厥阴其死
生全关乎少阴也不然厥阴之热深厥深何反谓之有阴无阳哉。
吐利汗出发热恶寒。四肢拘急。手足厥冷者。四逆汤主之。
吐利汗出发热恶寒者。阳气外脱也。四肢拘急手足厥冷者。亡阳不能温养经脉也。故主四逆汤以温之。
且吐且利。小便复利而大汗出。下利清谷。内寒外热脉微欲绝者。四逆汤主之。
吐利不止而且下利清谷加之小便复利。津液四脱。里之虚寒极矣况外热而汗大出为阳复。外脱脉微欲绝者。阳气衰
微可知。急宜四逆汤复阳为要也。设四逆不足以杀其势。其用通脉四逆具见言外矣。
可已下断汗出而厥。四肢拘急不解。脉微欲绝者。通脉四逆加猪胆汁汤主之。
可已下止。当渐向安。不得复有汗出厥而四肢拘急也。今脉微欲绝者则其吐下已断。又为真阳垂绝矣。急宜通脉四
逆和复元阳更加猪胆为阴向导也。
恶寒脉微而复利。利止亡血也。四逆加人参汤主之。
亡血本不宜用姜附以损阴阳虚又不当用归芍以助阴。此以利后恶寒不止。阳气下脱已甚。故用四逆以复阳为急也。
其所以加人参者。不特护持津液。兼阳药得之愈加得力耳。设误用阴药必致腹满不食。或重加泄利呕逆转成下脱矣。
伤寒五六日。不结胸腹濡。脉虚复厥者。不可下。此为亡血。下之死。
伤寒五六日。邪入厥阴。其热深矣。乃阳邪不上结于胸。阴邪不下结于腹。其脉虚而复厥。乃非热深当下之比。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
当同上条亡血例治。设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。
病者手足厥冷。言我不结胸小腹满按之痛者。此冷结在膀胱关元也。
阳邪必结于阳。阴邪必结于阴。故手足厥冷。小腹满按之痛者。邪不上结于胸其非阳邪可知。其为阴邪下结可知。
则其当用温用灸更可知矣。
伤寒六七日脉微。手足厥冷烦燥。灸厥阴。厥不还者死。
脉微而厥冷加烦燥。则是阳微阴盛。灸毛际以通其阳而阳不回则死灸。所以通阳也。厥不还。则阳不回可知矣。
下利手足厥冷无脉者。灸之不温。若脉不还。反微喘者死。
灸之不温脉不还。已为死证。然或根柢未绝亦未可知。设阳气随阴火上逆。胸有微喘。则孤阳上脱而必死矣。与少
阴病六七日息高者死正同。
下利后脉绝。手足厥冷。 时脉还。手足温者生。脉不还者死。
脉绝不惟无阳而阴亦无矣。阳气破散。岂有阴气不消亡者乎。 时脉还乃脉之伏者。复出耳。仲景用灸法正所以通
阳气。而观其脉之绝与伏耳。故其方即名通脉四逆汤。服后利止脉出。则加人参以补其亡血。若服药 时。脉仍不出是
药已不应其为脉绝可知。
伤寒发热下利厥逆。躁不得卧者死。
躁不得卧肾中阳气越绝之象也。大抵下利而手中厥冷者。皆为危候。以四肢为诸阳之本故也。加以发热躁不得卧。
不但虚阳发露。而真阴亦已烁尽无余矣。安得不死乎。
伤寒发热。下利至甚。厥不止者死。
厥证但发热则不死。以发热则邪出于表而里证自除下利自止也。若反下。利厥逆烦躁有加。则其发热又为真阳外散
之候阴阳两绝故主死也。
发热而厥七日。下利者为难治。
厥利而热不两存之势也。发热而厥七日。是热者自热厥利者自厥利。阴阳两造其偏漫无相协之期。故虽未见烦躁已
为难治。盖治其热则愈厥愈利治其厥利则愈热不至阴阳两绝不止耳。
伤寒脉迟六七日而反与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。
脉迟为寒。寒则胃中之阳气已薄不可更用寒药矣腹中。即胃中今胃冷而反能食。则是胃气发露无余其阳亦必渐去不
能久存。故为必死较后条之食以索饼不发热者。自是天渊。
以上纯阴无阳证。
下利脉大者。虚也。以其强下之故也。设脉浮革。因尔肠鸣者属当归四逆汤主之。
下利脉大为虚阳下陷。设脉浮革为风邪乘虚袭肝。风邪结聚。则水饮停留。因尔肠鸣者。宜当归四逆以散风利水也。
手足厥寒脉细欲绝者。当归四逆汤主之。若其人内有久寒者。宜当归四逆加茱萸生姜汤主之。
手足厥寒脉细欲绝似乎阴寒之极盖缘阳邪流入厥阴营分以水虚不能作热。故脉细欲绝也。此为阴。郁阳邪所以仲景
处方。仍用桂枝汤和其中外加当归以和厥阴之营血。通草以通太阳之本。细辛以净少阴之源。使阳邪得从外解本非治阴
寒四逆之药也。盖脉细欲绝。为阴气衰于内不能鼓动其脉而肌表之阳亦虚。非真阳内亏之比。故药中宜归芍以济阴。不
宜姜附以劫其阴。即其人素有久寒者。但增吴茱萸生姜。由是观之则干姜附子宁不在所禁乎。久寒者陈。久之寒非时下
直中之寒也。明矣。○前条下利脉大亦用此汤者以下多伤阴。阴伤则阳不归附故脉虽浮大而证仍属血虚也。
伤寒脉促。手足厥逆者。可灸之。
手足厥逆本当用四逆汤以其脉促。知为阳气内陷而非阳虚。故但用灸以通其阳。不可用温经药以助阳也。
诸四逆厥者。不可下之虚家亦然。凡厥者阴阳气不相顺接便为厥。厥者手足逆冷是也。
厥有寒热之异。治虽霄壤而不可下则一。总由脾胃之阴阳不相顺接。所以不能温顺四末耳。
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。
热少厥微指头微寒其候原不为重然默默不欲食。烦躁数日胃中津液伤而困矣。若小便利色白则邪热暗除胃气渐复故
欲得食。若厥而呕。胸胁满不去。则邪聚中焦。故呕而烦满其后阴邪必走下窍而便血。以厥阴主血故也。
下利寸脉反浮数。尺中自涩者必清脓血。
下利为阴邪浮数为阳脉。若阴尽复阳则尺脉自和。今尺中自涩。乃热邪搏结于阴分。虽寸口得阳脉。究竟阴邪。必
走下窍而便脓血也。○此条与上条厥呕胸胁烦满者。虽有轻重之殊而治法不异并宜白头翁汤脓血止芍药甘草汤。
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。
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复阳也。然热气有余又为内外痈脓便血
之兆矣。
伤寒发热始六日厥反九日而利。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
In the Jueyin Chapter, the sequence of conditions varies. There are cases of pure Yang without Yin, and cases of pure Yin without Yang. There are cases where Yin and Yang are imbalanced in degree, cases where Yang advances indicating recovery, and cases where Yin advances indicating non-recovery. Generally speaking, Yang pulse and Yang syndromes should be treated according to the methods of the Three Yang meridians; Yin pulse and Yin syndromes should be treated in conjunction with the methods of the Shaoyin meridian. In Jueyin disease, the appearance of Yang signs is considered a reverse condition (but indicates potential recovery), while the appearance of Yin signs makes recovery difficult. When Yin and Yang are mixed and indistinguishable, one must first warm the interior and then release the exterior. If symptoms such as throat obstruction and coughing up pus and blood appear, warming methods are contraindicated, and the exterior should still be released first. Physicians of later generations, when encountering various Jueyin conditions, feel like they are crossing a vast ocean, bewildered and boundless, thus making errors upon treatment. To facilitate learning, these conditions are categorized into five sections.
The typical presentation of Jueyin disease includes excessive thirst (Xiao Ke), Qi rushing upward to strike the heart, pain and heat sensation in the heart region, hunger without desire to eat, vomiting after eating (often involving roundworms if present), and diarrhea that persists if purgatives are misused.
Excessive thirst refers to drinking much water but producing little urine. When pathogenic heat in the Jueyin meridian is vigorous, it consumes Kidney Water, resulting in both consumption and thirst that cannot be quenched by drinking alone. Qi rushing to strike the heart and pain/heat in the chest result from Liver Fire attacking upwards, as Liver Qi connects with Heart Qi. Hunger without desire to eat occurs because Wood (Liver) evil invades horizontally, restraining Earth (Spleen/Stomach). Vomiting after eating happens because the Stomach is empty/hungry, and the odor of food triggers expulsion. Misusing purgatives leads to persistent diarrhea because the pathogen is in Jueyin; purging only injures the Yangming Stomach, allowing Wood to further overcome its controlled element (Earth), causing vomiting and diarrhea. Note: Jueyin disease originally has no indication for purging, so this serves as a warning. "Diarrhea after purging" is mentioned because Jueyin often presents with diarrhea, which can contain fatal patterns. Although Xiao Chengqi Tang is occasionally used for dry feces in the Stomach, this targets the Stomach, not the Jueyin pathogen. Jueyin and Shaoyang are exterior-interior pairs; since Shaoyang has three prohibitions, Jueyin certainly should not be purged. The phrase "Jue should be purged" refers to internal resolution of heat rather than external sweating; one must not rigidly adhere to "purge" and violate Jueyin prohibitions. Modern practitioners often say "purge after six or seven days," referring only to Yang pathogens entering the Fu organs, never implying Jueyin transmission warrants purging. Zhang Qingzi noted cases of Jueyin excessive thirst with red tongue, cold limbs, faint pulse, and severe thirst, unresponsive to Baihu Tang or Huanglian Tang. This is because Jueyin excessive thirst involves mixed cold-heat pathogens, not pure Yang hyperthermia, hence these cooling formulas fail.
In Shanghan, a faint pulse and cold limbs persisting for seven to eight days, with cold skin and restlessness without respite, indicate Zang Jue (Visceral Cold Reversal), not Tui Jue (Roundworm Reversal). Tui Jue patients typically vomit roundworms. The current patient is quiet but intermittently irritable due to Stomach cold causing roundworms to ascend to the Diaphragm; irritation ceases briefly. Eating causes vomiting and irritability as roundworms react to food odors. Tui Jue is treated with Wu Mei Wan, which also treats chronic diarrhea.
Zang Jue patients have deficient Yang and extreme depletion of Kidney True Yang. Tui Jue originates from cold pathogens exacerbated by excessive sweating, vomiting, or purging, or accumulation of cold fluids in the Stomach, creating mixed cold-heat that disturbs roundworms. Faint pulse and cold limbs indicate Yang deficiency. Differentiation relies on skin coldness, relentless restlessness, and absent Duyang pulse for Zang Jue, treated with Fuzi Lizhong Tang and moxibustion; if reversal does not return, death ensues. Tui Jue features intermittent irritation and is not necessarily fatal, though progression to Stomach Yang depletion is dangerous. Wu Mei Wan uses sour, bitter, acrid, and warm herbs to treat mixed Yin-Yang disorders, harmonizing Stomach cold-heat and calming roundworms. Jueyin often presents with diarrhea and reversal; chronic diarrhea turning to pus/blood falls under this treatment scope.
If a patient with cold syndrome undergoes repeated sweating, Stomach cold will cause vomiting of roundworms. Patients with prior cold-fluid retention who are sweated again severely damage Chest Yang, aggravating Stomach cold-fluid rebellion and roundworm disturbance. Later physicians use Lizhong Wan plus Wu Mei, adhering to Zhang Zhongjing's principles.
In Shanghan with pre-existing cold-type diarrhea, erroneous vomiting and purging worsen the cold obstruction, leading to violent vomiting and diarrhea. If food is vomited immediately upon entry, Gan Jiang Huang Lian Huang Qin Ren Shen Tang (Dried Ginger, Coptis, Scutellaria, and Ginseng Decoction) is indicated. Erroneous treatment damages Chest Yang, causing obstruction and Yin-Yang blockage. Gan Jiang disperses rebellious Qi and regulates Yang (acrid); Huang Qin clears obstruction and regulates Yin (bitter); Ren Shen tonifies Stomach Qi and harmonizes the Middle (sweet).
On the fifth or sixth day of Shanghan, abdominal pain with Qi moving downward to the lower abdomen indicates impending spontaneous diarrhea. Abdominal pain is usually deficiency-cold, distinct from excess fullness. Downward Qi movement confirms cold-induced diarrhea. Early intervention is advised. Note: Fire-type abdominal pain moves upward; downward-moving pain is definitely cold.
In diarrhea with deep-slow pulse, slight facial redness, mild body fever, and undigested food in stool, recovery through delirium/sweating is possible. The patient may have slight cold limbs due to Dai Yang (floating Yang) and lower deficiency. This differs from Taiyang-Yangming combined disease with full-face redness (Yang stagnation requiring release). Here, Yin cold repels Yang outward (mild fever) and upward (slight facial redness). Zhang Zhongjing calls this "deficiency" because Yang is absent internally but floating externally/upward. If Yang roots remain, warming drugs can overcome Yin and assist Yang. As Yang returns and contends with Yin, brief delirium precedes sweating, resolving the pathogen externally and stopping diarrhea.
For diarrhea with undigested food, interior cold with exterior heat, sweating, and cold limbs, Tong Mai Si Ni Tang (Pulse-Returning Four Reversals Decoction) is indicated. This complements the previous diagnostic description with therapeutic action. It was also used in Shaoyin disease with similar symptoms. "Unblocking" achieves "consolidating"; otherwise, adding Scallion (Cong Bai) for sweating would be illogical.
For diarrhea with abdominal fullness and body pain, warm the interior first, then attack the exterior. Use Si Ni Tang to warm the interior and Gui Zhi Tang to release the exterior. This mirrors the Taiyang chapter's approach to diarrhea and body ache. Here, abdominal fullness results from diarrhea, whereas previously, diarrhea resulted from erroneous purging. Warming the interior is urgent. Body pain requires differentiation: if pain persists after bowel movements normalize, it belongs to the exterior. This was detailed in the Taiyang chapter.
Diarrhea with undigested food contraindicates exterior release. Sweating will cause abdominal fullness. This reiterates the prohibition against exterior release in undigested-food diarrhea, explaining why interior warming must precede exterior release. Erroneous sweating causes Yang to escape and Yin to obstruct, leading to abdominal fullness. Niu Pi Sheng Jiang Ban Xia Gan Cao Ren Shen Tang (Magnolia Bark, Fresh Ginger, Pinellia, Licorice, and Ginseng Decoction) warms the Stomach and reduces fullness.
Dry heaving, vomiting of saliva/froth, and headache are treated with Wu Zhu Yu Tang. Wu Zhu Yu Tang has three indications: Yangming vomiting after eating, Shaoyin vomiting/diarrhea with cold limbs and severe irritability, and here, dry heaving/vomiting froth/headache. Though manifestations differ, the mechanism is the same: turbid Yin Qi from the Lower Jiao attacks the Clear Yang region of the Chest, trapping True Qi below. Dry heaving and froth result from turbulent turbid Qi. Headache occurs because the Jueyin meridian meets the Du Meridian at the vertex. Vomiting after eating indicates turbid Qi above; diarrhea indicates clear Qi below; cold limbs indicate internal Yin-cold; severe irritability indicates disturbed deficient Yang. Wu Zhu Yu opens the Chest obstruction; Ginseng, Ginger, and Jujube assist Stomach Clear Yang to dispel turbidity, allowing Clear Yang to ascend and Turbid Yin to descend.
Vomiting with weak pulse, free urination, mild fever, and cold limbs is difficult to treat; Si Ni Tang is indicated. Vomiting and mild fever suggest exterior pathogen, but weak pulse indicates weak exterior pathogen, and free urination indicates weak interior pathogen. Thus, vomiting stems from Yin pathogen obstructing Qi; mild fever is residual Yang heat. Cold limbs indicate Yang obscured by Yin, a critical state requiring Si Ni Tang for rescue.
These are cases of Yin advancement/non-recovery.
Profuse sweating with persistent fever, internal cramping, limb pain, plus diarrhea, cold reversal, and aversion to cold are treated with Si Ni Tang. Persistent fever after profuse sweating risks Yang collapse. Cramping, limb pain, diarrhea, and cold reversal indicate interior Yin-cold, requiring Si Ni Tang to restore Yang and dissipate Yin.
Profuse sweating or severe diarrhea leading to cold limbs is treated with Si Ni Tang. This case lacks exterior heat, making Yin-cold obvious. Although profuse sweating/diarrhea depletes Yin fluids, restoring Yang is urgent; Yin can be addressed later once Yang returns.
Shanghan lasting six to seven days, initially without diarrhea, suddenly presenting with fever, diarrhea, and unremitting sweating indicates death due to "Yin present, Yang absent." Sudden fever and diarrhea imply interior deficiency allowing exterior pathogen invasion ("Yin"). Unremitting sweating implies exterior deficiency allowing interior Yang to escape ("Outer Yang"). This harbors crisis. Zhang Zhongjing advises early warming/moxibustion to secure Yang. Waiting until unremitting sweating is too late. Life/death in Juevon disorder depends on Shaoyin. Otherwise, deep heat with deep cold reversal would not be termed "Yin present, Yang absent."
Vomiting, diarrhea, sweating, fever, aversion to cold, limb cramping, and cold hands/feet are treated with Si Ni Tang. These symptoms indicate Yang collapse and failure of Yang to nourish channels. Si Ni Tang warms and restores.
Simultaneous vomiting and diarrhea, free urination, profuse sweating, undigested food in stool, interior cold with exterior heat, and faint/almost imperceptible pulse are treated with Si Ni Tang. Persistent vomiting/diarrhea with undigested food and free urination indicates total fluid loss and extreme interior cold-exterior heat. Faint pulse confirms severe Yang deficiency. Urgent restoration of Yang via Si Ni Tang is essential. If insufficient, Tong Mai Si Ni Tang is implied.
If diarrhea stops but sweating, cold reversal, limb cramping persist, and pulse is faint/almost imperceptible, Tong Mai Si Ni Tang plus Pig Bile Juice is indicated. Diarrhea cessation should bring relief, but persistent sweating/cramping with faint pulse indicates impending True Yang collapse. Tong Mai Si Ni Tang restores Yuan Yang; Pig Bile acts as a guide for Yin fluids.
Aversion to cold, faint pulse, and subsequent diarrhea cessation due to blood loss are treated with Si Ni Tang plus Ginseng. Blood loss contraindicates Ginger/Aconite; Yin deficiency contraindicates Rehmannia/Peony. Here, post-diarrhea aversion to cold indicates severe Yang collapse, necessitating Si Ni Tang for urgent Yang restoration. Ginseng protects fluids and enhances Yang-tonifying drugs. Misusing Yin herbs causes abdominal fullness/anorexia or worsens diarrhea/vomiting, leading to lower collapse.
Shanghan on day five or six, without Jie Xiong (Chest Binding), soft abdomen, weak pulse, and cold reversal should not be purged. This is blood loss; purging causes death. Pathogen enters Jueyin with deep heat, but neither binds in Chest (Yang) nor Abdomen (Yin). Weak pulse and cold reversal indicate blood/fluid deficiency and dry stool, not Yangming excess. Warning against purging is issued. Weak pulse/soft abdomen confirm no interior heat; cold reversal indicates Yin dominance. Treat as blood loss. If Yin blood is severely depleted or mixed with Yang pathogen intolerant to acrid-warm herbs, Dang Gui Si Ni Tang applies.
Patients with cold hands/feet, no chest binding, lower abdominal fullness/tenderness have cold binding at Bladder Guanyuan point. Yang pathogens bind in Yang positions; Yin pathogens bind in Yin positions. Cold limbs with lower abdominal tenderness confirm Yin pathogen binding below, warranting warming/moxibustion.
Shanghan on day six or seven, faint pulse, cold hands/feet, irritability: Moxibustion on Jueyin points. If reversal does not return, death ensues. Faint pulse/cold reversal/irritability indicate Yang deficiency/Yin excess. Moxibustion at Mao Ji (near Qugu) unblocks Yang. Failure to recover indicates Yang collapse.
Diarrhea with cold limbs and absent pulse: If moxibustion fails to warm or restore pulse, and slight panting develops, death ensues. Absent pulse/persistence of cold indicates death. However, if root remains, survival is possible. Panting suggests Lone Yang escaping upward, fatal, similar to Shaoyin "high breathing" death.
Post-diarrhea absent pulse and cold limbs: If pulse temporarily returns and limbs warm, survival; if not, death. Absent pulse implies Yin/Yang exhaustion. Temporary return indicates hidden pulse re-emerging. Moxibustion unblocks Yang. Tong Mai Si Ni Tang is named for this purpose. If pulse returns after medication, add Ginseng for blood loss. If pulse remains absent, medication failed, confirming pulse absence.
Shanghan with fever, diarrhea, cold reversal, and restlessness preventing lying down indicates death. Restlessness indicates Kidney Yang collapse. Diarrhea with cold hands is critical as limbs are the root of Yang. Fever with restlessness shows exposed deficient Yang and exhausted True Yin, guaranteeing death.
Shanghan with fever, severe diarrhea, and unremitting cold reversal indicates death. Fever in reversal cases usually indicates recovery (pathogen exiting exterior, interior clearing). However, worsening diarrhea/cold reversal/irritability with fever indicates True Yang scattering and dual Yin-Yang extinction, leading to death.
Fever and cold reversal for seven days, followed by diarrhea, is difficult to treat. Reversal/diarrhea and heat are mutually exclusive. Prolonged coexistence indicates Yin-Yang polarization without reconciliation. Difficulty arises even without irritability; treating heat worsens reversal/diarrhea, and vice versa, leading to dual extinction.
Shanghan with slow pulse on day six/seven, erroneously treated with Huang Qin Tang for heat. Slow pulse indicates cold; Stomach Yang is thin. Further cooling harms. "Abdominal cold" refers to Stomach. Ability to eat despite cold Stomach indicates Stomach Qi exposure and imminent Yang departure, ensuring death. This contrasts with the later case of eating wheat cakes without fever, indicating preserved Stomach Qi.
These are pure Yin without Yang cases.
Diarrhea with large pulse indicates deficiency due to forced purging. If pulse is floating/wiry with borborygmus, Dang Gui Si Ni Tang is indicated. Large pulse indicates sinking deficient Yang; floating/wiry pulse with borborygmus indicates Wind pathogen invading Liver due to deficiency, causing fluid retention. Dang Gui Si Ni Tang disperses wind and promotes fluid metabolism.
Cold hands/feet with fine/almost imperceptible pulse are treated with Dang Gui Si Ni Tang. If internal chronic cold exists, use Dang Gui Si Ni Tang plus Evodia and Fresh Ginger. Fine/almost imperceptible pulse suggests extreme Yin-cold but actually results from Yang pathogen entering Jueyin Ying level with Water deficiency failing to generate heat. This is Yin-stagnated Yang pathogen. Formula uses Gui Zhi Tang to harmonize Middle, plus Dang Gui for Jueyin Ying blood, Tong Cao for Taiyang root, and Xi Xin for Shaoyin source, allowing Yang pathogen to exit externally. It is not a standard Si Ni treatment for Yin-cold. Fine pulse indicates internal Yin deficiency failing to propel pulse and exterior Yang deficiency, distinct from internal True Yang deficit. Thus, use Dang Gui/Shao Yao to nourish Yin, avoiding Ginger/Aconite to prevent Yin depletion. Even with chronic cold, only add Evodia/Ginger, excluding Dried Ginger/Aconite. Chronic cold refers to long-standing cold, not acute direct invasion. Previous case of large pulse diarrhea uses this formula because purging damages Yin, causing Yang to detach, resulting in large pulse despite blood deficiency pattern.
Shanghan with rapid pulse (Cu) and cold hands/feet: Moxibustion is applicable. Cold reversal usually requires Si Ni Tang, but rapid pulse indicates internal Yang sinking, not deficiency. Moxibustion unblocks Yang; warming herbs are avoided.
All Si Ni/Jue cases contraindicate purging, including deficient patients. Jue results from failure of Yin-Yang Qi to connect smoothly, manifesting as cold extremities. Jue varies by cold/heat, treatments differ vastly, but purging is universally contraindicated due to Spleen-Stomach Yin-Yang disconnection failing to warm extremities.
Shanghan with slight heat and mild Jue (cold fingertips), silence, anorexia, and irritability for several days, with clear urine, indicates heat resolution. Desire to eat signals recovery. If Jue accompanies vomiting and chest/hypochondriac fullness, hematochezia will follow. Mild Jue is not severe, but prolonged irritability/anorexia injures Stomach fluids. Clear urine indicates heat dissipation and Stomach Qi recovery. Persistent Jue/vomiting/fullness indicates pathogen aggregation in Middle Jiao, leading to lower orifice bleeding due to Jueyin governing blood.
Diarrhea with floating-rapid Cun pulse and obstructed Chi pulse indicates pus/blood in stool. Diarrhea is Yin pathogen; floating-rapid is Yang pulse. If Yin resolves to Yang, Chi pulse normalizes. Obstructed Chi pulse indicates heat binding in Yin level. Despite Yang pulse at Cun, Yin pathogen will exit via lower orifices as pus/blood. This parallels the previous vomiting/fullness case; treatment is identical: Bai Tou Weng Tang for pus/blood, followed by Shao Yao Gan Cao Tang.
Shanghan fever for four days, Jue for three, then fever for four days (less Jue, more heat) indicates recovery. If fever persists on day seven, pus/blood in stool follows. Conversely, Jue for four days, fever for three, then Jue for five days (more cold, less heat) indicates progression due to Yang retreat. Taiyang progression fears interior transmission; Jueyin improvement welcomes Yin-to-Yang transition. Excess heat predicts abscesses or bleeding.
Shanghan fever for six days, Jue for nine days with diarrhea. Normally, Jue/diarrhea patients cannot eat. Ability to eat suggests Chu Zhong (Elimination of Central Qi - false appetite). Feeding wheat cakes: if no fever, Stomach Qi remains, recovery expected. Fear of sudden...