【纲】仲景曰。尺寸脉微缓者。厥阴受病也。当六七日发。其症少腹烦满而囊缩。
【目】朱肱曰。厥阴病。其脉微浮为欲愈。不浮为未愈。宜小建中汤。脉微缓者。必囊不缩。
外症必发热恶寒似疟。为欲愈。宜桂枝麻黄合半汤。尺寸俱沉短者。必囊缩。表气入腹。宜承气汤
下之。大抵伤寒脏腑传变。阳经先受病。次传入阴经。以阳主生。阴主杀也。若六七日传厥阴。脉得
微缓微浮。为脾胃脉也。故知土气不受克。邪无所容。荣卫将复。水升火降。则寒热作而大汗出矣。
王好古曰。厥阴病者。烦满囊缩。大小便不通。发热引饮腹满。尺寸脉俱微缓。烦者。火也。
满者。木也。虽不吐蛔囊缩。但急者。亦木也。火木相合。四肢厥逆。而爪甲青。大小便不通。地
道塞也。发热引饮。邪气在里。宜温之下之。
有以上诸症。大小便俱通。地道不塞。不发渴引饮。邪不在里。则宜温之灸之。则里外相接。
以复阳气。宜正阳散。
【纲】仲景曰。伤寒一二日。至四五日。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。脉滑而厥者。里有热也。白虎汤主之。
【目】朱肱曰。手足逆冷。此名厥也。厥者。逆也。阴阳不相顺接。故手足逆冷也。阳气衰。
阴气盛。阴胜于阳。故阳脉为之逆。不通于手足。所以逆冷也。伤寒热多厥少者。其病当愈。
厥多热少者。其病为进。然有冷厥。有热厥。当仔细辨认。冷厥者。初得病日。便四肢逆冷。脉沉
微而数。足多蜷卧而恶寒。或自引衣盖覆。不饮水。或下利清谷。或清便自调。或小便数。外症多
惺惺而静。脉虽沉实。按之迟而弱者。知其冷厥也。四逆汤、理中汤、通脉四逆汤、当归四逆汤、
当归四逆加吴萸生姜汤、白通加猪胆汁汤选用。热厥者。初病必身热头痛。别有阳症。二三日至四
五日。乃发厥兼热。厥至半日。却身热。盖热气深方发厥。须在二三日后也。若微厥即发热者。热
厥故也。脉虽沉伏。按之而滑。为里有热。其人或畏热。或饮水。或扬手掷足。烦躁不得卧。大
便秘。小便赤。外症多昏愦者。知其热厥也。白虎承气随症用之。本条云。厥应下之。以热厥当下。
若反发汗。必口伤烂赤也。又有下症悉具而见四逆者。是失下后血气不通。四肢便厥。医人不识。
疑是阴厥。反进热药。祸如反掌。大抵热厥。须脉沉伏而滑。头汗。手虽冷。爪甲时温。须承气下之。
勿拘忌。
诸手足逆冷。皆属厥阴。不可汗下。然有须汗须下者。谓虽逆冷。时有温时。手足掌心暖。非
正厥逆也。当消息之。若寒热而厥。面色。不泽。冒昧。两手忽无脉。或一手无脉者。必是有正汗
也。多用绵衣包手足令暖。急用五味子汤。或兼与麻黄细辛甘草汤。服之 时。必大汗解。或厥逆
怔忡者。宜先治水。茯苓甘草汤。然后治厥不然。水浸入胃。必下利。又有手足厥冷。脉乍结者。
邪结在胸也。心下满而烦。饥不能食者。病在胸中。吐之。瓜蒂散。盖病在胸中。亦令人手足厥。
但认脉乍结是也。脉阴虚则结。脉来缓。时一止。复来。曰结。主胸满烦躁。太阴少阴脉俱不至头。
俱无头疼症。仲景只有厥阴一症。吴茱萸汤治干呕吐涎沫头疼而已。大抵属三阳者。头疼为多也。若非次头疼。胸中满。
及发寒热。脉紧而不大者。即是膈上有痰。瓜蒂末一钱水调下。吐涎立愈。重阳必阴。重阴必阳。寒暑之变也。假令手
足逆冷。大便秘。小便赤。或大便黑。脉沉而滑。阳症似阴也。轻则白虎。重则承气。
伤寒失下。血气不通。令四肢逆冷。此是伏热
深。故厥亦深。急用大承气加分剂下之。汗出立瘥。仲景所谓厥宜下之者此也。
热厥与阴厥。自不同。热厥者。微厥即发热。阴厥即不发热。四肢逆冷。恶寒脉细。大小便滑
泄矣。
王好古曰。仲景言四逆与厥者非一。或曰四逆。或曰厥逆、厥冷、厥寒。或曰厥。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。何异乎。然四肢与手足却有分。以四字加逆字上。是通指手足
臂胫以上言也。以手足字加厥逆等字上。及无手足字。是独指手足言也。虽然。厥冷俱为寒冷。却
有阴阳之殊。热极而厥逆。阳极似阴也。以四逆散寒药治之。寒极而厥逆。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。至少阴病四逆条下。又谓四逆为寒甚。不自悖乎。是知
四肢冷。犹厥之有寒
有热。但四肢通冷。比之手足独冷则异耳。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。虽通由诸症兼见而然。然死者以逆言。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。
王肯堂曰。凡言四逆。或言厥言逆者。皆为重症。皆言四肢耳。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。踝上为胫也。其病之轻重浅深。皆寓于
书法中。宜审。
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。此为阳症似阴。白虎汤。重者大承气。不可误也。
张介宾曰。厥有二症。曰阳厥。曰阴厥。阳厥者。热厥也。必其先自三阳传入阴分。故初起必
头疼发热。自浅入深。然后及于三阴。变为四肢逆冷。或时乍温。其症必便结躁烦。谵语发渴。
不恶寒。反恶热。脉沉有力。此以传经热邪所化。外虽手足厥冷。内则因于热邪。阳症发厥。故为阳
厥。乃阳极似阴也。其症由邪热内结。或伏阳失下之所致也。凡厥微
热亦微。宜四逆散之类。厥甚热亦甚。宜大承气之类。阴厥者。寒厥也。初无三阳传经实热等症。
而真寒直入三阴。则畏寒厥冷。腹痛吐泻。战栗不渴。脉沉无力。此阴寒厥逆。独阴无阳也。故为
阴厥。轻则理中汤。重则四逆汤。回阳汤。主之。按阳厥阴厥。其辨如此。此先哲之大法也。然愚
则犹有辨。如厥阴一症。既无阳症阳脉。而病寒若此。明是阴症。今人但曰中寒者。即其病也。然
犯此者无几。知此者无难。治宜温中。无待辨也。惟是阳厥则有不得不辨者矣。夫厥由三阳所传。
为阳厥固矣。即以传经者言之。又岂尽无阴症乎。故凡病真阳不足者。即阳中之阴厥也。脉弱无神
者。即阳中之阴厥也。攻伐清凉太过者。即阳中之阴厥也。四肢为诸阳之本。使非有热结烦渴胀实
等症。而见厥逆者。皆由阳气不足也。成无己曰。大抵厥逆为阴所主。寒者多矣。又曰。厥为阴之
盛也。故凡属挟虚伤寒。则虽自阳经传入者。是亦阳中之阴厥也。阴中之阴者。宜温。阳中之阴者。
果宜凉乎。勿谓其先有头疼发热。但自三阳传至者。便为阳厥。而寒因热用之。则为害不小矣。
柯琴曰。首条。明热厥之理。二条。明热厥之脉与方。脉滑以弱。是有胃气。缓而滑。名热中。
与寒厥之。脉微欲绝不同。
【纲】仲景曰。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。
【目】喻昌曰。厥终不过五日。即上句之注脚。见热与厥相应。阴阳一胜一复。恰恰相当。故
可勿药自愈。
魏荔彤曰。此与上一二日至四五日条。乃申解厥阴病厥热互见。以明其阳陷入阴之深浅。均应
理其热邪。毋伤阴分。不可误见阳陷为厥。即以为寒。亦不可见阳升发热。即为可汗。而妄治也。
上条言一二日至四五日。夫久病非寒。故知其为传经之热。阳陷于阴而得厥也。厥者必发热。是因
后之必发热。知为热厥而非寒厥也。前热者后必厥。正见传经热邪。入于厥阴。升降不能。故发为厥
热互见之症也。厥深。为日多也。热入阴分之深也。故厥后必热。热亦因深而久也。厥微。为日少也。热入阴分微也。
故厥后必热。热亦因浅而暂也。推之热后必厥者亦如之。总为阳陷之故
也。阳气亦热邪。热邪即阳气也。然热微则陷者浅。可以升举。热深则陷者深。不可升举。乘其陷
入之势。与以荡涤之施。是厥阴无下法。又未尝无下法也。喻氏用小承气。下热邪而净阴分也。然
大柴胡尤为对症。不然。热入之深而反发汗。并失其升举之道矣。若妄施之。邪热愈炽。口伤烂赤。
必矣。试就其厥与热互见之日明之。如本条厥五日。阳入也。热亦五日。阳出也。设六日当复厥。阳
又入也。不厥。则阳不入而直出透表矣。所以知其能自愈。倘复厥。其日亦不过五。以前阳出之数
计之。知阳入又必五日而出也。更推之。凡阳入几日。厥几日。必阳出几日。热几日也。
均应理热邪。亦未能尽。如渐厥多热少。则又当理其寒邪。勿伤阳分矣。然厥多热少。渐致有
厥无热。自各有专条也。
【纲】仲景曰。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。
【目】张云岐曰。热少厥微。即热微厥亦微之症也。但曰指头寒。不言手足逆冷。其为热亦有
限矣。
【纲】仲景曰。伤寒脉微而厥。至七八日。肤冷。其人躁无暂安时者。此为脏厥。非蛔厥也。
蛔厥者。其人当吐蛔。今病者静而复时烦者。此为脏寒。蛔上入其膈。故烦。须臾复止。得食而呕。
又烦者。蛔闻食臭出。其人当自吐蛔。蛔厥者。乌梅丸主之。又主久利。
【目】成无己曰。脏厥者死。阳气绝也。蛔厥虽厥而烦。吐蛔已则静。不若脏厥而躁无临时安
也。
【纲】仲景曰。伤寒发热四日。厥反五日。复热四日。厥少热多。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。
【目】喻昌曰。以阴阳进退之义互举。其旨跃然。
【纲】仲景曰。伤寒先厥。后发热而利者。必自止。见厥。复利。伤寒先厥。后发热下利。必
自止。而反汗出。咽中痛者。其喉为
痹。发热无汗而利。必自止。若不止。必便脓血。便脓血者。其喉不痹。
【目】魏荔彤曰。此与上发热四日厥反三日条。申明热厥互见。并详其传经之热邪。上冲下注
不同。即此可知阳气升陷之几。而病势之进退决焉。盖传经之邪。其有深浅升降固已。然就深浅言。
此热原为传经之邪。就升降言。此热又为正阳之气。非阳气升透。则热入既深。漫无出路。其患非
上冲。即下注。岂能遽言愈哉。
厥阴病。总宜升阳于阴分。散热于表分也。此与上条。又在厥阴中辨病势吉凶之大关键也乎。
【纲】仲景曰。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。
【目】魏荔彤曰。凡仲景言日。如他条一二日四五日。及五日六日四日三日。与本条九日。皆
设以为验之辞。俱不可拘。如算法设为问答。以明其数。使人得较量其亏盈也。
【纲】仲景曰。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。
【目】王好古曰。厥阴症。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。按之无力者。为阴。则当温。宜四逆汤。
喻昌曰。寸脉沉而迟。明是阳去入阴之故。非阳气衰微可拟。故虽手足厥逆。下部脉不至。泄
利不止。其不得为纯阴无阳可知。况咽喉不利。唾脓血。又阳邪搏阴。上逆之征验。所以仲景特于
阴中提出其阳得汗出。而错杂之邪尽解也。
魏荔彤曰。寸。上焦之部位。阳分之脉也。而见沉迟。寒格于热。上热伏于寒下可知。手足厥冷。阳陷入阴。寒格
热伏又
可知。下部尺脉不至。平日之寒下肾虚又可知。是肾阳素弱。阳陷于阴。热格于寒之故。如绘目前。
何可任阳澌灭乎。但阳毕竟在阴中。虽弱。未尝无也。热毕竟伏寒下。惟郁。故反能为害也。咽喉
不利。唾脓血者。热邪不肯屈伏而上冲于肺为患也。泄利不止。热邪既不能上达。不得不随阴气。
而为挟热之利也。即是热邪伏郁阴中。阳气必勃动于阴分。固极难为升举。不易致透表散邪。治之
得愈矣。然非有阴无阳。厥去不还之死症也。仍当以破阴升阳为主治。用麻黄升麻汤。与乌梅丸。
[Outline] Zhang Zhongjing said: When the pulse at both the Cun (inch) and Chi (cubit) positions is slightly slow and moderate (Wei Huan), it indicates that the Jueyin meridian is affected. This typically manifests on the sixth or seventh day of illness. The symptoms include a sensation of vexation and fullness in the lower abdomen, and retraction of the scrotum.
[Commentary] Zhu Gong said: In Jueyin disease, if the pulse is slightly floating, recovery is imminent; if not floating, the disease has not yet resolved. Xiao Jianzhong Tang (Minor Construct the Middle Decoction) is appropriate. If the pulse is slightly slow and moderate, the scrotum will not retract. The external symptoms must include fever and aversion to cold resembling malaria, which indicates impending recovery. Guizhi Mahuang Ban Tang (Guizhi and Mahuang Half-Combination Decoction) is appropriate. If the pulses at both Cun and Chi are deep and short, scrotal retraction will certainly occur. This is due to exterior pathogens penetrating into the interior. Chengqi Tang (Purgative Decoction) should be used to purge. Generally, in Shanghan (Cold Damage) diseases, transmission follows the zang-fu organs: Yang meridians are affected first, then transmitted to Yin meridians, because Yang governs generation and Yin governs destruction. If transmission reaches Jueyin after six or seven days, and the pulse becomes slightly slow/moderate or slightly floating, this reflects the spleen-stomach pulse. Thus, one knows that Earth Qi (Spleen/Stomach energy) is not being overcome, pathogens have no place to reside, and Ying and Wei (Nutritive and Defensive) energies are about to recover. With Water ascending and Fire descending, alternating chills and fever will occur followed by profuse sweating.
Wang Haogu said: Symptoms of Jueyin disease include vexation, fullness, scrotal retraction, obstruction of urination and defecation, fever with thirst, and abdominal distension, with pulses at Cun and Chi being slightly slow/moderate. Vexation belongs to Fire; fullness belongs to Wood. Even without vomiting roundworms, if there is scrotal retraction accompanied by a sense of urgency, it also relates to Wood. The combination of Fire and Wood leads to cold limbs (Jue Ni), cyanosis of the fingernails, and obstruction of urination and defecation, indicating blockage of the "Earthly Path" (lower jiao/intestines). Fever with thirst indicates pathogens in the interior; warm methods combined with purging are appropriate.
If the aforementioned symptoms are present but urination and defecation are unobstructed, and there is no thirst, the pathogen is not deeply entrenched in the interior. Warm methods combined with moxibustion should be used to connect interior and exterior Yang Qi and restore it. Zhengyang San (Zhengyang Powder) is appropriate.
[Outline] Zhang Zhongjing said: In Shanghan, from the first or second day to the fourth or fifth day, if cold limbs (Jue) appear, fever will inevitably follow. If fever preceded cold limbs, cold limbs will follow. The deeper the cold limbs, the deeper the internal heat; the milder the cold limbs, the milder the internal heat. Cold limb syndromes should be treated with purging. If sweating is induced instead, oral ulcers and redness will certainly result. If the pulse is slippery with cold limbs, there is heat in the interior, treated by Baihu Tang (White Tiger Decoction).
[Commentary] Zhu Gong said: Cold reversal of the hands and feet is called "Jue". Jue means reversal. Because Yin and Yang Qi fail to connect smoothly, the hands and feet become cold. When Yang Qi is weak and Yin Qi is strong, Yin overcomes Yang, causing Yang pulses to reverse and fail to reach the extremities, resulting in coldness. In Shanghan, if fever predominates over cold limbs, the disease will heal; if cold limbs predominate over fever, the disease progresses. However, one must distinguish between Cold Jue (Han Jue) and Heat Jue (Re Jue). In Cold Jue, from the onset, limbs are cold, the pulse is deep, fine, and rapid, legs are curled up with aversion to cold, the patient may pull clothes over themselves, refuse water, suffer from diarrhea with undigested food, or have normal stool or frequent urination. Externally, the patient is usually alert and quiet. Although the pulse may feel deep and solid, pressing reveals it as slow and weak, indicating Cold Jue. Options include Sini Tang, Lizhong Tang, Tongmai Sini Tang, Danggui Sini Tang, Danggui Sini plus Wuzhuyu and Shengjiang Decoction, and Baitong plus Zhu Danzhi Decoction.
In Heat Jue, initial symptoms include body fever and headache, distinct from typical Yang syndrome patterns. On the second to fifth day, cold limbs appear accompanied by heat. After half a day of cold limbs, fever returns because deep heat triggers cold limbs, usually appearing after two to three days. If mild cold limbs are quickly followed by fever, it is Heat Jue. The pulse may be deep and hidden but feels slippery upon pressure, indicating internal heat. Patients may fear heat, desire water, toss about restlessly, suffer constipation, and have dark urine. Externally, they may appear confused. This indicates Heat Jue. Baihu Tang or Chengqi Tang should be selected based on symptoms. The text states "Jue should be purged," referring to Heat Jue requiring purgation. Inducing sweat instead causes oral damage. If all purgative indications are present but cold limbs appear, it is due to blood and Qi stagnation from missed purgation. Misdiagnosing this as Yin Jue and administering hot medicines causes disaster. Heat Jue requires a deep, hidden, slippery pulse, head sweating, and warm nail beds despite cold hands. Purge with Chengqi Tang without hesitation.
All cold reversals of hands and feet belong to Jueyin, generally prohibiting sweating or purging. However, exceptions exist where sweating or purging is needed if the cold is intermittent and palms are warm, indicating it is not true Jue Ni. One must exercise judgment. If accompanied by chills and fever, pale complexion, dizziness, and absent radial pulses, normal sweating will likely occur. Keep limbs warm with cotton; urgently use Wuweizi Decoction or combine with Mahuang Xixin Gancao Decoction. Profuse sweating will resolve the condition. If cold reversal is accompanied by palpitations, treat fluid retention first with Fuling Gancao Decoction, then address Jue. Otherwise, fluid invading the stomach causes diarrhea. If cold limbs are accompanied by an intermittent pulse (Jie Mai), pathogens are knotted in the chest. Fullness and vexation below the heart, hunger without appetite, indicate pathology in the chest; induce vomiting with Gudi San. Chest pathology can cause cold limbs; identify by the intermittent pulse. A deficient pulse knots; a slow pulse with occasional stops is called Jie, indicating chest fullness and vexation. Taiyin and Shaoyin pulses do not reach the head, so no headache occurs. Zhang Zhongjing mentions only one Jueyin symptom for headache with dry vomiting and saliva, treated by Wuzhuyu Tang. Headaches are common in Yang meridians. Non-routine headaches with chest fullness, chills/fever, and tight/large-inadequate pulses indicate phlegm in the diaphragm; administer Gudi powder mixed with water to vomit saliva and cure. Extreme Yang transforms to Yin, extreme Yin transforms to Yang, reflecting seasonal changes. For example, cold limbs, constipation, dark urine or black stool, with deep/slippery pulses, indicate Yang syndrome resembling Yin. Mild cases use Baihu Tang; severe cases use Chengqi Tang.
Missed purgation in Shanghan causes Qi/Blood stagnation and cold limbs due to deep latent heat, hence deep cold limbs. Urgently purge with a larger dose of Da Chengqi Tang; sweating resolves it. This is what Zhang Zhongjing meant by "Jue should be purged."
Heat Jue and Yin Jue differ. Heat Jue features mild cold limbs followed by fever; Yin Jue features no fever, cold limbs, aversion to cold, fine pulse, and loose stools.
Wang Haogu noted that Zhang Zhongjing uses various terms for cold limbs: Si Ni, Jue Ni, Jue Leng, Jue Han, Jue, Shou Zu Ni Leng, etc., all denoting cold. "Jue Ni" is often used interchangeably. There is no distinction between "Ni" (not warm) and "Jue" (cold); both imply cold. However, "Si Zhi" (four limbs) differs from "Shou Zu" (hands and feet). Adding "Si Zhi" before "Ni" refers to arms and calves; using "Shou Zu" specifies hands and feet. Although both denote cold, they differ in Yin/Yang nature. Extreme heat causing Jue Ni is "Extreme Yang resembling Yin," treated with cooling herbs like Sini San. Extreme cold causing Jue Ni is "Yin alone without Yang." Although Zhang Zhongjing lacks explicit texts on using hot medicines like Sini Tang for Si Ni, the name implies treating cold limbs. Using Sini Tang for hand/foot coldness suggests no difference between Ni and Jue. Cheng Wuji stated Si Ni is heat pathogen, yet later called it severe cold in Shaoyin context, which seems contradictory. Thus, limb coldness, like Jue, has cold and heat types. General limb coldness differs from isolated hand/foot coldness. Zhang Zhongjing stated: "Shaoyin disease with vomiting, diarrhea, irritability, and Si Ni is fatal." And "Shaoyin disease with Si Ni, aversion to cold, curling up, absent pulse, irritability, and restlessness is fatal." But "Shaoyin disease with vomiting, diarrhea, cold limbs, and severe irritability" is treatable with Wuzhuyu Tang. Two are fatal, one treatable. Fatal cases use "Ni"; treatable cases use "Jue Leng." Thus, Si Ni is more severe than Jue Leng. Cheng Wuji's claim that Jue is worse than Ni is erroneous.
Wang Kentang said: Terms like Si Ni, Jue, or Ni indicate severe conditions affecting four limbs. Mentioning cold fingertips or specific hand/foot coldness indicates mild Jue. Anatomy matters: wrist above hand, arm above wrist; ankle above foot, calf above ankle. Severity is encoded in terminology.
Transition from heat to warmth to cold limbs indicates transmitted pathogenic heat, treated with Sini San. Cold reversal with constipation, dark urine/stool, and deep/slippery pulse is Yang syndrome resembling Yin, treated with Baihu Tang or Da Chengqi Tang.
Zhang Jiebin said: Jue has two types: Yang Jue and Yin Jue. Yang Jue is Heat Jue, originating from Yang meridians transmitting to Yin. Initial symptoms include headache and fever, progressing to cold limbs with intermittent warmth. Symptoms include constipation, irritability, delirium, thirst, aversion to heat, and deep/forceful pulse. Internal heat causes external cold limbs; this is Yang Jue (Extreme Yang resembling Yin), caused by internal heat knotting or missed purgation. Mild Jue/heat uses Sini San; severe uses Da Chengqi Tang. Yin Jue is Cold Jue, lacking Yang meridian heat signs, with true cold entering Yin meridians directly. Symptoms include aversion to cold, cold limbs, abdominal pain, vomiting/diarrhea, shivering, no thirst, and deep/weak pulse. This is Yin cold reversal (Yin alone without Yang), treated with Lizhong Tang (mild) or Sini Tang/Huiyang Tang (severe).
I offer further clarification. Jueyin disease without Yang signs/pulses is clearly Yin. Modern practitioners call this "Zhong Han" (Cold Strike), but it is rare and easily treated with warming the middle. Differentiation is crucial for Yang Jue. While Yang Jue stems from Yang meridians, transmitted cases can involve Yin patterns. Those with deficient True Yang suffer from "Yin within Yang." Weak pulses indicate "Yin within Yang." Overuse of cooling/purging drugs causes "Yin within Yang." Limbs are the root of Yang; without heat knots/thirst/distension, cold limbs stem from Yang deficiency. Cheng Wuji stated Jue is governed by Yin and is mostly cold. He also said Jue represents盛 (abundance) of Yin. Thus, even transmitted cases with deficiency are "Yin within Yang." Should "Yin within Yin" be warmed? Yes. Should "Yin within Yang" be cooled? No. Do not assume all transmitted cases are Yang Jue simply due to initial fever/headache; using cold for heat here causes harm.
Ke Qin said: The first clause explains the principle of Heat Jue. The second clause explains its pulse and formula. A slippery yet weak pulse indicates Stomach Qi; slow and slippery indicates "Heat in the Middle." This differs from the faint/almost absent pulse of Cold Jue.
[Outline] Zhang Zhongjing said: In Shanghan, five days of cold limbs followed by five days of fever. If the sixth day brings recurrent cold limbs, the disease heals if cold limbs do not recur. Cold limbs last no more than five days; since fever lasts five days, self-healing is expected.
[Commentary] Yu Chang explained: The limit of five days for cold limbs notes the previous sentence, showing correspondence between fever and cold limbs. Yin and Yang advance and retreat equally, allowing spontaneous recovery without medication.
Wei Litong stated: This clarifies the alternating nature of Jue and Re in Jueyin disease, indicating the depth of Yang sinking into Yin. One must regulate heat pathogens without damaging Yin. Do not mistake Yang sinking for cold, nor assume fever allows for sweating. The previous clause (days 1-2 to 4-5) indicates long-standing illness is not cold but transmitted heat. Yang sinks into Yin causing Jue; subsequent fever confirms Heat Jue. Preceding fever leading to Jue shows heat entering Jueyin, disrupting ascent/descent, causing alternating Jue/Re. Deep Jue implies many days and deep heat entry, leading to prolonged post-Jue fever. Mild Jue implies few days and shallow heat entry, leading to brief post-Jue fever. Conversely, post-fever Jue follows similar logic. All result from Yang sinking. Yang Qi is heat pathogen. Mild heat sinks shallowly and can be lifted; deep heat sinks deeply and cannot. Utilizing the sinking momentum to purge is valid; thus, Jueyin is not devoid of purgation. Yu Chang used Xiao Chengqi Tang to purge heat and cleanse Yin. Da Chaihu Tang is also suitable. Mistaken sweating deepens heat, blocking lifting pathways, causing oral ulcers. Analyzing days: 5 days Jue (Yang enters), 5 days Re (Yang exits). Day 6 recurrence of Jue means Yang re-enters. No Jue means Yang exits directly to surface, ensuring healing. If Jue recurs, it lasts 5 days, predicting another 5-day exit. Generally, days of Yang entry equal days of Jue, which equal days of Yang exit and Re. Regulate heat, but if Jue increases while Re decreases, regulate cold to protect Yang. Specific clauses cover Jue-dominant cases.
[Outline] Zhang Zhongjing said: In Shanghan, mild heat and mild Jue manifest as cold fingertips, silence, anorexia, and irritability. After several days, clear urine indicates heat removal. Desire for food signals recovery. If Jue is accompanied by vomiting and chest/hypochondriac fullness, hematochezia will follow.
[Commentary] Zhang Yunqi noted: Mild heat/Jue implies limited heat. Specifying only cold fingertips, rather than full limb coldness, confirms limited heat.
[Outline] Zhang Zhongjing said: In Shanghan, a faint pulse with cold limbs persisting to the 7th-8th day, with cold skin and constant restlessness (no respite), indicates Zang Jue (Visceral Cold), not Huo Jue (Roundworm Jue). Huo Jue patients vomit roundworms. Current patient is quiet but intermittently vexed due to visceral cold causing roundworms to ascend to the diaphragm. Vexation ceases briefly. Eating induces vomiting and vexation as roundworms smell food and emerge; patient vomits roundworms. Huo Jue is treated with Wumei Wan (Dark Plum Pill), also for chronic dysentery.
[Commentary] Cheng Wuji stated: Zang Jue is fatal due to Yang exhaustion. Huo Jue involves Jue and vexation, but settles after vomiting roundworms, unlike the constant restlessness of Zang Jue.
[Outline] Zhang Zhongjing said: In Shanghan, fever for 4 days, then cold limbs for 5 days, then fever for 4 days. Less Jue, more Re indicates healing. If fever persists from day 4 to 7, pus and blood in stool will occur. If Shanghan presents with 4 days Jue, then 3 days Re, then 5 days Jue, the disease progresses. More cold, less heat indicates Yang decline.
[Commentary] Yu Chang noted: The interplay of Yin/Yang advancement/retreat makes the intent clear.
[Outline] Zhang Zhongjing said: In Shanghan, initial Jue followed by fever and diarrhea leads to spontaneous cessation. Recurrence of Jue restarts diarrhea. If initial Jue is followed by fever and diarrhea cessation, but sweating occurs with throat pain, Bi Syndrome (throat obstruction) results. If fever, no sweating, and diarrhea cease spontaneously but continue, pus/blood in stool occurs. If pus/blood occurs, throat Bi does not.
[Commentary] Wei Litong stated: This clarifies alternating Heat/Jue and details how transmitted heat ascends or descends. This reveals the mechanism of Yang rising/sinking and determines disease progression. Transmitted pathogens have depth and direction. Heat is both pathogen and Zheng Yang. Without Yang lifting, deep heat has no outlet, causing upper or lower complications. Jueyin treatment requires lifting Yang in Yin and dispersing heat in the exterior. This distinguishes auspicious/inauspicious trends in Jueyin.
[Outline] Zhang Zhongjing said: In Shanghan, initial fever for 6 days, then Jue for 9 days with diarrhea. Typically, Jue/diarrhea patients cannot eat. If able to eat, suspect Chu Zhong (stomach Qi returning falsely). Feed Suo Bing (noodles). If no fever ensues, Stomach Qi remains, and healing is expected. Fear sudden transient heat. Three days later, if pulse shows sustained heat, expect healing by midnight of the next day. Reason: 6 days fever + 3 days recent fever = 9 days, matching 9 days of Jue. If pulse is rapid and heat persists after three days, excess heat will cause abscesses/pus.
[Commentary] Wei Litong stated: Zhang Zhongjing's day counts (e.g., 9 days) are hypothetical calculations to illustrate balance/imbalance, not rigid timelines.
[Outline] Zhang Zhongjing said: In Shanghan, after severe purgation on days 6-7, if Cun pulse is deep/slow, limbs are cold, lower pulses are absent, throat is obstructed, pus/blood is vomited/spit, and diarrhea is unceasing, it is difficult to treat. Mahuang Shengma Decoction is indicated.
[Commentary] Wang Haogu said: Jueyin symptoms with cold limbs, cyanotic nails, and deep/rapid forceful pulse indicate Yang; purge with Da Chengqi Tang. Deep/weak pulse indicates Yin; warm with Sini Tang.
Yu Chang stated: Deep/slow Cun pulse indicates Yang retreating into Yin, not mere Yang deficiency. Despite cold limbs and absent lower pulses/diarrhea, it is not pure Yin without Yang. Throat obstruction and spitting pus/blood show Yang pathogen attacking Yin and reversing upward. Zhang Zhongjing extracts Yang from Yin to induce sweating and resolve complex pathogens.
Wei Litong stated: Cun pulse (upper jiao/Yang) being deep/slow indicates cold blocking heat, with upper heat trapped by lower cold. Cold limbs show Yang sinking into Yin. Absent Chi pulse indicates kidney Yang deficiency from prior cold purgation. Kidney Yang is weak, Yang sinks into Yin, heat blocked by cold. Throat obstruction and pus/blood show heat attacking lungs. Unceasing diarrhea shows heat following Yin qi as heat-induced diarrhea. Heat is trapped in Yin; Yang struggles to rise and disperse. Treatment must break Yin and lift Yang using Mahuang Shengma Decoction and Wumei Wan.