之说略同。汪氏又引常器之云。灸太冲。郭白云云。灸太溪。脉经云。灸厥阴俞。俱误也。
厥阴之为病。消渴。气上撞心。心中疼热。饥而不欲食。食则吐蛔。下之利不止。（玉函。食则上。有甚
者二字。利不止。作不肯止。脉经。千金翼。并同。无食则之食。）
〔程〕厥阴者。两阴交尽。阴之极也。极则逆。逆固厥。其病多自下而上。所以厥阴受寒。则雷龙之火。
逆而上奔。撞心而动心火。心火受触。则上焦俱扰。是以消渴。而心烦疼。胃虚而不能食也。食则吐蛔。则胃
中自冷可知。以此句结前证。见为厥阴自病之寒。非传热也。且以见乌梅丸。为厥阴之主方。不但治蛔宜之。
盖肝脉中行。通心肺。上巅。故无自见之证。见之中上二焦。其厥利发热。则厥阴之本证。胃虚脏寒。下之则
上热未除。下寒益甚。故利不止。〔钱〕邪入厥阴。则阴邪自下。迫阳于上。故气上撞心。心中疼热。而消渴
也。消渴者。饮水多而渴不止也。阴中之阳。受迫而在上。故消渴而胃觉饥。然终是阴邪。所以不欲食。客热
尚不杀谷。况阴邪乎。即使强食。阴邪不能腐化。湿热郁蒸。顷刻化而为蛔。随阴气之上逆。故吐蛔也。若不
知。而以苦寒误下之。则胃阳败绝。真阳下脱。故利不止也。〔舒〕按此条。阴阳杂错之证也。消渴者。膈有
热也。厥阴邪气上逆。故上撞心。疼热者。热甚也。心中疼热。阳热在上也。饥而不欲食者。阴寒在胃也。强
与之食。亦不能纳。必与饥蛔俱出。故食则吐蛔也。此证上热下寒。若因上热误下之。则上热未必即去。而下
寒必更加甚。故利不止也。〔张〕张卿子曰。尝见厥阴消渴数证。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。〔鉴〕此条。
总言厥阴为病之大纲也。厥阴者。为阴尽阳生之脏。与少阳为表里者也。邪至其经。从阴化寒。从阳化热。故
其为病。阴阳错杂。寒热混淆也。
杨氏活人总括云。张氏有言。厥阴为病。消渴。气上冲心。饥不欲食。食即吐蛔。吐蛔既出于胃冷。役
有消渴之证。何哉。盖热在上焦。而中焦下焦。虚寒无热耳。设或大便硬结。是亦蕴毒使然。又不可指为燥粪。
但用生料理中汤。加大黄。入蜜。以利之。白术干姜。所以辅大黄也。（案六书。加味理中饮。本于此说。当考。）
厥阴中风。脉微浮为欲愈。不浮为未愈。（玉函。千金翼。脉上。有其字。）
〔鉴〕厥阴中风。该伤寒而言也。脉微。厥阴脉也。浮。表阳脉也。厥阴之病。既得阳浮之脉。是其邪
已还于表。故为欲愈也。不浮则沉。沉。里阴脉也。是其邪仍在于里。故为未愈也。〔锡〕王良能曰。阳病得阴
脉者死。不浮。未必即是阴脉。故止未愈。不曰沉而曰不浮。下字极活。〔张〕案仲景三阴。皆有中风。然但
言欲愈之脉。而未及于证治者。以风为阳邪。阴经之中。得风气流动。反为欲愈之机。
厥阴病。欲解时。从丑至卯上。（玉函。千金翼。作从丑尽卯。）
〔锡〕少阳旺于寅卯。从丑至卯。阴尽而阳生也。厥阴病解于此时者。中见少阳之化也。徐旭升曰。三
阳解时。在三阳旺时而解。三阴解时。亦从三阳旺时而解。伤寒以生阳为主也。
厥阴病。渴欲饮水者。少少与之愈。（玉函。千金翼。愈上有即字。喻本程本钱本魏本。并无渴字。）
〔程〕厥阴之见上热。由阴极于下。而阳阻于上。阴阳不相顺接使然。非少阴水来克火。亡阳于外者比。
寒凉不可犯下焦。而不妨济上焦。欲饮水者少少与之。使阳神得以下通。而复不犯及中下二焦。亦阴阳交接之
一法也。
案成氏以降。以渴欲饮水。为阳回气暖。欲解之佳兆。殊不知消渴。乃厥阴中之一证。特柯氏注云。水
能生木。能制火。故厥阴消渴最宜之。是也。盖曰愈者。非厥阴病愈之义。仅是渴之一证。得水而愈也。汪氏
引武陵陈氏。辨篇首消渴。与此条之消渴不同。竟不免牵强耳。
诸四逆厥者。不可下之。虚家亦然。
〔锡〕诸病而凡四逆厥者。俱属阴寒之证。故不可下。然不特厥逆为不可下。即凡属虚家。而不厥逆者。
亦不可下也。张均卫曰。虚家伤寒。未必尽皆厥逆。恐止知厥逆为不可下。而不知虚家虽不厥逆。亦不可下。
故并及之。〔汪〕仲景于后条。虽云热厥者应下之。然方其逆厥之时。下之一法。不轻试也。诸字。是该下文
诸厥之条而言。虚家亦然者。言人于未病之前。气血本虚家也。
案玉函。从此条以下至篇末。别为一篇。题曰辨厥利呕哕病形证治第十。
伤寒先厥。后发热而利者。必自止。见厥复利。
〔成〕阴气胜则厥逆而利。阳气复则发热。利必自止。见厥则阴气还胜。而复利也。〔张〕伤寒先厥。
后发热而利。言伤寒表证罢。先见厥利而后发热。非阴证始病。便见厥利也。先厥后发热。而利必自止。乃厥
阴之常候。下文见厥复利。乃预为防变之辞。设厥利止。而热不已。反见咽痛喉痹。或便脓血。又为阳热有余
之证矣。
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。（【原注】一云消中。）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。（食
以索饼。千金翼。作食之黍饼。后日脉之。成本。玉函。作后三日脉之。玉函。无所以然以下三十八字。）
〔钱〕自始发热。至夜半愈。是上半截原文。所以然者。至必发痈脓止。乃仲景自为注脚也。但厥反九日而
利句下。疑脱复发热三日利止七字。不然。如何下文有恐暴热来出而复去二句。且所以然句下云。发热六日。
厥反九日。复发热三日。并前六日。亦为九日。是明明说出。其为脱落无疑矣。然何以知其为复发热利止乎。
上条云。先厥后发热。利必自止。况自食索饼后。并不言利。是以知其复发热而利止也。言始初邪入厥阴。而
发热者六日。热后厥者九日。是发热止六日。而厥反九日。厥多于热者三日矣。故寒邪在里而下利也。厥后复
发热三日。利必自止。大凡厥冷下利者。因寒邪伤胃。脾不能散精以达于四肢。四肢不能禀气于胃而厥。厥则
中气已寒。当不能食。今反能食者。似乎胃气已回。但恐为下文之除中。则胃阳欲绝。中气将除。胃中垂绝之
虚阳复焰。暂开而将必复闭。未可知也。姑且食以索饼。索饼者。疑即今之条子面。及 子之类。取其易化也。
食后不停滞而发热。则知已能消谷。胃气无损而尚在。其病为必愈也。何也。恐其后发之暴热暂来。出而复去
故也。食后三日脉之。而厥后之热续在者。即期之明日夜半愈。所以然者。以其本发热六日。厥反九日。计后
三日续发之热又三日。并前六日亦为九日。与厥相应。为阴阳相均。胜复之气当和。故期之
且日夜半。阴极阳回之候。其病当愈。所谓厥阴欲解时。自丑至卯上也。所谓后三日脉之。其热续在。为阴阳
相当而愈。则其热当止矣。若脉仍数。而其热不罢者。此为热气有余。阳邪太过。随其蕴蓄之处。必发痈脓也。
〔汪〕即来复骤去者。此胃中真气得食。而尽泄于外。即名除中。而必死矣。〔魏〕食索饼以试之。若发热者。
何以知其胃气亡。则此热。乃暴来出而复去之热也。即如脉暴出者。知其必死之义也。阴已盛极于内。孤阳外
走。出而离阴。忽得暴热。此顷刻而不救之证也。凡仲景言曰。皆约略之辞。如此九日之说。亦未可拘。总以
热与厥。较其均平耳。如热七八日。厥七八日。亦可。热五六日。厥五六日。俱可。不过较量其阴阳盛衰。非
定谓必热九日厥九日。方可验准也。〔柯〕发痈肿。是阳邪外溢于形身。俗所云伤寒留毒者。是也。
案金鉴云。不发热之不字。当是若字。若是不字。即是除中。何以下接恐暴热来出而复去之文也。盖二恐
字。皆疑为除中而下之。若是发热。则不可更言恐暴热来出而复去也。此说不可从。
案方云。索当作素。谓以素常所食之饼饵饲之。一说。无肉曰素。志聪云。索饼。麦饼也。此说非也。刘
熙释名云。饼。并也。溲面使合并也。蒸饼汤饼蝎饼髓饼金饼索饼之属。皆随形而名之。缃素杂记云。凡以面
为食具。皆谓之饼。清来集之倘湖樵书云。今俗以麦面之线索而长者。曰面。其圆块而匾者。曰饼。考之古人。
则皆谓饼也。汉张仲景伤寒论云。食以索饼。饼而云索。乃面耳。此汉人以面为饼之一证也。知是钱氏为条子
面者。确有根据也。
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。（今与。玉函。作而与。此名。玉函。千金翼。作此为。钱曰。彻。读为撤。）
〔汪〕脉迟为寒。不待智者而后知也。六七日反与黄芩汤者。必其病初起。便发厥而利。至六七日。阳气
回复。乃乍发热。而利未止之时。粗工不知。但见其发热下利。误认以为太少合病。因与黄芩汤彻其热。彻。
即除也。又脉迟云云者。是申明除其热之误也。〔成〕除。去也中。胃气也。言邪气太甚。除去胃气。胃欲引
食自救。故暴能食也。〔柯〕除中。则中空无阳。反见善食之状。俗云食禄将尽者。是也。〔程〕对上文看。
则食入必发热可知矣。必见下利厥逆发躁等证而死。上条脉数。此条脉迟。是题中二眼目。
案金鉴云。伤寒脉迟六七日之下。当有厥而下利四字。若无此四字。则非除中证矣。有此四字。始与下文
反与黄芩汤之义相属。此说颇有理。然而汪氏太明备。不必补厥而下利四字。而义自通矣。
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。
〔汪〕先厥后发热。下利必自止。阳回变热。热邪太过。而反汗出。咽中痛者。此热伤上焦气分也。其喉
为痹。痹者。闭也。此以解咽中痛甚。其喉必闭而不通。以厥阴经。循喉咙之后。上入颃颡故也。又热邪太过。
无汗而利不止。便脓血者。此热伤下焦血分也。热邪泄于下。则不干于上。故云其喉不痹。或问。中寒之邪。
缘何变热。余答曰。元气有余之人。寒邪不能深入。才着肌表。即便发热。此伤寒也。元气不足之人。寒邪直
中阴经。不能发热。此中寒也。寒中厥阴。为阴之极。阴极则阳生。故发热。然亦当视其人之元气何如。若发
热则自愈者。元气虽不足。不至太虚。故得愈也。
元气太虚之人。不能发热。但厥而至于死者。此真阳脱也。有发热而仍厥者。此阳气虽复而不及。全赖热药以
扶之也。有发热而至于喉痹便脓血。如上证者。此阳气虽复而太过。其力不能胜邪热。全赖凉药以平之也。余
疑此条证。或于发厥之时。过服热药。而至于此。学人临证。宜细辩之。
案汪云。常器之曰。喉痹。可桔梗汤。便脓血。可桃花汤。然桃花汤内有干姜。过于辛热。不可用也。
如黄芩汤。可借用之。张云。便脓血者。白头翁汤。未知何是。
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。（四五日下。成本。玉函。有而字。）
〔程〕伤寒母论一二日。至四五日。而见厥者。必从发热得之。热在前厥在后。此为热厥。不但此也。他
证发热时不复厥。发厥时不复热。盖阴阳互为胜复也。唯此证。孤阳操其胜势。厥自厥。热仍热。厥深则发热
亦深。厥微则发热亦微。而发热中。兼夹烦渴不下利之里证。总由阳陷于内。菀其阴于外。而不相接也。须用
破阳行阴之法。下其热。而使阴气得伸。逆者顺矣。不知此而反发汗。是徒从一二日。及发热上起见。认为表
寒故也。不知热得辛温。而助其升散。厥与热两不除。而早口伤烂赤矣。〔喻〕前云诸四逆厥者。不可下矣。此
云厥应下之者。其辨甚微。盖先四逆而后厥。与先发热而后厥者。其来迥异。故彼云不可下。此云应下之也。
以其热深厥深。当用苦寒之药。清解其在里之热。即名为下。如下利谵语。但用小承气汤止耳。从未闻有峻下
之法也。若不用苦寒。反用辛甘发汗。宁不引热势上攻。口伤烂赤。与喉痹互意。
案喻注云。先四逆而后厥。则似以四逆与厥。分为二证。
钱氏于四逆散注。辨厥四逆同一义。极是。当参考。
案注云。此条。系阳明篇错简。此说非也。此证固是阳明胃家实。然以其厥者。与厥阴之厥相似。故揭于
此篇。与下白虎汤条同意。
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。
The above explanation is roughly the same. Wang Shi further quotes Chang Qizhi, saying that Taichong (LR3) should be moxibusted. Guo Baiyun says that Taixi (KI3) should be moxibusted. The *Mai Jing* (Pulse Classic) says that Jueyin Shu (BL47) should be moxibusted; all of these are incorrect.
The manifestations of Jueyin disease include: excessive thirst (Xiao Ke), a sensation of Qi rushing upward to strike the heart, pain and burning heat in the heart region, a feeling of hunger without an appetite for food, vomiting of roundworms if food is ingested, and diarrhea that will not cease if purgatives are used. (In the *Yu Han Jing*, the characters "Shen Zhe" [severe cases] appear after "Shi Ze Tu". "Li Bu Zhi" is written as "Bu Ken Zhi". The *Mai Jing* and *Qian Jin Yi Fang* are consistent with this, omitting the character "Shi" in "Shi Ze Tu".)
[Cheng] Jueyin represents the convergence of two Yin meridians and is the extreme of Yin. When reaching the extreme, reversal occurs; this reversal is termed Jue (cold extremities). The pathology often progresses from below upwards. Therefore, when Jueyin contracts cold, the Fire of Lei Long (Mingmen fire) rebels and rushes upward, striking the Heart and disturbing Heart Fire. Once disturbed, the Upper Jiao is thoroughly disrupted, leading to excessive thirst, vexation, and pain. The Stomach is deficient and unable to accept food. Vomiting roundworms upon eating indicates that the interior of the Stomach is cold. This statement summarizes the preceding symptoms, indicating that this is a cold pattern originating from Jueyin itself, not a transmitted heat pathogen. It also demonstrates why Wumei Wan (Mume Pill) is the principal formula for Jueyin disease; it is suitable not only for treating roundworms but because the Liver meridian runs through the middle, connecting to the Heart and Lungs, and ascending to the vertex. Thus, there are no specific external signs unique to Jueyin alone; the manifested signs appear in the Middle and Upper Jiao. Cold extremities, diarrhea, and fever are the fundamental patterns of Jueyin. With Stomach deficiency and organ coldness, using purgatives fails to clear the upper heat while exacerbating the lower cold, resulting in unceasing diarrhea.
[Qian] When pathogens enter Jueyin, Yin pathogens rise from below, forcing Yang upward. Hence, Qi strikes the heart, causing pain and burning heat in the chest, along with thirst. Xiao Ke (excessive thirst) refers to drinking large amounts of water yet remaining thirsty. The Yang within Yin is forced upward, causing thirst and a sensation of stomach hunger. However, since it is ultimately a Yin pathogen, there is no desire to eat. Even if guest heat cannot digest grain, how much less can a Yin pathogen? Even if one forces food intake, the Yin pathogen cannot rot or transform it. Damp-heat stagnates and steams, transforming into roundworms almost instantly, which are then vomited up following the rebellious ascent of Yin Qi. If this is misunderstood and treated incorrectly with bitter-cold purgatives, Stomach Yang will collapse, and True Yang will descend and escape, leading to unceasing diarrhea.
[Shu] According to this clause, this is a pattern of mixed Yin and Yang. Excessive thirst indicates heat in the diaphragm. Rebellious Jueyin pathogens cause Qi to strike upward against the heart. Pain and burning heat indicate severe heat; pain and burning in the heart region signify Yang heat residing above. Hunger without desire to eat indicates Yin cold in the Stomach. Forcing food will not be accepted; it must come out together with hungry roundworms, hence vomiting roundworms upon eating. This pattern features upper heat and lower cold. If purged due to the upper heat, the upper heat may not be cleared immediately, while the lower cold will surely worsen, leading to unceasing diarrhea.
[Zhang] Zhang Qingzi stated: I have observed cases of Jueyin excessive thirst where the tongue was entirely red and crimson, with cold extremities, faint pulse, and extreme thirst. Treatments with Baihu Tang (White Tiger Decoction) and Huanglian Tang failed to save them. This is because Jueyin excessive thirst involves mixed cold and heat pathogens, not a pure Yang hyperactive heat pattern. Could such medicines as Baihu Tang or Huanglian Tang treat it?
[Jian] This clause outlines the general principles of Jueyin disease. Jueyin is the organ where Yin ends and Yang begins, exterior-interior related to Shaoyang. When pathogens reach this meridian, they can transform into cold from Yin or heat from Yang. Thus, its diseases are characterized by mixed Yin and Yang, and confused cold and heat.
Yang Shi's *Huoren Shu* summarizes: Zhang said that Jueyin disease presents with excessive thirst, Qi rushing upward to strike the heart, hunger without desire to eat, and vomiting roundworms upon eating. Since vomiting roundworms stems from Stomach cold, why is there also excessive thirst? This is because heat resides in the Upper Jiao, while the Middle and Lower Jiao are deficient, cold, and devoid of heat. If stool becomes hard and dry, this is also caused by accumulated toxicity; it should not be mistaken for dry feces. One should use Lizhong Tang (Regulate the Middle Decoction) with added Rhubarb and honey to promote bowel movement. Atractylodes Macrocephala and Dried Ginger assist the Rhubarb. (Note: The modified Lizhong Yin in the *Liu Shu* originates from this theory and should be verified.)
In Jueyin wind-stroke, a slightly floating pulse indicates impending recovery; a non-floating pulse indicates no recovery. (*Yu Han Jing* and *Qian Jin Yi Fang* add the character "Qi" before "Mai").
[Jian] Jueyin wind-stroke includes cold damage. A slight pulse is characteristic of Jueyin; a floating pulse is a superficial Yang pulse. If a Jueyin disease manifests a floating Yang pulse, it indicates the pathogen has returned to the exterior, signifying impending recovery. If not floating, it is sinking. A sinking pulse is a deep Yin pulse, indicating the pathogen remains in the interior, signifying no recovery.
[Xi] Wang Liangneng said: If a Yang disease presents a Yin pulse, death ensues. Not floating does not necessarily mean a Yin pulse; thus, it is merely "no recovery." Using "not floating" instead of "sinking" is very flexible in wording.
[Zhang] Note: Zhongjing mentions wind-stroke in all three Yin meridians. However, he only discusses the pulse indicating recovery, not the treatment, because wind is a Yang pathogen. In the Yin meridians, the movement of wind Qi acts as a mechanism for recovery.
Jueyin disease tends to resolve between Chou hour (01:00–03:00) and Mao hour (05:00–07:00). (*Yu Han Jing* and *Qian Jin Yi Fang* read "from Chou until the end of Mao").
[Xi] Shaoyang is prosperous during Yin and Mao hours. From Chou to Mao, Yin ends and Yang begins. Jueyin disease resolves at this time due to the transformation of its intermediate Shaoyang Qi. Xu Xusheng said: Three Yang diseases resolve during their prosperous times; Three Yin diseases also resolve during the prosperous times of the Three Yang. Shanghan emphasizes protecting generating Yang.
In Jueyin disease, if the patient desires water, giving small amounts of water leads to recovery. (*Yu Han Jing* and *Qian Jin Yi Fang* add "Ji" [immediately] before "Yu". Editions by Yu, Cheng, Qian, and Wei lack the character "Ke" [thirst]).
[Cheng] The appearance of upper heat in Jueyin results from Yin extremity at the bottom blocking Yang at the top, preventing smooth connection between Yin and Yang. This differs from Shaoyin Water overcoming Fire and losing Yang externally. Cold-cold herbs should not invade the Lower Jiao, but aiding the Upper Jiao is permissible. For those desiring water, giving small amounts allows Yang Spirit to descend smoothly without invading the Middle and Lower Jiao; this is one method of Yin-Yang connection.
Note: Since Cheng Wuji, it has been believed that desiring water indicates Yang recovery and warmth, a good omen of resolution. However, Xiao Ke (excessive thirst) is merely one symptom within Jueyin disease. Specifically, Ke Qin noted: Water generates Wood and controls Fire, so water is most suitable for Jueyin excessive thirst. Here, "recovery" does not mean the entire Jueyin disease is cured, but specifically that the symptom of thirst resolves with water. Wang Shi cites Chen Shi from Wuling, distinguishing the Xiao Ke at the beginning of the chapter from this clause's Xiao Ke, which seems forced.
For all cases of Sini (cold extremities) and Jue (cold limbs), purgatives are contraindicated; the same applies to patients with deficiency constitutions.
[Xi] All diseases presenting with Sini and Jue belong to Yin-cold patterns, so purgatives are contraindicated. Moreover, not only is Jue contraindicated for purging; even for deficiency constitutions without Jue, purgatives are contraindicated. Zhang Junwei said: Deficient patients with cold damage do not necessarily present with Jue. One might know that Jue is contraindicated for purging but fail to realize that deficiency constitutions, even without Jue, are also contraindicated for purging; hence, both are mentioned.
[Wang] Zhongjing later states that Heat Jue should be purged. However, during the phase of cold extremities, purging is not lightly attempted. The word "Zhu" (all/any) refers to the subsequent clauses on Jue. "Xu Jia Yi Ran" means that prior to illness, the person’s Qi and Blood were inherently deficient.
Note: In the *Yu Han Jing*, from this clause to the end of the chapter forms a separate section titled "Chapter 10: Differentiating Forms, Symptoms, and Treatment of Jue, Diarrhea, Vomiting, and Hiccups."
In cold damage, if cold extremities appear first, followed by fever and diarrhea, the diarrhea will stop spontaneously; if cold extremities reappear, diarrhea returns.
[Cheng] When Yin Qi prevails, cold extremities and diarrhea occur. When Yang Qi recovers, fever appears, and diarrhea stops. If cold extremities reappear, Yin Qi prevails again, and diarrhea returns.
[Zhang] "Cold damage first Jue, then fever with diarrhea" means that after the exterior syndrome of cold damage resolves, cold extremities and diarrhea appear first, followed by fever. It does not mean Yin syndrome presents with cold extremities and diarrhea from the onset. First Jue then fever, with spontaneous cessation of diarrhea, is the normal course of Jueyin. The phrase "seeing Jue, diarrhea returns" is a precaution against changes. If cold extremities and diarrhea cease but fever persists, sore throat and bi obstruction may occur, or dysentery (pus and blood in stool) may develop, indicating excess Yang heat.
If cold damage begins with six days of fever, followed by nine days of cold extremities and diarrhea: Generally, those with cold extremities and diarrhea should be unable to eat. Now, if the patient can eat, it may be "Chu Zhong" (Elimination of the Center). [Original Note: Alternatively called "Xiao Zhong"]. Feed them Suobing (noodle strips). If there is no sudden fever afterward, it indicates Stomach Qi is still present, and recovery is certain. We fear sudden heat coming and going quickly. Pulse diagnosis after several days: if the fever persists, recovery is expected at midnight of the next day. The reason is: originally fever lasted six days, cold extremities lasted nine days. Then fever returned for three more days. Adding these three to the original six makes nine days, matching the duration of cold extremities. Hence, recovery is expected at midnight. If, after three more days, the pulse is rapid and fever does not abate, this indicates excess heat, likely leading to carbuncles and pus. (Feed Suobing: *Qian Jin Yi Fang* reads "feed millet cakes". Pulse diagnosis: *Cheng Ben* and *Yu Han Jing* read "pulse after three days". *Yu Han Jing* lacks the 38 characters starting from "Suo Yi Ran Zhe".)
[Qian] From initial fever to recovery at midnight constitutes the first half of the original text. From "Suo Yi Ran Zhe" to "Bi Fa Yong Nong" is Zhongjing's own annotation. However, after "Jue Fan Jiu Ri Er Li", seven characters "Fu Fa Re San Ri Li Zhi" (fever returns for three days, diarrhea stops) seem missing. Otherwise, how could the text mention "fear of sudden heat coming and going"? And under "Suo Yi Ran", it says: "Fever six days, Jue nine days, fever returns three days, plus previous six days equals nine days." This clearly indicates omission. How do we know fever returned and diarrhea stopped? The previous clause says: "First Jue then fever, diarrhea stops." Also, after eating Suobing, no mention of diarrhea is made, implying fever returned and diarrhea stopped. Initially, pathogen entered Jueyin, fever for six days, then Jue for nine days. Fever lasted six days, Jue lasted nine days—Jue exceeded fever by three days. Thus, cold pathogen in the interior caused diarrhea. After Jue, fever returned for three days, and diarrhea stopped. Generally, cold extremities and diarrhea result from cold pathogen injuring the Stomach; Spleen cannot distribute essence to limbs; limbs cannot receive Qi from Stomach, leading to Jue. Jue implies cold Middle Qi, so inability to eat is expected. Now, ability to eat suggests Stomach Qi has returned, but fear of "Chu Zhong"—Stomach Yang about to perish, Middle Qi about to vanish. The failing Yang of the Stomust flares up temporarily, opening briefly before closing again. Feed Suobing tentatively. Suobing likely refers to modern noodle strips or similar foods, chosen for easy digestion. If, after eating, there is no stagnation and no fever, it indicates the ability to digest grain, Stomach Qi is intact, and recovery is certain. Why? Fear that subsequent sudden heat comes and goes. Pulse check three days post-eating: if heat from Jue persists, expect recovery at midnight the next day. Reason: Originally fever six days, Jue nine days. Plus three days of subsequent heat equals nine days total, matching Jue duration. Yin and Yang are balanced; winning and reversing Qi harmonize. Hence, recovery at midnight, when Yin ends and Yang returns ("Jueyin resolves from Chou to Mao"). If "pulse after three days shows persistent heat," indicating balanced Yin and Yang, heat should cease. If pulse remains rapid and heat persists, this is excess heat, excessive Yang pathogen, likely causing carbuncles and pus where it accumulates.
[Wang] If heat comes suddenly and departs, this is Stomach True Qi leaking out completely upon eating, named "Chu Zhong," leading to death.
[Wei] Feeding Suobing tests the condition. If fever occurs, how do we know Stomach Qi is lost? This heat is the sudden heat coming and going. Similar to a sudden pulse emergence indicating death. Yin is extremely strong internally; lone Yang escapes outward, separating from Yin, suddenly experiencing intense heat. This is a critical condition requiring immediate rescue. Zhongjing's statements are approximate. The "nine days" figure should not be rigidly applied. Essentially, compare whether heat and Jue are balanced. Heat 7-8 days, Jue 7-8 days is acceptable. Heat 5-6 days, Jue 5-6 days is acceptable. It is about weighing Yin and Yang excess/deficiency, not strictly requiring nine days each for verification.
[Ke] Carbuncle swelling indicates Yang pathogen overflowing to the body surface, commonly known as "retained toxin from cold damage."
Note: Jin Jian states that the character "Bu" (not) in "Bu Fa Re" should be "Ruo" (if). If it were "Bu," it would be Chu Zhong, contradicting the following text "fear of sudden heat..." Both "fears" imply suspicion of Chu Zhong. If it were fever, one wouldn't say "fear of sudden heat..." This view is rejected.
Note: Fang states "Suo" should be "Su" (plain/unadorned), meaning feeding plain cakes. Another view: "Su" means meatless. Zhi Cong says Suobing is wheat cake. This is incorrect. Liu Xi's *Shi Ming* explains: Bing (cake/pastry) means combining; mixing flour to combine. Steamed cakes, soup cakes, etc., are named by shape. *Xiangsu Zaji* states all flour-based foods are called Bing. Qing Lai Jizhi's *Tanghu Qiaoshu* notes modern distinction: long thread-like wheat products are noodles; round flat ones are cakes. Ancient texts call them all Bing. Han Zhongjing's *Shanghan Lun* says "Feed Suobing." Bing described as Suo refers to noodles. This proves Han people considered noodles a type of Bing. Qian's identification as noodle strips is well-founded.
If cold damage presents with a slow pulse for six to seven days, and mistakenly treated with Huangqin Tang to clear heat: A slow pulse indicates cold. Giving Huangqin Tang removes heat. The abdomen should feel cold, and the patient should be unable to eat. Now, if the patient can eat, this is named "Chu Zhong" and leads to death. ("Jin Yu" in *Yu Han Jing* reads "Er Yu"; "Ci Ming" in *Yu Han Jing* and *Qian Jin Yi Fang* reads "Ci Wei". Qian reads "Che" as "Che" [remove].)
[Wang] Slow pulse indicates cold, obvious to anyone. Mistakenly giving Huangqin Tang after six-seven days implies the patient initially had Jue and diarrhea. By day six or seven, Yang recovered, causing transient fever while diarrhea persisted. Unskilled physicians, seeing fever and diarrhea, misdiagnosed it as Taiyang-Shaoyang combined disease and used Huangqin Tang to remove heat. "Che" means remove. The subsequent text clarifies the error of removing heat.
[Cheng] Chu means removal; Zhong means Stomach Qi. Severe pathogenic factors remove Stomach Qi. The Stomach seeks self-rescue by craving food, hence sudden ability to eat.
[Ke] Chu Zhong means emptiness inside without Yang, manifesting as good appetite. Commonly known as "running out of luck/food allowance."
[Cheng] Comparing with the previous clause, eating causes fever. Death ensues with diarrhea, cold extremities, and restlessness. The previous clause had a rapid pulse; this one has a slow pulse—these are key diagnostic points.
Note: Jin Jian suggests adding "Jue Er Xia Li" (cold extremities and diarrhea) after "Shanghan Mai Chi Liu Qi Ri." Without these four characters, it is not Chu Zhong. With them, it connects to the error of giving Huangqin Tang. This is reasonable. However, Wang's explanation is sufficient without adding characters.
In cold damage, first Jue then fever, diarrhea stops spontaneously. But if sweating occurs and throat pain develops, Bi obstruction of the throat occurs. If fever with no sweating occurs and diarrhea persists, dysentery (pus and blood) develops. Those with dysentery do not have Bi obstruction of the throat.
[Wang] First Jue then fever, diarrhea stops; Yang recovers turning to heat. Excessive heat causes sweating and throat pain, injuring Upper Jiao Qi level. Bi obstruction means closure. Severe throat pain leads to throat closure. Jueyin meridian passes behind the throat and enters the nasopharynx. Excessive heat without sweating and persistent diarrhea leads to dysentery, injuring Lower Jiao Blood level. Heat draining downward does not affect the upper, hence no throat Bi. Question: How does cold pathogen transform into heat? Answer: In persons with abundant Yuan Qi, cold cannot penetrate deeply; touching the muscle layer causes immediate fever (Shanghan). In persons with deficient Yuan Qi, cold directly invades Yin meridians without fever (Zhonghan). Cold invading Jueyin, the extreme of Yin, leads to Yang generation upon Yin extremity, causing fever. Recovery depends on Yuan Qi. If fever leads to self-recovery, Yuan Qi is insufficient but not too weak. If Yuan Qi is too weak to generate fever, only Jue leading to death occurs (True Yang collapse). If fever occurs with persistent Jue, Yang recovers but insufficiently; requires hot herbs to support. If fever leads to throat Bi and dysentery, Yang recovers excessively, unable to overcome heat pathogen; requires cool herbs to calm. I suspect this case resulted from overdosing hot herbs during Jue. Clinicians should differentiate carefully.
Note: Wang cites Chang Qizhi: Throat Bi can be treated with Jiegeng Tang. Dysentery with Tao Hua Tang. However, Tao Hua Tang contains Gan Jiang (Dried Ginger), too acrid-hot, and should not be used. Huangqin Tang can be borrowed. Zhang says: Dysentery should use Baitouweng Tang. Unclear what is meant.
From one to five days of cold damage, if Jue occurs, fever must follow; if fever preceded, Jue follows. Deep Jue indicates deep heat; slight Jue indicates slight heat. Jue should be purged; if mistakenly sweated, mouth injuries and redness will occur. (*Cheng Ben* and *Yu Han Jing* add "Er" after "Si Wu Ri").
[Cheng] Regardless of one to five days, if Jue appears, it stems from fever. Heat precedes Jue; this is Heat Jue. Other patterns alternate: fever without Jue, Jue without fever, as Yin and Yang win and reverse. Only this pattern features lone Yang dominating; Jue is Jue, heat is heat. Deep Jue means deep heat; slight Jue means slight heat. Accompanying internal signs include vexation, thirst, and no diarrhea. Total Yang sinks internally, trapping Yin externally, preventing connection. Must use methods to break Yang and move Yin, purge heat, allow Yin Qi to extend, turning rebellion to compliance. Ignoring this and sweating treats only early stages and fever as exterior cold. Heat combined with acrid-warm herbs aids dispersion; neither Jue nor heat resolves, leading to early mouth injury and redness.
[Yu] Previously stated all Sini Jue are contraindicated for purging. Here, Jue should be purged. The distinction is subtle. Preceding Sini then Jue differs from preceding fever then Jue. Hence, former contraindicates purging, latter mandates it. Due to deep heat causing deep Jue, bitter-cold herbs should clear internal heat, termed "purging." E.g., diarrhea with delirium uses Xiao Chengqi Tang. No drastic purging is heard of. Using acrid-sweet sweating instead of bitter-cold invites heat upward, causing mouth injury and redness, analogous to throat Bi.
Note: Yu's note distinguishes Sini and Jue as two patterns.
Qian's commentary on Sini San correctly identifies Jue and Sini as having the same meaning; refer to this.
Note: Some claim this clause is a misplaced excerpt from the Yangming chapter. Incorrect. Although this is Yangming Stomach excess, because Jue resembles Jueyin Jue, it is placed here, consistent with the subsequent Baihu Tang clause.
In cold damage disease, five days of Jue, five days of fever. If on the sixth day Jue returns, it does not return; self-recovery. Jue does not exceed five days; matched by five days of fever, hence self-recovery.