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(Visual impairment with unclear vision)

Cheng Wuji's Commentary: "Direct gaze" (Zhishi) refers to staring at objects without the eyeballs rotating. If the eyeballs can rotate, it is not this condition. The essence of Water is called "Zhi" (Will), and the essence of Fire is called "Shen" (Spirit). The eyes are the messengers of the Heart, the abode of the Spirit, and the external manifestation of the Liver; here, the spirit and essence are nourished. The *Zhen Jing* (Needle Classic) states: The Qi of the five zang organs and six fu organs all ascend to the eyes to form their essence. (The gathering place of essence is the eye socket; the essence of Bone manifests as the pupil; the essence of Sinew manifests as the black part of the eye; the essence of Blood manifests as the collaterals; the essence of Qi manifests as the white part of the eye; the essence of Muscle manifests as the structures that constrain eyelid movement). When the Qi and Blood of the five zang organs are harmonious and the essence is abundant and nourishing, the eyes will be clear and bright. If pathogenic factors are excessive and overwhelm the healthy Qi, consciousness becomes dull; if the essence-storing Qi of the viscera fails to ascend to nourish the eyes, direct gaze occurs. In Shanghan disease, the appearance of direct gaze indicates that pathogenic factors have reached an extreme level, and such conditions are mostly difficult to treat. (Manic speech with direct gaze indicates Kidney exhaustion; direct gaze with head shaking indicates Heart exhaustion; direct gaze with delirium and wheezing/fullness leads to death; those with diarrhea also die. In more severe cases, during attacks, the patient does not recognize people, picks at clothes and touches the bed, feels terrified and uneasy, has slight wheezing and direct gaze. If the pulse is wiry, there is hope for survival; if the pulse is choppy, death ensues. These are all signs of excessive pathogenic factors and depletion of healthy Qi.) The *Jing* (Classic) states: Those who frequently suffer from epistaxis should not undergo sweating therapy. If sweating is induced erroneously, the forehead may sink, the pulse becomes tight, the eyes stare directly without blinking, and sleep is impossible. (This is because the Liver receives blood to enable vision; in those who have lost blood, Liver Qi is already deficient, and Wood Qi is also weak. Inducing sweating further causes loss of Yang, resulting in deficiency of both Yin and Yang.) Although this is a adverse condition, it is not yet the most severe. Furthermore, "direct gaze" and "unclear vision within the eyes" appear similar, but one is treatable while the other is not.

Taiyang Chapter: Those who frequently suffer from epistaxis should not undergo sweating therapy. If sweating is induced erroneously, the forehead sinks, the pulse becomes tight, the eyes stare directly without blinking, and sleep is impossible. (See detailed notes on Epistaxis). After sweating, if the body remains burning hot, it is named Fengwen (Wind-Warmth). The pulse is floating at cun, guan, and chi positions simultaneously, with spontaneous sweating, heavy body, excessive drowsiness, and difficulty speaking. If purgation is erroneously applied, it leads to difficulty in urination, direct gaze, and involuntary loss of urine and stool. (See detailed notes on Wind-Warmth).

Yangming Chapter: After Shanghan disease has been treated with vomiting or purging methods but remains unresolved, with no bowel movement for over ten days, tidal fever occurs in the late afternoon. There is aversion to cold absent, and the patient speaks alone as if seeing ghosts. In severe cases, during attacks, the patient does not recognize people, picks at clothes and touches the bed, feels terrified and uneasy, has slight wheezing and direct gaze. If the pulse is wiry, there is hope for survival; if the pulse is choppy, death ensues.
Direct gaze with delirium and wheezing/fullness leads to death; with diarrhea, death also ensues.
In Shanghan disease, after six or seven days, if the vision appears dim and unclear, the eyeballs move freely but lack brightness, without obvious exterior or interior syndromes, accompanied by difficulty in defecation and slight body heat, this is an Excess syndrome. Urgent purgation is required, using Da Chengqi Tang (Major Order the Qi Decoction).

Wu Qian's Commentary: If the eyes roll upward (Daiyan) and opisthotonos occurs, this is an upper visual exhaustion syndrome. Profuse sweating emerges like beads strung together that do not flow, indicating Bladder exhaustion. "Unclear vision within the eyes" refers to the ability to see only half of an object and not the other half, accompanied by delirious rambling. If there is internal excess with constipation, purgation is appropriate; if there is internal deficiency, treatment is mostly difficult.