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。邪气传里。在上则为结胸。在下则为腹满而实。若不结胸。腹濡而脉复虚。则表
里上下都无结聚。其邪为已解矣。解则其人不当复厥。而反厥者。非阳热深入也。乃血不足而不荣
于四末也。是宜补而不可下。下之是虚其虚也。玉函云、虚者重泻。其气乃绝。故死。
诸四逆厥者。不可下之。虚家亦然。
按成氏曰、四逆、四肢不温也。厥者。手足冷也。然本篇云、厥者手足逆冷是也。又云、伤寒
脉促。手足厥逆者。可灸之。其他凡言厥逆之处不一。则四逆与厥。本无分别。特其病有阴阳之异
耳。此条盖言阴寒厥逆。法当温散温养之。故云不可下之。前条云厥应下之者。则言邪热内陷之厥
逆也。学人辨之。虚家、体虚不足之人也。虽非四逆与厥。亦不可下之。经云、毋实实。毋虚虚。
而遗人夭殃。此之谓也。
呕家有痈脓者。不可治呕。脓尽自愈。
痈脓者。伤寒热聚于胃口而不行。则生肿痈。而脓从呕出。痈不已则呕不止。是因痈脓而呕。
故不可概以止呕之药治之。脓尽痈已。则呕自止。此胃痈杂病。当隶阳明。不当入厥阴也。以下九
条。均非厥阴本病。叔和不察。误编厥阴篇中。兹特检出。另列简误。其他厥阴进退。及下利呕逆
等证。亦有不必定属厥阴者。叔和以为不便清晰。故总隶厥阴。而实为三阴并有之证。兹仍其旧。
学人当以意会之。
伤寒大吐大下之。极虚。复极汗出者。以其人外气怫郁。复与之水。以发其汗。因得哕。所以
然者。胃中寒冷故也。
伤寒大吐大下之。既损其上。复伤其下。为极虚矣。纵有外气怫郁不解。亦必先固其里。而后
疏其表。乃复饮水以发其汗。遂极汗出。胃气重虚。水冷复加。冷虚相搏。则必作哕。哕、呃逆也
。此阳病误治而变为寒冷者。非厥阴本病也。
病患手足厥冷。脉乍紧者。邪结在胸中。心下满而烦。饥不能食者。病在胸中。当吐之。宜瓜
蒂散。
脉紧为实。乍紧者。胸中之邪能结而不能实也。夫胸中阳也。阳实气于四肢。邪结胸中。其阳
不布。则手足无气而厥冷也。而胃居心下。心处胸间。为烦满。为饥而不能食。皆邪结胸中。逼处
不安之故。经云、其高者。引而越之。胸邪最高。故当吐之。瓜蒂苦而能涌。能吐胸中结伏之邪也
。此证不必定属阴经。即阳病亦有之也。
伤寒哕而腹满。视其前后。知何部不利。利之愈。
哕而腹满者。病在下而气溢于上也。与病患欲吐不可下之者不同。彼为上行极而欲下。此为下
行极而复上也。经曰、在下者。引而竭之。故当视其前后二阴。知何部不利而利之。则病从下出而气
不上逆。腹满与哕俱去矣。此热入太阴而上攻阳明之证。与厥阴无涉也。
呕而发热者。小柴胡汤主之。
此邪在少阳之经。非厥阴本病。故以小柴胡汤和解少阳之邪。邪解则呕热俱止。或厥阴病而外
连少阳者亦有之。然亦必以小柴胡先解少阳为急。所谓病自内之外。而盛于外者。先解其外。而后
治其内。下利谵语者。有燥屎也。宜小承气汤。
谵语者。胃实之征。下利得此。为有燥屎。所谓利者不利是也。与小承气汤下其燥屎。屎去脏
通。下利自止。经云、通因通用。此之谓也。金匮治下利。按之心下坚者。与大承气汤。与此同意
。所当互考。此太阴转入阳明之证。与厥阴无涉也。
下利清谷。不可攻表。汗出必胀满。
清、与圊同。即完谷也。乃阳不运而谷不腐也。是当温养中土。不可攻表出汗。汗出则阳益虚
。阳虚则气不化。故必胀满。此寒中太阴之证。非厥阴病也。
少阴负趺阳者。为顺也。
少阴、肾脉也。趺阳、胃脉也。下利为土负水胜之病。少阴负趺阳者。水负而土胜也。故曰顺。
此条当为太阴下利而设。亦与厥阴无涉也。
伤寒脉滑而厥者。里有热也。白虎汤主之。
伤寒脉微而厥。阴邪所中。寒在里。脉滑而厥。阳邪所伤。热在里。阳热在里。阴气被格。阳
反在内。阴反在外。设身热不除。则其厥不已。故主白虎汤。以清里而除热也。此阳明热极发厥之证
。误编入厥阴者也。
In the fifth or sixth day of a cold damage disease, if there is no chest binding (Jie Xiong), the abdomen is soft, the pulse is deficient, and cold limbs recur, purgation must not be used. This is due to blood loss; purgation would lead to death.
In the fifth or sixth day of a cold damage disease, the pathogenic factor has transmitted inward. If it is in the upper part, it forms chest binding; if in the lower part, it causes abdominal fullness and excess. If there is no chest binding, the abdomen is soft, and the pulse is deficient, it indicates that there is no accumulation of pathogens in the exterior, interior, above, or below, and the pathogen has resolved. Once resolved, the patient should not experience cold limbs again. The recurrence of cold limbs indicates that it is not due to deep penetration of yang-heat, but rather insufficient blood failing to nourish the four extremities. Tonification is appropriate, while purgation is contraindicated. Purgation would further weaken an already deficient constitution. The *Yufang Jing* states: "Heavy purgation on a deficient person leads to the exhaustion of vital qi," resulting in death.
For all cases of Si Ni (Four Extremities Inversion) or Jue (Cold Limbs), purgation is contraindicated. The same applies to persons with a deficient constitution.
Cheng Wuji stated: Si Ni refers to limbs that are not warm; Jue refers to cold hands and feet. However, this chapter defines Jue as inverted cold of the hands and feet. It also states: "In cold damage with a rapid pulse and inverted cold limbs, moxibustion may be used." Since references to Jue Ni vary throughout the text, Si Ni and Jue are essentially indistinguishable, differing only in whether the pathology is yin-cold or yang-heat. This clause discusses cold-limb inversion caused by yin-cold, which requires warming and dispersing or warming and tonifying methods; thus, purgation is contraindicated. The previous clause stating "Jue should be treated with purgation" refers to inversion caused by internal entrapment of pathogenic heat. Students must distinguish between these. "Xu Jia" refers to individuals with weak constitutions and insufficient healthy qi. Even without symptoms of Si Ni or Jue, purgation is contraindicated for them. The Classic says: "Do not reinforce excess, do not deplete deficiency, lest you bring about premature death." This refers to such situations.
In patients who vomit pus from carbuncles, vomiting should not be treated directly. Once the pus is exhausted, the condition will resolve spontaneously.
Carbuncle and pus result from heat pathogens aggregating at the stomach opening without flowing freely, leading to swelling and suppuration, with pus being expelled via vomiting. As long as the carbuncle persists, vomiting continues. Since the vomiting is caused by the pus, anti-emetic drugs should not be used indiscriminately. Once the pus is cleared and the carbuncle heals, vomiting will cease naturally. This belongs to miscellaneous diseases of gastric carbuncles and should be classified under Yangming, not Jueyin. The following nine clauses do not represent primary Jueyin diseases. Wang Shuhe failed to notice this and erroneously compiled them into the Jueyin chapter. They are hereby extracted and listed separately as "Brief Errors." Other Jueyin progressions, as well as diarrhea and vomiting, may also not necessarily belong to Jueyin. Wang Shuhe considered this classification unclear and grouped them under Jueyin, although they actually involve combined syndromes of the three Yin meridians. We retain the original arrangement here; students should understand the intent through careful consideration.
After severe emesis and purgation in cold damage, the patient becomes extremely deficient. If excessive sweating occurs subsequently because the physician gave water to induce sweating while the exterior qi was constrained, hiccups (Yue) result. This happens because the middle jiao (stomach) is cold.
Severe emesis and purgation damage both the upper and lower jiao, leading to extreme deficiency. Even if exterior qi remains constrained, the interior must first be secured before releasing the exterior. Giving water to induce sweating in this state causes extreme sweating, further weakening stomach qi. The combination of cold water and deficiency leads to hiccups. Yue refers to hiccups. This is a transformation into cold syndrome due to mismanagement of a Yang disease, not a primary Jueyin condition.
When a patient presents with cold limbs and a pulse that suddenly becomes tight, the pathogen is bound in the chest. Symptoms include fullness and irritability in the epigastrium, hunger, but inability to eat. The pathology is located in the chest, and emesis should be induced using Gua Di San (Thistle Powder).
A tight pulse indicates excess. A sudden tightness suggests that pathogens in the chest can bind but do not form solid accumulations. The chest is the domain of Yang; Yang qi must充盈 (fill) the four extremities. When pathogens bind in the chest, Yang qi cannot distribute, causing the limbs to lose warmth and become cold. The stomach is located below the heart, and the heart is within the chest. Irritability, fullness, hunger, and anorexia are all caused by pathogens binding in the chest, disturbing the organs. The Classic states: "For high-pathologies, use induction to vomit." Since chest pathogens are highest, emesis is indicated. Gua Di is bitter and induces vomiting, expelling bound pathogens from the chest. This syndrome is not exclusive to Yin meridians; it can occur in Yang diseases as well.
In cold damage, if hiccups accompany abdominal fullness, observe the anterior and posterior orifices to determine which is obstructed; unblocking it will cure the disease.
Hiccups with abdominal fullness indicate pathology in the lower jiao with qi overflowing upward. This differs from cases where patients desire to vomit but cannot be purged. In those cases, upward movement reaches its limit and seeks downward release; here, downward movement reaches its limit and reverses upward. The Classic states: "For low-pathologies, use draining to empty them." Therefore, one must examine the anterior (urethra) and posterior (anus) orifices. Unblocking the obstruction allows pathogens to exit downward, preventing qi rebellion, thereby resolving abdominal fullness and hiccups. This is a syndrome of heat entering Taiyin and attacking Yangming, unrelated to Jueyin.
Vomiting accompanied by fever is primarily treated with Xiao Chai Hu Tang (Minor Bupleurum Decoction).
This indicates pathogens in the Shaoyang meridian, not a primary Jueyin disease. Xiao Chai Hu Tang harmonizes and resolves Shaoyang pathogens. Once resolved, vomiting and fever cease. There are cases where Jueyin disease extends to Shaoyang, but resolving Shaoyang with Xiao Chai Hu Tang is the urgent priority. This follows the principle: "When disease moves from interior to exterior and intensifies externally, resolve the exterior first, then treat the interior."
Diarrhea accompanied by delirium indicates dry fecal matter. Xiao Cheng Qi Tang (Minor Order the Qi Decoction) is indicated.
Delirium is a sign of stomach excess. Diarrhea presenting with this symptom indicates dry feces, exemplifying the principle of "treating flow with flow" (using purgatives for diarrhea). Administering Xiao Cheng Qi Tang removes the dry feces; once the bowels are clear, diarrhea stops. The Classic calls this "Tong Yin Tong Yong" (Using unblocking methods for unblocking symptoms). In *Jin Gui Yao Lue*, treating diarrhea with hardness upon pressing the epigastrium involves Da Cheng Qi Tang, consistent with this logic; these should be cross-referenced. This is a syndrome transitioning from Taiyin to Yangming, unrelated to Jueyin.
Diarrhea with undigested food (Qing Gu) contraindicates exterior attack via sweating. Sweating will inevitably cause abdominal fullness.
"Qing" is synonymous with "Qing" (to defecate), referring to undigested food in stool. This results from yang failing to transform and digest food. The treatment should be to warm and tonify the Middle Earth (Spleen/Stomach); exterior attack via sweating is contraindicated. Sweating further depletes yang. Yang deficiency impairs qi transformation, leading to abdominal fullness. This is a cold syndrome invading Taiyin, not a Jueyin disease.
If the Shaoyin pulse is weaker than the Fuyang pulse, it is a favorable sign (Shun).
Shaoyin corresponds to the Kidney pulse; Fuyang corresponds to the Stomach pulse. Diarrhea is a disease of Earth deficiency and Water excess. If the Shaoyin pulse is weaker than the Fuyang pulse, it indicates Water is deficient and Earth is dominant, hence it is favorable. This clause is likely intended for Taiyin diarrhea and is unrelated to Jueyin.
In cold damage, if the pulse is slippery and the limbs are cold, there is heat in the interior. Bai Hu Tang (White Tiger Decoction) is indicated.
A faint pulse with cold limbs indicates invasion by yin pathogens and interior cold. A slippery pulse with cold limbs indicates injury by yang pathogens and interior heat. Interior yang-heat repels yin qi, trapping yang inside and pushing yin outside. If body heat does not subside, cold limbs will persist. Therefore, Bai Hu Tang is used to clear interior heat. This is a case of厥 (cold limbs) caused by extreme heat in Yangming, erroneously included in the Jueyin chapter.