Library

Because there is an excess of heat, carbuncles and pus will inevitably develop.

[Commentary]
The character "bu" (not) in "no fever" should be the character "ruo" (if). If it were "bu" (not), it would indicate Chu Zhong (false appetite due to stomach qi exhaustion), which contradicts the following text stating, "fear that sudden heat may appear and then disappear."

[Annotation]
Fever without cold limbs belongs to Yang syndromes; cold limbs without fever belong to Yin syndromes. In Shanghan (Cold Damage disease), if there is fever for six days initially, and cold limbs for six days, and on the seventh day there is still fever without cold limbs, this indicates the return of Yang Qi, and the disease should heal spontaneously. Now, if cold limbs last for nine days, three days longer than the fever, this indicates Yin dominance over Yang, hence diarrhea. In cases of cold limbs accompanied by diarrhea, the Middle Jiao must be cold, and the patient should not be able to eat. However, if the patient can eat now, it is feared that the Yin pathogen has depleted the Yang Qi of the Stomach, leading to the condition of Chu Zhong (false appetite). The word "kong" (fear/likely) expresses uncertainty. Therefore, Su Bing (noodles/plain cakes) are used as a test: if there is no fever after eating, it is Chu Zhong; if there is fever, it indicates that Stomach Qi remains, so it is not Chu Zhong, and recovery can be assured. If there is sudden fever after eating, but the fear is that the heat appears temporarily and then disappears, it is still Chu Zhong. Thus, one must wait for three days; if the heat persists and corresponds with the duration of cold limbs, recovery can be expected by midnight of the next day. If after three days, the heat does not cease but the patient does not recover, and the pulse remains rapid, this indicates an excess of heat lingering in Ying (Nutrient) and Wei (Defensive) levels, inevitably leading to carbuncles and pus.

[Collected Commentaries]
Fang Youzhi stated: "Shi" (eat/feed) means to feed. "Suo" means ordinary or usual. It refers to feeding the patient with plain cakes they usually eat. Another interpretation says "suo" refers to meatless food, meaning to avoid dietary restrictions. "Dan ri" refers to the early morning of the next day, a time when Yang Qi grows; "Ye ban" (midnight) is when Yin ends and Yang is born. Counting days helps monitor the heat. Carbuncles and pus occur because Jueyin governs Blood; prolonged blood heat causes stagnation and stasis, which putrefy and transform into pus, so this outcome is certain.

Wu Renju stated: "Chu" means removal; "Zhong" means Middle Qi (Stomach/Spleen Qi). It means Middle Qi is removed, and the body seeks external food to save itself.

@@@

In Shanghan, if the pulse is slow for six or seven days, and one mistakenly administers Huangqin Tang (Scutellaria Decoction) to clear the heat, since a slow pulse indicates Cold, administering Huangqin Tang again clears the heat further. The abdomen should become cold, and the patient should not be able to eat. If the patient can eat now, this is called Chu Zhong, and death is inevitable.

[Commentary]
Under "Shanghan, pulse slow for six or seven days," the four characters "Jue er xia li" (cold limbs and diarrhea) should be present. Without these four characters, it would not be a Chu Zhong syndrome. With these four characters, it connects logically to the subsequent text about mistakenly administering Huangqin Tang.

[Annotation]
In Shanghan, if the pulse is rapid for six or seven days, with cold limbs and diarrhea, this is Heat Jue (cold limbs due to heat) with diarrhea, and Huangqin Tang should be administered to clear the heat. However, in this case, Shanghan presents with a slow pulse for six or seven days, with cold limbs and diarrhea; this is Cold Jue (cold limbs due to cold) with diarrhea, and Lizhong Tang (Regulate the Middle Decoction) should be administered to warm the cold. Instead, Huangqin Tang was given to clear the heat again. The abdomen should be cold, and the patient should not be able to eat. Since the patient can eat now, this is called Chu Zhong. It signifies that Stomach Qi is about to exhaust, seeking food for self-rescue, but ultimately providing no benefit to the Stomach. Hence, it is said to be fatal.

[Collected Commentaries]
Fang Youzhi stated: "Fan" (instead/reverse) means acting contrary to the Dao. Huangqin Tang is a cold medicine. "Che" also means to clear. "Ying" also means should. The ability to eat instead indicates that Stomach Qi is exhausted and drawing in food to save itself. "Zhong" refers to the Stomach. "Si" (death) means that all things cannot grow without Earth (metaphor for Stomach Qi being the root of life).

Cheng Zhi stated: This states that a slow pulse indicates Cold, so cold medicines should not be used further to avoid causing Chu Zhong. When Middle Qi is eradicated by Yin-Cold, the rootless Yang Qi in the Stomach is about to be completely eliminated and seeks rescue through food, thus constituting a fatal syndrome.

@@@

In Shanghan, if there are cold limbs first, followed by fever, and diarrhea occurs, the diarrhea will stop spontaneously. If cold limbs reappear, diarrhea will recur.

[Annotation]
Cold limbs (Jue) belong to Yin. Fever belongs to Yang. If there are cold limbs first, followed by fever, and the diarrhea stops spontaneously, this indicates Yin retreating and Yang advancing. If cold limbs reappear and diarrhea recurs, this indicates Yang retreating and Yin advancing. If heat exceeds cold limbs, even severe illness can heal; if cold limbs exceed heat, even mild illness can worsen. Thus, the alternation of cold limbs and fever is the key mechanism of Yin-Yang advance and retreat, determining life and death.

[Collected Commentaries]
Wang Hu stated: Jueyin represents the extreme of Yin. The Yang Qi in the Jueyin meridian is very weak. Therefore, regardless of whether the syndrome is Yin or Yang, or the pathogen is Cold or Heat, once it reaches the Jueyin meridian, cold limbs invariably occur. Essentially, Jue implies reversal, starting from the hands and feet. Here, "first Jue" means cold limbs at the onset. If Jue is accompanied by diarrhea, and later fever occurs, it indicates the restoration of Yang Qi, and the diarrhea will stop spontaneously.

@@@

In Shanghan, if there are cold limbs first, followed by fever, the diarrhea will stop spontaneously. However, if sweating occurs instead, and there is pain in the throat, the throat will become Bi (obstructed). If there is fever without sweating, and the diarrhea does not stop, pus and blood will inevitably appear in the stool. If pus and blood appear in the stool, the throat will not be obstructed.

[Annotation]
This elaborates on the previous clause to distinguish the syndromes. If there are cold limbs first, followed by fever, and the diarrhea stops spontaneously, indicating the return of warmth and cessation of diarrhea, if the heat subsides, it indicates impending recovery. If the warmth returns and diarrhea stops, but the heat persists, and sweating occurs instead, this is a Jueyin syndrome transforming into Heat from Yang. The pathogen follows the meridian upward, causing throat pain and obstruction (Bi). If warmth returns with fever, but there is no sweating and diarrhea continues, this is Jueyin pathogenic heat forcing downward due to diarrhea, damaging the blood in the vessels, inevitably leading to pus and blood in the stool. If pus and blood appear in the stool, the throat will not be obstructed, meaning the pathogenic heat is directed downward and does not affect the throat pain above. Conversely, if the diarrhea stops and the throat becomes Bi, it means the heat has moved upward, causing throat pain, and thus no longer affects the lower jiao (diarrhea).

[Collected Commentaries]
Yu Chang stated: After initial cold limbs, subsequent fever and cessation of diarrhea indicate the disease is resolving. However, if sweating and throat pain occur instead, it indicates excess heat attacking the throat upwards, causing Bi. Although there is fever without sweating, since Yang Qi has returned, the diarrhea should stop spontaneously. If it does not stop, the lack of sweating clearly shows the pathogen cannot exit outward; heat is constrained internally, inevitably leading to pus and blood in the stool. If pus and blood appear in the stool, the throat will not be Bi, showing that heat constrained internally does not manifest externally, and heat in the lower part does not manifest in the upper part.

Wang Hu stated: Throat pain indicates heat damaging the Qi level of the Upper Jiao. Bi means closure. Severe throat pain leads to throat closure and obstruction because the Jueyin meridian runs behind the throat and enters the nasopharynx. No sweating, continued diarrhea, and pus/blood in stool indicate heat damaging the Blood level of the Lower Jiao. Heat sinking downward does not interfere with the upper part, hence: the throat will not be Bi.

@@@

In diarrhea, if the pulse is rapid, with slight fever and sweating, the disease will heal spontaneously. If the pulse becomes tight again, the disease is unresolved.

[Annotation]
Rapid pulse in Jueyin diarrhea indicates Heat Diarrhea. If the heat is slight and there is sweating, it indicates the pathogen is weak and resolving, so the diarrhea will stop spontaneously, leading to healing. If the pulse becomes tight again, it indicates the exterior pathogen is still strong and unresolved.

[Collected Commentaries]
Cheng Wuji stated: Diarrhea is a Yin disease. Rapid pulse is a Yang pulse. When a Yin disease presents a Yang pulse, there is hope for life. Slight fever and sweating indicate the unblocking of Yang Qi, so diarrhea will heal spontaneously. All tight pulses indicate Cold. If the pulse becomes tight again, the Cold pathogen is still strong, hence: unresolved.

Shen Mingzong stated: These clauses refer to cases of cold limbs, diarrhea, and pus/blood in stool. Observing various pulses such as Excess-Surging, Floating-Rapid, Weak, Deep-Choppy, String-Tight, or Surging-Long allows differentiation between Deficiency, Excess, Cold, and Heat, revealing whether recovery is imminent. This is truly the subtle essence of disease examination.

@@@

In diarrhea, with slight fever and thirst, and a weak pulse, the disease will heal spontaneously.

[Annotation]
In Jueyin diarrhea, high fever and thirst with a strong pulse indicate both pathogen and heat are excessive. Now, with slight fever and thirst, and a weak pulse, it indicates the pathogenic heat is declining. Since the pathogenic heat has declined, spontaneous healing is possible.

[Collected Commentaries]
Fang Youzhi stated: Slight fever indicates gradual return of Yang. Thirst indicates internal dryness has not yet recovered. Weak pulse indicates the retreat of the pathogen. Healing spontaneously means no treatment is required.

Cheng Zhi stated: Diarrhea resolves when Yang returns and the pathogen weakens. Slight fever and thirst show the syndrome has turned Yang; a weak pulse indicates the pathogen has retreated, so it heals without treatment. If diarrhea presents with high fever and surging pulse, it is an adverse sign.

@@@

In diarrhea, if the pulse is rapid and there is thirst, the disease will heal spontaneously. If it does not improve, pus and blood will inevitably appear in the stool, due to the presence of heat.

[Annotation]
This complements the previous clause to detail variations. Rapid pulse and thirst in diarrhea indicate internal heat. If there is no body fever, the pathogen has weakened, and spontaneous healing is possible. However, if rapid pulse and thirst persist in diarrhea for a long time without improvement, even without body fever, pus and blood will inevitably appear in the stool, due to internal heat damaging Yin fluids.

[Collected Commentaries]
Fang Youzhi stated: Rapid pulse clarifies the previous mention of slight fever.

Cheng Yingmao stated: Rapid pulse and thirst indicate Yang overcoming Yin, so it may heal spontaneously. If it does not improve, Yin deficiency allows heat to enter. As the Classics state: if rapid pulse persists and diarrhea continues, it will inevitably involve heat and lead to pus and blood in the stool.

@@@

In diarrhea, if the Cun (inch) pulse is unexpectedly floating and rapid, while the Chi (cubit) pulse is naturally choppy, pus and blood will inevitably appear in the stool.

[Annotation]
In Jueyin Heat Diarrhea, the Cun pulse should be Deep-Rapid. Now, the Cun pulse is unexpectedly Floating-Rapid, indicating heat is in the Exterior rather than the Interior. The naturally Choppy Chi pulse indicates that the exterior heat has not resolved; taking advantage of the diarrhea, it penetrates inward, damaging Yin. Heat and blood stasis combine, inevitably leading to pus and blood in the stool.

[Collected Commentaries]
Yu Chang stated: A Floating-Rapid pulse might suggest the pathogen returning to the exterior, in which case the Chi pulse would naturally be normal. Now, the Chi pulse is naturally choppy, indicating heat pathogen knotting in the Yin levels. Although the Cun position yields a Yang pulse, ultimately the Yin pathogen will exit through the lower orifices, leading to pus and blood in the stool.

Wang Hu stated: This clause describes the progression of diarrhea to pus and blood. A Rapid pulse in Heat Diarrhea is not abnormal; a Floating pulse is abnormal. This clause discusses the syndrome without prescribing a method; it is appropriate to substitute Zhang Zhongjing's Huangqin Tang.

@@@

In diarrhea, if the pulse is Deep-Stringy, there is a sensation of tenesmus (heaviness in the lower abdomen/rectum). If the pulse is Large, the disease has not stopped. If the pulse is Weak-Rapid, the disease is about to stop spontaneously; even with fever, death will not occur.

[Annotation]
This elaborates on the previous clause regarding the syndrome and pulse of diarrhea with pus and blood. Deep pulse indicates Interior; String-Tight pulse indicates urgency. "Xia zhong" refers to tenesmus. Diarrhea with Deep-Stringy pulse indicates interior urgency and tenesmus. In general, for diarrhea, fever with a Large pulse indicates excess pathogen, meaning the disease has not stopped. A Weak-Rapid pulse indicates declining pathogen, meaning the disease is about to stop; even with fever, death will not occur. From this, we know that in dysentery, Large pulse with body fever indicates fatality.

[Collected Commentaries]
Yu Chang stated: Diarrhea with Deep-Stringy pulse indicates interior urgency and tenesmus, forming the syndrome of Zhixia (dysentery), currently known as Li syndrome. Large pulse refers to the Large quality within the Deep-Stringy pulse; Weak-Rapid refers to the Weak-Rapid quality within the Deep-Stringy pulse.

@@@

If there is diarrhea and the patient desires to drink water, it is due to heat; Baitouweng Tang (Pulsatilla Decoction) is indicated. For Heat Diarrhea with tenesmus, Baitouweng Tang is indicated.

[Annotation]
This follows the previous clause to reveal the treatment. Desire to drink water in diarrhea indicates Heat Diarrhea draining body fluids, seeking water to relieve dryness. Heat Diarrhea with tenesmus indicates heat damaging Qi and causing stagnation, resulting in interior urgency, tenesmus, and pus/blood in stool. Both conditions are treated with Baitouweng Tang because it is greatly bitter and cold; cold overcomes heat, and bitterness dries dampness.

[Collected Commentaries]
Cheng Zhi stated: Regarding Shaoyin spontaneous diarrhea with thirst, there are cases of deficiency seeking water for self-rescue, which should be distinguished by the color of urine (red or white) and pulse speed (slow or rapid). This clause refers to internal binding of heat pathogen. Internal heat binding causes tenesmus, so purely bitter-cold herbs are used to overcome heat and strengthen the intestines.