@@@
脉濡而弱，弱反在关，濡反在巅，微反在上，涩反在下，微则阳气不足，涩则无血，
阳气反微，中风汗出，而反躁烦，涩则无血，厥而且寒，阳微则不可下，下之则心下
痞□。
【注】
此即前不可发汗之条。所谓关脉浮濡沉弱，寸脉微，尺脉涩，阳虚血少之诊也。汗既
不可，下亦不可，均为阳虚故也。若误下之，则寒虚内竭，心下痞□，必成太阴误下
下利之痞□矣。
【集注】
程应旄曰：误汗亡阳分之阳，误下亡阴分之阳，无阳则阴独，而地气得以上居，故心
下痞□。
@@@
脉濡而弱，弱反在关，濡反在巅，弦反在上，微反在下，弦为阳运，微为阴寒，上实
下虚，意欲得温，微弦为虚，虚者不可下也。
【注】
此亦前不可发汗之条。所谓关脉浮濡沉弱，寸脉弦，尺脉微，上实下虚之诊也。微弦
为虚，既不可汗，亦不可下，下虚故也。
【集注】
成无己曰：虚家下之，是为重虚。
脉濡而弱，弱反在关，濡反在巅，浮反在上，数反在下，浮为阳虚，数为无血，浮为
虚，数生热，浮为虚，自汗出而恶寒，数为痛，振而寒栗，微弱在关，胸下为急，喘
汗而不得呼吸，呼吸之中，痛在于□，振寒相抟，形如疟状，医反下之，故令脉数发
热，狂走见鬼，心下为痞，小便淋漓 ，少腹甚□，小便则尿血也。
【注】
此谓关脉浮濡沉弱，寸脉浮，尺脉数也。关濡弱为中气虚乏，寸浮无力为阳虚，尺数
无力为血虚。阳虚故汗自出而恶寒，血虚故身痛振寒而栗，中气虚乏故胸膈气急，喘
汗而不得呼吸，呼吸之中，痛引于□也。振寒相抟，形如疟状，里邪不实，表邪未解
，医反下之，虚阳未罢之表尽陷于里，故令脉虚数无伦，发热狂走见鬼，心下为痞，
少腹甚□，小便淋漓尿血也。
【集注】
张璐曰：寸口浮濡而关弱尺数者，以其人阳气本虚，虚阳陷于阴分也，若误下伤血，
必致狂走痞满尿血也。
魏荔彤曰：前虚寒之忌下易知，此虚而兼热之忌下难知，故两条相映互言，以示禁也
。
@@@
脉濡而紧，濡则卫气微，紧则荣中寒，阳微卫中风，发热而恶寒，荣紧卫气冷，微呕
心内烦，医为有大热，解肌而发汗，亡阳虚烦躁，心下苦痞坚。表里俱虚竭，卒起而
头眩，客热在皮肤，怅怏不得眠，不知胃气冷，紧寒在关元，技巧无所施，汲水灌其
身，客热因时罢，栗栗而振寒，重被而覆之，汗出而冒巅，体惕而又振，小便为微难
，寒气因水发，清谷不容间，呕变反肠出，颠倒不得安，手足为微逆，身冷而内烦，
迟欲从后救，安可复追还。
【注】
脉濡而紧，谓浮濡而沉紧也。濡则卫表微，紧则荣里寒，外有发热汗出恶寒之表，内
有微呕心烦之里。医为有热，解肌发汗，表阳愈虚，而生烦躁，里寒更急，心下痞□
，表虚里冷，故卒起头眩，怅怏不眠。若徒以客热在肤，不知中寒在里，而以冷水灌
身，虽客热因而时罢，但栗栗振寒，不容不重被而覆之，汗出必眩，惕振厥逆，下利
清谷，烦躁不安而死，以中外之阳两亡，不能复还也。
【集注】
张锡驹曰：汗出而冒巅者，汗出则阳气外亡，头昏冒而目不明，故曰冒巅。小便为微
难，阳亡而气不施化也。清谷不容间，下利清谷无间隙之时也。呕变者，呕出之味变
也。肠出者，下利而广肠脱出也。
@@@
脉浮而大，浮为气实，大为血虚，血虚为无阴，孤阳独下阴部者，小盒饭赤而难，胞
中当虚，今反小便利而大汗出，法应卫家当微，今反更实，津液四射，荣竭血尽，干
烦而不得眠，血薄肉消，而成暴液，医复以毒药攻其胃，此为重虚，客阳去有期，必
下如污泥而死。
【注】
脉浮而大，谓脉浮取有力，按之大而无力，乃革脉象也。浮为气实外急，大为血虚中
空，血虚甚则亡阴，阴亡则阳无偶也，故曰孤阳独下阴部。谓卫阳下就其阴，小盒饭
赤而难，以胞中虚竭也。若阳不下就其阴，则小便反利而大汗出，是卫阳表虚，邪阳
内入，无阴以化，故反更实，致津液四射，荣竭血尽，肉消胃干，烦不得眠也。医不
知此，乃以中空暴液之阳明，误为胃实，复以峻药攻之，则为虚虚，胃阳之去可期，
必下污秽如泥而死也。
【集注】
程知曰：此言气实血虚之脉，小便利而大汗出者，不可下也。
程应旄曰：无阴而孤阳独下阴部，倘得小便赤而难，则胞中不虚，仅为阳搏。阳未离
，则阴得滞而未散，今反小便利而大汗出，则卫气更微矣。其反更实者，非卫阳之实
，而客阳之实也。卫阳犹或抱阴，客阳则专于攻阴，故津液四射，而为小便利，为大
汗出。热甚逼阴，所以荣竭血尽，干烦而不得眠，血薄肉消而成暴液。暴液云者，点
滴皆火气煎熬而出也。毒药攻胃，则土败而四藏无生，下如污泥而死矣。
@@@
伤寒脉，阴阳俱紧，恶寒发热，则脉欲厥；厥者脉初来大，渐渐小，更来渐大，是其
候也。如此者，恶寒甚者，翕翕汗出，喉中痛；若热多者，目赤脉多，睛不慧，医复
发之，咽中则伤；若复下之，则两目闭，寒多便清谷，热多便脓血；若熏之则身发黄
；若熨之则咽燥；若小便利者，可救之；若小便难者，为危殆。
【注】
伤寒脉阴阳俱紧，恶寒发热，太阳表证也。则脉欲厥，谓浮紧之脉，初大渐小，知为
欲厥之脉也。初来，大阳为之也，故发热；渐渐小，阴为之也，故发厥。更大更热，
更小更厥，是其候也。如此者，当以寒热别其厥。恶寒甚，翕翕汗出，咽中痛，是少
阴寒厥也。发热多，目赤脉多，睛不了了，是阳明热厥也。寒甚热多之厥，而误发之
，则咽痛似伤；而误下之，则两目多闭。凡厥者必下利，寒厥之利，下利清谷也。热
厥之利，下利脓血也；此又以利辨厥之寒热也。若以薰蒸取汗，则发身黄，湿热合也
。若以火熨取汗，则咽燥，火甚伤津也。若小便利者，则阴未亡，故可救之；小便难
者，则阴已亡，为危殆也。
【集注】
程知曰：言外伤于寒，为湿热之病，不可汗、下、薰、熨也。
张璐曰：脉来厥者，知厥逆之寒热交胜也。初来大者，为邪气鼓动；渐渐小，为正气
受伤；更来渐渐大，为邪气复进也。盖因其人正气本虚，不能主持，随邪气进退，故
其脉亦随邪气进退，忽大忽小也。小便利者，津液未竭；小便难者，津液已绝，为危
殆也。
@@@
伤寒发热，口中勃勃气出，头痛目黄，衄不可制，贪水者必呕，恶水者厥。若下之，
咽中生疮，假令手足温者，必下重便脓血。头痛目黄者，若下之，则目闭。贪水者，
若下之，其脉必厥，其声嘤，咽喉塞；若发汗，则战栗，阴阳俱虚。恶水者，若下之
，则里冷不嗜食，大便完谷出；若发汗，则口中伤，舌上白胎，烦躁，脉数实，不大
便六、七日，后必便血；若发汗，则小便自利也。
【注】
伤寒发热，口中勃勃气盛而出，头痛目黄，将欲作衄，衄不可制，以阳邪盛，故衄之
甚也。贪水者，水与热搏，故呕也；恶水者，里阴寒盛，故厥也。伤寒发热，口中出
气盛者，若下之，热邪入浅，咽中生疮；入深，下重脓血。头痛目黄者，若下之，则
两目闭，液伤干涩也。贪水者，若下之，热去水停，故肢厥声嘤，咽喉塞也；若发汗
过多亡阳，故战栗，表里俱虚也。恶水者，若下之，里寒更甚，故不嗜食，下利完谷
也；若发汗动其虚阳，故口中疮，舌上白胎，烦躁也。若脉数有力，不大便而恶水，
热在于阴，故六、七日后必便血也。若更发其汗，阴阳俱虚，故小便自利也。
【集注】
程知曰：伤寒发热，热在表也；口中勃勃气出，热在里也。头痛目黄，衄不可制，所
感之寒与所郁之热，共蒸于上也。此当以贪水恶水辨之，贪水者，阴虚而热胜，水入
而热与之拒，故呕也；恶水者，阳虚而寒胜，水入而阳气不任，故厥也。盖热气挟寒
邪上蒸，法当辨寒热多寡而用清解，设不知而妄下之，是强抑之而邪不服，必至咽疮
，若手足温而不厥者，其热为胜，必以下而致便脓血也。头痛目黄者，下之则热内陷
而目闭，若贪水者，阴虚为寒下所抑，其脉必厥，其声必如嘤儿餲塞不扬也。此而更
发其汗，则亡阳战栗，阳亦与阴俱虚矣。若恶水者，阳虚，加之寒下，则有里冷不嗜
食，大便完谷出之变也。此而更发其汗，则虚阳外发，必口烂舌白胎而烦躁也。脉数
实不大便者，至六、七日后当便血，此当下之，若更发其汗，则非惟大便不行，并小
便亦为之不利矣。
@@@
微则为欬，欬则吐涎，下之则欬止，而利因不休，利不休，则胸中如虫囓，粥入则出
，小便不利，两□拘急，喘息为难，颈背相引，臂则不仁，极寒反汗出，身冷若冰，
眼睛不慧，语言不休，而谷气多入，此为除中 ，口虽欲言，舌不得前。
【注】
阳盛为痰，阳虚为饮，欬而脉微为阳虚之欬，故欬则吐涎饮也。若脉实，下之可也，
今脉微，下之寒虚更甚，故欬虽止，而利因不休也。胸中如虫囓，是胃寒虫动，故粥
入则出也。下利上吐，中寒也；小便不利，停饮也；两□拘急，喘息为难，颈背相引
，臂则不仁，此皆中外寒饮之证。比之少阴停饮，此无身痛，彼无项背相引，臂则不
仁也。若极寒而甚，则反汗出，身冷如冰，目睛不慧，语言不休而死也。以如是之证
，而谷气多入，此为除中。口虽欲言，舌短难伸，亦死也。
【集注】
张璐曰：误下之下利不止，胃中空虚，而反暴食，为除中。少阴虚寒而反冷汗，为外
脱，及口虽欲言，舌萎不能前等、死证皆起。误下之害如是。
@@@
脉数者，久数不止，止则邪结，正气不能复，正气□结于藏，故邪气浮之，与皮毛相
得，脉数者，不可下，下之必烦，利不止。
【注】
脉数者，谓久数不止，有热之人也。若脉数动时一止，热仍不退，是邪气结，正气不
能复，正气结于藏，邪气浮于外故也。脉虽数促，不可下也，若误下之，则邪热乘虚
入里，必烦利不止也。
@@@
脉浮大，应发汗，医反下之，此为大逆。
【注】
脉浮大，此为表实之脉，应发其汗，若医误以大为里实，而反下之，此为大逆也。
【集注】
程应旄曰：脉大与脉浮而大，差别盛实，纯在表也，虽有里证，仍宜从表发汗，下之
则为大逆。
@@@
动气在右，不可下，下之则津液内竭，咽燥鼻干，头眩心悸也。动气在左，不可下，
下之则腹内拘急，食不下，动气更剧，虽有身热，卧则欲蜷。动气在上，不可下，下
之则掌握热烦，身上浮冷，热汗自泄，欲得水自灌。动气在下，不可下，下之则腹胀
满，卒起头眩，食则下清谷，心下痞也。
【注】
动气在右，肺失治矣。下之则肺先虚，津液内竭，故咽燥鼻干，头眩心悸也。动气在
左，肝失治矣。下之则肝气益急，故食不下，腹内拘急，动气更剧，表实未减，里虚
益甚，故虽有身热，卧则欲蜷也。动气在上，心失治矣。下之则阴液益伤，心火更甚
，故掌心握热，烦热汗出，欲得水浇，即有身上浮冷，亦火盛格阴使然也。动气在下
，肾失治矣。下之则寒虚内甚，而腹胀满，故卒起头眩，心下痞满，食则下利清谷也
。
【集注】
程应旄曰：动气误下，是为犯藏，左右上下，随其经气而致逆，故禁同汗例。
@@@
咽中闭塞，不可下，下之则上轻下重，水浆不下，卧则欲蜷，身急痛，下利日数十行
。
【注】
咽中闭塞，燥干肿痛者，少阴阳邪也，宜下之。今不燥干，不肿痛者，少阴阴邪也，
不可下，下之则阳愈衰，阴愈盛，故曰上轻下重也。水浆不入，卧欲蜷，身急痛，下
利日数十行，中外阳虚也。
【集注】
张璐曰：言初病咽干闭塞，以其人少阴之真阳素亏，故汗下俱禁，若下之，则少阴虚
寒，诸证蜂起矣。
程应旄曰：肾邪上逆，故有咽中闭塞之证，下之阳气益虚，阴气益甚，故有上轻下重
等证。
13
诸外实者，不可上，下之则发微热，亡脉厥者，当脐握热。
【注】
诸外实者，里必虚，即有不大便，无所苦之里，亦不可下。若下之，外发之热虽微，
内虚之寒则盛。若无脉而厥，当脐握热始暖，亦寒之甚也。
【集注】
方有执曰：诸外实，指一切之邪在表而言也。发微热，邪入里也。无脉，阳内陷也。
程知曰：下之则表邪内陷，外不热而内发微热也。其亡脉而厥者，则寒气内深，惟当
脐一握热耳。
@@@
太阳病，有外证未解，不可下，下之为逆。
【注】
此重出，以申叮咛告戒之意。
【集注】
程应旄曰：未解较不解稍异，势虽欲下，仍须俟之。
@@@
病欲吐者，不可下。呕多虽有阳明证，不可攻之。
【注】
欲吐者，邪在膈上，可吐之证也。呕多者，邪在少阳，可和之证也。虽具里证，戒人
不可先攻下也。
@@@
Pulse is soft and weak; the weak pulse appears at the Guan position, the soft pulse appears at the Cun position (Cun refers to the upper part of the wrist), the faint pulse appears at the upper part (Cun), and the choppy pulse appears at the lower part (Chi). Faintness indicates insufficiency of Yang Qi; choppy indicates lack of Blood. If Yang Qi is weak, contracting Wind-Strike leads to sweating, yet restlessness and irritability occur instead; a choppy pulse indicates lack of Blood, leading to cold limbs and chills. When Yang Qi is faint, purgation must not be used; if mistakenly purged, it will result in epigastric fullness and obstruction (Pi).
[Note]
This corresponds to the previous clause regarding contraindications for diaphoresis. The description of a Guan pulse that is superficially soft but deeply weak, a Cun pulse that is faint, and a Chi pulse that is choppy represents a diagnosis of Yang deficiency and Blood scarcity. Since diaphoresis is contraindicated, purgation is also contraindicated, both due to Yang deficiency. If mistakenly purged, internal cold and deficiency will be exhausted, leading to epigastric fullness and obstruction, inevitably resulting in Pi syndrome caused by erroneous purgation in Taiyin disease.
[Collected Notes]
Cheng Yingmao stated: Erroneous diaphoresis depletes Yang from the Yang aspect; erroneous purgation depletes Yang from the Yin aspect. Without Yang, Yin stands alone, allowing Earth Qi (Yin-cold) to ascend, thus causing epigastric fullness and obstruction.
The pulse is soft and weak; the weak pulse appears at the Guan position, the soft pulse appears at the Cun position, the wiry pulse appears at the upper part, and the faint pulse appears at the lower part. A wiry pulse indicates Yang movement (here referring to Yang stagnation or floating externally), while a faint pulse indicates Yin-cold. Upper excess and lower deficiency characterize the patient, who desires warmth. A faint and wiry pulse indicates deficiency; deficiency states are not suitable for purgation.
[Note]
This also corresponds to the previous clause regarding contraindications for diaphoresis. The description of a Guan pulse that is superficially soft but deeply weak, a Cun pulse that is wiry, and a Chi pulse that is faint represents a diagnosis of upper excess and lower deficiency. A faint and wiry pulse indicates deficiency; since diaphoresis is contraindicated, purgation is also contraindicated, due to lower deficiency.
[Collected Notes]
Cheng Wuji stated: Purging a deficient person constitutes "double deficiency" (making the deficient even more deficient).
The pulse is soft and weak; the weak pulse appears at the Guan position, the soft pulse appears at the Cun position, the floating pulse appears at the upper part, and the rapid pulse appears at the lower part. A floating pulse indicates Yang deficiency; a rapid pulse indicates lack of Blood. Floating indicates deficiency; rapid generates heat. Due to floating (deficiency), there is spontaneous sweating and aversion to cold; rapid indicates pain, trembling, and chills. Weakness at the Guan causes urgency below the chest, panting, sweating, and difficulty breathing. During respiration, pain radiates to [missing character]. Trembling and chills intermingle, resembling malaria. If the physician mistakenly uses purgation, it results in a rapid pulse with fever, manic running, hallucinations of ghosts, epigastric fullness, dribbling urination, severe pain/fullness in the lower abdomen, and hematuria.
[Note]
This describes a Guan pulse that is superficially soft but deeply weak, a Cun pulse that is floating, and a Chi pulse that is rapid. Softness and weakness at Guan indicate deficiency of Middle Qi; floating and forcelessness at Cun indicate Yang deficiency; rapidity and forcelessness at Chi indicate Blood deficiency. Yang deficiency causes spontaneous sweating and aversion to cold; Blood deficiency causes body pain, trembling, and chills. Deficiency of Middle Qi causes chest and diaphragm qi urgency, panting, sweating, and difficulty breathing, with pain radiating during respiration. Trembling and chills intermingle, resembling malaria. The interior pathogen is not excess, and the exterior pathogen has not resolved. If the physician mistakenly uses purgation, the unresolved exterior pathogen associated with deficient Yang sinks entirely into the interior, resulting in an extremely disordered rapid pulse, fever, manic running, hallucinations, epigastric fullness, severe [pain/fullness] in the lower abdomen, dribbling urination, and hematuria.
[Collected Notes]
Zhang Lu stated: A Cun pulse that is soft and floating, with a weak Guan and rapid Chi, occurs because the person's original Yang is deficient, causing deficient Yang to sink into the Yin aspect. If mistakenly purged, damaging Blood, it will inevitably lead to manic running, fullness, and hematuria.
Wei Litong stated: The contraindication of purgation for previous deficiency-cold patterns is easy to understand; the contraindication for this pattern of deficiency combined with heat is difficult to understand. Thus, these two clauses mirror each other to demonstrate the prohibition.
The pulse is soft and tight; softness indicates weak Wei Qi, and tightness indicates Cold in the Ying aspect. Yang is weak, and Wei is affected by Wind, causing fever and aversion to cold; Ying is tight, and Wei Qi is cold, causing slight vomiting and internal irritability. The physician, perceiving great heat, uses muscle-relaxing diaphoresis, leading to loss of Yang, deficient irritability, and bitter epigastric hardness. Exterior and Interior are both exhausted. Upon sudden rising, dizziness occurs. Guest Heat resides on the skin, causing dissatisfaction and insomnia. Unaware of the Cold Stomach Qi and Tight Cold at the Guanyuan point, even skilled physicians find no remedy. Pouring cold water on the body temporarily stops the guest heat, but causes shivering and chills. Covering with heavy blankets induces sweating and head vertigo, body tremors, and slight difficulty in urination. Cold Qi arises from the water, causing continuous diarrhea of undigested food, vomiting with intestinal prolapse, restlessness, slight cold extremities, body coldness, and internal irritability. Even if one wishes to save them later, life cannot be recovered.
[Note]
A soft and tight pulse means superficially soft and deeply tight. Softness indicates weak Wei exterior; tightness indicates Cold in the Ying interior. There is an exterior syndrome of fever, sweating, and aversion to cold, and an interior syndrome of slight vomiting and irritability. The physician, believing there is heat, uses diaphoresis, further weakening exterior Yang and generating irritability, while intensifying interior Cold and causing epigastric fullness. With exterior deficiency and interior cold, sudden rising causes dizziness and dissatisfaction/insomnia. If one only sees guest heat on the skin and ignores interior middle Cold, pouring cold water may temporarily stop the guest heat, but causes shivering. Heavy blankets induce sweating and vertigo, tremors, cold limbs, diarrhea of undigested food, and irritability, leading to death. This is because both external and internal Yang are lost and cannot recover.
[Collected Notes]
Zhang Xiju stated: "Sweating and head vertigo" means sweating causes Yang to escape externally, leading to dizziness and blurred vision, hence "Mao Dian". Slight difficulty in urination is due to Yang loss and failure of Qi transformation. "Continuous diarrhea of undigested food" means diarrhea without pause. "Ou Bian" refers to the change in taste of vomitus. "Chang Chu" refers to rectal prolapse due to severe diarrhea.
The pulse is floating and large; floating indicates Qi excess, and large indicates Blood deficiency. Blood deficiency implies lack of Yin. When solitary Yang descends alone into the Yin region, urine should be red and difficult. The uterus should be empty. Now, however, urination is free and there is profuse sweating. According to the method, Wei Qi should be weak, but now it appears stronger. Fluids scatter in all directions, Ying is exhausted, Blood is depleted, causing dry irritability and insomnia. Blood becomes thin, muscles waste away, forming "Bao Ye" (fluids boiled out by heat). If the physician again uses toxic drugs to attack the Stomach, this is double deficiency. The departure of guest Yang is imminent, and death will follow with diarrhea like mud.
[Note]
A floating and large pulse means strong upon superficial palpation but large and hollow upon deep pressure, representing the Ge pulse image. Floating indicates exterior tension of Qi excess; large indicates interior hollowness of Blood deficiency. Severe Blood deficiency leads to Yin loss; Yin loss leaves Yang without a partner, hence "solitary Yang descends alone into the Yin region." This means Wei Yang descends to join Yin, causing red and difficult urination due to uterine exhaustion. If Yang does not descend, urination would be free and sweating profuse, indicating Wei Yang exterior deficiency and evil Yang entering internally. Without Yin to transform, it appears as excess, causing fluids to scatter, Ying exhaustion, Blood depletion, muscle wasting, stomach dryness, irritability, and insomnia. Unaware of this, the physician mistakes the hollow, boiling-stomach Yangming pattern for Stomach excess and uses harsh drugs to purge, creating double deficiency. The departure of Stomach Yang is inevitable, leading to death with foul, muddy diarrhea.
[Collected Notes]
Cheng Zhi stated: This discusses the pulse of Qi excess and Blood deficiency; when urination is free and sweating is profuse, purgation is contraindicated.
Cheng Yingmao stated: Without Yin, solitary Yang descends alone into the Yin region. If urine were red and difficult, the uterus would not be empty, merely Yang pulsation. Since Yang has not separated, Yin remains stagnant and不散. Now, with free urination and profuse sweating, Wei Qi is even weaker. The apparent "excess" is not Wei Yang excess, but Guest Yang excess. Wei Yang still clings to Yin, but Guest Yang attacks Yin exclusively, causing fluid scattering, free urination, and profuse sweating. Intense heat forces Yin out, leading to Ying exhaustion, Blood depletion, dry irritability, insomnia, thin blood, muscle wasting, and Bao Ye. "Bao Ye" refers to drops squeezed out by fire-like heat. Using toxic drugs to attack the Stomach causes Earth failure and death of the Five Zang, leading to death with diarrhea like mud.
In Shanghan, if the pulse is tight in both Yin and Yang aspects, with aversion to cold and fever, the pulse tends toward Jue (reversal); Jue pulses start large, gradually become small, then grow large again. This is the sign. In such cases, severe aversion to cold with翕翕 (gentle) sweating and throat pain indicates Shaoyin cold Jue. More heat, red eyes, numerous pulses, and unclear vision indicate Yangming heat Jue. If Jue with severe cold and heat is mistakenly treated with diaphoresis, the throat suffers pain; if mistakenly purged, the eyes close. All Jue syndromes involve diarrhea; cold Jue involves diarrhea of undigested food, while heat Jue involves pus and blood in stool. This distinguishes cold and heat Jue by stool. Moxibustion/fumigation causes jaundice (damp-heat); fire ironing causes dry throat (fire injuring fluids). If urination is free, it can be saved; if urination is difficult, it is critical.
[Note]
Shanghan with tight Yin and Yang pulses, aversion to cold and fever, is a Taiyang exterior syndrome. "Pulse tending toward Jue" means the floating-tight pulse starts large and gradually shrinks, indicating impending Jue. Initially large is Yang causing fever; gradually small is Yin causing reversal. Larger and hotter, smaller and colder, are the signs. One must distinguish Jue by cold and heat. Severe aversion to cold, gentle sweating, and throat pain indicate Shaoyin cold Jue. More fever, red eyes, numerous pulses, and unclear vision indicate Yangming heat Jue. Mistaken diaphoresis in severe cold/heat Jue injures the throat; mistaken purgation closes the eyes. All Jue involves diarrhea: cold Jue is undigested food, heat Jue is pus and blood. Fumigation causes jaundice; fire ironing causes dry throat. Free urination means Yin is not exhausted and can be saved; difficult urination means Yin is exhausted and is critical.
[Collected Notes]
Cheng Zhi stated: External cold injury leads to damp-heat diseases; diaphoresis, purgation, fumigation, and ironing are all contraindicated.
Zhang Lu stated: A Jue pulse indicates alternating cold and heat in reversal. Initially large is pathogen agitation; gradually small is righteous Qi injury; growing large again is pathogen resurgence. Due to original righteous Qi deficiency, it cannot maintain control, following pathogen advance/retreat, so the pulse fluctuates. Free urination means fluids are not exhausted; difficult urination means fluids are exhausted, which is critical.
In Shanghan fever, hot air rushes from the mouth, headache, yellow eyes, uncontrollable epistaxis. Those craving water will vomit; those repelling water will have Jue. If purged, sores form in the throat; if hands and feet are warm, there will be heaviness and pus/blood in stool. If purged in headache/yellow eyes, eyes close. If purged in those craving water, pulse becomes Jue, voice is hoarse, throat feels blocked; if diaphoresis is used, trembling occurs, and both Yin and Yang are deficient. If purged in those repelling water, interior cold increases, appetite decreases, undigested food passes; if diaphoresis is used, mouth injuries, white tongue coating, irritability, rapid solid pulse, constipation for 6-7 days, followed by bloody stool; if diaphoresis is used again, urination becomes spontaneous/free.
[Note]
Shanghan fever with rushing hot air, headache, yellow eyes, impending uncontrollable epistaxis, is due to excess Yang pathogen. Craving water means water fights heat, causing vomiting; repelling water means interior Yin-cold excess, causing Jue. If purged in fever/hot air, shallow heat causes throat sores, deep heat causes lower heaviness and pus/blood. If purged in headache/yellow eyes, eyes close due to fluid injury and dryness. If purged in those craving water, heat leaves, water stays, causing limb Jue, hoarse voice, throat blockage; excessive diaphoresis loses Yang, causing trembling and exterior-interior deficiency. If purged in those repelling water, interior cold worsens, causing anorexia and undigested stool; diaphoresis moves deficient Yang, causing mouth sores, white tongue coating, irritability. If rapid solid pulse and constipation with repelling water, heat is in Yin, causing bloody stool after 6-7 days. Further diaphoresis makes both Yin and Yang deficient, causing spontaneous urination.
[Collected Notes]
Cheng Zhi stated: Shanghan fever is heat in the exterior; rushing hot air is heat in the interior. Headache, yellow eyes, uncontrollable epistaxis result from cold pathogen and constrained heat steaming upward. Differentiate by craving/repelling water. Craving water: Yin deficiency with heat excess, water rejects heat, causing vomiting. Repelling water: Yang deficiency with cold excess, Yang cannot bear water, causing Jue. Heat carrying cold steams up; clear resolution based on cold/heat ratio is needed. Mistaken purgation suppresses pathogen, causing throat sores. If hands/feet are warm (not Jue), heat wins, purgation causes pus/blood stool. Purgation in headache/yellow eyes traps heat, closing eyes. In those craving water, Yin deficiency suppressed by cold purgation causes Jue pulse and hoarse voice. Further diaphoresis loses Yang, causing trembling and Yin-Yang deficiency. In those repelling water, Yang deficiency plus cold purgation causes interior cold, anorexia, undigested stool. Further diaphoresis sends deficient Yang outward, causing mouth ulcers, white tongue, irritability. Rapid solid pulse with constipation leads to bloody stool after 6-7 days; purgation is indicated here, but further diaphoresis prevents bowel movement and urination.
Faint pulse indicates cough; coughing produces saliva. If purged, cough stops, but diarrhea continues incessantly. Incessant diarrhea causes chest sensation like insect biting; drinking porridge leads to immediate expulsion. Urination is difficult, legs/tendons are cramped, breathing is difficult, neck and back pull together, arms are numb. Extreme cold causes sweating, body cold as ice, unclear vision, incessant speech despite food intake. This is Chu Zhong (return of stomach Qi before death). Mouth wants to speak, but tongue cannot extend forward.
[Note]
Yang excess creates Phlegm; Yang deficiency creates Fluid retention. Cough with faint pulse is Yang-deficient cough, producing saliva. If pulse were excess, purgation would be okay. Now pulse is faint; purgation worsens cold and deficiency. Cough stops, but diarrhea continues. Chest like insect biting indicates Stomach cold moving worms, causing porridge expulsion. Diarrhea and vomiting indicate middle Cold; difficult urination indicates retained Fluid; leg cramps, breathing difficulty, neck/back pulling, arm numbness are all exterior-interior cold-fluid syndromes. Compared to Shaoyin retained Fluid (which has body pain but no neck/back/arm symptoms), this lacks body pain. Extreme cold causes sweating, icy body, unclear vision, incessant speech, leading to death. Food intake in this state is Chu Zhong. Tongue shortening is also a death sign.
[Collected Notes]
Zhang Lu stated: Erroneous purgation causes incessant diarrhea; stomach emptiness leads to binge eating, called Chu Zhong. Shaoyin deficiency-cold with cold sweat is exterior collapse. Tongue inability to extend are death signs. Harm of erroneous purgation is thus.
Rapid pulse lasting long without stopping; if it stops, pathogen knots, righteous Qi cannot recover, knotting in Zang, causing pathogen to float to skin/hair. Rapid pulse is not suitable for purgation; purgation causes irritability and incessant diarrhea.
[Note]
Rapid pulse indicates heat. If rapid pulse stops occasionally, heat remains, indicating pathogen knotting and righteous Qi failure to recover, knotting in Zang, pathogen floating externally. Even if rapid and frequent, purgation is contraindicated. Mistaken purgation allows pathogen heat to enter interior, causing irritability and incessant diarrhea.
Pulse floating and large requires diaphoresis; if physician mistakenly purges, it is a major deviation.
[Note]
Floating-large pulse is exterior excess; diaphoresis is required. Mistaking largeness for interior excess and purging is a major deviation.
[Collected Notes]
Cheng Yingmao stated: Large pulse and floating-large pulse differ in excess strength; purely exterior. Even with interior symptoms, diaphoresis is preferred. Purging is a major deviation.
Moving Qi in the Right (Lung area): Do not purge. Purging exhausts internal fluids, causing dry throat/nose, dizziness, and palpitations. Moving Qi in the Left (Liver area): Do not purge. Purging causes abdominal cramping, poor appetite, intensified moving Qi. Even with fever, patient curls up when lying down. Moving Qi in the Upper (Heart area): Do not purge. Purging damages Yin fluids, intensifies Heart Fire, causing hot palms, irritability, sweating, desire for water pouring. Body surface coldness is due to fire repelling Yin. Moving Qi in the Lower (Kidney area): Do not purge. Purging worsens interior cold/deficiency, causing abdominal fullness, dizziness upon rising, undigested stool, epigastric fullness.
[Note]
Moving Qi in Right indicates Lung dysfunction. Purging first damages Lung, exhausting fluids, causing dry throat/nose, dizziness, palpitations. Moving Qi in Left indicates Liver dysfunction. Purging intensifies Liver Qi, causing poor appetite, abdominal cramping, intensified moving Qi. Exterior excess remains, interior deficiency worsens, so despite fever, patient curls up. Moving Qi in Upper indicates Heart dysfunction. Purging damages Yin, intensifies Heart Fire, causing hot palms, irritability, sweating, desire for water. Surface coldness is fire repelling Yin. Moving Qi in Lower indicates Kidney dysfunction. Purging worsens interior cold/deficiency, causing fullness, dizziness, undigested stool, epigastric fullness.
[Collected Notes]
Cheng Yingmao stated: Erroneous purgation of Moving Qi offends the Zang. Left/right/up/down deviations follow meridian Qi, so prohibition is same as diaphoresis.
Throat closure: Do not purge. Purging causes upper lightness/lower heaviness, inability to swallow liquids, curling up, body pain, frequent diarrhea.
[Note]
Throat closure with dryness/pain/swelling is Shaoyang Yang pathogen, suitable for purgation. Current case without dryness/pain/swelling is Shaoyin Yin pathogen, not suitable for purgation. Purging further declines Yang, increases Yin, causing upper lightness/lower heaviness. Inability to swallow, curling, pain, frequent diarrhea indicate exterior-interior Yang deficiency.
[Collected Notes]
Zhang Lu stated: Initial throat dryness/closure indicates original Shaoyin True Yang deficiency; both diaphoresis and purgation are prohibited. Purging causes Shaoyin deficiency-cold and various symptoms.
Cheng Yingmao stated: Kidney pathogen reverses upward, causing throat closure. Purging further declines Yang, increases Yin, causing upper lightness/lower heaviness.
13. Exterior Excess: Do not purge. Purging causes slight fever. Loss of pulse and Jue with warmth at umbilicus indicates extreme cold.
[Note]
Exterior excess implies interior deficiency. Even with constipation and no interior distress, do not purge. Purging makes exterior heat slight but interior cold severe. No pulse and Jue with warmth at umbilicus indicates extreme cold.
[Collected Notes]
Fang Youzhi stated: Exterior excess refers to all pathogens in exterior. Slight fever indicates pathogen entering interior. No pulse indicates Yang sinking.
Cheng Zhi stated: Purging sinks exterior pathogen inward, causing slight internal heat instead of external heat. No pulse and Jue indicate deep internal cold, with only umbilical warmth.
Taiyang disease with unresolved exterior symptoms: Do not purge. Purging is adverse.
[Note]
Repeated for emphasis and warning.
[Collected Notes]
Cheng Yingmao stated: "Unresolved" differs slightly from "not resolved"; although purging seems necessary, one must wait.
Patient desiring to vomit: Do not purge. Frequent vomiting, even with Yangming symptoms, prohibits attacking/purging.
[Note]
Desire to vomit indicates pathogen above diaphragm, suitable for emesis. Frequent vomiting indicates pathogen in Shaoyang, suitable for harmonizing. Even with interior symptoms, warn against premature purgation.