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，下之则心下痞硬。
【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，心下痞硬，必成太阴误下下利之痞硬矣。
【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，故心下痞硬。
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，痛在于胁。振寒相搏，
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，少腹甚硬，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，呼吸之中痛引于胁也。
振寒相搏，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，少腹甚硬，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，紧则营中寒；阳微卫中风，发热而恶寒；营紧卫气冷，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，紧则营里寒，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，心下痞硬，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，不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；营竭血尽，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，营竭血尽，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，仅为阳抟。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，所以营竭血尽，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，则土败而四脏无生，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。若以熏蒸取汗，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、熏、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，舌上白苔，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，舌上白苔烦躁也。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 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、舌白苔而烦躁也。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。
微则为咳，咳则吐涎，下之则咳止，而利因不休；利不休，则胸中如虫啮，粥入则出，小便不利，两胁拘
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，咳而脉微为阳虚之咳，故咳则吐涎饮也。若脉实，下之可也，今脉微，下之
寒虚更甚，故咳虽止，而利因不休也。胸中如虫啮，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；两胁拘急，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，正气却结于脏，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
于脏，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，是为犯脏，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】咽中闭寒，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。
诸外实者，不可下；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。
夫病阳多者热，下之则硬。
【注】阳病里热多者，宜乎下；表热多者，宜乎汗。若表里热多，当两解也。若单下之，表不解则里虚，
表热内陷，因作硬也。
【集注】张璐曰∶阳热证多，即有阳明证见，亦属经证，不可下也。不当下而误下之，则阳邪乘虚内陷，
不作结胸，则为痞硬也。
程应旄曰∶阳病，谓表里热俱多，下之则胃中水竭。其硬也，非转属阳明之硬也。
无阳阴强大便硬者，下之，必清谷腹满。
The pulse is soft and weak; the weak pulse appears at the Guan position, while the soft pulse appears at the Cun position (top). The faint pulse appears in the upper part, and the choppy pulse appears in the lower part. A faint pulse indicates insufficiency of Yang Qi; a choppy pulse indicates deficiency of Blood. If Yang Qi is weak and Wind strikes with Heat (Zhong Feng), sweating occurs, accompanied by restlessness and irritability. Due to choppy pulse indicating Blood deficiency, there is coldness in the extremities (Jue) and chills. When Yang Qi is faint, purgation must not be used; if mistakenly purged, epigastric fullness and hardness (Pi Ying) will result.
[Note] This refers to the previously mentioned contraindication for diaphoresis. It describes a scenario where the Guan pulse is floating-soft and sinking-weak, the Cun pulse is faint, and the Chi pulse is choppy, indicating a diagnosis of Yang deficiency and Blood scarcity. Since diaphoresis is contraindicated, purgation is also contraindicated due to Yang deficiency. If mistakenly purged, internal cold and deficiency will become depleted, leading to epigastric fullness and hardness, inevitably resulting in Pi syndrome with diarrhea caused by erroneous purgation in Tai Yin 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 Yin-cold qi to ascend, causing epigastric fullness and hardness.
The pulse is soft and weak; the weak pulse appears at the Guan position, while the soft pulse appears at the Cun position. The wiry pulse appears in the upper part, and the faint pulse appears in the lower part. A wiry pulse indicates the movement of Yang; a faint pulse indicates Yin-cold. This presents as excess above and deficiency below; the patient desires warmth. A faint and wiry pulse indicates deficiency; deficiency states are not suitable for purgation.
[Note] This also refers to the previously mentioned contraindication for diaphoresis. It describes a scenario where the Guan pulse is floating-soft and sinking-weak, the Cun pulse is wiry, and the Chi pulse is faint, indicating a diagnosis of excess above and deficiency below. A faint and wiry pulse indicates deficiency; since it is deficient, neither diaphoresis nor purgation should be used, due to lower Jiao deficiency.
[Collected Notes] Cheng Wuji stated: Purging a deficient person constitutes "double deficiency" (Chong Xu).
The pulse is soft and weak; the weak pulse appears at the Guan position, while the soft pulse appears at the Cun position. The floating pulse appears in the upper part, and the rapid pulse appears in the lower part. A floating pulse indicates Yang deficiency; a rapid pulse indicates lack of Blood. Floating indicates deficiency, leading to spontaneous sweating and aversion to cold. Rapid indicates pain, tremors, and chills. Weakness at the Guan position causes urgency below the chest, wheezing, sweating, and difficulty breathing; during respiration, pain radiates to the hypochondrium. Chills and tremors intertwine, resembling malaria. If the physician erroneously uses purgation, it leads to a rapid pulse, fever, manic wandering, hallucinations of seeing ghosts, epigastric fullness, dribbling urination, severe hardness in the lower abdomen, and hematuria.
[Note] This describes a Guan pulse that is floating-soft and sinking-weak, a Cun pulse that is floating, and a Chi pulse that is rapid. Guan softness and weakness indicate deficiency of Middle Qi; floating and forceless Cun pulse indicates Yang deficiency; rapid and forceless Chi pulse indicates Blood deficiency. Due to Yang deficiency, there is spontaneous sweating and aversion to cold; due to Blood deficiency, there is body pain, tremors, and chills. Due to deficiency of Middle Qi, there is chest oppression, wheezing, sweating, and dyspnea, with pain radiating to the hypochondrium during breathing. Chills and tremors intertwine, resembling malaria. The interior pathogen is not solid, and the exterior pathogen has not resolved. Erroneous purgation causes the unresolved exterior pathogen associated with deficient Yang to sink into the interior, resulting in an erratic rapid pulse, fever, mania, wandering, hallucinations, epigastric fullness, severe lower abdominal hardness, dribbling urination, and hematuria.
[Collected Notes] Zhang Lu stated: When the Cun pulse is floating-soft, Guan is weak, and Chi is rapid, it is because the person's original Yang is deficient, and deficient Yang sinks into the Yin aspect. Erroneous purgation damaging Blood will inevitably lead to mania, 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 recognize. Thus, these two clauses mirror each other to demonstrate the prohibition.
The pulse is soft and tight; softness indicates Wei Qi (Defensive Qi) is weak, and tightness indicates Cold in Ying Blood (Nutritive Blood). Yang is weak, and Wei Qi is struck by Wind, causing fever and aversion to cold. Ying Blood is tight, and Wei Qi is cold, causing slight vomiting and inner irritability. The physician, perceiving great heat, uses muscle-relaxing diaphoresis, leading to loss of Yang, deficiency-induced irritability, and bitter epigastric fullness and hardness. Both exterior and interior are exhausted. Rising suddenly causes dizziness. External heat remains on the skin, causing melancholy and insomnia. Unaware of the cold Stomach Qi and Cold at the Guan Yuan point, even skilled physicians find no remedy. Pouring cold water on the body temporarily dissipates the external heat but causes intense shivering and chills. Covering with heavy blankets induces sweating and head vertigo, body trembling, and cold limbs. Urination becomes slightly difficult. Cold Qi arises from the water, leading to continuous diarrhea of undigested food, vomiting with intestinal prolapse, restlessness, slight coldness of hands and feet, body coldness, and inner irritability. Delayed rescue cannot recover what is lost.
[Note] A soft and tight pulse means floating-soft and sinking-tight. Softness indicates weak Wei surface; tightness indicates Cold in 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, mistaking it for heat, uses diaphoresis, further weakening Exterior Yang and generating irritability, while intensifying Interior Cold, causing epigastric fullness and hardness. With exterior deficiency and interior cold, sudden rising causes dizziness and insomnia. If one only sees external heat on the skin and ignores internal cold, pouring cold water may temporarily stop the external heat but causes intense shivering. Covering with blankets causes sweating, vertigo, trembling, cold limbs, diarrhea of undigested food, and irritability, leading to death due to the loss of both internal and external Yang, which cannot be restored.
[Collected Notes] Zhang Xiju stated: Sweating leading to head vertigo occurs because sweating causes Yang Qi to escape externally, resulting in dizziness and blurred vision, hence "Mao Dian." Slight difficulty in urination occurs because Yang loss impairs Qi transformation. Continuous diarrhea of undigested food means there is no interval without diarrhea. "Ou Bian" refers to changed taste in 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. If lone Yang descends alone into the Yin region, urination should be red and difficult, and the uterus should be empty. However, now urination is free and sweating is profuse. According to the method, Wei Qi should be weak, but now it appears more solid, causing fluids to scatter in all directions. Ying exhaustion and Blood depletion lead to dry irritability and insomnia, thinning of flesh, and consumption, resulting in "Bao Ye" (rapid fluid loss). If the physician again uses toxic drugs to attack the Stomach, this is double deficiency. The departure of guest Yang has a deadline; death will follow with stool like mud.
[Note] A floating and large pulse means forceful upon superficial palpation but large and hollow upon deep pressure, characteristic of a Ge Pulse (Leather Pulse). Floating indicates exterior tension of Qi excess; large indicates hollowness of Blood deficiency. Severe Blood deficiency leads to Yin collapse; when Yin collapses, Yang has no companion, hence "Lone Yang descends alone into the Yin region." This means Wei Yang descends to join Yin, causing red and difficult urination due to uterine emptiness. If Yang does not descend to join Yin, urination becomes free and sweating profuse, indicating Wei Yang exterior deficiency and Evil Yang entering internally. Without Yin to transform, it appears "more solid," causing fluid scattering, Ying exhaustion, Blood depletion, flesh consumption, stomach dryness, irritability, and insomnia. The physician, unaware of this, mistakes the hollow, rapidly losing-fluid Yang Ming condition for Stomach Excess and uses harsh purgatives, constituting "deficientizing the deficient." The departure of Stomach Yang is imminent, leading to death with excrement like mud.
[Collected Notes] Cheng Zhi stated: This discusses the pulse of Qi excess and Blood deficiency; those with free urination and profuse sweating must not be purged.
Cheng Yingmao stated: Without Yin, lone Yang descends alone into the Yin region. If urination were red and difficult, the uterus would not be empty, representing merely Yang stagnation. If Yang has not separated, Yin can remain stagnant and not scatter. Now, with free urination and profuse sweating, Wei Qi is even weaker. The so-called "appearing more solid" is not the solidity of Wei Yang, but of Guest Yang. While Wei Yang may still cling to Yin, Guest Yang attacks Yin exclusively, causing fluid scattering, free urination, and profuse sweating. Intense heat forces Yin, leading to Ying exhaustion, Blood depletion, dry irritability, insomnia, thinning blood, flesh consumption, and Bao Ye. "Bao Ye" refers to fluids being squeezed out by fire-like heat. Using toxic drugs to attack the Stomach causes Earth failure and death of the four Zang organs, leading to death with stool like mud.
In Shang Han, if the pulse is tightly bound in both Yin and Yang positions, with aversion to cold and fever, the pulse may become Jue (extremity reversal); Jue is characterized by the pulse initially coming large, gradually becoming small, then coming large again. This is its sign. In such cases, severe aversion to cold with slight sweating and throat pain indicates Sha Yin Cold Jue; more heat with red eyes, multiple pulse changes, and unclear vision indicates Yang Ming Heat Jue. Misusing diaphoresis on such Cold and Heat Jue injures the throat; misusing purgation causes closed eyes. Cold Jue involves diarrhea of undigested food; Heat Jue involves bloody pus in stool. This distinguishes Cold and Heat Jue via stool. Moxibustion/fumigation causes jaundice (damp-heat combination); fire ironing causes dry throat (fire injuring fluids). If urination is free, it can be saved (Yin not exhausted); if urination is difficult, it is critical (Yin exhausted).
[Note] Shang Han with tightly bound Yin-Yang pulses, aversion to cold, and fever is a Tai Yang exterior syndrome. "Pulse wanting to become Jue" refers to the floating-tight pulse changing from large to small, indicating impending Jue. Initially large represents Yang, causing fever; gradually small represents Yin, causing Jue. Larger and hotter, smaller and colder, are its signs. One must distinguish Jue by cold and heat. Severe cold with slight sweating and throat pain is Sha Yin Cold Jue; more heat with red eyes and unclear vision is Yang Ming Heat Jue. Misdiagnosing Cold/Heat Jue and using diaphoresis causes throat injury; using purgation causes eye closure. All Jue involves diarrhea; Cold Jue diarrhea is undigested food; Heat Jue diarrhea is bloody pus. Fumigation causes jaundice; fire ironing causes dry throat. Free urination means Yin is intact and treatable; difficult urination means Yin is exhausted and critical.
[Collected Notes] Cheng Zhi stated: External cold invasion leads to damp-heat disease; diaphoresis, purgation, fumigation, and ironing are contraindicated.
Zhang Lu stated: A Jue pulse indicates alternating cold and heat in Jue Ni. Initially large indicates pathogenic agitation; gradually small indicates righteous Qi injury; returning large indicates pathogen advance. Due to original righteous Qi deficiency, it cannot maintain control, following pathogen进退 (advance/retreat), causing the pulse to fluctuate. Free urination means fluids are not exhausted; difficult urination means fluids are exhausted, which is critical.
In Shang Han fever, if hot breath rushes from the mouth, headache, yellow eyes, and uncontrollable epistaxis occur, those craving water will vomit, and those rejecting water will experience Jue. If purged, ulcers form in the throat; if hands and feet are warm, tenesmus and bloody pus in stool will occur. If purged in headache/yellow eyes cases, eyes will close. If purged in water-craving cases, the pulse will become Jue, voice hoarse, and throat blocked; if diaphoresed, tremors occur, and both Yin and Yang become deficient. If purged in water-rejecting cases, interior cold, anorexia, and undigested stool occur; if diaphoresed, oral ulcers, white tongue coating, irritability, rapid-solid pulse, constipation for 6-7 days, and subsequent hematochezia occur; if diaphoresed again, urination becomes free.
[Note] Shang Han fever with rushing hot breath, headache, yellow eyes, and impending uncontrollable epistaxis is due to excessive Yang pathogen. Craving water indicates water-heat conflict causing vomiting; rejecting water indicates severe interior Yin-cold causing Jue. If purged, shallow heat enters causing throat ulcers; deep heat enters causing tenesmus and bloody pus. In headache/yellow eyes, purgation causes eye closure due to fluid injury and dryness. In water-craving cases, purgation removes heat but leaves water, causing limb Jue, hoarse voice, and throat blockage; excessive diaphoresis causes Yang loss, tremors, and dual deficiency. In water-rejecting cases, purgation worsens interior cold, causing anorexia and undigested stool; diaphoresis moves deficient Yang, causing oral ulcers, white coating, and irritability. If pulse is rapid-strong with constipation and water rejection, heat is in Yin, leading to hematochezia after 6-7 days. Further diaphoresis causes dual Yin-Yang deficiency and free urination.
[Collected Notes] Cheng Zhi stated: Shang Han fever indicates heat in the exterior; rushing breath indicates heat in the interior. Headache, yellow eyes, and epistaxis result from cold and constrained heat steaming upward. Differentiate by craving/rejecting water. Craving water indicates Yin deficiency with dominant heat; water conflicts with heat, causing vomiting. Rejecting water indicates Yang deficiency with dominant cold; Yang cannot bear water, causing Jue. Heat carrying cold steams upward; treatment should clear and resolve based on cold/heat ratio. Erroneous purgation suppresses pathogen, causing throat ulcers. If hands/feet are warm (heat dominant), purgation causes bloody pus. In headache/yellow eyes, purgation sinks heat, closing eyes. In water-craving (Yin deficient), purgation suppresses with cold, causing Jue pulse and hoarse voice. Further diaphoresis causes Yang loss and tremors. In water-rejecting (Yang deficient), cold purgation causes interior cold and undigested stool. Further diaphoresis sends deficient Yang outward, causing oral ulcers and irritability. With rapid-solid pulse and constipation, hematochezia occurs after 6-7 days; this requires purgation. Further diaphoresis prevents bowel movement and urination.
If the pulse is faint, there is cough; coughing produces saliva. Purgation stops the cough but causes persistent diarrhea. Persistent diarrhea leads to a sensation of insect biting in the chest; drinking porridge results in immediate regurgitation. Urination is difficult, hypochondriac spasm, difficult breathing, neck-back traction, arm numbness. Extreme cold with sweating, ice-cold body, unclear vision, and incessant speech. Excessive grain intake here is called "Chu Zhong" (Elimination of the Center). Although the mouth wants to speak, the tongue cannot extend forward.
[Note] Yang excess creates Phlegm; Yang deficiency creates Fluid Retention. Cough with faint pulse indicates Yang-deficient cough, producing saliva. If the pulse were solid, purgation would be acceptable. Now, with a faint pulse, purgation increases cold and deficiency. Thus, cough stops, but diarrhea persists. Chest sensation like insect biting indicates Stomach cold moving worms, causing regurgitation of porridge. Diarrhea and vomiting indicate Middle Cold; difficult urination indicates Fluid retention. Hypochondriac spasm, breathing difficulty, neck-back traction, and arm numbness are signs of interior-exterior cold-fluid. Compared to Sha Yin Fluid retention, this lacks body pain, whereas Sha Yin lacks neck-back-arm symptoms. If extreme cold is severe, sweating occurs, body becomes ice-cold, vision blurs, speech continues until death. Grain intake in this state is "Chu Zhong." Tongue retraction is also a death sign.
[Collected Notes] Zhang Lu stated: Erroneous purgation causing persistent diarrhea, with an empty Stomach leading to binge eating, is "Chu Zhong." Sha Yin deficiency-cold with cold sweat is "External Collapse." Death signs include inability to extend the tongue. The harm of erroneous purgation is thus.
If the pulse is rapid, persistently rapid without stopping, or stopping intermittently, it indicates pathogen binding. Righteous Qi cannot recover; righteous Qi binds in the Zang, while pathogen floats on the exterior, interacting with skin and hair. Rapid pulse indicates heat; do not purge. Purging causes irritability and persistent diarrhea.
[Note] A persistent rapid pulse indicates heat. If the rapid pulse stops intermittently while heat remains, it indicates pathogen binding and failure of righteous Qi to recover. Righteous Qi binds in the Zang, and pathogen floats externally. Even with a rapid-hurrying pulse, do not purge. Erroneous purgation allows pathogen-heat to enter the interior vacuously, causing irritability and persistent diarrhea.
A floating-large pulse requires diaphoresis; erroneous purgation is a major deviation.
[Note] A floating-large pulse indicates exterior excess; diaphoresis is indicated. Mistaking largeness for interior excess and purging is a major deviation.
[Collected Notes] Cheng Yingmao stated: The difference between a large pulse and a floating-large pulse lies in the degree of excess. Purely exterior conditions, even with interior symptoms, require diaphoresis; purgation is a major deviation.
Moving Qi in the Right Lung position: Do not purge. Purging exhausts internal fluids, causing dry throat, dry nose, dizziness, and palpitations. Moving Qi in the Left Liver position: Do not purge. Purging causes abdominal cramping, inability to eat, worsening moving Qi, and desire to curl up despite fever. Moving Qi in the Upper Heart position: Do not purge. Purging causes hot palms, irritability, floating cold on the body, spontaneous sweating, and desire to pour water on oneself. Moving Qi in the Lower Kidney position: Do not purge. Purging causes abdominal fullness, dizziness upon standing, diarrhea of undigested food, and epigastric fullness.
[Note] Moving Qi in the Right indicates Lung dysfunction. Purging first damages Lung, exhausting fluids, causing dry throat/nose, dizziness, and palpitations. Moving Qi in the Left indicates Liver dysfunction. Purging intensifies Liver Qi, causing eating difficulties, abdominal cramping, worsening moving Qi, and unrelieved exterior excess with increased interior deficiency, leading to curling up despite fever. Moving Qi in the Upper indicates Heart dysfunction. Purging damages Yin fluids, intensifying Heart Fire, causing hot palms, irritability, sweating, and desire for water cooling. Any floating cold is due to Fire repelling Yin. Moving Qi in the Lower indicates Kidney dysfunction. Purging intensifies internal cold-deficiency, causing abdominal fullness, dizziness, epigastric fullness, and undigested stool.
[Collected Notes] Cheng Yingmao stated: Erroneous purgation of Moving Qi offends the Zang. Left, right, upper, and lower reversals follow their meridian Qi, hence prohibited like diaphoresis.
Throat obstruction: Do not purge. Purging causes upper lightness and lower heaviness, inability to swallow liquids, desire to curl up, body stiffness/pain, and frequent diarrhea.
[Note] Throat obstruction with dryness, swelling, and pain is Sha Yang pathogen, suitable for purgation. Now, without dryness/pain, it is Sha Yin Yin pathogen; do not purge. Purging further declines Yang and increases Yin, causing upper lightness/lower heaviness. Inability to swallow, curling up, stiffness, and frequent diarrhea indicate interior-exterior Yang deficiency.
[Collected Notes] Zhang Lu stated: Initial throat dryness/obstruction in Sha Yin true Yang deficiency prohibits both diaphoresis and purgation. Purging causes Sha Yin deficiency-cold and myriad symptoms.
Cheng Yingmao stated: Kidney pathogen reversing upward causes throat obstruction. Purging further declines Yang and increases Yin, causing upper lightness/lower heaviness.
Exterior excess conditions: Do not purge. Purging causes slight fever. In pulse-loss Jue, warmth at the navel indicates severe 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. In pulse-loss Jue, warmth at the navel indicates extreme cold.
[Collected Notes] Fang Youzhi stated: Exterior excess refers to all pathogens in the exterior. Slight fever indicates pathogen entering the interior. No pulse indicates Yang sinking internally.
Cheng Zhi stated: Purging causes exterior pathogen to sink inward, appearing as slight internal heat rather than external heat. In pulse-loss Jue, cold is deep internally, with only navel warmth.
Tai Yang disease with unresolved exterior symptoms: Do not purge; purging is adverse.
[Note] This repetition emphasizes caution.
[Collected Notes] Cheng Yingmao stated: "Unresolved" differs slightly from "not resolved"; although purgation seems desired, one must wait.
Desire to vomit: Do not purge. Frequent vomiting, even with Yang Ming symptoms, prohibits attacking with purgatives.
[Note] Desire to vomit indicates pathogen above the Diaphragm, suitable for emesis. Frequent vomiting indicates pathogen in Shao Yang, suitable for harmonization. Even with interior symptoms, do not attack with purgation first.
Diseases with abundant Yang present heat; purging causes hardness.
[Note] Yang diseases with much interior heat suit purgation; exterior heat suits diaphoresis. If both exterior and interior have much heat, resolve both. Single purgation fails to resolve the exterior, causing interior deficiency and sinking of exterior heat, leading to hardness.
[Collected Notes] Zhang Lu stated: Abundant Yang-heat syndromes, even with Yang Ming signs, belong to Meridian syndromes and must not be purged. Erroneous purgation allows Yang pathogen to sink vacuously, causing Pi hardness instead of Jie Xiong.
Cheng Yingmao stated: Yang disease means both exterior and interior heat are abundant. Purging exhausts Stomach fluids. The hardness is not the transition to Yang Ming hardness.
No Yang, strong Yin, hard stool: Purging causes undigested stool and abdominal fullness.