【注】浮为阳，滑为实，阳实相搏，其脉行于脉外者，数且疾矣。卫气行疾，营气行迟，营卫不相辅而行，
故曰失度。浮、滑、数、疾，有余之脉，见发热无汗有余之证，脉证相合则为可治；若见发热汗出不足之证，
脉证不合，不治明矣。
【集注】成无己曰∶浮、滑、数、疾之脉，发热汗出解者，邪气退也。若不解者，正气脱也，必不可治。
经曰∶脉阴阳俱盛大，汗出不解者死。
脉浮而数，浮为风，数为虚，风为热，虚为寒，风虚相搏，则洒淅恶寒也。
【按】数为虚之“虚”字，当是“热”字。“风为热，虚为寒”二句当是衍文。风虚相搏之“虚”字，亦
当是热“字”。
【注】风寒在表则脉浮紧，风热在表则脉浮数。表受风邪，故洒淅恶寒也。
诸脉浮数，当发热而洒淅恶寒，若有痛处，饮食如常者，蓄积有脓也。
【注】诸脉浮数，谓寸、关、尺六脉俱浮数也。浮则为风，数则为热，风热遏郁于表，则当发热而洒淅
恶寒也。若有隐痛之处，饮食如常者，非表邪之诊，乃内痈蓄积有脓之
诊，于此知浮数之脉，不可概为风热。
【集注】王肯堂曰∶人身有 肿痛楚处，未有不自觉者，此条所言，必是内痈，故曰∶蓄积有脓也。如
胃脘痈。肺痈，肠痈，皆各有辨，而胃痈之脉，人迎反盛，未有不误以为伤寒者，故宜察之。
程应旄曰∶脉证似伤寒，若不于若有痛处，饮食如常之证参酌，而误以辛温发散，助其阳热，否则误以
寒凉彻热，遏住邪气，滋害深矣。
张璐曰∶若有 肿，为热壅经络；若无肿处，必邪留脏腑，随内外而发痈脓也。
脉浮而大，浮为风虚，大为气强。风气相搏，必成瘾疹。身体为痒，痒者名泄风，久久为痂癞。
【注】六脉俱浮而大，浮为风虚，大为气强。强者，热也。风热相搏，必成瘾疹也。身体为痒，痒者肌
虚，热气外薄故也，名为泄风。若久不愈，则成痂癞。痂癞，疥、癣、疠、癞之类是也。
【集注】成无己曰∶痂癞者，疠风也，眉少发稀，身有干疮而腥臭，经云∶脉风成疠是也。
朱震亨曰∶经云∶诸痒为虚，血燥不荣肌腠，所以痒也。
方有执曰∶经云∶外在腠理，则为泄风。
寸口诸微亡阳，诸濡亡血，诸弱发热，诸紧为寒，诸乘寒者则为厥。郁冒不仁，以胃无谷气，脾涩不通，
口急不能言，战而栗也。
【按】濡浮而无力，候阳虚也，岂有亡血之理？弱沉而无力，候阴虚也，岂止发热而已？诸濡亡血，当
是诸濡卫虚；诸弱发热，当是诸弱营虚。
【注】寸口者，指寸、关、尺三部而言也。诸微，谓凡病见微脉，皆亡阳也。诸濡，谓凡病见濡脉，皆
卫虚也。诸弱，谓凡病见弱脉，皆营虚也。诸紧，谓凡病见紧脉，皆为寒也。诸乘寒者，谓诸微濡弱脉，亡阳
营卫不足之人，一病即见残贼。紧脉则为寒乘病厥也。厥于中者，郁冒昏迷，不知痛痒；厥于经者，战栗口噤
不能言语，以平日胃虚损谷，脾虚不运，中虚不胜外邪也。
【集注】程知曰∶诸乘寒者，则以阳极虚，而阴寒直乘之也，故为厥逆。其所以昏冒不知人，强直而无觉
者，则以胃无谷气，脾不流通，故使口噤不能言，外战内栗而厥也。
问曰∶曾为人所难，紧脉从何而来？师曰∶假令亡汗若吐，以肺里寒，故令脉紧也；假令咳者，坐饮冷水，
故令脉紧也；假令下利，以胃中虚冷，故令脉紧也。
【注】此详申上条，诸亡阳营卫不足之人，而见紧脉之义也。曾为人所难，问紧脉为寒实之诊，虚冷亦见
紧脉，是从何而来也？师曰∶假令其人亡汗表虚，若吐胸虚，下利里虚，寒邪乘虚为病，或外感寒邪，或内饮
冷水，或中寒阴化，皆令脉紧也。若与浮同见，无汗，则为伤寒实邪；有汗，则为亡阳虚邪。与沉同见，腹痛
不便，则为中寒实邪；腹痛下利，则为中寒虚邪。由此推之，凡诸实脉从虚化者，即未可谓之实矣。
【集注】程应旄曰∶紧则为寒，称曰乘脉，今复列之残贼何义？曰∶虚则为人乘，实则乘人，凡脉皆然，
不独紧也。
寸口脉微，尺脉紧，其人虚损多汗，知阴常在，绝不见阳也。
【注】上条以浮沉见微紧，此条以寸尺见微紧，皆阴盛阳亡之诊，故曰∶知阴常在，绝不见阳也。只曰虚
损多汗者，略言之也。
【集注】程知曰∶言寸微、尺紧为虚损多汗之证也。寸微弱为亡阳，尺紧疾为阴胜，阴胜于内，阳绝于外，
故为虚损多汗。
师曰∶病患脉微弱涩者，此为医所病也。大发其汗，又数大下之，其人亡血，病当恶
寒，后乃发热，无休止时。夏月盛热，欲着复衣；冬月盛寒，欲裸其身。所以然者，阳微则恶寒，阴弱则发热。
此医发其汗，使阳气微，又大下之，令阴气弱。五月之时，阳气在表，胃中虚冷，以阳气内微，不能胜冷，故
欲着复衣。十一月之时，阳气在里，胃中烦热，以阴气内弱，不能胜热，故欲裸其身。又阴脉迟涩，故知血亡也。
【按】“又阴脉迟涩，故知血亡也”二句，与上文义不属，非有阙文，即是衍文。
【注】病患脉微而涩，询之为医大发其汗，又数大下之，所以致此病也。其人亡血，略辞也，谓亡其血
气也。气亡则阳微，阳微则恶寒；血亡则阴弱，阴弱则发热；阳微阴弱，故病当恶寒后乃发热也。轻者邪不留
连，遇所不胜时则愈；重者无休止时，即遇所不胜尤甚也。然恶寒虽遇夏月盛热，欲着复衣。所以然者，五月
之时，阳气在外，胃中虚冷，大发其汗，令阳气微，故不胜寒也。发热虽遇冬月盛寒，欲裸其身。所以然者，
十一月之时，阳气在内，胃中烦热，又数下之，令阴气弱，故不能胜热也。此即论中所谓热在骨髓寒在皮肤、
寒在骨髓热在皮肤，沉痼寒热之病也。
【集注】王肯堂曰∶非必遇夏乃寒，遇冬乃热也。此但立其例，论其理耳。
寸口脉微而缓，微者卫气疏，疏则其肤空；缓则胃气实，实则谷消而水化也。谷入于胃，脉道乃行，水
入于经，其血乃成。荣盛则其肤必疏，三焦绝经，名曰血崩。
【注】寸口脉微而缓，微者卫气疏，疏则其表空虚也；缓者胃气实，实则消化水谷也。谷入于胃，脉道
之气乃行；水入于经，脉络之血乃成。今荣愈盛而卫愈疏，血愈多而气愈少，气血失其经常之道，故曰∶三焦
绝经。气不能制血，血不能归经，故血妄行而崩也。
【集注】成无己曰∶卫气者，温分肉，肥腠理。卫气既疏，皮肤不得温，肥则空虚也。经曰∶缓者胃气
有余。有余为实。故云∶缓者胃气实。《内经》曰∶食入于胃，淫精于脉。是谷入于胃，脉道乃行也。《针经》
曰∶饮而液渗于络，合和于血。是水入于经，其血乃成也。经，常也。三焦者，气之道路。卫气疏则气不循常
度，故三焦绝其常度也。
方有执∶疏言不能固护，实犹言强也。谷入于胃至其血乃成，乃承上文谷消而水化也。阴血大下，而曰
崩者，言其不能止静，如山坏之势也。
寸口脉微而涩，微者卫气不行，涩者荣气不逮，荣卫不能相将，三焦无所仰，身体痹不仁，荣气不足，
则烦疼口难言，卫气虚，则恶寒数欠，三焦不归其部，上焦不归者，噫而酢吞；中焦不归者，不能消谷引食；
下焦不归者，则遗溲。
【注】凡经脉内外，荣卫也；脏腑内外，三焦也。故经曰∶荣行脉中，卫行脉外。上焦心肺主之，中焦
脾胃主之，下焦肝肾主之。分而言之，荣也，卫也，三焦也；合而言之，皆本乎一气之流行，随其所在而得名
也。脉微而涩，荣卫不足，不足则荣卫不能相将而行，三焦无所仰赖，故身体周痹不仁。荣气不足，故身烦疼，
口难言语；卫气不足，故恶寒数欠也。上焦司降，降者，清中之浊。下焦司升，升者，浊中之清。中焦司升降，
清者令其上升，浊者令其下降。今荣卫不相将而行，三焦无所仰赖，故不能各归其部，而失其职矣。上焦不归，
则浊气不降，噫气而吞酸；中焦不归，则升降相违，故不能消谷引食；下焦不归，则清气不升，故不能约束而
遗溲也。
寸口脉微而涩，微者卫气衰，涩者荣气不足。卫气衰，面色黄；荣气不足，面色青。荣为根，卫为叶，
荣卫俱微，则根叶枯槁，而寒粟咳逆，唾腥吐涎沫也。
【注】此详申荣卫上焦之证也。面色黄青，
荣卫不足之色也。恶寒而栗，咳嗽唾腥，吐痰涎沫，肺损之证也。肺主皮毛，皮毛者，荣卫之所居，故肺损则
皮聚而毛落，荣卫枯槁也。
【集注】成无己曰∶荣行脉中为根，卫行脉外为叶，根叶俱微，则阴阳之气衰也。
寸口脉弱而迟，弱者卫气微，迟者营中寒。营为血，血寒则发热；卫为气，气微者，心内饥，饥而虚满，
不能食也。
【按】条末“心内饥，饥而虚满不能食”句，此是论脾胃，不关营卫。故弱者卫气微，当是“阳气微”；
迟者营中寒，当是“脾中寒”，上下文义始属。营为血，血寒则发热，岂有血寒发热之理乎？卫为气，气微者，
当是阳气微。脾中寒者，心内饥，阅下条言胃气有余，自知。
【注】此详申营卫中焦之证也。缓以候胃，迟以候脾。胃主纳谷，脾主化谷，故能食者胃也，能化者脾也。
今阳微中寒，脾胃俱病，所以心内虽饥，饥而虚满不能食也。
【集注】方有执曰∶饥而虚满者，阳主化谷，卫阳衰微不化谷，故虚满而不能食也。
寸口脉弱而缓，弱者阳气不足，缓者胃气有余，噫而吞酸，食卒不下，气填于膈上也。
【注】此又详申中焦之证也。寸口脉弱而缓，弱者阳气不足，缓者胃气有余，不足则脾失健运，有余则胃
强能食。此胃强脾弱，所以虽能食而不能消化也，故使吞酸而噫，食卒不化，气填胀闷于膈中也。
【集注】方有执曰∶阳气以胃中之阳气言，不足则不能化谷；胃气以胃中谷气言，有余言有宿食也。有宿
食则郁而生热，故噫饱而吞酸，此盖以饮食之内伤者言也。
趺阳脉迟而缓，胃气如经也。趺阳脉浮而数，浮则伤胃，数则动脾。此非本病，医特下之所为也。营卫内
陷，其数先微，脉反但浮，其人必大便硬，气噫而除。何以言之？本以数脉动脾，其数先微，故知脾气不治，
大便硬，气噫而除，今脉反浮，其数改微，邪气独留，心中则饥，邪热不杀谷，潮热发渴。数脉当迟缓，脉因
前后度数如法，病者则饥；数脉不时，则生恶疮也。
【注】此以下辨趺阳之脉、少阴之脉也。趺阳一名冲阳，在脚背上，去陷骨三寸脉动处，乃是阳明胃经之
动脉也。少阴一名太溪，在足内踝后跟骨上脉动处，乃足少阴肾经之动脉也。趺阳、少阴，乃古诊法。越人以
十二经虽皆有动脉，独取寸口以决死生者，以寸口乃脉之大要会也。然此法不行久矣。设有危急之病，寸口脉
不见，诊此以决死生可也。若在平时，总不如以关脉为趺阳，尺脉为少阴，更为愈也。如趺阳胃脉迟而和缓，
是胃气不病，如经脉也，今趺阳脉浮而数，按之无力，浮以候腑，浮而无力，则为伤胃；沉以候脏，数而无力，
则为伤脾。询之病者，特为医下之所为，以致营卫之气内陷。其先数脉变微，为脾弱也；浮脉仍浮反甚，为胃
强也。胃强则邪气独留，故大便硬，潮热发渴也；脾弱则脾气不运，故邪热不能杀谷，虽饥不食，气噫而快也。
医者前后施治如法，而浮数之脉，自当迟缓如经，则饥欲食，病者愈也；若施治失宜，数脉终始不退，则生恶
疮也。
【集注】方有执曰∶恶疮与尿脓虽不同，其为血热则皆然也。
程知曰∶此言趺阳脉迟缓，妄下则有浮数之变也。
趺阳脉浮而涩，少阴脉如经者，其病在脾，法当下利。何以知之？若脉浮大者，气实血虚也，今趺阳脉浮
而涩，故知脾气不足，胃气虚也；以少阴脉弦而浮才见，此为调脉，故称如经也。若反滑而数者，故知当屎脓也。
【按】“若脉浮大者，气实血虚也”二句，
与上文义不属，当是衍文。少阴脉弦而浮，岂可谓如经乎？当改，“沉而滑”字。
【注】脾肾皆病下利，今趺阳胃脉浮涩，少阴肾脉如常，是病在脾不在肾也，何以知之？浮为阳，以候胃；
涩为阴，以候脾。浮与涩合，故知脾气不足，胃气虚也。以少阴脉见沉而滑，故称如经也。若沉滑而数者，是
阳邪伤阴，故知当屎脓血也。
【集注】程知曰∶水谷之下利属于脾胃，而脓血之下利属于肾，此可诊趺阳、太溪而辨之也。
趺阳脉伏而涩，伏则吐逆，水谷不化，涩则食不得入，名曰关格，
【按】水谷不化之“化”字，当是“入”字，若是“化”字，是能食也，何名曰格？食不得入，当是不得
小便，若有小便，是水道通也，何名曰关？必是传写之误。
【注】前论以浮沉、尺寸候关格，此以趺阳候关格之诊法也。趺阳者，胃脉也。脉伏而涩，伏则尺寸之阴
阳停升降也，涩则三焦之元气不流通也。不升降流通，故上则吐逆，下则不得小便，病名曰关格也。
趺阳脉滑而紧，滑者胃气实，紧者脾气强，持实击强，痛还自伤，以手把刃，坐作疮也。
[Note] A floating pulse belongs to Yang, and a slippery pulse indicates excess. When Yang Qi and pathogenic excess contend with each other, the pulse qi moving outside the vessels becomes rapid and hurried. Wei Qi moves swiftly, while Ying Qi moves slowly; when Ying and Wei fail to circulate in coordination, it is termed "loss of rhythm." Floating, slippery, rapid, and hurried pulses are all signs of excess. If accompanied by symptoms of excess such as fever without sweating, where the pulse and symptoms correspond, the condition is treatable. However, if symptoms of deficiency such as fever with sweating appear, indicating a mismatch between pulse and symptoms, incurability is evident.
[Collected Notes] Cheng Wuji stated: With floating, slippery, rapid, and hurried pulses, if the disease resolves through sweating, it indicates the retreat of pathogenic factors. If it does not resolve, it signifies the collapse of healthy Qi, rendering the condition incurable. The Classics state: "When both Yin and Yang aspects of the pulse are excessively full, and sweating fails to resolve the condition, death ensues."
A pulse that is floating and rapid: floating indicates Wind, rapid indicates deficiency; Wind generates Heat, and deficiency generates Cold. When Wind and deficiency contend, chills and aversion to cold occur.
[Commentary] The character "deficiency" (xu) in "rapid indicates deficiency" should be "Heat" (re). The phrases "Wind generates Heat, deficiency generates Cold" are likely interpolations. Similarly, the "deficiency" in "Wind and deficiency contend" should be "Heat."
[Note] When Wind-Cold is on the exterior, the pulse is floating and tight; when Wind-Heat is on the exterior, the pulse is floating and rapid. The exterior is affected by Wind pathogen, resulting in chills and aversion to cold.
In cases where various pulses are floating and rapid, one should expect fever and chills. If there is a specific area of pain but dietary intake remains normal, this indicates the accumulation of pus internally.
[Note] "Various pulses floating and rapid" refers to the floating and rapid nature of the Cun, Guan, and Chi positions simultaneously. Floating indicates Wind, and rapid indicates Heat. When Wind-Heat is constrained at the exterior, fever and chills manifest. If there is hidden pain yet dietary intake is normal, this is not a diagnostic sign of exterior pathogens, but rather of an internal abscess with accumulated pus. Thus, one must understand that floating and rapid pulses cannot be universally attributed to Wind-Heat.
[Collected Notes] Wang Kentang said: Any swelling, pain, or discomfort in the body is consciously felt by the patient. This passage must refer to an internal abscess, hence it states: "accumulation of pus." Examples include gastric abscess, lung abscess, and intestinal abscess, each having distinct differentiations. In gastric abscess, the Renying pulse is often prominent, leading to frequent misdiagnosis as Taiyang syndrome; thus, careful examination is required.
Cheng Yingmao stated: Although the pulse and symptoms resemble Taiyang syndrome, if one fails to consider the signs of localized pain and normal diet, and mistakenly uses acrid-warm dispersing methods, it will exacerbate Yang heat. Alternatively, mistakenly using cold-cooling methods to clear heat will trap the pathogen, causing severe harm.
Zhang Lu stated: If there is swelling, it is due to Heat obstructing the meridians; if there is no swelling, the pathogen has remained in the Zang-Fu organs, developing into abscesses and pus depending on internal or external factors.
A pulse that is floating and large: floating indicates Wind-deficiency, and large indicates strong Qi. When Wind and Heat contend, urticaria (wind rashes) will form. The body will itch; itching is called "leaking Wind." If prolonged, it develops into scaly lesions (such as tinea, leprosy, etc.).
[Note] When all six pulse positions are floating and large, floating indicates Wind-deficiency, and large indicates strong Qi. "Strong" refers to Heat. The contention of Wind and Heat inevitably causes urticaria. Body itching occurs because the muscle layer is deficient and Heat presses outwardly; this is named "leaking Wind." If chronic, it becomes scaly lesions. Scaly lesions refer to conditions like tinea, prurigo, and leprosy.
[Collected Notes] Cheng Wuji stated: Scaly lesions refer to leprosy (li feng), characterized by sparse eyebrows and hair, dry scabs on the body with a foul odor. The Classics say: "Pulse due to Wind becomes Li," which refers to this.
Zhu Zhenheng stated: The Classics say: "All itching is due to deficiency." Dry blood fails to nourish the skin and interstices, causing itching.
Fang Youzhi stated: The Classics say: "When pathogen is at the exterior interstices, it becomes leaking wind."
At the Cun Kou position, various thready (wei) pulses indicate the loss of Yang; various soggy (ru) pulses indicate the loss of Blood; various weak (ruo) pulses indicate fever; various tight (jin) pulses indicate Cold. Various pulses indicating invasion by Cold result in Jue (cold extremities/counterflow). There is oppression, dizziness, and numbness because the Stomach lacks Grain Qi, the Spleen is stagnant and unblocked, the mouth/jaw is tight preventing speech, and there is trembling and shivering.
[Commentary] A soggy pulse is floating and forceless, indicating Yang deficiency; how can it indicate Blood loss? A weak pulse is deep and forceless, indicating Yin deficiency; how can it only indicate fever? "Various soggy pulses indicate Blood loss" should be "Various soggy pulses indicate Wei deficiency"; "Various weak pulses indicate fever" should be "Various weak pulses indicate Ying deficiency."
[Note] "Cun Kou" refers to the three positions: Cun, Guan, and Chi. "Various thready" means any disease presenting with a thready pulse indicates loss of Yang. "Various soggy" means any disease presenting with a soggy pulse indicates Wei deficiency. "Various weak" means any disease presenting with a weak pulse indicates Ying deficiency. "Various tight" means any disease presenting with a tight pulse indicates Cold. "Various invaded by Cold" refers to those with thready, soggy, and weak pulses, suffering from loss of Yang and insufficiency of Ying and Wei; upon falling ill, they are immediately attacked by harmful pathogens. A tight pulse indicates Cold invading and causing Jue. Jue in the Middle Jiao leads to oppression, dizziness, coma, and insensitivity to pain/itch; Jue in the meridians leads to tremors, jaw lock, and inability to speak. This is because daily Stomach deficiency impairs grain reception, and Spleen deficiency impairs transportation, leaving the Middle Jiao unable to resist external pathogens.
[Collected Notes] Cheng Zhi stated: "Invaded by Cold" occurs because Yang is extremely deficient, allowing Yin-Cold to directly invade, resulting in counterflow. The reason for coma, unconsciousness, rigidity, and lack of sensation is the lack of Grain Qi in the Stomach and stagnation in the Spleen, causing jaw lock, inability to speak, external trembling, internal shivering, and Jue.
Question: Having been challenged previously, where does the tight pulse come from? Master said: Suppose a person suffers from profuse sweating or vomiting; due to Cold in the Lung interior, the pulse becomes tight. Suppose a person coughs; because they drank cold water, the pulse becomes tight. Suppose a person has diarrhea; because the Stomach middle is deficient and cold, the pulse becomes tight.
[Note] This elaborates on the previous section regarding why those with loss of Yang and insufficiency of Ying/Wei present with a tight pulse. The challenge asked: Tight pulse is a diagnosis of Cold-excess; why does deficiency-cold also show a tight pulse, and from where does it arise? The Master said: Suppose the person has lost sweat (exterior deficiency), vomited (chest deficiency), or has diarrhea (interior deficiency); Cold pathogen takes advantage of the deficiency to cause disease. Whether it is external Cold contraction, internal drinking of cold water, or internal Cold transforming into Yin, all cause a tight pulse. If seen with a floating pulse and no sweat, it is Taiyang Cold-excess; if with sweat, it is Yang-loss deficiency. If seen with a deep pulse, abdominal pain, and constipation, it is Zhong-Jiao Cold-excess; if with abdominal pain and diarrhea, it is Zhong-Jiao Cold-deficiency. From this, we deduce that any excess pulse transforming from deficiency cannot simply be called excess.
[Collected Notes] Cheng Yingmao stated: Tight indicates Cold, termed "invading pulse." Why list it among harmful pulses? Answer: Deficiency allows others to invade it; excess invades others. This applies to all pulses, not just tight.
At the Cun Kou, if the pulse is thready and the Chi pulse is tight, the person is deficient and sweats profusely. It is known that Yin persists, while Yang is completely absent.
[Note] The previous section discussed thready/tight via floating/deep; this section discusses it via Cun/Chi. Both are diagnoses of Yin-excess and Yang-loss, hence: "Yin persists, Yang is absent." Mentioning only "deficient and sweaty" is a brief statement.
[Collected Notes] Cheng Zhi stated: Cun thready and Chi tight indicate deficient and sweaty syndromes. Cun thready/weak indicates Yang loss; Chi tight/hurried indicates Yin excess. Yin excess inside, Yang absence outside, results in deficiency and sweating.
Master said: If a patient's pulse is thready, weak, and choppy, this is iatrogenic injury. After excessive sweating and repeated purging, the person loses Blood. The illness initially presents with aversion to cold, followed by fever, which has no cessation. In summer heat, the patient desires thick clothing; in winter cold, the patient desires to be naked. Why? Yang deficiency causes aversion to cold; Yin weakness causes fever. The doctor's excessive sweating made Yang weak; excessive purging made Yin weak. In the fifth month, Yang is at the exterior, and the Stomach middle is cold-deficient. Because internal Yang is weak and cannot overcome cold, the patient desires thick clothing. In the eleventh month, Yang is inside, and the Stomach middle is vexed-heat. Because internal Yin is weak and cannot overcome heat, the patient desires to be naked. Furthermore, a slow and choppy Yin pulse indicates Blood loss.
[Commentary] The sentence "Furthermore, a slow and choppy Yin pulse indicates Blood loss" does not connect logically with the preceding text; it is either missing text or an interpolation.
[Note] A patient with thready and choppy pulses, upon inquiry, reveals that excessive sweating and repeated purging caused this condition. "Losing Blood" is a shorthand for losing Qi and Blood. Loss of Qi leads to weak Yang, causing aversion to cold; loss of Blood leads to weak Yin, causing fever. With weak Yang and Yin, the illness begins with aversion to cold followed by fever. Mild cases do not linger and resolve during their controlling time; severe cases have no cessation and worsen even during their controlling time. Despite summer heat, aversion to cold makes the patient desire thick clothing. Why? In the fifth month, Yang is at the exterior, Stomach middle is cold-deficient. Excessive sweating weakens Yang, making it unable to resist cold. Despite winter cold, fever makes the patient desire nudity. Why? In the eleventh month, Yang is inside, Stomach middle is vexed-heat. Repeated purging weakens Yin, making it unable to resist heat. This corresponds to the Treatise's description of "Heat in Marrow, Cold in Skin" or "Cold in Marrow, Heat in Skin," representing entrenched alternating cold and heat.
[Collected Notes] Wang Kentang stated: It is not necessarily that cold occurs only in summer and heat only in winter. This merely establishes the principle and explains the theory.
At the Cun Kou, if the pulse is thready and slow: thready indicates dispersed Wei Qi, dispersion leads to empty skin; slow indicates sufficient Stomach Qi, sufficiency leads to digestion of grains and transformation of water. Grains entering the Stomach allow the vessel pathways to flow; water entering the meridians allows Blood to form. When Ying is abundant, the skin becomes loose/dispersed. The San Jiao severs its meridians, named "Blood Collapse" (metrorrhagia/metrostaxis).
[Note] At the Cun Kou, thready and slow: thready indicates dispersed Wei Qi, meaning the exterior is empty; slow indicates sufficient Stomach Qi, meaning digestion of food and drink. Grains entering the Stomach allow Qi in the vessels to move; water entering the meridians allows Blood in the vessels to form. Now, as Ying becomes more abundant, Wei becomes more dispersed; as Blood increases, Qi decreases. Qi and Blood lose their normal regulation, hence "San Jiao severs its meridians." Qi cannot control Blood, and Blood cannot return to its vessels, causing Blood to move recklessly and collapse.
[Collected Notes] Cheng Wuji stated: Wei Qi warms the flesh and plumps the interstices. If Wei Qi is dispersed, the skin is not warmed or plumped, becoming empty. The Classics say: "Slow indicates surplus Stomach Qi." Surplus means excess. Hence, "Slow indicates sufficient Stomach Qi." *Nei Jing* says: "Food enters the Stomach, essence overflows into the vessels." This is why grains entering the Stomach allow vessel pathways to flow. *Zhen Jing* says: "Drinking fluids seep into the collaterals, harmonizing with Blood." This is why water entering the meridians allows Blood to form. "Jing" means constant/routine. San Jiao is the pathway of Qi. Dispersed Wei Qi means Qi does not follow routine, so San Jiao severs its routine.
Fang Youzhi stated: "Dispersed" means inability to secure and protect; "Sufficient" means strong. "Grains enter... Blood forms" continues from "grains digest and water transforms." Massive downward loss of Yin Blood is called "collapse," describing its unstoppable nature, like a mountain crumbling.
At the Cun Kou, if the pulse is thready and choppy: thready indicates Wei Qi does not flow; choppy indicates Ying Qi does not reach. Ying and Wei cannot follow each other, and San Jiao has nothing to rely upon. The body experiences Bi-numbness. Ying deficiency causes vexing pain and difficulty speaking; Wei deficiency causes aversion to cold and frequent yawning. If San Jiao does not return to its sector: Upper Jiao failure causes belching and acid regurgitation; Middle Jiao failure causes inability to digest food and ingest meals; Lower Jiao failure causes urinary incontinence.
[Note] Inside and outside the meridians are Ying and Wei; inside and outside the Zang-Fu are San Jiao. Thus, the Classics say: "Ying flows within vessels, Wei flows outside." Upper Jiao is governed by Heart and Lung; Middle Jiao by Spleen and Stomach; Lower Jiao by Liver and Kidney. Separately, they are Ying, Wei, and San Jiao; collectively, they originate from the circulation of one Qi, named according to their location. Thready and choppy pulses indicate Ying and Wei insufficiency. Insufficiency means Ying and Wei cannot follow each other, leaving San Jiao without reliance, causing generalized Bi-numbness. Ying deficiency causes vexing pain and speech difficulty; Wei deficiency causes aversion to cold and yawning. Upper Jiao governs descending (turbid from clear); Lower Jiao governs ascending (clear from turbid); Middle Jiao governs both ascending and descending. Now, Ying and Wei do not follow each other, and San Jiao lacks reliance, so they cannot return to their sectors and lose function. Upper Jiao failure means turbid Qi does not descend, causing belching and acid; Middle Jiao failure means ascending/descending conflict, causing inability to digest food; Lower Jiao failure means clear Qi does not ascend, causing inability to restrain and urinary incontinence.
At the Cun Kou, if the pulse is thready and choppy: thready indicates declining Wei Qi; choppy indicates insufficient Ying Qi. Declining Wei Qi manifests as a sallow complexion; insufficient Ying Qi manifests as a bluish complexion. Ying is the root, Wei is the leaf. If both Ying and Wei are thready, the root and leaf wither, leading to chills, cough, and counterflow Qi, spitting blood/fishy saliva, and spitting saliva/phlegm.
[Note] This elaborates on Upper Jiao syndromes of Ying and Wei. Sallow and blue complexions are colors of Ying/Wei insufficiency. Chills, shivering, cough, spitting fishy saliva, and phlegm are signs of Lung damage. Lung governs skin and hair, which are the dwelling places of Ying and Wei. Thus, Lung damage causes skin contraction and hair loss, and Ying/Wei withering.
[Collected Notes] Cheng Wuji stated: Ying flowing in vessels is the root; Wei flowing outside vessels is the leaf. If root and leaf are both thready, Yin and Yang Qi decline.
At the Cun Kou, if the pulse is weak and slow: weak indicates minimal Wei Qi; slow indicates Cold in Ying. Ying is Blood; Cold in Blood causes fever. Wei is Qi; minimal Qi causes hunger in the heart/chest, emptiness/fullness despite hunger, and inability to eat.
[Commentary] The ending phrase "hunger in chest, emptiness/fullness despite hunger, inability to eat" discusses Spleen/Stomach, unrelated to Ying/Wei. Therefore, "weak indicates minimal Wei Qi" should be "minimal Yang Qi"; "slow indicates Cold in Ying" should be "Cold in Spleen," for context to match. Can Cold in Blood cause fever? No. Minimal Wei Qi should be minimal Yang Qi. Regarding Spleen Cold causing chest hunger, see the next section on Stomach Qi surplus.
[Note] This elaborates on Middle Jiao syndromes of Ying and Wei. Slow diagnoses Stomach; slow diagnoses Spleen. Stomach receives grains; Spleen transforms grains. Eating ability belongs to Stomach; transforming ability belongs to Spleen. Now, with minimal Yang and Middle Cold, both Spleen and Stomach are diseased. Thus, although hungry, emptiness/fullness prevents eating.
[Collected Notes] Fang Youzhi stated: Hunger with emptiness/fullness: Yang transforms grains. If Wei-Yang declines and fails to transform grains, emptiness/fullness results, preventing eating.
At the Cun Kou, if the pulse is weak and slow: weak indicates insufficient Yang Qi; slow indicates surplus Stomach Qi. Belching and acid regurgitation occur; food suddenly stops coming down, Qi fills the upper Diaphragm.
[Note] This further elaborates on Middle Jiao syndromes. Weak indicates insufficient Yang Qi; slow indicates surplus Stomach Qi. Insufficiency means Spleen fails in transportation; surplus means Stomach is strong and capable of eating. This is Stomach-strength with Spleen-weakness. Thus, although able to eat, digestion fails, causing acid regurgitation and belching, sudden food stagnation, and Qi distension in the Diaphragm.
[Collected Notes] Fang Youzhi stated: Yang Qi refers to Yang Qi in the Stomach; insufficiency means inability to transform grains. Stomach Qi refers to grain Qi in the Stomach; surplus means retained food. Retained food stagnates and generates Heat, causing belching and acid regurgitation. This discusses internal injury from diet.
At the Fu Yang pulse, if slow and relaxed, the Stomach Qi is normal. At the Fu Yang pulse, if floating and rapid: floating injures the Stomach; rapid disturbs the Spleen. This is not the primary disease but caused by the physician's inappropriate purging. Ying and Wei sink inward. The rapid pulse first becomes thready; the pulse reverses to only floating. The person will have hard stool, belching, and relief. Why? Originally, the rapid pulse disturbed the Spleen; since the rapid pulse first became thready, we know Spleen Qi is disordered, causing hard stool and belching with relief. Now the pulse reverses to floating, and the rapid changes to thready. Pathogen remains alone. The mind feels hungry, but pathogenic Heat cannot digest grains. There is tidal fever and thirst. The rapid pulse should become slow and relaxed. If the pulse degrees before and after are correct, the patient will feel hungry [and recover]; if the rapid pulse persists irregularly, malignant sores will develop.
[Note] This distinguishes Fu Yang and Shao Yin pulses. Fu Yang, also called Chong Yang, is located 3 cun anterior to the ankle bone on the dorsum of the foot, where the Yangming Stomach meridian pulses. Shao Yin, also called Tai Xi, is located behind the medial malleolus on the heel, where the Foot-Shaoyin Kidney meridian pulses. Fu Yang and Shao Yin are ancient diagnostic methods. Yue Ren (Bian Que) believed that although all twelve meridians have pulses, taking only the Cun Kou determines life and death because Cun Kou is the great convergence of pulses. However, this method has long fallen out of use. In critical illnesses where Cun Kou pulse is undetectable, diagnosing here to determine prognosis is acceptable. In ordinary times, using Guan as Fu Yang and Chi as Shao Yin is superior. If Fu Yang Stomach pulse is slow and relaxed, Stomach Qi is healthy, like normal meridians. Now, Fu Yang is floating and rapid; pressing reveals forcelessness. Floating diagnoses Fu-organs; floating and forceless indicates Stomach injury. Deep diagnoses Zang-organs; rapid and forceless indicates Spleen injury. Inquiry reveals this was caused by physician purging, causing Ying/Wei to sink inward. The prior rapid changing to thready indicates Spleen weakness; the persistent/reversed floating indicates Stomach strength. Stomach strength allows pathogen to remain alone, causing hard stool, tidal fever, and thirst. Spleen weakness prevents Spleen transportation, so pathogenic Heat cannot digest grains; though hungry, the patient does not eat, feeling relieved after belching. If physicians treat correctly beforehand and afterwards, the floating/rapid pulse should naturally become slow/relaxed like normal, the patient will feel hungry/want to eat, and recover. If treatment is improper and the rapid pulse persists, malignant sores will develop.
[Collected Notes] Fang Youzhi stated: Malignant sores and pus in urine differ, but both involve Blood Heat.
Cheng Zhi stated: This discusses how Fu Yang slow/relaxed pulses change to floating/rapid after mistaken purging.
At the Fu Yang pulse, if floating and choppy, and the Shao Yin pulse is normal ("like the meridian"), the disease is in the Spleen. According to method, there should be diarrhea. How do we know? If the pulse were floating and large, it would be Qi-excess and Blood-deficiency. Now, Fu Yang is floating and choppy, so we know Spleen Qi is insufficient and Stomach Qi is deficient. Because Shao Yin shows only slight string-taut and floating, this is a harmonious pulse, hence called "normal." If it reverses to slippery and rapid, we know there will be pus in stool.
[Commentary] The sentences "If the pulse were floating and large, it would be Qi-excess and Blood-deficiency" do not connect with the context and are likely interpolations. Can string-taut and floating Shao Yin be called "normal"? It should be corrected to "deep and slippery."
[Note] Both Spleen and Kidney diseases can cause diarrhea. Now, Fu Yang Stomach pulse is floating/choppy, and Shao Yin Kidney pulse is normal. The disease is in Spleen, not Kidney. How do we know? Floating is Yang, diagnosing Stomach; choppy is Yin, diagnosing Spleen. Floating combined with choppy indicates Spleen insufficiency and Stomach deficiency. Because Shao Yin shows deep and slippery, it is called "normal." If deep, slippery, and rapid, it indicates Yang pathogen injuring Yin, so we know there will be pus and blood in stool.
[Collected Notes] Cheng Zhi stated: Diarrhea of food/water belongs to Spleen/Stomach; diarrhea of pus/blood belongs to Kidney. This can be distinguished by diagnosing Fu Yang and Tai Xi.
At the Fu Yang pulse, if hidden and choppy: hidden indicates vomiting and counterflow; food/water is not digested. Choppy indicates food cannot enter. This is named Guan Ge (Obstruction and Repletion).
[Commentary] The character "digest" (hua) in "food/water not digested" should be "enter" (ru). If it were "digest," it would mean able to eat, why call it Ge (Repletion)? "Food cannot enter" should be "urine cannot pass." If urine passes, the water pathway is open, why call it Guan (Obstruction)? This must be a transcription error.
[Note] Previous discussions used floating/deep and Cun/Chi to diagnose Guan Ge; this uses Fu Yang to diagnose Guan Ge. Fu Yang is the Stomach pulse. Hidden and choppy: hidden indicates stopping of ascending/descending of Yin/Yang at Cun/Chi; choppy indicates non-circulation of Yuan Qi in San Jiao. Lack of ascending/descending/circulation causes upper vomiting and lower inability to urinate. The disease is named Guan Ge.
At the Fu Yang pulse, if slippery and tight: slippery indicates Stomach Qi excess; tight indicates Spleen Qi strength. Holding excess to strike strength, pain harms oneself. Like holding a blade with hands, sitting and creating sores.