为热气有余，必发痈脓也。
【按】
不发热者之「不」字，当是「若」字，若是「不」字，即是除中，何以下接恐暴热来
出而复去之文也？
【注】
热而不厥为阳，厥而不热为阴。伤寒始发热六日，厥亦六日，至七日仍发热而不厥者
，是阳来复，当自愈也，今厥九日，较热多三日，是阴胜阳，故下利也。凡厥利者，
中必寒，当不能食，今反能食，恐是阴邪除去胃中阳气，而为除中之病也。恐者，疑
而未定之辞也。故以索饼试之，食后不发热，则为除中，若发热，知胃气尚在，则非
除中，可必愈也。若食后虽暴发热，恐热暂出而复去，仍是除中，故必俟之三日，其
热续在不去，与厥相应，始可期之旦日夜半愈也。若俟之三日后，虽热不罢而亦不愈
，且脉犹数者，此为热气有余，留连荣卫，必发痈脓也。
【集注】
方有执曰：食，饲也。索，常也。谓以素常所食之饼饲之也。一说无肉曰索，谓不令
犯食禁也。旦日、明日平旦，朝而阳长之时也；夜半，阴尽阳生之时也，数以候热。
痈脓者，厥阴主血，血热持久则壅瘀，壅瘀则腐化，故可必也。
吴人驹曰：除者，去也；中者，中气也，乃中气除去，欲引外食以自救也。
@@@
伤寒脉迟六、七日，而反与黄芩汤彻其热，脉迟为寒，今与黄芩汤复除其热，腹中应
冷，当不能食，今反能食，此名除中，必死。
【按】
「伤寒脉迟六、七日」之下，当有「厥而下利」四字，若无此四字，则非除中证矣。
有此四字，始与下文反与黄芩汤之义相属。
【注】
伤寒脉数，六、七日，厥而下利，热厥下利也，当与黄芩汤彻其热。今伤寒脉迟六、
七日，厥而下利，寒厥下利也，当与理中汤温其寒。而反与黄芩汤复除其热，腹中应
冷，当不能食，今反能食，此名除中，乃胃气将绝，求食以救，终无补于胃也，故曰
必死。
【集注】
方有执曰：反者，言不顺于道也。黄芩汤，寒药也。彻，亦除也。应，亦当也。反能
食者，胃欲绝引食以自救也。中，以胃言。死，谓万物无土不生也。
程知曰：言脉迟为寒，不宜更用寒药，以致有除中之变也。中气为阴寒革除，则胃中
无根之阳气将欲尽除，而求救于食，故为死证。
@@@
伤寒，先厥后发热而利者，必自止，见厥复利。
【注】
厥逆，阴也。发热，阳也。先厥后发热，而利必自止者，是阴退而阳进也。见厥复利
者，是阳退而阴进也。热多厥少，病虽甚者亦可愈；厥多热少，病虽微者亦转甚。可
知厥热，乃阴阳进退生死之机也。
【集注】
汪琥曰：厥阴者，阴之尽，厥阴之经，阳气甚微，故不论阴阳二证，寒热之邪，但至
其经，无有不发厥者，盖厥即为逆，起于手足，今曰先厥者，此初起便厥，厥即下利
发热者，则阳气复而利必自止也。
@@@
伤寒先厥后发热，下利必自止，而反汗出，咽中痛者，其喉为痹，发热无汗，而利必
自止，若不止，必便脓血，便脓血者，其喉不痹。
【注】
此承上条而详辨之，以出其证也。先厥后发热，下利必自止，厥回利止，其热若退，
为欲愈也。若厥回利止，其热不退，而反汗出者，是厥阴病。从阳化热，其邪上循本
经之脉，故咽喉痛痹也。若厥回发热，无汗利不止者，是厥阴邪热。因利下迫，伤及
脉中之血，故必便脓血也。便脓血者，其喉不痹，谓热邪下利，而不复上病咽痛也。
可知下利止，其喉为痹者，谓热邪已上，病咽痛，即不复病下利也。
【集注】
喻昌曰：先厥后热下利止，其病为欲愈矣。乃反汗出咽中痛，是热邪有余，上攻咽喉
而为痹也。既发热虽无汗，为其阳已回，所以利亦必自止，若不止，则无汗明系邪不
外出，热郁在里，必主便脓血也。便脓血者，其喉不痹，见热邪在里，即不复在表，
在下，即不复在上也。
汪琥曰：咽中痛者，此热伤上焦气分也。痹者，闭也。咽中痛甚，其喉必闭而不通，
以厥阴经循喉咙之后，上入颃颡故也。无汗利不止，便脓血者，此热伤下焦血分也，
热邪注下，则不干上，故曰：其喉不痹。
@@@
下利脉数，有微热，汗出，令自愈，设复紧，为未解。
【注】
厥阴下利脉数，热利也。若热微汗出，知邪微欲解，下利必自止，故令自愈也。设脉
复紧，为表邪犹盛，未能解也。
【集注】
成无己曰：下利，阴病也。脉数，阳脉也。阴病见阳脉者生，微热汗出，阳气得通也
，利必自愈。诸紧为寒，设复脉紧，寒邪犹盛，故云：未解。
沈明宗曰：数条乃指厥而下利便脓血者。或见实大、浮数、微弱、沉涩、弦紧、洪长
诸脉，当分虚、实、寒、热，即知欲愈未愈，真为察病之微旨也。
@@@
下利有微热而渴，脉弱者，令自愈。
【注】
厥阴下利，有大热而渴，脉强者，乃邪热俱盛也。今下利有微热而渴，脉弱者，是邪
热衰也，邪热既衰，故可令自愈也。
【集注】
方有执曰：微热，阳渐回也。渴，内燥未复也。脉弱，邪退也。令自愈，言不须治也
。
程知曰：下利以阳复邪微为愈，微热而渴，证已转阳，脉弱则邪气已退，故不治自愈
。若下利大热脉盛，又是逆候矣。
@@@
下利脉数而渴者，令自愈，设不差，必圊脓血，以有热故也。
【注】
此承上条互言，以详其变也。下利脉数而渴者，是内有热也，若身无热，其邪已衰，
亦可令自愈也。设下利脉数而渴，日久不差，虽无身热，必圊脓血，以内热伤阴故也
。
【集注】
方有执曰：脉数，与上文微热，互相发明。
程应旄曰：脉数而渴，阳胜阴矣，故亦令自愈。若不差，则阴虚热入，经所云脉数不
解，而下利不止，必协热而便脓血是也。
@@@
下利，寸脉反浮数，尺中自涩者，必圊脓血。
【注】
厥阴热利，寸脉当沉数，今寸脉反浮数，是热在外而不在内也。尺中自涩者，是在外
之热不解，乘下利入里，伤及其阴，热与血瘀，必圊脓血也。
【集注】
喻昌曰：脉见浮数，若是邪还于表，则尺脉自知，今尺中自涩，乃热邪抟结于阴分，
虽寸口得阳脉，究竟阴邪必走下窍，而便脓血也。
汪琥曰：此条乃下利变脓血之候也。热利而得数脉非反也，得浮脉则为反矣。此条论
无治法，宜以仲景黄芩汤代之。
@@@
下利脉沉弦者，下重也。脉大者，为未止，脉微弱数者，为欲自止，虽发热，不死。
【注】
此详申上条，下利圊脓血之证脉也。脉沉，主里，脉弦，主急。下重，后重也。下利
、脉沉弦，故里急后重也。凡下利之证，发热脉大者，是邪盛，为未止也。脉微弱数
者，是邪衰，为欲自止，虽发热不死也。由此可知滞下脉大身热者，必死也。
【集注】
喻昌曰：下利而脉沉弦，主里急后重，成滞下之证，即今所称痢证也。脉大者，即沉
弦中之大，脉微弱数者，即沉弦中之微弱数也。
@@@
下利欲饮水者，以有热故也，白头翁汤主之。热利下重者，白头翁汤主之。
【注】
此承上条以出其治也。下利欲饮水者，热利下夺津液，求水以济干也。热利下重者，
热伤气滞，里急后重，便脓血也。二者皆以白头翁汤主之者，以其大苦大寒，寒能胜
热，苦能燥湿也。
【集注】
程知曰：按少阴自利而渴，亦有虚而引水自救者，犹当以小便之赤白，脉之迟数辨之
。此言热邪内结者也，热邪内结而致下重，故纯用苦寒以胜热而厚肠也。
因为热气有余，必然发生痈肿化脓。
【按语】
原文中“不发热”的“不”字，应当是“若”字。如果是“不”字，那就是“除中”证，怎么会接着下文说“恐怕突然发热出现然后又消失”的文字呢？
【注解】
发热而不四肢厥冷属于阳证，四肢厥冷而不发热属于阴证。伤寒病开始发热六天，四肢厥冷也是六天，到了第七天仍然发热而没有四肢厥冷的情况，这是阳气来复，应当自愈。现在四肢厥冷九天，比发热多三天，这是阴气胜而阳气衰，所以下利。凡是四肢厥冷兼下利的患者，中焦必定寒，应当不能进食，现在反而能进食，恐怕是阴邪去除了胃中的阳气，从而形成“除中”的病证。“恐”字，表示怀疑而未确定的语气。所以用索饼（面条）来试探，如果吃完后不发热，就是“除中”；如果发热，说明胃气还在，就不是“除中”，可以断定会痊愈。如果吃完后虽然突然发热，但恐怕热势暂时出现后又消失，仍然是“除中”，所以必须等待三天，如果热势持续存在不消失，且与四肢厥冷的时间相应，才可以期待在第二天半夜痊愈。如果等待三天后，虽然热势不退但也未痊愈，且脉象仍然数疾，这是因为热气有余，留连于营卫之间，必然发生痈肿化脓。
【集注】
方有执说：食，是喂养的意思。索，是平常、素常的意思。意思是喂以平时所吃的饼。另一种说法认为无肉的饼叫索，意思是不要让病人违反饮食禁忌。旦日，即明天清晨，是阳气增长的时候；夜半，是阴气尽而阳气生的时候，通过计算时间以观察热势。痈脓，是因为厥阴主血，血热持久则壅滞瘀结，壅滞瘀结则腐败化脓，所以可以断定会发生。
吴人驹说：除，是去除的意思；中，是中气，即中气被去除，想要借助外来的食物来自救。
@@@
伤寒脉迟六七天，反而给予黄芩汤清除其热，脉迟主寒，现在给予黄芩汤又清除其热，腹中应当寒冷，应当不能进食，现在反而能进食，这叫做“除中”，必然死亡。
【按语】
在“伤寒脉迟六七天”之下，应当有“厥而下利”四个字，如果没有这四个字，那就不是“除中”证了。有了这四个字，才与下文“反而给予黄芩汤”的意义相衔接。
【注解】
伤寒脉数，六七天，四肢厥冷并下利，这是热厥下利，应当给予黄芩汤清除其热。现在伤寒脉迟六七天，四肢厥冷并下利，这是寒厥下利，应当给予理中汤温散其寒。却反而给予黄芩汤再次清除其热，腹中应当寒冷，应当不能进食，现在反而能进食，这叫做“除中”，这是胃气将绝，寻求食物以自救，终究对胃没有补益作用，所以说必然死亡。
【集注】
方有执说：反，是说违背道理。黄芩汤，是寒性药物。彻，也是清除的意思。应，也是应当的意思。反而能进食，是胃气欲绝，引食物来自救。中，指胃。死，是说万物没有土就不能生长（比喻胃气绝则生命终结）。
程知说：这里说脉迟主寒，不应当再用寒药，以致产生“除中”的变证。中气被阴寒革除，那么胃中无根的阳气将要被完全清除，而向食物求救，所以是死证。
@@@
伤寒，先出现四肢厥冷，后来发热并且下利的，下利必然自行停止；见到四肢厥冷再次出现，下利也会再次发作。
【注解】
四肢厥逆，属阴。发热，属阳。先四肢厥冷后来发热，并且下利必然自行停止的，这是阴气退去而阳气进逼。见到四肢厥冷再次出现，下利也再次发作的，这是阳气退去而阴气进逼。热多厥少，病情即使严重也可以痊愈；厥多热少，病情即使轻微也会加重。可知厥冷与发热的交替，是阴阳进退、决定生死的关键。
【集注】
汪琥说：厥阴，是阴气的尽头，厥阴经的阳气非常微弱，所以不论阴阳二证，寒热之邪，只要到达厥阴经，没有不发生厥冷的，大概厥就是逆，起于手足。现在说“先厥”，是指初起就厥冷。如果厥冷伴随下利，后来发热，则是阳气恢复，下利必然自行停止。
@@@
伤寒先四肢厥冷后来发热，下利必然自行停止，却反而出汗，咽喉疼痛的，喉部会痹阻不通；发热无汗，而下利如果不止，必然大便带脓血，大便带脓血的，喉部不会痹阻不通。
【注解】
这是承接上一条详细辨析，以揭示其证候。先四肢厥冷后来发热，下利必然自行停止，厥冷回退、下利停止，如果热势消退，是想要痊愈。如果厥冷回退、下利停止，但热势不退，却反而出汗的，这是厥阴病从阳化热，邪气沿本经脉上循，所以咽喉疼痛痹阻。如果厥冷回退、发热，无汗且下利不止的，这是厥阴邪热因下利下迫，伤及脉中之血，所以必然大便带脓血。大便带脓血的，喉部不会痹阻不通，是说热邪下利，不再向上侵犯咽喉疼痛。可知下利停止，喉部痹阻的，是说热邪已经上行，病在咽喉疼痛，就不再病在下利。
【集注】
喻昌说：先厥冷后来发热，下利停止，病情是想要痊愈了。却反而出汗、咽喉疼痛，是热邪有余，向上攻冲咽喉导致痹阻。既然发热虽然无汗，但因为阳气已回，所以下利也必然自行停止，如果不停止，则无汗明确显示邪气不能外出，热郁在体内，必然导致大便带脓血。大便带脓血的，喉部不会痹阻不通，见热邪在体内，就不在体表，在下部，就不在上部。
汪琥说：咽喉疼痛，是热邪损伤上焦气分。痹，是闭塞的意思。咽喉疼痛严重，喉部必然闭塞不通，因为厥阴经循行喉咙之后，向上进入颃颡（鼻咽部）。无汗且下利不止，大便带脓血的，是热邪损伤下焦血分，热邪注于下部，就不干扰上部，所以说：喉部不会痹阻。
@@@
下利脉数，伴有微热、出汗的，令其自愈；如果脉象重新变得紧，为病未解。
【注解】
厥阴下利脉数，是热利。如果热微且出汗，知道邪气微弱想要解除，下利必然自行停止，所以令其自愈。如果脉象重新变紧，为表邪仍然强盛，未能解除。
【集注】
成无己说：下利，是阴病。脉数，是阳脉。阴病见到阳脉者生，微热出汗，阳气得以通达，下利必然自愈。各种紧脉主寒，如果脉象重新变紧，寒邪仍然强盛，所以说：未解。
沈明宗说：这几条是指四肢厥冷、下利、大便带脓血的情况。或者见到实大、浮数、微弱、沉涩、弦紧、洪长等各种脉象，应当分辨虚、实、寒、热，即可知道是否欲愈，真是洞察病情的精微旨意。
@@@
【注解】
厥阴下利，有大热且口渴，脉强的，是邪热俱盛。现在下利伴有微热且口渴，脉弱的，是邪热衰退，邪热既然衰退，所以可令其自愈。
【集注】
方有执说：微热，是阳气逐渐恢复。渴，是内部燥热尚未恢复。脉弱，是邪气退去。令其自愈，说不需要治疗。
程知说：下利以阳气恢复、邪气微弱为痊愈，微热而口渴，证候已转阳，脉弱则邪气已退，所以不治自愈。如果下利大热脉盛，又是逆证了。
@@@
下利脉数且口渴的，令其自愈；如果不好转，必然大便带脓血，因为有热的原因。
【注解】
这是承接上一条互文见义，以详细说明其变化。下利脉数且口渴的，是内有热，如果身体无热，邪气已衰，也可令其自愈。假设下利脉数且口渴，日久不好转，虽然身体无热，必然大便带脓血，因为内热损伤阴液的原因。
程应旄说：脉数且口渴，是阳胜阴，所以也令其自愈。如果不好转，则阴虚热入，经文中所说脉数不解，而下利不止，必然协热而大便带脓血。
@@@
下利，寸脉反而浮数，尺脉自涩的，必然大便带脓血。
【注解】
厥阴热利，寸脉应当沉数，现在寸脉反而浮数，是热在外而不在内。尺脉自涩的，是在外的热邪不解，乘下利入里，伤及其阴，热与血瘀结，必然大便带脓血。
【集注】
喻昌说：脉见浮数，如果是邪气还于体表，则尺脉自然正常，现在尺脉自涩，是热邪搏结于阴分，虽然寸口得阳脉，终究阴邪必走下窍，而大便带脓血。
汪琥说：这一条是下利变为脓血的征候。热利得到数脉并不反常，得到浮脉才是反常。这一条论述没有治疗方法，宜用仲景的黄芩汤代替。
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下利脉沉弦的，有里急后重感。脉大的，为病未止；脉微弱数的，为病欲自止，虽然发热，也不死。
【注解】
这是详细申述上一条，下利大便带脓血的证候和脉象。脉沉，主里；脉弦，主急。下重，即后重感。下利、脉沉弦，所以是里急后重。凡下利的证候，发热脉大的，是邪气盛，为病未止。脉微弱数的，是邪气衰，为病欲自止，虽然发热，也不死。由此可知，痢疾脉大身热的，必然死亡。
【集注】
喻昌说：下利而脉沉弦，主里急后重，形成滞下的证候，即现在所称的痢疾证。脉大，即沉弦中的大脉；脉微弱数，即沉弦中的微弱数脉。
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下利想喝水的，因为有热的原因，白头翁汤主治。热利伴有里急后重的，白头翁汤主治。
【注解】
这是承接上一条以揭示其治法。下利想喝水的，是热利下夺津液，求水以济干燥。热利伴有里急后重的，是热伤气滞，里急后重，大便带脓血。这两种情况都以白头翁汤主治，因为它大苦大寒，寒能胜热，苦能燥湿。
【集注】
程知说：按少阴自利而口渴，也有虚而引水自救的，还应当以小便的赤白、脉的迟数来辨别。这里说的是热邪内结的情况，热邪内结而导致下重，所以纯用苦寒药物以胜热而厚肠。
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.
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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.