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。阳微不可下。下之则心下痞硬。
阳微下之。阳气已虚阴气内甚。故心下痞硬。
动气在右。不可下。下之则津液内竭。咽燥鼻干。头眩心悸也。
动气在右。肺之动也。下之伤胃动肺津液内竭。咽燥鼻干者。肺属金。主燥也。头
眩心悸者。肺主气而虚也。
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。
动气在左。肝之动也。下之损脾。而肝气益胜。复行于脾。故腹内拘急。食不下。动
气更剧也。虽有身热。以里气不足。故卧则欲蜷。
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。
动气在上。心之动也。下之则伤胃。内动心气。心为火。主热。针经曰。心所生病
者。掌中热。肝为脏中之阴。病则虽有身热。卧则欲蜷。作表热里寒也。心为脏中之阳。病
则身上浮冷。热汗自泄。欲得水自灌。作表寒里热也。二脏阴阳寒热。明可见焉。
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。
动气在下。肾之动也。下之则伤脾。肾气则动。肾寒乘脾。故有腹满头眩下清谷。心下
痞之证也。
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。
咽中闭塞。胃已不利也。下之则闭塞之邪。为上轻。复伤胃气为下重。至水浆不下。
卧则欲蜷。身急痛。下利日数十行。知虚寒也。
诸外实者。不可下。下之则发微热。若亡脉。厥者。当脐握热。
外实者。表热也。汗之则愈。下之为逆。下后里虚。表热内陷。故发微热。厥深者。热
亦深。亡脉厥者。则阳气深陷。客于下焦。故当脐握热。
诸虚者不可下。下之则大渴。求水者欲愈。恶水者剧。
金匮玉函曰。虚者十补。勿一泻之。虚家下之为重虚。内竭津液。故令大渴。求水
者。阳气未竭。而犹可愈。恶水者。阳气已竭。则难可制。
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。
虚家下之。是为重虚。难经曰。实实虚虚。损不足。益有余。此者。是中工所害也。
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。
内经曰。感于寒。则受病。微则为咳。甚则为泄。为痛。肺感微寒为咳。则脉亦微
也。下之气下。咳虽止。而利因不休。利不休。则夺正气而成危恶。胸中如虫啮。粥入
则出。小便不利。两胁拘急。喘息为难者。里气损也。颈背相引。臂为不仁。极寒反汗
出。身冷如冰者。表气损也。表里损极。至阴阳俱脱。眼睛不慧语言不休。难经曰。脱
阳者见鬼。脱阴者目盲。阴阳脱者。应不能食。而谷多入者。此为除中。是胃气除去也。
口虽欲言。舌不得前。气已衰脱。不能运也。
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。数为热。浮为虚。自汗出而恶寒。数为痛。振寒而栗。微弱在关。胸下为急。喘汗而
不得呼吸。呼吸之中。痛在胸胁。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。小便淋沥。小腹甚硬。小便则尿血也。
弱在关。则阴气内弱。濡在巅。则阳气外弱。浮为虚。浮在上。则卫不足也。故云
阳虚。阳虚不固。故腠理汗出。恶寒。数亦为虚。数在下。则荣不及。故云亡血。亡血
则不能温润腑脏。脉数而痛。振而寒栗。微弱在关。邪气传里也。里虚遇邪。胸下为急。
喘而汗出。胁下引痛。振寒如疟。此里邪未实。表邪未解。医反下之。里气益虚。邪热
内陷。故脉数发热。狂走见鬼。心下为痞。此热陷于中焦者也。若热气深陷。则客于下
焦。使小便淋沥。小腹甚硬。小便尿血也。
脉濡而紧。濡则胃气微。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
热应时罢。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。
胃冷荣寒。阳微中风。发热恶寒。微呕心烦。医不温胃。反为有热。解饥发汗。则表
虚亡阳烦躁。心下痞坚。先里不足。发汗又虚其表。表里俱虚竭。卒起头眩。客热
在表。怅怏不得眠。医不救里。但责表热。汲水灌洗以却热。客热易罢。里寒益增。栗
而振寒。复以重被覆之。表虚遂汗出。愈使阳气虚也。巅、顶也。巅冒而体振寒。小便
难者。亡阳也。寒因水发。下为清谷。上为呕吐。外有厥逆。内为躁烦。颠倒不安。虽
欲拯救。不可得也。本草曰。病势已过。命将难全。
张卿子云。除脉濡而紧四字为题。自是一首汉人古诗。为清凉解利之戒。孙思邈所
谓伤寒于大毒诸寒药者。比比也。
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。
卫为阳。荣为阴。卫气强实。阴血虚弱。阳乘阴虚。下至阴部。阴部。下焦也。阳
为热。则消津液。当小便赤而难。今反小便利而大汗出者。阴气内弱也。经曰。阴弱者
汗自出。是以卫家不微。而反更实。荣竭血尽。干烦而不眠。血薄则肉消而成暴液者。
津液四射也。医反下之。又虚其里。是为重虚。孤阳因下而又脱去。气血皆
竭。胃气内尽。必下如污泥而死也。
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。下之则必烦。利不止。
数为热。止则邪气结于经络之间。正气不能复行于表。则邪结于脏。邪气独浮于皮
毛。下之虚其里。邪热乘虚而入。里虚叶热。必烦。利不止。
脉浮大。应发汗。医反下之。此为大逆。
浮大属表。故不可下。
病欲吐者不可下。呕多虽有阳明证。不可攻之。
为邪犹在胸中也。
大阳病。外证未解。不可下。下之为逆。
表未解者。虽有里证。亦不可下。当先解外为顺。若反下之。则为逆也。经曰。本发
汗而反下之。此为逆也。若先发汗。治不为逆。
夫病阳多者热。下之则硬。
阳热证多。则津液少。下之。虽除热。复损津液。必便难也。或谓阳多者表热也。下
之则心下硬。
戴元礼云。阳明下证已具。其人喘嗽。或微恶寒。为太阳阳明。或往来寒热。为少
阳阳明。于阳明证中而有太阳少阳证未罢。此非正阳明也。慎未可遽下。所以古注阳明
有三。常须识此。
无阳阴强。大便硬者。下之。则必清谷腹满。
无阳者。亡津液也。阴强者。寒多也。大便硬。则为阴结。下之虚胃。阴寒内甚。
必清谷腹满。
伤寒发热。头痛。微汗出。发汗则不识人。熏之则喘。不得小便。心腹满。下之则
短气。小便难。头痛背强。加温针则衄。
伤寒则无汗。发热头痛。微汗出者。寒邪变热。欲传于里也。发汗则亡阳增热。故
不识人。若以火熏之。则火热伤气。内消津液。结为里实。故喘。不得小便。心腹满。
若反下之。则内虚津液。邪欲入里。外动经络。故短气。小便难。头痛背强。若加温针。
益阳增热。必动其血。而为衄也。
伤寒脉阴阳俱紧。恶寒发热则脉欲厥。厥者脉初来大。渐渐小。更来渐渐大。是其
候也。如此者恶寒。甚者翕翕汗出。喉中痛。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。寒多者便清谷。热多者便脓血。若熏之。则身发黄。若
熨之。则咽燥。若小便利者。可救之。小便难者。为危殆。
脉阴阳俱紧。则清邪中上。浊邪中下。太阳少阴俱感邪也。恶寒者少阴。发热者太
阳脉欲厥者。表邪欲传里也。恶寒甚者。则变热。翕翕汗出。喉中痛。以少阴之脉。循喉
咙故也。热多者。太阳多也。目赤脉多者。睛不慧。以太阳之脉。起于目故也。发汗攻
阳。则少阴之热因发而上行。故咽中伤。若复下之。则太阳之邪。因虚而内陷。故两目
闭。阴邪下行。为寒多。必便清谷。阳邪下行。为热多。必便脓血。熏之。则火热甚。
身必发黄。熨之。则火热轻。必为咽燥。小便利者。为津液未竭。犹可救之。小便难者。
津液已绝。则难可制而危殆矣。
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。则两目闭。贪水者。
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。
伤寒发热。寒变热也。口中勃勃气出。热客上膈也。头痛目黄。血不可制者。热蒸
于上也。千金曰。无阳即厥。无阴即呕。贪水者必呕。则阴虚也。恶水者厥。则阳虚也。发
热口中勃勃气出者。咽中已热也。若下之。亡津液。则咽中生疮。热因里虚而下。若热
气内结。则手足必厥。设手足温者。热气不结而下行。作叶热利。下重。便脓血也。头
痛目黄者。下之。热气内伏。则目闭也。贪水为阴虚。下之又虚其里。阳气内陷。故脉
厥。声嘤。咽喉闭塞。阴虚发汗。又虚其阳。使阴阳俱虚而战栗也。恶水为阳虚。下之
又虚胃气。虚寒内甚。故里冷不嗜食。阳虚发汗。则上焦虚燥。故口中伤烂。舌上白苔
而烦躁也。经曰。脉数不解。合热则消谷喜饥。至六七日不大便者。此有瘀血。此脉数
实。不大便六七日。热蓄血于内也。七日之后。邪热渐解。迫血下行。必便血也。便血发汗。
阴阳俱虚。故小便利。
下利脉大者。虚也。以其强下之故也。设脉浮革。因尔肠鸣者。属当归四逆汤主之。
脉大为虚。以未应下而下之。利因不休也。浮者。按之不足也。革者。实大而长微
弦也。浮为虚革为寒。寒虚相搏。则肠鸣。与当归四逆汤。补虚散寒。
活人云。虚者。十补勿一泻。强实者泻之。虚实等者。虽泻勿大泄之。此金匮语也。
吴氏云。凡有恶风恶寒者。凡腹满时减时满者。凡腹胀满。可揉可按虚软者。凡阴虚劳
倦。凡手足逆冷尺脉弱者。凡脉在表俱不可下。凡脉沉不实不疾。按之无力者。凡亡血
家。及妇人经水适来适断。或热入血室。与夫胎前产后崩漏等证。及小便频数。小便清而
大便秘者。俱不可下。
脉象濡软而微弱。弱脉反而出现在关部，濡脉反而出现在寸部（巅指寸部）。微脉反而出现在上部，涩脉反而出现在下部。脉微说明阳气不足，脉涩说明阴血亏虚。阳气反而微弱，患中风病时出汗却反而出现躁动烦乱；脉涩说明无血，导致四肢厥冷且发寒。阳气微弱不可使用下法，若误用下法，会导致心下痞塞坚硬。
阳气微弱而误用下法，会使阳气更加虚弱，阴气在体内盛极，所以出现心下痞塞坚硬的症状。
脐右跳动不安，不可使用下法。若误用下法，会耗竭体内津液，导致咽喉干燥、鼻腔干涩、头晕目眩和心悸。
脐右跳动不安，是肺脏之气异常搏动所致。误用下法会损伤胃气并扰动肺津，导致津液内竭。咽喉干燥、鼻腔干涩，是因为肺属金，主燥。头晕目眩、心悸，是因为肺主气而肺气虚弱。
脐左跳动不安，不可使用下法。若误用下法，会导致腹部内部拘急挛缩，饮食难进，跳动不安的症状加剧。即使身体发热，患者也倾向于蜷卧。
脐左跳动不安，是肝脏之气异常搏动所致。误用下法会损伤脾脏，使得肝气更加亢盛，进而乘犯脾土，所以出现腹部拘急、饮食不下、跳动不安加剧的症状。即使身体发热，因为里气不足，所以患者喜欢蜷卧。
脐上跳动不安，不可使用下法。若误用下法，会导致手掌心发热烦扰，身上感觉浮肿般的寒冷，热汗自出，想要用水浇淋自己。
脐上跳动不安，是心脏之气异常搏动所致。误用下法会损伤胃气，内动心气。心属火，主热。《针经》说：心所生的疾病，表现为掌心发热。肝为脏中之阴，患病时即使身体发热，也喜欢蜷卧，这是表热里寒的表现。心为脏中之阳，患病时身上感觉浮肿般的寒冷，热汗自出，想要用水浇淋，这是表寒里热的表现。这两脏的阴阳寒热属性，可以清楚地看到。
脐下跳动不安，不可使用下法。若误用下法，会导致腹部胀满，突然起身时头晕目眩，进食后随即排出未消化的食物（完谷不化），心下痞塞。
脐下跳动不安，是肾脏之气异常搏动所致。误用下法会损伤脾脏，肾气因而妄动。肾寒乘袭脾土，所以出现腹部胀满、头晕目眩、完谷不化、心下痞塞的症状。
咽喉中有闭塞感，不可使用下法。若误用下法，会导致上部轻浮下部沉重，水浆无法咽下，喜欢蜷卧，身体拘急疼痛，腹泻每天达数十次。
咽喉闭塞，说明胃气已经不利。误用下法，使闭塞之邪转为上部轻浮，又损伤胃气导致下部沉重，直到水浆不下，喜欢蜷卧，身体拘急疼痛，腹泻日行数十次，可知这是虚寒证。
凡是外表实热的病症，不可使用下法。若误用下法，会引发轻微发热，或者脉象消失，四肢厥冷，此时肚脐周围会有握持感的温热。
外实是指表热。应当用发汗法治疗才能痊愈，误用下法是逆治。下法之后里气虚弱，表热内陷，所以引发轻微发热。厥逆越深重，内热也越深重。脉象消失且四肢厥冷的，是阳气深陷，客居于下焦，所以肚脐周围感到温热。
凡是虚证，不可使用下法。若误用下法，会导致极度口渴。想喝水的病情较轻，容易治愈；厌恶喝水的病情严重，难以治愈。
《金匮玉函经》说：虚证应当十次补益，不要一次泻下。虚人误用下法，会造成双重虚损，内竭津液，所以导致极度口渴。想喝水的，说明阳气尚未枯竭，还可以治愈；厌恶喝水的，说明阳气已经枯竭，则难以控制。
脉象濡软而微弱。弱脉反而出现在关部，濡脉反而出现在寸部。弦脉反而出现在上部，微脉反而出现在下部。弦脉代表阳气运行（或阳动），微脉代表阴寒。上部实而下部虚，意念中希望得到温养。微弦脉属于虚证，虚证不可使用下法。
虚人误用下法，称为双重虚损。《难经》说：实证用泻法使其更实，虚证用补法使其更虚，损害不足的，增加有余的，这是中等水平的医生造成的危害。
脉微则会咳嗽，咳嗽则吐出涎沫。若误用下法，咳嗽虽然停止，但腹泻不会停止。腹泻不停止，会导致胸中感觉像有虫子咬噬一样，喝粥则吐出来，小便不利，两胁拘急，呼吸喘息困难，颈背相互牵引，手臂麻木不仁，极度寒冷反而出汗，身体冷得像冰一样，眼睛视物不清，语言不休，但食物摄入很多，这叫做“除中”（胃气将绝的假象）。口虽想说话，但舌头不能前伸。
《内经》说：感受寒气，就会生病，轻微的就咳嗽，严重的就腹泻、疼痛。肺感受轻微寒气而咳嗽，脉象也会微。下法使气下行，咳嗽虽止，但腹泻不停。腹泻不停，就会剥夺正气而形成危重恶候。胸中如虫咬，喝粥即吐，小便不利，两胁拘急，呼吸喘息困难，是里气受损。颈背相引，手臂麻木，极度寒冷反而出汗，身体冷如冰，是表气受损。表里之气受损至极，导致阴阳俱脱。《难经》说：脱阳者见鬼，脱阴者目盲。阴阳俱脱的人，应该不能进食，但食物摄入很多，这叫“除中”，意味着胃气已去。口虽想说话，舌头不能前伸，是因为气已衰脱，无法运化。
脉象濡软而微弱。弱脉反而出现在关部，濡脉反而出现在寸部。浮脉反而出现在上部，数脉反而出现在下部。浮脉代表阳虚，数脉代表无血。浮脉为虚，数脉为热。浮脉为虚，自汗出且恶寒；数脉为痛，振栗发寒。微弱脉在关部，胸下拘急，喘息出汗且呼吸困难，呼吸时胸胁疼痛，振栗与寒邪相搏，症状像疟疾一样。医生反而误用下法，所以导致脉数、发热、狂跑、看见鬼怪，心下痞塞，小便淋漓不尽，小腹非常坚硬，小便尿血。
弱脉在关部，说明阴气内部虚弱；濡脉在寸部，说明阳气外部虚弱。浮脉为虚，浮在上部，说明卫气不足，所以说阳虚。阳虚不固，所以腠理开泄出汗，恶寒。数脉也为虚，数在下部，说明营血不及，所以说亡血。亡血就不能温润脏腑，脉数且痛，振栗发寒。微弱脉在关部，说明邪气传入里部。里虚遇邪，胸下拘急，喘息出汗，胁下牵引疼痛，振栗如疟，这是里邪未实，表邪未解。医生反而误用下法，里气更加虚弱，邪热内陷，所以脉数发热，狂走见鬼，心下痞塞，这是热邪陷入中焦。如果热气深陷，客居于下焦，导致小便淋漓，小腹坚硬，小便尿血。
脉象濡软而紧。濡软说明胃气微弱，紧说明营分有寒。阳气微弱，卫分中风，发热且恶寒；营分紧，卫气冷，轻微呕吐，心中烦闷。医生认为是大热证，用解肌发汗法，导致亡阳、虚性烦躁，心下苦于痞塞坚硬，表里俱虚竭，突然起身头晕目眩，客热在皮肤，惆怅郁闷不得睡眠。不知道胃气寒冷，紧寒在关元穴部位，医术高超者也无处施展。汲冷水灌洗其身，客热暂时消退，但战栗发寒加重。盖上厚被覆盖，出汗且头昏目眩，身体颤抖，小便微难。寒气因水而发作，完谷不化不容间断，呕吐变为反胃肠出，颠倒不安，手足微冷，身体冷而内心烦乱。迟了想要从后补救，怎么能够追回呢？
胃冷营寒，阳微中风，发热恶寒，轻微呕吐心烦。医生不温胃，反而认为有热，用解肌发汗法，导致表虚亡阳烦躁，心下痞坚。先里气不足，发汗又虚其表，表里俱虚竭，突然起身头晕目眩，客热在表，惆怅不得眠。医生不救里，只责备表热，汲水灌洗以退热，客热易退，里寒更增，战栗发寒，再用厚被覆盖，表虚遂出汗，更加使阳气虚弱。巅，就是顶。头昏目眩且身体战栗发寒，小便难，这是亡阳。寒因水而发作，下为完谷不化，上为呕吐，外有厥逆，内有躁烦，颠倒不安，虽然想要拯救，也不可能了。《本草》说：病势已过，性命将难保全。
张卿子说：除了“脉濡而紧”这四个字作为题目外，这是一首汉代古诗，用来告诫人们慎用清凉解利之药。孙思邈所说的伤寒滥用大毒诸寒药的情况，比比皆是。
脉象浮而大。浮代表气实，大代表血虚。血虚就是无阴，孤阳独自下行至阴部，小便应当赤涩难通，胞宫应当空虚。现在反而小便通利且大汗出，按照常理卫气应当微弱，现在反而更实，津液四散流失，营血枯竭，干枯烦闷且不得睡眠，血液稀薄肌肉消瘦，而成暴液（津液暴脱）。医生再用毒药攻伐胃气，这是双重虚损。客居的阳气离去有期，必定大便如污泥而死。
卫为阳，荣为阴。卫气强实，阴血虚弱，阳乘阴虚，下行至阴部。阴部，指下焦。阳为热，会消耗津液，应当小便赤涩难通。现在反而小便通利且大汗出，是阴气内部虚弱。《经》说：阴弱者汗自出。因此卫气不微弱，反而更实。营竭血尽，干枯烦闷不眠。血薄则肉消而成暴液，是津液四散流失。医生反而用下法，又虚其里，这是双重虚损。孤阳因下法而再次脱失，气血皆竭，胃气在内耗尽，必定大便如污泥而死。
脉数，久数不止，若脉律间歇，则是邪气结聚，正气不能恢复。正气退缩结于脏，所以邪气浮越，与皮毛相合。脉数的不可用下法，误用下法则必烦乱，腹泻不止。
数为热，间歇则邪气结于经络之间，正气不能复行于表，则邪结于脏。邪气独浮于皮毛，下法使里虚，邪热乘虚而入，里虚受热，必烦乱，腹泻不止。
浮大属表，所以不可下。
表证未解，即使有里证，也不可下。应当先解表为顺。如果反而用下法，就是逆治。《经》说：本应发汗反而用下法，这是逆治。如果先发汗，治疗就不为逆。
凡是病属阳多者表现为热，误用下法会导致便秘硬结。
阳热证多，则津液少。误用下法，虽然除热，又损伤津液，必然导致大便困难。有人说是阳多者为表热，误用下法会导致心下硬。
戴元礼说：阳明下法适应证已具备，但其人喘嗽，或轻微恶寒，这是太阳阳明；或往来寒热，这是少阳阳明。在阳明证中夹杂有太阳、少阳证未罢，这不是纯正的阳明证。慎重起见，不可急于用下法。所以古注阳明有三变，必须识得这一点。
无阳阴强，大便硬者，误用下法，必定完谷不化且腹部胀满。
无阳，指亡失津液。阴强，指寒邪多。大便硬，属于阴结。误用下法损伤胃气，阴寒内盛，必定完谷不化且腹部胀满。
伤寒发热，头痛，微微汗出。若发汗，则神志不清不认识人；若用火熏，则气喘，小便不通，心腹满；若用下法，则短气，小便难，头痛背强；若加温针，则鼻衄。
伤寒通常无汗，发热头痛，微微汗出，是寒邪变热，欲传于里。发汗则亡阳增热，所以神志不清。若用火熏，火热伤气，内消津液，结为里实，所以气喘，小便不通，心腹满。若反而用下法，则内虚津液，邪欲入里，外动经络，所以短气，小便难，头痛背强。若加温针，益阳增热，必动其血，而为鼻衄。
伤寒脉阴阳俱紧，恶寒发热则脉象欲厥。厥是指脉初来大，渐渐小，再来渐渐大，这是其征候。如此者恶寒，严重者翕翕汗出，喉中痛。热多者，目赤脉多，眼睛视物不清。医生再发汗，咽喉受伤；若再下之，则两眼闭合。寒多者便完谷不化，热多者便脓血。若熏之，则身发黄；若熨之，则咽燥。若小便利者，可救；小便难者，为危殆。
脉阴阳俱紧，清邪中于上部，浊邪中于下部，太阳少阴俱感邪。恶寒者是少阴，发热者是太阳。脉欲厥，是表邪欲传里。恶寒甚者，则变热，翕翕汗出，喉中痛，因为少阴经脉循喉咙。热多者，太阳多也。目赤脉多，眼睛视物不清，因为太阳经脉起于目。发汗攻阳，则少阴之热因发而上行，故咽喉受伤。若再下之，则太阳之邪因虚而内陷，故两眼闭合。阴邪下行，为寒多，必便完谷不化。阳邪下行，为热多，必便脓血。熏之，则火热甚，身必发黄。熨之，则火热轻，必为咽燥。小便利者，为津液未竭，犹可救。小便难者，津液已绝，则难控制而危殆。
伤寒发热，口中勃勃气出，头痛目黄，鼻衄不可制止。贪水者必呕，恶水者厥。若下之，咽中生疮。假如手足温者，必下重，便脓血。头痛目黄者，若下之，则两眼闭合。贪水者，脉必厥，声音低微，咽喉堵塞。若发汗，则战栗，阴阳俱虚。恶水者，若下之，则里冷不嗜食，大便完谷不化。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。
伤寒发热，寒变热也。口中勃勃气出，热客上膈。头痛目黄，血不可制者，热蒸于上也。《千金方》说：无阳即厥，无阴即呕。贪水者必呕，则阴虚也。恶水者厥，则阳虚也。发热口中勃勃气出者，咽中已热。若下之，亡津液，则咽中生疮。热因里虚而下，若热气内结，则手足必厥。设手足温者，热气不结而下行，作协热利，下重，便脓血。头痛目黄者，下之，热气内伏，则目闭。贪水为阴虚，下之又虚其里，阳气内陷，故脉厥，声嘤，咽喉闭塞。阴虚发汗，又虚其阳，使阴阳俱虚而战栗。恶水为阳虚，下之又虚胃气，虚寒内甚，故里冷不嗜食。阳虚发汗，则上焦虚燥，故口中伤烂，舌上白苔而烦躁。《经》说：脉数不解，合热则消谷喜饥，至六七日不大便者，此有瘀血。此脉数实，不大便六七日，热蓄血于内。七日之后，邪热渐解，迫血下行，必便血。便血发汗，阴阳俱虚，故小便利。
下利脉大者，是虚证，因为强行用下法导致的。假如脉浮革，因此肠鸣的，属于当归四逆汤主治。
脉大为虚，因为不应下而下之，腹泻因此不停。浮脉，按之不足。革脉，实大而长微弦。浮为虚，革为寒。寒虚相搏，则肠鸣。给予当归四逆汤，补虚散寒。
《活人书》说：虚者，十补勿一泻。强实者泻之。虚实等者，虽泻勿大泄之。这是《金匮要略》的话。
吴氏说：凡是有恶风恶寒的，凡是腹满时减时满的，凡是腹胀满，可按揉且柔软无力的，凡是阴虚劳倦的，凡是手足逆冷尺脉弱的，凡是脉在表的都不可下。凡是脉沉不实不疾，按之无力的，凡是亡血家，以及妇人经水适来适断，或热入血室，以及胎前产后崩漏等证，及小便频数，小便清而大便秘的，都不可下。
The pulse is soft and weak. The weak pulse appears at the Guan position, while the soft (Ru) pulse appears at the Cun position (referred to as "Dian" or peak). The faint (Wei) pulse appears in the upper part, and the choppy (Se) 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, Wind-Strike may present with sweating but also restlessness and irritability. A choppy pulse indicates lack of Blood, leading to cold extremities and aversion to cold. When Yang Qi is weak, purgation must not be used; if mistakenly purged, it leads to epigastric fullness and hardness.
If purgation is used when Yang Qi is weak, the already deficient Yang becomes further depleted, allowing Yin Qi to become excessive internally, resulting in epigastric fullness and hardness.
Palpitations felt on the right side indicate that purgation is contraindicated. Mistaken purgation depletes internal fluids, causing dry throat, dry nose, dizziness, and palpitations.
Palpitations on the right reflect abnormal movement of Lung Qi. Purgation damages Stomach Qi and disturbs Lung fluids, leading to internal fluid depletion. Dry throat and nose occur because the Lung belongs to Metal and governs dryness. Dizziness and palpitations occur because the Lung governs Qi and Lung Qi is deficient.
Palpitations felt on the left side indicate that purgation is contraindicated. Mistaken purgation causes abdominal cramping, inability to eat, and exacerbates the palpitations. Even if there is body heat, the patient prefers to curl up.
Palpitations on the left reflect abnormal movement of Liver Qi. Purgation damages the Spleen, allowing Liver Qi to become hyperactive and invade the Spleen, causing abdominal cramping, food intolerance, and worsening palpitations. The preference for curling up despite body heat is due to interior Qi deficiency.
Palpitations felt above the navel indicate that purgation is contraindicated. Mistaken purgation causes heat and irritability in the palms, a sensation of floating coldness on the body, spontaneous hot sweating, and a desire to pour water over oneself.
Palpitations above the navel reflect abnormal movement of Heart Qi. Purgation damages Stomach Qi and agitates Heart Qi. The Heart belongs to Fire and governs heat. The *Classic of Acupuncture* states: diseases generated by the Heart manifest as heat in the palms. The Liver is Yin within the Zang organs; when diseased, even with body heat, the patient curls up, indicating exterior heat and interior cold. The Heart is Yang within the Zang organs; when diseased, it presents with floating coldness, hot sweating, and desire for water pouring, indicating exterior cold and interior heat. The Yin-Yang and cold-heat distinctions of these two organs are clearly visible.
Palpitations felt below the navel indicate that purgation is contraindicated. Mistaken purgation causes abdominal distension, dizziness upon sudden rising, passage of undigested food after eating, and epigastric fullness.
Palpitations below the navel reflect abnormal movement of Kidney Qi. Purgation damages the Spleen, causing Kidney Qi to move recklessly. Kidney Cold invades the Spleen, leading to abdominal distension, dizziness, undigested stools, and epigastric fullness.
A sensation of obstruction in the throat contraindicates purgation. Mistaken purgation results in a feeling of lightness above and heaviness below, inability to swallow liquids, preference for curling up, body stiffness and pain, and diarrhea dozens of times a day.
Throat obstruction indicates impaired Stomach Qi. Purgation causes the obstructed pathogen to float upward (lightness) and further damages Stomach Qi (heaviness), leading to inability to swallow, curling up, stiffness, pain, and severe diarrhea, indicating a deficiency-cold syndrome.
Exterior excess conditions contraindicate purgation. Mistaken purgation induces slight fever, loss of pulse, cold extremities, and warmth around the umbilicus.
Excess refers to exterior heat. It should be treated with diaphoresis; purgation is contrary to treatment principles. Post-purgation interior deficiency allows exterior heat to sink inward, causing slight fever. Deeper cold extremities indicate deeper internal heat. Loss of pulse with cold extremities indicates deep sinking of Yang Qi into the Lower Jiao, causing warmth around the umbilicus.
Deficiency conditions contraindicate purgation. Mistaken purgation causes extreme thirst. Patients desiring water have a milder condition and can recover; those rejecting water have a severe condition and are difficult to treat.
The *Jin Gui Yu Han Jing* states: For deficiency, tonify ten times, do not purge once. Purging the deficient causes double deficiency and internal fluid depletion, leading to extreme thirst. Desire for water indicates Yang Qi is not yet exhausted and recovery is possible; rejection of water indicates exhausted Yang Qi, which is hard to control.
The pulse is soft and weak. Weak at Guan, soft at Cun. Wiry (Xian) at the upper part, faint at the lower part. Wiry indicates Yang movement; faint indicates Yin cold. Upper excess and lower deficiency suggest a desire for warmth. Faint and wiry indicate deficiency; deficiency contraindicates purgation.
Purging the deficient creates double deficiency. The *Nan Jing* warns against reinforcing excess and draining deficiency, damaging what is insufficient and adding to what is excessive; this is the error of mediocre physicians.
Faint pulse leads to coughing and expectoration of saliva. Mistaken purgation stops the cough but causes persistent diarrhea. Persistent diarrhea leads to a sensation of insects biting in the chest, regurgitation of ingested porridge, difficulty urinating, hypochondriac cramping, dyspnea, neck and back traction, arm numbness, extreme cold with sweating, icy body, blurred vision, incessant speech, yet increased food intake. This is called "Chu Zhong" (Elimination of Central Qi), where the mouth wants to speak but the tongue cannot advance.
The *Nei Jing* states: Cold invasion causes disease; mild cases result in cough, severe cases in diarrhea or pain. Mild Cold invading the Lung causes cough and a faint pulse. Purgation directs Qi downward; cough stops but diarrhea persists. Persistent diarrhea depletes Zheng Qi, leading to critical danger. Chest sensations, regurgitation, urinary difficulty, hypochondriac cramping, and dyspnea indicate interior Qi damage. Neck-back traction, arm numbness, extreme cold with sweating, and icy body indicate exterior Qi damage. Extreme damage to both interior and exterior leads to exhaustion of Yin and Yang. The *Nan Jing* states: Exhaustion of Yang causes hallucinations; exhaustion of Yin causes blindness. Although exhaustion should prevent eating, increased intake indicates "Chu Zhong," meaning Stomach Qi has departed. Inability to move the tongue indicates Qi exhaustion and failure of transformation.
The pulse is soft and weak. Weak at Guan, soft at Cun. Floating (Fu) at the upper part, rapid (Shu) at the lower part. Floating indicates Yang deficiency; rapid indicates Blood deficiency. Floating is deficiency, rapid is heat. Floating deficiency causes spontaneous sweating and aversion to cold. Rapid indicates pain, chills, and trembling. Weakness at Guan, urgency below the chest, dyspnea, sweating, and breathing difficulty with pain in the chest and hypochondrium during respiration, chills resembling malaria. If the physician mistakenly uses purgation, it leads to rapid pulse, fever, running wildly, seeing ghosts, epigastric fullness, dribbling urination, hard lower abdomen, and hematuria.
Weakness at Guan indicates interior Yin deficiency; softness at Cun indicates exterior Yang deficiency. Floating at the upper part indicates insufficient Wei Qi, hence Yang deficiency. Yang deficiency fails to secure the pores, causing sweating and aversion to cold. Rapidness at the lower part indicates Ying Blood insufficiency, hence Blood loss. Blood loss fails to moisten the Zang-Fu, causing painful rapid pulse and chills. Weakness at Guan indicates pathogen transmission to the interior. Interior deficiency meeting pathogen causes chest urgency, dyspnea, sweating, hypochondriac pain, and chills. This is interior pathogen not yet solid and exterior pathogen not yet resolved. Mistaken purgation increases interior deficiency and allows pathogenic heat to sink inward, causing rapid pulse, fever, madness, epigastric fullness (heat sinking to Middle Jiao). If heat sinks deeply to Lower Jiao, it causes dribbling urination, hard lower abdomen, and hematuria.
The pulse is soft and tight. Soft indicates weak Stomach Qi; tight indicates Cold in Ying. Yang deficiency with Wind in Wei causes fever and aversion to cold. Ying tightness with cold Wei Qi causes slight vomiting and inner irritability. If the physician mistakes this for high heat and uses muscle-relaxing diaphoresis, it causes Yang collapse, vacuous irritability, and stubborn epigastric fullness, leaving both exterior and interior exhausted. Sudden rising causes dizziness; lingering heat on the skin causes restlessness and insomnia. Ignoring cold Stomach Qi and tight Cold at Guan Yuan leaves skilled physicians helpless. Pouring cold water on the body temporarily removes lingering heat but intensifies shivering. Covering with heavy blankets causes sweating, dizziness, tremors, and difficult urination. Cold is triggered by water, leading to undigested stools, vomiting, intestinal prolapse, restlessness, cold extremities, and internal irritability. Recovery is impossible.
Cold Stomach and Cold Ying with Yang deficiency and Wind cause fever, aversion to cold, vomiting, and irritability. Failure to warm the Stomach and instead using diaphoresis for perceived heat causes exterior deficiency, Yang collapse, irritability, and epigastric fullness. Pre-existing interior deficiency plus diaphoresis exhausts both exterior and interior. Dizziness, lingering heat, and insomnia follow. Using cold water to wash away exterior heat increases interior cold, causing shivering. Heavy blankets cause sweating, further weakening Yang. Dizziness and tremors with difficult urination indicate Yang collapse. Cold triggered by water causes undigested stools and vomiting. Exterior cold extremities and interior irritability lead to death. As the *Ben Cao* states: Once the disease process passes, life is hard to save.
Zhang Qingzi notes that apart from the title "Soft and Tight Pulse," this is an ancient Han poem warning against cooling and purgative therapies. Sun Simiao observed frequent misuse of harsh cold medicines for Shanghan.
The pulse is floating and large. Floating indicates Qi excess; Large indicates Blood deficiency. Blood deficiency means Yin absence. If solitary Yang descends alone to the Yin region, urine should be red and difficult, and the uterus empty. Instead, urine is clear and profuse sweating occurs. Normally, Wei Qi should be weak, but here it appears strong, causing fluid leakage, Ying exhaustion, Blood depletion, dry irritability, and insomnia. Thin blood and muscle wasting lead to sudden fluid loss. If the physician uses toxic drugs to attack the Stomach, it causes double deficiency. The departing Yang will leave, and death will occur with stool like mud.
Wei is Yang, Ying is Yin. Strong Wei Qi and weak Ying Blood allow Yang to invade Yin deficiency, descending to the Lower Jiao. Yang heat consumes fluids, normally causing red, difficult urine. Clear urine and sweating indicate interior Yin weakness. The Classic states: Weak Yin causes spontaneous sweating. Thus, Wei is not weak but strong. Ying exhaustion and Blood depletion cause dry irritability and insomnia. Thin blood and muscle wasting indicate fluid leakage. Mistaken purgation further empties the interior, causing double deficiency. Solitary Yang departs again, Qi and Blood are exhausted, Stomach Qi is gone internally, leading to death with muddy stools.
A continuous rapid pulse without interruption indicates pathogen binding; Zheng Qi cannot recover. Zheng Qi retreats and binds in the Zang, so pathogen floats with the skin and hair. Rapid pulse contraindicates purgation; purgation causes irritability and persistent diarrhea.
Rapid indicates heat. Interruption indicates pathogen binding in collaterals; Zheng Qi cannot return to the exterior, binding in Zang. Pathogen floats on skin/hair. Purgation empties the interior, allowing pathogenic heat to enter, causing irritability and diarrhea.
Floating-large pulse requires diaphoresis; mistaken purgation is a major error.
Floating-large belongs to the exterior, so purgation is contraindicated.
Desire to vomit contraindicates purgation. Frequent vomiting, even with Yangming signs, contraindicates attacking methods.
Because the pathogen is still in the chest.
Taiyang disease with unresolved exterior signs contraindicates purgation; purgation is contrary.
Unresolved exterior contraindicates purgation even with interior signs. Resolving the exterior first is correct; purgation is contrary. The Classic states: Diaphoresis should be used first; purgation is contrary.
Yang-dominant heat conditions: purgation causes hardness.
Yang-heat excess reduces fluids. Purgation removes heat but damages fluids, causing constipation. Some say Yang excess is exterior heat; purgation causes epigastric hardness.
Dai Yuanli states: If Yangming purgation indications are met but accompanied by Taiyang signs (cough, slight aversion to cold) or Shaoyang signs (alternating chills and fever), it is not pure Yangming. Do not rush to purge. Ancient commentaries note three variations of Yangming; one must recognize this.
"No Yang, strong Yin" with hard stool: purgation causes undigested stools and abdominal fullness.
"No Yang" means fluid loss; "Strong Yin" means excess cold. Hard stool indicates Yin binding. Purgation damages Stomach Qi, increasing interior cold, leading to undigested stools and fullness.
Shanghan with fever, headache, slight sweating: Diaphoresis causes delirium. Moxibustion/fumigation causes dyspnea, urinary retention, and abdominal fullness. Purgation causes shortness of breath, difficult urination, headache, and stiff back. Warm needle causes epistaxis.
Shanghan usually has no sweat. Fever, headache, slight sweating indicates Cold transforming to Heat, transmitting inward. Diaphoresis collapses Yang and increases heat, causing delirium. Fumigation damages Qi, consumes fluids, creates interior excess, causing dyspnea, urinary retention, and fullness. Purgation empties interior fluids, allows pathogen to enter, disturbs collaterals, causing shortness of breath, difficult urination, headache, and stiff back. Warm needle increases Yang/Heat, disturbing Blood and causing epistaxis.
Shanghan with Yin-Yang pulses both tight, aversion to cold and fever, pulse suggests "Jue" (extremity reversal). Jue means pulse starts large, gets smaller, then larger. Severe aversion to cold brings slight sweating and sore throat. Heat-dominant cases have red eyes and many vessels, blurred vision. Mistaken diaphoresis injures the throat. Mistaken purgation closes the eyes. Cold-dominant cases pass undigested stools; heat-dominant cases pass pus and blood. Fumigation causes jaundice; moxibustion causes dry throat. Beneficial prognosis if urination is free; dangerous if difficult.
Tight Yin-Yang pulses indicate Clear Evil attacking upper, Turbid Evil attacking lower, affecting Taiyang and Shaoyin. Aversion to cold is Shaoyin; fever is Taiyang. Pulse Jue indicates exterior pathogen transmitting inward. Severe cold transforms to heat, sweating, sore throat (Shaoyin channel passes throat). Heat-dominant (Taiyang) causes red eyes, blurred vision (Taiyang channel starts at eye). Diaphoresis attacks Yang, sending Shaoyin heat upward, injuring throat. Purgation sends Taiyang pathogen inward due to deficiency, closing eyes. Yin pathogen descending causes cold/undigested stools; Yang pathogen descending causes heat/pus-blood. Fumigation causes jaundice; moxibustion causes dry throat. Free urination means fluids intact (salvageable); difficult urination means fluids exhausted (critical).
Shanghan fever, rushing breath from mouth, headache, yellow eyes, uncontrollable epistaxis. Thirsty patients vomit; aversive-to-water patients have cold extremities. Purgation causes throat ulcers. If hands/feet are warm, tenesmus and pus-blood occur. Headache/yellow eyes + purgation closes eyes. Thirsty patients have Jue pulse, low voice, blocked throat. Diaphoresis causes shivering (Yin-Yang deficiency). Aversive-to-water patients + purgation causes interior cold, anorexia, undigested stools. Diaphoresis causes mouth injury, white tongue coating, irritability, rapid-solid pulse, constipation. After 6-7 days, hematochezia occurs. Diaphoresis leads to free urination.
Fever indicates Cold transforming to Heat. Rushing breath indicates Heat in Upper Jiao. Headache/yellow eyes/uncontrollable bleeding indicates steaming Heat upward. *Qian Jin Fang*: No Yang causes Jue; No Yin causes vomiting. Thirst/vomiting indicates Yin deficiency; aversion/cold indicates Yang deficiency. Rushing breath indicates throat heat. Purgation loses fluids, causing throat ulcers. Heat sinking due to interior deficiency: if bound, cold extremities; if unbound (warm extremities),協熱利 (collateral heat diarrhea) with tenesmus/pus-blood. Headache/yellow eyes + purgation traps heat, closing eyes. Thirst (Yin def) + purgation empties interior, Yang sinks, causing Jue pulse, low voice, throat block. Diaphoresis on Yin def empties Yang, causing shivering. Aversion (Yang def) + purgation empties Stomach, increasing cold, causing anorexia. Diaphoresis on Yang def dries Upper Jiao, causing mouth injury, white coating, irritability. Classic: Rapid pulse unresolved, combined heat causes hunger. Constipation after 6-7 days indicates Blood stasis. Rapid-solid pulse + constipation indicates Heat storing Blood. After 7 days, Heat resolves, forcing Blood downward, causing hematochezia. Diaphoresis after bleeding causes Yin-Yang deficiency, leading to free urination.
Diarrhea with large pulse indicates deficiency caused by forced purgation. If pulse is floating-leather (Ge) with borborygmus, use Danggui Sini Tang.
Large pulse indicates deficiency from inappropriate purgation. Floating means deficiency upon pressure; Leather means large, long, slightly wiry. Floating is deficiency, Leather is cold. Cold-deficiency interaction causes borborygmus. Danggui Sini Tang tonifies deficiency and disperses cold.
*Huo Ren Shu* states: Tonify deficiency ten times, do not purge once. Purge excess. If mixed, purge gently. This is from *Jin Gui*.
Wu Shi states: Contraindications for purgation include aversion to wind/cold, intermittent abdominal fullness, soft/distended abdomen, Yin deficiency fatigue, cold extremities with weak Chi pulse, superficial pulses, deep-weak pulses, blood-loss history, menstruation changes, Heat entering Blood Chamber, pre/post-natal bleeding, frequent clear urination with constipation.