此更申明上文之寒气暴上，而尽其形气皆逆满而上者，脉必急大且坚，而尺肤涩，与脉不相应，何也？此
脉之急大，本非气血有余，以其精气内夺，故脉无柔和之象，精气枯，故尺肤涩而不润。如是者，手足温，则中
宫犹有阳气布于四肢，为从而可生；手足寒，则阳败为逆而死也。
五实五虚
《素问·玉机真脏论》帝曰∶余闻虚实以决死生，愿闻其情。岐伯曰∶五实死，五虚死。脉盛，皮热，
腹胀，前后不通，瞀闷，此谓五实；脉细，皮寒，气少，泄利前后，饮食不入，此谓五虚。帝曰∶其时有生者
何也？岐伯曰∶浆粥入胃，泄注止，则虚者活；身汗，得后利，则实者活。此其候也。
此统言外感内伤虚实之证也。脉盛，皮热，腹胀，是邪盛于
表里也，前后便不通，则邪结无出路，而昏瞀躁闷，则元气绝而死，名五实也；脉细，皮寒，气少，表里精气
皆夺也，而二便泄利，饮食不进，则本元竭而死，名五虚也。实者身汗得后利，则表里邪解而正气渐苏；虚者
泄利止而浆粥进，则生气渐续，故皆可活也。
三焦气虚
《灵枢·口问篇》曰∶上气不足，脑为之不满，耳为之苦鸣，头为之苦倾，目为之眩；中气不足，溲便
为之变，肠为之苦鸣；下气不足，则为痿厥心 。
上焦如雾者，清阳之气氤氲旋转，如云之上腾，而充于头脑也，故气不足，则脑中如空，耳鸣头倾目眩者，
清阳不伸，则浊阴上僭，浊阴上僭，则头重而倾，阳郁于下，则耳鸣目眩也；中焦如沤者，脾胃蕴酿水谷，由
中焦输化津液，故气不足，则输化失度，溲便皆变其常，肠中传导无力，则郁结而鸣也；下焦如渎者，滓浊水
液由之而出，藉肾中元阳以蒸化者，故下元气虚，或足痿无力，或厥冷不温，其滓浊反壅而不出，故上逆而心
， 者，满闷也。
这是对上文所述寒气突然上逆，导致形体与气机全部逆乱胀满情况的进一步阐明。此时脉象必定急、大且坚硬，尺部皮肤干枯涩滞，与脉象不相符合，为什么呢？这种脉象的急大，本来并非气血有余，而是因为精气在内被耗夺，所以脉象缺乏柔和之象；精气枯竭，所以尺部皮肤干枯涩滞而不润泽。像这种情况，如果手足温暖，说明中焦脾胃还有阳气布达于四肢，属于顺证，可以生存；如果手足寒冷，说明阳气败坏而逆乱，就会死亡。
五实五虚
《素问·玉机真脏论》记载：黄帝说：我听说通过虚实可以判断死生，希望听听其中的道理。岐伯说：出现五种实证会死，出现五种虚证也会死。脉象盛大，皮肤发热，腹部胀满，大小便不通，神志昏蒙烦闷，这叫做五实；脉象细弱，皮肤发冷，气短少力，大小便泄利不止，饮食无法入口，这叫做五虚。黄帝说：其中有时能存活的原因是什么？岐伯说：如果浆粥能够进入胃中，泄泻停止，那么虚证患者就能活；如果身体出汗，大小便通畅，那么实证患者就能活。这就是存活的征候。
这里总括论述了外感和内伤导致的虚实证候。脉象盛大，皮肤发热，腹部胀满，是邪气盛于表里；大小便不通，则邪气结聚没有出路，加上神志昏蒙躁动烦闷，则元气断绝而死，称为五实；脉象细弱，皮肤发冷，气短少力，是表里的精气都被耗夺，加上二便泄利不止，饮食不进，则根本元气竭尽而死，称为五虚。实证患者若身体出汗且大小便通畅，则表里邪气解除，正气逐渐复苏；虚证患者若泄利停止且能进食浆粥，则生气逐渐接续，所以都可以存活。
三焦气虚
《灵枢·口问篇》说：上焦之气不足，头脑就会感到空虚不满，耳朵会痛苦地鸣响，头部会因沉重而难以抬起，眼睛会眩晕；中焦之气不足，小便和大便会发生异常变化，肠道会痛苦地鸣响；下焦之气不足，就会导致肢体痿软厥冷，心中烦闷不安。
上焦如雾，是指清阳之气氤氲旋转，像云雾升腾一样，充养头脑。所以气不足时，脑中感觉空虚，出现耳鸣、头倾、目眩，这是因为清阳不能伸展，导致浊阴上僭越；浊阴上僭越，则头部沉重而倾斜；阳气郁结在下，则出现耳鸣和目眩。中焦如沤，是指脾胃酝酿水谷，由中焦输布化生津液。所以气不足时，输布化失度，小便和大便都改变常态，肠道传导无力，则气机郁结而产生鸣响。下焦如渎，是指糟粕和水液由此排出，依赖肾中元阳来蒸化。所以下焦元气虚弱，或者足部痿软无力，或者四肢厥冷不温，那些糟粕反而壅滞而不能排出，所以上逆导致心中烦闷不安（心 ），这里的“ ”指满闷的感觉。
This further elucidates the previously mentioned condition where cold qi suddenly ascends, causing both form and qi to reverse and become full. The pulse must be rapid, large, and firm, while the skin of the forearm (Chifu) is rough and dry, inconsistent with the pulse. Why? The rapidity and largeness of this pulse are not originally due to an excess of Qi and Blood; rather, because Essence and Qi have been depleted internally, the pulse lacks a soft and harmonious appearance. With the depletion of Essence and Qi, the Chifu becomes rough and dry without moisture. In such cases, if the hands and feet are warm, it indicates that the Middle Jiao still has Yang Qi distributing to the four limbs, representing a favorable prognosis for survival; if the hands and feet are cold, it indicates the failure and reversal of Yang Qi, leading to death.
Five Excesses and Five Deficiencies
The *Suwen: Yuji Zhenzang Lun* states: The Yellow Emperor said, "I have heard that life and death can be determined by Excess and Deficiency; I wish to hear the details." Qibo replied, "Death occurs with Five Excesses and death occurs with Five Deficiencies. A surging pulse, hot skin, abdominal distension, obstruction of urination and defecation, and dizziness with oppression constitute the Five Excesses; a fine pulse, cold skin, shortness of breath, incontinence of urine and stool, and inability to ingest food constitute the Five Deficiencies." The Yellow Emperor asked, "Under what circumstances might there be survival?" Qibo answered, "If gruel and porridge enter the Stomach and diarrhea stops, the deficient patient will live; if the body sweats and bowel movements become unobstructed, the excess patient will live. These are the signs of survival."
This passage generally discusses the syndromes of Excess and Deficiency arising from external contraction and internal injury. A surging pulse, hot skin, and abdominal distension indicate pathogenic factors prevailing in the exterior and interior. Obstruction of urination and defecation means pathogens have no outlet, and dizziness with restlessness and oppression indicates the exhaustion of Yuan Qi, leading to death; this is named Five Excesses. A fine pulse, cold skin, and shortness of breath indicate the depletion of Jing-Qi in both the exterior and interior. Incontinence of urine and stool combined with inability to eat leads to the exhaustion of the root Yuan Qi, resulting in death; this is named Five Deficiencies. For excess conditions, sweating and unobstructed urination/defecation allow the resolution of exterior-interior pathogens and the gradual recovery of healthy Qi. For deficiency conditions, the cessation of diarrhea and the intake of gruel/porridge allow the gradual continuation of generating Qi. Thus, both can survive.
Qi Deficiency of the Triple Burner
The *Lingshu: Kouwen Pian* states: When Qi at the Upper Jiao is insufficient, the brain feels empty and unsatisfied, the ears suffer from tinnitus, the head feels heavy and difficult to hold upright, and the eyes experience vertigo. When Qi at the Middle Jiao is insufficient, urination and defecation undergo abnormal changes, and the intestines suffer from borborygmus. When Qi at the Lower Jiao is insufficient, it leads to flaccidity and cold extremities, along with mental restlessness and oppression (*Xin Xian*).
"Upper Jiao is like mist" refers to clear Yang Qi swirling and rotating, ascending like clouds to nourish the brain and head. Therefore, when Qi is insufficient, the brain feels empty, and symptoms such as tinnitus, head heaviness, and vertigo occur because clear Yang fails to extend, allowing turbid Yin to ascend improperly. When turbid Yin ascends improperly, the head becomes heavy and tilts; when Yang is depressed below, tinnitus and vertigo arise. "Middle Jiao is like a fermenting vat" refers to the Spleen and Stomach brewing food and drink, transporting and transforming fluids via the Middle Jiao. Thus, when Qi is insufficient, transport and transformation lose their measure, causing abnormalities in urination and defecation. Weak intestinal conduction leads to stagnation and borborygmus. "Lower Jiao is like a ditch" refers to waste and fluids exiting through it, relying on the Yuan Yang of the Kidney for steaming and transformation. Therefore, when Lower Jiao Yuan Qi is deficient, one may experience leg flaccidity and weakness or cold extremities. If waste stagnates and cannot exit, it reverses upward, causing mental restlessness and oppression (*Xin Xian*), where "Xian" denotes a sensation of fullness and oppression.