①微厥：謂厥逆很輕微。
鄭論：按熱少厥微，是陽厥之最輕者也。至於默默不欲食，煩躁，至小便白色，此時內無熱邪可征，故曰熱除。欲得食，是胃氣漸複之機，故為欲愈。倘嘔而胸脅煩滿，此中宮不宣，胃氣滯塞，斷為便血者，是因其氣機之滯而決之也。
【闡釋】傷寒熱少厥微為熱厥輕證，故僅見指頭寒；陽熱內鬱不甚，故默默不欲食；鬱極求伸，故見煩躁。數日後小便通暢色白者，此熱邪已除，欲進食者乃胃氣已和，此病為欲愈。若厥複見，其熱不解，上逆而嘔，且有胸脅煩滿之證，是熱又深入，傷及陰絡，必便血矣。仲景對此未提治法，柯韻伯謂：“微熱者可用小柴胡湯，熱深者用大柴胡湯”。筆者認為此二方可供臨證選用。
十三、傷寒發熱四日，厥反三日，複熱四日，厥少熱多〔者〕，其病當愈；四日至七日，熱不除者，（其後）必便膿血。原文341
鄭論：按熱多厥少，是陽有餘，特患者熱不除耳，熱除自愈。熱不除者，陽勝血虧，即有逼血下行之事，故斷之曰便膿血。至寒多熱少者，陰有餘，陽必虧，其病為進者，即小人道長，君子道消之意也，知此可與論藥論方也。
【闡釋】此條從厥和熱的多少來觀察病變，這和前面十條是一致的。厥少熱多是身體抗病力戰勝病變的象徵，所以當主病癒。若熱仍不止，則熱郁于陰，即鄭氏所說：“陽勝於陰，即有逼血下行之勢”，其後必便膿血。至寒多熱少，則為陰盛陽衰，衰極則有亡陽之虞。至於治法，陽勝宜下，陰盛宜溫。
十四、傷寒六七日，脈微，手足厥冷，煩（燥）〔躁〕，灸厥陰②，厥不還者，死。原文343
②灸厥陰：灸厥陰經的孔穴。據張令韶的意思，可灸厥陰經的行間和章門穴。
鄭論：按脈微而厥，乃陽衰陰盛之征，迨至煩躁，上下有不交之勢，灸厥陰，原正所以扶陽禦陰也。陽回即是生機，不還即是死機，不易之理也。
【闡釋】自此以下三節，皆言陰中亡陽之死證也。本節是厥陰髒厥之重證，內外皆寒，一派陰霾之象，故急用灸法以回其陽。灸宜關元、氣海即丹田穴；並可內服大劑四逆湯等一類方劑，以救欲脫的陽氣，當能增加療效。如手足逆冷，過時不還，是陽已亡，故死。
十五、傷寒發熱，下利厥逆，躁不得臥者，死。原文344
鄭論：按發熱下利，乃陰陽欲脫之征，何也？發熱者，陽竭於上也；下利者，陰竭於下也。其人苟未見厥逆、躁，尚未得以脫論，此以斷為脫者，正於厥、躁論之也。
【闡釋】此條內真寒而外假熱的危候。傷寒發熱，若屬陽回，下利當自止，手足當溫。今雖見發熱，下利厥逆依然，可知此非陽回之熱，乃陰盛於內，格陽於外，更加躁不得臥，亦即鄭氏所說：“陰陽欲脫之征”。急與大劑通脈四逆湯，或可救危亡于萬一。
十六、傷寒發熱，下利至甚，厥不止者，死。原文345
鄭論：按發熱下利至甚，將脫之兆，況加以厥而不回，烏得不死。
【闡釋】此條乃陰陽離絕之危候，與上條同一病理。雖無躁不得臥之證狀，但不利言至甚，厥逆言不止，其厥利程度，較上條嚴重，發熱亦屬虛陽外浮。遇此危候，當用大劑四逆、白通溫經止泄以回其厥。若厥回可生，不回則死。
十七、發熱而厥，（不）〔七日〕下利者，為難治。原文348
鄭論：按發熱而厥，乃陽厥之征，務要察其人果現有熱象可憑，即照陽厥法治之。至七日下利，是邪盤據不欲下趨，熱與厥不退，故曰難治。若下之而利，熱退厥回，即是生機；下之而不利，厥不回，方為難治。
【闡釋】本條與上十五、十六兩條同為陰寒內盛，陽氣外浮而呈現的厥利。
本條雖同是真寒假熱證，但無上述兩條嚴重，所以不言主死，而雲難治。然難治非不治之謂，更非代表死候，可選用大劑白通，四逆等湯治之，可救危亡。
十八、傷寒六七日不利，便發熱而利①，其人汗出不止者，死，有陰無陽故也②。原文346
①便：作忽然解。
鄭論：按六七日不利，至發熱而利，裏已通矣，裏通表暢，發熱亦是病解之機。但其人汗出不止為可慮，可慮者，汗出亡陽，不止，是陽無所附，脫離即在轉瞬，不死何待？
【闡釋】鄭氏謂“汗出亡陽”，此即辨證大眼目。汗出不止，是陰盛于內，陽浮於外，是謂有陰無陽，故死。
十九、病（人）〔者〕手足厥冷，言我不結胸，小腹滿，按之痛者，此冷結在膀胱關元也③。原文340
③膀胱關元：關元為任脈經穴，在臍下三寸。治臍下痛，炙之良。膀胱關元，是指病的部位在臍下。
鄭論：按四肢厥，而無熱形可征，則為陰盛無疑，寒結於下，未在中上，故不結胸，而獨在小腹，故痛亦在小腹也。
【闡釋】此種證狀，經常見之。筆者常用大劑回陽之方，如四逆、白通之類，加肉桂、小茴以治之；外則用肉桂、小茴、花椒、橘葉以熨痛處。屢用屢效者。
二十、傷寒五六日，不結胸，腹濡④，脈虛複厥者㈠，不可下，此亡血⑤，下之死。原文347
④腹濡：腹部按之柔軟。
⑤亡血：指血分不足。
㈠腹濡脈虛複厥，，明明陰盛陽微，下之則微陽立消，烏得不死？（頂批）
鄭論：按脈微而厥，明明陰盛，而非陽盛也。陽盛始能傷血，血傷故不可下，今所見者，陽虛的候，非陰虛的候，何所見而為亡血乎？餘甚不解。
【闡釋】陽盛始能傷血，血傷始見亡血之證，今所見者為陽虛的候，非陰虛的候，故鄭氏曰：“何所見而為亡血乎？餘甚不解。”此血虛致厥，下之安得不死!
二十一、手足厥寒，脈細欲絕者①，當歸四逆湯主之。若其人內有久寒者，宜當歸四逆加吳萸生薑湯主之。原文351、352
①脈細：指其脈體細如絲狀。
鄭論：按四肢厥，而脈細微欲絕，陰盛陽虛之明驗也。此際正宜大劑回陽，茲以當歸四逆湯主之，決非確論，餘不敢從。
【闡釋】本條鄭氏認為係“陰盛陽虛之明驗，正宜大劑回陽，以當歸四逆湯主之，決非確論。”但歷代注家謂手足厥冷，既不同于陽微陰盛的四逆湯證；亦不同於熱深厥深的白虎湯證；更不是陽氣郁遏於裏，不能透達的四逆散證。而是血虛寒郁，不能榮於脈中，而四肢失于溫養，所以手足厥寒。本方不用姜附回陽而亦以四逆名湯者，正像四逆散一樣，以其能治四肢逆冷之故。故鄭氏所說：“決非確論”是當深思的。
當歸四逆湯（校補）
當歸三兩桂枝三兩（去皮）芍藥三兩細辛三兩甘草二兩（炙）通草二兩②大棗二十五枚（擘），一法十二枚上七味，以水八升，煮取三升，去渣，溫服一升，日三服。
當歸四逆加吳茱萸生薑湯方（校補）
即前方加生薑半斤（切）吳茱萸二升上九味，以水六升，清酒六升和，煮取五升，去渣，溫分五服。
【方解及其應用範圍】本方即桂枝湯去生薑，倍用大棗，加當歸、細辛、木通而成。桂枝湯本調和營衛之方，但本證屬血虛寒凝，故用當歸補心血為君藥，芍藥收心氣，大棗、甘草、木通緩肝急，生肝血，桂枝、細辛溫陽散寒。合之則治血虛寒滯，陽氣虛衰，脈行不利之證，是溫血散寒，補血助陽之劑。若其人內有久寒者，宜當歸四逆加吳茱萸生薑湯治之。吳茱萸辛溫以散久寒，生薑辛溫以行陽氣，再以清酒和之，以助藥之行，則陰陽調和，手足自溫。關於本方應用範圍，《傷寒論》原文所載主治“手足厥寒，脈細欲絕者”。其病機在於血虛寒滯。由於血被寒邪凝滯之程度和部位不同，則臨床見證各異，一切陰寒凝結之血虛氣滯，皆可用本方溫而通之以取效。如一身痛、四肢關節痛、腰痛、腿痛、胸痛、巔頂頭痛、虛寒下痢，婦女經期痛、行經時四肢麻木抽搐、手足厥寒、小兒麻痹症，以及脫疽（栓塞性脈管炎）等，皆可用本方治療而獲效。筆者曾治胡某二十餘年之腰腿關節疼痛，其症狀為痛有定處，下肢冷，遇寒痛增，似覺骨痛，麻木、拘攣，沉重，伸縮行動困難，須靠攙扶方能移步。經當地醫院診斷為風濕性關節炎，但治之無效。其面容黯黑，舌質微烏，苔灰白而膩，脈微細，參之以上述證狀，此為血虛氣滯，寒邪內搏所致。法當養血通絡，溫經散寒，以當歸四逆湯加味治之，連續服二十劑而痊癒。
厥陰中篇
計十七法
一、大汗出，熱不去，內拘急①，四肢疼，又下利厥逆而惡寒者，四逆湯主之。原文353
①內拘急：腹中攣急，動不自如。
鄭論：按汗出熱不去，非外感之熱，乃元陽外出之熱也。汗過甚，血液虧，不能營養筋脈，故內拘急，而四肢疼，況又下利而厥，此刻陽虛已極，大有欲脫之機，非大劑四逆，何能挽回？
【闡釋】本條是真寒假熱之證。大汗出是陽亡於外，四肢疼，下利厥逆是寒盛於裏。均是陰盛陽亡之證，故應以四逆湯急救回陽。誠如鄭氏所說；“此刻陽虛已極，大有欲脫之機，非大劑四逆，何能挽回”？
鄭論：按大汗、大下利而厥冷，皆陰陽兩脫之候，理應大劑四逆回陽，千古定論。
【闡釋】大汗大下，均能傷陽，其亡津液，損陽氣一也，而致手足逆冷，陰陽兩脫之候也。鄭氏所說：“理應大劑四逆回陽，千古定論”為不謬。
三、傷寒脈促，手足厥逆，可灸之。原文349
鄭論：按脈促、厥逆，係陰寒阻滯之征，灸之是祛陰散寒之意；理實可從，不易之論也。
【闡釋】手足厥逆，本當用四逆湯。因脈促當屬陽為陰阻，而非陽虛也，故可用灸法以運行陽氣。當灸“湧泉”，引血下趨，髒複而心力強，陽可不致外越。若厥而脈微者，則非用四逆湯不可。
四、傷寒脈滑而厥者，裏有熱（也），白虎湯主之。原文350
鄭論：按滑脈主痰，滑而厥，誠濕痰閉束氣機，不能達於四肢也。此以為裏有熱，而用白虎湯，果何所見也？當其時，口燥舌幹歟？氣粗口渴飲冷歟？不然，何所見而必用此方，學者不可執一，總要四面搜求裏熱實據，庶不致誤。
【闡釋】厥有陽厥陰厥之別，陽厥必有汗出惡熱，煩渴等證，知其厥為熱深厥亦深之假像。但此僅無形之熱，宜清而不宜下，故用白虎湯以清裏熱，裏熱除則厥逆自解。鄭氏說：“總要四面搜求裏熱實據，庶不致誤”，乃經驗之談，可為後學之助。
五、病人手足厥冷，脈乍緊者，邪結在胸中，心下滿而煩，而不能食者，病在胸中，當須吐之，宜瓜蒂散①。原文355
①此條與卷七少陰痰證之第三條完全相同，錄之以存原書全貌。但鄭氏所論與前論不同，故以下照錄，亦就鄭論：作出相應闡釋。
鄭論：按手足厥冷，乃寒結于胸，陽氣不能達於四末也。胸滿而不能食，中宮為寒所阻滯，運力微耳。原文主瓜蒂散以吐之，是為邪壅於上說法也。但此證乃寒邪阻滯，吐之能不更傷其中乎？以餘拙見，理應大劑溫中醒脾為是。
【闡釋】鄭氏謂：“此證乃寒邪阻滯，吐之能不更傷其中乎”？實則本條為痰飲食積壅塞胸中而厥冷，病在上焦，而中下焦無病，用瓜蒂散湧吐其胸中之邪，就是內經所謂：“其高者因而越之”的治療法則。筆者認為邪去正虛，然後以理中湯調養之。
六、傷寒厥而心下悸（者），宜先治水，當（用）〔服〕茯苓甘草湯，卻治其厥；不爾，水漬入胃②，必作利也。原文356
②水漬人胃：飲水滲入胃腸係水邪阻遏胸中之陽所致。茯苓甘草湯為治水飲之方，其證有心下悸，較五苓散證為輕。鄭氏認為此方力薄，恐不能勝任，主用苓桂朮甘湯重加附子。筆者認為再加上肉桂以化膀胱之氣，其效果更好。
鄭論：按厥而心下悸者，寒水淩於心下也，此以茯苓甘草湯，與理頗是，但其力薄，恐不勝任，莫若用苓桂朮甘湯，重加附子為妥。
【闡釋】水飲停蓄心下則悸，胸陽被遏而不達四末則厥。本條悸、厥之證，
七、傷寒六七日，大下後，寸脈沉而遲，手足厥（冷）〔逆〕，下部脈不至①，咽喉不利②，唾膿血，泄利不止者，為難治，麻黃升麻湯主之。原文357
①下部脈：指尺脈而言。
②咽喉不利：咽喉疼痛，吞咽困難的意思。
鄭論：按經大下脈遲，手足厥冷，下部脈不至，其陽虛之極已明甚。至咽喉不利，氣化不宣也。吐膿血者，濁陰不降也。泄利不止者，下焦虛寒，不能收束也。法宜大劑回陽，陽回利止；手足溫，斯為合法。原文所主麻黃升麻湯，係太陽陽明發散之藥，並非厥陰所宜，大非其法，恐有錯誤。
【闡釋】對於本條，歷代注家如柯韻伯、舒馳遠等均持否定態度。鄭氏認為此證“陽虛之極已明甚，法宜大劑回陽，陽回利止，手足溫，方為合法。”是有見地的。筆者認為此條方證不相符，原文後雲“難治”，論中凡言難治，仲景多不出方，“麻黃升麻湯主之”一句，當係衍文。
麻黃升麻湯方（校補）
① Slight Jue (Cold Extremities): Refers to the symptom of cold extremities being very mild.
Zheng Qin'an's Commentary: In cases where heat is slight and Jue is mild, this represents the mildest form of Yang Jue (Yang Cold Extremities). Regarding symptoms such as taciturnity, loss of appetite, irritability, until the urine becomes clear and colorless, at this time there are no signs of pathogenic heat in the interior, hence it is called "heat has been eliminated." The desire to eat indicates that the Stomach Qi is gradually recovering, thus it is judged as impending recovery. If vomiting occurs accompanied by vexation and fullness in the chest and hypochondrium, this signifies that the Qi mechanism of the Middle Jiao (Spleen and Stomach) is not unobstructed, and Stomach Qi is stagnant and blocked; a diagnosis of bloody stool is made based on the stagnation of Qi mechanism.
[Elucidation]: In Shanghan disease, slight heat and mild Jue belong to the mild syndrome of Re Jue (Heat Cold Extremities); therefore, only the tips of the fingers are cold. Since internal Yang heat is not severely constrained, the patient presents with taciturnity and lack of appetite. When constraint reaches its peak and seeks release, irritability appears. After several days, if urination is smooth and the urine is clear and white, this indicates that pathogenic heat has been cleared. The desire to eat shows that Stomach Qi has harmonized, indicating the disease is about to heal. If Jue recurs and fever persists, with Qi rebelling upward causing vomiting and symptoms of chest and hypochondriac vexation and fullness, this means heat has penetrated deeper into the body, damaging the Yin collaterals, inevitably leading to bloody stool. Zhang Zhongjing did not propose a treatment for this; Ke Yunbo stated, "For slight heat, Xiao Chai Hu Tang may be used; for deep heat, Da Chai Hu Tang should be used." The author believes these two formulas can be selected for clinical practice.
13. In Shanghan disease, if there is fever for four days, followed by Jue for three days, and then fever returns for four days, meaning Jue is less frequent than fever [the patient] will likely recover; if from the fourth to the seventh day the fever does not cease, [subsequently] pus and blood will likely appear in the stool. Original Text 341
Zheng Qin'an's Commentary: Heat exceeding Jue indicates excess Yang; however, the patient merely suffers from persistent fever. Once the heat subsides, recovery ensues naturally. If the fever persists, it signifies Yang excess and Blood deficiency, leading to forced downward movement of blood; hence, it is diagnosed as "pus and blood in the stool." Conversely, when cold exceeds heat, it indicates Yin excess and inevitable Yang deficiency, causing the disease to progress, analogous to the saying "the way of petty men grows while the way of gentlemen declines." Understanding this allows one to discuss medication and prescriptions.
[Elucidation]: This clause observes pathological changes through the frequency of Jue and fever, consistent with the preceding ten clauses. Less Jue and more fever symbolize the body's resistance overcoming the pathology, indicating recovery. If fever continues, heat constrains within the Yin aspect, as Zheng described: "When Yang overcomes Yin, there is a tendency to force blood downward," subsequently leading to pus and blood in the stool. When cold exceeds heat, it indicates Yin excess and Yang decline; extreme decline risks Yang collapse. Regarding treatment, Yang excess warrants purgation, while Yin excess warrants warming.
14. In Shanghan disease, after six or seven days, if the pulse is faint, hands and feet are cold, and there is irritability, moxa should be applied to the Jueyin meridian②; if Jue does not return, death ensues. Original Text 343
② Moxa on Jueyin: Applying moxibustion to acupoints on the Jueyin meridian. According to Zhanglingshao, points Xingjian (LR2) and Zhangmen (LR13) on the Jueyin meridian can be moxed.
Zheng Qin'an's Commentary: A faint pulse with Jue is a sign of Yang decline and Yin excess. When irritability arises, there is a trend of non-interaction between upper and lower. Moxing the Jueyin meridian aims to support Yang and resist Yin. Yang returning signifies life; failing to return signifies death. This is an immutable principle.
[Elucidation]: The following three sections all describe fatal syndromes of Yang collapse within Yin. This section describes a severe case of Zang Jue (Visceral Cold Extremities) of Jueyin, characterized by cold inside and out, presenting a purely Yin image. Therefore, urgent moxibustion is required to restore Yang. Suitable points include Guanyuan (CV4), Qihai (CV6), also known as Dantian. Internally administering large doses of Si Ni Tang (Frigid Extremities Decoction) or similar formulas can rescue collapsing Yang and enhance efficacy. If cold extremities persist beyond time without recovery, Yang has perished, resulting in death.
15. In Shanghan disease, with fever, diarrhea, cold extremities, and restlessness preventing lying down, death ensues. Original Text 344
Zheng Qin'an's Commentary: Fever with diarrhea is a sign of impending Yin-Yang collapse. Why? Fever indicates Yang exhaustion above; diarrhea indicates Yin exhaustion below. If cold extremities and restlessness were absent, collapse could not yet be diagnosed. The diagnosis of collapse here is precisely based on the presence of Jue and restlessness.
[Elucidation]: This clause describes a critical condition of true cold inside and false heat outside. In Shanghan fever, if it results from Yang recovery, diarrhea should stop spontaneously, and hands and feet should warm. Although fever is present, diarrhea and cold extremities persist, indicating this is not heat from Yang recovery but rather Yin excess internally repelling Yang externally. Coupled with restlessness preventing lying down, it aligns with Zheng's description: "signs of impending Yin-Yang collapse." Urgently administering large doses of Tong Mai Si Ni Tang (Pulse-Resuscitating Frigid Extremities Decoction) might save the patient in rare instances.
16. In Shanghan disease, with fever, severe diarrhea, and unremitting cold extremities, death ensues. Original Text 345
Zheng Qin'an's Commentary: Severe fever and diarrhea indicate impending collapse. Added to this is Jue that does not resolve; how can survival be expected?
[Elucidation]: This clause represents a critical state of Yin-Yang separation, sharing the same pathology as the previous clause. Although lacking restlessness, the severity of diarrhea and persistence of Jue make this condition more severe than the previous one. The fever belongs to floating deficient Yang. In such critical states, large doses of Si Ni Tang or Bai Tong Tang should be used to warm meridians, stop diarrhea, and restore Yang. If Jue resolves, life is possible; otherwise, death follows.
17. With fever and Jue, [if] diarrhea occurs after (not) [seven] days, it is difficult to treat. Original Text 348
Zheng Qin'an's Commentary: Fever with Jue is a sign of Yang Jue. One must verify if genuine heat signs exist; if so, treat according to Yang Jue methods. By the seventh day, if diarrhea occurs, it indicates pathogens are entrenched and unwilling to descend, with heat and Jue persisting; hence, it is termed difficult to treat. If purgation leads to cessation of diarrhea, resolution of heat, and return of warmth, it indicates vitality. If purgation fails to stop diarrhea or resolve Jue, then it is truly difficult to treat.
[Elucidation]: This clause, like clauses 15 and 16, involves excessive internal Yin-cold with floating external Yang, presenting Jue and diarrhea.
Although this is also a true cold/false heat syndrome, it is less severe than the aforementioned two, hence not declared fatal but "difficult to treat." However, "difficult" does not mean untreatable or necessarily fatal. Large doses of Bai Tong Tang or Si Ni Tang can be selected to rescue critical conditions.
18. In Shanghan disease, after six or seven days without diarrhea, sudden onset of fever and diarrhea①, with incessant sweating, results in death due to having Yin but no Yang②. Original Text 346
① Sudden: Interpreted as suddenly.
② Having Yin but no Yang: Diarrhea is a Yin syndrome; incessant sweating indicates Yang collapse; hence termed "having Yin but no Yang."
Zheng Qin'an's Commentary: After six or seven days without diarrhea, the sudden onset of fever and diarrhea suggests the interior has opened. Interior opening and exterior smoothing imply fever could be a sign of disease resolution. However, incessant sweating is concerning because sweating causes Yang collapse. If sweating does not cease, Yang has no attachment and detachment occurs instantly; death is inevitable.
[Elucidation]: Zheng's statement "sweating causes Yang collapse" is the key to differentiation. Incessant sweating indicates Yin excess internally and Yang floating externally, termed "having Yin but no Yang," leading to death.
19. Patients with cold hands and feet who state they do not have chest binding, but have lower abdominal fullness and pain upon pressure, have cold binding at the Bladder and Guanyuan area③. Original Text 340
③ Bladder and Guanyuan: Guanyuan is an Ren Meridian point located three cun below the umbilicus. Effective for treating lower abdominal pain via moxibustion. "Bladder and Guanyuan" refers to the disease location being in the lower abdomen.
Zheng Qin'an's Commentary: Limb Jue without heat signs confirms Yin excess. Cold binds below, not in the middle or upper regions; thus, there is no chest binding, but pain is isolated to the lower abdomen.
[Elucidation]: This presentation is common. The author often uses large-dose Yang-restoring formulas such as Si Ni Tang or Bai Tong Tang, added with Rou Gui (Cinnamon Bark) and Xiao Hui Xiang (Fennel), combined with external application of Rou Gui, Xiao Hui Xiang, Hua Jiao (Sichuan Pepper), and Ju Ye (Tangerine Leaf) to fumigate painful areas. These methods have proven effective repeatedly.
20. In Shanghan disease, after five or six days, absence of chest binding, soft abdomen④, deficient pulse with recurrent Jue㈠, contraindicates purgation. This indicates Blood depletion⑤; purgation leads to death. Original Text 347
④ Soft Abdomen: The abdomen feels soft upon palpation.
⑤ Blood Depletion: Refers to insufficiency in the Blood aspect.
㈠ Soft abdomen, deficient pulse, and recurrent Jue clearly indicate Yin excess and weak Yang. Purgation would immediately extinguish weak Yang; how could survival be expected? (Marginal note)
Zheng Qin'an's Commentary: Faint pulse with Jue clearly indicates Yin excess, not Yang excess. Only Yang excess damages Blood; since Blood is damaged, purgation is contraindicated. What is observed here is a Yang deficiency pattern, not Yin deficiency. On what basis is this diagnosed as Blood depletion? I find this incomprehensible.
[Elucidation]: Yang excess damages Blood; only after Blood damage does Blood depletion manifest. Here, Yang deficiency is observed, not Yin deficiency. Thus, Zheng asks, "On what basis is this Blood depletion?" This Jue caused by Blood deficiency cannot survive purgation!
21. For cold hands and feet with a fine pulse nearly imperceptible①, Dang Gui Si Ni Tang (Angelica Sinensis Decoction for Cold Extremities) is indicated. If the patient has chronic cold internally, Dang Gui Si Ni Tang plus Wu Zhu Yu and Sheng Jiang (Fresh Ginger) Decoction is indicated. Original Texts 351, 352
① Fine Pulse: The pulse body is thin like a silk thread.
Zheng Qin'an's Commentary: Limb Jue with a fine, nearly imperceptible pulse is clear evidence of Yin excess and Yang deficiency. At this stage, large-dose Yang restoration is appropriate. Using Dang Gui Si Ni Tang here is definitely incorrect; I cannot agree.
[Elucidation]: Zheng considers this "clear evidence of Yin excess and Yang deficiency, requiring large-dose Yang restoration," and rejects Dang Gui Si Ni Tang as incorrect. However,历代 commentators argue that cold extremities differ from the Si Ni Tang syndrome of Yang deficiency/Yin excess; they differ from the Bai Hu Tang syndrome of deep heat/cold extremities; and they differ from the Si Ni San syndrome of constrained Yang unable to penetrate. Instead, this is Blood deficiency with Cold constraint, failing to nourish the vessels, causing limbs to lose warmth. The formula is named Si Ni despite not using Ginger and Aconite for Yang restoration, similar to Si Ni San, because it treats cold extremities. Zheng's rejection warrants deep reflection.
Dang Gui Si Ni Tang (Corrected and Supplemented)
Dang Gui (Angelicae Sinensis Radix) 3 liang, Gui Zhi (Cinnamomi Ramulus) 3 liang (bark removed), Shao Yao (Paeoniae Radix Alba) 3 liang, Xi Xin (Asari Radix) 3 liang, Gan Cao (Glycyrrhizae Radix et Rhizoma) 2 liang (roasted), Tong Cao (Tetrapanacis Medulla) 2 liang②, Da Zao (Zizyphi Fructus) 25 pieces (broken), alternatively 12 pieces. Seven ingredients, decocted in 8 sheng of water to obtain 3 sheng, strain, take 1 sheng warm, three times daily.
Dang Gui Si Ni Tang plus Wu Zhu Yu and Sheng Jiang Decoction (Corrected and Supplemented)
Add Sheng Jiang (Zingiberis Rhizoma Recens) half jin (cut) and Wu Zhu Yu (Evodiae Fructus) 2 sheng to the previous formula. Nine ingredients, decocted in 6 sheng of water and 6 sheng of clear wine to obtain 5 sheng, strain, divide into five warm doses.
② Tong Cao: In this formula, Tong Cao corresponds to modern Mu Tong (Akebiae Caulis).
[Formula Analysis and Scope of Application]: This formula is derived from Gui Zhi Tang (Cinnamon Twig Decoction) by removing Sheng Jiang, doubling Da Zao, and adding Dang Gui, Xi Xin, and Mu Tong. While Gui Zhi Tang harmonizes Ying and Wei, this syndrome involves Blood deficiency and Cold coagulation. Thus, Dang Gui tonifies Heart Blood as the sovereign herb; Shao Yao collects Heart Qi; Da Zao, Gan Cao, and Mu Tong soothe Liver urgency and generate Liver Blood; Gui Zhi and Xi Xin warm Yang and dispel Cold. Together, they treat Blood deficiency with Cold stagnation, deficient Yang, and impaired pulse flow, serving as a formula to warm Blood, dispel Cold, tonify Blood, and assist Yang. For patients with chronic internal Cold, Dang Gui Si Ni Tang plus Wu Zhu Yu and Sheng Jiang Decoction is indicated. Wu Zhu Yu is pungent and warm to disperse chronic Cold; Sheng Jiang is pungent and warm to move Yang Qi; mixed with clear wine to aid drug action, harmonizing Yin and Yang, allowing hands and feet to warm. Regarding application scope, the original text specifies "cold hands and feet with a fine, nearly imperceptible pulse." The pathogenesis is Blood deficiency with Cold stagnation. Depending on the degree and location of Cold coagulation affecting Blood, clinical manifestations vary. All Yin-Cold凝结 patterns of Blood deficiency and Qi stagnation can be treated effectively with this formula to warm and unblock. Examples include generalized body pain, limb joint pain, lumbar pain, leg pain, chest pain, vertex headache, deficiency-cold diarrhea, dysmenorrhea, limb numbness and spasms during menstruation, cold extremities, infantile paralysis, and gangrene (thromboangiitis obliterans). The author once treated a patient with over twenty years of lumbar and leg joint pain, characterized by fixed pain, cold lower limbs, worsening with cold exposure, bone-like pain, numbness, spasms, heaviness, difficulty moving, requiring assistance. Diagnosed locally as rheumatoid arthritis with ineffective treatment, the patient had a dark complexion, slightly purple tongue coating, gray-white greasy coating, and a faint, fine pulse. Based on these symptoms, the diagnosis was Blood deficiency with Qi stagnation and internal Cold constraint. The method was to nourish Blood, unblock collaterals, warm meridians, and dispel Cold using modified Dang Gui Si Ni Tang. After twenty doses, the patient recovered.
Jueyin Middle Chapter
Seventeen Methods
1. Profuse sweating, fever persists, internal tension①, limb pain, accompanied by diarrhea, cold extremities, and aversion to cold: Si Ni Tang (Frigid Extremities Decoction) is indicated. Original Text 353
① Internal Tension: Spasmodic tightness in the abdomen, movement is restricted.
Zheng Qin'an's Commentary: Sweating with persistent fever is not external pathogenic heat but Yuan Yang (Original Yang) escaping outward. Excessive sweating depletes Blood, failing to nourish sinews and vessels, causing internal tension and limb pain. Complicated by diarrhea and Jue, Yang deficiency is now extreme, with high risk of collapse. Without large-dose Si Ni Tang, how can it be reversed?
[Elucidation]: This clause describes true cold with false heat. Profuse sweating indicates Yang collapse externally; limb pain, diarrhea, and Jue indicate severe Cold internally. Both are signs of Yin excess and Yang collapse; thus, Si Ni Tang must be urgently administered to restore Yang. As Zheng stated: "At this moment, Yang deficiency is extreme, with great risk of collapse; without large-dose Si Ni Tang, how can it be saved?"
2. Profuse sweating, or severe diarrhea, with cold extremities: Si Ni Tang (Frigid Extremities Decoction) is indicated. Original Text 354
Zheng Qin'an's Commentary: Profuse sweating and severe diarrhea with Jue are signs of dual Yin-Yang collapse. It is logical to use large-dose Si Ni Tang to restore Yang; this is an established conclusion throughout history.
[Elucidation]: Profuse sweating and severe purgation both damage Yang, consuming fluids and damaging Qi, leading to cold extremities and dual Yin-Yang collapse. Zheng's statement that large-dose Si Ni Tang restores Yang is correct.
3. Shanghan disease with rapid pulse (Cu Mai), cold extremities: Moxibustion may be applied. Original Text 349
Zheng Qin'an's Commentary: Rapid pulse and Jue are signs of Yin-Cold obstruction. Moxibustion aims to dispel Yin and scatter Cold; this reasoning is sound and irrefutable.
[Elucidation]: Cold extremities typically require Si Ni Tang. However, a rapid pulse suggests Yang is obstructed by Yin, not deficient; thus, moxibustion can be used to promote Yang circulation. Yongquan (KI1) should be moxed to guide Blood downward, restoring organ function and strengthening heart power, preventing Yang from floating outward. If Jue accompanies a faint pulse, Si Ni Tang is indispensable.
4. Shanghan disease with slippery pulse and Jue indicates Heat in the Interior (also), treated with Bai Hu Tang (White Tiger Decoction). Original Text 350
Zheng Qin'an's Commentary: Slippery pulse governs Phlegm. Slippery pulse with Jue implies damp-phlegm blocking Qi mechanism, preventing reach to limbs. How can this be considered interior Heat warranting Bai Hu Tang? Was there dry mouth and tongue? Rough breathing, thirst, and desire for cold drinks? Otherwise, why insist on this formula? Scholars must not be rigid; always seek solid evidence of interior Heat from all angles to avoid error.
[Elucidation]: Jue distinguishes between Yang Jue and Yin Jue. Yang Jue must present with sweating, aversion to heat, vexation, and thirst, revealing Jue as a false appearance of "deep heat, deep Jue." This involves formless Heat, suitable for clearing rather than purging; thus, Bai Hu Tang clears interior Heat, resolving Jue upon heat elimination. Zheng's advice to "seek solid evidence of interior Heat from all angles" is experiential wisdom helpful to students.
5. Patient with cold hands and feet, intermittent tight pulse, pathogens bound in the Chest, epigastric fullness and vexation, inability to eat: Disease is in the Chest, requiring emesis; Gua Di San (Melon Sepal Powder) is indicated①. Original Text 355
① This clause is identical to Clause 3 of Shaoyin Phlegm Syndrome in Volume 7, recorded to preserve the original text. However, Zheng's commentary differs from previous discussions; thus, Zheng's commentary and corresponding elucidation are recorded below.
Zheng Qin'an's Commentary: Cold extremities result from Cold binding in the Chest, preventing Yang Qi from reaching the extremities. Chest fullness and inability to eat indicate the Middle Jiao is blocked by Cold, with weak transport function. The original text prescribes Gua Di San for emesis, addressing pathogens obstructing above. But this syndrome involves Cold obstruction; will emesis not further damage the Middle? In my humble opinion, large-dose warming of the Middle and awakening of the Spleen is appropriate.
[Elucidation]: Zheng questions whether emesis harms the Middle in Cold obstruction. Actually, this clause involves Phlegm, Food, and Accumulation obstructing the Chest causing Jue. The disease is in the Upper Jiao, with no pathology in Middle/Lower Jiao. Using Gua Di San to vomit pathogens from the Chest follows the Neijing principle: "For those high up, induce vomiting." The author believes that after pathogens are expelled and Righteous Qi is deficient, Li Zhong Tang (Regulate the Middle Decoction) should be used for regulation.
6. Shanghan with Jue and epigastric palpitations (should): First treat Water Retention by administering Fu Ling Gan Cao Tang (Poria and Licorice Decoction), then treat Jue; otherwise, Water infiltrates the Stomach②,必定 causing diarrhea. Original Text 356
② Water Infiltrating Stomach: Drinking water seeping into intestines/stomach is caused by Water Pathogen obstructing Chest Yang. Fu Ling Gan Cao Tang treats Water-Fluid Retention; its syndrome includes epigastric palpitations, milder than Wu Ling San syndrome. Zheng认为 this formula is too weak and prefers Ling Gui Zhu Gan Tang (Poria, Cinnamon, Atractylodes, and Licorice Decoction) with heavy Aconite. The author believes adding Rou Gui (Cinnamon Bark) to transform Bladder Qi yields better results.
Zheng Qin'an's Commentary: Jue with epigastric palpitation indicates Cold Water overwhelming the epigastrium. Fu Ling Gan Cao Tang aligns with principles but is too weak. Ling Gui Zhu Gan Tang with heavy Aconite is preferable.
[Elucidation]: Water-Fluid retention in the epigastrium causes palpitations; Chest Yang obstruction failing to reach extremities causes Jue. The palpitation and Jue in this clause...
7. Shanghan disease after six or seven days, following severe purgation, Cun pulse is deep and slow, hands and feet are cold (extremities), Lower pulses are absent①, throat discomfort②, spitting pus and blood, unremitting diarrhea: Difficult to treat, Ma Huang Sheng Ma Tang (Ephedra and Corydalis Decoction) is indicated. Original Text 357
① Lower Pulses: Refers to Chi pulse.
② Throat Discomfort: Means throat pain and difficulty swallowing.
Zheng Qin'an's Commentary: After severe purgation, slow pulse, cold extremities, and absent lower pulses clearly indicate extreme Yang deficiency. Throat discomfort indicates failure of Qi transformation to circulate. Spitting pus and blood indicates Turbid Yin failing to descend. Unremitting diarrhea indicates Lower Jiao deficiency-cold failing to consolidate. The method should be large-dose Yang restoration; upon Yang return, diarrhea stops; hands and feet warm, which is lawful. The original prescription Ma Huang Sheng Ma Tang consists of Taiyang and Yangming dispersing herbs, unsuitable for Jueyin, largely contrary to principles, possibly erroneous.
[Elucidation]:历代 commentators like Ke Yunbo and Shu Chiyuan hold negative views on this clause. Zheng argues that given "extreme Yang deficiency," the method should be large-dose Yang restoration, stopping diarrhea and warming limbs, which is lawful. This view is insightful. The author believes the formula-syndrome mismatch is evident; the text later says "difficult to treat," and Zhang Zhongjing rarely provides formulas for "difficult to treat" cases. The phrase "Ma Huang Sheng Ma Tang is indicated" is likely a textual error.
Ma Huang Sheng Ma Tang Formula (Corrected and Supplemented)