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Pulse is floating and slow, indicating exterior heat and interior cold, accompanied by diarrhea with undigested food; Si Ni Tang (Four Reversal Decoction) should be primarily used.

A floating pulse indicates the pathogen is in the exterior, while a slow pulse indicates it is in the Zang organs (internal organs). A slow quality seen within a floating pulse signifies deficiency of Qi at the exterior with heat, and cold in the interior. Diarrhea with undigested food occurring without prior erroneous purgation indicates that the exterior syndrome is deficient heat, while the interior harbors true cold. Whenever Zhang Zhongjing treats deficiency syndromes, he prioritizes the interior. For patients with Xie Re Xia Li (diarrhea with accompanying heat) and a faint pulse, Ren Shen (Ginseng Radix et Rhizoma) is added; for those with body pain after sweating and a deep, slow pulse, Ren Shen (Ginseng Radix et Rhizoma) is added. In this case, the slow pulse and diarrhea with undigested food, along with absence of irritability or coughing, indicate severe deficiency of Middle Qi and depletion of Yuan Qi (Original Qi). If one only warms without tonifying, how can one rescue the critical reversal? Observing that Fu Ling Si Ni Tang (Poria Four Reversal Decoction) uses Ren Shen (Ginseng Radix et Rhizoma) even when irritability is present, how much more so Tong Mai Si Ni Tang (Pulse-Reviving Four Reversal Decoction), which must have originally contained Ren Shen (Ginseng Radix et Rhizoma)? It is likely that the current text is missing ingredients due to textual loss.

This is a Shang Han (Cold Damage) syndrome. However, a floating pulse with exterior heat also indicates the disease originated from Yang channels, known in the world as "Lou Di Shang Han" (Leaky Bottom Cold Damage). This occurs because the person's Stomach Qi was originally deficient, allowing Cold pathogens to directly invade the Spleen and Stomach without affecting the Tai Yang (Greater Yang) and Shao Yang (Lesser Yang) channels; thus, there are no exterior symptoms such as bitter taste, dry throat, dizziness, or stiffness of the neck and back. Nevertheless, relying on this exterior heat can still help rescue the interior cold.

When there is diarrhea with undigested food, one must not attack the exterior. Sweating will inevitably lead to abdominal fullness.

With severe deficiency of Interior Qi, the ability to store Essence and serve as the guard of Yang is compromised. Fortunately, the Exterior Yang remains, capable of guarding the exterior and maintaining solidity. Attacking the exterior would further weaken it. Sweat is generated from Grain Qi; sweating leads to the loss of Yang, and severe interior cold generates fullness diseases.

Diarrhea with abdominal fullness and body pain: one should first warm the interior.

After Shang Han has been treated with purgatives, if diarrhea with undigested food continues incessantly and body pain persists, one must urgently rescue the interior, preferably using Si Ni Tang (Four Reversal Decoction).

Diarrhea indicates interior cold; body pain indicates exterior cold. The exterior should be warmed and dispersed, while the interior should be warmed and tonified. Rescuing the interior first addresses the root cause.

If the patient has fever, headache, but the pulse is surprisingly deep, and if it does not improve, leading to persistent body pain, one should rescue the interior, preferably using Si Ni Tang (Four Reversal Decoction).

This corresponds to the Ma Huang Tang (Ephedra Decoction) syndrome of Tai Yang (Greater Yang). The pathogen is in the exterior, so the pulse should be floating; a deep pulse here is an adverse sign. If sweating fails to improve the condition and body pain persists, one should judge based on the deep pulse that the disease is now in the interior. An Yang syndrome presenting with Yin pulses is a sign of Yang declining and Yin growing. Although heat originates in the exterior, it is deficient Yang; cold occupies the interior, representing true Yin. There must be latent interior signs not yet manifested. Relying on the remaining exterior Yang, and taking advantage of the fact that Yin cold has not fully erupted, one should intercept it. This may prevent complications like vomiting, diarrhea, and limb coldness. Once the interior harmonizes, the exterior resolves spontaneously.

Where evil gathers, Qi must be deficient. Therefore, if the pulse appears excessive but symptoms are deficient, follow the symptoms; if symptoms appear excessive but the pulse is deficient, follow the pulse. Excess may be false, but deficiency is true. This is the core method of Zhang Zhongjing.

Profuse sweating, or severe diarrhea, accompanied by cold limbs: Si Ni Tang (Four Reversal Decoction) should be primarily used.

Profuse sweating leads to the loss of Yang; severe diarrhea leads to the loss of Yin. With both Yin and Yang deficient, cold limbs occur. However, since the diarrhea is not with undigested food, urgent warming is required; if Yang returns, survival is possible.

Profuse sweating with persistent fever, internal cramping/tightness, pain in the four limbs, accompanied by diarrhea, cold limbs, and aversion to cold: Si Ni Tang (Four Reversal Decoction) should be primarily used.

Improper treatment results in profuse sweating with persistent fever and aversion to cold, indicating the exterior pathogen remains. Internal cramping and diarrhea indicate interior cold has erupted; pain in the four limbs and cold limbs indicate exterior cold is also present. Thus, "exterior heat and interior cold" actually refers to exterior cold with Yang collapse.

Vomiting with a weak pulse, clear urination, slight body heat, and presence of cold limbs: difficult to treat, use Si Ni Tang (Four Reversal Decoction) primarily.

Vomiting with fever is a Xiao Chai Hu Tang (Minor Bupleurum Decoction) syndrome. Here, the weak pulse and slight heat do not indicate vigorous Minister Fire. Internally lacking heat explains clear urination; exterior cold and deficiency explain the cold limbs; cold-fluid retention above the diaphragm explains the vomiting. In Shang Han (Cold Damage), Yang is paramount. As Yang declines and Yin grows, it becomes difficult to treat.

Simultaneous vomiting and diarrhea, clear urination, profuse sweating, diarrhea with undigested food, interior cold with exterior heat, and a pulse so faint it is nearly imperceptible: Si Ni Tang (Four Reversal Decoction) should be primarily used.

Simultaneous vomiting and diarrhea indicate severe deficiency of Middle Qi and failure to digest food. A pulse nearly imperceptible indicates loss of Qi and Blood. Clear urination and profuse sweating indicate failure of the pores to close. Fortunately, body heat remains and hands/feet are not cold, meaning the defensive Yang and the root of all Yang remain. The pulse is not yet absent, leaving a thread of vitality. Urgently rescue the interior; if Zheng Qi (Upright Qi) prevails, evil can be repelled.

Vomiting and diarrhea, sweating, fever with aversion to cold, cramping of the four limbs, and cold hands and feet: Si Ni Tang (Four Reversal Decoction) should be primarily used.

Here, the vomiting and diarrhea are not with undigested food, sweating is not profuse, and the pulse is not weak. Relying on this exterior heat/Yang, assisted by Si Ni Tang (Four Reversal Decoction) to warm the interior, there is hope for survival.

Spontaneous diarrhea without thirst belongs to Tai Yin (Greater Yin) syndrome, due to cold in the Zang organs. It should be warmed, preferably using Si Ni Tang (Four Reversal Decoction) category formulas.

In Shao Yin (Lesser Yin) disease, if the pulse is deep, urgent warming is required, preferably using Si Ni Tang (Four Reversal Decoction).

If there is cold-fluid retention above the diaphragm, it should be warmed, preferably using Si Ni Tang (Four Reversal Decoction).

Aversion to cold, faint pulse, and diarrhea; if diarrhea stops due to blood loss, Si Ni Jia Ren Shen Tang (Four Reversal Decoction plus Ginseng) should be primarily used.

Although diarrhea has stopped, aversion to cold persists, so Si Ni Tang (Four Reversal Decoction) is still appropriate. Because the faint pulse indicates lack of blood, Ren Shen (Ginseng Radix et Rhizoma) should be added to promote circulation.

The above discusses the pulses and syndromes of Si Ni Tang (Four Reversal Decoction).

In Shao Yin (Lesser Yin) disease, with diarrhea of undigested food, interior cold with exterior heat, cold limbs, a pulse faint and nearly imperceptible, yet the body feels no aversion to cold, and the face is red; or accompanied by abdominal pain, dry retching, sore throat, cessation of diarrhea, or absence of pulse: Tong Mai Si Ni Tang (Pulse-Reviving Four Reversal Decoction) should be primarily used.

This is a syndrome of half-cold and half-heat. Diarrhea with undigested food indicates Yin cold excess in the interior; cold limbs indicate cold excess in the exterior. No aversion to cold and red face indicate Yang constrained in the exterior; sore throat and cessation of diarrhea indicate Yang returning to the interior. Abdominal pain and dry retching indicate struggle between cold and heat. Warming the interior and reviving the pulse is the method of supporting Yang. The pulse is the governor of life; if the pulse returns, one lives via Yang; if cold limbs persist, one dies via Yin.

Diarrhea with undigested food, interior cold with exterior heat, sweating, and cold limbs: Tong Mai Si Ni Tang (Pulse-Reviving Four Reversal Decoction) should be primarily used. If diarrhea presents with a deep, slow pulse, slight facial redness, mild body heat, and diarrhea with undigested food, resolution will likely occur through Yu Mao (dizziness/stuffiness) followed by sweating. The patient will likely experience mild cold limbs. This is because of Dai Yang (floating Yang/Diagonal Yang) and deficiency below.

Compared to the previous clause, the pulses and syndromes are milder, allowing self-resolution through Yu Mao (dizziness/stuffiness) and sweating. Red face indicates Dai Yang (floating Yang/Diagonal Yang), with Yang rising upward. Due to Dai Yang, Yu Mao and sweating occur; due to lower deficiency, diarrhea with undigested food and cold limbs occur. Mild heat results in mild cold limbs, hence slight facial redness. This represents equality of Yin and Yang, and natural harmony of cold and heat, making it easy to heal.

After vomiting and diarrhea cease, but sweating and cold limbs persist, with cramping of the four limbs not resolving and a pulse faint and nearly imperceptible: Tong Mai Si Ni Jia Zhu Dan Jiang Tang (Pulse-Reviving Four Reversal Decoction plus Pig Gallbladder Bile) should be primarily used.

This must be a syndrome of Yin excess repelling Yang, hence Pig Gallbladder Bile is added as a counter-agent (Fan Zuo). Refer to the Bai Tong Tang (White Pass Decoction) clause for understanding.

If vomiting and diarrhea cease and the pulse becomes peaceful, with only slight irritability, it is because the newly weakened body cannot tolerate the energy from grain food.

Si Ni Tang (Four Reversal Decoction):
Gan Cao (Licorice Root, two liang, honey-fried); Gan Jiang (Dried Ginger, one and a half liang); Fu Zi (Aconite Lateralis Radix Praeparata, one piece, raw, peeled, broken into eight pieces).
These three ingredients are boiled in three sheng of water to obtain one sheng and two he of decoction. Strain and divide into two warm doses. For strong individuals, use one large Fu Zi (Aconite Lateralis Radix Praeparata) and three liang of Gan Jiang (Dried Ginger).

Tong Mai Si Ni Tang (Pulse-Reviving Four Reversal Decoction):
Gan Cao (Licorice Root, two liang, honey-fried); Fu Zi (Aconite Lateralis Radix Praeparata, one large piece, raw, peeled, broken into eight pieces); Gan Jiang (Dried Ginger, three liang, four liang for strong individuals).
These three ingredients are boiled in three sheng of water to obtain two sheng and two he of decoction. Strain and divide into two warm doses. Recovery is indicated if the pulse reappears. If the face is red, add nine stems of Cong Bai (Allii Fistulosae Bulbus). If there is abdominal pain, remove Cong Bai (Allii Fistulosae Bulbus) and add two liang of Shao Yao (Peony Root). If vomiting occurs, add two liang of Sheng Jiang (Fresh Ginger Rhizome). If there is a sore throat, remove Shao Yao (Peony Root) and add one liang of Jie Geng (Platycodon Root). If diarrhea stops and the pulse does not emerge, remove Jie Geng (Platycodon Root) and add two liang of Ren Shen (Ginseng Radix et Rhizoma). Administer only when the syndrome matches the formula.

Tong Mai Si Ni Jia Zhu Dan Jiang Tang (Pulse-Reviving Four Reversal Decoction plus Pig Gallbladder Bile):
Add one he of Zhu Dan Jiang (Porci Vesica Biliae) to the preceding formula. The rest follows the previous method.

In Shang Han (Cold Damage), after six or seven days, following severe purgation, if the Cun (Cun position) pulse is deep and slow, hands and feet are cold, the Chi (Chi position) pulse is absent, there is difficulty in the throat, expectoration of pus and blood, and incessant diarrhea, it is difficult to treat.

Deep and slow Cun pulse indicates the Qi Kou (Radial Artery) pulse is level. Absence of the Chi (Chi position) pulse indicates the root is exhausted. When Qi of the Six Fu organs fails externally, hands and feet become cold; when Qi of the Five Zang organs fails internally, diarrhea becomes uncontrollable. Difficulty in the throat indicates the passage of water and grain is blocked.

Fluids fail to transform, becoming pus and blood, flowing downward and regurgitating upward. This is Xia Jue Shang Jie (Lower Reversal and Upper Exhaustion), a sign of separation of Yin and Yang, with vital Qi about to perish internally. Old editions contain Ma Huang Sheng Ma Tang (Ephedra and Cimicifuga Decoction). Its formula has many ingredients with light dosages, focusing on sweating and dispersing while fearing warming and tonifying. This is the technique of later incompetent physicians, certainly not Zhang Zhongjing’s prescription. For this syndrome and pulse, urgently using Ren Shen (Ginseng Radix et Rhizoma) and Fu Zi (Aconite Lateralis Radix Praeparata) to restore Yang might still fail to save the patient. Using agents for Yang excess to treat Yang collapse is like attacking a fallen enemy. How could one expect recovery through sweating? Death by absolute sweating is inevitable. The formula is attached here for discerning experts.

Ma Huang Sheng Ma Tang (Ephedra and Cimicifuga Decoction):
Ma Huang (Ephedrae Herba, two and a half liang, nodes removed); Sheng Ma (Cimicifugae Rhizoma, one liang and one qian); Dang Gui (Angelicae Sinensis Radix, one liang and one qian); Huang Qin (Scutellariae Radix); Wei Rui (Polygonati Odorati Rhizoma) [each six zhu]; Shao Yao (Paeoniae Radix Alba); Zhi Mu (Anemarrhenae Rhizoma, eighteen zhu); Tian Dong (Asparagi Radix, heart removed); Gui Zhi (Cinnamomi Ramulus, bark removed); Gan Jiang (Zingiberis Rhizoma Recens); Gan Cao (Glycyrrhizae Radix et Rhizoma, honey-fried); Shi Gypsum (Gypsum Fibrosum, crushed, wrapped in silk); Bai Zhu (Atractylodis Macrocephalae Rhizoma); Fu Ling (Poria) [each six qian].
These fourteen ingredients are boiled in ten dou of water. First boil Ma Huang (Ephedrae Herba) for one or two boils, remove the foam on top, then add the other herbs. Boil to obtain three sheng of decoction. Strain and divide into three warm doses. Take them within the time it takes to cook three dou of rice, until sweating occurs and the patient recovers.