【纲】仲景曰。少阴病。下利清谷。里寒外热。手足厥逆。脉微欲绝。身反不恶寒。其人面色
赤。或腹痛。或干呕。或利止。脉不出者。通脉四逆汤主之。下利清谷。里寒外热。汗出而厥者。
通脉四逆汤主之。下利。脉沉而迟。其人面少赤。身有微热。下利清谷者。必郁冒。汗出而解。病
人必微厥。所以然者。其面戴阳。下虚故也。脉浮而迟。表热里寒。下利清谷者。四逆汤主之。
【目】朱肱曰。大抵阴症发热。终是不同。脉须沉。或下利。手足厥也。病患尺寸脉俱沉细。
但欲寐者。少阴症也。急作四逆汤复其阳。
柯琴曰。首条。寒热相半症。下利清谷。阴盛于里也。二条。比首条脉症皆轻。因其下虚。故
下利清谷而厥逆。此阴阳相等。寒热自和。故易愈。三条之脉。浮中见迟。未经妄下而利清谷。是
表为虚热。里有真寒也。仲景凡治虚症。以里为主。
【纲】仲景曰。下利清谷。不可攻表。汗出必胀满。
【目】张兼善曰。里气其既虚矣。其何能藏精而为阳之守乎。幸得表阳尚存。可以卫外。而犹不
致于坏也。若又攻之。则表亦必虚。表虚则汗泄。汗出亡阳。其脏必寒而生胀满矣。可不戒哉。
【纲】仲景曰。伤寒下之后。续得下利清谷不止。身疼痛者。急当救里。宜四逆汤。
【目】徐彬曰。病。医下之。续得下利清谷不止。身体疼痛者。急当救里。后身体疼痛。清便
自调者。急当救表。按此言医宜知缓急先后之序也。谓表里分治。常理也。乃有表而复有里。倘因
误下而来。不得如余邪未清。双解表里。虽身疼痛。不可治表。谓稍缓而表邪将尽入内。故曰。急
当救里。迨清便调而身仍痛。又不得以余邪而忽之。谓内既曾利。稍缓而里将复受表邪。下利不止
也。故又曰。急当救表。
【纲】仲景曰。既吐且利。小便复利。而大汗出。下利清谷。内寒外热。脉微欲绝者。四逆汤
主之。
【目】黄仲理曰。此乃气血丧亡。故完谷不化。脉微欲绝也。
[General Principle] Zhang Zhongjing stated: In Shaoyin disease (a syndrome caused by pathogenic invasion of the Shaoyin meridians), characterized by diarrhea with undigested food, internal cold and external heat, cold extremities, and a faint pulse nearly imperceptible. The body may paradoxically feel no aversion to cold, and the patient's complexion may appear red. Alternatively, there may be abdominal pain, dry retching, or cessation of diarrhea while the pulse remains unpalpable. In such cases, Tongmai Sini Decoction (Cinnamon Twig and Aconite Decoction for Unblocking the Pulse) is indicated. If the presentation involves diarrhea with undigested food, internal cold and external heat, sweating, and cold extremities, Tongmai Sini Decoction is also indicated. If there is diarrhea, a deep and slow pulse, slight facial redness, mild body heat, and diarrhea with undigested food, the patient will inevitably experience dizziness and confusion (Yu Mao), which will resolve through sweating. The patient will likely exhibit mild cold extremities. This occurs because of "floating yang on the face" (Dai Yang), resulting from deficiency-cold in the lower jiao. If the pulse is floating and slow, indicating external heat and internal cold, accompanied by diarrhea with undigested food, Sini Decoction (Aconite Decoction) is indicated.
[Commentary] Zhu Gong stated: Generally, fever in Yin syndromes (syndromes of yin nature or involving yin meridians) is distinct. The pulse must be deep, possibly accompanied by diarrhea and cold extremities. If both the Cun (inch) and Chi (cubit) pulses are deep and fine, and the patient desires sleep, it is a Shaoyin syndrome. One should urgently prepare Sini Decoction to restore yang qi.
Ke Qin stated: The first clause describes a condition where cold and heat are equally present; diarrhea with undigested food indicates excess yin-cold within. The second clause presents milder symptoms and pulse compared to the first. Due to lower jiao deficiency, diarrhea with undigested food and cold extremities occur. Here, yin and yang are balanced, and cold and heat harmonize naturally, making recovery easier. In the third clause, the pulse is floating yet reveals slowness; diarrhea with undigested food occurs without prior erroneous purgation, indicating empty-heat at the exterior and true cold within. Whenever treating deficiency syndromes, Zhang Zhongjing prioritizes regulating the interior.
[General Principle] Zhang Zhongjing stated: In cases of diarrhea with undigested food, one must not attack the exterior (use diaphoresis). Sweating will inevitably lead to abdominal distension.
[Commentary] Zhang Jianshan stated: Since the interior qi is already deficient, how can it store essence and serve as the guardian of yang? Fortunately, if exterior yang remains, it can protect the exterior, preventing deterioration. However, if one again attacks the exterior, the exterior qi will become deficient. Exterior deficiency leads to sweat leakage; loss of sweat results in loss of yang, causing the zang organs to become cold and generate distension. How can one not be vigilant?
[General Principle] Zhang Zhongjing stated: After a Taiyang cold injury has been treated with purgation, if diarrhea with undigested food persists incessantly, accompanied by body pain, one must urgently rescue the interior. Sini Decoction is appropriate.
[Commentary] Xu Bin stated: When a patient suffers from illness and the physician erroneously uses purgation, leading to incessant diarrhea with undigested food and body pain, one must urgently rescue the interior. Later, if body pain persists but bowel movements normalize, one must urgently rescue the exterior. This illustrates that physicians must understand the order of urgency and priority. Treating exterior and interior separately is the general rule. However, when both exterior and interior syndromes exist, especially if caused by erroneous purgation, one cannot simply resolve both simultaneously as with residual pathogens. Even with body pain, the exterior should not be treated, as delaying might allow exterior pathogens to fully enter the interior. Hence, "urgently rescue the interior." Once bowels are regulated but pain persists, one must not ignore it as mere residual pathogen, because previous diarrhea implies the interior is vulnerable to re-invasion by exterior pathogens, potentially causing persistent diarrhea. Hence, "urgently rescue the exterior."
[General Principle] Zhang Zhongjing stated: In cases of simultaneous vomiting and diarrhea, frequent urination, profuse sweating, diarrhea with undigested food, internal cold and external heat, and a faint pulse nearly imperceptible, Sini Decoction is indicated.
[Commentary] Huang Zhongli stated: This results from the loss of qi and blood, leading to the excretion of undigested food and a faint, nearly imperceptible pulse.