【纲】仲景曰。脉阴阳俱紧者。口中气出。唇口燥干。鼻中涕出。蜷卧足冷。舌上胎滑。勿妄
治也。到六七日以来。其人微发热。手足温者。此为欲解。或到八日以上。反大发热者。此为难治。
设使恶寒者。必欲呕也。腹内痛者。必欲利也。
【目】柯琴曰。设使到七日来。以阴阳俱紧之脉。不发热反恶寒。是寒甚于表。上焦应之。必
欲呕也。反腹痛。是寒甚于里。中焦受之。必欲利也。
【纲】仲景曰。少阴病。二三日不已。至四五日。腹痛。小便不利。四肢沉重疼痛。自下利者。
此为有水气。其人或咳。或小便利。或下利。或呕者。真武汤主之。
【目】魏荔彤曰。此申解少阴病有水气为兼症。当于温里之中。寓镇奠之义。盖兼水气。则不
特寒邪。亦湿寓焉。如二三日不已。就脏邪言也。至四五日腹痛。必隐隐常痛。乃寒湿凝滞之象。
非时痛时止之热痛也。且寒湿痛必兼满。按之少可。而非热痛不欲近人也。且验小便不利。湿盛而
气壅也。单为寒。色白且利。兼湿。虽白不利。此寒热之可据者也。且单寒。则身体骨节痛而不沉
重。兼湿。则沉重多而痛少。故先言沉重。后言疼痛。就缓急言也。或自下利。亦湿邪下注。惟小
便不利。则大便湿行。种种审谛。知其人有水气兼寒邪。得中少阴。亦如太阳有水气。更感风寒。
以水气为兼病。而治法必当更为推求也。咳呕皆水气上逆。亦有小便自利者。则寒湿又兼虚气不能
收摄之故。膀胱与肾表里。水气浸淫于腑。阴寒固冱于脏。法当温脏回阳。以治寒邪。燥脾暖土。
以制水气。故主真武汤。而以附子治寒邪。其余治水气也。
【纲】仲景曰。少阴病。二三日至四五日。腹痛。小便不利。下利不止。便脓血者。桃花汤主之。
【目】魏荔彤曰。腹痛小便不利。乃热在下焦。熏蒸中焦。使气化因热郁不行。大便因热盛而
自利也。利久不止。肠胃间秽浊之物。如脓带血。尽随大便而下。热不消。利不止。危矣。故用本
汤以固涩之。
【纲】仲景曰。下利腹胀满。身体疼痛。先温其里。
【目】庞安常曰。下利。里寒也。身疼。表寒也。先温里。从本治也。
【纲】仲景曰。少阴病。四逆。其人或咳。或悸。或小便不利。或腹中痛。或泄利下重者。四
逆散主之。
【目】魏荔彤曰。此申解少阴热邪。散见四末。热极似寒。手足逆冷之症。不可误认为寒。逆而
妄治也。少阴病。热邪能弥漫于上下。亦能流行于四肢。可以为热厥似寒厥以误人。此少阴病热极似
寒。寒极似热。大有真假。当详为考辨。不可就病言病。失毫厘而谬千里也。如四逆。本寒邪也。
或咳或悸。即热邪上冲。咽痛心烦之变出者也。小便不利。腹中痛。泄利下重。即热邪下行。热在
膀胱。下血下脓之变出者也。然则此逆非寒逆。直可名之曰热逆也。夫热。但厥不逆。兹何以曰
热逆。不知寒固逆而厥。热逆亦厥。有阴阳不顺接之厥在内。有真热似寒之厥亦在内。不容不严辨
也。于此等症。必合脉与症以为辨。他条沉数二字。原足以定传经之热邪。合观诸条脉沉。复微而紧
细。又足以定直中之寒邪。再按他条之症口中和三字。亦足以知内为真寒。咽中痛三字。亦足以知内
为真热。明乎此。则少阴前篇之大热似寒。少阴后篇之大寒似热。俱可洞如观火矣。此皆最要之处。
生死关头。温凉失度。顷刻人亡。岂细故乎。仲师于此用四逆散。名亦四逆也。而汤散之义不同
也。
凡厥逆中。自有寒湿杂合。所谓阴阳不顺接也。至于诸痛。亦必杂合交结方痛。故药亦杂合。
然后专寒专热之品。可开结止痛也。泄利至于下重。即滞下之意。金匮要略主用小柴胡。亦杂合寒
热之治。故四逆散一方。近小柴胡。
[General Principle] Zhang Zhongjing stated: When the pulse is tight at all three positions (cun, guan, chi), with hot breath exhaled from the mouth, dry lips and oral cavity, clear nasal discharge, a curled-up posture while lying down, and cold feet, with a slippery coating on the tongue, do not treat rashly. After six or seven days, if the patient exhibits slight fever and warm hands and feet, this indicates that the disease is about to resolve. However, if after eight or more days, high fever appears instead, it is difficult to treat. If accompanied by aversion to cold, vomiting is likely; if accompanied by abdominal pain, diarrhea is likely.
[Commentary] Ke Qin said: Assuming that by the seventh day, given the pulse of tightness in both yin and yang positions, if there is no fever but rather aversion to cold, it indicates severe cold in the exterior affecting the upper jiao, leading to vomiting. If abdominal pain occurs instead, it indicates severe cold in the interior affecting the middle jiao, leading to diarrhea.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease (a syndrome caused by pathogenic factors invading the Shaoyin meridian), if it persists for two to three days and progresses to four or five days, presenting with abdominal pain, difficulty in urination, heaviness and pain in the four limbs, and spontaneous diarrhea, this is due to the presence of fluid retention (water qi). Among these patients, some may have cough, or normal urination, or diarrhea, or vomiting. Zhenwu Tang (True Warrior Decoction) should be used as the primary treatment.
[Commentary] Wei Litong explained: This further clarifies that in Shaoyin disease, fluid retention acts as a concurrent symptom. The treatment should incorporate the principle of stabilizing and anchoring within the method of warming the interior. Since fluid retention is present, not only is there cold pathogen, but dampness also attaches to it. For instance, persistence for two to three days refers to the pathogen residing in the zang organs. By four or five days, abdominal pain manifests as a constant, dull ache, which is a sign of stagnation due to cold-dampness, distinct from intermittent heat pain. Furthermore, pain caused by cold-dampness is typically accompanied by distension and feels relieved upon pressure, unlike heat pain which dislikes touch. Verifying difficulty in urination indicates excessive dampness causing qi stagnation. Pure cold results in white, free-flowing stool; combined with dampness, although white, the flow is obstructed. This serves as a basis for distinguishing cold from heat. Additionally, pure cold causes pain in the body and joints without heaviness; combined with dampness, heaviness predominates over pain. Thus, heaviness is mentioned before pain, reflecting the urgency of symptoms. Spontaneous diarrhea also results from dampness sinking downward. Only when urination is difficult does the stool become loose. Careful examination reveals fluid retention accompanying cold pathogen entering the Shaoyin channel. Similar to Taiyang disease where fluid retention complicates wind-cold invasion, the treatment strategy requires deeper investigation. Cough and vomiting result from the rebellion of fluid retention upward. In cases where urination is normal, it is due to deficiency qi failing to retain fluids alongside cold-dampness. The Bladder and Kidney are exterior-interior pairs; fluid retention invades the fu organs, while yin-cold solidifies in the zang organs. The method should warm the kidney and restore yang to treat cold, and dry the spleen and warm the earth to control fluid retention. Therefore, Zhenwu Tang is prescribed, using Fuzi (Prepared Lateral Root of Aconite) to treat cold, while other herbs address fluid retention.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease, progressing from two to three days to four or five days, presenting with abdominal pain, difficulty in urination, persistent diarrhea, and pus and blood in the stool, Taohua Tang (Peach Blossom Decoction) should be used.
[Commentary] Wei Litong said: Abdominal pain and difficulty in urination indicate heat in the lower jiao steaming the middle jiao, causing qi transformation to be blocked by heat stagnation, leading to spontaneous diarrhea due to excess heat. If diarrhea persists for a long time, turbid matter in the intestines and stomach, resembling pus and blood, will pass with the stool. If heat is not eliminated, diarrhea will not stop, which is critical. Therefore, this decoction is used to astringe and stop diarrhea.
[General Principle] Zhang Zhongjing stated: In cases of diarrhea with abdominal fullness and body pain, one should first warm the interior.
[Commentary] Pang Anchang said: Diarrhea indicates interior cold; body pain indicates exterior cold. Warming the interior first treats the root cause.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease, presenting with cold extremities (Jue), and among these patients, some may have cough, palpitations, difficulty in urination, abdominal pain, or diarrhea with a sensation of rectal tenesmus (heaviness/restriction at the anus), Sini San (Four Reversal Powder) should be used.
[Commentary] Wei Litong said: This further explains that in Shaoyin disease, heat pathogens disperse to the extremities. Extreme heat can mimic cold, causing cold extremities. One must not mistake this for cold and treat rashly. Heat pathogens in Shaoyin disease can diffuse upwards and downwards or circulate through the limbs, creating Heat Jue (cold extremities due to internal heat obstruction) that mimics Cold Jue (cold extremities due to internal cold deficiency), potentially misleading diagnosis. This represents the complexity of extreme heat mimicking cold and extreme cold mimicking heat, requiring careful differentiation. Do not judge the disease superficially, lest a minor error lead to significant deviation. For example, cold extremities are originally caused by cold pathogens; cough or palpitations are variations of heat pathogens rushing upward, manifesting as sore throat and irritability. Difficulty in urination, abdominal pain, and diarrhea with rectal tenesmus are variations of heat pathogens moving downward, involving heat in the bladder, manifesting as bloody or purulent stools. Thus, this type of cold extremity is not cold Jue but can be termed Heat Jue. While heat typically causes Jue (extremity cold) without necessarily causing "Ni" (reversal/coldness extending up), here it is called "Re Ni" (Heat Reversal). It is unknown that cold naturally causes reversal and Jue, but heat-induced reversal also causes Jue. There is Jue due to failure of yin and yang qi to connect smoothly, and there is Jue due to true heat mimicking cold. Strict differentiation is necessary. For such symptoms, pulse and signs must be combined for differentiation. The terms "deep and rapid" in other clauses determine transmitted heat pathogens; observing deep pulses that are also faint, tight, and thin determines direct invasion of cold pathogens. Furthermore, "mouth feels neutral" in other clauses indicates true interior cold, while "sore throat" indicates true interior heat. Understanding this allows one to clearly see the great heat mimicking cold in the earlier Shaoyin chapters and the great cold mimicking heat in the later chapters. These are critical junctures of life and death; improper use of warming or cooling agents can lead to death instantly. Is this a trivial matter? Zhang Zhongjing uses Sini San here. Although named "Sini" (Four Reversals), the meaning of the powder form differs from the decoction form. In all cases of Jue, there is often a mixture of cold and dampness, described as the failure of yin and yang qi to connect smoothly. Regarding various pains, they must also involve mixed and intertwined pathogens to occur. Therefore, the prescription involves mixed herbs. Only then can specific cold or specific heat herbs effectively open blockages and relieve pain. Diarrhea with rectal tenesmus implies dysentery. The *Jin Gui Yao Lue* advocates using Xiao Chai Hu Tang (Minor Bupleurum Decoction), which is also a treatment combining cold and heat. Thus, Sini San is close in nature to Xiao Chai Hu Tang.