【纲】仲景曰。脉浮而迟。表热里寒。下利清谷者。四逆汤主之。
【目】柯琴曰。浮中见迟。是浮为表虚。迟为脏寒。未经妄下而利清谷。是表为虚热。里有真
寒矣。
【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】成无己曰。吐利亡津液。则小便宜少。小便复利而大汗出。津液不禁。阳气大虚也。脉
微为亡阳。若无外热。但内寒。下利清谷。为纯阴。此以外热为阳未绝。犹可与通脉四逆汤救之。
【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。或咽痛。或利止脉不出者。通脉四逆汤主之。
【目】喻昌曰。下利里寒。种种危殆。其表反热。其面反赤。其身反不恶寒。而手足厥。脉欲
绝。明系群阴格阳于外不能内返也。故仿白通之法。加入四逆中。以入阴迎阳也。
魏荔彤曰。脉者本阴阳相合而无间之神也。今阴独阳无。脉故微绝。必复回其阳。俾与阴两相
调匀。而后脉可得通。酌用四逆为主。更增减之。使阳回脉通。此于脉出不出。见愈不愈之机。从
至险处立救法也。
【纲】仲景曰。下利清谷。里寒外热。汗出而厥者。通脉四逆汤主之。
【目】许叔微曰。此条比之上条。其症较轻也。
【纲】仲景曰。少阴病。恶寒而蜷。时自烦。欲去衣被者。可治。
【目】王肯堂曰。表热里寒者。脉虽沉而迟。手足厥逆。下利清谷。此里寒也。所以阴症亦有
发热者。此表解也。表寒里热者。脉必滑。身厥舌干也。所以少阴恶寒而蜷。此表寒也。时时自烦。
不欲近衣。此里热也。
魏荔彤曰。此不言下利。则阳旺于中焦。较他条下利而利自止者。又胜。虽恶寒足蜷。亦见少
阴症象。然阳时烦而阴不躁。且欲去衣被。内有阳存。不须言矣。不但当辨其经邪脏邪。为温为汗。
本易为力。且当识其烦而欲去衣被之故。为阳存之有余。而扶阳抑阴。亦不可过为猛烈矣。此又阴
病见阳症易治之一也。
[General Principle] Zhang Zhongjing stated: When the pulse is floating and slow, it indicates exterior heat and interior cold. If there is diarrhea with undigested food in the stool (clear谷物), Si Ni Tang (Four Reversal Decoction) should be administered.
[Annotation] Ke Qin stated: A floating pulse accompanied by slowness indicates that the floating nature represents exterior deficiency, while slowness indicates cold in the zang organs. Diarrhea with undigested food occurring without prior erroneous purgation indicates that the exterior condition is deficient heat, while the interior contains true cold.
[General Principle] Zhang Zhongjing stated: When there is both vomiting and diarrhea, urination is frequent/clear, profuse sweating occurs, diarrhea involves undigested food, there is interior cold with exterior heat, and the pulse is faint and nearly imperceptible, Si Ni Tang (Four Reversal Decoction) should be administered.
[Annotation] Cheng Wuji stated: Vomiting and diarrhea deplete body fluids (Jin Ye), so urination should normally decrease. The fact that urination remains clear/frequent despite profuse sweating indicates that body fluids are uncontrolled due to severe yang deficiency. A faint pulse signifies loss of yang. Without exterior heat, only interior cold with diarrhea of undigested food constitutes a pure yin syndrome. However, the presence of exterior heat indicates that yang has not yet perished, and Tong Mai Si Ni Tang (Pulse-Returning Four Reversal Decoction) can still be used for rescue.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease (Lesser Yin Disease), if there is diarrhea with undigested food, interior cold with exterior heat, cold extremities (Jue Ni), a faint and nearly imperceptible pulse, the body feels no aversion to cold, the patient's face appears red, or there is abdominal pain, dry heaving, sore throat, or cessation of diarrhea with an unpalpable pulse, Tong Mai Si Ni Tang (Pulse-Returning Four Reversal Decoction) should be administered.
[Annotation] Yu Chang stated: Diarrhea with interior cold presents various critical dangers. The fact that the exterior feels hot, the face is red, the body is not averse to cold, yet the extremities are cold and the pulse is about to vanish, clearly indicates that yin pathogens are repelling yang to the exterior, preventing its return inward. Therefore, following the method of Bai Tong Tang (White Connecting Decoction), herbs are added to Si Ni Tang (Four Reversal Decoction) to enter the yin level and welcome the return of yang.
Wei Litong stated: The pulse is originally the manifestation of spirit where yin and yang combine without gap. Now, with yin existing alone and yang absent, the pulse becomes faint and nearly vanished. Yang must be restored so that yin and yang harmonize evenly, allowing the pulse to become accessible. Using Si Ni Tang (Four Reversal Decoction) as the main formula, modified according to circumstances, restores yang and opens the pulse. This determines the prognosis based on the presence or absence of the pulse, establishing emergency treatment methods at the brink of extreme danger.
[General Principle] Zhang Zhongjing stated: With diarrhea involving undigested food, interior cold with exterior heat, sweating, and cold extremities, Tong Mai Si Ni Tang (Pulse-Returning Four Reversal Decoction) should be administered.
[Annotation] Xu Shuwei stated: Compared to the previous clause, the symptoms here are milder.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease (Lesser Yin Disease), if the patient is averse to cold and curled up, yet occasionally feels vexed and desires to remove clothing and bedding, the condition is treatable.
[Annotation] Wang Kentang stated: In cases of exterior heat and interior cold, although the pulse may be deep and slow, with cold extremities and diarrhea of undigested food, this is interior cold. Thus, yin syndromes can also present with fever when the exterior pathogen has resolved. In cases of exterior cold and interior heat, the pulse is typically slippery, accompanied by cold limbs and a dry tongue. Thus, in Shaoyin disease, aversion to cold and curling up indicate exterior cold; occasional internal vexation and desire to avoid covering oneself indicate interior heat.
Wei Litong stated: The absence of diarrhea mentioned here suggests that yang qi is vigorous in the middle jiao, which is better than conditions where diarrhea stops spontaneously. Although there is aversion to cold and curling of the feet, reflecting Shaoyin signs, the occasional yang-related vexation without yin agitation, and the desire to remove coverings, indicate the presence of interior yang. It is not necessary to elaborate further. One must distinguish whether the pathogen is in the meridians or zang organs to decide between warming or sweating methods, which is straightforward. Furthermore, one must understand the reason for vexation and the desire to remove coverings: it stems from surplus yang. Therefore, when supporting yang and suppressing yin, overly harsh measures should be avoided. This is another instance where yin diseases presenting with yang signs are easier to treat.