【纲】仲景曰。少阴病。身体痛。手足寒。骨节痛。脉沉者。附子汤主之。
【目】鳌按。本条纯阴无阳。阴寒切肤。故身体痛。四肢无阳。故手足寒。阴寒内注。故骨节
疼。则此身疼骨痛。虽与麻黄症相似。而寒热阴阳。彼此判然。
此身体骨节疼痛。固非太阳之症。并非少阴之经。直属少阴之脏。盖肾主骨。肾寒故骨疼。即此
一端。盒饭急救其脏中之阳矣。舍附子汤。曷足以济。
【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。
病发热头疼。脉反沉。汗之。若不瘥。身体疼痛者。当救其里。宜四逆汤。
【目】柯琴曰。病为在表。脉当浮。今曰脉反沉。此为逆。汗之不瘥。即身体疼痛不罢。当凭
其脉之沉而为在里矣。
表宜温散。里宜温补。先救里。治其本也。
【纲】仲景曰。少阴病。下利。若利自止。恶寒而蜷卧。手足温者。可治。少阴病。恶寒身蜷
而利。手足逆冷者。不治。
【目】成无己曰。蜷者。屈缩不伸也。皆阴寒之极。虽在阳经。见是症者。即有表症。亦宜用
温经之剂。桂枝附子是也。况在三阴。里寒下利厥逆者乎。四逆之类。其可缺诸。若有阴无阳者。
为不治。
【纲】仲景曰。少阴病。恶寒而蜷。时自烦。欲去衣被者。可治。少阴病。四逆。恶寒而身蜷。
脉不至。不烦而躁者死。
【目】魏荔彤曰。少阴寒邪。固有在经在脏之不同。而治之之法。必以存阳为第一义。脏邪温
之。固存阳也。即经邪汗
之。亦存阳也。舍此无他计也。如前条利忽自止。则阳盛于中焦。不致随阴沉陷。恶寒蜷卧。虽纯
为阴寒之象。而手足能温。则真阳自在。于此审其为脏邪。温之固易。即审其为经邪。汗之亦易。
故曰可治。又如本条。并不下利。则阳更旺于中焦。虽恶寒足蜷。亦见少阴症象。然阳时烦而欲去
衣被。内有阳存。而扶阳抑阴。亦不可过为猛烈也。其经邪脏邪之当审。而温之汗之。又不待言矣。
至次条。不烦而躁。则阳已离阴。阴孤求侣不得。扰乱不宁。所谓阴躁者也。宜其死矣。
[General Principle] Zhang Zhongjing stated: In Shaoyin disease, characterized by body pain, coldness of the hands and feet, pain in the bone joints, and a deep pulse (Chen Mai), Fuzi Tang (Aconite Decoction) is the primary treatment.
[Commentary] Shen Jin'ao notes: This syndrome is purely Yin-cold without Yang energy. The Yin-cold pathogen penetrates the skin, causing body pain; the lack of Yang warming in the four limbs results in cold hands and feet; the internal infiltration of Yin-cold leads to pain in the bone joints. Therefore, although this body and bone pain resembles the exterior excess pattern treated with Mahuang Tang (Ephedra Decoction), the nature of Cold-Heat and Yin-Yang are distinctly different between the two.
This pain in the body and bone joints is certainly not a Taiyang meridian symptom, nor merely a Shaoyin meridian issue, but directly belongs to the Shaoyin Zang (Kidney) pathology. Since the Kidney governs the bones, coldness in the Kidney causes bone pain. From this single aspect, it is imperative to urgently rescue the Yang Qi within the Zang. Aside from Fuzi Tang, what other formula could suffice for such rescue?
[General Principle] Zhang Zhongjing stated: After a Shaoyang disease has been treated with purgation, if persistent diarrhea with undigested food (Qing Gu) continues, accompanied by body pain, one must urgently treat the interior deficiency-cold, preferably using Sini Tang (Frigid Extremities Decoction).
If a patient presents with fever, headache, and a paradoxically deep pulse, and after sweating therapy the condition does not improve, with body pain persisting, one should also prioritize treating the interior deficiency-cold, preferably using Sini Tang (Frigid Extremities Decoction).
[Commentary] Ke Qin stated: When the pathogen is in the exterior, the pulse should be floating (Fu Mai). The statement that the pulse is paradoxically deep indicates an adverse condition. If sweating therapy fails to resolve the condition and body pain persists, one should determine the interior location of the disease based on the deep pulse.
Exterior patterns should be treated with warming dispersal methods, while interior patterns require warming tonification. Treating the interior first addresses the root cause.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease, if diarrhea occurs but stops spontaneously, and although there is aversion to cold and curling up in bed, the hands and feet are warm, the prognosis is treatable. In Shaoyin disease, if there is aversion to cold, curling up in bed, diarrhea, and cold reversal of the hands and feet (Ni Leng), the prognosis is untreatable.
[Commentary] Cheng Wuji explained: "Quan" refers to a state of flexion and contraction where the limbs cannot extend. This signifies extreme Yin-cold. Even if such symptoms appear in Yang meridians, even if exterior symptoms exist, warming meridian formulas such as Guizhi Fuzi Tang (Cinnamon Twig and Aconite Decoction) should be used. How much more so in the Three Yin meridians presenting with interior cold, diarrhea, and cold reversal? Formulas like Sini Tang (Frigid Extremities Decoction) cannot be omitted. If there is Yin without Yang, it is considered untreatable.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease, with aversion to cold and curling up in the body, if there is occasional mental restlessness (Fan) and a desire to remove clothing and blankets, the prognosis is treatable. In Shaoyin disease, with cold reversal of the four limbs, aversion to cold, curling up in the body, an absent pulse, absence of mental restlessness but presence of agitation (Zao), the prognosis is fatal.
[Commentary] Wei Litong stated: Shaoyin cold pathogens may reside in the meridians or the Zang organs, but the therapeutic principle must prioritize preserving Yang Qi. Warming the Zang pathogens preserves Yang; even sweating the meridian pathogens preserves Yang. There is no other method.
In the previous case, the spontaneous cessation of diarrhea indicates that Yang Qi is vigorous in the Middle Jiao and will not sink with the Yin-cold. Although aversion to cold and curling up are pure Yin-cold signs, warm hands and feet indicate that True Yang remains. Whether identifying it as a Zang pathogen (treated with warming) or a meridian pathogen (treated with sweating), the approach is clear. Hence, it is "treatable."
In the current case, the absence of diarrhea suggests even stronger Yang Qi in the Middle Jiao. Although there is aversion to cold and curling up, reflecting Shaoyin symptoms, the occasional mental restlessness and desire to remove coverings indicate that Yang still exists internally. In supporting Yang and suppressing Yin, the medication should not be excessively harsh. The distinction between meridian and Zang pathogens and the application of sweating or warming methods are self-evident.
Regarding the next case, the absence of mental restlessness but presence of agitation indicates that Yang has separated from Yin. Yin is isolated and seeking companionship but failing, leading to chaotic unrest, known as "Yin Agitation" (Yin Zao). Such a condition is indeed fatal.