伤寒脉促。手足厥逆。可灸之。（【原注】促。一作纵。○成本。玉函。逆下。有者字。）
〔喻〕伤寒脉促。则阳气 可知。更加手足厥逆。其阳必为阴所格拒。而不能返。故宜灸以通其阳也。
案汪引常器之云。灸太冲穴。未知是否。
伤寒脉滑而厥者。里有热。白虎汤主之。（成本。玉函。热下。有也字。）
〔钱〕滑者。动数流利之象。无沉细微涩之形。故为阳脉。乃伤寒郁热之邪在里。阻绝阳气。不得畅达
于四肢而厥。所谓厥深热亦深也。〔鉴〕伤寒脉微细。身无热。小便清白而厥者。是寒虚厥也。当温之。脉乍
紧。身无热。胸满而烦。厥者。是寒实厥也。当吐之。脉实大。小便闭。腹满硬痛而厥者。热实厥也。当下之。
今脉滑而厥。滑为阳脉。里热可知。是热厥也。然内无腹满痛不大便之证。是虽有热。而里未实。不可下而可
清。故以白虎汤主之。〔印〕此章因厥故。复列于厥阴篇中。亦非厥阴之本病也。
活人书云。热厥者。国中病。必身热头痛。外别有阳证。至二三日。乃至四五日。方发厥。其热厥者。
厥至半日。却身热。盖热气深。则方能发厥。须在二三日后也。若微厥。即发热者。热微故也。其脉虽沉伏。
按之而滑。为里有热。其人或畏热。或饮水。或扬手掷足。烦躁不得眠。大便秘。小便赤。外证多昏愦者。知
其热厥。白虎汤。又有下证悉具。而见四逆者。是失下后。血气不通。四肢便厥。医人不识。却疑是阴厥。复
进热药。祸如反掌。大抵热厥。须脉沉伏而滑。头上有汗。其手虽冷。时复指爪温。须便用承气汤下之。不可
拘忌也。
手足厥寒。脉细欲绝者。当归四逆汤主之。（玉函。千金翼。作脉为之细绝。无者字。）
〔钱〕四肢为诸阳之本。邪入阴经。致手足厥而寒冷。则真阳衰弱可知。其脉微细欲绝者。素问脉要精
微论云。脉者血之府也。盖气非血不附。血非气不行。阳气既已虚衰。阴血自不能充实。当以四逆汤。温复其
真阳。而加当归以营养其阴血。故以当归四逆汤主之。
当归四逆汤方
当归（三两） 桂枝（三两去皮） 芍药（三两） 细辛（三两○玉函。作一两。） 甘草（二两炙）
通草（二两） 大枣（二十五枚擘一法十二枚○枚。成本。作个。）
上七味。以水八升。煮取三升。去滓。温服一升。日三服。
〔钱〕手足厥寒。即四逆也。故当用四逆汤。而脉细欲绝。乃阳衰而血脉伏也。故加当归。是以名之曰
当归四逆汤也。不谓方名虽曰四逆。而方中并无姜附。不知何以挽回阳气。是以不能无疑也。恐是历年久远。
散失遗亡。讹舛于后人之手。未可知也。从来注伤寒家。皆委曲顺解。曾不省察其理。
亦何异于成氏之随文顺释乎。〔柯〕此条证为在里。当是四逆本方加当归。如茯苓四逆之例。若反用桂枝汤攻表。
误矣。既名四逆汤。岂得无姜附。
若其人内有久寒者。宜当归四逆加吴茱萸生姜汤。
〔钱〕此承上文言。手足厥寒。脉细欲绝。固当以当归四逆治之矣。若其人平素。内有久寒者。而又为客
寒所中。其涸阴冱寒。难于解散。故更加吴茱萸之性燥苦热。及生姜之辛热以泄之。而又以清酒。扶助其阳气。
流通其血脉也。
当归四逆加吴茱萸生姜汤方
当归（三两） 芍药（二两炙○玉函。作三两。） 通草（二两○玉函。作三两。） 桂枝（三两去皮）
细辛（三两） 生姜（半斤切○千金翼作八两。方周钱鉴。作三两。） 大枣（二十五枚擘） 茱萸（二升○
玉函。千金翼。作吴茱萸二两。方周钱鉴。作半斤。）
上九味。以水六升。清酒六升。和煮取五升。去滓。温分五服。（【原注】一方。水酒各四升。○玉函。
千金翼。并用水酒各四升。）
〔柯〕此本是四逆。与吴茱萸相合。而为偶方也。吴茱萸。配附子。生姜佐干姜。久寒始去。
严氏济生方。通脉四逆汤。治霍乱多寒。肉冷脉绝。
即本方。加附子。
大汗出。热不去。内拘急。四肢疼。又下利厥逆而恶寒者。四逆汤主之。（千金翼。无内字。又作若。）
〔鉴〕通身大汗出。热当去矣。热仍不去。而无他证。则为邪未尽而不解也。今大汗出热不去。而更见拘
急肢疼。且下利厥逆而恶寒。是阳亡于表。寒盛于里也。故主四逆汤。温经以胜寒。回阳而敛汗也。〔汪〕内
拘急。此寒气深入于里。寒主收引。当是腹以内拘急。
案方氏云。内拘急。四肢疼者。亡津液而骨气不利也。乃以内拘急。为手足拘急。然内字不妥帖。
大汗若大下利。而厥冷者。四逆汤主之。（玉函。千金翼。汗下。有出字。）
〔钱〕上条大汗出。而热不去。此条大汗出。而不言热。是无热矣。或曰。上文下利厥逆而恶寒。且多
内拘急四肢疼之证。此条亦大下利厥冷。而不恶寒。其不言热。乃阳气犹未飞越于外。得毋较前为稍轻乎。曰
无热则阳气更微。大下利则阴邪更盛。故亦以四逆汤主之。
案玉函经。此下有两条。曰表热里寒者。脉虽沉而迟。手足微厥。下利清谷。此里寒也。所以阴证亦有
发热者。此表热也。曰表寒里热者。脉必滑。身厥舌干也。所以少阴恶寒而倦。此表寒也。时时自烦。不欲浓
衣。此里热也。
病患手足厥冷。脉乍紧者。邪结在胸中。心下满而烦。饥不能食者。病在胸中。当须吐之。宜瓜蒂散。
（辨可吐篇。乍紧。作乍结。成本。玉函。心下。作心中。）
〔印〕曰病患者。非厥阴之为病。而亦非外受之寒邪也以手足厥冷。故列于厥阴篇中。〔鉴〕病患手足厥
冷。若脉微而细。是寒虚也。寒虚者可温可补。今脉乍紧劲。是寒实也。寒实者。宜温宜吐也。时烦吐蛔。饥
不能食。乃病在胃中也。今心中烦满。饥不能食。是病在胸中也。寒饮实邪。壅塞胸中。则胸中阳气。为邪所
遏。不能外达四肢。是以手足厥冷。胸满而烦。饥不能食也。当吐之。宜瓜蒂散。涌其在上之邪。则满可消。
而厥可回矣。
伤寒厥而心下悸。宜先治水。当服茯苓甘草汤。却治其厥。不尔水渍入胃。必作利也。（成本。玉函。
悸下。有者字。玉函。作与。）
〔钱〕金匮云。水停心下。甚者则悸。太阳篇中。有饮水多者。心下必悸。此二语。虽皆仲景本文。然此
条并不言饮水。盖以伤寒见厥。则阴寒在里。里寒则胃气不行。水液不
布。必停蓄于心下。阻绝气道。所以筑筑然而悸动。故宜先治其水。当服茯苓甘草汤。以渗利之。然后却与治
厥之药。不尔则水液既不流行。必渐渍入胃。寒厥之邪在里。胃阳不守。必下走而作利也。〔鉴〕伤寒太阳篇。
汗出表未和。小便不利。此条伤寒表未解。厥而心下悸。二证皆用茯苓甘草汤者。盖因二者见证虽不同。而里
无热表未和。停水则同也。故一用之谐和营卫以利水。一用之解表通阳以利水。无不可也。此证虽不曰小便不
利。而小便不利之意自在。若小便利。则水不停。则厥悸属阴寒矣。岂宜发表利水耶。〔汪〕郭雍云。以四逆
汤治厥。
金鉴云。厥而心下悸者之下。当有以饮水多四字。若无此四字。乃阴盛之悸。非停水之悸矣。何以即知是
水。而曰宜先治水耶。○案此说近是。汪氏周氏。以此条证。为热厥兼停水。误矣。
伤寒六七日。大下后。寸脉沉而迟。手足厥逆。下部脉不至。喉咽不利。唾脓血。泄利不止者。为难治。
麻黄升麻汤主之。（玉函。无而字。喉咽。作咽喉。成本同。千金翼。无寸字。）
〔柯〕寸脉沉迟。气口脉平矣。下部脉不至。根本已绝矣。六腑气绝于外者。手足寒。五脏气绝于内者。
利下不禁。喉咽不利。水谷之道绝矣。汁液不化。而成脓血。下濡而上逆。此为下厥上竭。阴阳离决之候。生
气将绝于内也。麻黄升麻汤。其方味数多。而分两轻。重汗散而畏温补。乃后世粗工之伎。必非仲景方也。此
证此脉。急用参附以回阳。尚恐不救。以治阳实之品治亡阳之证。是操戈下石矣。敢望其汗出而愈哉。绝汗出
而死。是为可必。仍附其方。以俟识者。
麻黄升麻汤方
麻黄（二两半去节） 升麻（一两一分） 当归（一两一分○玉函。升麻。当归。各
一两六铢。千金翼同。） 知母（十八铢） 黄芩（十八铢） 葳蕤（十八铢一作菖蒲） 芍药（六铢） 天门
冬（六铢去心○玉函。千金翼。作麦门冬。） 桂枝（六铢） 茯苓（六铢） 甘草（六铢炙） 石膏（六铢碎
绵裹） 白术（六铢） 干姜（六铢）
上十四味。以水一斗。先煮麻黄一两沸。去上沫。纳诸药。煮取三升。去滓。分温三服。相去如炊三斗
米顷令尽。汗出愈。
案此条。证方不对。注家皆以为阴阳错杂之证。回护调停。为之诠释。而柯氏断然为非仲景真方。可谓
千古卓见矣。兹不敢繁引诸说云。○又案外台引短剧。载本方。方后云。此张仲景伤寒论方。
伤寒选录云。此药之大者。若瘟毒瘴利。表里不分。毒邪沉炽。或咳或脓或血者。宜前药。
伤寒四五日。腹中痛。若转气下趣少腹者。此欲自利也。（此。玉函。作为。趣。正脉本。作趋。诸本
同。唯方本作趣。）
〔钱〕伤寒四五日。邪气入里。传阴之时也。腹中痛。寒邪入里。胃寒而太阴脾土病也。转气下趋少腹
者。言寒邪盛。而胃阳不守。水谷不别。声响下奔。故为欲作自利也。〔周〕愚案腹中痛。又何以知是虚寒。
若火痛。必自下逆攻而上。若热痛。必胸结烦满而实。故下气转趋。知为寒欲利无疑也。
伤寒本自寒下。医复吐下之。寒格更逆吐下。若食入口即吐。干姜黄芩黄连人参汤主之。（复吐下之。
玉函。千金翼。全书。作复吐之。玉函。无若字。即吐。作即出者。千金翼。寒格上。有而字。）
〔王〕案本自寒下。恐是本自吐下。玩复字可见。盖胃寒则吐。下寒则利。胃寒者不宜吐。医反吐之。
则伤胃气。遂成寒格。下文文气不贯。当有阙文。
金鉴云。经论中。并无寒下之病。亦无寒下之文。玩本条下文。寒格更逆吐下。可知寒下之下字。当是
格字。文义
始属。注家皆释胃寒下利。不但文义不属。且与芩连之药不合。○案柯本。删更逆吐下四字。要之此条。必有误脱。
干姜黄芩黄连人参汤方
干姜 黄芩 黄连 人参（各三两）
上四味。以水六升。煮取二升。去滓。分温再服。
〔柯〕伤寒吐下后。食入口即吐。此寒邪格热于上焦也。虽不痞硬。而病本于心。故用泻心之半。调其
寒热。以至和平。去生姜半夏者。心下无水气也。不用甘草大枣者。呕不宜甘也。〔鉴〕朝食暮吐。脾寒格也。
食入即吐。胃热格也。寒格。当以理中汤。温其太阴。加丁香降其寒逆。可也。热格。当用干姜人参安胃。黄
连黄芩。降胃火也。
案金匮。食已即吐者。大黄甘草汤主之。金鉴注文。与此条意同。
保幼大全。四味人参汤。治伤寒脉迟。胃冷呕吐。（即本方）
下利有微热而渴。脉弱者。令自愈。（令。成本。作今。玉函无。）
〔程〕下利脉绝者死。脉实者亦死。必何如而脉与证合也。缘厥阴下利。为阴寒胜。微热而渴。则阳热
复也。脉弱。知邪已退。而经气虚耳。故令自愈。〔钱〕脉弱者。方见其里气本然之虚。无热气太过。作痈脓
便脓血。及喉痹口伤烂赤之变。故可不治。令其自愈也。若或治之。或反见偏胜耳。
案汪氏魏氏周氏。以此条证。为传经热利。误矣。
溯洄集云。六经病篇。必非叔和所能赞辞也。但厥阴经中下利呕哕诸条。却是叔和因其有厥逆而附。遂
并无厥逆而同类者。亦附之耳。
下利脉数。有微热汗出。令自愈。设复紧为未解。（【原注】一云。设脉浮复紧。○千金翼。有。作若。
令。成本。作今。玉函。千金翼。作者。）
〔成〕下利。阴病也。脉数。阳脉也。阴病见阳脉者生。
微热汗出。阳气得通也。利必自愈。诸紧为寒。设复脉紧。阴气犹胜。故云未解。
下利。手足厥冷。无脉者。灸之不温。若脉不还。反微喘者死。（玉函。若。作而。）
〔钱〕阴寒下利。而手足厥冷。至于无脉。是真阳已竭。已成死证。故虽灸之。亦不温也。若脉不还。反
见微喘。乃阳气已绝。其未尽之虚阳。随呼吸而上脱。其气有出无入。故似喘非喘而死矣。〔汪〕喘非灸所致。
阳气不因灸复。则绝证以次第而至。尚论篇云。孤阳随火气上逆而脱。误矣。此条。仲景不言当灸何穴。常器
之云。当灸关元气海二穴。
少阴负趺阳者。为顺也。（原本。及千金翼。志聪本。锡驹本。接前条。今据成本。及玉函。分为别条）
〔钱〕少阴负趺阳句。疑有脱字。不然何至词不达义邪。前注。皆以少阴为水。趺阳为土。恐土不能制
水。得以泛溢而为呕吐下利。予其权于土。土强则水有制。而平成可几。（案此喻注。盖本成注。方意亦同。）
愚恐犹未合于至理。夫少阴。肾也。水中有火。先天之阳也。趺阳。胃脉也。火生之土。后天之阳也。此承上
Taiyang disease with a rapid pulse (Cù Mài, Rapid Pulse) and cold extremities (Shǒu Zú Jué Nì, Cold Extremities) can be treated with moxibustion. ([Original Note] "Rapid" is alternatively read as "unrestrained". ○ Cheng Ben and Yu Han editions have the character "zhě" after "extremities".)
[Yu Jia Yan] A rapid pulse in Taiyang disease indicates hyperactive Yang Qi. If accompanied by cold extremities, it implies that Yang Qi is rejected by Yin-Cold and cannot return to its source. Therefore, moxibustion is suitable to unblock and restore Yang Qi.
Case: Wang Ang cites Chang Qizhi, who suggests moxibustion at Taichong (LR3), but it is uncertain if this is correct.
In Taiyang disease, if the pulse is slippery (Huá Mài, Slippery Pulse) and there are cold extremities, there is heat in the interior; Baihu Tang (White Tiger Decoction) should be administered. (Cheng Ben and Yu Han editions have the character "yě" after "heat".)
[Qian Tianlai] The slippery pulse is characterized by movement, speed, and smoothness, lacking the form of sinking, fine, minute, or choppy qualities; thus, it belongs to Yang pulses. This indicates that constrained heat pathogen from Taiyang disease is in the interior, obstructing Yang Qi and preventing it from reaching the limbs smoothly, resulting in cold extremities. This is what is meant by "the deeper the cold extremities, the deeper the heat." [You Zaijing] In Taiyang disease, if the pulse is minute and fine, the body is not hot, urination is clear and copious, and there are cold extremities, this is a deficiency-cold type of cold extremities (Jué). It should be treated with warming methods. If the pulse suddenly becomes tight, the body is not hot, there is chest fullness and irritability, and cold extremities, this is an excess-cold type of cold extremities. It should be treated with emesis. If the pulse is substantial and large, urination is blocked, the abdomen is full, hard, and painful, and there are cold extremities, this is an excess-heat type of cold extremities. It should be treated with purgation. Now, with a slippery pulse and cold extremities, since slipperiness indicates a Yang pulse, interior heat is evident; this is a heat-type cold extremities. However, since there are no symptoms of abdominal fullness, pain, or constipation, although there is heat, the interior is not yet solidified. Purgation is contraindicated, but clearing heat is appropriate. Therefore, Baihu Tang is used. [Wu Qian] This clause is listed in the Jueyin chapter due to the presence of cold extremities, but it is not the primary disease of Jueyin.
The *Liuren Shu* states: Heat-type cold extremities is an internal disease. There must be body fever and headache, along with other exterior Yang syndrome manifestations. By the second or third day, or even fourth or fifth day, cold extremities may occur. In such heat-type cold extremities, after half a day of cold extremities, body heat returns. This is because deep heat is required to induce cold extremities, which takes two to three days. If mild cold extremities are followed immediately by fever, it indicates slight heat. Although the pulse may be deep and hidden, pressing reveals slipperiness, indicating interior heat. The patient may fear heat, desire water, throw hands and feet about, feel irritable, unable to sleep, have dry stool, and red urine. With external signs of confusion, one can identify heat-type cold extremities and use Baihu Tang. If all indications for purgation are present but four-chill occurs, it is due to failure to purge earlier, causing blood and Qi stagnation and limb coldness. If physicians do not recognize this and suspect Yin-cold, administering hot medicines will cause disaster swiftly. Generally, heat-type cold extremities require a deep, hidden, and slippery pulse, sweating on the head, and despite cold hands, occasional warmth in the fingernails. In such cases, Chengqi Tang should be used for purgation without hesitation.
Cold extremities with a fine pulse nearly imperceptible (Xì Yù Jué, Fine and Nearly Absent Pulse) are treated with Danggui Sini Tang (Angelica Sinensis Decoction for Reversing Cold). (Yu Han and Qianjin Yi editions read "pulse becomes fine and absent," omitting "zhě".)
[Qian Tianlai] The four limbs are the root of Yang. When pathogens enter Yin meridians, causing cold extremities, it indicates depletion of True Yang. The fine, nearly absent pulse aligns with the *Suwen*: "Pulse is the residence of Blood." Qi attaches to Blood, and Blood moves with Qi. Since Yang Qi is deficient, Yin Blood cannot be sufficient. One should use Sini Tang (Four Counterflow Decoction) to warm and restore True Yang, adding Dang Gui (Dong Quai Root) to nourish Yin Blood. Hence, Danggui Sini Tang is used.
Formula: Danggui Sini Tang
Dang Gui (Three Liang), Guizhi (Three Liang, peeled), Shaoyao (Three Liang), Xixin (Three Liang ○ Yu Han edition: One Liang), Gancao (Two Liang, honey-fried), Tongcao (Two Liang), Dazao (Twenty-five fruits, split; alternative method: twelve fruits ○ "Mei" in Cheng Ben is "Ge").
These seven ingredients are boiled in eight Sheng of water to obtain three Sheng. Strain and take one Sheng warm, three times daily.
[Qian Tianlai] Cold extremities constitute Si Ni (Four Counterflow/Cold Extremities), so Sini Tang is indicated. However, the fine, nearly absent pulse indicates Yang deficiency and latent blood vessels. Thus, Dang Gui is added, naming it Danggui Sini Tang. It is puzzling that a formula named "Si Ni" contains no Ganjiang (Dried Ginger) or Fuzi (Prepared Aconite), raising doubts about how it restores Yang. Perhaps due to age, texts were lost or corrupted by later editors. Commentators often force interpretations rather than examining the logic, similar to Cheng Wuji's literal explanations. [Ke Qin] This condition is interior; it should be Sini Tang plus Dang Gui, analogous to Fuling Sini Tang. Using Guizhi Tang to attack the exterior would be an error. How can a formula named "Si Ni" lack Ginger and Aconite?
If the patient has chronic cold within, Danggui Sini Tang plus Wuzhuyu and Shengjiang Decoction (Danggui Sini Tang plus Evodia and Fresh Ginger Decoction) is appropriate.
[Qian Tianlai] This follows the previous text: cold extremities with a fine, nearly absent pulse require Danggui Sini Tang. If the patient has chronic internal cold exacerbated by exogenous cold, the freezing Yin is difficult to resolve. Therefore, add Wuzhuyu (Evodia Fruit), which is dry, bitter, and hot, and Shengjiang (Fresh Ginger), which is pungent and hot, to dissipate the cold. Qingjiu (Clear Wine) is added to assist Yang Qi and circulate blood vessels.
Formula: Danggui Sini Tang plus Wuzhuyu and Shengjiang
Dang Gui (Three Liang), Shaoyao (Two Liang, honey-fried ○ Yu Han: Three Liang), Tongcao (Two Liang ○ Yu Han: Three Liang), Guizhi (Three Liang, peeled), Xixin (Three Liang), Shengjiang (Half Jin, sliced ○ Qianjin Yi: Eight Liang; Fang, Zhou, Qian, Jian: Three Liang), Dazao (Twenty-five fruits, split), Zhuyu (Two Sheng ○ Yu Han, Qianjin Yi: Wuzhuyu Two Liang; Fang, Zhou, Qian, Jian: Half Jin).
These nine ingredients are boiled with six Sheng of water and six Sheng of clear wine to obtain five Sheng. Strain and divide into five warm doses. ([Original Note] One prescription uses four Sheng each of water and wine. ○ Yu Han and Qianjin Yi both use four Sheng each.)
[Ke Qin] This is originally Sini Tang combined with Wuzhuyu, forming an even pair. Wuzhuyu pairs with Fuzi, and Shengjiang assists Ganjiang; only then can chronic cold be removed.
Yan Shi's *Jisheng Fang*'s Tongmai Sini Tang treats Huoluan with excessive cold, cold flesh, and absent pulse.
It is the base formula plus Fuzi.
Profuse sweating with persistent fever, internal tension, limb pain, diarrhea, cold extremities, and aversion to cold are treated with Sini Tang. (Qianjin Yi omits "internal"; "again" reads as "if".)
[You Zaijing] Profuse sweating should resolve fever. If fever persists without other symptoms, the pathogen remains unresolved. Here, profuse sweating with persistent fever, plus tension, limb pain, diarrhea, cold extremities, and aversion to cold, indicates Yang collapse at the exterior and severe Cold in the interior. Sini Tang is used to warm the meridians to overcome Cold, restore Yang, and stop sweating. [Wang Ang] "Internal tension" refers to Cold penetrating deeply; Cold causes contraction, implying abdominal tension.
Case: Fang Shi states that internal tension and limb pain result from fluid loss and unfavorable bone-Qi. He interprets "internal tension" as limb tension, finding the term "internal" inappropriate.
Profuse sweating or severe diarrhea leading to cold extremities are treated with Sini Tang. (Yu Han and Qianjin Yi add "out" after "sweating/diarrhea".)
[Qian Tianlai] The previous clause mentions profuse sweating with persistent fever. This clause mentions profuse sweating without mentioning fever, indicating absence of heat. Some argue: The previous clause had diarrhea, cold extremities, aversion to cold, and tension/pain. This clause has severe diarrhea and cold extremities without aversion to cold. The absence of fever might indicate Yang Qi has not yet fled outward, suggesting a milder condition? Response: Absence of heat means Yang is more depleted; severe diarrhea means Yin pathogen is stronger. Thus, Sini Tang is still used.
Case: *Yu Jing* adds two clauses here: Exterior Heat Interior Cold presents with deep/slow pulse, mild cold extremities, and clear watery diarrhea (Interior Cold); thus, Yin syndromes can have fever (Exterior Heat). Exterior Cold Interior Heat presents with slippery pulse, body cold extremities, and dry tongue (Exterior Cold); Shaoyin aversion to cold and fatigue is Exterior Cold. Frequent inner restlessness and dislike of thick clothing is Interior Heat.
Patient with cold extremities and sudden tight pulse: Pathogen knots in the chest, causing epigastric fullness and irritability, hunger but inability to eat. The disease is in the chest; emesis is indicated, using Genti San (Thistle Powder). (Differentiation of Emesis Chapter reads "sudden knot" for "sudden tight". Cheng Ben and Yu Han read "heart" for "epigastrium".)
[Wu Qian] The patient does not have Jueyin disease nor exogenous Cold. It is listed in Jueyin due to cold extremities. [You Zaijing] If pulse is minute/fine, it is Cold Deficiency, treatable with warming/tonifying. Sudden tight pulse indicates Cold Excess, treatable with warming/emesis. Irritation and vomiting worms suggest Stomach disease. Chest fullness and irritation with hunger but inability to eat indicate Chest disease. Cold-fluid excess obstructs the Chest, blocking Yang Qi from reaching limbs, causing cold extremities, chest fullness, irritation, and anorexia. Emesis with Genti San expels upper pathogens, resolving fullness and reversing cold extremities.
Taiyang disease with cold extremities and palpitations: Treat water retention first with Fuling Gancao Tang (Poria and Licorice Decoction), then treat cold extremities. Otherwise, water will soak into the Stomach, causing diarrhea. (Cheng Ben and Yu Han add "zhě" after "palpitations"; Yu Han reads "yu" for "ze".)
[Qian Tianlai] *Jingui Yaolue* states: Water stagnant in the heart region causes palpitations. Taiyang chapter notes excessive drinking causes heart palpitations. Although these are Zhang Zhongjing's words, this clause does not mention drinking. Cold extremities indicate Yin-Cold in the interior; interior Cold stops Stomach Qi and fluid distribution, causing water accumulation in the heart region, obstructing Qi channels, leading to palpitations. Treat water first with Fuling Gancao Tang to promote diuresis, then treat cold extremities. Otherwise, stagnant water enters the Stomach, and interior Cold damages Stomach Yang, causing downward diarrhea. [You Zaijing] Taiyang chapter has sweating, unharmonized exterior, and dysuria. This clause has unhealed exterior, cold extremities, and palpitations. Both use Fuling Gancao Tang because both lack interior heat, have unharmonized exterior, and retain water. One harmonizes Ying-Wei to drain water; the other releases exterior and unblocks Yang to drain water. Both are valid. Although dysuria isn't mentioned, the implication exists. If urination were free, water wouldn't accumulate, and cold/extremities/palpitations would be pure Yin-Cold, making exterior-releasing/diuretic treatment inappropriate. [Wang Ang] Guo Yong says treat cold extremities with Sini Tang.
*Jinjian* states: After "cold extremities and palpitations," the phrase "due to excessive drinking" should exist. Without it, palpitations are due to Yin excess, not water retention. How to know it's water? ○ Case: This view is near correct. Wang and Zhou incorrectly identified this as Heat-type cold extremities with water retention.
After six or seven days of Taiyang disease, following severe purgation: Cun (inch) pulse is deep and slow, cold extremities, lower pulses are absent, throat discomfort, spitting pus/blood, and unremitting diarrhea. This is difficult to treat; Mahuang Shengma Tang (Ephedra and Cimicifuga Decoction) is used. (Yu Han omits "ér"; "Houyan" reads "Yanhóu"; Cheng Ben same. Qianjin Yi omits "Cun".)
[Ke Qin] Deep/slow Cun pulse indicates Qi mouth is level. Absent lower pulses indicate root exhaustion. Six Fu organs exhausted externally cause cold limbs. Five Zang organs exhausted internally cause uncontrollable diarrhea. Throat discomfort blocks food/water passage. Fluids fail to transform, becoming pus/blood. Downward weakness with upward reversal constitutes "Lower Cold, Upper Exhaustion," a sign of Yin-Yang separation and impending death. Mahuang Shengma Tang has many ingredients with light dosages, focusing on sweating while fearing warming/tonification, resembling later incompetent practitioners' methods, likely not Zhang Zhongjing's original formula. For this condition and pulse, urgent Shen-Fu (Ginseng and Aconite) to restore Yang is needed, though rescue is doubtful. Treating Yang collapse with Yang-excess agents is like attacking a fallen enemy. Sweating to recovery is impossible; death from collapse sweat is certain. The formula is attached for scholars to judge.
Formula: Mahuang Shengma Tang
Mahuang (Two and a half Liang, nodes removed), Shengma (One Liang and one fen), Dang Gui (One Liang and one fen ○ Yu Han: Shengma and Dang Gui each One Liang and six Zhu; Qianjin Yi same), Zhimu (Eighteen Zhu), Huangqin (Eighteen Zhu), Weirui (Eighteen Zhu, alternatively Changpu), Shaoyao (Six Zhu), Tiantaomen Dong (Six Zhu, hearts removed ○ Yu Han, Qianjin Yi: Maidong), Guizhi (Six Zhu), Fuling (Six Zhu), Gancao (Six Zhu, honey-fried), Shigao (Six Zhu, crushed, wrapped in silk), Baizhu (Six Zhu), Ganjiang (Six Zhu).
These fourteen ingredients are boiled in ten Dou of water. First boil Mahuang until bubbling once, remove foam. Add remaining herbs. Boil to obtain three Sheng. Strain and divide into three warm doses. Take within the time it takes to cook three Dou of rice. Recovery follows sweating.
Case: The symptoms and formula do not match perfectly. Commentators attribute this to mixed Yin-Yang pathology, offering reconciliatory interpretations. Ke Qin decisively rejects it as non-Zhang Zhongjing, a profound insight. I will not cite others extensively. ○ Also: *Waitai Miyao* citing *Duanju* records this formula, stating: "This is Zhang Zhongjing's *Shanghan Lun* formula."
*Shanghan Xuanlu* states: This powerful medicine is suitable for plague toxins and damp-heat dysentery where exterior/interior are indistinguishable, toxins are deep and intense, presenting with cough, pus, or blood.
On the fourth or fifth day of Taiyang disease, abdominal pain with gas moving downward toward the lower abdomen indicates impending spontaneous diarrhea. (Ci reads "wei" in Yu Han. Qu reads "Qu" in Zhengmai Ben; others same. Fang Ben reads "Qu".)
[Qian Tianlai] Day 4-5 is when pathogens enter the interior and transmit to Yin. Abdominal pain indicates Cold entering the interior, Stomach Cold, and Taiyin Spleen pathology. Gas moving down indicates strong Cold, failing Stomach Yang, improper separation of water/grain, and sound rushing down, signaling impending diarrhea. [Zhou Xuehai] Case: Abdominal pain—how to distinguish deficiency-cold? Fire pain attacks upward from below. Heat pain causes chest binding, irritability, and fullness. Downward gas movement confirms Cold impending diarrhea.
Taiyang disease originally involving Cold-downward; physician erroneously applied emesis and purgation. Cold rejection causes further reverse vomiting/diarrhea. If food is vomited immediately upon entry, Ganjiang Huangqin Huanglian Renshen Tang (Dried Ginger, Scutellaria, Coptis, and Ginseng Decoction) is used. (Fu tu xia zhi reads Fu tu zhi in Yu Han, Qianjin Yi, Quan Shu. Yu Han omits "ruo". Ji tu reads ji chu zhe in Qianjin Yi. Er zi before Han Ge in Qianjin Yi.)
[Wang Kentang] Case: "Originally Cold-downward" is likely "originally vomiting/downward." The character "fu" (again/repeatedly) implies this. Stomach Cold causes vomiting; Lower Cold causes diarrhea. Stomach Cold should not be emetic; physician erred, damaging Stomach Qi, causing Cold rejection. The text flow is broken; missing characters are likely.
*Jinjian* states: Classics contain no "Cold-downward" disease or text. Reading "Han Ge geng ni tu xia" (Cold rejection causes further reverse vomiting/diarrhea), the "xia" in "Han xia" should be "ge" (reject). Text makes sense then. Commentators explain as Stomach Cold-diarrhea, which contradicts text and matches poorly with Huangqin/Huanglian. ○ Case: Ke Ben deletes "geng ni tu xia." This clause definitely has errors/omissions.
Formula: Ganjiang Huangqin Huanglian Renshen Tang
Ganjiang, Huangqin, Huanglian, Renshen (Each Three Liang).
These four ingredients are boiled in six Sheng of water to obtain two Sheng. Strain and divide into two warm doses.
[Ke Qin] After emesis/purgation, immediate vomiting indicates Cold rejecting Heat in the Upper Jiao. Though no epigastric hardness, the root is Heart-related. Use half of Xiexin Tang to balance Cold/Heat. Remove Shengjiang/Banxia because no water-Qi in epigastrium. Remove Gancao/Dazao because vomiting dislikes sweet. [You Zaijing] Morning eating evening vomiting is Spleen Cold rejection. Eating immediately vomiting is Stomach Heat rejection. Cold rejection requires Lizhong Tang to warm Taiyin, adding Dingxiang to descend Cold. Heat rejection requires Ganjiang/Renshen to calm Stomach, Huanglian/Huangqin to descend Stomach Fire.
Case: *Jingui Yaolue* states: Vomiting immediately after eating is treated with Dahuang Gancao Tang. *Jinjian* commentary aligns with this clause.
*Bao You Daquan*'s Siwei Renshen Tang treats Taiyang with slow pulse, Cold Stomach vomiting. (Same formula.)
Diarrhea with slight fever and thirst, weak pulse: Spontaneous recovery. (Ling reads Jin in Cheng Ben; omitted in Yu Han.)
[Cheng Jiaoqian] Diarrhea with absent pulse dies; solid pulse also dies. Pulse and syndrome must match. Jueyin diarrhea is Yin-Cold excess. Slight fever/thirst indicates Yang-Heat recovery. Weak pulse indicates pathogen retreat and meridian Qi deficiency. Thus, spontaneous recovery. [Qian Tianlai] Weak pulse shows intrinsic interior deficiency without excessive Heat transforming into abscesses, bloody stools, or throat/mouth lesions. Thus, no treatment allows spontaneous recovery. Intervention might cause imbalance.
Case: Wang, Wei, and Zhou incorrectly identified this as transmitted Heat-diarrhea.
*Suhui Ji* states: The Six Meridian chapters were not authored by He Huan. However, Jueyin chapter's diarrhea/vomiting/hiccups clauses were appended by He Huan based on cold extremities, including similar cases without cold extremities.
Diarrhea with numerical pulse, slight fever, and sweating: Spontaneous recovery. If pulse becomes tight again, unresolved. ([Original Note] Alternatively: If pulse floats and becomes tight. ○ Qianjin Yi has "ruo", reads "ruo". Ling reads Jin in Cheng Ben. Yu Han/Qianjin Yi read "zhe".)
[Cheng Wuji] Diarrhea is Yin disease. Numerical pulse is Yang pulse. Yin disease showing Yang pulse indicates life.
Slight fever/sweating indicates Yang Qi communication. Diarrhea will self-resolve. Tightness indicates Cold. If pulse becomes tight again, Yin Qi prevails; thus, unresolved.
Diarrhea with cold extremities and absent pulse: Moxibustion fails to warm. If pulse does not return and slight panting occurs: Death. (Yu Han reads "ér" for "ruo".)
[Qian Tianlai] Yin-Cold diarrhea with cold extremities and absent pulse indicates True Yang exhaustion, a death syndrome. Moxibustion fails to warm. If pulse doesn't return and slight panting occurs, it signifies Yang exhaustion; residual floating Yang escapes via respiration, having exit but no entry, appearing as panting but not true panting, leading to death. [Wang Ang] Panting is not caused by moxibustion. If Yang doesn't recover via moxibustion, death signs follow sequentially. *Shanglun Pian* claims isolated Yang rises with fire and escapes; this is wrong. Zhang Zhongjing does not specify acupoints here; Chang Qizhi suggests Guan Yuan (CV4) and Qi Hai (CV6).
Shaoyin being inferior to Fuyang is favorable. (Original, Qianjin Yi, Zhicong Ben, Xiju Ben connect to previous clause. Based on Cheng Ben and Yu Han, separated.)
[Qian Tianlai] "Shaoyin inferior to Fuyang" sentence seems to have missing characters; otherwise, meaning is unclear. Previous notes interpret Shaoyin as Water and Fuyang as Earth, fearing Earth cannot control Water, leading to vomiting/diarrhea. Empowering Earth ensures Water control, allowing peace. (Case: Yu's note follows Cheng's note; Fang's intent is similar.)
I fear this does not fully align with ultimate principles. Shaoyin is Kidney, containing Fire within Water, the Pre-heaven Yang. Fuyang is Stomach pulse, Earth generated by Fire, the Post-heaven Yang. This continues from...