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。（成本。玉函。色赤。作赤色。止下。玉函。有而字。）
〔成〕下利清谷。手足厥逆。脉微欲绝。为里寒。身热不恶寒。面色赤。为外热。此阴甚于内。格阳于外。
不相通也。与通脉四逆汤。散阴通阳。〔汪〕武陵陈氏云。里寒外热者。寒甚于里。有阴无阳。而无根失守之火。
浮越于外也。与通脉四逆汤。以温里散寒。〔澜〕格。拒格也。亦曰隔阳。阴阳
隔离也。又曰戴阳。浮于上如戴也。夫真寒入里。阴气未有不盛者。然其剧不过阳愈微阴愈盛耳。
通脉四逆汤方
甘草（二两炙○全书。作三两。） 干姜（三两强人可四两） 附子（大者一枚生用去皮破八片）
上三味。以水三升。煮取一升二合。去滓。分温再服。其脉即出者愈。面色赤者。加葱九茎。腹中痛者。
去葱。加芍药二两。呕者。加生姜二两。咽痛者。去芍药。加桔梗一两。利止脉不出者。去桔梗。加人参二两。
病皆与方相应者。乃服之。（千金翼。葱下。有白字。玉函。作桔梗二两。全书。作人参一两。成本。玉函。
无病皆以下十字。玉函。无去葱去芍药去桔梗八字。千金翼。乃服间。有加减二字。汪氏云。去葱去芍药去桔
梗。此系衍文。）
〔汪〕武陵陈氏云。通脉四逆。即四逆汤也。其异于四逆者。附子云大。甘草干姜之分两加重。然有何大
异。而加通脉以别之。曰四逆汤者。治四肢逆也。论曰。阴阳之气。不相顺接。便为厥。厥者。阳气虚也。故
以四逆益真阳。使其气相顺接。而厥逆愈矣。至于里寒之甚者。不独气不相顺接。并脉亦不相顺接。其证更剧。
故用四逆汤。而制大其剂。如是则能通脉矣。同一药耳。加重则其治不同。命名亦别。方亦灵怪矣哉。〔钱〕
加减法。揣其词义浅陋。料非仲景本意。何也。原文中。已先具诸或有之证。然后出方立治。则一通脉四逆汤。
其证皆可该矣。岂庸续用加减邪。况其立意。庸恶陋劣。要皆出于鄙俗之辈。未敢竟削。姑存之以备识者之鉴云。
汪氏云。据条辨。云通脉者。加葱之谓。其言甚合制方之意。况上证云。脉微欲绝云云。其人面赤色。其
文一直贯上。则葱宜加入方中。不当附于方后。虽通脉之力不全在葱。
实赖葱为引。而效始神。方中无葱者。乃传写之漏。不得名通脉也。钱氏云。以四逆汤。而倍加干姜。其助阳
之力。或较胜。然既增通脉二字。当自不同。恐是已加葱白。以通阳气。有白通之义。故有是名。疑是久远差
讹。或编次之失。致原方中脱落。未可知也。○案二氏之说。未知果是否。姑附存于斯。
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。
〔锡〕凡少阴病四逆。俱属阳气虚寒。然亦有阳气内郁。不得外达而四逆者。又宜四逆散主之。枳实。胃
家之宣品。所以宣通胃络。芍药。疏泄经络之血脉。甘草。调中。柴胡。启达阳气于外行。阳气通而四肢温矣。
魏士千曰。泄利下重者。里急后重也。其非下利清谷明矣。〔鉴〕四逆。虽阴盛不能外温。然亦有阳为阴郁。
不得宣达。而令四肢逆冷者。但四逆而无诸寒热证。是既无可温之寒。又无可下之热。惟宜疏畅其阳。故用四
逆散主之。〔钱〕少阴病者。即前所谓脉微细。但欲寐之少阴病也。成氏云。四逆。四肢不温也。其说似与厥
冷有异。然论中或云厥。或云厥逆。或云四逆。或云厥冷。或云手足寒。或云手足厥寒。皆指手足厥冷而言也。
案成氏周氏魏氏。并以此条证。为传经邪气之热厥。钱氏指摘其非。是矣。
四逆散方
甘草（炙） 枳实（破水渍炙干） 柴胡 芍药
上四味。各十分。捣筛。白饮和服方寸匕。日三服。咳者。加五味子干姜各五分。并主下利。悸者。加桂
枝五分。小便不利者。加茯苓五分。腹中痛者。加附子一枚。炮令拆。泄利下重者。先以水五升。煮薤白三升。
煮取三升。去滓。
以散三方寸匕。纳汤中。煮取一升半。分温再服。
〔注〕案此方。虽云治少阴。实阳明少阳药也。〔柯〕加味俱用五分。而附子一枚。薤白三升。何多寡不
同若是。不能不疑于叔和编集之误耳。〔钱〕详推后加减法。凡原文中。每具诸或有之证者。皆有之。如小柴
胡汤。小青龙汤。真武汤。通脉四逆汤。四逆散。皆是也。愚窃揆之以理。恐未必皆出于仲景。
程云。四逆散一证。寒热未经详定。姑根据小柴胡例。从事和解。然黄芩已经革去。而使人知少阴之有火。
诚人身之至宝。而不可须臾失也。
医学入门。祝仲宁号橘泉。四明人。治周身百节痛。及胸腹胀满。目闭肢厥。爪甲青黑。医以伤寒治之。
七日昏沉。弗效。公曰。此得之怒火。与痰相搏。与四逆散。加芩连。泻三焦火而愈。○案此案本出程篁墩文集。
橘泉翁传。但不着四逆散之名。云与柴胡枳壳芍药芩连。泻三焦火。明日而省。久之愈。
少阴病。下利六七日。咳而呕渴。心烦不得眠者。猪苓汤主之。（千金翼。下利。作不利。）
〔锡〕少阴病。下利六七日。阴尽出阳之期也。〔鉴〕凡少阴下利清谷。咳呕不渴。属寒饮也。今少阴
病。六七日。下利粘秽。咳而呕渴。烦不得眠。是少阴热饮为病也。饮热相搏。上攻则咳。中攻则呕。下攻则
利。热耗津液。故渴。热扰于心。故烦不得眠。宜猪苓汤。利水滋燥。饮热之证。皆可愈矣。〔汪〕此方。乃治
阳明病。热渴引饮。小便不利之剂。此条病。亦借用之。何也。盖阳明病。发热渴欲饮水。小便不利者。乃水
热相结而不行。兹者少阴病。下利。咳而呕渴。心烦不得眠者。亦水热搏结而不行也。病名虽异。而病源则
同。故仲景同用猪苓汤主之。不过是清热利水。兼润燥滋阴之义。
案此条。视之黄连阿胶汤证。乃有咳呕渴。及小便不利。而大便下利之诸证。所以不同也。又案前条云。
少阴病欲吐不吐。心烦但欲寐。五六日自利而渴者。属少阴也。虚故引水自救。若小便色白者。少阴病形悉具。
小便白者。以下焦虚有寒。不能制水。故令色白也。可知此条下利呕渴心烦同证。而有不得眠及不白之异。乃
是寒热分别处。
少阴病。得之二三日。口燥咽干者。急下之。宜大承气汤。
〔钱〕此条得病才二三日。即口燥咽干。而成急下之证者。乃少阴之变。非少阴之常也。然但口燥咽干。
未必即是急下之证。亦必有胃实之证。实热之脉。其见证虽少阴。而有邪气复归阳明。即所谓阳明中土。万物
所归。无所复传。为胃家实之证据。方可急下。而用大承气汤也。其所以急下之者。恐入阴之证。阳气渐亡。
胃腑败损。必至厥躁呃逆。变证蜂起。则无及矣。故不得不急也。〔舒〕少阴挟火之证。复转阳明。而口燥咽
干之外。必更有阳明胃实诸证兼见。否则大承气汤。不可用也。
少阴病。自利清水。色纯青。心下必痛。口干燥者。可下之。宜大承气汤。（【原注】一法。用大柴胡。
○自利。玉函。脉经。作下利。可字。成本。玉函。作急。是也。宜下。脉经。有大柴胡汤四字。宜。作属。
大承气汤下。有证字。）
〔钱〕此亦少阴之变例也。自利。寒邪在里也。自利清水。即所谓清水完谷。此则并无完谷。而止利清水。
其色且纯青矣。清水固属寒邪。而青则又寒色也。故属少阴。成氏及方注。皆以为肝色。误矣。若证止如此。
其为四逆汤证无疑。不谓胃中清水。虽自利而去其谷食之渣滓。热邪尚留于胃。
所以心下按之必痛。且口中干燥。则知邪气虽入少阴。而阳明实热尚在。非但少阴证也。其热邪炽盛。迫胁胃
中之津液下奔。下焦寒甚。故皆清水。而色纯青也。阳邪暴迫。上则胃中之津液。下则肾家之真阴。皆可立尽。
故当急下之也。
名医类案曰。孙兆治东华门窦太郎患伤寒。经十余日。口燥舌干而渴。心中疼。自利清水。众医皆相守。
但调理耳。汗下皆所不敢。窦氏亲故相谓曰。伤寒邪气。害人性命甚速。安可以不次之疾。投不明之医乎。召
孙至曰。明日即已不可下。今日正当下。遂投小承气汤。大便通得睡。明日平复。众人皆曰。此证因何下之而
愈。孙曰读书不精。徒有书尔。口燥舌干而渴。岂非少阴证耶。少阴证。固不可下。岂不闻少阴一证。自利清
水。心下痛。下之而愈。仲景之书。明有此说也。众皆钦服。
少阴病。六七日。腹胀不大便者。急下之。宜大承气汤。（胀字。玉函。脉经。千金。及翼。并作满。）
〔钱〕少阴病。而至六七日。邪入已深。然少阴每多自利。而反腹胀不大便者。此少阴之邪。复还阳明也。
所谓阳明中土。万物所归。无所复传之地。故当急下。与阳明篇。腹满痛者急下之。无异也。以阴经之邪。而
能复归阳明之腑者。即灵枢邪气脏腑病形篇。所谓邪入于阴经。其脏气实。邪气入而不能容。故还之于腑。中
阳则溜于经。中阴则溜于腑之义也。然必验其舌。聚其脉。有不得不下之势。方以大承气下之耳。〔舒〕少阴
复转阳明之证。腹胀不大便者。然必兼见舌苔干燥。恶热饮冷。方为实证。
少阴病。脉沉者。急温之。宜四逆汤。
〔汪〕少阴病。本脉微细。但欲寐。今者轻取之微脉不见。重取之细脉几亡。伏匿而至于沉。此寒邪深中于
里。殆将入
脏。温之不容以不急也。少迟则恶寒身蜷。吐利躁烦。不得卧寐。手足逆冷。脉不至等。死证立至矣。四逆汤
之用。其可缓乎。〔成〕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。不云急温。此
少阴病脉沉。而云急温者。彼虽寒甚。然而证已形见于外。治之则有成法。此初头脉沉。未有形证。不知邪气
所之。将发何病。是急与四逆汤温之。
少阴病。饮食入口则吐。心中温温欲吐。复不能吐。始得之手足寒。脉弦迟者。此胸中实。不可下也。当
吐之。若膈上有寒饮。干呕者。不可吐也。当温之。宜四逆汤。（心中温温。玉函。作心下 。千金。作心
中愠愠。当。玉函。成本。作急。非也。）
〔鉴〕饮食入口即吐。且心中 欲吐。复不能吐。恶心不已。非少阴寒虚吐也。乃胸中寒实吐也。故始
得之。脉弦迟。弦者饮也。迟者寒也。而手足寒者。乃胸中阳气。为寒饮所阻。不能通于四肢也。寒实在胸。
当因而越之。故不可下也。若膈上有寒饮。但干呕有声。而无物出。此为少阴寒虚之饮。非胸中寒实之饮也。
故不可吐。惟急温之。宜四逆汤。或理中汤。加丁香吴茱萸。亦可也。〔程〕温温字。与下文寒饮字对。欲吐
复不能吐。与下文干呕字对。干。空也。饮食入口即吐。业已吐讫矣。仍复温温欲吐。复不能吐。此非关后入
之饮食。吐之未尽。而胸中另有物。为之格拒也。胸中实者。寒物窒塞于胸中。则阳气不得宣越。所以脉弦迟。
而非微细者比。手足寒。而非四逆者比。但从吐治。一吐而阳气得通。若膈上有寒饮。干呕者。虚寒从下上。
而阻留其饮于胸中。究非胸中之病也。直从四逆汤。急温其下矣。〔柯〕当吐之。宜瓜蒂散。
少阴病。下利脉微涩。呕而汗出。必数更衣。反少者。
当温其上灸之。（【原注】脉经云。灸厥阴可五十壮。）
〔钱〕阳气衰少则脉微。寒邪在经则脉涩。阴邪下走则利。上逆则呕也。肾脏之真阳衰微。不能升越而
为卫气。卫气不密。故汗出也。必数更衣。反少者。即里急后重之谓也。乃下焦阳虚。清阳不能升举。少阴寒
甚。阴气内迫。而下攻也。阳气陷入阴中。阴阳两相牵制。致阴邪欲下走而不得。故数更衣。阳气虽不得上行。
犹能提吸。而使之反少也。当温其上。前注皆谓灸顶上之百会穴。以升其阳。或曰。仲景无明文。未可强解。
以意测之。非必巅顶然后谓之上也。盖胃在肾之上。当以补暖升阳之药温其胃。且灸之。则清阳升。而浊阴降。
水谷分消。而下利自止矣。灸之者。灸少阴之脉穴。或更灸胃之三脘也。即前所谓当灸之。附子汤主之之法。
〔舒〕此证阳虚气坠。阴弱津衰。故数更衣。而出弓反少也。（更衣者。古人如厕。大便必更衣。出弓者。矢
去也。）曾医一妇人。腹中急痛。恶寒厥逆。呕而下利。脉见微涩。予以四逆汤投之。无效。其夫告曰。昨夜
依然。作泄无度。然多空坐。 胀异常。尤可奇者。前阴 出一物。大如柚子。想是尿脬。老妇尚可生乎。予
即商之仲远。仲远踌蹰。曰。是证不可温其下。以逼迫其阴。当用灸法温其上。以升其阳而病自愈。予然其言。
而根据其法。用生姜一片。贴头顶百会穴上。灸艾火三壮。其脬即收。仍服四逆汤。加 术。一剂而愈。
案温其上灸之。义未详。方氏云。上。谓顶百会是也。汪氏云。百会。治小儿脱肛久不瘥。此证亦灸之
者。升举其阳也。喻氏程氏柯氏金鉴。皆从方说为解。特志聪锡驹并云。温其上。助上焦之阳。与钱所援或曰
Shaoyin disease presenting with diarrhea of undigested food. This indicates interior cold and exterior heat. The hands and feet are cold and inverted (cold extremities). The pulse is faint and nearly imperceptible. The body actually does not feel aversion to cold. The person's facial color is red. There may also be abdominal pain, dry retching, or sore throat.
If the diarrhea stops but the pulse remains absent, Tongmai Sini Decoction (Pulse-Rescuing Four-Inverted Decoction) should be primarily administered. (Cheng Ben edition and Yuhan edition record "facial color red" as "red color". Under the character for "stop", the Yuhan edition has an additional "er" [and] character.)
[Cheng Wuji's Commentary] Diarrhea of undigested food, cold extremities, and a faint pulse nearly imperceptible indicate interior cold. Body heat without aversion to cold and a red facial color indicate exterior heat. This occurs when Yin cold is excessive internally, repelling Yang to the exterior, causing a lack of communication between Yin and Yang. Administer Tongmai Sini Decoction to disperse Yin cold and unblock Yang. [Wang Hu's Commentary] Chen Shi of Wuling stated: What is meant by interior cold and exterior heat is that cold is extreme in the interior, leaving Yin without Yang, and the rootless, uncontrolled fire floats outward. Administer Tongmai Sini Decoction to warm the interior and dispel cold. [Lan's Note] "Ge" means rejection or blockage. It is also called Ge Yang (separated Yang), meaning the isolation of Yin and Yang. It is also called Dai Yang (floating Yang), referring to Yang floating upward as if wearing a hat. When true cold enters the interior, Yin qi inevitably becomes abundant. However, its severity lies only in Yang becoming more deficient and Yin becoming more abundant.
Formula for Tongmai Sini Decoction
Gancao (Licorice Root, two liang, roasted ○ Quan Shu edition makes it three liang.) Ganjiang (Dried Ginger, three liang; four liang for strong individuals.) Fuzi (Aconite Root, one large piece, raw, peeled, broken into eight pieces.)
These three ingredients are boiled in three sheng of water to obtain one sheng and two he of decoction. Strain the dregs. Divide into two doses and take warm. If the pulse reappears, the patient will recover. For those with a red facial color, add nine stalks of Congbai (Scallion White). For abdominal pain, remove Congbai and add Shaoyao (Peony Root), two liang. For vomiting, add Shengjiang (Fresh Ginger), two liang. For sore throat, remove Shaoyao and add Jiegeng (Platycodon Root), one liang. For diarrhea stopping but pulse remaining absent, remove Jiegeng and add Renshen (Ginseng Root), two liang. Only administer this formula when the symptoms correspond to the prescription. (Qianjin Yi Fang has the character "Bai" [white] after "Cong". Yuhan edition writes "Jiegeng" as "two liang". Quan Shu edition writes "Renshen" as "one liang". Cheng Ben edition and Yuhan edition lack the ten characters "bing jie yu fang xiang ying zhe". Yuhan edition lacks the eight characters "qu cong, qu shaoyao, qu jiegeng". Qianjin Yi Fang has the characters "jia jian" [modifications] between "nai fu". Wang Shi states that "remove Cong, remove Shaoyao, remove Jiegeng" are interpolations.)
[Wang Hu's Commentary] Chen Shi of Wuling said: Tongmai Sini Decoction is essentially Sini Decoction. Its difference from Sini Decoction lies in using a large Fuzi and increasing the dosage of Gancao and Ganjiang. But what is the significant difference that warrants the addition of "Tongmai" [unblocking pulse] to distinguish it? I say: Sini Decoction treats limb inversion (cold extremities). The Treatise states: When Qi of Yin and Yang do not connect smoothly, it is called Jue (inversion/cold extremities). Jue is due to deficiency of Yang Qi. Thus, Sini Decoction supplements True Yang to ensure smooth connection of Qi, curing inversion. In cases of severe interior cold, not only is Qi connection disrupted, but also pulse connection, making symptoms more severe. Therefore, Sini Decoction is used with increased dosage to unblock the pulse. The herbs are the same; increasing the dosage changes the treatment effect and thus the name. The efficacy of formulas is truly miraculous. [Qian Huang's Commentary] The modification methods seem shallow and vulgar in their wording, likely not Zhang Zhongjing's original intent. Why? The original text lists various possible symptoms first, then presents the formula and treatment. Thus, one Tongmai Sini Decoction covers all these symptoms. Why would supplementary modifications be needed? Moreover, the intention seems vulgar and baseless, originating from petty scholars. I dare not delete them entirely but preserve them for experts to judge.
Wang Shi says: According to Tiao Bian, "Tongmai" refers to adding Congbai. This aligns well with the formula's intent. Furthermore, the preceding text mentions "pulse faint and nearly imperceptible... facial color red," flowing continuously, so Congbai should be included in the formula, not appended afterward. Although the power to unblock the pulse does not solely reside in Congbai, it relies on Congbai as a guiding herb for divine efficacy. The absence of Congbai in the formula is a transcription error; without it, it cannot be named "Tongmai." Qian Shi says: Using Sini Decoction with doubled Ganjiang might enhance Yang-assisting power. Since "Tongmai" was added, there must be a difference. Perhaps Congbai was already added to unblock Yang Qi, implying the meaning of Baitong Tang, hence the name. It is suspected to be an ancient error or editorial omission causing the loss of the original formula. ○ Case: Whether these two scholars' views are correct is unknown; they are preserved here tentatively.
In Shaoyin disease, presenting with cold extremities. The patient may have cough, palpitations, difficulty urinating, abdominal pain, or diarrhea with a sensation of heaviness/tenesmus at the anus. Sini San (Four-Inverted Powder) should be primarily administered.
[Xi Ju's Commentary] All cases of cold extremities in Shaoyin disease belong to deficiency-cold of Yang Qi. However, there are cases where Yang Qi is internally constrained and cannot reach the exterior, causing cold extremities; these are suitable for Sini San. Zhishi (Immature Bitter Orange) is a dispersing agent for the Stomach, used to unblock Stomach collaterals. Shaoyao (Peony Root) drains blood vessels in meridians. Gancao (Licorice Root) harmonizes the Middle Jiao. Chaihu (Bupleurum Root) guides Yang Qi outward. When Yang Qi flows freely, limbs become warm. Wei Shiqian said: Diarrhea with anal heaviness is tenesmus. This is clearly distinct from diarrhea of undigested food. [Jian's Commentary] Cold extremities, although caused by Yin excess failing to warm the exterior, can also result from Yang being depressed by Yin, unable to disseminate, leading to cold limbs. However, with only cold extremities and no other cold-heat signs, there is neither cold to warm nor heat to purge. It is only appropriate to soothe and unblock Yang. Hence, Sini San is used. [Qian Huang's Commentary] Shaoyin disease refers to the Shaoyin disease mentioned earlier with faint-thin pulse and desire to sleep. Cheng Wuji said: "Sini" means limbs are not warm. This seems different from Jueleng (cold extremities), but in the Treatise, terms like Jue, Jueni, Sini, Jueleng, Shouzu Han, and Shouzu Juehan all refer to cold extremities. Case: Cheng Wuji, Zhou Yuzai, and Wei Liting interpreted this syndrome as heat-Jue from transmitted pathogenic factors. Qian Shi correctly pointed out their error.
Formula for Sini San
Gancao (Licorice Root, roasted) Zhishi (Immature Bitter Orange, broken, soaked in water, roasted dry) Chaihu (Bupleurum Root) Shaoyao (Peony Root)
These four ingredients, each taken in parts of ten, are crushed and sifted. Mix with rice water and administer one Fang Cun Bi (square-inch spoonful) of powder orally, three times daily. For cough, add Wuweizi (Schisandra Berry) and Ganjiang (Dried Ginger), each five fen; this also treats diarrhea. For palpitations, add Guizhi (Cinnamon Twig), five fen. For difficulty urinating, add Fuling (Poria), five fen. For abdominal pain, add Fuzi (Aconite Root), one piece, roasted until cracked. For diarrhea with tenesmus, first boil Xiebai (Macrostemon Bulb) in five sheng of water with three sheng of Xiebai, reduce to three sheng, strain.
Add three Fang Cun Bi of the powder to the decoction, boil to obtain one sheng and half, divide into two warm doses.
[Note] Case: Although this formula is said to treat Shaoyin disease, it actually contains herbs for Yangming and Shaoyang. [Ke Qin's Commentary] Added herbs are all five fen, while Fuzi is one piece and Xiebai is three sheng. Why such disparity? One cannot help suspecting an error in Wang Shuhe's compilation. [Qian Huang's Commentary] Examining the subsequent modification methods, every time the original text lists "various possible symptoms," corresponding modifications follow. Such as Xiaochaihu Tang, Xiao Qinglong Tang, Zhenwu Tang, Tongmai Sini Tang, and Sini San are all examples. I speculate rationally that these may not all originate from Zhang Zhongjing.
Cheng Yunlai said: For the Sini San syndrome, cold and heat are not yet clearly defined. Tentatively following the example of Xiaochaihu Tang, employ harmonizing methods. However, Huangqin (Scutellaria Root) has been removed, indicating that Fire in Shaoyin is indeed the supreme treasure of the human body and cannot be lost for a moment.
*Medical Beginner* records: Zhu Zhongning, courtesy name Juquan, from Siming, treated a case of pain in all joints of the body, chest and abdominal distension, closed eyes, cold extremities, and cyanotic nails. Physicians treated it as Taiyang disease. After seven days of lethargy with no effect, he said: This resulted from anger-fire combusting with phlegm. He administered Sini San plus Huangqin and Huanglian to drain Fire of the Three Jiao, resulting in recovery. ○ Case: This case originally appeared in Cheng Huangkun's *Collected Works* in the biography of Juquan Weng, but did not name Sini San, stating instead the administration of Chaihu, Zhike, Shaoyao, Huangqin, and Huanglian to drain Three Jiao Fire, with consciousness returning the next day and full recovery later.
In Shaoyin disease, with diarrhea for six or seven days, accompanied by cough, vomiting, thirst, irritability, and inability to sleep, Zhuling Tang (Polyporus Decoction) should be primarily administered. (Qianjin Yi Fang writes "xia li" [diarrhea] as "bu li" [difficulty urinating].)
[Xi Ju's Commentary] Shaoyin disease with diarrhea for six or seven days marks the period when Yin ends and Yang emerges. [Jian's Commentary] Generally, Shaoyin diarrhea of undigested food with cough, vomiting, and no thirst belongs to cold-fluid retention. Now, in Shaoyin disease, after six or seven days, sticky/foul diarrhea with cough, vomiting, thirst, irritability, and insomnia indicates Shaoyin heat-fluid pathology. Fluid and heat combusting, attacking upward causes cough, attacking middle causes vomiting, attacking downward causes diarrhea. Heat consumes fluids, causing thirst. Heat disturbs the Heart, causing irritability and insomnia. Zhuling Tang is appropriate to promote urination and moisten dryness. Both fluid and heat syndromes can be cured. [Wang Hu's Commentary] This formula is originally for Yangming disease with heat-thirst, desire to drink, and difficulty urinating. This clause borrows it. Why? Yangming disease with fever, thirst, desire to drink, and difficulty urinating involves water-heat binding and stagnation. Here, Shaoyin disease with diarrhea, cough, vomiting, thirst, and insomnia also involves water-heat binding and stagnation. Although disease names differ, the source is the same. Thus, Zhang Zhongjing uses Zhuling Tang for both. It embodies clearing heat, promoting urination, and simultaneously moistening dryness and nourishing Yin.
Case: Comparing this clause with Huanglian Ejiao Tang syndrome, the differences lie in the presence of cough, vomiting, thirst, difficulty urinating, and diarrhea. Also, the previous clause states: Shaoyin disease with desire to vomit but cannot, irritability, and desire to sleep, self-diarrhea with thirst after five or six days, belongs to Shaoyin. Due to deficiency, it draws water to save itself. If urine is white, Shaoyin syndrome characteristics are complete. White urine indicates lower-jiao deficiency-cold failing to control water. Knowing this, although diarrhea, vomiting, thirst, and irritability are common to both, the differences in insomnia and urine color distinguish cold from heat.
In Shaoyin disease, developing mouth dryness and throat dryness within two or three days of onset, urgent purgation is required. Dachengqi Tang (Major Order the Qi Decoction) is appropriate.
[Qian Huang's Commentary] Developing mouth and throat dryness into an urgent purgation indication within two or three days is a variation of Shaoyin, not the norm. Mere mouth and throat dryness does not necessarily warrant urgent purgation. There must also be evidence of Stomach excess and excess-heat pulse. Although the presentation appears as Shaoyin, if pathogenic factors return to Yangming—described as "Yangming Central Earth, the destination of all things, where no further transmission occurs"—becoming evidence of Stomach excess, then urgent purgation with Dachengqi Tang is justified. Urgent purgation is necessary because entering Yin stages risks gradual Yang depletion and Stomach failure, leading to cold extremities, restlessness, hiccups, and myriad complications, which would be untreatable. Hence urgency. [Shu Chiyuan's Commentary] Shaoyin syndromes with Fire transforming to Yangming must present with Yangming Stomach excess symptoms alongside mouth/throat dryness; otherwise, Dachengqi Tang is contraindicated.
In Shaoyin disease, spontaneous diarrhea of clear water, purely green in color, with必 (must) pain in the epigastrium and dry mouth/throat, purgation is permissible. Dachengqi Tang is appropriate. ([Original Note] Another method uses Daichaihu Tang. ○ "Zili" [spontaneous diarrhea], Yuhan and Maijing editions write "xiali" [diarrhea]. "Ke" [can/permissible], Cheng Ben and Yuhan editions write "ji" [urgent], which is correct. Under "Yi" [appropriate], Maijing has "Daichaihu Tang". "Yi" is written as "Shu". After Dachengqi Tang, there is the character "Zheng" [syndrome].)
[Qian Huang's Commentary] This is also a variation of Shaoyin. Spontaneous diarrhea indicates interior cold. Diarrhea of clear water, described as clear water with undigested food, here lacks undigested food, consisting only of clear water, purely green. Clear water suggests cold, and green is a cold color, thus belonging to Shaoyin. Cheng Wuji and Fang Zhu incorrectly attribute green to Liver color. If symptoms were limited to this, it would undoubtedly be a Sini Tang syndrome. Unexpectedly, gastric clear water, though expelling food residue via diarrhea, leaves heat pathogens in the Stomach.
Thus, pressing the epigastrium causes必 (must) pain, and dry mouth indicates that although pathogens entered Shaoyin, Yangming excess-heat remains. It is not merely a Shaoyin syndrome. Excessive heat forces Stomach fluids downward, while lower-jiao cold causes pure clear water, green in color. Violent Yang pathogens threaten upper Stomach fluids and lower Kidney True Yin, which could be exhausted instantly. Hence, urgent purgation is required.
*Classified Cases of Famous Physicians* records: Sun Zhao treated Dou Ta-lang of Donghua Gate suffering from Taiyang disease for over ten days, with mouth/throat dryness, thirst, heart pain, and spontaneous clear water diarrhea. Physicians merely observed and regulated, fearing sweating or purging. Relatives questioned hiring an unclear physician for such a dangerous illness. Summoning Sun, he said: Tomorrow it will be too late to purge; today is the right time. He administered Xiao Chengqi Tang. After bowel movement, the patient slept and recovered fully the next day. Everyone asked why purging worked. Sun said: Superficial reading of books. Mouth/throat dryness and thirst—isn't this a Shaoyin syndrome? Shaoyin usually forbids purging. Did you not hear of the Shaoyin syndrome of spontaneous clear water diarrhea and heart pain, cured by purging? Zhang Zhongjing's book explicitly states this. All were convinced.
In Shaoyin disease, after six or seven days, abdominal fullness and constipation require urgent purgation. Dachengqi Tang is appropriate. ("Zhang" [swollen/full], Yuhan, Maijing, Qianjin, and Yi Fang editions all write "Man" [full].)
[Qian Huang's Commentary] By six or seven days in Shaoyin disease, pathogens have penetrated deeply. However, Shaoyin typically features diarrhea; conversely, abdominal fullness and constipation indicate Shaoyin pathogens returning to Yangming. This is the "Yangming Central Earth, destination of all things, no further transmission" location. Urgent purgation is required, identical to Yangming chapter's "abdominal fullness/pain requires urgent purgation." For Yin channel pathogens returning to Yangming Fu organs, this aligns with *Ling Shu: Pathogenic Factors, Zang-Fu, and Meridian Manifestations*: "When pathogens enter Yin channels, if Zang Qi is solid, pathogens cannot reside and return to Fu organs. Entering Yang flows to meridians; entering Yin flows to Fu organs." However, tongue coating and pulse must confirm an unavoidable need for purgation before using Dachengqi Tang. [Shu Chiyuan's Commentary] Shaoyin transforming to Yangming, with abdominal fullness and constipation, must also present with dry tongue coating, aversion to heat, and preference for cold drinks to confirm excess syndrome.
In Shaoyin disease, with a sinking pulse, urgent warming is required. Sini Tang (Four-Inverted Decoction) is appropriate.
[Wang Hu's Commentary] Shaoyin disease typically has faint-thin pulse and desire to sleep. Now, light pressure reveals no faint pulse, and heavy pressure shows thin pulse nearly vanished, sinking deep. This indicates cold pathogens deeply entrenched in the interior, approaching the Zang organs. Warming cannot be delayed. Delay leads to aversion to cold, curled posture, vomiting/diarrhea, restlessness, insomnia, cold extremities, and absent pulse—imminent death. How can Sini Tang use be delayed? [Cheng Wuji's Commentary] Cases with vomiting, diarrhea, free urination, profuse sweating, undigested food diarrhea, interior cold/exterior heat, and faint/nearly absent pulse are not described as requiring urgent warming. This clause specifies urgent warming for sinking pulse because, although cold is severe, symptoms are manifest externally with established treatment protocols. Here, initially only a sinking pulse exists without other manifestations; the pathogen's location and future progression are unknown. Thus, urgently administer Sini Tang to warm.
In Shaoyin disease, vomiting immediately upon swallowing food, feeling nauseous in the heart/chest but unable to vomit. Initially, cold hands and feet, with wiry-slow pulse indicate excess in the Chest. Purging is contraindicated; emesis is indicated. If there is cold-fluid above the diaphragm causing dry retching, emesis is contraindicated; warming is indicated. Sini Tang is appropriate. ("Xinzhong Wenwen" [warmth in heart], Yuhan writes "Xinxia Yunyun" [warmth below heart], Qianjin writes "Xinzhong Yinyin" [anger/warmth in heart]. "Dang" [should], Yuhan and Cheng Ben write "Ji" [urgent], which is incorrect.)
[Jian's Commentary] Vomiting immediately upon eating, nausea, inability to vomit, persistent恶心 (nausea) is not Shaoyin deficiency-cold vomiting, but Chest cold-excess vomiting. Hence, initial wiry-slow pulse: wiry indicates fluid, slow indicates cold. Cold hands result from Chest Yang blocked by cold-fluid, unable to reach limbs. Cold-excess in Chest requires inducing vomiting (emesis). Thus, purging is contraindicated. If cold-fluid above diaphragm causes only dry retching without expulsion, this is Shaoyin deficiency-cold fluid, not Chest cold-excess. Emesis is contraindicated; urgent warming with Sini Tang is indicated. Or Lizhong Tang plus Dingxiang (Clove) and Wuzhuyu (Evodia Fruit) is also acceptable. [Cheng Zhi's Commentary] "Wenwen" contrasts with "Han Yin" [cold-fluid] below. "Yu tu fu bu neng tu" [desire to vomit but cannot] contrasts with "gan ou" [dry retching] below. "Gan" [dry] means empty. Immediate vomiting empties the stomach. Persistent nausea despite emptying indicates obstruction in the Chest. Cold-excess in Chest blocks Yang dissemination, causing wiry-slow pulse (not faint-thin) and cold hands (not full inversion). Treatment via emesis restores Yang flow. If cold-fluid above diaphragm causes dry retching, deficiency-cold rises from below, trapping fluid in Chest. This is not a Chest disease but lower-jiao deficiency. Urgently warm the lower with Sini Tang. [Ke Qin's Commentary] For emesis, Guodi San (Melon Sepal Powder) is appropriate.
In Shaoyin disease, diarrhea with faint-choppy pulse, vomiting, and sweating, frequent trips to toilet but small volume.
Warm the upper part and apply moxibustion. ([Original Note] Maijing says: Moxa Jueyin point, fifty moxa cones.)
[Qian Huang's Commentary] Yang deficiency causes faint pulse. Cold in meridians causes choppy pulse. Yin pathogens moving downward cause diarrhea; moving upward cause vomiting. Kidney True Yang deficiency fails to ascend as Wei Qi. Unsecured Wei Qi causes sweating. Frequent trips with small volume is tenesmus. Lower-jiao Yang deficiency fails to raise Clear Yang. Severe Shaoyin cold forces Yin downward. Yang sinks into Yin, Yin-Yang constrain each other, preventing Yin from descending fully. Hence frequent trips. Although Yang cannot ascend, it still attempts to lift, resulting in small volume. Warm the upper part. Previous commentators suggest moxa at Baihui (GV20) on the vertex to raise Yang. Others argue Zhang Zhongjing provided no explicit text, so interpretation is speculative. "Upper" may not strictly mean vertex. Stomach is above Kidney; warming Stomach with tonifying-warming herbs and moxa raises Clear Yang, descends Turbid Yin, separates water/grain, and stops diarrhea. Moxa targets Shaoyin meridian points or Stomach Sanwan points, similar to the "moxa" instruction in Fuzi Tang. [Shu Chiyuan's Commentary] This syndrome features Yang deficiency with Qi sinking and Yin/fluid deficiency, causing frequent trips with little output. ("Gengyi" [changing clothes] refers to toileting; "Chu Gong" [bow departing] refers to defecation.) I once treated a woman with acute abdominal pain, aversion to cold, cold extremities, vomiting, and diarrhea. Pulse was faint-choppy. I administered Sini Tang with no effect. Her husband reported continued excessive diarrhea with straining and abnormal bloating. Notably, a mass the size of a pomelo protruded from the vagina, likely the bladder. Can an elderly woman survive? I consulted Zhongyuan. He hesitated, saying: Do not warm the lower, forcing Yin. Use moxa on the upper to raise Yang. I agreed, applied ginger slice to Baihui (GV20), moxa three cones. The bladder retracted. Continued Sini Tang plus Baizhu (Atractylodes Macrocephala Rhizome); one dose cured her.
Case: Meaning of "warm upper and moxa" is unclear. Fang Youzhi said: Upper refers to Baihui on vertex. Wang Hu said: Baihui treats pediatric rectal prolapse; here it raises Yang. Yu Jiayuan, Cheng Zhi, Ke Qin, and Jinjian follow Fang. Te Zhi Cong and Xi Ju said: Warm upper assists Upper Jiao Yang. With Qian's cited "or says"...