伤寒脉微而厥。至七八日。肤冷。其人躁无暂安时者。此为脏厥。非蛔厥也。蛔厥者。其人当
吐蛔。今病者静而复时烦。此为脏寒。蛔上入膈。故烦。须臾复止。得食而呕。又烦者。蛔闻食臭出
。其人当自吐蛔。蛔厥者。乌梅丸主之。又主久痢。
伤寒脉微而厥。寒邪中于阴也。至七八日。身不热而肤冷。则其寒邪未变可知。乃其人躁无暂
安时者。
此为脏厥发躁。阳气欲绝。非为蛔厥也。蛔厥者。蛔动而厥。其人亦躁。但蛔静则躁亦自止。蛔动
则时复自烦。非若脏寒之躁无有暂安时也。然蛔之所以时动而时静者。何也。蛔性喜温。脏寒
则蛔不安而上膈。蛔喜得食。脏虚则蛔复上而求食。甚则呕吐。涎液从口中出。按古云、蛔得甘则
动。得苦则安。又曰、蛔闻酸则静。得辛热则止。故以乌梅之酸。连柏之苦。姜、辛、归、附、椒
、桂之辛。以安蛔温脏而止其厥逆。加人参者。以蛔动中虚。故以之安中而止吐。且以御冷热诸药
之悍耳。
乌梅丸方
乌梅（三百个） 黄连（一斤） 干姜（十两） 细辛 附子（炮） 桂枝 人参 黄柏（各
六两） 当归 蜀椒（各四两）
上十味。异捣筛。合治之。以苦酒渍乌梅一宿。去核。蒸之五升米下。饭熟捣成泥。和药令相
得。内臼中。与蜜杵二千下。丸如桐子大。先食饮服十丸。日三服。稍加至二十丸。禁生冷滑
物臭食等。干呕吐涎沫。头痛者。吴茱萸汤主之。
干呕吐涎沫者。厥阴寒邪上攻阳明也。头痛者。厥阴之脉上出额。与督脉会于巅。寒气随经上
入于头。故痛也。然头者诸阳之会。以阴邪而得干之。其阳不振甚矣。故以吴茱萸辛热。入厥阴散寒
邪为君。生姜辛温。和胃止呕吐为臣。人参、大枣甘温。助正气养阳气为佐也。
手足厥寒。脉细欲绝者。当归四逆汤主之。若其人内有久寒者。宜当归四逆加吴茱萸生姜汤主
之。
手足厥寒。脉微欲绝者。阳之虚也。宜四逆辈。脉细欲绝者。血虚不能温于四末。并不能荣于脉中
也。夫脉为血之府。而阳为阴之先。故欲续其脉。必益其血。欲益其血。必温其经。方用当归、芍
药之润以滋之。甘草、大枣之甘以养之。桂枝、细辛之温以行之。而尤藉通草之入经通脉。以续其
绝而止其厥。若其人内有久寒者。必加吴茱萸、生姜之辛以散之。而尤藉清酒之濡经浃脉。以散其
久伏之寒也。
当归四逆汤方
当归（三两） 桂枝（三两） 芍药（三两） 细辛（三两） 通草（二两） 甘草（二两
炙） 大枣（二十五枚擘一法十二枚）
上七味。以水八升。煮取三升。去滓。温服一升。日三服。
当归四逆加吴茱萸生姜汤方
当归（三两） 桂枝（三两） 芍药（三两） 细辛（三两） 通草（二两） 甘草（二两
炙） 大枣（二十五枚） 吴茱萸（二升） 生姜（半斤切）
上九味。以水六升。清酒六升。和煮取五升。去滓。温分五服。一方水酒各四升。
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。
此过汗伤阳。病本热而变为寒之证。大汗出。热不去者。邪气不从汗解。而阳气反从汗亡也
。阳气外亡。则寒冷内生。内冷则脉拘急而不舒也。四肢者。诸阳之本。阳虚不足。不能实气于四肢
。则为之疼痛也。
甚至下利厥逆而恶寒。则不特无以内守。亦并不为外护矣。故必以四逆汤救阳驱阴为主。余谓传经
之热。久亦成阴者。此类是也。
大汗。若大下利而厥逆者。四逆汤主之。
此亦阳病误治而变阴寒之证。成氏所谓大汗若大下利。表里虽殊。其亡津液损阳气一也。阳虚
阴胜。则生厥逆。虽无里急下利等证。亦必以救阳驱阴为急。易曰、履霜坚冰至。阴盛之戒。不可
不凛也。
伤寒脉促。手足厥逆者。可灸之。
脉阳盛则促。阴盛则结。手足厥逆而脉促者。非阳之虚。乃阳之郁而不通也。灸之所以引阳外
出。若厥而脉微者。则必更以四逆汤温之。岂特灸之哉。
呕而脉弱。小便复利。身有微热。见厥者。难治。四逆汤主之。
脉弱便利而厥。为内虚且寒之候。则呕非火邪。乃是阴气之上逆。热非寒邪。乃是阳气之外越
矣。故以四逆汤救阳驱阴为主。然阴方上冲而阳且外越。其离决之势。有未可即为顺接者。故曰难
治。或曰呕与身热为邪实。厥利脉弱为正虚。虚实互见。故曰难治。四逆汤。舍其标而治其本也。
亦通。
下利清谷。里寒外热。汗出而厥者。通脉四逆汤主之。
挟热下利者。伤在太阴之阴。中寒清谷者。伤在少阴之阳。里寒外热。汗出而厥。为阴内盛而
阳外越之象。故于四逆加干姜一倍。以温里而胜寒邪。曰通脉者。盖欲使阳气内行。而厥与利俱止
耳。
伤寒厥而心下悸者。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。
伤寒寒胜则厥。心下有水则悸。厥而心下悸者。寒中于阴而水聚于心下也。是宜以茯苓甘草汤
先治其水。水去然后治厥。如伤寒二三日。心中悸而烦者。先服建中汤之意也。建中者。创建中气
。恐其中虚而邪易入。邪入则烦不止矣。茯苓甘草汤甘淡利水益中气。恐其水渍入胃而作利。
利作则厥不回矣。仲景治病。每以正气为虑如此。
伤寒本自寒下。医复吐下之。寒格更逆吐下。若食入口即吐。干姜黄连黄芩人参汤主之。
伤寒本自寒下。盖即太阴腹满自利之证。医不知而复吐下之。里气遂虚。阴寒益甚。胃中之阳
。被格而上逆。脾中之阴。被抑而下注。得不倍增吐下乎。至食入口即吐。则逆之甚矣。若以寒治
逆。则寒下转增。或仅投温剂。则必格拒而不入。故以连、芩之苦。以通寒格。参、姜之温。以复
正气而逐阴邪也。
干姜黄连黄芩人参汤方
干姜（三两） 黄连（三两） 黄芩（三两） 人参（三两）
上四味。以水六升。煮取二升。去滓。分温再服。
In Shaoyang disease (disease of the Shaoyang channel), if the pulse is faint and there is cold extremities, after seven or eight days, the skin becomes cold. If the patient is restless with no moment of peace, this is Zang Jue (Jue syndrome caused by extreme depletion of internal organ Yang qi), not Hui Jue (Jue syndrome caused by ascariasis disturbance). Patients with Hui Jue typically vomit roundworms. The current patient is quiet but occasionally irritable; this is due to internal cold causing the worms to move upward into the diaphragm, thus causing irritability. After a while, it stops. Vomiting occurs after eating, followed by irritability again, because the worms come out upon smelling food odor, and the patient will likely vomit roundworms spontaneously. For Hui Jue, Wumei Wan (Mume Pill) is the primary formula. It is also indicated for chronic dysentery.
Shaoyang disease with a faint pulse and cold extremities indicates cold pathogen invading the Yin channels. After seven or eight days, the body is not hot but the skin is cold, indicating the cold pathogen has not transformed. However, the patient's restlessness without any moment of peace indicates the agitation of Zang Jue, signifying impending exhaustion of Yang qi, rather than Hui Jue. In Hui Jue, agitation is caused by worm movement; when the worms are still, agitation ceases; when they move, irritability recurs intermittently. This differs from the continuous restlessness of Zang cold. Why do the worms move intermittently? Because worms prefer warmth; internal cold makes them uneasy and ascend to the diaphragm. Worms seek food; internal deficiency causes them to ascend again to find food, potentially leading to vomiting and salivation. Ancient texts state: "Worms move with sweetness, settle with bitterness." Also: "Worms stay quiet with sourness, stop moving with pungent-hot herbs." Therefore, the sourness of Wu Mei (Fructus Mume), the bitterness of Lian Lian (Rhizoma Coptidis) and Huang Bo (Cortex Phellodendri), and the pungency of Gan Jiang (Rhizoma Zingiberis), Xi Xin (Herba Asari), Dang Gui (Radix Angelicae Sinensis), Fu Zi (Radix Aconiti Lateralis Preparata), Shu Jiao (Semen Zanthoxyli), and Gui Zhi (Ramulus Cinnamomi) are used to calm the worms, warm the organs, and arrest Jue. Ren Shen (Radix Ginseng) is added because worm movement depletes middle Qi; it stabilizes the middle, stops vomiting, and mitigates the harshness of other cold and hot herbs.
Formula: Wumei Wan (Mume Pill)
Ingredients: Wu Mei (300 fruits), Lian Lian (1 jin), Gan Jiang (10 liang), Xi Xin, Fu Zi (prepared), Gui Zhi, Ren Shen, Huang Bo (each 6 liang), Dang Gui, Shu Jiao (each 4 liang).
Process: Grind the ten ingredients separately and sift. Mix them. Soak Wu Mei in vinegar overnight, remove pits, steam over five sheng of rice until cooked, mash into paste, mix with herbs, place in mortar, add honey, pound two thousand times, form pills the size of tung seeds. Take ten pills before meals with water, three times daily, gradually increasing to twenty pills. Avoid raw, cold, slippery, foul-smelling foods. For dry heaving, vomiting of saliva/phlegm, and headache, Wuzhuyu Tang (Evodia Decoction) is indicated.
Dry heaving and vomiting saliva/phlegm indicate Jueyin cold pathogen attacking the Yangming stomach. Headache occurs because the Jueyin meridian ascends to the forehead and meets the Du vessel at the vertex; cold follows the meridian upward into the head, causing pain. The head is the convergence of all Yang meridians; invasion by Yin cold indicates severe depression of Yang. Thus, Wuzhu Yu (Fructus Evodiae) is used as the sovereign herb for its pungent-hot nature to disperse cold in the Jueyin channel; Sheng Jiang (Rhizoma Zingiberis Recens) is the minister herb for its pungent-warm nature to harmonize the stomach and stop vomiting; Ren Shen and Da Zao (Fructus Jujubae) are the assistant herbs for their sweet-warm nature to support healthy Qi and nourish Yang.
For cold hands and feet with a fine pulse nearly imperceptible, Danggui Sini Tang (Angelica Four-Reverse Decoction) is indicated. If there is long-standing cold inside, Danggui Sini Tang plus Wuzhuyu and Sheng Jiang (Danggui Sini Tang plus Evodia and Fresh Ginger Decoction) is appropriate.
Cold hands and feet with a faint pulse nearly imperceptible indicate Yang deficiency, treated with Si Ni Tang (Four-Reverse Decoction) type formulas. A fine pulse nearly imperceptible indicates blood deficiency failing to warm the extremities and fill the vessels. Vessels are the residence of blood, and Yang precedes Yin. To restore the pulse, one must tonify blood; to tonify blood, one must warm the channels. Dang Gui and Bai Shao (Radix Paeoniae Alba) moisten and nourish; Gan Cao (Radix Glycyrrhizae Preparata) and Da Zao nourish; Gui Zhi and Xi Xin warm and promote circulation. Tong Cao (Medulla Tetrapanacis) is crucial for entering channels and unblocking vessels to restore the pulse and stop Jue. If long-standing cold exists internally, add Wuzhu Yu and Sheng Jiang to disperse cold, aided by Qing Jiu (clear wine) to moisten channels and penetrate vessels to dispel entrenched cold.
Formula: Danggui Sini Tang (Angelica Four-Reverse Decoction)
Ingredients: Dang Gui (3 liang), Gui Zhi (3 liang), Bai Shao (3 liang), Xi Xin (3 liang), Tong Cao (2 liang), Gan Cao (prepared, 2 liang), Da Zao (25 pieces, split; alternative: 12 pieces).
Process: Seven ingredients, boil in 8 sheng of water to obtain 3 sheng, strain, take 1 sheng warm, three times daily.
Formula: Danggui Sini Tang plus Wuzhuyu and Sheng Jiang (Danggui Sini Tang plus Evodia and Fresh Ginger Decoction)
Ingredients: Dang Gui (3 liang), Gui Zhi (3 liang), Bai Shao (3 liang), Xi Xin (3 liang), Tong Cao (2 liang), Gan Cao (prepared, 2 liang), Da Zao (25 pieces), Wuzhu Yu (2 sheng), Sheng Jiang (half jin, sliced).
Process: Nine ingredients, boil in 6 sheng water and 6 sheng clear wine to obtain 5 sheng, strain, divide into five warm doses. Alternative: 4 sheng water and 4 sheng wine.
Profuse sweating, fever persisting, internal cramping, limb pain, accompanied by diarrhea, cold extremities, and aversion to cold, is treated with Si Ni Tang (Four-Reverse Decoction).
This results from excessive sweating damaging Yang, transforming a heat pattern into a cold one. Profuse sweating with persistent fever means pathogens did not resolve via sweat, but Yang escaped with the sweat. External loss of Yang leads to internal cold, causing vessel tension and discomfort. Limbs are the root of Yang; Yang deficiency fails to fill limbs with Qi, causing pain. Severe cases with diarrhea, cold extremities, and aversion to cold indicate failure to guard internally and externally. Thus, Si Ni Tang is essential to rescue Yang and expel Yin. Heat transmitted through channels may eventually become Yin-cold patterns, such as these.
Profuse sweating, or severe diarrhea with cold extremities, is treated with Si Ni Tang (Four-Reverse Decoction).
This is also an error in treating Yang disease leading to Yin-cold transformation. Cheng Wuji stated that profuse sweating or severe diarrhea, though differing in exterior/interior location, both result in loss of fluids and damage to Yang. Yang deficiency and Yin excess cause Jue. Even without tenesmus or diarrhea, rescuing Yang and expelling Yin is urgent. The I Ching warns: "Treading on frost, firm ice arrives." One must beware of Yin excess.
Shaoyang disease with rapid pulse and cold extremities can be treated with moxibustion.
A rapid pulse indicates Yang excess; a knotted pulse indicates Yin excess. Cold extremities with a rapid pulse indicate not Yang deficiency, but Yang stagnation and obstruction. Moxibustion guides Yang outward. If Jue is accompanied by a faint pulse, Si Ni Tang (Four-Reverse Decoction) must be used to warm, not just moxibustion.
Vomiting with weak pulse, frequent urination, slight fever, and Jue is difficult to treat; Si Ni Tang (Four-Reverse Decoction) is indicated.
Weak pulse, frequent urination, and Jue indicate internal deficiency and cold. Vomiting is due to counterflow of Yin Qi, not fire pathogen. Fever is due to floating of Yang Qi, not cold pathogen. Si Ni Tang rescues Yang and expels Yin. However, with Yin surging up and Yang floating out, separation is imminent, making recovery difficult ("difficult to treat"). Alternatively, vomiting and fever represent excess pathogens, while Jue, diarrhea, and weak pulse represent deficient healthy Qi; mixed excess and deficiency make it difficult. Si Ni Tang treats the root, ignoring the branch.
Diarrhea with undigested food, interior cold with exterior heat, sweating, and Jue is treated with Tongmai Sini Tang (Pulse-Rescuing Four-Reverse Decoction).
Diarrhea with heat damages Taiyin Yin; cold-induced undigested stool diarrhea damages Shaoyin Yang. Interior cold with exterior heat, sweating, and Jue indicate Yin excess internally and Yang floating externally. Doubling the dosage of Gan Jiang (Rhizoma Zingiberis) in Si Ni Tang warms the interior and overcomes cold. It is called "Tongmai" (Unblocking Pulse) to guide Yang inward, stopping Jue and diarrhea.
Shaoyang disease with Jue and palpitations under the heart requires treating water retention first with Fuling Gancao Tang (Poria and Licorice Decoction), then treating Jue. Otherwise, water infiltrating the stomach will cause diarrhea.
Excess cold causes Jue; water in the heart region causes palpitations. Jue with palpitations indicates cold invading Yin and water accumulating below the heart. Treat water first with Fuling Gancao Tang. This parallels using Xiaojianzhong Tang (Minor Construct the Middle Decoction) for palpitations and irritability in early Shaoyang disease, to build Middle Qi and prevent pathogen invasion which causes irritability. Fuling Gancao Tang drains water and benefits Middle Qi, preventing water infiltration and subsequent diarrhea, which would prevent reversal of Jue. Zhang Zhongjing always considers the strength of Healthy Qi.
Shaoyang disease originally involving cold-type diarrhea, mistreated with emesis or purgation, leads to cold rejection worsening vomiting and diarrhea. If food is vomited immediately upon entry, Ganjiang Liandan Huangqin Renshen Tang (Ginger, Coptis, Scutellaria, and Ginseng Decoction) is indicated.
Original cold diarrhea resembles Taiyin fullness and spontaneous diarrhea. Mistreatment with emesis/purgation further depletes interior Qi and intensifies Yin cold. Stomach Yang is rejected upward, Spleen Yin is suppressed downward, exacerbating vomiting and diarrhea. Immediate vomiting indicates severe counterflow. Cold herbs would worsen cold-diarrhea; warm herbs alone might be rejected. Thus, bitter Lian Lian and Huang Qin (Scutellariae Radix) open cold rejection; warm Ren Shen and Gan Jiang restore Healthy Qi and expel Yin cold.
Formula: Ganjiang Liandan Huangqin Renshen Tang (Ginger, Coptis, Scutellaria, and Ginseng Decoction)
Ingredients: Gan Jiang (3 liang), Lian Lian (3 liang), Huang Qin (3 liang), Ren Shen (3 liang).
Process: Four ingredients, boil in 6 sheng of water to obtain 2 sheng, strain, take warm in two doses.