治少阴下痢清谷, 里寒外热, 手足厥逆, 脉微欲
绝,身反不恶寒, 其人面赤色, 或腹痛, 或干呕, 或咽痛, 或痢止脉
不出者. 厥阴下痢清谷, 里寒外热, 汗出而厥者主之.
干姜三两 强人可四两 甘草 ( 炙 ) 二两 附子 ( 生用, 去皮 )
大者一枚, 右三味, 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, 去芍药, 加桔梗一两. 痢止脉不出者, 加人
参二两.
【注】论中扶阳抑阴之剂: 中寒阳微不能外达, 主以四逆. 中外俱寒
,阳气虚甚, 主以附子. 阴盛于下, 格阳于上, 主以白通. 阴盛于内
,格阳于外, 主以通脉. 是则可知四逆运行阳气者也, 附子温补阳气
者也, 白通宣通上下之阳气者也, 通脉通达内外之阳气者也. 今脉微
欲绝, 里寒外热, 是肾中阴盛, 格阳于外, 故主之也. 倍干姜加甘草
佐附子, 易名通脉四逆汤者, 以其能大壮元阳, 主持中外, 共招外热
反之于内. 盖此时生气已离, 亡在俄顷, 若以柔缓之甘草为君, 岂能
疾呼外阳耶? 故易以干姜. 然必加甘草与干姜等分者, 恐涣漫之余,
姜,附之猛不能安养元气, 所谓有制之师也. 若面赤者, 加葱以通格
上之阳. 腹痛者, 加芍药以和在里之阴. 呕逆者, 加生姜以止呕. 咽
痛者, 加桔梗以利咽. 痢止脉不出气少者, 俱倍人参, 以生元气而复
脉也.
Indicated for Shaoyin disease presenting with diarrhea of undigested food, internal cold with external heat, cold limbs (Jue Ni), and a pulse so faint as to be nearly imperceptible. The body may paradoxically not feel aversion to cold, and the patient's face may appear red. It is also indicated if accompanied by abdominal pain, dry retching, sore throat, or if the diarrhea stops but the pulse remains absent. For Jueyin disease presenting with diarrhea of undigested food, internal cold with external heat, sweating, and cold limbs, this formula is also indicated.
Dried Ginger (Gan Jiang) 3 liang (4 liang for robust individuals), Honey-fried Licorice Root (Zhi Gan Cao) 2 liang, Raw Aconite Root (Sheng Fu Zi, peeled) one large piece. These three ingredients are decocted in 3 sheng of water until 1.2 sheng remains. Strain the dregs and divide into two warm doses. If the pulse returns, the patient will recover. If the complexion is red, add 9 stalks of Scallion White (Cong Bai). If there is abdominal pain, remove the Scallion White and add 2 liang of Peony Root (Bai Shao). If there is vomiting, add 2 liang of Fresh Ginger (Sheng Jiang). If there is a sore throat, remove the Peony Root and add 1 liang of Platycodon Root (Jie Geng). If the diarrhea stops but the pulse does not emerge, add 2 liang of Ginseng Root (Ren Shen).
[Annotation] Regarding formulas that support Yang and suppress Yin: When cold injury causes Yang Qi to become weak and unable to reach the exterior, Si Ni Tang (Four Counterflow Decoction) is indicated. When both interior and exterior are cold and Yang Qi is extremely deficient, Aconite Root (Fu Zi) [contextually implying formulas heavily relying on Fu Zi, such as Tong Mai Si Ni Tang] is indicated. When Yin excess is at the lower jiao and repels Yang to the upper jiao, Bai Tong Tang (White Pass Decoction) is indicated. When Yin excess is within and repels Yang to the outside, Tong Mai Si Ni Tang (Pulse-Resuscitating Four Counterflow Decoction) is indicated. Thus, it can be known that Si Ni Tang circulates Yang Qi; [formulas emphasizing] Fu Zi warms and tonifies Yang Qi; Bai Tong Tang unblocks Yang Qi between the upper and lower; and Tong Mai Si Ni Tang unblocks Yang Qi between the interior and exterior. Now, with a pulse faint as if absent and internal cold with external heat, this indicates Yin excess in the Kidney repelling Yang to the exterior; hence, this formula is indicated. By doubling the Dried Ginger and adding Licorice Root to assist Aconite Root, and renaming it Tong Mai Si Ni Tang, it is because it greatly strengthens the Primordial Yang, governs the interior and exterior, and collectively draws the external heat back into the interior. At this time, the vital Qi has already dispersed, and death is imminent. If soft and slow Licorice Root were used as the Sovereign herb, how could it swiftly call back the external Yang? Therefore, Dried Ginger is changed to be primary. However, Licorice Root must be added in equal proportion to Dried Ginger, fearing that amidst the dispersion of residual Qi, the fierce nature of Dried Ginger and Aconite Root cannot nourish the Primordial Qi; this is what is meant by "a disciplined army." If the face is red, add Scallion White to unblock Yang repelled to the upper part. If there is abdominal pain, add Peony Root to harmonize Yin within. If there is vomiting and counterflow, add Fresh Ginger to stop vomiting. If there is a sore throat, add Platycodon Root to benefit the throat. If diarrhea stops, the pulse does not emerge, and Qi is deficient, double the dose of Ginseng Root to generate Primordial Qi and restore the pulse.