于桂枝汤方内。更加芍药三两。随前共六两。余根据桂枝汤法。
大实痛者。桂枝加大黄汤主之。
大实大满。自可除下之。故加大黄。以下大实。
桂枝（三两去皮） 大黄（一两） 芍药（六两） 生姜（三两切） 甘草（二两
炙） 大枣（十二枚擘）
上六味。以水七升。煮取三升。去滓。温服一升。日三服。
娄氏云。用四逆辈。固所当然。复用桂枝大黄。夫大黄大寒。何为用于阴经。又兼
桂枝。寒热相杂。何也。曰。自利而渴者。属少阴。为寒在下焦。自利不渴者。属太阴。
为寒在中焦。以四逆等汤温其脏。此本经当用之药也。其太阳病。反下之。表邪
未解。乘虚传于太阴。因而腹满时痛。大实痛者。桂枝加芍药大黄为宜。
赵嗣真云。太阴腹满证有三有次第传经之邪。有直入本经之邪。有下后内陷之邪。
不可不辨。
太阴为病。脉弱。其人续自便利。设当行大黄芍药者。宜减之。以其人胃气弱。易
动故也。
腹满痛者。太阴病也。脉弱。其人续自便利。则邪虽在里。未成大实。欲与大黄芍
药攻满痛者。宜少与之。以胃气尚弱。易为动利也。
少阴之为病。脉微细。但欲寐也。
少阴为病。脉微细。为邪气传里深也。卫气行于阳则寤。行于阴则寐。邪传少阴。
则气行于阴而不行于阳。故但欲寐。
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。
欲吐不吐心烦者。表邪传里也。若腹满痛则属太阴。此但欲寐。则知属少阴。五六
日邪传少阴之时。自利不渴者。寒在中焦。属太阴。此自利而渴。为寒在下焦。属少阴。
肾虚水燥。渴欲引水自救。下焦虚寒。不能制水。小便色白也。经曰。下利欲饮水者。
以有热故也。此下利虽渴。然以小便色白。明非里热。不可不察。
王三阳云。此寒中阴经而传入阴脏者。虽引水自救。浮阳在上也。若有大渴。方可
论阳邪传阴热证。
病患脉阴阳俱紧。反汗出者。亡阳也。此属少阴。法当咽痛而复吐利。
脉阴阳俱紧。为少阴伤寒。法当无汗。反汗出者。阳虚不固也。故云亡阳。以无阳
阴独。是属少阴。内经曰。邪客少阴之络。令人嗌痛。不可内食。少阴寒甚。是当咽痛
而复吐利。
少阴病。咳而下利谵语者。被火气劫故也。小便必难。以强责少阴汗也。
咳而下利。里寒而亡津液也。反以火劫。强责少阴汗者。津液内竭。加火气烦之。
故谵语小便难也。
少阴病。脉细沉数。病为在里。不可发汗。
少阴病。始得之。反发热。脉沉者。为邪在经。可与麻黄附子细辛汤发汗。此少阴
病脉细沉数。为病在里。故不可发汗。
王三阳云。此无发热证。故不可汗。
少阴病。脉微。不可发汗。亡阳故也。阳已虚。尺脉弱涩者。复不可下之。
脉微为亡阳。表虚不可发汗。脉弱涩为亡阳。里虚复不可下。
王三阳云。脉弱涩。涩者、阴也。涩为血少。乃亡阴也。故不可下。阳字误。
少阴病。脉紧。至七八日。自下利。脉暴微。手足反温脉紧反去者。为欲解也。虽
烦。下利必自愈。
少阴病脉紧者。寒甚也。至七八日传经尽。欲解之时。自下利。脉暴微者。寒气得
泄也。若阴寒胜止。阳虚而泄者。则手足厥而脉紧不去。今手足反温。脉紧反去。知阳
气复。寒气去。故为欲解。下利烦躁者逆。此正胜邪微。虽烦。下利必自止。
少阴病。下利。若利自止恶寒而蜷卧。手足温者可治。
少阴病。下利。恶寒蜷卧。寒极而阴胜也。利自止。手足温者。里和。阳气得复。
故为可治。
少阴病。恶寒而蜷。时自烦。欲去衣被者。可治。
恶寒而蜷。阴寒甚也。时时自烦。欲去衣被。为阳气得复。故云可治。
少阴中风。脉阳微阴浮者。为欲愈。
少阴中风。阳脉当浮。而阳脉微者。表邪缓也。阴脉当沉。而阴脉浮者。里气和也。
阳中有阴。阴中有阳。阴阳调和。故为欲愈。
少阴病欲解时。从子至寅上。
阳生于子。子为一阳。丑为二阳。寅为三阳。少阴解于此者。阴得阳则解也。
少阴病。吐利。手足不逆冷。反发热者。不死。脉不至者。灸少阴七壮。
经曰。少阴病。吐利。躁烦。四逆者。死。吐利。手足不厥冷者。则阳气不衰。虽
反发热。不死。脉不至者。吐利暴虚也。灸少阴七壮。以通其脉。
少阴病。八九日。一身手足尽热者。以热在膀胱。必便血也。
膀胱、太阳也。少阴太阳为表里。少阴病。至八九日。寒邪变热。复传太阳。太阳
为诸阳主气。热在太阳。故一身手足尽热。太阳经多血。少气为热所乘。则血散下行。
必便血也。
少阴病。但厥无汗。而强发之。必动其血。未知从何道出。或从口鼻。或从目出。
是名下厥上竭。为难治。
但厥无汗。热行于里也。而强发汗。虚其经络。热乘经虚。迫血妄行。从虚而出。或
从口鼻。或从目出。诸厥者。皆属于下。但厥为下厥。血亡于上。为上竭。伤气损血。
邪甚正虚。故为难治。
王宇泰云。但厥无汗。热入里而外寒甚也。当温之。而强发其汗。则卫寒甚而汗不
能出。必内伤其荣血而妄行也。
少阴病。恶寒。身蜷而利。手足逆冷者。不治。
针经曰。多热者易已。多寒者难已。此内外寒极。纯阴无阳。故云不治。
少阴病。吐利。躁烦四逆者死。
吐利者。寒甚于里。四逆者。寒甚于表。躁烦则阳气欲绝。是知死矣。
少阴病。下利止。而头眩。时时自冒者死。
下利止。则水谷竭。眩冒。则阳气脱故死。
少阴病。四逆。恶寒而身蜷。脉不至。不烦而躁者死。
四逆恶寒而身蜷。则寒甚。脉不至。则真气绝。烦、热也。躁、乱也。若愤躁之躁。从烦
至躁。为热来有渐。则犹可。不烦而躁。是气欲脱而争也。譬犹灯将灭而暴明。其能久
乎。
少阴病。六七日。息高者死。
肾为生气之源。呼吸之门。少阴病。六七日不愈而息高者。生气断绝也。
少阴病。脉微、细、沉。但欲卧。汗出。不烦。自欲吐。至五六日。自利。复烦躁。
不得卧寐者死。
阴气方盛。至五六日传经尽。阳气得复则愈。反更自利。烦躁。不得卧寐。则正气
弱。阳不能复。病胜脏。故死。
少阴病。始得之反发热。脉沉者。麻黄附子细辛汤主之。
少阴病当无热恶寒。反发热者。邪在表也。虽脉沉。以始得则邪气未深。亦当温剂
发汗以散之。
In the prescription of Guizhi Tang (Cinnamon Twig Decoction), add an additional three liang of Shaoyao (White Peony Root). Together with the previous amount, it totals six liang. The rest should follow the preparation and administration method of Guizhi Tang.
If there is severe pain accompanied by excess syndrome (Da Shi Tong), Guizhi Jia Dahuang Tang (Cinnamon Twig Decoction with Added Rhubarb) should be used as the primary treatment.
For cases of severe abdominal fullness and excess, purgation can naturally be employed to eliminate the pathogenic factor; therefore, Dahuang (Rhubarb) is added to purge the severe excess.
[Prescription Composition]
Guizhi (Cinnamon Twig, peeled, three liang), Dahuang (Rhubarb, one liang), Shaoyao (White Peony Root, six liang), Shengjiang (Fresh Ginger, sliced, three liang), Gancao (Licorice Root, honey-fried, two liang), Dazao (Jujube, broken open, twelve pieces).
Take these six ingredients, decoct in seven sheng of water, reduce to three sheng of liquid, remove the dregs, and take one sheng warm per dose, three times daily.
Lou commented: Using Si Ni Tang (Frigid Extremities Decoction) or similar formulas is indeed appropriate; however, using both Guizhi and Dahuang together raises a question. Dahuang is extremely cold in nature; why is it used for a Yin channel? Moreover, combining it with Guizhi creates a mixture of cold and hot properties. The answer is: For spontaneous diarrhea accompanied by thirst, the condition belongs to Shaoyin disease, indicating cold in the Lower Jiao. For spontaneous diarrhea without thirst, the condition belongs to Taiyin disease, indicating cold in the Middle Jiao. Using Si Ni Tang to warm the viscera is the standard medication for this classic text. However, if a Taiyang disease was incorrectly treated with purgation, causing the exterior pathogen to remain unresolved and enter the Taiyin due to deficiency, resulting in abdominal fullness and intermittent pain, or severe pain with excess, adding Dahuang to Guizhi Jia Shaoyao Tang is suitable.
Zhao Sizhen commented: There are three types of abdominal fullness in Taiyin disease: pathogens transmitted sequentially through the channels, pathogens entering the channel directly, and pathogens sinking inward after incorrect purgation. These must be distinguished.
In Taiyin disease, the pulse is weak, and the patient continues to have normal bowel movements. If Da Huang and Shao Yao were indicated, their dosages should be reduced because such patients have weak Stomach Qi and are prone to diarrhea induced by the medicine.
Abdominal fullness and pain indicate Taiyin disease. If the pulse is weak and the patient continues to have normal bowel movements, although the pathogen is in the interior, it has not formed a severe excess syndrome. To use Da Huang and Shao Yao to attack the fullness and pain, they should be given in small amounts because the Stomach Qi is still weak and easily disturbed into diarrhea.
The defining symptoms of Shaoyin disease are a faint and fine pulse, and a desire only to sleep (Dan Yu Mei).
In Shaoyin disease, the faint and fine pulse indicates that the pathogen has penetrated deeply into the interior. Wei Qi (Defensive Qi) moves in the Yang aspect leading to wakefulness, and in the Yin aspect leading to sleep. When the pathogen transmits to Shaoyin, Qi moves in the Yin but not in the Yang, hence the symptom of desiring only to sleep.
In Shaoyin disease, if there is a desire to vomit but nothing comes up, irritability, and a desire only to sleep. After five or six days, if spontaneous diarrhea occurs accompanied by thirst, it belongs to Shaoyin disease. This is due to internal deficiency, prompting the intake of water for self-rescue. If the urine is colorless white, the signs of Shaoyin disease are fully present. Urine being white indicates deficiency-cold in the Lower Jiao, which fails to control water metabolism, resulting in pale urine.
Desire to vomit without vomiting and irritability indicate the transmission of exterior pathogen to the interior. If accompanied by abdominal fullness and pain, it belongs to Taiyin; here, only desiring to sleep indicates Shaoyin. During the fifth or sixth day when the pathogen transmits to Shaoyin, spontaneous diarrhea without thirst indicates cold in the Middle Jiao, belonging to Taiyin. Here, spontaneous diarrhea with thirst indicates cold in the Lower Jiao, belonging to Shaoyin. Kidney deficiency leads to dryness of water, causing thirst and a desire to drink water for self-rescue. Lower Jiao deficiency-cold fails to control water, resulting in white urine. The Classic states: "Diarrhea with a desire to drink water is due to heat." Although there is thirst here, the white urine clearly indicates it is not interior heat; this must be carefully examined.
Wang Sanyang commented: This is cold invading the Yin channels and transmitting to the Yin viscera. Although drinking water for self-rescue occurs, it is due to floating Yang in the upper body. Only in cases of extreme thirst can one discuss the heat syndrome caused by Yang pathogen transmitting to Yin.
If the patient's pulse is tight in all positions (Yin and Yang) but sweat appears spontaneously, this is Wang Yang (Loss of Yang). This belongs to Shaoyin disease. By protocol, it should manifest as sore throat accompanied by vomiting and diarrhea.
A tight pulse in all positions indicates Shaoyin Cold Damage. By protocol, there should be no sweat. Spontaneous sweating indicates Yang deficiency failing to secure the exterior. Hence, it is called Loss of Yang. With Yang exhausted and Yin alone remaining, it belongs to Shaoyin. The Inner Canon states: "When pathogen lodges in the Luo vessels of Shaoyin, it causes sore throat and inability to eat." Severe cold in Shaoyin should manifest as sore throat accompanied by vomiting and diarrhea.
In Shaoyin disease, if there is coughing, diarrhea, and delirium (Zhan Yu), it is caused by Fire Therapy劫夺 (robbing) the fluids. The urine will certainly be difficult to pass, due to forcibly inducing sweat in Shaoyin disease.
Coughing and diarrhea indicate interior cold and loss of body fluids. Applying fire therapy to forcibly induce sweat in Shaoyin disease depletes internal fluids. Combined with the harassing effect of fire heat, delirium and difficulty urinating result.
In Shaoyin disease, if the pulse is fine, deep, and rapid, the disease is in the interior, and sweating therapy is contraindicated.
In early Shaoyin disease, if there is fever contrary to expectation and a deep pulse, the pathogen is in the channels. Mahuang Fuzi Xixin Tang (Ephedra, Aconite, and Asarum Decoction) may be used to induce sweating. In contrast, the current Shaoyin disease with fine, deep, and rapid pulse indicates the disease is in the interior, so sweating is contraindicated.
Wang Sanyang commented: Since there is no fever symptom here, sweating is contraindicated.
In Shaoyin disease, if the pulse is faint, sweating is contraindicated because it leads to Loss of Yang. If Yang is already deficient, and the Chi (cun-kou) pulse is weak and choppy, purgation is also contraindicated.
A faint pulse indicates Loss of Yang; exterior deficiency precludes sweating. A weak and choppy pulse indicates Loss of Yang (or Yin); interior deficiency precludes purgation.
Wang Sanyang commented: A weak and choppy pulse, where choppy represents Yin, indicates blood deficiency, which is Loss of Yin. Therefore, purgation is contraindicated. The character "Yang" in the original text might be an error.
In Shaoyin disease, if the pulse is tight, and after seven or eight days, spontaneous diarrhea occurs, the pulse suddenly becomes faint, the hands and feet become warm instead of cold, and the tight pulse disappears, this indicates the disease is about to resolve. Although there is irritability, the diarrhea will likely stop on its own.
A tight pulse in Shaoyin disease indicates severe cold. After seven or eight days, when the transmission cycle ends, it is the time for resolution. Spontaneous diarrhea and a suddenly faint pulse indicate the release of cold qi. If Yin-cold were overwhelming and Yang deficiency caused the diarrhea, the hands and feet would be cold and the tight pulse would persist. Now, since the hands and feet are warm and the tight pulse has disappeared, we know Yang Qi has recovered and cold has departed, hence the disease is resolving. Diarrhea with irritability is a adverse sign; here, righteous Qi overcomes the weak pathogen. Although there is irritability, the diarrhea will stop.
In Shaoyin disease with diarrhea, if the diarrhea stops spontaneously, there is aversion to cold and curling up, but the hands and feet are warm, the condition is treatable.
In Shaoyin disease, diarrhea, aversion to cold, and curling up indicate extreme cold and Yin dominance. If the diarrhea stops spontaneously and the hands and feet are warm, it indicates harmony in the interior and recovery of Yang Qi, hence it is treatable.
In Shaoyin disease, if there is aversion to cold and curling up, occasional spontaneous irritability, and a desire to remove clothing and blankets, the condition is treatable.
Aversion to cold and curling up indicate severe Yin-cold. Occasional spontaneous irritability and desire to remove coverings indicate recovery of Yang Qi, hence it is treatable.
In Shaoyin Wind Strike, if the Yang pulse (Cun) is faint and the Yin pulse (Chi) is floating, the disease is about to heal.
In Shaoyin Wind Strike, the Yang pulse should be floating; if it is faint, the exterior pathogen is easing. The Yin pulse should be deep; if it is floating, the interior Qi is harmonious. Yang contains Yin, and Yin contains Yang; with Yin-Yang harmony, healing is expected.
Shaoyin disease tends to resolve from Zi hour to Yin hour.
Yang Qi generates at Zi hour. Zi is One Yang, Chou is Two Yang, and Yin is Three Yang. Shaoyin resolves at this time because Yin conditions resolve upon receiving Yang.
In Shaoyin disease, if there is vomiting and diarrhea, but the hands and feet are not cold, and there is fever, death is not inevitable. If the pulse is absent, moxibustion should be applied to the Shaoyin points for seven moxa cones.
The Classic states: "Shaoyin disease with vomiting, diarrhea, irritability, and cold extremities is a fatal case." With vomiting and diarrhea, if the hands and feet are not cold, Yang Qi is not exhausted. Even with fever, it is not fatal. An absent pulse results from sudden deficiency due to vomiting and diarrhea. Moxibustion on Shaoyin points for seven cones helps to unblock the pulse.
In Shaoyin disease, after eight or nine days, if the whole body and hands/feet become hot, the heat is in the Bladder, and hematochezia (blood in stool) will likely occur.
The Bladder belongs to the Taiyang channel. Shaoyin and Taiyang are exterior-interior partners. In Shaoyin disease, after eight or nine days, cold pathogen transforms into heat and transmits back to Taiyang. Taiyang governs all Yang Qi. Heat in Taiyang causes heat throughout the body and extremities. Taiyang channels are rich in blood; when attacked by heat, blood scatters and flows downward, leading to hematochezia.
In Shaoyin disease, if there is only cold extremities without sweat, and forced sweating is attempted, it will inevitably disturb the blood. It is unknown from which orifice it will exit, either from the mouth/nose or from the eyes. This is called Lower Jue and Upper Exhaustion, a difficult-to-treat condition.
Only cold extremities without sweat indicate heat moving in the interior. Forced sweating empties the channels and collaterals. Heat takes advantage of this deficiency, forcing blood to move recklessly and exit through weak points. Whether from mouth/nose or eyes, all Jue syndromes belong to the lower. Isolated cold extremities constitute Lower Jue. Blood loss from above constitutes Upper Exhaustion. Damaging Qi and Blood, with strong pathogen and weak righteous Qi, makes it difficult to treat.
Wang Yutai commented: Only cold extremities without sweat indicate heat entering the interior while exterior cold is severe. It should be treated with warming methods. Forcing sweat makes Wei Qi colder and prevents sweating, inevitably injuring Ying Blood internally and causing reckless movement.
In Shaoyin disease, if there is aversion to cold, curling up, diarrhea, and cold extremities, it is incurable.
The Needle Classic states: "Diseases with much heat are easy to cure; diseases with much cold are hard to cure." This is extreme cold inside and out, pure Yin without Yang, hence incurable.
In Shaoyin disease, vomiting, diarrhea, irritability, and cold extremities indicate death.
Vomiting and diarrhea indicate severe interior cold; cold extremities indicate severe exterior cold. Irritability indicates impending exhaustion of Yang Qi, confirming death.
In Shaoyin disease, if diarrhea stops but dizziness occurs, with frequent sensations of blackout, it indicates death.
Stopping of diarrhea indicates exhaustion of water and grain essence. Dizziness and blackout indicate exhaustion of Yang Qi, hence death.
In Shaoyin disease, with cold extremities, aversion to cold, curling up, absent pulse, no irritability but restlessness, indicates death.
Cold extremities, aversion to cold, and curling up indicate severe cold. Absent pulse indicates exhaustion of True Qi. "Fan" (Irritability) relates to heat; "Zao" (Restlessness) relates to chaos. If it progresses from Fan to Zao, heat is gradually increasing, which might still be treatable. However, Zao without Fan indicates Qi attempting to break away and struggle. Like a lamp about to go out flashing brightly, it cannot last long.
In Shaoyin disease, after six or seven days, if breathing is shallow and high (Xi Gao), it indicates death.
The Kidney is the source of vital Qi and the gate of respiration. In Shaoyin disease, if after six or seven days the condition does not improve and breathing becomes shallow/high, it indicates severance of vital Qi.
In Shaoyin disease, with faint, fine, and deep pulse, desire only to sleep, sweating, no irritability, desire to vomit, progressing to the fifth or sixth day with spontaneous diarrhea, followed by irritability and inability to lie down or sleep, indicates death.
Yin Qi is abundant. By the fifth or sixth day, when transmission ends, recovery depends on Yang restoration. Instead, spontaneous diarrhea, irritability, and insomnia indicate weak righteous Qi and failure of Yang to recover. Pathogen overwhelms the Zang organs, hence death.
In Shaoyin disease, if initially there is fever contrary to expectation and a deep pulse, Mahuang Fuzi Xixin Tang (Ephedra, Aconite, and Asarum Decoction) is the primary treatment.
Shaoyin disease should present without fever and with aversion to cold. Fever contrary to expectation indicates the pathogen is in the exterior. Although the pulse is deep, since it is early stage, the pathogen has not penetrated deeply. Warming agents should be used to induce sweating and disperse the pathogen.