这个四肢不温是从四肢远端，也就是肢末开始。虽然在太阴的时候程度不会很厉害，但是，这已经是一个明显的信号。它提示疾病已经开始向三阴发展，机体的体质已经趋于虚寒。这个时候应该赶快温里，这时的温里往往见效特快，可以比较容易地将虚寒的体质转变过来，从而避免疾病继续向少阴发展。所以，在太阴的阶段谈四逆，实在具有非常重要的警示意义。而在太阴的阶段用四逆汤，则有防微杜渐之功。另外，逆还有一个很特殊的意义，这个意义在《素问·平人气象论》中有专门的论述，其曰：“平人之常气禀于胃，胃者平人之常气也，人无胃气曰逆，逆者死。”什么是逆呢？这里讲得很清楚，就是人无胃气的意思。人无胃气曰逆，逆者死。所以，逆证，亦即四逆证，实际上就是一个危证、险证、甚至是死证。而证之于《伤寒论》，四逆汤亦确实是一个救治危证、险证、甚至是死证的方剂。在《伤寒论》中，太阴篇只是在理上提出这个四逆来，好让大家留心，好让大家注意，好让大家把好太阴这个关口。如果这个关口没有把好，那就会进入到少阴、厥阴，从而出现事上的四逆来。所以，太阴病的治疗我们要很注意这个“当温之，宜服四逆辈。”这里面的内涵很深，切莫轻易滑过。（2）四逆汤解四逆汤是三阴通用的方子，是一个温里之方、壮火之方，也是一个救逆之方。四逆汤的三味药中，附子、干姜都是大温大热，用以温里、壮火理所当然，没有任何疑问。有疑问的是甘草这味药，甘草在四逆汤中排在首位。大家知道，《伤寒论》方剂中药物的排列次序是有规矩的，不容乱来。这有些像当今领导出场，谁走先谁走后是有严格规定的，这就是身份等级的象征。所以，经方里排列在前的往往是君药、主药，排列在后的则为辅药、臣使药。炙甘草虽是中土药的王牌，但其性究属平和，与四逆汤之温里、壮火、救逆似乎无关紧要。但，恰是这样一味无关紧要的药却置于四逆汤之首，这便引出许多争议来。部分医家因甘草在此方中的排列位置，坚持以甘草为君，如成无己云：“却阴扶阳，必以甘为主，是以甘草为君。”《医宗金鉴》亦云：“君以炙草之甘温，温养阳气，臣以姜附之辛温，助阳胜寒。”而大部分医家究因甘草性味平和，于温阳助火剂中不应占主导地位，故应为佐使，起到调和姜附，使其性勿过燥的作用。炙甘草究竟是佐使药还是君药呢？我的看法应该偏于君药。但是，为什么是君药？这个道理得说清楚。四逆汤是温阳、壮火、逐寒、救逆之剂，这一点是有定论的。虽然我们前面提到过在太阴的阶段抓住时机用四逆辈，具有防微杜渐的意义。可是四逆汤的正用还是在少阴及厥阴病里。这个时候阴寒很盛，不仅上中二焦的阳气亏虚了，而且下元的阳也不行了。如果阴寒盛，而阳气进一步亏虚，就很容易产生一个现象。这就是我们常说的“水寒不藏龙”。龙藏不住了，这个龙雷之火，这个生气的来源、生命的根本就要飞越。龙火飞越起来会产生什么现象呢？这个时候尽管很寒，尽管阳很虚，可是却会出现少阴篇通脉四逆汤证的“身反不恶寒，其人面色赤”，龙火飞越此乃性命攸关之大事，此时尚有一线生机，就是看你的治疗能否把飞越的龙火重新送回原位。为什么方书把四逆、通脉四逆这一类的方子称为回阳救逆呢？所谓回阳就是使龙归原位，所谓救逆就是使龙火不再飞腾。阳气虚衰，阴寒内盛的人本该温里、壮火、逐寒，本该用温热药、用火药。可是这个时候由于水寒，真龙不得安身，龙火已然跃跃欲越了。这个时候的状况则如丹家所言，是药水汞而非真汞，遇火即飞。所以，温热的药，像姜附这类火药下去，欲越的龙火飞潜得更快。为什么很多人阳虚的证候非常典型，可是一碰姜附就上火，就咽喉肿痛，就口舌生疮呢？道理就在这里。因此，对于阳虚的病人，我们用温热药，用一团火，究竟能不能起到真实的作用？究竟能不能让这一团火温养到下元，温养到生命的根本，真正起到持续地温煦作用，而不是遇火即飞，见火即炎，这便成为我们用温阳、用壮火剂的一个十分关键的技术问题。谈到这个技术问题，很自然地就想到了甘草，甘草在四逆汤中的作用是否就是为了解决这个问题呢？记得小时候在农村，要到很远的地方去放牛或打柴，中午饭不能回家吃，怎么办呢？就带几个红薯或芋头。等把牛赶到目的地，就先挖一些土块起一座小窑，再拾一些干柴放到小土窑里点起来。等烧到小土窑快发红的时候，就把柴都掏出来，然后将带的红薯或芋头塞到土窑里，一脚将土窑踏平。到了中午肚子饿的时候，就去将踏平的小土窑挖开，等待你的就是香喷喷的、热乎乎的一顿美餐。这样烧出的红薯或芋头熟得又透，可是一点也不焦，比烤出来的还要香甜可口。孩时的往事虽已过去几十年，可至今想起来还直流口水。孩提时候的这件事对解决我们今天的问题会很有帮助，我们直接用这个火来烤红薯，很可能红薯的表皮已成炭，可里面还没熟。而换成上面的方法，先将土烧“熟”，然后再用烧熟的土去煨红薯，那煨出来的红薯不但熟得很透，而且表皮一点也不焦。这就是土的妙用。土的藏性可以将火的烧炎灼烈之性转变成持续的温煦作用，所以，火经土的作用后，则既能温物、熟物，却不焦物、炎物。言至于此，明眼人就应该知道，四逆汤中为什么要用甘草呢？起的就是这个土的作用。土虽非火，可是却能使火的作用真正落到实处，使火熟物而不焦物，使火温物而不炎物。前面我们谈到，阴寒内盛，阳气虚衰的时候，龙火、药汞遇火即飞，可有了这个甘草，有了这个土，就能解决这个问题。就能使龙火回头，使姜附发挥煦煦的温养作用。由斯可见，四逆汤要想真正的发挥温养的作用、回阳救逆的作用，炙甘草便是关键的关键。诚如《长沙方歌括》所言：“建功姜附如良将，将将从容借草筐。”能够将将的是什么呢？当然是君，当然是帅。所以，对于四逆汤中的甘草大家不要小看了，它实在是用温热剂的一个关窍所在。很多中医不敢用热性的药，一用病人就叫上火，其实就是因为没有把握好这个关窍。通过这些年的临床，对上述问题的感慨越来越深。不少的医生在用温热药的时候，一碰到病人上火，就把持不住了，而反过来改用寒凉。很多的病人亦因吃一些油炸煎炒就咽痛、就长疮，而自取寒凉。几番折腾，便将一片大好河山糟蹋得不成样子。无怪乎《内经》要说“谨熟阴阳，无与众谋”。阴阳你谨熟了，阴阳你能了然于心，还怕什么上火不上火。就怕你阴阳不熟，脚跟不稳，那自然就东说东倒，西说西倒。近治一咽喉肿痛月余的病人，已输抗菌素半月，并自服牛黄解毒一类，咽痛丝毫未减。诊时见扁桃体大，且满布脓点，舌淡，边齿印，苔薄白，脉双沉细弱，口甚苦。察舌按脉，一派阴寒，故用抗菌、清热杳无疗效。以此咽肿非热毒之肿，乃龙火沸腾所致。理当温潜之剂方能奏效。然顾及“口甚苦”一证，还是有些投鼠忌器。思索再三，遂以小柴胡汤打头，合郑钦安习用之潜阳丹，药用柴胡、黄芩、党参、半夏、炙甘草、大枣、生姜、附片、砂仁、龟板、桔梗。处方五剂，以为必效无疑。谁知五天以后，病人复诊，仍无点滴之效。再诊舌脉，仍是一派虚寒，绝无阳证可言。乃毅然剔除小柴胡汤，纯用温热之剂。药用附片、砂仁、龟板、炙甘草、桔梗、熟地。附片用至 60克，炙甘草用至 24克。五剂以后，咽痛消失，脓点不见，扁桃体亦大大回缩。可见肿痛的不一定是热，化脓的不一定是热，口苦的也不一定是热。要在于通过四诊，通过舌脉，鉴出阴阳。阴阳了然了，就能高屋建瓴，就能八九不离十。诸位要是信得过，且听我一句话，那就是抱定这个阴阳，朝于斯，夕于斯，流离于斯，颠沛于斯。果能如此，不出数年，包管大家在中医上有一个境界。也包管大家能够真正列入仲景的门墙。现在很多人只知道苦寒能降火，滋阴能降火，如果用了苦寒，用了滋阴，这个火还是降不下来，他就没招了。应该知道降火有多途。特别我们学习了太阴篇，知道太阴的开就是为了使这个火入里，就是为了使这个火收藏，就是为了使这个火能降下来，甘温为什么能除大热呢？其实就是着眼在太阴这个开机上。从太阴的开机着眼，也就能够很好地理解四逆汤中甘草的重要作用，也就能够很好地理解太阴篇的意义所在。太阴的问题就讨论到这里。
第九章 少阴病纲要
The coldness of the four limbs begins from the distal ends, that is, the extremities. Although the severity may not be extreme during the Taiyin stage, this is already a clear signal. It indicates that the disease has begun to develop into the Three Yin stages, and the body's constitution is tending towards deficiency-cold. At this time, it is urgent to warm the interior; warming the interior at this stage often yields rapid results, making it relatively easy to transform the deficiency-cold constitution, thereby preventing the disease from progressing further into the Shaoyin stage. Therefore, discussing "Si Ni" (cold extremities) during the Taiyin stage holds significant warning value. Using Si Ni Tang (Four Reversal Decoction) during the Taiyin stage serves the purpose of preventing minor issues from escalating. Furthermore, "Ni" (reversal) carries a special meaning, which is specifically discussed in *Su Wen: Ping Ren Qi Xiang Lun* (Plain Questions: Normal People's Qi and Pulse Phenomena), stating: "The normal qi of a healthy person is derived from the Stomach; the Stomach is the source of normal qi for a healthy person. If a person lacks Stomach qi, it is called 'Ni' (reversal); 'Ni' implies death." What is "Ni"? This is explained clearly here: it means the absence of Stomach qi. A person lacking Stomach qi is termed "Ni," and "Ni" leads to death. Thus, a "Ni syndrome," also known as Si Ni syndrome, is essentially a critical, dangerous, or even fatal condition. In the context of *Shang Han Lun* (Treatise on Cold Damage), Si Ni Tang is indeed a formula used to rescue patients from critical, dangerous, or fatal states. In the Taiyin chapter of *Shang Han Lun*, the concept of "Si Ni" is raised theoretically to alert practitioners to pay attention and guard the Taiyin threshold. If this threshold is not guarded properly, the disease will progress to Shaoyin and Jueyin, resulting in actual clinical manifestations of "Si Ni." Therefore, in treating Taiyin disease, we must carefully heed the statement: "It should be warmed, and formulas similar to Si Ni Tang are appropriate." The implications here are profound and should not be overlooked lightly. (2) Analysis of Si Ni Tang
Si Ni Tang is a universal formula for the Three Yin stages, serving as a formula to warm the interior, strengthen Fire (Yang), and rescue reversal. Among the three herbs in Si Ni Tang, Fu Zi (Aconiti Lateralis Radix Praeparata) and Gan Jiang (Zingiberis Rhizoma) are both strongly warm and hot, used to warm the interior and strengthen Yang, which is unquestionable. The question arises regarding Gan Cao (Glycyrrhizae Radix et Rhizoma), which is listed first in Si Ni Tang. As everyone knows, the order of herbs in *Shang Han Lun* formulas follows strict rules and cannot be arbitrary. This is somewhat like the protocol for leaders appearing in public, where who walks first and who follows is strictly regulated, symbolizing status and hierarchy. Therefore, in Jing Fang (Classical Formulas), herbs listed first are usually the Jun (Sovereign/Main) herbs, while those listed later are Chen (Minister/Assistant) or Shi (Envoy) herbs. Zhi Gan Cao (Honey-fried Glycyrrhizae Radix et Rhizoma), although a premier herb for the Middle Earth (Spleen/Stomach), is inherently mild and peaceful, seemingly irrelevant to the warming, strengthening, and rescuing functions of Si Ni Tang. However, precisely because this seemingly insignificant herb is placed at the head of Si Ni Tang, it has sparked much controversy. Some physicians, based on its position in the formula, insist that Gan Cao is the Jun herb. For example, Cheng Wuji stated: "To repel Yin and support Yang, sweetness must be primary; therefore, Gan Cao is the Jun herb." *Yi Zong Jin Jian* (Golden Mirror of Medicine) also states: "The Jun herb is Zhi Cao, with its sweet and warm nature, to warm and nourish Yang; the Chen herbs are Jiang and Fu, with their acrid and warm nature, to assist Yang and overcome cold." Most other physicians, however, argue that due to Gan Cao's mild nature, it should not dominate a formula designed to warm Yang and boost Fire; thus, it should serve as a Zuo Shi (Assistant/Envoy) herb, harmonizing Jiang and Fu to prevent their properties from becoming overly drying. Is Zhi Gan Cao an Assistant/Envoy herb or a Jun herb? My view leans towards it being a Jun herb. But why? This principle must be clarified. Si Ni Tang is a formula for warming Yang, strengthening Fire, dispelling cold, and rescuing reversal; this conclusion is definitive. Although we previously mentioned that seizing the opportunity to use formulas similar to Si Ni Tang during the Taiyin stage has preventive significance, the primary indication for Si Ni Tang lies in Shaoyin and Jueyin diseases. At this stage, Yin-Cold is extremely prevalent. Not only is the Yang of the Upper and Middle Jiao deficient, but the Yuan Yang (Original Yang) of the Lower Jiao is also failing. If Yin-Cold is severe and Yang continues to decline, a specific phenomenon easily occurs. This is what we commonly call "Cold Water Fails to Hide the Dragon." When the Dragon cannot hide, this Dragon-Lei Fire (Fire of the Dragon and Thunder), which is the source of vitality and the root of life, will fly away uncontrollably. What phenomena arise when Dragon Fire flies away? At this time, despite the extreme cold and severe Yang deficiency, symptoms such as those seen in the Tong Mai Si Ni Tang syndrome of the Shaoyin chapter appear: "the body is actually not averse to cold, and the person's face appears red." The flight of Dragon Fire is a matter of life and death. At this point, there is still a sliver of hope, depending on whether treatment can return the flying Dragon Fire to its original position. Why do medical texts classify formulas like Si Ni Tang and Tong Mai Si Ni Tang as "Returning Yang and Rescuing Reversal" formulas? "Returning Yang" means restoring the Dragon to its proper place; "Rescuing Reversal" means stopping the Dragon Fire from soaring. Patients with Yang deficiency and internal excess Yin-Cold should naturally receive warming and fire-strengthening treatments using hot herbs. However, at this moment, due to "Cold Water," the True Dragon finds no rest, and the Dragon Fire is ready to leap. As Daoist alchemists describe, this state is like "water-mixed mercury" rather than true mercury; it flies upon contact with fire. Therefore, when hot herbs like Jiang (Ginger) and Fu (Aconite) are administered, the eager Dragon Fire flies away even faster. Why do many patients with typical Yang deficiency syndromes experience "fire toxicity" (signs of heat), such as sore throat, swelling, and mouth ulcers, immediately upon taking Jiang and Fu? The reason lies here. Thus, for patients with Yang deficiency, when we use hot herbs—a mass of fire—can they truly exert their effect? Can this mass of fire nourish the Lower Jiao and the root of life, providing sustained warmth, rather than flying away upon contact with fire or flaring up immediately? This becomes a crucial technical issue in using Yang-warming and Fire-strengthening formulas. Discussing this technical issue naturally leads us to Gan Cao. Is the role of Gan Cao in Si Ni Tang precisely to solve this problem? I recall my childhood in the countryside, when I had to go far away to herd cattle or gather firewood and could not return home for lunch. What did we do? We brought sweet potatoes or taro. Upon reaching the destination, we would dig some soil to build a small kiln, gather dry firewood, and light it inside the small earth kiln. When the kiln glowed red, we removed the firewood, stuffed the sweet potatoes or taro into the kiln, and flattened it with our feet. When hunger struck at noon, we dug open the flattened kiln, revealing a fragrant, hot meal. The sweet potatoes or taro cooked thoroughly without burning, tasting sweeter and more delicious than roasted ones. Although decades have passed since those childhood memories, thinking of them still makes my mouth water. This childhood experience is very helpful in solving our current problem. If we roast sweet potatoes directly over fire, the skin may turn to charcoal while the inside remains uncooked. By using the method described above—first heating the soil until it is "ripe," then using the hot soil to bake the sweet potatoes—the result is thoroughly cooked without burnt skin. This demonstrates the妙用 (wonderful utility) of earth. The storing nature of earth can transform the scorching and fierce nature of fire into a sustained warming effect. Thus, after interacting with earth, fire can warm and cook objects without burning or inflaming them. At this point, discerning eyes should understand why Gan Cao is used in Si Ni Tang: it performs the function of earth. Although earth is not fire, it allows the action of fire to be grounded effectively, cooking without burning and warming without inflaming. As discussed earlier, when internal Yin-Cold is excessive and Yang is deficient, Dragon Fire and medicinal "mercury" fly away upon contact with fire. With Gan Cao and this "earth" element, this problem can be resolved. It can cause the Dragon Fire to return and allow Jiang and Fu to exert a gentle, nourishing warming effect. From this, it is evident that for Si Ni Tang to truly exert its warming, nourishing, and Yang-returning effects, Zhi Gan Cao is the key factor. As stated in *Chang Sha Fang Ge Kuo* (Song Verses of Chang Sha Formulas): "Jiang and Fu perform feats like capable generals; the general relies calmly on the grass basket [Gan Cao]." Who is the "general" referred to? Naturally, it is the Jun herb, the commander. Therefore, one should not underestimate Gan Cao in Si Ni Tang; it is indeed the pivotal point in using warm and hot formulas. Many TCM practitioners dare not use hot herbs; if a patient complains of "fire toxicity" upon use, they panic and switch to cold herbs. Many patients also self-medicate with cold herbs after experiencing sore throats or sores from eating fried foods. Through repeated mishandling, they ruin their health. No wonder *Nei Jing* says: "Carefully master Yin and Yang, do not consult with the masses." If you have carefully mastered Yin and Yang and understand them thoroughly, why fear "fire toxicity"? The danger lies in unfamiliarity with Yin and Yang and instability in your foundation, leading to erratic advice. Recently, I treated a patient with sore throat lasting over a month. They had received antibiotics for half a month and self-administered Niuhuang Jiedu Pian (Calculus Bovis and Scutellaria Decoction), yet the sore throat persisted unchanged. Examination revealed enlarged tonsils covered with pus points, a pale tongue with teeth marks, thin white coating, and deep, fine, weak pulses bilaterally, along with a very bitter taste in the mouth. Observing the tongue and pulse indicated a pattern of pure Yin-Cold; thus, antibiotic and heat-clearing treatments were ineffective. This tonsillar swelling was not due to heat-toxin but rather boiling Dragon Fire. A warming and subduing formula was indicated. However, considering the symptom of "very bitter taste," I hesitated slightly. After careful thought, I started with Xiao Chai Hu Tang (Minor Bupleurum Decoction) combined with Qian Yang Dan (Subduing Yang Powder), a formula frequently used by Zheng Qin'an. The prescription included Chai Hu, Huang Qin, Dang Shen, Ban Xia, Zhi Gan Cao, Da Zao, Sheng Jiang, Fu Pian, Sha Ren, Gui Ban, and Jie Geng. Five doses were prescribed, expected to be effective. However, five days later, upon follow-up, there was no improvement. Re-examination of the tongue and pulse still showed pure deficiency-cold, with no signs of Yang patterns. I decisively eliminated Xiao Chai Hu Tang and used purely warm formulas: Fu Pian, Sha Ren, Gui Ban, Zhi Gan Cao, Jie Geng, and Shu Di. Fu Pian was dosed at 60g, and Zhi Gan Cao at 24g. After five doses, the sore throat disappeared, pus points vanished, and the tonsils significantly reduced in size. This shows that swelling does not necessarily indicate heat, suppuration does not necessarily indicate heat, and bitterness in the mouth does not necessarily indicate heat. The key is to distinguish Yin and Yang through the Four Diagnostic Methods, especially tongue and pulse. Once Yin and Yang are clearly understood, one can command the situation with authority and achieve high accuracy. If you trust me, listen to this advice: hold fast to Yin and Yang, practice them morning and night, wander with them, and struggle with them. If you can do this, within a few years, I guarantee you will reach a new realm in TCM and truly become a disciple of Zhang Zhongjing. Many people today only know that bitter-cold herbs can reduce fire and yin-nourishing herbs can reduce fire. If these fail to lower the fire, they are at a loss. One should know that reducing fire has multiple pathways. Especially after studying the Taiyin chapter, we understand that the opening mechanism of Taiyin is intended to draw this fire inward, store it, and bring it down. Why can sweet-warm herbs eliminate great heat? It focuses on the opening mechanism of Taiyin. Viewing from the perspective of Taiyin's opening mechanism helps us better understand the important role of Gan Cao in Si Ni Tang and the significance of the Taiyin chapter. The discussion on Taiyin concludes here.
Chapter 9: General Principles of Shaoyin Disease