（此方自仲景原论中第二卷集入于此）
甘草（二两炙） 干姜（一两半） 附子（一枚生用去皮破八片）
上三味。 咀。以水三升。煮取一升二合。去滓。分温再服。强人可大附子一枚。干姜三两。
成氏明理论云。四逆者。四肢逆而不温也。四肢者。诸阳之本。阳气不足。阴寒加之。阳气不相顺接。是致手
足不温。而成四逆。此汤升发阳气。却散阴寒。温经暖肌。是以四逆名之。甘草味甘平。内经曰。寒淫于内。治以
甘热。却阴扶阳。必以甘为主。是以甘草为君。干姜味辛热。内经曰。寒淫所胜。平以辛热。逐寒正气。必先辛热。
是以干姜为臣。附子味辛大热。内经曰。辛以润之。开发腠理。致津液。通气也。暖肌温经。必凭大热。是以附子
为使。此奇制之大剂也。四逆属少阴。少阴者。肾也。肾肝位远。非大剂则不能达。内经曰。远而奇偶。制大其服。
此之谓也。
内台方议云。病在于表之阳者。葛根汤。麻黄汤。可汗之。病在于表之阴者。桂枝汤。麻黄附子细辛汤。可汗
之。病在于里之阳者。大小承气汤。大柴胡汤。皆可下之。病在于里之阴者。四逆汤。白通汤。真武汤。皆可温之。
今此四逆汤。乃□病在里之阴者用也。上条不言少阴病诸证。但是脉息沉。沉为虚脱。不饮水者。属阴寒也。必以
附子为君。以温经济阳。以干姜为臣辅佐之。甘草为使。以调和二药。而散其寒也。内经曰。寒淫于内治以甘热。
又曰。寒淫所胜。平以辛热。乃附子之热。干姜之辛。甘草之甘是也。
琥按上议君使药。实得仲景之旨。成氏以甘草分两特重。指以为君。殊欠斟酌。
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。急温之。宜四逆汤。（此条亦少阴中寒。当急温之证也。少阴病脉不微细。
庶几以但欲寐辩之。少阴之脉上膈。循喉咙。出络心。注胸中。寒邪直中其经。故饮食入口即吐。其有至心胸中者。
又温温欲吐。复不能吐。皆寒邪阻隔于胸咽之间。而气壅塞不通也。曰始得之。手足寒。正以辩其非传经热邪之证
诊其脉不微细而迟。迟者寒也。又见弦脉。为胸中实。为饮。大抵实热之证可下。寒实之证不可下也当吐之者。非
真用吐法也。谓中寒之证。亦有口食寒物一条。使胸中果有寒物。不妨就其欲吐之势而吐之。若膈上所停之物止寒
饮。寒饮者。似痰而清。得辛热之药。实时便能消散。并非有物可以吐出。故但干呕。止有急温一法。宜四逆汤。
恐缓则不救耳。○愚按上条证用四逆汤。能温经散寒。补虚暖胃。○或问胃寒欲吐。何以不用理中汤丸。余答云。
理中之寒。寒在中焦。今者少阴病寒自下焦而起。肾虚不能约束水液。故上溢于膈而为寒饮。方用四逆汤者。使直
达下焦以治其本也。○或又疑蜜炙甘草。得毋吐家所忌。余答云。实热之吐。中满作胀。故忌甘草。今者胸中无物。
纯是虚寒之气。方中全赖炙甘草以温补中气。至于生附子。但能走肾。而散少阴经之寒。干姜虽能守中止呕。而亦
不补。得其要领。又何待拟议邪。或又云。既吐且呕。生姜可以加否。斯言于义。为得之矣。）
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。（此条乃少阴中寒艾灸之法也。少阴
之脉本微。为阳虚。因下利。则脉涩。涩为血少。乃下多亡阴也。呕者。寒气上逆也。阳虚不能外固。故汗出。阳
气下陷。必数更衣。更衣注。见伤寒辩注第六卷阳明病中。反少者。空坐弩责而所下之物不多。乃血少也。故用灸
法。以消其阴寒。提其阳气。则利自止。而诸证悉平矣。○按此条论。仲景不言当灸何穴。脉经云。灸厥阴俞。补
亡论常器之云。灸太冲。皆误。郭白云云。灸太溪。虽系少阴经穴。亦误。愚以仲景云。宜温其上。条辩云。上谓
顶百会是也。图经云。一名三阳五会。在前顶后。一寸五分。顶中央。旋毛中。可容豆。原治小儿脱肛久不瘥。可
灸七壮。上证亦灸之者。升举其阳。以调夫阴也。）
\r百会穴图\pt158a4.bmp\r
上二十七条证（见原论中第六卷少阴病治法第十一）
伤寒先厥。后发热。而利者。必自止。见厥。复利。（此条伤寒乃厥阴中寒。厥利相连之证。厥阴者。阴之尽。
厥阴之经。阳气甚微。故不论阴阳二证。寒热之邪。但至其经。无有不发厥者。盖厥即为逆。起于手足。而通身皆
冷。今日先厥者。此初起便厥。厥即下利。成注所云阴气胜。则厥逆为利也。后发热者。阳气复也。阳气复。则利
者必自止。倘调理失宜。误服凉药而仍见厥。亦必复利。以阳气负而阴气胜。必加危也。○按此条论。仲景无治法。
补亡论常器之云。白头翁汤。郭白云云。白头翁汤治热利。此更当审证冷热用之。愚以上证。乃阴寒发厥下利。轻
者吴茱萸汤。重者四逆汤辈。○愚又按上证云。先厥后发热。是初起便发厥且利。以见其非是阳经传来者。阳经之
邪。必先热。后厥。若得下利。则热邪亦泄。便不发厥。则是既厥且利者。谓非阴寒之证而何。○或问云。阳证初
起。亦有手足厥冷。而后发热者。余答云。阳证必显头痛等证。且手足发厥之时。身必大热。无有但厥而不发热。
至厥有四日。五日。七八日。及肤冷之异者。至于热邪传入厥阴。亦有发厥甚则通身皆冷。直与阴证无别矣。学人
临证。宜细辩之。）
伤寒脉迟。六七日。而反与黄芩汤。彻其热。脉迟为寒。今与黄芩汤。复除其热。腹中应冷。当不能食。今反
能食。此名除中。必死。（此条伤寒。乃厥阴中寒。误服凉药而致死之证。脉迟为寒。不待智者而后知也。六七日
反与黄芩汤者必其病初起。便发厥而利。至六七日。阳气回复。乃乍发热而利未止之时。粗工不知。但见其发热下
利。误认以为太少合病。因与黄芩汤彻其热。彻即除也。又脉迟云云者。是申明除其热之误也。腹中应冷。胃无火
也。胃无火。当不能食。今反能食者。此名除中。除中者。胃中无根之阳气。所余无几。将欲尽除而求救于食。故
云必死。○愚按厥阴伤寒。有热除中。即原文前条证也。此厥阴中寒。又有冷除中。可见万病当分阴阳寒热。不可
溷也。）
伤寒先厥。后发热。下利必自止。而反汗出。咽中痛者。其喉为痹。发热无汗。而利必自止。若不止。必便脓
血。便脓血者。其喉不痹。（此条乃厥阴中寒。阳回变热。以至喉痹便脓血之证。先厥后发热。下利必自止。注已
见前第一条证矣。然阳回变热。热邪太过而反汗出。咽中痛者。此热伤上焦气分也。其喉为痹。痹者。闭也。此以
解咽中痛甚。其喉必闭而不通。以厥阴经循喉咙之后。上入颃颡故也。又热邪太过。无汗而利不止。便脓血者。此
热伤下焦血分也。热邪泄于下。则不干于上。故云其喉不痹。○愚按此条论。仲景无治法。补亡论常器之云。喉痹。
可桔梗汤。便脓血。可桃花汤。二方皆从少阴病治法中借用。然桃花汤内有干姜。过于辛热。不可用也。上条虽系
中寒证。然阳气回。已变成热。热邪酝酿而为脓血。此非少阴中寒下利便脓血之比。伤寒论中。如仲景黄芩汤。可
借用之。○或问中寒之邪。缘何变热。余答云。元气有余之人寒邪不能深入。才着肌表。即便发热。此伤寒也。元
气不足之人。寒邪直中阴经。不能发热。此中寒也。寒中厥阴。为阴之极。阴极则阳生。故发热。然亦当视其人之
元气何如。若发热而自愈者。元气虽不足。不至大虚。故得愈也。元气大虚之人。有不能发热。但厥而至于死者。
此真阳脱也。有发热而仍厥者。此阳气虽复而不及。全赖热药以扶之也。有发热而至于喉痹便脓血。如上证者。此
阳气虽复而太过。其力不能胜邪热。全赖凉药以平之也。余疑此条证。或于发厥之时。过服热药而至于此。学人临
证。宜细辩之。）
伤寒病。厥五日。热亦五日。设六日当复厥不厥者。自愈厥终不过五日。以热五日。故知自愈。（此条乃厥阴
中寒。阳气回复而自愈之证。厥热之日数相当。而厥不复发。乃真阳胜而阴寒散。故知自愈。）
伤寒脉微而厥。至七八日肤冷。其人躁。无暂安时者。此为脏厥。非为蛔厥也。蛔厥者。其人当吐蛔。令病者
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。又主久利方。（此条伤寒。乃中寒证。特分脏厥。与蛔厥之异。脉微而厥。二证皆然。若脏厥。至七
八日肤冷。乃通身之肌肉皆冷。其人躁无暂安时者。肾中之真阳。为寒邪所迫。神志欲脱而不安也。此自是少阴脏
厥。为不治之证。非厥阴蛔厥比也。蛔厥者。当吐蛔。病者本静。此厥阴肝脏为寒所中也。而复时烦者。蛔上入膈。
膈中不宁。故心为之烦也。须臾复止。是又静。与脏厥证无暂安时之躁大别。得食而呕。又烦者。蛔闻食之臭。则
上而求食欲出。盖蛔居胃中。胃气本温。今者胃中虚冷而食气温。故闻食臭。当自吐蛔也。与乌梅丸以温脏安虫。
又主久利方者。以久利蛔从大便中出。亦可以兼治也。○按脏厥证。仲景本无治法。补亡论庞安时云。宜四逆汤辈
冷服之。常器之云。可当归四逆汤。）
（此方从张仲景原论的第二卷收集编入此处）
甘草（二两，炙用） 干姜（一两半） 附子（一枚，生用，去皮，破成八片）
以上三味药。切碎。用水三升。煮取一升二合。去渣。分两次温服。体质强壮的人可用大附子一枚，干姜三两。
成无己在《明理论》中说：所谓四逆，是指四肢逆冷而不温暖。四肢是诸阳经的根本。阳气不足，阴寒之邪侵袭，阳气不能顺接贯通，导致手足不温，从而形成四逆证。此汤能升发阳气，驱散阴寒，温通经脉，暖润肌肤，因此命名为四逆汤。甘草味甘平，《内经》说：寒邪内盛，治疗应用甘热之法。驱除阴寒、扶持阳气，必须以甘味药为主，所以甘草为君药。干姜味辛热，《内经》说：寒邪偏胜，治疗应用辛热之法。驱逐寒邪、扶助正气，必先使用辛热之品，所以干姜为臣药。附子味辛大热，《内经》说：辛味能滋润（通过开发腠理，致津液，通气机）。暖肌温经，必须凭借大热之性，所以附子为使药。这是奇制的大剂量方剂。四逆汤属于少阴病范畴。少阴对应肾脏。肾与肝的位置较深且远，如果不是大剂量则药力不能到达。《内经》说：病位深远且病情复杂（奇偶），应加大服药量。说的就是这种情况。
《内台方议》中说：病在表之阳的，用葛根汤、麻黄汤，可以发汗解表。病在表之阴的，用桂枝汤、麻黄附子细辛汤，可以发汗解表。病在里之阳的，大小承气汤、大柴胡汤，都可以攻下。病在里之阴的，四逆汤、白通汤、真武汤，都可以温里。如今这个四逆汤，正是用于病在里之阴的情况。上一条条文没有提及少阴病的各种症状，只是提到脉象沉。沉脉主虚脱，不饮水说明属于阴寒证。必须以附子为君药，以温经助阳；以干姜为臣药辅助；甘草为使药，调和这两味药并驱散寒邪。《内经》说：寒邪内盛，治疗应用甘热之法；又说：寒邪偏胜，治疗应用辛热之法。这就是附子的热、干姜的辛、甘草的甘。
琥按：上述关于君使药的议论，确实符合张仲景的本意。成无己因为甘草的分量特别重，就指认为君药，实在不够斟酌。
少阴病。饮食入口即吐，心中感觉温热泛恶想吐，却又吐不出来。刚发病时，手足寒冷，脉象弦迟的，这是胸中有实邪，不可用攻下法，应当用涌吐法。如果是膈上有寒饮，出现干呕的，不可用涌吐法，应当紧急温阳，适宜用四逆汤。（这一条也是少阴中寒，应当紧急温阳的证候。少阴病的脉象如果不微细，可以通过但欲寐来辨别。少阴经脉上行穿过膈部，沿着喉咙，出络于心，注入胸中。寒邪直中其经脉，所以饮食入口即吐。寒气上至心胸部位，又感到温热泛恶想吐，却又吐不出来，这都是寒邪阻隔在胸咽之间，气机壅塞不通所致。说“刚发病时手足寒冷”，正是为了辨别这不是传经而来的热邪。诊察脉象，脉不微细而迟，迟脉主寒。又见到弦脉，主胸中实邪，主水饮。大体来说，实热证可以用攻下法，寒实证不可用攻下法。说应当涌吐，并非真正使用吐法，而是指中寒证中，也有因进食寒物一条。如果胸中确实有寒物，不妨顺应其想吐的趋势而吐出它。如果膈上所停之物仅仅是寒饮，寒饮像痰一样清稀，遇到辛热药物，立刻就能消散，并不是真的有有形之物可以吐出。所以只是干呕，只有紧急温阳这一种方法，适宜用四逆汤，恐怕延误时机就无法救治了。○愚按：上一条证候使用四逆汤，能够温经散寒，补虚暖胃。○有人问：胃寒想吐，为什么不用理中汤丸？我回答说：理中汤所治的寒，寒在中焦。现在的少阴病，寒自下焦而起，肾虚不能约束水液，所以上溢于膈成为寒饮。方中使用四逆汤，是为了让药力直达下焦以治本。○又有人怀疑蜜炙甘草，是否是呕吐患者所忌讳的？我回答说：实热引起的呕吐，伴有中满腹胀，所以忌讳甘草。现在胸中无实邪，纯粹是虚寒之气，方中全赖炙甘草来温补中气。至于生附子，只能走肾，疏散少阴经的寒邪；干姜虽然能守中止呕，但不能补益。得其要领，又何待犹豫呢？又有人说：既吐又呕，生姜可以加吗？这话在义理上是正确的。）
少阴病。下利，脉微涩，呕吐且出汗，必然频繁上厕所，反而排便量少，应当在头部施灸温阳。（这一条是少阴中寒采用艾灸的方法。少阴脉本微弱，主阳虚，因为下利，所以脉涩。涩脉主血少，这是下利多导致亡阴。呕吐，是寒气上逆。阳虚不能固护体表，所以出汗。阳气下陷，必然频繁上厕所。“更衣”注释见《伤寒辩注》第六卷阳明病中。反而排便量少，空蹲努责而排出的东西不多，这是血少的表现。所以用灸法，以消除阴寒，提举阳气，则下利自然停止，各种证候都平息了。○按：这一条论述，张仲景没有说明应当灸哪个穴位。《脉经》说：灸厥阴俞。《补亡论》常器之说：灸太冲穴，都是错误的。郭白云说：灸太溪穴，虽然是少阴经穴位，也是错误的。我认为张仲景说“宜温其上”，条辩说：“上”指的是头顶百会穴。《图经》说：百会又名三阳五会，在前顶穴后一寸五分，头顶中央旋毛处，可容纳一颗豆子。原本治疗小儿脱肛久不痊愈，可灸七壮。上述证候也灸此穴，是为了升举阳气，以调节阴气。）
[图片：百会穴图]
以上二十七条证候（见原论中第六卷少阴病治法第十一）
伤寒先出现四肢厥冷，后来发热，而下利，必定自行停止。如果再次出现厥冷，下利也会复发。（这一条伤寒属于厥阴中寒，厥冷与下利相连的证候。厥阴是阴气的尽头。厥阴经脉，阳气非常微弱，所以不论阴阳两种证候，寒热之邪，只要到了厥阴经，没有不发生厥冷的。大概厥就是逆，起于手足，全身都冷。这里说先厥，是指初起就发生厥冷。厥冷即伴随下利，成无己注释所说：阴气胜，则厥逆并见下利。后来发热，是阳气回复。阳气回复，则下利必定自行停止。倘若调理失当，误服凉药而仍然出现厥冷，也必然会再次下利，因为阳气负而阴气胜，病情必定加重危殆。○按：这一条论述，张仲景没有给出治法。《补亡论》常器之说：白头翁汤。郭白云说：白头翁汤治疗热利，这里更应当审证辨冷热使用。我认为上述证候，是阴寒发厥下利，轻者用吴茱萸汤，重者用四逆汤之类。○我又按：上述证候说“先厥后发热”，是初起就发厥且下利，以此表明这不是从阳经传来的病邪。阳经的病邪，必须先发热，后厥冷。如果得到下利，热邪也就泄掉了，便不会发厥。那么既然已经厥冷且下利，如果不是阴寒证是什么？○有人问：阳证初起，也有手足厥冷，而后发热的情况吗？我回答说：阳证必定显现头痛等症状，而且手足发厥的时候，身体必定大热，没有只厥冷而不发热，持续厥冷四日、五日、七八日及全身皮肤冷的情况。至于热邪传入厥阴，也有发厥严重到全身皆冷，直接与阴证没有区别了。学人临证，应当仔细辨别。）
伤寒脉迟，六七天，反而给予黄芩汤，清除其热。脉迟主寒，现在给予黄芩汤，又除去其热，腹中应当寒冷，应当不能进食，现在反而能进食，这名叫除中，必定死亡。（这一条伤寒，属于厥阴中寒，误服凉药而导致死亡的证候。脉迟主寒，不需要智者就知道。六七天反而给予黄芩汤，一定是因为病初起就发厥下利，到了六七天，阳气回复，是乍然发热而下利未止的时候。粗工不知道，只见其发热下利，误认为是太阳少阳合病，因而给予黄芩汤清除其热。“彻”即除也。又说脉迟云云，是申明清除其热的错误。腹中应当寒冷，是因为胃中没有火。胃中没有火，应当不能进食。现在反而能进食，这名叫除中。除中，是指胃中无根的阳气，所剩无几，将要被完全清除而向食物求救，所以说必定死亡。○愚按：厥阴伤寒，有热除中，就是原文前一条的证候。这一条厥阴中寒，又有冷除中，可见万病应当分清阴阳寒热，不可混淆。）
伤寒先厥冷，后来发热，下利必定自行停止，却反而出汗，咽喉疼痛的，其喉部会发生痹阻。发热无汗，而下利必定自行停止，如果不停止，必定大便脓血。大便脓血的，其喉部不会痹阻。（这一条属于厥阴中寒，阳气回复变为热邪，以至于喉痹、便脓血的证候。先厥冷后发热，下利必定自行停止，注释已见于前面第一条证候了。然而阳气回复变为热邪，热邪太过而反而出汗，咽喉疼痛的，这是热邪损伤上焦气分。其喉部发生痹阻，痹的意思是闭塞。这是因为咽喉疼痛严重，喉部必然闭塞不通，因为厥阴经脉循行喉咙之后，上入颃颡的缘故。又热邪太过，无汗而下利不止，大便脓血的，这是热邪损伤下焦血分。热邪泄于下部，就不干扰上部，所以说其喉部不会痹阻。○愚按：这一条论述，张仲景没有给出治法。《补亡论》常器之说：喉痹，可用桔梗汤。便脓血，可用桃花汤。这两个方子都是从少阴病治法中借用的。然而桃花汤内有干姜，过于辛热，不可用。上条虽然系中寒证，但阳气回复，已经变成热邪，热邪酝酿而成脓血，这与少阴中寒下利便脓血不同。《伤寒论》中，如张仲景的黄芩汤，可以借用。○有人问：中寒之邪，为何会变成热邪？我回答说：元气有余之人，寒邪不能深入，刚附着肌表，即便发热，这叫伤寒。元气不足之人，寒邪直中阴经，不能发热，这叫中寒。寒中厥阴，为阴之极，阴极则阳生，所以发热。但也应当看人的元气如何。如果发热而自愈，说明元气虽不足，不至大虚，所以能痊愈。元气大虚之人，有的不能发热，只厥冷直至死亡，这是真阳脱绝。有的发热但仍然厥冷，这是阳气虽回复但不及，全赖热药来扶持。有的发热以至于喉痹便脓血，像上述证候，这是阳气虽回复但太过，其力量不能胜过邪热，全赖凉药来平抑。我怀疑这一条证候，或许是在发厥之时，过服热药而至于此。学人临证，应当仔细辨别。）
伤寒病，厥冷五日，发热亦五日。假设第六天应当再次厥冷，如果不厥冷的，就会自愈。厥冷终不过五日，因为发热五日，所以知道会自愈。（这一条属于厥阴中寒，阳气回复而自愈的证候。厥冷和发热的天数相当，且厥冷不再复发，是真阳胜而阴寒散，所以知道会自愈。）
伤寒脉微而厥冷，到了七八天皮肤冷，其人烦躁，没有片刻安宁的时候，这叫脏厥，不是蛔厥。蛔厥的病人，应当吐蛔虫。令病人安静，却又时不时心烦，这叫脏寒。蛔虫上入膈部，所以心烦。一会儿又停止，得食后呕吐，又心烦的，是蛔虫闻到食物的气味而出，其人应当自己吐出蛔虫。蛔厥，用乌梅丸主治。又主治久利方。（这一条伤寒，是中寒证，特别区分脏厥与蛔厥的不同。脉微而厥冷，两个证候都一样。如果是脏厥，到了七八天皮肤冷，乃全身肌肉皆冷，其人烦躁没有片刻安宁，是肾中的真阳，被寒邪逼迫，神志欲脱而不安。这自然是少阴脏厥，是不治之证，不像厥阴蛔厥。蛔厥者，应当吐蛔虫。病人本来安静，这是厥阴肝脏被寒邪所中，却又时不时心烦，是蛔虫上入膈部，膈中不安宁，所以心为之烦。一会儿又停止，又是安静的，与脏厥证没有片刻安宁的烦躁大不相同。得食后呕吐，又心烦，是蛔虫闻到食物的气味，就上而求食欲出。大概蛔虫居住在胃中，胃气本温，现在胃中虚冷而食物气温，所以闻到食臭，应当自己吐出蛔虫。给予乌梅丸以温脏安虫。又主治久利方的原因，是因为久利蛔虫从大便中排出，也可以兼治。○按：脏厥证，张仲景原本没有治法。《补亡论》庞安时说：宜四逆汤类冷服。常器之说：可用当归四逆汤。）
(This formula was collected from the second volume of Zhang Zhongjing's original treatise and compiled here.)
Gancao (Licorice Root, *Glycyrrhizae Radix et Rhizoma*, 2 liang, processed with honey/heat) Ganjiang (Dried Ginger, *Zingiberis Rhizoma*, 1.5 liang) Fuzi (Prepared Aconite Root Lateralis, 1 piece, used raw, skin removed, broken into eight pieces).
The above three ingredients. Coarsely crush. Add three sheng of water. Boil to obtain one sheng and two he. Remove the dregs. Divide into two doses and take warm. For robust individuals, a large Fuzi (one piece) and Ganjiang (3 liang) may be used.
Cheng Wuji stated in his *Ming Lilun* (Theory of Clarification): "Si Ni" refers to the reversal coldness of the four limbs, making them not warm. The four limbs are the root of all Yang meridians. When Yang Qi is insufficient and Yin-Cold pathogen attacks, Yang Qi fails to connect smoothly, resulting in cold hands and feet, thus forming the Si Ni syndrome. This decoction raises and generates Yang Qi, dispels Yin-Cold, warms the meridians, and warms the muscles; hence it is named Si Ni Tang. Gancao has a sweet and neutral flavor. The *Neijing* states: "When Cold invades internally, treat with Sweet-Hot methods." To repel Yin and support Yang, Sweet substances must be primary; therefore, Gancao serves as the Sovereign drug. Ganjiang has a pungent and hot flavor. The *Neijing* states: "When Cold prevails excessively, level it with Pungent-Hot methods." To drive out Cold and assist healthy Qi, Pungent-Hot agents must be used first; therefore, Ganjiang serves as the Minister drug. Fuzi has a pungent and greatly hot flavor. The *Neijing* states: "Pungent moistens by opening the interstices, distributing fluids, and promoting Qi circulation." To warm muscles and meridians, greatly hot properties are essential; therefore, Fuzi serves as the Envoy drug. This is an unconventional large-dose prescription. Si Ni belongs to Shaoyin disease. Shaoyin corresponds to the Kidney. The positions of Kidney and Liver are deep and distant; without a large dose, the medicinal power cannot reach them. The *Neijing* states: "When the disease site is distant and complex (odd/even), increase the dosage." This refers to such cases.
*Neitai Fangyi* states: For diseases in the exterior-Yang, Ge Gen Tang and Ma Huang Tang can be used for sweating. For diseases in the exterior-Yin, Gui Zhi Tang and Ma Huang Fuzi Xixin Tang can be used for sweating. For diseases in the interior-Yang, Xiao Cheng Qi Tang and Da Chai Hu Tang can be used for purging. For diseases in the interior-Yin, Si Ni Tang, Bai Tong Tang, and Zhen Wu Tang can be used for warming. Now, this Si Ni Tang is precisely used for diseases in the interior-Yin. The previous clause did not mention various symptoms of Shaoyin disease, only noting a deep pulse. A deep pulse indicates deficiency and collapse; lack of desire to drink water indicates Yin-Cold. Fuzi must be the Sovereign drug to warm the meridians and assist Yang; Ganjiang as the Minister assists; Gancao as the Envoy harmonizes these two drugs and disperses Cold. The *Neijing* states: "When Cold invades internally, treat with Sweet-Hot methods"; and again: "When Cold prevails excessively, level it with Pungent-Hot methods." These refer to the heat of Fuzi, the pungency of Ganjiang, and the sweetness of Gancao.
Hu notes: The above discussion on Sovereign and Envoy drugs truly captures the intent of Zhang Zhongjing. Cheng Wuji, because the dosage of Gancao was particularly heavy, designated it as the Sovereign drug, which is indeed insufficiently considered.
Shaoyin disease. Food vomited immediately upon entering the mouth, a sensation of warmth and nausea in the heart/chest with an urge to vomit but inability to do so. At the onset, cold hands and feet, and a string-taut and slow pulse indicate excess in the chest; purgation is contraindicated, and emesis should be induced. If there is cold fluid retention above the diaphragm causing dry retching, emesis is contraindicated; urgent warming is required, suitable for Si Ni Tang. (This clause also represents a case of Shaoyin middle-cold requiring urgent warming. Shaoyin disease pulses are not necessarily fine and weak; differentiation can be made via lethargy/desire to sleep. The Shaoyin meridian ascends through the diaphragm, follows the throat, connects to the heart, and enters the chest. Cold pathogen directly strikes its meridian, hence food is vomited immediately upon entry. When cold reaches the heart-chest, there is a warm nausea and urge to vomit but inability, all due to Cold pathogen blocking the chest-throat region, causing Qi stagnation and obstruction. "Onset with cold hands and feet" is to differentiate this from transmitted heat pathogens. Diagnosing the pulse as not fine/weak but slow indicates Cold. The presence of a string-taut pulse indicates chest excess and fluid retention. Generally, excess-heat conditions allow purgation, while excess-cold conditions do not. Saying "emesis should be induced" does not mean actually using emetic therapy; it refers to a type of middle-cold caused by eating cold food. If there is indeed cold matter in the chest, one might顺应 the urge to vomit to expel it. If the retention above the diaphragm is merely cold fluid (clear like phlegm), it dissipates instantly with Pungent-Hot medicine and is not tangible matter to be vomited. Thus, with only dry retching, only urgent warming is applicable, suitable for Si Ni Tang, lest delay render it incurable. ○ I note: The previous condition using Si Ni Tang can warm meridians, disperse cold, tonify deficiency, and warm the stomach. ○ Question: Why not use Li Zhong Tang/Wan for stomach cold with vomiting? Answer: Li Zhong treats cold in the Middle Jiao. Here, Shaoyin disease cold arises from the Lower Jiao; Kidney deficiency fails to control fluids, causing overflow to the diaphragm as cold fluid. Si Ni Tang is used to direct the action to the Lower Jiao to treat the root. ○ Doubt: Is honey-processed Gancao contraindicated for vomiting patients? Answer: Excess-heat vomiting with fullness/bloating contraindicates Gancao. Here, the chest has no excess, only deficient-cold Qi; the formula relies entirely on honey-processed Gancao to warm and tonify Middle Qi. Raw Fuzi travels to the Kidney to scatter Shaoyin meridian cold; Ganjiang guards the center and stops vomiting but does not tonify. Grasping the key principle, why hesitate? ○ Another question: With both vomiting and retching, can Sheng Jiang (Fresh Ginger) be added? This statement is theoretically sound.)
Shaoyin disease. Diarrhea with a faint and choppy pulse, vomiting with sweating, frequent bowel movements but scant output, should be treated with moxibustion on the upper body. (This clause describes the method of moxibustion for Shaoyin middle-cold. The Shaoyin pulse is naturally faint, indicating Yang deficiency. Due to diarrhea, the pulse becomes choppy, indicating blood deficiency caused by excessive loss of Yin through stool. Vomiting is counterflow of Cold Qi. Yang deficiency fails to secure the exterior, causing sweating. Yang Qi sinking leads to frequent bowel movements ("changing clothes" refers to defecation, see Vol 6 Yangming disease). Scant output despite straining indicates blood deficiency. Therefore, moxibustion is used to eliminate Yin-Cold and lift Yang Qi, stopping diarrhea and resolving all symptoms. ○ Note: Zhang Zhongjing did not specify which acupoint to moxa. *Mai Jing* suggests Jueyin Shu. *Bu Wang Lun* Chang Qizi suggests Taichong; both are errors. Guo Baiyun suggests Taixi; although a Shaoyin point, it is also an error. I believe "warm the upper" refers to the top of the head, Baihui. *Tu Jing* says: Baihui, also called San Yang Wu Hui, is 1.5 cun behind Qian Ding, at the center of the scalp hair whorl, space for a bean. Originally indicated for pediatric rectal prolapse, seven moxa cones can be applied. Moxa for the above condition lifts Yang to regulate Yin.)
[Image: Baihui Acupoint Diagram]
The above twenty-seven conditions (seen in Volume 6, Shaoyin Disease Treatment Methods, Chapter 11 of the original treatise).
Shanghan presenting initially with Jue (cold extremities), followed by fever, the diarrhea will stop spontaneously. If Jue returns, diarrhea recurs. (This Shanghan condition is Jueyin middle-cold, characterized by linked Jue and diarrhea. Jueyin is the end of Yin. The Jueyin meridian has very little Yang Qi; thus, regardless of Yin or Yang syndromes, or Cold or Heat pathogens, once they enter this meridian, Jue occurs. Jue means reversal/cold extremities starting from hands and feet, spreading coldness throughout the body. "Initial Jue" means Jue occurs at onset. Jue accompanies diarrhea. As Cheng's commentary states: when Yin Qi prevails, Jue and diarrhea occur. Subsequent fever indicates Yang Qi recovery. Yang recovery causes spontaneous cessation of diarrhea. If mismanagement or mistaken use of cooling herbs causes Jue to return, diarrhea will recur because Yang is defeated and Yin prevails, leading to critical danger. ○ Note: Zhang Zhongjing provided no treatment method here. *Bu Wang Lun* Chang Qizi suggests Bai Tou Weng Tang. Guo Baiyun states Bai Tou Weng Tang treats heat-diarrhea; here, one must distinguish cold/heat. I consider the above condition to be Yin-Cold Jue-diarrhea; mild cases use Wu Zhu Yu Tang, severe cases Si Ni Tang. ○ I further note: "Initial Jue then fever" implies Jue and diarrhea occurred at onset, indicating non-transmission from Yang meridians. Yang meridian pathogens cause heat first, then Jue. If diarrhea occurs, heat pathogen is expelled, preventing Jue. Thus, simultaneous Jue and diarrhea must be Yin-Cold. ○ Question: Can Yang syndromes present with initial cold extremities followed by fever? Answer: Yang syndromes show headache etc.; during Jue, the body is hot. There is no case of isolated Jue lasting days without fever. However, heat pathogen transmitting to Jueyin can cause severe Jue with whole-body cold, indistinguishable from Yin syndromes. Clinicians must differentiate carefully.)
Shanghan with a slow pulse, persisting for six to seven days, yet mistakenly given Huang Qin Tang to clear heat. Slow pulse indicates Cold. Giving Huang Qin Tang removes heat, causing abdominal coldness and anorexia. The patient now eats voluntarily; this is called Chu Zhong (Elimination of the Middle), indicating certain death. (This Shanghan condition is Jueyin middle-cold, fatal due to mistaken cooling medication. Slow pulse indicates Cold, obvious to any. Mistakenly giving Huang Qin Tang at day six/seven implies the illness started with Jue and diarrhea. By day six/seven, Yang recovered, causing transient fever while diarrhea persisted. Unskilled physicians saw fever and diarrhea, mistook it for Taiyang-Shaoyang combined disease, and used Huang Qin Tang to clear heat ("Che" means remove). Explaining the error: Abdominal coldness means no Stomach Fire. No Stomach Fire implies anorexia. Voluntary eating here is Chu Zhong. Chu Zhong means the rootless Yang Qi in the Stomach is nearly exhausted, seeking salvation through food before being completely eliminated; hence, certain death. ○ I note: Jueyin Shanghan has Heat-Chu Zhong (previous clause). This Jueyin middle-cold has Cold-Chu Zhong. All diseases must be distinguished by Yin/Yang and Cold/Heat, not confused.)
Shanghan initial Jue, subsequent fever, diarrhea stops spontaneously. Instead, sweating occurs and throat pain develops; the throat becomes Bi (obstructed). Fever without sweating, diarrhea stops spontaneously; if it does not stop, pus and blood appear in stool. If pus and blood appear, the throat is not obstructed. (This condition is Jueyin middle-cold where Yang recovery transforms into Heat, leading to throat Bi and bloody stool. Initial Jue then fever stops diarrhea (see Clause 1). However, excessive Heat from Yang recovery causes sweating and throat pain, injuring Upper Jiao Qi. "Bi" means closure; severe throat pain causes throat obstruction because the Jueyin meridian passes behind the throat and enters the nasopharynx. Excessive Heat without sweating and persistent diarrhea causes pus/blood in stool, injuring Lower Jiao Blood. Heat venting downward spares the upper, hence no throat Bi. ○ Note: Zhang Zhongjing gave no treatment. *Bu Wang Lun* Chang Qizi suggests Jie Geng Tang for Bi and Tao Hua Tang for bloody stool, borrowed from Shaoyin treatments. However, Tao Hua Tang contains Ganjiang, too pungent/hot, and should not be used. Although originally middle-cold, Yang recovery turned it to Heat, fermenting into pus/blood, distinct from Shaoyin middle-cold bloody stool. In *Shanghan Lun*, Zhongjing's Huang Qin Tang could be borrowed. ○ Question: Why does middle-cold transform to heat? Answer: Those with sufficient Yuan Qi resist deep invasion; Cold stays on the surface causing fever (Shanghan). Those with deficient Yuan Qi suffer direct strike to Yin meridians without fever (Zhonghan). Cold striking Jueyin (extreme Yin) generates Yang (Ji Yin Ze Yang Sheng), causing fever. Recovery depends on Yuan Qi. Mild deficiency allows recovery via fever. Severe deficiency leads to death via Jue alone (True Yang collapse). Fever with persistent Jue requires hot herbs to support Yang. Fever leading to Bi/bloody stool (as above) indicates Yang recovery is excessive, unable to overcome pathogenic Heat, requiring cooling herbs to pacify. I suspect this condition resulted from overusing hot herbs during Jue. Clinicians must differentiate carefully.)
Shanghan disease: Jue for five days, fever for five days. If on the sixth day Jue should return but does not, the patient heals spontaneously. Jue never exceeds five days because fever lasted five days; thus, spontaneous healing is known. (This condition is Jueyin middle-cold where Yang recovers and heals spontaneously. Equal duration of Jue and fever, with no recurrence of Jue, indicates True Yang prevails and Yin-Cold scatters, confirming spontaneous healing.)
Shanghan with faint pulse and Jue, progressing to day seven or eight with cold skin. The patient is restless with no moment of peace; this is Zang Jue (Organ Jue), not Hui Jue (Roundworm Jue). Hui Jue patients vomit roundworms. The patient is usually quiet but experiences intermittent vexation; this is Zang Cold. Roundworms ascend to the diaphragm, causing vexation. It stops after a moment, returning to quietness. Eating causes vomiting and renewed vexation because roundworms smell food and emerge; the patient vomits roundworms. Hui Jue is treated with Wu Mei Wan. It also treats chronic diarrhea. (This Shanghan condition distinguishes Zang Jue from Hui Jue in middle-cold. Both have faint pulse and Jue. In Zang Jue, by day seven/eight, skin is cold (whole body muscle cold), and restlessness with no peace indicates Kidney True Yang forced by Cold, with spirit about to collapse. This is Shaoyin Zang Jue, an incurable condition, unlike Jueyin Hui Jue. Hui Jue involves vomiting roundworms. The patient is normally quiet; Jueyin Liver struck by Cold causes intermittent vexation as roundworms disturb the diaphragm. Quietness returns briefly, contrasting with Zang Jue's constant restlessness. Eating causes vomiting/vexation as roundworms seek food warmth in a cold stomach. Wu Mei Wan warms the organ and calms worms. It treats chronic diarrhea because roundworms exit via stool in chronic cases. ○ Note: Zhang Zhongjing gave no treatment for Zang Jue. *Bu Wang Lun* Pang Anshi suggests Si Ni Tang taken cold. Chang Qizi suggests Dang Gui Si Ni Tang.)