身有微热。下利清谷者。必郁冒。汗出而解。病患必微厥。所以然者。其面戴阳。下虚故也。
【目】柯琴曰。此比上条脉症皆轻。热微厥亦微。此阴阳相等。寒热自和。故易愈。
【纲】仲景曰。吐已下断。汗出而厥。四肢拘急。不解。脉微欲绝者。通脉四逆加猪胆汁汤主
之。
【目】杨士瀛曰。加猪胆汁于通脉汤中者。反佐之法也。必有阴盛格阳之症。故用之。观白通
汤可知。
【纲】仲景曰。伤寒六七日。大下后。寸脉沉而迟。手足厥冷。下部脉不至。咽喉不利。吐脓
血。泄利不止者。为难治。伤寒六七日。脉微。手足厥冷。烦躁。灸厥阴。厥不还者死。下利。手
足逆冷。无脉者。灸之。不温。若脉不还。微喘者死。下利后。脉绝。手足厥逆。 时脉还。手足
温者生。脉不还者死。
【目】柯琴曰。寸脉沉迟。气口脉平矣。下部脉不至。根本已绝矣。诸症皆内外。水谷之道俱
绝。故此为下厥上竭。阴阳离决之候。生气将绝于内也。厥阴。肝脉也。应春生之气。故灸其五俞
而阳可回也。
三条四条两症。不呕不烦。反佐而服白通。外灸丹田气海。或可救于万一。
鳌按。三四条之生死。总以脉为凭
【纲】仲景曰。手足厥冷。脉细欲绝者。当归四逆汤主之。
下后。复发汗。昼日烦躁。不得眠。夜而安静。不呕不渴。无表症。
脉沉微。身无大热者。干姜附子汤主之。下之后。复发汗。必振寒。脉微细。所以然者。内外俱虚
故也。
【目】柯琴曰。首条。虽无外卫之微阳。亦未见内寒诸险症。二条。当汗而反下。下后又发汗。
以至纯阴无阳。而脉沉微。此四逆之变剂也。三条。内阳虚。故脉微细。外阳虚。故振栗恶寒。亦
即干姜附子症。
【纲】仲景曰。伤寒五六日。不结胸。腹濡。脉虚。复厥者。不可下。此为亡血。下之死。伤
寒脉促。手足厥者。可灸之。
【目】鳌按。脉象空虚。故为亡血。促为阳脉。阳虚而促。理固然矣。然阴气太盛。亦往往见
促脉者。总之促结代。皆是虚脉非灸不可。
【纲】仲景曰。少阴病。下利。脉微者。与白通汤。利不止。厥逆。无脉。干呕烦者。白通加
猪胆汁汤主之。服汤。脉暴出者死。微续者生。
【目】喻昌曰。与白通反至厥无脉。干呕而烦。此非药之不胜病也。以无向导之力。宜其不入
耳。故复加人尿猪胆汁之阴。以引阳药深入。然脉暴出死。微续生。亦危矣哉。
身体有轻微发热，腹泻排出未消化的食物残渣的，必然会出现头目昏蒙、如物覆盖的郁冒症状，随后通过出汗而病愈。患者必定出现四肢微冷。之所以如此，是因为其面部泛红（戴阳），这是下焦虚寒的缘故。
【目】柯琴说：这一条与上一条相比，脉象和症状都较轻。热象轻微，厥冷也轻微，这是阴阳平衡，寒热自然调和，所以容易痊愈。
【纲】张仲景说：呕吐和下利已经停止，但出汗且四肢厥冷，四肢拘挛紧急不能缓解，脉搏微弱几乎摸不到的，用通脉四逆加猪胆汁汤主治。
【目】杨士瀛说：在通脉汤中加入猪胆汁，是反佐的方法。一定是有阴寒过盛格拒阳气于外的症状，所以才使用它。从白通汤的使用可以明白这一点。
【纲】张仲景说：伤寒六七天，经过猛烈攻下后，寸口脉沉而迟，手足冰冷，尺部（下部）脉搏摸不到，咽喉不利，吐脓血，泄泻不止的，属于难治之证。伤寒六七天，脉象微弱，手足冰冷，烦躁不安，应艾灸厥阴经穴位；如果灸后厥冷不回，则死。下利，手足逆冷，没有脉搏的，进行艾灸；如果灸后不温暖，若脉搏仍不恢复，出现轻微喘息的，则死。下利之后，脉搏消失，手足厥冷逆乱，如果偶尔脉搏恢复，手足转温的，可生；脉搏不恢复的，则死。
【目】柯琴说：寸脉沉迟，气口脉看似平和了，但下部脉搏摸不到，说明根本已绝。各种症状都表明内外不通，水谷之道俱断，因此这是下厥上竭，阴阳离决的征候，生气将在体内终结。厥阴，是肝的经脉，对应春天的生发之气，所以艾灸其五输穴，阳气就可以回复。
第三条和第四条两种病症，不呕吐不烦躁，反而采用反佐法服用白通汤，并在体外艾灸丹田、气海穴，或许能有一线生机。
沈金鳌按：第三、四条的生死判断，总以脉象为依据。
【纲】张仲景说：手足冰冷，脉象细弱几乎摸不到的，用当归四逆汤主治。
经过攻下之后，又再次发汗，白天烦躁，无法入睡，夜间却安静，不呕吐也不口渴，没有表证，脉象沉微，身体没有大热的，用干姜附子汤主治。攻下之后，又再次发汗，必定出现畏寒战栗，脉象微细。之所以如此，是因为内外都虚弱的缘故。
【目】柯琴说：第一条，虽然没有体表卫护的微阳，但也未见内寒的各种险症。第二条，本该发汗却反而攻下，攻下后又发汗，导致纯阴无阳，脉象沉微，这是四逆汤的变方。第三条，内里阳气虚，所以脉微细；外表阳气虚，所以战栗恶寒，也就是干姜附子汤证。
【纲】张仲景说：伤寒五六天，没有形成结胸证，腹部柔软，脉象虚弱，再次出现厥冷的，不可攻下。这是因为亡血，攻下会导致死亡。伤寒脉促，手足厥冷的，可以用艾灸治疗。
【目】沈金鳌按：脉象空虚，所以称为亡血。促脉属于阳脉，阳气虚而出现促脉，道理上是这样的。然而阴气太盛，也往往出现促脉。总之，促脉、结脉、代脉，都是虚脉，非用艾灸不可。
【纲】张仲景说：少阴病，下利，脉象微弱的，给予白通汤。如果下利不止，出现厥逆，没有脉搏，干呕心烦的，用白通加猪胆汁汤主治。服药后，脉搏突然暴出的，死；脉搏微微持续存在的，生。
【目】喻昌说：给予白通汤后反而出现厥冷无脉，干呕而烦躁，这不是药力不胜任病情，而是因为缺乏向导的力量，药力应当无法进入体内。所以再次加入人尿、猪胆汁这些阴性物质，来引导阳药深入体内。然而脉搏突然暴出会死，脉搏微微持续存在才能生，这也非常危险啊。
The body has slight fever. If there is diarrhea with undigested food, there will inevitably be "Yu Mao" (a sensation of dizziness and heaviness as if covered by a cloth), which will resolve through sweating. The patient must have slight coldness in the extremities. The reason for this is that the face shows "Dai Yang" (floating yang, characterized by a red flush on the face while the lower body is cold) due to deficiency in the lower jiao.
[Mu] Ke Qin said: Compared with the previous clause, both the pulse and symptoms here are milder. The heat is slight, and the coldness is also slight; this indicates an equality of yin and yang, where cold and heat naturally harmonize, so it is easy to cure.
[Gang] Zhang Zhongjing said: When vomiting and diarrhea have ceased, but sweating occurs accompanied by cold extremities, and the limbs are cramped and rigid without relief, and the pulse is faint and nearly imperceptible, Tongmai Sini Jia Zhu Danzhi Tang (Pulse-Returning Decoction of Radix Aconiti Lateralis Preparata plus Porcine Bile) should be administered.
[Mu] Yang Shiy ing said: Adding porcine bile to Tongmai Tang is a method of "fan zuo" (counter-assistance). It is used when there are symptoms of excessive yin rejecting yang. This can be understood by observing the use of Baotong Tang.
[Gang] Zhang Zhongjing said: In cold damage after six or seven days, following severe purgation, if the cun (inch) pulse is deep and slow, the hands and feet are cold, the pulses at the lower part (chi position) are absent, there is throat obstruction, hemoptysis with pus and blood, and unceasing diarrhea, it is difficult to treat. In cold damage after six or seven days, if the pulse is faint, the hands and feet are cold, and there is irritability, moxibustion should be applied to the Jueyin meridian. If the coldness does not return after moxibustion, death ensues. With diarrhea, cold reversal of the hands and feet, and absence of pulse, moxibustion should be applied. If warmth does not return and the pulse does not reappear, accompanied by slight asthma, death ensues. After diarrhea, if the pulse vanishes and the hands and feet are cold and reversed, but the pulse occasionally returns and the hands and feet become warm, life is possible; if the pulse does not return, death ensues.
[Mu] Ke Qin said: The deep and slow cun pulse suggests the qi mouth pulse appears level, but the absence of the lower pulse indicates the root is exhausted. All symptoms indicate that both internal and external pathways, including the passage of water and grain, are cut off. Thus, this is a condition of "lower coldness and upper exhaustion," a sign of separation of yin and yang, where the vital energy is about to perish within. Jueyin is the liver meridian, corresponding to the spring generating qi. Therefore, moxibustion on its five shu points can restore yang.
For the two conditions in clauses three and four, where there is no vomiting or irritability, administering Baotong Tang using the counter-assistance method, combined with external moxibustion on Qihai (CV-12) and Shenque (CV-8), might save one in ten thousand cases.
Shen Jin'ao noted: The determination of life and death in clauses three and four relies entirely on the pulse.
[Gang] Zhang Zhongjing said: For cold extremities and a pulse that is fine and nearly imperceptible, Danggui Sini Tang (Angelica Sinensis Decoction for Cold Extremities) should be administered.
After purgation, followed by re-induction of sweating, if there is irritability during the day and inability to sleep, but quietness at night, without vomiting or thirst, and without exterior symptoms, and the pulse is deep and faint, with no significant heat in the body, Ganjiang Fuzi Tang (Dried Ginger and Prepared Aconite Root Decoction) should be administered. After purgation, followed by re-induction of sweating, there will inevitably be chills and tremors, and the pulse will be faint and fine. The reason is that both interior and exterior are deficient.
[Mu] Ke Qin said: In the first clause, although there is no slight yang protecting the exterior, there are also no severe signs of interior cold. In the second clause, sweating was indicated but purgation was used instead; after purgation, sweating was induced again, leading to pure yin without yang, and a deep, faint pulse. This is a variant formula of Sini Tang. In the third clause, interior yang deficiency causes a faint and fine pulse; exterior yang deficiency causes trembling and aversion to cold. This is also the syndrome for Ganjiang Fuzi Tang.
[Gang] Zhang Zhongjing said: In cold damage after five or six days, if there is no chest binding, the abdomen is soft, the pulse is deficient, and coldness recurs, purgation is contraindicated. This is due to loss of blood; purgation will cause death. In cold damage, if the pulse is rapid (cu) and the hands and feet are cold, moxibustion may be applied.
[Mu] Shen Jin'ao noted: An empty pulse indicates loss of blood. Cu (rapid) is a yang pulse; it is logical for a deficient yang to present with a cu pulse. However, excessive yin qi often also presents with a cu pulse. In summary, cu, jie (knotted), and dai (intermittent) pulses are all deficiency pulses, requiring moxibustion.
[Gang] Zhang Zhongjing said: In Shaoyin disease, with diarrhea and a faint pulse, administer Baotong Tang. If diarrhea continues, accompanied by cold reversal, absence of pulse, dry heaving, and irritability, Baotong Jia Zhu Danzhi Tang (Baotong Decoction plus Porcine Bile) should be administered. If, after taking the decoction, the pulse suddenly emerges violently, death ensues; if the pulse gradually and continuously returns, life is possible.
[Mu] Yu Chang said: Administering Baotong Tang results in cold reversal, absence of pulse, dry heaving, and irritability. This is not because the medicine is insufficient for the disease, but because there is no guiding force, so the medicine fails to enter. Therefore, adding the yin substances of human urine and porcine bile guides the yang medicine deeply into the interior. However, a sudden violent emergence of the pulse leads to death, while a gradual continuation leads to survival; this is indeed critical.