【纲】仲景曰。凡厥者。阴阳气不相顺接便为厥。厥者手足逆冷是也。
诸四逆厥者。不可下之。虚家亦然。
【目】朱震亨曰。凡手足六经之脉。皆自阴传阳。自阳传阴。阴气胜。则阳不达于四肢。故为
寒厥。
热厥可下。寒厥惟有温补。
【纲】仲景曰。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
耳目。是名下厥上竭。为难治。
【目】成无己曰。厥者。冷也。甚于四逆也。阴阳气不相接。谓阳气内陷。热气逆伏。故手足
冷也。夫厥者必发热。前热者后必厥。厥深者热亦深。厥微者热亦微。是知内陷者。手足为厥矣。
强发汗而动血。亦是发动其热。先热而后厥者。热伏于内也。先厥而后热者。阴退而阳气得复也。
若始得之便厥。则是阳气不足而阴气胜矣。大抵厥逆为阴所主。寒者多矣。
【纲】仲景曰。大汗。若大下利。而厥冷者。四逆汤主之。大汗出。热不去。内拘急。四肢疼。
又下利。厥逆而恶寒者。四逆汤主之。
【目】危亦林曰。阴阳二厥脉皆沉。所以使人疑之。然阴厥脉沉迟而弱。阳厥脉沉伏而滑。阳厥
指甲时一温。阴厥指甲常冷。足蜷不渴。清便如常。外症则自惺惺也。若未辨阴阳。宜用理中汤试之。阳厥则便热。阴
厥则不热。
柯琴曰。大汗亡阳。大下亡阴。阴阳俱虚。故厥冷。但利非清谷。急温之。阳回而生可望也。二
条。治之失宜。虽大汗出而热不去。恶寒不止。表未除也。内拘急而下利。里寒已发。四肢疼而厥
冷。表寒又见矣。可知表热里寒者。即表寒亡阳者矣。
【纲】仲景曰。呕而脉弱。小便复利。身有微热。见厥者。难治。四逆汤主之。
【目】张云岐曰。里无热。故小便利。表虚寒。故见厥。伤寒以阳为主。今则阳消阴长。故难
治。
【纲】仲景曰。吐利汗出。发热恶寒。四肢拘急。手足厥冷者。四逆汤主之。
【目】成无己曰。大抵下利之人。见厥复利。厥者复为热。为阳气得复。而利必自止。热者便
为厥。是阴气远胜也。故复下利。
龚信曰。此条吐利。不言清谷。汗出不言大。脉不言微弱。幸有此表阳。再以四逆温其里。可
望其生也。
【纲】仲景曰。少阴病。下利清谷。里寒外热。手足厥逆。脉微欲绝。身反不恶寒。其人面色
赤。或腹痛。或干呕。或咽痛。或利止。脉不出者。通脉四逆汤主之。下利清谷。里寒外热。汗出
而厥者。通脉四逆汤主之。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。
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。
伤寒五六日。不结胸。腹濡。脉虚。复厥者。不可下。此为亡血。下之死。
病者手足厥冷。言我不结胸。小腹满。按之痛者。此冷结在膀胱关元也。
【目】鳌按。首条厥逆。因寒盛于外也。二条厥逆。因下虚也。然比首条脉症皆轻。三条厥逆。
因阴盛格阳也。故加猪胆汁为反佐。四条厥逆。因六腑气绝于外也。五条厥逆。因于亡血也。何
以知之。其脉空虚也。六条厥逆。因结胸也。与五
条合看。当知结胸症有热厥者也。
【纲】仲景曰。伤寒脉促。手足厥者。可灸之。伤寒六七日。脉微。手足厥冷。烦躁。灸厥阴。
脉不还者死。
【目】陈士铎曰。伤寒阴症发厥。灸其厥阴之经。亦不得已之法。原不及汤药之神也。然苟以
参药救之。未有不生者。方名还厥汤。白术四两。附子、干姜各三钱。水煎。一帖而苏。凡具有厥
逆等症。即以此方投之。神效如响。盖白术最利腰脐。阴寒初入。原从脐始。利其腰脐。则肾宫有
生气。佐以姜附。则无微不达。而邪又安留乎。
鳌按。此二条。皆属阴虚。故皆用灸法。盖脉之促者。虽为阳脉。亦有阳虚而促者。亦有阴盛
而促者。此则阴盛而促者也。
【纲】仲景曰。少阴病。吐利。手足厥冷。烦躁欲死者。吴茱萸汤主之。
【目】柯琴曰。四逆者。四肢厥冷。兼臂胫而言。此手足。是言指掌也。四肢之阳犹在。
【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。服汤后。脉暴出者死。微续者生。下利。手足逆冷。无脉者。灸之。不温。若脉不还。
反微喘者死。下利后。脉绝。手足厥逆。 时脉还。手足温者生。脉不还者死。
【目】陈士铎曰。二条脉症。当急灸关元之脉。以寒极而脉伏。非灸则脉不能出也。今灸之而
脉仍不还。反为微喘。此气逆而不下。乃奔于上而欲绝也。本是死症。而吾以为可生者。正以其无脉
也。夫人死而后无脉。今未死而无脉。非无也。乃伏也。灸之不还。岂真无脉可还乎。无脉。应死
矣。而仍未死。止作微喘。是脉欲还而不能遽还也。方用人参一两。熟地五钱。牛膝三钱。甘草、
附子各一钱。名还脉汤。一帖而脉骤出者死。苟得渐出。可望生矣。三条。 时脉还。亦用灸法而
还者也。然亦必手足温者可生。正见阳气之尚留耳。倘脉不还。则手足终无温热之时。是阳不可返。
而死不
可生矣。不知脉之不返。因灸法而不能返也。灸之力微。终不及药之力浓。吾以人参三两灌之。则
脉自欲生矣。
鳌按。首条。下利厥逆。服白通汤。恶脉之骤出。二三条。下利。厥逆无脉。用灸法。欲脉之
猝还。一死一生者。何也。一用灸而一用药也。可见用药之能速出脉也。
【纲】仲景曰。少阴病。四逆。其人或咳。或悸。或小便不利。或腹中痛。或泄利下重者。四
逆散主之。
【目】柯琴曰。四肢为诸阳之本。阳气不达于四肢。因而厥逆。故四肢多属于阴。此则泄利下
重。阳邪下陷入阴中。阳内而阴反外。以致阴阳脉气不相顺接也。可知以手足厥冷为热厥。手足厥
逆为寒厥者。亦凿矣。条中无主症。而皆是或然症。故小便不利。同小青龙症。厥悸。同茯苓甘草
症。咳利腹痛。小便不利。同真武症。种种是水气为患。不用利水者。泄利下重故也。泄利下重。
又不用白头翁汤者。四逆故也。此少阴之枢无主。故多或然症。因取四物以散四逆之热邪。随症加
减。以治或然症。此少阴气分之下剂也。所谓厥因下之者此方矣。
【纲】仲景曰。手足厥冷。脉乍紧。邪结在胸中。心中满而烦。饥不能食。病在胸中。当吐之。
【目】成无己曰。诸阳受气于胸中。邪气客胸。郁郁留结。则阳气不得敷布。而手足为之厥也。
【纲】仲景曰。少阴病。恶寒。身蜷而利。手足逆冷者。不治。
【目】柯琴曰。利而手足温。是阳回。故可治。利不止而手足逆冷。是纯阴无阳。所谓六腑气
绝于外者。手足寒。五脏气绝于内者。下利不禁矣。
【纲】仲景曰。少阴病。四逆。恶寒而蜷。脉不至。不烦而躁者死。少阴病。吐利。烦躁。四
逆者死。
【目】成无己曰。四逆者。四肢逆而不温也。伤寒之始。邪在皮肤。当太阳阳明受邪。则一身
尽热。太阴少阴受邪。则手足自温。是表邪渐缓而欲传里也。伤寒四五日。手足温而渴者。小柴胡
汤。是太阳邪传少阳也。脉浮。手足温。为系在
太阴。是少阳邪传太阴也。是知邪在半表里。则手足不热而自温。至邪传少阴。为里症已深。虽未
至厥。而手足已不温。是四逆也。若至厥阴。则厥冷矣。四逆散枳实、柴胡、白芍、甘草皆寒凉。
而专主四逆之疾。是知四逆。非尽虚寒症也。四逆汤干姜、附子。皆热药。亦治四逆手足寒。旨哉。
若手足自热而至温。从四逆而至厥者。传经之邪也。用四逆散。若始得手足厥而不温者。是阴经受
邪。阳气不足。用四逆汤温之。毋令误也。
陈士铎曰。少阴症。上吐下利。且兼烦躁。则阴阳扰乱拂抑。而无生气可知。况手足逆冷。是
脾胃之气又将绝也。自是死症。然而治之于早。未尝不可救。急以人参、白术各二两。肉桂、丁香
各二钱。灌之。尚可救耳。方名止逆奠安汤。人参救元阳之绝。白术救脾胃之崩。丁香止呕。肉桂温
中。又能止泻。救中土之危亡。奠上下之变乱。转生机于顷刻。岂能舍此方哉。
少阴症。四逆。恶寒身蜷。脉不至。不烦而躁。亦是死症。而吾以为可救者。全在脉不至。不
烦而躁。夫病至四肢之逆。阴阳之将绝可知。脉之不至。未必非寒极而伏也。不然。阳绝则心宜烦。
乃不烦。但嫌其烦而不躁。则阳未绝而将绝。为可畏耳。阳既欲绝。则阴亦随绝。故一补阳。阳
回而阴亦回也。急用生生汤可活。人参三两。枣仁炒五钱。附子三钱。水煎。人参以回阴阳。附子
祛寒。枣仁安心。则心定而躁可去。脉可出矣。死中求活。其在此方乎。
【纲】张仲景说：凡是厥证，都是由于阴阳之气不能顺利衔接所致。所谓厥，就是手足逆冷。
凡是出现四肢逆冷或厥逆症状的，不可使用攻下法。体质虚弱的人也是如此。
【目】朱震亨说：凡是在手足六经中的脉气，都是从阴经传向阳经，从阳经传向阴经。如果阴气偏胜，阳气就不能通达于四肢，因此发生寒厥。
热厥可以使用攻下法治疗，寒厥只有用温补法治疗。
【纲】张仲景说：少阴病，仅见厥逆，无汗，如果强行发汗，必然扰动血分。不知道血液会从哪个部位溢出，有的从口鼻出，有的从耳目出，这叫做“下厥上竭”，属于难治之证。
【目】成无己说：厥，就是寒冷，比四肢逆冷更严重。阴阳之气不相接，是指阳气内陷，热气郁伏在内，所以手足寒冷。大凡厥证必定伴有发热，先前发热而后出现厥逆的，说明热邪深伏于内。厥逆程度深的，热邪也深；厥逆程度轻的，热邪也轻。由此可知，热邪内陷会导致手足厥冷。强行发汗而引发出血，也是发动了体内的热邪。先发热后厥逆的，是热邪伏于体内；先厥逆后发热的，是阴退而阳气恢复。如果一开始就出现厥逆，则是阳气不足而阴气偏胜。大抵厥逆是由阴气所主，多为寒证。
【纲】张仲景说：大汗出，或者严重腹泻导致厥冷的，用四逆汤主治。大汗出，发热不退，体内拘急不舒，四肢疼痛，又伴有腹泻，出现厥逆且恶寒的，用四逆汤主治。
【目】危亦林说：阴厥和阳厥的脉象都表现为沉脉，所以容易让人产生疑惑。然而，阴厥的脉象沉迟而弱，阳厥的脉象沉伏而滑。阳厥在按压指甲时偶尔会感到温暖，阴厥的指甲则始终寒冷。足部蜷缩但不口渴，大小便正常，外在表现神志清醒。如果不能辨别阴阳，宜先用理中汤试探。如果是阳厥，服药后身体会变热；如果是阴厥，则不会变热。
柯琴说：大汗导致亡阳，大泻导致亡阴，阴阳俱虚，所以出现厥冷。但这里的腹泻并非完谷不化（清谷），急需温阳，阳气回复则有生的希望。上述两条，如果治疗不当，虽然大汗出但热不退，恶寒不止，说明表证未除。体内拘急且腹泻，说明里寒已发；四肢疼痛且厥冷，说明表寒又现。由此可见，表热里寒的情况，也就是表寒导致亡阳的情况。
【纲】张仲景说：呕吐而脉象微弱，小便反而通利，身体有微热，出现厥逆的，属于难治之证，用四逆汤主治。
【目】张云岐说：体内无热，所以小便通利；体表虚寒，所以出现厥逆。伤寒病以阳气为主，现在则是阳气消减、阴气增长，所以难治。
【纲】张仲景说：呕吐、腹泻、出汗，伴有发热、恶寒，四肢拘急挛缩，手足厥冷的，用四逆汤主治。
【目】成无己说：大抵腹泻的病人，如果出现厥逆后又腹泻，如果厥逆转为发热，这是阳气恢复的表现，腹泻自然会停止。如果发热转为厥逆，这是阴气极度偏胜的表现，所以再次腹泻。
龚信说：这一条提到的呕吐腹泻，没有提到完谷不化，出汗没有提到是大汗，脉象没有提到微弱，幸好还有表阳存在，再用四逆汤温补里阳，有望痊愈。
【纲】张仲景说：少阴病，腹泻排出未消化的食物，里有寒邪外有假热，手足厥逆，脉象微弱几乎摸不到，身体反而不恶寒，病人面色发红，或者腹痛，或者干呕，或者咽痛，或者腹泻停止但脉搏摸不到的，用通脉四逆汤主治。腹泻排出未消化的食物，里有寒邪外有假热，出汗且厥逆的，用通脉四逆汤主治。呕吐已止，腹泻已断，但出汗且厥逆，四肢拘急痉挛不能缓解，脉象微弱几乎摸不到的，用通脉四逆加猪胆汁汤主治。
伤寒病六七天，经过猛烈攻下后，寸脉沉而迟，手足厥冷，下部脉搏摸不到，咽喉不利，吐脓血，腹泻不止的，属于难治。
伤寒病五六天，没有形成结胸证，腹部柔软，脉象虚弱，又出现厥逆的，不可攻下。这是因为亡血，攻下会导致死亡。
病人手足厥冷，说自己没有结胸证，小腹胀满，按压疼痛的，这是寒气凝结在膀胱关元穴部位。
【目】沈金鳌按语：第一条厥逆，是因为外寒盛极所致。第二条厥逆，是因为下焦虚损所致。但这比第一条的脉症都要轻。第三条厥逆，是因为阴盛格阳（阴寒内盛将阳气格拒于外）所致，所以加入猪胆汁作为反佐药。第四条厥逆，是因为六腑之气在外衰竭所致。第五条厥逆，是因为亡血所致。怎么知道的呢？因为脉象空虚。第六条厥逆，是因为结胸所致。结合第五条来看，应当知道结胸证也有热厥。
【纲】张仲景说：伤寒病脉象急促，手足厥冷的，可以用艾灸治疗。伤寒病六七天，脉象微弱，手足厥冷，烦躁不安的，灸厥阴经穴位。如果脉象不恢复的，预后不良（死）。
【目】陈士铎说：伤寒阴证发厥，灸其厥阴经，也是不得已的方法，原本不如汤药的神效。但如果用人参等药物救治，没有不活的。方名还厥汤，白术四两，附子、干姜各三钱，水煎服，一帖就能苏醒。凡是具有厥逆等症状的，就用此方投喂，神效如响应声。因为白术最利于腰脐，阴寒初入，原本从脐开始，疏通腰脐，则肾宫有生气，配合姜、附，则无处不达，邪气又如何能留存呢？
沈金鳌按语：这两条，都属于阴虚，所以都用灸法。脉象急促，虽然是阳脉，但也有因阳虚而促的，也有因阴盛而促的。这里属于阴盛而促。
【纲】张仲景说：少阴病，呕吐腹泻，手足厥冷，烦躁欲死的，用吴茱萸汤主治。
【目】柯琴说：四逆，是指四肢厥冷，兼及手臂和小腿。这里说的“手足”，是指手指和手掌。四肢的阳气尚存。
【纲】张仲景说：少阴病，腹泻，脉象微弱的，给予白通汤。如果腹泻不止，出现厥逆、无脉、干呕、心烦的，用白通加猪胆汁汤主治。服药后，脉象突然暴出的，预后不良（死）；脉象逐渐微续的，预后良好（生）。腹泻，手足逆冷，无脉的，进行艾灸。如果不回暖，如果脉象不恢复，反而轻微喘息的，预后不良（死）。腹泻后，脉象绝灭，手足厥冷，偶尔脉象恢复，手足转温的，预后良好（生）；脉象不恢复的，预后不良（死）。
【目】陈士铎说：这两条的脉症，应当紧急灸关元穴，因为寒极导致脉伏，不灸则脉不能复出。现在灸了但脉仍不恢复，反而轻微喘息，这是气逆而不降，奔涌向上将要断绝。这本来是死症，但我认为可以救活，正是因为他还没有死却无脉。人死后才无脉，现在没死却无脉，不是真的无脉，而是脉伏藏。灸了不恢复，难道是真的没有脉可恢复吗？无脉本该死，但仍然没死，只是轻微喘息，这是脉想要恢复但不能立刻恢复。此时方用人参一两，熟地五钱，牛膝三钱，甘草、附子各一钱，名为还脉汤。一帖后脉象骤然出现的会死，如果能逐渐出现，就有望生存。第三条，偶尔脉象恢复，也是用了灸法而恢复的。但也必须手足转温的才能生存，正说明阳气尚存。如果脉不恢复，那么手足最终不会有温热的时候，这是阳气无法返回，死亡无法挽救。不知道脉不返回，是因为灸法力度不够而不能返回。灸的力量微弱，终究不及药力浓厚。我用三两人参灌服，脉自然就会想恢复。
沈金鳌按语：第一条，下利厥逆，服用白通汤，厌恶脉象骤然出现。第二三条，下利，厥逆无脉，使用灸法，希望脉象猝然恢复。一死一生，为什么呢？一个用灸法，一个用药。可见用药能使脉象迅速出现。
【纲】张仲景说：少阴病，四肢逆冷，其中有的人咳嗽，有的人心悸，有的人小便不利，有的人腹痛，有的人泄利下重（腹泻伴肛门坠胀感），用四逆散主治。
【目】柯琴说：四肢是诸阳之本，阳气不能通达于四肢，因而发生厥逆，所以四肢多归属于阴。这里却是泄利下重，阳邪下陷入阴中，阳在内而阴反在外，导致阴阳脉气不能顺利衔接。由此可知，把手足厥冷称为热厥，手足逆冷称为寒厥的说法，也是错误的。条文里没有主症，都是或然症（可能出现的症状）。所以小便不利，同小青龙汤证；厥悸，同茯苓甘草汤证；咳、利、腹痛、小便不利，同真武汤证。种种都是水气为患，不用利水药的原因，是因为泄利下重。泄利下重，又不用白头翁汤的原因，是因为有厥逆。这是少阴枢机无主，所以多有或然症。因此取四物（指柴胡、枳实、芍药、甘草）来疏散四逆的热邪，随症加减，以治疗或然症。这是少阴气分的下剂。所谓“厥因下之”（因误下导致的厥逆）就是这个方子。
【纲】张仲景说：手足厥冷，脉象突然紧束，邪气结聚在胸中，心中胀满而烦闷，饥饿但不能进食，病位在胸中，应当用吐法治疗。
【目】成无己说：诸阳之气受于胸中，邪气客居胸中，郁结停留，则阳气不能敷布，从而导致手足厥冷。
【纲】张仲景说：少阴病，恶寒，身体蜷缩且腹泻，手足逆冷的，预后不良（不治）。
【目】柯琴说：腹泻而手足温暖，是阳气回复，所以可治。腹泻不止且手足逆冷，是纯阴无阳，所谓六腑之气在外衰竭。手足寒冷，是五脏之气在内衰竭，导致下利不禁。
【纲】张仲景说：少阴病，四肢逆冷，恶寒而身体蜷缩，脉象摸不到，不烦躁但躁动的，预后不良（死）。少阴病，呕吐腹泻，烦躁，四肢逆冷的，预后不良（死）。
【目】成无己说：四逆，是指四肢逆冷而不温暖。伤寒初期，邪气在皮肤，当太阳、阳明经受邪时，全身都会发热；太阴、少阴经受邪时，手足自然温暖。这说明表邪渐缓而欲传入里。伤寒四五天后，手足温暖且口渴的，用小柴胡汤，这是太阳邪气传入少阳。脉浮，手足温暖，是病系在太阴，这是少阳邪气传入太阴。由此可知，邪在半表半里时，手足不热而自温。等到邪气传入少阴，成为里证且病位已深，虽未到厥逆的程度，但手足已不温暖，这就是四逆。如果传到厥阴，就会厥冷了。四逆散中的枳实、柴胡、白芍、甘草都是寒凉药，却专门主治四逆之疾，由此可知四逆并不全是虚寒证。四逆汤中的干姜、附子都是热药，也治疗四逆手足寒。说得真好。如果手足由热转温，从四逆转为厥冷，这是传经之邪，用四逆散。如果一开始就手足厥冷不温，这是阴经受邪，阳气不足，用四逆汤温之，不要弄错了。
陈士铎说：少阴症，上吐下利，且兼烦躁，则阴阳扰乱拂抑，可知没有生气。何况手足逆冷，说明脾胃之气也将要断绝。这自然是死症，然而如果在早期治疗，未必不能救。紧急用人参、白术各二两，肉桂、丁香各二钱，灌服，还可以救活。方名止逆奠安汤。人参救元阳之绝，白术救脾胃之崩，丁香止呕，肉桂温中又能止泻，拯救中土之危亡，安定上下之变乱，在顷刻间扭转生机，怎么能舍弃这个方子呢？
少阴症，四肢逆冷，恶寒身体蜷缩，脉象摸不到，不烦躁但躁动，也是死症，但我认为可以救活，全在于脉象摸不到，不烦躁但躁动。病发展到四肢逆冷，可知阴阳将要断绝。脉象摸不到，未必不是寒极而脉伏藏。不然的话，阳绝则心应该烦躁，现在不烦躁，只担心他烦躁但不躁动，那是阳未绝而将绝，这才是可怕的。阳既然想要绝，阴也会随之绝。所以一旦补阳，阳回则阴也回。紧急用生生汤可以救活：人参三两，炒枣仁五钱，附子三钱，水煎。人参用来回复阴阳，附子祛寒，枣仁安心，则心定而躁动可去，脉象可出。死中求活，大概就在于这个方子吧。
[General Principle] Zhang Zhongjing stated: In all cases of Jue (Jue syndrome, characterized by cold extremities due to the failure of Yin and Yang Qi to connect smoothly), it is because the Yin and Yang Qi fail to connect in a smooth sequence. "Jue" refers to the reversal coldness of the hands and feet.
In all cases of Si Ni (four limbs reversal cold) or Jue, purgative methods should not be used. This also applies to patients with deficient constitutions.
[Detailed Commentary] Zhu Zhenheng stated: The meridians of the six channels of the hands and feet all transmit from Yin to Yang, and from Yang to Yin. When Yin Qi prevails, Yang Qi cannot reach the four limbs, thus resulting in Cold Jue.
Hot Jue can be treated with purgation; Cold Jue can only be treated with warming and tonification.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease, if there is only Jue without sweating, forcing sweating will inevitably disturb the blood. It is unknown from which orifice the blood will emerge; it may come from the mouth and nose, or from the ears and eyes. This is called "Lower Jue and Upper Exhaustion" (Xia Jue Shang Jie), which is difficult to treat.
[Detailed Commentary] Cheng Wuji stated: Jue means cold, more severe than Si Ni. The disconnection of Yin and Yang Qi refers to Yang Qi sinking inward and heat being suppressed internally, causing cold hands and feet. Generally, Jue is accompanied by fever. If fever precedes Jue, it indicates heat trapped inside. The deeper the Jue, the deeper the heat; the milder the Jue, the milder the heat. Thus, we know that internal trapping of heat leads to cold extremities. Forcing sweating and causing bleeding also stirs up internal heat. Fever preceding Jue indicates heat trapped inside; Jue preceding fever indicates Yin retreating and Yang recovering. If Jue occurs immediately upon onset, it indicates insufficient Yang Qi and prevailing Yin Qi. Generally, Jue is governed by Yin and is mostly cold.
[General Principle] Zhang Zhongjing stated: After profuse sweating or severe diarrhea leading to cold extremities, Sini Tang (Four Counterflow Decoction) should be administered. If there is profuse sweating, fever that does not subside, internal stiffness, pain in the four limbs, accompanied by diarrhea, Jue, and aversion to cold, Sini Tang should be administered.
[Detailed Commentary] Wei Yilin stated: Both Yin Jue and Yang Jue present with a deep pulse, which causes confusion. However, the pulse of Yin Jue is deep, slow, and weak, while the pulse of Yang Jue is deep, hidden, and slippery. In Yang Jue, the fingernails may feel warm when pressed occasionally; in Yin Jue, the fingernails are always cold. The legs are curled, there is no thirst, urination and defecation are normal, and the external manifestation shows clear consciousness. If Yin and Yang cannot be distinguished, Lizhong Tang (Regulate the Middle Decoction) should be tried first. If it is Yang Jue, the body will become warm after taking the medicine; if it is Yin Jue, it will not.
Ke Qin stated: Profuse sweating leads to loss of Yang; severe purgation leads to loss of Yin. With both Yin and Yang deficient, cold extremities occur. However, the diarrhea is not undigested food (Qing Gu). Urgent warming is required; if Yang recovers, survival is possible. Regarding the previous two conditions, if treatment is inappropriate, although there is profuse sweating, the fever does not subside, and aversion to cold persists, indicating the exterior syndrome has not been resolved. Internal stiffness and diarrhea indicate interior cold has developed; limb pain and cold extremities indicate exterior cold is present again. Thus, exterior heat with interior cold is equivalent to exterior cold leading to Yang collapse.
[General Principle] Zhang Zhongjing stated: In vomiting with a weak pulse, frequent urination, slight body heat, and presence of Jue, it is difficult to treat. Sini Tang should be administered.
[Detailed Commentary] Zhang Yunqi stated: There is no heat inside, hence frequent urination; the exterior is deficient and cold, hence Jue appears. Shanghan (Cold Damage) prioritizes Yang Qi. Now, Yang is declining and Yin is growing, making it difficult to treat.
[General Principle] Zhang Zhongjing stated: In vomiting, diarrhea, sweating, accompanied by fever, aversion to cold, tetanic spasms of the four limbs, and cold extremities, Sini Tang should be administered.
[Detailed Commentary] Cheng Wuji stated: Generally, in patients with diarrhea, if Jue appears followed by recurrent diarrhea, if Jue turns into heat, it indicates Yang recovery, and diarrhea will stop spontaneously. If heat turns into Jue, it indicates extreme Yin excess, leading to recurrent diarrhea.
Gong Xin stated: This condition mentions vomiting and diarrhea but not undigested food; sweating but not profuse sweating; pulse but not weak/thready. Fortunately, exterior Yang remains. By using Sini Tang to warm the interior, recovery is hopeful.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease, with diarrhea of undigested food, interior cold with exterior false heat, cold extremities, thready pulse almost imperceptible, body actually not averse to cold, facial redness, or abdominal pain, dry retching, sore throat, or cessation of diarrhea with absent pulse, Tongmai Sini Tang (Pulse-Returning Sini Decoction) should be administered. With diarrhea of undigested food, interior cold with exterior false heat, sweating, and Jue, Tongmai Sini Tang should be administered. After vomiting stops and diarrhea ceases, but with sweating, Jue, tetanic spasms of limbs that do not resolve, and a thready pulse almost imperceptible, Tongmai Sini Tang plus Pig Bile should be administered.
In Shanghan disease lasting six or seven days, after severe purgation, if the Cun (inch) pulse is deep and slow, cold extremities, lower pulses absent, throat obstruction, expectoration of pus and blood, and uncontrollable diarrhea, it is difficult to treat.
In Shanghan disease lasting five or six days, without Chest Binding (Jie Xiong), soft abdomen, deficient pulse, and recurrent Jue, purgation is contraindicated. This is due to blood loss; purgation will lead to death.
If a patient has cold extremities, states they have no Chest Binding, lower abdominal fullness, and tenderness on pressure, this is cold binding at the Bladder Guan Yuan point.
[Detailed Commentary] Shen Jin'ao noted: The first case of Jue is due to extreme exterior cold. The second case is due to lower deficiency, though milder than the first. The third case is due to Yin excess repelling Yang (Yin Sheng Ge Yang), hence Pig Bile is added as an antipodal agent. The fourth case is due to the exhaustion of the Six Fu organs' Qi externally. The fifth case is due to blood loss, evidenced by the empty pulse. The sixth case is due to Chest Binding. Comparing with the fifth case, one should understand that Chest Binding can also involve Hot Jue.
[General Principle] Zhang Zhongjing stated: In Shanghan disease with a rapid/crowded pulse and cold extremities, moxibustion can be applied. In Shanghan disease lasting six or seven days, with a faint pulse, cold extremities, and irritability, moxibustion should be applied to the Jueyin channel. If the pulse does not return, death ensues.
[Detailed Commentary] Chen Shiduo stated: For Shanghan Yin syndrome with Jue, moxibustion on the Jueyin channel is a method of last resort, originally inferior to the efficacy of decoctions. However, if rescued with Ginseng, survival is certain. The formula is named Huan Jue Tang (Return-to-Jue Decoction): Bai Zhu (Atractylodis Macrocephalae Rhizoma) 4 liang, Fu Zi (Aconiti Lateralis Radix Praeparata) and Gan Jiang (Zingiberis Rhizoma) 3 qian each. Decoct in water; one dose restores consciousness. For any case with Jue symptoms, this formula is effective. Bai Zhu benefits the waist and umbilicus; Yin cold enters via the umbilicus. Benefiting the waist/umbilicus generates life in the Kidney Palace. Assisted by Ginger and Aconite, nothing is unreachable, and evil cannot remain.
Shen Jin'ao noted: These two cases belong to Yin deficiency, hence moxibustion is used. Although a rapid pulse is typically Yang, it can result from Yang deficiency or Yin excess. This case is Yin excess causing rapidity.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease with vomiting, diarrhea, cold extremities, and severe irritability, Wuzhuyu Tang (Evodiae Fructus Decoction) should be administered.
[Detailed Commentary] Ke Qin stated: "Si Ni" refers to cold extremities including arms and calves. Here, "hands and feet" refers specifically to fingers and palms. The Yang Qi of the four limbs is still present.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease with diarrhea and a faint pulse, Baicong Tang (White Onion Decoction) should be given. If diarrhea persists, with Jue, absent pulse, dry retching, and irritability, Baicong Tang plus Pig Bile should be administered. If the pulse suddenly bursts out after taking the medicine, death ensues; if the pulse gradually returns, life ensues. In diarrhea with cold extremities and absent pulse, apply moxibustion. If not warmed, and pulse does not return, but slight panting occurs, death ensues. After diarrhea, if the pulse vanishes and extremities are cold, but occasionally the pulse returns and extremities warm, life ensues; if the pulse does not return, death ensues.
[Detailed Commentary] Chen Shiduo stated: For these two cases, urgent moxibustion at the Guan Yuan point is indicated because extreme cold suppresses the pulse; without moxibustion, the pulse cannot emerge. If moxibustion fails to restore the pulse, and slight panting occurs, it indicates rebellious Qi rushing upward toward collapse. Although this seems fatal, I believe it can be saved precisely because the patient is not yet dead despite having no pulse. Death follows pulse absence; here, absence is due to suppression. If moxibustion fails, use Ren Shen (Ginseng Radix) 1 liang, Shu Di Huang (Rehmanniae Radix Preparata) 5 qian, Niu Xi (Achyranthis Bidentatae Radix) 3 qian, Gan Cao (Glycyrrhizae Radix et Rhizoma) and Fu Zi 1 qian each. Named Huan Mai Tang (Return-Pulse Decoction). If the pulse bursts out suddenly after one dose, death ensues; if it emerges gradually, survival is possible. In the third case, occasional pulse return is achieved via moxibustion. Survival requires warm extremities, indicating residual Yang. If the pulse does not return, extremities never warm, meaning Yang cannot return and death is inevitable. Moxibustion is too weak; use 3 liang of Ren Shen to induce pulse return.
Shen Jin'ao noted: The first case uses Baicong Tang for diarrhea/Jue, avoiding sudden pulse emergence. Cases two and three use moxibustion for diarrhea/Jue/absent pulse, seeking sudden pulse return. One dies, one lives: one uses moxibustion, the other uses herbs. Herbs can rapidly restore the pulse.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease with Si Ni, if the patient has cough, palpitations, dysuria, abdominal pain, or tenesmus (heavy sensation during diarrhea), Sini San (Four Counterflow Powder) should be administered.
[Detailed Commentary] Ke Qin stated: The four limbs are the root of all Yang. When Yang Qi fails to reach the limbs, Jue occurs, so limbs often relate to Yin. Here, however, tenesmus indicates Yang pathogen sinking into Yin. Yang is internal, Yin is external, causing disconnection of Yin-Yang Qi. Thus, distinguishing Hot Jue (cold extremities) from Cold Jue (reversal cold) is erroneous. There are no principal symptoms, only optional ones. Dysuria resembles Xiao Qinglong Tang syndrome; Jue and palpitations resemble Fuling Gancao Tang syndrome; cough, diarrhea, abdominal pain, and dysuria resemble Zhenwu Tang syndrome. All involve Water Qi pathology. Diuretics are not used due to tenesmus. White Touweng Tang is not used due to Si Ni. This is Shaoyin pivot dysfunction causing optional symptoms. Sini San disperses Heat Evil of Si Ni. Symptomatic modification treats optional symptoms. This is the descending agent for Shaoyin Qi level. It is the formula for "Jue caused by purgation."
[General Principle] Zhang Zhongjing stated: With cold extremities, intermittent tight pulse, evil knotting in the chest, chest fullness and irritability, hunger but inability to eat, the disease is in the chest. Vomiting (emetic therapy) should be induced.
[Detailed Commentary] Cheng Wuji stated: All Yang Qi originates in the chest. When evil lodges in the chest and knots郁 (depresses), Yang Qi cannot distribute, causing cold extremities.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease with aversion to cold, body curling, diarrhea, and cold extremities, it is untreatable (fatal).
[Detailed Commentary] Ke Qin stated: Diarrhea with warm extremities indicates Yang recovery, hence treatable. Unstopping diarrhea with cold extremities indicates pure Yin without Yang, i.e., exhaustion of Six Fu Qi externally. Cold extremities indicate exhaustion of Five Zang Qi internally, leading to uncontrollable diarrhea.
[General Principle] Zhang Zhongjing stated: In Shaoyin disease with Si Ni, aversion to cold, body curling, absent pulse, no irritability but restlessness, death ensues. In Shaoyin disease with vomiting, diarrhea, irritability, and Si Ni, death ensues.
[Detailed Commentary] Cheng Wuji stated: Si Ni means extremities are reversed and cold. At the start of Shanghan, evil is in the skin. Taiyang and Yangming involvement causes whole-body heat; Taiyin and Shaoyin involvement causes warm extremities, indicating exterior evil easing and transmitting inward. On day 4-5, warm extremities with thirst suggest Xiaochaihu Tang (Minor Chaihu Decoction), transmission from Taiyang to Shaoyang. Floating pulse with warm extremities suggests Taiyin involvement, transmission from Shaoyang to Taiyin. Thus, half-exterior/half-interior evil results in warm, not hot, extremities. Transmission to Shaoyin makes interior disease deep; even without Jue, extremities are not warm, termed Si Ni. Transmission to Jueyin causes Jue. Sini San contains cooling herbs (Zhishi, Chaihu, Shaoyao, Gancao) treating Si Ni, proving Si Ni is not always deficiency-cold. Sini Tang contains heating herbs (Ganjiang, Fuzi) also treating Si Ni. Correct. If extremities go from hot to warm, from Si Ni to Jue, it is transmitted evil; use Sini San. If extremities are cold from onset, it is Yin channel evil with insufficient Yang; use Sini Tang to warm. Do not err.
Chen Shiduo stated: Shaoyin syndrome with vomiting, diarrhea, and irritability indicates chaotic Yin/Yang and lack of life force. Cold extremities indicate impending Spleen/Stomach Qi collapse. Naturally fatal, but early treatment may save. Use Ren Shen and Bai Zhu 2 liang each, Rou Gui (Cinnamomi Cortex) and Dingxiang (Caryophylli Flos) 2 qian each. Named Zhi Ni Dian An Tang. Ren Shen saves Yuan Yang collapse; Bai Zhu saves Spleen/Stomach collapse; Dingxiang stops vomiting; Rou Gui warms middle and stops diarrhea, saving Earth and stabilizing chaos. Can one abandon this?
Shaoyin syndrome with Si Ni, aversion to cold, curling, absent pulse, no irritability but restlessness is also fatal, but I believe it can be saved due to absent pulse and restlessness without irritability. Disease reaching extremities indicates impending Yin/Yang collapse. Absent pulse may be due to extreme cold suppressing the pulse. If Yang collapsed, heart would be irritable; since it is not, but restless, Yang is not yet collapsed but about to be, which is fearful. As Yang desires collapse, Yin follows. Tonifying Yang restores both. Use Sheng Sheng Tang: Ren Shen 3 liang, Chao Zao Ren (Ziziphi Spinosae Semen) 5 qian, Fu Zi 3 qian. Ren Shen restores Yin/Yang; Fu Zi dispels cold; Zao Ren calms heart, stopping restlessness and restoring pulse. Seeking life in death lies in this formula.