暂假之。以和胃气。而止谵语也。〔徐〕仲景用此汤。凡七见。或因吐下津干。或因烦满气热。总为胃中燥热
不和。而非大实满者比。故不欲其速下。而去枳朴。欲其恋鬲而生津。特加甘草。以调和之。故曰调胃。〔柯〕
不用气药。而立名承气者。调胃所以承气也。经曰。平人胃满则肠虚。肠满则胃虚。更虚更实。故气得上下。
今气之不承。由胃家之热实。必用硝黄。以濡胃家之糟粕。而气得以下。同甘草。以生胃家之津液。而气得以
上。推陈之中。便寓致新之义。一攻一补。调胃之法备矣。
千金方。本方。加枳实五枚。单名承气汤。
外台。集验。生地黄汤。疗伤寒有热。虚羸少气。心下满。胃中有宿食。大便不利。
于本方。加生地黄三斤。大枣二十枚。
圣济总录。大黄汤。灸发背后服之方。
于本方。去甘草。
十形三疗。一小儿。小溲不通。号跳旋转。下则成砂石。大便秘。肛门脱出一二寸。戴人曰。此下焦塞
也。不吐不下。则何以开。不令饮水。小溲何以利。以调胃承气汤一两。加牵牛子头末三钱。河水煎服。又用
瓜蒂末。糊丸芥子许。六十丸吞下。上吐下泻。一时齐出。有脓有血。涌泄既定。令饮新水。二三十次。每次
饮一盏。其病如失。试效方。调胃承气汤。治消中渴而饮食多。
卫生宝鉴。治面热。以本方七钱。加黄连二钱。犀角一钱。（案张氏医通云。饮食不节。则胃病。胃病则
气短。精神少。而生大热。有时火上行。而独燎其面。针经云。面热者。足阳明病。调胃承气汤。加犀角。川连。）
又牛黄通膈汤。觉中风一二日。实则急宜下之。
于本方。加牛黄。与芒硝同研末。调服。
又破棺丹。治疮肿一切风热。
即本方。为末。炼蜜丸。
医垒元戎。治大头病。本方。加牛蒡子。寒水石。为细末。炼蜜酒服。
又涤毒散。治时气疙瘩。五发疮疡。喉闭雷头。
于本方。加当归。
又玉烛散。本方。与四物汤。各半合。
经验良方。调胃承气汤。治热留胃中发斑。及服热药过多。亦发斑。此药主之。
四逆汤方
甘草（二两炙○千金翼。霍乱门。作一两） 干姜（一两半） 附子（一枚生用去皮破八片○玉函。作
生去皮破）
上三味。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。（味下。成本。
有咀二字。）
〔钱〕四逆汤者。所以治四肢厥逆。而名之也。素问阳明脉解云。四肢者。诸阳之本也。阳盛则四肢实。
即阴阳应象论之清阳实四肢也。灵枢终始篇云。阳受气于四末。阴受气于五脏。盖以谷入于胃。气之清者为营。
行于脉中。浊者降于下焦。为命门真阳之所蒸腾。其气直达皮肤。而为卫气。先充满于四末。然后还而温肌肉。
密腠理。行于阴阳。各二十五度。故四肢为诸阳之本。此以真阳虚衰。阴邪肆逆。阳气不充于四肢。阴阳不相
顺接。故手足厥冷。而为厥逆咽中干也。若重发其汗。更加烧针取汗。则孤阳将绝矣。仲景急以温经复阳为治。
故立四逆汤。其以甘草为君者。以甘草甘和而性缓。可缓阴气之上逆。干姜温中。可以救胃阳。而温脾土。即
所谓四肢皆禀气于胃。而不得至经。必因于脾。乃得禀焉。此所以脾主四肢也。附子辛热。直走下焦。大补命
门之真阳。故能治下焦逆上之寒邪。助清阳之升发。而腾达于四肢。则阳回气暖。而四肢无厥逆之患矣。是以
名之曰四逆汤也。
顾宪章伤寒溯源集云。案言四者。四肢之省文也。四肢。自指至肘。足至膝。是也。其病为深。凡言手足
者。自指至腕。足至踝而已。其病尚浅。仲景下字不苟。其轻重浅深。一览了然矣。○案四逆字。见于灵素。
亦是四肢厥逆之义。柯氏谓本方脱人参。乃以四物救逆名之。误也。
吴遵程方注云。从前附子。皆野生。大者极是难得。重半两者即少。不若今时之种附子。重一两外也。
近世用二三钱一剂。即与仲景时二三枚分三剂相等耳。
医经会解云。阴毒心硬肢冷。加麝香。皂荚。俱用少许。呕吐涎沫。或小腹痛。加盐炒吴茱萸。半夏。
生姜。呕吐不止。加半夏。生姜汁。泻不止。加白术。人参。黄 。茯苓。开麻。
名医类案云。郭雍治一人。盛年恃健不善养。因极饮冷酒食。内外有所感。初得疾。即便身凉自利。手
足厥。额上冷汗不止。遍身痛。呻吟不绝。偃卧不能转侧。心神俱无昏愦。不恍惚。请医视之。治不力。言曰。
此证甚重。而病患甚静。殊不昏愦。身重不能起。自汗自利。四肢厥。此阴证无疑也。又遍身痛。不知处所。
出则身如被杖。阴毒证也。当急治之。医言谬悠不可听。郭令服四逆汤。灸关元及三阴交。未知。加服九炼金
液丹。利厥汗证少止。稍缓药艾。则诸证复出。再急灸治。如此进退者三。凡三日两夜。灸千余壮。服金液丹。
亦千余粒。四逆汤一二斗。方能住灸汤药。阳气虽复。而汗不出。证复如太阳病。未敢服药。以待汗二三日。
复大烦躁饮水。次则谵语斑出。热甚无可奈何。复与调胃承气汤。得利大汗而解。阴阳反复。有如此者。前言
烦躁不可投凉药。此则可下证具。非小烦躁而已。故不同也。
问曰。证象阳旦。案法治之。而增剧。厥逆。咽中干。两胫拘急。而谵语。师曰。言夜半手足当温。两
脚当伸。后如师言。何以知此。答曰。寸口脉浮而大。浮为风。大为虚。风则生微热。虚则两胫挛。病形象桂
枝。因加附子参其间。增桂令汗出。附子温经。亡阳故也。厥逆。咽中干。烦躁。阳明内结。谵语烦乱。更饮
甘草干姜汤。夜半阳气还。两足当热。胫尚微拘急。重与芍药甘草汤。尔乃胫伸。以承气汤微溏。则止其谵语。
故知病可愈。（玉函。无师曰之曰。此。作之。为字上。并有即字。参。作于。无重字。成本。为上。并有则
字。病形。作病证。躁。作燥。）
〔成〕阳旦。桂枝汤别名也。〔程〕此条。即上条注脚。借问答。以申明其义也。证象阳旦句。应前条伤
寒脉浮自汗出。小便数。心烦微恶寒。脚挛急一段。案法治之句。应前条反
与桂枝汤。欲攻其表一段。而增剧。至拘急而谵语句。应前条此误也。得之便厥。咽中干。烦躁吐逆者一段。
师言夜半手足当温。两胫当伸。后如师言。何以知此句。应前条已用甘草汤。并调胃承气汤一段。答曰寸口脉
浮而大。浮则为风。大则为虚。风则生微热。虚则两胫挛。证象桂枝。因加附子参其间。增桂令汗出。附子温
经。亡阳故也数句。发明以补出前证病源。及用桂枝之误。见证象桂枝而实非桂枝证。将成亡阳也。厥逆。咽
中干。烦躁。阳明内结。谵语烦乱。申叙前证。以着亡阳之实。更饮甘草汤。夜半阳气回。两足当温。重应前
条甘草干姜汤一段。胫尚微拘急。重与芍药甘草汤。尔乃胫伸。重应前条芍药甘草汤一段。以承气汤微溏。
则止其谵语。重应前条调胃承气汤一段。故知其病可愈。亦非泛结。见其愈也。由于救之得法。万一为烦躁谵
语等证所惑。而大青龙之见。不无交互于胸中。欲其病之愈也得乎。〔钱〕象桂枝汤证。故仍于桂枝汤中。加附
子参于其间。则真阳有助。不患其汗泄。故又增桂令汗出。以解卫分之阳邪也。其所以加附子温经者。以下焦
无阳也。此法。即误汗亡阳。桂枝加附子汤。乃为伤寒脉浮。自汗出。小便数。心烦微恶寒。脚拘挛之正治也。
若不察其微恶寒。脚拘挛之亡阳虚证。已经反与桂枝汤。误攻其表。使阳气愈虚。阴邪上逆。以致厥逆咽中干
等证也。
案喻氏以阳旦汤。为千金方桂枝加黄芩之方。魏氏汪氏钱氏辈。参量证辨其非。以文繁不载于斯。
案柯氏注本。阙此一条。详其文义。似后人所增。柯氏删之。实有所见也。
暂时借用此方，来调和胃气，从而停止谵语。〔徐〕张仲景使用这个汤剂，共有七次出现。有的因为吐下导致津液干枯，有的因为烦满气热，总归是胃中燥热不和，而不是那种大实满的情况相比。所以不希望它迅速泻下，而去掉了枳实、厚朴；希望它留恋膈间而生津液，特意加入甘草，来调和它。所以叫“调胃”。〔柯〕不用行气药，却立名为承气，是因为调胃就是为了承接胃气。经书说：正常人胃满则肠虚，肠满则胃虚，更替虚实，所以气能上下流通。现在气不能承接，是由于胃家热实，必须用芒硝、大黄，来润湿胃中的糟粕，使气能下行；配合甘草，来生养胃中的津液，使气能上行。在推陈出新的过程中，便蕴含了致新的意义。一攻一补，调胃的方法就完备了。
《千金方》：本方加枳实五枚，单名承气汤。
《外台秘要》集验方：生地黄汤，治疗伤寒发热，身体虚弱消瘦，气短，心下痞满，胃中有宿食，大便不通。在本方基础上加生地黄三斤，大枣二十枚。
《圣济总录》：大黄汤，灸发背后服用的方子。在本方基础上去掉甘草。
《十形三疗》：有一个小儿，小便不通，哭闹翻滚，排尿时结成砂石，大便秘结，肛门脱出一二寸。戴人（张从正）说：这是下焦堵塞。不吐不下，怎么能够开通？不让喝水，小便怎么能通利？用调胃承气汤一两，加牵牛子头末三钱，河水煎服。又用瓜蒂末，糊丸如芥菜籽大小，吞服六十丸。上吐下泻，一时同时排出，有脓有血。涌泄之后，让喝新水，二三十次，每次饮一盏，病就好了。《试效方》：调胃承气汤，治疗消渴症，饮食多。
《卫生宝鉴》：治疗面热，用本方七钱，加黄连二钱，犀角一钱。（按：《张氏医通》说：饮食不节制，就会胃病。胃病则气短，精神少，而生大热。有时火气上行，单独烧灼面部。《针经》说：面热，是足阳明经的病。调胃承气汤加犀角、川连。）又有牛黄通膈汤，感觉中风一二天，实证应当急下。在本方基础上加牛黄，与芒硝同研为末，调服。又有破棺丹，治疗疮肿一切风热。即本方为末，炼蜜为丸。
《医垒元戎》：治疗大头病，本方加牛蒡子、寒水石，为细末，炼蜜酒服。又有涤毒散，治疗时气疙瘩，五发疮疡，喉闭雷头。在本方基础上加当归。又有玉烛散，本方与四物汤各半合。
《经验良方》：调胃承气汤，治疗热留在胃中发斑，以及服用热药过多，也发斑。此药主治。
四逆汤方
甘草（二两炙○《千金翼方·霍乱门》作一两） 干姜（一两半） 附子（一枚生用去皮破八片○《玉函经》作生去皮破）
以上三味，用水三升，煮取一升二合，去渣，分两次温服。体壮的人可用大附子一枚，干姜三两。（味下，《成本》有“咀”二字。）
〔钱〕四逆汤，是用来治疗四肢厥逆的，所以以此命名。《素问·阳明脉解》说：四肢，是诸阳的根本。阳气盛则四肢充实，也就是《阴阳应象大论》所说的清阳充实四肢。《灵枢·终始篇》说：阳受气于四末，阴受气于五脏。大概因为谷入于胃，气之清者为营，行于脉中；浊者降于下焦，为命门真阳所蒸腾，其气直达皮肤，而为卫气，先充满于四末，然后返回而温肌肉，密腠理，行于阴阳，各二十五度。所以四肢是诸阳的根本。这里是因为真阳虚衰，阴邪肆意逆乱，阳气不能充养四肢，阴阳不相顺接，所以手足厥冷，而为厥逆咽中干。如果再次发汗，再加烧针取汗，那么孤阳就要绝灭了。张仲景急以温经复阳为治法，所以创立四逆汤。它以甘草为君药，因为甘草甘和而性缓，可以缓解阴气之上逆；干姜温中，可以救胃阳，而温脾土，也就是所谓的“四肢皆禀气于胃，而不得至经，必因于脾，乃得禀焉”，这就是脾主四肢的原因。附子辛热，直走下焦，大补命门之真阳，所以能治疗下焦逆上的寒邪，助清阳之升发，而腾达于四肢，那么阳回气暖，而四肢就没有厥逆的患害了。因此命名为四逆汤。
顾宪章《伤寒溯源集》说：案语中说“四”，是“四肢”的省文。四肢，是指自指至肘，足至膝。这种病较深。凡是说“手足”的，是指自指至腕，足至踝而已，这种病尚浅。张仲景用字不苟且，轻重浅深，一览了然。○案“四逆”二字，见于《灵枢》、《素问》，也是四肢厥逆的意思。柯氏认为本方脱漏人参，乃以四物救逆命名，是错误的。
吴遵程《方注》说：以前的附子，都是野生的，大的极难得到，重半两的就很少，不如现在的种植附子，重一两以外。近世用药二三钱一剂，就与张仲景时代二三枚分三剂相等罢了。
《医经会解》说：阴毒心硬肢冷，加麝香、皂荚，俱用少许。呕吐涎沫，或小腹痛，加盐炒吴茱萸、半夏、生姜。呕吐不止，加半夏、生姜汁。泻不止，加白术、人参、黄芪、茯苓、麻黄。
《名医类案》说：郭雍治疗一个人，正值壮年，倚仗身体健壮而不善于保养，因为极度饮用冷酒食，内外有所感受，初得病，即便身凉自利，手足厥冷，额上冷汗不止，遍身痛，呻吟不绝，偃卧不能转侧，心神都不昏愦，不恍惚。请医生诊治，治疗效果不力。医生说：这个证很重，而病患很安静，完全不昏愦，身重不能起，自汗自利，四肢厥冷，这是阴证无疑。又遍身痛，不知处所，外出则身如被杖打，是阴毒证。应当急治。医生说谬悠不可听。郭雍令服用四逆汤，灸关元及三阴交，未见好转，加服九炼金液丹，利、厥、汗证稍止。稍微缓和药艾，则诸证复出。再急灸治，如此进退三次。凡三日两夜，灸千余壮，服金液丹，亦千余粒，四逆汤一二斗，才能停止灸汤药。阳气虽恢复，而汗不出，证复如太阳病，不敢服药，等待出汗二三日，又出现大烦躁饮水，随后谵语斑出，热甚无可奈何，又给予调胃承气汤，得利大汗而解。阴阳反复，有像这样的。前言烦躁不可投凉药，此时则可下证具，不是小烦躁而已，所以不同。
问曰：证象阳旦，按照法治之，反而加重，出现厥逆，咽中干，两胫拘急，而谵语。老师说：言说半夜手足当温，两脚当伸，后来像老师说的那样，为什么知道这一点？回答说：寸口脉浮而大，浮为风，大为虚。风则生微热，虚则两胫挛。病形象桂枝汤证，因此加附子参于其间，增桂令汗出。附子温经，是因为亡阳的缘故。厥逆，咽中干，烦躁，阳明内结，谵语烦乱，再饮甘草干姜汤，夜半阳气还，两足当热，胫尚微拘急，重与芍药甘草汤，尔乃胫伸，以承气汤微溏，则止其谵语，所以知道病可愈。（《玉函经》无“师曰”之“曰”字，“此”作“之”，“为”字上并有“即”字，“参”作“于”，无“重”字。《成本》，“为”作“上”，并有“则”字，“病形”作“病证”，“躁”作“燥”。）
〔成〕阳旦，是桂枝汤的别名。〔程〕此条，即是上条的注脚，借问答，来申明其义。证象阳旦句，对应前条伤寒脉浮自汗出、小便数、心烦微恶寒、脚挛急一段。案法治之句，对应前条反与桂枝汤、欲攻其表一段。而增剧，至拘急而谵语句，对应前条此误也、得之便厥、咽中干、烦躁吐逆者一段。师言夜半手足当温、两胫当伸、后如师言、何以知此句，对应前条已用甘草汤、并调胃承气汤一段。答曰寸口脉浮而大，浮则为风，大则为虚，风则生微热，虚则两胫挛，证象桂枝，因加附子参其间，增桂令汗出，附子温经，亡阳故也数句，发明以补出前证病源，及用桂枝之误，见证象桂枝而实非桂枝证，将成亡阳也。厥逆，咽中干，烦躁，阳明内结，谵语烦乱，申叙前证，以着亡阳之实。更饮甘草汤，夜半阳气回，两足当温，重应前条甘草干姜汤一段。胫尚微拘急，重与芍药甘草汤，尔乃胫伸，重应前条芍药甘草汤一段。以承气汤微溏，则止其谵语，重应前条调胃承气汤一段。故知其病可愈，亦非泛结，见其愈也，由于救之得法。万一为烦躁谵语等证所惑，而大青龙之见，不无交互于胸中，欲其病之愈也得乎？〔钱〕象桂枝汤证，故仍于桂枝汤中，加附子参于其间，则真阳有助，不患其汗泄，故又增桂令汗出，以解卫分之阳邪也。其所以加附子温经者，以下焦无阳也。此法，即误汗亡阳，桂枝加附子汤，乃为伤寒脉浮、自汗出、小便数、心烦微恶寒、脚拘挛之正治也。若不察其微恶寒、脚拘挛之亡阳虚证，已经反与桂枝汤，误攻其表，使阳气愈虚，阴邪上逆，以致厥逆咽中干等证也。
案喻氏以阳旦汤，为《千金方》桂枝加黄芩之方，魏氏、汪氏、钱氏辈，参量证辨其非，以文繁不载于斯。
案柯氏注本，阙此一条，详其文义，似后人所增，柯氏删之，实有所见也。
Temporarily borrow this formula to harmonize the Stomach Qi, thereby stopping delirium. [Xu] Zhang Zhongjing used this decoction in seven instances. Sometimes it was due to dryness of body fluids from vomiting or purging; sometimes due to irritability, fullness, and Qi heat. In all cases, it was due to dry-heat disharmony in the Stomach, not comparable to severe excess-fullness. Therefore, rapid purging was not desired, so Zhi Shi (Immature Bitter Orange) and Hou Po (Magnolia Bark) were removed. The intention was for the formula to linger in the diaphragm to generate body fluids, hence Gan Cao (Licorice Root) was specifically added to harmonize it. Thus it is called "Tiao Wei" (Regulate the Stomach). [Ke] Not using Qi-moving herbs, yet naming it Cheng Qi (Assist Qi), is because regulating the Stomach is how one assists the Qi. The Classics state: A healthy person has a full Stomach and empty Intestines; when the Intestines are full, the Stomach is empty. Alternating emptiness and fullness allows Qi to move up and down. Now, the failure of Qi to descend is due to heat-excess in the Stomach-intestine system. One must use Mang Xiao (Mirabilite) and Da Huang (Rhubarb) to moisten the fecal matter in the Stomach-intestines, allowing Qi to descend; combined with Gan Cao (Licorice Root) to generate Stomach fluids, allowing Qi to ascend. Within the process of eliminating the old, the meaning of generating the new is contained. One attack, one tonification; the method of regulating the Stomach is complete.
*Qian Jin Fang*: Add Wu Zhi Shi (Immature Bitter Orange, 5 pieces) to this formula, named simply *Cheng Qi Tang*.
*Waitai Miyao* (Ji Yan): *Sheng Di Huang Tang* treats Shanghan with fever, emaciation, shortness of breath, epigastric fullness, retained food in the Stomach, and difficulty defecating. Add Sheng Di Huang (Rehmannia Root, 3 jin) and Da Zao (Jujube, 20 pieces) to this formula.
*Shengji Zonglu*: *Da Huang Tang*, a formula taken after moxibustion on the back of the head. Remove Gan Cao (Licorice Root) from this formula.
*Shi Xing San Liao*: A child had no urination, rolling and crying in distress, passing sand-like stones upon urination, constipation, and rectal prolapse of one to two cun. Dai Ren (Zhang Congzheng) said: This is blockage in the Lower Jiao. Without vomiting or purging, how can it be opened? Without drinking water, how can urination be facilitated? Use *Tiao Wei Cheng Qi Tang* (1 liang) plus Qian Niu Zi (Pharbitis Seed, head powder, 3 qian), decocted in river water. Also use Gua Di (Melon Twig) powder, made into pills the size of mustard seeds, swallow 60 pills. Vomiting and purging occur simultaneously, expelling pus and blood. After the emetic and purgative effects subside, have him drink fresh water, 20-30 times, one zhan each time. The illness disappears. *Shi Xiao Fang*: *Tiao Wei Cheng Qi Tang* treats Xiao Ke (Wasting-Thirst) with polyphagia.
*Wei Sheng Bao Jian*: Treats facial heat. Use this formula (7 qian) plus Huang Lian (Coptis Rhizome, 2 qian) and Xi Jiao (Rhinoceros Horn, 1 qian). (Note: *Zhang Shi Yi Tong* states: Irregular diet damages the Stomach. Stomach disease leads to shortness of Qi, reduced spirit, and generation of great heat. Sometimes Fire ascends, burning only the face. *Zhen Jing* states: Facial heat indicates Foot Yangming disease. *Tiao Wei Cheng Qi Tang* plus Xi Jiao and Chuan Lian.) There is also *Niu Huang Tong Ge Tang*. If stroke symptoms appear for one or two days, and it is an excess pattern, purging should be urgent. Add Niu Huang (Calculus Bovis) to this formula, grind together with Mang Xiao (Mirabilite) into powder, mix and take. There is also *Po Guan Dan*, treating all wind-heat conditions of carbuncles and swellings. Grind this formula into powder, refine honey to make pills.
*Yi Lei Yuan Rong*: Treats Da Tou Bing (Big Head Disease). Add Niu Bang Zi (Arctii Fructus) and Han Shui Shi (Halloysitum Rubrum) to this formula, grind into fine powder, take with refined honey and wine. There is also *Di Du San*, treating epidemic nodules, five types of sores/ulcers, throat closure, and Lei Tou Bing (Thunder Head Disease). Add Dang Gui (Angelica Sinensis) to this formula. There is also *Yu Zhu San*, mixing this formula with *Si Wu Tang* (Four Substances Decoction) in equal halves.
*Jing Yan Liang Fang*: *Tiao Wei Cheng Qi Tang* treats macules caused by heat lingering in the Stomach, or caused by excessive intake of hot medicines. This formula is indicated.
**Si Ni Tang Formula**
Gan Cao (2 liang, roasted ○ *Qian Jin Yi Fang, Huo Luan Men*: 1 liang)
Gan Jiang (Dried Ginger, 1.5 liang)
Fu Zi (Aconite Root, 1 raw piece, peeled and broken into 8 slices ○ *Yu Han Jing*: raw, peeled, broken)
These three ingredients, add 3 sheng of water, boil to obtain 1.2 sheng, remove dregs, divide into two warm doses. Strong individuals may use one large Fu Zi (Aconite Root) and 3 liang of Gan Jiang. (Below the ingredients, *Cheng Ben* has the character "Ju" [chew/crush].)
[Qian] *Si Ni Tang* is named so because it treats Si Zhi Jue Ni (Cold Reversal of the Four Limbs). *Su Wen, Yang Ming Mai Jie* states: The four limbs are the root of all Yang meridians. When Yang is abundant, the four limbs are solid, which corresponds to "Clear Yang fills the four limbs" in *Yin Yang Ying Xiang Lun*. *Ling Shu, Zhong Shi Pian* states: Yang receives Qi at the four extremities; Yin receives Qi in the five Zang organs. Generally, grain enters the Stomach; the clear part of Qi becomes Ying (Nutritive Qi), circulating within the vessels; the turbid part descends to the Lower Jiao, where it is steamed by the True Yang of the Ming Men (Gate of Life). This Qi reaches the skin directly, becoming Wei (Defensive Qi), first filling the four extremities, then returning to warm the muscles and tighten the interstices, circulating through Yin and Yang, 25 degrees each. Thus, the four limbs are the root of all Yang. Here, because True Yang is deficient and Yin pathogens are rampant, Yang Qi fails to fill the four limbs, and Yin and Yang fail to connect smoothly, resulting in cold reversal of the hands and feet, and dryness in the throat. If sweating is induced again, or if burning needle therapy is used to induce sweat, the solitary Yang will perish. Zhang Zhongjing urgently employs warming the meridians and restoring Yang as the treatment, thus establishing *Si Ni Tang*. Gan Cao (Licorice Root) is the sovereign herb because its sweet and mild nature can restrain the counterflow of Yin Qi. Gan Jiang (Dried Ginger) warms the Middle, rescuing Stomach Yang and warming Spleen Earth, corresponding to "The four limbs all receive Qi from the Stomach, but cannot reach the meridians directly; they must rely on the Spleen to receive it." This is why the Spleen governs the four limbs. Fu Zi (Aconite Root) is acrid and hot, acting directly on the Lower Jiao, greatly tonifying the True Yang of the Ming Men. Thus, it treats cold pathogens reversing upward from the Lower Jiao, assisting the ascending and developing of Clear Yang, allowing it to reach the four limbs. Then Yang returns, Qi becomes warm, and there is no danger of cold reversal in the limbs. Hence it is named *Si Ni Tang*.
Gu Xianzhang in *Shanghan Su Yuan Ji* states: The character "Si" mentioned here is an abbreviation for "Si Zhi" (Four Limbs). "Si Zhi" refers to fingers to elbow, toes to knee. This indicates a deeper condition. Whenever "Shou Zu" (Hands and Feet) is mentioned, it refers to fingers to wrist, toes to ankle, indicating a shallower condition. Zhang Zhongjing did not choose words lightly; the severity and depth are clear at a glance. ○ Note that the term "Si Ni" appears in *Ling Shu* and *Su Wen*, also meaning cold reversal of the four limbs. Ke's assertion that this formula lacks Ren Shen (Ginseng) and was named based on Si Wu (Four Substances) to save from reversal is incorrect.
Wu Zun Cheng in *Fang Zhu* states: Previously, Fu Zi (Aconite Root) were wild; large ones were extremely rare, and those weighing half a liang were few. They are not like modern cultivated Fu Zi, which weigh over one liang. Modern usage of 2-3 qian per dose is equivalent to Zhang Zhongjing's usage of 2-3 pieces divided into three doses.
*Yi Jing Hui Jie* states: For Yin Toxin with hard chest and cold limbs, add She Xiang (Musk) and Zao Jiao (Tamarisk Pod), both in small amounts. For vomiting saliva/froth or lower abdominal pain, add Yan Chao Wu Zhu Yu (Evodia Fruit salt-fried), Ban Xia (Pinellia Tuber), and Sheng Jiang (Fresh Ginger). For persistent vomiting, add Ban Xia (Pinellia Tuber) and Sheng Jiang Zhi (Fresh Ginger Juice). For persistent diarrhea, add Bai Zhu (Atractylodes Macrocephala Rhizome), Ren Shen (Ginseng), Huang Qi (Astragalus Root), Fu Ling (Poria), and Ma Huang (Ephedra Stem).
*Ming Yi Lei An* states: Gu Yong treated a man in his prime who relied on his health and failed to cultivate himself properly. Due to extreme consumption of cold wine and food, and internal/external pathogenic influences, he initially presented with cool body temperature, spontaneous diarrhea, cold reversal of hands and feet, continuous cold sweat on the forehead, generalized body pain, incessant groaning, inability to turn over while lying prone, but his mind and spirit were not confused or恍惚 (dazed). The physician's treatment was ineffective. Gu Yong said: This syndrome is severe, yet the patient is very quiet, completely unconfused, heavy-bodied unable to rise, with spontaneous sweating and diarrhea, and cold reversal of limbs. This is undoubtedly a Yin syndrome. Furthermore, generalized pain without fixed location, feeling as if beaten when moving out, indicates Yin Toxin. Urgent treatment is required. The physician's advice was absurd and should not be heard. Gu Yong ordered the administration of *Si Ni Tang*, moxibustion on Guan Yuan (CV4) and San Yin Jiao (SP6). Upon no improvement, he added Jiu Lian Jin Ye Dan (Nine-Refined Golden Liquid Pill). The diarrhea, cold reversal, and sweating subsided slightly. When the medicinal and moxa treatment was relaxed, the symptoms returned. Urgent moxibustion was repeated. This ebb and flow occurred three times. Over three days and two nights, over a thousand moxa cones were burned, over a thousand Golden Liquid Pills were taken, and one to two dou of *Si Ni Tang* were consumed before the moxa and herbal treatments could cease. Although Yang Qi recovered, sweat did not appear, and the presentation resembled Taiyang disease. Medication was withheld for two to three days waiting for sweat. Then, severe irritability and thirst appeared, followed by delirium and emergence of macules. With intense heat and no other recourse, *Tiao Wei Cheng Qi Tang* was given again. Defecation and profuse sweat ensued, resolving the condition. Yin and Yang reversed in such a manner. Previously stated that irritability precludes cooling herbs; now the indications for purging are complete, not mere slight irritability, hence the difference.
Question: The syndrome resembles Yang Dan, yet following the treatment protocol worsened it, causing cold reversal, dry throat, cramped calves, and delirium. The Master said: "By midnight, the hands and feet will become warm, and the legs will extend." Later, this happened as predicted. How did you know this? Answer: The Cun Kou pulse is floating and large. Floating indicates Wind; Large indicates Deficiency. Wind generates slight heat; Deficiency causes calf cramping. The syndrome resembles Gui Zhi Tang pattern, so Fu Zi (Aconite Root) was added, and Gui Zhi (Cinnamon Twig) increased to induce sweating. Fu Zi warms the meridians because of Yang collapse. Cold reversal, dry throat, irritability, Yangming internal binding, delirious confusion. Drink Gan Cao Gan Jiang Tang (Licorice and Dried Ginger Decoction) again. By midnight, Yang Qi returns, feet become warm. Calves still slightly cramped. Administer Shao Yao Gan Cao Tang (Peony and Licorice Decoction) again, then calves extend. Use Cheng Qi Tang to cause slight loose stools, then delirium stops. Thus, we know the disease can be cured. (*Yu Han Jing*: omits "Shuo Yue", changes "Ci" to "Zhi", adds "Ji" above "Wei", changes "Can" to "Yu", omits "Zhong". *Cheng Ben*: "Wei" is "Shang", adds "Ze", "Bing Xing" is "Bing Zheng", "Zao" is "Zao".)
[Cheng] Yang Dan is another name for Gui Zhi Tang. [Cheng] This paragraph serves as a footnote to the previous one, using question-and-answer to clarify the meaning. "Syndrome resembles Yang Dan" corresponds to the previous paragraph on Shanghan with floating pulse, spontaneous sweating, frequent urination, vexation, slight aversion to cold, and cramped foot. "Following the treatment protocol" corresponds to the previous paragraph on mistakenly giving Gui Zhi Tang to attack the exterior. "Worsened, leading to cramping and delirium" corresponds to the previous paragraph on "This is an error; obtaining cold reversal, dry throat, irritability, and vomiting immediately." "Master said... how did you know?" corresponds to the previous paragraph on having already used Gan Cao Tang and Tiao Wei Cheng Qi Tang. "Answer: Cun Kou pulse floating and large... Yang collapse" explains the source of the previous syndrome and the error of using Gui Zhi Tang, showing that although it resembles Gui Zhi Tang pattern, it is not actually that pattern, and is progressing toward Yang collapse. "Cold reversal, dry throat, irritability, Yangming internal binding, delirious confusion" restates the previous syndrome to emphasize the reality of Yang collapse. "Drink Gan Cao Gan Jiang Tang... feet warm" responds to the previous paragraph on Gan Cao Gan Jiang Tang. "Calves still slightly cramped... administer Shao Yao Gan Cao Tang... calves extend" responds to the previous paragraph on Shao Yao Gan Cao Tang. "Use Cheng Qi Tang... delirium stops" responds to the previous paragraph on Tiao Wei Cheng Qi Tang. "Thus we know the disease can be cured" is not a generic conclusion; seeing the cure demonstrates that it was due to correct rescue methods. If one were confused by symptoms like irritability and delirium, and considered Da Qing Long Tang, would the disease truly heal? [Qian] Resembling Gui Zhi Tang pattern, Fu Zi (Aconite Root) was still added to Gui Zhi Tang. Thus True Yang has assistance, and sweating loss is not feared. Hence Gui Zhi (Cinnamon Twig) was increased to induce sweating and resolve Wei-level Yang pathogens. The reason for adding Fu Zi (Aconite Root) to warm the meridians is the absence of Yang in the Lower Jiao. This method addresses Yang collapse from mistaken sweating. Gui Zhi Jia Fu Zi Tang (Gui Zhi Decoction plus Aconite) is the correct treatment for Shanghan with floating pulse, spontaneous sweating, frequent urination, vexation, slight aversion to cold, and cramped feet. If one fails to observe the deficiency-Yang syndrome indicated by slight aversion to cold and foot cramping, and mistakenly gives Gui Zhi Tang to attack the exterior, Yang Qi becomes more deficient, Yin pathogens reverse upward, leading to cold reversal, dry throat, etc.
Note: Yu Shi identified Yang Dan Tang as the Gui Zhi Jia Huang Qin Tang (Gui Zhi Decoction plus Scutellaria Root) from *Qian Jin Fang*. Wei Shi, Wang Shi, Qian Shi, etc., analyzed the syndrome and determined this to be incorrect. Due to length, it is not recorded here.
Note: Ke Shi's annotated edition omits this paragraph. Examining the text, it seems to be a later addition. Ke Shi's deletion shows true insight.