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。（成本。玉函。色赤。作赤色。止下。玉函。有而字。）
〔成〕下利清谷。手足厥逆。脉微欲绝。为里寒。身热不恶寒。面色赤。为外热。此阴甚于内。格阳于外。
不相通也。与通脉四逆汤。散阴通阳。〔汪〕武陵陈氏云。里寒外热者。寒甚于里。有阴无阳。而无根失守之火。
浮越于外也。与通脉四逆汤。以温里散寒。〔澜〕格。拒格也。亦曰隔阳。阴阳
隔离也。又曰戴阳。浮于上如戴也。夫真寒入里。阴气未有不盛者。然其剧不过阳愈微阴愈盛耳。
通脉四逆汤方
甘草（二两炙○全书。作三两。） 干姜（三两强人可四两） 附子（大者一枚生用去皮破八片）
上三味。以水三升。煮取一升二合。去滓。分温再服。其脉即出者愈。面色赤者。加葱九茎。腹中痛者。
去葱。加芍药二两。呕者。加生姜二两。咽痛者。去芍药。加桔梗一两。利止脉不出者。去桔梗。加人参二两。
病皆与方相应者。乃服之。（千金翼。葱下。有白字。玉函。作桔梗二两。全书。作人参一两。成本。玉函。
无病皆以下十字。玉函。无去葱去芍药去桔梗八字。千金翼。乃服间。有加减二字。汪氏云。去葱去芍药去桔
梗。此系衍文。）
〔汪〕武陵陈氏云。通脉四逆。即四逆汤也。其异于四逆者。附子云大。甘草干姜之分两加重。然有何大
异。而加通脉以别之。曰四逆汤者。治四肢逆也。论曰。阴阳之气。不相顺接。便为厥。厥者。阳气虚也。故
以四逆益真阳。使其气相顺接。而厥逆愈矣。至于里寒之甚者。不独气不相顺接。并脉亦不相顺接。其证更剧。
故用四逆汤。而制大其剂。如是则能通脉矣。同一药耳。加重则其治不同。命名亦别。方亦灵怪矣哉。〔钱〕
加减法。揣其词义浅陋。料非仲景本意。何也。原文中。已先具诸或有之证。然后出方立治。则一通脉四逆汤。
其证皆可该矣。岂庸续用加减邪。况其立意。庸恶陋劣。要皆出于鄙俗之辈。未敢竟削。姑存之以备识者之鉴云。
汪氏云。据条辨。云通脉者。加葱之谓。其言甚合制方之意。况上证云。脉微欲绝云云。其人面赤色。其
文一直贯上。则葱宜加入方中。不当附于方后。虽通脉之力不全在葱。
实赖葱为引。而效始神。方中无葱者。乃传写之漏。不得名通脉也。钱氏云。以四逆汤。而倍加干姜。其助阳
之力。或较胜。然既增通脉二字。当自不同。恐是已加葱白。以通阳气。有白通之义。故有是名。疑是久远差
讹。或编次之失。致原方中脱落。未可知也。○案二氏之说。未知果是否。姑附存于斯。
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。
〔锡〕凡少阴病四逆。俱属阳气虚寒。然亦有阳气内郁。不得外达而四逆者。又宜四逆散主之。枳实。胃
家之宣品。所以宣通胃络。芍药。疏泄经络之血脉。甘草。调中。柴胡。启达阳气于外行。阳气通而四肢温矣。
魏士千曰。泄利下重者。里急后重也。其非下利清谷明矣。〔鉴〕四逆。虽阴盛不能外温。然亦有阳为阴郁。
不得宣达。而令四肢逆冷者。但四逆而无诸寒热证。是既无可温之寒。又无可下之热。惟宜疏畅其阳。故用四
逆散主之。〔钱〕少阴病者。即前所谓脉微细。但欲寐之少阴病也。成氏云。四逆。四肢不温也。其说似与厥
冷有异。然论中或云厥。或云厥逆。或云四逆。或云厥冷。或云手足寒。或云手足厥寒。皆指手足厥冷而言也。
案成氏周氏魏氏。并以此条证。为传经邪气之热厥。钱氏指摘其非。是矣。
四逆散方
甘草（炙） 枳实（破水渍炙干） 柴胡 芍药
上四味。各十分。捣筛。白饮和服方寸匕。日三服。咳者。加五味子干姜各五分。并主下利。悸者。加桂
枝五分。小便不利者。加茯苓五分。腹中痛者。加附子一枚。炮令拆。泄利下重者。先以水五升。煮薤白三升。
煮取三升。去滓。
以散三方寸匕。纳汤中。煮取一升半。分温再服。
〔注〕案此方。虽云治少阴。实阳明少阳药也。〔柯〕加味俱用五分。而附子一枚。薤白三升。何多寡不
同若是。不能不疑于叔和编集之误耳。〔钱〕详推后加减法。凡原文中。每具诸或有之证者。皆有之。如小柴
胡汤。小青龙汤。真武汤。通脉四逆汤。四逆散。皆是也。愚窃揆之以理。恐未必皆出于仲景。
程云。四逆散一证。寒热未经详定。姑根据小柴胡例。从事和解。然黄芩已经革去。而使人知少阴之有火。
诚人身之至宝。而不可须臾失也。
医学入门。祝仲宁号橘泉。四明人。治周身百节痛。及胸腹胀满。目闭肢厥。爪甲青黑。医以伤寒治之。
七日昏沉。弗效。公曰。此得之怒火。与痰相搏。与四逆散。加芩连。泻三焦火而愈。○案此案本出程篁墩文集。
橘泉翁传。但不着四逆散之名。云与柴胡枳壳芍药芩连。泻三焦火。明日而省。久之愈。
少阴病。下利六七日。咳而呕渴。心烦不得眠者。猪苓汤主之。（千金翼。下利。作不利。）
〔锡〕少阴病。下利六七日。阴尽出阳之期也。〔鉴〕凡少阴下利清谷。咳呕不渴。属寒饮也。今少阴
病。六七日。下利粘秽。咳而呕渴。烦不得眠。是少阴热饮为病也。饮热相搏。上攻则咳。中攻则呕。下攻则
利。热耗津液。故渴。热扰于心。故烦不得眠。宜猪苓汤。利水滋燥。饮热之证。皆可愈矣。〔汪〕此方。乃治
阳明病。热渴引饮。小便不利之剂。此条病。亦借用之。何也。盖阳明病。发热渴欲饮水。小便不利者。乃水
热相结而不行。兹者少阴病。下利。咳而呕渴。心烦不得眠者。亦水热搏结而不行也。病名虽异。而病源则
同。故仲景同用猪苓汤主之。不过是清热利水。兼润燥滋阴之义。
案此条。视之黄连阿胶汤证。乃有咳呕渴。及小便不利。而大便下利之诸证。所以不同也。又案前条云。
少阴病欲吐不吐。心烦但欲寐。五六日自利而渴者。属少阴也。虚故引水自救。若小便色白者。少阴病形悉具。
小便白者。以下焦虚有寒。不能制水。故令色白也。可知此条下利呕渴心烦同证。而有不得眠及不白之异。乃
是寒热分别处。
少阴病。得之二三日。口燥咽干者。急下之。宜大承气汤。
〔钱〕此条得病才二三日。即口燥咽干。而成急下之证者。乃少阴之变。非少阴之常也。然但口燥咽干。
未必即是急下之证。亦必有胃实之证。实热之脉。其见证虽少阴。而有邪气复归阳明。即所谓阳明中土。万物
所归。无所复传。为胃家实之证据。方可急下。而用大承气汤也。其所以急下之者。恐入阴之证。阳气渐亡。
胃腑败损。必至厥躁呃逆。变证蜂起。则无及矣。故不得不急也。〔舒〕少阴挟火之证。复转阳明。而口燥咽
干之外。必更有阳明胃实诸证兼见。否则大承气汤。不可用也。
少阴病。自利清水。色纯青。心下必痛。口干燥者。可下之。宜大承气汤。（【原注】一法。用大柴胡。
○自利。玉函。脉经。作下利。可字。成本。玉函。作急。是也。宜下。脉经。有大柴胡汤四字。宜。作属。
大承气汤下。有证字。）
〔钱〕此亦少阴之变例也。自利。寒邪在里也。自利清水。即所谓清水完谷。此则并无完谷。而止利清水。
其色且纯青矣。清水固属寒邪。而青则又寒色也。故属少阴。成氏及方注。皆以为肝色。误矣。若证止如此。
其为四逆汤证无疑。不谓胃中清水。虽自利而去其谷食之渣滓。热邪尚留于胃。
所以心下按之必痛。且口中干燥。则知邪气虽入少阴。而阳明实热尚在。非但少阴证也。其热邪炽盛。迫胁胃
中之津液下奔。下焦寒甚。故皆清水。而色纯青也。阳邪暴迫。上则胃中之津液。下则肾家之真阴。皆可立尽。
故当急下之也。
名医类案曰。孙兆治东华门窦太郎患伤寒。经十余日。口燥舌干而渴。心中疼。自利清水。众医皆相守。
但调理耳。汗下皆所不敢。窦氏亲故相谓曰。伤寒邪气。害人性命甚速。安可以不次之疾。投不明之医乎。召
孙至曰。明日即已不可下。今日正当下。遂投小承气汤。大便通得睡。明日平复。众人皆曰。此证因何下之而
愈。孙曰读书不精。徒有书尔。口燥舌干而渴。岂非少阴证耶。少阴证。固不可下。岂不闻少阴一证。自利清
水。心下痛。下之而愈。仲景之书。明有此说也。众皆钦服。
少阴病。六七日。腹胀不大便者。急下之。宜大承气汤。（胀字。玉函。脉经。千金。及翼。并作满。）
〔钱〕少阴病。而至六七日。邪入已深。然少阴每多自利。而反腹胀不大便者。此少阴之邪。复还阳明也。
所谓阳明中土。万物所归。无所复传之地。故当急下。与阳明篇。腹满痛者急下之。无异也。以阴经之邪。而
能复归阳明之腑者。即灵枢邪气脏腑病形篇。所谓邪入于阴经。其脏气实。邪气入而不能容。故还之于腑。中
阳则溜于经。中阴则溜于腑之义也。然必验其舌。聚其脉。有不得不下之势。方以大承气下之耳。〔舒〕少阴
复转阳明之证。腹胀不大便者。然必兼见舌苔干燥。恶热饮冷。方为实证。
少阴病。脉沉者。急温之。宜四逆汤。
〔汪〕少阴病。本脉微细。但欲寐。今者轻取之微脉不见。重取之细脉几亡。伏匿而至于沉。此寒邪深中于
里。殆将入
脏。温之不容以不急也。少迟则恶寒身蜷。吐利躁烦。不得卧寐。手足逆冷。脉不至等。死证立至矣。四逆汤
之用。其可缓乎。〔成〕既吐且利。小便复利。而大汗出。下利清谷。内寒外热。脉微欲绝者。不云急温。此
少阴病脉沉。而云急温者。彼虽寒甚。然而证已形见于外。治之则有成法。此初头脉沉。未有形证。不知邪气
所之。将发何病。是急与四逆汤温之。
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。当温之。宜四逆汤。（心中温温。玉函。作心下 。千金。作心
中愠愠。当。玉函。成本。作急。非也。）
〔鉴〕饮食入口即吐。且心中 欲吐。复不能吐。恶心不已。非少阴寒虚吐也。乃胸中寒实吐也。故始
得之。脉弦迟。弦者饮也。迟者寒也。而手足寒者。乃胸中阳气。为寒饮所阻。不能通于四肢也。寒实在胸。
当因而越之。故不可下也。若膈上有寒饮。但干呕有声。而无物出。此为少阴寒虚之饮。非胸中寒实之饮也。
故不可吐。惟急温之。宜四逆汤。或理中汤。加丁香吴茱萸。亦可也。〔程〕温温字。与下文寒饮字对。欲吐
复不能吐。与下文干呕字对。干。空也。饮食入口即吐。业已吐讫矣。仍复温温欲吐。复不能吐。此非关后入
之饮食。吐之未尽。而胸中另有物。为之格拒也。胸中实者。寒物窒塞于胸中。则阳气不得宣越。所以脉弦迟。
而非微细者比。手足寒。而非四逆者比。但从吐治。一吐而阳气得通。若膈上有寒饮。干呕者。虚寒从下上。
而阻留其饮于胸中。究非胸中之病也。直从四逆汤。急温其下矣。〔柯〕当吐之。宜瓜蒂散。
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。（【原注】脉经云。灸厥阴可五十壮。）
〔钱〕阳气衰少则脉微。寒邪在经则脉涩。阴邪下走则利。上逆则呕也。肾脏之真阳衰微。不能升越而
为卫气。卫气不密。故汗出也。必数更衣。反少者。即里急后重之谓也。乃下焦阳虚。清阳不能升举。少阴寒
甚。阴气内迫。而下攻也。阳气陷入阴中。阴阳两相牵制。致阴邪欲下走而不得。故数更衣。阳气虽不得上行。
犹能提吸。而使之反少也。当温其上。前注皆谓灸顶上之百会穴。以升其阳。或曰。仲景无明文。未可强解。
以意测之。非必巅顶然后谓之上也。盖胃在肾之上。当以补暖升阳之药温其胃。且灸之。则清阳升。而浊阴降。
水谷分消。而下利自止矣。灸之者。灸少阴之脉穴。或更灸胃之三脘也。即前所谓当灸之。附子汤主之之法。
〔舒〕此证阳虚气坠。阴弱津衰。故数更衣。而出弓反少也。（更衣者。古人如厕。大便必更衣。出弓者。矢
去也。）曾医一妇人。腹中急痛。恶寒厥逆。呕而下利。脉见微涩。予以四逆汤投之。无效。其夫告曰。昨夜
依然。作泄无度。然多空坐。 胀异常。尤可奇者。前阴 出一物。大如柚子。想是尿脬。老妇尚可生乎。予
即商之仲远。仲远踌蹰。曰。是证不可温其下。以逼迫其阴。当用灸法温其上。以升其阳而病自愈。予然其言。
而根据其法。用生姜一片。贴头顶百会穴上。灸艾火三壮。其脬即收。仍服四逆汤。加 术。一剂而愈。
案温其上灸之。义未详。方氏云。上。谓顶百会是也。汪氏云。百会。治小儿脱肛久不瘥。此证亦灸之
者。升举其阳也。喻氏程氏柯氏金鉴。皆从方说为解。特志聪锡驹并云。温其上。助上焦之阳。与钱所援或曰
少阴病出现下利且排出未消化的食物。这是体内寒冷而体表发热。手足冰冷逆冷。脉搏微弱几乎摸不到。身体反而不觉得怕冷。病人的面色发红。或者伴有腹痛。或者干呕。或者咽喉疼痛。
或者腹泻停止但脉搏仍摸不到的情况。应当用通脉四逆汤主治。（成本本、玉函本记载“面色赤”写作“赤色”。在“止”字下，玉函本多一个“而”字。）
〔成无己注〕下利排出未消化食物、手足厥冷、脉搏微弱欲绝，这是里寒的表现。身体发热但不怕冷、面色发红，这是外热的表现。这是因为阴寒极盛于内，将阳气格拒于外，导致阴阳不相交通。给予通脉四逆汤，以发散阴寒、通达阳气。〔汪琥注〕武陵陈氏说：所谓里寒外热，是寒邪极盛于里，有阴无阳，那无根且失守的虚火，浮越于体外。给予通脉四逆汤，用以温补里气、驱散寒邪。〔澜按〕“格”，就是拒格的意思。也称为隔阳，即阴阳隔离。也称为戴阳，指阳气浮越于上，如同戴帽一般。真寒侵入体内，阴气没有不旺盛的。然而其严重程度不过是阳气越微弱，阴气越旺盛罢了。
通脉四逆汤方
甘草（二两，炙○全书本作三两。） 干姜（三两，体质强壮者可增至四两） 附子（大者一枚，生用，去皮，破成八片）
以上三味药，用水三升，煮取一升二合药液。去掉药渣。分两次温服。如果脉搏随即复出，说明病愈。面色发红的，加葱九茎。腹中痛的，去葱，加芍药二两。呕吐的，加生姜二两。咽喉痛的，去芍药，加桔梗一两。腹泻停止但脉搏不出来的，去桔梗，加人参二两。病情与方剂证候相符的，才服用此药。（千金翼方在“葱”下有“白”字。玉函本将“桔梗”作“二两”。全书本将“人参”作“一两”。成本本、玉函本没有“病皆与方相应者”这十个字。玉函本没有“去葱、去芍药、去桔梗”这八个字。千金翼方在“乃服”之间有“加减”二字。汪氏说：“去葱、去芍药、去桔梗”这几句是衍文。）
〔汪琥注〕武陵陈氏说：通脉四逆汤，就是四逆汤。它与四逆汤的不同之处在于：附子用大的，甘草和干姜的分量加重。但这有什么大的不同，却要加上“通脉”二字来区别呢？我说：四逆汤，治疗四肢厥逆。《伤寒论》说：阴阳之气，不能顺接，就称为厥。厥，是因为阳气虚弱。所以用四逆汤来增益真阳，使气机顺接，从而治愈厥逆。至于里寒严重的，不仅气机不顺接，血脉也不顺接，症状更加剧烈。所以使用四逆汤，并加大剂量。这样就能通达血脉了。药物是一样的，加重分量则疗效不同，命名也就有别。方剂的奥妙真是神奇啊。〔钱潢注〕加减法，推敲其词义浅陋，料想不是张仲景的本意。为什么呢？原文中，已经先列出了各种可能出现的证候，然后出方确立治法。那么一通脉四逆汤，其证候都可以涵盖。哪里还需要续用加减法呢？况且其立意庸俗恶劣，都出自鄙俗之辈之手。不敢直接删削，暂且保存以供识者鉴别。
汪氏说：据条辨，说“通脉”是指加葱白。这种说法很符合制方的意图。况且上文说“脉微欲绝……其人面色赤”，文意一贯到底，那么葱白应该加入方中，不应当附在方后。虽然通脉的力量不全在葱白，但实际上依赖葱白作为引经药，疗效才开始神妙。方中没有葱白，乃是传抄遗漏，不能称为通脉。钱氏说：用四逆汤，加倍增加干姜，其助阳的力量，或许胜过原方。既然增加了“通脉”二字，应当有所不同。恐怕是已经加了葱白，以通达阳气，有白通汤的含义，所以有此名称。怀疑是年代久远导致的差错，或者是编次时的失误，致使原方中脱落，也未可知。○案：这两家的说法，不知道究竟是否正确，暂且附存于此。
少阴病，出现四肢厥逆。病人有的咳嗽，有的心悸。有的小便不利。有的腹中痛。有的泄泻且肛门重坠感。应当用四逆散主治。
〔锡驹注〕凡是少阴病的四肢厥逆，都属于阳气虚寒。但也有阳气内郁，不能外达而导致四肢厥逆的，又适宜用四逆散主治。枳实，是胃家的宣通之品，用来宣通胃络。芍药，疏泄经络的血脉。甘草，调和中焦。柴胡，引导阳气向外运行。阳气通畅，四肢就温暖了。魏士千说：泄泻且肛门重坠感，就是里急后重。这就明显不是下利清谷了。〔鉴注〕四肢厥逆，虽然是阴盛不能外温，但也有阳气被阴邪郁遏，不能宣达，而导致四肢逆冷的。只是四肢厥逆而没有其他寒热证候，这是既没有可温的寒邪，也没有可下的热邪，只适宜疏畅阳气。所以用四逆散主治。〔钱潢注〕少阴病，就是前文所说的脉微细、只想睡觉的少阴病。成无己说：四逆，指四肢不温。这种说法似乎与厥冷有区别，但在《伤寒论》中，有时说厥，有时说厥逆，有时说四逆，有时说厥冷，有时说手足寒，有时说手足厥寒，都是指手足厥冷而言。案：成无己、周禹载、魏荔彤都将此条证候，解释为传经邪气的热厥。钱氏指出他们的错误，是正确的。
四逆散方
甘草（炙） 枳实（破开，水浸后炙干） 柴胡 芍药
以上四味药，各取十分，捣碎过筛。用米汤送服一方寸匕的药粉，每日三次。咳嗽的，加五味子、干姜各五分，同时也主治下利。心悸的，加桂枝五分。小便不利的，加茯苓五分。腹中痛的，加附子一枚，炮裂。泄泻且肛门重坠感的，先用水五升，煮薤白三升，煮取三升药液，去掉药渣。
将散药三方寸匕，纳入汤液中，煮取一升半，分两次温服。
〔注〕案：此方，虽然说是治疗少阴病，实际上是阳明、少阳的药物。〔柯琴注〕加味的药都用五分，而附子用一枚，薤白用三升，为什么多少差距如此之大？不能不怀疑是王叔和编集时的错误。〔钱潢注〕详细推究后面的加减法，凡是原文中列出“诸或有之证”的，都有相应的加减法。如小柴胡汤、小青龙汤、真武汤、通脉四逆汤、四逆散，都是这种情况。我私下推测，恐怕未必都出于张仲景之手。
程云来说：四逆散这一证候，寒热尚未详细确定，姑且根据小柴胡汤的例子，从事和解之法。然而黄芩已经被去掉，以此让人知道少阴中有火，确实是人身至宝，不可片刻丢失。
《医学入门》记载：祝仲宁号橘泉，是四明人。治疗周身百节疼痛，以及胸腹胀满，眼睛闭合，四肢厥冷，指甲青黑。医生用治疗伤寒的方法治疗，七天昏沉，无效。他说：这是怒火与痰相搏结所致。给予四逆散，加黄芩、黄连，泻三焦之火而痊愈。○案：此案原本出自程篁墩文集《橘泉翁传》，但没有写明四逆散的名字，说是给予柴胡、枳壳、芍药、黄芩、黄连，泻三焦之火，第二天神志清醒，很久才痊愈。
少阴病，下利六七天，咳嗽且呕吐、口渴、心烦不能入睡的，应当用猪苓汤主治。（千金翼方中，“下利”写作“不利”。）
〔锡驹注〕少阴病，下利六七天，是阴尽出阳的时期。〔鉴注〕凡是少阴病下利清谷，咳嗽呕吐且不渴，属于寒饮。现在少阴病，六七天，下利粘秽，咳嗽且呕吐、口渴，烦躁不能入睡，这是少阴热饮致病。饮邪与热邪相搏结，向上攻冲则咳嗽，向中攻冲则呕吐，向下攻冲则下利。热邪消耗津液，所以口渴。热邪扰乱心神，所以烦躁不能入睡。适宜用猪苓汤，利水滋燥。饮热之证，都可以痊愈。〔汪琥注〕此方，本是治疗阳明病，热渴引饮、小便不利的药剂。这条病证，也是借用它。为什么呢？因为阳明病，发热口渴想喝水，小便不利，是水热互结而不行。如今少阴病，下利，咳嗽且呕吐、口渴，心烦不能入睡，也是水热搏结而不行。病名虽然不同，但病源相同。所以张仲景同样用猪苓汤主治。不过具有清热利水，兼润燥滋阴的意义。
案：此条证候，对比黄连阿胶汤证，是有咳嗽、呕吐、口渴及小便不利，以及大便下利等证候，所以不同。又案：前文说：少阴病想吐吐不出，心烦只想睡觉，五六天自利且口渴的，属于少阴病。因为虚，所以引水自救。如果小便颜色白的，少阴病的形证就具备了。小便白，是因为下焦虚寒，不能制约水液，所以令其色白。可知此条下利、呕吐、口渴、心烦同属一证，但有不得眠和小便不白的差异，这是寒热分别的关键点。
少阴病，得病二三天，口燥咽干的，应当紧急攻下。适宜用大承气汤。
〔钱潢注〕此条得病才二三天，就出现口燥咽干，而成急下之证的，这是少阴病的变证，不是少阴病的常证。然而仅仅口燥咽干，未必就是急下之证。也必须有胃家实的证候，实热的脉象。其见证虽然表现为少阴，但有邪气复归阳明，即所谓的“阳明中土，万物所归，无所复传”，成为胃家实的证据，才可以急下，而用大承气汤。之所以要急下，是担心进入阴分的证候，阳气逐渐亡失，胃腑败损，必然导致四肢厥冷、躁扰、呃逆，变证蜂起，那就来不及了。所以不得不急。〔舒驰远注〕少阴挟火的证候，又转属阳明，而在口燥咽干之外，必须更有阳明胃实的诸证兼见，否则大承气汤不可用。
少阴病，自利清水，颜色纯青，心下必定疼痛，口干燥的，可以攻下。适宜用大承气汤。（【原注】另一法，用大柴胡汤。○“自利”，玉函本、脉经本作“下利”。“可”字，成本本、玉函本作“急”，是对的。“宜”下，脉经本有“大柴胡汤”四字。“宜”作“属”。大承气汤下，有“证”字。）
〔钱潢注〕这也是少阴病的变例。自利，是寒邪在里。自利清水，就是所谓的清水完谷。这里并没有完谷，只是利清水，而且颜色纯青。清水固然属于寒邪，而青色又是寒色。所以属于少阴。成无己及方注，都认为是肝色，这是错误的。如果证候仅止于此，无疑是四逆汤证。没想到胃中的清水，虽然自利排除了谷食的渣滓，但热邪尚留在胃中。
所以心下按压必定疼痛，且口中干燥，就知道邪气虽入少阴，而阳明实热仍在。不仅仅是少阴证。热邪炽盛，逼迫胁迫胃中的津液下奔，下焦寒甚，所以都是清水，且颜色纯青。阳邪暴迫，向上则胃中之津液，向下则肾家之真阴，都可以立即耗尽。所以应当急下。
《名医类案》记载：孙兆治疗东华门窦太郎患伤寒。经过十多天，口燥舌干而渴，心中疼，自利清水。众医生都守着，只是调理而已。汗法和下法都不敢用。窦氏亲友互相说：伤寒邪气，害人性命很快，怎么能因为非正常的疾病，投给不明理的医生呢？召请孙兆来。孙兆说：明天就不能下了，今天正当下。于是投用小承气汤。大便通利后得以睡眠，第二天平复。众人都说：此证为何下之而愈？孙兆说：读书不精，徒有书而已。口燥舌干而渴，难道不是少阴证吗？少阴证，固不可下。岂不闻少阴有一证，自利清水，心下痛，下之而愈。仲景的书，明确有此说法。众人都钦佩信服。
少阴病，六七天，腹胀不大便的，应当紧急攻下。适宜用大承气汤。（“胀”字，玉函本、脉经本、千金翼方，都作“满”。）
〔钱潢注〕少阴病，到了六七天，邪气已深入。然而少阴病多自利，反而腹胀不大便的，这是少阴的邪气，又回归阳明。所谓“阳明中土，万物所归，无所复传之地”。所以应当急下，与阳明篇中“腹满痛者急下之”无异。以阴经的邪气，而能复归阳明之腑的，即《灵枢·邪气脏腑病形篇》所说的“邪入于阴经，其脏气实，邪气入而不能容，故还之于腑。中阳则溜于经，中阴则溜于腑”的道理。然而必须查验其舌苔，诊察其脉象，有不得不下的形势，才用大承气汤攻下。〔舒驰远注〕少阴病又转属阳明的证候，腹胀不大便的。然而必须兼见舌苔干燥，恶热喜冷饮，才是实证。
少阴病，脉沉的，应当紧急温补。适宜用四逆汤。
〔汪琥注〕少阴病，本脉微细，只想睡觉。如今轻取之微脉不见，重取之细脉几近消失，伏匿而至于沉。这是寒邪深中于里，快要入脏了。温补不容许不紧急。稍迟一点，就会出现恶寒身蜷、吐利躁烦、不得卧寐、手足逆冷、脉不至等死证，立刻到来。四逆汤的使用，怎么可以迟缓呢？〔成无己注〕既呕吐又下利，小便又通利，且大汗出，下利清谷，内寒外热，脉微欲绝的，不说急温。此条少阴病脉沉，而说急温的，彼处虽然寒甚，然而证候已经显现于外，治疗则有定法。此处初头脉沉，还没有形证，不知道邪气所在，将要发作什么病。是紧急给予四逆汤温补。
少阴病，饮食入口就吐，心中温温欲吐，却又吐不出来。刚开始时手足寒冷，脉弦迟的，这是胸中实邪，不可攻下。应当用吐法。如果是膈上有寒饮，干呕的，不可用吐法。应当温补。适宜用四逆汤。（“心中温温”，玉函本作“心下愠愠”，千金翼本作“心中愠愠”。“当”字，玉函本、成本本作“急”，是不对的。）
〔鉴注〕饮食入口即吐，且心中温温欲吐，却又吐不出来，恶心不已，这不是少阴寒虚之吐。而是胸中寒实之吐。所以刚开始时，脉弦迟。弦主饮，迟主寒。而手足寒冷的，是胸中阳气，被寒饮所阻，不能通达于四肢。寒实在胸中，应当因势利导，使其从上而出。所以不可攻下。如果是膈上有寒饮，只有干呕有声，而无物吐出，这是少阴寒虚之饮，不是胸中寒实之饮。所以不可吐。只应急温之，适宜用四逆汤。或者理中汤，加丁香、吴茱萸，也可以。〔程知注〕“温温”字，与下文“寒饮”字相对。“欲吐复不能吐”，与下文“干呕”字相对。“干”，空也。饮食入口即吐，业已吐完了。仍然温温欲吐，却又吐不出来。这不是关涉后进的饮食，吐之未尽，而是胸中另有物体，为之格拒。胸中实者，寒物窒塞于胸中，则阳气不得宣发。所以脉弦迟，而不是微细那种。手足寒，而不是四逆那种。只从吐法治，一吐而阳气得通。若膈上有寒饮，干呕的，虚寒从下往上，而阻留其饮于胸中。终究不是胸中之病。直从四逆汤，急温其下。〔柯琴注〕当吐之，适宜用瓜蒂散。
少阴病，下利脉微涩，呕吐且汗出，必定频繁上厕所，反而量少。
应当温其上，并用灸法。（【原注】脉经说：灸厥阴穴，可五十壮。）
〔钱潢注〕阳气衰少则脉微。寒邪在经脉则脉涩。阴邪下走则下利，上逆则呕吐。肾脏之真阳衰微，不能升越而为卫气。卫气不固密，所以汗出。必定频繁上厕所，反而量少，就是里急后重的意思。这是下焦阳虚，清阳不能升举。少阴寒甚，阴气内迫，而下攻。阳气陷入阴中，阴阳两相牵制，致使阴邪欲下走而不得。所以频繁上厕所。阳气虽然不得上行，犹能提吸，而使排便反少。应当温其上。前注都认为灸头顶的百会穴，以升其阳。或者说：张仲景没有明文，不可强行解释。凭心意推测，不一定非要巅顶才叫“上”。大概胃在肾之上，应当用补暖升阳的药温其胃，并且灸之，则清阳升，而浊阴降，水谷分消，而下利自然停止。灸之者，灸少阴之脉穴，或者再灸胃之三脘穴。即前文所说的“当灸之”，附子汤主之的方法。〔舒驰远注〕此证阳虚气坠，阴弱津衰，所以频繁上厕所，而出矢反而少。（更衣者，古人如厕，大便必更衣。出弓者，矢去也。）我曾医治一位妇人，腹中急痛，恶寒厥逆，呕吐而下利。脉见微涩。我给予四逆汤投服，无效。她的丈夫告诉我说：昨夜依然，泄泻无度，然而多空坐，腹胀异常。尤其奇怪的是，前阴脱出一物，大如柚子，想是尿脬。老妇还能活吗？我随即与仲远商量。仲远犹豫说：此证不可温其下，以免逼迫其阴。应当用灸法温其上，以升其阳而病自愈。我认为他的话有理，而根据其法，用生姜一片，贴于头顶百会穴上，灸艾火三壮。其脬即收回。仍服四逆汤，加白术，一剂而愈。
案：“温其上灸之”，含义不详。方有执说：上，谓顶百会是也。汪琥说：百会，治小儿脱肛久不瘥。此证亦灸之者，升举其阳也。喻嘉言、程知、柯琴、金鉴，都依从方有执的说法解释。特志聪、锡驹并说：温其上，助上焦之阳。与钱氏所援或曰...
Shaoyin disease presenting with diarrhea of undigested food. This indicates interior cold and exterior heat. The hands and feet are cold and inverted (cold extremities). The pulse is faint and nearly imperceptible. The body actually does not feel aversion to cold. The person's facial color is red. There may also be abdominal pain, dry retching, or sore throat.
If the diarrhea stops but the pulse remains absent, Tongmai Sini Decoction (Pulse-Rescuing Four-Inverted Decoction) should be primarily administered. (Cheng Ben edition and Yuhan edition record "facial color red" as "red color". Under the character for "stop", the Yuhan edition has an additional "er" [and] character.)
[Cheng Wuji's Commentary] Diarrhea of undigested food, cold extremities, and a faint pulse nearly imperceptible indicate interior cold. Body heat without aversion to cold and a red facial color indicate exterior heat. This occurs when Yin cold is excessive internally, repelling Yang to the exterior, causing a lack of communication between Yin and Yang. Administer Tongmai Sini Decoction to disperse Yin cold and unblock Yang. [Wang Hu's Commentary] Chen Shi of Wuling stated: What is meant by interior cold and exterior heat is that cold is extreme in the interior, leaving Yin without Yang, and the rootless, uncontrolled fire floats outward. Administer Tongmai Sini Decoction to warm the interior and dispel cold. [Lan's Note] "Ge" means rejection or blockage. It is also called Ge Yang (separated Yang), meaning the isolation of Yin and Yang. It is also called Dai Yang (floating Yang), referring to Yang floating upward as if wearing a hat. When true cold enters the interior, Yin qi inevitably becomes abundant. However, its severity lies only in Yang becoming more deficient and Yin becoming more abundant.
Formula for Tongmai Sini Decoction
Gancao (Licorice Root, two liang, roasted ○ Quan Shu edition makes it three liang.) Ganjiang (Dried Ginger, three liang; four liang for strong individuals.) Fuzi (Aconite Root, one large piece, raw, peeled, broken into eight pieces.)
These three ingredients are boiled in three sheng of water to obtain one sheng and two he of decoction. Strain the dregs. Divide into two doses and take warm. If the pulse reappears, the patient will recover. For those with a red facial color, add nine stalks of Congbai (Scallion White). For abdominal pain, remove Congbai and add Shaoyao (Peony Root), two liang. For vomiting, add Shengjiang (Fresh Ginger), two liang. For sore throat, remove Shaoyao and add Jiegeng (Platycodon Root), one liang. For diarrhea stopping but pulse remaining absent, remove Jiegeng and add Renshen (Ginseng Root), two liang. Only administer this formula when the symptoms correspond to the prescription. (Qianjin Yi Fang has the character "Bai" [white] after "Cong". Yuhan edition writes "Jiegeng" as "two liang". Quan Shu edition writes "Renshen" as "one liang". Cheng Ben edition and Yuhan edition lack the ten characters "bing jie yu fang xiang ying zhe". Yuhan edition lacks the eight characters "qu cong, qu shaoyao, qu jiegeng". Qianjin Yi Fang has the characters "jia jian" [modifications] between "nai fu". Wang Shi states that "remove Cong, remove Shaoyao, remove Jiegeng" are interpolations.)
[Wang Hu's Commentary] Chen Shi of Wuling said: Tongmai Sini Decoction is essentially Sini Decoction. Its difference from Sini Decoction lies in using a large Fuzi and increasing the dosage of Gancao and Ganjiang. But what is the significant difference that warrants the addition of "Tongmai" [unblocking pulse] to distinguish it? I say: Sini Decoction treats limb inversion (cold extremities). The Treatise states: When Qi of Yin and Yang do not connect smoothly, it is called Jue (inversion/cold extremities). Jue is due to deficiency of Yang Qi. Thus, Sini Decoction supplements True Yang to ensure smooth connection of Qi, curing inversion. In cases of severe interior cold, not only is Qi connection disrupted, but also pulse connection, making symptoms more severe. Therefore, Sini Decoction is used with increased dosage to unblock the pulse. The herbs are the same; increasing the dosage changes the treatment effect and thus the name. The efficacy of formulas is truly miraculous. [Qian Huang's Commentary] The modification methods seem shallow and vulgar in their wording, likely not Zhang Zhongjing's original intent. Why? The original text lists various possible symptoms first, then presents the formula and treatment. Thus, one Tongmai Sini Decoction covers all these symptoms. Why would supplementary modifications be needed? Moreover, the intention seems vulgar and baseless, originating from petty scholars. I dare not delete them entirely but preserve them for experts to judge.
Wang Shi says: According to Tiao Bian, "Tongmai" refers to adding Congbai. This aligns well with the formula's intent. Furthermore, the preceding text mentions "pulse faint and nearly imperceptible... facial color red," flowing continuously, so Congbai should be included in the formula, not appended afterward. Although the power to unblock the pulse does not solely reside in Congbai, it relies on Congbai as a guiding herb for divine efficacy. The absence of Congbai in the formula is a transcription error; without it, it cannot be named "Tongmai." Qian Shi says: Using Sini Decoction with doubled Ganjiang might enhance Yang-assisting power. Since "Tongmai" was added, there must be a difference. Perhaps Congbai was already added to unblock Yang Qi, implying the meaning of Baitong Tang, hence the name. It is suspected to be an ancient error or editorial omission causing the loss of the original formula. ○ Case: Whether these two scholars' views are correct is unknown; they are preserved here tentatively.
In Shaoyin disease, presenting with cold extremities. The patient may have cough, palpitations, difficulty urinating, abdominal pain, or diarrhea with a sensation of heaviness/tenesmus at the anus. Sini San (Four-Inverted Powder) should be primarily administered.
[Xi Ju's Commentary] All cases of cold extremities in Shaoyin disease belong to deficiency-cold of Yang Qi. However, there are cases where Yang Qi is internally constrained and cannot reach the exterior, causing cold extremities; these are suitable for Sini San. Zhishi (Immature Bitter Orange) is a dispersing agent for the Stomach, used to unblock Stomach collaterals. Shaoyao (Peony Root) drains blood vessels in meridians. Gancao (Licorice Root) harmonizes the Middle Jiao. Chaihu (Bupleurum Root) guides Yang Qi outward. When Yang Qi flows freely, limbs become warm. Wei Shiqian said: Diarrhea with anal heaviness is tenesmus. This is clearly distinct from diarrhea of undigested food. [Jian's Commentary] Cold extremities, although caused by Yin excess failing to warm the exterior, can also result from Yang being depressed by Yin, unable to disseminate, leading to cold limbs. However, with only cold extremities and no other cold-heat signs, there is neither cold to warm nor heat to purge. It is only appropriate to soothe and unblock Yang. Hence, Sini San is used. [Qian Huang's Commentary] Shaoyin disease refers to the Shaoyin disease mentioned earlier with faint-thin pulse and desire to sleep. Cheng Wuji said: "Sini" means limbs are not warm. This seems different from Jueleng (cold extremities), but in the Treatise, terms like Jue, Jueni, Sini, Jueleng, Shouzu Han, and Shouzu Juehan all refer to cold extremities. Case: Cheng Wuji, Zhou Yuzai, and Wei Liting interpreted this syndrome as heat-Jue from transmitted pathogenic factors. Qian Shi correctly pointed out their error.
Formula for Sini San
Gancao (Licorice Root, roasted) Zhishi (Immature Bitter Orange, broken, soaked in water, roasted dry) Chaihu (Bupleurum Root) Shaoyao (Peony Root)
These four ingredients, each taken in parts of ten, are crushed and sifted. Mix with rice water and administer one Fang Cun Bi (square-inch spoonful) of powder orally, three times daily. For cough, add Wuweizi (Schisandra Berry) and Ganjiang (Dried Ginger), each five fen; this also treats diarrhea. For palpitations, add Guizhi (Cinnamon Twig), five fen. For difficulty urinating, add Fuling (Poria), five fen. For abdominal pain, add Fuzi (Aconite Root), one piece, roasted until cracked. For diarrhea with tenesmus, first boil Xiebai (Macrostemon Bulb) in five sheng of water with three sheng of Xiebai, reduce to three sheng, strain.
Add three Fang Cun Bi of the powder to the decoction, boil to obtain one sheng and half, divide into two warm doses.
[Note] Case: Although this formula is said to treat Shaoyin disease, it actually contains herbs for Yangming and Shaoyang. [Ke Qin's Commentary] Added herbs are all five fen, while Fuzi is one piece and Xiebai is three sheng. Why such disparity? One cannot help suspecting an error in Wang Shuhe's compilation. [Qian Huang's Commentary] Examining the subsequent modification methods, every time the original text lists "various possible symptoms," corresponding modifications follow. Such as Xiaochaihu Tang, Xiao Qinglong Tang, Zhenwu Tang, Tongmai Sini Tang, and Sini San are all examples. I speculate rationally that these may not all originate from Zhang Zhongjing.
Cheng Yunlai said: For the Sini San syndrome, cold and heat are not yet clearly defined. Tentatively following the example of Xiaochaihu Tang, employ harmonizing methods. However, Huangqin (Scutellaria Root) has been removed, indicating that Fire in Shaoyin is indeed the supreme treasure of the human body and cannot be lost for a moment.
*Medical Beginner* records: Zhu Zhongning, courtesy name Juquan, from Siming, treated a case of pain in all joints of the body, chest and abdominal distension, closed eyes, cold extremities, and cyanotic nails. Physicians treated it as Taiyang disease. After seven days of lethargy with no effect, he said: This resulted from anger-fire combusting with phlegm. He administered Sini San plus Huangqin and Huanglian to drain Fire of the Three Jiao, resulting in recovery. ○ Case: This case originally appeared in Cheng Huangkun's *Collected Works* in the biography of Juquan Weng, but did not name Sini San, stating instead the administration of Chaihu, Zhike, Shaoyao, Huangqin, and Huanglian to drain Three Jiao Fire, with consciousness returning the next day and full recovery later.
In Shaoyin disease, with diarrhea for six or seven days, accompanied by cough, vomiting, thirst, irritability, and inability to sleep, Zhuling Tang (Polyporus Decoction) should be primarily administered. (Qianjin Yi Fang writes "xia li" [diarrhea] as "bu li" [difficulty urinating].)
[Xi Ju's Commentary] Shaoyin disease with diarrhea for six or seven days marks the period when Yin ends and Yang emerges. [Jian's Commentary] Generally, Shaoyin diarrhea of undigested food with cough, vomiting, and no thirst belongs to cold-fluid retention. Now, in Shaoyin disease, after six or seven days, sticky/foul diarrhea with cough, vomiting, thirst, irritability, and insomnia indicates Shaoyin heat-fluid pathology. Fluid and heat combusting, attacking upward causes cough, attacking middle causes vomiting, attacking downward causes diarrhea. Heat consumes fluids, causing thirst. Heat disturbs the Heart, causing irritability and insomnia. Zhuling Tang is appropriate to promote urination and moisten dryness. Both fluid and heat syndromes can be cured. [Wang Hu's Commentary] This formula is originally for Yangming disease with heat-thirst, desire to drink, and difficulty urinating. This clause borrows it. Why? Yangming disease with fever, thirst, desire to drink, and difficulty urinating involves water-heat binding and stagnation. Here, Shaoyin disease with diarrhea, cough, vomiting, thirst, and insomnia also involves water-heat binding and stagnation. Although disease names differ, the source is the same. Thus, Zhang Zhongjing uses Zhuling Tang for both. It embodies clearing heat, promoting urination, and simultaneously moistening dryness and nourishing Yin.
Case: Comparing this clause with Huanglian Ejiao Tang syndrome, the differences lie in the presence of cough, vomiting, thirst, difficulty urinating, and diarrhea. Also, the previous clause states: Shaoyin disease with desire to vomit but cannot, irritability, and desire to sleep, self-diarrhea with thirst after five or six days, belongs to Shaoyin. Due to deficiency, it draws water to save itself. If urine is white, Shaoyin syndrome characteristics are complete. White urine indicates lower-jiao deficiency-cold failing to control water. Knowing this, although diarrhea, vomiting, thirst, and irritability are common to both, the differences in insomnia and urine color distinguish cold from heat.
In Shaoyin disease, developing mouth dryness and throat dryness within two or three days of onset, urgent purgation is required. Dachengqi Tang (Major Order the Qi Decoction) is appropriate.
[Qian Huang's Commentary] Developing mouth and throat dryness into an urgent purgation indication within two or three days is a variation of Shaoyin, not the norm. Mere mouth and throat dryness does not necessarily warrant urgent purgation. There must also be evidence of Stomach excess and excess-heat pulse. Although the presentation appears as Shaoyin, if pathogenic factors return to Yangming—described as "Yangming Central Earth, the destination of all things, where no further transmission occurs"—becoming evidence of Stomach excess, then urgent purgation with Dachengqi Tang is justified. Urgent purgation is necessary because entering Yin stages risks gradual Yang depletion and Stomach failure, leading to cold extremities, restlessness, hiccups, and myriad complications, which would be untreatable. Hence urgency. [Shu Chiyuan's Commentary] Shaoyin syndromes with Fire transforming to Yangming must present with Yangming Stomach excess symptoms alongside mouth/throat dryness; otherwise, Dachengqi Tang is contraindicated.
In Shaoyin disease, spontaneous diarrhea of clear water, purely green in color, with必 (must) pain in the epigastrium and dry mouth/throat, purgation is permissible. Dachengqi Tang is appropriate. ([Original Note] Another method uses Daichaihu Tang. ○ "Zili" [spontaneous diarrhea], Yuhan and Maijing editions write "xiali" [diarrhea]. "Ke" [can/permissible], Cheng Ben and Yuhan editions write "ji" [urgent], which is correct. Under "Yi" [appropriate], Maijing has "Daichaihu Tang". "Yi" is written as "Shu". After Dachengqi Tang, there is the character "Zheng" [syndrome].)
[Qian Huang's Commentary] This is also a variation of Shaoyin. Spontaneous diarrhea indicates interior cold. Diarrhea of clear water, described as clear water with undigested food, here lacks undigested food, consisting only of clear water, purely green. Clear water suggests cold, and green is a cold color, thus belonging to Shaoyin. Cheng Wuji and Fang Zhu incorrectly attribute green to Liver color. If symptoms were limited to this, it would undoubtedly be a Sini Tang syndrome. Unexpectedly, gastric clear water, though expelling food residue via diarrhea, leaves heat pathogens in the Stomach.
Thus, pressing the epigastrium causes必 (must) pain, and dry mouth indicates that although pathogens entered Shaoyin, Yangming excess-heat remains. It is not merely a Shaoyin syndrome. Excessive heat forces Stomach fluids downward, while lower-jiao cold causes pure clear water, green in color. Violent Yang pathogens threaten upper Stomach fluids and lower Kidney True Yin, which could be exhausted instantly. Hence, urgent purgation is required.
*Classified Cases of Famous Physicians* records: Sun Zhao treated Dou Ta-lang of Donghua Gate suffering from Taiyang disease for over ten days, with mouth/throat dryness, thirst, heart pain, and spontaneous clear water diarrhea. Physicians merely observed and regulated, fearing sweating or purging. Relatives questioned hiring an unclear physician for such a dangerous illness. Summoning Sun, he said: Tomorrow it will be too late to purge; today is the right time. He administered Xiao Chengqi Tang. After bowel movement, the patient slept and recovered fully the next day. Everyone asked why purging worked. Sun said: Superficial reading of books. Mouth/throat dryness and thirst—isn't this a Shaoyin syndrome? Shaoyin usually forbids purging. Did you not hear of the Shaoyin syndrome of spontaneous clear water diarrhea and heart pain, cured by purging? Zhang Zhongjing's book explicitly states this. All were convinced.
In Shaoyin disease, after six or seven days, abdominal fullness and constipation require urgent purgation. Dachengqi Tang is appropriate. ("Zhang" [swollen/full], Yuhan, Maijing, Qianjin, and Yi Fang editions all write "Man" [full].)
[Qian Huang's Commentary] By six or seven days in Shaoyin disease, pathogens have penetrated deeply. However, Shaoyin typically features diarrhea; conversely, abdominal fullness and constipation indicate Shaoyin pathogens returning to Yangming. This is the "Yangming Central Earth, destination of all things, no further transmission" location. Urgent purgation is required, identical to Yangming chapter's "abdominal fullness/pain requires urgent purgation." For Yin channel pathogens returning to Yangming Fu organs, this aligns with *Ling Shu: Pathogenic Factors, Zang-Fu, and Meridian Manifestations*: "When pathogens enter Yin channels, if Zang Qi is solid, pathogens cannot reside and return to Fu organs. Entering Yang flows to meridians; entering Yin flows to Fu organs." However, tongue coating and pulse must confirm an unavoidable need for purgation before using Dachengqi Tang. [Shu Chiyuan's Commentary] Shaoyin transforming to Yangming, with abdominal fullness and constipation, must also present with dry tongue coating, aversion to heat, and preference for cold drinks to confirm excess syndrome.
In Shaoyin disease, with a sinking pulse, urgent warming is required. Sini Tang (Four-Inverted Decoction) is appropriate.
[Wang Hu's Commentary] Shaoyin disease typically has faint-thin pulse and desire to sleep. Now, light pressure reveals no faint pulse, and heavy pressure shows thin pulse nearly vanished, sinking deep. This indicates cold pathogens deeply entrenched in the interior, approaching the Zang organs. Warming cannot be delayed. Delay leads to aversion to cold, curled posture, vomiting/diarrhea, restlessness, insomnia, cold extremities, and absent pulse—imminent death. How can Sini Tang use be delayed? [Cheng Wuji's Commentary] Cases with vomiting, diarrhea, free urination, profuse sweating, undigested food diarrhea, interior cold/exterior heat, and faint/nearly absent pulse are not described as requiring urgent warming. This clause specifies urgent warming for sinking pulse because, although cold is severe, symptoms are manifest externally with established treatment protocols. Here, initially only a sinking pulse exists without other manifestations; the pathogen's location and future progression are unknown. Thus, urgently administer Sini Tang to warm.
In Shaoyin disease, vomiting immediately upon swallowing food, feeling nauseous in the heart/chest but unable to vomit. Initially, cold hands and feet, with wiry-slow pulse indicate excess in the Chest. Purging is contraindicated; emesis is indicated. If there is cold-fluid above the diaphragm causing dry retching, emesis is contraindicated; warming is indicated. Sini Tang is appropriate. ("Xinzhong Wenwen" [warmth in heart], Yuhan writes "Xinxia Yunyun" [warmth below heart], Qianjin writes "Xinzhong Yinyin" [anger/warmth in heart]. "Dang" [should], Yuhan and Cheng Ben write "Ji" [urgent], which is incorrect.)
[Jian's Commentary] Vomiting immediately upon eating, nausea, inability to vomit, persistent恶心 (nausea) is not Shaoyin deficiency-cold vomiting, but Chest cold-excess vomiting. Hence, initial wiry-slow pulse: wiry indicates fluid, slow indicates cold. Cold hands result from Chest Yang blocked by cold-fluid, unable to reach limbs. Cold-excess in Chest requires inducing vomiting (emesis). Thus, purging is contraindicated. If cold-fluid above diaphragm causes only dry retching without expulsion, this is Shaoyin deficiency-cold fluid, not Chest cold-excess. Emesis is contraindicated; urgent warming with Sini Tang is indicated. Or Lizhong Tang plus Dingxiang (Clove) and Wuzhuyu (Evodia Fruit) is also acceptable. [Cheng Zhi's Commentary] "Wenwen" contrasts with "Han Yin" [cold-fluid] below. "Yu tu fu bu neng tu" [desire to vomit but cannot] contrasts with "gan ou" [dry retching] below. "Gan" [dry] means empty. Immediate vomiting empties the stomach. Persistent nausea despite emptying indicates obstruction in the Chest. Cold-excess in Chest blocks Yang dissemination, causing wiry-slow pulse (not faint-thin) and cold hands (not full inversion). Treatment via emesis restores Yang flow. If cold-fluid above diaphragm causes dry retching, deficiency-cold rises from below, trapping fluid in Chest. This is not a Chest disease but lower-jiao deficiency. Urgently warm the lower with Sini Tang. [Ke Qin's Commentary] For emesis, Guodi San (Melon Sepal Powder) is appropriate.
In Shaoyin disease, diarrhea with faint-choppy pulse, vomiting, and sweating, frequent trips to toilet but small volume.
Warm the upper part and apply moxibustion. ([Original Note] Maijing says: Moxa Jueyin point, fifty moxa cones.)
[Qian Huang's Commentary] Yang deficiency causes faint pulse. Cold in meridians causes choppy pulse. Yin pathogens moving downward cause diarrhea; moving upward cause vomiting. Kidney True Yang deficiency fails to ascend as Wei Qi. Unsecured Wei Qi causes sweating. Frequent trips with small volume is tenesmus. Lower-jiao Yang deficiency fails to raise Clear Yang. Severe Shaoyin cold forces Yin downward. Yang sinks into Yin, Yin-Yang constrain each other, preventing Yin from descending fully. Hence frequent trips. Although Yang cannot ascend, it still attempts to lift, resulting in small volume. Warm the upper part. Previous commentators suggest moxa at Baihui (GV20) on the vertex to raise Yang. Others argue Zhang Zhongjing provided no explicit text, so interpretation is speculative. "Upper" may not strictly mean vertex. Stomach is above Kidney; warming Stomach with tonifying-warming herbs and moxa raises Clear Yang, descends Turbid Yin, separates water/grain, and stops diarrhea. Moxa targets Shaoyin meridian points or Stomach Sanwan points, similar to the "moxa" instruction in Fuzi Tang. [Shu Chiyuan's Commentary] This syndrome features Yang deficiency with Qi sinking and Yin/fluid deficiency, causing frequent trips with little output. ("Gengyi" [changing clothes] refers to toileting; "Chu Gong" [bow departing] refers to defecation.) I once treated a woman with acute abdominal pain, aversion to cold, cold extremities, vomiting, and diarrhea. Pulse was faint-choppy. I administered Sini Tang with no effect. Her husband reported continued excessive diarrhea with straining and abnormal bloating. Notably, a mass the size of a pomelo protruded from the vagina, likely the bladder. Can an elderly woman survive? I consulted Zhongyuan. He hesitated, saying: Do not warm the lower, forcing Yin. Use moxa on the upper to raise Yang. I agreed, applied ginger slice to Baihui (GV20), moxa three cones. The bladder retracted. Continued Sini Tang plus Baizhu (Atractylodes Macrocephala Rhizome); one dose cured her.
Case: Meaning of "warm upper and moxa" is unclear. Fang Youzhi said: Upper refers to Baihui on vertex. Wang Hu said: Baihui treats pediatric rectal prolapse; here it raises Yang. Yu Jiayuan, Cheng Zhi, Ke Qin, and Jinjian follow Fang. Te Zhi Cong and Xi Ju said: Warm upper assists Upper Jiao Yang. With Qian's cited "or says"...