当归（三两） 桂枝（三两） 芍药（三两） 细辛（三两） 大枣（二十五个） 甘草（二两炙） 通草（二两）
上七味。以水八升。煮取三升。去滓。温服一升。日三服。
成注引内经曰。脉者血之府也。诸血者皆属心。通脉者。必先补心益血。苦先入心。当归之苦以助心血。心苦
缓。急食酸以收之。芍药之酸以收心气。肝苦急。急食甘以缓之。大枣甘草通草之甘。以缓阴血。
琥按足厥阴之脏。本属肝。肝者藏血之府。成注不言当归入肝。反言补心。殊非紧要语。
内台方议曰。阳气外虚。则不能温于四末。阴血内虚。则不能营于脉。故手足厥寒。脉细欲绝也。方用当归为
君以补血。芍药为臣。辅之而养营气。桂枝细辛之辛。以散寒温气为佐。以大枣甘草之甘。为使而益其中。补之不
足。复以通草之淡。而通行其脉道与厥也。
若用四逆。则汤中附子干姜。过于燥烈。大非血虚所宜。故后条辩亦云。少阴所主者气。厥则为寒。当纳气归
肾。厥阴所主者血。厥则为虚。当温经复营。此大法也。○愚按厥则为虚。虚字当兼寒燥看。
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。（此条当是寒中少阴。反发热不去。
遂入厥阴而见厥利之证。汗出热去者。伤寒热病皆然。今者中寒为真寒病。大汗出。热不去。此真阳欲脱而热。非
邪郁于表而发热也。兼之内拘急。此寒气深入于里。寒主收引。当是腹以内拘急。已具恶寒之状。四肢者。诸阳之
本。汗不出而四肢疼。则为邪实。大汗出而四肢疼。则为阳虚。疼者。即拘急而疼。总属寒邪入里之状。又下利厥
逆者。乃寒邪深入厥阴。前热已去而但恶寒。此恶寒非表寒。乃里寒而直达于四肢手足之末也。以寒从少阴经来。
故与四逆汤以复阳散寒。○或问大汗出热不去。既系阳气越出躯壳之外而欲脱。加之下利。即为死证。此与最前条
有阴无阳。无以异也。何以又用四逆汤。为可治之证。余答云。大汗出热不去。乃大汗出后仍热。非汗出不止也。
内拘急四肢疼。又厥利恶寒者。方其厥利恶寒之时。其时之热。必重敛于内而伏匿矣。此真阳之根犹未脱。但群阴
用事而孤阳伏匿。故用四逆汤以复阳散寒也。）
大汗若大下利而厥冷者。四逆汤主之。（此条病。亦系少阴中寒。兼中厥阴者。但比前条之病略轻。然阳亡于
表。阴甚于里。非四逆汤。无以回阳而胜阴也。）
下利。手足厥冷。无脉者。灸之不温。若脉不还。反微喘者死。（此条乃阴胜阳绝之证。下利手足厥冷。此厥
阴中寒之常。至无脉。则真阳之气脱矣。其时汤药已无及。惟赖灸以补接之。若灸之。手足不温。脉不还。反加微
喘。为上下俱脱。不死何待。武陵陈氏云。阳热气绝之证。其喘必大。阴寒气绝之证。其喘必微。故条辩云息短而
声不续也。又喘非灸所致。阳气不因灸复。则绝证以次第而至。尚论篇云。孤阳随火气上逆而脱。误矣。○按此条
论。仲景不言当灸何穴。补亡论常器之云。当灸关元气海二穴。穴注已见前。）
下利清谷。不可攻表。汗出必胀满。（此言下利禁发汗也。厥阴下利为里寒。清谷者。谷色不变而完出。乃胃
中无火。不能传化水谷也。此际惟以温胃为治利之本。不可误攻其表而使汗出。汗本胃中水谷之气而成。胃气重伤。
则大虚极寒。必生胀满。○或问厥阴下利。何以反言胃中虚寒而无火。余答云。寒中厥阴之经。厥阴脉本挟胃。胃
中受寒气所侵而无火。所以下利清谷。至误攻其表而汗出。胃亡津液。因成胀满。胀满者。全是太阴病。然此系厥
阴风寒甚而木强克土。乃兼证也。故从厥阴经例。○按此条论。仲景无治法。补亡论郭白云云。宜通脉四逆汤。又
仲景凡言攻表。是用桂枝汤。此言不可攻表。当是禁用桂枝也。）
下利。脉沉而迟。其人面少赤。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。（此条言下利。又宜汗解之证。下利脉沉而迟。里寒也。所下者清谷。里寒甚也。面少赤。身微热。
下焦虚寒。无根失守之火。浮于上。越于表也。以少赤微热之故。其人阳气虽虚。犹能与阴寒相争。必作郁冒汗出
而解。郁冒者。头目之际。郁然昏冒。乃真阳之气。能胜寒邪。里阳回而表和顺。故能解也。病患必微厥者。此指
未汗出郁冒之时而言。面戴阳系下虚。此申言面少赤之故。下虚。即下焦元气虚。虽指厥阴肝脏。而命门相火亦在
其中。乃寒邪兼及之证也。○愚按此条论。仲景虽云汗出而解。然于未解之时。当用何药。补亡论郭白云云。不解。
宜通脉四逆汤少与之。其人下利清谷。里寒外热。正通脉四逆证也。○或问少阴病下利清谷。里寒外热。手足厥逆。
脉微欲绝。身反不恶寒。其人面色赤者。通脉四逆汤。上条系厥阴证。而郭氏议用之。何也。余答云。肝肾之病。
本同一治。水温。则寒木得以发生。理固然也。以其人面少赤。身微热。手足微厥。故云少与之。又前条证云。不
可攻表使汗出。此条证又云。汗出而解。盖此条证。系阳回。里寒散而营卫和。故汗出。非攻表而使之汗出也。否
则后条证云。汗出而厥。正阴证危极之时。何云解乎。）
下利后。脉绝。手足厥冷。 时脉还。手足温者生。脉不还者死。（此言下利后死证。 时。周时也。脉绝。
手足冷。此下利之时已然。今云下利后。则利已止矣。然须待以周时。脉还手足温。为阳气复则生。若手足仍冷。
脉不还。为阳气绝。则死。武陵陈氏云。与少阴篇下利止而头眩。时时自冒者死。意同。皆下利后死证也。○按此
条论。仲景云死证。本无治法。补亡论郭白云云。宜通脉四逆汤。此必是待其脉还时所用之药也。）
下利清谷。里寒外热。汗出而厥者。通脉四逆汤主之。（此条乃下利当急温之证。下利清谷。为里寒也。外热。
为身微热。兼之汗出。此真阳之气外走而欲脱也。前条汗出为欲解。此条汗出而反厥。成注云。阳气大虚也。与通
脉四逆汤。以温经固表通内外阳气。○愚按人之肢体属阴。内有火。则温而生。今者下利清谷。是内无火。纯是阴
邪之气。为里寒。肢体之间。反热而汗出。为外热。乃阴阳之气不相顺接。故见厥也。于四逆汤内。加葱。以救表
里而通调阴阳之气。不然。岂有汗出而反加葱之理。尚论篇云。通之正所以收之。此之谓也。）
下利腹胀满身体疼痛者。先温其里。乃攻其表。温里宜四逆汤。攻表。宜桂枝汤。（此条系厥阴下利。兼有表
邪者。下利不可攻表最前条已垂戒矣。故此条以温里为急。下利里腹胀满。必下利久。中气虚寒而作胀满。其人既
虚。风寒复袭故身体疼痛。此系利后之兼证。非初病起而身疼痛也。与四逆汤先温其里。使真阳之气得复而里和利
止。后宜桂枝汤以攻表。乃散风邪。和营卫。而止身疼痛也。假使先后倒施。则中气无固岂堪外行发散邪。）
呕而脉弱小便复利。身有微热。见厥者。难治。四逆汤主之。（此条乃虚寒作呕。为难治之证。厥阴之脉挟胃。
经中之寒侵胃。胃虚气逆。则呕而脉弱。小便复利者。真气虚寒。不能摄水也。身微热而见厥。乃阴寒之邪。迫微
阳而欲脱。故为难治。急与四逆汤。以温里助阳。○愚按诸条厥利证。皆大便利。此条虽以呕为主病。然止小便利
而见厥。即为难治之证。可见中寒证。最畏真阳气脱。前后不能关锁。上证用四逆汤者。以附子散寒。下逆气。补
命门之火。上以除呕。下以止小便。外以回厥逆。干姜温中除呕。敛阳气。使身不微热。炙甘草温中补气。大治胃
虚寒作呕。总而言之。四逆汤虽治三阴厥逆。其力大能温肾。使水温。斯肝木之寒得解。木柔土暖而呕立止。洵不
诬矣。）
干呕。吐涎沫。头痛者。吴茱萸汤主之。（此条乃大虚极寒。故见呕吐头痛之证。厥阴之脉。挟胃贯膈。循喉
咙之后。干呕为厥阴寒气上逆。至吐涎沫。则胃中虚寒极矣。武陵陈氏云。涎沫者。清寒之象。若胃热。则变而为
浊痰矣。头痛为肝脏虚。厥阴大寒之气上攻。故头额与巅顶作痛。以厥阴之脉连目系。上出额。与督脉会于巅故也。
与吴茱萸汤以温里散寒。补虚下逆气。）
当归（三两） 桂枝（三两） 芍药（三两） 细辛（三两） 大枣（二十五个） 甘草（二两，炙用） 通草（二两）
以上七味药。用水八升。煮取三升。滤去药渣。温服一升。每日三次服用。
成无己注解说引用《内经》的话说：脉是血液汇聚的府库。所有的血都属于心。想要通畅血脉，必须先补益心脏、增益血液。苦味药物先入心。当归的苦味用来助益心血。心脏苦于涣散，应当急食酸味药物来收敛它。芍药的酸味用来收敛心气。肝脏苦于拘急，应当急食甘味药物来缓和它。大枣、甘草、通草的甘味，用来缓和阴血。
琥按语：足厥阴经所属的脏器，本来属于肝。肝是藏血的府库。成无己的注解没有提到当归入肝，反而说补心，这确实不是紧要的关键之语。
《内台方议》议论说：阳气在外虚弱，就不能温暖四肢末端；阴血在内虚弱，就不能滋养经脉。所以出现手足厥冷寒凉，脉象细微几乎要断绝的情况。方中用当归为君药以补血，芍药为臣药，辅助它来滋养营气。桂枝、细辛的辛味，用来散发寒气、温煦阳气作为佐药。用大枣、甘草的甘味，作为使药来补益中焦。在补益不足的基础上，再用通草的淡味，来通行其脉道并治疗厥逆。
如果使用四逆汤，那么汤中的附子、干姜过于燥热猛烈，非常不适合血虚的病症。所以后文的辨析也说：少阴经所主的是气，发生厥逆就是寒证，应当纳气归肾。厥阴经所主的是血，发生厥逆就是虚证，应当温通经脉、恢复营气。这是大的法则。○愚按语：“厥则为虚”的“虚”字，应当兼有寒和燥的意思来看待。
大汗出，发热不退，体内拘挛紧急，四肢疼痛，又伴有下利，手足厥冷且恶寒的，用四逆汤主治。（这一条应当是寒邪侵入少阴经，反而发热不退，进而传入厥阴经而出现厥逆和下利的证候。如果是汗出后热退，那是伤寒热病的常规情况。现在是中寒病，属于真寒证。大汗出而热不退，这是真阳欲脱而产生的假热，并非邪气郁结在体表而发热。加上体内拘挛紧急，这是寒气深入于里。寒性主收引，应当是腹部以内拘挛紧急。已经具备恶寒的症状。四肢是诸阳之本，不出汗而四肢疼，是邪气实证；大汗出而四肢疼，是阳气虚证。疼痛，就是拘挛而痛，总属寒邪入里的表现。又下利、厥逆，是寒邪深入厥阴经，前面的热已退而只恶寒。这种恶寒不是表寒，而是里寒直达于四肢手足末端。因为寒从少阴经传来，所以给予四逆汤以回复阳气、驱散寒邪。○有人问：大汗出热不退，既然是阳气越出躯壳之外而欲脱，加上又有下利，就是死证。这与最前面的“有阴无阳”条没有区别。为什么又是可治之证？我回答说：大汗出热不退，是大汗出之后仍然发热，并非汗出不止。体内拘挛紧急、四肢疼痛，又厥逆下利恶寒，当处于厥逆下利恶寒的时候，当时的热势必定被重敛于内而伏匿了。这是真阳的根基还没有脱落，只是群阴用事而孤阳伏匿。所以用四逆汤来回复阳气、驱散寒邪。）
如果大汗出或者严重下利并且手足冰冷的，用四逆汤主治。（这一条病，也是少阴经中寒，兼及厥阴经。但比前一条的病略轻。然而阳气亡失于表，阴寒盛极于里，不用四逆汤，就无法回阳而战胜阴寒。）
下利，手足厥冷，无脉的，施灸后不回暖。如果脉搏不还复，反而轻微喘息的，预后不良（死）。（这一条是阴盛阳绝的证候。下利、手足厥冷，这是厥阴经中寒的常态。到了无脉的程度，真阳之气已经脱失。此时汤药已经来不及救治，只能依靠艾灸来补接阳气。如果施灸后，手足不温暖，脉搏不还复，反而加重微喘，这是上下俱脱，不死还等什么？武陵陈氏说：阳气热气绝的证候，喘息一定剧烈；阴寒气绝的证候，喘息一定微弱。所以《条辩》说呼吸短促且声音不接续。另外，喘息不是艾灸导致的，如果阳气不因艾灸而恢复，那么绝证就会依次而至。《尚论篇》说：孤阳随着火气上逆而脱失，这是错误的。○按此条论述，张仲景没有说明应当灸哪个穴位，《补亡论》常器之说：应当灸关元、气海两个穴位。穴位的注释已在前面见到。）
下利完谷不化，不可攻表发汗。若发汗导致出汗，必然会出现腹胀满。（这里说的是下利禁止发汗。厥阴经下利属于里寒。完谷不化，指食物颜色不变原样排出，是胃中没有火力，不能腐熟传化水谷的缘故。这个时候只应以温胃作为治疗下利的根本，不可错误地攻伐其表而导致出汗。汗是由胃中水谷之气化生而成的。胃气受到重伤，就会大虚极寒，必然产生胀满。○有人问：厥阴经下利，为什么反而说胃中虚寒而无火？我回答说：寒邪侵入厥阴之经，厥阴脉本来挟持胃部，胃中受寒气侵扰而没有火力，所以下利完谷不化。至于错误地攻伐其表而发汗，胃中津液亡失，因而形成胀满。胀满，完全是太阴病的表现。然而这是厥阴风寒甚盛而木气强盛克制土气，属于兼证。所以遵循厥阴经的例法。○按此条论述，张仲景没有给出治法，《补亡论》郭白云说：宜用通脉四逆汤。另外，张仲景凡是说攻表，是用桂枝汤。这里说不可攻表，应当是禁用桂枝。）
下利，脉象沉而迟，病人面部微微发红，身体有轻微发热，下利完谷不化的，一定会出现郁冒（头晕目眩昏蒙），通过出汗而解除。病人必定有轻微厥冷。之所以这样，是因为面戴阳（面部泛红如妆），下部虚弱的缘故。（这一条说的是下利，又适宜通过汗解的证候。下利、脉沉而迟，是里寒。所下的东西是完谷不化，是里寒很严重。面部微微发红，身体轻微发热，是下焦虚寒，无根失守之火，浮越于上，发散于体表。因为面微红、身微热的缘故，病人的阳气虽然虚弱，还能够与阴寒相争，一定会出现郁冒、出汗而解除。郁冒，是指头目之间，郁然昏蒙，是真阳之气能够战胜寒邪，里阳回复而表和顺，所以能够解除。病人必定有轻微厥冷的，这是指尚未出汗、出现郁冒的时候而言。面戴阳系于下部虚弱，这里申述面部微红的缘故。下部虚弱，即下焦元气虚，虽然指厥阴肝脏，但命门相火也在其中，是寒邪兼及的证候。○愚按语：这一条论述，张仲景虽然说出汗而解除，然而在未解除的时候，应当用什么药？《补亡论》郭白云说：不解，宜少量给予通脉四逆汤。其人下利完谷不化，里寒外热，正是通脉四逆汤的证候。○有人问：少阴病下利完谷不化，里寒外热，手足厥逆，脉微欲绝，身体反而不恶寒，病人面色赤的，用通脉四逆汤。上一条是厥阴证，而郭氏建议用它，为什么呢？我回答说：肝肾的疾病，本可以用同样的方法治疗。水温，则寒木得以生发，道理当然是这样的。因为病人面微红、身微热、手足微厥，所以说少量给予。另外前一条证候说：不可攻表使出汗。这一条证候又说：出汗而解除。大概这一条证候，是阳气回复，里寒消散而营卫调和，所以出汗，并非攻表而使之出汗。否则后一条证候说：出汗而厥逆，正是阴证危极的时候，为什么说解除呢？）
下利之后，脉搏消失，手足冰冷。过一段时间脉搏还复，手足温暖的，预后良好（生）。脉搏不还复的，预后不良（死）。（这一条说的是下利后的死证。“时”，指一周的时间。脉搏消失，手足冷，这在当下利的时候就已经存在。现在说下利后，则下利已经停止。然而需要等待一周的时间，如果脉搏还复、手足温暖，为阳气回复则生。如果手足仍然冷，脉搏不还复，为阳气绝，则死。武陵陈氏说：与少阴篇中“下利止而头眩，时时自冒者死”意思相同，都是下利后的死证。○按此条论述，张仲景说是死证，本来没有治法，《补亡论》郭白云说：宜用通脉四逆汤。这一定是等待其脉搏还复时所用的药物。）
下利完谷不化，里寒外热，出汗而厥逆的，用通脉四逆汤主治。（这一条是下利应当紧急温里的证候。下利完谷不化，是里寒。外热，是指身体轻微发热，加上出汗，这是真阳之气向外走散而欲脱失。前一条出汗是欲解除，这一条出汗反而厥逆。成无己注解说：阳气大虚。给予通脉四逆汤，以温通经脉、固护体表、通达内外阳气。○愚按语：人的肢体属阴，内有火，则温暖而生。现在的下利完谷不化，是内无火，纯是阴邪之气，为里寒。肢体之间，反而发热而出汗，为外热，这是阴阳之气不相顺接，所以出现厥逆。在四逆汤内，加入葱白，以救表里而通调阴阳之气。不然，哪里有出汗反而加葱的道理？《尚论篇》说：通正是为了收。说的就是这个意思。）
下利、腹胀满、身体疼痛的，先温其里，然后攻其表。温里宜用四逆汤。攻表，宜用桂枝汤。（这一条是厥阴经下利，兼有表邪的证候。下利不可攻表，在最前面的条文中已经垂示警戒了。所以这一条以温里为急务。下利、腹部胀满，必然是下利日久，中气虚寒而产生胀满。病人既然虚弱，风寒再次侵袭，所以身体疼痛。这是下利后的兼证，并非初起病就身体疼痛。给予四逆汤先温其里，使真阳之气得以回复而里气和、下利止。随后宜用桂枝汤以攻表，乃散发风邪、调和营卫，而止身体疼痛。假如先后顺序颠倒施用，那么中气无固护，哪里能承受外行的发散药邪？）
呕吐而脉弱，小便反而通利，身体有轻微发热，出现厥逆的，难治。用四逆汤主治。（这一条是虚寒作呕，为难治的证候。厥阴之脉挟持胃部，经中的寒气侵入胃，胃虚气逆，则呕吐而脉弱。小便反而通利的，是真气虚寒，不能摄纳水液。身体微热而见厥逆，是阴寒之邪，逼迫微阳而欲脱失，所以为难治。急予四逆汤，以温里助阳。○愚按语：各条厥逆下利的证候，都是大便通利。这一条虽然以呕吐为主病，然而只要小便利而见厥逆，就是难治的证候。可见中寒证，最畏惧真阳气脱，前后不能关锁。上证用四逆汤的原因，是因为附子散寒，降逆气，补命门之火，上以除呕，下以止小便频数，外以回厥逆。干姜温中除呕，收敛阳气，使身体不微热。炙甘草温中补气，大治胃虚寒作呕。总而言之，四逆汤虽然治疗三阴厥逆，其力大能温肾，使水温，则肝木之寒得以解除，木柔土暖而呕吐立即停止，确实没有虚假。）
干呕，吐涎沫，头痛的，用吴茱萸汤主治。（这一条是大虚极寒，所以出现呕吐、头痛的证候。厥阴之脉，挟胃贯膈，循喉咙之后。干呕是厥阴寒气上逆，到了吐涎沫，则胃中虚寒极矣。武陵陈氏说：涎沫，是清寒的现象。如果是胃热，则会变为浊痰。头痛是肝脏虚，厥阴大寒之气上攻，所以额头与巅顶作痛。因为厥阴之脉连目系，上出额，与督脉会于巅顶的缘故。给予吴茱萸汤以温里散寒，补虚降逆气。）
Danggui (Radix Angelicae Sinensis, 3 liang), Guizhi (Ramulus Cinnamomi, 3 liang), Shaoyao (Radix Paeoniae Rubra or Radix Paeoniae Alba, 3 liang), Xixin (Herba Asari, 3 liang), Dazao (Fructus Jujubae, 25 pieces), Gancao (Radix Glycyrrhizae Preparata with Honey, 2 liang), Tongcao (Medulla Tetrapanacis, 2 liang).
The above seven ingredients. Boil in eight sheng of water. Decoct to obtain three sheng. Remove the dregs. Take one sheng warm. Three times a day.
Cheng Wuji’s commentary cites the *Neijing* saying: "Mai (Pulse/Vessels) is the residence of blood. All blood belongs to the Heart. To unblock the vessels, one must first tonify the Heart and benefit the blood. Bitter flavors enter the Heart first. The bitterness of Danggui assists Heart blood. The Heart suffers from flaccidity; urgently eat sour flavors to astringe it. The sourness of Shaoyao astringes Heart Qi. The Liver suffers from tension; urgently eat sweet flavors to relax it. The sweetness of Dazao, Gancao, and Tongcao relaxes Yin blood."
Hu's note: The organ belonging to the Foot-Jueyin meridian originally belongs to the Liver. The Liver is the residence storing blood. Cheng Wuji’s commentary does not mention Danggui entering the Liver, but instead speaks of tonifying the Heart. This is indeed not the crucial point.
*Neitai Fangyi* discusses: When Yang Qi is deficient externally, it cannot warm the four extremities. When Yin Blood is deficient internally, it cannot nourish the vessels. Thus, there is coldness in the hands and feet, and the pulse is fine and nearly absent. In the formula, Danggui is used as the Sovereign herb to tonify blood; Shaoyao as the Minister herb, assisting it to nourish Ying Qi. The pungency of Guizhi and Xixin disperses cold and warms Qi as the Assistant herbs. The sweetness of Dazao and Gancao acts as the Envoy herb to benefit the Middle Jiao. After supplementing deficiencies, the blandness of Tongcao is used to unblock the vessel pathways and treat Jue Ni (Reversal Cold).
If Sini Tang (Four Reversals Decoction) were used, the Aconite and Ginger within the decoction would be too drying and hot, which is highly unsuitable for blood deficiency. Therefore, subsequent discussions also state: The Shao Yin meridian governs Qi; when Jue occurs, it is Cold, and Qi should be guided back to the Kidney. The Jue Yin meridian governs Blood; when Jue occurs, it is Deficiency, and the channels should be warmed to restore Ying Qi. This is the general principle. ○ My note: The character "Deficiency" in "Jue implies Deficiency" should be viewed as encompassing both Cold and Dryness.
Profuse sweating, fever that does not cease, internal cramping and tightness, pain in the four limbs, accompanied by diarrhea, cold reversal in the hands and feet, and aversion to cold: Si Ni Tang (Four Reversals Decoction) is indicated. (This clause likely refers to Cold invading the Shao Yin meridian, with fever persisting, then entering the Jue Yin meridian presenting with Jue Ni and diarrhea. In typical cold damage febrile diseases, if sweating occurs, the heat ceases. However, this is a True Cold disease caused by mid-cold. Profuse sweating with persistent heat indicates True Yang about to collapse generating false heat, not exterior heat constrained by pathogenic factors. Combined with internal cramping, this indicates deep invasion of Cold into the interior. Cold governs contraction and drawing inward; thus, the abdomen is likely cramped and tight. The symptom of aversion to cold is already present. The four limbs are the root of all Yang Qi. Pain in the limbs without sweating indicates excess of pathogenic factors; pain in the limbs with profuse sweating indicates Yang Qi deficiency. Pain here refers to cramping and pain, collectively representing the state of Cold pathogen entering the interior. Diarrhea and Jue Ni indicate deep invasion of Cold into the Jue Yin meridian; the previous heat has ceased, leaving only aversion to cold. This aversion to cold is not exterior Cold, but interior Cold reaching the extremities of the hands and feet. Since the Cold comes from the Shao Yin meridian, Si Ni Tang is given to restore Yang and scatter Cold. ○ Question: Profuse sweating with persistent heat, since Yang Qi is escaping outside the body and about to collapse, combined with diarrhea, constitutes a death syndrome. How is this different from the earlier clause "Yin present, Yang absent"? Why is it considered treatable? Answer: "Profuse sweating with persistent heat" means heat persists after profuse sweating, not continuous sweating. Internal cramping, limb pain, Jue Ni, diarrhea, and aversion to cold: during the time of Jue Ni, diarrhea, and aversion to cold, the heat must be heavily contained internally and hidden. This indicates the root of True Yang has not yet collapsed; rather, Yin pathogens are dominant while isolated Yang is hidden. Thus, Si Ni Tang is used to restore Yang and scatter Cold.)
If there is profuse sweating or severe diarrhea accompanied by cold reversal in the hands and feet: Si Ni Tang (Four Reversals Decoction) is indicated. (This condition also involves Cold damaging the Shao Yin meridian, involving the Jue Yin meridian as well. It is slightly milder than the previous clause. However, Yang collapses at the exterior, and Yin is excessive in the interior. Without Si Ni Tang, there is no way to restore Yang and overcome Yin.)
Diarrhea, cold reversal in the hands and feet, absence of pulse: If moxibustion does not produce warmth, and if the pulse does not return, but slight panting occurs, the prognosis is fatal. (This is a syndrome of Yin excess and Yang exhaustion. Diarrhea and cold reversal in the hands and feet are common in Jue Yin Cold damage. Absence of pulse indicates depletion of True Yang Qi. At this stage, herbal decoctions are ineffective; only moxibustion can supplement and connect the Qi. If after moxibustion, the hands and feet do not warm, the pulse does not return, and slight panting worsens, it indicates collapse of both upper and lower aspects. Death is inevitable. Chen of Wuling states: In syndromes of Qi and Heat exhaustion, panting is vigorous; in syndromes of Yin and Cold exhaustion, panting is slight. Thus, *Tiaobian* states short breath with discontinuous voice. Furthermore, panting is not caused by moxibustion; if Yang Qi does not recover due to moxibustion, death syndromes will follow sequentially. *Shanglun Pian* states "isolated Yang follows Fire Qi upward and collapses," which is incorrect. ○ Note: In this clause, Zhang Zhongjing does not specify which acupoints to moxa. *Buwang Lun* Chang Qizhi states: Moxa Guan Yuan (CV4) and Qi Hai (CV6). Acupoint notes have been seen previously.)
Diarrhea with undigested food (Qing Gu): Do not attack the exterior. Sweating will inevitably cause abdominal fullness. (This prohibits diaphoresis for diarrhea. Jue Yin diarrhea is interior Cold. Qing Gu means the color of food remains unchanged and passes completely, indicating lack of Fire in the Stomach unable to transform water and grain. At this time, warming the Stomach is the fundamental treatment for diarrhea. One must not mistakenly attack the exterior causing sweating. Sweat is formed from the Qi of water and grain in the Stomach. Severe injury to Stomach Qi leads to extreme deficiency and cold, inevitably producing fullness. ○ Question: Why speak of Stomach deficiency and Cold without Fire regarding Jue Yin diarrhea? Answer: Cold damages the Jue Yin meridian; the Jue Yin meridian accompanies the Stomach. Invasion of Cold into the Stomach depletes Fire, resulting in diarrhea with undigested food. Mistakenly attacking the exterior causes sweating, leading to loss of Stomach fluids and formation of fullness. Fullness is entirely a Tai Yin syndrome. However, this is due to severe Wind-Cold in Jue Yin with strong Wood overacting on Earth, a concurrent syndrome. Thus, it follows the Jue Yin meridian example. ○ Note: Zhang Zhongjing provides no treatment method in this clause. *Buwang Lun* Guo Baiyun states: Use Tong Mai Si Ni Tang (Pulse-Restoring Four Reversals Decoction). Also, whenever Zhang Zhongjing mentions attacking the exterior, he uses Gui Zhi Tang (Cinnamon Twig Decoction). Saying "do not attack the exterior" implies prohibiting Gui Zhi.)
Diarrhea, pulse deep and slow, face slightly red, body slightly warm, diarrhea with undigested food: Must experience Yu Mao (depressive vertigo/dizziness), and resolve through sweating. The patient must have slight cold reversal. The reason is Dai Yang (Face wearing Yang/flushed face) due to lower deficiency. (This clause describes a case of diarrhea suitable for resolution via sweating. Diarrhea with deep and slow pulse indicates interior Cold. Passing undigested food indicates severe interior Cold. Slight facial redness and slight body warmth indicate deficiency-cold in the Lower Jiao, where rootless and unanchored Fire floats upward and diffuses to the exterior. Due to slight redness and warmth, although Yang Qi is deficient, it can still contend with Yin Cold. It will inevitably produce Yu Mao and resolve through sweating. Yu Mao refers to depression and dizziness in the head and eyes; it indicates True Yang Qi overcoming Cold pathogens, interior Yang returning, and exterior harmony, thus resolving. Slight cold reversal refers to the time before sweating and Yu Mao. Dai Yang results from lower deficiency. This reiterates the cause of slight facial redness. Lower deficiency means deficiency of Yuan Qi in the Lower Jiao. Although referring to the Jue Yin Liver, Ming Men Minister Fire is also involved, indicating Cold pathogen involvement. ○ Note: Although Zhang Zhongjing says it resolves through sweating, what medicine should be used before resolution? *Buwang Lun* Guo Baiyun states: If unresolved, give small amounts of Tong Mai Si Ni Tang. Diarrhea with undigested food, interior Cold with exterior Heat, is exactly the indication for Tong Mai Si Ni Tang. ○ Question: Shao Yin disease with diarrhea, undigested food, interior Cold/exterior Heat, cold reversal, faint pulse, body not averse to cold, flushed face uses Tong Mai Si Ni Tang. The previous clause is Jue Yin syndrome, yet Guo suggests using it. Why? Answer: Diseases of the Liver and Kidney share similar treatments. Warming Water allows Cold Wood to generate. This is logical. Because the face is slightly red, body slightly warm, and hands/feet slightly cold, it says "give small amounts." Previously, it said "do not attack exterior to induce sweating." Here it says "resolves through sweating." This syndrome represents Yang recovery, scattering of interior Cold, and harmony of Ying and Wei, hence sweating. It is not induced by attacking the exterior. Otherwise, the next clause says "sweating with Jue Ni," which is the critical moment of Yin syndrome. How can it be called resolution?)
After diarrhea, pulse vanishes, hands and feet cold. If pulse returns after a period of time and hands and feet become warm, life is preserved. If pulse does not return, death ensues. (This describes a fatal syndrome after diarrhea. "Time" refers to a full cycle (12 hours). Pulse vanish and cold hands/feet existed during diarrhea. Now stating "after diarrhea" means diarrhea has stopped. However, one must wait a full cycle. Pulse return and warm hands/feet indicate Yang restoration, so survival. If hands/feet remain cold and pulse does not return, Yang exhaustion leads to death. Chen of Wuling states: This is similar to the Shao Yin chapter "diarrhea stops but dizziness occurs, frequent spontaneous vertigo is fatal." Both are fatal syndromes after diarrhea. ○ Note: Zhang Zhongjing calls this a fatal syndrome and provides no treatment. *Buwang Lun* Guo Baiyun states: Use Tong Mai Si Ni Tang. This must be the medicine used when waiting for pulse return.)
Diarrhea with undigested food, interior Cold with exterior Heat, sweating with cold reversal: Tong Mai Si Ni Tang (Pulse-Restoring Four Reversals Decoction) is indicated. (This is a case requiring urgent warming for diarrhea. Undigested food indicates interior Cold. Exterior Heat refers to slight body warmth. Combined with sweating, this indicates True Yang Qi moving outward and about to collapse. In the previous clause, sweating indicated impending resolution; here, sweating with Jue Ni indicates severe Yang deficiency (Cheng Wuji's note). Tong Mai Si Ni Tang is given to warm the channels, secure the exterior, and connect interior and exterior Yang Qi. ○ Note: The human body limbs belong to Yin. Internal Fire warms and generates life. Current undigested food indicates internal lack of Fire, purely Yin pathogenic Qi, constituting interior Cold. The limbs feel hot and sweat, constituting exterior Heat. This is because Yin and Yang Qi fail to connect smoothly, resulting in Jue Ni. Add Scallion White (Cong Bai) to Si Ni Tang to rescue exterior and interior and regulate Yin and Yang Qi. Otherwise, how could one add Scallion White when sweating? *Shanglun Pian* states: Unblocking is precisely for gathering. This is what it means.)
Diarrhea, abdominal fullness, body pain: First warm the interior, then attack the exterior. For warming the interior, use Si Ni Tang (Four Reversals Decoction). For attacking the exterior, use Gui Zhi Tang (Cinnamon Twig Decoction). (This is Jue Yin diarrhea with concurrent exterior pathogen. Prohibition against attacking exterior for diarrhea was warned in the earliest clause. Thus, warming the interior is urgent. Abdominal fullness with diarrhea implies long-standing diarrhea, Middle Qi deficiency and Cold causing fullness. The patient is deficient, and Wind-Cold attacks again, causing body pain. This is a concurrent syndrome after diarrhea, not initial body pain. Give Si Ni Tang first to warm the interior, allowing True Yang to recover, interior to harmonize, and diarrhea to stop. Then use Gui Zhi Tang to attack the exterior, dispersing Wind pathogen, harmonizing Ying and Wei, and stopping body pain. If the order is reversed, Middle Qi lacks consolidation and cannot withstand external dispersing agents.)
Vomiting, weak pulse, urination is free, slight body warmth, presence of Jue Ni: Difficult to treat. Si Ni Tang (Four Reversals Decoction) is indicated. (This is vomiting due to deficiency-Cold, a difficult syndrome. Jue Yin meridian accompanies the Stomach. Cold in the meridian invades the Stomach; Stomach deficiency and Qi rebellion cause vomiting and weak pulse. Free urination indicates deficiency-Cold of True Qi failing to control water. Slight body warmth with Jue Ni indicates Yin-Cold pathogen forcing slight Yang to collapse, hence difficult to treat. Urgently give Si Ni Tang to warm the interior and assist Yang. ○ Note: In all clauses regarding Jue Ni and diarrhea, stool is loose. This clause focuses on vomiting, but free urination with Jue Ni makes it difficult to treat. This shows that mid-cold syndromes most fear collapse of True Yang Qi, with inability to lock front and back. The reason for using Si Ni Tang here is: Fuzi (Prepared Aconite Root) scatters Cold, directs rebellious Qi downward, tonifies Ming Men Fire, stops vomiting above, controls urination below, and reverses Jue Ni externally. Shengjiang (Fresh Ginger) warms the middle, stops vomiting, consolidates Yang Qi, preventing slight body warmth. Zhi Gancao (Honey-fried Licorice Root) warms the middle and tonifies Qi, greatly treating Stomach deficiency-Cold vomiting. In summary, although Si Ni Tang treats Jue Ni of the Three Yin, its power strongly warms the Kidney. Warmed Water allows Cold Wood to resolve; Wood becomes soft, Earth becomes warm, and vomiting stops immediately. Indeed, this is not false.)
Dry retching, spitting saliva and froth, headache: Wu Zhu Yu Tang (Evodia Decoction) is indicated. (This is extreme deficiency and extreme Cold, presenting with vomiting and headache. Jue Yin meridian accompanies the Stomach, pierces the Diaphragm, and follows behind the throat. Dry retching is Jue Yin Cold Qi rebelling upward. Spitting saliva and froth indicates extreme deficiency-Cold in the Stomach. Chen of Wuling states: Saliva and froth are signs of clear Cold. If Stomach Heat, it would transform into turbid phlegm. Headache is Liver deficiency. Great Cold Qi of Jue Yin attacks upward, causing pain in the forehead and vertex. This is because the Jue Yin meridian connects to the eye system, emerges above the forehead, and meets the Du Meridian at the vertex. Wu Zhu Yu Tang is given to warm the interior, scatter Cold, tonify deficiency, and direct rebellious Qi downward.)