甘草（二两炙） 附子（大者一枚生用去皮破八片） 干姜（三两强人可四两）
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。
后加减法
面色赤者。加葱九茎。（不言白者。省文也。）腹中痛。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。久病。脉与方相应者。乃可服之。
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。
琥按上汤。成氏无正解。其义止见于四逆汤中。据条辩云。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。其文一直贯下。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。
琥又按葱味辛。入手太阴经。故能引诸药料以通脉。盖两手之脉。实属手太阴肺经也。又入足阳明经。故能上
行于面。面通阳气。以足阳明之脉。循鼻外。上耳前。实面部也。原方中无葱者。乃传写之漏。不得名通脉也。
琥又按上方后云。其脉即出者愈。尚论篇云。其辩最细。盖暴出。则脉已离根。即出。则阳已返舍。由其外反
热。反不恶寒。真阳尚在躯壳。然必通其脉而脉即出。始为休征。设脉出艰迟。其阳已随热势外散。又主死矣。
琥又按成氏注上加减法原云。腹中痛加芍药。谓芍药之性。能通寒利腹中痛。大谬之极。今录内台方注于下。
面色赤者。加葱九茎。（葱味辛。能通阳也。）腹中痛者。加白芍药二两。（芍药能安中补血。行营止痛。故用
之。）呕者。加生姜二两。（生姜之辛。能止呕散气也。）咽痛者。加桔梗一两。（桔梗能利咽下气。故加之。）利止。
脉不出者。加人参二两。（利止脉不出者亡血也。加人参。益气生血。）
琥。按前加减法。有云去葱。去芍药。去桔梗。此系衍文。故内台注不言及。又仲景原文。加人参二两下。有
久病脉与方相应者。乃可服之句。正以见先圣用药。必任重其事。成注移入注中。忽之甚矣。
或问腹中痛。系里寒甚。何以加芍药。余答云。芍药之性平。用入芩连等剂。则和血分之热。用入姜附等剂。
则和血分之寒。在配合之得其宜耳。且上文云。腹中痛。系寒伤营。少阴之邪。侵入中焦。脾气虚寒。故加白芍药
于四逆汤中。
少阴病。脉沉者。急温之。宜四逆汤。（此条乃少阴中寒宜急温之证。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。）
甘草（二两，炙） 附子（大者一枚，生用，去皮，破成八片） 干姜（三两，体质强壮者可增至四两）
以上三味药。用水三升。煮取一升二合。去渣。分两次温服。如果脉搏随即复出者，病愈。
后加减法
面色发赤的。加葱九茎。（文中未言明白葱，是省略写法。）腹中痛的。去掉葱。加芍药二两。呕吐的。加生姜二两。咽痛的。去掉芍药加桔梗一两。腹泻停止但脉搏仍不出来的。去掉桔梗。加人参二两。久病患者。脉象与方剂证候相应的。才可以服用。
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。然而有什么巨大的差异，而要加上“通脉”二字来区别它呢？说四逆汤，是治疗四肢厥逆的。《伤寒论》说：阴阳之气不相顺接，便形成厥。厥，是因为阳气虚衰。所以用四逆汤来增益真阳，使气机相顺接而厥逆痊愈。至于里寒极严重的，不仅气不相顺接，连脉也不相顺接。其症状更剧烈。所以用四逆汤而加大剂量。像这样，就能通脉了。药物是一样的。加重剂量，则治疗作用不同。命名也因此有别。方剂的灵妙神奇啊！
琥按：上述汤剂，成无己没有正解。其含义仅见于对四逆汤的注解中。据条辩云：通脉是指加入葱而言。这种说法很符合制方的意图。况且上文说脉微欲绝等症，其人面赤色，这段文字一直贯穿下来，那么葱应当加入方中，不应当附在方后。虽然通脉之力，不全在于葱，但实际上依赖葱作为引经药，疗效才神妙。
琥又按：葱味辛。入足太阴脾经（注：原文此处可能有误或特指，通常葱白入肺胃，但依原文翻译），故能引诸药料以通脉。盖两手之脉，实属手太阴肺经也。又入足阳明经，故能上行于面。面部通阳气，因为足阳明之脉，循行鼻外，上耳前，实际覆盖面部。原方中没有葱，乃是传写时的遗漏，不能称为通脉。
琥又按：上方后说：其脉即出者愈。《尚论篇》说：其辨析最细致。盖暴出，则脉已离根；即出，则阳已返舍。由其外反热，反不恶寒，真阳尚在躯壳。然而必须通其脉而脉随即复出，始为好转之征。假如脉出艰难迟缓，其阳已随热势外散，又主死矣。
琥又按：成无己注上加减法原云：腹中痛加芍药，谓芍药之性，能通寒利腹中痛。这大谬之极。现在录入《内台方议》的注于下：
面色赤者。加葱九茎。（葱味辛。能通阳也。）腹中痛者。加白芍药二两。（芍药能安中补血。行营止痛。故用之。）呕者。加生姜二两。（生姜之辛。能止呕散气也。）咽痛者。加桔梗一两。（桔梗能利咽下气。故加之。）利止。脉不出者。加人参二两。（利止脉不出者亡血也。加人参。益气生血。）
琥按：前加减法中，有云去葱、去芍药、去桔梗，这些是衍文（多余的文字）。所以《内台方议》的注中不言及。另外仲景原文，在加人参二两之下，有“久病，脉与方相应者，乃可服之”一句。正是为了显示先圣用药，必任重其事。成无己将其移入注中，忽视得太严重了。
有人问：腹中痛，属于里寒甚重，为什么加芍药？我回答说：芍药之性平，用于芩连等剂中，则调和血分之热；用于姜附等剂中，则调和血分之寒。关键在于配合得当。况且上文说：腹中痛，系寒伤营，少阴之邪，侵入中焦，脾气虚寒。所以加白芍药于四逆汤中。
少阴病。脉沉的。急温之。宜四逆汤。（此条乃少阴中寒宜急温之证。少阴病，本脉微细，但欲寐。如今轻取之，微脉不见；重取之，细脉几亡。伏匿而至于沉。这是寒邪深中于里，殆将入脏。温之不容以不急也。稍迟，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，岂可缓乎？）
Gancao (Licorizia Radix et Rhizoma Praeparata cum Melle, 2 liang) Fuzi (Aconiti Lateralis Radix Praeparata, one large piece, used raw, skin removed, broken into eight pieces) Ganjiang (Zingiberis Rhizoma, 3 liang; for strong individuals, may increase to 4 liang)
The above three herbs. Boil with three sheng of water. Decoct until one sheng and two he remain. Remove the dregs. Divide into two doses and take warm. If the pulse immediately reappears, the disease will be cured.
Post-prescription modifications
If the facial complexion is red. Add Congbai (Allii fistulosi Bulbus, nine stalks). (The text does not specify white scallion, which is an omission.) If there is abdominal pain. Remove Congbai. Add Shaoyao (Paeoniae Radix Alba, 2 liang). If there is vomiting. Add Shengjiang (Zingiberis Rhizoma Recens, 2 liang). If there is sore throat. Remove Shaoyao and add Jiegeng (Platycodonis Radix, 1 liang). If diarrhea stops but the pulse does not emerge. Remove Jiegeng and add Renshen (Ginseng Radix et Rhizoma, 2 liang). In chronic cases. Only administer if the pulse corresponds to the syndrome indicated by the formula.
Chen from Wuling stated: Tongmai Sini Tang (Decoction for Reviving the Pulse and Restoring Yang) is essentially Sini Tang (Four Reversals Decoction). The difference lies in using a larger Fuzi and increasing the dosage of Gancao and Ganjiang. However, what significant difference exists that warrants the addition of "Tongmai" (Reviving the Pulse) to distinguish it? Sini Tang treats Si Ni (Cold Extremities). The Treatise states: When Yin and Yang Qi fail to connect smoothly, Jue (Reversal/Cold Extremities) occurs. Jue is due to deficiency of Yang Qi. Therefore, Sini Tang is used to augment True Yang, enabling smooth connection of Qi and curing cold extremities. In cases of severe interior Cold, not only does Qi fail to connect smoothly, but the Pulse also fails to connect smoothly. The symptoms are more severe. Thus, Sini Tang is used with an increased dosage. By doing so, the Pulse can be revived. The herbs are the same. Increasing the dosage changes the therapeutic effect. Hence, the naming differs. How miraculous and subtle formulas can be!
Hu notes: Cheng Wuji provided no direct explanation for the above decoction. Its meaning appears only in his commentary on Sini Tang. According to Tiaobian, "Tongmai" refers to the addition of Congbai. This interpretation aligns well with the intent of the prescription. Moreover, the preceding text mentions "pulse faint and near extinction" and "facial redness," running continuously. Therefore, Congbai should be included in the main formula, not appended afterward. Although the power to revive the pulse does not rely solely on Congbai, it truly depends on Congbai as a guiding herb for the efficacy to be divine.
Hu further notes: Congbai has a pungent flavor. It enters the Hand Taiyin Lung Meridian (Note: Text says Hand Taiyin, though traditionally associated with Lung/Stomach), thus guiding other herbs to revitalize the pulse. The pulses of both hands belong to the Hand Taiyin Lung Meridian. It also enters the Foot Yangming Stomach Meridian, allowing it to ascend to the face. The face connects with Yang Qi, as the Foot Yangming Meridian runs along the outside of the nose, up to the front of the ear, covering the face. The absence of Congbai in the original formula is likely a transcription error; without it, it cannot be called "Tongmai."
Hu further notes: The post-prescription text states: "If the pulse immediately reappears, the disease will be cured." Shanglun Pian states: The differentiation here is most detailed. A sudden appearance indicates the pulse has detached from its root; an immediate reappearance indicates Yang has returned to its residence. Due to external heat and absence of aversion to cold, True Yang remains within the body shell. However, the pulse must be unblocked and immediately reappear to signify a favorable outcome. If the pulse emerges slowly and with difficulty, Yang has dispersed outward with the heat, indicating death.
Hu further notes: Cheng Wuji's commentary on the modifications states: "Add Shaoyao for abdominal pain, claiming Shaoyao's nature can unblock Cold and relieve abdominal pain." This is extremely erroneous. Now recording the commentary from Neitai Fangyi below:
If the facial complexion is red. Add Congbai (Allii fistulosi Bulbus, nine stalks). (Congbai is pungent and can unblock Yang.) If there is abdominal pain. Add Baishao (Paeoniae Radix Alba, 2 liang). (Shaoyao can calm the middle, nourish blood, move Ying, and stop pain. Hence its use.) If there is vomiting. Add Shengjiang (Zingiberis Rhizoma Recens, 2 liang). (The pungency of Shengjiang can stop vomiting and disperse Qi.) If there is sore throat. Add Jiegeng (Platycodonis Radix, 1 liang). (Jiegeng can benefit the throat and direct Qi downward. Hence its addition.) If diarrhea stops but the pulse does not emerge. Add Renshen (Ginseng Radix et Rhizoma, 2 liang). (Stopping diarrhea with non-emerging pulse indicates loss of blood. Adding Renshen tonifies Qi and generates blood.)
Hu notes: The previous modification instructions mention removing Congbai, Shaoyao, and Jiegeng. These are interpolations (superfluous text). Therefore, the Neitai Fangyi commentary does not mention them. Furthermore, in Zhang Zhongjing's original text, after "add Renshen 2 liang," there is the sentence: "In chronic cases, only administer if the pulse corresponds to the syndrome." This precisely demonstrates that the ancient sages treated medication with great seriousness. Cheng Wuji moved this into his commentary, showing excessive disregard.
Someone asked: Abdominal pain indicates severe interior Cold. Why add Shaoyao? I answered: Shaoyao has a neutral nature. Used in formulas with Huangqin and Huanglian, it harmonizes Heat in the Blood level. Used in formulas with Jiang and Fu, it harmonizes Cold in the Blood level. It depends entirely on appropriate combination. Moreover, the preceding text states: Abdominal pain results from Cold injuring the Ying level, with Shaoyin pathogenic factors invading the Middle Jiao, causing Spleen Qi deficiency and Cold. Therefore, Baishao is added to Sini Tang.
Shaoyin disease. With a deep pulse. Urgently warm it. Use Sini Tang. (This clause describes Shaoyin Cold invasion requiring urgent warming. Shaoyin disease typically presents with a faint and thin pulse, and desire to sleep. Now, light palpation reveals no faint pulse; heavy palpation shows the thin pulse nearly extinct. Hidden and sinking, this indicates Cold pathogens deeply entrenched in the interior, likely entering the Zang organs. Warming cannot be delayed. Delaying even slightly leads to aversion to cold, curled posture, vomiting and diarrhea, restlessness, inability to sleep, cold extremities, and absent pulse—deadly signs arriving immediately. Can the use of Sini Tang be delayed?)