少阴里寒外热证，面赤身反不恶寒，厥利清谷脉微绝，通脉四逆主之先，利止参加
脉不出，葱入面色赤炎炎，腹痛加芍咽桔梗，呕加圣药用姜鲜。
【注】少阴里寒外热之证，面赤不恶寒，格阳外热也。四肢厥冷，下利清谷，脉微欲
绝，阴极里寒也，宜通脉四逆汤主之。服四逆汤下利止，脉仍不出加人参，面色赤者加
葱，腹痛加芍药，咽痛加桔梗，呕加生姜。详少阴篇。
一日太阳少阴病，头痛口干渴而烦。二日阳明太阴病，满不欲食身热谵。三日少阳
厥阴病，耳聋囊缩厥逆寒，水浆不入神昏冒，六日气尽命难全。
【注】两感者，脏腑表里同病也。一日，头痛、太阳也；口干烦渴、少阴也。二日，身
热谵语、阳明也；腹满不欲食、太阴也。三日，耳聋、少阳也；囊缩而厥、厥阴也。传
经之邪其为病也渐，两感之邪其为病也速。盖因阳邪酷烈，正不能御，所以三日后水浆不
入，六腑之气欲绝，昏不知人，五脏之神已败，而不即死者，赖有胃气未尽耳，故又三
日其气乃尽而死。张洁古制大羌活汤，以羌、独、芩、连辈，辛甘以散太阳之表，苦寒以
清少阴之热，施之于表里不急者，固为得法也。若夫一日则头痛口干烦渴，二日则身热
谵语腹满不欲食，三日则耳聋囊缩而厥，水浆不入，昏不知人，传变如此迅速，恐用大
羌活汤平缓之剂，反失机宜，当遵仲景治有先后之说，审其表里孰急，随证治之，犹或
可活。故于此证初病，一日表里俱热者，根据少阴病得之二、三日，口燥咽干之法，用大
承气汤重剂以泻阳邪之烈；表里俱寒者，根据
少阴病始得之，反发热脉沉之法，用麻黄附子细辛汤，以解阴邪之急。二日表里俱实者，
根据阳明病谵语有潮热，腹满时减，减不足言之法，用大承气汤攻之；表里虚者，根据三阳
合病，腹满身重，面垢谵语之法，用大剂白虎加人参汤清之。三日表里热者，根据厥深热
亦深之法，用大承气汤下之；表里寒者。根据脉微欲绝手足厥寒之法，用当归四逆加吴茱
萸生姜汤温之。缓则不及事矣。其间颇有得生者，后之学人其留意焉。
少阴病里寒外热的证候，表现为面部发红、身体反而不恶寒，四肢厥冷、下利清谷（完谷不化）、脉象微弱甚至摸不到，治疗应以通脉四逆汤为主。如果服药后腹泻停止但脉搏仍不出，可加入人参；面色红赤如火的，加入葱白；腹痛的，加入芍药；咽痛的，加入桔梗；呕吐的，加入生姜。
第一天出现太阳经和少阴经同时发病的症状，表现为头痛、口干、口渴且心烦。第二天出现阳明经和太阴经同时发病的症状，表现为腹部胀满、不想进食、身体发热、胡言乱语。第三天出现少阳经和厥阴经同时发病的症状，表现为耳聋、阴囊收缩、四肢厥冷且寒冷，水浆无法入口、神志昏迷，到了第六天正气耗尽，生命难以保全。
【注释】两感病，是指脏腑表里同时受邪发病。第一天，头痛属于太阳经病变；口干心烦口渴属于少阴经病变。第二天，身体发热、胡言乱语属于阳明经病变；腹部胀满、不想进食属于太阴经病变。第三天，耳聋属于少阳经病变；阴囊收缩且四肢厥冷属于厥阴经病变。循经传变的邪气，其病情发展是逐渐加重的；两感病的邪气，其病情发展是迅速的。这是因为阳热邪气酷烈，正气不能抵御，所以三天后水浆无法进入，六腑之气将要断绝，神志昏迷不知人，五脏的神气已经败坏，之所以没有立即死亡，是因为胃气尚未完全耗尽的缘故，因此再过三天，气才会耗尽而死。张洁古制定了大羌活汤，用羌活、独活、黄芩、黄连等药物，以辛甘之味发散太阳经在表的邪气，以苦寒之味清解少阴经在里的热邪，适用于表里病情不急迫的情况，这确实是得法的治疗。但是如果第一天就出现头痛、口干、心烦口渴，第二天出现身体发热、胡言乱语、腹部胀满不想进食，第三天出现耳聋、阴囊收缩且四肢厥冷、水浆无法入口、神志昏迷不知人，病情变化如此迅速，恐怕使用大羌活汤这种平缓的药物，反而会错失治疗时机，应当遵循张仲景关于治疗有先后的原则，审察表里哪一方更急迫，根据证候进行治疗，或许还有救活的可能。所以对于此证初病，第一天表里都发热的，依据少阴病发病二三天后口燥咽干的方法，使用大承气汤重剂来泻除阳热邪气的猛烈之势；表里都寒冷的，依据少阴病刚发病时反而发热、脉沉的方法，使用麻黄附子细辛汤，以解除阴寒邪气的急迫。第二天表里都实证的，依据阳明病胡言乱语伴有潮热、腹部胀满但有时减轻、减轻程度不足以说明问题的方法，使用大承气汤攻下；表里都虚证的，依据三阳合病时腹部胀满、身体沉重、面部污垢、胡言乱语的方法，使用大剂量白虎加人参汤清解；第三天表里都发热的，依据“厥深者热亦深”的方法，使用大承气汤攻下；表里都寒冷的，依据脉象微弱欲绝、手脚厥冷的寒冷方法，使用当归四逆加吴茱萸生姜汤温补。如果治疗迟缓就来不及处理了。这其中颇有能存活下来的案例，后来的学医者务必留意。
The syndrome of interior cold and exterior heat in Shaoyin disease manifests as facial redness, a body that paradoxically does not feel aversion to cold, cold limbs (Jue), diarrhea with undigested food (Qinggu), and a faint or imperceptible pulse. It should be treated primarily with Tongmai Sini Tang (Pulse-Reviving Four Reversal Decoction). If diarrhea ceases but the pulse remains absent after administration, add Renshen (Ginseng Radix et Rhizoma); if the face is intensely red, add Congbai (Allii Fistulosi Bulbus); if there is abdominal pain, add Shaoyao (Paeoniae Radix Alba); if there is sore throat, add Jiegeng (Platycodonis Radix); if there is vomiting, add Shengjiang (Zingiberis Rhizoma Recens).
On the first day, simultaneous involvement of Taiyang and Shaoyin presents with headache, dry mouth, thirst, and irritability. On the second day, simultaneous involvement of Yangming and Taiyin presents with abdominal fullness, anorexia, fever, and delirious speech. On the third day, simultaneous involvement of Shaoyang and Jueyin presents with deafness, retraction of the testicles, cold limbs, inability to take fluids, and coma. By the sixth day, vital energy is exhausted, and life is difficult to preserve.
[Note] "Lianggan" (simultaneous contraction of two meridians) refers to the simultaneous pathogenic invasion of zang-fu organs and their corresponding exterior-interior pairs. On the first day, headache indicates Taiyang involvement; dry mouth, irritability, and thirst indicate Shaoyin involvement. On the second day, fever and delirium indicate Yangming involvement; abdominal fullness and anorexia indicate Taiyin involvement. On the third day, deafness indicates Shaoyang involvement; retraction of the testicles and cold limbs indicate Jueyin involvement. Pathogens transmitted via meridian transmission progress gradually, whereas pathogens causing Lianggan progress rapidly. This is because the yang pathogen is fierce, and the righteous qi cannot resist it. Consequently, after three days, the intake of fluids ceases, the qi of the six fu organs is about to perish, consciousness is lost, and the spirit of the five zang organs has failed. The reason for not dying immediately is that the stomach qi has not yet completely exhausted. Therefore, after another three days, the qi fully exhausts, leading to death. Zhang Jiegu formulated Da Qianghuo Tang (Great Notopterygium Decoction), using herbs such as Qianghuo (Notopterygii Rhizoma et Radix), Duhuo (Angelicae Pubescentis Radix), Huangqin (Scutellariae Radix), and Lianhua (Lotus Plumule), employing acrid-sweet properties to disperse the exterior pathogen of Taiyang and bitter-cold properties to clear the interior heat of Shaoyin. This method is appropriate for cases where the exterior and interior conditions are not urgent. However, if on the first day there is headache, dry mouth, irritability, and thirst; on the second day, fever, delirium, abdominal fullness, and anorexia; and on the third day, deafness, retraction of the testicles, cold limbs, inability to take fluids, and coma, with such rapid progression, using the mild Da Qianghuo Tang may cause one to miss the optimal treatment window. One should follow Zhang Zhongjing’s principle of prioritizing treatment based on urgency, assessing whether the exterior or interior condition is more critical, and treating according to the syndrome, which might still offer a chance of survival. Thus, for this syndrome at its onset, if both exterior and interior present with heat on the first day, following the method for Shaoyin disease presenting with dry mouth and throat after two or three days, use a heavy dose of Dachengqi Tang (Major Order the Qi Decoction) to purge the fierce yang pathogen. If both exterior and interior present with cold, following the method for early-stage Shaoyin disease presenting with fever and a deep pulse, use Mahuang Fuzi Xixin Tang (Ephedra, Aconite, and Asarum Decoction) to relieve the urgent yin pathogen. On the second day, if both exterior and interior present with excess, following the method for Yangming disease with delirium, tidal fever, abdominal fullness that occasionally relieves but insufficiently, use Dachengqi Tang to attack. If both exterior and interior present with deficiency, following the method for combined disease of the three yang meridians with abdominal fullness, heaviness of the body, greasy complexion, and delirium, use a large dose of Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) to clear. On the third day, if both exterior and interior present with heat, following the principle that "the deeper the cold reversal, the deeper the heat," use Dachengqi Tang to purge. If both exterior and interior present with cold, following the method for faint pulse and cold limbs, use Danggui Sini Jia Wuzhuyu Shengjiang Tang (Angelica Sinensis Decoction Modified with Evodia and Fresh Ginger) to warm. Delayed treatment will be ineffective. Some patients do survive among these cases; future practitioners must pay close attention.