痛。或利止脉不出者。通脉四逆汤主之。其脉即出者愈。
清谷。清水完谷也。里寒外热。阴盛格阳于外也。寒甚于里。故下利清谷。四肢厥逆而脉见微细欲绝也。
寒甚则当恶寒。而反不恶寒。寒甚则面不当赤而反赤色。虚阳上浮而戴阳也。寒邪在里。或作腹痛。阴气上逆。
或作干呕。少阴之脉循喉咙。若阴盛迫阳于上。或作咽痛。寒凝水涸而利反止。阴盛阳衰之极。营血不流。
阳气不行而至于脉不出者。当以通脉四逆汤主之。前阳明中寒。表热里寒。下利清谷者。尚以四逆汤主之。况
少阴乎。服汤后。阳回气动。其脉即出而仍还于有者。乃阳气未竭。一时为盛寒所抑。郁伏不出耳。故即出为
愈也。然即出之脉。与下文暴出者异。所谓即出者。言即渐而出。至于复有。自有而常有。所以为愈。不若暴
出之自无而忽有。既有而仍无。如灯光之回焰。乃阳气已竭。得汤之温暖。而作返照之光。则阳气欲绝而死矣。
通脉四逆汤方
甘草（三两炙） 干姜（三两） 附子（大者一枚生去皮破八片）
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。
通脉四逆汤。即四逆汤而增入甘草一两。倍加干姜也。四逆汤义。见太阳下编阳旦条下。愚窃论之。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。其后加减法。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。
面色赤者。加葱九茎。
面色之赤。乃阴盛格阳。虚阳上泛。附子之温。能直达命门。大补坎中之真阳。自能引火归源。导龙归海。
何必葱白。其所以用葱白者。盖为阳气不得流通。下利脉微。至厥逆无脉而设也。夫脉者。气血流行之发现处也。
阴血非阳气不行。寒邪固闭。阳气郁伏。故以葱白通行阳气。助姜附温经复脉之功耳。然葱之功力。岂能导火归根。
而能治面色之赤哉。吾不信也。
腹中痛者。去葱加芍药二两。
寒邪在里而腹痛。既有姜附。自可温中。即加芍药。更为相宜矣。脉又不至。何必去葱。揆之于理。岂非庸
俗之见乎。
呕者。加生姜二两。
姜能宣通阳气而解散寒邪。且千金谓生姜为呕家圣药。加入为宜。
咽痛者。去芍药。加桔梗一两。
此所谓少阴咽痛者。以少阴之脉贯肾络于肺。循喉咙。挟舌本。所谓咽者。阴阳应象论云。地气通于嗌。嗌者。
咽物之咽也。地气者。肾中命门之阳气也。犹天地之气。一阳生于黄泉之义。此以阴盛迫阳。下焦真阳失守。虚火在上。
故作
咽痛。附子峻补真阳。直走下焦。引火归根。其痛自止。未可与下文热在少阴。二三日咽痛。与甘草桔梗
汤同论也。一寒一热。阴阳迥殊。况桔梗为舟楫之剂。乘载药力以入肺。不使下行之品。正欲令其虚火
下降为宜。岂可更与上焦风热。肺家天气病之喉痛。同日而语哉。至于芍药。性虽酸收。亦可敛火下降。
其去留亦无大关系。又何足论哉。
利止脉不出者。去桔梗。加人参二两。
桔梗固为当去。而人参之加。亦可以助姜附而补下利清谷之虚。并可以补气血而鼓动其不至之脉。可
称允当。
少阴病。下利。白通汤主之。
上文下利已多。皆属寒在少阴。下焦清阳不升。胃中阳气不守之病。而未有用白通汤者。此条但云下
利。而用白通汤者。以上有少阴病三字。则知有脉微细。但欲寐。手足厥之少阴证。观下文下利脉微。方
与白通汤。则知之矣。利不止而厥逆无脉。又加猪胆人尿。则尤知非平常下利矣。盖白通汤。即四逆汤
而以葱易甘草。甘草所以缓阴气之逆。和姜附而调护中州。葱则辛滑行气。可以通行阳气而解散寒邪。
二者相较。一缓一速。故其治亦颇有缓急之殊也。
白通汤方
葱白（四茎） 干姜（一两） 附子（一枚生用去皮破八片）
上三味。以水三升。煮取一升。去滓。分温再服。（义见注中）
少阴病。下利脉微者。与白通汤。利不止。厥逆无脉。干呕烦者。白通汤加猪胆汁汤主之。服汤脉
暴出者死。微续者生。
上文少阴下利。即以白通汤主之矣。此则下利而脉微。足见阳气愈微。故与白通汤以恢复真阳。消除寒气。
不谓服汤之后。利仍不止。反见四肢厥逆而无脉。阴邪上逆而干呕。虚阳受迫而作烦闷者。此非药之误也。
以阴寒太盛。热药不得骤入。阴邪纵肆猖獗。 格而不入耳。故用素问至真要大论中热因寒用之法。从而
逆之。反佐以取之。所谓寒热温凉。反从其病之义也。故用咸寒下走之人尿。苦寒滑下之猪胆。以反从其
阴寒之性。导姜附之辛热下行。为反佐入门之导引。王启玄所谓下嗌之后。冷体既消。热性便发。使其气
相从。而无拒格之患也。服汤后。其脉忽暴出者。是将绝之阳。得热药之助。勉强回焰。一照而熄。故死。
若得汤而其脉微续渐出者。为阳气复回。故为生也。阴寒至此。真阳或几乎熄矣。危哉。
少阴负趺阳者。为顺也。
少阴负趺阳句。疑有脱字。不然。何至词不达义耶。前注皆以少阴为水。趺阳为土。恐土不能制水。
得以泛溢而为呕吐下利。予其权于土。土强则水有制而平成可几。愚恐犹未合于至理。夫少阴。肾也。
水中有火。先天之阳也。趺阳。胃脉也。火生之土。后天之阳也。此承上文下利而言。凡少阴证中诸阳虚
阴盛之证。而至于下利。及下利清谷之证。皆由寒邪太盛。非惟少阴命门真火衰微。且火不能生土。中
焦胃脘之阳不守。故亦败泄而为下利。少阴脉虽微细欲绝。而为阴寒所胜。则为少阴之真阳负矣。若趺阳
脉尚无亏损。则是先天之阳。虽为寒邪之所郁伏。而后天胃脘之阳尚在。为真阳犹未磨灭。所谓有胃气者生。
故为顺也。若趺阳亦负。则为无胃气而死矣。
少阴病。脉微沉细。但欲卧。汗出不烦。自欲吐。至五六日自利。后烦躁。不得卧寐者死。
首条云少阴之为病。脉微细。但欲寐也。此条又见沉脉。则寒邪更深。汗出者。内无真阳。卫气不固而腠理不收也。
不烦者。虚阳犹未上奔也。自欲吐。即前欲吐不吐之证也。少阴之见证如此。乃当急温急补之时。
失此不治。至五六日而更加自利。乃至不烦之证。至阳欲亡而作烦。阴迫阳而发躁。以但欲寐者而不得卧寐。则
阳神飞越。真气败亡而死矣。虽欲温之。所谓渴而穿井。斗而铸兵。不亦晚乎。
少阴病。恶寒身蜷而利。手足逆冷者不治。
前恶寒而蜷。因有烦而欲去衣被之证。为阳气犹在。故为可治。又下利自止。恶寒而蜷。以手足温者。
亦为阳气未败。而亦曰可治。此条恶寒身蜷而利。且手足逆冷。则四肢之阳气已败。故不温。又无烦与欲去衣被
之阳气尚存。况下利又不能止。是为阳气已竭。故为不治。虽有附子汤。及四逆白通等法。恐亦不能挽回既
绝之阳矣。
少阴病。吐利烦躁四逆者死。
寒邪上逆则吐。下攻则利。阳虚则烦。阴极则躁。而四肢乃诸阳之本也。以吐利烦躁并作。而又四肢逆冷。
为阳气竭绝。故死。虽不言脉。脉亦可知矣。
少阴病。下利止而头眩。时时自冒者死。
前条利自止而手足温。则为可治。此则下利止而头眩。头眩者。头目眩晕也。且时时自冒。冒者。蒙冒昏晕也。
虚阳上冒于巅顶。则阳已离根而上脱。下利无因而自止。则阴寒凝闭而下竭。是亦所谓上厥下竭矣。于此可见阳回
之利止则可治。阳脱之利止则必死矣。正所谓有阳气则生。无阳气则死也。然既曰死证。则头眩自冒之外。或更有恶寒
四逆等证。及可死之脉。未可知也。但未备言之耳。
少阴病。四逆恶寒而身蜷。脉不至。不烦而躁者死。
恶寒身蜷而利。手足逆冷者。固为不治。此条但不利耳。下文吐利烦躁四逆者死。此虽不吐利。而已不
见阳烦。但见阴躁。则有阴无阳矣。其为死证无疑。况又脉不至乎。前已有脉不至者。因反发热。故云不死。
又有脉不出者。虽里寒而犹有外热。身反不恶寒而面赤。其阳气未绝。故有通脉四逆汤之治。此则皆现阴
极无阳之证。且不烦而躁。并虚阳上逆之烦。亦不可得矣。宁有不死者乎。
少阴病。六七日息高者死。
少阴病而至六七日不解。其本经之自受者。至此则阴邪已深。脏气已败。若传经之邪。自阳入阴。五日而少
阴受之。又已三日。亦不为不深矣。一呼一吸为一息。人身阳气。出自下焦。故命门为三焦之原。阳气上行而
为宗气。聚于膻中。故膻中为气之海。上通于肺而为呼吸。一息而脉行六寸。一日一夜。共一万三千五百息。
当万物之数。脉行八百一十丈。其气皆由丹田之关元气海而出。谓之胞中气街者是也。所以肺主出气而肾主纳气。
一呼一吸而肾为之本。肺为之末。以少阴肾脏受邪。至于喘息之声已高。是膻中之气。有出无入。欲归丹田而
纳诸肾脏。其可得乎。阳气离根。已从上脱。有不立尽者耶。
疼痛。如果腹泻停止但脉搏无法触及的，用通脉四逆汤主治。如果服药后脉搏随即恢复的，就会痊愈。
完谷不化（大便中含有未消化的食物）。清水完谷是指大便中既有清水又有未消化的食物。这是里寒外热、阴寒内盛将阳气格拒于外的表现。因为寒邪在体内严重，所以出现下利清谷；四肢厥冷逆乱，脉搏表现为微弱细软，似有似无。
寒邪严重时应当恶寒，反而不恶寒；寒邪严重时面色本不应发红，反而出现红色。这是虚阳上浮导致的戴阳证。寒邪在体内，有时引起腹痛；阴气上逆，有时引起干呕。少阴经脉循行经过喉咙，如果阴寒过盛逼迫阳气上浮，有时会引起咽痛。寒凝导致津液枯竭而下利反而停止，这是阴盛阳衰到了极点，营血运行不畅，阳气不能通行而导致脉搏无法触及的情况，应当用通脉四逆汤主治。之前阳明中寒，表热里寒，下利清谷的，还用四逆汤主治，何况是少阴病呢？服用汤药后，阳气回复，气动，脉搏随即恢复并重新变得有力，这说明阳气没有竭绝，只是一时被盛寒所抑制，郁伏而不能外达。所以脉搏随即恢复就是痊愈。然而这种“即出”的脉搏，与下文提到的“暴出”是不同的。所谓“即出”，是说脉搏逐渐复出，直到恢复正常，由无到有，再由有到常，这才是痊愈。不像“暴出”那样从无突然变为有，有了之后又立刻消失，就像灯光回光返照一样，那是阳气已经竭绝，得到汤药的温暖而发出的最后光芒，这预示着阳气将要绝灭而死。
通脉四逆汤方
甘草（三两，炙） 干姜（三两） 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，去渣，分两次温服。服药后脉搏随即恢复的，就会痊愈。
通脉四逆汤，就是在四逆汤的基础上增加甘草一两，加倍使用干姜。四逆汤的含义，见太阳篇下编阳旦条之下。我私下议论，既然在四逆汤基础上加倍干姜，其助阳的力量或许更强。但既然增加了“通脉”二字，自然有所不同。恐怕是已经加入了葱白以通达阳气，具有白通汤的意义，所以有此名称。怀疑是年代久远产生的讹误，或者是编纂时的失误，导致原方中脱落了葱白，这也是未可知的事。后面的加减法，揣测其词义浅陋，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症状，然后给出方剂确立治法，那么一通脉四逆汤，其证候都可以概括了，哪里还需要继续添加加减法呢？况且其立意庸俗恶劣，都出自鄙陋之辈之手。我不敢完全删去，暂且保留它以供有见识的人鉴别。
面色发红的，加葱九茎。
面色的红，是阴盛格阳，虚阳上泛。附子的温热，能直达命门，大补坎中的真阳，自然能引火归源，导龙归海，何必用葱白？之所以用葱白，是因为阳气不得流通，针对下利脉微，甚至厥逆无脉的情况而设的。脉，是气血流行的显现之处。阴血非阳气推动不能运行，寒邪固闭，阳气郁伏，所以用葱白通行阳气，辅助姜、附温经复脉的功效罢了。然而葱白的功力，怎么能引导火气归根，治疗面色发红呢？我不相信这一点。
腹中痛的，去掉葱白，加芍药二两。
寒邪在体内导致腹痛，既有姜、附，自然可以温中，再加芍药，更为适宜。但是脉搏又不至，何必去掉葱白？推究其理，难道不是庸俗之见吗？
呕吐的，加生姜二两。
生姜能宣通阳气而解散寒邪，而且《千金方》称生姜为呕家圣药，加入为宜。
咽痛的，去掉芍药，加桔梗一两。
这就是所说的少阴咽痛。因为少阴经脉贯穿肾脏络于肺，循行喉咙，挟持舌根。所谓咽，在《阴阳应象大论》中说：“地气通于嗌。”嗌，就是吞咽食物的咽部。地气，就是肾中命门的阳气。犹如天地之气，一阳生于黄泉的道理。这里是因为阴盛逼迫阳气，下焦真阳失守，虚火在上，所以造成咽痛。附子峻补真阳，直走下焦，引火归根，疼痛自然停止。这不能与下文热在少阴，二三日咽痛，用甘草桔梗汤同论。一寒一热，阴阳截然不同。况且桔梗是舟楫之剂，承载药力进入肺脏，不让下行性质的药物直接下行，正希望它让虚火下降为宜，怎么可以和上焦风热、肺家天气病的喉痛同日而语呢？至于芍药，性虽酸收，也可以收敛火气下降，它的去留也没有太大关系，又有什么可讨论的呢？
下利停止但脉搏无法触及的，去掉桔梗，加人参二两。
桔梗固然应当去掉，而加入人参，也可以辅助姜、附来补益下利清谷造成的虚弱，并且可以补益气血而鼓动那不至的脉搏，可以说是恰当的。
少阴病，下利，用白通汤主治。
上文提到的下利很多，都属于寒在少阴，下焦清阳不升，胃中阳气不守的病证，但没有用到白通汤的。这一条只说下利，而用白通汤，是因为上面有“少阴病”三个字，就知道有脉微细、但欲寐、手足厥冷的少阴证。看下文“下利脉微，方与白通汤”，就知道了。如果利不止且厥逆无脉，又加猪胆、人尿，那就更知道这不是平常的下利了。大概白通汤，就是四逆汤用葱白代替甘草。甘草是用来缓和阴气的上逆，调和姜、附而调护中州的；葱白则是辛散滑利行气，可以通行阳气而解散寒邪。两者相比，一缓一速，所以它们的治疗也有颇有缓急的不同。
白通汤方
葱白（四茎） 干姜（一两） 附子（一枚，生用，去皮，破成八片）
以上三味药，用水三升，煮取一升，去渣，分两次温服。（含义见注释中）
少阴病，下利脉微的，给予白通汤。如果利不止，厥逆无脉，干呕心烦的，用白通汤加猪胆汁汤主治。服药后脉搏突然暴出的会死，脉搏微微续接的会生。
上文少阴下利，直接用白通汤主治了。这里则是下利而脉微，足见阳气更加微弱，所以给予白通汤以恢复真阳，消除寒气。没想到服药之后，利仍不止，反而出现四肢厥逆而无脉，阴邪上逆而干呕，虚阳受迫而作烦闷的情况。这不是药误。而是因为阴寒太盛，热药不得骤然进入，阴邪放纵猖獗，格拒而不入。所以用《素问·至真要大论》中“热因寒用”的方法，从而逆其病势，反佐以取效。这就是所谓寒热温凉，反从其病性的意思。所以用咸寒下走的人尿，苦寒滑下的猪胆，以反从其阴寒之性，引导姜、附的辛热下行，作为反佐入门的导引。王启玄所说“下咽之后，冷体既消，热性便发”，使其气相从，而没有拒格之患。服药后，脉搏忽然暴出的，是将绝之阳，得到热药的帮助，勉强回光返照，一照就熄灭，所以死。如果得汤药后脉搏微微续接渐出的，是阳气复回，所以为生。阴寒到了这种地步，真阳几乎要熄灭了，危险啊！
少阴脉负于趺阳脉的，为顺证。
“少阴负趺阳”这句，怀疑有脱字，不然，怎么会词不达意呢？之前的注释都以少阴为水，趺阳为土，恐怕土不能制水，得以泛溢而为呕吐下利，赋予土以权柄，土强则水有制约而平成有望。我担心这仍未合乎至理。夫少阴，是肾，水中有火，是先天之阳。趺阳，是胃脉，火生之土，是后天之阳。这是承接上文下利而言。凡是少阴证中诸阳虚阴盛的证候，而至于下利，以及下利清谷的证候，都是因为寒邪太盛，不仅少阴命门真火衰微，而且火不能生土，中焦胃脘之阳不守，所以也败泄而为下利。少阴脉虽然微细欲绝，被阴寒所胜，那就是少阴的真阳“负”了。如果趺阳脉还没有亏损，那就是先天之阳，虽然被寒邪所郁伏，而后天胃脘之阳尚在，真阳尚未磨灭，所谓有胃气者生，所以为顺证。如果趺阳脉也负，那就是无胃气而死证了。
少阴病，脉微沉细，只想睡觉，出汗且不烦躁，自己想要呕吐，到了五六天自下利，后来烦躁，不能卧睡的，死。
首条说少阴之为病，脉微细，但欲寐。这一条又见到沉脉，说明寒邪更深。汗出，是因为内无真阳，卫气不固而腠理不收。不烦，是因为虚阳还未上奔。自欲吐，就是前面说的欲吐不吐的证候。少阴的见证如此，正当紧急温补的时候。错过这个时机不治疗，到了五六天而更加自利，乃至从不烦的证候，发展到阳气欲亡而作烦，阴迫阳而发躁，以本来只想睡觉的人却不得卧睡，那么阳神飞越，真气败亡而死。虽然想温补，所谓渴了才挖井，打仗了才铸兵器，不也太晚了吗？
少阴病，恶寒身体蜷缩而下利，手足逆冷的，不治。
前面的恶寒而蜷，因为有烦躁而想去除衣被的证候，说明阳气犹在，所以为可治。又有下利自止，恶寒而蜷，因为手足温暖的，也是阳气未败，也说可治。这一条恶寒身体蜷缩而下利，且手足逆冷，那么四肢的阳气已败，所以不温。又没有烦躁和想去除衣被的阳气尚存，况且下利又不能止，这是阳气已竭，所以为不治。虽然有附子汤，及四逆、白通等法，恐怕也不能挽回既绝之阳了。
少阴病，吐利烦躁四逆的，死。
寒邪上逆则吐，下攻则利。阳虚则烦，阴极则躁。而四肢乃诸阳之本。以吐利烦躁并作，而又四肢逆冷，为阳气竭绝，所以死。虽然没提脉，脉也可知了。
少阴病，下利止而头眩，时时自冒的，死。
前条利自止而手足温，则为可治。这里则是下利止而头眩。头眩，就是头目眩晕。且时时自冒。冒，就是蒙冒昏晕。虚阳上冒于巅顶，则阳已离根而上脱。下利无因而自止，则阴寒凝闭而下竭。这也是所谓上厥下竭。于此可见阳回之利止则可治，阳脱之利止则必死矣。正所谓有阳气则生，无阳气则死也。既然说是死证，那么头眩自冒之外，或许还有恶寒四逆等证，以及可死的脉，也未可知。只是没有详细陈述罢了。
少阴病，四逆恶寒而身蜷，脉不至，不烦而躁的，死。
恶寒身蜷而下利，手足逆冷的，固然是不治。这一条只是不下利。下文说吐利烦躁四逆的死。这里虽然不吐利，但已经不见阳烦，只见阴躁，则有阴无阳了。其为死证无疑。况且又脉不至呢？前面已有脉不至的，因为反发热，所以说不死。又有脉不出的，虽然里寒而犹有外热，身体反而不恶寒而面色赤，其阳气未绝，所以有通脉四逆汤的治疗。这里则全是现阴极无阳的证候，且不烦而躁，连虚阳上逆的烦也不可得了，哪有能活的呢？
少阴病，六七天息高的，死。
少阴病而至六七天不解，其本经自受的病邪，到这里则阴邪已深，脏气已败。如果是传经之邪，自阳入阴，五日而少阴受之，又过了三天，也不算不深了。一呼一吸为一息。人身阳气，出自下焦，所以命门为三焦之原，阳气上行而为宗气，聚于膻中，所以膻中为气之海，上通于肺而为呼吸。一息而脉行六寸，一日一夜，共一万三千五百息，当万物之数，脉行八百一十丈，其气皆由丹田之关元气海而出，谓之胞中气街的就是这个。所以肺主出气而肾主纳气，一呼一吸而肾为之本，肺为之末。以少阴肾脏受邪，至于喘息之声已高，是膻中之气，有出无入，想归丹田而纳诸肾脏，怎么可能呢？阳气离根，已从上脱，有不立即尽绝的吗？
Pain. If diarrhea ceases but the pulse is unobtainable, Tongmai Sini Tang (Cinnamon Twig and Aconite Decoction for Unblocking the Pulse) should be administered. If the pulse returns immediately after administration, recovery will ensue.
Passing undigested food in stool (Qinggu). "Clear water and undigested food" refers to stools containing both clear fluid and undigested food particles. This indicates interior cold with exterior heat, where excess Yin repels Yang to the exterior due to severe interior cold. Because the cold is severe in the interior, diarrhea with undigested food occurs; the four limbs are cold and reversed, and the pulse appears faint, fine, and nearly absent.
When cold is severe, aversion to cold should occur, yet there is no aversion to cold. When cold is severe, the face should not be red, yet it appears red. This is Daiyang syndrome (Daiyang condition), where deficient Yang floats upward. Cold pathogen resides in the interior, sometimes causing abdominal pain; when Yin Qi rebels upward, dry retching may occur. The Shaoyin meridian circulates along the throat. If excess Yin forces Yang upward, pharyngeal pain may result. Cold coagulation and fluid depletion cause diarrhea to stop; this represents the extreme of excess Yin and deficient Yang, where Ying blood does not flow and Yang Qi cannot circulate, leading to an unobtainable pulse. In such cases, Tongmai Sini Tang should be administered. Previously, in Yangming middle-jiao cold with exterior heat, interior cold, and diarrhea with undigested food, Sini Tang was used. How much more so for Shaoyin disease? After taking the decoction, if Yang recovers and Qi moves, and the pulse returns becoming palpable, it indicates that Yang has not exhausted; it was merely suppressed by severe cold and郁伏 (depressed and hidden), unable to emerge. Thus, immediate return of the pulse signifies recovery. However, this "immediate return" differs from the "sudden emergence" mentioned later. "Immediate return" means the pulse gradually emerges until it becomes normal—going from non-existent to existent, then to constant—which constitutes recovery. It is unlike "sudden emergence," which appears abruptly from nothing, exists briefly, then vanishes again, like a candle flame flickering back before extinguishing. This indicates exhausted Yang receiving warmth from the decoction as a final reflection, signaling impending death due to Yang exhaustion.
Tongmai Sini Tang Formula
Gancao (Licorice Root, 3 liang, honey-fried)
Ganjiang (Dried Ginger, 3 liang)
Fuzi (Prepared Aconite Root, one large piece, raw, skin removed, broken into eight pieces)
The above three ingredients are boiled in three sheng of water to obtain one sheng and two he. Strain the dregs. Divide into two warm doses. If the pulse returns immediately after ingestion, recovery ensues.
Tongmai Sini Tang is essentially Sini Tang with one additional liang of Gancao and doubled Ganjiang. The meaning of Sini Tang is explained under the Yangdan section of the Taiyang chapter. I privately argue that doubling Ganjiang in Sini Tang enhances its Yang-assisting power. However, since the term "Tongmai" (Unblocking Pulse) is added, it must differ. It is likely that Congbai (Scallion White) was originally added to unblock Yang Qi, possessing the significance of Baitong Tang, hence the name. It is suspected that this is an error from long ago or a compilation mistake, causing Congbai to be omitted from the original formula. The subsequent modification methods seem shallow and vulgar, 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 Tang covers all these syndromes; why add further modifications? Moreover, the reasoning is crude and base, likely originating from inferior practitioners. I dare not delete it entirely but retain it for scholars' reference.
If the face is red, add nine stalks of Congbai.
Facial redness results from excess Yin repelling Yang, causing deficient Yang to float upward. Fuzi’s warmth reaches the Mingmen (Gate of Life) directly, greatly supplementing the True Yang within Kan. It naturally guides fire back to its source and leads dragons to the sea. Why use Congbai? Congbai is used because Yang Qi fails to circulate freely, specifically for cases of diarrhea, faint pulse, even cold extremities and unobtainable pulse. The pulse is the manifestation of Qi and Blood circulation. Yin Blood requires Yang Qi to move. Cold pathogen constricts, depressing Yang Qi; thus, Congbai is used to unblock Yang Qi, assisting Jiang and Fu in warming meridians and restoring the pulse. Yet, can Congbai truly guide fire back to its root and treat facial redness? I do not believe so.
If there is abdominal pain, remove Congbai and add Shaoyao (Peony Root), 2 liang.
Cold pathogen in the interior causing abdominal pain is already addressed by Jiang and Fu for warming the middle. Adding Shaoyao is appropriate. But if the pulse is still unobtainable, why remove Congbai? Reasoning suggests this view is vulgar.
If there is vomiting, add Shengjiang (Fresh Ginger), 2 liang.
Shengjiang promotes Yang Qi circulation and disperses cold pathogen. Furthermore, Qianjin Fang regards Shengjiang as the sacred medicine for vomiting, making its addition suitable.
If there is pharyngeal pain, remove Shaoyao and add Jiegeng (Platycodon Root), 1 liang.
This refers to Shaoyin pharyngeal pain. The Shaoyin meridian passes through the Kidney, connects to the Lung, circulates along the throat, and binds to the tongue base. As stated in the *Yin Yang Ying Xiang Da Lun* (Great Treatise on Images Correspondence of Yin and Yang): "Earth Qi connects to the Yi." Yi refers to the pharynx for swallowing. Earth Qi is the Yang Qi of the Kidney’s Mingmen, analogous to Heaven and Earth Qi, where one Yang arises from the Yellow Springs. Here, excess Yin forces Yang upward, the Lower Jiao’s True Yang loses control, and deficient fire rises, causing pharyngeal pain. Fuzi strongly supplements True Yang, acting directly on the Lower Jiao to guide fire back to its root, stopping pain. This should not be conflated with heat in Shaoyin causing pharyngeal pain after two to three days, treated with Gancao Jiegeng Tang. One is cold, one is heat; Yin and Yang are vastly different. Moreover, Jiegeng acts as a boat and oar, carrying medicinal power into the Lung, preventing downward-draining agents from going down too quickly, aiming to descend deficient fire. How can it be equated with upper Jiao wind-heat or Lung Tianqi diseases causing sore throat? Regarding Shaoyao, although its nature is sour and astringent, it can also gather fire and direct it downward. Its removal or retention makes little difference, warranting little discussion.
If diarrhea stops but the pulse is unobtainable, remove Jiegeng and add Renshen (Ginseng Root), 2 liang.
Removing Jiegeng is correct. Adding Renshen assists Jiang and Fu in tonifying deficiency caused by diarrhea with undigested food, and tonifies Qi and Blood to stimulate the unobtainable pulse. This is considered appropriate.
Shaoyin disease with diarrhea is primarily treated with Baitong Tang.
Previous mentions of diarrhea mostly belonged to cold in Shaoyin, where Lower Jiao Clear Yang fails to ascend and Stomach Yang fails to guard. None used Baitong Tang. This clause only says "diarrhea" but uses Baitong Tang because of the preceding "Shaoyin disease," implying symptoms like faint/fine pulse, desire to sleep, and cold extremities characteristic of Shaoyin. Observing the later text: "Diarrhea with faint pulse, then give Baitong Tang," confirms this. If diarrhea continues with cold extremities and unobtainable pulse, adding Pig Gallbladder Juice and Human Urine indicates this is not ordinary diarrhea. Essentially, Baitong Tang is Sini Tang replacing Gancao with Congbai. Gancao moderates rebellious Yin Qi, harmonizes Jiang and Fu, and protects the Middle Jiao. Congbai is pungent, slippery, and moves Qi, unblocking Yang Qi and dispersing cold. Compared, one is slow, one is fast; thus, their treatments differ in urgency.
Baitong Tang Formula
Congbai (Scallion White, 4 stalks)
Ganjiang (Dried Ginger, 1 liang)
Fuzi (Prepared Aconite Root, one piece, raw, skin removed, broken into eight pieces)
The above three ingredients are boiled in three sheng of water to obtain one sheng. Strain. Divide into two warm doses. (Meaning seen in notes.)
Shaoyin disease with diarrhea and faint pulse: Give Baitong Tang. If diarrhea continues, with cold extremities, unobtainable pulse, dry retching, and irritability: Treat with Baitong Tang plus Pig Gallbladder Decoction. If the pulse suddenly emerges violently after ingestion, death ensues; if the pulse slowly and continuously returns, life ensues.
Previously, Shaoyin diarrhea was treated directly with Baitong Tang. Here, diarrhea with faint pulse indicates even weaker Yang, so Baitong Tang is given to restore True Yang and eliminate cold. Unexpectedly, after ingestion, diarrhea persists, worsening to cold extremities, unobtainable pulse, dry retching from Yin rebellion, and irritability from forced deficient Yang. This is not a medication error. Severe Yin-cold prevents hot medicines from entering immediately; rampant Yin pathogen repels them. Therefore, following the *Suwen: Zhi Zhen Yao Da Lun* principle of "treating heat with cold" (using cold substances to facilitate entry of hot drugs), we reverse the approach using counter-agents. This aligns with the concept of opposing the disease's nature with contrary temperatures. Thus, salty-cold Human Urine descending downward and bitter-cold Pig Gallbladder Juice are used to mimic Yin-cold properties, guiding the pungent-hot Jiang and Fu downward as introductory counter-agents. Wang Qixuan stated: "After swallowing, the cold nature dissipates, and the hot nature activates," allowing Qi to follow without rejection. If the pulse suddenly emerges violently after ingestion, the dying Yang receives help from hot medicine, forcing a brief resurgence before extinguishing—death. If the pulse slowly and continuously returns after ingestion, Yang recovers—life. At this stage of Yin-cold, True Yang is nearly extinguished. Dangerous!
If the Shaoyin pulse is "negative" relative to the Fuyang pulse, it is a favorable sign.
The phrase "Shaoyin negative Fuyang" likely has missing characters, otherwise, it lacks clarity. Previous annotations viewed Shaoyin as Water and Fuyang as Earth, fearing Earth cannot control Water, leading to overflow causing vomiting and diarrhea, empowering Earth to control Water. I fear this does not fully align with profound principles. Shaoyin is the Kidney, Water containing Fire, the Pre-heaven Yang. Fuyang is the Stomach pulse, Fire-generated Earth, the Post-heaven Yang. Continuing from the previous context of diarrhea: In Shaoyin syndromes with Yang deficiency and Yin excess leading to diarrhea or passing undigested food, it is due to excessive cold. Not only is the Mingmen True Fire weak, but Fire fails to generate Earth, causing Middle Jiao Stomach Yang to fail, resulting in leakage and diarrhea. Although the Shaoyin pulse is faint, fine, and nearly absent, overcome by Yin-cold, the Shaoyin True Yang is "defeated" (fu). If the Fuyang pulse remains intact, although Pre-heaven Yang is depressed by cold, Post-headen Stomach Yang remains. True Yang is not yet erased. As stated, "Having Stomach Qi means life"; thus, it is favorable. If the Fuyang pulse is also defeated, there is no Stomach Qi, leading to death.
Shaoyin disease with faint, deep, fine pulse, desire to lie down, sweating without irritability, and spontaneous urge to vomit. By the fifth or sixth day, spontaneous diarrhea occurs. Later, irritability develops, preventing sleep. This is fatal.
The first clause states Shaoyin disease features faint/fine pulse and desire to sleep. This clause adds a deep pulse, indicating deeper cold. Sweating indicates lack of internal True Yang, insecure Wei Qi, and open pores. Lack of irritability means deficient Yang has not yet rushed upward. Spontaneous urge to vomit corresponds to the earlier "urge to vomit but unable to." With these Shaoyin signs, urgent warming and tonification are required. Missing this window, by the fifth or sixth day, spontaneous diarrhea worsens. From non-irritable to irritability as Yang perishes, Yin pressing Yang causing restlessness. The one who desired sleep now cannot sleep; Yang Spirit flies away, True Qi perishes, leading to death. Even if one wishes to warm, it is like digging a well when thirsty or forging weapons when fighting—too late.
Shaoyin disease with aversion to cold, curled body posture, diarrhea, and cold extremities: Untreatable.
Earlier, aversion to cold and curling were treatable because irritability and desire to remove blankets indicated remaining Yang. Also, if diarrhea stopped, with cold/curled posture but warm extremities, Yang was not ruined, hence treatable. Here, aversion to cold, curled posture, diarrhea, and cold extremities indicate limb Yang is ruined, hence cold. There is no irritability or desire to remove blankets, indicating no residual Yang. Diarrhea does not stop. This is exhausted Yang, hence untreatable. Although Fuzi Tang, Sini Tang, and Baitong Tang exist, they likely cannot recover exhausted Yang.
Shaoyin disease with vomiting, diarrhea, irritability, and cold extremities: Fatal.
Cold pathogen rebelling upward causes vomiting; attacking downward causes diarrhea. Yang deficiency causes irritability (Fan); Yin extreme causes restlessness (Zao). Limbs are the root of all Yang. With vomiting, diarrhea, irritability, restlessness occurring together, plus cold extremities, Yang is exhausted. Hence fatal. Although pulse is not mentioned, it can be inferred.
Shaoyin disease with cessation of diarrhea, dizziness, and frequent sensation of being covered/misted: Fatal.
Previously, cessation of diarrhea with warm extremities was treatable. Here, cessation of diarrhea with dizziness. Dizziness refers to vertigo. Frequent "mao" (misted/covered sensation) implies mental confusion/dizziness. Deficient Yang floats to the vertex, detaching from its root and escaping upward. Diarrhea stops spontaneously without cause, indicating Yin-cold constricts and Lower Jiao exhausts. This is Upper Collapse and Lower Exhaustion. Thus, cessation of diarrhea due to Yang return is treatable; cessation due to Yang escape is fatal. As stated, "With Yang Qi, life; without Yang Qi, death." Since it is a fatal syndrome, besides dizziness and misted sensation, there may be other signs like aversion to cold, cold extremities, or fatal pulses, though not detailed.
Shaoyin disease with cold extremities, aversion to cold, curled body, unobtainable pulse, no irritability but restlessness: Fatal.
Aversion to cold, curled body, diarrhea, and cold extremities are untreatable. This clause omits diarrhea. The next clause states vomiting, diarrhea, irritability, and cold extremities are fatal. Here, although no vomiting/diarrhea, there is no Yang-related irritability, only Yin-related restlessness. Having Yin without Yang confirms fatality. Plus, unobtainable pulse. Earlier, unobtainable pulse was not fatal due to rebound fever. Another case had unobtainable pulse but exterior heat, no aversion to cold, and red face, indicating Yang not exhausted, treated with Tongmai Sini Tang. Here, all signs show Yin extreme and Yang absence. No irritability, only restlessness; even Yang-rebellion irritability is absent. How could survival be possible?
Shaoyin disease persisting six to seven days with high-pitched breathing: Fatal.
Shaoyin disease unresolved for six to seven days, whether self-infected or transmitted from Yang channels (entering Yin on the fifth day, lasting three more days), indicates deep Yin pathogen and failed Zang Qi. One breath cycle is one "xi." Body Yang originates from the Lower Jiao; Mingmen is the source of the San Jiao. Yang Qi ascends to become Zong Qi, gathering at Danzhong (Chest Center), the Sea of Qi, connecting to the Lung for respiration. Each breath moves the pulse six cun. In one day and night, there are 13,500 breaths, corresponding to the number of myriad things, moving the pulse 810 zhang. This Qi emanates from the Dantian/Guan Yuan Qi Hai, called Baozhong Qi Jie. Thus, the Lung governs exhalation, and the Kidney governs inhalation. Respiration relies on the Kidney as root and Lung as branch. With Shaoyin Kidney affected, wheezing sounds become high. This means Danzhong Qi exits but does not enter; returning to Dantian and storing in Kidneys is impossible. Yang Qi has detached from its root and escaped upward. Will it not perish immediately?