脉浮而迟，表热里寒，下利清谷者，四逆汤主之。
脉浮为在表，迟为在藏，浮中见迟，是浮为表虚，迟为藏寒。未经妄下而利清谷，是表为虚热，里有真寒
矣。仲景凡治虚证，以里为重，协热下利脉微弱者，便用人参，汗后身疼脉沉迟者，便加人参。此脉迟而利清
谷，且不烦不咳，中气大虚，元气已脱，但温不补，何以救逆乎？观茯苓四逆之烦躁，且用人参，况通脉四逆，
岂得无参？是必因本方之脱落而成之耳。
此是伤寒证。然脉浮表热，亦是病发于阳，世所云漏底伤寒也。必其人胃气本虚，寒邪得以直入脾胃，
不犯太、少二阳，故无口苦、咽干、头眩、项强痛之表证。然全赖此表热，尚可救其里寒。
下利清谷，不可攻表，汗出必胀满。
里气大虚，不能藏精而为阳之守，幸表阳之尚存，得以卫外而为固，攻之更虚其表。汗生于谷，汗出阳亡，
藏寒而生满病也。
下利腹胀满，身体疼痛，先温其里。
伤寒下之后，续得下利清谷不止，身疼痛者，急当救里，宜四逆汤。
下利是里寒，身痛是表寒。表宜温散，里宜温补。先救里者，治其本也。
病发热头疼，脉反沉，若不瘥，身体疼痛，当救其里，宜四逆汤。
此太阳麻黄汤证。病为在表，脉当浮而反沉，此为逆也。若汗之不瘥，即身体疼痛不罢，当凭其脉之沉而
为在里矣。阳证见阴脉，是阳消阴长之兆也。热虽发于表，为虚阳，寒反据于里，是真阴矣。必有里证伏而
未见，藉其表阳之尚存，乘其阴之未发，迎而夺之，庶无吐利厥逆之患，里和而表自解矣。
邪之所凑，其气必虚。故脉有余而证不足，则从证；证有余而脉不足，则从脉。有余可假，而不足为真，
此仲景心法。
大汗，若大下利，而厥冷者，四逆汤主之。
大汗则亡阳，大下则亡阴，阴阳俱虚，故厥冷。但利非清谷，急温之，阳回而生可望也。
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。
治之失宜，虽大汗出而热不去，恶寒不止，表未除也。内拘急而下利，里寒已发，四肢疼而厥冷，表寒又
见矣。可知表热里寒者，即表寒亡阳者矣。
呕而脉弱，小便复利，身有微热，见厥者难治，四逆汤主之。
呕而发热者，小柴胡证。此脉弱而微热，非相火明矣。内无热，
故小便利；表寒虚，故见厥；是膈上有寒饮，故呕也。伤寒以阳为主，阳消阴长，故难治。
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，四逆汤主之。
吐利交作，中气大虚，完谷不化，脉微欲绝，气血丧亡矣。小便复利而大汗出，是门户不要，玄府不闭矣。
所幸身热未去，手足不厥，则卫外之阳，诸阳之本犹在，脉尚未绝，有一线之生机，急救其里，正胜而邪可却
也。
吐利汗出，发热恶寒，四肢拘急，手足厥冷者，四逆汤主之。
此吐利非清谷，汗出不大，而脉不微弱，赖此发热之表阳，助以四逆而温里，尚有可生之望。
自利不渴者属太阴，以其藏有寒故也，当温之，宜四逆辈。
少阴病脉沉者，急温之，宜四逆汤。
若膈上有寒饮者，当温之，宜四逆汤。
恶寒脉微而复利，利止亡血也，四逆加人参汤主之。
利虽止而恶寒未罢，仍宜四逆；以其脉微为无血，当仍加人参以通之也。
上论四逆脉证。
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。
此寒热相半证。下利清谷，阴盛于里也；手足厥逆，寒盛于外也。身不恶寒面赤，阳郁在表也；咽痛利止，
阳回于内也。腹痛干呕，寒热交争也。温里通脉，乃扶阳之法。脉为司命，脉出则从阳而生，厥逆则从阴而死。
下利清谷，里寒外热，汗出而厥者，通脉四逆汤主之。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。
此比上条脉证皆轻，故能自作郁冒汗出而解。面赤为戴阳，阳在上也。因其戴阳，故郁冒而汗出；因其下虚，
故下利清谷而厥逆。热微厥亦微，故面亦少赤。此阴阳相等，寒热自和，故易愈。
吐已下断，汗出而厥，四肢拘急不解，脉微欲绝者，通脉四逆加猪胆汁汤主之。
此必有阴盛格阳之证，故加胆汁为反佐，阅白通证可知。
吐利止而脉平，小烦者，以新虚不胜谷气故也。
四逆汤∶
甘草（二两，炙） 干姜（一两半） 附子（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。强人可大附子一枚，干姜三两。
通脉四逆汤∶
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，煮取二升二合，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。
通脉四逆加猪胆汁汤∶
前方加猪胆汁一合。余同前法。
伤寒六七日，大下后，寸脉沉而迟，手足厥冷，下部脉不至，咽喉不利，吐脓血，泄利不止者，为难治。
寸脉沉迟，气口脉平矣。下部脉不至，根本已绝矣。六腑气绝于外者，手足寒；五脏气绝于内者，利下不禁。
咽喉不利，水谷之道绝矣。
汁液不化而成脓血，下濡而上逆。此为下厥上竭，阴阳离决之候，生气将绝于内也。旧本有麻黄升麻汤，其方味
数多而分两轻，重汗散而畏温补，乃后世粗工之伎，必非仲景方也。此证此脉，急用参、附以回阳，尚恐不救，
以治阳实之品，治亡阳之证，是操戈下石矣，敢望其汗出而愈哉？绝汗出而死，是为可必，仍附其方，以俟识者。
麻黄升麻汤∶
麻黄（二两半，去节） 升麻（一两一钱） 当归（一两一钱） 黄芩 葳蕤（各六铢） 芍药 知母（十
八铢） 天冬（去心） 桂枝（去皮） 干姜 甘草（炙） 石膏（碎绵裹） 白术 茯苓（各六钱）
上十四味，以水一斗，先煮麻黄一二沸，去上沫，内诸药，煮取三升，去滓，分温三服，相去如炊三斗米顷，
令尽汗出愈。
脉象浮而迟缓，表现为体表发热、体内虚寒，且伴有完谷不化的腹泻，应当用四逆汤主治。
脉浮说明病邪在表，脉迟说明病邪在脏（内脏），浮脉中兼见迟脉，意味着表气虚而有热，里气寒。未经误用攻下法而出现完谷不化的腹泻，说明表证是虚热，里有真寒。张仲景凡是治疗虚证，都以顾护里气为重；对于协热下利且脉象微弱的患者，便加入人参；对于发汗后身体疼痛且脉象沉迟的患者，便加入人参。此症脉迟且泻下完谷不化，且不烦躁不咳嗽，说明中气大虚，元气已脱，如果只温阳而不补气，怎么能挽救危逆之证呢？观察茯苓四逆汤证中出现烦躁，尚且用人参，何况通脉四逆汤证，难道可以没有参吗？这一定是因为原方中的药物脱落才变成现在的样子。
这是伤寒证。然而脉浮表热，也是病发于阳经，就是世人所说的“漏底伤寒”。必定是此人胃气原本虚弱，寒邪得以直接侵入脾胃，不侵犯太阳、少阳二经，所以没有口苦、咽干、头晕、项背强痛等表证。然而全赖这股表热，还可以救助里的寒邪。
里气大虚，不能固藏精气作为阳气的守备，幸好表阳尚存，能够卫护体表保持坚固，若攻表会更虚其表。汗液由水谷精微化生，出汗则阳气亡失，里寒盛而产生胀满病。
伤寒经过攻下之后，继续出现完谷不化的腹泻不止，身体疼痛的，应当紧急救治里气，适宜用四逆汤。
腹泻是里寒，身体疼痛是表寒。表证宜温散，里证宜温补。先救里，是治其根本。
患病发热头痛，脉象反而沉，如果不好转，身体疼痛，应当救治里气，适宜用四逆汤。
这是太阳病的麻黄汤证。病邪在表，脉象应当浮而反而沉，这是逆证。如果发汗后不好转，即身体疼痛不消除，应当凭据其脉象沉而判断为病在里了。阳证见到阴脉，是阳气消减、阴气增长的征兆。热虽然发于表，但是属于虚阳，寒反而占据于里，这是真阴。一定里有伏邪而未显现，凭借表阳尚存，趁着阴寒未大发，迎头截击，或许可以避免呕吐、腹泻、四肢厥逆的祸患，里气调和而表证自然解除。
邪气聚集的地方，正气必定虚弱。所以脉象有余而症状不足，就顺从症状判断；症状有余而脉象不足，就顺从脉象判断。有余可能是假象，而不足才是真实情况，这是张仲景的诊疗心法。
大汗则亡失阳气，大下利则亡失阴液，阴阳俱虚，所以四肢厥冷。但此处腹泻并非完谷不化，急需温阳，阳气回复则有望生存。
大汗出，发热不退，内部拘急挛缩，四肢疼痛，又伴有腹泻、四肢厥逆且恶寒的，用四逆汤主治。
治疗不当，虽然大汗出但热不退，恶寒不止，表证未除。内部拘急且腹泻，说明里寒已发作，四肢疼痛且厥冷，说明表寒又出现了。可知表热里寒者，其实就是表寒亡阳者。
呕吐且脉象弱，小便清长，身体有微热，出现四肢厥冷的难治，用四逆汤主治。
呕吐且发热者，是小柴胡汤证。此症脉弱而微热，不是相火旺盛。内无热，所以小便通利；表寒虚，所以出现厥冷；这是膈上有寒饮，所以呕吐。伤寒以阳气为主，阳气消减阴气增长，所以难治。
既呕吐又腹泻，小便清长，且大汗出，泻下完谷不化，内寒外热，脉象微弱几乎摸不到，用四逆汤主治。
吐利交作，中气大虚，完谷不化，脉象微弱几乎摸不到，气血丧亡。小便清长且大汗出，是门户失守，腠理不闭合。所幸身热未去，手足不厥冷，则卫外的阳气，诸阳之本犹在，脉尚未绝，还有一线生机，急救里气，正气胜则邪气可退。
呕吐腹泻，汗出，发热恶寒，四肢拘急，手足厥冷的，用四逆汤主治。
此处的吐利并非完谷不化，汗出不多，且脉象不微弱，依靠这股发热的表阳，借助四逆汤温补里气，尚有可生的希望。
自发性腹泻且不口渴的，属于太阴病，因为脏腑有寒，应当温补，适宜用四逆汤类方剂。
恶寒、脉微弱且腹泻，腹泻停止是因为亡血，用四逆加人参汤主治。
腹泻虽止但恶寒未罢，仍宜用四逆汤；因为其脉微弱表示无血，应当再加人参以通补。
以上论述四逆汤的脉证。
少阴病，下利完谷不化，里寒外热，手足厥逆，脉象微弱几乎摸不到，身体反而不恶寒，其人面色发红，或者腹痛、或者干呕、或者咽痛、或者腹泻停止、脉不出，用通脉四逆汤主治。
这是寒热各半的证候。下利完谷不化，是阴寒盛于里；手足厥逆，是寒盛于外。身体不恶寒且面赤，是阳气郁滞在表；咽痛且腹泻停止，是阳气回复于内。腹痛干呕，是寒热交争。温里通脉，是扶阳的方法。脉是生命的关键，脉复出则从阳而生，厥逆则从阴而死。
下利完谷不化，里寒外热，汗出且四肢厥冷的，用通脉四逆汤主治。下利脉沉而迟，其人面色微红，身体有微热，下利完谷不化的，必定会出现郁冒汗出而解，病患必定轻微厥冷。之所以这样，是因为面戴阳，下部虚的缘故。
这比上一条脉证都轻，所以能自行通过郁冒汗出而解。面赤为戴阳，阳气在上。因为戴阳，所以郁冒而汗出；因为下虚，所以下利完谷不化且厥逆。热微则厥亦微，所以面色也微红。这是阴阳相等，寒热自和，所以容易痊愈。
呕吐腹泻停止，但汗出且四肢厥冷，四肢拘急不缓解，脉象微弱几乎摸不到的，用通脉四逆加猪胆汁汤主治。
这必定是有阴盛格阳的证候，所以加胆汁作为反佐，参考白通汤证可知。
呕吐腹泻停止而脉象平和，轻微心烦的，是因为新虚不胜受纳谷气所致。
四逆汤：
甘草（二两，蜜炙） 干姜（一两半） 附子（一枚，生用，去皮，破成八片）
以上三味药，用水三升，煮取一升二合，去渣，分两次温服。体质强壮者可加大附子一枚，干姜三两。
通脉四逆汤：
甘草（二两，蜜炙） 附子（大者一枚，生用，去皮，破成八片） 干姜（三两，体质强壮者可四两）
以上三味药，用水三升，煮取二升二合，去渣，分两次温服，脉象复出者愈。面色赤者加葱九茎。腹中痛者去葱，加芍药二两。呕吐者加生姜二两。咽痛者去芍药，加桔梗一两。腹泻停止脉不出者去桔梗，加人参二两。病症与方剂相应者乃服用。
伤寒六七日，经过严重攻下后，寸脉沉而迟，手足厥冷，下部脉摸不到，咽喉不利，吐脓血，泄利不止的，为难治。
寸脉沉迟，气口脉平。下部脉不至，根本已绝。六腑之气绝于外，则手足寒冷；五脏之气绝于内，则泄利不禁。咽喉不利，水谷之道断绝。
津液不化而成脓血，下濡而上逆。此为下厥上竭，阴阳离决的征候，生气将绝于内。旧本中有麻黄升麻汤，其方药味多而分量轻，重在发汗发散而畏惧温补，乃是后世粗劣医工的手法，必定不是张仲景的方子。此证此脉，急用参、附以回阳，尚恐不能救治，用治疗阳实证的方法来治疗亡阳证，这是落井下石，怎敢期望其汗出而愈呢？绝汗出而死，是必然的结果，仍附上该方，以等待识者。
麻黄升麻汤：
麻黄（二两半，去节） 升麻（一两一钱） 当归（一两一钱） 黄芩 葳蕤（各六铢） 芍药 知母（十八铢） 天冬（去心） 桂枝（去皮） 干姜 甘草（炙） 石膏（碎，绵裹） 白术 茯苓（各六钱）
以上十四味药，用水一斗，先煮麻黄一二沸，去掉上浮的泡沫，加入其他药物，煮取三升，去渣，分三次温服，间隔时间如同做三斗米饭的时间，令其尽服后汗出而愈。
Pulse is floating and slow, indicating exterior heat and interior cold, accompanied by diarrhea with undigested food; Si Ni Tang (Four Reversal Decoction) should be primarily used.
A floating pulse indicates the pathogen is in the exterior, while a slow pulse indicates it is in the Zang organs (internal organs). A slow quality seen within a floating pulse signifies deficiency of Qi at the exterior with heat, and cold in the interior. Diarrhea with undigested food occurring without prior erroneous purgation indicates that the exterior syndrome is deficient heat, while the interior harbors true cold. Whenever Zhang Zhongjing treats deficiency syndromes, he prioritizes the interior. For patients with Xie Re Xia Li (diarrhea with accompanying heat) and a faint pulse, Ren Shen (Ginseng Radix et Rhizoma) is added; for those with body pain after sweating and a deep, slow pulse, Ren Shen (Ginseng Radix et Rhizoma) is added. In this case, the slow pulse and diarrhea with undigested food, along with absence of irritability or coughing, indicate severe deficiency of Middle Qi and depletion of Yuan Qi (Original Qi). If one only warms without tonifying, how can one rescue the critical reversal? Observing that Fu Ling Si Ni Tang (Poria Four Reversal Decoction) uses Ren Shen (Ginseng Radix et Rhizoma) even when irritability is present, how much more so Tong Mai Si Ni Tang (Pulse-Reviving Four Reversal Decoction), which must have originally contained Ren Shen (Ginseng Radix et Rhizoma)? It is likely that the current text is missing ingredients due to textual loss.
This is a Shang Han (Cold Damage) syndrome. However, a floating pulse with exterior heat also indicates the disease originated from Yang channels, known in the world as "Lou Di Shang Han" (Leaky Bottom Cold Damage). This occurs because the person's Stomach Qi was originally deficient, allowing Cold pathogens to directly invade the Spleen and Stomach without affecting the Tai Yang (Greater Yang) and Shao Yang (Lesser Yang) channels; thus, there are no exterior symptoms such as bitter taste, dry throat, dizziness, or stiffness of the neck and back. Nevertheless, relying on this exterior heat can still help rescue the interior cold.
When there is diarrhea with undigested food, one must not attack the exterior. Sweating will inevitably lead to abdominal fullness.
With severe deficiency of Interior Qi, the ability to store Essence and serve as the guard of Yang is compromised. Fortunately, the Exterior Yang remains, capable of guarding the exterior and maintaining solidity. Attacking the exterior would further weaken it. Sweat is generated from Grain Qi; sweating leads to the loss of Yang, and severe interior cold generates fullness diseases.
Diarrhea with abdominal fullness and body pain: one should first warm the interior.
After Shang Han has been treated with purgatives, if diarrhea with undigested food continues incessantly and body pain persists, one must urgently rescue the interior, preferably using Si Ni Tang (Four Reversal Decoction).
Diarrhea indicates interior cold; body pain indicates exterior cold. The exterior should be warmed and dispersed, while the interior should be warmed and tonified. Rescuing the interior first addresses the root cause.
If the patient has fever, headache, but the pulse is surprisingly deep, and if it does not improve, leading to persistent body pain, one should rescue the interior, preferably using Si Ni Tang (Four Reversal Decoction).
This corresponds to the Ma Huang Tang (Ephedra Decoction) syndrome of Tai Yang (Greater Yang). The pathogen is in the exterior, so the pulse should be floating; a deep pulse here is an adverse sign. If sweating fails to improve the condition and body pain persists, one should judge based on the deep pulse that the disease is now in the interior. An Yang syndrome presenting with Yin pulses is a sign of Yang declining and Yin growing. Although heat originates in the exterior, it is deficient Yang; cold occupies the interior, representing true Yin. There must be latent interior signs not yet manifested. Relying on the remaining exterior Yang, and taking advantage of the fact that Yin cold has not fully erupted, one should intercept it. This may prevent complications like vomiting, diarrhea, and limb coldness. Once the interior harmonizes, the exterior resolves spontaneously.
Where evil gathers, Qi must be deficient. Therefore, if the pulse appears excessive but symptoms are deficient, follow the symptoms; if symptoms appear excessive but the pulse is deficient, follow the pulse. Excess may be false, but deficiency is true. This is the core method of Zhang Zhongjing.
Profuse sweating, or severe diarrhea, accompanied by cold limbs: Si Ni Tang (Four Reversal Decoction) should be primarily used.
Profuse sweating leads to the loss of Yang; severe diarrhea leads to the loss of Yin. With both Yin and Yang deficient, cold limbs occur. However, since the diarrhea is not with undigested food, urgent warming is required; if Yang returns, survival is possible.
Profuse sweating with persistent fever, internal cramping/tightness, pain in the four limbs, accompanied by diarrhea, cold limbs, and aversion to cold: Si Ni Tang (Four Reversal Decoction) should be primarily used.
Improper treatment results in profuse sweating with persistent fever and aversion to cold, indicating the exterior pathogen remains. Internal cramping and diarrhea indicate interior cold has erupted; pain in the four limbs and cold limbs indicate exterior cold is also present. Thus, "exterior heat and interior cold" actually refers to exterior cold with Yang collapse.
Vomiting with a weak pulse, clear urination, slight body heat, and presence of cold limbs: difficult to treat, use Si Ni Tang (Four Reversal Decoction) primarily.
Vomiting with fever is a Xiao Chai Hu Tang (Minor Bupleurum Decoction) syndrome. Here, the weak pulse and slight heat do not indicate vigorous Minister Fire. Internally lacking heat explains clear urination; exterior cold and deficiency explain the cold limbs; cold-fluid retention above the diaphragm explains the vomiting. In Shang Han (Cold Damage), Yang is paramount. As Yang declines and Yin grows, it becomes difficult to treat.
Simultaneous vomiting and diarrhea, clear urination, profuse sweating, diarrhea with undigested food, interior cold with exterior heat, and a pulse so faint it is nearly imperceptible: Si Ni Tang (Four Reversal Decoction) should be primarily used.
Simultaneous vomiting and diarrhea indicate severe deficiency of Middle Qi and failure to digest food. A pulse nearly imperceptible indicates loss of Qi and Blood. Clear urination and profuse sweating indicate failure of the pores to close. Fortunately, body heat remains and hands/feet are not cold, meaning the defensive Yang and the root of all Yang remain. The pulse is not yet absent, leaving a thread of vitality. Urgently rescue the interior; if Zheng Qi (Upright Qi) prevails, evil can be repelled.
Vomiting and diarrhea, sweating, fever with aversion to cold, cramping of the four limbs, and cold hands and feet: Si Ni Tang (Four Reversal Decoction) should be primarily used.
Here, the vomiting and diarrhea are not with undigested food, sweating is not profuse, and the pulse is not weak. Relying on this exterior heat/Yang, assisted by Si Ni Tang (Four Reversal Decoction) to warm the interior, there is hope for survival.
Spontaneous diarrhea without thirst belongs to Tai Yin (Greater Yin) syndrome, due to cold in the Zang organs. It should be warmed, preferably using Si Ni Tang (Four Reversal Decoction) category formulas.
In Shao Yin (Lesser Yin) disease, if the pulse is deep, urgent warming is required, preferably using Si Ni Tang (Four Reversal Decoction).
If there is cold-fluid retention above the diaphragm, it should be warmed, preferably using Si Ni Tang (Four Reversal Decoction).
Aversion to cold, faint pulse, and diarrhea; if diarrhea stops due to blood loss, Si Ni Jia Ren Shen Tang (Four Reversal Decoction plus Ginseng) should be primarily used.
Although diarrhea has stopped, aversion to cold persists, so Si Ni Tang (Four Reversal Decoction) is still appropriate. Because the faint pulse indicates lack of blood, Ren Shen (Ginseng Radix et Rhizoma) should be added to promote circulation.
The above discusses the pulses and syndromes of Si Ni Tang (Four Reversal Decoction).
In Shao Yin (Lesser Yin) disease, with diarrhea of undigested food, interior cold with exterior heat, cold limbs, a pulse faint and nearly imperceptible, yet the body feels no aversion to cold, and the face is red; or accompanied by abdominal pain, dry retching, sore throat, cessation of diarrhea, or absence of pulse: Tong Mai Si Ni Tang (Pulse-Reviving Four Reversal Decoction) should be primarily used.
This is a syndrome of half-cold and half-heat. Diarrhea with undigested food indicates Yin cold excess in the interior; cold limbs indicate cold excess in the exterior. No aversion to cold and red face indicate Yang constrained in the exterior; sore throat and cessation of diarrhea indicate Yang returning to the interior. Abdominal pain and dry retching indicate struggle between cold and heat. Warming the interior and reviving the pulse is the method of supporting Yang. The pulse is the governor of life; if the pulse returns, one lives via Yang; if cold limbs persist, one dies via Yin.
Diarrhea with undigested food, interior cold with exterior heat, sweating, and cold limbs: Tong Mai Si Ni Tang (Pulse-Reviving Four Reversal Decoction) should be primarily used. If diarrhea presents with a deep, slow pulse, slight facial redness, mild body heat, and diarrhea with undigested food, resolution will likely occur through Yu Mao (dizziness/stuffiness) followed by sweating. The patient will likely experience mild cold limbs. This is because of Dai Yang (floating Yang/Diagonal Yang) and deficiency below.
Compared to the previous clause, the pulses and syndromes are milder, allowing self-resolution through Yu Mao (dizziness/stuffiness) and sweating. Red face indicates Dai Yang (floating Yang/Diagonal Yang), with Yang rising upward. Due to Dai Yang, Yu Mao and sweating occur; due to lower deficiency, diarrhea with undigested food and cold limbs occur. Mild heat results in mild cold limbs, hence slight facial redness. This represents equality of Yin and Yang, and natural harmony of cold and heat, making it easy to heal.
After vomiting and diarrhea cease, but sweating and cold limbs persist, with cramping of the four limbs not resolving and a pulse faint and nearly imperceptible: Tong Mai Si Ni Jia Zhu Dan Jiang Tang (Pulse-Reviving Four Reversal Decoction plus Pig Gallbladder Bile) should be primarily used.
This must be a syndrome of Yin excess repelling Yang, hence Pig Gallbladder Bile is added as a counter-agent (Fan Zuo). Refer to the Bai Tong Tang (White Pass Decoction) clause for understanding.
If vomiting and diarrhea cease and the pulse becomes peaceful, with only slight irritability, it is because the newly weakened body cannot tolerate the energy from grain food.
Si Ni Tang (Four Reversal Decoction):
Gan Cao (Licorice Root, two liang, honey-fried); Gan Jiang (Dried Ginger, one and a half liang); Fu Zi (Aconite Lateralis Radix Praeparata, one 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 and divide into two warm doses. For strong individuals, use one large Fu Zi (Aconite Lateralis Radix Praeparata) and three liang of Gan Jiang (Dried Ginger).
Tong Mai Si Ni Tang (Pulse-Reviving Four Reversal Decoction):
Gan Cao (Licorice Root, two liang, honey-fried); Fu Zi (Aconite Lateralis Radix Praeparata, one large piece, raw, peeled, broken into eight pieces); Gan Jiang (Dried Ginger, three liang, four liang for strong individuals).
These three ingredients are boiled in three sheng of water to obtain two sheng and two he of decoction. Strain and divide into two warm doses. Recovery is indicated if the pulse reappears. If the face is red, add nine stems of Cong Bai (Allii Fistulosae Bulbus). If there is abdominal pain, remove Cong Bai (Allii Fistulosae Bulbus) and add two liang of Shao Yao (Peony Root). If vomiting occurs, add two liang of Sheng Jiang (Fresh Ginger Rhizome). If there is a sore throat, remove Shao Yao (Peony Root) and add one liang of Jie Geng (Platycodon Root). If diarrhea stops and the pulse does not emerge, remove Jie Geng (Platycodon Root) and add two liang of Ren Shen (Ginseng Radix et Rhizoma). Administer only when the syndrome matches the formula.
Tong Mai Si Ni Jia Zhu Dan Jiang Tang (Pulse-Reviving Four Reversal Decoction plus Pig Gallbladder Bile):
Add one he of Zhu Dan Jiang (Porci Vesica Biliae) to the preceding formula. The rest follows the previous method.
In Shang Han (Cold Damage), after six or seven days, following severe purgation, if the Cun (Cun position) pulse is deep and slow, hands and feet are cold, the Chi (Chi position) pulse is absent, there is difficulty in the throat, expectoration of pus and blood, and incessant diarrhea, it is difficult to treat.
Deep and slow Cun pulse indicates the Qi Kou (Radial Artery) pulse is level. Absence of the Chi (Chi position) pulse indicates the root is exhausted. When Qi of the Six Fu organs fails externally, hands and feet become cold; when Qi of the Five Zang organs fails internally, diarrhea becomes uncontrollable. Difficulty in the throat indicates the passage of water and grain is blocked.
Fluids fail to transform, becoming pus and blood, flowing downward and regurgitating upward. This is Xia Jue Shang Jie (Lower Reversal and Upper Exhaustion), a sign of separation of Yin and Yang, with vital Qi about to perish internally. Old editions contain Ma Huang Sheng Ma Tang (Ephedra and Cimicifuga Decoction). Its formula has many ingredients with light dosages, focusing on sweating and dispersing while fearing warming and tonifying. This is the technique of later incompetent physicians, certainly not Zhang Zhongjing’s prescription. For this syndrome and pulse, urgently using Ren Shen (Ginseng Radix et Rhizoma) and Fu Zi (Aconite Lateralis Radix Praeparata) to restore Yang might still fail to save the patient. Using agents for Yang excess to treat Yang collapse is like attacking a fallen enemy. How could one expect recovery through sweating? Death by absolute sweating is inevitable. The formula is attached here for discerning experts.
Ma Huang Sheng Ma Tang (Ephedra and Cimicifuga Decoction):
Ma Huang (Ephedrae Herba, two and a half liang, nodes removed); Sheng Ma (Cimicifugae Rhizoma, one liang and one qian); Dang Gui (Angelicae Sinensis Radix, one liang and one qian); Huang Qin (Scutellariae Radix); Wei Rui (Polygonati Odorati Rhizoma) [each six zhu]; Shao Yao (Paeoniae Radix Alba); Zhi Mu (Anemarrhenae Rhizoma, eighteen zhu); Tian Dong (Asparagi Radix, heart removed); Gui Zhi (Cinnamomi Ramulus, bark removed); Gan Jiang (Zingiberis Rhizoma Recens); Gan Cao (Glycyrrhizae Radix et Rhizoma, honey-fried); Shi Gypsum (Gypsum Fibrosum, crushed, wrapped in silk); Bai Zhu (Atractylodis Macrocephalae Rhizoma); Fu Ling (Poria) [each six qian].
These fourteen ingredients are boiled in ten dou of water. First boil Ma Huang (Ephedrae Herba) for one or two boils, remove the foam on top, then add the other herbs. Boil to obtain three sheng of decoction. Strain and divide into three warm doses. Take them within the time it takes to cook three dou of rice, until sweating occurs and the patient recovers.