【纲】仲景曰。少阴病。脉沉者。急温之。宜四逆汤。
自利。不渴者。属太阴。以其脏有寒故也。急温之。宜四逆辈。
若膈上有寒饮者。急温之。宜四逆汤。
【目】李 曰。脉沉厥冷。膈上寒饮。干呕。或时头痛。皆寒气上攻也。急温之。三味参萸汤。
内寒已极。厥逆吐利。不渴静蜷。阳和之气欲绝。六脉若有若无。急温之。四逆汤。凡言急者。
病势已笃。将有变革。非若他病可以缓也。他如太阳汗出不止。汗后恶风。汗后烦躁心悸身痛。皆
急用附子加肉桂、白芍之类。三阳脉迟腹痛。建中汤。当先施也。但一服中病即止。伤寒之药皆然。
鳌按。脏有寒。则寒之蓄于内者甚深。脉沉为在里。亦知其内寒已甚。阳和之气欲绝。膈上寒
饮。则阴寒之气固结不散。皆用温法。所谓救急之方也。
【纲】仲景曰。病患脉阴阳俱紧。反汗出者。亡阳也。此属少阴。法当咽痛而复吐利。脉阴阳
俱紧。至于吐利。其脉独不解。紧去人安。此为欲解。少阴病。脉解。至七八日。自下利。脉暴微。
手足反温。脉紧反去者。为欲解也。虽烦下利。必自愈。
【目】朱肱曰。伤寒下利多种。须辨阴阳。勿令差误。三阳下利则身热。太阴下利则手足温。
少阴厥阴下利则身不热。以此别之。大抵下利挟太阳脉症。便不得用温药。俗医但见下利。便作阴
症。用温热药。鲜不发黄生斑而死。
大抵伤寒下利。须识脉与外症不同。下利而脉大者。虚也。脉微弱者。为自止。下利日十余行。脉
反实者逆。下利脉数而滑。有宿食也。下之愈。脉迟而滑者。实也。其利未得便止。宜更下之。下
利三部脉皆平。按其心下硬者。急下之。协热利者。脐下必实。大便赤黄色。及肠间津液垢腻。寒
毒入胃。则脐下必寒。腹胀满。大便或黄白青黑。或下利清谷。温毒瓦斯盛。则下利腹痛。大便如脓血。
如烂肉汁。更下利。欲饮水者。有热也。下利谵语。有燥屎也。寒毒入胃者。四逆汤、理中汤、白
通汤、附子四逆散。加薤白主之。协热利者。黄芩汤、白头翁汤、三黄熟艾汤、赤石脂丸。温毒下
脓血者。桃花汤、地榆散、黄连阿胶汤。虽然。自利而渴。属少阴。然三阳下利。亦有饮水者。乃有
热也。三阴下利。宜温之。然少阴自利清水。心下痛。口干燥者。却宜下之。此又不可不知也。
少阴泄利下重。不可投热药。先浓煎薤白汤。内四逆散。缘此散用枳实、芍药辈也。又寻常胃中
不和。腹痛肠鸣下利者。生姜泻心汤最妙。此二法。不特伤寒症也。若脉沉自利。而身体痛者。阴
症也。急当救里。宜四逆汤、附子汤、真武汤。大抵大便利而身体疼者。当救里。大便如常而身体
痛者。当救表。不可不知。
成无己曰。自利者。不因攻下而自泄泻也。有表邪传里。里虚协热而利者。有不因攻下而遂利者。
皆协热也。又三阳
合病。皆作自利。有攻表攻里和解之不同。何则。太阳阳明合病。为在表。故与葛根汤汗之。太阳少
阳合病。为半表里。故与黄芩汤和之。阳明少阳合病。为少阳邪气入里。故与承气下之。
下利虽有表症。不可发汗。以下利为邪气内攻。走津液而胃虚也。经曰。下利不可攻表。汗出。
必胀满是也。盖三阴自利居多。然自利家身凉脉静为顺。身热脉大为逆。大抵下利。脱气。又为难
治。盖邪盛正虚。邪壅正气下脱。多下利而死也。
【纲】仲景曰。脉阴阳俱紧者。口中气出。唇口燥干。鼻中涕出。蜷卧。足冷。舌上胎滑。勿
妄治也。到六七日以来。其人微发热。手足温者。此为欲解。或到八日以上。反大发热者。此为难
治。设使恶寒者。必欲呕也。腹内痛者。必欲利也。
【目】柯琴曰。使七八日来。不能发热。以阴阳俱紧之脉。反加恶寒。是寒甚于表。上焦应之。
必呕。反加腹痛。是寒甚于里。中焦受之。必利。
【纲】仲景曰。少阴病。吐利。手足不逆冷。反发热者。不死。脉不至者。灸少阴七壮。
少阴病。吐利。烦躁。四逆者死。
【目】庞安常曰。此由胃脘之阳将绝。故上吐而下利也。
【纲】仲景曰。少阴病。脉微涩。呕而汗出。大便数而少者。宜温其上。灸之。少阴病。脉沉
微细。但欲卧。汗出
不烦。自欲吐。至六日。自利。复烦躁。不得卧寐者死。
【目】陈士铎曰。伤寒而脉沉微细。明是阴症。况欲卧而欲动乎。汗已出矣。内无阳症可知。
心中不烦。时欲呕吐。此阳邪已散。阴邪作祟。急宜祛寒为是。乃失此不温。至五六日而下利。是
上下俱乱也。此时尚不烦躁。则肾中之真阳未散。今又加烦躁不得卧寐。明是奔越而不可回之兆矣。
非死症而何。然其先原因失治而不可救。非本不可救而成此扰乱之症也。有一奇方。名转阳援绝汤。
人参、白术、枣仁各一两。茯神五钱。肉桂二钱。水煎。一帖即安。人参救绝。白术、茯神分消水
湿而止利。桂以温中去寒。枣仁安心解躁。
【纲】仲景曰。少阴病。二三日不止。至四五日。腹痛。小便不利。四肢沉重疼痛。自下利者。
此为有水气。其人或咳。或小便利。或下利。呕者。真武汤主之。
【目】吴绶曰。凡自利者。不因攻下而自泻利。俗言漏底伤寒是也。有协热。有协寒。俱宜详
辨。原病式曰。泻白为寒。泻青黄赤黑。皆为热也。大抵完谷不化。色不寒。有如 溏。或泻利腥
臭。小便澄彻清冷。口无燥渴。其脉沉细。或迟微无力。或身虽热。手足逆冷。恶寒蜷卧。此皆寒也。
凡热症。口中燥渴。小便黄赤。或涩。或所下如垢腻。其脉多数。或浮。或滑。或弦。或大。或洪。
或邪热不杀谷。其物不消化者。当以脉症别之。凡胃虚内热。烦渴泻利。脉弱者。七味人参白术
散。若发热者。参胡三白汤。去黄芩加炒黄连。若腹满小便不利者。五苓散合理中汤。若呕者。加
藿香、半夏、生姜、陈皮。如湿多而泻不止者。加二术。腹胀。加浓朴。腹疼。加白芍、肉桂、木
香。凡伤寒作利。脉浮。表未解。仲景以小青龙去麻黄加炒芫花二钱。盖散表即治水也。若小便涩。
大便水泻不止。五苓散。水甚不解。亦加芫花二钱以行水。或车前子汤。利自止也。凡下利。不
可发汗。当先治利。利止内实。正气得复。邪气得解。则汗出而愈也。盖利下由内虚。若加发汗。
则内外皆虚。变症。为难治也。
苏颂曰。为有水气。是真武汤本旨。下利亦水气为患也。后三项。乃真武汤加减法。
【纲】仲景曰。少阴病。二三日至四五日。腹痛小便不利。下利不止。便脓血者。桃花汤主之。
【目】庞安常曰。此由寒毒入胃。故腹痛而下利也。
【纲】仲景曰。大汗。若大下利。而厥冷者。四逆汤主之。
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。自利。不渴者。属
太阴。以其脏有寒故也。当温之。宜四逆辈。
【目】柯琴曰。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。二条。是治之失宜
者。虽大汗出而热不去。恶寒。表未除也。拘急下利。里寒已发。肢疼厥冷。表寒又见。可知表热
里寒者。即表寒亡阳也。
【纲】仲景曰。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。
【目】柯琴曰。咽痛利止。阳回于内也。腹痛干呕。寒热交争也。
【纲】仲景曰。少阴病。咳而下利。谵语者。被火气劫故也。小便必难。以强责少阴汗也。
【目】喻昌曰。少阴之脉。从足入腹。上循喉咙。萦绕舌根。故多咽痛之症。其支别出肺。故
间有咳症。今以火气强劫其汗。则热邪挟火力上攻。必为咳。以肺金恶火故也。下攻必为利。以火
势逼迫而走空窍故也。内攻。必谵语。以火势燔灼而乱神明故也。小便必难者。见三症皆妨小便。
若肺为火气所伤。则膀胱气化不行。大肠奔迫无度。则水谷并趋一路。心胞燔灼不已。则小肠枯
涸不至耳。少阴可强责其汗乎。
肾有热邪。其表腑之膀胱必应。小便所以不利也。咳而下利。肺大肠表里之义乎。
魏荔彤曰。此申解少阴传经热邪。入里为患。不可认为直中之寒邪误治。反强责其汗以致难治
也。少阴病。有传经热邪。有直中寒邪。固已。然热邪之传。原在经也。而肾脏可以并见。病若直
中之邪。则必分为经为脏矣。为脏者。尚单用温而不用散。为经者。方既用温而复用散。是脏病原
无散法也。况为传经入里之热邪乎。又岂可以温散之法治之乎。故热邪久而方炽。必不可用温。又
传入里而愈深。更不可用散。此在太阳入阳明之里。已忌发汗矣。再递传三阴。至少阴。下之极。
深之尽。为里中之里矣。其忌妄发强责其汗也。何待言乎。惟是少阴一经。兼直中之寒邪在内。法
有温经散寒。近于取汗之义。仲师恐人误认以之治传经之少阴。故特标出示之。正见附子麻黄细辛
甘草纯为寒邪直中少阴经而设也。寒邪直中少阴脏。且言温而不言散也。并非为少阴传经之热邪。
病及于少阴肾脏者言也。
此乃大关键处。历来无明白剖析者。不可不详辨也。如本条之上曰。少阴病。脉细沉数。病为在里。
不可发汗。而继之以本条云云。夫少阴脉本微细。今细如故。而见沉见数。盖细乃厥阴之少阴也。而
沉为少阴正脉也。今不见太阴之微。而反见阳脉之数。数者迟之对。见为微为数。皆于沉中重取辨
之也。推此则为细为弦。亦于沉之轻取辨之也。所以沉为少阴本脉也。诊其人。轻取之。沉上见细。
重取之。沉下见微。此少阴直中之寒邪也。或宜温中。或宜散寒。再徐察之。而直中少阴之脏病
经病咸得矣。若诊其人。轻取。沉上仍见细。重取之。沉中不见微而见数矣。此乃少阴传经之热邪
也。就沉中重取一诊。而分少阴寒热之二邪。此定诀也。审乎此。则知非直中之表病。而为传经之
里病也。盖在风寒初感。不论何经。总为表症。当发汗。故三阴即少阴亦可发汗。如麻黄附子细辛
甘草汤症是也。在传经愈深。不论何经。总为里症。皆不当发汗。故三阳即太阳亦不可发汗。如抵
当汤、五苓散等症是也。知乎此。方可言表里。不致以三阳定为表。三阴定为里。固执不通之论所
惑也。且明乎发汗之义。则治传里之热邪。方有随机应变之法。而亦不可执一。故仲师但言不可发
汗。并不出方。不出方者。方出之于后也。但言不可发汗者。妄发强责。则为祸不旋踵也。请试申
之。如咳而下利谵语者。此传经之热邪递及少阴也。设以火劫汗。少阴一经。气血本少。热邪又入
耗损。又火劫强责其汗。则阴愈亏短。津液内亡。小便必难也。胃亡津而小便利者。津亡于上而气
化尚行于下。此则肾阴有伤。津亡于下。而气化不行矣。强责少阴之汗。用火劫。似邪止伤其阳分
表分。而津亡气耗。为害已如是。可不慎乎。
【纲】仲景曰。伤寒六七日。大下后。寸脉沉而迟。手足厥冷。下部脉不至者。咽喉不利。吐
脓血。泄利不止者。此为难治。
【目】陶华曰。六腑气绝于外者。手足寒。五脏气绝于内者。下利不禁。此之谓也。
【纲】仲景曰。少阴病。吐利。手足厥冷。烦躁欲死者。吴茱萸汤主之。
干呕。吐涎沫。头痛者。吴茱萸汤主之。
食谷欲呕者。属阳明也。吴茱萸汤主之。得汤反剧者。属上虚也。
【目】鳌按。吐利烦躁。是阴邪入于合。而不得从阳以出乎外也。干呕者。呕而无物。胃虚也。
吐涎沫。胃寒也。食谷欲呕。谷气入于胃。即拒之而出。亦胃寒也。得汤者。即吴茱萸汤也。服之
反剧。以上焦有痰饮。俟呕尽自愈也。
【纲】仲景曰。少阴病。下利。脉微者。与白通汤。利不止。厥逆无脉。干呕烦者。白通加猪
胆汁汤主之。服汤后。脉暴出者死。微续者生。
【目】张元素曰。或谓白通汤、白通加猪胆汁汤、真武汤、通脉四逆汤。皆为少阴下利而设。
除用姜附相同。其余之药。俱各殊异。何也。盖病殊则药殊。夫少阴下利。寒气已甚。非姜附不治。
然下利之理无殊。而兼有之症不一。用药故不同耳。如白通用姜附以散寒止利。加葱白以通调阳气。
若利而干呕烦者。寒太甚。内为格拒。姜附非烦者之所宜。必呕而不纳。加人尿猪胆汁于白通汤中。
候温冷服之。二味皆咸苦性寒。是以纳而不阻。至其所。则冷体既消。热性便发。真武治少阴二三
日至四五日。腹痛小便不利四肢沉重疼痛自下利者。为有水气。故多或为之症。夫水气者。寒湿也。
肾主之。肾病不能制水。水饮停蓄。为腹痛。寒湿内甚也。肢重疼痛。寒湿外甚也。小便不利。
自下利者。湿甚而水谷不能别也。经曰。脾恶湿。甘先入脾。苓、术之甘以益脾逐水。湿所胜。平
以辛热。湿淫所胜。佐以酸辛。附子、芍药、生姜之酸辛。以温经散湿。小青龙症。亦为有水气。
【纲】张仲景说：少阴病，脉象沉的，应当紧急温阳，适宜用四逆汤。
自发性腹泻，口不渴的，属于太阴病，因为脏腑内有寒邪的缘故，应当紧急温阳，适宜使用四逆汤一类的方剂。
如果胸膈上有寒饮停滞的，应当紧急温阳，适宜用四逆汤。
【目】李氏说：脉沉、四肢厥冷、胸膈上有寒饮、干呕，或者偶尔头痛，都是寒气上攻所致。应当紧急温阳，可用三味参萸汤。
体内寒邪已至极点，出现四肢厥逆、呕吐腹泻、口不渴、安静蜷卧，阳气调和之气即将断绝，六脉若有若无，应当紧急温阳，用四逆汤。凡是说“急”的，说明病势已经严重，即将发生变故，不像其他疾病可以缓慢治疗。其他的如太阳病汗出不止，发汗后恶风，发汗后烦躁、心悸、身体疼痛，都应当紧急使用附子加肉桂、白芍之类的药物。三阳经脉迟、腹痛的，应当先施用建中汤。但只需服用一次，若病症缓解即停药，伤寒的药物都是这样。
沈金鳌按语：脏腑有寒，则寒邪蓄积于内部非常深重；脉沉表示病在里，也说明内寒已经很严重，阳气调和之气即将断绝。胸膈上有寒饮，则是阴寒之气固结不散，都应当使用温法，这就是所谓的急救之方。
【纲】张仲景说：病人脉象寸关尺三部都紧，反而出汗的，这是亡阳，属于少阴病，按照法则应当咽喉痛并且伴有呕吐腹泻。脉象寸关尺三部都紧，到了出现呕吐腹泻的时候，唯独紧脉不解去，紧脉消失而病人安和，这是病情将要解除的表现。少阴病，脉象变化，到了七八天，自发性下利，脉象突然变得微弱，手足反而温暖，紧脉反而消失的，是病情将要解除的表现。虽然心烦且下利，必定会自愈。
【目】朱肱说：伤寒引起的下利有很多种，必须辨别阴阳，不要弄错。三阳经下利则身体发热，太阴经下利则手足温暖，少阴、厥阴经下利则身体不发热，以此加以区别。大抵下利兼有太阳经脉症状的，就不能使用温药。庸俗的医生只见下利，就当作阴症，使用温热药，很少有不因发黄生斑而死亡的。
大抵伤寒下利，必须识别脉象与外部症状的不同。下利而脉大的，是虚证；脉微弱的，表示下利将自止。下利一天十几次，脉象反而实的，是逆证（难治）。下利脉数而滑的，是有宿食，用泻下法可愈。脉迟而滑的，是实证，其下利不能立刻停止，应当再用泻下法。下利寸关尺三部脉都平和，但按压心下部硬满的，应当紧急泻下。协热利（伴随发热的下利），脐下必然实满，大便呈赤黄色，以及肠间津液垢腻。寒毒进入胃中，则脐下必然寒冷，腹胀满，大便或黄白青黑，或者下利完谷不化。温毒瓦斯旺盛，则下利腹痛，大便像脓血，像烂肉汁。如果再下利，想要喝水的，是有热。下利说胡话的，是有燥屎。寒毒入胃的，用四逆汤、理中汤、白通汤、附子四逆散，加薤白主治。协热利的，用黄芩汤、白头翁汤、三黄熟艾汤、赤石脂丸。温毒导致下脓血的，用桃花汤、地榆散、黄连阿胶汤。虽然如此，自发性下利且口渴的，属于少阴病。然而三阳经下利，也有想喝水的，那是因为有热。三阴经下利，应当温补。然而少阴病自利清水，心下部疼痛，口干燥的，却应当用泻下法。这又是不可不知道的。
少阴病泄利伴有肛门重坠感，不可投用热药。先浓煎薤白汤，加入四逆散。因为这个方子用了枳实、芍药等药。另外，寻常的胃中不和，腹痛肠鸣下利的，生姜泻心汤最妙。这两种方法，不仅适用于伤寒症。如果脉沉自利，而身体疼痛的，是阴症，应当紧急救里，适宜用四逆汤、附子汤、真武汤。大抵大便通畅而身体疼痛的，应当救里；大便正常而身体疼痛的，应当救表，不可不知道。
成无己说：自利，是指没有经过攻下治疗而自行泄泻。有表邪传入里，里虚协热而利的，有未经过攻下而直接下利的，都属于协热利。又有三阳合病，都会出现自利，治疗方法有攻表、攻里、和解的不同。为什么呢？太阳阳明合病，病在表，所以用葛根汤发汗；太阳少阳合病，在半表半里，所以用黄芩汤和解；阳明少阳合病，是少阳邪气入里，所以用承气汤泻下。
下利虽然有表证，不可发汗，因为下利是邪气内攻，耗伤津液导致胃虚。经文说：下利不可攻表，发汗必然导致胀满。大概三阴经自利居多，然而自利的病人身体凉、脉静顺，身体热、脉大逆。大抵下利脱气，又为难治。因为邪气盛正气虚，邪气壅滞正气下脱，多因下利而死。
【纲】张仲景说：脉象寸关尺三部都紧的，口中呼气，嘴唇口干，鼻中流涕，蜷缩而卧，脚冷，舌苔滑润，不要胡乱治疗。到了六七天以后，病人微微发热，手足温暖的，这是病情将要解除。或者到了八天以上，反而大发热的，这是难治。假使恶寒的，必定想呕吐；腹内痛的，必定想下利。
【目】柯琴说：如果七八天来，不能发热，以阴阳俱紧的脉象，反而加重恶寒，是寒邪甚于表，上焦受之，必定呕吐；反而加重腹痛，是寒邪甚于里，中焦受之，必定下利。
【纲】张仲景说：少阴病，呕吐下利，手足不厥冷，反而发热的，不会死。脉象摸不到的，灸少阴经穴位七壮。
少阴病，呕吐下利，烦躁，四肢厥冷的，死。
【目】庞安常说：这是由于胃脘的阳气即将断绝，所以上吐而下利。
【纲】张仲景说：少阴病，脉象微涩，呕吐而出汗，大便次数多但量少，应当温其上焦，并施以艾灸。少阴病，脉象沉微细，只想睡觉，出汗，心中不烦，自己想吐，到了第六天，自发性下利，又烦躁，不能卧睡寐的，死。
【目】陈士铎说：伤寒而脉象沉微细，明明是阴症，况且想睡却又想动吗？汗已经出了，可知内部没有阳症。心中不烦，时常想呕吐，这是阳邪已散，阴邪作祟，应当紧急祛寒才是。如果失去这个机会不温补，到了五六天而下利，这是上下都乱了。此时如果不烦躁，则肾中的真阳未散。现在又加上烦躁不得卧睡，明显是元气奔越而不可挽回的征兆。这不是死症是什么？然而其先前的原因是失治而导致不可救，并非本病不可救而成此扰乱之症。有一个奇方，名叫转阳援绝汤，人参、白术、枣仁各一两，茯神五钱，肉桂二钱，水煎服，一帖即安。人参救绝，白术、茯神分消水湿而止利，桂枝温中去寒，枣仁安心解躁。
【纲】张仲景说：少阴病，两三天不止，到了四五天，腹痛，小便不利，四肢沉重疼痛，自发性下利的，这是有水气。其人或者咳嗽，或者小便利，或者下利，呕吐的，用真武汤主治。
【目】吴绶说：凡是自利，是指没有经过攻下而自行泻利，俗语说的漏底伤寒就是这种。有协热，有协寒，都应当详细辨别。《原病式》说：泻白色为寒，泻青色、黄色、红色、黑色，都为热。大抵完谷不化，颜色不寒，像溏便，或者泻利腥臭，小便清澈清冷，口无燥渴，脉象沉细，或者迟微无力，或者身体虽热，手足厥冷，恶寒蜷卧，这些都是寒症。凡是热症，口中燥渴，小便黄赤，或者涩，或者所下的东西像垢腻，脉象多数，或者浮，或者滑，或者弦，或者大，或者洪，或者邪热不杀谷（食物不消化），其物不消化的，应当以脉症区别。凡是胃虚内热，烦渴泻利，脉弱的，用七味人参白术散。如果有发热的，用参胡三白汤，去掉黄芩加炒黄连。如果腹满小便不利的，用五苓散合理中汤。如果呕吐的，加藿香、半夏、生姜、陈皮。如果湿气多而泻不止的，加苍术、白术。腹胀的，加厚朴。腹痛的，加白芍、肉桂、木香。凡是伤寒引起下利，脉浮，表证未解，张仲景用小青龙汤去掉麻黄加炒芫花二钱。大概发散表邪即是治水。如果小便涩，大便水泻不止，用五苓散。水邪很甚不解的，也加芫花二钱以行水，或者用车前子汤，下利自然停止。凡是下利，不可发汗，应当先治下利，下利停止内实，正气得复，邪气得解，则出汗而痊愈。大概下利由于内虚，如果再加发汗，则内外皆虚，变症，难治。
苏颂说：为有水气，是真武汤的本旨。下利也是水气为患。后三项，是真武汤的加减法。
【纲】张仲景说：少阴病，两三天到四五天，腹痛小便不利，下利不止，大便带脓血的，用桃花汤主治。
【纲】张仲景说：大汗出，或者大下利，而四肢厥冷的，用四逆汤主治。
大汗出，热不退，内部拘急，四肢疼痛，又下利，厥逆而恶寒的，用四逆汤主治。自发性下利，口不渴的，属于太阴病，因为脏腑有寒的缘故，应当温补，适宜用四逆汤一类的方剂。
【目】柯琴说：大汗则亡阳，大下利则亡阴，阴阳都虚，所以四肢厥冷。但下利不是完谷不化，紧急温阳，阳气回复而生还有望。这两条，是治疗不当的情况。虽然大汗出而热不退，恶寒，表证未除，拘急下利，里寒已发，肢疼厥冷，表寒又见，可知表热里寒者，就是表寒亡阳。
【纲】张仲景说：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，其人面色发红，或者腹痛，或者干呕，或者咽痛，或者下利停止，脉不出来的，用通脉四逆汤主治。
【目】柯琴说：咽痛利止，是阳气回复于内。腹痛干呕，是寒热交争。
【纲】张仲景说：少阴病，咳嗽而下利，说胡话的，是被火气劫夺汗液所致。小便必定困难，因为强行索取少阴病的汗液。
【目】喻昌说：少阴的经脉，从足入腹，上行沿喉咙，环绕舌根，所以多有咽痛的症候。其支别出于肺，所以间或有咳嗽的症候。现在用火气强行劫夺其汗，则热邪挟火力上攻，必定咳嗽，因为肺金厌恶火。下攻必定下利，因为火势逼迫而走空窍。内攻，必定说胡话，因为火势燔灼而扰乱神明。小便必难的，是因为看到这三个症候都妨碍小便。如果肺被火气所伤，则膀胱气化不行；大肠奔迫无度，则水谷并趋一路；心胞燔灼不已，则小肠枯涸不至耳。少阴病可以强行索取汗液吗？
肾有热邪，其表腑的膀胱必定应验，小便所以不利。咳嗽而下利，是肺与大肠表里的关系吗？
魏荔彤说：这是申述解释少阴传经热邪，入里为患，不可认为是直中的寒邪而误治，反而强行索取汗液以致难治。少阴病，有传经热邪，有直中寒邪，固然如此。然而热邪的传变，原本在经，而肾脏也可以并见。病如果是直中的邪气，则必须分为经和脏。为脏的，尚且单用温而不用散；为经的，方既用温又复用散，是脏病原无散法。何况是传经入里的热邪呢？又岂可以用温散法治它呢？所以热邪久而方炽，必不可用温；又传入里而愈深，更不可用散。这在太阳传入阳明之里，已经忌讳发汗了。再递传三阴，至少阴，是下之极，深之尽，为里中之里。其忌讳妄发强求其汗，何待言乎。只是少阴一经，兼有直中的寒邪在内，法有温经散寒，近于取汗的意义。仲景恐怕人误认用它来治传经的少阴，所以特别标示出来以示人，正见附子、麻黄、细辛、甘草纯为寒邪直中少阴经而设。寒邪直中少阴脏，且只说温而不说散。并不是为少阴传经的热邪，病及于少阴肾脏者而言的。
这是大关键之处，历来没有明白剖析的，不可不详辨。如本条之上说：少阴病，脉细沉数，病为在里，不可发汗。而继之以本条云云。夫少阴脉本微细，今细如故，而见沉见数，盖细乃厥阴之少阴也，而沉为少阴正脉也。今不见太阴之微，而反见阳脉之数，数是迟的对立面，见为微为数，都在沉脉中重取辨别。推此则为细为弦，也在沉脉中轻取辨别。所以沉为少阴本脉。诊其人，轻取，沉上见细，重取，沉下见微，这是少阴直中的寒邪。或者宜温中，或者宜散寒，再慢慢观察，而直中少阴的脏病经病都得以明了。如果诊其人，轻取，沉上仍见细，重取，沉中不见微而见数了，这是少阴传经的热邪。就在沉脉中重取一诊，而分少阴寒热之二邪，这是定诀。审察于此，则知非直中的表病，而为传经的里病。大概在风寒初感，不论何经，总为表症，当发汗，所以三阴即少阴亦可发汗，如麻黄附子细辛甘草汤症是这种。在传经愈深，不论何经，总为里症，皆不当发汗，所以三阳即太阳亦不可发汗，如抵当汤、五苓散等症是这种。知道于此，方可言表里，不致以三阳定为表，三阴定为里，固执不通之论所惑。且明乎发汗的意义，则治传里的热邪，方有随机应变之法，而亦不可执一。所以仲师只说不可发汗，并不出方。不出方的原因，方出之于后也。只说不可发汗的原因，妄发强求，则为祸不旋踵也。请试申述之。如咳而下利谵语的，这是传经的热邪递及少阴。假设用火劫汗，少阴一经，气血本少，热邪又入耗损，又火劫强求其汗，则阴愈亏短，津液内亡，小便必难。胃亡津而小便利的，津亡于上而气化尚行于下，此则肾阴有伤，津亡于下，而气化不行矣。强求少阴之汗，用火劫，似邪止伤其阳分表分，而津亡气耗，为害已如是，可不慎乎。
【纲】张仲景说：伤寒六七天，大下之后，寸脉沉而迟，手足厥冷，下部脉摸不到的，咽喉不利，吐脓血，泄利不止的，这是难治。
【目】陶华说：六腑气绝于外的，手足寒，五脏气绝于内的，下利不禁，说的就是这个。
【纲】张仲景说：少阴病，呕吐下利，手足厥冷，烦躁欲死的，用吴茱萸汤主治。
干呕，吐涎沫，头痛的，用吴茱萸汤主治。
进食就想呕吐的，属于阳明病，用吴茱萸汤主治。服药后反而加剧的，属于上虚。
【目】沈金鳌按语：吐利烦躁，是阴邪进入合穴，而不能从阳外出。干呕，是呕而无物，胃虚。吐涎沫，是胃寒。进食就想呕吐，谷气进入胃，即被拒绝而出，也是胃寒。得汤，即吴茱萸汤。服用后反而加剧，是因为上焦有痰饮，等待呕尽自然痊愈。
【纲】张仲景说：少阴病，下利，脉微的，给白通汤。下利不止，厥逆无脉，干呕烦的，用白通加猪胆汁汤主治。服药后，脉象突然暴出的死，脉象微微续接的活。
【目】张元素说：有人说白通汤、白通加猪胆汁汤、真武汤、通脉四逆汤，都是为少阴下利而设。除了用姜附相同，其余的药物，都各不相同，为什么呢？大概病情不同则药物不同。夫少阴下利，寒气已甚，非姜附不能治。然而下利的道理无殊，而兼有的症候不一，用药故不同。如白通用姜附以散寒止利，加葱白以通调阳气。如果下利而干呕烦的，寒太甚，内部格拒，姜附不适合烦者，必定呕吐而不纳。加人尿猪胆汁于白通汤中，候温冷服。二味皆咸苦性寒，所以纳而不阻，到达病所，则冷体既消，热性便发。真武治少阴两三天到四五天，腹痛小便不利四肢沉重疼痛自下利的，为有水气，所以多有或者为之症。夫水气者，寒湿也。肾主之，肾病不能制水，水饮停蓄，为腹痛，寒湿内甚也。肢重疼痛，寒湿外甚也。小便不利，自下利的，湿甚而水谷不能别也。经文说：脾恶湿，甘先入脾，苓、术之甘以益脾逐水。湿所胜，平以辛热。湿淫所胜，佐以酸辛。附子、芍药、生姜之酸辛，以温经散湿。小青龙症，也为有水气。
[Outline] Zhang Zhongjing said: In Shaoyin disease, if the pulse is deep (Chen), urgent warming is required. Si Ni Tang (Cinnamon Twig and Prepared Aconite Decoction) is indicated.
Spontaneous diarrhea with no thirst belongs to Taiyin disease, due to cold in the zang organs. Urgent warming is required; a class of formulas similar to Si Ni Tang is indicated.
If there is cold-fluid retention above the diaphragm, urgent warming is required. Si Ni Tang is indicated.
[Commentary] Li said: Deep pulse, cold extremities, cold-fluid retention above the diaphragm, dry retching, or occasional headache are all caused by cold qi attacking upwards. Urgent warming is required. San Wei Shen Yu Tang (Three-Ingredient Ginseng and Cornus Decoction) can be used.
When internal cold is extreme, presenting with cold extremities, vomiting and diarrhea, no thirst, quiet curling up, and the harmonious qi of yang about to perish, with six pulses appearing as if present or absent, urgent warming is required using Si Ni Tang. Whenever "urgent" is mentioned, it indicates that the disease progression is severe and changes are imminent, unlike other diseases that can be treated slowly. For example, in Taiyang disease, if sweating does not stop, or after sweating there is aversion to wind, restlessness, palpitations, and body pain, Fuzi (Prepared Aconite Root) added with Rougui (Cinnamon Bark) and Baishao (White Peony Root) should be used urgently. For three-yang meridians with slow pulse and abdominal pain, Jian Zhong Tang (Middle-Building Decoction) should be applied first. However, stop taking it after one dose if symptoms improve; this applies to all Shanghan medicines.
Shen Jin'ao notes: Cold in the zang organs means cold accumulates deeply internally. A deep pulse indicates the disease is interior, confirming severe internal cold and the impending loss of harmonious yang qi. Cold-fluid retention above the diaphragm signifies congealed yin-cold qi that does not dissipate. Both require warming methods, which are the so-called emergency rescue formulas.
[Outline] Zhang Zhongjing said: If a patient's pulse is tight at both cun and chi positions but sweats, this is Yang collapse (Wang Yang), belonging to Shaoyin. By law, this should present with sore throat accompanied by vomiting and diarrhea. When the pulse is tight at both cun and chi, and vomiting and diarrhea occur, if only the tightness disappears and the patient feels comfortable, this indicates the condition is resolving. In Shaoyin disease, if the pulse changes, and after seven or eight days, spontaneous diarrhea occurs, the pulse becomes suddenly faint (Wei), hands and feet become warm, and the tight pulse disappears, this indicates resolution. Although there is irritability and diarrhea, self-healing will occur.
[Commentary] Zhu Gong said: There are many types of diarrhea in Shanghan; one must distinguish between Yin and Yang to avoid errors. Diarrhea from the Three Yang meridians presents with fever; diarrhea from Taiyin presents with warm hands and feet; diarrhea from Shaoyin and Jueyin presents without fever. This distinguishes them. Generally, if diarrhea accompanies Taiyang pulse and symptoms, warming herbs must not be used. Quack doctors see only diarrhea and treat it as a Yin syndrome with warming-hot herbs, rarely resulting in death from jaundice and macules.
Generally, in Shanghan diarrhea, one must recognize differences between pulse and external symptoms. Diarrhea with a large pulse indicates deficiency; a faint pulse indicates diarrhea will stop spontaneously. Diarrhea occurring more than ten times a day with a surprisingly solid pulse is an adverse sign. Diarrhea with a rapid and slippery pulse indicates retained food; purgation will cure it. A slow and slippery pulse indicates excess; diarrhea will not stop immediately, and further purgation is appropriate. If the pulse at all three positions is level but pressing on the epigastrium reveals hardness, urgent purgation is needed. For heat-collusion diarrhea (Xie Re Li), there is fullness below the navel, reddish-yellow stool, and greasy intestinal fluids. If cold poison enters the stomach, there is cold below the navel, abdominal distension, and stools of various colors or undigested food. If warm-toxin qi is abundant, there is painful diarrhea with pus and blood resembling rotten meat juice. If thirst follows, there is heat. Delirium with diarrhea indicates dry feces. For cold poison entering the stomach, use Si Ni Tang, Li Zhong Tang, Bai Tong Tang, or Fu Zi Si Ni San plus Xiebai (Allium macrostemon Bulb). For heat-collusion diarrhea, use Huang Qin Tang, Bai Tou Weng Tang, San Huang Shu Ai Tang, or Chi Shi Zhi Wan. For warm-toxin causing pus and blood in stool, use Tao Hua Tang, Di Yu San, or Huang Lian E Jiao Tang. Although spontaneous diarrhea with thirst belongs to Shaoyin, Three Yang diarrhea may also involve thirst due to heat. Three Yin diarrhea requires warming. However, for Shaoyin clear-water diarrhea with epigastric pain and dry mouth, purgation is indicated. This must be known.
For Shaoyin diarrhea with a feeling of heaviness in the anus, hot herbs must not be given. First, decoct Xiebai (Allium macrostemon Bulb) tea thickly, then add Si Ni San (Bupleurum Decoction). This formula uses Zhi Shi (Immature Bitter Orange) and Shaoyao (Peony Root). For ordinary stomach disharmony with abdominal pain, borborygmus, and diarrhea, Sheng Jiang Xie Xin Tang (Ginger Decoction for Draining the Epigastrium) is best. These two methods apply not only to Shanghan. If the pulse is deep with spontaneous diarrhea and body pain, it is a Yin syndrome; urgent rescue of the interior is needed with Si Ni Tang, Fu Zi Tang, or Zhen Wu Tang. Generally, if stool is normal but body hurts, rescue the interior; if stool is normal but body hurts, rescue the exterior. This must be known.
Cheng Wuji said: Spontaneous diarrhea refers to loose stools without prior purgation. It can be due to exterior pathogen transmitting inward with interior deficiency and heat-collusion, or direct spontaneous diarrhea, both involving heat-collusion. Also, combined diseases of the Three Yang cause spontaneous diarrhea, treated by attacking the exterior, interior, or harmonizing. Why? Taiyang-Yangming combined disease is exterior, so Ge Gen Tang (Kudzu Decoction) is used to sweat. Taiyang-Shaoyang combined disease is half-exterior half-interior, so Huang Qin Tang is used to harmonize. Yangming-Shaoyang combined disease involves Shaoyang pathogen entering the interior, so Cheng Qi Tang (Order the Qi Decoction) is used to purge.
Even if diarrhea has exterior symptoms, do not sweat, because diarrhea indicates pathogen attacking inward, depleting fluids and weakening the stomach. The Classic states: Do not attack the exterior in diarrhea; sweating will cause abdominal fullness. Mostly, Three Yin spontaneous diarrhea occurs. However, cool body and quiet pulse in diarrhea is favorable; fever and large pulse is adverse. Generally, diarrhea with Qi depletion is difficult to treat because strong pathogen and deficient Zheng Qi lead to downward collapse of Qi, often resulting in death from diarrhea.
[Outline] Zhang Zhongjing said: If the pulse is tight at both cun and chi, with breath exiting the mouth, dry lips and mouth, runny nose, curling up to sleep, and cold feet, with a slippery tongue coating, do not treat rashly. After six or seven days, if the patient has slight fever and warm hands and feet, this indicates resolution. Or, if after eight days there is sudden high fever, this is difficult to treat. If there is aversion to cold, vomiting will likely occur; if there is abdominal pain, diarrhea will likely occur.
[Commentary] Ke Qin said: If after seven or eight days there is no fever, and with a tight pulse, aversion to cold worsens, cold is severe in the exterior affecting the Upper Jiao, leading to vomiting. If abdominal pain worsens, cold is severe in the interior affecting the Middle Jiao, leading to diarrhea.
[Outline] Zhang Zhongjing said: In Shaoyin disease, with vomiting and diarrhea, if hands and feet are not cold but instead feverish, death will not occur. If the pulse is unobtainable, moxa seven burns on Shaoyin points.
In Shaoyin disease, with vomiting, diarrhea, irritability, and cold extremities, death occurs.
[Commentary] Pang Anchang said: This is due to the impending extinction of Yang qi in the stomach and duodenum, causing upper vomiting and lower diarrhea.
[Outline] Zhang Zhongjing said: In Shaoyin disease, with a faint and choppy pulse, vomiting and sweating, frequent but scanty bowel movements, warm the upper part and apply moxibustion. In Shaoyin disease, with a deep, faint, and fine pulse, desire to sleep, sweating, no irritability, and desire to vomit, if on the sixth day spontaneous diarrhea occurs, followed by irritability and inability to sleep, death occurs.
[Commentary] Chen Shiduo said: Shanghan with deep, faint, and fine pulse is clearly a Yin syndrome. Moreover, desiring to sleep yet wanting to move? Sweat has occurred, indicating no interior Yang syndrome. No irritability in the heart, frequent desire to vomit, shows Yang pathogen has dispersed and Yin pathogen is acting. Urgent removal of cold is correct. Losing this chance not to warm leads to diarrhea on the fifth or sixth day, meaning chaos in both upper and lower. If not irritable then, true Yang in Kidney is not scattered. Now adding irritability and insomnia indicates irreversible scattering of Yuan Qi. Is this not a death case? However, the cause was missed treatment, not incurable disease becoming chaotic. There is a miraculous formula called Zhuan Yang Yuan Jue Tang (Turning Yang to Rescue Extinction Decoction): Ren Shen (Ginseng Root), Bai Zhu (Atractylodes Rhizome), Suan Zao Ren (Ziziphus Seed) each 1 liang, Fu Shen (Poria with Hostwood) 5 qian, Rou Gui (Cinnamon Bark) 2 qian. Decoct in water; one dose brings relief. Ren Shen rescues extinction; Bai Zhu and Fu Shen drain dampness and stop diarrhea; Gui warms middle and removes cold; Suan Zao Ren calms mind and relieves restlessness.
[Outline] Zhang Zhongjing said: In Shaoyin disease, persisting from two to three days to four to five days, with abdominal pain, difficulty urinating, heavy and painful limbs, and spontaneous diarrhea, this is Water Qi (fluid retention). The patient may cough, have free urination, have diarrhea, or vomit. Zhen Wu Tang (True Warrior Decoction) governs.
[Commentary] Wu Shou said: Spontaneous diarrhea refers to loose stools without purgation, commonly called "leaky bottom Shanghan." There is heat-collusion and cold-collusion, requiring detailed differentiation. *Yuan Bing Shi* states: White discharge is cold; green, yellow, red, black are heat. Generally, undigested food, non-cold color, like mush, or foul-smelling diarrhea, clear cold urine, no dry mouth/thirst, deep/fine or slow/faint/weak pulse, or fever with cold limbs, aversion to cold, curling up, are all cold syndromes. Heat syndromes feature dry mouth/thirst, yellow/red or obstructive urine, greasy discharge, and numerous/rapid/slippery/wiry/large/hyperactive pulses, or heat failing to digest food. Differentiate by pulse and symptoms. For stomach deficiency with internal heat, irritability, thirst, diarrhea, and weak pulse, use Qi Wei Ren Shen Bai Zhu San (Seven-Ingredient Ginseng and Atractylodes Powder). If feverish, use Shen Hu San Bai Tang (Ginseng, Bupleurum, and Three Whites Decoction), remove Huang Qin, add fried Huang Lian. If abdominal fullness and difficulty urinating, use Wu Ling San (Five-Ingredient Poria Powder) combined with Li Zhong Tang. If vomiting, add Huo Xiang (Patchouli), Ban Xia (Pinellia Tuber), Sheng Jiang (Fresh Ginger), Chen Pi (Tangerine Peel). If dampness causes persistent diarrhea, add Bai Zhu and Cang Zhu (Atractylodes). If abdominal distension, add Hou Po (Magnolia Bark). If abdominal pain, add Bai Shao and Rou Gui, Mu Xiang (Aucklandia Root). For Shanghan diarrhea with floating pulse and unresolved exterior, Zhang Zhongjing uses Xiao Qing Long Tang (Minor Green Dragon Decoction) removing Ma Huang and adding fried Yuan Hua (Genkwa Flower) 2 qian. Dispersing exterior treats water. If obstructive urination and watery diarrhea, use Wu Ling San. If severe water retention unresolved, add Yuan Hua 2 qian or Che Qian Zi (Plantago Seed) soup to stop diarrhea. Generally, do not sweat in diarrhea; treat diarrhea first. Once stopped, interior solidifies, Zheng Qi recovers, pathogen resolves, then sweating cures. Diarrhea stems from interior deficiency; sweating makes both interior and exterior deficient, causing difficult-to-treat complications.
Su Song said: "Water Qi" is the original intent of Zhen Wu Tang. Diarrhea is also caused by Water Qi. The latter three items are modifications of Zhen Wu Tang.
[Outline] Zhang Zhongjing said: In Shaoyin disease, from two to three days to four to five days, with abdominal pain, difficulty urinating, persistent diarrhea, and bloody/purulent stool, Tao Hua Tang (Peach Kernel Decoction) governs.
[Commentary] Pang Anchang said: This is due to cold poison entering the stomach, causing abdominal pain and diarrhea.
[Outline] Zhang Zhongjing said: Profuse sweating or severe diarrhea with cold extremities: Si Ni Tang governs.
Profuse sweating with persistent fever, internal cramping, limb pain, plus diarrhea, cold extremities, and aversion to cold: Si Ni Tang governs. Spontaneous diarrhea with no thirst belongs to Taiyin due to cold in zang organs; warm it with Si Ni Tang class.
[Commentary] Ke Qin said: Profuse sweating causes Yang collapse; severe diarrhea causes Yin collapse. Both Yin and Yang are deficient, hence cold extremities. But diarrhea is not undigested food; urgent warming allows Yang return and hope of life. These two cases result from improper treatment. Although profuse sweating persists with fever, aversion to cold indicates unresolved exterior. Cramping and diarrhea indicate developed interior cold. Limb pain and cold extremities show exterior cold again. Thus, exterior heat with interior cold is actually exterior cold with Yang collapse.
[Outline] Zhang Zhongjing said: In Shaoyin disease, diarrhea with undigested food, interior cold with exterior heat, cold extremities, faint pulse nearly imperceptible, body not averse to cold, flushed face, or abdominal pain, dry retching, sore throat, or cessation of diarrhea with unobtainable pulse: Tong Mai Si Ni Tang (Pulse-Returning Cinnamon and Aconite Decoction) governs.
[Commentary] Ke Qin said: Sore throat and cessation of diarrhea indicate Yang returning internally. Abdominal pain and dry retching indicate struggle between cold and heat.
[Outline] Zhang Zhongjing said: In Shaoyin disease, cough with diarrhea and delirium results from fire therapy forcing sweat. Urination will certainly be difficult due to forcibly demanding sweat from Shaoyin.
[Commentary] Yu Chang said: The Shaoyin meridian enters the abdomen from the foot, ascends along the throat, and surrounds the tongue root, hence frequent sore throats. Its branch emerges from the Lung, hence occasional coughs. Forcing sweat with fire causes heat pathogen to attack upward with fire power, causing cough (Lung Metal dislikes fire). Downward attack causes diarrhea (fire forces exit through orifices). Internal attack causes delirium (fire scorers and confuses Shen). Difficulty urinating occurs because these three symptoms obstruct urination. If Lung is injured by fire, Bladder Qi transformation fails; if Large Intestine rushes excessively, water and grain follow one path; if Pericardium scorers endlessly, Small Intestine dries up. Can Shaoyin be forcibly sweated?
Kidney heat affects its exterior organ, the Bladder, causing difficult urination. Cough and diarrhea reflect the exterior-interior relationship of Lung and Large Intestine.
Wei Litong said: This explains Shaoyin transmitted heat pathogen causing interior harm, not mistaken for direct cold pathogen. Forcibly sweating makes it difficult. Shaoyin disease has transmitted heat and direct cold. Heat transmission starts in the meridian but involves Kidney. Direct cold divides into meridian and zang. Zang uses only warming, not dispersing; meridian uses warming and dispersing. Zang pathology has no dispersing method. How much less for transmitted interior heat? Thus, prolonged intense heat cannot be warmed; deep interior heat cannot be dispersed. This applies to Taiyang transmitting to Yangming interior where sweating is contraindicated. Further transmitting to Three Yin, reaching Shaoyin (extreme depth, interior of interiors), forbidding forced sweating is obvious. Only Shaoyin includes direct cold, treated by warming meridians and dispersing cold, akin to sweating. Zhang Zhongjing warns against using this for transmitted Shaoyin heat, specifically marking Fu Zi, Ma Huang, Xi Xin, Gan Cao for direct cold Shaoyin meridian. Direct cold Shaoyin zang mentions only warming, not dispersing. It is not for transmitted heat affecting Kidney zang.
This is a critical point lacking clear analysis. Above this clause: "Shaoyin disease, fine/deep/rapid pulse, disease is interior, do not sweat." Followed by this clause. Shaoyin pulse is normally faint/fine; now fine remains, showing deep/rapid. Fine relates to Jueyin-Shaoyin; deep is proper Shaoyin pulse. Absence of Taiyin faintness but presence of Yang rapid pulse (opposite of slow) requires heavy pressing in deep position to distinguish. Similarly, fine/wiry pulses require light pressing in deep position. Thus, deep is Shaoyin root pulse. Light pressing shows fine above deep; heavy pressing shows faint below deep: this is direct cold Shaoyin. Warm middle or disperse cold accordingly. Light pressing shows fine above deep; heavy pressing shows rapid instead of faint in deep: this is transmitted heat Shaoyin. One pulse in deep position distinguishes Shaoyin cold/heat. Knowing this clarifies it is not direct exterior disease but transmitted interior disease. Initial wind-cold is always exterior, requiring sweating (even Shaoyin, e.g., Ma Huang Fu Zi Xi Xin Gan Cao Tang). Deep transmission is always interior, prohibiting sweating (even Taiyang, e.g., Di Dang Tang, Wu Ling San). Understanding this avoids rigid exterior/interior definitions. Knowing sweating principles allows flexible treatment of interior heat. Zhang Zhongjing says "do not sweat" without prescribing because the formula follows later. He warns against forced sweating to prevent immediate disaster. Consider cough/diarrhea/delirium: transmitted heat reaching Shaoyin. Fire forcing sweat depletes Shaoyin Qi/Blood and Yin fluids, causing difficult urination. Stomach fluid loss with free urination means fluid loss above with lower Qi transformation intact. Here, Kidney Yin is damaged, fluid loss below stops Qi transformation. Forcing Shaoyin sweat with fire seems to injure only Yang/exterior, but fluid/Qi loss is severe. Be cautious!
[Outline] Zhang Zhongjing said: After six or seven days of Shanghan, following severe purgation, if cun pulse is deep and slow, hands/feet are cold, lower pulses are unobtainable, throat is obstructed, expectoration of pus/blood occurs, and diarrhea is uncontrollable, this is difficult to treat.
[Commentary] Tao Hua said: Six-Fu Qi perishing externally causes cold hands/feet; Five-Zang Qi perishing internally causes uncontrollable diarrhea. This is what is meant.
[Outline] Zhang Zhongjing said: In Shaoyin disease, with vomiting, diarrhea, cold extremities, and severe irritability, Wu Zhu Yu Tang (Evodia Decoction) governs.
Dry retching, spitting saliva/phlegm, headache: Wu Zhu Yu Tang governs.
Desire to vomit after eating belongs to Yangming; Wu Zhu Yu Tang governs. If symptoms worsen after taking the decoction, it belongs to Upper Jiao deficiency.
[Commentary] Shen Jin'ao notes: Vomiting, diarrhea, irritability indicate Yin pathogen entering the He-sea points, unable to exit via Yang. Dry retching (vomiting without matter) indicates stomach deficiency. Spitting saliva/phlegm indicates stomach cold. Desire to vomit after eating, where grain is rejected, also indicates stomach cold. "Taking the decoction" refers to Wu Zhu Yu Tang. Worsening after ingestion is due to phlegm-fluid in Upper Jiao; self-healing occurs after vomiting clears it.
[Outline] Zhang Zhongjing said: In Shaoyin disease, with diarrhea and faint pulse, give Bai Tong Tang. If diarrhea persists, with cold extremities, unobtainable pulse, dry retching, and irritability, Bai Tong Jia Zhu Dan Ye Tang (Bai Tong Decoction with Pig Bile) governs. After taking the decoction, if pulse suddenly appears, death; if pulse gradually returns, survival.
[Commentary] Zhang Yuansu said: Some say Bai Tong Tang, Bai Tong Jia Zhu Dan Ye Tang, Zhen Wu Tang, and Tong Mai Si Ni Tang are all for Shaoyin diarrhea. Except for Ginger and Aconite, other herbs differ. Why? Different diseases require different drugs. Shaoyin diarrhea involves severe cold, requiring Ginger and Aconite. However, while diarrhea mechanism is similar, accompanying symptoms vary, hence different prescriptions. Bai Tong uses Ginger/Aconite to disperse cold and stop diarrhea, adds Cong Bai (Scallion White) to regulate Yang Qi. If diarrhea with dry retching/irritability, cold is too severe with internal rejection; Ginger/Aconite are unsuitable for irritability, causing vomiting/refusal. Adding Ren Nao (Human Urine) and Zhu Dan Ye (Pig Bile) to Bai Tong Tang, taken warm/cold. These two are salty/bitter/cold, allowing intake without rejection. Upon reaching the site, cold nature dissipates, hot nature activates. Zhen Wu Tang treats Shaoyin days 2-4 with abdominal pain, difficulty urinating, heavy/painful limbs, spontaneous diarrhea due to Water Qi. Water Qi is cold-dampness, governed by Kidney. Kidney failure to control water leads to stagnation, causing abdominal pain (internal cold-damp), heavy/painful limbs (external cold-damp), difficulty urinating, and spontaneous diarrhea (dampness preventing separation of water/grain). Classic states: Spleen dislikes dampness; sweet enters Spleen first. Licorice/Poria sweetness tonifies Spleen and drains water. To balance dampness excess, use pungent-hot. To assist dampness excess, use sour-pungent. Aconite, Shaoyao, Sheng Jiang are sour-pungent to warm meridians and disperse dampness. Xiao Qing Long Tang also addresses Water Qi.