伤寒脉促。手足厥逆。可灸之。（【原注】促。一作纵。○成本。玉函。逆下。有者字。）
〔喻〕伤寒脉促。则阳气 可知。更加手足厥逆。其阳必为阴所格拒。而不能返。故宜灸以通其阳也。
案汪引常器之云。灸太冲穴。未知是否。
伤寒脉滑而厥者。里有热。白虎汤主之。（成本。玉函。热下。有也字。）
〔钱〕滑者。动数流利之象。无沉细微涩之形。故为阳脉。乃伤寒郁热之邪在里。阻绝阳气。不得畅达
于四肢而厥。所谓厥深热亦深也。〔鉴〕伤寒脉微细。身无热。小便清白而厥者。是寒虚厥也。当温之。脉乍
紧。身无热。胸满而烦。厥者。是寒实厥也。当吐之。脉实大。小便闭。腹满硬痛而厥者。热实厥也。当下之。
今脉滑而厥。滑为阳脉。里热可知。是热厥也。然内无腹满痛不大便之证。是虽有热。而里未实。不可下而可
清。故以白虎汤主之。〔印〕此章因厥故。复列于厥阴篇中。亦非厥阴之本病也。
活人书云。热厥者。国中病。必身热头痛。外别有阳证。至二三日。乃至四五日。方发厥。其热厥者。
厥至半日。却身热。盖热气深。则方能发厥。须在二三日后也。若微厥。即发热者。热微故也。其脉虽沉伏。
按之而滑。为里有热。其人或畏热。或饮水。或扬手掷足。烦躁不得眠。大便秘。小便赤。外证多昏愦者。知
其热厥。白虎汤。又有下证悉具。而见四逆者。是失下后。血气不通。四肢便厥。医人不识。却疑是阴厥。复
进热药。祸如反掌。大抵热厥。须脉沉伏而滑。头上有汗。其手虽冷。时复指爪温。须便用承气汤下之。不可
拘忌也。
手足厥寒。脉细欲绝者。当归四逆汤主之。（玉函。千金翼。作脉为之细绝。无者字。）
〔钱〕四肢为诸阳之本。邪入阴经。致手足厥而寒冷。则真阳衰弱可知。其脉微细欲绝者。素问脉要精
微论云。脉者血之府也。盖气非血不附。血非气不行。阳气既已虚衰。阴血自不能充实。当以四逆汤。温复其
真阳。而加当归以营养其阴血。故以当归四逆汤主之。
当归四逆汤方
当归（三两） 桂枝（三两去皮） 芍药（三两） 细辛（三两○玉函。作一两。） 甘草（二两炙）
通草（二两） 大枣（二十五枚擘一法十二枚○枚。成本。作个。）
上七味。以水八升。煮取三升。去滓。温服一升。日三服。
〔钱〕手足厥寒。即四逆也。故当用四逆汤。而脉细欲绝。乃阳衰而血脉伏也。故加当归。是以名之曰
当归四逆汤也。不谓方名虽曰四逆。而方中并无姜附。不知何以挽回阳气。是以不能无疑也。恐是历年久远。
散失遗亡。讹舛于后人之手。未可知也。从来注伤寒家。皆委曲顺解。曾不省察其理。
亦何异于成氏之随文顺释乎。〔柯〕此条证为在里。当是四逆本方加当归。如茯苓四逆之例。若反用桂枝汤攻表。
误矣。既名四逆汤。岂得无姜附。
若其人内有久寒者。宜当归四逆加吴茱萸生姜汤。
〔钱〕此承上文言。手足厥寒。脉细欲绝。固当以当归四逆治之矣。若其人平素。内有久寒者。而又为客
寒所中。其涸阴冱寒。难于解散。故更加吴茱萸之性燥苦热。及生姜之辛热以泄之。而又以清酒。扶助其阳气。
流通其血脉也。
当归四逆加吴茱萸生姜汤方
当归（三两） 芍药（二两炙○玉函。作三两。） 通草（二两○玉函。作三两。） 桂枝（三两去皮）
细辛（三两） 生姜（半斤切○千金翼作八两。方周钱鉴。作三两。） 大枣（二十五枚擘） 茱萸（二升○
玉函。千金翼。作吴茱萸二两。方周钱鉴。作半斤。）
上九味。以水六升。清酒六升。和煮取五升。去滓。温分五服。（【原注】一方。水酒各四升。○玉函。
千金翼。并用水酒各四升。）
〔柯〕此本是四逆。与吴茱萸相合。而为偶方也。吴茱萸。配附子。生姜佐干姜。久寒始去。
严氏济生方。通脉四逆汤。治霍乱多寒。肉冷脉绝。
即本方。加附子。
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。（千金翼。无内字。又作若。）
〔鉴〕通身大汗出。热当去矣。热仍不去。而无他证。则为邪未尽而不解也。今大汗出热不去。而更见拘
急肢疼。且下利厥逆而恶寒。是阳亡于表。寒盛于里也。故主四逆汤。温经以胜寒。回阳而敛汗也。〔汪〕内
拘急。此寒气深入于里。寒主收引。当是腹以内拘急。
案方氏云。内拘急。四肢疼者。亡津液而骨气不利也。乃以内拘急。为手足拘急。然内字不妥帖。
大汗若大下利。而厥冷者。四逆汤主之。（玉函。千金翼。汗下。有出字。）
〔钱〕上条大汗出。而热不去。此条大汗出。而不言热。是无热矣。或曰。上文下利厥逆而恶寒。且多
内拘急四肢疼之证。此条亦大下利厥冷。而不恶寒。其不言热。乃阳气犹未飞越于外。得毋较前为稍轻乎。曰
无热则阳气更微。大下利则阴邪更盛。故亦以四逆汤主之。
案玉函经。此下有两条。曰表热里寒者。脉虽沉而迟。手足微厥。下利清谷。此里寒也。所以阴证亦有
发热者。此表热也。曰表寒里热者。脉必滑。身厥舌干也。所以少阴恶寒而倦。此表寒也。时时自烦。不欲浓
衣。此里热也。
病患手足厥冷。脉乍紧者。邪结在胸中。心下满而烦。饥不能食者。病在胸中。当须吐之。宜瓜蒂散。
（辨可吐篇。乍紧。作乍结。成本。玉函。心下。作心中。）
〔印〕曰病患者。非厥阴之为病。而亦非外受之寒邪也以手足厥冷。故列于厥阴篇中。〔鉴〕病患手足厥
冷。若脉微而细。是寒虚也。寒虚者可温可补。今脉乍紧劲。是寒实也。寒实者。宜温宜吐也。时烦吐蛔。饥
不能食。乃病在胃中也。今心中烦满。饥不能食。是病在胸中也。寒饮实邪。壅塞胸中。则胸中阳气。为邪所
遏。不能外达四肢。是以手足厥冷。胸满而烦。饥不能食也。当吐之。宜瓜蒂散。涌其在上之邪。则满可消。
而厥可回矣。
伤寒厥而心下悸。宜先治水。当服茯苓甘草汤。却治其厥。不尔水渍入胃。必作利也。（成本。玉函。
悸下。有者字。玉函。作与。）
〔钱〕金匮云。水停心下。甚者则悸。太阳篇中。有饮水多者。心下必悸。此二语。虽皆仲景本文。然此
条并不言饮水。盖以伤寒见厥。则阴寒在里。里寒则胃气不行。水液不
布。必停蓄于心下。阻绝气道。所以筑筑然而悸动。故宜先治其水。当服茯苓甘草汤。以渗利之。然后却与治
厥之药。不尔则水液既不流行。必渐渍入胃。寒厥之邪在里。胃阳不守。必下走而作利也。〔鉴〕伤寒太阳篇。
汗出表未和。小便不利。此条伤寒表未解。厥而心下悸。二证皆用茯苓甘草汤者。盖因二者见证虽不同。而里
无热表未和。停水则同也。故一用之谐和营卫以利水。一用之解表通阳以利水。无不可也。此证虽不曰小便不
利。而小便不利之意自在。若小便利。则水不停。则厥悸属阴寒矣。岂宜发表利水耶。〔汪〕郭雍云。以四逆
汤治厥。
金鉴云。厥而心下悸者之下。当有以饮水多四字。若无此四字。乃阴盛之悸。非停水之悸矣。何以即知是
水。而曰宜先治水耶。○案此说近是。汪氏周氏。以此条证。为热厥兼停水。误矣。
伤寒六七日。大下后。寸脉沉而迟。手足厥逆。下部脉不至。喉咽不利。唾脓血。泄利不止者。为难治。
麻黄升麻汤主之。（玉函。无而字。喉咽。作咽喉。成本同。千金翼。无寸字。）
〔柯〕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。喉咽不利。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。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。
麻黄升麻汤方
麻黄（二两半去节） 升麻（一两一分） 当归（一两一分○玉函。升麻。当归。各
一两六铢。千金翼同。） 知母（十八铢） 黄芩（十八铢） 葳蕤（十八铢一作菖蒲） 芍药（六铢） 天门
冬（六铢去心○玉函。千金翼。作麦门冬。） 桂枝（六铢） 茯苓（六铢） 甘草（六铢炙） 石膏（六铢碎
绵裹） 白术（六铢） 干姜（六铢）
上十四味。以水一斗。先煮麻黄一两沸。去上沫。纳诸药。煮取三升。去滓。分温三服。相去如炊三斗
米顷令尽。汗出愈。
案此条。证方不对。注家皆以为阴阳错杂之证。回护调停。为之诠释。而柯氏断然为非仲景真方。可谓
千古卓见矣。兹不敢繁引诸说云。○又案外台引短剧。载本方。方后云。此张仲景伤寒论方。
伤寒选录云。此药之大者。若瘟毒瘴利。表里不分。毒邪沉炽。或咳或脓或血者。宜前药。
伤寒四五日。腹中痛。若转气下趣少腹者。此欲自利也。（此。玉函。作为。趣。正脉本。作趋。诸本
同。唯方本作趣。）
〔钱〕伤寒四五日。邪气入里。传阴之时也。腹中痛。寒邪入里。胃寒而太阴脾土病也。转气下趋少腹
者。言寒邪盛。而胃阳不守。水谷不别。声响下奔。故为欲作自利也。〔周〕愚案腹中痛。又何以知是虚寒。
若火痛。必自下逆攻而上。若热痛。必胸结烦满而实。故下气转趋。知为寒欲利无疑也。
伤寒本自寒下。医复吐下之。寒格更逆吐下。若食入口即吐。干姜黄芩黄连人参汤主之。（复吐下之。
玉函。千金翼。全书。作复吐之。玉函。无若字。即吐。作即出者。千金翼。寒格上。有而字。）
〔王〕案本自寒下。恐是本自吐下。玩复字可见。盖胃寒则吐。下寒则利。胃寒者不宜吐。医反吐之。
则伤胃气。遂成寒格。下文文气不贯。当有阙文。
金鉴云。经论中。并无寒下之病。亦无寒下之文。玩本条下文。寒格更逆吐下。可知寒下之下字。当是
格字。文义
始属。注家皆释胃寒下利。不但文义不属。且与芩连之药不合。○案柯本。删更逆吐下四字。要之此条。必有误脱。
干姜黄芩黄连人参汤方
干姜 黄芩 黄连 人参（各三两）
上四味。以水六升。煮取二升。去滓。分温再服。
〔柯〕伤寒吐下后。食入口即吐。此寒邪格热于上焦也。虽不痞硬。而病本于心。故用泻心之半。调其
寒热。以至和平。去生姜半夏者。心下无水气也。不用甘草大枣者。呕不宜甘也。〔鉴〕朝食暮吐。脾寒格也。
食入即吐。胃热格也。寒格。当以理中汤。温其太阴。加丁香降其寒逆。可也。热格。当用干姜人参安胃。黄
连黄芩。降胃火也。
案金匮。食已即吐者。大黄甘草汤主之。金鉴注文。与此条意同。
保幼大全。四味人参汤。治伤寒脉迟。胃冷呕吐。（即本方）
下利有微热而渴。脉弱者。令自愈。（令。成本。作今。玉函无。）
〔程〕下利脉绝者死。脉实者亦死。必何如而脉与证合也。缘厥阴下利。为阴寒胜。微热而渴。则阳热
复也。脉弱。知邪已退。而经气虚耳。故令自愈。〔钱〕脉弱者。方见其里气本然之虚。无热气太过。作痈脓
便脓血。及喉痹口伤烂赤之变。故可不治。令其自愈也。若或治之。或反见偏胜耳。
案汪氏魏氏周氏。以此条证。为传经热利。误矣。
溯洄集云。六经病篇。必非叔和所能赞辞也。但厥阴经中下利呕哕诸条。却是叔和因其有厥逆而附。遂
并无厥逆而同类者。亦附之耳。
下利脉数。有微热汗出。令自愈。设复紧为未解。（【原注】一云。设脉浮复紧。○千金翼。有。作若。
令。成本。作今。玉函。千金翼。作者。）
〔成〕下利。阴病也。脉数。阳脉也。阴病见阳脉者生。
微热汗出。阳气得通也。利必自愈。诸紧为寒。设复脉紧。阴气犹胜。故云未解。
下利。手足厥冷。无脉者。灸之不温。若脉不还。反微喘者死。（玉函。若。作而。）
〔钱〕阴寒下利。而手足厥冷。至于无脉。是真阳已竭。已成死证。故虽灸之。亦不温也。若脉不还。反
见微喘。乃阳气已绝。其未尽之虚阳。随呼吸而上脱。其气有出无入。故似喘非喘而死矣。〔汪〕喘非灸所致。
阳气不因灸复。则绝证以次第而至。尚论篇云。孤阳随火气上逆而脱。误矣。此条。仲景不言当灸何穴。常器
之云。当灸关元气海二穴。
少阴负趺阳者。为顺也。（原本。及千金翼。志聪本。锡驹本。接前条。今据成本。及玉函。分为别条）
〔钱〕少阴负趺阳句。疑有脱字。不然何至词不达义邪。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。（案此喻注。盖本成注。方意亦同。）
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
伤寒脉象急促，手足冰冷，可以用艾灸治疗。（【原注】促，一作纵。○成本、玉函本在“逆”字下有“者”字。）
〔喻嘉言〕伤寒脉象急促，说明阳气亢盛。如果再加上手足厥冷，那么阳气必然被阴寒格拒，不能返回体内。所以适宜用艾灸来通达阳气。
案：汪氏引用常器之的说法，认为应灸太冲穴，不知是否正确。
伤寒脉象滑利而手足厥冷的，是里有热邪，用白虎汤主治。（成本、玉函本在“热”字下有“也”字。）
〔钱天来〕滑脉，是动数流利之象，没有沉细微涩的形状，所以属于阳脉。这是伤寒郁积的热邪在体内，阻绝了阳气，使其不能畅达于四肢而导致厥冷。这就是所说的“厥深热亦深”。〔柯琴〕伤寒脉微细，身体无发热，小便清白而手足厥冷的，是寒性虚厥。应当用温法。脉象突然紧束，身体无发热，胸中胀满而烦躁，手足厥冷的，是寒性实厥。应当用吐法。脉象实大，小便不通，腹部胀满硬痛而手足厥冷的，是热性实厥。应当用下法。现在脉象滑利而手足厥冷，滑为阳脉，可知里有热，这是热厥。然而内部没有腹部胀满疼痛、大便不通的症状，这说明虽然有热，但里实未成，不可用下法而可用清法。所以用白虎汤主治。〔徐大椿〕这一条因为出现厥逆，所以重新列在厥阴篇中，但这并非厥阴的本病。
《活人书》说：热厥证，是国家的常见病。必定身体发热、头痛，外部另有阳证表现。到了二三天，甚至四五天，才发生厥逆。这种热厥，厥逆持续半天后，身体又发热。这是因为热气深沉，才能引发厥逆，必须经过两三天才会发作。如果是轻微厥逆，随即发热的，是因为热势轻微。其脉象虽然沉伏，但按之滑利，说明里有热。其人或者怕热，或者想喝水，或者扬手掷足，烦躁不得睡眠，大便秘结，小便色赤，外部症状多昏沉混乱的，可以知道是热厥，用白虎汤。又有具备所有下法适应证，却出现四肢逆冷的，这是失于攻下之后，血气不通，四肢便发生厥逆。医生不认识这种情况，反而怀疑是阴厥，再次进服热药，祸患如反掌之间。大抵热厥，必须脉象沉伏而滑，头上有汗，虽然手脚冷，但时常指爪温暖，必须立即使用承气汤攻下，不可拘泥忌讳。
手足寒冷，脉象细弱几乎要断绝的，用当归四逆汤主治。（玉函本、千金翼本作“脉为之细绝”，没有“者”字。）
〔钱天来〕四肢是诸阳的根本。邪气侵入阴经，导致手足厥冷而寒冷，可知真阳衰弱。其脉象微细欲绝，《素问·脉要精微论》说：“脉是血的府库。”大概气依附于血，血依靠气运行。阳气既然已经虚衰，阴血自然不能充实。应当用四逆汤温复真阳，并加入当归以滋养阴血。所以用当归四逆汤主治。
当归四逆汤方
当归（三两） 桂枝（三两，去皮） 芍药（三两） 细辛（三两○玉函本作一两。） 甘草（二两，炙）
通草（二两） 大枣（二十五枚，擘开；一说十二枚○枚，成本本作“个”。）
以上七味药，用水八升，煮取三升，去渣滓，温服一升，每日三次服用。
〔钱天来〕手足厥寒，就是四逆证。所以应当用四逆汤。但脉象细欲绝，是阳衰而血脉潜伏所致。所以加入当归，因此命名为当归四逆汤。没想到方名虽叫四逆，但方中并没有干姜、附子，不知道如何挽回阳气。对此我不能不怀疑。恐怕是年代久远，散失遗亡，被后人讹误错乱，这也是可能的。历来注释伤寒的医家，都委婉曲解顺从文意，不曾省察其中的道理。这与成无己随文顺释有什么区别呢？〔柯琴〕这条证的病位在里，应当是四逆汤本方加当归，如同茯苓四逆汤的例子。如果用桂枝汤攻表，就错了。既然名叫四逆汤，难道能没有干姜、附子吗？
如果患者体内有久寒的，适宜用当归四逆加吴茱萸生姜汤。
〔钱天来〕这是承接上文而言。手足厥寒，脉细欲绝，固然应当用当归四逆汤治疗。但如果患者平素体内有久寒，而又被客寒所伤，其阴液枯竭，寒气凝滞，难以解散。所以更加入吴茱萸燥苦热的药性，以及生姜辛热的药性以驱散它，并且用清酒扶助阳气，流通血脉。
当归四逆加吴茱萸生姜汤方
当归（三两） 芍药（二两，炙○玉函本作三两。） 通草（二两○玉函本作三两。） 桂枝（三两，去皮）
细辛（三两） 生姜（半斤，切○千金翼本作八两，方周钱鉴本作三两。） 大枣（二十五枚，擘开） 吴茱萸（二升○玉函、千金翼本作吴茱萸二两，方周钱鉴本作半斤。）
以上九味药，用水六升，清酒六升，混合煮取五升，去渣滓，分五次温服。（【原注】一方，水酒各四升。○玉函、千金翼本，均用水酒各四升。）
〔柯琴〕这原本是四逆汤，与吴茱萸相合，成为偶方。吴茱萸配附子，生姜佐干姜，久寒才能去除。
严氏济生方的通脉四逆汤，治疗霍乱多寒，肌肉冷，脉绝。
即本方加附子。
大汗出，热不退，内部拘急，四肢疼痛，又伴有下利、厥逆和恶寒的，用四逆汤主治。（千金翼本无“内”字，“又”作“若”。）
〔柯琴〕全身大汗出，热应当退去。热仍不退，且没有其他症状，则是邪气未尽而不解。现在大汗出热不退，而且更见拘急肢疼，并且下利、厥逆而恶寒，这是阳气亡于体表，寒邪盛于体内。所以主用四逆汤，温经以胜寒，回阳以敛汗。〔汪昂〕内拘急，这是寒气深入于里。寒主收引，应当是腹部以内拘急。
案：方有执说，内拘急、四肢疼，是亡津液而骨气不利。他把“内拘急”解释为手足拘急。然而“内”字不妥帖。
大汗或大下利，而手足冰冷的，用四逆汤主治。（玉函、千金翼本在“汗下”后有“出”字。）
〔钱天来〕上一条是大汗出而热不退，这一条是大汗出而不提热，是没有热了。有人说：上文有下利、厥逆而恶寒，且多有内拘急、四肢疼的症状。这一条也是大下利、厥冷，但不恶寒。不提热，是因为阳气还没有飞越于外，难道比前证稍轻吗？回答说：无热则阳气更微弱。大下利则阴邪更盛。所以也用四逆汤主治。
案：玉函经在此之下有两条，一条说：表热里寒，脉象虽沉而迟，手足微厥，下利清谷，这是里寒。所以阴证也有发热的，这是表热。另一条说：表寒里热，脉必滑，身体厥冷舌干。所以少阴恶寒而倦怠，这是表寒。时时自烦，不欲穿厚衣，这是里热。
病患手足厥冷，脉象突然紧束的，邪气结在胸中，心下胀满而烦躁，饥饿但不能进食的，病在胸中，应当用吐法，适宜瓜蒂散。（辨可吐篇中，“乍紧”作“乍结”。成本、玉函本，“心下”作“心中”。）
〔徐大椿〕说病患，不是厥阴的本病，也不是外受的寒邪。因为手足厥冷，所以列在厥阴篇中。〔柯琴〕病患手足厥冷，如果脉微而细，是寒虚。寒虚的可以温补。现在脉象突然紧劲，是寒实。寒实的，宜温宜吐。时而烦躁、吐蛔虫，饥饿不能进食，是病在胃中。现在心中烦满，饥饿不能进食，是病在胸中。寒饮实邪，壅塞胸中，则胸中阳气被邪气遏制，不能外达四肢，所以手足厥冷，胸满而烦，饥饿不能进食。应当用吐法，适宜瓜蒂散，涌吐在上部的邪气，则胀满可消，而厥逆可回。
伤寒厥逆而心下悸动的，适宜先治水，应当服用茯苓甘草汤，然后再治其厥逆。不然，水气浸渍入胃，必定会发生下利。（成本、玉函本在“悸”字下有“者”字。玉函本作“与”。）
〔钱天来〕《金匮要略》说：水停心下，严重的就会悸动。太阳篇中说：饮水多的，心下必定悸动。这两句话，虽然是张仲景的原文，但这一条并不提及饮水。大概因为伤寒见到厥逆，则阴寒在里。里寒则胃气不行，水液不布散，必定停蓄于心下，阻绝气道，所以心脏筑筑然而悸动。所以适宜先治其水，应当服用茯苓甘草汤，以渗利之。然后才给予治厥逆的药。不然，水液既不流行，必定逐渐浸渍入胃。寒厥之邪在里，胃阳不守，必定向下走而发生下利。〔柯琴〕伤寒太阳篇中，汗出表未和，小便不利。这一条伤寒表未解，厥而心下悸。两个证候都用茯苓甘草汤，大概因为二者见证虽然不同，但里无热、表未和、停水的情况相同。所以一个用它调和营卫以利水，一个用它解表通阳以利水，都可以。这个证候虽然没有说小便不利，但小便不利之意自在其中。如果小便利，则水不停留，那么厥悸属于阴寒了，岂宜发表利水呢？〔汪昂〕郭雍说：用四逆汤治厥。
金鉴说：厥而心下悸者的下面，应当有“以饮水多”四个字。如果没有这四个字，乃是阴盛之悸，非停水之悸。怎么就知道是水，而说适宜先治水呢？○案：这种说法接近正确。汪氏、周氏把这个证候认为是热厥兼停水，是错误的。
伤寒六七天，经过大力攻下后，寸脉沉而迟，手足厥逆，下部脉摸不到，咽喉不利，唾脓血，泄利不止的，为难治。用麻黄升麻汤主治。（玉函本无“而”字，“喉咽”作“咽喉”，成本同。千金翼本无“寸”字。）
〔柯琴〕寸脉沉迟，气口脉平了。下部脉不至，根本已绝了。六腑之气绝于外，则手足寒。五脏之气绝于内，则下利不禁。咽喉不利，水谷之道绝了。汁液不化，而成脓血。下濡而上逆，这是下厥上竭，阴阳离决的征候。生气将绝于内。麻黄升麻汤，其药物数量多，而分量轻，重在发汗发散而畏惧温补，是后世粗工的技巧，必定不是张仲景的方子。这个证候这个脉象，急用人参、附子来回阳，还恐怕救不回来。用治疗阳实证的方法治疗亡阳证，这是落井下石。敢希望他出汗而痊愈吗？绝汗出而死，这是必然的。仍然附上这个方子，以等待识者。
麻黄升麻汤方
麻黄（二两半，去节） 升麻（一两一分） 当归（一两一分○玉函本，升麻、当归，各一两六铢。千金翼同。） 知母（十八铢） 黄芩（十八铢） 葳蕤（十八铢，一作菖蒲） 芍药（六铢） 天门冬（六铢，去心○玉函、千金翼本作麦门冬。） 桂枝（六铢） 茯苓（六铢） 甘草（六铢，炙） 石膏（六铢，碎，绵裹） 白术（六铢） 干姜（六铢）
以上十四味药，用水一斗，先煮麻黄一两沸，去掉上面的沫，纳入其他药，煮取三升，去渣滓，分三次温服。间隔时间像做三斗饭的时间那样喝完。出汗则愈。
案：这一条，证候与方剂不对应。注家都认为这是阴阳错杂的证候，进行回护调停的解释。而柯氏断然认为不是张仲景的真方，可以说是千古卓见了。这里不敢繁引各种说法。○又案：《外台秘要》引《短剧》，记载本方，方后说：这是张仲景《伤寒论》方。
《伤寒选录》说：此药的大用，如果是瘟毒瘴痢，表里不分，毒邪沉炽，或者咳嗽、或者脓、或者血的，适宜前面的药。
伤寒四五日，腹中痛，如果有转气向下趋向少腹的，这是将要自行下利。（此，玉函本作“为”。趣，正脉本作“趋”，诸本同。只有方本作“趣”。）
〔钱天来〕伤寒四五日，邪气入里，是传入阴经的时候。腹中痛，是寒邪入里，胃寒而太阴脾土生病。转气下趋少腹，是说寒邪盛，而胃阳不守，水谷不分，声响下奔，所以为将要发生自行下利。〔周学海〕愚案：腹中痛，又怎么能知道是虚寒？如果是火痛，必定自上而下逆攻。如果是热痛，必定胸中结聚烦满而实。所以下气转趋，知道是寒欲下利无疑。
伤寒本来就有寒性下利，医生又用吐法、下法。寒邪格拒，更逆乱吐下，如果食物入口即吐的，用干姜黄芩黄连人参汤主治。（复吐下之，玉函、千金翼、全书本作“复吐之”。玉函本无“若”字。“即吐”，作“即出者”，千金翼本在“寒格”上有“而”字。）
〔王肯堂〕案：本来就有寒性下利，恐怕是本来就有吐下。玩味“复”字可见。大概胃寒则吐，下寒则利。胃寒的不宜吐，医生反而吐之，则伤胃气，遂成寒格。下文文气不连贯，应当有缺文。
金鉴说：经论中，并没有寒下的病，也没有寒下的文字。玩味本条下文“寒格更逆吐下”，可知“寒下”的“下”字，应当是“格”字，文义才通顺。注家都解释为胃寒下利，不但文义不通，而且与芩连的药物不合。○案：柯本，删去了“更逆吐下”四字。总之这一条，必定有误脱。
干姜黄芩黄连人参汤方
干姜 黄芩 黄连 人参（各三两）
以上四味药，用水六升，煮取二升，去渣滓，分两次温服。
〔柯琴〕伤寒吐下后，食入口即吐，这是寒邪格热于上焦。虽然不痞硬，但病本在心，所以用泻心汤的一半，调和寒热，以达到和平。去掉生姜半夏，是因为心下无水气。不用甘草大枣，是因为呕吐不宜甘味。〔柯琴〕朝食暮吐，是脾寒格拒。食入即吐，是胃热格拒。寒格，应当用理中汤，温太阴，加丁香降其寒逆，可以。热格，应当用干姜人参安胃，黄连黄芩降胃火。
案：《金匮要略》说：食已即吐者，大黄甘草汤主治。金鉴注文，与此条意思相同。
《保幼大全》的四味人参汤，治疗伤寒脉迟，胃冷呕吐。（即本方）
下利有微热而口渴，脉弱的，令其自愈。（令，成本本作“今”。玉函本无。）
〔程郊倩〕下利脉绝者死，脉实者亦死。必须怎样才脉与证合呢？因为厥阴下利，是阴寒胜。微热而渴，则阳热恢复。脉弱，知道邪气已退，而经气虚罢了。所以令其自愈。〔钱天来〕脉弱，正显示出里气本然的虚，没有热气太过，发生痈脓、便脓血，及喉痹、口伤烂赤的变化。所以可以不治，令其自愈。如果加以治疗，反而会出现偏胜。
案：汪氏、魏氏、周氏，把这个证候认为是传经热利，是错误的。
《溯洄集》说：六经病篇，必定不是叔和所能赞辞的。只是厥阴经中下利、呕哕诸条，却是叔和因其有厥逆而附带。于是并无厥逆而同类者，也附带进来。
下利脉数，有微热汗出，令其自愈。如果脉又变紧，为未解。（【原注】一云：设脉浮复紧。○千金翼本有“若”字，作“若”。令，成本本作“今”。玉函、千金翼本作“者”。）
〔成无己〕下利，是阴病。脉数，是阳脉。阴病见阳脉者生。
微热汗出，阳气得通了。下利必定自愈。诸紧为寒。如果脉又紧，阴气犹胜。所以说未解。
下利，手足厥冷，无脉的，艾灸后如果不温，如果脉不还，反而微喘的，死。（玉函本“若”作“而”。）
〔钱天来〕阴寒下利，而手足厥冷，至于无脉，是真阳已竭，已成死证。所以虽然艾灸，也不温。如果脉不还，反而见微喘，乃阳气已绝，其未尽之虚阳，随呼吸而上脱，其气有出无入，所以似喘非喘而死。〔汪昂〕喘不是艾灸导致的。阳气不因艾灸恢复，则绝证依次而至。《尚论篇》说：孤阳随火气上逆而脱，是错误的。这一条，仲景没有说要灸什么穴位。常器之说：应当灸关元、气海二穴。
少阴脉负于趺阳脉的，为顺。（原本、及千金翼、志聪本、锡驹本，接前条。今据成本、及玉函，分为别条）
〔钱天来〕少阴负趺阳句，疑有脱字。不然怎么会词不达义呢？前注，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。予其权于土，土强则水有制，而平成可几。（案：这个比喻注，大概是根据成注，方意也相同。）
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。这是承接上
Taiyang disease with a rapid pulse (Cù Mài, Rapid Pulse) and cold extremities (Shǒu Zú Jué Nì, Cold Extremities) can be treated with moxibustion. ([Original Note] "Rapid" is alternatively read as "unrestrained". ○ Cheng Ben and Yu Han editions have the character "zhě" after "extremities".)
[Yu Jia Yan] A rapid pulse in Taiyang disease indicates hyperactive Yang Qi. If accompanied by cold extremities, it implies that Yang Qi is rejected by Yin-Cold and cannot return to its source. Therefore, moxibustion is suitable to unblock and restore Yang Qi.
Case: Wang Ang cites Chang Qizhi, who suggests moxibustion at Taichong (LR3), but it is uncertain if this is correct.
In Taiyang disease, if the pulse is slippery (Huá Mài, Slippery Pulse) and there are cold extremities, there is heat in the interior; Baihu Tang (White Tiger Decoction) should be administered. (Cheng Ben and Yu Han editions have the character "yě" after "heat".)
[Qian Tianlai] The slippery pulse is characterized by movement, speed, and smoothness, lacking the form of sinking, fine, minute, or choppy qualities; thus, it belongs to Yang pulses. This indicates that constrained heat pathogen from Taiyang disease is in the interior, obstructing Yang Qi and preventing it from reaching the limbs smoothly, resulting in cold extremities. This is what is meant by "the deeper the cold extremities, the deeper the heat." [You Zaijing] In Taiyang disease, if the pulse is minute and fine, the body is not hot, urination is clear and copious, and there are cold extremities, this is a deficiency-cold type of cold extremities (Jué). It should be treated with warming methods. If the pulse suddenly becomes tight, the body is not hot, there is chest fullness and irritability, and cold extremities, this is an excess-cold type of cold extremities. It should be treated with emesis. If the pulse is substantial and large, urination is blocked, the abdomen is full, hard, and painful, and there are cold extremities, this is an excess-heat type of cold extremities. It should be treated with purgation. Now, with a slippery pulse and cold extremities, since slipperiness indicates a Yang pulse, interior heat is evident; this is a heat-type cold extremities. However, since there are no symptoms of abdominal fullness, pain, or constipation, although there is heat, the interior is not yet solidified. Purgation is contraindicated, but clearing heat is appropriate. Therefore, Baihu Tang is used. [Wu Qian] This clause is listed in the Jueyin chapter due to the presence of cold extremities, but it is not the primary disease of Jueyin.
The *Liuren Shu* states: Heat-type cold extremities is an internal disease. There must be body fever and headache, along with other exterior Yang syndrome manifestations. By the second or third day, or even fourth or fifth day, cold extremities may occur. In such heat-type cold extremities, after half a day of cold extremities, body heat returns. This is because deep heat is required to induce cold extremities, which takes two to three days. If mild cold extremities are followed immediately by fever, it indicates slight heat. Although the pulse may be deep and hidden, pressing reveals slipperiness, indicating interior heat. The patient may fear heat, desire water, throw hands and feet about, feel irritable, unable to sleep, have dry stool, and red urine. With external signs of confusion, one can identify heat-type cold extremities and use Baihu Tang. If all indications for purgation are present but four-chill occurs, it is due to failure to purge earlier, causing blood and Qi stagnation and limb coldness. If physicians do not recognize this and suspect Yin-cold, administering hot medicines will cause disaster swiftly. Generally, heat-type cold extremities require a deep, hidden, and slippery pulse, sweating on the head, and despite cold hands, occasional warmth in the fingernails. In such cases, Chengqi Tang should be used for purgation without hesitation.
Cold extremities with a fine pulse nearly imperceptible (Xì Yù Jué, Fine and Nearly Absent Pulse) are treated with Danggui Sini Tang (Angelica Sinensis Decoction for Reversing Cold). (Yu Han and Qianjin Yi editions read "pulse becomes fine and absent," omitting "zhě".)
[Qian Tianlai] The four limbs are the root of Yang. When pathogens enter Yin meridians, causing cold extremities, it indicates depletion of True Yang. The fine, nearly absent pulse aligns with the *Suwen*: "Pulse is the residence of Blood." Qi attaches to Blood, and Blood moves with Qi. Since Yang Qi is deficient, Yin Blood cannot be sufficient. One should use Sini Tang (Four Counterflow Decoction) to warm and restore True Yang, adding Dang Gui (Dong Quai Root) to nourish Yin Blood. Hence, Danggui Sini Tang is used.
Formula: Danggui Sini Tang
Dang Gui (Three Liang), Guizhi (Three Liang, peeled), Shaoyao (Three Liang), Xixin (Three Liang ○ Yu Han edition: One Liang), Gancao (Two Liang, honey-fried), Tongcao (Two Liang), Dazao (Twenty-five fruits, split; alternative method: twelve fruits ○ "Mei" in Cheng Ben is "Ge").
These seven ingredients are boiled in eight Sheng of water to obtain three Sheng. Strain and take one Sheng warm, three times daily.
[Qian Tianlai] Cold extremities constitute Si Ni (Four Counterflow/Cold Extremities), so Sini Tang is indicated. However, the fine, nearly absent pulse indicates Yang deficiency and latent blood vessels. Thus, Dang Gui is added, naming it Danggui Sini Tang. It is puzzling that a formula named "Si Ni" contains no Ganjiang (Dried Ginger) or Fuzi (Prepared Aconite), raising doubts about how it restores Yang. Perhaps due to age, texts were lost or corrupted by later editors. Commentators often force interpretations rather than examining the logic, similar to Cheng Wuji's literal explanations. [Ke Qin] This condition is interior; it should be Sini Tang plus Dang Gui, analogous to Fuling Sini Tang. Using Guizhi Tang to attack the exterior would be an error. How can a formula named "Si Ni" lack Ginger and Aconite?
If the patient has chronic cold within, Danggui Sini Tang plus Wuzhuyu and Shengjiang Decoction (Danggui Sini Tang plus Evodia and Fresh Ginger Decoction) is appropriate.
[Qian Tianlai] This follows the previous text: cold extremities with a fine, nearly absent pulse require Danggui Sini Tang. If the patient has chronic internal cold exacerbated by exogenous cold, the freezing Yin is difficult to resolve. Therefore, add Wuzhuyu (Evodia Fruit), which is dry, bitter, and hot, and Shengjiang (Fresh Ginger), which is pungent and hot, to dissipate the cold. Qingjiu (Clear Wine) is added to assist Yang Qi and circulate blood vessels.
Formula: Danggui Sini Tang plus Wuzhuyu and Shengjiang
Dang Gui (Three Liang), Shaoyao (Two Liang, honey-fried ○ Yu Han: Three Liang), Tongcao (Two Liang ○ Yu Han: Three Liang), Guizhi (Three Liang, peeled), Xixin (Three Liang), Shengjiang (Half Jin, sliced ○ Qianjin Yi: Eight Liang; Fang, Zhou, Qian, Jian: Three Liang), Dazao (Twenty-five fruits, split), Zhuyu (Two Sheng ○ Yu Han, Qianjin Yi: Wuzhuyu Two Liang; Fang, Zhou, Qian, Jian: Half Jin).
These nine ingredients are boiled with six Sheng of water and six Sheng of clear wine to obtain five Sheng. Strain and divide into five warm doses. ([Original Note] One prescription uses four Sheng each of water and wine. ○ Yu Han and Qianjin Yi both use four Sheng each.)
[Ke Qin] This is originally Sini Tang combined with Wuzhuyu, forming an even pair. Wuzhuyu pairs with Fuzi, and Shengjiang assists Ganjiang; only then can chronic cold be removed.
Yan Shi's *Jisheng Fang*'s Tongmai Sini Tang treats Huoluan with excessive cold, cold flesh, and absent pulse.
It is the base formula plus Fuzi.
Profuse sweating with persistent fever, internal tension, limb pain, diarrhea, cold extremities, and aversion to cold are treated with Sini Tang. (Qianjin Yi omits "internal"; "again" reads as "if".)
[You Zaijing] Profuse sweating should resolve fever. If fever persists without other symptoms, the pathogen remains unresolved. Here, profuse sweating with persistent fever, plus tension, limb pain, diarrhea, cold extremities, and aversion to cold, indicates Yang collapse at the exterior and severe Cold in the interior. Sini Tang is used to warm the meridians to overcome Cold, restore Yang, and stop sweating. [Wang Ang] "Internal tension" refers to Cold penetrating deeply; Cold causes contraction, implying abdominal tension.
Case: Fang Shi states that internal tension and limb pain result from fluid loss and unfavorable bone-Qi. He interprets "internal tension" as limb tension, finding the term "internal" inappropriate.
Profuse sweating or severe diarrhea leading to cold extremities are treated with Sini Tang. (Yu Han and Qianjin Yi add "out" after "sweating/diarrhea".)
[Qian Tianlai] The previous clause mentions profuse sweating with persistent fever. This clause mentions profuse sweating without mentioning fever, indicating absence of heat. Some argue: The previous clause had diarrhea, cold extremities, aversion to cold, and tension/pain. This clause has severe diarrhea and cold extremities without aversion to cold. The absence of fever might indicate Yang Qi has not yet fled outward, suggesting a milder condition? Response: Absence of heat means Yang is more depleted; severe diarrhea means Yin pathogen is stronger. Thus, Sini Tang is still used.
Case: *Yu Jing* adds two clauses here: Exterior Heat Interior Cold presents with deep/slow pulse, mild cold extremities, and clear watery diarrhea (Interior Cold); thus, Yin syndromes can have fever (Exterior Heat). Exterior Cold Interior Heat presents with slippery pulse, body cold extremities, and dry tongue (Exterior Cold); Shaoyin aversion to cold and fatigue is Exterior Cold. Frequent inner restlessness and dislike of thick clothing is Interior Heat.
Patient with cold extremities and sudden tight pulse: Pathogen knots in the chest, causing epigastric fullness and irritability, hunger but inability to eat. The disease is in the chest; emesis is indicated, using Genti San (Thistle Powder). (Differentiation of Emesis Chapter reads "sudden knot" for "sudden tight". Cheng Ben and Yu Han read "heart" for "epigastrium".)
[Wu Qian] The patient does not have Jueyin disease nor exogenous Cold. It is listed in Jueyin due to cold extremities. [You Zaijing] If pulse is minute/fine, it is Cold Deficiency, treatable with warming/tonifying. Sudden tight pulse indicates Cold Excess, treatable with warming/emesis. Irritation and vomiting worms suggest Stomach disease. Chest fullness and irritation with hunger but inability to eat indicate Chest disease. Cold-fluid excess obstructs the Chest, blocking Yang Qi from reaching limbs, causing cold extremities, chest fullness, irritation, and anorexia. Emesis with Genti San expels upper pathogens, resolving fullness and reversing cold extremities.
Taiyang disease with cold extremities and palpitations: Treat water retention first with Fuling Gancao Tang (Poria and Licorice Decoction), then treat cold extremities. Otherwise, water will soak into the Stomach, causing diarrhea. (Cheng Ben and Yu Han add "zhě" after "palpitations"; Yu Han reads "yu" for "ze".)
[Qian Tianlai] *Jingui Yaolue* states: Water stagnant in the heart region causes palpitations. Taiyang chapter notes excessive drinking causes heart palpitations. Although these are Zhang Zhongjing's words, this clause does not mention drinking. Cold extremities indicate Yin-Cold in the interior; interior Cold stops Stomach Qi and fluid distribution, causing water accumulation in the heart region, obstructing Qi channels, leading to palpitations. Treat water first with Fuling Gancao Tang to promote diuresis, then treat cold extremities. Otherwise, stagnant water enters the Stomach, and interior Cold damages Stomach Yang, causing downward diarrhea. [You Zaijing] Taiyang chapter has sweating, unharmonized exterior, and dysuria. This clause has unhealed exterior, cold extremities, and palpitations. Both use Fuling Gancao Tang because both lack interior heat, have unharmonized exterior, and retain water. One harmonizes Ying-Wei to drain water; the other releases exterior and unblocks Yang to drain water. Both are valid. Although dysuria isn't mentioned, the implication exists. If urination were free, water wouldn't accumulate, and cold/extremities/palpitations would be pure Yin-Cold, making exterior-releasing/diuretic treatment inappropriate. [Wang Ang] Guo Yong says treat cold extremities with Sini Tang.
*Jinjian* states: After "cold extremities and palpitations," the phrase "due to excessive drinking" should exist. Without it, palpitations are due to Yin excess, not water retention. How to know it's water? ○ Case: This view is near correct. Wang and Zhou incorrectly identified this as Heat-type cold extremities with water retention.
After six or seven days of Taiyang disease, following severe purgation: Cun (inch) pulse is deep and slow, cold extremities, lower pulses are absent, throat discomfort, spitting pus/blood, and unremitting diarrhea. This is difficult to treat; Mahuang Shengma Tang (Ephedra and Cimicifuga Decoction) is used. (Yu Han omits "ér"; "Houyan" reads "Yanhóu"; Cheng Ben same. Qianjin Yi omits "Cun".)
[Ke Qin] Deep/slow Cun pulse indicates Qi mouth is level. Absent lower pulses indicate root exhaustion. Six Fu organs exhausted externally cause cold limbs. Five Zang organs exhausted internally cause uncontrollable diarrhea. Throat discomfort blocks food/water passage. Fluids fail to transform, becoming pus/blood. Downward weakness with upward reversal constitutes "Lower Cold, Upper Exhaustion," a sign of Yin-Yang separation and impending death. Mahuang Shengma Tang has many ingredients with light dosages, focusing on sweating while fearing warming/tonification, resembling later incompetent practitioners' methods, likely not Zhang Zhongjing's original formula. For this condition and pulse, urgent Shen-Fu (Ginseng and Aconite) to restore Yang is needed, though rescue is doubtful. Treating Yang collapse with Yang-excess agents is like attacking a fallen enemy. Sweating to recovery is impossible; death from collapse sweat is certain. The formula is attached for scholars to judge.
Formula: Mahuang Shengma Tang
Mahuang (Two and a half Liang, nodes removed), Shengma (One Liang and one fen), Dang Gui (One Liang and one fen ○ Yu Han: Shengma and Dang Gui each One Liang and six Zhu; Qianjin Yi same), Zhimu (Eighteen Zhu), Huangqin (Eighteen Zhu), Weirui (Eighteen Zhu, alternatively Changpu), Shaoyao (Six Zhu), Tiantaomen Dong (Six Zhu, hearts removed ○ Yu Han, Qianjin Yi: Maidong), Guizhi (Six Zhu), Fuling (Six Zhu), Gancao (Six Zhu, honey-fried), Shigao (Six Zhu, crushed, wrapped in silk), Baizhu (Six Zhu), Ganjiang (Six Zhu).
These fourteen ingredients are boiled in ten Dou of water. First boil Mahuang until bubbling once, remove foam. Add remaining herbs. Boil to obtain three Sheng. Strain and divide into three warm doses. Take within the time it takes to cook three Dou of rice. Recovery follows sweating.
Case: The symptoms and formula do not match perfectly. Commentators attribute this to mixed Yin-Yang pathology, offering reconciliatory interpretations. Ke Qin decisively rejects it as non-Zhang Zhongjing, a profound insight. I will not cite others extensively. ○ Also: *Waitai Miyao* citing *Duanju* records this formula, stating: "This is Zhang Zhongjing's *Shanghan Lun* formula."
*Shanghan Xuanlu* states: This powerful medicine is suitable for plague toxins and damp-heat dysentery where exterior/interior are indistinguishable, toxins are deep and intense, presenting with cough, pus, or blood.
On the fourth or fifth day of Taiyang disease, abdominal pain with gas moving downward toward the lower abdomen indicates impending spontaneous diarrhea. (Ci reads "wei" in Yu Han. Qu reads "Qu" in Zhengmai Ben; others same. Fang Ben reads "Qu".)
[Qian Tianlai] Day 4-5 is when pathogens enter the interior and transmit to Yin. Abdominal pain indicates Cold entering the interior, Stomach Cold, and Taiyin Spleen pathology. Gas moving down indicates strong Cold, failing Stomach Yang, improper separation of water/grain, and sound rushing down, signaling impending diarrhea. [Zhou Xuehai] Case: Abdominal pain—how to distinguish deficiency-cold? Fire pain attacks upward from below. Heat pain causes chest binding, irritability, and fullness. Downward gas movement confirms Cold impending diarrhea.
Taiyang disease originally involving Cold-downward; physician erroneously applied emesis and purgation. Cold rejection causes further reverse vomiting/diarrhea. If food is vomited immediately upon entry, Ganjiang Huangqin Huanglian Renshen Tang (Dried Ginger, Scutellaria, Coptis, and Ginseng Decoction) is used. (Fu tu xia zhi reads Fu tu zhi in Yu Han, Qianjin Yi, Quan Shu. Yu Han omits "ruo". Ji tu reads ji chu zhe in Qianjin Yi. Er zi before Han Ge in Qianjin Yi.)
[Wang Kentang] Case: "Originally Cold-downward" is likely "originally vomiting/downward." The character "fu" (again/repeatedly) implies this. Stomach Cold causes vomiting; Lower Cold causes diarrhea. Stomach Cold should not be emetic; physician erred, damaging Stomach Qi, causing Cold rejection. The text flow is broken; missing characters are likely.
*Jinjian* states: Classics contain no "Cold-downward" disease or text. Reading "Han Ge geng ni tu xia" (Cold rejection causes further reverse vomiting/diarrhea), the "xia" in "Han xia" should be "ge" (reject). Text makes sense then. Commentators explain as Stomach Cold-diarrhea, which contradicts text and matches poorly with Huangqin/Huanglian. ○ Case: Ke Ben deletes "geng ni tu xia." This clause definitely has errors/omissions.
Formula: Ganjiang Huangqin Huanglian Renshen Tang
Ganjiang, Huangqin, Huanglian, Renshen (Each Three Liang).
These four ingredients are boiled in six Sheng of water to obtain two Sheng. Strain and divide into two warm doses.
[Ke Qin] After emesis/purgation, immediate vomiting indicates Cold rejecting Heat in the Upper Jiao. Though no epigastric hardness, the root is Heart-related. Use half of Xiexin Tang to balance Cold/Heat. Remove Shengjiang/Banxia because no water-Qi in epigastrium. Remove Gancao/Dazao because vomiting dislikes sweet. [You Zaijing] Morning eating evening vomiting is Spleen Cold rejection. Eating immediately vomiting is Stomach Heat rejection. Cold rejection requires Lizhong Tang to warm Taiyin, adding Dingxiang to descend Cold. Heat rejection requires Ganjiang/Renshen to calm Stomach, Huanglian/Huangqin to descend Stomach Fire.
Case: *Jingui Yaolue* states: Vomiting immediately after eating is treated with Dahuang Gancao Tang. *Jinjian* commentary aligns with this clause.
*Bao You Daquan*'s Siwei Renshen Tang treats Taiyang with slow pulse, Cold Stomach vomiting. (Same formula.)
Diarrhea with slight fever and thirst, weak pulse: Spontaneous recovery. (Ling reads Jin in Cheng Ben; omitted in Yu Han.)
[Cheng Jiaoqian] Diarrhea with absent pulse dies; solid pulse also dies. Pulse and syndrome must match. Jueyin diarrhea is Yin-Cold excess. Slight fever/thirst indicates Yang-Heat recovery. Weak pulse indicates pathogen retreat and meridian Qi deficiency. Thus, spontaneous recovery. [Qian Tianlai] Weak pulse shows intrinsic interior deficiency without excessive Heat transforming into abscesses, bloody stools, or throat/mouth lesions. Thus, no treatment allows spontaneous recovery. Intervention might cause imbalance.
Case: Wang, Wei, and Zhou incorrectly identified this as transmitted Heat-diarrhea.
*Suhui Ji* states: The Six Meridian chapters were not authored by He Huan. However, Jueyin chapter's diarrhea/vomiting/hiccups clauses were appended by He Huan based on cold extremities, including similar cases without cold extremities.
Diarrhea with numerical pulse, slight fever, and sweating: Spontaneous recovery. If pulse becomes tight again, unresolved. ([Original Note] Alternatively: If pulse floats and becomes tight. ○ Qianjin Yi has "ruo", reads "ruo". Ling reads Jin in Cheng Ben. Yu Han/Qianjin Yi read "zhe".)
[Cheng Wuji] Diarrhea is Yin disease. Numerical pulse is Yang pulse. Yin disease showing Yang pulse indicates life.
Slight fever/sweating indicates Yang Qi communication. Diarrhea will self-resolve. Tightness indicates Cold. If pulse becomes tight again, Yin Qi prevails; thus, unresolved.
Diarrhea with cold extremities and absent pulse: Moxibustion fails to warm. If pulse does not return and slight panting occurs: Death. (Yu Han reads "ér" for "ruo".)
[Qian Tianlai] Yin-Cold diarrhea with cold extremities and absent pulse indicates True Yang exhaustion, a death syndrome. Moxibustion fails to warm. If pulse doesn't return and slight panting occurs, it signifies Yang exhaustion; residual floating Yang escapes via respiration, having exit but no entry, appearing as panting but not true panting, leading to death. [Wang Ang] Panting is not caused by moxibustion. If Yang doesn't recover via moxibustion, death signs follow sequentially. *Shanglun Pian* claims isolated Yang rises with fire and escapes; this is wrong. Zhang Zhongjing does not specify acupoints here; Chang Qizhi suggests Guan Yuan (CV4) and Qi Hai (CV6).
Shaoyin being inferior to Fuyang is favorable. (Original, Qianjin Yi, Zhicong Ben, Xiju Ben connect to previous clause. Based on Cheng Ben and Yu Han, separated.)
[Qian Tianlai] "Shaoyin inferior to Fuyang" sentence seems to have missing characters; otherwise, meaning is unclear. Previous notes interpret Shaoyin as Water and Fuyang as Earth, fearing Earth cannot control Water, leading to vomiting/diarrhea. Empowering Earth ensures Water control, allowing peace. (Case: Yu's note follows Cheng's note; Fang's intent is similar.)
I fear this does not fully align with ultimate principles. Shaoyin is Kidney, containing Fire within Water, the Pre-heaven Yang. Fuyang is Stomach pulse, Earth generated by Fire, the Post-heaven Yang. This continues from...