案据少阴篇厥阴篇之例。此条所主。当是通脉四逆汤。
吐已下断。汗出而厥。四肢拘急不解。脉微欲绝者。通脉四逆加猪胆汤主之。（成本。玉函。胆下。有汁
字。外台。不用猪胆汁。千金同。）
〔锡〕吐已下断者。阴阳气血俱虚。水谷津液俱竭。无有可吐而自已。无有可下而自断也。故汗出而厥。
四肢拘急之亡阴证。与脉微欲绝之亡阳证。仍然不解。更宜通脉四逆加
猪胆。启下焦之生阳。而助中焦之津液。〔志〕霍乱之证。至汗出而厥。四肢拘急。脉微欲绝。乃惟阴无阳。
用四逆汤。不必言矣。又加胆汁人尿者。津液竭而阴血并虚。不当但助其阳。更当滋益其阴之意。
案志聪锡驹注。本方更加人尿。然原文中无所考。盖据白通加猪胆汁汤。而有此说耳。锡驹云。每见夏
月霍乱之证。四肢厥逆。脉微欲绝。投以理中四逆。不能取效。反以明矾少许。和凉水服之。而即愈。亦即胆
汁人尿之意。先贤立法。可谓周遍详明矣。霍乱用矾石。原见于华佗危病方。与胆汁人尿。盖其意迥别。
通脉四逆加猪胆汤方
甘草（二两炙） 干姜（三两强人可四两） 猪胆汁（半合○玉函。作四合。肘后。作一合。） 附子
（大者一枚生去皮破八片）
上四味。以水三升。煮取一升二合。去滓。纳猪胆汁。分温再服。其脉即来。无猪胆。以羊胆代之。
〔吴〕汗出而厥。阳微欲绝。而四肢拘急。全然不解。又兼无血以柔其筋。脉微欲绝。固为阳之欲亡。亦
兼阴气亏损。故用通脉四逆以回阳。而加猪胆汁以益阴。庶几将绝之阴。不致为阳药所劫夺也。注认阳极虚。
阴极盛。故用反佐之法。以通其格拒。误矣。（案成氏。方氏。钱氏。金鉴。并同。）
程云。吐已下断。犹阴邪坚结。阳气难伸。所以证则汗出而厥。四肢拘急不解。脉则微而欲绝。此汤主
之。于回阳救急中。交通其气。善后犹难为力如此。敢不慎厥初哉。○案此亦一说。故附存于此。
吐利发汗。脉平。小烦者。以新虚不胜谷气故也。（发汗吐下后篇。汗下。有后字。）
〔魏〕吐利发汗后。脉遂就平。病遂瘥可。此尤为素日胃
气有余。而病邪轻微之效也。但余小烦。乃胃气暴为吐下所虚。非素虚乃新虚也。胃既新虚。仍与以旧日之谷
数。则谷气多于胃气。所以不胜谷气。而作小烦也。仲景不言治法。盖损其谷则愈之治。见于大病瘥后之条矣。
故不复赘此。凡病可云然也。
根据少阴篇和厥阴篇的体例，这一条所主治的方剂，应当是通脉四逆汤。
呕吐停止，腹泻也停止了，但是出现出汗且四肢厥冷，四肢拘挛紧急不能缓解，脉搏微弱几乎要断绝的情况，用通脉四逆加猪胆汤来主治。（成本《伤寒论》本、玉函《金匮玉函经》在“胆”字下有“汁”字；《外台秘要》不用猪胆汁，《千金方》同。）
〔锡驹注〕呕吐停止、腹泻断绝，是因为阴阳气血都虚弱，水谷津液都枯竭了，没有东西可吐而自然停止，没有东西可下而自然断绝。所以出现出汗且四肢厥冷，四肢拘挛紧急这种亡阴证，以及脉搏微弱几乎要断绝这种亡阳证，仍然不能缓解。更适宜用通脉四逆加猪胆汤，以激发下焦的生发之阳气，并辅助中焦的津液。
〔志聪注〕霍乱的病证，发展到出汗且四肢厥冷、四肢拘挛紧急、脉搏微弱几乎要断绝的地步，这是只有阴寒而没有阳气的表现。使用四逆汤，是不必多说的了。又加入胆汁和人尿，是因为津液枯竭且阴血同时也虚弱，不应当只帮助阳气，更应当滋益阴液的用意。
按：志聪（张志聪）和锡驹（尤怡，号锡驹）的注释中，本方还加入了人尿，但在原文中找不到依据。这大概是依据白通加猪胆汁汤的说法而产生的见解。锡驹说：我常见夏季霍乱的病证，四肢厥逆，脉搏微弱几乎要断绝，投用理中汤或四逆汤，不能取得疗效，反而用少许明矾，配合凉水服用，随即痊愈。这也体现了胆汁和人尿的用意。先贤制定的法则，可以说是周全详细明了了。霍乱使用矾石，原本见于华佗的危病方，与胆汁和人尿相比，其用意截然不同。
通脉四逆加猪胆汤方
甘草（二两，炙） 干姜（三两，体质强壮者可增至四两） 猪胆汁（半合○《玉函》作四合，《肘后备急方》作一合） 附子（大者一枚，生用，去皮，破成八片）
以上四味药，用水三升，煮取一升二合，去渣，纳入猪胆汁，分两次温服。如果脉搏恢复，说明有效。如果没有猪胆，可以用羊胆代替。
〔吴谦注〕出汗且四肢厥冷，阳气微弱几乎要断绝，同时四肢拘挛紧急完全不能缓解，又兼有血液不足无法濡养筋脉。脉搏微弱几乎要断绝，固然是阳气将要亡失的表现，也兼有阴气亏损。所以用通脉四逆汤来回阳救逆，并加入猪胆汁来益阴，这样才使得将绝的阴液，不至于被阳热药物所劫夺耗伤。注家认为阳极虚、阴极盛，所以用反佐之法，以通达格拒之气，这是错误的。（按：成无己、方有执、钱潢、《医宗金鉴》都与此观点相同。）
程云波说：呕吐停止、腹泻断绝，还是因为阴邪坚固结聚，阳气难以伸展。所以症状表现为出汗且四肢厥冷，四肢拘挛紧急不能缓解，脉搏微细几乎要断绝。此汤主治这种情况，在回阳救急之中，交通阴阳之气，善后调理尚且难以有力如此。岂能不谨慎对待疾病初起之时呢？○按：这也是另一种说法，所以附存于此。
霍乱伴有呕吐腹泻，又经过发汗治疗，脉搏平和，只是轻微心烦的，是因为新近虚弱（的病体）承受不住谷气（食物消化产生的能量/负担）的缘故。（此条出自“辨发汗吐下后病脉证并治”篇，原文中“汗下”后有“后”字。）
〔魏荔彤注〕呕吐腹泻之后，又经过发汗，脉搏于是变得平和，病情于是好转，这是素日胃气有余，而病邪轻微的效验。但残留轻微的心烦，是因为胃气突然因呕吐腹泻而变得虚弱，并非素来虚弱，而是新近虚弱。胃既然新近虚弱，如果仍然给予往日那样的饮食数量，那么谷气就会多于胃气，所以承受不住谷气，而产生轻微的心烦。仲景没有提及治疗方法，大概减少饮食即可痊愈的治疗方法，已经见于大病痊愈后的条文中了，所以不再赘述。凡是疾病都可以这样说。
Based on the style of the Shaoyin (Lesser Yin) and Jueyin (Terminal Yin) chapters, the formula indicated in this clause should be Tongmai Sini Tang (Pulse-Reviving Cold-Reversing Decoction).
If vomiting has ceased and diarrhea has stopped, yet sweating occurs accompanied by cold limbs, persistent stiffness and cramping of the four limbs that does not resolve, and a faint pulse nearly imperceptible, Tongmai Sini Tang with Porcine Bile is indicated. (Cheng's edition and *Jin Gui Yu Han Jing* include the character "juice" after "bile"; *Wai Tai Mi Yao* does not use porcine bile, consistent with *Qian Jin Fang*.)
[Commentary by Xi Ju] When vomiting ceases and diarrhea stops, it is because both Yin and Yang, Qi and Blood are deficient, and the fluids and essence from food and drink are exhausted. There is nothing left to vomit, so it stops naturally; there is nothing left to purge, so diarrhea stops naturally. Consequently, sweating and cold limbs occur, representing a syndrome of Yin exhaustion, while the faint, nearly imperceptible pulse represents a syndrome of Yang exhaustion. Since these conditions persist, one should further utilize Tongmai Sini Tang with Porcine Bile to stimulate the generating Yang of the Lower Jiao and assist the fluids of the Middle Jiao.
[Commentary by Zhi Cong] In cases of Huoluan (Vomiting-Regurgitation and Diarrhea Syndrome), when the condition progresses to sweating, cold limbs, persistent limb stiffness/cramping, and a faint, nearly imperceptible pulse, it indicates an excess of Yin and absence of Yang. The use of Sini Tang is self-evident. The addition of bile and human urine implies that since fluids are exhausted and Yin blood is also deficient, treatment should not merely tonify Yang but also nourish and benefit Yin.
Note: Both Zhi Cong and Xi Ju mention the addition of human urine to this formula in their commentaries, but this cannot be verified in the original text. This assertion likely stems from the precedent set by Baitong Tang with Porcine Bile. Xi Ju stated: "I often see cases of summer Huoluan where limbs are cold and pulse is faint/nearly imperceptible. Administering Lizhong Tang or Sini Tang yields no effect. However, administering a small amount of alum mixed with cool water results in immediate recovery." This reflects the intent behind using bile and human urine. The legislative principles of the sages were indeed comprehensive and clear. The use of alum for Huoluan originally appeared in Hua Tuo's formulas for critical illnesses, which differs significantly in intent from the use of bile and human urine.
**Tongmai Sini Tang with Porcine Bile Formula**
Gancao (Licorice Root, 2 liang, honey-fried)
Ganjiang (Dried Ginger, 3 liang; up to 4 liang for robust individuals)
Zhuzhilian (Porcine Bile, 0.5 he) (*Jin Gui Yu Han Jing* states 4 he; *Zhou Hou Bei Ji Fang* states 1 he)
Fuzi (Aconite Root, 1 large piece, raw, skin removed, broken into 8 slices)
Take the above four ingredients, decoct in 3 sheng of water until 1.2 he remains. Strain the dregs, add the porcine bile, and divide into two warm doses. If the pulse returns, it indicates efficacy. If porcine bile is unavailable, sheep bile may be substituted.
[Commentary by Wu Qian] Sweating and cold limbs indicate that Yang is weak and nearly extinct, while persistent stiffness and cramping of the four limbs suggest a lack of blood to soften the sinews. A faint, nearly imperceptible pulse confirms impending Yang collapse, compounded by Yin deficiency. Therefore, Tongmai Sini Tang is used to restore Yang, and porcine bile is added to nourish Yin. This ensures that the nearly extinct Yin fluid is not seized and depleted by the hot Yang-tonifying herbs. Commentators who argue that extreme Yang deficiency and extreme Yin excess require counter-agent methods to overcome rejection are mistaken. (Note: Cheng Wuji, Fang Youzhi, Qian Huang, and *Yi Zong Jin Jian* agree with this view.)
Cheng Yunbo stated: "Even if vomiting and diarrhea have ceased, Yin pathogens may remain firmly entrenched, making it difficult for Yang Qi to extend. Thus, symptoms manifest as sweating, cold limbs, unresolved limb stiffness, and a faint, nearly imperceptible pulse. This formula addresses such cases, facilitating the communication of Qi amidst the rescue of Yang and emergency revival. Even post-recovery management is challenging in such severe cases. How can one not exercise caution at the onset?" Note: This is another interpretation, preserved here for reference.
In cases of Huoluan with vomiting and diarrhea, followed by diaphoresis, if the pulse becomes normal but slight irritability persists, it is due to the newly weakened state being unable to handle the qi of grain (food digestion burden). (This clause appears in the chapter on Post-Diaphoresis, Post-Purging, etc., where the character 'hou' [after] follows 'han xia'.)
[Commentary by Wei Litong] After vomiting, diarrhea, and diaphoresis, if the pulse becomes normal and the illness resolves, this indicates that the patient had abundant Stomach Qi normally, and the pathogenic factor was mild. The residual slight irritability arises because the Stomach Qi was suddenly depleted by vomiting and diarrhea; it is not a constitutional deficiency but a new, acute deficiency. If the diet remains at the previous volume, the qi of grain will exceed the capacity of the weakened Stomach Qi, causing slight irritability due to inability to process the food. Zhang Zhongjing did not specify a treatment method because the remedy—reducing dietary intake—is already covered in the clauses regarding convalescence after major illnesses. Thus, no further elaboration is needed. This principle applies to all diseases.