救里）。大汗、大下、利而厥冷者，四逆汤主之。吐利汗出，发热恶寒，四肢拘急，手足厥冷
者，四逆汤主之。（虽有表证，急当救里）。既吐且利、小便复利（二便俱利，内阳将尽）、大
汗出、下利清谷、内寒外热，（虽有外热表证，而里证重极）。脉微欲绝，四逆汤主之。下后复
发汗、昼日烦躁不得眠、夜来安静，（阳虚有二证，阴阳两虚者畏阳，阴不虚者喜阳）。不呕不
渴、无表证、脉沉微、身无大热者，干姜附子汤主之。发汗复下之，病仍不解，烦躁者（此
阳气不摄而烦，所谓阴烦也。然必参以他证，方不致误）。茯苓四逆汤主之（茯苓、人参、附
子、甘草、干姜）。太阳病发汗，汗出不解，其人仍发热、心下悸、头眩、身 动、振振欲
擗地者，真武汤主之。此发汗太过，水邪随阳气上逆，比茯苓四逆汤证较重。彼因汗、下两
伤，故用人参、干姜；此因汗伤水逆，故用真武镇伏水邪，挽回阳气。真武属北方水神，故
取以为名。（茯苓、芍药、生姜、白术、附子）。若吐若下后，心下逆满，气上冲胸，起则头眩
，脉沉紧者，茯苓桂枝白术甘草汤主之。此亦阳虚水逆之证，即真武证之轻者。若再发汗，
则动经气，而身为振振摇矣。发汗病不解，反恶寒者，虚故也，芍药甘草附子汤主之。太阳
病外证未除，而数下之，遂协热下利、利下不止、心下痞硬（邪在上焦），表里不解，桂枝人
参汤主之（桂枝、甘草、白术、人参、干姜）。伤寒下利不止，心下痞硬，服泻心已，复以他
药下之（一误再误），利不止，医以理中与之，利益甚。理中者，理中焦也。此利在下焦，（下
药太过，大肠受伤），赤石脂禹余粮汤主之（涩以止脱）。复利不止，当利其小便（分其清浊，
则便自坚）。凡此皆误汗、误下，伤及真阳，故转而用温，以救其误，非表寒化热之正方也
。
若夫里寒一证，不外脾肾阳虚，阳虚则化湿，故夹湿者多，治法不外四逆、真武、理中
三法。四逆一类，不离姜、附，再观方中加减，皆欲其通阳开闭，重在肾也；真武一类，不
离苓、附、生姜，欲其温阳镇水，亦重在肾也；理中一类，不离干姜、白术，欲其守中，重
在脾也；其桂枝附子一类，为风湿阳虚而设，欲其解肌温阳化湿，表里兼治，重在里。此治
里寒之大较也。试详言之。论曰∶发热，头痛（表邪），脉反沉（里脉），若不瘥，身体疼痛，
当急救里，宜四逆汤（甘草、干姜、附子。身体疼痛，表寒、里寒阴阳二证皆有之。虽沉为
里脉，而表邪郁遏者亦有之。必审其人不烦不渴，脉沉而至数清楚，一派皆属阴象，乃可用
之，切勿孟浪）！脉浮而迟、表热里寒、下利清谷者，四逆汤主之。自利不渴，属太阴，脏
有寒也，当温之，宜四逆辈。（凡温热之剂，皆可选用，故不曰汤而曰辈）。少
阴病，饮食入口则吐、心中温温、欲吐复不能吐。始得之，手足寒、脉弦迟者，此胸中实
（寒实），不可下也，当吐之（在上者因而越之）。若膈上有寒饮，干呕者，（干呕无物，知其为
饮），不可吐也，当温之（寒散则饮化，凡治饮皆当用温）。宜四逆汤；恶寒脉微，而复利，
利止，亡血也，（利尽而止，津液内竭。亡血，即亡阴也），四逆加人参汤主之（回阳生津）。
少阴病，下利清谷、里寒外热（寒逼阳于外）、手足厥逆、脉微欲绝、身反不恶寒（寒邪入里）
、其人面色赤（逼阳于外，名曰戴阳）。或腹痛、或干呕、或咽痛（寒逼阳上升）、或利止脉不
出者，通脉四逆汤主之，其脉即出者愈。（四逆汤，面赤加葱。腹痛去葱，加芍药。呕加生姜
。咽痛去芍药，加桔梗。利止脉不出去桔梗，加人参。诸证或阴或阳，皆闭塞不通之故，
故用辛温通阳）。下利清谷、里寒外热、汗出而厥者，通脉四逆汤主之（厥而汗出，阳有立亡
之象）。吐已下断（利止也）、汗出而厥、四肢拘急不解、脉微欲绝者，四逆加猪胆汁汤主之（
取其苦滑，直达下焦）。少阴病，下利，白通汤主之（干姜附子汤加葱白四茎，取其通少阴之
阳气）。少阴下利、脉微者，与白通汤；利不止、厥逆无脉、干呕烦者，白通加猪胆汁童便
汤主之（取童便引阳药直达至阴，经所云反佐是也）。手足厥寒、脉细欲绝者，当归四逆汤主
之（当归、桂枝、芍药、细辛、甘草、通草、大枣）；若其人内有久寒者，当归四逆加吴萸生
姜汤主之。所谓四逆一类，重在通阳开闭者，此也。
试再言真武。少阴病，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（加五味、干姜、细辛），或小便利（去茯苓），或下利（去芍药，加干姜），或呕者（去附
子，加干姜）。真武汤主之。少阴病，身体疼、手足寒、骨节痛、脉沉者，附子汤主之（真武
汤去生姜，加人参）。所谓真武一类，重在温阳行水（水即是湿）者，此也。至理中丸一方，（人
参、甘草、白术、干姜。脐上筑筑欲作奔豚者，肾气动也，去白术，加桂枝。吐者去白术，
加生姜。悸者加茯苓。渴欲饮水者加术，消饮生津。腹中虚痛，加人参。寒加干姜。腹满者
去术，加附子）。乃大病瘥后，喜唾（胃液不藏，兼有寒饮），久不了了，胃上有寒，当以丸
药缓理之。
若桂枝附子一类，乃解肌、化湿、温阳，表里兼治之剂。论曰∶伤寒八九日，风湿相搏
，身体疼烦、不能自转侧（湿则身重）、不呕不渴（湿为阴邪）、脉浮虚而涩（表里皆虚），桂枝
附子汤主之（桂枝、附子、甘草、生姜、大枣）。若其人大便硬、小便自利者，去桂加白术汤
主之（白术生肠胃之津液）。若大便不硬、小便不利，仍当加桂（观此条，可知桂枝能通小便，
故五苓散用之）。服后其人如冒状，勿怪。此以附、术并走皮肉，逐水气，未得除，故使之
。其法当加桂以治之。又有风湿相搏，骨节疼烦、掣痛、不得屈伸、近之则痛剧、汗出短气
、小便不利、恶风不欲去衣、或身微肿者，甘草附子汤主之，得微汗则解（即桂枝附子汤去
姜、枣，加白术。此条因汗出，故去姜、枣，虽用桂枝，而其意则重在甘草、附子温阳，故
以名汤。风湿发汗，汗大出者，但风气去，湿气在，故不愈。治风湿，微微似欲出汗者，风
湿俱去也）。此治风湿之大法也。他如食谷欲呕者（必食谷而始呕，受病在纳谷之处，与干呕
不同），属阳明也（虚寒），吴茱萸汤主之（吴萸、人参、生姜、大枣）。得汤反剧者，属上焦
也（停饮）。又有少阴病，吐利、手足厥冷、烦躁欲死者，吴茱萸汤主之（胃气虚寒）。干呕，
吐涎沫（胃中寒饮），头痛者（阳明之脉上于头），吴茱萸汤主之。又有少阴病，腹痛、小便不
利、下利不止、便脓血者，桃花汤主之（赤石脂、干姜、粳米）。一服愈，余勿服。又有伤寒
脉微而厥，至七八日，肤冷（阳不卫外），其人躁无暂安时者，此为脏厥（不治），非蛔厥也。
蛔厥者，其人当吐蛔。今病者静而复时烦，此为脏寒。蛔上入其膈，其人当自吐蛔。蛔厥者
，乌梅丸主之，又主久痢。（乌梅、细辛、干姜、当归、附子、蜀椒、桂枝、黄连、黄柏、人
参。先食后服十丸，渐加至二十丸，禁食生冷滑臭等物）。凡此皆治里寒者也。余故曰《伤
寒论》当分两大段看法。
又有表寒坏证，如伤寒六七日，大下后，寸脉沉迟、尺脉不至、手足厥逆、咽喉不利、
唾脓血、泄利不止者，为难治，麻黄升麻汤主之，汗出愈（麻黄、升麻、当归、桂枝、白芍
、茯苓、甘草、干姜、白术、石膏、知母、黄芩、玉竹、天冬）。此上热下寒互伤之证，病
证之杂，药味之多，为古方所仅见，观此可悟古人用药之法。又有表寒方愈，因交接感其余
热，名阴阳易病，其人身体重、少气、少腹里急、或引阴中拘挛、热上冲胸、头重不欲举、
眼中生花、膝胫拘急者，烧 散主之（男取妇 裆，妇取男 裆，烧灰，和服
方寸匕，三服小便即利，阴头微肿则愈，盖引其邪火从阴处出也）。此又以意用药法也。观
《伤寒》一书，立方错综变化，皆本自《内经》，用药又与《神农本草》所载一一吻合。余
止言其大略，学人于全书讲求而推展之，则操纵在我，万病皆得所指归矣，岂徒作伤寒书读
哉！？
按∶《伤寒论》中表寒一类，本是寒燥之邪，所立诸方，只此麻黄、桂枝、葛根、柴胡
四味药，系为经邪而设，其余皆从三焦论治，与温病原不相悖，观诸方便知。麻黄专主开表
，温病忌用，若严寒天气，实因感受风寒，新邪引动伏邪，如吴又可所云感冒兼役之证，麻
杏石甘汤，亦不妨暂用。其桂枝一味，为温病所最忌，以其温里故也。书云∶桂枝入口，阳
盛（热盛）则毙，承气入胃，阴盛（寒盛）则亡。尝见误服桂枝，变证蜂起，不可不知。葛根辛甘凉
润，为阳明药。柴胡主治邪郁胸胁，温病亦有阳明及胸胁证，故间有用之者。总之，有是病
则用是药，不可拘执。至救误诸方，如四逆、真武、理中辈，乃为伤寒误汗、误下伤阳而设
，皆与温病相反。伤寒多伤阳，故末路以扶阳为急务；温病多伤阴，故末路以养阴为要法。
此又寒温判若霄壤者也。故并记之。
（针对）救里的治法。出现大汗、大下之后，或者腹泻且四肢厥冷的情况，用四逆汤主治。（虽然可能有表证，但必须紧急救治里虚寒）。出现呕吐、腹泻、出汗，伴有发热和恶寒，四肢拘挛急迫，手足冰冷的情况，用四逆汤主治。（虽然有表证，但必须紧急救治里虚）。既呕吐又腹泻，小便反而通利（二便都通利，说明体内阳气即将耗尽），大汗出，腹泻排出未消化的食物残渣，内部寒冷外部发热（虽然有外热和表证，但里证极其严重），脉象微弱几乎摸不到，用四逆汤主治。使用泻下法后又发汗，白天烦躁得无法入睡，夜晚却安静（阳虚有两种证候，阴阳两虚的人畏惧阳气，阴不虚的人喜欢阳气），不呕吐、不口渴、没有表证、脉象沉而微弱、身体没有大热的情况，用干姜附子汤主治。发汗后又使用泻下法，病仍未解除，出现烦躁的情况（这是阳气不能固摄而产生的烦，也就是所谓的“阴烦”。但必须结合其他证候来判断，才不会误诊），用茯苓四逆汤主治（茯苓、人参、附子、甘草、干姜）。太阳病发汗后，汗出后病仍未解，病人仍然发热、心下悸动、头晕目眩、身体颤动、振动欲倒地的情况，用真武汤主治。这是因为发汗太过，水邪随着阳气上逆，比茯苓四逆汤的证候更重。茯苓四逆汤是因为汗法和下法两伤正气，所以用人参、干姜；这里是因为发汗损伤导致水气上逆，所以用真武汤来镇伏水邪，挽回阳气。真武是北方水神的名字，所以取这个名字作为方名。（茯苓、芍药、生姜、白术、附子）。如果经过呕吐或泻下治疗后，心下逆满，气向上冲至胸部，起身时头晕目眩，脉象沉紧的情况，用茯苓桂枝白术甘草汤主治。这也是阳虚导致水气上逆的证候，是真武汤证的轻症。如果再发汗，就会扰动经气，导致身体震颤摇晃。发汗后病未解除，反而恶寒的，是因为虚损的缘故，用芍药甘草附子汤主治。太阳病表证未除，却多次使用泻下法，于是导致协热下利、腹泻不止、心下痞硬（邪气在上焦），表里同病，用桂枝人参汤主治（桂枝、甘草、白术、人参、干姜）。伤寒导致腹泻不止，心下痞硬，服用泻心汤类方剂后，又用其他药物泻下（一误再误），腹泻仍不止，医生用理中汤与之，腹泻反而加重。理中汤是调理中焦的。这里的腹泻在下焦（因为下药太过，大肠受伤），用赤石脂禹余粮汤主治（用涩味药以止住滑脱）。如果腹泻仍不止，应当利小便（分清泌浊，大便自然成形）。以上这些情况都是因为误汗、误下，损伤了真阳，所以转而使用温补之法来补救错误，并不是治疗表寒化热的正治方法。
至于里寒这一证候，不外乎脾肾阳虚，阳虚则生湿，所以常夹杂湿气，治疗方法不外乎四逆汤、真武汤、理中汤三法。四逆汤一类，离不开干姜、附子，再看方中的加减，都是想要通达阳气、开通闭塞，重点在肾；真武汤一类，离不开茯苓、附子、生姜，想要温阳镇水，也重点在肾；理中汤一类，离不开干姜、白术，想要守持中焦，重点在脾；桂枝附子汤一类，是为风湿兼阳虚而设的，想要解肌、温阳、化湿，表里兼治，重点在里。这是治疗里寒的大致原则。试详细论述一下。《伤寒论》说：发热，头痛（表邪），脉象反而沉（里脉），如果不好转，身体疼痛，应当紧急救治里虚，宜用四逆汤（甘草、干姜、附子。身体疼痛，表寒和里寒的阴阳两种证候都有。虽然沉脉主里，但表邪郁遏也有可能出现。必须审察病人不烦不渴，脉沉而至数清楚，一派都是阴象，才能使用此方，切勿鲁莽）！脉浮而迟、表热里寒、腹泻排出未消化食物的情况，用四逆汤主治。自发性腹泻且不口渴的，属于太阴病，脏腑有寒，应当温补，宜用四逆汤这类方剂。（凡是温热性质的药剂，都可以选用，所以不说某汤而说“辈”）。少阴病，饮食入口就吐，心中泛泛不适，想吐又吐不出来。刚发病时，手足寒冷，脉象弦迟的，这是胸中有实邪（寒实），不可用泻下法，应当用涌吐法（病位在上者，因势利导使其吐出）。如果膈上有寒饮，干呕的，（干呕无物，知道是寒饮所致），不可用涌吐法，应当用温法（寒气散则饮邪化，凡是治疗饮邪都应当用温药）。宜用四逆汤；如果恶寒、脉微，又腹泻，腹泻停止的，是亡血（腹泻尽而停止，津液内竭。亡血，就是亡阴的意思），用四逆加人参汤主治（回阳生津）。
少阴病，腹泻排出未消化食物、里寒外热（寒气逼迫阳气外越）、手足厥冷、脉微弱几乎摸不到、身体反而不恶寒（寒邪入里）、病人面色发红（寒气逼迫阳气浮越于外，名叫戴阳）。或者腹痛、或者干呕、或者咽痛（寒气逼迫阳气上升）、或者腹泻停止但脉搏摸不到的情况，用通脉四逆汤主治，如果脉搏随即出现就是好转。（四逆汤，面赤加葱白。腹痛去葱白，加芍药。呕吐加生姜。咽痛去芍药，加桔梗。腹泻停止脉搏不出去桔梗，加人参。各种证候或阴或阳，都是因为闭塞不通的缘故，所以用辛温药通达阳气）。腹泻排出未消化食物、里寒外热、出汗且四肢厥冷的情况，用通脉四逆汤主治（四肢厥冷且出汗，阳气有立即消亡的迹象）。呕吐已止、腹泻已断（腹泻停止）、出汗且四肢厥冷、四肢拘挛急迫不能缓解、脉微弱几乎摸不到的情况，用四逆加猪胆汁汤主治（取其苦滑之性，直达下焦）。少阴病，腹泻，用白通汤主治（干姜附子汤加四茎葱白，取其通达少阴阳气之意）。少阴病腹泻、脉微的，给白通汤；如果腹泻不止、四肢厥冷、无脉、干呕心烦的，用白通加猪胆汁童便汤主治（取童便引导阳药直达至阴之地，经文所说的反佐法就是这样）。手足厥冷、脉细弱几乎摸不到的情况，用当归四逆汤主治（当归、桂枝、芍药、细辛、甘草、通草、大枣）；如果病人内有久寒的，用当归四逆加吴茱萸生姜汤主治。所谓四逆汤一类，重在通达阳气、开通闭塞的，就是这个方子。
再谈谈真武汤。少阴病，腹痛，小便不利，四肢沉重疼痛，自发性腹泻的，这是有水气，病人或者咳嗽（加五味子、干姜、细辛），或者小便通利（去茯苓），或者腹泻（去芍药，加干姜），或者呕吐的（去附子，加干姜）。用真武汤主治。少阴病，身体疼痛、手足寒冷、骨节疼痛、脉沉的，用附子汤主治（真武汤去生姜，加人参）。所谓真武汤一类，重在温阳行水（水即是湿）的，就是这个方子。至于理中丸一方，（人参、甘草、白术、干姜。脐上跳动欲作奔豚状的，是肾气动，去白术，加桂枝。呕吐的去白术，加生姜。心悸的加茯苓。口渴想喝水的加白术，以消除饮邪、生津液。腹中虚痛的，加人参。寒重的加干姜。腹满的去白术，加附子）。这是大病初愈后，喜欢流口水（胃液不能固藏，兼有寒饮），久久不能痊愈，胃上有寒，应当用丸药缓慢调理。
至于桂枝附子汤一类，是解肌、化湿、温阳，表里兼治的方剂。《伤寒论》说：伤寒八九日，风湿相搏，身体疼痛烦扰、不能自行翻身（湿邪导致身重）、不呕吐不口渴（湿为阴邪）、脉浮虚而涩（表里皆虚），用桂枝附子汤主治（桂枝、附子、甘草、生姜、大枣）。如果病人大便硬、小便自利的，用去桂加白术汤主治（白术能生肠胃津液）。如果大便不硬、小便不利，仍然应当加桂枝（看这一条，可知桂枝能通利小便，所以五苓散中使用它）。服药后病人感觉像头昏蒙一样的状态，不要奇怪。这是因为附子、白术并走皮肉，驱逐水气，尚未完全去除，所以导致这种现象。这种方法应当加桂枝来治疗。又有风湿相搏，骨节疼痛烦扰、牵掣痛、不能屈伸、靠近就痛剧、出汗短气、小便不利、怕风不想穿衣、或者身体轻微浮肿的，用甘草附子汤主治，得到微微出汗就能解除（即桂枝附子汤去生姜、大枣，加白术。这一条因为出汗，所以去生姜、大枣，虽然用了桂枝，但其意重在甘草、附子温阳，所以以此命名汤剂。治疗风湿发汗，如果汗出太多，只有风气去了，湿气还在，所以不愈。治疗风湿，要微微似欲出汗的样子，风湿才能俱去）。这是治疗风湿的大法。其他的如进食就想呕吐的（一定是吃了东西才吐，病变在受纳食物的地方，与干呕不同），属于阳明病（虚寒），用吴茱萸汤主治（吴茱萸、人参、生姜、大枣）。喝了药反而加重的，属于上焦（停饮）。又有少阴病，呕吐腹泻、手足厥冷、烦躁欲死的，用吴茱萸汤主治（胃气虚寒）。干呕，吐涎沫（胃中寒饮），头痛的（阳明经脉上行于头部），用吴茱萸汤主治。又有少阴病，腹痛、小便不利、腹泻不止、大便带脓血的，用桃花汤主治（赤石脂、干姜、粳米）。服一次就好了，剩下的不要喝。又有伤寒脉微而四肢厥冷，到了七八天，皮肤冰冷（阳气不能卫护体表），病人躁动没有片刻安宁的，这是脏厥（不治之症），不是蛔厥。蛔厥的病人，应当吐蛔虫。现在病人安静却又时不时烦躁，这是脏寒。蛔虫上行进入膈部，病人应当自己吐蛔虫。蛔厥的，用乌梅丸主治，也主治久痢。（乌梅、细辛、干姜、当归、附子、蜀椒、桂枝、黄连、黄柏、人参。先吃饭后服药十丸，逐渐增加到二十丸，禁止食用生冷、滑腻、腥臭等食物）。以上这些都是治疗里寒的方法。所以我常说《伤寒论》应当分两大段来看待。
又有表寒导致的坏证，如伤寒六七天，大泻之后，寸脉沉迟、尺脉摸不到、手足厥冷、咽喉不利、唾脓血、泄利不止的，为难治，用麻黄升麻汤主治，出汗即可痊愈（麻黄、升麻、当归、桂枝、白芍、茯苓、甘草、干姜、白术、石膏、知母、黄芩、玉竹、天冬）。这是上热下寒互相损伤的证候，病证复杂，药味众多，是古方中罕见的，看这个方子可以领悟古人用药的方法。又有表寒刚刚痊愈，因为房事感染其余热，名叫阴阳易病，病人身体沉重、气短、少腹里急、或者牵引阴中拘挛、热气上冲胸部、头重不想抬起、眼中生花、膝胫拘急的，用烧裈散主治（男取妇女内裤裆部，女取男子内裤裆部，烧成灰，调和服用一方寸匕，三次服药后小便即通利，阴头轻微肿胀即痊愈，大概是引导邪火从阴处排出）。这也是以意用药的方法。观察《伤寒论》一书，立方错综变化，都本源于《内经》，用药又与《神农本草经》所载一一吻合。我只说其大概，学习的人在整本书中讲求并推展它，那么就能操纵自如，万病都能找到归宿，难道只是当作一本治伤寒的书来读吗！？
按语：《伤寒论》中的表寒一类，本是寒燥之邪，所立的诸方，只用了麻黄、桂枝、葛根、柴胡这四味药，系为经络之邪而设，其余都是从三焦论治，与温病学说不相违背，看各个方子就知道了。麻黄专门主司开表，温病忌用，如果是严寒天气，确实因感受风寒，新邪引动伏邪，如吴又可所说的感冒兼役之证，麻杏石甘汤，也不妨暂时使用。桂枝这一味药，是温病最忌讳的，因为它温里缘故。书云：桂枝入口，阳盛（热盛）则毙命，承气汤入胃，阴盛（寒盛）则死亡。曾见误服桂枝，变证蜂起，不可不知道。葛根辛甘凉润，是阳明经的药。柴胡主治邪气郁结在胸胁，温病也有阳明及胸胁证，所以间或有使用的。总之，有病则用相应的药，不可拘泥固执。至于补救错误的诸方，如四逆汤、真武汤、理中汤之类，是为伤寒误汗、误下损伤阳气而设的，都与温病相反。伤寒多损伤阳气，所以末路阶段以扶阳为急务；温病多损伤阴液，所以末路阶段以养阴为要法。这又是寒温学说判若霄壤的地方。所以一并记录下来。
(Regarding) the treatment method of "rescuing the interior". In cases of profuse sweating, severe purgation, or diarrhea accompanied by cold extremities, Si Ni Tang (Four Reversal Decoction) is the primary formula. (Although exterior symptoms may be present, urgent rescue of the interior deficiency-cold is required). In cases of vomiting and diarrhea with sweating, fever, aversion to cold, spasm and tightness of the four limbs, and cold hands and feet, Si Ni Tang (Four Reversal Decoction) is the primary formula. (Although exterior symptoms may be present, urgent rescue of the interior is required). In cases of simultaneous vomiting and diarrhea, with urination becoming frequent (both stool and urine are clear/profuse, indicating that internal Yang Qi is nearly exhausted), profuse sweating, diarrhea passing undigested food ("clear谷"), internal cold with external heat (although there is external heat and exterior syndrome, the interior syndrome is extremely severe), and a pulse that is faint and almost imperceptible, Si Ni Tang (Four Reversal Decoction) is the primary formula. After using purgation followed by diaphoresis, if the patient experiences restlessness during the day preventing sleep, but remains quiet at night (Yang deficiency presents in two ways: those with both Yin and Yang deficiency fear Yang, while those without Yin deficiency prefer Yang); in cases where there is no vomiting, no thirst, no exterior syndrome, a deep and faint pulse, and no significant body heat, Gan Jiang Fu Zi Tang (Dried Ginger and Aconite Decoction) is the primary formula. If after diaphoresis and purgation the disease persists and restlessness occurs (this is restlessness caused by Yang Qi failing to secure, known as "Yin Restlessness". However, other symptoms must be considered to avoid misdiagnosis), Fu Ling Si Ni Tang (Poria Four Reversal Decoction) is the primary formula (containing Poria, Ginseng, Aconite, Licorice, Dried Ginger). In Taiyang disease, if after diaphoresis the condition does not resolve, and the patient still has fever, palpitations in the epigastrium, dizziness, tremors of the body, and a sensation of shaking as if about to fall to the ground, Zhen Wu Tang (True Warrior Decoction) is the primary formula. This is due to excessive diaphoresis causing Water Pathogen to reverse upwards following Yang Qi; this syndrome is more severe than that of Fu Ling Si Ni Tang. The latter involves injury from both sweating and purging, hence Ginseng and Dried Ginger are used; here, sweating injures the water mechanism leading to reversal, hence Zhen Wu Tang is used to suppress the Water Pathogen and restore Yang Qi. "Zhen Wu" refers to the Northern Water Deity, hence the name. (Contains Poria, Peony, Fresh Ginger, Atractylodes, Aconite). If after vomiting or purging, there is fullness and counterflow in the epigastrium, Qi rushing up to the chest, dizziness upon rising, and a deep, tight pulse, Fu Ling Gui Zhi Bai Zhu Gan Cao Tang (Poria, Cinnamon Twig, Atractylodes, and Licorice Decoction) is the primary formula. This is also a syndrome of Yang deficiency with Water Pathogen reversal, representing a milder form of the Zhen Wu Tang syndrome. If diaphoresis is applied again, it will disturb the Jing Qi, causing the body to tremble and sway. If after diaphoresis the disease does not resolve but aversion to cold worsens, it is due to deficiency; Shao Yao Gan Cao Fu Zi Tang (Peony, Licorice, and Aconite Decoction) is the primary formula. In Taiyang disease, if the exterior syndrome persists but multiple purgations are performed, resulting in "xie re xia li" (diarrhea accompanying heat), incessant diarrhea, and epigastric hardness/pathological fullness (pathogen in the Upper Jiao), with both exterior and interior unresolved, Gui Zhi Ren Shen Tang (Cinnamon Twig and Ginseng Decoction) is the primary formula (contains Cinnamon Twig, Licorice, Atractylodes, Ginseng, Dried Ginger). In Shanghan (Cold Damage) with incessant diarrhea and epigastric hardness, if after taking Xie Xin Tang (Drain the Epigastrium formulas) another purgative is administered (a second error), and diarrhea persists, and the physician administers Li Zhong Tang (Regulate the Middle Decoction), worsening the diarrhea. Li Zhong Tang regulates the Middle Jiao. Here, the diarrhea is in the Lower Jiao (due to excessive purgation injuring the Large Intestine); Chi Shi Zhi Yu Yi Liang Tang (Red Halloysite and Hematite Decoction) is the primary formula (using astringents to stop collapse). If diarrhea persists, one should promote urination (separating the clear from the turbid will firm the stool). All these cases result from erroneous sweating and purging damaging True Yang, thus requiring warming methods to correct the errors; they are not standard treatments for exterior cold transforming into heat.
Regarding interior cold syndromes, they essentially involve Spleen and Kidney Yang deficiency. Yang deficiency generates dampness, so dampness is often involved. Treatment methods essentially fall into three categories: Si Ni Tang, Zhen Wu Tang, and Li Zhong Tang. Formulas in the Si Ni category rely on Dried Ginger and Aconite; observing their modifications, they aim to unblock Yang and open closures, focusing on the Kidney. Formulas in the Zhen Wu category rely on Poria, Aconite, and Fresh Ginger, aiming to warm Yang and suppress water, also focusing on the Kidney. Formulas in the Li Zhong category rely on Dried Ginger and Atractylodes, aiming to stabilize the Middle Jiao, focusing on the Spleen. The Gui Zhi Fu Zi Tang category is designed for Wind-Dampness with Yang deficiency, aiming to release the muscle layer, warm Yang, and transform dampness, treating both exterior and interior with a focus on the interior. This is the general principle for treating interior cold. Let us elaborate. The Treatise states: Fever and headache (exterior pathogen), but the pulse is surprisingly deep (interior pulse). If it does not improve and body pain persists, urgently rescue the interior with Si Ni Tang (Licorice, Dried Ginger, Aconite). Body pain can occur in both exterior cold and interior cold/Yin-Yang syndromes. Although deep pulse indicates interior, it can also occur when exterior pathogen is constrained. One must verify that the patient is not restless or thirsty, the pulse is deep but distinct, and all signs point to Yin/cold before using it; do not act rashly! If the pulse is floating and slow, with exterior heat and interior cold, and diarrhea passing undigested food, Si Ni Tang (Four Reversal Decoction) is the primary formula. Spontaneous diarrhea without thirst belongs to Taiyin disease, indicating cold in the Zang organs; it should be warmed with formulas like Si Ni Tang. (Any warm-hot agents can be selected, hence "lei" [category] is used instead of "tang" [decoction]). In Shaoyin disease, if food is vomited immediately upon entering the mouth, with a sense of warmth and discomfort in the heart, wanting to vomit but unable to do so; if at onset there are cold hands and feet and a string-taut, slow pulse, this is excess in the chest (cold excess); purgation is contraindicated, and emesis should be induced (for pathogens above, use the method of evacuation from above). If there is cold-fluid retention above the diaphragm causing dry retching (dry retching without substance indicates fluid retention), emesis is contraindicated; warming should be used (when cold disperses, fluid transforms; all fluid treatments require warming). Si Ni Tang (Four Reversal Decoction) is appropriate. If there is aversion to cold, faint pulse, and subsequent diarrhea, and the diarrhea stops, this indicates loss of blood/fluids (diarrhea stopping after exhaustion means internal depletion of fluids. Loss of blood here implies loss of Yin); Si Ni Jia Ren Shen Tang (Four Reversal Decoction plus Ginseng) is the primary formula (to restore Yang and generate fluids).
In Shaoyin disease, with diarrhea passing undigested food, interior cold with exterior heat (cold forcing Yang outward), cold extremities, faint/almost imperceptible pulse, absence of aversion to cold (cold pathogen entered the interior), and red complexion (Yang forced outward, called "Dai Yang" or Floating Yang). With possible abdominal pain, dry retching, sore throat (cold forcing Yang upward), or cessation of diarrhea with absent pulse, Tong Mai Si Ni Tang (Pulse-Resuscitating Four Reversal Decoction) is the primary formula; if the pulse returns, recovery ensues. (For Si Ni Tang: add Scallion for red face; remove Scallion and add Peony for abdominal pain; add Fresh Ginger for vomiting; remove Peony and add Platycodon for sore throat; remove Platycodon and add Ginseng for stopped diarrhea/absent pulse. Whether Yin or Yang syndromes, obstruction causes blockage, hence acrid-warm herbs are used to unblock Yang). For diarrhea passing undigested food, interior cold with exterior heat, sweating, and cold extremities, Tong Mai Si Ni Tang (Pulse-Resuscitating Four Reversal Decoction) is the primary formula (cold extremities with sweating indicate imminent collapse of Yang). If vomiting and diarrhea have ceased, but sweating and cold extremities persist, with spasm/tightness of limbs not resolving and faint/almost imperceptible pulse, Si Ni Jia Zhu Dan Jiang Tang (Four Reversal Decoction plus Pig Bile) is the primary formula (utilizing its bitter and slippery nature to reach the Lower Jiao directly). For Shaoyin disease with diarrhea, Bai Tong Tang (White Connective Decoction) is the primary formula (Gan Jiang Fu Zi Tang plus four stalks of Scallion White, to unblock Shaoyin Yang Qi). For Shaoyin diarrhea with faint pulse, administer Bai Tong Tang; if diarrhea persists, with cold extremities, absent pulse, dry retching, and restlessness, Bai Tong Jia Zhu Dan Jiang Tong Bian Tang (White Connective Decoction plus Pig Bile and Child's Urine) is the primary formula (child's urine guides Yang herbs to the extreme Yin, illustrating the "counter-assistance" method mentioned in classics). For cold extremities and fine/almost imperceptible pulse, Dang Gui Si Ni Tang (Angelica Four Reversal Decoction) is the primary formula (contains Angelica, Cinnamon Twig, Peony, Asarum, Licorice, Tetrapanax, Jujube). If there is long-standing cold within, Dang Gui Si Ni Jia Wu Zhu Yu Sheng Jiang Tang (Angelica Four Reversal Decoction plus Evodia and Fresh Ginger) is the primary formula. This exemplifies the Si Ni category focusing on unblocking Yang and opening closure.
Let us discuss Zhen Wu Tang further. In Shaoyin disease, with abdominal pain, difficulty urinating, heavy/painful limbs, and spontaneous diarrhea, this indicates water retention. Modifications include: adding Schisandra, Dried Ginger, and Asarum if coughing; removing Poria if urination is normal; removing Peony and adding Dried Ginger if diarrhea persists; removing Aconite and adding Dried Ginger if vomiting occurs. Zhen Wu Tang (True Warrior Decoction) is the primary formula. For Shaoyin disease with body pain, cold hands/feet, bone/joint pain, and deep pulse, Fu Zi Tang (Aconite Decoction) is the primary formula (Zhen Wu Tang minus Fresh Ginger, plus Ginseng). This exemplifies the Zhen Wu category focusing on warming Yang and promoting water metabolism (water is dampness). Regarding Li Zhong Wan (Regulate the Middle Pill): (contains Ginseng, Licorice, Atractylodes, Dried Ginger). Modifications: remove Atractylodes and add Cinnamon Twig if palpitations below the navel suggest Kun Peng Qi movement; remove Atractylodes and add Fresh Ginger if vomiting; add Poria for palpitations; add Atractylodes for thirst/water craving to resolve fluid and generate fluids; add Ginseng for empty/cold abdominal pain; add Dried Ginger for cold; remove Atractylodes and add Aconite for abdominal fullness. This formula is for post-major illness salivation (stomach fluid not stored, combined with cold-fluid retention) persisting for a long time due to stomach cold; pills are used for slow regulation.
The Gui Zhi Fu Zi Tang category releases the muscle layer, transforms dampness, warms Yang, and treats both exterior and interior. The Treatise states: After 8-9 days of Shanghan, Wind-Dampness intermingling causes painful body aches preventing turning over (dampness causes heaviness), no vomiting/thirst (dampness is Yin pathogen), and floating-deficient/choppy pulse (exterior and interior deficiency). Gui Zhi Fu Zi Tang (Cinnamon Twig and Aconite Decoction) is primary (contains Cinnamon Twig, Aconite, Licorice, Fresh Ginger, Jujube). If stool is hard and urination normal, use Qu Gui Jia Bai Zhu Tang (Remove Cinnamon Twig, Add Atractylodes Decoction) (Atractylodes generates stomach/intestine fluids). If stool is not hard and urination is difficult, Cinnamon Twig should be added (this shows Cinnamon Twig promotes urination, hence used in Wu Ling San). Post-medication dizziness is normal; Aconite and Atractylodes move to skin/flesh to expel water qi, which takes time. Add Cinnamon Twig to treat this. Another Wind-Dampness case: painful joints, pulling pain, inability to flex/extend, severe pain on touch, sweating, shortness of breath, difficulty urinating, aversion to wind/preference for clothing, or slight edema. Gan Cao Fu Zi Tang (Licorice and Aconite Decoction) is primary; mild sweating resolves it (This is Gui Zhi Fu Zi Tang minus Fresh Ginger/Jujube, plus Atractylodes. Due to sweating, Ginger/Jujube are removed; although Cinnamon Twig is used, the focus is on Licorice/Aconite warming Yang, hence the name. Sweating too much removes Wind but leaves Dampness, causing failure. Mild sweating removes both). This is the major method for Wind-Dampness. Other examples: Vomiting after eating (pathology in receiving food, different from dry retching) belongs to Yangming (deficiency-cold); Wu Zhu Yu Tang (Evodia Decoction) is primary (Evodia, Ginseng, Fresh Ginger, Jujube). If worsening after ingestion, it belongs to Upper Jiao (fluid retention). Also, Shaoyin disease with vomiting/diarrhea, cold extremities, and severe restlessness; Wu Zhu Yu Tang (Evodia Decoction) is primary (stomach Qi deficiency-cold). Dry retching, vomiting saliva/phlegm (cold-fluid in stomach), with headache (Yangming meridian ascends to head); Wu Zhu Yu Tang (Evodia Decoction) is primary. Also, Shaoyin disease with abdominal pain, difficulty urinating, incessant diarrhea, and pus/blood in stool; Tao Hua Tang (Peach Blossom Decoction) is primary (Red Halloysite, Dried Ginger, Rice). One dose cures; do not take remaining. Also, Shanghan with faint pulse and cold extremities; by day 7-8, cold skin (Yang fails to protect exterior), restlessness without respite indicates Zang Jue (incurable), not Hui Jue (Roundworm Jue). Hui Jue patients vomit roundworms. Current patient is quiet but intermittently restless, indicating Zang cold. Roundworms ascend to Diaphragm, causing vomiting of worms. Hui Jue is treated with Wu Mei Wan (Mume Pill) (contains Mume, Asarum, Dried Ginger, Angelica, Aconite, Sichuan Pepper, Cinnamon Twig, Coptis, Phellodendron, Ginseng). Take 10 pills after meals, increasing to 20; avoid raw/cold/slippy/strong-smelling foods. These all treat interior cold. Thus, I say Shanghan Lun should be viewed in two major sections.
There are also complicated exterior-cold syndromes. E.g., Shanghan for 6-7 days, after severe purgation: Cun pulse deep/slow, Chi pulse absent, cold extremities, throat obstruction, spitting pus/blood, incessant diarrhea. Difficult to treat; Ma Huang Sheng Ma Tang (Ephedra and Corydalis Decoction) is primary, resolving with sweating (contains Ephedra, Corydalis, Angelica, Cinnamon Twig, Peony, Poria, Licorice, Dried Ginger, Atractylodes, Gypsum, Anemarrhena, Scutellaria, Polygonatum, Ophiopogon). This is upper-heat/lower-cold mutual injury, complex pathology, many ingredients, rare in ancient formulas; observe to understand ancient prescribing logic. Also, "Yin Yang Yi" disease: after exterior cold resolves, intercourse transmits residual heat. Symptoms: heavy body, shortness of breath, lower abdominal urgency, contraction of genitals, heat rushing to chest, heavy head unwilling to lift, visual disturbances, knee/shin stiffness. Shao Kun San (Burnt Underwear Powder) is primary (burnt male/female underwear crotch, mixed and taken; urination clears, slight penile swelling indicates cure, guiding evil fire out via Yin pathway). This illustrates intuitive prescribing. Observing Shanghan Lun, formulas vary based on Nei Jing, matching Shennong Bencao Jing. I state only the broad principles; students should study the whole book to master applications for all diseases, not just read it as a Shanghan text!
Note: Exterior cold in Shanghan Lun involves Cold/Dry pathogens. Only four herbs—Ephedra, Cinnamon Twig, Kudzu Root, Bupleurum—are set for meridian pathogens; others treat via Jiao systems, consistent with Wen Bing (Warm Disease) theory. Ephedra opens the exterior; contraindicated in Warm Diseases. In severe cold weather, if Wind-Cold triggers latent pathogens (as Wu Keyke described), Ma Xing Shi Gan Tang (Ephedra, Apricot Kernel, Gypsum, Licorice Decoction) may be temporarily used. Cinnamon Twig is most contraindicated in Warm Diseases due to its interior-warming nature. Classics warn: Cinnamon Twig enters, Yang-excess (heat) leads to death; Cheng Qi enters stomach, Yin-excess (cold) leads to death. Misuse of Cinnamon Twig causes myriad complications; this must be known. Kudzu Root is acrid-sweet-cool-moist, a Yangming herb. Bupleurum treats constraint in chest/hypochondrium; Warm Diseases also have Yangming/chest-hypochondrium patterns, so it is occasionally used. Ultimately, use herbs corresponding to the disease; do not be rigid. Rescue formulas like Si Ni, Zhen Wu, Li Zhong are for Shanghan errors damaging Yang, opposite to Warm Disease treatment. Shanghan damages Yang, so late stage prioritizes supporting Yang; Warm Diseases damage Yin, so late stage prioritizes nourishing Yin. This distinguishes Cold and Warm schools. Recorded here.