寒气亦为阴，两阴相合而偏于下利，则与阳气隔绝不能通，姜、附之力，虽能益阳，不能使真阳之气必入于阴
中，惟葱白味辛，能通阳气，令阴得阳而利，庶可愈矣。盖大辛、大热之药，不过借以益人阳气，非有以通之，
令真阳和会，而何以有济也耶？
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。服汤脉暴出者死，
微续者生。
【注】此承上条详申其脉，以明病进之义也。少阴病下利脉微者，与白通汤，下利当止。今利不止。而转
见厥逆无脉，更增干呕而烦者，此阴寒盛极，格阳欲脱之候也。若专以热药治寒，寒既甚，必反格拒而不入，
故于前方中加人尿、猪胆之阴，以引阳药入阴。经曰∶逆者从之。此之谓也。无脉者，言诊之而欲绝也。服汤
后，更诊其脉，若暴出者，如烛烬焰高，故主死。若其脉徐徐微续而出，则是真阳渐回，故可生也。故上条所
以才见下利，即用白通以治于未形，诚善法也。
【集注】程知曰∶此言阴盛格阳，用胆汁通阴法也。以白通与之，宜乎阳可救。今乃利不止，反至厥逆无
脉，则阴邪愈无忌矣。干呕而烦，则阳药在膈而不入阴矣。此非药不胜病，乃无乡导之力也。加人尿、猪胆之
阴寒，则可引姜、附之温，入格拒之寒而调其逆。此《内经》从治之法也。
程应旄曰∶脉暴出者死，无根之阳骤迸诸外也。微续者生，阳气渐交，阴肯纳也。
白通加猪胆汁汤方
葱白（四茎） 干姜（一两） 附子（生，去皮，破八片，一枚） 人尿（五合） 猪胆汁（一合）
以上三味，以水三升，煮服一升，去滓；纳胆汁、人尿，和令相得，分温再服。若无胆，亦可用。
【方解】是方即前白通汤加人尿、猪胆汁也。加尿、胆者，从其类也。下咽之后，冷体既消，热性便发，
情且不违而致大益，则二气之格拒可调，上下之阴阳可通矣。
少阴病，欲吐不吐，心烦，但欲寐，五六日，自利而渴者，属少阴也。虚故引水自救，若小便色白者，少
阴病形悉具。小便白者，以下焦虚，有寒，不能制水，故令色白也。
【注】少阴病欲吐不吐，心中烦，但欲寐，五六日，自利而渴者，此属少阴传邪，寒热俱有之证也。若是
少阴热而燥干，引水之渴，小便必色赤，乃少阴燥不能生津，下焦有热也。今为少阴虚，而引水自救之渴，故
小便则色白，是少阴虚冷，不能化液，下焦有寒也。于此可知少阴病形悉具，而渴者有寒热二端之别也。
【集注】成无己曰∶欲吐不吐，心烦者，表邪传里也。若腹满痛，则属太阴，此但欲寐，则知属少阴。五
六日邪传少阴之时，若自利不渴，寒在中焦，属太阴也；此自利而渴，为寒在下焦，属少阴也。肾虚水燥，故
渴欲引水自救。下焦虚寒，故小便色白。下利而渴，小便色白，非里热可知矣。
方有执曰∶此反复申明，晓人勿认烦渴均为热证，以致误之意。
程应旄曰∶烦证不尽属少阴，故指出但欲寐来；渴证不尽属少阴，故指出小便白来。结以下焦虚有寒，教
人上病治在下也。盖上虚而无阴以济，总由下虚而无阳以温也。二“虚”字皆由“寒”字得来。又曰∶吐利而
渴，与猪苓汤证同，其别在但欲寐。且猪苓证，小便必不利而色赤饮水，与白头翁证同，彼曰∶以有热故也，
小便亦必不白。
林澜曰∶欲吐不吐，心烦，阳虚格越于上。但欲寐，自利，小便白，里之真寒已深。要知此渴，与口燥舌
干之渴不同。若兼腹满、
便闭、谵语诸证，自当作阳邪传里治之。既里虚自利小便白，其为虚寒明甚。特曰下焦者，足见阴既盛于下，
阳必格于上，岂可以烦渴而误攻其热哉！
汪琥曰∶以全文观之大似热证，惟小便色白，知为真寒之证。此但欲寐与热邪不同，其寐必不昏浊，其呼
吸必促而细。曰属少阴者，以别其非阳邪之渴，乃内无津液引水自救之渴，试以冷水饮之，必不多也。细察其
小便，若色白者，此少阴虚寒之证悉具也，非热邪可知矣。
沈明宗曰∶此少阴虚寒，似乎热证之辨也。世但知四肢厥逆为虚寒证，讵知小便色白，乃为的验乎？
吴人驹曰∶阳明之欲吐则不得寐，在少阴则但欲寐，引此以为盛虚之别。
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，不可下也，当
吐之。若膈上有寒饮，干呕者，不可吐也，当温之，宜四逆汤。
【按】温温，当是“ ”。 者，乃吐饮之状也。
【注】此承上条欲吐不吐详别脉证，以明其治也。饮食入口即吐，且心中 欲吐复不能吐，恶心不已，
非少阴寒虚吐也，乃胸中寒实吐也。故始得之脉弦迟。弦者饮也，迟者寒也。而手足寒者，乃胸中阳气为寒饮
所阻，不能通于四肢也。寒实在胸，当因而越之，故不可下也。若膈上有寒饮，但干呕有声而无物出，此为少
阴寒虚之饮，非胸中寒实之饮也，故不可吐，惟急温之，宜四逆汤或理中汤加丁香、吴茱萸亦可也。
【集注】程知曰∶此言少阴饮吐，为肾邪上逆，当温不当吐也。欲吐不吐，阴邪上逆之证也。若始得病时，
邪未深入，其手足但寒而不厥，脉但弦迟而不沉细，则为邪实胸中，寒尚在表，属于阳分，当吐而不当下。吐
者有物，呕则无物，两者须辨。若膈上有寒饮，但见干呕而不能吐出，则是阴寒上逆，当温而不当吐也。曰急
温者，明不温则见厥逆无脉诸变证也。
程应旄曰∶寒在胸中，法不可下，而属实邪，但从吐法一吐，而阳气得通，吐法便是温法。若膈上有寒饮
干呕者，虚寒从下而上，阻留其饮于胸中，究非胸中之病也，直从四逆汤，急温其下可矣。
少阴病，脉微细沉，但欲卧，汗出不烦，自欲吐，至五六日，自利，复烦躁不得卧寐者，死。
【注】此发明上条，互详脉证，失于急温致变之义也。脉微细沉、但欲卧，少阴寒也。当无汗，今反汗出
不烦，乃少阴亡阳也。且自欲吐，阴寒之邪上逆，正当急温，失此不治，因循至五六日，加之自利，复烦躁不
得卧寐者，此少阴肾中真阳扰乱，外越欲绝之死证，此时即温之，亦无及矣。
【集注】方有执曰∶脉微沉细，但欲卧，少阴本病也。汗出而不作烦热，无阳也。欲吐，经中之邪不退也。
自利，脏病进也。更复烦躁不得卧寐者，阳欲绝而扰乱不宁也。
程应旄曰∶今时论治者，不至于恶寒蜷卧、四肢逆冷等证叠见，则不敢温，不知证已到此，温之何及？况
诸证有至死不一见者，则盍于本论中之要旨，一一申详之∶少阴病，脉必沉而微细，论中首揭此，盖已示人以
可温之脉矣。少阴病但欲卧，论中又已示人以可温之证矣。汗出，在阳经不可温，在少阴宜急温，论中又切示
人以亡阳之故矣。况复有不烦、自欲吐，阴邪上逆之证乎？则真武、四逆，诚不啻三年之艾矣。乃不知预为绸
缪，延缓至五六日，前欲吐，今且利矣；前不烦，今烦且躁矣；前欲卧，今不得卧矣。阳虚扰乱，阴盛转加，
焉有不死者乎？
少阴病，二三日不已，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，或小便不利，或下利，或呕者，真武汤主之。
【注】论中心下有水气，发热有汗，烦渴引饮，小便不利者，属太阳中风，五苓散证也。发热无汗，干呕
不渴，小便不利者，属太阳伤寒，小青龙汤证也。今少阴病，二三日不已，至四五日腹痛下利，阴寒深矣。设
小便利，是纯寒而无水，乃附子汤证也。今小便不利，或咳或呕，此为阴寒兼有水气之证。故水寒之气，外攻
于表，则四肢沉重疼痛；内盛于里，则腹痛自利也；水气停于上焦胸肺，则咳喘而不能卧；停于中焦胃腑，则
呕而或下利；停于下焦膀胱，则小便不利，而或少腹满。种种诸证，总不外乎阴寒之水。而不用五苓者，以非
表热之饮也；不用小青龙者，以非表寒之饮也。故惟主以真武汤，温寒以制水也。
【集注】喻昌曰∶太阳篇中，厥逆、筋惕肉 而亡阳，用真武矣。兹少阴之水湿上逆，仍用真武以镇摄之，
可见太阳膀胱与少阴肾，一脏一腑，同为寒水。腑邪为阳邪，藉用麻桂为青龙；脏邪为阴邪，藉用附子为真武。
真武汤方
茯苓（三两） 芍药（三两） 生姜（切，三两） 白术（二两） 附子（炮，去皮，破八片，一枚）
上五味，以水八升，煮取三升，去滓，温服七合，日三服。
若咳者，加五味子半升，细辛、干姜各一两。若小便利者，去茯苓。若下利者，去芍药，加干姜二两。若
呕者，去附子加生姜，足前成半斤。
【方解】小青龙汤，治表不解，有水气，中外皆寒实之病也；真武汤，治表已解，有水气，中外皆寒虚之
病也。真武者，北方司水之神也，以之名汤者，赖以镇水之义也。夫人一身制水者，脾也；主水者，肾也；肾
为胃关，聚水而从其类者。倘肾中无阳，则脾之枢机虽运，而肾之关门不开，水虽欲行，孰为之主，故水无主
制，泛溢妄行而有是证也。用附子之辛热，壮肾之元阳，而水有所主矣；白术之苦燥，创建中土，而水有所制
矣；生姜之辛散，佐附子以补阳，温中有散水之意；茯苓之淡渗，佐白术以健土，制水之中有利水之道焉。而
尤妙在芍药之酸敛，加于制水、主水药中，一以泻水，使子盗母虚，得免妄行之患；一以敛阳，使归根于阴，
更无飞越之虞。孰谓寒阴之品，无益于阳乎？而昧者不知承制之理，论中误服青龙发汗亡阳，用此汤者，亦此
义也。然下利减芍药者，以其阳不外散也；加干姜者，以其温中胜寒也。水寒伤肺则咳，加细辛、干姜者，散
水寒也。加五味子者，收肺气也。小便利者去茯苓，以其虽寒而水不能停也。呕者，去附子倍生姜，以其病非
下焦，水停于胃也。所以不须温肾以行水，只当温胃以散水。佐生姜者，功能止呕也。
【集解】程知曰∶白通、通脉、真武皆为少阴下利而设。白通四证，附子皆生用，惟真武一证熟用者，盖
附子生用则温经散寒，炮熟则温中去饮。白通诸汤以通阳为重，真武汤以益阳为先，故用药有轻重之殊。干姜
能佐生附以温经，生姜能资熟附以散饮也。
张璐曰∶按真武汤方本治少阴病，水饮内结，所以首推术、附兼茯苓、生姜之运脾渗水为务，此人所易明
也。至用芍药之微旨，非仲景不能。盖此证虽曰少阴本病，而实缘水饮内蓄，所以腹痛自利，四肢疼重，而小
便反不利也。若极虚极寒，则小便必清白无禁矣，安有反不利之理哉！此证不但真阳不足，真阴亦必素亏，或
阴中伏有阳邪所致，若不用芍药固护其阴，岂能胜附子之雄烈乎？
病患身大热，反欲得衣者，热在皮肤，寒在骨髓也；身大寒，反不欲近衣者，寒在皮肤，热在骨髓也。
【注】身体为表，脏腑为里，此以内外分表里也。皮肤为表，骨髓为里；六腑为表，五
脏为里，此以身体之浅深，脏腑之阴阳分表里也。病患，已病之人也。身大热，谓通身内外皆热，三阳证也。
反欲得近衣者，乃是假热，虽在皮肤之浅，而真寒实在骨髓之深，阴极似阳证也。身大寒，谓通身内外皆寒，
三阴证也。反不欲近衣者，乃是假寒，虽在皮肤之浅，而真热实在骨髓之深，阳极似阴证也。
【按】此以人之苦欲，测其寒热真假，而定阴阳之证也。当与少阴、厥阴病论中表热里寒、里热表寒、脉
滑而厥、恶寒不欲近衣、口燥咽干等条参看。
【集注】成无己曰∶皮肤言浅，骨髓言深；皮肤言外，骨髓言内。身热欲近衣，表热里寒也；身寒不欲近
衣，表寒里热也。大抵表热里寒，脉必沉迟；里热表寒，脉必滑数。须当辨之。
郑重光曰∶皮肤者，骨髓之外，浮浅之分也；骨髓者，皮肤之内，沉深之分也。欲得近衣，借外以御内，
此真寒也；体有着而成忤，不在衣之浓薄，此假寒也。不察人之苦欲，何以测其真寒、真热而定标本乎？
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。
【注】少阴肾也，肾象乎坎。一阳陷于二阴之中，二阴若盛，则一阳必衰，阴邪始得内侵，孤阳因之而外
越也。下利清谷，手足厥冷，脉微欲绝，里阴盛极也；身反不恶寒，面色反赤，其外反热，格阳于外也。故虽
有腹痛、干呕、咽痛等证，亦当仿白通汤之法，加葱于四逆汤中，以消其阴，而复其阳可也。
【集注】程应旄曰∶热因寒格，无论腹痛、干呕、咽痛，皆下利中格阳之证。即使利止，而脉仍前，欲绝
不出，亦不得谓里寒已退，辄妄治其外热也。须循四逆汤例，消阴翳于下部，但加葱白，宣阳气于下焦，使阳
气通而脉亦出，始为真愈。
林澜曰∶格，拒格也。亦曰“隔阳”，阴阳隔离也。又曰“戴阳”，浮于上如戴也。夫真寒入里，阴气未
有不盛者。然其剧，不过阳愈微阴愈盛耳！
通脉四逆汤方
寒气也属于阴，两股阴气相合并偏盛于下焦导致腹泻，就会与阳气隔绝而不能相通。干姜、附子的药力，虽然能够补益阳气，但不能保证真阳之气必然进入阴中。只有葱白味道辛散，能够通达阳气，使阴寒得到阳气的温煦而止利，这样才可能痊愈。大概大辛、大热的药物，不过是借以补益人的阳气，如果没有办法通达它，使真阳之气得以和合聚会，那又怎么能起到治疗作用呢？
少阴病，出现腹泻且脉象微弱的，给予白通汤；如果服药后腹泻不止，出现四肢厥冷、无脉搏、干呕且心烦的，用白通加猪胆汁汤主治。服药后，如果脉搏突然暴出（浮大无根）的预后不良（主死），如果脉搏逐渐微弱接续出现的预后良好（主生）。
【注】这一段承接上一条详细阐述脉象，以说明病情进展的含义。少阴病出现腹泻且脉象微弱的，给予白通汤，腹泻应当停止。现在腹泻不止，反而转为四肢厥冷、无脉搏，更增加了干呕和心烦的症状，这是阴寒极盛，格拒阳气即将脱失的征候。如果只用热药治疗寒证，因为寒邪太盛，必然会反过来格拒药物使其无法入内，所以在前方中加入人尿、猪胆汁这些阴性药物，用来引导阳药进入阴分。《内经》说：“逆其病势者，顺从其性质而治。”说的就是这种情况。“无脉”，是指诊察时脉搏似乎要断绝的样子。服药后再诊察脉搏，如果脉搏突然暴出，就像蜡烛烧尽时火焰突然升高一样，所以主死。如果脉搏徐徐地、微弱地接续而出，则是真阳逐渐恢复，所以可以生还。所以上一条之所以刚见到腹泻，就用白通汤在病形未完全显露之前进行治疗，确实是好的治疗方法。
【集注】程知说：这里讲的是阴盛格阳，使用胆汁通达阴气的方法。给予白通汤，按理说阳气是可以挽救的。现在却腹泻不止，反而到了四肢厥冷、无脉搏的地步，那么阴邪更加肆无忌惮了。干呕且心烦，说明阳药停留在膈上而不能进入阴分。这不是药力不能战胜病邪，而是缺少向导的力量。加入人尿、猪胆汁的阴寒之性，就可以引导干姜、附子的温热之性，进入被格拒的寒邪之中来调和逆乱。这就是《内经》所说的从治法。
程应旄说：脉搏突然暴出而死，是因为无根的阳气骤然迸发于外。脉搏微弱接续而生，是因为阳气逐渐交接，阴气愿意接纳。
白通加猪胆汁汤方
葱白（四茎） 干姜（一两） 附子（生用的，去皮，破成八片，一枚） 人尿（五合） 猪胆汁（一合）
以上五味药，用水三升，煮取一升，去掉药渣；纳入胆汁和人尿，混合均匀，分两次温服。如果没有猪胆，也可以用其他替代品。
【方解】这个方子就是在前面的白通汤基础上加入人尿、猪胆汁。加入尿和胆汁，是顺应阴类的特性。咽下之后，冷的本性既已消除，热的药性随即发挥，药性与病情不违背从而产生巨大的益处，那么阴阳二气的格拒就可以调和，上下的阴阳就可以通畅了。
少阴病，想吐却吐不出来，心中烦躁，只想睡觉，过了五六天，自己腹泻且口渴的，属于少阴病。因为虚，所以想喝水来自救。如果小便颜色发白的，少阴病的症状就全部具备了。小便发白，是因为下焦虚寒，不能制约水液，所以让小便颜色发白。
【注】少阴病想吐却吐不出来，心中烦躁，只想睡觉，过了五六天，自己腹泻且口渴的，这属于少阴病传变而来的邪气，是寒热都有的证候。如果是少阴热证导致的燥渴，想要喝水解渴，小便一定颜色发红，这是少阴燥热不能生津，下焦有热的表现。现在是少阴虚寒，想要喝水自救的口渴，所以小便则颜色发白，这是少阴虚冷，不能化生津液，下焦有寒的表现。从这里可以看出少阴病的症状全部具备，而口渴分为寒热两种不同的情况。
【集注】成无己说：想吐却吐不出来，心中烦躁，是表邪传入里部。如果腹部胀满疼痛，则属于太阴病，这里只是只想睡觉，就知道属于少阴病。五六天邪气传入少阴的时候，如果腹泻且不口渴，是寒在中焦，属于太阴病；这里腹泻且口渴，是寒在下焦，属于少阴病。肾虚水燥，所以口渴想喝水自救。下焦虚寒，所以小便颜色发白。腹泻且口渴，小便颜色发白，这就不是里热证了。
方有执说：这里反复申明，是为了告诉人们不要认为烦躁和口渴都是热证，以免误治的意思。
程应旄说：烦躁的证候并不全属于少阴，所以指出“只想睡觉”这一症状；口渴的证候并不全属于少阴，所以指出“小便发白”这一症状。归结为下焦虚寒，教导人们上部的病要从下部治疗。因为上部的虚而没有阴气来济助，总归是由于下部的虚而没有阳气来温煦。两个“虚”字都是由“寒”字得来的。又说：呕吐腹泻且口渴，与猪苓汤证相同，区别在于是否只想睡觉。而且猪苓汤证，小便一定不利且颜色发红，饮水与白头翁汤证相同，那里说：“因为有热，所以小便也不发白。”
林澜说：想吐却吐不出来，心中烦躁，是阳虚格越于上部。只想睡觉，腹泻，小便发白，是内部的真寒已经很深了。要知道这种口渴，与口燥舌干的口渴不同。如果兼有腹部胀满、便秘、胡言乱语等症状，自然当作阳邪传入里部来治疗。既然内部虚弱导致腹泻且小便发白，其为虚寒是非常明显的。特别提到下焦，足见阴气在下部已经强盛，阳气必然格拒于上部，难道可以因为烦躁口渴就错误地攻伐热邪吗！
汪琥说：纵观全文，很像热证，只有小便颜色发白，才知道是真寒证。这种只想睡觉与热邪不同，睡眠一定不清醒浑浊，呼吸一定急促而细微。说属于少阴，是为了区别于非阳邪引起的口渴，这是内部没有津液而引水自救的口渴，试着给冷水喝，一定喝不了多少。仔细察看他的小便，如果颜色发白，这说明少阴虚寒的症状全部具备，不是热邪，这是很明显的。
沈明宗说：这是辨别少阴虚寒与看似热证的差异。世人只知道四肢厥冷是虚寒证，哪里知道小便颜色发白，才是确切的验证呢？
吴人驹说：阳明病的想吐则不能安睡，在少阴病则是只想睡觉，引用这一点作为盛实与虚损的区别。
少阴病，饮食入口就吐，心中感觉恶心想要吐却又吐不出来。刚开始得病时，手脚冰凉，脉象弦迟的，这是胸中有实邪，不可用泻下法，应当用催吐法。如果是膈上有寒饮，干呕的，不可用催吐法，应当用温法，适宜用四逆汤。
【按】“温温”二字，应当是“愠愠”。愠愠，是呕吐痰饮的状态。
【注】这一段承接上一条“想吐却吐不出来”，详细辨别脉证，以说明治疗方法。饮食入口即吐，且心中恶心想要吐却又吐不出来，恶心不停止，这不是少阴寒虚引起的呕吐，而是胸中寒实引起的呕吐。所以刚开始得病时脉象弦迟。弦脉代表饮邪，迟脉代表寒邪。而手脚冰凉，是因为胸中的阳气被寒饮阻滞，不能通达于四肢。寒实邪气在胸中，应当顺着病势向上涌吐，所以不可用泻下法。如果是膈上有寒饮，只是干呕有声而没有东西吐出，这是少阴寒虚产生的饮邪，不是胸中寒实的饮邪，所以不可催吐，只能紧急温补，适宜用四逆汤或者理中汤加丁香、吴茱萸也可以。
【集注】程知说：这里讲的是少阴病因饮邪呕吐，是肾邪上逆，应当温补而不应当催吐。想吐却吐不出来，是阴邪上逆的证候。如果刚开始生病时，邪气尚未深入，手脚只是凉而不是厥冷，脉象只是弦迟而不是沉细，那就是邪气实于胸中，寒邪还在表，属于阳分，应当催吐而不应当泻下。吐是有东西吐出，呕是没有东西吐出，这两者必须辨别。如果是膈上有寒饮，只见干呕而不能吐出，那就是阴寒上逆，应当温补而不应当催吐。说“急温”，是明确如果不温补就会出现四肢厥冷、无脉搏等变证。
程应旄说：寒邪在胸中，依法不可泻下，但属于实邪，只要通过吐法一吐，阳气就能通达，吐法也就是温法。如果是膈上有寒饮导致干呕，是虚寒从下部向上，阻留饮邪在胸中，终究不是胸中的病，直接服用四逆汤，紧急温补下部就可以了。
少阴病，脉象微细沉，只想睡觉，出汗且不烦躁，自己想吐，到了五六天，出现腹泻，又烦躁不得睡觉的，预后不良（死）。
【注】这一段阐发上一条，互相详细论述脉证，说明未能紧急温补而导致病变的含义。脉象微细沉、只想睡觉，是少阴寒证。应当无汗，现在反而出汗且不烦躁，这是少阴亡阳。而且自己想吐，是阴寒邪气上逆，正当紧急温补，错过此时不治疗，拖延到五六天，加上腹泻，又烦躁不得睡觉，这是少阴肾中真阳扰乱，向外越脱欲绝的死证，此时即使温补，也来不及了。
【集注】方有执说：脉微沉细，只想睡觉，是少阴本病。出汗而不感到烦热，是无阳。想吐，是经中的邪气不退。腹泻，是脏病进展。又加上烦躁不得睡觉，是阳气将要断绝而扰乱不宁。
程应旄说：现在的医生治病，不到恶寒蜷卧、四肢逆冷等症状接连出现，就不敢用温法，不知道证候已经到了这一步，温补又怎么来得及呢？况且有些证候直到死亡都不一定全部出现，为什么不把本论中的重要主旨一一详细阐明呢：少阴病，脉必沉而微细，论中首先揭示这一点，大概是告诉人们这是可以温补的脉象。少阴病只想睡觉，论中又告诉人们这是可以温补的证候。出汗，在阳经不可温补，在少阴宜紧急温补，论中又急切地告诉人们亡阳的缘故。何况还有不烦躁、自己想吐，阴邪上逆的证候呢？那么真武汤、四逆汤，确实像陈年的艾草一样珍贵（指需要预先准备）。然而不知道预先筹划，拖延到五六天，前面想吐，现在已经腹泻了；前面不烦躁，现在又烦躁又躁动不安了；前面想睡觉，现在不能睡觉了。阳虚扰乱，阴盛加重，哪有不死的呢？
少阴病，两三天没有好，到了四五天，出现腹痛，小便不利，四肢沉重疼痛，自己腹泻的，这是因为有水气。其中有的人咳嗽，或者小便不利，或者腹泻，或者呕吐的，用真武汤主治。
【注】论中说心下有 water qi（水气），发热有汗，烦躁口渴想喝水，小便不利的，属于太阳中风，是五苓散的证候。发热无汗，干呕不口渴，小便不利的，属于太阳伤寒，是小青龙汤的证候。现在少阴病，两三天没有好，到了四五天出现腹痛腹泻，阴寒已经很深了。假设小便通利，是纯寒而无水气，那是附子汤的证候。现在小便不利，或者咳或者呕，这是阴寒兼有水气的证候。所以水寒之气，向外攻袭体表，则四肢沉重疼痛；向内盛于里部，则腹痛腹泻；水气停在上焦胸肺，则咳嗽气喘而不能躺卧；停在中焦胃腑，则呕吐或腹泻；停在下焦膀胱，则小便不利，或少腹胀满。种种症状，总离不开阴寒之水。而不用五苓散，是因为不是表热的饮邪；不用小青龙汤，是因为不是表寒的饮邪。所以只主张用真武汤，温散寒邪以制约水气。
【集注】喻昌说：太阳篇中，出现厥逆、筋惕肉瞤而亡阳，用了真武汤。这里少阴的水湿上逆，仍然用真武汤来镇摄它，可见太阳膀胱与少阴肾，一脏一腑，同为寒水。腑邪属于阳邪，借助麻黄、桂枝成为青龙汤；脏邪属于阴邪，借助附子成为真武汤。
真武汤方
茯苓（三两） 芍药（三两） 生姜（切，三两） 白术（二两） 附子（炮制过的，去皮，破成八片，一枚）
以上五味药，用水八升，煮取三升，去掉药渣，温服七合，每天三次。
如果咳嗽的，加五味子半升，细辛、干姜各一两。如果小便通利的，去掉茯苓。如果腹泻的，去掉芍药，加干姜二两。如果呕吐的，去掉附子加生姜，补足前量成半斤。
【方解】小青龙汤，治疗表证未解，有水气，内外都是寒实证的疾病；真武汤，治疗表证已解，有水气，内外都是寒虚证的疾病。真武，是北方掌管水的神灵，用它来命名汤剂，是依靠它来镇水的意义。人体一身中制约水的是脾；主管水的是肾；肾是胃的关隘，聚集水而跟随同类。如果肾中没有阳气，那么脾的枢纽虽然运转，而肾的关门不开，水虽然想流动，谁来做它的主宰呢？所以水没有主宰控制，泛滥妄行而出现这些症状。用附子的辛热，壮旺肾的元阳，水就有了主宰；用白术的苦燥，建立中土，水就有了制约；用生姜的辛散，辅助附子来补阳，有温中散水的意思；用茯苓的淡渗，辅助白术来健运脾土，在制水之中有利水的方法。尤其妙在用芍药的酸敛，加在制水、主水的药物中，一来泻水，防止子盗母虚，避免妄行的祸患；二来收敛阳气，使其归根于阴，更没有飞越的忧虑。谁说寒阴的药物，对阳气没有益处呢？而愚昧的人不懂承制的道理，论中说误服青龙汤发汗导致亡阳，用这个汤剂，也是这个道理。然而腹泻减去芍药，是因为阳气不外散；加干姜，是因为温中胜寒。水寒伤肺导致咳嗽，加细辛、干姜，是散水寒。加五味子，是收敛肺气。小便通利去掉茯苓，是因为虽然有寒但水不能停留。呕吐，去掉附子倍用生姜，是因为病不在下焦，水停在胃里。所以不需要温肾来行水，只应当温胃来散水。辅助生姜，功能是止呕。
【集解】程知说：白通汤、通脉四逆汤、真武汤都是为了少阴病腹泻而设的。白通汤的四证，附子都是生用的，只有真武汤一证是熟用的，大概附子生用则温经散寒，炮熟则温中去饮。白通诸汤以通达阳气为重，真武汤以补益阳气为先，所以用药有轻重的不同。干姜能辅助生附子以温经，生姜能资助熟附子以散饮。
张璐说：按真武汤方原本治疗少阴病，水饮内结，所以首先推崇白术、附子兼茯苓、生姜运脾渗水为主要任务，这是人们容易明白的。至于使用芍药的微妙旨意，非张仲景不能理解。因为这个证候虽然说是少阴本病，但实际上是因为水饮内蓄，所以腹痛腹泻，四肢疼痛沉重，而小便反而不利。如果极度虚弱极度寒冷，小便必定清白且不受控制，哪里有反而不利的道理呢！这个证候不但真阳不足，真阴也必定素来亏损，或者阴中潜伏有阳邪所致，如果不用芍药固护其阴，怎么能承受附子的雄烈呢？
病人身体大热，反而想要穿衣服的，是热在皮肤（浅表），寒在骨髓（深层）；身体大寒，反而不想靠近衣服的，是寒在皮肤（浅表），热在骨髓（深层）。
【注】身体为表，脏腑为里，这是以内外来分表里。皮肤为表，骨髓为里；六腑为表，五脏为里，这是以身体的浅深、脏腑的阴阳来分表里。病患，是指已经生病的人。身体大热，指全身内外都热，是三阳证。反而想要靠近衣服，这是假热，虽然在皮肤的浅层，而真寒实在骨髓的深层，是阴极似阳的证候。身体大寒，指全身内外都寒，是三阴证。反而不想靠近衣服，这是假寒，虽然在皮肤的浅层，而真热实在骨髓的深层，是阳极似阴的证候。
【按】这是根据病人的痛苦和欲望，来推测寒热的真假，从而确定阴阳的证候。应当与少阴、厥阴病论中表热里寒、里热表寒、脉滑而四肢厥冷、恶寒不想靠近衣服、口燥咽干等条文参考对照阅读。
【集注】成无己说：皮肤指浅，骨髓指深；皮肤指外，骨髓指内。身热想靠近衣服，是表热里寒；身寒不想靠近衣服，是表寒里热。大体上表热里寒，脉必沉迟；里热表寒，脉必滑数。必须辨别清楚。
郑重光说：皮肤是骨髓之外，浮浅的部分；骨髓是皮肤之内，深沉的部分。想要靠近衣服，是借外部来抵御内部，这是真寒；身体穿着衣服感到违和不适，不在于衣服的厚薄，这是假寒。不考察病人的痛苦和欲望，怎么能推测真寒、真热来确定标本呢？
少阴病，腹泻排出未消化的食物，内部寒外部热，手脚厥冷，脉象微弱几乎摸不到，身体反而不恶寒，那个人面色发红，或者腹痛，或者干呕，或者咽痛，或者腹泻停止但脉搏不出来的，用通脉四逆汤主治。
【注】少阴对应肾，肾象坎卦。一阳陷于二阴之中，二阴如果强盛，那么一阳必然衰败，阴邪才得以内侵，孤阳因此向外越脱。腹泻排出未消化的食物，手脚厥冷，脉象微弱几乎摸不到，是里阴极盛；身体反而不恶寒，面色反而发红，这是外部反热，格拒阳气于外。所以虽然有腹痛、干呕、咽痛等症状，也应当仿照白通汤的方法，在四逆汤中加入葱白，以消散阴邪，而恢复阳气。
【集注】程应旄说：热因寒格，无论腹痛、干呕、咽痛，都是腹泻中格阳的证候。即使腹泻停止，而脉搏仍然像以前一样，微弱欲绝不出，也不能说里寒已经退去，就胡乱治疗外部发热。必须遵循四逆汤的例子，在下部消除阴翳，只要加入葱白，宣通阳气于下焦，使阳气通达而脉搏复出，这才是真正的痊愈。
林澜说：格，是格拒的意思。也叫“隔阳”，是阴阳隔离。又叫“戴阳”，浮于上部如同戴帽子一样。真寒入里，阴气没有不强盛的。然而严重起来，不过是阳愈微阴愈盛罢了！
Cold pathogen also belongs to Yin. When two Yins combine and bias towards the lower jiao causing diarrhea, it cuts off communication with Yang Qi, making it unable to penetrate. The power of Ganjiang (Dried Ginger) and Fuzi (Prepared Aconite Root), although capable of tonifying Yang, cannot ensure that True Yang Qi necessarily enters the Yin. Only Congbai (Scallion White), with its pungent flavor, can unblock Yang Qi, allowing Yin to receive Yang's warmth to stop diarrhea, thus potentially leading to recovery. Generally, Great Pungent and Great Hot medicines merely borrow their power to benefit human Yang Qi; without a means to unblock them so that True Yang Qi can harmonize and gather, how can they be of any help?
Shaoyin disease presenting with diarrhea and a faint pulse should be treated with Baitong Tang (White Pass Decoction). If diarrhea persists after administration, accompanied by cold extremities, absence of pulse, dry retching, and irritability, Baitong Jia Zhuzhi Tang (White Pass Decoction with Pig Bile) is the primary treatment. If the pulse suddenly bursts forth (floating and rootless) after taking the decoction, the prognosis is fatal; if the pulse gradually and weakly resumes, the prognosis is favorable for survival.
[Annotation] This section elaborates on the pulse condition from the previous paragraph to clarify the meaning of disease progression. In Shaoyin disease with diarrhea and a faint pulse, administering Baitong Tang should stop the diarrhea. Now, however, the diarrhea persists, turning into cold extremities and absent pulse, further adding dry retching and irritability. This indicates extreme excess of Yin-Cold and a pattern where Yang is rejected and about to collapse. If one solely uses hot medicines to treat cold, the severe cold will inevitably reject the medicine, preventing it from entering. Therefore, adding the Yin substances of Renao (Human Urine) and Zhuzhi (Pig Bile) to the previous formula guides the Yang-tonifying drugs into the Yin. As the Classics state: "Treat contrary conditions by following their nature." This refers to such cases. "Absent pulse" means the pulse feels as if it is about to cease upon palpation. After taking the medicine, re-palpating the pulse: if it suddenly bursts forth, like a flame rising high when a candle burns out, death ensues. If the pulse slowly and weakly resumes, it indicates the gradual return of True Yang, hence survival is possible. Thus, in the previous paragraph, using Baitong Tang immediately upon seeing diarrhea, before the pathology fully manifests, is indeed an excellent method.
[Collected Annotations] Cheng Zhi says: This discusses Yin-excess rejecting Yang, using bile to unblock Yin. Administering Baitong Tang should theoretically save the Yang. Now, however, diarrhea persists, progressing to cold extremities and absent pulse, meaning the Yin pathogen is even more unrestrained. Dry retching and irritability indicate that the Yang medicine remains in the diaphragm and cannot enter the Yin. This is not because the medicine is insufficient against the disease, but due to the lack of a guide. Adding the Yin-cold nature of human urine and pig bile can guide the warmth of Ginger and Aconite into the rejected cold to regulate the reversal. This is the method of "following treatment" from the *Neijing*.
Cheng Yingmao says: Pulse bursting forth leads to death because the rootless Yang suddenly bursts outward. Pulse resuming weakly leads to life because Yang gradually connects, and Yin accepts it.
Baitong Jia Zhuzhi Tang Formula
Congbai (Scallion White) - 4 stems
Ganjiang (Dried Ginger) - 1 liang
Fuzi (Raw, peeled, broken into 8 pieces, 1 piece)
Renao (Human Urine) - 5 he
Zhuzhi (Pig Bile) - 1 he
Take the above five ingredients, boil in 3 sheng of water until 1 sheng remains, remove the dregs; add the bile and urine, mix well, divide into two warm doses. If bile is unavailable, substitutes may be used.
[Formula Analysis] This formula is the previous Baitong Tang plus human urine and pig bile. Adding urine and bile follows their affinity (Yin nature). After swallowing, the cold nature dissipates, and the hot medicinal properties activate. The medication does not conflict with the condition but brings great benefit, thereby regulating the rejection between Yin and Yang energies and unblocking the upper and lower Yin-Yang.
Shaoyin disease presenting with a desire to vomit but inability to do so, mental restlessness, only wanting to sleep, and after five or six days, spontaneous diarrhea with thirst, belongs to Shaoyin. Due to deficiency, the patient seeks water to self-rescue. If the urine is white, the signs of Shaoyin disease are complete. Urine is white because of deficiency-cold in the Lower Jiao, which fails to control water metabolism, resulting in pale urine.
[Annotation] Shaoyin disease with desire to vomit but inability to do so, mental restlessness, only wanting to sleep, spontaneous diarrhea, and thirst after five or six days, belongs to transmitted pathogens in Shaoyin, representing a syndrome with both cold and heat elements. If this were Shaoyin Heat causing dryness and thirst, seeking water would result in red urine, indicating Shaoyin dryness failing to generate fluids and heat in the Lower Jiao. Now, however, the thirst from seeking water due to Shaoyin deficiency indicates Shaoyin deficiency-cold failing to transform fluids, with cold in the Lower Jiao. From this, we see that while Shaoyin signs are complete, thirst distinguishes between cold and heat etiologies.
[Collected Annotations] Cheng Wuji says: Desire to vomit but inability to do so, with mental restlessness, indicates exterior pathogens transmitting inward. If abdominal fullness and pain occur, it belongs to Taiyin; here, only wanting to sleep indicates Shaoyin. At five or six days, when pathogens transmit to Shaoyin, if diarrhea occurs without thirst, cold is in the Middle Jiao (Taiyin); here, diarrhea with thirst indicates cold in the Lower Jiao (Shaoyin). Kidney deficiency and dry water cause thirst for self-rescue. Lower Jiao deficiency-cold causes white urine. Diarrhea with thirst and white urine clearly indicates non-Interior-Heat.
Fang Youzhi says: This repeatedly clarifies to warn people not to mistake all irritability and thirst for Heat syndromes, leading to misdiagnosis.
Cheng Yingmao says: Irritability does not exclusively belong to Shaoyin, hence "only wanting to sleep" is pointed out; thirst does not exclusively belong to Shaoyin, hence "white urine" is pointed out. It concludes with Lower Jiao deficiency-cold, teaching that diseases above should be treated from below. The deficiency above without Yin to nourish stems from deficiency below without Yang to warm. Both "deficiencies" derive from "cold". Furthermore, vomiting/diarrhea with thirst resembles Zhu Ling Tang syndrome, distinguished by "only wanting to sleep". Also, Zhu Ling Tang presents with difficult urination and red urine; Bai Tou Weng Tang shares similar features, stating "due to heat, urine is not white".
Lin Lan says: Desire to vomit but inability, with irritability, indicates Yang deficiency rejecting upward. Only wanting to sleep, diarrhea, and white urine indicate deep Interior True Cold. Note that this thirst differs from thirst with dry mouth and tongue. If accompanied by abdominal fullness, constipation, and delirium, it should be treated as Yang pathogen transmitting inward. Since there is Interior deficiency with spontaneous diarrhea and white urine, the deficiency-cold is evident. Mentioning the Lower Jiao shows that since Yin is excessive below, Yang must be rejected above; one cannot mistakenly attack heat due to irritability and thirst!
Wang Hu says: Viewing the whole text, it resembles a Heat syndrome, but white urine reveals it is True Cold. The "only wanting to sleep" differs from Heat pathogens; sleep is not turbid/confused, and breathing is rapid and fine. Saying "belongs to Shaoyin" distinguishes it from non-Yang-pathogen thirst; this is thirst from internal fluid deficiency seeking self-rescue. Testing with cold water shows little intake. Careful observation of white urine confirms complete Shaoyin deficiency-cold, clearly not Heat pathogen.
Shen Mingzong says: This distinguishes Shaoyin deficiency-cold from apparent Heat syndromes. People know cold extremities indicate deficiency-cold, but few know white urine is the definitive sign.
Wu Renju says: Yangming disease with desire to vomit prevents sleep; Shaoyin disease features "only wanting to sleep", using this to distinguish excess-deficiency.
Shaoyin disease where food intake triggers immediate vomiting, with a sensation of nausea in the heart/chest desiring to vomit but unable to do so. In the early stage, with cold hands and feet and a string-tight (Xian) and slow (Chi) pulse, this is Excess in the Chest; purgation is contraindicated, emesis is indicated. If there is Cold-Fluid in the Diaphragm causing dry retching, emesis is contraindicated; warming is indicated, suitable for Sini Tang (Frigid Extremities Decoction).
[Note] "Wenwen" should likely be "Yunyun" (feeling nauseous/uneasy). Yunyun describes the state of vomiting fluid.
[Annotation] This continues the previous discussion on "desire to vomit but inability," differentiating pulses and symptoms to clarify treatment. Vomiting immediately after eating, with chest nausea desiring to vomit but unable, and persistent nausea, is not Shaoyin deficiency-cold vomiting, but Chest Cold-Excess vomiting. Hence, early-stage pulses are Xian (fluid) and Chi (cold). Cold extremities occur because Chest Yang is blocked by Cold-Fluid, unable to reach the limbs. Cold-Excess in the Chest requires upward expulsion (emesis); thus, purgation is forbidden. If there is Cold-Fluid in the Diaphragm causing only dry retching without material output, this is Shaoyin deficiency-cold fluid, not Chest Cold-Excess fluid; thus, emesis is forbidden, and urgent warming is required, suitable for Sini Tang or Lizhong Tang plus Dingxiang (Clove) and Wuzhuyu (Evodia Fruit).
[Collected Annotations] Cheng Zhi says: This discusses Shaoyin fluid-induced vomiting due to Kidney pathogen reversing upward, requiring warming, not emesis. Desire to vomit but inability is Yin pathogen reversing upward. If early in the disease, with cold (not cold extremities) and Xian-Chi (not Chen-Xi) pulses, it is Excess in the Chest, Cold still in the Exterior/Yang aspect, requiring emesis, not purgation. Emesis involves material output; retching does not. Differentiate these. If Diaphragm Cold-Fluid causes only dry retching, it is Yin-Cold reversing upward, requiring warming, not emesis. "Urgent warming" implies that without it, cold extremities and absent pulse will occur.
Cheng Yingmao says: Cold in the Chest prohibits purgation; being Excess, emesis unblocks Yang, so emesis acts as warming. If Diaphragm Cold-Fluid causes dry retching, deficiency-cold rises from below, trapping fluid in the Chest, which is ultimately not a Chest disease; directly warming the Lower Jiao with Sini Tang is sufficient.
Shaoyin disease with faint, thin, deep pulses, only wanting to lie down, sweating without irritability, and desire to vomit. By the fifth or sixth day, spontaneous diarrhea occurs, followed by irritability and inability to sleep; this is fatal.
[Annotation] This elucidates the previous point, detailing pulses and symptoms, explaining the consequences of failing to warm urgently. Faint, thin, deep pulses and wanting to lie down indicate Shaoyin Cold. Sweating without irritability indicates Shaoyin Yang Collapse. Desire to vomit indicates Yin-Cold pathogen reversing upward, necessitating urgent warming. Neglecting this, delaying to the fifth/sixth day, adding diarrhea, and then developing irritability and insomnia indicates Shaoyin Kidney True Yang disturbance and external collapse—a fatal syndrome. Even warming at this stage is futile.
[Collected Annotations] Fang Youzhi says: Faint, deep, thin pulses and wanting to lie down are Shaoyin fundamental disease. Sweating without feverish irritability indicates no Yang. Desire to vomit indicates meridian pathogens remain. Diarrhea indicates Zang disease progression. Irritability and insomnia indicate Yang about to collapse and restless disturbance.
Cheng Yingmao says: Modern physicians hesitate to use warming unless cold aversion, curled-up posture, and cold extremities appear, not realizing that once symptoms reach this stage, warming is already late. Moreover, some symptoms may never fully manifest. One should review the core principles: Shaoyin disease features sinking, faint, thin pulses—indicating a pulse suitable for warming. Wanting to lie down indicates a symptom suitable for warming. Sweating in Yang meridians prohibits warming, but in Shaoyin requires urgent warming due to Yang collapse. With non-irritability and desire to vomit (Yin reversal), Zhenwu Tang and Sini Tang are as precious as aged mugwort. Yet, failing to prepare and delaying allows the initial desire to vomit to become diarrhea; non-irritability becomes irritability/restlessness; wanting to sleep becomes inability to sleep. Yang deficiency with disturbance and increasing Yin excess inevitably leads to death.
Shaoyin disease persisting for two to three days, progressing to four to five days with abdominal pain, difficult urination, heavy/painful extremities, and spontaneous diarrhea, indicates Water-Qi retention. If the patient also has cough, or difficult urination, or diarrhea, or vomiting, Zhenwu Tang (True Warrior Decoction) is the primary treatment.
[Annotation] The Treatise states that Heart-Substratum Water-Qi with fever, sweating, irritability, thirst, and difficult urination belongs to Taiyang Wind-Strike, treated with Wuling San. Fever, no sweat, dry retching, no thirst, and difficult urination belong to Taiyang Cold-Strike, treated with Xiao Qinglong Tang. Now, Shaoyin disease persisting to four/five days with abdominal pain and diarrhea indicates deep Yin-Cold. If urination were normal, it would be pure Cold without Water-Qi, treated with Fuzi Tang. Now, with difficult urination, cough, or vomiting, it is Yin-Cold combined with Water-Qi. Thus, Cold-Water attacking the exterior causes heavy/painful extremities; accumulating internally causes abdominal pain/diarrhea; stagnating in Upper Jiao/Chest-Lungs causes cough/asthma/inability to lie down; stagnating in Middle Jiao/Stomach causes vomiting/diarrhea; stagnating in Lower Jiao/Bladder causes difficult urination/hypogastric fullness. All symptoms stem from Yin-Cold Water. Wuling San is excluded as it treats Exterior-Heat fluid; Xiao Qinglong Tang is excluded as it treats Exterior-Cold fluid. Thus, Zhenwu Tang is used to warm Cold and control Water.
[Collected Annotations] Yu Chang says: In the Taiyang chapter, cold extremities, muscle twitching, and Yang collapse used Zhenwu Tang. Here, Shaoyin Water-Dampness reversing upward also uses Zhenwu Tang to suppress it. This shows Taiyang Bladder and Shaoyin Kidney, one Fu and one Zang, both govern Cold-Water. Fu pathogens are Yang pathogens, utilizing Ma Huang/Gui Zhi for Qinglong Tang; Zang pathogens are Yin pathogens, utilizing Fu Zi for Zhenwu Tang.
Zhenwu Tang Formula
Fuling (Poria) - 3 liang
Shaoyao (Peony Root) - 3 liang
Shengjiang (Fresh Ginger, sliced) - 3 liang
Baizhu (Atractylodes Macrocephala Rhizome) - 2 liang
Fuzi (Prepared Aconite Root, processed, peeled, broken into 8 pieces) - 1 piece
Boil the above five ingredients in 8 sheng of water until 3 sheng remain, remove dregs, warm dose of 7 he, three times daily.
If coughing, add Wuweizi (Schisandra Berry) 0.5 sheng, Xixin (Asarum) and Ganjiang (Dried Ginger) 1 liang each. If urination is free, remove Fuling. If diarrhea, remove Shaoyao, add Ganjiang 2 liang. If vomiting, remove Fuzi, increase Shengjiang to total half jin.
[Formula Analysis] Xiao Qinglong Tang treats Exterior unresolved with Water-Qi, Cold-Excess internally and externally. Zhenwu Tang treats Exterior resolved with Water-Qi, Cold-Deficiency internally and externally. "Zhenwu" is the Northern deity governing water; naming the decoction after him signifies relying on his power to suppress water. The Spleen controls water in the body; the Kidney masters water. The Kidney is the gate of the Stomach, gathering water according to its kind. If Kidney lacks Yang, Spleen transport functions虽 operate, the Kidney gate remains closed; water cannot flow freely without a master, leading to overflow and these symptoms. Fuzi's pungent-hot nature strengthens Kidney Yuan Yang, giving water a master. Baizhu's bitter-dry nature establishes Central Earth, controlling water. Shengjiang's pungent-dispersing nature assists Fuzi in tonifying Yang and dispersing water within warmth. Fuling's bland-draining nature assists Baizhu in strengthening Earth and draining water. Particularly ingenious is Shaoyao's sour-astringent nature added to water-controlling/mastering herbs: first, to drain water preventing "son stealing mother's deficiency" and avoiding reckless flow; second, to astringe Yang returning it to Yin, preventing flight. Who says cold-yin herbs benefit no Yang? Ignorant people misunderstand the principle of control/subjugation. The Treatise notes误using Qinglong Tang causing sweating and Yang collapse, treated with this decoction, for the same reason. Reducing Shaoyao for diarrhea is because Yang does not scatter externally; adding Ganjiang warms the Middle to overcome cold. Water-cold injuring Lung causes cough; adding Xixin/Ganjiang disperses water-cold. Adding Wuweizi collects Lung Qi. Removing Fuling when urination is free is because although cold, water does not stagnate. For vomiting, removing Fuzi and doubling Shengjiang is because the disease is not in the Lower Jiao, but water stagnates in the Stomach. Thus, warming Kidney to move water is unnecessary; warming Stomach to disperse water is key. Shengjiang aids in stopping vomiting.
[Collected Exegesis] Cheng Zhi says: Baitong, Tongmai, and Zhenwu are all set for Shaoyin diarrhea. Baitong formulas use raw Fuzi; Zhenwu uses processed Fuzi. Raw Fuzi warms meridians and dispels cold; processed Fuzi warms the Middle and removes fluid. Baitong formulas prioritize unblocking Yang; Zhenwu prioritizes tonifying Yang, hence dosage differences. Ganjiang assists raw Fuzi to warm meridians; Shengjiang assists processed Fuzi to disperse fluid.
Zhang Lu says: Zhenwu Tang originally treats Shaoyin disease with internal water-fluid accumulation, prioritizing Baizhu/Fuzi with Fuling/Shengjiang for Spleen transport and fluid drainage, which is obvious. The subtle use of Shaoyao is unique to Zhang Zhongjing. Although called Shaoyin fundamental disease, it is actually due to internal water accumulation causing abdominal pain, diarrhea, heavy painful extremities, and paradoxically difficult urination. In extreme deficiency-cold, urine would be clear/white and uncontrollable, not difficult. This syndrome involves not only Yuan Yang deficiency but also inherent True Yin deficiency or latent Yang pathogen within Yin. Without Shaoyao to protect Yin, how can one withstand the fierce nature of Fuzi?
Patients with significant body heat who nevertheless desire clothing have Heat in the Skin (superficial) and Cold in the Marrow (deep). Patients with significant body cold who do not desire proximity to clothing have Cold in the Skin (superficial) and Heat in the Marrow (deep).
[Annotation] The body is Exterior, Zang-Fu are Interior; this divides Exterior/Interior by inside/outside. Skin is Exterior, Marrow is Interior; Six Fu are Exterior, Five Zang are Interior; this divides Exterior/Interior by bodily depth and Zang-Fu Yin-Yang. "Patient" refers to the ill person. "Significant body heat" means whole-body internal/external heat, a Three-Yang syndrome. Desiring to wear clothes indicates False Heat; although superficial in the skin, True Cold is deep in the marrow, representing Extreme Yin resembling Yang. "Significant body cold" means whole-body internal/external cold, a Three-Yin syndrome. Not desiring clothing indicates False Cold; although superficial in the skin, True Heat is deep in the marrow, representing Extreme Yang resembling Yin.
[Note] This determines the true/false nature of Cold/Heat based on patient preferences to establish Yin-Yang syndromes. Refer to Shaoyin/Jueyin chapters regarding Exterior-Heat/Interior-Cold, Interior-Heat/Exterior-Cold, slippery pulse with cold extremities, cold aversion without desire for clothing, dry mouth/throat, etc.
[Collected Annotations] Cheng Wuji says: Skin denotes shallow/exterior; Marrow denotes deep/interior. Body heat desiring clothing is Exterior-Heat Interior-Cold; body cold not desiring clothing is Exterior-Cold Interior-Heat. Generally, Exterior-Heat Interior-Cold presents with sinking-slow pulse; Interior-Heat Exterior-Cold presents with slippery-rapid pulse. Must differentiate.
Zheng Zhongguang says: Skin is outside Marrow, superficial layer; Marrow is inside Skin, deep layer. Desiring clothing borrows external warmth to resist internal cold, indicating True Cold. Body discomfort regardless of clothing thickness indicates False Cold. Without observing patient preference, how can one gauge True Cold/Heat to determine root/accompaniment?
Shaoyin disease with diarrhea of undigested food, Interior-Cold Exterior-Heat, cold extremities, faint pulse nearly imperceptible, body not feeling cold, facial redness, or abdominal pain, or dry retching, or sore throat, or cessation of diarrhea with absent pulse, should be treated with Tongmai Sini Tang (Pulse-Restoring Frigid Extremities Decoction).
[Annotation] Shaoyin corresponds to Kidney, symbolized by Kan (Water). One Yang trapped within two Yins: if Yin excesses, Yang declines, allowing Yin pathogen to invade internally, causing solitary Yang to escape externally. Diarrhea of undigested food, cold extremities, faint pulse nearly absent indicate extreme Interior Yin excess. Body not feeling cold, facial redness, external heat indicate Yang rejected externally. Thus, despite abdominal pain, dry retching, sore throat, follow Baitong Tang method: add Congbai (Scallion White) to Sini Tang to dissipate Yin and restore Yang.
[Collected Annotations] Cheng Yingmao says: Heat rejected by Cold, whether abdominal pain, dry retching, or sore throat, are all Yang-rejection syndromes during diarrhea. Even if diarrhea stops but pulse remains faint/near-absent, do not assume Interior-Cold has retreated and blindly treat external heat. Follow Sini Tang example: eliminate Yin shadows in the Lower Jiao, add Congbai to vent Yang Qi in the Lower Jiao, allowing Yang to connect and pulse to emerge, achieving true recovery.
Lin Lan says: "Ge" means rejection. Also called "Ge Yang" (Separated Yang), meaning Yin-Yang isolation. Also called "Dai Yang" (Crowning Yang), floating upwards like a crown. True Cold entering the interior invariably leads to Yin excess. Severe cases simply mean Yang becomes weaker and Yin stronger.
Tongmai Sini Tang Formula