治吐以下断。汗出而厥。四肢拘急。脉微欲绝者。此汤主之。
通脉四逆原方加猪胆汁（四合。）通脉四逆汤煎成。内猪胆汁。分温再服。其脉即出。
歌曰 生附一枚三两姜。炙甘二两玉函方。（此遵宋本金匮玉函经。坊刻伤寒论甘草三
两炙。）脉微内竭（吐以下断。津液竭于内也。四肢拘急。津液竭于内而不荣乎外也。）资真
汁。（经
汁止半合。）
蔚按。论云。吐以下断者。言阴阳气血俱虚。水谷俱竭。无有可吐而自已。无有可下而
自断也。曰汗出而厥脉微欲绝者。无阳气以主之也。曰四肢拘急者。无津液以养之也。此际
若用四逆汤姜、附之温。未尝不可以回阳。倍用甘草之甘。未尝不可以滋阴。然犹恐其缓而
无济也。若用通脉四逆汤。倍干姜之勇。似可追返元阳。然犹恐大吐大利之余。骤投大辛之
味。内而津液愈涸。外而筋脉愈挛。顷刻死矣。师于万死中觅一生路。取通脉四逆汤以回其
厥。以止其汗。更佐以猪胆生调。取生气俱在。苦先入心而脉复。以汁补中焦之汁。灌溉于
筋则拘急解。辛甘与苦甘相济。斯阴阳二气。顷刻调和。即四逆加人参汤之意。但人参亦无
情之草根。不如猪胆汁之异类有情。生调得其生气。为效倍神也。诸家囿于白通加法。谓格
阳不入。借苦寒以从治之。堪发一笑。按古本只加胆汁。无人尿。张隐庵注有人尿。必有所
本。读其注文。极有见解。张隐庵云。此节重言。以结上文两节之意。上两节皆主四逆汤。
此
内竭。
所谓脉微欲绝之脉。依然如故。此为阴阳血气皆虚。更宜通脉四逆加猪胆汁汤主之。通脉四
逆汤解见少阴篇。加水畜之甲胆。乃起肾脏之精汁上资心主之血。更加人尿。乃引膀胱之津
液还入胃中。取精汁内滋而血气调和之意。盖风雨寒暑之邪直入中焦。皆为霍乱。若吐利太
过。而生气内伤。手足厥冷。脉微欲绝。皆宜四逆汤主之。无分寒与暑也。何也。正气受伤。
止救
药亦愈。即阴阳汤、黄土汤。皆能疗之。若霍乱里虚。古圣止立四逆、理中二方。为急救正
气之法。有谓藿香正气散治暑霍乱者。亦非也。愚每见暑月病霍乱。四肢逆冷无脉而死。藿
香正气。不过宽胸解表之剂。恶能治之。况夏月元气发泄在外。中气大虚。外邪卒至。救正
犹迟。况疏散之剂乎。夫邪正相搏。有风雨寒暑之分。正受邪伤。止论正气之虚实。入脏即
为不治之死证。非风暑为阳而寒雨为阴也。此为霍乱之大纲。学人宜服膺而勿失。 高子曰。
霍
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。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。
治疗呕吐与下利停止后，出现汗出且四肢厥冷、四肢拘挛紧急、脉搏微弱似有若无的症状。此证由通脉四逆加猪胆汁汤主治。
在通脉四逆汤原方基础上加入猪胆汁（四合）。将通脉四逆汤煎煮完成后，纳入猪胆汁，分两次温服。服药后脉搏即可恢复。
歌诀曰：生附子一枚重三两，干姜二两，炙甘草二两（依据《宋版金匮玉函经》，坊间刻本《伤寒论》中甘草为三两并炙）。脉象微弱说明体内津液枯竭（呕吐与下利停止，是因为体内津液已竭；四肢拘挛紧急，是因为体内津液枯竭无法濡养体表）。需借助真阴之汁（经文中“汁”仅指半合，此处指猪胆汁）。
蔚按（作者评论）：《伤寒论》中说“呕吐与下利停止”，是指阴阳气血俱虚，水谷精微皆已耗尽，没有东西可吐而自然停止，也没有东西可下而自然断绝。说“汗出且四肢厥冷、脉搏微弱似有若无”，是因为没有阳气来主持固摄。说“四肢拘挛紧急”，是因为没有津液来滋养筋脉。在此危急时刻，若使用四逆汤中的干姜、附子的温热之性，未尝不能回阳救逆；加倍使用甘草的甘缓之性，未尝不能滋阴。然而仍担心药力迟缓而无济于事。若使用通脉四逆汤，重用干姜的辛热之性，似乎可以追回元阳。但仍担心在大吐大泻之后，骤然投以大辛大热的药物，会导致内部津液更加枯竭，外部筋脉更加痉挛，患者顷刻间就会死亡。张仲景于万死之中寻找一线生机，取通脉四逆汤以回阳救逆、止汗，更佐以猪胆汁生调服用。取猪胆具有生气，苦味先入心而有助于脉复，用汁液补充中焦的津液，灌溉于筋脉则拘急得以缓解。辛甘与苦甘相互济助，使得阴阳二气在顷刻间调和。这也就是四逆加人参汤的意思。但人参不过是无情的草根，不如猪胆汁属于异类有情之物。生调得其生气，疗效倍增神奇。各家受白通加猪胆汁汤成见的影响，认为格阳不入，借苦寒以从治（反佐），实在令人发笑。按古本只加胆汁，无人尿。张隐庵注中有提到人尿，必定有所本。读他的注文，极有见解。张隐庵说：这一节是重言，用来总结上文两节的意旨。上两节都主用四逆汤，这里提到“内竭”，所谓“脉搏微弱似有若无”的脉象，依然如故。这是阴阳血气皆虚，更宜用通脉四逆加猪胆汁汤主治。通脉四逆汤的解释见少阴篇。加入水畜（肾）的甲胆（猪胆），乃是起肾脏之精汁上资心主之血；再加人尿，乃是引膀胱之津液还入胃中，取精汁内滋而血气调和之意。大概风雨寒暑之邪直入中焦，都会导致霍乱。如果吐利太过，导致生气内伤，手足厥冷，脉搏微弱似有若无，都适宜用四逆汤主治，不分寒邪与暑邪。为什么呢？正气受伤，只需救助正气，药到病除。即如阴阳汤、黄土汤，都能治疗。如果是霍乱里虚，古代圣人只设立四逆汤、理中汤两个方剂，作为急救正气的法则。有人说藿香正气散治疗暑天霍乱，也不对。我常见夏天患霍乱的人，四肢逆冷无脉而死，藿香正气散不过是宽胸解表的药剂，怎么能治疗呢？况且夏月元气发泄在外，中气大虚，外邪突然来袭，救助正气尚且嫌迟，何况是疏散的药剂呢？邪正相搏，有风雨寒暑之分，正气受邪损伤，只讨论正气的虚实，邪气入脏即为不治的死证，并非风暑属阳而寒雨属阴。这是霍乱的总纲，学习者应当铭记勿失。高子说：霍乱用到猪胆汁、人尿，是因为津液枯竭而阴血并虚，不应当只助其阳，更应当滋益其阴。我常见夏天霍乱的病症，四肢厥逆，脉搏微弱似有若无，投用理中汤、四逆汤，不能取效，反而用少许明矾和凉水服用即愈。这也符合猪胆汁、人尿的意思。先贤立法，可谓周全详明矣。
It treats cases where vomiting and diarrhea have ceased, yet sweating occurs accompanied by cold limbs (limbs cold to the touch), tetanic stiffness of the four limbs, and a faint pulse nearly imperceptible. This decoction is indicated.
To the original formula of Tongmai Sini Decoction (Pulse-Reviving Cold-Limb Decoction), add pig bile (4 he). After decocting Tongmai Sini Decoction, incorporate the pig bile. Divide into two doses and take warm. The pulse will then emerge.
The song states: One raw Fuzi (Aconiti Lateralis Radix Praeparata) weighing three liang, two liang of Ganjiang (Zingiberis Rhizoma), two liang of Zhigancao (Glycyrrhizae Radix et Rhizoma Praeparata cum Melle) [This follows the Song edition of *Jinkui Yufan Jing*; commercial editions of *Shanghan Lun* state three liang of Gancao roasted with honey]. A faint pulse indicates internal exhaustion [Vomiting and diarrhea ceasing means fluids are exhausted internally; tetanic stiffness means fluids are exhausted internally and cannot nourish the exterior]. Rely on the true fluid [The text mentions "fluid" as only half a he; here referring to pig bile].
Commentary by Wei: The Treatise says "vomiting and diarrhea cease," meaning both Yin and Yang, Qi and Blood are deficient, and water and grain essences are exhausted, so there is nothing left to vomit or purge naturally. It says "sweating and cold limbs with a faint pulse nearly imperceptible," indicating a lack of Yang Qi to govern and secure. It says "tetanic stiffness of the four limbs," indicating a lack of Jin-Ye (Body Fluids) to nourish. At this critical juncture, if one uses the warming properties of Ganjiang and Fuzi in Sini Decoction (Cold-Limb Decoction), it might not fail to restore Yang. If one doubles the sweet nature of Gancao, it might not fail to nourish Yin. However, there is still fear that the action would be too slow to be effective. If one uses Tongmai Sini Decoction, doubling the potency of Ganjiang, it seems capable of retrieving primal Yang. Yet, there remains concern that after severe vomiting and diarrhea, suddenly administering large amounts of acrid-hot substances would cause internal fluids to dry up further and external sinews and vessels to spasm more intensely, leading to death within moments. The Master sought a path to life amidst ten thousand deaths, taking Tongmai Sini Decoction to reverse cold limbs and stop sweating, assisted by pig bile mixed raw. Taking advantage of its vital energy, the bitter taste enters the Heart first to restore the pulse, and the fluid replenishes the middle Jiao's fluids, irrigating the sinews so stiffness resolves. Acrid-sweet and bitter-sweet mutually assist each other, harmonizing Yin and Yang Qi within moments. This is essentially the intent of Sini Jia Renshen Tang (Sini Decoction plus Ginseng Decoction). However, Renshen (Ginseng Radix) is merely an insensate root, unlike pig bile which belongs to a different species and possesses vital energy. Mixed raw to obtain its vital energy, its efficacy is doubly miraculous. Various schools, constrained by the precedent of Baitong Jia Zhuyedan Tang (Baitong Decoction plus Pig Bile and Human Urine Decoction), claim that due to Yang repulsion preventing entry, bitter-cold is borrowed for counter-treatment (antidotal therapy). This is laughable. According to ancient texts, only bile is added, without human urine. Zhang Yinan's commentary includes human urine, likely based on some source. Reading his commentary reveals profound insight. Zhang Yinan stated: This section repeats the statement to conclude the meaning of the previous two sections. The previous two sections both primarily used Sini Decoction. Here, mentioning "internal exhaustion," the so-called "faint pulse nearly imperceptible" remains unchanged. This indicates deficiency of Yin, Yang, Blood, and Qi, making Tongmai Sini Jia Zhuyedan Tang the appropriate treatment. The explanation of Tongmai Sini Decoction is found in the Shaoyin Chapter. Adding the gallbladder of the Water Element animal (pig), which is the Jia Gallbladder, initiates the essence fluid of the Kidney to nourish the Blood of the Heart Master. Additionally, adding human urine draws the fluid from the Bladder back into the Stomach, aiming for internal nourishment by essence fluid and harmony of Blood and Qi. Generally, pathogens of wind, rain, cold, and heat directly entering the Middle Jiao all result in Huoluan (Cholera-like disease). If vomiting and purging are excessive, damaging vital Qi internally, causing cold hands and feet and a faint pulse nearly imperceptible, Sini Decoction should be used regardless of whether the pathogen is cold or heat. Why? Because when Zheng Qi (Upright Qi) is injured, one need only rescue Zheng Qi, and the illness will heal. Even Yin-Yang Tang or Huangtu Tang can treat it. If Huoluan involves interior deficiency, the ancient sages established only two formulas, Sini Tang and Lizhong Tang, as methods for emergency rescue of Zheng Qi. Some say Huoxiang Zhengqi San (Agastache Powder to Regulate the Qi and Rectify the Middle) treats summerheat Huoluan; this is incorrect. I often see patients dying of Huoluan in summer with cold limbs and no pulse. Huoxiang Zhengqi San is merely a formula to broaden the chest and release the exterior; how can it treat this? Moreover, in summer, Yuan Qi (Primal Qi) dissipates outward, leaving the Middle Qi greatly deficient. When external pathogens strike suddenly, rescuing Zheng Qi is already late enough, let alone using dispersing agents. When pathogens and Zheng Qi contend, there are distinctions among wind, rain, cold, and heat. When Zheng Qi is injured by pathogens, one only discusses the deficiency or excess of Zheng Qi. Entering the Zang organs constitutes an untreatable fatal syndrome; it is not that wind and summerheat are Yang while cold and rain are Yin. This is the general principle of Huoluan. Students should keep it firmly in mind and not lose it. Gao Zi said: In Huoluan, the use of pig bile and human urine implies that since Jin-Ye are exhausted and Yin Blood is simultaneously deficient, one should not merely assist Yang but also nourish and benefit Yin. I often see cases of summer Huoluan with cold limbs and a faint pulse nearly imperceptible. Administering Lizhong Tang or Sini Tang fails to produce results, whereas administering a small amount of Mingfan (Alumen) mixed with cool water cures them immediately. This aligns with the intent of pig bile and human urine. The legislation of the sages was indeed comprehensive and detailed.