【纲】仲景曰。若阳明胃实。发热恶寒。脉浮紧。下之者。则腹满小便难也。
【目】王肯堂曰。胁痛身黄小便难。若阳明胃实未下者。小柴胡汤。若下后不食项强者。忌柴
胡。
鳌按。三阳皆有小便不利症。不独太阳也。如少阳伤寒。五六日中风。往来寒热。心烦胁痛。
或心下悸。而小便不利者。仲景则主小柴胡汤。若五六日已汗复下。胁满微结。渴而不呕。但头汗
出。心烦。往来寒热。为未解。而小便不利者。仲景又主柴胡桂姜汤。若八九日下之。烦惊。谵语
身重。而小便不利者。仲景又主柴胡加龙骨牡蛎汤也。
【纲】仲景曰。伤寒脉弦细。头痛。发热者。属少阳。少阳不可发汗。发汗则谵语。此属胃。
胃和则愈。胃不和。则烦而躁。
【目】朱肱曰。足少阳胆经之脉。起目外 。络于耳。遂分为四道。下缺盆。循于胁。并正别
脉六道上下。主经营百节。流气三部。故病患胸胁痛而耳聋。或口苦咽干。或往来寒热而呕。其脉尺
寸俱弦者。知少阳经受病也。
少阳受病。口苦咽干目眩。宜小柴胡汤以解表。不可发汗。发汗则谵语。谵语属胃。胃和则愈。
胃不和则烦而躁。宜调胃承气汤。此属少阳阳明也。脉细头疼。呕而发热者。属少阳也。小柴胡
汤。病患不渴。外有微热者。小柴胡加桂枝也。夫小柴胡加桂。主表热最良。不特伤寒也。仲景云。
表有热者。小柴胡加桂也。里有热者。白虎加人参也。大抵身热不饮水者。为表热。口燥烦渴
者。为里热。二药均治发热。然分表里焉。
王好古曰。辨表里中三说。假令少阳症。头痛。往来寒热。脉浮。此三症但有其一。即为表也。
口失滋味。腹中不和。大小便或秘而不通。或泄而不调。但有其一。即为里也。如无上下表里症。
余皆虚热也。是病在其中矣。
张元素曰。少阳胆经。萦迂盘曲。多于各经。乃少阳篇中症治至简。又不闻何药为本经正法。
何也。夫经络所据。太阳在后。为表。阳明在前。为里。少阳在侧。夹于表里之间。故曰半表半里。治
法。表宜汗。里宜下。既居两间。非汗下所宜。故治疗无正法。经云。少阳不可发汗。发汗则谵语。
又曰。不可吐下。吐下则惊而悸。则汗吐下三法。皆少阳所忌。其剂不过和解而已。所以仲景止
用小柴胡至当也。然而经络未别。虽多所行非由正道。（少阳所以病少之故）故为病亦不多也。
喻昌曰。少阳伤寒。禁汗。少阳中风。禁吐下。二义互举。其旨益严。盖伤寒之头痛发热。似
宜发汗者。尚不可汗。则伤风
之不可汗。不待言矣。中风之胸满而烦。痰饮上逆。似宜可吐下者。尚不可吐下。则伤寒之不可吐
下。更不待言矣。脉弦细者。邪欲入里。在胃之津液必为热耗。重复发汗。而驱其液于外出。安得
不谵语乎。胃和者。邪散而津回。不和者。津枯而饮结。所以烦而悸也（他条曰。少阳中风。两耳
无所闻。目赤。胸中满而烦者。不可吐下。吐下则悸而惊。）
鳌按。洁古以少阳不可汗吐下。谓治疗无正法。此盖其语病也。特其意义犹未乖耳。盖病在太
阳之表。固以汗为正法。病在阳明之里。又以下为正法。症在太阳阳明可上越者。更以吐为正法。
今症在半表半里之间。既不可汗吐下。因设立小柴胡和解法。有和法。则无须于下而自泄。有解法。
则无须于汗而自达。有和且解法。则无须于吐而自升。是汗为太阳正法。下为阳明正法。吐为太
阳阳明俱用之正法者。和解即少阳之正法。而小柴胡汤。即治疗少阳正法之药也。岂必以汗吐下方
为正法。而舍汗吐下之外。和解即非正法乎。甚矣其语之为病也。
弦。直也。直而细。是木初生之象。故弦细之脉属少阳。得是脉而但见头疼发热。无太阳脉症
者。盒饭从少阳而以和解为法。不可作太阳治也。
【纲】仲景曰。伤寒阳脉涩。阴脉弦。法当腹中急痛。先用建中汤。不瘥者。小柴胡汤主之。
【目】魏荔彤曰。阳脉以虚而反见涩。阴脉以寒而独见弦。是阳微而阴盛之诊。若执一以用小
柴胡。恐半表者以虚。而不能越于外。半里者以寒。而更且陷下。故当其症见腹中急痛。虽属少阳
病。或中之一症。亦且不治其表。里急治其里虚。仲师示人先用小建中以奠安内虚。助其生胃阳。
使小柴胡之力。有所凭借。然后能上升下降。指挥如意。所以服建中汤后。少阳病不瘥。仍与小柴
胡汤主之。法无改图。而道有先后。亦即太阳阳明诸篇里虚先治里之义。
柯琴曰。尺寸俱弦。少阳受病也。今阳涩阴弦。是寒伤厥阴而不在少阳矣。寸为阳。阳主表。
涩者。阳气不舒。表寒不解。弦为木邪。必挟相火。相火不能御寒。必还入厥阴而为患。厥阴脉抵少
腹。挟胃。属肝。络胆。则腹中皆厥阴部也。尺为
阴。阴主里。弦者。为肝脉。必当腹中急痛矣。肝苦急。甘缓酸泻辛散。此小建中为厥阴驱寒发表。
平肝逐邪之。先着也。岂漫用着哉。
鳌按。魏柯二家之说不同。柏乡专主虚寒。谓与太阳阳明诸症。同一里虚先治里之义。固非无
识。而韵伯据腹中急痛。特揭寒伤厥阴。不在少阳。更为眼明手捷。且少阳厥阴相表里。但病而伤及
肝。亦里之常。况脉阳反涩而阴独弦。其非专属少阳受病。而尺寸俱弦者可比矣。且两说虽异。而
理不悖。故并存之。阅者互参可也。
【纲】仲景曰。伤寒五六日。头汗出。微恶寒。手足冷。心下满。口不欲食。大便硬。脉沉细
者。此为阳微结。必有表复有里也。脉沉亦在里也。汗出为阳微结。假令纯阴结。不得复有外症。
悉入在里矣。此为半在表半在里也。脉虽沉紧。不得为少阴病。所以然者。阴不得有汗。今头汗出。
故知非少阴也。可与小柴胡汤。设不了了者。得屎而解。
【目】朱肱曰。假令病患心下满。口不欲食。大便硬。脉沉细。是里症当下。其人头汗出。微
恶寒。手足冷。却当汗。此两症俱见者。仲景所谓半在表半在里也。小柴胡汤主之。
魏荔彤曰。有太阳阳明。二阳为病。但见少阳脉。即当从少阳法治者。尤不可不辨明其阴阳虚
实。而妄为汗下与温补也。得屎而解有二义。如其不了了。旋复自能得屎。则不了了者亦了了矣。
此一义也。如不了了。而阳明之里已有燥屎。因用大柴胡兼调胃承气荡涤之。则浊降清升。不了了
者始得了了。此又一义也。
【纲】仲景曰。得病六七日。脉迟浮弱。恶风寒。手足温。医二三下之。不能食。而胁下满痛。
面目及身黄。颈项强。小便难者。与柴胡汤。后必下重。本渴。而饮水呕。食谷哕者。柴胡不中
与也。
【目】柯琴曰。浮弱为桂枝脉。恶风寒为桂枝症。然手足温而身不热。脉迟为寒。为无阳。为
在脏。是表里虚寒也。法当温中散寒。而反二三下之。故成太阳中风之坏病。非柴胡症矣。
【纲】仲景曰。本太阳病不解。转入少阳者。胁下硬满。干呕。不能食。往来寒热。尚未吐下。
脉弦细者。与小柴胡汤。若已吐下。发汗。温针。谵语。柴胡症罢。此为坏病。知犯何逆。以法
治之。
【目】朱肱曰。太阳病不解。转入少阳云云。以小柴胡主之者。盖脉弦细头痛发热。属少阳也。
方中行曰。坏病之成。不必若吐若下若温针。一误再误三误。方谓之坏病。但应与而不与。不
应与而与。以致病变他症者。皆坏病也。即屡误至再至三。而病未尝变。虽误又何尝坏乎。仍以
本症之法治之。治其误。而坏痞亦同法也。所以名之为坏者。由于误。误必救之。救其逆而反于顺
也。故坏病不必论其重轻。视其本病。及误坏之治。各有轻重焉。治法亦救其可救。不必震于坏误
之名。遂束手也。不能救其不可救者。固以前医药之咎。然人生有命。正于此可参观矣。
【纲】仲景曰。阳明少阳合病。必自下利。其脉不负者。顺也。负者。失也。互相克贼。名为
负。少阳负趺阳者。为顺也。
【目】魏荔彤曰。仲师他处但言逆顺。此独言胜负者。知其胜负。而后可言顺逆也。又独言失
而不言得。以顺逆之故明。而得失了然矣。请申互相克贼之义。此得失顺逆之大关乎。胃之本为阳
土。标为燥金。能腐化水谷。燥金之气。为用大矣。今使少阳相火乘之。则金气柔而不刚。乌能熟
化水谷。且有湿腻粘滞之物。乌得不留停。故人知胃土。受木克贼者多。而知燥金受相火克贼者甚
少。故特明曰。互相克贼。示人切矣。况胃。阳土也。虽津液与水谷相溷于内。然实以津液消水谷。
而又以水谷化津液。以消即为化。以化即为消。其理微妙。苟非燥金之气流动充满。何以为消化乎。是此金气。即天一
至清之气。又与津液相附而不相杂。如在天之气。在地之气。共一理也。有时此金气为正气而生津液。有时此金气为寒
燥反耗津液。此理至幻而至常。非知此。何以明阳明胃土为本燥金为用乎。再者。脾与胃
表里。固为输运之专司。但终在胃外斡旋。其燥金之气则流行胃中。而主消化之权者。何容有负而
致败乎。学人于
六经标本。由此推详得解。庶可言医也。夫胜负之机如用兵。然必养之裕。培之浓。斯有胜无负。
若不培养。必至负也。非借外援以相救。则另攻其要害。使之自退而已。小柴胡之用。攻木之要害。
使自退也。用黄芩借外救以苏燥金之气也。
危亦林曰。两阳合病者。其脉必兼见两阳也。阳明之脉大。少阳之脉弦。此顺脉也。若但大而
不弦。则少阳负矣。但弦而不大。则阳明负矣。皆不顺之脉。所谓互相克贼也。然木克土。是少阳
为贼邪。若少阳负而阳明不负。亦负中之顺脉也。此不可不知。
【纲】仲景曰。太阳与少阳并病。脉弦。头项强痛。或眩冒。时如结胸。心下痞硬者。当刺大
椎第一间。肺俞肝俞。慎不可发汗。发汗则谵语。脉弦。五六日谵语不止。当刺期门。
【目】魏荔彤曰。考穴图。大椎为督脉之穴。居身后。肺肝俞。俱属膀胱之穴。亦次第由大椎
而下。同居于背。是皆太阳行身后之道路也。于此三刺。皆泄太阳经表邪。而于肺肝膀胱之脏腑无
涉。诸家牵附。总由不知刺三穴。泄经邪之义耳。
李时珍曰。脉弦为少阳。头项强痛为太阳。眩冒结胸心下痞。则两阳皆有也。
【纲】仲景曰。伤寒三日。少阳脉小者。欲已也。
【目】喻昌曰。脉不弦大。邪微欲解之先征也。
魏荔彤曰。少阳之脉本木形。因邪在而增助其弦长。今邪渐欲已。故脉见小弱。正为邪退之象。
不可误以为正虚脉微。妄为温补也。
【纲】张仲景说：如果是阳明胃腑实证，出现发热、恶寒、脉象浮紧的症状，如果误用泻下法，就会导致腹部胀满、小便困难。
【目】王肯堂说：胁痛、身黄、小便困难，如果是阳明胃实证尚未使用泻下法的，用小柴胡汤治疗。如果是泻下后出现不能进食、项部强直的，忌用柴胡剂。
沈金鳌按语：三阳经（太阳、阳明、少阳）都有小便不利的症状，不仅仅局限于太阳经。例如少阳伤寒，发病五六天或中风后，出现往来寒热、心烦、胁痛，或者心下悸动而小便不利的，张仲景主张用小柴胡汤治疗。如果是发病五六天后已经发汗又误用泻下，出现胁部胀满、轻微结滞、口渴但不呕吐、仅头部出汗、心烦、往来寒热的，病邪仍未解除，且伴有小便不利的，张仲景又主张用柴胡桂枝干姜汤治疗。如果是发病八九天误用泻下，出现烦躁惊悸、谵语、身体沉重而小便不利的，张仲景又主张用柴胡加龙骨牡蛎汤治疗。
【纲】张仲景说：伤寒脉象弦细，头痛、发热的，属于少阳病。少阳病不可发汗，发汗则会导致谵语，这属于胃家实。胃气调和则痊愈，胃气不和，则会出现烦闷和躁扰。
【目】朱肱说：足少阳胆经的经脉，起于目外眦，联络耳部，随后分为四道，下行至缺盆，沿着胁肋部行走，并与正别脉六道上下并行，主管经营全身关节，流通气机于三部。所以患者出现胸胁痛、耳聋，或者口苦咽干，或者往来寒热并伴有呕吐，其脉象寸关尺三部都呈现弦象的，可知是少阳经受病。
少阳受病，出现口苦、咽干、目眩，宜用小柴胡汤来解表。不可发汗，发汗则导致谵语，谵语属于胃家实。胃气调和则痊愈，胃气不和则烦闷躁扰，宜用调胃承气汤治疗。这属于少阳阳明合病。脉细、头痛、呕吐且发热的，属于少阳病，用小柴胡汤。患者口不渴，体表有微热的，用小柴胡汤加桂枝。小柴胡汤加桂枝，主治表热效果最好，不仅限于伤寒。张仲景说：表有热的，用小柴胡汤加桂枝；里有热的，用白虎加人参汤。大抵身体发热但不想喝水的，为表热；口燥、心烦、口渴的，为里热。这两种药都能治疗发热，但分别针对表和里。
王好古说：辨别表、里、中三方面的说法，假设是少阳症，头痛、往来寒热、脉浮，这三症只要具备其一，就是表证。口中失去滋味，腹中不和，大小便或者秘结不通，或者泄泻而不调，只要具备其一，就是里证。如果没有上下的表里症，其余都是虚热。这是病在中间了。
张元素说：少阳胆经，迂回盘曲，多于其他各经，然而少阳篇中的症治非常简单，又不曾听说什么药是本经的正法。为什么呢？经络的位置，太阳在后，为表；阳明在前，为里；少阳在侧，夹在表里之间，所以说它是半表半里。治疗方法，表证宜发汗，里证宜泻下。既然居于两经之间，就不适宜用发汗或泻下法，所以治疗没有固定的正法。经文说：少阳不可发汗，发汗则谵语。又说：不可吐下，吐下则惊悸。那么汗、吐、下三法，都是少阳所禁忌的。其方剂不过和解而已。所以张仲景只使用小柴胡汤是最恰当的。然而经络未明确区分，虽然多所运行，并非由正道。（这也是少阳病较少的原因），所以生病也不多。
喻昌说：少阳伤寒，禁止发汗；少阳中风，禁止吐下。这两层意思互相列举，旨意更加严密。大概伤寒的头痛发热，似乎适宜发汗，尚且不可发汗，那么伤风的不可以发汗，就不用说了。中风的胸满而烦，痰饮上逆，似乎适宜吐下，尚且不可吐下，那么伤寒的不可以吐下，更不用说了。脉象弦细的，邪气欲入里，胃中的津液必然被热邪消耗，重复发汗，将津液驱赶外出，怎么能不谵语呢？胃和，是指邪气消散而津液回复；不和，是指津液枯竭而水饮结聚，所以烦闷而悸动（其他条文说：少阳中风，两耳无所闻，目赤，胸中满而烦者，不可吐下，吐下则悸而惊）。
沈金鳌按语：洁古认为少阳不可汗、吐、下，谓治疗没有正法，这大概是他的语言毛病。只是其意义还没有违背道理。大概病在太阳之表，固以发汗为正法；病在阳明之里，又以泻下为正法；症在太阳阳明可向上涌越的，更以催吐为正法。现在症在半表半里之间，既不可汗、吐、下，因此设立小柴胡和解法。有和法，则不需要泻下而自然通泄；有解法，则不需要发汗而自然通达；有和且解法，则不需要催吐而自然升散。是发汗为太阳正法，泻下为阳明正法，催吐为太阳阳明共同使用的正法，那么和解就是少阳的正法，而小柴胡汤，就是治疗少阳正法的药物。难道必须以汗、吐、下为正法，而在汗、吐、下之外，和解就不是正法吗？他的语言毛病太严重了。
弦，是直的意思。直而细，是木气初生的形象，所以弦细的脉象属于少阳。得到这种脉象而只见到头疼发热，没有太阳脉症的，应当从少阳而以和解为法，不可当作太阳病治疗。
【纲】张仲景说：伤寒阳脉涩，阴脉弦，依法应当腹中急痛，先用建中汤，如果不愈的，用小柴胡汤主治。
【目】魏荔彤说：阳脉因虚反而见涩，阴脉因寒而独见弦，这是阳微而阴盛的诊象。如果固执地用小柴胡汤，恐怕半表者因虚而不能透达于外，半里者因寒而更加陷下。所以当症见腹中急痛时，虽然属于少阳病，或者是其中一症，也不治其表，里急治其里虚。仲师指示人先用小建中汤来奠安内虚，助其生发胃阳，使小柴胡的力量有所凭借，然后能上升下降，指挥如意。所以服用建中汤后，少阳病不愈，仍与小柴胡汤主治。法无改变，但道有先后，也即太阳阳明诸篇中里虚先治里的含义。
柯琴说：尺寸俱弦，是少阳受病。现在阳涩阴弦，是寒伤厥阴而不在少阳了。寸为阳，阳主表，涩者，阳气不舒，表寒不解。弦为木邪，必挟相火，相火不能御寒，必还入厥阴而为患。厥阴脉抵少腹，挟胃，属肝，络胆，则腹中皆厥阴部位。尺为阴，阴主里，弦者，为肝脉，必当腹中急痛。肝苦急，甘缓酸泻辛散，此小建中汤是为厥阴驱寒发表、平肝逐邪的第一步。难道是漫无目的的使用吗？
沈金鳌按语：魏、柯二家的说法不同。柏乡（魏荔彤）专主虚寒，谓与太阳阳明诸症，同一里虚先治里的含义，固然不是无识，而韵伯（柯琴）根据腹中急痛，特别揭示寒伤厥阴，不在少阳，更为眼明手捷。且少阳与厥阴相表里，但病而伤及肝，也是里证的常理。况且脉阳反涩而阴独弦，其非专属少阳受病，而与尺寸俱弦者可比。且两说虽异，而理不悖，故并存之。读者互参即可。
【纲】张仲景说：伤寒五六日，头汗出，微恶寒，手足冷，心下满，口不欲食，大便硬，脉沉细的，此为阳微结。必有表复有里。脉沉也在里。汗出为阳微结。假如是纯阴结，不得再有外症，悉入在里了。此为半在表半在里。脉虽沉紧，不得为少阴病。之所以这样，是因为阴不得有汗，现在头汗出，故知非少阴也。可与小柴胡汤。设不了了者，得屎而解。
【目】朱肱说：假令患者心下满，口不欲食，大便硬，脉沉细，是里症当下。其人头汗出，微恶寒，手足冷，却当汗。此两症俱见的，张仲景所谓半在表半在里。用小柴胡汤主治。
魏荔彤说：有太阳阳明，二阳为病，但见少阳脉，即当从少阳法治的，尤其不可不辨明其阴阳虚实，而妄为汗下与温补。得屎而解有二义。如其不了了，旋复自能得屎，则不了了者亦了了矣。这是一义。如不了了，而阳明之里已有燥屎，因用大柴胡兼调胃承气荡涤之，则浊降清升，不了了者始得了了。这是又一义。
【纲】张仲景说：得病六七日，脉迟浮弱，恶风寒，手足温，医二三下之，不能食，而胁下满痛，面目及身黄，颈项强，小便难者，与柴胡汤，后必下重。本渴，而饮水呕，食谷哕者，柴胡不中与也。
【目】柯琴说：浮弱为桂枝脉，恶风寒为桂枝症。然手足温而身不热，脉迟为寒，为无阳，为在脏，是表里虚寒也。法当温中散寒，而反二三下之，故成太阳中风之坏病，非柴胡症矣。
【纲】张仲景说：本太阳病不解，转入少阳者，胁下硬满，干呕，不能食，往来寒热，尚未吐下，脉弦细者，与小柴胡汤。若已吐下，发汗，温针，谵语，柴胡症罢，此为坏病。知犯何逆，以法治之。
【目】朱肱说：太阳病不解，转入少阳云云。以小柴胡主之者，盖脉弦细头痛发热，属少阳也。
方中行说：坏病的形成，不必像吐、下、温针那样，一误再误三误，才谓之坏病。但应与而不与，不应与而与，以致病变他症的，都是坏病。即使屡误至再至三，而病未尝变，虽误又何尝坏乎？仍以本症之法治之。治其误，而坏痞亦同法也。所以名之为坏者，由于误。误必救之，救其逆而反于顺也。故坏病不必论其重轻，视其本病，及误坏之治，各有轻重焉。治法亦救其可救，不必震于坏误之名，遂束手也。不能救其不可救者，固以前医药之咎，然人生有命，正于此可参观矣。
【纲】张仲景说：阳明少阳合病，必自下利。其脉不负者，顺也。负者，失也。互相克贼，名为负。少阳负趺阳者，为顺也。
【目】魏荔彤说：仲师他处但言逆顺，此独言胜负者，知其胜负，而后可言顺逆也。又独言失而不言得，以顺逆之故明，而得失了然矣。请申互相克贼之义，此得失顺逆之大关乎。胃之本为阳土，标为燥金，能腐化水谷，燥金之气，为用大矣。今使少阳相火乘之，则金气柔而不刚，乌能熟化水谷。且有湿腻粘滞之物，乌得不留停。故人知胃土受木克贼者多，而知燥金受相火克贼者甚少。故特明曰：互相克贼，示人切矣。况胃，阳土也。虽津液与水谷相溷于内，然实以津液消水谷，而又以水谷化津液，以消即为化，以化即为消，其理微妙。苟非燥金之气流动充满，何以为消化乎？是此金气，即天一至清之气，又与津液相附而不相杂，如在天之气，在地之气，共一理也。有时此金气为正气而生津液，有时此金气为寒燥反耗津液，此理至幻而至常，非知此，何以明阳明胃土为本燥金为用乎？再者，脾与胃表里，固为输运之专司，但终在胃外斡旋，其燥金之气则流行胃中，而主消化之权者，何容有负而致败乎？学人于六经标本，由此推详得解，庶可言医也。夫胜负之机如用兵，然必养之裕，培之浓，斯有胜无负。若不培养，必至负也。非借外援以相救，则另攻其要害，使之自退而已。小柴胡之用，攻木之要害，使自退也。用黄芩借外救以苏燥金之气也。
危亦林说：两阳合病者，其脉必兼见两阳也。阳明之脉大，少阳之脉弦，此顺脉也。若但大而不弦，则少阳负矣。但弦而不大，则阳明负矣。皆不顺之脉，所谓互相克贼也。然木克土，是少阳为贼邪，若少阳负而阳明不负，亦负中之顺脉也。此不可不知。
【纲】张仲景说：太阳与少阳并病，脉弦，头项强痛，或眩冒，时如结胸，心下痞硬者，当刺大椎第一间，肺俞，肝俞，慎不可发汗，发汗则谵语。脉弦，五六日谵语不止，当刺期门。
【目】魏荔彤说：考穴图，大椎为督脉之穴，居身后，肺肝俞，俱属膀胱之穴，亦次第由大椎而下，同居于背，是皆太阳行身后之道路也。于此三刺，皆泄太阳经表邪，而于肺肝膀胱之脏腑无涉。诸家牵附，总由不知刺三穴，泄经邪之义耳。
李时珍说：脉弦为少阳，头项强痛为太阳，眩冒结胸心下痞，则两阳皆有也。
【目】喻昌说：脉不弦大，邪微欲解之先征也。
[Outline] Zhang Zhongjing said: If there is a Yangming stomach-fullness syndrome, presenting with fever, aversion to cold, and a floating-tight pulse, if purgation is mistakenly applied, it will result in abdominal fullness and difficult urination.
[Commentary] Wang Kentang said: For hypochondriac pain, jaundice, and difficult urination, if the Yangming stomach-fullness has not yet been purged, Xiao Chai Hu Tang (Minor Bupleurum Decoction) should be used. If after purgation, anorexia and neck stiffness occur, Chai Hu (Bupleuri Radix) preparations are contraindicated.
Shen Jin'ao's Note: The three Yang meridians (Taiyang, Yangming, Shaoyang) all have symptoms of difficult urination, not limited solely to Taiyang. For example, in Shaoyang Cold Damage, occurring five or six days after onset or after Wind Strike, presenting with alternating chills and fever, irritability, hypochondriac pain, or epigastric palpitations accompanied by difficult urination, Zhang Zhongjing advocates using Xiao Chai Hu Tang (Minor Bupleurum Decoction). If after five or six days, sweating and purgation have already been applied, resulting in hypochondriac fullness, slight binding, thirst without vomiting, sweating only on the head, irritability, and alternating chills and fever, where the pathogen remains unresolved and is accompanied by difficult urination, Zhang Zhongjing advocates using Chai Hu Gui Zhi Gan Jiang Tang (Bupleurum, Cinnamon Twig, and Dried Ginger Decoction). If after eight or nine days, purgation was mistakenly applied, resulting in restlessness,惊悸 (palpitations/fright), delirium, heaviness of the body, and difficult urination, Zhang Zhongjing advocates using Chai Hu Jia Long Gu Mu Li Tang (Bupleurum plus Dragon Bone and Oyster Shell Decoction).
[Outline] Zhang Zhongjing said: In Cold Damage, if the pulse is wiry-thin, accompanied by headache and fever, it belongs to Shaoyang disease. Shaoyang disease must not be treated with diaphoresis (sweating method); if diaphoresis is applied, it leads to delirium, which indicates involvement of the Stomach. If the Stomach Qi harmonizes, recovery ensues; if the Stomach Qi does not harmonize, irritability and restlessness occur.
[Commentary] Zhu Gong said: The Foot-Shaoyang Gallbladder Meridian originates at the outer canthus, connects with the ear, then divides into four pathways, descends to the Clavicular Fossa (Quepen), follows the hypochondrium, and runs up and down alongside the primary and collateral meridians. It governs the joints and circulates Qi through the three regions. Therefore, patients present with chest and hypochondriac pain, deafness, bitter taste in the mouth, dry throat, alternating chills and fever with vomiting, and a wiry pulse at all three positions (Cun, Guan, Chi), indicating disease of the Shaoyang meridian.
When Shaoyang is affected, presenting with bitter taste, dry throat, and vertigo, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is suitable to release the exterior. Diaphoresis is contraindicated; if applied, it causes delirium, which belongs to the Stomach. If the Stomach harmonizes, recovery occurs; if it does not, irritability and restlessness arise, and Tiao Wei Cheng Qi Tang (Regulate the Stomach and Order the Qi Decoction) is indicated. This belongs to Shaoyang-Yangming combined disease. With a thin pulse, headache, vomiting, and fever, it belongs to Shaoyang, treated with Xiao Chai Hu Tang (Minor Bupleurum Decoction). If the patient has no thirst and slight external heat, Xiao Chai Hu Tang (Minor Bupleurum Decoction) added with Gui Zhi (Cinnamon Twig) is used. Adding Gui Zhi (Cinnamon Twig) to Xiao Chai Hu Tang (Minor Bupleurum Decoction) is excellent for treating exterior heat, not limited to Cold Damage. Zhang Zhongjing stated: For exterior heat, use Xiao Chai Hu Tang (Minor Bupleurum Decoction) with Gui Zhi (Cinnamon Twig); for interior heat, use Bai Hu Jia Ren Shen Tang (White Tiger plus Ginseng Decoction). Generally, body heat without desire to drink indicates exterior heat; dry mouth, irritability, and thirst indicate interior heat. Both medicines treat fever but differentiate between exterior and interior.
Wang Haogu said: Regarding the differentiation of exterior, interior, and middle: Assuming Shaoyang symptoms, if headache, alternating chills and fever, or floating pulse presents any one of these, it is an exterior syndrome. Loss of taste in the mouth, disharmony in the abdomen, constipation or diarrhea, if any one presents, it is an interior syndrome. If there are no upper/lower exterior/interior symptoms, the remainder are deficiency-heat. The disease lies in the middle.
Zhang Yuansu said: The Shaoyang Gallbladder Meridian winds and curves more than other meridians, yet the treatments in the Shaoyang chapter are very simple, and no specific herb is mentioned as the principal method for this meridian. Why? Anatomically, Taiyang is posterior (Exterior), Yangming is anterior (Interior), and Shaoyang is lateral, sandwiched between Exterior and Interior, hence called Half-Exterior Half-Interior. Treatment principles dictate that Exterior syndromes require diaphoresis, and Interior syndromes require purgation. Since Shaoyang resides between the two, neither diaphoresis nor purgation is suitable. Thus, there is no fixed standard treatment. The classic states: Shaoyang must not be sweated; sweating causes delirium. It also states: Vomiting and purgation are contraindicated; they cause fright and palpitations. Therefore, the methods of sweating, vomiting, and purgation are all contraindicated for Shaoyang. Its formulas rely merely on harmonization. Hence, Zhang Zhongjing’s exclusive use of Xiao Chai Hu Tang (Minor Bupleurum Decoction) is most appropriate. However, since the meridians were not clearly distinguished, although Qi flows extensively, it does not follow the correct path (this is why Shaoyang diseases are fewer), so illnesses are not numerous.
Yu Chang said: Shaoyang Cold Damage prohibits diaphoresis; Shaoyang Wind Strike prohibits vomiting and purgation. These two meanings reinforce each other, making the principle stricter. Although headache and fever in Cold Damage seem suitable for diaphoresis, it is still prohibited; thus, the prohibition for Wind Strike is self-evident. Although chest fullness, irritability, and upward counterflow of phlegm-fluids in Wind Strike seem suitable for vomiting/purgation, it is still prohibited; thus, the prohibition for Cold Damage is even more evident. A wiry-thin pulse indicates the pathogen desires to enter the Interior, consuming Stomach fluids with heat. Repeated diaphoresis drives fluids outward, inevitably causing delirium. "Stomach harmonizes" means pathogens disperse and fluids return; "does not harmonize" means fluids are depleted and fluid retention binds, causing irritability and palpitations (Other texts state: In Shaoyang Wind Strike, deafness, red eyes, chest fullness, and irritability prohibit vomiting/purgation; doing so causes palpitations and fright).
Shen Jin'ao's Note: Jiegu (Zhang Yuansu) claimed that because Shaoyang prohibits sweating, vomiting, and purging, there is no standard treatment; this is a linguistic flaw, though the meaning is not entirely wrong. Generally, disease in Taiyang Exterior requires diaphoresis as the standard; disease in Yangming Interior requires purgation as the standard; symptoms in Taiyang-Yangming suitable for emesis require vomiting as the standard. Now, symptoms are in the Half-Exterior Half-Interior region, prohibiting sweating, vomiting, and purging. Therefore, the Harmonizing Method (Xiao Chai Hu Tang) was established. With Harmonization, purgation is unnecessary for natural drainage; with Resolution, diaphoresis is unnecessary for natural unblocking; with both Harmony and Resolution, emesis is unnecessary for natural ascending. Thus, diaphoresis is the standard for Taiyang, purgation for Yangming, and emesis for both; Harmonization is the standard for Shaoyang, and Xiao Chai Hu Tang (Minor Bupleurum Decoction) is the medicine for this standard. Must one insist that only sweating, vomiting, and purging are standards, and anything else is not? His linguistic error is severe.
"Wiry" means straight. Straight and thin represents the image of wood initially sprouting; thus, a wiry-thin pulse belongs to Shaoyang. Obtaining this pulse with only headache and fever, without Taiyang pulse/symptoms, one should treat from Shaoyang using Harmonization, not as Taiyang.
[Outline] Zhang Zhongjing said: In Cold Damage, if the Yang pulse is choppy and the Yin pulse is wiry, according to the law, there should be acute abdominal pain. First use Jian Zhong Tang (Establish the Middle Decoction). If not improved, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is the main treatment.
[Commentary] Wei Litong said: The Yang pulse is choppy due to deficiency, and the Yin pulse is wiry due to cold, indicating weak Yang and flourishing Yin. If one rigidly uses Xiao Chai Hu Tang (Minor Bupleurum Decoction), the Half-Exterior may fail to reach the exterior due to deficiency, and the Half-Interior may sink further due to cold. When acute abdominal pain appears, although it belongs to Shaoyang disease (or one of its symptoms), one should not treat the Exterior. For interior urgency, treat the interior deficiency. Master Zhongshi instructs to first use Xiao Jian Zhong Tang (Minor Establish the Middle Decoction) to stabilize internal deficiency and assist the generation of Stomach Yang, providing a foundation for Xiao Chai Hu Tang (Minor Bupleurum Decoction) to ascend and descend freely. Thus, after taking Jian Zhong Tang, if Shaoyang disease persists, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is still administered. The method remains unchanged, but the sequence differs, aligning with the principle in Taiyang and Yangming chapters of treating interior deficiency first.
Ke Qin said: Wiry pulses at Cun and Chi indicate Shaoyang disease. Now, a choppy Yang pulse and wiry Yin pulse indicate Cold injuring Jueyin, not Shaoyang. Cun is Yang, governing Exterior; choppy indicates unsoothed Yang Qi and unresolved Exterior Cold. Wiry represents Wood Pathogen carrying Ministerial Fire; unable to resist Cold, it returns to Jueyin. Jueyin meridian reaches the lower abdomen, flanks the Stomach, belongs to Liver, and connects with Gallbladder, so the abdomen is Jueyin territory. Chi is Yin, governing Interior; wiry is the Liver pulse, inevitably causing acute abdominal pain. Liver suffers from tension; Sweet softens, Sour drains, Pungent disperses. Xiao Jian Zhong Tang (Minor Establish the Middle Decoction) is the first step for Jueyin to expel Cold and release the Exterior, calm the Liver, and drive out pathogens. Is it used arbitrarily?
Shen Jin'ao's Note: Wei and Ke differ. Boxiang (Wei Litong) emphasizes deficiency-cold, aligning with the principle of treating interior deficiency first in Taiyang/Yangming, which is not ignorant. Yunbo (Ke Qin) highlights Cold injuring Jueyin based on acute abdominal pain, showing keen insight. Since Shaoyang and Jueyin are exterior-interior paired, illness affecting the Liver is common in interior diseases. Moreover, a choppy Yang and wiry Yin pulse differ from the uniformly wiry pulse of pure Shaoyang disease. Although their views differ, the logic is consistent; both are preserved for cross-reference.
[Outline] Zhang Zhongjing said: In Cold Damage, five or six days later, with sweating only on the head, slight aversion to cold, cold hands and feet, epigastric fullness, lack of desire to eat, hard stool, and a deep-thin pulse, this is Yang Minor Binding. There must be both Exterior and Interior aspects. A deep pulse indicates Interior involvement. Sweating indicates Yang Minor Binding. If it were Pure Yin Binding, there would be no exterior symptoms, all entering the Interior. This is Half-Exterior Half-Interior. Even with a deep-tight pulse, it cannot be Shaoyin disease. Why? Yin conditions do not sweat; now there is head sweating, so it is known not to be Shaoyin. Xiao Chai Hu Tang (Minor Bupleurum Decoction) may be given. If the patient feels unsettled ("bu liao liao"), resolution comes with passing stool.
[Commentary] Zhu Gong said: If a patient has epigastric fullness, lack of desire to eat, hard stool, and deep-thin pulse, it is an Interior syndrome requiring purgation. But with head sweating, slight aversion to cold, and cold extremities, it requires diaphoresis. When both sets of symptoms appear, as Zhang Zhongjing describes as Half-Exterior Half-Interior, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is the main treatment.
Wei Litong said: In Sun-Yang-Ming combined disease, if only Shaoyang pulse is seen, treatment should follow Shaoyang laws. One must distinguish Yin-Yang deficiency-excess to avoid reckless sweating, purging, or warming-tonifying. "Resolution with passing stool" has two meanings: 1. If the patient feels unsettled but naturally passes stool, the unsettlement resolves. 2. If unsettled and Yangming Interior has dry feces, use Da Chai Hu Tang (Major Bupleurum Decoction) combined with Tiao Wei Cheng Qi Tang (Regulate the Stomach and Order the Qi Decoction) to purge turbidity and raise clarity, resolving the unsettlement.
[Outline] Zhang Zhongjing said: After contracting disease for six or seven days, with slow-floating-weak pulse, aversion to wind and cold, warm hands and feet, if the physician purges two or three times, leading to inability to eat, hypochondriac fullness and pain, yellowing of face/body, neck stiffness, and difficult urination, giving Chai Hu Tang will likely cause a sensation of rectal heaviness. If originally thirsty but vomiting after drinking water, or hiccups after eating, Chai Hu Tang is not suitable.
[Commentary] Ke Qin said: Floating-weak is the Gui Zhi (Cinnamon Twig) pulse; aversion to wind/cold is the Gui Zhi syndrome. However, warm hands/feet without body heat and a slow pulse indicate Cold, absence of Yang, and Zang involvement, representing Exterior-Interior deficiency-cold. The law dictates warming the Middle and dispelling Cold. Mistaken purgation creates a complicated disease from Taiyang Wind Strike, not a Chai Hu syndrome.
[Outline] Zhang Zhongjing said: If original Taiyang disease does not resolve and transfers to Shaoyang, presenting with hardness/fullness below the hypochondrium, dry retching, inability to eat, alternating chills and fever, and before vomiting/purgation, with a wiry-thin pulse, give Xiao Chai Hu Tang (Minor Bupleurum Decoction). If vomiting, purging, diaphoresis, or moxibustion have already occurred, leading to delirium, the Chai Hu syndrome ceases; this is a Complicated Disease (Huai Bing). Identify the deviation and treat accordingly.
[Commentary] Zhu Gong said: Taiyang disease transferring to Shaoyang... using Xiao Chai Hu Tang (Minor Bupleurum Decoction) is because wiry-thin pulse, headache, and fever belong to Shaoyang.
Fang Zhongxing said: Complicated diseases do not require multiple errors (sweating, purging, moxa) to be defined as such. Any failure to treat when indicated, or treating when not indicated, causing symptom changes, constitutes a Complicated Disease. Even with repeated errors, if the disease doesn't change, it's not complicated; treat with the original method. The term "Complicated" arises from error. Errors must be corrected to restore harmony. Severity depends on the original disease and the nature of the error. Do not be paralyzed by the name "Complicated." If irrecoverable, it is due to prior medical mistakes, but fate plays a role.
[Outline] Zhang Zhongjing said: In Yangming-Shaoyang combined disease, spontaneous diarrhea must occur. If the pulse does not show "defeat" (Fu), it is favorable (Shun). "Defeat" implies loss. Mutual overacting is called defeat. If Shaoyang defeats Yuyang (Stomach pulse), it is favorable.
[Commentary] Wei Litong said: Master Zhong usually speaks of favorable/unfavorable, here speaking of victory/defeat to clarify the basis for favorability. He mentions loss rather than gain to highlight the mechanism. Regarding mutual overacting: The Stomach's root is Yang Earth, marked by Dry Metal, capable of rotting and transforming food. Dry Metal Qi is crucial. If Shaoyang Ministerial Fire attacks it, Metal Qi becomes soft and unable to cook food, leading to retention of damp/sticky substances. People know Earth is overcome by Wood, but rarely know Dry Metal is overcome by Ministerial Fire. Hence, "mutual overacting" is emphasized. Stomach (Yang Earth) contains fluids and food; fluids transform food, and food generates fluids. This subtle process relies on flowing Dry Metal Qi. This clear Qi attaches to fluids without mixing, like Heaven and Earth Qi. Sometimes it generates fluids; sometimes cold-dryness consumes them. Understanding this clarifies Stomach Earth as Root and Dry Metal as Function. Spleen and Stomach are exterior-interior, managing transport, but Dry Metal Qi circulates in the Stomach to dominate digestion. How could it "lose"? Scholars must deduce this from the Six Meridians' Roots and Marks. Victory/defeat is like warfare; one must nourish and cultivate to win. Without cultivation, one loses. One must either seek external aid (e.g., Huang Qin / Scutellariae Radix to revive Dry Metal) or attack the vital point (Wood) to make it retreat. Xiao Chai Hu Tang (Minor Bupleurum Decoction) attacks Wood's vital point; Huang Qin (Scutellariae Radix) provides external aid to revive Dry Metal.
Wei Yilin said: Combined disease of two Yangs shows pulses of both. Yangming pulse is large; Shaoyang pulse is wiry—this is favorable. Large without wiry means Shaoyang defeated; wiry without large means Yangming defeated—both unfavorable, indicating mutual overacting. Wood overacts Earth, so Shaoyang is the pathogenic factor. If Shaoyang is defeated but Yangming is not, it is a favorable outcome within defeat. This must be known.
[Outline] Zhang Zhongjing said: In Taiyang-Shaoyang concurrent disease, with wiry pulse, stiff/painful head and neck, dizziness/vertigo, occasional feeling of chest binding, and epigastric hardness, puncture the first interspace of the Dazhui (GV14) point, Feishu (BL13), and Ganshu (BL18). Strictly avoid diaphoresis; sweating causes delirium. If the pulse remains wiry and delirium persists for five to six days, puncture Qimen (LR14).
[Commentary] Wei Litong said: Examining acupoint maps, Dazhui (GV14) is on the Governing Vessel, posterior. Feishu (BL13) and Ganshu (BL18) belong to the Bladder Meridian, descending from Dazhui on the back. These are pathways of Taiyang along the posterior. Puncturing these three drains Exterior pathogens from the Taiyang meridian without involving Lung, Liver, or Bladder organs. Previous commentators erred by failing to understand this principle of draining meridian pathogens.
Li Shizhen said: Wiry pulse indicates Shaoyang; stiff/painful head/neck indicates Taiyang. Dizziness, chest binding, and epigastric hardness involve both Yangs.
[Outline] Zhang Zhongjing said: In Cold Damage, on the third day, if the Shaoyang pulse becomes small, the disease is about to resolve.
[Commentary] Yu Chang said: A pulse that is not wiry-large is a precursor of resolving minor pathogens.
Wei Litong said: Shaoyang pulse naturally has a Wood character; pathogens enhance its wiry-long quality. As pathogens recede, the pulse becomes small-weak, indicating pathogen retreat. Do not mistake this for deficiency-micro pulse and recklessly apply warming-tonification.