议曰。桂枝汤中。桂枝芍药等分。以芍药佐桂枝。而治卫气也。建中汤中。芍药多半。而桂枝减少。以桂枝佐
芍药。而益其营气也。是以大有不同。愚以盖桂枝汤中。以芍药佐桂枝。则辛甘相合。散而助表。建中汤中。
以桂枝佐芍药。则酸甘相合。敛而补中。能达此义。斯仲景制方之意。无余蕴矣。〔柯〕建中汤禁。与酒客不
可与桂枝同义。
案小建中。视之大建中。药力和缓。故曰小尔。金鉴云。小小创建中气。恐非也。钱氏注。及王子接解。同义。
医方集解曰。昂案此汤。以饴糖为君。故不名桂枝芍药。而名建中。今人用小建中者。绝不用饴糖。失
仲景遗意矣。
伤寒蕴要曰。胶饴。即饧糖也。其色紫深。如琥珀者佳。
案外台载集验黄 汤。即黄 建中汤。方后云。呕者。倍生姜。又古今录验黄 汤。亦即黄 建中汤。
方后云。呕即除饴糖。千金治虚劳内伤。寒热呕逆吐血方。坚中汤。即本方。加半夏三两。总病论曰。旧有微
溏或呕者。不用饴糖也。据以上数条。呕家亦不可全禁建中汤。
案此方金匮要略。治虚劳里急悸衄。腹中痛。梦失精。四肢酸疼。手足烦热。咽干口燥。又治男子黄胆。
小便自利。后来方书。增减药味。所用颇博。今以本方治杂病者。兹录其一二。
苏沈良方曰。此药治腹痛如神。然腹痛按之便痛。重按
却不甚痛。此止是气痛。重按愈痛而坚者。当自有积也。气痛不可下。下之愈甚。此虚寒证也。此药。偏治腹
中虚寒补血。尤止腹痛。若作散。即每五钱匕。生姜五片。枣三个。饴一栗大。若疾势甚。须作汤剂。散服恐
力不胜病也。
本事方后集。治肠风痔漏。赤芍药。官桂去皮。甘草炙。以上等分。上 咀。每服二钱。生姜二片。白糖
一块。水一盏。同煎至七分。去滓。空心服。（坊本。糖字。作矾。误。）
证治准绳曰。治痢不分赤白久新。但腹中大痛者。神效。其脉弦急。或涩浮大。按之空虚。或举按皆无力
者。是也。
赤水玄珠曰。张二尹近川翁。始以内伤外感。过服发散消导之剂。致胃脘当心而痛。六脉皆弦而弱。此法
当补而敛之也。白芍药。酒炒五钱。炙甘草三钱。桂枝一钱半。香附一钱。大枣三枚。饴糖一合。煎服。一帖
而瘳。张氏医通。形寒饮冷。咳嗽。兼腹痛脉弦者。小建中汤。加桔梗。以提肺气之陷。寒热自汗。加黄 。
又云。案虚劳而至于亡血失精。消耗津液。枯槁四出。难为力矣。内经于针药莫制者。调以甘药。金匮遵之。
而用小建中汤。黄 建中汤。以急建其中气。俾饮食增而津液旺也。
证治大还曰。凡膈气病。由脾胃不足。阳气在下。浊气在上。故痰气壅塞膈上。而饮食难入也。若脉弦。
宜建中汤。
伤寒中风。有柴胡证。但见一证便是。不必悉具。（玉函。作小柴胡。误。）
〔汪〕伤寒中风者。谓或伤寒。或中风。不必拘也。柴胡证者。谓邪入少阳。在半表半里之间也。但见一
证。谓或口苦。或咽干目眩。或耳聋无闻。或胁下硬满。或呕不能食。往来寒热等。便宜与柴胡汤。故曰。呕
而发热者。小柴胡汤主之。不必待其证候全具也。〔志〕恐泥或烦或渴或痛或痞或
悸或咳之并呈。故于此申明之。
凡柴胡汤病证而下之。若柴胡证不罢者。复与柴胡汤。必蒸蒸而振。却复发热汗出而解。（玉函。千金
翼。无病字。若字。及却复之复。成本。亦无复字。）
〔成〕邪在半表半里之间。为柴胡证。即未作里实。医便以药下之。若柴胡证仍在者。虽下之不为逆。可
复与柴胡汤。以和解之。得汤邪气还表者。外作蒸蒸而热。先经下里虚。邪气欲出。内则振振然也。正气胜阳
气生。却复发热汗出而解也。〔钱〕蒸蒸者。热气从内达外。如蒸炊之状也。邪在半里。不易达表。必得气蒸
肤润。振战鼓栗。而后发热。汗出而解也。〔柯〕此与下后复用桂枝同局。因其人不虚。故不为坏病。
顾氏溯源集曰。翕翕者。热在表也。蒸蒸者。热在里也。绎蒸字之义。虽不言有汗。而义在其中矣。
伤寒二三日。心中悸而烦者。小建中汤主之。（外台。作伤寒一二日。）
〔钱〕心中。心胸之间。非必心脏之中也。悸。虚病也。〔鉴〕伤寒二三日。未经汗下。即心悸而烦。必其
人中气素虚。虽有表证。亦不可汗之。盖心悸阳已微。心烦阴已弱。故以小建中汤。先建其中。兼调营卫也。
〔程〕虽悸与烦。皆小柴胡汤中兼见之证。而得之二三日。里证未必便具。小柴胡汤非所与也。
太阳病。过经十余日。反二三下之。后四五日。柴胡证仍在者。先与小柴胡。呕不止。心下急。（【原
注】一云。呕止小安。）郁郁微烦者。为未解也。与大柴胡汤。下之则愈。（反字。玉函。外台。作及字。仍。
脉经。千金翼。作续。小柴胡下。成本。玉函。脉经。千金翼。外台。有汤字。玉函。脉经。千金翼。呕不止。
心下急。作呕止小安。郁郁上。有其人二字。大
柴胡汤之汤。成本脱。）
〔汪〕此条。系太阳病传入少阳。复入于胃之证。太阳病过经十余日。知其时已传入少阳矣。故以二三
下之为反也。下之而四五日后。更无他变。前此之柴胡证仍在者。其时纵有可下之证。须先与小柴胡汤。以和
解半表半里之邪。如和解之。而呕止者。表里气和。为已解也。若呕不止。兼之心下急。郁郁微烦。心下者。
正当胃腑之中。急则满闷已极。郁烦为热结于里。此为未解也。后与大柴胡汤。以下其里热则愈。〔林〕呕不
止。则半表里证犹在。然心下急。郁郁微烦。必中有燥屎也。非下除之不可。故以大柴胡。兼而行之。
案过经。成注各条。其解不同。注本条云。日数过多。累经攻下。注调胃承气汤条云。再传经尽。谓之
过经。注阳明篇汗出谵语条云。过太阳经无表证。考之原文。曰。太阳病过经十余日。又曰。伤寒十三日。过
经谵语者。又曰。须下者。过经乃可下之。凡曰过经者。与此条总四条。并言过太阳经无表证。明矣。其他二
说。不可从也。柯氏云。经者。常也过经。是过其常度。非经络之经也。发于阳者。七日愈。七日已上自愈。
以行其经尽故也。七日不愈。是不合阴阳之数。便为过经。此解亦似未允。
大柴胡汤方
柴胡（半斤○千金翼。八两） 黄芩（三两） 芍药（三两） 半夏（半升洗○外台半升。水洗） 生姜
（五两切○玉函。三两。） 大枣（十二枚擘○外台。十三枚。） 枳实（四枚炙）
上七味。以水一斗二升。煮取六升。去滓再煎。温服一升。日三服。一方。加大黄二两。若不加。恐不为
大柴胡汤。（再煎下。玉函。外台。有取三升三字。根据小柴胡汤煎法。此系脱文。成本。玉函。本方。有大黄
二两。玉函。上七味。作八味。云一方。无大黄。不加不得名大柴胡汤也。案一方
加大黄以下。肘后。千金。千金翼。外台。及成本。共载之。本事方。本方有大黄。注云。伊芳尹汤液论。大柴
胡。同姜枣共八味。今监本无。脱之也。）
〔鉴〕许叔微曰。大柴胡汤。一方无大黄。一方有大黄。此方用大黄者。以大黄有荡涤蕴热之功。为伤寒中
要药。王叔和云若不用大黄。恐不名大柴胡汤。且经衣冠文物言下之则愈。若无大黄。将何以下心下之急乎。应从
叔微为是。柴胡证在。又复有里。故立少阳两解之法。以小柴胡汤。加枳实芍药者。解其外以和其内也。去参
草者。以里不虚也。少加大黄。所以泻结热也。倍生姜者。因呕不止也。
吴遵程方注曰。此汤。治少阳经邪。渐入阳明之腑。或误下引邪内犯。而过经不解之证。故于小柴胡汤中。
除去人参甘草。助阳恋胃之味。而加芍药枳实大黄之沉降。以涤除热滞也。与桂枝大黄汤同义。彼以桂枝甘草
兼大黄。两解太阳误下之邪。此以柴胡黄芩半夏兼大黄。两解少阳误下之邪。两不移易之定法也。
汪昂医方集解曰。此乃少阳阳明。故加减小柴胡小承气。而为一方。少阳固不可下。然兼阳明腑证则当
下。宜大柴胡汤。
总病论。干地黄汤。治妇人伤寒。瘥后犹有余热不去。谓之遗热。
于本方。去半夏枳实姜枣。加干地黄黄连。（方用大黄。）
卫生宝鉴。柴胡饮子。解一切骨蒸热。积热作发。或寒热往来。蓄热寒战。及伤寒发汗不解。或不经发汗。
传受表里俱热。口干烦渴。或表热入里。下证未全。下后热未除及汗后余热劳复。或妇人经病不快。产后。但
有如此证。并宜服之。
于本方。去半夏枳实大枣。加人参当归甘草。（方用大黄。）
名医类案曰。传爱川治一人脉弦细而沉。天明时发寒热。至晚二腿汗出。手心热甚。则胸满拘急。大便实
而能食。似劳怯。询之因怒而得。用大柴胡汤。但胸背拘急不能除。后用二陈汤。加羌活防风红花黄芩。煎服
愈。直指方附遗。本方。治下痢舌黄口燥。胸满作渴。身热腹胀谵语。此必有燥屎。宜下。后服木香黄连苦坚之。
又大柴胡汤。治疟热多寒少。目痛多汗。脉大。以此汤微利为度。
医经会解曰。本大柴胡证当下。医以丸药下之。病不解。胸胁满而呕。日晡潮热微利。仍宜再下。加芒硝。
○连日不大便。热盛烦躁。舌焦口渴。饮水短气。面赤脉洪实。加芒硝。○心下实满。连于左胁。难以侧卧。
大便闭而痛。加栝蒌青皮。○昏乱谵语。加黄连山栀。○发狂。加生地牡丹皮玄参。○发黄。加茵陈黄柏。○
鼻衄。加犀角。○夏月热病烦躁。脉洪大。加知母麦门冬石膏。
伤寒十三日不解。胸胁满而呕。日晡所发潮热。已而微利。此本柴胡证。下之以不得利。今反利者。知
医以丸药下之。此非其治也。潮热者实也。先宜服小柴胡汤以解外。后以柴胡加芒硝汤主之。（玉函。无所字。
玉函。脉经。千金翼。无已字。外台。作热毕。脉经。千金翼。本下。有当字。以不之以。外台。无。成本。
作而。无此非之此。先先宜之宜。玉函。脉经。千金翼。作再字。）
〔程〕胸胁满而呕。日晡所发潮热。此伤寒十三日不解之本证也。微利者。已而之证也。本证经而兼腑。
自是大柴胡。能以大柴胡下之。本证且罢。何有于已而之下利。乃医不以柴胡之辛寒下。而以丸药之毒热下。
虽有所去。而热以益热。遂复留中而为实。所以下利自下利。而潮热仍潮热。盖邪热不杀谷。而逼液下行。谓
云热利是也。潮热者。实也。恐人
疑攻后之下利为虚。故复指潮热以证之。此实得之攻后。究竟非胃实。不过邪热抟结而成。只须于小柴胡解外。
后但加芒硝一洗涤之。以从前已有所去。大黄并可不用。盖节制之兵也。
钱云。胃邪虽实。奈少阳半表之邪未去。当用小柴胡汤。以解外邪。
明理论曰。潮热。若潮水之潮。其来不失其时也。一日一发。指时而发者。谓之潮热。若日三五发者。即
是发热。非潮热也。潮热属阳明。必于日晡时发。阳明者胃。属土。应时则王于四季。应日则王于未申。邪气
入于胃。而不复传。郁而为实热。随王而潮。是以日晡所发潮热者。属阳明也。喻氏云。申酉戌间独热。余时
不热者。为潮热。若他时热。即为忽闪热。非潮热矣。汪氏云。潮热二字。原兼汗出而言。然发热汗出。为太
阳中风本有者。何以辨之。不知太阳之发热汗出。自是汗。阳明之大热汗出。自是潮。潮者潮润也。谓汗者汗
漫之谓。各有意象。今谚谓潮湿者。即此。乃由热气熏蒸。郁闷而作。当每年霉雨之时。衣物之间。无不潮湿
者此也。案汪注奇甚。然潮热。竟未知何义。
胡加芒硝汤方
柴胡（二两十六铢） 黄芩（一两） 人参（一两） 甘草（一两炙） 生姜（一两切） 大枣（四枚擘）
半夏（二十铢本云五枚洗○玉函。外台。五枚。千金翼。一合。洗） 芒硝（二两○外台。二合）
上八味。以水四升。煮取二升。去滓。纳芒硝。更煮微沸。分温再服。不解更作。（【原注】臣亿等谨案
金匮玉函。方中无芒硝。别一方云。以水七升。下芒硝二合。大黄四两。桑螵蛸五枚。煮取一升半。服五合。
微下即愈。本云柴胡。再服以解其外。余二升。加芒硝大黄桑螵蛸也。○外台。煮取间。有七味二字。煮微沸。
作上火煎一二沸七字。再服下。玉函。有以解为瘥四字。千金翼。有以解
其外四字。成本。不载本方。第十卷云。小柴胡方内。加芒硝六两。余根据前法服。不解更服。案今本玉函。有
芒硝二两。而方后云。上七味。知是后人所添。而本方后。更载柴胡加大黄芒硝桑螵蛸汤方。柴胡二两。黄芩。
人参。甘草。炙。生姜。各十八铢。半夏五枚。大枣四枚。芒硝三合。大黄四两。桑螵蛸五枚。上前七味。以
水四升。煮取二升。去滓。下芒硝大黄桑螵蛸。煮取一升半。去滓。温服五合。微下即愈。本方柴胡汤。再服
以解其外。余一服加芒硝大黄桑螵蛸。千金翼并同。作大黄四分。上方解。详见王子接古方选注。）
【按语】在桂枝汤中，桂枝与芍药用量相等。以芍药辅助桂枝，用于治疗卫气（行于脉外、具有温养和防御作用的阳气）。在建中汤中，芍药的用量多于桂枝，而桂枝的用量减少。以桂枝辅助芍药，以补益营气（行于脉中、具有营养作用的阴血）。因此，两者的功效有很大不同。我认为，在桂枝汤中，以芍药辅助桂枝，辛味与甘味相合，起到发散并助益表邪的作用；在建中汤中，以桂枝辅助芍药，酸味与甘味相合，起到收敛并补益中焦的作用。能够通达这一义理，张仲景制定方剂的意旨就没有遗漏了。〔柯琴〕建中汤的禁忌，与酒客（长期饮酒者）不可服用桂枝汤的道理相同。
【案语】小建中汤，与大建中汤相比，药力较为缓和，所以称为“小”。《医宗金鉴》说：“小小创建中气”，恐怕不对。钱氏的注解及王子接的解释，与此观点相同。汪昂在《医方集解》中说：“此汤以饴糖为君药，所以不叫桂枝芍药汤，而叫建中汤。现在人使用小建中汤时，完全不用饴糖，失去了张仲景的原意。”
《伤寒蕴要》说：“胶饴，就是饧糖。颜色紫深，像琥珀一样的最好。”
【案语】《外台秘要》记载的集验黄耆汤，就是黄耆建中汤。方后注说：如果有呕吐症状，增加生姜用量。还有《古今录验》黄耆汤，也是黄耆建中汤。方后注说：如果呕吐，去掉饴糖。《千金方》治疗虚劳内伤、寒热呕吐逆气吐血的方子，坚中汤，就是本方加半夏三两。《总病论》说：素有大便溏泄或呕吐的人，不用饴糖。根据以上几条，呕吐患者也不是完全禁止使用建中汤。
【案语】此方出自《金匮要略》，治疗虚劳引起的里急、心悸、鼻衄、腹中痛、梦遗精滑、四肢酸痛、手足烦热、咽干口燥。又治疗男子黄疸，小便自利。后来的方书，增减药味，应用范围很广。现在记录用本方治疗杂病的一两个案例。
《苏沈良方》说：“此药治疗腹痛如神。但是按压腹部就痛，重按却不怎么痛的，这只是气痛。重按更痛且腹部坚硬的，应当是有积滞。气痛不可攻下，攻下会更严重。这是虚寒证。此药偏治腹中虚寒补血，尤其能止腹痛。如果做成散剂，每次五钱匕，生姜五片，大枣三个，饴糖如栗子大小。如果病情严重，必须做成汤剂，服散剂恐怕药力不足以治病。”
《本事方后集》治疗肠风痔漏，用赤芍药、官桂（去皮）、甘草（炙），以上等分。捣碎，每次服二钱，生姜二片，白糖一块，水一盏，同煎至七分，去渣，空腹服用。（坊间刻本，“糖”字作“矾”，是错误的。）
《证治准绳》说：“治疗痢疾不分赤白新旧，只要腹中大痛的，效果神奇。其脉象弦急，或涩浮大，按之空虚，或举按皆无力的，适用此法。”
《赤水玄珠》说：“张二尹近川翁，起初因内伤外感，过服发散消导的药物，导致胃脘当心而痛，六脉皆弦而弱。此法应当补益而收敛。白芍药（酒炒）五钱，炙甘草三钱，桂枝一钱半，香附一钱，大枣三枚，饴糖一合，煎服。一帖即愈。”《张氏医通》说：形寒饮冷导致的咳嗽，兼有腹痛脉弦的，用小建中汤加桔梗，以提举肺气之陷。寒热自汗的，加黄耆。又说：虚劳发展到亡血失精，消耗津液，枯槁四出，很难救治了。《内经》对于针药不能控制的，用甘药调理。《金匮要略》遵循这一原则，使用小建中汤、黄耆建中汤，以急切地建立中气，使饮食增加而津液旺盛。
《证治大还》说：“凡是膈气病，由脾胃不足，阳气在下，浊气在上，所以痰气壅塞膈上，导致饮食难入。如果脉弦，宜用建中汤。”
伤寒或中风，有柴胡证，只要见到一个证候即可，不必全部具备。（《玉函经》作“小柴胡”，错误。）
〔汪琥〕伤寒中风，指或者是伤寒，或者是中风，不必拘泥。柴胡证，指邪气进入少阳，在半表半里之间。只要见到一个证候，指或者是口苦，或者是咽干目眩，或者是耳聋无闻，或者是胁下硬满，或者是呕不能食，往来寒热等，就适宜给予柴胡汤。所以说：“呕而发热者，小柴胡汤主之。”不必等到证候全部具备。〔尤怡〕担心人们拘泥于或烦或渴或痛或痞或悸或咳等症状同时出现，所以在此申明这一点。
凡是柴胡汤病证被误用下法治疗后，如果柴胡证没有罢除的，再次给予柴胡汤，一定会出现蒸蒸而振（体内热气向外蒸腾并伴有战栗），随后发热汗出而解。（《玉函经》、《千金翼方》没有“病”字、“若”字以及“却复”的“复”字，《成本》也没有“复”字。）
〔成无己〕邪气在半表半里之间，为柴胡证，此时尚未形成里实。医生就用下药攻下。如果柴胡证仍在，虽然经过攻下也不算逆证，可以再次给予柴胡汤，以和解之法。得到汤药后，邪气回归体表，外在表现为蒸蒸而热，先前因为攻下导致里虚，邪气欲出，内在表现为振振然（战栗）。正气胜阳气生，随后发热汗出而解。〔钱潢〕蒸蒸，是热气从内达外，像蒸炊的样子。邪气在半里，不易达表，必须得气蒸肤润，振战鼓栗，然后发热汗出而解。〔柯琴〕这与下法之后复用桂枝汤的情况类似，因为病人不虚，所以不变成坏病。
顾氏《溯源集》说：“翕翕，是热在表。蒸蒸，是热在里。推究‘蒸’字的含义，虽然没有说有汗，但意思在其中了。”
伤寒二三日，心中悸动而心烦的，用小建中汤主治。（《外台秘要》作“伤寒一二日”。）
〔钱潢〕心中，指心胸之间，不一定是心脏之中。悸，是虚病。〔吴谦〕伤寒二三日，未经汗下，就出现心悸而烦，必定此人中气素虚。虽然有表证，也不可发汗。因为心悸说明阳气已微，心烦说明阴气已弱，所以用小建中汤，先建立中气，兼调营卫。〔程应旄〕虽然悸与烦，都是小柴胡汤中兼见的证候，但得病才二三日，里证未必就具备，不适用小柴胡汤。
太阳病，过了经期十余日，反而用了二三次下法，之后四五日，柴胡证仍在的，先给予小柴胡汤。如果呕吐不止，心下急迫（胃脘部拘急不适），郁郁微烦的，为病未解，给予大柴胡汤，攻下则愈。（“反”字，《玉函经》、《外台秘要》作“及”字。“仍”字，《脉经》、《千金翼方》作“续”字。“小柴胡”下，《成本》、《玉函经》、《脉经》、《千金翼方》、《外台秘要》有“汤”字。“呕不止，心下急”，《玉函经》、《脉经》、《千金翼方》作“呕止小安”，“郁郁”上有“其人”二字。“大柴胡汤”的“汤”字，《成本》脱漏。）
〔汪琥〕此条，是太阳病传入少阳，又传入胃的证候。太阳病过了经期十余日，知道此时已传入少阳了。所以用二三次下法是反常的。下法之后四五日，如果没有其他变化，之前的柴胡证仍在，此时即使有可下的证候，也必须先给予小柴胡汤，以和解半表半里的邪气。如果和解后，呕吐停止，表里气和，就是已解。如果呕吐不止，兼有心下急迫，郁郁微烦，心下正当胃腑之中，急迫说明满闷已极，郁烦说明热结于里，此为未解。后来给予大柴胡汤，以攻下里热则愈。〔林佩琴〕呕吐不止，说明半表里证犹在。然而心下急迫，郁郁微烦，中间必有燥屎。非攻下除去不可，所以用大柴胡汤，兼而行之以攻下。
【案语】关于“过经”，成无己在各条注释中的解释不同。注释本条说：“日数过多，累经攻下。”注释调胃承气汤条说：“再传经尽，谓之过经。”注释阳明篇汗出谵语条说：“过太阳经无表证。”考证原文，说：“太阳病过经十余日。”又说：“伤寒十三日，过经谵语者。”又说：“须下者，过经乃可下之。”凡是说“过经”的，与本条总共四条，都说明过太阳经无表证，很明显。其他两种说法，不可采用。柯琴说：“经，是常的意思。过经，是超过其常度，不是经络的经。”“发于阳者，七日愈。七日以上自愈，以行其经尽故也。”七日不愈，是不合阴阳之数，便为过经。这种解释似乎也欠妥当。
大柴胡汤方
柴胡（半斤○《千金翼方》八两） 黄芩（三两） 芍药（三两） 半夏（半升洗○《外台》半升，水洗） 生姜（五两切○《玉函经》三两） 大枣（十二枚擘○《外台》十三枚） 枳实（四枚炙）
以上七味，用水一斗二升，煮取六升，去渣，再煎。温服一升，每日三次。一方，加大黄二两。如果不加大黄，恐怕不能称为大柴胡汤。（“再煎”下，《玉函经》、《外台》有“取三升”三字，根据小柴胡汤煎法，此处系脱文。《成本》、《玉函经》本方，有大黄二两。《玉函经》上七味作八味，云一方无大黄，不加不得名大柴胡汤。案语：一方加大黄以下，《肘后方》、《千金方》、《千金翼方》、《外台秘要》及《成本》共同记载。《本事方》本方有大黄，注云：“伊芳尹《汤液论》，大柴胡同姜枣共八味，今监本无，脱之也。”）
〔吴谦〕许叔微说：“大柴胡汤，一方无大黄，一方有大黄。此方用大黄，是因为大黄有荡涤蕴热之功，为伤寒中的重要药物。王叔和说：若不用大黄，恐不名大柴胡汤。况且经文说‘下之则愈’，若无大黄，将何以攻下心下之急呢？应当听从许叔微的观点。柴胡证在，又复有里证，所以立少阳两解之法。以小柴胡汤加枳实芍药，是解其外以和其内。去参草，是因为里不虚。少加大黄，所以泻结热。倍生姜，是因为呕吐不止。”
吴遵程《方注》说：“此汤，治疗少阳经邪气，渐入阳明之腑，或误下引邪内犯，而过经不解的证候。所以在小柴胡汤中，除去人参甘草助阳恋胃之味，而加芍药枳实大黄之沉降，以涤除热滞。与桂枝大黄汤同义。彼以桂枝甘草兼大黄，两解太阳误下之邪；此以柴胡黄芩半夏兼大黄，两解少阳误下之邪。这是两不移易的定法。”
汪昂《医方集解》说：“这是少阳阳明合病，所以加减小柴胡汤和小承气汤而为一方。少阳固不可下，然而兼阳明腑证则当下，宜用大柴胡汤。”
《总病论》干地黄汤，治疗妇人伤寒，病愈后犹有余热不去，谓之遗热。
于本方，去半夏枳实姜枣，加干地黄黄连。（方用大黄。）
《卫生宝鉴》柴胡饮子，解一切骨蒸热，积热发作，或寒热往来，蓄热寒战，及伤寒发汗不解，或不经发汗，传受表里俱热，口干烦渴，或表热入里，下证未全，下后热未除及汗后余热劳复，或妇人经病不快，产后，只要有如此证候，并宜服用。
于本方，去半夏枳实大枣，加人参当归甘草。（方用大黄。）
《名医类案》说：“传爱川治疗一人，脉弦细而沉，天明时发寒热，至晚两腿汗出，手心热甚，则胸满拘急，大便实而能食，似劳怯。询问得知因怒而得。用大柴胡汤，但胸背拘急不能除。后用二陈汤，加羌活防风红花黄芩，煎服痊愈。《直指方》附遗：本方，治疗下痢舌黄口燥，胸满作渴，身热腹胀谵语，此必有燥屎，宜下。后服木香黄连苦坚之。又大柴胡汤，治疗疟疾热多寒少，目痛多汗，脉大，以此汤微利为度。”
《医经会解》说：“本大柴胡证当下，医生用丸药下之，病不解，胸胁满而呕，日晡潮热微利，仍宜再下，加芒硝。○连日不大便，热盛烦躁，舌焦口渴，饮水短气，面赤脉洪实，加芒硝。○心下实满，连于左胁，难以侧卧，大便闭而痛，加栝蒌青皮。○昏乱谵语，加黄连山栀。○发狂，加生地牡丹皮玄参。○发黄，加茵陈黄柏。○鼻衄，加犀角。○夏月热病烦躁，脉洪大，加知母麦门冬石膏。”
伤寒十三日不解，胸胁满而呕，日晡所发潮热，已而微利。此本柴胡证，下之以不得利，今反利者，知医以丸药下之，此非其治也。潮热者实也。先宜服小柴胡汤以解外，后以柴胡加芒硝汤主之。（《玉函经》无“所”字。《玉函经》、《脉经》、《千金翼方》无“已”字。《外台》作“热毕”。《脉经》、《千金翼方》本“下”字，有“当”字。“以不之”，《外台》无。《成本》作“而”，无“此非”之“此”。“先先宜”之“宜”，《玉函经》、《脉经》、《千金翼方》作“再”字。）
〔程应旄〕胸胁满而呕，日晡所发潮热，这是伤寒十三日不解的本证。微利，是已而的证候。本证经腑兼病，自然是大柴胡汤证。能用大柴胡汤下之，本证且罢，何有于已而之下利？乃是医生不以柴胡之辛寒下，而以丸药之毒热下，虽有所去，而热以益热，遂复留中而为实。所以下利自下利，而潮热仍潮热。盖邪热不杀谷，而逼液下行，谓云热利是也。潮热者，实也。恐人疑攻后之下利为虚，故复指潮热以证之。此实得之攻后，究竟非胃实，不过邪热抟结而成，只须于小柴胡解外，后但加芒硝一洗涤之，以从前已有所去，大黄并可不用。盖节制之兵也。
钱潢说：“胃邪虽实，奈少阳半表之邪未去，当用小柴胡汤，以解外邪。”
《明理论》说：“潮热，像潮水之潮，其来不失其时也。一日一发，指时而发者，谓之潮热。若日三五发者，即是发热，非潮热也。潮热属阳明，必于日晡时发。阳明者胃，属土，应时则王于四季，应日则王于未申。邪气入于胃，而不复传，郁而为实热，随王而潮，是以日晡所发潮热者，属阳明也。喻嘉言说：申酉戌间独热，余时不热者，为潮热。若他时热，即为忽闪热，非潮热矣。汪氏说：潮热二字，原兼汗出而言。然发热汗出，为太阳中风本有者，何以辨之？不知太阳之发热汗出，自是汗；阳明之大热汗出，自是潮。潮者潮润也，谓汗者汗漫之谓。各有意象。今谚谓潮湿者，即此。乃由热气熏蒸，郁闷而作，当每年霉雨之时，衣物之间，无不潮湿者此也。案语：汪注奇甚，然潮热，竟未知何义。”
胡加芒硝汤方（应为柴胡加芒硝汤）
柴胡（二两十六铢） 黄芩（一两） 人参（一两） 甘草（一两炙） 生姜（一两切） 大枣（四枚擘） 半夏（二十铢本云五枚洗○《玉函经》、《外台》五枚，《千金翼方》一合，洗） 芒硝（二两○《外台》二合）
以上八味，用水四升，煮取二升，去渣，纳芒硝，更煮微沸，分温再服。不解更作。（【原注】臣亿等谨案：《金匮玉函》方中无芒硝，别一方云：以水七升，下芒硝二合，大黄四两，桑螵蛸五枚，煮取一升半，服五合，微下即愈。本云柴胡，再服以解其外，余二升，加芒硝大黄桑螵蛸也。○《外台》煮取间，有“七味”二字。煮微沸，作“上火煎一二沸”七字。再服下，《玉函经》有“以解为瘥”四字。《千金翼方》有“以解其外”四字。《成本》不载本方，第十卷云：小柴胡方内，加芒硝六两，余根据前法服，不解更服。案：今本《玉函经》有芒硝二两，而方后云“上七味”，知是后人所添，而本方后，更载柴胡加大黄芒硝桑螵蛸汤方：柴胡二两，黄芩、人参、甘草（炙）、生姜各十八铢，半夏五枚，大枣四枚，芒硝三合，大黄四两，桑螵蛸五枚。上前七味，以水四升，煮取二升，去滓，下芒硝大黄桑螵蛸，煮取一升半，去滓，温服五合，微下即愈。本方柴胡汤，再服以解其外，余一服加芒硝大黄桑螵蛸。《千金翼方》并同，作大黄四分。上方解，详见王子接《古方选注》。）
[Commentary] In Guizhi Tang (Cinnamon Twig Decoction), Cinnamon Twig and White Peony Root are used in equal proportions. White Peony Root assists Cinnamon Twig to treat Wei Qi (Defensive Qi, the Yang qi circulating outside the vessels responsible for warming and defense). In Jianzhong Tang (Middle-Builder Decoction), the dosage of White Peony Root is greater than that of Cinnamon Twig, while the dosage of Cinnamon Twig is reduced. Cinnamon Twig assists White Peony Root to nourish Ying Qi (Nutritive Qi, the Yin blood circulating within the vessels responsible for nourishment). Therefore, their effects differ significantly. I believe that in Guizhi Tang, with White Peony Root assisting Cinnamon Twig, the Acrid and Sweet flavors combine to disperse and assist the Exterior. In Jianzhong Tang, with Cinnamon Twig assisting White Peony Root, the Sour and Sweet flavors combine to astringe and tonify the Middle Jiao. To comprehend this principle is to fully understand Zhang Zhongjing's intent in formulating these prescriptions. [Ke Qin] The contraindication for Jianzhong Tang is the same as that for patients who consume alcohol regularly (Jiu Ke) taking Guizhi Tang.
[Case Note] Compared with Dajianzhong Tang (Great Middle-Builder Decoction), Xiao Jianzhong Tang (Minor Middle-Builder Decoction) has a milder medicinal force, hence the name "Minor". *Yizong Jinjian* (Golden Mirror of the Medical Tradition) states: "To slightly establish the Middle Qi," which is likely incorrect. Qian's annotation and Wang Zijie's explanation share this view. Wang Ang in *Yifang Jijie* (Collection of Explanations on Medical Prescriptions) says: "This decoction uses Yitang (Maltose) as the Sovereign herb; therefore, it is not named Guizhi Shaoyao Tang but Jianzhong Tang. Nowadays, people use Xiao Jianzhong Tang without using Yitang at all, losing Zhang Zhongjing's original intent."
*Shanghan Yunyao* states: "Jiaoyi is the same as Xingtang (malt sugar). The one with a deep purple color, resembling amber, is superior."
[Case Note] *Waitai Miyao* records Jiyan Huangqi Tang, which is Huangqi Jianzhong Tang. The post-prescription note says: If there is vomiting, increase the dosage of Shengjiang (Fresh Ginger). Also, *Gujin Luyuan* Huangqi Tang is also Huangqi Jianzhong Tang. The post-prescription note says: If there is vomiting, remove Yitang. *Qianjin Fang* prescribes Jianzhong Tang for deficiency-wasting with internal injury, alternating chills and fever, vomiting and reflux, and hematemesis; this is the present formula plus Banxia (Pinellia Rhizome) 3 liang. *Zongbing Lun* states: For those with chronic loose stools or vomiting, do not use Yitang. Based on the above points, patients with vomiting are not absolutely prohibited from using Jianzhong Tang.
[Case Note] This formula comes from *Jingui Yaolue*, treating deficiency-wasting characterized by internal tension, palpitations, epistaxis, abdominal pain, nocturnal emission, soreness and pain in the four limbs, heat sensation in the hands and feet, dry throat and mouth. It also treats male jaundice with spontaneous urination. Later medical books modified the ingredients, broadening its application. Here are one or two examples of using this formula for miscellaneous diseases.
*Sushen Liangfang* states: "This medicine treats abdominal pain miraculously. However, if pressing the abdomen causes pain, but firm pressure does not cause much pain, this is merely Qi pain. If firm pressure causes more pain and the abdomen feels hard, there must be an accumulation. Qi pain should not be purged; purging will worsen it. This is a Deficiency-Cold syndrome. This medicine specifically treats Deficiency-Cold in the abdomen and nourishes blood, especially stopping abdominal pain. If made into a powder, take 5 qianbi per dose with 5 slices of ginger, 3 dates, and a piece of maltose the size of a chestnut. If the condition is severe, it must be prepared as a decoction; taking powder may not provide sufficient strength to overcome the disease."
*Benshi Fang Houji* treats intestinal wind and hemorrhoids/fistulas with Chishao Yao (Red Peony Root), Guan Gui (Cinnamon Bark, peeled), and Zhi Gancao (Honey-fried Licorice Root) in equal parts. Coarsely crush, take 2 qian per dose with 2 slices of ginger and a piece of white sugar, decoct in one cup of water until reduced to 70%, strain, and take on an empty stomach. (Commercial editions mistakenly print 'Fan' (Alum) instead of 'Tang' (Sugar).)
*Zhengzhi Zhunsheng* states: "For dysentery regardless of color (red/white) or duration (new/chronic), if there is severe abdominal pain, this is miraculous. The pulse is wiry and rapid, or choppy, floating, and large, feeling empty upon pressure, or weak upon both lifting and pressing. This applies."
*Chuishui Xuanzhu* states: "Zhang Er Yin Jin Chuan Weng initially suffered from internal injury and external pathogenic factors, overusing diaphoretic and digestive-promoting agents, resulting in pain in the epigastrium below the heart. All six pulses were wiry and weak. This method requires tonification and astringency. Jiu-chao Baishao Yao (White Peony Root wine-fried) 5 qian, Zhi Gancao 3 qian, Guizhi 1.5 qian, Xiangfu 1 qian, 3 Dazao (Jujubes), Yi Tang 1 he. Decoct and take. One dose resulted in recovery." *Zhangshi Yitong* states: For cough caused by cold exposure and cold drinks, accompanied by abdominal pain and wiry pulse, use Xiao Jianzhong Tang plus Jiegeng (Platycodon Root) to lift the sinking Lung Qi. For alternating chills/fever and spontaneous sweating, add Huangqi (Astragalus Root). It further states: When deficiency-wasting progresses to loss of blood and essence, consuming body fluids, leading to emaciation, it is difficult to treat. *Neijing* states that for conditions unmanageable by acupuncture and herbs, sweet medicines should be used to regulate. *Jingui Yaolue* follows this, using Xiao Jianzhong Tang and Huangqi Jianzhong Tang to urgently establish Middle Qi, thereby increasing food intake and generating abundant body fluids.
*Zhengzhi Dahuan* states: "All cases of Ge Qi (Diaphragmatic Qi Stagnation) arise from Spleen and Stomach insufficiency, with Yang Qi sinking below and Turbid Qi rising above, causing Phlegm-Qi to obstruct the upper diaphragm, making swallowing difficult. If the pulse is wiry, Jianzhong Tang is suitable."
In Shanghan (Cold Damage) or Fengzhong (Wind Strike), if there are Chaihu Syndrome manifestations, observing just one symptom is sufficient; it is not necessary for all symptoms to be present. (*Yuyan Jing* erroneously reads "Xiao Chaihu").
[Wang Hu] "Shanghan Fengzhong" refers to either Cold Damage or Wind Strike, without rigid distinction. "Chaihu Syndrome" refers to pathogenic factors entering Shaoyang, located between the Exterior and Interior. Observing just one symptom means either bitter taste in the mouth, dry throat and dizziness, deafness, fullness and hardness in the hypochondrium, vomiting with inability to eat, or alternating chills and fever. In such cases, it is appropriate to administer Chaihu Tang immediately. Hence, "vomiting with fever" is treated with Xiao Chaihu Tang. There is no need to wait for all symptoms to manifest. [You Yi] This clarification prevents confusion regarding the simultaneous occurrence of irritability, thirst, pain, stuffiness, palpitations, or cough.
If a patient with Chaihu Syndrome indications undergoes purgation, and the Chaihu Syndrome persists, administering Chaihu Tang again will result in "zhengzheng er zhen" (internal heat steaming outward accompanied by shivering), followed by fever, sweating, and resolution. (*Yuyan Jing*, *Qianjin Yifang* omit the characters 'bing', 'ruo', and the second 'fu' in 'que fu'. *Chengben* also omits 'fu'.)
[Cheng Wuji] Pathogens between the Exterior and Interior constitute Chaihu Syndrome. At this stage, interior excess has not yet formed. If a physician incorrectly uses purgatives, and Chaihu Syndrome remains, although purgation was performed, it is not a counter-indication. Chaihu Tang can be administered again to harmonize. Upon receiving the decoction, pathogens return to the Exterior, manifesting externally as steaming heat. Previously, purgation caused interior deficiency; as pathogens attempt to exit, the interior manifests as shivering. As righteous Qi overcomes and Yang Qi generates, fever and sweating occur, leading to resolution. [Qian Huang] "Zhengzheng" describes heat radiating from inside to outside, like steaming. Pathogens in the semi-interior are hard to expel to the Exterior. One must achieve steaming skin and moisture, shivering and chattering, before fever and sweating resolve the condition. [Ke Qin] This parallels the scenario where Guizhi Tang is reused after purgation. Because the patient is not deficient, it does not become a complicated disease.
Gu Shi *Suyuan Ji* states: "Xi Xi" indicates heat in the Exterior. "Zheng Zheng" indicates heat in the Interior. Analyzing the meaning of "Zheng" (steam), although sweat is not explicitly mentioned, the implication is inherent.
In Shanghan, after two or three days, if there is palpitation and irritability, Xiao Jianzhong Tang is indicated. (*Waitai Miyao* reads "one or two days".)
[Qian Huang] "Xin Zhong" refers to the region of the heart and chest, not necessarily the anatomical heart itself. "Ji" (palpitation) is a deficiency disease. [Wu Qian] In Shanghan, after two or three days, without prior diaphoresis or purgation, if palpitation and irritability appear, it indicates the patient has always had deficient Middle Qi. Even if Exterior symptoms exist, diaphoresis is contraindicated. Palpitation indicates diminished Yang Qi; irritability indicates weakened Yin Qi. Thus, Xiao Jianzhong Tang is used to first establish the Middle and simultaneously regulate Ying and Wei Qi. [Cheng Yingmao] Although palpitation and irritability are concurrent symptoms in Xiao Chaihu Tang, after only two or three days, Interior symptoms may not yet be fully established, so Xiao Chaihu Tang is not applicable.
In Taiyang Disease, after passing the meridian cycle for more than ten days, if the physician incorrectly performs purgation two or three times, and after another four or five days, Chaihu Syndrome persists, first administer Xiao Chaihu Tang. If vomiting continues unabated, accompanied by urgency and discomfort in the epigastrium (note: some versions read "vomiting stops and slight relief"), and mild depression with irritability, the disease is unresolved. Administer Da Chaihu Tang; purgation will lead to cure. ("Fan" is read as "Ji" in *Yuyan* and *Waitai*. "Reng" is read as "Xu" in *Maijing* and *Qianjin Yifang*. "Xiao Chaihu" is followed by "Tang" in *Chengben*, *Yuyan*, *Maijing*, *Qianjin Yifang*, and *Waitai*. "Ou bu zhi, xin xia ji" is read as "Ou zhi xiao an" in *Yuyan*, *Maijing*, *Qianjin Yifang*, with "Qi Ren" preceding "Yu Yu". The character "Tang" in "Da Chaihu Tang" is missing in *Chengben*.)
[Wang Hu] This clause describes Taiyang disease transmitting to Shaoyang and then to the Stomach. After ten-plus days past the meridian cycle, transmission to Shaoyang is evident. Hence, performing purgation two or three times is erroneous. Four or five days post-purgation, if no other changes occur and Chaihu Syndrome persists, even if purge-indications exist, one must first give Xiao Chaihu Tang to harmonize the Semi-Exterior/Semi-Interior pathogens. If harmonization stops the vomiting, Exterior and Interior Qi harmonize, indicating resolution. If vomiting persists, combined with epigastric urgency and depressed irritability—where "epigastrium" corresponds to the Stomach organ, "urgency" implies extreme fullness, and "depressed irritability" implies interior heat binding—the disease is unresolved. Subsequently, Da Chaihu Tang is given to purge interior heat, leading to cure. [Lin Peiqin] Persistent vomiting indicates Semi-Exterior/Semi-Interior pathogens remain. However, epigastric urgency and depressed irritability suggest dry feces must be present. Purging is indispensable; thus, Da Chaihu Tang is used to address both.
[Case Note] Regarding "Guo Jing" (passing the meridian), Cheng Wuji's annotations vary. For this clause, he notes: "Too many days, cumulative purgation." For Tiaowei Chengqi Tang, he notes: "Completing the transmission through meridians twice is called Guo Jing." For the Yangming chapter clause on sweating and delirium, he notes: "Passing Taiyang meridian without Exterior symptoms." Examining the original text: "Taiyang disease passing meridian for ten-plus days"; "Shanghan thirteen days, passing meridian with delirium"; "Those requiring purgation must pass the meridian before purging." All four instances of "Guo Jing" clarify that passing Taiyang meridian implies absence of Exterior symptoms. Other interpretations are invalid. Ke Qin argues: "Jing" means constant norm. "Guo Jing" means exceeding the normal cycle, not the meridian itself. "Emanating from Yang, healing in seven days... if not healed in seven days, it exceeds the number of Yin and Yang, thus becoming Guo Jing." This interpretation is also deemed unsatisfactory.
Da Chaihu Tang Formula
Chaihu (8 liang ○ *Qianjin Yifang*: 8 liang) Huangqin (3 liang) Shaoyao (3 liang) Banxia (half sheng, washed ○ *Waitai*: half sheng, water-washed) Shengjiang (5 liang, sliced ○ *Yuyan*: 3 liang) Dazao (12 pieces, split ○ *Waitai*: 13 pieces) Zhishi (4 pieces, honey-fried)
These seven ingredients are boiled in 12 sheng of water to yield 6 sheng. Strain, then decoct again. Take 1 sheng warm, three times daily. Another version adds Dahuang (Rhubarb Root) 2 liang. Without Dahuang, it arguably cannot be called Da Chaihu Tang. (The phrase "qu san sheng" after "zai jian" in *Yuyan* and *Waitai* is likely a textual omission based on Xiao Chaihu Tang preparation. *Chengben* and *Yuyan* include Dahuang 2 liang. *Yuyan* lists eight ingredients, noting another version lacks Dahuang, stating "without adding Dahuang, it is not named Da Chaihu Tang." Case Note: The addition of Dahuang is recorded in *Zhoubou*, *Qianjin*, *Qianjin Yifang*, *Waitai*, and *Chengben*. *Benshi Fang* includes Dahuang, noting: "Yi Fangyin's *Tangye Lun* lists Da Chaihu with Ginger and Dates totaling eight ingredients; the current official edition omits this.")
[Wu Qian] Xu Shumi states: "Da Chaihu Tang exists in versions with and without Dahuang. Using Dahuang leverages its ability to cleanse accumulated heat, making it essential in Shanghan. Wang Shuhe said: Without Dahuang, it cannot be named Da Chaihu Tang. Moreover, the text states 'purge to cure'; without Dahuang, how can epigastric urgency be resolved? We should follow Xu Shumi. With Chaihu Syndrome present and interior involvement, this establishes a dual-resolution method for Shaoyang. Adding Zhishi and Shaoyao to Xiao Chaihu Tang resolves the exterior and harmonizes the interior. Removing Renshen and Gancao is because the interior is not deficient. Adding a small amount of Dahuang clears heat binding. Doubling Shengjiang addresses persistent vomiting."
Wu Zuncheng *Fangzhu* states: "This decoction treats Shaoyang channel pathogens gradually entering the Yangming fu organs, or pathogens drawn inward due to incorrect purgation, failing to resolve after passing the meridian. Thus, from Xiao Chaihu Tang, Renshen and Gancao (which aid Yang and cling to the Stomach) are removed, and Shaoyao, Zhishi, and Dahuang (sinking and descending) are added to clear heat stagnation. This parallels Guizhi Dahuang Tang. That formula combines Guizhi and Gancao with Dahuang to dual-resolve Taiyang pathogens from incorrect purgation; this formula combines Chaihu, Huangqin, and Banxia with Dahuang to dual-resolve Shaoyang pathogens from incorrect purgation. These are immutable fixed methods."
Wang Ang *Yifang Jijie* states: "This is a Shaoyang-Yangming combination. Hence, modifying Xiao Chaihu Tang and Xiao Chengqi Tang creates this formula. Shaoyang generally prohibits purgation, but when accompanied by Yangming fu syndrome, purgation is indicated. Da Chaihu Tang is appropriate."
*Zongbing Lun* Gan Dihuang Tang treats women with Shanghan who, after recovery, still have lingering residual heat, termed "Liu Re" (Remaining Heat).
From the base formula, remove Banxia, Zhishi, Shengjiang, and Dazao; add Gan Dihuang (Rehmannia Root) and Huanglian (Coptis Rhizome). (Formula uses Dahuang.)
*Weisheng Baojian* Chaihu Yinzi resolves all types of bone-steaming fever, accumulated heat attacks, alternating chills and fever, heat retention with chattering, Shanghan unresolvable by sweating, or transmission causing simultaneous Exterior-Interior heat, dry mouth, irritability, thirst, or Exterior heat entering Interior with incomplete purge indications, residual heat post-purgation or post-sweating, fatigue relapse, or menstrual irregularities/postpartum issues. Any such symptoms warrant administration.
From the base formula, remove Banxia, Zhishi, and Dazao; add Renshen, Danggui (Angelica Sinensis), and Gancao. (Formula uses Dahuang.)
*Mingyi Leian* records: "Chuan Aichuan treated a patient with wiry, fine, and deep pulses. Chills and fever started at dawn, sweating in both legs by evening, intense palm heat, chest fullness and stiffness, solid stool but able to eat, resembling consumption. Inquiry revealed onset due to anger. Used Da Chaihu Tang, but chest/back stiffness persisted. Later used Erchen Tang plus Qianghuo, Fangfeng, Honghua, and Huangqin, decocted and taken, resulting in cure. *Zhizhi Fang* appendix: This formula treats dysentery with yellow tongue coating, dry mouth, chest fullness, thirst, fever, abdominal distension, and delirium, indicating dry feces requiring purgation. Follow with Muxiang and Huanglian to astringe. Additionally, Da Chaihu Tang treats malaria with more heat than chills, eye pain, profuse sweating, and large pulse. Use this decoction to induce mild purgation as the limit."
*Yijing Huijie* states: "The original Da Chaihu indication required purgation. The physician used pill-based purgatives, failing to resolve the disease. Chest/hypochondriac fullness, vomiting, afternoon tidal fever, and mild diarrhea persist. Re-purgation with Mangxiao (Mirabilite) is still appropriate. ○ Constipation for consecutive days, intense heat, irritability, scorched tongue, thirst, shortness of breath upon drinking, red face,洪实 pulse: add Mangxiao. ○ Fullness and hardness in epigastrium extending to left hypochondrium, difficulty turning side, constipation with pain: add Gualou and Qingpi. ○ Confusion and delirium: add Huanglian and Zhizi. ○ Mania: add Shengdi, Mudanpi, and Xuanshen. ○ Jaundice: add Yinchen and Huangbai. ○ Epistaxis: add Xijiao. ○ Summerheat disease with irritability,洪大 pulse: add Zhimu, Maidong, and Shigao."
Shanghan unresolved for thirteen days, with chest/hypochondriac fullness and vomiting, afternoon tidal fever, followed by mild diarrhea. This is originally a Chaihu Syndrome. Purgation should not have caused diarrhea; the fact that diarrhea occurred indicates the physician used pill-based purgatives, which is incorrect treatment. Tidal fever indicates excess. First, administer Xiao Chaihu Tang to resolve the Exterior. Subsequently, Chaihu Jia Mangxiao Tang is indicated. (*Yuyan* omits "suo". *Yuyan*, *Maijing*, *Qianjin Yifang* omit "yi". *Waitai* reads "re bi". *Maijing*, *Qianjin Yifang* add "dang" after "xia". *Waitai* omits "yi bu zhi". *Chengben* reads "er", omitting "ci fei". *Yuyan*, *Maijing*, *Qianjin Yifang* read "zai" instead of "yi" in "xian yi yi".)
[Cheng Yingmao] Chest/hypochondriac fullness, vomiting, and afternoon tidal fever are the original symptoms of unresolved Shanghan for thirteen days. Mild diarrhea is the subsequent symptom. The original syndrome involves both channel and fu organs, naturally calling for Da Chaihu Tang. If Da Chaihu could purge it, the original syndrome would cease, let alone the subsequent diarrhea. However, the physician did not use the acrid-cold Chaihu for purgation but used toxic-hot pills. Although something was expelled, heat increased heat, leaving pathogens in the middle to become excess. Thus, diarrhea occurs independently, and tidal fever persists. Pathogenic heat fails to digest grain and forces fluids downward, termed heat diarrhea. Tidal fever indicates excess. To prevent mistaking post-purge diarrhea for deficiency, tidal fever is pointed out to confirm excess. This excess resulted from improper purgation; ultimately, it is not Stomach excess but pathogenic heat binding. Only Xiao Chaihu is needed to resolve the Exterior, followed by Mangxiao to wash away the remainder. Since expulsion has already occurred, Dahuang is unnecessary. This represents disciplined military strategy.
Qian Huang states: "Although Stomach pathogen is excess, the Shaoyang Semi-Exterior pathogen remains. Xiao Chaihu Tang should be used to resolve the Exterior pathogen."
*Ming Lilun* states: "Tidal fever, like the tide of water, arrives punctually. Occurring once daily at specific times is called tidal fever. Occurring three to five times daily is mere fever, not tidal fever. Tidal fever belongs to Yangming, occurring specifically at dusk (Wei/Shen hours). Yangming is the Stomach, belonging to Earth. It reigns in the seasons and at the Wei/Shen hours. Pathogens entering the Stomach do not transmit further, stagnate, and become excess heat, surging with the reigning time. Hence, afternoon tidal fever belongs to Yangming. Yu Jiayan states: Heat exclusively between Shen/You/Xu hours, with no heat at other times, is tidal fever. Heat at other times is fleeting fever, not tidal fever. Wang Shi states: The term 'tidal fever' originally implies sweating. However, fever with sweating is intrinsic to Taiyang Wind Strike. How to distinguish? Taiyang fever/sweating is simply sweating; Yangming great heat/sweating is 'tidal'. 'Tidal' implies moistening/dampness; 'sweating' implies flooding. Each has distinct imagery. Modern colloquialism 'damp/moist' reflects this. It arises from heat steaming and oppression, similar to clothes becoming damp during annual rainy seasons. Case Note: Wang's annotation is peculiar, yet the exact meaning of 'tidal fever' remains unclear."
Chaihu Jia Mangxiao Tang Formula
Chaihu (2 liang 16 zhu) Huangqin (1 liang) Renshen (1 liang) Gancao (1 liang, honey-fried) Shengjiang (1 liang, sliced) Dazao (4 pieces, split) Banxia (20 zhu, originally stated as 5 pieces, washed ○ *Yuyan*, *Waitai*: 5 pieces; *Qianjin Yifang*: 1 he, washed) Mangxiao (2 liang ○ *Waitai*: 2 he)
These eight ingredients are boiled in 4 sheng of water to yield 2 sheng. Strain, add Mangxiao, boil briefly until simmering. Divide into two warm doses. If unresolved, prepare again. ([Original Note: Chen Yi et al. carefully examined: *Jingui Yuyan* lacks Mangxiao in the formula. Another version states: Boil 7 sheng water, add Mangxiao 2 he, Dahuang 4 liang, Sangpiaoxiao 5 pieces, boil to yield 1.5 sheng, take 5 he, mild purgation leads to cure. Originally stated as Chaihu, take again to resolve Exterior, remaining 2 sheng add Mangxiao, Dahuang, Sangpiaoxiao. ○ *Waitai* inserts "seven ingredients" between boiling steps. "Boil briefly" reads "place on fire boil one or two boils". *Yuyan* adds "yi jie wei chai" after "zai fu". *Qianjin Yifang* adds "yi jie qi wai". *Chengben* does not record this formula; Vol 10 states: Add Mangxiao 6 liang to Xiao Chaihu formula, follow previous methods, take again if unresolved. Case Note: Current *Yuyan* has Mangxiao 2 liang, but formula header says "upper seven ingredients", indicating later addition. The formula post-text further records Chaihu Jia Dahuang Mangxiao Sangpiaoxiao Tang: Chaihu 2 liang, Huangqin, Renshen, Gancao (fried), Shengjiang each 18 zhu, Banxia 5 pieces, Dazao 4 pieces, Mangxiao 3 he, Dahuang 4 liang, Sangpiaoxiao 5 pieces. Boil upper seven ingredients in 4 sheng water to yield 2 sheng, strain, add Mangxiao, Dahuang, Sangpiaoxiao, boil to yield 1.5 sheng, strain, take 5 he warm, mild purgation cures. Base Chaihu Tang taken again to resolve Exterior, remaining one dose adds Mangxiao, Dahuang, Sangpiaoxiao. *Qianjin Yifang* agrees, reading Dahuang as 4 fen. Explanation of above formulas detailed in Wang Zijie's *Gufang Xuanzhu*.)