柴胡半筋 黄芩三两 半夏（洗）半升 芍药三两 枳实（炙）四枚 大黄二两 生
姜（切）五两 大枣（擘）十二枚
右八味，以水一斗二升，煮取六升，去滓再煎，温服一升，日三服。
【按】
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。且经文明言下之则愈
，若无大黄，将何以下心下之急乎？应从叔和为是。
【方解】
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
。
@@@
太阳病，过经十余日，心中温温欲吐，而胸中痛，大便反溏，腹微满，郁郁微烦，先
此时，自极吐下者，与调胃承气汤，若不尔者，不可与。但欲呕，胸中痛，微溏者，
此非柴胡证。以呕，故知极吐、下也。
【按】
王肯堂曰：「温温」当是「嗢嗢」。又云：「以呕」之下，当有阙文。
【注】
太阳病过经十余日，曾经吐、下不解者：以极吐则虚其胸，邪热乘虚入胸，故心下嗢
嗢欲吐，而胸中痛也。极下则虚其里，邪热乘虚入里，故大便反溏腹微满，郁郁微烦
也。询知先时若果经极吐下，则为在表之邪热，悉陷胸腹，而所见者，皆是里证未和
，故宜与调胃承气汤下而和之。若不尔者，谓不因极吐、极下而有斯证，则又不可与
是汤也。夫但欲呕者，少阳也；胸中痛者，太阳也；微溏者，太阳少阳合病之利也，
并无心中嗢嗢郁郁，腹满烦热等证，固不可与承气汤矣。然此亦非柴胡证，故柴胡汤
亦不可与也。须从太阳、少阳合病，下利，若呕者，与黄芩加半夏生姜汤可也。
【集注】
方有执曰：胸中痛，邪在膈也。若曾极吐，则应有心下嗢嗢欲吐之状，何也？以胃口
已被吐伤，邪热上抟于膈，故欲吐而不得吐也。腹微满郁郁微烦，邪在胃也。若曾极
下，则应大便微溏，何也？以下则胃虚，邪虽实于胃，大便反不能结□也。故曰：先
此时自极吐下者，与谓胃承气汤。言当荡其热以和其胃也，不尔，言未经极吐下也。
但欲呕至末，申明上文之意。
喻昌曰：太阳病过经十余日，心下嗢嗢，欲吐而不吐，其人胸中痛，大便反溏，腹微
满郁郁微烦者，此有二辨：若曾经大吐、大下者，表邪从吐解，且已入里，可用调胃
承气之法；若未经极吐、下，但欲呕不呕，胸中痛微溏者，是痛非吐所伤，溏非下所
致，调胃之法不可用矣。
程知曰：过经者，谓病过七、八日至十三日，经气已周犹不解也。岂惟十三日，且有
二十余日者矣。盖过经不解，病必皆在阳经留连；若在阴经，则又岂能若是之持久耶
！久持且不能，安望其生乎？
程应旄曰：大便溏则气得下泄，腹不应满，烦不应郁郁，今仍腹微满，郁郁微烦，必
胃有阻留，而下后仍不快畅也。病属阳明证，反无阳明，而只有少阳，其中必有所误
，故直穷其所以致证之由，而后可从证上认病。
@@@
伤寒十三日不解，胸□满而呕，日晡所发潮热，已而微利，此本柴胡证，下之而不得
利。今反利者，知医以丸药下之，非其治也。潮热者，实也，先宜小柴胡汤以解外，
后以柴胡加芒硝汤主之。
【注】
凡伤寒过经不解，热邪转属胃府者多，皆当下之。今伤寒十三日不解过经，胸□满而
呕，日晡所发潮热，已而微利，此本大柴胡证也。下之而不通利，今反利者，询知为
医以丸药迅下之，非其治也。迅下则水虽去，而燥者仍存，恐医以下后之利为虚，故
复指曰潮热者实也，是可再下者也。但胸□之邪未已，故先宜小柴胡汤以解少阳以外
，复以小柴胡汤加芒硝，以下少阳之里。不用大黄而加芒硝者，因里不急且经迅下，
惟欲其耎坚润燥耳！是又下中兼和之意也。
【集注】
『内台方』议曰：潮热者，实也，何不用大柴胡、大小承气下之，却用芒硝何也？盖
潮热虽属实，然已先用丸药，伤动藏府，若再用大黄下之，则脾气伤而成坏证矣，祗
用芒硝润燥以取利也。
方有执曰：十三日，过经也。不解，坏证也，非其治也。以上乃原其坏，由于医之误
。以下至末，救误之治也。
【大柴胡汤方】
柴胡半斤，黄芩三两，半夏（洗）半升，芍药三两，枳实（炙）四枚，大黄二两，生姜（切）五两，大枣（擘开）十二枚。
以上八味药，用水一斗二升，煎煮至剩余六升，滤去药渣，再次煎煮浓缩，每次温服一升，每日服用三次。
【按语】
许叔微说：大柴胡汤这一方剂，有的版本没有大黄，有的版本有大黄。本方使用大黄，是因为大黄具有荡涤积滞蕴结之热的功效，是治疗伤寒病中的重要药物。王叔和说：如果不使用大黄，恐怕就不能称为大柴胡汤了。况且《伤寒论》原文中明确提到“下之则愈”（通过泻下法可以痊愈），如果没有大黄，用什么来攻下心下部位的急迫痞满呢？所以应当以王叔和的观点为正确。
【方解】
柴胡证（少阳病证）依然存在，同时又兼有里证，因此确立了解除少阳与阳明两经邪气的方法。用小柴胡汤加上枳实、芍药，是为了疏散外邪并调和内部气血。去掉人参、甘草，是因为体内正气不虚；稍微加大黄的用量，是为了泻除结聚的热邪；加倍使用生姜，是因为呕吐不止。
@@@
太阳病（太阳经受邪所致的病证）经过十余日，患者心中泛泛想吐，且胸中疼痛，大便反而稀溏，腹部轻微胀满，情绪抑郁且略有烦躁。如果在此时之前，患者曾经接受过剧烈的催吐或泻下治疗，可给予调胃承气汤；如果不是这种情况，则不可给予此方。如果只是想要呕吐，胸中痛，大便微溏，这不属于柴胡证。因为出现呕吐症状，所以知道这是之前剧烈吐、下所致。
【按语】
王肯堂说：“温温”应当是“嗢嗢”（形容恶心欲吐的样子）。又说：“以呕”之下，可能有脱文（缺失的文字）。
【注释】
太阳病经过十余日，曾经经过吐、下治疗后病情未解的：因为剧烈催吐会损伤胸中正气，邪热乘虚侵入胸中，所以心下感到恶心欲吐，且胸中疼痛。剧烈泻下会损伤体内正气，邪热乘虚侵入体内，所以大便反而稀溏，腹部轻微胀满，情绪抑郁且略有烦躁。询问得知此前如果确实经过剧烈的吐、下治疗，那么原本在表的邪热就会全部陷入胸腹，所表现出的都是里证未调和的症状，所以适宜用调胃承气汤进行泻下以调和胃肠。如果不是这样，指的不是因为剧烈吐、下而出现这些症状，那么又不可以给予这个汤剂。凡是只想呕吐的，属于少阳病；胸中痛的，属于太阳病；大便微溏的，属于太阳与少阳合病引起的腹泻。并没有心中恶心、情绪抑郁、腹部胀满、烦热等症状，固然不可以给予承气汤。然而这也不属于柴胡证，所以柴胡汤也不可以给予。应当从太阳、少阳合病，伴有下利，若伴有呕吐的情况考虑，可使用黄芩加半夏生姜汤。
【集注】
方有执说：胸中痛，说明邪气在膈部。如果曾经剧烈催吐，应该有心下恶心想吐的现象，为什么呢？因为胃口已经被吐伤，邪热向上搏结于膈部，所以想吐却吐不出来。腹部轻微胀满、情绪抑郁且略有烦躁，说明邪气在胃。如果曾经剧烈泻下，应该大便微溏，为什么呢？因为泻下导致胃气虚弱，虽然邪气实于胃，但大便反而不能干结。所以说：在此之前自行经过剧烈吐、下的，给予调胃承气汤。意思是应当荡涤其热邪以调和胃气。“不尔”，指未曾经过剧烈吐、下。从“但欲呕”到文末，是申述上文的意思。
喻昌说：太阳病经过十余日，心下恶心，想吐却吐不出，其人胸中痛，大便反而稀溏，腹部轻微胀满，情绪抑郁且略有烦躁，这里有两种辨别方法：如果曾经经历大吐、大下，表邪随吐而解，且已入里，可用调胃承气汤的方法；如果未曾剧烈吐、下，只是想吐不吐，胸中痛，大便微溏，这说明疼痛不是由吐造成的，稀溏不是由下导致的，调胃承气汤的方法不可用。
程知说：过经，指疾病超过七、八日至十三日，经气已经循环一周但仍不解。岂止十三日，甚至有二十多日的。大概过经不解，病邪必定都在阳经流连；如果在阴经，又怎么能持久如此呢！连持久都做不到，怎么指望能痊愈呢？
程应旄说：大便溏泄则气机向下排泄，腹部不应胀满，烦躁不应表现为抑郁，现在仍然腹部轻微胀满，情绪抑郁且略有烦躁，必然是胃中有阻滞留停，且泻下后仍不痛快。病属阳明证，却没有典型的阳明证表现，只有少阳证，其中必有误治之处，所以要直接探究导致这种症状的原因，然后才能根据症状认定病机。
@@@
伤寒病十三日未解，胸部胀满且呕吐，傍晚时分发作潮热，随后出现轻微腹泻。这本来是大柴胡汤证，经过泻下治疗后并未通便。如今反而腹泻，可知医生使用了丸药进行泻下，这不是正确的治疗方法。潮热，说明是实证，先宜用小柴胡汤以解除表邪，后用柴胡加芒硝汤主治。
【注释】
凡是伤寒病经过多日未解，热邪转属胃腑的多，都应当用泻下法。如今伤寒十三日未解，已过经，胸部胀满且呕吐，傍晚时分发作潮热，随后出现轻微腹泻，这本来是大柴胡汤证。经过泻下而未通利，如今反而腹泻，询问得知是医生用丸药迅速泻下，这不是正确的治法。迅速泻下虽然去了水湿，但燥屎仍然存在。恐怕医生认为泻下后的腹泻是虚证，所以再次指出：潮热是实证，这是可以再泻下的。但胸部的邪气尚未消除，所以先宜用小柴胡汤以解除少阳之邪，再用小柴胡汤加芒硝，以泻下少阳之里的邪热。不用大黄而加芒硝，是因为里证不急且已经经过迅速泻下，只希望软坚润燥罢了！这也是泻下中兼有和解之意。
【集注】
《内台方议》说：潮热是实证，为何不用大柴胡汤、大小承气汤泻下，却用芒硝呢？盖因潮热虽属实证，但已经先用丸药，损伤了脏腑，若再用大黄泻下，则会损伤脾气而成坏证，只用芒硝润燥以取利即可。
方有执说：十三日，是过经的表现。不解，是坏证，说明之前的治疗不正确。以上部分是追溯坏证产生的原因，是由于医生的误治。以下部分到文末，是纠正误治的治疗方法。
[Da Chai Hu Tang Formula]
Chai Hu (Bupleuri Radix) half a jin, Huang Qin (Scutellariae Radix) three liang, Ban Xia (Pinelliae Rhizoma Praeparatum cum Zingibere et Alumine) (washed) half sheng, Shao Yao (Paeoniae Radix Alba) three liang, Zhi Shi (Aurantii Fructus Immaturus) (roasted) four pieces, Da Huang (Rhei Radix et Rhizoma) two liang, Sheng Jiang (Zingiberis Rhizoma Recens) (sliced) five liang, Da Zao (Jujubae Fructus) (broken open) twelve pieces.
The above eight herbs are boiled in one dou and two sheng of water, reduced to six sheng, the dregs are strained out, and it is decocted again. Take one sheng warm each time, three times a day.
[Commentary]
Xu Shuwei said: In the Da Chai Hu Tang formula, some versions do not contain Da Huang, while others do. This formula uses Da Huang because Da Huang has the function of sweeping away accumulated heat, making it an important herb for treating Shang Han (Cold Damage). Wang Shuhe said: If Da Huang is not used, it probably cannot be called Da Chai Hu Tang. Moreover, the classic text explicitly states that "purging will lead to cure." Without Da Huang, what would be used to purge the urgency and fullness in the epigastrium? Therefore, Wang Shuhe's view should be considered correct.
[Formula Analysis]
Since the Chai Hu syndrome (Shaoyang disease pattern) persists and there is also a interior syndrome, a method to resolve both Shaoyang and Yangming is established. Using Xiao Chai Hu Tang (Minor Bupleurum Decoction) plus Zhi Shi and Shao Yao is to release the exterior and harmonize the interior. Ginseng and Licorice are removed because the interior is not deficient; a slight increase in Da Huang is to purge the knotted heat; doubling the amount of Sheng Jiang is due to persistent vomiting.
@@@
In Tai Yang disease (disease of the Tai Yang channel), after more than ten days, the patient feels nauseous with a desire to vomit, experiences pain in the chest, has loose stools instead of constipation, mild abdominal fullness, and is slightly irritable with a depressed mood. If prior to this time, the patient had undergone severe emesis or purgation, Tiao Wei Cheng Qi Tang (Regulate the Stomach and Direct Downward Powder) may be given; otherwise, it should not be given. If there is only a desire to vomit, chest pain, and loose stools, this is not a Chai Hu syndrome. The presence of vomiting indicates that this was caused by previous severe emesis or purgation.
[Commentary]
Wang Kentang stated that "Wen Wen" should be "Wa Wa" (describing nausea and the urge to vomit). He also added that there might be missing text after "because of vomiting."
[Annotation]
In Tai Yang disease persisting for over ten days, unresolved after emesis or purgation: Severe emesis damages the chest qi, allowing pathogenic heat to enter the chest vacuously, causing nausea and chest pain. Severe purgation damages the interior qi, allowing pathogenic heat to enter the interior vacuously, resulting in loose stools, mild abdominal fullness, and slight irritability/depression. Upon inquiry, if it is confirmed that severe emesis or purgation occurred previously, the pathogenic heat originally on the exterior has sunk into the chest and abdomen, presenting as unharmonized interior syndromes. Thus, Tiao Wei Cheng Qi Tang is appropriate to purge and harmonize. If this is not the case—meaning these symptoms did not arise from severe emesis or purgation—this formula should not be used. A mere desire to vomit belongs to Shaoyang; chest pain belongs to Tai Yang; loose stools belong to the diarrhea of combined Tai Yang and Shaoyang diseases. Since there are no symptoms like nausea, depression, abdominal fullness, or feverish sensation, Cheng Qi Tangs are certainly contraindicated. However, this is also not a Chai Hu syndrome, so Chai Hu Tang is also contraindicated. One should consider combined Tai Yang and Shaoyang disease with diarrhea and vomiting, and use Huang Qin Jia Ban Xia Sheng Jiang Tang (Scutellaria Decoction with Added Pinellia and Fresh Ginger).
[Collected Notes]
Fang Youzhi said: Chest pain indicates the pathogen is in the diaphragm. If severe emesis had occurred, there should be a sensation of nausea in the epigastrium. Why? Because the stomach opening has been injured by emesis, and pathogenic heat struggles upward in the diaphragm, causing the desire to vomit without success. Mild abdominal fullness and slight irritability indicate the pathogen is in the stomach. If severe purgation had occurred, stools should be loose. Why? Because purgation weakens the stomach; although pathogens are excess in the stomach, the stools cannot become dry. Thus, it says: "If severe emesis or purgation occurred prior to this time," give Tiao Wei Cheng Qi Tang. This means to sweep away heat and harmonize the stomach. "Otherwise" means no severe emesis or purgation occurred. From "mere desire to vomit" to the end, reiterates the preceding meaning.
Yu Chang said: In Tai Yang disease persisting for over ten days, with nausea, desire to vomit but inability to do so, chest pain, loose stools, mild abdominal fullness, and slight irritability, there are two distinctions: If there was prior severe emesis or purgation, the exterior pathogen resolved via emesis and entered the interior; Tiao Wei Cheng Qi Tang method can be used. If there was no severe emesis or purgation, and there is merely a desire to vomit without actual vomiting, chest pain, and loose stools, then the pain is not caused by emesis, and the looseness is not caused by purgation; the Tiao Wei method is not applicable.
Cheng Zhi said: "Passing the stage" refers to illness lasting beyond seven to thirteen days, where the channel qi has circulated once but remains unresolved. It may even last twenty-plus days. Generally, if unresolved after passing the stage, the pathogen lingers in the Yang channels; if in Yin channels, how could it persist so long? If it cannot persist, how can recovery be expected?
Cheng Yingmao said: Loose stools imply qi descending, so the abdomen should not be full, nor should irritability be depressed. The current mild fullness and depressed irritability suggest gastric obstruction, and purgation failed to bring relief. Although belonging to Yangming syndrome, typical Yangming signs are absent, leaving only Shaoyang signs. There must have been mismanagement. Thus, one must trace the cause of these symptoms to correctly identify the disease based on the presentation.
@@@
Shang Han (Cold Damage) persisting for thirteen days without resolution, accompanied by chest fullness and vomiting, tidal fever in the late afternoon, followed by mild diarrhea. This was originally a Da Chai Hu Tang syndrome, which should have responded to purgation with bowel movement. Now, however, there is diarrhea, indicating the physician used pill-based purgatives, which was incorrect treatment. Tidal fever indicates excess; first, use Xiao Chai Hu Tang (Minor Bupleurum Decoction) to resolve the exterior, then treat with Chai Hu Jia Mang Xiao Tang (Bupleurum Decoction with Added Niter).
[Annotation]
Generally, when Shang Han persists past its stage and heat transfers to the Stomach Fu, purgation is indicated. Here, Shang Han persists for thirteen days, having passed the stage, with chest fullness, vomiting, tidal fever in the late afternoon, and subsequent mild diarrhea. This was originally a Da Chai Hu Tang syndrome. Purgation failed to produce bowel movements, yet now there is diarrhea. Inquiry reveals the physician used rapid-acting pill purgatives, which was inappropriate. Rapid purgation removes fluid but leaves dryness intact. Perhaps the physician mistook the post-purgation diarrhea for deficiency, hence the clarification: tidal fever indicates excess, warranting further purgation. However, since the pathogen in the chest remains, first use Xiao Chai Hu Tang to resolve the Shaoyang exterior, then use Xiao Chai Hu Tang with added Mang Xiao (Natrii Sulfas) to purge the Shaoyang interior. Da Huang is omitted and Mang Xiao added because the interior condition is not urgent and rapid purgation has already occurred; the goal is merely to soften hardness and moisten dryness. This reflects a combination of purgation and harmonization.
[Collected Notes]
*Nei Tai Fang Yi* discusses: Tidal fever indicates excess. Why not use Da Chai Hu Tang or Da/Xiao Cheng Qi Tang for purgation, but instead use Mang Xiao? Although tidal fever is excess, the prior use of pills has damaged the Zang-Fu organs. Using Da Huang again would damage Spleen qi and create a critical condition. Only Mang Xiao is needed to moisten dryness and induce mild purgation.
Fang Youzhi said: Thirteen days indicates passing the stage. Lack of resolution indicates a corrupted syndrome, implying incorrect prior treatment. The preceding text traces the corruption to medical error. The following text to the end describes the corrective treatment.