麻黄（去节）二两半 升麻一两一分 当归一两一分 知母十八铢 黄芩十八铢 萎
蕤十八铢 石膏（碎绵裹）六铢 白术六铢 干姜六铢 芍药六铢 天冬（去心）六
铢桂枝六铢 茯苓六铢 甘草（炙）六铢
右十四味，以水一斗，先煮麻黄一、二沸，去上沬，内诸药，煮取三升，去滓，分温
三服，相去如炊三升米顷，令尽。汗出愈。
【方解】
下寒上热若无表证，当以黄连汤为法，今有表证，故复立此方，以示随证消息之始也
。升麻、萎蕤、黄芩、石膏、知母、天冬，乃升举走上清热之品，用以避下寒，且以
滋上也；麻黄、桂枝、干姜、当归、白芍、白术、茯苓、甘草，乃辛甘走外温散之品
，用以远上热，且以和内也。分温三服令尽，汗出愈，其意在缓而正不伤，彻邪而尽
除也。脉虽寸脉沉迟，尺脉不至；证虽手足厥逆，下利不止。究之原非纯阴寒邪，故
兼咽喉痛，唾脓血之证，是寒热混淆阴阳错杂之病，皆因大下夺中所变。故仲景用此
汤，以去邪为主，邪去而正自安也。
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伤寒八、九日，下之，胸满烦惊，小便不利，□语，一身尽重，不可转侧者，柴胡加
龙骨牡蛎汤主之。
【注】
伤寒八、九日，邪不解，表不尽，不可下也，若下之，其邪乘虚内陷。在上者，轻则
胸满，重则结胸，胸满者，热入于胸，气壅塞也。在中者，轻则烦惊，重则昏狂，烦
惊□语者，热乘于心，神不宁也。在下者，轻则小便不利，重则少腹满痛，小便不利
者，热客下焦，水道阻也。邪壅三焦，则荣卫不行，水无去路，则外渗肌体，故一身
尽重，不可转侧也。以柴胡加龙骨牡蛎汤主之，其大意在和解镇固，攻补兼施也。
【按】
此条乃阳经湿热之身重，若以为津亡血涩，阳气不能宣布，阴经湿寒之身重则误矣。
寒湿身重，用真武汤、桂枝附子汤，以不渴里无热也；热湿身重，用白虎汤、柴胡加
龙骨牡蛎汤，以□烦胃有热也。其风湿、风温身重，亦不外乎兼寒兼热，故此汤中用
苓、半、大黄为佐也。
【集注】
方有执曰：胸满者，下后里虚，外热入里，挟饮上抟于膈，所以烦也。惊伤心，心藏
神而居膈，正虚邪胜所以不宁。一身尽重，不可转侧者，伤寒本一身疼痛，亡津液而
血涩不利，故变为沉滞而重甚也。
程知曰：下而心烦腹满，治以栀、朴，为邪入腹也。下而胸满烦惊，治以龙、牡，为
邪入心也。因火劫而致烦惊，治以桂枝龙牡，挽心阳之外越也。因下而致烦惊，治以
柴胡龙骨牡蛎，解心阳之内塞也。大、小陷胸，以高下缓急别之；诸泻心汤，以寒热
虚实辨之。半、苓治痰，芩、连降逆，栀、豉涌虚烦，参、附回阳虚，下后大法，备
于斯矣。
喻昌曰：八、九日过经乃下之，可谓慎矣！孰知外邪未尽，乘虚而陷，邪方在表里，
其患已及于神明，于此而补天浴日，岂复易易。
张璐曰：此系少阳之里证，诸家注作心经病误也。盖少阳有三禁，不可妄犯。虽八、
九日过经，下之尚且邪气内犯，胃土受伤，胆木失荣，痰聚膈上，有如是之变，故主
以小柴胡和解内外，逐饮通津，加龙骨、牡蛎，以镇肝胆之惊也。
麻黄（去除节段）二两半，升麻一两一分，当归一两一分，知母十八铢，黄芩十八铢，萎蕤（玉竹）十八铢，石膏（打碎并用绵布包裹）六铢，白术六铢，干姜六铢，芍药六铢，天冬（去除心部）六铢，桂枝六铢，茯苓六铢，甘草（蜜炙）六铢。
以上十四味药，用水一斗，先煮麻黄一至二沸，去掉水面上的浮沫，加入其余药物，煎煮取汁三升，滤去药渣，分三次温服，两次服药间隔时间约为煮熟三升米所需的时间，务必服完。出汗后病愈。
【方解】
若为下寒上热且无表证的情况，应当采用黄连汤的治法；如今伴有表证，因此另行设立此方，以展示根据病情变化灵活施治的开始。升麻、萎蕤、黄芩、石膏、知母、天冬，是升举上行、清热的药物，用来避开下部的寒邪，并且滋养上部；麻黄、桂枝、干姜、当归、白芍、白术、茯苓、甘草，是辛甘发散、走表温散的药物，用来远离上部的热邪，并且调和内部。分三次温服并服完，其意图在于缓和地祛邪而不损伤正气，彻底清除病邪。脉象虽然寸脉沉迟，尺脉摸不到；症状虽然手足厥冷，腹泻不止。但究其根本并非纯粹的阴寒邪气，所以兼有咽喉疼痛、咳吐脓血的症状，这是寒热混淆、阴阳错杂的疾病，都是因误用大剂量泻下药攻伐中焦而变生出来的。所以张仲景使用此汤，以祛除邪气为主，邪气去除则正气自然安宁。
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伤寒病经过八、九天，误用泻下法，出现胸中满闷、烦躁惊悸、小便不利、谵语，全身沉重，不能翻身转侧的，由柴胡加龙骨牡蛎汤主治。
【注】
伤寒病经过八、九天，邪气未解，表证未尽，不可使用泻下法。如果误用泻下法，邪气便会乘虚内陷。在上部的，轻则胸中满闷，重则形成结胸，胸中满闷是因为热邪进入胸中，气机壅塞所致。在中部的，轻则烦躁惊悸，重则昏迷发狂，烦躁惊悸、谵语是因为热邪侵犯心脏，神志不宁所致。在下部的，轻则小便不利，重则少腹满痛，小便不利是因为热邪客居下焦，水道阻塞所致。邪气壅滞于三焦，导致营卫运行不畅，水液没有出路，便外渗至肌体，所以全身沉重，不能翻身转侧。用柴胡加龙骨牡蛎汤主治，其大意在于和解少阳、镇惊固涩，攻邪与补正兼施。
【按】
这一条所述的是阳经湿热导致的身体沉重，如果认为是津液枯竭、血液涩滞，阳气不能宣通，从而误认为是阴经湿寒导致的身体沉重，那就错了。寒湿导致的身重，使用真武汤、桂枝附子汤治疗，因为患者口不渴、体内无热；热湿导致的身重，使用白虎汤、柴胡加龙骨牡蛎汤治疗，因为患者烦渴、胃中有热。风湿、风温导致的身重，也不外乎兼夹寒邪或热邪，所以此方中使用茯苓、半夏、大黄作为佐药。
【集注】
方有执说：胸中满闷，是泻下后里气虚弱，外部热邪入里，挟带饮邪向上冲逆于膈膜，所以感到烦闷。惊悸伤及心脏，心藏神且居于膈下，正气虚弱邪气盛实，所以神志不宁。全身沉重，不能翻身转侧，是因为伤寒原本全身疼痛，亡失津液导致血液涩滞不通，所以变为沉滞且沉重感加重。
程知说：泻下后心烦腹满，用栀子、厚朴治疗，是因为邪气进入腹部。泻下后胸中满闷、烦躁惊悸，用龙骨、牡蛎治疗，是因为邪气进入心脏。因火疗劫迫而导致烦惊，用桂枝加龙骨牡蛎汤治疗，是为了挽回外越的心阳。因误下而导致烦惊，用柴胡加龙骨牡蛎汤治疗，是为了解除心阳的内塞。大陷胸汤和小陷胸汤，是根据病位高下和病情缓急来区分的；各种泻心汤，是根据寒热虚实来辨别的。半夏、茯苓治疗痰饮，黄芩、黄连降逆气，栀子、豆豉涌吐虚烦，人参、附子回阳救逆，误下后的治疗大法，都包含在这里了。
喻昌说：过了八、九天的病程才进行泻下，可以说是谨慎了！谁知道外邪尚未完全解除，便乘虚内陷，邪气尚在表里之间，祸患已经波及神明，在此时想要补救，难道容易吗？
张璐说：这属于少阳病的里证，各家注解将其当作心经疾病是错误的。少阳病有三禁，不可妄犯。虽然过了八、九天的病程，误用泻下法尚且导致邪气内犯，胃土受伤，胆木失去荣养，痰聚积在膈上，产生如此多的变证，所以主张用小柴胡汤和解内外，逐除饮邪、通畅津液，加上龙骨、牡蛎，来镇摄肝胆的惊悸。
Ephedrae Herba (Mahuang, 麻黄) [removed nodes] 2.5 liang, Cimicifugae Rhizoma (Shengma, 升麻) 1.1 liang, Angelicae Sinensis Radix (Danggui, 当归) 1.1 liang, Anemarrhenae Rhizoma (Zhimu, 知母) 18 zhu, Scutellariae Radix (Huangqin, 黄芩) 18 zhu, Polygonati Odorati Rhizoma (Weirui, 萎蕤) 18 zhu, Gypsum Fibrosum (Shigao, 石膏) [crushed and wrapped in cotton] 6 zhu, Atractylodis Macrocephalae Rhizoma (Baizhu, 白术) 6 zhu, Zingiberis Rhizoma Recens (Ganjiang, 干姜) 6 zhu, Paeoniae Radix Alba (Shaoyao, 芍药) 6 zhu, Asparagi Radix (Tian dong, 天冬) [core removed] 6 zhu, Cinnamomi Ramulus (Guizhi, 桂枝) 6 zhu, Poria (Fuling, 茯苓) 6 zhu, Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) [honey-fried] 6 zhu.
The above fourteen ingredients are decocted with one dou of water. First, boil Ephedrae Herba for one or two boils, remove the foam on the surface, then add the remaining herbs. Decoct until three sheng of liquid remain, filter out the dregs, and divide into three warm doses. The interval between doses should be approximately the time it takes to cook three sheng of rice. Take all the medicine. Recovery occurs when sweating ensues.
[Fangjie - Formula Analysis]
If the condition presents as cold below and heat above without exterior syndrome, the method of Huanglian Tang (Coptis Decoction) should be adopted. Since an exterior syndrome is present now, this formula is established separately to demonstrate the beginning of flexible treatment based on symptom changes. Cimicifugae Rhizoma, Polygonati Odorati Rhizoma, Scutellariae Radix, Gypsum Fibrosum, Anemarrhenae Rhizoma, and Asparagi Radix are herbs that ascend and clear heat; they are used to avoid the cold below and nourish the upper part. Ephedrae Herba, Cinnamomi Ramulus, Zingiberis Rhizoma Recens, Angelicae Sinensis Radix, Paeoniae Radix Alba, Atractylodis Macrocephalae Rhizoma, Poria, and Glycyrrhizae Radix et Rhizoma are acrid-sweet herbs that move outward and disperse warmth; they are used to distance from the heat above and harmonize the interior. Dividing into three warm doses ensures complete intake; the intention is to expel pathogens gently without damaging healthy qi, thoroughly eliminating the pathogen. Although the pulse is deep and slow at the Cun position and absent at the Chi position; although symptoms include cold extremities and continuous diarrhea; fundamentally, it is not a pure yin-cold pathogen. Therefore, there are concurrent symptoms of sore throat and expectoration of pus and blood. This is a disease of confused cold and heat, mixed yin and yang, resulting from severe purgation damaging the middle jiao. Thus, Zhang Zhongjing uses this decoction primarily to expel pathogens; once pathogens are expelled, healthy qi naturally settles.
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In Taiyang Cold Damage (Shanghan), after eight or nine days, if purgation is mistakenly applied, resulting in chest fullness, irritability, fright, difficulty in urination, delirious speech, heaviness of the entire body, and inability to turn over, Chaihu Jia Longgu Muli Tang (Bupleurum Decoction plus Dragon Bone and Oyster Shell) is indicated.
[Zhu - Annotation]
After eight or nine days of Taiyang Cold Damage, if the pathogen is unresolved and the exterior syndrome is not cleared, purgation should not be used. If purgation is mistakenly applied, the pathogen will sink inward due to deficiency. In the upper part, mild cases present with chest fullness, while severe cases present with Jie Xiong (chest binding); chest fullness is caused by heat entering the chest and qi stagnation. In the middle part, mild cases present with irritability and fright, while severe cases present with coma and mania; irritability, fright, and delirious speech are caused by heat affecting the Heart, leading to restless Shen (spirit). In the lower part, mild cases present with difficulty in urination, while severe cases present with hypogastric fullness and pain; difficulty in urination is caused by heat lodging in the Lower Jiao, obstructing the water passages. Pathogenic factors stagnating in the San Jiao (Triple Burner) prevent the smooth flow of Ying (Nutritive) and Wei (Defensive) Qi. With no outlet for water, it seeps externally into the muscles and skin, causing heaviness of the entire body and inability to turn over. Chaihu Jia Longgu Muli Tang is used; its main principle is to harmonize and sedate, combining attack and tonification.
[An - Commentary]
This clause describes body heaviness due to damp-heat in the Yang meridians. It would be erroneous to attribute it to fluid depletion and blood stasis preventing the dissemination of Yang Qi, which would characterize body heaviness due to damp-cold in the Yin meridians. For body heaviness due to cold-damp, Zhenwu Tang (True Warrior Decoction) and Guizhi Fuzi Tang (Cinnamon Twig and Aconite Decoction) are used because there is no thirst and no internal heat. For body heaviness due to heat-damp, Baihu Tang (White Tiger Decoction) and Chaihu Jia Longgu Muli Tang are used because there is irritability/thirst and stomach heat. Body heaviness due to Wind-Damp or Wind-Warmth also involves combinations of cold or heat; thus, this formula uses Poria, Pinelliae Rhizoma, and Rhei Radix et Rhizoma as assistants.
[Jizhu - Collected Annotations]
Fang Youzhi stated: Chest fullness results from interior deficiency after purgation, allowing external heat to enter the interior and carry phlegm-fluid upward to the diaphragm, causing irritability. Fright injures the Heart; the Heart houses the Shen and resides below the diaphragm. When healthy qi is deficient and pathogenic factors prevail, the Shen becomes restless. Heaviness of the entire body and inability to turn over occur because Taiyang Cold Damage originally causes whole-body pain. Depletion of body fluids leads to blood stasis and obstruction, transforming into sinking stagnation and increased heaviness.
Cheng Zhi stated: Irritability and abdominal fullness after purgation are treated with Gardeniae Fructus and Magnoliae Officinalis Cortex because the pathogen has entered the abdomen. Chest fullness, irritability, and fright after purgation are treated with Dragon Bone and Oyster Shell because the pathogen has entered the Heart. Irritability and fright caused by fire therapy are treated with Guizhi Jia Longgu Muli Tang to rescue the outwardly floating Heart Yang. Irritability and fright caused by purgation are treated with Chaihu Jia Longgu Muli Tang to resolve the internal blockage of Heart Yang. Xiaoxianxiong Tang (Minor Intra-thoracic Binding Decoction) and Daxianxiong Tang (Major Intra-thoracic Binding Decoction) are distinguished by high/low location and urgency/xiety. Various Xiexin Tang (Drain the Epigastrium Decoctions) are differentiated by cold/heat and deficiency/excess. Pinelliae Rhizoma and Poria treat phlegm; Scutellariae Radix and Scutellariae Barbatae? No, Huanglian (Coptidis Rhizoma) directs rebellious qi downward; Gardeniae Fructus and Sojae Preparata (Zhi Chi) induce vomiting for empty irritability; Ginseng Radix and Aconiti Lateralis Radix Praeparata restore Yang in deficiency. The major principles of treatment after purgation are fully contained herein.
Yu Chang stated: Purging after passing eight or nine days seems cautious! Who knew that incomplete external pathogens would sink inward due to deficiency? While the pathogen is still between the exterior and interior, the affliction has already reached the Shen (Spirit). To remedy this situation, is it easy?
Zhang Lu stated: This belongs to the interior syndrome of Shaoyang (Lesser Yang). Previous annotations incorrectly classified it as a Heart Meridian disease. Shaoyang has three prohibitions and must not be violated arbitrarily. Even after eight or nine days, mistaken purgation causes the pathogen to invade internally, injuring Stomach Earth and depriving Gallbladder Wood of nourishment. Phlegm accumulates above the diaphragm, causing such transformations. Therefore, Xiaochaihu Tang (Minor Bupleurum Decoction) is used to harmonize the interior and exterior, expel fluid retention, and unblock fluids, supplemented with Dragon Bone and Oyster Shell to calm the fright of the Liver and Gallbladder.