程应旄曰∶如得阳明病而发潮热，似乎胃实之征矣。但胃实必大便硬而小便数，今大便溏小便自可，是热
非入腑之热也，再以胸胁征之，则主以小柴胡汤无疑矣。
阳明病，胁下硬满，不大便而呕，舌上白苔者，可与小柴胡汤，上焦得通，津液得下，胃气因和，身
然汗出而解。
【注】阳明病，不大便，胁下硬满而呕，是阳明传少阳病也。若舌上黄苔涩者，为阳明之热未尽，则当与
大柴胡汤两解之。今舌上白苔滑者，是已传少阳，故可与小柴胡汤和解之。俾上集得通，则呕可止，津液得下，
则便可通，胃气因和而硬满除，则身心 然汗出而解矣。
【集注】程知曰∶此言阳明兼少阳，宜用小柴胡也。不但大便溏为胃未实，即使不大便而呕，亦为邪未
入里。硬满在胁而不在腹，舌苔白而不黄，皆少阳之见证多。故当从小柴胡分解阴阳，则上下通和， 然汗出，
而表里之邪为之一撤矣。
程应旄曰∶胁下硬满，不大便而呕，是大柴胡汤证也。其用小柴胡汤者，以舌上白苔，犹带表寒故也。若
苔不滑而涩，则所谓舌上干燥而烦，欲饮水数升，谓里热已耗及津液，此汤不可主矣。又曰∶上焦得通，照胁
下硬满言；津液得下，照舌苔与呕言；胃气因和，照不大便言。上条阳明病，从潮热上见，此条阳明病，从不
大便上见。
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，却发热汗出而解。
【注】凡柴胡汤病证，不与柴胡汤而反下之，不变他病，柴胡证仍在者，可复与柴胡汤则解。但以误下，
其证必虚，故解必蒸蒸而热，振振而寒，邪正交争，然后汗出而解也。
【集注】方有执曰∶蒸蒸而振作战汗也，必如此而后解者，以下后里虚故也。
程知曰∶邪气还表，故蒸蒸而热；下后正虚，故振振而动。
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，本渴而饮水呕者，柴胡汤不中与也，食谷者哕。
【按】“食谷者哕”四字，衍文。食谷呕者有之，从无哕者。
【注】得病六七日，少阳入太阴之时也。脉迟太阴脉也，浮弱太阳脉也，恶风寒太阳证也，手足温太阴证
也，医不以柴胡桂枝汤解而和之，反二三下之，表里两失矣。今不能食，胁下满痛，虽似少阳之证，而实非少
阳也。面目及身发黄，太阴之证已具也；颈项强，则阳明之邪未已也。小便难者，数下夺津之候也。此皆由医
之误下，以致表里杂揉，阴阳同病，若更以有少阳胁下满痛之一证不必悉具，而又误与柴胡汤，则后必下重，
是使邪更进于太阴也。虽有渴证，乃系数下夺津之渴。其饮水即呕，亦非少阳本证之呕，缘误下所致，故柴胡
汤不中与也。
【集注】程知曰∶前言柴胡证，但见一证便是。此更言胁下满痛，亦有不宜柴胡者，以为戒也。
程应旄曰∶以一渴证辨之，前条之手足温而渴者，热在里，未经数下，自能消水。今本渴而饮水则呕，知
其渴为膈燥津亡之渴，数下中虚，不能消水，究于胃阳无涉。然则柴胡汤之于少阳，岂可云但见一证便是乎？
又岂可云下之而柴胡证不罢者复与柴胡汤乎？
伤寒六七日，发热微恶寒，支节烦疼，微呕，心下支结，外证未去者，柴胡桂枝汤主之。
【注】伤寒六七日，发热微恶寒，支节烦疼，微呕，心下支结者，是太阳之邪传少阳也。故取桂枝之半，
以散太阳未尽之邪；取柴胡之半，以散少阳呕结之实病。而不名桂枝柴胡汤者，以太阳外证虽未去，而病机已
见于少阳里也。故以柴胡冠桂枝之上，意在解少阳为主而散太阳为兼也。支者，侧也，小也。支结者，即心下
侧之小结也。
【集注】方有执曰∶支节，四肢骨节也。支结，言支饮抟聚而结也。发热至微呕，太阳之表也，故曰∶外
证未去。
程知曰∶此邪入少阳，而太阳证未去者也。发热恶寒，支节烦疼，太阳证也；乃恶寒而微，但支节烦痛，
而不头项强痛，则太阳证亦稍减矣。呕而支结，少阳证也；乃呕逆而微，但结于心下之偏旁，而不结于两胁之
间，则少阳亦尚浅也。若此者，惟当以柴胡汤和解少阳，而加以桂枝汤发散太阳，此不易之法也。
柴胡桂枝汤方
柴胡（四两） 桂枝（一两半） 人参（一两半） 甘草（炙，一两） 半夏（洗，二合半） 黄芩
（一两半） 芍药（一两半） 大枣（擘，六枚） 生姜（切，一两半）
上九味，以水七升，煮取三升，去滓，温服一升。
【集解】柯琴曰∶仲景书中最重柴、桂二方。以桂枝解太阳肌表，又可以调诸经之肌表；小柴胡解少阳半
表，亦可以和三阳之半表。故于六经病外，独有桂枝证、柴胡证之称，见二方之任重不拘于经也。如阳浮阴弱
条，是仲景自为桂枝证之注释；血弱气尽条，是仲景自为柴胡证之注释。桂枝有坏病，柴胡亦有坏病。桂枝有
疑似证，柴胡亦有疑似证。如病似桂枝证，脚挛急与胸中痞硬者，及病似柴胡证，本渴而饮水呕，与但欲呕胸
中痛者是已。此条言伤寒六七日，寒热当退之时，反见发热恶寒诸表证，更见心下支结诸里证，表里不解，法
当表里双解之矣。然恶寒微，则发热亦微，可知支节烦疼，则一身骨节不疼；可知微呕心下亦微结，故谓之支
结，是表证虽不去而已轻，里证虽已见而未甚。故取桂枝之半以散太阳未尽之邪，取柴胡之半以解少阳微结之
证。口不渴身有微热者，法当去人参，以六七日邪虽未解，而正已虚，故仍用之。外证虽在，而病机已见于里，
故方以柴胡冠桂枝之上，为双解两阳之轻剂也。
伤寒五六日，已发汗而复下之，胸胁满微结，小便不利，渴而不呕，但头汗出，往来寒热，心烦者，此为
未解也，柴胡桂枝干姜汤主之。
【注】伤寒五六日，已发其汗，表未解而复下之，若邪陷入阳明之里，则必作结胸痞硬，协热下利等证。
今邪陷入少阳之里，故令胸胁满微结也。小便不利渴而不呕者，非停水之故，乃汗下损其津液也。论中有身无
汗，独头汗出，发热不恶寒心烦者，乃阳明表热郁而不得外越之头汗也。今但头汗出，往来寒热，心烦者，无
阳明证，知为少阳表热，郁而不和，上蒸之头汗也。此为少阳表里未解之证，故主柴胡桂枝干姜汤，以专解半
表之邪，兼散半里之结也。
【集注】林澜曰∶五六日，已经汗下之后，则邪当解。今胸胁满微结，寒热心烦者，是邪犹在半表半里
之间也。小便不利而渴，乃汗下后亡津液内燥也。若有热饮，其人必呕，今渴而不呕，知非饮热也。伤寒汗出
则和，今但头汗出，余处无汗者，津液不足而未和也，与柴胡桂枝干姜汤，以解表里而复津液也。
汪琥曰∶伤寒头汗出者，乃阳郁于表，非阳虚于上也。
柴胡桂枝干姜汤方
柴胡（半斤） 桂枝（三两） 干姜（二两） 栝蒌根（四两） 黄芩（三两） 牡蛎（二两） 甘草（炙，二两）
上七味，以水一斗二升，煮取六升，去滓，再煎，取三升，温服一升，日三服，初服微烦，复服汗出便愈。
【方解】少阳表里未解，故以柴胡桂枝合剂而主之，即小柴胡汤之变法也。去人参者，因其正气不虚；
减半夏者，以其不呕，恐助燥也。加栝蒌根，以其能止渴兼生津液也；倍柴胡加桂枝，以主少阳之表；加牡蛎，
以软少阳之结。干姜佐桂枝，以散往来之寒；黄芩佐柴胡，以除往来之热，且可制干姜不益心烦也。诸药寒温
不一，必需甘草以和之。初服微烦，药力未及；复服汗出即愈者，可知此证非汗出不解也。
服柴胡汤已，渴者，属阳明，以法治之。
【注】风寒之邪从阳明而传少阳，起初不渴，今服柴胡汤已，反渴者，是少阳转属阳明也。以法治之，
谓当分其经腑见证而治之也。葛根、白虎、调胃间，各从其宜而用之可耳！
【集注】方有执曰∶已，毕也。服柴胡汤已毕而渴，则非暂渴，其为热已入胃亡津液而渴可知，故曰∶
属阳明也。
沈明宗曰∶服柴胡汤已渴者，乃少阳之邪不传三阴，而转入阳明矣，即当随阳明现
证而治，故谓以法治之。
郑重光曰∶少阳、阳明之病机，在呕渴中分，渴则转属阳明，呕则仍在少阳。如呕多虽有阳明证，不可攻
之，因病未离少阳也，服柴胡汤渴当止。若服柴胡汤已加渴者，是热入胃腑。耗津消水，此属阳明胃病也。
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，假令纯阴结，不得复有外证，悉入在里，此为半在里半在外也。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。
【按】脉细，当是“脉沉细”，观本条下文，“脉沉亦在里也”之“亦”字，自知。脉虽沉紧之“紧”字，
当是“细”字。本条上文并无“紧”字，如何说脉虽沉紧，“虽”字何所谓耶？必是传写之误。
【注】伤寒五六日，虽表有头汗出，微恶寒之阳邪未罢，里有心下满，口不欲食，大便硬之阳结已形，但
手足冷脉沉细，则阳邪所结殊微也，故曰，此为阳微结，必有表复有里也。然脉沉细，似乎里阴盛，而头汗出，
则为表阳郁也。假令纯阴结，则不得复有头汗出之外证，始合悉入在里之纯阴结矣。夫既非悉入在里之纯阴结，
此必为半在里、半在表之阳微结也，故脉虽沉细，不得为少阴病。所以然者，三阴不得有汗，今头汗出，故知
非少阴也。可与小柴胡汤者，和其不通身汗出微恶寒也。设不了了者，必大便之硬未除，自宜利其大便使得屎
而解也。
【集注】喻昌曰∶阳微结者，阳邪微结未尽散也。旧注作阳气衰微，故邪气结聚大差。果尔，则头汗出为
亡阳之证，非半表半里之证矣；果尔，则阴结又是阴气衰微矣。玩本文假令纯阴结，及阳邪若不微结，是纯阴
邪内结，则不得复有外证等语，其义甚明。
程知曰∶此言少阳病有似少阴者，当细辨其脉证也。
程应旄曰∶凡脉细、脉沉，皆阴脉也。今与阳证同见，则为阳热郁结之诊，无关少阴也。可见阳气一经郁
结，不但阳证似阴，并阳脉亦似阴矣。
沈明宗曰∶得屎而解，当用大柴胡之法也。
吴人驹曰∶此证尝见有误作阴寒而施温热以致大逆者，盖因其恶寒，手足冷，脉细而沉，不究其证之始
末由来也。
周扬俊曰∶此条恶寒肢冷不欲食，脉细或沉，有似乎阴，最难辨晰，仲景特出“阳微结”三字，昭示千
古。以头汗出为阳，阴不得有汗也。至五六日头痛发热，证原属阳也，故纵见少阴之脉，不得为少阴之病。然
独未见少阳一证，何遽得为少阳病耶？此仲景所以又明言半在表半在里也。尔时里证既多，不得纯以表药汗之；
外证似阴，不得复以里药温之，故取小柴胡提出其邪于表里之半，而大便硬不了了者，则当下之得屎无疑也。
仲景恐人未明，自为详辨，然后知手足冷微恶寒者，正因阳邪郁结，不外通于肢体，故独头汗出也。
伤寒阳脉涩，阴脉弦，法当腹中急痛者，先与小建中汤，不瘥者，与小柴胡汤主之。
【注】伤寒脉得浮涩，营卫不足也；脉得沉弦，木入土中也。营卫不足则表虚，木入土中则里急。惟表
虚里急，腹中急痛，所以先用小建中汤，以其能补营卫兼缓中急，则痛可瘥也。或不瘥，必邪尚滞于表。知涩
为营卫不通，弦为少阳本脉，故与小柴胡汤，按法施治也。成无己去黄芩加芍药，疏外调中，其说亦是。
【集注】汪琥曰∶弦脉不除，痛犹未止者，为不瘥，此为少阳经有留邪也。
伤寒胸中有热，胃中有邪气，腹中痛，欲
呕吐者，黄连汤主之。
【注】伤寒未解欲呕吐者，胸中有热邪上逆也；腹中痛者，胃中有寒邪内攻也。此热邪在胸，寒邪在胃，
阴阳之气不和，失其升降之常，故用黄连汤，寒温互用，甘苦并施，以调理阴阳而和解之也。然此属外，因上
下寒热之邪，故有如是之证；若内因杂病，呕吐而腹痛者，多因宿食。由此推之，外因、内因，证同而情异，
概可知矣。
【集注】程知曰∶阴邪在腹，则阳不得入而和阴，为腹痛；阳邪在上，则阴不得入而和阳，为欲呕逆。
汪琥曰∶《尚论篇》皆以风寒二邪，分阴阳寒热。殊不知风之初来未必非寒，寒之既入亦能化热，不可拘也。
郑重光曰∶此热邪中于上焦，寒邪中于下焦，阴阳不相入，失其上下升降之常也。
黄连汤方
黄连（三两） 甘草（炙，三两） 干姜（三两） 人参（二两） 桂枝（三两） 半夏（洗，半升） 大枣
（擘，十二枚）
上七味，以水一斗，煮取六升，去滓，温服，昼三夜二。
【方解】伤寒邪气入里，因人脏气素有之寒热而化病。如阳明病，硬满不大便而呕，舌上白苔者，以小
柴胡汤，及太阳病下之里虚懊 ，舌上如苔者，以栀子豉汤之类，是随胸中有寒，丹田有热化者也。此则随胃
程应旄说：如果得了阳明病，出现定时发热（潮热），这似乎是胃中有实邪的表现。但是，胃中实邪必定是大便干硬且小便频数，现在大便稀溏、小便正常，说明这是热邪而非入腑的实热。再结合胸胁部的症状来看，主治方剂无疑是小柴胡汤。
阳明病，胁下部位硬满，不大便并且呕吐，舌苔白滑的，可以给予小柴胡汤。上焦气机通畅后，津液得以输布下行，胃气因此调和，身体便会微微出汗而痊愈。
【注】阳明病，出现不大便、胁下硬满并伴有呕吐，这是阳明病传变为少阳病的表现。如果舌苔黄且干燥涩滞，说明阳明之热未尽，则应当用大柴胡汤表里双解。如今舌苔白且滑润，说明病已传入少阳，所以可以给予小柴胡汤和解少阳。使得上焦通畅，呕吐即可停止；津液下行，大便即可通畅；胃气调和，硬满消除，身体便会微微出汗而痊愈。
【集注】程知说：这里讲的是阳明病兼有少阳病，适宜使用小柴胡汤。不仅大便溏说明胃未实，即使不大便且呕吐，也说明邪气未完全入里。硬满位于胁下而非腹部，舌苔白而非黄，这些都是少阳见证较多的表现。因此应当通过小柴胡汤来分解阴阳，使得上下通和，微微出汗，表里之邪便随之消除。
程应旄说：胁下硬满、不大便且呕吐，本是大柴胡汤的适应证。之所以用小柴胡汤，是因为舌苔白，还带有表寒的缘故。如果舌苔不滑而涩，那就是所谓的“舌上干燥而烦，想喝几升水”，说明里热已经耗伤津液，这种时候就不适用此汤了。他又说：“上焦得通”是呼应胁下硬满；“津液得下”是呼应舌苔与呕吐；“胃气因和”是呼应不大便。上一条提到的阳明病，是从潮热方面体现的；这一条提到的阳明病，是从不大便方面体现的。
凡是柴胡汤证的病人，如果被误用攻下法，若柴胡证没有消失的，再次给予柴胡汤，病人一定会出现全身蒸热并战栗，随后发热出汗而痊愈。
【注】凡是柴胡汤证，如果不给柴胡汤反而误用攻下法，病情没有转变为其他疾病，柴胡证仍在的，可以再次给予柴胡汤从而痊愈。但因为误用攻下，正气必然虚弱，所以痊愈时必定先出现蒸蒸发热、振寒冷战，这是邪气与正气交争，然后出汗而解。
【集注】方有执说：蒸蒸而振表现为战汗，必须这样之后才能痊愈，是因为攻下后里气虚弱的缘故。
程知说：邪气回归体表，所以全身蒸热；攻下后正气虚弱，所以身体振颤动摇。
患病六七天，脉象迟而浮弱，怕风怕冷，手脚温暖，医生连续两次三次地攻下，导致不能进食，且胁下满痛，面目及全身发黄，颈项强直，小便困难的，如果给予柴胡汤，之后必定会出现肛门坠重感。原本口渴但喝水即呕吐的，不可给予柴胡汤，进食谷物时会打嗝。
【按】“食谷者哕”这四个字，是衍文（多余的文字）。有进食呕吐的情况，但从没有进食打嗝的情况。
【注】患病六七天，是少阳病转入太阴病的时候。脉迟是太阴脉，浮弱是太阳脉，恶风寒是太阳证，手足温是太阴证。医生不用柴胡桂枝汤来解表和里，反而连续攻下，导致表里两伤。现在不能进食、胁下满痛，虽然看似少阳证，但实际上并非少阳证。面目及全身发黄，说明太阴证已具备；颈项强直，说明阳明邪气尚未消除。小便困难，是多次攻下夺去津液的征候。这都是因为医生误用攻下，导致表里杂糅，阴阳同病。如果仅仅因为有少阳胁下满痛这一个症状就认为不必全部具备，又误用柴胡汤，那么之后必定出现肛门坠重，这是使邪气进一步陷入太阴。虽然有口渴的症状，但这属于多次攻下夺去津液引起的口渴。喝水即呕吐，也不是少阳本证的呕吐，而是由误下导致的，所以柴胡汤不可用。
【集注】程知说：前面说柴胡证只要见到一个症状就可以确诊。这里更进一步说，即使是胁下满痛，也有不宜使用柴胡汤的情况，以此作为警戒。
程应旄说：通过一个口渴的症状来辨别，前一条提到手足温且口渴的，是热在里，未经过多次攻下，自然能消化水液。如今本来口渴但喝水就呕吐，可知其渴是由于膈部燥热、津液亡失所致，多次攻下导致中气虚弱，不能消化水液，这与胃阳无关。既然这样，那么对于少阳病，难道可以说只要见到一个症状就是柴胡汤证吗？难道可以说攻下后柴胡证没消失就可以再次给予柴胡汤吗？
伤寒六七天，发热且轻微怕冷，四肢关节烦痛，轻微呕吐，心下部支撑胀满，外部表证仍未解除的，主方为柴胡桂枝汤。
【注】伤寒六七天，出现发热、轻微怕冷、四肢关节烦痛、轻微呕吐、心下部支撑胀满，这是太阳之邪传入少阳的表现。所以取桂枝的一半剂量，以发散太阳未尽的邪气；取柴胡的一半剂量，以消散少阳呕逆结滞的实证。而不命名为桂枝柴胡汤的原因，是因为虽然太阳外证未除，但病机已经体现在少阳里证上了。所以将柴胡冠于桂枝之上，意在以解少阳为主，发散太阳为兼治。支，意为侧、小。支结，即心下部侧面小结滞的意思。
【集注】方有执说：支节，指四肢骨节。支结，指支饮聚结而成。从发热到轻微呕吐，属于太阳表证，所以说：外证未去。
程知说：这是邪气进入少阳，而太阳证未去的情况。发热恶寒、四肢关节烦痛，是太阳证；但恶寒轻微，仅四肢关节烦痛，而没有头项强痛，说明太阳证也已稍减。呕吐且心下支结，是少阳证；但呕吐轻微，仅结于心下偏侧，而未结在两胁之间，说明少阳病位尚浅。像这种情况，只应当用柴胡汤和解少阳，加上桂枝汤发散太阳，这是不变的方法。
柴胡桂枝汤方
柴胡（四两） 桂枝（一两半） 人参（一两半） 甘草（炙，一两） 半夏（洗，二合半） 黄芩（一两半） 芍药（一两半） 大枣（掰开，六枚） 生姜（切，一两半）
以上九味药，用水七升，煮取三升，去渣，温服一升。
【集解】柯琴说：仲景书中最重视柴胡、桂枝两个方子。桂枝汤能解太阳肌表之邪，也可以调理各经的肌表；小柴胡汤能解少阳半表之邪，也可以调和三阳的半表。所以在六经病之外，独有桂枝证、柴胡证的称呼，可见这两个方子的作用重大，不拘泥于某一经。如“阳浮阴弱”条，是仲景自为桂枝证的注释；“血弱气尽”条，是仲景自为柴胡证的注释。桂枝汤证有坏病，柴胡汤证也有坏病。桂枝汤证有疑似证，柴胡汤证也有疑似证。如病似桂枝证，脚挛急与胸中痞硬的，以及病似柴胡证，本来口渴但喝水呕吐，与只想呕吐胸痛的都是。这一条讲伤寒六七天，寒热应当退去的时候，反而出现发热恶寒等表证，更见心下支结等里证，表里都不解，依法应当表里双解。然而恶寒轻微，则发热也轻微，可知四肢关节烦痛，则全身骨节不疼；可知轻微呕吐心下也微结，所以称为支结，这说明表证虽未去但已轻，里证虽已现但未甚。所以取桂枝的一半以散太阳未尽之邪，取柴胡的一半以解少阳微结之证。口不渴身有微热的，依法应当去掉人参，因为六七天邪气虽未解，但正气已虚，所以仍用人参。外证虽在，但病机已见于里，所以方名以柴胡冠于桂枝之上，成为双解两阳的轻剂。
伤寒五六天，已经发汗却又攻下，胸胁满闷微有结滞，小便不利，口渴但不呕吐，只有头部出汗，往来寒热，心烦的，这是病未解除，主方为柴胡桂枝干姜汤。
【注】伤寒五六天，已经发汗，表证未解却又攻下，如果邪气陷入阳明之里，必定会出现结胸痞硬、协热下利等症状。如今邪气陷入少阳之里，所以导致胸胁满闷微有结滞。小便不利、口渴但不呕吐，不是停水的缘故，而是汗下损伤了津液。论著中有身无汗、独头汗出、发热不恶寒心烦的，那是阳明表热郁结不得外越导致的头汗。如今只是头汗出、往来寒热、心烦，没有阳明证，可知这是少阳表热郁结不和，向上蒸腾导致的头汗。这是少阳表里未解的证候，所以主用柴胡桂枝干姜汤，专门解半表之邪，兼散半里之结。
【集注】林澜说：五六天，已经经过汗下治疗后，邪气应当解除。如今胸胁满闷微结，寒热心烦，说明邪气仍在半表半里之间。小便不利而渴，是汗下后津液亡失、内部干燥所致。如果有热饮，人必定呕吐，如今渴而不呕，可知不是饮热。伤寒出汗则平和，如今只有头汗出，其余地方无汗，是津液不足而未调和，给予柴胡桂枝干姜汤，以解表里并恢复津液。
柴胡桂枝干姜汤方
柴胡（半斤） 桂枝（三两） 干姜（二两） 栝蒌根（四两） 黄芩（三两） 牡蛎（二两） 甘草（炙，二两）
以上七味药，用水一斗二升，煮取六升，去渣，再煎，取三升，温服一升，每日三次。初服时轻微心烦，再服后出汗即愈。
【方解】少阳表里未解，所以用柴胡桂枝合剂为主方，这是小柴胡汤的变法。去掉人参，是因为正气不虚；减半夏，是因为不呕吐，恐怕助燥。加栝蒌根，是因为它能止渴兼生津液；倍用柴胡加桂枝，以主治少阳之表；加牡蛎，以软坚散结少阳之结。干姜佐桂枝，以散往来寒热中的寒；黄芩佐柴胡，以除往来寒热中的热，且可制约干姜不加重心烦。诸药寒温不一，必需甘草来调和它们。初服轻微心烦，是药力未到；再服出汗即愈，可知此证非出汗不解。
服用柴胡汤后，出现口渴的，属于阳明病，按照阳明病的方法治疗。
【注】风寒之邪从阳明传入少阳，起初不口渴，如今服用柴胡汤后，反而口渴，这是少阳转属阳明。按照法治之，意思是应当区分经络和脏腑的见证来治疗。葛根汤、白虎汤、调胃承气汤之间，各自根据适宜情况选用即可！
【集注】方有执说：已，意为完毕。服用柴胡汤完毕后出现口渴，则不是暂时口渴，可知是热邪已入胃中、亡失津液而致渴，所以说：属于阳明。
沈明宗说：服用柴胡汤后出现口渴的，是少阳之邪不传三阴，而转入阳明了，就应当随阳明现证而治，所以说按照法治之。
郑重光说：少阳、阳明病的病机，在呕和渴中区分，口渴则转属阳明，呕吐则仍在少阳。如呕吐多即使有阳明证，也不可攻下，因病未离少阳。服用柴胡汤后渴应当停止。如果服用柴胡汤后反而加重口渴，是热入胃腑，耗伤津液消水，这属于阳明胃病。
伤寒五六天，头汗出，轻微怕冷，手脚冷，心下满，口不想吃东西，大便硬，脉细的，这是阳微结，既有表证又有里证，脉沉也在里。汗出为阳微，假如是纯阴结，不得再有外部证候，全部入在里，这是半在里半在外。脉虽沉紧，不能诊断为少阴病，之所以这样，是因为阴证不得有汗，如今头汗出，所以知道不是少阴病，可以给予小柴胡汤。如果病势不缓解，排大便后即可痊愈。
【按】脉细，应当是“脉沉细”，看本条下文，“脉沉亦在里也”的“亦”字，自然知晓。脉虽沉紧的“紧”字，应当是“细”字。本条上文并无“紧”字，怎么说脉虽沉紧，“虽”字从何说起呢？必定是传写错误。
【注】伤寒五六天，虽然表有头汗出、轻微怕冷的阳邪未罢，里有心下满、口不想吃东西、大便硬的阳结已形成，但手脚冷、脉沉细，说明阳邪结聚非常轻微，所以说：这是阳微结，既有表证又有里证。然而脉沉细，似乎里阴盛，但头汗出，则是表阳郁结。假如是纯阴结，就不会再有头汗出这样的外部证候，这才符合悉入在里的纯阴结。既然不是悉入在里的纯阴结，这必定是半在里、半在表的阳微结，所以脉虽沉细，不能诊断为少阴病。之所以这样，是因为三阴证不得有汗，如今头汗出，所以知道不是少阴病。可以给予小柴胡汤，是为了调和不通畅的身体、轻微怕冷的症状。如果病势不缓解，必定是大便硬未除，自然应当通利大便，使得排大便后痊愈。
【集注】喻昌说：阳微结，是指阳邪微结未尽散。旧注作阳气衰微，所以邪气结聚大错。果真那样，则头汗出就是亡阳的证候，不是半表半里的证候了；果真那样，则阴结又是阴气衰微了。玩味本文“假令纯阴结”及“阳邪若不微结，是纯阴邪内结，则不得复有外证”等语，其义非常明显。
程知说：这里讲的是少阳病有类似少阴的情况，应当仔细辨别其脉证。
程应旄说：凡是脉细、脉沉，都是阴脉。如今与阳证同时出现，就是阳热郁结的诊断，与少阴无关。可见阳气一经郁结，不但阳证似阴，连阳脉也似阴了。
吴人驹说：这个证候曾见有人误作阴寒而施以温热药，导致大逆，大概是因为看到恶寒、手脚冷、脉细而沉，不探究证候的始末由来。
周扬俊说：这一条恶寒肢冷不欲食，脉细或沉，有类似阴证的样子，最难辨晰，仲景特意提出“阳微结”三个字，昭示千古。以头汗出为阳，阴证不得有汗。到了五六天头痛发热，证原属阳，所以纵然见到少阴之脉，不得诊断为少阴病。然而唯独未见少阳一证，怎么就能说是少阳病呢？这就是仲景所以要明确说明半在表半在里的原因。此时里证既多，不得纯用表药发汗；外证似阴，不得再用里药温补，所以取小柴胡汤将其邪气提出于表里之间，而大便硬病势不缓解的，则当下之，排大便无疑。
仲景恐人不明白，自为详细辨析，然后知道手脚冷、轻微怕冷，正是因为阳邪郁结，不能通达于肢体，所以只有头汗出。
伤寒阳脉涩，阴脉弦，依法应当腹中急痛的，先给予小建中汤，不愈的，给予小柴胡汤为主方。
【注】伤寒脉得浮涩，是营卫不足；脉得沉弦，是木入土中。营卫不足则表虚，木入土中则里急。只有表虚里急，腹中急痛，所以先用小建中汤，因为它能补营卫兼缓中急，则疼痛可愈。或者不愈，必定是邪气尚滞留于表。知涩为营卫不通，弦为少阳本脉，所以给予小柴胡汤，按照法则施治。成无己去掉黄芩加芍药，疏外调中，他的说法也是对的。
【集注】汪琥说：弦脉不除，疼痛仍未停止的，为不愈，这是少阳经有留邪。
【注】伤寒未解想要呕吐的，是胸中有热邪上逆；腹中痛的，是胃中有寒邪内攻。这是热邪在胸，寒邪在胃，阴阳之气不和，失去升降常态，所以用黄连汤，寒温互用，甘苦并施，以调理阴阳而和解。然而这属于外感，因上下寒热之邪，所以有此证候；若是内伤杂病，呕吐而腹痛的，多因宿食。由此推之，外因、内因，证候相同而情状不同，概可知矣。
【集注】程知说：阴邪在腹，则阳不得入而和阴，为腹痛；阳邪在上，则阴不得入而和阳，为欲呕逆。
汪琥说：《尚论篇》皆以风寒二邪分阴阳寒热。殊不知风之初来未必非寒，寒之既入亦能化热，不可拘泥。
郑重光说：此热邪中于上焦，寒邪中于下焦，阴阳不相入，失去上下升降常态。
黄连汤方
黄连（三两） 甘草（炙，三两） 干姜（三两） 人参（二两） 桂枝（三两） 半夏（洗，半升） 大枣（掰开，十二枚）
以上七味药，用水一斗，煮取六升，去渣，温服，白天三次晚上两次。
【方解】伤寒邪气入里，因人脏气素有之寒热而化病。如阳明病，硬满不大便而呕，舌上白苔者，以小柴胡汤，及太阳病下之里虚懊憹，舌上如苔者，以栀子豉汤之类，是随胸中有寒，丹田有热化者也。此则随胃……
Cheng Yingmao stated: If a patient with Yangming disease presents with tidal fever (periodic high fever), it might seem like a sign of excess in the stomach. However, stomach excess must present with hard stools and frequent urination. Since the current case has loose stools and normal urination, this is heat but not the heat that has entered the fu organs. Considering the symptoms in the chest and hypochondrium, the primary formula should undoubtedly be Xiaochaihu Tang (Minor Bupleurum Decoction).
In Yangming disease, if there is hardness and fullness below the costal margin, constipation accompanied by vomiting, and a white coating on the tongue, Xiaochaihu Tang (Minor Bupleurum Decoction) may be administered. Once the Upper Jiao (Upper Burner) becomes unobstructed, body fluids can descend, the Stomach Qi harmonizes, and the patient will recover through slight sweating.
[Annotation] In Yangming disease, constipation combined with hardness/fullness below the costal margin and vomiting indicates that the Yangming disease has transmitted to Shaoyang (Lesser Yang). If the tongue coating is yellow and dry/astringent, it means the Yangming heat is not yet exhausted, and Daxiehu Tang (Major Bupleurum Decoction) should be used for simultaneous resolution of exterior and interior. Since the current tongue coating is white and slippery, the disease has transmitted to Shaoyang, so Xiaochaihu Tang (Minor Bupleurum Decoction) can be used to harmonize. By unblocking the Upper Jiao, vomiting stops; by allowing fluids to descend, bowel movements normalize; as Stomach Qi harmonizes, hardness and fullness are removed, and recovery occurs through slight sweating.
[Collected Annotations] Cheng Zhi said: This passage discusses Yangming disease concurrent with Shaoyang disease, for which Xiaochaihu Tang (Minor Bupleurum Decoction) is appropriate. Not only does loose stool indicate the stomach is not excess; even with constipation and vomiting, it indicates the pathogen has not fully entered the interior. Hardness and fullness are located in the hypochondrium, not the abdomen, and the tongue coating is white, not yellow, all indicating more signs of Shaoyang. Therefore, one should use Xiaochaihu Tang (Minor Bupleurum Decoction) to resolve Yin and Yang, leading to harmony between upper and lower, slight sweating, and the elimination of exterior and interior pathogens.
Cheng Yingmao said: Hardness/fullness below the costal margin, constipation, and vomiting are indications for Daxiehu Tang (Major Bupleurum Decoction). The reason for using Xiaochaihu Tang (Minor Bupleurum Decoction) here is that the white tongue coating still carries exterior cold. If the coating were not slippery but dry/astringent, it would correspond to "dry tongue with irritability, desiring to drink several liters of water," indicating interior heat has consumed body fluids, making this decoction unsuitable. He further stated: "Unblocking the Upper Jiao" corresponds to hardness/fullness below the costal margin; "fluids descending" corresponds to the tongue coating and vomiting; "Stomach Qi harmonizing" corresponds to constipation. The previous mention of Yangming disease was manifested through tidal fever; this mention is manifested through constipation.
For any patient with Chaihu Tang (Bupleurum Decoction) syndrome who undergoes purgation, if the Chaihu syndrome persists, administering Chaihu Tang (Bupleurum Decoction) again will result in intense internal heat and shivering, followed by fever, sweating, and recovery.
[Annotation] For any Chaihu Tang (Bupleurum Decoction) syndrome, if Chaihu Tang (Bupleurum Decoction) is withheld and purgation is mistakenly applied, provided no other disease develops and the Chaihu syndrome remains, Chaihu Tang (Bupleurum Decoction) can be readministered for recovery. However, due to the mistaken purgation, the righteous Qi is necessarily deficient; thus, recovery involves intense heat (zhengzheng) and shivering (zhenzhen), representing the struggle between pathogen and righteous Qi, culminating in sweating and resolution.
[Collected Annotations] Fang Youzhi said: Intense heat and shivering manifest as "battle sweat" (Zhan Han); recovery requires this process because the interior is deficient after purgation.
Cheng Zhi said: The pathogen returns to the exterior, causing intense heat; deficiency of righteous Qi after purgation causes shivering.
After six or seven days of illness, with a slow, floating, and weak pulse, aversion to wind and cold, warm hands and feet, if the physician performs purgation two or three times, leading to inability to eat, fullness and pain below the costal margin, yellowing of the face and body, stiffness of the neck, and difficulty urinating, administering Chaihu Tang (Bupleurum Decoction) will likely result in a sensation of heaviness in the rectum later. If the patient is thirsty but vomiting upon drinking water, Chaihu Tang (Bupleurum Decoction) is contraindicated; eating food will cause hiccups.
[Commentary] The four characters "eating food causes hiccups" are interpolations (erroneous additions). There are cases of vomiting after eating, but never hiccups after eating.
[Annotation] Six or seven days after onset is when Shaoyang (Lesser Yang) disease transitions to Taiyin (Greater Yin). A slow pulse is characteristic of Taiyin; floating and weak pulses are characteristic of Taiyang; aversion to wind and cold are Taiyang signs; warm hands and feet are Taiyin signs. The physician failed to use Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) to harmonize the exterior and interior, instead performing purgation repeatedly, damaging both exterior and interior. Now, inability to eat and fullness/pain below the costal margin appear similar to Shaoyang signs but are not truly Shaoyang. Yellowing of the face and body indicates Taiyin signs are established; neck stiffness indicates Yangming pathogen persists. Difficulty urinating indicates fluid depletion from repeated purgation. These result from the physician's erroneous purgation, causing mixed exterior-interior and simultaneous Yin-Yang pathology. If one mistakenly administers Chaihu Tang (Bupleurum Decoction) based solely on the presence of hypochondriac fullness/pain (without requiring all Shaoyang symptoms), it will lead to rectal heaviness, driving the pathogen deeper into Taiyin. Although thirst exists, it is caused by fluid depletion from purgation. Vomiting upon drinking is not the original Shaoyang vomiting but results from erroneous purgation; thus, Chaihu Tang (Bupleurum Decoction) is contraindicated.
[Collected Annotations] Cheng Zhi said: Previously, it was stated that seeing one Chaihu symptom is sufficient for diagnosis. Here, it clarifies that even with hypochondriac fullness/pain, Chaihu Tang (Bupleurum Decoction) may be inappropriate, serving as a warning.
Cheng Yingmao said: Differentiating via thirst: in the previous case, warm hands/feet with thirst indicated interior heat without prior purgation, allowing natural digestion of water. Here, thirst with immediate vomiting upon drinking indicates thirst due to dryness and fluid loss in the Diaphragm, with middle deficiency preventing water digestion, unrelated to Stomach Yang. Thus, can we say that for Shaoyang, seeing one symptom suffices for Chaihu Tang? Can we say that if Chaihu symptoms persist after purgation, Chaihu Tang can be readministered?
In Shanghan (Cold Damage) lasting six or seven days, with mild fever and aversion to cold, painful joints, mild vomiting, subcostal support-like fullness (Zhijie), and unresolved exterior signs, Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) is the primary formula.
[Annotation] In Shanghan lasting six or seven days, presenting with mild fever/aversion to cold, painful joints, mild vomiting, and subcostal fullness, this indicates Taiyang pathogen transmitting to Shaoyang. Therefore, half the dose of Guizhi Tang (Cinnamon Twig Decoction) is used to disperse residual Taiyang pathogen; half the dose of Chaihu Tang (Bupleurum Decoction) is used to resolve Shaoyang vomiting and stagnation. It is not named Guizhi Chaihu Tang because, although Taiyang exterior signs persist, the pathological mechanism is evident in the Shaoyang interior. Placing Chaihu before Guizhi emphasizes resolving Shaoyang primarily while dispersing Taiyang secondarily. "Zhi" means side or small. "Zhijie" refers to slight stagnation on the side of the epigastrium.
[Collected Annotations] Fang Youzhi said: Zhijie refers to the bones and joints of the four limbs. Zhijie (support-knot) refers to the accumulation and knotting of fluid retention. From fever to mild vomiting represents Taiyang exterior, hence "exterior signs unresolved."
Cheng Zhi said: This describes pathogen entering Shaoyang while Taiyang signs remain. Fever, aversion to cold, and joint pain are Taiyang signs; however, mild aversion to cold and pain limited to joints (without neck stiffness) indicate reduced Taiyang signs. Vomiting and subcostal fullness are Shaoyang signs; however, mild vomiting and knotting only at the side of the epigastrium (not between both hypochondria) indicate shallow Shaoyang involvement. In such cases, Chaihu Tang (Bupleurum Decoction) should harmonize Shaoyang, supplemented by Guizhi Tang (Cinnamon Twig Decoction) to disperse Taiyang; this is an immutable method.
Chaihu Guizhi Tang Formula
Chaihu (Bupleuri Radix) (4 liang), Guizhi (Cinnamomi Ramulus) (1.5 liang), Renshen (Ginseng Radix et Rhizoma) (1.5 liang), Gancao (Glycyrrhizae Radix et Rhizoma, prepared) (1 liang), Banxia (Pinelliae Tuber) (washed, 2.5 he), Huangqin (Scutellariae Radix) (1.5 liang), Shaoyao (Paeoniae Radix) (1.5 liang), Dazao (Ziziphi Jujubae Fructus, split) (6 pieces), Shengjiang (Zingiberis Rhizoma Recens, sliced) (1.5 liang).
Nine ingredients. Boil in 7 sheng of water, reduce to 3 sheng, remove dregs, take 1 sheng warm.
[Collected Commentary] Ke Qin said: Among Zhang Zhongjing's works, the Chaihu and Guizhi formulas are most valued. Guizhi Tang (Cinnamon Twig Decoction) resolves Taiyang muscle-surface pathogen and regulates the surface of all meridians; Xiaochaihu Tang (Minor Bupleurum Decoction) resolves Shaoyang half-exterior/half-interior pathogen and harmonizes the half-exterior of the Three Yang. Hence, outside the Six Meridians, there are specific references to Guizhi Syndrome and Chaihu Syndrome, showing these formulas' broad applicability beyond single meridians. The "Floating Yang, Weak Yin" section annotates Guizhi Syndrome; the "Weak Blood, Exhausted Qi" section annotates Chaihu Syndrome. Both Guizhi and Chaihu syndromes have "ruined" (Huai Bing) conditions and ambiguous presentations. For example, cases resembling Guizhi syndrome include leg cramps and chest oppression; cases resembling Chaihu syndrome include thirst with vomiting upon drinking and desire to vomit with chest pain. This passage describes Shanghan at day 6-7, where fever/aversion to cold (exterior signs) and subcostal fullness (interior signs) coexist, requiring simultaneous exterior-interior resolution. Since aversion to cold is mild, fever is mild; joint pain implies no general body ache; mild vomiting implies mild epigastric knotting ("Zhijie"). Thus, exterior signs are light, interior signs are not severe. Half-dose Guizhi disperses residual Taiyang pathogen; half-dose Chaihu resolves mild Shaoyang knotting. If mouth is not dry and body has slight heat, Renshen should theoretically be removed; however, since righteousness is deficient by day 6-7 despite unresolved pathogen, Renshen is retained. With exterior signs present but pathology rooted in the interior, placing Chaihu before Guizhi creates a light agent for dual resolution of Two Yangs.
After five or six days of Shanghan, having undergone sweating followed by purgation, if there is chest/hypochondriac fullness with slight knotting, difficulty urinating, thirst without vomiting, only head sweating, alternating chills and fever, and irritability, the disease is unresolved. Chaihu Guizhi Ganjiang Tang (Bupleurum, Cinnamon Twig, and Dried Ginger Decoction) is the primary formula.
[Annotation] After five or six days of Shanghan, if sweating fails to resolve the exterior and purgation is subsequently applied, pathogen sinking into Yangming interior would cause Jie Xiong (Chest Binding) or Pi Ying (Epigastric Fullness) with协同 Heat diarrhea. Here, pathogen sinks into Shaoyang interior, causing chest/hypochondriac fullness with slight knotting. Difficulty urinating, thirst, and absence of vomiting indicate fluid damage from sweating/purgation, not fluid retention. While texts describe head sweating with fever/irritability as Yangming heat stagnation, here, with alternating chills/fever and irritability but no Yangming signs, the head sweating is Shaoyang exterior heat stagnation steaming upward. This is a Shaoyang exterior-interior unresolved condition, treated with Chaihu Guizhi Ganjiang Tang to resolve half-exterior pathogen and disperse half-interior knotting.
[Collected Annotations] Lin Lan said: By day 5-6 post-sweating/purgation, pathogen should resolve. Persistent chest/hypochondriac fullness/knotting, chills/fever, and irritability indicate pathogen remains in half-exterior/half-interior. Difficulty urinating and thirst indicate fluid loss and internal dryness post-sweating/purgation. If heat-fluid existed, vomiting would occur; absence of vomiting rules out heat-fluid. Sweating usually brings harmony; isolated head sweating indicates insufficient fluids and lack of harmony. Chaihu Guizhi Ganjiang Tang resolves exterior-interior and restores fluids.
Wang Hu said: Head sweating in Shanghan indicates Yang pathogen constrained at the exterior, not Yang deficiency above.
Chaihu Guizhi Ganjiang Tang Formula
Chaihu (Bupleuri Radix) (8 liang), Guizhi (Cinnamoli Ramulus) (3 liang), Ganjiang (Zingiberis Rhizoma) (2 liang), Gualougen (Trichosanthis Radix) (4 liang), Huangqin (Scutellariae Radix) (3 liang), Muli (Ostreae Concha) (2 liang), Gancao (Glycyrrhizae Radix et Rhizoma, prepared) (2 liang).
Seven ingredients. Boil in 12 sheng of water, reduce to 6 sheng, remove dregs, decoct again to 3 sheng. Take 1 sheng warm, three times daily. Initial dose may cause slight irritability; subsequent doses induce sweating and cure.
[Formula Analysis] Shaoyang exterior-interior unresolved requires combining Chaihu and Guizhi, a variation of Xiaochaihu Tang (Minor Bupleurum Decoction). Renshen is omitted because righteous Qi is not deficient; Banxia is halved because there is no vomiting, avoiding drying effects. Gualougen is added to stop thirst and generate fluids; doubling Chaihu and adding Guizhi targets Shaoyang exterior; adding Muli softens Shaoyang knotting. Ganjiang assists Guizhi to dispel chills; Huangqin assists Chaihu to clear fever and counteracts Ganjiang's potential to worsen irritability. As herbs vary in temperature, Gancao harmonizes them. Initial slight irritability indicates drug efficacy has not yet reached; subsequent sweating confirms resolution requires diaphoresis.
If thirst develops after taking Chaihu Tang (Bupleurum Decoction), the condition belongs to Yangming; treat according to Yangming methods.
[Annotation] If Wind-Cold pathogen transmits from Yangming to Shaoyang, initial thirst is absent. Thirst appearing after Chaihu Tang (Bupleurum Decoction) indicates Shaoyang transforming into Yangming. "Treat according to method" means distinguishing meridian vs. fu organ manifestations for treatment. Ge Gen Tang (Kudzu Decoction), Bai Hu Tang (White Tiger Decoction), or Tiao Wei Cheng Qi Tang (Regulate the Waist and Direct to the Interior Decoction) may be selected based on suitability.
[Collected Annotations] Fang Youzhi said: "Yi" means completion. Thirst completing Chaihu Tang administration indicates persistent, not transient, thirst, confirming heat has entered the Stomach and depleted fluids, hence "belongs to Yangming."
Shen Mingzong said: Thirst after Chaihu Tang indicates Shaoyang pathogen did not transmit to the Three Yin but moved to Yangming; treat according to Yangming manifestations.
Zheng Zhongguang said: The distinction between Shaoyang and Yangming lies in vomiting and thirst: thirst indicates transformation to Yangming; vomiting indicates retention in Shaoyang. Even with Yangming signs, excessive vomiting precludes purgation as the pathogen remains in Shaoyang. Chaihu Tang should stop thirst; if thirst worsens post-administration, heat has entered the Stomach Fu, consuming fluids, belonging to Yangming Stomach disease.
In Shanghan lasting five or six days, with head sweating, mild aversion to cold, cold hands/feet, epigastric fullness, desire not to eat, hard stools, and fine pulse, this is "Yang Mild Knotting" (Yang Wei Jie), involving both exterior and interior signs. A sunken pulse also indicates interior involvement. Sweating indicates mild Yang constraint. If it were pure Yin Knotting, there would be no exterior signs, only interior. This is half-exterior, half-interior. Even if the pulse is sunken and tight, it cannot be Shaoyin disease because Yin diseases do not present with sweating. Head sweating confirms it is not Shaoyin. Xiaochaihu Tang (Minor Bupleurum Decoction) may be given. If symptoms persist, defecation will resolve the condition.
[Commentary] "Fine pulse" should be "sunken-fine pulse," evident from the text "Sunken pulse also indicates interior." The character "tight" in "even if sunken-tight" should be "fine," as "tight" appears nowhere else in the passage, making "even if" nonsensical. This is a transcription error.
[Annotation] At day 5-6, although exterior Yang pathogen (head sweating, mild aversion to cold) persists, interior Yang knotting (epigastric fullness, anorexia, hard stools) has formed. Cold hands/feet and sunken-fine pulse indicate the Yang knot is very mild, hence "Yang Mild Knotting," involving both exterior and interior. Sunken-fine pulse suggests interior Yin excess, but head sweating indicates exterior Yang constraint. Pure Yin Knotting would lack exterior signs like head sweating. Since it is not pure interior Yin, it is half-exterior/half-interior Yang Mild Knotting. Thus, sunken-fine pulse does not indicate Shaoyin disease, as Yin diseases do not sweat. Head sweating confirms non-Shaoyin status. Xiaochaihu Tang (Minor Bupleurum Decoction) harmonizes the lack of whole-body sweating and mild aversion to cold. If unresolved, hard stools remain, requiring purgation for resolution.
[Collected Annotations] Yu Chang said: "Yang Mild Knotting" means residual mild Yang pathogen constraint. Old annotations interpreting it as Yang Qi deficiency are incorrect. If true, head sweating would indicate Yang collapse, not half-exterior/half-interior pathology. Examining the text "assuming pure Yin Knotting... pure Yin pathogen internally knotted... no exterior signs" clarifies the meaning.
Cheng Zhi said: This discusses Shaoyang disease mimicking Shaoyin, requiring careful pulse/symptom differentiation.
Cheng Yingmao said: Fine and sunken pulses are Yin pulses. Co-occurring with Yang signs indicates Yang heat constraint, unrelated to Shaoyin. Yang Qi constraint makes both Yang signs and pulses resemble Yin.
Shen Mingzong said: Resolution via defecation implies using Daxiehu Tang (Major Bupleurum Decoction) principles.
Wu Renju said: This case is often misdiagnosed as Yin-Cold and treated with warming herbs, causing adverse reactions, due to focusing on aversion to cold, cold extremities, and fine/sunken pulse without investigating the origin.
Zhou Yangjun said: This passage features aversion to cold, cold limbs, anorexia, and fine/sunken pulses, mimicking Yin syndrome, making differentiation difficult. Zhang Zhongjing explicitly uses "Yang Mild Knotting" to clarify history. Head sweating indicates Yang (Yin does not sweat). By day 5-6, headache/fever indicate Yang nature; thus, Shaoyin pulse does not equal Shaoyin disease. However, lacking typical Shaoyang signs, why call it Shaoyang? Zhang explains it is half-exterior/half-interior. With many interior signs, pure exterior diaphoretics are contraindicated; with exterior signs mimicking Yin, pure interior warming is contraindicated. Xiaochaihu Tang (Minor Bupleurum Decoction) extracts pathogen from the half-exterior/half-interior boundary. If hard stools persist, purgation is necessary. Zhang elaborates to clarify that cold limbs/mild aversion to cold result from Yang constraint failing to reach limbs, causing isolated head sweating.
In Shanghan, with Yang pulse coarse (Se) and Yin pulse string-taut (Xian), abdominal acute pain is expected per theory. First administer Xiao Jianzhong Tang (Minor Construct the Middle Decoction); if ineffective, administer Xiaochaihu Tang (Minor Bupleurum Decoction) as primary.
[Annotation] Floating-coarse pulse indicates Deficiency of Ying and Wei; sunken-string-taut pulse indicates Wood invading Earth. Ying/Wei deficiency leads to exterior deficiency; Wood invading Earth leads to interior tension. Only with exterior deficiency and interior tension does acute abdominal pain occur. Hence, Xiao Jianzhong Tang (Minor Construct the Middle Decoction) is used first to tonify Ying/Wei and relieve interior tension/pain. If ineffective, pathogen likely remains in the exterior. Coarse pulse indicates Ying/Wei obstruction; string-taut pulse is the root Shaoyang pulse. Thus, Xiaochaihu Tang (Minor Bupleurum Decoction) is administered according to protocol. Cheng Wuji's modification (removing Huangqin, adding Shaoyao) to disperse exterior and regulate middle is also valid.
[Collected Annotations] Wang Hu said: Persistence of string-taut pulse with continued pain indicates ineffectiveness, signifying lingering pathogen in Shaoyang meridian.
In Shanghan, with Heat in the Chest, Pathogenic Qi in the Stomach, abdominal pain, and desire to vomit, Huanglian Tang (Coptis Decoction) is the primary formula.
[Annotation] Desire to vomit in unresolved Shanghan indicates Heat pathogen reversing upward in the Chest; abdominal pain indicates Cold pathogen attacking inward in the Stomach. Heat in Chest, Cold in Stomach disrupt Yin-Yang harmony and normal ascending/descending functions. Huanglian Tang (Coptis Decoction) uses cold and hot herbs together, sweet and bitter flavors combined, to regulate Yin-Yang and harmonize. This reflects external pathogens causing upper-lower cold-heat disharmony. Internal miscellaneous diseases with vomiting/abdominal pain are often due to retained food. Thus, external vs. internal etiologies yield similar symptoms but different pathogenesis.
[Collected Annotations] Cheng Zhi said: Yin pathogen in abdomen prevents Yang from harmonizing Yin, causing pain; Yang pathogen above prevents Yin from harmonizing Yang, causing vomiting/reversal.
Wang Hu said: *Shanglun Pian* distinguishes Wind/Cold into Yin/Yang Cold/Heat. However, Wind may originate as Cold, and Cold may transform into Heat; one should not be rigid.
Zheng Zhongguang said: Heat pathogen strikes the Upper Jiao; Cold pathogen strikes the Lower Jiao. Yin-Yang fail to interact, losing normal ascending/descending order.
Huanglian Tang Formula
Huanglian (Coptidis Rhizoma) (3 liang), Gancao (Glycyrrhizae Radix et Rhizoma, prepared) (3 liang), Ganjiang (Zingiberis Rhizoma) (3 liang), Renshen (Ginseng Radix et Rhizoma) (2 liang), Guizhi (Cinnamomi Ramulus) (3 liang), Banxia (Pinelliae Tuber) (washed, 0.5 sheng), Dazao (Ziziphi Jujubae Fructus, split) (12 pieces).
Seven ingredients. Boil in 1 dou of water, reduce to 6 sheng, remove dregs. Take warm, three times during day, twice at night.
[Formula Analysis] Shanghan pathogen enters the interior, transforming based on pre-existing organ cold/heat. For example, Yangming disease with hardness/fullness, constipation, vomiting, and white tongue coating is treated with Xiaochaihu Tang (Minor Bupleurum Decoction); Taiyang disease post-purgation with interior deficiency, restlessness, and tongue coating resembling moss is treated with Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction). These follow the pattern of "Cold in Chest, Heat in Dantian." This case follows the Stomach...