伤寒表不解。心下有水气。干呕发热而咳。或渴或利。或噎。或小便不利。少腹满。或喘者。小青龙汤主之。
此以下二条。非风寒并感之证也。因小青龙汤当附大青龙汤之后。故亦入下编。
伤寒表不解。谓头痛项强。发热体痛无汗之证。未得汗解也。心下。心之下。胃脘之分也。水气。水饮之属也。
寒邪在膈。气不流行。故水饮停蓄也。寒邪尚在表而未解。何水饮即停蓄于心下乎。痹论云。卫气循皮肤之中。
分肉之间。熏于肓膜。散于胸腹。逆其气则病。以寒邪在营卫之间。邪随卫气而入也。干呕发热。太阳表证也。喘咳。
水寒伤肺而气逆也。经云。形寒饮冷则伤肺。以肺主皮毛。寒邪在表。水气停蓄。故伤肺气也。或利者。水寒伤
胃而下流也。或噎者。水气寒邪。窒碍胃中。气不通行也。或渴或小便不利者。水寒固闭于中焦。则下焦之阳气。
不得上腾而为津液。故渴。上焦之清气不得下降而为渗利。其升降之气化不行。故小便不利而少腹满也。或者。
或有或无。非必诸证皆见也。前以风寒郁热之邪不得外泄而烦躁。故以大青龙汤汗泄凉解之。此条以寒邪未解。
水饮停蓄。肺脏伤而喘咳并见。中气寒而气滞不行。宜温宜散。可发可收。故以小青龙汤主之。
小青龙汤方
麻黄（三两去节） 芍药（三两） 五味子（半升） 干姜（三两） 桂枝（三两） 半夏（半升汤洗）
甘草（三两炙） 细辛（三两）
上八味。以水一斗。先煮麻黄减二升。去上沫。内诸药。煮取三升。去滓。温服一升。
小青龙。即大青龙之变制也。谓之小者。控制而小用之也。盖龙蟠蠖屈。非若升腾飞越之势之大也。夫前以天
地郁蒸。非风狂雨骤。雷雨满盈。不足以散郁蒸之热气。此则水滞寒凝。非雨润云蒸。水泉流动。岂能解冱结之寒邪。
是以
大青龙为辛凉发汗之剂。故用麻黄全汤。兼桂枝之半。又倍增麻黄而加石膏也。小青龙乃辛温发散。敛逆之药。故
用桂枝全汤。去姜枣而兼麻黄之半。又加干姜细辛者。一以助麻黄桂枝之辛温发散。李时珍谓使寒邪水气。从毛
孔中散。一取其暖中去寒。温肺泄肺之功也。更加芍药五味者。所以收肺气之逆。皆控御节制之法也。盖细辛干姜
之用。以肾与膀胱。相为表里。素问病机云。诸寒收引。皆属于肾。故藏气发时论云。肾苦燥。急食辛以润之。开腠理。
致
津液。通气也。张元素云。细辛味辛而热。温少阴之经。能散水气。去内寒。李时珍谓辛能泄肺。故风寒咳嗽。上气者
宜
之。五味芍药。所以收肺气之逆也。李东垣曰。酸以收逆气。肺寒气逆。宜与干姜同用。有痰者以半夏为佐。皆本诸此
也。愚窃谓肺寒而气逆者。可以酸收。若肺热而气满者。未可概用也。观仲景制方。以大青龙之兴云致雨。而脉微弱
汗出恶风者。犹禁止之曰不可用。若误用之。尚有厥逆惕 之变。至于小青龙。则其制方之义。周旋规矩。不离方寸。
后人岂可亦以小青龙养成头角。翻江搅海为喻乎。皆一时纵笔任意。为快口之谈耳。恐未足为定训也。
加减法
若微利者。去麻黄。加芫花如鸡子大。熬令赤色。
既见微利。则知水气下走。当因其势而导使下泄。去麻黄者。恐内外两亡津液也。此说亦通。然表寒重而全未解者。
尚当斟酌。若竟去麻黄而留芍药五味之酸收。其如伤寒表不解何。
渴者去半夏。加栝蒌根三两。
夫渴虽一证而各经不同。如太阳邪热入里。则五苓散之渴也。阳明邪热入胃。白虎汤之渴也。少阳则或渴或不渴。
皆以小柴胡汤主之。若服柴胡汤已而渴者。即属阳明矣。三阴本不应渴。而少阴有引水自救之渴。及厥阴之消渴。
皆非真渴也。少阴更有咳而呕渴之证。亦不过以猪苓汤导水而已。此条或渴之证。乃水寒在胃。下焦之气液不得
上腾而为涕唾。故渴。心下既有水气。岂可亦以栝蒌根为生津而用之邪。若未以为然。观下文服汤已而渴。为寒去
欲解。则知不必以撤热生津为治矣。若必用撤热。胡不去干姜之辛热邪。况半夏本辛滑之品。诸家俱以其燥津液
而去之。何也。李时珍本草。列之滑剂中。云引痰涎自小便去者。则半夏茯苓之属。又云半夏南星。皆辛而涎滑。皆泄
湿气。通大便。盖辛能润。能走气。能化液也。或以为燥物。谬矣。湿去则土燥。非二物性燥也。以此推之。必非
仲景所加。非王叔和。即成无己辈。仿佛小柴胡汤之加减而增入也。以致朱奉议陶节庵辈。凡遇渴证。必去半夏而
加栝蒌根。曾不稍揆时义。察其阴阳寒热。而率意妄为加减。每效前人之非而不觉。谓之一代名家。是耶非耶。
若噎者。去麻黄。加附子一枚。
噎者。心下有水气而胃气不通也。所谓水寒相搏。其人必KT 。噎与KT 同。盖呃逆也。夫呃逆。有火呃实呃冷
呃之不同。此水寒相搏。故加附子以温散之。若寒甚而阳气虚者。去麻黄而不使汗泄其虚阳亦可。
若小便不利。少腹满。去麻黄。加茯苓四两。
小便不利而少腹满。为下焦无火。不能气化而出也。真阳不足。去麻黄而不使汗泄。则可矣。茯苓不过味淡
渗泄而已。岂能助下焦气化之功哉。
若喘者。去麻黄。加杏仁半升。去皮尖。
喘为肺气逆满之证。加杏仁以助麻黄利肺气可也。若加杏仁而去麻黄。施之于表不解之伤寒。恐未切当。若肺虚
而喘。则又宜补不宜泻。非惟麻黄当去。并杏仁亦不可加矣。
伤寒心下有水气。咳而微喘。发热不渴。服汤已渴者。此寒去欲解也。小青龙汤主之。
伤寒心下有水气。咳而微喘。与上文同义。发热不渴者。因心下有水气。故虽发热亦不渴也。服汤。谓服小
青龙汤也。服汤已而渴。则知心下之水气已消。胃中之寒湿已去。但以发热之后。温解之余。上焦之津液尚少。
所以反渴也。前以有水气。故发热不渴。今服汤已而渴。故知寒水去而欲解也。
辨误 小青龙汤主之句。当在发热不渴句下。今作末句者。是补出前所服之汤。非谓寒去欲解之后。更当以小青
龙汤主之也。注家谓寒去欲解。仍以小青龙汤主之。言以轻剂助其欲解之势耳。愚谓寒邪既去而欲解。岂可再用
麻黄桂枝发汗。以耗其津液。干姜细辛之辛热。增其燥渴邪。况麻黄桂枝干姜各三两。五味子半升。岂轻剂邪。此与
前发烦目瞑衄乃解之后。及不发汗因致衄者。皆以麻黄汤主之之义相同。岂衄血之后。更可用麻黄发其汗邪。因
不先以麻黄汤发汗。因致衄耳。故下文曰当以麻黄汤主之。盖与此条同一补出之法也。
The exterior syndrome of Cold Damage (Shanghan) is not resolved. There is an accumulation of water-fluid qi in the epigastrium (heart below). Symptoms include dry retching, fever, and coughing. Alternatively, there may be thirst, diarrhea, a sensation of choking in the throat, dysuria with fullness in the lower abdomen, or wheezing. This is primarily treated with Xiao Qing Long Tang (Minor Blue Dragon Decoction).
The following two clauses do not represent syndromes where wind and cold strike simultaneously. Because Xiao Qing Long Tang should follow Da Qing Long Tang (Major Blue Dragon Decoction), it is also included in the lower section.
"Exterior syndrome of Cold Damage not resolved" refers to symptoms such as headache and stiffness of the neck, fever, body pain, and absence of sweating, which have not yet been resolved through diaphoresis. "Heart below" refers to the area below the heart, specifically the region of the stomach (Wei). "Water qi" refers to pathogenic water-fluids.
When cold pathogens remain in the diaphragm, the movement of qi becomes obstructed, causing water-fluids to stagnate and accumulate. If cold pathogens are still on the exterior and unresolved, why would water-fluids accumulate in the epigastrium? The *Bi Lun* (Treatise on Bi Syndromes) states: Wei Qi circulates within the skin and between muscle textures, steaming into the Hui membrane and dispersing throughout the chest and abdomen. If its flow is reversed, disease occurs. Since cold pathogens reside between Ying (Nutrient) and Wei (Defensive) levels, the pathogen enters along with Wei Qi. Dry retching and fever are exterior signs of the Taiyang (Greater Yang) channel. Wheezing and coughing result from water-cold injuring the Lung and causing rebellious Qi. The Classics state: "Cold affecting the form and cold drinks injuring the interior damage the Lung." Since the Lung governs the skin and hair, when cold pathogens are on the exterior and water-fluids stagnate, Lung Qi is injured. Diarrhea occurs because water-cold injures the Stomach and flows downward. Choking sensation occurs because water-qi and cold pathogens obstruct the Stomach, preventing smooth Qi flow. Thirst or dysuria occur because water-cold binds and closes the Middle Jiao; thus, Yang Qi from the Lower Jiao cannot ascend to transform into fluids, causing thirst. Clear Qi from the Upper Jiao cannot descend to facilitate excretion, leading to impaired ascending-descending Qi transformation, resulting in dysuria and lower abdominal fullness. The term "or" indicates that these symptoms may appear individually or not at all, rather than all appearing simultaneously. Previously, due to wind-cold constraining heat that could not vent outward, causing irritability, Da Qing Long Tang was used for diaphoresis and cooling resolution. In this clause, because cold pathogens are unresolved and water-fluids are stagnant, with Lung injury manifesting as wheezing and coughing, and Middle Qi being cold and stagnant, warming and dispersing are indicated, allowing for both releasing and restraining methods. Therefore, Xiao Qing Long Tang is used.
Formula for Xiao Qing Long Tang (Minor Blue Dragon Decoction):
Ephedrae Herba (Mahuang, 麻黄) - 3 liang, nodes removed
Paeoniae Radix Alba (Baishao, 芍药) - 3 liang
Schisandrae Fructus (Wuweizi, 五味子) - half sheng
Zingiberis Rhizoma Recens (Ganjiang, 干姜) - 3 liang
Cinnamomi Ramulus (Guizhi, 桂枝) - 3 liang
Pinelliae Rhizoma Preparatum (Banxia, 半夏) - half sheng, washed with boiling water
Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) - 3 liang, prepared with honey
Asari Radix (Xixin, 细辛) - 3 liang
These eight ingredients are boiled in one dou of water. First, boil Ephedrae Herba until reduced by two sheng, removing the foam on top. Then add the remaining herbs. Boil to obtain three sheng. Strain. Take one sheng warm.
Xiao Qing Long Tang is a modified version of Da Qing Long Tang. It is called "Minor" because it is controlled and used in smaller doses. Like a dragon coiling or a inchworm curling, it lacks the grand momentum of soaring flight. Previously, it was stated that for stifling heat in heaven and earth, only violent winds, heavy rains, and thunderstorms can dissipate the stifling heat. Here, however, with stagnant water and congealed cold, only rain nourishment, cloud vaporization, and flowing springs can resolve the frozen cold pathogens. Thus, Da Qing Long Tang is a pungent-cool diaphoretic agent, using the full dose of Ephedrae Herba, half the dose of Cinnamomi Ramulus, doubled Ephedrae Herba, plus Gypsum Fibrosum (Shigao). Xiao Qing Long Tang is a pungent-warm dispersant and anti-rebellious agent, using the full dose of Cinnamomi Ramulus, removing Ginger and Jujube, using half the dose of Ephedrae Herba, plus Zingiberis Rhizoma Recens and Asari Radix. This aids the pungent-warm dispersal of Ephedrae Herba and Cinnamomi Ramulus. Li Shizhen stated that it allows cold pathogens and water-fluids to disperse through the pores. Secondly, it utilizes warmth to dispel cold and warms/disperses Lung Qi. Paeoniae Radix Alba and Schisandrae Fructus are added to restrain rebellious Lung Qi, employing methods of control and regulation. The use of Asari Radix and Zingiberis Rhizoma Recens is based on the exterior-interior relationship between the Kidney and Bladder. The *Suwen* Pathogenesis states: "All cold-related contraction and pulling belong to the Kidney." The *Zangqi Fashi Lun* states: "The Kidney dislikes dryness; urgently eat pungent substances to moisten it," opening the cou li, generating fluids, and unblocking Qi. Zhang Yuansu stated: "Asari Radix is pungent and hot, warms the Shaoyin channel, disperses water-fluids, and removes internal cold." Li Shizhen said pungency can drain the Lung, making it suitable for wind-cold cough and rebellious Qi. Paeoniae Radix Alba and Schisandrae Fructus restrain rebellious Lung Qi. Li Dongyuan said: "Sour substances restrain rebellious Qi. For cold-Lung rebellious Qi, it is suitable to use with Zingiberis Rhizoma Recens. With phlegm, Pinelliae Rhizoma Preparatum serves as an assistant." I privately believe that for cold-Lung with rebellious Qi, sour astringents can be used. However, for heat-Lung with Qi fullness, they should not be generally applied. Observing Zhang Zhongjing's formula construction, for Da Qing Long Tang, even if there is pulse weakness, sweating, and aversion to wind, it is prohibited. Misuse leads to jue (cold extremities) and palpitations. Regarding Xiao Qing Long Tang, its formulation principles are precise and regulated. How can later generations metaphorically describe it as growing horns or stirring seas? These are merely impulsive remarks for rhetorical pleasure, insufficient as definitive doctrines.
Modifications:
If there is mild diarrhea, remove Ephedrae Herba and add Kansui Radix (Yuanhua, 芫花) the size of a chicken egg, roasted until red.
Seeing mild diarrhea indicates water-fluids moving downward. One should guide them downward. Removing Ephedrae Herba prevents dual loss of fluids internally and externally. This reasoning is valid. However, if exterior cold is severe and unresolved, caution is needed. Completely removing Ephedrae Herba while retaining the sour-astringent Paeoniae Radix Alba and Schisandrae Fructus leaves the unresolved exterior Cold Damage unaddressed.
If there is thirst, remove Pinelliae Rhizoma Preparatum and add Trichosanthis Radix (Gualougen, 栝蒌根) 3 liang.
Thirst varies by channel. Taiyang heat entering the interior causes thirst treated by Wuling San (Five-Ingredient Powder with Poria). Yangming heat entering the Stomach causes thirst treated by Baihu Tang (White Tiger Decoction). Shaoyang presents with intermittent thirst or no thirst, treated by Xiaochaihu Tang (Minor Bupleurum Decoction). If thirst persists after taking Chaihu Tang, it belongs to Yangming. The Three Yin channels generally do not present with thirst, but Shaoyin has thirst seeking water for self-rescue, and Jueyin has excessive thirst, neither being true thirst. Shaoyin also has cough, vomiting, and thirst, treated by Zhu Ling Tang (Polyporus Decoction). The thirst in this clause results from water-cold in the Stomach, preventing Lower Jiao Qi and fluids from ascending to become saliva/throat moisture. Given water-fluids in the epigastrium, how can Trichosanthis Radix be used for generating fluids? If one disagrees, observe that thirst after taking the decoction indicates cold departure and impending resolution, showing that clearing heat and generating fluids is not the treatment. If clearing heat were necessary, why keep pungent-hot Zingiberis Rhizoma Recens? Pinelliae Rhizoma Preparatum is pungent and slippery; many remove it fearing it dries fluids. However, Li Shizhen lists it as a slipping agent, aiding expectoration via urine. He notes Pinelliae Rhizoma Preparatum and Arisaematis Rhizoma (Nanxing, 南星) are pungent, slippery, drain dampness, and unblock bowels. Pungency can moisten, move Qi, and transform fluids. Calling them drying agents is erroneous. Dampness removal leads to dry Earth, not inherent drug dryness. Thus, this modification is likely not by Zhang Zhongjing, but by Wang Shuhe or Cheng Wuji, mimicking Xiaochaihu Tang modifications. This led to Zhu Fengyi and Tao Jian'an removing Pinelliae Rhizoma Preparatum and adding Trichosanthis Radix for all thirst cases without considering Yin-Yang and cold-heat patterns, blindly following predecessors' errors. Is this worthy of being called a master physician?
If there is a choking sensation, remove Ephedrae Herba and add Aconiti Lateralis Radix Praeparata (Fuzi, 附子) one piece.
Choking indicates water-fluids in the epigastrium blocking Stomach Qi, described as water-cold clashing, often accompanied by hiccups (Ni, 哕). Hiccups vary by fire, excess, and cold. Here, due to water-cold clash, Aconiti Lateralis Radix Praeparata is added to warm and disperse. If cold is severe and Yang Qi is deficient, removing Ephedrae Herba to prevent sweating depleting deficient Yang is appropriate.
If there is dysuria with lower abdominal fullness, remove Ephedrae Herba and add Poria (Fuling, 茯苓) 4 liang.
Dysuria and lower abdominal fullness indicate lack of fire in the Lower Jiao, failing to transform Qi for excretion. Due to deficiency of True Yang, removing Ephedrae Herba to prevent sweating is correct. Poria is merely bland and leaching; it cannot assist Lower Jiao Qi transformation.
If there is wheezing, remove Ephedrae Herba and add Armeniacae Semen Amarum (Xingren, 杏仁) half sheng, skin and tips removed.
Wheezing is a sign of rebellious and full Lung Qi. Adding Armeniacae Semen Amarum to assist Ephedrae Herba in benefiting Lung Qi is acceptable. However, adding Armeniacae Semen Amarum while removing Ephedrae Herba for unresolved exterior Cold Damage is inappropriate. For deficiency-Lung wheezing, tonification is preferred over purgation; thus, Ephedrae Herba should be removed, and Armeniacae Semen Amarum should not be added.
In Cold Damage with water-fluids in the epigastrium, presenting with cough and mild wheezing, fever without thirst, if thirst develops after taking the decoction, this indicates cold departure and impending resolution. [Note: The original text places "Xiao Qing Long Tang is primarily used" here incorrectly, see Correction].
Cold Damage with water-fluids in the epigastrium, cough and mild wheezing, shares the same meaning as above. Fever without thirst occurs because water-fluids in the epigastrium prevent thirst despite fever. "Taking the decoction" refers to taking Xiao Qing Long Tang. Thirst after taking the decoction indicates water-fluids in the epigastrium have dissipated and cold-dampness in the Stomach has cleared. However, post-fever and post-warm-resolution, Upper Jiao fluids are still scarce, causing relative thirst. Previously, water-fluids caused fever without thirst. Now, thirst after medication confirms cold-water departure and resolution.
Correction: The phrase "Xiao Qing Long Tang is primarily used" should follow "fever without thirst." Placed at the end, it retroactively identifies the previously taken medicine, implying that after cold departure and resolution, one does NOT need to use Xiao Qing Long Tang again. Commentators suggest using it as a light agent to aid resolution. I argue that once cold departs and resolves, using pungent-warm diaphoretics like Ephedrae Herba and Cinnamomi Ramulus consumes fluids, and pungent-hot Zingiberis Rhizoma Recens and Asari Radix exacerbates dryness-thirst. Moreover, the doses (3 liang each of Ephedrae Herba, Cinnamomi Ramulus, Zingiberis Rhizoma Recens; half sheng Schisandrae Fructus) are not light. This parallels the principle of using Mahuang Tang after nosebleed resolves irritability or after spontaneous nosebleed due to lack of sweating. Can Ephedrae Herba be used for sweating after nosebleed? No, because the nosebleed resulted from failing to sweat initially. Hence, "Mahuang Tang should be used" follows, employing the same retroactive clarification method.