伤寒五六日，中风，往来寒热，胸胁苦满，默默不欲饮食，心烦喜呕，或胸中烦而不呕，或渴，或腹中痛，
或胁下痞硬，或心下悸小便不利，或不渴身有微热，或咳者，小柴胡汤主之。
此非言伤寒五六日而更中风也。言往来寒热有三义∶少阳自受寒邪，阳气衰少，既不能退寒，又不能发热，
至五六日郁热内发，始得与寒气相争，而往来寒热，一也；若太阳受寒，过五六日阳气始衰，余邪未尽，转
属少阳，而往来寒热，二也；风为阳邪，少阳为风藏，一中于风便往来寒热，不必五六日而始见，三也。少阳脉
循胸胁，邪入其经故苦满，胆气不舒故默默，木邪犯土故不欲饮食，相火内炽故心烦，邪正相争故喜呕。盖少
阳为枢，不全主表，不全主里，故六证皆在表里之间。仲景本意重半里，而柴胡所主又在半表，故少阳证必见
半表，正宜柴胡加减。如悉入里，则柴胡非其任矣。故小柴胡称和解表里之主方。
寒热往来，病情见于外；苦喜不欲，病情得于内。看喜、苦、欲等字，非真呕、真满、不能饮食也。看往、
来二字，见有不寒热时。寒热往来，胸胁苦满，是无形之半表；心烦喜呕，默默不欲饮食，是无形之半里。虽
然七证皆偏于里，惟微热为在表；皆属无形，惟心下悸为有形；皆风寒通证，惟胁下痞硬属少阳。总是气分为
病，非有实可据，故皆从半表半里之治法。
血弱气虚，腠理开，邪气因入，与正气相搏，结于胁下。正邪分争，往来寒热，休作有时。默默不欲饮食，
脏腑相连，其痛不下，邪高痛下，故使呕也。
此仲景自注柴胡证。首五句，释胸胁苦满之因。正邪三句，释往来寒热之义。此下多有阙文，故文理不连
属也。
小柴胡汤∶
柴胡（半斤） 半夏（半升） 人参 甘草 黄芩 生姜（各三两） 大枣（十二枚）
以水一斗二升，煮取六升，去滓，再煎取三升，温服一升，日三服。若胸中烦而不呕者，去半夏、人参，
加栝蒌实一枚。若渴者，去半夏，加人参，合前成四两半，加栝蒌根四两。若腹中痛者，去黄芩，加芍药三两。
若胁下痞硬，去大枣，加牡蛎四两。若心下悸，小便不利者，去黄芩，加茯苓四两。若不渴、外有微热者，
去人参，加桂枝三两，温服，取微汗愈。若咳者，去人参、大枣、生姜，加五味子半升、干姜二两。
柴胡感一阳之气而生，故能直入少阳，引清气上升而行春令，为治寒热往来之第一品药。少阳表邪不解，
必需之。半夏感一阴之气而生，故能开结气、降逆气、除痰饮，为呕家第一品药。若不呕而胸烦口渴者去之，以
其散水气也。黄芩外坚内空，故能内除烦热，利胸膈逆气。腹中痛者，是少阳相火为害，以其苦从火化，故易
芍药之酸以泻之。心下悸，小便不利者，以苦能补肾，故易茯苓之淡以渗之。
人参、甘草，补中气和营卫，使正胜则邪却，内邪不留，外邪勿复入也。仲景于表证不用人参，此因有半
里之无形证，故用之以扶元气，使内和而外邪勿入也。身有微热是表未解，不可补；心中烦与咳，是逆气有余，
不可益气，故去之。如太阳汗后身痛而脉沉迟，下后协热利而心下硬，是太阳之半表半里证也。表虽不解，因
汗、下后重在里，故参、桂兼用。先辈论此汤，转旋在柴、芩二味，以柴胡清表热、黄芩清里热也。卢氏以柴胡、
半夏得二至之气而生，为半表半里之主治，俱似有理。然本方七味中，半夏、黄芩俱在可去之例，惟不去柴胡、
甘草。当知寒热往来，全赖柴胡解外、甘草和中。故大柴胡去甘草，便另名汤，不入加减法。
伤寒中风，有柴胡证，但见一证便是，不必悉具。
柴胡为枢机之剂，凡寒气不全在表未全入里者，皆服之。证不必悉具，故方亦无定品。
呕而发热者，小柴胡汤主之。
伤寒则呕逆，中风则干呕。凡伤寒中风，无麻黄、桂枝证。但见喜呕一证。则发热者，便可用柴胡汤，不必
寒热往来而始用也。发热而呕，则人参当去，而桂枝非所宜矣。其目赤、耳聋、胸满而烦者，用柴胡去参、夏加
栝蒌实之法∶脉弦细而头痛发热者，从柴胡去参加桂之法。
伤寒五六日，头汗出，微恶寒，手足冷，心下满，口不欲食，大便硬，脉沉细者，此为阳微结，必有表复
有里也。脉沉亦在里也。汗出为阳微结。假令纯阴结，不得复有外证，悉入在里矣。此为半在里半在表也。脉虽
沉细，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。
大便硬谓之结。脉浮数能食曰阳结，沉迟不能食曰阴结。此条俱是少阴脉，谓五六日又少阴发病之期。若
谓阴不得有汗，则少阴亡阳，脉紧汗出者有矣。然亡阳与阴结有别∶亡阳咽痛吐利，阴结不能食而大便反硬也。
亡阳与阳结亦有别∶三阴脉不至头，其汗在身；三阳脉盛于头，阳结则汗在头也。邪在阳明，阳盛，故能食，
此谓纯阳结；邪在少阳，阳微，故不欲食，此谓阳微结，宜属小柴胡矣。然欲与柴胡汤，必究其病在半表。而
微恶寒，亦可属少阴；但头汗，始可属之少阳。欲反复讲明头汗之义，可与小柴胡而勿疑也。上焦得通，则心
下不满而欲食；津液得下，则大便自软而得便矣。此为少阴、少阳之疑似证。
上论小柴胡主证。
伤寒四五日，身热恶风，头项强，胁下满，手足温而渴者，小柴胡汤主之。
身热恶风，头项强，桂枝证未罢。胁下满，已见柴胡一证，盒饭用小柴胡去参、夏加桂枝、栝蒌以两解之。
不任桂枝而主柴胡者，从枢故也。
阳明病，发潮热，大便溏，小便自可，胸胁满者，小柴胡汤主之。
潮热已属阳明，然大便溏而小便自可，未为胃实。胸胁苦满，便用小柴胡和之，热邪从少阳而解，不复入
阳明矣。上条经四五日，是太阳少阳并病，此是阳明少阳合病。若谓阳明传入少阳，则谬矣。
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
然汗出而解也。
不大便属阳明，然胁下硬满而呕，尚在少阳部。舌上白苔者，痰饮溢于上焦也。与小柴胡汤，则痰饮化为津
液而燥土和，上焦仍得汗出而充身泽毛矣。
伤寒呕多，虽有阳明证，不可攻之。
呕者，水气在上焦，上焦得通，津液得下，胃气因和矣。
服柴胡汤已，渴者，属阳明也，以法治之。
柴胡汤有芩、参、甘、枣，皆生津之品。服之反渴者，必胃家已实，津液不足以和胃也，当行白虎、承气等
法。仍用柴胡加减，非其治矣。此少阳将转属阳明之证。
上论两经合并病。
妇人中风七八日，续得寒热，发作有时，经水适断者，此为热入血室，其血必结，故使如疟状，发作有时，小
柴胡汤主之。
中风至七八日，寒热已过，复得寒热，发作有期，与前之往来寒热无定期者不侔，此不在气分而在血分矣。
凡诊妇人，必问月事，经水适断于寒热时，是不当止而止也。必其月事下而血室虚，热气乘虚而入，其余血之未
下者，干结于内，故适断耳。用小柴胡和之，使结血散则寒热自除矣。余义详阳明篇。
上论热入血室。
伤寒六七日，发热微恶寒，肢节烦疼，微呕，心下支结，外证未去者，柴胡桂枝汤主之。
伤寒至六七日，正寒热当退之时，反见发热恶寒证，此表证而兼心下支结之里证，表里未解也。然恶寒微，
则发热亦微。但肢节烦疼，则一身骨节不烦疼可知。支如木之支，即微结之谓也。表证微，故取
桂枝之半；内证微，故取柴胡之半。此因内外俱虚，故以此轻剂和解之也。
上论柴胡桂枝证。
柴胡桂枝汤∶
柴胡（四两） 黄芩 人参 生姜 芍药 桂枝（各两半） 甘草（一两） 半夏（二合半） 大枣（六枚）
以水七升，煮取三升，去滓，温服一升。
桂、芍、甘草，得桂枝之半；柴、参、芩、夏，得柴胡之半；姜、枣得二方之半，是二方合半非各半也。与
麻黄桂枝合半汤又不同。
伤寒，阳脉涩，阴脉弦，法当腹中急痛，先用小建中汤。不瘥者，小柴胡汤主之。
前条偏于半表，此条偏于半里。注详建中汤证中。
本太阳病不解，转入少阳者，胁下硬满，干呕不能食，往来寒热，尚未吐、下，脉弦细者，与小柴胡汤。
若已吐、下、发汗、温针、谵语，柴胡证罢，此为坏病。知犯何逆，以法治之。
少阳为枢，太阳外证不解，风寒从枢而入少阳矣。若见胁下硬满、干呕不能食、往来寒热之一，便是柴胡
证未罢，即误于吐、下、发汗、温针，尚可用柴胡治之。若误治后，不见半表半里证而发谵语，是将转属阳明，
而不转属少阳矣。柴胡汤不中与之，亦不得以谵语即为胃实也。知犯何逆，治病必求其本也，与桂枝不中与同
义。此太阳坏病，而非少阳坏病也。
凡柴胡汤病而反下之，若柴胡证不罢者，复与柴胡汤，必蒸蒸而振，却发热汗出而解。
此与下后复用桂枝同局。因其人不虚，故不为坏病。
伤寒五六日，呕而发热者，柴胡汤证具，而以他药下之。若心下满而硬痛者，此为结胸也，大陷胸汤主之。
但满而不痛者为痞，柴胡不中与之，宜半夏泻心汤。
注详泻心汤证中。此为柴胡坏证，故不中与之。
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、食谷哕者，柴胡不中与也。
浮弱为桂枝脉，恶风寒为桂枝证，然手足温而身不热。脉迟为寒，为无阳，为在藏，是表里虚寒也。法当
温中散寒，而反二三下之，胃阳丧亡，不能食矣。食谷则哕，饮水则呕。虚阳外走，故一身面目悉黄；肺气不化，
故小便难而渴；营血不足，故颈项强；少阳之枢机无主，故胁下满痛。此太阳中风误下之坏病，非柴胡证矣。
柴胡证不欲食，非不能食；小便不利，非小便难；胁下痞硬，不是满痛；或渴，不是不能饮水；喜呕，不是饮
水而呕。与小柴胡汤后必下利者，虽有参、甘，不禁柴、芩、栝蒌之寒也。此条亦是柴胡疑似证，而非柴胡坏
证。前条似少阴而实少阳，以条似少阳而实太阳坏病，得一证相似处。大宜着眼。
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。初服微烦，复服汗出便愈。
汗下后，而柴胡证仍在者，仍用柴胡汤加减。此因增微结一证，故变其方名耳。此微结与阳微结不同。阳
微结对纯阴结而言，是指大便硬，病在胃。此微结对大结胸而言，是指心下痞，其病在胸胁，与心下痞硬，心下支
结同义。
柴胡桂枝干姜汤∶
柴胡（半斤） 黄芩 桂枝（各三两） 栝蒌根（四两） 干姜 牡蛎 甘草（各二两）
煎服同前法。
此方全是柴胡加减法。心烦不呕而渴，故去参、夏加栝蒌根；胸胁满而微结，故去枣加蛎；小便虽不利而心
下不悸，故不去黄芩不加茯苓；虽渴而表未解，故不用参而加桂；以干姜易生姜，散胸胁之满结也。初服烦即
微者，黄芩，栝蒌之效；继服汗出周身而愈者，姜、桂之功也。小柴胡加减之妙，若无定法而实有定局矣。
伤寒八九日，下之，胸满，烦惊，小便不利，谵语，一身尽
重不可转侧者，柴胡加龙骨牡蛎汤主之。
妄下后热邪内攻，烦惊谵语者，君主不明，而神明内乱也。小便不利者，火盛而水亏也；一身尽重者，阳内
而阴反外也；难以转侧者，少阳之枢机不利也。此下多亡阴，与火逆亡阳不同。
柴胡加龙骨牡蛎汤∶
柴胡（四两） 黄芩 人参 生姜 茯苓 铅丹 桂枝 龙骨 牡蛎（各一两半） 大黄（二两） 半夏
（一合） 大枣（六枚）
水八升，煮取四升，内大黄，更煮一二沸，去滓，温服一升。
此方取柴胡汤之半，以除胸满心烦之半里。加铅丹、龙、蛎，以镇心惊，茯苓以利小便，大黄以止谵语。
桂枝者，甘草之误也。身无热无表证，不得用桂枝。去甘草则不成和剂矣。心烦谵语而不去人参者，以惊故也。
伤寒十三日，下之，胸胁满而呕，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，先宜小柴胡以解外，后以柴胡加芒硝汤主之。
日晡潮热，已属阳明，而微利可疑。利既不因于下药，潮热呕逆又不因利而除，故知误不在下而在丸药也。
丸药发作既迟，又不能荡涤肠胃，以此知日晡潮热，原因胃实。此少阳阳明并病，先服小柴胡二升，以解少阳
之表；其一升加芒硝，以除阳明之里。不加大黄者，以地道原通；不用大柴胡者，以中气已虚也。后人有加大
黄、桑螵蛸者，大背仲景法矣。
太阳病过经十余日，心下温温欲吐，而胸中痛，大便反溏，腹微满，郁郁微烦，先其时极吐下者，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。
After five or six days of Taiyang disease (Disease of the Taiyang Channel), or contracting Wind-stroke (Wind-stroke), presenting with alternating chills and fever, fullness and distension in the chest and hypochondrium, a silent desire not to eat, mental irritability, and frequent vomiting; or presenting with mental irritability in the chest but no vomiting, or thirst, or abdominal pain, or fullness and hardness under the hypochondrium, or palpitations in the epigastrium with difficulty in urination, or no thirst but slight body heat, or coughing: Xiao Chai Hu Tang (Minor Bupleurum Decoction) is the primary treatment.
This does not mean that after five or six days of Cold Damage, one contracts Wind-stroke. The phrase "alternating chills and fever" has three meanings: First, when Shaoyang (Lesser Yang) receives cold pathogenic factors directly, yang qi becomes deficient. It cannot dispel the cold nor generate heat. By the fifth or sixth day, depressed heat erupts internally, contending with the cold pathogen, resulting in alternating chills and fever—this is the first case. Second, if Taiyang (Greater Yang) receives cold, after five or six days the yang qi begins to decline, residual pathogens remain unfinished, and the condition transfers to Shaoyang, resulting in alternating chills and fever—this is the second case. Third, wind is a yang pathogen, and Shaoyang governs wind. Upon contracting wind, alternating chills and fever appear immediately, without waiting for five or six days—this is the third case. The Shaoyang channel traverses the chest and hypochondrium; thus, when pathogens enter this channel, fullness occurs. Because gallbladder qi is not free-flowing, the patient remains silent. Wood pathogen invading Earth (Spleen/Stomach) causes loss of appetite. Ministerial fire blazing internally causes mental irritability. Contention between healthy qi and pathogenic factors causes frequent vomiting. Generally, because Shaoyang serves as the pivot, it neither fully governs the exterior nor the interior; therefore, all these symptoms exist between the exterior and interior. Zhang Zhongjing's original intent emphasizes the semi-interior aspect, while Chai Hu (Bupleuri Radix) primarily treats the semi-exterior aspect. Thus, Shaoyang syndrome must present with semi-exterior signs, making it appropriate to use Chai Hu decoctions with modifications. If pathogens completely enter the interior, Chai Hu decoction is no longer suitable. Therefore, Xiao Chai Hu Tang is regarded as the principal formula for harmonizing the exterior and interior.
Alternating chills and fever manifest the pathology externally; feelings of distress, preference for vomiting, and lack of desire to eat reflect the pathology internally. The characters "preference," "distress," and "desire" indicate that these are not necessarily true vomiting, true fullness, or absolute inability to eat. The characters "going" and "coming" imply periods where there are no chills or fever. Alternating chills and fever with chest and hypochondriac fullness constitute the formless semi-exterior syndrome; mental irritability, preference for vomiting, silence, and lack of desire to eat constitute the formless semi-interior syndrome. Although all seven symptoms lean toward the interior, only slight heat indicates the exterior. All belong to formless pathogens, except for palpitations in the epigastrium, which involves form. All are common patterns of wind-cold, except for fullness and hardness under the hypochondrium, which specifically belongs to Shaoyang. In summary, these are disorders of the qi level, lacking substantial evidence, so they are treated according to the semi-exterior semi-interior method.
When blood is weak and qi is deficient, the interstices (cou li) open, allowing pathogens to enter and contend with healthy qi, knotting at the hypochondrium. Healthy qi and pathogens contend, causing alternating chills and fever with regular intervals of remission and exacerbation. Silence and lack of desire to eat occur because the zang-fu organs are connected; the pain does not descend. Since the pathogen is high and the pain is low, vomiting results.
This is Zhang Zhongjing's own annotation of the Chai Hu syndrome. The first five sentences explain the cause of chest and hypochondriac distress. The three sentences regarding healthy and pathogenic qi explain the meaning of alternating chills and fever. There are likely missing texts here, causing discontinuity in the logic.
Xiao Chai Hu Tang (Minor Bupleurum Decoction):
Chai Hu (Bupleuri Radix) - 8 liang, Ban Xia (Pinelliae Rhizoma) - 0.5 sheng, Ren Shen (Ginseng Radix), Gan Cao (Glycyrrhizae Radix et Rhizoma), Huang Qin (Scutellariae Radix), Sheng Jiang (Zingiberis Rhizoma Recens) - each 3 liang, Da Zao (Jujubae Fructus) - 12 pieces.
Boil in 12 sheng of water, reduce to 6 sheng, remove dregs, boil again to reduce to 3 sheng. Take 1 sheng warm, three times daily.
If there is mental irritability in the chest but no vomiting, remove Ban Xia and Ren Shen, add Gua Lou Shi (Trichosanthis Fructus) - 1 piece.
If there is thirst, remove Ban Xia, increase Ren Shen to 4.5 liang total, add Gua Lou Gen (Trichosanthis Radix) - 4 liang.
If there is abdominal pain, remove Huang Qin, add Bai Shao (Paeoniae Radix Alba) - 3 liang.
If there is fullness and hardness under the hypochondrium, remove Da Zao, add Mu Li (Ostreae Concha) - 4 liang.
If there are palpitations in the epigastrium and difficulty in urination, remove Huang Qin, add Fu Ling (Poria) - 4 liang.
If there is no thirst but slight external heat, remove Ren Shen, add Gui Zhi (Cinnamomi Ramulus) - 3 liang. Take warm to induce slight sweating for cure.
If there is coughing, remove Ren Shen, Da Zao, and Sheng Jiang, add Wu Wei Zi (Schisandrae Fructus) - 0.5 sheng, Gan Jiang (Zingiberis Rhizoma) - 2 liang.
Chai Hu grows by absorbing the qi of one yang, allowing it to enter Shaoyang directly, guiding clear qi upward and executing the spring-like function. It is the premier herb for treating alternating chills and fever. When Shaoyang exterior pathogens are unresolved, it is essential. Ban Xia grows by absorbing the qi of one yin, allowing it to resolve stagnation, direct rebellious qi downward, and eliminate phlegm-fluids. It is the premier herb for treating vomiting. If there is no vomiting but chest irritability and thirst, it should be removed because it disperses fluid qi. Huang Qin is hard outside and hollow inside, allowing it to clear internal irritant heat and unblock rebellious qi in the chest and diaphragm. Abdominal pain is caused by Shaoyang ministerial fire; since Huang Qin's bitter nature transforms into fire, it is replaced by the sour nature of Bai Shao to drain the fire. Palpitations and difficulty in urination are treated by replacing Huang Qin with the bland nature of Fu Ling to promote diuresis (Note: Original text logic regarding bitter flavor tonifying kidney is specific to this commentary context).
Ren Shen and Gan Cao tonify middle qi and harmonize Ying and Wei, ensuring that when healthy qi prevails, pathogens retreat, internal pathogens do not linger, and external pathogens do not re-enter. Zhang Zhongjing does not use Ren Shen in exterior syndromes generally, but here uses it to support primordial qi due to the formless semi-interior syndrome, ensuring internal harmony prevents external invasion. Slight body heat indicates unresolved exterior, so tonification is contraindicated. Mental irritability and coughing indicate excess rebellious qi, so tonifying qi is contraindicated; hence, they are removed. For example, body ache with deep, slow pulse after sweating, or epigastric hardness with diarrhea after purging in Taiyang disease, represents a semi-exterior semi-interior Taiyang syndrome. Although the exterior is unresolved, the focus shifts to the interior after sweating or purging, so Ren Shen and Gui Zhi are used together. Ancestors argue that the key to this decoction lies in Chai Hu and Huang Qin, as Chai Hu clears exterior heat and Huang Qin clears interior heat. Lu氏 argues that Chai Hu and Ban Xia, born from the qi of the two solstices, govern the semi-exterior semi-interior, which seems reasonable. However, among the seven herbs, Ban Xia and Huang Qin can be removed, but Chai Hu and Gan Cao cannot. One must know that alternating chills and fever rely entirely on Chai Hu to resolve the exterior and Gan Cao to harmonize the middle. Therefore, Da Chai Hu Tang removes Gan Cao and is named separately, not included in the modification rules of Xiao Chai Hu Tang.
In Cold Damage or Wind-stroke, if Chai Hu syndrome is present, observing just one symptom is sufficient; it is not necessary for all symptoms to be present.
Chai Hu is a pivot-regulating agent. For any condition where cold pathogens are neither fully in the exterior nor fully in the interior, it can be taken. Since symptoms need not be complete, the formula composition is not fixed.
For vomiting accompanied by fever, Xiao Chai Hu Tang is the primary treatment.
Cold Damage causes severe vomiting; Wind-stroke causes dry heaving. In any Cold Damage or Wind-stroke case, if there are no Ma Huang Tang or Gui Zhi Tang indications, but the symptom of "frequent vomiting" is present, and fever exists, Chai Hu Tang can be used without waiting for alternating chills and fever. With fever and vomiting, Ren Shen should be removed, and Gui Zhi is inappropriate. For red eyes, deafness, chest fullness, and irritability, use the method of removing Ren Shen and Ban Xia and adding Gua Lou Shi from Chai Hu Tang. For wiry-thin pulse with headache and fever, add Gui Zhi to Chai Hu Tang.
After five or six days of Cold Damage, with head sweating, slight aversion to cold, cold hands and feet, epigastric fullness, lack of desire to eat, hard stool, and deep-thin pulse, this is called "Yang Mild Knotting." It implies both exterior and interior involvement. Deep pulse indicates interior involvement. Head sweating indicates Yang Mild Knotting. If it were pure Yin Knotting, there would be no exterior symptoms, as everything would be in the interior. This is half-interior, half-exterior. Although the pulse is deep and thin, it cannot be diagnosed as Shao Yin disease. Why? Because Yin syndromes should not have sweating. Since there is head sweating, it is known not to be Shao Yin. Xiao Chai Hu Tang may be given. If the patient still feels uncomfortable afterward, relief comes with defecation.
Hard stool is called "Knotting." Floating-rapid pulse with ability to eat is "Yang Knotting"; deep-slow pulse with inability to eat is "Yin Knotting." This clause mentions Shao Yin pulses, noting that five or six days is also the period for Shao Yin onset. If one says Yin syndromes cannot sweat, then Shao Yin Yang Collapse with tight pulse and sweating exists. However, Yang Collapse differs from Yin Knotting: Yang Collapse presents with sore throat, vomiting, and diarrhea; Yin Knotting presents with inability to eat and hard stool. Yang Collapse also differs from Yang Knotting: Three Yin channels do not reach the head, so sweating is on the body; Three Yang channels flourish at the head, so Yang Knotting presents with head sweating. Pathogens in Yang Ming, with excess Yang, allow eating (Pure Yang Knotting); pathogens in Shaoyang, with weak Yang, cause lack of desire to eat (Yang Mild Knotting), suitable for Xiao Chai Hu Tang. However, to give Chai Hu Tang, one must verify the pathology is semi-exterior. Slight aversion to cold could belong to Shao Yin; only head sweating begins to belong to Shaoyang. To clarify the significance of head sweating, Xiao Chai Hu Tang can be given without doubt. Once the Upper Jiao is unblocked, epigastric fullness resolves and appetite returns; once fluids descend, stool softens naturally. This is a differential diagnosis between Shao Yin and Shaoyang.
The above discusses the main symptoms of Xiao Chai Hu Tang.
After four or five days of Cold Damage, with body heat, aversion to wind, stiffness of the head and neck, fullness under the hypochondrium, warm hands and feet, and thirst, Xiao Chai Hu Tang is the primary treatment.
Body heat and aversion to wind with head/neck stiffness indicate Gui Zhi Tang syndrome is not yet resolved. Fullness under the hypochondrium indicates one Chai Hu symptom. One should use Xiao Chai Hu Tang removing Ren Shen and Ban Xia, adding Gui Zhi and Gua Lou Shi to address both aspects. It relies on Chai Hu rather than Gui Zhi because it follows the pivot mechanism.
In Yang Ming disease, with tidal fever, loose stool, normal urination, and chest/hypochondriac fullness, Xiao Chai Hu Tang is the primary treatment.
Tidal fever belongs to Yang Ming, but loose stool and normal urination indicate gastric excess is not yet formed. Chest/hypochondriac distress calls for harmonization with Xiao Chai Hu Tang. Heat pathogens resolve via Shaoyang and do not enter Yang Ming. The previous clause (4-5 days) describes Taiyang-Shaoyang concurrent disease; this describes Yang Ming-Shaoyang combined disease. To say Yang Ming transmits to Shaoyang is incorrect.
In Yang Ming disease, with hardness/fullness under the hypochondrium, constipation, vomiting, and white coating on the tongue, Xiao Chai Hu Tang may be given. Once the Upper Jiao is unblocked, fluids descend, stomach qi harmonizes, and slight sweating leads to resolution.
Constipation belongs to Yang Ming, but hypochondriac hardness and vomiting indicate Shaoyang involvement. White tongue coating indicates phlegm-fluid overflowing into the Upper Jiao. Giving Xiao Chai Hu Tang transforms phlegm-fluid into fluids, harmonizes the dry earth (Stomach), and allows the Upper Jiao to sweat, nourishing the body and hair.
In Cold Damage with frequent vomiting, even if Yang Ming symptoms exist, purgatives must not be used.
Vomiting indicates water-qis in the Upper Jiao. Once the Upper Jiao is unblocked, fluids descend, and stomach qi harmonizes.
If thirst develops after taking Chai Hu Tang, it indicates transmission to Yang Ming. Treat accordingly.
Chai Hu Tang contains Huang Qin, Ren Shen, Gan Cao, and Da Zao, all generating fluids. If thirst persists after ingestion, gastric excess has occurred, and fluids are insufficient to harmonize the stomach. Baicao Tang or Chengqi Tang methods should be used. Continuing to modify Chai Hu Tang is incorrect. This represents Shaoyang about to transmit to Yang Ming.
The above discusses combined diseases of two channels.
In women with Wind-stroke for seven or eight days, if chills and fever continue with regular timing, and menstruation has just ceased, this is "Heat Entering the Blood Chamber." Blood will knot, causing malaria-like symptoms with regular timing. Xiao Chai Hu Tang is the primary treatment.
By seven or eight days, initial chills and fever should have passed. New chills and fever with regular timing differ from irregular alternating chills and fever; this pathology is in the blood level, not the qi level. When diagnosing women, menstrual history must be asked. Menstruation ceasing during chills and fever is abnormal cessation. Likely, menstruation lowered, leaving the Blood Chamber empty, allowing heat pathogens to enter vacantly. Residual blood knots internally, causing cessation. Xiao Chai Hu Tang harmonizes, dissipating knotted blood and resolving chills and fever. See Yang Ming chapter for further details.
The above discusses Heat Entering the Blood Chamber.
After six or seven days of Cold Damage, with slight fever and aversion to cold, painful limbs and joints, slight vomiting, epigastric support-knotting, and unresolved exterior symptoms, Chai Hu Gui Zhi Tang (Bupleurum and Cinnamon Twig Decoction) is the primary treatment.
At six or seven days, chills and fever should subside. Their recurrence indicates exterior syndrome combined with epigastric support-knotting (interior syndrome), with both exterior and interior unresolved. Slight aversion to cold implies slight fever. Painful limbs imply whole-body joint pain. "Support" (Zhi) refers to slight knotting, like tree branches. Exterior syndrome is mild, so half of Gui Zhi Tang is used; interior syndrome is mild, so half of Chai Hu Tang is used. This light harmonizing agent is used because both interior and exterior are deficient.
The above discusses Chai Hu Gui Zhi syndrome.
Chai Hu Gui Zhi Tang:
Chai Hu (4 liang), Huang Qin, Ren Shen, Sheng Jiang, Bai Shao, Gui Zhi (each 1.5 liang), Gan Cao (1 liang), Ban Xia (2.5 he), Da Zao (6 pieces).
Boil in 7 sheng of water, reduce to 3 sheng, remove dregs, take 1 sheng warm.
Gui Zhi, Bai Shao, Gan Cao represent half of Gui Zhi Tang; Chai Hu, Ren Shen, Huang Qin, Ban Xia represent half of Chai Hu Tang; Sheng Jiang and Da Zao represent half of both formulas. This is a combination of halves, not simply taking half of each ingredient. It differs from combining Ma Huang Tang and Gui Zhi Tang.
In Cold Damage, with superficial pulse sluggish and deep pulse wiry, abdominal acute pain is expected. Use Xiao Jian Zhong Tang first. If ineffective, use Xiao Chai Hu Tang.
The previous clause leans semi-exterior; this leans semi-interior. See annotations in Jian Zhong Tang syndrome.
If original Taiyang disease fails to resolve and transfers to Shaoyang, presenting with hypochondriac hardness, dry heaving, inability to eat, alternating chills and fever, and wiry-thin pulse (without prior emesis, purging, sweating, or warm needle therapy), give Xiao Chai Hu Tang.
If emesis, purging, sweating, or warm needle therapy have already been performed, leading to delirium, and Chai Hu syndrome has ceased, this is a "Ruined Syndrome" (Bad Disease). Determine the error and treat accordingly.
Shaoyang is the pivot. If Taiyang exterior symptoms persist, wind-cold enters Shaoyang via the pivot. If one observes hypochondriac hardness, dry heaving/inability to eat, or alternating chills and fever, Chai Hu syndrome persists. Even if mistreated with emesis/purging/sweating/warm needles, Chai Hu treatment may still apply. However, if after mistreatment, semi-exterior/semi-interior symptoms disappear and delirium appears, the condition is transferring to Yang Ming, not Shaoyang. Chai Hu Tang is inappropriate. Do not assume delirium equals gastric excess. Determine the error and treat based on the root. This parallels the logic of whether to give Gui Zhi Tang. This is a Taiyang Ruined Syndrome, not a Shaoyang Ruined Syndrome.
If Chai Hu Tang syndrome is mistakenly purged, but Chai Hu syndrome persists, giving Chai Hu Tang again will cause shivering followed by fever and sweating for resolution.
This parallels using Gui Zhi Tang after purging. Because the patient is not deficient, it does not become a Ruined Syndrome.
After five or six days of Cold Damage, with vomiting and fever (Chai Hu syndrome present), if mistaken purgatives are used:
If epigastric fullness is hard and painful, it is Jie Xiong (Chest Binding); use Da Xian Xiong Tang (Major Gallbladder Detoxifying Decoction).
If full but not painful, it is Pi (Glomus); Chai Hu Tang is inappropriate; use Ban Xia Xie Xin Tang (Pinellia Heart-Draining Decoction).
See annotations in Xie Xin Tang syndrome. This is a Chai Hu Ruined Syndrome, so Chai Hu Tang is inappropriate.
Six or seven days after illness, with slow-floating-weak pulse, aversion to wind/cold, warm hands/feet, if the physician purges multiple times, leading to inability to eat, hypochondriac fullness/pain, yellowing of face/body, neck stiffness, and difficulty urinating: Giving Chai Hu Tang will cause heaviness in defecation. If originally thirsty but drinking causes vomiting, or eating causes hiccups: Chai Hu Tang is inappropriate.
Floating-weak pulse is Gui Zhi pulse; aversion to wind/cold is Gui Zhi syndrome. But warm hands/feet without body heat indicates cold. Slow pulse indicates cold, lack of Yang, and interior organ involvement—exterior-interior deficiency-cold. Warm middle and dispel cold is indicated. Mistaken purging destroys Stomach Yang, causing inability to eat. Eating causes hiccups; drinking causes vomiting. Deficient Yang floats outward, causing jaundice. Lung qi fails to transform, causing difficulty urinating and thirst. Ying-blood deficiency causes neck stiffness. Shaoyang pivot lacks mastery, causing hypochondriac fullness/pain. This is a Taiyang Wind-stroke Ruined Syndrome due to mistaken purging, not Chai Hu syndrome.
Chai Hu syndrome involves lack of desire to eat, not inability to eat; difficulty urinating, not difficult urination; hypochondriac fullness/hardness, not fullness/pain; thirst, not inability to drink; preference for vomiting, not vomiting upon drinking. Giving Xiao Chai Hu Tang will cause diarrhea because, despite Ren Shen and Gan Cao, the cold nature of Chai Hu, Huang Qin, and Gua Lou is intolerable. This is a Chai Hu differential syndrome, not a Ruined Syndrome. The previous clause resembles Shao Yin but is actually Shaoyang; this clause resembles Shaoyang but is actually a Taiyang Ruined Syndrome. Note the similarity carefully.
After five or six days of Cold Damage, if sweating was performed followed by purging, presenting with chest/hypochondriac fullness with slight knotting, difficulty urinating, thirst without vomiting, only head sweating, alternating chills and fever, and mental irritability: The disease is unresolved. Use Chai Hu Gui Zhi Gan Jiang Tang (Bupleurum, Cinnamon Twig, and Dried Ginger Decoction). Initial dose causes slight irritability; subsequent doses induce sweating and cure.
After sweating and purging, if Chai Hu syndrome persists, modify Chai Hu Tang. The name changes due to the added symptom of slight knotting. This slight knotting differs from Yang Mild Knotting. Yang Mild Knotting contrasts with Pure Yin Knotting, referring to hard stool in the Stomach. This slight knotting contrasts with Da Jie Xiong (Major Chest Binding), referring to epigastric glomus in the chest/hypochondrium, synonymous with epigastric hardness or epigastric support-knotting.
Chai Hu Gui Zhi Gan Jiang Tang:
Chai Hu (8 liang), Huang Qin, Gui Zhi (each 3 liang), Gua Lou Gen (4 liang), Gan Jiang, Mu Li, Gan Cao (each 2 liang).
Decoct and administer as before.
This formula is entirely derived from Chai Hu Tang modifications. Mental irritability without vomiting but with thirst: remove Ren Shen and Ban Xia, add Gua Lou Gen. Chest/hypochondriac fullness with slight knotting: remove Da Zao, add Mu Li. Difficulty urinating without epigastric palpitations: keep Huang Qin, do not add Fu Ling. Thirst with unresolved exterior: do not use Ren Shen, add Gui Zhi. Replace Sheng Jiang with Gan Jiang to disperse chest/hypochondriac fullness/knotting. Initial slight irritability resolves due to Huang Qin and Gua Lou; subsequent sweating cures due to Gan Jiang and Gui Zhi. The subtlety of Chai Hu Tang modifications appears rule-less but has definite principles.
After eight or nine days of Cold Damage, if purged, presenting with chest fullness, mental irritability/fright, difficulty urinating, delirium, and whole-body heaviness preventing turning: Use Chai Hu Jia Long Gu Mu Li Tang (Bupleurum Plus Dragon Bone and Oyster Shell Decoction).
Mistaken purging allows heat pathogens to attack inward. Irritability, fright, and delirium indicate the Sovereign (Heart) is unclear and Spirit is chaotic internally. Difficulty urinating indicates fire excess and water deficiency. Whole-body heaviness indicates Yang trapped inside and Yin floating outside. Inability to turn indicates Shaoyang pivot dysfunction. This is Yin depletion from excessive purging, different from Yang collapse due to fire reversal.
Chai Hu Jia Long Gu Mu Li Tang:
Chai Hu (4 liang), Huang Qin, Ren Shen, Sheng Jiang, Fu Ling, Qian Dan (Lead Carbonate), Gui Zhi, Long Gu (Fossilized Mammal Bones), Mu Li (each 1.5 liang), Da Huang (Rhei Radix et Rhizoma) (2 liang), Ban Xia (1 he), Da Zao (6 pieces).
Boil in 8 sheng of water, reduce to 4 sheng. Add Da Huang, boil 1-2 more boils. Remove dregs, take 1 sheng warm.
This formula takes half of Chai Hu Tang to address semi-interior chest fullness and irritability. Adds Qian Dan, Long Gu, Mu Li to calm fright and settle spirit; Fu Ling to promote urination; Da Huang to stop delirium. Gui Zhi is likely a typo for Gan Cao. Without heat or exterior symptoms, Gui Zhi is contraindicated. Removing Gan Cao ruins the harmonizing nature. Ren Shen is kept despite irritability/delirium due to fright.
After thirteen days of Cold Damage, if purged, presenting with chest/hypochondriac fullness and vomiting, tidal fever at dusk, followed by slight diarrhea: This was originally Chai Hu syndrome. Purging should not cause diarrhea. The fact that diarrhea occurred indicates the physician used pill-based purgatives, which is incorrect. Tidal fever indicates excess. First, use Xiao Chai Hu Tang to resolve the exterior; then use Chai Hu Jia Mang Xiao Tang (Bupleurum Plus Niter Decoction).
Tidal fever at dusk belongs to Yang Ming, but slight diarrhea is suspicious. Diarrhea is not due to purgatives; tidal fever/vomiting do not resolve with diarrhea. Thus, the error lies in the pill purgatives, not the act of purging. Pill purgatives act slowly and fail to cleanse the intestines. Tidal fever at dusk is due to gastric excess. This is Shaoyang-Yang Ming concurrent disease. Take 2 sheng of Xiao Chai Hu Tang to resolve Shaoyang exterior; add Mang Xiao (Natrii Sulfas) to the remaining 1 sheng to clear Yang Ming interior. Da Huang is not added because the bowel pathway is originally open; Da Chai Hu Tang is not used because Middle Qi is already deficient. Later additions of Da Huang and Sang Piao Xiao (Mantis Egg Case) greatly violate Zhongjing's method.
Taiyang disease passing its stage for over ten days, with epigastric nausea, chest pain, loose stool, slight abdominal fullness, and suppressed mental irritability: If the patient underwent extreme emesis or purging previously, give Tiao Wei Cheng Qi Tang (Regulate the Stomach and Direct Downward Decoction). If not, do not give it. If only nausea, chest pain, and slight loose stool are present, this is not Chai Hu syndrome. The presence of nausea indicates extreme emesis/purging occurred.