伤寒十三日不解。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。先宜小柴胡汤以解外。后以柴胡加芒硝汤以治
其里也。
此少阳经邪兼阳明内实之证。少阳病在经。故胸胁满而呕。所谓柴胡证也。下之而三字。疑衍
。凡柴胡证不得利。今反利者。知医以丸药下之。为医之误。非病之情也。潮热者。阳明之实也
。实则可下。而证兼少阳。则不可下。故先宜小柴胡以解其外。后以柴胡加芒硝汤以治其里。亦如
下条之先与小柴胡。后与大柴胡之例也。亦太阳篇移入。
尚从善云、此本柴胡证。下之而不得利。仲景谓此本柴胡证。医设以大柴胡汤下之。则表里俱
解。何至有下利之证云。
柴胡加芒硝汤方
于小柴胡汤内加芒硝六两。余根据前法服。不解更服。
太阳病。过经十余日。反二三下之。后四五日。柴胡证仍在者。先与小柴胡汤。呕不止。心下
急。郁郁微烦者。为未解也。与大柴胡汤。下之则愈。
太阳病。过经十余日。而有柴胡证。乃邪气去太阳之阳明。而复之少阳也。少阳不可下。而反
二三下之。
于法为逆。若后四五日。柴胡证仍在者。先与小柴胡汤。所谓柴胡汤病证而下之。若柴胡证不罢者
。复与柴胡是也。若服汤已。呕不止。心下急。郁郁微烦者。邪气郁滞于里。欲出不出。欲结不结。
为未解也。与大柴胡以下里热则愈。亦先表后里之意也。此条自太阳篇移入。
大柴胡汤方
柴胡（八两） 半夏（八两） 黄芩（三两） 生姜（五两） 枳实（四枚） 芍药（三两）
大枣（十二枚擘） 大黄（二两酒浸）
上八味。以水一斗二升。煮取六升。去滓。再煎取三升。温服一升。日三服。
按大柴胡有柴胡、生姜、半夏之辛而走表。黄芩、芍药、枳实、大黄之苦而入里。乃表里并治
之剂。而此云大柴胡下之者。谓病兼表里。故先与小柴胡解之。而后以大柴胡下之耳。盖分言之。
则大小柴胡各有表里。合言之。则小柴胡主表。而大柴胡主里。古人之言。当以意。逆往往如此。
Taiyang disease (Disease of the Taiyang/Bladder channel) has persisted for thirteen days without resolution. The patient presents with fullness and distension in the chest and hypochondrium accompanied by vomiting, tidal fever (fever that peaks at a specific time, typically late afternoon) occurring daily around dusk, followed by slight diarrhea. This originally belonged to the Shaoyang pattern (a syndrome characteristic of the Shaoyang/Gallbladder channel). Previously, the physician mistakenly applied purgation therapy; since purgation should not have induced diarrhea in this context, the subsequent occurrence of diarrhea indicates that the physician used pill-based purgatives, which was an incorrect treatment method. Tidal fever indicates the presence of internal excess accumulation. Therapeutically, one should first administer Xiao Chai Hu Tang (Minor Bupleurum Decoction) to resolve the exterior pathogenic factor, and subsequently use Chai Hu Jia Mang Xiao Tang (Bupleurum Decoction with Natrii Sulfas) to treat the interior excess heat.
This is a syndrome where Shaoyang channel pathogen remains unresolved, complicated by Yangming interior excess (internal solidification). Since the Shaoyang pathogen resides in the channels, it manifests as chest/hypochondriac fullness and vomiting, known as the "Chai Hu pattern." The phrase "after purgation" is suspected to be a textual error (interpolated text). Typically, Chai Hu patterns do not present with diarrhea; the current occurrence suggests the physician erroneously used pill-purgatives, representing medical error rather than the natural progression of the disease. Tidal fever signifies Yangming excess. Although excess syndromes are amenable to purgation, the concurrent Shaoyang involvement contraindicates direct harsh purgation. Therefore, one should initially use Xiao Chai Hu Tang to harmonize the exterior, followed by Chai Hu Jia Mang Xiao Tang to address the interior excess. This follows the precedent mentioned in the next paragraph: first giving Xiao Chai Hu Tang, then Da Chai Hu Tang. This clause was transferred from the *Taiyang Chapter*.
Shang Congshan stated: This was originally a Chai Hu pattern. After erroneous purgation, diarrhea occurred. Zhang Zhongjing noted that if the physician had initially used Da Chai Hu Tang (Major Bupleurum Decoction) for purgation, both exterior and interior pathogens would have been resolved, preventing such diarrhea.
Formula: Chai Hu Jia Mang Xiao Tang (Bupleurum Decoction with Natrii Sulfas)
Add six liang of Mang Xiao (Natrii Sulfas, Mirabilite) to Xiao Chai Hu Tang (Minor Bupleurum Decoction). Prepare and administer according to the previous method. If symptoms persist, continue administration.
In Taiyang disease, after more than ten days, the physician incorrectly performed purgation two or three times. Four or five days later, if the Chai Hu pattern persists, administer Xiao Chai Hu Tang (Minor Bupleurum Decoction) first. If vomiting continues incessantly, there is urgency and tension in the epigastrium, and the patient feels郁郁微烦 (internally constrained and slightly vexed), indicating the disease is not yet resolved. Administer Da Chai Hu Tang (Major Bupleurum Decoction); purging the interior will lead to recovery.
When Taiyang disease persists beyond ten days and Chai Hu patterns emerge, it indicates the pathogen has left the Taiyang channel, entered the Yangming, and then shifted to the Shaoyang channel. Shaoyang disorders contraindicate purgation, yet the physician purged two or three times, which is therapeutically adverse. If four or five days later the Chai Hu pattern remains, administer Xiao Chai Hu Tang (Minor Bupleurum Decoction) first. This aligns with the principle: "If purgation is wrongly applied to a Chai Hu pattern, and the pattern persists, re-administer Chai Hu [formulas]." If, after taking the decoction, vomiting persists, epigastric urgency occurs, and internal constraint/vexation arises, it indicates pathogen stagnation in the interior—unable to exit, unable to fully consolidate—signifying unresolved disease. Administer Da Chai Hu Tang (Major Bupleurum Decoction) to purge interior heat, leading to recovery. This also reflects the principle of treating the exterior before the interior. This clause was also transferred from the *Taiyang Chapter*.
Formula: Da Chai Hu Tang (Major Bupleurum Decoction)
Chai Hu (Radix Bupleuri, 8 liang), Ban Xia (Rhizoma Pinelliae Preparatum, 8 liang), Huang Qin (Radix Scutellariae, 3 liang), Sheng Jiang (Rhizoma Zingiberis Recens, 5 liang), Zhi Shi (Fructus Aurantii Immaturus, 4 pieces), Shao Yao (Radix Paeoniae Alba, 3 liang), Da Zao (Fructus Jujubae, 12 pieces, split), Da Huang (Radix et Rhizoma Rhei, 2 liang, soaked in wine).
Take the above eight ingredients, boil in 12 sheng of water, reduce to 6 sheng, remove dregs, and further decoct to obtain 3 sheng. Warm and take 1 sheng per dose, three times daily.
Commentary: Da Chai Hu Tang (Major Bupleurum Decoction) contains acrid-warm herbs like Chai Hu, Sheng Jiang, and Ban Xia to disperse the exterior, and bitter-cold herbs like Huang Qin, Shao Yao, Zhi Shi, and Da Huang to enter the interior, making it a formula that treats both exterior and interior simultaneously. When the text states Da Chai Hu Tang is used for "purging," it implies that because the disease involves both exterior and interior, one first uses Xiao Chai Hu Tang (Minor Bupleurum Decoction) to resolve the exterior, then uses Da Chai Hu Tang to purge the interior. Separately considered, both Minor and Major Bupleurum formulas address both levels; collectively, Xiao Chai Hu Tang primarily addresses the exterior, while Da Chai Hu Tang primarily addresses the interior. Ancient texts require interpretation through contextual understanding, which is often the case here.