于小柴胡汤方内，加芒硝六两，余根据前法服，不解更服。
@@@
伤寒十三日不解过经，□语者，以有热也，当以汤下之。若小便利者，大盒饭□，而
反下利，脉调和者，知医以丸药下之，非其治也。若自下利者，脉当微厥，今反和者
，此为内实也，调胃承气汤主之。
【注】
此承上条互发其义，以详其治也。伤寒十三日不解，过经，□语者，以有热也，当以
汤药下其热。但上条潮热之热，热在表里，当大便不□；此条□语之热，热归胃府，
法当大便□。若小便利者，大盒饭□，今大便不□而反下利，脉调和者，知为医以丸
药下之之利，非其治也。如未经丸药下之，自下利者，则为内虚，内虚之利，脉当微
弱而厥，今反和而不微厥，此为内实有热，非内虚有寒也，虽下利乃热利也。仍当下
其热，故以调胃承气汤主之。
@@@
伤寒三日，三阳为尽，三阴当受邪，其人反能食而不呕，此为三阴不受邪也。
【注】
伤寒之邪，一日太阳受之，二日阳明受之，三日少阳受之，四日太阴受之，五日少阴
受之，六日厥阴受之，此传经之次第也。今伤寒三日，三阳表邪为尽，三阴当受邪，
其人当不能食而呕，今反能食而不呕者此为里和，三阴不受邪也。然此乃『内经』以
其大概而言，究不可以日数拘也。
【集注】
成无己曰：表邪传里，里不和则不能食而呕，今反能食而不呕，是邪不传阴，但在阳
也。
方有执曰：阳以表言，阴以里言，能食不呕，里气和而胃气回，阴不受邪可知矣。
汪琥曰：邪在少阳，原呕不能食，今反能食而不呕，可征里气之和，而少阳之邪自解
也。里既和而少阳之邪解 ，则其不传三阴，断断可必，故云：三阴不受邪也。
@@@
伤寒六、七日，无大热，其人躁烦者，此为阳去入阴故也。
【注】
伤寒六、七日，邪欲入里之时也。无大热，表热微也。躁烦者，里热盛也。此为阳去
入阴也。阳去入阴者，谓阳邪去表入里，传于三阴也。
【集注】
成无己曰：内热为烦。谓心中郁烦也；外热为躁，谓身外热躁也。内热为有根之火，
故但烦不躁，乃先烦后躁者，皆可治；外热为无根之火，故但躁不烦，及先躁后烦者
，皆不可治。
方有执曰：去，往也。言表邪去而入于里，所以外无他热，而内则烦躁也。
@@@
妇人中风，发热恶寒，经水适来，得之七、八日，热除而脉迟身凉，胸□下满，如结
胸状，□语者，此为热入血室也，当刺期门，随其实而泻之。
【注】
妇人中风，发热恶寒，表病也。若经水不来，热必无由传于血室，今经水适来，得之
七、八日后，脉迟热除，身凉似乎表欲解矣。若复见胸□下满，如结胸状，□语之证
，则知非表解入里，乃表邪之热因经水适来，乘虚而入于血室也，法当刺期门。期门
为肝之穴，肝为藏血之所，今邪入血室，故刺期门，随其血分实热而泻之也。
【集注】
方有执曰：血室，为荣血停留之所，经血集会之处，即冲脉所谓血海是也。其脉起于
气冲，并少阴之经，夹脐上行至胸中而散，故热入而病作，其证则如是也。期门二穴
在不容两傍，各去同身寸之一寸五分，肝之募也。肝纳血，故刺期门，所以泻血分之
实热也。
汪琥曰：邪传少阳，热入血室，故作□语等证。仲景恐人误认为阳明府实证，轻用三
承气以伐胃气，故特出一刺期门法以疗之。
@@@
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。
【注】
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，血与热抟，
其血必结。然虽结而无胸□满，如结胸□语等证，是为结而未实也。尚有如疟状之寒
热，发作有时，乃为邪在少阳，半表半里也。故用小柴胡汤以和表里，热自解也。
【集注】
方有执曰：前经水适来者，因热入血室，血出而热遂遗也。此适断者，热乘血来而遂
入之，与后血相抟，俱留而不出，故曰其血必结也。
程知曰：前证经水来，而胸□满结□语，是邪实于藏也，故用刺以泻之。此证因血结
而寒热如疟，是邪发于经也，故用小柴胡汤和之。
@@@
妇人伤寒，发热，经水适来，昼日明了，暮则□语，如见鬼状者，此为热入血室，无
犯胃气及上二焦，必自愈。
【注】
上二条，发明风邪热入血室之证；此条发明寒邪热入血室之证。妇人伤寒，发热无汗
，经水适来，则必热入血室。故昼则明了，知邪不在阳也；暮则□语，如见鬼状者，
是为邪在阴也。无犯胃气及上二焦者，通谓三焦也。盖禁人汗、吐、下三法，皆不可
轻用，当俟其经行，必热随血去而愈也。
【集注】
方有执曰：必自愈者，言俟其经行血下，则邪热得以随血而俱出，犹之鼻衄红汗，故
自愈也。盖警人勿妄攻，以致变乱之意。
林澜曰：伤寒发热者，寒已成热也。经水适来、则血室空虚，邪热乘虚入于血室。若
昼日谵语，为邪客于府与阳争也。此昼日明了，暮则□语如见鬼状者。是邪不入府，
而入于血室与阴争也。阳盛□语宜下，此不可下者，犯胃气也。彼热入血结寒热者，
与小柴胡汤散邪发汗；此虽热入血室，而不留结，不可与发汗药、犯其上焦也。若热
入胸□满如结胸者，可刺期门；此虽热入血室而无满结。不可刺期门，以犯其中焦也
。必自愈者，以经行则热随血去，血下则邪热悉除而愈矣。
@@@
血弱气尽，腠理开，邪气因入，与正气相抟，结于□下，正邪分争，往来寒热，休作
有时，默默不欲饮食，藏府相连，其痛必下，邪高痛下〔一云：藏府相连，其病必下
，□膈中痛〕，故使呕也，小柴胡汤主之。
【注】
此详申上三条，妇人中风、伤寒，经水适来过多，以致血弱气尽，腠理不密，邪热之
气乘虚入于血室，邪与正相抟，结于少阳之界，故邪结于□下也。邪正相争，争于阳
则热，争于阴则寒，故往来寒热也；争已必衰，衰则止，故休作有时也；少阳病已入
半里，将近厥阴，故默默不欲饮食也；少阳胆与厥阴肝相为表里，故曰：藏府相连也
。少阳之脉，下胸中，循□表；厥阳之脉，抵少腹，循□里，故其痛必及于□下也。
少阳之邪，从胸而下□，因胸而病及于□，故曰：邪高痛下也。邪从胸循□入里，里
气上拒，故使呕也。仲景重出此条，仍主之以小柴胡汤者，使知法不外少阳，不必另
从厥阴血室中求治也。
【集注】
喻昌曰：四条皆互文见意也。一云：经水适来，一云：经水适断。一云：七、八日热
除，而脉迟身凉，一云：七、八日续得寒热，发作有时。一云：胸□下满，一云：邪
气因入与正气相抟，结于□下。一云：如结胸状，一云：邪高痛下。一云：□语。一
云：昼日明了，暮则□语如见鬼状。一云：如疟状，一云：往来寒热休作有时。一云
：刺期门，一云：用小柴胡汤。一云：毌犯胃气及上二焦。皆互文以明大意，而自为
注脚也。学者试因此而细绎全书，思过半矣。「如结胸状」四字，仲景当恐形容不尽
，重以藏府相连，邪高痛下之语，畅发病情。盖血室者冲脉也，下居腹内，厥阴肝之
所主也。而少阳之胆与肝相连，府邪在上，藏邪在下，，胃口逼处二邪之界，所以默
默不欲饮食，而但喜呕耳。期门者。肝之募也，随其实而泻之，泻肝之实也，又刺期
门之注脚也。小柴胡汤，治少阳之正法也。毋犯胃气及上二焦，则舍期门、小柴胡汤
，更无他法矣。
@@@
呕而发热者，小柴胡汤主之（衍文，已见太阳中篇半夏泻心汤条上）。少阳病，欲解
时，从寅至辰上。
【注】
寅、卯、辰、木旺之时也。经云：阳中之少阳，通于春气，故少阳之病，每乘气旺之
时而解，经气之复，理固然也。
【集注】
魏荔彤曰：病在少阳，乘其正旺，如法治之，何病不已。
音切
少去声 涩音色 嗢乙骨切 腠音凑
In the formula of Xiao Chai Hu Tang (Minor Bupleurum Decoction), add Liu Liang (six taels) of Mangxiao (Natrii Sulfas). Prepare and administer the remaining herbs according to the previous method. If the condition does not resolve, continue administration.
@@@
If Shaoyang disease (Disease of the Gallbladder and Sanjiao) persists for thirteen days without resolution and has passed its meridian stage, accompanied by delirium (speaking incoherently due to heat disturbing the mind), it is caused by internal heat. It should be treated with a decoction to purge the heat downward. If urination is free and clear, the stool should normally be dry; however, if diarrhea occurs instead, and the pulse is harmonious, it indicates that the physician incorrectly used pill-form purgatives. This is not the correct treatment. If the patient had diarrhea spontaneously (without prior medication), the pulse should be faint or associated with cold extremities. Since the pulse is now harmonious, this indicates internal excess (accumulation of pathogenic factors). The primary treatment is Tiaowei Chengqi Tang (Regulate the Stomach and Inherit Qi Decoction).
[Annotation]
This passage elaborates on the meaning of the preceding clause to detail the treatment. Shaoyang disease persisting for thirteen days without resolution implies the pathogen has moved beyond its initial meridian. Delirium indicates internal heat, which should be purged using a decoction. However, the heat causing tidal fever in the previous clause was located between the exterior and interior, so the stool would not be dry. The heat causing delirium in this clause has entered the Stomach organ, so logically the stool should be dry. If urination is free, the stool should indeed be dry. The fact that the stool is not dry but rather loose, combined with a harmonious pulse, reveals that the diarrhea was induced by the physician's inappropriate use of pill-purgatives, rather than being a natural progression of the disease. Had the diarrhea occurred spontaneously without such medication, it would indicate internal deficiency, characterized by a faint pulse and cold extremities. The current harmonious pulse contradicts this, confirming internal excess and heat rather than internal deficiency and cold. Although diarrhea is present, it is a heat-type diarrhea. Therefore, the heat must still be purged, hence the use of Tiaowei Chengqi Tang.
@@@
After three days of Shanghan (Cold Damage), the pathogenic factors in the Three Yang meridians are exhausted, and the Three Yin meridians should theoretically become affected. However, if the patient can eat and does not vomit, it indicates that the Three Yin meridians have not been affected by the pathogen.
[Annotation]
The pathogen of Shanghan enters sequentially: Day 1 affects the Taiyang (Greater Yang) meridian; Day 2, the Yangming (Yang Brightness) meridian; Day 3, the Shaoyang (Lesser Yang) meridian; Day 4, the Taiyin (Greater Yin) meridian; Day 5, the Shaoyin (Lesser Yin) meridian; and Day 6, the Jueyin (Terminal Yin) meridian. This is the sequence of meridian transmission. On the third day of Shanghan, the exterior pathogens of the Three Yang meridians are exhausted, and the Three Yin meridians should theoretically be affected. Consequently, the patient should lose their appetite and vomit. The fact that the patient can eat and does not vomit indicates that the interior is harmonious and the Three Yin meridians remain unaffected. Note that this description from the *Neijing* (Classic of Internal Medicine) provides a general overview; one should not rigidly adhere to specific days for diagnosis.
[Collected Annotations]
Cheng Wuji stated: When exterior pathogens transmit to the interior, disharmony in the interior leads to an inability to eat and vomiting. The current ability to eat without vomiting indicates the pathogen has not transmitted to the Yin meridians and remains in the Yang.
Fang Youzhi stated: Yang refers to the exterior, and Yin refers to the interior. The ability to eat without vomiting signifies that the interior Qi is harmonious and the Stomach Qi has recovered, indicating the Yin meridians are not affected.
Wang Hu stated: Pathogens in the Shaoyang meridian typically cause vomiting and an inability to eat. The current ability to eat without vomiting verifies the harmony of the interior Qi and the spontaneous resolution of Shaoyang pathogens. With the interior harmonious and Shaoyang pathogens resolved, it is certain they will not transmit to the Three Yin meridians. Hence, it is said: "The Three Yin meridians do not receive pathogens."
@@@
In Shanghan, after six or seven days, if there is no significant external heat but the patient exhibits restlessness and irritability, this is because the Yang pathogen has left the exterior and entered the Yin.
[Annotation]
Six or seven days into Shanghan is the time when pathogens tend to enter the interior. The absence of significant external heat indicates mild exterior heat. Restlessness and irritability indicate intense internal heat. This scenario represents the transition of Yang pathogens entering the Yin. "Yang leaving to enter Yin" means the Yang pathogen leaves the exterior and transmits to the interior, specifically affecting the Three Yin meridians.
[Collected Annotations]
Cheng Wuji stated: Internal heat causes "fan" (irritability/restlessness of the mind), referring to mental郁结 (depression/stagnation). External heat causes "zao" (physical restlessness/agitation). Internal heat is like fire with roots; thus, cases with only irritability or those progressing from irritability to physical restlessness are treatable. External heat is like fire without roots; thus, cases with only physical restlessness or those progressing from physical restlessness to irritability are untreatable.
Fang Youzhi stated: "Qu" (leave) means "to go." It describes exterior pathogens departing and entering the interior, resulting in no external heat but internal irritability and restlessness.
@@@
In women suffering from Fengzhong (Wind Strike/Exterior Syndrome), if there is fever and aversion to cold, and menstruation happens to begin, and after seven or eight days the fever subsides, the pulse becomes slow, and the body becomes cool, yet there is fullness and distension in the chest and hypochondrium resembling Jie Xiong (Chest Binding) syndrome, accompanied by delirium, this is Re Ru Xue Shi (Heat Entering the Blood Chamber). The treatment should involve puncturing Qimen (LR-14) and applying the draining method according to the excess pattern.
[Annotation]
Women with Fengzhong presenting fever and aversion to cold have an exterior syndrome. If menstruation had not started, the heat would likely not have transmitted to the Blood Chamber. Since menstruation coincided with the onset, and after seven or eight days the fever subsided, the pulse slowed, and the body cooled, it might seem the exterior syndrome was resolving. However, the appearance of chest/hypochondriac fullness resembling Chest Binding and delirium indicates that this is not a simple exterior resolution leading to interior transmission. Rather, the exterior pathogenic heat took advantage of the open state during menstruation to enter the Blood Chamber vacuously. The treatment is to puncture Qimen. Qimen is an acupoint of the Liver meridian, and the Liver stores blood. Since the pathogen has entered the Blood Chamber, puncturing Qimen allows for the draining of the excess heat in the blood level.
[Collected Annotations]
Fang Youzhi stated: The Blood Chamber is where Ying (Nutrient) blood stays and menstrual blood gathers, also known as the Sea of Blood of the Chong Mai (Penetrating Vessel). Its vessel originates at Qichong, runs alongside the Shaoyin meridian, flanks the navel upward to the chest, and disperses. Thus, when heat enters, these symptoms arise. Qimen consists of two points located beside Burong (ST-19), each 1.5 cun away, and is the Front-Mu point of the Liver. As the Liver receives blood, puncturing Qimen drains excess heat from the blood level.
Wang Hu stated: When pathogens transmit to Shaoyang and heat enters the Blood Chamber, symptoms like delirium occur. Zhang Zhongjing feared practitioners might mistake this for Yangming Fu-organ excess and lightly use the three Chengqi formulas to damage Stomach Qi. Therefore, he specifically proposed puncturing Qimen as the treatment.
@@@
In women with Fengzhong, if after seven or eight days intermittent chills and fever recur at regular intervals, and menstruation happens to cease, this is Heat Entering the Blood Chamber. The blood must be congealed, causing symptoms resembling malaria with regular paroxysms. The primary treatment is Xiao Chai Hu Tang (Minor Bupleurum Decoction).
[Annotation]
In women with Fengzhong, if after seven or eight days intermittent chills and fever recur regularly, and menstruation ceases, this indicates Heat Entering the Blood Chamber. The blood and heat contend with each other, causing the blood to congeal. However, although congealed, there is no chest/hypochondriac fullness or delirium, indicating the congestion is not yet solid/excess. The presence of malaria-like chills and fever at regular intervals suggests the pathogen is in the Shaoyang meridian, situated between the exterior and interior. Therefore, Xiao Chai Hu Tang is used to harmonize the exterior and interior, allowing the heat to resolve naturally.
[Collected Annotations]
Fang Youzhi stated: In the previous case where menstruation began, heat entered the Blood Chamber, and the flowing blood carried the heat away. In this case where menstruation ceased, heat entered while blood was present, contending with subsequent blood, causing them to remain together without exiting. Hence, it is said the blood must congeal.
Cheng Zhi stated: In the former case, with menstruation flowing, chest/hypochondriac fullness, congealment, and delirium indicated pathogens were excess in the Zang organs, so puncturing was used to drain them. In this case, blood congealment causing malaria-like chills and fever indicated pathogens were manifesting in the Jing (Meridians), so Xiao Chai Hu Tang was used to harmonize them.
@@@
In women with Shanghan, if there is fever and menstruation happens to begin, and the patient is lucid during the day but experiences delirium at night, appearing to see ghosts, this is Heat Entering the Blood Chamber. Do not violate the Stomach Qi or the Upper and Middle Jiao; the condition will heal itself.
[Annotation]
The previous two clauses explained the patterns of Wind-pathogen Heat Entering the Blood Chamber; this clause explains Cold-pathogen Heat Entering the Blood Chamber. In women with Shanghan, fever, and no sweat, if menstruation begins, heat inevitably enters the Blood Chamber. Lucidity during the day indicates the pathogen is not in the Yang aspects. Delirium at night, resembling hallucinations, indicates the pathogen is in the Yin aspects. "Do not violate the Stomach Qi and the Upper and Middle Jiao" generally refers to all three Jiaos. It prohibits the light use of sweating, vomiting, and purging methods. One should wait for menstruation to flow; the heat will likely exit with the blood, leading to recovery.
[Collected Annotations]
Fang Youzhi stated: "Will heal itself" means waiting for menstruation to flow allows the pathogenic heat to exit with the blood, similar to epistaxis acting as a "red sweat," thus healing naturally. This warns against reckless attacking treatments that could cause complications.
Lin Lan stated: Fever in Shanghan indicates cold has transformed into heat. Menstruation beginning means the Blood Chamber is empty, allowing pathogenic heat to enter vacuously. Daytime delirium suggests pathogens contesting with Yang in the Fu organs. Here, daytime lucidity and nighttime delirium/hallucinations indicate pathogens contesting with Yin in the Blood Chamber, not the Fu organs. While Yang-excess delirium warrants purging, here purging is contraindicated as it violates Stomach Qi. For heat entering blood congealment with chills/fever, Xiao Chai Hu Tang disperses pathogens and induces sweating. Here, although heat enters the Blood Chamber, it does not congeal, so sweating agents are contraindicated to avoid violating the Upper Jiao. If heat enters causing chest/hypochondriac fullness like Chest Binding, puncturing Qimen is appropriate. Here, without fullness/congealment, puncturing Qimen is contraindicated to avoid violating the Middle Jiao. Healing naturally occurs because menstruation flows, carrying heat and pathogens out, clearing the system.
@@@
When blood is weak and Qi is exhausted, the couli (pores/skin texture) open, allowing pathogens to enter. They contend with healthy Qi, knotting below the hypochondrium. Healthy and pathogenic Qi struggle, causing alternating chills and fever occurring at intervals. The patient is silent, has no desire to eat, and suffers pain below (due to the connection of Zang and Fu organs; another reading: pain in the epigastrium). This causes vomiting. The primary treatment is Xiao Chai Hu Tang (Minor Bupleurum Decoction).
[Annotation]
This passage elaborates on the previous three clauses regarding women with Fengzhong or Shanghan who experience excessive menstruation, leading to blood weakness and Qi exhaustion. The couli become lax, allowing pathogenic heat to enter the Blood Chamber vacuously. The pathogen contends with healthy Qi, knotting at the boundary of the Shaoyang meridian, hence the knotting below the hypochondrium. Contention in Yang generates heat; contention in Yin generates cold, causing alternating chills and fever. After contention, strength wanes, causing pauses in symptoms. Shaoyang disease entering the semi-interior approaches Jueyin, causing silence and anorexia. Shaoyang Gallbladder and Jueyin Liver are exterior-interior pairs, hence "Zang and Fu are connected." The Shaoyang meridian descends through the chest and along the hypochondrium; the Jueyin meridian reaches the lower abdomen and runs along the inner hypochondrium, so pain extends below the hypochondrium. Shaoyang pathogens move from the chest down to the hypochondrium, causing illness in the hypochondrium due to chest pathology, hence "Pathogen is high, pain is low." Pathogens moving from the chest along the hypochondrium into the interior meet resistance from interior Qi, causing vomiting. Zhang Zhongjing repeats this clause, advocating Xiao Chai Hu Tang, to show that the treatment principle remains within Shaoyang, and one need not seek treatment solely from the perspective of Jueyin Blood Chamber.
[Collected Annotations]
Yu Chang stated: These four clauses use mutual textual references to reveal intent. Variations include: menstruation starting vs. stopping; fever subsiding with slow pulse vs. recurring chills/fever; chest/hypochondriac fullness vs. pathogen knotting below hypochondrium; resembling Chest Binding vs. high pathogen/low pain; delirium vs. daytime lucidity/nighttime delirium; malaria-like symptoms vs. alternating chills/fever; puncturing Qimen vs. using Xiao Chai Hu Tang; avoiding Stomach Qi/Jiao violation. All are mutual texts clarifying the main idea. Regarding "resembling Chest Binding," Zhang Zhongjing added "Zang and Fu connected, high pathogen/low pain" to fully describe the pathology. The Blood Chamber is the Chong Mai, located in the abdomen, governed by Jueyin Liver. Shaoyang Gallbladder connects with Liver. Fu pathogens are upper, Zang pathogens are lower. The stomach area lies between these two pathogens, causing anorexia and a tendency to vomit. Qimen is the Liver Mu point; draining it treats Liver excess, serving as a note for puncturing Qimen. Xiao Chai Hu Tang is the standard treatment for Shaoyang. Avoiding Stomach Qi and the Jiaos leaves no other method besides Qimen and Xiao Chai Hu Tang.
@@@
For vomiting accompanied by fever, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is the primary treatment. (Note: This line is a duplicate/error, already appearing in the Taiyang chapter under Ban Xia Xie Xin Tang). Shaoyang disease tends to resolve from Yin hour to Chen hour (3 AM to 7 AM).
[Annotation]
Yin, Mao, and Chen hours correspond to the peak of Wood Qi. The classics state: "Shaoyang within Yang corresponds to Spring Qi." Therefore, Shaoyang diseases often resolve when Qi is abundant. The recovery of meridian Qi follows this natural principle.
[Collected Annotations]
Wei Litong stated: When the disease is in Shaoyang, treating it according to the law while the healthy Qi is strong ensures recovery.
Phonetic Guide
Shao: Qu-sheng (Departing tone)
Se: Yin-se (Oblique tone)
Wa: Yi-gu-qie (Cut sounding like 'yi')
Cou: Pronounced as 'cou'