有声无痰曰咳。咳者。肺气上逆也。肺为主气之脏。通呼吸而行卫气。若气上逆。则不宜于补。故去人参大枣之甘。
生
姜则不必去也。加五味子干姜者。即小青龙汤之制也。小青龙以水寒伤肺。故以此收肺气之逆。此方用之。其义一
也。但肺寒气逆者宜之。肺热气盛者。未可加也。所谓半升者。非今升斗之升也。以五味子而加半升。令人读之。无不
骇异。以为五味子之酸收。本为难用。宁有即用半升之理。孰知古之所谓升者。其大如方寸匕。以铜为之。上口方各
一寸。下底各六分。深仅八分。状如小熨斗而方形。尝于旧器中见之。而人皆不识。疑其为香炉中之器用。
而不知即古人用药之升也。与陶隐居名医别录之形象分寸皆同。但多一柄。想亦所以便用耳。如以此升之半。
作一剂而分三次服之。亦理之所有。无足怪也。今废而不用久矣。故人皆不知有此。谓即当今升斗之升。所
以骇其用之不当。而曰古方不可治今病也。宜哉。
辨误 条辨及尚论。皆作伤寒五六日。中风往来寒热。成无己注本。作伤寒中风五六日。其注中谓玉
函曰。中风五六日。伤寒往来寒热。即是或中风。或伤寒。非是伤寒再中风。中风复伤寒也。即仲景所谓伤
寒中风。有柴胡证。但见一证便是。正或中风或伤寒也。其说颇合于理。当从之。方氏云。脉经作中风
往来寒热。伤寒五六日之后。心烦作烦心。心下作心中。身有作外有。虽传写之不同。其实非二义也。
伤寒中风。有柴胡证。但见一证便是。不必悉具。
前二条。备言少阳经之诸见证。然未必诸证悉备。恐后人必以诸证全见者。方为少阳病。故又立此条。
以申明上文或胸中烦。或渴或腹中痛等诸或有或无之义也。伤寒中风者。或伤寒或中风也。言伤寒中风证中。
凡见少阳证。即为柴胡汤证。即使但见一证。便是邪气已入少阳。不必如上文之诸证悉具也。如但见少阳
本经证。止宜以小柴胡汤主之。若有他经兼症者。仍当以小柴胡为主。而兼用他经药治之。如已见柴胡证。
而有太阳证未罢者。即以小柴胡加桂枝汤主之。如少阳未解。而阳明之里邪已急。则用小柴胡去参甘。
增入大黄为大柴胡汤以两解之矣。又如少阳误治而为坏病。则有柴胡加芒硝汤。及柴胡桂枝干姜汤。
柴胡龙骨牡蛎汤等方。皆一小柴胡汤之变制也。盖
以每见少阳一证。即以小柴胡主治。故称柴胡证也。旧本柴胡汤诸加减方。皆杂入太阳篇中。今悉收置少阳篇内。
以小柴胡为主方而总统之。而以诸方隶其下。俾学人循其序而施治焉。庶或可以希仲景之意。稍得其一二。未可
知也。
伤寒四五日。身热恶风。颈项强。胁下满。手足温而渴者。小柴胡汤主之。
四五日。三阳传遍之后也。身热恶风项强。皆太阳表证也。胁下满。邪传少阳也。手足温而渴。知其邪未
入阴也。以太阳表症言之。似当汗解。然胁下已满。是邪气已入少阳。仲景原云伤寒中风。有柴胡证。
但见一证便是。不必悉具。故虽有太阳未罢之证。汗之则犯禁例。故仍以小柴胡汤主之。但小柴胡汤。当从加减
例用之。太阳表证未除。宜去人参加桂枝。胁下满。当加牡蛎。渴则去半夏。加栝蒌根为是。
伤寒阳脉涩。阴脉弦。法当腹中急痛者。先用小建中汤。不瘥者。与小柴胡汤主之。
阳主表。阴主里。弦主肝邪劲急。涩为营血留滞。故弦属肝邪。涩为阴脉也。寒在半表。卫气不行。营血不贯。
则脉不流利而涩。邪入少阳。肝木气旺。脉来劲急则弦。阳脉涩者。盖轻取其浮候则涩也。阴脉弦者。重按其沉
候则弦也。阳脉涩。则知营卫不和。气血涩滞而邪在半表。阴脉弦。则知邪气半已入里。木旺乘土。太阴受病矣。
太阴脾土。为肝邪所犯。故腹中急痛也。腹中者。足太阴之脉。起于足大趾之端。上膝股内前廉。入腹属脾络胃。
故腹为太阴之部位也。急痛者。厥阴肝木劲急之阴邪伤脾也。藏气发时论云。肝苦急。急食甘以缓之。又云脾欲缓。
急食甘以缓之。故先用小建中汤之甘。以缓肝脾之急而创建中气也。中气已旺。肝邪当退矣。若犹不瘥者。是少
阳之邪犹未解也。仍与小柴
胡汤主之。以和解其邪。但恐腹中急痛。其中气必寒。成氏去黄芩加芍药之外。或姜桂可加入也。
伤寒五六日。头汗出。微恶汗。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。（此句应下文脉虽沉紧）汗出为阳微。假令纯阴结。不复有外证。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。
此条非但别少阳少阴之疑似。推而广之。实六经辨别阴阳之精义也。五六日。邪气入里之候也。
头汗出。邪在阳经也。恶寒为三阴之本证。而三阳之表证。亦皆恶寒心下满者。少阳病有胸满。而少阴
证中亦有胸满。手足冷为少阴。而厥阴有厥深热亦深者。少阳有默默不欲食。而厥阴亦默默不欲食。
唯大便硬。则与三阴无涉矣。诸证杂见。阴阳参错。难于辨认。详察其脉。若但细而未见沉迟者。此
为犹在少阳。但阳微阴盛。阴邪结于里。故有手足冷。心下满。口不欲食之阴寒里证。而更有头汗出之阳证在。
以此推之。此为阳微而结。其邪必有表复有里也。若其脉沉。亦邪气在里之脉也。虽手足冷。不饮食。
似乎皆为在里之阴邪。然头汗出。犹为阳证。但阳气微弱耳。何以言之。假令纯阴结。不得复有头汗出
之外证。邪气当悉入在里矣。此因尚有阳经之外证为半在里。半在外。故谓之有表复有里也。所以脉虽沉紧。
尚不得为少阴病。其所以然者。邪在阴经。不得有汗。故少阴证中之汗曰反汗出而为亡阳也。今头汗
出。则三阳之经络皆上至头。三阴之经脉剂颈而还。皆不上头。故知非少阴也。邪气仍在半表半里。是仍
在少阳也。可与小柴胡汤以和解之。设不了了者。设或目中不了了也。若至目中不了了。则邪气已离少阳
而归阳明之里矣。
即阳明中篇之所谓目中不了了。睛不和。无表里症。大便难。此为实也。急下之之义。故当用土郁夺之之法。
所以谓之得屎而解也。若未至不了了。则邪气尚在少阳。未可妄下也。
辨误 尚论谓阳微结者。阳邪微结。未尽散也。以方注作阳气衰微。故邪气结聚为大差。云果尔。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。愚窃谓阳微结三字。而以阳邪微结解之。
是以微结二字联讲。故以阳气衰微为误。然则下文汗出为阳微句之阳微二字。又当作如何解。若以头汗出为
亡阳。则太阳上编脉浮动数条中之但头汗出。余无汗。剂颈而还者。及阳明篇中之但头汗出。身无汗。
剂颈而还。小便不利。身必发黄者。皆为亡阳证邪。更以阴结为阴气衰微。则又是以曲作直。指鹿为马之谈矣。
岂知仲景本意。谓伤寒本应无汗。以卫阳衰弱。阳气不固。所以头汗出而微恶寒。故云汗出为阳微。以见虽
有手足冷。心下满。口不欲食之阴寒里证。而尚有汗。出恶寒在表之阳邪。非纯阴结也。假令纯是阴邪内结。
不得复有外证。当悉入在里矣。以阳气虽微。而其阳证尚在。故为半在里半在外也。如此。则为阳气衰微而
阴邪内结也明矣。岂可强词夺理。谬以汗出为亡阳之证。阴结为阴气衰微乎。平心论之。是邪非邪。况目
中不了了。自有阳明原文具在。宁可又以大柴胡为和法乎。
伤寒腹满谵语。寸口脉浮而紧。此肝乘脾也。名曰纵。刺期门。
此二条。又示人以病无定例。法无定法。于艰难疑惑之中。另辟手眼。即内经所谓揆度奇恒之类也。腹满。
足太阴脾病也。谵语。足阳明胃实也。腹满为脾脏寒。有可温之理。谵语则胃家热。又有可下之机矣。寸口。
气口也。气口为手太阴之脉。乃主气之脏。营卫之气。五十度而复会于手太阴。故为胃气之脉。而胃为水谷之海。
五脏六腑之大源。五味
入口。藏于肠胃。以养五脏气。皆变现于气口。今气口脉浮而紧。浮则为风。紧则为寒。皆邪气在表之脉也。
论证则邪不在表。言脉则邪不在里。况太阴篇之腹满。全无可汗之法。即阳明篇之腹满。若脉浮而紧者。
亦无可下之条。脉证参差。艰于施治。深察其故。若果邪气在表。不应寸口独浮独紧。脉尚浮紧。邪当在表。
亦不应腹满谵语。唯仲景知其邪犯中焦。所以独变现于气口。故命之曰。此肝乘脾也。谓之肝乘脾者。
乘其所胜也。以木性本能制土。乃五行生克之常。于理为顺。于事为直。故名之曰纵。纵者。纹理顺直之谓也。
既无汗下之法。又知肝木克制脾土。故以泄肝为治。期门者。足厥阴肝经之募穴也。其脉起于足大趾之大敦穴。
终于乳下巨阙两旁各四寸半之期门穴。自此内入。则属肝络胆矣。故刺之以泻其盛。所谓随其实而泻之。
则其气平而邪自解矣。
伤寒发热。啬啬恶寒。大渴欲饮水。其腹必满。自汗出。小便利。其病欲解。此肝乘肺也。名曰横。刺期门。
伤寒发热。乃已发热之伤寒也。啬啬恶寒。风邪在表也。大渴欲饮水之证。上编中风发热。六七日不解而烦。
有表里症。故渴欲饮水。此邪犯太阳之里而渴也。又太阳病发汗后。大汗出。胃中干。欲得饮水。此因大汗出后。
胃中津液干燥而渴也。上文风寒并感之渴欲饮水。及阳明篇之渴欲饮水。口干舌燥者。皆以白虎加人参汤主之。
此等俱无表证而热邪入胃之渴也。今发热而啬啬恶寒。则邪犹在表。大渴欲饮水。则邪又在里。以表邪如此之盛。
或兼见里证者固有之。然未必有若此之里症也。里症如此之甚。表邪未解者亦有之。而未必犹有若此之表证也。
其所以然者。虽系伤寒发热而啬啬恶寒。乃营卫不和之证也。盖以肺主皮毛而通行营卫。肺脏受邪。皮毛不密。
故啬啬恶寒也。大渴欲饮水者。注家俱谓木盛则热炽。非也。其腹必满。岂独饮水而后满乎。腹满本为脾病。经脉
别论云。饮入于胃
游溢精气。上输于脾。脾气散精。上归于肺。通调水道。下输膀胱。水精四布。五经并行。岂有所谓大渴
欲饮水之证乎。此因肝木克制脾土。故知其腹必满。以脾病而不能散精。无以上输于肺。则肺气困弱。
何以朝百脉而输精于皮毛乎。是以啬啬恶寒。大渴欲饮水。以润其枯涸也。此所谓肝乘肺者。肺本金藏。
肝木之所受制。焉能乘之。以肝木之旺气。乘克土之胜。贾其余勇。来侮困弱之肺金。于理为不顺。
故谓之横。若肺能自振。终不为木所侮。其气自能行营卫。通皮毛而自汗出。则发热恶寒当解。能通水道。
输膀胱。则小便利而腹满当消。故曰其病欲解。若未得解者。刺期门以泄肝邪之旺。则脾肺之围解矣。
有声但无痰称为咳。咳嗽，是肺气上逆的表现。肺是主宰气的脏器，主管呼吸并运行卫气。如果气机上逆，就不适宜使用补益法。因此去掉人参、大枣的甘缓之性。
生姜则不必去掉。加入五味子、干姜，就是小青龙汤的组方原理。小青龙汤是因为水寒伤肺，所以用此方收敛上逆的肺气。本方使用它的道理也是一样的。但是，适用于肺寒气逆的情况；如果是肺热气盛，则不可以加入。所谓“半升”，不是现代升斗的升。如果用五味子加半升，让人读起来，无不感到惊骇诧异，认为五味子的酸收之性本来难以掌握，哪有直接用半升的道理？殊不知古代所说的“升”，其大小如同方寸匕，用铜制成，上口四方各一寸，下底各六分，深度仅八分，形状像方形的小熨斗。我曾经在旧器物中见过它，但人们都不认识，怀疑它是香炉中的器具，却不知道这就是古人用药的升。这与陶隐居《名医别录》中描述的形制尺寸完全相同，只是多了一个柄，想必是为了方便使用罢了。如果用这个升的一半量，作为一剂药分三次服用，也是合乎情理的，不足为怪。现在废弃不用已经很久了，所以人们都不知道有这个度量衡，误认为是当今的升斗，因此惊骇于古方用药不当，从而说古方不能治疗今病，这也是理所当然的。
【辨误】柯韵伯（条辨）及喻嘉言（尚论）都将原文写作“伤寒五六日，中风往来寒热”。成无己注本写作“伤寒中风五六日”。成氏在注释中说，《玉函经》记载：“中风五六日，伤寒往来寒热。”意思是或者是中风，或者是伤寒，并不是伤寒之后又中风，或者中风之后又伤寒。这正是张仲景所说的“伤寒中风，有柴胡证，但见一证便是”，指的就是或中风或伤寒的情况。这种说法很合情理，应当遵从。方有执说，《脉经》作“中风往来寒热，伤寒五六日之后，心烦”作“烦心”，“心下”作“心中”，“身有”作“外有”。虽然传抄书写不同，但其实意思并非两样。
“伤寒中风，有柴胡证，但见一证便是，不必悉具。”
前两条详细论述了少阳经的各种见证，然而未必所有症状都具备。恐怕后人一定认为只有诸证全部出现，才算是少阳病，所以设立这一条，以申明上文所述“或胸中烦，或渴，或腹中痛”等或有或无的含义。“伤寒中风”，是指或伤寒或中风。意思是说，在伤寒或中风的证候中，凡是见到少阳证，就是柴胡汤证。即使只见到一个症状，也表明邪气已经传入少阳，不必像上文所说的那样诸证全部具备。如果只见到少阳本经的症状，只宜用小柴胡汤主治。如果有其他经络兼夹症状，仍当以小柴胡汤为主，兼用其他经络的药物进行治疗。例如，已经见到柴胡证，而太阳表证未解的，就用小柴胡加桂枝汤主治。如果少阳病未解，而阳明里邪已急迫，则用小柴胡汤去掉人参、甘草，加入大黄，组成大柴胡汤来表里双解。又如少阳病误治而成坏病，则有柴胡加芒硝汤，以及柴胡桂枝干姜汤、柴胡龙骨牡蛎汤等方剂，这些都是小柴胡汤的变方。大概因为每见到少阳的一个症状，就以小柴胡汤为主治，所以称为柴胡证。旧版书籍中柴胡汤的各种加减方，都混杂在太阳篇中，现在全部收录到少阳篇内，以小柴胡汤为主方统领它们，并将各方附属于其下，使学习者能按照次序施治，或许可以揣摩张仲景的本意，稍微得到其中一二，这也不是不可能的。
伤寒四五日，身体发热，怕风，颈项强直，胁下胀满，手足温暖且口渴的，用小柴胡汤主治。
四五日，是三阳经传变完毕之后的时间。身体发热、怕风、项强，都是太阳表的证候。胁下胀满，是邪气传入少阳。手足温暖且口渴，说明邪气没有进入阴经。从太阳表证的角度来看，似乎应当发汗解表。然而胁下已经胀满，说明邪气已经传入少阳。张仲景原本就说：“伤寒中风，有柴胡证，但见一证便是，不必悉具。”所以虽然有太阳表证未解的症状，发汗则违反禁忌条例，因此仍用小柴胡汤主治。但小柴胡汤应当按照加减例使用。太阳表证未除，应当去掉人参，加入桂枝。胁下胀满，应当加入牡蛎。口渴，则应当去掉半夏，加入栝蒌根才是正确的。
伤寒患者，阳脉涩，阴脉弦，按理应出现腹部拘急剧痛，先用小建中汤治疗，如果不愈，再与小柴胡汤主治。
阳脉主表，阴脉主里。弦脉主肝邪劲急，涩脉主营血留滞。所以弦脉属于肝邪，涩脉属于阴脉。寒邪在半表，卫气运行不畅，营血不通贯，则脉流不利而呈现涩象。邪气传入少阳，肝木气旺，脉来劲急则呈现弦象。阳脉涩，是指轻取浮候时脉涩。阴脉弦，是指重按沉候时脉弦。阳脉涩，可知营卫不和，气血涩滞而邪在半表。阴脉弦，可知邪气一半已入里，木旺乘土，太阴脾脏受病了。太阴脾土被肝邪侵犯，所以腹部拘急剧痛。腹部，是足太阴脾经所过之处，经脉起于足大趾末端，上行至膝股内侧前缘，入腹属脾络胃，所以腹部是太阴的部位。急痛，是厥阴肝木劲急的阴邪伤害脾脏所致。《藏气法时论》说：“肝苦急，急食甘以缓之。”又说：“脾欲缓，急食甘以缓之。”所以先用小建中汤的甘味，来缓解肝脾的急迫，建立中气。中气旺盛后，肝邪自然消退。如果仍然不愈，说明少阳之邪仍未解除，仍用小柴胡汤主治，以和解邪气。但恐怕腹部拘急剧痛，其中气必然偏寒，除了成无己去掉黄芩加入芍药之外，也可以加入生姜、桂枝。
伤寒五六日，头部出汗，轻微恶寒，手足冷，心下胀满，口不想吃东西，大便硬，脉细的，这叫阳微结。一定有表证又有里证。脉沉也属于里证。（这句应接下文“脉虽沉紧”）。出汗是因为阳气微弱。假如是纯阴结，就不会再有外证，邪气全部入在里。这是邪气一半在里，一半在外。脉虽然沉紧，也不能诊断为少阴病。之所以这样，是因为阴证不应该有汗，现在头部出汗，所以知道不是少阴病。可以与小柴胡汤。如果服药后病情仍不缓解，通过排便即可解除。
这一条不仅辨别少阳和少阴的疑似症状，推而广之，实际上是六经辨别阴阳的精义所在。五六日，是邪气入里的征候。头部出汗，说明邪在阳经。恶寒是三阴的本证，但三阳的表证也都恶寒。心下胀满，少阳病有胸满，少阴证中也有胸满。手足冷是少阴证，但厥阴病有“厥深热亦深”的情况。少阳病有默默不欲食，厥阴病也有默默不欲食。只有大便硬，才与三阴病无关。各种症状混杂出现，阴阳参错，难以辨认。仔细诊察脉象，如果只是细而没有见到沉迟，这说明邪气仍在少阳，只是阳气微弱而阴气盛，阴邪结聚在里，所以有手足冷、心下满、口不欲食这些阴寒里证，但同时还有头部出汗这个阳证。由此推断，这是阳微而结，邪气一定有表又有里。如果脉沉，也是邪气在里的脉象。虽然手足冷、不饮食，似乎都是在里的阴邪，然而头部出汗，仍然是阳证，只是阳气微弱罢了。为什么这样说？假如是纯阴结，就不会再有头部出汗这样的外证，邪气应当全部入在里了。这是因为还有阳经的外证，所以说是半在里、半在外，故称有表复有里。所以脉虽然沉紧，还不能诊断为少阴病。之所以这样，是因为邪气在阴经，不应该有汗，所以少阴证中的汗叫做“反汗出”，属于亡阳。现在头部出汗，因为三阳经络都上达头部，三阴经脉只到颈部而还，都不上头，所以知道不是少阴病。邪气仍在半表半里，也就是仍在少阳。可以与小柴胡汤来和解。如果服药后病情仍不缓解（设不了了者），指的是眼睛视物不清。如果到了眼睛视物不清的程度，邪气就已经离开少阳而归入阳明之里了。即阳明中篇所说的“目中不了了，睛不和，无表里症，大便难，此为实也，急下之”的意思。所以应当用“土郁夺之”的方法，所以称为得屎而解。如果未到视物不清的程度，则邪气尚在少阳，不可妄用攻下法。
【辨误】喻嘉言（尚论）认为“阳微结”是指阳邪微结，未尽散也。以方注解释为阳气衰微，导致邪气结聚，这就差得太远了。如果说果真如此，那么头部出汗就是亡阳的证候，而不是半表半里的证候了。果真如此，那么阴结又是阴气衰微了。我私下认为，“阳微结”三个字，如果解释为阳邪微结，是将“微结”二字连讲，所以将阳气衰微视为错误。然而，下文“汗出为阳微”句中的“阳微”二字，又该作何解释？如果把头部出汗当作亡阳，那么太阳上编脉浮动数条中的“但头汗出，余无汗，剂颈而还”，以及阳明篇中的“但头汗出，身无汗，剂颈而还，小便不利，身必发黄”，都成了亡阳证吗？再把阴结解释为阴气衰微，那更是歪曲事实、指鹿为马的言论了。哪里知道张仲景的本意，是说伤寒本来应该无汗，因为卫阳衰弱，阳气不固，所以头部出汗而轻微恶寒。所以说“汗出为阳微”，以此表明虽然有手足冷、心下满、口不欲食这些阴寒里证，但还有汗出、恶寒在表的阳邪，不是纯阴结。假如完全是阴邪内结，就不会再有外证，应当全部入在里了。因为阳气虽然微弱，但其阳证还在，所以说是半在里、半在外。这样看来，就是阳气衰微而阴邪内结，这是很明显的了。怎么能强词夺理，谬把汗出当作亡阳证，阴结当作阴气衰微呢？平心而论，这究竟是邪还是非邪？况且“目中不了了”自有阳明原文存在，怎么又能把大柴胡汤当作和法呢？
伤寒腹部胀满，说胡话，寸口脉浮而紧，这是肝木乘袭脾土，名叫纵，针刺期门穴。
这两条，又是向人们展示疾病没有固定的规律，治疗方法也没有固定的法则，在艰难疑惑之中，另辟蹊径，正如《内经》所说的“揆度奇恒”之类。腹部胀满，是足太阴脾的病。说胡话，是足阳明胃的实证。腹部胀满是脾脏寒，有可温的道理；说胡话则是胃家热，又有可下的时机。寸口，就是气口。气口是手太阴肺经的脉，肺是主宰气的脏器，营卫之气运行五十周次后重新会合于手太阴肺经，所以它是胃气的脉象表现。而胃是水谷之海，五脏六腑的大源。五味入口，储藏于肠胃，以滋养五脏之气，都变现于气口。现在气口脉浮而紧，浮则为风，紧则为寒，都是邪气在表的脉象。但从论证来看，邪气不在表；从脉象来看，邪气不在里。况且太阴篇中的腹满，完全没有可汗的方法；即使是阳明篇中的腹满，如果脉浮而紧，也没有可下的条文。脉证参差，难以施治。深入探究其原因，如果果真是邪气在表，不应只有寸口独浮独紧。脉尚浮紧，邪应当在表，也不应有腹满谵语。只有张仲景知道邪气侵犯中焦，所以单独变现于气口，因此命名为：“这是肝乘脾。”称为肝乘脾，是因为乘其所胜。以木性本能克制土，这是五行生克的常理，于理为顺，于事为直，所以名叫纵。纵，就是纹理顺直的意思。既然没有汗法和下法，又知道肝木克制脾土，所以以泄肝为治法。期门穴，是足厥阴肝经的募穴。其经脉起于足大趾的大敦穴，终于乳下巨阙两旁各四寸半的期门穴。从此处向内，则属肝络胆。所以针刺它以泻其盛气，所谓“随其实而泻之”，则其气平和而邪气自解。
伤寒发热，啬啬恶寒，极度口渴想喝水，腹部必定胀满。如果自汗出，小便利，病情就会解除。这是肝木乘袭肺金，名叫横，针刺期门穴。
伤寒发热，是指已经发热的伤寒。啬啬恶寒，是风邪在表。极度口渴想喝水的证候，在上编中风发热部分提到，六七日不解而烦躁，有表里证，所以渴欲饮水，这是邪气侵犯太阳之里而导致的渴。另外，太阳病发汗后，大汗出，胃中干燥，想要喝水，这是因大汗出后，胃中津液干燥而渴。上文风寒并感导致的渴欲饮水，以及阳明篇中的渴欲饮水、口干舌燥，都用白虎加人参汤主治。这些都没有表证，而是热邪入胃导致的渴。现在发热而啬啬恶寒，说明邪气仍在表；极度口渴想喝水，说明邪气又在里。以表邪如此盛大，有时兼见里证是有的，但未必有如此严重的里证。里证如此严重，而表邪未解的情况也有，但未必还有如此严重的表证。之所以这样，虽然表现为伤寒发热而啬啬恶寒，但这其实是营卫不和的证候。因为肺主皮毛而通行营卫，肺脏受邪，皮毛不致密，所以啬啬恶寒。极度口渴想喝水，注家们都认为是木盛则热炽，这是不对的。腹部必定胀满，难道仅仅是喝水后才胀满吗？腹满本来是脾的病。《经脉别论》说：“饮入于胃，游溢精气，上输于脾，脾气散精，上归于肺，通调水道，下输膀胱，水精四布，五经并行。”哪里有极度口渴想喝水的证候呢？这是因为肝木克制脾土，所以知道腹部必定胀满。因为脾病而不能散精，无法上输于肺，则肺气困弱，怎么能朝百脉而输精于皮毛呢？所以出现啬啬恶寒、极度口渴想喝水，以滋润其枯涸。这就是所谓的肝乘肺。肺本是金脏，是肝木所制约的，怎么能被乘袭呢？是因为肝木旺气，乘克土的胜势，借剩余的力量，来侮慢困弱的肺金，于理不顺，所以叫作横。如果肺能自我振作，终究不被木所侮，其气自然能行营卫，通皮毛而自汗出，则发热恶寒当解；能通水道，输膀胱，则小便利而腹满当消。所以说病情欲解。如果未能解除，针刺期门以泄肝邪之旺气，则脾肺的围困就解除了。
Without sound but with phlegm is not cough. Cough, without sound but with phlegm, is called "ke". Cough is the upward reversal of Lung Qi. The Lung is the zang organ that governs Qi, controlling respiration and circulating Wei Qi (Defensive Qi). If Qi reverses upward, tonification is inappropriate. Therefore, the sweet properties of Ren Shen (Ginseng Radix) and Da Zao (Jujube Fruit) are removed.
Sheng Jiang (Zingiberis Rhizoma Recens, Fresh Ginger) need not be removed. The addition of Wu Wei Zi (Schisandrae Fructus) and Gan Jiang (Zingiberis Rhizoma, Dried Ginger) follows the formulation principle of Xiao Qing Long Tang (Minor Blue Dragon Decoction). Xiao Qing Long Tang is used because cold-water injury damages the Lung; thus, it uses these herbs to astringe the upward-reversing Lung Qi. The rationale for using them in this formula is identical. However, this combination is suitable for cases of Cold-Phlegm in the Lung with Qi reversal; it should not be added in cases of Lung Heat with excess.
The term "half sheng" does not refer to the modern unit of measurement "sheng". Adding half a sheng of Wu Wei Zi would startle readers, who might find it hard to believe that such an astringent herb could be used in such a large quantity. It is unknown to many that the ancient "sheng" was roughly the size of a "fang cun bi" (square-inch spoon), made of copper, with a square top one inch on each side, a bottom six fen deep, and a depth of only eight fen. It resembled a small, square iron. I have seen such old vessels, but people did not recognize them, suspecting them to be incense burner accessories, unaware that they were actually ancient measuring vessels for herbs. This description matches the dimensions and shape recorded by Tao Hongjing in *Ming Yi Bie Lu* (Classification of Famous Physicians' Records), except for the handle, which was likely added for convenience. Using half of this ancient sheng as one dose, divided into three servings, is reasonable and not surprising. This measure has long been abandoned, so people are unaware of its existence, mistaking it for the modern sheng. Consequently, they are startled by the perceived impropriety of ancient prescriptions, claiming that ancient formulas cannot treat modern diseases—a conclusion that is understandable given this misunderstanding.
[Correction of Errors] Ke Yunbo (*Tiao Bian*) and Yu Jiayan (*Shang Lun*) both transcribed the text as "Shang Han (Cold Damage) five or six days, Zhong Feng (Wind Strike) alternating chills and fever." Cheng Wuji's annotated version reads "Shang Han Zhong Feng five or six days." In his annotation, Cheng cites the *Yu Han Jing* (Jade Chamber Classic): "Zhong Feng five or six days, Shang Han alternating chills and fever." He interprets this to mean either Zhong Feng or Shang Han, not Shang Han followed by Zhong Feng, nor Zhong Feng followed by Shang Han. This aligns with Zhang Zhongjing’s statement: "In Shang Han or Zhong Feng, if there are Chai Hu syndrome signs, observing just one symptom is sufficient." This refers to either Zhong Feng or Shang Han. This interpretation is logical and should be adopted. Fang Youzhi states that the *Mai Jing* (Pulse Classic) reads "Zhong Feng alternating chills and fever, after five or six days of Shang Han," and "Xin Fan" (heart vexation) as "Fan Xin," "Xin Xia" (epigastrium) as "Xin Zhong," and "Shen You" (body has) as "Wai You." Although transmission variations exist, the meaning remains the same.
"In Shang Han or Zhong Feng, if there are Chai Hu syndrome signs, observing just one symptom is sufficient; all symptoms need not be present."
The previous two clauses detailed various manifestations of Shaoyang channel pathology, yet not all symptoms necessarily appear. To prevent later practitioners from assuming that only the presence of all symptoms constitutes Shaoyang disease, this clause was established to clarify the "either-or" nature of symptoms mentioned earlier, such as "vexation in the chest," "thirst," or "abdominal pain." "Shang Han Zhong Feng" means either Shang Han or Zhong Feng. It implies that within the context of Shang Han or Zhong Feng, any appearance of Shaoyang symptoms indicates a Chai Hu Tang syndrome. Even observing just one symptom confirms that pathogenic factors have entered the Shaoyang stage, without requiring all symptoms to be present as described previously. If only Shaoyang channel-specific symptoms are present, Xiao Chai Hu Tang (Minor Bupleurum Decoction) should be used primarily. If there are concurrent symptoms from other channels, Xiao Chai Hu Tang should still be the primary formula, supplemented by herbs targeting the other channels. For instance, if Chai Hu syndrome signs are present but Taiyang exterior symptoms persist, Xiao Chai Hu Tang plus Gui Zhi Tang (Cinnamon Twig Decoction) should be used. If Shaoyang disease is unresolved but Yangming interior pathogens are urgent, Da Chai Hu Tang (Major Bupleurum Decoction) is formed by removing Ren Shen and Gan Cao from Xiao Chai Hu Tang and adding Da Huang (Rhei Radix et Rhizoma) to resolve both exterior and interior simultaneously. Furthermore, if Shaoyang disease becomes a "ruined disease" due to mis-treatment, formulas such as Chai Hu Jia Mang Xiao Tang (Bupleurum Decoction plus Mirabilite), Chai Hu Gui Zhi Gan Jiang Tang (Bupleurum, Cinnamon Twig, and Dried Ginger Decoction), and Chai Hu Long Gu Mu Li Tang (Bupleurum, Dragon Bone, and Oyster Shell Decoction) may be employed. These are all modifications of Xiao Chai Hu Tang. Since observing any single Shaoyang symptom warrants treatment with Xiao Chai Hu Tang, these conditions are termed "Chai Hu syndromes." In older editions, various modified Chai Hu Tang formulas were mixed into the Taiyang chapter. Now, they are collected in the Shaoyang chapter, governed by Xiao Chai Hu Tang as the principal formula, with modified versions listed beneath it, allowing students to follow the sequence for treatment. This approach may help approximate Zhang Zhongjing’s intent, perhaps grasping even a fraction of his wisdom.
After four or five days of Shang Han, if the patient presents with body heat, aversion to wind, stiffness in the neck and occiput, fullness under the costal margin, warm hands and feet, and thirst, Xiao Chai Hu Tang should be administered.
Four or five days mark the completion of transmission through the Three Yang channels. Body heat, aversion to wind, and neck stiffness are Taiyang exterior symptoms. Fullness under the costal margin indicates pathogenic factors entering Shaoyang. Warm hands and feet and thirst indicate that the pathogen has not entered the Yin channels. From the perspective of Taiyang exterior syndrome, sweating therapy might seem appropriate. However, since fullness under the costal margin is already present, the pathogen has entered Shaoyang. As Zhang Zhongjing stated, "In Shang Han or Zhong Feng, if there are Chai Hu syndrome signs, observing just one symptom is sufficient; all symptoms need not be present." Therefore, despite the persistence of Taiyang exterior symptoms, inducing sweat would violate contraindications. Thus, Xiao Chai Hu Tang remains the primary treatment. However, it must be used according to modification principles. If Taiyang exterior symptoms persist, Ren Shen should be removed and Gui Zhi (Cinnamomi Ramulus, Cinnamon Twig) added. For fullness under the costal margin, Mu Li (Ostrea Concha, Oyster Shell) should be added. For thirst, Ban Xia (Pinelliae Rhizoma, Pinellia Tuber) should be removed and Gua Lou Gen (Trichosanthis Radix, Trichosanthes Root) added.
In Shang Han, if the Yang pulse is choppy (Se) and the Yin pulse is wiry (Xian), abdominal cramping pain is expected. Treat first with Xiao Jian Zhong Tang (Minor Construct the Middle Decoction). If ineffective, administer Xiao Chai Hu Tang.
Yang pulses relate to the exterior, and Yin pulses relate to the interior. A wiry pulse indicates Liver pathogenic factors causing tension and urgency. A choppy pulse indicates stagnation of Ying Blood (Nutritive Blood). Thus, wiry relates to Liver pathogenic factors, and choppy relates to Yin. When cold is at the semi-exterior/semi-interior boundary, Wei Qi fails to circulate, and Ying Blood does not flow smoothly, resulting in a choppy pulse. When pathogens enter Shaoyang, Liver Wood qi becomes hyperactive, causing a wiry pulse. A choppy Yang pulse indicates taking the superficial floating position lightly. A wiry Yin pulse indicates pressing the deep沉 position heavily. A choppy Yang pulse reveals disharmony between Ying and Wei, stagnation of Qi and Blood, and pathogens at the semi-exterior. A wiry Yin pulse indicates pathogens partially entering the interior, with Wood overacting on Earth, affecting the Taiyin Spleen. The Taiyin Spleen Earth is invaded by Liver pathogenic factors, causing abdominal cramping pain. The abdomen is the territory of the Foot-Taiyin Spleen meridian, which originates at the tip of the great toe, ascends along the medial anterior aspect of the knee and thigh, enters the abdomen, connects with the Spleen, and links with the Stomach. Hence, the abdomen is the domain of Taiyin. Cramping pain results from the severe Yin pathogenic factors of Jueyin Liver Wood injuring the Spleen. The *Su Wen: Zang Qi Fa Shi Lun* states: "The Liver suffers from tension; urgently use sweet flavors to relax it." It also states: "The Spleen desires relaxation; urgently use sweet flavors to relax it." Therefore, Xiao Jian Zhong Tang is used first for its sweet property to relieve the tension of the Liver and Spleen and establish Middle Qi. Once Middle Qi is robust, Liver pathogenic factors will recede. If symptoms persist, Shaoyang pathogens remain unresolved, and Xiao Chai Hu Tang should be used to harmonize and resolve them. Given the abdominal cramping, Middle Qi deficiency-cold is likely. Besides Cheng Wuji’s removal of Huang Qin (Scutellariae Radix, Skullcap Root) and addition of Shao Yao (Paeoniae Radix Alba, White Peony Root), Sheng Jiang and Gui Zhi could also be added.
After five or six days of Shang Han, if there is sweating only on the head, slight aversion to cold, cold hands and feet, epigastric fullness, desire to eat nothing, hard stools, and a fine pulse, this is termed "Yang Micro-Constriction." There must be both exterior and interior involvement. A deep pulse also indicates interior involvement. Sweating indicates Yang micro-deficiency. If it were pure Yin constriction, there would be no exterior symptoms; all pathogens would be interior. This represents pathogens half in the interior and half in the exterior. Even if the pulse is deep and tight, it cannot be diagnosed as Shaoyin disease. Why? Because Yin syndromes should not present with sweating. The presence of head sweating indicates it is not Shaoyin. Xiao Chai Hu Tang may be administered. If the condition remains unrelieved ("liao liao bu liao"), resolution occurs through defecation.
This clause not only differentiates suspected Shaoyang and Shaoyin syndromes but, extended further, embodies the essence of distinguishing Yin and Yang across the Six Channels. Five or six days indicate pathogens entering the interior. Head sweating indicates pathogens in Yang channels. Aversion to cold is a fundamental symptom of Three Yin, but Taiyang exterior symptoms also include aversion to cold. Epigastric fullness occurs in Shaoyang (chest fullness) and Shaoyin syndromes. Cold hands and feet are characteristic of Shaoyin, but Jueyin presents with "deeper cold, deeper heat." Both Shaoyang and Jueyin present with "silent desire not to speak/eat." Only hard stools distinguish this from Three Yin syndromes. With mixed symptoms and confusing Yin-Yang patterns, careful pulse diagnosis is required. If the pulse is merely fine without being deep and slow, the pathogen remains in Shaoyang, with weak Yang and excess Yin. Yin pathogens constricting the interior cause cold extremities, epigastric fullness, and anorexia, while head sweating remains a Yang sign. Thus, this is "Yang Micro-Constriction," indicating pathogens involving both exterior and interior. A deep pulse confirms interior involvement. Although cold extremities and anorexia suggest interior Yin pathogens, head sweating remains a Yang sign, albeit weak. Why? Pure Yin constriction would lack exterior signs like head sweating, with all pathogens interior. The presence of Yang channel exterior signs means pathogens are half interior, half exterior, hence "exterior and interior." Thus, even with a deep-tight pulse, it is not Shaoyin. Yin channel pathogens do not typically cause sweating; in Shaoyin, sweating is "counterflow" and indicates collapse of Yang. Head sweating occurs because Yang channels ascend to the head, while Yin channels stop at the neck. Therefore, it is not Shaoyin. Pathogens remain at the semi-exterior/semi-interior, i.e., Shaoyang. Xiao Chai Hu Tang should be used to harmonize. If "liao liao bu liao" (unclear/unresolved vision) persists, it implies the pathogen has moved from Shaoyang to Yangming interior, akin to the Yangming chapter's description of "unclear vision, unstable pupils, no exterior/interior symptoms, difficult defecation, indicating excess, requiring urgent purgation." Hence, the method of "attacking Earth stagnation" (purging bowels) is indicated, leading to resolution via stool. If vision is not yet unclear, pathogens remain in Shaoyang, and purgation is contraindicated.
[Correction of Errors] Yu Jiayan (*Shang Lun*) interprets "Yang Micro-Constriction" as mild constriction of Yang pathogens, not fully dispersed. Interpreting it as Yang Qi collapse leading to pathogen constriction is a significant error. If true, head sweating would indicate Yang collapse, not semi-exterior/semi-interior status. Similarly, "Yin Constriction" would imply Yin Qi collapse. I argue that interpreting "Yang Micro-Constriction" as mild Yang pathogen constriction links "micro" and "constriction." Thus, interpreting it as Yang Qi collapse is incorrect. However, how should "Yang micro" in "sweating indicates Yang micro" be interpreted? If head sweating is Yang collapse, then cases in the Taiyang chapter ("head sweating only, no other sweat, stopping at the neck") and Yangming chapter ("head sweating only, body no sweat, stopping at the neck, dry urine, likely jaundice") would all be Yang collapse. Interpreting Yin Constriction as Yin Qi collapse is similarly absurd. Zhang Zhongjing’s intent was that Shang Han normally causes no sweat. Due to weakened Wei Yang and insecure Yang Qi, head sweating and slight aversion to cold occur. "Sweating indicates Yang micro" shows that despite Yin-cold interior symptoms (cold extremities, epigastric fullness, anorexia), the presence of sweating and aversion to cold indicates residual Yang pathogens in the exterior, not pure Yin constriction. Pure Yin constriction would lack exterior signs and be entirely interior. Since Yang is weak but Yang signs persist, it is half interior, half exterior. This clearly indicates Yang Qi weakness with internal Yin pathogen constriction. One cannot force interpretations, mistakenly labeling sweating as Yang collapse or Yin constriction as Yin Qi collapse. Regarding "unclear vision," the Yangming chapter provides clear guidance. How can Da Chai Hu Tang be considered a harmonizing method here?
In Shang Han, if there is abdominal fullness and delirious speech, and the Cun Kou (radial artery at the wrist) pulse is floating and tight, this is Liver Wood overacting on Spleen Earth, termed "Zong" (Vertical/Unrestrained). Treat by puncturing Qi Men.
These two clauses demonstrate that diseases and treatments have no fixed rules, offering new perspectives amidst difficulty, similar to the *Nei Jing*’s concept of "evaluating the extraordinary." Abdominal fullness is a Foot-Taiyin Spleen disease. Delirious speech is a Foot-Yangming Stomach excess condition. Abdominal fullness suggests Spleen Cold, warranting warming. Delirious speech suggests Stomach Heat, warranting purgation. Cun Kou, or Qi Kou, is the pulse point of the Hand-Taiyin Lung meridian. The Lung governs Qi, and Ying-Wei Qi reconverges here after fifty cycles. Thus, it reflects Stomach Qi. The Stomach is the Sea of Water and Grain, the source of the Five Zang and Six Fu organs. Flavors enter the stomach and intestines to nourish the Zang organs, manifesting at Qi Kou. Here, the Qi Kou pulse is floating and tight. Floating indicates Wind; Tight indicates Cold. These are exterior pathogen pulses. However, the symptoms (fullness, delirium) suggest pathogens are not exterior. The pulse suggests pathogens are not interior. In the Taiyin chapter, abdominal fullness has no sweating indication. In the Yangming chapter, abdominal fullness with floating-tight pulses has no purgation indication. Pulse and symptoms contradict, making treatment difficult. Deep analysis reveals that if pathogens were truly exterior, only Cun Kou would not be floating and tight alone. If pulse remained floating-tight, pathogens would be exterior, yet abdominal fullness and delirium would not occur. Zhang Zhongjing recognized that pathogens invade the Middle Jiao, manifesting uniquely at Qi Kou. Hence, he named it "Liver overacting on Spleen." "Overacting" means attacking what it controls. Wood naturally controls Earth, following the normal cycle of Five Elements generation and restriction. This is logical and direct, hence termed "Zong" (Vertical/Unrestrained), implying smooth texture. With no sweating or purgation methods available, and knowing Liver Wood controls Spleen Earth, treatment focuses on draining the Liver. Qi Men is the Front-Mu point of the Foot-Jueyin Liver meridian. The meridian starts at Da Dun on the big toe and ends at Qi Men, located 4.5 cun lateral to Ju Que below the nipple. From here, it enters to connect with the Liver and Gallbladder. Puncturing it drains excess, following the principle of "draining based on excess," thereby calming Qi and resolving pathogens.
In Shang Han, if there is fever, slight aversion to cold, extreme thirst desiring water, and abdominal fullness, but spontaneous sweating and free urination occur, the disease will resolve. This is Liver Wood overacting on Lung Metal, termed "Heng" (Horizontal/Rebellious). Treat by puncturing Qi Men.
Shang Han fever refers to established fever in Shang Han. Slight aversion to cold indicates Wind pathogens in the exterior. Extreme thirst desiring water was discussed in the Shang Han section regarding Wind Strike: fever for six or seven days unresolved with vexation and exterior-interior symptoms leads to thirst. This is thirst caused by pathogens invading the Taiyang interior. Also, after excessive sweating in Taiyang disease, stomach dryness causes thirst. Thirst from combined Wind-Cold invasion and Yangming chapter cases of thirst with dry mouth/tongue are treated with Bai Hu Jia Ren Shen Tang (White Tiger plus Ginseng Decoction). These involve no exterior symptoms, with Heat pathogens entering the Stomach. Here, fever and slight aversion to cold indicate pathogens still in the exterior. Extreme thirst indicates pathogens in the interior. While exterior pathogens can coexist with interior symptoms, such severe interior symptoms with persistent exterior signs are unusual. Why? Although presenting as Shang Han fever with slight aversion to cold, this is actually Ying-Wei disharmony. The Lung governs skin/hair and circulates Ying-Wei. Lung pathogen invasion causes loose skin pores, leading to slight aversion to cold. Commentators attribute extreme thirst to Wood excess generating intense Heat, which is incorrect. Abdominal fullness does not result solely from drinking water. Abdominal fullness is a Spleen disease. The *Jing Mai Bie Lun* states: "Water enters the stomach, essence floats up, transports to the Spleen, Spleen scatters essence, returns to the Lung, regulates water passages, descends to the Bladder, water essence distributes four directions, flows through five meridians." Where does extreme thirst fit? This occurs because Liver Wood overacts on Spleen Earth, causing abdominal fullness. Spleen disease fails to scatter essence and transport it to the Lung, weakening Lung Qi. Weak Lung Qi cannot govern the hundred vessels and transmit essence to skin/hair, causing slight aversion to cold and extreme thirst to moisten dryness. This is Liver overacting on Lung. Lung is Metal, controlled by Wood. How can it be overacted upon? It is because strong Liver Wood, having conquered Earth, borrows strength to insult weak Lung Metal. This is irregular, hence termed "Heng" (Horizontal/Rebellious). If Lung strengthens itself, it will not be insulted. Its Qi will circulate Ying-Wei, open skin/hair, induce sweating, resolve fever/aversion to cold, regulate water passages, promote urination, and reduce abdominal fullness. Thus, the disease resolves. If unresolved, puncture Qi Men to drain excess Liver Qi, relieving the siege on Spleen and Lung.