案胃气及上二焦。方氏程氏汪氏并云。言汗吐也。柯氏改作上下焦。盖僭妄耳。脉经疑之。似是。成氏以
汗为小柴胡。且以刺期门为犯中焦。于义未妥。然亦他无明注。故姑揭成注尔。
程林金匮直解曰。上章以往来寒热如疟。故用小柴胡。以解其邪。下章以胸胁下满。如结胸状。故刺期门。
以泻其实。此章则无上下二证。似待其经行血去。邪热得以随血出。而解也。
伤寒六七日。发热微恶寒。支节烦疼。微呕。心下支结。外证未去者。柴胡桂枝汤主之。（支节。玉函。
作肢节。成本。柴胡下。有加字。）
〔柯〕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。〔王〕支节。犹云枝节。古字通也。支结。犹云支撑而结。南阳云。外
证未解。心下妨闷者。非痞也。谓之支结。
案方氏云。支节者。四肢百节也。若言百节。则似周身百节烦疼。此恐不然。当是四肢之关节烦疼。柯
注为得。明理论曰。烦疼。即热疼。
钱氏云。成氏曰。支。散也。王肯堂云。支结。支撑而结也。若训作散。则不能结矣。方注云。支结。言
支饮搏聚而结也。喻氏云。心下支结。邪结于心下偏旁。不中正也。若谓支饮结于心下。梦语喃喃。吾不识支
饮为何物也。诸说纷纷。略无定论。当以支撑之解为近是。○案金鉴云。支。侧也。小也。支结者。即心下侧之
小结也。此解尤非。伤寒百问经络图曰。心下妨闷者。非痞也。谓之支结。王冰曰。支。拄妨也。按心下满 。
若柔人者。皆治之。○案王说。见六元正纪支痛注。为是。
柴胡桂枝汤方
黄芩（一两半） 人参（一两半） 甘草（一两炙） 半夏（二合半洗） 芍药（一两半） 大枣（六
枚擘） 生姜（一两半切） 柴胡（四两） 桂枝（去皮○成本。玉函。一两半）
上九味。以水七升。煮取三升。去滓。温服一升。本云。人参汤。作如桂枝法。加半夏柴胡黄芩。复如柴
胡法。今用人参。作半剂。（成本。不见此方。载在第十卷。无本云二十九字。玉函同。）
〔鉴〕不名桂枝柴胡汤者。以太阳外证虽未去。而病机已
见于少阳里也。故以柴胡冠桂枝之上。意在解少阳为主。而散太阳为兼也。
外台秘要。疗寒疝腹中痛者。柴胡桂枝汤。（即本方）
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。
〔成〕伤寒五六日。已经汗下之后。则邪当解。今胸胁满微结。小便不利。渴而不呕。但头汗出。往来寒
热。心烦者。即邪气犹在半表半里之间。为未解也。胸胁满微结。寒热心烦者。邪在半表半里之间也。小便不
利而渴者。汗下后亡津夜内燥也。若热消津液。令小便不利而渴者。其人必呕。今渴而不呕。知非里热也。伤
寒汗出则和。今但头汗出。而余处无汗者。津液不足。而阳虚于上也。与柴胡桂枝干姜汤。以解表里之邪。复
津液而助阳也。〔汪〕微结者。言其邪不甚。未入于腑。正当表里之间也。小便不利者。此因汗下之后。而津
液少也。惟津液少。而非停饮。以故渴而不呕。但头汗出者。此热郁于经。不得外越。故但升于头而汗出也。
柴胡桂枝干姜汤方（○外台。名小柴胡汤。而主疗。系中篇第六十八条。）
柴胡（半斤） 桂枝（三两去皮） 栝蒌根（四两） 干姜（二两○全书。外台。作三两） 黄芩（三两）
甘草（二两炙） 牡蛎（二两。熬○全书。外台。作三两）
上七味。以水一斗二升。煮取六升。去滓再煎。取三升。温服一升。日三服。初服微烦复服。汗出便愈。
〔汪〕即小柴胡汤加减方也。据原方加减法云。胸中烦而不呕者。去半夏人参。加栝蒌实。若渴者。去半
夏。兹者。心烦渴而不呕。故去人参半夏。加栝蒌根四两。若胁下痞硬。去大枣。加牡蛎。兹者。胸胁满微结。
即痞硬也。故去大枣。加牡蛎二两。若心悸小便不利者。去黄芩。加茯苓。兹者小
便不利。心不悸而但烦。是为津液少而躁热。非水蓄也。故留黄芩。不加茯苓。又云。若咳者。去人参大枣生
姜。加五味子干姜。兹不因咳。而以干姜易生姜者。何也。盖干姜味辛而气热。其用有二。一以辛散胸胁之微
结。一以热济黄芩栝蒌根之苦寒。使阴阳和而寒热已焉。
金匮要略附方。外台。柴胡桂姜汤。治疟寒多微有热。或但寒不热。服一剂如神。（案今外台。无所考。）
活人书。干姜柴胡汤。妇人伤寒。经脉方来初断。寒热如疟。狂言见鬼。（即本方。无黄芩。）
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。假令纯阴结。不得复有外证。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。（玉函。在里也。作为病在里。）
〔知〕此言少阳病。有似少阴者。当细辨其脉证也。〔成〕伤寒五六日。邪当传里之时。头汗出微恶寒者。
表仍未解也。手足冷。心下满。口不欲食。大便硬脉细者。邪结于里也。大便硬为阳结。此邪热虽传于里。然
以外带表邪。则热结犹浅。故曰阳微结。脉沉虽为在里。若纯阴结。则更无头汗恶寒之表证。诸阴脉。皆至颈
胸中而还。不上循头。今头汗出。知非少阴也。与小柴胡汤。以除半表半里之邪。服汤已。外证罢而不了了者。
为里热未除。与汤取其微利则愈。故云得屎而解。〔程〕半里之热。以怫郁不能外达。故头汗出。半表之寒。以
持久不能解散。故微恶寒。两邪互拒。知阳气郁滞而成结矣。唯其阳气郁而滞也。所以手足冷。心下满。口不
欲食。大便硬。既有结滞之证。便成结滞之脉。所以脉亦细。
所云阳证似阴者。此其类也。凡脉细。脉沉。脉紧。皆阳热郁结之诊。无关少阴也。可见阳气一经郁结。不但
阳证似阴。并阳脉似阴矣。只据头汗出一证。其人阳气郁结。必夹苦口咽干目眩而成。其余半在表证。但一审
之微恶寒。而凡往来寒热等证。不必一具。即可作少阳病处治。与以小柴胡汤矣。得屎自解。即大柴胡。与柴
胡加芒硝汤。皆所当斟酌者耳。
案汗出为阳微。锡驹云。汗出为太阳表气虚微。与阳微结之微不同。钱氏以为阳微而结。与汗出为阳微。
同为阳气衰微之义。汪氏则并下阳微。为阳微结之义。俱失之。金鉴云。脉细当是脉沉细。观本条下文。脉沉
亦在里也之亦字自知。脉虽沉紧之紧字。当是细字。本条上文。并无紧字。如何说。虽沉紧。虽字何所谓耶。
必是传写之误。此说亦不必矣。
案汪氏云。补亡论。郭白云云。实者。大柴胡汤。虚者。蜜煎导之。其说甚是。而今推成氏之意。当是调
胃承气汤。本事方曰。有人患伤寒。五六日。头汗出。自颈以下无汗。手足冷。心下痞闷。大便秘结。或者见
四肢冷。又汗出满闷。以为阴证。予诊其脉。沉而紧。予曰。此证诚可疑。然大便结。非虚结也。安得为阴脉。
虽沉紧为少阴。多是自利。未有秘结者。予谓此正半在里半在表。投以小柴胡得愈。仲景称伤寒五六日。头汗
出云云此疾证候同。故得屎而解也。
伤寒五六日。呕而发热者。柴胡汤证具。而以他药下之。柴胡证仍在者。复与柴胡汤。此虽已下之。不为
逆。必蒸蒸而振。却发热汗出而解。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。此为痞。
柴胡不中与之。宜半夏泻心汤。（外台。此条作太阳病下之。其脉促不结胸者。此为欲解也。若心下满硬痛者。
此为结胸也。大陷胸汤主之。但满而不痛者。此为痞。柴胡不中与之也。宜半夏
泻心汤主之。玉函。发热下无者字。已。作以。但。作若。不中与之。作不中复与之也。）
〔志〕此节分三段。上段言柴胡证具。虽下不为逆。复可与柴胡汤。中段言下之而成结胸。大陷胸汤。下
段言痞证但满不痛。不可与柴胡。而宜半夏泻心汤。〔柯〕呕而发热者。小柴胡症也。呕多。虽有阳明症。不
可攻之。若有下症。亦宜大柴胡。而以他药下之。误矣。误下后。有二症者。少阳为半表半里之经。不全发阳。
不全发阴。故误下之变。亦因偏于半表者成结胸。偏于半里者。心下痞耳。此条本为半夏泻心而发。故只以痛
不痛。分结胸与痞。未及他症。〔钱〕他药者。即承气之类。非有别药也。蒸蒸。身热汗欲出之状也。振者。
振振然动摇之貌。即寒战也。以下后正气已虚。难于胜邪。故必战而后汗也。〔魏〕结胸不言柴胡汤不中与。
痞证乃言柴胡汤不中与者。何也。结胸证显而易认。痞证甚微难认。且大类于前条所言支结。故明示之。意详哉。
半夏泻心汤方
黄芩 干姜 人参 甘草（炙各三两） 半夏（半升洗○外台注。一方五两。） 黄连（一两） 大枣（十
二枚擘○玉函作十六枚）
上七味。以水一斗。煮取六升。去滓再煎。取三升。温服一升。日三服。须大陷胸汤者。方用前第二法。
（再煎。成本。玉函。作再煮。须以下十二字。成本无。）
〔程〕泻心虽同。而证中且呕。则切专涤饮。故以半夏名汤耳。曰泻心者。言满在心下清阳之位。热邪夹饮。
尚未成实。故清热涤饮。使心下之气得过。上下自无阻留。阴阳自然交互矣。然枢机全在于胃。故复补胃家之
虚。以为之斡旋。与实热入胃。而泻其蓄满者。大相迳庭矣。痞虽虚邪。乃表气入里。寒成热矣。寒虽成热。
而热非实。故用苦寒。以泻其热。兼佐辛甘。以补其虚。不必攻痞。而痞自散。所以一
方之中。寒热互用也。〔柯〕即小柴胡。去柴胡。加黄连干姜汤也。不往来寒热。是无半表症。故不用柴胡。痞
因寒热之气。互结而成。用黄连干姜之大寒大热者。为之两解也。〔吴〕去滓复煎者。要使药性合而为一。漫无
异同。并停胃中。少顷随胃气以敷布。而里之未知者。遂无不和。
医方考曰。伤寒下之早。以既伤之中气。而邪乘之。则不能升清降浊。痞塞于中。如天地不交而成否。
故曰痞。泻心者。泻心下之邪也。姜夏之辛。所以散痞气。芩连之苦。所以泻痞热。已下之后。脾气必虚。人
参甘草大枣。所以补脾之虚。
伤寒选录曰。凡言泻心者。少阳邪将入太阴。邪在胸中之下。非心经受邪也。伤寒蕴要曰。泻心非泻心火
之热。乃泻心下痞之满也。
千金心虚实门。泻心汤。治老少下利。水谷不消。肠中雷鸣。心下痞满。干呕不安。（即本方）
煮法后云。并治霍乱。若寒。加附子一枚。渴。加栝蒌根二两。呕。加橘皮一两。痛。加当归一两。客
热。以生姜代干姜。
又冷痢门。泻心汤。治卒大下利热。唇干口燥。呕逆引饮。
于本方。去大枣。加栝蒌根。橘皮。（注。引胡洽。文与心虚实门同。唯云。仲景用大枣十二枚。）
三因心实热门。泻心汤。治心实热。心下痞满。身重发热。干呕不安。腹中雷鸣。泾溲不利。水谷不消。
欲吐不吐。烦闷喘急。
于本方。去大枣。
太阳少阳并病。而反下之。成结胸。心下硬。下利不止。
水浆不下。其人心烦。（玉函。脉经。利下。有复字。不下间。有肯字。其人下。有必字。）
〔汪〕太阳病在经者。不可下。少阳病下之。亦所当禁。故以下之为反也。下之则阳邪乘虚。上结于胸。
则心下硬。下入于肠。则利不止。中伤其胃。则水浆不入。其人心烦者。正气已虚。邪热躁极也。条辨云。心
烦下。疑有脱简。大抵其候为不治之证。仲景云。结胸证悉具。烦躁者。亦死。况兼下利。水浆不下者邪。其
为不治之证宜也。〔锡〕凡遇此病。宜重用温补。即小陷胸亦不可与也。
案此条证。喻氏以降。皆以为死证。特钱氏云。愚恐未必尽皆死证。或有治法。未可知也。当于仲景诸烦
证中。约略寻讨其活法可也。
脉浮而紧。而复下之。紧反入里。则作痞。按之自濡。但气痞耳。（玉函。复。作反。）
〔方〕濡与软同。古字通用。复。亦反也。紧反入里。言寒邪转内伏也。濡。言不硬不痛。而柔软也。痞。
言气隔不通而痞塞也。〔钱〕脉浮而紧。浮为在表。紧则为寒。乃头痛发热。身疼腰痛。恶风无汗。寒邪在表之
脉。麻黄汤证也。而复下之者。言不以汗解。而反误下之也。紧反入里者。言前所见紧脉之寒邪。因误下之虚。
陷入于里。而作心下痞满之症也。此不过因表邪未解。误下里虚。无形之邪气。陷入于里而成痞耳。其脉证不
同。治法各异者。又于下条分出。以为临症施治之用。
案此条症。常器之主小陷胸汤。生姜泻心汤。郭白云。主半夏泻心汤。枳实理中丸。喻氏程氏魏氏。主大
考察胃气及上、中二焦。方有执、程林、汪琥均认为，这是指发汗和催吐疗法。柯琴改为上、下二焦，这大概是僭越妄改。《脉经》对此表示怀疑，这种看法似乎是正确的。成无己将“汗”解释为小柴胡汤证，并且认为刺期门穴是侵犯中焦，这在义理上并不妥当。然而也没有其他明确的注释，所以暂且列出成无己的注解。
程林在《金匮直解》中说：上一章因往来寒热如疟疾，所以用小柴胡汤来解除邪气；下一章因胸胁部胀满，像结胸的样子，所以针刺期门穴以泻其实邪。这一章则没有上述上下两方面的证候，似乎应当等待月经来潮，瘀血排出，邪热得以随血外出而解除。
伤寒病六七天，发热，轻微恶寒，四肢关节烦痛，轻微呕吐，心下部支撑感且结滞，外部表证仍未消除的，用柴胡桂枝汤主治。（注：“支节”，《玉函经》写作“肢节”。成本本在“柴胡”二字下，多出一个“加”字。）
〔柯琴〕伤寒到了六七天，正是寒热应当退去的时候，反而出现发热恶寒的症状，这是表证兼有心下部支撑结滞的里证，表里均未解除。然而恶寒轻微，那么发热也轻微。只有四肢关节烦痛，说明全身骨节并不都烦痛，由此可知表证轻微，所以取桂枝汤的一半剂量。内证轻微，所以取小柴胡汤的一半剂量。这是因为内外俱虚，所以用这个轻剂来和解。〔王肯堂〕“支节”，就是“枝节”的意思，古字通用。“支结”，就是“支撑而结滞”的意思。张仲景说：外部表证未解，心下部妨碍闷塞的，不是痞证，叫做支结。
〔考证〕方有执说：支节，是指四肢百节。如果说百节，那就像是周身百节都烦痛，这恐怕不对。应当是四肢关节烦痛。柯琴的注解比较恰当。《明理论》说：烦疼，就是热疼。
钱潢说：成无己说：“支”，是散的意思。王肯堂说：支结，是支撑而结滞的意思。如果解释为“散”，就不能称为“结”了。方有执注解说：支结，是说支饮搏聚而结滞。喻嘉言说：心下支结，是邪气结在心下的偏侧，不中正。如果说支饮结于心下，那是梦话喃喃自语，我不明白支饮是什么东西。各种说法纷纷扬扬，没有定论。应当以“支撑”的解释为接近正确。○〔考证〕尤在泾（金鉴）说：支，是侧，是小。支结，就是心下侧边的小结滞。这个解释尤其不对。《伤寒百问经络图》说：心下部妨碍闷塞的，不是痞证，叫做支结。王冰说：支，是拄持妨碍的意思。按：心下部胀满，像柔人（一种病症或比喻）那样的，都治疗它。○〔考证〕王冰的说法，见于《素问·六元正纪大论》支痛的注释，是正确的。
柴胡桂枝汤方
黄芩（一两半） 人参（一两半） 甘草（一两，炙） 半夏（二合半，洗） 芍药（一两半） 大枣（六枚，掰开） 生姜（一两半，切） 柴胡（四两） 桂枝（去皮○成本本、《玉函经》为一两半）
以上九味药，用水七升，煮取三升，去渣滓。温服一升。原本说是：人参汤，按照桂枝汤的方法制作，加入半夏、柴胡、黄芩，再按照小柴胡汤的方法制作。现在用人参，做成半剂。（成本本不见此方，记载在第十卷，没有“本云”这二十九个字，《玉函经》相同。）
〔尤在泾〕不命名为桂枝柴胡汤的原因，是因为太阳外部表证虽然未去，但病机已经显现于少阳里证。所以把柴胡冠于桂枝之上，意在主要解除少阳邪气，而发散太阳邪气只是兼带。
《外台秘要》记载：治疗寒疝腹中疼痛的，用柴胡桂枝汤。（即本方）
伤寒五六天，已经发汗，又再次使用下法，胸胁胀满，轻微结滞，小便不利，口渴但不呕吐，只有头部出汗，往来寒热，心烦的，这是邪气未解。用柴胡桂枝干姜汤主治。
〔成无己〕伤寒五六天，经过发汗和下法之后，邪气应当解除。现在胸胁胀满轻微结滞，小便不利，口渴但不呕吐，只有头部出汗，往来寒热，心烦，这就是邪气仍然在半表半里之间，属于未解。胸胁胀满轻微结滞，寒热心烦，是邪气在半表半里之间。小便不利而口渴，是发汗和下法后津液亏损，内部干燥。如果热邪消耗津液，导致小便不利而口渴，病人一定会呕吐。现在口渴但不呕吐，知道不是里热。伤寒出汗则调和，现在只有头部出汗，其余部位无汗，是津液不足，阳气虚于上部。给予柴胡桂枝干姜汤，以解除表里之邪，恢复津液并助阳。〔汪琥〕微结，是说邪气不重，未进入腑，正当表里之间。小便不利，是因为发汗和下法之后，津液减少。正因为津液少，而不是停饮，所以口渴但不呕吐。只有头部出汗，是因为热郁滞在经脉，不能向外透越，所以只上升于头部而出汗。
柴胡桂枝干姜汤方（○《外台秘要》名为小柴胡汤，主治内容系中篇第六十八条。）
柴胡（半斤） 桂枝（三两，去皮） 栝蒌根（四两） 干姜（二两○全书、《外台》作三两） 黄芩（三两） 甘草（二两，炙） 牡蛎（二两，熬○全书、《外台》作三两）
以上七味药，用水一斗二升，煮取六升，去渣滓，再煎，取三升。温服一升，每日三次。初服时轻微心烦，再服后，出汗便痊愈。
〔汪琥〕这就是小柴胡汤的加减方。根据原方的加减法说：胸中烦而不呕的，去掉半夏、人参，加栝蒌实。如果口渴的，去掉半夏。此时心烦渴而不呕，所以去掉人参、半夏，加栝蒌根四两。如果胁下痞硬，去掉大枣，加牡蛎。此时胸胁满微结，就是痞硬，所以去掉大枣，加牡蛎二两。如果心悸、小便不利的，去掉黄芩，加茯苓。此时小便不利，心不悸而只是烦，这是津液少而躁热，不是水蓄积，所以保留黄芩，不加茯苓。又说：如果咳嗽的，去掉人参、大枣、生姜，加五味子、干姜。此时不因咳嗽，而是用干姜替换生姜，为什么呢？大概干姜味辛而气热，其作用有二：一是用辛散胸胁的微结，二是用热济助黄芩、栝蒌根的苦寒，使阴阳调和而寒热停止。
《金匮要略》附方，《外台秘要》：柴胡桂姜汤，治疗疟疾寒多微有热，或者但寒不热。服一剂如神效。（〔考证〕如今《外台秘要》中无法考证。）
《活人书》：干姜柴胡汤，妇人伤寒，月经刚断，寒热如疟，狂言见鬼。（即本方，无黄芩。）
伤寒五六天，头部出汗，轻微恶寒，手足冷，心下部胀满，口不想吃东西，大便硬，脉细的，这是阳微结。一定有表证，又有里证。脉沉，也在里。出汗为阳微。假如是纯阴结，不得再有外部表证，全部入在里，这是半在里，半在外。脉虽然沉紧，不能诊断为少阴病。之所以这样，是因为阴证不得有汗，现在头部出汗，所以知道不是少阴。可以给予小柴胡汤。如果服药后仍感觉不舒服，得大便通畅即可解除。（《玉函经》，“在里也”写作“病在里”。）
〔尤在泾〕这里说的是少阳病，有类似少阴的情况，应当仔细辨别其脉证。〔成无己〕伤寒五六天，邪气应当传里的时期，头部出汗、轻微恶寒，表证仍未解除。手足冷，心下部胀满，口不想吃东西，大便硬，脉细，是邪气结在里。大便硬为阳结。此邪热虽然传入里，但因为外部带有表邪，所以热结尚浅，所以说阳微结。脉沉虽为在里，如果是纯阴结，则更没有头部出汗、恶寒的表证。诸阴脉，都至颈胸中而回，不上循头部。现在头部出汗，知道不是少阴。给予小柴胡汤，以清除半表半里之邪。服药后，外部表证罢除但仍感觉不舒服的，是因为里热未除，给汤药使其轻微通利则痊愈。所以说得屎而解。〔程林〕半里的热，因怫郁不能外达，所以头部出汗。半表的寒，因持久不能解散，所以轻微恶寒。两邪互相抗拒，知道阳气郁滞而成结。正因为阳气郁而滞，所以手足冷，心下部胀满，口不想吃东西，大便硬。既有结滞的证候，便形成结滞的脉象，所以脉也细。
所说的阳证似阴者，就是这一类。凡是脉细、脉沉、脉紧，都是阳热郁结的诊象，与少阴无关。可见阳气一经郁结，不但阳证似阴，连阳脉也似阴了。只依据头部出汗这一证，其人阳气郁结，必然夹杂苦口、咽干、目眩等症状。其余半在表的证候，只要审察一下轻微恶寒，那么凡往来寒热等证，不必全部具备，就可以作为少阳病处理，给予小柴胡汤。得大便自解，也就是大柴胡汤、柴胡加芒硝汤，都是应当斟酌使用的。
〔考证〕出汗为阳微。锡驹说：出汗为太阳表气虚微，与阳微结的“微”不同。钱潢认为阳微而结，与出汗为阳微，同为阳气衰微的意义。汪琥则将下面的“阳微”合并为阳微结的意义，都失之偏颇。尤在泾说：脉细应当是脉沉细，看本条下文“脉沉亦在里也”的“亦”字自然知晓。脉虽沉紧的“紧”字，应当是“细”字。本条上文，并没有“紧”字，怎么说“虽沉紧”呢？“虽”字从何而来呢？必定是传写错误。这种说法也不必深究。
〔考证〕汪琥说：《补亡论》，郭白云说：实证，用大柴胡汤；虚证，用蜜煎导法。这种说法很对。而今推测成无己的意思，应当是调胃承气汤。《本事方》说：有人患伤寒，五六天，头部出汗，自颈部以下无汗，手足冷，心下部痞闷，大便秘结。有人见四肢冷，又汗出满闷，以为是阴证。我诊其脉，沉而紧。我说：此证确实可疑，但大便结，不是虚结，怎么能说是阴脉？虽然沉紧为少阴脉，多是自利，未有秘结的。我认为这正是半在里半在表，投以小柴胡汤而愈。仲景称伤寒五六日，头汗出云云，此疾病证候相同，所以得屎而解。
伤寒五六天，呕吐而发热的，柴胡汤证具备，却用其他药物攻下。柴胡证仍在的，再给予柴胡汤。这虽然已经攻下，不算逆证，必定会蒸蒸而振栗，随后发热出汗而解。如果心下部胀满而且硬痛，这是结胸，用大陷胸汤主治。只是胀满而不痛的，这是痞证，柴胡汤不适合给予，宜用半夏泻心汤。（《外台秘要》，此条作太阳病攻下，其脉促不结胸的，这是欲解。如果心下部胀满硬痛，这是结胸，大陷胸汤主治。只是胀满而不痛的，这是痞证，柴胡汤不适合给予，宜半夏泻心汤主治。《玉函经》，发热下无“者”字。“已”作“以”。“但”作“若”。“不中与之”作“不中复与之”。）
〔张志聪〕这一节分三段。上段说柴胡证具备，虽然攻下不为逆，再可与柴胡汤。中段说攻下而成结胸，用大陷胸汤。下段说痞证只是胀满不痛，不可与柴胡，而宜半夏泻心汤。〔柯琴〕呕吐而发热，是小柴胡症。呕多，虽有阳明症，不可攻下。如果有下症，也宜用大柴胡汤，却用其他药物攻下，这是误治。误下后，有两种症状：少阳为半表半里之经，不全发阳，不全发阴，所以误下后的变证，也因偏于半表者成结胸，偏于半里者，心下痞耳。此条本是为半夏泻心汤而发，所以只用痛与不痛，区分结胸与痞，未涉及其他症状。〔钱潢〕他药，就是承气汤之类，并非有别药。蒸蒸，是身热汗欲出的样子。振，是振振然动摇的样子，就是寒战。因为攻下后正气已虚，难以胜邪，所以必战而后汗。〔魏荔彤〕结胸不言柴胡汤不中与，痞证乃言柴胡汤不中与，为什么呢？结胸证显而易见易认，痞证甚微难认，且大类乎前条所言支结，所以明示之，用意详尽啊。
半夏泻心汤方
黄芩 干姜 人参 甘草（炙，各三两） 半夏（半升，洗○《外台》注：一方五两。） 黄连（一两） 大枣（十二枚，掰开○《玉函》作十六枚）
以上七味药，用水一斗，煮取六升，去渣滓，再煎，取三升。温服一升，每日三次。需要大陷胸汤者，方用前第二法。（再煎，成本本、《玉函》作再煮。须以下十二字，成本本无。）
〔程林〕泻心虽同，而证中且有呕吐，则切专涤除饮邪，所以以半夏名汤。曰泻心，是说满在心下清阳之位，热邪夹饮，尚未成实，所以清热涤饮，使心下之气得过，上下自然无阻留，阴阳自然交互。然而枢机全在于胃，所以又补胃家之虚，以为之斡旋。这与实热入胃，而泻其蓄满者，大相径庭。痞虽是虚邪，乃是表气入里，寒化成热。寒虽成热，而热非实，所以用苦寒，以泻其热，兼佐辛甘，以补其虚，不必攻痞，而痞自散。所以一方之中，寒热互用。〔柯琴〕就是小柴胡汤，去掉柴胡，加黄连、干姜汤。没有往来寒热，是无半表症，所以不用柴胡。痞因寒热之气，互结而成，用黄连、干姜之大寒大热者，为之两解。〔吴谦〕去渣滓再煎，是要使药性合而为一，漫无异同，并停胃中，片刻后随胃气以敷布，而里之未知的，遂无不和。
《医方考》说：伤寒攻下过早，以既伤之中气，而邪乘之，则不能升清降浊，痞塞于中，如天地不交而成否卦。故曰痞。泻心，是泻心下之邪。姜夏之辛，所以散痞气；芩连之苦，所以泻痞热。已下之后，脾气必虚，人参、甘草、大枣，所以补脾之虚。
《伤寒选录》说：凡言泻心者，是少阳邪将入太阴，邪在胸中之下，非心经受邪。《伤寒蕴要》说：泻心非泻心火之热，乃泻心下痞之满。
《千金要方·心虚实门》：泻心汤，治疗老少下利，水谷不消，肠中雷鸣，心下痞满，干呕不安。（即本方）
煮法后说：并治霍乱。如果寒，加附子一枚；渴，加栝蒌根二两；呕，加橘皮一两；痛，加当归一两。客热，以生姜代干姜。
又冷痢门：泻心汤，治疗突然大下利热，唇干口燥，呕逆引饮。
于本方，去掉大枣，加栝蒌根、橘皮。（注：引用胡洽，文与心虚实门同，唯云：仲景用大枣十二枚。）
《三因极一病证方论·心实热门》：泻心汤，治疗心实热，心下痞满，身重发热，干呕不安，腹中雷鸣，泾溲不利，水谷不消，欲吐不吐，烦闷喘急。
于本方，去掉大枣。
太阳少阳并病，反而攻下，造成结胸，心下部硬，下利不止，
水浆不下，其人烦躁。（《玉函经》、《脉经》，利下有“复”字，不下间有“肯”字，其人有“必”字。）
〔汪琥〕太阳病在经者，不可下。少阳病下之，亦所当禁，所以下之为反。下之则阳邪乘虚，上结于胸，则心下部硬；下入于肠，则利不止；中伤其胃，则水浆不入。其人烦躁，是正气已虚，邪热躁极。《条辨》说：心烦下，疑有脱简。大抵其候为不治之证。仲景说：结胸证悉具，烦躁者，亦死。何况兼下利，水浆不下呢？其为不治之证，适宜啊。〔锡驹〕凡遇此病，宜重用温补，即使小陷胸汤也不可给予。
〔考证〕此条证候，喻嘉言以降，都认为死证。唯独钱潢说：我恐未必尽皆死证，或有治法，未可知也。应当在仲景诸烦证中，约略寻找其活法可也。
脉浮而紧，又反而攻下，紧脉反入里，则作痞。按之柔软，只是气痞。（《玉函经》，复，作反。）
〔方有执〕濡与软同，古字通用。复，也是反的意思。紧反入里，是说寒邪转内伏。濡，是不硬不痛，而柔软。痞，是气隔不通而痞塞。〔钱潢〕脉浮而紧，浮为在表，紧则为寒，是头痛发热，身疼腰痛，恶风无汗，寒邪在表的脉，麻黄汤证。而复下之，是说不用汗解，反而误下。紧反入里，是说前所见紧脉之寒邪，因误下之虚，陷入于里，而作心下部痞满之症。这不过是因表邪未解，误下里虚，无形之邪气，陷入于里而成痞。其脉证不同，治法各异，又在下一条分出，以为临症施治之用。
Examine the Stomach Qi and the Upper and Middle Jiao. Fang Youzhi, Cheng Lin, and Wang Hu all state that this refers to sweating (Han) and vomiting (Tu). Ke Qin changed it to Upper and Lower Jiao, which is likely an overstepping and arbitrary alteration. *Mai Jing* expresses doubt about this, a view that seems correct. Cheng Wuji interpreted "sweating" as referring to Xiao Chai Hu Tang (Minor Galla Decoction), and further stated that needling Qimen (LR14) invades the Middle Jiao, which is not appropriate in principle. However, there are no other clear annotations, so Cheng Wuji's annotation is tentatively presented here.
Cheng Lin in *Jingui Zhijie* states: In the previous chapter, due to alternating chills and fever resembling malaria, Xiao Chai Hu Tang (Minor Galla Decoction) was used to resolve the pathogen. In the next chapter, due to fullness in the chest and hypochondrium resembling Jie Xiong (Chest Binding), needling Qimen (LR14) was used to drain excess. This chapter lacks both of these upper and lower manifestations; it seems one should wait for the menses to flow, allowing blood stasis to be expelled, so that the pathogenic heat can exit with the blood and resolve.
In Shaoyang disease (Disease of the Shaoyang Channel) after six or seven days, with slight fever and aversion to cold, vexing pain in the limbs and joints, slight vomiting, and a sensation of support and binding in the epigastrium, while exterior symptoms remain unresolved, Chai Hu Gui Zhi Tang (Bupleurum and Cinnamon Twig Decoction) is indicated. (Note: "Zhi Jie" is written as "Zhi Jie" in *Yu Han Jing*. The Cost Edition places this note under "Chai Hu" and adds the character "Jia".)
[Ke Qin] When Shaoyang disease reaches six or seven days, it is the time when chills and fever should recede. The recurrence of fever and aversion to cold indicates an exterior syndrome accompanied by an interior syndrome of support and binding in the epigastrium, meaning neither the exterior nor the interior is resolved. However, since the aversion to cold is slight, the fever is also slight. The presence of only vexing pain in the limbs and joints, without general body ache, indicates a mild exterior syndrome; thus, half the dosage of Gui Zhi Tang (Cinnamon Twig Decoction) is taken. Since the interior symptoms are mild, half the dosage of Xiao Chai Hu Tang (Minor Galla Decoction) is taken. Because both the interior and exterior are deficient, this light formula is used to harmonize. [Wang Kentang] "Zhi Jie" means "branch joints," using ancient interchangeable characters. "Zhi Jie" means "supporting and binding." Zhang Zhongjing said: When exterior symptoms are unresolved and the epigastrium feels obstructed and stuffy, it is not Pi Syndrome (Stagnation Syndrome); it is called Zhi Jie.
[Commentary] Fang Youzhi states: Zhi Jie refers to the four limbs and hundred joints. If it meant all hundred joints, it would imply whole-body joint pain, which is unlikely. It should refer to vexing pain in the joints of the four limbs. Ke Qin's annotation is more accurate. *Ming Li Lun* states: Vexing pain means hot pain.
Qian Huang states: Cheng Wuji says: "Zhi" means scattered. Wang Kentang says: Zhi Jie means supporting and binding. If interpreted as "scattered," it cannot be "binding." Fang Youzhi annotates: Zhi Jie means fluid retention (Zhi Yin) gathering and binding. Yu Jia Yan states: Zhi Jie in the epigastrium means pathogenic factors bind to the side of the epigastrium, not centrally. To say fluid retention binds in the epigastrium is nonsense; I do not know what fluid retention is. Various theories abound without consensus. The interpretation of "supporting" is likely closer to the truth. ○ [Commentary] You Yiren (Jin Jian) states: "Zhi" means side or small. Zhi Jie is a small binding on the side of the epigastrium. This explanation is particularly incorrect. *Shaoyang Baiwen Jingluo Tu* states: Obstruction and stuffiness in the epigastrium, which is not Pi Syndrome, is called Zhi Jie. Wang Bing states: "Zhi" means prop-up obstruction. Note: Fullness in the epigastrium, resembling the condition of "Rou Ren," is treated accordingly. ○ [Commentary] Wang Bing's view is found in the annotation for "Zhi Tong" in *Su Wen: Liu Yuan Zheng Ji Da Lun*, which is correct.
Chai Hu Gui Zhi Tang Formula
Huang Qin (Scutellariae Radix) 1 liang 1/2
Ren Shen (Ginseng Radix) 1 liang 1/2
Gan Cao (Licorice Radix et Rhizoma), prepared 1 liang
Ban Xia (Pinelliae Tuber) 2 he 1/2, washed
Shao Yao (Paeoniae Radix Alba) 1 liang 1/2
Da Zao (Ziziphi Jujubae Fructus) 6 pieces, split
Sheng Jiang (Zingiberis Rhizoma Recens) 1 liang 1/2, sliced
Chai Hu (Bupleuri Radix) 4 liang
Gui Zhi (Cinnamomi Ramulus) peeled (Cost Edition and *Yu Han Jing* record 1 liang 1/2)
The above nine ingredients are boiled in 7 sheng of water to obtain 3 sheng. Strain and discard the dregs. Take 1 sheng warm. Originally stated: This is Renshen Tang, prepared like Gui Zhi Tang (Cinnamon Twig Decoction), adding Ban Xia, Chai Hu, and Huang Qin, then prepared like Xiao Chai Hu Tang (Minor Galla Decoction). Now using Ren Shen, make half a dose. (Not found in the Cost Edition, recorded in Volume 10, lacking the 29 characters "Originally stated.")
[You Yiren] It is not named Gui Zhi Chai Hu Tang because although the Taiyang exterior symptoms remain, the pathological mechanism has appeared in the Shaoyang interior. Therefore, Chai Hu is placed before Gui Zhi, intending primarily to resolve Shaoyang pathogens, while dispersing Taiyang pathogens is secondary.
*Waitai Miyao* records: For cold hernia with abdominal pain, use Chai Hu Gui Zhi Tang (i.e., this formula).
After five or six days of Shaoyang disease, having already been sweated and then purged, with fullness in the chest and hypochondrium, slight binding, difficulty in urination, thirst without vomiting, only sweating from the head, alternating chills and fever, and irritability, this indicates the pathogen is unresolved. Use Chai Hu Gui Zhi Gan Jiang Tang (Bupleurum, Cinnamon Twig, and Dried Ginger Decoction).
[Cheng Wuji] After five or six days of Shaoyang disease, following sweating and purging, the pathogen should have resolved. Now, slight binding in the chest and hypochondrium, difficulty in urination, thirst without vomiting, only sweating from the head, alternating chills and fever, and irritability indicate the pathogen remains between the exterior and interior, unresolved. Slight binding in the chest and hypochondrium, chills, fever, and irritability signify the pathogen between the exterior and interior. Difficulty in urination and thirst result from fluid depletion and internal dryness after sweating and purging. If heat consumed fluids causing difficulty in urination and thirst, vomiting would necessarily occur. Since there is thirst but no vomiting, it is known not to be interior heat. Sweating harmonizes Shaoyang disease; now only the head sweats while the rest is dry, indicating insufficient fluids and Yang deficiency in the upper part. Administer Chai Hu Gui Zhi Gan Jiang Tang to resolve exterior-interior pathogens, restore fluids, and assist Yang. [Wang Hu] "Slight binding" means the pathogen is not severe and has not entered the Fu organs, residing exactly between the exterior and interior. Difficulty in urination is due to reduced fluids after sweating and purging. Precisely because fluids are low, rather than fluid retention, there is thirst without vomiting. Only sweating from the head occurs because heat is constrained in the channels, unable to vent outward, thus rising only to the head to cause sweating.
Chai Hu Gui Zhi Gan Jiang Tang Formula (*Waitai Miyao* names it Xiao Chai Hu Tang, with treatment details in Chapter 68 of the middle section.)
Chai Hu (Bupleuri Radix) 8 liang
Gui Zhi (Cinnamomi Ramulus) 3 liang, peeled
Gua Lou Gen (Trichosanthis Radix) 4 liang
Gan Jiang (Zingiberis Rhizoma) 2 liang (Complete Book and *Waitai* record 3 liang)
Huang Qin (Scutellariae Radix) 3 liang
Gan Cao (Licorice Radix et Rhizoma), prepared 2 liang
Mu Li (Ostreae Concha) 2 liang, roasted (Complete Book and *Waitai* record 3 liang)
The above seven ingredients are boiled in 12 sheng of water to obtain 6 sheng. Strain, decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily. Initially, slight irritability may occur; upon subsequent doses, sweating will occur and recovery follows.
[Wang Hu] This is a modified formula of Xiao Chai Hu Tang (Minor Galla Decoction). According to the original modification rules: If there is irritability in the chest without vomiting, remove Ban Xia and Ren Shen, add Gua Lou Shi. If thirsty, remove Ban Xia. Here, irritability, thirst, and no vomiting lead to removing Ren Shen and Ban Xia, adding 4 liang of Gua Lou Gen. If there is fullness and hardness under the hypochondrium, remove Da Zao, add Mu Li. Here, fullness and slight binding in the chest and hypochondrium equate to fullness and hardness, so Da Zao is removed and 2 liang of Mu Li added. If there is palpitations and difficulty in urination, remove Huang Qin, add Fu Ling. Here, difficulty in urination exists without palpitations but with irritability, indicating fluid deficiency and restless heat, not water accumulation; thus, Huang Qin is retained and Fu Ling not added. Also, if coughing, remove Ren Shen, Da Zao, Sheng Jiang, add Wu Wei Zi and Gan Jiang. Here, Gan Jiang replaces Sheng Jiang despite no cough. Why? Gan Jiang is acrid and hot, serving two purposes: first, acridity disperses the slight binding in the chest and hypochondrium; second, heat balances the bitter-cold nature of Huang Qin and Gua Lou Gen, harmonizing Yin and Yang to stop chills and fever.
*Jingui Yaolue* Appendix, *Waitai Miyao*: Chai Hu Gui Jiang Tang treats malaria with predominant chills and slight fever, or only chills without fever. One dose works miraculously. ([Commentary] Cannot be verified in current *Waitai Miyao*.)
*Huo Ren Shu*: Gan Jiang Chai Hu Tang treats women with Shaoyang disease whose menstruation has just stopped, presenting with chills and fever like malaria, delirium, and seeing ghosts. (i.e., this formula, without Huang Qin.)
After five or six days of Shaoyang disease, with sweating from the head, slight aversion to cold, cold hands and feet, fullness in the epigastrium, desire not to eat, hard stools, and a fine pulse, this is Yang Mild Binding. There must be an exterior syndrome and an interior syndrome. A deep pulse also indicates interior involvement. Sweating indicates Yang mildness. If it were pure Yin Binding, there would be no exterior symptoms, all entering the interior. This is half in the interior, half in the exterior. Although the pulse is deep and tight, it cannot be diagnosed as Shaoyin disease. The reason is that Yin syndromes do not present with sweating; now there is sweating from the head, so it is known not to be Shaoyin. Xiao Chai Hu Tang (Minor Galla Decoction) may be given. If the patient still feels unwell after taking it, recovery comes with defecation. (*Yu Han Jing*: "in the interior" is written as "disease in the interior".)
[You Yiren] This discusses Shaoyang disease resembling Shaoyin; one must carefully distinguish the pulse and symptoms. [Cheng Wuji] After five or six days of Shaoyang disease, when the pathogen should transmit to the interior, sweating from the head and slight aversion to cold indicate the exterior is still unresolved. Cold hands and feet, fullness in the epigastrium, desire not to eat, hard stools, and fine pulse indicate pathogen binding in the interior. Hard stools indicate Yang Binding. Although the pathogenic heat has transmitted to the interior, because it carries exterior pathogen, the heat binding is shallow, hence "Yang Mild Binding." A deep pulse indicates interior involvement, but if it were pure Yin Binding, there would be no head sweating or aversion to cold exterior symptoms. All Yin pulses return at the neck and chest, not ascending to the head. Now there is head sweating, so it is not Shaoyin. Give Xiao Chai Hu Tang (Minor Galla Decoction) to eliminate pathogens between the exterior and interior. After taking the decoction, if exterior symptoms cease but the patient still feels unwell, it is because interior heat remains; giving the decoction to induce mild purgation cures it. Hence, "recovery with stool." [Cheng Lin] Interior heat, constrained and unable to vent outward, causes head sweating. Exterior cold, persisting and unable to disperse, causes slight aversion to cold. The two pathogens repel each other, indicating Yang Qi stagnation forming binding. Precisely because Yang Qi is constrained and stagnant, there are cold hands and feet, epigastric fullness, desire not to eat, and hard stools. Having binding symptoms forms binding pulses, hence the fine pulse.
This is what is meant by "Yang syndrome resembling Yin." Any fine, deep, or tight pulse is a diagnosis of Yang-heat constraint, unrelated to Shaoyin. Thus, once Yang Qi is constrained, not only does the Yang syndrome resemble Yin, but the Yang pulse also resembles Yin. Relying solely on head sweating, the person's Yang Qi constraint must accompany bitter taste, dry throat, and vertigo. Regarding other half-exterior symptoms, merely examining slight aversion to cold allows diagnosing Shaoyang disease even without all alternating chills and fever symptoms, permitting the use of Xiao Chai Hu Tang (Minor Galla Decoction). Recovery with stool implies considering Da Chai Hu Tang (Greater Galla Decoction) or Chai Hu Jia Mang Xiao Tang (Bupleurum plus Gypsum Decoction) as options.
[Commentary] Sweating indicates Yang mildness. Xi Ju states: Sweating indicates Taiyang exterior Qi deficiency and mildness, different from the "mild" in Yang Mild Binding. Qian Huang considers "Yang mild binding" and "sweating indicates Yang mildness" as both meaning Yang Qi decline. Wang Hu merges the lower "Yang mild" into "Yang Mild Binding," all deviating. You Yiren states: Fine pulse should be deep and fine; knowing this from the word "also" in "Deep pulse is also in the interior" below. The "tight" in "Although deep and tight" should be "fine." There is no "tight" earlier in the text; how can it say "although deep and tight"? The word "although" makes no sense. It must be a transcription error. This discussion is unnecessary.
[Commentary] Wang Hu states: *Bu Wang Lun*, Guo Baiyun says: Excess type uses Da Chai Hu Tang (Greater Galla Decoction); deficiency type uses Honey Suppository. This view is correct. Inferring Cheng Wuji's intent, it should be Tiao Wei Cheng Qi Tang (Regulate the Waist and Direct Downward Decoction). *Ben Shi Fang* records: A patient had Shaoyang disease for five or six days, sweating from the head, no sweat from neck down, cold hands and feet, epigastric oppression, constipation. Some saw cold limbs and sweating with oppression, assuming Yin syndrome. I palpated the pulse: deep and tight. I said: This case is indeed suspicious, but constipation is not deficiency binding; how can it be a Yin pulse? Although deep and tight suggests Shaoyin, it usually presents with diarrhea, rarely constipation. I considered this half-interior, half-exterior; administered Xiao Chai Hu Tang (Minor Galla Decoction) and cured. Zhang Zhongjing's description of Shaoyang disease for five or six days with head sweating matches this case, hence "recovery with stool."
After five or six days of Shaoyang disease, with vomiting and fever, the Xiao Chai Hu Tang (Minor Galla Decoction) syndrome is complete, but other drugs were used to purge. If the Xiao Chai Hu syndrome persists, administer Xiao Chai Hu Tang (Minor Galla Decoction) again. Although purged, this is not adverse. The patient will inevitably experience vigorous shaking and trembling, followed by fever and sweating, leading to resolution. If the epigastrium is full and painfully hard, this is Jie Xiong (Chest Binding), treated with Da Xian Xiong Tang (Major Chest Draining Decoction). If only full without pain, this is Pi Syndrome (Stagnation Syndrome); Xiao Chai Hu Tang (Minor Galla Decoction) is not suitable; Ban Xia Xie Xin Tang (Pinellia Drain the Epigastrium Decoction) is indicated. (*Waitai Miyao*: This clause reads Taiyang disease purged, pulse rapid, no Chest Binding, indicating impending resolution. If epigastrium is full and painfully hard, this is Chest Binding, treated with Da Xian Xiong Tang. If only full without pain, this is Pi Syndrome; Xiao Chai Hu Tang is not suitable; Ban Xia Xie Xin Tang is indicated. *Yu Han Jing*: No "zhe" after "fa re." "Yi" becomes "yi." "Dan" becomes "ruo." "Bu zhong yu zhi" becomes "bu zhong fu yu zhi.")
[Zhang Zhicong] This section divides into three parts. The first part states that if Xiao Chai Hu syndrome is complete, purging is not adverse, and Xiao Chai Hu Tang can be given again. The second part states that purging leads to Chest Binding, treated with Da Xian Xiong Tang. The third part states that Pi Syndrome presents with fullness but no pain; Xiao Chai Hu Tang is contraindicated, and Ban Xia Xie Xin Tang is indicated. [Ke Qin] Vomiting and fever constitute the Xiao Chai Hu syndrome. Frequent vomiting, even with Yangming symptoms, prohibits purging. If purging is necessary, Da Chai Hu Tang (Greater Galla Decoction) is appropriate. Using other drugs to purge is erroneous. After erroneous purging, two outcomes arise: Shaoyang is the channel between exterior and interior, emitting neither fully Yang nor fully Yin; thus, post-purging complications depend on bias. Bias toward the exterior forms Chest Binding; bias toward the interior forms Epigastric Pi. This clause originates from the indication for Ban Xia Xie Xin Tang, distinguishing Chest Binding from Pi solely by pain vs. no pain, omitting other symptoms. [Qian Huang] "Other drugs" refers to Cheng Qi Tang types, not distinct herbs. "Zheng Zheng" describes body heat and impending sweat. "Zhen" describes trembling, i.e., rigors. Post-purification Qi deficiency makes overcoming pathogens difficult, necessitating rigor before sweating. [Wei Litong] Chest Binding does not mention contraindicating Xiao Chai Hu Tang; Pi Syndrome explicitly states Xiao Chai Hu Tang is contraindicated. Why? Chest Binding is obvious and easy to recognize; Pi Syndrome is subtle and hard to recognize, closely resembling the "Zhi Jie" mentioned in the previous clause, hence explicitly stated for detailed clarification.
Ban Xia Xie Xin Tang Formula
Huang Qin (Scutellariae Radix)
Gan Jiang (Zingiberis Rhizoma)
Ren Shen (Ginseng Radix)
Gan Cao (Licorice Radix et Rhizoma), prepared, each 3 liang
Ban Xia (Pinelliae Tuber) 1/2 sheng, washed (*Waitai* note: another version 5 liang)
Huang Lian (Coptidis Rhizoma) 1 liang
Da Zao (Ziziphi Jujubae Fructus) 12 pieces, split (*Yu Han Jing* records 16 pieces)
The above seven ingredients are boiled in 10 sheng of water to obtain 6 sheng. Strain, decoct again to obtain 3 sheng. Take 1 sheng warm, three times daily. If Da Xian Xiong Tang is required, use the second method above (decoct again). The Cost Edition and *Yu Han Jing* write "decoct again" as "boil again." The twelve characters following "Xu" are absent in the Cost Edition.
[Cheng Lin] Although "Xie Xin" is similar, the presence of vomiting requires specifically draining fluid retention, hence named after Ban Xia. "Xie Xin" means fullness is in the Qing Yang position of the epigastrium; heat pathogen combined with fluid retention has not yet solidified. Thus, clearing heat and draining fluid allows Qi in the epigastrium to pass freely, eliminating obstruction above and below, naturally interacting Yin and Yang. However, the pivot relies entirely on the Stomach; thus, tonifying Stomach deficiency provides mediation. This differs greatly from clearing accumulated fullness in cases of excess heat entering the Stomach. Pi is a deficiency pathogen where exterior Qi enters the interior, transforming cold into heat. Although cold transforms to heat, the heat is not excess. Thus, bitter-cold herbs clear heat, while acrid-sweet herbs tonify deficiency. There is no need to attack Pi directly; Pi dissipates naturally. Hence, cold and hot herbs are used together in one formula. [Ke Qin] This is Xiao Chai Hu Tang (Minor Galla Decoction) minus Chai Hu, plus Huang Lian and Gan Jiang. Absence of alternating chills and fever indicates no half-exterior symptom, hence no Chai Hu. Pi forms from mutual binding of cold and heat Qi; using the extreme cold of Huang Lian and extreme heat of Gan Jiang resolves both. [Wu Qian] Straining and decocting again ensures medicinal properties merge uniformly, staying in the Stomach, spreading with Stomach Qi, harmonizing the interior unknowns.
*Yi Fang Kao* states: Premature purging in Shaoyang disease injures Middle Qi, allowing pathogen to exploit it, preventing ascending clear and descending turbid functions, causing obstruction in the middle, like Heaven and Earth not interacting forming the Hexagram Pi. Hence called Pi. "Xie Xin" means draining pathogen from the epigastrium. Acridity of Ginger and Pinellia disperses Pi Qi; bitterness of Scutellaria and Coptis drains Pi Heat. Post-purging, Spleen Qi is definitely deficient; Ginseng, Licorice, and Jujube tonify Spleen deficiency.
*Shaoyang Xuanlu* states: Whenever "Xie Xin" is mentioned, it means Shaoyang pathogen is about to enter Taiyin; pathogen is below the chest, not affecting the Heart Channel. *Shaoyang Yunyao* states: "Xie Xin" does not drain Heart Fire heat, but drains epigastric Pi fullness.
*Qianjin Fang · Xin Xu Shi Men*: Xie Xin Tang treats diarrhea in young and old, undigested food, borborygmus, epigastric fullness, dry retching, and unrest. (i.e., this formula)
Post-boiling instructions: Also treats Cholera. If cold, add 1 Fuzi; if thirsty, add 2 liang Gua Lou Gen; if vomiting, add 1 liang Ju Pi; if painful, add 1 liang Dang Gui. For external heat, replace Gan Jiang with Sheng Jiang.
Cold Dysentery Section: Xie Xin Tang treats sudden severe hot diarrhea, dry lips and mouth, retching with drinking urge.
Modify this formula by removing Da Zao, adding Gua Lou Gen and Ju Pi. (Note: Cites Hu Qian, text same as Heart Deficiency-Excess section, except stating Zhang Zhongjing used 12 pieces of Da Zao.)
*Sanyin Fang · Xin Shi Re Men*: Xie Xin Tang treats Heart Excess Heat, epigastric fullness, heavy body with fever, dry retching, unrest, borborygmus, difficult urination and defecation, undigested food, urge to vomit without vomiting, vexation, stifling sensation, wheezing, and urgency.
Modify this formula by removing Da Zao.
When Taiyang and Shaoyang diseases coexist, erroneous purging leads to Chest Binding, hardness in the epigastrium, incessant diarrhea,
inability to swallow liquids, and irritability. (*Yu Han Jing*, *Mai Jing*: "Li" has "Fu"; "Bu Xia" has "Ken"; "Qi Ren" has "Bi".)
[Wang Hu] Taiyang disease in the channels cannot be purged. Purging Shaoyang disease is also prohibited; hence purging is termed "erroneous." Purging allows Yang pathogen to exploit deficiency, binding upward to the chest causing epigastric hardness; descending into intestines causing incessant diarrhea; injuring Stomach causing inability to swallow liquids. Irritability indicates deficient righteous Qi and extreme pathogenic heat agitation. *Tiao Bian* suspects missing text after "Irritability." Generally, this prognosis is untreatable. Zhang Zhongjing states: If all Chest Binding symptoms are present with irritability, death ensues. How much more so with diarrhea and inability to swallow liquids? Being untreatable is appropriate. [Xi Ju] For such cases, heavy warming and tonification are suitable; even Xiao Xian Xiong Tang (Minor Chest Draining Decoction) is contraindicated.
[Commentary] From Yu Jia Yan onwards, this clause is considered a death syndrome. Only Qian Huang states: I fear not all are death cases; perhaps there is a treatment method, unknown. One should roughly search for life-saving methods among Zhang Zhongjing's various irritability clauses.
Pulse floating and tight, followed by erroneous purging, the tight pulse retreats into the interior, forming Pi (Stagnation). Palpation reveals softness; it is merely Qi Pi. (*Yu Han Jing*: "Fu" becomes "Fan".)
[Fang Youzhi] "Ru" is synonymous with "Ruan," interchangeable in ancient texts. "Fu" also means "Fan." "Tight pulse retreating into interior" means cold pathogen turns inward. "Ru" means not hard, not painful, but soft. "Pi" means Qi obstruction causing stagnation. [Qian Huang] Floating and tight pulse: floating indicates exterior, tight indicates cold. This is headache, fever, body and waist pain, aversion to wind, anhidrosis, the pulse of cold pathogen in the exterior, Ma Huang Tang (Ephedra Decoction) syndrome. "And then purged" means not resolving via sweating but erroneously purging. "Tight pulse retreating into interior" means the cold pathogen of the previously observed tight pulse, due to deficiency from erroneous purging, sinks into the interior, causing epigastric Pi fullness. This is merely due to unresolved exterior pathogen, erroneous purging causing interior deficiency, formless pathogen sinking into the interior forming Pi. Its pulse and symptoms differ, and treatments vary, distinguished in the next clause for clinical application.
[Commentary] For this clause's symptoms, Chang Qizhu advocates Xiao Xian Xiong Tang (Minor Chest Draining Decoction) and Sheng Jiang Xie Xin Tang (Fresh Ginger Drain the Epigastrium Decoction). Guo Baiyun advocates Ban Xia Xie Xin Tang (Pinellia Drain the Epigastrium Decoction) and Zhi Shi Li Zhong Wan (Immature Bitter Orange and Magnolia Bark Pill Regulating the Center). Yu Jia Yan, Cheng Lin, and Wei Litong advocate Da