〔汪〕医用丸药。此是许学士所云巴豆小丸子药。强迫溏粪而下。夫巴豆辛烈。大伤胃气。若仍用大柴胡。
则枳实大黄之峻。胃中之气。已不堪受其削矣。故易以小柴胡加芒硝汤。用人参甘草。以扶胃气。且微利之后。
溏者已去。燥者自留。加芒硝者。能胜热攻坚。又其性速下。而无碍胃气。乃一举而两得也。〔柯〕不加大黄
者。以地道原通。不用大柴胡者。以中气已虚也。后人有加大黄桑螵蛸者。大背仲景法矣。
伤寒类方曰。本草。芒硝治六腑积聚。因其利而复下之。所谓通因通用之法也。潮热而利。则邪不停结。
故较之大柴胡症。用药稍轻。
又曰不解。不大便也。此药剂之最轻者。以今秤计之。约二两。分二服。则一服止一两耳。案大柴胡汤。
加大黄枳实。乃合用小承气也。此加芒硝。乃合用调胃承气也。皆少阳阳明同治之方。○案不解。邪气不解散
也。以大便解之。恐非也。
案张锡驹云。本柴胡症。乃大柴胡也。柴胡加芒硝。亦大柴胡加芒硝也。其不言小者。大柴胡可知矣。此
说不可从。
伤寒十三日。过经谵语者。以有热也。当以汤下之。若小便利者。大盒饭硬。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。（成本。过经上。有不解二字。玉函。脉经。千金翼。谵上。有而字。以有热也。作
内有热也。千金翼。无调胃字。柯本删厥字。）
〔鉴〕此承上条。互发其义。以详其治也。〔汪〕谵语者。自言也。寒邪郁里。胃中有热。热气熏膈。则
神昏而自言也。谵语有热。法当以汤荡涤之。若小便利者。津液偏渗。大盒饭坚硬而不出。今反下利。及诊其
脉又调和。而非自利之脉。知医非其治。而以丸药下之也。若其人不因误下。而自利者。其脉当微。而手足见
厥。此为内虚。不可下也。今脉反和。反和者。言其脉与阳明腑证不相背之意。若脉果调和。则无病矣。此为
内实。故见谵语下利等证。与调胃承气汤者。以下胃中之实热也。肠中坚实之物不能去。所下者旁流溏垢耳。
据仲景法。下利谵语者。有燥屎也。宜小承气汤。今改用调胃者。以医误下之故。内实不去。胃气徒伤。故于
小承气汤。去浓朴枳实。而加甘草。以调和之也。因大便坚实。以故复加芒硝。〔锡〕若胃气虚寒。而自利者。
脉当微厥。厥者。脉初来大。渐渐小。更来渐渐大也。
成云。当以诸承气汤下之。钱云。曰汤而不曰承气者。以上四句。是起下文语。乃借客形主之词。故在
所忽也。案汪注。脉微而手足厥。本于成注。锡驹以厥为脉状。出于不可下编。钱氏云。微厥者。忽见微细也。
微厥则正气虚衰。真阳欲亡。乃虚寒之脉证也。意与锡驹同。此他诸家并与成注同。
太阳病不解。热结膀胱。其人如狂。血自下。下者愈。其外不解者。尚未可攻。当先解其外。外解已。
但少腹急结者。乃可攻之。宜桃核承气汤。（【原注】后云解外。宜桂枝汤。○玉函。自上。有必字。愈上。
有即字。成本。解下。无其字。脉经。其外下。有属桂枝汤证五字。千金翼同。）
〔成〕太阳。膀胱经也。太阳经邪热不解。随经入腑。为热结膀胱。其人如狂者。为未至于狂。但不宁尔。
经曰。其人如狂者。以热在下焦。太阳多热。热在膀胱。必与血相搏。若血不为蓄。为热迫之。则血自下。血
下则热随血出而愈。若血不下者。则血为热搏。蓄积于下。而少腹急结。乃可攻之。与桃核承气汤。下热散血。
〔柯〕冲任之血。会于少腹。热极而血不下而反结。故急。然病自外来者。当先审表热之轻重。以治其表。继
用桃核承气。以攻其里之结血。〔汪〕解其外。补亡论。郭白云采千金方云。宜桂枝汤。及考内台方议云。若其
外证不解。或脉带浮。或恶寒。或身痛等证。尚未可攻。且与葛根汤。以解其外。二汤。皆太阳病解外之药。
学人宜临证消息用之。（案金鉴。当先以麻黄汤解外。）〔钱〕注家有血蓄膀胱之说。尤为不经。盖太阳在经之
表邪不解。故热邪随经。纳入于腑。而瘀热结于膀胱。则热在下焦。血受煎迫。故溢入回肠。其所不能自下者。
蓄积于少腹。而急结也。膀胱为下焦清道。其蒸腾之气。由气化而入。气化而出。未必能藏蓄血也。若果膀胱
之血。蓄而不行。则膀胱瘀塞。所谓少腹硬满。小便自利者。又何自出乎。有识者不为然也。
案伤寒类方曰。当先解外。宜桂枝汤。注云。宜桂枝汤四字。从金匮增入。然金匮无所考。活人书亦云。
宜桂枝汤。总病论曰。不恶寒。为外解。
桃核承气汤方（○玉函。作桃仁承气汤。脉经同。案桃核。即是桃仁。犹杏子杏仁。）
桃仁（五十个去皮尖） 大黄（四两） 桂枝（二两去皮） 甘草（二两炙） 芒硝（二两○千金翼。一两）
上五味。以水七升。煮取二升半。去滓。纳芒硝。更上火微沸下火。先食温服五合。日三服。当微利。（玉
函。作先煮四
味。取二升半。去滓。纳硝。更煮微沸。温服云云。千金翼。作更煎一沸。分温三服。）
〔成〕少腹急结。缓以桃仁之甘。下焦蓄血。散以桂枝辛热之气。故加二物于调胃承气汤中也。〔钱〕神
农本经。桃仁主瘀血血闭。洁古云。治血结血秘。通润大肠。破硝血。大黄下瘀血积聚。荡涤肠胃。推陈致新。
芒硝走血软坚。热淫于内。治以咸寒之义也。桂之为用。通血脉。消瘀血。尤其所长也。甘草所以保脾胃。和
大黄芒硝之寒峻耳。
医方考曰。伤寒外证已解。小腹急。大便黑。小便利。其人如狂者。有蓄血也。此方主之。无头痛发热恶
寒者。为外证已解。小腹急者。邪在下焦也。大便黑者。瘀血渍之也。小便利者。血病而气不病也。上焦主阳。
下焦主阴。阳邪居上焦者。名曰重阳。重阳则狂。今瘀热客于下焦。下焦不行。则干上部清阳之分。而天君不
宁矣。故其证如狂。桃仁润物也能润肠而滑血。大黄行药也。能推陈而致新。芒硝咸物也。能软坚而润燥。甘
草平剂也。能调胃而和中。桂枝辛物也。能利血而行滞。又曰。血寒则止。血热则行。桂枝之辛热。君以桃仁
硝黄。则入血而助下行之性矣。斯其制方之意乎。
案方中用桂枝。方氏喻氏程氏汪氏柯氏魏氏并云。以太阳随经之热。原从表分传入。非桂枝不解耳。恐不
尔。本草序例曰。病在胸膈以上者。先食后服药。病在心腹以下者。先服药而后食。
伤寒类方曰。微利。则仅通大便。不必定下血也。
柯氏方论曰。此方。治女子月事不调。先期作痛。与经闭不行者。最佳。
外台。古今录验。疗往来寒热。胸胁逆满。桃仁承气汤。（即本方）
总病论曰。桃仁承气汤。又治产后恶露不下。喘胀欲死。服之十瘥十。
三因阴 门。兼金丸。治热入膀胱。脐腹上下。兼胁肋疼痛。便燥欲饮水。按之痛者。本方五味为末。
蜜丸梧子大。米饮下。五七丸至十丸。妇人血闭疼痛。亦宜服之。
直指方。桃仁承气汤。治下焦蓄血。漱水迷忘。小腹急痛。内外有热。加生蒲黄。出小便不通门。
儒门事亲。夫妇人月事沉滞。数月不行。肌肉不减。内经曰。此名为瘕为沉也。沉者。月事沉滞不行也。
急宜服桃仁承气汤。加当归。大作剂料服。不过三服立愈。后用四物汤补之。
医史撄宁生传。马万户妻。体肥而气盛。自以无子。尝多服暖子宫药。积久火甚。迫血上行为衄。衄必
数升余。面赤脉躁疾。神 如痴。医者犹以治上盛下虚丹剂镇坠之。滑寿曰。经云。上者下之。今血气俱盛。
溢而上行。法当下导。奈何实实耶。即与桃仁承气汤。三四下积瘀。既去。继服既济汤。二十剂而愈。证治准
绳。撄宁生卮言云。血溢血泄。诸蓄妄证。其始也。予率以桃仁大黄。行血破瘀之剂。折其锐气。而后区别治
之。虽往往获中。犹不得其所以然也。后来四明。遇故人苏伊芳举。问论诸家之术。伊芳举曰。吾乡有善医者。每
治失血蓄妄。必先以快药下之。或问失血复下。虚何以当。则曰血既妄行。迷失故道不去蓄利瘀。则以妄为常。
曷以御之。且去者自去。生者自生。何虚之有。予闻之愕然曰。名言也。昔者之疑。今释然矣。
诸证辨疑。一妇长夏患痢疾。痛而急迫。其下黄黑色。诸医以薷苓汤。倍用枳壳黄连。其患愈剧。因请余
治。诊脉两尺脉紧而涩。知寒伤营也。细问之。妇人答曰。行经之时。渴饮冷水一碗。遂得此症。余方觉悟。
血被冷水所凝。瘀血归于大肠。热气所以坠下。遂用桃仁承气汤。内加马鞭草玄胡索。一服。次早下黑血升许。痛止脏
清。次用调脾活血之剂。其患遂痊。今后治痢。不可不察。不然。则误人者多矣。
传信尤易方。治淋血。桃仁承气汤。空心服效。
证治大还。吐血势不可遏。胸中气塞。上吐紫黑血。此瘀血内热盛也。桃仁承气汤。加减下之。打扑内
损。有瘀血者。必用。
张氏医通。虚人虽有瘀血。其脉亦芤。必有一部带弦。宜兼补以去其血。桃核承气。加人参五钱。分三
服。缓攻之。可救十之二三。
又龋齿。数年不愈。当作阳明蓄血治。桃核承气。为细末。炼蜜丸如桐子大。服之。好饮者多此。屡服有效。
伤寒八九日下之。胸满烦惊。小便不利。谵语。一身尽重。不可转侧者。柴胡加龙骨牡蛎汤主之。（下之
下。外台。有后字。脉经。千金翼。有尽重二字。）
〔张〕此系少阳之里证。诸家注作心经病。误也。盖少阳有三禁。不可妄犯。虽八九日过经下之。尚且邪
气内犯。胃土受伤。胆木失荣。痰聚膈上。故胸满烦惊。惊者。胆不宁。非心虚也。小便不利。谵语者。胃中
津液竭也。一身尽重者。邪气结聚痰饮于胁中。故令不可转侧。主以小柴胡。和解内外。逐饮通津。加龙骨牡
蛎。以镇肝胆之惊。
柴胡加龙骨牡蛎汤方
柴胡（四两） 黄芩（○成本。无） 生姜（切） 铅丹（○玉函。作黄丹） 桂枝（去皮） 茯苓
（各一两半） 半夏（二合半洗○千金翼。一合。成本。二合） 大黄（二两） 大枣（六枚擘） 牡蛎（一
两半熬○外台。一两半。全书。 ） 人参 龙骨
上十二味。以水八升。煮取四升。纳大黄切如棋子。更煮一两沸。去滓。温服一升。本云柴胡汤。今加龙
骨等。（成
本。十二味。作十一味。切如棋子。玉函。无。外台。棋上。有博字。一两沸。玉函。外台。作取二升。服一
升。外台。作分再服。本云以下。玉函。作本方柴胡汤内。加龙骨牡蛎黄丹桂茯苓大黄也。今分作半剂二十四字。）
〔吴〕此汤治少阳经邪犯本之证。故于本方中。除去甘草。减大枣上行阳分之味。而加大黄行阴。以下夺
其邪。兼茯苓以分利小便。龙骨牡蛎铅丹。以镇肝胆之怯。桂枝以通血脉之滞也。与救逆汤同义。彼以龙骨牡
蛎。镇太阳经火逆之神乱。此以龙骨牡蛎铅丹。镇少阳经误下之惊烦。亦不易之定法也。
伤寒类方曰。此乃正气虚耗。邪已入里。而复外扰三阳。故现症错杂。药亦随症施治。真神化无方者也。
案此方。能治肝胆之惊痰。以之治癫痫。必效。
又曰。大黄只煮一二沸。取其生而流利也。
案汪氏云。是方也。表里齐走。补泻兼施。通涩并用。恐非仲景之旧。或系叔和采辑时。有差错者。若
临是证而用是药。吾不敢也。何也。倘谓胸满谵语。是实证。则当用大黄者。不当用人参。倘谓惊烦小便不利
身重。是虚证。则当用人参大枣茯苓龙骨等药者。不当用大黄。况龙骨牡蛎铅丹。皆系重坠收涩阴毒之品。恐
非小便不利所宜也。汪氏此说。似有所见。然而今以是方治此症。而奏效者不鲜。故未敢为得矣。
伤寒腹满谵语。寸口脉浮而紧。此肝乘脾也。名曰纵。刺期门。（玉函。脉经。满下。有而字。钱本。柯
本。周本。张本。无此及次条。）
〔成〕腹满谵语者。脾胃疾也。浮而紧者。肝脉也。脾病见肝脉。木行乘土也。经曰水行乘火。木行乘土。
名曰纵。此其类矣。期门者肝之募。刺之以泻肝经盛气。〔锡〕纵。谓纵势而往。无所顾虑也。〔鉴〕伤寒脉
浮紧。太阳表寒证也。
腹满谵语。太阴阳明里热也。欲从太阳而发汗。则有太阴阳明之里。欲从太阴阳明。而下之。又有太阳之表。
主治诚为两难。故不药而用刺法也。虽然太阴论中。太阳表不解。太阴腹满痛。而用桂枝加大黄汤。亦可法也。
此肝乘脾。名曰纵。刺期门。与上文义不属。似有遗误。
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。（水。玉函。脉经。作酢浆二字。千金翼。作截浆。）
〔成〕伤寒发热。啬啬恶寒。肺病也。大渴欲饮水。肝气胜也。玉函曰。作大渴欲饮酢浆。是知肝气胜也。
伤寒欲饮水者愈。若不愈而腹满者。此肝行乘肺。水不得行也。经曰。水行乘金名横。刺期门以泻肝之盛气。
【汪】医生使用了丸药。这就是许学士所说的巴豆小丸子药。它强迫稀便排出。巴豆辛热猛烈，严重损伤胃气。如果此时仍使用大柴胡汤，那么枳实、大黄这种峻猛的攻下药，对于已经受损的胃气来说，已经无法承受其削弱了。所以改用加芒硝的小柴胡汤。用人参、甘草来扶助胃气。而且经过轻微泻下后，稀便已经去除，燥屎自然留存。加入芒硝，能够胜热攻坚，且它的性质速下，而不伤胃气，这是一举两得的方法。【柯】不加大黄，是因为肠道原本通畅；不用大柴胡汤，是因为中气已经虚弱。后世有人加大黄、桑螵蛸的，完全违背了张仲景的法度。
《伤寒类方》说：本草记载芒硝治疗六腑积聚。因为已有通利之象而再次用泻下法，这就是“通因通用”的治疗方法。出现潮热并伴有腹泻，说明邪气没有停聚结块。所以相比大柴胡汤证，用药稍微轻一些。
又说：“不解”，是指大便不通畅。这是药剂中最轻的一剂。以现在的秤计算，大约二两。分两次服用，那么每次只服一两罢了。按语：大柴胡汤加大黄、枳实，是合用小承气汤的意思。这里加芒硝，是合用调胃承气汤的意思。都是少阳阳明同治的方子。○按语：“不解”指邪气不散。认为是指大便通畅，恐怕不对。
按语：张锡驹说：本条是柴胡证，就是大柴胡汤证。柴胡加芒硝汤，也是大柴胡汤加芒硝。它不说“小”，是因为大柴胡汤显而易见。这种说法不可采纳。
伤寒过了十三天，经过传经出现谵语的，是因为有热。应当用汤药攻下。如果小便通利的，大便应当坚硬，反而出现腹泻，脉象调和的，知道医生用了丸药攻下，这不是正确的治法。如果是病人自己腹泻，脉象应当微弱或手足厥冷。现在脉象反而调和，这是体内有实邪。用调胃承气汤主治。（成本在“过经”上有“不解”二字，《玉函》、《脉经》、《千金翼》在“谵”字上有“而”字。“以有热也”作“内有热也”。《千金翼》无“调胃”二字。柯本删去“厥”字。）
【鉴】这是承接上一条，互相阐发其义，以详细说明治法。【汪】谵语，是病人自言自语。寒邪郁结在里，胃中有热，热气熏蒸胸膈，导致神志昏乱而自言自语。谵语属于有热，按照法度应当用汤药荡涤。如果小便通利，津液偏渗于膀胱，大便应当坚硬而排不出。现在反而腹泻，且诊察脉象又调和，而不是自利（虚寒腹泻）的脉象，知道医生不是正确治疗，而是用丸药攻下。如果这个人不是因为误下而自利，他的脉应当微弱，且手足见厥冷，这是内虚，不可攻下。现在脉象反而调和，“反和”的意思是说脉象与阳明腑实证不相违背。如果脉果真是平和无病，那就没病了。这是体内有实邪，所以出现谵语、下利等症状。给予调胃承气汤，是为了攻下胃中的实热。肠中坚硬的燥屎不能去除，所下的只是旁流的稀溏污秽之物。根据仲景的法度，下利伴谵语的，是有燥屎，宜用小承气汤。现在改用调胃承气汤，是因为医生误下，内实未去，徒然伤了胃气。所以在小承气汤中去掉厚朴、枳实，加上甘草来调和。因为大便坚实，所以再加芒硝。【锡】如果胃气虚寒而自利，脉应当微弱厥冷。厥，是指脉初来时大，渐渐变小，再来的时候又渐渐变大。
成无己说：应当用各种承气汤攻下。钱潢说：说用“汤”而不说“承气”，是因为前四句是引出下文的话，是借客人来衬托主人的词句，所以容易被忽略。按语：汪注中“脉微而手足厥”，源于成注。张锡驹将“厥”解释为脉状，出自《不可下编》。钱氏说，“微厥”是忽见微细。微厥则正气虚衰，真阳欲亡，这是虚寒的脉证。意思与张锡驹相同。其他各家都与成注相同。
太阳病如果不解，热邪结聚在膀胱。病人神情如狂。如果血自行排出，排出后就痊愈了。如果表证仍未解除，还不可以攻里。应当先解表。表证解除后，只有少腹急迫结滞的，才可以攻里。宜用桃核承气汤。（【原注】后文说解外，宜桂枝汤。○《玉函》从“自”字上有“必”字。“愈”字上有“即”字。成本在“解”字下无“其”字。《脉经》在“其外”下有“属桂枝汤证”五字。《千金翼》同。）
【成】太阳，是膀胱经。太阳经的邪热不解，随经传入腑，成为热结膀胱。病人神情如狂，是指还没到真正发狂的程度，只是不安宁而已。经文说：病人如狂，是因为热在下焦。太阳多热，热在膀胱，必定与血相搏。如果血不被蓄积，被热逼迫，就会自行排出。血排出则热随血出而痊愈。如果血不排出，则血被热搏结，蓄积在下焦，导致少腹急结，才可以攻里。给予桃核承气汤，下热散血。
【柯】冲任之血会聚于少腹。热极而血不下行反而结聚，所以急迫。然而病从外来，应当先审察表热的轻重，以治疗表证。继之用桃核承气汤攻里之结血。
【汪】解其外，《补亡论》引郭白云采自《千金方》，说宜桂枝汤。及考《内台方议》说：如果外证不解，或者脉带浮，或者恶寒，或者身痛等证，还不可以攻里。暂且用葛根汤解外。这两张汤，都是太阳病解外的药。学者应当临证斟酌使用。（按语：《金鉴》认为当先用麻黄汤解外。）
【钱】注家有关于血蓄膀胱的说法，尤其是不合常理的。盖太阳在经的表邪不解，所以热邪随经，纳入于腑，而瘀热结于膀胱，则热在下焦。血受热煎迫，所以溢入回肠。其中不能自行排出的，蓄积于少腹，而急结。膀胱是下焦的清道，其蒸腾之气，由气化而入，由气化而出，未必能藏蓄血。如果确实是膀胱的血蓄积不行，则膀胱瘀塞，所谓少腹硬满、小便自利的情况，又从哪里出来呢？有见识的人不以为然。
按语：《伤寒类方》说：当先解外，宜桂枝汤。注解说：“宜桂枝汤”四字是从《金匮》增入的。然而《金匮》无可考证。《活人书》也说宜桂枝汤。《总病论》说：不恶寒，就是外解。
桃核承气汤方（○《玉函》作桃仁承气汤。《脉经》同。按：桃核即是桃仁，就像杏子与杏仁一样。）
桃仁（五十个，去皮尖） 大黄（四两） 桂枝（二两，去皮） 甘草（二两，炙） 芒硝（二两○《千金翼》一两）
以上五味药，用水七升，煮取二升半，去渣，纳芒硝，再上火微沸后下火。饭前温服五合，每日三次。应当轻微腹泻。（《玉函》作先煮四味，取二升半，去渣，纳硝，更煮微沸，温服云云。《千金翼》作更煎一沸，分温三服。）
【成】少腹急结，用桃仁之甘缓急。下焦蓄血，用桂枝辛热之气消散。所以在调胃承气汤中加入这两味药。【钱】《神农本草经》：桃仁主瘀血血闭。洁古说：治血结血秘，通润大肠。破硝血，大黄下瘀血积聚，荡涤肠胃，推陈致新。芒硝走血软坚。热淫于内，治以咸寒的道理。桂枝的作用，通血脉，消瘀血，更是其所长。甘草所以保脾胃，调和黃连、芒硝的寒峻之性。
《医方考》说：伤寒外证已解，小腹急，大便黑，小便利，病人如狂的，是有蓄血。此方主治。无头痛发热恶寒者，为外证已解。小腹急者，邪在下焦。大便黑者，瘀血浸渍所致。小便利者，血病而气不病。上焦主阳，下焦主阴。阳邪居上焦者，名曰重阳。重阳则狂。现在瘀热客于下焦，下焦不行，则干扰上部清阳之分，而心神不宁。所以症状如狂。桃仁是润物，能润肠滑血。大黄是行药，能推陈致新。芒硝是咸物，能软坚润燥。甘草是平剂，能调胃和中。桂枝是辛物，能利血行滞。又说：血寒则止，血热则行。桂枝的辛热，君以桃仁、硝、黄，则入血而助下行性子。这就是制方的用意吧。
按语：方中用桂枝，方氏、喻氏、程氏、汪氏、柯氏、魏氏都说：因为太阳随经之热，原本从表分传入，非桂枝不解。恐怕不是这样。《本草序例》说：病在胸膈以上者，先食后服药。病在心腹以下者，先服药而后食。
《伤寒类方》说：微利，则仅通大便，不一定下血。
柯氏《方论》说：此方治疗女子月经不调，先期作痛，以及经闭不行的，最佳。
《外台》、《古今录验》：治疗往来寒热，胸胁逆满。桃仁承气汤。（即本方）
《总病论》说：桃仁承气汤，又治疗产后恶露不下，喘胀欲死。服之十次治愈十次。
《三因极一病证方论·阴门》：兼金丸，治疗热入膀胱，脐腹上下，兼胁肋疼痛，便燥欲饮水，按之痛的。用本方五味药为末，蜜丸梧子大，米饮送下，五七丸至十丸。妇人血闭疼痛，也宜服用。
《直指方》：桃仁承气汤，治疗下焦蓄血，漱水不欲咽，健忘，小腹急痛，内外有热。加生蒲黄。出自小便不通门。
《儒门事亲》：夫妇人月经沉滞，数月不行，肌肉不减。《内经》说：这名为瘕，为沉。沉者，月经沉滞不行。急宜服桃仁承气汤，加当归，大作剂料服。不过三服立愈。后用四物汤补之。
《医史·撄宁生传》：马万户妻，体肥而气盛，自认为无子，曾多服暖子宫药。积久火甚，迫血上行为衄血。衄血必数升余，面赤脉躁疾，神志痴呆如痴。医者还用治上盛下虚的丹剂镇坠。滑寿说：经云：上者下之。现在血气俱盛，溢而上行，法当下导。奈何实其实呢？即给予桃仁承气汤。三四次下积瘀。既去，继服既济汤。二十剂而愈。《证治准绳·撄宁生卮言》说：血溢血泄，诸蓄妄证，起初，我率用桃仁大黄行血破瘀之剂，折其锐气，而后区别治之。虽往往获中，犹不得其所以然也。后来到了四明，遇故人苏伊芳举，问论诸家之术。伊芳举说：吾乡有善医者，每治失血蓄妄，必先以快药下之。或问失血复下，虚何以当？则曰：血既妄行，迷失故道，不去蓄利瘀，则以妄为常，曷以御之？且去者自去，生者自生，何虚之有？予闻之愕然曰：名言也。昔者之疑，今释然矣。
《诸证辨疑》：一妇长夏患痢疾，痛而急迫，其下黄黑色。诸医以薷苓汤，倍用枳壳黄连，其患愈剧。因请余治。诊脉两尺脉紧而涩，知寒伤营也。细问之，妇人答曰：行经之时，渴饮冷水一碗，遂得此症。余方觉悟。血被冷水所凝，瘀血归于大肠，热气所以坠下。遂用桃仁承气汤，内加马鞭草、玄胡索。一服，次早下黑血升许，痛止脏清。次用调脾活血之剂，其患遂痊。今后治痢，不可不察。不然，则误人者多矣。
《证治大还》：吐血势不可遏，胸中气塞，上吐紫黑血。此瘀血内热盛也。桃仁承气汤，加减下之。打扑内损，有瘀血者，必用。
《张氏医通》：虚人虽有瘀血，其脉亦芤。必有一部带弦。宜兼补以去其血。桃核承气，加人参五钱，分三服，缓攻之。可救十之二三。
又龋齿，数年不愈，当作阳明蓄血治。桃核承气，为细末，炼蜜丸如桐子大，服之。好饮者多此。屡服有效。
伤寒八九日，下之，胸满烦惊，小便不利，谵语，一身尽重，不可转侧者，柴胡加龙骨牡蛎汤主之。（下之下，《外台》有“后”字。《脉经》、《千金翼》有“尽重”二字。）
【张】这是少阳的里证。诸家注作心经病，误也。盖少阳有三禁，不可妄犯。虽八九日过经下之，尚且邪气内犯，胃土受伤，胆木失荣，痰聚膈上，故胸满烦惊。惊者，胆不宁，非心虚也。小便不利，谵语者，胃中津液竭也。一身尽重者，邪气结聚痰饮于胁中，故令不可转侧。主以小柴胡，和解内外，逐饮通津。加龙骨牡蛎，以镇肝胆之惊。
柴胡加龙骨牡蛎汤方
柴胡（四两） 黄芩（○成本无） 生姜（切） 铅丹（○《玉函》作黄丹） 桂枝（去皮） 茯苓（各一两半） 半夏（二合半洗○《千金翼》一合，成本二合） 大黄（二两） 大枣（六枚擘） 牡蛎（一两半熬○《外台》一两半，《全书》...） 人参 龙骨
以上十二味药，用水八升，煮取四升，纳大黄切如棋子，更煮一两沸，去滓，温服一升。本云柴胡汤，今加龙骨等。（成本十二味，作十一味。切如棋子。《玉函》无。《外台》棋上有博字。一两沸，《玉函》、《外台》作取二升，服一升。《外台》作分再服。本云以下，《玉函》作本方柴胡汤内，加龙骨牡蛎黄丹桂茯苓大黄也。今分作半剂二十四字。）
【吴】此汤治少阳经邪犯本之证。故于本方中，除去甘草，减大枣上行阳分之味，而加大黄行阴，以下夺其邪。兼茯苓以分利小便。龙骨牡蛎铅丹，以镇肝胆之怯。桂枝以通血脉之滞也。与救逆汤同义。彼以龙骨牡蛎，镇太阳经火逆之神乱。此以龙骨牡蛎铅丹，镇少阳经误下之惊烦。亦不易之定法也。
《伤寒类方》说：此乃正气虚耗，邪已入里，而复外扰三阳，故现症错杂，药亦随症施治，真神化无方者也。
又说：大黄只煮一二沸，取其生而流利也。
按语：汪氏说：是方也，表里齐走，补泻兼施，通涩并用，恐非仲景之旧。或系叔和采辑时，有差错者。若临是证而用是药，吾不敢也。何也？倘谓胸满谵语，是实证，则当用大黄者，不当用人参。倘谓惊烦小便不利身重，是虚证，则当用人参大枣茯苓龙骨等药者，不当用大黄。况龙骨牡蛎铅丹，皆系重坠收涩阴毒之品，恐非小便不利所宜也。汪氏此说，似有所见。然而今以是方治此症，而奏效者不鲜，故未敢为得矣。
伤寒腹满谵语，寸口脉浮而紧，此肝乘脾也。名曰纵。刺期门。（《玉函》、《脉经》满下有而字。钱本、柯本、周本、张本无此及次条。）
【成】腹满谵语者，脾胃疾也。浮而紧者，肝脉也。脾病见肝脉，木行乘土也。经曰：水行乘火，木行乘土，名曰纵。此其类矣。期门者肝之募，刺之以泻肝经盛气。
【锡】纵，谓纵势而往，无所顾虑也。
【鉴】伤寒脉浮紧，太阳表寒证也。腹满谵语，太阴阳明里热也。欲从太阳而发汗，则有太阴阳明之里。欲从太阴阳明而下之，又有太阳之表。主治诚为两难。故不药而用刺法也。虽然太阴论中，太阳表不解，太阴腹满痛，而用桂枝加大黄汤，亦可法也。此肝乘脾，名曰纵，刺期门，与上文义不属，似有遗误。
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。（水，《玉函》、《脉经》作酢浆二字。《千金翼》作截浆。）
【成】伤寒发热，啬啬恶寒，肺病也。大渴欲饮水，肝气胜也。《玉函》曰：作大渴欲饮酢浆，是知肝气胜也。伤寒欲饮水者愈。若不愈而腹满者，此肝行乘肺，水不得行也。经曰：水行乘金名横。刺期门以泻肝之盛气。
[Wang] The physician used pill medicines. This is what Xu Xueshi referred to as "Radix Crotonis Tiglii small pills." They forcibly expel loose stools. Radix Crotonis Tiglii (Badi Dou, 巴豆) is acrid and hot, severely damaging the Stomach Qi. If Da Chai Hu Tang (Greater Bupleurum Decoction) were still used, the harshness of Rhizoma Zingiberis Preparatum (Zhishi, 枳实) and Radix Rheomi Palmati (Dahuang, 大黄) would be unbearable for the already compromised Stomach Qi. Therefore, Xiao Chai Hu Tang (Lesser Bupleurum Decoction) with added Natrii Sulfas (Mangxiao, 芒硝) is substituted. Ginseng Radix et Rhizoma (Renshen, 人参) and Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) are used to support the Stomach Qi. Moreover, after mild purgation, the loose stool has been removed, while the dry feces remain. Adding Natrii Sulfas can overcome heat and attack hardness; its nature is rapid in purging without harming the Stomach Qi. This achieves two benefits with one move. [Ke] Not adding Radix Rheomi Palmati is because the intestinal pathway was originally patent; not using Da Chai Hu Tang is because the Middle Qi is already deficient. Later physicians who added Radix Rheomi Palmati and Ootheca Mantidis (Sangpiaoxiao, 桑螵蛸) completely violated Zhang Zhongjing's principles.
*Shanghan Leifang* states: Materia Medica records that Natrii Sulfas treats accumulations in the Six Fu organs. Since there is already a tendency toward diarrhea, applying another purgative follows the method of "treating obstruction with draining methods" (Tong Yin Tong Yong). With tidal fever accompanied by diarrhea, it indicates that the pathogenic factor is not stagnant or knotted. Thus, compared to the Da Chai Hu Tang syndrome, the medication is slightly milder.
It also says: "Not resolved" refers to bowel movements not being smooth. This is the mildest preparation among them. Calculated by modern weights, it is approximately two liang. Divided into two doses, each dose is only one liang. Note: Da Chai Hu Tang with added Radix Rheomi Palmati and Rhizoma Zingiberis Preparatum combines the effects of Xiao Cheng Qi Tang (Minor Order the Qi Decoction). Here, adding Natrii Sulfas combines the effects of Tiao Wei Cheng Qi Tang (Regulate the Stomach Order the Qi Decoction). Both are formulas treating Shaoyang and Yangming simultaneously. ○ Note: "Not resolved" means the pathogenic qi is not dispersed. Interpreting it as smooth bowel movements is likely incorrect.
Note: Zhang Xiju said: This is a Chai Hu syndrome, specifically Da Chai Hu Tang. Chai Hu Jia Mang Xiao Tang (Bupleurum Plus Natrii Sulfas Decoction) is also Da Chai Hu Tang plus Natrii Sulfas. The omission of "Xiao" (Lesser/Minor) implies Da Chai Hu Tang is understood. This interpretation should not be followed.
After thirteen days of Shanghan, passing through the stages and presenting with delirious speech due to heat, decoctions should be used to purge. If urination is free, the stool should be hard, yet diarrhea occurs instead, and the pulse is harmonious. This indicates the physician used pill medicines for purgation, which was inappropriate. If the patient had spontaneous diarrhea, the pulse should be faint or extremities cold. Now that the pulse is harmonious, this indicates internal excess. Tiao Wei Cheng Qi Tang is indicated. (Cheng Ben adds "not resolved" after "passing stages"; Yu Han, Mai Jing, Qianjin Yi add "and" before "delirious speech"; "due to heat" is written as "internal heat" in some texts; Qianjin Yi omits "Tiao Wei"; Ke Ben deletes "cold".)
[Jian] This continues the previous clause, mutually elaborating its meaning to detail the treatment. [Wang] Delirious speech involves the patient talking to themselves. Cold pathogens constrained internally generate heat in the Stomach. Heat steaming the diaphragm causes mental confusion and self-talk. Delirium due to heat requires purging with decoctions. If urination is free, fluids drain preferentially to the bladder, making the stool hard and difficult to pass. Yet now there is diarrhea, and the pulse is harmonious, unlike the pulse of spontaneous deficiency-cold diarrhea. This reveals the physician incorrectly used pill medicines for purgation. If the patient had spontaneous diarrhea without erroneous purgation, the pulse would be faint with cold extremities, indicating internal deficiency where purgation is contraindicated. Now the pulse is harmonious; "harmonious here" means the pulse aligns with Yangming Fu-excess patterns. If the pulse were truly normal, there would be no disease. This is internal excess, hence delirium and diarrhea. Tiao Wei Cheng Qi Tang is given to purge Stomach excess-heat. The solid dry feces in the intestines cannot be expelled; what passes is merely paralogous loose foul matter. According to Zhongjing's principles, diarrhea with delirium indicates dry feces, warranting Xiao Cheng Qi Tang. Here, Tiao Wei Cheng Qi Tang is used because the physician's erroneous purgation failed to remove the internal excess and injured the Stomach Qi. Thus, from Xiao Cheng Qi Tang, Cortex Magnoliae Officinalis (Houpo, 厚朴) and Rhizoma Zingiberis Preparatum are removed, and Glycyrrhizae Radix et Rhizoma is added to harmonize. Because the stool is hard, Natrii Sulfas is also added. [Xi] If Stomach Qi is deficient and cold causing spontaneous diarrhea, the pulse should be faint and cold. "Cold" (Jue) refers to the pulse initially large, gradually becoming smaller, then larger again.
Cheng Wuji stated: One should use various Cheng Qi Decoctions to purge. Qian Huang stated: It says "decoction" rather than "Cheng Qi" because the preceding four sentences introduce the following text, serving as a rhetorical device to highlight the main point, often overlooked. Note: Wang's note on "faint pulse and cold extremities" derives from Cheng's commentary. Zhang Xiju interpreted "Jue" as a pulse characteristic, from *Bu Ke Xia Bian*. Qian described "faint and Jue" as suddenly appearing fine and weak. Faint and Jue indicates righteous Qi deficiency and impending loss of True Yang, representing deficiency-cold pulse/symptoms, consistent with Zhang's view. Other commentators agree with Cheng.
If Taiyang syndrome is not resolved, heat knots in the Bladder. The patient appears manic. If blood discharges spontaneously, the condition resolves. If exterior symptoms persist, interior attacking is premature. One must first resolve the exterior. Once the exterior is resolved, if only urgency and binding in the lower abdomen remain, interior attacking may proceed. Tao He Cheng Qi Tang (Peach Kernel Order the Qi Decoction) is indicated. ([Original Note] Later text suggests resolving the exterior with Guizhi Tang. ○ Yu Han adds "must" after "from"; adds "immediately" after "resolve". Cheng Ben omits "its" after "resolve". Mai Jing adds "belongs to Guizhi Tang syndrome" five characters after "exterior". Qianjin Yi agrees.)
[Cheng] Taiyang corresponds to the Bladder meridian. Unresolved heat pathogens from the Taiyang meridian enter the Fu organ via the channel, causing heat knotting in the Bladder. "Appearing manic" means not fully manic, but restless. The Classic states: Manic appearance is due to heat in the Lower Jiao. Taiyang is prone to heat; heat in the Bladder clashes with blood. If blood is not retained but forced by heat, it discharges spontaneously. Blood discharge allows heat to exit with it, resolving the condition. If blood does not discharge, it is clamped by heat and accumulates in the Lower Jiao, causing lower abdominal urgency and binding. Only then can one attack the interior with Tao He Cheng Qi Tang to purge heat and dissipate blood stasis.
[Ke] Blood from the Chong and Ren meridians converges in the lower abdomen. Extreme heat prevents blood flow, causing binding and urgency. Since the illness originates externally, one must first assess the severity of exterior heat and treat the exterior. Subsequently, use Tao He Cheng Qi Tang to attack interior blood binding.
[Wang] Resolving the exterior: *Bu Wang Lun*, citing Guo Baiyun from *Qianjin Fang*, suggests Guizhi Tang. *Neitai Fangyi* states: If exterior symptoms persist, such as floating pulse, aversion to cold, or body pain, interior attacking is premature. Use Gegen Tang (Kudzu Decoction) to resolve the exterior. Both are formulas for resolving Taiyang exterior. Scholars should apply them based on clinical judgment. (Note: *Jin Jian* suggests Ma Huang Tang first.)
[Qian] Commentators' theory of "blood retention in the Bladder" is unreasonable. When exterior pathogens in the Taiyang channel are unresolved, heat enters the Fu organ via the channel, forming stasis-heat in the Bladder/Lower Jiao. Blood is scorced by heat and overflows into the ileum. What cannot discharge spontaneously accumulates in the lower abdomen, causing urgency. The Bladder is the clear pathway of the Lower Jiao; its vaporization enters and exits via Qi transformation; it does not store blood. If blood were truly retained in the Bladder, causing blockage, how could there be "lower abdominal hardness/fullness with free urination"? Insightful scholars disagree.
Note: *Shanghan Leifang* states: Resolve exterior first, use Guizhi Tang. Commentary notes "use Guizhi Tang" was added from *Jingui Yaolue*, though unverifiable there. *Huoren Shu* also suggests Guizhi Tang. *Zong Bing Lun* states: No aversion to cold indicates exterior resolution.
Tao He Cheng Qi Tang Formula (○ Yu Han calls it Tao Ren Cheng Qi Tang; Mai Jing agrees. Note: Tao He is Tao Ren, like Xing Zi and Xing Ren.)
Tao Ren (Peach Kernel, Semen Persicae, 50 pieces, skin and tip removed) Dahuang (Radix Rheomi Palmati, 4 liang) Guizhi (Cortex Cinnamomi, 2 liang, bark removed) Gancao (Glycyrrhizae Radix et Rhizoma, 2 liang, honey-fried) Mangxiao (Natrii Sulfas, 2 liang ○ Qianjin Yi: 1 liang)
These five ingredients, boil in 7 sheng of water to obtain 2.5 sheng. Remove dregs, add Mangxiao, boil briefly over fire, then remove from heat. Take 5 he warm before meals, three times daily. Mild purgation should occur. (Yu Han: Boil first four ingredients to 2.5 sheng, remove dregs, add Mangxiao, boil briefly, take warm. Qianjin Yi: Boil one more bubble, divide into three warm doses.)
[Cheng] Lower abdominal urgency is eased by the sweetness of Tao Ren. Lower Jiao blood stasis is dissipated by the acrid-hot nature of Guizhi. Hence these two are added to Tiao Wei Cheng Qi Tang. [Qian] *Shennong Ben Cao Jing*: Tao Ren treats blood stasis and closure. Jiegu treated blood binding and constipation, unblocking and moistening the Large Intestine. Breaking blood stasis, Dahuang purges accumulated blood stasis, cleansing the intestines, eliminating old and generating new. Mangxiao moves in blood and softens hardness. "Heat rampant within, treat with salty-cold" principle applies. Guizhi's function is unblocking vessels and dissipating stasis, its specialty. Gancao protects the Spleen and Stomach, moderating the cold harshness of Dahuang and Mangxiao.
*Yifang Kao* states: After Shanghan exterior symptoms resolve, if lower abdomen is urgent, stool is black, urination is free, and patient appears manic, this is blood retention. This formula treats it. No headache, fever, or aversion to cold indicates resolved exterior. Lower abdominal urgency indicates pathogen in Lower Jiao. Black stool indicates blood stasis infiltration. Free urination indicates blood pathology without Qi pathology. Upper Jiao governs Yang, Lower Jiao governs Yin. Yang pathogen in Upper Jiao is called Double Yang; Double Yang leads to mania. Now stasis-heat lodges in Lower Jiao; if Lower Jiao fails to circulate, it disturbs the Upper Clear Yang, causing mental unrest ("appearing manic"). Tao Ren is moistening, lubricating intestines and blood. Dahuang is moving, eliminating old and generating new. Mangxiao is salty, softening hardness and moistening dryness. Gancao is neutral, regulating Stomach and harmonizing middle. Guizhi is acrid, benefiting blood and moving stagnation. Also: Cold blood stops; hot blood moves. Guizhi's acrid-hot nature, combined with Tao Ren, Mangxiao, and Dahuang, enters the blood level to assist downward movement. This is the rationale of the formula.
Note: Regarding Guizhi in the formula, Fang, Yu, Cheng, Wang, Ke, and Wei all state: Because Taiyang heat entering via the channel originates from the exterior level, only Guizhi can resolve it. This is likely incorrect. *Bencao Xuli* states: For diseases above the diaphragm, take medicine after food; for diseases below the heart and abdomen, take medicine before food.
*Shanghan Leifang* states: Mild purgation only clears the bowels, not necessarily blood.
Ke's *Fanglun* states: This formula is best for women with irregular menstruation, early onset with pain, or amenorrhea.
*Waitai*, *Gujin Luyan*: Treats alternating chills and fever, chest/hypochondriac fullness/reversal. Tao Ren Cheng Qi Tang (i.e., this formula).
*Zong Bing Lun*: Also treats postpartum lochia retention with panting/distension nearing death. Ten cures out of ten.
*Sanyin Yimen*: Jianjin Wan treats heat entering Bladder, pain above/below umbilicus and hypochondrium, dry stool with thirst, tenderness on pressure. Powder the five ingredients of this formula, honey-pill size of wu zi. Take with rice drink, 5-10 pills. Also suitable for women with blood closure and pain.
*Zhizhi Fang*: Tao He Cheng Qi Tang treats Lower Jiao blood retention, rinsing mouth without swallowing, forgetfulness, lower abdominal urgent pain, internal/external heat. Add Sheng Puhuang. From section on urinary obstruction.
*Rumen Shiqin*: Women with stagnant menstruation, absent for months, without muscle wasting. *Neijing* calls this "Jia" or "Chen" (sunken). Chen means stagnant menstruation. Urgently take Tao He Cheng Qi Tang with Danggui, large dose. Cure within three doses. Follow with Siwu Tang to tonify.
*Yishi Yingningsheng Zhuan*: Wife of Marshal Ma, obese with vigorous Qi, took many utus-warming pills due to infertility. Long-term accumulation caused intense fire, forcing blood upward causing epistaxis (several sheng), red face, rapid/restless pulse, dementia-like state. Physicians used sedative cinnabar pills for upper excess/lower deficiency. Hua Shou said: Classic says "treat high by lowering." Now Qi and Blood are excessive, overflowing upward; law dictates downward guidance. Why reinforce excess? Prescribed Tao He Cheng Qi Tang. Three to four purgations removed accumulated stasis. Then administered Jiji Tang for twenty doses until cured. *Zhengzhi Zhunsheng Yingningsheng Zhiyan* stated: Initially, I used Tao Ren/Dahuang blood-moving/stasis-breaking agents to curb sharpness, then differentiated treatment. Though effective, I didn't understand why. Later in Siming, met friend Su Yifangju. Asked about methods. He said: My hometown has skilled physicians who treat hemorrhage/retention by first using strong purgatives. Questioned: Purge after bleeding? Won't it cause deficiency? Answer: Blood has wandered off course. If stasis isn't removed, wandering becomes normal. How to control it? Those expelled leave; those generated grow. Where is the deficiency? I was startled: Profound words! My past doubts are now cleared.
*Zhuzheng Bianyi*: A woman contracted dysentery in mid-summer, painful urgency, yellow-black stool. Physicians used Ruling Tang with doubled Zhike/Huanglian, worsening condition. Consulted me. Pulse at both Chi positions was tight and choppy, indicating Cold injuring Ying. Inquiry revealed she drank a bowl of cold water during menstruation. Realized: Blood congealed by cold, stasis returned to Large Intestine, heat dragged downward. Used Tao He Cheng Qi Tang plus Mabianncao/Xuanshusuo. One dose, next morning passed a sheng of black blood, pain stopped, bowels cleared. Then used Spleen-regulating/Blood-moving agents. Cured. Future dysentery treatment must investigate this; otherwise, many errors occur.
*Chuanxin Youyifang*: Treats hematuria. Tao He Cheng Qi Tang, taken on empty stomach, effective.
*Zhengzhi Dahuan*: Unstoppable hematemesis, chest oppression, vomiting purple-black blood. Indicates internal stasis-heat excess. Tao He Cheng Qi Tang, modified and purged. Essential for traumatic internal injury with stasis.
*Zhangshi Yitong*: Deficient persons with stasis have Koub pulse. Must have a string-taut quality in one position. Combine tonification with stasis removal. Tao He Cheng Qi Tang plus 5 qian Renshen, divided into three doses, slow attack. Can save 20-30%.
Also for dental caries lasting years: Treat as Yangming blood retention. Powder Tao He Cheng Qi Tang, honey-pill size of tung seed. Effective, especially for drinkers. Repeated use effective.
After eight to nine days of Shanghan, purgation was applied, resulting in chest fullness, vexation/fright, difficulty urinating, delirium, heaviness of the whole body, inability to turn. Chai Hu Jia Longgu Muli Tang (Bupleurum Plus Dragon Bone and Oyster Shell Decoction) is indicated. (Waitai adds "after" under "purgation"; Mai Jing/Qianjin Yi add "heaviness" characters.)
[Zhang] This is a Shaoyang interior syndrome. Commentators mistakenly attribute it to Heart meridian disease. Shaoyang has three prohibitions; do not violate them. Even after eight-nine days, purgation allowed pathogens to invade internally, injuring Stomach Earth and Gallbladder Wood. Phlegm gathers above the diaphragm, causing chest fullness, vexation, fright. Fright indicates Gallbladder unrest, not Heart deficiency. Difficulty urinating and delirium indicate exhaustion of Stomach fluids. Whole-body heaviness and inability to turn result from pathogen/phlegm-fluid knotting in the hypochondrium. Base treatment on Xiao Chai Hu Tang to harmonize interior/exterior, expel fluid, and unblock fluids. Add Longgu/Muli to calm Gallbladder/Liver fright.
Chai Hu Jia Longgu Muli Tang Formula
Chaihu (Bupleuri Radix, 4 liang) Huangqin (Scutellariae Radix, ○ Cheng Ben: none) Shengjiang (Zingiberis Rhizoma Recens, sliced) Qiandan (Galena, ○ Yu Han: Huangdan) Guizhi (Cortex Cinnamomi, peeled) Fuling (Poria, 1.5 liang each) Banxia (Pinelliae Rhizoma, 2.5 he, washed ○ Qianjin Yi: 1 he, Cheng Ben: 2 he) Dahuang (Radix Rheomi Palmati, 2 liang) Dazao (Jujubae Fructus, 6 pieces, split) Muli (Concha Ostreae, 1.5 liang, calcined ○ Waitai: 1.5 liang, Quan Shu: ...) Renshen (Ginseng Radix et Rhizoma) Longgu (Os Draconis/Fossilia Ossis Mastodi)
Twelve ingredients, boil in 8 sheng water to obtain 4 sheng. Add Dahuang cut like chess pieces, boil one-two bubbles, remove dregs, take 1 sheng warm. Originally Chai Hu Tang, now added Longgu etc. (Cheng Ben counts 11 ingredients. Cut like chess pieces. Yu Han omits. Waitai adds "Go" character before chess. One-two bubbles, Yu Han/Waitai: obtain 2 sheng, take 1 sheng. Waitai: divide into two doses. "Originally..." Yu Han: Inside this Chai Hu Tang formula, add Longgu, Muli, Huangdan, Guizhi, Fuling, Dahuang. Divide current half-dose into 24 characters.)
[Wu] This decoction treats Shaoyang channel pathogens invading the root. Thus, in the base formula, Gancao is removed, and the ascending Yang-nature of Dazao is reduced. Dahuang is added to move Yin and purge evil downward. Fuling drains urination. Longgu, Muli, Qiandan calm Gallbladder/Liver timidity. Guizhi unblocks vessel stagnation. Same principle as Niujie Tang. There, Longgu/Muli calm Sun Yang fire-reversal spirit chaos. Here, Longgu/Muli/Qiandan calm Shaoyang erroneous-purgation fright/vexation. An unchangeable fixed method.
*Shanghan Leifang* states: Righteous Qi is depleted, pathogen entered interior, disturbing Three Yang externally. Symptoms are mixed; medication adapts to symptoms. Truly miraculous and formless.
Note: This formula treats Liver/Gallbladder fright-phlegm; effective for epilepsy.
Also: Dahuang boiled only one-two bubbles to retain rawness and fluidity.
Note: Wang stated: This formula attacks interior/exterior simultaneously, tonifies/attacks together, unblocks/astringes together. Likely not Zhongjing's original. Perhaps errors by He Hanzhong during compilation. If facing this syndrome and using this medicine, I dare not. Why? If chest fullness/delirium is excess, Dahuang is appropriate, but Renshen is not. If fright/urinary difficulty/heaviness is deficiency, Renshen/Dazao/Fuling/Longgu are appropriate, but Dahuang is not. Moreover, Longgu, Muli, Qiandan are heavy, sinking, astringent, yin-toxic substances, likely unsuitable for urinary difficulty. Wang's view seems insightful. However, clinically using this formula for this syndrome yields frequent success, so I dare not claim absolute correctness.
Shanghan with abdominal fullness and delirium, Cun/Kou pulse floating and tight: This is Liver overacting on Spleen. Named "Zong" (Vertical). puncture Qimen. (Yu Han/Mai Jing add "and" after fullness. Qian/Ke/Zhou/Zhang versions omit this and next clause.)
[Cheng] Abdominal fullness and delirium are Spleen/Stomach diseases. Floating/tight is Liver pulse. Spleen disease showing Liver pulse indicates Wood overacting on Earth. Classic: Water overacting on Fire, Wood overacting on Earth, named "Zong". This is similar. Qimen is Liver Mu point; puncture to drain Liver excess Qi.
[Xi] Zong means proceeding vertically without restraint.
[Jian] Shanghan floating/tight pulse is Taiyang exterior cold. Abdominal fullness/delirium is Taiyin/Yangming interior heat. Wanting to sweat via Taiyang encounters Taiyin/Yangming interior. Wanting to purge via Taiyin/Yangming encounters Taiyang exterior. Treatment is difficult. Hence acupuncture instead of herbs. Although *Taiyin* chapter says Taiyang exterior unresolved with Taiyin abdominal fullness/pain uses Guizhi Jia Dahuang Tang, which is also applicable. This "Liver overacting on Spleen, named Zong, puncture Qimen" seems disconnected from previous text, possibly an error/omission.
Shanghan with fever, slight aversion to cold, great thirst wanting to drink, abdominal fullness, spontaneous sweating, free urination: Condition desires resolution. This is Liver overacting on Lung. Named "Heng" (Horizontal). Puncture Qimen. (Water, Yu Han/Mai Jing: Cu Jiang (vinegar juice); Qianjin Yi: Jie Jiang.)
[Cheng] Shanghan fever, slight aversion to cold: Lung disease. Great thirst wanting to drink: Liver Qi excess. Yu Han says: Wants to drink vinegar juice, confirming Liver excess. Shanghan patients wanting to drink water recover. If not recovered but abdominal fullness occurs, this is Liver overacting on Lung, Water failing to move. Classic: Water overacting on Metal named "Heng". Puncture Qimen to drain Liver excess Qi.