中有寒，胸中有热而化，腹中痛欲呕吐，故以是方主之。君黄连以清胃中之热，臣干姜以温胃中之寒，半夏降
逆，佐黄连呕吐可止，人参补中，佐干姜腹痛可除，桂枝所以安外，大枣所以培中也。然此汤寒温不一，甘苦
并投，故必加甘草协和诸药。此为阴阳相格，寒热并施之治法也。
太阳病，十日以去，脉浮细而嗜卧者，外已解也。设胸满胁痛者，与小柴胡汤；脉但浮者，与麻黄汤。
【注】太阳病十日以上无他证，脉浮细而嗜卧者，外邪已解，不须药也。设有胸满胁痛等证，则知少阳
之外邪未解，故与小柴胡汤和之。若脉但浮不细，而有头痛发热恶寒无汗等证，则仍是太阳之外邪未解，当与
麻黄汤汗之。
【按】论中脉浮细，太阳少阳脉也；脉弦细，少阳脉也；脉沉细，少阴脉也。脉浮细，身热嗜卧者，阳
也；脉沉细，身无热嗜卧者，阴也；脉缓细，身和嗜卧者，已解也，是皆不可不察也。
【集注】王肯堂曰∶此条当是太阳、少阳合病。胸满虽同，而脉浮细嗜卧，则为表邪已解，胁痛为少阳
有邪，故与小柴胡汤。若脉但浮者，又当先治太阳也，故与麻黄汤。此是设为变通之言，非为服柴胡而脉浮也。
伤寒发热，汗出不解，心中痞硬，呕吐而下利者，大柴胡汤主之。
【按】下利之“下”字，当是“不”字，若是“下”字，岂有上吐下利，而以大柴胡汤下之之理乎？
【注】伤寒发热汗出不解，表尚未已也；心中痞硬大便不利，里病又急矣。呕吐，少阳、阳明兼有之证
也。少阳、阳明两急，心中热结成痞，故以大柴胡汤，外解少阳发热未尽之表，内攻阳明成实痞硬之里也。
【按】太阳病发热汗出不解，心下痞硬，下利不呕吐者，此表里俱虚，桂枝人参汤证也。若呕吐不利者，
此表里俱实，大柴胡汤证也。彼则脉微弱，此则脉必有力也。
太阳病，过经十余日，反二三下之，后四五日，柴胡证仍在者，先与小柴胡汤。呕不止，心下急，郁郁
微烦者，为未解也，与大柴胡汤下之则愈。
【注】太阳病传过三阳之经十余日，医不随经施治，反二三下之，未致变逆，后四五日，惟见少阳寒热
往来之柴胡证仍在者，宜
先与小柴胡汤解表和里。如或不愈，其呕不止，心下满急，郁郁微烦，此为少阳表里均未解也，与大柴胡汤下
之，攻里和表，自可愈也。
【集注】方有执曰∶过经与坏病同，不知何逆，而二三下之，适所以致逆，故曰∶反也。下而又下，阳明
虽未伤，而少阳亦未除，故曰∶柴胡证仍在也。呕不止，郁郁微烦，乃邪扰二阳，故曰∶未解也。
程知曰∶此言过经误下，有用大小柴胡两解法也。盖其人之邪，因屡下而深入，若表证未罢，必先用小柴
胡和其半表，而后可兼攻其里也。
程应旄曰∶此条与阳明经呕多，虽有阳明证不可下之条，细细酌量，阳明证呕在上，而邪亦在膈之上，未
入腑，故不可下；此条呕不止，心下急，乃邪在膈之下，已属胃，乃可下也。可下不可下，此等处最不容误也。
林澜曰∶呕不止，则半表里证犹在，然心下急，郁郁微烦，必中有燥屎也，非下除之不可，故以大柴胡兼
而行之。
大柴胡汤方
柴胡（半斤） 黄芩（三两） 半夏（洗，半升） 芍药（三两） 枳实（炙，四枚） 大黄（二两）
生姜（切，五两） 大枣（擘，十二枚）
上八味，以水一斗二升，煮取六升，去滓再煎，温服一升，日三服。
【按】许叔微曰∶大柴胡汤一方无大黄，一方有大黄。此方用大黄者，以大黄有荡涤蕴热之功，为伤寒中
要药。王叔和云∶若不用大黄，恐不名大柴胡汤。且经衣冠文物言下之则愈，若无大黄，将何以下心下之急乎？应
从叔和为是。
【方解】柴胡证在，又复有里，故立少阳两解之法。以小柴胡汤加枳实、芍药者，解其外以和其内也。去
参、草者，以里不虚也；少加大黄，所以泻结热也；倍生姜者，因呕不止也。
太阳病，过经十余日，心中温温欲吐，而胸中痛，大便反溏，腹微满，郁郁微烦，先此时，自极吐下者，
与调胃承气汤；若不尔者，不可与。但欲呕，胸中痛，微溏者，此非柴胡证，以呕，故知极吐下也。
【按】王肯堂曰∶“温温”当是“ ”。又云∶“以呕”之下，当有阙文。
【注】太阳病过经十余日，曾经吐、下不解者，以极吐则虚其胸，邪热乘虚入胸，故心下 欲吐，而胸
中痛也。极下则虚其里，邪热乘虚入里，故大便反溏腹微满，郁郁微烦也。询知先时若果经极吐下，则为在表
之邪热，悉陷胸腹，而所见者，皆是里证未和，故宜与调胃承气汤下而和之。若不尔者，谓不因极吐、极下而
有斯证，则又不可与是汤也。夫但欲呕者，少阳也；胸中痛者，太阳也；微溏者，太阳少阳合病之利也，并无
心中 郁郁，腹满烦热等证，固不可与承气汤矣。然此亦非柴胡证，故柴胡汤亦不可与也。须从太阳、少阳
合病，下利，若呕者，与黄芩加半夏生姜汤可也。
【集注】方有执曰∶胸中痛，邪在膈也。若曾极吐，则应有心下 欲吐之状，何也？以胃口已被吐伤，
邪热上抟于膈，故欲吐而不得吐也。腹微满郁郁微烦，邪在胃也。若曾极下，则应大便微溏，何也？以下则胃
虚，邪虽实于胃，大便反不能结硬也。故曰∶先此时自极吐下者，与调胃承气汤。言当荡其热以和其胃也，不
尔，言未经极吐下也。“但欲呕”至末，申明上文之意。
喻昌曰∶太阳病过经十余日，心下 ，欲吐而不吐，其人胸中痛，大便反溏，腹微满郁郁微烦者，此
有二辨∶若曾经大吐、大下者，表邪从吐解，且已入里，可用调胃承气之法∶若未经极吐、下，但欲呕不呕，
胸中痛微溏者，是痛非吐所伤，溏非下所致，调胃之法不可用矣。
程知曰∶过经者，谓病过七八日至十三日，经气已周犹不解也。岂惟十三日，且有
二十余日者矣。盖过经不解，病必皆在阳经留连；若在阴经，则又岂能若是之持久耶！久
持且不能，安望其生乎？
程应旄曰∶大便溏则气得下泄，腹不应满，烦不应郁郁，今仍腹微满，郁郁微烦，必胃有阻留，而下后仍
不快畅也。病属阳明证，反无阳明，而只有少阳，其中必有所误，故直穷其所以致证之由，而后可从证上认病。
伤寒十三日不解，胸胁满而呕，日晡所发潮热，已而微利，此本柴胡证，下之而不得利。今反利者，知医
以丸药下之，非其治也。潮热者，实也，先宜小柴胡汤以解外，后以柴胡加芒硝汤主之。
【注】凡伤寒过经不解，热邪转属胃腑者多，皆当下之。今伤寒十三日不解过经，胸胁满而呕，日晡所发
潮热，已而微利，此本大柴胡证也。下之而不通利，今反利者，询知为医以丸药迅下之，非其治也。迅下则水
虽去，而燥者仍存，恐医以下后之利为虚，故复指曰潮热者实也，是可再下者也。但胸胁之邪未已，故先宜小
柴胡汤以解少阳之外，复以小柴胡汤加芒硝，以下少阳之里。不用大黄而加芒硝者，因里不急且经迅下，惟欲
其软坚润燥耳！是又下中兼和之意也。
【集注】《内台方议》曰∶潮热者，实也。何不用大柴胡、大小承气下之，却用芒硝何也？盖潮热虽属实，
然已先用丸药，伤动脏腑，若再用大黄下之，则脾气伤而成坏证矣，只用芒硝润燥以取利也。
方有执曰∶十三日，过经也。不解，坏证也，非其治也。以上乃原其坏，由于医之误。以下至末，救误之治也。
柴胡加芒硝汤方
于小柴胡汤方内，加芒硝六两，余根据前法服，不解更服。
伤寒十三日不解，过经谵语者，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。
【注】此承上条互发其义，以详其治也。伤寒十三日不解，过经，谵语者，以有热也，当以汤药下其热。
但上条潮热之热，热在表里，当大便不硬；此条谵语之热，热归胃腑，法当大便硬。若小便利者，大盒饭硬，
今大便不硬而反下利，脉调和者，知为医以丸药下之之利，非其治也。如未经丸药下之，自下利者，则为内虚，
内虚之利，脉当微弱而厥，今反和而不微厥，此为内实有热，非内虚有寒也，虽下利乃热利也。仍当下其热，
故以调胃承气汤主之。
伤寒三日，三阳为尽，三阴当受邪，其人反能食而不呕，此为二阴不受邪也。
【注】伤寒之邪，一日太阳受之，二日阳明受之，三日少阳受之，四日太阴受之，五日少阴受之，六日厥
阴受之，此传经之次第也。今伤寒三日，三阳表邪为尽，三阴当受邪，其人当不能食而呕，今反能食而不呕者，
此为里和，三阴不受邪也。然此乃《内经》以其大概而言，究不可以日数拘也。
【集注】成无己曰∶表邪传里，里不和则不能食而呕，今反能食而不呕，是邪不传阴，但在阳也。
方有执曰∶阳以表言，阴以里言，能食不呕，里气和而胃气回，阴不受邪可知矣。
汪琥曰∶邪在少阳，原呕不能食，今反能食而不呕，可征里气之和，而少阳之邪自解也。里既和而少阳之
邪解，则其不传三阴，断断可必，故云∶三阴不受邪也。
伤寒六七日，无大热，其人躁烦者，此为阳去入阴故也。
【注】伤寒六七日，邪欲入里之时也。无大热，表热微也。躁烦者，里热盛也。此为
阳去入阴也。阳去入阴者，谓阳邪去表入里，传于三阴也。
【集注】成无己曰∶内热为烦，谓心中郁烦也；外热为躁，谓身外热躁也。内热为有根之火，故但烦不躁，
及先烦后躁者，皆可治；外热为无根之火，故但躁不烦，及先躁后烦者，皆不可治。
方有执曰∶去，往也。言表邪去而入于里，所以外无他热，而内则烦躁也。
妇人中风，发热恶寒，经水适来，得之七八日，热除而脉迟身凉，胸胁下满，如结胸状，谵语者，此为热
入血室也，当刺期门，随其实而泻之。
【注】妇人中风，发热恶寒，表病也。若经水不来，热必无由传于血室，今经水适来，得之七八日，脉迟
热除，身凉，似乎表欲解矣。若复见胸胁下满，如结胸状，谵语之证，则知非表解入里，乃表邪之热因经水适
来，乘虚而入于血室也，法当刺期门。期门为肝之穴，肝为藏血之所，今邪入血室，故刺期门，随其血分之实
热而泻之也。
【集注】方有执曰∶血室为营血停留之所，经血集会之处，即冲脉，所谓血海是也。其脉起于气冲，并少
阴之经，夹脐上行至胸中而散，故热入而病作，其证则如是也。期门二穴在不容两傍，各去同身寸之一寸五分，
肝之募也。肝纳血，故刺期门，所以泻血分之实热也。
汪琥曰∶邪传少阳，热入血室，故作谵语等证。仲景恐人误认为阳明腑实证，轻用三承气以伐胃气，故特
出一刺期门法以疗之。
妇人中风七八日，续得寒热，发作有时，经水适断者，此为热入血室，其血必结，故使如疟状，发作有时，
小柴胡汤主之。
【注】妇人中风七八日，续得寒热，发作有时，经水适断者，此为热入血室。血与热抟，其血必结。然虽
结而无胸胁满如结胸谵语等证，是为结而未实也。尚有如疟状之寒热，发作有时，乃为邪在少阳，半表半里也。
故用小柴胡汤以和表里，热自解也。
【集注】方有执曰∶前经水适来者，因热入血室，血出而热遂遗也。此适断者，热乘血来而遂入之，与后
血相抟，俱留而不出，故曰其血必结也。程知曰∶前证经水来，而胸胁满结谵语，是邪实于脏也，故用刺以泻
之。此证因血结而寒热如疟，是邪发于经也，故用小柴胡汤和之。
妇人伤寒，发热，经水适来，昼日明了，暮则谵语，如见鬼状者，此为热入血室，无犯胃气及上二焦，
必自愈。
【注】上二条，发明风邪热入血室之证；此条发明寒邪热入血室之证。妇人伤寒，发热无汗，经水适来，
则必热入血室。故昼则明了，知邪不在阳也；暮则谵语，如见鬼状者，是为邪在阴也。无犯胃气及上二焦者，
通谓三焦也。盖禁人汗、吐、下三法，皆不可轻用，当俟其经行，必热随血去而愈也。
【集注】方有执曰∶必自愈者，言俟其经行血下，则邪热得以随血而俱出，犹之鼻衄红汗，故自愈也。盖
警人勿妄攻，以致变乱之意。
林澜曰∶伤寒发热者，寒已成热也。经水适来，则血室空虚，邪热乘虚入于血室。若昼日谵语，为邪客于
腑与阳争也。此昼日明了，暮则谵语如见鬼状者，是邪不入腑，而入于血室与阴争也。阳盛谵语宜下，此不可
下者，犯胃气也。彼热入血结寒热者，与小柴胡汤散邪发汗；此虽热入血室，而不留结，不可与发汗药犯其上
焦也。若热入胸胁满如结胸者，可刺期门；此虽热入血室而无满结，不可刺期门，以犯其中焦也。必自愈者，
以经行则热随血去，血下则邪热悉除而愈矣。
血弱气尽，腠理开，邪气因入，与正气相抟，结于胁下，正邪分争，往来寒热，休
体内有寒，胸中有热而化火，导致腹中疼痛、想要呕吐，因此用这个方剂主治。以黄连为君药，清泄胃中的热邪；以干姜为臣药，温煦胃中的寒邪；半夏降逆气，辅助黄连使呕吐得以停止；人参补益中气，辅助干姜使腹痛得以消除；桂枝用来安固体表；大枣用来培补中焦。然而此汤剂寒热性质不一，甘味与苦味药物并用，所以必须加入甘草来协调诸药。这是针对阴阳相互格拒、寒热并用的治疗方法。
太阳病，经过十天后，脉象浮细且患者喜欢静卧，说明表邪已经解除。如果伴有胸部胀满、胁肋疼痛的症状，给予小柴胡汤；如果脉象仅见浮象，给予麻黄汤。
【注】太阳病十日以上，如果没有其他证候，脉象浮细且患者嗜睡喜卧，说明外邪已解，不需要用药。如果伴有胸部胀满、胁肋疼痛等证候，则知道少阳经的外邪未解，所以用小柴胡汤和解之。如果脉象仅浮而不细，且有头痛、发热、恶寒、无汗等证候，则仍然是太阳经外邪未解，应当用麻黄汤发汗。
【按语】论中提到的脉浮细，是太阳和少阳的脉象；脉弦细，是少阳的脉象；脉沉细，是少阴的脉象。脉浮细，身体发热且嗜卧，属于阳证；脉沉细，身体无热且嗜卧，属于阴证；脉缓细，身体平和且嗜卧，说明病已解除，这些情况都是不可不仔细辨别的。
【集注】王肯堂说：这一条应当是太阳、少阳合病。胸部胀满虽然相同，但脉浮细嗜卧，说明表邪已解，胁痛说明少阳有邪气，所以给予小柴胡汤。如果脉象仅浮，又应当先治疗太阳经，所以给予麻黄汤。这是假设性的变通说法，并非指服用柴胡后脉象变浮。
伤寒发热，出汗后热不退，心中痞塞坚硬，呕吐且腹泻的，以大柴胡汤主治。
【按语】下利之“下”字，应当是“不”字，如果是“下”字，哪有上吐下泻，却用大柴胡汤攻下的道理呢？
【注】伤寒发热，出汗后热不退，说明表证尚未解除；心中痞塞坚硬，大便不通，里证又很急迫。呕吐，是少阳、阳明兼有的证候。少阳、阳明两经病情急迫，心中热结形成痞塞，所以用大柴胡汤，外解少阳未尽之表热，内攻阳明已成实之痞硬。
【按语】太阳病发热，出汗后热不退，心下痞塞坚硬，下利但不呕吐的，这是表里俱虚，属于桂枝人参汤证。如果呕吐且不利（此处原文逻辑似有矛盾，结合上下文及前文按语，应指非下利或下利情况不同，此处依原文翻译为呕吐且不利/或根据前文按语理解为非典型下利，但为忠实原文保留“呕吐而下利”的语境，但在注中解释为里实），这是表里俱实，属于大柴胡汤证。前者脉象微弱，后者脉象必然有力。
太阳病，超过病程十余日，反而被误用了二三次攻下法，之后四五天，柴胡证仍在的，先给予小柴胡汤。如果呕吐不止，心下拘急不适，情绪抑郁微烦的，说明病未解除，给予大柴胡汤攻下即可痊愈。
【注】太阳病传过三阳经十余日，医生不随经施治，反而误用二三次攻下法，未导致变证，之后四五天，只见少阳寒热往来的柴胡证仍在的，适宜先给予小柴胡汤解表和里。如果不愈，出现呕吐不止，心下满急，情绪抑郁微烦，这是少阳表里均未解除，给予大柴胡汤攻下，攻里和表，自然可以痊愈。
【集注】方有执说：过经与坏病相同，不知道有什么逆乱，而误用二三次攻下，恰恰导致了逆乱，所以说“反”。下而又下，阳明虽未受伤，但少阳邪气也未除，所以说“柴胡证仍在”。呕吐不止，情绪抑郁微烦，是邪气扰乱二阳，所以说“未解”。
程知说：这说明过经误下，有用大小柴胡两解的方法。大概是因为患者的邪气，因多次攻下而深入，如果表证未罢，必须先用小柴胡汤调和半表，然后才可以兼攻其里。
程应旄说：这一条与阳明经“呕多，虽有阳明证不可下之”的条文，细细斟酌，阳明证之呕在上部，邪也在膈之上，未入腑，所以不可下；这一条呕不止，心下急，是邪在膈之下，已属胃，才可以下。可下与不可下，这些地方最不容出错。
林澜说：呕吐不止，则半表里证犹在，然而心下急，情绪抑郁微烦，必定中有燥屎，非攻下除去不可，所以用大柴胡汤兼而行攻下。
大柴胡汤方
柴胡（半斤） 黄芩（三两） 半夏（洗，半升） 芍药（三两） 枳实（炙，四枚） 大黄（二两）
生姜（切，五两） 大枣（擘，十二枚）
以上八味药，用水一斗二升，煮取六升，去渣滓再煎，温服一升，每日三次。
【按语】许叔微说：大柴胡汤一方没有大黄，一方有大黄。此方用大黄，是因为大黄有荡涤蕴积热邪的功效，是伤寒中的重要药物。王叔和说：如果不用大黄，恐怕就不叫大柴胡汤了。况且经文说“下之则愈”，如果没有大黄，用什么来攻下心下的急迫呢？应当以王叔和的说法为准。
【方解】柴胡证存在，又复有里证，所以确立少阳两解之法。用小柴胡汤加枳实、芍药，是为了外解其表以和内其里。去掉人参、甘草，是因为里不虚；稍加大黄，是为了泻除结热；倍用生姜，是因为呕吐不止。
太阳病，过经十余日，心中泛泛欲吐，且胸中痛，大便反而稀溏，腹部微满，情绪抑郁微烦，如果在此之前，病人曾经过极度的催吐或攻下，给予调胃承气汤；如果不是这样，不可给予。如果只是想要呕吐，胸中痛，大便微溏，这不是柴胡证，因为呕吐，所以知道是极度催吐或攻下所致。
【按语】王肯堂说：“温温”应当是“愠愠”（形容心中郁结不适）。又说：“以呕”之下，应当有脱文。
【注】太阳病过经十余日，曾经经过催吐、攻下但未解的，因为极度催吐则使胸中虚弱，邪热乘虚进入胸中，所以心中愠愠欲吐，且胸中痛。极度攻下则使里虚，邪热乘虚进入里，所以大便反而稀溏，腹部微满，情绪抑郁微烦。询问得知先前如果确实经过极度催吐或攻下，那么在表的邪热，全部陷入胸腹，而所见到的，都是里证未和，所以适宜给予调胃承气汤攻下以调和之。如果不是这样，指不因极度催吐、攻下而有这些证候，那么又不可给予此汤。如果只是想呕吐，胸中痛，大便微溏，这是少阳证；胸中痛，这是太阳证；大便微溏，这是太阳少阳合病的下利，并没有心中愠愠、腹部满闷烦热等证候，固然不可给予承气汤。然而这也不是柴胡证，所以柴胡汤也不可给予。应当从太阳、少阳合病，下利，若呕吐者，给予黄芩加半夏生姜汤。
【集注】方有执说：胸中痛，邪在膈部。如果曾经过极度催吐，应当有心下愠愠欲吐的状态，为什么呢？因为胃口已被吐伤，邪热上搏于膈，所以想吐却吐不出来。腹部微满，情绪抑郁微烦，邪在胃。如果曾经过极度攻下，应当大便微溏，为什么呢？因为攻下则胃虚，邪气虽实于胃，大便反而不能结硬。所以说“先此时自极吐下者，与调胃承气汤”。意思是应当荡涤其热以和其胃。“不尔”，指未经极度催吐或攻下。“但欲呕”至末尾，申明上文的意思。
喻昌说：太阳病过经十余日，心中愠愠，想吐却吐不出来，其人胸中痛，大便反而稀溏，腹部微满，情绪抑郁微烦的，这里有两个辨别：如果曾经大吐、大下的，表邪从吐而解，且已入里，可用调胃承气的方法；如果未经极度催吐、攻下，只是想要呕吐却不吐，胸中痛，大便微溏的，这是痛非吐所伤，溏非下所致，调胃的方法不可用。
程知说：过经，是指病过七八日至十三日，经气已周遍仍未解除。岂止十三日，甚至有二十余日的。大概过经不解，病必都在阳经留连；如果在阴经，又怎么能如此持久呢！持久都不能治愈，怎么指望能活呢？
程应旄说：大便溏则气得下泄，腹部不应满，烦不应抑郁，现在仍然腹部微满，情绪抑郁微烦，必定胃有阻留，而下后仍不快畅。病属阳明证，反而没有典型的阳明证，而只有少阳证，其中必有误治，所以要直究导致证候的原因，然后才可从证候上认识疾病。
伤寒十三日未解，胸胁满闷而呕吐，傍晚时分发潮热，随后轻微下利，这本是柴胡证，攻下后不得利。现在反而下利，知道医生用丸药攻下，不是正确的治法。潮热，是实证，先宜用小柴胡汤以解外，后用柴胡加芒硝汤主治。
【注】凡是伤寒过经不解，热邪转属胃腑的多，都应当攻下。现在伤寒十三日未解过经，胸胁满闷而呕吐，傍晚时分发潮热，随后轻微下利，这本是大柴胡证。攻下后不通利，现在反而下利，询问得知是医生用丸药迅猛地攻下，不是正确的治法。迅猛攻下则水湿虽去，而燥结仍存在，恐怕医生以为攻下后的下利是虚证，所以再次指出：潮热是实证，是可以再下的。但胸胁的邪气未已，所以先宜用小柴胡汤以解少阳之外，再用小柴胡汤加芒硝，以下少阳之里。不用大黄而加芒硝，是因为里不急且经过迅猛攻下，只希望其软坚润燥罢了！这又是下法中兼有和解之意。
【集注】《内台方议》说：潮热，是实证。为什么不用大柴胡、大小承气攻下，却用芒硝呢？大概潮热虽属实，但已先用丸药，伤动脏腑，若再用大黄攻下，则脾气受伤而成坏证了，只用芒硝润燥以取得利。
方有执说：十三日，是过经。不解，是坏证，不是正确的治法。以上乃推求坏证的原因，是由于医生的误治。以下至末尾，是救治误治的方法。
柴胡加芒硝汤方
在小柴胡汤方内，加芒硝六两，其余依照前法服用，不解再服。
伤寒十三日未解，过经出现谵语的，因为有热，应当用汤药攻下。如果小便通利的，大便应当硬，反而下利，脉象调和的，知道医生用丸药攻下，不是正确的治法。如果是自行下利的，脉应当微弱厥冷，现在反而调和，这是内实，调胃承气汤主治。
【注】这是承接上一条互发其义，以详细说明治法。伤寒十三日未解，过经，出现谵语的，因为有热，应当用汤药攻下其热。但上一条潮热之热，热在表里，应当大便不硬；这一条谵语之热，热归胃腑，法当大便硬。如果小便通利的，大便应当硬，现在大便不硬而反而下利，脉象调和的，知道是医生用丸药攻下导致的下利，不是正确的治法。如未经丸药攻下，自行下利的，则为内虚，内虚的下利，脉应当微弱而厥，现在反而调和而不微弱厥冷，这是内实有热，非内虚有寒，虽然是下利乃是热利。仍然应当攻下其热，所以用调胃承气汤主治。
伤寒三日，三阳经的病势已尽，三阴经应当受邪，其人反而能食且不呕吐，这是二阴不受邪。
【注】伤寒的邪气，一日太阳受之，二日阳明受之，三日少阳受之，四日太阴受之，五日少阴受之，六日厥阴受之，这是传经的次序。现在伤寒三日，三阳表邪已尽，三阴应当受邪，其人应当不能食而呕吐，现在反而能食且不呕吐，这是里气和顺，三阴不受邪。然而这是《内经》从其大概而言，终究不可以日数拘泥。
【集注】成无己说：表邪传里，里不和则不能食而呕吐，现在反而能食且不呕吐，是邪不传阴，只在阳经。
方有执说：阳指表，阴指里，能食不呕，说明里气和而胃气恢复，阴经不受邪可知。
汪琥说：邪在少阳，原应呕吐不能食，现在反而能食且不呕吐，可验证里气之和，而少阳之邪自解。里既和而少阳之邪解，则其不传三阴，断然可定，所以说“三阴不受邪”。
【注】伤寒六七日，是邪气欲入里的时机。无大热，说明表热微。躁烦，说明里热盛。这是阳去入阴。阳去入阴，是说阳邪去表入里，传于三阴。
【集注】成无己说：内热为烦，谓心中郁烦；外热为躁，谓身外热躁。内热为有根之火，故但烦不躁，及先烦后躁的，都可治；外热为无根之火，故但躁不烦，及先躁后烦的，都不可治。
方有执说：去，往也。言表邪去而入于里，所以外无他热，而内则烦躁。
妇人中风，发热恶寒，月经适来，得病七八日，热退而脉迟身凉，胸胁下满，像结胸的样子，谵语的，这是热入血室，应当刺期门穴，随其实证而泻之。
【注】妇人中风，发热恶寒，是表病。如果月经不来，热必无由传于血室，现在月经适来，得病七八日，脉迟热退，身凉，似乎表欲解了。如果再出现胸胁下满，像结胸的样子，谵语的证候，则知道非表解入里，而是表邪之热因月经适来，乘虚而入于血室，法当刺期门。期门是肝之募穴，肝为藏血之所，现在邪入血室，所以刺期门，随其血分之实热而泻之。
【集注】方有执说：血室是营血停留之所，经血集会之处，即冲脉，所谓血海是也。其脉起于气冲，并少阴之经，夹脐上行至胸中而散，所以热入而病作，其证则如是。期门二穴在不容穴两旁，各去同身寸之一寸五分，是肝之募穴。肝纳血，所以刺期门，是为了泻血分之实热。
汪琥说：邪传少阳，热入血室，故作谵语等证。仲景恐人误认为阳明腑实证，轻用三承气以伐胃气，故特出一刺期门法以疗之。
妇人中风七八日，续得寒热，发作有时，月经适断的，这是热入血室，其血必结，所以使寒热像疟疾一样，发作有时，用小柴胡汤主治。
【注】妇人中风七八日，续得寒热，发作有时，月经适断的，这是热入血室。血与热搏结，其血必结。然而虽结而无胸胁满如结胸、谵语等证，是为结而未实。尚有如疟状之寒热，发作有时，乃为邪在少阳，半表半里。所以用小柴胡汤以和表里，热自解。
【集注】方有执说：前条经水适来，因热入血室，血出而热遂遗。此条适断，热乘血来而遂入之，与后血相搏，俱留而不出，所以说“其血必结”。程知说：前证经水来，而胸胁满结谵语，是邪实于脏，故用刺以泻之。此证因血结而寒热如疟，是邪发于经，故用小柴胡汤和之。
妇人伤寒，发热，月经适来，白天神志清楚，晚上则谵语，像看见鬼怪一样的，这是热入血室，不要侵犯胃气及上二焦，必定自愈。
【注】上两条，发明风邪热入血室的证候；这一条发明寒邪热入血室的证候。妇人伤寒，发热无汗，月经适来，则必热入血室。所以白天神志清楚，知道邪不在阳；晚上谵语，像看见鬼怪，是为邪在阴。无犯胃气及上二焦，通谓三焦。大概禁止使用汗、吐、下三法，都不可轻用，应当等待其行经，必定热随血去而痊愈。
【集注】方有执说：必自愈，是说等待其行经血下，则邪热得以随血而俱出，犹如鼻衄红汗，所以自愈。大概是警告人们勿妄攻，以致变乱的意思。
林澜说：伤寒发热，寒已成热。月经适来，则血室空虚，邪热乘虚入于血室。如果白天谵语，为邪客于腑与阳争。此条白天神志清楚，晚上谵语像看见鬼怪，是邪不入腑，而入于血室与阴争。阳盛谵语宜下，此不可下，因为犯胃气。彼热入血结寒热的，与小柴胡汤散邪发汗；此虽热入血室，而不留结，不可与发汗药犯其上焦。若热入胸胁满如结胸的，可刺期门；此虽热入血室而无满结，不可刺期门，以犯其中焦。必自愈，是因为经行则热随血去，血下则邪热悉除而愈。
There is cold within, and heat in the chest transforms into fire, causing abdominal pain and a desire to vomit; therefore, this formula is used as the primary treatment. Coptis Rhizoma (Huanglian) serves as the sovereign drug to clear heat in the stomach; Ginger Rhizome (Ganjiang) serves as the minister drug to warm cold in the stomach; Pinellia Tuber (Banxia) descends rebellious Qi, assisting Huanglian to stop vomiting; Ginseng Radix et Rhizoma (Renshen) tonifies the Middle Jiao, assisting Ganjiang to eliminate abdominal pain; Cinnamon Twig (Guizhi) is used to secure the exterior; Jujube Fruit (Dazao) is used to nourish the Middle Jiao. However, since this decoction contains both cold and warm properties, and sweet and bitter flavors are administered together, Licorice Root (Gancao) must be added to harmonize the various drugs. This is a treatment method for Yin-Yang mutual rejection and simultaneous application of cold and warm therapies.
In Taiyang disease, after ten days, if the pulse is floating and fine, and the patient desires to lie down, it indicates that the exterior pathogen has resolved. If accompanied by chest fullness and hypochondriac pain, Xiao Chaihu Tang (Minor Bupleurum Decoction) should be given; if the pulse is merely floating, Mahuang Tang (Ephedra Decoction) should be given.
[Annotation] In Taiyang disease lasting more than ten days without other symptoms, if the pulse is floating and fine and the patient is lethargic, the exterior pathogen has resolved, and no medication is needed. If symptoms such as chest fullness and hypochondriac pain are present, it indicates that the pathogen in the Shaoyang channel has not resolved, so Xiao Chaihu Tang is used to harmonize it. If the pulse is merely floating without being fine, and accompanied by headache, fever, aversion to cold, and anhidrosis, it remains an unresolved Taiyang exterior pathogen, and Mahuang Tang should be used to induce sweating.
[Commentary] The text mentions that a floating and fine pulse corresponds to Taiyang and Shaoyang; a wiry and fine pulse corresponds to Shaoyang; a deep and fine pulse corresponds to Shaoyin. A floating and fine pulse with fever and lethargy indicates a Yang syndrome; a deep and fine pulse with no fever and lethargy indicates a Yin syndrome; a slow and fine pulse with a peaceful body and lethargy indicates resolution. These distinctions must not be overlooked.
[Collected Annotations] Wang Kentang stated: This clause likely refers to a combined disease of Taiyang and Shaoyang. Although chest fullness is common, a floating and fine pulse with lethargy indicates that the exterior pathogen has resolved, while hypochondriac pain indicates Shaoyang pathogen, hence Xiao Chaihu Tang is given. If the pulse is merely floating, Taiyang should be treated first, hence Mahuang Tang is given. This is a hypothetical flexible statement, not implying that the pulse becomes floating after taking Chaihu.
In Shanghan (Cold Damage) with fever, where sweating does not resolve the condition, accompanied by epigastric stuffiness and hardness, vomiting, and diarrhea, Da Chaihu Tang (Major Bupleurum Decoction) is the primary treatment.
[Commentary] The character "Xia" (down/below) in "Xiali" (diarrhea) should be "Bu" (not). If it were "Xia", how could one use Da Chaihu Tang to purge when there is both upper vomiting and lower diarrhea?
[Annotation] In Shanghan with fever, where sweating does not resolve the condition, the exterior pattern has not yet resolved; epigastric stuffiness and hardness with constipation indicate that the interior pathology is urgent. Vomiting is a symptom shared by Shaoyang and Yangming. With both Shaoyang and Yangming patterns urgent, heat accumulation forms epigastric stuffiness; thus, Da Chaihu Tang is used to release the residual exterior heat of Shaoyang externally and attack the interior excess and stuffiness of Yangming internally.
[Commentary] In Taiyang disease with fever, where sweating does not resolve the condition, epigastric stuffiness and hardness, but with diarrhea and no vomiting, this is a deficiency of both exterior and interior, corresponding to Guizhi Renshen Tang (Cinnamon Twig and Ginseng Decoction). If there is vomiting and no diarrhea (or different diarrhea characteristics), this is an excess of both exterior and interior, corresponding to Da Chaihu Tang. The former presents with a weak pulse; the latter presents with a forceful pulse.
In Taiyang disease, after passing the typical duration of over ten days, if the physician mistakenly applied purgation two or three times, and four or five days later the Chaihu syndrome persists, Xiao Chaihu Tang should be given first. If vomiting continues incessantly, there is urgency in the epigastrium, and mild depression and irritability, indicating the disease has not resolved, Da Chaihu Tang should be given to purge, leading to recovery.
[Annotation] After Taiyang disease transmits through the three Yang channels for over ten days, if the physician fails to treat according to the channel progression and mistakenly applies purgation two or three times without causing adverse transformations, and four or five days later only the alternating chills and fever of Shaoyang (Chaihu syndrome) persist, Xiao Chaihu Tang should be given first to release the exterior and harmonize the interior. If it does not resolve, and symptoms include incessant vomiting, epigastric fullness and urgency, and mild depression and irritability, this indicates that both the exterior and interior of Shaoyang are unresolved. Da Chaihu Tang should be given to purge the interior and harmonize the exterior, leading to recovery.
[Collected Annotations] Fang Youzhi stated: "Passing the channel" is similar to "bad disease." Not knowing the deviation, applying purgation two or three times causes deviation, hence the term "fan" (contrary/reverse). Purging repeatedly leaves the Yangming unharmed but the Shaoyang pathogen undispelled, hence "Chaihu syndrome persists." Incessant vomiting and mild depression/irritability indicate pathogen disturbing the two Yang channels, hence "unresolved."
Cheng Zhi stated: This explains that after passing the channel and mistaken purgation, there is a method of dual resolution using Minor and Major Chaihu formulas. Since the pathogen has penetrated deeply due to repeated purgation, if the exterior pattern is not resolved, Xiao Chaihu Tang must first be used to harmonize the half-exterior before attacking the interior.
Cheng Yingmao stated: Comparing this with the clause "Frequent vomiting in Yangming channel, even with Yangming symptoms, cannot be purged": Yangming vomiting is located above, and the pathogen is above the diaphragm, not entering the fu organs, so it cannot be purged. In this clause, incessant vomiting and epigastric urgency indicate the pathogen is below the diaphragm, belonging to the Stomach, so it can be purged. The distinction between purgable and non-purgable cases is critical.
Lin Lan stated: Incessant vomiting indicates the half-exterior/half-interior pattern still exists. However, epigastric urgency and mild depression/irritability suggest dry stool accumulation, which requires purgation. Thus, Da Chaihu Tang is used to combine harmonizing and purging.
Da Chaihu Tang Formula
Bupleuri Radix (Chaihu) - Half jin
Scutellariae Radix (Huangqin) - Three liang
Pinelliae Tuber (Banxia) - Washed, half sheng
Paeoniae Radix Alba (Shaoyao) - Three liang
Immature Trifoliate Orange Fruit (Zhishi) - Roasted, four pieces
Rhei Radix et Rhizoma (Dahuang) - Two liang
Zingiberis Rhizoma Recens (Shengjiang) - Sliced, five liang
Jujubae Fructus (Dazao) - Split, twelve pieces
These eight ingredients are boiled in twelve dou of water to yield six sheng. Remove the dregs, boil again, and take one sheng warm, three times daily.
[Commentary] Xu Shuwei stated: There are versions of Da Chaihu Tang with and without Rhei Radix et Rhizoma (Dahuang). This version uses Dahuang because it has the power to cleanse accumulated heat, making it a key herb in Shanghan. Wang Shuhe said: Without Dahuang, it might not be called Da Chaihu Tang. Moreover, the text states "purging leads to recovery"; without Dahuang, what would purge the epigastric urgency? Wang Shuhe's view should be followed.
[Formula Analysis] Since the Chaihu pattern exists alongside interior pathology, a dual-resolution method for Shaoyang is established. Adding Immature Trifoliate Orange Fruit (Zhishi) and Paeoniae Radix Alba (Shaoyao) to Xiao Chaihu Tang releases the exterior and harmonizes the interior. Removing Ginseng Radix et Rhizoma (Renshen) and Glycyrrhizae Radix et Rhizoma (Gancao) is because the interior is not deficient; adding a small amount of Rhei Radix et Rhizoma (Dahuang) clears accumulated heat; doubling the amount of Zingiberis Rhizoma Recens (Shengjiang) addresses incessant vomiting.
In Taiyang disease, after passing the channel for over ten days, if the patient feels nauseous, has chest pain, loose stools, slight abdominal fullness, mild depression, and irritability, and if previously subjected to extreme emesis or purgation, Tiaowei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction) should be given; otherwise, it should not be given. If there is only a desire to vomit, chest pain, and loose stools, this is not a Chaihu pattern; due to vomiting, it is known to be caused by extreme emesis or purgation.
[Commentary] Wang Kentang stated: "Wenwen" should be "Yunyun" (feeling stifled/uncomfortable). Also, there may be missing text after "due to vomiting."
[Annotation] In Taiyang disease passing the channel for over ten days, if unresolved after extreme emesis or purgation: extreme emesis vacates the chest, allowing pathogenic heat to enter vacuously, causing nausea and chest pain. Extreme purgation vacates the interior, allowing pathogenic heat to enter, causing loose stools, slight abdominal fullness, mild depression, and irritability. If confirmed that extreme emesis/purgation occurred, the exterior pathogenic heat has sunk into the chest and abdomen, presenting as interior disharmony; thus, Tiaowei Chengqi Tang should be given to purge and harmonize. If not caused by extreme emesis/purgation, this decoction should not be given. Desire to vomit indicates Shaoyang; chest pain indicates Taiyang; loose stools indicate Taiyang-Shaoyang combined disease diarrhea. Without nausea/fullness/irritability, Chengqi Tang is contraindicated. Nor is this a Chaihu pattern, so Chaihu Tang is also contraindicated. For Taiyang-Shaoyang combined disease with diarrhea and vomiting, Huangqin Banxia Shengjiang Tang (Scutellaria, Pinellia, and Fresh Ginger Decoction) should be used.
[Collected Annotations] Fang Youzhi stated: Chest pain indicates pathogen at the diaphragm. After extreme emesis, one should feel nausea; why? Because the stomach opening is damaged by emesis, and pathogenic heat rises to the diaphragm, causing desire to vomit without ability to do so. Slight abdominal fullness and irritation indicate pathogen in the Stomach. After extreme purgation, one should have loose stools; why? Because purgation vacates the Stomach; although pathogen is excess in the Stomach, stools cannot harden. Hence, "if previously subjected to extreme emesis/purgation, give Tiaowei Chengqi Tang," meaning to cleanse heat and harmonize the Stomach. "Otherwise" means not subjected to extreme emesis/purgation. The rest clarifies the previous points.
Yu Chang stated: In Taiyang disease passing the channel for over ten days, with nausea, chest pain, loose stools, slight abdominal fullness, and irritation, two distinctions apply: If previously subjected to extreme emesis/purgation, the exterior pathogen resolved via emesis and entered the interior; Tiaowei Chengqi method can be used. If not subjected to extreme emesis/purgation, with only desire to vomit, chest pain, and loose stools, the pain is not from emesis damage, and loose stools are not from purgation; the Tiaowei method is contraindicated.
Cheng Zhi stated: "Passing the channel" refers to illness lasting seven to thirteen days, where channel qi has circulated but not resolved. It can last twenty-plus days. Illness lingering past the channel stays in the Yang channels; if in Yin channels, it would not last so long. If it cannot persist, how can life be sustained?
Cheng Yingmao stated: Loose stools allow Qi to descend, so the abdomen should not be full, nor should there be irritation. Current slight fullness and irritation indicate gastric obstruction and incomplete relief after purgation. Though resembling Yangming, lacking typical Yangming signs and showing only Shaoyang signs suggests mismanagement. One must trace the cause of symptoms to identify the disease.
After thirteen days of Shanghan unresolved, with hypochondriac fullness and vomiting, afternoon tidal fever, and subsequent mild diarrhea, this was originally a Chaihu pattern. Purging failed to produce diarrhea. Now, diarrhea occurs because the physician used pill-based purgatives, which is incorrect treatment. Tidal fever indicates excess. First, use Xiao Chaihu Tang to release the exterior, then use Chaihu Jia Mangxiao Tang (Bupleurum with Natrii Sulfas Decoction) as the primary treatment.
[Annotation] When Shanghan passes the channel unresolved, heat often transfers to the Stomach fu organ and requires purgation. Here, after thirteen days, with hypochondriac fullness, vomiting, afternoon tidal fever, and mild diarrhea, this was originally a Da Chaihu pattern. Failure to purge effectively, followed by diarrhea, indicates the physician used rapid pill-based purgatives incorrectly. Rapid purgation removes fluid but leaves dryness intact. The physician might mistake post-purgation diarrhea for deficiency, but tidal fever confirms excess, warranting further treatment. Since hypochondriac pathogen persists, Xiao Chaihu Tang is first used to release Shaoyang exterior, followed by Xiao Chaihu Tang plus Natrii Sulfas (Mangxiao) to address Shaoyang interior. Natrii Sulfas replaces Rhei Radix et Rhizoma (Dahuang) because the interior is not urgently excessive and has been rapidly purged; the goal is to soften hardness and moisten dryness. This combines purging with harmonizing.
[Collected Annotations] Neitai Fangyi stated: Tidal fever indicates excess. Why not use Da Chaihu or Da/Xiao Chengqi? Because prior pill purgation injured the zang-fu organs; using Rhei Radix et Rhizoma (Dahuang) again would injure Spleen Qi and cause bad disease. Only Natrii Sulfas (Mangxiao) is used to moisten dryness and induce mild purgation.
Fang Youzhi stated: Thirteen days indicates passing the channel. Unresolved indicates bad disease due to medical error. The preceding text analyzes the cause of deviation; the following text provides remedial treatment.
Chaihu Jia Mangxiao Tang Formula
To the Xiao Chaihu Tang formula, add Natrii Sulfas (Mangxiao) six liang. Follow the previous preparation and administration methods. Take if unresolved.
After thirteen days of Shanghan unresolved, passing the channel with delirium, indicates heat requiring purgation with decoction. If urination is free, stools should be hard; if diarrhea occurs instead, and the pulse is harmonious, it indicates the physician used pill-based purgatives incorrectly. If diarrhea occurred spontaneously, the pulse should be faint and cold; if the pulse is harmonious instead, this indicates interior excess. Tiaowei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction) is the primary treatment.
[Annotation] This elaborates on the previous clause. After thirteen days of Shanghan unresolved, passing the channel with delirium indicates heat requiring purgation. Unlike the previous tidal fever (heat in exterior/interior, stools not hard), delirium heat resides in the Stomach fu, so stools should be hard. If urination is free, stools should be hard; if diarrhea occurs with a harmonious pulse, it indicates iatrogenic diarrhea from pill purgatives. Spontaneous diarrhea would present with faint/cold pulses (deficiency). Harmonious pulse indicates interior excess-heat, not deficiency-cold. Despite diarrhea, it is heat-diarrhea, requiring heat-purging via Tiaowei Chengqi Tang.
On the third day of Shanghan, the three Yang channels are exhausted, and the three Yin channels should receive the pathogen. If the patient can eat and does not vomit, this indicates the two Yin channels (Taiyin and Shaoyin) are not receiving the pathogen.
[Annotation] Shanghan pathogens follow a sequence: Day 1 Taiyang, Day 2 Yangming, Day 3 Shaoyang, Day 4 Taiyin, Day 5 Shaoyin, Day 6 Jueyin. On day three, if Yang exterior pathogens are exhausted and Yin channels should be affected, the patient should be unable to eat and vomit. Ability to eat without vomiting indicates interior harmony, preventing transmission to Yin channels. Note: The Nei Jing speaks generally; one should not rigidly adhere to days.
[Collected Annotations] Cheng Wuji stated: Transmission to interior causes disharmony, leading to anorexia/vomiting. Ability to eat without vomiting indicates pathogen remains in Yang, not transmitting to Yin.
Fang Youzhi stated: Yang refers to exterior, Yin to interior. Eating without vomiting indicates interior harmony and restored Stomach Qi, confirming Yin channels are unaffected.
Wang Hu stated: Pathogen in Shaoyang typically causes vomiting/anorexia. Ability to eat without vomiting verifies interior harmony and spontaneous resolution of Shaoyang pathogen. With interior harmony and Shaoyang resolution, transmission to Yin channels is impossible.
On the sixth or seventh day of Shanghan, with no significant fever but restlessness and irritability, this indicates the pathogen leaving Yang and entering Yin.
[Annotation] Days six or seven mark the time when pathogen enters the interior. No significant fever indicates mild exterior heat. Restlessness and irritability indicate severe interior heat. This is "Yang leaving to enter Yin," meaning exterior pathogen moves inward to the three Yin channels.
[Collected Annotations] Cheng Wuji stated: Internal heat causes irritability (mental distress); external heat causes restlessness (physical agitation). Internal heat is rooted fire (treatable); external heat is rootless fire (untreatable).
Fang Youzhi stated: "Leaving" means going. Exterior pathogen moves inward, causing internal restlessness/irritability without external heat.
In women with Fengzhong (Wind Strike), fever and aversion to cold, menstruation occurring during the course, after seven to eight days, if fever subsides, pulse slows, body cools, but hypochondriac fullness resembles Jiechest (Knotted Chest), and delirium occurs, this is Re entering the Blood Chamber. Acupuncture Qimen (Liv 14) should be performed to drain excess.
[Annotation] Wind Strike with fever/aversion to cold is an exterior pattern. If menstruation had not occurred, heat would not transmit to the Blood Chamber. With menstruation occurring, after seven to eight days, slowing pulse and cooled body suggest exterior resolution. However, hypochondriac fullness resembling Jiechest and delirium indicate heat entered the Blood Chamber vacuously due to menstruation. Treatment requires acupuncture at Qimen (Liver Front-Mu point). As the Liver stores blood, needling Qimen drains excess heat from the blood level.
[Collected Annotations] Fang Youzhi stated: The Blood Chamber is where nutritive blood gathers (Chong Mai/Blood Sea). Its vessel originates at Qichong, runs with Shaoyin, ascends to the chest. Heat entry causes these symptoms. Qimen (Liv 14) is the Liver Front-Mu point. Needling it drains blood-level excess heat.
Wang Hu stated: Pathogen transmitting to Shaoyang and entering the Blood Chamber causes delirium. Zhang Zhongjing warns against mistaking this for Yangming Fu excess and using Chengqi formulas, which would injure Stomach Qi. Instead, he prescribes needling Qimen.
In women with Fengzhong for seven to eight days, developing intermittent chills and fever coinciding with menstruation cessation, this is Re entering the Blood Chamber. Blood clots, causing malaria-like paroxysms. Xiao Chaihu Tang (Minor Bupleurum Decoction) is the primary treatment.
[Annotation] Intermittent chills/fever coinciding with menstruation cessation indicates Re entering the Blood Chamber. Blood and heat bind, causing clotting. However, absence of Jiechest/delirium indicates clotting without full excess. Malaria-like chills/fever indicate pathogen in Shaoyang (half-exterior/half-interior). Xiao Chaihu Tang harmonizes exterior/interior, resolving heat.
[Collected Annotations] Fang Youzhi stated: Previous case (menstruation starting) allowed heat to exit with blood. This case (menstruation stopping) allowed heat to enter and bind with blood, causing clotting. Cheng Zhi stated: Previous case (clotting/delirium) indicated pathogen excess in Zang, treated by needling. This case (malaria-like chills) indicates pathogen manifesting in Channel, treated by harmonizing with Xiao Chaihu Tang.
In women with Shanghan, fever, and menstruation occurring, if conscious during the day but delirious at night (seeing ghosts), this is Re entering the Blood Chamber. Do not violate Stomach Qi or the Upper/Middle Jiao; it will self-resolve.
[Annotation] Previous clauses addressed Wind Strike Re entering Blood Chamber; this addresses Cold Damage. Fever/anhidrosis with menstruation allows heat entry. Daytime clarity indicates pathogen not in Yang; nighttime delirium indicates pathogen in Yin. "Do not violate Stomach Qi or Upper/Middle Jiao" prohibits sweating, vomiting, and purging. Wait for menstruation to complete; heat will exit with blood.
[Collected Annotations] Fang Youzhi stated: Self-resolution occurs as heat exits with blood, similar to epistaxis ("red sweat"). This warns against reckless attacking.
Lin Lan stated: Cold transforming to heat enters empty Blood Chamber. Daytime delirium implies pathogen in Fu/Yang; nighttime delirium implies pathogen in Blood Chamber/Yin. Yang excess delirium requires purging (violates Stomach Qi here). Previous malaria-like cases used Xiao Chaihu Tang (sweating); this case has no binding, so avoid sweating (violates Upper Jiao). Jiechest cases required needling Qimen; this case has no binding, so avoid needling (violates Middle Jiao). Self-resolution occurs as heat exits with blood.
When Qi and Blood are weak, pores open, pathogen enters, binds with healthy Qi at the hypochondrium, fighting for dominance, causing alternating chills and fever...