治服桂枝汤或下之, 仍头项强痛,
翕翕发热, 无汗, 心下满微痛, 小便不利者, 桂枝去芍药加茯苓白术
汤主之.
于桂枝汤方内, 去芍药加茯苓, 白术各三两, 余根据桂枝汤法煎服. 小
便利则愈.
【注】服桂枝汤已汗也, 或下之已下也, 今仍有头项强痛, 翕翕发热
无汗之表; 心下满微痛, 小便不利停饮之里; 无汗表不解, 心下有水
气,当用小青龙汗之. 今无汗表不解, 有水气, 心下满微痛, 小便不
利,而不用小青龙者, 以其已经汗下, 表里俱虚也. 故仍用桂枝汤以
解表, 去芍药之酸收, 避无汗心下之满; 加茯苓之燥渗, 因水停小便
不利也. 余根据桂枝汤法煎服, 谓根据桂枝汤法取汗也. 小便利则愈, 谓
饮病输水道则愈也. 此方即桂苓甘术汤而有生姜, 大枣. 其意专在解
肌,利水次之, 故用生姜, 大枣佐桂枝, 以通津液取汗也. 桂苓甘术
汤不用生姜, 大枣而加茯苓, 其意专在利水, 扶阳次之, 故倍加茯苓
君桂枝, 于利水中扶阳也. 故方后不曰根据服桂枝汤方也.
治太阳中风表解,???? 汗出而不恶寒, 里有水气, 小
便不利, 呕逆短气, 心下至胁痞满硬痛者. 此治水之急方也.
大枣 ( 擘 ) 十枚 甘遂 大戟 芫花 ( 熬 ) 各等分, 右三味, 各
别捣为散, 以水一升半, 先煮大枣肥者十枚, 取八合, 去滓, 纳药末
,强人一钱, 羸人服半钱, 平旦温服. 若下少病不除者, 明日再服,
加半钱. 得快下后, 糜粥自养.
【集注】柯琴曰: 仲景治水之方, 种种不同, 此其最峻者也. 凡水气
为患, 或喘或咳, 或悸或噎, 或吐或痢, 病在一处而止. 此则水邪留
结于中, 心腹□下痞满硬痛, 三焦升降之气阻隔难通. 此时表邪已罢
,非汗散之法所宜, 里饮实盛, 又非淡渗之品所能胜, 非选逐水至峻
之品以折之, 则中气不支, 束手待毙矣. 甘遂, 芫花, 大戟三味, 皆
辛苦气寒而禀性最毒, 并举而用之, 气味相济相须, 故可夹攻水邪之
巢穴, 决其渎而大下之, 一举而患可平也. 然邪之所凑, 其气必虚;
以毒药攻邪, 必伤及脾胃, 使无?? 和甘缓之品为主宰, 则邪气尽而
大命亦随之矣. 然此药最毒, 参术所不能君, 甘草又与之相反, 故选
十枣之大而肥者以君之, 一以顾其脾胃, 一以缓其峻毒. 得快痢后,
糜粥自养, 一以使谷气内充, 一以使邪不复作. 此仲景用毒攻病之法
,尽美又尽善也. 眛者惑于甘能中满之说, 而不敢用, 岂知承制之理
乎?
Treat cases where, after administering Guizhi Tang (Cinnamon Twig Decoction) or following purgation therapy, symptoms such as stiffness and pain in the head and neck, mild continuous fever resembling a feather covering (Xi Xi Fa Re), absence of sweating, fullness and slight pain in the epigastrium, and dysuria persist. These should be primarily treated with Guizhi Qu Shaoyao Jia Fuling Baizhu Tang (Cinnamon Twig Decoction without Peony plus Poria and Atractylodes Macrocephala Decoction).
In the formula of Guizhi Tang, remove Shaoyao (Paeoniae Radix Alba), and add Fuling (Poria) and Baizhu (Atractylodis Macrocephalae Rhizoma), each three liang. The remaining preparation and administration follow the method of Guizhi Tang. Recovery occurs when urination becomes smooth.
[Annotation] After taking Guizhi Tang, sweating has already occurred; or after purgation, the current presentation still includes exterior signs such as stiffness and pain in the head and neck, mild continuous fever, and absence of sweating. Fullness and slight pain in the epigastrium, along with dysuria, indicate interior retention of fluid-dampness. Absence of sweating implies the exterior is not resolved, and fluid-qi in the heart region suggests Xiao Qinglong Tang (Minor Blue Dragon Decoction) should be used to resolve via sweating. However, since the patient has already undergone sweating and purgation, both the exterior and interior are deficient. Therefore, Guizhi Tang is still used to release the exterior. Shaoyao is removed for its sour and astringent properties to avoid aggravating epigastric fullness in the context of absent sweating. Fuling is added for its drying and leaching properties to address fluid retention causing dysuria. "Following the method of Guizhi Tang" refers to obtaining sweating according to Guizhi Tang protocols. "Recovery when urination becomes smooth" means the fluid disease resolves through the unblocking of water pathways. This formula is essentially Linggui Zhugan Tang (Poria, Cinnamon Twig, Licorice, and Atractylodes Macrocephala Decoction) plus Shengjiang (Zingiberis Rhizoma Recens) and Dazao (Jujubae Fructus). Its primary intent is to release the muscle layer; promoting diuresis is secondary. Thus, Shengjiang and Dazao assist Guizhi to circulate body fluids and induce sweating. Linggui Zhugan Tang does not use Shengjiang and Dazao but increases the dosage of Fuling; its primary intent is promoting diuresis, while supporting Yang is secondary. Therefore, Fuling is doubled as the sovereign herb paired with Guizhi to support Yang during diuresis. Hence, the post-formula instructions do not say "follow the Guizhi Tang prescription."
Treat Taiyang Wind-strike (Taiyang Fengzhong) where the exterior syndrome has resolved, yet there is sweating without aversion to cold, interior fluid-qi, dysuria, vomiting and regurgitation, shortness of breath, and distending fullness, hardness, and pain from the epigastrium to the hypochondrium. This is an urgent and potent formula for treating water retention.
Dazao (broken open) ten pieces; Gansui (Kansui Radix), Daji (Euphorbiae Pekinensis Radix), Yuanhua (Genkwa Flos [roasted]) in equal parts. The above three herbs are separately pounded into powder. Take one sheng and half liang of water, first boil ten large Dazao until reduced to eight ge. Remove the dregs, then add the herbal powders. For robust individuals, administer one qian; for frail individuals, administer half a qian. Take warm on an empty stomach at dawn. If bowel movement is insufficient and the pathogen remains, administer again the next day, increasing by half a qian. After rapid purgation, nourish oneself with millet porridge.
[Collected Annotations] Ke Qin stated: Zhang Zhongjing's formulas for treating fluid-qi vary greatly; this is the most峻猛 (potent/severe) among them. Generally, when fluid-qi causes pathology, it may manifest as wheezing, coughing, palpitations, choking, vomiting, or diarrhea, stopping within one location. Here, however, evil-fluid stagnates and knots in the middle jiao, causing distending fullness, hardness, and pain in the heart and abdomen, blocking the ascending and descending qi mechanisms of the three jiao. At this time, exterior pathogens have ceased, making sweating and dispersing methods inappropriate. Interior fluid-excess is severe, exceeding the capacity of bland leaching agents. Without selecting the most potent water-draining substances to subdue it, the middle qi would collapse, leaving one helpless awaiting death. Gansui, Yuanhua, and Daji are all bitter, pungent, cold in nature, and possess extreme toxicity. Used together, their flavors complement and enhance each other, allowing them to attack the nest of evil-fluid, dredge the waterways, and purge vigorously, resolving the illness in one stroke. However, where evil gathers, qi must be deficient; using toxic drugs to attack pathogens inevitably damages the spleen and stomach. Without sweet and緩 (soothing/moderating) substances as masters, once the evil is eliminated, life itself would perish. Since these drugs are extremely toxic, Renshen (Ginseng Radix) and Baizhu cannot serve as sovereigns, and Gancao (Licorice Root) is contraindicated (Eighteen Incompatibilities). Therefore, ten large and plump Dazao are chosen as the sovereign herb: to protect the spleen and stomach, and to moderate the harsh toxicity. After rapid purgation, consuming millet porridge serves two purposes: to fill the interior with grain qi and to prevent the recurrence of pathogens. This is Zhang Zhongjing's method of using toxic drugs to attack disease—perfect in beauty and perfection. Ignorant people, confused by the theory that "sweetness causes middle-fullness," dare not use it, failing to understand the principle of mutual restraint and control.