于桂枝汤方内。去桂枝。加茯苓白术各三两。余根据前法煎服。小便利则愈。
王宇泰云。或问头项强痛。此邪气仍在表也。虽经汗下而未解。何故去桂加茯苓白
术。是无意于表也。曰、此非桂枝证。乃属饮家也。夫头项强痛。既经汗下而
不解。心下满而微痛。小便不利。此为水饮内蓄。邪不在表。故去桂枝。加茯苓白术。
若得小便利。水饮行。腹满减而热自除。则头项强痛悉愈矣。且如十枣汤证。头亦痛。
乃邪热内蓄而有伏饮。故头痛。其饮水头痛。不须攻表。但宜逐饮。饮尽、则病安矣。
张卿子云。逐饮何不用橘皮半夏。可见此停饮。以胃虚。故无汗耳。与五苓散近似。
伤寒脉浮。自汗出。小便数。心烦、微恶寒。脚挛急。反与桂枝汤。欲攻其表。此
误也。得之便厥咽中干。烦燥。吐逆者。作甘草干姜汤与之。以复其阳。若厥愈足温者。
更作芍药甘草汤与之。其脚即伸。若胃气不和。谵语者。少与调胃承气汤。若重发汗。复
加烧针者。四逆汤主之。
脉浮。自汗出。小便数而恶寒者。阳气不足也。心烦、脚挛急者。阴气不足也。阴阳
血气俱虚。则不可发汗。若与桂枝汤攻表。则又损阳气。故为误也。得之便厥。咽中干。
烦燥。吐逆者。先作甘草干姜汤复其阳气。得厥愈足温。乃与芍药甘草汤。益其阴血。
则脚 得伸。阴阳虽复。其有胃燥谵语。少与谓胃承气汤。微溏以和
其胃。重发汗为亡阳。加烧针则损阴。内经曰。荣气微者。加烧针。则血不流行。重发
汗。复烧针。是阴阳之气大虚。四逆汤以复阴阳之气。
Within the formula of Guizhi Tang (Cinnamon Twig Decoction), remove Guizhi (Cinnamon Twig) and add Fuling (Poria) and Baizhu (Atractylodes Macrocephala Rhizome), each three liang. Prepare and administer the remaining ingredients according to the previous method. The patient will recover when urination becomes smooth.
Wang Yutai stated: One might ask, "Head stiffness and pain indicate that the pathogenic factor remains in the exterior. Although sweating and purging therapies have been applied without resolution, why remove Guizhi and add Fuling and Baizhu? Does this imply neglecting the exterior syndrome?" The response is: This is not a Guizhi Tang syndrome but belongs to patients with retained fluid retention. Head stiffness and pain, which persist despite prior sweating and purging, accompanied by fullness and slight pain in the epigastrium and difficulty in urination, indicate internal accumulation of water-fluids; the pathogen is not in the exterior. Therefore, Guizhi is removed, and Fuling and Baizhu are added. If urination becomes unobstructed, the water-fluids move, abdominal fullness subsides, and heat naturally dissipates, thereby resolving the head stiffness and pain completely. Consider the Shizao Tang (Ten Date Decoction) syndrome, where headache also occurs due to internal accumulation of pathogenic heat and latent fluids causing the headache. In cases of headache caused by drinking water, exterior-releasing therapy is unnecessary; instead, one should only expel the fluids. Once the fluids are eliminated, the disease resolves.
Zhang Qingzi remarked: Why not use Jupi (Tangerine Peel) and Banxia (Pinellia Tuber) to expel fluids? It can be seen that this retention of fluids is due to deficiency of Stomach Qi, resulting in anhidrosis (absence of sweating). This condition is similar to Wuling San (Five-Ingredient Powder with Poria).
In Shanghan (Cold Damage), if the pulse is floating, there is spontaneous sweating, frequent urination, irritability, slight aversion to cold, and cramping of the legs, administering Guizhi Tang to attack the exterior is an error. Following this mistake, the patient may develop cold limbs (Jue), dryness in the throat, irritability, and vomiting or regurgitation. In such cases, prepare Gancao Ganjiang Tang (Licorice and Dried Ginger Decoction) for the patient to restore Yang Qi. If the cold limbs resolve and the feet become warm, subsequently prepare Shaoyao Gancao Tang (Peony and Licorice Decoction) for the patient, allowing the legs to extend. If there is disharmony of Stomach Qi manifesting as delirious speech (Shanyu), administer a small amount of Xiaochengqi Tang or Tiaowei Chengqi Tang (Regulate the Stomach and Purge the Yang Decoction variant). If excessive sweating is induced again, combined with the application of burning needles (Shaozhen), Sini Tang (Frigid Extremities Decoction) should be used as the primary treatment.
Floating pulse, spontaneous sweating, frequent urination, and aversion to cold indicate insufficiency of Yang Qi. Irritability and leg cramps indicate insufficiency of Yin Qi. When both Yin and Yang, as well as Blood and Qi, are deficient, sweating therapy must not be employed. Administering Guizhi Tang to attack the exterior would further damage Yang Qi, constituting an error. Upon developing cold limbs, dry throat, irritability, and vomiting, first prepare Gancao Ganjiang Tang to restore Yang Qi. Once the cold limbs resolve and the feet warm up, then administer Shaoyao Gancao Tang to nourish Yin and Blood, enabling the legs to extend. Although Yin and Yang are restored, if gastric dryness causes delirium, a small amount of Tiaowei Chengqi Tang should be given to slightly loosen the bowels and harmonize the Stomach. Excessive sweating leads to loss of Yang, while burning needles damage Yin. The Neijing (Inner Canon) states: "In cases of faint Ying Qi (Nutritive Qi), applying burning needles causes blood circulation to stagnate." Excessive sweating followed by burning needles results in severe deficiency of both Yin and Yang Qi; Sini Tang is used to restore Yin and Yang Qi.