于桂枝汤方内。去芍药。加附子一枚。炮去皮。破八片。余根据桂枝汤法。
或问太阳病至误下。则脉促胸满。虽邪未结实。恐终非虚寒证。又微恶寒。焉知非表邪盛。便与桂枝汤去芍药。
加附子服之。临期不无所误。奈何。余答云。阳气本虚之人。卒中风寒。逗留太阳寒水之经。表气既虚。里无郁热。
不可发汗。何由更下。一误下之。则病患胸中阳气。欲脱殆尽。纯是阴寒之邪所客。故脉见促而胸满。且微恶寒。
方可用桂枝去芍药。加附子汤。为对证之药。若病患胸中苟有阳气。又当用泻心等汤矣。故余于前法中。曾云。病
人脉促。须辩其有力无力。胸中满。须辩其痛与不痛。恶寒。须辩其可发热。斯临证自无误尔。○尚论篇以胸满为
阳邪仍盛于阳位。且以太阳病桂枝证。医反下之云云。脉促喘而汗出之条。纽合作解云。脉促胸满。喘而汗出之内。
原伏虚阳欲脱之机。又注微恶寒而云。可见汗不出之恶寒。即非阳虚。牵强穿凿。殊悖于理。
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
躁。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。（此条伤寒。乃中寒证。脉浮自汗出。小便数者。阳虚。气
不收摄也。心烦者。真阳虚脱。其气浮游而上走也。恶寒曰微。此真寒之形已见也。脚挛急者。寒入阴经。血脉凝
泣而缩急也。当其时。急宜温经散寒。反与桂枝汤。欲攻其表。非误而何。得汤便厥者。桂枝攻表误汗。更损其阳。
阳愈虚。故手足为之厥冷也。咽中干。烦躁者。误汗损阳。津液耗竭。阳虚烦躁。作假热之象也。吐逆者。阴寒气
盛而拒膈也。因作甘草干姜汤。散寒温中。以复其阳。则厥自愈。足自温。夫足温已有欲伸之机。其尚未伸者。阳
气虽回。阴血未和也。更作芍药甘草汤。以和其营血。而脚即伸。设若胃气不和。谵语者。胃中津液。为前桂枝干
姜等。辛热药所耗。后条辩云。此非胃中实热者比。故少与调胃承气汤和之。乃从治之法也。若不知此证之不可汗。
而重发其汗。复加烧针以劫之。则阳气几亡。阴血复凝。能不急用四逆汤。以回其阳。兼复其阴邪。以四逆汤中有
炙甘草。复能生血故也。证治之难如此。用药者。可无次序乎哉。）
在桂枝汤的方剂中，去掉芍药，加入一枚附子（炮制、去皮、破成八片）。其余部分均依照桂枝汤的煎服方法。
有人问：太阳病（太阳经受邪所致的病证）到了误用下法之后，出现脉促（脉搏急促有力或间歇）和胸满（胸部胀闷），虽然邪气尚未结实，但恐怕终究不是虚寒证。又有轻微恶寒（怕冷），怎么知道不是表邪强盛？于是给予桂枝去芍药加附子汤服用，临证时难道不会有所失误吗？该怎么办？我回答说：阳气本来虚弱的人，突然遭受风寒侵袭，邪气停留在太阳寒水之经。既然表气已经虚弱，体内没有郁热，不可发汗，又怎能再用下法？一旦误用下法，病患胸中的阳气就会几乎脱失殆尽，纯粹是阴寒之邪客居体内，所以脉象表现为促而胸部胀满，并且伴有轻微恶寒。这时才可以使用桂枝去芍药加附子汤，这是对症的药物。如果病患胸中尚存阳气，又应当使用泻心汤类方剂了。所以我之前曾说：病人脉促，必须辨别其有力还是无力；胸部胀满，必须辨别疼痛还是不痛；恶寒，必须辨别是否伴有发热。这样临证自然就不会有误了。○《尚论篇》认为胸满是阳邪仍然盛于阳位，并且将“太阳病桂枝证，医反下之”等条文与“脉促喘而汗出”的条文牵强地解释在一起，说“脉促胸满、喘而汗出”之中，原本潜伏着虚阳欲脱的机理。又注释“微恶寒”时说：“可见汗不出之恶寒，即非阳虚。”这种解释牵强穿凿，严重违背医理。
伤寒病，脉浮，自汗出，小便频数，心烦，轻微恶寒，脚部拘挛急迫，反而给予桂枝汤，想要攻解表邪，这是错误的。服药后随即出现四肢厥冷（手足逆冷）、咽喉干燥、烦躁、呕吐逆气等症状，应制作甘草干姜汤给予患者以恢复其阳气。如果四肢厥冷痊愈、足部转温，再制作芍药甘草汤给予患者，其脚部即可伸展。如果胃气不和，出现谵语（神志不清，胡言乱语），少量给予调胃承气汤。如果再次发汗，并加上烧针治疗，则用四逆汤主治。（这一条所说的伤寒，实际上是中寒证。脉浮、自汗出、小便频数，是因为阳虚，气不能固摄。心烦，是真阳虚脱，气浮游而上走。恶寒称为“微”，说明真寒的征象已经显现。脚部拘挛急迫，是因为寒邪侵入阴经，血脉凝滞收缩急迫。在当时，急需温经散寒，反而给予桂枝汤想要攻表，这不是错误是什么？服药后出现四肢厥冷，是因为桂枝汤攻表导致误汗，进一步损伤阳气，阳气越虚，所以手足为之厥冷。咽喉干燥、烦躁，是因为误汗损伤阳气，津液耗竭，阳虚烦躁，呈现出假热的象。呕吐逆气，是因为阴寒气盛而格拒于膈间。因此制作甘草干姜汤，散寒温中，以恢复阳气，那么厥冷自愈，足部自然转温。足部转温已有想要伸展的迹象，那些尚未伸展的，是因为阳气虽回，但阴血尚未调和。再制作芍药甘草汤，以调和营血，脚部即可伸展。假如胃气不和，出现谵语，是因为胃中津液被前文桂枝、干姜等辛热药物所耗伤。后文辨析说：这并非胃中实热可比拟。所以少量给予调胃承气汤来调和它，这是从治的方法。如果不知道此证不可发汗，而再次发汗，并加上烧针来劫夺正气，那么阳气几乎亡失，阴血再次凝滞，能不急用四逆汤来回阳，兼复阴血吗？因为四逆汤中有炙甘草，又能生血。证治的难度如此，用药者，难道可以不讲究次序吗？）
In the prescription of Guizhi Tang (Cinnamon Twig Decoction), remove Shaoyao (Paeoniae Radix Alba) and add one Fuzi (Aconiti Lateralis Radix Praeparata), which should be processed (pao), peeled, and broken into eight pieces. The remainder follows the method of Guizhi Tang.
Someone asked: When Taiyang disease (disease of the Taiyang channel) progresses to the point of mistaken purgation, resulting in a rapid or intermittent pulse (cui mai) and chest fullness, although the pathogenic factor has not yet solidified, it is feared that this is ultimately not a deficiency-cold syndrome. Furthermore, with slight aversion to cold, how can one know it is not an excess of exterior pathogenic factors? Thus, administering Guizhi Qu Shaoyao Jia Fuzi Tang (Guizhi Decoction without Paeonia plus Prepared Aconite) might lead to errors at the time of treatment. What should be done? I replied: In individuals whose Yang Qi (vital energy) is originally deficient, sudden exposure to wind-cold causes the pathogen to linger in the Taiyang Water channel. Since the exterior Qi is already deficient and there is no stagnant heat inside, sweating (diaphoresis) is contraindicated; how could purgation be used? Once mistakenly purged, the Yang Qi in the patient's chest will nearly exhaust itself, leaving only Yin-cold pathogens occupying the interior. Therefore, the pulse appears rapid/intermittent with chest fullness and slight aversion to cold. Only then can Guizhi Qu Shaoyao Jia Fuzi Tang be used, as it is the appropriate remedy for the syndrome. If the patient still possesses Yang Qi in the chest, Xie Xin Tang (Drain the Epigastrium Decoction) formulas should be used instead. Hence, I previously stated: When a patient has a rapid/intermittent pulse, one must distinguish whether it is forceful or feeble; regarding chest fullness, one must distinguish between pain and no pain; regarding aversion to cold, one must distinguish whether fever is present. In this way, clinical practice will naturally avoid error. ○ *Shanglun Pian* argues that chest fullness indicates Yang pathogens are still excessive in Yang positions. It forcibly combines the clause "Taiyang disease, Guizhi syndrome, but the physician mistakenly purged" with the clause "rapid pulse, panting, and sweating," interpreting them together to say that within "rapid pulse, chest fullness, panting, and sweating," there is originally a mechanism of deficient Yang about to collapse. It also annotates "slight aversion to cold" by stating, "It can be seen that aversion to cold without sweating is not due to Yang deficiency." This interpretation is forced and artificial, seriously violating medical principles.
In Shanghan disease, if the pulse is floating, there is spontaneous sweating, frequent urination, irritability, slight aversion to cold, and cramping stiffness of the legs, administering Guizhi Tang to attack the exterior is an error. Upon taking it, symptoms such as limb coldness (Jue), dry throat, irritability, and vomiting may arise. One should prepare Gancao Ganjiang Tang (Licorice and Dried Ginger Decoction) to restore their Yang Qi. If the limb coldness resolves and the feet become warm, one should then prepare Shaoyao Gancao Tang (Peony and Licorice Decoction); the legs will then extend. If there is stomach Qi disharmony leading to delirious speech (shanyu), administer a small amount of Tiaowei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction). If heavy sweating is induced again, combined with burning needle therapy, Sini Tang (Frigid Extremities Decoction) should be the primary treatment. (This clause on Shanghan disease actually describes a Zhonghan (cold strike) syndrome. Floating pulse, spontaneous sweating, and frequent urination indicate Yang deficiency where Qi cannot hold and secure. Irritability indicates true Yang deficiency and collapse, with Qi floating upward. Aversion to cold described as "slight" shows that the manifestation of true cold is already visible. Cramping stiffness of the legs indicates cold entering the Yin channels, causing blood vessels to stagnate and contract. At that time, warming the channels and dispersing cold was urgently needed. Instead, giving Guizhi Tang to attack the exterior is indeed an error. Developing limb coldness after taking the decoction occurs because Guizhi Tang attacking the exterior caused mistaken sweating, further damaging Yang. As Yang becomes more deficient, the hands and feet become cold. Dry throat and irritability result from mistaken sweating damaging Yang and exhausting body fluids; Yang deficiency leads to irritability, presenting as false heat. Vomiting and regurgitation occur because Yin-cold pathogens are excessive and rejecting at the diaphragm. Therefore, Gancao Ganjiang Tang is prepared to disperse cold and warm the middle to restore Yang; thus, limb coldness heals spontaneously, and feet become warm. The fact that feet are warm indicates a desire to extend; those not yet extending show that although Yang Qi has returned, Yin Blood is not yet harmonized. Preparing Shaoyao Gancao Tang harmonizes Ying-Blood, allowing the legs to extend. If stomach Qi disharmony leads to delirium, it is because stomach fluids were consumed by the previous acrid-warm herbs like Guizhi and Ganjiang. The subsequent analysis states: this is not comparable to excess heat in the stomach. Thus, a small amount of Tiaowei Chengqi Tang is given to harmonize it, which is a method of treating according to the condition. If one does not realize this syndrome is incompatible with sweating, and induces heavy sweating again, adding burning needles to coerce the Zheng Qi, Yang Qi will nearly perish, and Yin Blood will congeal again. Is it not urgent to use Sini Tang immediately to return Yang and simultaneously restore Yin/Blood? Because Sini Tang contains Zhi Gancao (Honey-fried Licorice), which can generate blood. The difficulty of syndrome differentiation and treatment is so great; can prescribers neglect order?)