（此方自原论中第十卷采附于此）
于桂枝汤方内更加芍药三两。通前共六两。余根据桂枝汤法。
琥按上方。乃治太阳表邪未尽。太阴里气虚热。而腹痛者也。武陵陈氏云。上证原从误治。引太阳之邪入里。其邪
未尽离乎太阳。未全归于太阴。自表而入。还欲其自表而出。故仍用桂枝汤。驱太阳未尽之邪。况桂枝辛温。建中亦可
温中而救。误下之害其加芍药者。专主腹痛。腹痛宜和。凡属寒之痛。宜姜附之热以和之。而芍药在所不用。属热之痛。
宜芍药之寒以和之。而姜附又非所宜。此阳经之邪。侵入太阴作痛者。故当以芍药和之。芍药性寒。寒能御热而泻侵脾
之热邪。芍药味酸。酸能收敛脾气。使不受外邪所侵。此其所以用桂枝汤而加芍药也。后世不论寒痛热痛。而概用芍药
者。岂不谬哉。
大实痛者。桂枝加大黄汤主之。（此承上文而言。如腹满痛甚。又为大实之证。其用桂枝汤。不可加芍药以治之。何
也。以其人胃家本实。虽因太阳病误下。热邪传入太阴之经。然太阴之邪。已归阳明而入于府。此非里虚痛。乃里实痛
也。成注云。大实大满。自可下除之。故加大黄以下里实。其仍用桂枝汤者。以太阳之邪。犹未尽故也。）
（此方自原论中第十卷采附于此）
桂枝（三两去皮） 大黄（一两） 芍药（六两） 生姜（三两切） 甘草（二两炙） 大枣（十二枚擘）
上六味。以水七升。煮取三升。去滓温服一升。日三服。
琥按上方仲景既云。加大黄。则不当加芍药矣。而方中用芍药至六两。所以条辩云。此皆后人之苟用者。当斟酌
也。内台于上方。止用赤芍药一两。虽变仲景之法。实得用药之旨。
内台方议曰。表邪未罢。若便下之。则虚其中。邪气反入里。若脉虚弱。因而腹满时痛者。乃脾虚也。不可再下急
与桂枝加芍药汤。以止其痛。若脉沉实。大实而痛。以手按之不止者。乃脾实也。
即胃实急宜再下。与桂枝汤以和表。加芍药大黄。以攻其里。且赤芍药性凉而能泻中。大黄苦寒而能除其实。泻其
脾也。
内台方疑问曰。桂枝加芍药汤用白芍药。加大黄汤用赤芍药。二证皆同。何得有异答曰。白芍药能补脾止痛。赤芍
药能泻脾利痛。前证加芍药汤。乃治虚邪。后证加大黄汤。乃治实邪。以此虚实之不同。故补泻之有异。非明智者孰能
辩之。
琥又按上桂枝加大黄汤。仲景虽入太阴经例实则治太阳阳明之药也。与大柴胡汤治少阳阳明证义同。
太阴为病脉弱。其人续自便利。设当行大黄芍药者宜减之。以其人胃气弱。易动故也。（此承上两节而言。太阴病者。
腹满时痛是也。但腹满痛者。其脉未必尽弱。今者太阴之脉既弱。其人肠胃之气。必不能固。其大便必接续。自利而通。
设于未利之先。当行大黄芍药者。方中宜减用之。以其人脉弱。则胃气亦弱。大便易于动利故也。诊其脏脉。可以知腑。
医人用药。可不详慎。以保其中州之气乎。或问大黄能伤胃气。故宜减芍药能扶脾阴。何以减之。余答云。脉弱而胃气
弱者。弱则气馁不充。仲景以甘温之药能生气。芍药之味酸寒。虽不若大黄之峻。要非气弱者所宜多用。以故减之亦宜。）
（琥）按以上方论。乃仲景治太阴病法也。要之人病太阴伤寒。其脉证实不止此。学人须于昔贤方论。参合用之。
（此方从《伤寒论》原书第十卷摘录附于此）
在桂枝汤的基础上增加芍药三两。总计芍药用量为六两。其余煎服方法均依照桂枝汤的法度进行。
琥按：上述方剂，是用于治疗太阳表邪尚未完全解除，同时太阴里气虚弱伴有虚热，从而出现腹痛的病症。武陵陈氏说：上述证候原本是由于误治引起，导致太阳之邪内传入里。此时邪气既未完全离开太阳经，也未完全归入太阴经。病邪自表而入，治疗上仍希望它从表而解。因此仍然使用桂枝汤，来驱散太阳未尽之邪。况且桂枝性味辛温，既能建立中气，也能温中救助因误下造成的伤害。之所以加入芍药，专门是为了治疗腹痛。腹痛适宜用调和之法。凡是属于寒性的疼痛，适宜用干姜、附子等大热之药来调和，此时不宜使用芍药；凡是属于热性的疼痛，适宜用芍药的寒性来调和，此时干姜、附子又不适宜。这是阳经之邪侵入太阴引起疼痛的情况，所以应当用芍药来调和。芍药性寒，寒性能抵御热邪并泻除侵犯脾脏的热邪；芍药味酸，酸性能够收敛脾气，使其不受外邪侵袭。这就是为什么在桂枝汤中加入芍药的原因。后世医生不论寒痛还是热痛，一概使用芍药，这难道不是错误的吗？
如果是大实痛，则主用桂枝加大黄汤。（这是承接上文而言。如果腹部胀满疼痛非常严重，又属于大实证，此时使用桂枝汤，就不应该加芍药来治疗了。为什么呢？因为患者胃家本实，虽然是因为太阳病误下，导致热邪传入太阴经，但太阴的邪气已经归入阳明并进入腑。这不是里虚引起的疼痛，而是里实引起的疼痛。成无己注解说：大实大满，自然可以通过攻下法去除，所以加入大黄以攻下里实。之所以仍用桂枝汤，是因为太阳之邪尚未完全解除的缘故。）
（此方从《伤寒论》原书第十卷摘录附于此）
桂枝（三两，去皮） 大黄（一两） 芍药（六两） 生姜（三两，切） 甘草（二两，炙） 大枣（十二枚，掰开）
以上六味药，用水七升，煮取三升，去渣，温服一升，每日三次。
琥按：上述方剂，仲景既然说了加大黄，按理说不应当再加芍药了。但方中芍药用量高达六两。所以条辩中说：这都是后人随意使用的结果，应当斟酌考量。《内台方议》在上述方剂中，只使用赤芍药一两。虽然改变了仲景的法度，但实际上得到了用药的精义。
《内台方议》说：表邪未罢，如果立即攻下，会导致中焦空虚，邪气反而陷入里。如果脉象虚弱，因而出现腹满时痛，这是脾虚，不可再攻下，应立即给予桂枝加芍药汤，以止其痛。如果脉象沉实，大实且痛，用手按压疼痛不缓解的，这是脾实。
即胃实，急宜再次攻下。给予桂枝汤以调和表邪，加入芍药和大黄，以攻逐里实。而且赤芍药性凉能泻中焦，大黄苦寒能消除实邪，以泻脾实。
《内台方疑问》说：桂枝加芍药汤使用白芍药，桂枝加大黄汤使用赤芍药，两个证候相同，为什么会有区别？回答说：白芍药能补脾止痛，赤芍药能泻脾利痛。前一个证候加芍药汤，是治疗虚邪；后一个证候加大黄汤，是治疗实邪。因为虚实不同，所以补泻有别。如果不是明智之人，谁能辨别呢？
琥又按：上述桂枝加大黄汤，仲景虽然将其列入太阴经的范畴，但实际上是治疗太阳阳明病的药物。这与大柴胡汤治疗少阳阳明证的义理相同。
太阴病脉象弱，其人持续自行大便通畅。假设应当使用大黄、芍药的，应当减量使用。因为患者胃气虚弱，容易动泄。（这是承接上面两节而言。太阴病，表现为腹满时痛。但是腹满痛的人，脉象未必都弱。现在太阴脉既已弱，其人肠胃之气必然不能固摄，其大便必定接续不断，自行通利。如果在尚未通利之前，应当使用大黄、芍药的，方中应当减少用量。因为患者脉弱，则胃气也弱，大便容易动泄。诊察脏脉，可以推知腑病。医生用药，能不详细审慎，以保全其中州脾胃之气吗？有人问：大黄能伤胃气，所以应当减量；芍药能扶助脾阴，为什么要减量？我回答说：脉弱而胃气弱者，弱则气馁不充。仲景认为甘温的药物能生气，芍药味酸寒，虽然不如大黄峻烈，但对于气虚者也不宜多用。因此减量也是适宜的。）
(This prescription is excerpted from Volume 10 of the original *Shanghan Lun* and attached here.)
Add three liang of Shaoyao (Paeoniae Radix) to the Guizhi Tang (Cinnamon Twig Decoction). The total amount of Shaoyao becomes six liang. All other decoction and administration methods follow the principles of Guizhi Tang.
Hu notes: The above prescription is used to treat cases where the pathogenic factor of Taiyang exterior syndrome (disease pattern caused by invasion of the Taiyang channel) has not yet completely resolved, while there is deficiency-heat in the interior of the Taiyin spleen/stomach, resulting in abdominal pain. Chen Wuling stated: The aforementioned syndrome originally resulted from mis-treatment, causing the Taiyang pathogen to enter the interior. At this stage, the pathogen has neither fully left the Taiyang nor completely entered the Taiyin. Since the disease entered from the exterior, treatment should still aim to expel it via the exterior. Therefore, Guizhi Tang is still employed to drive out the residual Taiyang pathogen. Moreover, Guizhi is acrid and warm; it can establish the middle jiao and warm the middle to remedy the harm caused by inappropriate purgation. The reason for adding Shaoyao is specifically to treat abdominal pain. Abdominal pain requires harmonization. For pain due to cold, hot herbs like Jiang (Zingiberis Rhizoma) and Fu Zi (Aconiti Lateralis Preparata Radix) are suitable for harmonization, whereas Shaoyao should not be used. For pain due to heat, the cooling nature of Shaoyao is suitable for harmonization, while Jiang and Fu Zi are inappropriate. This is a case where a pathogen from a Yang channel invades the Taiyin, causing pain; thus, Shaoyao should be used to harmonize. Shaoyao is cold in nature; its coldness can resist heat and drain the heat pathogen invading the spleen. Shaoyao is sour in taste; its sourness can astringe Spleen Qi, preventing invasion by external pathogens. This explains why Shaoyao is added to Guizhi Tang. In later generations, physicians indiscriminately use Shaoyao for both cold and heat pains; is this not erroneous?
If there is severe excess pain (Da Shi Tong), Guizhi Jia Dahuang Tang (Cinnamon Twig Decoction with Added Rheum) is the primary prescription. (This follows the previous discussion. If abdominal fullness and pain are severe, indicating an Excess syndrome, using Guizhi Tang without adding Shaoyao is necessary. Why? Because the patient's Stomach house is inherently full/excess. Although the heat pathogen was transmitted to the Taiyin channel due to mis-purgation of a Taiyang disease, the Taiyin pathogen has already merged with Yangming and entered the fu organs. This is not pain due to interior deficiency, but pain due to interior excess. Cheng Wuji’s commentary states: Severe excess and fullness can naturally be removed by purgation; hence, Dahuang (Rhei Radix et Rhizoma) is added to purge interior excess. The reason for still using Guizhi Tang is that the Taiyang pathogen has not yet completely resolved.)
(This prescription is excerpted from Volume 10 of the original *Shanghan Lun* and attached here.)
Guizhi (Cinnamomi Ramulus, 3 liang, bark removed), Dahuang (Rhei Radix et Rhizoma, 1 liang), Shaoyao (Paeoniae Radix, 6 liang), Shengjiang (Zingiberis Rhizoma Recens, 3 liang, sliced), Gancao (Glycyrrhizae Radix et Rhizoma, 2 liang, honey-fried), Dazao (Ziziphi Jujubae Fructus, 12 pieces, split open).
The above six ingredients are boiled in seven sheng of water until reduced to three sheng. Strain the dregs and take one sheng warm, three times daily.
Hu notes: Regarding the above prescription, since Zhongjing specified adding Dahuang, theoretically, Shaoyao should not have been added. Yet, the formula uses six liang of Shaoyao. Therefore, the *Tiaobian* states: These are arbitrary usages by later generations and require careful consideration. *Neitai Fangyi* uses only one liang of Chishaoyao (Red Paeonia Root) in the above prescription. Although this alters Zhongjing’s method, it actually captures the essence of herbal usage.
*Neitai Fangyi* states: If exterior pathogenic factors have not subsided, immediate purgation will cause deficiency in the middle jiao, allowing pathogens to sink into the interior. If the pulse is weak and accompanied by intermittent abdominal fullness and pain, this indicates Spleen deficiency. Further purgation is contraindicated; instead, Guizhi Jia Shaoyao Tang (Cinnamon Twig Decoction with Added Paeonia) should be administered immediately to stop the pain. If the pulse is deep and solid, with severe excess pain unrelieved by pressure, this indicates Spleen excess.
In cases of Stomach excess, urgent secondary purgation is required. Administer Guizhi Tang to harmonize the exterior, and add Shaoyao and Dahuang to attack the interior. Chishaoyao is cool and can drain the middle; Dahuang is bitter and cold and can eliminate excess, thereby draining the Spleen.
*Neitai Fangyi Yiwenn* asks: Guizhi Jia Shaoyao Tang uses Baishaoyao (White Paeonia Root), while Guizhi Jia Dahuang Tang uses Chishaoyao. The syndromes are similar; why the difference? The answer is: Baishaoyao tonifies the Spleen and stops pain, while Chishaoyao drains the Spleen and relieves pain. The former prescription treats deficiency pathogens, while the latter treats excess pathogens. Due to the difference between deficiency and excess, the approaches of tonification and drainage differ. Only a wise person can distinguish them.
Hu further notes: Although Zhongjing included Guizhi Jia Dahuang Tang under the Taiyin channel examples, it is essentially a formula treating Taiyang-Yangming diseases. Its principle is similar to Da Chaihu Tang (Major Bupleurum Decoction) treating Shaoyang-Yangming syndromes.
In Taiyin disease, the pulse is weak, and the patient experiences continuous spontaneous bowel movements. If Dahuang or Shaoyao were indicated, they should be reduced in dosage. This is because the patient’s Stomach Qi is weak and prone to loose stools. (This follows the previous two sections. Taiyin disease presents with intermittent abdominal fullness and pain. However, patients with abdominal fullness and pain do not necessarily have a weak pulse. Now that the Taiyin pulse is weak, the Qi of the intestines and stomach cannot remain secure, leading to continuous spontaneous diarrhea. If, before the onset of diarrhea, Dahuang and Shaoyao were deemed necessary, their dosage in the formula should be reduced. Because a weak pulse indicates weak Stomach Qi, making loose stools more likely. Examining the zang organ pulses allows one to infer the state of the fu organs. Physicians must exercise caution in prescribing to preserve the Qi of the Middle Jiao. A question arises: Dahuang damages Stomach Qi, so it should be reduced; Shaoyao supports Spleen Yin, why reduce it? I reply: When the pulse is weak and Stomach Qi is deficient, the Qi is insufficient. Zhongjing held that sweet-warm herbs generate Qi. Shaoyao is sour and cold; although less harsh than Dahuang, it is not suitable for excessive use in those with Qi deficiency. Hence, reduction is appropriate.)
(Hu) According to the above prescriptions and discussions, this represents Zhongjing’s method for treating Taiyin disease. In summary, for Taiyin Cold Damage, the pulse and excess signs are not limited to these manifestations. Scholars must refer to and integrate the formulas and theories of past sages in their practice.