葛根半筋 黄芩三两 黄连三两 甘草（炙）二两
右四味，以水八升，先煮葛根，减二升，内诸药，煮取二升，去滓，分温再服。
【集解】
柯琴曰：外热不除，是表不解；下利不止，是里未和。误下致利，病因则同。一则脉
微弱，心下痞□，是脉不足而证有余也；一则脉促而喘反汗自出，是脉有余而证不足
也。表里、虚实，当从脉辨，况弱脉见于数下后，则痞□为虚，更可知也。故用理中
之辛甘温补，止下利化痞□，，又加桂枝以解表。先煮四味，后内桂枝，和中之力饶
，而解肌之气锐，是于两解中寓权宜法也。桂枝证本脉缓，误下后而反促，阳气内盛
，邪蒸于外，故汗出也；热暴于内，火逆上冲，故为喘也；暴注下迫，故为利也。故
君清轻升发之葛根，以解肌而止利；佐苦寒清肃之芩连，以止汗而定喘；又加甘草以
和中。先煮葛根，后内诸药，解肌之力纯，而清中之气锐，又与补中逐邪者殊法矣。
太阳病，下之后，脉促胸满者，桂枝去芍药汤主之。若微恶寒者，去芍药方中，加附
子汤主之。
【按】
若微恶寒者，当是汗出微恶寒方合。若无「汗出」二字，乃表未解，无取乎加附子也
。
【注】
太阳病，表未解而下之，胸实邪陷，则为胸满，气上冲咽喉不得，息瓜蒂散证也。胸
虚邪陷，则为气上冲，桂枝汤证也。今下之后，邪陷胸中，胸满脉促，似乎胸实而无
冲喉不得息之证，似乎胸虚又见胸满之证，故不用瓜蒂散以治实，亦不用桂枝汤以治
虚，惟用桂枝之甘辛，以和太阳之表，去芍药之酸收，以避胸中之满。若汗出微恶寒
，去芍药方中加附子主之者，以防亡阳之变也。
【按】
上条脉促，喘而汗出不恶寒，下利不止，云属实热。此条脉促胸满，汗出微恶寒，不
喘不下利，反属虚寒者何也？上条是里热蒸越之汗，故汗出不恶寒，阳实也，喘而下
利，皆为热也。此条乃表阳不固之汗，故汗出微恶寒，阳虚也，即不喘利亦为寒也。
要知仲景立法，每在极微处设辨，恐人微处易忽也。今以微恶寒发其义，却不在汗出
上辨寒热，而在汗出恶寒、不恶寒上辨寒热；不在脉促上辨寒热，而在脉促之有力、
无力辨寒热。于此又可知不惟在胸满上辨虚实，而当在胸满之时满、时不满、常常满
而不减上辨虚实矣。
【集注】
喻昌曰：此条之微恶寒，合上条观之，则脉促、胸满、喘而汗出之内，原伏有虚阳欲
脱之机。故仲景于此条，特以「微恶寒」三字发其义，可见阳虚则恶寒矣。又可见汗
不出之恶寒，即非阳虚矣。
程应旄曰：有阳盛而见促脉，亦有阳虚而见促脉者，当辨之于有力无力，仍须辨之于
外证也。
沈明宗曰：误下扰乱阴阳之气则脉促，邪入胸膈几成结胸，但结满而未痛耳！故以桂
枝汤单提胸膈之邪，使从表解。去芍药者，恶其酸收，引邪内入故也。若脉促胸满、
而微恶寒，乃虚而跼踖，阳气欲脱，又非阳实之比，所以加附子固护真阳也。然伤风
下后之恶寒，与未下之恶寒，回然有别。而汗后之恶寒，与未汗之恶寒亦殊。
葛根半斤，黄芩三两，黄连三两，甘草（炙）二两。
以上四味药，用水八升，先煮葛根，水量减少二升后，加入其余药物，煎煮至取药液二升，滤去药渣，分两次温服。
【集解】
柯琴说：体表发热不退，说明表证未解；腹泻不止，说明里气不和。因误用下法导致腹泻，病因是相同的。一种情况是脉象微弱，心下痞塞胀满，这是脉象显示正气不足而症状表现为邪气有余；另一种情况是脉象急促且喘息反而伴有自汗，这是脉象显示邪气有余而症状表现为正气不足。表证与里证、虚证与实证，应当通过脉象来辨别，何况弱脉出现在多次误下之后，那么心下痞塞胀满属于虚证，就更可以推知了。所以使用理中汤的辛甘温补之法，以止住腹泻并化解心下痞塞胀满，又加入桂枝以解除表邪。先煮前四味药，后加入桂枝，使得调和中焦的力量雄厚，而解除肌表的药效锐利，这是在表里双解之中寓含权宜变通之法。桂枝证原本脉象缓弱，误下之后反而出现促脉，说明阳气内盛，邪气蒸腾于外，所以出汗；热势暴烈于内，火气逆上冲，所以发生喘息；急迫泄泻，所以发生腹泻。因此，以清轻升发的葛根为君药，以解除肌表之邪并止住腹泻；以苦寒清肃的黄芩、黄连为佐药，以止住汗出并平定喘息；又加入甘草以调和中焦。先煮葛根，后加入其余药物，使得解除肌表的药效纯粹，而清泄中焦热邪的药效锐利，这与补益中气、驱逐邪气的方法截然不同。
太阳病，经过攻下治疗后，脉象急促且胸部胀满的，主治方剂是桂枝去芍药汤。如果伴有轻微恶寒的，在去芍药方的基础上，加附子汤主治。
【按】
如果有轻微恶寒的情况，应当是“汗出且轻微恶寒”这一方证相合。如果没有“汗出”二字，则是表证未解，不需要使用加附子的方法。
【注】
太阳病，表证未解而误用攻下法，胸中实邪内陷，就会造成胸部胀满，气向上冲击咽喉导致呼吸困难，这是瓜蒂散的主治证候。胸中虚邪内陷，就会造成气向上冲逆，这是桂枝汤的主治证候。现在攻下之后，邪气陷入胸中，胸部胀满且脉象急促，似乎像胸实证却没有冲击咽喉导致呼吸困难的证候，似乎又像胸虚证却又见胸部胀满的证候，所以不用瓜蒂散治疗实证，也不用桂枝汤治疗虚证，只用桂枝的甘辛之性，来调和太阳经的表邪，去掉芍药的酸收之性，以避免加重胸中的胀满。如果伴有汗出和轻微恶寒，在去芍药方中加入附子主治，是为了防止亡阳的变证。
【按】
上一条所述脉象急促，喘息且出汗但不恶寒，腹泻不止，判定为实热证。这一条所述脉象急促、胸部胀满、出汗且轻微恶寒，不喘也不腹泻，反而属于虚寒证，为什么呢？上一条是里热蒸腾外越导致的汗出，所以出汗且不恶寒，这是阳气实证，喘息和腹泻都是热证。这一条是表阳不固导致的汗出，所以出汗且轻微恶寒，这是阳气虚证，即使不喘也不腹泻也是寒证。要知道张仲景确立法则，往往在极其细微之处进行鉴别，是担心人们在细微处容易疏忽。现在以“轻微恶寒”来阐发其义，不在“汗出”这一点上辨别寒热，而在“汗出伴恶寒”与“汗出不恶寒”上辨别寒热；不在“脉促”这一点上辨别寒热，而在“脉促有力”与“脉促无力”上辨别寒热。从这里又可以知道，不仅要在胸部胀满上辨别虚实，而且应当在胸部胀满是时作时止、还是持续胀满不减上来辨别虚实。
【集注】
喻昌说：这一条的“轻微恶寒”，结合上一条来看，则在脉象急促、胸部胀满、喘息且出汗之内，原本潜伏着虚阳欲脱的机转。所以张仲景在这一条中，特意用“轻微恶寒”三个字来阐发其义，可见阳气虚则恶寒。又可见不出汗的恶寒，就不是阳气虚了。
程应旄说：有阳气盛而出现促脉的，也有阳气虚而出现促脉的，应当辨别其有力或无力，仍然需要结合外在证候来辨别。
沈明宗说：误用下法扰乱阴阳之气则脉象急促，邪气进入胸膈几乎形成结胸证，只是结聚胀满而没有疼痛罢了！所以用桂枝汤单独提举胸膈之邪，使其从表而解。去掉芍药的原因，是厌恶其酸收之性，会引邪气向内深入。如果脉象急促、胸部胀满且轻微恶寒，这是正气虚弱而局促不安，阳气欲脱，又不是阳气实证可比，所以加入附子以固护真阳。然而伤风误下后的恶寒，与未误下的恶寒，截然不同。而发汗后的恶寒，与未发汗的恶寒也各不相同。
Radix Puerariae (Ge Gen) 8 liang, Radix Scutellariae (Huang Qin) 3 liang, Rhizoma Coptidis (Huang Lian) 3 liang, Radix Glycyrrhizae (Gan Cao), prepared (Zhi) 2 liang.
The above four ingredients are decocted with eight sheng of water. First, boil the Radix Puerariae until the volume decreases by two sheng. Then add the remaining herbs, and continue boiling until two sheng of liquid remains. Strain out the dregs, and divide into two doses to be taken warm.
[Collected Explanations]
Ke Qin stated: The persistence of external heat indicates that the exterior syndrome is not resolved; the continuous diarrhea indicates that the interior qi is not harmonized. Although the etiology of diarrhea caused by erroneous purgation is the same, there are distinctions. In one case, the pulse is faint and weak, and there is epigastric fullness and obstruction (Pi Zhang); this indicates that the pulse reflects deficiency of righteous qi while the symptoms reflect excess of pathogenic factors. In another case, the pulse is rapid and intermittent (Cu Mai), accompanied by wheezing and spontaneous sweating; this indicates that the pulse reflects excess of pathogenic factors while the symptoms reflect deficiency of righteous qi. Exterior vs. Interior, and Deficiency vs. Excess should be differentiated based on the pulse. Moreover, since a weak pulse appears after multiple erroneous purgations, it can be further deduced that the epigastric fullness and obstruction is due to deficiency. Therefore, the acrid-sweet-warm tonifying method of Lizhong Tang is used to stop diarrhea and resolve epigastric fullness and obstruction, and Guizhi Tang (Cinnamon Twig Decoction) is added to release the exterior. By decocting the first four ingredients first and adding Guizhi later, the power to harmonize the middle jiao is profound, while the energy to relieve the muscle layer is sharp. This embodies a flexible approach within simultaneous resolution of both exterior and interior. The Guizhi pattern originally presents with a slow pulse; after erroneous purgation, the pulse becomes rapid and intermittent, indicating internal abundance of yang qi and pathogenic steaming outward, causing sweating. Heat raging internally causes fire to rebel and rush upward, resulting in wheezing; sudden urgent diarrhea results in purging. Therefore, Ge Gen, which is clear, light, ascending, and stimulating, is used as the sovereign herb to relieve the muscle layer and stop diarrhea; Huang Qin and Huang Lian, which are bitter and cold, clearing and肃 (descending), are used as assistant herbs to stop sweating and calm wheezing; Gan Cao is added to harmonize the middle. By decocting Ge Gen first and adding other herbs later, the power to relieve the muscle layer is pure, and the qi to clear the interior is sharp, which is distinct from methods that tonify the middle and expel pathogens.
In Taiyang disease, if after purgation the pulse is rapid and intermittent (Cu Mai) and there is chest fullness, Guizhi Qu Shaoyao Tang (Cinnamon Twig Decoction without Paeonia) is the primary formula. If there is slight aversion to cold, Fuzi Tang (Aconite Decoction) added to the Guizhi Qu Shaoyao Tang formula is the primary treatment.
[Commentary]
If there is slight aversion to cold, it should correspond to the pattern of "sweating with slight aversion to cold." Without the phrase "sweating," it indicates the exterior is not yet resolved, and there is no need to use the formula with added Fuzi.
[Annotation]
In Taiyang disease, if the exterior is not resolved and purgation is erroneously applied, real pathogenic factors sinking into the chest cause chest fullness, with qi rushing up to the throat causing dyspnea; this is the indication for Goudi San (Melon Seed Powder). If deficient pathogenic factors sink into the chest, it causes qi rushing upward, which is the indication for Guizhi Tang. Now, after purgation, pathogenic factors sink into the chest, causing chest fullness and a rapid and intermittent pulse. It seems like a chest excess pattern but lacks the symptom of qi rushing to the throat causing dyspnea; it seems like a chest deficiency pattern but presents with chest fullness. Therefore, Goudi San is not used to treat excess, nor is Guizhi Tang used to treat deficiency. Instead, the sweet and acrid nature of Guizhi is used to harmonize the Taiyang exterior, and the sour-astringent nature of Shaoyao is removed to avoid aggravating the chest fullness. If there is sweating and slight aversion to cold, adding Fuzi to the Guizhi Qu Shaoyao Tang formula is used to prevent the complication of Yang collapse.
[Commentary]
The previous clause described a rapid and intermittent pulse, wheezing, sweating, aversion to cold absent, and continuous diarrhea, classified as an Excess-Heat syndrome. This clause describes a rapid and intermittent pulse, chest fullness, sweating, slight aversion to cold, no wheezing, and no diarrhea, classified as a Deficiency-Cold syndrome. Why? The sweating in the previous clause was caused by internal heat steaming outward, hence sweating without aversion to cold, representing Yang Excess; wheezing and diarrhea were both Heat syndromes. The sweating in this clause was caused by failure of Exterior Yang to secure, hence sweating with slight aversion to cold, representing Yang Deficiency; even without wheezing or diarrhea, it is a Cold syndrome. One must understand that Zhang Zhongjing established his principles by distinguishing at extremely subtle points, fearing that people might overlook these subtleties. Here, he uses "slight aversion to cold" to elucidate the meaning. The differentiation of Cold vs. Heat is not based on "sweating," but on "sweating with aversion to cold" versus "sweating without aversion to cold"; it is not based on "rapid and intermittent pulse," but on whether the pulse is "forceful" or "weak." From this, we can also know that differentiation of Deficiency vs. Excess is not only based on chest fullness, but also on whether the fullness is intermittent or constant and unrelenting.
[Collected Notes]
Yu Chang said: Observing the "slight aversion to cold" in this clause together with the previous one reveals that within the rapid and intermittent pulse, chest fullness, wheezing, and sweating, there was originally a latent mechanism of collapsing deficient Yang. Thus, Zhang Zhongjing specifically used the three characters "slight aversion to cold" to elucidate the principle, showing that Yang deficiency leads to aversion to cold. It also shows that aversion to cold without sweating is not due to Yang deficiency.
Cheng Yingmao said: There are cases where Yang excess presents with a rapid and intermittent pulse, and cases where Yang deficiency presents with such a pulse. One must differentiate based on forcefulness or weakness, and still rely on external symptoms for differentiation.
Shen Mingzong said: Erroneous purgation disturbs the qi of Yin and Yang, leading to a rapid and intermittent pulse. Pathogens enter the chest and diaphragm, nearly forming Jie Xiong (Chest Binding), but there is only fullness and obstruction without pain. Therefore, Guizhi Tang is used to lift the pathogen from the chest and diaphragm so it may be resolved from the exterior. Shaoyao is removed because its sour-astringent nature is disliked, as it would draw pathogens inward. If the pulse is rapid and intermittent, there is chest fullness, and slight aversion to cold, this indicates deficiency and constriction, with Yang Qi about to collapse, which is not comparable to Yang Excess. Therefore, Fuzi is added to protect the True Yang. However, aversion to cold after purgation for wind injury is completely different from aversion to cold before purgation. Similarly, aversion to cold after sweating is different from aversion to cold before sweating.