芍药三两 甘草(炙)二两 附子(炮去皮,破八片)一枚
已上三味,以水五升,煮取一升五合,去滓,分温服。
【集解】
程应旄曰:伤寒发汗一法,原为去寒而设,若表已解,较前反恶寒者,非复表邪可知
。缘汗外泄而表遂虚,故主之以芍药甘草附子汤。芍药得桂枝则发表,得附子则补表
,甘草和中从阴分,敛戢其阳,阳回而虚者不虚矣。
发汗后恶寒者,虚故也;不恶寒但热者,实也,当和胃气,与调胃承气汤。
【注】
伤寒发汗,汗出病解,必不恶寒,亦不恶热,始可为愈。若发汗后恶寒者,是阳虚也
,宜用芍药甘草附子汤主之。今发汗后不恶寒,但恶热,则是胃实也,故与调胃承气
汤泻热以和胃也。
【集注】
方有执曰:发汗后不恶寒,其人表气强也。但热、亡津液而胃中干,故曰实也。当和
胃气,以干在胃而实也。故曰与调胃承气汤所以泻实,而甘草则有泻中调和之义。
程知曰:汗后恶寒,则为荣卫俱虚;汗后不恶寒但发热,则为津干胃实,故有调胃通
津之法。然曰当、曰与,则似深有酌量而不肯妄下,以重虚其津者。
调胃承气汤方 见阳明篇
脉浮紧者,法当身疼痛,宜以汗解之,假令尺中迟者,不可发汗。何以知之?然以荣
气不足血少故也。
【注】
脉浮紧者,寒伤荣之脉也;身痛者,寒伤荣之证也。脉证皆表实邪,则当发汗,宜麻
黄汤。设若寸关脉浮紧,惟尺中迟者,则又不可发汗。何也?以其人平素荣气不足血
少故也。由此可知,脉阴阳不俱紧,不可轻汗也。
【集注】
方有执曰:尺以候阴,迟为不足,荣主血,汗者血之液,尺迟不宜汗者,嫌夺血也。
张璐曰:尺中脉迟,不可用麻黄发汗,当频与小建中汤和之。和之而邪解,不须发汗
;设不解,不妨多与之,覆而汗之可也。
发汗后,身疼痛,脉沉迟者,桂枝加芍药生姜各一两,人参二两,新加汤主之。
【注】
发汗后,身疼痛脉浮紧或浮数,乃发汗未彻,表邪未尽也,仍当汗之,宜桂枝汤。今
发汗后身虽疼痛,脉见沉迟,是荣卫虚寒,故宜桂枝新加汤,以温补其荣卫也。
【集注】
成无己曰:表邪盛则身疼,血虚亦身疼。其脉浮紧者邪盛也,脉沉迟者血虚也。盛者
损之则安,虚者益之则愈。
喻昌曰:脉沉迟者,六部皆然,与尺迟大异。尺迟乃素虚,此为发汗所虚,故于桂枝
方中,倍加芍药生姜各一两以去邪,加人参三两以补正。名曰新加汤者,明非桂枝汤
中之旧法也。
汪琥曰:身疼痛脉沉迟,焉知非中寒证?要知此证,乃太阳伤寒发汗后身疼不止,脉
变沉迟,非中寒比也。
芍药三两,甘草(炙)二两,附子(炮制后去皮,破成八片)一枚。
以上三味药,用水五升,煎煮至取汁一升五合,滤去药渣,分两次温服。
【集解】
程应旄说:伤寒发汗这一治法,原本是为了祛除寒邪而设立的。如果表证已经解除,反而比之前更怕冷,这就知道不再是表邪了。因为汗液外泄导致卫表虚弱,所以主治用芍药甘草附子汤。芍药配合桂枝能发散表邪,配合附子则能温补卫表;甘草调和脾胃之气,从阴分收敛阳气,阳气回复而虚损得以填补,虚象就不存在了。
发汗后出现怕冷的,是正气虚的缘故;不怕冷只发热的,是实证,应当调和胃气,给予调胃承气汤。
【注】
伤寒经过发汗治疗,汗出后病愈,一定既不恶寒也不恶热,这才算是痊愈。如果发汗后仍然怕冷,这是阳气虚衰,适宜用芍药甘草附子汤主治。现在发汗后不怕冷,只怕热,这是胃中实热,所以给予调胃承气汤泻除热邪以调和胃气。
【集注】
方有执说:发汗后不怕冷,说明此人表气强盛。只是发热、津液耗亡导致胃中干燥,所以称为实证。应当调和胃气,因为病根在胃且属实证。所以说给予调胃承气汤是为了泻除实邪,而其中的甘草则有泻中焦之实并调和的作用。
程知说:发汗后怕冷,就是营卫俱虚;发汗后不怕冷只发热,就是津液干涸、胃中实证,所以有调和胃气、通利津液的方法。然而文中用“当”、“与”等词,似乎经过深思熟虑而不肯轻易用药,以免进一步损伤津液。
调胃承气汤方 见阳明篇
脉象浮紧的,按规定应当身体疼痛,适宜用发汗法解除,假如尺部脉搏迟缓的,不可发汗。为什么这样知道呢?这是因为营气不足、血少的缘故。
【注】
脉象浮紧,是寒邪伤及营分的脉象;身体疼痛,是寒邪伤及营分的症状。脉象和症状都显示为表实邪气,就应当发汗,适宜用麻黄汤。假设寸关脉浮紧,只有尺部脉迟缓的,那么又不可以发汗。为什么呢?因为这个人平素营气不足、血少。由此可知,脉象阴阳两部不都紧实的,不可轻易发汗。
【集注】
方有执说:尺脉候阴,迟脉代表不足,营主血,汗是血的液体表现,尺脉迟缓不宜发汗,是担心夺血。
张璐说:尺中脉迟,不可用麻黄发汗,应当频繁给予小建中汤调和它。调和之后邪气解除,不需要发汗;如果邪气未解,不妨多给几次,覆盖衣被使其出汗即可。
发汗后,身体疼痛,脉象沉迟的,用桂枝加芍药生姜各一两,人参二两的新加汤主治。
【注】
发汗后,身体疼痛,脉象浮紧或浮数,这是发汗不彻底,表邪未尽,仍然应当发汗,适宜用桂枝汤。现在发汗后身体虽然疼痛,脉象呈现沉迟,这是营卫虚寒,所以适宜用桂枝新加汤,来温补营卫。
【集注】
成无己说:表邪盛则身体疼痛,血虚也会身体疼痛。脉象浮紧的是邪气盛,脉象沉迟的是血虚。邪盛的通过损耗(祛邪)就能安宁,血虚的通过补益就能痊愈。
喻昌说:脉象沉迟,是六部脉都如此,与尺脉迟缓大不相同。尺脉迟缓是素体虚弱,此为发汗导致的虚弱,所以在桂枝方中,加倍增加芍药、生姜各一两以祛除邪气,加入人参三两以补益正气。命名为新加汤,表明这不是桂枝汤中的旧法。
汪琥说:身体疼痛脉象沉迟,怎么知道不是中寒证?要知道此证,是太阳伤寒发汗后身体疼痛不止,脉象变为沉迟,不能与中寒证相比。
San Liao (3 qian), Gancao (Zhi) (2 qian), Fuzi (Pao, qu pi, po ba pian) (1 piece).
The above three herbs are boiled in five sheng of water until one sheng and five he remain. The dregs are removed, and the decoction is divided into two doses to be taken warm.
[Ji Jie]
Cheng Yingmao said: The method of inducing sweating for Shanghan was originally established to dispel cold. If the exterior syndrome has resolved but the patient feels more aversion to cold than before, it is evident that this is no longer an exterior pathogen. Since sweat leakage leads to deficiency of the defensive exterior, the main treatment is Shaoyao Gancao Fuzi Tang. When Shaoyao is combined with Guizhi, it releases the exterior; when combined with Fuzi, it tonifies the exterior. Gancao harmonizes the middle jiao and draws from the yin aspect to restrain yang. Once yang returns and deficiency is filled, the state of deficiency ceases to exist.
Aversion to cold after inducing sweating indicates deficiency; absence of aversion to cold but presence of heat indicates excess. One should harmonize the stomach qi and administer Tiaowei Chengqi Tang.
[Zhu]
In Shanghan, if sweating occurs and the disease resolves, there will be neither aversion to cold nor aversion to heat, which signifies recovery. If aversion to cold persists after sweating, it indicates yang deficiency, and Shaoyao Gancao Fuzi Tang is appropriate as the primary treatment. Now, if after sweating there is no aversion to cold but only aversion to heat, this indicates stomach excess. Therefore, Tiaowei Chengqi Tang is given to purge heat and harmonize the stomach.
[Ji Zhu]
Fang Youzhi said: Absence of aversion to cold after sweating indicates strong exterior qi. Heat alone, accompanied by loss of body fluids and dryness in the stomach, constitutes excess. One should harmonize the stomach qi because the pathology lies in the stomach and is excess in nature. Thus, giving Tiaowei Chengqi Tang purges excess, while Gancao within it has the meaning of purging the middle and harmonizing.
Cheng Zhi said: Aversion to cold after sweating implies deficiency of both ying and wei; absence of aversion to cold but presence of fever after sweating implies dried fluids and stomach excess. Hence, there is a method of harmonizing the stomach and unblocking fluids. However, the use of terms like "should" (dang) and "give" (yu) suggests careful deliberation rather than reckless administration, so as not to further deplete fluids.
Tiaowei Chengqi Tang formula is found in the Yangming chapter.
When the pulse is floating and tight, body pain is expected according to the law, and sweating should be used to resolve it. If, however, the chi position pulse is slow, sweating must not be induced. How do we know this? Because it is due to insufficiency of ying qi and blood deficiency.
[Zhu]
A floating and tight pulse is the pulse pattern of cold injuring ying; body pain is the symptom of cold injuring ying. Both pulse and symptoms indicate exterior excess pathogens, so sweating is indicated, and Mahuang Tang is suitable. If the cun and guan pulses are floating and tight, but only the chi pulse is slow, then sweating is contraindicated. Why? Because the person inherently suffers from ying qi insufficiency and blood deficiency. From this, we can see that if the yin and yang aspects of the pulse are not both tight, one should not lightly induce sweating.
[Ji Zhu]
Fang Youzhi said: The chi position reflects yin; slow indicates insufficiency. Ying governs blood, and sweat is the fluid of blood. A slow chi pulse makes sweating inadvisable, lest blood be depleted.
Zhang Lu said: A slow pulse at the chi position contraindicates the use of Mahuang for sweating. Instead, Xiaojianzhong Tang should be frequently administered to harmonize. If harmonization resolves the pathogen, no sweating is needed; if unresolved, repeated administration followed by covering to induce sweating is permissible.
After inducing sweating, if body pain persists and the pulse is deep and slow, Guizhi Jia Shaoyao Shengjiang Ge Yi Liang, Renshen Er Liang Xinjia Tang should be used as the main treatment.
[Zhu]
After inducing sweating, if body pain is accompanied by a floating and tight or floating and rapid pulse, it means sweating was incomplete and exterior pathogens remain; sweating should still be performed, and Guizhi Tang is suitable. Now, if after sweating body pain persists but the pulse is deep and slow, this indicates deficiency and cold of ying and wei. Therefore, Guizhi Xinjia Tang is suitable to warm and tonify ying and wei.
[Ji Zhu]
Cheng Wuji said: Exuberant exterior pathogens cause body pain; blood deficiency also causes body pain. A floating and tight pulse indicates pathogen exuberance; a deep and slow pulse indicates blood deficiency. Exuberance is settled by reducing (dispelling); deficiency is healed by tonifying.
Yu Chang said: A deep and slow pulse applies to all six positions, which is vastly different from a slow chi pulse. A slow chi pulse indicates inherent deficiency; here, deficiency results from sweating. Therefore, in the Guizhi Tang formula, Shaoyao and Shengjiang are each doubled by one liang to expel pathogens, and Renshen three liang is added to tonify healthy qi. It is named Xinjia Tang (Newly Added Decoction) to clarify that this is not the old method within Guizhi Tang.
Wang Hu said: Body pain with a deep and slow pulse—how do we know it is not a Zhonghan (cold strike) syndrome? One must understand that this syndrome involves persistent body pain after sweating for Taiyang Shanghan, with the pulse changing to deep and slow; it cannot be compared to Zhonghan.