于桂枝汤方内去芍药。加附子一枚。泡去皮。破八片。余根据前法。
太阳病。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
上条脉促胸满。是下后阳虚。阴邪搏膈。但当姜桂助阳散邪。不宜芍药益阴
增满。若微恶寒。则搏膈之阴邪。渐将侵越卫外。瞬有亡阳之变矣。前方虽去芍药。而姜桂
之力
。尚不足以胜回阳之任。故必藉附子之刚烈。迅走卫外。以驱阴而复阳。预杜亡阳之变也。
于桂枝汤方内。加浓朴二两。杏仁五十个。去皮尖。余根据前法。
此亦当与葛根黄连黄芩汤证参看。经云。太阳病。下之微喘者。表未解故也。桂枝加浓
朴杏
仁汤主之。同属喘之一证。有表有里。不可不辨。下后汗出而喘者。其喘必盛。是里热壅遏
。火炎故也。下后微喘者。其汗必不大出。是表邪闭遏。气逆故也。表未解仍宜从表。治主
桂枝解表。加朴杏以下逆气。按本草浓朴杏仁。主消痰下气。故又曰喘家作桂枝汤。加浓朴
杏子佳也。
喻嘉言曰。此误风邪误下作喘治法之大要。若寒邪误下作喘。当用麻黄石膏。即此可推
。
于桂枝汤方内。更加芍药三两。随前共六两。余根据桂枝汤法。
桂枝汤原方倍加芍药。即另立汤名。主治各别。与桂枝加桂汤同妙。经云。本太阳病
。医
反下之。因尔腹满时痛者属太阴也。桂枝加芍药汤主之。大实痛者。桂枝加大黄汤主之。按
腹满时痛。痛而不实。即已伏下利之机。但究因太阳误下。表邪内陷。留滞太阴。非太阴藏
寒本病。故仍用桂枝领出太阳陷入太阴之邪。但倍芍药滋脾阴而除满痛耳。
再按腹满时痛。倍用芍药。得毋疑其太敛。程郊倩曰。以其邪陷已深。一经桂枝升举阳
邪。正防脾阴随表药而外泄。此为独得真解。
在桂枝汤的方剂中,去掉芍药。加入一枚附子,经过炮制后去皮,破成八片。其余部分按照前面的煎服方法处理。
太阳病,出现脉促、胸部胀满的症状,应当用桂枝去芍药汤来主治。如果伴有轻微怕冷的症状,应当在去掉芍药的方剂中加入附子,用桂枝去芍药加附子汤来主治。按:
上一条提到的脉促、胸满,是因为误用下法导致阳气虚弱,阴邪搏结于膈部。此时只应当用干姜、桂枝来助阳散邪,不适宜用芍药来益阴而增加胀满感。如果有轻微怕冷,说明搏结于膈部的阴邪,逐渐将要侵犯卫气之外,瞬间就有亡阳的变化发生。前面的方剂虽然去掉了芍药,但干姜、桂枝的力量,还不足以胜任挽回阳气的重任。所以必须借助附子的刚烈之性,迅速运行到卫外,以驱除阴邪并恢复阳气,预先杜绝亡阳的变化。
在桂枝汤的方剂中,加入厚朴二两、杏仁五十个,去掉皮和尖。其余部分按照前面的煎服方法处理。
这也应当与葛根黄连黄芩汤的证候参照来看。经文说:太阳病,误用下法后出现轻微气喘的,是因为表证未解除的缘故。应当用桂枝加厚朴杏子汤来主治。同属于气喘这一证候,有表证和里证的区别,不可不辨别。误下后汗出且气喘的,其气喘必然严重,这是里热壅盛阻滞,火气上炎所致。误下后轻微气喘的,其汗出必然不多,这是表邪闭阻,气机上逆所致。表证未解仍然应当从表论治,治疗主要以桂枝解表为主,加入厚朴、杏仁以降逆气。按:本草记载厚朴、杏仁,主要功效是消除痰饮、降逆气。所以说“素有喘疾的人服用桂枝汤,加入厚朴、杏仁效果更佳”。
喻嘉言说:这是风邪误用下法导致气喘的治疗方法的纲要。如果是寒邪误用下法导致气喘,应当使用麻黄石膏(汤)。由此可以类推。
在桂枝汤的方剂中,再增加芍药三两,连同前面的总共六两。其余部分按照桂枝汤的方法处理。
桂枝汤原方加倍增加芍药,就另外确立汤名,主治各不相同,这与桂枝加桂汤同样精妙。经文说:原本患太阳病,医生反而误用下法,因此出现腹部胀满、时时疼痛的症状,这归属于太阴病。应当用桂枝加芍药汤来主治。如果腹部大实且疼痛剧烈,应当用桂枝加大黄汤来主治。按:腹部胀满、时时疼痛,痛处不实,这就已经潜伏了腹泻的机转。但究其原因是因为太阳病误用下法,表邪内陷,留滞于太阴,并非太阴脏寒的本病。所以仍然使用桂枝引领陷入太阴的太阳邪气外出,只是加倍使用芍药来滋养脾阴从而消除胀满和疼痛罢了。
再按:腹部胀满、时时疼痛,加倍使用芍药,难道不让人怀疑其收敛作用太强吗?程郊倩说:因为邪气内陷已经很深,一旦用桂枝升举阳气,正担心脾阴随着解表药而外泄。这才是独到的深刻见解。
In the formula of Guizhi Tang (Cinnamon Twig Decoction), remove Shaoyao (Paeoniae Radix Alba). Add one Fuzi (Aconiti Lateralis Radix Praeparata), which has been processed, peeled, and broken into eight pieces. The rest follows the previous method.
For Taiyang disease (Disease of the Taiyang/Bladder Channel) presenting with a rapid pulse (Mai Cu) and chest fullness, Guizhi Qushaoyao Tang (Cinnamon Twig Decoction without White Peony Root) is the primary treatment. If there is slight aversion to cold, add Fuzi to the formula that has had Shaoyao removed; Guizhi Qushaoyao Jia Fuzi Tang (Cinnamon Twig Decoction without White Peony Root plus Prepared Aconite Root) is the primary treatment. Note:
The aforementioned rapid pulse and chest fullness result from yang deficiency caused by inappropriate purgation, with yin pathogens clashing in the diaphragm region. At this time, only Ganjiang (Zingiberis Rhizoma) and Guizhi (Cinnamomi Ramulus) should be used to assist yang and scatter pathogens; it is inappropriate to use Shaoyao (Paeoniae Radix Alba) to nourish yin and increase fullness. If there is slight aversion to cold, it indicates that the yin pathogens clashing in the diaphragm are gradually invading beyond the defensive exterior, posing an imminent risk of collapse of yang (Wang Yang). Although the previous formula removes Shaoyao, the power of Ganjiang and Guizhi is still insufficient to fulfill the task of rescuing yang. Therefore, it is necessary to rely on the fierce nature of Fuzi to rapidly reach the defensive exterior, drive out yin pathogens, restore yang, and preemptively prevent the collapse of yang.
In the formula of Guizhi Tang (Cinnamon Twig Decoction), add Houpo (Magnoliae Officinalis Cortex) two liang and Xingren (Armeniacae Semen Amarum) fifty seeds, removing the skin and tips. The rest follows the previous method.
This should also be compared with the syndrome of Gegen Huanglian Huangqin Tang (Kudzu, Coptis, and Scutellaria Decoction). The classic states: For Taiyang disease, if mild wheezing occurs after purgation, it is because the exterior condition remains unresolved. Guizhi Jia Houpo Xingren Tang (Cinnamon Twig Decoction plus Magnolia Bark and Apricot Seed) is the primary treatment. Both belong to the category of wheezing, but one involves the exterior and the other the interior; they must not fail to be distinguished. After purgation, if sweating and wheezing occur, the wheezing will likely be severe, indicating internal heat congestion and fire flaring upward. After purgation, if only mild wheezing occurs, sweating will likely be minimal, indicating exterior pathogen closure and rebellious qi. Since the exterior condition remains unresolved, treatment should still focus on the exterior, primarily using Guizhi to release the exterior, adding Houpo and Xingren to direct rebellious qi downward. Note: Materia Medica records that Houpo and Xingren mainly eliminate phlegm and direct qi downward. Hence it is said, "For patients with chronic wheezing taking Guizhi Tang, adding Houpo and Xingren is excellent."
Yu Jiayan stated: This outlines the main principles for treating wheezing caused by wind pathogens mismanaged by purgation. If wheezing is caused by cold pathogens mismanaged by purgation, Mahuang Shigao Tang (Ephedra and Gypsum Decoction) should be used. This can be inferred analogously.
In the formula of Guizhi Tang (Cinnamon Twig Decoction), add an additional three liang of Shaoyao (Paeoniae Radix Alba), totaling six liang together with the previous amount. The rest follows the method of Guizhi Tang.
Doubling the Shaoyao in the original Guizhi Tang creates a separate decoction name with distinct indications, as ingenious as Guizhi Jia Gui Tang (Cinnamon Twig Decoction plus More Cinnamon Twig). The classic states: Originally suffering from Taiyang disease, if the physician inappropriately uses purgation, resulting in abdominal fullness and intermittent pain, this belongs to Taiyin disease. Guizhi Jia Shaoyao Tang (Cinnamon Twig Decoction plus More White Peony Root) is the primary treatment. For severe excess pain, Guizhi Jia Dahuang Tang (Cinnamon Twig Decoction plus Greater Rhubarb) is the primary treatment. Note: Abdominal fullness and intermittent pain, where the pain is not firm/excess, already harbors the potential for diarrhea. However, investigating the cause reveals that due to inappropriate purgation of Taiyang disease, exterior pathogens have sunk inward and stagnated in the Taiyin system. This is not the fundamental disease of Taiyin organ cold. Therefore, Guizhi is still used to lead the Taiyang pathogens that have sunk into Taiyin outward, while doubling Shaoyao nourishes spleen yin to relieve fullness and pain.
Furthermore, regarding abdominal fullness and intermittent pain, doubling the use of Shaoyao might raise concerns about its overly astringent nature. Cheng Jiaoqian stated: Because the pathogens have sunk deeply, once Guizhi lifts the yang pathogens, one must fear that spleen yin will leak outward along with the exterior-releasing herbs. This is a unique and profound insight.