(此方自原论中第十卷采附于此。与前方药味相同。但分两各别耳)
桂枝(一两十七铢去皮) 芍药(一两六铢) 麻黄(十六铢去节) 生姜(一两六铢切) 杏人(十六个去皮尖)
甘草(一两二铢炙) 大枣(五枚擘)
上七味以水五升。先煮麻黄一二沸。去上沫。内诸药。煮取二升。去滓。温服一升。日再。
琥按上方。乃治太阳病服桂枝汤大汗出后。其形如疟之证。内台方议云。是原发汗不尽。余邪在经所致。然既大
汗出。矣。何以犹有余邪。盖取汗之法。不可令如水流漓。是不惟中风之候不除。更袭以外寒之气。故以桂枝汤为主。
略加麻黄杏人。以散轻寒也。
服桂枝汤。大汗出后。大烦渴不解。脉洪大者。白虎加人参汤主之。(桂枝汤从今从俗。成注云。大汗出脉洪大不渴
邪气犹在表也。可更与桂枝汤。兹则更增。大烦渴不解。是为风寒之邪。尽郁而为燥热。热邪传里。表里皆热。故改用
白虎汤。以解表里之烦热。更加人参以生津止渴也。方见后第六卷阳明篇中。愚按此条。当是太阳证罢。转属阳明之证。
因上条大汗出后。脉洪大。虽与桂枝汤。已有传入阳明之势。此增烦渴。的系白虎证。而非太阳病矣。其不入阳明篇者。
以其服桂枝汤后之变证。且与上条脉证相同。但加烦渴。用药霄壤。前贤着书。欲使后学悉心体认。即此二条中。一为
详辩。则用药制方之道。实非苟焉而已。)
太阳病发热恶寒。热多寒少脉微弱者。此无阳也。不可发汗宜桂枝二越婢一汤(发汗之发一作更。太阳病发热恶寒。
热多寒少。前已注明。但前用麻黄桂枝各半汤。以面有热色。身必发痒。脉犹微缓而未弱也。故云宜小汗之。此则微而
更加弱焉。故云。不可发汗此无阳也句。成注缺解。尚论篇云。无阳二字。乃仲景亡津液之通称。盖无当作亡。惟亡阳。
故脉微弱而不可发汗。然病犹在太阳。发热恶寒之证不除。仍当取桂枝之二以散风邪。越婢之一以治郁热。越婢云者。
取石膏之辛凉。以化胃家之郁热。则热化津生而脾气发越。得以行其胃液。故外台方以婢改名脾也。)
(此方从原书第十卷摘录附于此。与前方药物组成相同,但剂量各不相同。)
桂枝(一两十七铢,去皮) 芍药(一两六铢) 麻黄(十六铢,去节) 生姜(一两六铢,切片) 杏仁(十六个,去皮尖)
甘草(一两二铢,炙烤) 大枣(五枚,掰开)
以上七味药,用水五升。先煮麻黄,煮沸一两次,去掉水面上的浮沫,再加入其他药物,煮取药液二升,滤去药渣。每次温服一升,每日服用两次。
琥按:上方是治疗太阳病(太阳经受邪所致的病证)服用桂枝汤(调和营卫、解肌发表之剂)后大汗出,出现类似疟疾寒热往来症状的证候。内台方议论认为,这是原本发汗不彻底,残余邪气留在经络所致。然而既然已经大汗出,为何还有余邪?大概取汗的方法,不可令汗出如水流漓不止。这不仅不能解除中风(外感风邪)的症状,反而更会侵袭外寒之气。因此以桂枝汤为主,略微加入麻黄和杏仁,以疏散轻微的外寒。
服用桂枝汤后,大汗出,出现严重烦躁、口渴且无法缓解,脉象洪大的,用白虎加人参汤(清热生津之剂)主治。(桂枝汤依从当今习俗。成无己注解说:大汗出、脉洪大但不口渴,说明邪气仍在表,可以再给予桂枝汤。此处则增加了严重烦躁、口渴无法缓解的症状,这是因为风寒之邪完全郁结化为燥热,热邪传入里,表里皆热,所以改用白虎汤来解除表里的烦热,再加人参以生津止渴。该方见后第六卷阳明篇中。我按:此条应当是太阳证罢除,转属阳明(阳明经受邪所致的病证)的证候。因为上一条大汗出后,脉洪大,虽然给予桂枝汤,已有传入阳明的趋势,此处增加烦渴,确实是白虎证的指征,而不是太阳病了。其未收入阳明篇的原因,是因为这是服用桂枝汤后的变证,且与上一条脉证相同,只是增加了烦渴,用药天差地别。前贤著书,想让后学者悉心体认,仅在这两条中就详细辨析,那么用药制方的道理,实在不是草率行事而已。)
太阳病发热恶寒,热多寒少,脉微弱的,这是无阳(阳气虚衰或津液亏损)的表现,不可发汗,宜用桂枝二越婢一汤(调和营卫兼清郁热之剂)。(发汗的“发”字一作“更”。太阳病发热恶寒,热多寒少,前面已注明。但前面使用麻黄桂枝各半汤,是因为面有热色,身体必发痒,脉象尚微缓而未弱。所以说适宜小汗法。此处脉象微弱更加明显,所以说不可发汗。“此无阳也”一句,成无己注解缺失。《尚论篇》说,“无阳”二字,是张仲景对亡失津液的通称。大概“无”当作“亡”。正因为亡失津液,所以脉微弱而不可发汗。然而病仍在太阳,发热恶寒的症状未除,仍当取桂枝汤二分以疏散风邪,越婢汤一分以治疗郁热。“越婢”的意思是,取石膏的辛凉性质,以化解胃家(脾胃系统)的郁热,这样热化津生而脾气发越,能够运行胃液,所以《外台秘要》将“婢”改名“脾”。)
(This prescription is extracted from Volume 10 of the original treatise and attached here. It has the same ingredients as the preceding formula, but the dosages are different.)
Guizhi (Cinnamon Twig) [Rami Cinnamomi] (1 liang 17 zhu, bark removed) Shaoyao (Peony Root) [Radix Paeoniae Alba] (1 liang 6 zhu) Mahuang (Ephedra) [Herba Ephedrae] (16 zhu, joints removed) Shengjiang (Fresh Ginger) [Rhizoma Zingiberis Recens] (1 liang 6 zhu, sliced) Xingren (Apricot Seed) [Semen Armeniacae Amarum] (16 seeds, skin and tips removed)
Gancao (Licorice Root) [Radix Glycyrrhizae] (1 liang 2 zhu, honey-fried) Dazao (Jujube) [Fructus Jujubae] (5 pieces, split open)
The above seven herbs are boiled in five sheng of water. First, boil Mahuang for one or two boils, remove the foam on the surface, then add the remaining herbs. Boil until two sheng of liquid remain, filter out the dregs. Take one sheng warm, twice a day.
Hu notes: The above formula treats the syndrome of Taiyang disease (disease pattern caused by pathogenic factors invading the Taiyang channel) where, after taking Guizhi Tang (a decoction to harmonize Ying and Wei and release the muscle layer), profuse sweating occurs, followed by symptoms resembling malaria with alternating chills and fever. The Neitai Fang commentary suggests this is due to incomplete initial diaphoresis, leaving residual pathogens in the channels. However, since profuse sweating has already occurred, why are there still residual pathogens? Generally, the method of inducing sweating should not result in sweat flowing like water. This not only fails to resolve the Wind-stroke (exogenous wind pathogen) condition but may also invite external cold qi. Therefore, Guizhi Tang is used as the main base, slightly augmented with Mahuang and Xingren to disperse mild cold.
After taking Guizhi Tang, if profuse sweating leads to severe restlessness, unquenchable thirst, and a surging pulse (Hongda), Baizhu Jia Renshen Tang (White Tiger Decoction plus Ginseng) is indicated. (Guizhi Tang follows contemporary usage. Cheng Wuji's annotation states: Profuse sweating with a surging pulse but no thirst indicates the pathogen remains in the exterior; Guizhi Tang can be administered again. Here, however, severe restlessness and unquenchable thirst are added. This signifies that Wind-Cold pathogens have fully stagnated and transformed into dry heat. The heat pathogen has transmitted inward, causing heat in both interior and exterior. Thus, Baizhu Tang is changed to relieve exterior-interior restlessness and heat, with added Renshen to generate fluids and quench thirst. See this formula in Volume 6, Yangming Chapter. I note: This clause likely represents the resolution of the Taiyang syndrome and its transmission to Yangming disease (disease pattern caused by pathogenic factors invading the Yangming channel). Because in the previous clause, after profuse sweating, the pulse was surging; although Guizhi Tang was given, there was a trend toward transmission to Yangming. Here, the addition of restlessness and thirst confirms it is a Baizhu syndrome, not a Taiyang disease. It is not included in the Yangming chapter because it is a modified syndrome following Guizhi Tang administration, and shares similar pulse and symptom patterns with the previous clause, differing only in the addition of restlessness and thirst, leading to vastly different treatments. The ancients wrote to enable students to carefully comprehend; detailed differentiation in these two clauses demonstrates that the principles of medication and formula preparation are not arbitrary.)
In Taiyang disease, if there is fever and aversion to cold, with more heat than chills, and a faint pulse (Weiruo), this indicates "Wu Yang" (absence/deficiency of Yang/qi/fluids). Diaphoresis is contraindicated; instead, Guizhi Er Yuebi Yi Tang (Two Parts Guizhi Tang and One Part Yuebi Tang) is appropriate. (The character "fa" in diaphoresis is alternatively read as "geng". Taiyang disease with fever, aversion to cold, more heat than chills was noted previously. Previously, Mahuang Guizhi Ban Tang (Half-Mahuang Half-Guizhi Decoction) was used because the face had a hot color and the body likely felt itchy, with the pulse still slightly slow but not weak. Hence, it was said to be suitable for mild diaphoresis. Here, the pulse is fainter and weaker, hence diaphoresis is contraindicated. The phrase "this is Wu Yang" lacks Cheng Wuji's explanation. Shanglun Pian states that "Wu Yang" is Zhang Zhongjing's general term for loss of body fluids. "Wu" should likely be "Wang" (loss). Because of fluid loss, the pulse is faint and diaphoresis is contraindicated. However, the disease remains in Taiyang, and fever and aversion to cold persist. One should still use two parts of Guizhi Tang to disperse wind pathogens and one part of Yuebi Tang to treat stagnant heat. "Yuebi" implies using the acrid-cool property of Shigao (Gypsum Fibrosum) to transform stagnant heat in the Stomach system. As heat transforms and fluids generate, the Spleen Qi rises and functions, allowing stomach fluids to circulate. Thus, Waitai Mi Yao renamed "Bi" to "Pi" (Spleen).)