黄连 甘草(炙) 干姜 桂枝(去皮各三两) 人参(二两) 半夏(半升洗) 大枣(十二枚擘)
上七味。以水一斗。煮取六升。去滓。温服一升。日三服。夜二服。
成注云。上热者。泄之以苦。黄连之苦以降阳。下寒者。散之以辛。桂姜半夏之辛以升阴。脾欲缓。急食甘以缓
之。人参甘草大枣之甘。以益胃。按上云。益胃。则知其人胃气素虚。故其中虽有寒邪之气。不能作郁热也。
琥按上方。乃半夏泻心汤内。去黄芩。加桂枝也。内台方议云。加桂枝者。升降阴阳之气也。为下寒腹中痛。故去
黄芩。推许氏议方之意。以汤中既有黄连。以清上热。故不须用黄芩。盖黄芩之苦寒。能走大肠。为有碍于寒。腹痛也。
加桂枝而云。升降阴阳之气。不足以尽其用。夫病本太阳伤寒。邪传入里。胃中有寒邪之气。故于麻黄汤中。止取桂枝
甘草二味。辛甘相合。以散其寒也。邪之所凑。其气必虚。故用人参大枣以益胃。用半夏者。以其能挟黄连。清胸中热。
止呕吐也。用干姜者。以其能挟桂枝。散胃中寒。除腹中痛也。且也。药分寒热。甘草复有调和相协之义。要之此汤。
病患涉虚者宜用之。否则勿轻投也。
伤寒八九日。风湿相搏。身体疼烦。不能自转侧。
不呕不渴。脉浮虚而涩者。桂枝附子汤主之。(此条云。伤寒。乃是中寒病。寒气与风湿相搏。至八九日。经中不作
郁热。故不呕不渴。知其非热病也。正文与注见中寒论中)
若其人大便硬。小便自利者。去桂枝。加白术汤主之。(此即上条病。复分其候。而出其治也。故即以桂枝附子汤。
加减主之。)
桂枝附子汤方(正文与注俱见中寒论中)
风湿相搏。骨节烦疼掣痛。不得屈伸。近之则痛剧。汗出短气。小便不利。恶风。不欲去衣。或身微肿者。甘草附
子汤主之。(此条病。名为风湿。实系真寒之证也。正文与注并)
甘草附子汤方(俱见中寒论中)
(附后例)伤寒脉浮滑。此表有热。里有寒。白虎汤主之。(此条系阳明病。正文与注并)
白虎汤方(俱见后第六卷阳明篇中)
伤寒脉结代。心动悸。炙甘草汤主之。(结代脉名义。详见下文。大抵伤寒之病。见此等脉。成注所云。气血虚衰。
不能相续也。悸。心动也。心中动悸。则知营血内虚。真气已馁。而藏神不自宁也。与炙甘草汤。以补血气。而散微邪。
愚按此条伤寒。必系发汗过剂。汗多亡阳。阳亡则气馁。又汗为血液。汗多则血虚。血虚气馁。以故心动悸。而脉结代
也。夫结者。邪气之结代者。正气之虚。所以炙甘草汤。成注虽云。益虚。而散邪之义。即在其中矣。)
黄连、甘草(炙)、干姜、桂枝(去皮,各三两)、人参(二两)、半夏(半升,洗净)、大枣(十二枚,掰开)。
以上七味药。用水一斗。煮取六升。滤去药渣。每次温服一升。白天服三次,晚上服两次。
成无己注解说:上焦有热,用苦味药泄降。黄连的苦味能下降阳气;下焦有寒,用辛味药发散。桂枝、干姜、半夏的辛味能上升阴气。脾脏喜欢缓和,急需甘味食物来缓和它。人参、甘草、大枣的甘味,用来补益胃气。按上文所说“补益胃气”,可知此人胃气原本虚弱,所以其中虽然有寒邪之气,但不能形成郁结之热。
琥按上方,是半夏泻心汤去掉黄芩,加上桂枝而成。内台方议云:加桂枝是为了升降阴阳之气。因为下焦寒邪导致腹中疼痛,所以去掉黄芩。推许氏对方义的议论,认为汤中既有黄连来清上焦之热,所以不需要用黄芩。大概黄芩的苦寒之性,能走大肠,对于寒性腹痛会有妨碍。加桂枝说能升降阴阳之气,不足以完全尽其作用。夫病本属太阳伤寒,邪气传入里部,胃中有寒邪之气,所以在麻黄汤中,只取桂枝、甘草两味药,辛味与甘味相合,以散其寒邪。邪气聚集的地方,正气必然虚弱,所以用人参、大枣来补益胃气。用半夏,是因为它能配合黄连,清除胸中之热,止住呕吐。用干姜,是因为它能配合桂枝,散发胃中之寒,消除腹中之痛。况且药物分寒热属性,甘草又有调和协同的意义。总之此汤,适用于涉及虚证的病患,否则不要轻易投用。
伤寒病程已过八九天,风邪与湿邪相互搏结,身体疼痛烦扰,不能自行转侧。
没有呕吐,没有口渴,脉象浮虚而涩的,用桂枝附子汤主治。(此条说“伤寒”,其实是中寒病。寒气与风湿相搏,到了八九天,经络中没有形成郁热,所以不呕不渴,知道这不是热病。正文与注释见《中寒论》中)
如果其人大便硬,小便自利者,去掉桂枝,加白术汤主治。(这就是上一条的病,进一步区分其症状,并给出治法。所以就在桂枝附子汤基础上加减来主治。)
桂枝附子汤方(正文与注释均见《中寒论》中)
风湿相互搏结,骨节烦疼牵引作痛,不能屈伸,靠近则疼痛剧烈,出汗短气,小便不利,怕风,不想脱衣,或者身体轻微浮肿的,用甘草附子汤主治。(此条病名为风湿,实际上是真寒证。正文与注释并见)
甘草附子汤方(均见《中寒论》中)
(附后例)伤寒脉浮滑,这是表有热,里有寒,用白虎汤主治。(此条属于阳明病,正文与注释并见)
白虎汤方(均见后第六卷阳明篇中)
伤寒脉结代,心动悸,用炙甘草汤主治。(结代脉的名称含义,详见下文。大抵伤寒病,出现这种脉象,成注所说,是气血虚衰,不能相继。悸,就是心动。心中动悸,就知道营血内部虚弱,真气已经衰竭,而藏神的功能不能安宁。给予炙甘草汤,以补血气,而疏散微邪。我按:此条伤寒,必定是发汗过度,汗多亡阳,阳亡则气馁,又汗为血液,汗多则血虚,血虚气馁,因此心动悸,而脉结代。所谓结,是邪气之结;代,是正气之虚。所以炙甘草汤,成注虽说是补益虚弱,而散邪的意思也就在其中了。)
Coptidis Rhizoma (Huanglian), Glycyrrhizae Radix et Rhizoma (Gancao) [roasted], Zingiberis Rhizoma (Ganjiang), Cinnamomi Ramulus (Guizhi) [bark removed, each 3 liang], Ginseng Radix (Renshen) [2 liang], Pinelliae Tuber (Banxia) [half sheng, washed], Jujubae Fructus (Dazao) [12 pieces, split].
The above seven ingredients. Boil with one dou of water. Decoct to obtain six sheng. Remove the dregs. Take warm, one sheng per dose. Three times during the day, two times at night.
Cheng Wuji commented: For heat in the upper jiao, drain it with bitter flavors. The bitterness of Huanglian descends yang qi. For cold in the lower jiao, disperse it with pungent flavors. The pungency of Guizhi, Ganjiang, and Banxia ascends yin qi. The spleen desires relaxation; urgently feed it with sweet flavors to relax it. The sweetness of Renshen, Gancao, and Dazao tonifies stomach qi. According to the text above mentioning "tonifying stomach qi," it is known that this person's stomach qi was originally deficient. Therefore, although there is cold pathogenic qi within, it cannot form stagnant heat.
Hu notes: The above formula is Banxia Xiexin Tang minus Huangqin plus Guizhi. Neitai Fangyi states: Adding Guizhi is to regulate the ascending and descending of yin and yang qi. Because cold in the lower jiao causes abdominal pain, Huangqin is removed. Inferring Xu's discussion on the formula's intent, since the decoction already contains Huanglian to clear upper heat, Huangqin is unnecessary. Presumably, the bitter-cold nature of Huangqin travels to the large intestine, which would hinder cold-type abdominal pain. Saying that adding Guizhi regulates yin and yang qi does not fully exhaust its utility. The disease originates from Taiyang Shanghan (Exterior Cold Syndrome); the pathogen transmits inward, and there is cold pathogenic qi in the stomach. Thus, from Mahuang Tang, only Guizhi and Gancao are taken. Pungent and sweet flavors combine to disperse cold. Wherever pathogenic qi gathers, healthy qi must be deficient. Therefore, Renshen and Dazao are used to tonify stomach qi. Banxia is used because it cooperates with Huanglian to clear heat in the chest and stop vomiting. Ganjiang is used because it cooperates with Guizhi to disperse cold in the stomach and eliminate abdominal pain. Moreover, medicines have cold and hot properties; Gancao also has the meaning of harmonization and coordination. In summary, this decoction is suitable for patients involving deficiency; otherwise, do not administer lightly.
After eight or nine days of Shanghan, wind and dampness contend with each other. The body aches and feels vexed, unable to turn over independently.
Without vomiting or thirst, and with a pulse that is floating, deficient, and choppy, Guizhi Fuzi Tang is the primary treatment. (This clause mentions "Shanghan," but it is actually Zhonghan disease. Cold qi contends with wind-dampness. By the eighth or ninth day, no stagnant heat forms in the meridians, hence no vomiting or thirst, indicating it is not a heat disease. The main text and commentary are found in Zhonghan Lun.)
If the patient has hard stool and spontaneous urination, remove Guizhi and add Baizhu Tang as the primary treatment. (This addresses the same condition as the previous clause, further differentiating symptoms and providing treatment. Thus, it modifies Guizhi Fuzi Tang for treatment.)
Guizhi Fuzi Tang Formula (Main text and commentary are both found in Zhonghan Lun.)
When wind-dampness contends, joints ache painfully and pull, inability to flex or extend, pain worsens upon touch, sweating occurs with shortness of breath, urination is difficult, aversion to wind, unwillingness to remove clothing, or slight swelling of the body, Gancao Fuzi Tang is the primary treatment. (This condition is named wind-dampness, but it is essentially a true cold syndrome. Main text and commentary are included.)
Gancao Fuzi Tang Formula (Both found in Zhonghan Lun.)
(Attached later example) Shanghan with a floating and slippery pulse indicates exterior heat and interior cold; Baihu Tang is the primary treatment. (This clause belongs to Yangming Bing. Main text and commentary are included.)
Baihu Tang Formula (Both found in Volume 6, Yangming Chapter, later.)
Shanghan with knotted and intermittent pulse, and palpitations; Zhigancao Tang is the primary treatment. (The meaning of knotted and intermittent pulses is detailed below. Generally, in Shanghan diseases, seeing such pulses, as Cheng noted, indicates deficiency and decline of qi and blood, unable to continue sequentially. Ji refers to heart movement. Palpitations in the heart indicate internal deficiency of Ying-blood, depletion of true qi, and the spirit housed in the heart being unsettled. Administer Zhigancao Tang to nourish blood and qi, and dissipate slight pathogens. I observe: This case of Shanghan must result from excessive sweating, leading to loss of yang. Loss of yang leads to qi exhaustion. Sweat is blood; excessive sweating leads to blood deficiency. Blood deficiency and qi exhaustion cause palpitations and knotted/intermittent pulses. 'Jie' refers to pathogenic stagnation; 'Dai' refers to healthy qi deficiency. Thus, Zhigancao Tang, while Cheng noted it benefits deficiency, also contains the meaning of dissipating pathogens.)