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浅析中医当归六黄汤:李东垣创造的治盗汗圣药,到底应当如何理解?-
浅析中医当归六黄汤:李东垣创造的治盗汗圣药,到底应当如何理解?

浅析中医当归六黄汤:李东垣创造的治盗汗圣药,到底应当如何理解?

在我们熟知、习用的名方中,较难理解的当推李东垣的方剂,当归六黄汤就是其中之一。

当归六黄汤见于《兰室秘藏》,由当归、生地黄、熟地黄、黄柏、黄芩、黄连各等份,黄芪倍量组成,原书指出本方为“治盗汗之圣药也”。后世医家对本方倍加推崇,认为本方为治疗盗汗之主方。当代医家也有将其主治范围扩大到自汗以及其他杂病方面。

浅析中医当归六黄汤:李东垣创造的治盗汗圣药,到底应当如何理解?

对于本方的主治,历代医家几乎众口一词,认为主治“阴虚有火,令人盗汗者”(《医方考》)。对本方的功用,多认为是滋阴泻火、固表止汗。对其方解,《医方集解》中的论述最具代表性:“盗汗由于阴虚,当归、二地所以滋阴;汗由火扰,黄芩、连、柏所以泻火;汗由腠理不固,倍用黄芪,所以固表。”

笔者在学习、使用当归六黄汤过程中,不免生出些许疑问。如果说盗汗由于阴虚,那么用药时为什么多用苦寒(黄芩、黄连、黄柏)和重用甘温(黄芪)?毕竟,苦燥、温燥具有伤阴之嫌。汗由火扰,究竟是实火还是虚火?如属阴虚虚火,用药似乎应以甘寒为主,而不宜主用甘温(当归、熟地黄)配苦寒。如属阴虚、实火并见,火扰汗出,泻火即所以止汗,没有理由使用且重用甘温益气固表之黄芪,因为黄芪可以壅气助热。还有,如阴虚与实火并见,二者之间有无主、次和因果关系?种种疑惑,不得而解。

浅析中医当归六黄汤:李东垣创造的治盗汗圣药,到底应当如何理解?

徐大椿《医略六书·杂病证治》中说:“血气两亏,三焦火迫,故营阴失守,盗汗不已焉⋯⋯此清补之剂,为血气虚弱、火迫盗汗之耑方。”这一解释,一改单纯阴虚有火之说,明确提到了气虚和实火。吴昆在《医方考》中说:“阴虚有火,令人盗汗者,此方主之⋯⋯伤寒盗汗是由于半表半里之邪未尽,杂证盗汗则阴虚而已。”这里明确提出本方主治盗汗非外感盗汗。难道本方证可以从李东垣内伤脾胃学说中得到破解?笔者重新学习东垣著作,又有新的认识。

当归六黄汤见于《兰室秘藏·自汗门》,自汗门开篇有一小节“自汗论”,与《脾胃论·阳明病湿胜自汗论》几乎雷同。《脾胃论》中说:“或曰:湿之与汗,阴乎阳乎?曰:西南坤土地,脾胃也。人之汗犹天地之雨也,阴滋其湿,则为雾露为雨也,阴湿寒,下行之地气也,汗多则亡阳⋯⋯《内经》曰:气虚则外寒,虽见热中,蒸蒸为汗,终传大寒,知始为热中,表虚之阳⋯⋯”在这段文字中,李东垣把汗证的病位定位在脾胃,病机可见到气虚、热中。沿着这一思路,我们可对当归六黄汤方证作如下解释。

浅析中医当归六黄汤:李东垣创造的治盗汗圣药,到底应当如何理解?

脾胃内伤,初为热中。气虚不运,升降枢转失常,三焦郁滞,阴火内生。阴火内蒸,迫津外泄,而成盗汗。阴火耗气,也可伤阴;汗多“亡阳(气)”,也能“亡阴”。也就是说,盗汗之起由于气虚,盗汗之成由于阴火,而结果是阴血耗伤(也包括气伤)。治疗时,泻阴火即可止盗汗,但气虚、阴血耗伤也需同时顾及。何况“火与元气不两立,一胜则一负”,治阴火也需补元气。基于此,李东垣用生地黄、黄柏、黄芩、黄连苦寒、甘寒泻阴火,熟地黄、当归甘温补阴血,倍用黄芪甘温补元气,合而组成“治盗汗之圣药”。当然,苦寒、甘寒泻阴火之品只为“暂用”、“从权而用”,得效之后转以恢复正气为要。

或谓黄芪减量或减去黄芪确可治疗阴虚有火之盗汗,但这属方剂加减应用,与原方证有别。

山西中医学院第二中医院高建忠

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