《伤寒论》小青龙汤“噎者去麻黄加附子”探析

Analysis of “removing ephedra and adding aconite for dysphagia” in Xiao Qing Long Tang of Treatise on Cold Damage Diseases

关键词:  《伤寒论》  小青龙汤  噎者  麻黄  附子

Key words:  Treatise on Cold Damage Diseases  Xiao Qing Long Tang  dysphagia  ephedra  aconite

摘要:

《伤寒论》第40条小青龙汤方后有小字注“若噎者，去麻黄加附子一枚，炮”，对此成无己、吕震名等医家多从麻黄、附子药物功效进行解释，但未阐明医理；陈修园等医家则认为麻黄散水气功甚著，不可去。文章基于《易经》《神农本草经》《黄帝内经》《伤寒杂病论》，从噎者病机、小青龙之名、麻黄附子之用及例证探讨发现，“噎者”为胃、肾阳虚水气盛而上逆所致，无表证，故去麻黄防止其辛燥伤津耗气，推测加附子与白芍配伍取真武汤温阳治水之义解水逆之噎。张仲景意在强调噎与胃肾阳虚的密切关系，此加减策略是其遣方用药的一大特色。

Abstract:

Footnote 40 of Treatise on Cold Damage Diseases states “for dysphagia，remove ephedra（Mahuang） and add one piece of prepared aconite（Fuzi）”. While CHENG Wuji and LYU Zhenming explained this modification through pharmacological properties，they failed to clarify the medical rationale. Contrarily，CHEN Xiuyuan argued that ephedra’s diuretic effect should be preserved. Through interdisciplinary analysis of Yi Jing，Shennong’s Classic of Materia Medica，Huangdi Neijing，and Treatise on Cold Damage Diseases，the study reveals that dysphagia results from yang deficiency of stomach/kidney with water-qi rebellion. Without exterior syndrome，removing ephedra prevents fluid consumption，while adding aconite with paeonia（Shaoyao） mirrors Zhenwu Tang’s mechanism for warming yang and resolving water retention. ZHANG Zhongjing’s modification highlights the pathophysiological connection between dysphagia and visceral yang deficiency，demonstrating his characteristic prescription strategy.