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    淺析《傷寒論》寒熱并用
    關鍵字:淺析,IJ,KL,EF,CD,yz,AB,MN,OP,WX, 發布時間:2011-08-20

    光明中醫2010年8月第25卷第8期 CJGMCM August2010.Vol25.8 ?1335? 引臍中。 2.1.6消渴病腎氣虧虛證:男子消渴,小便反多,飲 一斗,小便一斗。腎氣虛弱,命門火衰,既不能化氣行 水,蒸騰津液以上潤,又不能攝水和制約偏滲之津液, 故渴欲飲水,小便反多,以飲一斗,小便一斗,形成渴飲 無度的下消病。 2.1.7小便不利證 2.1.7.1上燥下寒水停證小便不利,水氣內停,口 渴。腎主水而司氣化,腎與膀胱相表里,膀胱氣化之 源,由腎所主,腎陽不足,膀胱氣化失職,故小便不利, 水氣內停;真陽不足,亦不能蒸化津液上承,而致上焦 燥熱,口渴為所苦。 2.1.7.2水熱互結傷陰證脈浮發熱,渴欲飲水,小 便不利脈浮發熱,不是病邪在表,而是郁熱在里,擾及 肺衛,肺熱郁蒸于皮毛,故見脈浮發熱,因與外邪無關, 故雖有發熱而不惡寒;水熱互結,郁熱傷陰,津氣不能 濡潤,故渴欲飲水;水與熱結,既有水停膀胱氣化不行, 又有郁熱傷陰,故小便不利。 2.1.8妊娠腹痛脈弦發熱,胎脹,腹痛惡寒,少腹如 扇腎陽虧虛,陰寒內盛,氣機滯于內則脈弦,虛陽浮于 外為發熱,寒凝氣滯則胎脹腹痛,腎陽虛不能溫煦胞 宮,惡寒少腹如扇。 2.1.9轉胞臍下急痛,小便不通,飲食如故,煩熱不 得臥病在膀胱,故少腹急痛不得尿,病在下而不在胃, 則飲食如故,水氣不化濁陰上逆則煩熱,水不得下行, 故倚息不得臥,總因腎氣虛弱,膀胱氣化不行所致。 2.2腎病侮脾 2.2.1頭眩證 畏寒惡風,頭重眩,苦極,不知食昧, 脾腎陽虛,水濕不化,清陽不升,濁陰不降,風寒內攻, 清竅不利,頭目失于溫煦,故見畏風寒,頭重著昏眩,痛 苦之極;寒濕內盛,脾陽被困,運化失職,故飲食乏味。 2.2.2正水脈沉遲,外證自喘,腹滿。脾腎陽虛,水 氣失于溫化,聚而成腫,里陽不足,寒水內盛,故其脈沉 遲,水停于里,上射于肺,肺失肅降而喘,脾腎陽虛,水 蓄于內,當有腹滿。 2.2.3腎水其腹大,臍腫腰痛,不得溺,陰下濕如牛 鼻上汗,其足逆冷,面反瘦。腎為水臟,又為為胃之關, 腎陽不足,不能化氣行水,于是水蓄于下焦,且關門不 利,水反侮土,故而水聚于腹,而腹大臍腫;寒水之邪著 于腰部,陽氣為之痹阻不行,故而腰痛;腎虛不能化膀 胱之氣,因而不得溺;腎開竅于二陰,水寒積于腹內,不 得外泄,必下注浸淫于前陰,因而陰下濕如牛鼻上汗; 陽虛不能溫煦于下,因此其足逆冷;腎水陰盛于下,五 臟氣血不能上榮于面,故面反瘦,是相對于臍腫而言。 2.3腎(膀胱)病傳心(小腸) 2.3.1虛勞失精男子失精,女子夢交,脈芤動微緊。 心腎不交,精關不固,故男子遺精,女子夢交。陰損及 陽故脈芤動微緊。 2.3.2腎氣奔豚證發汗后,燒針令汗,針處被寒,核 起而赤,氣從小腹上至心。本自津傷,復用燒針迫汗, 汗為心之液,由陰及陽,致心陽虛,不能下濟腎水,而致 下焦陰寒之氣內盛,引動沖氣上逆至心,故出現針處被 寒,氣從小腹上至心的感覺。 綜上所述,《金匱要略》十分重視腎與膀胱疾病的 臟腑經絡辨證。由于臟腑經絡是統一的整體,經絡與 臟腑之間互相關聯。就腎與膀胱疾病發病而論,大而 言之,不外乎先經絡病后內傳臟腑、先臟腑病后外達經 絡、先此經絡病后傳至彼經絡、先此臟腑病后傳至彼臟 腑及經絡臟腑同病等。而這種先后順序始終貫穿于臟 腑乃至經絡間的生克乘侮所導致的腎與膀胱疾病當 中。 (本文校對:陳國權收稿日期:2010—02—25) 淺析《傷寒論》寒熱并用 朱太平朱彥昭漯河醫學高等專科學校第二附屬醫院(漯河462300) 蔣麗娜 河南省漯河醫學高等專科學校(漯河462300) 關鍵詞:《傷寒論);寒熱并用 doi:10.3969/j.issn.1003—8914.2010.08.010文章編號:1003-8914(2010)-08—1335-02 治寒以熱藥,治熱以寒藥,乃為純寒證和純熱證之 治療法則。若為寒熱并存之證,治當寒熱并治。仲師 《傷寒論》一書,可謂是寒熱并治之典范。無論表寒里 熱,下寒上熱,寒熱互結,寒熱錯雜等證,其醫理之精 辟,其治法之詳實,其制方之完備,其配伍之精妙,其意 義之博大,難及萬一。余等就《傷寒論》寒熱藥并用的 作用特點淺析如下,以作拋磚引玉。 寒性藥和熱性藥是性味、功用完全相反的兩種藥, 萬方數據 換頁 ?1336? 光明中醫2010年8月第25卷第8期CJGMCMAugust2010.Vol25.8 將其集于一方之中,似屬雜投,但正如陸淵雷所說: “中醫學上所謂寒與熱,別有意義,與一般的寒熱之觀 念不同。例如熱水與冷水合并,則相混而中和成溫水 ……而藥性之寒熱則不然,一方中寒熱并用則各奏其 效,并不中和成溫涼適中之劑。”徐靈胎也說:“蓋藥之 性各盡其能,攻者必攻強,補者必補弱,如大黃與人參 同用大黃必能逐去堅積,決不反傷正氣……以此類推, 無不盡然……凡寒熱并用之法,亦同此義。”所有這些 都是對寒熱并用法作了較詳細的論述。 例如:大青龍湯,其所主之證是“脈浮緊,發熱惡 寒,身疼痛。不汗出而煩躁。”這是外有寒邪,內有邪 熱,表里寒熱并存,寒熱之證互見,所以在治療上也采 取寒熱并用之法,將寒熱藥物集于一方之中,其寒者必 然直清里熱,其熱者必然走表散寒,絕不會以熱助熱, 以寒增寒,這是由藥物本身的特性和功用所決定的。 又如,附子瀉心湯,其所主之證既有心下之痞,又 有表陽不足之虛,也是寒熱之證互見,但又不同于大青 龍湯證,大青龍湯證是表里俱實,而本證是虛實并見。 所以在用藥上補瀉合參,以三黃清熱消痞,以附子溫經 回陽,既除心下之痞,又補表陽不足之虛。這種治法正 如尤在涇所說:“此證邪熱有余,而正陽不足,設祛邪 而遺正,則惡寒益甚,或補陽而遺熱,則痞滿愈增,此方 寒熱補瀉并投互治……藥雖同行而功則各奏。” 以上兩個證例,從藥物與疾病的關系這個角度說 明:寒熱并用法并不使寒熱兩種藥物的藥效相互抵消, 或互相干擾,而是并行不悖,各奏其效。從而使錯綜復 雜的病證一并而除,使機體從病理狀態下恢復到正常 的生理狀態。 但是,這并不是說寒熱兩種藥物在治病過程中互 不關聯,各行其是,如果那樣,就失去了方劑配伍的重 要意義。我們所說的“并行不悖,各奏其效”是指寒熱 兩種藥物的療效不受對方的干擾或破壞,而這種療效 的取得,卻又往往依賴對方的制約或協同作用。 以麻杏石膏湯中麻黃與石膏的配伍為例:麻黃辛 苦而溫,長于發汗解表,宣肺平喘;石膏辛甘大寒,為清 解氣分實熱之要藥,兩藥配伍,取石膏之清肺熱,麻黃 之宣肺氣,清宣并進,相反相成,且石膏用量倍于麻黃, 有監制麻黃發汗之力,所以可用于邪熱壅肺,汗出而喘 之證。另外,“辛寒之石膏與辛溫之麻黃,在藥性上, 寒與溫雖相對應,但在藥味上,辛與辛卻又一致。由此 可見,石膏對麻黃一方面起到制約作用,一方面又起到 協同作用。”二者相伍,一寒一溫,寒以制溫,兩辛相 得,相反相成,因而使肺中郁熱宣暢清泄,喘遂自平。 又如三瀉心湯,皆以苦寒之芩、連與辛溫之姜、夏 合用。這兩類藥一寒一溫,一升一降,一開一泄,其藥 性和作用都是相反的,但對于寒熱互結之痞證,都非二 者合用不可,因其在配伍過程中,相互協同,能斡旋中 焦,調理氣機,升清降濁,疏通腸胃,共收辛開苦降,散 結消痞之功。以上兩個例證,從寒熱藥物配伍的角度 說明:寒熱藥并用法之所以能把性味、功用截然相反的 兩種藥物集于一方之中而獲良效,是因為寒熱兩種藥 物在其配伍過程中,充分發揮了藥物之間的相互制約, 又相互依賴的協同作用,使其相反相成,最后達到治療 疾病的目的。這種相反相成的用藥方法,實際上也是 辯證唯物主義的對立統一規律在中醫治療學中的具體 運用。 綜上所述,寒熱藥并用法的作用特點主要表現在 兩方面,一方面是利用藥物各自特有的功效,針對病證 的寒熱錯雜,分別治之;另一方面,又利用藥物之間相 互對立又相互統一規律,充分發揮藥物的最佳療效,從 而達到“扶正祛邪,調整陰陽”的治療目的。 但是,這種寒熱并用法,并非是寒熱兩種性味、功 用相反的藥物隨意堆砌,而是有一定條件的。這種條 件,主要是指藥物的特性和疾病的屬性。也就是說,只 有在某些藥物的特性適合于某些病情時,那些性質相 反、作用不同的藥物才能配合在一起,而起到相互協 同、相反相乘的作用。因此,抓住疾病的內在矛盾,和 掌握藥物的特性是寒熱并用法的關鍵。 疾病有寒熱的區別,藥物亦有寒熱的不同,病勢有 向上向下、在表在里的差異,藥性也有升降浮沉的區 別;疾病發生部位有在臟腑經絡的不同,藥性也有歸入 某經的區分……疾病的不同屬性,決定了藥物不同配 伍。《傷寒論》寒熱并用,充分體現了這一點。 例如:治療“汗出而喘,無大熱”的麻杏甘石湯,為 什么用麻黃配伍石膏,而不用麻黃配伍大黃呢?這是 因為大黃雖能清熱,但不能解肌透表,且大黃偏于走 下,善清腸胃實熱,若把石膏換成大黃,則恐在監制之 外,其苦寒下降之性,反而削弱了麻黃辛溫宣散止喘的 作用,故本方用麻黃伍石膏,而不伍大黃。 又如用梔子干姜湯治療傷寒誤下的上熱下寒證, 之所以用梔子伍干姜而不伍附子,是因為此證是腸胃 有寒,且寒不太甚,干姜、附子雖同為溫陽祛寒之藥,但 附子力猛,多用于陽衰陰寒之證,且附子偏于溫腎散 寒,而干姜偏于溫胃散寒。所以當腸胃有寒時,用于姜 而不用附子。 參考文獻 [1】李培生.傷寒論講義[M].上海科學技術出版社,1986:27,106, 182,293,345. (本文校對:謝有良收稿日期:2009—12—21) 萬方數據 換頁

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