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白虎湯組成,主治,方解,醫案

道(dao)醫(yi) 2023-06-25 02:23:42

[方劑組成]知母六兩,石膏(gao)一斤(碎),甘草二(er)兩(炙),粳米六合。

上四味(wei),以(yi)水一斗,煮米熟,湯成去滓,溫服(fu)一升,日三(san)服(fu)。(臣億等謹按(an):前(qian)篇云(yun)(yun)熱(re)結在里,表(biao)里俱熱(re)者(zhe),白(bai)虎(hu)湯主之(zhi)。又云(yun)(yun)其表(biao)不解不可與白(bai)虎(hu)湯。此云(yun)(yun)脈浮滑,表(biao)有熱(re),里有寒者(zhe),必(bi)表(biao)里字差矣。又陽(yang)明一證云(yun)(yun),脈浮遲(chi),表(biao)熱(re)里寒,四逆湯主之(zhi)。以(yi)此表(biao)里自差明矣。《千(qian)金(jin)翼方》云(yun)(yun)白(bai)通(tong)湯,非也。)

[主治(zhi)]170,176,219,350條(tiao)。以上條(tiao)文(wen)指出白虎湯主要用(yong)于(yu):

①陽明邪熱亢盛證(176);

②三陽(yang)合(he)病,以陽(yang)明經證(zheng)為(wei)主的證(zheng)治(219);

③里熱盛極而致(zhi)之(zhi)厥(jue)證(zheng)(350)。并指出白虎湯證(zheng)禁(jin)忌汗下(219),表不解者,不可用(yong)白虎湯(170)等。

[證(zheng)(zheng)(zheng)(zheng)(zheng)候(hou)分析]陽(yang)(yang)(yang)(yang)明(ming)(ming)經(jing)(jing)證(zheng)(zheng)(zheng)(zheng)(zheng),是(shi)邪(xie)熱(re)(re)(re)熾(chi)盛(sheng)(sheng),津(jin)液受(shou)損,而(er)(er)(er)腸中糟(zao)粕(po)尚未(wei)(wei)結成燥(zao)屎的證(zheng)(zheng)(zheng)(zheng)(zheng)侯。176條正是(shi)說(shuo)明(ming)(ming)傷寒(han)太陽(yang)(yang)(yang)(yang)證(zheng)(zheng)(zheng)(zheng)(zheng)罷,邪(xie)傳陽(yang)(yang)(yang)(yang)明(ming)(ming),表里(li)(li)俱熱(re)(re)(re)而(er)(er)(er)未(wei)(wei)成實,故(gu)(gu)脈(mo)(mo)見(jian)(jian)浮滑(hua)。浮為(wei)(wei)陽(yang)(yang)(yang)(yang)盛(sheng)(sheng)于(yu)外,當(dang)(dang)見(jian)(jian)身(shen)熱(re)(re)(re)汗(han)(han)出(chu);滑(hua)為(wei)(wei)熱(re)(re)(re)盛(sheng)(sheng)于(yu)里(li)(li),當(dang)(dang)煩(fan)(fan)渴引飲。故(gu)(gu)曰表里(li)(li)俱熱(re)(re)(re),可(ke)(ke)(ke)用白(bai)虎(hu)湯清(qing)陽(yang)(yang)(yang)(yang)明(ming)(ming)獨盛(sheng)(sheng)之(zhi)(zhi)(zhi)(zhi)熱(re)(re)(re)。所以此湯以身(shen)熱(re)(re)(re)、汗(han)(han)出(chu)、不(bu)(bu)(bu)(bu)(bu)(bu)(bu)惡(e)(e)寒(han)反(fan)惡(e)(e)熱(re)(re)(re)、口(kou)渴,脈(mo)(mo)浮滑(hua)等為(wei)(wei)主要(yao)特點。據219條并(bing)參看221條,其(qi)兼證(zheng)(zheng)(zheng)(zheng)(zheng)可(ke)(ke)(ke)見(jian)(jian)咽燥(zao)口(kou)渴,腹滿微喘,身(shen)重(zhong),面赤或面垢,甚則(ze)(ze)(ze)心煩(fan)(fan)躁(zao)擾,譫語(yu)遺尿,舌(she)(she)苔薄黃(huang)(huang)干燥(zao)等。如(ru)陽(yang)(yang)(yang)(yang)明(ming)(ming)之(zhi)(zhi)(zhi)(zhi)熱(re)(re)(re)盛(sheng)(sheng)極(ji)而(er)(er)(er)郁(yu)伏(fu)(fu)于(yu)內(nei),不(bu)(bu)(bu)(bu)(bu)(bu)(bu)能外達四肢(zhi)(zhi),反(fan)可(ke)(ke)(ke)出(chu)現四肢(zhi)(zhi)厥冷的假寒(han)現象。350條即是(shi)由于(yu)邪(xie)熱(re)(re)(re)深(shen)伏(fu)(fu),陽(yang)(yang)(yang)(yang)氣不(bu)(bu)(bu)(bu)(bu)(bu)(bu)能透達于(yu)外而(er)(er)(er)見(jian)(jian)“脈(mo)(mo)滑(hua)而(er)(er)(er)厥”的證(zheng)(zheng)(zheng)(zheng)(zheng)象,也(ye)(ye)就是(shi)“厥陰(yin)(yin)(yin)篇”里(li)(li)所說(shuo)的熱(re)(re)(re)厥證(zheng)(zheng)(zheng)(zheng)(zheng)。滑(hua)為(wei)(wei)陽(yang)(yang)(yang)(yang)脈(mo)(mo),滑(hua)多粗(cu)大。厥為(wei)(wei)陰(yin)(yin)(yin)寒(han),手足厥冷。滑(hua)加(jia)厥,這(zhe)是(shi)熱(re)(re)(re)厥辨(bian)證(zheng)(zheng)(zheng)(zheng)(zheng)的眼(yan)目,全憑以脈(mo)(mo)辨(bian)證(zheng)(zheng)(zheng)(zheng)(zheng)之(zhi)(zhi)(zhi)(zhi)意(yi)。以脈(mo)(mo)測(ce)證(zheng)(zheng)(zheng)(zheng)(zheng),除脈(mo)(mo)滑(hua)而(er)(er)(er)外,當(dang)(dang)有(you)(you)胸腹灼(zhuo)熱(re)(re)(re),口(kou)干舌(she)(she)燥(zao),煩(fan)(fan)渴引飲,小便黃(huang)(huang)赤等。熱(re)(re)(re)厥者(zhe)(zhe)(zhe),熱(re)(re)(re)深(shen)厥亦(yi)深(shen),外見(jian)(jian)假寒(han),里(li)(li)有(you)(you)真熱(re)(re)(re),實為(wei)(wei)陽(yang)(yang)(yang)(yang)盛(sheng)(sheng)格陰(yin)(yin)(yin),亦(yi)即《內(nei)經(jing)(jing)》所說(shuo)“陽(yang)(yang)(yang)(yang)極(ji)似陰(yin)(yin)(yin)"證(zheng)(zheng)(zheng)(zheng)(zheng)。故(gu)(gu)用白(bai)虎(hu)湯清(qing)解里(li)(li)熱(re)(re)(re),熱(re)(re)(re)得(de)清(qing)透,陽(yang)(yang)(yang)(yang)氣自(zi)可(ke)(ke)(ke)宣通,則(ze)(ze)(ze)肢(zhi)(zhi)厥諸證(zheng)(zheng)(zheng)(zheng)(zheng)可(ke)(ke)(ke)愈。本證(zheng)(zheng)(zheng)(zheng)(zheng)與335條“厥應下(xia)之(zhi)(zhi)(zhi)(zhi)”雖同屬于(yu)熱(re)(re)(re)深(shen)厥亦(yi)深(shen),但(dan)性(xing)質上有(you)(you)所不(bu)(bu)(bu)(bu)(bu)(bu)(bu)同。本證(zheng)(zheng)(zheng)(zheng)(zheng)僅(jin)是(shi)無形之(zhi)(zhi)(zhi)(zhi)邪(xie)熱(re)(re)(re)郁(yu)伏(fu)(fu),故(gu)(gu)治(zhi)宜清(qing)而(er)(er)(er)禁(jin)下(xia)。同時,219條三陽(yang)(yang)(yang)(yang)合病提出(chu)禁(jin)汗(han)(han)、禁(jin)下(xia)。由于(yu)本證(zheng)(zheng)(zheng)(zheng)(zheng)證(zheng)(zheng)(zheng)(zheng)(zheng)候(hou)復雜(za),最易(yi)誤治(zhi),故(gu)(gu)列舉汗(han)(han)、下(xia)之(zhi)(zhi)(zhi)(zhi)禁(jin)。正如(ru)《金鑒(jian)》所說(shuo):“若(ruo)從太陽(yang)(yang)(yang)(yang)之(zhi)(zhi)(zhi)(zhi)表發(fa)汗(han)(han),則(ze)(ze)(ze)津(jin)液愈竭,而(er)(er)(er)胃熱(re)(re)(re)愈深(shen),必(bi)更增譫語(yu);若(ruo)從陽(yang)(yang)(yang)(yang)明(ming)(ming)之(zhi)(zhi)(zhi)(zhi)里(li)(li)下(xia)之(zhi)(zhi)(zhi)(zhi),則(ze)(ze)(ze)陰(yin)(yin)(yin)益傷而(er)(er)(er)陽(yang)(yang)(yang)(yang)無依則(ze)(ze)(ze)散,故(gu)(gu)額汗(han)(han)肢(zhi)(zhi)冷也(ye)(ye)。要(yao)當(dang)(dang)審其(qi)未(wei)(wei)經(jing)(jing)汗(han)(han)下(xia),而(er)(er)(er)身(shen)熱(re)(re)(re)汗(han)(han)自(zi)出(chu)者(zhe)(zhe)(zhe),始為(wei)(wei)陽(yang)(yang)(yang)(yang)明(ming)(ming)的證(zheng)(zheng)(zheng)(zheng)(zheng),宜主以白(bai)虎(hu)湯,大清(qing)胃熱(re)(re)(re),急救津(jin)液,以存(cun)其(qi)陰(yin)(yin)(yin)可(ke)(ke)(ke)也(ye)(ye)。”且(qie)170條也(ye)(ye)指出(chu):脈(mo)(mo)浮發(fa)熱(re)(re)(re),汗(han)(han)不(bu)(bu)(bu)(bu)(bu)(bu)(bu)出(chu),口(kou)不(bu)(bu)(bu)(bu)(bu)(bu)(bu)渴,麻黃(huang)(huang)湯證(zheng)(zheng)(zheng)(zheng)(zheng)尚在(zai)者(zhe)(zhe)(zhe),其(qi)表不(bu)(bu)(bu)(bu)(bu)(bu)(bu)解,不(bu)(bu)(bu)(bu)(bu)(bu)(bu)可(ke)(ke)(ke)與白(bai)虎(hu)湯。曹穎甫說(shuo):“一經(jing)(jing)誤用,不(bu)(bu)(bu)(bu)(bu)(bu)(bu)惟遏寒(han)邪(xie)外出(chu)之(zhi)(zhi)(zhi)(zhi)路,抑且(qie)表里(li)(li)俱寒(han),此其(qi)所以不(bu)(bu)(bu)(bu)(bu)(bu)(bu)可(ke)(ke)(ke)與也(ye)(ye)。”若(ruo)陰(yin)(yin)(yin)(氣)虛發(fa)熱(re)(re)(re)者(zhe)(zhe)(zhe),其(qi)狀類似白(bai)虎(hu)證(zheng)(zheng)(zheng)(zheng)(zheng),惟脈(mo)(mo)象洪(hong)大而(er)(er)(er)按之(zhi)(zhi)(zhi)(zhi)無力或重(zhong)。按全無者(zhe)(zhe)(zhe),或陰(yin)(yin)(yin)虛潮熱(re)(re)(re)者(zhe)(zhe)(zhe),皆非白(bai)虎(hu)證(zheng)(zheng)(zheng)(zheng)(zheng),辨(bian)之(zhi)(zhi)(zhi)(zhi)必(bi)難。這(zhe)些在(zai)臨床上都是(shi)值得(de)注意(yi)的。

[方解]柯韻伯(bo)云:“石膏大寒(han)(han),寒(han)(han)能勝熱,味甘(gan)歸脾,質剛(gang)而主降(jiang),備中(zhong)土生金(jin)(jin)之(zhi)(zhi)體;色白(bai)(bai)通(tong)肺(fei)(fei),質重而含脂,具(ju)金(jin)(jin)能生水(shui)之(zhi)(zhi)用(yong),故以為(wei)(wei)君(jun)。知母(mu)氣寒(han)(han)主降(jiang),苦以瀉肺(fei)(fei)火,辛以潤腎燥,故以為(wei)(wei)臣。甘(gan)草(cao)為(wei)(wei)中(zhong)宮舟楫,能土中(zhong)瀉火,寒(han)(han)藥得之(zhi)(zhi)慢其寒(han)(han),用(yong)此為(wei)(wei)佐,沉降(jiang)之(zhi)(zhi)性亦得留連(lian)于脾胃(wei)之(zhi)(zhi)間(jian)矣。粳米稼稿作(zuo)甘(gan),氣味溫和,稟容平(ping)之(zhi)(zhi)德,為(wei)(wei)后天養命之(zhi)(zhi)資,得此為(wei)(wei)佐,陰寒(han)(han)之(zhi)(zhi)物庶(shu)無傷脾胃(wei)之(zhi)(zhi)慮(lv)也。煮(zhu)湯入(ru)胃(wei),輸脾歸肺(fei)(fei),水(shui)精四(si)布,大煩(fan)大渴(ke)可除矣。白(bai)(bai)虎為(wei)(wei)西(xi)方金(jin)(jin)神(shen),用(yong)以名(ming)湯者,秋金(jin)(jin)得令而炎暑自解,此四(si)時(shi)之(zhi)(zhi)序也。”

臨(lin)床對典型的(de)白虎湯(tang)證辨證不難理解,但(dan)對“熱深(shen)厥(jue)深(shen)”,外(wai)有假寒,內屬真熱者,難以掌握(wo),應當仔細審辨。本湯(tang)兼治(zhi)暑(shu)(shu)火熾盛而引起的(de)霍亂、中暑(shu)(shu)等(deng)。石膏乃是治(zhi)暑(shu)(shu)之良藥,故用之取效尤捷(jie)。凡邪火在胃為主,而引起其兼證者,皆可以此化(hua)裁治(zhi)療。

白虎湯醫案醫案:熱厥

譚某之女,發(fa)熱,醫數日未愈,忽(hu)于(yu)黎明(ming)邀診。至則其發(fa)熱大(da)(da)渴(ke),手足逆冷,脈浮滑。遂斷曰:“此熱厥也,太陽表邪隨(sui)熱氣入(ru)里,致陰陽氣不相順接而厥耳”,“此證(zheng)原系(xi)少陽,小柴胡湯本可解決,乃誤服以燥藥為(wei)主之劑,故變為(wei)熱厥也。”遂與(yu)大(da)(da)劑白虎湯而愈。(《傷(shang)寒(han)論方醫案選編(bian)》)

按:此本少(shao)陽證,誤(wu)用燥藥而變為(wei)熱(re)(re)厥(jue)(jue)(jue)證。邪入少(shao)陽,既(ji)不(bu)能汗以解表,也(ye)不(bu)能下以攻里,惟(wei)宜以和解一法(fa),使(shi)“上焦得(de)通(tong)(tong),津(jin)液(ye)得(de)下,胃氣(qi)(qi)因和”,最為(wei)適當。然該證原本少(shao)陽證,則(ze)前(qian)醫乃誤(wu)服羌活(huo)、獨(du)活(huo)等燥藥為(wei)主之(zhi)劑,傷(shang)其津(jin)液(ye),致邪傳陽明(ming),陽熱(re)(re)內(nei)盛,格(ge)陰于(yu)(yu)外(wai),而成熱(re)(re)深(shen)厥(jue)(jue)(jue)深(shen)之(zhi)熱(re)(re)厥(jue)(jue)(jue)證。邪熱(re)(re)充斥內(nei)外(wai),故脈(mo)見浮滑,熱(re)(re)熾于(yu)(yu)內(nei),故發熱(re)(re)、大渴;陰被阻(zu)格(ge)于(yu)(yu)外(wai),故手足厥(jue)(jue)(jue)冷。治療只有用大劑白虎,以清(qing)解里熱(re)(re),滋養(yang)胃腑(fu)氣(qi)(qi)液(ye),以免中(zhong)寒之(zhi)弊,里熱(re)(re)得(de)以清(qing)透,陽氣(qi)(qi)自可(ke)宣通(tong)(tong),則(ze)肢(zhi)厥(jue)(jue)(jue)可(ke)愈,其病乃解。不(bu)難看出(chu)真寒、真熱(re)(re),以其脈(mo)之(zhi)真諦為(wei)辨證確據,即可(ke)一目(mu)了然。

醫案:熱厥昏迷

史某,女性,38歲,甘肅某公社社員。1963年8月7日請出(chu)急(ji)診,至則病人(ren)已陷(xian)入昏迷(mi)3小時,發熱已2天(tian),急(ji)性熱性病容,體質、營養均良好(hao)。全身多汗,皮膚濕潤(run),體溫(wen)40.5℃,手(shou)足微冷,心跳急(ji)速,口腔干燥,白色薄苔,脈滑有力。腹診:腹壁緊(jin)張度(du)良好(hao),無(wu)抵抗、壓痛(tong)。告以(yi)病重,須(xu)住院。來院后靜(jing)脈注射(she)25%葡萄(tao)糖100毫升(sheng),為處白虎(hu)湯原方。6小時后病人(ren)訴口渴,給飲涼開水少(shao)量(liang),頻(pin)給,次日神識清楚,訴頭痛(tong)乏力,體溫(wen)38.5℃,續服前方,病情繼(ji)(ji)有好(hao)轉。第3天(tian)恢復常溫(wen),能下床大(da)小便,繼(ji)(ji)與前方5天(tian)量(liang),住院1周,痊愈出(chu)院。(《雷(lei)聲治驗》,轉引自(zi)陜西(xi)中醫學院編《傷寒醫案(an)選》)

按(an):此(ci)亦熱(re)厥(jue)(jue)。因陽(yang)明(ming)熱(re)盛(sheng),邪熱(re)蒸(zheng)迫(po),神(shen)明(ming)逆亂(luan)而(er)致昏迷。主癥見高(gao)熱(re)神(shen)昏,心(xin)跳急速(su),汗多口燥,手(shou)足(zu)冷而(er)脈(mo)(mo)滑(hua)有(you)力等(deng)。《傷(shang)寒(han)論》云:“傷(shang)寒(han)脈(mo)(mo)滑(hua)而(er)厥(jue)(jue)者,里有(you)熱(re),白虎湯主之(zhi)(zhi)。”其脈(mo)(mo)滑(hua)屬陽(yang)明(ming),滑(hua)為(wei)陽(yang)脈(mo)(mo),里熱(re)可知(zhi)。脈(mo)(mo)滑(hua)既為(wei)陽(yang)盛(sheng)之(zhi)(zhi)脈(mo)(mo),雖(sui)有(you)手(shou)足(zu)冷,知(zhi)其冷為(wei)熱(re)深(shen)厥(jue)(jue)亦深(shen)、熱(re)微厥(jue)(jue)亦微之(zhi)(zhi)假寒(han)象。里有(you)真熱(re),熱(re)盛(sheng)迫(po)津(jin)外泄(xie),故(gu)汗出(chu);熱(re)盛(sheng)傷(shang)津(jin)故(gu)口腔干燥;陽(yang)明(ming)熱(re)盛(sheng),邪熱(re)蒸(zheng)迫(po),神(shen)明(ming)逆亂(luan),故(gu)而(er)心(xin)跳急速(su),神(shen)識(shi)昏迷。藥后熱(re)勢得(de)減,神(shen)明(ming)漸(jian)復,乃訴(su)口渴者,成無己云:“凡(fan)得(de)病(bing)反能(neng)飲(yin)水(shui),此(ci)為(wei)欲愈之(zhi)(zhi)病(bing)。”但微陽(yang)初(chu)復,故(gu)欲飲(yin)水(shui)者,皆(jie)當少(shao)少(shao)與之(zhi)(zhi),以和胃(wei)氣。本為(wei)邪熱(re)蒸(zheng)追,上攻腦(nao)部之(zhi)(zhi)機,神(shen)識(shi)清楚(chu),故(gu)始(shi)訴(su)頭痛乏(fa)力,效不更方,堅(jian)持到底,而(er)痊愈出(chu)院。

醫案:陽證似陰

汪氏(shi)婦患熱(re)(re)(re)(re)病(bing),壯熱(re)(re)(re)(re)不(bu)(bu)退,目赤唇(chun)干(gan),舌(she)黑起刺,便(bian)閉(bi)溺(ni)赤,診脈弦數有力,應(ying)用清劑(ji)無(wu)疑。試問渴(ke)乎?曰不(bu)(bu)甚渴(ke),惟喜飲沸(fei)湯數口,稍涼即不(bu)(bu)思飲。如此獲證(zheng)當(dang)渴(ke)飲水,何反思飲沸(fei)湯?若(ruo)以此一(yi)端,而從陰治,似乎不(bu)(bu)可(ke)。今脈癥均屬陽熱(re)(re)(re)(re),烏可(ke)以喜飲沸(fei)湯一(yi)事(shi)為(wei)(wei)疑。先(xian)與小(xiao)白湯(小(xiao)劑(ji)白虎湯),病(bing)狀仿佛,知其藥不(bu)(bu)勝病(bing),乃進大劑(ji)白虎湯,石膏(gao)重用四兩,因其胃熱(re)(re)(re)(re)上沖(chong),嘔惡不(bu)(bu)食(shi),更加蘆(lu)根、竹茄為(wei)(wei)引,另取玄明(ming)粉(fen)蜜拌涂舌(she),以潤其燥,如此寒涼疊進,閱十四期,始得熱(re)(re)(re)(re)退神清,便(bian)通舌(she)潤,使拘古法(fa),以喜熱(re)(re)(re)(re)從陰,而投溫(wen)藥,不(bu)(bu)幾抱薪救火(huo)乎!“盡信書不(bu)(bu)如無(wu)書”,斯(si)言(yan)可(ke)證(zheng)矣。(《程杏軒醫案》)

按:此(ci)陽(yang)證似陰(yin),火(huo)極(ji)似水(shui),真(zhen)熱假寒(han)(han)之(zhi)(zhi)證。癥見壯熱不(bu)退,便(bian)閉尿赤(chi),乃(nai)熱盛(sheng)化(hua)火(huo),火(huo)熱上沖而(er)為(wei)(wei)之(zhi)(zhi)嘔惡不(bu)食(shi);目赤(chi)唇干、舌黑起刺(ci),為(wei)(wei)熱極(ji)津枯之(zhi)(zhi)象(xiang);脈見弦數有力者(zhe),仲景以(yi)(yi)弦為(wei)(wei)陰(yin),所(suo)謂(wei)弦、細、芤、遲(chi),皆虛脈也(ye),故(gu)此(ci)屬(shu)(shu)陽(yang)盛(sheng)而(er)見陰(yin)脈;火(huo)熱傷津引水(shui)自救(jiu),則口渴飲冷,是應(ying)有之(zhi)(zhi)征。辨真(zhen)寒(han)(han)假熱證,其(qi)真(zhen)寒(han)(han)之(zhi)(zhi)征為(wei)(wei)口渴,則曰雖(sui)口渴而(er)喜(xi)(xi)熱飲,或飲亦不(bu)多,為(wei)(wei)一(yi)派里寒(han)(han)之(zhi)(zhi)真(zhen)諦見,則為(wei)(wei)陰(yin)盛(sheng)格(ge)陽(yang)之(zhi)(zhi)證。此(ci)則脈癥均屬(shu)(shu)陽(yang)熱,故(gu)不(bu)可以(yi)(yi)喜(xi)(xi)飲沸湯(tang)(tang)一(yi)事而(er)為(wei)(wei)疑,當是火(huo)極(ji)似水(shui),陽(yang)證似陰(yin),真(zhen)熱假寒(han)(han)之(zhi)(zhi)確據(ju)。然(ran)乎(hu)否乎(hu),質之(zhi)(zhi)高(gao)明。故(gu)方用白虎湯(tang)(tang)為(wei)(wei)主(zhu),大劑久服,始得熱退神清,便(bian)通舌潤。辨證之(zhi)(zhi)常(chang),雖(sui)皆以(yi)(yi)喜(xi)(xi)熱從陰(yin),喜(xi)(xi)涼從陽(yang),而(er)此(ci)處乃(nai)常(chang)中之(zhi)(zhi)變(bian),也(ye)不(bu)可不(bu)知。臨床(chuang)具體(ti)問題,具體(ti)分析,不(bu)可不(bu)仔(zi)細推(tui)敲。用小白湯(tang)(tang)者(zhe),屬(shu)(shu)于白虎湯(tang)(tang)試用之(zhi)(zhi)法。

醫案:熱厥

鄭某,男,22歲。外感時邪,高熱神糊,手足厥冷如冰,且時時索(suo)水喝,睡則囈語(yu)頻作。切其(qi)脈(mo)洪大任按,視(shi)其(qi)舌質絳(jiang)而苔黃(huang)。問(wen)其(qi)二便,尚皆(jie)通順(shun),唯(wei)小便則色黃(huang)。

辨(bian)證:為陽明“熱(re)(re)厥”之證,熱(re)(re)邪有內(nei)閉之危。治當辛寒重(zhong)劑,以清陽明之熱(re)(re);佐以芳開(kai),以杜(du)邪傳(chuan)厥陰心包(bao)之路。

處方(fang):生石膏(gao)30克,知母(mu)9克,甘草6克,粳米(mi)二大撮,廣犀角3克,菖蒲3克,連翹心3克,郁(yu)金(jin)3克。

此方共服2劑,則熱退厥回,病愈而安。(《傷寒論十四講》)

按:此熱(re)(re)(re)厥之(zhi)(zhi)(zhi)(zhi)重(zhong)者,陽明熱(re)(re)(re)盛,邪(xie)(xie)氣內陷(xian),心(xin)(xin)營被灼(zhuo),而(er)有內閉之(zhi)(zhi)(zhi)(zhi)險。熱(re)(re)(re)盛陽明,故大(da)熱(re)(re)(re),口渴,苔黃,脈洪(hong)大(da)而(er)任(ren)按;熱(re)(re)(re)邪(xie)(xie)內陷(xian),陽氣被郁(yu),故手(shou)足厥冷(leng)如冰(bing),厥深(shen)者熱(re)(re)(re)亦深(shen);心(xin)(xin)包(bao)為(wei)心(xin)(xin)之(zhi)(zhi)(zhi)(zhi)外衣,神(shen)(shen)(shen)明出(chu)入之(zhi)(zhi)(zhi)(zhi)所,熱(re)(re)(re)邪(xie)(xie)內陷(xian),則(ze)竅機被堵,因而(er)出(chu)現神(shen)(shen)(shen)糊,囈語(yu)頻(pin)作;舌質紅(hong)絳(jiang)者,系心(xin)(xin)營熱(re)(re)(re)極之(zhi)(zhi)(zhi)(zhi)征。故用(yong)辛寒(han)重(zhong)劑(ji)以清陽明之(zhi)(zhi)(zhi)(zhi)熱(re)(re)(re),佐廣(guang)犀角、菖蒲、連翹、郁(yu)金,以芳香開竅,清心(xin)(xin)安(an)神(shen)(shen)(shen)。2劑(ji)而(er)熱(re)(re)(re)退厥回,神(shen)(shen)(shen)明自(zi)安(an)。劉渡舟老師(shi)治(zhi)病(bing)(bing),不(bu)僅注重(zhong)抓住(zhu)主(zhu)證(zheng),而(er)且照顧兼(jian)證(zheng),既主(zhu)治(zhi)陽明熱(re)(re)(re)盛,又杜絕邪(xie)(xie)傳心(xin)(xin)包(bao)之(zhi)(zhi)(zhi)(zhi)路(lu),此即(ji)“不(bu)治(zhi)已(yi)病(bing)(bing)治(zhi)未(wei)病(bing)(bing)”之(zhi)(zhi)(zhi)(zhi)意也。

醫案:熱深厥深

狄右,傷(shang)寒兩候(hou),壯熱無汗,譫語煩躁(zao),舌焦無津,脈象沉數,肢反厥(jue)冷,五(wu)六日不(bu)(bu)更衣。此邪已化(hua)熱,由(you)陽明而傳厥(jue)陰(yin)(yin),陰(yin)(yin)液已傷(shang),燥矢不(bu)(bu)下,有熱深厥(jue)深之見象。風動(dong)痙厥(jue),恐在目(mu)前。急擬生津清熱,下則存陰(yin)(yin),以望轉機(ji)。

生石(shi)膏四(si)錢(qian),生甘草五(wu)分(fen),肥知母(mu)錢(qian)半,鮮生地六錢(qian),玄參(can)三錢(qian),鮮石(shi)斛三錢(qian),郁(yu)李(li)仁三錢(qian)(研),大麻仁四(si)錢(qian)(研),天花粉三錢(qian),茅、蘆根各一(yi)兩(去心、節),清(qing)寧丸三錢(qian)(包煎(jian))。

二診:昨進生津清(qing)熱(re),下則存陰(yin)(yin)之(zhi)劑,得便甚(shen)暢,壯熱(re)漸減,微汗蒸(zheng)蒸(zheng),四(si)肢轉溫。書所謂里(li)氣通(tong)而(er)表自和之(zhi)意。惟(wei)口干(gan)欲(yu)飲,尚(shang)有(you)譫語,舌上干(gan)糙未潤(run),少陰(yin)(yin)津液已傷,陽(yang)明伏(fu)熱(re)尚(shang)熾(chi),脈(mo)數未靜。仍宜滋少陰(yin)(yin)之(zhi)陰(yin)(yin),清(qing)陽(yang)明之(zhi)熱(re),冀其津生邪卻,始得入于坦途。

生石膏四錢(qian)(qian),肥知母錢(qian)(qian)半(ban),生甘草五(wu)錢(qian)(qian),天花(hua)粉(fen)三(san)錢(qian)(qian),鮮生地六錢(qian)(qian),鮮石斛三(san)錢(qian)(qian),玄參三(san)錢(qian)(qian),川貝二(er)錢(qian)(qian),冬(dong)桑葉(xie)二(er)錢(qian)(qian),粉(fen)丹皮二(er)錢(qian)(qian),北秫米三(san)錢(qian)(qian)(包),茅、蘆根各(ge)一兩(去心、節)。

三診:兩進生(sheng)津(jin)清(qing)熱(re)(re)之劑,壯(zhuang)熱(re)(re)大減,譫語(yu)亦止(zhi),舌(she)糙黑未(wei)潤,口干欲飲,脈數溲赤,陰(yin)液被熱(re)(re)銷(xiao)鑠,津(jin)無上承。再擬(ni)甘涼生(sheng)津(jin),以清(qing)邪熱(re)(re)。

羚(ling)羊角五(wu)分(代),鮮(xian)生(sheng)地八錢(qian)(qian),鮮(xian)石斛五(wu)錢(qian)(qian),生(sheng)石膏四(si)錢(qian)(qian)(打),冬桑葉二錢(qian)(qian),玄參三錢(qian)(qian),生(sheng)甘草五(wu)分,肥知母(mu)錢(qian)(qian)半,粉丹皮二錢(qian)(qian),大麥冬三錢(qian)(qian),茅(mao)、蘆根(gen)各一兩(去心、節)。

四診:表里(li)之邪(xie),均已大(da)減(jian),舌焦黑轉為紅(hong)絳,津液有來(lai)復之漸,邪(xie)熱有退(tui)化之機,脈數(shu)較(jiao)和。仍(reng)守甘涼生津,以清余焰。

西洋(yang)參(can)一錢(qian),鮮(xian)生地(di)八(ba)錢(qian),鮮(xian)石斛(hu)五錢(qian),肥知母錢(qian)半(ban),玄參(can)三(san)錢(qian),大麥(mai)冬三(san)錢(qian),天花粉三(san)錢(qian),生甘草五分,桑葉(xie)二(er)錢(qian),粉丹皮三(san)錢(qian),川貝母二(er)錢(qian),北秫米(mi)三(san)錢(qian)(包),茅、蘆根各(ge)一兩(去心、節)。(《丁甘仁醫案》)

按:此(ci)熱(re)(re)深厥深,熱(re)(re)灼津(jin)液,陽(yang)(yang)明燥結證。傷(shang)寒兩候,邪(xie)氣(qi)(qi)(qi)內傳,熱(re)(re)盛陽(yang)(yang)明,則(ze)壯(zhuang)熱(re)(re)而(er)(er)(er)脈(mo)見沉數。胃中熱(re)(re)盛,上乘于心(xin),心(xin)為(wei)熱(re)(re)冒,則(ze)神昏亂(luan)而(er)(er)(er)言無次,成譫妄之(zhi)語。張景岳云:“熱(re)(re)甚反不(bu)(bu)(bu)得汗出者(zhe),此(ci)陽(yang)(yang)氣(qi)(qi)(qi)發泄,陰(yin)(yin)(yin)血不(bu)(bu)(bu)足故也(ye)。”熱(re)(re)灼于里(li),煎熬陰(yin)(yin)(yin)液,因而(er)(er)(er)舌焦便閉。心(xin)熱(re)(re)則(ze)煩,腎熱(re)(re)則(ze)躁,“陽(yang)(yang)煩陰(yin)(yin)(yin)躁”,火熱(re)(re)入胃,邪(xie)氣(qi)(qi)(qi)在里(li),既傷(shang)胃液,又下劫肝腎之(zhi)陰(yin)(yin)(yin),故生煩躁。熱(re)(re)郁于里(li),氣(qi)(qi)(qi)血不(bu)(bu)(bu)得宣通,陽(yang)(yang)極似(si)陰(yin)(yin)(yin),故肢反厥冷。雖有(you)燥矢不(bu)(bu)(bu)下,而(er)(er)(er)非大(da)實(shi)滿可比(bi),況(kuang)又陰(yin)(yin)(yin)血不(bu)(bu)(bu)足,故不(bu)(bu)(bu)用承氣(qi)(qi)(qi)之(zhi)峻猛,擬生津(jin)清熱(re)(re),下則(ze)存(cun)陰(yin)(yin)(yin)之(zhi)法。藥后(hou),腑氣(qi)(qi)(qi)得通,熱(re)(re)勢得減,陰(yin)(yin)(yin)陽(yang)(yang)通順,津(jin)液得復,始得微汗,表(biao)氣(qi)(qi)(qi)自和。繼因熱(re)(re)未盡除,津(jin)未復原(yuan),而(er)(er)(er)用滋陰(yin)(yin)(yin)清熱(re)(re),以(yi)使津(jin)生邪(xie)卻。終以(yi)甘(gan)涼(liang)生津(jin)而(er)(er)(er)收全功。

醫案:暑熱內伏、熱深厥深

蘇州閶門外營盤場(chang),有程姓少年,亦病霍亂,吐(tu)(tu)瀉不已(yi),煩躁畏(wei)熱(re)(re),身無寸縷,而(er)猶畏(wei)熱(re)(re)異(yi)常(chang),欲臥冷(leng)地,四肢(zhi)悉冷(leng),胸腹(fu)部亦均不熱(re)(re),口渴欲食(shi)西瓜,小(xiao)便短赤(chi),頭項微汗,腳腓痙攣,脈息寸關俱數,舌苔黃燥無津(jin)。此暑熱(re)(re)內伏,熱(re)(re)深厥深,內真熱(re)(re)而(er)外假寒之病也。乃(nai)以白虎湯合黃連香薷飲(yin)(yin),去(qu)厚樸、粳米,加麥冬(dong)、苡仁、石斛,陰陽水煎。一服(fu)吐(tu)(tu)止,再劑利(li)亦止,而(er)煩渴亦大定矣。惟肢(zhi)體尚冷(leng),囑以稀粥與飲(yin)(yin),安睡一夜,體溫(wen)逐復常(chang)度。于是但(dan)以飲(yin)(yin)食(shi)調養(yang),不勞他(ta)藥而(er)瘳。(《叢桂(gui)草堂醫草》)

按(an):此(ci)因暑(shu)(shu)熱(re)(re)內(nei)伏而(er)(er)(er)(er)致熱(re)(re)深(shen)厥(jue)深(shen)之(zhi)(zhi)(zhi)(zhi)(zhi)證。沈金鰲(ao)云(yun):“諸(zhu)病(bing)喘(chuan)嘔(ou),暴(bao)注(zhu)下迫,霍亂(luan)轉筋(jin),身熱(re)(re)瞀郁,小(xiao)便(bian)濁赤,皆(jie)屬于熱(re)(re)。"《經》言熱(re)(re)而(er)(er)(er)(er)不言暑(shu)(shu)者(zhe),固以(yi)熱(re)(re)即(ji)是暑(shu)(shu)。而(er)(er)(er)(er)此(ci)案霍亂(luan)吐瀉(xie)(xie)(xie),腳腓筋(jin)攣,小(xiao)便(bian)短赤,煩(fan)躁畏熱(re)(re),甚至身無(wu)寸縷,而(er)(er)(er)(er)猶(you)畏熱(re)(re)異常,欲臥冷地,口渴(ke)(ke)欲食(shi)西瓜,此(ci)皆(jie)暑(shu)(shu)熱(re)(re)之(zhi)(zhi)(zhi)(zhi)(zhi)見癥(zheng),且暑(shu)(shu)熱(re)(re)內(nei)伏,陽(yang)(yang)極(ji)而(er)(er)(er)(er)反寒厥(jue),故(gu)見四肢(zhi)悉(xi)冷,胸腹部亦均不熱(re)(re)。頭項(xiang)多(duo)汗(han)者(zhe),乃(nai)陽(yang)(yang)熱(re)(re)上越之(zhi)(zhi)(zhi)(zhi)(zhi)象。舌苔黃燥無(wu)津(jin),脈息寸關俱數,可見其熱(re)(re)之(zhi)(zhi)(zhi)(zhi)(zhi)盛(sheng),故(gu)其厥(jue)亦深(shen)。方用白虎合(he)黃連(lian)香(xiang)薷飲治之(zhi)(zhi)(zhi)(zhi)(zhi),方中(zhong)石膏、知母、麥冬、石斛甘(gan)寒滋潤,清(qing)熱(re)(re)而(er)(er)(er)(er)生津(jin);香(xiang)薷、扁豆、薏苡仁(ren)、甘(gan)草清(qing)暑(shu)(shu)益胃(wei)(wei)(wei)(wei),和中(zhong)化濕;黃連(lian)清(qing)熱(re)(re)瀉(xie)(xie)(xie)火(huo),乃(nai)治邪火(huo)內(nei)熾亢盛(sheng)炎上之(zhi)(zhi)(zhi)(zhi)(zhi)圣藥(yao),用之(zhi)(zhi)(zhi)(zhi)(zhi)治煩(fan)渴(ke)(ke)吐瀉(xie)(xie)(xie)尤為(wei)有(you)力;厚樸破氣用非(fei)所宜(yi),故(gu)去之(zhi)(zhi)(zhi)(zhi)(zhi);扁豆、薏苡仁(ren)既有(you)與粳米相同的(de)和胃(wei)(wei)(wei)(wei)氣養胃(wei)(wei)(wei)(wei)陰之(zhi)(zhi)(zhi)(zhi)(zhi)效而(er)(er)(er)(er)兼(jian)具化濕之(zhi)(zhi)(zhi)(zhi)(zhi)能(neng),用之(zhi)(zhi)(zhi)(zhi)(zhi)為(wei)優,故(gu)取而(er)(er)(er)(er)代之(zhi)(zhi)(zhi)(zhi)(zhi)。若(ruo)論香(xiang)薷之(zhi)(zhi)(zhi)(zhi)(zhi)用,如(ru)景(jing)岳所說:“香(xiang)薷一物,氣香(xiang)竄而(er)(er)(er)(er)性(xing)沉寒,所以(yi)能(neng)解(jie)渴(ke)(ke)除煩(fan),而(er)(er)(er)(er)清(qing)搏結之(zhi)(zhi)(zhi)(zhi)(zhi)火(huo)邪。然(ran)必(bi)是屬陽(yang)(yang),臟果有(you)大邪,果脾(pi)胃(wei)(wei)(wei)(wei)氣強,肥(fei)甘(gan)過(guo)度而(er)(er)(er)(er)宜(yi)寒畏熱(re)(re)者(zhe),乃(nai)足(zu)以(yi)當之(zhi)(zhi)(zhi)(zhi)(zhi)。若(ruo)氣本(ben)不足(zu),則服(fu)之(zhi)(zhi)(zhi)(zhi)(zhi)最能(neng)損氣;火(huo)本(ben)非(fei)實而(er)(er)(er)(er)服(fu)之(zhi)(zhi)(zhi)(zhi)(zhi),乃(nai)以(yi)敗陽(yang)(yang)。”此(ci)處用之(zhi)(zhi)(zhi)(zhi)(zhi)雖當,但(dan)不宜(yi)久服(fu)。本(ben)病(bing)2劑而(er)(er)(er)(er)病(bing)除,囑以(yi)稀粥為(wei)飲,并飲食(shi)調(diao)養,不勞(lao)他藥(yao)而(er)(er)(er)(er)瘳者(zhe),乃(nai)“陰陽(yang)(yang)自和者(zhe),必(bi)自愈"之(zhi)(zhi)(zhi)(zhi)(zhi)意。

若以吐瀉(xie)、肢冷、痙攣(luan)轉筋、煩躁(zao)畏熱、欲坐臥井中冷地,則寒熱難(nan)別。而脈見(jian)(jian)沉伏甚(shen)或全無,口(kou)渴(ke)不飲或飲亦(yi)不多,舌苔白而津潤,或脈息寸關俱數,口(kou)渴(ke)引飲,舌苔黃燥(zao)無津及(ji)小(xiao)便短赤(chi),乃是辨(bian)別真假本質的真憑。由此可見(jian)(jian),辨(bian)脈驗舌,察口(kou)渴(ke)之(zhi)(zhi)真偽及(ji)二(er)便之(zhi)(zhi)屬寒屬熱,尤以脈舌辨(bian)識真假最為靠實。

——本段摘自《寒熱真假辨(bian)證一百案》

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