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桂枝二越婢一湯治愈癮疹1例

道醫 2023-06-25 10:54:14

病案:

李某,女,24歲,學生,2008年10月28日就診。

患(huan)者(zhe)全身起(qi)(qi)風(feng)(feng)團癢(yang)(yang)疹(zhen)(zhen)4日(ri)。10月24日(ri)患(huan)者(zhe)中(zhong)午(wu)(wu)起(qi)(qi)腹(fu)股溝(gou)(gou)瘙(sao)癢(yang)(yang),下午(wu)(wu)三點左右午(wu)(wu)休醒則腰臀、腹(fu)股溝(gou)(gou)及(ji)雙下肢(zhi)起(qi)(qi)風(feng)(feng)團塊(kuai),下午(wu)(wu)四點半左右洗澡(zao)后加(jia)劇,入(ru)夜(ye)受(shou)風(feng)(feng)寒(han),兩(liang)脅、少(shao)(shao)腹(fu)、胭窩、足背(bei)(bei)、兩(liang)腋、兩(liang)臂內側、頸背(bei)(bei)、雙手手背(bei)(bei)起(qi)(qi)大(da)(da)如(ru)(ru)鴨(ya)蛋、小(xiao)(xiao)(xiao)(xiao)如(ru)(ru)黃(huang)豆大(da)(da)小(xiao)(xiao)(xiao)(xiao)團塊(kuai),高出(chu)(chu)(chu)(chu)(chu)皮(pi)膚,色淡紅,瘙(sao)癢(yang)(yang)難(nan)耐。患(huan)者(zhe)畏風(feng)(feng)怕冷(leng),微(wei)發熱,煩(fan)躁(zao)不得入(ru)眠。次日(ri)晨起(qi)(qi)疹(zhen)(zhen)消,一(yi)點全無(wu),一(yi)日(ri)避風(feng)(feng)無(wu)事,唯黃(huang)昏單衣出(chu)(chu)(chu)(chu)(chu)門遇(yu)風(feng)(feng),回(hui)即身癢(yang)(yang),入(ru)夜(ye)疹(zhen)(zhen)起(qi)(qi),次晨又消,如(ru)(ru)是(shi)反復(fu)四天(tian)。現在癥(zheng):惡寒(han),煩(fan)躁(zao),口干,手心熱甚,身困(kun)乏力,遏風(feng)(feng)感(gan)寒(han)則疹(zhen)(zhen)起(qi)(qi),疹(zhen)(zhen)色淡紅,大(da)(da)小(xiao)(xiao)(xiao)(xiao)如(ru)(ru)黃(huang)豆到鴨(ya)蛋不等(deng)(deng),高出(chu)(chu)(chu)(chu)(chu)皮(pi)膚,連(lian)接(jie)成片,胃納欠佳,小(xiao)(xiao)(xiao)(xiao)便(bian)調(diao),大(da)(da)便(bian)秘(mi),舌淡尖(jian)紅舌體(ti)胖有齒痕,苔(tai)薄白(bai),脈浮緩。滬(hu)醫(yi)開清熱涼血,活血祛風(feng)(feng)方,藥(yao)(yao)(yao)用(yong)玄參,柴(chai)胡,生地,當歸,制大(da)(da)黃(huang),川(chuan)芎,防風(feng)(feng),紅花,金銀花,烏梅,甘草(cao)(cao)等(deng)(deng)。服(fu)藥(yao)(yao)(yao)后10余(yu)分(fen)鐘(zhong)即嘔出(chu)(chu)(chu)(chu)(chu),藥(yao)(yao)(yao)不得入(ru)。余(yu)等(deng)(deng)討論(lun)(lun)病情后認為當用(yong)麻桂(gui)各半湯(tang)加(jia)減治療,卻因病人(ren)煩(fan)躁(zao)口干一(yi)癥(zheng)而束手,似辨證(zheng)不準。遂求教于南京中(zhong)醫(yi)藥(yao)(yao)(yao)大(da)(da)學(xue)傷(shang)寒(han)論(lun)(lun)教研室老師趙鳴芳(fang),師言:“可(ke)用(yong)桂(gui)枝二越婢一(yi)湯(tang),用(yong)量可(ke)據寒(han)熱多(duo)少(shao)(shao)而定(ding)。”受(shou)師之鼓勵,余(yu)等(deng)(deng)大(da)(da)膽(dan)一(yi)試,成方如(ru)(ru)下:桂(gui)枝10g,白(bai)芍(shao)(shao)藥(yao)(yao)(yao)12g,麻黃(huang)5g,石膏15g,炙甘草(cao)(cao)5g,大(da)(da)棗7枚(mei),生姜(jiang)5片,3劑,水煎(jian)(jian)服(fu)。囑其(qi)煎(jian)(jian)藥(yao)(yao)(yao)一(yi)大(da)(da)碗(wan),分(fen)兩(liang)次服(fu)下,藥(yao)(yao)(yao)后服(fu)熱稀粥以增(zeng)藥(yao)(yao)(yao)力。31日(ri)復(fu)診,述藥(yao)(yao)(yao)后微(wei)汗出(chu)(chu)(chu)(chu)(chu),夜(ye)寐可(ke),胃納佳,偶受(shou)風(feng)(feng)疹(zhen)(zhen)出(chu)(chu)(chu)(chu)(chu)如(ru)(ru)綠豆大(da)(da)小(xiao)(xiao)(xiao)(xiao),出(chu)(chu)(chu)(chu)(chu)疹(zhen)(zhen)面積較(jiao)小(xiao)(xiao)(xiao)(xiao),癢(yang)(yang)感(gan)輕,30日(ri)下午(wu)(wu)停藥(yao)(yao)(yao)一(yi)頓,入(ru)夜(ye)疹(zhen)(zhen)出(chu)(chu)(chu)(chu)(chu)如(ru)(ru)前(qian),二便(bian)調(diao),舌紅苔(tai)薄白(bai),脈弦滑有力。原方加(jia)大(da)(da)藥(yao)(yao)(yao)量:桂(gui)枝15g,白(bai)芍(shao)(shao)藥(yao)(yao)(yao)25g,麻黃(huang)5g,石膏30g,炙甘草(cao)(cao)10g,大(da)(da)棗9枚(mei),生姜(jiang)5片,5劑,水煎(jian)(jian)服(fu),服(fu)法(fa)如(ru)(ru)前(qian)。后隨訪,患(huan)者(zhe)自述服(fu)藥(yao)(yao)(yao)1劑盡愈。

辨證分析及方解:

此病發(fa)于霜降后(hou),天氣(qi)(qi)驟冷,患者(zhe)正氣(qi)(qi)不(bu)足,皮毛汗孔開(kai)合失司,予風寒(han)之(zhi)邪所乘,榮衛俱傷(shang),加之(zhi)時值秋燥當令,大氣(qi)(qi)下降,燥氣(qi)(qi)早伏,今又外(wai)感表郁,陽(yang)氣(qi)(qi)不(bu)得外(wai)達(da)。表郁而內(nei)熱,營衛不(bu)合,故患者(zhe)既現惡寒(han)發(fa)熱,遇風受冷則(ze)疹出(chu)之(zhi)證,又有(you)煩躁口(kou)干之(zhi)候。

治應以調(diao)(diao)(diao)和(he)(he)營(ying)衛為(wei)(wei)主,故以桂(gui)枝(zhi)(zhi)湯為(wei)(wei)主方(fang)。桂(gui)枝(zhi)(zhi)辛溫通陽,溫經(jing)散寒(han);白芍酸(suan)苦微寒(han),斂陰(yin)和(he)(he)營(ying),二者相(xiang)合一散一斂調(diao)(diao)(diao)和(he)(he)營(ying)衛;患者體弱,納差食少,又有脾胃(wei)虛弱之象,炙草、生姜、大(da)棗大(da)補中氣,內外兼調(diao)(diao)(diao),中氣復,榮衛和(he)(he),患者無汗(han)惡(e)寒(han),故少加(jia)(jia)麻黃(huang),與桂(gui)枝(zhi)(zhi)相(xiang)合小發其(qi)(qi)汗(han),祛邪外出(chu);又病煩躁口干,故加(jia)(jia)石膏清其(qi)(qi)內熱(re),方(fang)中姜棗量大(da),又囑其(qi)(qi)服熱(re)稀粥(zhou),防其(qi)(qi)寒(han)涼敗(bai)胃(wei)。成方(fang)即(ji)為(wei)(wei)桂(gui)枝(zhi)(zhi)二越婢一湯,唯用量隨證之寒(han)熱(re)而加(jia)(jia)減(jian)矣。

 體會

對于蕁(qian)麻(ma)(ma)疹,中(zhong)醫認(ren)為是(shi)(shi)(shi)血(xue)中(zhong)有(you)(you)熱,血(xue)熱生風(feng)所致(zhi)(zhi)(zhi),“祛風(feng)先(xian)活血(xue),血(xue)行(xing)風(feng)自(zi)滅”,大都(dou)采(cai)用(yong)清(qing)熱涼(liang)血(xue),活血(xue)祛風(feng)方藥(yao)(yao)治(zhi)(zhi)(zhi)(zhi)療(liao)。以此理論(lun)指導下對該病(bing)(bing)人(ren)(ren)(ren)進行(xing)辨證(zheng)施(shi)治(zhi)(zhi)(zhi)(zhi),在治(zhi)(zhi)(zhi)(zhi)療(liao)無效,且病(bing)(bing)人(ren)(ren)(ren)并現(xian)嘔(ou)吐(tu)后(hou)(hou),帶(dai)(dai)教老(lao)(lao)師(shi)想(xiang)放棄中(zhong)醫治(zhi)(zhi)(zhi)(zhi)療(liao),改用(yong)西藥(yao)(yao)掛水的情(qing)形(xing)下,余等再三揣摩,提出(chu)試用(yong)桂麻(ma)(ma)各半(ban)湯(tang)(tang)治(zhi)(zhi)(zhi)(zhi)療(liao)。《傷寒(han)論(lun)》麻(ma)(ma)桂合(he)劑(ji)一般作為解表(biao)使用(yong),治(zhi)(zhi)(zhi)(zhi)療(liao)“表(biao)郁輕證(zheng)”。本例(li)蕁(qian)麻(ma)(ma)疹病(bing)(bing)人(ren)(ren)(ren)沒(mei)有(you)(you)惡寒(han)發熱之(zhi)象,之(zhi)所以選用(yong)其治(zhi)(zhi)(zhi)(zhi)療(liao),一是(shi)(shi)(shi)病(bing)(bing)因相同,是(shi)(shi)(shi)受(shou)風(feng)寒(han)所致(zhi)(zhi)(zhi),二是(shi)(shi)(shi)病(bing)(bing)人(ren)(ren)(ren)皮膚瘙癢(yang),與(yu)桂麻(ma)(ma)各半(ban)湯(tang)(tang)證(zheng)之(zhi)“身(shen)癢(yang)”一致(zhi)(zhi)(zhi),三是(shi)(shi)(shi)皮疹色紅與(yu)原湯(tang)(tang)證(zheng)中(zhong)“面赤”相仿。由于病(bing)(bing)人(ren)(ren)(ren)有(you)(you)內熱煩躁,征(zheng)求趙老(lao)(lao)師(shi)意見而最終改用(yong)桂枝二越婢(bi)一湯(tang)(tang)。成方之(zhi)后(hou)(hou)請臨床(chuang)帶(dai)(dai)教老(lao)(lao)師(shi)簽(qian)字(zi)。老(lao)(lao)師(shi)看(kan)后(hou)(hou)問這是(shi)(shi)(shi)何(he)方,答“桂枝二越婢(bi)一湯(tang)(tang)”,老(lao)(lao)師(shi)聽后(hou)(hou)搖(yao)了搖(yao)頭,似覺用(yong)藥(yao)(yao)太(tai)少,又非猛劑(ji),如(ru)何(he)能(neng)(neng)治(zhi)(zhi)(zhi)(zhi)這怪病(bing)(bing),最終卻還是(shi)(shi)(shi)簽(qian)了字(zi),也(ye)許是(shi)(shi)(shi)覺得此方雖不(bu)能(neng)(neng)治(zhi)(zhi)(zhi)(zhi)病(bing)(bing)卻也(ye)不(bu)致(zhi)(zhi)(zhi)吃壞吧(ba)!莫說老(lao)(lao)師(shi),就是(shi)(shi)(shi)余等雖知辨證(zheng)準確,但(dan)見此方如(ru)此“單薄”,一共(gong)5味藥(yao)(yao)(姜棗(zao)自(zi)備)而已,心中(zhong)也(ye)著實(shi)沒(mei)底。直到病(bing)(bing)人(ren)(ren)(ren)吃完頭3副藥(yao)(yao)后(hou)(hou)病(bing)(bing)情(qing)好轉(zhuan),才敢放膽(dan)加量。

人(ren)說中醫(yi)見效慢(man),《傷(shang)寒論(lun)》已(yi)過(guo)時,余(yu)等(deng)以親(qin)眼所見推翻此(ci)等(deng)謬論(lun)。此(ci)方療(liao)效如此(ci)之好,讓余(yu)等(deng)對中醫(yi)充滿(man)信心,對《傷(shang)寒論(lun)》興趣十足。經(jing)方制方嚴謹,配伍精妙,對經(jing)方的(de)學習有助(zhu)于(yu)初涉臨床的(de)醫(yi)學生增加自(zi)信心,提高辨證論(lun)治能(neng)力,培養(yang)良好的(de)用藥習慣,有百利而無一(yi)害。《傷(shang)寒論(lun)》(不管她淪為(wei)選修課(ke))魅力極大,奉勸各位在(zai)校(xiao)生苦讀(du),實習工作(zuo)時自(zi)能(neng)體會(hui)其(qi)妙處!

本文來源:按摩與康復醫(yi)學雜(za)志(zhi)? ? ?作者:呂振雷

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