烏梅丸(wan)(wan)出(chu)自《傷寒論(lun)》厥(jue)(jue)陰(yin)(yin)病篇。《傷寒論(lun)》第(di)388條:“傷寒,脈(mo)微而厥(jue)(jue),至七八日膚(fu)冷(leng),其人(ren)躁無暫安(an)時(shi),此(ci)(ci)(ci)為(wei)(wei)藏(zang)厥(jue)(jue),非(fei)蛔(hui)(hui)厥(jue)(jue)也。蛔(hui)(hui)厥(jue)(jue)者,其人(ren)當吐蛔(hui)(hui)。今病者靜,而復時(shi)煩者,此(ci)(ci)(ci)為(wei)(wei)藏(zang)寒。蛔(hui)(hui)上入(ru)其膈,故煩,須臾(yu)復止(zhi),得食而嘔,又煩者,蛔(hui)(hui)聞食臭出(chu),其人(ren)常自吐蛔(hui)(hui)。蛔(hui)(hui)厥(jue)(jue)者,烏梅丸(wan)(wan)主之,又主久(jiu)利。”從(cong)此(ci)(ci)(ci),烏梅丸(wan)(wan)就以(yi)安(an)蛔(hui)(hui)、驅蛔(hui)(hui)的良好效(xiao)果被后世醫(yi)家推崇為(wei)(wei)蛔(hui)(hui)厥(jue)(jue)之代(dai)表方藥(yao)。但縱觀歷(li)代(dai)醫(yi)家,對烏梅丸(wan)(wan)的認識卻(que)遠不局限于蛔(hui)(hui)厥(jue)(jue)之證:《臨(lin)證指南醫(yi)案(an)》載葉(xie)天士以(yi)本方化裁治“暑邪不解(jie),陷(xian)入(ru)厥(jue)(jue)陰(yin)(yin)”。《圣(sheng)濟總錄》用(yong)其治療(liao)“產后冷(leng)熱痢(li),久(jiu)下不止(zhi)”。《溫病條辨》中也曾用(yong)加(jia)減(jian)烏梅丸(wan)(wan)治療(liao)“厥(jue)(jue)陰(yin)(yin)三瘧(nve),日久(jiu)不已,勞(lao)則發(fa)熱,或有(you)痞結,氣逆(ni)欲嘔”。由此(ci)(ci)(ci)可見,后世眾多(duo)醫(yi)家均認為(wei)(wei)“烏梅丸(wan)(wan)為(wei)(wei)厥(jue)(jue)陰(yin)(yin)病之主方,而非(fei)蛔(hui)(hui)厥(jue)(jue)之劑也。”
烏(wu)梅(mei)丸組方合理,配伍精當(dang)。屬(shu)寒(han)性(xing)之(zhi)黃連、黃柏與(yu)屬(shu)熱性(xing)之(zhi)細辛(xin)、桂枝、附子(zi)、干(gan)姜相配;酸性(xing)之(zhi)烏(wu)梅(mei)、苦酒(jiu)與(yu)辛(xin)味(wei)之(zhi)細辛(xin)、干(gan)姜、蜀椒(jiao)相合;方中既有苦味(wei)的(de)黃連、黃柏,又(you)有甘(gan)昧的(de)人參、當(dang)歸(gui)、米(mi)飯、蜂(feng)蜜(mi)。全方寒(han)熱并用、酸辛(xin)苦甘(gan)、辛(xin)開苦降、剛柔相濟。無(wu)}圣乎有人將其推(tui)崇為《內經(jing)》氣味(wei)組方理論下的(de)經(jing)典方劑。
臨證中,筆(bi)者運(yun)用烏(wu)梅(mei)丸治(zhi)療消化系(xi)統疾病(bing),也收到了良好的效果(guo)。
1 氣亂者用烏梅丸
氣(qi)(qi)亂,指(zhi)氣(qi)(qi)機逆亂,不(bu)(bu)循常(chang)道,攻竄不(bu)(bu)定,發(fa)作無時,與(yu)“氣(qi)(qi)上(shang)撞心(xin)”,有互文見(jian)意之(zhi)(zhi)(zhi)處(chu)。氣(qi)(qi)機歸肝所主,與(yu)厥(jue)陰(yin)相關(guan)。“厥(jue)陰(yin)之(zhi)(zhi)(zhi)上(shang),風(feng)氣(qi)(qi)主之(zhi)(zhi)(zhi),中見(jian)少陽”,氣(qi)(qi)亂病(bing)機的關(guan)鍵在于一個“風(feng)”字。風(feng)木(mu)生火而灼津液,故見(jian)消(xiao)渴(ke);風(feng)氣(qi)(qi)主動,肝氣(qi)(qi)通于心(xin),肝風(feng)夾(jia)熱(re)沖心(xin)則“氣(qi)(qi)上(shang)撞心(xin),心(xin)中疼熱(re)”,夾(jia)寒乘脾(pi)(pi)(pi)則“下之(zhi)(zhi)(zhi),利不(bu)(bu)止(zhi)”;“風(feng)木(mu)一動,必乘脾(pi)(pi)(pi)胃(wei)”、“見(jian)肝之(zhi)(zhi)(zhi)病(bing),知肝傳脾(pi)(pi)(pi)”,故厥(jue)陰(yin)病(bing)多兼脾(pi)(pi)(pi)胃(wei)癥。木(mu)郁土虛(xu),脾(pi)(pi)(pi)失健運,則“饑而不(bu)(bu)欲食(shi)”;脾(pi)(pi)(pi)虛(xu)腸寒,進食(shi)不(bu)(bu)得(de)腐熟消(xiao)化,致胃(wei)氣(qi)(qi)上(shang)逆而嘔(ou)吐。仲景以(yi)“消(xiao)渴(ke),氣(qi)(qi)上(shang)撞心(xin),心(xin)中疼熱(re),饑不(bu)(bu)欲食(shi),食(shi)則吐蛔。下之(zhi)(zhi)(zhi),利不(bu)(bu)止(zhi)。”作為厥(jue)陰(yin)病(bing)之(zhi)(zhi)(zhi)提綱,正是對厥(jue)陰(yin)之(zhi)(zhi)(zhi)風(feng)善行數變、動蕩不(bu)(bu)安的最好詮釋。
大凡治風(feng)之法,外風(feng)宜散(san)、內風(feng)宜熄、寒風(feng)溫(wen)散(san)、熱風(feng)清泄、實風(feng)掣制、虛風(feng)填固,葉天士曾以“厥(jue)陰(yin)肝(gan)(gan)(gan)(gan)風(feng)振(zhen)動內起……甘以理(li)胃,酸(suan)以制肝(gan)(gan)(gan)(gan)”談到厥(jue)陰(yin)之風(feng)的(de)治療(liao)方法。肝(gan)(gan)(gan)(gan)體陰(yin)而用(yong)陽,肝(gan)(gan)(gan)(gan)體陰(yin)血(xue)不(bu)足,則肝(gan)(gan)(gan)(gan)臟的(de)疏泄條達之性(xing)必然失和,以致(zhi)氣血(xue)運行不(bu)暢、脾胃的(de)運化功(gong)能紊亂。烏梅丸一方,正是(shi)重用(yong)烏梅、苦酒之酸(suan),酸(suan)入肝(gan)(gan)(gan)(gan)木(mu),二藥相配,補益陰(yin)血(xue)、滋(zi)養肝(gan)(gan)(gan)(gan)體、平抑肝(gan)(gan)(gan)(gan)木(mu)。此外,《素問·藏氣法時論》說:“肝(gan)(gan)(gan)(gan)欲散(san),急食辛(xin)(xin)(xin)以散(san)之,用(yong)辛(xin)(xin)(xin)補之,酸(suan)瀉之。”方中配伍辛(xin)(xin)(xin)溫(wen)燥(zao)烈的(de)附子、桂枝(zhi)、蜀椒、細辛(xin)(xin)(xin)溫(wen)陽而理(li)氣、疏木(mu)達郁,又恐肝(gan)(gan)(gan)(gan)木(mu)生(sheng)火,灼(zhuo)傷陰(yin)液(ye),以黃連(lian)、黃柏之苦寒之性(xing)清泄肝(gan)(gan)(gan)(gan)火。
辛甘化(hua)陽(yang)、酸甘化(hua)陰、溫中(zhong)有(you)清(qing)、散中(zhong)有(you)收(shou),此(ci)烏梅丸組方之(zhi)(zhi)精妙也。臨證(zheng)之(zhi)(zhi)時,更應(ying)明(ming)辨疾病寒熱之(zhi)(zhi)多少、虛實之(zhi)(zhi)偏頗,隨癥加減,以常達變。
2 寒熱錯雜之肢厥用烏梅丸
《靈樞·終始》:“陰者(zhe)(zhe)主臟(zang)(zang),陽者(zhe)(zhe)主腑(fu),陽受(shou)氣于四(si)末,陰受(shou)氣于五臟(zang)(zang)。”意(yi)思是(shi)人體之氣不斷(duan)地補(bu)充、接濟敷布于體表四(si)肢(zhi)之氣,從而保持肢(zhi)體的溫暖。若內(nei)臟(zang)(zang)之氣因虛衰(shuai)而無力外達或因邪阻而不能透出肌表,就會出現《傷寒論》第337條中所(suo)云“厥者(zhe)(zhe),手足逆冷(leng)是(shi)也(ye)”。仲景開篇明(ming)意(yi),諄(zhun)(zhun)諄(zhun)(zhun)告誡(jie)后世,只(zhi)有明(ming)辨臟(zang)(zang)厥及蛔厥,才能正確使(shi)用烏梅丸。
臟厥乃陽(yang)(yang)(yang)氣衰(shuai)(shuai)微(wei),陰(yin)(yin)寒(han)內盛,在(zai)少陰(yin)(yin)心腎真(zhen)陽(yang)(yang)(yang)衰(shuai)(shuai)微(wei)的基礎上(shang),又(you)出現了厥陰(yin)(yin)相火(huo)的衰(shuai)(shuai)竭。從而造(zao)成人體五臟六(liu)腑的真(zhen)陽(yang)(yang)(yang)都虛衰(shuai)(shuai)。故在(zai)癥狀上(shang)除肢(zhi)冷(leng)外,更有“至七(qi)八日膚(fu)冷(leng)”、“躁無(wu)(wu)暫安時”。此時獨(du)陰(yin)(yin)無(wu)(wu)陽(yang)(yang)(yang),生機(ji)泯滅,預后不良。治療用四逆(ni)輩(bei)回陽(yang)(yang)(yang)救逆(ni)或是急灸(jiu)厥陰(yin)(yin);
蛔(hui)厥(jue)一證,亦有“脈微膚冷者”,其病機為上熱(re)下(xia)寒,蛔(hui)蟲內擾(rao),擾(rao)亂體(ti)內陽氣的正常(chang)運行。正如柯韻伯所說(shuo):“其顯證在吐蛔(hui),而細辨在煩(fan)(fan)躁(zao),臟寒則躁(zao)而不煩(fan)(fan),內熱(re)則煩(fan)(fan)而不躁(zao),其人靜而時(shi)煩(fan)(fan),與躁(zao)而無暫安(an)者迥(jiong)異矣”。
3 烏梅丸的臨證運用
筆(bi)者(zhe)(zhe)在(zai)(zai)臨床運用(yong)(yong)(yong)烏梅丸時(shi),也有(you)以(yi)下體會:方(fang)(fang)中(zhong)(zhong)含附(fu)子(zi)、桂枝、蜀椒、細辛,辛竄燥烈之品較多,易動血而截陰(yin),故陰(yin)虛(xu)者(zhe)(zhe)慎用(yong)(yong)(yong);方(fang)(fang)中(zhong)(zhong)散中(zhong)(zhong)有(you)補(bu),以(yi)散為(wei)(wei)主,為(wei)(wei)驅邪之劑,純(chun)虛(xu)證的患(huan)者(zhe)(zhe)勿用(yong)(yong)(yong);病(bing)情急(ji)重(zhong)者(zhe)(zhe)應(ying)予以(yi)湯劑,病(bing)情和緩者(zhe)(zhe)宜予以(yi)丸劑。在(zai)(zai)加(jia)減運用(yong)(yong)(yong)方(fang)(fang)面,若寒(han)重(zhong)熱輕者(zhe)(zhe),則(ze)宜在(zai)(zai)烏梅丸中(zhong)(zhong)重(zhong)用(yong)(yong)(yong)附(fu)子(zi)、肉(rou)桂、干(gan)姜、細辛、蜀椒;熱重(zhong)寒(han)輕者(zhe)(zhe),則(ze)重(zhong)用(yong)(yong)(yong)黃連、黃柏;若肝風肆虐,則(ze)加(jia)重(zhong)烏梅用(yong)(yong)(yong)量(liang);虛(xu)多實少(shao)(shao)者(zhe)(zhe),加(jia)重(zhong)人參與(yu)當歸。用(yong)(yong)(yong)藥(yao)過程中(zhong)(zhong),更應(ying)循序漸進,從少(shao)(shao)量(liang)用(yong)(yong)(yong)起,注意觀察患(huan)者(zhe)(zhe)對藥(yao)物的反應(ying),以(yi)便及時(shi)調整藥(yao)量(liang)。
4 典型病例
湯某某,男(nan),35歲,因“左下腹部疼痛2月”來診,疼痛呈痙攣性,有時伴有腹瀉,無便血(xue)、排(pai)膿,納、眠差,時有煩(fan)躁,小便略熱,雙手不(bu)溫。舌紅,苔黃膩(ni)花剝,脈沉(chen)細。
中(zhong)醫診斷(duan):腹痛(tong)(窠熱錯(cuo)雜(za));西(xi)醫診斷(duan):腸易激綜(zong)合癥
治以(yi)平調寒熱。方選(xuan)烏梅丸(wan)加減(jian):烏梅15g、熟附子(先(xian)煎)10g,肉桂1.5g(焗服),太子參15g,當歸(gui)5g,細辛1g,干姜(jiang)5g,黃連10gI黃柏15g,白(bai)(bai)頭翁20g,生地10g,白(bai)(bai)芍30g。予(yu)以(yi)上方7劑(ji)。
二診(zhen);患者用藥后腹痛減(jian)(jian)輕(qing),煩(fan)躁好(hao)轉(zhuan),納一般,眠好(hao)轉(zhuan),小便(bian)略(lve)黃,無發(fa)熱(re)感,雙(shuang)手變(bian)暖,偶有噯氣,舌(she)紅,苔黃膩花剝,脈略(lve)弱(ruo)偏滑。予上(shang)方中(zhong)減(jian)(jian)黃柏(bo)為10g、白(bai)頭(tou)翁10g,繼續予14劑(ji)。
三診:用(yong)藥后(hou)腹痛癥(zheng)狀消(xiao)失,大便(bian)時硬時軟,排(pai)出欠通暢,納(na)可,小(xiao)便(bian)偏(pian)黃,舌(she)淡紅,舌(she)尖偏(pian)紅,苔薄黃,脈細(xi)。予(yu)上方中去白頭翁,加用(yong)防風10g,予(yu)再服7劑后(hou),隨(sui)訪3月,患者未(wei)述癥(zheng)狀反復(fu)。
患(huan)(huan)(huan)(huan)者(zhe)(zhe)“左下(xia)腹部痙攣性疼痛,時有腹瀉”此為(wei)厥(jue)陰(yin)之(zhi)(zhi)(zhi)(zhi)(zhi)風(feng)(feng)(feng)(feng)內(nei)動之(zhi)(zhi)(zhi)(zhi)(zhi)象。厥(jue)陰(yin)之(zhi)(zhi)(zhi)(zhi)(zhi)風(feng)(feng)(feng)(feng)夾寒(han)下(xia)迫大腸,可(ke)見下(xia)利;患(huan)(huan)(huan)(huan)者(zhe)(zhe)煩(fan)躁、眠差,小便偏(pian)熱(re)(re),為(wei)心中有熱(re)(re),下(xia)移小腸所(suo)致,證屬“上熱(re)(re)下(xia)寒(han)”。患(huan)(huan)(huan)(huan)者(zhe)(zhe)舌(she)紅,苔黃(huang)膩花剝,又有濕(shi)熱(re)(re)和陰(yin)虛之(zhi)(zhi)(zhi)(zhi)(zhi)象。用(yong)藥(yao)時,選用(yong)寒(han)熱(re)(re)并(bing)(bing)用(yong)的烏梅丸,重用(yong)烏梅,突(tu)出酸收,以斂肝(gan)熄風(feng)(feng)(feng)(feng),重用(yong)黃(huang)連、黃(huang)柏并(bing)(bing)加(jia)(jia)(jia)用(yong)白頭翁以加(jia)(jia)(jia)強清(qing)熱(re)(re)之(zhi)(zhi)(zhi)(zhi)(zhi)效。清(qing)熱(re)(re)之(zhi)(zhi)(zhi)(zhi)(zhi)藥(yao),多苦寒(han)燥濕(shi),加(jia)(jia)(jia)之(zhi)(zhi)(zhi)(zhi)(zhi)患(huan)(huan)(huan)(huan)者(zhe)(zhe)舌(she)苔花剝,已(yi)有傷陰(yin)之(zhi)(zhi)(zhi)(zhi)(zhi)象,故(gu)方中以佐以養陰(yin)之(zhi)(zhi)(zhi)(zhi)(zhi)品,并(bing)(bing)以益(yi)氣(qi)(qi)養陰(yin)之(zhi)(zhi)(zhi)(zhi)(zhi)太(tai)子參(can)(can)易人參(can)(can);二診時,患(huan)(huan)(huan)(huan)者(zhe)(zhe)煩(fan)躁,睡眠好(hao)轉,舌(she)苔較(jiao)前變薄,濕(shi)熱(re)(re)之(zhi)(zhi)(zhi)(zhi)(zhi)邪漸(jian)去,故(gu)減少(shao)苦寒(han)之(zhi)(zhi)(zhi)(zhi)(zhi)品用(yong)量(liang)。三(san)診時患(huan)(huan)(huan)(huan)者(zhe)(zhe)舌(she)象提示有形(xing)之(zhi)(zhi)(zhi)(zhi)(zhi)邪基(ji)本(ben)退去,可(ke)進一(yi)步(bu)調整寒(han)性藥(yao)物(wu)的用(yong)量(liang),并(bing)(bing)加(jia)(jia)(jia)入(ru)防風(feng)(feng)(feng)(feng)以風(feng)(feng)(feng)(feng)藥(yao)條暢(chang)氣(qi)(qi)機,順應肝(gan)的調達之(zhi)(zhi)(zhi)(zhi)(zhi)性。
文章來源:按摩與康復醫學
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