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試從三焦理論認識柴胡類證的證治規律

醫案日記 2023-05-16 16:57:59

劉英鋒 劉 敏(指導(dao) 熊(xiong)曼琪 陳瑞春(chun)) 廣州中醫藥大(da)學

《傷寒論》小柴胡湯不(bu)僅因其(qi)立法精要(yao)巧妙(miao)、療效(xiao)歷驗不(bu)爽而著稱于醫史,更以其(qi)配伍化裁靈活、變通(tong)應用廣泛而盛行于歷代。然而,要(yao)能真(zhen)正從(cong)醫理的(de)高(gao)度把握(wo)小柴胡湯及其(qi)化裁方的(de)運用規(gui)律(lv),僅以現在(zai)通(tong)行的(de)“少(shao)陽(yang)半表半里、寒熱虛實夾雜”或“肝膽脾胃不(bu)和”等主治病機來駕(jia)馭之,不(bu)僅有捉襟(jin)見肘之感,更未能真(zhen)正窮盡其(qi)妙(miao)!

清代柯琴、唐(tang)容川等名家,曾(ceng)一(yi)改以(yi)往之(zhi)俗套,“只在(zai)(zai)六(liu)經(jing)上(shang)求根本,不在(zai)(zai)諸病(bing)名目(mu)上(shang)尋枝(zhi)葉(xie)”,在(zai)(zai)闡發仲景六(liu)經(jing)乃(nai)為(wei)百病(bing)立(li)法(fa)、界(jie)(jie)定仲景六(liu)經(jing)乃(nai)經(jing)界(jie)(jie)地域(yu)之(zhi)義的(de)(de)同時(shi),曾(ceng)提出(chu)了(le)少(shao)陽(yang)證(zheng)(zheng)(zheng)治關(guan)乎三(san)(san)(san)焦(jiao)(jiao)(jiao)之(zhi)腑、柴(chai)胡(hu)之(zhi)劑貴在(zai)(zai)轉運機樞等獨(du)具匠心的(de)(de)觀點,江(jiang)西名老中(zhong)醫姚荷(he)生先生、陳瑞春教授,則從實踐檢驗(yan)理論、理論指導臨床的(de)(de)角度,結合切身經(jing)驗(yan),對其(qi)(qi)中(zhong)蘊含(han)的(de)(de)真知灼見作了(le)更深入的(de)(de)發明(ming)與印證(zheng)(zheng)(zheng)。他(ta)們認為(wei):少(shao)陽(yang)經(jing)界(jie)(jie)乃(nai)統(tong)屬手、足少(shao)陽(yang)兩大經(jing)系(xi),其(qi)(qi)病(bing)理范圍絕不限于腠理與膽系(xi),尤其(qi)(qi)包括(kuo)六(liu)腑之(zhi)一(yi)的(de)(de)三(san)(san)(san)焦(jiao)(jiao)(jiao),因此少(shao)陽(yang)辨證(zheng)(zheng)(zheng)自然關(guan)乎三(san)(san)(san)焦(jiao)(jiao)(jiao)病(bing)變(bian),少(shao)陽(yang)立(li)法(fa)、選方與用(yong)藥也(ye)不能(neng)脫離(li)三(san)(san)(san)焦(jiao)(jiao)(jiao)特(te)性,而《傷寒論》諸柴(chai)胡(hu)湯(tang)證(zheng)(zheng)(zheng),正(zheng)是(shi)與這類病(bing)變(bian)及其(qi)(qi)證(zheng)(zheng)(zheng)治密切相關(guan)的(de)(de)典型范例。下(xia)面(mian)筆者根據從師所學,試以(yi)六(liu)經(jing)經(jing)界(jie)(jie)的(de)(de)眼光,立(li)足少(shao)陽(yang)之(zhi)三(san)(san)(san)焦(jiao)(jiao)(jiao),就(jiu)仲景有(you)關(guan)柴(chai)胡(hu)類證(zheng)(zheng)(zheng)(以(yi)柴(chai)胡(hu)命名的(de)(de)湯(tang)證(zheng)(zheng)(zheng))之(zhi)證(zheng)(zheng)(zheng)治規律,作一(yi)系(xi)統(tong)分析。

一、少陽本證(zheng):大、小柴(chai)胡證(zheng)的對待與比較(jiao)

1.少陽小柴(chai)胡證乃屬手足兩經同病而偏重三焦者(zhe)

眾所周(zhou)知,該(gai)證病機(ji)(ji)(ji)本屬少(shao)(shao)陽(yang)(yang)寒(han)風(feng)郁(yu)火(huo)(huo)(huo),正(zheng)(zheng)邪分爭于(yu)(yu)(yu)(yu)(yu)表(biao)里(li)之(zhi)(zhi)(zhi)(zhi)半,而(er)此“表(biao)里(li)之(zhi)(zhi)(zhi)(zhi)半”正(zheng)(zheng)是(shi)三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao)膜腠(cou)之(zhi)(zhi)(zhi)(zhi)所在!因(yin)(yin)為(wei)(wei)(wei)三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao)者(zhe),乃是(shi)居“臟(zang)腑(fu)(內(nei)臟(zang))之(zhi)(zhi)(zhi)(zhi)外(wai)(wai),軀體(ti)(軀殼(ke))之(zhi)(zhi)(zhi)(zhi)內(nei),包(bao)(bao)羅諸(zhu)臟(zang),一(yi)(yi)腔之(zhi)(zhi)(zhi)(zhi)大府(fu)也(ye)”(張景岳《類經(jing)(jing)(jing)(jing)(jing)》),其(qi)(qi)(qi)(qi)處內(nei)鄰臟(zang)腑(fu),外(wai)(wai)連腠(cou)理(li),正(zheng)(zheng)當表(biao)里(li)之(zhi)(zhi)(zhi)(zhi)間也(ye),故(gu)(gu)外(wai)(wai)邪侵(qin)犯少(shao)(shao)陽(yang)(yang)經(jing)(jing)(jing)(jing)(jing)界,手(shou)(shou)經(jing)(jing)(jing)(jing)(jing)三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao)首當其(qi)(qi)(qi)(qi)沖。因(yin)(yin)此,在小柴胡證的(de)七大主癥(zheng)之(zhi)(zhi)(zhi)(zhi)中(zhong)(即往來寒(han)熱(re)(re)、胸脅苦(ku)滿(man)、嘿嘿不(bu)欲飲食、心(xin)煩喜(xi)嘔(ou)(ou),結合少(shao)(shao)陽(yang)(yang)提綱,則口苦(ku)、咽(yan)干、目(mu)眩(xuan)也(ye)為(wei)(wei)(wei)其(qi)(qi)(qi)(qi)應有(you)表(biao)現),除喜(xi)嘔(ou)(ou)、不(bu)欲飲食能顯示膽(dan)(dan)郁(yu)犯胃的(de)機(ji)(ji)(ji)制之(zhi)(zhi)(zhi)(zhi)外(wai)(wai),其(qi)(qi)(qi)(qi)余五(wu)癥(zheng)無(wu)(wu)一(yi)(yi)不(bu)與(yu)手(shou)(shou)經(jing)(jing)(jing)(jing)(jing)三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao)有(you)關。如:口苦(ku)、咽(yan)干、目(mu)眩(xuan)乃少(shao)(shao)陽(yang)(yang)相(xiang)(xiang)火(huo)(huo)(huo)循(xun)其(qi)(qi)(qi)(qi)經(jing)(jing)(jing)(jing)(jing)脈(包(bao)(bao)括(kuo)手(shou)(shou)少(shao)(shao)陽(yang)(yang)經(jing)(jing)(jing)(jing)(jing)脈)上犯清(qing)竅使然,相(xiang)(xiang)火(huo)(huo)(huo)雖(sui)寄(ji)于(yu)(yu)(yu)(yu)(yu)膽(dan)(dan),而(er)其(qi)(qi)(qi)(qi)游(you)行(xing)上下內(nei)外(wai)(wai),無(wu)(wu)不(bu)依(yi)賴于(yu)(yu)(yu)(yu)(yu)三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao)火(huo)(huo)(huo)腑(fu)的(de)氣機(ji)(ji)(ji)升(sheng)(sheng)降與(yu)三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao)通(tong)道的(de)內(nei)外(wai)(wai)轉輸。因(yin)(yin)此少(shao)(shao)陽(yang)(yang)一(yi)(yi)有(you)風(feng)寒(han)外(wai)(wai)來,令其(qi)(qi)(qi)(qi)游(you)行(xing)之(zhi)(zhi)(zhi)(zhi)相(xiang)(xiang)火(huo)(huo)(huo)失于(yu)(yu)(yu)(yu)(yu)宣達而(er)怫郁(yu)于(yu)(yu)(yu)(yu)(yu)內(nei),則會蓄積于(yu)(yu)(yu)(yu)(yu)膽(dan)(dan)腑(fu)而(er)犯胃口、逆循(xun)于(yu)(yu)(yu)(yu)(yu)經(jing)(jing)(jing)(jing)(jing)脈(包(bao)(bao)括(kuo)手(shou)(shou)少(shao)(shao)陽(yang)(yang)經(jing)(jing)(jing)(jing)(jing)脈)而(er)擾(rao)清(qing)竅,故(gu)(gu)而(er)才使嘔(ou)(ou)不(bu)能食與(yu)口苦(ku)、咽(yan)干、目(mu)眩(xuan)同時并發。心(xin)煩與(yu)胸脅苦(ku)滿(man),雖(sui)然各與(yu)膽(dan)(dan)腑(fu)的(de)中(zhong)正(zheng)(zheng)之(zhi)(zhi)(zhi)(zhi)官(guan)和位居脅下有(you)關,但三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao)之(zhi)(zhi)(zhi)(zhi)腑(fu)上絡心(xin)包(bao)(bao),而(er)由三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao)郁(yu)火(huo)(huo)(huo)循(xun)絡擾(rao)神,引起發煩則更加直接。胸脅地帶屬于(yu)(yu)(yu)(yu)(yu)身之(zhi)(zhi)(zhi)(zhi)兩側,而(er)兩脅不(bu)僅有(you)膽(dan)(dan)經(jing)(jing)(jing)(jing)(jing)分布(bu)(bu),三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao)之(zhi)(zhi)(zhi)(zhi)經(jing)(jing)(jing)(jing)(jing)也(ye)同行(xing)其(qi)(qi)(qi)(qi)間,更何況左右(you)(兩脅)者(zhe)乃三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao)水(shui)(shui)火(huo)(huo)(huo)氣機(ji)(ji)(ji)升(sheng)(sheng)降之(zhi)(zhi)(zhi)(zhi)道路(lu),三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao)膜腠(cou)遍布(bu)(bu)其(qi)(qi)(qi)(qi)內(nei),其(qi)(qi)(qi)(qi)與(yu)膽(dan)(dan)腑(fu)獨居一(yi)(yi)側也(ye)有(you)不(bu)同,因(yin)(yin)此,一(yi)(yi)旦“血弱氣盡(jin),腠(cou)理(li)開,邪氣因(yin)(yin)入(ru)(ru)”,便會循(xun)其(qi)(qi)(qi)(qi)膜腠(cou)之(zhi)(zhi)(zhi)(zhi)連系,傳入(ru)(ru)軀殼(ke)之(zhi)(zhi)(zhi)(zhi)內(nei),而(er)“與(yu)正(zheng)(zheng)氣相(xiang)(xiang)搏,結于(yu)(yu)(yu)(yu)(yu)脅下”,出(chu)現胸脅之(zhi)(zhi)(zhi)(zhi)苦(ku)滿(man)與(yu)脹痛,所以(yi)該(gai)證已不(bu)只是(shi)邪氣阻滯其(qi)(qi)(qi)(qi)淺在的(de)經(jing)(jing)(jing)(jing)(jing)脈,更多的(de)是(shi)影響水(shui)(shui)火(huo)(huo)(huo)升(sheng)(sheng)降之(zhi)(zhi)(zhi)(zhi)機(ji)(ji)(ji)樞的(de)結果。至于(yu)(yu)(yu)(yu)(yu)往來寒(han)熱(re)(re),作(zuo)為(wei)(wei)(wei)正(zheng)(zheng)邪分爭于(yu)(yu)(yu)(yu)(yu)半表(biao)半里(li)的(de)特(te)有(you)指(zhi)征,更是(shi)非三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao)莫屬,因(yin)(yin)為(wei)(wei)(wei)三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao)者(zhe),其(qi)(qi)(qi)(qi)位外(wai)(wai)連腠(cou)理(li),內(nei)鄰臟(zang)腑(fu),正(zheng)(zheng)當表(biao)里(li)出(chu)入(ru)(ru)之(zhi)(zhi)(zhi)(zhi)地帶,其(qi)(qi)(qi)(qi)用(yong)又為(wei)(wei)(wei)“原氣之(zhi)(zhi)(zhi)(zhi)別使”(《難經(jing)(jing)(jing)(jing)(jing)》),有(you)“通(tong)會元真(zhen)(zhen)”以(yi)充腠(cou)理(li)之(zhi)(zhi)(zhi)(zhi)職(《金匱要略》),故(gu)(gu)其(qi)(qi)(qi)(qi)癥(zheng)見“往來寒(han)熱(re)(re)者(zhe),(正(zheng)(zheng)是(shi)風(feng)寒(han)之(zhi)(zhi)(zhi)(zhi))邪(自肌腠(cou)乘真(zhen)(zhen)元之(zhi)(zhi)(zhi)(zhi)不(bu)足,侵(qin))入(ru)(ru)軀殼(ke)之(zhi)(zhi)(zhi)(zhi)里(li)、臟(zang)腑(fu)之(zhi)(zhi)(zhi)(zhi)外(wai)(wai),兩夾界之(zhi)(zhi)(zhi)(zhi)隙地,所謂(wei)半表(biao)半里(li),少(shao)(shao)陽(yang)(yang)(三(san)焦(jiao)(jiao)(jiao)(jiao)(jiao)(jiao))所主之(zhi)(zhi)(zhi)(zhi)部位。故(gu)(gu)(風(feng)寒(han)之(zhi)(zhi)(zhi)(zhi)邪)入(ru)(ru)而(er)并于(yu)(yu)(yu)(yu)(yu)陰(里(li))則寒(han),出(chu)而(er)并于(yu)(yu)(yu)(yu)(yu)陽(yang)(yang)(表(biao))則熱(re)(re),出(chu)入(ru)(ru)無(wu)(wu)常,所謂(wei)寒(han)熱(re)(re)間作(zuo)”也(ye)(方中(zhong)行(xing)《傷寒(han)論條辨》)。

小柴(chai)胡(hu)(hu)湯,作為和解少陽(yang)之第一主方,所以(yi)取柴(chai)、芩、夏、參、姜(jiang)、棗、草(cao),不(bu)(bu)同(tong)性味之品(pin)合于一方,能得寒(han)(han)熱(re)并用,攻補兼施,升(sheng)降宣通之義(yi),也無不(bu)(bu)與三焦氣機水火交織紛紜的發(fa)病機制密(mi)切相關(guan)。如柴(chai)胡(hu)(hu)辛(xin)平升(sheng)發(fa),其(qi)疏利少陽(yang)氣機,不(bu)(bu)只在膽(dan)而更在三焦,以(yi)三焦總(zong)司諸氣之轉(zhuan)樞,其(qi)轉(zhuan)樞利則氣機和而膜腠暢,元真(zhen)之氣得以(yi)伸張而能驅邪外達(da);黃(huang)芩苦寒(han)(han),以(yi)清郁積之相火;半夏辛(xin)溫,以(yi)散(san)停滯之水飲;參、草(cao)味甘,以(yi)助(zhu)偏衰之元氣;生姜(jiang)、大棗,資助(zhu)營衛,以(yi)隨氣機外達(da)而抵御(yu)外來之風寒(han)(han)。是故全方應(ying)機立法(fa),相反相成,協(xie)同(tong)達(da)到疏利膜腠以(yi)和表里,分(fen)解水火以(yi)和寒(han)(han)熱(re),扶正(zheng)祛(qu)邪以(yi)和虛實的至和之治!

另外,特(te)別值得(de)注(zhu)意的(de)(de)是(shi),《傷寒論》中(zhong)(zhong)第96條小(xiao)柴胡湯證(zheng)中(zhong)(zhong)列(lie)舉的(de)(de)一系(xi)列(lie)撲(pu)朔迷(mi)離的(de)(de)或(huo)(huo)(huo)然癥及(ji)其(qi)藥(yao)物加(jia)減,正是(shi)對三(san)(san)焦(jiao)(jiao)(jiao)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)腑兼涉廣泛、病(bing)機多樣等特(te)點(dian)的(de)(de)寫照。因為三(san)(san)焦(jiao)(jiao)(jiao)者,決(jue)瀆之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)官(guan),水(shui)道出焉,同時,三(san)(san)焦(jiao)(jiao)(jiao)又下(xia)系(xi)命門,而(er)游行(xing)相火(huo),受病(bing)自多水(shui)火(huo)失調(diao)而(er)為證(zheng)寒熱(re)(re)夾(jia)雜(za)。其(qi)于(yu)(yu)(yu)(yu)寒熱(re)(re)夾(jia)雜(za)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)中(zhong)(zhong),若寒邪偏(pian)(pian)重(zhong)(zhong),則(ze)(ze)氣(qi)(qi)化(hua)易阻(zu)而(er)停水(shui)較甚(shen),或(huo)(huo)(huo)停于(yu)(yu)(yu)(yu)上(shang)焦(jiao)(jiao)(jiao)而(er)殃(yang)及(ji)肺臟則(ze)(ze)“或(huo)(huo)(huo)咳”,可(ke)加(jia)干姜、五味(wei),兼以(yi)(yi)溫(wen)(wen)肺化(hua)飲;或(huo)(huo)(huo)停于(yu)(yu)(yu)(yu)中(zhong)(zhong)焦(jiao)(jiao)(jiao)而(er)殃(yang)及(ji)胃腸(chang)則(ze)(ze)“或(huo)(huo)(huo)心下(xia)悸”,或(huo)(huo)(huo)停于(yu)(yu)(yu)(yu)下(xia)焦(jiao)(jiao)(jiao)而(er)殃(yang)及(ji)膀胱則(ze)(ze)“或(huo)(huo)(huo)小(xiao)便不(bu)利”,均可(ke)去黃(huang)芩(qin)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)寒凝,加(jia)茯苓之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)淡滲,以(yi)(yi)通調(diao)其(qi)水(shui)道。若于(yu)(yu)(yu)(yu)寒熱(re)(re)夾(jia)雜(za)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)中(zhong)(zhong),熱(re)(re)勢(shi)偏(pian)(pian)重(zhong)(zhong),則(ze)(ze)火(huo)氣(qi)(qi)易亢(kang)而(er)消水(shui)較甚(shen),火(huo)炎于(yu)(yu)(yu)(yu)上(shang)焦(jiao)(jiao)(jiao),但擾于(yu)(yu)(yu)(yu)心包則(ze)(ze)“或(huo)(huo)(huo)胸(xiong)中(zhong)(zhong)煩(fan)(甚(shen))而(er)不(bu)(一定)嘔”,可(ke)去人參之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)甘(gan)壅、半夏之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)溫(wen)(wen)燥,加(jia)瓜(gua)(gua)蔞(lou)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)涼潤(run)以(yi)(yi)清化(hua)痰(tan)火(huo);火(huo)消于(yu)(yu)(yu)(yu)中(zhong)(zhong)焦(jiao)(jiao)(jiao),胃津受劫則(ze)(ze)“或(huo)(huo)(huo)渴(ke)(ke)”,可(ke)去半夏之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)溫(wen)(wen)燥,加(jia)人參、瓜(gua)(gua)蔞(lou)根,以(yi)(yi)益氣(qi)(qi)生津。再因三(san)(san)焦(jiao)(jiao)(jiao)者,內裹臟腑,外連肌腠,主(zhu)司諸氣(qi)(qi)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)轉樞,故本證(zheng)于(yu)(yu)(yu)(yu)表里(li)出入之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)間(jian),在病(bing)勢(shi)初淺、內郁較輕時,則(ze)(ze)可(ke)得(de)太陽表解之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)機,而(er)有(you)“或(huo)(huo)(huo)(口)不(bu)(干)渴(ke)(ke),身(僅)有(you)微熱(re)(re)”,此可(ke)加(jia)桂枝兼以(yi)(yi)解表;若病(bing)勢(shi)深入,內及(ji)臟腑,則(ze)(ze)可(ke)因氣(qi)(qi)機郁滯(zhi)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)甚(shen),導致木不(bu)疏土而(er)“或(huo)(huo)(huo)腹中(zhong)(zhong)痛”,此可(ke)去黃(huang)芩(qin)之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)寒凝滯(zhi)氣(qi)(qi),加(jia)芍藥(yao)以(yi)(yi)和肝(gan)(gan)脾;也可(ke)因飲邪蓄結之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)久,阻(zu)滯(zhi)肝(gan)(gan)脾而(er)有(you)“或(huo)(huo)(huo)脅下(xia)痞硬”,此又可(ke)去大棗之(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)甘(gan)壅,加(jia)牡蠣(li)以(yi)(yi)軟堅……證(zheng)治(zhi)變化(hua)雖多,實(shi)不(bu)離三(san)(san)焦(jiao)(jiao)(jiao)一宗!

2.少陽大柴胡(hu)證乃屬(shu)手足兩(liang)經同病而偏重(zhong)膽腑者(zhe)

大(da)、小(xiao)(xiao)柴(chai)胡證(zheng)雖然(ran)因同(tong)具往來寒(han)熱(re)(re)而(er)(er)(er)同(tong)屬少(shao)陽(yang)(yang)半表半里(li)之(zhi)證(zheng),但彼(bi)此之(zhi)淺深(shen)輕(qing)重(zhong)(zhong)顯然(ran)不(bu)同(tong),而(er)(er)(er)其原由(you),則(ze)首先(xian)是因為(wei)其半表半里(li)的(de)病(bing)位偏重(zhong)(zhong)使(shi)然(ran)。即小(xiao)(xiao)柴(chai)胡證(zheng)側(ce)重(zhong)(zhong)半表,乃為(wei)三焦(jiao)膜(mo)腠(cou)所(suo)主(zhu),大(da)柴(chai)胡證(zheng)側(ce)重(zhong)(zhong)半里(li),則(ze)已由(you)焦(jiao)膜(mo)內聚膽腑,陽(yang)(yang)明胃腸也受影響。至(zhi)于病(bing)證(zheng),前(qian)(qian)者(zhe)多(duo)寒(han)熱(re)(re)而(er)(er)(er)不(bu)得汗(han),痛苦以(yi)(yi)彌漫(man)胸脅(xie)為(wei)主(zhu),可見頭(角)痛等經(jing)脈癥狀;后(hou)(hou)(hou)者(zhe)則(ze)可“傷寒(han)發熱(re)(re),汗(han)出不(bu)解”,痞痛必有心下(xia)固定之(zhi)處(chu)(包括右(you)上(shang)腹處(chu)),可兼下(xia)利不(bu)暢等胃腸反應。而(er)(er)(er)于治法,兩方雖同(tong)用柴(chai)、芩、半夏以(yi)(yi)疏氣機而(er)(er)(er)治水火,但一(yi)者(zhe)佐人參以(yi)(yi)助正達邪,一(yi)者(zhe)配枳(zhi)、芍甚至(zhi)加大(da)黃以(yi)(yi)破里(li)結(jie),是前(qian)(qian)者(zhe)注(zhu)重(zhong)(zhong)安外(wai)以(yi)(yi)攘(rang)內,欲求戰汗(han)而(er)(er)(er)解,后(hou)(hou)(hou)者(zhe)注(zhu)重(zhong)(zhong)攘(rang)內以(yi)(yi)安外(wai),必得“下(xia)之(zhi)則(ze)愈”。因此,兩者(zhe)的(de)相互關系,也可看(kan)作少(shao)陽(yang)(yang)自身病(bing)變由(you)淺入(ru)深(shen)之(zhi)連續過程(cheng)的(de)前(qian)(qian)后(hou)(hou)(hou)階(jie)段(duan)。

二、少陽兼證:柴胡化裁方證的同異(yi)衍化

少陽病變(bian),由(you)于三焦“孤腑”有(you)(you)遍歷上(shang)下(xia),通連內外(wai)的(de)特點,致使其病證(zheng)類(lei)型(xing)可(ke)以兼(jian)(jian)涉(she)甚廣,變(bian)異甚多。對(dui)兼(jian)(jian)變(bian)較輕(qing)者(zhe),可(ke)仿上(shang)述的(de)柴(chai)胡(hu)證(zheng)加減法,以大、小(xiao)柴(chai)胡(hu)稍作進退,但對(dui)兼(jian)(jian)變(bian)較重者(zhe),又當另作化(hua)裁而獨(du)立方證(zheng)。因此《傷(shang)寒論》中便有(you)(you)柴(chai)胡(hu)桂枝(zhi)湯證(zheng)、柴(chai)胡(hu)桂枝(zhi)干(gan)姜湯證(zheng)、柴(chai)胡(hu)加芒硝湯證(zheng)和柴(chai)胡(hu)加龍(long)骨牡蠣湯證(zheng)之例(li)。

1.柴胡桂枝湯證——少陽(yang)膜腠外涉太(tai)陽(yang)肌(ji)表(biao),寒風外束為主(zhu)

太陽(yang)(yang)主(zhu)表(biao)(biao)而(er)(er)外(wai)應(ying)皮(pi)毛(mao),少陽(yang)(yang)居間則外(wai)連腠理。太陽(yang)(yang)風寒(han)表(biao)(biao)證(zheng)不(bu)解,即可由皮(pi)毛(mao)而(er)(er)至(zhi)腠理,漸入少陽(yang)(yang)地帶。傳入少陽(yang)(yang),本當以(yi)小柴胡治之(zhi)(zhi),但若傳變之(zhi)(zhi)中,癥見發(fa)熱之(zhi)(zhi)中仍(reng)(reng)微(wei)惡寒(han),或伴肢(zhi)節煩疼,而(er)(er)口苦(ku)、咽干、目眩之(zhi)(zhi)類尚未(wei)(wei)顯著,微(wei)嘔、心(xin)下支結(微(wei)小的梗阻感)也僅(jin)僅(jin)初見端倪,是太陽(yang)(yang)之(zhi)(zhi)表(biao)(biao)未(wei)(wei)罷而(er)(er)初及少陽(yang)(yang)未(wei)(wei)深,寒(han)風外(wai)束尚在而(er)(er)火(huo)郁水滯未(wei)(wei)甚,病位之(zhi)(zhi)重心(xin)仍(reng)(reng)在經脈、肌腠與焦膜的軀殼之(zhi)(zhi)端,治法適以(yi)小和少陽(yang)(yang)兼以(yi)發(fa)表(biao)(biao),故取柴胡、桂枝兩方各半之(zhi)(zhi)法可以(yi)恰到(dao)好處!

2.柴胡桂枝(zhi)干姜(jiang)湯證——少陽(yang)膜腠內涉太(tai)陰脾臟(zang),寒飲內結偏勝

少(shao)(shao)陽受(shou)病(bing),病(bing)本夾雜,其(qi)(qi)(qi)于(yu)(yu)(yu)進退之(zhi)(zhi)(zhi)(zhi)間,不僅(jin)有(you)表里多少(shao)(shao)之(zhi)(zhi)(zhi)(zhi)偏(pian),還有(you)寒熱(re)(re)多寡(gua)之(zhi)(zhi)(zhi)(zhi)異。如見熱(re)(re)一(yi)味清下,或陽弱陰(yin)勝之(zhi)(zhi)(zhi)(zhi)體,勢足(zu)以(yi)(yi)使少(shao)(shao)陽夾雜之(zhi)(zhi)(zhi)(zhi)機(ji),向著寒多熱(re)(re)少(shao)(shao)的(de)方向轉(zhuan)變(bian),此(ci)際則陽氣易困、水(shui)(shui)(shui)(shui)氣易停,病(bing)勢難(nan)免(mian)由(you)(you)陽及陰(yin)、由(you)(you)腑及臟(zang),其(qi)(qi)(qi)中(zhong)(zhong)(zhong)以(yi)(yi)太(tai)陰(yin)首當其(qi)(qi)(qi)沖(chong),以(yi)(yi)少(shao)(shao)陽三焦(jiao)(jiao)(jiao)為(wei)行水(shui)(shui)(shui)(shui)之(zhi)(zhi)(zhi)(zhi)腑,太(tai)陰(yin)脾肺(fei)為(wei)運水(shui)(shui)(shui)(shui)之(zhi)(zhi)(zhi)(zhi)臟(zang),三焦(jiao)(jiao)(jiao)升降之(zhi)(zhi)(zhi)(zhi)樞在(zai)(zai)于(yu)(yu)(yu)中(zhong)(zhong)(zhong),而(er)(er)中(zhong)(zhong)(zhong)焦(jiao)(jiao)(jiao)樞機(ji)根于(yu)(yu)(yu)脾,因此(ci)少(shao)(shao)陽主證(zheng)(zheng)偏(pian)于(yu)(yu)(yu)寒化(hua)而(er)(er)內(nei)涉(she)太(tai)陰(yin),乃(nai)其(qi)(qi)(qi)常見轉(zhuan)歸之(zhi)(zhi)(zhi)(zhi)一(yi),柴(chai)胡桂(gui)枝干(gan)(gan)姜(jiang)湯證(zheng)(zheng)即屬此(ci)例(li)。試(shi)觀該(gai)證(zheng)(zheng),“胸脅滿……往來寒熱(re)(re)(寒多熱(re)(re)少(shao)(shao))”,是(shi)(shi)少(shao)(shao)陽膜腠(cou)受(shou)病(bing)之(zhi)(zhi)(zhi)(zhi)象(xiang),而(er)(er)其(qi)(qi)(qi)“胸脅(按之(zhi)(zhi)(zhi)(zhi)已(yi))微結(硬),……小(xiao)便不利,(而(er)(er))渴”,則顯露其(qi)(qi)(qi)飲停中(zhong)(zhong)(zhong)焦(jiao)(jiao)(jiao)欲成(cheng)蓄結之(zhi)(zhi)(zhi)(zhi)勢,致使水(shui)(shui)(shui)(shui)液不得上蒸清竅、下達(da)膀胱(guang),故(gu)辨其(qi)(qi)(qi)渴必飲熱(re)(re),小(xiao)腹不滿,知(zhi)其(qi)(qi)(qi)既非(fei)(fei)轉(zhuan)屬陽明(ming),也(ye)非(fei)(fei)太(tai)陽蓄水(shui)(shui)(shui)(shui),乃(nai)是(shi)(shi)飲結于(yu)(yu)(yu)中(zhong)(zhong)(zhong);其(qi)(qi)(qi)所以(yi)(yi)不嘔,正是(shi)(shi)中(zhong)(zhong)(zhong)焦(jiao)(jiao)(jiao)水(shui)(shui)(shui)(shui)飲所涉(she)之(zhi)(zhi)(zhi)(zhi)臟(zang)器已(yi)由(you)(you)腑入臟(zang)——不在(zai)(zai)胃,而(er)(er)在(zai)(zai)脾!好在(zai)(zai)一(yi)派的(de)靜象(xiang)之(zhi)(zhi)(zhi)(zhi)中(zhong)(zhong)(zhong),尚有(you)“但(dan)頭汗出……心煩”等動機(ji),可(ke)(ke)知(zhi)寒飲內(nei)盛之(zhi)(zhi)(zhi)(zhi)中(zhong)(zhong)(zhong),仍有(you)郁火(huo)存(cun)在(zai)(zai),說明(ming)并(bing)非(fei)(fei)純屬陰(yin)結,病(bing)機(ji)之(zhi)(zhi)(zhi)(zhi)重(zhong)心仍在(zai)(zai)少(shao)(shao)陽,故(gu)仍可(ke)(ke)從少(shao)(shao)陽和(he)法(fa)之(zhi)(zhi)(zhi)(zhi)中(zhong)(zhong)(zhong)尋(xun)求(qiu)戰機(ji),所不同的(de)是(shi)(shi),寒溫(wen)并(bing)用之(zhi)(zhi)(zhi)(zhi)中(zhong)(zhong)(zhong)當側(ce)重(zhong)溫(wen)化(hua)、辛開(kai)苦降之(zhi)(zhi)(zhi)(zhi)中(zhong)(zhong)(zhong)當注重(zhong)辛開(kai)。因此(ci),方以(yi)(yi)小(xiao)柴(chai)胡去人參、半夏(xia),易干(gan)(gan)姜(jiang)、桂(gui)枝以(yi)(yi)溫(wen)脾化(hua)飲,去生(sheng)姜(jiang)、大棗,易牡蠣、瓜蔞根以(yi)(yi)軟堅散結,如此(ci)不失為(wei)立足(zu)少(shao)(shao)陽、兼顧(gu)太(tai)陰(yin)之(zhi)(zhi)(zhi)(zhi)良策。

3.柴(chai)胡加芒硝湯證(zheng)——少(shao)陽膜(mo)腠內(nei)涉陽明胃腸(chang),火熱內(nei)實偏勝

少陽(yang)(yang)三(san)焦(jiao),其(qi)膜包連五臟六(liu)腑(fu)(fu),其(qi)道(dao)通行(xing)水火(huo)兩氣,且少陽(yang)(yang)經期,又正當由陽(yang)(yang)入陰(yin)之(zhi)(zhi)(zhi)際,故(gu)少陽(yang)(yang)病變內傳臟腑(fu)(fu),既可(ke)兼涉(she)太陰(yin)而(er)從陰(yin)化寒,也(ye)(ye)可(ke)兼涉(she)陽(yang)(yang)明(ming)而(er)從陽(yang)(yang)化熱(re)(re)。因此(ci),少陽(yang)(yang)兼涉(she)陽(yang)(yang)明(ming),以(yi)致火(huo)熱(re)(re)內實偏(pian)勝者,也(ye)(ye)是少陽(yang)(yang)病變的常見轉(zhuan)歸(gui)之(zhi)(zhi)(zhi)一。前(qian)文所論(lun)的大(da)(da)柴(chai)(chai)(chai)胡湯證(zheng)(zheng),雖已牽涉(she)此(ci)機(ji),不(bu)過彼則側(ce)重(zhong)(zhong)少陽(yang)(yang)之(zhi)(zhi)(zhi)半(ban)里,以(yi)膽腑(fu)(fu)為主(zhu),而(er)此(ci)之(zhi)(zhi)(zhi)柴(chai)(chai)(chai)胡加芒硝湯證(zheng)(zheng),則是側(ce)重(zhong)(zhong)少陽(yang)(yang)之(zhi)(zhi)(zhi)半(ban)表,以(yi)三(san)焦(jiao)為主(zhu)者。試觀其(qi)癥(zheng)仍(reng)以(yi)往(wang)來寒熱(re)(re)(而(er)不(bu)得(de)汗(han)),或(huo)“胸脅(xie)(苦(ku))滿而(er)(喜)嘔”等為主(zhu)癥(zheng),此(ci)與(yu)大(da)(da)柴(chai)(chai)(chai)胡湯證(zheng)(zheng)的汗(han)出(chu)不(bu)解(jie)、心(xin)下痞硬(ying)或(huo)急痛者有(you)淺深之(zhi)(zhi)(zhi)不(bu)同,而(er)從其(qi)伴見日晡所發潮熱(re)(re),可(ke)知其(qi)又兼涉(she)陽(yang)(yang)明(ming)燥熱(re)(re),至于(yu)(yu)何(he)以(yi)出(chu)現“反下利(li)者”,除(chu)了(le)原文提及的誤治因素(su)外,實與(yu)少陽(yang)(yang)三(san)焦(jiao)水道(dao)不(bu)利(li)、逆(ni)行(xing)腸間,以(yi)致分清別(bie)濁失(shi)職也(ye)(ye)有(you)一定關系。由于(yu)(yu)該證(zheng)(zheng)病機(ji)重(zhong)(zhong)心(xin)不(bu)僅(jin)仍(reng)在少陽(yang)(yang),而(er)又不(bu)似大(da)(da)柴(chai)(chai)(chai)胡證(zheng)(zheng)之(zhi)(zhi)(zhi)少陽(yang)(yang)偏(pian)里,故(gu)只需以(yi)小柴(chai)(chai)(chai)胡湯加芒硝,于(yu)(yu)和解(jie)少陽(yang)(yang)之(zhi)(zhi)(zhi)中,對(dui)陽(yang)(yang)明(ming)燥熱(re)(re)略加兼顧即可(ke)!

4.柴胡(hu)加龍(long)骨牡蠣湯證——少陽膜腠(cou)兼涉厥(jue)陰包絡,水(shui)火(huo)逆(ni)擾心神

少陽(yang)厥(jue)陰,經脈相絡,互為表里,且臟器之間,不(bu)(bu)僅有肝膽相寄(ji),還有三(san)(san)焦(jiao)之焦(jiao)膜與心(xin)(xin)包(bao)(bao)之胞(bao)膜“以(yi)膜相連”。因此,少陽(yang)病變失治(zhi)誤治(zhi),極有可(ke)能循此聯系(xi)殃(yang)及厥(jue)陰。柴胡(hu)加(jia)(jia)龍骨(gu)牡(mu)蠣(li)湯(tang)證(zheng)(zheng)即是(shi)其中(zhong)的(de)代(dai)表。該證(zheng)(zheng)的(de)發病機理(li),乃是(shi)少陽(yang)病邪(xie)彌漫三(san)(san)焦(jiao),水(shui)道火郁,上擾心(xin)(xin)包(bao)(bao)。故其見癥(zheng)是(shi)在(zai)柴胡(hu)證(zheng)(zheng)的(de)基(ji)礎上,續(xu)發“胸(xiong)滿煩(fan)驚(jing),小便(bian)不(bu)(bu)利,譫語(yu),一(yi)(yi)身(shen)盡(jin)重,不(bu)(bu)可(ke)自轉側(ce)”等癥(zheng),即:水(shui)氣上逆心(xin)(xin)包(bao)(bao)則小便(bian)不(bu)(bu)利而(er)驚(jing)悸,火氣上攻心(xin)(xin)包(bao)(bao)則胸(xiong)中(zhong)煩(fan)滿而(er)譫語(yu),水(shui)逆火郁于胸(xiong)中(zhong),上焦(jiao)陽(yang)氣不(bu)(bu)得(de)宣達周身(shen),則一(yi)(yi)身(shen)盡(jin)重而(er)不(bu)(bu)可(ke)自轉側(ce)。若論治(zhi)法(fa)(fa),則柴胡(hu)加(jia)(jia)龍骨(gu)牡(mu)蠣(li)湯(tang),一(yi)(yi)取小柴胡(hu)湯(tang)法(fa)(fa),疏利三(san)(san)焦(jiao),正本清源(yuan),二加(jia)(jia)茯苓、大(da)黃(huang)通利二便(bian),以(yi)降(jiang)水(shui)火,三(san)(san)加(jia)(jia)龍骨(gu)、牡(mu)蠣(li)、鉛丹,鎮定心(xin)(xin)包(bao)(bao),以(yi)制其亂,四加(jia)(jia)桂枝宣通胸(xiong)陽(yang),以(yi)布(bu)周身(shen)。

三(san)、少陽鄰證(zheng):柴胡類方的變通應用

柴(chai)胡方(fang)(fang)雖本為和(he)解少陽而設,但(dan)由于少陽三焦(jiao)身居內(nei)外之間(jian),遍歷(li)上下諸(zhu)臟,為通身氣(qi)機水(shui)火升降出入之通道與樞(shu)紐,故柴(chai)胡和(he)解之法(fa)不(bu)僅可(ke)以主治少陽自身氣(qi)機、水(shui)火失調諸(zhu)證,而且(qie)可(ke)以借(jie)助疏利三焦(jiao)樞(shu)機之治,達到間(jian)接(jie)調理鄰臟病變(bian)的效果。因此,仲景使用(yong)柴(chai)胡方(fang)(fang)還有(you)不(bu)少靈活變(bian)通之例。

1.借道少陽,轉出厥陰表(biao)邪

少(shao)陽與(yu)(yu)厥陰(yin)(yin),不僅(jin)經脈(mo)(mo)互為(wei)絡屬,經氣(qi)互為(wei)中見(jian),而(er)(er)且由于少(shao)陽三焦,身居臟腑軀殼之間,通里(li)(li)而(er)(er)達(da)表,故厥陰(yin)(yin)受邪,病(bing)勢(shi)(shi)未(wei)深(shen)之初,尚可(ke)借(jie)道少(shao)陽轉(zhuan)(zhuan)邪出(chu)(chu)表。如《傷寒(han)論(lun)》厥陰(yin)(yin)篇327條(“厥陰(yin)(yin)中風,脈(mo)(mo)微浮(fu)為(wei)欲(yu)愈(yu),不浮(fu)為(wei)未(wei)愈(yu)”),和379條(“嘔而(er)(er)發熱(re)者(zhe),小柴胡湯主(zhu)之”)等,即(ji)是(shi)其例。具(ju)體來說,其證(zheng)(zheng)治大意可(ke)以(yi)整理如下:厥陰(yin)(yin)中風(327),嘔而(er)(er)發熱(re)(379),(但)熱(re)少(shao)厥微,(僅(jin))指頭寒(han),嘿嘿不欲(yu)食,(時自(zi))煩躁(欲(yu)去(qu)衣被)(339),脈(mo)(mo)沉緊(弦)者(zhe)(140),(是(shi)寒(han)風郁(yu)熱(re)由厥陰(yin)(yin)之表而(er)(er)初及其里(li)(li)的證(zheng)(zheng)候,仍可(ke)以(yi)借(jie)助(zhu)與(yu)(yu)其相為(wei)表里(li)(li)的少(shao)陽樞機,轉(zhuan)(zhuan)邪出(chu)(chu)表,故可(ke)變通以(yi))小柴胡湯主(zhu)之(379)。“(服(fu)湯后(hou),若轉(zhuan)(zhuan))脈(mo)(mo)微浮(fu)(為(wei)邪得(de)外(wai)達(da)之機,則病(bing)勢(shi)(shi))欲(yu)愈(yu),(若)不(得(de)脈(mo)(mo))浮(fu)(則知病(bing)邪未(wei)得(de)外(wai)達(da),勢(shi)(shi)必內(nei)陷,故)為(wei)未(wei)愈(yu)(327)”。

2.還道(dao)少(shao)陽,透出血(xue)室之熱

三焦焦膜(mo)遍歷胸腹諸臟(zang),女(nv)子血(xue)(xue)(xue)(xue)室(shi)(shi)——胞官也(ye)(ye)(ye)在其(qi)(qi)中(zhong)。少(shao)(shao)陽(yang)受邪可以循(xun)其(qi)(qi)焦膜(mo)內傳諸臟(zang),血(xue)(xue)(xue)(xue)室(shi)(shi)之(zhi)胞宮亦不例(li)外,故(gu)《傷(shang)寒(han)論》中(zhong)也(ye)(ye)(ye)有(you)(you)此(ci)例(li)證。如144條:“婦(fu)人中(zhong)風(feng),七八日續得寒(han)熱(re),發(fa)作(zuo)有(you)(you)時(shi),經(jing)水(shui)(shui)適(shi)(shi)斷者,此(ci)為熱(re)入血(xue)(xue)(xue)(xue)室(shi)(shi),其(qi)(qi)血(xue)(xue)(xue)(xue)必結(jie),故(gu)使如瘧(nve)狀(zhuang)發(fa)作(zuo)有(you)(you)時(shi),小柴胡湯(tang)主之(zhi)”,此(ci)即少(shao)(shao)陽(yang)寒(han)風(feng)郁(yu)火,適(shi)(shi)逢婦(fu)人經(jing)期,趁之(zhi)血(xue)(xue)(xue)(xue)海空虛,循(xun)其(qi)(qi)腠膜(mo)內陷血(xue)(xue)(xue)(xue)室(shi)(shi)之(zhi)證。血(xue)(xue)(xue)(xue)室(shi)(shi)本屬厥陰(yin)(yin)(yin),熱(re)入血(xue)(xue)(xue)(xue)室(shi)(shi)本當仿(fang)照143條“……熱(re)入血(xue)(xue)(xue)(xue)室(shi)(shi)也(ye)(ye)(ye),當(以針(zhen))刺(ci)期門,(或以涼(liang)肝之(zhi)品),隨其(qi)(qi)實(shi)而瀉(xie)之(zhi)”,但(dan)因(yin)此(ci)例(li),僅僅“經(jing)水(shui)(shui)適(shi)(shi)斷”而尚無“譫語”,是(shi)郁(yu)熱(re)初陷血(xue)(xue)(xue)(xue)分(fen)未(wei)深,寒(han)熱(re)“如瘧(nve)狀(zhuang)發(fa)作(zuo)有(you)(you)時(shi)”,是(shi)氣分(fen)寒(han)風(feng)未(wei)罷,故(gu)宣達少(shao)(shao)陽(yang)尤有(you)(you)“透熱(re)轉氣”之(zhi)機,何況(kuang)病勢傳變來自少(shao)(shao)陽(yang),與(yu)(yu)所陷之(zhi)厥陰(yin)(yin)(yin)又互為表里,故(gu)與(yu)(yu)小柴胡湯(tang)變通,引厥陰(yin)(yin)(yin)之(zhi)邪還道少(shao)(shao)陽(yang)而出,正(zheng)屬“逆(ni)流挽舟”救治(zhi)之(zhi)法。

3.通達(da)氣(qi)機(ji),疏(shu)解(jie)土中郁木

三焦焦膜上(shang)裹心(xin)肺(fei),下系(xi)肝腎,中(zhong)連(lian)脾(pi)(pi)胃。故(gu)少(shao)陽(yang)病變連(lian)及陽(yang)明胃腸(chang)者固然(ran)多見,而與太陰脾(pi)(pi)病相(xiang)互影響者也(ye)非絕(jue)無僅有。《傷寒論(lun)》100條(tiao)“傷寒,陽(yang)脈澀,陰脈弦(xian),法(fa)當腹(fu)中(zhong)急(ji)痛(tong),先與小(xiao)建中(zhong)湯,不(bu)差(cha)者,小(xiao)柴(chai)胡(hu)(hu)湯主之(zhi)”。即是根據脾(pi)(pi)與三焦的橫(heng)向聯系(xi),變通柴(chai)胡(hu)(hu)之(zhi)法(fa),借(jie)助三焦氣(qi)道(dao)(dao),疏(shu)解(jie)上(shang)中(zhong)郁(yu)滯的例子(zi)。因為(wei)中(zhong)土轉運,動力(li)雖在脾(pi)(pi),但道(dao)(dao)路在三焦,故(gu)對(dui)太陰“腹(fu)中(zhong)急(ji)痛(tong)”而溫中(zhong)健脾(pi)(pi)不(bu)效者,恐其虛中(zhong)夾滯,再以小(xiao)柴(chai)胡(hu)(hu)湯疏(shu)利中(zhong)焦氣(qi)機,以助脾(pi)(pi)運,也(ye)不(bu)失為(wei)常中(zhong)求變的間治之(zhi)法(fa)。

4.舒(shu)氣散結,伸張腑中郁結之陽

少陽(yang)(yang)(yang)為(wei)(wei)(wei)(wei)樞(shu)(shu),其(qi)義有(you)(you)三:一為(wei)(wei)(wei)(wei)表里出(chu)入之(zhi)樞(shu)(shu),二(er)為(wei)(wei)(wei)(wei)上下升降(jiang)之(zhi)樞(shu)(shu),三為(wei)(wei)(wei)(wei)陰(yin)(yin)陽(yang)(yang)(yang)交(jiao)接之(zhi)樞(shu)(shu)。其(qi)出(chu)入之(zhi)樞(shu)(shu)不(bu)(bu)(bu)利,則營衛(wei)外達不(bu)(bu)(bu)暢,寒熱為(wei)(wei)(wei)(wei)之(zhi)往來;升降(jiang)之(zhi)樞(shu)(shu)不(bu)(bu)(bu)利,則水火敷布不(bu)(bu)(bu)均,而嘔逆口苦(ku)、兩脅脹滿乃(nai)作;交(jiao)接之(zhi)樞(shu)(shu)不(bu)(bu)(bu)利,則陽(yang)(yang)(yang)氣(qi)郁(yu)(yu)(yu)結(jie)不(bu)(bu)(bu)宣,而肢(zhi)逆、脘痞(pi)可征。如《傷寒論》148條“傷寒四五(wu)日,頭汗(han)出(chu),微惡(e)寒,手足冷(leng),心下滿,口不(bu)(bu)(bu)欲食,大(da)便硬(ying),脈細(xi)者(zhe),此為(wei)(wei)(wei)(wei)陽(yang)(yang)(yang)(氣(qi))微結(jie),……脈沉亦在(zai)里也,汗(han)出(chu)為(wei)(wei)(wei)(wei)陽(yang)(yang)(yang)微(結(jie)),假令純(chun)陰(yin)(yin)結(jie),不(bu)(bu)(bu)得(de)復有(you)(you)外證,悉入在(zai)里,此為(wei)(wei)(wei)(wei)半在(zai)表半在(zai)里也,脈雖沉緊,不(bu)(bu)(bu)得(de)為(wei)(wei)(wei)(wei)少陰(yin)(yin)病(bing),所以(yi)然者(zhe),陰(yin)(yin)不(bu)(bu)(bu)得(de)有(you)(you)汗(han),今頭汗(han)出(chu),故知非(fei)(fei)少陰(yin)(yin)也,可以(yi)小柴胡湯,設不(bu)(bu)(bu)了(le)(le)了(le)(le)者(zhe),得(de)屎而解(jie)”。此即屬寒束少陽(yang)(yang)(yang),氣(qi)失宣達,以(yi)致(zhi)胃陽(yang)(yang)(yang)不(bu)(bu)(bu)伸,腑氣(qi)不(bu)(bu)(bu)降(jiang)而為(wei)(wei)(wei)(wei)陽(yang)(yang)(yang)氣(qi)郁(yu)(yu)(yu)結(jie)之(zhi)證,其(qi)受病(bing)之(zhi)所雖在(zai)陽(yang)(yang)(yang)明胃、腸,但其(qi)發病(bing)之(zhi)源(yuan)則始(shi)于少陽(yang)(yang)(yang)三焦(jiao)、膽,其(qi)惡(e)寒、肢(zhi)逆、脈細(xi)沉緊雖似(si)陰(yin)(yin)經寒結(jie),但反頭汗(han)出(chu),大(da)便硬(ying),知有(you)(you)火郁(yu)(yu)(yu)其(qi)中(zhong),非(fei)(fei)純(chun)陰(yin)(yin)結(jie),乃(nai)“陰(yin)(yin)中(zhong)有(you)(you)陽(yang)(yang)(yang)”——腑氣(qi)郁(yu)(yu)(yu)結(jie)、陽(yang)(yang)(yang)氣(qi)不(bu)(bu)(bu)達,故其(qi)治(zhi)法,通(tong)陽(yang)(yang)(yang)不(bu)(bu)(bu)在(zai)溫而在(zai)利氣(qi)機,通(tong)氣(qi)不(bu)(bu)(bu)在(zai)腸而在(zai)利三焦(jiao),是以(yi)小柴胡湯,疏氣(qi)以(yi)開痞(pi)、通(tong)陽(yang)(yang)(yang)以(yi)治(zhi)逆,令“上(二(er))焦(jiao)得(de)通(tong),津液得(de)下,胃(腸之(zhi))氣(qi)因(yin)和”(230條)則會(hui)“得(de)屎而(病(bing))解(jie)”。(148條)

5.調理三焦,分(fen)消內(nei)外彌漫之邪

風(feng)(feng)寒(han)(han)(han)之(zhi)(zhi)(zhi)邪,表里(li)傳變,既有(you)分(fen)經(jing)而至、主(zhu)次分(fen)明者,也有(you)彌漫(man)多(duo)經(jing)、主(zhu)次難(nan)分(fen)者。前者論(lun)(lun)治(zhi),可以(yi)分(fen)別先(xian)后、或主(zhu)治(zhi)兼治(zhi);后者論(lun)(lun)治(zhi),則(ze)須圓機活法(fa),巧以(yi)變通。如《傷寒(han)(han)(han)論(lun)(lun)》99條(tiao)“傷寒(han)(han)(han)四五(wu)日,身熱(re)(re)(re)惡風(feng)(feng),頸項(xiang)強,脅(xie)下(xia)滿,手足溫(wen)而渴者,小柴胡湯主(zhu)之(zhi)(zhi)(zhi)”。正是(shi)風(feng)(feng)寒(han)(han)(han)郁(yu)熱(re)(re)(re)彌漫(man)多(duo)經(jing)的(de)一(yi)種(zhong)證(zheng)治(zhi)類型(xing),即“身熱(re)(re)(re)惡風(feng)(feng),頸項(xiang)強”是(shi)風(feng)(feng)寒(han)(han)(han)外束(shu)于(yu)太(tai)陽之(zhi)(zhi)(zhi)表,“手足自溫(wen)而渴”是(shi)化熱(re)(re)(re)、動(dong)濕(shi)于(yu)陽明、太(tai)陰(yin)之(zhi)(zhi)(zhi)里(li),“脅(xie)下(xia)滿”是(shi)寒(han)(han)(han)熱(re)(re)(re)相(xiang)搏于(yu)少(shao)陽之(zhi)(zhi)(zhi)半(ban),三者表里(li)寒(han)(han)(han)熱(re)(re)(re)之(zhi)(zhi)(zhi)間(jian)勢均(jun)力敵,治(zhi)法(fa)上若側重(zhong)辛(xin)溫(wen)發表,則(ze)有(you)助熱(re)(re)(re)動(dong)濕(shi)之(zhi)(zhi)(zhi)慮;若側重(zhong)清熱(re)(re)(re)利(li)濕(shi),則(ze)有(you)寒(han)(han)(han)涼礙(ai)邪出表之(zhi)(zhi)(zhi)忌(ji);若表里(li)并治(zhi),仍有(you)少(shao)陽之(zhi)(zhi)(zhi)半(ban)不可兼得,更(geng)何況少(shao)陽為病,又有(you)汗下(xia)之(zhi)(zhi)(zhi)慎,唯(wei)有(you)以(yi)柴胡湯,中(zhong)(zhong)取少(shao)陽和法(fa),通過轉疏三焦機樞(shu),達到一(yi)法(fa)三顧(gu)的(de)目的(de),即外以(yi)暢營衛、內以(yi)調水火,中(zhong)(zhong)以(yi)利(li)氣機,于(yu)兼顧(gu)表里(li)寒(han)(han)(han)熱(re)(re)(re)之(zhi)(zhi)(zhi)中(zhong)(zhong),無犯虛虛實實之(zhi)(zhi)(zhi)戒(jie),論(lun)(lun)治(zhi)可謂(wei)巧妙!

6.運(yun)轉中樞(shu),協(xie)調脾胃肝膽之氣

疸(dan)病(bing)多不離(li)濕,蘊熱(re)則尤易(yi)發黃(huang)(huang)(huang)(huang),土壅(yong)為濕熱(re)之(zhi)根,木郁為發黃(huang)(huang)(huang)(huang)之(zhi)所(suo),故治(zhi)(zhi)(zhi)黃(huang)(huang)(huang)(huang)疸(dan)有(you)從清熱(re)利(li)濕治(zhi)(zhi)(zhi)其(qi)本者(zhe)(zhe)(如茵陳蒿(hao)湯、茵陳五苓散(san)之(zhi)類),有(you)從疏(shu)肝(gan)利(li)膽(dan)治(zhi)(zhi)(zhi)其(qi)標(biao)者(zhe)(zhe)(如四逆散(san)、龍膽(dan)瀉(xie)肝(gan)湯之(zhi)屬),而(er)此以(yi)(yi)柴胡(hu)(hu)(hu)湯治(zhi)(zhi)(zhi)之(zhi)者(zhe)(zhe),意在借助三焦(jiao)機樞,協調(diao)脾(pi)胃肝(gan)膽(dan)諸氣,即用柴胡(hu)(hu)(hu)轉(zhuan)疏(shu)氣機以(yi)(yi)利(li)肝(gan)膽(dan),用芩(qin)、夏降火散(san)水以(yi)(yi)化(hua)濕熱(re),參、草、姜、棗(小(xiao)柴胡(hu)(hu)(hu))與枳實(shi)、大(da)黃(huang)(huang)(huang)(huang)(大(da)柴胡(hu)(hu)(hu)),則隨(sui)其(qi)脾(pi)胃之(zhi)虛實(shi)多少(shao)而(er)選擇配(pei)(pei)伍。故以(yi)(yi)其(qi)治(zhi)(zhi)(zhi)疸(dan),力雖不專,但適應甚廣,少(shao)陽(yang)、陽(yang)明、太陰(yin)、厥陰(yin)諸經發黃(huang)(huang)(huang)(huang),皆可適當配(pei)(pei)用,尤其(qi)是夾雜外感而(er)引動者(zhe)(zhe),更有(you)內外兼顧之(zhi)妙,正(zheng)如《金匱要略》黃(huang)(huang)(huang)(huang)疸(dan)病(bing)篇(pian)所(suo)云:“諸黃(huang)(huang)(huang)(huang),腹痛(tong)而(er)嘔(ou)(ou)者(zhe)(zhe),宜柴胡(hu)(hu)(hu)湯”,《醫宗金鑒(jian)》則注到(dao):“嘔(ou)(ou)而(er)腹痛(tong),……若(ruo)無潮熱(re)便軟,則當用小(xiao)柴胡(hu)(hu)(hu)湯去黃(huang)(huang)(huang)(huang)芩(qin)加白芍和(he)之(zhi)可也”。

7.和解水火(huo),平衡一時陰陽之(zhi)偏

“水火(huo)者(zhe),陰陽(yang)(yang)(yang)之(zhi)(zhi)征兆(zhao)也(ye)”,三(san)焦者(zhe),水火(huo)之(zhi)(zhi)道路也(ye)。故一(yi)身陰陽(yang)(yang)(yang)之(zhi)(zhi)協調(diao)平(ping)衡,也(ye)與三(san)焦樞機之(zhi)(zhi)升降(jiang)出(chu)入間有關聯,而(er)(er)一(yi)身陰陽(yang)(yang)(yang)之(zhi)(zhi)失調(diao),也(ye)有可(ke)(ke)與小(xiao)柴(chai)胡(hu)(hu)湯間而(er)(er)調(diao)之(zhi)(zhi)者(zhe)。如(ru)《金匱要(yao)(yao)略(lve)》婦(fu)人產(chan)(chan)后(hou)病篇第二條:“產(chan)(chan)婦(fu)郁(yu)冒(mao),其(qi)脈微(稍)弱(ruo),嘔不能(neng)食,大便(bian)反堅,但頭汗出(chu)。所以(yi)(yi)然者(zhe),血虛(xu)(xu)而(er)(er)厥,厥而(er)(er)必冒(mao);冒(mao)家欲(yu)解,必大汗出(chu)。以(yi)(yi)血虛(xu)(xu)下厥,孤陽(yang)(yang)(yang)上出(chu),故頭汗出(chu)。所以(yi)(yi)產(chan)(chan)婦(fu)喜汗出(chu),亡陰血虛(xu)(xu),陽(yang)(yang)(yang)氣獨盛(sheng),故使汗出(chu),陰陽(yang)(yang)(yang)乃(nai)復。大便(bian)堅,嘔不能(neng)食,小(xiao)柴(chai)胡(hu)(hu)湯主之(zhi)(zhi)”。此(ci)(ci)即(ji)惜(xi)調(diao)三(san)焦水火(huo)升降(jiang)出(chu)入之(zhi)(zhi)機,以(yi)(yi)平(ping)產(chan)(chan)后(hou)陰陽(yang)(yang)(yang)氣血之(zhi)(zhi)偏(pian),尤其(qi)在產(chan)(chan)后(hou)虛(xu)(xu)人受風而(er)(er)引(yin)發郁(yu)冒(mao)者(zhe),更(geng)顯得恰到(dao)好處。正如(ru)《金匱要(yao)(yao)略(lve)心典(dian)》所注:“郁(yu)冒(mao)雖有客邪(xie)(xie),而(er)(er)其(qi)本則為(wei)(wei)里虛(xu)(xu),故脈微弱(ruo)也(ye),小(xiao)柴(chai)胡(hu)(hu)主之(zhi)(zhi)者(zhe),以(yi)(yi)邪(xie)(xie)氣不可(ke)(ke)不散,而(er)(er)正氣不可(ke)(ke)不顧,惟此(ci)(ci)法為(wei)(wei)能(neng)解散客邪(xie)(xie),而(er)(er)和利(li)陰陽(yang)(yang)(yang)耳”。

以(yi)上是筆者就《傷寒論(lun)(lun)(lun)(lun)》中有限的(de)柴胡類(lei)(lei)證,試從(cong)三(san)焦的(de)病機(ji)特點(dian)上,做了一(yi)些系(xi)統整理(li)與分類(lei)(lei),但其(qi)意義并(bing)不僅(jin)是依據三(san)焦之(zhi)說闡明柴胡類(lei)(lei)方的(de)運用規律,而且可(ke)由(you)此(ci)看出,中醫歷來存在(zai)的(de)“三(san)焦實(shi)質”與“有名(ming)無實(shi)”的(de)理(li)論(lun)(lun)(lun)(lun)之(zhi)爭,若能(neng)真正本(ben)著理(li)論(lun)(lun)(lun)(lun)指導實(shi)踐、實(shi)踐驗證理(li)論(lun)(lun)(lun)(lun)的(de)精神,緊扣(kou)辨證論(lun)(lun)(lun)(lun)治的(de)要求,加以(yi)系(xi)統整理(li)與臨床印證,是不難得出其(qi)應有的(de)結論(lun)(lun)(lun)(lun)的(de)。據此(ci),也足以(yi)顯示在(zai)中醫博大(da)精深的(de)辨證論(lun)(lun)(lun)(lun)治體(ti)系(xi)中,還(huan)有許(xu)多先輩們遺(yi)留給我們的(de)證治經驗,有待得到切(qie)實(shi)的(de)總結與繼(ji)承!

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