伤寒论第三节少阳病兼变证.ppt

2023/6/15,伤寒论,1,第三节 少阳病兼变证,少阳病变证治则(267)柴胡桂枝汤证(146)少阳兼太阳之表 大柴胡汤证(103、165）少阳兼阳明之里 柴胡加芒硝汤证（104）柴胡桂枝干姜汤证（147）少阳兼水饮内结 柴胡加龙骨牡蛎汤证（107）少阳兼火逆心包 热入血室证（143、144、145）,2023/6/15,伤寒论,2,第三节 少阳病兼变证,一、少阳病变证治则：若已吐下發汗温針，讝語，柴胡湯證罷，此為壞病，知犯何逆，以法治之。（267）If after vomiting,precipitation,promotion of sweating,or warm needling,there is delirious speech,and the Minor Bupleurum Decoction pattern ceases,this is a aggravated disease,therefore one should be aware of what error one has commited,and use the appropriate method to treate it.释义坏病即变证。变证治则“知犯何逆，以法治之”，即审因辨证，以法论治。,2023/6/15,伤寒论,3,第三节 少阳病兼变证,二、少阳兼太阳之表证治柴胡桂枝汤证：146伤寒六七日，发热、微恶寒、肢节烦痛、微呕、心下支结、外证未去者，柴胡桂枝汤主之。When in cold damage for six or seven days,there is fever,mild aversion to cold,vexing pain of the limb joints,mild retching,fullness below the heart,and exterior pattern is still present,Bupleurum and Cinnamon Twig Decoction governs.,2023/6/15,伤寒论,4,第三节 少阳病兼变证,释义1、辨证：发热微恶寒，肢节烦疼太阳表证未罢 太阳表证未罢而 风寒留连于表 初及少阳未深，微呕，心下支结（梗阻感）邪犯少阳 太少并病，证候口苦咽干目眩未显著少阳未深，火郁未盛 俱轻。2、治法、方剂：调和营卫，解肌辛散桂枝汤治太阳之表 合方为柴胡桂枝汤和解少阳，宣转枢机小柴胡汤治少阳半 但用量各为原方一 表半里 半（轻剂）,2023/6/15,伤寒论,5,第三节 少阳病兼变证,3.临床应用：1）体虚感冒或流感身热恶寒、关节酸楚、呕恶纳呆、胸胁满闷、苔微黄或白腻。有咽痛者加桔梗、玄参。身热重、脉数者加大柴胡剂量。2）风湿病四肢烦疼、兼胸胁苦满或胁背作痛者3）慢性胆囊炎或胆石症胸胁支满、胆囊区疼痛、口苦恶心、纳呆便溏苔白腻而滑者，加金钱草、蒲公英、山楂。4）神经官能症自觉气在周身窜动、气窜处有疼痛发胀感，嗳气打嗝，随之缓解。4、本方是和法兼汗法汗吐下之禁只是针对少阳本证而言。,2023/6/15,伤寒论,6,第三节 少阳病兼变证,三、少阳兼阳明里实证治大柴胡汤证、柴胡加芒硝汤证1、大柴胡汤证：103太阳病，过经十余日，反二、三下之。后四、五 日，柴胡证仍在者，先与小柴胡。呕不止、心下急、郁郁微烦者，为未解也，与大柴胡汤下之则愈。大柴胡湯方 柴胡半斤 黃芩三兩 芍藥三兩 半夏半升（洗）生薑五兩（切）枳實四枚（炙）大棗十二枚（擘）上七味，以水一斗二升，煮取六升，去滓，再煎，温服一升，日三服。一方加大黃二兩。若不加，恐不為大柴胡湯。When in Tai yang disease,ten or more days after channel passage,precipitation has been used two or three times,after four or five days,if the Minor Bupleurum Decoction pattern is still present,first give,2023/6/15,伤寒论,7,第三节 少阳病兼变证,Minor Bupleurum Decoction.If there is incessant retching,distress below the heart,and depression and mild vexation,it means that the disease has not yet resolved;giving Major Bupleurium Decoction to precipitate will lead to recovery.165伤寒发热、汗出不解，心中痞硬、呕吐而下利者，大柴胡汤主之。When in cold damage there is fever and sweating that brings no resolution,fullness and hardness in the heart,retching,vomiting,and diarrhea,then Major Bupleurum Decoction governs.,2023/6/15,伤寒论,8,第三节 少阳病兼变证,释义1、辨证：（1）太阳病 少阳病，误下后柴胡证仍在先用小柴胡汤治疗病愈。（2）病未愈仍有柴胡证：寒热往来 少阳郁热 胸胁苦满 少阳病兼 因误下出现变证：呕不止心下急 阳明里实 郁郁微烦（大便 邪入阳明 秘结或热结旁流）化燥成实,2023/6/15,伤寒论,9,第三节 少阳病兼变证,2、治法、方剂：和解少阳，通下里实大柴胡汤3、方解：柴胡、黄芩、半夏疏畅少阳气机而治水火（同小柴胡汤）枳实 利气消痞，通下热结，泻阳明之实大黄 芍药 酸苦涌泄，以平肝胆气逆 缓急止痛生姜止呕大枣和中,2023/6/15,伤寒论,10,第三节 少阳病兼变证,4、适应证：1）急性胆囊炎寒热往来、胸胁疼痛剧烈、口苦呕恶、大便秘结或干结、腹胀或黄疸（阳黄）。2）胆石证、急性胰腺炎有以上表现者。5、疗效判断：应观察热、呕、痛、秘四方面表现，以秘为重点。服汤后，腑气通，大小便利，则发热、呕吐很快会缓解。辨证论治要抓住这一关键。,2023/6/15,伤寒论,11,第三节 少阳病兼变证,2、柴胡加芒硝汤证：傷寒十三日不解，胸脇滿而嘔，日晡所發潮熱，已而微利，此本柴胡證，下之以不得利，今反利者，知醫以丸藥下之，此非其治也。潮熱者，實也，先宜服小柴胡湯以解外，後以柴胡加芒消湯主之。（104）柴胡加芒消湯方 柴胡二兩十六銖 黃芩一兩 人參一兩甘草一兩（炙）生薑一兩（切）半夏二十銖（本云五枚，洗）大棗四枚（擘）芒消二兩上八味，以水四升，煮取二升，去滓，內芒消，更煮微沸，分温再服，不解更作。,2023/6/15,伤寒论,12,第三节 少阳病兼变证,When in cold damage not resolved in thirteen days,fullness in the chest and rib-side,retching,late afternoon tidal fever,and shortly afterward mild diarrhea.This was originally a Major Bupleurum Decoction pattern in which precipitation should not cause diarrhea,yet now diarrhea is due to use of pill medicine to precipitate,this is not appropriate treatment.Tidal fever means excess.It is appropriate to first to take Minor Bupleurm Decoction in order to resolve the external aspect,afterward,Bupleurum Decoction plus Mirabilite governs.,2023/6/15,伤寒论,13,第三节 少阳病兼变证,释义1、辨证：胸胁满而呕邪传少阳，枢机不利 少阳兼阳明里实，日晡发潮热邪入阳明，腑实已成 正气已伤。微利误用丸药，正气已伤、治法、方剂：和解少阳，泻热（轻剂）柴胡加芒硝汤（剂量为小柴胡汤 1/3）、鉴别：大柴胡汤都用于少阳-正气未伤通腑之力强柴胡加芒硝汤兼阳明里实-正气已伤破结之力较弱，但 泄热润燥力强。,2023/6/15,伤寒论,14,第三节 少阳病兼变证,四、少阳兼水饮内结柴胡桂枝干姜汤：傷寒五六日，已發汗而復下之，胸脇滿微結，小便不利，渴而不嘔，但頭汗出，往來寒熱，心煩者，此為未解也，柴胡桂枝乾薑主之。（147）柴胡桂枝乾薑湯方柴胡半斤 桂枝三兩（去皮）乾薑二兩 栝樓根四兩 黃芩三兩 牡蠣二兩（熬）甘草二兩（炙）上七味，以水一斗二升，煮取六升，去滓，再煎取三升，温服一升，日三服，初服微煩，復服汗出便愈。,2023/6/15,伤寒论,15,第三节 少阳病兼变证,When cold damage has lasted five or six days,and diaphoresis and purgation have been applied,there is fullness in the chest and rib-side,inhibited urination,thirst without retching,sweating only from the head,alternating cold and fever,and heart vexation,it means that the disease has not yet resolved,therefore,Bupleurum,Cinnamon Twig,and dried Ginger Decoction governs.,2023/6/15,伤寒论,16,第三节 少阳病兼变证,释义、辨证：伤寒五六日，误用汗下邪传少阳：邪正交争往来寒热胆火上扰心心烦经气郁结胸胁满微结枢机不利三焦决渎失常，水饮内结口渴，小便不利水饮内结病不在胃不呕水饮郁火结而上蒸头汗出、治法、方剂：和解少阳，温化水饮柴胡桂枝干姜汤,2023/6/15,伤寒论,17,第三节 少阳病兼变证,、方解：柴胡、黄芩清解少阳之邪桂枝、干姜通阳散寒，温化水饮寒温并用侧重温化瓜蒌根、牡蛎逐饮开结辛开苦降注重辛开甘草调和诸药4、应用：用于感冒、胸膜炎、瘰疬、黄疸、胆囊炎，尤其适用于慢性肝炎之肝胆有热兼脾阳虚胁痛腹胀、便溏、口干者。,2023/6/15,伤寒论,18,第三节 少阳病兼变证,五、少阳兼火逆心包 柴胡加龙骨牡蛎汤证：*107伤寒八九日，下之，胸满、烦惊、小便不利、谵语、一身尽重，不可转侧者，柴胡加龙骨牡蛎汤主之。柴胡加龍骨牡蠣湯方 柴胡 龙骨 黄芩 生姜 铅丹 人参 桂枝 茯苓 半夏 大黄 牡蛎 大枣 上十二味，以水八升，煮取四升，内大黄，切如棋子，更煮一两沸，去滓，温服一升。本云柴胡汤，今加龙骨等。,2023/6/15,伤寒论,19,第三节 少阳病兼变证,When cold damage has lasted for eight or nine days,purgation is used,and there is fullness in the chest,vexation and fright,inhibited urination,delirious speech,heaviness of the entire body,and inability to turn sides,Bupleurum Decoction Plus Dragon Bone and Oyester Shell governs.,2023/6/15,伤寒论,20,第三节 少阳病兼变证,释义、辨证：水气上逆心包惊悸，小便不利少阳病邪弥漫三焦郁火上攻心包胸中烦满而谵语水逆火郁上扰心包水逆火郁于胸一身尽重不可自上焦阳气不得宣达周身转侧、治法、方剂：和解少阳，降水火，重镇安神柴胡加龙骨牡蛎汤,2023/6/15,伤寒论,21,第三节 少阳病兼变证,、方解：小柴胡汤（去甘草）和解少阳，疏利三焦茯苓、大黄通利二便，以降水火龙骨、牡蛎、铅丹镇惊安神桂枝宣通胸阳，以布周身4、应用：神经系统多种疾病精神分裂症、癫痫、高血压、神经官能症、美尼尔氏综合症、更年期综合症、失眠等。以热、实、半表半里为主往来寒热、胸胁满闷 烦躁多言错语、惊惕不安、失眠恶梦多、身重、苔黄厚浊腻。脉沉弦。,2023/6/15,伤寒论,22,第三节 少阳病兼变证,婦人中風，發熱惡寒，經水適來，得之七八日，熱除而脉遲身凉。胸脇下滿，如結胸狀，讝語者，此為熱入血室也，當刺期門，隨其實而取之。（143）When a woman with wind strike has fever and aversion to cold,and the menstrual flow happens to arrive,seven or eight days,then the fever is gone,the pulse is slow and there is generalized coldness,fullness under the chest and rib-side,signs like chest bind and delirious speech,this means that the heat has entered the blood chamber,one should needle Qimen(Liv-14),choosing this point in the view of the excess.,2023/6/15,伤寒论,23,第三节 少阳病兼变证,婦人中風，七八日續得寒熱，發作有時，經水適斷者，此為熱入血室，其血必結，故使如瘧狀，發作有時，小柴胡湯主之。（144）When a woman with wind strike seven or eight days has a periodic fever and cold,and the menstrual flow happens to stop,this means that the heat has entered the blood chamber and the blood will bind,causing a malaria-like condition that occurs at(set)times;therefore,Minor Bupleurum Decoction governs.,2023/6/15,伤寒论,24,第三节 少阳病兼变证,六、热入血室证治：婦人傷寒，發熱，經水適來，晝日明了，暮則讝語，如見鬼狀者，此為熱入血室，無犯胃氣，及上二焦，必自愈。（145）When a woman with cold damage has fever,and the menstrual flow happens to arrive and she is clear-headed during the day and speaks deliriously in the evening,as if seeing a ghost,this means that the heat has entered the blood chamber;but do not assail the stomach qi and the upper and the middle burners,recovery will be spontaneous.,2023/6/15,伤寒论,25,第三节 少阳病兼变证,释义 妇人经期感受外邪，血室（womb)空虚，外邪从少阳三焦内陷血室热入血室证。（1）脉迟邪与血结，气血涩滞 刺期门泄实去热 胸胁下满如结胸状肝胆气机疏泄不利 肝经之热除，血室 谵语血热上扰心神 之热解。（2）寒热往来如 少阳邪热初陷血 治从少阳之枢而解 疟状，发作有时 室（血分）未深 小柴胡汤 无谵语（3）病在血室下焦，与上、中二焦及胃无关。血下则热邪有外泄之机经水未断，邪热外泄而自愈。,2023/6/15,伤寒论,26,第四节 少阳病传变及预后,傷寒六七日，無大熱，其人躁煩者，此為陽去入陰故（269）When in cold damage six or seven days,high fever is absent and the person is agitated and vexed,this is because the evil in the yang abating and entering yin.傷寒三日，三陽為盡，三陰當受邪，其人反能食而不嘔，此為三陰不受邪也。（270）When in cold damage three days,the three yang channels have all been run through,and three yin channels should contract the evil,but instead,the person has a good appetite and no retching,which means that the three yin channels will not contract the evil.,2023/6/15,伤寒论,27,第四节 少阳病传变及预后,傷寒三日，少陽脉小者，欲已也。（271）When in cold damage three days,the disease is in the Shaoyang,and the pulse is small,the disease is about to resolve.释义：少阳病传变及预后：1、病进：伤寒六、七日为传变之期：表无大热邪已入里 传阳明兼恶热口渴汗出腹胀便烦躁表病入里，阳去入阴 秘脉沉实有力。传三阴兼吐利肢厥脉微,2023/6/15,伤寒论,28,第四节 少阳病传变及预后,2、病退：（1）病入少阳，枢机不利，引起胃气不和呕吐、不能食。现在能食而不呕说明少阳邪衰，但胃气尚旺，此为 病退，疾病未传变。（2）少阳病之脉应当是弦脉，如脉不见弦而是小脉（脉渐平和）说明少阳病邪微，疾病向痊愈方面发展。,2023/6/15,伤寒论,29,第五节 少阳病欲解时,少阳病欲解时，从寅至辰上。（272）The time when Shaoyang disease is about to resolve is from Yin to Chen.释义 少阳之气旺于寅、卯、辰三个时辰（上午3点到9点），在此时间段内，少阳经气得自然界阳气之助，则正气抗邪有力，疾病易解。,2023/6/15,伤寒论,30,小结,本章讨论了少阳病病因病机、主症、治法、禁忌、预后及兼变证，共有六个方证。1、少阳病的病因病机：病因：多由正气虚弱，风寒之邪侵入少阳。病机：正邪分争，枢机不利，胆火内郁，虚实夹杂。2、少阳病主症：往来寒热、胸胁苦满、默默不欲食、心烦喜呕、口苦、咽干、目眩、脉弦。小柴胡汤适应证为：1）少阳半表半里证；2）肝旺脾虚之腹痛；3）三阳合病，阳明里实不显著者；4）阳明病潮热、大便溏、胸胁满不去者或阳明病胁下硬满、大便秘结而舌苔白者；5）阳微结之大便硬者；6）妇人热入血室者；7）厥阴病呕而发热者；8）伤寒瘥后更发热者。,2023/6/15,伤寒论,31,小结,3、少阳病治法与禁忌：治法：和解少阳。禁忌：禁用汗、吐下三法。4、少阳病兼变证：1）少阳兼太阳之表柴胡桂枝汤证；2）少阳兼阳明之里大柴胡汤证、柴胡加芒硝汤证；3）少阳兼水饮内结柴胡桂枝干姜汤证；4）少阳兼火逆心包柴胡加龙骨牡蛎汤证。5、少阳病预后、欲解时：病进伤寒六、七日，身无大热、烦躁者，“阳去入阴”；病退少阳病反见能食不呕者，少阳邪衰胃气转和；少阳病不见弦脉而见小脉者，是少阳邪微而气和，向愈发展。6、少阳病欲解时寅、卯、辰时（上午39点）,2023/6/15,伤寒论,32,（完）Thank you!,