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1、少陽病兼變證第三節(jié) 少陽病兼變證v少陽病變證治則(267)v柴胡桂枝湯證(146)少陽兼太陽之表少陽兼太陽之表 v大柴胡湯證(103、165）少陽兼陽明之里少陽兼陽明之里 柴胡加芒硝湯證（104）v柴胡桂枝干姜湯證（147）少陽兼水飲內(nèi)結(jié)少陽兼水飲內(nèi)結(jié) v柴胡加龍骨牡蠣湯證（107）少陽兼火逆心包少陽兼火逆心包 v熱入血室證（143、144、145）少陽病兼變證第三節(jié) 少陽病兼變證v一、少陽病變證治則：v若已吐下發(fā)汗溫針，讝語，柴胡湯證罷，此為壞病，知犯何若已吐下發(fā)汗溫針，讝語，柴胡湯證罷，此為壞病，知犯何逆，以法治之。（逆，以法治之。（267267）vIf after vomiting,pr

2、ecipitation,promotion of If after vomiting,precipitation,promotion of sweating,or warm needling,there is delirious sweating,or warm needling,there is delirious speech,and the Minor Bupleurum Decoction pattern speech,and the Minor Bupleurum Decoction pattern ceases,this is a aggravated disease,theref

3、ore one ceases,this is a aggravated disease,therefore one should be aware of what error one has commited,and should be aware of what error one has commited,and use the appropriate method to treate it.use the appropriate method to treate it.釋義釋義 壞病壞病即變證。即變證。變證治則變證治則“知犯何逆，以法治之知犯何逆，以法治之”，即審因辨證，以法論治。，即審

4、因辨證，以法論治。少陽病兼變證第三節(jié) 少陽病兼變證二、少陽兼太陽之表證治少陽兼太陽之表證治柴胡桂枝湯證：v146傷寒六七日，發(fā)熱、微惡寒、肢節(jié)煩痛、微傷寒六七日，發(fā)熱、微惡寒、肢節(jié)煩痛、微嘔、心下支結(jié)、外證未去者，柴胡桂枝湯主之。嘔、心下支結(jié)、外證未去者，柴胡桂枝湯主之。vWhen 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 p

5、attern is still present,Bupleurum and Cinnamon Twig Decoction governs.少陽病兼變證第三節(jié) 少陽病兼變證釋義1、辨證：發(fā)熱微惡寒，肢節(jié)煩疼太陽表證未罷 太陽表證未罷而 風寒留連于表 初及少陽未深，微嘔，心下支結(jié)（梗阻感）邪犯少陽 太少并病，證候口苦咽干目眩未顯著少陽未深，火郁未盛 俱輕。2、治法、方劑：調(diào)和營衛(wèi)，解肌辛散桂枝湯治太陽之表 合方為柴胡桂枝湯和解少陽，宣轉(zhuǎn)樞機小柴胡湯治少陽半 但用量各為原方一 表半里 半（輕劑）少陽病兼變證第三節(jié) 少陽病兼變證3.臨床應用：1）體虛感冒或流感身熱惡寒、關(guān)節(jié)酸楚、嘔惡納呆、胸脅滿悶、

6、苔微黃或白膩。有咽痛者加桔梗、玄參。身熱重、脈數(shù)者加大柴胡劑量。2）風濕病四肢煩疼、兼胸脅苦滿或脅背作痛者3）慢性膽囊炎或膽石癥胸脅支滿、膽囊區(qū)疼痛、口苦惡心、納呆便溏苔白膩而滑者，加金錢草、蒲公英、山楂。4）神經(jīng)官能癥自覺氣在周身竄動、氣竄處有疼痛發(fā)脹感，噯氣打嗝，隨之緩解。4、本方是和法兼汗法汗吐下之禁只是針對少陽本證而言。少陽病兼變證第三節(jié) 少陽病兼變證三、少陽兼陽明里實證治少陽兼陽明里實證治大柴胡湯證、柴胡加芒硝湯證1、大柴胡湯證：v103太陽病，過經(jīng)十余日，反二、三下之。后四、五太陽病，過經(jīng)十余日，反二、三下之。后四、五 日，日，柴胡證仍在者，先與小柴胡。嘔不止、心下急、郁郁微煩者，

7、柴胡證仍在者，先與小柴胡。嘔不止、心下急、郁郁微煩者，為未解也，與大柴胡湯為未解也，與大柴胡湯下之則愈下之則愈。大柴胡湯方大柴胡湯方 柴胡半斤柴胡半斤 黃芩三兩黃芩三兩 芍藥三兩芍藥三兩 半夏半升（洗）半夏半升（洗）生薑五兩（切）生薑五兩（切）枳實四枚（炙）枳實四枚（炙）大棗十二枚（擘）大棗十二枚（擘）上七味，以水一斗二升，煮取六升，去滓，再煎，溫服一升，日三服。上七味，以水一斗二升，煮取六升，去滓，再煎，溫服一升，日三服。一方加大黃二兩。若不加，恐不為大柴胡湯。一方加大黃二兩。若不加，恐不為大柴胡湯。vWhen in Tai yang disease,ten or more days aft

8、er 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 少陽病兼變證第三節(jié) 少陽病兼變證Minor Bupleurum Decoction.If there is incessant retching,distress below the heart,and depression and mild vexation,it means t

9、hat the disease has not yet resolved;giving Major Bupleurium Decoction to precipitate will lead to recovery.v165165傷寒發(fā)熱、汗出不解，心中痞硬、嘔吐而下利者，大柴傷寒發(fā)熱、汗出不解，心中痞硬、嘔吐而下利者，大柴胡湯主之。胡湯主之。v When in cold damage there is fever and sweating that brings no resolution,fullness and hardness in the heart,retching,vomitin

10、g,and diarrhea,then Major Bupleurum Decoction governs.少陽病兼變證第三節(jié) 少陽病兼變證釋義1、辨證：（1）太陽病 少陽病，誤下后柴胡證仍在先用小柴胡湯治療病愈。（2）病未愈仍有柴胡證：寒熱往來 少陽郁熱 胸脅苦滿 少陽病兼 因誤下出現(xiàn)變證：嘔不止心下急 陽明里實 郁郁微煩（大便 邪入陽明 秘結(jié)或熱結(jié)旁流）化燥成實少陽病兼變證第三節(jié) 少陽病兼變證2、治法、方劑：和解少陽，通下里實大柴胡湯3、方解：柴胡、黃芩、半夏疏暢少陽氣機而治水火（同小柴胡湯）枳實 利氣消痞，通下熱結(jié)，瀉陽明之實大黃 芍藥 酸苦涌泄，以平肝膽氣逆 緩急止痛生姜止嘔大棗和中少

11、陽病兼變證第三節(jié) 少陽病兼變證4、適應證：1）急性膽囊炎寒熱往來、胸脅疼痛劇烈、口苦嘔惡、大便秘結(jié)或干結(jié)、腹脹或黃疸（陽黃）。2）膽石證、急性胰腺炎有以上表現(xiàn)者。5、療效判斷：應觀察熱、嘔、痛、秘四方面表現(xiàn)，以秘為重點。服湯后，腑氣通，大小便利，則發(fā)熱、嘔吐很快會緩解。辨證論治要抓住這一關(guān)鍵。少陽病兼變證第三節(jié) 少陽病兼變證2、柴胡加芒硝湯證：v傷寒十三日不解，胸脇滿而嘔，日晡所傷寒十三日不解，胸脇滿而嘔，日晡所發(fā)潮熱，已而微利，發(fā)潮熱，已而微利，此本柴胡證，下之以不得利，今反利者，知醫(yī)以丸藥下之，此本柴胡證，下之以不得利，今反利者，知醫(yī)以丸藥下之，此非其治也。潮熱此非其治也。潮熱者，實也，先

12、宜服小柴胡湯以解外，後者，實也，先宜服小柴胡湯以解外，後以柴胡加芒消湯主之。（以柴胡加芒消湯主之。（104104）v柴胡加芒消湯方柴胡加芒消湯方 柴胡二兩十六銖柴胡二兩十六銖 黃芩一兩黃芩一兩 人參一兩甘草一兩人參一兩甘草一兩（炙）（炙）生薑一兩（切）生薑一兩（切）半夏二十銖（本云五枚，洗）半夏二十銖（本云五枚，洗）大棗四枚（擘）大棗四枚（擘）芒消二兩芒消二兩v上八味，以水四升，煮取二升，去滓，內(nèi)芒消，更煮微沸，上八味，以水四升，煮取二升，去滓，內(nèi)芒消，更煮微沸，分溫再服，不解更作。分溫再服，不解更作。少陽病兼變證第三節(jié) 少陽病兼變證vWhen in cold damage not resol

13、ved 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

14、 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.少陽病兼變證第三節(jié) 少陽病兼變證釋義1、辨證：胸脅滿而嘔邪傳少陽，樞機不利 少陽兼陽明里實，日晡發(fā)潮熱邪入陽明，腑實已成 正氣已傷。微利誤用丸藥，正氣已傷、治法、方劑：和解少陽，瀉熱

15、（輕劑）柴胡加芒硝湯（劑量為小柴胡湯 1/3）、鑒別：大柴胡湯都用于少陽-正氣未傷通腑之力強柴胡加芒硝湯兼陽明里實-正氣已傷破結(jié)之力較弱，但 泄熱潤燥力強。少陽病兼變證第三節(jié) 少陽病兼變證四、少陽兼水飲內(nèi)結(jié)少陽兼水飲內(nèi)結(jié)柴胡桂枝干姜湯：柴胡桂枝干姜湯：v傷寒五六日，已發(fā)汗而復下之，胸脇滿微結(jié)，小便不利，渴傷寒五六日，已發(fā)汗而復下之，胸脇滿微結(jié)，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。（桂枝乾薑主之。（147147）v柴胡桂枝乾薑湯方柴胡桂枝乾薑湯方v柴胡半斤柴胡半斤 桂枝三兩（去皮）桂枝三兩（去皮）乾薑二

16、兩乾薑二兩 栝樓根四兩栝樓根四兩 黃黃芩三兩芩三兩 牡蠣二兩（熬）牡蠣二兩（熬）甘草二兩（炙）甘草二兩（炙）v上七味，以水一斗二升，煮取六升，去滓，再煎取三升，溫上七味，以水一斗二升，煮取六升，去滓，再煎取三升，溫服一升，日三服，初服微煩，復服汗出便愈。服一升，日三服，初服微煩，復服汗出便愈。少陽病兼變證第三節(jié) 少陽病兼變證vWhen cold damage has lasted five or six days,and diaphoresis and purgation have been applied,there is fullness in the chest and rib-side

17、,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.少陽病兼變證第三節(jié) 少陽病兼變證釋義、辨證：傷寒五六日，誤用汗下邪傳少陽：邪正交爭往來寒熱膽火上擾心心煩經(jīng)氣郁結(jié)胸脅滿微結(jié)樞機不利

18、三焦決瀆失常，水飲內(nèi)結(jié)口渴，小便不利水飲內(nèi)結(jié)病不在胃不嘔水飲郁火結(jié)而上蒸頭汗出、治法、方劑：和解少陽，溫化水飲柴胡桂枝干姜湯柴胡桂枝干姜湯少陽病兼變證第三節(jié) 少陽病兼變證、方解：柴胡、黃芩清解少陽之邪桂枝、干姜通陽散寒，溫化水飲寒溫并用側(cè)重溫化瓜蔞根、牡蠣逐飲開結(jié)辛開苦降注重辛開甘草調(diào)和諸藥4、應用：用于感冒、胸膜炎、瘰疬、黃疸、膽囊炎，尤其適用于慢性肝炎之肝膽有熱兼脾陽虛脅痛腹脹、便溏、口干者。少陽病兼變證第三節(jié) 少陽病兼變證五、少陽兼火逆心包少陽兼火逆心包 柴胡加龍骨牡蠣湯證：v*107傷寒八九日，下之，胸滿、煩驚、小便不利、傷寒八九日，下之，胸滿、煩驚、小便不利、譫語、一身盡重，不可轉(zhuǎn)側(cè)

19、者，柴胡加龍骨牡蠣湯譫語、一身盡重，不可轉(zhuǎn)側(cè)者，柴胡加龍骨牡蠣湯主之。主之。v柴胡加龍骨牡蠣湯方柴胡加龍骨牡蠣湯方v 柴胡柴胡 龍骨龍骨 黃芩黃芩 生姜生姜 鉛丹鉛丹 人參人參 桂枝桂枝 茯苓茯苓 半夏半夏 大黃大黃 牡蠣牡蠣 大棗大棗 上十二味，以水八升，煮取上十二味，以水八升，煮取四升，內(nèi)大黃，切如棋子，更煮一兩沸，去滓，溫四升，內(nèi)大黃，切如棋子，更煮一兩沸，去滓，溫服一升。本云柴胡湯，今加龍骨等。服一升。本云柴胡湯，今加龍骨等。少陽病兼變證第三節(jié) 少陽病兼變證vWhen cold damage has lasted for eight or nine days,purgation is

20、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.少陽病兼變證第三節(jié) 少陽病兼變證釋義、辨證：水氣上逆心包驚悸，小便不利少陽病邪彌漫三焦郁火上攻心包胸中煩滿而譫語水逆火郁上擾心包水逆火郁于胸一身盡重不可自上焦陽氣不得

21、宣達周身轉(zhuǎn)側(cè)、治法、方劑：和解少陽，降水火，重鎮(zhèn)安神柴胡加龍骨牡蠣湯少陽病兼變證第三節(jié) 少陽病兼變證、方解：小柴胡湯（去甘草）和解少陽，疏利三焦茯苓、大黃通利二便，以降水火龍骨、牡蠣、鉛丹鎮(zhèn)驚安神桂枝宣通胸陽，以布周身4、應用：神經(jīng)系統(tǒng)多種疾病精神分裂癥、癲癇、高血壓、神經(jīng)官能癥、美尼爾氏綜合癥、更年期綜合癥、失眠等。以熱、實、半表半里為主往來寒熱、胸脅滿悶 煩躁多言錯語、驚惕不安、失眠惡夢多、身重、苔黃厚濁膩。脈沉弦。少陽病兼變證第三節(jié) 少陽病兼變證v婦人中風，發(fā)熱惡寒，經(jīng)水適來，得之七八日，熱除而脈遲婦人中風，發(fā)熱惡寒，經(jīng)水適來，得之七八日，熱除而脈遲身涼。胸脇下滿，如結(jié)胸狀，讝語者，此為

22、熱入血室身涼。胸脇下滿，如結(jié)胸狀，讝語者，此為熱入血室也，也，當刺期門當刺期門，隨其實而取之。（，隨其實而取之。（143143）vWhen a woman with wind strike has fever and aversion When a woman with wind strike has fever and aversion to cold,and the menstrual flow happens to arrive,to cold,and the menstrual flow happens to arrive,seven or eight days,then the fe

23、ver is gone,the seven or eight days,then the fever is gone,the pulse is slow and there is generalized coldness,pulse is slow and there is generalized coldness,fullness under the chest and rib-side,signs like fullness under the chest and rib-side,signs like chest bind and delirious speech,this means

24、that chest bind and delirious speech,this means that the heat has entered the blood chamber,one should the heat has entered the blood chamber,one should needle Qimen(Liv-14),choosing this point in the needle Qimen(Liv-14),choosing this point in the view of the excess.view of the excess.少陽病兼變證第三節(jié) 少陽病

25、兼變證v婦人中風，七八日續(xù)得寒熱，發(fā)作有時，經(jīng)水適斷者，此為婦人中風，七八日續(xù)得寒熱，發(fā)作有時，經(jīng)水適斷者，此為熱入血室，其血必結(jié)，故使如瘧狀，發(fā)作有時，小柴胡湯主熱入血室，其血必結(jié)，故使如瘧狀，發(fā)作有時，小柴胡湯主之。（之。（144144）vWhen a woman with wind strike seven or eight When a woman with wind strike seven or eight days has a periodic fever and cold,and the days has a periodic fever and cold,and the me

26、nstrual flow happens to stop,this means menstrual flow happens to stop,this means that the heat has entered the blood chamber that the heat has entered the blood chamber and the blood will bind,causing a malaria-and the blood will bind,causing a malaria-like condition that occurs at(set)times;like c

27、ondition that occurs at(set)times;therefore,Minor Bupleurum Decoction governs.therefore,Minor Bupleurum Decoction governs.少陽病兼變證第三節(jié) 少陽病兼變證六、熱入血室證治：六、熱入血室證治：v婦人傷寒，發(fā)熱，經(jīng)水適來，晝?nèi)彰髁?，暮則讝語，婦人傷寒，發(fā)熱，經(jīng)水適來，晝?nèi)彰髁?，暮則讝語，如見鬼狀者，此為熱入血室，無犯胃氣，及上二焦如見鬼狀者，此為熱入血室，無犯胃氣，及上二焦 ，必自愈。（，必自愈。（145145）vWhen a woman with cold damage ha

28、s fever,and When a woman with cold damage has fever,and the menstrual flow happens to arrive and she the menstrual flow happens to arrive and she is clear-headed during the day and speaks is clear-headed during the day and speaks deliriously in the evening,as if seeing a deliriously in the evening,a

29、s if seeing a ghost,this means that the heat has entered ghost,this means that the heat has entered the blood chamber;but do not assail the the blood chamber;but do not assail the stomach qi and the upper and the middle stomach qi and the upper and the middle burners,recovery will be spontaneous.bur

30、ners,recovery will be spontaneous.少陽病兼變證第三節(jié) 少陽病兼變證釋義 婦人經(jīng)期感受外邪，血室（womb)空虛，外邪從少陽三焦內(nèi)陷血室熱入血室證。（1）脈遲邪與血結(jié)，氣血澀滯 刺期門泄實去熱 胸脅下滿如結(jié)胸狀肝膽氣機疏泄不利 肝經(jīng)之熱除，血室 譫語血熱上擾心神 之熱解。（2）寒熱往來如 少陽邪熱初陷血 治從少陽之樞而解 瘧狀，發(fā)作有時 室（血分）未深 小柴胡湯 無譫語（3）病在血室下焦，與上、中二焦及胃無關(guān)。血下則熱邪有外泄之機經(jīng)水未斷，邪熱外泄而自愈。少陽病兼變證第四節(jié) 少陽病傳變及預后v傷寒六七日，無大熱，其人躁煩者，此為陽去入陰故（傷寒六七日，無大熱，其

31、人躁煩者，此為陽去入陰故（269269）vWhen in cold damage six or seven days,high fever is When in cold damage six or seven days,high fever is absent and the person is agitated and vexed,this is absent and the person is agitated and vexed,this is because the evil in the yang abating and entering yin.because the evil

32、in the yang abating and entering yin.v傷寒三日，三陽為盡，三陰當受邪，其人反能食而不嘔，此為傷寒三日，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。（三陰不受邪也。（270270）vWhen in cold damage three days,the three yang When in cold damage three days,the three yang channels have all been run through,and three yin channels have all been run through,and thre

33、e yin channels should contract the evil,but instead,the channels should contract the evil,but instead,the person has a good appetite and no retching,which person has a good appetite and no retching,which means that the three yin channels will not contract means that the three yin channels will not c

34、ontract the evil.the evil.少陽病兼變證第四節(jié) 少陽病傳變及預后v傷寒三日，少陽脈小者，欲已也。（傷寒三日，少陽脈小者，欲已也。（271271）vWhen in cold damage three days,the disease When in cold damage three days,the disease is in the Shaoyang,and the pulse is small,is in the Shaoyang,and the pulse is small,the disease is about to resolve.the disease i

35、s about to resolve.釋義釋義：少陽病傳變及預后：少陽病傳變及預后：1、病進：傷寒六、七日為傳變之期：、病進：傷寒六、七日為傳變之期：表無大熱表無大熱邪已入里邪已入里 傳陽明傳陽明兼惡熱口渴汗出腹脹兼惡熱口渴汗出腹脹便便煩躁煩躁表病入里，陽去入陰表病入里，陽去入陰 秘脈沉實有力。秘脈沉實有力。傳三陰傳三陰兼吐利肢厥脈微兼吐利肢厥脈微少陽病兼變證第四節(jié) 少陽病傳變及預后2、病退：（1）病入少陽，樞機不利，引起胃氣不和嘔吐、不能食?，F(xiàn)在能食而不嘔說明少陽邪衰，但胃氣尚旺，此為 病退，疾病未傳變。（2）少陽病之脈應當是弦脈，如脈不見弦而是小脈（脈漸平和）說明少陽病邪微，疾病向痊愈方面

36、發(fā)展。少陽病兼變證第五節(jié) 少陽病欲解時v少陽病欲解時，從寅至辰上。（272）vThe time when Shaoyang disease is about to resolve is from Yin to Chen.釋義釋義 少陽之氣旺于寅、卯、辰三個時辰（上午少陽之氣旺于寅、卯、辰三個時辰（上午3 3點到點到9 9點），點），在在此時間段內(nèi)，少陽經(jīng)氣得自然界陽氣之助，則正氣抗邪有力，此時間段內(nèi)，少陽經(jīng)氣得自然界陽氣之助，則正氣抗邪有力，疾病易解。疾病易解。少陽病兼變證小結(jié) 本章討論了少陽病病因病機、主癥、治法、禁忌、預后及兼變證，共有六個方證。1、少陽病的病因病機：病因：多由正氣虛弱，風

37、寒之邪侵入少陽。病機：正邪分爭，樞機不利，膽火內(nèi)郁，虛實夾雜。2、少陽病主癥：往來寒熱、胸脅苦滿、默默不欲食、心煩喜嘔、口苦、咽干、目眩、脈弦。小柴胡湯適應證為：1）少陽半表半里證；2）肝旺脾虛之腹痛；3）三陽合病，陽明里實不顯著者；4）陽明病潮熱、大便溏、胸脅滿不去者或陽明病脅下硬滿、大便秘結(jié)而舌苔白者；5）陽微結(jié)之大便硬者；6）婦人熱入血室者；7）厥陰病嘔而發(fā)熱者；8）傷寒瘥后更發(fā)熱者。少陽病兼變證小結(jié)3、少陽病治法與禁忌：治法：和解少陽。禁忌：禁用汗、吐下三法。4、少陽病兼變證：1）少陽兼太陽之表少陽兼太陽之表柴胡桂枝湯證；2）少陽兼陽明之里少陽兼陽明之里大柴胡湯證、柴胡加芒硝湯證；3）少陽兼水飲內(nèi)結(jié)少陽兼水飲內(nèi)結(jié)柴胡桂枝干姜湯證；4）少陽兼火逆心包少陽兼火逆心包柴胡加龍骨牡蠣湯證。5、少陽病預后、欲解時：病進傷寒六、七日，身無大熱、煩躁者，“陽去入陰”；病退少陽病反見能食不嘔者，少陽邪衰胃氣轉(zhuǎn)和；少陽病不見弦脈而見小脈者，是少陽邪微而氣和，向愈發(fā)展。6、少陽病欲解時寅、卯、辰時（上午39點）少陽病兼變證（完）（完）Thank you!少陽病兼變證