通脉四逆汤证 - 伤寒研读 - 岐黄中医网

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少陰病，下利清穀，裏寒外熱，手足厥逆，脉微欲絕，身反不惡寒，其人面色赤，或腹痛，或乾嘔，或咽痛，或利止脉不出者，通脉四逆湯主之。（317）【提要】  少阴病阴盛格阳的证治。【分析】  少阴病下利清谷，是脾肾阳微、水谷不化所致，此为少阴虚寒下利的特有表现。手足厥冷，是少阴阳气大衰，阳气不达于四末所致。脉微欲绝，是阳衰至甚，不能鼓动血脉所致。如此一派阳气大衰，阴寒邪盛之象，而见“身反不恶寒，其人面色赤”，是阴盛格阳之表现。盖阴盛于内，虚阳被格于外，故有反不恶寒之假象；残阳不能归根，扰于上部，则见面赤，亦为假热之象。本证面赤必红而娇嫩，如饰如妆，与阳明热盛之满面通红者大异。本条为阴盛格阳之重证，病情危笃，变化亦多，故有许多或然证，如脾肾阳衰，寒邪凝聚，则腹痛；阴寒上逆犯胃，则干呕；虚阳上浮，损害少阴经脉，则咽痛；泻利过甚，阳虚阴竭，则利止脉不出。同时，从通脉四逆汤方后加减法云“面色赤者，加葱九茎”，因知面色赤亦当为其或然证。一般说来，疾病的现象和本质是一致的。如寒证多表现一派寒象，热证多表现一派热象，如此，辨证不难。然事物的表现是复杂的，阴寒至极，“寒极生热”；或邪热极盛，“热极生寒”，则会出现现象与本质不一致的假象。此时，辨证尤当注意，必须认真分析，透过现象看本质，然后针对其根本治疗，方不致误。本条所谓“里寒外热”，里寒是真、是本质，外热是假、是现象。辨证须着重抓住“手足厥冷，下利清谷，脉微欲绝”的内真寒本质，识破“身反不恶寒，其人面色赤”外热之假象，切勿标本不辨，以假乱真。本证与四逆汤证鉴别表 \n \n \n 四逆汤证\n \n 通脉四逆汤证\n 病　机\n 同\n 阳衰阴盛\n 异\n \n 以阳衰阴盛为主\n \n 阳衰阴盛，虚阳外越，阴阳格拒\n 主　证\n 同\n \n 脉微细，但欲寐，下利清谷，手足厥逆\n 异\n \n 无假热或有轻度假热现象\n \n 明显的身反不恶寒、面赤、咽痛、脉微欲绝等假热现象\n 治　法\n 同\n \n 回阳救逆\n 异\n \n \n \n 兼通达内外\n 方　药\n 同\n \n 干姜　附子　甘草\n 异\n \n \n \n 重用干姜、附子面赤、不恶寒之虚实鉴别表\n \n \n 阳明病\n \n 本　证\n 疑似症\n 不恶寒，面赤\n 证候特点及兼证\n \n 身热，胸腹灼手，大渴引饮，不恶寒反恶热。面赤如醉，脉数大有力，舌苔黄燥。\n \n 虽不恶寒，而四肢厥冷；或自觉发热，而扪之不热。面红如妆，咽痛不红肿，伴下利清谷、脉微欲绝、舌淡苔白。\n 属  性\n \n 属阳、热、实\n \n 属阴、寒、虚\n 病  机\n \n 燥热内炽（真热）\n \n 阳衰阴盛，虚阳外越（假热）【选注】  尤在泾：此寒中少阴，阴盛格阳之证。下利清谷，手足厥逆，脉微欲绝者，阴盛于内也；身热不恶寒，面赤色者，格阳于外也。真阳之气被阴寒所迫，不安其处，而游散于外，故显诸热象，实非热也。通脉四逆即四逆加干姜一倍，为阴内阳外，脉绝不通，故增辛热以逐寒邪，寒去则阳复反，而脉复出，故曰其脉即出者愈。  （《伤寒贯珠集·少阴篇》）【治法】  破阴回阳、通达内外。【方药】  通脉四逆湯方甘草二兩  附子大者一枚，生用，去皮，破八片  乾薑三兩，強人可四兩上三味，以水三升，煮取一升二合，去滓，分溫再服。其脉即出者愈。面色赤者，加蔥九莖；腹中痛者，去蔥，加芍藥二兩；嘔者，加生薑二兩；咽痛者，去芍藥，加桔梗一兩；利止脉不出者，去桔梗，加人參二兩；病皆與方相應者，乃服之。【方义】  通脉四逆汤与四逆汤药味相同，惟姜、附用量较大，附子用大者一枚，干姜由一两半增至三两，如此则增强破阴回阳之力，以速破在内之阴寒，而除阴阳格拒之势，挽回欲脱之元阳。加减法：①若面色赤，为阴盛格阳，虚阳浮越于上所致，故加葱白以交通上下阳气。②腹中痛，为阳衰阴盛，气血阻滞，脾络不和所致，故去葱白加芍药以和络止痛。③干呕，为阴寒气逆犯胃所致，故加生姜和胃降逆止呕。④咽痛为虚阳上扰，咽喉不利所致，故去苦泄之芍药，加桔梗以利咽喉。⑤利止脉不出，为阳脱阴竭，故去桔梗，加人参以益气生津，扶正固脱而复脉。【案例】　徐国帧伤寒六七日，身热目赤，索水至前，置而不饮，异常大躁，门牖洞启，身卧地上，辗转不快，要求入井。一医汹汹急以承气与服。余诊其脉洪大无伦，重按无力。余曰：阳欲暴脱，外显假热，内有真寒，以姜附投之，尚恐不胜回阳之任，况敢以纯阴之药，重劫其阳乎?观其得水不欲咽，情已大露，岂水尚不能咽，而反可咽大黄、芒硝乎?天气燠热，必有大雨，此证倾刻一身大汗，不可救矣。于是，以附子、干姜各15g，人参9g，甘草6g，煎成冷服。服后寒战戛齿有声，以重棉和头覆之，缩手不肯与诊，阳微之状始著，再与前药一剂，微汗热退而安。（《寓意草》）"}