《伤寒论》上热下寒证浅析

An Analysis of Upper-Heat and Lower-Cold Syndrome in Treatise on Cold Damage Diseases

上热下寒证属虚实夹杂、病机复杂的临床证候,基本病机为阴阳之气升降失常,正常的气机运行规律被打破,可分为中焦脾胃升降失职及肝肺失和,在气机上存在上部相对郁阻和下部相对气血不足之象。《伤寒论》中上热下寒方证有:胃热脾寒,中土失运—黄连汤证、干姜黄芩黄连人参汤证;风寒郁遏,相火内扰——厥阴病提纲证、乌梅丸证;失治邪陷,膈热脾寒——栀子干姜汤证;正虚邪郁,肺热脾寒——麻黄升麻汤证;枢机不利,胆热脾寒——柴胡桂枝干姜汤证。张仲景治疗上热下寒证的核心思想大致分为三点:其一,上热者清之,下寒者温之,寒热调和,用药大胆精细,对药物的作用把握得极其准确。其二,注重气机的调畅,要注意的是调畅气机应在顺应各个脏腑生理功能的基础上进行,要注意顾护脏腑本身的特性,不可一味地使用行气或梳理气机之品,应以增强脏腑本身的生理功能为主。其三,根据患者的脉象、证候去分析其内在病因病机,“治病必求于本”,要寻找患者的主要致病因素,进而从阴阳的大方向上去调整,追求阴平阳秘的生理状态。

Upper-heat and lower-cold syndrome belongs to a clinical syndrome with a mixture of deficiency and excess,and a complex pathogenesis.The basic pathogenesis is the abnormal ascending and descending of yin-yang qi,and the normal operation law of qi is blocked.It can be roughly divided into the dysfunction of the spleen and stomach in the middle energizer and the disharmony of liver and lungs.There is a phenomenon of upper relative stagnation and lower relative deficiency of qi and blood in terms of the qi mechanism.In Treatise on Cold Damage Diseases,the formula-syndromes with upper heat and lower cold include:stomach heat and spleen cold,dysfunction in the middle earth,leading to Coptis Decoction syndrome,and Rhizoma Zingiberis and Scutellaria,and Coptis and Ginseng Decoction syndrome,wind-cold stagnation,internal disturbance of ministerial fire,leading to reverting yin disease outline syndrome and Mume Pill syndrome;Mistreatment and pathogenic stagnation,diaphragmatic heat and spleen cold,leading to Gardenia and Rhizoma Zingiberis Decoction syndrome;Deficient healthy qi and pathogenic stagnation,lung heat and spleen cold,leading to Ephedra and Cimicifuga Decoction syndrome;Cardinal dysfunction,gallbladder heat and spleen cold,leading to Bupleurum and Cinnamon Twig and Dried Ginger Decoction syndrome.The core idea of Zhang Zhongjing′s treatment of upper-heat and lower-old syndrome can be roughly divided into three points:Firstly,in terms of the distribution of cold and heat,the upper heat should be cleared,the lower cold should be warmed,the cold and heat should be balanced,and the medication should be bold and precise,with an extremely accurate grasp of the effects of the related medicines.Secondly,emphasis should be placed on smoothly regulating qi.It is crucial to regulate qi based on the physiological functions of various organs and consider the characteristics of the organs themselves.Products that promote or regulate qi circulation should not be used blindly;instead,focus should primarily be on enhancing the physiological functions of the organs themselves.Thirdly,based on patients′ pulse condition and symptoms,it is necessary to analyze their underlying causes and pathogenesis."Treatment must be based on the root cause," requiring identification of the main pathogenic factors affecting patients.Subsequently,from an overall perspective on yin and yang directionality,adjustments should aim for a physiological state characterized by yin-yang balance.