辨證論治概說（詳本）

Pattern Differentiation: The Complete Account

據《台北臨床三十年·辨證論治概說》(pp.100–104) 整理。Organized from the source text; no content invented. For education; suitability is decided by in-person assessment.

開篇：中醫治病，不重病名

中醫治病，不重病名，不論有無病菌，或傳染何病，概依「辨證論治」來處理。「傷寒論」「金匱」兩書，是辨證論治的典籍。所謂辨證論治，是從多數症候之中，經過辨證，找出疾病的本質，然後立法、處方、用藥。

中醫診斷與西醫不同之處，即在於此：西醫以病名為據，中醫以證為據。辨證論治，是中醫普遍應用的診療法則。

Chinese medicine treats the pattern, not the disease name. Whether or not a pathogen is identified, treatment follows one method: pattern differentiation and treatment determination. The Shanghan Lun and Jingui Yaolue are the canonical texts of this method. From the full array of signs and symptoms, differentiation identifies the essential character of the disorder; only then are the treatment principle, the formula, and the medicinals chosen. Where Western diagnosis proceeds from the disease name, Chinese diagnosis proceeds from the pattern — this is the universal clinical method of Chinese medicine.

什麼是辨證的內容？辨證應該注意那些問題？

一、辨病因

什麼是病因？外感六淫、內傷七情、飲食所傷、蟲積、勞傷等等，都是病因。

如頭痛一證，上述病因都可引起——這必須通過辨證，找出產生頭痛的原因，才能達到治本的目的。否則就會變成頭痛醫頭：見頭痛就用治頭痛的藥，見腹痛就用治腹痛的藥。這是對症，不對證；是治標，不是治本。

例如：風寒頭痛，病因是感受風寒。但是也有感受風寒而不發生頭痛的——必須兼體質軟弱，並產生發熱、周身酸痛、惡寒無汗，或自汗惡風等一系列的臨床表現，才能反映出「風寒頭痛」一證。單有病因，沒有人體的反應，就構不成一個證。

What counts as a cause?

The six external excesses (wind, cold, summer-heat, dampness, dryness, fire), the seven internal emotions, injured food and drink, parasites, overexertion — all are causes. A single headache may arise from any of them. Unless differentiation finds the cause behind this headache, treatment cannot reach the root. Otherwise it becomes “headache, treat the head”: a headache remedy for headache, an abdominal-pain remedy for abdominal pain — that addresses the symptom, not the pattern; the branch, not the root.

Wind-cold headache, for instance, is caused by invasion of wind-cold — yet not everyone who encounters wind-cold develops the headache. A weakened constitution must meet the invasion, producing fever, generalized aching, aversion to cold with absent sweating, or sweating that brings aversion to wind — only this complete clinical picture constitutes the pattern “wind-cold headache.” A cause without the body’s response does not make a pattern.

二、辨體質

由於人體的強弱，和五臟的虛實，各有不同，雖同為一病，或發病的原因也相同，其病變和病變的發展，可以完全不一樣。

如外感病，在陽虛的人和陰虛的人之間，在體質強壯的人和體質虛弱的人之間，就有不同的臨床表現。如陽虛的人患傷寒，多從陰化寒，其發病迅速，甚至直中三陰；陰虛的人患溫病，多從陽化熱。即使同是外感風寒，體質強壯而正氣亦盛的人，邪正相爭，多形成實證；正氣較弱、病邪久纏的人，多發展成虛證。

所以辨證必須辨體質：離開了體質，就無從判斷病變的走向。

The constitution decides the course

Bodies differ in strength; the five zang differ in depletion and repletion. The same disease, even from the same cause, may unfold entirely differently. In external invasion, the yang-depleted and the yin-depleted present differently, as do the robust and the frail. A yang-depleted person contracting cold damage tends to transform toward yin-cold, sometimes striking directly into the three yin. With strong antipathogenic qi meeting a strong pathogen, the struggle forms an excess pattern; with weak antipathogenic qi and a lingering pathogen, it develops into deficiency. Differentiation without the constitution cannot judge where the illness is heading.

三、辨病位

由於邪氣侵襲，與病理損害不同，病變可發生在人體之表、內臟不同的部位，必須通過辨證，以分析疾病之所在。

(1) 要辨表裏。 一般以病在皮毛、肌肉、經絡，為在表；病在五臟、六腑，為在裏。從病之在表在裏，可以分析出疾病向外或向內發展的趨勢，同時亦可測知輕重、淺深。

(2) 要辨上下。 一般以心（怔忡）、肺（咳嗽）見證，為病在上焦；以大小腸（便秘、腹瀉）、膀胱（遺尿、失禁）見證，為病在下焦。也有證見於上下二焦，而病不屬上下二焦的——如清濁升降紊亂，發生脘滿、嘔逆之證，則是中焦之病。更有三焦辨證：上焦、中焦、下焦，各有其傳變規律。

Location: exterior/interior, above/below

The invading pathogen and the tissue damage differ; the disorder may lodge in the exterior or in different organs, and differentiation must locate it. Exterior vs. interior: skin, flesh, and channels are exterior; the five zang and six fu are interior. From this, the direction of the illness — outward or inward — is read, and its depth and gravity gauged. Above vs. below: heart signs (palpitations) and lung signs (cough) place it in the upper burner; large and small intestine signs (constipation, diarrhea) and bladder signs (enuresis, incontinence) place it in the lower burner. Some signs span both burners while the disease belongs to neither — disordered ascent and descent of clear and turbid producing epigastric fullness and vomiting belongs to the middle burner. The three-burner system carries its own laws of transmission.

辨證的三個要訣

辨證除應注意上面幾個方向之外，還須掌握下面三個要訣。

要訣之一：辨主次

一個證候，可以有幾個不同的證狀；同一證狀，又可以出現在不同的證候。因此，要根據證狀來辨別證候，就要抓住能反映疾病本質的主證——主要證狀。

例如：患者突然腹痛，要辨別腹痛屬於一個什麼證候，必須將其他兼證結合起來進行審辨，看它和主證有無聯繫。如腹痛的同時，兼有反酸、嘔吐、泄瀉、胃脘拒按、瀉後痛減等證——主證既定，就可以斷定是「飲食內傷」之證。

又如：患者頭痛頭暈，有兩種不同的證候。其一，面赤耳鳴，怔忡不寧，證屬肝陽上擾；其二，胸滿嘔逆，食少苔膩，證屬痰濁上逆。前一證若無面赤，肝風之證不能成立；後一證若無苔膩，濁痰之證不能成立。主證是診斷的支柱，抓不住主證，診斷就站不穩。

Key one: chief and accompanying

One pattern may carry several signs, and one sign may appear in several patterns. Differentiation must seize the chief sign — the one reflecting the disorder’s essence. Sudden abdominal pain with acid reflux, vomiting, diarrhea, epigastric tenderness refusing pressure, and pain easing after the bowels move: with the chief sign fixed, the verdict is internal injury by food and drink. Headache with dizziness divides two ways: red face, tinnitus, palpitations and restlessness — liver yang harassing upward; chest fullness, vomiting, poor appetite, greasy tongue coat — turbid phlegm rebelling upward. Without the red face, the liver-wind pattern cannot stand; without the greasy coat, the turbid-phlegm pattern cannot stand. The chief sign is the pillar of diagnosis.

要訣之二：辨同異

在整個病情變化之中，對一切證狀的產生和消退，有決定性意義的證狀，必須特別注意。

例如：溫病病在氣分，舌苔黃白相兼，證見壯熱煩渴、大便秘結；病入血分，舌現絳色。這些證狀都是隨舌苔轉變而轉變的——舌苔是辨別氣分血分的關鍵。

將要確定一個證候的時候，發現其中一兩個證狀，不應該在這個證候出現，就應當根據這一兩個證狀，從「同中辨異」，重新考慮。如口渴一證：燥熱口渴，則大渴引飲；痰飲口渴，則先渴後嘔；腹瀉一證：熱瀉則糞便腥臭灼熱，寒瀉則清稀如水。同是口渴、同是腹瀉，異中之同、才是辨證的落點。

Key two: same, yet different

Across the whole course of illness, the signs decisive for how all other signs arise and recede deserve special attention. In warm disease at the qi level, the tongue coat is yellow-white and the pattern shows high fever, thirst, constipation; entering the blood level, the tongue turns crimson — the signs follow the coat. When fixing a pattern, one or two signs that do not belong demand reconsideration through “difference within sameness.” Thirst from dryness-heat: great thirst with gulping; thirst from phlegm-fluid: thirst then vomiting. Diarrhea from heat: foul and scalding; from cold: clear and watery. Same thirst, same diarrhea — it is the difference within the sameness that settles the differentiation.

要訣之三：辨真假

病人的外表現象，一般可以說是疾病本質的反映，現象與本質是一致的。但是也有不一致的時候——真寒可以現假熱，真熱可以現假寒。現象與本質是否一致，必須辨明；辨不明真假，就會治反。

Key three: true and false

Outer signs usually mirror the essence. But not always — true cold can wear the mask of false heat, true heat the mask of false cold. Whether appearance and essence agree must be differentiated; misread it and treatment goes the wrong way.

治療：反治與正治

上面已將辨證的大要說明。辨證既明，以下言治療。

一、反治

什麼叫反治？就是用與病氣相同的性味，來治病的方法。因為證有真假：真的可以用正治，假的就要用反治。

熱因熱用——治假熱。 如患者熱邪內伏，格陰於外，證見身熱、面赤、口渴，但口渴喜熱飲，脈沉細而弱，舌淡苔白：此外熱皆假象，實為真寒假熱之證。治宜附子、乾薑之屬，以熱藥治其假熱——此即「熱因熱用」。

寒因寒用——治假寒。 如患者外見四肢厥冷，似是寒證；但同時胸腹灼熱、口渴喜冷飲、脈滑數、舌紅苔黃燥：此外寒皆假象，實為真熱假寒之證。治宜石膏、知母之屬，以寒藥治其假寒——此即「寒因寒用」。

又有塞因塞用——治假實；通因通用——治假虛。總之，反治治的是假象，透過假象治其真實。

Paradoxical treatment: treating the mask

Paradoxical treatment uses medicinals of the same nature as the disease qi. Patterns being true or false, the true take direct treatment and the false take the paradoxical. Heat with heat for false heat: deep heat constraining yin outward — feverish body, red face, thirst, yet thirst relieved by hot drinks, deep thready weak pulse, pale tongue with white coat: the heat is false, the cold true. Treat with aconite and dried ginger — heat treating false heat. Cold with cold for false cold: cold limbs suggesting cold, yet burning chest and abdomen, thirst for cold drinks, slippery rapid pulse, red tongue with dry yellow coat: the cold is false, the heat true. Treat with gypsum and anemarrhena — cold treating false cold. Likewise supplementation-blockage for false excess and unblocking-flow for false deficiency. The paradoxical treats the mask to reach the truth beneath.

二、正治

什麼叫正治？就是用與病氣相反的性味，來治病的方法——「逆者正治」之道。熱者寒之，寒者熱之；虛者補之，實者瀉之。徐之才說：「十劑者……」——十劑皆所以成正治之用。（詳見另篇《十劑》）

Direct treatment: opposing the nature

Direct treatment uses medicinals of opposite nature to the disease qi — the way of “opposing is direct.” Heat is cooled, cold is warmed; deficiency is supplemented, excess is drained. Xu Zhicai’s “ten agents” all serve this direct treatment. (See the companion article, The Ten Agents.)

---

White Cedar Acupuncture · 雪松馆

747 Altos Oaks Dr., Ste 1, Los Altos, CA 94024 · 669-669-1142

By appointment · 預約制 · whitecedaracu.com