基于《伤寒论》六经辩证体系探讨三阴病小便异常的诊疗思路

Discussion on the Diagnosis and Treatment of Abnormal Urination in Three Yin Diseases Based on the Six-Channel Syndrome Differentiation System of Treatise on Cold Pathogenic Diseases

摘要: 小便排泄状态是中医审察脏腑功能、辨析病机病势的重要指征，《伤寒论》将小便异常纳入六经辨证核心指标，然仲景详述三阳而略叙三阴，对三阴病小便异常的病机与证治规律缺乏系统梳理，难以彰显六经体系下三阴病小便异常的辨治价值。三阴病总以正气亏虚、脏腑功能失常、阴阳失和为基本病机，其所致小便异常虽统属于“小便不利”范畴，却因病位深浅、病性寒热、病机虚实的差异而各具特征：太阴病小便异常以脾阳亏虚、寒湿内停为核心，治当温运脾阳、散寒化湿，以四逆辈为核心施治；少阴病小便异常分心肾阳虚寒化与阴虚火旺热化两端，寒化证多见小便清长、频数失禁，治以温肾回阳、化气利水，热化证多见小便短少、艰涩难出，治以滋阴清热、利水育阴；厥阴病小便异常以寒热错杂、气机逆乱、阴阳失于顺接为核心，多呈现寒热错杂、时通时闭之象，治以调畅厥阴枢机、平调寒热、恢复肝之疏泄与三焦气化，主以乌梅丸为核心，临证可据兼证灵活化裁，拟为提供基于三阴经小便异常的诊疗思路参考。

Abstract: The state of urination is a key indicator in traditional Chinese medicine (TCM) for evaluating the function of zang-fu organs and differentiating the pathogenesis and progression of diseases. In Treatise on Cold Pathogenic Diseases, abnormal urination is included as a core index of six-channel syndrome differentiation. However, Zhang Zhongjing elaborated on the three yang diseases in detail while gave only a brief account of the three yin diseases, with no systematic collation of the pathogenesis and rules of syndrome differentiation and treatment for abnormal urination in three yin diseases. It is thus difficult to fully demonstrate the diagnostic and therapeutic value of abnormal urination in three yin diseases under the six-channel differentiation system. The basic pathogenesis of three yin diseases is generally characterized by deficiency of vital qi, dysfunction of zang-fu organs, and disharmony between yin and yang. The resultant abnormal urination, though generally classified into the category of “dysuria”, presents distinct features due to differences in the depth of disease location, cold or heat nature of the disease, and deficiency or excess state of pathogenesis. For abnormal urination in Taiyin disease, the core pathogenesis is deficiency of spleen yang and internal retention of cold-dampness; the treatment principle should focus on warming and activating spleen yang, dispersing cold and resolving dampness, with the Sini decoction and its analogous formulas as the core prescriptions. Abnormal urination in Shaoyin disease is divided into two patterns: the cold transformation pattern caused by deficiency of heart and kidney yang, and the heat transformation pattern caused by hyperactive fire due to yin deficiency. The cold transformation pattern is mostly manifested as clear and profuse urination, frequent urination and incontinence, which should be treated by warming the kidney and restoring yang, transforming qi and promoting urination; the heat transformation pattern is commonly marked by scanty, difficult and hesitant urination, which should be treated by nourishing yin and clearing heat, promoting urination and nourishing yin. For abnormal urination in Jueyin disease, the core pathogenesis is intermingled cold and heat, disorder of qi movement, and failure of smooth interaction between yin and yang, mostly manifested as mixed cold and heat symptoms with intermittent urination. The treatment principle should focus on regulating and smoothing the Jueyin pivot, balancing cold and heat, restoring the liver’s function of governing free flow of qi and the qi transformation of triple energizer, with Wumei Pill as the core prescription. The formula can be flexibly modified according to the accompanying syndromes in clinical practice, so as to provide a reference for the diagnosis and treatment of abnormal urination based on the three yin channels.