【作者】 张金玺；

【导师】 张六通；

【作者基本信息】 湖北中医药大学 ， 中医基础理论， 2014， 博士

【摘要】 目的本研究试图以三分思维建立广义“脏气”的“气分为三”假说，以替代建立在二分思维基础上的“气分阴阳”学说，以期既能达到“气分阴阳”学说纠正既往混乱的初衷目的，又能纠正“气分阴阳“学说自身带来的新的混乱，从而实现理论上的自洽性和临床上的可证性。方法本研究包括以下五个部分。第一部分：“精”、“气”、“血”、“阴”、“阳”、“津液”的概念及其逻辑关系研究。通过文献评析，结合临床实际，本研究认为，“气”与“精”、“血”、“津液”一样，是构成人体和维持人体生命活动的精微物质。气之“功能”说、“可为物质可为功能”说、“既为物质又为功能”说、“物质功能征象”说、“活力之气为功能，气血之气为物质”说、“物质运动之象”说等，均不可取。“心阴”、“心阳”等物质层面上的“脏阴”、“脏阳”，应该归属于广义“脏气”的范畴，“脏阴”、“脏阳”、“脏气”（狭义）共同组成了广义“脏气”。物质层面上的“脏阴”，与“精”、“血”、“津液”彼此概念独立，互不包容，“阴虚”与“精虚”、“血虚”、“津液不足”等也彼此概念独立，互不包容。物质层面上的“脏阳”与狭义的“脏气”都为广义“脏气”的一部分，“脏阳”与狭义的“脏气”彼此概念独立，互不包容，“阳虚”与“气虚”（即狭义脏气之虚亏，也即在临床上被广泛称谓的“气虚”）也彼此概念独立，互不包容，“阳虚”不是“气虚”的发展，“阳虚”自身并不包含“气虚”。第二部分：“气分阴阳”学说的合理之处。通过辨析，本研究认为，“气分阴阳”学说的合理之处主要表现在以下几个方面：进一步肯定了“气”的物质性、纠正了既往认识中物质层面上的“阴”与“精”、“血”、“津液”的概念混淆、纠正了既往认识中物质层面上的“阳”与“气”合称为“阳气”之不妥、纠正了既往认识中“阳虚”与“气虚”概念之不清。第三部分：“气分阴阳”学说的不合理之处。通过辨析，并密切联系临床实际，本研究认为“气分阴阳”学说存在以下几方面谬误。一是与临床组方原则的相悖。如该学说认为，阳气和阴气共同组成了“气”，临床上的“气虚”即是阳气和阴气的对等皆不足。如此则可推断，治疗气虚证时，即使不用补气药，而只选用补阳药和补阴药并使两者药力平衡，也能治疗气虚证。这显然与临床组方原则相悖。二是与中药学理论的相违。如，按照“气分阴阳”学说，气虚为阳气和阴气的对等俱虚，那么以此推论，香附等行气药的行气作用即包括了通行阳气和通行阴气两部分的作用。此与中药学对香附等行气药的功能认识相违。三是与“气阴两虚”等证候的相左。持“气分阴阳”学说的学者认为，由于“气”包含了“阴”和“阳”两个方面，故“气”不可能与它的一部分“阴”或“阳”构成两虚，因此，目前所谓的“气阴两虚”和“气阳两虚”证候均属于逻辑学上的悖论。此种推论与当前中医临床广泛共识相左。四是与病机学说的不符。如该学说认为，“气”分为“阳气”和“阴气”两部分，阳气主推动，阴气主宁静，临床上的“气虚”为阳气和阴气的对等皆不足。按此之论，则不能合理解释“气虚血瘀”病机。因为在阳气和阴气对等皆不足情况下，阳气的推动力和阴气的宁静力均衡下降，应该不会导致血行瘀阻。因此，该学说与病机学说不相契合。第四部分：广义“脏气”的“气分为三”假说之建立。“气分为三”假说的主要内容是：脏气（广义）分为脏阴、脏阳和脏气（狭义）三部分，即“气分为三”，如心气（广义）分为心阴、心阳和心气（狭义），其它四脏类推。“气分为三”之语中的“气”，指的是广义“脏气”，广义“脏气”在学术交流和临床实践中，一般不作为特定术语出现。作为特定术语出现的“脏气”，指的是狭义“脏气”。例如，言“心气”时，若不加特殊说明，指的即是狭义心气；当今临床上广泛称谓的“心气虚”，指的即是狭义“心气”的不足。脏气（狭义）主推动和固摄，脏阴主凉润、宁静和潜降，脏阳主温煦、兴奋和升发。“气分为三”假说对五脏有关生理功能暂作以下简要描述：对于心而言，心主血脉的功能主要是由心气（狭义，下同）完成的。心气具有推动和固摄功能，一方面推动血液运行，另一方面又固摄血液循于常道。心阳的温煦、兴奋功能激发并参与心气的推动作用，心阴的凉润、宁静功能增强并参与心气的固摄作用。心阳和心阴的协调平衡，保证了心脏搏动的正常节律和血管的舒缩有度。对于肺而言，肺主呼吸的功能主要是由肺气完成的，肺气的推动功能推动肺脏吸清呼浊而发挥主司呼吸作用，肺气的固摄功能又固摄吸入的清气潜于体内而不至于外散。肺阳的温煦和兴奋功能激发并参与肺气的推动作用，肺阴的凉润、宁静功能增强并参与肺气的固摄作用。肺之宣发是肺阳引导并参与肺气向上和向外升宣布散，肺之肃降是肺阴引导并参与肺气向下和向内清肃通降。对于脾而言，脾气的推动功能推动脾脏的运化，脾气的固摄作用固摄血液循于常道。脾阳的温煦和兴奋功能激发并参与脾气的推动作用，脾阴的凉润和宁静功能又使脾之运化功能不致太过；脾阴的凉润和宁静功能增强并参与脾气的固摄功能，脾阳的温煦和兴奋功能又使脾之固摄功能不致太过。脾阳的升发功能引导并参与脾气的升举而使脏器位置恒定，脾阴的潜降功能又牵制其升举太过。对于肝而言，肝气的推动功能使气机调畅，肝气的固摄功能使血有所藏。肝阳的温煦和兴奋功能激发并参与肝气的推动作用，肝阴的凉润和宁静功能增强并参与肝气的固摄作用。肝阳的升发功能激发并参与肝气的升发疏泄作用，而肝阴的潜降功能又防其升泄太过。肝阴的潜降功能增强并参与肝的藏血功能，而肝阳的升发功能又防其藏之太过。对于肾而言，肾主人体生长发育生殖的功能主要是由肾气（还有肾精）完成的，肾阳的兴奋、温煦功能激发并参与肾气主人体生长发育生殖的功能，而肾阴的宁静、凉润功能又能防其太过。肾的藏精功能主要是由肾气的固摄作用完成的，肾阴的凉润和宁静功能增强并参与肾气的固摄作用，而肾阳的兴奋和温煦功能又防其固摄太过。肾的主水功能主要是由肾气的推动作用完成的，肾阳的温煦、兴奋和升发功能激发并参与肾气的推动作用，而肾阴的凉润、宁静和潜降功能又使其不致太过。肾的纳气功能主要是由肾气的固摄作用完成的，肾阴的凉润、宁静和潜降功能增强并参与肾气的固摄，而肾阳的温煦、兴奋和升发功能又防其摄纳太过。本部分的论证内容包括：“气分为三”假说的哲学基础、《内经》分类方法对“气分为三”假说建立的启发、“气阴两虚”证候对“气分为三”假说的佐释、临床用药对“气分为三”假说的反证。第五部分：基于“气分为三”假说的肝气虚证、肝阳虚证、肺阳虚证、脾阴虚证、肾气虚证研究。参照“气分为三”假说，五脏虚证应该有以上五个证候的存在，但目前各种版本的《中医诊断学》教材均对其没有记载，中医临床文献资料中虽有散在论述，但也缺乏系统的整理和确立，致使五脏虚证辨证体系失之系统。本文参照“气分为三”假说的有关观点，从理论渊源、临床表现、遣方用药等方面对以上证候进行研究，以期完善五脏虚性证候体系。结果2003年以来的连续三版《中医基础理论》规划教材（俗称七版、八版、九版统编教材）均收录采纳了中医气学理论研究中的所谓“气分阴阳”学说。该学说对纠正既往“阴虚”、“血虚”的混淆和“阳虚”、“气虚”的混淆等，确有积极意义。但是，“气分阴阳”学说在纠正既往混乱的同时，学说自身又带来了新的混乱，如否认“气阴两虚”证候的客观存在、无法自圆其说地解释“气虚血瘀”病机等等。本研究认为，现行《中医基础理论》规划教材所持的“气分阴阳”学说，与中医临床组方原则颇为相悖，与病机学说和中药学理论有所相违，其否定“气阴两虚”证候的客观存在更难取得广泛共识，是机械套用阴阳学说“一分为二”思维和忽视临床实际的结果，不能有效指导临床实践且易造成临证思维混乱，亟待重新评价与改良。本研究认为，如果以广义”脏气“的“气分为三”假说对五脏之气重新进行考量，则既能达到“气分阴阳”学说纠正既往概念混乱的初衷目的，又能纠正“气分阴阳”学说自身引起的新的混乱。”气分为三“假说认为：广义脏气分为脏阴、脏阳、脏气（狭义）三部分。脏气（狭义）属于广义脏气中的中性部分，具有推动和固摄作用；脏阳属于广义脏气中的阳性部分，具有温煦、兴奋、升发作用，脏阴属于广义脏气中的阴性部分，具有凉润、宁静、潜降作用。脏气（狭义）、脏阴、脏阳处于同一物质层次，内涵彼此独立，互不包容，但在五脏生理功能发挥上，又相互协调密切配合。脏之生理功能的发挥主要依赖于脏气（狭义），脏气（狭义）的推动和固摄作用实现脏的生理功能，但在发挥作用的同时，又与脏阴和脏阳密切配合。脏阳温煦和兴奋功能激发和参与脏气推动功能，脏阴凉润和宁静功能增强和参与脏气固摄功能。三者分则为三，合则为一，三位一体，和谐配合，共同完成五脏的生理功能，体现为广义脏气的综合功能。结论在脏气的分类方法研究上，应该以广义“脏气”的“气分为三”假说替代“气分阴阳”学说。更多还原

【Abstract】 PurposeThis research tried to replace the theory of “Yin and Yang Qi”,which isbased on the thought of “One divides into two”, by using the thought of “Onedivides into three” to build the “Qi is divided into three” hypothesis ofgeneralized “Visceral-Qi”. For one thing, hoping to get the purpose that thetheory of “Yin and Yang Qi” correct the previous confusion; for another,expecting to reclaim the new confusion that the theory of “Yin and Yang Qi”brings. Thereby, to realize the self-consistency of the theory and theprovability of clinical practice.MethodThis research includes following five parts.First part: The definition and research on the logic relationship of“Essence”,“Qi”,“Blood”,“Yin”,“Yang”,“Body fluid”. By reviewing thereferences and combining the clinical practice, maintained that the “qi” is thesame as the “essence”,“blood” and “body fluid”, which belong to the nutrientsubstance that constitute the human body and maintain life activities of humanbeings. The theory of “function”;“for material or function”;“both materialand function”;“material function signs”;“vigorous qi is the function, qi and blood is the material”;“the manifestation of the material motion” of qi, all ofthese are not desirable. The “Heart Yin”;“Heart Yang”, and “Visceral Yin”;“Visceral Yang” of material aspects, should belong to the category of thegeneralized “Visceral-Qi”.“Visceral Yin”,“Visceral Yang” and “Visceral-Qi”,which belong to the narrow sense, all of these formed the generalized“Visceral-Qi”. The “Visceral Yin” in material aspect is independent andcontradictory to the concept of “Essence”,“Qi” and “Blood”. Moreover, theconcept of “deficiency of yin” is also independent and contradictory to the“deficiency of essence”,“deficiency of blood” and “deficiency of body fluid”.The “Visceral Yang”, in the material aspect, is a part of the generalized“Visceral-Qi”; as well as the conception of the “Visceral-Qi”,from the narrowsense. The “Visceral Yang” is independent and contradictory to the“Visceral-Qi” of narrow sense; as well as the “Yang deficiency” and “Qideficiency”(namely, the deficiency of the narrow sense visceral-qi, or theextensive so-called the “Qi deficiency” in the present clinical practice). Theconception of “Yang deficiency” is not the development of the “Qi deficiency”,and the conception itself not included the “Qi deficiency”.Second part: The reasonable section of the “Yin and Yang Qi” theory.By analysis, this research considers that the reasonable section of the “Yin andYang Qi” theory mainly in the following aspects: it make further efforts toaffirm the materiality of “Qi”; correct the former understanding on thematerial aspect that the confusion of the conception between “Yin” and“Essence”,“Blood”,“Body fluid”; rectify the former understanding on thematerial aspect that the improper that the “Yang” and “Qi” are collectivelyreferred to as the “Yang qi”; redress the former understanding on the materialaspect that the unclear between the conception “Yang deficiency” and “Qideficiency”. Third part: The unreasonable section of the “Yin and Yang Qi” theory.By analysis and contact with the clinical practice closely, this research deemsthat the theory of “Yin and Yang Qi” exists following several fallacies. First, itis in contradiction with the principle of clinical prescription. For instance, thistheory considers that the “Yin” and “Yang” come together to complete theconcept of “Qi”, the “Qi deficiency” in clinical practice is the equivalencedeficiencies of Yin-qi and Yang-qi. So, it can be inferred that when treating thesyndrome of Qi deficiency, even without the medicine of tonifying Qi, butonly select the medicine of tonifying Yang and yin tonics, can also cure thesyndrome of Qi deficiency. This is obviously inconsistent with the clinicalprescription principle. Second, it is contrary to the Chinese medicine theory.For example, according to the theory of “Yin and Yang Qi”, qi-deficiency isthe peer to peer with asthenia of both yin-qi and yang-qi. So, according to thistheory, the function of conduct qi, which the qi medicine such as RhizomaCyperi possessed, is consist of two parts of the effect, that called activatingyang-qi and yin-qi. This understanding of Rhizoma Cyperi and any otherQi-medicine is opposite to the function, which the Chinese traditionalmedicine preferred. Third, it is at odds with the syndrome of “Deficiency ofboth Qi and Yin”. The scholars, who in favor of the “Yin and Yang Qi” theory,believe that due to the concept of “Qi” includes two aspects, which is called“Yin” and “Yang”, so Qi cannot formed the syndrome of deficiency of bothwith Yin or Yang. Therefore, the so-called syndromes “Deficiency of both qiand Yin” and "Deficiency of both qi and yang” belong to the paradox of logic.This inference is at odds with the present extensive consensus of TCM clinicalpractice. Fourth, it is inconsistent with the theory of pathogenesis. Such as thistheory thought that Qi consists of two parts, which is called “Yin-qi” and“Yang-qi”, Yang-qi possesses promoting, while Yin-qi owns serenity. The “Qi deficiency” in clinical practice is the equivalence deficiencies of Yin-qi andYang-qi. According to this theory, it can not explain the pathogenesis of “Qideficiency and blood stasis” reasonably. Because under the circumstance ofthe equivalence deficiencies of Yin-qi and Yang-qi, the descending ofequilibrant between the impetus of Yang-qi and the serenity of Yin-qi shouldnot cause the blood stasis. Accordingly, there is a contradiction between thistheory and the theory of pathogenesis.Forth part: The establishment of the “Qi is divided into three”hypothesis based on the generalized “Visceral-Qi”. The main content of the“Qi is divided into three” hypothesis: the generalized “Visceral-Qi” can beclassified as Zang-yin, Zang-yang and Zang-qi in the narrow sense, all thesecan be called the “Qi is divided into three”, for example, the generalizedHeart-qi can be divided into three parts, heart-yin, heart-yang and heart-qi inthe narrow sense, other four viscera can be deduced. The “Qi” in the “Qi isdivided into three” refers to the generalized “Visceral-Qi”, which is notgenerally used as the specific term in the academic exchange and clinicalpractice. When used as the specific term, it means the Zang-qi from thenarrow sense. For instance, without special instructions, the “Heart-qi” refersto the heart-qi from the narrow sense; the “Deficiency of heart-qi” in presentclinical practice means the deficiency of the “heart-qi” in the narrow sense.The Zang-qi, in the narrow sense, has the characters of moving andcontaining; the Zang-yin possesses the characters of moistening, serenity anddescending; the Zang-yang owns the characters of warming, exciting andascending.The related physiological functions what the hypothesis of “Qi isdivided into three” affects the five viscera can make the following briefdescriptions temporarily. As for the heart, the heart dominating blood circulation and vessels is accomplished by the heart-qi, in the narrow sense.The heart-qi, in the narrow sense, has the characters of promoting andcontaining, on one hand, it promoting blood circulation; on the other hand, italso containing blood circulate by the routine way. The warming and excitingcharacters of the heart-yang motivate and participate the promoting characterof the heart-qi, while the moistening and serenity characters of the heart-yinenhance and participate the containing character of the heart-qi. TheCoordination and balance of the heart-yang and the heart-yin, ensure thenormal heart rhythm fluctuations and the degree of vascular contractions. Asfor the lung, the function of governing respiratory qi is accomplished by thelung-qi. The promoting function of the lung-qi can exert the function ofgoverning respiratory qi by the means of inhale clear air and exhale turbidgases, while the containing function of the lung-qi can contain the inhaledclear air hiding in the body without getting dispersing. The warming andexciting characters of the lung-yang motivate and participate the promotingcharacter of the lung-qi, while the moistening and serenity characters of thelung-yin enhance and participate the containing character of the lung-qi. Thediffusion of the lung-qi includes diffusing upwards and dispersing outwardswhat the lung-yang guided and involved. The descent includes purifying anddescending means the lung-qi can go downwards and inwards what thelung-yin guided and involved. As for the spleen, the promoting function of thespleen-qi can exert the function of transportation and transformation of thespleen, while the containing function of the spleen-qi can containing bloodcirculate by the routine way. The warming and exciting characters of thespleen-yang motivate and participate the promoting character of the spleen-qi,while the moistening and serenity characters of the spleen-yin can contain thefunction of transportation and transformation of the spleen. The moistening and serenity characters of the spleen-yin enhance and participate thecontaining character of the spleen-qi, while the warming and excitingcharacters of the spleen-yang can contain the containing character of thespleen-qi. The function of ascent and dispersion of the spleen-qi guide andparticipate in the ascent of the spleen-yang that the positions of the internalorgans are kept relatively fixed, while the descending function of thespleen-yin contains the ascending. As for the liver, the promoting function ofthe liver-qi can smoothing qi dynamic, while the containing function of theliver-qi can storing blood. The warming and exciting characters of theliver-yang motivate and participate the promoting character of the liver-qi,while the moistening and serenity characters of the liver-yin enhance andparticipate the containing character of the liver-qi. The function of ascent anddispersion of the liver-yang motivate and participate the ascent and dispersionof the liver-qi, while the descending function of the liver-yin contains theascending. The containing character of the liver-yin enhance and participatethe function of storing blood, while the function of ascent and dispersion ofthe liver-yang could avoid the excess. As for the kidney, the growth anddevelopment of human body that the kidney dominate is accomplished by thekidney-qi, and the essence-qi in the kidney. The warming and excitingcharacters of the kidney-yang motivate and participate the function of humangrowth and development that the kidney-qi is dominated, while the moisteningand serenity characters of the kidney-yin could avoid the excess. The functionof store essence is accomplished by the containing character of the kidney-qi,the moistening and serenity characters of the kidney-yin enhance andparticipate the containing character of the kidney-qi, while the warming andexciting characters of the kidney-yang could avoid the excess. The function ofgoverning water is accomplished by the promoting function of the kidney-qi, the warming, exciting and ascending characters of the kidney-yang motivateand participate the promoting character of the kidney-qi, while the moistening,serenity and descending characters of the kidney-yin could avoid the excess.The function of kidney receiving respiratory qi is accomplished by thecontaining character of the kidney-qi, the moistening, serenity and descendingcharacters of the kidney-yin enhance and participate the containing of thekidney-qi, while the warming, exciting and ascending character of thekidney-yang could avoid the excess.The discussion content of this part including: the philosophicalfoundation of the “Qi is divided into three” hypothesis; the inspiration of thefoundation of the “Qi is divided into three” hypothesis which is based on theclassification method in Neijing; the accessorial explanation of the “Qi isdivided into three” hypothesis which is based on the syndrome of “Deficiencyof both Qi and Yin”; the disproval that the clinical medication to the “Qi isdivided into three” hypothesis.Fifth part: The normalized research on the syndrome of deficiency ofliver-qi, the syndrome of deficiency of liver-yang, the syndrome of deficiencyof lung-yang, the syndrome of deficiency of spleen-yin and the syndrome ofdeficiency of kidney-qi, all these are based on the “Qi is divided into three”hypothesis. According to the “Qi is divided into three” hypothesis, thesyndrome of deficiency of five viscera should have the existence of suchsyndromes, such as,“the deficiency of liver-yang”,“the deficiency of liver-qi”,“the deficiency of lung-yang”,“the deficiency of spleen-yin”,“the deficiencyof kidney-qi”. But, there has no records of these syndromes in variousversions textbooks of diagnostics of traditional Chinese medicine, which ispublished already. Although there has scattered discussion in bibliographicalinformations of clinical traditional Chinese medicine, but it still lack of systematic arrangement and establishment so that the syndrome differentiationsystem of five Zang-Viscera deficiency is incomplete. In this paper, the “Qi isdivided into three” hypothesis as the theoretical basis to begin for thestandardized study from such aspects as the theory origin, clinicalmanifestation and prescription, in order to improve the viscera deficiencysyndrome system.ResultSince2003, the planning textbook of Fundamental Theory ofTraditional Chinese Medicine is included and adopted the so-called theory of“Yin and Yang Qi”, that is existed among three continuous editions (which iscommonly known as the seventh edition, the eighth edition and the ninthedition of planning textbook). The theory of “Yin and Yang Qi” has positivesignificance in rectify the confusion between “yin-deficiency” and “blooddeficiency”;“yang deficiency” and “qi deficiency”. However, the theory itselfalso brings new confusions, such as it denied the objective existence of thesyndrome, which is called “deficiency of both qi and yin”; moreover, it cannotexplain the pathogenesis of “blood stasis due to qi deficiency” perfectly and soon.This research considers that the theory of “Yin and Yang Qi”, whichthe planning textbook of Fundamental Theory of Traditional ChineseMedicine maintained, is inconsistent with the general principles of clinicalprescription and also contrary to the theory of pathogenesis and the theory ofChinese medicine. It is more difficult to gain broad consensus due to thedenial of the objective existence of the syndrome, which is called “deficiencyof both qi and yin”. All these above are the results of applying the Yin-YangTheory’s thought of “One divides into two” mechanically and neglect theclinical practice, so it cannot guide the clinical practice effectively and can cause clinical practice confusion easily. All these need reevaluation andimprovement.This research believes that if the reconsideration of Qi of the five-viscera,which is based on the establishment of the “Qi is divided into three”hypothesis based on the generalized “Visceral-Qi”, it can achieve the originalpurpose that the theory of “Yin and Yang Qi” correct the previous confusion ofconception; and also can rectify the new confusion which the theory of “Yinand Yang Qi” brings. The hypothesis of “Qi is divided into three” considersthat the generalized “Visceral-Qi” can be classified as Zang-yin, Zang-yangand Zang-qi in the narrow sense. The Zang-qi which is from the narrow sense,belongs to the neutral part of the generalized “Visceral-Qi”, possesses thecharacters of promoting and containing; Zang-yang belongs to the positivepart of the generalized “Visceral-Qi”, owns the characters of warming,exciting and ascending; while the Zang-yin possesses the characters ofmoistening, serenity and descending. Zang-qi which is in the narrow sense,Zang-yin and Zang-yang are under the same material level, the connotationsof them are independent and contradictory, while they can coordinate witheach other closely in exerting the physiologic function of the five-viscera. Theexerting of the physiologic function of the five-viscera is mainly depend onthe Zang-qi, which is from the narrow sense, its characters of promoting andcontaining achieve the physiologic function of the viscera, while in themeantime, it also closely cooperate with Zang-yin and Zang-yang. Thewarming and exciting characters of Zang-yang motivate and participate thepromoting character of Zang-qi; while the moistening and serenity charactersof Zang-yin strengthen and participate the containing character of Zang-qi.They separate as three, combine as one, are closely connected. Theharmonious coordination of each other accomplish the physiologic function of the five-viscera together, attributes to the comprehensive function of thegeneralized visceral-qi.ConclusionOn the research of the classification method of the visceral-qi, the theoryof “Yin and Yang Qi” should be replaced by the “Qi is divided into three”hypothesis.更多还原