【作者】 李清；

【导师】 潘桂娟；

【作者基本信息】 中国中医科学院 ， 中医基础理论， 2010， 博士

【摘要】 “郁”是中医理论的重要概念,郁证是中医临床的常见病证。中医学有关“郁”的理论认识经过历代医家的不断发挥和创新,形成了丰富的学术思想和临床诊疗经验。本文在梳理中医学“郁”的理论源流的基础上,综合提炼出中医学“郁”的基础理论。1中医学“郁”的理论源流此项研究,梳理了秦汉至明清时期中医医籍中关于“郁”的理论论述和临床医案,总结了不同历史时期医家对“郁”的理论及其治法方药等方面的不同认识特点和创新发挥,明确了中医学“郁”理论的学术源流。秦汉时期——系统阐发运气之郁秦汉时期中医典籍中对“郁”的论述充分体现了气化的观点,内容主要集中在天地自然气化和人体疾病过程两个不同的层面。前者包括运气异常致郁、天地之间气机升降出入失常等内容。后者则多为对与“郁”相关的症状和病机的描述。三国两晋南北朝时期——发展病机理论魏晋南北朝时期社会动乱不安,当时的中医书籍流传至今者较少,现存文献中所见大多是转引《伤寒论》和《金匮要略》中关于“郁”的论述,书中记载了治郁方药,对“郁”的病机理论有所发展。隋唐时期——拓展治法理论隋唐时期中医典籍对“郁”的论述较秦汉魏晋时期有所扩充,并从具体治法方面拓展了五郁之治的内容。医家将壅积不泄的气机异常状态,扩充到对自然环境的认识当中,扩大了“郁”的概念范畴；疾病病机方面,认识到脾胃内伤导致湿热内郁而发病。此外,疾病病因方面,开始出现情志致郁而为病的论述。两宋时期——扩充治疗方药这一时期医家将《黄帝内经》以来的运气理论加以运用,提出了相应的方药及加减变化。疾病病因方面,认为内因七情与“郁”的关系最为密切,与此前文献对情志之郁的零散记载形成鲜明对比。疾病病机方面,医籍中论及的病机与“郁”相关的病证范围较前代大大扩充。金元时期——各家理论发挥金元时期医家多注重将《黄帝内经》的五郁之治运用于人体疾病的治疗,尤其是从气机升降出入的角度对五郁之治进行阐发和运用。也有医家以人体自身为主,对“郁”进行分类。有的医家则受理学的影响,开始探求“郁”的本源。明代——创新发展理论这一时期的医籍大多单列“郁证”一门,对其理法方药进行全面总结,明确界定五郁之治的运用范围,完善六郁的脉症治方,出现了“郁”的不同分类方法。此外,情志之郁已经逐渐成为郁证的重要内容,并出现以脏腑名称命名的郁证。清代——丰富病机治法理论这一时期的医家,从五行角度对五郁之治进行阐发,还创造性地将五郁之治运用于对药物性味和外治法的选择运用,明确了“郁”的不同分类,总结治疗郁证的用药细节,并从“郁”探讨伤寒和温病病机。随着疫病出现和医家对其认识的发展,从“郁”认识疫病发病规律及其治疗用药都得到了相应的发展。2中医学“郁”的基础理论中医学“郁”的理论,是在长期同疾病作斗争的经验基础上,结合中国古代的哲学思想逐渐形成和总结出来的,内容包括天地自然之郁和人体之郁。在人体则具体表现为气血津液之郁、脏腑之郁、经络之郁等。“郁”的概念中医学“郁”的内涵,是指在气机升降出入失常的条件下,形成的以“结聚而不得发越”、“抑而不通”等为特点的一种状态。基于中医的气化观,本文提出,中医学“郁”概念的外延主要包括三个范畴的内容,即天地自然气机之郁、天地自然影响人体所致之郁以及人体自身气机之郁。在现代中医学理论中,郁证多被认为与情志相关,此为狭义之“郁”。本文所论述的郁证是指以气机升降出入失常为基础病机的证候。郁证病机的基本特点笔者认为,郁证的基本病机是气机不畅,其转归易于化火,其与虚证之间互为因果,可以相互转化,且临证常见各种郁证兼夹为病。脏腑之郁的病机特点脏腑之郁,常在气机不调的基础上,兼见与该脏腑功能密切相关的病机特点。五脏之郁偏于气机壅塞,六腑之郁多偏于饮食消化障碍。肝郁首先影响气机的运行,进而影响血液运行、津液敷布及饮食运化等。胆郁则实证多于虚证,多见火热煎熬津液成痰。脾郁以脾气壅塞导致饮食、津液代谢紊乱为主,多见于气分。胃郁以食气互郁为基本病机,常见胃郁不降,或肠胃郁结不通,久则化为郁火。肺气壅郁而失于宣降,则水液输布排泄障碍,生痰或成饮,日久可影响心主血脉的功能。大肠传导无力而郁阻,多郁积成热化火潜毒。肾郁则气必不宣,主要影响气机运行和水液代谢。膀胱之郁以气郁为主,易化热化火。心气郁则血行不利,神志不明。小肠之气郁结不通或小肠郁火,不能泌清别浊,则水谷不化,精微混杂而下。情志之郁最能影响全身脏腑经络、气血津液的运行,其在妇人尤多。从发病病机上看,七情之郁主要可分为三类：一为怒郁,大怒气逆之时,实邪在肝。怒后逆气已去,惟中气受伤。二为思郁,思则气结于心脾,病甚上连肺胃,下连肝肾。三为忧郁,多因衣食之累,利害之牵,及悲忧惊恐所致。悲则气消,忧则气沉,惊则气乱,恐则气下,多属虚证,初郁之时即平调而不消散。郁证的治疗原则郁证的治疗原则是,调气为先、审因论治、移情易性。情志之郁当先调摄情志,继以药物调畅脏腑气血；杂病之郁当以药物治疗为主,辅以调畅情志。脏腑之郁的治疗肝胆之郁“轻者可降,重则从其性而升之”,治疗宜急疏肝胆之本气,兼滋其阴血。脾胃之郁“当攘而夺之,以复其健运之常”,治疗宜疏通其土,使脾胃之气升腾则郁气可解。肺与大肠之郁“当疏而泄之,以肃其清降之常”,治疗宜泄肺金之气,并大补肾水,水足则心火不再犯肺,故补肾水即泄肺金。肾与膀胱之郁“当决而折之,以导其东归之常”,治疗要于水中补火,火足而水自旺,水旺则不郁。心与小肠之郁“当发而越之,以返其自然之常”,治疗宜解心包之郁火。情志之郁初起伤气,继而及血,不可治以消散,应治以苦辛凉润宣通。除汤药外,还多用艾灸、饮醇酒、怡情、以情胜情等法治疗。郁证的预防“法于阴阳,和于术数,食饮有节,起居有常,不妄作劳”,可以预防脏腑经络之郁。七情有度,心胸开阔,避免情志刺激和忧思过度,可以预防情志之郁。运气之郁常影响人体而致郁,必要时可以用针刺补虚泻实,解郁而防病。经过历代医家的不断创新发挥,中医学“郁”的理论逐渐丰富,在临床实践中发挥着重要的指导作用。现代中医学对“郁”的理论缺乏系统阐发,郁证的狭义化也不利于中医学“郁”的理论在当今临床发挥指导作用,希望通过本文对中医学“郁”的理论的系统研究和深入阐发,拓展和深化医者对“郁”的理论认识,促进郁证临床诊疗实践的发展。更多还原

【Abstract】 Depression is an important concept in the basic theory of Chinese Medicine, and depressive syndrome is very common in clinic. This article refines the depression theory in Chinese Medicine based on its historic origin and development.In Qin and Han Dynasty, the discussion on depression fully reflected Qi transformation, which included the nature, human body and the food. In Wei and Jin Dynasty, depression was related to the pathogenesis of diseases. In Sui and Tang Dynasty, the concept and category of depression were expanded and there were discussions on emotional depression as an etiological factor.In Song Dynasty, doctors put forward the corresponding prescription to treat the depression of Five Evolutive Phases and Six Climatic Factors. Diseases related to depression in medical books were greatly expanded. In Jin and Yuan Dynasty, doctors began to classify the human body’s own depression and some physicians began to explore the nature of depression.In Ming Dynasty, doctors clearly defined the application scope of Five Depression, and there were different classification of depression. Emotional depression became an important content in medical books, and some depressive syndromes were named with Zang viscera and Fu viscera.In Qing Dynasty, doctors illustrated the Five Depression based on the nature of five elements, and applied creatively on the external treatment. The classification of depression was clarified and doctors discussed various diseases from depression.Through the historical research of literature, we can conclude that the connotation of depression is related with abnormal and unsmooth Qi movement. Depressive syndrome can appear in many diseases. The extension of depression contains the depression of nature, the depression of human body caused by the nature, and the depression of human body itself.The character of depressive syndrome’s pathogenesis is unsmooth Qi movement, which is easy to turn to be fire. Depressive syndrome and deficient syndrome are reciprocal causation. It is very common for several kinds of depression existing at the same time in clinic.The pathogenesis of Zang viscera and Fu viscera depression are as follows, which are closely related with the function of Zang and Fu viscera. Five Zang viscera depression emphasizes on Qi depression, while Six Fu viscera emphasizes on abnormal digestion. Liver depression influence Qi movement first, and Blood, Fluid movement and digestion can be influenced later. Gallbladder depression is characterized by phlegm fire. Spleen depression influences digestion and Fluid movement. Stomach depression is characterized by stagnated Qi and food, which is easy to turn to fire. Lung depression influences body Fluid movement mostly, which can cause phlegm or influence blood movement. Large intestine depression always cause fire or turn to toxin. Kidney depression always influences Qi and Blood movement. Bladder depression causes Qi stagnation, which is easy to turn to heat or fire. Heart depression influences blood movement and mind. Small intestine depression is characterized by pain near umbilicus, upset, mouth and tongue sores.Emotional depression can influence Qi, Blood and Fluid movement of Zang and Fu viscera, which is very common for women. Anger is related to liver, anxiety cause spleen Qi stagnation, and melancholy consumes Qi.Qi, Blood and Fluid depression, Zang viscera and Fu viscera depression, meridians and collaterals depression, emotional depression are always influenced by each other, which should be combined in clinic.Therapeutic principles of depressive syndrome are regulating Qi, treating differently according to different reason, and adjusting emotion. Zang and Fu viscera depression can be treated with dissipating medicine, while the treatment for emotional depression is different. According to the doctrine of five elements, the treatment of liver and gallbladder depression can be facilitating the stagnant wood. The treatment of spleen and stomach depression can be eliminating the stagnant earth. The treatment of lung and large intestine depression can be purging the stagnant metal. The treatment of kidney and bladder depression can be draining the stagnant water. The treatment of heart and small intestine depression can be dissipating excessive stagnation of fire. The prevention of depressive syndrome is proper diet, daily life and emotion. Acupuncture can prevent human body from nature depression.In conclusion, depression theory in Chinese Medicine plays an important role in guiding clinic treatment. Hope this article can deepen doctors’recognition of depression and develop the treatment of depressive syndrome.更多还原