“肝苦急急食甘以缓之”本义探讨及临床意义研究

【作者】 赵旻；

【导师】 张保春；

【作者基本信息】 北京中医药大学 ， 中医基础理论， 2009， 硕士

【摘要】 《素问·藏气法时论》基于天人相应思想提出“肝苦急,急食甘以缓之”的肝证治则。与“肝欲散,急食辛以散之”和“用辛补之,酸泻之”被后世医家尊为《黄帝内经》治肝三大法则。《素问·阴阳应象大论》云:“风气通于肝”,《素问·至真要大论》亦云:“诸风掉眩,皆属于肝”。肝为厥阴风木之脏,内寄相火,其性急,急则有化火生风之变。盖“肺气不降,肾气不摄,冲气胃气又复上逆”,皆可导致肝之气化上升太过,而成“肝苦急”之证。“肝苦急”病证复杂多变,故而治疗当“急食甘以缓之”,盖甘味药物善于缓急,且能温养脏腑。临床上治疗“肝苦急”病证当以甘味药物为主,配伍其它药物,例如:辛甘寒药物善于佐金平木、甘温药物善于扶土制木、甘寒濡润药物善于滋水涵木。针对不同病机,辨证施治,可复肝之条达之性。论文正文分为五个部分。第一部分为“肝苦急”本义探讨。通过整理和分析古代文献资料中“肝”、“苦”、“急”的含义,并结合历代医家有关“肝苦急”的论述,本文得出《素问·藏气法时论》中“肝苦急”的两种基本病理变化:肝升太过和肝血不充。第二部分为“肝苦急”因症分析。此部分在本义探讨的基础之上,对造成“肝苦急”的病因病机、病理演变特点以及临床表现分别进行了深入的总结和讨论。其中,“肝苦急”的病因病机包括:气候因素、木郁生风、木郁化火、七情所伤、阴血耗伤风阳相煽、过用温燥扰动肝阳、过用升散引动肝风、胆胃不降肝阳独升、外感风热引动肝风、脾肾衰惫肝从邪化。“肝苦急”病理演变特点包括:肝乘脾、肝侮肺、肝火耗伤肝血、肝阳内盛煎津为痰。“肝苦急”临床表现包括:中风、眩晕、神志病、咳嗽、呕吐、厥阴热痢、泄泻、胃脘痛、吐血、鼻衄、咳血、呃逆、喉痹、痉厥、妊娠恶阻、崩漏、堕胎、小产、瘰疬瘿瘤,涉及内科、妇科、外科共计十九种疾病。第三部分为“急食甘以缓之”本义和临证应用。酸、苦、甘、辛、咸五味各有所主,各有所入,各自具备独特的临床药用价值,正如《素问·脏气法时论》所云:“辛散、酸收、甘缓、苦坚、咸软。”甘味药物善于缓急,又能温养脏腑,在治疗“肝苦急”病证中的作用不可忽视。本部分将“急食甘以缓之”的治疗法则归纳总结为辛甘化风法、甘温实脾法和甘寒育阴法三大类,并从理、法、方、药各个层面展开探讨,并于每法后附以名家验案,以期为临床遣方用药提供指导。第四部分为“肝苦急,急食甘以缓之”处方用药的统计分析。本部分以《临证指南医案》和《名医类案》做为资料来源,从中筛选符合“肝苦急”病机的医案,对这些医案所用处方中的用药频率进行数据统计分析,以期找出“急食甘以缓之”对于治疗“肝苦急”类疾病的临床指导意义和具体用药规律。统计结果显示《临证指南医案》治疗“肝苦急”的处方中,甘寒(清热养阴生津)药的使用频率最高,使用频率达到了27%。此类药物按使用频率由高到低依次为:生地、天冬、麦冬、石斛、玄参、龟甲。甘味(养血补阴)药物使用频率排在第二,为19%,此类药物包括了阿胶、枸杞、制首乌、熟地、当归、黑豆皮六味药物。以上两类药物的使用频率总数与其它类别药物差异显著,这充分反映了叶氏对于“肝苦急”病证的认识,即“肝为风脏,因精血衰耗,水不涵木,木少滋荣,故肝阳偏亢,内风时起”,同时,本部分的统计分析结果更为叶氏“治以滋液熄风,濡养营络,补阴潜阳”的治法原则提供了佐证。对于《名医类案》的统计结果显示《名医类案》中治疗“肝苦急”病证,以甘味补气药的应用频率为最多,包括甘草、人参、白术、黄芪四味药物。使用频率排名第二位的一类药物是辛温理气化痰药,包括陈皮、半夏、生姜、南星四味药物。这种用药规律体现了明代以前的医学中,重阳思想的深入影响和用药以温燥为主的特点。第五部分为本文的结语和讨论。本文从探讨《素问·藏气法时论》中“肝苦急,急食甘以缓之”本义入手,借助文献学和医学统计学研究方法,从历代中医学典籍中,提炼出“肝苦急”的基本病机为:肝升太过和肝血不充。并且详细归纳整理总结出“肝苦急”之病因、病机和临床表现。在“肝苦急”病证的治疗方面,本文以“急食甘以缓之”为切入点,结合名家验案和作者自身临床体会,详细论述此类疾病的诊疗特色,以及名家审证求因的思维过程,最终达到为临床服务的目的。研究中医理论,有必要返本归原,在回归历史的前提下对该理论的本义进行探讨,发掘概念内涵,并紧密结合临床实际,对是否符合中医理论原旨作出判断和辨析。只有在较为全面把握概念的基础上,才能更好地发挥理论对临床的指导作用,从而切实为提高临床疗效服务。更多还原

【Abstract】 According to the correspondence between nature and human,"Plain Questions—Study on time and method of Visceral Qi’s nurturing" said that spasm does harms to the liver,thus one should take something sweet at once to relieve it.This therapeutic principle,together with the rules that "Since the liver like being unconstrained,one should take something pungent to sooth it" and that "Taking something pungent to reinforce it and taking something sour to discharge it",is respected by the doctors at the late ages as the tree methods of the liver therapy in "the Yellow Emperor’s Internal Classic"."Plain Questions—Study on corresponding signs of Yin-yang" said, "The wind and liver share some basic natures".And the "Plain Questions" also said,"syndromes characterized by shaking,dizziness and vertigo induced by wind are all related to the liver." Liver is a viscera of wind-wood and reverting yin and It stores ministerial fire.It’s impatient and this impatience could be transformed into fire and wind easily."the lung qi failing to bear downward,the kidney failing to receive qi,and the stomach qi ascending counterflow",all of these could induce ascendant hyperactivity of liver qi and finally become the syndromes that "spasm does harms to the liver".The method of treatment of those syndromes should be "taking something sweet at once to relieve it" since the sweet herbal is good at relieving spasm,and it also does well in nourishing the viscera and bowels. The pungent,sweet and cold herbs are good at treating the metal to subdue the wood.Then the sweet and warm herbs are good at strengthening the earth to constrain the wood.And the sweet,cold and moist herbs are good at enriching the water to nourish the wood.If it could be diagnosed and treated on the basis of syndrome differentiation,the liver could return to its nature of being unconstrained.This thesis includes five parts.The first part is a discussion on the original meaning of "gan ku ji". According to the definition of "gan" "ku" "ji" in the ancient literature and the discussion on "gan ku ji" of physicians of past generations,the author get its connotation from its extension.It’s embodied in two kinds of pathological mechanism,i.e.over ascending of liver qi and lack of liver blood.The second part is the analysis on etiology and syndromes of "spasm does harms to the liver".On the basic of the study results of its original meaning, this part has made a profound conclusion and discussion on its etiology and pathogen(including climate factors,depressed wood engendering wind, depressed wood transforming into fire,hurt by seven emotions,mutual inducing of wind and yang due to the depletion of yin blood,liver yang harassed and stirring for abusing warm-dry medicinal,liver wind induced by abusing ascending and dispersing medicinal,fail to descend gallbladder-stomach qi with liver yang ascending,liver wind induced by external contraction of wind-heat,evil qi invading into liver due to the deficiency of spleen and kidney),its characteristics of pathologic changes(including liver overwhelming spleen,liver rebelling lung,liver fire depleted liver blood, internal exuberant liver yang blazing the fluid into phlegm) and its clinical performance(including 99 diseases related to surgery,internal medicine and gynecology such as stroke,dizziness,spirit-emotion disease,cough,vomiting, dysentery cause by reversal yin,diarrhea,pain in stomach duct,hematemesis, epistaxis,hemoptysis,hiccupping,throat block,spasm and reversing,morning sick,metrorrhagia and metrostaxis,abortion,miscarriage and scrofula)The third part is about the original meaning and clinical application of the theory "ji shi gan yi huan zhi".That each of the sour,the bitter,the sweet,the pungent and the salty has its own function and distinctive medical value in clinic has been known to the traditional Chinese medicine for a long time,just as it’s mentioned in "Plain Questions—Study on time and method of Visceral Qi’s nurturing" that "The pungent has the function of dispersion; the sour has the function of astringency;the sweet has the function of relief; the bitter has the function of preserving;and the salty has the function of softening." Since the sweet herbal is good at relieving spasm,and it also does well in nourishing the viscera and bowels,it plays a key role in the treatment of the disease "spasm does harms to the liver" According to that, this part classified the method of the treatment that "taking the sweet medicinal at once to relieve the harms to liver done by spasm" into three kinds:Dispersing the wind with pungent-sweet herbs;strengthening the spleen with sweet-warm herbs;nourishing the yin with sweet-cold herbs.According to this classification,the author discussed them from four aspects of theory, method,formula,and drugs followed with proved cases of famous physicians in order to make it could actually serve for the clinical practice.The forth part is the Statistical Analysis of the medication in those formulae guided by the theory "spasm does harms to the liver,thus one should take something sweet at once to relieve it".Taking "A Guide to Clinical Practice with Medical Records" and "Classified Medical Records of Famous Physicians" as data sources,from which the author chose the cases whose pathogen are fit for "spasm does harms to the liver" and does a Statistical Analysis on their frequency of medicinal in formulae in order to find out the guiding significance of the theory "one should take something sweet at once to relieve the harms to liver done by spasm" and the rules of medicating in the treatment of this kind of disease.The final results indicated that in those formulae who treat the disease that "spasm does harm to liver",the sweet-cold substances whose function is clearing heat,nourishing yin, engendering fluid were used most with a use rate of 27%.According to their use frequency,the substances belong to this categorization were listed as following from top to low:shengdi,tiandong,maidong,shihu,xuanshen and guijia.Then,with a use rate of 19%,the sweet medicinal whose function is nourishing blood and yin were taken as the second most used medicinal, including ejiao,gouqi,zhishouwu,shudi,danggui and heidoupi.The obvious difference use frequency between the two mentioned categorization above and others completely revealed Ye’s understanding on disease and pattern as "spasm does harm to liver",namely,"liver is a wind viscus,and due to the depletion of essence and blood,the water fails to nourish the wood,thus liver yang hyper activates and internal wind induced." Over more,the results also gave evidence to Ye’s therapeutic principle:"nourishing humor and distinguishing fire,moistening and nourishing nutrient aspect and collaterals,nourishing yin and descending yang ".While the results of formulae from "Classified Medical Records of Famous Physicians" used to treat the same disease showed that the most used medicinal were the sweet, qi reinforcing substances,mainly including gancao,renshen,baizhu,huangqi. And the second most used medicinal were the pungent-warm,qi regulating and phlegm resolving substances,including chenpi,banxia,shengjiang,nanxing. This rule of medication had reflected the profound influence of the thought giving prominence to yang and the medicating method characterized by mainly using the warm-dry substances in Chinese medicine before Ming dynasty.The fifth part is a conclusion and discussion of this thesis.Beginning with the original meaning of "gan ku ji,ji shi gan yi huan zhi"(from "Plain Questions—Study on time and method of Visceral Qi’s nurturing"),with the help of study method in Documentation Science and medical statistics,from those ancient traditional Chinese medical(TCM) literatures,this thesis finally got a conclusion of etiology of the disease "spasm does harms to the liver",i.e.over ascending of Liver Qi and lack of liver blood.And it also got a specific conclusion of its etiology, disease mechanism and clinical performance.Then,on the aspect of it disease and pattern,taking the theory "one should take something sweet at once to relieve the harms to liver done by spasm" as a cut-in point,combined with the proved cases of famous physicians and the author’s personal clinical experience,this thesis discusses in detail the therapeutic characteristics and the thinking process of famous physicians in diagnosing the pathogenic factors based on the differentiation of syndromes in order to make sure that it could finally serve for the clinical treatment.It’s necessary to return to the root in the study of TCM theory.One should discuss the original meaning of the theory and find out its concept connotation,and at the same time,should combine it closely with the clinical practice to make a judgment and analysis on whether it could match the theory well or not.Only if one could comprehensively master the concept,one could really put the theory into practice very well and could really get the clinical therapeutic effect improved.更多还原