本文關(guān)鍵詞：從圓運動氣機升降理論探討桂枝湯類方的證治規(guī)律　出處：《廣州中醫(yī)藥大學》2017年博士論文　論文類型：學位論文

  更多相關(guān)文章： 桂枝湯類方 圓運動 氣機升降 傷寒論

【摘要】：《傷寒論》作為中醫(yī)界最重要的經(jīng)典著作之一,自成書以來,一直都是歷代醫(yī)家學習和研究的熱點。從理論到臨床,從考據(jù)到藥理,《傷寒論》幾乎每個字都被學者研究過,隨著研究方法的更新及研究思路的拓展,大家仍在孜孜不倦的挖掘著,以期更好的理解和闡述這一中醫(yī)學的寶貴財富,更好的指導臨床;盡管如此,我們?nèi)圆荒芡笍氐睦斫庠摃拿恳粋�問題。對于《傷寒論》中的方藥,用"類方"的方法,可以劃分為桂枝湯類、麻黃湯類、承氣湯類、柴胡湯類、四逆湯類等十余種,桂枝湯作為《傷寒論》的第一方,盡管人們對桂枝湯類方做了大量的研究,但筆者仍希望能從一個新的角度來研究它,以期有不一樣的發(fā)現(xiàn),能更好的解讀并應用于臨床。近年來"圓運動"理論越來越受到中醫(yī)學者的重視,本文試圖以圓運動的氣機升降理論作為切入點來解析桂枝湯類方的證治規(guī)律。本文采用文獻研究的方法,以圓運動氣機升降理論作為切入點,用氣機升降的理論來分析總結(jié)桂枝湯類方的證治規(guī)律。本文搜集了與圓運動理論相關(guān)的研究文獻,對其理論進行概括、分析、提煉、總結(jié),重點闡述圓運動的氣機升降理論。結(jié)合圓運動理論來分析《傷寒論》桂枝湯類方的方義、原文、應用等,并系統(tǒng)總結(jié)現(xiàn)代中醫(yī)學者運用桂枝湯類方(從圓運動理論切入)的臨床經(jīng)驗,分析他們的典型醫(yī)案,以期得出圓運動理論指導下桂枝湯類方的證治規(guī)律。本論文分為四部分,分別為圓運動理論研究、氣機升降理論研究、桂枝湯類方研究及當代醫(yī)家應用桂枝湯類方的經(jīng)驗及典型醫(yī)案分析。第一部分是圓運動理論研究,旨在探討研究圓運動理論認識源流及主要學術(shù)觀點。圓運動理論源于《周易》的河圖、洛書、先天八卦、后天八卦;此后的《黃帝內(nèi)經(jīng)》(以下簡稱《內(nèi)經(jīng)》)及《傷寒論》均有圓運動理論的繼承;到清代的黃元御和鄭欽安,本理論得到進一步發(fā)展;至民國名醫(yī)彭子益撰寫成《圓運動的古中醫(yī)學》,正式提出"圓運動"一詞,標志著圓運動理論的成熟。需要指出的是,黃元御和鄭欽安的圓運動理論的立足點不同,黃氏側(cè)重于中土圓運動,鄭氏則側(cè)重水火圓運動。彭子益汲取歷代醫(yī)家的的研究經(jīng)驗和學術(shù)精華,著有《圓運動的古中醫(yī)學》,著中用圓運動理論闡述天地的圓運動規(guī)律,并推及人體生理及病理,涵蓋陰陽、五行、六氣、十二經(jīng)絡(luò)、二十四節(jié)氣圓運動理論,創(chuàng)立以五臟為核心的圓運動體系,并用圓運動理論解析《傷寒論》的六經(jīng)用藥。第二部分是氣機升降理論研究,旨在對氣機的升降理論進行系統(tǒng)研究。氣機升降浮沉理論是圓運動理論的重要組成部分,"浮"是氣"升"至極,"沉"為氣"降"至極。升降出入,作為人體氣機運行的主要形式,如果明白氣機升降的道理,同樣可以明白人身的生理,也可以明白人身的病理。氣機升降浮沉理論起源于先秦時期的《內(nèi)經(jīng)》。中醫(yī)先哲認為,物質(zhì)組成宇宙,物質(zhì)存在之根本形式為運動。氣是宇宙最原始的物質(zhì),是構(gòu)成天地萬物的最小單元。把宇宙物質(zhì)的運動變化歸于一氣的升降,這是氣機升降理論樸素的唯物觀。醫(yī)圣張仲景繼承并發(fā)展《內(nèi)經(jīng)》的基本學術(shù)觀點,在《傷寒論》中記載較多的由氣機升降失常導致的各種病證。時至金元時期,名醫(yī)輩出,開創(chuàng)中醫(yī)學術(shù)爭鳴的繁榮局面,對氣機升降理論的闡述,則是見仁見智,各位醫(yī)家從不同的角度發(fā)展氣機升降理論的主要內(nèi)容。其中,張子和以吐法來論氣機升降,臨證以攻邪為主,倡導吐汗下法,而其吐法,尤有創(chuàng)見。到了明清時期,對氣機升降理論的發(fā)揮運用頗多,從而推動了氣機升降理論的普及與發(fā)展。在《傷寒論》中,氣機升降理論的應用包括:脾胃升降、心腎升降、肝膽升降、肺腎升降、脾肺升降。氣機升降理論與六經(jīng)病的關(guān)系如下:太陽病側(cè)重于營衛(wèi)出入之失調(diào),陽明病側(cè)重于陽土(戊土)之氣的失降,少陽病側(cè)重于樞機不暢,太陰病側(cè)重于陰土(己土)之氣的不升,少陰病側(cè)重于水火升降之失常,厥陰病側(cè)重于氣血升降之逆亂。第三部分是桂枝湯類方研究,旨在對桂枝湯類方的證治規(guī)律進行系統(tǒng)研究。首先對桂枝湯類方進行梳理,以確定本文研究的桂枝湯類方范圍,本課題中,選擇與大多數(shù)醫(yī)家相一致的觀點,在劉渡舟教授和熊曼琪教授所選擇的21方的基礎(chǔ)上,選用臨床最常見最典型的十個方劑作為研究對象。此次所選十個方劑的組方中均包含了桂枝湯中的桂枝、芍藥、生姜、大棗、炙甘草五味基本藥物,而去桂枝、去芍藥之類方并未納入研究,十個方劑分別為:桂枝湯、桂枝加葛根湯、桂枝加附子湯、桂枝加厚樸杏子湯、桂枝加芍藥生姜各一兩人參三兩新加湯、桂枝加桂湯、桂枝加芍藥湯、桂枝加大黃湯、小建中湯、桂枝麻黃各半湯。本部分主要運用圓運動理論對桂枝湯類方從方義及條文兩部分進行論述。桂枝湯是桂枝湯類方的基礎(chǔ)方,桂枝辛溫,升人體之陽,主升;芍藥酸苦寒,主收斂,主降;桂枝、芍藥一升一降,自成一圓運動,生姜、大棗、甘草同主中州,顧護中土,穩(wěn)固圓運動之中軸;桂枝、芍藥一升一降,輔助中土調(diào)暢氣機,調(diào)和營衛(wèi)。桂枝加厚樸杏子湯,桂枝加厚樸杏子湯證主要是斂降之力不足,故加厚樸,厚樸對應于西方的肅降之性;杏仁,其色白,味苦,主入肺、大腸經(jīng),苦則降泄,可助西方金氣下降,兼有潤腸通便之效。一方面可以肅降西方上沖之氣,另一方面可以調(diào)理胃氣,中土氣機升降調(diào)和,有助于東方之氣的上升與西方之氣的下降。一方面調(diào)暢圓運動之軸的氣機,一方面順應于西方氣機的肅降,以制約氣機上沖之勢。桂枝新加湯,桂枝新加湯證為氣血不足,營陰消耗之后,可知身疼痛為氣血不足以濡養(yǎng)經(jīng)脈所致,在桂枝湯原方基礎(chǔ)上加人參,人參有"補五臟"之功(《神農(nóng)本草經(jīng)》),增強補中之力,可使圓運動之軸更加穩(wěn)固,將生姜、芍藥的用量從三兩增加到四兩,加重生姜的用量可以提高中焦脾胃的運化之力,穩(wěn)定圓運動之軸,以化生氣血;增加芍藥的用量則加強了收斂的功效,以養(yǎng)陰生津。小建中湯,小建中湯證主東方木氣疏泄不利,中央脾土虛弱,木氣橫犯中土,倍用芍藥,一方面可以柔肝緩急,另一方面芍藥與炙甘草、大棗相配,酸甘化陰,以養(yǎng)血和營。飴糖氣味甘溫,歸脾、胃、肺經(jīng),具有補中益氣、緩急止痛、潤肺止咳的功效。方中加入飴糖一升,以補中益氣,恢復中氣,固護中央土氣,調(diào)和東方木氣的疏泄。桂枝加葛根湯,桂枝加葛根湯證中加用的葛根為陽明經(jīng)主藥,可宣達陽明中土之氣,而又外合于太陽經(jīng)脈,足陽明胃經(jīng)主降濁,經(jīng)氣降則熱氣降;足太陰脾經(jīng)主升清,葛根可助人體陰氣的上升,恢復軸樞的升清降濁功能,解除陽明經(jīng)氣不利的情況。桂枝加附子湯,桂枝加附子湯證中加用的附子主溫陽,可溫散人體一切陰寒之氣,溫養(yǎng)心腎,恢復身體左升的功能,陽氣能自東方左升,就能在西方肅降;此外,附子溫脾陽、散寒濕,可恢復四維和軸樞之力。桂枝加桂湯,桂枝加桂湯證中重用桂枝至五兩,主要是取其"降逆氣、降沖氣"的作用。加之芍藥收斂的功用,人體陽氣才能有序下降,肝氣條達,上逆之氣也終得復歸其位。另外,方中生姜、大棗、炙甘草三味藥同主中洲,增強中焦脾胃之氣,中焦斡旋之力得以復原,從而共同平復沖氣。桂枝加芍藥湯,桂枝加芍藥湯證乃太陽病誤下所致,芍藥可以"主邪氣腹痛",本方中增加了芍藥的用量,增強了右降的力量,用于收斂橫逆中土的肝木之氣,使逆氣循正道而行。桂枝加大黃湯,桂枝加大黃證是太陽病誤下寒入太陰之后,形成有形之實邪結(jié)聚之腹痛。本方在桂枝加芍藥湯基礎(chǔ)上加用大黃二兩,增加大黃以后,圓運動右方收斂收藏之力進一步加強。與芍藥不同的是,大黃所降所收則更側(cè)重于有形之實邪。在桂枝湯的基礎(chǔ)上,大黃祛除有形之實邪,與方中芍藥斂降逆亂之氣相配合,可用于太陽中風表證未解,肝木之氣橫逆中土導致的腹部大實痛。桂枝麻黃各半湯,桂枝麻黃各半湯證為太陽中風和太陽傷寒兼具之輕證。桂枝麻黃各半湯為桂枝湯原方的藥量和麻黃湯原方的藥量各取三分之一,兩者合二為一,各占一半,故名為桂枝麻黃各半湯。麻黃助陽氣上升,更側(cè)重作用于機體之表皮,可助正氣沖破表皮寒邪之閉郁;表寒破除,隨之汗出癥減。方中杏仁色白入肺,味苦可助肺氣之收斂,條暢氣機之逆亂,與麻黃一升一降,形成麻黃湯中的圓運動。在本方中,桂枝湯與麻黃湯減量后各取一半,可用于太陽中風與太陽傷寒兼有之輕證。第四部分是當代醫(yī)家應用桂枝湯類方的經(jīng)驗及典型醫(yī)案分析,從當代傷寒大家劉渡舟教授、梅國強教授、陳亦人教授、黃煌教授的傷寒學術(shù)思想及桂枝湯的應用進行論述。劉渡舟教授推崇經(jīng)方,經(jīng)方與時方有機結(jié)合,不薄時方,提倡古今接軌;并提出方證相對,精研類方,對經(jīng)方運用有獨到認識,善用桂枝劑、苓桂劑類方,積累了寶貴的臨床經(jīng)驗和診治特色。梅國強教授融會傷寒和溫病學說,認為傷寒外感病遣方須辨表里緩急、重視陰津,發(fā)揚張仲景六經(jīng)辨證之論,潛心研究擴大《傷寒論》諸方的臨床運用途徑;梅老認為,桂枝湯配伍嚴謹,有主有從,臨床療效顯著。桂枝湯作為《傷寒論》的群方之首,主要在于調(diào)和營衛(wèi)之氣,重在斂肝,辛甘化陽,解決脾胃虛弱的問題。陳亦人教授致力于《傷寒論》教學和研究,頗多創(chuàng)見,他主編的《傷寒論譯釋》和《傷寒論求是》,在全國影響較大,陳老用主方增減的類比法將以桂枝湯類方分為21方進行研究。黃煌教授注重經(jīng)方研究,倡導方證研究,并開創(chuàng)體質(zhì)辨證,提出了 "方人""藥人"的新概念,歸納總結(jié)出"桂枝體質(zhì)"。本文通過對圓運動理論、氣機升降理論、桂枝湯類方進行系統(tǒng)研究,得出以下結(jié)論:桂枝湯類方組成藥物主要以桂枝湯原方中的五味藥物為基礎(chǔ),其它類方在此基礎(chǔ)上加味衍生而成;在組方、藥量及病機上,同主中洲、顧護中土的三味藥物生姜、大棗、炙甘草,其藥量基本不變,也體現(xiàn)了中土厚重淳和、承載萬物、不易變動的特點,是桂枝湯類方之中軸。其它根據(jù)病機需要可分為兩類,或增加桂枝、葛根、附子等升散之性藥物用量來加強辛溫升達之力,或增加芍藥、厚樸、杏子、大黃等苦寒性味藥物增強收斂下降之力。桂枝湯類方,"在外解肌和營衛(wèi),在內(nèi)化氣調(diào)陰陽",既可用于外感熱病,亦能用于內(nèi)傷雜病。圓運動理論認為,中土如軸,四維如輪,輪軸互應,疾無所依;一切外感、內(nèi)傷諸病,皆因"中軸失靈、四維倒作"而起;醫(yī)道雖繁,實"軸輪"而已。桂枝湯類方有機融合了 "運軸行輪"、"運輪復軸"、"軸輪并運"三法。本文的創(chuàng)新點在于:1、以《傷寒論》中最具代表性的十個桂枝湯類方為研究對象,用圓運動的氣機升降理論來分析桂枝湯類方的組方、方義、應用和醫(yī)案,并初步從圓運動的氣機升降理論得出了桂枝湯類方的證治規(guī)律。2、首次提出了桂枝湯的中和理論。
[Abstract]:< > treatise on as one of the most important Chinese Medicine Classics, since the book has always been a hot spot of ancient physicians to learn and study. From theory to clinical practice, from the textual treatise on < > to pharmacological, almost every word by scholars, with the idea of expanding the research methods and research updates. We are still diligently mining, in order to better understand and explain the TCM valuable wealth, better clinical guidance; nevertheless, we still cannot understand every problem in the book thoroughly. For < treatise on Medicine >, "method", can divided into Guizhi Decoction group, ephedra decoction, Dachengqi Decoction, Radix Bupleuri decoction, four inverse soup more than ten kinds of Guizhi Decoction as < > treatise on the first party, although people of Guizhi Decoction has done a lot of research, but I still hope from a new angle study on it, in order not to As the discovery, better interpretation and clinical application in recent years. "The circle movement" theory has attracted more and more attention of Chinese scholars, this paper attempts to gas lift theory of circular motion as a starting point to analyze the class Guizhi Decoction Treatment of the law. By using literature research, with a circular motion of gas lift theory as a starting point, with the lifting of the law theory to analyze and summarize the syndrome and treatment of Guizhi Decoction group. This paper collects the related literature and circular motion theory, the theoretical analysis, refining, summary, focuses on the circular air lift movement. Combined with the theory of circular movement theory to analyze the "Treatise on Febrile Diseases > Guizhi Decoction group square, the original application, etc., and summarize modern Chinese scholars use Guizhi Decoction (starting from the circular movement theory) clinical experience, analysis of typical cases of them, in order to circular motion theory The law under the guidance of Guizhi Decoction treatment class. This thesis is divided into four parts, respectively for the theoretical research of circular movement, gas lift theory research, analysis of Guizhi Decoction and application of Guizhi Decoction of modern doctors' experience and typical cases. The first part is the theory of circular movement, in order to understand the origin of and the main academic point of view of circular motion theory. The theory of circular motion in the river, the source of the book < > Luoshu, congenital, acquired gossip; since the "Yellow Emperor" (hereinafter referred to as the "Neijing > < >) inheritance and treatise on both circular motion theory of the Qing Dynasty; Huang Yuan Yu and Zheng Qinan this theory, further to the Republic of China; the famous doctor Peng Ziyi write a" circular motion of the ancient Chinese medicine ", formally proposed the" circular movement ", marks the maturity of the theory of circular motion. It is necessary to point out that Huang Yuan and Zheng Qinan's theory of imperial circle movement footholddifferent, Huang side In the middle of circular motion, circular motion and Zheng is focused on. Peng Ziyi from the ancient physicians research experience and academic essence, the author of "circular motion of the ancient Chinese medicine", with the circular motion law of circular motion theory in the world, and then human physiology and pathology, including Yin and Yang, five lines, six gas. Twelve channels, twenty-four solar term circular motion theory, the creation of circular motion system with internal organs as the core, and use the circular motion theory analytic < treatise on > six medication. The second part is the theoretical study of gas lift, aimed at lifting theory of gas machine system. Research of gas lifting machine is an important part of the theory circle theory of the motion, "floating" gas "or" extremely, "sink" gas "drop" extremely. Lift access, as the main form of body qi movement, if that lifting the truth, also can understand the physiology of the human body, also can understand human body disease Daniel. Air lifting theory originated in the pre Qin period. In that the Chinese sages ", composition of the universe, the fundamental form of material existence for the movement. Gas is the universe's original material, which is the smallest unit of the universe. The movement of the substance of the universe to a lift, this is the materialism of Qi the simple concept of lifting theory. San Zhang Zhongjing inherits and develops the basic < > in < treatise on the academic point of view, > recorded in more machine caused by abnormal movements of gas diseases. Up to the Jin and Yuan Dynasties, Chinese doctors come forth in large numbers, creating academic contending prosperity situation of Qi theory, is the main content of each Different people, different views., doctors from different angles the development of Qi theory. Among them, Zhang Zi and spit on gas lift, clinical to attack evil, advocate the sweat vomit down, vomiting, especially invasive. To the Ming and Qing Dynasties During the period, on the gas lift theory use a lot, so as to promote the popularization and development of gas lift theory. In "Treatise on Febrile Diseases", including the application of gas lift Theory: the spleen and stomach, heart and kidney lifting, lifting the lifting of lung and kidney, liver, spleen and lung. The lifting gas lift theory and the following relationship six: the sun disease focus on Ying Wei access disorders, Yangming disease focuses on Yang (E soil) soil gas loss drop, shaoyang disease focus on cardinal poor, Taiyin disease focus on soil Yin (f soil) of the gas does not rise, Shaoyin disease focus on arrhythmia and lifting. Jueyin disease focuses on the movements of the blood against the chaos. The third part is the study of Guizhi Decoction, Guizhi Decoction for the treatment of the law system research. We first analyzed Guizhi Decoction, Guizhi Decoction to determine the scope of the research, this paper, choice is consistent with the most medical opinion, in Based on Professor Liu Duzhou and Professor Xiong Manqi selected 21 party on the selection of the most common clinical ten most typical prescription as the research object. The selected ten prescription prescription were included in Guizhi Decoction of cassia twig, peony, ginger, jujube, licorice five kinds of essential drugs, and go to twig, peony such parties are not included in the study, ten prescriptions were: Guizhi Decoction, Guizhi Gegen decoction, Guizhi Fuzi decoction, Guizhi Houpu Xingzi decoction, Guizhi Shaoyao ginger one or two ginseng 32 new Guangxi soup, Guizhi Decoction, Guizhi Shaoyao decoction, Guizhi Decoction plus rhubarb, Xiaojianzhong decoction, Guizhi Mahuang each this part mainly uses the Bantang circular motion theory of Guizhi Decoction was discussed from two parts of Fang Yi, and provisions. Guizhi Decoction is the foundation, side Guizhi soups Guizhi Xin, Yang l body, or the main peony; acid bitter cold, the main convergence, Lord; cassia twig, peony 涓，

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