从圆运动气机升降理论探讨桂枝汤类方的证治规律

发布时间：2018-01-02 17:10

  本文关键词：从圆运动气机升降理论探讨桂枝汤类方的证治规律　出处：《广州中医药大学》2017年博士论文　论文类型：学位论文

  更多相关文章： 桂枝汤类方 圆运动 气机升降 伤寒论

【摘要】：《伤寒论》作为中医界最重要的经典著作之一,自成书以来,一直都是历代医家学习和研究的热点。从理论到临床,从考据到药理,《伤寒论》几乎每个字都被学者研究过,随着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着,以期更好的理解和阐述这一中医学的宝贵财富,更好的指导临床;尽管如此,我们仍不能透彻的理解该书的每一个问题。对于《伤寒论》中的方药,用"类方"的方法,可以划分为桂枝汤类、麻黄汤类、承气汤类、柴胡汤类、四逆汤类等十余种,桂枝汤作为《伤寒论》的第一方,尽管人们对桂枝汤类方做了大量的研究,但笔者仍希望能从一个新的角度来研究它,以期有不一样的发现,能更好的解读并应用于临床。近年来"圆运动"理论越来越受到中医学者的重视,本文试图以圆运动的气机升降理论作为切入点来解析桂枝汤类方的证治规律。本文采用文献研究的方法,以圆运动气机升降理论作为切入点,用气机升降的理论来分析总结桂枝汤类方的证治规律。本文搜集了与圆运动理论相关的研究文献,对其理论进行概括、分析、提炼、总结,重点阐述圆运动的气机升降理论。结合圆运动理论来分析《伤寒论》桂枝汤类方的方义、原文、应用等,并系统总结现代中医学者运用桂枝汤类方(从圆运动理论切入)的临床经验,分析他们的典型医案,以期得出圆运动理论指导下桂枝汤类方的证治规律。本论文分为四部分,分别为圆运动理论研究、气机升降理论研究、桂枝汤类方研究及当代医家应用桂枝汤类方的经验及典型医案分析。第一部分是圆运动理论研究,旨在探讨研究圆运动理论认识源流及主要学术观点。圆运动理论源于《周易》的河图、洛书、先天八卦、后天八卦;此后的《黄帝内经》(以下简称《内经》)及《伤寒论》均有圆运动理论的继承;到清代的黄元御和郑钦安,本理论得到进一步发展;至民国名医彭子益撰写成《圆运动的古中医学》,正式提出"圆运动"一词,标志着圆运动理论的成熟。需要指出的是,黄元御和郑钦安的圆运动理论的立足点不同,黄氏侧重于中土圆运动,郑氏则侧重水火圆运动。彭子益汲取历代医家的的研究经验和学术精华,著有《圆运动的古中医学》,著中用圆运动理论阐述天地的圆运动规律,并推及人体生理及病理,涵盖阴阳、五行、六气、十二经络、二十四节气圆运动理论,创立以五脏为核心的圆运动体系,并用圆运动理论解析《伤寒论》的六经用药。第二部分是气机升降理论研究,旨在对气机的升降理论进行系统研究。气机升降浮沉理论是圆运动理论的重要组成部分,"浮"是气"升"至极,"沉"为气"降"至极。升降出入,作为人体气机运行的主要形式,如果明白气机升降的道理,同样可以明白人身的生理,也可以明白人身的病理。气机升降浮沉理论起源于先秦时期的《内经》。中医先哲认为,物质组成宇宙,物质存在之根本形式为运动。气是宇宙最原始的物质,是构成天地万物的最小单元。把宇宙物质的运动变化归于一气的升降,这是气机升降理论朴素的唯物观。医圣张仲景继承并发展《内经》的基本学术观点,在《伤寒论》中记载较多的由气机升降失常导致的各种病证。时至金元时期,名医辈出,开创中医学术争鸣的繁荣局面,对气机升降理论的阐述,则是见仁见智,各位医家从不同的角度发展气机升降理论的主要内容。其中,张子和以吐法来论气机升降,临证以攻邪为主,倡导吐汗下法,而其吐法,尤有创见。到了明清时期,对气机升降理论的发挥运用颇多,从而推动了气机升降理论的普及与发展。在《伤寒论》中,气机升降理论的应用包括:脾胃升降、心肾升降、肝胆升降、肺肾升降、脾肺升降。气机升降理论与六经病的关系如下:太阳病侧重于营卫出入之失调,阳明病侧重于阳土(戊土)之气的失降,少阳病侧重于枢机不畅,太阴病侧重于阴土(己土)之气的不升,少阴病侧重于水火升降之失常,厥阴病侧重于气血升降之逆乱。第三部分是桂枝汤类方研究,旨在对桂枝汤类方的证治规律进行系统研究。首先对桂枝汤类方进行梳理,以确定本文研究的桂枝汤类方范围,本课题中,选择与大多数医家相一致的观点,在刘渡舟教授和熊曼琪教授所选择的21方的基础上,选用临床最常见最典型的十个方剂作为研究对象。此次所选十个方剂的组方中均包含了桂枝汤中的桂枝、芍药、生姜、大枣、炙甘草五味基本药物,而去桂枝、去芍药之类方并未纳入研究,十个方剂分别为:桂枝汤、桂枝加葛根汤、桂枝加附子汤、桂枝加厚朴杏子汤、桂枝加芍药生姜各一两人参三两新加汤、桂枝加桂汤、桂枝加芍药汤、桂枝加大黄汤、小建中汤、桂枝麻黄各半汤。本部分主要运用圆运动理论对桂枝汤类方从方义及条文两部分进行论述。桂枝汤是桂枝汤类方的基础方,桂枝辛温,升人体之阳,主升;芍药酸苦寒,主收敛,主降;桂枝、芍药一升一降,自成一圆运动,生姜、大枣、甘草同主中州,顾护中土,稳固圆运动之中轴;桂枝、芍药一升一降,辅助中土调畅气机,调和营卫。桂枝加厚朴杏子汤,桂枝加厚朴杏子汤证主要是敛降之力不足,故加厚朴,厚朴对应于西方的肃降之性;杏仁,其色白,味苦,主入肺、大肠经,苦则降泄,可助西方金气下降,兼有润肠通便之效。一方面可以肃降西方上冲之气,另一方面可以调理胃气,中土气机升降调和,有助于东方之气的上升与西方之气的下降。一方面调畅圆运动之轴的气机,一方面顺应于西方气机的肃降,以制约气机上冲之势。桂枝新加汤,桂枝新加汤证为气血不足,营阴消耗之后,可知身疼痛为气血不足以濡养经脉所致,在桂枝汤原方基础上加人参,人参有"补五脏"之功(《神农本草经》),增强补中之力,可使圆运动之轴更加稳固,将生姜、芍药的用量从三两增加到四两,加重生姜的用量可以提高中焦脾胃的运化之力,稳定圆运动之轴,以化生气血;增加芍药的用量则加强了收敛的功效,以养阴生津。小建中汤,小建中汤证主东方木气疏泄不利,中央脾土虚弱,木气横犯中土,倍用芍药,一方面可以柔肝缓急,另一方面芍药与炙甘草、大枣相配,酸甘化阴,以养血和营。饴糖气味甘温,归脾、胃、肺经,具有补中益气、缓急止痛、润肺止咳的功效。方中加入饴糖一升,以补中益气,恢复中气,固护中央土气,调和东方木气的疏泄。桂枝加葛根汤,桂枝加葛根汤证中加用的葛根为阳明经主药,可宣达阳明中土之气,而又外合于太阳经脉,足阳明胃经主降浊,经气降则热气降;足太阴脾经主升清,葛根可助人体阴气的上升,恢复轴枢的升清降浊功能,解除阳明经气不利的情况。桂枝加附子汤,桂枝加附子汤证中加用的附子主温阳,可温散人体一切阴寒之气,温养心肾,恢复身体左升的功能,阳气能自东方左升,就能在西方肃降;此外,附子温脾阳、散寒湿,可恢复四维和轴枢之力。桂枝加桂汤,桂枝加桂汤证中重用桂枝至五两,主要是取其"降逆气、降冲气"的作用。加之芍药收敛的功用,人体阳气才能有序下降,肝气条达,上逆之气也终得复归其位。另外,方中生姜、大枣、炙甘草三味药同主中洲,增强中焦脾胃之气,中焦斡旋之力得以复原,从而共同平复冲气。桂枝加芍药汤,桂枝加芍药汤证乃太阳病误下所致,芍药可以"主邪气腹痛",本方中增加了芍药的用量,增强了右降的力量,用于收敛横逆中土的肝木之气,使逆气循正道而行。桂枝加大黄汤,桂枝加大黄证是太阳病误下寒入太阴之后,形成有形之实邪结聚之腹痛。本方在桂枝加芍药汤基础上加用大黄二两,增加大黄以后,圆运动右方收敛收藏之力进一步加强。与芍药不同的是,大黄所降所收则更侧重于有形之实邪。在桂枝汤的基础上,大黄祛除有形之实邪,与方中芍药敛降逆乱之气相配合,可用于太阳中风表证未解,肝木之气横逆中土导致的腹部大实痛。桂枝麻黄各半汤,桂枝麻黄各半汤证为太阳中风和太阳伤寒兼具之轻证。桂枝麻黄各半汤为桂枝汤原方的药量和麻黄汤原方的药量各取三分之一,两者合二为一,各占一半,故名为桂枝麻黄各半汤。麻黄助阳气上升,更侧重作用于机体之表皮,可助正气冲破表皮寒邪之闭郁;表寒破除,随之汗出症减。方中杏仁色白入肺,味苦可助肺气之收敛,条畅气机之逆乱,与麻黄一升一降,形成麻黄汤中的圆运动。在本方中,桂枝汤与麻黄汤减量后各取一半,可用于太阳中风与太阳伤寒兼有之轻证。第四部分是当代医家应用桂枝汤类方的经验及典型医案分析,从当代伤寒大家刘渡舟教授、梅国强教授、陈亦人教授、黄煌教授的伤寒学术思想及桂枝汤的应用进行论述。刘渡舟教授推崇经方,经方与时方有机结合,不薄时方,提倡古今接轨;并提出方证相对,精研类方,对经方运用有独到认识,善用桂枝剂、苓桂剂类方,积累了宝贵的临床经验和诊治特色。梅国强教授融会伤寒和温病学说,认为伤寒外感病遣方须辨表里缓急、重视阴津,发扬张仲景六经辨证之论,潜心研究扩大《伤寒论》诸方的临床运用途径;梅老认为,桂枝汤配伍严谨,有主有从,临床疗效显著。桂枝汤作为《伤寒论》的群方之首,主要在于调和营卫之气,重在敛肝,辛甘化阳,解决脾胃虚弱的问题。陈亦人教授致力于《伤寒论》教学和研究,颇多创见,他主编的《伤寒论译释》和《伤寒论求是》,在全国影响较大,陈老用主方增减的类比法将以桂枝汤类方分为21方进行研究。黄煌教授注重经方研究,倡导方证研究,并开创体质辨证,提出了 "方人""药人"的新概念,归纳总结出"桂枝体质"。本文通过对圆运动理论、气机升降理论、桂枝汤类方进行系统研究,得出以下结论:桂枝汤类方组成药物主要以桂枝汤原方中的五味药物为基础,其它类方在此基础上加味衍生而成;在组方、药量及病机上,同主中洲、顾护中土的三味药物生姜、大枣、炙甘草,其药量基本不变,也体现了中土厚重淳和、承载万物、不易变动的特点,是桂枝汤类方之中轴。其它根据病机需要可分为两类,或增加桂枝、葛根、附子等升散之性药物用量来加强辛温升达之力,或增加芍药、厚朴、杏子、大黄等苦寒性味药物增强收敛下降之力。桂枝汤类方,"在外解肌和营卫,在内化气调阴阳",既可用于外感热病,亦能用于内伤杂病。圆运动理论认为,中土如轴,四维如轮,轮轴互应,疾无所依;一切外感、内伤诸病,皆因"中轴失灵、四维倒作"而起;医道虽繁,实"轴轮"而已。桂枝汤类方有机融合了 "运轴行轮"、"运轮复轴"、"轴轮并运"三法。本文的创新点在于:1、以《伤寒论》中最具代表性的十个桂枝汤类方为研究对象,用圆运动的气机升降理论来分析桂枝汤类方的组方、方义、应用和医案,并初步从圆运动的气机升降理论得出了桂枝汤类方的证治规律。2、首次提出了桂枝汤的中和理论。
[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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