“气郁”病机基础理论研究

【作者】 郭女菁；

【导师】 王洪图；

【作者基本信息】 北京中医药大学 ， 中医基础， 2007， 博士

【摘要】 气郁病机是中医理论重要的组成部分，首载于《内经》，是最常见最主要的病机类型，可见于临床各科多种疾病的进程中。气郁病机理论被历代医家所重视，并不断地发挥和广泛地运用，成为一个完整的系统的理论体系。随着社会的进步，医学科学的发展，人类的疾病谱发生了重大变化，气机郁结所致疾病也一一凸现出来。本课题首先运用文献研究的方法：一．撷取古今医学文献中有关气郁病机理论的精华，对气郁理论的形成与发展进行回顾和讨论，全面、系统、深入地分析气郁理论的本质、总结出其梳理其源流及学术特征。首次提出中医学对气郁病机的认识历经四个时期：即先秦至宋为气郁病机的产生和形成时期，此时期以《内经》提出的“五郁”为核心，对五运六气异常引起对应人体五脏的气郁有一定认识。自《内经》中提出五郁，后世医家根据五行运气变化与疾病的关系，提出了其它关于气郁病机的观点。第二阶段金元时期，气郁病机理论有了新的发展，在诸郁理论与临床方面影响最大的当为朱丹溪，朱氏从机体的某些物质与病理产物运化失常出发，提出了气血痰湿食火“六郁之说”，并将六郁看作许多疾病的肇始，尤其重视对“气郁”的治疗，创“越鞠丸”妙以一方统诸郁。刘河间对“火郁病机”有新的发展提出“怫郁化火”等理论，治疗中善用寒凉药物解热开郁。明清时期为第三阶段，是气郁病机理论完善的时期，此时，医家对气郁理论的研究和论述十分丰富，在对前代“五脏郁”、“六郁”等气郁理论进行总结和梳理的前提下，临证重视对情志内伤导致气郁病机和肝气郁结病机理论的研究。同时，认为气郁不仅是疾病初起的常见病机，而且气郁病机与体质有密切的关系，此时期理论的特点是偏重“肝气郁结”病机的研究，治疗中强调“调肝”的重要性；第四阶段，即近代以来，医家对气郁病机的认识更加深入，对气郁与临床各科疾病的关系认识更加明确，认为在绝大多数疾病的发生发展过程中均伴有气郁病机的发生。认为气郁病机的病位主要在肝、胆、心、肺、脾、胃与三焦，而与肾、大肠、膀胱、脑相关，经络亦为常见病位。病机以脏腑气郁、经络气郁为主。诸郁之中仍以“肝郁为主”的深入认识居主导地位。纵观气郁病机理论的发展轨迹，对“脾郁”的研究似乎略显不足。尤其清代之后较少医家重视“脾郁”在气郁病机理论体系中的重要地位，脾与胃相表里共处中焦，为后天之本，又对上、下焦气机的正常升降有重要的作用，脾虚运行无力或脾郁气机不畅均会引起三焦气机的失调，诸病丛生。因此，深入研究“脾郁”的病机，无疑可以进一步完善“气郁病机”理论，促进临床对该类病证的认识和治疗。二．阐述了气郁病机的概念及其形成原因，从而为基础研究和临床治疗提了供有价值的研究线索。气郁的形成，可以是由外界致病因素所致，也可以是由情志内伤所引起，还可以因痰、湿、食、血等郁积所成。因湿、痰、食积、瘀血等有形之邪阻碍气机。气郁可导致湿、食、痰、瘀的形成和稽留，而这些病理产物的停留又可进一步壅塞气机，导致气滞证，常互为因果。当各种致病因素作用于人体，导致全身或局部的气机失调或气化异常，则必然对人体脏腑、经络、气血、津液及气化过程等诸方面产生重要影响，使机体产生多种疾病。气的病理改变，不仅有量的改变，如量的不足而致气虚，更常见的是气的运动发生障碍，是产生气郁而引发众多疾病的重要因素。《褚氏遗书·本气》中亦曰：“痰积虚耳，或痰聚上，或积恶中，遏气之流，艰于流转，则上气逆上，下气郁下，脏腑失常，形骸受害”。即气郁可反映出病变的本质，影响到人体的气机运动和气化过程，临床的各种常见病、多发病，都有可能与气郁有关，尤其是疑难杂证，更要从气的方面来考虑。三．通过对古今文献的研究，讨论五运气郁病机与五脏的关系。五郁理论是《内经》运气学说的重要组成部分。火郁与木郁、金郁、土郁、水郁合称五郁。《素问·六元正纪大论》言五郁之发，是因五运之气，有太过不及，胜复之变而致天地之郁，人与天地相应，亦能因郁致病。五郁实则概括了五脏的特性及其病理特点。张景岳言：“凡五气之郁则诸病皆有，诸郁皆脏气病也”。因脏腑功能障碍，影响气机可致郁：如肝失疏泄，肝郁气滞；肺失宣肃，肺气郁滞不畅；脾胃升降失常，气机不能转枢等。同时五脏之郁可以相互影响，而不限于某一脏，五行相因，自然之理，治疗气郁重视调肝与脾。然而明清以下乃至现代，对气郁理论的认识多以“肝郁”为核心，对气郁病机理论的研究有失全面。四．首次运用统计学分析方法，分析了古今141部专著中有关气郁病机文献资料，进一步归纳历代医家对气郁与五脏之间关系的认识，深入探讨气郁病机理论与五脏的相关性，探讨学术分歧的原因，然而在五脏与气郁关系统计的频率中表明，《内经》五郁学说是后世五脏郁理论之源，在明代之前以脾胃的出现次数为最多，其次是心、肺。均突出古人对气机失调以脾胃与肺最为重要的认识，并以“六郁”说及“郁在中焦”说的理论为主导；至清代以后医家则以肝与气郁关系最密切为主流。笔者也认为，治疗郁证不能只一味强调肝脏的生理病理特点而行疏肝解郁法，故气郁病机可发生于各脏腑，五脏中任何一脏的郁滞都可影响其它脏腑使其致郁，但无论从临床中或理论上，应着重肝与脾兼顾的观点。如李杲《脾胃论》说：“治肝、心、肺、肾，有余不足，或补或泻，唯益脾胃之药为切。”即使，果是肝郁亦应体现张仲景“见肝之病，知肝传脾，当先实脾”之旨。近代名医张锡纯说：“欲治肝者，原当升降脾胃，培养中官，俾中官气化敦厚，肝木自理，即有时少用理肝之药，亦不过为调理脾胃剂中辅佐之品。”临证中治疗情志类气郁病证亦当兼顾“脾郁”的调理。五．探讨气郁病机形成的规律与特点，并联系临床实际，论述了气郁病机的普遍性和特殊性及其与多种疾病发生的相关性。认为气郁与其导致的病理变化常常互为因果，相互影响。气郁可致津血运行不畅，故气郁可致诸郁。诸郁既成又可反碍五脏气机导致气郁，且五脏之郁亦表现为气机升降紊乱，如《素问·举痛论》中明确指出：“余知百病生于气也，怒则气上……恐则气下，惊则气乱……思则气结。”因此说气郁为诸郁之初始，而诸郁相因为患最终亦是导致气郁。正是基于以上原因，所以气郁病机也错综复杂，具有起病慢，不易察觉；病位较广，与肝、肺、脾关系密切；易阻气机，郁久易化火伤阴；与体质和情志密切相关；病证虚实互见等致病特点。最后，根据上述理论研究的结果，就脏腑与气郁理论而言，无论是“郁在肝”之说还是“郁在脾”之说，应强调人体五脏的整体性，具有包容性与互为性，不可单一理解为一个脏腑主管，五脏整体协调是其关键。更多还原

【Abstract】 The Pathogenesis of Qi-stagnation is a significant part of the medical theory of CM, whichwas firstly recorded in Huangdi’s Classic on Medicine(Huang Di Nei Jing). It is the mostfrequent pathogenesis, that appears in the proceeding of many kinds of diseases. The attentionof the pathogenesis theory of Qi-stagnation was paid by doctors in successive dynasties. Thetheory of Qi-stagnation was constantly developed and widely applied in clinic, and finallyevolved into a integral system of medical theory. With the progress of society and thedevelopment of medical science, the spectrum of disease of human being has taken a greatchange, and the diseases that caused by the stagnation of Qi have increased and becamepopular in clinic.This thesis applied the method of literature study:Firstly, chosing quintessence about the Pathogenesis theory of energy-stagnation fromancient and modern medical literature, we looked back and discussed how the theory ofQi-stagnation had been formed and developed. Then we analyzed the essence of the theory ofQi-stagnation, combed its developing locus and academic features. For the first time inacademic, We introduced the cognition of Qi-stagnation has experienced four periods in thehistory of Traditional Chinese Medicine. From earlier Qin dynasty to Song dynasty, the theoryof Qi-stagnation was first mentioned and studied. After the five stagnation, that posed byHuang Di’s Classic on Medical(Huang Di Nei Jing), doctors began to pay attention to fiveelements’ motion and six kinds of natural factors, which is one of the causes of diseases.During Jing and Yuan dynasty, the pathogenesis theory of Qi-stagnation had furtherdevelopment. The well-known clinic doctor, Zhu Danxi, invent the theory of the six stagnation,including energy, blood, phlegm, moist,food,fire, the six factors produced by the body ordiseases. He believes that these six factors have interaction among each other, and especiallythe Qi-stagnation, should be treated first. Liu Hejian contributed to the theory of stagnated QItransforming into fire, and he is good at treating these diseases by using cold and cool drugs.The pathogenesis theory of Qi-stagnation reached its consummate stage in Ming and Qingdynasty. Doctors’ study focus on the theory of stagnation of liver-QI, they acclaimed theimportance of adjust liver-Qi in treating this kinds of diseases. In modern times, medicalscientise insists that pathogenesis of Qi-stagnation is popular in most diseases. It can behappened in organs such as liver, gall-bladder, heart, lung, spleen, stomach and triplewarmer. The pathogenesis is mainly about the qi stagnation of zang-fu organs and meridians.But stagnation of liver-QI is the mainly cause of Qi-stagnation in clinic.The stagnation of spleen-Qi seems to be neglected in the history of the development ofQi-stagnation., especially after Qing dynasty. However, the stagnation of spleen-Qi is quiteimportant in clinic. It will be benefit the clinic to have a further study on this topic.Secondly, we supports clues to theory research and clinic treatment by explaining theconcept and cause of pathogenesis of Qi stagnation. Both the inner and external factors cancause Qi stagnation. Many common illness, and frequently encountered disease, might beattributed to the qi stagnation.Thirdly, after reviewing on the ancient and modern literature, we discuss the relationshipbetween pathogenesis of qi stagnation caused by the five-motions, and five zang-organs. Thefive stagnation The theory of five stagnation is an important part of doctrine on yunq in HungDi’s Classic on Medical. It believes that the five zang-organs can have qi stagnation either, andhave interaction among each other. But after Qing dynasty till today, the study on the theory ofqi stagnation is mainly focus on the stagnation of liver-Qi, which somehow has some defects. Fourthly, we sum up the cognition of the relationship between Qi stagnation and fivezang-organs by medical scientist of past dynastis, to find the dependability between thetwo. The result reveals that doctors in Jing and Yuan dynasty pay more attention on adjustingthe stagnation of spleen-Qi. When treating Qi stagnation that caused by emotional disorder, itis necessary to take drugs with the effect of adjust liver-Qi and spleen-Qi.Fifthly, discussing rule and features of the development of qi stagnation, combining withclinic practices, we hold the idea that qi stagnation and its product of pathological changeoften influence each other. Deficient and excessive syndromes appearing together is onefeature of Qi stagnation.Finally, based on our study, no matter the stagnation of liver-Qi or spleen-Qi, we shouldemphasize the entirety of the five zang-organs and consider their interaction when applyingthe treating method of adjusting five zang-organs Qi.更多还原