《金匮要略》虚劳辨治纲要补遗_王桂彬.pdf

第 39 卷第 3 期2023 年 3 月长春中医药大学学报Journal of Changchun University of Chinese MedicineVol.39 No.3Mar.2023252DOI:10.13463/ki.cczyy.2023.03.005金匮要略虚劳辨治纲要补遗王桂彬1，曹 于2*，庞 博1（1.中国中医科学院广安门医院，北京 100053；2.中国中西医结合医院，北京 100038）摘要：金匮要略虚劳一证，历来诸多医家对在经旨原意基础之上多有发挥，将虚劳之证归为内伤诸症末节，从气虚、血虚、阴虚、阳虚（或阴阳两虚）分类概括，或与虚、怯、劳、瘵混而谈之，然临床所见诸多虚劳病证，虚实皆现，混而难辨，教材所示五脏气血阴阳各设独立之病证、方药，亦难以随手择取效验于临床。通过对经旨中有关虚劳理论进行梳理与归纳，指出虚劳之治，当以补虚为要，权以调中复衡;气血为辨，施以祛风逐瘀；温养为要，勿忘育阴化气；补虚为基，应遵缓中图治；营卫为法，守机观变达权。并借此管窥仲师血痹虚劳经旨心法所在，以期更好地指导并应验于临床。关键词：虚劳；病机；辨治；思维中图分类号：R222 文献标志码：A 文章编号：2095-6258(2023)03-0252-04Supplement to the syndrome differentiation and treatment of the consumptive Supplement to the syndrome differentiation and treatment of the consumptive syndromes in syndromes in Synopsis of the Golden ChamberSynopsis of the Golden ChamberWANG Guibin1,CAO Yu2*,PANG Bo1(1.Guang anmen Hospital,China Academy of Chinese Medical Sciences,Beijing 100053,China;2.Chinese Hospital of Integrated Traditional and Western Medicine,Beijing 100038,China)Abstract:Abstract:A number of doctors of different generations have explored the consumptive syndromes recorded in the Synopsis of the Golden Chamber by Zhang Zhongjing on the basis of its original denotation,categorizing it as the last of internal injuries,generalizing it into the categories of qi deficiency,blood deficiency,yin deficiency,yang deficiency(or deficiency of both yin and yang),or mixing it with deficiency,timidity,fatigue and phthisis.However,in clinical practice,many consumptive syndromes are manifested as a syndrome of intermingled deficiency and excess,which are difficult to distinguish.Textbooks arrange consumptive syndromes by listing them as independent syndromes under the different sub-headings of the five viscera,qi,blood,yin and yang and offering varying prescriptions for them,which is also difficult to be conveniently referred for clinical effective applications.By sorting out and summarizing the relevant theories about the consumptive syndromes in the classical books,it is pointed out in the article that their treatment should prioritize toxifying the deficiency,supplemented by regulating the heart and stomach to resume a balance;their treatment should be based on the syndrome differentiation of qi and blood,dispelling wind and eliminating blood stasis;it is important to warm and nourish the heart and stomach,and to cultivate yin and transform qi as well;their treatment should be based on tonifying deficiency,following the principle of a gradual improvement;they should be treated by dealing with the disharmony between nutrient qi and defensive qi,in line with its pathogenesis to keep an eye on their transitions and to maintain a balance.It is expected that the article can shed a light on Zhang Zhongjings purport and treatment methods for bi diseases with the syndrome of blood deficiency and the consumptive syndrome,in order to better guide and apply them to clinical practice.基金项目：北京市自然科学基金面上项目（7222296）；北京市海淀区卫生健康系统高层次人才发展计划项目（2022HDXG003）；第六批北京市中医药专家学术经验继承项目（北京市中医管理局人才项目）作者简介：王桂彬（1993），男，博士研究生,主要从事中医药肿瘤防治与老中医经验传承研究*通信作者：曹 于，女，副主任医师，电子信箱-第 39 卷第 3 期2023 年 3 月长春中医药大学学报Journal of Changchun University of Chinese MedicineVol.39 No.3Mar.2023253 虚实为纲是中医论病的一大特点所在，而“虚劳”一病在中医学中所涉病证较为广泛1。金匮要略（简称金匮）始载“虚劳”之病名，并与“血痹”共论。而后历代医家对虚劳各有发挥演绎，所指不尽相同2-4。考镜中医文献，广义虚劳之病应包括虚损与劳瘵两大类。传统医学院参考教材以及近现代诸多虚劳专著在概念定义方面对其内涵及外延亦不甚明确，多归于“脏腑亏损，气血阴阳俱衰”5，由此内科病证所在终末期，脏腑气血亏损，均可归为虚损一证范畴，故虚劳大抵可释为各种原因导致的虚损性病证，究其病因多为七情、劳倦、饮食、酒色所伤，或病后失于调理，以致阴阳、气血、脏腑虚损6。然临床实察诸多虚劳病证，或为阴阳乖戾，寒热错杂，或为虚实皆现，混而难辨，虚证之上，有痰湿，有水饮，有瘀热，有伏寒，证候错杂难辨，然教材所示五脏气血阴阳各设独立之病证、方药，亦难以随手择取效验于临床。基于此，笔者立足于前贤所述，就金匮虚劳病篇辨治纲要寻余所集，进一步辨章仲景虚劳立论之心法，浅述于下。1 补虚为要，权以调中复衡 关于虚劳辨治纲目，近人多喜从阴虚、阳虚、气虚、血虚立论作为分类辨证7，然于临床而言多有，一则各类症状皆难悉举，再则阳虚与气虚、阴虚与血虚难以明确截然分开。若以气虚多偏重于脾经，血虚多责之于肝经，阳虚者多为命门火衰，阴虚者多见骨蒸潮热之象，实难服众，亦不可作规矩准绳为临床所效验。从这个角度看，传统教材所示脏腑、阴阳、气血诸多虚证条目，仅示学子病证备要之例，更当融汇结合临床以通病证之法。内经明言：“邪气盛则实，精气夺则虚”，虚劳者，精气竭绝，形体毁沮，形气散于外而脏腑真精夺于内，终为精华日脱，邪气乃并之证。仲景虚劳辨治之法，总不离补虚、祛风、逐瘀三法。吴澄曰：“元气不足者，谓之虚。不能任劳者，谓之怯。由是而五脏内伤，谓之损。”故虚损之证，首以补虚为要，但补虚之法，各有不同。以小建中汤之补虚为例，着眼于“土为万物之母，中央土以灌四旁”者，谓建中土，资化源以补五脏之虚；立论“欲求阴阳之和者，必于中气”者，认为诸症为阴阳并乖、营卫失调之象，里急，腹中痛者，四肢酸疼，阴独行之证；手足烦热、咽干口燥，阳独行之证。以上阴阳失和、寒热互现、营卫逆乱诸症皆为外象，灵枢：“中焦之所出中焦亦并胃口，出上焦之后，此所受气者，泌糟粕，蒸津液，化其精微，上注于肺脉，乃化而为血，以奉生身，莫贵于此，故独得行于经隧，命曰营气，营卫者精气也，血者神气也，故血之与气，异名同类焉。”“气得上下，五脏安定，血脉和利，精神乃居，故神者，水谷之精气也。”故精气者，营卫也；荣卫者，水谷精悍之气，皆出于中焦；阴阳者，中土安则阴阳相循，平秘不偏，寒热之证不现。分则为三，实则为一，前贤所云虚损有“自上而下”“自下而上”之异，旨在言明尚为可治之证，皆以中气为主，若过脾胃，则病重不治。中气建则营卫和畅，循环无端，阴阳无造偏之机。再如桂枝加龙骨牡蛎汤，失精里急之证，阳散于外，精孤于内，当以通阳固阴为要务，然骤失之精难以遂复，清谷亡血之漏法当亟固，全赖后天谷气资生，为从阳治阴、敛阳归土之法；若亡血失精、阴头寒、少腹弦急，果为阴寒所致，则另设天雄散一法，效直补元阳、补火生土之力。后世东垣补中斡旋诸方，从中而治，或升阳，或清降，或养元，或施云降雨，或布阳泽露，土旺则四维循序以生，内伤调中复衡之道，为治虚调和而设，亦为治本而设。肾气丸、酸枣仁制方之义亦作如是观，虚劳之病，并不单恃滋补，而是从根本上求出所以虚弱的原因作为处置的方针，余证不再赘述。2 气血为辨，施以祛风逐瘀 金匮云“夫人禀五常，因风气而生长，风气虽能生万物，亦能害万物”。五常者，五行之谓。此处风气，木之气，既言自然外界六淫之风，亦指人体肝木之风。薯蓣丸条所云：“虚劳诸不足，风气百疾”，此与黄芪建中汤条相比，少“里急”二字，可见此为内外俱虚之证，后世医家多喜从正虚易受风邪侵袭角度阐释，五版金匮要略教材亦认为：“风气百疾，是指感受外邪（含六淫之邪）所引起的多种疾病，因风为百病之长，故名”，认为当此之时，既不可独补其虚，亦不可一味祛风，盖补虚则恋邪，祛邪又恐重伤其正8。故必须寓祛邪于补正之中，使邪去而正不伤，此番见解，实有可取之处，却忽略内在风气。陈伯坛先生认为，“书虚劳诸不足，看似对写风气之有余，特无里急二字，非指风气实其里。无外证二字，Keywords:Keywords:consumptive syndrome;pathoge