《金匮要略》活血化瘀法的研究
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摘要
《伤寒杂病论》成书以来，因其创造性地融理、法、方、药与一体，一直是后代医家争相阅读之典范，被后人称为“方书之祖”、“医方之经”，是中医四大经典之一，也是我国目前中医学生重要的学习教材。《金匮要略》是其杂病部分，历代医家治疗杂病无不从此书着手。而对中医的学习，多数医家均主张应当先继承，在此基础上再进一步的发扬和创新。归纳总结前人宝贵的经验，继承他们治疗疾病的方法，既可以为当前临床治疗疾病提供参考，也为以后中医的发展和创新打下基础。
《金匮要略》所治疾病甚多，治法也是丰富多样。而活血化瘀法作为中医的一个重要治法，书中有大量的记载，但由于是分散在多个篇章中介绍，不易掌握。故本文从活血化瘀法角度着手，对其进行归纳整理，并系统探讨其形成过程、分类、方药配伍规律、主要方药的现代研究以及对后世的影响。希望本文能对大家有所裨益。
就活血化瘀法的产生而言，应当是人类祖先在同自然界的斗争中，逐渐发现和积累而成的。随着经验的不断积累，至《黄帝内经》问世时，对活血化瘀法已有相当多的阐述，起着重要的贡献，主要体现在以下四个方面：一是提出了血的正常流动的生理意义；二是对瘀血证有了较系统的认识；三是提出了活血化瘀法思想；四是给出了活血化瘀方剂，即四乌贼骨一芦茹丸。其后《神农本草经》对活血化瘀法也作出了巨大的贡献，书中记录具有明显活血化瘀作用的中药达41种，这也为活血化瘀法的基本形成创造条件。《金匮要略》在这个基础上，对活血化瘀法作了全面的整理和总结，主要表现在以下四个方面：一、创立瘀血证名，规范活血化瘀法的适应证候；二、记录瘀血脉症，确定活血化瘀法的使用指征；三、详述瘀血兼证，丰富活血化瘀法的临床应用；四、精选化瘀方药，提高活血化瘀法的临床疗效。可以这么说，《金匮要略》的问世，标志着活血化瘀法的基本形成。
活血化瘀法的适应证是瘀血证，这一点毋庸置疑。但由于瘀血证的形成多种多样，其兼证情况也是各不相同，为了更好地对证治疗，书中把活血化瘀法是分散在书中多个篇章中介绍的。本文将其全部整理出来并尝试进行分类，共分为13种，分别为：1清利化瘀法；2解毒祛瘀法．3温养化瘀法；4通阳化瘀法；5攻下逐瘀法；6理气活血法；7益气活血法；8活血通经法；9破瘀逐水法；10祛瘀生新法；11化瘀止血法；12化瘀消癥法；13化瘀退黄法。每种治法都有其适应证候及代表方剂，这种分类希望有助于大家对书中活血化瘀法有个系统的认识。
从活血化瘀法的分类及其代表方药，可以看出仲景在运用该法时具有以下特点：1化瘀常先治气。气虚或气滞均可导致瘀血的产生，故在治疗瘀血证时，常加用补气药或行气药以提高疗效。2化瘀不忘治水。瘀血产生以后，阻碍津液运行，即“血不利则为水”；另一方面，水湿痰饮产生后，也会阻碍血液的运行，故化瘀亦当治水。3化瘀以温为通。血液遇寒则凝，得温则通，故仲景治疗瘀血证时常选桂枝等以温通血脉，提高疗效。4攻补兼施,祛瘀生新。在治疗瘀血兼有虚证时(如大黄(?)虫丸),常以缓攻其瘀的方法,即所谓“瘀血不去,新血不生”;同时加用补益药以兼顾正气,防止伤正。5程度不同,用药有异。仲景在选药治疗瘀血证时,对于瘀血重证或久病之人,常以虫类药为主,而对于瘀血轻证或新病之人,则以植物药为主。6峻药缓攻,有故无殒。在运用活血较强的破血逐瘀药时,为了减少副作用,常以丸药的形式以缓攻,防止损伤正气。
仲景治瘀血之方,其方剂配伍具有一定的规律性,即活血化瘀药常配伍以理气、温经、化痰、利水、清热之品,或佐以扶正,或峻药缓攻、不伤正气,或攻补兼施、刚柔并济。主要是由于瘀血病机复杂,除去新停之瘀可攻可下之外,其他均非单一活血化瘀法可以解决,故只有进行一定配伍以求对证治疗,提高疗效。
对《金匮要略》中活血化瘀方药进行系统研究,是对其治法研究的重要组成部分,本文选择了书中17味中药和15首方剂为研究对象,选择的依据主要有以下三点:一是要具有明显的活血化瘀功效;二是目前临床仍然常用;三是近十几年来对该方药的临床研究和实验研究报道较多。这17味中药分别是:廑虫、虻虫、水蛭、鳖甲、蜣螂、蛴螬、大黄、当归、桃仁、丹皮、川芎、桂枝、王不留行、干漆、土瓜根、红蓝花、蒲黄;15首方剂分别是:大黄(?)虫丸、桂枝茯苓丸、鳖甲煎丸、温经汤、胶艾汤、黄芪桂枝五物汤、大黄牡丹皮汤、下瘀血汤、抵当汤、瓜蒌薤白白酒汤、硝石矾石散、旋复花汤、枳实芍药散、赤小豆当归散、蒲灰散。通过对以上中药的现代研究,我们可以发现,大多具有抗凝血或融栓等药理作用;而对以上方剂的研究则显示,不仅其治疗疾病的范围有所扩大,而且现代临床治疗疾病的大样本研究和药理研究也常证明了仲景使用该方治疗瘀血证的科学依据。这些研究不仅有助于我们科学认识书中活血化瘀方药,而且有利于我们对活血化瘀法的本质有所了解,为以后活血化瘀法的发展和创新打下基础。
仲景的活血化瘀法产生以后,对后世医家有着重要的影响,并在此基础上不断完善和发展,如隋唐时期的《诸病源候论》、《千金方》、《外台秘要》均引用了仲景活血化瘀方剂,并有所创新;而《新修本草》则增加了血竭、苏木、玄胡索等活血化瘀药物。宋金元时代,如《普济方》以及朱丹溪等都对活血化瘀法有着自己新的见解。明清时期,张景岳和叶天士均对活血化瘀法有所发展,但要数王清任和唐容川贡献最大,他们不仅对治法有新的认识,而且创立了许多行之有效的活血化瘀方剂(如补阳还五汤等),并且一直沿用至今,使活血化瘀法上升到了一个新的境界。
Many diseases can be cured in Jinkui Yaolue and its therapies are plentiful. Activating blood circulation to dissipate stasis is recorded many times in it as an important method. But it is dispersed in several chapters and difficult to master. This thesis start from the point of activating blood circulation to dissipate blood stasis to sum up and arrange, systematically investigate its process of formation, drug compatibility regularity, modern research about main formulas and its effect to later generations.
The appearance of Jinkui Yaolue is a sign that the therapy of activating blood circulation to dissipate stasis come into being initially. This thesis collect the relative contents from some chapters and try to classify them, which can be divided into 13 categories. They are: 1 clearing away heat evil, promoting diuresis and dissipating blood stasis therapy; 2 detoxicating and dissipating blood stasis therapy; 3 warm nourishing and dissipating blood stasis therapy; 4 activating Yang and dissipating blood stasis therapy; 5 eliminating extravasated blood by catharsis therapy; 6 regulating Qi and promoting blood flow therapy; 7 invigorating Qi and promoting blood flow therapy; 8 activating blood to promote menstruation therapy; 9 dissipating blood stasis fluid-purging therapy; 10 dissipating blood stasis and producing new blood therapy; 11 dissipating blood stasis and stopping bleeding therapy; 12 dissipating blood stasis and removing lump therapy; 13 dissipating blood stasis and eliminating jaundice therapy. Every therapy has its indication and representative formula. The classification will help everybody study systematically the activating blood circulation to dissipate blood stasis therapy.
From the classification of activating blood circulation to dissipate blood stasis therapy and its representative formula, we can find some characters when Zhang Zhongjin apply it, these characters are below: 1 dissipating blood stasis often treat Qi firstly. Deficient or sluggish Qi both result in stagnant blood, therefore, while treat stagnant blood , often add invigorating Qi medicine or drug that promote the movement of Qi to improve curative effect. 2 dissipating blood stasis should treat water together. Stagnant blood can hamper water to move, namely "blood can not move smoothly that will produce water", on the other hand, water damp phlegm all can interfere blood to move,so dissipating blood stasis should also treat water. 3 dissipating blood stasis should make use of warmth. Blood circle is stagnant when it is cool and smooth when it is warm. So Zhang Zhongjin often select ramulus cinnamomi to warm and smooth blood circle, raise therapeutic effect. 4 simultaneous application of eliminating-tonifying, removing blood stasis and producing new blood. When treating stagnant blood with deficiency(as Dahuang Zhechong Wan), he often eliminated stagnant blood slowly, namely stagnant blood don't go, new blood can't come. Meanwhile add tonic to improve healthy energy to prevent from hurting healthy energy. 5 extent is different, drug is different. When Zhang Zhongjin to treat stagnant blood, he often select worm drugs as main for serious and long patients and select plant drugs as main for slight and new patients. 6 drastic drug attack slowly, prevent from hurting healthy energy. Whin he applied drastic activating blood circulation drug, he often select pilulae to treat slowly to reduce side effect and prevent from hurting healthy energy.
Studying systematically drug and formula of activating blood circulation in Jinkui Yaolue is an important part of studying its treating methods. This thesis select 17 drugs and 15 formulas as research object. We select them based on 3 reasons below: 1 they have obvious effect of activating blood circulation; 2 they are still applied in modern clinic. 3 they have been reported about their clinical and experimental studies in later more than decade years. Here are 17 drugs: ground beetle, gadfly, leech, turtle shell, catharsius, grub, rhubarb, angelica, peach seed, tree peony bark, szechwan lovage rhizome, cassia twig, cowherb seed, dried lacquer, hungaian morningglory root, safflower, cat-tail pollen; here are 15 formulas: Dahuang Zhechong Wan, Guizhi Fuling Wan, Beijiajian Wan, Wenjin Tang, Jiaoai Tang, Huangqi Guizhi Wuwu Tang, Dahuang Mudanpi Tang, Xiayuxue Tang, Didang Tang, Gualou Xiebai Baijiu Tang, Xiaoshi Fanshi San, Xuanfuhua Tang, Zhishi Shaoyao San, Chixiaodou Danggui San, Puhui San. Through the studies of traditional Chinese drugs above, we can find that most of them have the pharmacological action of anticoagulated blood or moltening thrombus; the studies of formulas above show that not only their extent to treat diseases has been expanded, but also the studies of large sample from modern clinic and pharmacology all show Zhang Zhongjin's scientific proof for treating stagnant blood. These studies not only help us know scientifically these drugs and formulas of activating blood circulation to dissipate blood stasis in this book, but also profit us to comprehend the essence of activating blood circulation to dissipate blood stasis, and get the foundation for the development and innovation of it.
The appearance of Zhang Zhongjin's activating blood circulation to dissipate blood stasis therapy had an important impact on later doctors. They consummated and developed it. Some books in Sui and Tang dynasty such as Zhubin Yuanhou Lun, Qianjin Fang, Weitai Miyao all cited Zhang Zhongjin's formulas of activating blood circulation to dissipate blood stasis, and had some innovation. Xinxiu Bencao added dragon's blood, sapan wood, Rhizoma corydalis etc. In Song Jin Yuan dynasty such as Puji Fang and Zhu Danxi both had his new opinions for invigorating blood circulation and eliminating stasis therapy. In Ming and Qing dynasty, Zhang Jinyue and Ye Tianshi both developed the invigorating blood circulation and eliminating stasis therapy. But Wang Qingren and Tang Rongchuan are the greatest docters on it. They not only had new opinions for therapy, but created some effective formulas( for example Buyang Huanwu Tang etc.). Moreover, they are still applied on modern clinic, and make the therapy of invigorating blood circulation and eliminating stasis get a new stage.
《金匮要略》所治疾病甚多，治法也是丰富多样。而活血化瘀法作为中医的一个重要治法，书中有大量的记载，但由于是分散在多个篇章中介绍，不易掌握。故本文从活血化瘀法角度着手，对其进行归纳整理，并系统探讨其形成过程、分类、方药配伍规律、主要方药的现代研究以及对后世的影响。希望本文能对大家有所裨益。
就活血化瘀法的产生而言，应当是人类祖先在同自然界的斗争中，逐渐发现和积累而成的。随着经验的不断积累，至《黄帝内经》问世时，对活血化瘀法已有相当多的阐述，起着重要的贡献，主要体现在以下四个方面：一是提出了血的正常流动的生理意义；二是对瘀血证有了较系统的认识；三是提出了活血化瘀法思想；四是给出了活血化瘀方剂，即四乌贼骨一芦茹丸。其后《神农本草经》对活血化瘀法也作出了巨大的贡献，书中记录具有明显活血化瘀作用的中药达41种，这也为活血化瘀法的基本形成创造条件。《金匮要略》在这个基础上，对活血化瘀法作了全面的整理和总结，主要表现在以下四个方面：一、创立瘀血证名，规范活血化瘀法的适应证候；二、记录瘀血脉症，确定活血化瘀法的使用指征；三、详述瘀血兼证，丰富活血化瘀法的临床应用；四、精选化瘀方药，提高活血化瘀法的临床疗效。可以这么说，《金匮要略》的问世，标志着活血化瘀法的基本形成。
活血化瘀法的适应证是瘀血证，这一点毋庸置疑。但由于瘀血证的形成多种多样，其兼证情况也是各不相同，为了更好地对证治疗，书中把活血化瘀法是分散在书中多个篇章中介绍的。本文将其全部整理出来并尝试进行分类，共分为13种，分别为：1清利化瘀法；2解毒祛瘀法．3温养化瘀法；4通阳化瘀法；5攻下逐瘀法；6理气活血法；7益气活血法；8活血通经法；9破瘀逐水法；10祛瘀生新法；11化瘀止血法；12化瘀消癥法；13化瘀退黄法。每种治法都有其适应证候及代表方剂，这种分类希望有助于大家对书中活血化瘀法有个系统的认识。
从活血化瘀法的分类及其代表方药，可以看出仲景在运用该法时具有以下特点：1化瘀常先治气。气虚或气滞均可导致瘀血的产生，故在治疗瘀血证时，常加用补气药或行气药以提高疗效。2化瘀不忘治水。瘀血产生以后，阻碍津液运行，即“血不利则为水”；另一方面，水湿痰饮产生后，也会阻碍血液的运行，故化瘀亦当治水。3化瘀以温为通。血液遇寒则凝，得温则通，故仲景治疗瘀血证时常选桂枝等以温通血脉，提高疗效。4攻补兼施,祛瘀生新。在治疗瘀血兼有虚证时(如大黄(?)虫丸),常以缓攻其瘀的方法,即所谓“瘀血不去,新血不生”;同时加用补益药以兼顾正气,防止伤正。5程度不同,用药有异。仲景在选药治疗瘀血证时,对于瘀血重证或久病之人,常以虫类药为主,而对于瘀血轻证或新病之人,则以植物药为主。6峻药缓攻,有故无殒。在运用活血较强的破血逐瘀药时,为了减少副作用,常以丸药的形式以缓攻,防止损伤正气。
仲景治瘀血之方,其方剂配伍具有一定的规律性,即活血化瘀药常配伍以理气、温经、化痰、利水、清热之品,或佐以扶正,或峻药缓攻、不伤正气,或攻补兼施、刚柔并济。主要是由于瘀血病机复杂,除去新停之瘀可攻可下之外,其他均非单一活血化瘀法可以解决,故只有进行一定配伍以求对证治疗,提高疗效。
对《金匮要略》中活血化瘀方药进行系统研究,是对其治法研究的重要组成部分,本文选择了书中17味中药和15首方剂为研究对象,选择的依据主要有以下三点:一是要具有明显的活血化瘀功效;二是目前临床仍然常用;三是近十几年来对该方药的临床研究和实验研究报道较多。这17味中药分别是:廑虫、虻虫、水蛭、鳖甲、蜣螂、蛴螬、大黄、当归、桃仁、丹皮、川芎、桂枝、王不留行、干漆、土瓜根、红蓝花、蒲黄;15首方剂分别是:大黄(?)虫丸、桂枝茯苓丸、鳖甲煎丸、温经汤、胶艾汤、黄芪桂枝五物汤、大黄牡丹皮汤、下瘀血汤、抵当汤、瓜蒌薤白白酒汤、硝石矾石散、旋复花汤、枳实芍药散、赤小豆当归散、蒲灰散。通过对以上中药的现代研究,我们可以发现,大多具有抗凝血或融栓等药理作用;而对以上方剂的研究则显示,不仅其治疗疾病的范围有所扩大,而且现代临床治疗疾病的大样本研究和药理研究也常证明了仲景使用该方治疗瘀血证的科学依据。这些研究不仅有助于我们科学认识书中活血化瘀方药,而且有利于我们对活血化瘀法的本质有所了解,为以后活血化瘀法的发展和创新打下基础。
仲景的活血化瘀法产生以后,对后世医家有着重要的影响,并在此基础上不断完善和发展,如隋唐时期的《诸病源候论》、《千金方》、《外台秘要》均引用了仲景活血化瘀方剂,并有所创新;而《新修本草》则增加了血竭、苏木、玄胡索等活血化瘀药物。宋金元时代,如《普济方》以及朱丹溪等都对活血化瘀法有着自己新的见解。明清时期,张景岳和叶天士均对活血化瘀法有所发展,但要数王清任和唐容川贡献最大,他们不仅对治法有新的认识,而且创立了许多行之有效的活血化瘀方剂(如补阳还五汤等),并且一直沿用至今,使活血化瘀法上升到了一个新的境界。
Many diseases can be cured in Jinkui Yaolue and its therapies are plentiful. Activating blood circulation to dissipate stasis is recorded many times in it as an important method. But it is dispersed in several chapters and difficult to master. This thesis start from the point of activating blood circulation to dissipate blood stasis to sum up and arrange, systematically investigate its process of formation, drug compatibility regularity, modern research about main formulas and its effect to later generations.
The appearance of Jinkui Yaolue is a sign that the therapy of activating blood circulation to dissipate stasis come into being initially. This thesis collect the relative contents from some chapters and try to classify them, which can be divided into 13 categories. They are: 1 clearing away heat evil, promoting diuresis and dissipating blood stasis therapy; 2 detoxicating and dissipating blood stasis therapy; 3 warm nourishing and dissipating blood stasis therapy; 4 activating Yang and dissipating blood stasis therapy; 5 eliminating extravasated blood by catharsis therapy; 6 regulating Qi and promoting blood flow therapy; 7 invigorating Qi and promoting blood flow therapy; 8 activating blood to promote menstruation therapy; 9 dissipating blood stasis fluid-purging therapy; 10 dissipating blood stasis and producing new blood therapy; 11 dissipating blood stasis and stopping bleeding therapy; 12 dissipating blood stasis and removing lump therapy; 13 dissipating blood stasis and eliminating jaundice therapy. Every therapy has its indication and representative formula. The classification will help everybody study systematically the activating blood circulation to dissipate blood stasis therapy.
From the classification of activating blood circulation to dissipate blood stasis therapy and its representative formula, we can find some characters when Zhang Zhongjin apply it, these characters are below: 1 dissipating blood stasis often treat Qi firstly. Deficient or sluggish Qi both result in stagnant blood, therefore, while treat stagnant blood , often add invigorating Qi medicine or drug that promote the movement of Qi to improve curative effect. 2 dissipating blood stasis should treat water together. Stagnant blood can hamper water to move, namely "blood can not move smoothly that will produce water", on the other hand, water damp phlegm all can interfere blood to move,so dissipating blood stasis should also treat water. 3 dissipating blood stasis should make use of warmth. Blood circle is stagnant when it is cool and smooth when it is warm. So Zhang Zhongjin often select ramulus cinnamomi to warm and smooth blood circle, raise therapeutic effect. 4 simultaneous application of eliminating-tonifying, removing blood stasis and producing new blood. When treating stagnant blood with deficiency(as Dahuang Zhechong Wan), he often eliminated stagnant blood slowly, namely stagnant blood don't go, new blood can't come. Meanwhile add tonic to improve healthy energy to prevent from hurting healthy energy. 5 extent is different, drug is different. When Zhang Zhongjin to treat stagnant blood, he often select worm drugs as main for serious and long patients and select plant drugs as main for slight and new patients. 6 drastic drug attack slowly, prevent from hurting healthy energy. Whin he applied drastic activating blood circulation drug, he often select pilulae to treat slowly to reduce side effect and prevent from hurting healthy energy.
Studying systematically drug and formula of activating blood circulation in Jinkui Yaolue is an important part of studying its treating methods. This thesis select 17 drugs and 15 formulas as research object. We select them based on 3 reasons below: 1 they have obvious effect of activating blood circulation; 2 they are still applied in modern clinic. 3 they have been reported about their clinical and experimental studies in later more than decade years. Here are 17 drugs: ground beetle, gadfly, leech, turtle shell, catharsius, grub, rhubarb, angelica, peach seed, tree peony bark, szechwan lovage rhizome, cassia twig, cowherb seed, dried lacquer, hungaian morningglory root, safflower, cat-tail pollen; here are 15 formulas: Dahuang Zhechong Wan, Guizhi Fuling Wan, Beijiajian Wan, Wenjin Tang, Jiaoai Tang, Huangqi Guizhi Wuwu Tang, Dahuang Mudanpi Tang, Xiayuxue Tang, Didang Tang, Gualou Xiebai Baijiu Tang, Xiaoshi Fanshi San, Xuanfuhua Tang, Zhishi Shaoyao San, Chixiaodou Danggui San, Puhui San. Through the studies of traditional Chinese drugs above, we can find that most of them have the pharmacological action of anticoagulated blood or moltening thrombus; the studies of formulas above show that not only their extent to treat diseases has been expanded, but also the studies of large sample from modern clinic and pharmacology all show Zhang Zhongjin's scientific proof for treating stagnant blood. These studies not only help us know scientifically these drugs and formulas of activating blood circulation to dissipate blood stasis in this book, but also profit us to comprehend the essence of activating blood circulation to dissipate blood stasis, and get the foundation for the development and innovation of it.
The appearance of Zhang Zhongjin's activating blood circulation to dissipate blood stasis therapy had an important impact on later doctors. They consummated and developed it. Some books in Sui and Tang dynasty such as Zhubin Yuanhou Lun, Qianjin Fang, Weitai Miyao all cited Zhang Zhongjin's formulas of activating blood circulation to dissipate blood stasis, and had some innovation. Xinxiu Bencao added dragon's blood, sapan wood, Rhizoma corydalis etc. In Song Jin Yuan dynasty such as Puji Fang and Zhu Danxi both had his new opinions for invigorating blood circulation and eliminating stasis therapy. In Ming and Qing dynasty, Zhang Jinyue and Ye Tianshi both developed the invigorating blood circulation and eliminating stasis therapy. But Wang Qingren and Tang Rongchuan are the greatest docters on it. They not only had new opinions for therapy, but created some effective formulas( for example Buyang Huanwu Tang etc.). Moreover, they are still applied on modern clinic, and make the therapy of invigorating blood circulation and eliminating stasis get a new stage.
引文
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