木防己汤方证特征及其治疗重症心衰研究
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摘要
木防己汤出自《金匮要略》,主治"膈间支饮"。然而,该方结构奇特,寒温并用,补泻同施,不可以常理解读、诠释。研究发现,木防己汤属少阴阳明合病,且方中配伍生石膏这一千古疑难问题具有深刻的病理生理学基础,符合临床实际,并非"不可理喻"。木防己汤方证特征包括:(1)在现代医学的疾病方面,木防己汤可用于急慢性心力衰竭、右心功能不全、全心衰、舒张功能不全心衰等各种类型的心力衰竭;肺部感染加重心衰、慢性阻塞性肺病急性发作、肺源性心脏病急性加重等肺部疾病;全心衰导致的双侧大量胸腔积液,且运用常规利尿剂疗效不佳者;痹证的治疗,包括痛风急性发作、风湿热、风湿性关节炎、类风湿性关节炎;风湿热及风湿性心脏病在以前发病率很高,推测该方在古代很可能用于风湿性心脏病伴心力衰竭的治疗。(2)在症状方面,木防己汤还可用于:喘憋,胸闷,胸满,喘息不能平卧,呼吸困难,甚则端坐位;心下、胃脘部位的胀满不适;脸色发黑、发暗、发紫,二尖瓣面容;头面、四肢水肿;口干,口渴,欲冷饮方舒,贪凉,不愿厚衣、厚被,畏热喜凉,烦躁;神疲乏力,气短懒言,纳差,便秘,大便干结难解,甚至数日一行,下肢水肿伴有小便不利,小便量少,色黄,且对利尿剂反应较差,甚至出现利尿剂抵抗,对常规的利尿方案不敏感;心率快,很难用西药控制;真武汤治疗无效;舌质暗红,舌干少津,舌苔黄,苍老苔,脉数,或沉紧。在管理危重症患者过程中,还认识到:阳虚水饮是心衰之"常态",是临床最常见的证型,也是最简单的证型;阳虚水饮化热则是心衰之"变态",是临床中的特殊类型,但这是一种客观存在,且运用常规温阳化饮法基本无效,如真武汤;阳虚水饮化热证的背后,存在深刻而复杂的病理生理学作用机制,且化热多提示预后不良,是运用生石膏的指征;少阴热化证的病理生理学机制与此相同;对于木防己汤方中配伍生石膏的疑难问题,历代医家众说纷纭,但大多以经解经、随文敷衍、不求甚解、无解强解,甚至"以其昏昏使人昭昭",需要重新审视、解读;木防己汤方证加减法中的"虚"与"实"不是言病机,而是指体征,"虚"是指阳虚水饮化热合并阳明经证的治疗,而"实"是指阳虚水饮化热合并阳明腑证的治疗,该条文符合现今临床实际,其背后存在深刻的病理生理学作用机制。
Mufangji Decoction is a famous herbal formula from Synopsis of Golden Chamber. However,it is easy to be misunderstood due to so its unique compatability. The syndromes treated by Mufangji Decoction included the following aspects:(1) in terms of modern medicine,it could be used to treat acute and chronic heart failure,heart failure aggravated by lung infection,chronic obstructive pulmonary disease acute episode,pulmonary heart disease,bilateral pleural effusion,acute attack of gout,rheumatic fever,rheumatoid arthritis,and rheumatoid arthritis;(2) in terms of symptoms,it could be used to treat asthma,chest tightness,wheeze impacting prostration and dyspnea impacting sitting posture; gastric distention; dark face,cyanotic,and mitral valvular face; edema of head and extremities; dry mouth,thirsty,unwilling to wear thick clothes,intolerance of heat,and irritable; fatigue,shortness of breath,poor appetite,constipation,less urine,yellow color,poor response to diuretics,and diuretic resistance; fast heart rate,which is hard to be controlled by Western medicine and has no response to Zhenwu Decoction; dark red tongue,dry tongue with yellow fur,rapid pulse,or deep tight pulse. In emergency and severe cases,Yang deficiency and fluid retention are normal syndromes of heart failure,while Yang deficiency,fluid retention,and heat are metamorphic syndromes of heart failure,which possessed complex mechanisms of pathophysiology; the mechanisms of Shaoyin heat-conversion syndrome is similar to Yang deficiency,fluid retention,and heat syndrome; the reason of application of gypsum in Mufangji Decoction shall be further studied; the " empty" and " real" in modified Mufangji Decoction are physical signs,rather than pathogenesis.
Mufangji Decoction is a famous herbal formula from Synopsis of Golden Chamber. However,it is easy to be misunderstood due to so its unique compatability. The syndromes treated by Mufangji Decoction included the following aspects:(1) in terms of modern medicine,it could be used to treat acute and chronic heart failure,heart failure aggravated by lung infection,chronic obstructive pulmonary disease acute episode,pulmonary heart disease,bilateral pleural effusion,acute attack of gout,rheumatic fever,rheumatoid arthritis,and rheumatoid arthritis;(2) in terms of symptoms,it could be used to treat asthma,chest tightness,wheeze impacting prostration and dyspnea impacting sitting posture; gastric distention; dark face,cyanotic,and mitral valvular face; edema of head and extremities; dry mouth,thirsty,unwilling to wear thick clothes,intolerance of heat,and irritable; fatigue,shortness of breath,poor appetite,constipation,less urine,yellow color,poor response to diuretics,and diuretic resistance; fast heart rate,which is hard to be controlled by Western medicine and has no response to Zhenwu Decoction; dark red tongue,dry tongue with yellow fur,rapid pulse,or deep tight pulse. In emergency and severe cases,Yang deficiency and fluid retention are normal syndromes of heart failure,while Yang deficiency,fluid retention,and heat are metamorphic syndromes of heart failure,which possessed complex mechanisms of pathophysiology; the mechanisms of Shaoyin heat-conversion syndrome is similar to Yang deficiency,fluid retention,and heat syndrome; the reason of application of gypsum in Mufangji Decoction shall be further studied; the " empty" and " real" in modified Mufangji Decoction are physical signs,rather than pathogenesis.
引文
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[7]黄煌.张仲景五十味药证[M].北京:人民卫生出版社,1996.
[8]熊兴江.《伤寒论》与急危重症——基于CCU重症病例及中西医结合诠释经典条文内涵、经方剂量与六经实质[J].中国中药杂志,2018,43(12):2413.
[9]王阶,熊兴江,何庆勇,等.方证对应内涵及原则探讨[J].中医杂志,2009,50(3):197.
[10]张良,江振洲,卞勇,等.中药广防己与粉防己总提取物利尿效应及肾毒性比较研究[J].安徽医药,2009,13(12):1471.
[11]梁琦,倪诚,颜贤忠,等.广防己、粉防己的肝肾毒性及代谢组学比较研究[J].中国中药杂志,2010,35(21):2882.
[2]沈敏南.木防己汤的临床应用和体会[J].成都中医学院学报,1979(3):71.
[3]程志清.陆芷青教授经方实验录[J].吉林中医药,1993(5):7.
[4]李克绍.李克绍医学文集[M].济南:山东科学技术出版社,2006.
[5]王付.经方合用辨治慢性支气管炎[J].中医药通报,2010(9):8.
[6]王阶,熊兴江,何庆勇,等.方证对应内涵及原则探讨[J].中医杂志,2009,50(3):197.
[7]黄煌.张仲景五十味药证[M].北京:人民卫生出版社,1996.
[8]熊兴江.《伤寒论》与急危重症——基于CCU重症病例及中西医结合诠释经典条文内涵、经方剂量与六经实质[J].中国中药杂志,2018,43(12):2413.
[9]王阶,熊兴江,何庆勇,等.方证对应内涵及原则探讨[J].中医杂志,2009,50(3):197.
[10]张良,江振洲,卞勇,等.中药广防己与粉防己总提取物利尿效应及肾毒性比较研究[J].安徽医药,2009,13(12):1471.
[11]梁琦,倪诚,颜贤忠,等.广防己、粉防己的肝肾毒性及代谢组学比较研究[J].中国中药杂志,2010,35(21):2882.