導語：中(zhong)醫同病理論內(nei)涵(han)及(ji)其臨床應用(yong)一(yi)文來源于網友上傳，不代表本站觀(guan)點，若需要原創文章可咨詢(xun)客服(fu)老師(shi)，歡(huan)迎參考。

摘要：痰和瘀的中醫理論研究頗多，現將痰和瘀的中醫理論與現代醫學的內環境理論相結合，重新認識痰瘀互結。痰瘀互結的臨床癥狀諸多學者表述不一，主要有積包塊、神志失常、疼痛、肌膚麻木、肢體偏廢、癰瘍等。基于理論研究發現，大部分癥狀都可以歸納為疼痛和麻木２個核心癥狀，并系統闡述了痰瘀同病的病(bing)因病(bing)機，以冠心病(bing)、抑郁癥、陽痿３個(ge)臨床常見疾病(bing)為例(li)，探討從痰(tan)瘀論治在具體疾病(bing)中(zhong)的重要意義(yi)。

關鍵詞：痰；瘀；理論內涵；臨床特征；疼痛；麻木；臨床應用

痰瘀是(shi)多種慢性(xing)疾(ji)病(bing)的(de)(de)(de)基本(ben)病(bing)機，這一觀點已經得(de)到(dao)近(jin)代(dai)醫家的(de)(de)(de)普(pu)遍(bian)共識［１］。近(jin)些年來不少學者(zhe)提出從痰瘀論(lun)治(zhi)多種慢性(xing)疾(ji)病(bing)的(de)(de)(de)新(xin)主張，尤其是(shi)在(zai)腫瘤、高血壓、心腦血管疾(ji)病(bing)、代(dai)謝(xie)性(xing)疾(ji)病(bing)等領域發(fa)展(zhan)最(zui)為(wei)(wei)顯著，臨床療(liao)效顯著，相關研究進(jin)展(zhan)迅速(su)，成果(guo)豐富，痰瘀已成為(wei)(wei)多種疾(ji)病(bing)診治(zhi)的(de)(de)(de)關鍵環(huan)節。中醫學認為(wei)(wei)痰和瘀均為(wei)(wei)病(bing)理產物，津(jin)液代(dai)謝(xie)障礙(ai)則生(sheng)痰，血液運行(xing)障礙(ai)則生(sheng)瘀，二者(zhe)同(tong)時(shi)出現，將進(jin)一步導致新(xin)的(de)(de)(de)病(bing)變產生(sheng)，痰瘀共同(tong)致病(bing)，臨床癥狀(zhuang)多樣，治(zhi)療(liao)困難，因(yin)此，進(jin)一步探究痰瘀互(hu)結(jie)的(de)(de)(de)內涵與核(he)心癥狀(zhuang)對臨床上(shang)運用(yong)“異病(bing)同(tong)治(zhi)”理論(lun)，治(zhi)療(liao)各(ge)種疾(ji)病(bing)的(de)(de)(de)痰瘀互(hu)結(jie)證具有(you)實際意(yi)義。

１痰瘀的理論源流與基本內涵

１.１痰瘀理論的發展(zhan)源流

痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)同(tong)(tong)病(bing)(bing)(bing)的(de)(de)(de)(de)思想來(lai)源(yuan)已久，早(zao)在先秦兩(liang)漢(han)時期已經出(chu)現(xian)(xian)［２］。《五十二病(bing)(bing)(bing)方(fang)(fang)》中(zhong)(zhong)已有(you)痰(tan)(tan)(tan)(tan)(tan)(tan)、瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)藥物的(de)(de)(de)(de)記載，東漢(han)武威漢(han)簡中(zhong)(zhong)記載的(de)(de)(de)(de)“瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)方(fang)(fang)”，雖言治瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)，但(dan)其中(zhong)(zhong)已經配伍貝母(mu)化痰(tan)(tan)(tan)(tan)(tan)(tan)散(san)結，是痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)同(tong)(tong)治的(de)(de)(de)(de)雛形(xing)。《黃帝內(nei)經》雖尚未明(ming)確(que)提(ti)出(chu)痰(tan)(tan)(tan)(tan)(tan)(tan)、瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)，但(dan)已認(ren)(ren)(ren)識到痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)同(tong)(tong)病(bing)(bing)(bing)的(de)(de)(de)(de)形(xing)成機(ji)制，例如“濕(shi)氣不(bu)行，凝(ning)血(xue)蘊里而不(bu)散(san)，津液澀滲，著而不(bu)去，而積(ji)皆成矣”“汁(zhi)沫與(yu)血(xue)相(xiang)摶(tuan)，則(ze)并合(he)凝(ning)聚(ju)不(bu)得散(san)，而積(ji)成矣”，清晰(xi)地(di)闡(chan)述(shu)了(le)痰(tan)(tan)(tan)(tan)(tan)(tan)和瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)兼挾致病(bing)(bing)(bing)的(de)(de)(de)(de)過程。至漢(han)代(dai)張機(ji)，明(ming)確(que)提(ti)出(chu)了(le)痰(tan)(tan)(tan)(tan)(tan)(tan)飲(yin)(yin)和瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)血(xue)的(de)(de)(de)(de)病(bing)(bing)(bing)名［３］，《金(jin)匱要略》中(zhong)(zhong)有(you)“其人素盛今瘦，水(shui)走腸(chang)間，瀝瀝有(you)聲，謂之(zhi)痰(tan)(tan)(tan)(tan)(tan)(tan)飲(yin)(yin)”，并根據痰(tan)(tan)(tan)(tan)(tan)(tan)飲(yin)(yin)停留(liu)的(de)(de)(de)(de)位置分為(wei)(wei)(wei)痰(tan)(tan)(tan)(tan)(tan)(tan)飲(yin)(yin)、懸飲(yin)(yin)、支飲(yin)(yin)、溢飲(yin)(yin)，提(ti)出(chu)了(le)痰(tan)(tan)(tan)(tan)(tan)(tan)飲(yin)(yin)病(bing)(bing)(bing)的(de)(de)(de)(de)治療原則(ze)。《金(jin)匱要略?驚(jing)悸吐衄下血(xue)胸滿瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)血(xue)病(bing)(bing)(bing)脈證(zheng)治》曰：“胸滿，唇痿舌青，口(kou)燥但(dan)欲(yu)漱水(shui)，不(bu)欲(yu)咽(yan)，無寒熱，脈微(wei)(wei)大(da)來(lai)遲(chi)，腹不(bu)滿，其人言我(wo)滿，為(wei)(wei)(wei)有(you)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)血(xue)。”且張機(ji)的(de)(de)(de)(de)方(fang)(fang)藥中(zhong)(zhong)不(bu)乏活血(xue)、化痰(tan)(tan)(tan)(tan)(tan)(tan)、祛(qu)濕(shi)藥同(tong)(tong)用，可謂對痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)同(tong)(tong)治具有(you)實(shi)際的(de)(de)(de)(de)指導(dao)(dao)意(yi)義(yi)。痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)理論(lun)逐漸(jian)從(cong)痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)同(tong)(tong)病(bing)(bing)(bing)發展為(wei)(wei)(wei)痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)互(hu)結。結，意(yi)為(wei)(wei)(wei)痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)相(xiang)互(hu)搏結，進(jin)一(yi)步闡(chan)明(ming)了(le)痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)同(tong)(tong)病(bing)(bing)(bing)，可能導(dao)(dao)致新的(de)(de)(de)(de)病(bing)(bing)(bing)理變化。痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)互(hu)結的(de)(de)(de)(de)雛形(xing)最早(zao)源(yuan)自宋代(dai)許叔(shu)微(wei)(wei)的(de)(de)(de)(de)濕(shi)痰(tan)(tan)(tan)(tan)(tan)(tan)、痰(tan)(tan)(tan)(tan)(tan)(tan)飲(yin)(yin)成癖囊說，因其喜飲(yin)(yin)酒，日久出(chu)現(xian)(xian)腸(chang)中(zhong)(zhong)漉(lu)漉(lu)有(you)聲、脅痛、嘔吐酸苦(ku)水(shui)等(deng)癥，許叔(shu)微(wei)(wei)認(ren)(ren)(ren)為(wei)(wei)(wei)此(ci)為(wei)(wei)(wei)“癖囊”之(zhi)疾，并以蒼術一(yi)味(wei)治之(zhi)［４］。元代(dai)朱(zhu)震亨(heng)最先明(ming)確(que)提(ti)出(chu)了(le)痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)互(hu)結的(de)(de)(de)(de)觀點，并認(ren)(ren)(ren)為(wei)(wei)(wei)痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)互(hu)結形(xing)成的(de)(de)(de)(de)病(bing)(bing)(bing)理產物為(wei)(wei)(wei)窠囊，其《丹(dan)溪(xi)心法(fa)》中(zhong)(zhong)提(ti)出(chu)：“自郁(yu)成積(ji)，自積(ji)成痰(tan)(tan)(tan)(tan)(tan)(tan)，痰(tan)(tan)(tan)(tan)(tan)(tan)挾瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)血(xue)，遂成窠囊。”“肺脹而咳(ke)，或(huo)左或(huo)右，不(bu)得眠，此(ci)痰(tan)(tan)(tan)(tan)(tan)(tan)挾瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)血(xue)礙氣而病(bing)(bing)(bing)。”現(xian)(xian)代(dai)醫(yi)家關于痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)相(xiang)互(hu)轉化、互(hu)為(wei)(wei)(wei)因果，痰(tan)(tan)(tan)(tan)(tan)(tan)、瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)、水(shui)飲(yin)(yin)三者(zhe)實(shi)為(wei)(wei)(wei)“一(yi)源(yuan)三岐”等(deng)論(lun)述(shu)頗多［５］，且論(lun)據基本(ben)相(xiang)似，故本(ben)文不(bu)再贅述(shu)痰(tan)(tan)(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)(yu)(yu)(yu)同(tong)(tong)病(bing)(bing)(bing)的(de)(de)(de)(de)中(zhong)(zhong)醫(yi)學內(nei)涵。

１.２痰(tan)瘀的基本內涵

痰(tan)(tan)(tan)(tan)(tan)飲(yin)(yin)(yin)的(de)(de)(de)(de)(de)(de)(de)(de)(de)本(ben)質為(wei)(wei)(wei)(wei)(wei)津(jin)液(ye)(ye)代(dai)(dai)(dai)(dai)謝異常(chang)所(suo)生(sheng)病(bing)(bing)理(li)產(chan)物(wu)(wu)(wu)。“痰(tan)(tan)(tan)(tan)(tan)飲(yin)(yin)(yin)”一(yi)詞(ci)后世認(ren)為(wei)(wei)(wei)(wei)(wei)應為(wei)(wei)(wei)(wei)(wei)“淡(dan)(dan)(dan)(dan)飲(yin)(yin)(yin)”，王熙的(de)(de)(de)(de)(de)(de)(de)(de)(de)《脈經(jing)》和孫(sun)思邈(miao)的(de)(de)(de)(de)(de)(de)(de)(de)(de)《千金翼方》，其中(zhong)(zhong)(zhong)的(de)(de)(de)(de)(de)(de)(de)(de)(de)“痰(tan)(tan)(tan)(tan)(tan)飲(yin)(yin)(yin)”皆寫作“淡(dan)(dan)(dan)(dan)飲(yin)(yin)(yin)”。正(zheng)如《雜病(bing)(bing)廣(guang)要?痰(tan)(tan)(tan)(tan)(tan)涎》所(suo)言：“痰(tan)(tan)(tan)(tan)(tan)古作淡(dan)(dan)(dan)(dan)，淡(dan)(dan)(dan)(dan)、澹通，澹水(shui)(shui)(shui)動也(ye)，故水(shui)(shui)(shui)走腸(chang)間，名為(wei)(wei)(wei)(wei)(wei)淡(dan)(dan)(dan)(dan)飲(yin)(yin)(yin)。今之(zhi)痰(tan)(tan)(tan)(tan)(tan)者(zhe)(zhe)(zhe)，古之(zhi)云涕(ti)云唾云涎云沫是(shi)也(ye)。”明(ming)代(dai)(dai)(dai)(dai)醫(yi)(yi)(yi)(yi)(yi)(yi)(yi)家張(zhang)介賓(bin)言：“夫人之(zhi)多(duo)痰(tan)(tan)(tan)(tan)(tan)，悉(xi)由(you)中(zhong)(zhong)(zhong)虛而(er)然，蓋痰(tan)(tan)(tan)(tan)(tan)即水(shui)(shui)(shui)也(ye)。其本(ben)在(zai)(zai)(zai)腎，其標在(zai)(zai)(zai)脾(pi)。在(zai)(zai)(zai)腎者(zhe)(zhe)(zhe)，以水(shui)(shui)(shui)不歸源(yuan)，水(shui)(shui)(shui)泛為(wei)(wei)(wei)(wei)(wei)痰(tan)(tan)(tan)(tan)(tan)也(ye)；在(zai)(zai)(zai)脾(pi)者(zhe)(zhe)(zhe)，以食欲不化(hua)(hua)(hua)，土不能制水(shui)(shui)(shui)也(ye)。”［６］明(ming)《醫(yi)(yi)(yi)(yi)(yi)(yi)(yi)學(xue)(xue)(xue)入(ru)門(men)》曰：“痰(tan)(tan)(tan)(tan)(tan)乃津(jin)液(ye)(ye)所(suo)生(sheng)。”由(you)此可見，痰(tan)(tan)(tan)(tan)(tan)飲(yin)(yin)(yin)的(de)(de)(de)(de)(de)(de)(de)(de)(de)實(shi)質是(shi)未能正(zheng)常(chang)代(dai)(dai)(dai)(dai)謝的(de)(de)(de)(de)(de)(de)(de)(de)(de)水(shui)(shui)(shui)液(ye)(ye)。痰(tan)(tan)(tan)(tan)(tan)有(you)狹義(yi)和廣(guang)義(yi)之(zhi)分(fen)，狹義(yi)之(zhi)痰(tan)(tan)(tan)(tan)(tan)是(shi)指咳或吐(tu)出的(de)(de)(de)(de)(de)(de)(de)(de)(de)痰(tan)(tan)(tan)(tan)(tan)，又稱(cheng)為(wei)(wei)(wei)(wei)(wei)有(you)形(xing)(xing)之(zhi)痰(tan)(tan)(tan)(tan)(tan)；廣(guang)義(yi)之(zhi)痰(tan)(tan)(tan)(tan)(tan)是(shi)指臟(zang)(zang)腑的(de)(de)(de)(de)(de)(de)(de)(de)(de)一(yi)切廢物(wu)(wu)(wu)的(de)(de)(de)(de)(de)(de)(de)(de)(de)統(tong)稱(cheng)，又稱(cheng)為(wei)(wei)(wei)(wei)(wei)無形(xing)(xing)之(zhi)痰(tan)(tan)(tan)(tan)(tan)，這(zhe)里需要說明(ming)的(de)(de)(de)(de)(de)(de)(de)(de)(de)是(shi)痰(tan)(tan)(tan)(tan)(tan)在(zai)(zai)(zai)各版本(ben)的(de)(de)(de)(de)(de)(de)(de)(de)(de)《中(zhong)(zhong)(zhong)醫(yi)(yi)(yi)(yi)(yi)(yi)(yi)基礎理(li)論(lun)》教材中(zhong)(zhong)(zhong)都被認(ren)為(wei)(wei)(wei)(wei)(wei)是(shi)一(yi)種病(bing)(bing)理(li)產(chan)物(wu)(wu)(wu)，說明(ming)痰(tan)(tan)(tan)(tan)(tan)為(wei)(wei)(wei)(wei)(wei)病(bing)(bing)理(li)產(chan)物(wu)(wu)(wu)是(shi)中(zhong)(zhong)(zhong)醫(yi)(yi)(yi)(yi)(yi)(yi)(yi)學(xue)(xue)(xue)者(zhe)(zhe)(zhe)的(de)(de)(de)(de)(de)(de)(de)(de)(de)共識，而(er)病(bing)(bing)理(li)產(chan)物(wu)(wu)(wu)是(shi)有(you)形(xing)(xing)之(zhi)物(wu)(wu)(wu)，因(yin)此無形(xing)(xing)之(zhi)痰(tan)(tan)(tan)(tan)(tan)并(bing)(bing)非真的(de)(de)(de)(de)(de)(de)(de)(de)(de)“無形(xing)(xing)”，可能是(shi)古代(dai)(dai)(dai)(dai)醫(yi)(yi)(yi)(yi)(yi)(yi)(yi)家受到(dao)生(sheng)化(hua)(hua)(hua)驗(yan)檢手(shou)段(duan)的(de)(de)(de)(de)(de)(de)(de)(de)(de)局限無法對(dui)臟(zang)(zang)腑產(chan)生(sheng)的(de)(de)(de)(de)(de)(de)(de)(de)(de)代(dai)(dai)(dai)(dai)謝物(wu)(wu)(wu)有(you)清晰的(de)(de)(de)(de)(de)(de)(de)(de)(de)認(ren)識，因(yin)此將超出認(ren)知(zhi)的(de)(de)(de)(de)(de)(de)(de)(de)(de)“痰(tan)(tan)(tan)(tan)(tan)”稱(cheng)為(wei)(wei)(wei)(wei)(wei)“無形(xing)(xing)之(zhi)痰(tan)(tan)(tan)(tan)(tan)”。“痰(tan)(tan)(tan)(tan)(tan)”和“飲(yin)(yin)(yin)”常(chang)合并(bing)(bing)在(zai)(zai)(zai)一(yi)起稱(cheng)為(wei)(wei)(wei)(wei)(wei)“痰(tan)(tan)(tan)(tan)(tan)飲(yin)(yin)(yin)”，一(yi)般以較黏濁者(zhe)(zhe)(zhe)稱(cheng)之(zhi)為(wei)(wei)(wei)(wei)(wei)痰(tan)(tan)(tan)(tan)(tan)，清稀者(zhe)(zhe)(zhe)稱(cheng)之(zhi)為(wei)(wei)(wei)(wei)(wei)飲(yin)(yin)(yin)，痰(tan)(tan)(tan)(tan)(tan)和飲(yin)(yin)(yin)都是(shi)水(shui)(shui)(shui)液(ye)(ye)代(dai)(dai)(dai)(dai)謝障礙所(suo)形(xing)(xing)成的(de)(de)(de)(de)(de)(de)(de)(de)(de)病(bing)(bing)理(li)產(chan)物(wu)(wu)(wu)，因(yin)此在(zai)(zai)(zai)“痰(tan)(tan)(tan)(tan)(tan)瘀(yu)互結(jie)”的(de)(de)(de)(de)(de)(de)(de)(de)(de)表述中(zhong)(zhong)(zhong)受到(dao)４個字的(de)(de)(de)(de)(de)(de)(de)(de)(de)限制，“痰(tan)(tan)(tan)(tan)(tan)”往往也(ye)包(bao)含了(le)“飲(yin)(yin)(yin)”［７９］。瘀(yu)，《說文》：“積血(xue)(xue)(xue)(xue)(xue)也(ye)。”指體內有(you)血(xue)(xue)(xue)(xue)(xue)液(ye)(ye)停滯(zhi)，包(bao)括離經(jing)之(zhi)血(xue)(xue)(xue)(xue)(xue)積存體內，或血(xue)(xue)(xue)(xue)(xue)運不暢，阻滯(zhi)于經(jing)脈及臟(zang)(zang)腑內的(de)(de)(de)(de)(de)(de)(de)(de)(de)血(xue)(xue)(xue)(xue)(xue)液(ye)(ye)，均(jun)稱(cheng)為(wei)(wei)(wei)(wei)(wei)瘀(yu)血(xue)(xue)(xue)(xue)(xue)。現(xian)代(dai)(dai)(dai)(dai)醫(yi)(yi)(yi)(yi)(yi)(yi)(yi)學(xue)(xue)(xue)認(ren)為(wei)(wei)(wei)(wei)(wei)人體內環(huan)(huan)境(jing)是(shi)由(you)淋(lin)巴(ba)(ba)、血(xue)(xue)(xue)(xue)(xue)漿(jiang)(jiang)、組(zu)織(zhi)(zhi)(zhi)(zhi)液(ye)(ye)組(zu)成，三者(zhe)(zhe)(zhe)構成了(le)人體的(de)(de)(de)(de)(de)(de)(de)(de)(de)循環(huan)(huan)系(xi)統(tong)，其中(zhong)(zhong)(zhong)血(xue)(xue)(xue)(xue)(xue)漿(jiang)(jiang)和組(zu)織(zhi)(zhi)(zhi)(zhi)液(ye)(ye)可以相互流通，淋(lin)巴(ba)(ba)到(dao)血(xue)(xue)(xue)(xue)(xue)漿(jiang)(jiang)、組(zu)織(zhi)(zhi)(zhi)(zhi)液(ye)(ye)到(dao)淋(lin)巴(ba)(ba)是(shi)單向流通［１０］。我(wo)們認(ren)為(wei)(wei)(wei)(wei)(wei)，淋(lin)巴(ba)(ba)、血(xue)(xue)(xue)(xue)(xue)漿(jiang)(jiang)、組(zu)織(zhi)(zhi)(zhi)(zhi)液(ye)(ye)對(dui)應中(zhong)(zhong)(zhong)醫(yi)(yi)(yi)(yi)(yi)(yi)(yi)學(xue)(xue)(xue)生(sheng)理(li)狀(zhuang)態下的(de)(de)(de)(de)(de)(de)(de)(de)(de)津(jin)、血(xue)(xue)(xue)(xue)(xue)、液(ye)(ye)，痰(tan)(tan)(tan)(tan)(tan)飲(yin)(yin)(yin)由(you)津(jin)液(ye)(ye)而(er)生(sheng)，可以視為(wei)(wei)(wei)(wei)(wei)病(bing)(bing)理(li)狀(zhuang)態下的(de)(de)(de)(de)(de)(de)(de)(de)(de)淋(lin)巴(ba)(ba)和組(zu)織(zhi)(zhi)(zhi)(zhi)液(ye)(ye)，痰(tan)(tan)(tan)(tan)(tan)瘀(yu)互結(jie)實(shi)際(ji)上反映的(de)(de)(de)(de)(de)(de)(de)(de)(de)是(shi)血(xue)(xue)(xue)(xue)(xue)液(ye)(ye)、組(zu)織(zhi)(zhi)(zhi)(zhi)液(ye)(ye)、淋(lin)巴(ba)(ba)液(ye)(ye)的(de)(de)(de)(de)(de)(de)(de)(de)(de)病(bing)(bing)理(li)變化(hua)(hua)(hua)。《靈樞(shu)?邪(xie)客》曰：“營氣(qi)者(zhe)(zhe)(zhe)，泌其津(jin)液(ye)(ye)，注之(zhi)于脈，化(hua)(hua)(hua)以為(wei)(wei)(wei)(wei)(wei)血(xue)(xue)(xue)(xue)(xue)，以榮(rong)四末，內注五臟(zang)(zang)六(liu)腑。”津(jin)液(ye)(ye)可以化(hua)(hua)(hua)為(wei)(wei)(wei)(wei)(wei)血(xue)(xue)(xue)(xue)(xue)，這(zhe)與現(xian)代(dai)(dai)(dai)(dai)生(sheng)理(li)學(xue)(xue)(xue)中(zhong)(zhong)(zhong)認(ren)為(wei)(wei)(wei)(wei)(wei)淋(lin)巴(ba)(ba)和組(zu)織(zhi)(zhi)(zhi)(zhi)液(ye)(ye)能流通到(dao)血(xue)(xue)(xue)(xue)(xue)漿(jiang)(jiang)中(zhong)(zhong)(zhong)相符。《醫(yi)(yi)(yi)(yi)(yi)(yi)(yi)學(xue)(xue)(xue)正(zheng)傳》曰：“氣(qi)得邪(xie)而(er)郁，津(jin)液(ye)(ye)稠黏，為(wei)(wei)(wei)(wei)(wei)痰(tan)(tan)(tan)(tan)(tan)為(wei)(wei)(wei)(wei)(wei)飲(yin)(yin)(yin)，積久(jiu)滲入(ru)脈中(zhong)(zhong)(zhong)，血(xue)(xue)(xue)(xue)(xue)為(wei)(wei)(wei)(wei)(wei)之(zhi)濁，此陰(yin)滯(zhi)于陽也(ye)。”《血(xue)(xue)(xue)(xue)(xue)證(zheng)論(lun)》曰：“血(xue)(xue)(xue)(xue)(xue)積既久(jiu)，亦能化(hua)(hua)(hua)為(wei)(wei)(wei)(wei)(wei)痰(tan)(tan)(tan)(tan)(tan)水(shui)(shui)(shui)。”南海名醫(yi)(yi)(yi)(yi)(yi)(yi)(yi)何夢(meng)瑤在(zai)(zai)(zai)《醫(yi)(yi)(yi)(yi)(yi)(yi)(yi)碥》指出：“氣(qi)血(xue)(xue)(xue)(xue)(xue)水(shui)(shui)(shui)三者(zhe)(zhe)(zhe)，病(bing)(bing)常(chang)相因(yin)。……有(you)先(xian)病(bing)(bing)水(shui)(shui)(shui)腫(zhong)而(er)血(xue)(xue)(xue)(xue)(xue)隨敗者(zhe)(zhe)(zhe)，……有(you)先(xian)病(bing)(bing)血(xue)(xue)(xue)(xue)(xue)結(jie)而(er)水(shui)(shui)(shui)隨蓄者(zhe)(zhe)(zhe)。”這(zhe)些病(bing)(bing)理(li)過程均(jun)印證(zheng)了(le)血(xue)(xue)(xue)(xue)(xue)液(ye)(ye)、組(zu)織(zhi)(zhi)(zhi)(zhi)液(ye)(ye)、淋(lin)巴(ba)(ba)之(zhi)間的(de)(de)(de)(de)(de)(de)(de)(de)(de)循環(huan)(huan)流通關系(xi)。這(zhe)表明(ming)中(zhong)(zhong)(zhong)國古代(dai)(dai)(dai)(dai)醫(yi)(yi)(yi)(yi)(yi)(yi)(yi)家對(dui)人體循環(huan)(huan)系(xi)統(tong)的(de)(de)(de)(de)(de)(de)(de)(de)(de)認(ren)識遠(yuan)(yuan)遠(yuan)(yuan)早于西方醫(yi)(yi)(yi)(yi)(yi)(yi)(yi)學(xue)(xue)(xue)家。

２痰瘀致病的病因病機

痰(tan)(tan)(tan)飲(yin)，病(bing)(bing)位在肺、脾(pi)、腎及三焦，這些臟腑氣(qi)(qi)化功能失常，水液代謝障礙，可致水津停滯而(er)(er)形(xing)(xing)成痰(tan)(tan)(tan)飲(yin)，飲(yin)多(duo)(duo)(duo)留(liu)積(ji)于(yu)腸胃(wei)、胸(xiong)脅(xie)及肌膚，而(er)(er)痰(tan)(tan)(tan)則隨氣(qi)(qi)升降(jiang)流行(xing)(xing)，外(wai)至(zhi)筋骨(gu)皮肉，內至(zhi)臟腑，形(xing)(xing)成多(duo)(duo)(duo)種病(bing)(bing)證，因此有“百病(bing)(bing)多(duo)(duo)(duo)由痰(tan)(tan)(tan)作(zuo)祟”之(zhi)(zhi)說。瘀(yu)(yu)血(xue)(xue)(xue)的(de)形(xing)(xing)成，一方面是(shi)脈管內血(xue)(xue)(xue)行(xing)(xing)不(bu)暢而(er)(er)凝(ning)滯，多(duo)(duo)(duo)與氣(qi)(qi)血(xue)(xue)(xue)功能失調有關(guan)，正(zheng)所謂“氣(qi)(qi)為血(xue)(xue)(xue)之(zhi)(zhi)帥，血(xue)(xue)(xue)為氣(qi)(qi)之(zhi)(zhi)母”，氣(qi)(qi)虛、氣(qi)(qi)滯、血(xue)(xue)(xue)寒等(deng)都可以引發血(xue)(xue)(xue)瘀(yu)(yu)；二是(shi)血(xue)(xue)(xue)離經脈，積(ji)存(cun)于(yu)體內而(er)(er)成瘀(yu)(yu)血(xue)(xue)(xue)，可由于(yu)氣(qi)(qi)不(bu)攝血(xue)(xue)(xue)（脾(pi)不(bu)統血(xue)(xue)(xue)）、血(xue)(xue)(xue)熱妄行(xing)(xing)、內外(wai)之(zhi)(zhi)傷導(dao)致［１１］。生理(li)狀態下，津液與血(xue)(xue)(xue)在“氣(qi)(qi)化”作(zuo)用下可相互(hu)(hu)轉化，故在病(bing)(bing)理(li)條件下，氣(qi)(qi)化失常，痰(tan)(tan)(tan)飲(yin)和(he)瘀(yu)(yu)血(xue)(xue)(xue)也能相互(hu)(hu)影(ying)響，形(xing)(xing)成痰(tan)(tan)(tan)瘀(yu)(yu)互(hu)(hu)結(jie)。國醫大(da)師鄧鐵濤(tao)提出“痰(tan)(tan)(tan)是(shi)瘀(yu)(yu)的(de)初(chu)期階段，瘀(yu)(yu)是(shi)痰(tan)(tan)(tan)濁(zhuo)的(de)進一步發展”，一語中的(de)，明確指出了痰(tan)(tan)(tan)和(he)瘀(yu)(yu)的(de)病(bing)(bing)理(li)關(guan)系，提示臨(lin)床(chuang)上痰(tan)(tan)(tan)瘀(yu)(yu)互(hu)(hu)結(jie)狀態要考慮(lv)痰(tan)(tan)(tan)和(he)瘀(yu)(yu)的(de)多(duo)(duo)(duo)少，若痰(tan)(tan)(tan)多(duo)(duo)(duo)于(yu)瘀(yu)(yu)則處于(yu)病(bing)(bing)情早(zao)期，若瘀(yu)(yu)多(duo)(duo)(duo)于(yu)痰(tan)(tan)(tan)則處于(yu)病(bing)(bing)程晚期，治療上應有側重［１２］。

３痰瘀致病的臨床特征

痰瘀(yu)為(wei)患，常為(wei)多種疾病的(de)共同關鍵因素，因此(ci)涉及疾病廣(guang)泛，內(nei)可至臟腑經絡，外可達(da)肌膚腠理(li)，不同疾病之(zhi)間差異(yi)較大(da)，臨床表現復(fu)雜，癥(zheng)狀(zhuang)繁雜且多，常見的(de)包括：積包塊、疼(teng)痛、肢體偏廢、胸悶痰多、神志異(yi)常、肌膚麻木(mu)、癰瘍等(deng)［１３］。舌(she)(she)質暗或(huo)有瘀(yu)斑瘀(yu)點，舌(she)(she)苔厚(hou)膩(ni)，脈(mo)弦澀或(huo)沉澀等(deng)。總體上(shang)是痰證(zheng)與瘀(yu)證(zheng)并見，核(he)心癥(zheng)狀(zhuang)是疼(teng)痛和（或(huo)）麻木(mu)。

３.１疼痛

中醫學認為疼(teng)痛(tong)(tong)(tong)(tong)(tong)的病機主(zhu)要有２個(ge)：不(bu)(bu)(bu)(bu)通(tong)則(ze)(ze)痛(tong)(tong)(tong)(tong)(tong)和不(bu)(bu)(bu)(bu)榮則(ze)(ze)痛(tong)(tong)(tong)(tong)(tong)［１４］。痰(tan)瘀阻滯脈(mo)(mo)絡(luo)(luo)，不(bu)(bu)(bu)(bu)通(tong)則(ze)(ze)痛(tong)(tong)(tong)(tong)(tong)，與此同時，脈(mo)(mo)絡(luo)(luo)阻滯點遠端在沒有側支(zhi)循(xun)環(huan)或者代償循(xun)環(huan)的情況下會出現脈(mo)(mo)絡(luo)(luo)失去氣(qi)血(xue)滋養，不(bu)(bu)(bu)(bu)榮則(ze)(ze)痛(tong)(tong)(tong)(tong)(tong)。不(bu)(bu)(bu)(bu)通(tong)則(ze)(ze)痛(tong)(tong)(tong)(tong)(tong)多部(bu)位固定(ding)，或刺痛(tong)(tong)(tong)(tong)(tong)，或持續(xu)鎮痛(tong)(tong)(tong)(tong)(tong)，且(qie)疼(teng)痛(tong)(tong)(tong)(tong)(tong)較(jiao)頑固，如(ru)(ru)痰(tan)瘀互(hu)(hu)結(jie)于(yu)(yu)心(xin)則(ze)(ze)胸痹心(xin)痛(tong)(tong)(tong)(tong)(tong)，聚于(yu)(yu)胞宮(gong)則(ze)(ze)痛(tong)(tong)(tong)(tong)(tong)經，聚于(yu)(yu)肝則(ze)(ze)脅(xie)痛(tong)(tong)(tong)(tong)(tong)，聚于(yu)(yu)體表(biao)經絡(luo)(luo)則(ze)(ze)關(guan)節拘(ju)攣疼(teng)痛(tong)(tong)(tong)(tong)(tong)。不(bu)(bu)(bu)(bu)榮則(ze)(ze)痛(tong)(tong)(tong)(tong)(tong)多部(bu)位游(you)走，或脹痛(tong)(tong)(tong)(tong)(tong)，或跳痛(tong)(tong)(tong)(tong)(tong)，或隱(yin)痛(tong)(tong)(tong)(tong)(tong)，且(qie)疼(teng)痛(tong)(tong)(tong)(tong)(tong)時間長(chang)短不(bu)(bu)(bu)(bu)一，如(ru)(ru)張介賓云(yun)：“心(xin)主(zhu)血(xue)脈(mo)(mo)，血(xue)虛(xu)不(bu)(bu)(bu)(bu)能(neng)營養筋脈(mo)(mo)，故(gu)腰(yao)脅(xie)相引(yin)而痛(tong)(tong)(tong)(tong)(tong)。”［１５］痰(tan)瘀互(hu)(hu)結(jie)于(yu)(yu)心(xin)導致胸痹時，腰(yao)脅(xie)會因血(xue)虛(xu)缺乏滋養出現疼(teng)痛(tong)(tong)(tong)(tong)(tong)，現代醫學稱之(zhi)為“牽(qian)涉痛(tong)(tong)(tong)(tong)(tong)”［１６］。又如(ru)(ru)《東(dong)垣(yuan)十(shi)書》云(yun)：“頭痛(tong)(tong)(tong)(tong)(tong)耳(er)鳴，九竅不(bu)(bu)(bu)(bu)利者，腸胃之(zhi)所生，乃氣(qi)虛(xu)頭痛(tong)(tong)(tong)(tong)(tong)也(ye)。……久(jiu)病氣(qi)虛(xu)血(xue)損，及(ji)素作勞、羸弱之(zhi)人患(huan)心(xin)痛(tong)(tong)(tong)(tong)(tong)者，皆虛(xu)痛(tong)(tong)(tong)(tong)(tong)也(ye)。”氣(qi)虛(xu)引(yin)發痰(tan)瘀互(hu)(hu)結(jie)可出現頭痛(tong)(tong)(tong)(tong)(tong)耳(er)鳴和九竅不(bu)(bu)(bu)(bu)利，脈(mo)(mo)絡(luo)(luo)遠端氣(qi)血(xue)滋養不(bu)(bu)(bu)(bu)足，亦能(neng)引(yin)起心(xin)痛(tong)(tong)(tong)(tong)(tong)等各種(zhong)疼(teng)痛(tong)(tong)(tong)(tong)(tong)。

３.２麻木

在中醫(yi)學(xue)(xue)中，麻(ma)(ma)(ma)木(mu)(mu)(mu)指(zhi)肌膚感覺(jue)障礙。麻(ma)(ma)(ma)，肌膚蟻走(zou)感，或(huo)觸電感；木(mu)(mu)(mu)，皮肉(rou)(rou)不(bu)仁如(ru)(ru)木(mu)(mu)(mu)厚之(zhi)(zhi)(zhi)感。《雜病(bing)(bing)源流犀燭?麻(ma)(ma)(ma)木(mu)(mu)(mu)源流》：“麻(ma)(ma)(ma)木(mu)(mu)(mu)，風(feng)虛病(bing)(bing)亦兼寒濕(shi)(shi)痰(tan)(tan)(tan)血病(bing)(bing)也(ye)(ye)。麻(ma)(ma)(ma)，非癢(yang)非痛(tong)，肌肉(rou)(rou)之(zhi)(zhi)(zhi)內，如(ru)(ru)千萬孑蟲(chong)亂行，或(huo)遍身淫(yin)淫(yin)如(ru)(ru)蟲(chong)行有(you)聲(sheng)之(zhi)(zhi)(zhi)狀(zhuang)(zhuang)(zhuang)，按之(zhi)(zhi)(zhi)不(bu)止(zhi)，搔之(zhi)(zhi)(zhi)愈甚，有(you)如(ru)(ru)麻(ma)(ma)(ma)木(mu)(mu)(mu)之(zhi)(zhi)(zhi)狀(zhuang)(zhuang)(zhuang)。木(mu)(mu)(mu)，不(bu)癢(yang)不(bu)痛(tong)，自己肌肉(rou)(rou)如(ru)(ru)人肌肉(rou)(rou)，按之(zhi)(zhi)(zhi)不(bu)知，掐(qia)之(zhi)(zhi)(zhi)不(bu)覺(jue)，有(you)如(ru)(ru)木(mu)(mu)(mu)之(zhi)(zhi)(zhi)厚。”朱震亨認為(wei)“濕(shi)(shi)痰(tan)(tan)(tan)死血者肢(zhi)體麻(ma)(ma)(ma)木(mu)(mu)(mu)”［１７］，《醫(yi)學(xue)(xue)準繩?麻(ma)(ma)(ma)木(mu)(mu)(mu)》：“麻(ma)(ma)(ma)屬(shu)痰(tan)(tan)(tan)屬(shu)虛；木(mu)(mu)(mu)則全屬(shu)濕(shi)(shi)痰(tan)(tan)(tan)死血，一塊不(bu)知痛(tong)癢(yang)，若木(mu)(mu)(mu)然(ran)是(shi)(shi)(shi)也(ye)(ye)。”痰(tan)(tan)(tan)瘀(yu)互(hu)(hu)結阻滯氣血運行，肌膚失于濡養(yang)，則麻(ma)(ma)(ma)木(mu)(mu)(mu)不(bu)仁，日久不(bu)愈，或(huo)固(gu)定一處，或(huo)全然(ran)不(bu)知痛(tong)癢(yang)，故麻(ma)(ma)(ma)木(mu)(mu)(mu)是(shi)(shi)(shi)痰(tan)(tan)(tan)瘀(yu)互(hu)(hu)結的(de)(de)核心癥狀(zhuang)(zhuang)(zhuang)。麻(ma)(ma)(ma)木(mu)(mu)(mu)在現(xian)代(dai)漢(han)語中有(you)２層含義，一是(shi)(shi)(shi)失去知覺(jue)，又稱麻(ma)(ma)(ma)痹；二(er)是(shi)(shi)(shi)比喻(yu)思想不(bu)敏銳，反應遲(chi)鈍。現(xian)代(dai)漢(han)語中的(de)(de)第２層意(yi)思是(shi)(shi)(shi)麻(ma)(ma)(ma)木(mu)(mu)(mu)的(de)(de)引申義，由此(ci)可(ke)推(tui)論，痰(tan)(tan)(tan)瘀(yu)互(hu)(hu)結引發的(de)(de)臟腑不(bu)敏銳、反應遲(chi)鈍也(ye)(ye)可(ke)稱之(zhi)(zhi)(zhi)為(wei)臟腑麻(ma)(ma)(ma)木(mu)(mu)(mu)，具體表現(xian)為(wei)臟腑功能(neng)減退或(huo)消失，其引發的(de)(de)癥狀(zhuang)(zhuang)(zhuang)也(ye)(ye)可(ke)以概括為(wei)麻(ma)(ma)(ma)木(mu)(mu)(mu)。另(ling)外，許多學(xue)(xue)者認為(wei)瘕積(ji)(ji)聚(ju)(ju)也(ye)(ye)是(shi)(shi)(shi)痰(tan)(tan)(tan)瘀(yu)互(hu)(hu)結的(de)(de)典型表現(xian)［１８］，我們表示贊同(tong)，但不(bu)是(shi)(shi)(shi)所有(you)的(de)(de)痰(tan)(tan)(tan)瘀(yu)互(hu)(hu)結都(dou)會出現(xian)瘕積(ji)(ji)聚(ju)(ju)，瘕積(ji)(ji)聚(ju)(ju)出現(xian)時都(dou)會伴隨(sui)出現(xian)疼痛(tong)和（或(huo)）麻(ma)(ma)(ma)木(mu)(mu)(mu)的(de)(de)癥狀(zhuang)(zhuang)(zhuang)，故瘕積(ji)(ji)聚(ju)(ju)不(bu)是(shi)(shi)(shi)痰(tan)(tan)(tan)瘀(yu)互(hu)(hu)結的(de)(de)核心癥狀(zhuang)(zhuang)(zhuang)。

４痰瘀同病臨床病證分析舉隅

４.１冠心病

冠心(xin)病(bing)(bing)屬本虛(xu)(xu)標實，其痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)互結(jie)證(zheng)的(de)(de)(de)形成(cheng)主(zhu)要(yao)在于(yu)臟腑(fu)間(jian)氣(qi)(qi)(qi)(qi)(qi)(qi)血(xue)(xue)津(jin)液代謝異(yi)常(chang)所致(zhi)臟腑(fu)功能失(shi)(shi)調(diao)。主(zhu)要(yao)包括氣(qi)(qi)(qi)(qi)(qi)(qi)虛(xu)(xu)、氣(qi)(qi)(qi)(qi)(qi)(qi)滯(zhi)(zhi)、陽(yang)虛(xu)(xu)可(ke)致(zhi)痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)，同(tong)(tong)時(shi)寒(han)(han)邪(xie)(xie)和(he)熱邪(xie)(xie)也可(ke)致(zhi)痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)，臨證(zheng)表現(xian)均有胸(xiong)(xiong)痛(tong)(tong)(tong)［１９２４］。古籍(ji)中(zhong)早有痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)致(zhi)冠心(xin)病(bing)(bing)的(de)(de)(de)論(lun)述。《靈樞?百病(bing)(bing)始生(sheng)》曰(yue)：“凝血(xue)(xue)蘊裹而(er)(er)(er)(er)(er)(er)不(bu)(bu)散，津(jin)液澀(se)滲，著而(er)(er)(er)(er)(er)(er)不(bu)(bu)去，而(er)(er)(er)(er)(er)(er)積(ji)皆成(cheng)矣。”表明痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)同(tong)(tong)病(bing)(bing)的(de)(de)(de)病(bing)(bing)理(li)現(xian)象［２５］。《素問(wen)?舉(ju)痛(tong)(tong)(tong)論(lun)篇(pian)》云：“寒(han)(han)氣(qi)(qi)(qi)(qi)(qi)(qi)入經而(er)(er)(er)(er)(er)(er)稽遲……客(ke)于(yu)脈中(zhong)則(ze)(ze)(ze)(ze)氣(qi)(qi)(qi)(qi)(qi)(qi)不(bu)(bu)通，故(gu)(gu)(gu)卒然而(er)(er)(er)(er)(er)(er)痛(tong)(tong)(tong)。”《素問(wen)?舉(ju)痛(tong)(tong)(tong)論(lun)篇(pian)》云：“寒(han)(han)氣(qi)(qi)(qi)(qi)(qi)(qi)客(ke)于(yu)背俞之脈……血(xue)(xue)虛(xu)(xu)則(ze)(ze)(ze)(ze)痛(tong)(tong)(tong)，其俞注(zhu)于(yu)心(xin)，故(gu)(gu)(gu)相引而(er)(er)(er)(er)(er)(er)痛(tong)(tong)(tong)。”寒(han)(han)邪(xie)(xie)侵襲，凝結(jie)胸(xiong)(xiong)中(zhong)，久(jiu)則(ze)(ze)(ze)(ze)陽(yang)氣(qi)(qi)(qi)(qi)(qi)(qi)更傷，津(jin)得(de)寒(han)(han)而(er)(er)(er)(er)(er)(er)聚(ju)為(wei)(wei)痰(tan)(tan)(tan)，血(xue)(xue)遇寒(han)(han)則(ze)(ze)(ze)(ze)凝為(wei)(wei)瘀(yu)(yu)(yu)(yu)，氣(qi)(qi)(qi)(qi)(qi)(qi)血(xue)(xue)津(jin)液運(yun)行(xing)不(bu)(bu)暢(chang)，阻滯(zhi)(zhi)心(xin)胸(xiong)(xiong)，不(bu)(bu)通則(ze)(ze)(ze)(ze)痛(tong)(tong)(tong)，發(fa)為(wei)(wei)胸(xiong)(xiong)痹(bi)(bi)(bi)。《太(tai)平圣惠方?治(zhi)心(xin)痹(bi)(bi)(bi)諸方》曰(yue)：“心(xin)虛(xu)(xu)故(gu)(gu)(gu)邪(xie)(xie)乘之，邪(xie)(xie)積(ji)而(er)(er)(er)(er)(er)(er)不(bu)(bu)去……蘊蘊而(er)(er)(er)(er)(er)(er)痛(tong)(tong)(tong)，是謂心(xin)痛(tong)(tong)(tong)。”心(xin)氣(qi)(qi)(qi)(qi)(qi)(qi)虛(xu)(xu)推動無力，津(jin)血(xue)(xue)運(yun)行(xing)遲滯(zhi)(zhi)，留而(er)(er)(er)(er)(er)(er)成(cheng)痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)，痹(bi)(bi)(bi)阻血(xue)(xue)脈，心(xin)絡不(bu)(bu)通則(ze)(ze)(ze)(ze)痛(tong)(tong)(tong)。《癥(zheng)因(yin)脈治(zhi)》曰(yue)：“怫郁(yu)氣(qi)(qi)(qi)(qi)(qi)(qi)逆(ni)，則(ze)(ze)(ze)(ze)痰(tan)(tan)(tan)凝氣(qi)(qi)(qi)(qi)(qi)(qi)結(jie)……而(er)(er)(er)(er)(er)(er)悶閉胸(xiong)(xiong)痛(tong)(tong)(tong)矣。”《金匱(kui)要(yao)略(lve)》曰(yue)：“胸(xiong)(xiong)痹(bi)(bi)(bi)……氣(qi)(qi)(qi)(qi)(qi)(qi)結(jie)在胸(xiong)(xiong)也。”肝失(shi)(shi)疏(shu)泄，氣(qi)(qi)(qi)(qi)(qi)(qi)機失(shi)(shi)暢(chang)，氣(qi)(qi)(qi)(qi)(qi)(qi)血(xue)(xue)津(jin)液凝滯(zhi)(zhi)不(bu)(bu)通，津(jin)凝為(wei)(wei)痰(tan)(tan)(tan)，血(xue)(xue)滯(zhi)(zhi)為(wei)(wei)瘀(yu)(yu)(yu)(yu)，痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)乃生(sheng)。醫(yi)(yi)圣張機認(ren)為(wei)(wei)胸(xiong)(xiong)痹(bi)(bi)(bi)的(de)(de)(de)病(bing)(bing)機為(wei)(wei)“陽(yang)微(wei)陰(yin)弦(xian)”，心(xin)陽(yang)不(bu)(bu)足，寒(han)(han)自內生(sheng)，津(jin)血(xue)(xue)遇寒(han)(han)而(er)(er)(er)(er)(er)(er)凝成(cheng)痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)，痹(bi)(bi)(bi)阻血(xue)(xue)脈，不(bu)(bu)通則(ze)(ze)(ze)(ze)痛(tong)(tong)(tong)。《血(xue)(xue)證(zheng)論(lun)》曰(yue)：“火不(bu)(bu)宣發(fa)則(ze)(ze)(ze)(ze)為(wei)(wei)胸(xiong)(xiong)痹(bi)(bi)(bi)。”火熱邪(xie)(xie)氣(qi)(qi)(qi)(qi)(qi)(qi)聚(ju)集，日久(jiu)釀為(wei)(wei)熱毒，燔灼津(jin)血(xue)(xue)，煉為(wei)(wei)痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)，阻于(yu)心(xin)脈，不(bu)(bu)通則(ze)(ze)(ze)(ze)痛(tong)(tong)(tong)，發(fa)為(wei)(wei)胸(xiong)(xiong)痹(bi)(bi)(bi)。近現(xian)代醫(yi)(yi)家從痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)論(lun)治(zhi)冠心(xin)病(bing)(bing)的(de)(de)(de)亦(yi)不(bu)(bu)在少數，例如國醫(yi)(yi)大(da)師鄧鐵濤提(ti)出“氣(qi)(qi)(qi)(qi)(qi)(qi)血(xue)(xue)痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)相關”的(de)(de)(de)學術論(lun)點(dian)［２６］，國醫(yi)(yi)大(da)師周(zhou)仲瑛(ying)提(ti)出“五臟痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)”理(li)論(lun)［２７］，岳美中(zhong)亦(yi)認(ren)為(wei)(wei)：“因(yin)年(nian)高(gao)代謝失(shi)(shi)調(diao)，血(xue)(xue)行(xing)緩(huan)慢(man)瘀(yu)(yu)(yu)(yu)滯(zhi)(zhi)，易(yi)成(cheng)痰(tan)(tan)(tan)濁血(xue)(xue)瘀(yu)(yu)(yu)(yu)，故(gu)(gu)(gu)冠心(xin)病(bing)(bing)老(lao)年(nian)人尤為(wei)(wei)多見。”［２８］可(ke)見，冠心(xin)病(bing)(bing)從痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)論(lun)治(zhi)已(yi)經成(cheng)為(wei)(wei)治(zhi)療的(de)(de)(de)關鍵，痰(tan)(tan)(tan)瘀(yu)(yu)(yu)(yu)甚至可(ke)稱為(wei)(wei)其病(bing)(bing)機關鍵［２９］。

４.２抑郁癥

中醫(yi)(yi)學雖無抑(yi)(yi)郁(yu)(yu)癥(zheng)病(bing)(bing)名，但根(gen)據(ju)其臨(lin)(lin)床(chuang)癥(zheng)狀(zhuang)(zhuang)(zhuang)及(ji)(ji)發(fa)病(bing)(bing)轉(zhuan)歸，應屬“郁(yu)(yu)證(zheng)”范(fan)疇。《古今(jin)醫(yi)(yi)統(tong)大全?郁(yu)(yu)證(zheng)門》言：“郁(yu)(yu)為(wei)(wei)(wei)七情(qing)不(bu)舒，遂(sui)成郁(yu)(yu)結(jie)(jie)，既郁(yu)(yu)之(zhi)(zhi)久，變病(bing)(bing)多端。”提出(chu)(chu)郁(yu)(yu)證(zheng)之(zhi)(zhi)病(bing)(bing)因(yin)(yin)病(bing)(bing)機(ji)(ji)為(wei)(wei)(wei)情(qing)志(zhi)內(nei)傷(shang)，氣(qi)機(ji)(ji)郁(yu)(yu)滯(zhi)(zhi)(zhi)。因(yin)(yin)郁(yu)(yu)悶(men)、悲哀、憂(you)思、發(fa)怒(nu)、所(suo)欲(yu)不(bu)遂(sui)等(deng)情(qing)感(gan)因(yin)(yin)素(su)引發(fa)情(qing)志(zhi)失(shi)(shi)調者，易氣(qi)機(ji)(ji)郁(yu)(yu)滯(zhi)(zhi)(zhi)，肝(gan)失(shi)(shi)疏泄致臟腑(fu)功能(neng)紊亂，氣(qi)血(xue)(xue)(xue)津(jin)液(ye)運(yun)行失(shi)(shi)常(chang)(chang)，結(jie)(jie)局主(zhu)(zhu)要(yao)體現在(zai)２個方(fang)面：一是(shi)氣(qi)滯(zhi)(zhi)(zhi)使(shi)(shi)津(jin)液(ye)運(yun)行輸布失(shi)(shi)常(chang)(chang)，津(jin)凝(ning)(ning)液(ye)聚(ju)成痰(tan)(tan)(tan)(tan)，痰(tan)(tan)(tan)(tan)濁滋生；或(huo)憂(you)思傷(shang)脾(pi)，脾(pi)失(shi)(shi)健運(yun)，或(huo)肝(gan)氣(qi)郁(yu)(yu)結(jie)(jie)，肝(gan)木克伐脾(pi)土(tu)，致脾(pi)氣(qi)虛，不(bu)能(neng)運(yun)化(hua)水(shui)濕，濕聚(ju)凝(ning)(ning)結(jie)(jie)成痰(tan)(tan)(tan)(tan)，發(fa)為(wei)(wei)(wei)痰(tan)(tan)(tan)(tan)郁(yu)(yu)；二是(shi)氣(qi)病(bing)(bing)及(ji)(ji)血(xue)(xue)(xue)，可使(shi)(shi)血(xue)(xue)(xue)行郁(yu)(yu)滯(zhi)(zhi)(zhi)，瘀(yu)(yu)(yu)血(xue)(xue)(xue)內(nei)生。痰(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)本(ben)為(wei)(wei)(wei)氣(qi)血(xue)(xue)(xue)津(jin)液(ye)運(yun)行失(shi)(shi)常(chang)(chang)的病(bing)(bing)理產物，內(nei)蘊日久，反過來本(ben)身又(you)可作為(wei)(wei)(wei)致病(bing)(bing)因(yin)(yin)素(su)，使(shi)(shi)氣(qi)機(ji)(ji)愈(yu)加郁(yu)(yu)滯(zhi)(zhi)(zhi)，臟腑(fu)功能(neng)損(sun)傷(shang)更為(wei)(wei)(wei)嚴重(zhong)(zhong)，且痰(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)均為(wei)(wei)(wei)陰邪，在(zai)病(bing)(bing)理上有同源、同因(yin)(yin)、互(hu)(hu)生、同消同長、同病(bing)(bing)之(zhi)(zhi)特性，同性相求(qiu)，易互(hu)(hu)結(jie)(jie)為(wei)(wei)(wei)患，互(hu)(hu)生互(hu)(hu)病(bing)(bing)共存(cun)，而(er)成痰(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)互(hu)(hu)結(jie)(jie)，清竅神(shen)明(ming)被蒙閉之(zhi)(zhi)抑(yi)(yi)郁(yu)(yu)癥(zheng)。有學者認(ren)為(wei)(wei)(wei)抑(yi)(yi)郁(yu)(yu)癥(zheng)是(shi)因(yin)(yin)情(qing)志(zhi)失(shi)(shi)調，氣(qi)郁(yu)(yu)不(bu)伸，而(er)致氣(qi)滯(zhi)(zhi)(zhi)、血(xue)(xue)(xue)瘀(yu)(yu)(yu)、痰(tan)(tan)(tan)(tan)壅、火逆(ni)，漸(jian)至(zhi)臟腑(fu)失(shi)(shi)和(he)，損(sun)傷(shang)腦神(shen)而(er)出(chu)(chu)現心境低(di)(di)落等(deng)情(qing)志(zhi)癥(zheng)狀(zhuang)(zhuang)(zhuang)及(ji)(ji)能(neng)力下降表(biao)現［３０］。汪(wang)磊和(he)尤可［３１］認(ren)為(wei)(wei)(wei)痰(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)是(shi)血(xue)(xue)(xue)管性抑(yi)(yi)郁(yu)(yu)癥(zheng)的重(zhong)(zhong)要(yao)致病(bing)(bing)因(yin)(yin)素(su)及(ji)(ji)病(bing)(bing)理機(ji)(ji)制(zhi)(zhi)，痰(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)證(zheng)或(huo)以痰(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)為(wei)(wei)(wei)主(zhu)(zhu)兼(jian)夾(jia)他證(zheng)是(shi)血(xue)(xue)(xue)管性抑(yi)(yi)郁(yu)(yu)癥(zheng)的主(zhu)(zhu)要(yao)證(zheng)候。由是(shi)觀之(zhi)(zhi)，痰(tan)(tan)(tan)(tan)凝(ning)(ning)血(xue)(xue)(xue)瘀(yu)(yu)(yu)伴隨氣(qi)郁(yu)(yu)而(er)生，可貫穿于抑(yi)(yi)郁(yu)(yu)癥(zheng)發(fa)生、發(fa)展全過程，是(shi)該病(bing)(bing)病(bing)(bing)變過程中的重(zhong)(zhong)要(yao)病(bing)(bing)機(ji)(ji)，臨(lin)(lin)床(chuang)可見胸脅脹滿悶(men)痛或(huo)刺痛，舌(she)質紫暗或(huo)有瘀(yu)(yu)(yu)點、瘀(yu)(yu)(yu)斑。現代醫(yi)(yi)學研究表(biao)明(ming)抑(yi)(yi)郁(yu)(yu)癥(zheng)的病(bing)(bing)理機(ji)(ji)制(zhi)(zhi)為(wei)(wei)(wei)海馬(ma)等(deng)突(tu)觸間隙５羥(qian)色胺的水(shui)平降低(di)(di)，突(tu)觸間隙所(suo)屬的內(nei)環境為(wei)(wei)(wei)組(zu)織液(ye)［３２］。雖然現代醫(yi)(yi)學尚不(bu)明(ming)確這一現象的原因(yin)(yin)，但是(shi)可以肯定這里(li)的組(zu)織液(ye)存(cun)在(zai)病(bing)(bing)理改變，這與中醫(yi)(yi)學認(ren)為(wei)(wei)(wei)痰(tan)(tan)(tan)(tan)瘀(yu)(yu)(yu)互(hu)(hu)結(jie)(jie)是(shi)抑(yi)(yi)郁(yu)(yu)癥(zheng)的重(zhong)(zhong)要(yao)病(bing)(bing)機(ji)(ji)這一認(ren)識相符。同時，海馬(ma)等(deng)區域(yu)５羥(qian)色胺缺乏(fa)使(shi)(shi)神(shen)經沖動傳導不(bu)靈敏(min)、遲鈍，使(shi)(shi)患者出(chu)(chu)現表(biao)情(qing)淡(dan)漠(mo)，心情(qing)抑(yi)(yi)郁(yu)(yu)等(deng)癥(zheng)狀(zhuang)(zhuang)(zhuang)。

４.３陽痿

對于陽(yang)(yang)(yang)痿病機，賈(jia)海驊(hua)等［３３］提(ti)出“痰(tan)(tan)瘀(yu)互結(jie)，毒損(sun)宗(zong)筋(jin)(jin)(jin)(jin)”，認為(wei)“前陰者(zhe)，宗(zong)筋(jin)(jin)(jin)(jin)所(suo)聚；陽(yang)(yang)(yang)痿者(zhe)，宗(zong)筋(jin)(jin)(jin)(jin)縱弛(chi)；痰(tan)(tan)瘀(yu)者(zhe)，膠(jiao)結(jie)難解為(wei)毒；毒蘊者(zhe)，入絡損(sun)宗(zong)筋(jin)(jin)(jin)(jin)”。張介(jie)賓將宗(zong)筋(jin)(jin)(jin)(jin)中血(xue)液能否充(chong)盈以(yi)及充(chong)盈的(de)(de)程度(du)作為(wei)陽(yang)(yang)(yang)痿發生的(de)(de)病因［３４］，這與近現(xian)代醫學對陽(yang)(yang)(yang)痿的(de)(de)認識基本一(yi)致［３５］。在近現(xian)代醫學研究中，脂(zhi)質(zhi)代謝和血(xue)液流變學改(gai)變類似痰(tan)(tan)瘀(yu)病理特征(zheng)，動脈(mo)粥樣硬(ying)化(hua)過(guo)程是動脈(mo)內膜(mo)先有(you)(you)脂(zhi)質(zhi)沉著(zhu)，繼(ji)而有(you)(you)纖(xian)維組(zu)織的(de)(de)增生，甚至形成斑(ban)塊，使血(xue)管內皮細胞損(sun)傷，形成陽(yang)(yang)(yang)痿。這就(jiu)是痰(tan)(tan)邪(xie)留滯于脈(mo)，留駐而不(bu)去(qu)，血(xue)滯不(bu)行，痰(tan)(tan)瘀(yu)互結(jie)的(de)(de)形成過(guo)程［３６］。從另一(yi)個(ge)角度(du)看，陰莖海綿體血(xue)液充(chong)盈不(bu)夠，陰莖反(fan)應遲鈍，是麻木的(de)(de)表現(xian)，符合痰(tan)(tan)瘀(yu)互結(jie)的(de)(de)臨(lin)床(chuang)癥狀。

５小結

從現代醫(yi)(yi)學(xue)角度來看，冠心病、抑郁癥(zheng)、陽痿是(shi)３個不(bu)同的(de)病種(zhong)，但是(shi)背后卻有著相同的(de)中醫(yi)(yi)病機，即痰(tan)瘀(yu)(yu)互(hu)結。還有許多(duo)疾病都有著痰(tan)瘀(yu)(yu)互(hu)結的(de)病機，這里就(jiu)不(bu)再展開討(tao)論。臨床(chuang)上，快速初步診斷痰(tan)瘀(yu)(yu)互(hu)結可以從核心癥(zheng)狀入手，即觀察(cha)患(huan)者是(shi)否有疼痛和(he)（或）麻木的(de)癥(zheng)狀，以此制(zhi)定(ding)初步的(de)治療方案，這有利于中醫(yi)(yi)“異病同治”理念的(de)推廣，提升中醫(yi)(yi)臨床(chuang)診治的(de)效果和(he)效率。

作者:李(li)玉波 于眉 李(li)君(jun)玲 吳(wu)朦 單位:中(zhong)國中(zhong)醫(yi)(yi)(yi)科學院(yuan)中(zhong)醫(yi)(yi)(yi)基(ji)礎理論研究所(suo) 北京航天總醫(yi)(yi)(yi)院(yuan)中(zhong)醫(yi)(yi)(yi)科 首都醫(yi)(yi)(yi)科大學中(zhong)醫(yi)(yi)(yi)藥學院(yuan)