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人体气机圆转及升降法时

中医与命理 昌达空间 1870℃ 0评论

    人体气机升降调节中,心肾相交为一对,脾胃枢纽为一对,肝升肺降为一对,此配偶之功。如此,各显其功,各得其衡,人体气机升降之圆运动自能相谐而旋。

   《黄帝内经》有脏气法时观,再深化一步就是人体的升降法时。古人之论,多喜以年之春、夏、秋、冬,而临床之证,未必都经四季,故变之为昼、夜、晨、昏,应更具实操性。

  中医学本为体道之学,作为本原之道,中医学倾向于以“气”为道;作为规律之道,中医学更多的是参照阴阳、五行规律与法则。故由本原之道所演,天人合一、道理相贯之气在人体的运作,所循规律亦不离阴阳、五行法则,并主要体现在脏腑气机的升降上。

 1.jpg

气机圆转

  气机圆转,指人体内气的正常运行机制,包括脏腑经络等的功能活动。

    气运动的基本形式是升、降、出、入。而其过程主要是通过脏腑的功能及相互之间的协调来体现,并常以圆转之升降而显,如图1所示。

  图1之太极左阳右阴,左主升而右主降,中间为升降之枢轴。应于人体脏腑,脾胃居中,一升一降,为气机升降的枢纽。肝应春木,主疏泄,从左而升;肺应秋金,主肃降,从右而降,为气机升降之圆的外翼。心火宜降,肾水宜升,水升火降,相互为用,即为既济。既济者,水火之轮运转,升降由此启动。然此论尚简,个中义蕴对临证思路之启迪处,意犹未尽,仍可深论。

1.心肾相交启升降2.jpg

  心属火,配离卦,居太极之上而属阳;肾属水,配坎卦,居太极之下而属阴。两者关系主要表现为阴阳、水火、升降间的互制互用与平衡协调。从阴阳交感观念看,位于下者,以上升为顺;位于上者,以下降为和。所以,心火当下暖于肾,肾水须上济于心,这样心肾之间的生理功能才能协调。心与肾功能间若能建立这种良性联系,称为“心肾相交”,亦《易经》所云水火既济卦。此卦坎水居离火之上,上水能制约下火,下火能蒸腾上水,相互为用,故云“既济”,如图2。“既济”于人体言,喻心火能降于下而温肾水,故离火居于下;肾阳得心火之助则蒸水上腾以制心火,故坎水居上。如是则水火既济,心肾相交而相和谐。3.jpg

  然心属火,本居上,火性又炎上;肾属水,本居下,水性又润下,两者易分不易合。则水升当需上达之动力,火降亦需下行之引子。即“既济”是需要条件的,但条件在哪?八卦本有卦主之说,《易纂言外翼·卷一》云:“小成之卦八,震巽下为主,坎离中为主,艮兑上为主,此因乾坤交易而定也。”具体到坎、离两卦,则卦主为坎中之阳爻与离中之阴爻,此即“坎离中为主”。坎配肾,坎中之阳,即肾中之阳,火处水中,则易蒸津而使肾水上济,此自然界“地气上为云”之象;水既上济,即补离中之阴,离阴既足,其性降,仿若“天气下为雨”,引领离火下温坎阳,坎阳得离火之助,其力更充,蒸水化气之功愈强,水复腾上,更助离阴带动离火下降……如是不断坎离互转,水火既济,呈良性的功能循环。

  值得注意的是:心肾相交的意义并不局限在两脏间的功能协调,更是全身气机升降的动力,即朱丹溪《格致余论》所言的“人之有生,心为之火居上,肾为之水居下,水能升而火能降,一升一降,无有穷矣,故生意存也”。然心肾两者何为原动力?基于火性炎上原理,当阳居下位,其气温升自能煦暖其上之脏腑,且阳性主动,故坎中之阳(肾阳、命火、龙火)当为人体升降的原动力,下降的离火则为其最大助力。如此,阳木得煦则肝升,阴土得暖则脾升,启动人体太极左半圆之温升。此理置之临床,如中气下陷之证,以补中益气丸治之,若效不甚著,可加肾气丸少火生气以助温升;若不用丸而用补中益气汤,笔者常以李可先生之肾四味(补骨脂、淫羊藿、菟丝子、枸杞子)益之。若阳虚无力助肝升之证,同样可以在疏肝、升肝基础上以肾气丸为助。阳升至极则阴降,离中之阴(心阴)滋洒,燥金得润,肺能顺降;阳土受霖,胃自和降,旋转人体右半圆之凉降。古方麦冬之用颇值玩味,麦冬一味能滋心、润肺、益胃,故滋阴或兼滋阴的名方如麦门冬汤、沙参麦冬汤、百合固金汤、益胃汤、一贯煎、生脉饮、竹叶石膏汤、玉女煎,等剂中,其身影屡现,道理或在右半圆之凉降自心而降,方能甘霖遍洒。

2.脾升胃降枢轴转

  脾胃共居中焦,脾主升清,运精微与津液上达;胃主降浊,降食糜与糟粕下行。《临证指南医案》说:“脾宜升则健,胃宜降则和。”脾升胃降,对于全身气机的调节起的是中轴枢转作用。黄元御于《四圣心源》中谓:“四维之病,悉因于中气,中气者,和济水火之机,升降金木之轴。”彭子益的《圆运动的古中医学》承此意进一步论证:“中气左旋则木火左升,中气右转则金水右降,转者由上而下,旋者由下而上。中气为轴,四维为轮。”即中土脾升胃降为人体太极的枢纽,在此枢纽的升降带动下,肝木、肺金、心火、肾水四维均绕其周而旋转,共同完成人体生命的气化圆运动,其理仍可参图1。

  枢纽不是空谈,临证可法。譬如心肾不交的失眠,清心益肾同时,亦可旋转脾胃枢机,以促水火既济。南方人阳热易偏于上、外,而亏于下、内,因此心火旺、肾阳虚之心肾不交失眠者不在少数,笔者在临床上常以交泰丸加龙骨、牡蛎、白术、茯苓治之,疗效颇佳。方中黄连清心火,味苦能降,不仅降心火,亦可降胃浊;肉桂温肾阳,引火归源,肾阳暖则脾土得温而自能升。《医宗金鉴》云:“脾阳苟不运,心肾必不交。”南方不仅热,而且湿,湿易伤脾,则白术、茯苓一燥一渗,燥者温化而升清,渗者利湿而降浊;黄连、肉桂、白术、茯苓合而斡旋中州(脏腑与地势相应的部位。六腑膈下三脏应中州),运转枢轴,使水升火降,交相既济;龙骨、牡蛎镇心安神,引浮阳下潜,则心肾益交。

3.肝肺升降外翼旋

  中医向有左肝右肺之说,常遭垢病(指责),这是以解剖学视角,对中医观点断章取义的一例。上说非言肝、肺的解剖位置分列人体左右,而是依太极之圆(参图1),以左右为路径,肝从左升、肺从右降,协合为人体升降之外翼。

  太极左升右降之说,主要源于中国东南西北不同的地理阴阳环境。中国南方阳气旺,日照时间长,《周易·说卦》有:“圣人南面而听天下,向明而治。”南面、向明即面向阳,古谓主吉,于建筑物则利于采光。所以,自古以来从帝王到普通老百姓住的房子多是坐北向南。此时,南在前,北在后,东在左,西在右。而东方(左)是太阳升起的方位,西边(右)是太阳下山的方位,左阳右阴、左升右降的观念由此产生。《素问·阴阳应象大论》曰:“左右者,阴阳之道路也。”中医藏象学有着明显的重功能轻结构倾向。肝主疏泄,以木气之升发、条达(疏通)、舒畅为生理特性,故应四季之春,一日之晨,方位之东,为少阳之处,故从于左;肺主肃降,以金气之肃降、收敛为生理特性,故应四季之秋,一日之夕,方位之西,为少阴之处,故从于右。左肝右肺之说由是产生。至于肝肺的解剖位置,古人早有明述,并无错位。

  在这里,我们还要明白一个道理,中医所言的气机升降并非垂直升降,而是太极圆转的升降。圆,才有可能于旋转之中升极而降,降极而升,升降相因,相反相成,相互协调。如果是垂直升降,则降将有碍升,升将有碍降了。是以肝气升发与肺气肃降升降相因,相反相成,成人体气机升降之外翼,协调人体气机,保持升降平衡状态。

  笔者对肝气郁结证一般以四逆散或柴胡疏肝散治之,多能奏效。偶若未果,则喜加一味前胡,于大队疏肝、升肝之品中,略降肺气,以使肝升肺降,相因相成,太极旋转,一身之气自转,每能增效。柴胡与前胡之协,《本经疏证》有谓:“柴胡主肠胃中结气,前胡主心腹结气;柴胡主饮食积聚,前胡主痰满胸胁中痞。足以见柴胡之阻在下,前胡之阻在上,在下则有碍于升,在上则有碍于降,去其阻而气之欲升者得升,欲降者得降。”

  既为外翼,则肝升、肺降就不纯粹是两脏间的关系,它脏它腑亦可一借其力。如补中益气汤以黄芪、升麻升中土之脾气,然脾居太极之中,恐其升力有未逮(达不到),顾肝位太极之左,肝从左升,力矩较长,易于带动力矩短的脾升,是以加一柴胡,从肝、从木、从少阳之升以助脾升。《雷公炮制药性解》谓柴胡:“补中益气汤用之,亦以其能提肝气之陷者,由左而升也。” 肝升助脾升的药有了,然则降肺以助降胃的药有没有?有,枇杷叶、竹茹可降肺,亦可降胃,是一举两得之药。

  参考力矩作用,再考究力量,肝气、肝阳易亢不易虚,肺之肃降有赖呼吸,而呼吸是可自调的,若善于利用,两翼升降之力不比中轴之转为弱。故左半圆之升常依肝木生升,右半圆之降需赖肺金顺降。

  综合而论,在人体气机升降调节的功能配合中,心肾相交为一对,脾胃枢纽为一对,肝升肺降为一对,此配偶之功。肾、肝、脾,从左从阳而升,为一组;心、肺、胃,从右从阴而降,为另一组,此同心之力。肾、肝在下,在下者宜升;心、肺在上,在上者宜降;脾胃在中间,则一升一降,此交感之道。如此,各显其功,各得其衡,人体气机升降之圆运动自能相谐而旋。

  若轮失其转,多为配偶失谐,或同组离心,或交感不再,当察而调之。

 

升降法时

  法时,效法宇宙日出日落,四季交替的时间变化。

    《周易·系辞下》的“变通者,趣时者也”,以及《乾》文言的“终日乾乾,与时偕行”中所倡的“变通趣时,与时偕行”观,应是中医法时理论之源头。《黄帝内经》由是而有脏气法时观,再深化一步就是人体的升降法时。

  升降法时理论最实用处常显在临床之治。《侣山堂类辩》曰:“升降浮沉则顺之,寒热温凉则逆之。谓春宜用升,以助生气;夏宜用浮,以助长气,秋时宜降,以顺收令;冬时宜沉,以顺封藏。此药性之宜顺四时者也。”但古人之论,多喜以年之春、夏、秋、冬,大而化之而论。

    而临床之证,未必都会经历四季,因此,变之为昼、夜、晨、昏,更具实操性。如图3。夏天最热,中午是一天中温度最高,明亮度最大的时间,均有阳气最盛的特点,因此配太极图阳气最旺的太阳位(离);冬天最冷、夜半是一天中温度最底,明亮度最小的时间,均有阴气最盛的特点,因此配太极图阴气最重的太阴位(坎);春天气温回暖,阳气渐长,早上在一天中也是气温渐升,明亮度渐清之时,故处阳气渐长而未盛的少阳位(震);秋天气温转凉,阴气渐长,傍晚在一天中也是气温渐降,明亮度渐暗之时,故处阴气渐长而未盛的少阴位(兑)。故夏与午同位、冬与夜同位、春与晨同位、秋与夕同位,则“春宜用升,以助生气;夏宜用浮,以助长气,秋时宜降,以顺收令;冬时宜沉,以顺封藏”可作同位之词的置换而成:“晨宜用升,以助生气;午宜用浮,以助长气,夕时宜降,以顺收令;夜时宜沉,以顺封藏。”

  升降法时于临床如何把握?这里以一治验为例:曾接诊一男性患者,31岁,主诉是腰酸痛一年,余无明显不适,舌略淡,脉两尺略细,此肾虚无疑。患者无明显寒热表现,不难推断:不是肾气虚就是肾精虚。看过往治史,所开处方大多为金匮肾气丸,或济生肾气丸加减之类,只是易丸为汤。方证应是合拍,然何一直未效?仔细询之,他的“腰酸每发于早上5~7时,每因痛而醒”,这一句话引起了笔者注意。细思,卯时正当阳升之时,应于少阳。肾之精气不足,于阳升之时当升而无力升,故气憋郁而痛。于是,以金匮肾气丸为底方,加柴胡12克,葛根30克,七剂,嘱晨起5~6时服药。下周来复诊,诉仅服1剂,腰痛即愈,一周未犯。后因它病来诊,再询此患,回复是一直未再犯。

  本方所加柴胡、葛根两药,意在助其阳升,然升阳之药不少,何以选此两味?柴胡较易理解,在太极图中,卯时、春天、少阳均在东方、左边,格局相同。《本草经疏》谓:“柴胡禀仲春之气以生,兼得地之辛味。春气生而升,故味苦平,微寒而无毒,为少阳经表药。”《本经逢原》曰:“柴胡能引清阳之气,从左上升,足少阳胆经之药。”是以柴胡之升,在于升少阳,可助郁而不升之肾气,于少阳之时借时而升。《本草思辨录》所说的“人身生发之气,全赖少阳,少阳属春,其时草木句萌(嫩芽)以至鬯茂(茂盛),不少停驻。然当阴尽生阳之后,未离乎阴,易为寒气所郁,寒气郁之,则阳不得伸而与阴争,寒热始作。柴胡乃从阴出阳之药,香气彻霄,轻清疏达,以治伤寒寒热往来,正为符合。邹氏所谓鬯郁阳以化滞阴也”,可为笔者当时的用药思路作注。

  上说为常规之理。其实,当时笔者还有一个略深的想法,就是腰脊属督脉所过(图4),于经脉当属督病。若把督、任两脉放进太极图,则为“阳脉之海”的督脉,当循左、循阳而升;为“阴脉之海”的任脉(图5),当循右、循阴而降;既然督在左、在阳位,则与春天、卯时、少阳,在一定意义上也是同格局。“类同则比”,这是取象比类的基本原则或内在逻辑,前人虽然没有以柴胡升督之说,但既然格局相同,又安知柴胡不能因此而升督?不妨一试。至于葛根之用,则循另一思路,腰疼于骨属脊,于脏属肾,若从经络循行看,膀胱经所过正是肾脏所在,肾俞就是其对应穴,且肾与膀胱相为表里,表里经互用是针灸常法。《本草崇原》谓:“葛根延引藤蔓,则主经脉,甘辛粉白,则入阳明,皮黑花红,则合太阳,故葛根为宣达阳明中土之气,而外合于太阳经脉之药也。……起阴气者,藤引蔓延,从下而上也。”葛根的作用正是升膀胱经之气,当可助肾气上达。

4.jpg

  《孙子兵法·兵势》云:“凡战者,以正合,以奇胜。”奇正之道在于守正出奇。正者,就是以“正兵”当敌,“正兵”者,就是在预期的时间、地点,以预期的方式作战,就如本例以金匮肾气丸为底方,这是用兵的常法,也是遣方用药的常法。但当守“正”不能完全奏效时,就得考虑“出奇制胜”了,“奇”者,于兵法上就是用敌人认为不可能的,超越常规的作战方法,就如本例的柴胡、葛根之用,不属常法,颇有出其不意的“奇兵”之效。但用药之道,不能刻意为了翻新出奇而“奇”,“奇”也要“奇”得符合医理、药理。

5.jpg

  嘱晨起5~6时服药,当然是借自然之气与人体之气于卯时的升势以助药势了。效《孟子·公孙丑》的“虽有智慧,不如乘势”意。

  升降法时,顺时服药是一法,如本例的卯时服药;借药物所含时象亦是一法,如本例借柴胡内含之少阳时象。(本文节选自作者所著的《寻回中医失落的元神》一书)

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