臨證筆記      《內經.素問》中的放血治療   王全民醫師

 

注重活血化瘀善用三稜針點刺的放血治療(bloodletting) 是董氏針灸中的一大特色,可說是董師景昌先生的絕活之一。楊維傑師兄的一段話可以佐證:「余從董師學習多年隨侍老師之側,常見董師應用三稜針治療,數年大病往往霍然而癒,劇烈疼痛亦可止於傾劇,其效果真是令人難以思議。」

 

董師對於歷代有關活血化瘀文獻多有多涉獵,對於《內經》所言:「病久入深,營衛之行濇,經絡時疏,故不通。」「有所墮墜,惡血留內。」「寒氣客則脈不通」等瘀血學說均有所認識,故主張師「宛陳則除之」及「治風宜治血,血行風自滅」之法,運用三稜針點刺放血廣泛治療多種病變。這種放血技術的運用,在董師一九七三年原著中,說明十分清楚。在此要說明一點,所謂的放血(bloodletting)不是大量流血,而是針對特定穴位或血絡,做局部有限的出血而已,故放血亦稱刺絡(micropuncture)

 

董師的三稜針放血技術既出於《內經》,《內經》又分為《內經.素問》及《內經.靈樞》兩部分,《內經.靈樞》又稱針經,固然對放血多所著墨,不用多說。故筆者擬先從《內經.素問》來對放血技術先做一個報告。至於《內經.靈樞》部分則待他日再做報告。

 

在《內經.素問》中,放血技術雖然不敢說佔大主題,但是卻在全文中顯而易見,在八十一章中至少有十四章討論放血技術。此外,如《素問》第十四章〈湯液醪醴論〉中的「去宛陳莝」(remove the stagnated blood and cut out the accumulated water)亦間接的提及到放血治療。本句中的「宛」即「血鬱」,「莝」為動詞,意為「鍘鋤」,全句即除去血鬱,鍘鋤積水,也就是去陳布新的意思。

 

《內經.素問》中還有十四章提及到以石頭或尖銳物刺破皮膚,有放血的意涵在內,如第二十四章〈血氣形志篇〉:「形樂志樂,病生於肉,治之以鍼石。」(when the physical appearance is joyful and the mind is joyful too, the disease emerges in the flesh. Treat it with acupuncture and lithopuncture)Litho-即尖銳的石頭(砭石)。這段話是說形樂志樂屬心寬體胖型,生活優裕,又不耽心事,優哉游哉,又欠缺體力勞動,身體易於發福(胖),多生膩肉,故一旦生病,應該瀉多於補,所以金鍼及砭石來劃破皮膚肌肉,即略微放血之意了。

 

用砭石來劃皮膚來治病,多見於皮膚的癰腫的病變,如第四十六章〈病能論〉提到:「帝曰:有病頸癰者,或石治之,或鍼灸之,而皆已,其真安在?歧伯曰:此同名異等者也。夫癰氣之息者,宜以鍼開除去之。夫氣盛血聚者,宜石而瀉之,此所謂同病異治也。」所謂頸癰,實在是頸部的瘡癰(abscess),如果此類瘡癰結得很大,更兼有膿蓄積,當然應該用外科開刀放膿,或大陸現有結合中西的針刀術治療,則身體得安。癰氣之息者,指癰尚未致太厲害成上述積聚者,以鍼葯除去之。如上述已積蓄者,用砭石割穿族膿而治之(宜石而瀉之),程度不同,治法亦異。而砭石的割治,廣義而言,也是放血治療的一種。在此還要指出一點,在《內經.素問》中,所有的放血方法與氣的調治,都歸於鍼刺的範疇之內。(一)

 

所謂砭石的治療,早期則僅知利用天生扁平而銳利的石頭,繼則知道將石頭打磨成扁平而銳利,用於治療。但以砭石來割治瘡癰只是間接的說明砭石與放血治療(bloodletting)的關係,《內經.素問》七十六章〈示從容論〉中的雷公亦述及砭石放血之術:「雷公曰:於此有人,四支解墮,喘咳血泄。而愚診之,以為傷肺。切脈浮大而緊,愚不敢治。粗工下砭石病愈多出血,血止身輕。此何物也?」(I had a sick person who had the sensation of lassitude of the four limbs, rapid breathing, cough, at the same time, blood in the stools. I have felt the pulse, it was superficial, large but tight. I had thought that these were the harmed lung, but I had not dare to treat it. A common physician applied a sharp stone, the disease seemed to be cured  He let a large amount of blood. When the bleeding stopped, the body felt light. )本段中雷公的診斷是誤診為傷肺,關鍵在病人的泄血,泄血者,大便小便,比起喀血及吐血要輕得多,除非老年人血管硬化,腸胃壁血管破裂之大量出血,當然是非常危險之候。如果在上消化道之出血,都是下黑色血的大便,大部份是胃及十二指腸出血,但古人無法分辨。此處稱泄血,則知其血不屬於胃及十二指腸之血,不過是肛門直腸處的痔靜脈破裂之出血而已。痔靜脈破裂為靜脈曲張造成,此乃由於腹腔內壓增加,腹中腸運動量下降,生氣脹之故。四肢解墮是非常疲倦,故精神情緒相當低落。而喘咳乃因胃腸動量下降,影響橫隔膜而造成呼吸不利而已,並非傷肺有損害,至多肺活量不夠。當以砭石刺破孫絡放血,立可使精神興奮,改善下腔靜脈血流,便血一旦停止,人即覺得輕鬆。在筆者個人臨床經驗,以放血治療痔瘡一至三次,絕大多數能收到相當好的效果。

 

臨床上,這個簡單的放血療法,往往針對身體或整個系統的實證來治療。有關針灸虛實的運用原則,在《內經.素問》第五十四章〈針解篇〉裡有非常清楚的說明:「刺虛則實之者,鍼下熱也,氣實乃熱也。滿而泄之者,鍼下寒也,氣虛乃寒也。菀陳則除之者,出惡血也。」(When treating Xu (vacuity) syndrome with acupuncture, it should apply the supplementing (Bu) method, when there is hotness under the needle, it shows the healthy energy has been aroused to cause normality. When treating Shi (repletionl) syndrome with acupuncture, it should apply the draining (Xie) method, when there is coolness under the needle, it shows the evil-energy has been supplemented to cause normality. The blood in which the long stagnated evil-energy resides should be bloodletting. )這段在講針灸虛證用補法,針灸實證用瀉法,若久瘀之證則放血治療。詳細言之,當病人有感覺到冷的虛證時,是氣不足,人體體工會自動慢慢調整,但調節之力不夠,一經針刺,助體工一力,則寒冷漸漸轉熱,隨之調節,即內經所謂的得氣。反之,若其人本有熱感(實證),刺入針來調節至熱感消失,即實則瀉之。所謂補虛瀉實,是將其原來不太正常的條件,順其勢幫助其生理調節作用,故刺虛則實之,鍼下乃熱,氣實乃熱;滿而泄之,鍼下寒也,氣虛乃寒寒也。如果某處有鬱血,發現有鬱血之處,乃因循環失調而來,一般都在小血管為主,小血管在皮下,神經在皮下者特別敏感,針刺皮下,神經受影響很大,復加放血,則鬱血因其強大之刺激而暢通,雖然只些許出血,因調節而奏全功,故曰菀陳則除之者,出惡血也。此正與前文《內經.素問》第十四章間接所述「去宛陳莝」刺破皮膚的去陳出新互相呼應。放血療效,於此可見。

 

《內經.素問》第二十章〈三部九候論〉亦說:「經病者治其經,孫絡病者,治其孫絡血。血病身有痛者,治其經絡。...上實下虛,切而從之。索其結絡脈,刺出其血,以見通之。」(When the disease is in the channel, prick the channel; when the disease is in the grandchild network vessels, prick the grandchild network vessels until it bleeds; when the disease is associated with the blood with syndrome of pain, prick the channel and the network vessels……When the patient is repleton in the upper part and vacuity in the lower, one must palpate the channel and follow them with the fingers, search for their knotted network vessels firstly , then prick them until bleeding to harmony the energy. )前半段提出對證治療的原則,或在經,或在孫絡,或在經絡,來作放血治療。下半段則提出放血治療運用實例,所謂上實下虛,指上部頭部充血,雙足冰冷之謂,應該先沿其經脈摩擦,尋找血脈不通的部位(打結的部位),再針刺放血。(二)

 

《內經.素問》第二十二章〈臟氣法時論篇〉中列舉了肝,心,脾,肺,腎五臟的疾病及其相關的放血治療,但這些五臟的疾病,並非是按照經絡診斷決定,而是由病人的主訴證狀來定疾病,茲分述如下,首先來看肝病:「肝病者,兩脇下痛引少腹,令人善怒。虛則目荒荒無所見,耳無所聞,善恐,如人將補之,取其經,厥陰與少陽,氣逆則頭痛,耳聾不聰,頰腫,取血者。」(In the liver disease, when the liver is of full, there will be pain over the hypochondrium which affects the lower abdomen, and the patient will get angry often; if the liver is of deficiency, the two eyes of the patient will be dim with obscured views, his two ears can not hear things distinctly, being frightened often like some one is going to arrest him. The disease should be treated with pricking the shupoints of the Jueyin and Shaoyang channels. If the liver-energy is going up adversely, the patient will have the syndromes of pain in eyes, deaf of ears and swelling of cheeks, it should also prick the acupoints of Jueyin and Shaoyang channels until bleeding. )根據傳統中醫的解釋:肝脈布脇肋抵少腹,病實則兩脇下痛引少腹。肝主怒,肝氣鬱而不舒則善怒;肝開竅在目,肝而虛,則視物不明無所見,耳亦無所聞。肝藏魂,肝虛則魂不安,故常常驚恐,如有人將要捉他一樣。足厥陰肝與足少陽膽相表裡,臟病則腑病,故並取其二經以通氣。厥陰肝脈與督脈會於巔,肝氣逆,故頭痛;少陽膽脈入耳中下頰車,少陽氣逆則耳不聰而頰腫,在放血治療時,於肝膽二經脈上刺血以瀉其實。

 

依現代的解釋來看,此處所謂肝病,並非真正肝臟的病變,不過是神經容易緊張的證狀。長期神經緊張,使自律神經產生不平衡,甚則機能紊亂,影響腸胃,尤其是腸子生氣體積於結腸的右角及左角互相流動,則兩脇痛。腸子蠕動不良,腹壓上昇,則骨盤腔中壓力增加,有時亦痛引少腹,有時可能發生疝氣偏墮(hernia) 。精神衰弱,生虛性興奮,常生不愉快,使人發怒,情緒不良,心跳有時甚至發生頻率不整的昏厥,導致視物不明及耳無所聞的現象。長期精神過度興奮,可使甲狀腺機能亢進恆覺心跳善驚,如有人來捕捉。若再加上氣逆導致頭暈頭痛,耳聾不聰等等情況時,則有上部充血所造成的頰腫,因此選在肝膽經上放血,使其生鎮靜作用,便能改善。

 

其他四臟的疾病也都以放血治療為其首要:「心病者,胸中痛,脇支滿,脇下痛,膺背肩甲間痛,兩臂內痛。虛則胸腹大脇下,與腰相引而痛。取其經,少陰太陽。舌下血者,其變病刺郄中血者。」

 

「脾病者,身重善飢,肉痿,足不收行,善瘈。腳下痛。虛則腹滿,腸鳴飧泄,食不化。取其經,太陰陽明少陰血者。」

 

「肺病者,喘欬逆氣,肩背痛。汗出尻陰股膝,髀腨胻足皆痛。虛則少氣不能報息,耳聾嗌乾。取其經,太陰足太陽之外,厥陰納血者。」

 

「腎病者,腹大脛腫,喘欬身重,寢汗出憎風。虛則胸中痛,大腹小腹痛,清厥,意不樂。取其經,少陰太陽血者。」

 

從以上文字得知,五臟的病變,皆可以放血治療達到一定的治療效果。要注意的是,以上五臟病,都包括了虛實證狀在內,也就是放血治療局限在實證上的說法,是與本章抵觸的,原來不管五臟的病變是實,或是虛,都可以放血治療完成補瀉的功效。此外,各臟放血治療所採取的經絡,並不限制在本經或表裡經,也有運用他經來做放血治療。如心病有急劇轉變時,在膀胱經循行的膝後放血;脾病時除脾胃兩經放血外,亦可於腎經放血;肺病時除在肺經放血外,尚可選用膀胱經及肝經放血。道理為何呢?有謂心病轉劇,在膝後放血,目的是改善下腔靜脈循環,減輕胸腔的壓力;脾病刺腎經出血者,為利水故;肺病選用膀胱經放血者,著重在「汗出尻陰股膝髀腨胻足皆痛」,而肺病選用肝經放血者,重在「耳聾嗌乾」。但仍待進一步的研究。不過,五臟之病,要循序放血,即肝病放血先肝經後膽經;心病放血,先選心經小腸經,再選舌下放血,有劇變再選膝後放血;脾病放血次序是脾經,胃經再到腎經;肺病放血依肺,膀胱及肝經的次序;腎病放血則先腎後膀胱經。(三)

 

《內經.素問》中還屢屢提及放血與人體內氣的流動與調整有一定的關係,第二十六章〈八正神明論〉談到:「天溫日明,則血淖液而衛氣浮。故血易寫,氣易行...是以因天時而調氣血。」(If the weather warm and the sun is bright, the blood of the body will be moist and the defense qi (Wei-energy) will be abundant. Hence, the blood can be drained easily, and the qi can be move easily too…..therefore  the blood and qi should be regulated according to the weather changes. ) 天溫日明,應指春夏二季,人循環血流因氣候而有外向的趨勢,則人血淖液而衛氣浮,微小血管皮下末梢血管因天熱溫暖而外溢,所謂衛氣者,即身體的抵抗力,亦必須血液所達而乃能達,如今知血液流動向外,則抗力機轉當然隨之而向外,向外的末梢小血管擴張,則附著於血管壁上的大吞噬細胞及白血球當然增多,故血易瀉,刺之出血,以去瘀行氣。而天氣暖和,人的中樞神經活力增強,易受刺激而作用到末梢,即所謂氣易行。天寒日陰則反之。因此放血治療與四季節氣的變化有非常緊密的關係。

 

《內經.素問》第二十七章〈離合真邪論篇〉進一步說明運用放血治療的時機:「帝曰:補瀉奈何?歧伯曰:此攻邪也,疾出以去盛血,而復其真氣。此邪新客,溶溶末有定處也:推之則前;引之則止;逆而刺之,溫血也。刺出其血,其病立已。」(Huangdi asked, “ Supplemental and Draining methods which one should do firstly to save evil qi too strong and essential qi too weak condition,? Qibo answered: Evil qi should be attacked firstly. To reduce surplus of blood quickly to restore true qi (essential qi) return. Because the evil has just invaded the body and it runs without fixation. The  supplemental method will push the evil invading to more deep, and the drain method will stop the evil qi moving. So if  did the contradictory  way,  the supplemental method to warm blood, the evil qi will invade to more deep. Then do bloodletting immediately and the disease heals right away. “黃帝的問話,依據本段的前文,應該做如此的問話:如果邪氣盛則精氣奪,將先固正氣而補之,抑先攻邪氣而瀉之。然後再看歧伯的答案才有意義:這個時候以瀉邪氣為主,以三棱針迅速刺絡出血,如此則邪氣去而正氣(精氣)自復,即瀉中有補。歧伯進而說明當邪氣初入經脈,溶溶然流動尚無定處,此時如推針補之,則邪氣會隨補法內侵入體,會導致邪更深而精氣更弱;如用針引之(瀉之),則邪氣無法留在體內,應為正治。但若當瀉反補逆向針刺,即內溫血,大大地幫助邪氣內侵,此時必須即刻以三稜針放血,則邪隨血出,病就會痊癒了。總之,以瀉為補的觀念,是運用放血療法十分重要的一個觀念。其實不論寒邪或熱邪入侵體內,只要了解邪氣與正氣的消長之道,於正確的時機使用放血療法,往往可以達到良好的治療效果。

 

《內經.素問》第六十二章〈調經論篇〉對使用放血療法的時機,舉出實例來說明:「帝曰:(血有餘不足)補瀉奈何?歧伯曰:血有餘則瀉其盛經,出其血;不足則視其虛經,內鍼其脈中,久留而視。脈大疾出其鍼,無令血泄。」(Huangdi asked: How to treat blood surplus and insufficient condition with supplementation and drainage? Qibo answered: To treat blood surplus, the related channel with full blood to let out blood. To treat blood insufficiency, the deficient channel is needle with supplemental method. After insertion, the needle is retained for a longer period of time with careful observation. When the channel is dilated, the needle is withdrawn immediately without letting out blood. 當病診斷為有餘時,則先找其血流盛大的經脈,刺而使之略出血即平衡;虛則找其虛小的經脈下針並留針,等到其脈大盛時,立刻拔針,不可使之出血。說明血大餘的實證與血不足的虛證裡,只有實證才能運用放血療法。

 

在具體治療上,《內經.素問》尚有許多篇章,都談到放血療法的運用,如三十二章的「刺熱論」,三十六章的「刺瘧論」,四十一章的「刺腰痛篇」等等,都有待有心人士在《內經.素問》的領域裡,做更多的研究。

 

以上若有諮詢,請電針灸與脊椎骨科(Licensed Acupuncturist & Chiropractic Physician)王全民醫師(Dr. Chuan-Min Wang),電話630-932-1274,地址2S065 Hampton Lane, IL 60148,網站www.acup-chiro.com