基于开阖枢理论从气滞血瘀论治便秘的证治探讨

A Discussion on Syndrome Differentiation and Treatment of Constipation from Qi Stagnation and Blood Stasis Based on the Kai-He-Shu (Opening-Closing-Pivot) Theory

摘要: 便秘为临床多发疾病，其中气滞血瘀证型不仅占比颇高，且病情往往迁延难愈。笔者研习经典认为，此类便秘的核心症结在于阳明通降失司(阖机壅滞)，常伴随厥阴疏泄失常(阖机郁闭)与少阳枢转不利。治疗上主张行气活血以开郁结、通降阳明以复传导。笔者导师撷取开阖枢理论精华，自拟旋归调阖汤，重用旋覆花、当归为君，前者降逆气以复阳明之顺，后者润瘀血以通肠道之塞；佐以代赭石、半夏增强降逆和胃之效；伍以木香、香附、枳壳等疏解肝郁，调畅厥阴；配以白术、玄参、牡蛎等健脾助运、增液行舟。全方紧扣“调枢机、降胃气、化瘀滞”之旨。本文通过理论探源与病案佐证，系统阐释该方治疗气滞血瘀型便秘的机理，以期为临床提供新的诊疗思路。

Abstract: Constipation is a common clinical condition, among which the qi stagnation and blood stasis pattern not only represents a significant proportion but also tends to be protracted and refractory. Based on an examination of classical texts, the author posits that the core pathogenesis of this type of constipation lies in the dysfunction of Yangming regarding descending and closing functions (characterized by obstruction and stagnation), often accompanied by abnormal dispersion and discharge of Jueyin (marked by depression and blockage) and impaired pivoting of Shaoyang. In terms of treatment, the author advocates promoting qi and activating blood to relieve stagnation, and descending and unblocking Yangming to restore conduction. The author’s mentor, drawing on the essence of the opening-closing-pivoting theory, formulated the Xuanfu-Danggui Regulating Decoction, employing Inula Flower and Chinese Angelica in heavy doses as sovereign drugs: the former descends rebellious qi to restore the free flow of Yangming, and the latter nourishes blood to resolve stasis and unblock intestinal obstruction. Adjuvant herbs, including Hematite and Pinellia, are used to enhance the downbearing of rebellious qi and harmonize the stomach. The formula is further combined with Aucklandia Root, Cyperus Rhizome, and Bitter Orange to soothe Liver depression and regulate Jueyin, and supplemented with Atractylodes, Figwort Root, and Oyster Shell to invigorate the Spleen, assist transportation, generate fluids, and facilitate defecation. The entire formula adheres to the principle of “regulating the pivot, descending stomach qi, and resolving stasis”. This paper systematically elucidates the mechanism of this formula in treating qi stagnation and blood stasis type constipation through theoretical exploration and case studies, aiming to provide new diagnostic and therapeutic insights for clinical practice.