發(fā)布時間：2018-05-09 02:09

  本文選題：李東垣 + 學(xué)術(shù)思想　； 參考：《廣州中醫(yī)藥大學(xué)》2017年博士論文

【摘要】：研究背景:喘證在中醫(yī)學(xué)中既可單獨(dú)作為一個病證,也可作為其他疾病的伴隨癥狀出現(xiàn)。臨床上多表現(xiàn)為呼吸困難,嚴(yán)重者可伴有張口抬肩、鼻翼煽動、不能平臥等臨床表現(xiàn)。在西醫(yī)學(xué)中很多疾病都可出現(xiàn)喘證,如慢性阻塞性肺病、肺源性心臟病、哮喘、喘息性支氣管炎、重癥肺炎、肺氣腫、肺癌及癔病等疾病。臨床上中醫(yī)多按喘證辨證治療。喘證病機(jī)復(fù)雜,治療上較為棘手,嚴(yán)重影響患者身心健康,給國家、人民帶來沉重經(jīng)濟(jì)負(fù)擔(dān),是臨床常見的難治和危重病之一。中醫(yī)藥在治療疾病上講究辨證施治,注重整體原則。如《黃帝內(nèi)經(jīng)》就對喘證的病因病機(jī)作出了相關(guān)闡述,張仲景在內(nèi)經(jīng)理論的基礎(chǔ)上,亦對喘證作出相關(guān)論述,不僅在六經(jīng)辨證中論及喘證,在雜病中對喘證的論述更為詳盡。后世醫(yī)家對喘證也多有論治,有著豐富的臨床經(jīng)驗(yàn)。因此,加強(qiáng)對古醫(yī)家治療喘證經(jīng)驗(yàn)的整理與研究,具有重要現(xiàn)實(shí)意義。李東垣,本名李杲,字明之。其年少時拜易水先生張元素為師,與劉完素、張從正、朱震亨齊名,史稱"金元四大家"。其以脾胃立論,認(rèn)為許多疾病皆由"脾胃內(nèi)傷"所致。強(qiáng)調(diào)外感與內(nèi)傷的鑒別,提出了益氣升陽、甘溫除熱、甘寒瀉火等治療原則,形成了較為完整的脾胃內(nèi)傷辨治體系。李東垣認(rèn)為脾主四肢,胃主受納腐熟水谷,勞役過度、飲食不節(jié)可直接損傷脾胃,引起喘證。如其在《脾胃論》中提到"脾胃一虛,肺氣先絕",因虛作喘。在《蘭室秘藏》中提到外感風(fēng)寒可導(dǎo)致肺氣閉郁,上逆作喘。同時指出內(nèi)傷脾胃導(dǎo)致肺衛(wèi)不固,容易使人感受風(fēng)寒邪氣,體現(xiàn)了邪之所湊,其氣必虛的指導(dǎo)思想。在《活法機(jī)要》中提到脾虛不運(yùn),痰濁內(nèi)生,上犯于肺,會引起嚴(yán)重的咳喘疾病,并且遷延難愈。在《內(nèi)外傷辨惑論》中指出脾胃虛損,濁陰不降,導(dǎo)致大便艱澀,肺與大腸相表里,腑氣不通,肺氣上逆亦可作喘�？梢娖⑽柑摀p,可直接或間接影響肺的宣發(fā)肅降功能,導(dǎo)致喘證。目前國內(nèi)學(xué)者對李東垣學(xué)術(shù)思想的研究大多集中在脾胃、五官和瘡瘍病上,對其治喘學(xué)術(shù)思想的研究較少,國內(nèi)尚未見針對其治喘經(jīng)驗(yàn)的相關(guān)學(xué)術(shù)報道。因此,加強(qiáng)對李東垣治喘學(xué)術(shù)思想的研究,對喘證治療無疑有重要現(xiàn)實(shí)意義。目的:總結(jié)李東垣內(nèi)傷學(xué)術(shù)思想,在此基礎(chǔ)上深入剖析其治喘經(jīng)驗(yàn),探索其臨證證治規(guī)律,為臨床治療喘證提供理論支持。結(jié)合現(xiàn)代中醫(yī)臨床經(jīng)驗(yàn),探討李東垣治喘學(xué)術(shù)思想對現(xiàn)代臨床辨治喘證的指導(dǎo)意義。方法:運(yùn)用中醫(yī)文獻(xiàn)研究、醫(yī)史研究、古籍文本內(nèi)容分析等理論研究方法,通過收集整理李東垣相關(guān)學(xué)術(shù)著作,結(jié)合現(xiàn)代中醫(yī)理論,對其治喘學(xué)術(shù)思想進(jìn)行系統(tǒng)的整理和研究�？偨Y(jié)孫志佳教授"培土生金法"辨治慢性阻塞性肺病的臨床經(jīng)驗(yàn),探討李東垣治喘學(xué)術(shù)思想對現(xiàn)代臨床辨治喘證的指導(dǎo)意義。結(jié)果:本研究主要分為四部分:第一部分:簡述李東垣的醫(yī)學(xué)生涯與主要著作李東垣年少時素有盛名,《李濂醫(yī)史·東垣老人傳》中說他為人忠義,講信譽(yù),實(shí)事求是,與人交往很重注禮節(jié)。遇到饑荒,更是積極救助災(zāi)民�？梢娖湔�心仁厚,擁有一顆博愛之心。此時雖未有學(xué)醫(yī)之心,卻已是初具孫思邈《大醫(yī)精誠》中所提倡的大慈惻隱之心。東垣20歲時,母親病逝,東垣痛心疾首,始立志學(xué)醫(yī)。花重金拜河間張元素為師,學(xué)數(shù)年,盡得其法。此時東垣雖學(xué)醫(yī)有成,卻未有行醫(yī)之心,而是走上仕途。雖身在官海,東垣在百姓遭受瘟疫之苦時,亦是尋求古訓(xùn),終自創(chuàng)普濟(jì)消毒飲,救人無數(shù)。后金元交戰(zhàn),東垣為避戰(zhàn)亂,南下至臨安。此時,正式開始行醫(yī)生涯。在行醫(yī)過程中,多從脾胃論治,療效顯著,自此名聲大噪。并在此階段,開始整理其內(nèi)傷思想,并開始著手自己的第一本醫(yī)學(xué)專著《內(nèi)外傷辨惑論》的寫作。其晚年,則在河北老家一邊授徒,一邊整理自己的醫(yī)學(xué)經(jīng)驗(yàn)。據(jù)現(xiàn)代學(xué)者考據(jù)認(rèn)為《內(nèi)外傷辨惑論》是李東垣生前唯一一部著作,《脾胃論》為其晚年之作,刊行于其身后�！夺t(yī)學(xué)發(fā)明》、《活法機(jī)要》、《東垣試效方》、《蘭室秘藏》多認(rèn)為是其弟子羅天益整理之作。第二部分:對李東垣的內(nèi)傷思想進(jìn)行總結(jié)李東垣認(rèn)為外感風(fēng)寒皆有余之病,當(dāng)瀉不當(dāng)補(bǔ)。脾胃內(nèi)傷皆屬不足,當(dāng)補(bǔ)不當(dāng)瀉。飲食過饑過飽,形勞太過,導(dǎo)致脾胃之氣不足,營衛(wèi)失和,其人亦惡風(fēng)寒。世人大多將內(nèi)傷不足之惡風(fēng)寒誤認(rèn)為外感有余之邪,虛虛實(shí)實(shí),殺人而不自知。東垣從辨陰證陽證開始,從十三個方面對外感內(nèi)傷進(jìn)行鑒別。認(rèn)為人以胃氣為本,火與元?dú)獠粌闪�。脾胃虛�?導(dǎo)致陰火內(nèi)生,提出甘溫除大熱的觀點(diǎn),并根據(jù)《內(nèi)經(jīng)》相關(guān)理論,自創(chuàng)補(bǔ)中益氣湯。通過五行生克制化學(xué)說,將脾胃和其他臟腑有機(jī)結(jié)合起來,形成了以脾胃為核心的五臟傳變理論。其處方用藥注重藥物性味與歸經(jīng),強(qiáng)調(diào)結(jié)合四時氣候陰陽變化合理用藥。藥味雖多,但都謹(jǐn)遵法度、條理井然。注重養(yǎng)生攝養(yǎng),講究未病先防。第三部分:對李東垣治喘學(xué)術(shù)思想進(jìn)行系統(tǒng)的整理和研究李東垣認(rèn)為喘證的成因不外外感與內(nèi)傷兩端。外感多為風(fēng)寒、暑熱或疫癘乘襲,內(nèi)傷可由飲食、勞役、久病所致。外感與內(nèi)傷并不孤立,氣虛易感風(fēng)寒,暑熱亦可傷氣。喘證的病理性質(zhì)多為虛實(shí)夾雜,或兼痰飲,或兼氣亂,或兼陰火,或兼宿食,或兼積聚。發(fā)病機(jī)理與肺、脾、腎三臟臟腑功能失調(diào)密切相關(guān)。肺主氣的宣發(fā)肅降,開竅于鼻,外合皮毛。若外邪侵襲,或它臟病氣上犯,皆可導(dǎo)致肺氣不利而致喘滿。脾胃為氣血生化之源,脾虛則營衛(wèi)不調(diào),易感外邪,導(dǎo)致肺失宣降作喘。脾氣虛則陰火內(nèi)生,陰火可直接耗傷元?dú)?使肺虛作喘,又可直接上乘迫肺導(dǎo)致肺痿作喘。脾為濕土,主水液代謝,脾虛則易生痰積飲,痰飲阻滯氣機(jī),肺氣上逆作喘。脾主升清,脾不升清,濁陰不降,清濁相干,三焦氣亂作喘。脾陽不足,中焦虛寒,腸外血與津液凝結(jié)成積,迫肺作喘。腎為氣之根,腎陽衰憊,攝納失常則氣不歸元,上逆作喘。腎司二便,腎水不足,大便堅澀,肺與大腸相表里,腑氣不通,肺失肅降作喘。在治療風(fēng)寒致喘或暑熱致喘時不忘顧護(hù)胃氣。對于內(nèi)傷致喘,在補(bǔ)中益氣的基礎(chǔ)上,或是清熱,或是滋陰,或是行氣,或是化痰,或是逐飲,或是行瘀,或是溫里,形成了以脾胃為核心的治喘理論體系。第四部分:李東垣治喘學(xué)術(shù)思想臨床應(yīng)用探究李東垣基于《內(nèi)經(jīng)》,從脾胃立論,形成了以脾胃為核心的治喘理論,補(bǔ)充和豐富了現(xiàn)代辨治喘證的理論體系,有助于臨床工作者把握喘證虛實(shí)緩急,指導(dǎo)合理用藥。慢性阻塞性肺病是一種常見的呼吸系統(tǒng)疾病,它以不完全可逆的氣流受限為主要臨床特點(diǎn)。中醫(yī)臨床上多將慢性阻塞性肺病歸結(jié)為"肺脹"、"喘證"。孫志佳教授在慢性阻塞性肺病的治療中主張"急則治標(biāo),緩則治本"的治療原則,在急性期或是解表,或是化痰,或是逐瘀,或是行氣,以祛邪為主,不忘兼顧脾胃。在緩解期注重溫補(bǔ)脾腎,尤重脾胃,以固本培元。同時建議結(jié)合患者自身體質(zhì)和季節(jié)變化,制定合理養(yǎng)生方案,力求陰陽平衡。其辨治慢性阻塞性肺病的臨床經(jīng)驗(yàn),從某種程度上來講,既是對李東垣治喘學(xué)術(shù)思想的繼承,又是對李東垣治喘學(xué)術(shù)思想的發(fā)展。在一定程度上說明李東垣以脾胃為核心的治喘學(xué)術(shù)思想,在現(xiàn)代臨床實(shí)踐中具有理論指導(dǎo)意義。結(jié)論:李東垣治喘,不離外感、內(nèi)傷兩大端。認(rèn)為邪之所湊,其氣必虛。治療外感不忘顧護(hù)脾胃。對于內(nèi)傷致喘,多是從肺、脾、腎三臟入手,其中脾胃是關(guān)鍵。通過脾胃將肺、腎有機(jī)聯(lián)系起來,臨證多虛實(shí)夾雜。其以脾胃為核心的治喘學(xué)術(shù)思想,對現(xiàn)代臨床治療喘證具有重要指導(dǎo)意義。
[Abstract]:Background: asthma can be used as a syndrome in traditional Chinese medicine as a syndrome or as an accompanying symptom of other diseases. Many clinical manifestations are dyspnea, serious patients can be accompanied by mouth lifting, nasal alar incitement, and no supine clinical manifestations. In western medicine, many diseases can appear asthma, such as chronic obstructive pulmonary disease and pulmonary origin. Heart disease, asthma, asthmatic bronchitis, severe pneumonia, emphysema, lung cancer and hysteria. The clinical traditional Chinese medicine is treated with asthma syndrome differentiation and treatment. Asthma pathogenesis is complicated and the treatment is more difficult. It seriously affects the physical and mental health of the patients and brings heavy economic burden to the country and the people. It is one of the common difficult and critical diseases in the clinic. Chinese medicine is treated in the treatment of traditional Chinese medicine. On the basis of the theory of Zhang Zhongjing's internal meridian, we also make a related exposition of asthma, not only in the syndrome differentiation of the six meridians and asthma, but also in the discussion of the asthma in the miscellaneous diseases. It has a lot of clinical experience. Therefore, it is of great practical significance to strengthen the collation and research of ancient doctors' experience in treating asthma. Li Dongyuan, the present name, Li Gao, is clear. When he was young, Mr. Yi Shui, Zhang Yuansu, was named as Liu finished, Zhang Congzheng and Zhu Zhenheng, and the history called "Jin Yuan four people". It is caused by "internal injury of spleen and stomach". It emphasizes the differentiation of external and internal injuries, and puts forward the principle of improving Qi and Yang, removing heat from the heat of the spleen and reducing fire and so on, and forming a more complete system of differentiation and treatment of spleen and stomach internal injury. Li Dongyuan thinks that the spleen and stomach are the main limbs of the spleen, the main stomach of the stomach is absorbed by the decomposed water valley, the labor is overworked, and the drinking and feeding can directly damage the spleen and stomach and cause asthma. It mentioned "spleen and stomach deficiency, Lung Qi first", because of asthenia and asthenia. In the theory of differentiation of internal and external injuries, the deficiency of spleen and stomach, cloudy and cloudy and cloudy and difficult, the lung and the large intestine, the inflow of the organs and the Qi, the asthenia of the spleen and stomach can be seen. The research on Li Dongyuan's academic thought is mostly concentrated on the spleen and stomach, the five senses and the sore diseases, and less research on the academic thought of the treatment of asthma. There is no relevant academic report on the treatment of asthma in China. Therefore, it is of great practical significance to strengthen the study on the academic thought of Li Dongyuan's treatment of asthma. On this basis, we deeply analyze the experience of treating asthma, explore the rule of the treatment of its syndromes, provide theoretical support for clinical treatment of asthma, and combine the clinical experience of modern Chinese medicine to explore the guiding significance of Li Dongyuan's academic thought on modern clinical diagnosis and treatment of asthma. By collecting and sorting out the relevant academic works of Li Dongyuan and combining the theory of modern Chinese medicine, this paper systematically collates and studies the academic thought of treating asthma by combining the theory of modern Chinese medicine. It summarizes the clinical experience of Professor Sun Zhijia's "PEX Sheng Jin method" in the treatment of chronic obstructive pulmonary disease (COPD), and probes into the diagnosis and treatment of asthma by Li Dongyuan's academic thought on modern clinical treatment. The study is divided into four parts: the first part is divided into four parts: the first part is a brief description of the medical career and the main works of Li Dong Yuan. At 20 years old, Dongyuan was 20 years old, the mother died, and the East yuan was very sad, and began to study medicine. Heart, but walking on an official career. Although he was in the official sea, Dongyuan was also seeking ancient training in the suffering of plague in the people, and at the end of the war, he created Puji disinfection drink and saved countless people. After the war of gold and yuan, Dongyuan avoided war and south to Ling'an. At this time, it began to practise medical career. In the process of practicing medicine, the curative effect was remarkable. He began to organize his internal injury thought and began to write his first medical monograph, "internal and external injury discrimination theory". In his later years, he taught the apprentice on the side of Hebei's home and arranged his own medical experience. According to modern scholars, it was considered that the theory of internal and external injury differentiation was the only work before Li Dongyuan, and the spleen and stomach theory was the work of his later years. The second part: the second part: a summary of Li Dongyuan's Thoughts on internal injury: Li Dongyuan thinks that there is a disease that Li Dongyuan thinks that the external feeling is cold and cold. Too much, resulting in the spleen and stomach qi deficiency, the camp and the disharmony, the people also evil wind cold. Most of the world has mistaken the evil wind and cold of the internal injury, mistaken the external sense of the evil, the false and the murderous and unknowable. The East yuan from the Yin Syndrome from thirteen aspects of internal injury to identify. It leads to the endogenous growth of the Yin Fire, puts forward the idea of "Gan Wen" and "great heat". According to the theory of "internal meridian >", we set up the decoction of replenishing qi and replenishing qi. Through the five lines, the spleen and stomach and other viscera are organically combined together to form the theory of five Zang Zang organs transfer with the spleen and stomach as the core. The prescription drugs pay attention to the drug taste and the return of the meridian, emphasizing the combination of the climate Yin and Yang at the time of four. The third part: the third part: a systematic arrangement and Research on the academic thought of Li Dongyuan's treatment of asthma. Li Dongyuan thinks that the causes of asthma are not outside the external feeling and internal injury. It is caused by the long illness. The external and internal injuries are not isolated, the Qi deficiency and the cold and the heat can also hurt the Qi. The pathological nature of the asthma syndrome is mostly false and solid, or cum phlegm drink, or concurrently with Yin Fire, or concurrently with the three dirty viscera and concurrently accumulation. The pathogenesis of the lung, spleen and kidney is closely related to the dysfunction of the lungs and the nose and outer fur. The spleen and stomach are the source of Qi and blood biochemistry, the spleen and stomach are the source of Qi and blood biochemistry, the spleen deficiency is not adjusted in the camp and Wei, and the external evil is easy to feel. Metabolism, spleen deficiency is easy to produce phlegm, Qi block Qi machine, Lung Qi reverse asthma. Spleen main rise clear, spleen does not rise clear, cloudy Yin does not descend, cloudy and cloudy to make asthma, spleen yang deficiency, middle coke deficiency cold, intestinal blood and body fluid condense formation, lung make wheezing. Kidney is gas root, kidney yang decay, upper and reverse asthma. Kidney division two stool kidney, kidney kidney Water is not enough, the stool is hard, the lung and the large intestine are in the form of the stomach and the intestine, the organs and the air are not clear, the lung is lost and the stomach is breathed. In the treatment of the wind and cold and the heat caused by the asthma, it does not forget to care for the stomach qi. The fourth part: the fourth part: the clinical application of the academic thought of treating asthma by Li Dongyuan, based on the theory of spleen and stomach, it has formed the theory of treating asthma with spleen and stomach as the core, supplementing and enriching the theory system of modern diagnosis and treatment of asthma. It is helpful for clinical workers to make the deficiency and real urgency of the syndrome and guide the rational use of drugs. Sexual lung disease is a common respiratory disease, which is mainly characterized by incomplete and reversible airflow limitation. In clinical Chinese medicine, chronic obstructive pulmonary disease is mostly attributed to "lung distention" and "asthma". In the treatment of chronic obstructive pulmonary disease, Professor Sun Zhijia advocates the principle of "urgent rule treatment, slow rule" treatment, in acute period or to solve the table, Or to eliminate phlegm, or to remove stasis, or do Qi, to dispel evil spirits, not forget the spleen and stomach. In the remission period, pay attention to the spleen and kidney, especially the spleen and stomach, to fix this element. At the same time, it suggests combining the patient's own physique and seasonal change, making a reasonable regimen of health keeping and striving for the balance of yin and Yang. Speaking, it is not only the inheritance of Li Dongyuan's academic thought of treating asthma, but also the development of the academic thought of Li Dongyuan's treatment of asthma. To a certain extent, it shows that Li Dongyuan's thought of treating asthma with spleen and stomach as its core has theoretical guiding significance in modern clinical practice. Deficiency in the treatment of external sensation does not forget to care for the spleen and stomach. In the case of internal injury, it is mostly from the lung, the spleen and the kidney three organs, among which the spleen and stomach are the key. Through the spleen and stomach, the lung and kidney are linked together, and many deficiency and real inclusions are faced. The treatment of asthma with the spleen and stomach as the core is of important guiding significance for the modern clinical treatment of asthma.

【學(xué)位授予單位】：廣州中醫(yī)藥大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R256.12

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