节点文献
基于文献分析的“肺与大肠相表里”证治规律及其关系研究
【作者】 郜峦；
【导师】 王键；
【作者基本信息】 北京中医药大学 ， 中医基础理论， 2011， 博士
【摘要】 “肺与大肠相表里”理论是中医学原创性命题,是中医基础理论的重要组成部分之一,一直有效的指导着临床实践。但现代意义上的理论内涵及其实践运用规律研究却相对滞后,从而限制了该理论指导临床的应用,因此迫切需要对这一理论开展深入研究,本课题提出了“肺与大肠生理病理上存在相关性,证候表现上存在联系性,治疗效应上存在协同性”的科学假说。目的：系统整理古今中外“肺与大肠相表里”相关文献,揭示肺与大肠相关疾病证治规律,丰富“肺与大肠相表里”理论内涵,阐明肺与大肠之间生理和病理的关系,以进一步指导临床,提高临床疗效。方法：1通过梳理“肺与大肠相表里”理论相关的中医古籍以及近30年现代国内外文献,运用传统文献整理方法,厘清其理论渊源,探讨“肺与大肠相表里”理论的文献基础；2运用描述性统计分析方法,以近30年现代国内外文献资料为对象,分析肺肠相关疾病证候特征及治法方药分布规律；3利用数据挖掘关联分析方法,以近30年现代国内临床研究文献资料为对象,分析肺肠相关疾病症状、证型、治法、方剂、药物、归经之间的关联关系；4利用循证医学的评价方法,对上述研究中的“随机对照试验”文献进行质量评价,以期了解现有临床研究文献的科研方法学水平,评价其临床疗效。结果：1古代文献整理“肺与大肠相表里”理论渊源为：秦汉时期,初现雏形；隋唐时期,渐近发展；宋金元时期,趋于完善；明清时期,日臻成熟。2现代文献梳理“肺与大肠相表里”理论研究现状为：当前学术界多种观点并存；国外医学界,业已认识到呼吸系统与消化系统之间的相关性；国内医学界,在临床内科疾病、皮肤病等治疗中均得到广泛应用；现代实验研究中,动物模型的制作为结扎法和药物法,探讨肺病及肠和肠病及肺作用机制,肺与大肠相关具有一定的生物学基础。3证治规律分析(1)证候分布特点。①症状分布规律。肺系疾病主要症状包括肺系症状(咳嗽,气喘,发热,短气,咳痰,喉中痰鸣)、肠系症状(大便秘结,腹满)、痰热症状(舌红、苔黄、苔黄腻)肠系疾病主要症状包括肠系症状(大便秘结,大便艰难,食欲不振,腹满,腹泻,腹痛)、肺系症状(咳嗽)、气虚症状(舌淡白,疲乏)②证型分布规律。运用“肺与大肠相表里”的理论为指导时,肺系疾病最常见证型的是痰热壅肺,肠系疾病最多见的是肺气亏虚。在病性因素中,肺系疾病病性以实证为主,最常见的是痰和热。肠系疾病病性以虚证为主,最常见的因素是气虚。(2)治法方药分布规律。肺系疾病治法以通腑、清热、化痰、泻热为主；肠系疾病治法以通腑、补肺、润肠为主。自拟方占比重较大,其中,肺系疾病药物多以清热化痰通腑为主,肠系疾病药物多以补气通腑为主。肺系肠系疾病共同使用高频药物是瓜蒌、大黄、苦杏仁.甘草、厚朴、枳实。在肺系疾病中,最常见的药物归类是化痰止咳平喘药和清热药,药性以寒为主；而肠系药物中最多的是补虚药,药性以温为主。药物的五味归属上,都以苦味和甘味为多,归经都是肺、脾、胃、大肠经。4关联关系分析(1)肺系疾病关联分析：症状：咳嗽,气喘,发热,大便秘结,小便黄赤,脉滑数,舌红,短气。证型：痰热壅肺。治法：泻热,通腑、宣肺、化痰。药物：瓜蒌、大黄、苦杏仁。归经：肺与大肠经。以上具有较强关联度。(2)肠系疾病关联分析：症状：大便秘结,大便艰难,腹满,舌红。证型：肺气亏虚。治法：润肠,通腑,补气,宣肺,养阴；药物：瓜蒌、苦杏仁、黄芪、麦冬。归经：肺与大肠经。以上具有较强关联度。5循证医学评价符合随机对照要求的有25篇文献,19篇“肺病治肠法”及6篇“肠病治肺法”随机对照文献,仍存在一些问题,今后要加强临床试验方案的科学设计及方法学的运用。6肺与大肠之间的关系肺与大肠的关系不仅仅是经脉的络属,而是存在多种关系,主要包括：经脉络属关系、气机升降关系、水液代谢关系、水谷传导关系、阴阳润燥关系、表里通应关系等方面。结论：“肺与大肠相表里”理论作为中医基础理论的命题,具有扎实的理论基础、文献基础和临床基础。肺与大肠在生理上相互联系、病理上相互影响。证候特征在一定程度上有共同之处,病位都在肺和肠,症状表现则肺系与肠系症状并见。运用“肺与大肠相表里”的理论为指导时,肺系疾病最常见的证型是痰热壅肺：肠系疾病最常见证型是肺气亏虚。在治疗效应上存在协同性,常用治法都是通腑,但肺系疾病更侧重清热、化痰；肠系疾病侧重补肺、润肠。共同高频药物是瓜蒌、大黄、苦杏仁、甘草、厚朴.枳实。关联规则分析表明症状、证型、治法、方剂、药物、归经之间存在关联关系。肺与大肠具有经脉络属关系、气机升降关系、水液代谢关系、水谷传导关系、阴阳润燥关系、表里通应关系。
【Abstract】 The exterior-interior relationship between the lung and the large intestine, which have been effectively guiding the clinical practice, is one of the most important parts of traditional ChineseMedicine (TCM) basic theory. Yet its modern theoretical connotation and clinical application research relatively lags behind, consequently clinical applications are limited. So it is urgent to carry out the theoretical research. It was proposed in this research project that" the lung and large intestine exist correlation on physiology, pathology, the same with the performance of syndromes and therapeutic effects".Objective:To summarize the publications on "Exterior-interior relationship between the lung and the large intestine", to discuss the literature basis, to enrich its theoretical intension, to open out the law of its syndrome and treatment, to elucidate the physiological and pathological relationship between the lung and the large intestine, furthermore, to guide the clinic and to improve the clinical effect.Methods:1 The traditional texture analysis methods were adopted to summarize the literatures in the ancient Chinese Medicine books and modern national and international database nearly 30 years on exterior-interior relationship between the lung and the large intestine;2 The statistical methods were adopted to analyze the characters of the syndromes, the law of the principle of treatment and the prescriptions and drugs in the diseases related to the lung and the intestine;3 The data mining technique was adopted to analyze the relationship between symptoms, syndrome, principle of treatment, prescriptions, herbs and their meridian entry;4 The evidence-based medicine valuation methods were adopted to evaluate the quality and their clinical publications.Results:1 Arrangement of Ancient LiteraturesThe theory that the lung and large intestine are internally and externally related to each other appeared in the Qin and Han Dynasties, developed in Sui and Tang Dynasties, got advanced in Song and Yuan Dynasties and became perfect in Ming and Qing Dynasties.2 Sort of Modern Literatures Current researches on the theory hold the view that there is a coexistence of a variety of perspectives; foreign medical academics have realized the correlationship between the respiratory and digestive systems; in China, "Lung and Large Intestine" theory has been widely used in clinical medicine and dermopathy treatment; in modern experimental studies, animal models made by ligation and drug methods are applied to exploring the mechanism of lung diseases affecting large intestine, large intestine diseases affecting lung; physiologically and pathologically, the biological relationship between lung and large intestine has been confirmed.3 Analyses on Diagnosis and Treatment Regularity(1) Distribution Law of the Syndrome①Distribution Rule of the SymptomSymptoms of lung diseases distribution include pulmonary symptoms (cough, asthma, fever, short breath, expectoration, wheezing due to retention of phlegm in throat), intestinal symptoms (constipation, abdominal fullness), and phlegm-heat symptoms(red tongue, yellow tongue coating, yellow greasy tongue coating).Symptoms of large intestine diseases distribution include intestinal symptoms (constipation, hard stools, loss of appetite, abdominal fullness, diarrhea, abdominal pain),and pulmonary symptoms(cough),along with pale tongue, fatigue and other symptoms of qi-deficiency.②Distribution Characteristics of the SyndromeThe most common syndrome of pulmonary diseases is phlegm-heat obstructing lung, while the most common one of intestinal diseases is lung-qi deficiency. According to the pathological factors, vast majority of pulmonary diseases belong to excess syndrome, and the most common ones are due to sputum and heat, while vast majority intestinal diseases belong to deficiency syndrome, and the the most common disease factor is qi-deficiency.(2) Distribution Rule of the Therapy and the PrescriptionThe most common treatments for lung diseases are relieving constipation, clearing heat, dissipating phlegm, and purging heat, while treatments by relieving constipation, supplementing lung, smoothing intestine are used most frequently for intestine diseases.A majority of the formulas are self-created by doctors, in which drugs for pulmonary diseases are mostly used to clear heat, dissipate phlegm and relieve constipation, and drugs for intestinal diseases mostly tend to strengthen qi and relieve constipation. Herbs used in both pulmonary and intestinal diseases with high frequency are Trichosanthes, rhubarb, bitter almond, licorice, magnolia bark, citrus aurantium. In pulmonary diseases, the most commonly used herbs belong to phlem-resolving, cough-stopping, dyspnea-relieving and heat-clearing drugs, the main nature of which is cold. While the herbs for intestinal diseases belong to qi-invigorating drugs, the main nature of which is warm. The herbs referred above are mostly bitter and sweet, entering the lung, spleen, stomach, large intestine meridians.4 Association rules analysis(1) Diseases related to the lungSymptoms:cough, asthma, heat effusion, constipation, yellow urine, rapid and slippery pulse, red tongue, difficulty in breath. Syndrome:accumulation of phlem-heat in lung.Principle of treatment:purging heat, dredging fu-organ, dispersing lung, resolving phlem.Herbs:Gualou, Dahuang, Xingren. Meridians:lung and large intestine. The above are in strong correlation.(2) Diseases related to the intestineSymptoms:constipation, difficulty in defecation, abdominal distension, red tongue. Syndrome:deficiency of lung-qi. Principle of treatment:dredging fu-organ, supplementing qi, dispersing lung, and nourishing yin. Herbs:Gualou, Xingren, huangqi, maidong. Meridians:lung and large intestine. The above are in strong correlation.5 Evidence-based medical evaluation25 documents meet the randomly controlling requirements-19 of which are about the method of treating pulmonary diseases by treating intestines and 6 are about treating intestinal diseases by treating lung. However, there are still some problems that call for advanced scientific design and methodology in the future clinical trial programs.6 The relationship between the lung and large intestineThe relationship between the lung and large intestine is not just about meridian, but several coexisting relationships including meridians, ascending and descending of qi activity, water metabolism, conduction of food and water, moisture and dryness, induction of the exterior and interior and so on.Conclusions:The theory exterior-interior relationship between the lung and the large intestine, as the one of the basic theories of TCM, possesses solid theoretical, documentary and clinical bases. There are physical contact and pathological interaction between lung and large intestine, which demonstrate as a link between their symptoms and a synergistic curative effect in the treatment. The most common syndrome of pulmonary diseases is phlegm-heat obstructing lung, while the most common one of intestinal diseases is lung-qi deficiency. The most common treatments are both relieving constipation. And herbs used with high frequency are Trichosanthes, rhubarb, bitter almond, licorice, magnolia bark, citrus aurantium. Association rules analysis indicates that symptoms,Syndrome,Principle of treatment, herbs and meridians are in strong correlation. The relationship between the lung and large intestine includes meridians, ascending and descending of qi activity, water metabolism, conduction of food and water, moisture and dryness, induction of the exterior and interior and so on.