基于古代文献的“肺与大肠相表里”理论在儿科中的应用研究

【作者】 王柳青；

【导师】 高思华；

【作者基本信息】 北京中医药大学 ， 中医基础理论， 2012， 博士

【摘要】 “肺与大肠相表里”理论是中医藏象学说的重要内容之一,千百年来一直有效地指导着中医临床实践。本研究从古代儿科文献入手,探讨“肺与大肠相表里”理论在儿科中的应用。依据古代儿科文献资料所展示的各时期该理论发展的特点,可分四个时段。其一,“肺与大肠相表里”理论的形成,这一时期在唐及五代之前。中医藏象学说最早自成体系的记载见于《黄帝内经素问》(以下简称《素问》)。虽然《素问》中尚无直接论述五脏与六腑之间两两对应关系的文字,但在《素问·金匮真言篇第四》中已经提到了五脏六腑具有逆从、阴阳、表里、雌雄关系；《素问·五藏生成篇第十》中的“五决”诊法则明确指出属于肺的疾病(咳嗽上气)归咎于手阳明、太阴经脉。这就明确了肺与大肠之间可通过经络相联系,而无须借助社会结构的隐喻或五行模式的推导。在《灵枢》中出现了系统的脏腑相合论述,其中“肺合大肠”凡两见。这种相合关系的产生,据当代学者及本文的考证,都与经络学说有关,且在针刺实践中,已经出现了胸中属于肺之病采用刺手阳明络的方法。现存隋唐医学文献中,逐渐将在《素问》、《灵枢》中零散的肺合大肠、手太阴与手阳明为表里的表述摘引出来,作为五脏六腑病证前的重要理论之一其中《诸病源候论》中归纳为肺“与大肠合。大肠为府,主表；肺为藏,主里”。为后世“肺与大肠相表里”的归纳奠定了基础。《千金要方》则将肺与大肠结合起来论虚实,记载了“肺与大肠俱实”、“肺与大肠俱不足”的病证及相应的药疗方。同时《素问》肺咳日久移于大肠的病证传变途径也被纳入了五脏六腑病证系统。《外台秘要方》转引的《删繁方》治疗大肠实热、虚寒的方剂表明,药疗法中已经开始出现肺、肠同治的实例。其二,“肺与大肠相表里”理论在儿科中的最初应用,这一时期为宋金元时期。“肺与大肠相表里”理论开始在中医儿科中的得到应用。宋代其中两部官修的大型医方书(《太平圣惠方》与《圣济总录》)中,有若干关于肺与大肠关系的重要内容,二书的记载表明,肺合大肠的理论不仅用来解释某些疾病的病因,同时也越来越多地用于临床治疗,出现了肺病治肠,肠病治肺,或肺肠同治的药疗法。《圣济总录》中还第一次出现了“肺与大肠为表里”的提法,并用来解释血痔的成因。这意味着“肺与大肠相表里”理论在宋代已经最终形成。随着“肺与大肠为表里”理论的广泛运用,宋代儿科著作中也开始采用这一理论。南宋《小儿卫生总微论方》再次出现了“肺与大肠为表里”的提法,并用来解释小儿变蒸说中。在这一理论的指导下,这一时期的儿科学在临证中可以不受病位的限制,深入探求脏腑相关的病因,辨证用药,为儿科药疗提供了临床依据。其三,“肺与大肠相表里”理论诊治儿科病种的扩展与理论探讨,该时段主要是明代。明代儿科医书中与“肺与大肠相表里”理论相关的内容较多。这一时期众多医家较多运用“肺与大肠相表里”理论,对多种疾病(如肺热、脱肛、赤白痢、便血、麻疹、疳症等)的见证、病机等予以解说。“肺与大肠相表里”(王肯堂)一语在明代几乎取代了宋代出现的“肺与大肠为表里”,被后世学术界广为运用。明代“肺与大肠相表里”理论在儿科学中应用最多的是指导临床用药,其涉及的病种主要为杂病,以属于大肠腑证者(便血、脱肛、痢疾、泄泻、大便不通等)居多,也有属于肺疾(马脾风,咳嗽等证)或肺肠同病者。明代儿科疾病诊治中,运用“肺与大肠相表里”理论辨析所治疾病的病位、病因、病机,为选择先从肺治或先从肠治,或肺肠同治提供依据。此外,明代还开始总结某些具有肺肠兼顾药性的药物,以便临床选用。其四,“肺与大肠相表里”理论诊治儿科诸病的深化与医案分析,该时段主要是清代。清代是中医儿科应用和发挥“肺与大肠相表里”理论最多的一个时期。这一时期疫病流行频繁,危害小儿的疾病甚多,因而促使“肺与大肠相表里”理论更多地应用于儿科疾病诊治。鉴于儿科理论有“痘出于五脏,疹由于六腑”、“麻乃大肠主之”等说法,且麻疹多犯肺,因此清代“肺与大肠相表里”理论最多见用于麻疹诊治。此外,清代儿科应用“肺与大肠相表里”理论治疗杂病的记载较明代大为增多,但所治的疾病种类仍多局限于属大肠腑证的下部疾患(如脱肛、痢疾、大便不通、便血等),属于肺疾(咳嗽、肺热喘渴等)者甚少。这从一个侧面提示,小儿疾病运用“肺与大肠相表里”理论的病种主要与大肠腑有关。大肠可以发挥驱邪外出的通道作用,因此,“除肺热而不引大肠”,就容易导致“闭门杀贼”之弊。研究提示,“肺与大肠为表里”一语,其在《灵枢》的最早表述法是“肺合大肠”。这种“合”可以体会为配合、对应,也可以理解为两者有一定的络合关系,两者之间还有着以经脉为媒介的联络通道。“肺与大肠相表里”的“表里”,是引进经络学说阴阳经相表里的说法。在该理论运用的实例中,肺合大肠最多见是功能、气机的上下交流。在生理上二者互相配合,即肺气肃降正常,有助于大肠的传导,大肠传导功能正常,有助于肺气肃降顺畅而呼吸匀调。病理上互相影响,若肺气失于肃降,津液不能下达,或肺气虚弱,推动无力,可见大便困难或秘结。若大肠实热便秘,腑气不通,可影响肺气肃降而咳喘胸满。但是从广义上讲,肺与大肠相表里已经延伸扩展到了肺系与大肠系。肺系：皮毛、咽喉、胸、鼻；大肠系：大肠、肛门。肺与大肠在生理密切联系,功能上相互协调。肺肠之间病理上的相互影响主要表现在肺病及肠与肠病及肺以下两方面。通过研究,本文得出以下结论：(1)“肺与大肠相表里”理论逐渐形成于唐及五代以前。其前身脏腑相合理论见于《素问》、《灵枢》有关针刺经脉的篇章,是藏象学说与经络学说渗透交融的产物。其中“肺合大肠”两见于《灵枢》,并已运用于诊断与针刺疗法。隋唐时期药疗法中已经出现肺、肠同治的实例。(2)“肺与大肠相表里”理论在宋金元时期应用于脉诊、药疗,并开始运用儿科学中。《圣济总录》首次出现“肺与大肠为表里”的提法,并用此解释血痔成因。宋金元儿科学开始深入探求脏腑相关的病因,辨证用药,为儿科药疗提供了临床依据。(3)明代众多医家尝试运用“肺与大肠相表里”理论,对多种疾病(如肺热、脱肛、赤白痢、便血、麻疹、疳症等)的病证、病机等予以解说。“肺与大肠相表里”(王肯堂)一语逐渐被后世医学界广为运用。该理论在明代儿科学中有效地指导杂病临床用药,其适用范围比宋金元要广泛得多。(4)清代是肺肠相关理论在儿科中应用发展的鼎盛时期。其主要表现是越来越多地运用该理论诊治小儿疾病种。“肺与大肠相表里”理论,使大肠成为驱邪外出的通道,避免出现“闭门杀贼”之弊。本文基于系统梳理分析古代儿科文献,全面探讨了“肺与大肠相表里”理论的形成过程,及该理论应用于古代儿科的范围与特点。进而系统梳理了该理论在古代药疗及儿科中的应用与发展,其中包括脉诊分部、解释小儿变蒸阶段,以及在儿科麻疹及以大肠腑为主的杂病诊治中的运用,并分析其中相关的理论阐述。该理论是儿科病证“外感重肺肠”的一个方面,对总结儿科病证从肺、大肠论治的规律有所裨益。更多还原

【Abstract】 As one of the original kernel theories, Viscera theory is one of the most important part of Traditional Chinese Medicine which have been guiding the clinical practice through the ages and have obtained good effects. The relationship between the exterior-interior visceras is one important part of the Viscera Manifestation theory. "The exterior-interior relationship between the lung and the large intestine" theory is a typical representative of the relationship."Ancient" refers to the feudal society and the time before-the long period of time before year 1911."Pediatric Literature" refers to the special literature and some books for special pediatric diseases."The exterior-interior relationship between the lung and the large intestine "is a concept of the Viscera Manifestation theory which reflects the exterior-interior relationship between the lung-one of the five visceras and the large intestine-one of the six bowels in TCM. According to the development of the theory of ancient pediatric works inliterature, we can divide it into four stages.Firstly, the formation of "the exterior-interior relationship between the lung and the large intestine "theory, which can be traced back to the period before the Tang and the five dynasties.The earliest records of Viscera theory can be seen in HuangdiNeijingSuwen ( Hereinafter to be referred to as Suwen).While there are no direct discusses on the two-two corresponding relations between the viscera and bowels, the relationship between obverse and reverse,yin and yang,exterior and interior,male and female had been mentioned in Suwen; the"Wujue"treatment in Suwen explicitly pointed out that lung diseases such as cough and asthma were owing to the large intestine meridian and the lung meridian. These have made clear that the lung and the large intestine are connected through meridians and collaterals without the help of the metaphor of the structure of the society and the inference of the mode of Five Phases.It had been systematically discussed that the viscera and bowels are one to one corresponding in Lingshu, including two discusses about the correspondence between the lung and the large intestine. According to the textual research of contemporary scholars and this article, this has something to do with the meridian and collateral theory.What’s more, lung diseases can be cured by acupuncturing the Yang meridians of the hand which can be affirmed in the acupuncture practice. The scattered expression of the relationship between the lung and the large intestine can be found in the existing Sui and Tang dynasties’s medical literature, as one of the important part of theory about the disease of five zang organs and six fu organs. In Zhubingyuanhoulun, it was concluded that "the lung is corresponded to the large intestine and the large intestine is one of the bowels which decides the exterior, the lung is one of the viscuses which decides the interior", which have layed the foundation for the later conclusion.In Qianjinyaofang, the lung and the intestine were combined to discuss its deficiency and excess,the diseases and the corresponding treatments of "the lung and the large intestine are both excess or deficiency" were recorded. At the same time, in Suwen, the way diseases transmits as longtime coughing would be transferred into the large intestine was brought into the visceral system.The prescription for excessive heat in the intestine or deficiency-cold recorded in WaitaiMiyaofang which was quoted from Shanfanfang indicated that the treatments that the lung and the intestine diseases can be cured together were emerging.Secondly,the application of "the exterior-interior relationship between the lung and the large intestine"theory in pediatrics,which apprared in Song,Jin,and Yuan period. From then on,the theory began to be widely applied into TCM Pediatrics.Taipingshenghuifang and Shengjizonglu, two of the large-scaled medical formula books compiled by the government in Song dynasty have some important contents about the lung and the large intestine which indicates that the" all the large intestine lung" theory can not only be used to explain the causes of some particular diseases, but also the clinical care.The drug therapy of regulating the intestine function to treat lung diseases and regulating the lung function to treat intestine diseases and treating the lung and the intestine together.ShengJiZongLu first put forward"the exterior-interior relationship between the lung and the large intestine" theory, and used it to explain the causes of bleeding hemorrhoid, which means the theory finally formed in Song dynasty. Along with the widely application of the theory, it had been adopted in the pediatric works in Song dynasty.The theory appeared again in Xiaoerweishengzongweilunfang in the Southern Song dynasty and had been used to explain the infantile feverish perspiration theory. Under the guidance of this theory, pediatrics could break the restrain of the location of diseases, search for the causes of diseases related with visceras, diagnosis and prescription, the theory contributed greatly to the use of drugs for pediatrics.Thirdly, the extension of treating pediatric disease category by using"the exterior-interior relationship between the lung and the large intestine"theory and the theoretical discussion mainly showed up in the Ming dynasty.The theory was used by doctors at that time to explain the pathomechanism of many diseases such as lung heat, rectocele, red-white dysentery, hemafecia, measles and malnutrition. "The exterior-interior relationship between the lung and the large intestine"theory almost took the place of the saying "the lung and the large intestine has exterior-interior relationship"which appeared in Song dynasty and was widely used by the later academic circles.In Ming dynasty, the application in pediatrics was mostly for guiding the clinical drug use, the diseases involved were mainly miscellaneous diseases, and most of these fell into large intestine fu-organ diseases such as hemafecia, rectocele, dysentery, diarrhea, constipation, some fell into lung diseases such as Mapifeng, cough, some both.The theory was used to discriminate the location, the etiological factor and the pathomechanism of diseases which provided the basis of choosing whether to treat from the lung or the large intestine firstly or together in the diagnosis and treatment of diseases in pediatric in Ming dynasty, what’s more, drugs which have the properties of both the lung and the large intestine were summarized in Ming dynasty for clinical use.Fourthly, the deepening of treating pediatric diseases and the medical case analysis mostly appeared in Qing dynasty when the theory was widely applied in pediatrics.In this period of time epidemic diseases raged on and most of the diseases did harm to children which led the theory to the widely application for the diagnosis and treatment of pediatric diseases.As indicated by such sayings as"blain comes from five zang organs, rash comes from six fu organs""rash is masterd by the large intestine" and moreover, measles invaded lung most.Thus,the theory was mostly applied to the treatment of measles.Besides, the record of application of the treatment of miscellaneous diseases through the theory in pediatric in Ming dynasty had increased greatly than that in Qing dynasty, but the diseases involved were mostly confined to the large intestine fu organ diseases which located in the lower parts of the body such as rectocele, dysentery, constipation and hemafecia.Only a few diseases belong to the lung diseases such as cough and lung heat asthma.Out of this we can see that the pediatric diseases suitable for the theory are mainly related to the large intestine fu organs.The large intestine played an important role in eliminating pathogenic factors as a chanel.So, simply clearing away the pathogenic heat of lung without relaxing the bowels is just like "killing a thief in a closed door".Research showed that the saying"the lung and the large intestine has an exterior-interior relationship" was first recorded in Lingshu in a way goes that"All the large intestine lung", which we can define as cooperation and parallelism or we can consider that the lung and the large intestine have certain complex relationship and were connected by their meridians as chanels.The "exterior and interior"comes from the statement of exterior-interior relationship between the yin and yang meridians in the theory of meridian and collateral, actually the relationship never exists when it comes to the anatomical structure.In actual use of the theory , the relationship was mostly seen as the communication of function and qi activities.They cooperate with each other physiologically which means the normal descent of lung-qi helps the transmission of the large intestine and vice versa.They influence each other pathologically , if the descent of lung-qi is out of order, body fluid can’t be transferd to the underpart, or the weakness of the lung qi and its promotion all led to constipation and vice versa.Broadly speaking, "the exterior-interior relationship between the lung and the large intestine"theory has been extended to the lung system which includes skin and hair, throat, chest and nose and the large intestine system which includes large intestine and anus. They have close associations with each other in physiology and coordinate with each other in functions. The influence pathologically between the lung and the large intestine mainly shows in the following two ways, lung diseases spread to the large intestine and large intestine diseases spread to the lung.Four conclusions are drawn here in this research:1.The theory "exterior-interior relationship between the lung and the large intestine" gradually formed by the Tang and Five Dynasties.Its predecessor-"the visceras and the bowels are closely related to each other"theory was recorded in acupuncture and meridians literature like Lingshu and Suwen and was the product of the combination of the Viscus Manifestations theory and the meridian and collateral theory.Two descriptions were recorded in Lingshu on the theory that "the visceras and the bowels are closely related to each other"and had already been applied to diagnosis and acupuncture.Examples of curing the lung and the large intestine together emerged in the drug therapy in Sui and Tang dynasty.2.The theory "exterior-interior relationship between the lung and the large intestine" was used in pulse examination, medication and began to be applied to pediatric during Song-Jin-Yuan Dynasties.The theory was first put forward in Shengjizonglu and was used to explain the cause of internal hemorrhoids with massive bleeding.People began to explore the causes related to the visceras and bowels in pediatrics deeply and to use medicine dialectically in Song-Jin-Yuan Dynasties, which contributed greatly to pediatric therapy.3.Many physicians in Ming Dynasty tried to use the "’exterior-interior relationship between the lung and the large intestine" theory to explain the pathogenisis of many diseases such as the lung heat, rectocele, red-white dysentery, hemafecia, measles and malnutrition. The theory (by WangKentang) gradually became widely used by the later medical communities and have been guiding the clinical drug use for miscellaneous diseases in pediatrics since then.Its scope of application was much broader than that in Song-Jin-Yuan Dynasties. 4.Qing Dynasty is the flourishing period of the pulmonary intestinal-related theory. The main manifestation was that the theory was frequently used in pediatrics to treat diseases related to children. The "exterior-interior relationship between the lung and the large intestine" theory makes the large intestine a channel to eliminate pathogens, so as to avoid "killing a thief in a closed door".更多还原