【作者】 柳亚平；

【导师】 潘桂娟；

【作者基本信息】 中国中医科学院 ， 中医基础理论， 2008， 博士

【摘要】 “痰”是中医基础理论研究的重要内容之一。中医痰病学说经过历代医家不断创新和扬弃,内容相当丰厚。本项研究,在总结历代痰病各家学说特色的基础上,综合提炼中医学“痰”的基础理论。1源流研究不同时代医家对痰病的认识和研究各有侧重,产生了各具时代特点的中医痰病学说。先秦两汉虽然对“痰”已有一定认识,临床也使用治痰方药,但并未明确提出“痰”的名称。这一时期的医学著作中,对肉眼可见之痰,多用“唾”、“浊唾”、“涎”、“沫”等作称。《黄帝内经》和《伤寒杂病论》虽无“痰”字,书中却能找到痰病理论萌芽的痕迹,都有对唾痰现象进行描述的文字。《伤寒杂病论》记载有关痰病的多个方证。三国魏晋南北朝治痰方药不断积累,为后世痰病学术发展铺垫了道路,贡献极大。从现存书籍的内容来看,“痰”字使用在此时期已经出现,但其内涵与今之“痰”概念有一定差距。此期的“痰”概念内涵介于水饮和痰浊之间,有时指饮病而言,“痰”与“饮”概念含混未分。隋唐五代十国医家逐渐开始重视痰病;发现痰与饮的某些差异;关注痰涎成因,并探索其病机;痰病治疗实践也有较大发展。此期治痰以攻法为主,在方药总结上远远超出从前,并出现观想行气、灸法、食疗等多种疗法。宋代痰病理论和临床实践均出现新的发展,痰病诊法、治法和方药理论大有提高:在病机方面,重视痰涎与气机的关系;对痰病临床表现的观察和描述更详细具体,并总结出痰病常见症候规律;痰病分证较前系统化;从治法看,隋唐时期重视攻法,宋代开始注意使用调理法治痰病。金元痰病学说在理论和实践方面都有突出创新,无论从病因病机探讨,症候规律总结,还是治疗实践的丰富多彩,都体现出百家争鸣的特色,痰病学术发展呈现蒸蒸日上的趋势。痰病研究在诊断、治法和方药总结方面逐渐形成规模和体系,其影响范围也深入到儿科、外科等领域。明代医家一方面不断深化中医经典理论思维,一方面对长期积累的临床经验进行总结创新,形成多方面的独具特色的理论。痰病学术也得到长足发展,重视对前人观点的辨析,注重对痰与气血津液、痰与脏腑关系、痰致病症候规律等内容的探讨,形成有关痰病的各家学说。清代中医学的理论和实践经过长期的积淀,至清代已臻于完善和成熟。另外,在训诂考据学风影响下,清代痰病研究继续从多个方向深化发展。主要是对前人成果的综合归纳,在某些细节上更加深化;注重考据,对痰病病名的辨析,对痰饮异同的讨论,使得痰概念内涵益加清晰,带来了理论和临床实践的显著效应。近现代西方文化和科学技术的传入,与中国传统文化冲击碰撞,产生新的思想火花。近现代痰病研究也进入一个新领域,增加了一些认识痰病的新视角,痰病研究方向发生一些新的变化。一些学者试图从实验研究中找到痰的生化物质基础,并提出相关假说。结合古今医论对痰病理论展开研讨,提高了现代人认识痰病的水平。通过对中医学“痰”的理论源流研究和现状分析,笔者认为中医“痰”的理论具有丰富的思想内涵和实践价值。但是,迄今为止其理论仍有待深入挖掘、全面整理、综合分析、系统阐述。2理论研究本课题以理论思维为主导,结合中医文献学等研究方法,阐发中医学“痰”的理论。其主要内容如下:“痰”的概念中医学痰的概念,有物质、病因、病机、症候等多个层次的内涵。同一个“痰”字在不同时代、不同书中表达的内容不一定相同。对痰概念名词体系进行分类研究,发现这些概念分别从痰之成因、性状、质地、病程、结聚程度、颜色、气味、相关病症、治法特点等方面展现其丰富内涵。“痰”的基本概念和相关各类概念,既是对痰的生理、病理认识的总结,也是分析和诊断痰病证候及相关病症的归类方式,并引申为痰病治疗的推理模式。痰的生成痰来源于先天的禀赋体质和后天的饮食水谷,以及由此化生的精、血、津液等物质,还有津液停积形成的水饮。痰的产生受体质禀赋、饮食习惯、起居劳逸、衣物防护、情志异常、季节气候等内外诸多因素的影响。痰的形成过程,是脏腑的参与、气的变化和精血津液的转变综合作用的结果。痰的生成与脏腑气化失常有关。五脏中与痰生成之关系最密切的是脾和肾,其次也受肺、肝的影响。六腑中参与痰形成的主要是胃,也与膀胱、三焦和胆的功能活动相关。痰的生成与气化密不可分,痰是人体气化的产物。气化异常生痰有四种情形:一是正气亏虚,气化乏力,饮食水谷不能正常化生气血,而变化为痰;二是气机壅滞,精、血、津、液流布不畅,结聚成痰;三是气机逆乱,不循常道,精、血、津、液停滞成痰;四是人体六气气化失衡,或寒化、或热化、或湿化过度,饮食水谷化生的痰湿涎液过量,对人体造成危害。精、血、津、液与痰来源相同,而且都可以转化为痰,因而精、血、津、液中任何一者过多堆积,就容易转化成痰;反之,凡是使用攻痰破痰的药物,也容易损耗精、血、津、液。痰的致病痰的致病特点可概括为:分布广泛,症候多样;逐渐蓄积,伏结胶固;阻滞气机,凝涩血运;招引外邪,缠绵反复;挟风化热,上扰作乱;累生赘物,滞碍形体。痰的发展转归,与个人调摄、治疗是否恰当;是否兼挟内外多种复杂病邪;人体气血运行是否顺畅等因素有密切关系。合理的饮食、起居、劳作,愉悦的心情,正确的治疗措施,对减少痰的生成,消除局部堆积的痰浊,以及痰病的康复都有积极作用。痰病诊治防护最后,综合古今医家学说,从望形色、察目部、望舌、察痰、闻诊、问诊、切诊等方面介绍痰病诊法;从平衡阴阳、调和脏腑、调畅气血、祛除痰浊等四个层次分析痰病治疗原则;并简介痰病食疗、针灸、导引、外治等方法。总之,通过历代医家不断扬弃,中医痰病理论日益创新提升,在临床实践中发挥着重要指导作用,为攻克众多疑难杂症提供精妙的辨治思路及效验方药。希望通过本文对中医学“痰”理论的系统研究和深入阐发,能够拓展和深化对“痰”理论内涵的认识,并促进当代痰病临床诊疗实践的发展。更多还原

【Abstract】 The theory of phlegm is an important part of the basic theory of traditional Chinese medicine (TCM) . It has a long history and rich content. Many doctors have paid much attention to the phlegm theory. So this research summarizes the theory of phlegm based on historical doctrines.There are different characters about the theory of phlegm in different periods.The period of Qin Dynasty and Han Dynasty: People recognized "phlegm", and medicinal herbs were also used to treat phlegm. But there wasn’t the name of "phlegm" at that time. The names of "phlegm", in the period, were such as spittle, saliva and so on. Yellow Emperor’s Internal Classics and Treatise on Cold-Attack and Miscellaneous Diseases described the phenomenon of "phlegm". And, there were several formulas for phlegm illnesses in Treatise on Cold-Attack and Miscellaneous Diseases too.The period of Three Kingdoms, Wei Dynasty and Jin Dynasty: Formulas for phlegm illnesses continued to be accumulated. These formulas greatly contributed to the academic progress. The word "phlegm" emerged in medical books. But, in the period, "phlegm" and "fluid" had not the vague concept.The period of Sui Dynasty, Tang Dynasty and Five Dynasties: Researches on phlegm illnesses were gradually paid attention.The differences between "phlegm" and "fluid" were found. Doctors indicated the pathogenesis of Phlegm Syndrome, which guided the treatment of phlegm illnesses. The accumulation of useful formulas was far beyond the past. Other therapy, such as Qigong, moxibustion and food therapy for phlegm syndrome also had greater development.The period of Song Dynasty: the theory of diagnosis, therapy and formula about Phlegm Syndrome were greatly improved. They discussed the relationship between Qi and phlegm, observed and described phlegm symptoms, summerized some rules for them.The period of Jin and Yuan Dynasty: There were rich and various phlegm doctrines. Highlighted innovation of phlegm doctrines were in both theory and clinic practice. Phlegm academic development showed growing trend. It influenced pediatrics, surgery and other fields.The period of Ming Dynasty: Classical theory of TCM was deepening. Clinical experience accumulated for a long time and unique theoretical system of the Ming Dynasty medicine was formed. They paid attention to discriminate the views of their predecessors, focused on the relationship among the contents of Qi, Blood, Fluid and Phlegm, the relationship between phlegm and viscera, the symptoms of phlegm illnesses. Many theories formed a system of phlegm doctrine.The period of Qing Dynasty: The theory of TCM improved and matured after a long-term accumulation. In addition, under the influence of exegesis and textology, the development of phlegm study went in some new directions. They summarized the doctrines of their predecessors, analysed the naming of phlegm illnesses, discussed the similarities and differences between phlegm and fluid. The Connotation of phlegm concept got clear, which brought a significant effect on the phlegm theory and clinical practice.Nowadays, as western culture, science and technology coming, a collision with Chinese traditional culture generated new ideas. The apprehension about phlegm are mainly concentrated on the experimental study, the researchers pay much attention to the chemical and biological material basis. They have raised related hypotheses. On the right combination of ancient and modern medical theory, the level of modern phlegm theory has enhanced.Proved by the analysis of origins and status, phlegm theory has rich ideological content and practical value. However, so far this theory hasn’t yet been thoroughly studied and systematically illuminated.Guided by the theoretical thoughts, in order to make full use of the method of philology, this article is going to summarize the phlegm theory as followed:1. Concept: Narrow concept of phlegm is sticky and turbid pathological production due to metabolic disorders of water and food. Based on this, its broad concept refers to abstract summary of its relative syndrome, symptom, etiology and pathogenesis.2. Source and causes of phlegm illnesses: Phlegm illnesses may caused by genetic factors, or by diet-induced. Within the body, the sperm and blood, fluid, and other substances may be transformed into phlegm. Its pathogenesis will be also affected by the physical constitution, eating and living habits, clothing protections, emotion, seasonal climate, and so many kinds of internal and external factors.3. Formation mechanism: The Generation of phlegm include three ways, that is viscera dysfunction, abnormal changes in Qi, Blood and body fluid. Among the five internal organs, the formation of phlegm most closely related to spleen and kidney, also the lung and liver effects. Furthermore, stomach is the main participator in the formation of phlegm. The functions of bladder, Sanjiao and gallbladder are also related to that process. There are four cases in Qi abnormal changes: First, Qi deficiency. The materials from diet can not be normally used by human body, then phlegm forms. Second, Qi stagnation leads to poor blood and body fluid circulation, which provide conditions for the formation of phlegm. Third, the Qi-reverse chaos have the sperm, blood and body fluid stagnated. Fourth, the gasification of six Qi lose balance in the human body, including excessive cold, hot or wet, which changes the eaten food into a large quantity of phlegm, endangering human health. On the one hand, sperm, Blood, body fluid and phlegm have the same source. On the other hand, if the conditions exist, they may be converted into phlegm. Therefore, excessive use of medicinals are easy to damage the sperm, blood and body fluid.4. Pathogenesis features: Widely distributed, diverse symptoms; gradual accumulation, firmly cemented; blocking Qi and Blood circulation; provoking the agents in vitro, repeated incidence; relying on feng and heat, causing refractory diseases; generating tumor or Cancer.5. Development and prognosis: It depends on whether personal health concerns are active, and whether treatments are appropriate, and whether a variety of complex internal and external cause exists, and whether Qi and Blood of the body are running smoothly. And many other factors have great relationship with the prognosis. A reasonable diet, moderate labor, cheerful mood and correct treatments play a positive role in reducing phlegm production, eliminating the accumulation of local phlegm, as well as the rehabilitation of phlegm illnesses.6. Diagnosis, treatment and nursing: Finally, by the comprehensive theory of ancient and modern medicine, the article introduce the consultation of phlegm illnesses from inspecing shape, eyes and tongue, identifying phlegm, listening voices, smelling, feeling pulse and so on. The article analyses the treatments of phlegm illnesses as the following four levels: cleaning phlegm, smoothing Qi and Blood circulation, reconciling viscera functions and balancing Yin-Yang. It also introduces therapeutic diet, acupuncture, Daoyin, external treatments, etc.In short, through the choice of medical history, the phlegm theory of TCM has been innovated and improved, which plays an important role in clinical practice to overcome many incurable diseases, and to provide sophisticated diagnosis ideas, valid therapies, formulas and medicinals. This article is going to illuminate the phlegm theory systematically, expose the connotation of phlegm theory in depth, promote the development of clinical practice in phlegm illnesses.更多还原