【作者】 李花；

【导师】 蔡光先；

【作者基本信息】 湖南中医药大学 ， 中医内科学， 2010， 博士

【摘要】 本文运用文献研究的方法,广泛收集中医学中有关肝、脾及讨论肝与脾二脏相关性的各家学术观点及其文献研究资料,对肝与脾在生理、病理上的关联进行了深入探讨,并系统总结了肝脾相关理论在中医学领域中的应用情况,归纳出肝脾相关理论在中医病证治方面的运用规律。同时对功能性消化不良症(FD)中医临床证型分布及用药规律进行了回顾性研究。其主要内容与结论如下：1.系统研究了中医学在肝、脾二脏生理特性和功能认识上的发展演变。《内》、《难》时期多从五行生克制化和运气太过不及的角度来认识肝、脾的生理特性和功能,这一时期的肝脾相关思想带有明显的五行和运气学说色彩。后世医家在此基础上紧密结合临床,大胆创新,阐发了诸多新的理论和观点,如丹溪提出“肝主疏泄”，李中梓提出脾胃为“后天之本”,万全有“肝常有余”之说等,极大地丰富了肝、脾二脏的理论认识,并建立起了独特的中医肝、脾藏象理论体系。2.探讨了肝与脾如何在生理和病理上相互关联,创新性地提出了疾病的肝脾传变方式。根据历代医家的论述,肝与脾在生理上的联系主要表现在经络相通、气机同调、运化水谷、通行血液及代谢水液等方面,故病理上也可通过这些方面相互影响和传变,形成了临床上疾病的肝脾传变方式。具体而言,其传变形式可分为两大类：肝病传脾和脾病传肝,其中肝病传脾又可分为肝盛乘脾和肝虚传脾,脾病传肝又可分为土虚木乘和脾盛侮肝。3.系统总结了肝脾相关理论在中医学领域的应用情况,以及对肝脾相关理论进行了重要阐发的主要医家的学术思想。肝脾相关理论大致涉及以下六个方面的运用：(1)用于阐释病机；(2)用于疾病的诊断；(3)用于指导疾病治疗；(4)用于对疾病预后的判断；(5)用于指导养生及病后调养；(6)用于阐释药物功用及方解。历代医家对肝脾相关理论阐发颇多,肝脾相关理论肇始于《内经》,仲景运用于临床,首倡“肝病实脾”之法,明清医家多有发挥,卓有建树的医家有王肯堂、傅青主、叶天士、吴达、张锡纯等,著述颇丰,应用广泛,构筑了较为完整的“肝脾相关”理论体系。4.系统总结了肝脾相关理论的病证治规律。总结了病机以肝脾为主的中医内科病证29种,肝脾相关证候类型19种,肝脾同治的治法13种,收集体现肝脾同治思想的古方55首,涉及药物106味。对106味药物使用频数、归经频数及药物归类进行了统计,列出了排名前十位的常用药物和药物类别。通过分析发现古方常用药以祛湿类、温里类、理气类、补气类、化痰类、活血祛瘀类药物为主,功效多以柔肝理气、健脾益气、祛湿化痰为主,归经多入肝经和脾胃经。在这一研究基础上,提出肝脾相关病机是临床较为普遍的病机,疾病的肝脾之间传变是较为常见的传变方式,肝脾同治、兼治之法具有重要的临床应用价值。5.对功能性消化不良症中医临床证型分布及用药规律进行了回顾性研究。通过对10489例FD中医临床证型分布的探讨,发现临床上常见的证型为脾胃气虚、肝胃不和、饮食积滞、脾虚气滞、肝郁脾虚、脾胃湿热、肝胃热盛、肝郁气滞等8种证型,其构成比均在5%以上。在15组共19种中医证型中,直接涉及肝、脾胃的占15种,另饮食积滞、寒热错杂和痰湿内阻亦间接与肝脾二脏相关。在中药的使用方面,运用集中在健脾补气、疏肝理气、祛湿化痰、消食导滞等几类药物,从各中医证型的用药组成来看,最常用的药物也主要是以上几类。以上中医证型分布情况和用药特点表明在FD的发生发展过程中,肝脾二脏功能失调发挥了重要作用。因此,在治疗过程中,常需采用肝脾同调、肝脾兼治之法,以取得满意疗效。更多还原

【Abstract】 Using the methods of literary research, we extensively collected all kinds of academic points of view and materials about liver, spleen and theory of liver-spleen correlation in TCM, discussed the physiological and pathological correlation between liver and spleen, summarized the application of theory of liver and spleen correlation in TCM and its rules about diseases, syndromes and therapys. Distribution of syndrome pattern and the use of the traditional Chinese medicine of functional dyspepsia(FD) were retrospectively analyzed. Main contents and conclusions follows.1. Systematically studied the knowledge development of the features and functions of liver and spleen. Liver and spleen were always studied from the angle of wu-xing and yun-qi in the period of nei-jing and nan-jing. After this period, a lot of new ideas and theories were put forward. Zhu dan-xi considered that liver governed regulating, Li zhong-zhi thought spleen was the source of acquired constitution, e.g. These thoughts enrich the theory of liver and spleen correlation, and help to establish the viscera state theory system of liver and spleen in TCM.2. Summarized the knowledge of liver and spleen correlation theory in different dynasties, and discussed how the liver and spleen related in physiology and pathology. According to the view of doctors in different dynasties, the meridians and collaterals of liver and spleen link together, and they both participate in the adjustment of qi activity, the food transportation and governing blood and fluid. So they often affect each other in pathological conditions. Their pathological affection forms can be divided into two categories:liver affecting spleen and spleen affecting liver.3. Systematically summarized the application of theory of liver and spleen correlation in TCM, and the main points of views of different doctors. The theory are used in six fields:explaining pathogenesis, diseases diagnosis, diseases treatment, judging diseases prognosis, health cultivation and recuperation, and explaining the function of Chinese crude drug. Theory of liver and spleen correlation derived from nei-jing, and Zhang zhong-jing used it in clinical practice and developed a kind of treatment:"treat spleen in hepatopathy". Doctors in ming and qing dynasty developed the theory, wrote many books and eslablished the theory system.4. Summarized the application rules about diseases, syndromes and therapys of the theory. Sumed up 29 kinds of diseases in TCM,19 kinds of syndromes,13 therapies and 55 formulas which include 106 Chinese crude drugs. The frequency of every drug in the formulas was added up, and the top of ten were listed. We find that the common used traditional Chinese drugs are the kinds of tonifying the qi, tonifying the blood, regulating qi, clearing heat, eliminating damp, whose efficacy are nourishing the liver and regulating qi, strengthening the spleen and tonifying qi, clearing heat and inducing the damp. They are mainly related to the Spleen, Stomach and Liver Channels. On the base of the research, we consider that the pathogenesis of liver and spleen correlation is the common pathogenesis in clinlic. The affection between liver and spleen is also frequent, so treating liver and spleen in diseases at the same time has clinical significance.5. Distribution of syndrome pattern and the use of the traditional Chinese medicine of functional dyspepsia(FD) were retrospectively analyzed. By study on the distribution of syndrome pattern of 10489 cases of FD,we find that the most common syndromes of FD are deficiency of the splenic and gastric qi, hepatic qi affects the stomach, retention of food, deficiency of the spleen and stagnation of qi, the depressed liver with the insufficient spleen, heat and dampness in the spleen and stomach, heat in the liver and stomach, liver stasis and stagnation of qi. The constituent ratio of the eight syndrome patterns are all above 5%. There are 15 syndrome patterns are correlated with liver, spleen and stomach among the 19 syndrome patterns of 15 groups. The other three syndrome patterns, retention of food, intermingling of cold and heat, and obstruction of phlegm-damp, are indirectly correlated with liver, spleen. The most common used traditional Chinese drugs are the kinds of strengthening the spleen and tonifying qi, clearing the liver and regulating qi, inducing the damp and eliminating the phlegm, and promoting digestion and relieving stasis. They are also used very common in treating the syndromes. The distribution of syndrome pattern and the feature of the use of the traditional Chinese medicine of FD shows that liver and spleen have played an very important role in the formation and growth of FD. So we should treat both liver and spleen in order to get better curative effect.更多还原