张仲景方证论治体系研究及其方证数据库

【作者】 刘立杰；

【导师】 贾春华；

【作者基本信息】 北京中医药大学 ， 中医临床基础， 2009， 博士

【摘要】 方证论治是中医辨证论治的方法之一,它有别于传统的脏腑辨证、八纲辨证、六经辨证等辨证方法,要求“观其脉证,知犯何逆,随证治之”,临床时重在辨认症状,据症选择合适的方剂或对方剂进行适当加减。因而,证候与方剂是方证论治的两大核心问题,证候是确定方剂的依据,又是方剂干预的对象,二者密切相关,不可分割。基于上述认识,要求我们在对方证论治的研究中,研究方剂必然涉及证,研究证又必然与方剂关联。把二者作为整体,重点研究方与证相关的科学规律,对揭示证的科学内涵以及方剂治疗疾病的科学规律意义重大。1.目的(1)构建出张仲景方证论治体系;(2)建立“张仲景方证数据库”;(3)提炼张仲景方剂的核心药对及其对应的适应症状;(4)探索张仲景在治疗外感病与杂病方面的处方用药异同,进而探索仲景的组方用药思想及规律。2.方法(1)应用文献学及史学考证的方法对方证相关概念进行阐释,在此基础上对张仲景方证的渊源进行详尽的探讨;(2)运用数据统计的方法,基于“张仲景方证数据库”的统计结果,打破传统的《伤寒论》方、《金匮要略》方割裂的方剂划分方法,将张仲景方剂以类方的形式重新划分归类;从纵向上将张仲景方证体系划分成“方——证”“药对(药组)——主症(症群)”“药——症”三个层面的内容:①“方——证”层面,从类方的角度将《伤寒论》和《金匮要略》的方证重新划分,为避免给人以重复繁杂之感,在每一方名后只给出该方在原作中出现的条文号。②“药对——主症”层面,整理经方中的主要药对和药对的主治病症。这是论文的核心内容。③“药——症”层面,该部将张仲景方证中的单方和加减中典型的药物功效加以整理。(3)运用统计学的方法对上述划分的结果进行统计;提炼张仲景方剂的核心药对及其对应的适应症状;(4)运用逻辑学的方法对统计的结果及特殊现象进行分析。3.结果通过对张仲景方证体系的划分统计,结果发现:①张仲景方剂在药物使用方面,如果按照现代的中药功效划分标准,仲景经方中使用最多的药物为补虚药,占26.8%;其次为解表药,占18.3%;清热药占9.8%;化痰止咳平喘药占7.8%;祛湿药和温里药各占7.5%。如果将温里药亦归入补虚药,则补虚药占到了34.3%,占所用药次的1/3强。从绝对数量来看,使用次数在10次以上的24味药物中,解表药仅4味;而补气、补血之品竟达7味之多,如果加上扶阳的附子、干姜,则占到了38%。尽管现代中药功效与仲景之用药功效存在差异,但由于用药频率在一定程度上能反映组方遣药的总体倾向,体现出该类方剂配伍结构的相似性和稳定性,因此有理由认为仲景在外感病与杂病的治疗上,配伍用药主要涉及补虚、解表、清热、化痰止咳平喘、祛湿等方面。而补虚扶正的特点尤为突出。另据统计,在《伤寒论》398条和113方中,虚寒的脉象有100多种。经方用人参的方剂高达37首,用附子的达到34首;从使用的方剂来看,桂枝汤中的甘草、大枣,小柴胡汤中的人参,猪苓汤中的阿胶等扶正之品的使用,这亦说明了仲景重视使用补益扶正的方法。经方中的核心药物除生姜、茯苓外,其余药物在《神农本草经》中均有记载,去除这两味药,从药性看,包括:寒性4味,微寒2味,平性7味,温性9味;一般认为平性药与温性药用则温,与寒性药用则寒,因此可以不计入统计的范围,则经方用药偏温可以显而易见。从药味看,甘味药6味,苦味药9味,辛味药6味,成味药1味。辛甘合化为阳。从侧面说明了经方用药尚温的特点。②在常用方剂方面,张仲景使用次数≥5次的方剂依次为:大承气汤30次、小柴胡汤23次、桂枝汤22次、四逆汤16次、五苓散11次、麻黄汤10次、小承气汤8次、调胃承气汤8次、栀子豉汤7次、白虎加人参汤7次、小建中汤5次、十枣汤5次、大陷胸汤5次、抵当汤5次、小青龙汤5次。这些方剂在治法上主要侧重于:下法,包括三承气汤、十枣汤;和法,小柴胡汤;汗法,包括桂枝汤、麻黄汤;温法,四逆汤;补法,小建中汤;清法,栀子豉汤、白虎加人参汤等。而攻邪的治法比较突出。③在常用药对方面,统计发现仲景方剂在药对构成方面,姜、枣、草占用较大比重。从三者的功效来看,主要在于调药、和中,而在顾护脾胃方面的作用较为明显,因而提示经方重视顾护后天之本。4.结论综合上述统计结果与分析,笔者认为张仲景方证理论体系在处方用药方面存在以下特点:①治杂病,注重补虚,扶正以驱邪;治外感,注重驱邪,善用汗下之法;②顾护脾胃,重视后天之本,以期“阴阳自和”;③用药偏温,扶助阳气;④治疗八法之中,伤寒以驱邪为主;⑤使用方剂、药物具有明显的核心倾向;张仲景方剂在药物使用方面具有明显的核心倾向,形成以核心药物为主体,以常用药对为纽带,以基本方剂为中心的类方体系;⑥从所用核心药物、常用药对、基本方剂来看,《伤寒》、《金匮》处方用药大体一致;从中我们看出,《伤寒》与《金匮》在方证论治体系方面存在较多相似之处。更多还原

【Abstract】 Formula—Syndrome diagnosis and treatment is one of TCM diagnosis and treatment methods,it is different from the traditional Internal organs dialectical,Eight principal syndromes dialectical,six by the dialectical method of differentiation,such as calling "Observe whose syndromes,know his disease,follow a certificate prescription",Clinical focus on identifying when symptoms of disease,according to select appropriate prescription or other appropriate addition and subtraction agent.Thus,syndromes and prescription are to rule on two core issues.Identified syndrome are the basis for prescriptions,and prescriptions are the object of intervention,the two are closely related and inseparable.Based on the above understanding,this requires us to permit the study of governance,the study necessarily involves prescription,study Syndrome invariably associated with the prescription.Put the two as a whole,focuses on the side with the laws of relevant scientific evidence,the evidence reveals the scientific connotation,as well as prescription treatment of diseases of the scientific laws of great significance.1.Objectivs(1) To construct Zhang Zhongjing Formula—Syndrome to permit construction of a system of governance;(2) To establish "Zhang zhongjing Formula—Syndrome database";(3) Zhang refining the core of prescription drugs and the corresponding adaptation of the symptoms;(4) To explore in the treatment of Zhang zhongjing exopathic disease and miscellaneous diseases similarities and differences between the prescription of the medication,and to explore medication Zhongjing prescription thinking and the rule of parties.2.Methods(1)The application of philology and the method of history research evidence relatedto each other to explain the concept,based on this Formula of Zhang Zhongjing detailed evidence of the origin of;(2) The use of statistical methods,based on the "Zhang Zhongjing database to permit" the statistical results,breaking the traditional "typhoid" side, "Golden" to split the prescription into ways to Zhang’s prescription in order to type into the form of re-naturalization category;Zhang from the vertical Formula—Syndrome system will be divided into "Formula—Syndrome,"" Medicine suits(drug group)-the main disease(syndrome)" "drug-disease," the contents of three levels:①"Formula—Syndrome" level,from the category’s point of view of "typhoid fever" and "Essence" to permit the re-division,in order to avoid repeat,in each of the parties were only given the appeared in the provisions of the original number.②"Medicine suits-the main disease" level,finishing as the main prescription drugs and medicine on the charge of the disease.This is the core content of this papers.③"Drug-disease" level,that part of the initial decision to permit Zhang side of the unilateral and the addition and subtraction in a typical finishing a drug’s efficacy.(3) The use of statistical methods for the delineation of the results of the above-mentioned statistics;refining the core of Zhang Zhongjing prescription drugs and the corresponding adaptation of the symptoms;(4) The use of logic in the method of the survey results and analysis of a particular phenomenon.3.ResultsZhang zhongjing Formula—Syndrome system through the division of statistics,the results were as follows:①Prescription drug use,if the efficacy of Chinese medicine according to the modern criteria for the classification of Fangzhong Zhongjing’s most frequently used by drug Makes up empty drug,accounting for 26.8%; followed by relieving drugs,accounting for 18.3%;Qingre drugs accounted for 9.8%PingchuanReducing phlegm and stopping coughing drugs accounted for 7.8%;Qushi drugs and drug distribution in temperature of 7.5%.If the temperature is also classified as drugs in medicine Makes up empty drug,,the Makes up empty drug,drugs accounted for 34.3 percent,accounting for the drug over the 1/3.In absolute terms,the frequency of use in more than 10 drugs,the drug solution of Table 4 only flavor;and vitality and taste as much blood as many as 7,if the Young’s Aconite,Ginger,it accounted for 38%. Although the efficacy of modern medicine and Zhongjing differences in the effectiveness of the medication,but the frequency of administration to some extent,reflect the group sent to the general tendency of drugs shows the compatibility of such prescription is similar to the structure and stability,it has reason to that Zhongjing exopathic disease and miscellaneous in the treatment of disease,mainly related to drug Makes up empty compatibility, solution table,clearing away heat,Reducing phlegm and stopping coughingPingchuan,Qushi and so on.Fuzheng Makes up empty characteristics and is particularly prominent.According to statistics,in the "Treaty of Febrile and miscellaneous",there are 398 and 113 formulas,of which have more than 100 kinds of cold pulse.Ginseng by side with up to 37 prescriptions,the use of Aconite 34 to reach,from the use of the prescription, the Guizhi soup liquorice,jujube,Xiao Chai Hu Tang of ginseng,in Zhu-Ling-Tang Fuzheng Ejiao of goods,etc.use,this also shows that the emphasis on the use of benefit Fuzheng Zhongjing method.By the drug in addition to the core of Fangzhong ginger,Poria,the other drugs in the "after" in both records,the removal of these two drugs flavor,from the properties to see,including:cold 4 kinds,less cold 2,level 7 kinds,smell warm 9;is generally believed that leveling of medicinal drugs and the temperature is warm,and cold medicine is cold,it can not be included in the scope of statistics,the warm side by side can be obvious medication.From Taste,the sweet smell medicine 6,9,taste bitter medicine,medicine 6Pungent taste, salty taste drugs 1.Hop into Xin Gan Yang.From the side by side shows the characteristics of drug use is still warm.②In the commonly used formulas,Zhang Zhongjing use more than 5 times the number of prescriptions were as follows:Dachengqitang 30 times,23 times of Xiao Chai Hu Tang,Guizhi Tang 22,Sini Tang 16 Powder 11 Mahuangtang 10 times,small chengqitang 8 times Tiaowei chengqitang 8 times 7 times gardenia soy soup,plus Ginseng Decoction Baihu 7 times,small Jianzhong Tang 5 times 5 times 10 Decoction,Da Xianxiong tang 5 times Didangtang 5 times,5 times Xiaoqinglongtang.These Formulas in the law governing the main focus on:diarrhea agents,including three chengqitang ten Decoction;reconciliation agent,including Xiao Chai Hu Tang;Khan agents, including Guizhi soup,Ephedra Decoction;temperature agent,Sini Decoction; supplements,small Jian Zhong Tang;clearance agent gardenia soy soup,such as White Tiger plus Ginseng Decoction.And the evil attack of the more prominent law enforcement.③In the commonly used drug for the connection,the statistics found on the composition of drug Zhongjing,ginger,jujube,occupy a larger proportion of grass.Judging from the effectiveness of the three,mainly due to drugs and in tune,and in nursing care the role of the spleen and stomach are more obvious, and thus prompted by the spleen and stomach to attach more importance to nursing care.4.ConclusionThe results of the above statistics and analysis,I believe that the theoretical system of Zhang Zhongjing to permit prescription drug administration in the following characteristics:①Treats various illnesses,pays great attention to make up empty,straightens up exorcises,duplicate from goes evilly;Governs the external disease factors,pays great attention to exorcise,makes good use of under the perspiration the law,goes peacefully evilly from;②Attends to protects the taste,will take foundation of the day after tomorrow,by time "masculine and feminine elements from and";③The medication is warm, assists the Yang spirit;④Treats in eight law,typhus exorcises primarily;⑤The consumer medicinal preparation,the medicine have the obvious core tendency; Zhang Zhongjing prescription has the obvious core tendency in the medicine use aspect,forms take the core medicine as the main body,take often applies drugs to as the link,take the base we medicinal preparation as central kind of side system;⑥Looking from uses the core medicine,often to apply drugs to, the base we medicinal preparation,typhus,the gold bookcase prescription medication are roughly consistent;We see,"Shang han lun" and "Jin kui yao lue" governs the system aspect in Fang Zhenglun to have many similarities.更多还原