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赵绍琴温病学术思想在内伤杂病中的运用研究
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摘要
赵绍琴是我国当代著名中医学家、温病学家。他出身三代御医之家,师从御医瞿文楼、韩一斋及京城四大名医之一汪逢春,博采众家之长,行医六十余载,临证处方药少而精,疗效显著,被誉为“平正轻灵一名医”。
     赵绍琴研治医学最重临床实践,反对为医者“纸上谈病”。他将医学理论与临床实践紧密结合,不断验证与创新,在学术上自成体系,在温病学、内科学、脉学等多个领域为中医的发展做出了巨大的贡献,尤其在学术创新方面,堪称中医界的楷模。他突破性的将温病理论与内科诊疗相结合,不仅广泛运用于中医内伤杂病的治疗,在现代医学的疑难病领域,也取得了良好的临床疗效和令人瞩目的成就。
     切实的临床疗效是中医生存和发展的根本。研究赵绍琴将温病理论运用于内伤杂病的辨证论治这一具有创新意义的学术思想和临床经验,对于拓展中医临证思路,提高中医临床疗效,具有重要的现实指导意义。综观相关文献资料,在这一领域虽有一定的研究和报导,但赵绍琴将温病理论运用于内伤杂病辨证论治的学术思想尚有大量可挖掘之处。基于此,本文从以下方面对赵绍琴这一学术思想进行全面系统的整理和研究。
     第一部分,赵绍琴生平与学术成就。从家庭背景、师承渊源、行医生涯、教育教学、科学研究等方面呈现一代中医大家的医学人生及其主要学术成就。
     第二部分,温病证治发微。若要探讨赵绍琴运用温病理论辨治内伤杂病的学术思想,先要应对其主要温病学思想有所研究。本文综合赵绍琴温病学术思想,从四个方面加以论述。
     第一,温病首当与伤寒相鉴别,同为外感病,二者性质截然不同,故辨证、立法、方药均不同,不能混为一谈。
     第二,温病当分温热、湿热,二者证治迥异。赵绍琴提出将卫气营血辨证和三焦辨证分别作为温热病和湿热病的辨证纲领,更符合临床实际,便于理论指导和临床实践。
     第三,温热病的辨治要点。赵绍琴从温热病的角度出发阐释叶天士的温病治疗基本大法,指出:“在卫汗之”并非发汗解表,“汗之”不是方法而是目的;“到气才可清气”,意在说明温病不可早用、纯用、过用寒凉,否则凝涩邪气、邪无出路;“透热转气”适用于温病卫气营血各个阶段,以宣畅气机、透邪外出为原则,邪透则热自可退;血分证分“耗血”与“动血”,“凉血散血”针对的是动血而非耗血。
     第四,湿热病的辨治要点。赵绍琴将京城四大名医之一汪逢春的临床经验总结为“治疗湿热病十法”,并从中提炼出“治湿热必先治湿,治湿当先化气,化气必当宣肺”的湿热病治疗要法。他将湿热病的临床常见病情概括为湿阻、凉遏、寒凝、冰伏四种,为临床大量因误治造成疾病恶化的病例提供了有效的解决方案。
     第三部分,温病学术思想在内伤杂病中的运用。在回顾赵绍琴主要温病学术思想的基础上,根据现存的文献资料和临床病案,系统总结了赵绍琴温病学术思想在内伤杂病中的运用情况。
     第一,温病辨证理论在内伤杂病中的运用。赵绍琴运用温病卫气营血辨证和三焦辨证理论辨治的内伤杂病主要有两种情况。一是,直接划归为温病的内伤杂病,赵绍琴将病因病机、临床表现、发展规律均符合温病特征的杂病归于温病一类,作温病论治,如肺痈、痢疾等。二是,可用温病的卫气营血或三焦辨证进行辨治的杂病。当内伤杂病某阶段病证或旗下某子类型的病证与温病特征相符,便可运用卫气营血或三焦辨证理论对该阶段或该子类型的杂病进行论治,如血淋、消渴等。
     第二,代表性温病治法在内伤杂病中的运用。以温病的代表性治法为研究对象,介绍赵绍琴在内伤杂病中常用的温病治法。赵绍琴临床诊疗,以法为中心,上系病证病机,下连方药,中合辨证,他将温病的诸多治法引入内伤杂病的治疗之中,并善用、活用温病代表方药。具体如下:
     苦宣折热法,是用性味辛寒、苦寒而性质轻清的药物,宣畅气机,透热泄邪的温病治法,以栀子豉汤为代表。赵绍琴认为栀子豉汤具有“火郁发之”之功,外感、内伤凡病因热郁发热、心烦懊憹者,皆可用之。
     疏调升降法,是具有疏通解郁、调和升降等作用的温病治法,适用于温邪热郁不开或痰郁火结之证。内伤杂病凡因热郁于内,导致气机阻滞、升降失常者,皆可用此法治疗,代表方为升降散。升降散是赵绍琴临床使用频率最高的方剂之一,是赵绍琴内科证治的一大特色。他运用升降散的主治范围宽广,用法灵活多变,各脏腑系统疾病均有涉及,脏腑气血功能异常或实质病变均可应用,尤多用于肝胆郁热、湿热郁滞、血分郁热等证。无论升降散运用于何病何证,气机阻滞、升降失常是核心病机。
     宣畅三焦法,具有疏畅三焦、宣通气机、醒脾开胃、通利水道等作用,是湿热病证的治法。本文根据赵绍琴提出的湿热病临床治疗治湿、化气、宣肺三要法,以疏风化湿法、疏调三焦法、宣展肺气法等三个赵绍琴临床代表性治法为对象,分析了其在内伤杂病治疗中运用三要法即温病宣畅三焦法的情况。本文又从上三法中引申阐述了风药、大黄和杏仁等三味(类)赵绍琴临床代表性用药的使用情况,尤其介绍了他不同于常规的用药经验和临床心得,体现了赵绍琴对中药性能的透彻分析、精当把握和奇思妙用。
     第三,其他渗透于内伤杂病辨治中的温病思想。这一部分主要介绍了赵绍琴其他融汇于内伤杂病辨证论治之中的温病思想。主要包括以下三方面内容。
     内伤杂病亦有因外感而起或因外感诱发加重者,遇此情况,与温病的临证思维相同,应首先分清外邪的寒热性质、是否感有湿邪,并根据外感病的证治原则,依法调治。
     赵绍琴在温病气分证治中提出的勿早用、纯用、过用寒凉的“寒凉三忌”,在内伤杂病的治疗中亦当贯彻,不仅中药,抗生素、激素等西药也在“寒凉”之列,亦当遵循“三忌”。
     赵绍琴认为透热转气体现的是排除障碍、宣展气机、给邪气以出路的临证思想,不仅适用于温病各阶段,也应作为辨治内伤杂病的指导思想。具体体现在,无论何病何证,是何人群,凡有邪实存在,必有针对性地用药去其邪阻、通畅气机,否则不仅补法无法取效,甚则壅滞气机,郁而化热,反致病进。
     第四,温病学术思想在疑难病中的运用。赵绍琴创造性地将中医温病思想学术思想运用于西医的疑难病症,并取得良好疗效。这是赵绍琴晚年临证最为突出的成就,为中医打开了崭新的临床治疗思路。本文选取了慢性肾脏病、肝硬化、白血病等三种疾病加以具体阐述。
     运用中医中药攻克慢性肾脏病是赵绍琴最为世人瞩目的医学成就之一。他通过数十年的临床探索,总结出了从温病营血分证论治慢性肾脏病的治疗方法,取得了显著的临床疗效。他指出,慢性肾脏病的基本病机是热郁血分,治疗大法是凉血化瘀,并率先提出慢性肾病非虚论、慢性肾病忌食蛋白论、慢性肾病宜动不宜静论、慢性肾功能损害可逆论、慢性肾病可遗传论等一系列学术创新之说,合称为“慢性肾病新论”。他的很多观点对中医学传统观念和现代医学都是重大的挑战。
     在肝硬化的治疗方面,他提出“郁”、“瘀”、“虚”是肝硬化的主要病理改变,以“郁”为其根本,在治疗上,要以疏肝调郁为主要治法,先治“郁”,再调治“瘀”、“虚”,并配合饮食、运动和情志调理,有步骤、分阶段地进行治疗。
     对于白血病,赵绍琴认为该病因胎毒内蕴,病位在髓,呈现一派血分热盛之象,故当从温病论治,并提出“髓分证”一说。针对白血病热结、耗血、动血、停瘀并存的病机,当以凉血散血、泄热解毒、养阴展气三法为白血病的治疗大法,并注意饮食、运动调理。
     第四部分,分析与讨论。这一部分是对赵绍琴运用温病理论辨治内伤杂病的学术思想和临床经验的进一步探讨,阐述笔者的个人理解,是本研究的创新点。笔者认为,赵绍琴之所以能打破传统的辨证体系限制,将温病理法方药运用于内伤杂病的辨证论治,原因在于二者拥有相同的病机,这就是赵绍琴临床上反复提到的“火郁”。而蕴藏在赵绍琴“火郁观”背后的,放之一切证治而皆准的指导思想是赵绍琴对气机通畅的重视,笔者称之为赵绍琴的“血气流通观”,并提出“注重气机宣畅、一切调治手段皆以血气流通为目的是赵绍琴的医学思想内核”的观点。此外,赵绍琴在从温病营血分论治内伤杂病的过程中,还提出了全新的“髓分说”理论,通过温病学思想在内伤杂病中的运用,反过来又发展了温病学理论。
     总之,本课题通过对赵绍琴运用温病理论辨治内伤杂病的学术思想和临床经验的整理研究,展现了一代中医大家的学术风采。更重要的是,赵绍琴的学术思想的产生,是建立在大量的临床实践的基础上的,因此他的学术思想和临床经验行之有效,用之有验。这些丰富而宝贵的临床经验可为当下的临床诊疗活动提供重要参考,具有重要的实践价值。而通过对这些学术理论和学术思想的梳理和分析,有助于我们理解和传承温病学说的理论和辨证立法组方思路,扩大卫气营血和三焦辨证的使用范围,融会活用中医理论,同时可为久攻不下的疑难杂症、层出不穷的新病变证,拓宽临床思路提供有益参考。
Professor ZHAO Shao-qin is a famous contemporary physician in traditional Chinese medicine. He was born in an imperial physician family, and his father, grandfather and great-grandfather were all physicians work in the Forbidden City. He learned from Q.U Wen-lou, HAN Yi-zhai and WANG Feng-chun who were all outstanding physicians. QU and HAN were also imperial physician, and WANG is one of the most famous doctors in Beijing at that time. He was adept at drawing on others successful experience. His prescriptions are characterized by few ingredients and significant effect.
     Prof. ZHAO attached great importance to clinical practice. He kept researching all his life, and combined the medical theory and clinical practice closely together, made great progress in many fields of traditional Chinese medicine, such as Science of Epidemic Febrile Diseases, Chinese Internal Medicine and Pulse Making.
     One of his most important contributions to traditional Chinese medicine is that he used the theory and method of the warm disease to treat some internal disease, and the effect is significant. It is well-known that the warm disease belongs to exogenous disease, and it is treated by the syndrome differentiation of weifen, qifen, yingfen, xuefen or by the syndrome differentiation of sanjiao theory. And the internal disease usually treated by the syndrome differentiation of zang-fu viscera. How could these two kinds of diseases from different systems be used the same methods of syndrome differentiation, the same therapies, prescriptions and medicines? It is just what we should find out. This paper presents Prof. ZHAO's work, which is to use the theory and method of the warm disease to treat some internal disease, from the following aspects.
     Part One:This part is about the brief account of Prof. ZHAO's life and the main academic achievements. The brief account of Prof. ZHAO's life is introduced from his family, his learning career, physician career, teaching career, and his scientific work. The academic achievements mainly includes three parts, the first part is about the experience of Chinese medicine pulse making from his family, the second part is about his major points of the warm disease, the third part is his main contributions in the internal medicine. Prof. ZHAO's medical works are introduced in this part, too.
     Part Two:Prof. ZHAO's major points of the warm disease. This paper is going to study the situation that Prof. ZHAO used the theory and method of the warm disease to treat some internal disease, so what are Prof. ZHAO's major points of the warm disease and which theory and method of the warm disease were he got used to should be known firstly. This section was discussed in four aspects.
     Firstly, the warm disease is totally different from the cold pathogenic disease. The patients of warm disease and cold pathogenic disease suffer from different pathogenic qi. The former is wind-heat, and the latter is wind-cold. Their qualities are just the opposite. The causes of these two diseases are different, so they must be treated by different methods of syndrome differentiations. And the therapies, the prescriptions and the medicines for these two diseases of course won't be the same. To be doctor people can't mix them together.
     Secondly, when treating the warm disease, people should make a distinction between warm-heat disease and damp-heat disease. Although they are both warm diseases, they are totally different, either. The difference between these two warm diseases is that the cause of warm-heat disease is just heat pathogen, but the cause of damp-heat disease is not only heat but also dampness pathogen. Dampness is a heavy and turbid evil; it is sticky and stagnated which is hard to be converted. It is classified as yin pathogen. So we can not treat them in the same way. General speaking, people mix the syndrome differentiation of weifen, qifen, yingfen, xuefen and the syndrome differentiation of sanjiao theory to treat all kinds of warm diseases in clinical. But Prof. ZHAO found in the practice that the syndrome differentiation of weifen, qifen, yingfen, xuefen is suit for the warm-heat disease better, at the same time, the syndrome differentiation of sanjiao theory is suit for the damp-heat disease better. So he presented those points, used them to explain the warm disease theory and put them into clinical practice.
     Thirdly, Prof. ZHAO explained YE Tian-shi's warm disease theory, who was the most famous physician in Qing dynasty, using his own point mentioned above. He said that the therapy of Weifen syndrome is not relieving exterior syndrome by diaphoresis, but dispersing the heat from the skin and hair, so sweating is the purpose but not the method here. The warm disease is yang and heat syndrome actually, so it should be treated by cold and cool medicines. Prof. ZHAO reminded that the cold will coagulate qi movement, and block the way of the pathogen. So the dose of the cold and cool medicines should not be too high, and the cleaning heat method should not be used if it is not really qifen syndrome. The therapy named "clearing heat of yingfen to qifen" is the most important rule of treatment in the whole course of warm disease. Its main idea is that be sure to ensure the circulation of qi and make the pathogen out of body when treating the patient, so that the disease can be cured. Xuefen syndrome is the last stage of warm disease. It includes blood stirring and blood loss. The therapy of cooling blood and removing blood stasis is used for blood stirring with blood heat.
     Fourthly, Prof. ZHAO's main point of the treatment of damp-heat disease is as below. Prof. ZHAO summarized WANG Feng-chun's treatment experience of damp-heat disease and extracted his own three points of view. Firstly, damp pathogen should be cured first when treating damp-heat disease. Secondly, the circulation of qi should be ensured fluently when treating damp pathogen. Thirdly, ventilating lung qi is one of the most important ways to make the circulation of qi fluently. He also made a summing up of the common situations to damp obstruction, cool repression, cold coagulation and freezing, and provided the cure for each one.
     Part Three:This part makes a summary of the situation that Prof. ZHAO used the theory and method of the warm disease to treat some internal disease.
     Firstly, the syndrome differentiation of weifen, qifen, yingfen, xuefen and the syndrome differentiation of sanjiao theory are used for some internal disease. There are two kinds of condition. One is that the certain internal disease can be regarded as warm disease, which is fit very well with the warm disease in everywhere, such as the cause, the pathogenesis and the clinical presentation. The other is that the certain internal disease have the same features in some certain condition or its certain subtype have the warm disease's feature, so that the syndrome differentiation of weifen, qifen, yingfen, xuefen and sanjiao theory can be used in the condition or the subtype of the certain internal disease. The example of the first condition is abscess of lung and dysentery. The disease of the second condition likes stranguria due to hematuria and consumptive thirst.
     Secondly, to introduce the condition of the warm disease's representative methods of treatments those are used in the internal disease. Prof. ZHAO attached great importance to the method of treatment in the clinical practice. He considered the method of treatment as the core of the treatment. Its one side is the pathogenesis, the other side is prescription and the third side is the syndrome differentiation. All the elements of a disease are linked by the method of treatment. So many method of treatment of warm disease are used to treat internal diseases.
     The method of Ku Xuan Zhe Re is such a kind of warm disease's methods of treatment. It used the Chinese medicines, which have the pungent or bitter flavor, cool or cold nature and light feature, to make the circulation of qi fluently and expel the heat pathogen out of body. The typical prescription of this method is zhizichi decoction. It has the function of Huo Yu Fa Zhi. It is usually used to treat the symptom of fever or dysphoria which is caused by the heat stagnation.
     The method of Shu Tiao Sheng Jiang is a warm disease's method of treatments which is used for the syndrome of seriously heat stagnation or the syndrome of intermingled phlegm and heat. It also can be used for the internal diseases that caused by the similar pathogenesis. In the internal medicine the pathogenesis is called disorder of qi movement. The typical prescription of this method is shengjiang powder. Shengjiang powder is Prof. ZHAO's most frequently used prescription, and also is the most significant feature of Prof. ZHAO's prescription of internal diseases. He used shengjiang powder to cure many kinds of disease, which involved all systems of zang-fu viscera. The disorder can be taken place in qi or blood. And there can be the disorder of function or the essence pathological change. The syndrome of heat stagnation of liver and gallbladder, stagnant and jamming dampness-heat and heat stagnation of xuefen are the most frequently conditions that to be treated by shengjiang powder. In all, the key point of the adaptation disease is the pathogenesis that the disorder of qi movement occurred.
     The method of Xuan Chang Sanjiao is a compound damp-warm disease's method of treatments. It has the functions including promoting flow of Sanjiao, ensuring the circulation of qi fluently, promoting digestive function, dredging the passage of water-fluid and so on. Prof. ZHAO came up with ideas that to cure damp pathogen, to ensure the circulation of qi fluently, and ventilating lung qi are the key points of the treatment of the damp-heat disease. To use the method of resolving dampness with dispelling wind is Prof. ZHAO's characteristic treatment in the clinical practice. And the medicines of this method are called Feng Yao, which usually belong to the superficies-relieving medicine in general. Prof. ZHAO studied the medicine's nature and flavor deeply, and found out up to20new functions of Feng Yao. The method called dredging and regulating Sanjiao is using the medicine which can promote digestive function of the body, and some of the medicines have the function of diuresis. It is almost the necessary part of Prof. ZHAO's prescription, especially at this stage of recovery. It reflects that Prof. ZHAO attaches great importance to the role of spleen and stomach in middle jiao. Rhubarb is the member in the group of the dredging and regulating Sanjiao medicine. Prof. ZHAO's experience of application of Rhubarb is being introduced here. Using ventilating lung qi medicine to treat the diseases which are cause by damp pathogen is also Prof. ZHAO's very important experience in practice. The typical medicine is bitter apricot seed. He used it for several diseases. The main principle is to regulate qi, and utilizing the promoting qi method to help water circulation.
     Thirdly, there are some other warm disease's theories or methods to be used for internal disease.
     Internal disease can also be cause by exogenous pathogen. When we encountered this kind of internal disease, we should analyze the cause and pathogenesis like treating exogenous disease. Is the cause of disease is heat pathogen or cold pathogen? Whether the damp pathogen hit the patient or not? Prescribe work should be done after the series of thinking and make an accurate judgment.
     Prof. ZHAO emphasized time and again that the dose of the cold and cool medicines should not be too high, or the cold pathogen will coagulate qi movement, and block the way of the pathogen. This rule is also suitable for the internal disease. And the so-called cold and cool medicines do not only refer to Chinese medicine, but also the Western medicine such as antibiotics and hormone.
     The therapy named "clearing heat of yingfen to qifen" reflects a therapeutic principle that is to ensure the circulation of qi and make the pathogen out of body. This principle is suitable for all the treatment of all the disease, no matter internal or exogenous disease, and no matter how old the patient is and what his/her situation is now. It is noteworthy that if excessive pathogen existed, the pathogen should be eliminated by corresponding method as soon as possible, even though the patient was very old, or was very weak.
     Fourthly, Prof. ZHAO even extended the therapy of warm disease to the Western medicine, and cured many difficult and complicated cases, such as chronic glomerulonephritis, nephrotic syndrome, chronic renal failure, uremia, systemic lupus erythematosus, thrombocytopenic purpura, aplastic anemia, Leukemia, viral myocarditis, liver cirrhosis. It was the most outstanding achievement in his later years. Prof. ZHAO concludes the cases, and showed that there are certain rules between the Chinese medicine's therapy and the Western medicine's diseases, and using Chinese medicine's way to treat the difficult and complicated of Western medicine is entirely feasible. And these important experiences can help the doctors of Chinese medicine have wider and more flexible ideas. This paper chooses three typical diseases, and presents Prof. ZHAO's treatment experience.
     Curing chronic kidney diseases (CKD) using Chinese medicine is Prof. ZHAO's most significant achievement in his medical career. He had been studying the treatment of CKD for almost sixty years, and had experienced repeated failures, and found the solution in the seventies of last century finally. His therapy was clinically proved to cure CKD, including chronic renal failure and uremia, effectively. His showed that CKD's pathogenesis is heat stagnation in xuefen, but not kidney deficiency as common opinion. So people should treat it according the idea of cooling blood and removing blood stasis. The usual treatment of CKD is to tonify kidney. Whatever tonifying kidney-qi, kidney-yin, kidney-yang, or kidney essence, were not correct at all. Prof. ZHAO raised five new theses of CKD. First, CKD isn't deficient syndrome in the view of Chinese medicine. Second, the CKD patient should control the quantity of protein of his/her diet strictly, especially the high protein diet. And the vegetable protein from the bean and its products should not been taken at all. Third, the CKD patient should keep exercising instead of staying in bed or resting too much. Forth, the renal dysfunction can be recovered if the patient was taken the right treatment like cooling blood and removing blood stasis. Fifth, CKD is heritable, many CKD patient'family members suffer from this disease. Prof. ZHAO's new views were quite a challenge to both the Chinese medicine and Western medicine when they were raised. As time goes on, his views are all proved to be correct.
     Liver cirrhosis is a common disease in human. Prof. ZHAO regarded it as warm disease of Chinese medicine, too. He considered that stagnation, static blood and deficiency are the three main pathogenesis of Liver cirrhosis in Chinese medicine way. And the stagnation is the most important one. It is not only the pathogenesis but also the cause of the disease. To make the circulation of qi fluently is the essential treatment of Liver cirrhosis. Should make sure that the stagnation problem has been solved, and the qi movement recovers, before other treatment. The second step is removing blood stasis. Then the third step is tonifying deficiency, which should be used after the excessive pathogens have been cleared. The therapeutic process fully enshrines the principle of "clearing heat of yingfen to qifen".
     Leukemia is a serious disease of Hematological Disease. He considered that leukemia causes by the fetal toxicity coming from parents in the theory of Chinese medicine, and the fetal toxicity's feature is heat which stay in the marrow after birth. The disease breaks out in some certain condition, and its clinical manifestation shows that there is serious heat in the xuefen, and spreads from xuefen inside to yingfen and qifen outside. So leukemia can also be treated as warm disease. The pathogeneses of leukemia are heat stagnation, blood stirring, blood loss, and blood stasis. So leukemia should be treated from those aspects. Ensuring the circulation of qi and making the heat pathogen out of body are the initial treatments.
     Part Four:To analyze and discuss Prof. ZHAO's new academic points. Author thinks heat stagnation is the key point of all the multitudinous pathogenesis factors. Prof. ZHAO regarded the heat stagnation as the pathogenesis both of the warm disease and the internal disease. That is the reason that he can treat diseases belongs to different medical system by the same therapy. What is more is that he had been emphasizing ensuring the circulation of qi and making the heat pathogen out of body all the time. That means to make sure body's qi and xue circulation operate ordinarily is what should be done when a disease comes out. Doctor must keep the principle in his/her mind. And this principle is suitable for all the treatments. Prof. ZHAO found that there are some diseases come with the patient when he/she was born. It is somethink like gene in western medicine. He call that suifen (marrow) syndrome. He raised the new idea and developed the theory and method of the warm disease when he used the theory and method of the warm disease to treat the internal diseases.
     In all, this study shows Professor ZHAO Shao-qin's academic achievements, and focuses on his experience of using the theory and method of the warm disease to treat some internal medicine. More important is that these new ideas are all on the basis of his clinical practice. That guarantees the result of the methods. Hoping this study can provide a reference and take more new thoughts for both the clinical practice and the academic development of Chinese medicine.
引文
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