《临证指南医案》中黄柏应用的研究

发布时间：2018-04-05 20:46

本文选题：临证指南医案　切入点：叶天士　出处：《广州中医药大学》2016年博士论文

【摘要】：目的：通过研究《临证指南医案》中黄柏的应用规律,并与本草文献和《伤寒杂病论》内对黄柏之运用作比较,探索黄柏在应用规律和温病学派对伤寒之继承和发扬,总结黄柏之功效及运用原则,为现代中医临床正确地运用黄柏的依据。方法：以《临证指南医案》为基础,分析有关黄柏运用和含有黄柏的医案,对其病种、症状、证型、病程长短、就诊次数和各卷门中的应用、病机、望诊、舌诊、脉象、黄柏配伍、成方等,采用EXCEL建立数据库,整理相关数据,应用IBM SPSS Statistics 20进行统计分析。结果：在《临证指南医案》记载有关黄柏的医案中,(1) 10卷中各卷都有应用黄柏的医案,但其应用次数不同,其中卷七应用最多,共应用26次,占应用总数的25.2%；其次是卷三,共应用21次,占应用总数的20.4%。(2) 62门中共有39门应用黄柏,应用频次最多的依次为淋浊、遗精、痿、痢、便闭、疝、虫、便血、痹等。(3) 绝大部分医案全程运用黄柏,共80则,占所有103则医案的77.7%。(4) 记载的诊次一般为1次,共占所有医案的66.0%。其次为2次,占15.5%。(5) 应用黄柏医案遍及8大现代医学系统,应用较多的系统依次为消化、运动、泌尿、生殖、神经、循环等,其中消化系统最多(34次,33.0%)。(6) 只有3次论及患者舌象情况,其中舌白、舌干苔白、舌灰边白各1次。(7) 全书合共有23处记载脉象。依次序出现次数最多为数脉, 其后为其他相兼脉,沉脉,弦脉,细脉,实脉,洪大脉,散脉,濡脉及革脉。(8) 最多见的证型为实证(多为湿热、热毒、心肝肠实火),近45%,而虚证(多为肝、肾单独或同时阴虚)稍多于虚实夹杂证(多为肾虚合并湿热,或心肾不交)(9) 根据《医学心悟》治病八法,除汗法和吐法外,其余下、和、温、清、消、补,六法都有医案记录。其中以清兼补法用最多。其后依次为清法,温补法,清和法,消法,清兼下法,消补法,温下法与补法。。(10)共有103条含黄柏组方,共采用四种剂型,其中采用汤剂69条,占67%；丸剂31条,占30%。(11)含黄柏的成方只有9条,其中出现最多的是滋肾丸,共出现12次,占所有成方的31.6%；其次安胃丸7次,占18.4%。成方以丸剂多见,共出现30次,占78.9%；其次为汤剂,出现7次,占18.4%；散剂出现1次,占2.7%。(12)与黄柏配伍最多的中药依次是黄连、茯苓、知母、泽泻、熟地黄、白芍、川萆薛、生地、人参、肉桂、龟版(连同龟甲)、广皮、牛膝、山栀、青皮、茅苍术、川楝子、当归。配伍次数最多的是黄连,共28次,占4.1%。(13) 标记了7中炮制类型的黄柏,分别为：炒焦黄柏、炒黑黄柏、略炒黄柏、盐水炒黄柏、炒黄柏、黄柏、生黄柏。运用最多的是黄柏,共应用93次,占总数的90.3%。(14) 共有8处记载黄柏的用量,用量从5分到8两不等。结论：(1) 叶氏使用黄柏的医案多是一两剂药即对症取效,而且多在全程或前期就使用黄柏。疗效之显著,反映了叶氏辩证能力超群,或者揭示黄柏使用指征的把握其实并不困难。(2) 叶氏应用黄柏治疗的病症广泛,月.不同的炮制方法,能分治表里上、中、下三焦,或趋降其寒性,增加其疗效。但其主治仍离不开其清热燥湿,泻火除蒸,解毒疗疮,苦寒坚阴等。(3) 黄柏药性苦寒最善清化湿热,滋阴降火。故望诊中出现湿热蕴结(色黄、形膨、胀、肿)、湿热熏蒸蒙蔽清窍(色苍、神呆、迷、欲昏),叶氏承《神农本草经》之旨,认为黄柏善解湿热蕴结,可使湿去热走,燥湿而不伤阴。或阴虚火旺(形瘦)、虚火上炎(色赤)等证候是叶氏使用黄柏的指征,叶氏多次提及黄柏的潜阳、和阳功效。(4) 叶氏在医案中只有3次论及舌象。分别为舌白、舌干苔白、舌灰边白。证明黄柏在炮制后,寒性趋降,但仍能保持其化湿特性。(5) 所有黄柏医案中未见迟脉、结代脉等脉象,笔者认为若遇寒邪凝滞证型不宜用黄柏。(6) 脾胃虚弱、肾阴阳两虚、或素体虚寒者,慎用黄柏,或师李东垣法配伍健脾胃药或师朱丹溪法配伍补肾药。叶氏不只是一味使用黄柏泻实火,解热毒,还用来清虚火、潜阳、和阳,黄柏祛湿,湿去热走而阳气归源。(7) 清补法之所以使用最多,这是由于这些医案中,都不是以黄柏作为主药的缘故。(8) 叶氏擅长使用黄柏与其它药味配伍,实现相须为用或制约温燥药药性。(9) 叶氏使用含黄柏的内服膏剂和酊剂,这种剂型创新值得后世借鉴和研究。(10) 叶氏继承并进一步发扬了李东垣独创的滋肾丸,大胆创新性地使用滋肾丸治疗多种病症如肝风、遗精、淋浊、便闭、疝、诸痛等,并取得良效。叶氏安胃丸是在仲景《伤寒论》中乌梅丸化裁而来,体现了叶氏对经方的传承与创新。(11) 叶氏采用含黄柏成方时多选丸剂,表明其使用黄柏每次量少,且不入汤剂水提取药理成分,而以吞服为主的用药特色。(12) 叶氏认为黄柏炒制的辅料及程度如果不同,可能引起不同的疗效药性药理变化。(13) 叶氏使用黄柏量小效宏的临床经验值得进一步深入研究。
[Abstract]:Objective : To study the application of Cortex Phellodendri in the medical record of Chinese traditional Chinese medicine , and to explore the effect and application of Huangbai on the inheritance and development of Chinese traditional Chinese medicine and to summarize the efficacy and application principles of Cortex Phellodendri . The results show that in the medical record of Huang Bai ' s medical record , the application of Huang Bai is different , and the number of application is different . Among them , the application of Huang Bai is 26 times , which accounts for 25 . 2 % of the total number of applications .
( 2 ) There were 39 men in 62 families , accounting for 77.7 % of all medical cases . ( 3 ) Most of the cases were treated with Cortex Phellodendri , and the most of them were digestive , nocturnal emission , sexual impotence , dysentery , toilet , hernia , worm , hematochezia , arthralgia , etc . ( 3 ) The most of the cases were digested , moved , urinary , genital , nerve , circulation , etc . ( 7 ) A total of 23 records were recorded . The sequence appeared most frequently , followed by other phases and veins , pulse , pulse , pulse , pulse , pulse , pulse , pulse , pulse and vein .
There were only 9 Chinese medicinal pills containing Cortex Phellodendri , and most of them were Zishen Pill , accounting for 37.6 % of all the parties .
In the second place , the pill was used for 7 times , accounting for 18.4 % . There were 30 times , accounting for 78.9 % .
The second was decoction , which appeared 7 times , accounting for 18.4 % ;
A Chinese medicinal composition is prepared from Rhizoma Coptidis , Poria , Rhizoma Anemarrhenae , Alismatis Rhizoma , Radix Rehmanniae Preparata , Radix Paeoniae Alba , Rhizoma Dioscoreae , Rhizoma Alismatis , Radix Rehmanniae Preparata , Radix Paeoniae Alba , Rhizoma Dioscoreae Septemlobae , Radix Rehmanniae , Radix Ginseng , Cortex Cinnamomi , and Radix Angelicae Sinensis . Conclusion : ( 1 ) It is not difficult to use Cortex Phellodendri in the treatment of dampness and heat , and to increase its curative effect . ( 2 ) The symptoms of damp - heat accumulation ( color yellow , shape swelling , swelling and swelling ) and damp - heat fumigation are not necessary . ( 2 ) The symptoms of damp - heat accumulation ( color yellow , shape swelling , swelling and swelling ) and damp - heat fumigation are the indications of Ye ' s use of Cortex Phellodendri , and the symptoms of yin deficiency and fire ( shape thin ) , deficiency fire and inflammation ( color red ) are the indications of Ye ' s use of Cortex Phellodendri . ( 4 ) There are only 3 cases in Ye ' s medical record . The tongue is white , tongue dry and white , and the tongue gray is white . It is proved that it is not suitable to use Cortex Phellodendri . ( 5 ) It is not suitable to use Cortex Phellodendri . ( 5 ) It is not suitable to use Cortex Phellodendri . ( 10 ) Ye ' s inheritance and further promotion of the unique nourishing and kidney - nourishing pill of Li Dongyuan . It is a bold and innovative use of Zishen Pill for treating various conditions such as liver wind , spermatorrhea , clouding , defecate , hernia , and pain .

【学位授予单位】：广州中医药大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R249

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