©1994-2010ChinaAcademicJournalElectronicPublishingHouse.Allrightsreserved.http://www.cnki.net作者简介:张建华(1957—),男,副主任医师,陕西省大荔县医院(大荔715100)。·学术探讨·叶天士《临证指南医案》辨治咳嗽经验探析张建华摘要:叶天士《临证指南医案·咳嗽》中汇集了有关诊治咳嗽的医案142例,归纳为风寒袭肺、风热犯肺、肺燥津伤、肝火灼肺、脾虚肺弱和肺肾虚衰6型。通过分析,可以看出叶天士治疗咳嗽,并非见咳治咳,而是善于掌握病因病机。邪在表者予轻剂宣解,邪在里者或不治肺而治脾肾,注重顾护胃气和津液。充分体现了叶天士辨治咳嗽精深的学术见解与博通丰富的临证经验。关键词:叶天士;临证指南医案;咳嗽;治法中图分类号:R24912R256111文献标识码:A文章编号:1000-7156(2010)03-0001-03AnalysisonCharacteristicsofYETian2shiTreatingCoughinClinicalGuidetoMedicalRe2cardsZHANGJian2hua(DaliCountyHospitalinShanxi,Dali,715100,China)Abstract:ClinicalGuidetoMedicalRecordsisacollectionofYETian2shiπssucceedingcasesandprescriptionsonvariousdiseasesofinternalmedicine,gynecologicalandpediatricdiseases.Itcontainedatotalof142casesre2latedtodiagnosisandtreatmentofcough,whichwereroughlydividedintosixtypes,wind2coldpulmonarystheni2a,wind2heatpulmonarysthenia,consumptionofbodyfluidduetolung2dryness,liverheatinvadinglung,hypo2functionofspleenleadingtoweaknessoflung,anddeficiencyoflungandkidney.Bytheprescriptionsineverycase,wecanseethatYETian2shididnotliketokillthesymptomofcough,butgraspedthecauseandpathogene2sisofcoughtokillcoughwhilehetreatedit.Whenevilwasintheexterior,hewouldselecttheprescriptionforexpellingwind2eviltoopentheinhibitedlung2energy.Butwhenevilwasintheinterior,hewouldnottreatlungbuttreatspleenandkidney,focusingonprotectinggastricqiandbodyfluid.AllthosefullyreflectYETian2shi’streatmentcharacteristics,meticulousdifferentiationofsymptomsandsignsandgoodatseizingtheprincipalsyn2drome.Keywords:YETian2shi,ClinicalGuidetoMedicalRecords,cough,treatingmethod清代著名医家叶天士《临证指南医案·咳嗽》[1]中共收载142例医案,其中有关咳嗽病因病机、治疗法则及遣方用药的论述,多有创见,现归纳分析如下。1风寒袭肺111卫阳受伤,阻遏气机:本证计有8案。均系风寒所致。其证多见咳嗽,缠绵不已,形寒,头痛,舌苔白,脉浮缓或沉细,用桂枝汤调和营卫,或加杏仁苦以降肺,茯苓、薏苡仁淡以除饮,半夏燥以祛痰;如阳虚较甚,则去芍药之酸寒,生姜之辛散;痰湿较盛,则去大枣之甘腻;若因卫阳受损,遇风则咳者,则加黄芪、防风、白术(玉屏风散)以护阳,佐当归以和营;若兼津伤口渴,则加花粉生津止渴,总在随证加减,灵活应用。112风寒郁肺,清窍失和:本证计5案。风为阳邪,善行数变,寒为阴邪,凝滞郁闭,两者交困,易使清窍失和。证见头痛,鼻塞流涕,咳嗽声重,四肢酸痛,舌苔薄白,脉浮等。叶氏遇此等证,常用“辛以散邪,佐微苦以降气”,方取杏苏散出入,药用苏叶、杏仁、前胡、桔梗、陈皮、牛蒡子、薄荷、甘草等,或加半夏、贝母以祛痰,枳壳以理气,加茯苓、通草以渗湿,总以疏风散寒,化痰宣肺为治。113寒郁肺卫,郁久化热:本证计4案。风寒外束,伏热内蕴,出现恶寒发热,或身热出汗,咳嗽不已,音声渐窒,气急而喘,脉右寸独坚。当散寒清热,用麻杏石甘汤主治,或加入半夏祛痰,射干泻火,薏苡仁利湿,此证与燥邪伤肺不同,不宜使用滋润之药。114外寒袭表,中挟痰湿:本证计3案。因肺胃原有湿邪,复受风寒之侵,故痰浊内生,咳喘痰多,胸·1·山西中医2010年3月第26卷第3期SHANXIJOFTCMMar12010Vol126No13©1994-2010ChinaAcademicJournalElectronicPublishingHouse.Allrightsreserved.http://www.cnki.net脘不畅,脐左窒塞,二便不爽,舌苔腻,脉濡等证。方以苏梗、杏仁、陈皮、厚朴散寒理气,白芥子、苏子、莱菔子、苍术、薏苡仁等燥湿祛痰;若因寒湿郁胃,胸痹脘闷,咳甚呕吐,脉沉,此为“阳不旋运,浊泛呕吐”,用小半夏汤加姜汁祛痰止咳。2风热...
