王园园 刘培民 段海瑞 郭军辉

【摘 要】 反胃、噎膈、关格为三种不同的病症，综合历代医家对三者的描述，认为三者可出现于食管癌的不同发展阶段。《临证指南医案·噎膈反胃》篇记载反胃、噎膈、关格三种病证，较为集中地反映了叶天士的学术思想。文章以医案为依托，治法为主线，总结反胃治则：益火之源、温暖脾胃;噎膈治则：噎证-甘寒以救阴，膈证-化痰降逆、通络祛瘀、通补胃阳;关格治则：交通阴阳。同时叶天士注重顾护肺胃之津液，善用辛开苦降之法，用药多选用苦辛甘之品，为后世医家治疗食管癌提供思路。

【关键词】 临证指南医案;反胃;噎膈;关格;食管癌

【中图分类号】R256.3   【文献标志码】 A    【文章编号】1007-8517（2021）09-0096-03

Abstract：There are three different symptoms：regurgitation，dysphagia， obstruction and rejection.Based on the descriptions of doctors in the past dynasties， it is concluded that regurgitation，dysphagia， obstruction and rejection can appear in different stages of esophageal cancer.The article “Clinical Guide Medical Case Dysphagia and Regurgitation” records this three disease syndromes，and mainly reflects ye Tianshis academic thought.This paper is based on medical cases and the main line of treatment，summarizes the principles of regurgitation：beneficial to the source of fire， warm the spleen and stomach;Principles of dysphagia：Choking syndrome-Gan Han to save Yin，Diaphragmatic syndrome-eliminating phlegm， dispelling blood stasis， tonifying stomach Yang;Principles of Obstruction and Rejection：Bring Yin and Yang together.At the same time， Ye Tianshi paid attention to the body fluid of lung and stomach，made good use of the method of acid to diffuse and bitter descend，and Ye Tianshi's thought has provided the thought for the treatment of esophageal cancer for later generations.

Keywords：Clinical Guide Medical Case;Regurgitation;Dysphagia;Obstruction and Rejection;Esophageal Cancer

反胃、噎膈一般包括现代医学中的食管癌、反流性食道炎等[1]，二者有相通之处。关格与现代临床中肝肾综合征、肾功能衰竭的临床表现相似，然食管癌终末期亦可出现小便不通与呕吐并见的临床表现。中医学认为，反胃指饮食入胃以后，间隔一段时间又吐出，以宿食不化、脘腹胀满、朝食暮吐、暮食朝吐为主要临床表现的一种疾病[2]。噎膈则以吞咽障碍为主要临床表现。噎即噎塞，指吞咽时哽噎不顺，吞咽困难;膈即隔拒，指饮食不下，或进食即吐。噎可单独出现，又可为膈证的前期;噎是膈之始，膈为噎之渐[3]。古今医家大多认为关格是一种小便不通与呕吐并见为临床表现的危重病证，为阴阳失衡，不能互根互用的严重病理状态[4]。蒋宝素在《医略十三篇·卷十三·关格考（附刻）》中记载了反胃、噎膈、关格之间的关系：“……即由呕吐而反胃，反胃而噎膈，噎膈而关格……呕吐即反胃噎膈关格之始，关格即噎膈反胃呕吐之终也。