戴永生教授辨治胃脘痛的学术思想及规律研究

发布时间：2018-05-12 21:20

本文选题：胃脘痛 + 名老中医经验　；参考：《成都中医药大学》2016年博士论文

【摘要】：随着经济的发展和人民生活水平的提高,饮食的多样化,生活节奏加快,我国胃脘痛的发病率呈现升高的趋势,但近年来对本病大样本量的流行病学调研鲜有报道；由于本病病因复杂交织,病程较长,常迁延难愈,治疗颇为棘手；尽管历代医家对胃脘痛辨治的论述较多也有疗效,但未系统规范出各自特点,有碍了名老中医学术经验广泛的传承。戴永生教授系第五批国家级名老中医及学术经验继承工作指导老师,贵州省名中医、国家中医药管理局科技咨询与评审专家,世界传统医学联盟学术委员会委员,从医执教近50年,擅长消化内科各种难治病症的独特辨证论治。为较全面、系统地整理、总结戴永生教授辨治胃脘痛的学术思想与临床经验,探索其临证规律及学术特色,以便于更好地继承、弘扬戴老学术经验,指导临床运用,特立题进行研究。本研究首先从胃脘痛的病名、病因病机、辨证方法、辨证论治四方面进行了文献学研究,阐明导师学术源流,整理和总结戴老辨治胃脘痛学术经验及思想提供理论根据。在追本溯源的基础上,通过对随师门诊辨治2275例胃脘痛病例的回顾性调研、使用中医传承辅助系统软件对798首戴老辨治胃脘痛处方进行用药用方数据分析,结合导师临证医话及相关论著的整理、研究,采用系统分析方法,进行领悟、总结,提练出戴老对本病病因病机认识、辨证论治及用药处方的规律与特色,并加以深化升华和传承创新。主要研究内容有：1、戴老辨治胃脘痛学术思想及临床经验的整理。(1)重视胃脘痛的病因、病机及病位传变层次：在胃脘痛的发病病因方面,戴老认为：①首要承袭《内经》“饮食自倍,肠胃乃伤”和东垣“饮食不节则胃痛”的理念,重视“内伤饮食”致病,并认为饮食的太过、不及或饥饱不定,或五味偏嗜,一方面可作为胃脘痛的直接病因,另一方面在体质虚弱,正气亏虚时,又可作为胃脘痛的食复诱发因素。②强调情志失度既是导致胃脘痛的直接病因,也是引起胃脘痛复发的重要诱因,既可单一情志伤人,又可多种情志交织而伤人,可伤一脏,也可伤心、肝、脾多脏,致使胃脘痛有多脏兼证出现,因而其辨证具有复杂性。③注意外邪犯胃,戴老结合临床实际,认为外感邪气中以寒邪、湿邪、热邪最易犯胃,特点是多与内生五邪相合为病。④从体质的病理倾向及生理特点出发,强调体质差异对胃脘痛发病的影响。⑤认为食复、药复、劳复是导致胃脘痛久治不愈的主要原因。在胃脘痛病机方面,戴老强调,脾胃之间三大关系失调,即纳运失宜、升降相悖、燥湿不济是胃脘痛发生、发展的关键。纳运、升降、燥湿既可单独失调,也可复合失调致胃脘痛。同时脾胃的生理属性决定了脾胃受病的病理特点：脾易见虚证,胃多出现实证。脾虚指脾失健运、脾气不升、脾虚生湿；胃实指胃纳失常、胃气不降、燥热伤胃。脾虚胃实是脾胃三大关系失调的高度概括,是胃脘痛独特临床证型提出的基础。戴老在研究国内医家治疗胃脘痛过程中,认可并深化其病理因素为“三瘀”,即瘀血、瘀热、瘀毒。三者间互为因果,相互影响,甚至可相互转化。即疾病早期及中期以瘀热、瘀毒为主,后期三瘀并见。首次提出了胃脘痛病位传变层次有三,一为胃本腑自病、胃病及脾,二为胃(脾)病及它脏,三为它脏及胃(脾)。(2)胃脘痛辨证论治方面,戴老提倡以“辨证方法统分型,分型确立治法,治法指导方方组合处方并加减”的辨治思路模式。(3)胃脘痛治疗方面,强调平调脾胃与它脏五行制化关系。2、戴老辨证论治胃脘痛学术经验的临床研究。第一部分：辨证方法及辨证分型的调研(1)收集戴老胃脘痛辨治病例2275例,运用Exce1、SPSS19.0统计软件分别对患者性别构成情况、年龄构成情况、主要证型与年龄及性别间有无关联进行了统计学分析,充实了胃脘痛流行病学方面的研究。(2)运用频数分析出临床前10位的证型：分别为肝胃不和证(538例)脾虚胃实证(376例)、肝胃郁热证(222例)、肝脾不调证(187例)、食滞胃脘证(134例)、脾胃不和证(114例)、脾胃湿热证(109例)、气虚气滞证(73例)、土虚木乘证(65例)、气阴不足证(60例)。(3)总结胃脘痛辨证方法：脏腑辨证者占36.75%,其证型包括：肝胃不和证、脾胃不和证、肝脾不调证；使用病因辨证者占8.22%,其证型包括：食滞胃脘证、湿困脾土证；使用八纲辨证者占7.56%,主要证型有：胃热证、胃寒证；使用气血津液辨证者占10.77%,主要证型有：气阴不足证、气虚气滞证；使用五行辨证者占14.29%,临床常见证型包括：土虚木乘证、土虚火弱证、土不生金证、土虚水侮证、土实乘水证、土实侮木证、土燥及心火证；使用多种辨证方法优化组合的复合辨证(即交叉辨证)者占22.42%,主要证型有：脾虚胃实证(脏腑与八纲组合的辨证分型)、肝胃郁热证(脏腑与病因组合的辨证分型)、脾胃湿热证(这是脏腑与病因组合的辨证分型)。上述临床研究结果符合戴老提倡辨证方法统分型的辨治思路模式。第二部分：基于中医传承辅助系统数据挖掘的用方用药规律研究使用中医传承辅助系统软件进行数据挖掘,统计出戴老辨治胃脘痛798首处方中所用药物的使用频率；统计出药物的归类、四气五味、归经情况,从而得到戴老辨治胃脘痛用药总的主导趋势；在此基础上,将戴老辨治胃脘痛的10个临床常见证型分别进行用药频率、高频次药物相互间的用药相关度进行分析,从而得到戴老在各证型中的用药与组方规律。结果显示：(1)798首方剂中共使用中药167味,其中使用频次前十位的中药分别是土炒白术、茯苓、甘草、南沙参、陈皮、蒲公英、柴胡、枳壳、赤芍、白芍,并分析出该10味药物的常用剂量。(2)将798首处方中出现的用药频次大于等于10以上的中药,共78昧按药物药类进行人工分类,得到戴老在治疗胃脘痛时常用的药物主要为补虚类、理气类、清热类,显示出用药的集中性。(3)将798首处方中所涉及的167味药物进行药性(包括四气、五味)统计分析,戴老用药四气以寒、温、平为主,五味以苦、甘、辛为主。(4)将798首处方中所涉及的167味药物进行归经统计,并联系药效脏腑所在,戴老在治疗胃脘痛时除针对主病脏腑脾胃用药外,还涉及肺、肝、心、肾四脏及其他六腑。(5)对戴老辨治胃脘痛10个常见证型处方分别进行关联规则分析,分别得到各证型核心药物、组方规律,并进行网络展示,佐证了戴老喜用经方,随证方方组合的用方规律。(6)基于“熵聚类”和“改进的互信息法”进行层次聚类分析,得到临床10个常用证型的新方。通过上述两部分的研究,对戴永生教授辨治胃脘痛的思路及规律进行整理、总结：1、临证采用复合辨证法思路,即将《中医诊断学》上的八纲辨证、脏腑辨证、病因辨证、经络辨证、气血津液辨证等各种方法在胃脘痛辨证分型中交叉综合应用,形成复合辨证法。提倡以“辨证方法统分型,分型确立治法,治法指导方方组合处方并加减”的辨治思路模式。2、在胃脘痛的辨治中,引入戴老的五行辨证方法,以五行太过、不及统帅五行母子乘侮辨证,并运用五行理论指导临证用药。3、分型提出胃脘痛的脾虚胃实证及土虚木乘证分型证治。4、善用经典成方随辨证证型进行方与方相组合的处方规律,并提出随病各证区分轻、中、重用方。5、在胃脘痛辨治过程中,扩大了仲景“随证治之”理论,认为可从三方面进行考虑：一为随症(状)变化治之；二为随病(同病异治、异病同治)治之；三为提升到辨证方法的随“证”选用。6、整体把握胃脘痛病证辨治的系统性,表现在：①权衡胃脘痛辨治的三个层次,即一是胃脘痛本脏腑的寒热虚实辨治；二是胃脘痛病及其它四脏的五行辨治；三是它脏病及胃脘痛的五行辨治。在辨治本病时需权衡这三个层次轻重、主次。②重视胃脘痛胃病及脾证候的系统性,一般来说凡胃脘痛多为胃病及脾,除导致脾胃纳运、升降、燥湿三大功能的关系失调外,还可影响脾胃在外之象的“体、窍、华、液、志”失调。③强调需将中医传统宏观辨证与微观辨证有机结合,从整体出发,系统把握胃脘痛本质,以提高临床疗效。戴老在胃脘痛的辨治中,秉承经典、发挥东垣、吸收名家经验、自成系统,其学术思想和医疗经验升华的学术经验,具有可操作性和有效重复性,并推广到临床实践中。
[Abstract]:With the development of economy and the improvement of people ' s living standard , the diversification of diet and the quickening pace of life rhythm , the incidence of gastric abscess in our country is increasing trend , but in recent years there are few reports about the epidemiology of the large sample size of this disease ;
Because the cause of this disease is complex and interweave , the course is long , the persistent delay is difficult , the treatment is difficult ;
In this study , the author makes a literature study on the diagnosis and treatment of gastric cavity pain by Professor Dai Yongsheng . ( 1 ) To attach importance to the etiology , pathogenesis and level of gastric pain . In the pathogenesis of epigastralgia , Dai Lao thinks : ( 1 ) It is the direct cause of stomach pain , and it can be used as a direct cause of gastric pain . spleen deficiency and dampness ;
On the basis of the analysis of the symptoms and symptoms of gastric epigastralgia , the author points out that the syndrome differentiation of the spleen and stomach is divided into three groups : the syndrome differentiation of the spleen and the stomach , the deficiency of the spleen and the stomach ( spleen ) , the stagnation of the stomach ( 134 cases ) , the deficiency of the spleen and the stomach , the syndrome of the spleen and stomach ( 109 cases ) , the Qi deficiency Qi stagnation syndrome ( 73 cases ) , the syndrome of Qi deficiency and the syndrome ( 65 cases ) and the deficiency of qi yin ( 60 cases ) . ( 3 ) To summarize the syndrome differentiation method of gastric abscess : 36 . 75 % of the zang - fu organs ' syndrome differentiation , the syndrome types include : the liver - stomach syndrome , the spleen - stomach syndrome and the syndrome of liver - spleen syndrome ;
Among them , 8 . 22 % of the patients were identified by etiologic syndrome , and their syndrome types were : stagnation of gastric cavity syndrome and dampness - trapped spleen - soil syndrome ;
Using the eight - dimensional syndrome differentiation , 7.56 % , the main syndrome types were : stomach heat syndrome and stomach cold syndrome ;
The syndrome differentiation of qi and blood fluid was 10.77 % . The main symptoms were : Qi - yin deficiency syndrome and Qi - deficiency syndrome ;
By using five - line syndrome differentiation , 14.29 % , the common types of syndrome include : soil - deficiency - wood multiplication , soil - deficiency - fire weak evidence , soil - free gold syndrome , soil - deficiency water - bearing syndrome , soil - solid water - water syndrome , soil - solid - bullying , soil - dryness and fire - fire syndrome ;
In the second part , according to the prescription drug law of traditional Chinese medicine inheritance and auxiliary system data mining , data mining is carried out using the auxiliary system software of traditional Chinese medicine , and the usage frequency of the drug used in the 798 first prescription is statistically analyzed .
the classification of the medicine , the four - gas five - flavor and the gui menstruation are counted , so as to obtain the general dominant trend of Dai - aging treatment of the gastric cavity pain medication ;
A total of 78 Chinese herbs in the first prescription of 798 Chinese herbs were analyzed by using traditional Chinese medicines , such as white atractylodes rhizome , tuckahoe , licorice root , dried orange peel , dried orange peel , dandelion , Radix Bupleuri , Fructus Aurantii , Pericarpium Citri Tangerinae , Herba Taraxaci , Radix Bupleuri , Fructus Aurantii , Radix Paeoniae Rubra and Radix Paeoniae Alba . On the basis of the research of the two parts , the author puts forward a new prescription for the syndrome differentiation and treatment of gastric abscess .
2 is treated with the disease ( the same treatment as the disease and the treatment of different diseases ) ;
The third is to improve the syndrome differentiation of the syndrome differentiation method . 6 . To grasp the systematicness of the syndrome differentiation and treatment of the stomach pain , it is shown as follows : ( 1 ) weighing the three levels of the treatment of the stomach pain , namely , the cold and heat deficiency of the internal organs of the stomach ;
secondly , the five - row differentiation and treatment of gastric abscess and other four viscera ;
It is necessary to combine the traditional macro - differentiation of traditional Chinese medicine with the microcosmic syndrome differentiation . In general , it is necessary to combine the traditional macro - differentiation of traditional Chinese medicine with the microcosmic syndrome differentiation .

【学位授予单位】：成都中医药大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R249;R256.33

【相似文献】