基于医案的麻杏石甘汤证量效关系研究

发布时间：2017-12-27 14:17

本文关键词：基于医案的麻杏石甘汤证量效关系研究　出处：《北京中医药大学》2017年博士论文　论文类型：学位论文

【摘要】：证是中医学对诊断和认识疾病的高度概括,是中医学特有的学术概念。方药量效关系研究离不开证,证量效关系研究是方药量效关系研究的核心内容。证影响并决定着疗效,方药量效关系的研究不能脱离开"证"。本文旨在通过对经方麻杏石甘汤方证的研究试图阐释其证量效关系的特点和规律,以期更好地指导临床。首先,本文对历代医家使用麻杏石甘汤的病案进行了整理,共获得符合纳入标准的医案135个。然后对每个医案的症状进行重点解析,对主要症状之间的相关性进行研究,并对医家使用麻杏石甘汤原方的规律进行总结。在此基础上,运用数理统计方法(层次分析法)和专家调查法,对麻杏石甘汤适用的四个主要证型:外寒内热证、风热犯肺证、肺热炽盛证和痰热壅肺证,其主证隶属度进行评判,从而得出每一病案的治疗前后量化结果,进而对各证型的证量效关系进行分析。研究表明,麻杏石甘汤多用于治疗外感引发的发热咳喘类疾患,并以新感居多;在外感邪气方面,寒邪居首,其次为风热和时邪;风寒之邪侵袭人体后,以表邪悉入在里化热为主要发展趋势,寒邪侵袭人体,稽留体表的时间一般在1周以内;对麻杏石甘汤证而言,发热(86%)和喘促(76%)为麻杏石甘汤证的两个主要症状;在麻杏石甘汤证中,对于发热程度,从低热、中等热一直到高热、壮热,麻杏石甘汤证皆可见到,不必拘泥于"无大热",且发热程度与有无汗出以及汗出多少无明显相关性;咳喘与痰并见的可能性为50%。在治法方面,麻杏石甘汤证以清为主,往往清宣并用,可以"清、宣、开"三字概括;麻杏石甘汤原方用药特点为:麻黄用量的最大值与最小值之间相差为10倍,生石膏为5倍,甘草为4倍,杏仁为1.7倍。生石膏用量一般为麻黄的4倍,而麻黄用量略多于甘草。在麻杏石甘汤的加味药物(≤4味)中,被使用的频次由高到低依次为黄芩、桑白皮、贝母、葶苈子、桔梗、苏子、芦根和银花。在用量方面,麻黄主要集中在3克、5～6克和9～10克三个位点;杏仁主要集中在6克、9克和10克三个位点;生石膏用量则以30克为拐点;甘草用量以3克为最多,其次分别为6克和10克。在因地施量方面,对于麻黄的使用,南方医家用药量少于北方,表现为3个明显施量平台(9～10克、5～6克、3克)且用药较为平缓,而北方医家用药较为急骤,表现为2个施量平台(9～10克、6克);在生石膏、杏仁用量上,南北方没有明显差别;在甘草用量上,南方用量低于北方,这与麻黄的用量特点是一致的。在因人施量方面,麻杏石甘汤原方各药物组成在成人与婴幼儿之间差异显著。在麻黄用量上,成人是婴幼儿的2倍;在生石膏用量上,成人明显多于婴幼儿;在甘草用量上,成人近乎是婴幼儿的2倍。在因症施量方面,对于发热这一主要症状,生石膏用量表现出这样特点:即以高热(大于39℃)为拐点,随着热势增高,生石膏用量明显加大,与非高热比较,具有极显著差异(P0.001)。而喘的表现十分复杂,对于婴幼儿来说,随着喘促程度的加重,麻黄用量略有增加,而杏仁用量却有所减少,但均无统计学上意义。在因证施量方面,对于麻杏石甘汤原方,在生石膏和麻黄用比方面,外寒内热型最小(2.88:1),而风热犯肺型最高(5.7:1),其余两个证型略小于风热犯肺证。在证量效关系方面,病情程度越重(即病案分值越高),单剂治疗效果也越好,且患者一般服用一剂的效果,病情大约减轻1/3。随着麻杏石甘汤证的加重,无论是原方用量,还是加味后的整方用量,都显著增加。在组成麻杏石甘汤的四味药中,麻黄和杏仁用量与证的轻重无直接相关性,而生石膏则具有显著相关性。随着病情加重,生石膏用量也随之增加,并具有显著差异。此外,在甘草用量方面,也随着证候的加重略有所增加,且重证与轻证相比具有统计学上的差异。由此说明,生石膏用量对于治疗麻杏石甘汤证的重要性。最后,本文对《伤寒论》麻杏甘石汤证条文补充如下:伤寒二三日或四五日,发热,喘促气急,或咯痰(53%),或渴(38.5%),或汗出(28.9%),或咳(21%),脉数,舌上苔者,麻杏石甘汤主之。本研究创新之处在于,立足医案对"证-量-效"关系进行了较为系统的研究,即紧紧以"证"为核心,从病因、演变、症状、证候、药物用量等方面进行深入分析,力求体现中医学研究的特点和规律,并试图得出一些对临床有指导价值的结论。
[Abstract]:Syndrome is a high summary of diagnosis and understanding of diseases in traditional Chinese medicine. It is a unique academic concept in traditional Chinese medicine. The research on the effect relationship of prescription dose is inseparable from the evidence, and the research on the relationship between quantity and effect is the core content of the research on the dose effect relationship of square medicine. The evidence affects the effect and determines the effect. The research on the dose effect relationship of the prescription can not be removed from the "syndrome". This paper aims to study the prescription of Maxingshigan Decoction prescription to the characteristics and rules of dose-response relationship explains the evidence, in order to better guide clinical. First of all, this paper used Maxingshigan Decoction on the traditional medical records were collected, were obtained in accordance with the inclusion criteria of 135 cases. Then for each case the symptoms were analyzed, to study the correlation between the main symptoms, and the physicians used Maxingshigan Decoction of summary. On this basis, the use of mathematical statistics method (AHP) and Delphi method, four main syndromes of Maxingshigan decoction is: cold and heat syndrome, syndrome of wind heat invading lung, lung heat syndrome and phlegm heat in the lung, the main card membership evaluation obtained before and after treatment each record quantitative result, then analysis permits the quantity effect relationship of each type. Research shows that mxsgd for fever diseases caused by exogenous cough treatment, and a new sense of the majority; in exopathy, Hanxie first, followed by the wind and evil; the cold evil invasion of the body, the evil in the table noted as the main development trend in the hot and cold evil invasion the surface of the human body, missed time in 1 weeks; Gan Decoction on maxingshi, fever and dyspnea (86%) (76%) two main symptoms for maxing Gan Tang card; Gan Decoction in Maxing, the degree of fever, fever, from medium heat until hot and strong heat can be seen, maxing Gan Tang card, do not have to stick to the "hot", and the degree of fever with sweating sweating and many have no obvious correlation with phlegm and cough; possibility for 50%. In the method, mxsgd card to clear the main, often clearing and use, can "clear, declared," three words; Maxingshigan Decoction for drug use: the maximum amount of Ephedra and minimum difference of 10 times, 5 times of gypsum, licorice 4 times almond, 1.7 times. The amount of raw gypsum is generally 4 times as much as ephedra, while the amount of Ephedra is slightly more than that of Glycyrrhiza. Gan Jiawei Decoction in medicine maxingshi (less than 4, taste) is used in frequency from high to low as Radix Scutellariae, Morus alba, Fritillaria, Tinglizi, Platycodon root, perilla seed, reed rhizome and honeysuckle. In terms of dosage, ephedra mainly concentrated in three loci of 3 grams, 5~6 grams and 9~10 grams. The almond mainly concentrated in 6 grams, 9 grams and 10 grams three sites. The gypsum consumption was 30 grams, the licorice consumption was 3 grams, followed by 6 grams and 6 grams respectively. In due to the application amount, for the use of ephedra, south medicine dosage is less than the north, showed 3 distinct application platform (9 to 10 grams, 5 ~ 6 grams, 3 grams) and the drug is relatively smooth, and the north were compared for 2 more quickly, the amount of the platform (9 ~ 10 grams, 6 grams); in gypsum, almond dosage, there was no significant difference between North and South in the South; licorice dosage, dosage is less than the north, which is consistent with the characteristics of dosage of ephedra. The amount of people in terms of Maxingshigan decoction, the drug composition of significant differences between adult and infant. In the dosage of ephedra, the adult is 2 times as high as that of the infant; in the amount of raw gypsum, the adult is obviously more than the infant; in the dosage of Glycyrrhiza, the adult is almost 2 times more than that of the infant. In terms of the amount of disease, for the main symptom of fever, the dosage of gypsum is characterized by high heat (greater than 39 degrees) as the turning point. With the increase of heat potential, the dosage of gypsum is significantly increased, which is very different from that of non high fever (P0.001). And the manifestation of asthma is very complicated. For infants and young children, the amount of Ephedra increased slightly, and the amount of almond decreased, but there was no statistical significance. Because the amount of cards in hand, for Maxingshigan Decoction in gypsum and ephedra use ratio, cold heat type (2.88:1), minimum and maximum wind heat Fanfei type (5.7:1), the remaining two card type is slightly less than the syndrome of wind heat invading lung. In terms of dose effect relationship, the more serious the disease is, the higher the score of medical record is. The better the effect of single agent is, the more patients will take 1/3. With the aggravation of Maxingshigan decoction, regardless of the original amount, or modified after the whole prescription dosage, were significantly increased. In the composition of Maxingshigan Decoction of four drugs, no direct correlation between ephedra and almond dosage and syndrome severity, and is significantly associated with gypsum. With the aggravation of the disease, the amount of gypsum is also increased, and there is a significant difference. In addition, in the dosage of Glycyrrhiza, the aggravation of the syndrome is slightly increased, and there is a statistical difference between the heavy evidence and the light syndrome. This shows that gypsum dosage for the treatment of the importance of Maxingshigan Decoction syndrome. Finally, this article on the "Treatise on the" Maxinganshi Decoction provisions added as follows: two or three days or four or five days of fever, fever, dyspnea or shortness of breath, sputum (53%), or thirsty, or (38.5%) (28.9%), sweating or cough (21%), the number of vein, tongue moss, maxinshigan Decoction of. The innovations of this study is based on medical records, "syndrome - the dose-response relationship was studied systematically, which is tightly to the" card "as the core, evolution, from the etiology, symptoms, syndromes, drug dosage and other aspects of in-depth analysis, to study the characteristics and laws of TCM, and tries to get some guiding value for clinical results.
【学位授予单位】：北京中医药大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R289.5

【参考文献】