田金洲教授学术思想与临床经验总结及从肝论治失眠整理与研究

发布时间：2017-12-28 04:21

本文关键词：田金洲教授学术思想与临床经验总结及从肝论治失眠整理与研究　出处：《北京中医药大学》2016年博士论文　论文类型：学位论文

【摘要】：导师田金洲教授是我国著名的脑病专家,长江学者,第五批国家级名老中医药专家学术经验继承指导老师,从事脑病临床、科研和教学工作己40余年,长期致力于老年神经精神病学的研究,在老年痴呆、帕金森病、失眠、卒中、头痛等疾病的诊治领域有自己独到的见解。通过三年的跟师学习,采用临证抄方、跟师笔记、记录心得、重读典籍、查阅文献,以及师生问难、老师释疑、定期讲课、口传心授等方式,记录、领悟、整理、总结老师的学术思想、临证经验和诊疗特色。通过追溯导师学术思想渊源及理论依据,整理其师承学术脉络。同时应用现代统计方法,深入研究田金洲教授从肝论治失眠理论,总结其用药特点,归纳诊疗思路,阐述其理论创新点,以求进一步挖掘其临床经验及学术思想。本研究分为四部分。1.学术思想渊源：探究田金洲教授学术思想形成的渊源和根基。熟读经典是导师学术思想形成的基础,恩师引导为其学术之路指明了方向,海外留学拓展了其学术视野,坚持临床丰富了其临床经验。“读典、跟师、留学、临证”,既是田金洲教授成为名老中医之路,又因此形成了田金洲教授中西合璧的学术特点。2.学术思想及临床经验总结：在学术上导师倡导中西结合的灵活运用,提倡将中医的辨证论治与西药的靶点治疗相结合,辨证与辨病相结合,在中西医不同诊疗思路的交汇中找寻切入点,调动中西医优势。无论是提出从肝论治失眠,还是针对痴呆的三期划分及阶梯变化规律,彰显了导师在继承基础上的创新。导师强调治病求本,善抓主要矛盾,掌握标本转化的规律,从而做到“胸中了然”。导师认为肾虚髓减是神经变性病病本,因此补肾填髓在其治疗中占有重要的地位。“四诊合参”是收集患者信息的重要手段,田老师尤其注重舌象、脉象的变化,将其与临床症状巧妙结合,综合辨证,体现其中医临床诊断思维特色。对于每一种疾病的诊治思路中,都包涵着导师不断深入的临床思维过程。通过总结其临床经验,可进一步深入挖掘导师的学术理念。针对痴呆导师提出分期论治策略,即平台期强调补虚,波动期注重化痰,恶化期功专解毒。在分期论治的同时,结合虚实辨证,体现出田老师对痴呆发展过程的整体把握。失眠是常见病、难治病之一。田金洲教授认为慢性失眠多与肝密切相关,肝藏血,血舍魂,魂不入肝则生不寐。魂宜安,有疏肝、清肝、养肝治法；临床上贵在圆机活法,灵活应用。帕金森病非运动症状的发病率逐年升高,其对患者生活质量影响已越来越引起关注,其中顽固性便秘更为常见。导师提出阴虚肠燥为其病本,故而滋阴润肠是治疗根本,调补脾肾是关键,调畅气机为辅助,长期调理必不可少。导师认为脑积水属本虚标实,脾肾亏虚为本,瘀血、水湿阻滞为标,病机关键是颅脑水瘀,脑窍不通,治疗重在“补虚,化瘀,利水”。原发性头痛中医治疗具有极大的优势。田老师提出治疗头痛诊断为先、分经论治及重用川芎的诊疗思路,对临床帮助很大。分经论治头痛可以明确病位、确定病性、了解致病邪气的性质,为准确有效地治疗提供了保障。川芎辛温,既有活血祛瘀通经之效,又有行气开郁止痛之功,可引药上至颠顶,有血中气药之称,是治疗头痛之要药。田老师常在辨证论治的基础上,应用川芎治疗多种类型的头痛,临床疗效明显。多汗也是帕金森病患者自主神经功能障碍的表现。导师将当归六黄汤灵活运用于帕金森病多汗证的治疗,扩大了原方的适用范围,不仅临床疗效突出,而且对治疗多汗证有提纲携领之意。多系统萎缩根据其临床表现和发病特点,中医有“厥证”、“颤证”、“眩晕”、“虚劳”。病性或以本虚为主,或虚实兼顾。治疗重在扶正治本,或兼以治标。导师临证善用虫类药以搜风通络。通过用药的升降并举,以恢复机体正常的升降之职。眩晕是临床经常遇到的疾病,包括中枢性眩晕、周围性眩晕和其他原因引起的眩晕。田老师提出“治晕首辨病”,应首先明确导致眩晕病因,对因治疗,判断预后；眩晕病属本虚标实,病变涉及肝、脾、肾三脏,故强调“治晕不忘调肝养肾”,调肝施以疏肝、清肝、平肝、柔肝、镇肝；养肾重在补肾填精、养阴益髓；“治晕宜分缓急”,急性期泄实为主,缓解期兼顾补虚。3.从肝论治失眠的挖掘整理研究失眠尤其慢性失眠是临床常见病、多发病,现代医学多对症治疗,不能从根本调节患者失眠状况,停药后病情多易反复,且长期服用对其认知功能有一定的损害。由于中药毒副作用相对较少,并可针对病因进行整体调节,故很多失眠患者转而寻求中医治疗。选取2012年11月至2014年12月东直门医院脑病Ⅲ科田金洲教授收治的60例失眠患者作为研究对象,观察其临床治疗效果,并进行证候统计及药物统计,通过对统计结果深入分析,挖掘整理老师从肝论治失眠的经验。主要结论：1.失眠的病因病机：病位以肝为主,涉及心、脾、肾；痰、热、郁、瘀、虚皆为致病因素,病性总属阴阳不交,气血失和。2.治疗失眠12位核心药物组成基础方如下：炒枣仁、五味子、夜交藤、丹参、黄连、醋柴胡、三七面、枳壳、生地、白芍、珍珠母、生甘草。3.治疗失眠的基本法则是清热安神、解郁活血、养血安神。4.治疗失眠常在辨证论治的基础上,参以辨病论治,合理使用靶向作用明确的中草药。但强调辨证论治是基础,不可本末倒置。5.补虚药在总体药物的使用占第一位,其中以补血药与补阴药为主,在安神药的使用中滋养安神为主,充分体现阴血不足是失眠正虚的病理基础。6.重用酸枣仁是治疗失眠的特色,并且有量增效佳之势。7.通过学习总结田金洲治疗失眠经验,自己的体会如下：(1)很多失眠常伴胃气不和症状,所谓“胃不和则卧不安”。因而在疏肝理气的同时,还应从调理脾胃入手,达到安魂助眠之效。(2)针对失眠停药复发问题,初诊和复发再诊失眠患者,何为恰当有效的治疗时程,尚需进一步长期观察研究。(3)将老师治疗失眠从肝论治经验推而广之,帕金森合并失眠从其病机推导和临床实践观察发现,通过补养肝血,滋阴潜阳可以改善睡眠状况。但同中有异,在养肝、清肝、疏肝的基础上,全蝎、龟板、鳖甲等平肝熄风药常贯穿治疗始终。4.清肝化痰宁魂汤治疗失眠临床研究在挖掘、整理田金洲教授从肝论治失眠的理论基础上,观察清肝化痰宁魂汤治疗痰热内扰型失眠临床疗效。选取2014年12月-2015年5月宣武中医院老年病科门诊病例72例,采用随机对照的研究方法。治疗组36例清肝化痰宁魂汤治疗,对照组36例睡前服用艾司唑仑。期间治疗组脱落病例1例,对照组脱落2例,有效病例治疗组35例,对照组34例。结论：中医症候量化积分和匹兹堡睡眠质量积分经尼莫地平法定性后,经过秩和检验,得出清肝化痰宁魂汤治疗失眠与西药艾司唑仑效果相当。但中药组在恶梦、头目昏沉、口黏痰多、口苦心烦改善突出,尤其是恶梦、头目昏沉、口黏痰多三方面中医症候改善优于对照组。中药组在睡眠障碍、日间功能改善方面均优于西药对照组。且在观察期间未出现日间困倦、乏力、口干等不良反应。提示清肝化痰宁魂汤治疗失眠疗效肯定,且在提高患者白天生活、工作状态,提高患者睡眠质量,从整体调整痰热内扰症候方面优势明显。
[Abstract]:Professor Tian Jinzhou is a famous Chinese encephalopathy experts, Changjiang Scholars, the fifth batch of national TCM expert guidance teacher of academic experience inheritance, has been engaged in clinical work and scientific research and teaching encephalopathy 40 years, long-term commitment to the elderly Neuropsychiatry, have their own unique insights in the field of diagnosis and treatment of elderly dementia and Parkinson disease insomnia, headache, stroke and other diseases. Through three years of learning with the teacher, using the clinical side, copy with teacher notes, records, books, literature reading experience, teachers and students, teacher questioning construction, regular lectures, etc. records, oral teaching that inspires true understanding within, understanding and summarizing the teacher's academic thought and clinical experience and treatment characteristics. By tracing the tutor academic ideological origins and theoretical basis, finishing their teachers academic development. At the same time, we apply modern statistical methods to further study Professor Tian Jinzhou's theory of insomnia from the liver, summarize the characteristics of its medication, summarize the diagnosis and treatment ideas, and elaborate its theoretical innovation so as to further explore its clinical experience and academic thoughts. This study is divided into four parts. 1. origin of academic thought: To explore the origin and foundation of the formation of Professor Tian Jinzhou's academic thought. Read the classics is the formation of academic thought of the tutor, mentor and guide pointed out the direction for the academic road, overseas students expand the academic vision, adhere to enrich the clinical experience in clinical. "Classic reading, studying, with the teacher, Clinical Professor Tian Jinzhou", is to become an old Chinese road, and thus formed the academic characteristics of Professor Tian Jinzhou's Chinese and Western. 2. academic thoughts and clinical experience in the Academic Advisor: flexible use of a combination of Chinese and western, advocates the treatment based on syndrome differentiation of TCM combined with western medicine treatment target, combination of syndrome differentiation and disease differentiation, find the starting point in the intersection of Chinese and Western medicine treatment in different ways, their advantages in Western medicine. Whether it is proposed from the liver to treat insomnia, or for the three stages of dementia and the rules of the ladder, highlight the innovation of the tutor on the basis of inheritance. The tutor emphasizes the treatment of the disease, grasps the main contradictions, and grasps the law of the transformation of the specimen, so as to achieve "in the chest clear". The tutor believes that kidney deficiency myelosis is a neurodegenerative disease, so kidney filling plays an important role in the treatment of the disease. "Four diagnostic methods" is an important means to collect patient information, Tian teacher with particular emphasis on the changes of tongue and pulse, which combined with clinical symptoms, dialectical and comprehensive, embodies the characteristics of thinking in clinical diagnosis of tcm. In the diagnosis and treatment of every kind of disease, it includes the continuous thinking process of the tutor. By summarizing the clinical experience, we can further dig out the academic ideas of the tutor. In view of the dementia tutor, the strategy of staging is put forward, that is, the stage emphasizes the deficiency, and the fluctuation period pays attention to the phlegm, and the deterioration period is specially detoxified. At the same time, combined with the syndrome differentiation of virtual reality, the teacher's overall grasp of the development process of dementia is reflected. Insomnia is one of the common and refractory diseases. Professor Tian Jinzhou believes that chronic insomnia is closely related with the liver, liver blood, blood shed soul, the soul of liver health insomnia. The soul should, have the liver, liver, liver treatment; clinical in round way, flexible application. The incidence of non motor symptoms of Parkinson's disease has increased year by year, and its influence on the quality of life of the patients has attracted more and more attention, of which the intractable constipation is more common. The tutor put forward that yin deficiency and intestinal dryness is its disease, so nourishing yin and moistening intestines is the root of treatment, regulating the spleen and kidney is the key, regulating Qi Qi machine is auxiliary, long term conditioning is essential. Hydrocephalus instructors believe that this standard is false, the spleen and kidney deficiency, blood stasis, wet block as the standard, the key pathogenesis is brain water and blood stasis, brain orifices, treatment focuses on "tonic, removing blood stasis and diuresis". Traditional Chinese medicine for primary headache has great advantages. Tian teachers put forward the diagnosis and treatment of headache, treatment and reuse of Ligusticum chuanxiong, which is very helpful to the clinic. The headache can clear the disease, determine the disease, understand the nature of pathogens, provide a guarantee for the accurate and effective treatment. Chuanxiong Xinwen both blood stasis dredging effect, and qi stagnation relieving pain can lead to drugs on the top of the head, blood gas medicine said, is a headache to the drug. On the basis of syndrome differentiation and treatment, field teachers often use Ligusticum chuanxiong to treat various types of headache, and the clinical effect is obvious. Parkinson is sweating in patients with the symptoms of autonomic dysfunction. The instructor will use Angelica six Decoction in treating Parkinson's disease perspiration syndrome, expanding the scope of the original party, not only the clinical curative effect, and the outline of the treatment of hyperhidrosis syndrome. According to the clinical manifestation and the characteristics of the disease, the Chinese medicine has "syncope", "tremor", "vertigo" and "deficiency". The disease or the deficiency of the main, or the deficiency and reality. The treatment is on the basis of centralizability, or at the same time. The tutor uses the insect medicine to search the wind and dredge the collaterals. Through the lifting and lifting of drugs to restore the body's normal lifting and lifting. Vertigo is a common clinical disease, including vertigo, central vertigo, peripheral vertigo, and other causes. Tian teacher pointed out that "no halo first disease", we should determine the cause of vertigo due to the etiology, treatment, prognosis of vertigo; this standard is false, lesions involving the liver, spleen, kidney three dirty, so that "halo did not forget the liver and kidney, regulating" liver with Shugan, liver, liver, liver, liver and kidneys in the town; Bushentianjing, Yin marrow; treatment of halo should be divided into priorities ", acute diarrhea is mainly that remission both tonic. 3., the treatment and treatment of insomnia from the liver is a common disease and frequently occurring disease. Insomnia is often treated by modern symptomatic treatment. The condition of insomnia can not be fundamentally adjusted. After taking the medicine, the condition is more likely to relapse, and taking it for a long time has some damage on its cognitive function.
【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】：2016
【分类号】：R249;R256.23

【相似文献】