许铣教授学术思想及从肝肺论治银屑病传承研究

发布时间：2018-01-12 10:25

本文关键词：许铣教授学术思想及从肝肺论治银屑病传承研究　出处：《中国中医科学院》2016年博士论文　论文类型：学位论文

【摘要】：许铣教授,中国中医科学院广安门医院皮肤性病科研究员、主任医师,博士生导师,享受国务院政府特殊津贴,兼任中国中医科学院专家委员会委员,中央保健委员会会诊专家,第五批全国老中医药专家学术经验继承工作指导老师。许老对中西医都有过系统的学习经历,西医方面曾蒙受老一代著名医学家胡传葵、王光超、陈集舟、王双元等教授的教诲,中医方面师从20世纪七十年代西北地区名老中医张汉祥、于己柏、尚坦芝等,后又得到北京名医朱仁康的指导,继承了诸位前辈的宝贵经验,博采众长。从医近60年,勤奋努力,勇于创新,加之曾在多地工作涉及城市与农村、国内与国外,逐渐形成了其中医西医并重、经典理论与民间经验相结合的学术特色。临床方面诊治皮肤性病领域中诸多种疾病均有十分确切的疗效,尤擅治疗湿疹皮炎类、银屑病、痤疮、各种疣类皮肤病、结缔组织病等。我有幸作为许老学术继承人,通过跟师临证、听讲、整理医案、复习文献等对许老学术思想与临床经验进行较全面的总结,并在许老诊治银屑病经验基础上进一步研究探索,大胆提出“从肝肺论治银屑病”的新观点。本论文主要包括中医典籍学术思想在皮肤科的体现及应用、银屑病中西医研究概况及微观辨证研究现状、许老学术渊源与特色、许老治疗皮肤病临床经验总结、从肝肺论治银屑病的理论研究以及调肝理肺、活血解毒法联合小剂量阿维A治疗斑块状银屑病的临床研究六个方面。1中医典籍学术思想在皮肤科的体现及应用深入学习和挖掘中医经典著作中的理论要素,从中医皮肤科临床实际出发,探讨皮肤病辨证治疗的思路与方法。重点研读了《诸病源候论》、《黄帝内经》、《伤寒论》、《温病条辨》、《医林改错》、《医宗金鉴·外科心法要诀》等典籍,继承吸收其中的理论精髓,并在皮肤病之脏腑辨证、厥阴病诊治思路在皮肤科的应用、皮肤病之养阴护阴、活血化瘀以及皮肤科外治法等方面提出自己的观点与体会。2银屑病中西医研究概况及微观辨证研究现状通过文献研究,综述银屑病的流行概况及中西医治疗现状,指出中医药治疗银屑病的优势及存在的问题,着重分析斑块状银屑病的中西医治疗现状与研究意义。从皮肤组织病理及相关分子机制研究两方面整理分析银屑病的微观辨证研究现状,拓宽银屑病辨证治疗的思路与视野。3许铣教授学术渊源与特色许铣教授1958年毕业于北京医学院(现北京大学医学部),打下了坚实的西医理论基础,上世纪七十年代在甘肃支边阶段又脱产系统学习中医理论,并与基层、民间中医进行了深入交流,进一步吸纳了中医的文化和理念。因此,“实践中医,同时不离西医”是许铣教授临床一直奉行的原则。其学术特色概括如下。3.1中西并举,结合辨病与辨证：诊断主张以西医辨病,以中医辨证。治疗用药主张以中药为主,全面调理、内外兼治；以西药为辅,尽量用最小剂量的西药达到针对病因治疗的目的。这样既可以缓解症状、改善证候,使患者体质达到平和状态,又可以去除病因,同时将西药的副作用和风险降到最低,实现“减毒增效”。致力于将中医、西医从诊断到治疗相结合、相借鉴,在长期临床实践中已取得了比单纯中医或单纯西医更好的临床疗效。3.2辨证求本,兼顾局部与整体：传承了朱仁康教授的学术思想,既关注局部皮损辨证,同时也关注整体脏腑、气血的失调,力求兼顾局部与整体。同时,还重视从组织病理角度进行微观辨证。皮损辨证方面,主要以六淫辨证为主；整体辨证方面,注重脏腑经络辨证、卫气营血辨证；微观辨证方面,关注“湿邪”与“毒邪”。3.3内外兼治,重视中药外用：始终重视中药外治疗法,在许多皮肤病的中药外治方面积累了宝贵的经验。认为“古方中以及民间确有一些现代医者意想不到疗效的验方,应当细心地寻求”。3.4慢病难病,强调心身调节：认识到许多慢性、难治性皮肤病都属于心身疾病,如银屑病、白癜风、痤疮等。在临证时十分重视与患者的心理、精神上的交流,包括耐心告知患者疾病的转归预后等情况,给予必要的心理安慰；在药物治疗方面,酌情应用疏肝解郁、养心安神、重镇安神等方药,并密切观察患者的睡眠及情绪变化。4许铣教授治疗皮肤病临床经验总结4.1银屑病治疗经验：主张中西医结合,以西医的微观观念探寻本病之根源,以中医脏腑、气血之辨证理解本病不同阶段、不同表象之证候,分别又协同施以中西药物或其他科学治法(如光疗、药浴等),始能取得最圆满的疗效。具体分两期(急性期、慢性期)三型(血热、血虚、血瘀)论治,重视对慢性期患者的长期治疗监测；提倡中西药联合,力求增效减毒；擅长外治疗法,积极攻克顽固皮损；重视预防调护,争取逐年减轻。4.2痤疮治疗经验：重视病因病机,根据痤疮发病的四个环节采取针对性治疗,选择相应的中西药物；根据痤疮皮疹形态的四个阶段确定中医的理法方药,具体分肺经风热、胃肠湿热、痰凝血瘀三型论治：擅长应用中药液体面膜(经验方“四季汤”)湿敷患处,效佳价廉；适时补充维生素B、维生素C等,全面改善症状。4.3湿疹治疗经验：诊断方面,既强调经典湿疹与其他皮炎的区别,也重视湿疹可能合并感染或其他皮肤病等复杂情况;辨证方面,宏观与微观相结合,强调湿、热、风、瘀是湿疹辨证的要点；治疗方面,中西并重,标本兼顾,重视止痒及清“虚热”。4.4白癜风治疗经验：辨病为主,治疗重在活血化瘀、补肾益气,同时根据不同患者的脏腑失调情况,或疏肝、或理脾等有针对性地进行调治；注重心身调节及言语疏导；外用药复色与遮盖相结合。认为中西医结合治疗白癜风优势明显。4.5病毒性疣治疗经验：认为顽固性疣应使用内外兼治、中西药联合的综合疗法。内服中药强调分证施治,扁平疣重在解表祛湿；寻常疣(包括跖疣)重在活血解毒。外治法运用中药泡洗配合封包疗法,强调重用香加皮(北五加皮)。4.6慢性荨麻疹治疗经验：以脏腑辨证为主,认为脾虚是根本。治疗原则以补虚扶正为主,始终以健脾益气为核心,兼顾调理其他脏腑,根据患者的具体表现常辅以疏肝气、清心火、清肺热、补肾阴等。酌情联合西药抗组胺、调节免疫、抗感染等治疗。重视患者教育,帮助养成良好的生活习惯。4.7斑秃治疗经验：中西医并重,内外治结合,多角度出击(酌情应用免疫调节剂、维生素、微量元素及镇静安眠药物等),尽可能使患者得到全面而系统的治疗;中医辨证论治方面,重视从肝肾论治,与传统理论相比许老更重视对肝郁、肝火的治理。4.8常用经验方总结：列举了许铣教授治疗皮肤病常用经验方剂5首,包括内服方4首(丹参散结方、丹蛇解毒方、龙芩除湿方及消痤方),外敷方1首(四季汤),详细分析其方剂组成、功效主治及临床加减应用法则,并附典型病案。5从肝肺论治银屑病的理论研究立足脏腑辨证,整理银屑病中医辨证的各种理论与观点,结合中医藏象理论及对银屑病临床观察体会,提出“肝肺失调、外感毒邪、皮络损伤”是银屑病的核心病机。结合许铣老师治疗银屑病分急慢二期等思想及文献研究,提出急性期多以治肺为主,清热解毒、凉血平肝；慢性期多以调肝为主,活血解毒、养阴润肺。同时,在银屑病治疗全过程始终重视治疗“外感毒邪”,重视活血化瘀“通络”,并适当联合小剂量西药或物理疗法(如光疗等),形成有特色、较完整的银屑病治疗方案。6调肝理肺、活血解毒法联合小剂量阿维A治疗斑块状银屑病的临床研究基于“肝肺失调、外感毒邪、皮络损伤”是银屑病的核心病机这一创新观点,在继承许铣老师中西医结合学术思想以及治疗慢性期银屑病活血解毒搜风等临床经验基础上,确立调肝理肺、活血解毒法联合小剂量阿维A治疗斑块状银屑病的方案并开展临床研究。临床研究目的：客观评价调肝理肺、活血解毒法联合小剂量阿维A治疗斑块状银屑病的临床疗效。方法：采用随机、对照的方法,选择符合斑块状银屑病诊断的患者60例,分为联合治疗组和单纯中药组各30例。联合治疗组采用调肝肺活血解毒方联合小剂量阿维A口服(10mg/d),单纯中药组仅内服调肝肺活血解毒方。连续治疗8周,每2周复诊1次。观察并记录治疗前及治疗后第2、4、8周时皮损面积和严重程度指数(PASI)评分、瘙痒程度评分以及靶皮损不同症状(红斑、鳞屑、浸润)评分变化。结果：①联合治疗组痊愈6例,显效18例,总有效率为80.0%,单纯中药组痊愈3例,显效14例,总有效率为56.7%,联合治疗组总有效率高于单纯中药组,但差异无统计学意义(P=0.253);②两组患者疗后2周、4周、8周时与治疗前比较,除单纯中药组治疗2周时瘙瘁评分差异无统计学意义外,其余各时点皮损PASI评分、瘙痒程度评分差异均有统计学意义(P0.01)。治疗2周、4周、8周时,两组间同期比较,皮损PASI评分、瘙痒程度评分差异均无统计学意义(P0.05)；③两组患者疗后2周、4周、8周时与治疗前比较,靶皮损红斑、鳞屑、浸润评分差异均有统计学意义(P0.01或P0.05)；两组间治疗后靶皮损红斑、鳞屑、浸润评分同期比较,除治疗8周时两组靶皮损浸润评分差异有统计学意义(P0.05),其余各项差异均无统计学意义(P0.05)。结论：①调肝理肺、活血解毒法治疗斑块状银屑病临床疗效确切,能够有效地改善斑块状银屑病患者皮损的红斑、浸润、鳞屑及瘙痒症状,能够降低皮损局部的PASI评分；②联合治疗组治愈率和总有效率高于单纯中药组,在改善皮损浸润方面优于单纯中药组而总体PASI评分下降幅度也更大,且无明显副作用,说明中西药联合治疗银屑病能起到优势互补、增强疗效的作用,方向是正确的。
[Abstract]:Xu China milling Professor, Guanganmen Hospital of Chinese Academy of Sciences Department of Dermatology Professor, chief physician, tutor of doctoral students, enjoy special government allowances of the State Council, who is also a member of the Chinese Academy of Sciences China expert committee, the Central Committee on health care expert consultation, the fifth batch of the old Chinese medicine experts academic experience inheritance to guide the work of teachers. The traditional Chinese medicine and Western medicine are old Xu the system's learning experience, western medicine have been subject to the old generation of the famous physician Hu Chuankui, Wang Guangchao, Chen Jizhou, Wang Shuangyuan, Professor of education, Chinese medicine from twentieth Century 70s in the northwest of old Chinese Zhang Hanxiang, to Bo, is Tanzhi, then get the Beijing doctors Zhu Renkang, inherited the precious experience, you senior doctor. Learn widely from others'strong points for nearly 60 years, hard work, innovation, and had much work involved in city and countryside, domestic and foreign, gradually formed The medicine of Western medicine and academic characteristics, classical theory and folk experience combined. The clinical treatment of Dermatology fields are in various diseases and very effective, especially the treatment of eczema dermatitis, psoriasis, acne, warts, various skin diseases, connective tissue disease. I am fortunate as Xu old academic heir. With the teacher in class, finishing clinical, medical records, review of the literature on the old Xu conducted a comprehensive summary of academic thought and clinical experience in diagnosis and treatment of psoriasis and many old experience further study, put forward a new viewpoint of treating psoriasis "from the liver and lung. This paper mainly includes the academic thought in TCM Classics reflection and application of Department of Dermatology, western medicine research survey and research status of micro differentiation in psoriasis, academic origin and characteristics of the old Xu, Xu old treatment of skin disease clinical experience on the treatment of psoriasis, from the theory of liver and lung Study of Tiaoganlifei, huoxuejiedu method combined with small dose of acitretin A in the treatment of plaque psoriasis clinical research thought six.1 classics of Chinese medicine academic reflection and application in Department of Dermatology for further study and mining theory of traditional Chinese Medicine Classics of Chinese medicine from the Department of Dermatology, clinical practice, to explore the ideas and methods of treatment of skin diseases read the source key. < >, > < < Huangdi Neijing, treatise on differentiation and treatment of Epidemic Febrile Diseases > >, < < >, < yilingaicuo, golden mirror of Medicine & surgery to heart > and other books, which inherited and absorbed the theory essence, and differentiation in the organs of skin disease, Jueyin disease diagnosis and treatment in the Department of Dermatology application, skin disease of Yin protectscloudyly, put forward their views and experience of Western Medicine on.2 in psoriasis and microcosmic research status through literature research and Department of Dermatology external therapy of promoting blood circulation and removing blood stasis, review of psoriasis The treatment of traditional Chinese medicine and Western medicine and epidemic situation, points out that the traditional Chinese medicine treatment of psoriasis advantages and existing problems, focuses on the analysis of plaque psoriasis of traditional Chinese medicine and Western medicine treatment status and significance of the research. From two aspects of research and the related molecular mechanism of skin pathology and analysed the current research situation of micro differentiation of psoriasis, psoriasis and broaden the view of.3 treatment and differentiation Xu Xian s academic origin and characteristics of Xu Xian s 1958 graduated from Beijing Medical College (now Peking University Health Science Center), western medicine laid a solid theoretical foundation, in 70s the last century learning Chinese medicine theory in Gansu local stage full-time system, and with the grass-roots folk medicine, conducted in-depth exchanges, further absorb the Chinese culture and philosophy. Therefore, the practice of Chinese medicine, western medicine is not at the same time from "Xu has been pursuing a clinical professor of milling principle. Its characteristics are as follows.3.1 Chinese Simultaneously, combination of disease and syndrome differentiation diagnosis advocated by western medicine, TCM treatment. That is dominated by traditional Chinese medicine, comprehensive conditioning, internal and external; western medicine as a supplement, try to use the minimum dose of Western medicine to achieve the purpose of treatment for the cause. It can relieve the symptoms and improve the symptom of patients, make the physical reach peace, and can remove the cause, while the side effects of Western medicine and the risk to a minimum, to achieve "synergistic". Committed to the traditional Chinese medicine and Western medicine from diagnosis to treatment by combining phase reference, in the long-term clinical practice has achieved a better clinical effect than.3.2 differentiation of pure Chinese medicine or western medicine alone. For this, both local and global inheritance the academic thoughts of Professor Zhu Renkang, both concerned with local skin syndrome, also pay attention to the whole viscera, Qi and blood disorders, to both local and global. At the same time, but also from tissue disease Physical view of microcosmic syndrome differentiation. Differentiation of lesions, mainly in six with syndrome differentiation; integral syndrome differentiation, focusing on viscera meridian syndrome differentiation, weiqiyingxue syndrome differentiation; microcosmic syndrome differentiation, pay attention to "wet evil" and "evil".3.3 internal and external treatment, attention: Chinese traditional medicine has always attached importance to the external treatment of traditional Chinese medicine therapy in traditional Chinese medicine many of the external treatment of skin diseases has accumulated valuable experience. That "the ancient folk prescription and some modern medical treatment should be carefully unexpected, for" chronic disease.3.4 difficult disease, psychosomatic adjustment: recognizing that many stressed that chronic, intractable skin diseases are psychosomatic diseases, such as psoriasis, vitiligo acne. In clinical, and attaches great importance to the patient's psychological, spiritual communication, and patient prognosis including inform patients of the disease, to provide the necessary psychological comfort; in the treatment aspect, appropriate application Soothing, calming, soothing the nerves and other drugs, and close observation of sleep and mood changes in patients with.4 Xu Xian s treatment of skin disease to summarize the clinical experience of 4.1 psoriasis treatment experience: the idea of combining traditional Chinese and Western medicine, western medicine in micro concept explore the root causes of the disease, in TCM, Qi and blood dialectical understanding of different stages of the the appearance of disease, different syndromes, respectively with Chinese and Western medicine collaborative or other scientific treatment (such as phototherapy, bath, etc.) was the most satisfactory curative effect can be acquired. The two phases (acute, chronic) type three (blood heat, blood deficiency, blood stasis) on the treatment of attention to the long-term treatment of chronic phase monitoring with the combination of Chinese and Western medicine; advocate, and strive to synergistic; good therapy, actively overcome stubborn skin; the importance of preventive nursing for the treatment of acne, decrease year by year.4.2 experience: the importance of etiology and pathogenesis, according to the four aspects of the pathogenesis of acne take For the treatment, choose the corresponding Chinese and Western medicine; according to four stages of acne rash form the prescription of traditional Chinese medicine, the lung by wind heat, gastrointestinal damp heat, phlegm and blood stasis on the treatment of type three: at the application of traditional Chinese medicine liquid mask (the experience of "four soup") wet dressing effect is good, cheap; timely vitamin B, vitamin C, improve symptoms of.4.3: the experience in the treatment of eczema diagnosis, not only emphasizes the difference between classical and other eczema dermatitis, eczema may also pay attention to infection or other skin disease complex; syndrome differentiation, emphasizing the combination of macro and micro, wet, heat, wind, and blood stasis is the main points of syndrome differentiation eczema; treatment, both Chinese and western, both attention, antipruritic and clear "hot.4.4" treatment of vitiligo disease: experience, focusing on the treatment of blood stasis, kidney qi, and according to the different organs of patients with disorders, or Liver, spleen or other targeted treatment; pay attention to psychosomatic adjustment and verbal guidance; external medicine combined with complex color cover. That the treatment of vitiligo have obvious advantages.4.5 viral warts treatment experience of combining traditional Chinese and Western medicine: think of recalcitrant warts should be used for both internal and external treatment, comprehensive therapy of traditional Chinese and Western Medicine Combined Traditional Chinese medicine. Emphasize the syndrome treatment, flat wart on relieving dampness; verruca vulgaris (including warts) on blood detoxification. External treatment with traditional Chinese medicine bath with packet therapy, emphasize the reuse of cortex Periplocae (Bei Wujiapi) experience in the treatment of chronic urticaria with.4.6: viscera syndrome, spleen deficiency is the fundamental principle that buxufuzheng treatment. As always with Spleen Qi as the core, taking into account the conditioning of other organs, according to the specific performance of patients often with sparse liver qi, clearing heart fire, Qingfei heat, tonifying kidney yin. Appropriate combined with western medicine antihistamine, regulating immunity, anti sense Dyeing treatment. Pay attention to patient education, help the living habits of.4.7 good experience in the treatment of alopecia areata: both traditional Chinese medicine and Western medicine, and treatment with multi angle of attack (use of immunomodulator, vitamins, trace elements and sedative hypnotic drugs), as far as possible so that patients get a comprehensive and systematic treatment; TCM. Pay attention to treatment from the liver and kidney, compared with the traditional theory of Xu old pays more attention to the liver,.4.8 governance experience summary: common anger cited Xu Xian s prescription for treating skin disease commonly used experience of 5 songs, including oral 4 prescriptions (Dan Shen Sanjie, Dan Antidotarium snake, dragon and Xiaocuo Qin dehumidification 1 the first party), external party (four soup), a detailed analysis of the composition of the prescription, indications and clinical application of modified rules, with typical cases of.5 from lung and liver theory study of treatment of psoriasis based on TCM syndrome differentiation of Zang Fu, a variety of finishing psoriasis treatment The theory and view, combined with TCM theory and experience of psoriasis clinical observation, put forward the "lung and liver disorders, exogenous toxin, skin injury collaterals" is the core pathogenesis of psoriasis. Combining the treatment of psoriasis is divided into acute and chronic milling teacher thought and literature research phase two, put forward the acute stage to cure lung, clearing heat detoxification, cooling blood and liver; chronic phase in regulating liver, detoxification, nourishing yin and moistening lung. At the same time, the whole process in the treatment of psoriasis treatment has always attached importance to the "exogenous toxin", pay attention to blood circulation meridians, and appropriately combined with small dose of Western medicine and physical therapy (such as phototherapy, etc.) to form a distinctive, relatively complete the treatment of psoriasis.6 Tiaoganlifei, clinical study of Yiqihuoxuejiedu method combined with small dose A acitretin in treating plaque psoriasis on liver and lung disorders, exogenous toxin, skin injury collaterals "is the core pathogenesis of psoriasis is the innovation point of view, in the succession of Xu Combination of traditional Chinese and Western medicine based teacher milling academic thought and treatment of chronic psoriasis huoxuejiedu soufeng clinical experience, the establishment of Tiaoganlifei, huoxuejiedu method combined with small dose of acitretin A in the treatment of plaque psoriasis and carry out clinical research. Clinical research objective: To evaluate the clinical curative effect of Tiaoganlifei, huoxuejiedu method combined with small dose of acitretin A in the treatment of plaque psoriasis. Methods: a randomized, controlled method, 60 patients with plaque psoriasis patients, divided into treatment group and control group with 30 cases in each group. Combination therapy by regulating liver and lung Huoxue Jiedu recipe combined with low-dose oral acitretin A (10mg/d). The Chinese herbal medicine group only oral pulmonary tiaogan Huoxue Jiedu recipe. 8 weeks of continuous treatment, every 2 weeks for 1 times. Observed and recorded before and after treatment 2,4,8 weeks of lesions area and severity index (PASI) score, pruritus The target lesion score and different symptoms (erythema, scaling, infiltration) score changes. Results: the combined treatment group 6 cases were cured, 18 cases markedly effective, the total efficiency of 80%, the Chinese herbal medicine group 3 cases were cured, 14 cases markedly effective, the total effective rate was 56.7%, and the total effective rate of treatment group is higher than the pure traditional Chinese medicine group, but the difference was not statistically significant (P=0.253); the two groups of patients after treatment for 2 weeks, 4 weeks, 8 weeks compared with before treatment, except the Chinese medicine treatment group was not statistically significant at 2 weeks, pruritus score differences, the rest of the time the lesions PASI score, pruritus score differences were statistically significant (P0.01). For 2 weeks, 4 weeks, 8 weeks, two groups were compared, lesions PASI score, pruritus score showed no significant difference (P0.05); the two groups of patients after treatment for 2 weeks, 4 weeks, 8 weeks compared with before treatment, the target of erythema, scaling, infiltration score the differences were statistically significant (P0.01 or P0.05); between the two groups after treatment target of erythema, scaling, infiltration score comparison over the same period, except for 8 weeks when the two target lesions group infiltration score difference was statistically significant (P0.05), the differences were not statistically significant (P0.05). Conclusion: Tiaoganlifei, clinical curative effect of Huoxue Jiedu therapy for plaque psoriasis is effective, can effectively improve the plaque psoriatic erythema, infiltration, scaling and itching, can reduce the local lesions of the PASI score; the combined treatment group cure rate and the total efficiency is higher than that of pure traditional Chinese medicine group, improve skin lesions infiltration is better than pure Chinese medicine group and the overall rating of PASI

【学位授予单位】：中国中医科学院
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R249;R275.9

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