王道坤脾胃病学术思想与经验总结及消化性溃疡用药规律的研究

发布时间：2018-09-07 08:20

【摘要】：目的本研究通过对老师“调五脏以安脾胃”的脾胃病学术思想、临证治验进行较全面、系统的整理,对老师治疗消化性溃疡用药规律进行数据挖掘研究,以期总结、传承和升华老师的脾胃病论治学术思想,并为临床辨证论治脾胃病提供一定的经验借鉴。方法本研究以师承学习过程中的体悟、跟师临证记录、老师授课资料、老师公开发表的论文及公开出版的论著及其他继承人发表的对老师临证经验、学术思想总结的论文为主,参考相关流派及各医家的不同观点,从消化性溃疡中西医研究进展、老师学术渊源、老师调五脏安脾胃学术思想及应用、老师独特的遣方用药特色、老师消化性溃疡用药规律等方面作为研究内容进行研究。第一部分消化性溃疡中西医研究进展中,采用文献综述方法,从西医对消化性溃疡病因病机及治疗的研究、中医对消化性溃疡的病因病机、分型论治、中药抗幽门螺旋杆菌作用研究现状及中医药提高溃疡愈合质量的研究现状方面作了较为详尽的梳理和分析；第二部分学术渊源中,将老师所遵从的脾胃学说之渊源以年代久近之时间脉络分三阶段进行了梳理,并结合老师的主要学术思想进行分析,找到了老师学术思想之源流；第三部分老师“调五脏以安脾胃”学术思想、遣方用药特色及脾胃病诊疗经验总结中,采用了文献分析研究方法,结合中医传统经典理论从脾胃纳化五脏相关、“五脏之邪皆通脾胃”之生理病理观、重视饮食、大便、体质的脾胃病辨证观、“调五脏以安脾胃”的治病观、调补脾肾、消补兼施的药物养生观及老师独特的遣方用药特色等方面系统整理和总结老师辨治脾胃病的学术思想和经验；第四部分老师治疗消化性溃疡用药规律研究中,以中医传承辅助系统(Ⅵ.1)软件平台为基础,收集、整理、筛选了老师治疗消化性溃疡120首首诊处方,建立老师临床诊疗消化性溃疡信息采集的结构化病历模板,录入用药信息,形成老师治疗消化性溃疡病历处方数据库,利用软件中数据分析模块中的“方剂分析”、“统计报表”功能,采用关联规则、复杂系统熵聚类等无监督数据挖掘方法,从单味药频次、药对、多味药三个层面及组方规律和新处方进行研究分析。结果通过对老师学术渊源研究,明确了《内经》树立的“脾主运化,胃主受纳”、“人以胃气为本”、“人以水谷为本”的思想以及《伤寒杂病论》确立的辨证论治的思维方法为老师脾胃论学术思想奠定了坚实的理论基础；李杲创立的脾胃学说、钱乙奠定的小儿脾胃学说、王好古提出的阴证论、叶天士创立的胃阴学说、缪仲淳治脾阴虚之“甘凉滋润养阴”法及吴澄的“芳香甘平补中养阴”法等为王老师临床诊治脾胃病提供了深厚的理论依据；薛己侣导的“人以脾胃为本”、张景岳主张的“治脾胃即所以安五脏”、罗天益重视各脏器对脾胃的影响及邓铁涛教授提出的“五脏相关学说”为老师“调五脏以安脾胃”的治病观提供了确凿的借鉴经验；《内经》中病因与病位的有关论述及高锦庭的外科“部位辨证”思想,为老师按湿邪所居上、中、下部位和脏腑辨治湿疮具有简洁而有效的指导作用：《内经》提出“治未病”的理论及李中梓倡导的“脾为后天之本,肾为先天之本”论,是老师将调补脾肾、消补兼施贯穿于养生保健、抗衰防老以治未病为核心的养生观念之渊源。在第三部分对老师辨治脾胃病的研究表明老师基于脾胃纳化五脏相关及“五脏之邪皆通脾胃”之生理病理观,临证时重视“调五脏以安脾胃”的脾胃病治疗观。老师主张临证论治脾胃病必须着眼于肝、肺、心、肾,以平衡脾胃为要,包括调理脾胃,宜先达肝；疏脾益胃,宜先泄肺补肺：温补脾土,宜振心肾。临证时老师又重视脾胃的生理作用和病理影响,认为“调五脏以安脾胃的治病观”不只限于脾胃病,而是可广泛用于其它系统疾病的治疗,如“按部位和脏腑辨治湿疮”时湿在上部,治肺为先,宣气以助脾化湿：湿在中部,治肝脾为主,理气以助脾燥湿；湿在下部,治肾为重,化气以助脾利湿即是该学术思想的具体运用。老师崇尚仲景、东垣,借鉴敦煌医学及敦煌古方,形成了经方时方并重的独特遣方特色,结合自身的临证经验总结,创拟治疗脾胃病的系列经效良方,如治疗消化性溃疡的温中愈溃汤、养阴愈溃汤、疏肝愈溃汤、散寒愈溃汤等等；老师还注重发挥中药专长及相佐配伍以提高疗效,按照组方原理和配伍要求灵活使用升降并调、寒热并举、刚柔相济、补通兼顾、收散并行等相佐配伍组方规律,验之临床,疗效显著。老师自拟方疏肝和胃汤之疏肝理气、和胃降逆法治疗胃食管反流病,化瘀消痞汤之健脾和胃、行气化瘀法治疗慢性萎缩性胃炎,温中愈溃汤之温补脾胃、抑酸清肝法治疗消化性溃疡均为老师调五脏安脾胃治病观及独特遣方用药特色的体现。另外,老师还倡导调补脾肾、消补兼施以治未病为核心的药物养生观,并以此为指导从“敦煌石窟遗书”中化裁而成了敦煌石窒大宝胶囊,用药精当、配伍严谨,突出脾肾双补、消补兼施在延缓衰老中的作用。在第四部分基于关联规则和熵聚类算法的老师治疗消化性溃疡用药规律研究表明,老师治疗消化性溃疡120首处方所用药物频次规律由高到低前11位依次为海螵蛸117、浙贝母110、炙甘草97、黄芪83、白芍82、桂枝70、蒲公英69、茯苓59、黄连52、红景天51、吴茱萸49；老师治疗消化性溃疡常用三大类药物：第一类为温中补虚药物(黄芪、白芍、桂枝、茯苓、红景天、吴茱萸等),出现频率占前11位的58.54%,每味药的常用剂量分别为黄芪15～25g、白芍12～15g、桂枝6～12g、茯苓15～30g、红景天15g、吴茱萸10g；第二类为中和胃酸药物(海螵蛸、浙贝母),出现频率占前11位的27.05%,每味药的常用剂量分别为海螵蛸30～50g、浙贝母12g；第三类为清热祛湿药物(蒲公英、黄连),出现频率占前11位的14.41%,每味药的常用剂量分别为蒲公英10～12g、黄连3～5g;药物四气中温性+热性占所有药物出现频率的54.01%,而寒性+凉性出现频率占30.46%,温热药的使用频次、频率远大于寒凉药；五味情况甘味出现频率占34.18%,苦味出现频率占26.73%,辛味出现频率占21.46%,远多于酸味、咸味、涩味药物；所使用药物的归经频率居于前六位的是脾、胃、肝、肺、心、肾,累积频率达88.90%,其中归脾胃经占42.16%、归肝经占16.87%、归肺经占14.27%、归心经占9.12%、归肾经占6.48%；常用药对配伍主要有三类：寒温配伍(蒲公英-桂枝、蒲公英-海螵蛸、浙贝母-桂枝等)频率占47.08%；甘温配伍(桂枝-海螵蛸、红景天-桂枝、桂枝-吴茱萸等)频率占35.34%；苦寒配伍(浙贝母-蒲公英、蒲公英-红景天、蒲公英-白芍等)频率占17.68%。对以上结果分析显示,药物数据挖掘结果充分体现了老师对本病病因病机、治疗方法、药物选择及配伍等方面的认识。老师认为本病病位在胃,与肝脾密切相关；病机为本虚(脾胃虚弱)标实(湿热、气郁、血瘀等),故而止酸、健脾温中、清热除湿、行气活血为其主要治法；又因具体临床中本病多见寒疡(脾胃虚寒),老师认为治疗寒疡宜温补及补托,故温中补虚药出现频次最高,达58.54%,而且此类药物常用剂量也较大；再结合四性、五味频次统计分析,说明老师温中补虚重在甘辛温补——甘温益气以健脾养胃,并少佐辛散助运之品以防滞脾呆胃；中和胃酸类药物中海螵蛸、浙贝母居于全部三类药频次第一、二位,而且海螵蛸剂量为最大30-50g,药对组合挖掘也显示老师治疗消化性溃疡多用乌贝散(乌贼骨、浙贝母)来制酸止痛,均说明老师认为本病发生与胃酸之过度分泌密切相关及“无酸无溃疡”的观点,治疗时应止酸取效;结合归经分析可见老师治疗本病选药以直达脾胃为先,同时结合宣肺、达肝、温心肾,注重“调五脏以安脾胃”以提高疗效；药对配伍中除甘温配伍较多(达35.34%)外,寒温配伍出现频率也很高(达47.08%),体现了老师认为本病因病程较长、易于复发等,故而多有寒热错杂证,治疗用药时宜寒温并用,但老师临证时更注重甘温配伍,忌过投纯寒之药,以顾护脾胃之气。老师临床治疗本病常用苦寒药频次最高者为蒲公英和黄连,且用量均不大,蒲公英大多为10g,黄连仅为3～5g,且多与温热药配伍使用,如蒲公英伍桂枝、蒲公英伍红景天、蒲公英伍吴茱萸、黄连伍桂枝等,及药物配伍甘温+寒温出现频率为82.42%,远高于苦寒配伍(17.58%)均体现了老师忌寒凉、护脾胃的思想。老师认为脾胃病(包括消化性溃疡)的发生除脾胃虚弱之本虚外,脾胃气机壅滞、升降失常为必有之病变,病久则由于久病入络而又有兼血瘀为患,故行气活血的治疗也必不可少,老师常用枳壳、香附、甘松、三七、川芎、当归等行气活血药与健脾、清热药脾胃取效。结论老师所遵从的脾胃学说渊源深厚,老师辨治脾胃病的主要学术思想传承脉络清晰；老师临证论治脾胃病倡导五脏相关脾胃纳化及升降生理观、“五脏之邪皆通脾胃”病理观、重视饮食口味、大便、体质的脾胃病辨证观、“调五脏以安脾胃”的治病观、调补脾肾消补兼施的药物养生观及崇尚仲景、东垣、借鉴敦煌及药物相佐配伍提高疗效的组方用药特色,形成了老师独特的脾胃病学术体系;老师治疗消化性溃疡选用药物时紧扣本病病位在胃,与肝脾密切相关,及病机为本虚标实,发病与胃酸过度分泌密切相关,而以止酸、健脾温中、清热除湿、行气活血为主要治法,并注重“调五脏以安脾胃”以提高疗效；老师在具体治疗本病时尤重温中补虚,强调温中补虚重在甘辛温补,忌过投纯寒之药,以顾护脾胃之气。
[Abstract]:OBJECTIVE To summarize, inherit and sublimate the teacher's academic thought on spleen and stomach diseases, and to provide evidence for the treatment of spleen and stomach diseases by syndrome differentiation. Methods This study was based on the experience of teachers in the process of learning, the records of teachers'clinical symptoms, the materials of teachers' teaching, the papers published by teachers, the papers published by other heirs, and the papers summarized from the experience of teachers'clinical symptoms and academic thoughts. The research contents include the research progress of traditional Chinese and Western Medicine on sexual ulcer, the academic origin of teachers, the academic thought and application of regulating the five zang-zang organs and calming the spleen and stomach, the special prescription and medication characteristics of teachers, and the medication regularity of peptic ulcer. The etiology, pathogenesis and treatment of ulcer, the etiology and pathogenesis of peptic ulcer, the classification and treatment of peptic ulcer, the research status of anti-Helicobacter pylori effect of traditional Chinese medicine and the research status of improving the quality of ulcer healing of traditional Chinese medicine have been combed and analyzed in detail; the second part of the academic origin, the teacher followed the spleen and stomach theory The origin is sorted out in three stages according to the time course of the past and the main academic thoughts of the teacher are analyzed to find the origin of the teacher's academic thoughts. According to the classical theory of traditional Chinese medicine, it systematically arranges and summarizes the physiology and pathology view of spleen and stomach, the syndrome differentiation view of spleen and stomach disease of diet, stool, constitution, the treatment view of regulating five Zang-organs to calm spleen and stomach, the view of tonifying spleen and kidney, the view of nourishing health with drugs of digesting and tonifying, and the special characteristics of the teacher's prescriptions and medicines. Conclusion The teacher's academic thought and experience in the treatment of peptic ulcer. The fourth part of the teacher's treatment of peptic ulcer law of medication research, based on the Chinese Medicine Inheritance and assistance system (VI.1) software platform, collection, collation, screened the teacher's treatment of peptic ulcer 120 first prescriptions, to establish the teacher's clinical diagnosis and treatment of peptic ulcer information collection structure. Form the prescription database of the teacher's peptic ulcer case history by transforming the template of the medical record and inputting the medication information. Use the function of "prescription analysis" and "statistical report form" in the data analysis module of the software, adopt unsupervised data mining methods such as association rules, complex system entropy clustering and so on, from three levels and groups of single drug frequency, drug pairs and multi-flavor drugs. Results Through the study of teachers'academic origin, it was clear that the thought of "spleen governs transportation, stomach governs acceptance", "human being is based on stomach qi", "human being is based on water valley" and the thought method of syndrome differentiation and treatment established by "theory of typhoid fever and miscellaneous diseases" laid a solid foundation for the teacher's academic thought of spleen and stomach theory. The solid theoretical basis, Li Zhu's spleen-stomach theory, Qian Yi's spleen-stomach theory, Wang Haogu's Yin Syndrome theory, Ye Tianshi's Stomach-yin theory, Miao Zhongchun's "Ganliang Nurturing Yin" method for treating Spleen-Yin deficiency and Wu Cheng's "Aromatic Ganping Buzhong Nurturing Yin" method provide profound theories for the clinical diagnosis and treatment of Spleen-stomach diseases. According to Xue's "people are based on the spleen and stomach", Zhang Jingyue's "treating the spleen and stomach is therefore safe five zang-organs", Luo Tianyi attaches great importance to the influence of various organs on the spleen and stomach and Professor Deng Tietao's "five Zang-organs related theory" provides a solid reference experience for the teacher's "regulating the five Zang-organs to calm the spleen and stomach"; Causes and diseases in the "Internal Classics" The related exposition and Gao Jinting's thought of "part syndrome differentiation" in surgery have succinct and effective guiding function for teachers to treat dampness sores according to damp pathogens, middle and lower parts and viscera: the theory of "treating disease before treatment" put forward by "Neijing" and Li Zhongzi's theory of "spleen is acquired, kidney is congenital" advocated by the teacher will regulate and invigorate the spleen and kidney, and eliminate it. In the third part, the research on the differentiation and treatment of spleen and stomach diseases shows that the teacher attaches importance to the treatment of spleen and stomach diseases based on the physiological and pathological view that spleen and stomach are related to the absorption of the five Zang-organs and the evil of the five Zang-organs is connected with the spleen and stomach. Teachers advocate that the treatment of spleen and stomach disease must focus on the liver, lung, heart, kidney, to balance the spleen and stomach, including regulating the spleen and stomach, should first reach the liver; soothing the spleen and stomach, should first vent the lung and tonify the lung: warming the spleen and invigorating the heart and kidney. Gastric diseases, but can be widely used in the treatment of other system diseases, such as "according to the location and viscera treatment of dampness sores" when damp in the upper, treatment of the lung first, Xuanqi to help the spleen and dampness: dampness in the middle, treatment of the liver and spleen based, regulating Qi to help the spleen dry dampness; dampness in the lower, treatment of the kidney as the most important, and Qi to help the spleen and dampness is the specific application of this academic idea. Zhongjing, Dongyuan, drawing lessons from Dunhuang medicine and ancient Dunhuang prescriptions, formed a unique prescription characteristics of both classical prescriptions and times, combined with their own clinical experience, to create a series of effective and effective treatment of spleen and stomach diseases, such as the treatment of peptic ulcer Wenzhong Yukui decoction, Yangyin Yukui decoction, Shugan Yukui decoction, Sanhan Yukui decoction, etc. According to the principle of prescription and the requirement of compatibility, flexible use of ascending and descending and adjusting, cold and heat, rigidity and softness, complementation and relaxation, and concurrent collection and dispersal of drugs can improve the curative effect. The methods of invigorating spleen and stomach, activating qi and stasis to treat chronic atrophic gastritis, warming up the spleen and stomach, inhibiting acid and clearing the liver to treat peptic ulcer are all manifestations of the teacher's view of regulating the five zang-zang organs, calming the spleen and stomach, and the unique characteristics of prescriptions. As a guide, Dunhuang Shisui Dabao Capsule was made from Dunhuang Grotto Relics. It was used properly, with strict compatibility, highlighting the role of spleen-kidney double-tonic, eliminating and reinforcing both in delaying senility. The first 11 drugs used in 120 prescriptions of peptic ulcer were Octopus 117, Fritillaria thunbergii 110, Radix Glycyrrhizae 97, Radix Astragali 83, Radix Paeoniae Alba 82, Ramulus Cinnamomi 70, Taraxacum 69, Poria Cocos 59, Coptis chinensis 52, Rhodiola 51 and Evodia rutaecarpa 49 in turn. The first three drugs were commonly used in the treatment of peptic ulcer by teachers: warming and tonifying deficiency drugs (Astragalus membranaceus, Radix Paeoniae Paeo Ling, Rhodiola, Evodia rutaecarpa and so on, the frequency of occurrence accounted for 58.54% of the top 11, the common doses of each herb were Astragalus 15-25 g, Paeonia lactiflora 12-15 g, Cinnamomum cinnamomi 6-12 g, Poria cocos 15-30 g, Rhodiola 15 g, Evodia rutaecarpa 10 g, the second kind of neutralizing gastric acid drugs (Octopus japonicus, Fritillaria thunbergii), the frequency of occurrence accounted for 27.05% of the top 11 Octopus cuttlefish 30-50g, Fritillaria thunbergii 12g; the third category is heat-clearing and dampness-removing drugs (dandelion, Coptis chinensis), the frequency of occurrence of the first 11 14.41%, the common doses of each drug are 10-12g, Coptis chinensis 3-5g; the four-gas temperature + heat of drugs accounted for 54.01% of all the frequency of the occurrence of drugs, while cold + cool frequency accounted for 30.46%, thermophilic drugs caused The frequency of sweet taste was 34.18%, bitter taste was 26.73%, spicy taste was 21.46%, much more than sour taste, salty taste and astringent taste; the frequency of meridian attribution was 88.90% in the top six drugs, including spleen, stomach, liver, lung, heart and kidney, and 42.16% in the spleen and stomach meridian. Liver meridian accounted for 16.87%, lung meridian for 14.27%, heart meridian for 9.12%, kidney meridian for 6.48%; compatibility of cold and temperature (dandelion-cinnamon twig, dandelion-cuttlebone, Fritillaria thunbergii-cinnamomi twig, etc.) accounted for 47.08%; compatibility of sweet and warm (cinnamon twig-cuttlebone, rhodiola-cinnamon twig, cinnamon twig-evodia) accounted for 35.34%; compatibility of bitter and cold (Zhejiang Fritillaria twig-cinnamomordica rutaecarpa) accounted for 47.08%. The frequency of Fritillaria-Dandelion, Dandelion-Rhodiola, Dandelion-Paeony and so on was 17.68%. The analysis of the above results showed that the results of drug data mining fully reflected the teacher's understanding of the pathogenesis, treatment methods, drug selection and compatibility of the disease. Weakness (dampness and heat, Qi stagnation, blood stasis, etc.), so the main treatment is to stop acid, invigorate the spleen and warm up, clear away heat and dampness, and promote qi and blood circulation; and because of the specific clinical manifestations of the disease are often cold sores (spleen and stomach deficiency cold), the teacher thinks that the treatment of cold sores should be warm tonic and tonic, so the frequency of tonic drugs in the temperature is the highest, up to 58.54%, and the dosage of such drugs is also large; Combined with the statistical analysis of four properties and five flavors frequency, it shows that the teacher's warmth in tonifying deficiency in Ganxin Wenbu-Ganwenyiqi to invigorate the spleen and nourish the stomach, and less Zuoxin powder to prevent stagnation of the spleen and stomach; in neutralizing gastric acid drugs, cuttlebone, Fritillaria thunbergii occupies the first and second place in the frequency of all three kinds of drugs, and the maximum dose of cuttlebone is 30-50g, the combination of drugs. Digging also showed that the teacher treated peptic ulcer with Wubeisan (squid bone, fritillary Fritillaria thunbergii) to make acid analgesia, indicating that the occurrence of the disease is closely related to the excessive secretion of gastric acid and "no acid no ulcer" point of view, treatment should be acid effect; combined with meridian analysis can be seen that the teacher treatment of the disease to the spleen and stomach first drug selection, at the same time Combination of Xuanfei, liver, warm heart and kidney, pay attention to "regulating the five viscera to calm the spleen and stomach" to improve curative effect; drug pairs compatibility in addition to the more compatibility of sweet and warm (35.34%), cold and warm compatibility frequency is also high (47.08%), reflects that the teacher thinks that the cause of the disease is longer, easy to recur, so there are many cold and heat miscellaneous syndrome, treatment should be cold and warm, but Teachers pay more attention to the compatibility of sweet and warm, avoid the use of pure cold medicine, to protect the spleen and stomach Qi. Teachers clinical treatment of this disease often used the highest frequency of bitter and cold medicine for dandelion and coptis, and dosage is not large, most of the dandelion is 10 g, Coptis is only 3-5 g, and more with warm medicine compatibility, such as dandelion Wuguizhi, dandelion Wu Hongjingtian, dandelion The frequency of occurrence of Evodia rutaecarpa, Coptis chinensis and Cinnamomum cassia, and drug compatibility of Gan Wen and Han Wen was 82.42%, much higher than that of bitter cold compatibility (17.58%). The teacher thought that the occurrence of spleen and stomach disease (including peptic ulcer) was not only the weakness of the spleen and stomach, but also the stagnation of spleen and stomach Qi and the abnormality of ascending and descending were the necessary pathological changes. The treatment of Qi and blood stasis is indispensable for a long time. Teachers often use Fructus Aurantii, Rhizoma Cyperi, Gansong, Panax Notoginseng, Ligusticum Chuanxiong, Angelica sinensis and other Qi and Blood-activating drugs to invigorate the spleen, and Qingre drugs to improve the spleen and stomach. Teachers advocate the five viscera-related spleen and stomach absorption and ascending and descending physiology, the "five viscera evil all pass spleen and stomach" pathological view, pay attention to dietary taste, stool, constitution of spleen and stomach disease syndrome differentiation, "adjust the five viscera to calm the spleen and stomach" treatment view, adjust the spleen and kidney Xiaobu and admire Zhongjing, Dongyuan, draw lessons from Dunhuang and drugs The unique academic system of spleen and stomach diseases has been formed by the combination of prescriptions to improve the curative effect. As the main treatment, and pay attention to "regulating the five Zang-organs to calm the spleen and stomach" to improve the curative effect; the teacher in the specific treatment of this disease, especially in the revision of the deficiency, emphasize warming in the tonic
【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;R259

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