李乾构学术思想与临床经验总结及健脾理气汤治疗上腹疼痛综合征的研究
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摘要
研究目的：全面继承李乾构教授近半个世纪治疗脾胃病珍贵的学术思想和丰富的临床经验,指导临床实践,提高临床疗效。重点学习李乾构教授治疗胃痛的经验。
研究方法和内容：通过文献研究和理论研究,挖掘李乾构教授脾胃学术思想产生的渊源,对其进行客观深入的研究,进而升华生成具有临床指导意义的学术理论；通过跟师临证、授课等方式总结老师的辨证论治经验；并在门诊随机选取上腹疼痛综合征患者120例,采用“健脾理气汤”加减与奥美拉唑对照研究,比较临床疗效,检验跟师成果。
研究结果：
本论文分为三部分：
第一部分：李乾构教授学术渊源概述
李乾构教授认为中医脾胃学说始于《内经》,运用于仲景,发挥于东垣,是各流派和各家学术观点长期交流碰撞的产物。《内经》详细阐述了脾胃的生理功能活动规律,奠定了李乾构教授学术思想的基础；李乾构教授治疗脾胃病喜用甘味,补脾以治其本宗于《伤寒杂病论》。小建中汤、小柴胡汤、半夏泻心汤、枳术丸等都是李乾构教授治疗脾胃病的常用方剂；孙思邈重视胃肠病的治疗,提倡食养、食疗,是李乾构老师“药食同源”学术思想形成的理论基础；钱乙主张五脏分主证以治疗胃肠疾病,启迪了李乾构教授形成抓主症次症治疗胃痛的辨证思路；李乾构教授以脾虚为主要病机,健脾益气法广泛应用于胃肠病的学术思想就深受东垣补土思想的影响；李乾构教授在便秘时,多效法天士多采用甘润养津,滋阴降胃的方法,伺脾升胃降功能恢复,则大便自调。
关幼波先生丰富的学识经验是李老师学术思想的源流。关老重视脾胃病气血辨证之法和痰瘀致病的思想,以及治疗肝病和胃病的经验,都是李乾构教授学术体系中重要的内容。同时李教授注意旁纳近现代诸家之所长,借鉴现代医学发展,成为其学术思想的有益补充。
第二部分：李乾构教授的学术思想与临床经验总结
1.李乾构教授学术思想概述
1.1百病皆由脾胃虚而生脾胃的功能健旺,是保证机体健康的重要因素。①气机的升降以脾胃为中枢。中焦气机通畅,肺气得宣,肝气得疏,心火得下,肾水得上。脾胃气机通畅是人体各项生命活动正常运行的关键；②脾胃消化吸收功能关系着病人体质的强弱、疾病的转归；③诊察脉象中胃气的盛衰可判断病情的进退和预后。顾护胃气是临床用药的要义。④调理“后天之本”,可以更好地发挥口服药物的药效。
1.2消化系统疾病多从脾胃气虚论治李乾构教授认为消化系统疾病的临床表现实际上是脾胃纳运功能失职的结果,而导致脾胃纳运失职的根本原因就是脾胃气虚。①脾虚气滞论治胃病。李老师认为胃病临床上症状虽虚实夹杂,但以脾胃气虚为主者居多。②脾虚肠燥论治便秘。李教授经验多数便秘患者为虚实夹杂证,故健脾通下是关键。③脾虚湿困论治腹泻。泄泻大多是因为脾胃虚弱,脾不运化水湿所致。溃疡性结肠炎,无论发作期还是缓解期,都有脾虚的因素。④土虚木乘论治胆病。“土壅则木郁”,土虚则木乘。另一方面,肝胆产生病变脾土受损首当其冲,故治胆病当先补脾胃。
1.3治脾十五法中医脾的功能包涵西医的消化、血液、循环、运动及免疫等多个系统功能,“脾”是脾胃学说的核心部分。根据脾脏的生理功能和病理特点,李老师形成了特色的“调脾十五法”,是其学术思想的重要内容。
1.4脾胃病多治以甘李乾构教授治疗脾胃病时喜用参、术、芪、草等甘味药。健脾益胃多用甘。其中阳不足者治以甘温,阴不足者治以甘凉。攻邪扶正宜用甘,缓急止痛也用甘味药。
1.5论“润燥互用”脾虚饮食水谷不能被消化吸收利用,湿热内生。同时人体阴津生成是不足的,从而导致患者有口渴症状,所以李乾构教授在健脾化痰的基础上,加用养阴生津清肺之品,既针对湿热伤津,又能预防燥湿化痰诸药温燥伤阴。
1.6论药食同源药物与食物在起源上是共同的,既具有一定的食用价值和营养作用,又具有治疗疾病和保健强身的作用,构成了中医“药食同源”理论的物质基础。气味理论是药食同源的内在规律。应该在中医辨证施治理论的指导下辨证调理。
2李乾构教授临床经验总结
2.1李乾构教授辨证论治胃痛的经验①关于病名,李教授首次提出,“胃痛”区别于“胃脘痛”,是指上腹胃脘部发生疼痛为主症的病证,仅限于胃腑本身的病变；②提出“不通则痛,不荣亦痛”,反对“痛不可以补气”；③总结出胃痛按主症与次症相结合进行辨证论治的模式,使之更易于掌握,方便运用；④脾虚气滞是胃痛的基本病机,所以治疗胃痛常以四君子汤合香砂枳术丸,并根据辨证论治分型加减。同时李教授还强调胃痛要重视生活调养。
2.2慢性萎缩性胃炎李乾构老师认为基本病机是气虚血瘀。治疗时,要紧抓气虚血瘀的病机特点,及早用活血之药,截断扭转该病的病理变化。常在辨证论治的基础上用四君子汤加丹参、莪术化裁,贵在守方,多收良效。
2.3胃食管反流病李乾构教授提倡用“胸痞”作为病名。治疗“胸痞”常肝胃同治,用六君子汤、旋复代赭汤合柴胡疏肝散,随症加减。
2.4溃疡性结肠炎李乾构教授提出,认为脾虚湿热,肠络受损是其主要病机,分急性活动期与慢性缓解期两型论治。
2.5功能性便秘六腑以通为用,但通不是一味的攻下。常用四君子汤加减,健脾通下治疗便秘。其中要重用元参、生白术。分别按血虚肠燥、肾阴虚、肾阳虚、气虚加减,塞因塞用。对于实证便秘,同时可以合用承气类方。
2.6口腔溃疡要紧紧抓住一个“火”字,分清虚火与实火。实性的口疮乃心脾火盛所致。方用泻心汤合泻黄散加减。虚火多为心肾阴虚。方用知柏地黄汤合增液汤加减。同时配合局部用药,缓解疼痛效果更好。
2.7李乾构教授精于辨证的经验李乾构老师精于辨证论治,反对见一症加一药,头痛医头。强调去伪存真避免误辨：如舌诊、脉诊的影响因素在今天表现的更加复杂多变；患者经常并非单一寒、热证出现,不可见寒辨寒,见热言热；腹胀虽气滞于胃肠,但人体气机与脾、肝、肺三脏密切相关,行气消胀仅属于治标,调理人身气机升降出入才是治本之策；胃为多气多血之腑,故应重视气血辨证；提倡中医学宏观辨证和微观辨证相结合。
2.8李乾构教授治疗脾胃病的用药经验李乾构教授治疗脾胃病法随证出,方随法立,用药纯而不杂,贵在变通。如何在固护“后天之本”的基础上,应对诸多证型的变化,论文介绍了李教授相关的用药经验。
2.9其他除了消化系统疾病,李乾构教授还擅长舒颈止眩汤治疗颈源性眩晕,六君子汤加减治疗久咳。
第三部分：健脾理气汤治疗胃痛的临床研究
选取李乾构教授治疗胃痛的经验方健脾理气汤加减为治疗组,奥美拉唑为对照组进行研究。两组均为60例,在中医证候疗效和主症改善方面,两组比较差异有统计学意义。治疗组在改善胃痛、餐后不饱胀适和早饱感等症状方面优于对照组。
研究目的：
通过观察运用“健脾理气汤”加减治疗上腹痛综合征型功能性消化不良(EPS-FD)的临床疗效,评价健脾理气法在上腹疼痛综合征中的作用。
研究方法：
1.选取符合纳入标准的120例上腹疼痛综合征患者,随机分为治疗组60例,对照组60例。两组患者在年龄、性别及治疗前中医症状总积分上无明显差异。具有可比性(p<0.05)
2.治疗组患者方用健脾理气汤加减,每日2次,饭后半小时服用,连服4周；对照组服用奥美拉唑10mg,早餐前服用,每日一次,连服4周。
3.分别进行疗效性观察,比较两组治疗前后单项症状积分变化及总体症状疗效、证候总积分及总体证候疗效,以及生活质量改善情况评分。
4.统计学分析方法：采用SPSS 15.0软件包进行统计分析,计量资料用(x±S)表示,两组治疗前后比较采用配对样本t检验,两组间比较采用独立样本t检验；计数资料两组总体疗效评价采用非参数秩和检验。
结果：
1.在单项症状积分改善方面：健脾理气汤组能改善上腹部烧灼感和早饱(p<0.05),对上腹痛和餐后饱胀不适有显著效果(p<0.01)。且健脾理气汤组在缓解上腹痛和餐后饱胀不适症状上,优于奥美拉唑组(p<0.05)；1月后随访,健脾理气汤组对上腹痛和餐后饱胀不适有显著效果(p<0.01),且优于奥美拉唑组(p<0.05)
2.在总体症状评价方面：治疗组60例中,临床治愈17例,显效20例,有效17例,总有效率90%。对照组57例中,临床治愈10例,显效18例,有效12例,总有效率70.1%.治疗组总体疗效优于对照组(p<0.01)
3.在中医证候总体积分评价方面：两组治疗后中医证候积分改善明显(p<0.01)健脾理气汤组优于奥美拉唑组(p<0.05)；随访1月,健脾理气汤组明显优于奥美拉唑组(p<0.01)
4.总体证候疗效评价方面：治疗组60例中,临床控制19例,显效22例,有效15例,无效4例,总有效率93.3%；对照组57例中,临床控制12例,显效19例,有效15例,无效11例,总有效率80.7%。治疗组总体疗效优于对照组(p<0.05)
5.生活质量评价方面：两组治疗后,8个维度生活质量都有改善(p<0.05),中药组生理功能、社会功能、身体疼痛、精神健康方面有明显改善(p<0.01)；且在社会功能、身体疼痛、精神健康方面优于西药组(p<0.05)。
结论：
健脾理气汤在改善功能性消化不良的主要症状上腹部烧灼感、早饱、上腹痛和餐后饱胀不适方面有一定疗效,同时可以明显改善功能性消化不良患者的临床证候和生活质量。因此,健脾理气法是治疗功能性消化不良,尤其是上腹疼痛综合征的良好方法,值得在临床进一步推广应用研究。
Objective
To inherit Professor Li Qiangou's academic thoughts and precious clinical experience of treating the stomach diseases during nearly the past half century, to guide the clinical practices and improve the clinical efficacy, to learn Prof. Li's experience, especially in treating the stomach pain.
Methods:
To discover the sources of Prof. Li's academic thoughts through the documentation research and theoretical research, and have objective and deep research on them, then develop them into academic theory with the characteristics of guiding the clinic practices. To summarize the experience of diagnosis and treatment by following the teacher and giving lectures. We randomly selected 120 outpatients with functional dyspepsia of abdominal pain syndromes and divided them into the treatment group, guided by "spleen qi deficiency" theory, and the control group treated by omeprazole. The therapeutic effects and results were compared between the two groups.
Research Results
The paper consists of three parts: Part I:Prof. Li's academic origin
Prof. Li Qiangou takes that the Spleen and Stomach theory comes from the Yellow Emperor's Inner Classic, and was applied in clinic by Zhang Zhongjing and amplified by Li Dongyuan. It is a conclusion of long-term argument of every schools and practitioners. The Inner Classic has described the principle of spleen and stomach physiological function in detail, which paved the way of Prof.Li's academic thoughts. Prof. Li Qiangou tends to use sweet flavor and spleen-nourishing treatment as the fundamental methods to treat the spleen and stomach diseases which come from Treatise on Febrile Diseases. Xiao Jian Zhong decotion, Xiao Chai Hu decotion, Ban Xia Xie Xin decotion and Zhi Zhu pill are the commonly used formulae of Prof. Li in spleen and stomach diseases treatment. Sun Simiao thought highly of treating the spleen and stomach diseases by food nourishment, which is the theoretical foundation of "food as medicine theory" by Prof. Li Qiangou. Qian Yi suggested the five Viscera theory should be applied to treat the gastrointestinal diseases, which inspired Prof. Li Qiangou to invent the main-symptoms-priority-treatment thought. Prof. Li Qiangou regards the spleen deficiency as the main pathological mechanism and uses spleen nourishment as the universal treatment for gastrointestinal diseases, which is greatly influenced by Li Dongyuan's earth-nourishment thought. Prof. Li Qiangou follows Ye Tianshi to cure constipation by nourishing Yin of stomach.
Mr. Guan Youbo's thought is another academic source of Prof.Li. Mr.Guan emphasize on Qi and Blood of gastrointestinal disease and he regarded the phlegm and blood stasis as the disease cause, all of that and the liver disease treatment experience are absorbed by Prof. Li Qiangou in his academic structure. At the same time, Prof. Li keep a close study on modern scholars and ready to follow the modern medicine development, as a useful supplement of his own academic thoughts.
PartⅡ:Prof. Li's academic thought and clinical experience
1 Prof. Li's academic thought
1.1 All diseases resulting from the deficiency of the spleen and stomach
Vigorous function of the spleen is an important factor which ensures the health of the body.①The spleen and stomach is the center of qi ascending and descending. The qi movement in middle jiao is smooth, so lung qi is dispersing, liver qi flows normally, heart qi is descending, and kidney qi is ascending. Smooth qi movement of spleen and stomach is the key to life activities;②Functions of stomach digestion and absorption are related to patient's constitution and the diseases prognosis;③We can judge the development and prognosis of diseases through pulse examination of the stomach. Protecting stomach qi is the essence of using the herbs.④Regulate the spleen, the material basis of the acquired constitution, so that oral herbs get better efficacy.
1.2 Treating digestive system diseases based on qi deficiency of spleen and stomach
Prof. Li thinks the manifestations of digestive system diseases are the results of transportation dysfunction of spleen and stomach caused by the qi deficiency.①Treating the stomach diseases based on spleen qi deficiency. Prof. Li thinks the symptoms of stomach diseases in the clinic are inclusion of asthenia and sthenia, but mainly qi deficiency.②Treating constipation based on spleen qi deficiency. Prof. Li thinks the symptoms of constipation in the clinic are inclusion of asthenia and sthenia, so we should tonify the spleen and promote purgation.③Treating diarrhea based on spleen qi deficiency.Diarrhea is mostly caused by the deficiency of spleen and stomach and the spleen's dysfunction of not transporting the dampness. The spleen deficiency plays an important role both in acute and stable conditions of Ulcerative colitis.④Treating gallbladder diseases based on spleen qi deficiency. The wood is depressed if the soil is obstructed. The liver and gallbladder diseases will cause the spleen injury first, so we should tonify the spleen before treating gallbladder diseases.
1.3 Fifteen methods of treating the spleen
The function of the spleen refers to many systems including the digestion, blood, circulation, movement and immune system, "Spleen" is the core of the spleen and stomach theory. According to the physiological functions and pathological characteristics of the spleen, Prof. Li develops the unique fifteen methods of treating the spleen and the method are important parts of his academic thinking.
1.4 Treating the spleen and stomach diseases with the sweet flavor
Prof. Li prefers to the herbs of ginseng、atractylodes rhizome、astragalus、liquorice with sweet flavor, which can invigorate the spleen and benefit the stomach. He prefers to treat yang deficiency syndrome with sweet and warm flavor herbs, and to treat yin deficiency syndrome with sweet and cool flavor herbs. The sweet flavor herbs can remove the pathogenic factors, support the vital qi and relieve spasm and pain.
1.5 Coordinating the herbs with moisture and dryness nature
The food can not be digested and absorbed due to spleen deficiency, which also leads to the production of endogenous heat. Inadequate body fluid results in symptoms of thirst, so Prof. Li prefers the herbs with the function of tonifying the spleen and dissipating phlegm. He prescribes the herbs with the function of nourishing yin and generating body fluid, which can remove the dampness and heat, protect fluid, and also can prevent yin damage caused by the herbs with drying dampness and dispersing phlegm.
1.6 Homology of herbs and food
The source of herbs and food are the same. They not only have some food value and nutrition, but also can be used to treat diseases, keep health, which constitute the physical base of the Traditional Chinese Medicine theory called "the same source of medicine and food". The flavor theory is the inherent law and we should regulate diseases under the guidance of the dialectical theory.
2 Clinical experience of Professor Li Qiangou
2.1 Prof. Li's experience of diagnosing and treating the stomach pain
①Prof. Li first proposes that "Stomach pain" is different from "Stomachache". The former refers to the occurrence of stomach diseases, limited to the stomach organs.②He proposes that the pain is caused by deficient and excess syndrome, and opposes "no supplement qi if there is pain".③He summarizes the patterns referring to the main symptoms combining with the affiliated symptoms of stomach pain to make it easier to diagnose, treat and grasp.④He thinks that spleen qi stagnation is the basic pathogenesis of stomach pain, we use the Sijunzi decoction and Zhizhu pill to nourish the stomach, add or subtract the herbs based on syndrome differentiation. Meanwhile, Prof. Li also stresses the health preservation and rehabitation.
2.2 Prof. Li's experience of treating atrophic gastritis. Prof. Li thinks qi deficiency and blood stasis are the basic pathogenesis of atrophic gastritis. We should grasp the character and use the herbs of activating blood circulation as soon as possible to reverse the pathological changes of the diseases. He prefers to the Sijunzi decoction, with addition of salvia、zedoary turmeric and always gets good efficacy.
2.3 Prof. Li's experience of treating gastroesophageal reflux diseases. Prof. Li promotes "Xiongpi" as the disease name. He usually treats the liver and stomach together and use the Liujunzi decoction、Xuanfudaizhe decoction combining with Chaihushugan powder, adding or subtracting the herbs according to the syndromes.
2.4 Prof. Li's experience of treating ulcerative colitis. In the ulcerative colitis treatment, Prof. Li regards the wet and heat of spleen deficiency and the impairment of venae of intestinal tract as the main pathological mechanism. Prof. Li divides it into two types, as the acute and the chronic phase, for different treatment.
2.5 Prof. Li's experience of treating functional constipation. The function of six fu-viscera is well when unobstructed, but purgation is not the only way to get unobstruction. We often take the methods of spleen-tonifying and purgation,such as Sijunzi decoction, in which we use the ginseng、raw atractylodes rhizome. We add or subtract herbs according to syndromes, such as blood deficiency and dry intestine, yin deficiency of kidney, yang deficiency of kidney qi deficiency,and treat obstructive symptoms by tonification. For the constipation of excess pattern, we can use the Chengqi decoction together.
2.6 Prof. Li's experience of treating oral ulcers. He thinks we should seize the "fire" and make the excess fire different from the deficient fire. The sufficient ulcer is caused by excessive fire of spleen and heart and we use the Xiexin decoction and Xiehuang powder. The deficient ulcer caused by yin deficiency of kidney and heart and we use the Zhibaidihuang decoction and Zengye decoction, and combining with the local administration to relieve the pain.
2.7 Prof. Li's experience of syndrome differentiation
Prof. Li is skilled in diagnosis and treatment, opposes the methods of adding one herb when seeing one symptom. He stresses the truth to prevent the misdiagnosis:such as the factors affecting tongue diagnosis and pulse diagnosis are complicated; the symptoms of patients are often not a single cold or heat syndrome, so we should not regard it as cold syndrome when seeing the cold symptom, and heat syndrome when seeing the heat symptom. Qi stagnation can cause abdominal distension, but qi movement is closely related to spleen, liver, lung. So activating qi and removing the distension is only the temporary method, the radical method is to regulate qi movement, such as ascending, descending and lifting. The stomach is the organ with excessive qi and blood, so we should stress qi and blood differentiation, and advocate the combination of macroscopic syndrome differentiation and microscopic syndrome differentiation in TCM
2.8 Prof. Li's experience of treating stomach diseases with herbs
Prof. Li takes the methods of treating stomach diseases according to the syndromes, and prescribes the herbs based on the methods. He uses the effective but not complicated herbs, and stresses the changes. How to reply to the syndromes changes based on supporting and protecting the spleen, which is the materiel basis of the acquired constitution. The paper introduces Prof. Li's related experience of using the herbs.
2.9 Besides the digestive system diseases, Prof. Li Qiangou is also good at treating cervical vertigo and chronic coughing.
Part III:the clinical research on treating stomach pain with Jianpiliqi decoction
Select Prof. Li's experienced prescription of Jianpiliqi decoction to treat the stomach pain, and the omeprazole for the control group. There are 60 cases in each group. Compared to the TCM efficacy and improvement of the primary syndromes, there was a significant difference between the two groups. The treatment group was superior to control group in improving the stomach pain, epigastric fullness and distention, early satiety and other symptoms.
Objective
To evaluate the functions of strengthening spleen and regulating qi on treating dyspepsia epigastric pain syndrome of functional dyspepsia (EPS-FD) by observing the clinical effect of using " spleen-strengthening and qi-regulating formula " to treat epigastric pain syndrome of functional dyspepsia (EPS-FD).
Methods
1. A total of 120 patients were selected with epigastric pain syndrome, who were in accordance with the inclusion criteria, were randomly divided into the treatment group of 60 cases, the control group of 60 cases. There were no significant differences between two groups on age, gender and total scores of TCM symptoms before treatment and the two groups were comparable(P<0.05);
2. Patients in the treatment group were given spleen-strengthening and qi-regulating formula,2 times a day after half an hour of meals for 4 consecutive weeks; the control group were treated with omeprazole 10mg, taken before breakfast, once a day for 4 consecutive weeks.
3. The effects were observed respectively, then scores variation of individual symptoms and general symptoms, total scores of syndromes and overall syndrome effects, as well as the life quality scores were compared between the two groups before and after treatment.
4. Statistical analysis methods:SPSS 15 software package for statistical analysis, measurement data with (±S), before and after treatment of the groups were compared using paired sample t test, and the two groups were compared using independent samples t test; count data with both groups of overall efficacy were compared using the nonparametric Wilcoxon rank sum test.
Result
1. The improved aspects in the individual symptom scores:group that given spleen-strengthening and qi-regulating formula can relieve the epigastric burning sensation and early satiety (P<0.05),and can significantly improve the condition of upper abdominal pain and postprandial fullness (P<0.01).The effects of spleen-strengthening and qi-regulating formula group is better than the omeprazole group (P<0.05)in improving this condition; and results were the same after the follow-up for one month.
2. Evaluation on overall symptoms:among the 60 cases in treatment group,17 cases were clinical cured,20 cases were excellent effective and 17 cases were effective with the total effective rate of 90%. Among the57 cases in the control group,10 cases were clinical cured, 18 cases were excellent effective and 12 cases were effective with the total effective rate of 70.1%. The overall efficacy of treatment group was better than the control group (P<0.01).
3. The total scores of TCM symptoms:the total scores of TCM symptoms were both improved greatly after the treatment(P< 0.01)but the effects of spleen-strengthening and qi-regulating formula group is better than the omeprazole group (P<0.05); and also the same results after the follow-up for 1 month (P<0.01).
4. Evaluation on overall syndrome effects:among the 60 cases in treatment group,19 cases were clinical cured,22 cases were excellent effective and 15 cases were effective with 4 cases performing ineffectively; the total effective rate was 93.3%. Among the 57 cases in the control group,12 cases were clinical cured,19 cases were excellent effective,15 cases were effective with11 case performing ineffectively; the total effective rate was 80.7%. The overall efficacy of treatment group was better than the control group (P< 0.01).
5. Assessment on quality of life:two groups after the treatment,8 dimensions of quality of life has improved (P< 0.05). Chinese medicine group has improved significantly in physiological function, social function, physical pain and mental health (P< 0.01), and is better than Western medicine group in the social function, body pain, mental health aspects(P <0.05).
Conclusion
It suggested that spleen-strengthening and qi-regulating formula for some degree could improve the main functional dyspepsia symptoms with upper abdominal burning sensation, upper abdominal pain, early satiety and postprandial fullness and discomfort, and also can significantly improved clinical symptoms and life quality of patients with functional dyspepsia. Therefore, it was a good method of strengthening spleen and regulating qi to treat functional dyspepsia,especially the epigastric pain syndrome, and it was worthy of further promotion in clinical application.
研究方法和内容：通过文献研究和理论研究,挖掘李乾构教授脾胃学术思想产生的渊源,对其进行客观深入的研究,进而升华生成具有临床指导意义的学术理论；通过跟师临证、授课等方式总结老师的辨证论治经验；并在门诊随机选取上腹疼痛综合征患者120例,采用“健脾理气汤”加减与奥美拉唑对照研究,比较临床疗效,检验跟师成果。
研究结果：
本论文分为三部分：
第一部分：李乾构教授学术渊源概述
李乾构教授认为中医脾胃学说始于《内经》,运用于仲景,发挥于东垣,是各流派和各家学术观点长期交流碰撞的产物。《内经》详细阐述了脾胃的生理功能活动规律,奠定了李乾构教授学术思想的基础；李乾构教授治疗脾胃病喜用甘味,补脾以治其本宗于《伤寒杂病论》。小建中汤、小柴胡汤、半夏泻心汤、枳术丸等都是李乾构教授治疗脾胃病的常用方剂；孙思邈重视胃肠病的治疗,提倡食养、食疗,是李乾构老师“药食同源”学术思想形成的理论基础；钱乙主张五脏分主证以治疗胃肠疾病,启迪了李乾构教授形成抓主症次症治疗胃痛的辨证思路；李乾构教授以脾虚为主要病机,健脾益气法广泛应用于胃肠病的学术思想就深受东垣补土思想的影响；李乾构教授在便秘时,多效法天士多采用甘润养津,滋阴降胃的方法,伺脾升胃降功能恢复,则大便自调。
关幼波先生丰富的学识经验是李老师学术思想的源流。关老重视脾胃病气血辨证之法和痰瘀致病的思想,以及治疗肝病和胃病的经验,都是李乾构教授学术体系中重要的内容。同时李教授注意旁纳近现代诸家之所长,借鉴现代医学发展,成为其学术思想的有益补充。
第二部分：李乾构教授的学术思想与临床经验总结
1.李乾构教授学术思想概述
1.1百病皆由脾胃虚而生脾胃的功能健旺,是保证机体健康的重要因素。①气机的升降以脾胃为中枢。中焦气机通畅,肺气得宣,肝气得疏,心火得下,肾水得上。脾胃气机通畅是人体各项生命活动正常运行的关键；②脾胃消化吸收功能关系着病人体质的强弱、疾病的转归；③诊察脉象中胃气的盛衰可判断病情的进退和预后。顾护胃气是临床用药的要义。④调理“后天之本”,可以更好地发挥口服药物的药效。
1.2消化系统疾病多从脾胃气虚论治李乾构教授认为消化系统疾病的临床表现实际上是脾胃纳运功能失职的结果,而导致脾胃纳运失职的根本原因就是脾胃气虚。①脾虚气滞论治胃病。李老师认为胃病临床上症状虽虚实夹杂,但以脾胃气虚为主者居多。②脾虚肠燥论治便秘。李教授经验多数便秘患者为虚实夹杂证,故健脾通下是关键。③脾虚湿困论治腹泻。泄泻大多是因为脾胃虚弱,脾不运化水湿所致。溃疡性结肠炎,无论发作期还是缓解期,都有脾虚的因素。④土虚木乘论治胆病。“土壅则木郁”,土虚则木乘。另一方面,肝胆产生病变脾土受损首当其冲,故治胆病当先补脾胃。
1.3治脾十五法中医脾的功能包涵西医的消化、血液、循环、运动及免疫等多个系统功能,“脾”是脾胃学说的核心部分。根据脾脏的生理功能和病理特点,李老师形成了特色的“调脾十五法”,是其学术思想的重要内容。
1.4脾胃病多治以甘李乾构教授治疗脾胃病时喜用参、术、芪、草等甘味药。健脾益胃多用甘。其中阳不足者治以甘温,阴不足者治以甘凉。攻邪扶正宜用甘,缓急止痛也用甘味药。
1.5论“润燥互用”脾虚饮食水谷不能被消化吸收利用,湿热内生。同时人体阴津生成是不足的,从而导致患者有口渴症状,所以李乾构教授在健脾化痰的基础上,加用养阴生津清肺之品,既针对湿热伤津,又能预防燥湿化痰诸药温燥伤阴。
1.6论药食同源药物与食物在起源上是共同的,既具有一定的食用价值和营养作用,又具有治疗疾病和保健强身的作用,构成了中医“药食同源”理论的物质基础。气味理论是药食同源的内在规律。应该在中医辨证施治理论的指导下辨证调理。
2李乾构教授临床经验总结
2.1李乾构教授辨证论治胃痛的经验①关于病名,李教授首次提出,“胃痛”区别于“胃脘痛”,是指上腹胃脘部发生疼痛为主症的病证,仅限于胃腑本身的病变；②提出“不通则痛,不荣亦痛”,反对“痛不可以补气”；③总结出胃痛按主症与次症相结合进行辨证论治的模式,使之更易于掌握,方便运用；④脾虚气滞是胃痛的基本病机,所以治疗胃痛常以四君子汤合香砂枳术丸,并根据辨证论治分型加减。同时李教授还强调胃痛要重视生活调养。
2.2慢性萎缩性胃炎李乾构老师认为基本病机是气虚血瘀。治疗时,要紧抓气虚血瘀的病机特点,及早用活血之药,截断扭转该病的病理变化。常在辨证论治的基础上用四君子汤加丹参、莪术化裁,贵在守方,多收良效。
2.3胃食管反流病李乾构教授提倡用“胸痞”作为病名。治疗“胸痞”常肝胃同治,用六君子汤、旋复代赭汤合柴胡疏肝散,随症加减。
2.4溃疡性结肠炎李乾构教授提出,认为脾虚湿热,肠络受损是其主要病机,分急性活动期与慢性缓解期两型论治。
2.5功能性便秘六腑以通为用,但通不是一味的攻下。常用四君子汤加减,健脾通下治疗便秘。其中要重用元参、生白术。分别按血虚肠燥、肾阴虚、肾阳虚、气虚加减,塞因塞用。对于实证便秘,同时可以合用承气类方。
2.6口腔溃疡要紧紧抓住一个“火”字,分清虚火与实火。实性的口疮乃心脾火盛所致。方用泻心汤合泻黄散加减。虚火多为心肾阴虚。方用知柏地黄汤合增液汤加减。同时配合局部用药,缓解疼痛效果更好。
2.7李乾构教授精于辨证的经验李乾构老师精于辨证论治,反对见一症加一药,头痛医头。强调去伪存真避免误辨：如舌诊、脉诊的影响因素在今天表现的更加复杂多变；患者经常并非单一寒、热证出现,不可见寒辨寒,见热言热；腹胀虽气滞于胃肠,但人体气机与脾、肝、肺三脏密切相关,行气消胀仅属于治标,调理人身气机升降出入才是治本之策；胃为多气多血之腑,故应重视气血辨证；提倡中医学宏观辨证和微观辨证相结合。
2.8李乾构教授治疗脾胃病的用药经验李乾构教授治疗脾胃病法随证出,方随法立,用药纯而不杂,贵在变通。如何在固护“后天之本”的基础上,应对诸多证型的变化,论文介绍了李教授相关的用药经验。
2.9其他除了消化系统疾病,李乾构教授还擅长舒颈止眩汤治疗颈源性眩晕,六君子汤加减治疗久咳。
第三部分：健脾理气汤治疗胃痛的临床研究
选取李乾构教授治疗胃痛的经验方健脾理气汤加减为治疗组,奥美拉唑为对照组进行研究。两组均为60例,在中医证候疗效和主症改善方面,两组比较差异有统计学意义。治疗组在改善胃痛、餐后不饱胀适和早饱感等症状方面优于对照组。
研究目的：
通过观察运用“健脾理气汤”加减治疗上腹痛综合征型功能性消化不良(EPS-FD)的临床疗效,评价健脾理气法在上腹疼痛综合征中的作用。
研究方法：
1.选取符合纳入标准的120例上腹疼痛综合征患者,随机分为治疗组60例,对照组60例。两组患者在年龄、性别及治疗前中医症状总积分上无明显差异。具有可比性(p<0.05)
2.治疗组患者方用健脾理气汤加减,每日2次,饭后半小时服用,连服4周；对照组服用奥美拉唑10mg,早餐前服用,每日一次,连服4周。
3.分别进行疗效性观察,比较两组治疗前后单项症状积分变化及总体症状疗效、证候总积分及总体证候疗效,以及生活质量改善情况评分。
4.统计学分析方法：采用SPSS 15.0软件包进行统计分析,计量资料用(x±S)表示,两组治疗前后比较采用配对样本t检验,两组间比较采用独立样本t检验；计数资料两组总体疗效评价采用非参数秩和检验。
结果：
1.在单项症状积分改善方面：健脾理气汤组能改善上腹部烧灼感和早饱(p<0.05),对上腹痛和餐后饱胀不适有显著效果(p<0.01)。且健脾理气汤组在缓解上腹痛和餐后饱胀不适症状上,优于奥美拉唑组(p<0.05)；1月后随访,健脾理气汤组对上腹痛和餐后饱胀不适有显著效果(p<0.01),且优于奥美拉唑组(p<0.05)
2.在总体症状评价方面：治疗组60例中,临床治愈17例,显效20例,有效17例,总有效率90%。对照组57例中,临床治愈10例,显效18例,有效12例,总有效率70.1%.治疗组总体疗效优于对照组(p<0.01)
3.在中医证候总体积分评价方面：两组治疗后中医证候积分改善明显(p<0.01)健脾理气汤组优于奥美拉唑组(p<0.05)；随访1月,健脾理气汤组明显优于奥美拉唑组(p<0.01)
4.总体证候疗效评价方面：治疗组60例中,临床控制19例,显效22例,有效15例,无效4例,总有效率93.3%；对照组57例中,临床控制12例,显效19例,有效15例,无效11例,总有效率80.7%。治疗组总体疗效优于对照组(p<0.05)
5.生活质量评价方面：两组治疗后,8个维度生活质量都有改善(p<0.05),中药组生理功能、社会功能、身体疼痛、精神健康方面有明显改善(p<0.01)；且在社会功能、身体疼痛、精神健康方面优于西药组(p<0.05)。
结论：
健脾理气汤在改善功能性消化不良的主要症状上腹部烧灼感、早饱、上腹痛和餐后饱胀不适方面有一定疗效,同时可以明显改善功能性消化不良患者的临床证候和生活质量。因此,健脾理气法是治疗功能性消化不良,尤其是上腹疼痛综合征的良好方法,值得在临床进一步推广应用研究。
Objective
To inherit Professor Li Qiangou's academic thoughts and precious clinical experience of treating the stomach diseases during nearly the past half century, to guide the clinical practices and improve the clinical efficacy, to learn Prof. Li's experience, especially in treating the stomach pain.
Methods:
To discover the sources of Prof. Li's academic thoughts through the documentation research and theoretical research, and have objective and deep research on them, then develop them into academic theory with the characteristics of guiding the clinic practices. To summarize the experience of diagnosis and treatment by following the teacher and giving lectures. We randomly selected 120 outpatients with functional dyspepsia of abdominal pain syndromes and divided them into the treatment group, guided by "spleen qi deficiency" theory, and the control group treated by omeprazole. The therapeutic effects and results were compared between the two groups.
Research Results
The paper consists of three parts: Part I:Prof. Li's academic origin
Prof. Li Qiangou takes that the Spleen and Stomach theory comes from the Yellow Emperor's Inner Classic, and was applied in clinic by Zhang Zhongjing and amplified by Li Dongyuan. It is a conclusion of long-term argument of every schools and practitioners. The Inner Classic has described the principle of spleen and stomach physiological function in detail, which paved the way of Prof.Li's academic thoughts. Prof. Li Qiangou tends to use sweet flavor and spleen-nourishing treatment as the fundamental methods to treat the spleen and stomach diseases which come from Treatise on Febrile Diseases. Xiao Jian Zhong decotion, Xiao Chai Hu decotion, Ban Xia Xie Xin decotion and Zhi Zhu pill are the commonly used formulae of Prof. Li in spleen and stomach diseases treatment. Sun Simiao thought highly of treating the spleen and stomach diseases by food nourishment, which is the theoretical foundation of "food as medicine theory" by Prof. Li Qiangou. Qian Yi suggested the five Viscera theory should be applied to treat the gastrointestinal diseases, which inspired Prof. Li Qiangou to invent the main-symptoms-priority-treatment thought. Prof. Li Qiangou regards the spleen deficiency as the main pathological mechanism and uses spleen nourishment as the universal treatment for gastrointestinal diseases, which is greatly influenced by Li Dongyuan's earth-nourishment thought. Prof. Li Qiangou follows Ye Tianshi to cure constipation by nourishing Yin of stomach.
Mr. Guan Youbo's thought is another academic source of Prof.Li. Mr.Guan emphasize on Qi and Blood of gastrointestinal disease and he regarded the phlegm and blood stasis as the disease cause, all of that and the liver disease treatment experience are absorbed by Prof. Li Qiangou in his academic structure. At the same time, Prof. Li keep a close study on modern scholars and ready to follow the modern medicine development, as a useful supplement of his own academic thoughts.
PartⅡ:Prof. Li's academic thought and clinical experience
1 Prof. Li's academic thought
1.1 All diseases resulting from the deficiency of the spleen and stomach
Vigorous function of the spleen is an important factor which ensures the health of the body.①The spleen and stomach is the center of qi ascending and descending. The qi movement in middle jiao is smooth, so lung qi is dispersing, liver qi flows normally, heart qi is descending, and kidney qi is ascending. Smooth qi movement of spleen and stomach is the key to life activities;②Functions of stomach digestion and absorption are related to patient's constitution and the diseases prognosis;③We can judge the development and prognosis of diseases through pulse examination of the stomach. Protecting stomach qi is the essence of using the herbs.④Regulate the spleen, the material basis of the acquired constitution, so that oral herbs get better efficacy.
1.2 Treating digestive system diseases based on qi deficiency of spleen and stomach
Prof. Li thinks the manifestations of digestive system diseases are the results of transportation dysfunction of spleen and stomach caused by the qi deficiency.①Treating the stomach diseases based on spleen qi deficiency. Prof. Li thinks the symptoms of stomach diseases in the clinic are inclusion of asthenia and sthenia, but mainly qi deficiency.②Treating constipation based on spleen qi deficiency. Prof. Li thinks the symptoms of constipation in the clinic are inclusion of asthenia and sthenia, so we should tonify the spleen and promote purgation.③Treating diarrhea based on spleen qi deficiency.Diarrhea is mostly caused by the deficiency of spleen and stomach and the spleen's dysfunction of not transporting the dampness. The spleen deficiency plays an important role both in acute and stable conditions of Ulcerative colitis.④Treating gallbladder diseases based on spleen qi deficiency. The wood is depressed if the soil is obstructed. The liver and gallbladder diseases will cause the spleen injury first, so we should tonify the spleen before treating gallbladder diseases.
1.3 Fifteen methods of treating the spleen
The function of the spleen refers to many systems including the digestion, blood, circulation, movement and immune system, "Spleen" is the core of the spleen and stomach theory. According to the physiological functions and pathological characteristics of the spleen, Prof. Li develops the unique fifteen methods of treating the spleen and the method are important parts of his academic thinking.
1.4 Treating the spleen and stomach diseases with the sweet flavor
Prof. Li prefers to the herbs of ginseng、atractylodes rhizome、astragalus、liquorice with sweet flavor, which can invigorate the spleen and benefit the stomach. He prefers to treat yang deficiency syndrome with sweet and warm flavor herbs, and to treat yin deficiency syndrome with sweet and cool flavor herbs. The sweet flavor herbs can remove the pathogenic factors, support the vital qi and relieve spasm and pain.
1.5 Coordinating the herbs with moisture and dryness nature
The food can not be digested and absorbed due to spleen deficiency, which also leads to the production of endogenous heat. Inadequate body fluid results in symptoms of thirst, so Prof. Li prefers the herbs with the function of tonifying the spleen and dissipating phlegm. He prescribes the herbs with the function of nourishing yin and generating body fluid, which can remove the dampness and heat, protect fluid, and also can prevent yin damage caused by the herbs with drying dampness and dispersing phlegm.
1.6 Homology of herbs and food
The source of herbs and food are the same. They not only have some food value and nutrition, but also can be used to treat diseases, keep health, which constitute the physical base of the Traditional Chinese Medicine theory called "the same source of medicine and food". The flavor theory is the inherent law and we should regulate diseases under the guidance of the dialectical theory.
2 Clinical experience of Professor Li Qiangou
2.1 Prof. Li's experience of diagnosing and treating the stomach pain
①Prof. Li first proposes that "Stomach pain" is different from "Stomachache". The former refers to the occurrence of stomach diseases, limited to the stomach organs.②He proposes that the pain is caused by deficient and excess syndrome, and opposes "no supplement qi if there is pain".③He summarizes the patterns referring to the main symptoms combining with the affiliated symptoms of stomach pain to make it easier to diagnose, treat and grasp.④He thinks that spleen qi stagnation is the basic pathogenesis of stomach pain, we use the Sijunzi decoction and Zhizhu pill to nourish the stomach, add or subtract the herbs based on syndrome differentiation. Meanwhile, Prof. Li also stresses the health preservation and rehabitation.
2.2 Prof. Li's experience of treating atrophic gastritis. Prof. Li thinks qi deficiency and blood stasis are the basic pathogenesis of atrophic gastritis. We should grasp the character and use the herbs of activating blood circulation as soon as possible to reverse the pathological changes of the diseases. He prefers to the Sijunzi decoction, with addition of salvia、zedoary turmeric and always gets good efficacy.
2.3 Prof. Li's experience of treating gastroesophageal reflux diseases. Prof. Li promotes "Xiongpi" as the disease name. He usually treats the liver and stomach together and use the Liujunzi decoction、Xuanfudaizhe decoction combining with Chaihushugan powder, adding or subtracting the herbs according to the syndromes.
2.4 Prof. Li's experience of treating ulcerative colitis. In the ulcerative colitis treatment, Prof. Li regards the wet and heat of spleen deficiency and the impairment of venae of intestinal tract as the main pathological mechanism. Prof. Li divides it into two types, as the acute and the chronic phase, for different treatment.
2.5 Prof. Li's experience of treating functional constipation. The function of six fu-viscera is well when unobstructed, but purgation is not the only way to get unobstruction. We often take the methods of spleen-tonifying and purgation,such as Sijunzi decoction, in which we use the ginseng、raw atractylodes rhizome. We add or subtract herbs according to syndromes, such as blood deficiency and dry intestine, yin deficiency of kidney, yang deficiency of kidney qi deficiency,and treat obstructive symptoms by tonification. For the constipation of excess pattern, we can use the Chengqi decoction together.
2.6 Prof. Li's experience of treating oral ulcers. He thinks we should seize the "fire" and make the excess fire different from the deficient fire. The sufficient ulcer is caused by excessive fire of spleen and heart and we use the Xiexin decoction and Xiehuang powder. The deficient ulcer caused by yin deficiency of kidney and heart and we use the Zhibaidihuang decoction and Zengye decoction, and combining with the local administration to relieve the pain.
2.7 Prof. Li's experience of syndrome differentiation
Prof. Li is skilled in diagnosis and treatment, opposes the methods of adding one herb when seeing one symptom. He stresses the truth to prevent the misdiagnosis:such as the factors affecting tongue diagnosis and pulse diagnosis are complicated; the symptoms of patients are often not a single cold or heat syndrome, so we should not regard it as cold syndrome when seeing the cold symptom, and heat syndrome when seeing the heat symptom. Qi stagnation can cause abdominal distension, but qi movement is closely related to spleen, liver, lung. So activating qi and removing the distension is only the temporary method, the radical method is to regulate qi movement, such as ascending, descending and lifting. The stomach is the organ with excessive qi and blood, so we should stress qi and blood differentiation, and advocate the combination of macroscopic syndrome differentiation and microscopic syndrome differentiation in TCM
2.8 Prof. Li's experience of treating stomach diseases with herbs
Prof. Li takes the methods of treating stomach diseases according to the syndromes, and prescribes the herbs based on the methods. He uses the effective but not complicated herbs, and stresses the changes. How to reply to the syndromes changes based on supporting and protecting the spleen, which is the materiel basis of the acquired constitution. The paper introduces Prof. Li's related experience of using the herbs.
2.9 Besides the digestive system diseases, Prof. Li Qiangou is also good at treating cervical vertigo and chronic coughing.
Part III:the clinical research on treating stomach pain with Jianpiliqi decoction
Select Prof. Li's experienced prescription of Jianpiliqi decoction to treat the stomach pain, and the omeprazole for the control group. There are 60 cases in each group. Compared to the TCM efficacy and improvement of the primary syndromes, there was a significant difference between the two groups. The treatment group was superior to control group in improving the stomach pain, epigastric fullness and distention, early satiety and other symptoms.
Objective
To evaluate the functions of strengthening spleen and regulating qi on treating dyspepsia epigastric pain syndrome of functional dyspepsia (EPS-FD) by observing the clinical effect of using " spleen-strengthening and qi-regulating formula " to treat epigastric pain syndrome of functional dyspepsia (EPS-FD).
Methods
1. A total of 120 patients were selected with epigastric pain syndrome, who were in accordance with the inclusion criteria, were randomly divided into the treatment group of 60 cases, the control group of 60 cases. There were no significant differences between two groups on age, gender and total scores of TCM symptoms before treatment and the two groups were comparable(P<0.05);
2. Patients in the treatment group were given spleen-strengthening and qi-regulating formula,2 times a day after half an hour of meals for 4 consecutive weeks; the control group were treated with omeprazole 10mg, taken before breakfast, once a day for 4 consecutive weeks.
3. The effects were observed respectively, then scores variation of individual symptoms and general symptoms, total scores of syndromes and overall syndrome effects, as well as the life quality scores were compared between the two groups before and after treatment.
4. Statistical analysis methods:SPSS 15 software package for statistical analysis, measurement data with (±S), before and after treatment of the groups were compared using paired sample t test, and the two groups were compared using independent samples t test; count data with both groups of overall efficacy were compared using the nonparametric Wilcoxon rank sum test.
Result
1. The improved aspects in the individual symptom scores:group that given spleen-strengthening and qi-regulating formula can relieve the epigastric burning sensation and early satiety (P<0.05),and can significantly improve the condition of upper abdominal pain and postprandial fullness (P<0.01).The effects of spleen-strengthening and qi-regulating formula group is better than the omeprazole group (P<0.05)in improving this condition; and results were the same after the follow-up for one month.
2. Evaluation on overall symptoms:among the 60 cases in treatment group,17 cases were clinical cured,20 cases were excellent effective and 17 cases were effective with the total effective rate of 90%. Among the57 cases in the control group,10 cases were clinical cured, 18 cases were excellent effective and 12 cases were effective with the total effective rate of 70.1%. The overall efficacy of treatment group was better than the control group (P<0.01).
3. The total scores of TCM symptoms:the total scores of TCM symptoms were both improved greatly after the treatment(P< 0.01)but the effects of spleen-strengthening and qi-regulating formula group is better than the omeprazole group (P<0.05); and also the same results after the follow-up for 1 month (P<0.01).
4. Evaluation on overall syndrome effects:among the 60 cases in treatment group,19 cases were clinical cured,22 cases were excellent effective and 15 cases were effective with 4 cases performing ineffectively; the total effective rate was 93.3%. Among the 57 cases in the control group,12 cases were clinical cured,19 cases were excellent effective,15 cases were effective with11 case performing ineffectively; the total effective rate was 80.7%. The overall efficacy of treatment group was better than the control group (P< 0.01).
5. Assessment on quality of life:two groups after the treatment,8 dimensions of quality of life has improved (P< 0.05). Chinese medicine group has improved significantly in physiological function, social function, physical pain and mental health (P< 0.01), and is better than Western medicine group in the social function, body pain, mental health aspects(P <0.05).
Conclusion
It suggested that spleen-strengthening and qi-regulating formula for some degree could improve the main functional dyspepsia symptoms with upper abdominal burning sensation, upper abdominal pain, early satiety and postprandial fullness and discomfort, and also can significantly improved clinical symptoms and life quality of patients with functional dyspepsia. Therefore, it was a good method of strengthening spleen and regulating qi to treat functional dyspepsia,especially the epigastric pain syndrome, and it was worthy of further promotion in clinical application.
引文
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