摘要
目的：许彭龄教授在多年的临床实践中,逐渐形成了独特的认证用药理论体系。为了更好地继承发扬其学术思想和临床诊疗经验,从传承角度追源其形成的理论根源,将其用药特点与临床认证特点进行系统地总结归纳,通过规范化的临床疗效观察,发掘其用药规律,进行临床安全性的评价,使其成为系列化的可重复的应用原则,以利于今后临床推广。研究以总结名老中医学术思想、辨证思维、临证经验以及用药规律和学术传承方法为目标,以名老中医学术思想研究、治法研究为主线,分析、挖掘许彭龄教授治疗慢性胃炎的用药规律,探索名老中医经验整理传承的方法。
方法：
1、从传承的角度探讨许彭龄学术思想渊源
①归纳总结许公岩治病重在理脾的学术思想,以及其擅用合化、推化诊疗疾病的特点。②将《内经》、《伤寒论》、《金匮要略》中有关治病求和,以和治之的理论加以浓缩提炼,并提取其中有关运化、化生、合化等理论的核心内容,以及药物性味在临床应用的配伍意义,尤其从中提炼出许老对有关理论的独特理解与创意。③挖掘整理许老有关学术思想论述及弟子归纳总结之经验。
2、总结许彭龄学术思想及独特的诊疗经验
全面总结提炼许老治脾胃安五脏以及法尊和化的学术思想。挖掘整理许老的临床诊疗经验：包括应用和化法治疗慢性胃炎临床疗效观察及经验总结；许老针对慢性腹泻、眩晕、口腔溃疡等疾病的独特的诊疗经验；许老对舌脉的体会应用；许老遣方用药特点的归纳等。力求全面反映许老的学术思想及独特的诊疗经验
3、研究挖掘许彭龄治疗慢性胃炎用药规律
以许老治疗慢性胃炎212例,436诊次建立Access2000数据库,运用频数分析统计单味药应用频次,运用Weka3.4数据挖掘软件对许老治疗慢性胃炎常用药物配伍进行关联规则分析。采用点式互信息分析取得药物二元频度关系,即其治疗慢性胃炎常用药对,从中取得许老治疗慢性胃炎常用对药及配伍特点。
结果：
1、许彭龄学术思想之渊源
许老家学渊源,许父公岩擅以理脾法则治疗疾病,主张应遵循“简、便、廉、效”的治疗原则,以处方小,选药精,药量大,疗效佳而著称。许公岩擅用五味合化阴阳,提出应用推化法治疗积湿酿痰所致诸证,以使病人水谷精微代谢转为正常。
许老熟读经典,尤喜精研内难、伤寒,临证辨治疾病无不遵循《黄帝内经》以和为利、以和为顺的治疗思想。许老认为张仲景所谓的“和”是一个广泛意义上的“和”其治疗疾病均以恢复机体阴平阳密,气血和顺,脏腑经络功能谐调为目的。仲景应用气味相合来达到脏腑虚补实泻、治乱于平的辨治思想源于《内经》,其在诸多疾病的治疗当中贯彻了阴阳相循,升降相因,治乱于平的诊疗思想。
许老强调“和方之制,和其不和者也”,因邪有兼并,要明确寒热之多寡、禀质之虚实、脏腑之燥湿,法在变通,当以“和其不和”为治疗的总目标,临证之时结合具体辨证可配合多种兼治法。其拓展性的继承前贤父辈的医理医法,主张“治病求和,以化治之”,即以运化、推化、生化、合化之功,达到调和脏腑气血阴阳、虚实寒热之用。和合之剂,调之使和。研究证实,许老和化法则体现了中医治则的原则性与灵活性的高度统一,其应用范围广泛,适应证复杂,不失为临床使用广泛,且行之有效的治疗方法。
2、许彭龄学术思想及独特的诊疗经验
许老的学术思想主要体现在两个方面：一是强调脾统四脏,治脾胃可安五脏。许老重视维护脾胃升降功能,通过提升脾气、和降胃气来畅达气机,如此内可和顺脏腑气机,外而顺应自然之气。许老常以调理脾胃,强壮后天之法,治疗由于脾胃失调导致五脏功能异常的疾病。二是许老遵从治病必求于本的治疗原则,强调应用和化法调理脏腑功能,以自和为基础,以调和为法度,协调人体气血阴阳、表里寒热、脏腑虚实、饮食情志等,使人体机能恢复阴阳动态平衡状态。和化法利用药物相合以补偏救弊,调整气机,平衡阴阳,以求平和。
许老辨治脾胃病精于验舌,主张新病者观苔为主,久病者以观舌形为要,辨寒热重在观其舌色。通过观舌来判断病性之虚实,病位之深浅,寒热属性以及疾病的预后与转归,为脾胃病的辩治,提供了有力的临床依据。许老擅以和化法治疗慢性胃炎、慢性腹泻、口腔溃疡等疾病,经临床观察证实确有疗效,能很好的改善患者的临床症状,具有较好的后续疗效,且无不良反应。在辨证的基础上结合脾胃的功能特点,应用和化法治疗疾病,不失为较佳的选择方案。
许老用药倡导简、便、验、廉,组方严谨、药少而力专,和化相成,配伍灵动。其对甘草、吴茱萸、胡黄连及姜等药物应用皆有独到见解。甘草与它药配伍即可酸甘化阴,亦可辛甘化阳,既可清热又可补虚,还可防苦寒之品伤及脾胃。许老擅于用姜,凡正气不足所致病变而需温中益气者,必主以干姜,强调更须加以重量之甘草为伍,否则阳末复而燥扰加,且辛甘方能合化而为阳。许老强调应用胡黄连辨舌最为重要,还要考虑患者的体质因素,无论气滞、痰浊、湿阻、淤结,凡有实滞于内者皆可应用。
3、许彭龄治疗慢性胃炎用药规律研究
212例患者,处方436首,应用中药93种,记3661次,在所使用的93种中药中,使用频率大于30%的12味药中有半夏、干姜、黄芪、吴茱萸、甘草、诃子、肉苁蓉、厚朴、白芍等,常用的药对为吴茱萸配半夏、干姜配诃子、吴茱萸配干姜、吴茱萸配黄连、甘草配干姜、诃子等。温中燥湿、五味合化、辛开苦降、寒热并用、补泻兼施的配伍是其最为常见的药物组合,在半夏泻心汤、黄芪建中汤、左金丸方义基础上提炼之和化汤是其治疗慢性胃炎的基本方药。
结论：
许彭龄教授认为治脾胃可安五脏,主张治病求和,擅以和化法辨治疾病。通过和化之法,“补其不足”,“泻其有余”,“调其虚实”,“和其升降”,以合化、运化、推化、生化之法,达到调和脏腑气血阴阳、虚实寒热之用,使失调之脏腑功能得以复健,逆乱之气机恢复正常,通过和解调整矛盾的双方,使之趋于平衡。从而全面调整脏腑功能,使人体气血阴阳之虚得补,郁滞之气得行、痰瘀污浊得下,协调气血阴阳,扶正祛邪,如此外感内伤之病理因素均得以消除,可谓寓补泻温清升降于和化之中。
许老治疗慢性胃炎五味兼施,主以辛温甘温,佐以苦酸,酸甘化阴,辛甘化阳,辛开苦降,寒热并用,补消合剂,药物配伍相互协调。和化汤是许老积多年临证之心得,在半夏泻心汤、左金丸、黄芪建中汤基础上加减化裁而成,可作为治疗脾胃病的基本方药。许老治疗脾胃病采用和化法燮理阴阳、补虚泻实、调畅气机的治疗思想,为中医治疗慢性胃炎的研究提供了方法学参考。结合脾胃的功能特点在辨证的基础上采用和化之法不失为较佳治疗方案。
Objective:Chief Physician Xu Pengling had gradually generated a unique theoretical system about medication and syndrome differentiation. In order to apply and carry on the medication features of his harmonizing and transformation method for treating the spleen-stomach diseases and trace the theory root of the medication features, we systematically summarized his medication and clinical features of syndrome differentiation, observed the effects of medication compatibility for corresponding syndromes, explored his medication rules through normalized systematic clinical observation, and evaluated the clinic security. At the same time we approached the history of mediation and syndrome differentiation from the viewpoint of heritage, summarized Professor Xu's clinical treatment characteristics and made them repeatable application principle to benefit the clinical use in the future. This study was to summarize the academic thinking, syndrome differentiation, clinical experience, medication rules and the inheriting method of the famous veteran TCM doctors, doing the research on the academic thinking of the famous veteran TCM doctors and treatment method as the main line, analyzing and digging Professor Xu Pengling's medication rules for treatment of chronic gastritis to explore the inheriting methods of experiences of famous veteran TCM doctors.
Methods:
1. Discuss the academic origin of the harmonizing and transformation theory of Professor Xu Pengling from the view of in heritage.
①Summarize the Professor Xu's academic thinking that we should pay attention to regulate the spleen and use harmonizing and transformation method when treating diseases.②We concentrated and refined the theory about the harmonizing and transformation theory from Inner Canon of Yellow Emperor, Treatise on Febrile Diseases, and Variorum on Synopsis of Golden Cabinet, abstracted the core content, and especially refined Professor Xu's unique understanding and originality creativity on the related theory, which included the related statements about property and flavor in Inner Canon of Yel low Emperor and its guiding significance for clinic, about the harmonizing and transformation theory in Treatise on Febrile Diseases and Variorum on Synopsis of Golden Cabinet, the significance of the compatibility of medication property and flavor in the clinical application.③We summarized the features and experience of the academic thinking of Xu Gongyan from his students to authenticate the harmonizing and transformation theory of Professor Xu from syndrome and diseases in clinic.
2. Summarize the Professor Xu's academic thinking and unique treatment experience
We summarized the Professor Xu's academic thinking that treating spleen-stomach could regulate the five-zang organs and the importance of harmonizing and transformation method. We also collected and dig the clinical experience, including the clinical observation and summarization on chronic gastritis by using harmonizing and transformation method, the unique experience on treating chronic diarrhea, vertigo and oral ulcer, application of tongue inspection and summarization of characteristics of medication, all of which aimed to represent the Professor Xu's academic thinking and unique experience systematically.
3. Researching and digging Professor Xu Pengling's medication rules for treatment of chronic gastritis
We collected 212 typical medical cases and 436 Clinic visits from Professor Xu treating chronic gastritis, established Access 2000 databases, and used frequency analysis of statistical frequency of single herb applications, by Weka3.4, data analyzing software to analyze the compatibility of medication rules. Mutual information analysis was used to get two-dimension frequency relationship, which was to obtain the establishment of inter-related factors such as drug targets and baseline data correspondence between physical and chemical indicators that the calculation of the binary-related drugs frequency relationship, and then calculate the mutual information simplifies the herbs used for chronic gastritis and compatibility features.
Results:
1. The sources of Xu Pengling's academic thinking
Prof. Xu inherited a lot from his father, Xu Gongyan, who was good at regulating the spleen-stomach, and addressed the treatment principle of "easy, convenient, cheap and effective" with a few herbs, big dose and good effect. Xu Gongyan also was good at using harmonizing and transformation method by the five flavors and believed that harmonizing and transformation method could cure the symptoms caused by dampness and phlegm through normalizing the metabolism of water, grain and essence.
Prof. Xu did a lot of research on the classics, especially Inner Canon of Yellow Emperor and Treatise on Febrile Diseases, the followed the thinking of harmony from Inner Canon of Yellow Emperor. Prof. Xu believed that Zhang Zhongjing, the author of Treatise on Febrile Diseases, mentioned the "harmonizing" with a wide meaning, which aimed to maintain the balance o f qi-blood, yin-yang and organ-meridian. Zhang Zhongjing used the flavor theory to regulate the deficiency and excess, which originated from Inner Canon of Yellow Emperor, in which demonstrated the thinking of balancing and harmonizing.
Professor Xu emphasized "the harmonizing prescription made could harmonize the "unharmony". Because of combined pathogenic factors, if we wanted to identify the amount of cold and heat, excess and deficiency of the body, dryness and dampness of zang-fu organs, the methods should be flexibility, harmonization should be the total therapeutic target, and many kinds of combined treatments were used according to concrete syndrome differentiation in clinic. He expanded and inherited the medicine theories and methods of ancient famous doctors, claimed harmonization was the therapeutic essence and transformation was for treatment, which meant that through transportation and transformation and engendering transformation methods we got the effect for regulating yin and yang、qi and blood、zang-fu organs、cold and heat、deficiency and excess. The harmonizing and transforming fomula could regulate them to keep harmonization. The research showed that the harmonization and transformation method advocated by Professor Xu embodied the high-level unity of principle and flexibility of TCM therapeutic principle, had an extensive application and complicated indications, which indeed was an effective therapeutic method widespread used in clinic.
2. Prof. Xu's academic thinking and unique experience of diagnosis and treatment
Prof. Xu's academic thinking could be demonstrated in two aspects. The first aspect is, Prof. Xu's addressed that spleen governed the rest organs. He paid much attention on ascending the spleen qi and descending stomach qi to maintain the qi dynamics to follow the nature law. Tonifying the post-heaven and regulating the spleen-stomach could treat the five-zang organ diseases. The second aspect is, the principle of seeking the root of the diseases was followed all the time. And he also stressed regulating the functions of organs by using harmonizing and transformation method to maintain the balanced status of yin-yang, qi-blood, interior-exterior and deficiency-excess.
Prof. Xu was good at tongue inspection for treating spleen-stomach diseases, and argued that the tongue fur should be focused on for the shout-term patients, the tongue body for chronic illness and tongue color for identifying the cold or heat. The tongue inspection could give strong clinic evidence for spleen-stomach syndrome differentiation through the concept, location, cold-heat, prognosis and transformation of the diseases. Prof. Xu's harmonizing and transformation method had been proved to be effective for treating chronic gastritis, chronic diarrhea and oral ulcer through clinical observation, which had improved clinical symptoms, with good follow-up effect, and no adverse reactions. Based on the combination of the features of spleen-stomach and syndrome differentiation, the harmonizing and transformation method applications may be better clinical treatment options.
Prof. Xu addressed the prescription of easy, convenient, effective and cheap with a few herbs, guiding by harmonizing and transformation method. And Prof. Xu had a very unique understanding about the features of glycyrrhizae, evodiae, picrorhizae and ginger. Accompanied with other herbs, glycyrrhizae could only transform sour-sweet into yin, but also spicy-sweet into yang; not only clear heat and tonify the deficiency but also prevent spleen-stomach damage caused by too many cold herbs. Prof. Xu was good at using ginger. The entire deficiency requiring warm the middle would get the ginger and involved, for which the spicy-sweet would transform into yang, preventing from dryness. When using picrorhizae, tongue inspection and physical constitution would be so important. No matter qi stagnation, phlegm, dampness or stasis, it should be used.
3. The clinical research on the medication rule about Professor Xu Pengling treating chronic gastritis
For 212 patients,436 prescriptions used,93 kinds of Chinese medicinals applied, totally used for 3661 times. In the 93 kinds of Chinese herbs used, there were 12 kinds of herbs with usage rate of which was more than 30%, for example Rhizoma Pinelliae, dried ginger, fresh radix astragali, Fructus Evodiae, Radix Glycytthizae, Fructus Chebulae, Herba Cistanches, magnoliae cortex and Raidix Paeoniae Alba. The common couplet medicinal were Fructus Evodiae and Rhizoma Pinelliae used in pair, dried ginger with Fructus Chebulae, Fructus Evodiae with Rhizoma Coptidis, Radix Glycytthizae with Fructus Chebulae and dried ginger, et al. The compatibility methods like warming middle-jiao and drying the dampness, acrid and sweet in flavor transforming into yang, acrid medication for dispersion and bitter medication for descending, combination of cold and heat, and combination of tonic and purgative effect, were the most common medical prescriptions. The basic decoctions used by Professor Xu for chronic gastritis were Pinelliae Decoction for Purging Stomach-Fire, Left Metal Pill and Astragalus Decoction for tonifying middle-jiao.
Conclusions:Professor Xu Pengling believed that treating the spleen-stomach could harmonize the five-zang-organ, and the harmonizing and transformation method advocated by Professor Xu Pengling meant the combination of harmonizing method and transformation method. It not only could regulate yin and yang、qi and blood、zang-fu organs、cold and heat、deficiency and excess, also imply transportation and transformation and engendering transformation. The etiology and pathogenesis causing chronic gastritis is related to imbalance of yin-yang and qi-blood. This method could balance yin-yang and harmonize qi and blood, make the spleen and stomach functions recover to make the disease gradually improving. Professor Xu applied acrid and sweet in flavor transforming into yang, acrid medication for dispersion and bitter medication for descending, combination of cold and heat, and combination of tonic and purgative effect for harmonization to treat chronic gastritis.
The Prof.Xu's treatment for chronic gastritis was harmonizing and transformation, which meant harmonizing yin and yang, modifying the organs, adjusting deficiency-excess, regulating the qi dynamics as key method. And its medication should represent the thinking of spicy-warm, spicy-sweet and bitter-cold, the combination of five flavors with reducing-reinforcing, cold-heat, which would open the mind for us to treat the chronic gastritis. The harmonizing and transformation decoction is a combined formula based on modification of Pinelliae Decoction for Purging Stomach-Fire, Left Metal Pill, Astragalus Decoction for tonifying middle-jiao, which could be the basic formula for chronic gastritis. The therapeutic menthod of Professor Xu for chronic gastritis, like harmonizing and transforming yin-yang, treating deficiency by tonification and treating excess by purgation, regulating qi movement and so on, provide the methodology reference about the study on treatment for chronic gastritis with traditional Chinese medicine. Based on the characteristics of spleen-stomach and syndrome-differentiation, harmonizing and transformation could be a better treatment method for chronic gastritis.
引文
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