摘要
导师杨明会教授从事中西医结合临床工作30年,勤求古训,博采众方,临证经验十分丰富,对多种疾病有自己独到的见解。他认为:气虚肾虚血瘀和免疫功能紊乱是老年病的共同病理基础。人至耄耋之年,气血衰少,肾中精气逐渐亏虚,推动和温煦作用减弱,久则脉道阻塞成瘀,虚瘀互为因果,虚可致瘀,瘀又致虚,从而形成虚瘀互见的老年病病因病机。对帕金森病的认识,导师在尊重经典的基础上,突破了“诸风掉眩,皆属于肝”的传统认识,从补肾活血,益精填髓立论,拟“补肾活血饮”治疗帕金森病,应用于临床,取得可喜的疗效。中医治疗帕金森病具有多层次、多靶点的优势,中西医结合治疗方能提高疗效。导师认为:现代人胃病的病机随着饮食结构的变化而有所改变,以“寒热错杂,虚实互见”为主,治疗上提倡“攻补兼施,寒热并用”的辛开苦降之法。对恶性肿瘤的治疗提出“扶正固本,适时攻邪,随证治之”的基本原则。提出糖尿病的病机为“脾肾气虚为本,阴虚燥热血瘀为标”的独特见解。同时,他还提出“辨人识体”“审证求因”是辨证论治之关键的学术思想。
导师对失眠的病因病机,推崇“胃不和则卧不安”之论。认为失眠的病位主要在于心、脑。并从失眠发生的病因病机及睡眠与心、脑的关系深入研究,挖掘“胃不和”与“卧不安”的相关性,他主张从和胃安神论治失眠,因“胃和”则营卫和调,人始安寐;“胃和”则阴阳升降有序,寤寐有常;“胃和”则神有所藏,寤寐自晓。“和胃”安神,神安瞑寐乃知。故倡导以和胃安神法辨治失眠,拟“和胃安神汤”应用于临床。
在临床研究中发现:“和胃安神汤”在改善患者的总睡眠时间、深睡眠时间、总觉醒时间方面优于柏子养心丸。“和胃安神汤”使患者在睡眠改善的同时,日间功能、醒后感觉得到改善。在研究中还发现:失眠患者存在着脑内神经递质的异常变化,两法治疗失眠可通过改善中枢神经递质GABA、Glu、5-HT、EXC、NE、DA、Ach、INH的含量得以实现。但其改善睡眠的疗效只与GABA、EXC、DA改善的程度相关。由此得出初步结论:以和胃安神法治疗失眠安全有效。
My tutor,Professor Yang Minghui,has been engaged in the clinic work of integrated traditional and western medicine for 30 years.Assiduously learning from the ancient adages and widely adopting other's effective therapeutic methods,he gained rich clinical experience and formed original views toward many kinds of diseases.He thinks that qi deficiency with blood stasis and kidney deficiency and immunological functional disorder are the common pathologic basis of senile diseases.In the aged,as qi-blood and kidney essence becomes insufficient,the warming and promoting function declines and blood stasis forms. The "deficiency" and the "stasis" interact as both cause and effect,which forms the cause and mechanism of senile diseases.Based on the classics,breaking through the traditional understanding on Parkinson's disease that "all wind with vertigo and shaking is ascribed to the liver",Prof.Yang grounded the therapeutic argument of tonifying kidney-activating blood and replenishing essence-supplementing marrow,and treated PD with Bushen Huoxue Yin which indicated heartening effects.Having the advantages of multistrata and multitarget in the treatment of PD with TCM,combined treatment of traditional Chinese medicine and western medicine can improve the therapeutic effect.Regarding stomach disease,the tutor pointed out that the pathogenesis of it in modern people changes with diet and characterized by heat-cold complex and deficiency-excess complex.Accordingly,in the treatment,the method of dispersing with pungent-and-downbearing with bitter should be adopted which is characterized by treating with both tonifying and purgation,cooling and warming.Regarding the treatment of tumor,Prof.Yang pointed out the basic principles of "reinforcing the healthy qi-and-strengthening the root,eliminating the pathogenic factors at the right moment,and treating according to the syndrome".Regarding the mechanism of diabetes,Prof.Yang put forward the distinctive opinions that spleen-kidney qi deficiency is the primary aspect,whereas yin deficiency,dryness-heat and blood stasis is the secondary aspect".In addition,He raised the academic thought that the key to syndrome differentiation and treatment is constitution identification and cause seeking from careful examination.
Regarding the cause and mechanism of insomnia,the tutor emphasizes the theory of "stomach disharmony resulting in disturbed sleep".He thinks that the main location of insomnia is heart and brain.By researching the cause and mechanism of insomnia and the relation between sleep and heart-brain,he found out the associativity between" stomach disharmony" and " disturbed sleep".He advocates treating insomnia by harmonizing the stomach to tranquilize and applicates Hewei Anshen Tang in clinical practice,because he thinks only with the harmony stomach,the nutrient and defense harmony and the yin-yang upbearing-downbearing order can remains,the spirit can be stored and then the easy sleep can be available.
It was found in the clinical research that Hewei Anshen Tang was better than Baizi Yangxin Wan in prolonging patients' total and deep sleep time and shortening their total awake time.Besides the patients' sleep,Hewei Anshen Tang improved their daytime action and awake feeling.It was also found that the neurotransmitters changed in the insomnia patient's brain,and the two methods might better sleep by improving the contents of central neurotransmitters such as GABA、Glu、5—HT、EXC、NE、DA、Ach、INH、and so on,but the therapeutic effect is only in relation to the improvement degree of GABA,EXC and DA.To conclude,treating insomnia with Hewei Anshen Tang is safe and effective.
引文
[1]卫生部.中药新药临床研究指导原则[M].北京:人民卫生出版社,1993:186-187
[2]王晓青,戈之铮.胃食管反流病与睡眠障碍[J].国际消化病杂志,2008,28(2):127-129
[3]郭春荣,许维春,唐卫东,等.抑郁症患者脑电超慢涨落检测分析[J].临床精神医学杂志,2006,16(4):226-227
[4]沈雅琴.半夏的抗腹泻和抗炎作用[J].中药药理与临床,1998,14(2):29
[5]沈雅琴.半夏的镇痛、抗溃疡和抗血栓形成作用[J].中国生化药物杂志,1998,19(3):141
[6]张启荣,李莉,陈德森,等.厚朴、枳实、大黄、陈皮对兔离体胃底平滑肌运动的影响[J].中国中医药科技,2008,15(4):279-280
[7]张敏,高晓红,孙晓萌,等.茯苓的药理作用及研究进展[J].北华大学学报(自然科学版),2008,9(1):63-68
[8]陶崇斌,吴家丹.薏苡仁药理作用及鉴别的研究概括[J].中医药学刊,2005,23(5):919-920
[9]吕刚,李婷婷.石菖蒲的研究进展[J].时珍国医国药,2006,17(7):1291-1292
[10]冯淑香,刘耀明,董俊兴.中药益智仁化学成分与药理研究进展[J].现代中药研究与实践,2003,17(5):58-61
[11]李先端,胡世林,杨连菊.半夏类药材氨基酸和无机元素分析[J].中国中药杂志,1990,15(10):37-38
[12]刘守义,尤春来,王义明.半夏抗溃疡的实验研究[J].中药药理与临床,1993,9(3):27-29
[13]卢建中,喻萍,吕毅斌,等.茯苓提取物对铅致记忆损伤及相关抗原表达的影响[J].毒理学杂志,2006,820(4):224-226
[14]何晓阳,蔡一林.薏苡的与应用[J].天然产物研究与开发,1996,8(1):54-57
[15]段启,许冬谨,刘传祥,等.白术的研究进展[J].中草药,2008,39(5):附4-附6
[16]华夏中医药网.网址http://www.zyy123.tom
[17]陈俐,廖卫平.石菖蒲挥发油对癫痫大鼠海马氨基酸含量的影响[J].中国中药杂志2004,29(7):670
[18]唐洪梅,席萍,吴敏,等.石菖蒲对小鼠脑组织氨基酸类神经递质的影响[J].中药新药与临床药理,2004,15(5):310.
[19]曾远明,李长清,胡长林.慢性失眠病人脑内神经递质活动的超慢涨落图表现[J].临床神经电生理学杂志,2005,14(2):85-89
[20]李智欣,杨中平,石宝霞,等.夜交藤中改善睡眠成分的研究[J].食品科学,2007,28(4):327-330
[21]闫立地,郭冷秋,刘颖,等.夜交藤对自由活动大鼠睡眠时相的影响[J].辽宁中医杂志,2008,35(3):466-467
[22]钟恒亮,王荔萍,陈力.益智仁口服液镇静催眠作用实验研究[J].贵阳医学院学报,2002,27(2):132-133
[23]SharpleyAl,etal:Psychopharmacology(Berl).1998,139(3):286-287
[24]Saper CB,Scammell TE,Lu J.Hypothalamic regulation of sleep and circadian rhythms[J].Nature,2005,437(27):1257-1263
[25]ChastretteN,Cespuglio R,JouvetM.Proopiomelanocortin(POMC)derived pep tides and sleep in the rat.Partl.Hypogenic porperties,of ACTH derivatives[J].Neuropeptides,1990,15(2):61-74
[26]臧照辉,雷志勇,陈虹,等.睡眠-觉醒的神经调节机制[J].国际药学研究杂志,2008年,35(1):30-33
[1]《中医养生学》上海科学技术出版社,王玉川主编1992年,第1版;
[2]许国振.心脑共主神明论[J].新中医,1991(10):6
[3]张立,黄晖.“心神学”与“脑髓说”统一论[J].中国中医基础医学杂志,1995,1(3):13
[4]董宏利,董少龙,刘泰.中医对失眠病因病机的认识[J].辽宁中医药大学学报,2006,8(5):34-35
[5]焦安秀,厉建萍.中医对失眠的认识[J].河南中医,2008,28(8):15-16
[6]李景.失眠证从脾胃论治[J].中国中医基础医学杂志,2002,8(1):28
[7]马伯艳.温胆汤促H民作用及其治疗失眠症机制的实验研究.黑龙江中医药大学博士学位论文.2005年
[8]戴心发.失眠从肝论治的体会[J].四川中医,2008,26(2):30-31
[9]钱玉良,严冬.浅谈失眠从心肝论治[J].甘肃中医,2006,19(10):3-4
[10]张晓阳,张孟仁.郭赛珊治疗失眠的经验[J].辽宁中医杂志,2005,32(10):993-994
[11]张伯臾.不寐[M].中医内科学.1985年10月第一版,上海:上海科学技术出版社,1988年:113-116
[12]徐彦飞.从营卫失调论治失H民验案探微[J].光明中医,2008,23(7):1030-1031
[13]邱德文,沙风桐,熊兴平.博古通今的经方大家刘渡舟[M].中国名老中医药专家学术经验集,1996年5月第一版.贵阳:贵州科技出版社.1999年9月:58-59
[14]林虹,李翔.施今墨先生治疗失眠经验浅析天津中医[J],2000,17(5):1-2
[15]王翘楚,许红,苏泓.五脏皆有不寐及从肝论治法[J].上海中医药大学学报,2005,19(4):4
[16]许良.王翘楚治不寐学术思想初探[J].中医文献杂志,2002,4(4):42-43
[17]张钊,陈守强.相修平教授治疗顽固性失眠四法[J].河南中医,2005,25(3):27-28
[18]李源清.俞才钧治表邪不寐的经验[J].贵阳中医学院学报,1995,17(2):14
[19]童舜华.陈祖皋治疗胃不和所致失眠经验简介[J].山西中医,2003,19(5):7-8
[1]兰胜任.睡眠与失眠[M].北京:华夏出版社,1999.106-107
[2]失眠专题.承德健康网.2007-5-25
[3]刘连启,刘贤臣,刘兆玺,等.山东省城市老年人睡眠障碍患病率的现况调查[J].中华精神科杂志,2002,35(3):180-183
[4]张钦凤,高艳霞,薛雅卓,等.山东省青壮年睡眠状况的流行病学调查[J].中国临床康复,2004,8(18):3486-3487
[5]袁莉萍,雷晓燕,朱保权,等.兰州地区2-6岁儿童睡眠障碍流行病学调查[J].兰州大学学报,2005,31(3):33-35
[6]江帆,颜崇淮,吴胜虎.上海市1-6岁儿童睡眠状况的流行病学研究[J].中华儿科杂志,2001年,39(5):284-285
[7]程敬文,陈凯,郭铁军,等.广州市2-12岁儿童睡眠障碍流行病学调查[J].中国儿童保健杂志,2006,14(4):388-389
[8]雷晓梅,杨玉凤.西安市学龄儿童睡眠状况的流行病学调查[J].中国学校卫生,2007,28(2):119-120
[9]于守臣,宋彦,张忠山,等.黑龙江省6个城市4种职业人群睡眠障碍的流行学调查[J].中国神经精神疾病杂志,1995,21(4);207-208
[10]张忠山,于守臣,杨卫边.科技职业人群睡眠障碍的流行学调查[J].牡丹江医学院学报,2003,24(3):20-21
[11]于守臣,宋彦,张忠山.等.男性与女性职业人群睡眠障碍流行病学调查的对照研究[J].中国行为医学科学,1994,3(4):192-193
[12]Piccinelli M,Wilkinson G.Gender differences In depression:Critical review[J].Br J Psychiatry,2000,177:486-492.
[13]Lewinsohn PM,Gotlib IH,Lewinsohn M,et al.Gender differences in anxiety disorders and anxiety symptoms in adoiescents[J].J Abnorm Psychol,1998,107:109-117.
[14]Ford DE,Kamerow DB.Epidemiologic study of sleep disturbances and psychiatric disorders[J].An opportunity for prevention? JAMA,1989,262(11):1479-1484.
[15]Lindberg E,Janson C,Gislason T,et al.Sleep disturbances in ayoung adult population:can gender differences be expiained by differences in psychological status?[J].Sleep,1997,20(6):381-387.
[16]Kendler KS,Gardner CO,Prescott CA.A population based twin study of self esteem and gender[J].Psychol Med,1998,28:1403-1409.
[17]Khan AA,Gardner CO,Prescott CA,et al.Gender differences in the symptoms of major depression in opposite sex dizygotic twin pairs[J].Am J Psychiatry,2002,159(8):1427-1429.
[18]Verbrugge LM.Gender and health:an update on hypotheses and evidence[J].JHealth Soc Behav,1985,26:156-182.
[19]Jean Louis(3,MendlowIcz MV,Von GIzyckI H,et al.Assessment of physical activity and sleep by actigraphy:examination of gender differences[J].J WomensHealth,1999,8(8):1113-1117.
[20]Voderholzer U,Al ShajlawI A,Weske G,et al.Are there gender differences In objective and subjective sleep measures? A study of Insomniacs and healthy controls[J].Depress Anxiety,2003,17(3):162-172.
[21]Manber R,Armitage R.Sex,steroids,and sleep:a review[J].Sleep,1999,22(5):540-555.
[22]张斌,荣润国.失眠性别差异的荟萃分析[J].中国心理卫生杂志,2007,21(10):731-736
[23]游国雄,竺士秀,张可经.失眠和睡眠障碍性疾病[M].北京:人民军医出版社.2000
[24]陈眉.睡眠障碍研究进展[J].浙江中西医结合杂志,2003,13(2):67-68
[25]王红梅,董竞梅,赫楠.失眠的研究进展[J].齐齐哈尔医学院学报,2004,25(7):778-781
[26]竺士秀,张可经,游国雄.鼾症120例多导睡眠图分析[J].中华结核和呼吸杂志,1998,21(8):452
[27]杨军,俞梦孙,张春燕,等.睡H民中的心率变异性[J].北京生物医学工 程,1998,171:61-64
[28]Otzenberger H.Temporal relationship between dynamic heart rate variability and EEG activity during sleep in man[J].NeuroscIence Letters,1997,229:173-176
[29]Bonnet MH.Heart rate variability:sleep stage,time of night,and arousal influences[J].EEG and Clinical Neurophysiology,1997,102:390-396
[30]汪向东,王希林,马弘,等.心理卫生评定量表手册(增订版)[M].北京:中国心理卫生杂志社,2000
[31]Buysse DJ,Reynolds Ⅲ,Monk TH,et al.The Pittsburgh Sleep Quality Index:a new instrumentfor Psychiatric Practice and Research[J].Psychiatry Research,1989,28:193-213
[32]Nierenbery AA,Adler LA,Peselow E,et al.Trazoclone for antidepressant associated insomnia[J].Am Psychiatry,1994,151:1069
[33]刘贤臣,唐茂芹,胡蕾,等.匹兹堡睡眠质量指数的信度和效度研究[J].中华精神科杂志,1996,29(2):103-107
[34]共识专家组.失眠定义、诊断及药物治疗专家共识(草案)[J].中华神经科杂志,2006,39(2):141-143
[35]张鹏,鼓建伟.失眠症的研究进展[J].脑与神经疾病杂志,2001,9:128-130
[36]Kupfer DJ,Reynolds CF.Management of Insomnia[J].New Eng J Med,1997,336:341-346
[37]Hajak G,Clarenhach P,Pisher W,et al.Zopicolone improves sleep quality and daytime well-bing in imsomniac patients comparison with triazolam,flunitrazepam and placebollnt[J].J Clin Psychopharmacol,1994,9:251-261
[38]Barbone F,McMahon AD,Davey PG,et al.Association of road-traffic accidents with benzodiazepine use[J].Lancet,1998,352:1331-1336
[39]Hajak G,Bandelow W.Safety and tolerance ofzolpidem in the treatment of disturbed sleep apost-marketing surveillance of 16944 cases[J].J Clin Psych,1998,13:57-167
[40]Elie R,Ruther E,Farri,etal.Sleep latency is shortened during 4 weeks of treatment with zaleplon,anovel nonbenzodiazepine hypnotic[J].J Clin Psych,1999,60:536-544
[41]徐峰.褪黑素对睡眠的调节作用[J].国外医学精神病学分册,1999,24:68-73
[42]Seifritz E,Gillin JC,Rapaport MH,et al.Sleep electroen cephalographic response to muscarinic with major depression and in normal controls[J].Biol Psychiatry,1998,44:21-23
[43]MorinCM.Insomnia psychological assessment and management [J].NewYork:GuilfordPress,1993.
[44]Harvey AG.Pre-slep congnitive activity:a comparison of slep-onset Insomniacs and good sleepers[J].British Journal of Cllnlcal Psychology,2000,39:275-2861.
[45]Hoeh CC,Reynolds m CH,Buysse DJ,et al.Protecting slep quality In late rifle:a pilot study of bed restriction and sleep hygiene[J].Journals of gerontotogy Series B:Psychological Sciences and Social Sciences,2001,56:52-591.
[46]Lichstein KL.Wilson NM.Johnson CT.Psychological treatment of secondary insomnia[J].Psychology&Aging,2000,15:232-2401.
[47]刘志东,宋雪岩.失眠治疗的进展[J].中华临床医学实践杂志,2007,6(2):181-188
[48]Ascher LM,TurnerRM.Acomparison of two methods for the administration of paradoxical intention[J].Behaviour Research&Therapy,1980,18:121-1261.
[49]Morin CM,Hauri PJ,Espie CA et al.Non-pharmacologic treatment of chronic insomnia An American Academy of slep medicine review[J].Sleep,1999,22:1134-1156.
[50]许长春,王黎荔,刘军方等.低能量He-Ne激光脑定向治疗失眠症 [J].前卫医药杂志,2001,18(5):337-338.
[51]吴任钢,乌立新,张春改等.脑波同步化治疗非器质性失眠症临床疗效分析[J].中国心理卫生杂志,2001,15(2):119-120.
[1]Sherin JE,Shiromani P J,McCarley RW,etal.Activation of ventrolateral preoptic neurons during sleep[J].Science.1996,271(5246):216-219
[2]Jouvet M.Indolamines and sleep-inducing factors[J].Exp Brain Res,1984,54(Suppl):S81-94
[3]Portas CM,Bjorvan B,Fagerland S,etal.Online detection ofextracellar levels of serotonin in dorsalraphe nucleus and frontalcortex over the sleep-wake cycle in the freely moving rat[J].Neuroscience,1998,83(4):807-814
[4]EI Mansari M,Sakai K,Jouvet M.Unitary charactetistic of presumptive cholinergic tegmental neurous during the sleep-waking cycle of freely moving rats[J].Exp Brain,Res,1989,76:519
[5]赵忠新.临床睡眠障碍学[M].上海:第二军医大出版社,2003,39-41
[6]张瑾,李春华,钟明奎,等.海马CA1区微量注射去甲肾上腺素对慢波睡眠的影响[J].安徽医科大学学报,2006,41(1):7-9
[7]Oades,R,D and Halliday,G,M.(1987)Ventral tegmental(A10)system,neurobiology,anatomy and connectivity[J].Brain Res,Ren.12,117-165.
[8]刘彬,臧佩林.保神开郁冲剂影响失眠鼠中枢递质的实验研究[J].辽宁中医杂志,2000,27(2):92-94
[9]张文慧,钱朝霞,汪海宏,等.大鼠中脑腹侧被盖区在睡眠-觉醒调节中的作用[J].生理学报,1995,47(2):195-200
[10]皮敏,杜少辉,张宜.针刺治疗失眠及其对γ-氨基丁酸影响的研究[J].江西中医学院学报,2000,12(4):160
[11]王芳,邹丹,李经才,等.褪黑素受体与GABAA受体在褪黑素延长小鼠睡眠时间中的作用[J].中国应用生理学杂志,2003,19(4):402-405
[12]王升旭,李求实.睡眠剥夺对大鼠脑组织氨基酸类神经递质含量的影 响[J].第一军医大学学报.2002,22(10):888-890
[13]桂丽,章功良,张景行,等.兴奋和损毁外侧缰核对大鼠睡眠觉醒周期的影响[J].安徽医科大学学报,2006,41(5):511-512
[14]钟明奎,赵乐章,张瑾,等.海马微量注射乙酰胆碱和阿托品对大鼠睡眠的影响[J].中国中医基础医学杂志,2002,8(1):9-10
[15]刘彤,徐淑梅.睡眠剥夺对大鼠学习能力和海马乙酰胆碱含量的影响[J].临床和实验医学杂志,2007,6(3):12-13
[16]殷光甫,茹立强.乙酰胆碱[A].见:韩济生,关新民,等.医用神经生物学[M].武汉:武汉出版社,1996.51-69.