张炳厚学术思想与临床经验总结及应用虫类药治疗痛证与慢性肾炎蛋白尿的临床研究
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摘要
张炳厚教授学术思想与临床经验总结
张炳厚教授,主任医师、博士生导师,国家中医药继承工作师承老师,酷爱中医事业,刻苦钻研医术,谙熟中医经典,博览古今医籍。从医50年,奠定了扎实的中医基础,积累了丰富的临床经验,即继承岐黄生命科学之精华,又有独立创新之思想,形成了以“脏腑辨证”为核心的辨证论治规律,在治则治法上提出“顺其性即为补”,“补其正即为顺”的观点；方剂的使用从简驭繁,擅用类方,选方新颖；用药方面,君臣佐使配伍有序,轻重缓急主次分明,擅用活血化瘀、涤痰滚痰,尤其是虫蚁之品、毒麻之剂,遣药奇特,疗效显著。
学术渊源：通过检索中医古籍及对导师影响较大的名老中医学术思想的分析,探求张炳厚教授学术思想渊源。
古典医籍
1《黄帝内经》中一些朴素的辨证唯物主义思想对张炳厚教授学术思想的形成有着深远的影响。①整体观—辨病要“审查内外”；②治病必求于本—辨证求因；③用药讲究引经报使；另外,《素问·举痛论篇》对张炳厚教授认识痛证的病因病机、诊断及治疗有较大影响。
2《伤寒杂病论》是第一部对痛证病因病机、理法方药进行系统论述的中医学经典论著,并开创了“虫蚁通络”治疗大法的先河,为张炳厚教授应用虫蚁通络法治疗痛证奠定了理论基础。另外,张炳厚教授治疗头痛时多参考六经辨证,且必用引经药,善用类方等学术思想均来源于《伤寒杂病论》。
3《丹溪心法》：“阳常有余,阴常不足”,力倡滋阴降火,是张炳厚教授重视补肾,尤其是滋补肾阴的理论源泉。治疗水肿要“大补中宫”,及治疗滑精多从湿热论治等均源于丹溪理论。
4景岳学说：张炳厚教授非常推崇景岳学说,认为张景岳对“阴常不足”有所发挥,提出“真阴不足”的论点,并认为“人体虚多实少”。临证时重视补肾法,尤重滋补肾精,用药喜用大剂量熟地、龟版。景岳“不荣则痛”的理论,为张炳厚教授治痛大法“荣则不痛”的中医理论基础。
5《临证指南医案》中关于痛证的论治、通络法及虫蚁药的使用对张炳厚教授治疗痛证有较大影响。
6《医醇媵义》：张炳厚教授在辨证方面参考其关于“五脏咳”的辨证要点,且有所发挥,并扩大了费伯雄“自制滋生青阳汤”的应用范围,用于治疗肝风上扰、肝阳上亢引起的头痛、三叉神经痛等。
名老中医学术思想
1刘渡舟：①围绕主症进行辨证；②善用类方；③附子之运用；④经行腹痛的辨证。
2学习祝谌予重视脾胃升降功能,及治疗脾胃病的经验。通过研究中医升降出入理论,张老师提出了“顺其性即为补,补其正即为顺”的治疗方法。并对“施氏对药”提出独特见解。
3学习宋向元重视活血化瘀,善用血府逐瘀汤,及治疗妇科疾病,首重疏肝理气,但不可破气的学术思想,喜用逍遥散、爽胃饮等方剂,并将爽胃饮的应用范围扩大。
4学习王文鼎使用小青龙汤的经验及从痰论治精神疾患等学术思想。
学术思想及临床经验整理与总结
总结了张炳厚教授学术思想如下：
1以“脏腑辨证”为核心,诊病严格遵循审查内外、辨证求因、四诊合参三大原则。辨证时,重视五大要点：①证候全面确切是辨证的基础,重视问诊；②围绕主症进行辨证；③在疾病发展过程中辨证；④个别症状是辨证的关键；⑤既要辨证又要辨病。
2治疗上倡导“顺其性即为补”,“补其正即为顺”的原则。并将其泛用于治疗八法中,尤其在补法中最为常用。并对不同脏腑以及不同病位,在补剂中使用不同的顺气之品。
3重视补肾,尤重滋补肾阴的治疗大法,主张“善补阴者必阳中求阴；善补阳者必阴中求阳。”提出补肾八法,并创制地龟汤类方治疗肾虚诸病。
4创制类方,以简驭繁,将类方分为基础方和加减方,基础方多为成方或自拟经验方,治疗疾病的共性,加减方则针对不同病因病机、辨证而灵活化裁,治疗疾病的个性,根据基础方不同,分为：基础方治本、基础方治标、基础方引经三类。
5喜用成方,用药广泛。但张老师并不是简单地守方和仿效,而是“思变”,守其法而不泥其方,经辨证和辨病选方后,再根据辨证将所选方义加以引申扩展,变其方而治之。
6善用虫类药治疗痛证,为“治痛名家”。①“不通则痛”,重视用“通法”治疼痛；②擅用虫蚁之品,毒麻之剂,并总结张老师常用虫类药的药量、药对、配伍特点及治疗疾病。
详细总结了张炳厚教授诊疗经验,并附典型医案。
1慢性肾脏病：①病机属本虚标实,虚实夹杂之证,以本虚为主；②治疗以滋补肾阴为要,提出补肾八法；③创制地龟汤类方,配合补肾八法治疗各种肾病。
2胃痛：治疗注重健脾、疏肝、理气、活血,常将胃痛分为脾胃虚弱型,治以开胃进食汤；脾胃虚寒型,治以参芪建中汤；肝脾不调型,治以爽胃饮；肝胃不和型,治以解肝煎,并喜合用金铃子散类方活血止痛治疗胃痛之标。
3三叉神经痛：提出病因病机主要为肝肾阴虚,肝风上扰,或脾胃虚弱,阴火上行,与肝经风火相夹,流窜经络,上攻头面,阻滞头面经络,不通而痛,治疗以滋补肝肾,息风通络化痰为主,主方取滋生青阳汤。并重用虫类药透骨搜风,息风通络止痛,且有引经之意。
4失眠：临证时需先辨虚实,后分脏腑,病位主要在心,与肾、肝、脾关系密切。自拟二仁安寐汤类方治疗失眠,取得良好疗效。
5心律失常：常分四型辨证论治：①气阴两虚,心脉失养,治以炙甘草汤；②气虚血瘀,心脉闭阻,治以老师自拟方冠心六号；③心阳不振,水饮凌心,治以苓桂术甘汤加减；④痰热内扰,心神失养,治以黄连温胆汤加减。
6咳嗽：张炳厚教授认为“五脏六腑皆令人咳”,总结了五脏咳的临床表现及治法；归纳了张老师常用治咳方剂：小青龙汤加减治疗风寒咳嗽、麻杏石甘汤加减治疗热性咳嗽、清燥救肺汤治疗肺燥咳嗽、百合固金汤治疗肺肾阴虚咳嗽。
7内伤发热：认为内伤发热多生于火,火乃气有余。将内伤发热分为：阴虚发热、阳虚发热、气虚发热、饮食郁热、痰饮郁热、水湿郁热、肝气郁热、瘀血郁热、脾气郁热九种类型。并提出以清暑益气汤治疗气虚发热、三石汤加减治疗湿热发热、秦艽鳖甲汤加减治疗阴虚发热。
8痛经：总结妇科病总的病因病机为气血失调、脏腑功能紊乱、冲任二脉损伤,治疗原则为：调气血、和脾胃、疏肝气、补肾精。辨证月经不调多以月经之期、色、量、质为问诊的四大重点。
9慢性胆囊炎：提出慢性胆囊炎以肝胆湿热型最为常见,自制清肝利胆汤主治由肝胆湿热引起的慢性胆囊炎、胆石症、慢性肝炎等。
10皮疹：以五皮五藤饮类方治疗各种皮疹,取其“以皮达皮、以藤通络”之意。
张炳厚教授应用虫类药治疗痛证与慢性肾炎蛋白尿的临床研究
背景：虫类药是药用动物的一部分,具有独特的生物活性,所以备受历代医家推崇。张炳厚教授善治痛证和慢性肾脏病,应用虫类药治疗痛证是其最独特的临床经验之一,值得深入研究。通过数据库挖掘,总结出张炳厚教授重视虫蚁通络的学术思想。慢性肾炎病程迁延,缠绵难愈,治疗困难,根据中医“久病入络、久病必瘀”的理论,将虫类药与张炳厚教授治疗慢性肾炎经验方相结合,进行了临床研究。
第一部分文献综述：回顾了虫类药发展的历史沿革,总结了虫类药物的功效及药理作用,目前被广泛应用于临床各科的常见病、多发病,及诸多疑难杂症、沉疴痼疾。
第二部分张炳厚教授应用虫类药治疗痛证的临床研究
研究目的：运用结构化数据库和数据挖掘方法,整理和总结张炳厚教授学术经验,对其运用虫类药治疗痛证的经验进行系统、全面的研究,及学术思想的凝练和升华。
研究方法：从张炳厚教授治疗痛证的典型医案入手,通过数据库对典型医案中涉及的“药物”和“证候”等中医辨证要素进行频次统计及分析,对张炳厚教授虫类药用药特点和辨证思路进行总结。
研究结果：张炳厚教授典型医案数据库共录入痛证208例,位于前10位的疾病分别为痹证、头痛、胃脘痛、腰痛、面痛、胸痹、痛经、腹痛、胁痛、咽痛,以痹证、头痛最为多见。经拆分处理,共涉及证型有42个,总频数为498次,最常见的证型为瘀血阻络证、风寒湿痹证、肝肾阴虚证、肾阴虚证、气滞血瘀证、肝阳上亢证、肝火上扰证。脏腑辨证多定位在肝,认为诸痛皆属于肝。痛证病因病机以瘀血、风邪(包括内风、外风)、寒邪、湿邪、气虚、气滞、血虚、阴虚为主。数据库中共使用成方和自拟方32首,总频数231次,最常用的方剂依次为：疼痛三两三类方、滋生青阳汤、芍药甘草汤、川芎茶调散类方、血府逐瘀汤、补肾地龟汤(自拟方)等。数据库共使用药物314味,药物总频数3318次,使用频次最高的药物分别为甘草、白芍、黄芪、当归、全蝎、川芎、熟地、蜈蚣、血竭面、穿山甲、生地、地龙等。
痛证数据库中共使用虫类药16味,总频数518次,占所用药物的15%,常用的虫类药有全蝎、蜈蚣、穿山甲、地龙、龟版、水蛭、白花蛇、僵蚕、五灵脂、蝉蜕、鳖甲、蛤蚧、露蜂房、土鳖虫、晚蚕沙、蝼蛄,药味以“咸辛”为主,药性以“平”多见,多归肝经,功效以通络止痛、平肝息风、活血化瘀、补益培本、祛风除湿见长。
张炳厚教授痛证数据库中共收入痹证典型医案51例,其中风寒湿痹38例,分为经脉不通型30例,治以和血祛风,通络止痛,方用痹证三两三类方加减；久痹不已,内舍肝肾型8例,治以补益肝肾,通络止痛,方用独活寄生汤加减。风湿热痹13例,其中直接感受热邪6例,治以清热通络,疏风胜湿,方用白虎加桂枝汤加减；寒痹日久化热7例,治以温通经脉,兼散郁热,方用桂枝芍药知母汤加减。使用频次最高的药物分别为：甘草、当归、生黄芪、水蛭、川芎、血竭面、鸡血藤、白芍、全蝎、穿山甲、桂枝、白花蛇、熟地、蜈蚣、炙麻黄、僵蚕、地龙、龟版,其中虫类药有八味。张炳厚教授治疗痹证除善用虫类药,还重用黄芪,重视使用引经药。
痛证数据库中共录入头痛43例,其中肝阳头痛10例,肝风头痛9例,肝火头痛4例,肾虚头痛3例,气虚头痛5例,瘀血头痛4例,风湿头痛2例,血虚头痛2例,阴虚头痛2例,风热头痛2例。最常用方剂为：滋生青阳汤和茶调散类方。使用频次最高的药物分别为：甘草、全蝎、蜈蚣、白芍、生地、石决明、熟地、钩藤、川芎、生黄芪、天麻、麦冬、菊花、草决明、竹茹、半夏、蔓荆子、当归、僵蚕、白花蛇等。张炳厚教授独创性地以川芎茶调散类方治疗各种外感、内伤头痛,以滋生青阳汤治疗肝阳、肝火、肝风头痛,且治头痛必用虫类药,全蝎、蜈蚣为最常用药对,二者同用,息风止痉,通络止痛效果更佳,痛甚者加白花蛇。
结论：通过对数据库的挖掘,总结出张炳厚教授治疗痛证重视通络法,尤其是虫蚁通络法的学术思想。善用类方,以简驭繁。并认为诸痛皆属于肝,从肝论治痛证的学术特点。同时对张炳厚教授治疗痛证常用方剂及药物进行了归纳分析。
第三部分应用虫类药治疗慢性肾炎蛋白尿的临床研究
研究目的：观察虫类药配合张炳厚教授经验方治疗慢性肾小球肾炎蛋白尿的疗效及安全性。
研究方法：按照随机分组原则,将64例患者分为对照组、治疗组。对照组：予张炳厚教授经验方加味补肾利湿汤辨证治疗。治疗组：在加味补肾利湿汤辨证治疗基础上加龟版15-30g、蝉蜕15-20g、僵蚕6-20g、水蛭3-6g、全蝎3-6g、地龙15-30g、炒山甲6g。两组各治疗8周。观察两组中医证候积分、24小时尿蛋白定量及肝肾功等安全性指标变化。
研究结果：两组治疗后证候积分都较疗前下降,有统计学差异,但疗后两组间比较无统计学意义。两组治疗后24小时尿蛋白定量均较疗前下降,有统计学意义；治疗组疗后尿蛋白定量下降更为明显,与对照组比较差异有统计学意义。治疗过程中,两组患者生命体征平稳,复查血、尿、便常规及肝肾功能稳定,心电图及腹部B超较治疗前无明显动态变化。
结论：张炳厚教授经验方能够明显改善慢性肾炎患者症状,配合虫类药可更为有效的减少蛋白尿,安全性好。
提出新见解：
1通过总结张炳厚教授应用虫蚁通络法治疗痛证学术思想,将虫类药应用于新领域,与张老师治疗慢性肾炎经验有机结合,用于治疗慢性肾炎蛋白尿取得明显疗效。
2分析了通络法与活血法的关系,并提出扩大虫蚁通络的应用范围,将其应用于慢性肾脏病、中风、冠心病、糖尿病等常见疾病。
3虫类药的服用方法：应尽可能制成散剂装胶囊使用。主要原因如下：①虫类药多为动物蛋白,久煎可能会降低其生物活性,影响疗效。②节省药材、避免资源浪费。③虫类药均有腥味,装胶囊使用可减少异味,便于患者服用,减轻患者的恐惧心理。
4提出慢性肾炎蛋白尿的病机,以先天禀赋不足为根本,加之后天脾肾两伤,湿热、瘀血等致病因素共同导致。
5慢性肾炎从肾络论治：本人认为,在慢性肾炎的早期阶段就已存在“肾络受伤”,如能早期干预,在临床症状没有出现之前,就给予相应的治疗,可阻断病情的进展,防止患者进入终末期肾脏病。
6虫类药在慢性肾脏病中的应用：虫类药可以有效降低慢性肾炎患者蛋白尿,也适用于慢性肾脏病。在慢性肾脏病中应用虫类药应注意结合辨病及分期,并关注其安全性。
Summary of academic thoughts and clinical experience of Professor Zhang Binghou.
Professor Zhang Binghou, MD, PhD supervisor, is one of the inheriting teachers of state traditional Chinese medicine inheritance work. Since fancy of traditional Chinese medicine, he assiduously studied the TCM, read and got familiar with all ancient Chinese medical classics and modern medical literatures. After 50 years'work in the clinic, he has laid a solid theoretical foundation of traditional Chinese medicine and accumulated rich clinical experience. Having inherited the essence of the TCM, he has created the new perspective of the TCM. He who has taken the theory of Zang-fu organs as his core syndrome differentiation and treatment system has gradually formed his unique mehthods of syndrome differentiation and treatment. His characteristic viewpoint on the treatment principle is the proposal that "nurturing the vital qi by catering to its property, strengthening the vital qi to ensure its natural property ". He writes out not complex but simple herb prescriptions for patients, excels in using similar functional herb prescriptions and often selects original effective herb prescriptions for them. His application of herbs is of orderly monarch, minister, assistant and guide. He is well in using herbs activating blood circulation and removing sputum, especially Chinese insect drugs and toxic herbs. In treatment he often uses peculiar herbs which would have significant effects.
Academic origin:Retrieve ancient Chinese medicine classics, analyze famous TCM doctors academic thoughts which have had a greater impact on my instructor to explore academic origin of Professor Zhang Binghou.
Classical medical books:
1. Some native material ism ideas of Inner Canon of Yellow Emperor have a profound impact on the academic thought formation of Professor Zhang Binghou.①the whole concept-To differentiate the disease need to review the internal and external.②To seek the root cause before treatment.③To pay attention to envoy drugs, in addition, Basic Question Ju tong Lun chapter has a great impact on his understanding pain syndrome including its etiology, pathogenesis and treatment.
2. Treatise on Exogenous Febrile Diseases Theory is the first TCM classic which transcribes the etiology, pathogenesis, therapy and prescription of pain syndrom, made the history of the Chinese insect drugs therapy and laid a theoretical foundation on Professor Zhang Binghou's treating pain syndrome in Chinese insect drugs. In addition Professor Zhang Binghou treats headache according to the method of six meridians differentiation and uses guiding medicinals. His idea of using similar functional herb prescriptions orginates from the book Cold-induced Febrile Diseases.
3. Danxi's Experiential Therapy:Yang often excessive, yin often inadequate, which initiated nourish Yin and purge fire is the theory source of tonifying kidney of Pro. Zhang, especially nourshing kidney-yin. The ideas that to treat edema is to tonify middle energizer and treat involunta is to treat dampness and heat both orginate from Zhu Danxi's medical theory.
4. Jing Yue theory:Professor Zhang Binghou worships the theory of Zhang Jingyue and thinks that Zhang Jingyue develped the theory of yin often inadequate, put forward an argument that kidney-yin is inadequate and the deficency is more than excess in human body. While treatment Pro. Zhang focuses on the method of tonifying kidney, especially nourishing kidney essence. He likes to use large doses of medication Rehmannia and turtle version. The idea that lackage of nourshing results in pain of Zhang Jingyue is the theoritical foundation of the therapeutic method that the nourshing kills pain.
5. The articles of Guide to Clinical Medical Records on the pain treatment, dredging collaterals and application of Chinese insect drugs have a great impact on his treating pain syndrome.
6. "Yi Chun Teng Yi":Professor Zhang Binghou refers to differential guidelines of the book that five organs all can result in cough, develops the theory and expands the application range of Doctor Fei Boxiong's herb presription Zishengqingyangtang which were used in treating headache and trigeminal neuralgia that induced by liver wind disturbance and hyperactivity of liver-yang.
senior famous TCM doctors'academic thoughts:
1. Liu Duzhou:①To differentiate syndrome around the main symptom.②To use similar functional herb prescriptions in treatment.③Application of aconite.④Syndrome differentiation and treatment on menalgia.
2. Zhu Shenyu:To focus on spleen and stomach and study clinical experiences of treating spleen and stomach diseases. After studying the Qi-movement theory which is on ascending, descending, out and in, Zhang proposed the theory that Following its nature means tonifying and enhancing its nature means tonifying. He has a unique insight into Doctor Shi theory on double herbs.
3. Song xiangyuan:To study the method of blood circulation, the way how to excel in using Xuefuzhuyutang and the treatment of gynecological diseases. Pro. Zhang fouses on dispersing liver qi but not breaking the stagnant qi. He likes using Xiaoyaosan and Shuangweiyin prescriptions which application range was expanded.
4. To Learn how to apply Xiaoqinglongtang from Doctor Wang wending and academic thought of treatment in treating sputum.
A Summary of Academic Thoughts and Clinic Experience
The academic thoughts of Professor Zhang Binghou are summarized as follows.
1. In conformity to zang-fu syndrome differentiation theory, Professor Zhang strictly follows three fundamental principles in diagnosis:inspecting both the internal and the external, tracing the etiology by syndrome differentiation, and synthesizing the four diagnostic methods. He gives special attention to five key points in syndrome differentiation:①attain an explicit and comprehensive understanding of the syndrome, and lay more stress on inquiry;②conduct differentiation based on main syndromes;③differentiate the syndrome with an eye on the process of the disease;④several syndromes play a key role in differentiation;⑤in spite of the stress on syndrome differentiation, disease identification cannot be ignored either.
2. In treatment, Professor Zhang advocates the ideas "nurturing the vital qi by catering to its property", and "strengthening the vital qi to ensure its natural property". These ideas have extensive application in his eight methods of treatment, especially in the reinforcing one. He applies different tonifying medicine to cater to the natural property of vital qi in different zang-fu organ and diseased part.
3. Professor Zhang lays stress on tonifying the kidney and attaches particular importance to nourish the kidney yin. He holds that "to tonify yin, one must tonify the yin resided in yang; and to tonify yang, one must tonify the yang resided in yin". He puts forward eight methods of tonifying kidney and creates analogous prescription Digui Decoction (Digui Tang) to treat disease caused by kidney deficiency.
4. Grasping the key points to simplify the complex, Professor Zhang has created many analogous prescriptions and divided them into basic and modified ones. Basic prescriptions are mostly approved or self-formulated prescriptions aimed to tackle the general aspect of a disease. Modified prescriptions, however, are those aimed to tackle the individual aspect of a disease based on the identification of its specific etiology and pathogenesis. Basic prescriptions fall into three categories:the one for a permanent cure, the one for syndrome alleviation, and the one for ushering the medicine qi into its designated channel.
5. Though Professor Zhang has a good command of approved prescriptions and a large variety of Chinese medicine, he is no stickler. He follows the convention of Chinese medicine but is never bound by the specific composition. In treating a disease, he modifies the approved prescription based on a profound understanding of both the mechanism of the prescription and syndrome and disease differentiation of a specific case.
6. Professor Zhang is adept at using insect medicine to alleviate pain and has earned himself a reputation as "master of pain alleviation".①Based on the idea "channel blockage giving rise to pain", he stresses the importance of dredging channels and collaterals to alleviate pain.②He applies insects, ants and other medicine with toxic and anesthetic property. The paper summarizes the dosage, couplet, compatibility, and the method of application frequently used by Professor Zhang.
The paper summarizes the details of Professor Zhang Binghou's clinic practice, appended with representative case records.
1. Chronic kidney disease:①Pathogenesis of the disease is identified as deficiency in origin and excess in superficiality. The disease shows syndromes of intermingled deficiency and excess with deficiency as the main cause.②Treatment of the disease is focused on nourishing the kidney yin. Eight methods of tonifying the kidney are adopted too.③Analogous prescription Digui Decoction is applied in concert with eight methods of tonifying the kidney to treat various kidney disease.
2. Stomachache:Treatment of the disease is focused on invigorating the spleen, soothing the liver, regulating the qi flow, and invigorating blood circulation. The pattern of stomachache due to weakness of the spleen and stomach is treated by using Kaiwei Jinshi Decoction; the pattern due to deficiency-cold in spleen and stomach is treated by using Shenqi Jianzhong Decoction; the pattern due to liver-spleen disharmony is treated by using Shuangwei Potion; the pattern due to liver-stomach disharmony is treated by using Jiegan Decoction together with Jinlingzi Powder, an analogous prescription, to invigorate blood circulation and alleviate pain.
3. Trigeminal neuralgia:The etiology and pathogenesis of the disease is identified basically as liver-kidney yin deficiency causing upward disturbance of liver-wind. The disease may also be attributed to weakness of the spleen and stomach. The up-rising yin fire complicated by wind-fire in liver channel flows hither and thither along the channels and collaterals, attacks upward, and obstructs channels and collaterals in the head. As channel blockage gives rise to pain, treatment of the disease is focused on nourishing the liver and kidney, calming the endogenous wind, dredging the collateral, and eliminating the phlegm. Zisheng Qingyang Decoction is adopted as the main prescription and insect medicine is applied supplementarily to penetrate the bone to expel wind and dredge the channel to alleviate pain. Apart from that, insect medicine also serves the function of ushering medicine qi to its designated channel.
4. Insomnia:Differentiate firstly whethezair it is deficiency or excess pattern and then identify the Zang-fu syndrome. The disease is mostly located in the heart but is closely related to the kidney, liver and spleen. Self-formulated analogous prescription, Erren Anmei Decoction is applied to treat insomnia and the therapy has been proved quite effective.
5. Arrhythmias:Arrhythmias falls into four patterns:①The pattern due to dual qi-yin deficiency and malnourishment of heart channel is treated by using Zhi Gancao Decoction;②the pattern due to qi deficiency and blood stasis, and heart channel obstruction is treated by using prescription coronary six formulated by Professor Zhang;③the pattern due to devitalization of heart yang and fluid adversion attacking the heart is treated by using modified Linggui Zhugan Decoction;④the pattern due to internal attack of phlegm-heat and malnourishment of the heart spirit is treated by using modified Huanglian Wendan Decoction.
6. Cough:Professor Zhang Bing-hou holds that "five zang and six fu may all give rise to cough". This paper sums up clinical manifestations of cough related to five zang organs and their relevant therapy respectively. Prescriptions frequently used by Professor Zhang are modified Xiao Qinglong Decoction for cough caused by wind-cold, modified Maxing Shigan Decoction for cough caused by heat, Qingzao Jiufei Decoction for cough caused by lung dryness, and Baihe Gujin Decoction for cough caused by lung and kidney yin deficiency.
7. Fever due to internal damage:Heat by internal injury is mainly generated by fire, which is induced by excess of qi. Heat by internal injury falls into nine types, which are heat due to yin deficiency, heat due to yang deficiency, heat due to qi deficiency, stagnated heat due to food retention, stagnated heat due to phlegm and retained fluid, stagnated heat due to water and dampness, stagnated heat due to liver depression, stagnated heat due to static blood, and stagnated heat due to spleen qi. Qingshu Yiqi Decoction is used to treat heat due to qi deficiency, modified Sanshi Decoction is used to treat heat due to dampness, and modified Qinjiao Biejia Decoction is used to treat heat due to yin deficiency.
8. Dysmenorrhea:The etiology and pathogenesis of gynecopathy is identified as disorder of qi and blood, dysfunction of zang-fu organs, and injuries of conception and thoroughfare vessels. The principle of treatment is regulating qi-blood flow, harmonizing the spleen and stomach, soothing the liver qi, and tonifying kidney essence. Syndrome differentiation of dysmenorrhea by means of inquiry is focused mainly on the cycle, color, quantity, and substance of menstruation.
9. Chronic cholecystitis:Dampness heat in liver gallbladder is the pattern most frequently seen clinically. Self-formulated decoction, Qinggan Lidan Decoction is applied to treat chronic cholecystitis, cholelithiasis, and chronic hepatitis caused by dampness heat in liver gallbladder.
10. Skin rash:Analogous prescription, Wupi Wuteng Yin, is applied to treat various skin rash as it is believed that "the skin of plant can benefit the skin of human, while the plant rattan dredges the channel of human"
Study on the experience of Pro. Zhang in using insect drugs
Background:Insect drugs are part of medicinal animals. Because of its unique biological activity, it is extremely admired by ancient physicians. Pro. Zhang is good at treating pain disease and chronic kidney disease. One of his most unique clinical experiences is the treatment of pain disease using insect drugs, which is worth further studying. Through exploring the database, the paper summarizes Pro. Zhang's academic thoughts of focusing on unblocking meridians and collaterals with insect drugs. Chronic kidney disease is featured by prolonged course and difficulty in treatment. This paper makes clinical study on it according to the TCM theory of "intruding into meridians and producing hematoma after long time of disease" and by combining insect drugs and Pro. Zhang's experience in treating chronic nephritis.
PartⅠLiterature Review:It reviews the history of insect drug development and summarizes the effect of insect drug, its pharmacological actions, such as immunoregulation, anticoagulation, inhibition and killing of microorganism, analgesia, etc. as well as various common diseases, frequently-occurring diseases, difficult miscellaneous diseases, severe and lingering illness in which insect drugs are widely used in clinical treatment.
Part II Clinical Study on Treatment of Pain disease Using Insect Drugs by Pro. Zhang.
Purpose:In this study, by using the structured databases to analyze the series data, collect and summarize academic experience of Pro. Zhang, systematically and comprehensively study his own experience in using insect drugs to cure pain disease, and sublimate his academic ideals.
Method:Start ing with typical medical cases of Professor Zhang's treatment for pain disease, applying the database to summarize and analyze the frequency of "drugs" and "symptoms and signs" and other TCM elements, reveal the characteristics and dialectical thinking of Pro. Zhang on insect drugs medication.
Results:The database of Professor Zhang Binghou's typical medical cases totally include 208 cases of pain disease in the top 10 diseases are Bi syndrome, headache, epigastric pain, back pain, face pain, chest pain, dysmenorrhea, abdominal pain, hypochondriac pain, sore throat, among which Bi syndrome and headache are most common. The split process involves a total of 42 syndromes and the total frequency of 498 times. It showed that the most common syndromes is blood stasis, deficiency of liver and kidney-yin, deficiency of kidney-yin, Bi syndrome by the evil of wind cold dampness, qi stagnation and blood stasis, hyperactivity of liver-yang and flaming up of excessive heat of liver. The differentiation of Zang-Fu is mainly located on the liver due to the cause of various pains belonging to the liver. Pathogenesis of pain disease often exists in stasis, evil wind (including the wind inside and outside), pathogenic cold, dampness, qi deficiency, qi stagnation, blood deficiency and yin-deficiency. Database shows the used Chinese patent or self-made prescriptions are 32 recipes and the total frequency of 231 times. The most common prescriptions are pain Sanliang San decoction, the Zisheng Qingyang decoction, peony and licorice decoction, Chuan Xiong Chatiao power decoction, Xuefu Zhuyu decoction, reinforce kidney by turtle decoction (self-made side) and so on. 314 drugs were used in the database, the total frequency of drug is 3318 times, in which most frequently used drugs are licorice, peony root, astragalus, angelica, Scorpio, Chuanxiong, Rehmannia, centipedes, blood surface, pangolins, habitat, earthworm, etc. Pain disease database uses 16 kinds of Chinese use insect drugs and the total frequency of 518 times, accounting for 15% of all drugs. Drugs commonly used include insect scorpion, centipede, pangolins, earthworm, turtle shell, leech, nosed pit viper, stiff silkworm, trogopterus dung, cicada, turtle, gecko, honeycomb, Eupolyphaga, late silkworm excrement and mole crickets. Most taste "salty and pungent". The main herb characteristic is "mild". Many herbs belong to the liver, their effectiveness are prominently displayed at relieving the pain and pass qi through meridian and collaterals, subduing hyperactivity of liver-yang to cease endogenous wind, activating blood circulation, and replenishing deficiency of liver and kidney vital energy, expelling the evil wind & dampness.
51 typical cases of patients who have Bi syndrome have been collected into the database of pain disease of Pro. Zhang. Among them there are 38 cases of damp Bi syndrome, wherein,30 cases are meridians block, which can be treated by nourishing blood to expel wind; dredge collaterals to relieve pain, and pain Sanliang San decoction with modification is used; 8 cases are unceasingly long-term rheumatology and inner liver and spleen, which can be treated by reinforcing liver and kidney and dredging collaterals to relieve pain, and Duhuojisheng decoction with modification is used. 13 cases of rheumatism pyretic arthralgia are also divided in to two types.6 cases of them are directly affected by pathogenic heat and can be treated by clearing heat, dredging collaterals and clearing wind and dampness, and white tiger decoction added with cassia twig is used; 7 cases of them are long-term arthritis changing into rheumatism pyretic arthralgia and are treated by warming the meridians and clearing stagnated heat, and cassia twig and peony zhimu decoction with modification is used. The most frequently used drugs are:licorice, angelica, raw radix astragalis, leech, chuan xiong, dragon's blood, Caulis Spatholobi, peony root, scorpio, pangolins, cassia twig, long-noded pit viper, radix rehmanniae praeparata, centipede, roasted ephedra, stiff silkworm, lumbricus and tortoise plastron, and eight kinds of these drugs are insects. Pro. Zhang is good at using insect drugs to treat Bi syndrome and he also prefers to use astragalus and attaches importance to use guiding drug.
43 cases of patients who have headache are collected into database of pain diseases. Among them, there are 10 cases of liver yang headache, 9 cases of liver wind headache,4 cases of liver fire headache,3 cases of headache due to kidney insufficiency, 5 cases of qi deficiency, 4 cases of blood stasis headache, 2 cases of rheumatism headache,2 cases of headache due to deficiency of blood, 2 cases of headache due to deficiency of Yin and 2 cases of headache due to pathogenic wind-heat. The most commonly used prescriptions are Zisheng Qingyang Decoction and Chatiao powder Decoction. The most frequently used drugs are:licorice, scorpion, centipede, peony root, radix rehmanniae, concha haliotidis, radix rehmanniae preparata, uncaria, Chuanxiong, raw radix astragalis, gastrodia elata, radix ophiopogon japonicus, chrysanthemum, cassia obtusifolia, bamboo shavings, pinellia ternata, fructus viticis, Chinese angelica, stiff silkworm, long-noded pit viper, etc. Pro. Zhang originality uses Chuan Xiong Chatiao decoction in treating various types of headaches including headaches caused by external infection and internal damage.
Conclusion:Through exploring the database, it is concluded that Pro. Zhang attaches importance to the meridians activation method when treating the pain syndrome, especially his academic thought of unblocking meridians and collaterals with insect drugs. He prefers taking the simple prescription for patients instead of the complex, and is skilled in using similar functional prescriptions. He also thought that various pains can be attributed to liver, and talked about the academic features of pain syndrome from liver. At the same time, Pro. Zhang concluded and analyzed the prescriptions and drugs commonly used for curing pain disease.
PartⅢClinical Observation of Applying Insect Drugs to Cure Chronic Nephritic Proteinuria
Purpose:Observe the curative effect and safety of taking insect drugs to match up the prescription of Pro. Zhang in curing chronic glomerulonephritis proteinuria.
Method:Divide the 64 patients to control group and treatment group at random. Control group:dialectical treatment by using the experience prescription of flavored kidney tonifying and dampness decoction of Pro. Zhang. Treatment group: based on the above treatment, add turtle shell 15-30g, periostracum cicada 15-20g, stiff silkworm 6-20g, leech 3-6g, scorpio 3-6g, lumbricus 15-30g and pangolin 6g. Treat the two groups for 8 weeks respectively. Observe the change of safety indexes such as two groups of traditional Chinese symptom score,24h proteinuria and liver and kidney function.
Result:After treatment, the symptom scores of two groups all drop compared with that before treatment, but there is statistics difference. However, there is no statistics meaning for the comparison between two groups after treatment. After treatment, the 24h proteinuria of both two groups all drop compared with that before treatment and there is statistics significance; the drop of proteinuria of treatment group after treatment is more obvious, and there is statistics significance compared with the difference of control group. During treatment, the vital signs of two groups of patients are stable; reexamination shows that the regular functions of blood, urine and defecate and functions of liver and kidney are stable; compared with the conditions before treatment, the electrocardiogram and abdominal ultrasound have no obvious dynamic change.
Conclusion:The experience prescription of Pro. Zhang can obviously improve the symptoms of chronic nephritis patients, and matching up with insect drugs can more effectively lessen the proteinuria. This method is quite good.
Propose new opinions:
1. Through summarizing the academic thoughts of Pro. Zhang applying insect drugs meridians to unblock meridians in treating pain disease, obvious curative effect can be obtained by applying the insect drugs in new fields and dynamically integrating it with the experience of Mr. Zhang in treating chronic nephritis and chronic nephritic proteinuria.
2. Pointed out the difference between the treatment of promoting blood circulation and dredge collaterals, expanded the application of Chinese insect drugs and used them in treating CKD, Stroke, CHD, Type 2 DM and other common disease.
3. Taking method of insect drugs:make it into powder capsules as much as possible. The main reasons are as follows:①Most insect drugs are animal albumen, so long-term boiling may reduce its bioactivity and affect the curative effect.② Save medicinal materials and avoid wasting resources.③All insect drugs have fishy smell, using it by encapsulating can lessen the peculiar smell, offer convenience for patients to take and relieve the fear of patients.
4. Propose the pathogenesis of chronic nephritis proteinuria. This disease is jointly caused by insufficient congenital endowment (the root) and acquired impairment to spleen and kidney, dampness-heat and stasis of blood, etc.
5. reating CGN with Treatment by Regulating Kidney:I think kidney collaterals injury lied in the early stage of CGN. Early intervention with the corresponding treatment before clinical symptoms appearing can block the progress of the disease, prevent the patients from ESRD.
6. Application of Chinese insect drugs in treating CGN:Chinese insect drugs can reduce the proteinuria effectively and be applied in treating CKD. As we used them, we should pay attention to combining the treatment with the disease differentiation at different stages and the drug security.
张炳厚教授,主任医师、博士生导师,国家中医药继承工作师承老师,酷爱中医事业,刻苦钻研医术,谙熟中医经典,博览古今医籍。从医50年,奠定了扎实的中医基础,积累了丰富的临床经验,即继承岐黄生命科学之精华,又有独立创新之思想,形成了以“脏腑辨证”为核心的辨证论治规律,在治则治法上提出“顺其性即为补”,“补其正即为顺”的观点；方剂的使用从简驭繁,擅用类方,选方新颖；用药方面,君臣佐使配伍有序,轻重缓急主次分明,擅用活血化瘀、涤痰滚痰,尤其是虫蚁之品、毒麻之剂,遣药奇特,疗效显著。
学术渊源：通过检索中医古籍及对导师影响较大的名老中医学术思想的分析,探求张炳厚教授学术思想渊源。
古典医籍
1《黄帝内经》中一些朴素的辨证唯物主义思想对张炳厚教授学术思想的形成有着深远的影响。①整体观—辨病要“审查内外”；②治病必求于本—辨证求因；③用药讲究引经报使；另外,《素问·举痛论篇》对张炳厚教授认识痛证的病因病机、诊断及治疗有较大影响。
2《伤寒杂病论》是第一部对痛证病因病机、理法方药进行系统论述的中医学经典论著,并开创了“虫蚁通络”治疗大法的先河,为张炳厚教授应用虫蚁通络法治疗痛证奠定了理论基础。另外,张炳厚教授治疗头痛时多参考六经辨证,且必用引经药,善用类方等学术思想均来源于《伤寒杂病论》。
3《丹溪心法》：“阳常有余,阴常不足”,力倡滋阴降火,是张炳厚教授重视补肾,尤其是滋补肾阴的理论源泉。治疗水肿要“大补中宫”,及治疗滑精多从湿热论治等均源于丹溪理论。
4景岳学说：张炳厚教授非常推崇景岳学说,认为张景岳对“阴常不足”有所发挥,提出“真阴不足”的论点,并认为“人体虚多实少”。临证时重视补肾法,尤重滋补肾精,用药喜用大剂量熟地、龟版。景岳“不荣则痛”的理论,为张炳厚教授治痛大法“荣则不痛”的中医理论基础。
5《临证指南医案》中关于痛证的论治、通络法及虫蚁药的使用对张炳厚教授治疗痛证有较大影响。
6《医醇媵义》：张炳厚教授在辨证方面参考其关于“五脏咳”的辨证要点,且有所发挥,并扩大了费伯雄“自制滋生青阳汤”的应用范围,用于治疗肝风上扰、肝阳上亢引起的头痛、三叉神经痛等。
名老中医学术思想
1刘渡舟：①围绕主症进行辨证；②善用类方；③附子之运用；④经行腹痛的辨证。
2学习祝谌予重视脾胃升降功能,及治疗脾胃病的经验。通过研究中医升降出入理论,张老师提出了“顺其性即为补,补其正即为顺”的治疗方法。并对“施氏对药”提出独特见解。
3学习宋向元重视活血化瘀,善用血府逐瘀汤,及治疗妇科疾病,首重疏肝理气,但不可破气的学术思想,喜用逍遥散、爽胃饮等方剂,并将爽胃饮的应用范围扩大。
4学习王文鼎使用小青龙汤的经验及从痰论治精神疾患等学术思想。
学术思想及临床经验整理与总结
总结了张炳厚教授学术思想如下：
1以“脏腑辨证”为核心,诊病严格遵循审查内外、辨证求因、四诊合参三大原则。辨证时,重视五大要点：①证候全面确切是辨证的基础,重视问诊；②围绕主症进行辨证；③在疾病发展过程中辨证；④个别症状是辨证的关键；⑤既要辨证又要辨病。
2治疗上倡导“顺其性即为补”,“补其正即为顺”的原则。并将其泛用于治疗八法中,尤其在补法中最为常用。并对不同脏腑以及不同病位,在补剂中使用不同的顺气之品。
3重视补肾,尤重滋补肾阴的治疗大法,主张“善补阴者必阳中求阴；善补阳者必阴中求阳。”提出补肾八法,并创制地龟汤类方治疗肾虚诸病。
4创制类方,以简驭繁,将类方分为基础方和加减方,基础方多为成方或自拟经验方,治疗疾病的共性,加减方则针对不同病因病机、辨证而灵活化裁,治疗疾病的个性,根据基础方不同,分为：基础方治本、基础方治标、基础方引经三类。
5喜用成方,用药广泛。但张老师并不是简单地守方和仿效,而是“思变”,守其法而不泥其方,经辨证和辨病选方后,再根据辨证将所选方义加以引申扩展,变其方而治之。
6善用虫类药治疗痛证,为“治痛名家”。①“不通则痛”,重视用“通法”治疼痛；②擅用虫蚁之品,毒麻之剂,并总结张老师常用虫类药的药量、药对、配伍特点及治疗疾病。
详细总结了张炳厚教授诊疗经验,并附典型医案。
1慢性肾脏病：①病机属本虚标实,虚实夹杂之证,以本虚为主；②治疗以滋补肾阴为要,提出补肾八法；③创制地龟汤类方,配合补肾八法治疗各种肾病。
2胃痛：治疗注重健脾、疏肝、理气、活血,常将胃痛分为脾胃虚弱型,治以开胃进食汤；脾胃虚寒型,治以参芪建中汤；肝脾不调型,治以爽胃饮；肝胃不和型,治以解肝煎,并喜合用金铃子散类方活血止痛治疗胃痛之标。
3三叉神经痛：提出病因病机主要为肝肾阴虚,肝风上扰,或脾胃虚弱,阴火上行,与肝经风火相夹,流窜经络,上攻头面,阻滞头面经络,不通而痛,治疗以滋补肝肾,息风通络化痰为主,主方取滋生青阳汤。并重用虫类药透骨搜风,息风通络止痛,且有引经之意。
4失眠：临证时需先辨虚实,后分脏腑,病位主要在心,与肾、肝、脾关系密切。自拟二仁安寐汤类方治疗失眠,取得良好疗效。
5心律失常：常分四型辨证论治：①气阴两虚,心脉失养,治以炙甘草汤；②气虚血瘀,心脉闭阻,治以老师自拟方冠心六号；③心阳不振,水饮凌心,治以苓桂术甘汤加减；④痰热内扰,心神失养,治以黄连温胆汤加减。
6咳嗽：张炳厚教授认为“五脏六腑皆令人咳”,总结了五脏咳的临床表现及治法；归纳了张老师常用治咳方剂：小青龙汤加减治疗风寒咳嗽、麻杏石甘汤加减治疗热性咳嗽、清燥救肺汤治疗肺燥咳嗽、百合固金汤治疗肺肾阴虚咳嗽。
7内伤发热：认为内伤发热多生于火,火乃气有余。将内伤发热分为：阴虚发热、阳虚发热、气虚发热、饮食郁热、痰饮郁热、水湿郁热、肝气郁热、瘀血郁热、脾气郁热九种类型。并提出以清暑益气汤治疗气虚发热、三石汤加减治疗湿热发热、秦艽鳖甲汤加减治疗阴虚发热。
8痛经：总结妇科病总的病因病机为气血失调、脏腑功能紊乱、冲任二脉损伤,治疗原则为：调气血、和脾胃、疏肝气、补肾精。辨证月经不调多以月经之期、色、量、质为问诊的四大重点。
9慢性胆囊炎：提出慢性胆囊炎以肝胆湿热型最为常见,自制清肝利胆汤主治由肝胆湿热引起的慢性胆囊炎、胆石症、慢性肝炎等。
10皮疹：以五皮五藤饮类方治疗各种皮疹,取其“以皮达皮、以藤通络”之意。
张炳厚教授应用虫类药治疗痛证与慢性肾炎蛋白尿的临床研究
背景：虫类药是药用动物的一部分,具有独特的生物活性,所以备受历代医家推崇。张炳厚教授善治痛证和慢性肾脏病,应用虫类药治疗痛证是其最独特的临床经验之一,值得深入研究。通过数据库挖掘,总结出张炳厚教授重视虫蚁通络的学术思想。慢性肾炎病程迁延,缠绵难愈,治疗困难,根据中医“久病入络、久病必瘀”的理论,将虫类药与张炳厚教授治疗慢性肾炎经验方相结合,进行了临床研究。
第一部分文献综述：回顾了虫类药发展的历史沿革,总结了虫类药物的功效及药理作用,目前被广泛应用于临床各科的常见病、多发病,及诸多疑难杂症、沉疴痼疾。
第二部分张炳厚教授应用虫类药治疗痛证的临床研究
研究目的：运用结构化数据库和数据挖掘方法,整理和总结张炳厚教授学术经验,对其运用虫类药治疗痛证的经验进行系统、全面的研究,及学术思想的凝练和升华。
研究方法：从张炳厚教授治疗痛证的典型医案入手,通过数据库对典型医案中涉及的“药物”和“证候”等中医辨证要素进行频次统计及分析,对张炳厚教授虫类药用药特点和辨证思路进行总结。
研究结果：张炳厚教授典型医案数据库共录入痛证208例,位于前10位的疾病分别为痹证、头痛、胃脘痛、腰痛、面痛、胸痹、痛经、腹痛、胁痛、咽痛,以痹证、头痛最为多见。经拆分处理,共涉及证型有42个,总频数为498次,最常见的证型为瘀血阻络证、风寒湿痹证、肝肾阴虚证、肾阴虚证、气滞血瘀证、肝阳上亢证、肝火上扰证。脏腑辨证多定位在肝,认为诸痛皆属于肝。痛证病因病机以瘀血、风邪(包括内风、外风)、寒邪、湿邪、气虚、气滞、血虚、阴虚为主。数据库中共使用成方和自拟方32首,总频数231次,最常用的方剂依次为：疼痛三两三类方、滋生青阳汤、芍药甘草汤、川芎茶调散类方、血府逐瘀汤、补肾地龟汤(自拟方)等。数据库共使用药物314味,药物总频数3318次,使用频次最高的药物分别为甘草、白芍、黄芪、当归、全蝎、川芎、熟地、蜈蚣、血竭面、穿山甲、生地、地龙等。
痛证数据库中共使用虫类药16味,总频数518次,占所用药物的15%,常用的虫类药有全蝎、蜈蚣、穿山甲、地龙、龟版、水蛭、白花蛇、僵蚕、五灵脂、蝉蜕、鳖甲、蛤蚧、露蜂房、土鳖虫、晚蚕沙、蝼蛄,药味以“咸辛”为主,药性以“平”多见,多归肝经,功效以通络止痛、平肝息风、活血化瘀、补益培本、祛风除湿见长。
张炳厚教授痛证数据库中共收入痹证典型医案51例,其中风寒湿痹38例,分为经脉不通型30例,治以和血祛风,通络止痛,方用痹证三两三类方加减；久痹不已,内舍肝肾型8例,治以补益肝肾,通络止痛,方用独活寄生汤加减。风湿热痹13例,其中直接感受热邪6例,治以清热通络,疏风胜湿,方用白虎加桂枝汤加减；寒痹日久化热7例,治以温通经脉,兼散郁热,方用桂枝芍药知母汤加减。使用频次最高的药物分别为：甘草、当归、生黄芪、水蛭、川芎、血竭面、鸡血藤、白芍、全蝎、穿山甲、桂枝、白花蛇、熟地、蜈蚣、炙麻黄、僵蚕、地龙、龟版,其中虫类药有八味。张炳厚教授治疗痹证除善用虫类药,还重用黄芪,重视使用引经药。
痛证数据库中共录入头痛43例,其中肝阳头痛10例,肝风头痛9例,肝火头痛4例,肾虚头痛3例,气虚头痛5例,瘀血头痛4例,风湿头痛2例,血虚头痛2例,阴虚头痛2例,风热头痛2例。最常用方剂为：滋生青阳汤和茶调散类方。使用频次最高的药物分别为：甘草、全蝎、蜈蚣、白芍、生地、石决明、熟地、钩藤、川芎、生黄芪、天麻、麦冬、菊花、草决明、竹茹、半夏、蔓荆子、当归、僵蚕、白花蛇等。张炳厚教授独创性地以川芎茶调散类方治疗各种外感、内伤头痛,以滋生青阳汤治疗肝阳、肝火、肝风头痛,且治头痛必用虫类药,全蝎、蜈蚣为最常用药对,二者同用,息风止痉,通络止痛效果更佳,痛甚者加白花蛇。
结论：通过对数据库的挖掘,总结出张炳厚教授治疗痛证重视通络法,尤其是虫蚁通络法的学术思想。善用类方,以简驭繁。并认为诸痛皆属于肝,从肝论治痛证的学术特点。同时对张炳厚教授治疗痛证常用方剂及药物进行了归纳分析。
第三部分应用虫类药治疗慢性肾炎蛋白尿的临床研究
研究目的：观察虫类药配合张炳厚教授经验方治疗慢性肾小球肾炎蛋白尿的疗效及安全性。
研究方法：按照随机分组原则,将64例患者分为对照组、治疗组。对照组：予张炳厚教授经验方加味补肾利湿汤辨证治疗。治疗组：在加味补肾利湿汤辨证治疗基础上加龟版15-30g、蝉蜕15-20g、僵蚕6-20g、水蛭3-6g、全蝎3-6g、地龙15-30g、炒山甲6g。两组各治疗8周。观察两组中医证候积分、24小时尿蛋白定量及肝肾功等安全性指标变化。
研究结果：两组治疗后证候积分都较疗前下降,有统计学差异,但疗后两组间比较无统计学意义。两组治疗后24小时尿蛋白定量均较疗前下降,有统计学意义；治疗组疗后尿蛋白定量下降更为明显,与对照组比较差异有统计学意义。治疗过程中,两组患者生命体征平稳,复查血、尿、便常规及肝肾功能稳定,心电图及腹部B超较治疗前无明显动态变化。
结论：张炳厚教授经验方能够明显改善慢性肾炎患者症状,配合虫类药可更为有效的减少蛋白尿,安全性好。
提出新见解：
1通过总结张炳厚教授应用虫蚁通络法治疗痛证学术思想,将虫类药应用于新领域,与张老师治疗慢性肾炎经验有机结合,用于治疗慢性肾炎蛋白尿取得明显疗效。
2分析了通络法与活血法的关系,并提出扩大虫蚁通络的应用范围,将其应用于慢性肾脏病、中风、冠心病、糖尿病等常见疾病。
3虫类药的服用方法：应尽可能制成散剂装胶囊使用。主要原因如下：①虫类药多为动物蛋白,久煎可能会降低其生物活性,影响疗效。②节省药材、避免资源浪费。③虫类药均有腥味,装胶囊使用可减少异味,便于患者服用,减轻患者的恐惧心理。
4提出慢性肾炎蛋白尿的病机,以先天禀赋不足为根本,加之后天脾肾两伤,湿热、瘀血等致病因素共同导致。
5慢性肾炎从肾络论治：本人认为,在慢性肾炎的早期阶段就已存在“肾络受伤”,如能早期干预,在临床症状没有出现之前,就给予相应的治疗,可阻断病情的进展,防止患者进入终末期肾脏病。
6虫类药在慢性肾脏病中的应用：虫类药可以有效降低慢性肾炎患者蛋白尿,也适用于慢性肾脏病。在慢性肾脏病中应用虫类药应注意结合辨病及分期,并关注其安全性。
Summary of academic thoughts and clinical experience of Professor Zhang Binghou.
Professor Zhang Binghou, MD, PhD supervisor, is one of the inheriting teachers of state traditional Chinese medicine inheritance work. Since fancy of traditional Chinese medicine, he assiduously studied the TCM, read and got familiar with all ancient Chinese medical classics and modern medical literatures. After 50 years'work in the clinic, he has laid a solid theoretical foundation of traditional Chinese medicine and accumulated rich clinical experience. Having inherited the essence of the TCM, he has created the new perspective of the TCM. He who has taken the theory of Zang-fu organs as his core syndrome differentiation and treatment system has gradually formed his unique mehthods of syndrome differentiation and treatment. His characteristic viewpoint on the treatment principle is the proposal that "nurturing the vital qi by catering to its property, strengthening the vital qi to ensure its natural property ". He writes out not complex but simple herb prescriptions for patients, excels in using similar functional herb prescriptions and often selects original effective herb prescriptions for them. His application of herbs is of orderly monarch, minister, assistant and guide. He is well in using herbs activating blood circulation and removing sputum, especially Chinese insect drugs and toxic herbs. In treatment he often uses peculiar herbs which would have significant effects.
Academic origin:Retrieve ancient Chinese medicine classics, analyze famous TCM doctors academic thoughts which have had a greater impact on my instructor to explore academic origin of Professor Zhang Binghou.
Classical medical books:
1. Some native material ism ideas of Inner Canon of Yellow Emperor have a profound impact on the academic thought formation of Professor Zhang Binghou.①the whole concept-To differentiate the disease need to review the internal and external.②To seek the root cause before treatment.③To pay attention to envoy drugs, in addition, Basic Question Ju tong Lun chapter has a great impact on his understanding pain syndrome including its etiology, pathogenesis and treatment.
2. Treatise on Exogenous Febrile Diseases Theory is the first TCM classic which transcribes the etiology, pathogenesis, therapy and prescription of pain syndrom, made the history of the Chinese insect drugs therapy and laid a theoretical foundation on Professor Zhang Binghou's treating pain syndrome in Chinese insect drugs. In addition Professor Zhang Binghou treats headache according to the method of six meridians differentiation and uses guiding medicinals. His idea of using similar functional herb prescriptions orginates from the book Cold-induced Febrile Diseases.
3. Danxi's Experiential Therapy:Yang often excessive, yin often inadequate, which initiated nourish Yin and purge fire is the theory source of tonifying kidney of Pro. Zhang, especially nourshing kidney-yin. The ideas that to treat edema is to tonify middle energizer and treat involunta is to treat dampness and heat both orginate from Zhu Danxi's medical theory.
4. Jing Yue theory:Professor Zhang Binghou worships the theory of Zhang Jingyue and thinks that Zhang Jingyue develped the theory of yin often inadequate, put forward an argument that kidney-yin is inadequate and the deficency is more than excess in human body. While treatment Pro. Zhang focuses on the method of tonifying kidney, especially nourishing kidney essence. He likes to use large doses of medication Rehmannia and turtle version. The idea that lackage of nourshing results in pain of Zhang Jingyue is the theoritical foundation of the therapeutic method that the nourshing kills pain.
5. The articles of Guide to Clinical Medical Records on the pain treatment, dredging collaterals and application of Chinese insect drugs have a great impact on his treating pain syndrome.
6. "Yi Chun Teng Yi":Professor Zhang Binghou refers to differential guidelines of the book that five organs all can result in cough, develops the theory and expands the application range of Doctor Fei Boxiong's herb presription Zishengqingyangtang which were used in treating headache and trigeminal neuralgia that induced by liver wind disturbance and hyperactivity of liver-yang.
senior famous TCM doctors'academic thoughts:
1. Liu Duzhou:①To differentiate syndrome around the main symptom.②To use similar functional herb prescriptions in treatment.③Application of aconite.④Syndrome differentiation and treatment on menalgia.
2. Zhu Shenyu:To focus on spleen and stomach and study clinical experiences of treating spleen and stomach diseases. After studying the Qi-movement theory which is on ascending, descending, out and in, Zhang proposed the theory that Following its nature means tonifying and enhancing its nature means tonifying. He has a unique insight into Doctor Shi theory on double herbs.
3. Song xiangyuan:To study the method of blood circulation, the way how to excel in using Xuefuzhuyutang and the treatment of gynecological diseases. Pro. Zhang fouses on dispersing liver qi but not breaking the stagnant qi. He likes using Xiaoyaosan and Shuangweiyin prescriptions which application range was expanded.
4. To Learn how to apply Xiaoqinglongtang from Doctor Wang wending and academic thought of treatment in treating sputum.
A Summary of Academic Thoughts and Clinic Experience
The academic thoughts of Professor Zhang Binghou are summarized as follows.
1. In conformity to zang-fu syndrome differentiation theory, Professor Zhang strictly follows three fundamental principles in diagnosis:inspecting both the internal and the external, tracing the etiology by syndrome differentiation, and synthesizing the four diagnostic methods. He gives special attention to five key points in syndrome differentiation:①attain an explicit and comprehensive understanding of the syndrome, and lay more stress on inquiry;②conduct differentiation based on main syndromes;③differentiate the syndrome with an eye on the process of the disease;④several syndromes play a key role in differentiation;⑤in spite of the stress on syndrome differentiation, disease identification cannot be ignored either.
2. In treatment, Professor Zhang advocates the ideas "nurturing the vital qi by catering to its property", and "strengthening the vital qi to ensure its natural property". These ideas have extensive application in his eight methods of treatment, especially in the reinforcing one. He applies different tonifying medicine to cater to the natural property of vital qi in different zang-fu organ and diseased part.
3. Professor Zhang lays stress on tonifying the kidney and attaches particular importance to nourish the kidney yin. He holds that "to tonify yin, one must tonify the yin resided in yang; and to tonify yang, one must tonify the yang resided in yin". He puts forward eight methods of tonifying kidney and creates analogous prescription Digui Decoction (Digui Tang) to treat disease caused by kidney deficiency.
4. Grasping the key points to simplify the complex, Professor Zhang has created many analogous prescriptions and divided them into basic and modified ones. Basic prescriptions are mostly approved or self-formulated prescriptions aimed to tackle the general aspect of a disease. Modified prescriptions, however, are those aimed to tackle the individual aspect of a disease based on the identification of its specific etiology and pathogenesis. Basic prescriptions fall into three categories:the one for a permanent cure, the one for syndrome alleviation, and the one for ushering the medicine qi into its designated channel.
5. Though Professor Zhang has a good command of approved prescriptions and a large variety of Chinese medicine, he is no stickler. He follows the convention of Chinese medicine but is never bound by the specific composition. In treating a disease, he modifies the approved prescription based on a profound understanding of both the mechanism of the prescription and syndrome and disease differentiation of a specific case.
6. Professor Zhang is adept at using insect medicine to alleviate pain and has earned himself a reputation as "master of pain alleviation".①Based on the idea "channel blockage giving rise to pain", he stresses the importance of dredging channels and collaterals to alleviate pain.②He applies insects, ants and other medicine with toxic and anesthetic property. The paper summarizes the dosage, couplet, compatibility, and the method of application frequently used by Professor Zhang.
The paper summarizes the details of Professor Zhang Binghou's clinic practice, appended with representative case records.
1. Chronic kidney disease:①Pathogenesis of the disease is identified as deficiency in origin and excess in superficiality. The disease shows syndromes of intermingled deficiency and excess with deficiency as the main cause.②Treatment of the disease is focused on nourishing the kidney yin. Eight methods of tonifying the kidney are adopted too.③Analogous prescription Digui Decoction is applied in concert with eight methods of tonifying the kidney to treat various kidney disease.
2. Stomachache:Treatment of the disease is focused on invigorating the spleen, soothing the liver, regulating the qi flow, and invigorating blood circulation. The pattern of stomachache due to weakness of the spleen and stomach is treated by using Kaiwei Jinshi Decoction; the pattern due to deficiency-cold in spleen and stomach is treated by using Shenqi Jianzhong Decoction; the pattern due to liver-spleen disharmony is treated by using Shuangwei Potion; the pattern due to liver-stomach disharmony is treated by using Jiegan Decoction together with Jinlingzi Powder, an analogous prescription, to invigorate blood circulation and alleviate pain.
3. Trigeminal neuralgia:The etiology and pathogenesis of the disease is identified basically as liver-kidney yin deficiency causing upward disturbance of liver-wind. The disease may also be attributed to weakness of the spleen and stomach. The up-rising yin fire complicated by wind-fire in liver channel flows hither and thither along the channels and collaterals, attacks upward, and obstructs channels and collaterals in the head. As channel blockage gives rise to pain, treatment of the disease is focused on nourishing the liver and kidney, calming the endogenous wind, dredging the collateral, and eliminating the phlegm. Zisheng Qingyang Decoction is adopted as the main prescription and insect medicine is applied supplementarily to penetrate the bone to expel wind and dredge the channel to alleviate pain. Apart from that, insect medicine also serves the function of ushering medicine qi to its designated channel.
4. Insomnia:Differentiate firstly whethezair it is deficiency or excess pattern and then identify the Zang-fu syndrome. The disease is mostly located in the heart but is closely related to the kidney, liver and spleen. Self-formulated analogous prescription, Erren Anmei Decoction is applied to treat insomnia and the therapy has been proved quite effective.
5. Arrhythmias:Arrhythmias falls into four patterns:①The pattern due to dual qi-yin deficiency and malnourishment of heart channel is treated by using Zhi Gancao Decoction;②the pattern due to qi deficiency and blood stasis, and heart channel obstruction is treated by using prescription coronary six formulated by Professor Zhang;③the pattern due to devitalization of heart yang and fluid adversion attacking the heart is treated by using modified Linggui Zhugan Decoction;④the pattern due to internal attack of phlegm-heat and malnourishment of the heart spirit is treated by using modified Huanglian Wendan Decoction.
6. Cough:Professor Zhang Bing-hou holds that "five zang and six fu may all give rise to cough". This paper sums up clinical manifestations of cough related to five zang organs and their relevant therapy respectively. Prescriptions frequently used by Professor Zhang are modified Xiao Qinglong Decoction for cough caused by wind-cold, modified Maxing Shigan Decoction for cough caused by heat, Qingzao Jiufei Decoction for cough caused by lung dryness, and Baihe Gujin Decoction for cough caused by lung and kidney yin deficiency.
7. Fever due to internal damage:Heat by internal injury is mainly generated by fire, which is induced by excess of qi. Heat by internal injury falls into nine types, which are heat due to yin deficiency, heat due to yang deficiency, heat due to qi deficiency, stagnated heat due to food retention, stagnated heat due to phlegm and retained fluid, stagnated heat due to water and dampness, stagnated heat due to liver depression, stagnated heat due to static blood, and stagnated heat due to spleen qi. Qingshu Yiqi Decoction is used to treat heat due to qi deficiency, modified Sanshi Decoction is used to treat heat due to dampness, and modified Qinjiao Biejia Decoction is used to treat heat due to yin deficiency.
8. Dysmenorrhea:The etiology and pathogenesis of gynecopathy is identified as disorder of qi and blood, dysfunction of zang-fu organs, and injuries of conception and thoroughfare vessels. The principle of treatment is regulating qi-blood flow, harmonizing the spleen and stomach, soothing the liver qi, and tonifying kidney essence. Syndrome differentiation of dysmenorrhea by means of inquiry is focused mainly on the cycle, color, quantity, and substance of menstruation.
9. Chronic cholecystitis:Dampness heat in liver gallbladder is the pattern most frequently seen clinically. Self-formulated decoction, Qinggan Lidan Decoction is applied to treat chronic cholecystitis, cholelithiasis, and chronic hepatitis caused by dampness heat in liver gallbladder.
10. Skin rash:Analogous prescription, Wupi Wuteng Yin, is applied to treat various skin rash as it is believed that "the skin of plant can benefit the skin of human, while the plant rattan dredges the channel of human"
Study on the experience of Pro. Zhang in using insect drugs
Background:Insect drugs are part of medicinal animals. Because of its unique biological activity, it is extremely admired by ancient physicians. Pro. Zhang is good at treating pain disease and chronic kidney disease. One of his most unique clinical experiences is the treatment of pain disease using insect drugs, which is worth further studying. Through exploring the database, the paper summarizes Pro. Zhang's academic thoughts of focusing on unblocking meridians and collaterals with insect drugs. Chronic kidney disease is featured by prolonged course and difficulty in treatment. This paper makes clinical study on it according to the TCM theory of "intruding into meridians and producing hematoma after long time of disease" and by combining insect drugs and Pro. Zhang's experience in treating chronic nephritis.
PartⅠLiterature Review:It reviews the history of insect drug development and summarizes the effect of insect drug, its pharmacological actions, such as immunoregulation, anticoagulation, inhibition and killing of microorganism, analgesia, etc. as well as various common diseases, frequently-occurring diseases, difficult miscellaneous diseases, severe and lingering illness in which insect drugs are widely used in clinical treatment.
Part II Clinical Study on Treatment of Pain disease Using Insect Drugs by Pro. Zhang.
Purpose:In this study, by using the structured databases to analyze the series data, collect and summarize academic experience of Pro. Zhang, systematically and comprehensively study his own experience in using insect drugs to cure pain disease, and sublimate his academic ideals.
Method:Start ing with typical medical cases of Professor Zhang's treatment for pain disease, applying the database to summarize and analyze the frequency of "drugs" and "symptoms and signs" and other TCM elements, reveal the characteristics and dialectical thinking of Pro. Zhang on insect drugs medication.
Results:The database of Professor Zhang Binghou's typical medical cases totally include 208 cases of pain disease in the top 10 diseases are Bi syndrome, headache, epigastric pain, back pain, face pain, chest pain, dysmenorrhea, abdominal pain, hypochondriac pain, sore throat, among which Bi syndrome and headache are most common. The split process involves a total of 42 syndromes and the total frequency of 498 times. It showed that the most common syndromes is blood stasis, deficiency of liver and kidney-yin, deficiency of kidney-yin, Bi syndrome by the evil of wind cold dampness, qi stagnation and blood stasis, hyperactivity of liver-yang and flaming up of excessive heat of liver. The differentiation of Zang-Fu is mainly located on the liver due to the cause of various pains belonging to the liver. Pathogenesis of pain disease often exists in stasis, evil wind (including the wind inside and outside), pathogenic cold, dampness, qi deficiency, qi stagnation, blood deficiency and yin-deficiency. Database shows the used Chinese patent or self-made prescriptions are 32 recipes and the total frequency of 231 times. The most common prescriptions are pain Sanliang San decoction, the Zisheng Qingyang decoction, peony and licorice decoction, Chuan Xiong Chatiao power decoction, Xuefu Zhuyu decoction, reinforce kidney by turtle decoction (self-made side) and so on. 314 drugs were used in the database, the total frequency of drug is 3318 times, in which most frequently used drugs are licorice, peony root, astragalus, angelica, Scorpio, Chuanxiong, Rehmannia, centipedes, blood surface, pangolins, habitat, earthworm, etc. Pain disease database uses 16 kinds of Chinese use insect drugs and the total frequency of 518 times, accounting for 15% of all drugs. Drugs commonly used include insect scorpion, centipede, pangolins, earthworm, turtle shell, leech, nosed pit viper, stiff silkworm, trogopterus dung, cicada, turtle, gecko, honeycomb, Eupolyphaga, late silkworm excrement and mole crickets. Most taste "salty and pungent". The main herb characteristic is "mild". Many herbs belong to the liver, their effectiveness are prominently displayed at relieving the pain and pass qi through meridian and collaterals, subduing hyperactivity of liver-yang to cease endogenous wind, activating blood circulation, and replenishing deficiency of liver and kidney vital energy, expelling the evil wind & dampness.
51 typical cases of patients who have Bi syndrome have been collected into the database of pain disease of Pro. Zhang. Among them there are 38 cases of damp Bi syndrome, wherein,30 cases are meridians block, which can be treated by nourishing blood to expel wind; dredge collaterals to relieve pain, and pain Sanliang San decoction with modification is used; 8 cases are unceasingly long-term rheumatology and inner liver and spleen, which can be treated by reinforcing liver and kidney and dredging collaterals to relieve pain, and Duhuojisheng decoction with modification is used. 13 cases of rheumatism pyretic arthralgia are also divided in to two types.6 cases of them are directly affected by pathogenic heat and can be treated by clearing heat, dredging collaterals and clearing wind and dampness, and white tiger decoction added with cassia twig is used; 7 cases of them are long-term arthritis changing into rheumatism pyretic arthralgia and are treated by warming the meridians and clearing stagnated heat, and cassia twig and peony zhimu decoction with modification is used. The most frequently used drugs are:licorice, angelica, raw radix astragalis, leech, chuan xiong, dragon's blood, Caulis Spatholobi, peony root, scorpio, pangolins, cassia twig, long-noded pit viper, radix rehmanniae praeparata, centipede, roasted ephedra, stiff silkworm, lumbricus and tortoise plastron, and eight kinds of these drugs are insects. Pro. Zhang is good at using insect drugs to treat Bi syndrome and he also prefers to use astragalus and attaches importance to use guiding drug.
43 cases of patients who have headache are collected into database of pain diseases. Among them, there are 10 cases of liver yang headache, 9 cases of liver wind headache,4 cases of liver fire headache,3 cases of headache due to kidney insufficiency, 5 cases of qi deficiency, 4 cases of blood stasis headache, 2 cases of rheumatism headache,2 cases of headache due to deficiency of blood, 2 cases of headache due to deficiency of Yin and 2 cases of headache due to pathogenic wind-heat. The most commonly used prescriptions are Zisheng Qingyang Decoction and Chatiao powder Decoction. The most frequently used drugs are:licorice, scorpion, centipede, peony root, radix rehmanniae, concha haliotidis, radix rehmanniae preparata, uncaria, Chuanxiong, raw radix astragalis, gastrodia elata, radix ophiopogon japonicus, chrysanthemum, cassia obtusifolia, bamboo shavings, pinellia ternata, fructus viticis, Chinese angelica, stiff silkworm, long-noded pit viper, etc. Pro. Zhang originality uses Chuan Xiong Chatiao decoction in treating various types of headaches including headaches caused by external infection and internal damage.
Conclusion:Through exploring the database, it is concluded that Pro. Zhang attaches importance to the meridians activation method when treating the pain syndrome, especially his academic thought of unblocking meridians and collaterals with insect drugs. He prefers taking the simple prescription for patients instead of the complex, and is skilled in using similar functional prescriptions. He also thought that various pains can be attributed to liver, and talked about the academic features of pain syndrome from liver. At the same time, Pro. Zhang concluded and analyzed the prescriptions and drugs commonly used for curing pain disease.
PartⅢClinical Observation of Applying Insect Drugs to Cure Chronic Nephritic Proteinuria
Purpose:Observe the curative effect and safety of taking insect drugs to match up the prescription of Pro. Zhang in curing chronic glomerulonephritis proteinuria.
Method:Divide the 64 patients to control group and treatment group at random. Control group:dialectical treatment by using the experience prescription of flavored kidney tonifying and dampness decoction of Pro. Zhang. Treatment group: based on the above treatment, add turtle shell 15-30g, periostracum cicada 15-20g, stiff silkworm 6-20g, leech 3-6g, scorpio 3-6g, lumbricus 15-30g and pangolin 6g. Treat the two groups for 8 weeks respectively. Observe the change of safety indexes such as two groups of traditional Chinese symptom score,24h proteinuria and liver and kidney function.
Result:After treatment, the symptom scores of two groups all drop compared with that before treatment, but there is statistics difference. However, there is no statistics meaning for the comparison between two groups after treatment. After treatment, the 24h proteinuria of both two groups all drop compared with that before treatment and there is statistics significance; the drop of proteinuria of treatment group after treatment is more obvious, and there is statistics significance compared with the difference of control group. During treatment, the vital signs of two groups of patients are stable; reexamination shows that the regular functions of blood, urine and defecate and functions of liver and kidney are stable; compared with the conditions before treatment, the electrocardiogram and abdominal ultrasound have no obvious dynamic change.
Conclusion:The experience prescription of Pro. Zhang can obviously improve the symptoms of chronic nephritis patients, and matching up with insect drugs can more effectively lessen the proteinuria. This method is quite good.
Propose new opinions:
1. Through summarizing the academic thoughts of Pro. Zhang applying insect drugs meridians to unblock meridians in treating pain disease, obvious curative effect can be obtained by applying the insect drugs in new fields and dynamically integrating it with the experience of Mr. Zhang in treating chronic nephritis and chronic nephritic proteinuria.
2. Pointed out the difference between the treatment of promoting blood circulation and dredge collaterals, expanded the application of Chinese insect drugs and used them in treating CKD, Stroke, CHD, Type 2 DM and other common disease.
3. Taking method of insect drugs:make it into powder capsules as much as possible. The main reasons are as follows:①Most insect drugs are animal albumen, so long-term boiling may reduce its bioactivity and affect the curative effect.② Save medicinal materials and avoid wasting resources.③All insect drugs have fishy smell, using it by encapsulating can lessen the peculiar smell, offer convenience for patients to take and relieve the fear of patients.
4. Propose the pathogenesis of chronic nephritis proteinuria. This disease is jointly caused by insufficient congenital endowment (the root) and acquired impairment to spleen and kidney, dampness-heat and stasis of blood, etc.
5. reating CGN with Treatment by Regulating Kidney:I think kidney collaterals injury lied in the early stage of CGN. Early intervention with the corresponding treatment before clinical symptoms appearing can block the progress of the disease, prevent the patients from ESRD.
6. Application of Chinese insect drugs in treating CGN:Chinese insect drugs can reduce the proteinuria effectively and be applied in treating CKD. As we used them, we should pay attention to combining the treatment with the disease differentiation at different stages and the drug security.
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