摘要
通过临床跟师学习、记录跟师笔记、收集总结经验病案、检索查阅能反映老师学术思想的相关论文书籍、撰写跟师心得、与老师访谈等方式,总结了冯兴华教授学术思想渊源、有关痹证的学术思想,并通过临床研究,探讨了冯师从肝论治痹证法治疗偏头痛的临床疗效。
1冯兴华教授治疗痹证思想渊源
冯兴华教授的学术思想的形成有着深厚的理论基础和思想渊源。
阴阳学说、藏象学说、整体观是《内经》重要的理论体系。冯师学术思想中的“整体观”“辨证论治”“治未病”思想正是来源于《内经》。《素问·痹论篇》：“风寒湿三气杂至合而为痹也。”冯师认为：除风寒湿邪外,热邪、燥邪也是引起痹证的外邪。痹证病因非外感六邪,而饮食不洁、情志不畅、劳逸过度等都可致痹。这些认识是对《内经》即有继承,又有发挥。冯师在临床实践中经常以《内经》等理论去指导临床。
《金匮要略》提出多种痹病名称,对其病因病机进行阐述,开创了辨病辨证相结合的思想,对杂病的治疗充分体现了“同病异治,异病同治”的精神。这种病证结合、同病异治、异病同治的思想对冯师的学术思想影响深远。
《脾胃论》提出：脾胃是元气之本,是气机升降的枢纽,并创立脾胃内伤论。东垣提出“风能胜湿”,代表方羌活胜湿汤。冯师注重脾胃,健脾益气是冯师常用之法。冯师对风药有独特的经验,认为多数风药具有祛风、散寒除湿、行气通络止痛、疗火郁之证的功效。
《医宗必读》中提出治疗痹证的原则治行痹,散风为主,参以补血之剂；治痛痹,散寒为主,参以补火之剂；治着痹,利湿为主,参以补脾补气之剂。冯师认为这些观点反应了风湿病治疗中的祛邪与扶正的关系。
叶天士的《临证指南医案》主张用清法治疗热痹,吴鞠通《温病条辨》中宣痹汤治疗湿热痹,这些思想都是冯师重视湿热痹证的学术思想渊源。
王清任《医林改错》重视“瘀”和痹证的关系,并创立不同的活血祛瘀方剂。如通窍逐瘀汤、血府逐瘀汤、身痛逐瘀汤等。身痛逐瘀汤是冯师临床经常应用的方剂。
现代治疗痹证大家路志正、焦树德、朱良春、谢海洲、王为兰等名医的痹证思想都对冯师学术思想有着很大的影响。
2冯兴华教授治疗痹证经验总结
2.1冯兴华教授对痹证病因病机的认识
冯师对痹证病因认识：痹证的病因非独为外感风、寒、湿、热邪所致,痹证亦可单独因内伤七情、饮食失节及其它疾病发展而形成。同时提出痹证从肝论治的思想。外邪侵袭、痹阻经络,瘀血痰浊、痹阻经络,痹证日久、损伤正气,痹证日久、累及脏腑是冯师对痹证病机的认识。2.2冯兴华教授治疗痹证的总原则
根据中医理论及多年临床实践,冯师总结治疗痹证的原则是整体观及辨证论治思想,包括祛邪为主、顾护正气、因时制宜、调理情志、注重体质。
2.3冯兴华教授治疗痹证的学术思想特色
2.3.1清热利湿法治疗湿热痹证
痹证的外因,除了风寒湿三气外,热邪、燥邪等也是重要病因。导师认为“湿热之邪”在痹病的发生发展过程中起着非常重要的作用。2.3.2从肝论治痹证
冯师认为痹证的病因非独为外感风、寒、湿、热邪气所致,情志失调、肝气郁滞也可以引起痹证。同时,各种原因引起肝血不足,如失血过多,或生血不足,或久病耗伤肝血,均可发生痹证。因此,肝气被郁、肝血不足均可致痹。同时,冯师认为,肝气不舒,气机不畅,可以出现很多部位的疼痛。气滞于上,会出现头痛,气滞于关节,会出现肢体关节疼痛等等。
2.4各种痹证的诊疗特色
2.4.1类风湿关节炎的诊疗特色
冯师认为,类风湿关节炎的病因主要包括感受外邪与正气虚弱两个方面。
邪气阻于关节是类风湿关节炎发生肿胀的基本原因,外邪痹阻、痰瘀互阻、病久伤气是其发病病机。祛邪法是治疗类风湿关节炎的基本治法,扶正为了更好地祛邪。
湿热痹阻证。冯师治以清热利湿,宣痹通络,四妙丸和宣痹汤加减,热重者用白虎汤加味：
寒湿痹阻证。冯师治以散寒除湿,通络除痹,乌头汤合防己黄芪汤加减；
痰瘀互阻证。冯师治以活血化瘀,祛痰通络,身痛逐瘀汤加减;
肾阳亏虚证,冯师治以温阳补肾,祛邪通痹,补肾治尪汤加减；
肝肾阴虚证,冯师治以滋阴清热,祛邪通痹,知柏地黄汤加减；气血两虚证,治以补气养血,祛邪通痹,八珍汤加减。
2.4.2强直性脊柱炎的诊疗特色
冯师认为强直性脊柱炎的病因与先天禀赋不足,肾气亏虚,外感风寒湿热邪气,饮食不节等诸多因素有关,特别强调肾气亏须是本病的根本病因病机。
同时,冯师认为本病的急性发作期因外邪从阳化热,或病久郁而化热,常为湿热痹阻证候。急则治其标,故先清热利湿治其标,再补肾填髓治其本。
冯师认为,“血瘀”贯穿本病的各个阶段。
寒湿痹阻证冯师常用方为乌头汤合肾着汤加减；湿热痹阻证冯师应用自拟方清热强脊方；肾气亏虚证冯师用自拟方补肾强脊方。瘀血阻络证冯师方用身痛逐瘀汤加减。
2.4.3白塞氏病的诊疗特色
冯师认为,白塞氏病的病因为湿、热、毒邪,且湿热互结,毒邪入血凝结,缠绵难愈。
脾胃湿热证。湿热之邪侵袭人体,脾气受阻,湿浊内生,蕴结化热,热郁成火、成毒,毒火内扰。冯师常用芩连平胃散合白虎汤,治以清热解毒、燥湿化浊。
肝郁气滞、脾虚湿盛证。素体常常情志不舒、易怒,导致肝气郁滞,久化火郁,肝郁而脾困,湿浊内生,湿浊不化,而生热,冯师常用丹栀逍遥散加减,治以疏肝解郁,清热除烦、健脾祛湿。
热毒入血、气血凝滞证。湿热之毒在机体稽留日久,化热入血,使气血凝滞,血脉凝结而皮肤发斑发疹,冯师常用四妙勇安汤,治以养阴清热、解毒祛斑、养血活血。
2.4.4干燥综合征的诊疗特色
冯师认为本病为“虚”、“燥”、“毒”、“瘀”所致,“虚”为阴虚,为病之本,“燥”、“毒”、“瘀”为其标。临证中要根据燥痹累及的器官、脏腑不同而给予个体化、辨证治疗。“养阴润燥、解毒化瘀”是冯师治疗本病的基本治法。
肺胃阴虚证。冯师治以养阴益肺、滋阴清热、益胃生津,方以玄麦甘桔汤合二至丸加减。
肝肾阴虚证。冯师治以清肝明目、滋水涵木,方用小柴胡汤和二至丸加味。
气阴两虚证。冯师治以补益气血,健脾益肾。方用四君子汤加左归丸加减
2.4.5骨关节炎的诊疗特色
冯师认为骨关节病本质上是肝肾不足,是衰老的表现,风寒湿邪侵袭及跌仆扭伤为发病是诱因,以补肝肾、强筋骨、补益气血治其本,祛风散寒胜湿、活血通络止痛治其标,补益肝肾是基本治法。冯师强调,肾虚可以致血瘀,肾虚血瘀证是骨关节炎的常见证候,补肾化瘀治疗是卓有成效的。膝骨关节炎继发急性滑膜炎,关节积液,常表现为关节红肿热痛,为急症,急则治其标,因此治疗需要先清热利湿,再补益肝肾。
冯师常用自拟方健步汤,补益肝肾,强筋壮骨、活血化瘀。有急性滑膜炎症,表现为湿热痹阻证时,冯师常用四妙丸清热祛湿。
2.5总结了冯兴华教授治疗痹证常用治疗方法及常用药物
包括祛风法、散寒法、除湿法、清热法、化痰法、活血法、理气法、补气法、养血法、滋阴法、温阳法以及每个治法的常用药物、注意事项等。
3从肝论治痹证法治疗偏头痛
冯师认为,肝气不舒,气机不畅,可以出现很多部位的疼痛。痹证可以从肝论治。气血痹阻部位不同,可以出现诸多症状。气滞于上,会出现头痛,气滞于关节,会出现肢体关节疼痛等等。因此,冯师认为偏头痛也是痹证之一,可以从肝论治,“解郁止痛方”是冯师疏肝解郁法治疗偏头痛的体现。
采用前瞻性、同期非随机队列、单盲(评价者盲)的研究方法,探讨解郁止痛方治疗偏头痛的临床疗效。
研究对象：来自2010年3月—2011年9月期间广安门医脑病科门诊、宣武医院神经内科头痛专题门诊符合入选标准的肝郁气滞型偏头痛患者病人各60例。中药组：广安门医患者为一队列；对照组：宣武医院神经内科头痛专题门诊患者为一队列
治疗方法：中药组：给予中药自拟方解郁止痛方随证化裁。对照组：佐米曲普坦加度洛西丁,急性发作期服用佐米曲普坦2.5mg,间期服用度洛西丁30-60mg,一日一次。疗程：两组均治疗2个月。
观察指标：头痛-视觉模拟量表(VAS)。偏头痛残疾程度评估问卷(MIDAS)、偏头痛特异生活质量问卷(MSQ),中医症候。
结果：在头痛程度、发作次数、生活质量、中医症候等方面中药组治疗前后均有改善,有统计学意义。同时与西医治疗对照组比较,各项指标均优于对照组。
结论：解郁止痛汤治疗偏头痛临床疗效可靠。
By practicing with Professor Feng Xinghua, taking notes, collecting proved cases, retrieving and reading relevant literatures and books, talking and discussing with teacher, writing learning experience, I summed up Professor Feng Xinghua's thought about impediment syndrome and explored its origin and development. Moreover, based on these thoughts and my practice, I designed a clinical trial to explore the clinical effects of "treatment from liver".
1Origin and development of Professor Feng Xinghua's thought about impediment syndrome
Professor Feng Xinghua's thought about impediment syndrome had profound theoretical foundation and special origin.
Many of these thoughts came from Huang Di's Canon of Medicine, such as holistic view, preventive treatment of disease theory, treatment based on syndrome differentiation theory. Professor Feng thinks that heat evil, dryness evil, improper diet, emotional problems, overstrain can lead to impediment syndrome as same as wind, cold, dampness evil.
Synopsis of Golden Chamber presented many kinds of impediment syndrome and explained their mechanisms. It emphasized the connection of differentiation of disease and differentiation of pattern. What's more, it advocated treating the same disease with different methods and treating different disease with the same method. All of these had a profound influence on Professor Feng's thoughts.
Theory of Spleen and Stomach considered that spleen and stomach was the root of yuan qi, the junction of upward and downward. Professor Feng attaches great importance to spleen and stomach and often uses the method of invigorating spleen and supplementing qi.
Required Readings for Medical Profession put forward the rules of treating impediment syndrome:to treat migratory arthralgia, mainly dispersing the wind plus some drugs to enrich the blood; to treat arthralgia aggravated by cold, mainly dispersing the cold plus some drugs to warm the yang; to treat damp arthralgia, mainly eliminating dampness plus some drugs to strengthen the spleen and qi. All of the above had been integrated into Professor Feng's thoughs.
A guide to clinical practice with medical record and Treatise on Differentiation and Treatment of Epidemic Febrile Diseases were the origin of clearing the heat and eliminating the dampness in Professor Feng's thoughs.
Yilin Gaicuo paid much attention to the relation between impediment syndrome and blood stasis.It recorded many prescriptions such as Shen-Tong-Zhu-Yu Decoction, Xue-Fu-Zhu-Yu Decoction and Tong-Qiao-Zhu-Yu Decoction. Some of them were often used by Professor Feng in his clinical practice.
In addition, academic thoughts of Professor Lu Zhizheng, Professor Jiao Shude, Professor Zhu Liangchun, Professor Xie Haizhou, and Professor Wang Weilan had a positive impact on Professor Feng Xinghua's thought.
2Professor Feng Xinghua's academic thoughts of treating impediment syndrome
2.1Professor Feng's ideas to etiology and pathology of impediment syndrome
Professor Feng's new understanding to the etiology and pathogenesis of impediment syndrome:it is not only caused by feeling external evils such as wind, cold, wetness and heat, but also caused by the internal impairment of emotion, improper diet, or other diseases. Besides, he specially proposed "Bi disease treated from the liver".2.2Professor Feng's general therapeutic methods of treating impediment syndrome
According to the TCM theory and his own experience, treatment based on syndrome differentiation and holism are the two basic rules. The therapeutic methods which professor Feng often uses include eliminating pathogens, protecting the health qi, treating according the time, smoothing the emotion, taking care of the constitution.
2.3Professor Feng's specialty of treating impediment syndrome
2.3.1Pay much attention to dampness-heat pattern
Except wind, cold, dampness evil, heat and dry evil are important pathogens of impediment syndrome. Professor Feng thinks heat-dampness took a key point in disease's development.
2.3.2Treating impediment syndrome from liver
Professor Feng thinks that impediment syndrome was not only caused by exopathogens, but also by disorders of emotion and stagnation of liver qi. In addition, deficiency of liver blood, which caused by massive loss of blood and insufficient production of blood or chronic disease, can lead to impediment syndrome. So, both stagnation of liver qi and deficiency of liver blood can result in impediment syndrome.
2.4Professor Feng's experience of treating impediment syndrome
2.4.1Professor Feng's experience of treating rheumatoid arthritis
Causes of rheumatoid arthritis include two pails, which are feeling external evils and weakened body resistance.
Pathogenic qi obstructed in the joints is the basic reason of swollen. Exopathogens' blocking, phlegm coagulation, blood stasis, qi damage are the pathogenesis. Dispelling the evil qi is the basic treating method. In addition, strengthen the health qi can do well to dispelling evil.
Common syndromes and prescriptions:
Heat-dampness obstructing syndrome:To clear the heat, disinhibit the dampness, and free the collateral vessels; Modified Simiao Wan and Xuanbi Decoction, excessive heat needs modified white tiger decoction;
Cold-dampness obstructing syndrome:To disperse the cold, dispel the dampness, dispel phlegm and tree the collateral vessels; Modified decoction of Wutou Decoction and Fangji Huangqi Decoction;
Turbid phlegm and blood stasis syndrome:To activate blood, dispel phlegm to free the collateral vessels; Modified Shentong Zhuyu decoction;
Kidney yang deficiency syndrome:To warm the kidney yang, and eliminate the evil; Modified Bushen Zhiwang Decoction;
Liver and kidney deficiency syndrome:To nourish yin, clear heat, and free the collateral vessels; Modified Zhibai Dihuang Decoction;
Deficiency of qi and blood:To tonify qi and blood, eliminate the evil; Modified Bazhen Decoction.
2.4.2Professor Feng's experience of treating ankylosing spondylitis(AS)
Professor Feng thinks that the cause of ankylosing spondylitis had many aspects. A lack of innate endowment, kidney deficiency, exogenous pathogens (wind, cold and dampness), irregular diet, above all of these could promote AS. Especially, kidney qi deficiency is the fundamental pathogenesis.
Also, Professor Feng believes that:At the acute phase of the disease, the common pattern of heat-dampness obstructing was mainly caused by heat form excessive yang or heat from chronic stagnation.so, the primary treatment was to clear the heat and disinhibit the dampness, then tonify the kidney.
Professor Feng thinks that "blood stasis" runs through all stages of this disease.
To treat cold-dampness obstructing syndrome, Professor Feng often use Modified decoction of Wutou Decoction and Shenzhao Decoction; to treat heat-dampness obstructing syndrome,he often use his own prescription of Qingre Qiangji Decoction; Bushen. Qiangji Decoction is used to treat deficiency of kidney qi; Modified Shentong Zhuyu decoction is used to treat blood stasis.
2.4.3Professor Feng's experience of treating Behcet's syndrome
Professor Feng thinks that Behcet's syndrome is caused by dampness, heat, toxin evil, and binding of dampness-heat, toxin evil in blood, and this could be continuous.
Syndrome of dampness-heat in spleen and stomach:The dampness-heat evil hits the body; then the spleen qi is blocked; then damp turbidity emerges and could transform to heat because of long-time brewing and binding; at last, the heat could transform to fire, toxin, and result in worse state. Professor Feng often uses modified Qinlian Pingwei Decoction plus white tiger decoction to clear heat and resolve toxin and to dry dampness and transform turbidity.
Syndrome of liver depression and qi stagnation, spleen deficiency with exuberant dampness:this syndrome is often caused by emotional frustration, testiness. These factors could result in stagnation of liver qi, and the stagnation could transform to fire or cause spleen deficiency; then damp turbidity emerges because of spleen deficiency. Damp turbidity failing to transform could give birth to heat. Professor Feng often uses modified Danzhi Xiaoyao powder to course the liver and resolve depression, to clear heat and eliminate vexation, to fortify the spleen and disinhibit dampness.
Syndrome of heat-toxin invasion to blood, and qi-blood stagnate:long-time brewing and binding of dampness-heat in the body results in qi-blood stagnation, macular and papule eruption. Professor Feng often uses modified Simiao Yongan Decoction to nourish yin and clear heat, to resolve toxin and transform macules, to activate and nourish the blood.
2.4.4Professor Feng's experience of treating Sjogren syndrome
Professor Feng thinks that Sjogren syndrome is often caused by yin deficiency, dryness, toxin and stasis. Yin deficiency is the basis; whereas dryness, toxin and stasis are the developed results. Clinically, treatment should follow the rules of individualization and differentiation. Professor Feng often nourishes yin, moistens dryness, resolves toxin and transform stasis.
Syndrom of lung and stomach Yin deficiency:Professor Feng woud like to nourish lung and stomach yin, clear heat and he prefers the Xuanmai Ganjie Decoction and Erzhi Wan.
Syndrome of Liver and kidney yin deficiency:Professor Feng's treatment are clearing the liver and brightening the eyes, enriching water to moistening wood. The preferred prescriptions are modified Xiao Chaihu Decoction and Erzhi Wan.
Syndrome of qi and yin deficiency:Professor Feng often fortifies qi, blood, spleen and kidney. The preferred prescriptions are modified Si Junzi Decoction and Zuogui Wan.
2.4.5Professor Feng's experience of treating osteoarthritis
Professor Feng thinks that osteoarthritis is a sign of liver-kidney deficiency and aging, whereas invasion of wind, cold, dampness and trauma are the incentives of osteoarthritis. For treating the root, he supplements the liver and kidney, strengthens sinew and bone, and supplements qi and the blood; for treating the tip, he dispels wind, cold, and dampness, activates blood, frees the collaterals, and relieves the pain. Supplementing the liver and kidney is the fundamental treatment.
Professor Feng stresses that the kidney deficiency can cause blood stasis, and kidney deficiency with blood stasis syndrome is often seen, clinically. Fortifying kidney and resolving stasis are effective. Knee osteoarthritis with secondary acute synovitis and joint, effusion often manifests as joint swelling, thermal pain. For the emergency, we need to treat the tip, so we should clear the heat and drain dampness firstly, and supplements the liver and kidney secondly.
Professor Feng often uses Jianbu Decoction to supplement the liver and kidney, to strengthen sinew and bone strong gluten bones, to activate blood and resolve stasis. If there is synovitis with a heat-dampness obstructing syndrome, he often uses modified Simiao Wan to clear the heat and drain dampness.
2.5Common used methods professor Feng's treatment in impediment syndrome
Common used methods includes dispelling wind, cold, and dampness, clearing heat, transforming phlegm, activating the blood, regulating qi, tonifying qi, nourishing blood, nourishing yin, and warming yang.
3Inheritance and development of "treating impediment syndrome from liver"
Use prospective, nonrandomized queue over the same period, single blind (evaluators blind) research methods, to explore the clinical effect JIEYU ZHITONG TANG (depression-relieving and pain-stopping decoction) in treating migraine.
Research object:60migraine patients who were in accordance with the inclusion criteria came from encephalopathy outpatient of Guang'anmen Hospital and neurological department outpatient of Xuanwu Hospital during March2010to September2011. The patients were divided into two groups:treatment group formed by patients of Guang'anmen Hospital and control group formed by patients of Xuanwu Hospital.
Treatment:The patients in treatment group were treated by modified JIEYU ZHITONG TANG. The patients in control group were given Zolmitriptan plus Cymbalta. In acute attack, Zolmitriptan (2.5mg) was given. In paracmasis, Cymbalta (30-60mg) was given.1time per day,2months as a course.
Observation indexes:Headache-Visual Analogue Scale (VAS), Migraine Disability Assessment Questionnaire (MIDAS), Migraine-Specific Quality of Life Questionnaire (MSQ), and the TCM symptoms points.
Results:Contrast before and after treatment, the improvements of evaluation indexes such as the degree of headache, seizure frequency, and quality of life in treatment group all had statistical significance. The improvements of evaluation indexes in treatment group were obviously superior to the control group.
Conclusions:JIEYU ZHITONG TANG used to treat migraine can improve patients'symptoms and had obtained satisfying clinical effects.
引文
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