發(fā)布時間：2018-04-16 13:17

  本文選題：慢性肝炎 + 學(xué)術(shù)經(jīng)驗(yàn)　； 參考：《中國中醫(yī)科學(xué)院》2016年博士論文

【摘要】：目的：張武主任在肝病防治方面積累了豐富的臨床經(jīng)驗(yàn),此次通過系統(tǒng)收集、整理老師辨治慢性肝炎的學(xué)術(shù)經(jīng)驗(yàn),并對其臨床經(jīng)驗(yàn)方疏肝實(shí)脾湯治療慢性肝炎肝郁脾虛型進(jìn)行臨床研究,希冀可以升華傳承老師的學(xué)術(shù)思想,并為慢性肝炎的臨床辨治及進(jìn)一步研究提供參考。方法：本研究以跟師學(xué)習(xí)過程中老師的臨證指導(dǎo)為基礎(chǔ),結(jié)合老師多年來發(fā)表的論文、書寫的讀書心得、教學(xué)講稿及臨證經(jīng)驗(yàn)體會等第一手資料,以慢性肝炎的中西醫(yī)文獻(xiàn)綜述,老師的學(xué)術(shù)淵源、對慢性肝炎病因病機(jī)的認(rèn)識、辨治慢性肝炎的學(xué)術(shù)思想及經(jīng)驗(yàn)總結(jié)以及老師臨床經(jīng)驗(yàn)方疏肝實(shí)脾湯治療慢性肝炎肝郁脾虛型的臨床研究三部分為研究內(nèi)容。在第一部分慢性肝炎的中西醫(yī)文獻(xiàn)綜述中,中醫(yī)文獻(xiàn)部分分別從古代醫(yī)家的認(rèn)識、現(xiàn)代中醫(yī)名家的認(rèn)識以及當(dāng)代中醫(yī)的認(rèn)識等方面進(jìn)行系統(tǒng)的梳理及總結(jié)�，F(xiàn)代醫(yī)學(xué)研究部分則分別從慢性乙型肝炎的發(fā)病機(jī)制、診斷及治療等方面進(jìn)行論述；在第二部分老師的學(xué)術(shù)淵源及學(xué)術(shù)經(jīng)驗(yàn)研究中,將老師的肝病學(xué)術(shù)淵源進(jìn)行了全面的梳理,并系統(tǒng)總結(jié)了老師治療慢性肝炎的學(xué)術(shù)思想特色及臨床經(jīng)驗(yàn)；在第三部分疏肝實(shí)脾湯治療慢性肝炎肝郁脾虛型的臨床研究中,采用隨機(jī)對照的臨床研究方法,選擇符合納入標(biāo)準(zhǔn)的病例72例,按照隨機(jī)數(shù)字表隨機(jī)分為治療組和對照組,治療組入選病例37例,對照組入選病例35例,對兩組病例分別從年齡、性別、婚姻、病情輕重、病程、化驗(yàn)指標(biāo)、中醫(yī)證候分級等方面進(jìn)行資料分析,確定其具有可比性。其中,對照組予以西醫(yī)基礎(chǔ)治療,轉(zhuǎn)氨酶升高者予以口服葡醛內(nèi)酯片降酶保肝治療,病毒復(fù)制者口服恩替卡韋抗病毒治療,治療組在對照組基礎(chǔ)上加服老師臨床經(jīng)驗(yàn)方疏肝實(shí)脾湯。對兩組病例治療前后的中醫(yī)臨床證候積分、肝功能指標(biāo)、彩超情況以及HBV-DNA定量等方面進(jìn)行臨床療效評價。結(jié)果：1.通過對老師的肝病學(xué)術(shù)淵源及學(xué)術(shù)經(jīng)驗(yàn)的研究,探知其至今已行醫(yī)四十余年,八十年代初開始專攻中醫(yī)肝膽病。老師習(xí)醫(yī)并非家傳,其能取得一定成就,完全靠興趣愛好及自身勤奮。老師精研理論,勇于實(shí)踐,醫(yī)術(shù)精湛,醫(yī)德高尚。其學(xué)術(shù)思想,遠(yuǎn)宗《內(nèi)經(jīng)》、《金匱要略》、《脾胃論》等經(jīng)典之作,近承現(xiàn)代、當(dāng)代中醫(yī)各家之學(xué),擇精而選,繼承創(chuàng)新,從而自成一家。2.經(jīng)過多年臨床實(shí)踐總結(jié),老師認(rèn)為,慢性肝炎的病因有正虛不足、感受邪毒、情志不暢、飲食不節(jié)、失治誤治等種種,其病機(jī)可用虛、郁、濕、熱、瘀、毒六字加以概括。正氣不足,邪氣易侵,疾病可遷延及肝脾腎三臟；肝氣郁結(jié)失疏,則病癥由生；濕熱內(nèi)阻,既是獲病之因,又是患病之果;瘀血內(nèi)生,更是伴隨疾病全程;疫毒之邪壅滯,導(dǎo)致諸癥叢生,這也是疾病后期病勢纏綿,變癥叢生的重要原因。3.老師治療慢性肝炎的學(xué)術(shù)思想,可以簡述為以下四點(diǎn)：①治病求本、強(qiáng)調(diào)病因。因?yàn)榛颊叩呐R床表現(xiàn)錯綜復(fù)雜,所以要積極探求疾病的根本原因,針對根本原因施以正確的治本方法,老師常常從追因溯源、務(wù)求其本,標(biāo)本緩急、靈活取舍以及正治反治、隨癥而施三點(diǎn)著手。②扶正祛邪、攻補(bǔ)兼施。在臨床治療慢性肝炎的過程中,老師發(fā)現(xiàn),單純虛證或?qū)嵶C者很少見,多是虛實(shí)兼夾者,尤其到了慢性肝炎后期合并肝硬化腹水階段,患者的臨床表現(xiàn)更是虛實(shí)真假互見,所以老師常常扶正祛邪兼顧,必要時攻補(bǔ)兼施。③四診合參、中西合璧。老師認(rèn)為,在診治疾病的過程中,只有做到四診俱備,才能全面了解把握證候資料,準(zhǔn)確判斷出正邪虛實(shí),從而正確辨證施治。其次,因?yàn)橹形麽t(yī)各自的優(yōu)勢所在,還需要中西合璧,辨證與辨病相結(jié)合,才能在微觀及宏觀上對疾病有一個全面準(zhǔn)確的認(rèn)識,從而也才能更好的指導(dǎo)臨床用藥。④臨證治肝、尤重實(shí)脾。肝脾兩臟,在生理上相互依存,在病理上互相影響,“肝病實(shí)脾”之說由來己久,導(dǎo)師臨床中強(qiáng)調(diào)治療肝病不可“見肝只知治肝”,要重視他臟之變疾,尤其以調(diào)養(yǎng)脾胃為要,要重視“實(shí)脾”之法,才能取得良效。老師對“實(shí)脾”法有自己獨(dú)特的認(rèn)識和見解,總結(jié)了“實(shí)脾三法”,論文中有詳細(xì)論述。4.老師治療慢性肝炎的臨床經(jīng)驗(yàn),簡述為以下五個方面：①辨證分期論治。老師認(rèn)為,對于慢性肝炎而言,隨著病情的發(fā)展,不同病程階段的病機(jī)變化不同,治則也當(dāng)區(qū)別對待。疾病早期,病邪多以濕熱為主,或者肝郁,兼有脾虛,故當(dāng)以清熱利濕、疏肝健脾治療為主；疾病中期,病位多由肝脾兩臟延及到腎,導(dǎo)致諸臟虛損,出現(xiàn)肝腎陰虛,或陰損及陽,致脾腎陽虛不足之癥,故治療又當(dāng)以滋補(bǔ)肝腎或溫補(bǔ)脾腎為主；疾病后期,病機(jī)更為復(fù)雜,臟腑虧虛、氣血瘀毒內(nèi)阻,故治療應(yīng)以扶正祛邪、攻補(bǔ)兼施為務(wù)。②治肝以通為用。老師認(rèn)為,無論慢性肝炎初期、中期還是后期,都存在著病邪內(nèi)侵、臟腑受損的或虛或?qū)?或虛實(shí)互見等錯綜復(fù)雜局面,故治療肝病當(dāng)以“通”為法。這里所講的“通”,不單純指攻下之法,老師認(rèn)為,凡是辨證求因,給邪以出路者,皆謂之“通”。解表、發(fā)汗、通利小便謂之通,補(bǔ)益正氣、理氣消滯、活血通絡(luò)、滋補(bǔ)陰血、溫補(bǔ)陽氣、清熱利濕、化濕利水、驅(qū)寒破阻、滌痰開壅、破血逐瘀等均為通法之活用。③隨癥用藥。老師臨證用藥,還善于抓住疾病之主癥而選方用藥。文中主要從臨床常見的黃疸、脅痛、食欲不振、鼓脹等癥狀論述老師治療肝病的用藥特點(diǎn)。④治肝化瘀八法。老師認(rèn)為慢性肝炎病程中,瘀血或輕或重都會貫穿疾病始終,經(jīng)過多年臨床實(shí)踐,他總結(jié)了化瘀八法,分別為清熱解毒化瘀法、益氣扶正化瘀法、滋補(bǔ)陰血化瘀法、疏肝理氣化瘀法、健脾利濕化瘀法、溫補(bǔ)脾腎化瘀法、攻逐水飲化瘀法及軟堅散結(jié)化瘀法。⑤用藥精準(zhǔn)、注重調(diào)攝。老師臨床用藥力倡精準(zhǔn),喜用藥對、善用蟲類藥物以加強(qiáng)療效。其熟知藥性,臨床用藥生熟有別,故常能充分發(fā)揮藥效而取得良效。此外,因肝病的特殊性,用藥不當(dāng),或調(diào)攝失宜,均易致疾病難愈或變證叢生,故老師臨床中亦十分重視用藥禁忌及飲食、情志、勞逸等方面的調(diào)攝,認(rèn)為這些方面也是影響疾病治療不可或缺的一部分。5.老師認(rèn)為慢性肝炎病程中肝郁脾虛是為常見證型,經(jīng)過多年的臨床實(shí)踐,提出了疏肝實(shí)脾大法,并且創(chuàng)制了臨床驗(yàn)方“疏肝實(shí)脾湯”。臨床研究過程中,因多種原因,治療組共完成35例,對照組共完成32例。在疏肝實(shí)脾湯治療慢性乙型肝炎肝郁脾虛型的臨床研究中,治療組各種中醫(yī)證候均有不同程度改善(P0.01或P0.05),對照組部分臨床證候有一定程度改善(P0.01或P0.05)。兩組相比較,治療組在改善臨床證候方面優(yōu)于對照組。治療組總有效率為88.6%,對照組總有效率為59.4%,兩組總有效率比較,差異有顯著性意義。治療后兩組肝功能、HBV-DNA定量較治療前均有明顯改善,差異有顯著性意義,而腹部彩超結(jié)果提示治療組P0.01,改善明顯,差異有顯著統(tǒng)計學(xué)意義,對照組P0.05,治療前后無明顯改善,差異無統(tǒng)計學(xué)意義。兩組相比較,治療組各項(xiàng)指標(biāo)改善更為明顯。結(jié)論：老師的學(xué)術(shù)淵源,遠(yuǎn)宗經(jīng)典,近承各家,進(jìn)而發(fā)揚(yáng)創(chuàng)新；老師將慢性肝炎的病因總結(jié)為正虛不足、感受邪毒、情志不暢、飲食不節(jié)、失治誤治等,將其病機(jī)概括為虛、郁、濕、熱、瘀、毒；老師臨證治療中,倡導(dǎo)治病求本、強(qiáng)調(diào)病因,扶正祛邪、攻補(bǔ)兼施,四診合參、中西合璧,臨證治肝、尤重實(shí)脾,形成了其獨(dú)特的學(xué)術(shù)思想特色；診治疾病過程中,老師善于分期論治、辨證用藥,治療肝病時巧用通法,依據(jù)臨床癥狀選方用藥,活用活血化瘀之法,且用藥精準(zhǔn),關(guān)注調(diào)攝；老師根據(jù)慢性肝炎的病因病機(jī)特點(diǎn),提出了疏肝實(shí)脾大法,并創(chuàng)制了臨床驗(yàn)方疏肝實(shí)脾湯,臨床研究證實(shí)該方在緩解患者臨床癥狀、改善肝功能、降低病毒復(fù)制以及改善腹部彩超方面明顯優(yōu)于西藥對照組,是安全有效的。疏肝實(shí)脾湯是治療慢性乙型肝炎肝郁脾虛型的有效方藥。
[Abstract]:Objective : Zhang Wu ' s clinical experience in the prevention and treatment of chronic hepatitis , which is based on the clinical study of the traditional Chinese and western medicine literature of chronic hepatitis , and the clinical research on the clinical study of chronic hepatitis due to liver depression and spleen deficiency .
In the second part of the teachers ' academic origin and academic experience research , the teacher ' s academic origin of liver disease has been thoroughly combed , and the academic thought characteristics and clinical experience of the teacher in the treatment of chronic hepatitis are summarized systematically .
In the third part , the clinical curative effect of Shugan Shipi Tang in the treatment of chronic hepatitis due to liver depression and spleen deficiency was studied . Its pathogenesis can be summarized by deficiency , depression , dampness , heat , blood stasis , and toxic six characters . It is deficient in qi , easy to invade , disease can be prolonged , and liver and spleen kidney are three viscera ;
If the stagnation of liver qi is sparse , the condition is caused by birth ;
In the course of clinical treatment of chronic hepatitis , the teacher found that only four times of diagnosis and treatment should be made in order to fully understand the root cause of disease . In order to get good results , we should pay more attention to the changes of spleen and stomach , especially the method of nourishing spleen and stomach , to pay more attention to " real spleen " .
In the middle of the disease , the disease position is caused by the two organs of the liver and spleen to extend and to the kidney , leading to the deficiency of the viscera , the deficiency of the liver and kidney yin deficiency , or the yin loss and yang , the deficiency of the spleen and kidney yang deficiency , so the treatment is also mainly used for nourishing the liver and kidney or warming the spleen and kidney ;
In the later stage of the disease , the pathogenesis is more complicated , the zang - fu organs deficiency , qi and blood stasis toxin internal resistance , so the treatment should be used for strengthening body resistance , eliminating pathogenic factors and attacking and nourishing . The invention relates to a method for treating liver diseases , which comprises the following steps of : clearing heat and toxic materials removing blood stasis , invigorating qi , removing blood stasis , nourishing yin and blood , dispersing stagnated liver qi , dispelling blood stasis , invigorating spleen , promoting blood circulation , dispelling blood stasis , invigorating spleen , promoting blood circulation , dispelling blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , invigorating spleen , promoting blood circulation , removing blood stasis , promoting blood circulation , removing blood stasis , etc . In the treatment group , the total effective rate was 88.6 % , the total effective rate was 59.4 % in the treatment group and the control group was significantly improved ( P0.01 or P0.05 ) .
The teacher summarized the cause of chronic hepatitis to be deficiency of deficiency , feeling of evil spirit , unsmooth feeling , improper diet , missed treatment , etc . , summarized its pathogenesis as virtual , depressed , wet , heat , blood stasis , toxin ;
In the treatment of the teacher ' s syndrome , the author advocates the disease seeking , the emphasis on the cause , the strengthening of the body , the strengthening of the body , the treatment of the liver , especially the consolidation of the spleen , and the formation of its unique academic and ideological characteristics .
In the course of diagnosing and treating diseases , the teacher is good at the treatment of stage theory , treatment of syndrome differentiation , the treatment of liver disease by the coincidence method , according to the clinical symptom choice prescription drugs , living with the method of promoting blood circulation and removing blood stasis , and the medication is accurate and the focus is concerned ;
According to the characteristics of the etiology and pathogenesis of chronic hepatitis , the authors put forward the method of dispersing stagnated liver qi and strengthening spleen , and created a clinical laboratory for dispersing stagnated liver and spleen soup . The clinical study confirmed that the prescription is safe and effective in relieving the clinical symptoms of patients , improving liver function , reducing viral replication and improving abdominal color Doppler ultrasound , which is an effective prescription for treating chronic hepatitis B liver depression and spleen deficiency .

【學(xué)位授予單位】：中國中醫(yī)科學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R259;R249

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