本文選題：姚乃禮 + 傳承�。� 參考：《中國中醫(yī)科學院》2016年博士論文

【摘要】：中醫(yī)學是發(fā)祥于中國古代的研究健康、生命、疾病的科學,并在數千年的醫(yī)療實踐中積累了豐富的經驗,形成了獨特的理論體系。中醫(yī)學是中華傳統(tǒng)文化的瑰寶,同時也是世界醫(yī)學體系的重要組成部分。作為一名現代中醫(yī)師,若想真正的學習、掌握它,必須做好傳承工作。作為2012年第五批全國老中醫(yī)藥專家學術經驗繼承項目的繼承人,有幸?guī)煆闹袊嗅t(yī)科學院姚乃禮教授,通過“讀經典、跟名師、多臨床”,以期學習、傳承姚師的臨床經驗,進一步提高自己對中醫(yī)學的認識,爭取成為一名真正、優(yōu)秀的中醫(yī)師。一、文獻綜述1慢性萎縮性胃炎中醫(yī)診療進展從中醫(yī)對慢性萎縮性胃炎(Chronic Atrophic Gastritis,CAG)的病因病機的認識、中醫(yī)對CAG的臨床治療、對CAG的病機證候及其胃鏡像關系的研究等三方面總結了近年來中醫(yī)診治CAG的研究進展。其中中醫(yī)臨床治療部分從自擬方治療、辨證分型治療、針灸及針藥聯合治療等三方面進行了回顧。最后總結了既往研究的不足,并提出了自己的建議。2慢性胃炎胃鏡像與中醫(yī)證候的相關性研究進展從慢性胃炎(Chronic Gastritis,CG)中醫(yī)辨證分型與胃鏡下胃黏膜像的關系、CG中醫(yī)辨證分型與幽門螺桿菌感染的關系、CG患者舌象與胃鏡像的關系等三方面總結了近年來中醫(yī)學者對CG胃鏡像與中醫(yī)證候相關性研究的進展。最后總結了既往研究的不足,并提出了自己的建議。二、姚乃禮教授治療脾胃病的學術思想及思辨特點姚乃禮教授治療脾胃病的學術思想歸納為：“補益脾胃為本,和衡二法為常,通絡解毒為要,微觀辨治為輔”。分別從以下8個方面加以論述：①補益脾胃以固本：姚師認為脾胃虛弱是脾胃病的發(fā)病之本,包括脾氣虛或胃陰虛,以脾氣虛為主要致病因素,故治療脾胃病時強調以補益脾胃為本；②病證雙辨,尤重舌脈：主張辨病辨證與專病專方相結合,這其中尤其重視舌診、脈診,從而提高辨治的精準性；③注重調和肝脾,擅用“和法”：脾胃病多與情緒相關,姚師十分重視肝臟對脾胃功能的影響,擅用“和法”調和肝脾,治療脾胃��；④治中焦如衡,“衡法”為要：根據脾胃的生理病理特點,以“治中焦如衡”為指導辨治脾胃病的重要治則,通過“衡法”來糾正脾胃陰陽、寒熱、濕燥等偏盛的病理狀態(tài),恢復其正常生理功能；⑤疑難病重視從絡病論治：在臨床治療脾胃病的疑難病時,若符合絡病的發(fā)病特點則從絡病論治,如萎縮性胃炎及癌前病變、病毒性肝炎及肝炎后肝硬化；⑥重視微觀辨證：姚師診治脾胃病時,主張在宏觀辨證的基礎上,重視胃鏡下的微觀表現,宏微相參以準確辨治；⑦“治未病”思想貫穿始終：姚師認為“治未病”與脾胃病關系密切,若在脾胃病發(fā)作之初把握先機、盡早治療,則可未病先防、既病防變、瘥后防復； ⑧部分脾胃病診治經驗舉隅：總結了姚師診治頑固性便秘及運用“啟陷湯”加減治療難治性胃食管反流病的經驗。三、姚乃禮教授治療慢性萎縮性胃炎的臨床經驗研究1慢性萎縮性胃炎的基本病機特點總結了姚師從“絡病理論”探討慢性萎縮性胃炎及其癌前病變的病機特點。CAG的病機演變呈現為由氣及血入絡的病勢規(guī)律,“脾虛絡阻毒損”為CAG的根本病機。其中,脾胃虧虛是CAG的發(fā)病之本、始動因素；胃絡瘀阻是致病的關鍵條件；毒損胃絡是CAG演變?yōu)榘┣安∽?Precancerous lesions of gastric cancer, PLGC)的重要因素。病機演變表現為：脾胃虧虛→胃絡瘀組→毒損胃絡,即因虛致瘀,蘊久化毒。2基于“絡病理論”治療慢性萎縮性胃炎經驗根據CAG“脾虛絡阻毒損”的基本病機,姚師確立了“健脾通絡解毒”的治療法則,主要從補益脾胃、活血通絡、解毒散結三方面治療,并設立了“健脾通絡解毒方”為治療CAG基本方。臨診時,姚師重視胃鏡像表現,宏觀與微觀辨證相結合以提高中醫(yī)辨證的準確度,辨析“脾虛”、“絡阻”、“毒損”三者的虛實主次,以“健脾通絡解毒方”為基本方加減治療,從而有效治療本病,延緩甚則逆轉癌變趨勢。3“健脾通絡解毒方”治療萎縮性胃炎的療效觀察觀察慢性萎縮性胃炎患者33例,應用“健脾通絡解毒方”為基礎方,宏微辨證加減用藥治療。研究結果：①癥狀積分：經“健脾通絡解毒方”宏微辨證加減治療后,各主要、次要癥狀積分療后均低于療前,其中胃脘脹滿、胃部喜按、情志變化、嘈雜、口苦、胸悶、惡心、嘔吐、面色晦滯、咽喉異物感等諸癥療后較療前統(tǒng)計學有顯著性差異(P0.05)。并進一步對主癥、次癥及主次癥總積分進行療前療后比較,發(fā)現治療后主癥、次癥及總積分均明顯低于療前,統(tǒng)計學上均有顯著性差異(P0.05)。33例患者經治療,治愈1例(3.0%),顯效19例(57.6%),有效11例(33.3%),無效2例(6.1%),臨床總有效率93.9%,提示本方案治療CAG療效明顯、確切。②治療后萎縮及腸化積分均低于療前,其中療后腸化積分明顯低于療前(P0.05)；萎縮加重者為26.3%,腸化程度加重者為10.5%,腸化程度減輕者為57.9%。提示本次治療對于減輕萎縮及腸化程度有一定意義,其中減輕腸化療效較為明顯,可能對延緩甚至逆轉慢性胃炎→CAG→PLGC→胃癌(gastric cancer,GC)的演變趨勢具有一定意義。四、慢性胃炎胃鏡像的中醫(yī)證候屬性研究1姚乃禮教授結合胃鏡像微觀辨治慢性胃炎經驗分別從胃黏膜像、胃粘液像、胃運動像、胃增生像等四個方面探析慢性胃炎胃鏡像的中醫(yī)證候屬性,據此總結了姚師微觀辨治慢性胃炎的經驗。結論如下。傾向于“熱證”的胃鏡像：①胃黏膜呈絳紅色或櫻桃紅,伴充血水腫明顯；②胃液為黃綠色,質地粘稠渾濁者；③胃蠕動增快,甚至胃蠕動紊亂。傾向于“血瘀證”的胃鏡像：①胃黏膜色澤暗紅,伴黏膜下血管網隱見；②胃黏膜粗糙不平,伴結節(jié)狀或顆粒狀增生。傾向于“氣虛”的胃鏡像如下：①胃黏膜色澤蒼白；②胃蠕動減緩,伴胃液質稀量大；③幽門口松弛,呈開放狀。傾向于“氣滯”的胃鏡像：幽門閉合不開。傾向于“陰虛”的胃鏡像如下：胃液減少,胃黏膜呈龜裂狀。胃黏膜蒼白、出血糜爛、胃液呈黃綠色等表現的中醫(yī)證候屬性較為復雜,需進一步辨析。①胃黏膜蒼白：若同時胃黏膜光滑、黏膜下血管網未顯露,伴有胃蠕動減緩,則為脾陽虧虛,陽虛內寒；若胃黏膜粗糙不平,黏膜下可見樹枝狀血管網顯露,則為脾氣虧虛,兼夾血瘀。②胃黏膜糜爛、出血：若胃黏膜明顯充血紅腫,出血灶為鮮紅色,則為胃熱熾盛、迫血妄行；若胃黏膜呈暗紅色或灰白色,黏膜凹凸不平,多為胃絡瘀滯,血不循經；若胃黏膜色澤蒼白,蠕動減緩,出血灶為暗紅色陳舊出血或血痂,則多為脾胃氣虛,氣不攝血。③胃液呈黃綠色：若胃黏膜以紅相為主,伴有黏膜充血糜爛,提示為肝膽濕熱,膽汁上逆；若胃黏膜以白相為主,胃蠕動明顯減緩,則為脾胃氣虛,膽汁上逆。2 1167例慢性胃炎患者胃鏡像中醫(yī)證候屬性的臨床研究通過調查表收集了1167例慢性胃炎患者的胃鏡像表現,以深入研究慢性胃炎胃鏡像的中醫(yī)證候屬性。結論如下：①脾胃濕熱證與膽汁反流及粘液池在統(tǒng)計學上有顯著性差異,脾胃濕熱證較其他證型易出現膽汁反流、粘液池呈黃綠色(P0.05)。②脾胃虛弱(含虛寒)證與病變部位在統(tǒng)計學上有顯著性差異,提示全胃炎多發(fā)生于脾胃虛弱(含虛寒)證中(P0.05)。③脾虛氣滯證與賁門狀態(tài)在統(tǒng)計學上有顯著性差異(P0.05),提示脾虛氣滯證較其他證型易出現賁門松弛或疝囊形成。④黏膜色澤、黏膜顆粒樣改變及胃鏡下診斷與胃絡瘀阻證在統(tǒng)計學上均有顯著性差異,提示胃絡瘀阻證在黏膜以白相為主、呈顆粒樣改變及鏡下診斷為萎縮性胃炎等方面較其他證型多見(P0.05)。⑤胃絡瘀阻證與黏膜糜爛在統(tǒng)計學上有顯著性差異,提示胃絡瘀阻證出現黏膜糜爛者多于其他證型(P0.05)。⑥證型與黏膜血管網改變之間統(tǒng)計學上有顯著性差異,其中胃絡瘀阻(34.7%)及胃陰不足(28.0%)兩型黏膜血管網改變的比例較高(P0.05)。⑦進一步行l(wèi)ogistic統(tǒng)計分析,黏膜血管網改變、黏膜糜爛與胃絡瘀阻證關系較為密切,回歸方程模型的適配度有顯著性意義(P0.05)。提示胃絡瘀阻證胃鏡下黏膜出現血管網改變及糜爛的可能性明顯大于其他證型。部分佐證了姚師關于慢性胃炎微觀辨證的學術觀點。分析病理檢查結果與證候的關系,初步得出結論：CAG與胃絡瘀阻證關系較為密切(P0.05),其次多出現胃陰不足、脾胃虛弱(含虛寒)等脾虛證。提示CAG多見于胃絡瘀阻證、脾胃虧虛證,一定程度上佐證了姚師認為“脾虛絡阻毒損”為萎縮性胃炎基本病機的學術觀點。上述結論表明胃黏膜像與中醫(yī)證候有較為密切的關系,據此建立了據胃黏膜像辨證流程圖。
[Abstract]:Traditional Chinese medicine is a science that originated in ancient China to study health, life and disease. It has accumulated rich experience in thousands of years of medical practice and formed a unique theoretical system. Traditional Chinese medicine is the gem of Chinese traditional culture and an important component of the medical system of the world. As a modern Chinese medicine teacher, we want to learn true. As the successor of the fifth batch of Chinese traditional Chinese medicine experts' academic experience in 2012, he was fortunate to learn from Professor Yao Naili of the Chinese Academy of traditional Chinese medicine (Chinese Academy of traditional Chinese Medicine) by "reading classics, with famous teachers and more clinical" in order to learn and inherit the clinical experience of Yao teachers and to further improve their understanding of traditional Chinese medicine. In order to become a real and excellent doctor of traditional Chinese medicine. 1, literature review 1 the development of TCM diagnosis and treatment of chronic atrophic gastritis from the etiology and pathogenesis of chronic atrophic gastritis (Chronic Atrophic Gastritis, CAG), the clinical treatment of CAG, the pathogenesis of CAG and the study of the relationship of gastroscope, and so on in recent years. The research progress of Chinese medicine and treatment of CAG, the clinical treatment part of traditional Chinese medicine was reviewed from three aspects, such as self-made prescription, syndrome differentiation, acupuncture and acupuncture combined with acupuncture and medicine. Finally, the deficiency of previous research was summarized, and the relevant research progress of.2 chronic gastritis gastric image and TCM syndrome was proposed from chronic gastritis (Chr Onic Gastritis, CG) the relationship between TCM syndrome differentiation and gastric mucosal image under gastroscope, the relationship between the syndrome differentiation of CG and Helicobacter pylori infection, the relationship between the tongue image of CG and the mirror of the stomach in CG patients, summarized the progress in the study of the correlation between the CG and the TCM syndromes of the Chinese medicine in recent years. Finally, the deficiency of the previous study was summed up, and the shortcomings of the previous research were summarized. Two, Professor Yao Naili's academic thought and speculative characteristics for the treatment of spleen and stomach disease, Professor Yao Naili's academic thoughts on the treatment of spleen and stomach diseases are summed up as: "replenishing the spleen and stomach, and balancing two laws, collaterals, detoxification, and micro differentiation as auxiliary". From the following 8 sides to discuss: (1) tonifying the spleen and stomach to fix: Yao Division: Yao teacher It is believed that spleen and stomach weakness is the basis of spleen and stomach disease, including spleen qi deficiency or stomach yin deficiency, and spleen qi deficiency as the main pathogenic factor, so the spleen and stomach is emphasized in the treatment of spleen and stomach disease. 3. To harmonize liver and spleen, use "and method": the spleen and stomach disease is related to emotion, Yao teacher attaches great importance to the influence of liver to spleen and stomach function, to harmonize liver and spleen with the method of "harmony", to Treat Spleen and stomach disease; (4) to cure spleen and stomach disease, and to treat the spleen and stomach according to the physiologic and pathological characteristics of the spleen and stomach, and to distinguish the spleen and stomach disease with the guidance of "treating central coke as a balance" The important rule is to correct the pathological state of spleen and stomach yin, Yang, yin and Yang, cold and heat, wet dryness and so on, and restore its normal physiological function by "Heng Fa". 5. The difficult and difficult diseases should be treated from the theory of collateral disease. In the clinical treatment of the difficult diseases of the spleen and stomach disease, if the disease is conformed to the characteristics of the collateral disease, it is treated from the collateral disease, such as atrophic gastritis and precancerous lesions, viral hepatitis and Liver cirrhosis after hepatitis; 6. Pay attention to microscopic syndrome differentiation: Yao teacher's diagnosis and treatment of spleen and stomach disease, advocate on the basis of the macroscopic syndrome differentiation, pay attention to the microscopic manifestation under the gastroscope, macro and microscopical reference to accurately identify and treat; and the "cure the disease" thought through all the time: Yao teacher thinks that "the treatment of the disease" is closely related to the spleen and stomach disease, and if the first opportunity is grasped at the beginning of the attack of the spleen and stomach disease, we should do the best. Three, Professor Yao Naili's clinical experience in treating chronic atrophic gastritis (1 chronic atrophic gastritis). The characteristics of basic pathogenesis summarized Yao's pathogenesis of chronic atrophic gastritis and the pathogenesis of precancerous lesions from the theory of collateral disease. The pathogenesis of the pathogenesis of.CAG, which is the basic pathogenesis of CAG, is "spleen deficiency and collateral damage", and the deficiency of the spleen and stomach is the origin of the pathogenesis of CAG and the factors of initial movement; the stasis of the stomach and collaterals is the pathogeny. The key conditions of the toxic damage to the stomach and collaterals are the important factors of the evolution of CAG to the Precancerous lesions of gastric cancer (PLGC). The evolution of the pathogenesis is: deficiency of the spleen and stomach, the group of gastric collateral stasis, and the toxic loss of the stomach and collaterals, that is, the deficiency of the blood stasis, and the chronic atrophic gastritis based on the theory of collateral disease for the treatment of chronic atrophic gastritis based on the theory of collateral disease, based on the spleen deficiency collaterals. The basic pathogenesis of "poison damage", Yao Division established the treatment principle of "invigorating the spleen and collaterals and detoxifying", mainly from three aspects of nourishing the spleen and stomach, activating blood circulation to collaterals, detoxifying and dissolving the knot, and setting up the basic prescription of "invigorating the spleen and collaterals and detoxifying the poison", and setting up the basic prescription for the treatment of CAG. To make sure of the "Spleen Deficiency", "collaterals", "toxic loss", the main and the secondary of the three, with "Jianpi Tongluo Jiedu Fang" as the basic prescription treatment, so as to effectively treat the disease, and delay the tendency to reverse the trend of canceration,.3 "Jianpi Tongluo Jiedu" therapeutic effect of atrophic gastritis in the treatment of chronic atrophic gastritis, 33 cases of chronic atrophic gastritis, the application of "health" "Spleen Tongluo Jiedu recipe" as the basis, macro and micro differentiation and reduction of the treatment of drugs. There was significant difference (P0.05) compared with pre treatment statistics after the treatment of the throat foreign body sensation and other symptoms. Furthermore, the main symptoms, secondary symptoms and the total score of primary and secondary symptoms were compared, and the main symptoms, secondary symptoms and total scores were significantly lower than before treatment. There were significant differences (P0.05) in.33 patients, 1 cases (3%) were cured, and 19 were significantly effective. Cases (57.6%), effective 11 cases (33.3%), invalid 2 cases (6.1%), the total effective rate was 93.9%, suggesting that the therapeutic effect of CAG was obvious, accurate. 2. After treatment, the atrophy and intestinal integration were lower than before treatment, and the intestinal integration was significantly lower than before treatment (P0.05), atrophy plus weight was 26.3%, intestinal metaplasia was 10.5% and intestinal metaplasia was 57.9%. It is of certain significance to reduce the degree of atrophy and intestinal metaplasia. It is more obvious to reduce the effect of intestinal metaplasia. It may be of certain significance to postpone or reverse the evolution trend of chronic gastritis, CAG, PLGC, gastric cancer (gastric cancer, GC). Four, study of TCM syndrome properties of chronic gastritis with gastroscope image 1 professor Yao Naili combined with gastroscope Like micro differentiation and treatment of chronic gastritis experience, the TCM syndrome attributes of chronic gastritis and stomach mirrors were analyzed from four aspects of gastric mucosal image, gastric mucus image, gastric motility image, gastric hypertrophy and so on. According to this, the experience of Microcosmic Differentiation and treatment of chronic gastritis was summarized. Concomitant congestion and edema; (2) gastric juice is yellow green, sticky and cloudy; (3) gastric peristalsis faster, even gastric peristalsis disorder. The stomach mirror image of "blood stasis syndrome": (1) the color and lustre of the gastric mucosa is dark red with submucosal vascular network, and the gastric mucosa is rough, with nodular or granular hyperplasia. The gastroscope of the "Qi Deficiency" is like the gastroscope like "Qi Deficiency". Below: (1) the color and lustre of the gastric mucosa is pale; the gastric peristalsis slows down, and the gastric juice is thin and large; (3) the quiet door is relaxed and open. The stomach mirror of "qi stagnation" is not closed. The stomach mirrors of "Yin Deficiency" are as follows: the gastric juice is reduced, the gastric mucosa is cracked. The gastric mucosa is pale, bleeding and yellow green. The syndromes of traditional Chinese medicine are more complex and need to be further discriminated. (1) gastric mucosa paleness: if the gastric mucosa is smooth, the submucosal vascular network is not exposed and the gastric peristalsis slows down, the spleen yang deficiency and the Yang deficiency are cold; if the gastric mucosa is rough and the mucous membrane is unflat and the dendritic vascular network is revealed under the mucous membrane, it is the deficiency of spleen qi and blood stasis. Secondly, the gastric mucosa erosion, and the gastric mucosa erosion Blood: if the gastric mucosa is obviously congested and swollen, the bleeding focus is bright red, the stomach is hot and the blood is forced to go. If the gastric mucosa is dark red or gray, the mucous membrane is uneven, most of the stomach and blood stasis, blood does not follow the meridian; if the gastric mucosa is pale, the peristalsis slows down, the bleeding focus is dark red old bleeding or blood scab, it is mostly spleen stomach qi deficiency, Qi is not taken blood. (3) the gastric juice is yellow green: if the gastric mucosa is mainly red, accompanied by mucosal hyperemia and erosion, it is suggested that the liver and gallbladder are damp heat and the bile is reverse. If the gastric mucosa is mainly white, the gastric peristalsis is obviously slowed down, then the spleen and stomach qi deficiency, the clinical study of the TCM Syndromes of 1167 cases of chronic gastritis with the reverse.2 of the bile, 1167 cases are collected by the questionnaire. The manifestation of gastric mirror image of the patients with gastritis in order to study the TCM Syndromes of chronic gastritis and gastric mirrors. The conclusions are as follows: (1) there is significant difference between the spleen and stomach damp heat syndrome and the bile reflux and the mucous pool, and the spleen and stomach damp heat syndrome is easier to appear bile reflux than the other syndrome types, and the mucous pool is yellow green (P0.05). The lesion sites were statistically significant differences, suggesting that the total gastritis mostly occurred in the spleen and stomach weakness (P0.05). (3) there was a significant difference between the spleen qi stagnation syndrome and the cardia state (P0.05), suggesting that the spleen qi stagnation syndrome is more likely to appear cardia relaxation or hernia sac than the other syndrome types. There were significant differences between the gastroscope diagnosis and the stomach stasis syndrome, suggesting that the gastric stasis syndrome was mainly white in the mucous membrane, the particle change and the diagnosis of atrophic gastritis were more common than the other syndromes (P0.05). 5. There were significant differences in the statistical study of gastric stasis syndrome and mucous erosion, suggesting the appearance of gastric stasis syndrome. There were more than other syndrome types (P0.05). 6. There were significant differences between the syndrome type and the changes of mucosal vascular network. The proportion of gastric collateral stasis (34.7%) and gastric Yin deficiency (28%) was higher (P0.05). (7) further logistic statistical analysis, mucosal vascular network change, mucous erosion and gastric stasis syndrome clearance The adaptability of the regression equation model was significant (P0.05). It was suggested that the changes of vascular network and erosion in the gastric mucosa with gastric stasis syndrome were obviously greater than that of other syndromes. Conclusion: the relationship between CAG and gastric stasis syndrome is more closely related (P0.05), followed by deficiency of stomach yin, spleen and stomach weakness (containing deficiency cold) and other spleen deficiency syndrome. It suggests that CAG is more common in gastric stasis syndrome and deficiency syndrome of spleen and stomach. To a certain extent, the academic viewpoint of Yao division that "spleen deficiency collateral damage" is the basic pathogenesis of atrophic gastritis. Mucous membrane is closely related to TCM syndromes. Based on this, a flow chart based on differentiation of gastric mucosa is established.
【學位授予單位】：中國中醫(yī)科學院
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R259;R249

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