【摘要】：錢英教授,男,1937年出生,天津市人,首都醫(yī)科大學(xué)教授,主任醫(yī)師,國家級名老中醫(yī)。第三、四、五批全國老中醫(yī)藥專家學(xué)術(shù)經(jīng)驗繼承工作指導(dǎo)老師。錢英教授具有50余年臨床經(jīng)驗,以中醫(yī)肝病診療最為擅長,兼治腎病及雜病。50余年的臨床、教學(xué)和科研經(jīng)歷,使錢英教授擁有豐富的臨床經(jīng)驗和較高的中西醫(yī)理論功底,尤其在中醫(yī)藥治療肝病方面造詣頗深,倡導(dǎo)“體用同調(diào)”、“肝病固腎”和“和血法”治療各種肝病,療效卓著。本論文主要由錢英教授學(xué)術(shù)思想淵源、整理挖掘錢英教授學(xué)術(shù)思想、臨床經(jīng)驗及和血法治療乙肝肝硬化代償期的理論和臨床研究三部分組成。第一部分主要從錢英教授特殊的學(xué)習(xí)、成長和工作經(jīng)歷入手,探尋其學(xué)貫中西、博采眾長、兼收并蓄、師古而不泥古、勇于創(chuàng)新豐富的學(xué)術(shù)思想形成淵源。第二部分主要整理錢英教授學(xué)術(shù)思想和臨床經(jīng)驗,包括“體用同調(diào)”和“肝病固腎”學(xué)術(shù)思想總結(jié)和臨床經(jīng)驗總結(jié)。本部分首先總結(jié)了錢英教授兩個重要的學(xué)術(shù)思想,即體用同調(diào)和肝病固腎。體與用,本來是中國古代哲學(xué)中的一對范疇。體,指本體,用,指功能活動。中醫(yī)學(xué)用體和用來闡述生理物質(zhì)基礎(chǔ)與功能活動之間的關(guān)系。五臟均有體和用。肝體包括肝血與肝陰,肝用包括肝陽和肝氣。錢英教授認(rèn)為慢性肝病由輕到重的發(fā)生發(fā)展過程就是肝體受損而肝用失調(diào)的過程,即肝臟的生理結(jié)構(gòu)物質(zhì)基礎(chǔ)受到損害,而功能活動作用障礙,二者不協(xié)調(diào)的過程。因此,錢英教授提出治療肝病應(yīng)體用同調(diào)。“體用同調(diào)”的“調(diào)”首先是指調(diào)節(jié)肝本臟的肝體和肝用,即調(diào)養(yǎng)肝體,養(yǎng)肝血補(bǔ)肝陰柔肝體,為肝用提供物質(zhì)條件；同時調(diào)節(jié)肝用,疏肝氣補(bǔ)肝陽調(diào)肝用,發(fā)揮肝臟的正常生理功能。其次“體用同調(diào)”的“調(diào)”還指調(diào)節(jié)由肝累及他臟的他臟體用失常。錢英教授根據(jù)“肝腎同源”的理論,提出“見肝之病,其源在腎,亟當(dāng)固腎”的學(xué)術(shù)思想。他認(rèn)為慢性肝炎、肝纖維化、肝硬化、甚至肝癌的發(fā)生過程就是正虛邪戀、正不達(dá)邪的過程。正氣虧虛從根本上說首先是素體先天腎精不足；肝病日久,體用失調(diào),勢必子盜母氣,累及腎臟,導(dǎo)致腎陰腎陽虧虛。錢英教授提出治療肝病應(yīng)及早固腎,滋補(bǔ)腎陰、溫補(bǔ)腎陽以求陽中求陰、陰中求陽�；蛳日{(diào)肝后補(bǔ)腎,或先補(bǔ)腎后調(diào)肝,或重在肝,或重在腎,或重在陰或重在陽,靈活使用肝腎同治法,方能應(yīng)對復(fù)雜多變之證候。錢英教授強(qiáng)調(diào)亟當(dāng)固腎,并不排斥當(dāng)先實脾,他主張肝病的治療先后天并重,重視調(diào)理肝脾腎。其次本部分還總結(jié)了錢英教授的臨床經(jīng)驗,包括治療肝病的臨床經(jīng)驗總結(jié)和其他疾病總結(jié)。在肝病治療方面,總結(jié)了“快速截斷、逆流挽舟”治療慢性重型肝炎,扶正、解毒、化瘀治療肝癌,三焦氣化理論治療肝硬化腹水,祛濕、化痰、解毒、化瘀治療黃疸,體用同調(diào)、和肝解毒治療慢性乙型肝炎,肝腎同治、陰陽雙補(bǔ)治療肝性脊髓病,健脾祛濕、化痰通絡(luò)治療脂肪肝,祛濕化痰、解毒化瘀治療酒精性肝病,益氣養(yǎng)陰、調(diào)節(jié)免疫治療自身免疫性肝炎,理氣養(yǎng)陰、和血補(bǔ)腎治療原發(fā)性膽汁性肝硬化等十個方面。在其他疾病治療方面總結(jié)了泌尿系感染,乙肝相關(guān)性腎炎,IgA腎病,消化性潰瘍,梅核氣的治療。第三部分對錢英教授和血法治療乙肝肝硬化代償期的理論進(jìn)行總結(jié)并進(jìn)行了臨床研究。1、和血法治療肝病的理論研究錢英教授受中醫(yī)歷代醫(yī)家有關(guān)血證理論的影響,尤其受到其恩師秦伯未、關(guān)幼波、的影響,以及名老中醫(yī)劉奉五的影響。秦伯未先生認(rèn)為“在和血的基礎(chǔ)上行血,在行血的基礎(chǔ)上逐瘀,這是一個原則；再從瘀阻的原因,或加溫藥散其寒凝,或加氣藥疏其郁結(jié),這是處方的方法”。關(guān)幼波先生治療肝病提出“治病必治本,氣血要遵循”、“治黃必治血,血行黃易卻”。中醫(yī)婦科名家劉奉五先生“若欲通之、必先充之”。錢英教授深受這些學(xué)術(shù)觀點(diǎn)的影響,結(jié)合肝臟的生理病理特點(diǎn),以及自己深刻的臨床感悟,認(rèn)為肝血不和是肝病發(fā)生的基礎(chǔ),提出和血法治療慢性肝病的學(xué)術(shù)思想。他認(rèn)為和血法是屬于扶正為主、祛邪為輔的治療大法；治療慢性肝病不用血分藥,是藥不達(dá)所,猶如隔靴搔癢；“瘀血阻絡(luò)”雖然是慢性肝病的核心證候之一,但治療要以調(diào)和氣血為大綱,以體用同調(diào)為要旨,立足于“和”字,和血法包括補(bǔ)血養(yǎng)血和活血化瘀,而非單純活血化瘀。錢英教授認(rèn)為“和血法”兼具“理血法”和“和法”的含義,含有理血法的各種特點(diǎn),兼和法之精要。2、和血法治療乙肝肝硬化代償期的的臨床研究肝硬化在人類主要死亡原因中居第4位或第6位,在我國,由慢性乙型肝炎導(dǎo)致的乙型肝炎肝硬化是肝硬化的最主要原因。如何防治乙型肝炎肝硬化,延緩肝硬化的發(fā)展進(jìn)程,減少肝硬化失代償期的發(fā)生,減少不良結(jié)局發(fā)生,延長患者生命,提高患者的生活質(zhì)量,對患者進(jìn)行經(jīng)濟(jì)有效的醫(yī)學(xué)干預(yù),一直是國內(nèi)中醫(yī)藥臨床研究的熱門。錢英教授提出和血法治療慢性肝病,對乙肝肝硬化代償期患者,進(jìn)行了長期深入的研究,根據(jù)多年的臨床經(jīng)驗,創(chuàng)制了和血調(diào)肝湯。本論文臨床研究的目的：觀察和血調(diào)肝湯治療乙型肝炎肝硬化的臨床療效及安全性。方法：遵循隨機(jī)、對照的臨床研究原則,將60例符合乙型肝炎肝硬化血瘀證診斷的患者,隨機(jī)分為治療組30例和對照組30例。治療組給予口服恩替卡韋分散片0.5毫克,每日一次,并每日口服和血調(diào)肝湯；對照組給予口服恩替卡韋分散片0.5毫克,每日一次,療程均為12周。觀察治療前后患者癥狀體征積分變化情況,治療前后肝功能、乙肝病毒DNA、肝纖維化四項、甲胎蛋白指標(biāo)；治療前后門靜脈內(nèi)徑(DPV)、門靜脈血流速度(VPV)、脾靜脈內(nèi)徑(DSV)、脾靜脈血流速度(VSV)；治療前后肝臟硬度值LSM變化。檢測治療前后血常規(guī)、尿常規(guī)、大便常規(guī)、心電圖、腎功能的變化來判定用藥安全性。結(jié)果：1、治療前后癥狀評分比較：兩組均能改善臨床癥狀和體征的作用,治療組優(yōu)于對照組,兩組比較有統(tǒng)計學(xué)差異(P0.05)。2、療效評價：治療組總有效率為71.6%,對照組總有效率為30%,治療組優(yōu)于對照組,兩組比較有統(tǒng)計學(xué)差異(P0.05)。3、治療前后肝功能比較：肝功能指標(biāo)中ALT、AST在治療組及對照組在治療期均呈現(xiàn)下降趨勢,其中治療組下降程度更明顯,但與治療對照組比較無統(tǒng)計學(xué)意義p0.05;總膽紅素(TBIL)在兩組均呈現(xiàn)下降趨勢,治療組下降程度更明顯,治療12w時,兩組比較有明顯差異(P0.01)。治療12周,前白蛋白在治療組呈現(xiàn)上升,而對照組呈現(xiàn)下降,兩組比較有明顯差異(P0.05)。4、治療前后肝纖維化四項比較：治療12w,兩組血清HA、 IV-C、 P-ⅢP、 LN均較基線下降,治療組基線與12w比較,差異顯著P0.01；對照組基線與12w比較,無顯著性差異。治療12w,兩組組間比較,P0.05,無顯著性差異。5、治療前后甲胎蛋白比較：治療期間兩組甲胎蛋白變化不明顯,差異無統(tǒng)計學(xué)意義(p0.05)。6、治療前后乙肝病毒DNA載量比較：治療12周,兩組HBV-DNA載量比較,差異無統(tǒng)計學(xué)意義(p0.05)。7、治療前后B超指標(biāo)比較：治療12w,治療組門靜脈內(nèi)徑(Dpv)、脾靜脈內(nèi)徑(Dsv)較對照組門靜脈內(nèi)徑(Dpv)、脾靜脈內(nèi)徑(Dsv)均縮小,有非常顯著性差異(P0.01);治療組Dpv和Dsv治療前后,有顯著性差異(P0.05)；而對照組Dpv和Dsv治療前后,無顯著性差異(P0.05)。治療12w,治療組門脈血流速度(Vpv)、脾靜脈血流速度(Vsv)較對照組門脈血流速度(Vpv)、脾靜脈血流速度(Vsv)減慢,兩組比較,均有顯著性差異(P0.05)。8、兩組治療前后肝臟硬度值LSM變化：觀察組和對照組分別有26例、30例完成Fibroscan,治療12w,兩組LSM均較基線降低；但治療組基線與12w比較,有非常顯著性差異,P0.01；而對照組基線與12w比較,無顯著性差異(P0.05)。治療12w,兩組組間比較LSM, P0.05,有顯著性差異。9、安全性指標(biāo)：治療前后血常規(guī)、尿常規(guī)、大便常規(guī)、心電圖、腎功能均未見異常,兩組間變化差異無統(tǒng)計學(xué)意義(P0.05),無不良事件發(fā)生。結(jié)論：(1)和血調(diào)肝湯可改善乙型肝炎肝硬化患者的臨床癥狀,提高患者的生活質(zhì)量。(2)和血調(diào)肝湯可以改善乙型肝炎肝硬化代償期患者肝功能,尤其在降低總膽紅素和提高血清白蛋白方面效果較好；降低門靜脈系統(tǒng)壓力,減慢門靜脈及脾靜脈血流速度以及縮小門靜脈及脾靜脈內(nèi)徑方面效果明顯；改善肝纖維化指標(biāo)方面有顯著臨床意義,但在降低乙肝病毒DNA載量和甲胎蛋白方面療效不顯著。(3)和血調(diào)肝湯可改善乙型肝炎肝硬化代償期患者的肝臟硬度值。和血調(diào)肝湯具有用藥安全性。
[Abstract]:Professor Qian Ying, male, born in 1937, Tianjin City, Professor of Capital Medical University, chief physician, national famous old Chinese medicine. Third, fourth, the five batch of national traditional Chinese medicine experts' academic experience inheriting work instructor. Professor Qian Ying has more than 50 years of clinical experience, the most good at diagnosis and treatment of liver disease in Chinese medicine, and the treatment of kidney and miscellaneous diseases for the rest of the year of.50 clinical, teaching The experience of study and scientific research makes professor Qian Ying have rich clinical experience and high theory of Chinese and Western medicine, especially in the treatment of liver disease in Chinese medicine. It advocates "body use homology", "liver disease fixing kidney" and "Blood Law" to treat various liver diseases. This article is mainly based on the origin of Professor Qian Ying's academic thought. Professor Qian Ying is composed of three parts: academic thought, clinical experience and the theory and clinical study of liver cirrhosis compensatory period with blood method. The first part is mainly from Professor Qian Ying's special learning, growth and work experience to explore the academic thought of learning from the Chinese and the West. The second part mainly collects the academic thought and clinical experience of Professor Qian Ying, including the summary of the academic thought of "body and use homology" and "liver disease fixing kidney". This part first summarizes the two important academic ideas of Professor Qian Ying, namely, the body and the liver disease, the body and the use, originally in Chinese ancient philosophy. "A pair of categories. The body, refers to the body, used, and refers to functional activities. The relationship between the body of Chinese medicine and the relationship between the physical material base and the functional activities. The five organs have the body and use. The liver body includes liver and liver yin, and the liver uses liver Yang and liver qi. The process of regulating the physical structure of the liver is damaged, and the functional activity is impaired and the two is not coordinated. Therefore, Professor Qian Ying put forward the same adjustment for the treatment of liver diseases. "The tune" of "body use homology" first refers to the regulation of liver body and liver of the liver, that is, the liver body, the liver blood supplementing the liver and the liver and the liver, for the liver. Providing material conditions, regulating liver use, dispersing liver and liver Yang regulating liver, exerting the normal physiological function of the liver. Secondly, the "tune" of "body with the same tune" also refers to the adjustment of his dirty body involving the liver and his dirty. According to the theory of "liver and kidney origin", Professor Qian Ying's academic thoughts on the disease of the liver, its origin in the kidneys and the kidneys in urgent need. He thinks that the process of chronic hepatitis, liver fibrosis, liver cirrhosis and even liver cancer is the process of false and evil love, which is not the process of evil. The deficiency of positive Qi is fundamentally the deficiency of the congenital kidney essence of the vegetarian body; the liver disease is long, the body is misadjusted, it is bound to steal the mother Qi, and involve the kidney, causing the deficiency of kidney yin and kidney yang. Early fixation of kidney, nourishing kidney yin, invigorating kidney yang to seek Yang in the Yang, Yin in the Yang, or the first tonifying the liver, or the first tonifying the kidney, or reinventing the liver, or again in the liver, or heavy in the kidney, or heavy in the yin or the Yang, and flexibly using the hepatorenal therapy, can deal with the complex and changeable syndrome. In this part, the clinical experience of Professor Qian Ying, including the summary of clinical experience in the treatment of liver disease and the summary of other diseases, was summed up in this part. In the treatment of liver disease, the treatment of chronic severe hepatitis, Fuzheng, detoxification, removing stasis for the treatment of liver cancer and the theory of gasification of triple coke in the treatment of liver diseases The treatment of hepatocirrhosis ascites, dampness, phlegm, detoxification, removing blood stasis to treat jaundice, treatment of chronic hepatitis B, liver and kidney therapy, yin and Yang double complement treatment of hepatic myelopathy, invigorating spleen and dampness, removing phlegm and dredging collaterals to treat fatty liver, removing dampness and eliminating phlegm, removing toxin and removing blood stasis to treat alcoholic liver disease, nourishing qi and nourishing Yin, regulating immunotherapy of autoimmune hepatitis Ten aspects of the treatment of primary biliary cirrhosis, such as Qi Nourishing Yin and nourishing Yin, and blood tonifying kidney. The treatment of other diseases, such as urinary infection, hepatitis B related nephritis, IgA nephropathy, peptic ulcer, and the treatment of plum nuclear gas, was summarized and the third part of the theory of Qian Ying and blood therapy for hepatitis B cirrhosis compensatory period was summarized and carried out in clinical practice. The study of.1, and the theory of blood method for the treatment of liver disease, Professor Qian Ying's influence on the theory of blood syndrome by Chinese medical practitioners, especially his teacher Qin Bowei, the influence of Guan Yu, and the influence of the old Chinese medicine Liu Fengwu. From the cause of the stasis, or the warming medicine to disperse its cold coagulation, or the hyperthermia, it is a prescription method. The influence of the point of view, combined with the physiological and pathological features of the liver, and his profound clinical perception, that the liver blood is not the basis of the liver disease, put forward and the blood method for the treatment of chronic liver disease. "Blood stasis obstructing collaterals" is one of the core syndromes of chronic liver disease, but the treatment should be based on harmonizing Qi and blood as the outline, using the same tone as the keynote, based on the word "and", and blood methods including enriching blood, nourishing blood and activating blood and removing stasis, rather than activating blood and removing blood stasis. The clinical study of liver cirrhosis in the fourth or sixth of the main causes of human death. In China, hepatitis B cirrhosis caused by chronic hepatitis B is the most important cause of liver cirrhosis in China. How to prevent and control hepatitis B in China? Liver cirrhosis, postponing the development of liver cirrhosis, reducing the occurrence of decompensated cirrhosis, reducing the adverse outcome, prolonging the life of the patients, improving the quality of life of the patients, and taking effective medical intervention to the patients, has always been a hot topic in the clinical study of Chinese traditional Chinese medicine. Professor Qian Ying put forward the treatment of chronic liver disease and hepatitis B liver disease with blood method. The patients with sclerotic compensatory period were studied for a long time. According to many years of clinical experience, we created the decoction of blood regulating liver. The purpose of this clinical study was to observe the clinical efficacy and safety of blood regulating liver soup in the treatment of hepatitis B liver cirrhosis. Methods: following the randomized, controlled clinical study principles, 60 cases were conformed to hepatitis B liver hard. The patients diagnosed with blood stasis syndrome were randomly divided into 30 cases in the treatment group and 30 cases in the control group. The treatment group was given 0.5 mg of Entecavir Dispersible Tablets oral and daily oral and blood regulating liver soup, and the control group was given 0.5 mg of Entecavir Dispersible Tablets daily, once a day for 12 weeks. The symptoms and signs of the patients were observed before and after treatment. Liver function, hepatitis B virus DNA, liver fibrosis four, alpha fetoprotein index, portal vein diameter (DPV), portal vein flow velocity (VPV), splenic vein diameter (DSV), splenic vein blood velocity (VSV) before and after treatment, and changes of liver hardness LSM before and after treatment. Blood routine, urine routine, routine of stool, electrocardiogram, kidney before and after treatment. Results: 1. Results: 1, before and after treatment, symptom score comparison: the two groups can improve the effect of clinical symptoms and signs, the treatment group is better than the control group, the two groups have statistical difference (P0.05).2, the curative effect evaluation: the total effective rate of the treatment group is 71.6%, the total effective rate of the control group is 30%, the treatment group is better than the control group, two The group had a statistical difference (P0.05).3, the liver function before and after treatment: the liver function index of ALT, AST in the treatment group and the control group showed a downward trend in the treatment period, and the treatment group decreased more obviously, but compared with the treatment control group, there was no statistical significance P0.05; the total bilirubin (TBIL) in the two groups showed a downward trend, the treatment group under the treatment group. In the treatment of 12W, the two groups were significantly different (P0.01). In the 12 week treatment, prealbumin was increased in the treatment group, while the control group decreased, and the two groups were significantly different (P0.05).4. The four comparison of liver fibrosis before and after treatment: the treatment of 12W, the two groups of serum HA, IV-C, P- III P, LN were all lower than the baseline, and the baseline and 12W in the treatment group. Comparison, the difference was significant P0.01; there was no significant difference between the baseline and the 12W in the control group. The treatment 12W, the comparison between the two groups, P0.05, no significant difference.5, the comparison of alpha fetoprotein before and after treatment: there was no significant change in the alpha fetoprotein in the two groups during the treatment (P0.05).6, and the DNA load comparison of HBV before and after treatment was 12 weeks, There was no significant difference between the two groups of HBV-DNA load (P0.05), and the comparison of B-ultrasound indexes before and after treatment: the treatment of 12W, the internal diameter of the portal vein (Dpv), the internal diameter of the splenic vein (Dsv), the inner diameter of the portal vein (Dpv), the inner diameter of the splenic vein (Dsv), and the significant difference (P0.01); there were significant differences (P0.) before and after the treatment of Dpv and Dsv (P0.) in the treatment group (P0.) 05) and no significant difference (P0.05) before and after treatment of Dpv and Dsv in the control group. The treatment group was treated with 12W, the velocity of portal blood flow (Vpv), the velocity of splenic vein blood flow (Vsv) compared with the control group, the velocity of portal blood flow (Vpv), the velocity of splenic vein (Vsv) slowed, and the two groups were significantly different (P0.05).8, and the liver hardness value LSM changes before and after treatment in the two groups were observed. There were 26 cases in the group and the control group, 30 cases completed Fibroscan, the treatment of 12W, two groups of LSM were lower than the baseline, but the baseline and 12W in the treatment group were significantly different, P0.01, while the control group compared with 12W, there was no significant difference (P0.05). The two groups were compared with LSM, P0.05, significant difference.9, safety index: before treatment: safety index: before treatment: before treatment After blood routine, urine routine, stool routine, electrocardiogram and renal function, there was no significant difference between the two groups (P0.05) and no adverse events. Conclusion: (1) and blood regulating liver soup can improve the clinical symptoms and improve the quality of life of patients with hepatitis B liver cirrhosis. (2) and blood regulating liver soup can improve hepatitis B liver cirrhosis. The liver function of patients in compensatory period is better, especially in reducing total bilirubin and raising serum albumin, reducing portal pressure, slowing down the velocity of portal and splenic vein and reducing the internal diameter of portal vein and splenic vein, and it has significant clinical significance to improve the index of liver fibrosis, but in reducing hepatitis B disease. The effect of toxic DNA load and alpha fetoprotein was not significant. (3) and blood regulating liver soup could improve the liver hardness of the patients with liver cirrhosis and liver cirrhosis. And the decoction of blood regulating liver has the safety of medication.
【學(xué)位授予單位】：北京中醫(yī)藥大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R249;R259

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