【作者】 侯林毅；

【导师】 陈昭定；

【作者基本信息】 北京中医药大学 ， 中医儿科学， 2011， 博士

【摘要】 本研究主要继承陈昭定教授运用脾胃学术思想,治疗儿童常见病和疑难病的临床经验。继承名老中医的经验应该将其个人的学术渊源与时代背景结合起来分析。在儿科临床实践中,老师研读经典,勤求古训,博采众方,取各家之长。逐渐形成了“以脾胃为中心”的辨证思路与用药特色,重视脾胃是其诊治儿科疾病的特点并在治疗时顾护胃气,倡导脾以运为健。王鹏飞的脾胃学术思想是老师的主要学术渊源。老师在临床中不断继承发扬王鹏飞的脾胃学术思想,既重视脾胃,也重视气血,不断开创儿科领域的治疗。创建了胃镜检查室和胃肠电图室,建立了中医儿科脾胃病病区,打开了小儿脾胃病证辨证与辨病相结合,宏观与微观辨证相结合的诊断与治疗,在临床中注重科研,提倡剂型改革,不断地丰富儿科方剂学,使简、便、廉的方药可以更多地方便专用于儿童,在临床实践的探索中取得了多项科研成果,从而促进了中医儿科的学科发展。老师的脾胃学术思想渊源于名老中医的临床经验,但他更注意传承与创新,在小儿脾胃病和疑难重症的治疗运用中体现得更为突出。本研究从以下几方面进行总结。1.陈昭定主任认为小儿泄泻病因病机是脾胃虚弱为本,外邪、饮食、药物、情志等诱发因素为标。病位在脾胃、大肠,久及伤肾,寒热虚实,小儿病情易发生演变。他在辨证论治方面注重分型论治,但强调治病求本；指出小儿泄泻临床宜辨寒热虚实,谨守病机,中西医并重。治疗的经验是强调掌握中药性味归经,深刻理解组方意图,临证中通过配伍用药体现分型辨证思想；并重视中药现代药理研究,从而指导临床用药；促进剂型改革,便于服用,尽量服务患儿。2.重视小儿胃镜的检查手段,开展Hp感染的研究,利用中药治疗小儿慢性胃炎及幽门螺旋杆菌感染。3.认为小儿溃疡病属于“胃脘痛”范畴,胃脘痛病变在胃,与肝脾有密切关系,病因有寒、热、饮食不节、劳倦、血瘀等。治疗应从和胃健脾,理气止痛,活血化瘀着手。4.老师认为神经性厌食很难治疗,辨其虚实或虚中夹实尤为重要,治疗中应重视调节脾胃功能。方药组成：黄精、草寇、砂仁、建曲、焦白术、紫草。5.治疗乳儿肝炎综合征：认为多因母体胎孕之时,湿热熏蒸于胎胞,或产后感受湿热邪毒而致。郁阻于脾胃,熏蒸于肝胆,气机不畅,气滞血瘀,肝胆疏泄失常而发生黄疸。治疗清热祛湿,利胆退黄,疏肝健脾,活血通络是老师治疗黄疸的基本法则。6.儿童注意缺陷多动障碍(ADHD)是以注意缺陷、过度活动和冲动为核心症状,老师特别强调中医根据患儿不同症状、证候进行辨证论治,通过调整人体脏腑、经络气血功能活动及整体功能状态,提高患儿对社会和自然环境的适应能力,中医治疗不仅能改善核心症状还能改善影响患儿生活质量的一些伴随症状,用药安全、可控,可长期服用,且停药后复发率低,同时中西医相互配合,可提高临床疗效,减少西药不良反应。7.治疗过敏性紫癜性肾炎：老师总结多年的临床经验认为儿童紫癜性肾炎的病因病机可分为湿热内蕴、气滞血瘀以及久病肾虚三个方面,另外小儿藩篱不固,兼有风、毒外邪为患。临床表现繁多,病位主要责之肺脾肾,治则清热解毒,凉血止血,老师常用青代、紫草、丹皮、败酱草、赤小豆等。8.治疗小儿班替氏综合征：老师认为气滞、血瘀、食积为病因,结合小儿的病理特点,以活血化瘀,理气消导为主,但小儿毕竟形气未充,脏腑娇嫩,一味攻伐,必定损伤正气,所以在临床治疗时,要固护脾胃,使正气健运,利于去邪,去邪而不伤正,攻补兼施,是其脾胃学术思想的体现,以上是陈昭定主任脾胃学术思想在儿科临床运用的突出经验。临床上应用老师脾胃学术思想研究儿童腹型过敏性紫癜,体现他在临床上宏观与微观辨证相结合,辨病与辨证相结合,并注意对患儿疾病远期预后的随访情况的学术思想,深入研究老师的临床学术经验,提出规范化的研究方案,继承和发扬其脾胃学术思想和临床经验。青紫止痛汤方治疗儿童腹型过敏性紫癜临床研究2009年1月至2010年3月120例确诊腹过型敏性紫癜患儿,其中男：64例,女：56例。年龄最小4岁,最大16岁。3-7岁：19例；8-12岁：68例；>12岁33例。做胃镜结果显示：食管炎：4例；胃炎：9例,十二指肠炎：12例,胃、十二指肠炎：63例,胃溃疡：2例,十二指肠溃疡：30例。合并肾脏损害：43例,占35.8%。感染相关因素：支原体感染：9例,链球菌感染：8例；结核感染：6例,幽门螺旋杆菌感染：2例；单疱病毒、CMV感染各1例。120例患儿中医证候分型,各型之间的构成比：根据临床症状,四诊辨证分型,分为表邪入里,侵犯胃肠型有23例占19.1%；脾胃湿热74例占61.7%；血络受损20例占16.7%；脾肾阳虚3例占2.5%。对60例脾胃湿热型治疗的近期疗效及随访半年的远期疗效脾胃湿热型入选60例,随机分为2组,治疗和对照组各30例,资料经统计学分析具有可比性。治疗组：治愈20例,(66.7%),好转9例(30%)无效1例总有效率96.7%。对照组：治愈20例,(66.7%)好转8例(26.7%)无效2例总有效率93.3%。经统计学分析P>0.05。随访病人对照组出现2名肾脏损害病人,治疗组无肾损害病人。但由于入选病人例数较少,待增加样本量,以进一步研究得出结论。目的：临床上应用陈昭定主任脾胃学术思想研究儿童腹型过敏性紫癜,体现他在临床上宏观与微观辨证相结合,辨病与辨证相结合,并注意对患儿疾病远期预后的随访情况的学术思想,深入研究陈昭定的临床学术经验,提出规范化的研究方案,继承和发扬老师的学术经验。方法：选择符合纳入标准的腹型过敏性紫癜性患儿120例,均做胃镜检查,宏观与微观辨证相结合,进行辨证分型。然后对符合脾胃湿热型的患儿,采用前瞻性、随机对照的临床研究方法,按1：1比例,随机分为治疗组30例,对照组30例,治疗组采用“青紫止痛汤”中草药及西药治疗,对照组仅采用西药治疗,总疗程2-4周,填写临床病例观察表,利用SPSS软件进行统计处理,分析治疗组与对照组临床症状的改善情况的差异。并进行随访半年,观察分析肾脏受累情况。结果：1.120例儿童腹型过敏性紫癜临床分析2009年1月至2010年3月120例确诊腹过型敏性紫癜患儿,其中男：64例,女：56例。年龄最小4岁,最大16岁。3-7岁：19例；8-12岁：68例；>12岁33例。做胃镜结果显示：食管炎：4例；胃炎：9例,十二指肠炎：12例,胃、十二指肠炎：63例,胃溃疡：2例,十二指肠溃疡：30例。合并肾脏损害：43例,占35.8%。感染相关因素：支原体感染：9例,链球菌感染：8例；结核感染：6例,幽门螺旋杆菌感染：2例；单疱病毒、CMV感染各1例。2.120例患儿中医证候分型,各型之间的构成比：根据临床症状,四诊辨证分型,分为表邪入里,侵犯胃肠型有23例占19.1%；脾胃湿热74例占61.7%；血络受损20例占16.7%；脾肾阳虚3例占2.5%。3.对60例脾胃湿热型治疗的近期疗效及随访半年的远期疗效脾胃湿热型入选60例,随机分为2组,治疗和对照组各30例,资料经统计学分析具有可比性。治疗组：治愈20例,(66.7%),好转9例(30%)无效1例总有效率96.7%。对照组：治愈20例,(66.7%)好转8例(26.7%)无效2例总有效率93.3%。经统计学分析P>0.05。随访病人对照组出现2名肾脏损害病人,治疗组无肾损害病人。但由于入选病人例数较少,待增加样本量,以进一步研究得出结论。结论：1.本课题通过入选120例病例的临床研究,分析腹型过敏性紫癜中医证候特点和分型的构成比例,深化了儿童腹型过敏性紫癜的辨证论治研究。2.尤其通过宏观与胃镜微观辨证相结合的研究提示脾胃湿热型是主要的证型。3.并对比了西医治疗和西医结合“青紫止痛汤”治疗脾胃湿热型腹型过敏性紫癜的近期疗效,两者疗效相当,能缓解腹痛等临床症状,没有统计学差异,但青紫止痛汤治疗组对证候有良好的改善作用。4.初步了解了中西医结合治疗腹型过敏性紫癜的肾损害情况,通过远期随访提示有一定疗效,但需要更多样本量的支持和深入研究。更多还原

【Abstract】 This study basically inherited from the clinical experience of Professor Chen zhaoding, whose academic ideology of spleen and stomach to treat children’s diseases. In order to inherit the experience of famous doctor of traditional Chinese medicine should analysis both his academic origin and background.During the pediatric clinical practice, Professor Chen studied ancient classics, took the strengths of each, gradually formed a "spleen and stomach-centric" dialectical thinking and drug characteristics. A distinguishing feature of treating pediatric diseases is pay attention to spleen and stomach; propose spleen’s exercise for health.The main source of Professor Chen’s thoughts came from academic ideology of spleen and stomach of Mr. Wang Pengfei. Professor Chen constantly carried on the academic thought of Mr. Wang during the clinical practice. Chen not only paid attention to the spleen and stomach, but also attached importance to qi and blood, constantly opened up the field of treatment of pediatric. He established gastroscopy office, gastrointestinal electrogram office and traditional Chinese medicine pediatric ward of spleen and stomach disease, started the diagnosis and treatment of the combination between the differentiation of syndromes and the differentiation of disease in pediatric spleen and stomach disease, and the combination between macro and micro differentiation of syndromes. He put emphasis on clinical research, advocated the reform of preparation form, and continually enriched the pediatric prescriptions, so more and more simple, convenient and cheap herbs can be widespread use for children. At the same time, his research had achieved certain results thus promoting the development of traditional Chinese medicine pediatric subjects.Even though Professor Chen’s academic ideology originated from the old famous Chinese medicine doctor’s clinical experience, he paid more attention to tradition and innovation, especially in the treatment fields of pediatric spleen and stomach disease and difficult diseases. This study gives a summary from following aspects.1. Professor Chen considers that children diarrhea disease is mainly caused by hypofunctioning of spleen and stomach. He paid attention to the types in determination of treatment based of differentiation of syndromes. With his many years of experience in treatment, he pointed out the property and flavor, and meridian oriented effect in Chinese medicine, tried to have a deep understanding of the intention of prescription, use the prescription compatibility to reflect types to differentiation of syndromes.2. Pay attention to the methods of pediatric gastrocopy, to the research of Hp infection, and to treatment in pediatric stomach dampness heat with Chinese medicine.3. Professor Chen believed that pediatric ulceration belongs to stomachache category which means the stomachache lesions in stomach, close to liver and spleen, with the cause of cold, heat, diet, weary, blood stasis, etc. Treatment should start from regulating stomach, invigorating spleen, regulating qi, relief of pain, and activating blood circulation to remove blood stasis.4. Professor Chen thinks that it is difficult to treat anorexia nervosa, to distinguish deficiency and excess or both of them are particularly important. Treatment should pay attention to regulating the spleen and stomach function. Prescription composition:Rhizoma Polygonati, Fructus Amomi, Jian Qu, Jiao Baishu, Radix Arnebiae.5. Treatment for suckling hepatitis syndrome:Chen believes the disease usually caused by the damp-heat retained in the womb during maternal fetal pregnancy, or infects the damp-heat after birth. The damp-heat resistant in the spleen and stomach, fumigate in liver and gallbladder, Gas-poor, blood stasis, disorder in soothing liver and gallbladder and then cause jaundice. Removing heat and dampness, normalizing the gallbladder function to treat jaundice, soothing liver and invigorating spleen, promoting blood circulation to remove obstruction from meridians are the basic law of Professor Chen’s treatment experience of jaundice.6. Attention Deficit Hyperactivity Disorder (ADHD) is primarily characterized by the co-existence of attentional problems and hyperactivity. Professor Chen particular emphasis on pediatric treatment with different symptoms according to Chinese medicine, by adjusting the body’s organs, meridians, qi and blood function and overall functional status to improve children’s social and natural environment adaptability.7. Treatment of allergic purpura nephritis:with years of clinical experience of allergic purpura nephritis, Professor Chen divided the disease etiology and pathogenesis into three causes, as interior retention of damp-heat, blood stasis with qi stagnation, and deficiency in the lung caused by chronic diseases. In addition, the diminished function of children, invasion of the body by wind and exogenous pathogenic factors. With numerous clinical manifestations, the disease usually taken place in lung, spleen and kidney. Chen would use Qingdai, Radix Arnebiae, the root bark of the peony tree, Herba Patriniae, Semen Phaseoli, etc. for treatment in clearing heat, increasing secretion of urine and removing heat from blood to stop bleeding.8. Treatment for pediatric Banti’s syndrome:Professor believes that the causes of this disease are qi stagnation, blood stasis and indigestion. With the pathological features of children, activating blood circulation to remove blood stasis and regulating qi flow as primary achievements, it will certainly have a bad effect on treatment of qi just because of Children’s undetermined qi circulation and tender organs. These are the prominent pediatric clinical experience of Professor Chen’s ideology of spleen and stomach.This study using Professor Chen’s ideology to study children’s abdominal allergic purpura in clinical application; reflecting the ideology of the combination of macro and micro dialectic, identified diseases and syndromes, and the follow up survey of children’s disease; delving into his clinical experience; proposing standardized research programs, inheriting and carrying forwards Professor Chen’s academic experience.Clinical analysis in 120 cases of children’s abdominal allergic purpura.Cases enrolled in this issue since January 2001 to March 2010:120 cases of children, male: 64cases, female:56 cases. Youngest 4 years old, oldest 16 years old.3 to 7 years old:19 cases; 8 to 12 years old:68 cases; over 12 years old:33cases. The results of gastroscopy show: Esophagitis:4 cases; Gastritis:9 cases; Duodenitis:12 cases; Stomach and Duodenitis:63 cases; Gastrelceosis:2 cases; Duodenal ulcer: 30 cases. With renal injury:43 cases, accounting for 35.8%. Infection-related factors:Mycoplasma infection:9 cases; Streptococcus infection:8 cases; Tuberculosis:6 cases; Helicobacter pylori infection:2 cases; Herpes simplex virus:1 case, CMV infection:1 case.The composition ratio in 120 cases of children with TCM type:Based on clinical symptoms, divided into four diagnostic syndrome types, those are:(1) The pathogenic factors invade the interior of the body while the stomach is weak,23 cases, and accounting for 19.1%.(2) Damp-heat in spleen and stomach,74 cases, accounting for 61.7%.(3) Injury to superficial venules,20 cases, accounting for 16.7%.(4) Yang deficiency of spleen and kidney,3 cases, accounting for 2.5%.The short-term and follow-up six months of long-term treatment efficacy among the 60 cases of damp-heat in spleen and stomach type.Damp-heat in spleen and stomach type selected 60 patients is randomly divided into 2 groups, each of the treatment and the control groups get 30 patients. It is statistical analyzed and comparable.Treatment group:cured 20 cases (66.7%); improved,9 cases (30%); invalid,1 case; total efficiency,96.7%.Control group:cured,20 cases (66.7%); improved,8 cases (26.7%), invalid,2 case; total efficiency,93.3%.The statistical analysis P> 0.05. There are 2 patients with kidney damage in the control group, none in the treatment group. Objective:This study using Professor Chen’s ideology to study children’s abdominal allergic purpura in clinical application; reflecting the ideology of the combination of macro and micro dialectic, identified diseases and syndromes, and the follow up survey of children’s disease; delving into his clinical experience;proposing standardized research programs, inheriting and carrying forwards Professor Chen’s academic experience.Methods:Choosing 120 cases of children’s abdominal allergic purpura with gastroscopy, which can reflect the academic ideology of combination treatment between macro and micro differentiation of syndromes, and also between the differentiation of syndromes and the differentiation of disease in pediatric spleen and stomach disease. However, to the children whose damp-heat in spleen and stomach will be selected 60 cases of them, randomly divided into 2 groups, each of the treatment and the control groups get 30 patients. The treatment group use "Qing Zi Zhi Tong Decoction" with Western medicine treatment, the control group will only use Western medicine treatment. The total treatment course takes about 2 to 4 weeks; it need to fill out clinical watch list, use SPSS software for statistical processing, analysis the improvement differences between the treatment and the control groups. Get another follow-up six months of long-term treatment efficacy, observe and analyze the kidney involvement.Results:Clinical analysis in 120 cases of children’s abdominal allergic purpura.Cases enrolled in this issue since January 2001 to March 2010:120 cases of children, male:64, female:56 cases. Youngest 4 years old, oldest 16 years old.3 to 7 years old:19 cases; 8 to 12 years old:68 cases; over 12 years old:33 cases. The results of gastroscopy show:Esophagitis:4 cases; Gastritis:9 cases; Duodenitis:12 cases; Stomach and Duodenitis:63 cases; Gastrelceosis:2 cases; Duodenal ulcer:30 cases. With renal injury:43 cases, accounting for 35.8%. Infection-related factors: Mycoplasma infection:9 cases; Streptococcus infection:8 cases; Tuberculosis:6 cases; Helicobacter pylori infection:2 cases; Herpes simplex virus:1 case, CMV infection:1 case.The composition ratio in 120 cases of children with TCM type:Based on clinical symptoms, divided into four diagnostic syndrome types, those are:The pathogenic factors invade the interior of the body while the stomach is weak,23 cases, and accounting for 19.1%.Damp-heat in spleen and stomach,74 cases, accounting for 61.7%.Injury to superficial venules,20 cases, accounting for 16.7%.Yang deficiency of spleen and kidney,3 cases, accounting for 2.5%. The short-term and follow-up six months of long-term treatment efficacy among the 60 cases of damp-heat in spleen and stomach type.Damp-heat in spleen and stomach type selected 60 patients is randomly divided into 2 groups, each of the treatment and the control groups get 30 patients. It is statistical analyzed and comparable.Treatment group:cured 20 cases (66.7%); improved,9 cases (30%); invalid,1 case; total efficiency,96.7%.Control group:cured,20 cases (66.7%); improved,8 cases (26.7%), invalid,2 case; total efficiency,93.3%.The statistical analysis P> 0.05. There are 2 patients with kidney damage in the control group, none in the treatment group.Conclusion:1. The study selected 120 clinical cases, analysis the TCM characteristic of abdominal allergic purpura and the composition ratio of types, and deepens the study.2. In particular, further study to the different characteristics of macro-and micro-endoscopies of damp-heat in spleen and stomach type, which gets a large percentage in the abdominal allergic purpura.3. Compared the short-term effect between Western medicine treatment and Western medicine combine with "Qing Zi Zhi Tong Decoction" treatment for damp-heat in spleen and stomach type of abdominal allergic purpura.4. Preliminary understanding of the combination therapy of abdominal allergic purpura and the damage to kidney in long-term effect.更多还原