温病学理论指导治疗台湾地区湿热泄泻的研究

【作者】 庄鹤麟；

【导师】 宋乃光；

【作者基本信息】 北京中医药大学 ， 中医临床基础， 2010， 博士

【摘要】 湿热泄泻是以泻下急迫或泻下不爽,大便色黄秽臭,舌苔黄腻为主症的一类泄泻,在台湾地区,湿热泄泻是比较多见的泄泻证型。本课题主要是探讨用温病学理论来指导治疗台湾地区湿热泄泻的问题。文章首先对中医诊治湿热泄泻的现代研究进展进行了综述,包括对湿热泄泻病理机制的研究、古方和自拟方运用的研究、特殊药物和特殊疗法的研究、以及各家医论、对小儿泄泻的研究等。虽然收集到的文献较多,但较少有用温病学理论指导湿热泄泻治疗的论述和报道。考虑目前发表文章的多是中青年中医工作人员,他们在理论和经验上难免有所欠缺,而学习和继承名老中医的医疗经验是当前中医研究的重要任务,于是在导师的建议下,对国家重点图书——《中国百年百名中医临床家丛书》和《中国现代百名中医临床家丛书》中的名老中医的经验进行梳理。该丛书共有143个分册,每册一位中医共143位中医,其中有57位论述到泄泻的证治经验,共列举泄泻病案248例(病案记录过简的不计)。248例泄泻病案中,属于湿热泄泻的28例,占泄泻病案的11.3%。28例湿热泄泻除1例用针灸治疗外,全用中药治疗。对27例用中药治疗的湿热泄泻患者,他们的就诊季节、就诊地点、病证诊断、使用成方、治疗时程以及治疗用药的频次进行统计分析,结果显示,春季湿热泄泻占全年湿热泄泻的13.6%,夏季湿热泄泻占全年湿热泄泻的36.4%，秋季湿热泄泻也占全年湿热泄泻的36.4%，冬季湿热泄泻占全年湿热泄泻的13.6%,夏季和秋季合并计算,夏秋季湿热泄泻占全年湿热泄泻的72.8%，说明湿热泄泻的发病是有季节性的。结果还显示,湿热泄泻的分布有地域性。南方湿热泄泻占59.3%,北方湿热泄泻占22.2%，南方湿热泄泻要比北方湿热泄泻多得多,其主要原因可能还是和气候有关。用药频次的统计结果显示,治疗湿热泄泻的成方主要是葛根芩连汤,最常用的药是黄连、甘草、葛根、黄芩、木香、白芍、茯苓、枳壳和滑石。这一结果,基本反映了当前中医对湿热泄泻的认识和治疗趋势,但也暴露出治疗方法缺乏多样性和理论创新的不足。从以上资料可以看出,大陆地区泄泻中湿热泄泻证型所占比例并不太多,而台湾地区情况怎么样呢?台湾位于中国大陆东南沿海的大陆架上,地处东经119°18’03"至124°34’30",北纬20°45’25"至25°56’30"之间。台湾岛南北狭长,北回归线恰好横穿岛的中部偏南地区,北部地区属亚热带气候,南部地区属热带气候。台湾在气候上受海洋和大陆两方面的影响均较强烈,但海洋性气候更明显,整体上呈现高温、多雨、多风的气候特点。这种气候特点,势必造成台湾地区居民的体质和发病后证型有特点,为此,对台湾地区居民的中医体质类型和泄泻的证型做了调查。体质调查采取问卷形式。根据中华中医药学会2009年发布的关于“中医体质分类与判定”的标准,发放“体质调查表"700份,收回624份。剔除无效表格后,共得有效表格435份。435人中男性196人,女性239人。小于20岁者23人,21-59岁者386人,大于60岁者26人。在对435人的体质类型应用中华中医学会的体质标准进行判定时,发现有12例在按公式转换成“转化分数”后,无法判定体质类型,最后能判别体质的共423人。结果显示,如果以体质出现的频次统计,偏颇体质以阴虚质最多,其次是气虚质、阳虚质和痰湿质,如果将相兼体质简化,以偏颇体质出现的人数统计,偏颇体质以阳虚质为最多,其次为阴虚质、湿热质和气虚质。反映了台湾居民的偏颇体质有2个特点,一个是从正气虚角度讲,有两极分化的倾向,或者是阳虚,或者是阴虚；另一个从邪气实角度来讲,湿、瘀、郁三者比较,以湿为突出。这两个体质特点都与台湾的环境和气候有关。台湾天气热,人们就爱出汗,汗多伤津伤阴,故阴虚质多。天气热,人就喜欢吹空调、喝冷饮,故台湾凉茶盛行,这就造成了部分人,尤其是年青人阳虚质多。台湾天气潮湿,空气湿度大,反映在体质中也是湿偏盛,湿与阳虚质结合,造成痰湿质多,湿与阴虚质结合,造成湿热质多。对台湾地区泄泻证型的调查,采用国家中医药管理局发布的《中医病证诊断与疗效判定标准》,把泄泻分为寒湿证、湿热证、食滞证、肝郁乘脾证、脾胃虚弱证和肾阳虚衰证6型。由具有中医知识的临床医生担当调查员,调查对象为前来就诊的泄泻病人,在取得病人的同意后,由调查员填写《泄泻患者症状调查表》。《泄泻患者症状调查表》由二部分内容组成。一部分是患者基本情况,包括姓名、性别、年龄、烟酒嗜好、职业。另一部分是症状,是表中的主要部分。共调查86例,其中男性47例,女性39例。年龄分布：小于20岁者3例,21-29岁者23例,30-39岁者20例,40-49岁者17例,50-59岁者13例,大于60岁者10例。调查结果,寒湿证4例,占4.7%,湿热证22例,占25.6%，食滞证12例,占14.0%，肝郁乘脾证7例,占8.1%,脾胃虚弱证34例,占39.5%,肾阳虚衰证7例,占8.1%。结果所示脾胃虚弱证最多,占39.5%(34/86),其次为湿热证,占25.6%(22/86)。这一结果与前面探讨的全国57位著名老中医治疗泄泻案例的统计结果有很大的不同。前面248例泄泻病案中,属于湿热泄泻的只有28例,只占泄泻病案的11.3%。分析原因有二：一是地域差别,湿热泄泻多发生在南方,台湾属南方,且是一个海岛,长年湿热,自然发生湿热泄泻的机会多。另一个原因,与季节有关,我们的调查是5-7月份,正好是一年中湿热最盛的时期。上述两项调查有一个提示,中医研究一定要理论联系实际,理论学习要有的放矢,要带着问题学。台湾地区湿热证多,台湾地区的泄泻证型也是湿热泄泻多。温病学中有大量湿热证论治的理论和经验,学习温病学如能解决台湾地区的临床实际问题才是最好的学习。为此,本人在复习《温病学》教材的基础上,重点阅读了叶天士的《温热论》,吴鞠通的《温病条辨》和薛生白的《湿热条辨》。通过学习,对吴鞠通“治外感如将,治内伤如相”、“治中焦如衡,非平不安”,对叶天士“通阳不在温,而在利小便，，之论有了新的感受,它们既是治疗湿热泄泻的指导原则,也是治疗湿热泄泻的技巧。薛生白的《湿热条辨》是湿热病辨证论治的专书,其“湿热内滞太阴,郁久而为滞下，,虽言湿热痢疾,但所论病机“湿热之邪内伏太阴,阻遏气机,以致太阴失运……传导失其常度，，与湿热泄泻有相同之处,所用药物有木香、葛根、厚朴、黄芩,也都是临床上治疗湿热泄泻最常用的药。导师对温病学有很深造诣,并长期坚持临床,对治疗湿热泄泻有丰富的经验,特请其拟制了一首适合治疗台湾地区湿热泄泻的“祛湿清热止泄方”。本方组成为藿香、白术、葛根、黄连、木香、车前子、茵陈、半夏、炒山楂、黄芩、厚朴、咸丰草(鬼针草),共12味药,在台中市仁心医疗体系门诊进行病例观察。共选择治疗组52例,用祛湿清热止泄方治疗,对照组38例,用葛根芩连汤治疗。治疗方法是首先培训医生,凡是此一课题研究的医生都要经过培训,组织他们复习温病学有关知识,重点是运用温病学理论治疗湿热泄泻的思路和道理,阐发吴鞠通的“治外感如将,治内伤如相”和“治中焦如衡,非平不安”,以及叶天士的“通阳不在温,而在利小便”的学术思想。培养大家用这一学术思想指导湿热泄泻治疗的全过程。第二步是使用“祛湿清热止泄方”及其加减治疗湿热泄泻。服药2日为1个疗程,最多观察4个疗程。结果是52例湿热泄泻,在经过2个疗程治疗后,有效率为100%；在经过3个疗程治疗后,显效率为100%；在经过4个疗程治疗后,临床痊愈率为100%。疗效满意,而且比对照组疗效好。又回顾性调查30例,进一步证明了治疗湿热泄泻,有温病理论的指导和修养,与没有温病理论的指导与修养,是有很大差别的。通过课题的研究,使学生尝到了学习理论的甜头,不但解决了临床实际问题,而且使理论修养提高了一步,课题的完成不是学习的终结,而是更加深入学习的开始。更多还原

【Abstract】 Damp-heat diarrhea is a kind of diarrhea disease which mainly manifested as urgent diarrhea, or yellow foul smell stool, and greasy yellow tongue. In Taiwan province, Damp-heat diarrhea is the most common kind diarrhea. The issue aims at exploring the damp-heat diarrhea in Taiwan province using the Seasonal Febrile theory.The article firstly reviewed diagnosis and treatment progression of damp-heat diarrhea about the modern traditional Chinese medicine, it includes the pathological mechanism of damp-heat diarrhea, the ancient formula and self-creating foumula used for treating damp-heat diarrhea, special medication and special treatment studies, the theory advanced by famous chinese medcine doctors and Pediatric Diarrhea research. Although many literatures have been collected, but only a little reporting and thesises for Damp-heat Diarrhea treatment have been published. Considering the existing published articles are mostly published by young Chinese medicine staff, who inevitably lack of experience and knowledge, so an important task for the present study of traditional Chinese medicine is learn and inherit the experiences of the old Chinese medical doctors.In the instruction of my turtor, I have systematically studied the China nation Key Book-"Clinic experience Series of 100 chinese medicine doctor in a century". There are 143 volumes and 143 doctor’s Clinic experiences in the series in total, each book addresses a doctor. There are 57 doctors have addressed to the Diarrhea Treatment experience, and 248 diarrhea cases were listed(too simple documented medical records not counted). In these records, there are 28 cases of damp-heat diarrhea, of which, there are 27 cases treated with traditional Chinese medicine. Of these 27 cases, I have researched their treatment season, treatment location,diseases diagnosis, the use of set prescription, treatment duration and frequency of medication treatment, and the following results have got:damp-heat diarrhea in the spring, summer, autumn and winter respectively is 13.6%,36.4%,36.4%,13.6%, damp-heat diarrhea accounted for 72.8% happened in summer and autumn totally. All the results show that the distribution of damp-heat diarrhea are seasonal in nature. The results show that damp-heat diarrhea happened in the south and north of China respectively is 59.3% and 22.2%, this also show that the distribution of damp-heat diarrhea are regional, maybe the reason is the weather is more hot and humid in the South of China. Besides, the frequency statistics for the medicines used showed that Gegenqinlian Decoction is the most commonly used, and showed that the most commonly used drugs are berberine, licorice root, puerarin, baicalin, costas, Radix Paeoniae Alba, Poria, Citrus aurantium, and talc. This result globlally reflects the current understanding and advantages of traditional Chinese medicine for Damp-heat diarrhea,but also exposes the lack of diversity in treatment methods and theoretical innovation.From the above research we can see that the damp-heat diarrhea is not in the main proportion in mainland, but then how is the situation in Taiwan? Taiwan is located on the continental shelf in the southeast coast of mainland, its location is between east longitude 119°18’03" to 124°34’30 ", north latitude 20°45’25" to 25°56’30 ". The island is The long and narrow, the southerly island of the central region just across the Tropic of Cancer, the northern region is a subtropical climate, the southern region enjoys a tropical climate. Taiwan’s climate strongly influenced by both maritime and continental climate, but the maritime climate is more obvious, the climate characteristics shows high temperatures, rainy, windy in total. This climate characteristics is bound to result in differences in physical and disease syndromes.For which, I have investigated Chinese medicine physical type and the onset type of diarrhea of Taiwan residents.Physical survey was undertaken through questionnaires. According to the Chinese Medical Association published "Chinese constitution Classification and determination" issued in 2009,700 copies of "constitutions Survey Form" had been issued, and 624 copies had recovered. Excluding invalid form, a total of 435 forms were valid. In which, thare are 196 males and 239 females.23 people are less than 20 years old,386 people are between 21-59 years old,26 people are more than 60 years old. According to constitution judgement standards issued by the Chinese Society of Traditional Chinese Medicine, the constitution can eventually determined in 423 people. The results showed that:if we count according to the frequency of different constitutions, the most common constitution is yin dificience biased body, and followed by Qi dificience biased body, Yang dificience biased body and phlegm-dampness biased body;but if we simplify the relative constitution, then the most common constitution is yang dificience biased body, and followed by Yin dificience biased body, phlegm-dampness biased body and Qi dificience biased body. All these reflect two physical bias characteristics of Taiwan residents,that is:1) from the point of positive dificience vital Qi, there is a tendency to polarization, or yang, or yin deficiency;2) from the point of excess evil Qi, wet evil factor is more excess, compared between wet,stasis and stagnation. These two physical characteristics are related to Taiwan’s environment and climate-related. Taiwan’s climate is hot, people will have more sweat, sweat always injured the jin and yin,so the Yin dificience biased body is more common. Besides, because it’s hot, people liked have air conditioners, and drink cold drinks and herbal tea, which resulted in many people have Yang deficiency biased body, especially in youngsters. Taiwan’s climate is humid, the air humidity is very high, this cause Taiwan residents have wet excess baise body. If the wet excess baise body combined with the yang dificience quality, which will result in many people have phlegm-wet biased constitution.In the survey of Diarrhea Syndromes of the Taiwan, I have used " TCM Syndrome diagnosis and determine the efficacy of standards" issued by the State Chinese Medicine Administration.in this standards, the diarrhea is divided into 6 classification:cold-wet syndrome,damp-heat syndrome,food stagnation syndrome, liver depression spiting spleen syndrome, spleen-stomach deficiency syndrome and kidney deficiency syndrome. All investigators have abundant clinical knowledge of traditional Chinese medicine, and the objects of research are diarrhea patients. All investigation have got patient’s consent. The investigation form is writed by doctor, and there are two parts need to fill in:"diarrhea symptoms questionnaire" and "Diarrhea symptoms questionnaire". One pare is the basic conditions of the patient, including name, gender, age, tobacco and alcohol habits, occupation; Another part is about the symptoms, which is a major part of the table. I have totally investigated 86 cases,47 cases were males, and 39 females. Age distribution:3 cases are less than 20 years old,23 cases are 21 to 29 years old,20 cases are 30-39 years old,17 cases are 40-49 years old,13 cases are 50-59 years old,10 cases are more than 60 old. Finding: cold-wet syndrome 4 cases(4.7%),damp-heat syndrome 22 cases(25.6%), food stagnation syndrome 12 cases(14%), liver depression spiting spleen syndrome 7 cases(8.1%), spleen-stomach deficiency syndrome 34 cases(39.5%),kidney deficiency syndrome 7 cases(8.1%). The results shown in the spleen and stomach deficiency syndrome is most common(39.5%,34/86),followed by damp-heat syndrome (25.6%,22/86). This result is most different from the last research about national famous old Chinese medicine treatment of 57 cases of diarrhea results, in which including 248 cases of diarrhea, but there are only 248 cases of damp-heat diarrhea. There are maybe two reasons:1)regional differences.hot and humid diarrhea mostly occurs in the south, Taiwan is the South, and is an island, the climate is always hot and humid, the opportunities occurring hot and humid diarrhea is much more.2) our survey is between May to July, exactly the most hot and humid period in a year.My tutor has extensive knowledge on Febrile Diseases, and have extensive experience in treating damp-heat diarrhea. According to her clinic experience, she have created a formula-"Qu shi qing re zhi xie formula", which is especially suitable for damp-heat diarrhea in Taiwan. This formula is composed of Agastache rugosa, Atractylodes, puerarin, berberine, costas, Plantago, Artemisia, Pinellia, fried hawthorn, Huang Qin, Magnolia, Bidens (Bidens), a total of 12 Herbs. And the research is conducted at benevolence and the health care system in Taichung.52 cases were selected for treatment group, using’Qu shi qing re zhi xie formula’for treatment, and control group 38 cases, using’Ge gen qin lian tang’ for treatment.In the study, I have trained the doctors, all participating doctors must get the lesson. In the training, the following thesis must be mastered:learning knowledge of Febrile Diseases, focusing on the use of damp-heat diarrhea in Treating Febrile Diseases; guideing doctors using Febrile Diseases academic thinking to treatment hot and humid diarrhea; mastering the theory of Wujutong about ’treating exogenous evil invading disease likes general, and treating internal disease likes Chancellor’,’the middle energizer likes weight, the treating principal must be balance’;mastering the theory of Yetianshi about’do not warm to through yang qi, but induce urination’. The second step is to use " Qu shi qing re zhi xie formula " to treat damp-heat diarrhea. One treating course is 2 days, and the treating courses must less than 4. The result:in the 52 cases of damp-heat diarrhea, after two treatment courses,the total effective rate is 100%; three treatment courses, the markedly effective rate was 100%; 4 treatment courses, the clinical cure rate was 100%. The efficacy is satisfactory, and is much good effect than the control group. Besides, I have recalled 30 cases, by the recalling research, I have get the further evidence that if doctors have the thesis guide of Febrile Diseases, the treating effect will be much better, comparred to those who do not study the Febrile Diseases theory.Through research projects, I have learned so much. The Febrile Diseases can not only solve the clinical practice problems, but also improved my self-cultivation in TCM theory. The completion of the subject is not the end of learning, but more in-depth study start.更多还原