张炳厚学术思想与临床经验总结及应用地龟汤类方治疗慢性肾脏病的经验研究

【作者】 段昱方；

【导师】 张炳厚；

【作者基本信息】 北京中医药大学 ， 中医内科学， 2011， 硕士

【摘要】 张炳厚老师是国家级名老中医,第二、三、四批全国老中医药专家学术经验继承工作指导老师,有着近50年的临床工作经验,借助对中医理论和临床实践的刻苦钻研,总结出一套以脏腑辨证为核心,遣方新颖、用药独特的辨证论治规律。1张炳厚老师学术思想渊源张炳厚老师1964年毕业于北京中医学院,大学期间,张老师较长时间跟随秦伯未、王文鼎、宋向元、刘渡舟、王绵之、祝湛予等十余位名老中医,学习他们善抓主证,精于辨证,注重脏腑,重视脾肾,创建类方,应用成方,强调用量等学术特点,并学习他们治疗脾胃病、肾脏病、糖尿病、头痛、过敏性疾病等临床经验。张炳厚老师推崇朱丹溪“阳常有余,阴常不足”的观点,并以朱丹溪著名的滋阴降火方剂大补阴丸为基础,大胆化裁,演变出养阴为主的地龟汤。又学习张景岳重视先天,尤其重视肾阴,“阴中求阳”的学术观点,创建了地龟汤类方,治疗以肾虚为主的诸多病证。从《脾胃论》中,老师领悟到脾气升发的重要作用,并独创将清暑益气汤应用于气虚发热。此外,应用《医醇賸义》中滋生青阳汤治疗高血压、三叉神经痛；应用《医林改错》中活血化瘀法治疗痛证和疑难怪病；应用《医宗金鉴》中近千首方剂治疗内、外、妇、儿各科疾患,均取得较好疗效。体现了老师尚古而不泥古,尊古而有创新的学术风格。2张炳厚老师学术思想与临床经验2.1学术思想张炳厚老师强调辨证是诊疗过程的关键,证候又是辨证的基础,围绕主证进行辨证,在疾病的发展中辨证,辨证与辨病相结合,才能取得满意疗效。在辨证上老师强调抓住主证,四诊合参,以脏腑辨证为核心。在脏腑辨证中,尤其注重肾脏的重要性,因肾为先天之本,内涵真阴真阳,是各脏腑阴阳之根本。治疗上老师注重调理气机,顺应患病脏腑的特性。治疗心系疾患,以益气理气、养血活血为法,并强调振奋心阳；治疗肺脏病证注重降气；脾胃病则根据病位的不同,调理脾胃气机,使之升降有序；治疗肝胆疾患,除疏肝外,加用顺应肝木之性的药物；肾病治疗时以补肾为要,自创补肾八法：缓补法、峻补法、清补法、温补法、通补法、涩补法、双补法、间接补法。选方用药上,擅用类方,执简驭繁。老师认为类方中的基础方解决疾病的共性,加减化裁演变出的一组类方解决疾病的个性。2.2临床经验张炳厚老师在临床上的常用类方有三个方面：1、基础方治本,类方治标：地龟汤类方治疗肾虚诸病、三两三类方治疗风寒湿痹；2、基础方治标,类方治本：安寐汤类方治疗失眠；3、基础方引经：川芎茶调散类方治疗头痛、五皮五藤饮类方治疗皮肤病。老师将冠心病分为五种证型论治,但无论何种证型,其病机关键为胸阳不振,最终结果为血脉瘀阻。在治疗上,应用大量黄芪振奋心阳治其本,应用三七活血化瘀治其标。在脾胃病中,老师将涉及肝脏的证型细分为肝脾不和与肝胃不和。其中,肝脾不和应区分以肝郁为主,还是脾虚为主；肝胃不和又有肝郁气滞、肝阴不足、肝胆湿热的不同,应分而治之。老师认为,咳嗽日久必伤肺阴。因此在治疗久咳时,由轻到重分为肺燥重、伤阴轻；肺燥轻、伤阴重；肺肾阴虚三个阶段,分别应用清燥救肺汤、养阴清肺汤、百合固金汤治疗。对于痛经,老师应用温经散寒、理气活血、益气养血、健脾补肾四法治疗,均取得良好疗效。3张炳厚老师应用地龟汤类方治疗慢性肾脏病的临床研究本研究是在张炳厚老师的指导下,应用数据资料信息挖掘技术,整理、挖掘老师应用地龟汤类方治疗慢性肾脏病的辩证分型思维方法及药物应用规律。3.1研究方法采用传统研究与计算机信息技术相结合的方法。传统研究方法包括跟师抄方、文献整理、深度访谈。计算机信息技术是指我科应用Access创建了“张炳厚临床诊治系统”将114例,279诊次慢性肾脏病研究病例输入数据系统,经结构化、数据化处理后,对张炳厚老师治疗慢性肾脏病关注的证候、证型、地龟汤加味药物的规律进行深入分析、挖掘研究。3.2研究结果与结论慢性肾脏病的常见症状为腰酸或腰痛、水肿、尿黄、夜半咽干、手足心热等。慢性肾脏病为本虚标实或纯虚无实,本虚证以肾阴虚为最常见的类型,还有肾阳虚、肾气阴两虚、肾阴阳两虚、脾肾阳虚、肾阴虚脾气虚、肾阴血虚、肾胃肺阴虚,其中肾阴虚脾气虚与肾阴阳两虚为较多见的本虚证型；标实证皆为兼夹证候,不同虚证均可兼湿热、水湿、血热、瘀血、浊毒、肝阳等不同。慢性肾脏病的常见病种IgA肾病、慢性肾衰竭、慢性肾炎、肾病综合征、糖尿病肾病、隐匿性肾炎、紫癜性肾炎,有其各自的病机特点及相应的常见证型。石韦、土茯苓、土大黄三药加入地龟汤中演变为加味地龟汤,为治疗慢性肾脏病的基础方。其类方有：健脾加味地龟汤治疗肾阴虚合并脾气虚及蛋白尿较多者；温阳加味地龟汤治疗有肾阳虚证候者；清利加味地龟汤治疗下焦湿热者；利水加味地龟汤治疗水肿明显者；凉血加味地龟汤治疗血热之尿血；活血加味地龟汤治疗有瘀血证候者；化浊加味地龟汤治疗慢性肾衰竭浊毒内蕴明显者；平肝加味地龟汤治疗合并高血压者；降糖加味地龟汤治疗糖尿病肾病；化斑加味地龟汤治疗紫癜性肾炎皮肤紫癜明显者；二藤加味地龟汤治疗慢性肾衰竭合并痛风性关节炎者。运用数据资料信息挖掘技术学习、整理病例,有助于我们灵活地掌握和运用类方,并指导我们将中医治疗慢性肾脏病向简洁有效的方向发展。信息挖掘技术能从深度和广度上进一步挖掘名老中医经验,发展中医。张炳厚老师是我院肾病科学科带头人,在治疗慢性肾脏病方面有很深的造诣。本人在跟随张炳厚老师学习的三年中,收集老师临床验案数千例,其中有相当大的比重是治疗慢性肾脏病的典型病例,老师应用地龟汤类方治疗慢性肾脏病是其治疗的一大特色。1研究目的本研究是在张炳厚老师的指导下,应用数据资料信息挖掘技术,整理、挖掘老师应用地龟汤类方治疗慢性肾脏病的辩证思维方法及独特的治疗经验,挖掘其学术内涵,探索其临证规律,对于地龟汤类方的应用进行一次较为系统、全面的总结。2研究内容张炳厚老师认为,慢性肾脏病病程迁延,属慢性虚损性疾患,病机虽为虚实夹杂,但总以肾虚为本,兼加不同标证,故治疗应补肾为要,应用地龟汤为基础方,补肾以固其本,针对慢性肾衰竭、慢性肾炎、IgA肾病、肾病综合征、糖尿病肾病、隐匿性肾炎、紫癜性肾炎等常见的慢性肾脏病,分成不同的证型,加用不同药物治疗,将老师的辩证分型及药物应用规律加以挖掘,总结出具有临床指导意义的慢性肾脏病证治规律和用药特色。3研究方法采用传统研究与计算机信息技术相结合的方法。传统研究方法包括跟师抄方、文献整理、深度访谈。计算机信息技术是指我科应用Access创建了“张炳厚临床诊治系统”,将114例,279诊次慢性肾脏病研究病例输入数据系统,经结构化、数据化处理后,对张炳厚老师治疗慢性肾脏病关注的证候、证型、地龟汤加味药物的规律进行深入分析、挖掘研究。4研究结果与结论4.1症状分布规律慢性肾脏病的常见症状为腰酸或腰痛、水肿、尿黄、夜半咽干、手足心热等。4.2证型规律根据本研究分析挖掘的结果,可以得出张炳厚老师认为慢性肾脏病为本虚标实或纯虚无实,本虚证以肾阴虚为最常见的类型,此外,还有肾阳虚、肾气阴两虚、肾阴阳两虚、脾肾阳虚、肾阴虚脾气虚、肾阴血虚、肾胃肺阴虚,其中肾阴虚脾气虚与肾阴阳两虚为较多见的虚证证型；标实证皆为兼夹证候,不同虚证均可兼湿热、水湿、血热、瘀血、浊毒、肝阳等不同。慢性肾脏病常见的病种IgA肾病、慢性肾衰竭、慢性肾炎、肾病综合征、糖尿病肾病、隐匿性肾炎、紫癜性肾炎,有其各自的病机特点及相应的常见证型。4.3地龟汤类方应用规律石韦、土茯苓、土大黄三药应用频次最高,加入地龟汤中演变为加味地龟汤,作为治疗慢性肾脏病的基础方。其类方有：健脾加味地龟汤治疗肾阴虚合并脾气虚明显及蛋白尿较多者；温阳加味地龟汤治疗合并有肾阳虚证候者；清利加味地龟汤治疗尿黄尿热明显之下焦湿热者；利水加味地龟汤治疗水肿明显者；凉血加味地龟汤治疗阴虚内热,血热妄行之尿血；活血加味地龟汤治疗病程日久,有瘀血证候者；化浊加味地龟汤治疗慢性肾衰竭浊毒内蕴明显者；平肝加味地龟汤治疗合并高血压者；降糖加味地龟汤治疗糖尿病肾病；化斑加味地龟汤治疗紫癜性肾炎皮肤紫癜明显者；二藤加味地龟汤治疗慢性肾衰竭合并痛风性关节炎者。运用数据资料信息挖掘技术学习、整理病例,有助于我们灵活地掌握和运用类方,并指导我们将中医治疗慢性肾脏病向简洁有效的方向发展。信息挖掘技术能从深度和广度上进一步挖掘名老中医经验,发展中医。更多还原

【Abstract】 Zhang Binghou, the national famous old doctor of traditional Chinese medicine, who was the tutor of the second, the third and the forth groups of inheritance in the academic experience of the old Chinese medicine. He worked nearly 50 years and had a lot of experience. Depend on assiduous research on the theory of traditional Chinese medicine and the clinical practice, he summarized a set of special diagnosis and treatment rule which took the organs differentiation as the core and used the novel and unique drugs.1 The ideological origin of Zhang Binghou.Zhang Binghou was graduated from the Beijing university of traditional Chinese medicine in 1964.During the university period, teacher Zhang was studied from more than ten famous old doctors just as Qin Bowei, Wang Wending, Song Xiangyuan, Liu Duzhou, Wang Mianzhi, Zhu Zhanyu. He learnt how to seize the main card, proficient in syndrome differentiation, pay attention to the internal organs, pay attention to the Pi and kidney, create a class of prescriptions, application existing prescriptions, emphasize the content of drugs, and study their treating in Pi and stomach disease, kidney disease, diabetes mellitus, headache, allergic diseases, and so on.Zhang Binghou respected Yang Chang You Yu and Yin Chang Bu Zu, which was Zhu Danxi’s point of view. Based on Zhu’s famous Da Bu Yin Wan he created Digui soup. He also learnt Zhang Jingyue’s viewpoint that pay attention to Xian Tian, especially Shen Yin and Yin Zhong Qiu Yang, and created a class of new Digui soups, which were based on previous, to treat various pathologies of Shen Xu. From the "Treatise on the spleen and stomach" in, the teacher realized the important role of Pi Qi Sheng Fa, and created Qingshu Yiqi soup to treat Qi Xu Fa Re.In addition, he used Zisheng Qingyang soup which came from the book "Yi Chun Sheng Yi" to treat hypertension, trigeminal neuralgia. He used Huo Xue Hua Yu which came from "Yi Lin Gai Cuo" to treat pain syndrome and difficult disease. He used nearly 1000 prescriptions which came from "Yi Zong Jin Jian" to treat different diseases of nternal medicine, surgery, gynecology and pediatrics, and obtained good curative effects. This reflects the teacher is good at innovating. 2 Academic thoughts and clinical experiences of Professor Zhang Bingho2.1 Academic thoughtsZhang Binghou thought differentiation is the key in treating and syndromes are the basics of differentiation. By taking differentiation around the main syndromes, and taking differentiation in the development of diseases, and distinguishing differentiation and diseases, we can achieve satisfactory effects.On the differentiation Zhang Binghou focuses on the main symptoms, through the four kinds of diagnostic methods, and takes the organs differentiation as the core. He focuses on the importance of the kidney, because the kidney is the innate, which contents the true Yang and the true Yin, and is the root of yin and yang in organs.In the treatment he pays attention to movement form of Qi which conform to the characteristics of diseased organs. In treating diseases of Xin, Yi Qi, Li Qi, Yang Xue and Huo Xue are the commonly used and stressed on Zhen Fen Xin Yang. He believes that when treating lung disease lowering Fei Qi is important. He believes that it is normal law that Pi Qi should rise and Wei Qi should fall. In treating diseases of Gan and Dan, he used drugs of Shu Gan and even drugs which conforms Gan’s characteristic. He believes that deficiency of the kidney is a common disease and summarizes eight ways to treat different types of kidney disease. That are HuanBu, JunBu, QingBu, WenBu, SeBu, ShuangBu and JianJieBu.In selecting of drugs, he is good at using kinds of prescriptions, and uses simple medicine to win. My teacher believes that basic prescriptions are used to resolve the commonness of diseases, and prescriptions which evolved out from basics to resolve the individual circumstances.2.2 Clinical experiencesMy teacher Zhang Binghou likes to use prescriptions in the clinical can be divided into three parts. First, basic prescriptions treat Ben and prescriptions which evolved out from basics treat Biao, such as DiGui soup is used to treat Shen Xu, and San Liang San soup is used to treat Feng Han Shi Bi. Second, treat Biao, and prescriptions which evolved out from basics treat Ben, such as An Mei soup is used to treat insomnia. Third, basic prescriptions are use to lead all the drugs to sick organs, such as Chuan Xiong Cha Tiao soup is used to treat headache and Wu Pi Wu Teng soup is used to treat skin diseases.My teacher believes that coronary heart disease can be divided into five types, but no matter what type, the key to the pathogenesis is Xiong Yang Bu Zhen, and can lead to the result of Xue Mai Yu Zu. He applied a large number of Astragalus to Zhen Fen Xin Yang in order to treat Ben, and Pseudo-ginseng to Huo Xue Hua Yu in order to treat Biao.In the digestive system disease, liver disease is divided into Gan Pi Bu He and Gan Wei Bu He. Gan Pi Bu He should be divided into the GanYu-based, or to PiXu-based; Gan Wei Bu He also should be divided into Gan Yu Qi Zhi, Gan Yin Bu Zu and Gan Dan Shi Re, and should be treated separately.My teacher believes that if coughing last a long time, it should inevitably hurt Fei Yin. Therefore, in treatment of chronic cough, it should be divided into three stages by thecondition from light to serious: Fei Zao serious and Shang Yin light; Fei Zao light and Shang Yin serious; Fei Shen Yin Xu. And can be treated by Qing Zao Jiu Fei soup, Yang Yin Qing Fei soup and Bai He Gu Jin soup.My teacher applies four ways to treatdysmenorrhea, those are Wen Jing San Han, Li Qi Huo Xue, Yi Qi Yang Xue and Jian Pi Bu Shen, and has achieved good effect.3 The clinical research of Zhang Binghou in using Digui soup to treat chronic kidney diseaseUnder the guidance of Zhang Binghou we collected his experiences of differentiations and treatment in using Digui soup in the treatment of chronic kidney disease by using the application database. So that we can explore his academic connotation and his rule of treatment by using Digui soup, and make a good Summary.3.1 MethodWe worked with teacher to study his prescriptions, and organized the literature of Chinese medicine, and made interviews with patients. We input the import informations into database which named as "system of Zhang Binghou in clinical experience" by Access and analyzed.114 cases and 279 visits in chronic kidney disease were analyzed. 3.2 Results and conclusionsThe common symptoms of chronic kidney disease were pain in back, edema, yellow urine, nocturia increased, dry throat, weakness, frequent micturition, foam in urine, the palm of the hand and foot fever and so on.According to the analysis from the results, it can be seen that Zhang Binghou believes that Benxubiaoshi or Chunshiwuxu is the essence of chronic kidney disease and Yinxu is the most in common. Shen Yang Xu, Shen Qi Yin Xu, Shen Yin Yang Xu, Pi Shen Yang Xu, Shen Yin Xu and Pi Qi Xu, Shen Yin Xue Xu and Shen Wei Fei Yin Xu are also seen. Shen Yin Xu and Pi Qi Xu and Shen Yin Yang Xu are more common. Combined syndromes can be seen as Shire, Shuishi, Xuere, Yuxue, Zhuodu and Ganyang. IgA nephropathy, chronic renal failure, chronic nephritis, nephrotic syndrome, diabetic nephropathy, occult nephritis, purpuric nephritis are very common, and have their respective characteristics of the pathogenesis and the corresponding syndromes.Farwell, Tuckahoe and Rumex were added in Digui soup and were made into the new Digui soup which was as the based method of the treatment for chronic kidney disease. Others:Jianpi Digui soup in treating ShenYinXu combined with Pi Qi Xu and proteinuria is more obvious; Wen Yang Digui soup in the treatment with Shen Yang Xu, Qing Li Digui soup in the treatment of Xia Jiao Shi Re, Lishui Digui soup in the treatment of edema, Liangxue Digui soup in the treatment of hematuria by Xue Re, Huoxue Digui soup in the treatment Yuxue. Huazhuo Digui soupin the treatment of Zhuo Du Nei Yun, Pinggan Digui soup in the treatment with hypertension, Jiangtang Digui soup in the treatment of diabetic nephropathy, Huaban Digui soup in the treatment purpura nephritis which purpura is obvious, Erteng Digui soup in the treatment of chronic renal failure patients with gouty arthritis.Through the use of the database and finishing the case, we can flexibly mastering and using medicine, and can lead us using traditional Chinese medicine in the treatment of chronic kidney disease to the effective direction. Information mining technology can make us mining old traditional Chinese medicine experiences further more from the depth and breadth, which is beneficial to the development of traditional Chinese medicine. Zhang Binghou is the academic leaders of the department of nephropathy and has the very deep attainments in the treatment of chronic kidney disease. I followed him to study for three years and collected nearly a thousand cases of which contented a considerable number of CKD. His using DiGui soup in treatment of CKD is one of his characteristics.1 ObjectiveUnder the guidance of Zhang Binghou we collected his experiences of differentiations and treatment in using DiGui soup in the treatment of CKD by using the application database. So that we can explore his academic connotation and his rule of treatment by using DiGui soup, and make a good Summary.2 ContentsZhang Binghou believed that CKD is a kind of chronic deficiency disease, although the pathogenesis of the actual situation is mixture, but based on kidney deficiency, and with different symptoms. So BuShen is import. We use the DiGui soup as the based prescription to treat many diseases, such as CRF, CN, IgAN, NS, DN, ON, PN and so on. According to the different syndromes, corresponding drug are added. We summed up the teacher’s treating rule of CKD and his habit of using drugs.3 MethodWe worked with teacher to study his prescriptions, and organized the literature of chinese medicine, and made interviews with patients. We input the import informations into database and analyzed.114 cases and 279 visits in CKD were analyzed.4 Results and conclusions4.1 Symptoms regularityThe common symptoms of CKD were pain in back, edema, yellow urine, dry throat, the palm of the hand and foot fever and so on.4.2 Differentiations rule According to the analysis of the results, it can be seen that Zhang Binghou believes that Benxubiaoshi or Chunshiwuxu is the essence of CKD and Yinxu is the most in common.Yang deficiency of kidney, both yin and qi deficiency of kidney, yin and yang deficiency of kidney, yang deficiency of Pi and kidney, yin deficiency of kidney and qi deficiency of Pi, yin and blood deficiency of kidney, yin deficiency of kidney, Wei and Fei. Yin deficiency of kidney and qi deficiency of Pi and both yin and qi deficiency of kidney are more common. Combined syndromes can be seen as Shi and hot, Shuishi, Xuere, Yuxue, Zhuodu and Ganyang.IgAN, CRF, CN, NS, DN, ON, PN are very common, and have their respective characteristics of the pathogenesis and the corresponding syndromes.4.3 Experience and regularity in using Digui soupFarwell, Tuckahoe and Rumex were used in high frequency, made the Digui soup to the new Digui soup which was as the based method of the treatment for CKD. Others: Jianpi Digui soup in treating yin deficiency of kidney combined with Qi deficiency of Pi and proteinuria is more obvious; Wenyang Digui soup in the treatment with syndromes of yang deficiency of kidney; Qingli Digui soup in the treatment of yellow urine and hot urine; Lishui Digui soup in the treatment of edema; Liangxue Digui soup in the treatment of hematuria Yinxueneire and Xuerewangxing; Huoxue Digui soup in the treatment Yuxue; Huazhuo Digui soup in the treatment of Zhuoduneiyun; Pinggan Digui soup in the treatment with hypertension; Jiangtang Digui soup in the treatment of diabetic nephropathy; Huaban Digui soup in the treatment purpura nephritis which purpura is obvious; Erteng Digui soup in the treatment of chronic renal failure patients with gouty arthritis.Through the use of the database and finishing the case, we can flexibly mastering and using medicine, and can lead us using traditional Chinese medicine in the treatment of CKD to the effective direction. Information mining technology can make us mining old traditional Chinese medicine experiences further more from the depth and breadth, which is beneficial to the development of traditional Chinese medicine.更多还原