王琦教授辨体—辨病—辨证相结合学术思想与临床经验总结及治疗慢性失眠的临床研究

【作者】 姜敏；

【导师】 王琦；

【作者基本信息】 北京中医药大学 ， 中医内科学， 2011， 硕士

【摘要】 王琦教授是国家人事部、卫生部、国家中医药管理局遴选的全国五百名著名老中医之一,北京中医药大学教授,中医基础理论专业博士生导师。创建了中医体质学、中医男科学、挽救了中医腹诊法,构建了中医藏象学。1研究目的1.1本研究将王琦教授的辨体-辨病-辨证相结合的学术思想及临床运用经验进行全面整理总结,力求较深入地反映王琦教授这一学术思想,以指导我们继承人今后的临床实践。1.2总结王琦教授临床诊疗经验,使王琦教授的诊疗思路和用药特色得以传承和发扬。1.3通过对王琦教授治疗慢性失眠的经验方高枕无忧汤进行临床研究,为王琦教授临床经验的总结提供科学客观的统计依据,使之具备另人信服的说服力,将为王琦教授的诊疗方法在未来中医临床的广泛运用,起到积极的作用,并可充实经验传承的内容,成为师承实践中行之有效的思路和方法。2研究方法2.1总结王琦教授辨体-辨病-辨证相结合学术思想梳理辨体-辨病-辨证相结合学术思想的师承渊源、理论渊源及当前中医的诊疗模式(综述),整理总结辨体-辨病-辨证相结合的学术思想内涵及临床运用经验。2.2根据跟师体会,将王琦教授对疾病的认识、经验用方和特色用药进行整理,总结王琦教授七种临床擅治疾病的诊疗经验。2.3对王琦教授治疗慢性失眠的经验方高枕无忧汤进行临床研究采用前瞻性随机对照方法,共观察符合纳入标准的患者120例,均为继承人在北京世纪坛医院中医科门诊接诊的患者。其中治疗组60例,予王琦教授自拟的高枕无忧汤,结合患者体质、证型加味,每日2次,每次200毫升；对照组60例,予磁朱丸,每日口服2次,每次3g。21天为一疗程,记录治疗前后症状积分量表、匹兹堡睡眠指数量表和安全性观察表,对所有数据均采用SPSS16.0统计软件包进行统计处理。3研究结果3.1王琦教授辨体-辨病-辨证相结合学术思想辨体-辨病-辨证相结合即是在体质、疾病、证候三者之间内在联系的前提下,根据“体病相关”、“体质可调”的理论,以辨体论治为核心,将辨体、辨病、辨证密切结合,进行综合临床运用的一种诊疗思想。辨体是以人为目标,辨病是以疾病全过程的病理特点与规律为目标,辨证是以“病”过程中的某一阶段为目标,是疾病某一阶段的病理特点与规律的总结。在诊疗中,疾病的本质、规律与特征由体质、疾病、证候三者以不同的角度、不同的层面反映出来。体质、疾病、证候相互联系,密不可分,缺一不可,而其核心是辨体论治。体质在疾病的发生、发展、转归中起着重要作用,立法处方要充分考虑体质因素。3.2王琦教授辨体-辨病-辨证相结合临床运用经验辨证须辨体：临床辨识证候时,要不忘辨体质；治病先调体：对与体质密切相关的病、证,要从调体入手；治病兼调体：在治病过程中,辨证用药的同时要兼顾调整体质；无证可辨,调体为治：要“因人”论治“无证”之病；从辨体、调体入手以治本。3.3发挥与创新辨体-辨病-辨证相结合的诊疗模式以辨体为核心,强调个体体质的差异性及体质对疾病的发生、发展及用药的影响,体现了中医“以人为本”、“因人制宜”的学术思想；辨体-辨病-辨证相结合,从体、病、证不同层次认识疾病,由此制定的治法和方药具有相对的稳定性和可重复性,可使长期以来中医用药及疗效难以重复的问题得到解决。在学习和运用中我认识到：体质类型以“兼夹”为主要临床表现形式,应重视兼夹体质的调理；同时,临床运用中,对辨体用药的选择,要以辨证特点为指导。3.4王琦教授诊疗经验总结慢性前列腺炎以毒、瘀、浊犯扰精室为病机之要,根据“腑以通为用”活用经方,分期而治；阳痿从肝论治,药前予心理疏导,治用自拟疏肝振痿方；少、弱精子症以肾虚夹湿、热、瘀、毒、虫为病机特点,治以自拟升精赞育汤加减,同服黄精赞育胶囊；慢性泌尿系感染以毒瘀交结,湿热内扰为病机特点,治从毒瘀论治,兼以利湿清热,方用自拟五草汤；变应性鼻炎宜调体治本,抓主症,缓急分治；痤疮从湿热毒瘀而论,治用千金苇茎汤加马齿苋、白花蛇舌草；高血压以痰湿水邪内蕴、血瘀蕴热内阻、气失和降而逆为病机,治以自拟镇肝降压汤。运用附子时以“少火生气,壮火食气”为法度调控用量,以干姜、甘草配伍减毒；以舌添药汁无麻感为煎煮附子的尺度。3.5王琦教授经验方高枕无忧汤治疗慢性失眠的临床研究3.5.1两组治疗前在性别、年龄、病程、中医体质分类及中医症状积分、PSQI积分等方面的基线基本一致(P>0.05),提示两组患者的分布均衡,具有较好的可比性。3.5.2120例观察患者中,气虚体质1.67%；阳虚体质1.67%；阴虚体质12.50%；痰湿体质0%；湿热体质12.50%；血瘀体质33.33%；气郁体质38.33%,说明气郁体质、血瘀体质最易出现慢性失眠,痰湿体质、气虚体质、阳虚体质很少出现慢性失眠。3.5.3两组均可改善慢性失眠患者的临床症状总积分(P<0.05),治疗组的疗效较对照组磁朱丸显著(P<0.05),尤其对入睡困难、多梦、睡眠时间、易醒四症的改善较显著(P<0.05),而对困倦乏力的改善二者无显著性差异(P>0.05)。治疗组中医症状疗效的临床痊愈率36.67%,显效率48.33%,有效率10%,总有效率95%,经秩和检验,治疗组较对照组有显著性差异(P<0.05),治疗组中医症状疗效较对照组显著。3.5.4 PSQI积分的统计分析表明,两组均可改善慢性失眠患者的睡眠质量、入眠时间、睡眠时间、睡眠效率、睡眠障碍、日间功能及减少催眠药物(P<0.05),治疗组较对照组显著(P<0.05)。治疗组PSQI疗效：临床痊愈率28.33%,显效率51.66%；好转率13.34%,总有效率93.33%,经秩和检验,治疗组较对照组的PSQI疗效有显著性差异(P<0.05)。反映出对PSQI和相关成分的改善及PSQI疗效,王琦教授高枕无忧汤的疗效较磁朱丸显著。3.5.5在本项研究中,治疗组与对照组均未发现不良反应、未出现不良事件。4结论4.1“辨体-辨病-辨证相结合”是王琦教授的重要学术思想,贯穿于王琦教授临床诊病施方用药的全过程,其核心是辨体,治病求本,治本即是治体。临床运用的经验为：辨证须辨体、治病先调体、治病兼调体、无证可辨,调体入手。4.2王琦教授临床诊病经验丰富,对疾病的认识全面深刻,活用经方,善用自拟方。4.3运用中医症状积分表、匹兹堡睡眠指数量表,对王琦教授高枕无忧汤治疗慢性失眠临床疗效进行科学的统计、分析、总结,用客观数据表明了疗效的确切性及高效性,使之具备另人信服的说服力,丰富了王琦教授高枕无忧汤治疗慢性失眠的经验内涵,成为本课题研究的创新之处,为实践中医传承探索出一个行之有效的方法。目的为全面总结和传承王琦教授治疗慢性失眠的临床经验,采用随机对照的前瞻性临床研究方法,对王琦教授自拟的高枕无忧汤治疗慢性失眠进行分析研究,使疗效判定客观有据,信度提升,进一步丰富王琦教授治疗慢性失眠临床经验的内涵。方法1查阅梳理近五年来慢性失眠的中西药治疗状况,学习十余位现今中医名家治疗慢性失眠的经验及特色,以全面掌握慢性失眠的相关研究。2采用随机单盲对照的前瞻性临床研究方法,共观察符合纳入标准的患者120例,其中治疗组60例,予王琦教授自拟的高枕无忧汤,结合患者体质、证型加味,每日2次,每次200m1；对照组60例,予磁朱丸,每日口服2次,每次3g。21天为一疗程,记录治疗前后症状积分量表、匹兹堡睡眠指数量表(PSQI)和安全性观察表,对所有数据均采用SPSS16.0统计软件包进行统计处理。结果1两组治疗前在性别、年龄、病程、中医体质分类及中医症状积分、PSQI积分等方面的基线基本一致,提示两组分布均衡,具有较好的可比性。2120例观察患者中,气虚体质1.67%；阳虚体质1.67%；阴虚体质12.50%；痰湿体质0%；湿热体质12.50%；血瘀体质33.33%；气郁体质38.33%,说明气郁体质、血瘀体质最易出现慢性失眠,痰湿体质、气虚体质、阳虚体质很少出现慢性失眠。3两组均可改善慢性失眠患者的临床症状总积分(P<0.05),治疗组的疗效较对照组磁朱丸显著(P<0.05),尤其对入睡困难、多梦、睡眠时间、易醒四症的改善较显著(P<0.05),而对困倦乏力的改善二者无显著性差异(P<0.05)。治疗组中医症状疗效的临床痊愈率36.67%,显效率48.33%,有效率10%,总有效率95%,经秩和检验,治疗组较对照组有显著性差异(P<0.05)。4 PSQI积分的统计分析表明,两组均可改善慢性失眠患者的睡眠质量、入眠时间、睡眠时间、睡眠效率、睡眠障碍、日间功能及减少催眠药物(P<0.05),治疗组较对照组显著(P<0.05)。PSQI疗效：临床痊率28.33%,显效率51.66%；好转率13.34%,总有效率93.33%,经秩和检验,治疗组较对照组的PSQI疗效有显著性差异(P<0.05)。5在本项研究中,治疗组与对照组均未发现不良反应、未出现不良事件。结论王琦教授治疗慢性失眠的经验为首辨主因主症,审查病机；交通阴阳,调肝安魂；重调体质,病证结合。王琦教授自拟的“高枕无忧汤”,由夏枯草、半夏、苏叶、百合、合欢皮组成。其中半夏得阴而生,夏枯草得阳而长,二者配伍,可和调肝胃,平衡阴阳,使营卫循行有序,阴阳得以交通；苏叶辛温气薄,理气和营；百合甘微寒,善安定心神；合欢皮甘平,安神解郁,三药的生长特点均为昼开夜合,具有和人类寤寐同步的昼夜阴阳消长规律,可引阳入阴、交通阴阳。五药合用,共奏交通阴阳,序行营卫,调肝解郁的作用。临床研究表明：高枕无忧汤可显著改善患者入睡困难、多梦、睡眠时间、易醒等临床症状,总有效率可达95%；可改善PSQI各成分积分及总积分,提高睡眠质量,PSQI总有效率为93.33%,均较磁朱丸显著。创新点1课题研究方面：本项研究以随机对照的前瞻性研究方法,严格控制两组基线的一致性,采集量表,运用科学的统计方法进行分析,首次对王琦教授自拟的“高枕无忧汤”的临床疗效进行量化分析,使疗效判定客观有据,信度提升,亦使总结老中医经验的手段和方法进一步提升,丰富了王琦教授诊疗慢性失眠的临床经验内涵。2临床用药方面：在学习运用王琦教授治疗失眠的临床经验过程中,禀承王琦教授“女性当重冲任”的辨体论点,提出女性失眠兼调冲任,用于临床,取得了很好的疗效。3辅助治疗方面：在临床中,运用王琦教授经验给予内治的同时,注重运用经络中的跷脉理论进行外治足浴辅助,即符合了阴阳交合的睡眠理论,同时又内外同治,使失眠的治疗更加充分。更多还原

【Abstract】 Being the professor of Beijing University of Chinese Medicine and doctoral supervisor in Basic Theory of Traditional Chinese Medicine, Wang Qi is one of the 500 famous veteran doctors in TCM selected by Ministry of Personnel, Ministry of Health and State Administration of Traditional Chinese Medicine. He founded TCM constitutional doctrine, TCM andrology, saved the examination method of palpation of abdomen and constructed TCM visceral manifestation theory.OBJECTIVE:1 This research carries on complete summarizing to Wang Qi academic thoughts of combination of physique-disease-syndrome differentiation, which make us have an overall, clear and deep understanding to the thoughts, so that they can be passed on generation by generation and provide scientific guidance for clinical practice.2 This research tries to carry forward and develop the treatment thought and characteristic of drugs of professor Wang Qi by summarizing the clinical experiences in treatment.3 This research carries on investigation in the experiences of Wang Qi in treatment of chronic insomnia by Gaozhenwuyou decoction. we can provide scientific statistic evidence for Wang Qi experience, make it more convincing. This also will play an active role in the extensive use of experience of Wang Qi in TCM clinical and provide effective thought and method for the practice of succession of teachers of Chinese medicine.METHOD:1 Summarizing Wang Qi academic thoughts of combination of physique-disease-syndrome differentiationThis research makes an analysis of the succession and theoretical sources and clinical background of the thought of Wang Qi, organize and summarize the connotation in the thought of physique-disease-syndrome and clinical experience2 Summarizing the clinical experiences of Wang Qi in treatment of seven diseases with good effect according to the feeling of learning.3 Study on the clinical effect in treatment of chronic insomnia by Gaozhenwuyou decoction prescribed by professor Wang QI.In the prospective group controlled study,120 cases with chronic insomnia were divided into 2groups. All the patients came from TCM Department in Beijing Shijitan Hospital.60 cases in treating group were given Gaozhenwuyou decoction which was prescribed by professor Wang QI, modified according to physique and syndrome,200ml each time, two times daily. 60 cases in control group were given Cizhu pills,3g each time,two times daily.21days is for a course. All the patients of chronic insomnia were evaluated with syndrome integral scale, Pittsburgh sleep quality index(PSQI) and security scale before and after the treatment. All the data were analyzed with SPSS 16.0 statistical software package.RESULTS:1 Wang Qi academic thoughts of physique-disease-syndrome differentiationThe theory of Wang Qi is premised on the relationship of physique, disease and syndrome. It is also based on the thesis of adjustable physique and the relationship of physique and disease. The core of the theory is treatment based on differentiation of physique. Wang Qi emphasis that physique differentiation, disease differentiation and syndrome differentiation should be combined together to fully recognize the essence of disease, which will be helpful to the diagnosis and treatment.The objective of physique differentiation is human being. The objective of disease differentiation is the general understanding of the pathological characteristics and the law of occurrence and development in the whole process. The objective of syndrome differentiation is to uncover the pathological characteristics and rules, the situation of viscera, yin and yang,qi and blood in a certain stage. Physique, disease and syndrome reflect the essence and characteristic from different angles and levels. They are mutually connected, inseparable, unified and indispensable, while the key point is physique differentiation. Physique not only plays an important role in the occurrence, development and prognosis of the disease but also has great influence and restriction to the formation and evaluation of syndrome. The physical factors should be fully considered when we try to establish the therapeutic principles and prescriptions.2 clinical experiences of combination physique-disease-syndrome differentiation of Wang QiIt is necessary to identify physique before syndrome differentiation, physique differentiation should never be forgot when we diagnose disease. When physique is connected with diseases and the syndrome closely, treatment should begin with adjusting physique. For the disease without syndrome, the treatment should be given according to physique differentiation and physique adjusting.3 understanding and development This study reported that Combination is the main clinical manifestation of physical type in disease. Thus we should pay more attention to the adjustment of physique. At the same time, when we chose drugs to adjust physique in clinical treatment, the character of syndrome should be the guidance.4 Clinical experience of professor Wang QiThe mechanism of chronic prostatitis is toxin, stagnant blood, and turbid pathogen. It can be treated by classic prescriptions stage by stage. Impotence should be treated from liver, using Shuganzhenwei decoction. Psychological counseling before drugs can be helpful. The mechanism of azoospermia is toxin, stagnant blood, heat, parasitic, dampness and kidney insufficiency. It can be treated by Shengjingzanyu decoction and Huangjingzanyu capsule. The mechanism of chronic urinary infection is toxin being fastened with stagnant blood and damp-heat inside. It can be treated from toxin and stagnant blood while clearing heat and draining damp, using Wucao decoction prescribed by professor Wang Qi.Allergic rhinitis should be treated from adjusting physique. The treatment in acute period and remission period are different. Acne is treated by qianjinweijing decoction add purslane hurb and oldenlandia. The mechanism of hypertension is phlegm-damp, stagnant blood, reversed flow of Qi. It can be treated by Zhenganjiangya decoction. Control the dosage of prepared Common Monkshood Daughter Root. It is combined with Dried Ginger and Liquorice Root to reduce the toxicity.5 Clinic study of Gaozhenwuyou decoction prescribed by Professor Wang Qi in treatment of chronic insomnia.5.1 It was comparable between the two groups in gender, age, course of disease, the classification of TCM constitution, score of syndrome integral scale and Pittsburgh sleep quality index(PSQI).5.2 Among 120 subjects, deficient of Qi constitution 1.67%, deficient of Yang constitution 1.67%, deficient of Yin constitution 12.50%, phlegm-dampness constitution 0%, dampness-heat constitution 12.50%, stagnant blood constitution 33.33%, blahs<depressed> constitution 38.33%. The data shows that patients with stagnant blood constitution and blahs <depressed> constitution are more susceptible to chronic insomnia than patients with other constitution.5.3 All of the two treatments can improve the clinical symptoms of the patients(p< 0.05), but therapeutic group was superior to that of control group especially in difficulty falling asleep, sleeping time, dreaminess, frequent arousals (p< 0.05).There was no significant difference in fatigue between the two groups. (p>0.05). TCM syndrome efficiency rate in therapeutic group:cure rate36.67%, apparent rate 48.33%,response rate 10%,overall response rate 95%.Rank sum test show that the treatment effect in therapeutic group was significantly superior to that in the control groups, (p< 0.05).5.4 analyze of Pittsburgh sleep quality index(PSQI):Both of the two treatment can improve the patients’ sleep quality, sleep time, sleep efficiency, daytime function and reduce hypnotic(p< 0.05), but the therapeutic group was superior to that of control group. Pittsburgh sleep quality index(PSQI) efficiency rate:cure rate 28.33%, apparent rate 51.66%, response rate13.34%, overall response rate 93.33%. Rank sum test show that the treatment effect in therapeutic group was significantly superior to that in the control group. (p<0.05). This indicate the Jiaoheanmian Decoction of professor Wang Qi is more effective than CIZHU pills in improve the symptoms related to PSQI.5.5 There is no side effect and adverse event was found in both groups.CONCLUSION:1 Combination of physique-disease-syndrome differentiation is an important academic thoughts of professor Wang Qi. It exits all the processes of clinic treatment. The core of the theory is physique differentiation, which is the fundamental of disease and main target of treatment. The experience of clinic treatment is include:physique differentiation is necessary to syndrome differentiation, adjust the physique before medical treatment, treat disease while modulate individuals’body constitution, modulate individuals’body constitution when syndrome can not be identified.2 Professor Wang Qi has rich experience and his understanding to disease is comprehensive and profound. He can use classic prescriptions flexibly and make his own prescriptions.3 Using TCM symptom integral scale and Pittsburgh sleep quality index to statistic, analyze and summarize the experience of professor Wang Qi in the treatment of chronic insomnia. Objective data shows that the effect is definite and convincing. It also enriched the connotation of the effect in the treatment of insomnia and became an innovation of this study. It also provide an effective method to practice inheritance of Traditional Chinese Medicine. OBJECTIVE:In order to summarize and inherit the clinical experience of professor Wang Qi in treating chronic insomnia, we analyzes the clinical effect of Gaozhenwuyou decoction which is prescribed by professor Wang Qi in prospective group controlled study.This study aim to support the clinical effect with evidence, improve the reliability, and enrich the connotation of the experience of professor Wang Qi.METHOD:1 In order to grasp the related studies of chronic insomnia, we reviewed the treatment of insomnia in West medicine and Traditional Chinese Medicine and learn the experience of more than ten famous TCM doctors in treating the disease.2 In the prospective group controlled study,120 cases with chronic insomnia were divided into 2groups.60 cases were given Gaozhenwuyou decoction which was prescribed by professor Wang QI,200ml each time, two times daily.60 cases in control group were given Cizhu pills,3g each time,two times daily.21 days is for a course. All the patients of obstinate insomnia were evaluated with Syndrome integral scale, Pittsburgh sleep quality index(PSQI) and security scale before and after the treatment. All the data were analyzed with SPSS 16.0 statistical software package.RESULT:1 It was comparable between the two groups in gender, age, course of disease, the classification of TCM constitution, score of syndrome integral scale and Pittsburgh sleep quality index(PSQI).2 Among 120 subjects, deficient of Qi constitution 1.67%, deficient of Yang constitution 1.67%, deficient of Yin constitution 12.50%, phlegm-dampness constitution 0%, dampness-heat constitution 12.50%, stagnant blood constitution 33.33%, blahs<depressed> constitution 38.33%. The data shows that patients with stagnant blood constitution and blahs <depressed> constitution are more susceptible to chronic insomnia than patients with other constitution.3 All of the two treatments can improve the clinical symptoms of the patients(p< 0.05), but therapeutic group was superior to that of control group especially in difficulty falling asleep, sleeping time,dreaminess, frequent arousals (p< 0.05).There was no significant difference in fatigue between the two groups. (p>0.05). TCM syndrome efficiency rate in therapeutic group:cure rate 36.37%, apparent rate 48.33%,response rate10%,overall response rate 95%. Rank sum test show that the treatment effect in therapeutic group was significantly superior to that in the control groupe. (p< 0.05)4 Analyze of Pittsburgh sleep quality index(PSQI):Both of the two treatment can improve the patient,s sleep quality, sleep time sleep efficiency, daytime function and reduce hypnotic(p<0.05), but the therapeutic group was superior to that of control group. Pittsburgh sleep quality index(PSQI) efficiency rate: cure rate 28.33%, apparent rate 51.66%,response rate13.34%, overall response rate 93.33%. Rank sum test show that the treatment effect in therapeutic group was significantly superior to that in the control group. (p< 0.05).5 There is no side effect and adverse event wes found in both groups.CONCLUSION:Gaozhenwuyou decoction of professor WangQi is composed of Common Selfheal Fruit-spike, Pinellia Tuber, Perilla Leaf, Lilly Bulb, Silktree Albizia Bark. These two herbs are combined together to regulate liver and stomach, balance Yin and Yang. Thus nutrient and defense can move regularly, Yin and Yang can join each other. Perilla Leaf is pungent-warm. It can regulate Qi and harmonize nutrient blood. Lilly Bulb is sweet and cold and is good at tranquilizing. Silktree Albizia Bark is sweet and even. it is also good at at tranquilizing and anti-depression. The growth characteristic of these three drugs is bloom in day and close at night, which have the same sleep pattern with human. That is why the decoction can lead to a good clinical effect.The experience of professor Wang Qi in treating chronic insomnia is include:identify the main cause of disease, main syndrome and the mechanism of disease first; search for fundamental of disease in treatment; make Yin and Yang join each other; treat insomnia from regulating liver and tranquilizing; pay great importance to physique adjustment and tranquilize through stasis-resolving.INNOVATION:1 It is the first time to quantitative analyzes the clinical effect of Gaozhenwuyou decoction in a prospective group controlled study. In this study, the coherence of the baseline of two groups was strictly controlled, scales and scientific statistic method were used.These methods can support the clinical effect with evidence, improve the reliability, and enrich the connotation of the experience of professor Wang Qi. 2 I submit that doctors should pay more attention to regulate Qi and Blood when treating female patients with insomnia according to the theory of professor Wang Qi. This has leaded to a great effect in clinical treatment.3 Take foot bathing, one of the external treatments, as a adjuvant therapy of internal therapy to patients with insomnia. This treatment conforms the theory of joining Yin and Yang. Thus the patients with insomnia can be fully treated.更多还原