柴松岩教授学术思想与临床经验总结及基于关联规则的多囊卵巢综合征用药规律研究

【作者】 黄玉华；

【导师】 柴松岩；

【作者基本信息】 北京中医药大学 ， 中医妇科学， 2011， 博士

【摘要】 柴松岩老师是国家级名老中医,著名妇科专家,临床六十年,早年曾师从伤寒大家陈慎吾,苦读中医典籍,打下了深厚的理论基础；后又就读于北京医学院,接受了5年现代医学的系统培训。执业初期,柴老受诸多中医名家指点,潜心钻研,博采众家之长,在不断地实践中,创立了以“肾之四最”、“二阳致病”、“补肺启肾”、“暗耗论”及“妇科三论”学说为核心的学术思想,临床形成了以基础体温为用药指导,重视舌脉在临床中的辨证意义以及组方灵活、性味平和、药少力专的临床用药风格,善于治疗闭经、不孕以及妇科疑难杂症如多囊卵巢综合征、卵巢早衰等。本论文主要从柴松岩老师的学术渊源、主要学术思想和临床经验总结以及柴松岩老师临床治疗妇科疑难杂症——多囊卵巢综合征的临床经验总结三个方面对柴松岩老师的学术思想和临床经验进行研究和总结。第一部分柴松岩老师的学术思想渊源首先简要介绍柴松岩老师的生平经历和主要著述；学术思想渊源的探求从柴松岩老师执业初期的特殊时代背景开始,以柴松岩老师学术思想的代表“肾之四最”、“二阳致病”、“补肺启肾”为例,从经典渊源和师承渊源进行论述。前者以《黄帝内经》为代表。柴松岩老师中医的启蒙老师为伤寒大家、教育家陈慎吾,为其打下了扎实的中医基础；柴松岩老师自执业至今五十余年,一直工作在北京中医医院,行医初期适逢医院建院,当时医院名医荟萃,柴松岩老师幸得多位名医指点,对其影响较大的有刘奉五、祁振华、姚正平、卢冶忱,诸位名家的学术思想及临床经验对柴松岩老师学术思想的形成就起着重要的作用。第二部分柴松岩老师的主要学术思想和临床经验总结主要学术思想：1、“肾之四最”：即“肾生最先、肾足最迟、肾衰最早、肾最需护”,其中的“肾”,柴松岩老师解释为促使性征发育的肾气。源自《素问·上古天真论》,清代沈尧封《女科辑要》有：“肾生最先,肾足最迟,肾衰独早”,但未与临床病证相结合。柴松岩老师通过深入理解经典理论,结合临床,经过多年的实践,形成了自己对“三最”的系统认识,将其用于概括女性一生不同年龄阶段的生理特点,以及该年龄段易患疾病的病因病机特点,并以此为依据指导临床组方及用药特点。2、二阳致病：源自《素问·阴阳别论》。柴松岩老师认为：由于大肠传导功能失调,出现便秘或便结,而胃仍受纳入胃之食,因大肠不能照常传导,胃肠积聚浊热内生,邪热溢入血分,灼耗津液阴血,阴血不足,心气失养,而致生脾无力,脾虚失去为胃运化之功,而生血乏源,阴血更亏,如此循环往复,而生妇科诸病。3、“暗耗论”：“暗”,意为看不见,或时有时无,或呈持续性但不被觉察；“耗”意即“耗损”。女人以阴血为本,经、带、胎、产、乳无不与阴血密切相关。作为生理过程,当无临床症状时,其对阴血的耗损均被忽略。故“暗耗”既是女人的生理特点,也是妇科疾病的病理特点,体现在治疗上,应注意阴血的维护,临床用药当慎用阳动、耗散之品。4、妇科三论：所谓“三论”,即“水库论”、“土地论”、“种子论”。“水库”有两层意思：对患者而言,水库里的水犹如经血,在医者,水库如血海。若阴血不足,血海亏虚者,当重视阴血的养护,以“水满则溢”,勿滥用活血、破血、通利之品。“土地”借喻子宫及内膜的孕育功能,而土地上的“乱石杂草”则如子宫或内膜存在的病理状态,对肝郁气滞、痰湿阻滞等所致不孕不育患者,治疗先以疏肝理气、化瘀、除湿等法单用或多法合用为主而治之,益肾养血为其次。“种子”即卵子,卵子的优劣除父母先天决定外,也取决于其赖以生存的环境。在临床上,“三论”不是相互独立的,而是一有机的总体,只是解释具体疾病时各有所偏重。临床经验总结：1、舌象与辨证：以淡舌、嫩舌、暗舌、红舌、瘦舌、敛舌及剥脱苔、腻苔为例,总结柴松岩老师临床根据舌象、辨病辨证用药的经验。2、脉象与辨证：以妊娠病和月经病为例,如在妊娠病中,柴松岩老师通过脉象指导用药和判断预后；而在闭经患者中,则根据脉象来判断阴血的受损程度及判断治疗的难易程度；对崩漏患者,脉象指导着治疗原则为“治标”或“治本”的选择。3、根据基础体温指导临床用药：根据基础体温的形态,将其分为基础体温基线偏高、基线偏低、基础体温单相和异常双相等,结合典型医案总结柴松岩老师在基础体温不同形态、不同时期的用药特点。4、常见疾病治疗经验总结：选择了多囊卵巢综合征、卵巢早衰、高泌乳素血症、子宫内膜异位症、先兆流产、习惯性流产、妊娠呕吐、功能失调性子宫出血、盆腔炎、更年期综合征、小儿性早熟、乳腺增生等12种临床常见疾病,结合典型医案总结柴松岩老师的治疗经验以及自己的临床体会。5、柴松岩老师用药心得：用药灵活和轻巧是柴松岩老师临床的一大特点,以老师临床常用的疏肝药、益肾药、活血药为例总结其用药特点和规律。6、疑难医案举例：选择柴松岩老师治疗的两例疑难医案,即埋线减肥致毛发脱落案及双乳房不对称案,治疗中体现了柴松岩老师临床思路开阔、处方灵活、用药独特的特点。第三部分基于关联规则的柴松岩治疗多囊卵巢综合征用药规律研究本部分选择明确诊断为多囊卵巢综合征、经柴松岩老师诊治、结果有效的患者126例,共计648诊次,利用数据挖掘技术中的关联规则,对医案进行统计分析和数据挖掘研究,以总结其治疗多囊卵巢综合征的中医辨治特点和用药规律。研究结果为：柴松岩老师治疗多囊卵巢综合征最常用的10味药是：川芎、车前子、月季花、当归、桃仁、茜草、杜仲、女贞子、菟丝子、夏枯草；核心处方是：川芎、车前子、月季花、夏枯草、茜草、桃仁、茵陈、川断、合欢皮；本研究挖掘出7个新药对,为扁豆和茵陈,路路通和车前子、丝瓜络和车前子、泽兰和川芎、桂圆肉和川芎、石斛和月季花、薏苡仁和川芎。多囊卵巢综合征(polycystic ovary syndrome, PCOS)是常见的妇科内分泌疾病,以雄激素过多、胰岛素抵抗和持续无排卵为主要临床特征,是贯穿患者一生的疾病,其发病率为5-10%,而在无排卵性不孕症的患者中发病率高达30-60%。PCOS患者发生糖尿病、高血压、心血管疾病、代谢综合征及子宫内膜癌的风险性明显增加。柴松岩老师自上个世纪六十年代初开始潜心研究闭经和不孕,九十年代初,柴松岩老师发现自己门诊的不孕和闭经患者中PCOS的比例占50-60%,开始集中关注此病,查阅中西医文献,寻找本病辨证治疗及用药规律。经过多年的摸索,柴松岩老师发现本病病机以脾肾不足、痰湿阻滞(胞络)为主,创立了益肾健脾、养血通利的治疗法则,形成了特色鲜明的用药特点,采用纯中医治疗取得了确切满意的疗效。本研究利用数据库及数据挖掘技术对柴松岩老师治疗PCOS的中医诊疗医案进行统计分析和数据挖掘研,以总结其治疗PCOS的中医辨治特点和用药规律。[目的]本研究利用数据挖掘技术中的关联规则,柴松岩老师治疗PCOS的中医诊疗医案进行统计分析和数据挖掘研究,以总结其治疗PCOS的中医辨治特点和用药规律。[方法]选择明确诊断为PCOS、经柴松岩老师诊治、结果有效的患者共126例,共计648诊次,用Excel建立数据库,采用数据挖掘中的关联规则方法,使用visual studio 2005软件进行分析。对所有诊次中单味药物使用的频数、药对和药物组使用的频次和关联度(即支持度和置信度)进行分析,挖掘分析柴松岩老师处方中常用药对和药物组。又根据舌象分类,根据LH/FSH比值进行分型以及根据T值正常与否分组,再次对数据进行挖掘整理分析。[结果](1)挖掘出柴松岩老师治疗本病最常用药物,前10种药依次为川芎、车前子、月季花、当归、桃仁、茜草、杜仲、女贞子、菟丝子、夏枯草。(2)进行药物功效分类统计,发现补虚药和活血化瘀药的均数最高,其次利水渗湿药和的理气药。(3)新药对的挖掘：本研究挖掘出7个新药对,为扁豆和茵陈,路路通和车前子丝瓜络和车前子、泽兰和川芎、桂圆肉和川芎、石斛和月季花、薏苡仁和川芎。(4)对舌质的分析结发现：舌质以舌淡、舌暗、舌肥暗等为主,占46.87%；的,舌红、舌暗红等占9.10%。不同舌象相同用药为川芎、月季花、茜草、桃仁、合欢皮、车前子、夏枯草、茵陈、杜仲。(5)对舌苔分类分析发现：苔腻者参考选择用药为清半夏、郁金、扁豆、荷叶、冬瓜皮、莱菔子、川楝子等；苔干者参考选择用药为浙贝、茅根、天冬、熟地、百合、石斛、杏仁等。(6)根据LH／FSH比值≥2或<2,将病例分型发现：LH／FSH≥2以脾肾不足为主,LH／FSH<2以阴虚内热为主,临床用药与之吻合。更多还原

【Abstract】 Chai SongYan is a national lever famous veteran teran doctor of TCM and a famous gynecologic expert who has been engaged in clinical for more than fifty years. In her early years, she learned from Chen Shenwu who was versed in treatise on febrile disease. And she learned TCM classics through arduous efforts and had a solid theories foundation of TCM. Then she had been studying modern medical in Beijing medical colleage for five years. In her initial stage of clinical practice, she was instructed by many famous veteran teran doctors of TCM. Then she made further research on TCM and absorbed merits of the famous veteran teran doctors of TCM. After her continuous practices, she set up her own academic thoughts which were centred upon "The kidney has four specificities." "The pathogenicities of stomach channel of foot-yang ming and the large intestine meridian", "Nourishing lung and kidney", "The thery of invisible consumption. ", "Three theories of gynecologic." In clinical practice,she prescribed herbs by the guidance of basal body temperature and the dialectic of tongue and pulse. Her prescriptions are flexible and mild. The herbs of her prescriptions are less but have a good efficacy. She is expert in amenorrhea, infertility and gynecologic intractable diseases such as polycystic ovary syndrome, premature ovarian failure and so on. The thesis is the research and summary of Chai Songyan ’s academic thoughts and clinical experiences which includes three aspects.First, the academic origin and thoughts of Chai Songyan.Second, the summary of clinical experiences, third, the summary of Chai’s clinical experiences of treating gynecologic disease---polycystic ovary syndrome.First part The origin of Chai Songyan’s academic thoughtsAt first, the article briefly introduced Chai Songyan’s life experiences and the main writings. The origin of Chai’s academic thoughts were traced back to the special time background in her initial stage of clinical practice. As the example of her early stage of academic thoughts such as "The kidney has four specificities", "The pathogenicity of stomach channel of foot-yang ming and the large intestine meridian" and "Nourishing lung and kidney", the article discussed from classical origin and the disciple origin. The former is represented by the Canon of Internal Medicine. The TCM abecedarian of Chai Songyan was Chen Shenwu who was skilled in treatise on febrile disease and an educationist.So she had a solid theory basis. She has been engaged in clinical for more than fifty years in Bei jing Chinese Medicine hospital. When the hospital was established in the initial stage, there were many famous veteran teran doctors of TCM. Therefore,Chai was luckily instructed by these famous doctors. Among them, there were four of them(Liu Fengwu,Qi Zhenhua,Yao Zhengping,Lu Yechen)who affected Chai significantly. The academic thoughts of famous veteran teran doctors of TCM and their cl inical experiences also performed an significant function in formation of Chai Songyan’s academic thoughts.Second Part The main academic thoughts and the summary of clinical experiences of Chai SongyanThe main academic thoughts:1 "The kidney has four specificities":The kidney forms first, the kidney forms eventually, the impairment of the kidney is the first, the kidney is the.most necessary to be protected. The origin of the theory is《The Thinking of Old People Health Preservation in Plain Questions》.In Qing dynasty, Shen yaofeng’s《Gynecology Edits Wants)) has such setences:"the kidney forms first, the kidney forms eventually, the impairment of the kidney is the first".But it didn’t combine with clinicaldifferentiation of syndromes symptoms. Chai Songyan has formed her own understanding of "three specificities" by her efforts for many years in clinical practices. She summarized the physiological characteristics of female and the characteristics of etiology and pathogenesis of some diseases easily sufferred in such age group by "three specificities".And she uses "three specificities"to direct clinical prescriotions and the characteristic of medication,In 2008,she added "the kidney is the most necessary to be protected"to the theory of "three specificities" and formed the theory of "four specificities".2 The pathogenicities of stomach channel of foot-yang ming. and the large intestine meridian:The theory origins from plain questions of yin-yang various exposition. Because of large intestine’s dysfunction, it could lead to constipation or coprostasis. While the stomach continues to accommodate food, it could cause pathogenic heat in. stomach intestine. The pathogenic heat spills into blood, it would consume blood. Because of blood deficiency, it couldn’t nourish the heart qi.Because of heart qi deficiency, it could lead to spleen-deficiency. Furthermore, hematopoietic resources are deficiency, the blood is scarcity. Such process would circulate, various diseases would be caused in gynecology. 3 "The thery of invisible consumption.""Invisible" it means it can’t be seen or sometimes it has or not, or it happens without being aware. "consumption",It means exhaust ion. Women rely on blood, Menstruation, leucorrhea, pregnancy, parturition and lactation are closely related to blood. As physiological process, if there are no clinical syndromes, the consumption of blood will be over looked. Therefore,the invisible consumption is both the physiological characteristics of female and pathologic characteristics of gynecological disease. In treatment, it should protect the blood and use herbs with caustion.4. "Three theories of gynecologic"It includes "the theory of reservoir", "the theory of earth", "the theory of seed". " reservoir" has two meanings. To the patients,the water in the reservoir is menstruation. To the doctors, the reservoir is the sea of blood. If the blood is deficiency and the sea of blood is scarity, it should nourish the blood. When the water is full, it would spill.Don’t abuse herbs of activating blood, blood-breaking, and Tongli."The earth", it means the gestating function of uterus and intima. Riprap and weed in the earth are similar to pathological state of uterus or intima.To the patients of infertility and aphoria with stagnation of liver-qi or phlegm dampness stagnation, it shoud firstly treat with relieving the depressed liver, absorbing clots, dehumidification and so on.Then treat with supplementing kidney and nourishing blood. Seed is ovum. The ovum is superior or inferior that it not only depends on parents, but also depends on its survivable environment. In clinical practice, "The three theories" are not independent, they are a organic whole. But when they explain the concrete diseases, they have different emphasis.The clinical experience summaries:1 Picture of the tongue and diferentiation of syndromes:Take the pale tongue, the tender tongue, the dead colour tongue, the red tongue, the thin tongue for example, the article summarizes the experience of Chai Songyan’s diferentiation of syndromes and differential diagnosis of diseases and how to prescribe.2 Pulse condition and diferentiation of syndromes:Take the pregnancy disease and menopathy for example, Chai Songyan applies herbs through the pulse condition and judges the prognosis. While to the patient with amenorrheam, it needs to judge the injured degree of blood according to pulse condition and judges how difficult or easy extent to treat the disease. To the patient with metrorrhagia, the pulse condition instructs the principle of treatment which is the choice of " alleviate the symptoms of an illness" or "treat the root cause".3 According to basal body temperature to instructe clinical medication:According to the shape of basal body temperature, it is divided into basic line on the high side, on the low side, monophase,double phase of abnormality and so on. Then combine typical medical record and summarize Chai Songyan’s characteristics of medication according to the diverse shape and phases of basal body temperature.4 The summaries of usual illness’s treatment experience:It choses 12 species of common diseases in clinical practice, such as polycystic ovarian syndrome, premature ovarian failure, hyperprolactinemia, endometriosis, threatened abortion, habitual abortion, vomiting of pregnancy, dysfunctional uterine bleeding, pelvic inflammatory disease, menopausal syndrome, Sexual Precocity, hyperplasia of mammary glands and so on. Then combine typical medical record and summarize Chai Songyan’s treatment experience and my clinical experience.Chai Songyan’s gained knowledge of application of herbs:Applying drugs with flexible and light and handy is Chai Songyan’s major clinical characteristics. Take my teacher’s liver-clearing drugs, tonifying kidney drugs, drugs used to activate blood flow as example, the article summarizes the characteristics of medication and regular rules.6 Difficult and complicated cases:Choose two difficult and complicated cases which Chai Songyan treated. One is named to bury the line to lose weight and lead to shedding of the hair, the other is bimastism dissymmetry. By treating them, t represents Chai Songyan’s wide thinking, flexible prescription and unique characteristic of medication in clinical practice.Third Part Clinical law of chinese herbs compatibility reseach on Chai song-yan’s treatment of polycystic ovarian syndrome with association rulesThis part chooses 126 patients who were definite diagnosis of polycystic ovarian syndrome and were treated effectively by Chai Songyan, And includes 648 visits of these patients’ prescriptions. By applying the Data Mining of Association Rules, the medical records were conducted statistical analysis and date mining. Then summarized tcm differentiation and treatments of polycystic ovarian syndrome and its characteristics of medciation.The findings:the 10 common used herbs in Chai’s treating polycystic ovarian syndrome rhizome of Sichuan lovage, asiatic plantain seed, chinese rose flower, Chinese angel ica root, peach kernel, madder root, bark of eucommia, fruit of glossy privet, dodder, bugle. The core prescription:rhizome of Sichuan lovage, asiatic plantain seeds, chinese rose flower, bugle, madder root, peach kernel, capillary artemisia, dipsacus root, albizzia bark. This research excavates 7 new drug pairs. They are hyacinth bean and capillary artemisia, fruit of beautiful sweetgum and asiatic plantain seeds, loofah and asiatic plantain seeds, lycopus herbandrhizome of Sichuan lovage, cassia pulp and rhizome of Sichuan lovage, dendrobium stem and Chinese rose flower, job’s tears and rhizome of Sichuan lovage. Polycystic ovary syndrome (PCOS) is a common gynecological disease of endocrine disorders. The main clinical status are high androgenic hormones, insulin resistance and chronic anovulation. The disease couldn’t be cured. The incidence rate is 5-10%.But to the patients with anovulation and ilateral,the incidence rate could reach as high as 30-60%.The patients of PCOS have more chance to be sick with diabetes, hypertension, cardiovascular disease, metabolism syndrome and the endometrium cancer.Chai Songyan started to concentrate on studying the amenorrhea and dysgenesia from the early 1960s.In the early 1990s,Chai Songyan discovered that the PCOS occupied 50-60% in outpatients with dysgenesia and amenorrhea.So she began to focus on the disease.She referred to the literature of traditional Chinese medicine and Western Medicine to find PCOS’S treatment of differentiation and regular rule of applying herbs. After several years’exploration, Chai Songyan found that PCOS’s pathogenesis was mainly with deficiency of both the spleen and the kidney and stagnation of phlegm-wetness(the uterine vessels).She established the principle of tonifying kidney and strengthening the spleen and nourishing blood and relief of obstruction. She formed her particular characteristic of medication and gained a pleasing curative effect by tcm treatment. By applying ilatera and date mining techniques, the study carefully selected the tcm medical records of PCOS of Chai Songyan. And conducted the medical records with statistical analysis. In order to summarize her tcm differentiation and treatments of polycystic ovarian syndrome and her characteristics of medciation.Obejective:Based on Data Mining of Association Rules, the study carefully selected the tcm medical records of PCOS of Chai Songyan. And conducted the medical records with statistical analysis. In order to summarize her tcm differentiation and treatments of polycystic ovarian syndrome and her characteristics of medciation.Methods:Choose 126 patients who were definitely diagnosed with polycystic ovarian syndrome and were treated effectively by Chai Songyan. And include 648 visits of these patients’ prescriptions. The database was built in Excel, and all the results were analyzed by software of visual studio 2005.To analyze the frequency use of a single drug, the frequency and association (support and confidence)use of drug pair and drug group in all visits, the study excavates and anlalyzes the common drug pair and drug group in the prescriptions of Chai Songyan.Then according to classification of tongue picture,typing of LH/FSH ratio and grouping T figures or not,the study analyzes and revises the data again.Result(?)1)Excavate the most commonly used drugs of Chai Songyan. The first 10 drugs are in the order of rhizome of Sichuan lovage, ilater plantain seed, Chinese rose flower, Chinese angelica root, peach kernel,madder root, bark of eucommia, fruit of glossy privet, dodder, bugle.(2)To handle the drug efficacy with classification statistics, the study finds that the mean number of drugs in tonics and blood-activating and Stasis-eliminating drugs is the highest.Then are drugs removing dampness and promoting diuresis and qi regulating drugs. (3)Excavation of new drug pairs:This research excavates 7 new drug pairs. They are hyacinth bean and capillary ilateral, fruit of beautiful sweetgum and ilater plantain seeds, loofah and ilater plantain seeds, lycopus herb andrhizome of Sichuan lovage, cassia pulp and rhizome of Sichuan lovage, dendrobium stem and Chinese rose flower, job’s tears and rhizome of Sichuan lovage.(4)The finding of analyzing Tongue proper:The tongue proper is mainly with pale tongue, dark purple tongue, purplish and dark purple tongue.These tongues occupy 46.87%.The red tongue and the dark red tongue and so on occupy 9.10%.Different tongue pictures use the same drugs. These drugs are rhizome of Sichuan lovage, chinese rose flower, madder root, peach kernel,albizzia bark, ilater plantain seed, bugle, capillary ilateral, bark of eucommia.(5)The finding of the tongue coating:the patients with greasy tongue fur refer to use clear pinellia, curcuma root, hyacinth bean, lotus leaf, Chinese waxgourd peel, radish seed, fruit of ilater chinaberry and so on; the patients with dry tongue fur refer to use ilatera fritillary bulb, cogongras rhizome, arisaema tuber, prepared rehmannia root, lily bulb, dendrobium stem, almond and so on.(6)According to the ratio of LH/FSH>2 or<2, the study classifies the cases and has a finding. It finds that the ratio is more than or equal to 2,the case mainly belongs to deficiency of the spleen and kidney. The ratio is low than 2,the case mainly belongs to yin asthenia generating intrinsic heat.The finding is consistent with the clinical medication.更多还原