许心如学术思想和临床经验总结及三参通脉合剂治疗胸痹的临床研究

【作者】 陈嘉兴；

【导师】 许心如；

【作者基本信息】 北京中医药大学 ， 中西医结合临床心脑血管， 2011， 硕士

【摘要】 1.许心如教授学术思想渊源许心如教授出生于1924年12月,籍贯上海。1952年毕业于上海同济大学医学院,其后分配到北京工作。在五十年代响应我党“西医学中医,整理提高祖国医学”的思想号召,于1959年至1961年参加北京市第一届西医学中医脱产学习班,系统学习祖国传统医学近三年。许心如教授为国内名牌大学毕业后最早系统学习中医的中西医结合专家。1962年结业后至今一直在北京中医医院从事中医及中西医结合临床、科研及教学工作,退休后继续在北京中医医院从事专家门诊、特需门诊及师带徒工作,迄今行医近六十年。许心如教授擅长心脑血管疾病的诊治,是国家级名老中医,曾获“全国三八红旗手称号”。许心如教授出身中医世家,其曾祖父常常亲自采药给患者使用,外祖父姜子楣和舅舅姜嶽甫,是当时江浙一带的名医,曾师从孟河费伯雄。母亲姜毓清也常侍诊于外祖父左右,耳濡目染,亦得其要旨。继承和发扬了费伯雄“醇正”、“缓和”的医学思想。许心如教授从小就接受家族前辈的熏陶。许心如教授勤奋好学,因为工作关系,曾广泛向当时的姚正平、关幼波、王为兰、王鸿士、王大经等名老中医吸取经验,最终创建益气养阴,活血通脉的方法治疗胸痹的理论体系,组方为三参通脉合剂,临床疗效获得肯定。同期,在国内首创了泻肺利水法治疗心力衰竭的先河,研制了心衰合剂系列方剂运用于临床。许心如教授在长期的临床实践过程中,将各位名家的理论融会贯通,博采众长,在继承和研究前人学说的基础上,在理论上、用药上形成了自己的特色。许心如教授十分重视整体观念及辨证论治的原则,强调“治病必求其本”的思想。同时,在家学渊源影响下许心如教授非常注重遣方用药的平和配伍,讲求对患者气血的调整,使气血平稳调和,很少使用毒性很大的药物。胸痹、心痛属现代医学冠状动脉性心脏病(Coronary heart disease,CHD)属范畴,是临床常见的心血管疾病,也是当今社会导致死亡的主要疾病之一。流行病学研究显示我国的冠心病发病呈逐年上升趋势,在北京地区冠心病的发病率及病死率均排各种疾病之首。许心如教授通过数十年的临床实践和理论研究形成了诊疗胸痹(冠心病)独特的中医药诊疗思路。本研究将采用现代化的技术手段,以如实采集、原始保存、系统整理为原则,分析研究许心如教授运用益气养阴,活血通脉法对于胸痹(冠心病)治疗的学术渊源、学术思想、临证经验和思辨特点等,最终总结出许心如教授以益气养阴,活血通脉法治疗胸痹(冠心病)的思路、方法及经验。同时,总结出许心如教授在心衰病、眩晕、心悸、不寐、心肌桥等病症在中医临床实践中的学术成就和经验。从而有利于更全面系统地开展对许心如教授中医学术思想的继承工作,使更多的医务工作者了解、学习、掌握许心如教授的中医诊疗思路和方法,服务于更多患者。2.许心如教授学术思想和临床经验的整理与研究2.1胸痹心痛病(冠心病)许心如教授是首都医科大学附属北京中医医院心血管科学术带头人,在国内较早提出运用益气养阴,活血通脉法治疗胸痹心痛病(冠心病心绞痛)的思想,在治疗胸痹心痛病的临床观察工作,疗效显著,并逐步发展组方为三参通脉合剂。三参通脉合剂由生黄芪、太子参、玄参、丹参、赤芍、白芍、娑罗子、延胡索、柴胡等组成,取用标本兼顾之法,治以益气滋阴养血,理气活血化瘀,把扶正和驱邪有机地结合起来,配伍合理,取得明显疗效。2.2心衰病(心力衰竭)以往各方名医和专家大多采取益气温阳利水的方法治疗心衰病,许心如教授通过对心衰病(心力衰竭)竭患者的长期临床实践,又在研读古代文献的基础上,提出了泻肺利水治疗心衰病(心力衰竭)的学术思想。许心如教授结合中医经典理论和临床实践,总结出气虚血瘀水停是心衰病的重要病机。许心如教授根据心衰病气虚血瘀水停的病机,首创了泻肺利水法治疗心衰病,以《金匮要略》中的葶苈大枣泻肺汤为主方,组成了心衰合剂系列方剂。气虚重者加黄芪,气阴两虚加生脉散,血瘀水停加赤芍、水红花子等。泻肺利水法主要用于水气凌心、水饮射肺等标急之证。许心如教授在心衰合剂的基础上又研制了强心栓,创造性地开发了中药栓剂治疗心力衰竭,是中药治疗心力衰竭在制剂方面的又一创造性的工作。2.3眩晕病许心如教授认为从传统医学角度讲,眩晕就是指以头晕目眩为主症的疾病,轻者闭目即止,重者如坐车船,旋转不定,不能站立,或伴有恶心呕吐,汗出,甚至昏倒等症状。现代医学的很多疾病都可以引起眩晕,如高血压病、低血压病、美尼尔综合征、中枢性眩晕、周围性眩晕、神经衰弱、更年期综合征、颈椎病、脑供血不足等。从中医的传统治疗方法上,主要根据其症状及舌脉,辨证施治。对于颈椎病、脑供血不足可以酌情参合辨病治疗。2.4心悸病许心如教授认为心悸可分为惊悸和怔忡。惊悸多与情绪因素有关,如骤遇惊恐,忧思恼怒等。疾病特性多为阵发性,病情轻,实证多；怔忡多由久病体虚,心神受损,无精神等因素就可发生,常为持续性,不能自控。病情较重,多属虚证或虚实夹杂。临证时,心悸患者应重点看脉律是否整齐,心率是快还是慢,以指导辨证。心悸分虚实,虚证多为气阴亏虚,心阳不振；实证多见瘀血阻滞等。2.5不寐许心如教授认为,不寐是患者不易入睡、睡后易醒、或彻夜不眠为主要症状,或多梦的疾病。不寐的主要病机为脏腑功能阴阳失调,气血失和,致心神不安或心神失养。主要有虚实两方面,实者多为情绪易于波动、肝失条达、饮食不节、痰热上扰；虚者为心肾不交、水火不济、劳倦过度、耗伤气血、心脾两虚。治疗以调和气血,补益脾肾,清心安神为主。2.6心肌桥冠状动脉及其分支通常行走于心脏表面的心外膜下脂肪中或心外膜深面,当一段冠脉被心肌所包绕,该段心肌称为心肌桥(myocardialbridge),该段冠脉称为壁冠状动脉。心肌桥可能与冠心病的发病局部因素有关,也可能引起心肌缺血。可现代医学对有症状的心肌桥及心肌桥处有动脉粥样硬化斑块者可采用药物或手术治疗但疗效不佳或创伤较大。祖国传统医学没有关于“心肌桥”的任何记载,但目前就诊患者有愈来愈多的趋势,许心如教授根据发病特点,把辨证和辨病相结合,认为是中医所说的“筋经不舒,经脉拘挛”之证,故使用养血柔筋、舒缓经脉的方法可以减轻冠状动脉被压迫的情况,从而控制症状。2.7汗证许心如教授认为,汗证大部分以阴虚阳亢多见,阴不敛阳。男女均有潮热、汗出,要治疗要从调节阴阳,平肝养阴,治疗多用平肝养阴治疗；因汗为心之液,汗出过多可以造成心血不足、心气亏虚,故加益气养血活血之品,气虚者重在补气。动则汗出者不一定都是气虚,热邪内蒸也可以自汗出,气虚以活动后汗出为主。肾气虚者多伴腰膝酸软,腰以下汗多,应补肾气,固肾精。肺气虚者多上身汗多,易感冒。口干、口渴、大汗出者,面赤,饮水多者,是热邪内蒸,重在清气分热为主,灼加养阴之品以防伤阴。3.三参通脉合剂治疗胸痹的临床研究通过对110例冠心病患者随机对照分组,服用三参通脉合剂组和西药组,三参通脉组治疗后主要症状积分及主症、兼症总积分均较疗前显著减少,结果表明患者胸闷、疼痛程度、发作次数、持续时间、使用硝酸甘油、心悸、乏力等主、次症状均较对照组得到明显改善。许心如教授创立益气养阴,活血通脉法,使用三参通脉合剂辨证治疗胸痹(冠心病)疗效肯定。目的：观察三参通脉合剂治疗冠状动脉粥样硬化性心脏病的临床疗效。方法：将冠心病患者随机分为三参通脉组58例、西药组52例,西药组予常规西药治疗,三参通脉组在常规西药治疗的基础上加用三参通脉合剂治疗,疗程4周。观察患者症状、体征、心电图的变化。结果：三参通脉组患者治疗后较治疗前症状积分明显下降,临床疗效方面,其中显效40例(占总数68.96%),有效者18例(占31.03%),总有效率100%,与西药治疗组相比能减轻患者症状及中医兼证(P<0.05)。结论：三参通脉合剂可以明显改善冠心病患者的临床症状,提高患者的生活质量。更多还原

【Abstract】 1.Professor Xu Xin-ru:Academic Thoughts OriginProfessor Xu Xin-ru, who was born in December 1924, was a native of Shanghai and graduated from Shanghai Tongji university medical college, and then assigned to Beijing. From 1959 to 1961, for responsing to our party’s call of "Western medicine learn from traditional Chinese medicine (TCM) to improve medical health of China" , she participated in the first class named "Western learn from Chinese medicine" and systematically studied TCM for nearly three years. Professor Xu Xin-ru is an expert of combining traditional Chinese and western medicine, who was the earlist famous expert graduating from the famous university in our country. From graduated in 1962 until now, she has always been working in Beijing hospital of TCM in participating in clinical practice, scientific research, and education. After retiring from work, she continued to work in an expert outpatient service, the special consultation clinic and educational work, and so far, she has been practicing medicine in nearly 60 years. Professor Xu Xin-ru is skilled in the treatment of cardio-brain vascular disease. She is a state-level old doctor of traditional Chinese medicine, was awarded the "national march-eighth red-banner pacesetter title".Professor Xu Xin-ru was born in a family of TCM. Her greatgrandfather often gathered herbs personally to treat patients. Her maternal grandfather Jiang Zi-mei and her maternal uncle Jiang Yu-fu were both the famous dortors in the area of Jiangsu and Zhejiang provinces. They have learned from Fei Bo-xiong, a famous doctor from Menghe. Her mother Jiang Yu-qing also learned from her grandfather and grasped the key therapeutical ideas of her family. Professor Xu Xin-ru has accepted the edification of the family predecessors very early in her childhood.Professor Xu Xin-ru was a diligent and hard working expert. Because of the work affairs, she used to extensively learn from doctor Yao Zheng-ping, Guan You-bo, Wang Wei-Ian, Wang Hong-shi and Wang Da-jing, etc, for the excellent experiences of clinical practices and finally founded the "nourish Qi and Yin, and activating blood" treatment theory, and formed Sanshentongmai TCM formula which has been confirmed to be effective in the treatment of Xongbi. Meanwhile, she established the Xiefeilishui theory in the treatment of heart failure initiatively and developed a heart-failure formula called Xinshuai compound formula in the clinical practice. In the long-term practical process, professr Xu achieved mastery through a comprehensive study of the subject, and put all the theories from famous pactitioners together and took the best and formed her own characteristics at the basis of inheritance and research of the predecessors’ theory. Professor Xu Xin-ru always paid great importance in the principles of "holistic thinking" and "syndrome differentiation" and emphasized the "cure will ask its origin" in her clinical practice. At the same time, at the influnce of her family origin, professor Xu Xin-ru has paid much attention to the gentle compatibility of medicinal prescriptions and the adjustment of qi and blood of the patients in the treatment of disease and rarely used Chinese herbs with great toxicity.Xiongbi and Xintong are two terms in TCM which are belonging to the terms of coronary heart disease (CHD) in the western of medicine. It is commonly seen in patients with cardiovascular disease and is one of the leading causes of death in our society. Epidemiological studies have shown that the morbility of CHD has gradually increased each year in our country, and the morbility and mortality are both the head of the disease line in Beijing.Professor Xu Xin-ru has formed an unique TCM diagnostic and therapeutic thoughts in the treatment of Xiongbi (CHD) at the basis of decades of clinical practice and theory. Based on the modern technologies such as truthfully collection, originally save, systematically organization, the study was aimed to investigate the academic origin, academic thoughts, clinical experience, and the speculative characteristics of professor Xu Xin-ru in her treatment of Xiongbi (CHD) with her therapeutical theory "nourish Qi and Xue, activating blood" in the clinical practice. Finally, generalize the thoughts, methods, and experiences of her treatment of Xiongbi. And meanwhile, generalize the academic achievements and experiences in the treatment of heart failuer, dizziness, palpitation, insomnia and myocardial bridge,etc in TCM clinical practices. The purpose of the work above is to provide more benefit in the inheritence of experiences of professor Xu and made more younger doctors acknowledge the thoughts and methods of her clinical practice and help more people of our society.2. Arrangement and research of academic thoughts and clinical experience of professor Xu Xin-ru2.1 Xiongbi and Xintong (coronary artery disease, CHD)Professor Xu Xin-ru is the academic leader of cardiovascular department, Beijing hospital of TCM, capital university of medical sciences. She proposed the unique therapeutic theory of TCM "nourishing qi, nourishing yin, and activating blood" in the treatment of patients with xiongbi and xintong (CHD) and acquired excellent effect in clinical practice. And then, she developed Sanshentongmai herbal prescription, which were made up of astragalus membranaceus, radix pseudostellariae, radix scrophulariae, salvia miltiorrhiza, radix paeoniae rubra, white paeony root, aesculus chinensis bge, rhizoma corydalis, radix bupleuri, etc., and put it into clinics under the theory of "nurish qi and yin, activating blood". All of the above she has done combined a strengthening health with dispersing pathogenetic factor to come to a reasonable compatibility and the significant effect. 2.2 Xinshuai bing (heart failure, HF)Previously, many famous doctors or experts used to treat HF under the theories of "nourishing qi, warming yang, and promoting diuresis". Based on long-term of clinical practice and reviewing ancient literatures, professor Xu proposed the "xie lung and promote diuresis" theory in the treatment of HF. She thought that deficiency of vital energy, blood stasis, and water stasis were the basic pathological mechanisms involved in HF in TCM, so she founded the "nourish qi, warming yang, and promote diuresis" in treatment of HF and made Tinglidazaoxiefei prescription as the main formula to form a series of TCM prescriptions. She added astragalus mongholicus when qi deficiency and Shengmai San when qi and yin deficiency, added root of common peony and fruit of princesplume ladysthumb when it is in blood stasis. The theory of "xie lung and promote diuresis" often used in the water attacking the heart and Drink water shoot lung. Based on the xinshuai series of formulas, professor Xu has developed herbal suppository in the treatment of HF, which is another innovative work of pro. Xu in her TCM clinical career.2.3 Xuanyun bing (vertigo)Professor Xu thought that, from TCM point, vertigo refered to the syndromes that include dizziness and swirl. It usually stopped when closing the eyes, and aggreviated when being in a motor or a boat and can not stand upward. Sometimes, it usually accompanied with nausea and vomiting, sweating, even faint and other symptoms, In mordern medicine, vertigo can be caused by a series of disease such as hypertension, hypotention, Meniere’s syndrome, central dizziness, peripheral vertigo, neurasthenia, menopausal syndrome, cervical spondylosis, cerebral blood deficiency, etc.2.4 Xinji (palpitation)Professor Xu considered that the TCM term "palpitations" can be divided into two clinical syndromes called fright (xinji) and timidity (zhengzhong). Fright (xinji) usually related to more emotional factors, such as flash meet fear, anger, sorrow. It often occurs paroxysmally, with light condition and excess TCM syndrome. While timidity (zhengzhong) often brought about by the deficient condition after long-term disease and the injuried mind. It usually lasted for a very long time and can not be easily controlled. More attention should be paid in estimating whether the pulse is in order, fast or slow, in order to guide TCM syndrome differentiation. Palpation was divided in to deficient syndrome and excess syndrome. The deficient syndrome was qi and yin deficiency, heart yang deterioration, while excess syndrome was blood stasis, etc.2.5 Bumei (insomnia)Professor Xu considered that insomnia were a series of disorders which included hardness to sleep, wake up easily, or awake all night as the main symptoms, or of dreams. The main mechanisms of insomnia were the unbalance of yin and yang, qi and xue, which caused the disfunctions in the mind and spirit. It included two TCM syndromes:deficiency and excess. The excess syndrome were often shown as easily being interupted, hepatic disfunction, excessive diet, much heat and phlegm. While deficient syndrome can be concluded as disharmony of heart and kidney, water and fire, excessive working, injuried blood and qi, and deficiency of heart and spleen. Therefore, nourish spleen and kidney, refresh heart and slam down were both important methods for treatment of insomnia.2.6 Myocardial bridgeCoronary artery and its branches often traversed across the surface of the heart and in the epicardial fat or deep face. When a coronary artery was packaged by the myocardium, this myocardial can be called the myocardial bridge and this specific coronary artery was called mural coronary artery. The myocardial bridge may be related to the onset of coronary heart disease of local factors and also can cause myocardial ischemia. But now, in modem medicine, many treatment methods such as operation and drug medication can be applied in treatment of patients with myocardial brige or atherosclerosis plaques near the myocardial bridge. But both of these methods were poor effective and usually with wide range injuries. There was no literatures published in terms of myocardial bridge in acient times. But there are more and more patients who were suffered with myocardial bridge in clinical practice. Based on its characteristics, professor Xu thought that myocardial bridge can be defined as the TCM syndrome "disfunction of jin and muscularconstricture" and nourish blood tending medicte should be applied in relieving symptoms that were caused by repressing of the coronary artery, and finally to control the symptoms.2.7 Sweat syndromeProfessor Xu considered that sweat syndrome was more commonly seen in patients with yin deficiency and yang excess, and yin not gathering yang. Patients with sweat syndrome often had symptoms such as hot fever, sweat out, so the treatment method should be based on balancing yin and yang, inhibiting liver and nourish yin. Because sweat was the fluid of the heart, much sweating may cause deficiency of the blood and the healthy atmosphere, so the Chinese medical herbs which have the characteristics of nourishing qi and yin should be added. It is of importance to add herbs with nourishing qi characteristics when patients are in the qi deficiency condition. It is not always the qi deficiency syndrome when sweating after moving, and inner hot can also cause sweating. Patients of qi deficiency often exhibit sweating after moving. The kidney qi deficiency syndrome often accompanied with lumbar debility and sweat more under the waist, so Chinese herbs with nourishing qi and yin should be added. Patients of lung qi deficiency are often easily to catch a cold. Patients with the syndrome of inner hot often showed symptoms such as dry mouth, thirsty, sweat out, red face, drink much, so adding nourishing yin product to prevent yin injury.2.8 Academic experience of professor Xu in treatment of CHD:clinical study.In our clinical trial,110 patients with CHD are randomly divided into two groups, and respectively administered with Sanshentongmai compound prescription and normal western medical treatment. The observational indexes included main symptom scores, main symptom total scores, and accompanied symptoms scores. The results showed that the main symptom scores, main symptom total scores, and accompanied symptoms scores were significantly decreased compared to the pre-treatment. The symptoms of chest distress, degree of chest pain, chest pain frequency, consumed nitroglycerin, palpitation, and fatigue are both relieved in Sanshentongmai treatment group compared to those in the normal medical treatment group. The therapeutic view of "nourishing qi and yin, activating blood and promoting circulation", which is founded by professor Xu, is confirmed to be effective in treatment of Xiongbi (coronary artery disease) in clinical practice. Objective:To observe the clinical effect of Sanshen Tongmai Heji in the treatment of coronary atherosclerotic heart disease(CHD). Methods:Cornary atherosclerotic heart disease patients were randomly divided into 2 groups.The patients in the control group (52 cases) received conventional western medicine treatment, the Sanshen Tongmai Heji group (58 cases) received conventional western medicine treatment plus Sanshen Tongmai Heji. The follow-up underwent for 4 weeks.The changes of clinical symptoms and ECG were observed. Results:The symptom score decreased significantly after treatment. Better clinical effects were observed after treatment, there are 40 cases indicated excellent efficacy(68.96%),18 out of 58 had good efficacy(31.03%), total effective rate is 100%. Besides that, it can also relieve the symptoms compared with Western medicine group (P<0.05).Conclusion: Sanshen Tongmai Heji can significantly improved clinical effects of CHD patients and improve the quality of life for the patients.更多还原