黎明全应用柴胡加龙骨牡蛎汤治疗脑病经验辑要_李云强.pdf

浙江中医药大学学报2023年2月第47卷第2期黎明全应用柴胡加龙骨牡蛎汤治疗脑病经验辑要李云强陈冬雪黎明全长春中医药大学长春130117摘要：目的探析黎明全教授应用柴胡加龙骨牡蛎汤治疗脑病的临床经验和学术观点，为临证选方提供借鉴。方法选取黎师治疗的失眠、帕金森病伴抑郁、特发性震颤验案3则，结合平时侍诊的心得体会详加按评，从辨别患者体质和四纲辨证角度出发，探索黎师诊治脑病的特色和经验。结果柴胡加龙骨牡蛎汤为临床常用的经典名方，具有和解少阳、通阳泄热、重镇安神的功效。黎师提出，应用柴胡加龙骨牡蛎汤治疗脑病时首先辨识出柴胡体质属实证、热证的患者，然后根据患者的证候要素遣方用药，本方证多指“胸满烦惊，小便不利，谵语，一身尽重，不可转侧”，治疗具体疾病时再结合患者的证型辨证论治。所举失眠案乃痰热腑实、火扰心神之证，拟泻热通腑、和中安神为基本治法；所举帕金森病伴抑郁案为肝郁化火、痰热扰心之证，治以疏肝解郁、清热化痰法；所举特发性震颤验案为痰热动风、火扰清窍之证，治以清湿祛热、平肝熄风法，应用柴胡加龙骨牡蛎汤加减治疗后，均获得较好疗效。结论黎师应用柴胡加龙骨牡蛎汤治疗脑病注重“方证相应”，临床效果显著，其经验值得学习和借鉴。本方亦可以作为脑病的专用方，临床诊疾时可辨证与辨病相结合，提高临床疗效。通过复习验案，有助于读者了解准确应用柴胡加龙骨牡蛎汤的辨证要点，体会异病同治的精妙。关键词：柴胡加龙骨牡蛎汤；经典名方；方证相应；脑病；重镇安神；经验中图分类号：R651文献标志码：A文章编号：1005-5509（2023）02-0219-03DOI:10.16466/j.issn1005-5509.2023.02.020Summary of LI Mingquans Experience in the Treatment of Encephalopathy with Chaihu Plus Longgu Muli DecoctionLI Yunqiang，CHEN Dongxue，LI Mingquan Changchun University of Chinese Medicine，Changchun(130117)，ChinaAbstract:ObjectiveTo explore Professor LI Mingquans clinical experience and academic views on the application of Chaihu PlusLonggu Muli Decoction in the treatment of encephalopathy in order to provide reference for the selection of clinical evidence.MethodsSelecting three cases of Professor LI including insomnia，Parkinsons disease with depression，and idiopathic tremor，combined with theexperience of the usual clinic and detailed comments，the characteristics and experience of diagnosing and treating encephalopathy wereexplored from the perspective of identifying patients constitution and four-class syndrome differentiation.ResultsChaihu Plus LongguMuli Decoction is a classical formula commonly used in clinical practice，which has the effects of resolving Shaoyang，promoting Yangcirculation and relieving heat，and calming the mind.Professor LI proposes that when using Chaihu Plus Longgu Muli Decoction to treatencephalopathy，the first step is to identify patients with actual or heat symptoms，then according to the elements of the patientssymptoms，the formula is used，and the syndicme mostly refers to“chest fullness，irritability，urinary inconvenience，delirium，all-over heaviness，and inability to turn the side”，and the treatment of specific diseases should combine with the patients type ofsyndicme.The case of insomnia cited was syndrome of phlegm-heat accumulation in viscera and fire disturbing the heart and mind，thebasic treatment was to purge away heat and clear the viscera，harmonize the middle-Jiao and calm the mind；the case of Parkinsonsdisease with depression was syndrome of liver depression transforming into fire and phlegm-heat disturbing the heart，the treatment wasto dredge the liver and relieve depression，clear heat and reduce phlegm；the case of idiopathic tremor was syndrome of phlegm-heatmoving wind and fire disturbing the clear orifices，the treatment was to clear dampness and dispel heat，calm the liver and quench thewind.After treated wiht modified Chaihu Plus Longgu Muli Decoction，all of the patients above achieved good results.ConclusionWhen applying Chaihu Plus Longgu Muli Decoction in the treatment of encephalopathy，Professor LI pays attention to the“correspondence between formula and syndicme”，and the clinical results are remarkable，and this experience is worth learning from.The formula can be used as a special formula for encephalopathy and can be used to improve clinical efficacy by combining theidentification of syndicme and disease during clinical diagnosis.By reviewing clinical cases，it is helpful for readers to understand thekey points of accurate application of Chaihu Plus Longgu Muli Decoction and appreciate the subtlety of treating different diseasestogether.Key words:Chaihu Plus Longgu Muli Decoction；classic famous formula；the correspondence of formula and syndrome；cerebraldiseases；tranquilization with heavy drugs；experience基金项目：吉林省科技发展计划项目（20200404065YY）Fund project：Jilin Provinces Technology Development Plan Project(20200404065YY)通信作者：黎明全，E-mail：JOURNAL OF ZHEJIANG CHINESE MEDICAL UNIVERSITY VOL.47NO.2 Feb.2023硕博之窗219浙江中医药大学学报2023年2月第47卷第2期柴胡加龙骨牡蛎汤为临床常用的经典名方，始载于距今一千七百多年的伤寒论中。在现代研究领域中，此方依然有广泛的应用价值，用于治疗抑郁、焦虑、癫痫、失眠、眩晕、帕金森病、脑卒中后遗症和痴呆等疾病1-7。黎明全教授为长春中医药大学博士研究生导师，师从经方家黄煌教授，深得黄老辨证精髓，在临床上应用经方柴胡加龙骨牡蛎汤辨治脑病，疗效颇佳。笔者有幸侍诊于旁，现将黎师应用此方经验辑要详述于下，以飨同道，以期启迪思维，发人深省，使更多的医者掌握此方的应用指征。1证治初探黎师应用此方时借鉴黄老的体质学说，黄老8总结提炼的“柴胡体质”亦有助于此方方证的判断，即患者外观体形中等或偏瘦，面色多黯黄，少光泽，肌肉比较紧实；舌质坚老、舌体不淡胖，舌苔正常或偏干，脉象多弦细；主诉有较多的自觉症状，对温度的变化反应敏感，或时有寒热交替感，情绪波动比较大，食欲易受情绪影响，胸胁部时有气塞满闷感。黎师认为首先辨明体质，即便不能速愈，必无不见效之理。再通过四诊合参，分清患者的寒热、虚实，从病性上来说，总离不开寒热；从邪正盛衰的关系来说，主要表现为虚与实。临证施治，热者寒之，寒者热之，补不足而损有余，四纲分清，方可不犯“虚虚实实”之诫，最后根据方证相应，应用此方，往往效若桴鼔。2验案举隅2.1失眠案王某，女，60岁，2018年6月26日初诊。主诉：失眠2月余。患者就诊前2月出现入睡困难，勉强睡着后伴多梦，闻声立醒，惊悸不安，每夜睡眠最多2 h，白天困乏，深以为苦。刻诊：形体消瘦，面色暗黄，心情烦躁，健忘，并有口苦、胃胀、纳差，小便可，大便数日一行，舌质暗红，苔黄厚，脉弦数。中医诊断：不寐，辨证：痰热腑实、火扰心神。治则：泻热通腑、和中安神。处方：柴胡加龙骨牡蛎汤加减，方药：柴胡12 g，党参15 g，黄芩7 g，姜半夏12 g，桂枝15 g，白芍15 g，炙甘草15 g，生龙骨30 g，生牡蛎30 g，酒大黄10 g，磁石20 g，桃仁10 g，茯苓20 g，生姜15 g，大枣20 g。中药饮片10剂，水煎服，每次取汁300 mL，午晚饭后温服，并嘱患者适当进行体育锻炼。2018年7月10日二诊。患者失眠症状明显缓解，可快速入睡，梦少，舌苔稍薄，脉弦。效不更方，继以前方，共7剂，水煎服。之后未再来复诊。数月之后，电话随访得知，患者近期睡眠状况