基于系统科学理论的王永炎学术团队治疗中风急性期痰热腑实证医案研究
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摘要
系统科学是当今世界最有影响的一门综合性基础学科,它的应用已经渗透到了国家的工业、农业、国防、医药卫生和科学技术等各个部门。在我国,应用系统科学的方法和技术研究人口、财政补贴、工资的综合平衡等问题,取得了很好的效果,尤其是在航天领域,实践证明其十分有效。
系统科学的研究对象是系统,其是指由相互关联、相互制约的各个部分所组成的,具有一定功能的总体,主要特点包括整体性、关联性、动态性、有序性和预决性。研究系统的目的就是阐明系统内部要素之间的关系,并根据客观需要构建具有目标功能的优化的新系统。中医学中的整体观念、阴阳五行学说和脏腑经络理论等,都充分体现了系统的观念。中医学正是采用动态、全面、联系的观点来认识健康与疾病本质的,其总结概括了我国中医医疗实践的经验和规律,完全具备系统的特点。因此,中医学可以作为系统科学的研究对象,通过系统科学思想的指导,将更有助于我们把握中医辨证论治的总体变化趋势,亦能更加明确其内部各要素的发生规律及相互关系。
医案是在对临床事实真实记录的基础上,分析中医诊疗过程,总结临床实践的成功经验或误诊误治的失败教训,提炼医家的学术特色并有所发挥的叙议结合的文本。章太炎先生曾说：“中医之成绩,医案最著。欲求前人之经验心得,医案最有线索可寻,循此钻研,事半功倍。”通过医案研究,能够发现医案所蕴含的丰富的理论精华及医家的学术思想,更重要的是发掘医家的隐性知识,从而启迪临床思路,指导临床实践,提高临床疗效。值得注意的是,虽然目前医案研究正如火如荼的开展,但其中也暴露出一些问题,比如多种学科的理论概念和技术方法与中医学存在难以融合的问题,有时候理论方法可能很先进,但可能与中医研究并不匹配；或者医案研究的针对性不强,是研究医案的最佳体例,还是其临床借鉴价值,或是学术风格及流派,不同的研究目的,其内容应有不同的侧重。
基于上述介绍,我们认为系统科学与中医学具有十分相似的理论核心,运用系统科学理论研究中医医案,总结提炼其中的学术思想具有一定的科学性、可行性以及创新性。因此,本研究以我国著名中医专家王永炎教授的学术团队治疗中风急性期痰热腑实证患者的临床病案为研究对象,充分运用系统科学的思想和方法,总结提炼王永炎教授辨证论治的独特规律,以更好地继承和发扬其学术思想。
本研究主要分为文献综述、医案的系统研究、象思维的系统构建和王永炎教授治疗中风病学术思想探讨四个部分。
文献综述：我们对医案的现代研究方法与系统科学的研究概况两个方面进行了详细的阐述。
医案的系统研究包含3个部分,即论文的前三部分,分别是单病例研究、医案系统的总体设计和子系统构建,以及子系统的中医学术特点分析。
第一部分,单病例研究。目的是了解王永炎教授治疗中风急性期痰热腑实证的基本思路,为总体设计及子系统的构建提供依据。以纳入的82份病案为研究对象,采用领悟式分析方法,结合已经发表的相关文献,将每一份病案看做一个系统,进行逐一分析,从诊断、辨证、治法和方药四个方面梳理出每一个案的脉络结构,初步探明医案中各信息要素之间的关系。通过分析,我们初步了解王永炎教授治疗中风急性期痰热腑实证的基本思路,主要是采用主方加减的方式。
第二部分,医案系统的总体设计及子系统的构建。我们运用系统工程技术对医案系统进行了总体设计,将其分为主方子系统与加减子系统,并建立了医案的系统信息数据库。其中,主方子系统包含有6种参数,即“主要症状——主方”的组合；加减子系统中也包括了6种参数,即“次要症状——药物”的组合。通过对构成子系统的参数进行统计学分析,结果表明,绝大多数的医案都是由这两个子系统所构成；并且各子系统参数中,症状与药物的匹配关系具有较好的特异性。同时,根据关联规则的原理,研究还对发生率较高的主方子系统中的“症状—主方”关系进行了验证,结果提示其关联关系十分明显。说明我们对医案的系统化设计与王永炎教授的辨证论治思路基本相符。
第三部分,子系统的中医学术特点分析。通过医案的系统化研究,我们初步理解了医案信息的总体框架与层次,以及信息之间的密切联系。在此基础上,我们深入分析了医案中所蕴含的学术思想。就辨证而言,王永炎教授十分注重望、闻、问、切四诊的综合运用,并且还推崇多部位诊脉,使信息的收集全面细致；并且根据自身的临床经验对信息进行甄别分析,归类总结,从而得出准确的证候诊断。就治疗用药而言,上述医案充分体现了王永炎教授遣方用药的三大特点：首先,药少力专,配伍精当；即临床辨证准确,有的放矢,组方严谨,药简效著。其次,审时度势,精用大黄；即辨证论治中充分考虑病人的平素体质和病情程度,灵活变通；对大黄的应用,从用药剂量到炮制方法均细致入微,权衡其所用通腑泄热与活血化瘀作用的具体侧重,精确用药。再次,注重动态,既病防变。王永炎教授充分考虑到中风急性期病情变化迅速,以及证候复杂的特点,强调早期介入,及早阻断不良预后的发生。
象思维系统的构建,即论文的第四部分,基于医案研究的象思维概念系统的构建。象思维是指导中医科研与临床最重要的科学思维方法,在中医的临床实践中,象思维贯穿了辨证论治的全过程,其特点主要是重视主体,关注关系以及强调变化。为此,我们在医案研究的基础上,采用构建关系矩阵的方法,分别构建了症状矩阵、舌象矩阵、脉象矩阵、其他临床特点矩阵、证候要素矩阵、治则矩阵、治法矩阵和方药矩阵,并且建立了象思维总体矩阵结构模型,以进一步分析王永炎教授临床运用象思维不同阶段不同层次的象、素、候、证的矩阵组合,从而详细阐明了物象、具象和意象的具体内涵和相互联系,以及实施细节中的学术亮点。同时,我们还运用TRIZ技术构建了王永炎教授治疗中风急性期痰热腑实证的象思维过程模型,从而加深了我们对于象思维运用规律的掌握。通过这一研究,我们对象思维的核心本质和运用规律有了形象的认识和理解,对于我们防止或减少中医科研和临床实践中的决策失误,保证中医的科学发展具有重要意义。
王永炎教授治疗中风病学术思想探讨,即论文第五部分,我们主要从创新的学术理论和临床诊疗特色两个方面进行分析。“毒损脑络”理论是对中风核心病机的高度概括,是对传统中医理论的升华和创新。它高度概括了中风病发生、发展和预后各阶段的病机实质和变化趋势。我们医案研究中的痰热腑实证则是该理论在中风急性期的集中表现,它阐明了此阶段毒损剧烈,阻滞中焦气机,而致腑气不通浊毒上犯于脑的关键病机,为确立排毒和保护脑络的治则提供了科学的依据。在临床诊疗特色方面,王永炎教授十分强调整体恒动观对中医辨证论治的指导作用,重动态重趋势,并早期干预,及早阻断不良预后的发生；在辨证论治中,要求信息全面,诊断精确；具体遣方用药上,推崇经方,并发展超越。
王永炎教授倡导的运用通腑法治疗中风急性期痰热腑实证的思想,是中风病急性期中医辨证论治体系结构中的重要一环,从“毒损脑络”的病机认识到辨证论治中的象思维指导,最终的施治都由通腑法予以实现。近年来,以通腑法为基础,逐渐形成了科学的中医防治中风疾病的临床路径。为此,我们通过meta分析的方式对目前临床运用通腑法的状况进行了介绍。目的是探讨通腑法治疗脑出血急性期的临床疗效。我们运用计算机检索Pubmed、EMbase临床对照试验数据库、中国学术期刊全文数据库(CNKI)、中文科技期刊全文数据库(VIP)和万方数据库(WANFANG Data),检索时间为从建库至2011年9月。收集了运用通腑法治疗脑出血急性期的随机对照实验。对符合纳入标准的临床研究进行质量评价和资料提取后,采用RevMan5.0软件进行Meta分析。纳入文献9篇,组间异质性较小(P=0.98,X2=1.87),可以进行统计学分析。Meta分析结果显示：全部文献合并效应OR=2.54,95%的可信区间(CI)为[1.81,3.56],Z=5.39,P<0.00001。以“神经功能缺损减分率”为标准的6篇文献进行合并,合并效应OR=2.54,95%的CI为[1.62,3.99],P<0.0001。结论：通腑法联合常规疗法治疗脑出血急性期能够有效改善患者的意识状况,较之单纯常规治疗具有一定的优势。需要指出的是,虽然我们纳入的临床观察均为通腑法的疗效研究,但其具体的遣方用药仍存在差异,难免会对临床疗效有所影响。因此,积极开展王永炎教授的医案研究,为临床实践提供具体的治疗指南,就显得十分重要。
本研究运用系统科学的理论和方法对王永炎学术团队治疗中风急性期痰热腑实证的医案进行了深入的分析和探讨。在单病例分析基础上,采用系统工程技术对医案结构和信息层次进行了总体设计,构建了主方子系统和加减子系统,并详细解读了其中的辨证论治过程和中医理论特点。不仅如此,还以象思维作为核心主线,借助半定量关系矩阵的方式,构建了王永炎教授的象思维概念系统,探明了思维过程的实施细节及特点,再次证明象思维对于中医临床实践的指导意义。通过研究,加深了我们对“毒损脑络”病机的认识,进一步理解“毒”在中风发生、发展以及预后全过程中的主导作用,深刻领悟了“解毒、护脑络”的治疗原则。
总之,对王永炎教授学术思想的研究是一个逐步深入的过程,需要我们在探索中不断前进。传统的医案研究由于存在研究方法自身的限制,使我们对医案的认识只能是睹其外貌,犹如虽身处林海边缘,却只能望见一片“郁郁葱葱”,看到的是林而不是树。随着医案研究方法的不断拓展,挖掘医案精髓的工具有了,因此,我们就可以深入林海,不仅看到的是“郁郁葱葱”,还有“树密、根深、枝繁和叶茂”。
Systems science is one of the most influential integrated basic subjects in the world, and it has been penetrated in various sectors, for example, industry, agriculture, defense, medical and health, science and technology. In China, the application of methods and technology of system science in population, financial policy and wage distribution researches, all achieved good results. Especially, its application is very successful in the field of aerospace.
The research object of system science is the system, which is composed of interrelated and mutual restraint, with a certain function of the overall. The main features of the system contain the integrity, relevance, dynamic, orderly and pre-decision. The purpose of studying system is to clarify the relationship among internal elements of the system, and build a new system with objective function based on needs. The overall concept, yin and yang theory, organs and meridians coincide in Traditional Chinese Medicine are fully embodied in the concept of the system. TCM understand the nature of health and disease with the dynamic, comprehensive and contact views, which summed up the experience of clinical practice and theory, and it is fully equipped with characteristics of the system. Therefore, TCM can be used as the research object of system science. It will help us to grasp the overall trend of Chinese medicine syndrome and clarify the internal rules and mutual relations among various elements better, through the guidance of system scientific thoughts.
The medical case is the true record of the clinical facts, which is to summarize the successful experience of clinical practice or failures of misdiagnosis and mistreatment, and could help to refine the text of the classification proposed combination of the academic characteristics of physicians.Mr Zhang said:"Medical Records are suitable to reflect the role of Chinese medicine. If you want to get the successful experience of other people's, researching his medical cases is a good way." The medical case is true record of clinical practice, which can objectively reflect the physician's clinical experience and academic thinking, so this is an important carrier of the research on medical theory. We can found rich theoretical essence in medical cases and the academic thinking of physicians through medical case studies. More importantly, it can help to explore the tacit knowledge of physicians, and inspire clinical thinking to guide clinical practices and improve clinical outcomes. It is worth noting that, the medical case studies were exposed some problems although it was in full swing to carry out. For example, the theoretical concepts and techniques in a variety of disciplines are difficult to fusion with TCM, and maybe the advanced theoretical methods do not match with the study of medical case, sometimes. Alternatively, the objective of medical case studies is inconsistent with research methods.
Based on above introduction, we believe that the study of medical case with application of system science is feasible and innovative. Therefore, we studied the medical cases on the treatment of acute phase of stroke patients with phlegm-heat and bowel-repletion syndrome of Wang Yong-yan professor, who is the well-known traditional Chinese medicine expert, and summarized the law of clinical diagnosis and treatment to inherit and carry forward his academic thoughts.
This study is divided into the literature review, the systematic research of medical case, the systematic building of phenomenon thinking and the academic thoughts on treating stroke of Wang Yong-yan professor.
The literature review:we elaborated the overview on modern research methods of medical cases and system science research in detail.
The medical case research:including the single medical case research, the overall design of medical cases system, the construction of the subsystems and the analysis on academic characteristics of the medical cases.
Section1:The single medical case research. The aim is to understand his basic ideas on the treatment of acute phase of cerebral hemorrhage patients with the phlegm-heat and bowel-repletion syndrome, which can provide the basis for the overall design of medical cases and construction of subsystems. The object of study is the82cases. Apply the comprehension analysis method to analyze every medical record of this research, and make the medical case as a system. Tease out the context and structure of each record, from the four aspects of diagnosis, syndrome, therapy and prescription, to verify the interrelationship among the elements in records, based on the relevant literature of professor Wang. Through the above analysis, we have preliminary understood that Wang's basic idea on the treatment of stroke patients with the phlegm-heat and bowel-repletion syndrome is the main decoction and drug addition or subtraction.
Section2:The overall design of medical cases system and construction of the subsystems. We applyed the theory and methods of system engineering to overall design the medical cases system, which was divided into the main decoction subsystem and drug addition or subtraction subsystem, and established the system information database of medical cases. Among them, the main decoction subsystem consists of six parameters, namely the combination of main symptoms and main decoction; while the drug addition or subtraction subsystem also includes six parameters, namely the combination of secondary symptoms and complementary drugs. Through the statistic analysis of these parameters, the results showed that the vast majority of medical cases were constituted by the two subsystems, and the matching relationship of symptoms and drugs in every parameter was well specific. Meanwhile, the study also verified a higher incidence of the "primary-side subsystem in symptoms-the main square" relationship according to the principle of association rules, which suggest that the association is very clear. This indicated that our systematic design of medical records was in line with the diagnosis and treatment ideas of Wang Yong-yan professor.
Section3:The analysis on academic characteristics of the medical cases. We preliminarily understood the overall framework and level of medical cases, as well as the close links among these information, through the systematic study. On this basis, we analyzed the academic ideas contained in the medical cases in-depth. On the diagnosis of syndrome, professor Wang Yong-yan attaches great importance to the TCM diagnostic methods, and also uses the multi-pulse and humane care to receive the comprehensive and detailed collection of information. At the same time, these information is screened, categorized and summarized according to his clinical experience, in order to draw accurate syndrome diagnosis. Through the analysis, we believe that his main features of diagnosis and prescription should have3aspects. First, few drugs and powerful effect. He specifically use less drugs to force the compatibility, and target the clinical syndrome accurately, to play the effect of each drugs. Second, stock of the situation and ingenious use of rhubarb. He usually investigates the patient's physical and severity of disease and was flexible to give full consideration in the diagnosis and treatment; moreover, he pays attention to weigh the role of rhubarb in specific situations. Again, focus on dynamic and taking precautions. Moreover, he also gives full consideration to the rapid changes and complex syndromes in acute phase of stroke disease, and emphases on early intervention, early blocking a poor prognosis.
The systematic building of phenomenon thinking, namely section4in this paper, aims to build the systematic model of phenomenon thinking. The phenomenon thinking is the most important guide for the research and clinical practice of TCM, which is the scientific way of thinking. And it is throughout the whole process of diagnosis and treatment in TCM, which is characterized by great importance to the main focus on the relationship and the importance of changes. To this end, we built the symptoms matrix, the tongue phenomenon matrix, the pulse phenomenon matrix, the other clinical features matrix, the syndrome factor matrix, the rule matrix, the governance matrix and the prescriptions matrix, and established the structure model of the overall matrix of phenomenon thinking, based on the medical case researches. The work aims to analyze the combination of matrixes in different phases and different levels of phenomenon thinking, for example phenomenon, hormone and hou et al, as well as the academic details of implementation. At the same time, we also used the technology of TRIZ to construct the process model of phenomenon thinking about the treatment of heat phlegm syndrome in acute stage of stroke, so as to deepen our understanding for its application rules. Through this research, we had the recognition and understanding on the core essence and law of phenomenon thinking. This would help to prevent or reduce the decision-making error in TCM scientific research and clinical practice, and have an important and far-reaching significance to ensure the scientific development of TCM.
The academic thoughts on treating stroke of Wang Yong-yan professor, namely the5section in this paper. We mainly carried on the analysis from two aspects, which were the innovative academic theory and the clinical characteristics, respectively. The theory of poisonous injure of brain networks is the core of stroke pathogenesis, and the theory sublimation and innovation of TCM. It is highly summarized the occurrence, development and prognosis of stroke patients at various stages and trends. Under the guidance of the theory, we can understand the law on occurrence and development of phlegm-heat and bowel-repletion syndrome in acute phase of stroke, as well as the key factors which affect the outcomes and prognosis of stroke patients, more clearly. Professor Wang Yong-yan emphasizes the guidance of overall constant dynamic concept on syndrome differentiation treatment, and pays attention to the dynamic trends, and advocates early intervention, early blocking the adverse prognosis. In the syndrome differentiation and treatment, the comprehensive information, accurate diagnosis, specific herbal prescription and respected classical prescriptions are all his remarkable characteristic. At the same time, he also actively promotes the academic innovation and interdisciplinary integration of TCM, which formed his unique academic thought.
The use of tongfu therapy on phlegm-heat and bowel-repletion syndrome in the acute stage of stroke advocated by professor Wang Yong-yan, is one of the important annulus in system structure of TCM syndrome differentiation on stroke. Based on the pathogenesis theory of poisonous injure of brain networks and the guidance of phenomenon thoughts in syndrome differentiation and treatment, the final clinical efficacy is achieved by tongfu therapy. In recent years, the scientific clinical path on the prevention and treatment of stroke is gradually formed with tongfu therapy as the foundation. To this end, we designed the meta analysis to introduce the current clinical application of this approach. Objective:To evaluate the efficacy of the tongfu therapy on acute period of cerebral hemorrhage. Method: systematically search PubMed, EM base, CNKI, VIP and WanFang database, collect randomized controlled trial (RCT) of treatment cases of tongfu therapy on acute period of cerebral hemorrhage. Randomized controlled clinical trials were screened and reviewed by meta-analysis in RevMan version5.0software. Result:Nine controlled clinical trials were reviewed by meta-analysis. The result demonstrates that the effectiveness rate of treatment based on tongfu therapy show significant difference compared with the control group (OR:2.54,95%C1:1.81—3.56), also improve neurological function rating score significantly(OR:2.54,95%CI:1.62—3.99). Conclusion:The treatment based on tongfu therapy show advantage on efficacy and neurological function rating score compared to the control group. But due to quality of original literature, more studies of high quality and good design are expected to confirm the effectiveness and safety of tongfu therapy. It is fully proved that the tongfu therapy is the core method on the treatment of phlegm-heat and bowel-repletion syndrome in acute phase of stroke. Of course, it needs to be pointed out that, although the clinical observations incorporated by us are the researches about the efficacy of tongfu therapy, those specific herbal prescription could be quite different, which would be impact on clinical effect. Therefore, it is very important to develop the case study about professor Wang Yong-yan for providing the specific treatment guidelines.
In this study, we conducted in-depth analysis and discussion on medical cases of the famous TCM expert Wang Yong-yan in treatment of the acute phase of stroke, through the theories and methods of the system science. Based on careful single-case analysis, we understood the structure and the information level of the medical case through a systematic scientific approach. We conducted the overall design and build the main decoction subsystem and the drug addition or subtraction subsystem. We also carried on the detailed explanation about the diagnosis and treatment process and the characteristics of traditional Chinese medicine theory. Not only that, used the phenomenon thinking as the main line, we constructed a conceptual system of phenomenon thinking with semi-quantitative relationship matrix. And we understood its specific implementation details and academic characteristics. Moreover, we also profoundly comprehend the treatment principle of "detoxification and protection of brain networks". Meanwhile, we in-depth understand the "imagery of thinking" mode created by professor Wang.
In conclusion, the study on academic thoughts of Wang Yong-yan professor is a gradual deepening process, and we need to continue moving forward in exploring. Because of the limitation of research methods, in the traditional medical case researches, we can only understand the appearance of the connotation in medical cases. Like, although we live in the edge of woodlands, but only see a "lush", namely the forest but not the tree. With the broadening and development of methods on medical case studies, we can dredge the road of excavating the essence of medical cases, and have the tools. Therefore, we can drill woodlands, and see more than a "lush", but forest and trees, namely entirety and each contingent.
系统科学的研究对象是系统,其是指由相互关联、相互制约的各个部分所组成的,具有一定功能的总体,主要特点包括整体性、关联性、动态性、有序性和预决性。研究系统的目的就是阐明系统内部要素之间的关系,并根据客观需要构建具有目标功能的优化的新系统。中医学中的整体观念、阴阳五行学说和脏腑经络理论等,都充分体现了系统的观念。中医学正是采用动态、全面、联系的观点来认识健康与疾病本质的,其总结概括了我国中医医疗实践的经验和规律,完全具备系统的特点。因此,中医学可以作为系统科学的研究对象,通过系统科学思想的指导,将更有助于我们把握中医辨证论治的总体变化趋势,亦能更加明确其内部各要素的发生规律及相互关系。
医案是在对临床事实真实记录的基础上,分析中医诊疗过程,总结临床实践的成功经验或误诊误治的失败教训,提炼医家的学术特色并有所发挥的叙议结合的文本。章太炎先生曾说：“中医之成绩,医案最著。欲求前人之经验心得,医案最有线索可寻,循此钻研,事半功倍。”通过医案研究,能够发现医案所蕴含的丰富的理论精华及医家的学术思想,更重要的是发掘医家的隐性知识,从而启迪临床思路,指导临床实践,提高临床疗效。值得注意的是,虽然目前医案研究正如火如荼的开展,但其中也暴露出一些问题,比如多种学科的理论概念和技术方法与中医学存在难以融合的问题,有时候理论方法可能很先进,但可能与中医研究并不匹配；或者医案研究的针对性不强,是研究医案的最佳体例,还是其临床借鉴价值,或是学术风格及流派,不同的研究目的,其内容应有不同的侧重。
基于上述介绍,我们认为系统科学与中医学具有十分相似的理论核心,运用系统科学理论研究中医医案,总结提炼其中的学术思想具有一定的科学性、可行性以及创新性。因此,本研究以我国著名中医专家王永炎教授的学术团队治疗中风急性期痰热腑实证患者的临床病案为研究对象,充分运用系统科学的思想和方法,总结提炼王永炎教授辨证论治的独特规律,以更好地继承和发扬其学术思想。
本研究主要分为文献综述、医案的系统研究、象思维的系统构建和王永炎教授治疗中风病学术思想探讨四个部分。
文献综述：我们对医案的现代研究方法与系统科学的研究概况两个方面进行了详细的阐述。
医案的系统研究包含3个部分,即论文的前三部分,分别是单病例研究、医案系统的总体设计和子系统构建,以及子系统的中医学术特点分析。
第一部分,单病例研究。目的是了解王永炎教授治疗中风急性期痰热腑实证的基本思路,为总体设计及子系统的构建提供依据。以纳入的82份病案为研究对象,采用领悟式分析方法,结合已经发表的相关文献,将每一份病案看做一个系统,进行逐一分析,从诊断、辨证、治法和方药四个方面梳理出每一个案的脉络结构,初步探明医案中各信息要素之间的关系。通过分析,我们初步了解王永炎教授治疗中风急性期痰热腑实证的基本思路,主要是采用主方加减的方式。
第二部分,医案系统的总体设计及子系统的构建。我们运用系统工程技术对医案系统进行了总体设计,将其分为主方子系统与加减子系统,并建立了医案的系统信息数据库。其中,主方子系统包含有6种参数,即“主要症状——主方”的组合；加减子系统中也包括了6种参数,即“次要症状——药物”的组合。通过对构成子系统的参数进行统计学分析,结果表明,绝大多数的医案都是由这两个子系统所构成；并且各子系统参数中,症状与药物的匹配关系具有较好的特异性。同时,根据关联规则的原理,研究还对发生率较高的主方子系统中的“症状—主方”关系进行了验证,结果提示其关联关系十分明显。说明我们对医案的系统化设计与王永炎教授的辨证论治思路基本相符。
第三部分,子系统的中医学术特点分析。通过医案的系统化研究,我们初步理解了医案信息的总体框架与层次,以及信息之间的密切联系。在此基础上,我们深入分析了医案中所蕴含的学术思想。就辨证而言,王永炎教授十分注重望、闻、问、切四诊的综合运用,并且还推崇多部位诊脉,使信息的收集全面细致；并且根据自身的临床经验对信息进行甄别分析,归类总结,从而得出准确的证候诊断。就治疗用药而言,上述医案充分体现了王永炎教授遣方用药的三大特点：首先,药少力专,配伍精当；即临床辨证准确,有的放矢,组方严谨,药简效著。其次,审时度势,精用大黄；即辨证论治中充分考虑病人的平素体质和病情程度,灵活变通；对大黄的应用,从用药剂量到炮制方法均细致入微,权衡其所用通腑泄热与活血化瘀作用的具体侧重,精确用药。再次,注重动态,既病防变。王永炎教授充分考虑到中风急性期病情变化迅速,以及证候复杂的特点,强调早期介入,及早阻断不良预后的发生。
象思维系统的构建,即论文的第四部分,基于医案研究的象思维概念系统的构建。象思维是指导中医科研与临床最重要的科学思维方法,在中医的临床实践中,象思维贯穿了辨证论治的全过程,其特点主要是重视主体,关注关系以及强调变化。为此,我们在医案研究的基础上,采用构建关系矩阵的方法,分别构建了症状矩阵、舌象矩阵、脉象矩阵、其他临床特点矩阵、证候要素矩阵、治则矩阵、治法矩阵和方药矩阵,并且建立了象思维总体矩阵结构模型,以进一步分析王永炎教授临床运用象思维不同阶段不同层次的象、素、候、证的矩阵组合,从而详细阐明了物象、具象和意象的具体内涵和相互联系,以及实施细节中的学术亮点。同时,我们还运用TRIZ技术构建了王永炎教授治疗中风急性期痰热腑实证的象思维过程模型,从而加深了我们对于象思维运用规律的掌握。通过这一研究,我们对象思维的核心本质和运用规律有了形象的认识和理解,对于我们防止或减少中医科研和临床实践中的决策失误,保证中医的科学发展具有重要意义。
王永炎教授治疗中风病学术思想探讨,即论文第五部分,我们主要从创新的学术理论和临床诊疗特色两个方面进行分析。“毒损脑络”理论是对中风核心病机的高度概括,是对传统中医理论的升华和创新。它高度概括了中风病发生、发展和预后各阶段的病机实质和变化趋势。我们医案研究中的痰热腑实证则是该理论在中风急性期的集中表现,它阐明了此阶段毒损剧烈,阻滞中焦气机,而致腑气不通浊毒上犯于脑的关键病机,为确立排毒和保护脑络的治则提供了科学的依据。在临床诊疗特色方面,王永炎教授十分强调整体恒动观对中医辨证论治的指导作用,重动态重趋势,并早期干预,及早阻断不良预后的发生；在辨证论治中,要求信息全面,诊断精确；具体遣方用药上,推崇经方,并发展超越。
王永炎教授倡导的运用通腑法治疗中风急性期痰热腑实证的思想,是中风病急性期中医辨证论治体系结构中的重要一环,从“毒损脑络”的病机认识到辨证论治中的象思维指导,最终的施治都由通腑法予以实现。近年来,以通腑法为基础,逐渐形成了科学的中医防治中风疾病的临床路径。为此,我们通过meta分析的方式对目前临床运用通腑法的状况进行了介绍。目的是探讨通腑法治疗脑出血急性期的临床疗效。我们运用计算机检索Pubmed、EMbase临床对照试验数据库、中国学术期刊全文数据库(CNKI)、中文科技期刊全文数据库(VIP)和万方数据库(WANFANG Data),检索时间为从建库至2011年9月。收集了运用通腑法治疗脑出血急性期的随机对照实验。对符合纳入标准的临床研究进行质量评价和资料提取后,采用RevMan5.0软件进行Meta分析。纳入文献9篇,组间异质性较小(P=0.98,X2=1.87),可以进行统计学分析。Meta分析结果显示：全部文献合并效应OR=2.54,95%的可信区间(CI)为[1.81,3.56],Z=5.39,P<0.00001。以“神经功能缺损减分率”为标准的6篇文献进行合并,合并效应OR=2.54,95%的CI为[1.62,3.99],P<0.0001。结论：通腑法联合常规疗法治疗脑出血急性期能够有效改善患者的意识状况,较之单纯常规治疗具有一定的优势。需要指出的是,虽然我们纳入的临床观察均为通腑法的疗效研究,但其具体的遣方用药仍存在差异,难免会对临床疗效有所影响。因此,积极开展王永炎教授的医案研究,为临床实践提供具体的治疗指南,就显得十分重要。
本研究运用系统科学的理论和方法对王永炎学术团队治疗中风急性期痰热腑实证的医案进行了深入的分析和探讨。在单病例分析基础上,采用系统工程技术对医案结构和信息层次进行了总体设计,构建了主方子系统和加减子系统,并详细解读了其中的辨证论治过程和中医理论特点。不仅如此,还以象思维作为核心主线,借助半定量关系矩阵的方式,构建了王永炎教授的象思维概念系统,探明了思维过程的实施细节及特点,再次证明象思维对于中医临床实践的指导意义。通过研究,加深了我们对“毒损脑络”病机的认识,进一步理解“毒”在中风发生、发展以及预后全过程中的主导作用,深刻领悟了“解毒、护脑络”的治疗原则。
总之,对王永炎教授学术思想的研究是一个逐步深入的过程,需要我们在探索中不断前进。传统的医案研究由于存在研究方法自身的限制,使我们对医案的认识只能是睹其外貌,犹如虽身处林海边缘,却只能望见一片“郁郁葱葱”,看到的是林而不是树。随着医案研究方法的不断拓展,挖掘医案精髓的工具有了,因此,我们就可以深入林海,不仅看到的是“郁郁葱葱”,还有“树密、根深、枝繁和叶茂”。
Systems science is one of the most influential integrated basic subjects in the world, and it has been penetrated in various sectors, for example, industry, agriculture, defense, medical and health, science and technology. In China, the application of methods and technology of system science in population, financial policy and wage distribution researches, all achieved good results. Especially, its application is very successful in the field of aerospace.
The research object of system science is the system, which is composed of interrelated and mutual restraint, with a certain function of the overall. The main features of the system contain the integrity, relevance, dynamic, orderly and pre-decision. The purpose of studying system is to clarify the relationship among internal elements of the system, and build a new system with objective function based on needs. The overall concept, yin and yang theory, organs and meridians coincide in Traditional Chinese Medicine are fully embodied in the concept of the system. TCM understand the nature of health and disease with the dynamic, comprehensive and contact views, which summed up the experience of clinical practice and theory, and it is fully equipped with characteristics of the system. Therefore, TCM can be used as the research object of system science. It will help us to grasp the overall trend of Chinese medicine syndrome and clarify the internal rules and mutual relations among various elements better, through the guidance of system scientific thoughts.
The medical case is the true record of the clinical facts, which is to summarize the successful experience of clinical practice or failures of misdiagnosis and mistreatment, and could help to refine the text of the classification proposed combination of the academic characteristics of physicians.Mr Zhang said:"Medical Records are suitable to reflect the role of Chinese medicine. If you want to get the successful experience of other people's, researching his medical cases is a good way." The medical case is true record of clinical practice, which can objectively reflect the physician's clinical experience and academic thinking, so this is an important carrier of the research on medical theory. We can found rich theoretical essence in medical cases and the academic thinking of physicians through medical case studies. More importantly, it can help to explore the tacit knowledge of physicians, and inspire clinical thinking to guide clinical practices and improve clinical outcomes. It is worth noting that, the medical case studies were exposed some problems although it was in full swing to carry out. For example, the theoretical concepts and techniques in a variety of disciplines are difficult to fusion with TCM, and maybe the advanced theoretical methods do not match with the study of medical case, sometimes. Alternatively, the objective of medical case studies is inconsistent with research methods.
Based on above introduction, we believe that the study of medical case with application of system science is feasible and innovative. Therefore, we studied the medical cases on the treatment of acute phase of stroke patients with phlegm-heat and bowel-repletion syndrome of Wang Yong-yan professor, who is the well-known traditional Chinese medicine expert, and summarized the law of clinical diagnosis and treatment to inherit and carry forward his academic thoughts.
This study is divided into the literature review, the systematic research of medical case, the systematic building of phenomenon thinking and the academic thoughts on treating stroke of Wang Yong-yan professor.
The literature review:we elaborated the overview on modern research methods of medical cases and system science research in detail.
The medical case research:including the single medical case research, the overall design of medical cases system, the construction of the subsystems and the analysis on academic characteristics of the medical cases.
Section1:The single medical case research. The aim is to understand his basic ideas on the treatment of acute phase of cerebral hemorrhage patients with the phlegm-heat and bowel-repletion syndrome, which can provide the basis for the overall design of medical cases and construction of subsystems. The object of study is the82cases. Apply the comprehension analysis method to analyze every medical record of this research, and make the medical case as a system. Tease out the context and structure of each record, from the four aspects of diagnosis, syndrome, therapy and prescription, to verify the interrelationship among the elements in records, based on the relevant literature of professor Wang. Through the above analysis, we have preliminary understood that Wang's basic idea on the treatment of stroke patients with the phlegm-heat and bowel-repletion syndrome is the main decoction and drug addition or subtraction.
Section2:The overall design of medical cases system and construction of the subsystems. We applyed the theory and methods of system engineering to overall design the medical cases system, which was divided into the main decoction subsystem and drug addition or subtraction subsystem, and established the system information database of medical cases. Among them, the main decoction subsystem consists of six parameters, namely the combination of main symptoms and main decoction; while the drug addition or subtraction subsystem also includes six parameters, namely the combination of secondary symptoms and complementary drugs. Through the statistic analysis of these parameters, the results showed that the vast majority of medical cases were constituted by the two subsystems, and the matching relationship of symptoms and drugs in every parameter was well specific. Meanwhile, the study also verified a higher incidence of the "primary-side subsystem in symptoms-the main square" relationship according to the principle of association rules, which suggest that the association is very clear. This indicated that our systematic design of medical records was in line with the diagnosis and treatment ideas of Wang Yong-yan professor.
Section3:The analysis on academic characteristics of the medical cases. We preliminarily understood the overall framework and level of medical cases, as well as the close links among these information, through the systematic study. On this basis, we analyzed the academic ideas contained in the medical cases in-depth. On the diagnosis of syndrome, professor Wang Yong-yan attaches great importance to the TCM diagnostic methods, and also uses the multi-pulse and humane care to receive the comprehensive and detailed collection of information. At the same time, these information is screened, categorized and summarized according to his clinical experience, in order to draw accurate syndrome diagnosis. Through the analysis, we believe that his main features of diagnosis and prescription should have3aspects. First, few drugs and powerful effect. He specifically use less drugs to force the compatibility, and target the clinical syndrome accurately, to play the effect of each drugs. Second, stock of the situation and ingenious use of rhubarb. He usually investigates the patient's physical and severity of disease and was flexible to give full consideration in the diagnosis and treatment; moreover, he pays attention to weigh the role of rhubarb in specific situations. Again, focus on dynamic and taking precautions. Moreover, he also gives full consideration to the rapid changes and complex syndromes in acute phase of stroke disease, and emphases on early intervention, early blocking a poor prognosis.
The systematic building of phenomenon thinking, namely section4in this paper, aims to build the systematic model of phenomenon thinking. The phenomenon thinking is the most important guide for the research and clinical practice of TCM, which is the scientific way of thinking. And it is throughout the whole process of diagnosis and treatment in TCM, which is characterized by great importance to the main focus on the relationship and the importance of changes. To this end, we built the symptoms matrix, the tongue phenomenon matrix, the pulse phenomenon matrix, the other clinical features matrix, the syndrome factor matrix, the rule matrix, the governance matrix and the prescriptions matrix, and established the structure model of the overall matrix of phenomenon thinking, based on the medical case researches. The work aims to analyze the combination of matrixes in different phases and different levels of phenomenon thinking, for example phenomenon, hormone and hou et al, as well as the academic details of implementation. At the same time, we also used the technology of TRIZ to construct the process model of phenomenon thinking about the treatment of heat phlegm syndrome in acute stage of stroke, so as to deepen our understanding for its application rules. Through this research, we had the recognition and understanding on the core essence and law of phenomenon thinking. This would help to prevent or reduce the decision-making error in TCM scientific research and clinical practice, and have an important and far-reaching significance to ensure the scientific development of TCM.
The academic thoughts on treating stroke of Wang Yong-yan professor, namely the5section in this paper. We mainly carried on the analysis from two aspects, which were the innovative academic theory and the clinical characteristics, respectively. The theory of poisonous injure of brain networks is the core of stroke pathogenesis, and the theory sublimation and innovation of TCM. It is highly summarized the occurrence, development and prognosis of stroke patients at various stages and trends. Under the guidance of the theory, we can understand the law on occurrence and development of phlegm-heat and bowel-repletion syndrome in acute phase of stroke, as well as the key factors which affect the outcomes and prognosis of stroke patients, more clearly. Professor Wang Yong-yan emphasizes the guidance of overall constant dynamic concept on syndrome differentiation treatment, and pays attention to the dynamic trends, and advocates early intervention, early blocking the adverse prognosis. In the syndrome differentiation and treatment, the comprehensive information, accurate diagnosis, specific herbal prescription and respected classical prescriptions are all his remarkable characteristic. At the same time, he also actively promotes the academic innovation and interdisciplinary integration of TCM, which formed his unique academic thought.
The use of tongfu therapy on phlegm-heat and bowel-repletion syndrome in the acute stage of stroke advocated by professor Wang Yong-yan, is one of the important annulus in system structure of TCM syndrome differentiation on stroke. Based on the pathogenesis theory of poisonous injure of brain networks and the guidance of phenomenon thoughts in syndrome differentiation and treatment, the final clinical efficacy is achieved by tongfu therapy. In recent years, the scientific clinical path on the prevention and treatment of stroke is gradually formed with tongfu therapy as the foundation. To this end, we designed the meta analysis to introduce the current clinical application of this approach. Objective:To evaluate the efficacy of the tongfu therapy on acute period of cerebral hemorrhage. Method: systematically search PubMed, EM base, CNKI, VIP and WanFang database, collect randomized controlled trial (RCT) of treatment cases of tongfu therapy on acute period of cerebral hemorrhage. Randomized controlled clinical trials were screened and reviewed by meta-analysis in RevMan version5.0software. Result:Nine controlled clinical trials were reviewed by meta-analysis. The result demonstrates that the effectiveness rate of treatment based on tongfu therapy show significant difference compared with the control group (OR:2.54,95%C1:1.81—3.56), also improve neurological function rating score significantly(OR:2.54,95%CI:1.62—3.99). Conclusion:The treatment based on tongfu therapy show advantage on efficacy and neurological function rating score compared to the control group. But due to quality of original literature, more studies of high quality and good design are expected to confirm the effectiveness and safety of tongfu therapy. It is fully proved that the tongfu therapy is the core method on the treatment of phlegm-heat and bowel-repletion syndrome in acute phase of stroke. Of course, it needs to be pointed out that, although the clinical observations incorporated by us are the researches about the efficacy of tongfu therapy, those specific herbal prescription could be quite different, which would be impact on clinical effect. Therefore, it is very important to develop the case study about professor Wang Yong-yan for providing the specific treatment guidelines.
In this study, we conducted in-depth analysis and discussion on medical cases of the famous TCM expert Wang Yong-yan in treatment of the acute phase of stroke, through the theories and methods of the system science. Based on careful single-case analysis, we understood the structure and the information level of the medical case through a systematic scientific approach. We conducted the overall design and build the main decoction subsystem and the drug addition or subtraction subsystem. We also carried on the detailed explanation about the diagnosis and treatment process and the characteristics of traditional Chinese medicine theory. Not only that, used the phenomenon thinking as the main line, we constructed a conceptual system of phenomenon thinking with semi-quantitative relationship matrix. And we understood its specific implementation details and academic characteristics. Moreover, we also profoundly comprehend the treatment principle of "detoxification and protection of brain networks". Meanwhile, we in-depth understand the "imagery of thinking" mode created by professor Wang.
In conclusion, the study on academic thoughts of Wang Yong-yan professor is a gradual deepening process, and we need to continue moving forward in exploring. Because of the limitation of research methods, in the traditional medical case researches, we can only understand the appearance of the connotation in medical cases. Like, although we live in the edge of woodlands, but only see a "lush", namely the forest but not the tree. With the broadening and development of methods on medical case studies, we can dredge the road of excavating the essence of medical cases, and have the tools. Therefore, we can drill woodlands, and see more than a "lush", but forest and trees, namely entirety and each contingent.
引文
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