| Zhuang Zengyuan is a researcher at Eye Hospital of China Academy of Chinese Medical Sciences, chief physician, doctoral tutor, guide teacher of the fourth and fifth inheritance of academic experience of national famous veteran teran doctors of TCM, specialist of the workroom of national famous veteran teran doctors of TCM. During clinical work for more than 50 years, Zhuang Zengyuan keeps learning medical knowledge and summarizing his clinical experience. He has buildt up a syndrome differentiation and treatment system of fundus disease, by combining disease with syndrome and adopting essence-qi-blood-body fluid syndrome differentiation and treatment in different stages. Meanwhile, he has also developed the syndrome differentiation and treatment of fundus disease in TCM, with integration of principle-method-recipe-medicines, and it turns out that he has unique academic point and thinking.[Objective]1 To summarize the academic thinking of Zhuang Zengyuan in treating ophthalmopathy by combining disease with syndrome in different stages, and his clinical thinking and experience of applying essence-qi-blood-body fluid syndrome differentiation in fundus disease treatment. Based on this, to inherit and develop the features and characteristics of TCM, improve the clinical effect of TCM in preventing and treating blindness eye disease.2 To sum up the academic experience of Zhuang Zengyuan in treating age-related macular degeneration(AMD) by combining disease with syndromein different stages, adopting syndrome differentiation and treatment of essence-qi-blood-body fluid. 3 To evaluate the curative effect of Chaishao Tang in treating qi stagnation and water retention syndrome of AMD through clinical trials, applying the method of prospective case series, taking the maximum height value of retinal neuroepithelium detachment as main therapeutic effect assessment index. To provide valuable data for further clinical research. To deep analyze and evaluate the method of applying Xiang thinking of TCM in treating qi stagnation and water retention syndrome of AMD.[Methods]This paper applying the mode of "summarizing academic thinking and experience—focusing on diseases with advantages of treatment in TCM", carried out the study on inheriting experience of famous veteran teran doctors of TCM.1 Experience summary partInheritor summarized Zhuang Zengyuan’s clinical experience and methods of drugs selection,through theoretical study, prescription learning, clinical cases analysis, and learning from his articles and books. This paper summed up the academic thinking origin of him in treating fundus disease. Based on that, itconcluded his academic thinking from 4 aspects:clinical thinking, syndrome differentiation methods, therapeutic principles and methods, drugs and prescriptions application. In addition, this paper also summed up his clinical experience in treating fundus disease which he specialized in, such as retinal pigmental degeneration, pathological myopia, non-arteritic anterior ischemic optic neuropathy, age-related macular degeneration (AMD), etc. Based on above, it focused on summarize the experience in treating AMD, the predominant illness in ophthalmology of TCM, and 2 research works related has been carried out.2 Clinical research part(1) With the help of data analysis function of TCM Inheritance Support System(TCMISS), according to the clinical data of Zhuang Zengyuan in treating AMD, involving 78 patients and 101 prescriptions, this paper did statistical analysis of the frequency of each drugs, and analysis of composing principles based on association rules. And it explored and summarized therules of syndrome differentiation and treatment, as well as the characteristics of prescription and drug selection, which could complement and match up with his academic experience.(2) The research has applied the method of prospective case series, involved 30 cases of qi stagnation and water retention syndrome in AMD who accorded with the inclusive criteria, treated with Chaishao Tang for 6 months. It took the maximum height value of retinal neuroepithelium detachment as main therapeutic effect assessment index, compared the value of it before, after 3-month and 6-month treatment. Meanwhile, the adverse reaction should be recorded.3 Development and application partInheritorhas throughly learned classics and ophthalmologic monograph of TCM and improved theoretical level. Additionally, combining with the academic experience of Zhuang Zengyuan, inheritor aimed to develop and make innovation of it.(Results]1 Experience summary part1.1 The academic thinking origin of researcher Zhuang Zengyuan in treating fundus diseaseResearcher Zhuang Zengyuan has studied in Shanghai University of TCM, worked at ophthalmology department in Guang’anmen Hospital of China Academy of Chinese Medical Sciences and learned from doctor Tang Liangchen after he graduated at 1963. Since then, he started to specialize in ophthalmology. The experience of further studies in Peking union medical college hospital and Osaka university school of medicine, has laid the foundation of treating fundus disease through combining disease with syndrome in different stages. He has widely read ophthalmological books. In clinical practice, Zhuang Zengyuan realized that there were some aspects of syndrome differentiation in fundus disease could be improved. On the basis of inheriting, he thought it was still necessary to make improvements of the method, and promote its development. He gradually built up a syndrome differentiation and treatment system of fundus disease, by combining disease with syndrome and adopting essence-qi-blood-body fluid syndrome differentiation and treatment. And that was the core of his academic thinking in treating fundus disease.1.2 The academic thinking of researcher Zhuang Zengyuan in treating fundus disease1.2.1 Treating fundus disease through combining disease with syndrome in different stagesCombining disease with syndrome, as well as syndrome differentiation and treatment at different stages of disease were the first step for further improvement of the syndrome differentiation methods system of fundus disease of TCM. Combining the two above could help to grasp the course of disease more entirely, which also could contribute to standardize the diagnostic and treated program of single disease. The key points of that were applying etiopathogenisis and pathogenesis theory of TCM to explain the clinical manifestations in different stages of fundus disease, and summarize its basic pathogenesis and the main pathogenesis of each stage, and the evolution rules of syndrome. It was necessary to focus on the pathogenesis, make prescription medication, reveal characteristics of TCM, with the thinking of TCM throughout the whole course of disease.The most significant points of syndrome differentiation were grasping the main symptom, noticing the cause, analyzing the location and differentiating the nature of disease. During the process of diagnosis and treatment of disease, grasping the main symptom referred to get the approach point to analyze pathogenesis and syndrome differentiation through realizing the main symptom. For local symptoms of ocular disease, fundus symptoms still were the important and difficult points in fundus disease syndrome differentiation. Researcher Zhuang Zengyuan advocated applying Xiang thinking of TCM in the research of syndrome differentiation in fundus disease. The main causes of fundus disease were divided into 3 parts. The first one was insufficiency of transforming and generation among essence, qi, blood and body fluid. The second one was internal five evils due to dysfunction of zang and fu organs. And the third one was stagnation and pathological products resulted from blocked circulation of qi, blood and body fluid. The locations of ocular disease could be divided into general site and local site. Ocular disease caused by systemic disease could be attributed to its location, according to its belonging zang-fu organs, meridians and collaterals. For independent fundus disease, through microcosmic syndrome differentiation, he thought the fundus could be divided into two parts. One was related to the flow of qi and blood, consisting of collaterals and nutrient-blood. While another was about the flow of qi and fluid, made up with sweat pore and body fluid. The differentiation among deficiency and access, cold and heat of fundus disease implied differentiation among wax and wane, smooth and blocked of essence, qi, blood, and body fluid. Besides, noticing the cause and analyzing the disease location were also indispensable. Combining these together could help to find out the syndrome of the disease.1.2.2 Taking essence-qi-blood-body fluid syndrome differentiation as the main method in treating fundus diseaseAs basic materials of eye morphology, essence, qi, blood and body fluid also contributed to maintaining the functions and metabolism of the eye. And the disturbance of it resulted from the dysfunction of different zang-fu organs. Zhuang Zengyuan thought the fundus structure could be divided into two parts. One was related to the flow of qi and blood, consisting of collaterals and nutrient-blood. While another was about the flow of qi and fluid, made up with Xuanfu and body fluid. It was more appropriate for pathogenesis analysis to adopt essence-qi-blood-body fluid syndrome differentiation, which also can manifest the functions of different organs. Moreover, it was more accordant with the characteristics of fundus disease:complicated and multiform. Therefore, Zhuang Zengyuan took essence-qi-blood-body fluid syndrome differentiation as the main method in treating fundus disease, built up the normalized syndrome differentiation system according to it.1.2.3 Taking expelling evil and strengthening vital qi, regulating qi and blood as the main therapeutic principleFundus tissues include retina and optic nerve, and more easily suffer from qi-blood-body fluid stagnation. Based on this point, Zhuang Zengyuan insisted the theory of expelling and dredging. For those diseases resulted from the disturbance of qi-body fluid circulation, it was appropriate to open up Xuanfu and promote the flow of qi and blood was the way for it. For those diseases caused by stagnation of qi and blood, it was appropriate to dredge the collaterals, promote blood circulation and dissipate the stagnation. Zhuang Zengyuan treated deficiency of ocular disease with three ways:tonifying qi, nourishing blood and replenishing essence. In the meantime, he still realized the importance of the relationship of mutual generate and transform among essence, qi and blood. Moreover, considering that qi-blood-body fluid stagnation easily occur in ophthalmic disease, he emphasized the importance of the flow of qi and blood, pointed the main method is dredging and nourishing.1.2.4 Highly valuing characteristics of ophthalmology, guiding clinical application of prescription and drug with the theory of medicinal propertyIn A Valuable Manual of Ophthalmology, there was a saying that "the eye is a watery and deficient organ". According to this, Zhuang Zengyuan came up with the point of appropriate and inappropriate drugs selection in treating ophthalmological diseases. He deemed that eye located in a high position of our body, and the treatment should be dispelling evil, promoting yang and dispersing fire by using drugs with effect of expelling wind. Besides, the characteristics of eye were pure and watery. In the treatment of reinforcing deficiency, it was appropriate to combine the methods of clearing with tonifying instead of simply overusing tonifying drugs. Furthermore, the main principle of treating ocular disease was driving away the evil according to the general trend of disease, and the treatment tended to dissipate and disperse the evil rather than drastically extinguish it.1.3 Experience of researcher Zhuang Zengyuan in treating fundus disease through syndrome differentiation and treatment of essence-qi-blood-body fluid1.3.1 The experience of treating primary retinal pigment degenerationThe basic pathogenesis of retinal pigment degeneration was congenital dysfunction. For those patients of kidney qi and yang deficiency, as a result of genuine qi deficiency and lucid yang failing to ascend, the main prescriptions for it were Buzhongyiqi Tang and Yougui Yin. For patients of kidney yin deficiency, the cause was kidney yin and water insufficiency, and liver heat up flowing, while the main prescription was Zuogui Yin. If ocular symptoms were the major symptoms with little general symptom, it was important to do regional syndrome differentiation by stages. To be specific, at the early stage of it, the pathogenesis was kidney essence deficiency, and the treatment principle was replenishing kidney, tonifying qi and nourishing blood. While at the late stage, because of qi insufficiency and blood stagnation, the way was dredging and reinforcing collaterals.1.3.2 The experience of treating pathological myopiaThe basic pathogenesis of pathologic myopia was insufficiency of yin-blood, and occurrence of internal dryness. According to the fundus manifestations, it was important to focus on the main symptoms to treat. If retinal choroidal atrophy was the main symptom, the major pathogenesis was blood deficiency and internal dryness at the early stage of whole course of the disease. While at the late stage, it turned to essence deficiency. If the main symptom was macular hemorrhage, according to whether there was choroidal neovascularization, it could be divided into two types to treat:simplex type and neovascularization type. If asthenopia was the main symptom, whether because of the deficiency of Qi and blood, basic treatment was nourishing blood and replenishing essence.1.3.3 The experience of treating non-arteritic anterior ischemic optic neuropathyOptic nerve was the location of non-arteritic anterior ischemic optic neuropathy. When the lesion occurred in collaterals of optic nerve, the treatment was treating both xuanfu and collaterals. Qi deficiency failing to promote blood circulation, internal liver-wind, evil-wind attacking collaterals, or collaterals contraction, these above all could lead to obstruction of eye’s collaterals, and the optic nerve was lack of nutrient and nourishing, which could cause disease. At the acute stage of it, it was important to exterminate the causes and dredge the collateral and xuanfu. At the regression stage, on the basis of previous treatment, it was necessary to strengthen promoting qi circulation, removing stagnancy, dissipating blood stasis and dredging collateral. At the atrophic stage, the treatment should focus on fostering root and clearing fountainhead.1.3.4 The experience of treating age-related macular degeneration (AMD) by combining disease with syndrome, adopting syndrome differentiation and treatment of essence-qi-blood-body fluid in different stagesAMD is caused by the metabolic disorder of qi-blood-body fluid after deficiency of liver-qi and dysfunction of qi flow, with the basis of kidney-essence and vital qi insufficiency, which could be affected by phlegm-dampness and blood stasis, etc. And the pathogenesis of whole process changes from deficiency at beginning to intermingled deficiency and excess then. With the guideline of TCM theory, Zhuang Zengyuan focused on the main symptoms at different stages of AMD, made syndrome differentiation of essence-qi-blood-body fluid, to sum up five main types of it, such as essence-qi deficiency, qi stagnation and water retention, collateral injury and bleeding, intertwinement of phlegm and blood stasis, and essence-blood loss. He built up the normalized syndrome differentiation and treatment system of AMD.2 Results ofclinical research part2.1 Applying data analysis platform to statistically analyze and study Zhuang Zengyuan researcher’s clinical experience in treating AMDThere were 78 cases of AMD patients and 101 prescriptions in total recorded. According to statistical analysis, the main syndrome types of AMD were qi stagnation and water retention syndrome, deficiency of liver and kidney syndrome, collateral injury and bleeding syndrome, intertwinement of phlegm and blood stasis syndrome, as well as dampness stagnation due to spleen deficiency syndrome, etc. There were 161 kinds of drugs in the prescriptions, and total number of drug-using times was 1322, and 13.09 kinds in each prescription on average. The major drugs selection in treating deficiency of liver and kidney syndrome included gouqi fruit, baiju, shudihuang, shengdihuang, shangyurou, shanyao, danpi and fuling. And in treating qi stagnation and water retention syndrome, they were chaihu, huangqin, dangshen, zhigancao, jiangbanxia, shengbaizhu, fuling and zexie. And in treating intertwinement of phlegm and blood, they were jiangbanxia, fuling, chenpi, zhigancao, zhike, zhuru, danshen and pianjianghuang. The medication highly concentrated in prescriptions of mid-stage and Advanced wet AMD, while relatively decentralized in prescriptions of Wet AMD late。2.2 The short-term effect of Chaishao Tang in treating qi stagnation and water retention syndrome in AMDThere were 30 cases of patients involved in this research,27 completed and 3 eliminated. The maximum height value of retinal neuroepithelium detachment has declined and their vision has improved after 3-month and 6-month treatment, both with statistical significance. About the general symptoms of qi stagnation and water retention syndrome in AMD, except for the score of poor appetite symptom, other symptoms’ score has improved and the differences were statistically significant. After 6-month treatment,6 cases healed completely well,12 cases had marked effect,5 cases had effect, and total effective rate was 85.91%.3 Developing and application partWith learning from Zhuang Zengyuan of his academic thinking and clinical experience in treating fundus disease, the author has always been studying and summarizing the essence of it, applying into clinical practice, trying to improve clinical ability. By using the theory of Xuanfu and qi-f luid and combining disease with syndrome, this paper mainly aimed to describe the experience of essence-qi-blood-body fluid syndrome differentiation and treatment in central serous chorioretinopathy by stages. Additionally, it also intended to talk about the thinking and understanding of the theory of Xuanfu-qi and fluid.[Conclusion]1. Researcher Zhuang Zengyuan has built up a syndrome differentiation and treatment system of fundus disease, by combining disease with syndrome and adopting the method of essence-qi-blood-body fluid syndrome differentiation and treatment, which hadgreat effect on improving clinical thinking and ability.2. With the help of data analysis platform, the results complemented and matched up with researcher Zhuang Zengyuan’s academic experience, which contributed to deep learning and understanding of his academic experience in treating AMD. He treated AMD through combining syndrome with disease in different stages, focused on differentiating syndrome types during the whole course of disease, realized the correlation between the general and local symptoms from the aspect of essence-qi-blood-body fluid, built up the normalized syndrome differentiation and treatment system of AMD.3. Chaishao Tang had good effect and was also safe in treating qi stagnation and water retention syndrome of AMD, relieving retinal neuroepithelium detachment to some extent, improving patient’s vision and relieving general symptoms. It improved valuable scientific basis for further clinical research, and also deep evaluated the regularity of applying Chaishao Tang, under the guidance of Xiang thinking in TCM, in treating qi stagnation and water retention syndrome of AMD. |
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