md 02木丹顆粒防治糖尿病周圍神經(jīng)病變研究課件

2014-MD-02木丹顆粒防治糖尿病周圍神經(jīng)病變研究2014-MD-02木丹顆粒防治糖尿病周圍神經(jīng)病變研究1DPN發(fā)病機制1、多元醇代謝通路

活性增高2、蛋白非酶糖化

終產(chǎn)物的形成3、蛋白激酶C

通路激活血管障礙及血液流變學(xué)的變化神經(jīng)營養(yǎng)因子減少血管活性物質(zhì)減少代謝紊亂毛細血管基底膜增厚血栓形成微循環(huán)障礙神經(jīng)內(nèi)膜血管缺血缺氧Na+-k+-ATP酶下降組織內(nèi)肌醇降低神經(jīng)結(jié)構(gòu)和功能改變

神經(jīng)傳導(dǎo)速度減慢磷酸肌醇代謝改變外周神經(jīng)髓鞘蛋白糖基化破壞髓鞘的完整性損害神經(jīng)功能影響神經(jīng)微管系統(tǒng)改變神經(jīng)內(nèi)膜微環(huán)境血管通透性增加基底膜增厚血管內(nèi)皮細胞增殖血液動力學(xué)改變神經(jīng)遞質(zhì)合成減少；神經(jīng)元生成和逆向轉(zhuǎn)運降低抑制NO合成酶活性，NO減少，血管收縮神經(jīng)組織缺血神經(jīng)細胞水腫軸索變性神經(jīng)脫髓鞘神經(jīng)病變發(fā)生高血糖免疫因素，遺傳因素DPN發(fā)病機制1、多元醇代謝通路血管障礙及血液神經(jīng)營養(yǎng)因子減2DPN發(fā)病機制：糖代謝紊亂高血糖糖尿病神經(jīng)病變多元醇途徑（醛糖還原酶→山梨醇）NO↓谷胱甘肽↓AGE蛋白非酶糖化產(chǎn)物↑氧化應(yīng)激NO↓PARP↑細胞因子生長因子↓炎癥因子

↑DPN發(fā)病機制：糖代謝紊亂高血糖糖尿病神經(jīng)病變多元醇途徑AG3md02木丹顆粒防治糖尿病周圍神經(jīng)病變研究課件4md02木丹顆粒防治糖尿病周圍神經(jīng)病變研究課件5md02木丹顆粒防治糖尿病周圍神經(jīng)病變研究課件6朱禧星.現(xiàn)代糖尿病學(xué).上海：復(fù)旦大學(xué)出版社，2000.11:333-340.

脂代謝紊亂胰島素相對/絕對缺乏脂代謝障礙（γ-亞麻酸生成障礙）神經(jīng)膜結(jié)構(gòu)障礙前列腺素神經(jīng)血流障礙神經(jīng)功能障礙朱禧星.現(xiàn)代糖尿病學(xué).上海：復(fù)旦大學(xué)出版社，2000.17Joslin糖尿病學(xué).2007.50:874-875.HounsomL，CorderR,PatelJ,etal.Diabetologia,2001,44:424-428氧自由基損害氧化應(yīng)激自由基神經(jīng)細胞結(jié)構(gòu)、功能障礙神經(jīng)細胞凋亡Joslin糖尿病學(xué).2007.50:874-875.氧8神經(jīng)血管病變AVeves,ClinicalMangement,SecondEdition神經(jīng)血管病變AVeves,ClinicalMangem9循環(huán)纖維蛋白原水平升高（導(dǎo)致血液粘滯度升高、纖維蛋白沉降）血小板活性升高、聚集性升高紅細胞細胞膜變形能力下降，導(dǎo)致紅細胞硬化，并且趨于易發(fā)生聚集血液處于高凝狀態(tài)Joslin糖尿病學(xué).2007.50:873.施曉紅，周湘蘭，等.中國臨床醫(yī)學(xué)，2004，11(4)∶502-503L.L.TeunissenN.C.NotermansJ.H.J.Wokk.EurNeurol2000;44:1–7神經(jīng)組織缺血、缺氧血液流變學(xué)異常循環(huán)纖維蛋白原水平升高（導(dǎo)致血液粘滯度升高、纖維蛋白沉降）J10氮氧化物降低：NO,血管舒張功能障礙1前列腺素降低：血小板聚集，血管舒張功能障礙2粘附分子升高：血小板粘附，微血管阻塞3神經(jīng)組織缺血缺氧，結(jié)構(gòu)、功能障礙1.KiharaM,LowPA.ExpNeurol,1995,132:180-1852.ShimizuK,MuramatsuM,KakegawaY,etal.Diabetes,1993,4:1246-12523.JudeEB,AbbottCA,YoungMJ,etal.Diabetologia,1998,41:330-336

血管活性因子改變氮氧化物降低：NO,血管舒張功能障礙1神經(jīng)組織缺血缺11神經(jīng)生長因子胰島素樣生長因子其他神經(jīng)營養(yǎng)因子神經(jīng)細胞損傷、再生能力下降

YasudaH,TeradaM,MaedaK,etal.ProgNeurobiol,2003,69(4)∶229.神經(jīng)營養(yǎng)因子缺乏神經(jīng)生長因子神經(jīng)細胞損傷、再生能力下降YasudaH12抗氧化應(yīng)激，改善營養(yǎng)與血供等嚴(yán)控血糖和多重危險因素干預(yù)緩解疼痛減輕癥狀對癥治療對因治療預(yù)防抗氧化應(yīng)激，嚴(yán)控血糖和多重緩解疼痛對癥對因治療預(yù)13強化降糖達標(biāo)可降低DPN風(fēng)險控制血糖要平穩(wěn)治療前，神經(jīng)纖維一直處于高血糖狀態(tài)。用一般方法皮下注射胰島素治療，特別是對于1型糖尿病，用量不足糖代謝紊亂不能控制，神經(jīng)病變會繼續(xù)發(fā)展，如用量過多，血糖急劇下降，會出現(xiàn)治療后神經(jīng)病或胰島素性神經(jīng)炎。強化降糖達標(biāo)可降低DPN風(fēng)險控制血糖要平穩(wěn)治療前，神經(jīng)纖維一14基本病機：消渴病日久，肝腎不足，氣血兩虛，絡(luò)脈瘀阻。治療總則：益氣養(yǎng)陰，活血化瘀，通絡(luò)止痛。黃芪：抗氧化丹參、黃芪、川芎：抑制醛糖還原酶槲皮素：抑制蛋白非酶糖化三七、紅花：抗凝、抗血栓形成中醫(yī)中藥治療DPN木丹顆粒組方黃芪：大補元氣，使氣旺血行，能去瘀而不傷正。延胡索：活血化瘀，行氣止痛。三七：活血散瘀，止痛，更能祛瘀生新。赤芍：散瘀止痛，丹參：為活血化瘀之要藥，紅花：活血化瘀，通調(diào)經(jīng)脈。川芎：活血行氣。蘇木：活血祛瘀。雞血藤：補血活血。基本病機：消渴病日久，肝腎不足，氣血兩虛，絡(luò)脈瘀阻。治療總則15國藥準(zhǔn)字Z20080033發(fā)明專利ZL01106342.4國家醫(yī)保乙類品種中國首創(chuàng)明確治療糖尿病周圍神經(jīng)病變的現(xiàn)代專利中藥解除麻木疼痛；修復(fù)受損神經(jīng)；改善微循環(huán)；中國醫(yī)學(xué)科學(xué)院證實具有胰島修復(fù)作用;聯(lián)合丹紅、甲鈷胺或α硫辛酸協(xié)同增效;7盒一療程，可連續(xù)服用兩個療程.木丹顆粒國藥準(zhǔn)字Z20080033中國首創(chuàng)明確治療糖尿病周圍神經(jīng)病變16修復(fù)DPN受損神經(jīng)，提高神經(jīng)傳導(dǎo)速度提高Na+-K+-ATP酶活性增加神經(jīng)中cAMP和cGMP的含量顯著抑制紅細胞山梨醇含量改善神經(jīng)代謝物質(zhì)水平顯著的止痛鎮(zhèn)痛功效熱甩尾時間顯著增加，減少醋酸誘發(fā)小鼠扭體次數(shù)。改善血漿-EP水平,顯著提高DPN患者的痛閾改善血液微循環(huán)，提高神經(jīng)內(nèi)膜血液供應(yīng)改善血液流變學(xué)，具有顯著的活血作用提高神經(jīng)營養(yǎng)因子，改善神經(jīng)傳導(dǎo)提高神經(jīng)生長因子基因表達提高血管活性物質(zhì)，減少血管損傷木丹顆粒減少危險因素，阻斷多重機制，降低神經(jīng)病變修復(fù)DPN受損神經(jīng)，提高神經(jīng)傳導(dǎo)速度提高Na+-K+-17Na+-K+-ATP酶活性**##**與模型組比較**P＜0.01；與彌可保組比較##P＜0.01木丹顆粒藥效學(xué)研究，沈陽藥科大學(xué)木丹顆粒提高Na+-K+-ATP酶活性****△△與模型組比較*P＜0.05與彌可保組比較△P＞0.05cAMP、cGMP含量木丹顆粒增加cAMP、cGMP含量木丹顆粒改善神經(jīng)代謝物質(zhì)水平Na+-K+-ATP酶活性**##**與模型組比較**P＜木丹顆粒對鏈脲霉素糖尿病模型大鼠紅細胞山梨醇含量有顯著的影響，含量遠低于模型組（P＜0.05），也低于彌可保組，說明木丹顆粒能夠降低紅細胞山梨醇的含量，有利于受損神經(jīng)的恢復(fù)，優(yōu)于彌可保。與空白對照組比較*P＜0.05，**P＜0.01與模型組比較#P＜0.05***#*木丹顆粒藥效學(xué)研究，沈陽藥科大學(xué)木丹顆粒降低山梨醇含量，修復(fù)受損神經(jīng)木丹顆粒改善神經(jīng)代謝物質(zhì)水平木丹顆粒對鏈脲霉素糖尿病模型大鼠紅細胞山梨醇含量有顯著的影響木丹顆粒組大鼠尾神經(jīng)傳導(dǎo)速度接近于正常組，與鏈脲霉素糖尿病模型組有顯著的差異（P＜0.01），也優(yōu)于彌可保組，提示木丹顆粒有著顯著的提高神經(jīng)傳導(dǎo)速度的作用。STZ-DM大鼠尾神經(jīng)傳導(dǎo)速度*###***與空白對照組比較*P＜0.05，**P＜0.01與模型組比較#P＜0.05，##P＜0.01木丹顆粒藥效學(xué)研究，沈陽藥科大學(xué)木丹顆粒顯著提高神傳傳導(dǎo)速度木丹顆粒組大鼠尾神經(jīng)傳導(dǎo)速度接近于正常組，與鏈脲霉素糖尿病模試驗組：常規(guī)治療（控制血糖）+木丹顆粒對照組：常規(guī)治療（控制血糖）+彌可保片治療前后，兩組對FBG、2hPG無影響。治療前后臨床癥狀與體征比較：試驗組四肢發(fā)涼、感覺異常改善優(yōu)于對照組，自發(fā)性疼痛、四肢麻木、肢軟無力改善與對照組無差異。2組治療后脛神經(jīng)、腓總神經(jīng)和腓淺神經(jīng)傳導(dǎo)速度比較均有顯著性差異(p＜0.05)，試驗組治療后腓腸神經(jīng)傳導(dǎo)速度明顯快于對照組(p＜0.05),2組治療后神經(jīng)傳導(dǎo)速度與治療前比較均有明顯改善。在改善感覺神經(jīng)傳導(dǎo)速度方面效果優(yōu)于彌可保。木丹顆粒與彌可保治療糖尿病周圍神經(jīng)病變療效比較,現(xiàn)代中西醫(yī)結(jié)合雜志,2011.9木丹顆粒顯著提高神經(jīng)傳導(dǎo)速度試驗組：常規(guī)治療（控制血糖）+木丹顆粒治療前后，兩組對FBG21扭體次數(shù)熱甩尾反應(yīng)時間木丹顆粒能顯著延長鏈脲霉素糖尿病大鼠熱甩尾反應(yīng)時間，提高其痛域，顯示具有顯著的鎮(zhèn)痛作用。木丹顆粒能夠顯著減少醋酸誘發(fā)小鼠扭體次數(shù)（P＜0.01），提示木丹顆粒有著顯著的止痛作用。****與模型組比較*P＜0.05與空白對照組比較*P＜0.05，**P＜0.01木丹顆粒藥效學(xué)研究，沈陽藥科大學(xué)木丹顆粒具有顯著的鎮(zhèn)痛作用扭體次數(shù)熱甩尾反應(yīng)時間木丹顆粒能顯著延長鏈脲霉素糖尿病大鼠熱木丹顆粒對急性血瘀模型大鼠的血液流變學(xué)變化有著顯著的影響，其全血比粘度、血漿比粘度、紅細胞壓積都遠低于血瘀模型組，而阿司匹林組和彌可保組差異都不顯著。提示木丹顆粒有著顯著的活血作用。血瘀模型組木丹顆粒藥效學(xué)研究，沈陽藥科大學(xué)木丹顆粒改善血液流變學(xué)，顯著的活血作用木丹顆粒對急性血瘀模型大鼠的血液流變學(xué)變化有著顯著的影響，其試驗結(jié)果提示，糖尿病模型組成模6周時坐骨神經(jīng)NGFmRNA表達明顯下降，提示與糖尿病性周圍神經(jīng)病變的發(fā)生密切相關(guān)。木丹顆粒能夠上調(diào)NGFmRNA表達，這可能是其防治糖尿病性周圍神經(jīng)病變的機制之一。NGF含量與正常組比較**P＜0.01與模型組比較△P＜0.05****△**△木丹顆粒藥效學(xué)研究，沈陽藥科大學(xué)木丹顆粒能夠上調(diào)NGFmRNA表達正常對照組模型組木丹顆粒組彌可保組試驗結(jié)果提示，糖尿病模型組成模6周時坐骨神經(jīng)NGFmRNA木丹顆粒對糖尿病大鼠胰島細胞凋亡作用及TNF-α、Caspase-3表達的影響，遼寧中醫(yī)藥大學(xué)學(xué)報，2012，4本實驗研究表明，木丹顆粒中高劑量組可明顯降低TNF-α、Caspase-3的表達，抑制胰島細胞凋亡。胰島β細胞凋亡觀察木丹顆粒對TNF-α的表達影響木丹顆粒對Caspase-3表達的影響木丹顆粒抑制胰島細胞凋亡木丹顆粒對糖尿病大鼠胰島細胞凋亡作用及TNF-α、Caspa25與正常對照組相比,各糖尿病組大鼠血清sVCAM-1、sZCAM-1含量明顯升高(P<0.01),與模型組相比各治療組情況明顯改善(P<0.01),且木丹顆粒療效優(yōu)于彌可保(P<0.05)。結(jié)論:木丹顆粒對DPN大鼠血清sVCAM-1、sICAM-1含量有一定下調(diào)作用,從而達到防治DPN的作用。糖末寧對實驗性DPN大鼠血清sVCAM-1、sICAM-1含量的影響.實用糖尿病雜志第5卷,第2期木丹顆粒防治DPN組別NsICAM-1sVCAM-1正常對照組1087.3±11.50.74±0.278模型組8176.6±24.233.61±0.62彌可保組8122.1±15.661.94±0.48**木丹顆粒組9106.0±11.48**1.31±040**各組大鼠血清sVCAM-1、sICAM-1含量比較（均數(shù)±標(biāo)準(zhǔn)差）與正常組相比*P<0.05，**P<0.01；與糖尿病模型組相比，##P<0.01，與彌可保組比P<0.05與正常對照組相比,各糖尿病組大鼠血清sVCAM-1、s26木丹顆粒明顯改善DPN患者癥狀木丹顆粒的臨床試驗顯示，總有效率為93.23%。木丹顆粒治療糖尿病神經(jīng)病變的優(yōu)勢在于較短時間內(nèi)改善患者的臨床癥狀，如四肢麻木、疼痛、面色晦暗、倦怠乏力、自汗等均有較好的治療作用。木丹顆粒（糖末寧）治療糖尿病周圍神經(jīng)病變（氣虛絡(luò)阻證）432例臨床研究中醫(yī)證候療效四肢麻木、疼痛、面色晦暗、倦怠乏力、自汗木丹顆粒明顯改善DPN患者癥狀木丹顆粒的臨床試驗顯示，總有效27木丹顆粒提高DPN患者MNCVSNCV顯效：神經(jīng)傳導(dǎo)速度恢復(fù)正常或增加5m/s以上。有效：神經(jīng)傳導(dǎo)速度較前增加3m/s以上。無效：神經(jīng)傳導(dǎo)速度增加不足3m/s。肌電圖療效肌電圖療效分析顯示，經(jīng)木丹顆粒組治療后神經(jīng)傳導(dǎo)速度明顯改善，有顯著性差異（P＜0.01），與彌可保組比較，無統(tǒng)計學(xué)意義（P＞0.05），提示木丹顆粒對DPN有較好的治療作用。木丹顆粒（糖末寧）治療糖尿病周圍神經(jīng)病變（氣虛絡(luò)阻證）432例臨床研究木丹顆粒提高DPN患者MNCVSNCV顯效：神經(jīng)傳導(dǎo)速度28木丹顆粒減少危險因素，阻斷多重機制，降低神經(jīng)病變改善神經(jīng)代謝物質(zhì)水平提高Na+-K+-ATP酶活性增加神經(jīng)中cAMP和cGMP的含量顯著抑制紅細胞山梨醇含量修復(fù)DPN受損神經(jīng)，提高神經(jīng)傳導(dǎo)速度；提高神經(jīng)營養(yǎng)因子，改善神經(jīng)傳導(dǎo)改善血液微循環(huán)，提高神經(jīng)內(nèi)膜血液供應(yīng)提高血管活性物質(zhì)，減少血管損傷木丹顆粒改善神經(jīng)代謝物質(zhì)水平修復(fù)DPN受損神經(jīng)，提高神經(jīng)29謝謝！謝謝！30ASupermarketinCaliforniaByAllenGinsbergASupermarketinCaliforniaBy31BioHewasborninNewarkin1926anddiedin1997.Hisearlylifewastroubledbecauseofhismother’sbattlewithmentalillnessandthisinformedhispoems.Hetraveledextensivelythroughouttheworldandwasexpelledfrommanycommunistcountries(mostnotablyCuba)forbeingsubversive,thesetravelsinfluencedhiswork.HewontheNationalBookawardforTheFallofAmerica,andwasawardedtheOrderofArtsandLettersbytheFrenchCulturalministry.Hispoem“Howl”was(andis)thesourceofmuchcontroversyoverwhatsomeconsidertobeobscenethemesandwords.Itandotherpoemslikeitwasresponsiblefortherepealofmanyanti-obscenitylaws.Itremainshismostfamouswork.HewasalsoamusicianandappearsonTheClash’salbum“CombatRock.”Hewrote“ASupermarketinCalifornia”in1955whilelivinginBerkley.BioHewasborninNewarkin1932ASupermarketinCalifornia WhatthoughtsIhaveofyoutonight,WaltWhitman,for

Iwalkeddownthesidestreetsunderthetreeswithaheadache

self-consciouslookingatthefullmoon.

Inmyhungryfatigue,andshoppingforimages,Iwent

intotheneonfruitsupermarket,dreamingofyourenumerations!

Whatpeachesandwhatpenumbras!Wholefamilies

shoppingatnight!Aislesfullofhusbands!Wivesinthe

avocados,babiesinthetomatoes!--andyou,GarciaLorca,what

wereyoudoingdownbythewatermelons?

Isawyou,WaltWhitman,childless,lonelyoldgrubber,

pokingamongthemeatsintherefrigeratorandeyeingthegrocery

boys.

Iheardyouaskingquestionsofeach:Whokilledthe

porkchops?Whatpricebananas?AreyoumyAngel?

Iwanderedinandoutofthebrilliantstacksofcans

followingyou,andfollowedinmyimaginationbythestore

detective.

Westrodedowntheopencorridorstogetherinour

solitaryfancytastingartichokes,possessingeveryfrozen

delicacy,andneverpassingthecashier.ASupermarketinCalifornia Wh33ASupermarketinCalifornia Wherearewegoing,WaltWhitman?Thedoorsclosein

anhour.Whichwaydoesyourbeardpointtonight?

(Itouchyourbookanddreamofourodysseyinthe

supermarketandfeelabsurd.)

Willwewalkallnightthroughsolitarystreets?The

treesaddshadetoshade,lightsoutinthehouses,we'llbothbe

lonely.

WillwestrolldreamingofthelostAmericaoflove

pastblueautomobilesindriveways,hometooursilentcottage?

Ah,dearfather,graybeard,lonelyoldcourage-teacher,

whatAmericadidyouhavewhenCharonquitpolinghisferryand

yougotoutonasmokingbankandstoodwatchingtheboat

disappearontheblackwatersofLethe?

ASupermarketinCalifornia Wh34AllenGinsbergReads“ASupermarketinCalifornia”YouTube-AllenGinsberg-ASupermarketInCaliforniaAllenGinsbergReads“ASuperm35TheSpeakerThespeakeriseducated,butappearstobealonelybrokenman.Heissearchingformeaningandsomethingbeautiful,somethingnaturalinmodernAmerica.TheSpeakerThespeakeriseduc36TheSubjectThepoemdealswiththelossoftheoldAmerica,theAmericathatcouldhaveinspiredWhitman.WeseethroughthespeakerthealienationandhomogenizationofmodernAmerica,andthespeaker’ssadnessaboutwhathecanneverexperienceduetotheunfortunatetimingofhisbirth.TheSubjectThepoemdealswith37ImagesThefirstimagesweseeareinsidethesupermarket,wherethespeakerremarksontheproduceandthe“Aislesfullofhusbands!Wivesintheavocados,babiesinthetomatoes!”Hecomparestheshoppingfamiliestotheproduce,becausetohimtheyarenodifferent—noimportantstory,nodistinctiondeeperthanageorsex.ImagesThefirstimageswesee38Imagescont.GarciaLorcaisinsertedasacontrasttotheshoppers.HewasaSpanishpoetinthethirtieswhoseworkswerecensoredbythefascistgovernmentofFrancoafterhisdeath.HeisasymbolofrepressedartinAmerica,andthespeakerexpressessurprisetoseehimoutintheopenandinasoullesssupermarket.Imagescont.GarciaLorcaisin39Imagescont.WaltWhitmanisasymboloftheoldAmerica,theAmericathatthespeakerwantstolivein.Heisdescribedasanoldfoolwhodemandsthingsnooneasksorcaresaboutanymore“Whokilledtheporkchops?”tryingtofindthestorybehindwhatheisbuyingalthoughtherenolongerisanystorybehindanythinginthesupermarket.HeisportrayedthiswaybecauseaccordingtothespeakeramanlikeWhitmanwouldnotbeabletoremainsaneinmodernsociety,hewouldbereducedtoadodderingoldfoolwhowandersthesupermarketatnight.Imagescont.WaltWhitmanisa40Imagescont.TheblueautomobilesfurtherthesenseofconformityinAmerica,thewayitisstatedimpliesthatallofthecarsareblueandthesame.TheentirelaststanzausesmythologicalcharactersandsettingstoaddasenseofgrandeurtothedeathofWhitman.Imagescont.Theblueautomobil41OrganizationFivestanzasFreeverseMostlylongsentencesbrokenupbycommaswithafewbreaksofshortexclamations,orquestions.OrganizationFivestanzas42OrganizationIdivideditintofoursections:Firststanza(lines1-9),thespeakerdescribesthesupermarketanditspatrons.Secondstanza(lines10-20)Thespeaker“meets”WaltWhitmanandfollowshimthroughhisdazedsupermarketjourney.Questioning(lines21-29)Thespeakerquestions“Whitman”abouttheliteralplanfortheirnight,andindirectlythereader“Wherearewegoing,WaltWhitman?”ThissectionismeanttoquestionthecourseofmodernAmerica.TheDeathofWaltWhitman(lines30-34)thisbringsthecentralquestionofthepoemout“WhatAmericadidyouhave,”itquestionsboththeexistenceoftheAmericaboththespeakerandWhitmanyearnfor,andourownmodernAmerica;thespeakerisaskingthereaderdirectlyaboutwhatAmericatheyhave.OrganizationIdivideditinto43DictionandSyntaxTheuseoflongsentencesgivesthepoemthefeelofanolderwork,possiblyfromthetimeofWaltWhitman.Thisimpressionisreinforcedbytheelevatedlanguageused(enumerations,penumbras,etc.)Thepoemistoldinthepasttensebecausethespeakerisreflectinguponhisexperience,whichherealizesisabsurdwhenhefindstherealWhitmanrepresentedbythebook.Thisisdonetohighlightthequestionswhichareinthepresent“Wherearewegoing,”“Willwestroll.”Thequestionsareinthepresentbecausethespeakermeansforthemtotranscendthespecificcircumstancesofthepoemandbecomequestionsthereaderissupposedtoaskhimself.Theotherinstancethatthepresentisusedisinthedescriptionofthesupermarket.Itisusedtherebecausethoseshoppersandtheiractionsareinterchangeablewithallothershoppersatalltimes.TheobservationsatthesupermarketarealsogivenexclamationpointstoconveythefeelingthateverythinginmodernAmericaisloud,fulloffalseexcitment,andrightNOW!DictionandSyntaxTheuseofl44Conclusion“ASupermarketinCalifornia”isapoemthatismeanttoquestionthenotionsthatmodernizationisbetterandthatallprogressisgoodprogress.Itbemoanstheprevailingideasoffast,cheap,massproduced.Ityearnsforasimplertime,atimethatcouldproducemenlikeWaltWhitmanthe“oldcourage-teacher”whonotonlywasasymbolofoldAmerica,butalsoisasymbolofnon-conformismandprotest.TheAmericaseenbythepoemisonedevoidofartandoftruehumanexpression.Itencouragesustoquestion,toworkforchange,andtoappreciatethefewremainingvestigesofthe“l(fā)ostAmericaoflove”Conclusion“ASupermarketinCa45ASupermarketinCalifornia WhatthoughtsIhaveofyoutonight,WaltWhitman,for

Iwalkeddownthesidestreetsunderthetreeswithaheadache

self-consciouslookingatthefullmoon.

Inmyhungryfatigue,andshoppingforimages,Iwent

intotheneonfruitsupermarket,dreamingofyourenumerations!

Whatpeachesandwhatpenumbras!Wholefamilies

shoppingatnight!Aislesfullofhusbands!Wivesinthe

avocados,babiesinthetomatoes!--andyou,GarciaLorca,what

wereyoudoingdownbythewatermelons?

Isawyou,WaltWhitman,childless,lonelyoldgrubber,

pokingamongthemeatsintherefrigeratorandeyeingthegrocery

boys.

Iheardyouaskingquestionsofeach:Whokilledthe

porkchops?Whatpricebananas?AreyoumyAngel?

Iwanderedinandoutofthebrilliantstacksofcans

followingyou,andfollowedinmyimaginationbythestore

detective.

Westrodedowntheopencorridorstogetherinour

solitaryfancytastingartichokes,possessingeveryfrozen

delicacy,andneverpassingthecashier.ASupermarketinCalifornia Wh46ASupermarketinCalifornia Wherearewegoing,WaltWhitman?Thedoorsclosein

anhour.Whichwaydoesyourbeardpointtonight?

(Itouchyourbookanddreamofourodysseyinthe

supermarketandfeelabsurd.)

Willwewalkallnightthroughsolitarystreets?The

treesaddshadetoshade,lightsoutinthehouses,we'llbothbe

lonely.

WillwestrolldreamingofthelostAmericaoflove

pastblueautomobilesindriveways,hometooursilentcottage?

Ah,dearfather,graybeard,lonelyoldcourage-teacher,

whatAmericadidyouhavewhenCharonquitpolinghisferryand

yougotoutonasmokingbankandstoodwatchingtheboat

disappearontheblackwatersofLethe?

ASupermarketinCalifornia Wh472014-MD-02木丹顆粒防治糖尿病周圍神經(jīng)病變研究2014-MD-02木丹顆粒防治糖尿病周圍神經(jīng)病變研究48DPN發(fā)病機制1、多元醇代謝通路

活性增高2、蛋白非酶糖化

終產(chǎn)物的形成3、蛋白激酶C

通路激活血管障礙及血液流變學(xué)的變化神經(jīng)營養(yǎng)因子減少血管活性物質(zhì)減少代謝紊亂毛細血管基底膜增厚血栓形成微循環(huán)障礙神經(jīng)內(nèi)膜血管缺血缺氧Na+-k+-ATP酶下降組織內(nèi)肌醇降低神經(jīng)結(jié)構(gòu)和功能改變

神經(jīng)傳導(dǎo)速度減慢磷酸肌醇代謝改變外周神經(jīng)髓鞘蛋白糖基化破壞髓鞘的完整性損害神經(jīng)功能影響神經(jīng)微管系統(tǒng)改變神經(jīng)內(nèi)膜微環(huán)境血管通透性增加基底膜增厚血管內(nèi)皮細胞增殖血液動力學(xué)改變神經(jīng)遞質(zhì)合成減少；神經(jīng)元生成和逆向轉(zhuǎn)運降低抑制NO合成酶活性，NO減少，血管收縮神經(jīng)組織缺血神經(jīng)細胞水腫軸索變性神經(jīng)脫髓鞘神經(jīng)病變發(fā)生高血糖免疫因素，遺傳因素DPN發(fā)病機制1、多元醇代謝通路血管障礙及血液神經(jīng)營養(yǎng)因子減49DPN發(fā)病機制：糖代謝紊亂高血糖糖尿病神經(jīng)病變多元醇途徑（醛糖還原酶→山梨醇）NO↓谷胱甘肽↓AGE蛋白非酶糖化產(chǎn)物↑氧化應(yīng)激NO↓PARP↑細胞因子生長因子↓炎癥因子

↑DPN發(fā)病機制：糖代謝紊亂高血糖糖尿病神經(jīng)病變多元醇途徑AG50md02木丹顆粒防治糖尿病周圍神經(jīng)病變研究課件51md02木丹顆粒防治糖尿病周圍神經(jīng)病變研究課件52md02木丹顆粒防治糖尿病周圍神經(jīng)病變研究課件53朱禧星.現(xiàn)代糖尿病學(xué).上海：復(fù)旦大學(xué)出版社，2000.11:333-340.

脂代謝紊亂胰島素相對/絕對缺乏脂代謝障礙（γ-亞麻酸生成障礙）神經(jīng)膜結(jié)構(gòu)障礙前列腺素神經(jīng)血流障礙神經(jīng)功能障礙朱禧星.現(xiàn)代糖尿病學(xué).上海：復(fù)旦大學(xué)出版社，2000.154Joslin糖尿病學(xué).2007.50:874-875.HounsomL，CorderR,PatelJ,etal.Diabetologia,2001,44:424-428氧自由基損害氧化應(yīng)激自由基神經(jīng)細胞結(jié)構(gòu)、功能障礙神經(jīng)細胞凋亡Joslin糖尿病學(xué).2007.50:874-875.氧55神經(jīng)血管病變AVeves,ClinicalMangement,SecondEdition神經(jīng)血管病變AVeves,ClinicalMangem56循環(huán)纖維蛋白原水平升高（導(dǎo)致血液粘滯度升高、纖維蛋白沉降）血小板活性升高、聚集性升高紅細胞細胞膜變形能力下降，導(dǎo)致紅細胞硬化，并且趨于易發(fā)生聚集血液處于高凝狀態(tài)Joslin糖尿病學(xué).2007.50:873.施曉紅，周湘蘭，等.中國臨床醫(yī)學(xué)，2004，11(4)∶502-503L.L.TeunissenN.C.NotermansJ.H.J.Wokk.EurNeurol2000;44:1–7神經(jīng)組織缺血、缺氧血液流變學(xué)異常循環(huán)纖維蛋白原水平升高（導(dǎo)致血液粘滯度升高、纖維蛋白沉降）J57氮氧化物降低：NO,血管舒張功能障礙1前列腺素降低：血小板聚集，血管舒張功能障礙2粘附分子升高：血小板粘附，微血管阻塞3神經(jīng)組織缺血缺氧，結(jié)構(gòu)、功能障礙1.KiharaM,LowPA.ExpNeurol,1995,132:180-1852.ShimizuK,MuramatsuM,KakegawaY,etal.Diabetes,1993,4:1246-12523.JudeEB,AbbottCA,YoungMJ,etal.Diabetologia,1998,41:330-336

血管活性因子改變氮氧化物降低：NO,血管舒張功能障礙1神經(jīng)組織缺血缺58神經(jīng)生長因子胰島素樣生長因子其他神經(jīng)營養(yǎng)因子神經(jīng)細胞損傷、再生能力下降

YasudaH,TeradaM,MaedaK,etal.ProgNeurobiol,2003,69(4)∶229.神經(jīng)營養(yǎng)因子缺乏神經(jīng)生長因子神經(jīng)細胞損傷、再生能力下降YasudaH59抗氧化應(yīng)激，改善營養(yǎng)與血供等嚴(yán)控血糖和多重危險因素干預(yù)緩解疼痛減輕癥狀對癥治療對因治療預(yù)防抗氧化應(yīng)激，嚴(yán)控血糖和多重緩解疼痛對癥對因治療預(yù)60強化降糖達標(biāo)可降低DPN風(fēng)險控制血糖要平穩(wěn)治療前，神經(jīng)纖維一直處于高血糖狀態(tài)。用一般方法皮下注射胰島素治療，特別是對于1型糖尿病，用量不足糖代謝紊亂不能控制，神經(jīng)病變會繼續(xù)發(fā)展，如用量過多，血糖急劇下降，會出現(xiàn)治療后神經(jīng)病或胰島素性神經(jīng)炎。強化降糖達標(biāo)可降低DPN風(fēng)險控制血糖要平穩(wěn)治療前，神經(jīng)纖維一61基本病機：消渴病日久，肝腎不足，氣血兩虛，絡(luò)脈瘀阻。治療總則：益氣養(yǎng)陰，活血化瘀，通絡(luò)止痛。黃芪：抗氧化丹參、黃芪、川芎：抑制醛糖還原酶槲皮素：抑制蛋白非酶糖化三七、紅花：抗凝、抗血栓形成中醫(yī)中藥治療DPN木丹顆粒組方黃芪：大補元氣，使氣旺血行，能去瘀而不傷正。延胡索：活血化瘀，行氣止痛。三七：活血散瘀，止痛，更能祛瘀生新。赤芍：散瘀止痛，丹參：為活血化瘀之要藥，紅花：活血化瘀，通調(diào)經(jīng)脈。川芎：活血行氣。蘇木：活血祛瘀。雞血藤：補血活血?；静C：消渴病日久，肝腎不足，氣血兩虛，絡(luò)脈瘀阻。治療總則62國藥準(zhǔn)字Z20080033發(fā)明專利ZL01106342.4國家醫(yī)保乙類品種中國首創(chuàng)明確治療糖尿病周圍神經(jīng)病變的現(xiàn)代專利中藥解除麻木疼痛；修復(fù)受損神經(jīng)；改善微循環(huán)；中國醫(yī)學(xué)科學(xué)院證實具有胰島修復(fù)作用;聯(lián)合丹紅、甲鈷胺或α硫辛酸協(xié)同增效;7盒一療程，可連續(xù)服用兩個療程.木丹顆粒國藥準(zhǔn)字Z20080033中國首創(chuàng)明確治療糖尿病周圍神經(jīng)病變63修復(fù)DPN受損神經(jīng)，提高神經(jīng)傳導(dǎo)速度提高Na+-K+-ATP酶活性增加神經(jīng)中cAMP和cGMP的含量顯著抑制紅細胞山梨醇含量改善神經(jīng)代謝物質(zhì)水平顯著的止痛鎮(zhèn)痛功效熱甩尾時間顯著增加，減少醋酸誘發(fā)小鼠扭體次數(shù)。改善血漿-EP水平,顯著提高DPN患者的痛閾改善血液微循環(huán)，提高神經(jīng)內(nèi)膜血液供應(yīng)改善血液流變學(xué)，具有顯著的活血作用提高神經(jīng)營養(yǎng)因子，改善神經(jīng)傳導(dǎo)提高神經(jīng)生長因子基因表達提高血管活性物質(zhì)，減少血管損傷木丹顆粒減少危險因素，阻斷多重機制，降低神經(jīng)病變修復(fù)DPN受損神經(jīng)，提高神經(jīng)傳導(dǎo)速度提高Na+-K+-64Na+-K+-ATP酶活性**##**與模型組比較**P＜0.01；與彌可保組比較##P＜0.01木丹顆粒藥效學(xué)研究，沈陽藥科大學(xué)木丹顆粒提高Na+-K+-ATP酶活性****△△與模型組比較*P＜0.05與彌可保組比較△P＞0.05cAMP、cGMP含量木丹顆粒增加cAMP、cGMP含量木丹顆粒改善神經(jīng)代謝物質(zhì)水平Na+-K+-ATP酶活性**##**與模型組比較**P＜木丹顆粒對鏈脲霉素糖尿病模型大鼠紅細胞山梨醇含量有顯著的影響，含量遠低于模型組（P＜0.05），也低于彌可保組，說明木丹顆粒能夠降低紅細胞山梨醇的含量，有利于受損神經(jīng)的恢復(fù)，優(yōu)于彌可保。與空白對照組比較*P＜0.05，**P＜0.01與模型組比較#P＜0.05***#*木丹顆粒藥效學(xué)研究，沈陽藥科大學(xué)木丹顆粒降低山梨醇含量，修復(fù)受損神經(jīng)木丹顆粒改善神經(jīng)代謝物質(zhì)水平木丹顆粒對鏈脲霉素糖尿病模型大鼠紅細胞山梨醇含量有顯著的影響木丹顆粒組大鼠尾神經(jīng)傳導(dǎo)速度接近于正常組，與鏈脲霉素糖尿病模型組有顯著的差異（P＜0.01），也優(yōu)于彌可保組，提示木丹顆粒有著顯著的提高神經(jīng)傳導(dǎo)速度的作用。STZ-DM大鼠尾神經(jīng)傳導(dǎo)速度*###***與空白對照組比較*P＜0.05，**P＜0.01與模型組比較#P＜0.05，##P＜0.01木丹顆粒藥效學(xué)研究，沈陽藥科大學(xué)木丹顆粒顯著提高神傳傳導(dǎo)速度木丹顆粒組大鼠尾神經(jīng)傳導(dǎo)速度接近于正常組，與鏈脲霉素糖尿病模試驗組：常規(guī)治療（控制血糖）+木丹顆粒對照組：常規(guī)治療（控制血糖）+彌可保片治療前后，兩組對FBG、2hPG無影響。治療前后臨床癥狀與體征比較：試驗組四肢發(fā)涼、感覺異常改善優(yōu)于對照組，自發(fā)性疼痛、四肢麻木、肢軟無力改善與對照組無差異。2組治療后脛神經(jīng)、腓總神經(jīng)和腓淺神經(jīng)傳導(dǎo)速度比較均有顯著性差異(p＜0.05)，試驗組治療后腓腸神經(jīng)傳導(dǎo)速度明顯快于對照組(p＜0.05),2組治療后神經(jīng)傳導(dǎo)速度與治療前比較均有明顯改善。在改善感覺神經(jīng)傳導(dǎo)速度方面效果優(yōu)于彌可保。木丹顆粒與彌可保治療糖尿病周圍神經(jīng)病變療效比較,現(xiàn)代中西醫(yī)結(jié)合雜志,2011.9木丹顆粒顯著提高神經(jīng)傳導(dǎo)速度試驗組：常規(guī)治療（控制血糖）+木丹顆粒治療前后，兩組對FBG68扭體次數(shù)熱甩尾反應(yīng)時間木丹顆粒能顯著延長鏈脲霉素糖尿病大鼠熱甩尾反應(yīng)時間，提高其痛域，顯示具有顯著的鎮(zhèn)痛作用。木丹顆粒能夠顯著減少醋酸誘發(fā)小鼠扭體次數(shù)（P＜0.01），提示木丹顆粒有著顯著的止痛作用。****與模型組比較*P＜0.05與空白對照組比較*P＜0.05，**P＜0.01木丹顆粒藥效學(xué)研究，沈陽藥科大學(xué)木丹顆粒具有顯著的鎮(zhèn)痛作用扭體次數(shù)熱甩尾反應(yīng)時間木丹顆粒能顯著延長鏈脲霉素糖尿病大鼠熱木丹顆粒對急性血瘀模型大鼠的血液流變學(xué)變化有著顯著的影響，其全血比粘度、血漿比粘度、紅細胞壓積都遠低于血瘀模型組，而阿司匹林組和彌可保組差異都不顯著。提示木丹顆粒有著顯著的活血作用。血瘀模型組木丹顆粒藥效學(xué)研究，沈陽藥科大學(xué)木丹顆粒改善血液流變學(xué)，顯著的活血作用木丹顆粒對急性血瘀模型大鼠的血液流變學(xué)變化有著顯著的影響，其試驗結(jié)果提示，糖尿病模型組成模6周時坐骨神經(jīng)NGFmRNA表達明顯下降，提示與糖尿病性周圍神經(jīng)病變的發(fā)生密切相關(guān)。木丹顆粒能夠上調(diào)NGFmRNA表達，這可能是其防治糖尿病性周圍神經(jīng)病變的機制之一。NGF含量與正常組比較**P＜0.01與模型組比較△P＜0.05****△**△木丹顆粒藥效學(xué)研究，沈陽藥科大學(xué)木丹顆粒能夠上調(diào)NGFmRNA表達正常對照組模型組木丹顆粒組彌可保組試驗結(jié)果提示，糖尿病模型組成模6周時坐骨神經(jīng)NGFmRNA木丹顆粒對糖尿病大鼠胰島細胞凋亡作用及TNF-α、Caspase-3表達的影響，遼寧中醫(yī)藥大學(xué)學(xué)報，2012，4本實驗研究表明，木丹顆粒中高劑量組可明顯降低TNF-α、Caspase-3的表達，抑制胰島細胞凋亡。胰島β細胞凋亡觀察木丹顆粒對TNF-α的表達影響木丹顆粒對Caspase-3表達的影響木丹顆粒抑制胰島細胞凋亡木丹顆粒對糖尿病大鼠胰島細胞凋亡作用及TNF-α、Caspa72與正常對照組相比,各糖尿病組大鼠血清sVCAM-1、sZCAM-1含量明顯升高(P<0.01),與模型組相比各治療組情況明顯改善(P<0.01),且木丹顆粒療效優(yōu)于彌可保(P<0.05)。結(jié)論:木丹顆粒對DPN大鼠血清sVCAM-1、sICAM-1含量有一定下調(diào)作用,從而達到防治DPN的作用。糖末寧對實驗性DPN大鼠血清sVCAM-1、sICAM-1含量的影響.實用糖尿病雜志第5卷,第2期木丹顆粒防治DPN組別NsICAM-1sVCAM-1正常對照組1087.3±11.50.74±0.278模型組8176.6±24.233.61±0.62彌可保組8122.1±15.661.94±0.48**木丹顆粒組9106.0±11.48**1.31±040**各組大鼠血清sVCAM-1、sICAM-1含量比較（均數(shù)±標(biāo)準(zhǔn)差）與正常組相比*P<0.05，**P<0.01；與糖尿病模型組相比，##P<0.01，與彌可保組比P<0.05與正常對照組相比,各糖尿病組大鼠血清sVCAM-1、s73木丹顆粒明顯改善DPN患者癥狀木丹顆粒的臨床試驗顯示，總有效率為93.23%。木丹顆粒治療糖尿病神經(jīng)病變的優(yōu)勢在于較短時間內(nèi)改善患者的臨床癥狀，如四肢麻木、疼痛、面色晦暗、倦怠乏力、自汗等均有較好的治療作用。木丹顆粒（糖末寧）治療糖尿病周圍神經(jīng)病變（氣虛絡(luò)阻證）432例臨床研究中醫(yī)證候療效四肢麻木、疼痛、面色晦暗、倦怠乏力、自汗木丹顆粒明顯改善DPN患者癥狀木丹顆粒的臨床試驗顯示，總有效74木丹顆粒提高DPN患者MNCVSNCV顯效：神經(jīng)傳導(dǎo)速度恢復(fù)正?；蛟黾?m/s以上。有效：神經(jīng)傳導(dǎo)速度較前增加3m/s以上。無效：神經(jīng)傳導(dǎo)速度增加不足3m/s。肌電圖療效肌電圖療效分析顯示，經(jīng)木丹顆粒組治療后神經(jīng)傳導(dǎo)速度明顯改善，有顯著性差異（P＜0.01），與彌可保組比較，無統(tǒng)計學(xué)意義（P＞0.05），提示木丹顆粒對DPN有較好的治療作用。木丹顆粒（糖末寧）治療糖尿病周圍神經(jīng)病變（氣虛絡(luò)阻證）432例臨床研究木丹顆粒提高DPN患者MNCVSNCV顯效：神經(jīng)傳導(dǎo)速度75木丹顆粒減少危險因素，阻斷多重機制，降低神經(jīng)病變改善神經(jīng)代謝物質(zhì)水平提高Na+-K+-ATP酶活性增加神經(jīng)中cAMP和cGMP的含量顯著抑制紅細胞山梨醇含量修復(fù)DPN受損神經(jīng)，提高神經(jīng)傳導(dǎo)速度；提高神經(jīng)營養(yǎng)因子，改善神經(jīng)傳導(dǎo)改善血液微循環(huán)，提高神經(jīng)內(nèi)膜血液供應(yīng)提高血管活性物質(zhì)，減少血管損傷木丹顆粒改善神經(jīng)代謝物質(zhì)水平修復(fù)DPN受損神經(jīng)，提高神經(jīng)76謝謝！謝謝！77ASupermarketinCaliforniaByAllenGinsbergASupermarketinCaliforniaBy78BioHewasborninNewarkin1926anddiedin1997.Hisearlylifewastroubledbecauseofhismother’sbattlewithmentalillnessandthisinformedhispoems.Hetraveledextensivelythroughouttheworldandwasexpelledfrommanycommunistcountries(mostnotablyCuba)forbeingsubversive,thesetravelsinfluencedhiswork.HewontheNationalBookawardforTheFallofAmerica,andwasawardedtheOrderofArtsandLettersbytheFrenchCulturalministry.Hispoem“Howl”was(andis)thesourceofmuchcontroversyoverwhatsomeconsidertobeobscenethemesandwords.Itandotherpoemslikeitwasresponsiblefortherepealofmanyanti-obscenitylaws.Itremainshismostfamouswork.HewasalsoamusicianandappearsonTheClash’salbum“CombatRock.”Hewrote“ASupermarketinCalifornia”in1955whilelivinginBerkley.BioHewasborninNewarkin1979ASupermarketinCalifornia WhatthoughtsIhaveofyoutonight,WaltWhitman,for

Iwalkeddownthesidestreetsunderthetreeswithaheadache

self-consciouslookingatthefullmoon.

Inmyhungryfatigue,andshoppingforimages,Iwent

intotheneonfruitsupermarket,dreamingofyourenumerations!

Whatpeachesandwhatpenumbras!Wholefamilies

shoppingatnight!Aislesfullofhusbands!Wivesinthe

avocados,babiesinthetomatoes!--andyou,GarciaLorca,what

wereyoudoingdownbythewatermelons?

Isawyou,WaltWhitman,childless,lonelyoldgrubber,

pokingamongthemeatsintherefrigeratorandeyeingthegrocery

boys.

Iheardyouaskingquestionsofeach:Whokilledthe

porkchops?Whatpricebananas?AreyoumyAngel?

Iwanderedinandoutofthebrilliantstacksofcans

followingyou,andfollowedinmyimaginationbythestore

detective.

Westrodedowntheopencorridorstogetherinour

solitaryfancytastingartichokes,possessingeveryfrozen

delicacy,andneverpassingthecashier.ASupermarketinCalifornia Wh80ASupermarketinCalifornia Wherearewegoing,WaltWhitman?Thedoorsclosein

anhour.Whichwaydoesyourbeardpointtonight?

(Itouchyourbookanddreamofourodysseyinthe

supermarketandfeelabsurd.)

Willwewalkallnightthroughsolitarystreets?The

treesaddshadetoshade,lightsoutinthehouses,we'llbothbe

lonely.

WillwestrolldreamingofthelostAmericaoflove

pastblueautomobilesindriveways,hometooursilentcottage?

Ah,dearfather,graybeard,lonelyoldcourage-teacher,

whatAmericadidyouhavewhenCharonquitpolinghisferryand

yougotoutonasmokingbankandstoodwatchingtheboat

disappearontheblackwatersofLethe?

ASupermarketinCalifornia Wh81AllenGinsbergReads“ASupermarketinCalifornia”YouTube-AllenGinsberg-ASupermarketInCaliforniaAllenGinsbergReads“ASuperm82TheSpeakerThespeakeriseducated,butappearstobealonelybrokenman.Heissearchingformeaningandsomethingbeautiful,somethingnaturalinmodernAmerica.TheSpeakerThespeakeriseduc83TheSubjectThepoemdealswiththelossoftheoldAmerica,theAmericathatcouldhaveinspiredWhitman.WeseethroughthespeakerthealienationandhomogenizationofmodernAmerica,andthespeaker’ssadnessaboutwhathecanneverexperienceduetotheunfortunatetimingofhisbirth.TheSubjectThepoemdealswith84ImagesThefirstimagesweseeareinsidethesupermarket,wherethespeakerremarksontheproduceandthe“Aislesfullofhusbands!Wivesintheavocados,babiesinthetomatoes!”Hecomparestheshoppingfamiliestotheproduce,becausetohimtheyarenodifferent—noimportantstory,nodistinctiondeeperthanageorsex.ImagesThefirstimageswesee85Imagescont.GarciaLorcaisinsertedasacontrasttotheshoppers.HewasaSpanishpoetinthethirtieswhoseworkswerecensoredbythefascistgovernmentofFrancoafterhisdeath.HeisasymbolofrepressedartinAmerica,andthespeakerexpressessurprisetoseehimoutintheopenandinasoullesssupermarket.Imagescont.GarciaLorcaisin86Imagescont.WaltWhitmanisasymboloftheoldAmerica,theAmericathatthespeakerwantstolivein.Heisdescribedasanoldfoolwhodemandsthingsnooneasksorcaresaboutanymore“Whokilledtheporkchops?”tryingtofindthestorybehindwhatheisbuyingalthoughtherenolongerisanystorybehindanythinginthesupermarket.HeisportrayedthiswaybecauseaccordingtothespeakeramanlikeWhitmanwouldnotbeabletoremainsaneinmodernsociety,hewouldbereducedtoadodderingoldfoolwhowandersthesupermarketatnight.Imagescont.WaltWhitmanisa87Imagescont.TheblueautomobilesfurtherthesenseofconformityinAmerica,thewayitisstatedimpliesthatallofthecarsareblueandthesame.TheentirelaststanzausesmythologicalcharactersandsettingstoaddasenseofgrandeurtothedeathofWhitman.Imagescont.Theblueautomobil88OrganizationFivestanzasFreeverseMostlylongsentencesbrokenupbycommaswithafewbreaksofshortexclamations,orquestions.OrganizationFivestanzas89OrganizationIdivideditintofoursections:Firststanza(lines1-9),thespeakerdescribesthesupermarketanditspatrons.Secondstanza(lines10-20)Thespeaker“meets”WaltWhitmanandfollowshimthroughhisdazedsupermarketjourney.Questioning(lines21-29)Thespeakerquestions“Whitman”abouttheliteralplanfortheirnight,andindi