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Sacral Nerve Stimulation in Fecal Incontinence:Are There Factors Associated with Success?

Guillaume Gourcerol,M.D.,Syrine Gallas,M.D.,Francis Michot,Ph.D., Philippe Denis,Ph.D.,Anne-Marie Leroi,Ph.D.

Digestive Tract Research Group EA3234/IFRMP23,Rouen University Hospital,Rouen,France

PURPOSE:Sacral nerve stimulation has been used success-fully in treating fecal incontinence.This study was designed to evaluate the proportion of patients with unsuccessful implantation despite positive test stimulation and to examine and compare factors associated with the success of the transitory and permanent sacral nerve stimulation. METHODS:A total of61patients(55females;median age, 56(range,33–77)years)with refractory fecal incontinence underwent temporary stimulation.A50percent or greater improvement in the number of episodes of fecal inconti-nence or urgency was required to proceed to permanent implantation and was the criteria of success of permanent sacral nerve stimulation at the last follow-up visit in implanted patients.The factors compared between the success and the failure groups during temporary and permanent stimulation were patients_age and gender, diagnosis and characteristics of fecal incontinence,previ-ous surgery,quality of life scores,anorectal manometry, endoanal ultrasound,and electrophysiologic tests per-formed before stimulation.RESULTS:Temporary stimula-tion was successful in35patients(57.4percent).A permanent neurostimulation device was implanted in33 patients.Age was the only factor related to success of the temporary stimulation(P=0.03).After permanent implan-tation,31percent of patients did not attain screening phase results for the number of episodes of fecal incontinence or urgency.A neurologic disorder was more frequently the origin of fecal incontinence in the success group compared with others(P=0.03).The left bulbocavernosus reflex was more frequently delayed in the success group than in the others(P=0.03),and a prolonged or absent bulbocaverno-sus reflex was more frequent in the success group than in the failure group(P=0.03).CONCLUSIONS:Patients with fecal incontinence from neurologic origins could be good candidates for sacral nerve stimulation.[Key words:Fecal incontinence;Sacral nerve stimulation;Electrophysiologic anal test;Perineal neurologic disease;Predictive factors; Treatment]

S acral nerve stimulation,originally developed for urinary voiding dysfunction,has been used for the treatment of patients with fecal incontinence since1995.1Treatment with sacral nerve stimulation has been restricted to patients with at least one episode of fecal incontinence per week,who have failed conservative therapy,and are considering a surgical intervention,as long as they do not present a significant structural defect of the external anal sphincter.2Patients are selected for surgical implan-tation of a permanent neurostimulation device on the basis of clinical improvement during test stimula-tion.3No other predictor of functional outcome with chronic stimulation exists.In a systematic review of six studies,an average of56percent of patients with fecal incontinence seemed to be eligible for perma-nent sacral nerve stimulation after test stimulation (i.e.,they exhibit>50percent improvement in their fecal incontinence episodes during the test stimula-tion,criteria chosen according to the commonly allowed criteria in the literature).2A recent review of studies published for149incontinent patients treated by permanent sacral nerve stimulation

Presented at Digestive Disease Week,Los Angeles,California, May20to25,2006.

Correspondence to:Anne-Marie Leroi,Ph.D.,Physiology Unit, Ho?pital Charles Nicolle,1rue de Germont,Rouen Cedex76031, France,e-mail:anne-marie.leroi@chu-rouen.fr

Dis Colon Rectum2006;50:3–12

DOI:10.1007/s10350-006-0746-4

*The American Society of Colon and Rectal Surgeons

Published online:3November2006

reported a75to100percent success rate at a follow-up ranging from1to99months with a good correlation between temporary and permanent stimulation out-comes.2However,according to numerous studies on sacral nerve stimulation for urologic indications,>20 percent of patients with urgency–frequency or urge urinary incontinence and initially favorable test stim-ulation fail to respond after implantation for unknown reasons.4,5

The objectives of this study were:(1)to evaluate the proportion of patients with unsuccessful implan-tation despite positive test stimulation,(2)to exam-ine and compare factors associated with successful transitory and permanent sacral nerve stimulation.

PATIENTS AND METHODS

Data were collected from a prospective record that was kept for all patients receiving sacral nerve stimulation.All patients with severe fecal incontinence seen consecutively from August1998to March2005, who corresponded to the following criteria were considered for sacral nerve stimulation:1)patients with an average of more than one episode of fecal incontinence and/or urgency per week of solid or liquid stools for at least three months before enroll-ment;2)patients who had failed medical therapy, including treatment with antidiarrheal medication,and biofeedback.Patients with external anal sphincter damage on ultrasound were included in the study if the defect was not considered to be the main cause of fecal incontinence(i.e.,limited defect,e30-or limited to one part,superficial,middle,or deep part,of the external anal sphincter after previous sphincter repair or not).Exclusion criteria were:congenital anorectal malformation;rectal prolapse;anatomic limitations preventing surgical access;and pregnancy.Sixty-one patients(55females;median age,56(range,33–77) years)were included in this study.These patients represented all the patients tested for fecal inconti-nence in our hospital.We did not submit this study to our ethical committee because our goal was to follow-up a cohort of incontinent patients who were receiving a well-established treatment,whose effec-tiveness did not need to be demonstrated.Our purpose was not to evaluate a new practice or a new modality of follow-up but to study the character-istics of patients treated routinely and in a standard-ized well-established way,by sacral nerve stimulation, according to the results of the stimulation.The mean number of preoperative weekly incontinent episodes was six(standard deviation(SD),6),and the mean duration of symptoms was4.7(SD,5)years.Patients_ characteristics are given in Table1.

Evaluation

Before stimulation,all patients kept a diary card for at least three weeks.Patients recorded episodes of fecal incontinence,urgency,and bowel movements. Primary outcome measures were a reduction in the number of incontinent or urge episodes per week. Urgency was defined as the need to rush to the toilet to avoid fecal incontinence,with a delay to postpone defecation of less than15minutes.6Severity of incontinence was graded by the Cleveland Clinic Continence Scoring System.7The score ranged from 0(normal continence)to20(maximum inconti-nence).We assessed the quality of life(QOL)with

Table1.

Patients_Characteristics

Study Group

(n=61) Type of incontinence

Urge incontinence a31

Passive incontinence b14

Mixed incontinence14

Urgency without incontinence1 Causes of fecal incontinence

Idiopathic10

Neurologic36

Pudendal neuropathy21

Lumbosacral plexopathy11

Multiple sclerosis2

Spinal cord injury2 Internal anal sphincter defect7

IBS diarrhea predominant4

Obstetrical injury

Pudendal neuropathy9

Lumbosacral plexopathy4

Postsphincter or pelvic floor

repair

Internal anal sphincter defect3 Previous procedures

For fecal incontinence

Pelvic floor repair5

Sphincter repair5

Artificial bowel sphincter1 Other procedures

Hemorrhoidectomy5

Sphincterotomy6

Anal dilation2

Abdominal rectopexy6

IBS=irritable bowel syndrome;Urge incontinence=in-voluntary loss of stool preceded by the overwhelming desire to defecate(urgency).

a Inability to defer defecation.

b No awareness of loss of stool.

4GUILLAUME ET AL Dis Colon Rectum,January2007

the French version of The American Society of Colon and Rectal Surgeons(ASCRS)quality-of-life question-naire for FI(FIQL).8Because the French version of the FIQL questionnaire was recently validated,9only the patients implanted from the end of the Year2000 could complete it.In the questionnaire,four separate QOL domains were explored,including lifestyle, coping/behavior,depression/self-perception,and embarrassment.

All patients had to undergo a preoperative evaluation, including clinical examination,anorectal manometry, endoanal ultrasonography,10and electrophysiologic perineal tests.Anal manometry was performed accord-ing to our standard technique with a balloon catheter.11 Maximal anal resting and squeeze pressures(amplitude and duration)were recorded.Rectal sensation to balloon distention with air was assessed.The smallest amount of distention felt by the patient(i.e.,the threshold of conscious rectal sensation),the distending volume eliciting a call to defecate(constant sensation), and the maximum tolerable volume were then deter-mined.Electrophysiologic tests included bulbocaver-nosus muscle electromyography(EMG),pudendal nerve terminal motor latency(PNTMLs),12bulbocaver-nosus reflex latencies(BCRLs),and somatosensory evoked potentials of the pudendal nerve(SEPPNs).13 For research purposes and according to the normal values established in our unit,PNTMLs was considered normal if<2.5msec12and bulbocavernosus EMG was considered normal in the absence of loss of motor units and with a normal increase in motor unit recruitment during squeezing(interference pattern).The BCRLs were considered normal if they were<44msec in males and<49msec in females and the SEPPNs<53 msec.The diagnosis of a neurologic pathology was previously known before the initial evaluation and confirmed by electrophysiologic tests(multiple sclero-sis,spinal injury)or was performed once results of electrophysiologic tests were obtained.When the test was not performed in our unit,we only received the conclusion to explain the missing electrophysiology results.Further diaries were completed at6and12 months and yearly after permanent implantation.

Sacral Nerve Stimulation Technique The surgical procedure and equipment used for permanent electrode and stimulator implantation have been described previously.14Before permanent im-plantation,patients underwent temporary percutane-ous stimulation to assess their probable response to treatment.A20-gauge, 3.5-inch,insulated spinal needle was inserted bilaterally into the S3and S4 foramina and was then stimulated,using a portable stimulator(Medtronic Interstim i,model3625,Min-neapolis,MN)to elicit the best motor(i.e.,B bellows^ contraction of the perineum and contraction of the ipsilateral great toe)or sensory response to the lowest stimulus.This indicates the optimal foramen for stimulation.Once the optimal foramen was identified, an electrode was introduced at the needle place and connected to an external pulse generator(Medtronic Interstim i model3625).After every surgical proce-dure,an x-ray of the sacrum was performed to confirm the position of the electrode.Before January2003, temporary stimulation was performed with a tempo-rary,percutaneously placed test stimulation electrode (Medtronic Interstim i model3057;27initial patients) attached to the portable stimulator(Medtronic Inter-stim i model3625).Because this electrode dislodged easily,some patients later in the series(after January 2003)had a permanent quadripolar electrode implanted,usually used during the permanent implan-tation(Medtronic Interstim i model3093;34patients). This electrode had four electrodes at the distal part, followed by four rings of small anchors to fix the system in the sacral foramen,reducing the risk of electrode dislocation.15This electrode was then connected,via a percutaneous extension lead,to the portable stimulator (Medtronic Interstim i model3625).

All patients were tested for three weeks.They were then selected for permanent implantation based on the degree of improvement in continence as ascertained from bowel diaries completed before and during temporary stimulation,patients satisfaction, and lack of complications.A50percent or greater improvement in the total number of episodes of fecal incontinence or urgency(responders)was required to proceed to permanent implantation.Patients with a temporary test stimulation lead underwent simul-taneous implantation of the quadripolar lead and the pulse generator;those with a permanent quadripolar electrode previously in place underwent removal of the percutaneous extension(Medtronic Interstim i model3095)before placement of the pulse generator (Medtronic Interstim i model3023)subcutaneously, below the superficial fascia,in the upper part of buttocks ipsilateral to the permanent electrode.The lead contained four contact electrodes.The electrode combination that allowed the patient to have the best perception of the perineum muscle and anal sphinc-ter contraction was chosen for permanent stimula-

Vol.50,No.1SACRAL NERVE STIMULATION IN FECAL INCONTINENCE5

tion.Stimulation was continuous with a pulse width of210m sec,a frequency of14pulses per second,and current amplitude adapted to the patient_s percep-tion of perineal and anal sphincter muscle contrac-tion.The stimulator was left on during defecation and urinary voiding.

Statistics

We provided data as mean(standard deviations). We assessed changes on bowel-habit diary entries. For analyses of predictive factors of the clinical outcome of sacral nerve stimulation,we divided patients into two groups according to improvement of incontinent episodes and/or urgency episodes at the end of the temporary stimulation(responders: >50percent improvement in fecal or urgency episodes per week;nonresponders:<50percent improvement in fecal or urgency episodes per week) and the last follow-up visit after implantation(suc-cess:>50percent improvement in fecal or urgency episodes per week;failure:<50percent improve-ment in fecal or urgency episodes per week).The implantation was considered a definitive failure:1)if a lead dislodgment was ruled out;2)if several visits for reprogrammation of the implantable device were unsuccessful.

We used the X2test to compare gender,type of fecal incontinence(urge or passive),antecedents of pelvic surgery,cause of incontinence,clinical re-sponse during the temporary test of stimulation, endoanal ultrasonography,and some electrophysio-logic perineal tests results between the groups(i.e., responders-nonresponders and success-failures).We used the Mann-Whitney U test to compare the age, duration of incontinence,incontinence scores,FIQL questionnaires,incontinent and urgency episodes, manometry,and electrophysiologic results between the groups.P<0.05was considered statistically significant.The statistical power of the tests has been calculated.The analysis was performed with the Statview program(SAS Institute,Berkeley,CA).

RESULTS

Temporary stimulation was performed in61 patients and was successful(i.e.,Q50percent im-provement in the total number of episodes of fecal incontinence or urgency)in35(57.4percent).A permanent neurostimulation device was implanted in 33patients.In the remaining two,one could not stand the electric stimulation,although it was not perceived as painful and the other had persistent clinical benefit after temporary electrode ablation prevented permanent implantation.Efficacy of per-manent implantation was based on results from the 29patients who were followed for at least six (median,12;range,6–72)months.In the remaining four,severe pain unsolved by reprogramming,drugs, or repositioning of the pulse generator or lead dislodgement led to early reinterventions(within the6months)making the evaluation of sacral nerve stimulation efficacy among these patients impossible. The number of patients tested,implanted and followed up for6,12,24,and36months or more is given in Figure1.

Rate of Secondary Failures after Implantation At their last follow-up visit(median,12(range,6–72)months),the clinical effect at screening was ob-tained in one of the two primary outcome

measures

Figure1.Total number of patients tested and followed at the6,12,24,36-month follow-up visits after implantation and the number of patients that improved and did not improve at each visit.Follow-up was performed for each patient according to their date of implantation.Some patients were significantly improved by stimulation(suc-cesses)and others were not(failures)at follow-up.A new case of failure occurred when a patient was improved by stimulation until a visit occurred where there was no longer any improvement.For example,at12months we had16successes compared with20at the6-month visit, because2patients were new failures and2had been implanted less than a year before,so they did not undergo this follow-up.

6GUILLAUME ET AL Dis Colon Rectum,January2007

(i.e.,>50percent improvement in fecal incontinence and/or urgency episodes per week)in 20patients (69percent;success group).Nine patients (31percent)failed to achieve the effect of the screening phase (failure group).The rate of secondary failures was higher in the six months after implantation (31percent)than later (between 11and 18percent from the 12-month to the 36-month visit;Fig.1).

Patients in the success group showed a significant and constant decrease in fecal incontinence episodes at each follow-up visit but a significant decrease in the number of urgency episodes only at the six-month visit (Fig.2).Continence was fully restored in six patients at the last follow-up visit.No significant improvement of the number of fecal incontinence episodes or urgency was found in failure group (Fig.2).

Factors Associated with Success

During Temporary Stimulation.The age of patients had a relation with success or failure (Table 2).

Responders (i.e.,Q 50percent improvement in the number of episodes of fecal incontinence or urgency during the test)were significantly younger than nonresponders (P =0.03).There was no other difference between responders and nonresponders with regard to clinical characteristics (Table 2),anorectal manometry,electrophysiologic tests,or anal ultrasound performed before sacral nerve stimulation (Table 3).Individuals in the two groups had the same overall prevalence of neurologic conditions to explain fecal incontinence (28/35in responders vs.20/26in nonresponders;P =0.99).The success of the temporary test was not related to the type of stimulation lead used (i.e.,temporary or permanent stimulation lead;50percent of success with a temporary electrode vs.63.6percent with a permanent electrode;P =0.41).

During Permanent Implantation.When comparing successful and unsuccessful cases of sacral nerve stimulation at the last follow-up visit,no significant differences were found between these two groups

with

Figure 2.Improvement in fecal incontinence episodes and urgency episodes after permanent implantation in the success group (—)and failure group (j j j )after implantation.

Vol.50,No.1SACRAL NERVE STIMULATION IN FECAL INCONTINENCE 7

8GUILLAUME ET AL Dis Colon Rectum,January2007

Table2.

Comparison of Patients_Characteristics Before Temporary Test Between Responders and Nonresponders

Responders(n=35)Nonresponders(n=26)P Value Age(yr)52.4T11.759.5T10.60.02 Male/female ratio4/312/240.9 Previous pelvic surgeries for FI(no.of patients)820.2 Duration of fecal incontinence(mo)54.9T71.258.8T41.40.1 Active/passive/mixed FI17/7/1115/8/30.2 Bowel diaries

No.of stools/week14.2T9.114.5T9.30.9

FI episodes/week 5.2T4.57T7.40.9

Urgency episodes/week8.9T9.77.1T8.10.3 Cleveland Clinic score14.4T3.113.7T3.10.6 FIQL score(n=24)(n=14)0.1 Lifestyle2T0.9 2.4T0.90.4

Coping 1.6T0.6 1.7T0.50.6

Depression 2.3T0.9 2.5T0.70.5

Embarrassment 1.5T0.7 1.5T0.4

FI=fecal incontinence;FIQL=Fecal Incontinence Quality of Life.

Data are means T standard deviations unless otherwise indicated.

Table3.

Comparison of Preimplantation Anorectal Manometry,Electrophysiologic Tests,and Endoanal Ultrasonography

in Responders and Nonresponders

Responders(n=35)Nonresponders(n=26)P Value Anorectal manometry

Anal resting pressure(cm H2O):77.2T32.866.3T25.30.2 Maximum squeeze pressure:

Amplitude(cm H20)41.7T40.245T40.90.8

Duration(sec)16.9T14.324T16.10.08 Threshold volume(ml)17.9T2116T10.80.8 Constant sensation volume(ml)169.9T79.3150.4T73.30.2 Maximum tolerable volume(ml)223.3T87.6202.1T81.90.2 Endoanal ultrasonography

Internal anal sphincter

Defect/no defect9/268/180.9 Electrophysiologic tests

EMG

Normal/abnormal17/1313/80.9 PNTML right

Normal/abnormal/abolished25/6/216/4/30.7

Latency(msec) 2.2T0.3 2.2T0.30.7 PNTML left

Normal/abnormal/abolished20/12/116/5/20.4

Latency(msec) 2.4T0.6 2.2T0.40.5 BCRL right

Normal/abnormal/abolished14/10/710/10/30.6

Latency(msec)52.5T20.859.9T25.40.7 BCRL left

Normal/abnormal/abolished13/12/68/13/20.3

Latency(msec)53.4T18.954.6T17.60.8 SEPPN

Normal/abnormal/abolished19/0/714/0/60.9 EMG=electromyography;PNTML=pudendal nerve terminal motor latency;BCRL=bulbocavernosus reflex latency; SEPPN=somatosensory evoked potentials of the pudendal nerve.

Data are means T standard deviations unless otherwise indicated.

respect to gender,duration of incontinence,results of bowel diaries,gravity scores,or quality of life scores performed before implantation(Table4).The patients in the success group tended to be older than the patients in the failure group,but the difference was not significant(P=0.06).The result of sacral nerve stimulation also was independent of the type of fecal incontinence(i.e.,active or passive)and the antecedents of surgical therapies for fecal incontinence (Table4).Concerning the cause of fecal incontinence, patients in the success group were more likely to have neurologic incontinence than the others(18/20vs.4/9; P=0.03).The odds ratio for successful sacral nerve stimulation was estimated to be11.2higher for patients with a neurologic pathology responsible for incontinence than for others(95percent confidence interval, 1.2–143).The percentage of improvement (i.e.,Q80percent improvement in the total number of episodes of fecal incontinence vs.50to80percent of improvement)during the temporary stimulation was not related to success after implantation(P=0.9).In addition,success after implantation was independent of the type of electrode(i.e.,temporary or permanent stimulation lead)used during the temporary test of stimulation(6/10patients with temporary lead had successful sacral nerve stimulation vs.14/19with a permanent lead;P=0.73).Manometric data were comparable between the two groups(Table5). Electrophysiologic tests showed significantly longer left bulbocavernosus reflex latency in the success group than in the others(P=0.03;Table5).The right bulbocavernosus reflex latency was longer in the success group than in the others,but the difference was not significant(Table5).A prolonged or absence of at least one bulbocavernosus reflex(i.e.,left or right reflex)was more frequent in the success group than in the failure group(14/17vs.3/9;P=0.03;odds ratio=9.3;95percent confidence interval, 1.1–89). Anal ultrasound findings were similar in the two groups of patients(Table5).

However,these results must be cautiously inter-preted according to the power of the statistical tests used.Because of the number of patients included in this study,the power remained low(i.e.,between50 and70percent for statistically significant results, between30and50percent when the results were closed to the statistical significance,and<30percent for other comparisons).

DISCUSSION

Unlike previously published studies that demon-strate an excellent reproducibility of the therapeutic effect observed during the screening phase,2,3this study found a secondary loss of therapeutic effect in approximately one-third of the patients treated by permanent sacral nerve stimulation for fecal incon-tinence.Most failures were observed early after implantation,i.e.,within six months.Insufficient patient selection at the end of the screening phase is an unlikely explanation for this secondary failure rate.First,the criteria chosen to qualify patients for surgical implantation were the same as those used in other studies,16and second,we had a similar

Table4.

Comparison of Patients_Characteristics Before Stimulation Between the Success and Failure Group After Implantation

Success(n=20)Failures(n=9)P Value Age(yr)56.2T10.748.3T11.90.06 Male/female ratio2/181/80.99 Previous pelvic surgeries for FI(no.of patients)340.2 Duration of FI(mo)49.6T68.860.5T88.90.9 Active/passive/mixed FI11/3/64/3/20.1 Bowel diaries

No.of stools/week14.3T8.315.8T11.90.8 FI episodes/week 4.9T3.7 6.5T6.20.9 Urgency episodes/week7.9T5.613T18.30.7 Cleveland Clinic score14.3T2.914.1T3.0.7 FIQL score(n=14)(n=8)

Lifestyle2T0.9 1.7T0.90.5 Coping 1.5T0.6 1.7T0.60.6 Depression 2.2T0.9 2.5T0.90.6 Embarrassment 1.4T0.6 1.5T0.70.7

FI=fecal incontinence;FIQL=fecal incontinence quality of life.

Data are means T standard deviations unless otherwise indicated.

Vol.50,No.1SACRAL NERVE STIMULATION IN FECAL INCONTINENCE9

permanent implantation rate(57percent)than those usually reported.2In addition,these results are in agreement with urologic studies.4,5

Because of this unexplained early failure rate,the purpose of this study was to evaluate whether certain clinical variables and/or some anorectal manometric, neurophysiologic,or echographic results obtained before stimulation were associated with therapeutic success of the temporary or permanent stimulation. Our statistical analysis revealed age as the only single clinical parameter associated with success of the temporary stimulation.Nonresponders were signifi-cantly older than responders.Investigations and particularly neurophysiologic test outcomes did not correlate with the effect of temporary stimulation. Our results do not agree with a previous report, which showed that a normal anal sphincter electro-myography had a good positive predictive value for the outcome of the stimulation test.17Results were different after permanent implantation.According to our data,patients with a prolonged sacral reflex showed a better response to permanent stimulation than those with a normal reflex latency.In addition, patients with neurogenic anorectal dysfunction (mainly peripheral lesions,such as pudendal neu-ropathy)tended to respond better than patients in the other diagnostics groups.No other pretreatment clinical,manometric,electrophysiologic,or echo-graphic findings were associated with improvement after https://www.wendangku.net/doc/4116725372.html,rmation is lacking on the relative effectiveness of permanent sacral nerve stimulation for fecal incontinence from neurologic causes.Two studies,one by Rosen et al.18and the other by Jarrett et al.,19contained a majority of patients with fecal incontinence of neurologic origins and showed promising results in this indication. However,unlike our work,the main indication in these previous reports was incontinence of central (spinal lesion)and not peripheral neurologic origin. Although there is no specific study on patients with

Table5.

Comparison of Preimplantation Anorectal Manometry,Electrophysiologic Tests,and Endoanal Ultrasonography

Between the Success Group and Failure Group After Implantation

Success Failures P Value Anorectal manometry(n=20)(n=9)

Anal resting pressure(cm H2O)69.2T29.797.1T38.10.08 Maximum squeeze pressure

Amplitude(cm H20)46.8T47.840.4T31.90.9

Duration(sec)14.8T13.919.2T13.40.3 Threshold volume(ml)21.3T27.113.3T7.10.5

Constant sensation volume(ml)186.2T89.9149.4T50.90.4

Maximum tolerable volume(ml)237.4T93.4201.7T70.20.2 Endoanal ultrasonography

Internal anal sphincter3/171/80.99 Defect/no defect

Electrophysiologic tests

EMG

Normal/abnormal9/85/30.9 PNTML right

Normal/abnormal/abolished13/3/29/0/00.2

Latency(msec) 2.2T0.32T0.30.3 PNTML left

Normal/abnormal/abolished10/7/15/4/00.9

Latency(msec) 2.5T0.7 2.4T0.60.8 BCRL right

Normal/abnormal/abolished7/6/45/1/20.5

Latency(msec)52.3T16.845.7T15.20.5 BCRL left

Normal/abnormal/abolished5/8/46/1/10.08

Latency(msec)60.5T21.444.3T12.10.03 SEPPN

Normal/abnormal/abolished10/0/66/0/00.2 EMG=electromyography;PNTML=pudendal nerve terminal motor latency;BCRL=bulbocavernosus reflex latency; SEPPN=somatosensory evoked potentials of the pudendal nerve.

Data are means T standard deviations unless otherwise indicated.

10GUILLAUME ET AL Dis Colon Rectum,January2007

peripheral neurologic pathology,most of the studied patients had an intact sacral plexus and elicitable pudendal nerve latency on one or both sides.20 The results of our study suggest both that sacral nerve stimulation could be proposed in patients presenting fecal incontinence related to peripheral nerve lesions and that these patients would be better candidates for this treatment than others.Because of the small power of the statistical tests used,these preliminary results need to be confirmed by addi-tional studies that investigate perineum electrophys-iologic tests in further details,as indicators to predict sacral nerve stimulation outcome.The differences observed between factors related to success of temporary and permanent stimulation(i.e.,age, peripheral nerve lesion)suggested:1)that,as previously suggested,the mechanisms of action of these two types of stimulation may be not completely identical.21Unlike temporary stimulation,chronic stimulation may induce persistent changes through plasticity in the neuronal control mechanism of the central nervous system21;2)that it may be important to demonstrate the efficacy of temporary test stimu-lation to select the best candidates for sacral nerve stimulation,for example,by proposing systematic implantation in incontinent patients whatever the results of the test in a prospective study.

Despite the therapeutic escape observed in some patients,the success rate for fecal incontinence of 66percent,including a31percent cure at a median follow-up visit of12months remains remarkable in these difficult cases with no alternative other than more invasive procedures,such as artificial bowel sphincter and dynamic graciloplasty.However, sacral nerve stimulation must be compared with new therapeutics of fecal incontinence,such as the radiofrequency energy delivery to the anal canal22 and anal injection of biomaterials.23

To date,the use of sacral nerve stimulation has been limited.Because the technique is effective and as it becomes more widely accepted,more wide-spread use might be expected.2However,because of the percentage of secondary failures after implanta-tion and the cost of this treatment,candidates for this therapy should be selected more precisely.Our results suggest that patients with fecal incontinence from neurologic origins may be good candidates for sacral nerve stimulation.Further studies are needed to confirm the role of electrophysiologic tests as predictive factors of functional outcome with chronic stimulation.

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Validation of the French version of the Fecal Inconti-nence Quality-of-Life(FIQL)scale.Gastroenterol Clin Biol2004;28:562–8.

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Denis P.Results of sphincteroplasty in86patients with anal incontinence.Dis Colon Rectum2000;

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neuropathy and severity of incontinence but not presence of an anal sphincter defect may determine the response to biofeedback therapy in fecal inconti-nence.Dis Colon Rectum1999;42:762–9.

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tum lumbosacral plexopathy limited to autonomic and perineal manifestations:clinical and electrophysiologi-cal study of19patients.J Neurol Neurosurg Psychiatry 2000;68:771–3.

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nerve stimulation in patients with fecal and urinary incontinence.Dis Colon Rectum2001;44:779–89.

Vol.50,No.1SACRAL NERVE STIMULATION IN FECAL INCONTINENCE11

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in fecal incontinence:sacral nerve stimulation.Dis Colon Rectum2004;47:1720–8.

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12GUILLAUME ET AL Dis Colon Rectum,January2007

峄山碑及译文

《峄山碑》全文及译文《峄山碑》是秦始皇二十八年（公元前219年）东巡时所刻，下面是小编为大家带来的峄山碑全文及译文，欢迎阅读。碑文皇帝立国，维初在昔，嗣世称王讨伐乱逆，威动四极，武义直方戎臣奉诏，经时不久，灭六暴强廿有六年，上荐高号，孝道显明既献泰成，乃降专惠，亲巡远方登于绎山①，群臣从者，咸思攸长追念乱世，分土建邦，以开争理功战日作，流血于野，自泰古始世无万数，陀及五帝，莫能禁止廼今皇帝，壹家天下，兵不复起灾害灭除，黔首康定，利泽长久群臣诵略，刻此乐石，以箸经纪注：①绎山：指峄山。皇帝日：“金石刻尽，始皇帝所为也。今袭号而金石刻辞不称，始皇帝其于久远也。如后嗣为之者，不称成功盛德。”丞相臣斯、臣去疾，御史大夫臣德。昧死言，臣请具刻诏书，金石刻因明白矣。臣昧死请，制日可。注释：皇帝立国，维初在昔，嗣世称王（维是发语词，不翻。嗣世，一代代，继承。这三句，是一句话。）讨伐乱逆，威动四极，武义直方（武义直方，就相当于说正义战争。）戎臣奉诏，经时不久，灭六暴强（戎臣，就是带兵的将领。灭六暴强即诛灭六国。）廿有六年，上荐高号，孝道显明

（皇帝二十六年，公元前221年。群臣上表，请求秦王称皇帝号。就叫上荐高号。这个孝道，是说秦国各代国君，均有统一之志，始皇帝的统一，乃是完成祖先之道。）既献泰成，乃降专惠，亲巡远方（溥惠，尃惠。溥就是普。我用的书里面，百度百科里面，都错成了专字。既献泰成，乃降尃惠，亲巡远方。应该是这样子才对。既，就是完成了的意思。泰成，就是大成。完成了统一大业。普惠，把恩泽给了所有的人。寴车巛，就是亲巡。从车和从辵，都是表示动作的形符。坐车出巡，就是车巛。）登于绎山①，群臣从者，咸思攸长（登上峄山，大家都发起了怀古之悠情。）追念乱世，分土建邦，以开争理（过去是乱世，起因于分土建国，就是封建制。所以，大家才会去争斗。）功战日作，流血于野，自泰古始（功战就是攻战。自太古以来就是如此。）世无万数，，阤yi3及五帝，莫能禁止（无数代以来，到五帝时代，都不能禁止。阤，延续。）廼今皇帝，壹家天下，兵不复起（如今统一了，不再打仗了。）灾害灭除，黔首康定，利泽长久（黔首，就是百姓。）群臣诵略，刻此乐石，以箸经纪（诵略，因为皇帝的功德是说不完的，所以，大臣说的，只是大略。是为诵略。经纪，就是法度，秩序。）以上内容，是始皇帝的刻辞。下面，是秦二世的内容。上面的是四言诗。下面的，是散文了。皇帝曰：‘金石刻尽始皇帝所为也，令袭号而金石刻辞不称始皇帝。其于久远也，如后嗣为之者，不称成功盛德。丞相臣斯、臣去疾、御史大夫臣德昧死言：‘请具刻诏书，金石刻因明白矣。’臣昧死请。制曰：“可’。” 译文皇帝立国，维初在昔，嗣世称王讨伐乱逆，威动四极，武义直方戍臣奉诏，经时不久，灭六暴强

峄山碑释文

峄山碑释文皇帝立国，维初在昔，维是发语词，不翻。嗣世称王，一代代，继承。这三句，是一句话。讨伐乱逆，威动四极，武义直方。武义直方，就相当于说正义战争。我们的战争是正义的。我们作战的对象，是乱逆戎臣奉诏，经时不久，灭六暴强。戎臣，就是带兵的将领。诛灭六国。廿有六年，上荐高号，孝道显明。皇帝二十六年，公元前221年。群臣上表，请求秦王称皇帝号。就叫上荐高号。这个孝道，是说秦国各代国君，均有统一之志，始皇帝的统一，乃是完成祖先之道。既献泰成，乃降专惠，亲巡远方。溥惠，尃惠。溥就是普。我用的书里面，百度百科里面，都错成了专字。既献泰成，乃降尃惠，亲巡远方。应该是这样子才对。既，就是完成了的意思。泰成，就是大成。完成了统一大业。普惠，把恩泽给了所有的人。寴车巛，就是亲巡。从车和从辵，都是表示动作的形符。坐车出巡，就是车巛。登于峄山，群臣从者，咸思攸长。登上峄山，大家都发起了怀古之悠情。追念乱世，分土建邦，以开争理。过去是乱世，起因于分土建国，就是封建制。所以，大家才会去争斗。功战日作，流血于野，自泰古始。功战就是攻战。自太古以来就是如此。世无万数，陀及五帝，莫能禁止无数代以来，到五帝时代，都不能禁止。阤，延续。乃今皇帝，壹家天下，兵不复起如今统壹了，不再打仗了。灾害灭除，黔首康定，利泽长久黔首，就是百姓。群臣诵略，刻此乐石，以著经纪经纪，就是法度，秩序。

诵略，因为皇帝的功德是说不完的，所以，大臣说的，只是大略。是为诵略。以上内容，是始皇帝的刻辞。下面，是秦二世的内容。上面的是四言诗。下面的，是散文了。皇帝曰，金石刻尽始皇帝所为也，今袭号，而金石刻辞不称始皇帝，其于久远也。如后嗣为之者，不称成功盛德。丞相臣斯，这是李斯。臣去疾，此人据说是姓杜。御史大夫臣德，此人史传无载。左丞相，右丞相，御史大夫，是政府首脑。当时的官制，这三位均是宰相。当时的制度，是宰相负责制。可以开府。就是可以自己组成一个行政班子。人员由宰相任命。不通过皇帝。当时的宰相，权利是很大的。皇帝基本就是个国家象征。秦始皇很厉害，所以他能管事儿。到了二世，就不管事了。事全交给宰相处理。汉朝的皇帝，其实也是不太过问事情的。政务交给宰相处理。皇权，相权，在中国历史上，是皇权越来越大，相权越来越小。昧死言，臣请具刻诏书金石刻，因明白矣。臣昧死请。制曰，可。这是皇帝说的。皇帝说，可以。昧死言，就是冒着因冒犯皇帝而可能被处死的危险，来进言。这是一种大臣上书的格式。因为皇帝总是对的，皇帝即是圣人。你对他说话，可能就是错的。这个峄山刻石就讲完了。简单的，跟现代汉语没什么区别的词就不用讲了。其实在战国后期，所有的人，不论是哪国的百姓，都是希望统一的。春秋战国之际的所有思想家，其思想都是要求统一的。无论是儒，墨，老庄，都要求统一。社会整体的愿望就是统一，结束战争。所以，如果不是秦国政治比较急功近利，他完全可以是一个好的帝国。

峄山碑全文及译文

峄山碑全文及译文文件排版存档编号：[UYTR-OUPT28-KBNTL98-UYNN208]

（维是发语词，不翻。嗣世，一代代，继承。这三句，是一句话。）讨伐乱逆，威动四极，武义直方（武义直方，就相当于说正义战争。）戎臣奉诏，经时不久，灭六暴强（戎臣，就是带兵的将领。灭六暴强即诛灭六国。）廿有六年，上荐高号，孝道显明（皇帝二十六年，公元前221年。群臣上表，请求秦王称皇帝号。就叫上荐高号。这个孝道，是说秦国各代国君，均有统一之志，始皇帝的统一，乃是完成祖先之道。）既献泰成，乃降专惠，亲巡远方（溥惠，尃惠。溥就是普。我用的书里面，百度百科里面，都错成了专字。既献泰成，乃降尃惠，亲巡远方。应该是这样子才对。既，就是完成了的意思。泰成，就是大成。完成了统一大业。普惠，把恩泽给了所有的人。寴车巛，就是亲巡。从车和从辵，都是表示动作的形符。坐车出巡，就是车巛。）登于绎山①，群臣从者，咸思攸长（登上峄山，大家都发起了怀古之悠情。）追念乱世，分土建邦，以开争理（过去是乱世，起因于分土建国，就是封建制。所以，大家才会去争斗。）功战日作，流血于野，自泰古始（功战就是攻战。自太古以来就是如此。）世无万数，，阤yi3及五帝，莫能禁止（无数代以来，到五帝时代，都不能禁止。阤，延续。）廼今皇帝，壹家天下，兵不复起

姜夔《续书谱》原文、译文2

【原文】用笔用笔不欲太肥，肥则形浊；又不欲太瘦，瘦则形枯；不欲多露锋芒，露则意不持重；不欲深藏圭角，藏则体不精神；不欲上大下小，不欲左高右低，不欲前多后少。欧阳率更结体太拘，而用笔特备众美，虽小楷而翰墨洒落，追踵钟、王，来者不能及也。颜、柳结体既异古人，用笔复溺于一偏。予评二家为书法之一变，数百年间，人争效之，字画刚劲高明，固不为书法之无助，而魏、晋之风规，则扫地矣。然柳氏大字，偏旁清劲可喜，更为奇妙，近世亦有仿效之者，则浊俗不除，不足观。故知与其太肥，不若瘦硬也。【译文】用笔不要太肥，太肥了字形就浑浊；也不要太瘦，太瘦了字形就憔悴；不要多露锋芒，锋芒太露，字就不稳重；不要深藏棱角，不见棱角，字就没有精神；不要上面大，下面小；不要左边高，右边低；不要先占地位多，后占地位少。欧阳询的书法，结体虽太拘束，但用笔独具众美，就是小楷，笔墨也潇洒利落，上追钟王，后来人是谁也及不上他的。颜柳结体，既与古人不同，用笔又陷于偏执。我说这两家书派是书法的变体，几百年来，人们争相效学，固然其笔画的刚劲高明，对书法艺术的发展不能说毫无帮助，可是魏晋人的风格规模，究已扫地无遗。至柳氏的大字偏旁，清劲可喜，更为奇妙，近代也有效学的，那就免不了俗和浊，变得毫不可观，所以说字与其写得肥，还不如写得瘦些好。【解读】这一段主要讨论书法用笔的肥瘦问题。关于这一问题，古代书家多有讨论。所谓“古肥而今瘦”，常与“古质而今妍”对举。诗圣杜甫关于开元之前书法“书贵瘦硬”的判断，常被人误解为所有的书法都应该以瘦硬为上。杜甫在其论书诗《李潮八分小篆歌》中，写到：苍颉鸟迹既茫昧，字体变化如浮云。陈仓石鼓又已讹，大小二篆生八分。秦有李斯汉蔡邕，中间作者寂不闻。峄山之碑野火焚，枣木传刻肥失真。苦县光和尚骨立，书贵瘦硬方通神。……吴郡张颠夸草书，草书非古空雄壮。在杜甫看来，使用枣木传刻《峄山碑》而使其点画丰肥，坏了风气，书风不古。诗中对仓颉石鼓文、秦相李斯、东汉蔡邕书法的赞叹，对李潮“小篆逼秦相”的赞叹和对当时著名书家张旭“草书非古”的贬斥都反映出杜甫崇尚“瘦硬”的观念。杜甫的这种观念在论及初唐褚薛书风的时候更为突出，如《寄刘峡州伯华使君四十韵》云：“学并卢王敏，书偕禇薛能。”《发潭州》赞曰：“贾傅才未有，禇公书绝伦。”杜甫书贵瘦硬说，主要是就初唐书风而言。“书贵瘦硬”在作为他自己的审美概括的同时，也是初唐书风的真实写照。众所周知，初唐欧、虞、褚、薛四家、盛中唐颜真卿书风、中晚唐柳公权书风代表了唐楷演变三阶段。正如康有为所说：唐世书凡三变，唐初，欧、虞、褚、薛、王、陆，并辔叠轨，皆尚爽健。开元御宇，天下平乐，明皇极丰肥，故李北海、颜平原、苏灵芝辈并驱时主之好，皆宗肥厚。元和后沈传师柳公权出，矫肥厚之病，专尚清劲，然骨存肉削，天下病矣。从此角度来说，唐代书法史似乎可以看作肥瘦的演变史。这与姜夔的看法基

书法的故事｜秦始皇用他的字统一了中国文字!

书法的故事｜秦始皇用他的字统一了中国文字！书法的故事秦代刻石统一规范的小篆书法小篆的形成及其特点李斯小篆是秦代产生的规范篆书，与大篆（古文、籀文等）相对而言，也叫秦篆。在小篆这种新型字体形成的过程中，值得重视的历史人物是李斯。李斯（？—前208），楚上蔡（今属河南）人，秦朝丞相，书法家。据《太平广记》引《蒙恬笔经》载，公元前221年秦王政（秦始皇）统一中国后，丞相李斯上奏章说：“上古时所创制的大篆，在社会上还很通行，但这些大篆字体毕竟是远古时期的产物，很多人不认识。现在删略大篆中繁琐的笔画，选取复合字体中的一部分，加工改造，变成小篆。”他的建议得到秦始皇的恩准。于是，李斯等人以西周以来秦系文字为基础统一全国文字，并以新造的小篆作为学童启蒙的识字课本和推广应用的楷模，从此与先秦大篆相对而言的小篆就成了秦代的通行书体。李斯擅长书法，宦官赵高以下的官员，都佩服李斯创造小篆的才华。当时刻在名山、碑碣、印玺、铜人上的文字，都出自李斯的手笔。他在书秦望山记功石时，竟然说：“我死后五百三十年，当会有一个人接替我的书迹。”可见他在书法艺术上的自信心和自豪感。小篆有什么特点呢？与大篆相比，小篆的特点表现为：线条圆匀，结构统一定型，字形呈纵势长方。秦始皇留下的六处七篇刻石秦峄山刻石（五

代徐铉摹刻本）从书法发展上看，秦代以小篆光耀史册。而小篆又以秦始皇在位十二年间留下的六处七篇记功刻石文字最值得称道。这六处七篇刻石是：峄山刻石、泰山刻石、琅琊台刻石、之罘刻石、东观刻石（刻于之罘）、碣石刻石、会稽刻石。《史记·秦始皇本纪》载，秦始皇统一中国后，第三年（前219）即率大臣，浩浩荡荡东巡，宣扬其威德盛治，到峄山、泰山、琅琊山等处刻石，以歌颂其功业。第四年再东巡，在之罘山留下之罘刻石、东观刻石。过了三年再东巡至碣石，面对苍茫大海，他喜气洋洋不可一世，又立石颂德。第十年（前210），始皇南巡，至会稽，再刻石彪炳其伟业，愿江山千秋永固。这四次巡游，刻石六处，文章七篇。二世皇帝即位后下了一道诏书，命令在始皇帝所刻石上加刻一段文字，说明这是始皇帝所刻，使后世不疑。六处七篇刻石，据说都出自李斯手笔。其中东观刻石、碣石刻石，历代都无著录。之罘一刻，原石也早已散佚，欧阳修所得拓本，是二世皇帝加刻的诏书21字，原文付阙（见欧阳修《集古录跋尾》卷一）。传世仅见久已失真的宋代《汝帖》本13字，风格与其他刻本差别很大。因此宋代流传的秦始皇刻石拓本仅峄山、泰山、琅琊、会稽四种，称为“秦四山刻石”。秦峄山刻石拓本局部放大《峄山刻石》，又名《峄山碑》，为始皇东巡第一刻。其前段是秦始皇颂赞文，刻于秦始皇二十八年（前219）；后段是秦二世诏书，刻于秦二世元年（前209）。

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《会稽刻石》文言文原文阅读答案翻译注释作品原文皇帝休烈（1），平壹宇内，徳惠攸长（2）。卅有七年（3），寴?天下，周览远方。遂登会稽，宣省习俗（4），黔首齐庄（5）。群臣诵功，本原事迹，追道高明（6）。秦圣临国，始定刑名（7），显陈旧章。初平法式，审别职任，以立恒常。六王专倍（8），贪戾慠猛（9），率众自强。暴虐恣行，负力而骄，数动甲兵（10）。阴通间使，以事合从（11），行为辟方（12）。内饰诈谋，外来侵边，遂起祸殃。义威诛之，殄熄暴悖（13），乱贼灭亡。圣德广密，六合之中（14），被泽无疆。皇帝并宇，兼听万事，远近毕清。运理群物，考验事实，各载其名。贵贱并通，善否陈前（15），靡有隐情。饰省宣义（16），有子而嫁，倍死不贞。防隔内外，禁止淫佚，男女絜诚。夫为寄猳（17），杀之无罪，男秉义程（18）。妻为逃嫁，子不得母，咸化廉清。大治濯俗，天下承风，蒙被休经（19）。皆遵轨度，和安敦勉（20），莫不顺令。黔首修絜，人乐同则，嘉保太平。后敬奉法，常治无极，舆舟不倾。从臣诵烈，请刻此石，光陲休铭（21）。注释（1）休烈：盛美的事业。（2）攸：原作“修”，据严可均辑校《全秦文》卷一所收申屠駉重刻会稽碑拓本改。“攸”在此作语气助词。（3）卅：原作“三十”，据《全秦文》会稽碑拓本改。（4）省（xǐng）：明白。（5）黔首：战国时期及秦代对国民的称呼。

齐：肃敬。（6）道：原作“首”，据《全秦文》会稽碑拓本改。高明：指秦始皇的所作所为。（7）刑名：原本指形（事实）和名（名称）。先秦法家把“名”引申为法令、名份、言论，主张“审合刑名”，“循名责实”，以明赏罚。（8）六王：指楚、齐、燕、韩、魏、赵六国之王。专：独断专行。倍：通“背”。（9）慠（aò）：同“傲”。（10）甲兵：甲胄和武器。（11）合从：即合纵，战国后期纵横家提出的六国联合抗秦战略。（12）辟：同“僻”。方：通“旁”。辟方：不正当。（13）殄（tiǎn）熄：灭绝，扑灭。（14）六合：天地及四方。（15）否（pǐ）：恶。（16）饰：文饰。省：通“眚”，过失。（17）寄猳（jiā）：借给别家传种的公猪，比喻进入他人家中淫乱的男人。（18）秉：操持。义：礼仪容止。（19）休：美。（20）敦：督促。（21）陲：流传。作品译文皇帝创业美且盛，境内平定大一统，德泽恩惠长又长。始皇三十有七年，亲自出巡游天下，视察周遍到远方。于是登上会稽山，宣布教化树风尚，国民肃敬又端庄。臣子个个颂功德，寻根求原明事迹，追述往事赞秦皇。秦皇天圣做国君，始立法令正名实，明确公布旧规章。首先统一总法式，审别官职明任务，从此办事有恒常。六王专横背信义，贪心乖戾又凶猛，个个带头想逞强。随心所欲施暴虐，自恃军力太骄狂，屡次出兵动刀枪。暗中通使搞离间，串联合纵拒秦国，所作所为不正当。掩盖内心怀奸计，公然外来侵我疆，天下从此起祸殃。秦国正义威力强，

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姜夔《续书谱》原文、译文2

用笔不欲太肥，肥则形浊；又不欲太瘦，瘦则形枯；不欲多露锋芒，露则意不持重；不欲深藏圭角，藏则体不精神；不欲上大下小，不欲左高右低，不欲前多后少.欧阳率更结体太拘，而用笔特备众美，虽小楷而翰墨洒落，追踵钟、王，来者不能及也.颜、柳结体既异古人，用笔复溺于一偏.予评二家为书法之一变，数百年间，人争效之，字画刚劲高明，固不为书法之无助，而魏、晋之风规，则扫地矣.然柳氏大字，偏旁清劲可喜，更为奇妙，近世亦有仿效之者，则浊俗不除，不足观.故知与其太肥，不若瘦硬也. 【译文】用笔不要太肥，太肥了字形就浑浊；也不要太瘦，太瘦了字形就憔悴；不要多露锋芒，锋芒太露，字就不稳重；不要深藏棱角，不见棱角，字就没有精神；不要上面大，下面小；不要左边高，右边低；不要先占地位多，后占地位少.欧阳询地书法，结体虽太拘束，但用笔独具众美，就是小楷，笔墨也潇洒利落，上追钟王，后来人是谁也及不上他地.颜柳结体，既与古人不同，用笔又陷于偏执.我说这两家书派是书法地变体，几百年来，人们争相效学，固然其笔画地刚劲高明，对书法艺术地发展不能说毫无帮助，可是魏晋人地风格规模，究已扫地无遗.至柳氏地大字偏旁，清劲可喜，更为奇妙，近代也有效学地，那就免不了俗和浊，变得毫不可观，所以说字与其写得肥，还不如写得瘦些好. 文档来自于网络搜索【解读】这一段主要讨论书法用笔地肥瘦问题.关于这一问题，古代书家多有讨论.所谓“古肥而今瘦”，常与“古质而今妍”对举.诗圣杜甫关于开元之前书法“书贵瘦硬”地判断，常被人误解为所有地书法都应该以瘦硬为上.杜甫在其论书诗《李潮八分小篆歌》中，写到：文档来自于网络搜索苍颉鸟迹既茫昧，字体变化如浮云.陈仓石鼓又已讹，大小二篆生八分.秦有李斯汉蔡邕，中间作者寂不闻.峄山之碑野火焚，枣木传刻肥失真.苦县光和尚骨立，书贵瘦硬方通神.……吴郡张颠夸草书，草书非古空雄壮. 文档来自于网络搜索在杜甫看来，使用枣木传刻《峄山碑》而使其点画丰肥，坏了风气，书风不古.诗中对仓颉石鼓文、秦相李斯、东汉蔡邕书法地赞叹，对李潮“小篆逼秦相”地赞叹和对当时著名书家张旭“草书非古”地贬斥都反映出杜甫崇尚“瘦硬”地观念.杜甫地这种观念在论及初唐褚薛书风地时候更为突出，如《寄刘峡州伯华使君四十韵》云：“学并卢王敏，书偕禇薛能.”《发潭州》赞曰：“贾傅才未有，禇公书绝伦.”杜甫书贵瘦硬说，主要是就初唐书风而言.“书贵瘦硬”在作为他自己地审美概括地同时，也是初唐书风地真实写照.众所周知，初唐欧、虞、褚、薛四家、盛中唐颜真卿书风、中晚唐柳公权书风代表了唐楷演变三阶段.正如康有为所说：文档来自于网络搜索唐世书凡三变，唐初，欧、虞、褚、薛、王、陆，并辔叠轨，皆尚爽健.开元御宇，天下平乐，明皇极丰肥，故李北海、颜平原、苏灵芝辈并驱时主之好，皆宗肥厚.元和后沈传师柳公权出，矫肥厚之病，专尚清劲，然骨存肉削，天下病矣. 文档来自于网络搜索从此角度来说，唐代书法史似乎可以看作肥瘦地演变史.这与姜夔地看法基本一致.姜夔认为，欧阳询用笔极好，但颜又偏肥，柳又偏瘦，学颜柳者更将其缺点发挥，写颜更肥，学柳更瘦，“不足观”.这对于今天地书法学习无疑也有着作用.我们是否应该思考：唐楷诸家是否是书法入门地唯一选择？如何学习本来就已经偏肥或者偏瘦地颜体、柳体呢？在姜夔地辩证中，我们可以知道，肥瘦本身并无高下，只是不能太过，太肥则“形浊”，太瘦则“形枯”；藏露本身并无轩轾，只是不能过于偏执，太露则“不持重”，太藏则“不精神”；上下、左右、先后关系均需合理安排. 文档来自于网络搜索 [姜夔《续书谱》原文、译文与解读（）] 【原文】草书草书之体，如人坐卧行立，揖逊忿争，乘舟跃马，歌舞擗踊，一切变态，非苟然者.又

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一个无产阶级文化大革命的高潮，正在占世界人口1/4的社会主义中国兴起。在短短的几个月内，在党中央和毛主席的战斗号召下，亿万工农兵群众、广大革命干部和革命的知识分子，以毛泽东思想为武器，横扫盘踞在思想文化阵地上的大量牛鬼蛇神。其势如暴风骤雨，迅猛异常，打碎了多少年来剥削阶级强加在他们身上的精神枷锁，把所谓资产阶级的“专家”、“学者”、“权威”、“祖师爷”打得落花流水，使他们威风扫地。毛主席教导我们，在我国，在所有制的社会主义改造基本完成以后，阶级斗争并没有结束。“无产阶级和资产阶级之间的阶级斗争，各派政治力量之间的阶级斗争，无产阶级和资产阶级之间在意识形态方面的阶级斗争，是长时期的，曲折的，有时甚至是很激烈的。无产阶级要按照自己的世界观改造世界，资产阶级也要按照自己的世界观改造世界。在这一方面，社会主义和资本主义之间谁胜谁负的问题还没有真正解决。”我国解放16年以来无产阶级和资产阶级在意识形态领域内的阶级斗争，一直是十分激烈的。目前的社会主义文化大革命，正是这个斗争的继续发展。这场斗争是不可避免的。无产阶级和一切剥削阶级的意识形态是根本对立的，是不能和平共处的。无产阶级革命，是要消灭一切剥削阶级、消灭一切剥削制度的革命，是要逐步消灭工农之间、城乡之间、脑力劳动和体力劳动之间的差别的最彻底的革命，这不能不遇到剥削阶级最顽强的反抗。革命的根本问题是政权问题。上层建筑的各个领域，意识形态、宗教、艺术、法律、政权，最中心的是政权。有了政权，就有了一切。没有政权，就丧失一切。因此，无产阶级在夺取政权之后，无论有着怎样千头万绪的事，都永远不要忘记政权，不要忘记方向，不要失掉中心。忘记了政权，就是忘记了政治，忘记了马克思主义的

峄山碑全文及译文

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Sacral Nerve Stimulation

峄山碑及译文

峄山碑 释文

峄山碑全文及译文

姜夔《续书谱》原文、译文2

书法的故事｜秦始皇用他的字统一了中国文字!

峄山碑全文及译文修订稿

峄山碑及译文

《会稽刻石》文言文原文阅读答案翻译注释

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姜夔《续书谱》原文、译文2

横扫一切牛鬼蛇神》全文

峄山碑全文及译文

峄山碑释文