肾系内伤基础上外感病之一感冒的证治初探

【作者】 解红霞；

【导师】 姜良铎；

【作者基本信息】 北京中医药大学 ， 中医内科临床， 2010， 博士

【摘要】 肾系内伤基础上的外感是临床常见的疾病之一,属本虚之中又兼邪实范畴,临床常见,多发,较之单纯的外感,处理更为棘手。肾系内伤是指原有慢性肾脏疾病,如：原发性肾小球肾炎,肾病综合征,糖尿病肾病,高血压肾病,慢性肾功能不全等。肾系内伤基础上的外感是一种发生在这样的慢性肾系疾病基础之上,并有外感临床表现的整体疾病状态,而不是慢性肾脏疾病和外感的简单相加。因肾系疾病有其本身的临床特点,故而发生在其基础上的外感病也必然有其特殊性。本研究建立在导师外感病的内伤基础理论之上,探讨肾系内伤基础上外感的证治特点,并且总结导师运用外感病的内伤基础理论治疗肾系内伤基础上外感病的经验。本研究分为理论探讨、临床研究和结论三部分。一理论探讨肾系内伤基础上的外感是一种复杂的临床状态,既有外感的情况存在,又有肾系疾病内伤的情况存在,病因病机复杂,临床表现多样且病情多变。肾系疾病患者因其疾病特点影响,而表现出对外感病的易患性,其临床经过不同于其他外感病的一般规律而有其自身的特殊性。肾系疾病在发病初期,多仅表现为肾气亏虚,病久则阴阳失调,五脏俱损。脏腑功能失调,津液代谢障碍,气血运行受阻,三焦疏泄不利,易致痰浊瘀血内生,全身脉络瘀阻,气血失于流通,相关脏腑器官失去濡养而发生诸多变证。病变后期,阴阳俱虚,脾肾衰败,浊毒内停,危及生命。肾系内伤者外感发病后,整体病机发生变化,既不同于单纯的肾系内伤疾病,也不同于普通的感冒,而是在原有阴阳气血失调的基础上出现肺失宣肃,痰浊瘀血互阻于肺,在标有“肺卫失宣”,在本有“阴阳失调”。病理因素复杂多变,痰浊瘀血胶着难解,脏腑、三焦、经络、气血均不循常规、阻滞难通。肾系内伤患者外感时常表现出发病的不典型性和症状的不典型,病程中可见痰浊瘀血、三焦阻滞、疏泄不利等表现,瘀象贯穿始终,还有患者肝气受到影响而郁滞,使症状纷纭、证候更为复杂。大多患者不能用单一的证候类型概括其疾病特征。肾系内伤基础上外感病的辨证,需将脏腑辨证与三焦辨证相结合分析。从脏腑辨证来看,应分属肺、脾、肾三脏功能失常,若按照三焦辨证,则涉及上、中、下三焦,肺属上焦,脾属中焦,肾归下焦,其在脏腑辨证理论体系中的传变路径则可转换成上中下三焦之间的传变。肾系内伤疾病患者兼感外邪,证候复杂,症状累及多方面,常表里同病、虚实夹杂,病情较复杂,病势缠绵,常累及机体多个脏腑,在病机的把握上难度较大。在治疗上,既要补益肺脾肾三脏之虚,更要疏理三焦气机、通阳化气行水。这就要以三焦脏腑为切入点,运用和解少阳、疏利三焦的方法治疗,通过调整人体表里、内外状态的平衡,使气机条达,血脉通畅。二临床研究第一部分：有肾系内伤基础外感和无肾系内伤基础外感的前瞻性对照性研究1.病例来源临床收集2009年1月至2010年1月在姜良铎教授门诊、东直门医院肾病科病房及门诊就诊,符合慢性肾脏病诊断同时有急性上呼吸道感染的患者102例为观察组,同期收集在姜良铎教授门诊、东直门医院急诊、中日医院急诊就诊,符合急性上呼吸道感染,并能够按照性别、年龄与观察组进行1：1配比的患者102例为对照组Ⅰ。102例观察组患者中,来源于门诊者83人,来源于病房者19人。102例对照组Ⅰ患者中,来源于门诊者58人,来源于急诊者64人。各组男性35人,女性67人,男：女=1：1.9。2.两组患者外感季节的分布两组患者的外感病发病季节,以冬季最多,春季、秋季次之,夏季最少。说明寒邪和燥邪是肾系内伤基础上外感致病的主要因素。3.两组患者外感时体温的变化观察组患者体温无明显升高者64人,(占本组患者的62.75%),仅有27人(占本组患者的26.47%)体温在38℃以上；对照组Ⅰ患者体温无明显升高者34人,(占本组患者的33.33%),体温在38℃以上者有45人(占本组患者的44.12%)。4.两组患者外感病程的分布观察组患者外感病程以8-14天最多(50.98%),15-30天其次(34.31%),而≤7天(11.76%)和>30天(2.94%)相对较少。对照组Ⅰ患者外感病程以≤7天最多(57.84%),8-14天其次(40.20%),15-30天最少(1.96%),>30天者为O。5.两组患者外感前后肾功能的变化观察组患者外感发病72小时内和外感痊愈后肾功能均较外感发病前有明显降低,对照组Ⅰ患者外感发病前后肾功能无明显变化。6.两组患者外感前后伴随症状的变化观察组患者外感发病前临床症状多样,外感发病72小时内伴随症状进一步加重,外感病痊愈后伴随症状仍存在。对照组Ⅰ患者外感发病后偶有伴随症状,外感病痊愈后伴随症状大多能够消失。7.两组患者外感发病后舌象的变化观察组患者外感发病72小时内和外感病痊愈后内舌质均以暗(包括暗、暗红、暗淡、紫暗)为主,舌苔均以腻(包括白腻、黄腻)为主；对照组Ⅰ患者外感发病72小时内舌质以红为主,外感病痊愈后舌质以淡红为主,舌苔均以薄白、薄黄为主,8.两组患者外感发病前后脉象的变化观察组患者外感病前后单一脉象均以沉、细、弦为主；对照组Ⅰ患者单一脉象外感发病72小时内以浮、数、弦为主,外感病痊愈后以弦、和缓、细为主。9.两组患者外感证候的分布观察组患者外感病在卫表证上常伴有阳虚、阴虚、阴阳两虚、痰湿、瘀血或肝郁证候；对照组Ⅰ患者外感病多只有卫表证。第二部分：运用外感病的内伤基础理论治疗肾系内伤基础上外感病的疗效对比1.病例来源在观察组中,抽取39例经姜良铎教授中药治疗的患者为治疗组,同时抽取能够按照性别、年龄、外感发病前肾功能与治疗组进行1：1配比的未经姜良铎教授中药治疗的39例患者为对照组Ⅱ。治疗组患者均来源于姜良铎教授门诊,对照组Ⅱ患者来源于东直门医院肾病科病房者7人,来源于其它门诊者22人。各组男性13人,女性26人,男：女=1：2。2.治疗方法采用配比及自身前后对照研究。治疗组患者经导师运用外感病的内伤基础理论,结合患者自身状况,给予辨证中药汤剂治疗,治疗方案以中药汤剂为主；对照组Ⅱ患者未经导师中药汤剂治疗,其治疗方案以抗菌素及中成药治疗为主。3.两组患者外感病病程比较治疗组患者外感病病程8-14天者最多(66.67%),≤7天者其次(20.51%),>15天者最少(12.82%)；对照组Ⅱ患者外感病病程8-14天者最多(53.85%),≥15天者其次(38.46%),≤7天者最少(7.69%)。4.两组患者外感病前后肾功能情况比较治疗组和对照组Ⅱ两组患者外感前和外感发病72小时内肾功能均无差异,外感病痊愈后肾功能有显著差异,对照组Ⅱ患者的肾功能要明显低于治疗组。5.两组患者外感病前后伴随症状的变化比较外感发病72小时内,两组患者伴随症状积分相似,无显著差异；外感病痊愈后两组患者有多组伴随症状积分差异显著。经治疗后,治疗组患者多组伴随症状均有减轻,对照组Ⅱ患者伴随症状改善情况较差。6.两组患者用药比较治疗组患者经导师中药汤剂治疗,所用中药方剂以柴胡剂为主,根据用药频次统计,排在前30味的中药是：柴胡,黄芩,赤白芍,黄芪,桂枝,生甘草,知母,荆芥,姜半夏,防风,牛蒡子,党参,丹皮,白术,猪苓,熟大黄,女贞子,连翘,三七,瓜蒌,金银花,苏叶,仙鹤草,炒杏仁,菊花,当归,桑叶,丹参,地黄,枳壳实。对照组Ⅱ患者未经导师中药汤剂治疗,多使用抗菌素和中成药治疗,有一部分患者未服用任何药物。三结论1.肾系内伤基础上外感病机复杂多变,多表现为本虚标实之证,本虚为阳虚、阴虚、阴阳两虚,标实为痰湿、瘀血、肝郁。2.肾系内伤基础会使外感病病程延长,病势缠绵难愈,外感病也会加重原有肾系内伤疾病。3.三焦郁滞是肾系内伤基础上外感病的一个重要病机,治疗上应从三焦脏腑入手,疏利三焦,多用柴胡剂治疗,针对原有肾系内伤疾病,要注重补气活血,通阳化气利水,兼顾脾胃之能；针对外感之邪,选药宜无寒热偏重,药味轻灵之品。4.外感病的内伤基础理论是一种有效的临床中医理论,源于临床实践,既继承了辨证论治的精髓,又吸收了现代科学的新成果,实践证明它能有效地指导临床,因而值得推广应用。更多还原

【Abstract】 "External disease based on internal damage of the Kidney system" is one of the common clinical diseases and belongs to deficiency pattern complicated with excessive-pathogenic patthern category, which the treatment is more difficult than simple disease caused by exogenous pathogenic factors. Kidney internal injury includes the original kidney diseases, such as:primary glomerular nephritis, nephritic syndrome, diabetic nephropathy, hypertensive nephropathy, chronic renal insufficiency, etc. "External disease based on internal damage of the Kidney system" is a holistic pathologic status, which based on these set of chronic Kidney diseases with the exogenous symptoms, rather than simple addition of chronic kidney disease and exogenous. Kidney disease has its own clinical characteristics, so External diseases based on it have also its particularity. This research is establish on the theories of external diseases based on the internal injuries, and to investigate the pattern and treatment characteristics of on diseases of Kidney system, and also it concluded the experience of adviser’s clinical treatment method, on external disease based on internal damage of the Kidney system, by use of external diseases of the internal injuries theory.This paper is divided into three parts:theoretical discussion, clinical research and the conclusion.1 Theoretical discussionExternal disease based on internal damage of the Kidney system is a complicated clinical status which includes both the exogenous and the internal damage of the Kidney system with multiple etiological factors, pathogenesis and clinical manifestations. Because of the characteristics of Kidney disease, Patients are more vulnerable to exogenous pathogens attack, its clinical course different from other external diseases of the general principle and has its own special characteristics.In the early stage of kidney disease, mostly expressing on kidney deficiency, yin and yang imbalance in chronic disease, and all five organs damage. Dysfunctional in organs, body fluid metabolism disorders, blockage in qi and blood flow, flow or triple energizer interrupted, it prone to cause phlegm and stasis endogenous, systemic blood vessels stasis, qi and blood flow damaged in circulation, relevant zang-fu viscera loss its nutrient and complicated syndrome happened. In late stage, yin and yang deficiency, spleen and kidney decay, toxin stop inside, finally become life-threatening. Exogenous Kidney disease in the injured, the overall pathogenesis change is different from the simple internal injuries of Kidney disease, and it is also different from the common cold. It is original basis of yin and yang, qi and blood disorders, then lets to Lung disorder, phlegm and blood stasis block in the lung, which caused by "Lung and wei-qi impairment" and the root caused is "yin and yang imbalance". Pathological factors is complex and change easily, phlegm and blood stasis stalemate incomprehensible, zang-fu viscera, triple energizer, meridians, qi and blood are not in normal principle, blockage and difficult to hard to dredge.Patients with Kidney disease often show non-typical and atypical symptoms, In the course of disease, phlegm stasis, triple burner block and Negative catharsis can be seen, stasis is always existence. Liver stagnation can be effected, the symptoms becoming diverse and complex. It can not use a single type of general syndrome to sum up.Department of External disease based on internal damage of the Kidney system combine the Visceral Syndrome with Triple Burner Syndrome. In the Visceral Syndrome, it belongs to the lung, spleen and kidney, if in accordance with the triple burner syndrome, involves the upper, middle and lower triple burner. The transmission path in the Visceral Syndrome becomes the upper, middle and lower triple burner.Patients with Kidney disease and exogenous pathogens, symptoms are complex, multiple body organs will be involved and pathogenesis is difficult to hold. In treatment, it is necessary to benefit lung, spleen and kidney and reorganizing the triple burner. This requires to starting from triple burner organs, using reconciliation Shao Yang and Shu Li triple burner method, by adjusting the state of balance in human body, to make qi and blood smooth.2 Clinical researchPartⅠ:Forward-looking and Control of study between external disease based on internal damage of the Kidney system and external disease without internal damage of the Kidney system.1. Case Source102 observation group Patients are collected from January 2009 to January 2010 in Liang-duo Jiang Professor, Dongzhimen Hospital, Consistent with diagnosis of chronic kidney disease and Acute upper respiratory tract infection.102 control group I patients were collected in Liang-Duo Jiang Professor, Dongzhimen hospital emergency station, the Sino-Japanese hospital emergency station, consistent with acute upper respiratory tract infection, and can 1:1 ratio with observation group Patients according to gender and age.102 cases of observation group patients,83 were from out-patient,19 were from wards.102 cases of control groupⅠpatients,58 were from out-patient, and 64 were from emergency room. In each group, there were 35 male and 67 females, male:female= 1:1.9.2. Exogenous disease seasonal distribution of the two groups About two groups of exogenous disease season, the first was winter, spring and autumn followed, and the last was summer. Cold and dry evil are the main pathogenic factor.3. Temperature changes of two groups64 patients in the observation group had no significant increase in body temperature (accounting for 62.75% of patients in this group), only 27 people’s (accounting for 26.47% of patients in this group) temperature above 38℃; In the control group I,34 patients had significantly increase in body temperatures (accounting for 33.33%of patients in this group),45 people’s body temperature above 38℃(accounting for 44.12% of patients in this group).4. Exogenous disease course of two groupsPatients in the observation group with exogenous course of 8-14 days were most (50.98%), followed by 15-30 days (34.31%), and≤7 days (11.76%) and> 30 days (2.94%) were relatively least. Patients in the control group I with≤7天course were most (57.84%), followed by 8-14 days (40.20%),15-30 days at least (1.96%),> 30 days were 0.5. Changes in renal function between two groups before and after the exogenous diseaseAfter the exogenous disease, renal function in the observation group becomes lower. But in control group I was no significant changes.6. Changes of symptoms between the two groups before and after the exogenous diseaseBefore the exogenous disease, symptoms in the observation group patients were varied, these symptoms were further increase among the exogenous disease, after the exogenous disease, symptoms were still exists. In control group I, some symptoms can appear among the exogenous disease, but after the exogenous disease can disappear.7. Changes in tongue of the two groupsPatients tongue in the observation group are dark-based (including the dark, dark, dim, dark purple), tongue are tired of (including greasy, yellow and greasy) dominated; Patients tongue in control group I were red-based within 72 hours, after external disease was treatment, mainly with pink, white tongue coating are thin, thin yellow-based,8. Changes in pulse of the two groups The single pulse in the observation group are heavy, thin, string-based; in the control group I are floating, number and string-based within 72 hours, after external disease was treatment were string, moderate and mainly fine.9. Stasis in both groupsIn addition to the evidence of external diseases, deficiency of yang, deficiency of yin, deficiency of yang and yin, phlegm, blood stasis and stagnation of liver are existence in the observation group; But in the control group I, only the evidence of external diseases can be seen.PartⅡ:Contrasting between external disease based on internal damage of the Kidney system and external disease without internal damage of the Kidney system by using theory of external diseases based on internal damage.1. Case SourceIn the observation group,39 treatment group cases collected from liang-Duo Jiang Professor’s out by treating with traditional Chinese medicine,39 control groupⅡcases were without Liang-duo Jiang Professor treatment, but can 1:1 ratio with treatment group Patients according to gender, age and renal function. Treatment group were all from Liang-duo Jiang Professor Patient, in the control groupⅡ7 patients were from Dongzhimen Hospital Nephrology wards,22 were from other clinics, In each group, there were 13 males and 26 females, male:female=1:2.2. TreatmentUsing study of self-control and compared with oneself before and after. Treatment group treatment by using theory of external diseases based on internal damage, combined with patient’s own situation, different decoction was given different patient; control groupⅡwithout a mentor Decoction of patients, their treatment protocols were antibiotics and proprietary therapy.3. Exogenous disease course of two groupsExogenous disease course of patients with 8-14 days was maximum (66.67%),≤7 days followed (20.51%),≥15 days was the least (12.82%); control groupⅡexogenous disease course in patients with 8-14 days was maximum of (53.85%),≥15 days followed (38.46%),≤7 days was the least (7.69%).4. Changes in renal function between two groups before and after the exogenous disease Renal function had no difference between treatment group and control groupⅡbefore and within 72 hours of external disease, it changed after external disease. And renal function becomes lower in the control groupⅡ.5. Changes of symptoms between the two groups before and after the exogenous diseaseWithin 72 hours, two groups of patients with similar symptoms scores, no significant difference; after external disease, patients were more significant differences associated with symptom score. After treatment, the treatment groups of patients with symptoms were alleviated, the control groupⅡpatients with poor symptom improvement.6. Comparison of two groups of patients with medicationTreatment group are treatment by using theory of external diseases based on internal damage, Chinese herbal formula used by the main agent, according to agent frequency statistics, the top 30 flavor of traditional Chinese medicine are:Bupleurum, Scutellaria root, red peony root, astragalus, Guizhi, raw licorice, Zhimu, CARVACROL, Jiang Ban Xia, wind, Arctium, Codonopsis, paeonol, Atractylodes, Polyporus, Cooked rhubarb, Ligustrum lucidum, forsythia, san qi, Trichosanthes, honeysuckle, mulberry leaves, crane grass, fried almonds, Chrysanthemum, Angelica, mulberry leaf, red sage root, Rehmannia, Fructus real.Control groupⅡwithout a mentor Decoction of patients, greater use of antibiotics and traditional Chinese medicine, some patients were not taking any medications.3 Conclusion1. Pathogenesis of External disease based on internal damage of the Kidney system is complex, deficiency of yang, deficiency of yin, deficiency of yin and yang are the virtual, phlegm, blood stasis, stagnation are also existence.2. Internal damage of the Kidney system will extend external diseases, disease potential will hard to be cured, external diseases will increase the existing Department of internal injury of renal disease.3. Sanjiao stagnation is an important pathogenesis in external disease based on internal damage of the Kidney system, treatment should start organs triple burner, Bupleurum are used usually, About internal injury of kidney disease, we should pay attention to benefit qi and make xue live, Li Yang of gas water, spleen and stomach should be taken into account; Against the evil of exogenous drug selection and emphasis should not cold and heat. 4. The theory of external diseases based on internal damage is effective clinical medicine; it comes from clinical practice, not only inherits the essence of the diagnosis and therapy, but also absorbed the new achievements of modern science. It has been proved effectively and can guide Clinical, therefore should be widely applied.更多还原