基于《伤寒论》中寒热错杂证的辨治方法探讨艾滋病的辨治思路

【作者】 程五中；

【导师】 陈明；

【作者基本信息】 北京中医药大学 ， 中医临床基础， 2010， 博士

【摘要】 AIDS全称为获得性免疫缺陷综合征(acquired immunodeficiency syndrome)。是由人类免疫缺陷病毒(human immunodeficiency virus, HIV)引起的一种传染病。HIV/AIDS是上世纪80年代初新发现的疾病,短短28年,它夺走了千百万人的生命,并对社会和经济的发展造成了极大的阻碍,被称为“超级癌症”,“世纪瘟疫”。由于多种原因,到目前为止尚未总结出其证候分布和病机演变规律,直接影响了对该病的辨证论治和疗效评价。因此有必要根据中医学整体观和辨证论治的思想、运用临床流行病学、循证医学、统计学等方法,开展HIV/AIDS中医证候研究,收集HIV/AIDS的症状特点及证候特征,归纳出其基本中医证候类型,揭示艾滋病病机演变规律,将为中医药辨证治疗艾滋病以及开展其它相关研究提供证候学依据,同时会提高中医治疗HIV/AIDS的疗效。从检索到的文献和本课题已经进行的临床流行病学调查来看,HIV/AIDS患者在一定阶段的临床表现和病机与《伤寒论》寒热错杂证的临床表现和病机多有相似,所以借鉴《伤寒论》中寒热错杂方证的辨证论治的方法将会提高HIV/AIDS患者的治疗水平。研究目的1、探讨《伤寒论》寒热错杂方证的形成原因,症状特点,病机特征,组方思路,方药功用。2、通过大样本的临床流行病学调查,根据艾滋病的临床表现,探讨其病因病机。3、从寒热错杂证的辨证论治思路来探讨艾滋病的中医辨证治疗思路。研究方法1.通过文献检索来探讨《伤寒论》寒热错杂方证的形成原因,症状特点,病机特征,组方思路,方药功用。2.本研究采用多阶段分层整群随机抽样的方法,自2005年10月起在某省四地区,随机抽取HIV/AIDS患者和同地区的非HIV感染人群作为研究对象。收集HIV/AIDS患者和对照组的中医四诊信息和辨证结果。采用SPSS 13.0, Lisrel8.51等软件进行统计学处理与分析。数据采用X2检验等方法进行统计学推断,在单因素分析的基础上采用结构方程模型的方法探讨艾滋病中医症状与证候之间的相关性。结果1.寒热错杂方证的研究结果通过对《伤寒论》中寒热错杂证和历代寒热错杂证病案的分析,得出寒热错杂证发病的主要病位是中焦脾胃,与肝胆疏泄失职关系密切,多数病程较长并伴有正气不足的病机特征。寒热错杂证的主要临床表现多为肢厥,腹痛、胃痛、心下痞、饥不欲食、脐腹动悸、久利和大便长期异常等症状。脉弦、舌苔黄腻是寒热错杂证的特征性舌脉。2.HIV/AIDS患者中医证候调查结果本次调查共收集到HIV/AIDS患者组1279例合格病例、对照组778例合格病例,结果如下：2.1症状调查中HIV/AIDS患者组出现频率大于20%症状有25种。分别是属于脾胃系统的有口味,胃脘满痛,纳呆食少,呕恶,腹泻；属于肺系统的有咳嗽咳痰,喘息,咽喉病变；属于心系统的有心慌心悸,胸闷胸痛,神志异常；属于肝系统的头晕；属于肾系统的有小便异常；属于全身症状群的有神疲,乏力,躯体异常,恶寒,口渴,睡眠异常,汗出异常,头痛,皮肤瘙痒,脱发,消廋,淋巴结肿大。经统计学分析,患者组的25种症状与对照组比较均差异有统计学意义。2.2脉象患者组共出现175种脉象。前十位依次为沉细,沉,沉细弱,弦滑,数细,滑,弦细,沉数细,数滑,沉细虚,占全体脉象50.12%。对照组出现108种脉象。前十位依次为沉细,沉,平,弦细,滑,弦滑,沉弱,弦,沉弦,细,占全体脉象54.24%。经统计学分析,患者组脉沉、沉细弱、数细、弦细、滑数、沉细虚与对照组比较差异有统计学意义。2.3舌色患者组共出现26种舌色。前五位依次为淡红,红,暗,淡白,红暗,占总体舌象的91.23%。对照组出现18种舌色。前五位依次为淡红,红,淡白,暗,红暗,占总体舌象的95.67%。经统计分析,患者组舌色淡红、红、淡白与对照组相比差异有统计学意义。2.4舌形患者组共出现24种舌形,前五位依次为正常,胖大,薄廋,胖大齿痕,齿痕,占总体舌形的91.87%。对照组出现15种舌形。前五位依次为正常,胖大,薄廋,齿痕,胖大齿痕,占总体舌形的96.53%。经统计学分析,患者组舌形正常、胖大、胖大齿痕、齿痕与对照组比较差异有统计学意义。2.5舌态患者组出现了13例萎软舌、5例震颤舌,对照组没有出现,且两组比较差异有统计学意义。2.6舌下脉络患者组共出现11种舌下脉络。前五位依次为正常,粗胀,短缩,青紫,曲张,占总体98.59%。对照组出现8种舌下脉络。前五位依次为正常,短缩,粗胀,青紫,曲张,占总体99.11%。经统计学分析,患者组正常、粗胀、短缩、青紫、曲张与对照比较差异有统计学意义。2.7苔质患者组共出现42种苔质。前六位依次为薄,厚腻,薄腻,厚,腻,薄滑润,占总体85.14%。对照组共出现25种苔质。前六位依次为薄,厚腻,薄腻,薄滑润,腻,厚,占总体91.90%。经统计学分析,患者组舌苔薄、厚腻、厚、薄滑润与对照组比较,差异有统计学意义。2.8苔色患者组共出现11种苔色。前3位依次为白,黄,黄白相兼,占总体98.12%。对照组共出现9种。前3位依次白,黄,黄白相兼,占总体98.71%。经统计学分析,患者组苔色白、黄、黄白相兼与对照组比较,差异有统计学意义2.9证候患者组共出现123种证候。前十位依次为湿热内蕴兼脾气虚弱,湿热内蕴兼肺脾气虚,湿热内蕴兼气阴两虚,湿热内蕴,脾气虚弱,痰热蕴肺,湿热蕴毒兼脾气虚弱,湿热蕴毒兼肺脾气虚,湿热内蕴兼气血亏虚,肝郁气滞兼脾气虚弱,占总体证候的53.01%。对照组出现69种证候。前8位依次为正常,脾气虚弱,湿热内蕴,湿热内蕴兼脾气虚弱,肺脾气虚,肝郁气滞,肝郁气滞兼脾气虚弱,气阴两虚,占总体证候的72.10%。经统计学分析,患者组湿热内蕴兼脾气虚弱、湿热内蕴兼肺脾气虚、湿热内蕴兼气阴两虚、脾气虚弱、湿热蕴毒兼脾气虚弱、湿热蕴毒兼肺脾气虚、湿热内蕴兼气血亏虚、正常与对照组差异有统计学意义。2.10症状与证候关系结构方程模型(Structural Equation Modeling, SEM)研究结论艾滋病是感受HIV病邪所致的一种复杂病变,它不同于普通疫邪从口鼻感受,而是通过表络损伤入侵人体。发病后兼有外感和内伤为病的两种特征,其病程长,病情多变,病势深重,病变可涉及五脏六腑。病性上艾滋病既不是单纯伏气温病,也不是单纯内伤虚劳、癥瘕、恶核,而是一种正虚邪恋、虚实寒热错杂的复杂病变,有其独特的病机和传变规律。依据艾滋病患者的临床表现并结合艾滋病中医证候结构方程模型的分析结论得出,艾滋病的临床证候多见寒热虚实错杂证,病机关键是中焦脾胃失调、和湿热为患同时并存,常兼有肝失疏泄之证,并有湿热蕴结日久化毒的趋势,同时伴有气血津液亏损的特点。虚证以脾肺不足为主。实邪多为痰湿、热毒、血瘀。从上述结论来看,仲景所开创的辛开苦降方法可以适用于艾滋病一定阶段的辨证治疗。本次调查是基于一个省内艾滋病患者横断面调查,并且调查中收集到的艾滋病急性感染者和危重患者的病例很少,所以得出的症状群归类、证候分布,病机特点带有局限性。是否符合全国其它地区艾滋病的特点,以及本次所得出艾滋病中医证候结构方程模型是否能经得住其它地区艾滋病中医证候数据的检验,还有所提出的艾滋病治疗思路的疗效都有待以后作进一步深入研究。更多还原

【Abstract】 AIDS, with full name of Acquired Immunodeficiency Syndrome, is a kind of infectious disease caused by the Human Immunodeficiency Virus-HIV. From the period of early 1980s, when HIV/AIDS was discovered, until the present-nearly 28 years-it ha killed thousands of people. And this causes great troubles in social and economic development. So it is called a "Supercancer " or a "Plague of the Century"For many reasons, up to now we haven’t clearly categorized the syndrome, or the pathogenesis and evolution of AIDS. This has a direct and harmful influence on treatments, according to the differentiation of the syndrome, and evaluation of the effect of different therapies. So it is necessary for us to study HIV/AIDS syndrome from the perspective of traditional Chinese medicine(TCM). To collect the symptom characteristics and syndrome features by the way of clinic epidemiology while guided by the chief concept of TCM--wholism and treatment according to syndrome differentiation, evidence based medicine as well as statistic etc in order to identify syndrome type, and to discover the pathogenesis evolution law of HIV/AIDS, which will provide foundation for TCM treatment according to the syndrome and other related research. It will also improve the therapeutic Effect of HIV/AIDS by the way of TCM.Concluding from the retrieval documents/articles and the study of Clinical Epidemiological, the clinic manifestation and pathogenesis of HIV/AIDS is mainly same with the cold-heat complicated syndrome described in "ShangHanLun". So draw lessons from the trgeatment according to cold-heat complicated syndrome described in the "ShangHanLun", it will elevate the level of HIV/AIDS infection.ObjectiveTo explore the causes, syndrome characteristic, pathogenesis features, formulas of prescription and the function of prescription drugs of cold-heat complicated syndrome described in the "ShangHanLun"To explore the pathogenesis and syndromes of HIV/AIDS by means of a clinical epidemiological survey, with a large sample and clinic manifestation.To discuss the TCM treatment according to syndrome of HIV/AIDS from the view of formulas of prescription of cold-heat complicated syndrome.MethodsTo probe into the causes, syndrome characteristic, pathogenesis features, the formulas of prescription and the function of prescription drugs of cold-heat complicated syndrome described in the "Treatise on Exogenous Febrile Disease" by the way of study the retrieval documents/articles.HIV/AIDS infection and non-HIV/AIDS infection were selected randomly by Multistage-stratified-cluster sampling method from Oct.2005 in xx province. To gather the details of HIV/AIDS infection and the information which acquired through the four diagnostic methods as well as the final syndromes were recorded into the database which was established by Epidata3.01 software. Then do statistic data processing and analysis by software of SPSS 13.0, Lisre18.51.AdoptX2 inspection to deducing a statistic conclusion, and use SEM (structure equation model) in the research to explore the relationship between TCM symptom and syndrome of HIV/AIDS disease based on the Univariate analysis.Results1. Study results deduced from the analysis of cold-heat complicated syndrome in "ShangHanLun"Conclusion from the above mentioned cold-heat complicated syndrome described in "ShangHanLun" and the various practical case of cold-heat complicated syndrome:Features of cold-heat complicated syndrome were disordered of middle energizer of spleen and stomach.close realation of liver-gallbladder free coursing,long course of disease and deficiency of Zheng-qi. The main clinic manifestations are cold limbs, abdominalgia. stomachache, gastric stuffiness, anorexia, contracture of the umbilicus, chronic diarrhea and long-term of disorde diarrhea etc Syndromes. Stringy pulse coated yellow fur are the characters of tongue and pulse of cold-heat complicated syndrome. 2 Results of traditional chinese medicine(TCM) syndrome of HIV/AIDS patients2.1 Researcher had adopted of 1323 HIV/AIDS patients and 778 uninfected HIV control group. Results were as follows.The symptom frequency above 20% have 25 kinds in HIV/AIDS groups. Taste in the mouth,stomach duct pain,torpid intake,nausea and diarrhea were belong of spleen-stomach system.Cough.phlegm.dyspnea and throat-illness were belong of lung-system. Flusteredness-palpitations,chest pain and spirit disorder were belong of heart-system. Dizzyiness was belong of liver-system. spontaneous urination disorder was belong of kidney. lassitude of spirit, lack of strength, contracture of the body, aversion to cold, thirst, contracture of sleep, contracture of sweating, headache, generalized itching,lose hair,emaciated and enlargementlymph-knot were belong of the whole body symptom. There was difference between the two group on the 25 kinds of symptoms.2.2 Palse condition There were 175 kinds of palse condition in HIV/AIDS group.sunken_fine pulse,sunken pulse,sunken_fine weak pulse,string_like slipprey pulse,rapid_fine pulse, slipprey pulse, string_like fine pulse, sunken rapid_fine pulse, slipprey rapid pulse and sunken_fine vacuous pulse rounded off the top ten. There were 108 kinds of palse conditions in the controlling group. sunken_fine pulse, sunken pulse, regular, string_like fine pulse, slipprey pulse,string_like slipprey pulse, sunken_ weak pulse, string_like, sunken string_like pulse and fine pulse rounded off the top ten. There was difference between the two group on the sunken pulse, sunken_fine weak pulse, rapid_fine pulse, string_like fine pulse, slipprey rapid_fine and sunken_fine vacuous pulse.2.3Tongue colorThere were 26 kinds of tongue color tongue color in HIV/AIDS group. pale red tongue, blue tongue,pale tongue and red blue tongue rounded off the top five.There were 18 kinds of tongue color in the controlling group. pale red tongue, blue tongue and red blue tongue rounded off the top five. There was difference between the two group on the pale red tongue, red tongue and pale tongue.2.4 Form of the tongueThere were 24 kinds of form of the tongue in HIV/AIDS group. normal tongue, enlarged tongue, thin tongue, enlarged teeth-marked tongue and teeth-marked tongue rounded off the top five. There were 15 kinds of form of the tongue in the controlling group. normal tongue, enlarged tongue, thin tongue, teeth-marked tongue and enlarged teeth-marked tongue rounded off the top five. There was difference between the two group on normal tongue, enlarged tongue, enlarged teeth-marked tongue and teeth-marked tongue.2.5Motility of the tongueThere were 13 cases of limp wilting tongue and 5 cases of trembling tongue in HIV/AIDS group. There was not case in the controlling group. There was difference between the two group.2.6Sublingual collateral vesselsThere were 11 kinds of sublingual collateral vessels in HIV/AIDS group. Normal.thick.thin. blue purple and winding of sublingual collateral vessels rounded off the top five. There were 8 kinds of sublingual collateral vessels in the controlling group. There was difference between the two group on Normal.thick.thin, blue purple and winding of sublingual collateral vessels.2.7Texture of fur There were 42 kinds of texture of furin in HIV/AIDS group. Thin fur, thick slimy fur.thin slimy fur.thick fur.slimy fur and thin slipper moist fur rounded off the top six.There were 25 kinds of texture of fur in the controlling group, thin fur,thick slimy fur,thin slimy fur,thin slipper moist fur,slimy fur and thick fur rounded off the top six. There was difference between the two group on thin furthin fur,thick slimy fur, thick fur and thin slipper moist fur rounded off the top six. There was difference between the two group on Thin fur, thick slimy fur, thick fur and thin slipper moist fur.2.8 Fur colorThere were 11 kinds of fur color in HIV/AIDS group. white fur color, yellow fur color and white-yellow fur color rounded off the top three. There were 9 kinds of fur color in the controlling group. white fur color, yellow fur color and white-yellow fur color rounded off the top three. There was difference between the two group on white fur color, yellow fur color and white-yellow fur color.2.9 SyndromeThere were 123 kinds of syndromes in HIV/AIDS group. syndrome of internal obstruction of dampness-heat and spleen deficiency pattern, syndrome of internal obstruction of dampness-heat and spleen-lung deficiency pattern, syndrome of internal obstruction of dampness-heat and syndrome of dual deficiency of qi and yin, syndrome of internal obstruction of dampness-heat, spleen deficiency pattern, dampness-heat blocking the lung,syndrome of retained dampness-heat toxin and spleen deficiency pattern, syndrome of retained dampness-heat toxin and spleen-lung deficiency pattern, syndrome of internal obstruction of dampness-heat and syndrome of dual deficiency of qi and blood and Liver qi depression pattern and spleen deficiency pattern rounded off the top ten.There were 69 kinds of syndromes in the controlling group. Normal,spleen deficiency pattern,syndrome of internal obstruction of dampness-heat, syndrome of internal obstruction of dampness-heat and spleen deficiency pattern, spleen-lung deficiency pattern, Liver qi depression pattern, Liver qi depression pattern and spleen deficiency pattern, syndrome of dual deficiency of qi and yin rounded off the top eight. There was difference between the two group on syndrome of internal obstruction of dampness-heat and spleen deficiency pattern,syndrome of internal obstruction of dampness-heat and spleen-lung deficiency pattern. syndrome of internal obstruction of dampness-heat and syndrome of dual deficiency of qi and yin.spleen deficiency pattern, syndrome of retained dampness-heat toxin and spleen-lung deficiency pattern, syndrome of internal obstruction of dampness-heat and syndrome of dual deficiency of qi and blood and normal. 2.10 Syndrome and Structural Equation Modeling. SEMConclusionsFrom this Investigation and results of studies in the literature, the two features of the incidence of AIDS patients are exogenous and internal injuries, with long course, the variable condition, serious disease situation, the symptoms involve internal organs. AIDS is neither a simple V temperature disease, or purely internal injury consumptive, Zhengjia, evil nuclear, but a virtual cult love is false and true cold and heat mixed complex lesions. Mechanism of disease was unique on AIDS patients.Comprehensive AIDS clinical symptoms and tongue and pulse performance, AIDS stasis present mixed cold and heat, the key is hot and humid, additionally,spleen is weak, the long time of syndrome of internal obstruction of dampness-heat damage a healthy atmosphere, accompanied yin and yang loss of body fluid, qi and blood. Deficiency syndrome mainly present insufficient Yang gas of spleen and lung, involving the liver, kidney, heart, most of excess evil is wet and dirty, toxic heat, blood stasis. AIDS, often appearing mixture of cold and heat, can be created by using Xin Kai Ku Jiang method of Medical Saint Zhongjing, combined with AIDS pathogenic factors and characteristics of their own, different organs where the evil really different, of cutting and giving of treatment.The survey is based on a patient with AIDS, so the resulting symptoms grouping, syndrome classification, and pathogenesis have localized features. Whether Characteristics of the pathogenesis of AIDS equal with the rest, and the resulting AIDS TCM structural equation model is able to withstand the rest of AIDS TCM testing of data and the proposed treatment ways, which are needed to be studied in the future.更多还原