基于中医“四淫”、“八质”因素的外感病初期诊疗模式探讨

【作者】 董正平；

【导师】 肖相如；

【作者基本信息】 北京中医药大学 ， 中医临床基础， 2012， 博士

【摘要】 当前,外感病依然是严重影响人类健康与社会发展的疾病,外感病初期的正确辨治具有非常重要的现实意义。《内》、《难》以降,中医针对外感病初期的诊疗思路一直在变化、发展与丰富；然而,自古至今,外感病初期的误诊误治却时有发生。通过深入研究外感病初期诊疗以及误治的相关历史,本文发现,有两大因素在其中起着关键作用,这就是外邪与体质。首先,本文探讨了外邪与外感病初期的发病与诊疗。传统上认为,外邪主要包括六淫和疫疠之气(吴又可称之为“杂气”)。关于疫疠之气(或杂气),本文认为,该学说虽然有助于对瘟疫发病规律的深入阐释,但不能直接指导中医对瘟疫进行辨证施治。瘟疫的治疗仍然离不开中医传统的辨证,而通过辨证所求出来的、可以指导临床确立治法和方药的那个“因”,依然没能跳出六淫的范畴。关于六淫(风、寒、暑、湿、燥、火),本文主要做了以下两方面探讨：一、将外感病的病因从六淫简化为四淫,即寒、热、燥、湿四种外邪。本文认为有如下三方面理由：1.风邪或为一切外邪的总称,或为其他外邪的致病条件,而非独立的病因,所以可将它去除；2.暑邪的本质属性是“热”,所以六淫之“暑”可以用“热”来替代；3.火邪并非外感之邪,所以应将它去除。二、对传统上认为由风热外邪所导致的风热表证,以及与此相关的辛凉解表法、辛凉解表剂、辛凉解表药进行了深入探讨,认为：1.风热表证并非单纯的表证,其病机应该理解为：热邪犯肺为主,兼有寒邪束表(即肺热证兼有表寒证)。本文认为这种认识对于风热表证的辨证与治疗更有指导价值；2.辛凉解表应理解为“以清解肺热为主,兼以散寒解表”。通过这个思路,本文还对辛凉解表剂和辛凉解表药进行了认识上的深化。并以此为切入点,对“表证”的概念及其相关问题进行了规范。其次,本文探讨了体质与外感病初期的发病与诊疗。中医体质是指人体生命过程中,在先天禀赋和后天获得的基础上所形成的形态结构、生理功能和心理状态方面综合的、相对稳定的固有特质。本文认为,在外感病初期诊疗不断变化和发展的历史中,体质因素是贯穿于始终的一条“暗线”。它在外感病的发病与治疗过程中具有重要意义：1.在发病上,首先,不同体质的人容易感受的外邪也不同；此外,即使是感受同一种外邪,不同体质的人的发病倾向也不一样。2.在治疗上,兼顾患者体质往往能够达到较好的疗效；而忽视体质因素,则是外感病初期误治的一个重要原因。关于体质的分类,本文参考的是中华中医药学会2009年颁行的“中医体质分类与判定(ZYYXH/T157-2009)”标准。由于其中的“特禀质”无法直接指导中医确立治法和方药,所以,本文将与外感病初期发病与诊疗相关的体质类型从“九质”(平和质、气虚质、阳虚质、阴虚质、痰湿质、湿热质、气郁质、血瘀质、特禀质)简化为“八质”(“九质”减去“特禀质”)。最后,本文初步建立了“基于中医‘四淫’、‘八质’因素的外感病初期诊疗模式”本文以《黄帝内经》“正气存内,邪不可干”,“邪之所凑,其气必虚”,以及“虚邪之风,与其身形,两虚相得,乃客其形”为指导思想,以“四淫”(寒、热、燥、湿)和“八质”(平和质、气虚质、阳虚质、阴虚质、痰湿质、湿热质、气郁质、血瘀质)为相关因素,以“临床表现”、“证候分析”、“治法”、“方药”和“方药说明”为论述纲要,探讨了“八质”感受“四淫”之初的辨治规律。并提出了兼夹体质、兼夹外邪等问题以及相关的处理原则。在此基础上,初步建立了“基于中医‘四淫’、‘八质’因素的外感病初期诊疗模式”：一、流程简介：1.在平时,依据《中医体质分类与判定》“标准”(中华中医药学会2009年颁行版)对人群进行体质普查,建立体质档案；2.患者一旦出现外感病的症状,应尽早就医；3.医生通过查看患者体质档案了解其体质类型(“八质”之一,或是复合型体质)；4.医生根据患者当前的临床表现推断是感受了何种外邪(“四淫”之一,或是相兼为病)；5.综合分析其体质类型及所感外邪,参考“‘八质’感受‘四淫’之初的辨治”,进行“依质审因论治”。二、本模式的优势：1.在外感病的预防方面：由于本模式突出了体质因素在外感病发病过程中的意义,不同体质类型的人群可以有针对性地预防其易感外邪的侵袭；2.在外感病初期的诊断方面：本模式以外邪和体质为核心因素,不仅使外感病初期的证候诊断更加明晰,也避免了外感病病名诊断上的繁杂；3.在外感病初期的治疗方面：本模式以外邪和体质为核心因素,强调了内外因的相互作用,突出了内外兼顾的治疗思想,避免了既往在外感病初期的治疗上“多注重祛除外邪”的偏颇。通过该模式的建立,希望有助于中医对外感病初期的辨证和治疗。更多还原

【Abstract】 At present, exogenous diseases are still major health problems with serious impact on social development, therefore, correct pattern differentiation and treatment in its initial stage are of great significance. Since Huang Di Nei Jing (The Yellow Emperor’s Inner Classic) and Nan Jing (The Classic of Questioning), the treatment in the initial stage of exogenous diseases has been modified and enriched through ages. However, misdiagnosis and mistreatment in its initial stage happen occasionally ever since. In this thesis, deeply study on treatment and medical errors in initial stage of exogenous diseases was presented. It is revealed that two key factors dominate these processes, namely, external pathogen and constitution, respectively.To begin with, the relationship between external pathogen and onset of exogenous diseases as well as its treatment in its initial stage were discussed.Traditionally, the external pathogen includes six pathogenic factors and pestilence qi which is also called "miscellaneous qi" by Wu Youke (also named Wu Youxing (1582-1652), a famous Jiangsu Physician in the late Ming Dynasty, who has found a new doctrine of epidemic febrile diseases).In this thesis, the theory of pestilence qi or miscellaneous qi was thought to be useful for the explanation of how epidemic febrile diseases breaks out, however, it cannot directly guide the pattern differentiation and treatment. The epidemic treatment still depends largely on pattern differentiation in light of traditional Chinese medicine (TCM). The causes of disease which are derived from pattern differentiation and applied to guide therapeutic methods and prescriptions are still dominated by six pathogenic factors.As for six pathogenic factors, namely, wind, cold, summerheat, dampness, dryness and fire, were discussed in the following two aspects:1. These six pathogenic factors were simplified into four, namely, cold, heat, dryness and dampness. And three reasons are listed below.1) Wind is a general term that refers to all kinds of external pathogens but not a subordinate one, thus it could be eliminated; 2) The nature of summerheat is "heat", thus it could be replaced by "heat"; 3) Fire is not a kind of external pathogen, thus it was also deleted.2. Further analysis on wind-heat exterior pattern due to wind and heat pathogens were carried out, and related therapeutic methods, prescriptions as well as herbs to release exterior pathogens with pungent in flavor and cool in nature. The conclusions are summarized as below:1) The wind-heat exterior pattern is not simply a type of exterior pattern; its mechanism can be explained as follows:heat pathogen invades the lung, which is complicated with signs of wind-cold fettering the exterior (pattern of lung heat accompanied by exterior-cold). In this thesis, we believe that this mechanism has more value to the pattern differentiation and treatment of wind-heat exterior pattern.2) the therapeutic treatment of "Releasing exterior pathogens with pungent in flavor and cool in nature" should be understood as "clearing lung heat primarily and dispersing cold to release exterior concurrently". Based on these ideas, further understanding of prescriptions and herbs which can be used to release exterior with pungent in flavor and cool in nature were also discussed in this thesis.Next, the relationship between constitution and onset of exogenous diseases as well as its treatment in its initial stage were discussed.Constitution refers to the comprehensive characteristics of an individual, according to natural endowment and acquired after birth, which includes structural, functional and psychological characteristics, and are relatively stable.This thesis believed that constitution is a "covert factor" influencing the changes and development of the treatment in the initial stage of exogenous diseases. It is of great significance during the onset of exogenous diseases as well as its treatment in its initial stage as listed below:1).For the onset of exogenous diseases:different external pathogens tend to attack various constitutions; Also, even invaded by the same pathogen, different people of various constitutions present diverse signs and manifestations.2). For the treatment of exogenous diseases:taking constitution into consideration will always bring about expected therapeutic effects, while ignoring it will lead to mistreatment in initial stage of exogenous diseases.As for the classification of constitutions, this thesis refers to the "Classification and Determination of Constitution in TCMStandards" (ZYYXH/T157-2009) advocated by China Association of Chinese Medicine (CACM) in 2009. Clinically, special constitution is of little value in guiding therapeutic methods and prescriptions, therefore, it was not discussed in this thesis. Moreover, nine types of constitution was simplified into eight, namely, balanced yin-yang constitution, qi deficiency constitution, yang deficiency constitution, yin deficiency constitution, phlegm-dampness constitution, dampness-heat constitution, qi stagnation constitution and blood stasis constitution, respectively.Finally, based on four pathogenic factors and eight types of constitutions, a guideline for exogenous diseases in its initial stage was primarily established in this thesis.Ideas in Huang Di Nei Jing (The Yellow Emperor’s Inner Classic) were adhered to in this thesis, for instance,’’external pathogens cannot invade the body when there is sufficient healthy qi inside the body"; "the accumulation of pathogens indicates the deficiency of qi"; "the occurrence of disease must be caused by weakness of the body complicated by attack of external pathogens". Relevant factors involved in the discussion included four external pathogens (cold, heat, dryness and dampness) and eight types of constitutions (balanced yin-yang constitution, qi deficiency constitution, yang deficiency constitution, yin deficiency constitution, phlegm-dampness constitution, dampness-heat constitution, qi stagnation constitution and blood stasis constitution). Clinical signs, pattern analysis, therapeutic methods, prescriptions and herbs as well as the prescription drug instructions were discussed in this thesis as the outline. The rules of pattern differentiation and treatment were expounded when eight types of constitutions encounter with four external pathogens. Also, mingled constitution and external pathogen were discussed as well as related disposal principles.Based on all discussed above, a primary guideline for exogenous diseases in its initial stage upon four pathogenic factors and eight types of constitutions was carried out in this thesis.1. Process introduction:1.1 According to "Classification and Determination of Constitution in TCM Standards" (ZYYXH/T157-2009), we make an investigation on population constitution, and establish constitution record;1.2 The patients are willing to receive TCM therapy in the initial stage of exogenous diseases;1.3 The Physician will get a general idea of the patient’s constitution by checking out his constitution record, (either one of the eight types of constitutions, or composite type);1.4 Next, the physician will deduce what kind of exogenous pathogen the patient receive based on clinical manifestation.(either one of four pathogenic factors, or composite type);1.5 Finally, a Comprehensive analysis on external pathogen and constitution is carried out, according to "four pathogenic factors" invading "eight types of constitutions" in its initial stage, and pattern differentiation in light of traditional Chinese medicine (TCM) as well as external pathogen and constitution.2. The advantage of this guideline:2.1 On the prevention of exogenous diseases:Since this guideline places emphasis on constitution factor for the onset of exogenous diseases, therefore, people with different constitutional types could prevent the exogenous pathogen’s invasion accordingly.2.2 On the diagnosis of exogenous diseases in its initial stage:This guideline takes the external pathogen and constitution as the core, which not only clarify the diagnosis on patterns of exogenous diseases, but also avoid the complication on names of exogenous diseases.2.3 On the treatment of exogenous diseases in its initial stage:This guideline places the external pathogen and constitution as the center, which focus on the interaction between internal and external factors, highlight the idea of treatment on both the exterior and interior, therefore, can avoid the bias of traditional treatment of "focusing on the exterior" for the exogenous diseases in its initial stage.The establishment of this guideline is hoped to provide assistance for pattern differentiation and treatment in initial stage of exogenous diseases.更多还原