【作者】 汪敬超；

【导师】 汪悦；

【作者基本信息】 南京中医药大学 ， 中医内科学， 2009， 博士

【摘要】 本课题旨在通过对相关文献进行整理和归纳总结,并对200例类风湿性关节炎(RA)病例进行全面、系统的收集和分析,从而探讨RA中医证型特征、辨证用药规律,为今后的临床、科研提供参考依据。第一部分理论研究【目的与方法】:收集古今相关文献,系统总结归纳RA疾病范畴、病因病机、临床特征、辨证用药等概况。【结论】:RA属于中医学“痹证”范畴,又因本病可损及多系统,故又可将其称为“历节”、“白虎历节”、“鹤膝风”、“鼓槌风”、“顽痹”、“尫痹”等。正虚、邪侵、痰瘀是RA发生、发展及转归过程中的三个重要环节。发病之初,正气未伤,邪气痹阻经络,以邪实为主。日久,风寒湿热之邪留注经脉关节,影响气血津液运行,或病久肝肾亏虚,气血不足,使气血津液运行无力,导致痰瘀痹阻。若风寒湿热之邪经久不去,损伤正气,此时邪未尽而正已伤,呈虚实夹杂之候。RA早期以邪实为主,治宜祛邪通络止痛,祛邪要根据病邪的特点遣方用药。缓解期以正虚为主,虚实夹杂,治疗当攻补兼施。而各期均应适当配以化瘀、祛痰、通络之品以疏通气血。第二部分临床研究【目的与方法】:收集200例RA患者病例资料,对其发病原因、中医证型、治法、用药,以及治疗前后相关数据,采用SPASS软件统计分析,找出其中医辨证分型、治法及用药规律。【结果】:1.本研究200名病例中,男性42例(21%)、女性158例(79%),男女比例约为1:3.8。40岁以上患者共149例,占了所有病患的74.5%。春季发病或加重者52人(26%);夏季者67人(33.5%),秋季者35人(17.5%),冬季者46人(23%)。有明显外因者161例,有明显内因者35人,无明显诱因者4人。2.RA辨证分型,其中风寒湿证55例,占27.5%;风湿热证57例,占28.5%;寒热夹杂证15例,占7.5%;痰瘀痹阻证36例,占18%;正虚邪恋证37例,占18.5%。前三者病程短,后两者病程长,比较有显着性差异。3.200例患者,中药共使用214种,达3238次。其中主要包括:祛风湿药(占17.8%)、补虚药(占14.5%)、清热药(占14.5%)、活血药(占11.2%)、利水渗湿药(占7.9%)、解表药(占5.6%)、化痰药(占4.2%)、熄风通络药(占4.2%)、温经药(占2.8%)等。4.治愈4例,显效23例,有效118例,无效55例,总有效率72.5%。风寒湿证、风湿热证、寒热夹杂证治疗后关节功能恢复较痰瘀闭阻证、正虚邪恋证有显着性差异。【结论】:1.RA的病机特点为本虚标实,肝肾不足,气血亏虚是本源;风、寒、湿、热、痰浊、瘀血是其标。病初以实证为主,病久则寒热错杂、虚实相兼。2.RA主要可分为五型:风寒湿证、寒湿热证、寒热夹杂证、痰瘀痹阻证、正虚邪恋证。前三种证型病程短,属疾病早期;后两种证型病程长,属疾病中晚期。3.临证时明辨寒热病性,区别邪正虚实。辨证首辨寒热类别,以关节有无红肿热痛为要点。次辨病邪偏盛,以关节疼痛性质为要点。再辨证候虚实,一般而言,新病多实,久病多虚,或呈虚实夹杂之候。4.治疗应在整体观念指导下,扶正祛邪,攻补兼施。急性期以邪实为主,治宜祛邪通络止痛,根据其病邪偏盛的不同,分别有所侧重;缓解期以正虚为主,虚实夹杂,治当攻补兼施。5.RA用药以温性为主,配伍寒性药物,起到了一个寒热并用的特色。药味以苦味、辛味药物为主,辅以甘味的药物。归经以肝、脾、肾经为主。使用频率列前10位的依次是祛风湿药、补虚药、解表药、活血祛瘀药、清热药、利水药、熄风通络药、化湿药、祛痰药、温经药。6.本病病程短,预后佳;病程长,预后差。故应及早治疗,以防迁延不愈,病情复杂。更多还原

【Abstract】 [OBJECTIVE] This subject will study the clinical cases about Rheumatoid arthritis (RA) to summarize the common rules of syndrome differentiation of traditional Chinese medicine, the therapeutic method and constitution of medicine, the research has provided basis for the therapeutic method, composing prescriptions and new drug development of Traditional Chinese medicine of RA.[METHODS] Collect 200 clinical cases from the out-patient and in-patient department related to RA in Jiang Su Province TCM Hospital, and accompany with excel program for the Statistics analysis of pathogenesis, syndrome differentiation, the treatment and herbs. From the above stasis, the rules of syndrome differentiation of traditional Chinese medicine, the therapeutic method and using of medication can be figured out.[RESULTS] The syndrome type of TCM on RA divide into: wind cold with dampness type, accounts for 27.5%, wind heat with dampness type, accounts for 28.5%, cold and heat mixture type, accounts for 7.5%, sputum with blood stasis type, accounts for 18%, health-qi xu with pathogens type, accounts for 18.5%. The mainly therapeutic methods on RA syndrome differentiation include: disperse wind, resolve dampness, clear heat, dispel cold, smooth meridians, resolve blood stasis and etc.[CONCLUSION] The deficiency of health-qi, exogenous etiology affection and sputum with blood stasis is the three important factors in occur, progress and prognosis of RA. At the initial stage, pathogenic factors are the primary aspect; at the middle stage, the syndrome is excess with deficiency, and then, pheglm and blood-stasis can be made. The therapeutic method is to reinforce vital-qi or disperse pathogenic factors.更多还原