范永升教授治疗幼年特发性关节炎经验拾零.pdf
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1、748承.SofB.STingSchool浙江中医药大学学报2 0 2 3年7 月第47 卷第7 期范永升教授治疗幼年特发性关节炎经验拾零沈炎彬叶项盛1赵婷?范永升(指导)1.浙江中医药大学第一临床医学院杭州3100532.浙中医药大学基础医学院摘要:目的 总结范永升教授治疗幼年特发性关节炎的经验,为临床提供参考。方法 通过临证收集和记录门诊病历,整理范永升教授辨证论治幼年特发性关节炎的经验,总结其病因病机及遣方用药规律,并举医案一则加以佐证。结果 范永升教授认为,幼年特发性关节炎多由小儿正气不足、复感外邪所致,病机特点可概括为“湿、热、毒、虚”,急性期治以清热利湿、祛风通络,缓解期治以益气健
2、脾、祛风通络。范教授通过将小儿生理特点与幼年特发性关节炎起病转归有机结合的辨治思路,取得满意的临床疗效。所举医案中患儿处于疾病活动期,证属风湿热痹,治以清热利湿、祛风通络,方用白虎加桂枝汤合四妙丸加减,疗效确切。结论 范永升教授从“湿、热、毒、虚”角度辨证论治幼年特发性关节炎,疗效明显,其经验值得借鉴和推广关键词:幼年特发性关节炎;儿童;辨证论治;中医临床;验案;名医经验;范永升中图分类号:R658文献标志码:A文章编号:10 0 5-550 9(2 0 2 3)0 7-0 7 48-0 3DO1:10.16466/i.isssn1005-5509.2023.07.007tis SHEN Ya
3、nbin,YE Xiangsheng,ZHAOExperience of Professor FAN Yongsheng in Treating Juvenile Idiopathic Arthritis S,et al 1.The First Clinical Medical School of Zhejiang Chinese Medical University,Hangzhou(310053),China;2.asicMedicine,ZhejiangChinese Medical UniversityAbstract:Objective To summarize Professor
4、FAN Yongshengs experience of treating juvenile idiopathic arthritis(JIA),providing somereferences for clinical practice.Methods Through collecting and recording medical records from outpatient clinic,the experience ofProfessor FAN Yongsheng in treating JIA based on pattern differentiation was organi
5、zed,as well as his understanding of the etiologicalfactors and pathogenesis,and one medical case was attached as evidence.Results Professor FAN Yongsheng considers that JIA iscommonly caused by deficiency of healthy Qi in children with exposure to external pathogenic factors,with the pathogenesis ch
6、aracterizedby“dampness,heat,toxin and deficiency.For the treatment,the acute stage focuses on clearing heat and draining dampness,removingwind and unblocking collaterals,whereas the remission stage focuses on tonifying Qi and strengthening the spleen,removing wind andunblocking collaterals.Satisfact
7、ory clinical efficacy for JIA has been obtained with Professor FAN Yongshengs treatment based on patterndifferentiation by integrating childrens physiological characteristics with disease onset,development and outcomes.In the case record,the affected child was in the active stage of the disease mani
8、festing as wind-dampness-heat impediment,the treatment was to clear heat,drain dampness,remove wind and unblock collaterals using modified Baihu Jia Guizhi Decoction combined with Simiao Pill,and obviouscurative effect was obtained.Conclusion Professor FAN Yongsheng s treatment of JIA based on patte
9、rn differentiation considering thepathogenic factors of“dampness,heat,toxin and deficiency has a significant clinical effect,therefore the experience derived is worthy ofreference and promotion.Key words:juvenile idiopathic arthritis;children;treatment based on pattern differentiation;TCM clinical p
10、ractice;proven cases;experience of famous doctors;FAN Yongsheng2001年国际风湿病学联盟(InternationalLeagueof Associations for Rheumatology,ILAR)儿科常委专家组将16 岁以下儿童持续6 周以上的不明原因关节肿胀,排除其他疾病可能后,称为幼年特发性关节炎(j u v e n i l e i d i o p a t h i c a r t h r i t i s,JIA),临床上伴有长期发热、皮疹、关节疼痛及多脏器受损的表现。一般认为,JIA可能由感染引起的免疫应答和调节失衡导
11、致,也与遗传、环境、自身免疫因素等有关,目前临床上常用非留体类抗炎药物(nonsteroidalantinflamma-torydrugs,NSA ID s)、改善病情的抗风湿药物(dis-通信作者:赵婷,E-mail:ease modifying antirheumatic drugs,DMARDs)、类固醇激素和生物制剂等治疗。由于该病缺乏特异性的体征与实验室检查,早期容易误诊,延误治疗时机。同时,由于药物治疗的不良反应,可能导致JIA患儿发生关节外器官的不可逆损伤,如虹膜睫状体炎等,故本病预后较差。中医注重“治病求本”,对本病的认识与诊治具有特色,有助于早期诊治,以达到缓解病情、降低不良
12、反应、提高生活质量的目标。范永升教授为首届全国名中医,从事临床和科研工作40 余年,致力于中医药防治风湿免疫性疾病749性关节范永升4浙江中医药大学报2 0 2 3年7 月第47 卷第7 期的临床和基础研究,对于JIA的治疗具有独到的经验及方法,强调“湿、热、毒、虚”的病机特点,现将其经验介绍如下,以飨同道。1病因病机JIA根据其临床表现,可归属于“痹病”“小儿痹”“顽痹”“历节”“小儿鹤膝风”“内伤发热”等范畴。中医古籍中有类似本病的相关论述,如隋巢元方3在诸病源候论云:“小儿生血气不足,即肌肉不充,肢体柴瘦,骨节皆露,如鹤之脚节也。金张从正4在儒门事亲日:“小儿风、寒、湿三气合而为痹,及手
13、足麻痹不仁。”至此提出“小儿痹”一名,认为其发病与赋不足、外邪侵袭有密切联系。1.1赋不足,正气亏虚JIA患儿大多发病年龄小,先天赋不足,后天之本亦有亏虚,又处于快速生长期,生化乏源,血气不充,使得筋骨肌肉经脉失养,滕理不密,卫外不固,外邪乘虚侵袭肌肤;此时正气偏虚,亦无力祛邪外出,则病邪深入,进一步阻碍气血津液的流通输布。故脾肾亏虚、正气不足是该病发病的内因。1.2外邪侵袭,痹阻经络素问痹论日:“风寒湿三气杂至,合而为痹也。其风气胜者为行痹,寒气胜者为痛痹,湿气胜者为着痹。”明确指出了风、寒、湿等外邪侵袭是形成痹病的外在因素,由于小儿正虚,卫外不固,或因冒涉雨水等,致使风寒湿热等外邪侵袭,留
14、滞于肌肤、肌肉、关节、筋络中,阻滞气机、搏结气血,使气血运行不畅,最终痹阻经络为病1.3素体蕴热,湿热毒结吉小儿“纯阳之体”易从阳化热,风寒湿邪易郁遇阳气,化而为热;或初感外邪,郁于阴分,日久化热而为湿热痹。尤在泾6 在金匮要略心典中认为:“毒者,邪气蕴结不解之谓。”毒邪多因脏腑功能失调、气血亏虚日久,导致不能祛邪外出而产生。患儿体内湿郁热蒸,日久酿毒,毒流四肢筋络,发为痹症;或因风寒湿邪等外邪深入脏腑,化为邪毒,互结日久,伺机作变,酿而化热。范师根据历代文献及自身临床经验认为,此“毒”是在正虚基础上受外界因素影响而成,不同于普通外感、内伤之邪,与湿、热互结难解,故往往缠绵反复。综上所述,范师
15、提纲挚领地将本病的病机特点概括为“湿、热、毒、虚”,小儿正气虚弱是本病发生的根本原因,复感风寒湿热等外邪是疾病发生的外在因素,从而导致气血津液运行失常,痹阻筋脉,湿郁热蒸,毒流肢节,湿热毒互结不解,日久不愈,发为痹证。2治则治法范师治疗JIA,重视急性期和缓解期的分期辨治,根据“湿、热、毒、虚”的病机特点,并结合其临床症状分型,总结出基本治则治法,即以“急则治标、缓则治本”为基本治则,以“祛风通络”为基本治法。急性期邪气偏盛,湿热毒三者互结,当急则治其标,治以清热利湿、祛风通络,同时顾护胃气、攻不伤正;缓解期正虚邪恋,注重扶正祛邪、攻补兼施,治以益气健脾、祛风通络。2.1急性期治以清热利湿、祛
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