“培土生金”法在肺癌癌性发热中的应用_孙晓静.pdf

浙江中医药大学学报2023年2月第47卷第2期JOURNAL OF ZHEJIANG CHINESE MEDICAL UNIVERSITY VOL.47NO.2 Feb.2023硕博之窗“培土生金”法在肺癌癌性发热中的应用孙晓静1杨婕2张誉华3李文逸1周立捷1孙韬21.北京中医药大学北京1000202.北京中医药大学东方医院3.北京市门头沟区中医医院摘要：目的探讨“培土生金”法在肺癌癌性发热中的应用，以期为治疗该病提供新思路和新方法。方法基于“肺脾相关”理论，从“培土生金”的释义、脾虚致病的不同机制方面分析肺癌癌性发热的病因病机，探讨“培土生金”法在不同证型的肺癌癌性发热中的选方和用药，并列举临床验案加以佐证。结果肺癌癌性发热的不同证型均与脾虚密切相关，脾胃亏虚，气血两伤，内生虚热；脾失健运，痰瘀互结，滋生湿热；肺脾失和，气机升降失调，内生阴火；内外合邪，阴分伏热。在治疗上应以“培土生金”为基本大法，根据病性虚实和辨证分型化裁出多种补脾之法，给予肺脾同治、补中培元、健脾化湿、调畅气机等药物。验案中患者为晚期肺癌，化疗后出现癌性发热，结合患者症状，综观脉证，考虑病机为肺病及脾、肺脾两虚，故治以补气健脾、培土生金，方选补中益气汤加减以甘温除热，获得较好疗效。结论肺癌癌性发热的病机与“肺脾相关”理论相契合，“培土生金”法对该病的诊疗意义重大，临证应根据不同证型和病性特点辨证施治，值得临床推广应用。关键词：肺癌；癌性发热；培土生金；肺脾相关；虚则补其母；中医药；理论探讨；验案中图分类号：R273文献标志码：A文章编号：1005-5509（2023）02-0212-07DOI:10.16466/j.issn1005-5509.2023.02.019Clinical Experience of“Reinforcing Earth to Generate Metal”in the Treatment of Carcinogenic Fever of Lung CancerSUN Xiaojing1，YANG Jie2，ZHANG Yuhua3，et al 1.Beijing University of Chinese Medicine，Beijing(100020)，China；2.DongfangHospital of Beijing University of Chinese Medicine；3.Beijing Mentougou Hospital of Traditional Chinese MedicineAbstract:ObjectiveTo explore the application of“reinforcing earth to generate metal”method in the treatment of carcinogenic fever oflung cancer，in order to provide new ideas and methods for the treatment of this disease.MethodsBased on the theory of“lung andspleen correlation”，the etiology and pathogenesis of carcinogenic fever of lung cancer were analyzed from the definition of“reinforcingearth to generate metal”and different pathogenesis of spleen deficiency，and the prescription and medication of this method in differentsyndrome types of carcinogenic fever of lung cancer were discussed，and clinical case was listed for verification.ResultsDifferentsyndrome types of carcinogenic fever of lung cancer are closely related to spleen deficiency，spleen and stomach deficiency，Qi andblood injury，producing endogenous deficiency heat；spleen loss of health transport，phlegm and blood stasis mutually knot，breedingdampness and heat；lung and spleen disharmony，Qi movement disorder，producing endogenous Yin fire；combination of internal andexternal evil，causing latent heat in Yin.“Reinforcing earth to generate metal”should be taken as the basic method，according to thenature of disease and syndrome differentiation，cutting out a variety of spleen tonifying methods，giving drugs to benefit both the lungand spleen，replenish the spleen to nourish the vitality，invigorate the spleen and eliminate phlegm，regulate the movement of Qi.Thepatient in the case was of advanced lung cancer，and developed carcinogenic fever after chemotherapy，combined with the symptomsand the comprehensive view of the pulse syndrome，the pathogenesis was considered as the lung disease affecting the spleen，deficiencyof both the lung and spleen，so the treatment should be replenishing Qi and strengthening the spleen，reinforcing earth to generatemetal，and Buzhong Yiqi Decoction was modified to remove heat with sweet and warm.ConclusionThe pathogenesis of carcinogenicfever of lung cancer is consistent with the theory of“lung and spleen correlation”，and“reinforcing earth to generate metal”method is ofgreat significance to the diagnosis and treatment of this disease.It should be treated according to different syndrome types andpathological characteristics，which is worthy of clinical promotion and application.Key words：lung cancer；carcinogenic fever；reinforcing earth to generate metal；lung and spleen correlation；tonifying the mother or-gan in case of deficiency；traditional Chinese medicine；theoretical discussion；proved case基金项目：首都卫生发展科研专项项目（首发2020-2-1023）Fund project：Capital Health Development Scientific Research Project(S.F.2020-2-1023)通信作者：孙韬，E-mail：212浙江中医药大学学报2023年2月第47卷第2期肺癌是临床最常见的恶性肿瘤，发病率和死亡率逐年增加。最新流行病学调查显示，肺癌新发病例在全球高达220万例，预计2022年中国将新增87万；肺癌死亡率居全球第一，新增死亡病例占比18%，预计2022年中国将新增76万死亡病例1-2。癌性发热常见于约2/3的恶性肿瘤患者，是在排除感染、抗生素治疗无效的情况下出现的，直接与肿瘤相关的非感染性发热，或患者在肿瘤发展过程中因治疗而引起的发热3-4，诊断明确后患者5年死亡率在52%以上5-6。大多数患者表现为37.538 的中低度发热，伴有肌肉酸痛、疲乏无力、食欲下降等全身不适，持续发热或病久不愈还会引发水、电解质紊乱及酸碱代谢失衡，增加机体慢性消耗，导致免疫功能下降7。目前现代医学认为，癌性发热的产生可能与肿瘤细胞或者对肿瘤作出反应的巨噬细胞释放的热源性细胞因子有关，治疗方案主要采用手术减瘤和药物退热，其短期疗效显著，但病情易反复，且存在可能引起肿瘤恶病质等多重不良反应8，进一步加重癌症患者的身体负担。中医文献中并无癌性发热的记载，因病因与患者体内有形之癌肿相关，加之病程缠绵反复，热势较低，全身症状明显的特点，通常将其归为“内伤发热”的范畴。“百病皆由脾胃衰而生”915，脾虚贯穿于肺癌发生发展的各个阶段。癌性发热作为并发症，与肝脾肺肾均有关，尤以肺脾为重。脾肺两脏母子相生，所属同名经脉同气相求，一方面，患者自身脾虚，母病及子，久则加重肺虚，成为该病的发病基础；另一方面，患者肺虚日久，子盗母气，必累及于脾，而致肺脾两虚，进一步促进该病的进展。肺脾两虚、中气不足、痰湿内生、气机不畅、瘀毒互结、复感外邪均可引起癌性发热，可见肺癌癌性发热的发生、发展、预后与肺脾密切相关10。中医药治疗癌性发热疗效显著，历代诸多医家均有研究，多从“虚、瘀”等病理因素出发辨证论治。“培土生金”法来源于肺脾相关理论，治疗肺癌癌性发热符合中医理论特色，不仅可为患者缓解症状，也为临床诊疗提供了一种全新的思路和方法，故本文拟以此为切入点，探讨肺癌癌性发热的论治。1“培土生金”释义“培土生金”，又称补土生金、补脾益肺、肺脾同治，来源于黄帝内经中的五行理论和脏腑相关理论。素问 阴阳应象大论中言：“脾生肉，肉生肺。”根据五行相生理论，土能生金，脾为肺之母，肺为脾之子，两者相辅相成，彼此影响,共同生成宗气，共同生成卫气，抵御外邪，在水液代谢中也相互为用。医方集解载：“脾者，万物之母也，肺者，气之母也，脾胃一虚，肺气先绝。”1122若脾胃气虚，气血生化乏源，则肺失所养,宗气不足,元气亏虚；或脾失健化，肺失宣降，气血津液运行障碍，水湿、痰浊停滞局部，引发肺脾两虚、气滞痰阻的病理状态，日久则发展为全身气血阴阳失衡。因此，培土生金法建立在脾土与肺金的生理和病理联系之上，意指健脾益气以补益肺气，是治疗土不生金、肺脾气虚、脾虚痰阻的方法。仲景在金匮要略 痰饮咳嗽病中首次运用培土生金法，以甘补胃阴的麦门冬汤治疗“大逆上气，咽喉不利”的虚热肺痿，开“甘凉培土生金“法之先河；之后，仲景还以温中健脾、补肺益气之黄