中医临床病证哮病.ppt

WheezingSyndrome哮病,杨明山上海中医药大学教务处,Contents,TerminologyEtiologyMechanismManifestationTCMDiagnosisDifferentiationTherapyTCMFormulaeOthers,病名病因病机症候四诊辨证治则方药其他,Terminology,病名,医说,2000年前,内经,针灸资生经,1180年,医学正传,1224年,丹溪心法,1481年,1515年,01.内经素问阴阳别论篇提到“喘鸣”。古文：阴争于内阳扰于外，魄汗未藏，四逆而起，起则熏肺，使人喘鸣。Ifyindominatesinteriorlyandyangintrudesexteriorlyexteriorly,thesoulsweatingfailstobestoredandthedisordersdevelopsalloverthebody,startingwithlungdamagedwhichwillleadtowheezingwithstridor.,主,02.南宋嘉定(1220)王执中针灸资生经最早提出“哮喘”之名。古文：因与人治哮喘，只缪（刺）肺腧，不缪他穴。AcupointFeishumorethanothersisneedledtotreatasthma.03.南宋张杲医说卷四提到“齁喘”。古文：因食盐虾过多，遂得齁喘之疾。Takingtoomuchsaltyfishwillleadtoasthmaduetofish(Houchuan).,04.元朱丹溪首创“哮喘”病名，丹溪心法设独立篇名哮喘十四；另设喘十五；自此喘与哮分别叙述。Itsthefirsttimetogivename“asthma”tothisdisorderusedasthetitleofonechapterandthentodiscusswheezingsyndromeanddyspneasyndromeseparately.,06.明朝秦景明在症因脉治卷二哮病论提出“哮病”之病名。,古文：哮病内伤痰饮，外感风寒，合而成。英文：Wheezingsyndromeiscausedbybothinteriorphlegm-retentionandexteriorwind-cold.,05.明虞抟医学正传哮喘区别哮与喘。古文：哮以声响言，喘以气息言。Wediagnoseasthmaespeciallyfromitssound,anddiagnosegaspingfromitsbreath.,Terminology,喘：panting喘鸣：stridor喘证：gaspingsyndrome哮证：wheezingsyndrome哮喘：asthma,Etiology,病因,01内经素问阴阳别论篇认识到内外因素影响脏功能(尤其是肺)是哮病的主要病机。古文：阴争于内阳扰于外，魄汗未藏，四逆而起，起则熏肺，使人喘鸣。Ifyindominatesinteriorlyandyangintrudesexteriorly,thesoulsweatingfailstobestoredandthedisordersdevelopsalloverthebody,startingwithlungdamagedandleadingtostridorandwheezing.,02内经素问太阴阳明论提出外(风)邪致哮说。古文：犯贼风虚邪者，阳受之则入六腑入六腑则身热，不时卧，上为喘呼。Itproposedthetheorythatexogenousevilcancausetheillness,“Whenthebodyisinfectedbyoccultevilwind,yangsixFU-organsareaffectedifyangisinvolved,thenthepatienthasafeverandfailstosleepflat,leadingtowhoopingupward.,03黄帝内经灵枢邪气藏府病形提出外感“寒邪”之认识。古文：两寒相感，中外皆伤，故气逆而上。,Whentwokindsofcoldmeet,bothinteriorandexteriorofthebodyareimpaired,resultinginqiascendingreversely.,04元朱丹溪丹溪心法喘十五述及情志、饮食、体弱等多种病因。古文：六淫七情之所感伤，饱食动作，脏气不和，呼吸之息，不得宣畅而为喘急。亦有脾肾俱虚，体弱之人，皆能发喘。Damagedbysixclimaticexopathogensandsevenemotionsaswellasactionafterfullstomach,thevisceralqiwillbedisharmonizedresultinginobstructiverespirationandrapidgasping.Anybodywhosespleenandkidneyaredeficientcandevelopgaspingsyndrome.,04:Damagedbysixclimaticexopathogensandsevenemotionsaswellasactionafterfullstomach,thevisceralqiwillbedisharmonizedresultinginobstructiverespirationandrapidgasping.Anybodywhosespleenandkidneyaredeficientcandevelopgaspingsyndrome.,05明秦景明症因脉治喘指出体虚之病因。古文：气虚喘逆之因，或本元素虚，或大病后，大劳后，失于调养，元气大伤。Thecauseofwheezingconverselywithqideficiencyisduetofailureofrecoveryleadingtodamagingprimordialqiafterseverediseaseorexhaustion.,病因总结,wind,diet,cold,motion,morbid,overstrain,2000年前中国古代医学对于哮喘的病因记载已经相当完整,2000年前内经素问太阴阳明论提出风邪致哮说:犯贼风虚邪者,阳受之则入六腑,入六腑则身热，不时卧，上为喘呼。1938年西方撰此词古希腊医学认为此病与风相关。,相似何其乃尔,Mechanism,病机,01黄帝内经灵枢本藏第四十七最早提到肺与本病的特殊关系古文：肺高则上气肩息咳。,Ifthelungisinsuperiorposition,thepatientwillgaspandcoughwithraisedshoulder.,02黄帝内经素问至真要大论篇第七十四提出水饮之内因可上犯于肺引发本病。古文：饮发于中，咳喘有声。Whenthefluidretentionoccursinsidethebody,itwillcausecoughandwheezingwithstridor.,03隋巢元方550-630在诸病源候论卷十四咳嗽病诸候最早指出痰饮与本病的关系。古文：其胸膈痰饮多者，嗽则气动于痰，上搏喉咽之间，痰气相击，随嗽动息，呼呷有声，谓之呷嗽。Ifthereistoomuchphlegmabovethediaphragminthechest,theqivibratesupwardwiththephlegminthethroatwhenthephlegmandqistrugglemutuallyworseningwiththecoughingandwheezing,accompaniedbythesound,whichiscalledasXiasou(stridor).,Ifthereistoomuchphlegmabovethediaphragminthechest,theqivibratesupwardwiththephlegminthethroatwhenthephlegmandqistrugglemutuallyworseningwiththecoughingandwheezing,accompaniedbythesound,whichiscalledasxiasou(stridor).,04东汉张仲景在金匮要略痰饮咳嗽病脉证治第十二中，将哮证归为“伏饮”证。古文：膈上病痰，满喘咳吐，发则寒热，背痛腰疼，目泣自出，其人振振身膶剧，必有伏饮。Withdiseasedphlegmabovediaphragm,thepatientwillhaveheavypantingwithcoughandvomiting,andthendevelopfever,lowerbackache,spontaneoustearingandbodyshiveringduringattack,whichisrootedinconcealedfluidretentioninsidebody.,哮病的三饮水饮-痰饮-伏饮,水电解质失衡免疫反应,05明戴思恭1324-1405秘传证治要诀及类方哮喘明确提出本病的“宿根”之说。古文：喘气之病，哮吼如水鸡之声，牵引胸背，气不得息，坐卧不安。此为嗽而气喘，或宿有此根，遇寒暄则发，一时暴感。Thediseaseofgaspingsyndromeiswhoopingwithfrog-likesoundandraisingthechestandshouldersleadingtodyspneaandfailingtositandsleep.Itischaracterizedbycoughaccompaniedbygaspingorfundamentalillnesswhichwillrecurincaseofcoldparoxysmally.,06清李用粹正治汇补哮病全面阐明哮病病机。古文：哮即痰喘之久而常发者，因内有壅塞之气，外有非时之感，膈有胶固之痰，三者相合闭拒气道，搏击有声，发为哮病。Itsummedupthethreelinksofasthma:“Asthmaislong-termwheezingwithphlegmhavingfrequentrecurrencebecausethereisinteriorqiobstruction,inductionofexogenousfactorsandtenaciousphlegmabovethediaphragm,threeofwhichmeettogethertoobstructairway,fightingmutuallywithstridor,calledasasthma.,太复杂失去中医特色,Mechanism,Trilogy,inducedfactors,FluidretentionPhlegmr.RootConcealedr.,Manifestation,症候,01巢元芳诸病源候论卷之十四气病诸侯最早描述“水鸡之鸣”，犹如西医之喉鸣。古文：肺病令人上气，兼胸膈痰满，气行壅滞,喘息不调,致咽喉有声,如水鸡之鸣也。,Lungdiseasemakesqiascendwithchestfullofphlegmandqistagnation,causingabnormalbreathingandnoisysoundinthethroatlikethesoundoffrog.,02黄帝内经素问逆调论篇第三十四已经记载本病的端坐呼吸。古文：不得卧而息有音。Thepatientcantsleepflatandwheezingwithstridor.,03黄帝内经灵枢五阅五使第三十七已经提到呼吸衰竭时出现的鼻翼扇动。古文：肺病者，喘息鼻张。Apersonwiththepulmonarydiseasewillwheezewithnasalflaring.,04明李中梓1588-1655在医宗必读卷九(1637成)记载呼气性呼吸困难之表现。古文：哮者与喘相类，但不似喘开口出气之多，而有呀呷之音。,Asthmaandwheezingaresimilar，butasthmadoesnotbreatheasmuchaswheezing，andhaveitssoundlike“yaxia”,古代中医早已完整记载哮喘的临床表现,TCMDiagnosis,四诊,（一）望诊01唐朝王焘670-755在外台秘要卷九久咳坐卧不得方（752年撰成）准确描述哮证大作症候。古文：久患气嗽，发时奔喘，坐卧不得，并喉里呀声，气欲绝。Itrecordstheparoxysmalmanifestationsofseverewheezinganddyspneasyndrome:“Thepatientwithlong-termcoughingandwheezinghasheavywheezing,failstositandsleepwithstridorinthethroatandevenandisgoingtobesuffocatedduetodyspnea.,02明王肯堂1549-1613证治准绳喘描述哮证发作症候，与西医呼衰表现一致。古文：喘者，促促气急，喝喝息数，张口抬肩，摇身撷肚。Thepatientwithasthmaisoutofbreath,wheezingrapidlywithstridor,openingmouthandshruggingshoulder,aswellasshakingbodyandabdomengoingforward.,03清汪宏在望诊遵经卷二诊唇气色条目(撰于1875年)述及哮喘之望诊。古文：唇色黑瘀，目睛凸露，呼吸上逆者，哮喘也。Ifthepatienthasblackstasis,bulgingeyesandupwardbreathing,asthmawouldbediagnosed.,03清汪宏在望诊遵经卷二诊唇气色条目(撰于1875年)述及哮喘之望诊。古文：唇色黑瘀，目睛凸露，呼吸上逆者，哮喘也。Ifthepatienthasbluishcolortothelips,bulgingeyesandupwardbreathing,asthmawouldbediagnosed.,风寒犯肺,症状:主证加咳痰稀白,表寒证,口不渴。舌象:舌淡苔薄白而滑,痰热遏肺,症状：主证加咳嗽痰黄稠，咽干，口渴喜冷饮，尿赤，便结或发热。舌脉：舌红苔黄腻,（二）问诊03清何梦瑶在医碥喘哮指出哮与饮食的关系。古文：得之食味酸咸太过，幼时多食盐醋，往往成此疾，俗谓之盐哮。Wheezingsyndromeiscausedbytoomuchacidandsaltinthedietduringchildhood,itisreferredtosaltywheezingsyndrome.,（二）问诊04南宋张杲撰在医说卷四(1224刊)记载“鱼腥哮fish-asthma”。古文：因食盐虾过多，遂得齁喘之疾。Takingtoomuchsaltyfishwillleadtoasthmaduetofish(Houchuan).,（二）问诊05南宋许叔微1079-1154在普济本事方卷一（撰于1132年）中已经认识到本证具有遗传性。古文：此病有苦而至终身者，亦有母子相传者。Thepatientcansufferfromthisallhislifewhichcanalsobeinheritedfrommothertoson.,（三）闻诊06明朝虞抟1438-1517在医学正传卷之二哮喘（撰于1515年）提出“哮”与“喘”之别古文：夫喘促喉中如水鸡声者，谓之哮；气促而连属不能以息者，谓之喘。Itiscalledasthmaforthepatientiswheezingwithfrog-likesoundinthethroatanditiscalledgaspingsyndromeforthepatientispantingwithacceleratedandpantingrespiration.,（四）切诊07黄帝内经素问通评虚实篇第二十八中首次提到用脉象判断哮病的预后古文：乳子中风热，喘鸣肩息者，脉实大也。缓则生，急着死。TheInfantilepatientsufferingfromwheezingsyndromewithstridorandraisedshoulderhasalargeandexcesspulse.Hewillliveonwithrelaxedpulsebutdiewithswiftpulse.,Manifestations,（四）切诊08唐王焘外台秘要上气喉中水鸡鸣方记载脉诊诊断本病。古文：脉浮咳逆，咽喉中水鸡鸣，喘息不通，呼吸欲死。Thepatienthasfloatingpulse,badcoughandupwellingqiwithfrog-likesoundsinthethroat,gaspingbecauseofobstructionofairwaysandevenfeelingtodie.,TCMDifferentiation,辨证,01明虞抟1438-1517医学正传哮喘(1515年成）提出“哮”与“喘”之别古文：大抵哮以声响名，喘以气息言。Wediagnoseasthmaespciallyfromitssound,anddiagnosewheesingfromitsbreath.,02元朝朱丹溪1281-1358丹溪心法卷二哮喘十五提出虚实辨证。古文：实喘气实肺盛，虚喘由肾虚。Theexcessivewheezingsyndromeduetoexcessivelungqianddeficienctwheezingsyndromeduetokidneydeficiency.,肺盛,肾虚,03明张景岳景岳全书杂证归纳虚实两证。古文：实喘者有邪，邪气实也；虚喘者无邪，元气虚也。Excessivegaspingsyndromehasevilqiinwhichevilqiisexcessiveanddeficientgaspingsyndromehasnoevilinwhichvitalqiisdeficient.,05清林佩琴类证治裁卷之二哮症论治提出哮喘有冷哮、热哮两大证候。古文：遇风寒而发者为冷哮为实，伤暑热而哮者为热哮为虚，其盐哮、酒哮、糖哮，皆虚哮也。Coldasthmaistheexcessiveonecausedbycoldwindwhilethehotasthmaistheefficientcausedbysummerheatandasthmainducedbysalt,wineandsugararealldeficientone.,06明王肯堂在证治准绳第二册诸气门哮(撰于1608年)中对寒哮作进一步辨证。古文：哮喘遇冷则发者有二证其一属中外皆寒，。其二属寒包热，。译文：Wheezingsyndromeinducedbycoldhastwosubtypes:Onebelongstocoldwheezingsyndromewithbothinteriorandexteriorcold,theotherbelongstotheonewithexteriorcoldwrappingheat.,哮病虚实辨证-明清佳,TreatmentPrincipal,治则,01元朝朱丹溪（1281-1358）在丹溪心法卷二哮喘十五提出治疗“已发”与“未发”之别。古文：凡久喘之症，未发宜扶正气为主，已发用攻邪为主。Forthepatientwithlong-termdisease,vitalqihastobestrengthenedforpre-paroxysmswhileevilqihastobeeliminatedforparoxysm.,02明张景岳景岳全书杂证谟卷之十九明集喘促仔细分析哮证的治疗方法。古文：扶正气者，须辩阴阳，阴虚者补其阴，阳虚者补其阳。攻邪气者，须分微甚，或散其风，或温其寒，或清其痰火。Theyin-yangdifferentiationhastobemadeinthecaseofstrengtheningvitalQi,forwhichyinhastobereplenishedfortheyin-deficientwhileyanghastobereplenishedfortheyang-deficient.Thecarefuldifferentiationhastobemadeinthecaseofeliminatingevil,inwhichthewindhastobedispelled,thecoldbewarmedorthefirebecleared.,Theyin-yangdifferentiationhastobemadeinthecaseofstrengtheningvitalQi,forwhichyinhastobereplenishedfortheyin-deficientwhileyanghastobereplenishedfortheyang-deficient.Thecarefuldifferentiationhastobemadeinthecaseofeliminatingevil,inwhichthewindhastobedispelled,thecoldbewarmedorthefirebecleared.,03元朱丹溪(1281-1358)丹溪心法哮喘十四之治法为后世所宗。古文：哮喘必用薄滋味，专主于痰，宜大吐。Theplainfoodmustberecommendedtothepatientwithasthma,forwhomtheemeticagentsisusedtoresolvethephlegmspecifically.,04清林佩琴类证治裁卷二哮症论治(撰于1773年)提出外感内伤两种治法。古文：喘由外感者治肺，内伤者治肾。Gaspingsyndromecausedbyexogenousfactorshouldbetreatedwithfocusingonlung,whilebyinternaldamage,onkidney.,PrincipleofTreatment,凡久喘之症,未发宜扶正气为主,已发用攻邪为主。扶正气者,须辩阴阳,阴虚者补其阴,阳虚者补其阳。攻邪气者,须分微甚,或散其风,或温其寒,或清其痰火。喘由外感者治肺,内伤者治肾。大凡治哮病,宜忌燥药:亦不宜纯用凉药。,PrincipleofTreatment,(背诵)Forthepatientwithlong-termdisease,vitalqihastobestrengthenedforpre-paroxysmswhileevilqihastobeeliminatedforparoxysm.扶正气者,须辩阴阳,阴虚者补其阴,阳虚者补其阳。攻邪气者,须分微甚,或散其风,或温其寒,或清其痰火。喘由外感者治肺,内伤者治肾。大凡治哮病,宜忌燥药:亦不宜纯用凉药。,TCMFormulae,方药,（一）发作期：治寒哮01张仲景金匮要略肺痿肺痈咳嗽上气病脉证并治第七(撰于3世纪初)记载的射干麻黄汤为治疗哮病(寒哮大作)的祖方。古文：咳而上气，喉中水鸡声，射干麻黄汤主之。Ifthepatienthascoughwithupwellingqiandstridorafrog-likesoundinthroat,SheganMahuangdecoctionshouldbeusedasmainformula.,（一）发作期：治寒哮02东汉张仲景在伤寒论卷第三辨太阳病脉证并治中第六提出以小青龙汤治喘。古文：伤寒，心下有水气，咳而微喘，发热不渴。小青龙汤主之。Ifthereispathogenicwaterfluidbelowheart,coughandlittlegaspingandfeverwithoutthirstyduetodamagedcold,MinorBlueDragonDecoctionisused.,（一）发作期：治寒哮03东汉张仲景在伤寒论中记载治喘之方。古文：喘家作，桂枝加厚朴杏子佳。Whenthepatienthasanattackofwheezingwiththisprevioushistory,itisbettertogivehimGuizhiplusHoupuandXingzi.,（二）发作期：治热哮01明龚廷贤在寿世保元卷三哮吼用千金定喘汤治热哮。古文：千金定喘汤治哮吼如神。QianjinDingchuandecoctioniseffectiveinthetreatmentofwheezingwithstirdor.,（二）发作期：治热哮02清林佩琴在类证治裁卷二哮症论治(撰于1773)中提出治热哮之方。古文：热哮当暑月火盛痰喘者，桑白皮汤，或白虎汤加芩、枳、瓜蒌霜。Whenwheezingsyndromeattacksinsummerwithexuberantfireandphlegm-gasping,SangbaipiDecoctionorBaihuDecoctionplusPowderofBaicalSkullcap,OrangeFruit,andSnakegourdFruitisused.,（二）发作期：治热哮03清吴瑭温病条辨寒湿麻杏石甘汤治疗热饮。古文：喘咳患促，吐稀涎，脉洪效，右大于左，喉哑，是为热饮，麻杏石甘汤主之Ifthepatienthascoughandwheezingwiththinsalivaandhoarsevoice,whosepulseisrapidlysurgingwiththerightbiggerthantheleft,thediseaseisduetoheatfluidwhichshouldbetreatedwithMahuangXingrenGancao.,（三）缓解期01张仲景在金匮要略肺痿肺痈咳嗽上气病脉证并治第七（撰于3世纪初）记载麦门冬汤。古文：大逆上气，咽喉不利，止逆下气，麦门冬汤主之。Whenqiisascendingreverselyandthethroatisconstricted,Maimendongdecoctionisusedtocontrolreverseqi.,（四）喘脱01唐王焘670-755在外台秘要(撰于752年)用人参之治喘脱。古文：“疗咳上气，喘息便欲绝，以人参末之，日五次。Totreatcoughandupwardqisoastoresolvewheezingandgasping,ginsengpowdercouldbeusedfivetimesaday.,方药小结,MinorBlueDragonDecoction,Acupuncture&Moxibustion,针灸,（一）实证：宜针。01南宋王执中针灸资生经(撰于1180-1195)古文：凡有哮喘者，为按肺俞，无不酸痛，皆为缪刺肺俞，令灸而愈。Anypatientwithwheezingsyndromefeelsachewhenpressingacupointoffeishu,whichiscontraypunctureonFeishuandcouldbecuredwithmoxibustiononit.(CanonofPromotingHealthwithAcupunctureandMoxibustion).,（一）实证：宜针。02明杨继洲1522-1619针灸大成(1601)古文：哮吼嗽喘：俞府、天突、膻中、肺俞、三里、中脘(主要)WheezingSyndromewithcroup:Shufu,Tiantu,Danzhong,Feishu,SanliandZhongwanareused.,（二）虚证：宜灸01明朝高武针灸聚英（刊于1529年）古文：喘，灸中府、云门、天府、华盖、肺俞。Moxibustionisappliedinacupointsofzhongfu,yunmen,tianfu,huagaiandfeishuareselectedtotreatgaspingsyndrome.,总结,了解,DiagnosticTerms,喘证：gaspingsyndrome哮证：wheezingsyndrome哮喘：asthma,掌握,Mechanism,Trilogy,inducedfactors,FluidretentionPhlegmr.RootConcealedr.,Manifestations,掌握,方药小结,病案分析,杨某，男，20岁，工人。常发作性喉间哮鸣气急6年，入夏即发。最近哮喘又作，喘息抬肩，喉中痰鸣如锯，不能平卧，痰黄粘稠，咳吐不利，口渴喜冷饮，胸闷、心悸，疲乏无力，舌红，两侧糜烂，舌苔薄白，脉象细数。,CaseBriefMr.Yang,20-year-old,worker,hasparoxysmalwheezingwithstridorandshortnessofbreathfor6years,whichrecurinsummer.Recentlythepatienthasrecurrenceofasthmaagain,havingwheezingwithraisedshoulder,phlegmrattlinginthethroat,f