第一篇：愛愛醫資源-火熱學說(講稿)

火熱學說(講稿)火熱病機可以說是中醫病機中范圍最廣、影響最大的病機之一，歷代醫家有關探討火熱病機的理論浩如煙海，形成了中醫火熱學說。

火熱學說源于《黃帝內經》，在《黃帝內經》中，對“火熱”之邪的性質、特點以及致病機理進行了討論。在《陰陽應象大論》中有：“南方生熱，熱生火，火生苦，苦生心，??其在天為熱，在地為火?！睂⒒馃崤c四時五行五臟聯系起來，體現了《黃帝內經》的“天人相應”理論?！吨琳嬉笳摗返牟C十九條，其中涉及火熱的即有十條：“諸熱瞀疒契，皆屬于火”，“諸禁鼓栗，如喪神守，皆屬于火”，“諸腹脹大，皆屬于熱”，“諸逆沖上，皆屬于火”，“諸躁狂越，皆屬于火”，“諸病有聲，鼓之如鼓，皆屬于熱”，“諸病腑腫，疼疒皴驚駭，皆屬于火”，“諸轉反戾，水液渾濁，皆屬于熱”，“諸嘔吐酸，暴注下迫，皆屬于熱”，“諸痛癢瘡，皆屬于心（火）”。這十條把火熱病邪的病理性質、致病特點概括得十分詳細，成為火熱學說的淵藪。

后世醫家在《黃帝內經》的基礎上，對火熱病機的認識進一步深化，例如唐代醫家王冰在注解《黃帝內經》時，發展、闡明了陰陽偏勝的機理，提出了“人火”、“龍火”的概念，成為后世“龍雷之火”及“引火歸原法”之所本。

正式使火熱學說成為一大學派的，當推金元四大家之一的劉完素。劉完素以“主火論”著稱，他把《內經》的病機十九條關于火與熱致病的范圍進一步擴充，并在理論上提出“六氣皆從火化”和“五志過極皆為熱甚”的論點，從而闡發了疾病發生、發展中火熱病機的普遍性。并且劉完素提出了辛涼解表、表里雙解等清熱大法，突破了《傷寒論》注重辛溫解表、以寒統熱的局限，被后世稱為寒涼派。金代張從正也非常重視火熱病機，并在具體應用中有豐富經驗，例如他首先明確指出消渴當從火論治，《儒門事親·三消說當從火斷》云：“五行之中，惟火能焚物；六氣之中，惟火能消物，??（火）得其平則蒸煉飲食，糟粕去焉；不得其平，則燔灼臟腑，而津液竭焉。??夫一身之心火，甚于上為膈膜之消，甚于中則為腸胃之消，甚于下為膏液之消，甚于外為肌肉之消。上甚不已，而消及于肺；中甚而不已，則消及于脾；下甚而不已，則消及于肝腎；外甚而不已，則消及于筋骨；四臟皆消盡，則心始自焚而死矣?！?/p>

金元四大家中，倡論“內傷脾胃，百病由生”的李杲，闡發了脾胃“陰火”致勞倦發熱的機理，并且提出：“火”為“元氣之賊”、“火與元氣不兩立”的觀點，引起后世爭論不休。李氏以“升陽散火”之法來治療脾胃元氣虛損，“陰火”上乘之證，創“甘溫除大熱”之法。

朱丹溪則提出“相火論”。認為“凡動皆屬火”，人體以相火為主，相火是人體正常的生理活動表現，但相火妄動則為賊邪，所謂“相火，元氣之賊”。此外，朱丹溪還將各種火證歸納為實火、虛火和郁火三類，提出“氣有余便是火”的精辟之論。

后世醫家進一步對“君火”、“相火”進行探討，張景岳提出：“邪火可言賊，相火不可言賊?！睂嶋H上是強調將朱丹溪所論之生理相火與病理相火區分開來。趙獻可則提出：“君火為陽火，可以直折；相火為龍 火，僅可溫順，導之歸源?！碧岢鰧嵒鹋c虛陽浮越之證的不同治法。李中梓則著重從“水火互濟”來論述火熱病機，指出心腎相交，水火互濟是正常生理，如水不足而火旺，用六味丸壯水之源以制陽光；火不足而水盛，用八味丸益火之主以消陰翳。張景岳還總結了治內傷熱病的法則：“治熱之法，凡微熱之氣，宜涼以和之；大熱之氣，宜寒以制之；郁熱在經絡者，宜疏之、發之；結熱在臟腑者，宜通之、利之；陰虛之熱者，宜壯水以平之；無根之熱者，宜益火以培之?！保ā毒霸廊珪罚?/p>

清代嶺南醫家何夢瑤是火熱學說的集大成者，在其著作《醫碥》中，何夢瑤博采眾長，提出：“熱生于火，火本于氣，其理不外氣乖與氣郁兩端?！逼渲嘘庩柶珓伲磳贇夤裕欢鴼庥魟t更為普遍，何夢瑤謂：“郁未有不為火者，火未有不由郁者也?！币蛑岢鲋位馃嶙C治當“理氣為先”。

明清時期溫病學派的崛起，是對外感溫熱證治的重大突破。溫病醫家提出的衛氣營血辨證、三焦辨證等理論體系以及一系列溫病方藥，大大豐富了火熱學說的內容。

一、火熱學說理論概況(一)火熱之邪的概念與特性

火，屬五行之一，亦屬六氣之一?！渡袝ず榉丁氛f：“火曰炎上”；《易·說卦》稱：“燥萬物者，莫（火漢繁）乎火?！毖咨虾驮锶f物便成為火熱基本特性。在四時之中，孟夏屬火，還有君火、相火的區分：春分之后六十日，為君火之位，天氣溫暖；夏至前后各三十日，為相火之位，天氣炎熱，如時令錯亂君相之位不正，則易傷人。這些理論均被應用到醫學中。

醫學上，火有生理之火與病理之火，張景岳指出：“火，天地之陽氣也。天非此火，不能生物；人非此火，不能有生。故萬物之生皆由陽氣，但陽和之氣則生物，亢烈之火反害物，故火太過是氣反衰，火和平則氣乃壯?！保ā额惤洝罚┢渲凶鳛椴⌒爸?，往往火熱并稱，熱為火之漸，火為熱之極，二者性質相似，故合而論述?；馃嶂靶再|和致病特征如圖示：

火（熱）邪性質和致病特征

火（熱）邪性質 火性燔灼 火性炎上 傷津耗氣

致病特征

全身或局部熱象明顯，伴舌紅脈數等特征。

病變多表現于上部，如面紅耳赤，口舌糜爛，齒齦腫痛等。

迫津外泄，汗出，渴飲，便結，尿少等氣隨津耗，少氣懶言，肢倦乏力等。

生風動血

生風：熱極生風而現高熱，神昏，抽搐等。動血：迫血妄行而現各種出血。

易致腫瘍 易擾心神

腐蝕血肉，發為癰疽瘡瘍，以局部紅腫熱痛為特征。火擾心神則心煩失眠，狂躁譫語等。

在六淫之中，火、暑均屬熱邪，其區別正如王孟英《溫熱經緯》指出：“暑獨盛于夏令，火則四時皆 有?！币虼耍馃岵C不限于時令，是一種廣泛多發的病邪。

有關火熱的名詞，歷來醫家發揮頗多，介紹如下：

人火、龍火：是王冰在注解《至真要大論》中“寒者熱之，熱者寒之，微者逆之，甚者從之”時提出來的，他說：“夫病之微小者猶人火也，遇草而艸熱，得木而燔，可以濕伏，可以水滅，故逆其性氣以折之攻之。病之大甚者猶龍火也，得濕而焰，遇水而燔，不知其性，以水濕折之，適足以光焰詣天，物窮方止矣；識其性者反常之理，以火逐之，則燔灼自消，焰光撲滅?！币虼藢嶋H人火指一般火熱之邪，可用苦寒直折，即“微者逆之”；龍火指病勢較重之虛陽浮越，當“以火逐之”，即“甚者從之”之意，成為后世“引火歸源”治法的理論依據。

君火、相火：本是運氣學說的名詞，見于《素問·天元紀大論》：“君火以明，相火以位”。歷來對此君火、相火的注釋和理解最為復雜，不少醫家均在借對二詞的解釋中確立自已的理論。王冰將“明”改為“名”，朱丹溪據此認為君火是五行配屬之名，正常安靜不見其象，如腎陰虛不能潛藏，動則表現為相火。相火又有寄于肝、膽、腎、三焦等的不同；相火是正常生理活動的源泉，同時又是“元氣之賊”。張景岳則認為“君火以明”是主神明，他認為：“君火居上，為日之明，以昭天道，故于人屬心，而神明出焉；相火居下，為原泉之溫，以生養萬物，故于人屬腎，而元陽蓄焉?！碧岢鼍馂樾幕穑嗷馂槟I火。他把朱丹溪概念混淆的相火區分為正常與病理的不同：正常相火溫養人體，并無火熱之象；如由于腎陰虧虛導致陰虛有熱的證候，即表現為病理之相火。

龍雷之火：是朱丹溪對肝膽相火的命名，朱丹溪認為自然界之火有二：“出于龍雷，則木之氣；出于海，則水之氣也?！币蚨梭w之相火也有寄居于肝（木）、腎（水）的不同。據此后人以龍雷之火指代肝膽相火。

少火、壯火：見于《素問·陰陽應象大論》：“壯火之氣衰，少火之氣壯；壯火食氣，氣食少火；壯火散氣，少火生氣?！币蚨倩鹗侵溉梭w正常的陽氣，壯火是指過亢的陽氣或辛熱壯火之藥物。

陰火：是李東垣獨創的一個病理概念，指飲食勞倦，喜怒憂思所生之火?！镀⑽刚摗吩疲骸胺蝻嬍呈Ч潱疁夭贿m，則脾胃乃傷；喜怒憂恐，損耗元氣。既脾胃氣衰，元氣不足，而心火獨盛。心火者，陰火也，起于下焦，其系系于心，心不主令，相火代之。相火，下焦包絡之火，元氣之賊也?；鹋c元氣不兩立，一勝則一負。脾胃氣虛，則下溜于腎，陰火得以乘其土位，故脾證始得。”

(二)火熱疾病證治

1、實火：劉完素將《內經》病機十九條加以擴充，指出：諸病喘嘔吐酸、暴注下迫，轉筋，小便渾濁，腹脹大鼓之如鼓，癤疽瘍疹，瘤氣結核，吐下霍亂，瞀郁腫脹，鼻塞鼽衄，血溢血泄，淋門必，身熱，惡寒戰栗，驚惑，悲笑，譫妄，衄血蔑血汗，皆屬于熱；諸熱瞀疒契，暴喑冒昧，躁擾狂越，罵詈驚駭，月付腫疼疒皴，氣逆沖上，禁栗，如喪神守，嚏嘔，瘡瘍喉痹，耳鳴及聾，嘔涌，嗌食不下，目昧不明，暴注 目閏疒恝，暴病暴死，皆屬于火。其所列五十多證，多為實火的表現。對實火之證，又可分外感、內傷。外感可因火熱之邪侵犯人體，劉完素提出可以辛涼或甘寒以解表，創制了辛涼解表、表里雙解等法則，成為溫病學派的源頭；內傷則正如何夢瑤所言：“陰陽水火，原自和平，不寒不熱，是謂正氣。一有乖違，不無偏勝。《經》云：‘陽勝則熱’。此為亢陽之火?！笔顷柶珓賹е碌臒嵯?，亦即如朱丹溪所云“氣有余便是火”。對于內傷實火，劉完素提倡用下法，下其里熱。朱丹溪也指出可以“熱者寒之”，以苦寒直折為正治，如云：“人壯氣實，火盛癲狂者，可用正治，或硝黃冰水之類。”他提出用大補丸（一味黃柏）、三補丸（黃連、黃芩、黃柏）治療，是以清為補之意。此外，朱丹溪還善于對火熱熾盛之證用反佐法：“凡火盛者，不可驟用涼藥，必兼溫散?！逼浞ㄈ缬诳嗪幹屑尤虢?，或清熱藥用姜汁拌炒等。當然用寒涼清火亦不可過用，張景岳指出：“夫實熱者，??元氣本無所傷，故可以苦寒折之，信手任心，何難之有？然當熱去即止，不可過用，過則必傷元氣?！笔菫橐唤?。

2、虛火

張景岳謂：“虛火之病源有二，??一曰陰虛能發熱，此以真陰虧損，水不制火也；二曰陽虛，亦能發熱，此以元陽敗竭，火不歸原也。”其中，陰虛發熱最為多見，是陰不足陽相對偏盛導致的虛熱證。朱丹溪《格致余論》指出：“陰虛則發熱，夫陽在外為陰之衛，陰在內為陽之守，精神外馳，嗜欲無節，陰氣耗散，陽無所附，遂致浮散于肌表之間而惡熱也。實非有熱，當作陰虛治之，而用補養之法可也?！敝斓は委熖摶饛娬{以降火為主，滋陰為輔，其意瀉火即所以救陰，倡用知柏滋陰補腎。張景岳則更為強調“真陰”的作用和陰虛發熱的普遍性，他說：“今人之病，陰虛者十常八九”，“虛火為病者，十中常見六七，??虛火者真陰之虧也”。但他認為世人以苦寒為補陰，“非惟不能補陰，亦且善敗真火”，“虛火最忌寒涼，若妄用之，無不致死！”即使傳統補陰之六味丸也因“用茯苓、澤瀉，滲利太過”，而不喜用。對火熱不甚者自制左歸丸，“用六味之意，而不用六味之方”，作為治療真陰腎水不足的主方。另外，陰虛發熱還有另一種更為深重的情況為陰虛陽浮，蓋陰為陽之根，如陰虛不能斂陽，則導致亢陽上浮而發熱，治宜于滋陰藥中加附子、肉桂之類以引火歸原。

至于張景岳所講的“陽虛發熱”之虛火，則是指元陽衰敗，虛陽浮越的戴陽證，其實質并非真熱，而是下真寒上假熱證，治則宜溫燥，何夢瑤謂：“溫其中而陽內返，溫其下而火歸元，誤投寒涼立死?！保ā夺t碥·虛實寒熱》）

3、郁火

實際上，絕對的邪實或正虛相對少見，更多的火熱證多是虛實相兼，其重要的發病機理均是與郁有關。郁即氣郁，氣屬陽，郁則容易化火化熱，即使是實火或虛火，其病機中也多有氣機郁滯的一面，因此何夢瑤提出：“郁未有不為火者，火未有不由郁者也?！?/p>

實際上，劉完素認為火熱證的主要成因是“陽熱怫郁”，就已指出了氣機郁滯是火熱成因的重要一環。他所講的“六氣皆從火化”，其寒、濕等病邪化熱的機理便多是因陽氣閉郁而化熱；“五志過極皆為熱甚”更是由于情志不節，氣機郁滯直接導致。另外，火熱又可反而致郁，《素問玄機原病式》說：“郁，怫郁也，結滯壅塞而氣不通暢，所謂熱甚則腠理閉密而郁結也。如火煉物，熱極相合而不能相離，故熱郁則閉塞而不通暢也?！薄瓣枱嵋诪橛艚Y”，“病熱極，甚則郁結，氣血不能宣通?！彪砝礅鲇魟t發熱；營衛受阻則生癰瘍，津液失于宣行則化濕生痰，眩暈腹脹；血脈閉滯則血留止為瘀，為痛為腫；神機不運則譫狂癲癇；氣機不通，陰陽不相順接則四肢厥逆；臟腑升降失序則上為嘔惡噎膈，下則二便不通；郁熱伏火逼血妄行，則可出現斑疹、便血、吐血、衄血，最終都可傷陰劫液?？傊?，因郁生火，因火致郁，交相肆虐，皆以“怫郁”為關鍵。治療上則指出：“郁結散則氣液宣行，而津液生也?！狈謩e提出郁熱在表，用辛涼如蔥、豉、石膏、滑石等宣發；里熱壅滯胃腸則寒下，用三一承氣湯。表證已解，里熱未結，則如《內經》云“熱淫于內??以苦發之”之說，以辛苦治之，如黃連解毒湯。其后朱丹溪又有“氣有余便是火”和“氣屬陽，動作火”之論，其門人戴思恭謂：“悍衛沖和不息之謂氣，擾亂變常之謂火?！边M一步揭示了“氣→火”的病理機制，李東垣的“氣虛發熱”，實質也是郁火，對此何夢瑤指出，其證是“氣不足，郁而成火”?！端貑枴ふ{經論》曾記載：“有所勞倦，形氣衰少，谷氣不盛，上焦不行，下脘不通，胃氣熱，熱氣熏胸中，故內熱?！薄安恍小迸c“不通”正是胃氣熱的原因。李東垣在《內經》理論上發展成勞倦傷脾說，他指出：“脾胃之氣下流，使谷氣不得升浮，是升發之氣不行，則無陽以護其營衛，則不任風寒乃生寒熱?！逼⑽笟馓摚袣庀孪莶荒苌仙?，郁滯化熱，產生所謂“陰火”，所以李東垣雖稱“以甘溫之劑補其中、升其陽，甘寒以瀉其火則愈”，但其名方補中益氣湯中卻并無甘寒之品，而是在甘溫除熱中配用升麻、柴胡等升提發散之品，主要是取“火郁發之”之義，他還有升陽散火湯、升陽益胃湯等都是針對陽氣遏郁于脾胃的。

除了氣虛而郁外，更多見的是痰、濕、飲、瘀、食等各種病理產物導致的郁火?！兜は姆āち簟氛f：“氣血沖和，萬病不生，一有怫郁，諸病生焉。故人身諸病，多生于郁。”氣血郁滯則生熱，治療上當以解郁為先，對此趙獻可提出用逍遙散為主方通治，謂：“一方治其木郁，而諸郁皆因而愈。”形容其法如“吹面不寒楊柳風”，“溫風開，郁氣即通暢”。（《醫貫》）何夢瑤也認為郁火之治療，“大要以理氣為先。蓋氣滯則血亦滯，而飲食不行，痰濕停積，郁而成火。氣行則數者皆行，故所重在氣，不易之理也?！庇盟幧现赋觥坝舴切翢岵婚_”（《醫碥·郁》），可用火郁湯，升陽散火湯等辛散之劑以散火邪，不過亦要防其過于溫燥。另外，對于痰食濕瘀等導致的郁火，在其輕淺時固可以治氣為主，但如病勢較深則只有祛除遏郁氣機的病因，方能達到疏通氣機，解除郁熱的作用，對此應分別針對病因，采取化痰、燥濕、消食、祛瘀等方法。

情志不遂導致氣機郁滯，進而化熱，無疑也是郁火的一大成因，李杲說：“凡怒忿、悲、思、恐懼，皆損元氣，元氣耗損，則陰火內熾而發熱。”又說：“心生凝滯，七情不安故也。心君不寧，化而為火?！保ā镀⑽刚摗ぐ拆B心神調治脾胃論》）治療上則更主要以理氣為先，可用丹梔逍遙散等，注重加用開郁、安神等藥物。

（三）五臟之火

從臟腑角度而言，五臟各有其不同特性，因此同為火熱，如能結合五臟特點辨證論治，則認識可更深入。《素問·刺熱篇》首先提出五臟熱病的不同特點以及相應的針刺治法。宋代醫家錢乙在《小兒藥證直訣》中記載了肝熱、心熱、肺熱的不同治法。朱丹溪則明確提出：“五臟各有火，五志激之，其火隨起?！薄督饏T鉤玄》曰：“大怒則火起于肝，醉飽則火起于胃，房勞則火起于腎，悲哀動中則火起于肺，心謂君主，自焚則死矣。”

肝熱（火）《素問·刺熱篇》：“肝熱病者，小便先黃，腹痛多臥，身熱。熱爭則狂言及驚，脅滿痛，手足躁，不得安臥。”錢乙創瀉青丸以治肝熱，不但用山梔、大黃清熱，而且根據“肝欲散，急食辛以散之”的特點，用羌活、防風瀉肝，頗受后人推崇。由于肝主氣機，因此各種情志不調導致的氣滯化火尤為常見，后世醫家對此論述甚多，如朱丹溪云：“由肝木氣實火盛，或因怒氣大逆，肝郁木盛，或因謀慮不決，風中于肝，皆使木盛生火，火盛肝急而痛。”對于肝火的治療，清代醫家王旭高《西溪書屋夜話錄》作了歸納：“一法曰清肝”；“一法曰瀉肝，如龍膽瀉肝湯、瀉青丸、當歸龍薈丸之類”；“一法曰清金制木??乃清金以制木火之亢逆也”；“一法曰瀉子，如肝火實者，兼瀉心”；“一法曰化肝，景岳治郁怒傷肝，氣逆動火??方名化肝煎，是清化肝經之郁火也。”

心熱（火）《素問·刺熱篇》云：“心熱病者，先不樂，數日乃熱。熱爭則卒心痛，煩悶善嘔，頭痛面赤無汗。”心之熱證主要表現在神志癥狀和移熱于小腸上，宋代嚴用和《濟生方》指出：“夫心者，手少陰之經，與手太陽小腸之經相為表里。若憂愁思慮傷之，因其虛實，由是寒熱見焉。及其實也，實則生熱，熱則心神煩亂，面赤身熱，口舌生瘡，咽燥頭痛，喜笑恐悸，手心煩熱，汗出衄血?！卞X乙《小兒藥證直訣》云：“心氣熱則心胸亦熱，欲言不能而有就冷之意?！碧岢鲇脤С嗌⒅沃?。此外，“心腎不交”也是導致心火上亢一種因素，嚴用和《濟生方·遺濁》云：“腎藏精，藏精才不可傷。皆由不善衛生，喜怒勞逸，憂愁思慮，嗜欲過度，起居不常，遂至心火炎上而不息，令人遺精、白濁。??此皆心腎不交，關鍵不牢之致也。”可見此證兼由腎虛而致，治則以滋腎為主，可用天王補心丹合六味地黃丸，或于滋腎陰中佐清心火之品。

肺熱（火）

《素問·刺熱論》：“肺熱病者，先淅然厥，起毫毛，惡風寒，舌上黃，身熱。熱爭則喘咳，痛走胸膺背，不得大息，頭痛不堪，汗出而寒?！狈沃髌っ螣嵋酝飧袨槎啵娠L寒入里化熱或、燥熱之邪入侵而致，分別解表清熱諸法治之。如屬內傷，多由木火刑金，肝火上炎所致，治療上錢乙提出瀉白散治之。肺陰虛火熱之證亦多見，然正如《景岳全書·咳咯唾血證治》指出：“凡陰虛生火等證，多以真陰受傷，水虧而然。此所重在陰，不當在火?！惫手委熒隙嘤冒俸瞎探饻?、麥門冬湯等滋陰為主，兼以清熱。

腎熱（火）《素問·刺熱論》：“腎熱病者，先腰痛骨行酸，苦渴數飲身熱。熱爭則項痛而強。骨行寒且酸，足下熱，不欲言，其逆則項痛員員淡淡然?！蹦I之火熱，多由陰虛所致，朱丹溪之相火論、張景岳之陰虛虛火，都是著重針對此證而述，具已見前。朱丹溪云：“房勞則火起于腎”（《格致余論》），提出補腎 水，降相火之大補陰丸，張景岳則強調治陰虛之火忌用苦寒，提出：“善補陰者，必陽中求陰，則陰則陽升而泉源不竭。”創左歸丸以補陰精為主。

脾熱（火）

《素問·刺熱篇》：“脾熱病者，先頭重，頰痛，煩心，顏青，欲嘔，身熱。熱爭則腰痛，不可用俯仰，腹滿泄，兩頷痛?！敝斓は陡裰掠嗾摗吩疲骸白盹杽t火起于胃?！逼岫酁槲笩?，錢乙提出以瀉黃散“治脾熱弄舌”，但方中重用石膏，實是清胃火之品。此外，李杲“脾胃論”提出“氣虛發熱”，其“氣”主要是指脾胃中氣，認為脾氣下陷，陰火上乘是勞倦發熱的病因，提出“甘溫除熱”的代表方補中益氣湯，對后世醫家影響深遠。有人指出李東杲將脾胃勞倦之火名為“陰火”，是因脾為至陰而命名[1]。

二、火熱學說臨床應用

火熱學說在臨床上應用最廣的，自然是各種發熱性疾病。中醫火熱學說對臨床各種發熱疾病具有極大的指導治療作用，尤其是對各種非感染性的無名發熱，具有明顯的優勢。臨床常見和種種不明原因發熱，西醫學通常從神經精神因素、內分泌失調等加以解釋，由于病因不明，往往在治療上束手無策，而善于運用中醫火熱學說則往往能取得意想不到的療效。

除發熱性疾病外，其他臨床內外科疾病對火熱學說的應用也非常廣泛?；馃嶙C不但多見于外感疾病、急性病，許多慢性疾病也貫穿著火熱病機，在早期多表現出實熱證，中期往往由于痰、飲、瘀等病理產物停滯而出現郁熱、痰熱，后期正氣受損常常表現為虛熱，病深陰陽衰竭之際還可以出現戴陽、格陽等危證。試舉各系統病證一二簡介如下：

（一）消化系統疾病。火熱學說在消化系統應用頗廣，例如，火熱是導致上消化道出血的重要病機之一。胃熱（火）是上消化道出血最常見的證型，胃火沖激，迫血妄行，導致出血，治療上采取清熱瀉火，涼血止血,有人[2]用三黃瀉心湯或黃芩湯加丹皮、紫珠草、側柏葉、藕節炭；肝郁型則往往因肝郁化火，肝火犯胃導致的出血，治宜疏肝理氣，涼血止血，有人[3]用柴胡、枳實、黃芩、牡丹皮、白芍、生地、龍膽草、梔子炭、甘草；脾虛除部分屬脾胃虛寒，脾不統血外，多見脾虛肝郁，實際上也導致血氣滯血瘀化熱而迫血妄行，治宜健脾疏肝，清熱涼血，有單位[4]用四黃湯（黃芪、大黃、黃連、生地、甘草）為主治療上消出血100例，結果止血有效90例，總有效率為90%，大便隱血轉陰平均天數為3.1天；陰虛火旺導致的胃中虛熱出血，治療上則滋陰清熱止血，多用玉女煎加減[5]；瘀血阻胃，阻滯氣機并化熱動血則以活血化瘀止血，賴氏[2]用丹參飲或失笑散加大黃、三七粉、赤芍、延胡索治療?？偟膩砜矗F代偏向于將上消化道出血分為5種類型，即胃熱型、肝郁型、脾虛型、陰虛型及瘀血型。其中除脾虛中有一部分屬虛寒外，實際上均與火熱有關。

（二）內分泌系統疾病。內分泌疾病的糖尿病、甲狀腺機能亢進癥等，從中醫角度看都與火熱病機密切相關。以甲亢為例，有人[6]分三型論治：（1）胃火型，養陰清胃火，用養陰瀉火湯（石膏、麥冬、花粉、烏梅、石蓮肉、夏枯草、三黃、四物湯）；（2）肝經實火型，清瀉肝火，用龍膽瀉肝湯加減；（3）肝郁化熱 型，疏肝清熱，用丹梔逍遙散加減，治療32例治愈9例，總有效率93。75%。另有人[7]治療81例，辨證分型為：（1）肝郁心熱，治以疏肝理氣，清心安神，藥用：丹皮、梔子、柴胡、赤芍、當歸、茯神、山藥、生地、黃連、朱砂、玄胡索、炒香附、甘草等；（2）肝胃火旺，治以清瀉肝胃。藥用：龍膽草、黃芩、生梔子、生地、赤芍、生石膏、知母、花粉等。（3）心腎陰虛，治以養心益腎、滋陰清熱，藥用：生地、五味子、麥冬、天冬、玄參、丹參、太子參、當歸、茯神、灸遠志、柏子仁、棗仁、朱砂等。（4）痰氣凝結，治以燥濕化痰、行氣散結，藥用：海藻、昆布、海帶、半夏、陳皮、茯苓、貝母、炒枳殼、桔梗、郁金、當歸、川芎等，共治81例，3個月內治愈29例，顯效11例。綜之，甲亢現代臨床分型大致主要有：肝郁痰結、肝火亢盛或肝陽上亢、中焦蘊熱胃火熾盛、肝腎陰虛虛火內擾、氣陰兩虛、脾腎陽虛等。因此，甲亢責之肝氣郁滯、化火傷陰是最常見的病機，如有癭瘤，則多為痰濁所致，痰火互結。

（三）神經精神系統疾病。從中醫角度認識，神經精神疾病如癲癇、精神分裂、中風等多與火熱有關。以中風為例，有人[ 8]認為中風辨證以痰、火、風、虛、瘀五方面，其中虛（肝腎陰虛和氣虛）為本，而痰、火、風、瘀為標實，其中中風急性期以標實為主。以上諸因素都屬火熱或是導致火熱產生的因素，全國中風協作組也將中風（中經絡）分為：肝陽暴亢、風火上擾；風痰瘀血、痹阻脈絡；痰熱腑實、風痰上擾；氣虛血瘀；陰虛風動五型。這些都與中風急性期臨床表現是吻合的。王永炎[9]將缺血性中風分為風痰瘀血、痹阻脈絡型，治以平肝熄風、化痰通絡；風痰上擾、痰熱腑實型，治以通腑化痰；氣虛血瘀型，治以益氣活血；陰虛風動型，治以育陰熄風法。共治急性缺血性中風220例，結果痊愈90例，顯著進步65例，進步38例，總有效率87.7%。吳銀根[10]將出血性中風分為肝陽肝風型（用鎮肝熄風湯加減）、肝火肝風型（用龍膽瀉肝湯加減）、痰熱交阻型（用滌痰湯加減）、氣虛血瘀型（用補陽還五湯加減）、風中經絡型（用大秦艽湯加減）、肝腎虛衰型（分陰陽補肝腎），共治25例，存活17例，惡化1例，死亡7例。

（四）免疫系統疾病。免疫系統疾病如類風濕、系統性紅斑狼瘡乃至艾滋病，其表現都涉及火熱，并且火熱病機占較重要地位。以系統性紅斑狼瘡（SLE）為例，雖然SLE癥狀多端，但有人[11]認為SLE的種種病癥都是心火所致。具體分型上，張志禮[12]將本病分為：（1）熱毒熾盛、氣血兩燔型，藥用生玳瑁、生地炭、銀花炭、板藍根、白茅根、花粉、丹皮、赤芍等；（2）氣陰兩虛型，藥用沙參、石斛、黨參、黃芪、黃精、白花蛇舌草等；（3）脾腎不足、氣虛瘀滯型。藥用黃芪、黨參、白術、茯苓、菟絲子、女貞子、草河車等。（4）脾虛肝郁、脈絡阻隔型，藥用黃芪、黨參、白術、柴胡、川樸、丹參、雞血藤、首烏藤等。分單純中藥組、單純西藥組、中西醫結合組共治412例，結果中西醫結合組總有效率88.5%，高于其余兩組。有人[13]以清熱解毒為主，輔以涼血祛風、活血化瘀，自制狼瘡丸（金銀花、連翹、丹參、赤芍、蒲公英、白蘚皮、桃仁、紅花、蜈蚣等）治療SLE306例，總有效率85%，無副作用，對部分患者可用狼瘡丸代替激素的維持量。

三、火熱學說現代研究

（一）火熱證的實質研究

現代學者多采取給動物灌喂溫熱中藥（如附子、肉桂、干姜等）制造熱證動物模型，開展熱證實質研究。熱證現代研究概況，反映在以下幾方面：

（1）能量代謝

候燦[14]在1964年提出：“寒”、“熱”證可以看作是以熱量不足或熱量過剩為病因的一種機體典型反應狀態。基礎代謝率、紅細胞糖酵解和氧利用率、ATP含量，T3、T4等的測定表明，熱證時機體的物質代謝特別是分解代謝亢進，能量代謝增強，產熱效應加強。

（2）病理學形態學改變

匡調元[15]1975年報道，大多數臨床表現為熱證的患者常見急性炎癥以及動脈充血與出血等病變。

（3）神經系統

梁月華[16]等人以唾液量、血壓、體溫、心搏間隔、呼吸間隔等數值來衡量植物神經系統的機能狀態，并以Y值作為反映植物神經平衡狀態的指數，如Y為正值，表示交感神經系統活動增強，如為負值，則表示交感神經系統活動減弱或副交感神經系統活動增強。結果熱證組的植物神經平衡指數均為正值，且大多超過正常范圍。謝竹藩[17]等從虛寒與虛熱及虛熱與實熱患者尿中兒茶酚胺（CA）的比較中看出：虛寒與虛熱同屬虛證，但尿中CA的變化相反，虛寒者降低，虛熱者升高；虛熱與實熱一虛一實，尿CA卻都升高，僅程度不同，因此認為尿CA的排出量所表示的交感—腎上腺髓質系統功能活動不反映病癥的虛實，而與病癥的寒熱密切相關。

（4）前列腺素

謝竹藩等[18]人發現，虛寒組PGE2排出量低于對照組，而虛熱組明顯高于對照組。虛寒組PGE2a明顯增高，而虛熱組無明顯變化，PGE2 /PGE2a比值虛寒組明顯低，而虛熱組增高。

（二）清熱法的現代研究

清熱法又有清熱瀉火、清熱解毒、清營涼血、清熱除濕、清熱開竅等幾類，其中清熱藥物多屬苦寒。唐代孫思邈《千金要方》指出：“凡除熱解毒，無過苦酢之物，??夫熱盛非苦酢之物不解也。熱在身中既不時治，治之又不用苦酢之物，此如救火不以水也。”目前，大量藥理作用證實，清熱類中藥具有以下藥理作用：（1）抗病原體。有的藥物根據藥敏試驗單用或組方治療感染性疾病，收到良好的預期效果。從清熱解毒藥中提出的抗菌成分（如黃連、黃柏中的小蘗堿、魚腥草中癸酰乙醛）抗感染效果不比抗菌素差。從青蒿中提取的青蒿素口服后，血液中能達到有效抗瘧濃度。（2）抗炎。清熱類方藥可抑制炎癥滲出，抑制炎癥介質合成和釋放，增強腎上腺皮質功能，且一般不抑制白細胞趨化，甚至促進趨化，因而不致削弱機體抗炎的屏障功能。（3）解熱。清熱類方藥的解熱作用與解表類相比，不同的是一般無明顯出汗主要是降低體溫中樞興奮性，促進皮膚血管擴張散熱，抑制產熱代謝。（4）解毒。細菌釋放病毒素是引起發熱、組織損傷，機體代謝和血液動力學、血液流變學紊亂，削弱免疫功能的重要原因，實驗證實，清熱藥具有解毒作用，拮抗內毒素，且口服給藥能達到血藥濃度，個別復方可達到與地塞米松相似的效果[19]?，F認為大多數抗生素缺乏這種作用。（5）增強機體免疫。清熱解毒方藥能增強大、小吞噬細胞吞噬功能，提高補體、溶菌酶活性，誘生 干擾素，改善特異性體液免疫和細胞免疫。此外，據研究，清熱瀉火藥尚有降低中樞興奮性并加強保護性抑制過程，使腦內5-羥色胺增多，穩定內環境等作用[20]。

參考文獻：

[1] 李壽深，論東垣所創陰火為氣虛之火，山東中醫雜志，1987（3）8。[2] 賴祥林，廣西中醫藥，1985，（1）：7。[3] 李華佳，廣西中醫藥，1985，（1）：7。

[4] 蘭州化學工業分司職工醫院，中醫雜志，1983，12：939。

[5] 上消化道出血證治（筆談），中醫雜志，中醫藥治療上消化道出血近況，1985；26（8）：4。[6] 張俊文，上海中醫藥雜志，1981（8）：10。[7] 蔣珠玉，湖南中醫藥雜志，1987（7）：29。[8] 黃柄山，吉林中醫藥，1986，（2）：14。[9] 王永炎，等。遼寧中醫雜志，1984，9（9）：15。[10] 吳銀根，湖南中醫雜志，1986，（1）：10。[11] 譚宗健，湖南中醫學院學報，1986；（3）：19。[12] 張志禮，中醫雜志，1989；（9）：547。[13] 王仲英，中西醫結合雜志，1989；（8）：465。

[14] 候燦，八綱病理生理學基礎初步探討，中醫雜志，1964（12）：32。

[15] 重慶醫學院新醫病理研究小組，“八綱”之病理學基礎初探，新醫藥學雜志，1975，（3）：114。[16] 梁月華等，中醫寒熱本質的初步研究，中華醫學雜志，1979，（12）：705。

[17] 謝竹藩等，從虛證患者尿中兒茶酚胺量探討病證的寒熱，中西醫結合雜志，1988，8（11）：647。[18] 謝竹藩等，從尿中兒茶酚胺及cAMP、cGMP的排出量探討中醫寒證、熱證的本質，中西醫結合雜志，1986，6（11）651。

[19] 李鳴真等，中藥“熱毒清”注射液抗內毒素的實驗研究，《科研資料選編》（武漢同濟醫科大學中西醫結合研究所），1986。

[20] 梁月華等，寒涼藥溫熱藥對中樞遞質的影響（摘要），中西醫結合雜志，1985，5（2）：82。

第二篇：愛愛醫資源-工作年限及從業年限證明

執業藥師報名及工作年限證明

茲有我單位李安祥同志，碩士研究生，方劑學專業，工作年限1年；從2012年 8月至2013 年 8月在我單位從事中藥科研及中藥飲片管理工作（身份證號41***03016，網絡報名號：020421）

在我單位工作期間，該同志遵守國家和地方的法律、法規，無違反職業道德的行為。同意其報考執業中藥師。

特此證明。

單位（蓋章）2013年7 月 23日

第三篇：藏象學說 講稿

留學生班《中醫學》第三章 臟腑學說

講稿

附三院

周穎芳

Hello, everyone!Today we’ll talk about the theory of viscera and bowels.I am from the third affiliated hospital of Guangzhou Medical University, my name is Zhou Yingfang.I know you have learnt Yin-yang and the five elements doctrines, which make it easier to understand what we’ll learn today.Objectives

After the learning of this chapter, you should master the concept of viscera and bowels, the characteristics, the main functions of the five zang-organs and the six fu-organs, and the mutual relationships among them.At the beginning of learning TCM, not only you, but also the Chinese students have the problem in understanding and accepting the theory of TCM, because it is really different from that of the western medicine.I hope, from now on, you can make yourselves completely into the thinking mode of traditional Chinese medicine.Just like the picture, western medicine and TCM are two different ways, but their purposes are to deal with diseases and make human beings healthy.Let’s see the meaning of the Chinese words of viscera, 藏象。Zang has two pronunciations, one is cang, which means hiding;another is zang, which means the internal organs.Xiang indicates the phenomena and shapes/forms.These two words together implicate the physiological functions and pathological changes of the organs inside our body.The visceral manifestation theory is an important component of TCM.It consists of the study of the physiology and pathology of all the viscera, and the relationship between viscera.In Chinese medicine, each organ is a complex system which encompasses many aspects, such as, the material-anatomical body parts, mind-body-spirit connection, individual constitution, tissues, organs, and surrounding environment.This paradigm is the core of TCM.We divide the internal organs of the body into three kinds: The first one is five zang-viscera, which includes heart, liver, spleen, lung and kidney.Their physiological function is to produce and store essential qi.Essential qi is composed of the congenital essential qi, and the qi from food and drink by transformation and transportation of the spleen and stomach.The second one is six fu-viscera, they are gallbladder, stomach, small intestine, large intestine, urinary bladder and san-jiao.Their physiological function is receiving, transforming, and transporting food and water.If the passage way is not smooth, been obstructed, the person will feel distension in the stomach or the abdomen area.(The five zang-viscera store the essential qi but not discharge it, so they are full, but cannot be filled up.The six fu-viscera transform and digest the matter but do not store it, thus, they are filled, yet are not full.)

The third type is extraordinary fu-viscera.They are brain, marrow, bone, vessel, gallbladder and uterus.They are distinct from the fu-viscera in function.We’ll go into details later.The five zang-viscera 1．Heart The first content is heart.As we all known that the heart is located in the thorax and guarded externally by the pericardium.Let’s go into further understanding of the heart.The heart has the function of circulating blood through the vessels to nourish the whole body.Maybe it’s easier to understand, because it is similar to that in western medicine.The blood circulation looks like a ring without break, but the normal circulation of blood in the vessels depends on both the heart and vessels.The vessels are the pathways of blood circulation and the heart is the motive power of blood circulation.Heart qi can promote the blood circulation, and transport the nourishment materials to the tissues and organs.The beat of the heart relies on the promoting and regulating function of the heart qi.Shen refers to the control of whole body function in a broad sense.Specifically the heart governs spiritual activities, which includes mental aspects, consciousness and thought.Maybe it is the most difficult part for you to understand.In modern medicine, spiritual activities are the function of the cerebrum, or the cerebrum’s reflection, related to, and experiences with objective things.In TCM, heart governs the physiological activities of the organs and body orifices.The material basis of spiritual activities is blood.In physiological condition, if the function of governing spiritual activities is normal, one will be full of vitality, have a clear head, and be quick in both thought and response.But, in the pathological condition, the patient will be upset, have depressive psychosis and mania caused by phlegm-fire disturbing the heart, insomnia, frequent dreaming and palpitation.Here is an example, a person named Fan Jin in a novel of Qing dynasty, lived in poor, he had experienced the exams of more than 20 times, and all failed.Until nearly 60 years old, he got the former second degree candidate in the provincial examination.He was very very happy, and became mad.If we use TCM theory to explain it, it is because the overjoy emotion hurts the heart.In TCM, heart has close relationship with sweat.Sweat is derived from body fluid, and is important component part of blood.There are sayings, such as blood and sweat share a common source, sweat is the fluid from the heart.In normal condition, sweat can moist the skin, while too much sweating may injury heart blood and heart qi.For example, hot environment, too much clothes, or excessive exercises may cause abnormal sweat.And the patient may feel palpitation and feeling of fear.A much more serious condition is known as depletion of yang resulting from profuse sweat, which leads to night sweating.The heart opens to the tongue and manifests on the face.In acupuncture, the large divergent collateral of the heart meridian goes up to the tongue and the face.These areas are rich in blood vessels.You all know a TCM practitioner often looks at the tongue and face, so as to help he/she to make diagnosis.It is said that the tongue is the sprout of the heart.The physiological functions of the heart can be detected through changes in both color and luster of the face.In physiological condition, the heart functions are well, and the heart-blood is abundant, the face will be ruddy and lustrous, and the tongue will be light red and free in motion.In the pathological condition, the manifestations depend on the concrete reason.If the heart-blood is deficient, there will be a pallor complexion and pale tongue.If the heart blood is stagnated, purplish and dark complexion, echymoses or petechiae will appear.Dysfunction of heart in governing mental activities or spirit leads to stiff tongue, difficult in speaking, or aphasis.If the heart-fire is flaring up, there will be red tongue and carbuncles。

Hair is dependent upon the nourishment of blood, so it is said hair is the extension of blood.Pericardium It has the function of protecting the heart.In TCM, exogenous factors that invading the heart often first attack the pericardium.For example, febrile disease with high fever, coma, deep red tongue is known as “heat invading the pericardium” in TCM.2.Lung Governs Qi(1)Governs air breath “getting rid of the stale and taking in the fresh”(2)Governs Qi of the whole body Production of “pectoral qi”, which is composed of fresh air from nature inhaled by the lungs and essential qi from food, water, and stored in the thorax.Qi movement(ascent, descent, exit and entrance)of the whole body In charge of dispersing and descending The function of dispersing and descending involves the distribution of qi, blood, and body-fluid to the zang-fu organs, the muscles, skin and hair.Pathology: cough, difficulty in breathing;fullness of the chest, phlegm Smooth the water passages It means the ascending and descending functions of the lung qi have the function of smoothing and regulating the distribution, circulation and discharging of the water inside body.Discharge the metabolized water in the body in four processes: urine, sweat, respiration, and feces.“the lung is the upper source of water” Governs the skin and hair The skin and hair in this case, represent the entire surface of the body including skin, sweat gland pores, and hair.They acts as a barrier against the invasion of exogenous pathogenic factors.The lung spreads defensive-qi to the body surface, “warms the tissues between the skin and muscles, replenishes the skin, nourishes the muscles, and regulates the opening and closing of the pores”.Pathology: aversion to cold, fever, nasal obstruction, nasal discharge, cough, or even difficult breathing.Opens to the nose Nose is the gate of the lung, and the passage for air enter and exit.Proper function of the lung-qi: clear, unobstructed nasal breathing, smelling Pathology: stuffy nose, running nose, sneezing, itching of the throat.3.Spleen Governs transformation and transportation Substances:(1)food Function: digesting, absorbing and transporting nutritive substances Pathology: poor appetite, abdominal distention, diarrhea, lassitude, and emaciation(2)water Function: promotes water metabolism, moisten and nourish various tissues of the body, avoid retention of water, maintain water metabolism balance.Pathology: edema, phlegm-dampness syndrome, diarrhea Controls blood Function: controlling blood and circulating it within the vessels and prevents blood from extravasating.Pathology: bleeding Sends up essence “spleen qi is in charge of ascending”

Raising up Food Essence, raising up the Internal Organs Pathology: “sinking of the middle-jiao”

chronic diarrhea with proctoptosis uterine prolapse Dominates muscles and limbs Pathology: thin muscles, forceless, flaccid and atrophied limbs Opens to the mouth, manifests on the lips Appetite and taste Pathology: anorexia, tastelessness, or a sweet or sticky taste in the mouth, pale and lusterless lips 4.Liver Regulates the smooth flow of qi(1)Emotions Hypoactive: depression, sorrow, suspicion, sighing, and hypochondriac distress.Hyperactive: irritability, dizziness, vertigo, insomnia, and dream disturbed sleep.(2)Digestion and absorption The ascent and descent of spleen and stomach qi The normal secretion of bile Pathology: poor appetite, indigestion, belching, acid regurgitation, abdominal fullness, and diarrhea.(3)The smooth flow of qi and blood Maintaining normal circulation of qi and blood Pathology: distending pain in the hypochondrium, breast, or lower abdomen.qi is the commander of blood, qi stagnation will be followed by blood stagnation----stabbing pain in the hypochondrium, abdominal masses, irregular menstruation, dysmenorrhea, and amenorrhea.Liver can smooth the flow of qi in the san-jiao to regulate water passages.Otherwise, edema or ascites may appear.The smooth flow of liver qi results in normal sexual function.Hypoactive: impotence and premature ejaculation, or amenorrhea or dysmenorrhea.Hyperactive:

males----over indulgence

in sexual activities，and spermatorrhea females----dreams

of

sexual

fantasies，an

early

menstrual cycle, or metrorrhagia Stores blood Function: storing blood and regulating the volume of blood in circulation.Pathology: liver blood deficiency----blurred vision, night blindness, contracture of muscles and tendons, and motor impairment.women----scanty amenorrhea Dominates tendons and manifests on the nails Pathology: numb and impaired movement of limbs, tremor or spasm.heat-evil----loss of fluids----convulsion, opisthotonos, clenched jaw “the nails are the excretion of the tendons”

Opens to the eyes 5.Kidney The kidneys store vital essence, and are in charge of growth, development and reproduction Congenital and acquired essence Kidney qi in growth, development, reproduction and sexual function.Governs water metabolism

flow of menstrual blood

(1)in distributing body to nourish and moisten tissue(2)the discharge of utilized water by the tissue Governs the reception of Qi “the lungs govern respiration and the kidneys govern reception of qi” Kidneys dominate bone and manufacture marrow, which forms the brain and manifests in the hair.Pathology:

deficiency

of

kidney

essence----

weak or underdeveloped bone, delayed closure of the fontanel, weak bones in children Teeth are an extension of bone.The kidneys manufacture marrow, and the brain is the sea of marrow.The nourishment of hair comes from blood.The kidney stores vital essence which can be transformed into blood.The kidneys open to the ears and have two yin parts.The hearing function of the ear depends on nourishment from kidney essence qi.The two yin parts of the kidneys are the anterior and posterior yin(or the genitals and the anus).Six Fu-viscera

1.Gallbladder Six fu-viscera: hollow in structure, excrete bile to help digest food.Extraodinary fu-viscera: the bile stored in the gallbladder is transformed from the essential qi with similar functions of the five zang-viscera.Function: store, concentrate and excrete bile In terms of mental state, it is in charge of judgment and decision making.Pathology: distending pain in the hypochondriac region, poor appetite, abdominal distension, loose stool, bitter taste in the mouth, vomiting yellow-green and bitter fluid, jaundice.2.Stomach Location: below the diaphragm Function:

(1)Reservoir of foodstuff “barn”, “sea of water and cereal”, “reservoir of foodstuff”(2)Descending function of the stomach Along with the ascending function of the spleen The function of the whole digestive system Pathology: failure of descending of the stomach-qi may cause the adverse rising of the stomach-qi, marked by belching acid regurgitation, nausea, vomiting, hiccup, etc.3.Small Intestine Function:(1)Stores and digests food(2)Separates the clear from the turbid Pathology: fullness of the abdomen, pain of the abdomen, diarrhea, short of urine.4.Large Intestine

Function:

(1)Passes and eliminates waste(2)Governs body-fluid Pathology: constipation or loose stool, diarrhea 5.Urinary Bladder Function:(1)Stores urine(2)Discharges urine

The turbid fluid is formed after the water metabolism, and is transported downwards to the kidneys, where it turns into urine by the qi transformation of kidney.6.San-Jiao

The concept of San-Jiao has two meanings.First, it is one of the six Fu-organs and secondly, it represents the partition of human body, i.e.the generic term of the upper energizer, middle energizer and lower energizer.（1）San-Jiao of the six Fu-organs Function: passing through the original qi and water.San-Jiao is the route for the circulation of original qi and water.Original qi is the most fundamental qi of the human body, the motive power of human vital activities, which is derived from the kidney.The distribution and excretion of the water inside the body are accomplished by the synergistic function of many organs, including lung, spleen and kidney, etc.But the normal circulation of water must be based on the channel function of San-Jiao.（2）Partition Meaning of San-Jiao

As the region, San-Jiao can be divided into three parts, i.e.the upper energizer, middle energizer and lower energizer.It includes the whole body from the head to the feet.Each energizer has its own physiological characteristics.Generally, the chest part above the diaphragm, include heart, lungs, head and face, is called upper energizer.Sometimes, the upper limbs are attributed to the upper energizer too.Upper energizer can disperse the defense qi, distribute the food essence and fluid, nourish and moisten the whole body.Middle energizer refers to the upper abdomen between the diaphragm and the umbilicus, which is consisted by the spleen and stomach.Middle energizer has the function of digesting, absorbing and distributing the food essence and fluid, and producing qi and blood as well.The part below the umbilicus is named lower energizer, which includes small intestine, large intestine, liver, kidneys, bladder and uterus and lower limbs as well.It has the function of discharging the residues and urine.Extraordinary Fu-Organs The extraordinary Fu-organs include brain, marrow, bone, vessels, gallbladder and uterus.Most of them have no internal-external relation with other organs and no attachment with the five elements, except gallbladder with liver, as one of the six Fu-organs.1.Brain Brain is formed by the accumulation of marrow, and then it is called the sea of marrow.（1）Dominate Vital Activities and Spirits Brain is an organ that can produce recognition, emotions, will and behaviors, and it is also the key position of spirit activities.Physiology: full of spirit, clear consciousness, quick thinking, strong memory, clear language and normal emotions.Pathology: apathetic, slow reaction, memory deterioration, manic and irritability, and even coma.（2）Dominate Sense and Movement It means that the eyesight, hearing, speak and movement of the human body are related to the brain.Physiology: good eyesight, sharp hearing, keen sense of smell, normal sensation, light and powerful movement.Pathology: dim vision, loss of hearing, poor sense of smell, dull sensation, fatigue and even hemiplegia.2.Uterus（1）Controlling Menstruation Pathology: irregular

menstruation，such

as

amenorrhea, hypermenorrhea, hypomenorrhea, or metrorrhagia.Since women take blood as the fundament, and the heart controls blood, liver stores blood, spleen produces qi and blood, the menstrual bleeding and cycle are closely related to the physiological functions of the heart, liver and spleen.（2）Dominating Pregnancy The uterus gets the ability of pregnancy at the time of the first menstrual bleeding.After the pregnancy, the uterus becomes a main organ for protecting and developing the fetus.Mutual Relations among the Five Zang-Organs（1）Heart and Lung

Both the heart and lungs are located above the diaphragm.The heart governs the blood and vessels, and the lungs control qi and respiration.The relationship between heart and lungs mainly manifests as the relation of qi and blood.（2）Heart and Spleen Heart governs blood and spleen generates blood.Heart can promote blood circulation, and spleen controls blood and prevents it from bleeding.The relation between heart and spleen are mainly manifested in two aspects, the production of blood and the circulation of blood.（3）Heart and Liver

Heart can promote blood circulation and liver stores blood.Heart controls Shen, while liver governs free flow of qi and adjusts emotional activities.The relation between heart and liver is manifested on two aspects, blood circulation and emotional activities.（4）Heart and Kidney

Heart belongs to fire in the five elements theory, and it is located in the upper part of human body, so it is subordinated to yang.However, kidney belongs to water in the five elements theory, which is located in the lower part of human body, and subordinated to yin.For the ascending-descending theory of water and fire, Yin-Yang as well, it’s good for those at the bottom to go upwards, and those on the top to go downwards.（5）Lung and Spleen

Lungs govern the respiration, and spleen can generate food essence by the function of transportation and transformation.Lungs regulate water metabolism and spleen is also in charge of water metabolism.The relation between lungs and spleen mainly shows in two aspects, production of qi and water metabolism.（6）Lung and Liver

Lungs has descending functions and liver is characterized by dispersing.The relation between lungs and liver is mainly about the ascending and descending of qi movements.（7）Lung and Kidney

Lungs regulate waterways, and kidneys govern water.Lungs dominate respiration and kidneys govern the reception of qi.The relation between lungs and kidneys are mainly manifested by two aspects, water metabolism and respiration.（8）Liver and Spleen

Liver governs the free flow of qi and spleen has the function of transportation and transformation.Liver stores blood and spleen can generate and control blood.The relation between liver and spleen is mainly manifested on two aspects, digestion and absorption, blood regulation.（9）Liver and Kidney

Liver stores blood and kidney stores essence.Liver governs the free flow of qi and kidney is in charge of storage.For the five elements theory, liver belongs to the wood and kidney is attributed to water.They have mother-son relations.The relationship between liver and kidney is mainly manifested on three aspects: essence and blood have a common source, interdependence between storing and discharging, mutual nourishment and interaction between yin and yang.（10）Spleen and Kidney

Spleen is the postnatal base of life, while kidney is the congenital foundation of human body.Spleen participates in the water metabolism by its function of transportation and transformation and kidney governs water.The relation between spleen and kidney is mainly manifested on two aspects, postnatal and congenital bases, and water metabolism.Relations among the Six Fu-Organs The six Fu-organs include gallbladder, stomach, large intestine, small intestine, bladder and San-Jiao, all of which are characterized by transporting food and distributing fluids.The relations among the six Fu-organs are mainly manifested as the aspects of the digestion and absorption of food, distribution of fluid and discharge of residues.Relations among Zang-organs and Fu-organs（1）Heart and Small Intestine

Their relation is mainly manifested on the pathological aspect.If the heart has excessive fire, it will affect the small intestine along the meridians and scanty, red, painful or bloody urine occurs.If the small intestine has excessive heat, it also can influence heart by the upward flow of heat along the meridian and the symptoms include restlessness, red tongue and ulcers in the mouth and on the tongue.（2）Lung and Large Intestine

For the physiology, the descending of lung qi is helpful to the transportation of large intestine.The normal transportation of large intestine can assist the descending of lung qi.For the pathology, if the lungs cannot descend, the fluid will not go downwards and there will be constipation.If there is excessive heat in the large intestine, the qi of Fu-organs will not be smooth, which is able to affect the descending of lungs with symptoms of fullness in the chest, cough and asthma.If the lung qi is deficient and the large intestine is too weak to transport the residues, there will be constipation due to qi deficiency and difficulty in discharging feces.（3）Spleen and Stomach

Spleen and stomach accomplish the digestion, absorption and transportation of food together to nourish the human body, so they are called the postnatal basis.The relation between spleen and stomach is mainly manifested on three aspects:-coordination of receiving and transportation and transformation,-harmony between ascending and descending,-adjustment of dryness and dampness.（4）Liver and Gallbladder

The bile is derived from the liver and the storage and discharge of bile depend on the regulation of liver(free flow of qi).And the smooth discharging of bile is beneficial to the function of liver in governing free flow of qi.（5）Kidney and Bladder

Kidney is the Zang-organ of water and bladder is the Fu-organ of water.The function of bladder in storing and excreting urine depends on the qi transformation and controlling of kidney.

第四篇：愛愛醫資源-兒科心肺復蘇考試題(附答案)

6月兒科心肺復蘇及液體療法考試

1.評估新生兒需要復蘇最初依據什么體征？

（）1.呼吸

2.血壓

3.心率

4.膚色

a.1, 2, 3

b.1, 3, 4

c.1, 2, 4

d.2, 3, 4 2.觸覺刺激后新生兒仍無呼吸時,應采取哪項措施?（）a.吸引氣道 b.繼續觸覺刺激 c.給新生兒吸氧 d.正壓通氣給氧

3.大概有多少比例的新生兒至少需要一些幫助開始自發及規律的自主呼吸?（）a.1% b.3% c.10% d.20% 4.足月的新生兒正常分娩后心肺會按怎樣的步驟發生變化?（）1.動脈導管閉合 2.清除肺泡里的肺液 3.肺充氣擴張 4.肺動脈開始張開

a.1, 4, 3, 2

b.2, 1, 3, 4

c.3, 2, 4, 1

d.4, 2, 1, 3 5.新生兒出生時未能正常過渡,你將會可能發現以下哪種情況?

（）a.紫紺 b.心動過速 c.增加呼吸功 d.以上全部

6．原發性呼吸暫停與繼發性呼吸暫停的特點鑒別點是？

（）a.對觸覺刺激有反應 b.心率下降 c.喘息樣呼吸

d.血壓下降 7．在給早產兒復蘇時會遇到特殊的挑戰是因為：

（）

a.肺缺乏肺泡表面活性物質，造成通氣困難 b.不完全的體溫控制c.腦血管脆性大易于出血 d.以上都是

8．每次分娩中最少應該有多少訓練有素其主要職責是新生兒的處理的人員在場？（）a.1 b.2

c.3

d.4

9．當新生兒出生時有呼吸暫停：

（）

a.在1分鐘Apgar評分后采取治療措施 b.立即給予觸覺刺激

c.立即進行氣管插管

d.立即給予納絡酮

10．一個新生兒經過30s正壓通氣后，心率是55次/min，下面該做什么？（）a.僅提供觸覺刺激

b.開始胸外按壓并繼續正壓通氣 c.僅進行胸外按壓

d.停止正壓通氣

11.下列哪項是決定胎糞污染的新生兒是否需要插管并吸引的主要因素?（）

a.胎糞污染羊水的粘稠度 b.新生兒是否“有活力”

c.1分鐘Apgar評分

d.曾有異常胎心監測史 12.下列使新生兒呼吸的哪種刺激方式不可取?（）

a.用溫熱的毛巾擦拭 b.輕柔地摩擦新生兒的背部

c.托起新生兒拍打其臀部

d.輕輕拍打或彈腳跟 13.復蘇有呼吸暫停,且對擦干和摩擦背部無反應的新生兒最有效的措施是:（）a.常壓給氧

b.拍打腳后跟

c.用冷濕毛巾包裹四肢

d.輔助通氣

14.對于一個新生兒呼吸好,心率正常,但是有中心性紫紺,最好先進行哪項干預?（）a.常壓給氧

b.觸覺性刺激

c.用濃度100%氧正壓通氣

d.給納絡酮

15.足月新生兒提示其羊水中有粘稠的胎糞.當頭部娩出后,新生兒的口腔，咽和鼻都被吸引清理.將他放在預熱后的輻射保溫臺時,新生兒蒼白,軟弱,且無呼吸運動.首先應采取哪項措施?

（）

a.擦干新生兒

b.進行觸覺刺激

c.氣管插管并吸引下呼吸道

d.用氣囊-面罩輔助通氣 16.給新生兒數心率時,6s中心跳9次,這時其心率是:（）a.27次/min b.45次/min c.90次/min d.180次/min 17.當無胎糞時,下列哪項關于清理氣道的描述是正確的?

（）a.深而用力的吸引以清除所有多余的液體

b.先吸引鼻然后是口腔

c.使用連接機械裝置的球形注射器或導管吸引

d.使用大約200mmHg的負壓.18.評估和觸覺刺激后,新生兒心率仍小于100次/min,下一步哪項措施最合適?

（）a.防止體熱丟失

b.進行更多的觸覺刺激

c.常壓給氧

d.正壓通氣

19.一個裝有儲氧器的自動充氣式氣囊,并連接到濃度100%的氧源上,能將多少濃度的氧氣給新生兒?

（）a.30%~40%

b.50%~60%

c.70%~80%

d.90%~100%

20.一新生兒經過正壓通氣,心率大于100次/min,且有自主呼吸,你將:（）

a.繼續進行正壓通氣

b.氣管內插管,并繼續正壓通氣

c.停止正壓通氣

d.停止正壓通氣,給予溫和的刺激,并采取常壓給氧 21.如果一個新生兒需要用氣囊面罩較長時間的正壓通氣,則:（）

a.需要插入胃管

b.應插入口喉氣道

c.應給予腎上腺素

d.新生兒應被重新擺正體位 22.下列哪項不是復蘇中的新生兒狀況有所改善的表現?

（）a.心率增加

b.膚色改善

c.肌張力低降(肌肉放松)

d.自主呼吸 23.為有效的使用復蘇囊,你最好站立在:

（）

a.新生兒的頭側或足側

b.新生兒的身旁一側或頭側

c.新生兒的身旁一側或足側

d.僅在新生兒的右側 24.下列哪項不是氣流充氣式復蘇氣囊的優點?

（）

a.任何時候都可以傳送濃度100%的氧氣

b.新生兒面部未密封好時容易被發現 c.擠壓后總是能夠重新充盈,即使無加壓氧源

d.擠壓時能夠感受到肺的順應性 25.下列哪項是自動充氣式復蘇氣囊的缺點?

（）

a.即使面罩和新生兒面部之間無密封時,氣囊也能夠充盈

b.需要連接儲氧器才能提供大于40%濃度的氧氣 c.不能可靠的用于提供100%濃度的常壓氧氣

d.以上所有都是

26.快速分娩后,新生兒有呼吸暫停,肢軟,青紫,心率40次/min.羊水清.如新生兒仍無反應以下步驟應按何順序進行?

（）1.開始用100%濃度的氧氣正壓通氣

2.迅速給新生兒擺位;拿掉濕了的毛巾;吸引口和鼻;擦干新生兒;并刺激新生兒 3.測量新生兒的心率

4.開始胸外按壓

a.3, 1, 4，2b.1, 2, 3，4c.2, 1, 3, 4

d.3, 4, 2, 1 27.胸外按壓必須伴有:

（）

a.采用腎上腺素

b.用100%濃度氧正壓通氣

c.氣管插管

d.給擴容劑 28.當協調正壓通氣和胸外按壓時,大約每分鐘多少次?

（）a.40次呼吸,120次按壓 b.30次呼吸,90次按壓 c.60次呼吸,120次按壓 d.20次呼吸,80次按壓

29.進行新生兒心臟按壓時,按壓胸骨采取以下哪一個合適深度?

（）a.大約壓到胸廓前后徑的1/b.大約壓到1/3英寸

c.直到你能感覺到脊柱的前面部分

d.深到劍突下至肝臟的位置

30.當給新生兒進行胸外按壓時,通氣應:

（）

a.每分鐘40~60次的速率

b.每分鐘40次的速率

c.每次呼吸后插入一次胸外按壓

d.每3次胸外按壓后插入一次呼吸

31.新生兒起初需要進行胸外按壓,但是重新檢測心率是70次/min,你應該做什么?

（）a.繼續進行胸外按壓直到心率>80次/min

b.停止胸外按壓,繼續每分鐘40~60次的正壓通氣 c.給予腎上腺素

d.嘗試電擊復律（電擊使心臟恢復功能）32.胸外按壓即有規律的按壓胸骨

（）

1.增加胸內壓

2.向脊柱方向按壓心臟

3.將血液泵入靜脈

4.使血液運送到重要器官 a.1, 2, 3

b.1, 2, 4

c.1, 3, 4

d.2, 3, 4 33.剛剛分娩出后,新生兒青紫,軟弱,呼吸暫停.對刺激無反應,心率每分鐘40次,下列哪項最可能幫助恢復正常的自主性的心率?

（）

a.正壓通氣

b.給腎上腺素

c.給阿托品

d.給碳酸氫鈉 34.下列哪項可以提高胸外按壓的安全性和有效性?

（）

a.在胸外按壓放松的時候,使手指或拇指放在新生兒的胸部上.b.持續的壓下2~4英寸的深度 c.按壓時以1比1的頻次間隔通氣

d.每分鐘40~60次的通氣與心臟按壓同步進行 35.下列哪項關于胸外按壓和正壓通氣的配合的描述是正確的?

（）

a.一個人同時進行按壓和通氣 b.每3次通氣后,進行一次胸外按壓

c.大約2秒鐘進行一次4次的“循環”(3次按壓和一次通氣)d.為了使治療達到最佳的配合，一個人應該一手實施雙指胸外按壓法，同時用另一只手擠壓復蘇囊進行通氣

36.為了使用拇指技術或者雙指技術,你應:

（）

a.用軟的墊子支撐在嬰兒的背部以防止皮膚創傷

b.采用不同的位置,深度,和頻率

c.彎曲嬰兒的頸部（骸貼向胸部）37.新生兒復蘇中給予腎上腺素的適宜途徑是:

（）

1.靜脈

2.皮下

3.氣管導管

4.肌肉 a.1, 2

b.2, 4

c.1, 3

d.2, 4 38.在建立充分的通氣之前不宜給予腎上腺素的原因是:

（）

1.那樣會浪費應當用于建立通氣和給氧的寶貴時間

2.腎上腺素不像通氣設備那樣容易獲得

3.肺擴張后使得腎上腺素更好的分布

4.腎上腺素會增加工作負荷和耗氧量,那樣可能會導致不必要的心肌損傷 a.1, 2

b.2, 4

c.2, 3

d.1, 4 39.哪項是腎上腺素的推薦計量?

（）

a.1:10,000的溶液,0.1~0.3ml/kg

b.1:10,000的溶液,1~3ml

c.1:1,000的溶液,0.1~0.3ml/kg

d.1:1,000的溶液,1~3ml 40.以下哪些藥可以通過氣管內導管注入?

（）1.腎上腺素

2.納絡酮

3.碳酸氫鈉

4.白蛋白 a.1, 2

b.2, 3

c.3, 4

d.2, 4 41.下面哪項不是目前推薦的用于治療急性低血容量的方法?

（）

a.生理鹽水

b.白蛋白

c.乳酸林格氏液

d.O型陰性血(若時間允許,最好與母血交叉試驗吻合)42.下面哪些是使用碳酸氫鈉的指征?

（）

1.延長的復蘇

2.30秒輔助通氣和心臟按壓后心率仍小于60次/min 3.嚴重的代謝性酸中毒,可疑的或確診的4.蒼白,脈弱,對復蘇反應差 a.1, 3

b.1, 2

c.2, 3

d.2, 4 43.為什么在復蘇過程中過早的靜脈給予碳酸氫鈉會有危害?

（）a.重碳酸鹽會造成過多的酸累積

b 低張的碳酸氫鹽對氣道有腐蝕性 c.碳酸氫鹽導致額外的二氧化碳產生

d.鈉能轉變成晶體鹽從而阻塞血管 44.當需要給體重2400g的新生兒擴容劑時,應給多大劑量?

（）a.0.24ml

b.2.4ml

c.24ml

d.240ml 45.當需要給體重2400g的新生兒擴容劑時,應如何給?

（）

a.靜脈,快速給藥

b.靜脈,緩慢給藥

c.肌注,迅速給藥

d.氣管,緩慢給藥 46.下列哪項是碳酸氫鈉給藥的正確劑量,途徑,和速度?

（）

劑量途徑速度a.0.5mmol/ml(4.2%)的溶液，2mmol/kg臍靜脈慢速（小于1 mmol/min）

b.1:10,000的溶液，0.1~0.3ml/kg氣管導管或臍靜脈迅速

c.10ml/kg臍靜脈慢速（超過5~10分鐘）

d.0.5mmol/ml(4.2%)的溶液，2mmol/kg氣管導管迅速

47.下面哪些是低血容性休克的臨床指征？

（）

皮膚表現脈搏心率對復蘇的反應a.給氧后持續蒼白微弱高或低差B給氧后持續紫紺好低差C給氧后持續蒼白好高好D給氧后持續紫紺差低好

48.下面哪項是使用過量腎上腺素或快速輸入碳酸氫鈉可能產生的并發癥?

（）A.心率過低

B.肺部慢性疾病

C.顱內出血

D.高血壓

患兒，男，12月，因“解黃色稀水樣便4天，伴神疲少尿半天”入院，查體：體重10kg，嗜睡，前囟和眼窩明顯下陷，哭時淚少，口唇干，皮膚彈性差，腹稍脹，腸鳴音弱，余查體為見明顯異常。入院后查腎功能示鈉137mmol/L、鉀3.0mmol/L、二氧化碳結合力18 mmol/L余正常。

答案

1~5：BDCCA;

6~10：ADABD 11~15：BCDAA

16~20:CCCAD

21~25:CABCD

26~30:CBBAD 31~35:BBAAC

36~40:DCDAA

41~45:BACCB

46~48：AAC 3

第五篇：愛愛醫資源-目錄15---------醫院輻射環境監測方案

___________醫院輻射環境監測方案

一、我院輻射環境監測工作由放射防護領導小組組織，放射科具體實施。

二、我院工作人員從事放射診斷操作時必須穿防護服，帶鉛眼鏡和防護手套，配戴個人計量儀。

三、個人計量儀定期送達市疾控中心或環境監測部門進行劑量監測。

四、放射防護領導小組每季度應對放射防護裝置個人防護監測結果進行一次檢查和總結，確?？諝馕談┝柯实戎笜诉_到《電離國徽防護與國徽源安全基本標準》GB18871-2002和《醫院X射線診斷衛生防護標準》GBZ130-2002要求。

五、自覺接受衛生行政主管部門和環保行政主管部門對我院進行的輻射環境監測。當防護裝置發生變化時，主動邀請衛生、環保部門對新裝置的效果進行監測。