爱爱医资源-火热学说(讲稿)

第一篇：爱爱医资源-火热学说(讲稿)

火热学说(讲稿)火热病机可以说是中医病机中范围最广、影响最大的病机之一，历代医家有关探讨火热病机的理论浩如烟海，形成了中医火热学说。

火热学说源于《黄帝内经》，在《黄帝内经》中，对“火热”之邪的性质、特点以及致病机理进行了讨论。在《阴阳应象大论》中有：“南方生热，热生火，火生苦，苦生心，„„其在天为热，在地为火。”将火热与四时五行五脏联系起来，体现了《黄帝内经》的“天人相应”理论。《至真要大论》的病机十九条，其中涉及火热的即有十条：“诸热瞀疒契，皆属于火”，“诸禁鼓栗，如丧神守，皆属于火”，“诸腹胀大，皆属于热”，“诸逆冲上，皆属于火”，“诸躁狂越，皆属于火”，“诸病有声，鼓之如鼓，皆属于热”，“诸病腑肿，疼疒皴惊骇，皆属于火”，“诸转反戾，水液浑浊，皆属于热”，“诸呕吐酸，暴注下迫，皆属于热”，“诸痛痒疮，皆属于心（火）”。这十条把火热病邪的病理性质、致病特点概括得十分详细，成为火热学说的渊薮。

后世医家在《黄帝内经》的基础上，对火热病机的认识进一步深化，例如唐代医家王冰在注解《黄帝内经》时，发展、阐明了阴阳偏胜的机理，提出了“人火”、“龙火”的概念，成为后世“龙雷之火”及“引火归原法”之所本。

正式使火热学说成为一大学派的，当推金元四大家之一的刘完素。刘完素以“主火论”著称，他把《内经》的病机十九条关于火与热致病的范围进一步扩充，并在理论上提出“六气皆从火化”和“五志过极皆为热甚”的论点，从而阐发了疾病发生、发展中火热病机的普遍性。并且刘完素提出了辛凉解表、表里双解等清热大法，突破了《伤寒论》注重辛温解表、以寒统热的局限，被后世称为寒凉派。金代张从正也非常重视火热病机，并在具体应用中有丰富经验，例如他首先明确指出消渴当从火论治，《儒门事亲·三消说当从火断》云：“五行之中，惟火能焚物；六气之中，惟火能消物，„„（火）得其平则蒸炼饮食，糟粕去焉；不得其平，则燔灼脏腑，而津液竭焉。„„夫一身之心火，甚于上为膈膜之消，甚于中则为肠胃之消，甚于下为膏液之消，甚于外为肌肉之消。上甚不已，而消及于肺；中甚而不已，则消及于脾；下甚而不已，则消及于肝肾；外甚而不已，则消及于筋骨；四脏皆消尽，则心始自焚而死矣。”

金元四大家中，倡论“内伤脾胃，百病由生”的李杲，阐发了脾胃“阴火”致劳倦发热的机理，并且提出：“火”为“元气之贼”、“火与元气不两立”的观点，引起后世争论不休。李氏以“升阳散火”之法来治疗脾胃元气虚损，“阴火”上乘之证，创“甘温除大热”之法。

朱丹溪则提出“相火论”。认为“凡动皆属火”，人体以相火为主，相火是人体正常的生理活动表现，但相火妄动则为贼邪，所谓“相火，元气之贼”。此外，朱丹溪还将各种火证归纳为实火、虚火和郁火三类，提出“气有余便是火”的精辟之论。

后世医家进一步对“君火”、“相火”进行探讨，张景岳提出：“邪火可言贼，相火不可言贼。”实际上是强调将朱丹溪所论之生理相火与病理相火区分开来。赵献可则提出：“君火为阳火，可以直折；相火为龙 火，仅可温顺，导之归源。”提出对实火与虚阳浮越之证的不同治法。李中梓则着重从“水火互济”来论述火热病机，指出心肾相交，水火互济是正常生理，如水不足而火旺，用六味丸壮水之源以制阳光；火不足而水盛，用八味丸益火之主以消阴翳。张景岳还总结了治内伤热病的法则：“治热之法，凡微热之气，宜凉以和之；大热之气，宜寒以制之；郁热在经络者，宜疏之、发之；结热在脏腑者，宜通之、利之；阴虚之热者，宜壮水以平之；无根之热者，宜益火以培之。”（《景岳全书》）

清代岭南医家何梦瑶是火热学说的集大成者，在其著作《医碥》中，何梦瑶博采众长，提出：“热生于火，火本于气，其理不外气乖与气郁两端。”其中阴阳偏胜，即属气乖；而气郁则更为普遍，何梦瑶谓：“郁未有不为火者，火未有不由郁者也。”因之提出治火热证治当“理气为先”。

明清时期温病学派的崛起，是对外感温热证治的重大突破。温病医家提出的卫气营血辨证、三焦辨证等理论体系以及一系列温病方药，大大丰富了火热学说的内容。

一、火热学说理论概况(一)火热之邪的概念与特性

火，属五行之一，亦属六气之一。《尚书·洪范》说：“火曰炎上”；《易·说卦》称：“燥万物者，莫（火汉繁）乎火。”炎上和燥万物便成为火热基本特性。在四时之中，孟夏属火，还有君火、相火的区分：春分之后六十日，为君火之位，天气温暖；夏至前后各三十日，为相火之位，天气炎热，如时令错乱君相之位不正，则易伤人。这些理论均被应用到医学中。

医学上，火有生理之火与病理之火，张景岳指出：“火，天地之阳气也。天非此火，不能生物；人非此火，不能有生。故万物之生皆由阳气，但阳和之气则生物，亢烈之火反害物，故火太过是气反衰，火和平则气乃壮。”（《类经》）其中作为病邪之火，往往火热并称，热为火之渐，火为热之极，二者性质相似，故合而论述。火热之邪性质和致病特征如图示：

火（热）邪性质和致病特征

火（热）邪性质 火性燔灼 火性炎上 伤津耗气

致病特征

全身或局部热象明显，伴舌红脉数等特征。

病变多表现于上部，如面红耳赤，口舌糜烂，齿龈肿痛等。

迫津外泄，汗出，渴饮，便结，尿少等气随津耗，少气懒言，肢倦乏力等。

生风动血

生风：热极生风而现高热，神昏，抽搐等。动血：迫血妄行而现各种出血。

易致肿疡 易扰心神

腐蚀血肉，发为痈疽疮疡，以局部红肿热痛为特征。火扰心神则心烦失眠，狂躁谵语等。

在六淫之中，火、暑均属热邪，其区别正如王孟英《温热经纬》指出：“暑独盛于夏令，火则四时皆 有。”因此，火热病机不限于时令，是一种广泛多发的病邪。

有关火热的名词，历来医家发挥颇多，介绍如下：

人火、龙火：是王冰在注解《至真要大论》中“寒者热之，热者寒之，微者逆之，甚者从之”时提出来的，他说：“夫病之微小者犹人火也，遇草而艹热，得木而燔，可以湿伏，可以水灭，故逆其性气以折之攻之。病之大甚者犹龙火也，得湿而焰，遇水而燔，不知其性，以水湿折之，适足以光焰诣天，物穷方止矣；识其性者反常之理，以火逐之，则燔灼自消，焰光扑灭。”因此实际人火指一般火热之邪，可用苦寒直折，即“微者逆之”；龙火指病势较重之虚阳浮越，当“以火逐之”，即“甚者从之”之意，成为后世“引火归源”治法的理论依据。

君火、相火：本是运气学说的名词，见于《素问·天元纪大论》：“君火以明，相火以位”。历来对此君火、相火的注释和理解最为复杂，不少医家均在借对二词的解释中确立自已的理论。王冰将“明”改为“名”，朱丹溪据此认为君火是五行配属之名，正常安静不见其象，如肾阴虚不能潜藏，动则表现为相火。相火又有寄于肝、胆、肾、三焦等的不同；相火是正常生理活动的源泉，同时又是“元气之贼”。张景岳则认为“君火以明”是主神明，他认为：“君火居上，为日之明，以昭天道，故于人属心，而神明出焉；相火居下，为原泉之温，以生养万物，故于人属肾，而元阳蓄焉。”提出君火为心火，相火为肾火。他把朱丹溪概念混淆的相火区分为正常与病理的不同：正常相火温养人体，并无火热之象；如由于肾阴亏虚导致阴虚有热的证候，即表现为病理之相火。

龙雷之火：是朱丹溪对肝胆相火的命名，朱丹溪认为自然界之火有二：“出于龙雷，则木之气；出于海，则水之气也。”因而人体之相火也有寄居于肝（木）、肾（水）的不同。据此后人以龙雷之火指代肝胆相火。

少火、壮火：见于《素问·阴阳应象大论》：“壮火之气衰，少火之气壮；壮火食气，气食少火；壮火散气，少火生气。”因而少火是指人体正常的阳气，壮火是指过亢的阳气或辛热壮火之药物。

阴火：是李东垣独创的一个病理概念，指饮食劳倦，喜怒忧思所生之火。《脾胃论》云：“夫饮食失节，寒温不适，则脾胃乃伤；喜怒忧恐，损耗元气。既脾胃气衰，元气不足，而心火独盛。心火者，阴火也，起于下焦，其系系于心，心不主令，相火代之。相火，下焦包络之火，元气之贼也。火与元气不两立，一胜则一负。脾胃气虚，则下溜于肾，阴火得以乘其土位，故脾证始得。”

(二)火热疾病证治

1、实火：刘完素将《内经》病机十九条加以扩充，指出：诸病喘呕吐酸、暴注下迫，转筋，小便浑浊，腹胀大鼓之如鼓，疖疽疡疹，瘤气结核，吐下霍乱，瞀郁肿胀，鼻塞鼽衄，血溢血泄，淋门必，身热，恶寒战栗，惊惑，悲笑，谵妄，衄血蔑血汗，皆属于热；诸热瞀疒契，暴喑冒昧，躁扰狂越，骂詈惊骇，月付肿疼疒皴，气逆冲上，禁栗，如丧神守，嚏呕，疮疡喉痹，耳鸣及聋，呕涌，嗌食不下，目昧不明，暴注 目闰疒恝，暴病暴死，皆属于火。其所列五十多证，多为实火的表现。对实火之证，又可分外感、内伤。外感可因火热之邪侵犯人体，刘完素提出可以辛凉或甘寒以解表，创制了辛凉解表、表里双解等法则，成为温病学派的源头；内伤则正如何梦瑶所言：“阴阳水火，原自和平，不寒不热，是谓正气。一有乖违，不无偏胜。《经》云：‘阳胜则热’。此为亢阳之火。”是阳偏胜导致的热象，亦即如朱丹溪所云“气有余便是火”。对于内伤实火，刘完素提倡用下法，下其里热。朱丹溪也指出可以“热者寒之”，以苦寒直折为正治，如云：“人壮气实，火盛癫狂者，可用正治，或硝黄冰水之类。”他提出用大补丸（一味黄柏）、三补丸（黄连、黄芩、黄柏）治疗，是以清为补之意。此外，朱丹溪还善于对火热炽盛之证用反佐法：“凡火盛者，不可骤用凉药，必兼温散。”其法如于苦寒药中加入姜汁，或清热药用姜汁拌炒等。当然用寒凉清火亦不可过用，张景岳指出：“夫实热者，„„元气本无所伤，故可以苦寒折之，信手任心，何难之有？然当热去即止，不可过用，过则必伤元气。”是为一戒。

2、虚火

张景岳谓：“虚火之病源有二，„„一曰阴虚能发热，此以真阴亏损，水不制火也；二曰阳虚，亦能发热，此以元阳败竭，火不归原也。”其中，阴虚发热最为多见，是阴不足阳相对偏盛导致的虚热证。朱丹溪《格致余论》指出：“阴虚则发热，夫阳在外为阴之卫，阴在内为阳之守，精神外驰，嗜欲无节，阴气耗散，阳无所附，遂致浮散于肌表之间而恶热也。实非有热，当作阴虚治之，而用补养之法可也。”朱丹溪治疗虚火强调以降火为主，滋阴为辅，其意泻火即所以救阴，倡用知柏滋阴补肾。张景岳则更为强调“真阴”的作用和阴虚发热的普遍性，他说：“今人之病，阴虚者十常八九”，“虚火为病者，十中常见六七，„„虚火者真阴之亏也”。但他认为世人以苦寒为补阴，“非惟不能补阴，亦且善败真火”，“虚火最忌寒凉，若妄用之，无不致死！”即使传统补阴之六味丸也因“用茯苓、泽泻，渗利太过”，而不喜用。对火热不甚者自制左归丸，“用六味之意，而不用六味之方”，作为治疗真阴肾水不足的主方。另外，阴虚发热还有另一种更为深重的情况为阴虚阳浮，盖阴为阳之根，如阴虚不能敛阳，则导致亢阳上浮而发热，治宜于滋阴药中加附子、肉桂之类以引火归原。

至于张景岳所讲的“阳虚发热”之虚火，则是指元阳衰败，虚阳浮越的戴阳证，其实质并非真热，而是下真寒上假热证，治则宜温燥，何梦瑶谓：“温其中而阳内返，温其下而火归元，误投寒凉立死。”（《医碥·虚实寒热》）

3、郁火

实际上，绝对的邪实或正虚相对少见，更多的火热证多是虚实相兼，其重要的发病机理均是与郁有关。郁即气郁，气属阳，郁则容易化火化热，即使是实火或虚火，其病机中也多有气机郁滞的一面，因此何梦瑶提出：“郁未有不为火者，火未有不由郁者也。”

实际上，刘完素认为火热证的主要成因是“阳热怫郁”，就已指出了气机郁滞是火热成因的重要一环。他所讲的“六气皆从火化”，其寒、湿等病邪化热的机理便多是因阳气闭郁而化热；“五志过极皆为热甚”更是由于情志不节，气机郁滞直接导致。另外，火热又可反而致郁，《素问玄机原病式》说：“郁，怫郁也，结滞壅塞而气不通畅，所谓热甚则腠理闭密而郁结也。如火炼物，热极相合而不能相离，故热郁则闭塞而不通畅也。”“阳热易为郁结”，“病热极，甚则郁结，气血不能宣通。”腠理怫郁则发热；营卫受阻则生痈疡，津液失于宣行则化湿生痰，眩晕腹胀；血脉闭滞则血留止为瘀，为痛为肿；神机不运则谵狂癫痫；气机不通，阴阳不相顺接则四肢厥逆；脏腑升降失序则上为呕恶噎膈，下则二便不通；郁热伏火逼血妄行，则可出现斑疹、便血、吐血、衄血，最终都可伤阴劫液。总之，因郁生火，因火致郁，交相肆虐，皆以“怫郁”为关键。治疗上则指出：“郁结散则气液宣行，而津液生也。”分别提出郁热在表，用辛凉如葱、豉、石膏、滑石等宣发；里热壅滞胃肠则寒下，用三一承气汤。表证已解，里热未结，则如《内经》云“热淫于内„„以苦发之”之说，以辛苦治之，如黄连解毒汤。其后朱丹溪又有“气有余便是火”和“气属阳，动作火”之论，其门人戴思恭谓：“悍卫冲和不息之谓气，扰乱变常之谓火。”进一步揭示了“气→火”的病理机制，李东垣的“气虚发热”，实质也是郁火，对此何梦瑶指出，其证是“气不足，郁而成火”。《素问·调经论》曾记载：“有所劳倦，形气衰少，谷气不盛，上焦不行，下脘不通，胃气热，热气熏胸中，故内热。”“不行”与“不通”正是胃气热的原因。李东垣在《内经》理论上发展成劳倦伤脾说，他指出：“脾胃之气下流，使谷气不得升浮，是升发之气不行，则无阳以护其营卫，则不任风寒乃生寒热。”脾胃气虚，中气下陷不能上升，郁滞化热，产生所谓“阴火”，所以李东垣虽称“以甘温之剂补其中、升其阳，甘寒以泻其火则愈”，但其名方补中益气汤中却并无甘寒之品，而是在甘温除热中配用升麻、柴胡等升提发散之品，主要是取“火郁发之”之义，他还有升阳散火汤、升阳益胃汤等都是针对阳气遏郁于脾胃的。

除了气虚而郁外，更多见的是痰、湿、饮、瘀、食等各种病理产物导致的郁火。《丹溪心法·六郁》说：“气血冲和，万病不生，一有怫郁，诸病生焉。故人身诸病，多生于郁。”气血郁滞则生热，治疗上当以解郁为先，对此赵献可提出用逍遥散为主方通治，谓：“一方治其木郁，而诸郁皆因而愈。”形容其法如“吹面不寒杨柳风”，“温风开，郁气即通畅”。（《医贯》）何梦瑶也认为郁火之治疗，“大要以理气为先。盖气滞则血亦滞，而饮食不行，痰湿停积，郁而成火。气行则数者皆行，故所重在气，不易之理也。”用药上指出“郁非辛热不开”（《医碥·郁》），可用火郁汤，升阳散火汤等辛散之剂以散火邪，不过亦要防其过于温燥。另外，对于痰食湿瘀等导致的郁火，在其轻浅时固可以治气为主，但如病势较深则只有祛除遏郁气机的病因，方能达到疏通气机，解除郁热的作用，对此应分别针对病因，采取化痰、燥湿、消食、祛瘀等方法。

情志不遂导致气机郁滞，进而化热，无疑也是郁火的一大成因，李杲说：“凡怒忿、悲、思、恐惧，皆损元气，元气耗损，则阴火内炽而发热。”又说：“心生凝滞，七情不安故也。心君不宁，化而为火。”（《脾胃论·安养心神调治脾胃论》）治疗上则更主要以理气为先，可用丹栀逍遥散等，注重加用开郁、安神等药物。

（三）五脏之火

从脏腑角度而言，五脏各有其不同特性，因此同为火热，如能结合五脏特点辨证论治，则认识可更深入。《素问·刺热篇》首先提出五脏热病的不同特点以及相应的针刺治法。宋代医家钱乙在《小儿药证直诀》中记载了肝热、心热、肺热的不同治法。朱丹溪则明确提出：“五脏各有火，五志激之，其火随起。”《金匮钩玄》曰：“大怒则火起于肝，醉饱则火起于胃，房劳则火起于肾，悲哀动中则火起于肺，心谓君主，自焚则死矣。”

肝热（火）《素问·刺热篇》：“肝热病者，小便先黄，腹痛多卧，身热。热争则狂言及惊，胁满痛，手足躁，不得安卧。”钱乙创泻青丸以治肝热，不但用山栀、大黄清热，而且根据“肝欲散，急食辛以散之”的特点，用羌活、防风泻肝，颇受后人推崇。由于肝主气机，因此各种情志不调导致的气滞化火尤为常见，后世医家对此论述甚多，如朱丹溪云：“由肝木气实火盛，或因怒气大逆，肝郁木盛，或因谋虑不决，风中于肝，皆使木盛生火，火盛肝急而痛。”对于肝火的治疗，清代医家王旭高《西溪书屋夜话录》作了归纳：“一法曰清肝”；“一法曰泻肝，如龙胆泻肝汤、泻青丸、当归龙荟丸之类”；“一法曰清金制木„„乃清金以制木火之亢逆也”；“一法曰泻子，如肝火实者，兼泻心”；“一法曰化肝，景岳治郁怒伤肝，气逆动火„„方名化肝煎，是清化肝经之郁火也。”

心热（火）《素问·刺热篇》云：“心热病者，先不乐，数日乃热。热争则卒心痛，烦闷善呕，头痛面赤无汗。”心之热证主要表现在神志症状和移热于小肠上，宋代严用和《济生方》指出：“夫心者，手少阴之经，与手太阳小肠之经相为表里。若忧愁思虑伤之，因其虚实，由是寒热见焉。及其实也，实则生热，热则心神烦乱，面赤身热，口舌生疮，咽燥头痛，喜笑恐悸，手心烦热，汗出衄血。”钱乙《小儿药证直诀》云：“心气热则心胸亦热，欲言不能而有就冷之意。”提出用导赤散治之。此外，“心肾不交”也是导致心火上亢一种因素，严用和《济生方·遗浊》云：“肾藏精，藏精才不可伤。皆由不善卫生，喜怒劳逸，忧愁思虑，嗜欲过度，起居不常，遂至心火炎上而不息，令人遗精、白浊。„„此皆心肾不交，关键不牢之致也。”可见此证兼由肾虚而致，治则以滋肾为主，可用天王补心丹合六味地黄丸，或于滋肾阴中佐清心火之品。

肺热（火）

《素问·刺热论》：“肺热病者，先淅然厥，起毫毛，恶风寒，舌上黄，身热。热争则喘咳，痛走胸膺背，不得大息，头痛不堪，汗出而寒。”肺主皮毛，肺热以外感为多，由风寒入里化热或、燥热之邪入侵而致，分别解表清热诸法治之。如属内伤，多由木火刑金，肝火上炎所致，治疗上钱乙提出泻白散治之。肺阴虚火热之证亦多见，然正如《景岳全书·咳咯唾血证治》指出：“凡阴虚生火等证，多以真阴受伤，水亏而然。此所重在阴，不当在火。”故治疗上多用百合固金汤、麦门冬汤等滋阴为主，兼以清热。

肾热（火）《素问·刺热论》：“肾热病者，先腰痛骨行酸，苦渴数饮身热。热争则项痛而强。骨行寒且酸，足下热，不欲言，其逆则项痛员员淡淡然。”肾之火热，多由阴虚所致，朱丹溪之相火论、张景岳之阴虚虚火，都是着重针对此证而述，具已见前。朱丹溪云：“房劳则火起于肾”（《格致余论》），提出补肾 水，降相火之大补阴丸，张景岳则强调治阴虚之火忌用苦寒，提出：“善补阴者，必阳中求阴，则阴则阳升而泉源不竭。”创左归丸以补阴精为主。

脾热（火）

《素问·刺热篇》：“脾热病者，先头重，颊痛，烦心，颜青，欲呕，身热。热争则腰痛，不可用俯仰，腹满泄，两颔痛。”朱丹溪《格致余论》云：“醉饱则火起于胃。”脾热多为胃热，钱乙提出以泻黄散“治脾热弄舌”，但方中重用石膏，实是清胃火之品。此外，李杲“脾胃论”提出“气虚发热”，其“气”主要是指脾胃中气，认为脾气下陷，阴火上乘是劳倦发热的病因，提出“甘温除热”的代表方补中益气汤，对后世医家影响深远。有人指出李东杲将脾胃劳倦之火名为“阴火”，是因脾为至阴而命名[1]。

二、火热学说临床应用

火热学说在临床上应用最广的，自然是各种发热性疾病。中医火热学说对临床各种发热疾病具有极大的指导治疗作用，尤其是对各种非感染性的无名发热，具有明显的优势。临床常见和种种不明原因发热，西医学通常从神经精神因素、内分泌失调等加以解释，由于病因不明，往往在治疗上束手无策，而善于运用中医火热学说则往往能取得意想不到的疗效。

除发热性疾病外，其他临床内外科疾病对火热学说的应用也非常广泛。火热证不但多见于外感疾病、急性病，许多慢性疾病也贯穿着火热病机，在早期多表现出实热证，中期往往由于痰、饮、瘀等病理产物停滞而出现郁热、痰热，后期正气受损常常表现为虚热，病深阴阳衰竭之际还可以出现戴阳、格阳等危证。试举各系统病证一二简介如下：

（一）消化系统疾病。火热学说在消化系统应用颇广，例如，火热是导致上消化道出血的重要病机之一。胃热（火）是上消化道出血最常见的证型，胃火冲激，迫血妄行，导致出血，治疗上采取清热泻火，凉血止血,有人[2]用三黄泻心汤或黄芩汤加丹皮、紫珠草、侧柏叶、藕节炭；肝郁型则往往因肝郁化火，肝火犯胃导致的出血，治宜疏肝理气，凉血止血，有人[3]用柴胡、枳实、黄芩、牡丹皮、白芍、生地、龙胆草、栀子炭、甘草；脾虚除部分属脾胃虚寒，脾不统血外，多见脾虚肝郁，实际上也导致血气滞血瘀化热而迫血妄行，治宜健脾疏肝，清热凉血，有单位[4]用四黄汤（黄芪、大黄、黄连、生地、甘草）为主治疗上消出血100例，结果止血有效90例，总有效率为90%，大便隐血转阴平均天数为3.1天；阴虚火旺导致的胃中虚热出血，治疗上则滋阴清热止血，多用玉女煎加减[5]；瘀血阻胃，阻滞气机并化热动血则以活血化瘀止血，赖氏[2]用丹参饮或失笑散加大黄、三七粉、赤芍、延胡索治疗。总的来看，现代偏向于将上消化道出血分为5种类型，即胃热型、肝郁型、脾虚型、阴虚型及瘀血型。其中除脾虚中有一部分属虚寒外，实际上均与火热有关。

（二）内分泌系统疾病。内分泌疾病的糖尿病、甲状腺机能亢进症等，从中医角度看都与火热病机密切相关。以甲亢为例，有人[6]分三型论治：（1）胃火型，养阴清胃火，用养阴泻火汤（石膏、麦冬、花粉、乌梅、石莲肉、夏枯草、三黄、四物汤）；（2）肝经实火型，清泻肝火，用龙胆泻肝汤加减；（3）肝郁化热 型，疏肝清热，用丹栀逍遥散加减，治疗32例治愈9例，总有效率93。75%。另有人[7]治疗81例，辨证分型为：（1）肝郁心热，治以疏肝理气，清心安神，药用：丹皮、栀子、柴胡、赤芍、当归、茯神、山药、生地、黄连、朱砂、玄胡索、炒香附、甘草等；（2）肝胃火旺，治以清泻肝胃。药用：龙胆草、黄芩、生栀子、生地、赤芍、生石膏、知母、花粉等。（3）心肾阴虚，治以养心益肾、滋阴清热，药用：生地、五味子、麦冬、天冬、玄参、丹参、太子参、当归、茯神、灸远志、柏子仁、枣仁、朱砂等。（4）痰气凝结，治以燥湿化痰、行气散结，药用：海藻、昆布、海带、半夏、陈皮、茯苓、贝母、炒枳壳、桔梗、郁金、当归、川芎等，共治81例，3个月内治愈29例，显效11例。综之，甲亢现代临床分型大致主要有：肝郁痰结、肝火亢盛或肝阳上亢、中焦蕴热胃火炽盛、肝肾阴虚虚火内扰、气阴两虚、脾肾阳虚等。因此，甲亢责之肝气郁滞、化火伤阴是最常见的病机，如有瘿瘤，则多为痰浊所致，痰火互结。

（三）神经精神系统疾病。从中医角度认识，神经精神疾病如癫痫、精神分裂、中风等多与火热有关。以中风为例，有人[ 8]认为中风辨证以痰、火、风、虚、瘀五方面，其中虚（肝肾阴虚和气虚）为本，而痰、火、风、瘀为标实，其中中风急性期以标实为主。以上诸因素都属火热或是导致火热产生的因素，全国中风协作组也将中风（中经络）分为：肝阳暴亢、风火上扰；风痰瘀血、痹阻脉络；痰热腑实、风痰上扰；气虚血瘀；阴虚风动五型。这些都与中风急性期临床表现是吻合的。王永炎[9]将缺血性中风分为风痰瘀血、痹阻脉络型，治以平肝熄风、化痰通络；风痰上扰、痰热腑实型，治以通腑化痰；气虚血瘀型，治以益气活血；阴虚风动型，治以育阴熄风法。共治急性缺血性中风220例，结果痊愈90例，显著进步65例，进步38例，总有效率87.7%。吴银根[10]将出血性中风分为肝阳肝风型（用镇肝熄风汤加减）、肝火肝风型（用龙胆泻肝汤加减）、痰热交阻型（用涤痰汤加减）、气虚血瘀型（用补阳还五汤加减）、风中经络型（用大秦艽汤加减）、肝肾虚衰型（分阴阳补肝肾），共治25例，存活17例，恶化1例，死亡7例。

（四）免疫系统疾病。免疫系统疾病如类风湿、系统性红斑狼疮乃至艾滋病，其表现都涉及火热，并且火热病机占较重要地位。以系统性红斑狼疮（SLE）为例，虽然SLE症状多端，但有人[11]认为SLE的种种病症都是心火所致。具体分型上，张志礼[12]将本病分为：（1）热毒炽盛、气血两燔型，药用生玳瑁、生地炭、银花炭、板蓝根、白茅根、花粉、丹皮、赤芍等；（2）气阴两虚型，药用沙参、石斛、党参、黄芪、黄精、白花蛇舌草等；（3）脾肾不足、气虚瘀滞型。药用黄芪、党参、白术、茯苓、菟丝子、女贞子、草河车等。（4）脾虚肝郁、脉络阻隔型，药用黄芪、党参、白术、柴胡、川朴、丹参、鸡血藤、首乌藤等。分单纯中药组、单纯西药组、中西医结合组共治412例，结果中西医结合组总有效率88.5%，高于其余两组。有人[13]以清热解毒为主，辅以凉血祛风、活血化瘀，自制狼疮丸（金银花、连翘、丹参、赤芍、蒲公英、白藓皮、桃仁、红花、蜈蚣等）治疗SLE306例，总有效率85%，无副作用，对部分患者可用狼疮丸代替激素的维持量。

三、火热学说现代研究

（一）火热证的实质研究

现代学者多采取给动物灌喂温热中药（如附子、肉桂、干姜等）制造热证动物模型，开展热证实质研究。热证现代研究概况，反映在以下几方面：

（1）能量代谢

候灿[14]在1964年提出：“寒”、“热”证可以看作是以热量不足或热量过剩为病因的一种机体典型反应状态。基础代谢率、红细胞糖酵解和氧利用率、ATP含量，T3、T4等的测定表明，热证时机体的物质代谢特别是分解代谢亢进，能量代谢增强，产热效应加强。

（2）病理学形态学改变

匡调元[15]1975年报道，大多数临床表现为热证的患者常见急性炎症以及动脉充血与出血等病变。

（3）神经系统

梁月华[16]等人以唾液量、血压、体温、心搏间隔、呼吸间隔等数值来衡量植物神经系统的机能状态，并以Y值作为反映植物神经平衡状态的指数，如Y为正值，表示交感神经系统活动增强，如为负值，则表示交感神经系统活动减弱或副交感神经系统活动增强。结果热证组的植物神经平衡指数均为正值，且大多超过正常范围。谢竹藩[17]等从虚寒与虚热及虚热与实热患者尿中儿茶酚胺（CA）的比较中看出：虚寒与虚热同属虚证，但尿中CA的变化相反，虚寒者降低，虚热者升高；虚热与实热一虚一实，尿CA却都升高，仅程度不同，因此认为尿CA的排出量所表示的交感—肾上腺髓质系统功能活动不反映病症的虚实，而与病症的寒热密切相关。

（4）前列腺素

谢竹藩等[18]人发现，虚寒组PGE2排出量低于对照组，而虚热组明显高于对照组。虚寒组PGE2a明显增高，而虚热组无明显变化，PGE2 /PGE2a比值虚寒组明显低，而虚热组增高。

（二）清热法的现代研究

清热法又有清热泻火、清热解毒、清营凉血、清热除湿、清热开窍等几类，其中清热药物多属苦寒。唐代孙思邈《千金要方》指出：“凡除热解毒，无过苦酢之物，„„夫热盛非苦酢之物不解也。热在身中既不时治，治之又不用苦酢之物，此如救火不以水也。”目前，大量药理作用证实，清热类中药具有以下药理作用：（1）抗病原体。有的药物根据药敏试验单用或组方治疗感染性疾病，收到良好的预期效果。从清热解毒药中提出的抗菌成分（如黄连、黄柏中的小蘖碱、鱼腥草中癸酰乙醛）抗感染效果不比抗菌素差。从青蒿中提取的青蒿素口服后，血液中能达到有效抗疟浓度。（2）抗炎。清热类方药可抑制炎症渗出，抑制炎症介质合成和释放，增强肾上腺皮质功能，且一般不抑制白细胞趋化，甚至促进趋化，因而不致削弱机体抗炎的屏障功能。（3）解热。清热类方药的解热作用与解表类相比，不同的是一般无明显出汗主要是降低体温中枢兴奋性，促进皮肤血管扩张散热，抑制产热代谢。（4）解毒。细菌释放病毒素是引起发热、组织损伤，机体代谢和血液动力学、血液流变学紊乱，削弱免疫功能的重要原因，实验证实，清热药具有解毒作用，拮抗内毒素，且口服给药能达到血药浓度，个别复方可达到与地塞米松相似的效果[19]。现认为大多数抗生素缺乏这种作用。（5）增强机体免疫。清热解毒方药能增强大、小吞噬细胞吞噬功能，提高补体、溶菌酶活性，诱生 干扰素，改善特异性体液免疫和细胞免疫。此外，据研究，清热泻火药尚有降低中枢兴奋性并加强保护性抑制过程，使脑内5-羟色胺增多，稳定内环境等作用[20]。

参考文献：

[1] 李寿深，论东垣所创阴火为气虚之火，山东中医杂志，1987（3）8。[2] 赖祥林，广西中医药，1985，（1）：7。[3] 李华佳，广西中医药，1985，（1）：7。

[4] 兰州化学工业分司职工医院，中医杂志，1983，12：939。

[5] 上消化道出血证治（笔谈），中医杂志，中医药治疗上消化道出血近况，1985；26（8）：4。[6] 张俊文，上海中医药杂志，1981（8）：10。[7] 蒋珠玉，湖南中医药杂志，1987（7）：29。[8] 黄柄山，吉林中医药，1986，（2）：14。[9] 王永炎，等。辽宁中医杂志，1984，9（9）：15。[10] 吴银根，湖南中医杂志，1986，（1）：10。[11] 谭宗健，湖南中医学院学报，1986；（3）：19。[12] 张志礼，中医杂志，1989；（9）：547。[13] 王仲英，中西医结合杂志，1989；（8）：465。

[14] 候灿，八纲病理生理学基础初步探讨，中医杂志，1964（12）：32。

[15] 重庆医学院新医病理研究小组，“八纲”之病理学基础初探，新医药学杂志，1975，（3）：114。[16] 梁月华等，中医寒热本质的初步研究，中华医学杂志，1979，（12）：705。

[17] 谢竹藩等，从虚证患者尿中儿茶酚胺量探讨病证的寒热，中西医结合杂志，1988，8（11）：647。[18] 谢竹藩等，从尿中儿茶酚胺及cAMP、cGMP的排出量探讨中医寒证、热证的本质，中西医结合杂志，1986，6（11）651。

[19] 李鸣真等，中药“热毒清”注射液抗内毒素的实验研究，《科研资料选编》（武汉同济医科大学中西医结合研究所），1986。

[20] 梁月华等，寒凉药温热药对中枢递质的影响（摘要），中西医结合杂志，1985，5（2）：82。

第二篇：爱爱医资源-工作年限及从业年限证明

执业药师报名及工作年限证明

兹有我单位李安祥同志，硕士研究生，方剂学专业，工作年限1年；从2012年 8月至2013 年 8月在我单位从事中药科研及中药饮片管理工作（身份证号41***03016，网络报名号：020421）

在我单位工作期间，该同志遵守国家和地方的法律、法规，无违反职业道德的行为。同意其报考执业中药师。

特此证明。

单位（盖章）2013年7 月 23日

第三篇：藏象学说 讲稿

留学生班《中医学》第三章 脏腑学说

讲稿

附三院

周颖芳

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：爱爱医资源-儿科心肺复苏考试题(附答案)

6月儿科心肺复苏及液体疗法考试

1.评估新生儿需要复苏最初依据什么体征？

（）1.呼吸

2.血压

3.心率

4.肤色

a.1, 2, 3

b.1, 3, 4

c.1, 2, 4

d.2, 3, 4 2.触觉刺激后新生儿仍无呼吸时,应采取哪项措施?（）a.吸引气道 b.继续触觉刺激 c.给新生儿吸氧 d.正压通气给氧

3.大概有多少比例的新生儿至少需要一些帮助开始自发及规律的自主呼吸?（）a.1% b.3% c.10% d.20% 4.足月的新生儿正常分娩后心肺会按怎样的步骤发生变化?（）1.动脉导管闭合 2.清除肺泡里的肺液 3.肺充气扩张 4.肺动脉开始张开

a.1, 4, 3, 2

b.2, 1, 3, 4

c.3, 2, 4, 1

d.4, 2, 1, 3 5.新生儿出生时未能正常过渡,你将会可能发现以下哪种情况?

（）a.紫绀 b.心动过速 c.增加呼吸功 d.以上全部

6．原发性呼吸暂停与继发性呼吸暂停的特点鉴别点是？

（）a.对触觉刺激有反应 b.心率下降 c.喘息样呼吸

d.血压下降 7．在给早产儿复苏时会遇到特殊的挑战是因为：

（）

a.肺缺乏肺泡表面活性物质，造成通气困难 b.不完全的体温控制c.脑血管脆性大易于出血 d.以上都是

8．每次分娩中最少应该有多少训练有素其主要职责是新生儿的处理的人员在场？（）a.1 b.2

c.3

d.4

9．当新生儿出生时有呼吸暂停：

（）

a.在1分钟Apgar评分后采取治疗措施 b.立即给予触觉刺激

c.立即进行气管插管

d.立即给予纳络酮

10．一个新生儿经过30s正压通气后，心率是55次/min，下面该做什么？（）a.仅提供触觉刺激

b.开始胸外按压并继续正压通气 c.仅进行胸外按压

d.停止正压通气

11.下列哪项是决定胎粪污染的新生儿是否需要插管并吸引的主要因素?（）

a.胎粪污染羊水的粘稠度 b.新生儿是否“有活力”

c.1分钟Apgar评分

d.曾有异常胎心监测史 12.下列使新生儿呼吸的哪种刺激方式不可取?（）

a.用温热的毛巾擦拭 b.轻柔地摩擦新生儿的背部

c.托起新生儿拍打其臀部

d.轻轻拍打或弹脚跟 13.复苏有呼吸暂停,且对擦干和摩擦背部无反应的新生儿最有效的措施是:（）a.常压给氧

b.拍打脚后跟

c.用冷湿毛巾包裹四肢

d.辅助通气

14.对于一个新生儿呼吸好,心率正常,但是有中心性紫绀,最好先进行哪项干预?（）a.常压给氧

b.触觉性刺激

c.用浓度100%氧正压通气

d.给纳络酮

15.足月新生儿提示其羊水中有粘稠的胎粪.当头部娩出后,新生儿的口腔，咽和鼻都被吸引清理.将他放在预热后的辐射保温台时,新生儿苍白,软弱,且无呼吸运动.首先应采取哪项措施?

（）

a.擦干新生儿

b.进行触觉刺激

c.气管插管并吸引下呼吸道

d.用气囊-面罩辅助通气 16.给新生儿数心率时,6s中心跳9次,这时其心率是:（）a.27次/min b.45次/min c.90次/min d.180次/min 17.当无胎粪时,下列哪项关于清理气道的描述是正确的?

（）a.深而用力的吸引以清除所有多余的液体

b.先吸引鼻然后是口腔

c.使用连接机械装置的球形注射器或导管吸引

d.使用大约200mmHg的负压.18.评估和触觉刺激后,新生儿心率仍小于100次/min,下一步哪项措施最合适?

（）a.防止体热丢失

b.进行更多的触觉刺激

c.常压给氧

d.正压通气

19.一个装有储氧器的自动充气式气囊,并连接到浓度100%的氧源上,能将多少浓度的氧气给新生儿?

（）a.30%~40%

b.50%~60%

c.70%~80%

d.90%~100%

20.一新生儿经过正压通气,心率大于100次/min,且有自主呼吸,你将:（）

a.继续进行正压通气

b.气管内插管,并继续正压通气

c.停止正压通气

d.停止正压通气,给予温和的刺激,并采取常压给氧 21.如果一个新生儿需要用气囊面罩较长时间的正压通气,则:（）

a.需要插入胃管

b.应插入口喉气道

c.应给予肾上腺素

d.新生儿应被重新摆正体位 22.下列哪项不是复苏中的新生儿状况有所改善的表现?

（）a.心率增加

b.肤色改善

c.肌张力低降(肌肉放松)

d.自主呼吸 23.为有效的使用复苏囊,你最好站立在:

（）

a.新生儿的头侧或足侧

b.新生儿的身旁一侧或头侧

c.新生儿的身旁一侧或足侧

d.仅在新生儿的右侧 24.下列哪项不是气流充气式复苏气囊的优点?

（）

a.任何时候都可以传送浓度100%的氧气

b.新生儿面部未密封好时容易被发现 c.挤压后总是能够重新充盈,即使无加压氧源

d.挤压时能够感受到肺的顺应性 25.下列哪项是自动充气式复苏气囊的缺点?

（）

a.即使面罩和新生儿面部之间无密封时,气囊也能够充盈

b.需要连接储氧器才能提供大于40%浓度的氧气 c.不能可靠的用于提供100%浓度的常压氧气

d.以上所有都是

26.快速分娩后,新生儿有呼吸暂停,肢软,青紫,心率40次/min.羊水清.如新生儿仍无反应以下步骤应按何顺序进行?

（）1.开始用100%浓度的氧气正压通气

2.迅速给新生儿摆位;拿掉湿了的毛巾;吸引口和鼻;擦干新生儿;并刺激新生儿 3.测量新生儿的心率

4.开始胸外按压

a.3, 1, 4，2b.1, 2, 3，4c.2, 1, 3, 4

d.3, 4, 2, 1 27.胸外按压必须伴有:

（）

a.采用肾上腺素

b.用100%浓度氧正压通气

c.气管插管

d.给扩容剂 28.当协调正压通气和胸外按压时,大约每分钟多少次?

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

29.进行新生儿心脏按压时,按压胸骨采取以下哪一个合适深度?

（）a.大约压到胸廓前后径的1/b.大约压到1/3英寸

c.直到你能感觉到脊柱的前面部分

d.深到剑突下至肝脏的位置

30.当给新生儿进行胸外按压时,通气应:

（）

a.每分钟40~60次的速率

b.每分钟40次的速率

c.每次呼吸后插入一次胸外按压

d.每3次胸外按压后插入一次呼吸

31.新生儿起初需要进行胸外按压,但是重新检测心率是70次/min,你应该做什么?

（）a.继续进行胸外按压直到心率>80次/min

b.停止胸外按压,继续每分钟40~60次的正压通气 c.给予肾上腺素

d.尝试电击复律（电击使心脏恢复功能）32.胸外按压即有规律的按压胸骨

（）

1.增加胸内压

2.向脊柱方向按压心脏

3.将血液泵入静脉

4.使血液运送到重要器官 a.1, 2, 3

b.1, 2, 4

c.1, 3, 4

d.2, 3, 4 33.刚刚分娩出后,新生儿青紫,软弱,呼吸暂停.对刺激无反应,心率每分钟40次,下列哪项最可能帮助恢复正常的自主性的心率?

（）

a.正压通气

b.给肾上腺素

c.给阿托品

d.给碳酸氢钠 34.下列哪项可以提高胸外按压的安全性和有效性?

（）

a.在胸外按压放松的时候,使手指或拇指放在新生儿的胸部上.b.持续的压下2~4英寸的深度 c.按压时以1比1的频次间隔通气

d.每分钟40~60次的通气与心脏按压同步进行 35.下列哪项关于胸外按压和正压通气的配合的描述是正确的?

（）

a.一个人同时进行按压和通气 b.每3次通气后,进行一次胸外按压

c.大约2秒钟进行一次4次的“循环”(3次按压和一次通气)d.为了使治疗达到最佳的配合，一个人应该一手实施双指胸外按压法，同时用另一只手挤压复苏囊进行通气

36.为了使用拇指技术或者双指技术,你应:

（）

a.用软的垫子支撑在婴儿的背部以防止皮肤创伤

b.采用不同的位置,深度,和频率

c.弯曲婴儿的颈部（骸贴向胸部）37.新生儿复苏中给予肾上腺素的适宜途径是:

（）

1.静脉

2.皮下

3.气管导管

4.肌肉 a.1, 2

b.2, 4

c.1, 3

d.2, 4 38.在建立充分的通气之前不宜给予肾上腺素的原因是:

（）

1.那样会浪费应当用于建立通气和给氧的宝贵时间

2.肾上腺素不像通气设备那样容易获得

3.肺扩张后使得肾上腺素更好的分布

4.肾上腺素会增加工作负荷和耗氧量,那样可能会导致不必要的心肌损伤 a.1, 2

b.2, 4

c.2, 3

d.1, 4 39.哪项是肾上腺素的推荐计量?

（）

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.以下哪些药可以通过气管内导管注入?

（）1.肾上腺素

2.纳络酮

3.碳酸氢钠

4.白蛋白 a.1, 2

b.2, 3

c.3, 4

d.2, 4 41.下面哪项不是目前推荐的用于治疗急性低血容量的方法?

（）

a.生理盐水

b.白蛋白

c.乳酸林格氏液

d.O型阴性血(若时间允许,最好与母血交叉试验吻合)42.下面哪些是使用碳酸氢钠的指征?

（）

1.延长的复苏

2.30秒辅助通气和心脏按压后心率仍小于60次/min 3.严重的代谢性酸中毒,可疑的或确诊的4.苍白,脉弱,对复苏反应差 a.1, 3

b.1, 2

c.2, 3

d.2, 4 43.为什么在复苏过程中过早的静脉给予碳酸氢钠会有危害?

（）a.重碳酸盐会造成过多的酸累积

b 低张的碳酸氢盐对气道有腐蚀性 c.碳酸氢盐导致额外的二氧化碳产生

d.钠能转变成晶体盐从而阻塞血管 44.当需要给体重2400g的新生儿扩容剂时,应给多大剂量?

（）a.0.24ml

b.2.4ml

c.24ml

d.240ml 45.当需要给体重2400g的新生儿扩容剂时,应如何给?

（）

a.静脉,快速给药

b.静脉,缓慢给药

c.肌注,迅速给药

d.气管,缓慢给药 46.下列哪项是碳酸氢钠给药的正确剂量,途径,和速度?

（）

剂量途径速度a.0.5mmol/ml(4.2%)的溶液，2mmol/kg脐静脉慢速（小于1 mmol/min）

b.1:10,000的溶液，0.1~0.3ml/kg气管导管或脐静脉迅速

c.10ml/kg脐静脉慢速（超过5~10分钟）

d.0.5mmol/ml(4.2%)的溶液，2mmol/kg气管导管迅速

47.下面哪些是低血容性休克的临床指征？

（）

皮肤表现脉搏心率对复苏的反应a.给氧后持续苍白微弱高或低差B给氧后持续紫绀好低差C给氧后持续苍白好高好D给氧后持续紫绀差低好

48.下面哪项是使用过量肾上腺素或快速输入碳酸氢钠可能产生的并发症?

（）A.心率过低

B.肺部慢性疾病

C.颅内出血

D.高血压

患儿，男，12月，因“解黄色稀水样便4天，伴神疲少尿半天”入院，查体：体重10kg，嗜睡，前囟和眼窝明显下陷，哭时泪少，口唇干，皮肤弹性差，腹稍胀，肠鸣音弱，余查体为见明显异常。入院后查肾功能示钠137mmol/L、钾3.0mmol/L、二氧化碳结合力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：爱爱医资源-目录15---------医院辐射环境监测方案

___________医院辐射环境监测方案

一、我院辐射环境监测工作由放射防护领导小组组织，放射科具体实施。

二、我院工作人员从事放射诊断操作时必须穿防护服，带铅眼镜和防护手套，配戴个人计量仪。

三、个人计量仪定期送达市疾控中心或环境监测部门进行剂量监测。

四、放射防护领导小组每季度应对放射防护装置个人防护监测结果进行一次检查和总结，确保空气吸收剂量率等指标达到《电离国徽防护与国徽源安全基本标准》GB18871-2002和《医院X射线诊断卫生防护标准》GBZ130-2002要求。

五、自觉接受卫生行政主管部门和环保行政主管部门对我院进行的辐射环境监测。当防护装置发生变化时，主动邀请卫生、环保部门对新装置的效果进行监测。