有种尴尬叫十年“口臭”两茫茫

有种尴尬叫十年“口臭”两茫茫

有种尴尬叫十年“口臭”两茫茫

病案

汪某,女,42岁,2013年5月7日初诊。

主诉:口中酸臭10年。患者自觉口中酸臭,以酸味为重,口黏腻,面部起斑,伴月经量少,白带量多,长期耳鸣,手脚心发热,心烦急躁,无腹痛腹胀,纳可寐可,小便调,大便有时干。曾以中西药治疗无效。来诊时舌淡红微胖大,边有齿痕,苔薄白稍腻,脉弦。

辨证:患者长期情志不遂引起肝疏泄功能失常,肝木过旺则克脾土,土郁化热,故大便干结,口中酸臭,且心烦急躁,脉弦。证属肝气犯胃,脾胃郁热,治宜疏肝健脾,清热通腑。宗逍遥散合大柴胡汤加减。

处方: 柴胡10克,当归10克,白芍12克,赤芍15克,茯苓15克,枳实10克,熟大黄6克,黄芩10克,焦山楂10克,生麦芽10克,炒栀子6克,甘草6克,生姜3片,大枣5枚。

6剂,水煎2次兑匀,分2次温服。

有种尴尬叫十年“口臭”两茫茫

9月17日二诊:患者因事中断治疗3月,服上方后口中酸臭略有好转,仍有口中黏腻,耳鸣,舌淡红微胖大,边有齿痕,舌苔白腻较前略变薄,脉弦劲。

处方:北沙参12克,麦冬10克,桔梗10克,前胡6克,川贝粉2克(冲),杏仁10克,枇杷叶6克,黄芩10克,百合10克,生甘草6克。6剂,日1剂,水煎2次兑匀,分2次温服。

9月24日三诊:服上方后无不适感,大便通畅,口中酸臭略有改善,现耳鸣似蝉鸣音,两胁按压胀痛,舌淡红微胖大,边有齿痕,苔白腻,脉弦细。前方加柴胡10克,青皮10克。日1剂。

10月8日四诊:口中酸臭续有改善,自觉皮肤干,双腿尤甚,大便不干,无心烦、心急,苔薄白质淡边有齿痕,脉弦。近日妇科检查有滴虫性阴道炎。

处方:生地15克,熟地15克,茵陈20克,黄芩10克,枳壳10克,枇杷叶6克,石斛12克,杏仁10克,天花粉15克,北沙参15克,土茯苓20克,生甘草6克,浙贝母10克。日1剂。

10月15日五诊:口中臭味明显减轻,仍有酸味,自觉口中唾液分泌不足、口干口黏,伴皮肤干燥,双腿尤甚,耳鸣时有蝉鸣音,大便不干,无心烦、心急,月经提前,量少。舌淡,边有齿痕,苔薄白脉弦。前方祛土茯苓,加荆芥6克,防风6克。

10月22日六诊:口臭基本消失,偶有酸味,现面色红润有精神,仍觉口中唾液分泌不足,口干好转,仍有皮肤干,双腿尤甚,伴耳鸣时有蝉鸣音,两胁胀痛,阴部瘙痒减轻,白带偏黄。舌淡,边有齿痕,苔薄白,脉弦。前方黄芩10克改黄柏10克。

10月29日七诊:口中酸臭痊愈,偶有耳鸣,两胁胀痛减轻,近日白带黄,量多。舌质淡苔薄白脉弦缓。予中成药加味逍遥散、四妙丸善后。有种尴尬叫十年“口臭”两茫茫

讨 论

口臭的病因病机,历代医家有不同的阐述。隋·巢元方《诸病源候论·口臭候》曰:“口臭,五脏六腑不调,气上胸膈。然腑脏气臊腐不同,蕴积胸膈之间,而生于热,冲发于口,故令臭也。”归纳起来大致可分为四种:胃热炽盛、食滞胃肠、肝气犯胃、肝胃蕴热。

本案中患者初诊时口中酸臭,心烦急躁,大便干,脉弦。证属肝木疏泄功能失常克伐脾土,浊气上逆,升降失常,发为口臭。石国璧用逍遥散合大柴胡汤加减以疏肝健脾,但效果不明显。二诊时考虑患者口中酸臭10年,脉弦劲,病程较长,肝火过旺,仅疏肝效果不理想;另辟蹊径,运用中医五行金克木思路,从肺论治。

故先以沙参麦冬汤加减养阴润肺,补肺疏肝以克肝火,后继四诊投甘露饮,方中二地滋养肺胃生津,滋阴降火,石斛甘微咸,得水石清虚之气,故能清金保肺,布膻中之清化;伍以黄芩、枇杷叶补肺敛阴,泻火清金;杏仁、贝母宣肺化痰;枳壳通导腑气,运化脾胃;茵陈清热利湿,升发清气;再以甘草清热解毒,调和药性。诸药合用,既能清胃肠湿热、又能润肺滋肾凉肝,连服12剂,口臭全消。

患者口臭虽属小疾,但困扰患者10余年,久治不愈,顽固难去,求诊于石老6次,顽疾全消,体现了石国璧丰富的临证经验。

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