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。
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。
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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