1、第七章 辨证 Chapter 7 differentiation of syndrome Syndrome is the pathological summarization of a disease in a certain stage. It includes the location, cause, nature, and relationship between healthy qi and pathogenic factors. It reflects the essence of pathological changes in the process of the disease
2、at some stage, so it is more comprehensive, more profound and more correctly reveal the nature of the disease than the manifestations. 证（证候）证（证候）: : 是机体在疾病发展过程中的某一阶段是机体在疾病发展过程中的某一阶段 的病理概括。的病理概括。 它包括病变的部位、原因、性质及邪它包括病变的部位、原因、性质及邪 正关系，反映出疾病发展过程中某一阶正关系，反映出疾病发展过程中某一阶 段的病理变化的本质，因此它比症状更段的病理变化的本质，因此它比症状更 全面
3、、更深刻、更正确地揭示了疾病的全面、更深刻、更正确地揭示了疾病的 本质。本质。 The difference between Manifestation and Syndrome Manifestations reflect the outward sign of disease, Syndrome reflects the nature of the disease 症和证的区别：症和证的区别： 症状是疾病的外在表现，证是疾病的症状是疾病的外在表现，证是疾病的 本质反映。本质反映。 Differentiation of syndrome ： means to analyzing and ju
4、dging the data obtained from the four diagnostic methods so as to differentiation the nature of the disease and make clear the naming of the syndrome. 辨证：辨证：在中医学理论指导下在中医学理论指导下，通过四通过四 诊检查所得的临床资料诊检查所得的临床资料，对疾病所表现对疾病所表现 的具有内在联系的各种症状进行分析的具有内在联系的各种症状进行分析、 综合综合，从而确定病人属于何证的过程从而确定病人属于何证的过程。 辨证方法辨证方法 八纲辨证八纲辨
5、证用于确定疾病性质用于确定疾病性质 Syndrome differentiation with eight principles is used to determine the nature of disease 病因辨证病因辨证可以区分致病原因可以区分致病原因 Etiology differentiation of syndrome is used to distinguish the cause of disease 脏腑、经络辨证脏腑、经络辨证能够落实病变部位能够落实病变部位 Syndrome differentiation of viscera and meridians are h
6、elpful for the location of disease 气血津液辨证气血津液辨证则是分析人体生理功能与水则是分析人体生理功能与水 液、营养物质等的异常变化液、营养物质等的异常变化 Syndrome differentiation of qi, blood and body fluid means to analysis of abnormal changes in human physiological function and liquid water, nutrients, etc. 六经辨证六经辨证、卫气营血辨证卫气营血辨证及及三焦辨证三焦辨证，则，则 用于诊断外感热病用于
7、诊断外感热病 Syndrome differentiation of six-meridians and defensive qi, qi, nutrient qi and blood, and triple energizer are mainly used to differentiate syndromes in exogenous heat diseases 第一节第一节 八纲辨证八纲辨证 Syndrome differentiation with eight principles A comprehensive analysis to group the disease into e
8、ight categories of syndrome : yin and yang, internal and external aspects, cold and heat as well as asthenia and sthenia, based on the information obtained by four diagnostic methods and according to the depth of disease location, the nature and exuberance of the pathogenic factors, the strength of
9、the healthy qi . Syndrome differentiation with eight principles 八纲辨证：八纲辨证： 通过四诊通过四诊，掌握辨证的资料之后掌握辨证的资料之后，根据根据 病位的深浅病位的深浅，病邪的性质及盛衰病邪的性质及盛衰，人体正人体正 气的强弱等气的强弱等，加以综合分析加以综合分析，归纳为归纳为阴阴、 阳阳、表表、里里、寒寒、热热、虚虚、实实八类证候八类证候。 八纲：八纲：阴阴、阳阳、表表、里里、寒寒、热热、虚虚、实实 八个纲领八个纲领 “表里表里”是辨别是辨别病证的内外深浅位臵病证的内外深浅位臵的纲领。的纲领。 External or int
10、ernal are two principles used to differentiate the location of diseases. “寒热寒热”是辨别病证性质的纲领是辨别病证性质的纲领 Cold and heat are two principles used to differentiate the nature of diseases. “虚实虚实”是辨别病证邪正盛衰的纲领：是辨别病证邪正盛衰的纲领： Asthenia and sthenia are two principles to differentiate the conditions of healthy qi an
11、d pathogenic factors. 八纲之间的相互联系：八纲之间的相互联系： Interlinkages between the eight principles “阴阳阴阳”两纲可概括其他六纲：两纲可概括其他六纲： 表表、热热、实证属实证属“阳阳”， 里里、虚虚、寒证属寒证属“阴阴”， 所以所以“阴阳阴阳”又是八纲中的总纲又是八纲中的总纲。 Yin and yang can be used to general other six principles: external, heat and sthenia are of yang; while internal, cold and
12、asthenia are of yin. So yin and yang are the general principles in all the eight principles. 一、表里一、表里 Exernal and internal 表里是相对的概念表里是相对的概念 Exernal and internal are two relative concepts 即病证的内外深浅位臵都是相对而言的即病证的内外深浅位臵都是相对而言的。 The depth and inside or outside of the disease location are relative. . 表里病位的
13、简单划分：表里病位的简单划分： Simple division of external and internal location of diseases 外外( (皮毛、肌腠、经络皮毛、肌腠、经络) )有病有病-表，病较轻浅表，病较轻浅 Disease in external (skin, hair, muscular interstices, meridians and collaterals)-external, disease is relatively light and shallow 内内( (脏腑、血脉、骨髓脏腑、血脉、骨髓) )有病有病-里，病较深重里，病较深重 Diseas
14、e in internal(viscera, blood, bone marrow) internal, disease is relatively deeper and serious 表里辨证可测病势表里辨证可测病势： External and internal differentiation of Syndrome enables doctors to understand the development of pathological changes. 病邪由表入病邪由表入里里-病势进而加病势进而加重重； 病邪由里出病邪由里出表表-病势退而减病势退而减轻轻。 In exogenous
15、disease, pathogenic factors transmit In exogenous disease, pathogenic factors transmit from the exterior into the interiorfrom the exterior into the interior- disease disease developed and aggravateddeveloped and aggravated Pathogenic factors transmit from the interior into Pathogenic factors transm
16、it from the interior into the exteriorthe exterior-disease retreated and alleviateddisease retreated and alleviated （一）表证（一）表证 external syndrome 表证：表证：是指六淫是指六淫、疫疠等外邪经皮毛疫疠等外邪经皮毛、口口 鼻侵入鼻侵入，正气开始抗邪阶段所表现的轻浅正气开始抗邪阶段所表现的轻浅 证候证候。 External syndrome refers to the symptoms appearing at the primary stage of exo
17、genous diseases caused by invasion of six pathogenic factors into the body through skin, mouth and nose. 特点：特点：起病多急起病多急，病程较短病程较短，病情较轻病情较轻， 病性一般属实病性一般属实 。 CharacteristicsCharacteristics: : suddensudden onset,onset, shortshort duration,duration, lighterlighter condition,condition, is is generallygener
18、ally stheniasthenia syndromesyndrome. . 主症主症: : 发热恶寒或恶风发热恶寒或恶风、舌苔薄白舌苔薄白、脉浮脉浮为为 主主，兼见头身痛兼见头身痛、鼻塞鼻塞、咳嗽等症状咳嗽等症状。 Main symptoms: fever, aversion to cold or wind, thin and white fur and floating pulse, accompanied by head and body pain, stuffy nose and cough. （二）里证（二）里证 Internal syndrome 里证的概念：里证的概念：是泛指病
19、位在内是泛指病位在内，脏腑脏腑、气气 血血、骨髓等受病所反映的证候骨髓等受病所反映的证候。 Internal syndrome refers to the symptoms in disorders with deep location, such as viscera, qi and blood, and bone marrow. 形成里证的途径：形成里证的途径： ConditionsConditions contributedcontributed toto thethe formationformation ofof internalinternal syndromesyndrome 表
20、证不解表证不解，病邪传里病邪传里，形成里证：形成里证： furtherfurther developmentdevelopment ofof exogenousexogenous diseasedisease duedue toto interiorinterior transmissiontransmission ofof pathogenicpathogenic factorfactor fromfrom thethe exteriorexterior. . 外邪外邪“直中直中”脏腑脏腑，成为里证；成为里证； InvasionInvasion ofof thethe visceravisc
21、era byby thethe pathogenicpathogenic factorsfactors. . 情志内伤情志内伤、饮食劳倦等饮食劳倦等，或脏腑气血失调或脏腑气血失调， 气血津精等受病所表现的种种证候气血津精等受病所表现的种种证候。 Dysfunctions of the viscera and imbalance Dysfunctions of the viscera and imbalance between qi and blood due to impairment between qi and blood due to impairment of the viscera
22、caused by emotional upsets, of the viscera caused by emotional upsets, improper diet and improper daily lifeimproper diet and improper daily life 特点：无恶寒发热特点：无恶寒发热并见并见，并以脏腑症状为并以脏腑症状为 主要表现主要表现，其起病可急可缓其起病可急可缓，一般病情较一般病情较 重重、病程较长病程较长。 CharacteristicsCharacteristics: : No occurrence of fever and aversion
23、to cold, , visceraviscera dysfunctiondysfunction asas thethe basicbasic clinicalclinical manifestation,manifestation, suddensudden oror slowslow onset,onset, generallygenerally withwith seriousserious conditioncondition andand longlong durationduration. . （三）表证和里证的关系（三）表证和里证的关系 Relationship between
24、External and internal syndrome 表里同病：表里同病：表证和里证同时在一个病人身上出表证和里证同时在一个病人身上出 现，称为表里同病。现，称为表里同病。 Simultaneous external and internal disorder: External and internal syndrome appeared on the same patient simultaneously 表里转化：表里转化：表证和里证还可以相互转化，即所表证和里证还可以相互转化，即所 谓谓“由表入里由表入里”和和“由里出表由里出表”。 Transformation between
25、 External and internal syndrome: pathogenic factors transmit from the exterior into the interior, or from the interior into the exterior 表证和里证的鉴别要点表证和里证的鉴别要点: : 发热恶寒同时并见的属表证；但发热不恶寒或但寒发热恶寒同时并见的属表证；但发热不恶寒或但寒 不热的属里证。表证舌苔少变化，里证舌苔多有变不热的属里证。表证舌苔少变化，里证舌苔多有变 化，脉浮主表证，脉沉主里证。化，脉浮主表证，脉沉主里证。 Differential points
26、for External and internal syndrome: In exogenous disease, it belongs to external syndrome if fever and aversion to cold appear simultaneously, whereas, it belongs to internal syndrome if they appear separately; external syndrome comes with less changeable fur, internal syndrome comes with changeable
27、 fur; external syndrome comes with floating pulse, internal syndrome comes with deep pulse. 表里证鉴别要点表里证鉴别要点 Differential points forDifferential points for External and External and internal syndromeinternal syndrome 病程病程 寒热特点寒热特点 常见症状常见症状 舌象舌象 脉象脉象 表证表证 较短较短 恶寒发热恶寒发热 头身痛等头身痛等 不明显不明显 脉浮脉浮 里证里证 较长较长 但寒
28、不热但寒不热 内脏症状内脏症状 多有变化多有变化 脉沉脉沉 但热不寒但热不寒 Differential points for External and internal syndrome durati on features common symptom fur pulse external syndrome short fever and aversion to cold head and body pain not obvious floating internal syndrome long fever without aversion to cold or aversion to co
29、ld without fever viscera dysfunction changeab le deep 张某张某，男男，5050岁岁。时值冬日时值冬日，一周前一周前，晚晚 间外出沐浴间外出沐浴，出浴室后即感风寒透骨出浴室后即感风寒透骨，恶恶 寒寒怕冷怕冷，当夜即当夜即发热发热，鼻塞声重鼻塞声重，周身酸周身酸 楚楚。次日就诊次日就诊，可见舌苔薄白可见舌苔薄白，脉浮紧稍脉浮紧稍 数数。病人不以为意病人不以为意，仅服西药止痛消炎仅服西药止痛消炎， 虽汗出而热未退虽汗出而热未退。第三日发生第三日发生高热高热，汗出汗出， 口干口干，已二日不大便已二日不大便，胸闷胸闷，不欲食不欲食，查查 舌苔黄厚舌苔
30、黄厚、舌质红舌质红，脉洪数有力脉洪数有力。 练习病案练习病案 讨论讨论 提示提示：按病程,依据辨证 要点进行表里辨证。 本病例可分为两个阶段：本病例可分为两个阶段： 第一阶段：疾病初起第一阶段：疾病初起，因于外感寒邪因于外感寒邪，突见突见 恶寒恶寒、发热发热、身痛身痛、苔薄白苔薄白、脉浮脉浮等证等证， 其他症状不明显其他症状不明显。根据表证的辨证要点根据表证的辨证要点， 此属表证此属表证。 第二阶段：服西药后第二阶段：服西药后，虽汗而邪未解虽汗而邪未解，入里入里 化热化热，见见但热不寒但热不寒、胸闷不食胸闷不食、大便秘结大便秘结 等等内脏症状内脏症状，舌红苔黄而厚舌红苔黄而厚，舌象变化明舌象变
31、化明 显显，脉不浮脉不浮而洪数有力而洪数有力，当属里证当属里证。 病案分析示范病案分析示范 二、虚实二、虚实 asthenia and stheniaasthenia and sthenia Asthenia and sthenia are two principles to Asthenia and sthenia are two principles to differentiate the conditions of healthy qi differentiate the conditions of healthy qi and pathogenic factorsand pathog
32、enic factors： Asthenia refers to insufficiency of healthy qi, Asthenia refers to insufficiency of healthy qi, while sthenia refers to exuberance of while sthenia refers to exuberance of pathogenic fators.pathogenic fators. 虚实是辨别邪正盛衰的纲领：虚实是辨别邪正盛衰的纲领： 实指邪气盛实实指邪气盛实，虚指正气不足虚指正气不足。 即所谓即所谓“邪气盛则实邪气盛则实，精气夺则虚
33、精气夺则虚。” ( (素问素问 通评虚实论通评虚实论) )。 证候之虚实是依据双方的盛衰而定的证候之虚实是依据双方的盛衰而定的，即即 正盛邪实为正盛邪实为实证实证，正虚邪衰为正虚邪衰为虚证虚证，正虚正虚 邪实为邪实为虚实夹杂证虚实夹杂证。 Asthenia syndrome ConceptConcept: : symptomssymptoms markedmarked byby astheniaasthenia ofof healthyhealthy qiqi andand nonnon- -predominationpredomination ofof pathogenicpathogeni
34、c factorsfactors. . featurefeature ： astheniaasthenia ofof healthyhealthy qiqi andand nonnon- - predominationpredomination ofof pathogenicpathogenic factors,factors, characterizedcharacterized byby deficiency,deficiency, recession,recession, slack(deficiencyslack(deficiency ofof healthyhealthy qi,qi
35、, functionalfunctional decline,decline, clinicalclinical manifestationmanifestation ofof slack)slack) CorrespondingCorresponding toto differentdifferent degreedegree ofof asthenia,asthenia, clinicalclinical manifestationsmanifestations appearappear asas deficiency,deficiency, scarcity,scarcity, weak
36、ness,weakness, decline,decline, depletion,depletion, collapse,collapse, butbut nono obviousobvious boundariesboundaries betweenbetween themthem. . 虚虚 证证 概念：虚证是对人体正气虚弱概念：虚证是对人体正气虚弱、不足为主不足为主 所产生的各种虚弱证候的概括所产生的各种虚弱证候的概括。 特点：正虚而邪不显特点：正虚而邪不显，以不足以不足、衰退衰退、松松 弛等为特点弛等为特点（指正气不足指正气不足、功能衰退功能衰退、临临 床表现松弛床表现松弛）。虚损程
37、度有所不同虚损程度有所不同，临床临床 有不足有不足、亏虚亏虚、虚弱虚弱、虚衰虚衰、亡亡、脱之别脱之别， 但其间并没有明显的界线但其间并没有明显的界线。 Asthenia syndrome pathogenesispathogenesis analysisanalysis： CongenitalCongenital deficiencydeficiency oror postnatalpostnatal disorderdisorder oror consumptionconsumption ofof diseasedisease （ improperimproper diet,diet, im
38、pairmentimpairment ofof visceralvisceral qiqi andand blood,blood, overstrain,overstrain, excessiveexcessive coitus,coitus, prolongedprolonged diseasedisease andand mistreatmentmistreatment; ; sweat,sweat, vomit,vomit, andand bloodblood loss,loss, etcetc. .) ) SyndromeSyndrome causedcaused byby defic
39、iencydeficiency ofof YangYang qi,qi, YinYin fluid,fluid, essence,essence, mostlymostly involvinginvolving partsparts suchsuch asas Viscera,Viscera, bonebone marrow,marrow, mostlymostly onon infirminfirm patientspatients withwith prolongedprolonged chronicchronic diseasedisease andand excessiveexcess
40、ive consumptionconsumption 虚 证 病因病机：病因病机： 先天禀赋不足先天禀赋不足，后天失调或病耗后天失调或病耗（饮食失饮食失 调调、生化不足；思虑劳倦太过；房室不节；生化不足；思虑劳倦太过；房室不节； 久病失治久病失治、误治；汗误治；汗、吐吐、下下、失血失血、失失 精等精等）阳气阳气、阴液以及精阴液以及精、血血、津液津液、 营营、卫等亏虚不足所致证候卫等亏虚不足所致证候，多涉及脏腑多涉及脏腑、 骨髓等部位骨髓等部位。 临床多为久病临床多为久病、势缓势缓、耗损过多及体弱者耗损过多及体弱者。 clinical manifestations ： The clinical
41、manifestations of asthenia syndrome The clinical manifestations of asthenia syndrome vary with different types.vary with different types. The common symptoms: The common symptoms: pale or sallow pale or sallow complexioncomplexion, , listlessnesslistlessness, , fatiguefatigue, shortness of , shortne
42、ss of breath, palpitation, aversion to cold and cold breath, palpitation, aversion to cold and cold limbs, limbs, spontaneous sweatingspontaneous sweating, loose stool, urinary , loose stool, urinary incontinence, incontinence, fat pale tongue, fat pale tongue, weak deep slow weak deep slow pulsepul
43、se. Or . Or feverish sensation over the five centersfeverish sensation over the five centers, , emaciation, flushed cheeksemaciation, flushed cheeks, dry mouth and throat, , dry mouth and throat, night sweatingnight sweating, tidal fever, , tidal fever, reddish tongue with reddish tongue with little
44、 fur, little fur, weak fast thin pulseweak fast thin pulse. . 临床表现：临床表现： 各种虚证的表现极不一致很难全面概括各种虚证的表现极不一致很难全面概括。 常见的有；常见的有；面色淡白或萎黄面色淡白或萎黄 ，精神萎精神萎 靡靡，神疲乏力神疲乏力，心悸气短心悸气短，形寒肢冷形寒肢冷， 自汗自汗，大便滑脱大便滑脱，小便失禁小便失禁，舌淡胖舌淡胖， 脉虚沉迟脉虚沉迟，或为或为五心烦热五心烦热，消瘦颧红消瘦颧红， 口咽干燥口咽干燥，盗汗盗汗潮热潮热，舌红少苔舌红少苔，脉脉 虚细数虚细数。 Sthenia syndromeSthenia sy
45、ndrome concept: Sthenia syndrome is the generalization of Various clinical syndrome caused by invasion of pathogenic factors or due to dysfunction of yin, yang, qi, blood, marked by yang, heat, stagnation, obstruction, or produced by accumulation of pathological product. Features: predominant pathog
46、enic factors and non- asthenic healthy qi, conflicting of the two leads to accumulation of pathological products. 实证实证 概念概念: 实证是对人体感受实证是对人体感受外邪外邪或疾病过程中或疾病过程中 阴阳气血失调而以阴阳气血失调而以阳阳、热热、滞滞、闭闭等为主等为主， 或体内或体内病理产物蓄积病理产物蓄积所形成的各种临床证所形成的各种临床证 候的病理概括候的病理概括。 特点：邪盛而正气不虚特点：邪盛而正气不虚，正邪剧争正邪剧争，以有以有 余余、强烈强烈、停聚为特点停聚为特点（邪气
47、有余邪气有余，表现表现 强烈强烈，病理产物停聚病理产物停聚）。 Sthenia syndromeSthenia syndrome PathogenesisPathogenesis analysisanalysis： Invasion of exogenous pathogenic factors into the body and confliction with healthy qi 寒热显著，寒热显著， 疼痛剧烈，呕吐咳喘明显，二便不通，脉实等。疼痛剧烈，呕吐咳喘明显，二便不通，脉实等。 （病势亢奋，急迫。）（病势亢奋，急迫。） Dysfunction of the viscera, le
48、ading to the accumulation of pathological products痰、饮、痰、饮、 水、湿、瘀血、宿食等。水、湿、瘀血、宿食等。 Mostly on strong patients with emerging diseases or sudden severe diseases. 实实 证证 病因病机：病因病机： 六淫六淫( (疫疬、虫毒疫疬、虫毒) )等邪气侵袭，正气抗邪等邪气侵袭，正气抗邪 寒热显著，疼痛剧烈，呕吐咳喘明显，二寒热显著，疼痛剧烈，呕吐咳喘明显，二 便不通，脉实等。（病势亢奋，急迫。）便不通，脉实等。（病势亢奋，急迫。） 脏腑功能失调，气化障碍，气机阻滞脏腑功能失调，气化障碍
