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李纪元 肖相如频道
导读:今天学习李纪元先生治疗炎症性和血栓性眼底血证的临床经验。
01
遇“炎”勿专事寒凉
眼内出血是全身疾病的局部表现,故眼内出血必有所因,临床当审证以求因,审因以论治。
我在1983年10月,曾治一王姓,男,25岁的病人。
主诉左眼视物不清3个月余,经外院诊为“视网膜静脉周围炎”,使用中药治疗不效。
检查:左眼视力0.02,眼底无法窥及。裂隙灯显微镜检查:左眼玻璃体呈大片云絮状混浊,屈光间质模糊不清,呈红色反光,且有密集棕黄色素点飘浮。
舌质淡红、苔薄白,脉弦细无力。伴头晕,目涩,面色晄白,纳差便清,四肢困乏,气短懒言等症。
查阅患者过去病历,所服诸药不外丹皮、栀子、生地、紫草、知母等清热凉血止血之品。
今参合脉证,细究其本,乃系中气不足,脾不统血,血溢络外,蒙闭清窍之证。
遂拟温脾益气,固涩止血之法,治疗月余,视力恢复至1.2,诸症悉除而收功。
后悟前医以视网膜静脉周围炎,因而在“炎”字上着眼,一味使用清热凉血止血之品,过用寒凉,使眼底脉道之血凝涩而难以吸收,其致误之由,在于忽视治病求本的原则。
02
治“气”亦止目血
眼底血证,经久不愈,或形成后遗症,往往与气血虚亏有关,因气有生血并鼓动血液上行,濡养于目之作用,所以眼底血证亦应当注意到气的盛衰行滞,不能只重视凉血止血,或活血化瘀。
1984年5月,诊一患者赵某,男,干部。
主诉:2月前左眼突然视物模糊,平素头晕目眩,现口干舌燥,面无华色,心悸,多梦,难寐。
经外院检查为“视网膜静脉血栓”,曾用维生素类、血管扩张剂,及自服活血化瘀中药,治疗月余无效。
检查:左眼眼前指数,视盘边界不清,在上枝血管从视盘边缘开始,呈火焰状出血,伴有淡黄色渗出物,颞下静脉迂曲,动脉变细,血管壁反光增强,可见动脉交叉压迹。
舌质淡红,脉细弱。
本例虽因“血栓”而致暴盲(视网膜静脉血栓),但参合脉证,则属心阴不足,虚热内生,热迫血妄行而成是病。
其病机为阴血不足,“阳亢不入于阴,阴虚不受阳纳”,而心悸,多梦难寐;心主血,其华在面,血虚不能上营,则头晕目眩,面色无华;舌为心苗,心主血脉,心血不足故舌色淡红,脉细弱。
权衡病机,拟养心益血,健脾益气为主;平肝收敛,祛瘀生新为佐。
方选归脾汤加减。
药用人参、黄芪、白术、甘草,健脾益气以补生血之源;当归、茯神、远志、五味子、白芍,养阴以安心神;珍珠母、龙骨、牡蛎平肝收敛,重镇安神;加用丹参、牛膝、藕节、血余炭,以祛瘀生新。
全方补中寓散,动中藏静,施治相宜,逾半载而收功。
又于1986年9月,治一李某,47岁,家庭妇女。
主诉:右眼视物不清半年余,时轻时重,经外院诊为“视网膜静脉栓塞”,曾用针剂复方丹参、维脑路通、血管舒缓素,口服烟酸及中药桃仁四物、通经散等治疗,近视无进步。
检查:视力右0.05(不能矫正),眼底见动脉细,静脉怒张,视网膜乳头周围有放射状出血迹,累及黄斑部。伴有头晕目眩,口苦咽燥,胁疼,体倦乏力,精神易于激动。
舌质淡红,脉弦而虚。且平时家庭不睦,情志不畅,郁怒伤肝。
参合脉证,系属气机闭塞,疏泄失职而致肝气郁结为患。
故以丹栀逍遥散加香附、郁金以疏肝理气为主;辅以藕节、血余炭、茜草根等行血散瘀、止血退障明目;并酌情加入白芨、棕榈炭以寓动中有静,止中求活之意。
同时常以话语宽慰其心,治疗3个月而视力(右)达1.0,眼底出血吸收,余症悉除。追踪三载疗效巩固。
注:具体治疗与用药请遵医嘱!本文选摘自《皮肤病中医经验集成》,徐三文、梁延平、唐岛主编,湖北科学技术出版社出版,2010.4。本公众号仅用之进行学术交流,若有侵权请联系删除,转载请注明出处。
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