常用医学英语双语

Insomnia
Charles E. Henley    失  眠
(卡劳尔•布赖宁)
Insomnia is more than just being unable to fall asleep. It is a subjective condition of insufficient or nonrestorative sleep despite an adequate opportunity to sleep. The Institute of Medicine and most current studies place the prevalence of insomnia at 30% to 40% in the general adult population. Although the need for sleep does not necessarily decrease with age, the incidence of sleep disturbances appears to increase with age, particularly among women. Actually, the elderly are more prone to sleep maintenance problems, whereas younger people tend to have trouble falling asleep.  
失眠并不仅仅是无法入睡。失眠是在有足够睡眠机会时睡眠仍不充分或睡后精力无法恢复的一种主观病症。美国医学研究院和现有的多数研究都认为，失眠在普通成人中的流行率为30%至40%。虽然睡眠需要未必随年龄增长而减少，但睡眠障碍的发生率似乎是随年龄而增加的，特别是妇女。事实上，老年人更容易在睡眠维持方面出问题，而年轻人则往往是难以入睡。
I. Approach.    I. 诊断思路：
Insomnia represents a symptom of an underlying problem and is not in itself a disease entity. Sleep and alertness are regulated by a complex interaction between the body's internal biologic clocks, the reticular activating system, and various influences such as light or anxiety that can interfere with the normal sleep cycles. The approach to diagnosis should recognize the potential for various causes and use history and special studies to determine the cause of the insomnia.   
失眠是某种潜在疾病的一种症状，失眠本身并不是一种病质。睡眠和觉醒是众多复杂因素相互作用的结果，如人体内生物种、脑干网状激活体系统及其他各种可以影响正常睡眠周期的因素，如灯光、焦虑等。诊断时应该认清各种因素的影响力，并根据病史及其他特殊检查确定失眠原因。
A. Types of insomnia.    A. 失眠类型。
Although more than one classification system for insomnia exists, a consensus seems to support dividing insomnia into transient (lasting a few days), short-term (lasting weeks), and long-term or chronic (lasting many weeks to months or years). The Association for the Psychophysiological Study of Sleep has classified insomnia as:   
失眠分类方法不止一种，但公认的是将失眠分为暂时性（持续数天）、短期性（持续数周）和长期性或慢性（持续数周、月或年）这几种。睡眠社会心理生理研究协会将失眠分为以下几种：
1. Psychophysiologic, which covers the transient and short-term problems associated with situational factors such as concern about an ill family member.  
 1.  社会心理性失眠。该类失眠包括暂时性和短期性失眠，通常与环境因素有关，如对生病家属的担心。
2. Psychiatric, especially depression, which has a very high concordance with insomnia, and which also covers other affective disorders and psychosis.  
 2.  精神病性失眠。尤其是抑郁症引发的失眠，抑郁症与失眠有很高的关联性。其他因素包括情感障碍、精神错乱等。
3. Drugs and alcohol, especially chronic alcoholism, and the use of central nervous system stimulants such as caffeine, nicotine, or other drugs.   
3.  药物与酒精性失眠。特别是慢性酒精中毒和服用一些中枢神经系统兴奋剂，如咖啡因、尼古丁或其他药物。
4. Sleep-related movements syndromes. These syndromes comprise a special category related to behavioral or motor problems. Periodic limb movements and restless leg syndrome are the most frequent diagnoses.   
4.  睡眠相关运动综合症。这些综合症包括与行为或运动相关的一些特殊疾病，其中以周期性肢体运动和下肢不适综合症为最常见。
5. Sleep-induced respiratory problems (e.g., obstructive sleep apnea). With this condition, the patients usually have no trouble falling asleep initially, but have multiple arousals and awakenings during the night.   
5.  睡眠诱发的呼吸系统疾病（如阻塞性睡眠呼吸暂停）。患有这类疾病的病人通常无入睡困难，但在夜间醒来次数多。
6. Medical and environmental causes such as repeated rapid eye movement (REM) interruptions from outside noise.   
6.  医源及环境性失眠。如外界噪声多次打断快速眼球运动睡眠相。
7. Unknown causes--the patient may just be a short sleeper.  
7.  原因不明性失眠。也许病人本来就睡眠少。

B. Special concerns.    B. 特别注意问题。
Potentially, the most serious problem associated with insomnia is related to obstructive sleep apnea. If left untreated, it is associated with oxygen desaturation, hypercapnia, and hypopnea, which can lead to significant cardiovascular problems (e.g., systemic and pulmonary hyper tension, cor pulmonale, and right ventricular failure).   
与失眠相关的最严重的潜在问题是阻塞性睡眠呼吸暂时。如不治疗，会并发血氧饱和度下降、高碳酿血症和呼吸减慢，从而导致严重的心血管疾病（如系统性和肺动脉高压、肺心病和右心室衰竭）。

II. History    病史：
A. Characteristics of insomnia.  
A. 失眠的特点：
Insomnia cannot be diagnosed by the amount of time a person sleeps. Rather, it is distinguished by the daytime consequences of unsatisfactory sleep. A pertinent history for insomnia would include:   
不能根据病人睡眠时间长短来诊断失眠。应根据睡眠不足是否影响生活加以鉴别。与失眠相关的病史包括：
1. A history of restlessness, irritability, daytime somnolence, and impaired work or social functioning, which can lead to situational stress. This may be a transient problem, but it can lead to difficulties with initiation of sleep and early awakenings.   
1.  不安、易怒、昼间困倦及工作与社会职能障碍，均可导致环境压力。问题可能是暂时性的，但会造成入睡困难和早醒。
2. Use of caffeine or other stimulants, especially over-the-counter medications (e.g., decongestants) that may contain ephedrine or phenylpropanolamine. Late evening exercise can also be a stimulant. Alcohol may help induce sleep, but it interferes with REM sleep and leads to nonrestorative sleep and early awakenings.   
2.  服用咖啡因或其他兴奋剂，特别是含有麻黄碱或盐酸基丙醇胺的非处方药（如碱充血剂）。晚间锻炼也有兴奋作用。酒精有助入睡，但干扰快速眼球运动睡眠相，导致早醒和睡后精力未恢复。

3. Affect changes, sadness, hopelessness, and vegetative signs such as weight loss should suggest depression, the most common psychiatric disorder associated with insomnia (Chapter 3.3). This is especially true if the insomnia persists for weeks. Anxiety disorders cause difficulty with getting to sleep, whereas patients with depression may fall asleep more readily but have early awakening.   
3.  情感变化、悲伤、无助和营养机能变化引发的一些体征，如体重减轻，可提示抑郁症，它是最常见的失眠相关精神病。如果失眠持续数周，其诊断就更确凿无疑。焦虑症导致入睡困难，抑郁症病人则容易入睡，也易早醒。
4. Medical problems such as peptic ulcer disease and heart failure have been implicated in insomnia (Chapters 7.5 and 9.6). A history of frequent nocturnal urinations can also disrupt sleep and may indicate benign prostate hyperplasia or other prostate problems. Hyperthyroidism can cause irritability and insomnia, as can thyroid replacement therapy for hypothyroidism. Other problems such as asthma, angina, back pain, and sinusitis can also cause sleep disorders.   
4.  内科疾病。如消化性溃疡病和心力衰竭，都跟失眠有牵连。夜间尿频中断睡眠，多见于良性前列腺增生或其他前列腺疾病。甲状腺功能亢进可导致易怒和失眠，用甲状腺素替代疗法治疗甲状腺功能减退症时也会出现上述现象。其他疾病如哮喘、心绞痛、背痛和鼻窦炎等也可引起睡眠障碍。

5. Loud snoring, daytime somnolence, forgetfulness, difficulty concentrating, and a history from the bed partner of periods of discontinuation of breathing during sleep of 10 seconds or more should suggest a more thorough evaluation for obstructive sleep apnea. Daytime napping, associated findings of gastrointestinal reflux disease, and hypertension are also suggestive associations for sleep apnea.   
5.  严重打鼾、白天困倦、健忘、注意力难以集中、及睡伴对其睡眠呼吸中断10秒种或以上的描述等，这些现象都提示应进行更彻底的检查，以确定其是否有阻塞性睡眠呼吸暂停。昼间瞌睡、胃肠反流疾病相关检查结果和高血压等也提示与睡眠呼吸暂停有关。

6. The bed partner is also a good person to ask about leg movements during sleep. This could be suggestive of a periodic limb movement disorder. A similar syndrome, restless legs, is associated with a history of unpleasant sensations in the legs and a persistent desire to move them. Both conditions cause a delay in sleep onset and nocturnal awakenings.   
6.  睡伴也是病人睡眠时腿部运动的良好询问对象，提供情况对周期性肢体运动障碍有提示作用。类似的还有不安腿综合症，它通常伴有腿部不适感，并使患者想要不断地移动两腿。这两种疾病都导致入睡推迟和夜间觉醒。
7. Sleep phase disturbances caused by jet lag or shift work can be characterized by early awakening or by awakening later in the day.   
7.  时差或倒班引起睡眠相混乱，其特征是早醒或白天晚醒。

III. Physical examination.    III. 体格检查：
The physical examination for insomnia is more a search for other underlying disease states than for any specific signs for insomnia, although hypertension, obesity, and thick neck suggest consideration of sleep apnea.   
虽然高血压、肥胖症、短颈都可考虑有睡眠呼吸暂停，但失眠患者的体格检查更多的是检查其有否其他潜在疾病，而非检查失眠的特殊体征。

IV. Testing.    IV. 实验室检查：
The diagnosis of unexplained insomnia may involve testing in a sleep laboratory using polysomnography. This provides the opportunity to monitor such parameters as the electroencephalogram (EEG),'breathing, oxygen saturation, and body movements during sleep. Polysomnography can determine the disturbances in chronobiologic rhythms and loss of normal sleep-awake patterns associated with circadian rhythm disorders. The EEG results from the sleep laboratory will demonstrate a patient's ability to progress through the five cycles of normal sleep and where in the process any disturbances may be located. For instance, a short REM sleep latency period from initiation of sleep to actual REM sleep, along with increased REM sleep, and reduced total sleep time with frequent awakenings are all associated with depression.   
原因不明性失眠的诊断，应采用睡眠实验室多相睡眠描记仪进行检查，其监测参数包括：脑电波、呼吸、血氧饱和度及睡眠时的躯体运动等。多相睡眠描记仪可确诊时间生物节律紊乱和昼夜生理节律异常导致的正常睡眠—觉醒方式的丧失。睡眠实验室获得的脑电波可证明病人是否经历五个正常睡眠周期和异常出现的位置。如，初入睡至实际快速眼球运动睡眠之间快速眼球运动睡眠期的缩短，快速眼球运动睡眠延长、频繁觉醒导致总睡眠时间减少等，都与抑郁症有关。

V. Diagnostic assessment.    诊断评价：
The key to diagnosing insomnia and other sleep disorders is history and sleep laboratory monitoring. Short-term problems related to difficulty with initiating sleep may be situational or environmental. Long-term problems with sleep_, lasting weeks to months, may be more psychophysiologic such as with chronic anxiety or depression. A thorough history of personalor job-related issues, caffeine, alcohol and other drug use, related medical problems, abnormal leg and body movements at night, problems with daytime napping and somnolence as well as night time snoring, and apnea spells will all direct the practitioner to the cause of most problems. A good sleep study often confirms the diagnosis and leads to specific interventions.   
诊断失眠及其他睡眠障碍的关键是病史和睡眠实验室监测。与入睡困难相关的短期失眠一般是由环境因素引起的。持续数周甚至数月的长期睡眠问题更多的是由心理生理因素引起，如长期患有焦虑症或抑郁症。详细的病史检查，包括个人及工作情况问题，咖啡因、酒精及其他药物服用史，相关内科疾病，夜间腿部及躯体异常运动，昼间瞌睡，夜间打鼾及呼吸暂停时间等情况，都可以引导医生找到多数失眠的原因。对睡眠情况进行认真检查通常可以确诊失眠，进而采取特定的治疗措施。

Diarrhea        腹泻
Frequent loose bowel movements (4 to 6/day) may occur in normal infants; they are of no concern unless anorexia, vomiting, weight loss, failure to gain weight, or passage of blood also occurs. Breastfed infants tend to have frequent bowel movements, especially if they are not receiving solid food. The significance of diarrhea in a child at any age differs if it is acute (< 2 wk) or chronic (> 2 wk).       
正常婴儿一天可多次稀松排便（4－6次/天）。这不用担心，除非有厌食、呕吐、体征减轻、长不胖、便血等情况。母乳喂养婴儿排便次数较多，特别是在未添加固体食物情况下。任何年龄儿童腹泻意义各不相同，还要看是否是急性< 2 wk）或慢性（> 2 wk）。
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Etiology        病因学
Acute diarrhea is most likely infectious, especially if onset is sudden or accompanied by vomiting, bloody stools, fever, anorexia, or listlessness. Diagnosis is clinical, and treatment is supportive until the condition resolves spontaneously.       
急性腹泻最可能是感染性，特别是起病突然或伴有呕吐、便血、发烧、厌食或无精打采等情形。予门诊诊断、支持性治疗，直到病情自行消退。

Chronic diarrhea is usually more significant. Causes include gluten-induced enteropathy, cystic fibrosis, sugar malabsorption, and allergic gastroenteropathy. Inflammatory bowel disease and some infections (eg, with Giardia) can also cause chronic diarrhea.       
慢性腹泻较重要，其原因包括可谷胶所致肠病、囊性纤维病、糖吸收不良及过敏性胃肠病。炎性肠病和一些传染病（如贾第虫性）也能引起慢性腹泻。

With gluten-induced enteropathy (celiac sprue), the gluten fraction of wheat protein causes intestinal mucosal damage and malabsorption of dietary fats, resulting in malnutrition, anorexia, and bulky, foul-smelling stools. The change in stools starts when wheat and other gluten-containing foods are added.       
谷胶所致肠病：小麦蛋白谷胶引起肠粘膜损坏和饮食脂肪吸收不良，导致营养不良、厌食，大便成团、恶臭。当麦和其他含谷胶食物增加时大便就会发生变化。
With cystic fibrosis, pancreatic insufficiency results in trypsin and lipase deficits, causing high fecal losses of protein and fats with consequent malnutrition and growth retardation. The stool is voluminous and often foul-smelling. Children who have cystic fibrosis often have respiratory problems and growth failure.       
囊性纤维病：胰腺功能不足导致胰蛋白酶和脂酶不足，蛋白质和脂肪随粪便大量丢失，造成营养不良，发育迟滞，大便量多、味臭。有囊性纤维病儿童常常有呼吸道问题和生长不足。
With sugar malabsorption, intestinal mucosal enzymes, such as lactase, which splits lactose to galactose and glucose, may be congenitally absent or temporarily deficient secondary to GI infection. Improvement after eliminating lactose (or other carbohydrates) from the diet or after substituting a lactose-free formula strongly suggests the diagnosis.       
糖吸收不良：小肠粘膜酶，如乳糖酶能将乳糖分解成半乳糖和葡萄糖，可能是先天缺失或因胃肠感染引起暂时不足。从饮食中除去乳糖（或其他碳水化合物）或用无乳糖配方替代后症状改善，都有力支持本诊断。
With allergic gastroenteropathy, cow's milk protein may cause diarrhea, often with vomiting and blood in the stools, but intolerance to the carbohydrate fraction of the ingested food should be suspected also. Symptoms often abate promptly when soy formula is substituted for cow's milk and return if cow's milk is reintroduced. Some infants intolerant of cow's milk are also intolerant of soy, so a formula that has had the protein pre-digested and does not contain the offending disaccharide may be needed. Spontaneous improvement usually occurs toward the end of the 1st yr.       
过敏性胃肠病：牛奶蛋白可能引起腹泻，通常伴有呕吐和便血，但也应怀疑对摄入食物中的碳水化合物不耐受。用大豆配方替代后症状迅速减轻，但牛奶可使症状再现。有些对牛奶不耐受的婴儿通常对大豆也不耐受，因此，需要一种蛋白预先消化、不含双糖的配方。1周岁时症状会自行改善。

Evaluation        评估
History: History focuses on the quality and frequency of stools as well as accompanying signs and symptoms. Reports of vomiting or fever suggest GI infection. An accurate dietary history is critical. Reports of diarrhea beginning with the introduction of wheat cereal suggest celiac disease. Reports of variation in the stool pattern with certain elements of the diet suggest dietary intolerance. The persistent presence of blood in the stool mandates a careful search for more serious infection or GI disorder.       
病史：病史重点是大便质量和频率及伴随症状。呕吐或发烧提示有胃肠感染。准确的饮食史很关键，始于食用小麦类食品引起的腹泻提示有乳糜泻。大便形态各异伴未消化食物提示为饮食不耐受。持续便血就必须深查是否有严重感染或胃肠疾病。
Physical examination: Examination focuses on overall appearance and signs of dehydration, growth parameters, and abdominal findings; poor growth suggests more serious disorders. Pulmonary status is also evaluated in children in whom cystic fibrosis is suspected.       
体检：体检重点是总外表和脱水、生长发育、腹部检查症状等。发育不良提示有更严重的疾病。怀疑有囊性纤维化儿童还应作肺部评估。
Testing: Tests are ordered if history and examination suggest a chronic condition. Tests include electrolyte levels if there is dehydration; sweat Cl and Na levels for cystic fibrosis; cultures for viruses, bacteria, or parasites when infection appears to be present; and stool pH for disaccharide intolerance. Levels of certain antibodies are associated with celiac disease. Dietary manipulations can be diagnostic as well as therapeutic.       
化验：如病史和体检提示有慢性疾病则应作化验检查。如有脱水，应检查电解质水平；囊性纤维病检查氯和钠水平；如有感染则进行病毒、细菌或寄生虫培养检查；双糖耐受情况检查大便pH值。一定的抗体水平与乳糜泻有关。饮食控制既是诊断性也是治疗性的。

Treatment        治疗
Supportive care for acute diarrhea consists primarily of providing adequate oral (or rarely IV) rehydration. Antimotility agents (eg, loperamide: IMODIUM) are generally not recommended for infants and young children.       
急性腹泻的支持护理主要包括足够的口服补水（或IV补液）。抗能动类药（如洛哌丁胺：易蒙停）通常不建议婴儿和幼儿服用。
For chronic diarrhea, adequate nutrition must be maintained, particularly of fat-soluble vitamins. Specific treatments are indicated for certain causes (eg, gluten-free diet for those with celiac disease).       
慢性腹泻必须保持营养，尤其是脂溶性维生素。有些病因应采取对症疗法（如乳糜泻病人的无谷胶饮食）。

Pneumonia        肺    炎
BRONCHOPNEUMONIA        支气管肺炎
It may occur in previously normal lungs or be superimposed on underlying bronchitis or other respiratory disease, e. g. bronchiectasis or carcinoma. It is preceded by bronchial infection and is commonest in children (measles and whooping cough) and the elderly (chronic bronchitis and hypostatic pneumonia in debilitated patients in bed). In normal adults it may follow respiratory viral infections.       
可以发生在原来正常的肺，亦可在原有支气管  炎或其他呼吸道疾病(例如支气管扩张症或肺癌)的  基础上再发生本病。发病之前有支气管感染，这在儿童(麻疹及百日咳)及老年人(慢性支气管炎及卧  床不起者的体位性肺炎)最常见。在正常成年人可  在呼吸道病毒感染之后发生。

Clinical presentation        临床表现
The history is initially often of acute bronchitis. Fever and malaise develop with a cough producing infected (yellow or green) sputum. On examination, coarse crepitations may be areas of consolidation with dullness to percussion, increased vocal resonance and bronchial breathing.       
病史上常以急性支气管炎发病，出现发热，不  适，并咳脓痰(黄或绿色)。体检有粗的水泡音，部分肺野可能有实变，叩诊实音，语音共振增强，并有支气管性呼吸音。

Investigation        检查
Diagnosis is confirmed on chest X-ray. Blood cultures should be sent. Sputum should be sent for culture and Gram stain before starting antibiotics. These should not be withheld until sensitivities are available.       
胸部X线检查可确诊。应送血培养，在开始抗    生素治疗之前应送痰培养及革兰染色检查，但不必    等敏感试验的结果出来后再行治疗

Management Haemophilus influenzae and Streptococcus pneumoniae are the most common organisms but other bacteria (e.g. klebsiella and staphylococcus) may be responsible. Initial therapy involves the use of: (1) Oxygen--28% in the presence of respiratory chronic failure. (2) Antibiotics - erythromycin, amoxicillin or trimethoprim in the first instance. (3) Physiotherapy.       
处理  最常见的致病菌是流感嗜血杆菌及肺炎链球菌，但亦可由其他细菌(例如克雷白杆菌及葡  萄球菌)引起。开始时可用以下方法治疗：(1)氧气，有慢性呼吸衰竭出现时可给氧(28％)。(2)抗生素，  最先可用红霉素，羟氨苄青霉素或甲氧苄氨嘧啶。  (3)理疗。

Important predisposing causes should be considered including diabetes mellitus and carcinoma of the bronchus. Complications include lung abscess, pleural effusion and empyema.       
应考虑重要的诱发因素，包括糖尿病及支气管  癌。合并症有肺脓肿，胸腔积液及脓胸。
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LOBAR PNEUMONIA        大叶性肺炎
This has become less common since the advent of penicillin.       
自从青霉素问世以后，大叶肺炎已不常见。

Clinical presentation        临床表现
The onset is sudden with cough, rusty sputum, marked fever and rigors. There are signs of consolidation if a large area of lung is involved. Vesicles of herpes simplex occur around the lips. Chest X-ray shows consolidation in lobar distribution. Cerebral abscess is a rare complication. The pneumococcus is particularly dangerous to the splenectomised patient.       
突然发病，咳嗽、咳铁锈痰，高热及寒颤。如果一大片肺被侵犯则有实变征。唇部可发生单纯疱疹。胸部X线检查见有呈大叶性分布的实变阴影。脑脓肿是较少见的合并症。对脾切除患者，肺炎双球菌(感染)是特别危险的。

Management        处理
The organism most frequently cultured from sputum and blood is S. pneumoniae (pneumococcus) and this responds to i. m. crystalline penicillin (1-2 million units 6-hourly) which is the drug of first choice.       
从血及痰中培养出的细菌最常见的是肺炎双球    菌，肌内注射青霉素有效(100～200万uq6h)，故作为首选药物。
NB Lobar consolidation, particularly with loss of volume on chest X-ray, may indicate an underlying bronchial obstruction, e. g. neoplasm, foreign body.       
注意  大叶实变，特别是X线检查有肺不张，可能提示有潜在支气管阻塞性疾患(例如新生物，异物)。

OTHER BACTERIAL PNEUMONIAS        其他细菌性肺炎
Klebsiella pneumoniac (Fried!~nder's). This is rare and often opportunistic in patients with leukaemia, lymphomas or on steroids.  The history is of sudden prostration, fever, rigors and cough with blood-stained viscous sputum. The chest X-ray 'shows patchy areas of consolidation, often involving the upper lobe. The mortality is high (40%) and subsequent respiratory disability common.       
克雷白杆菌肺炎  罕见，偶可发生于白血病，淋巴瘤或激素治疗的患者。患者病情突然恶化，发热，寒颤，咳嗽并有带血的粘痰。胸部X线可见片块状实变区常累及上叶。死亡率高(占40％)。患者在以后常有呼吸功能异常。
The bacillus is not penicillin or ampicillin sensitive. It responds to streptomycin, chloramphenicol and with some strains, tetracyclines. Lung abscess and bronchiectasis are common complications.       
本菌对青霉素及氨苄青霉素不敏感，用链霉素、氯霉素有效。有些菌株用四环素有效。常合并肺脓肿及支气管扩张症。
Staphylococcal pneumonia  This produces widespread infection with abscess formation. It occurs in patients with underlying disease which prevents normal response to infection, e.g. chronic leukaemia. Hodgkln's disease, cystic fibrosis, and patients on steroid therapy. It may complicate influenzal pneumonia and this makes it relatively common during epidemics of influenza. The organism may not be penicillin sensitive, so flucloxacillin is the drug of choice. Lung abscess, empyema and subsequent bronchlectasis are relatively common complications.       
葡萄球菌肺炎  它引起广泛的感染和形成脓肿。常发生在有潜在疾患的病人，因为这些病妨碍了他们对感染的正常反应，例如慢性白血病、何杰金病、囊性纤维化，以及激素治疗的病人都常发生。可以并发流感肺炎，因而在流感流行时较常见。本菌可能对青霉素不敏感，因而可选用氟氯苯唑青霉素治疗。较常见的合并症有肺脓肿、脓胸及随后发生的支气管扩张症。

LEGIONNAIRE'S DISEASE        军  团  病
This was first described ill a group of American army veterans (legionnaires). It begins as an influenza-like illness with fever, malaise and myalgia and proceeds with cough (little sputum). dyspnoea and sometimes severe anoxia, marked confusion and coma. Diarrhoea and vomiting are common and renal failure may develop. Examination shows consolidation which usually affects one or both lung bases. Radiological changes may persist for more than 2 months after the acute illness. The bacterium is the Gramnegative bacillus Legionella pneumophila and the diagnosis confirmed by a rising antibody titre.       
本病首先报道是在一组美国陆军退伍军人中发生。发病时好似流感，有发热、乏力及肌痛，以后发生咳嗽(痰少)、气急。有时严重缺氧，显著的精神错乱及昏迷。常有腹泻及呕吐，且可发展为肾功    能衰竭。检查可见实变，常波及一侧或双侧肺底部。X线改变在急性病变后可持续2个月以上。本病由革兰阴性的需气军团杆菌所引起，抗体滴定度升高可确定诊断。

Erythromycin or tetracycline are the antibiotics of choice but the mortality remains high (20%).       
可选用红霉素或四环素治疗，但死亡率仍高 (占20％)。
NB  Legionnaire's disease (and Mycoplasma pneumoniae or psittacosis) should be suspected in all patients who develop atypical pneumonia which does not respond to standard antibiotics especially after travel away from home—often to the Mediterranean.       
注意  凡患有非典型肺炎而对标准的抗生素治疗无效，特别是离家出外旅行的患者——通常是到地中海地区，应疑患军团病(及肺炎支原体肺炎或鹦鹉病)。
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RECURRENT BACTERIAL PNEUMONIA        复发性细菌性肺炎
In the absence of chronic bronchitis, recurrent pneumonia arouses the suspicion of: (1) Bronchial carcinoma preventing drainage of infected areas of the lung.  (2) Bronchiectasis (including fibrocystic disease). (3) Achalasia of the cardia, 25% of which present as chest disease; pharyngeal pouch and neuromuscular disease of the oesophagus, e. g. bulbar palsy, (4) Hypogammaglobulinaemia and myeloma.       
如果患者没有慢性支气管炎而再发生肺炎，应考虑：(1)支气管癌妨碍了肺感染部位的引流。(2)支气管扩张症(包括纤维囊性疾病)。(3)胃贲门松弛不良患者，25％表现为胸部疾患，咽袋及食管的神经肌肉病(例如延髓麻痹)。(4)低γ-球蛋白血症及骨髓瘤。

VIRAL PNEUMONIA        病毒性肺炎
The most common virus producing pneumonia in children in this country and the USA is the respiratory syncytial virus (so called as it is a respiratory virus which produces syncytium formation when grown in tissue culture). The agent is not responsive to antibiotics and it may be indistinguishable from acute bacterial bronchitis or bronchiolitis in children and infants. The presence of an associated skin rash supports the likelihood of RSV infection.       
在英美的儿童中，最常见的肺炎病毒为呼吸道合胞病毒(之所以用这个名称是因为该病毒在组织培养时可以形成合胞体)。本病用抗生素无效。在婴儿及儿童患者，与急性细菌性支气管炎或细支气管炎不易区别。如果患者同时出现皮疹，则支持呼吸道合胞病毒感染。

Acute virus pneumonia in adults is very rare and occurs during epidemics of influenza A (Asian' flu). The picture is of rapid and progressive dyspnoea. Death may occur within hours from acute haemorrhagic disease of the lungs. The most common cause of pneumonia during epidemics of influenza results from secondary bacterial infection, the most serious being staphylococcal pneumonia. The viruses of measles, chickenpox, and herpes zoster may directly affect the lung. The diagnosis is confirmed by a rise in specific antibody titre.       
成人的病毒性肺炎极罕见，有时在A型流行性感冒(亚洲型流感)流行时发生。临床表现为迅速发生气急，并进行性加重。可能因急性肺出血性疾病而在数小时内死亡。在流感流行时发生的肺炎，最常见的病因是继发性细菌感染，最严重的是葡萄球菌性肺炎。麻疹、水痘及疱疹病毒可直接侵犯肺。特异性抗体滴定度升高可确定诊断。
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MYCOPLASMA PNEUMONIA        肺炎支原体肺炎

This is caused by Mycoplasma pneumoniae, the only mycoplasma definitely pathcgenic to man. The clinical picture resembles bacterial pneumonia although cough and sputum are absent in one-third of cases.      
 病因为肺炎支原体，是能使人致病的唯一支原体。临床表现类似细菌性肺炎，但l／3患者可不咳、无痰。
Respiratory symptoms and signs and. X-ray changes (patchy consolidation with small effusions) are usually preceded by several days of flu-like symptoms. Polyarthritis occurs and may persist for months. Malaise and fatigue may persist long after the acute illness is over. The diagnosis is confirmed by a rise of specific antibody titre, the presence of cold agglutinins and antibodies to Mycoplasma in the serum and/or isolation of the organism. Tetracycline (0.5--1.0gqds) is the antibiotic choice. Psittacosis and ornithosis (Bedsoniae) may cause a similar picture and also respond to tetracycline, though diarrhea is commoner.       
在出现呼吸道症状及X线征状的前几天常有流感样症状。X线表现为片块状实变及小量积液。可有多发性关节炎，并持续数月。不适及疲乏在急性期后可持续甚久。如特异性抗体滴定度升高，血清中存在冷凝集素，支原体抗体或分离出支原体(或同时出现后两者)，可确诊为本病。可选用四环素治疗(每次0．6一1．0g，每日4次)。鹦鹉热及鸟病毒病(衣原体属)的临床表现与之相同。用四环素亦有效，但腹泻较常见。

OPPORTUNISTIC INFECTION OF THE LUNGS        机遇性肺部感染
This is seen in immunosuppressed patients usually on steroids,  azathioprine, or cytotoxic agents following transplantation or for leukaemia or lymphoma. The range of organisms found is very wide and includes bacteria (Pseudomonas M. tuberculosis, E. coli), fungi (Aspergillus, Monilia, Cryptococcus). Viruses (Cytomegalo-Virus. Herpes zoster) and Pneumocystis carinii. It is important to attempt to isolate the organism from the sputum and to carry out blood culture, endobronchial brush biopsy, and/or percutaneous lung biopsy. Treatment should not be delayed, because the prognosis is very poor.       
在免疫受到抑制的病人可发生此病，患者因移植、白血病或淋巴瘤而常应用激素、硫唑嘌呤或细胞毒类药物治疗者。致病微生物的范围很广泛，包括细菌(假单胞菌属、结核杆菌，大肠杆菌)，真菌(曲霉属、念珠菌属、隐球菌属)，病毒(巨细胞病毒、疱疹病毒)及卡氏肺囊虫。努力从痰中分离出致病的微生物极为重要，送血培养，支气管刷洗活检，及(或)经皮穿刺作肺活检。治疗必须及时，因为本病预后差。
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ASPIRATION PNEUMONIA        吸入性肺炎
There are two main varieties differentiated from each other by the type of fluid aspirated and the circumstances in which it occurs.       
根据吸入的液体及得病的情况主要可分成两大类。
Aspiration of gastric contents may produce a severe chemical pneumonitis with considerable pulmonary oedema and bronchospasm (Mendelson's syndrome). The acute respiratory distress and shock can be rapidly fatal and very difficult to treat. It tends to occur in states of reduced consciousness such as general anaesthesia, drunks, and when gastric lavage (for drug overdose) has been performed inexpertly.       
吸入胃内容可以产生严重的化学性肺炎，有相当程度的肺水肿及支气管痉挛(Mendelson’s综合征)。急性呼吸困难及休克可迅速致死，很难治疗。意识模糊时易于发生，例如全麻、醉酒，以及由不熟练者洗胃(因药物过量)时均易发生。
Aspiration of bacteria from the oropharynx may follow dental anaesthesia and can occur in bulbar palsies. The bacteria, apart from bacteroides, are nearly all penicillin sensitive and crystalline penicillin with metronidazole are the antibiotics of choice initially until sensitivities are known. Recurrent episodes occur in some oesophageal diseases includinghiatus hernia, stricture, achalasia of the cardia, and in patients with diverticula or pharyngeal pouch.       
自口咽中吸入细菌可在牙科麻醉时发生，亦可在延髓麻痹时发生。除类杆菌感染以外，吸入的细菌差不多都对青霉素敏感，在获悉细菌药敏试验报告之前，可先选用青霉素及灭滴灵治疗。某些食管病患者可以并发此病，例如膈疝，狭窄、贲门松弛不良以及食管憩室或咽袋患者.

Sleeping        睡眠
Sleep behaviors are culturally determined, and problems tend to be defined as behaviors that vary from accepted customs or norms. In cultures where children sleep separately from their parents in the same house, sleep problems are among the most common that parents and children face. Infants generally adapt to a day-night sleep schedule between 4 and 6 mo. Sleep problems beyond these ages take many forms, including difficulty falling asleep at night, frequent nighttime awakening, atypical daytime napping, and dependence on feeding or being held for sleep. These problems are related to parental expectations, the child's temperament and biologic rhythms, and child-parent interactions. Inborn biologic patterns are central to an infant's sleep patterns, whereas emotional factors and established habits become more important in the toddler and older child. In addition, sleep disturbances become common at 9 mo and again around 18 mo, when separation anxiety, increasing ability of the child to move independently and control his environment, long late-afternoon naps, overstimulating play before bedtime, and nightmares tend to become more common.       
睡眠行为靠培养，睡眠问题是指违背公认习惯或标准的行为。在儿童与父母同屋单独睡的文化环境中，睡眠问题是父母儿童所面临的最常见问题之一。4－6个月大时的婴儿一般已适应了昼夜睡眠表。大于这个年龄的睡眠问题各不相同，如，夜间难以入睡、夜间频繁醒来、昼间瞌睡无规律，喂着或抱着才能入睡等。这些问题都与父母的期望、儿童性情和生物节律及父母与子女沟通有关。天生的生物形态是婴儿睡眠形态的主轴，情感因素和既成习惯对幼儿和儿童更重要。此外，睡眠紊乱在9个月时较普遍，18个月前后又是如此，此时，分离的焦虑、小儿独立活动与对环境控制能力的增强、长时间午睡、睡前玩耍兴奋过度及梦魇等更为常见。

Evaluation        评估
History: History focuses on the child's sleeping environment, consistency of bedtime, bedtime routines, and parental expectations. A detailed description of the child's average day can be useful. The history should probe for stressors in the child's life, such as difficulties in school, as well as exposure to unsettling television programs and caffeinated beverages (eg, sodas). Reports of inconsistent bedtimes, a noisy or chaotic environment, or frequent attempts by the child to manipulate parents by using sleep behaviors suggest the need for lifestyle changes. Extreme parental frustration suggests tension within the family or parents who are having difficulty being consistent and firm.       
病史：病史询问重点是儿童的睡眠环境、固定就寝时间、就寝常规和父母期望。儿童日常情况详细描述很有用。病史应调查儿童生活中的压力因素，如学习困难、及接触一些搅人心神的电视节目与含咖啡饮料（如碳酸钠）等。如反映就寝时间不定、环境噪杂、或儿童经常想利用睡眠行为操纵父母等，都提示有对生活方式改变的必要。父母极度失望提示家庭关系紧张或父母难以始终如一，无法坚持。
A sleep diary compiled over several nights may help identify unusual sleep patterns and sleep disorders (eg, sleepwalking, night terrors). Careful questioning of older children and adolescents about school, friends, anxieties, depressive symptoms, and overall state of mind often reveals a source for a sleep problem.       
几个晚上的睡眠日记可以帮助确认异常睡眠形态和睡眠障碍（梦游、夜惊等）。仔细询问儿童少年有关上学、交友、焦虑、抑郁症状及总体心理状态常常可以提示睡眠问题的原因。
Physical examination and testing: Examination and diagnostic testing generally yield little useful information.       
体检与化验：检查与诊断化验一般不会提供有用信息。

Treatment        治疗
The clinician's role in treatment is to present explanations and options to parents, who must implement changes to get the child on an acceptable sleep schedule. Approaches vary with age and circumstances. Infants are often comforted by swaddling, ambient noise, and movement. However, always rocking the infant to sleep does not allow the infant to learn how to fall asleep on his own, which is an important developmental task. As a substitute for rocking, the parent can sit quietly by the crib until the infant falls asleep, and the infant eventually learns to be comforted and to fall asleep without being held. All children awaken during the night, but children who have been taught to fall asleep by themselves will usually settle themselves back to sleep. When a child is unable to get back to sleep, parents can check on the child to reassure themselves of the child's safety and to reassure the child, but the child should then be allowed to settle himself back to sleep.
In older children, a period of “winding down” with quiet activities such as reading at bedtime facilitates sleep. A consistent bedtime is important, and a fixed ritual is helpful for young children. Asking a fully verbal child to recount the events of the day often eliminates nightmares and waking. Encouraging exercise in the daytime, avoiding scary television programs and movies, and refusing to allow bedtime to become an element of manipulation also help prevent sleep problems. Stressful events (eg, moving, illness) may cause acute sleep problems in older children; reassurance and encouragement are always ultimately effective. Allowing the child to sleep in the parents' bed in such instances almost always prolongs rather than resolves the problem.        
临床医师在治疗中的作用是向家长作出说明，提供解决方案，家长必须作出改变，说服小孩接受睡眠计划。具体方法则依小孩年龄与情况而定。婴儿常常可以从襁褓、周围声音和运动中得到安抚。不过，始终摇婴儿睡觉不会使其学会自行入睡。自行入睡恰恰是一项重要的成长任务。父母可以安静地坐在摇篮边直到婴儿入睡，慢慢地婴儿就会学会感到安抚，不用抱就可以入睡，这是替代摇睡的一个办法。儿童都会在夜间醒来，已学会自行入睡的儿童会自己睡着。如果小孩无法再次入睡，父母可以查看，确信小孩的安全，安抚小孩，然后让小孩自行入睡。大一点的小孩，通过一些安静的活动，如就寝时看看书，使他有一段时间“慢慢放松”，这有助于他入睡。让会说话的小孩讲讲白天的一些事情常常可以消除梦魇和梦游。鼓励白天运动、避免吓人的电视节目和电影、拒绝使就寝时间成为人为操纵的一个因素，这也有助于预防睡眠问题。一些让人感到压力的事情（如搬家、生病）可能引起较大儿童的急性睡眠问题。安慰和鼓励总是最有效的。让小孩睡在父母床上只会延长而不是解决问题。