3 中医临床病证--哮病

nullWheezing Syndrome 哮 病Wheezing Syndrome 哮 病杨明山 上海中医药大学教务处ContentsContents病名 病因 病机 症候 四诊 辨证 治则 方药 其他Terminology Etiology Mechanism Manifestation TCM Diagnosis Differentiation Therapy TCM Formulae Others TerminologyTerminology 病 名null医 说2000年前 内 经针灸资生经1180年 医学 正传1224年丹溪 心法1481年 1515年 null01.《内经∙素问∙阴阳别论篇》提到“喘鸣” 。 古文：阴争于内阳扰于外，魄汗未藏，四逆而起，起则熏肺，使人喘鸣。 If yin dominates interiorly and yang intrudes exteriorly exteriorly, the soul sweating fails to be stored and the disorders develops all over the body, starting with lung damaged which will lead to wheezing with stridor.主null02. 南宋嘉定(1220)王执中《针灸资生经》最早提出“哮喘”之名。 古文：因与人治哮喘，只缪（刺）肺腧，不缪他穴。 Acupoint Feishu more than others is needled to treat asthma. 03. 南宋张杲《医说∙卷四》提到“齁喘”。 古文：因食盐虾过多，遂得齁喘之疾。 Taking too much salty fish will lead to asthma due to fish (Houchuan).nullnull04.元朱丹溪首创“哮喘”病名，《丹溪心法》设独立篇名《哮喘十四》；另设《喘十五》；自此喘与哮分别叙述。 It’s the first time to give name “asthma” to this disorder used as the title of one chapter and then to discuss wheezing syndrome and dyspnea syndrome separately.06. 明朝秦景明在《症因脉治•卷二哮病论》提出“哮病”之病名。06. 明朝秦景明在《症因脉治•卷二哮病论》提出“哮病”之病名。古文：哮病内伤痰饮，外感风寒，合而成。 英文：Wheezing syndrome is caused by both interior phlegm-retention and exterior wind-cold.nullnull05.明虞抟《医学正传∙哮喘》区别哮与喘。 古文：哮以声响言，喘以气息言。 We diagnose asthma especially from it’s sound, and diagnose gasping from it’s breath.Terminology Terminology 喘： panting 喘鸣：stridor 喘证：gasping syndrome 哮证：wheezing syndrome 哮喘：asthmaEtiologyEtiology病 因null01《内经∙素问∙阴阳别论篇》认识到内外因素影响脏功能(尤其是肺)是哮病的主要病机。 古文：阴争于内阳扰于外，魄汗未藏，四逆而起，起则熏肺，使人喘鸣。 If yin dominates interiorly and yang intrudes exteriorly, the soul sweating fails to be stored and the disorders develops all over the body, starting with lung damaged and leading to stridor and wheezing.null02《内经·素问·太阴阳明论》 提出外(风)邪致哮说。 古文：犯贼风虚邪者， …阳受之则入六腑… 入六腑则身热，不时卧，上为喘呼。 It proposed the theory that exogenous evil can cause the illness, “When the body is infected by occult evil wind, … yang six FU-organs are affected if yang is involved, … then the patient has a fever and fails to sleep flat, leading to whooping upward. null03《黄帝内经·灵枢·邪气藏府病形》提出外感“寒邪”之认识。 古文：两寒相感，中外皆伤，故气逆而上。 When two kinds of cold meet, both interior and exterior of the body are impaired, resulting in qi ascending reversely. null04 元朱丹溪《丹溪心法·喘十五》述及情志、饮食、体弱等多种病因。 古文：六淫七情之所感伤，饱食动作，脏气不和，呼吸之息，不得宣畅而为喘急。亦有脾肾俱虚，体弱之人，皆能发喘。 Damaged by six climatic exopathogens and seven emotions as well as action after full stomach, the visceral qi will be disharmonized resulting in obstructive respiration and rapid gasping. Anybody whose spleen and kidney are deficient can develop gasping syndrome.null04: Damaged by six climatic exopathogens and seven emotions as well as action after full stomach, the visceral qi will be disharmonized resulting in obstructive respiration and rapid gasping. Anybody whose spleen and kidney are deficient can develop gasping syndrome.null05明秦景明《症因脉治∙喘》指出体虚之病因。 古文：气虚喘逆之因，或本元素虚，或大病后，大劳后，失于调养，元气大伤。 The cause of wheezing conversely with qi deficiency is due to failure of recovery leading to damaging primordial qi after severe disease or exhaustion.病因病因总结winddietcoldmotionmorbidoverstrainnull2000年前 中国古代医学对于哮喘的病因记载已经相当完整null2000年前 《内经·素问·太阴阳明论》提出风邪致哮说: 犯贼风虚邪者, 阳受之则入六腑, 入六腑则身热，不时卧，上为喘呼。 1938年 西方撰此词 古希腊医学认为此病与风相关。相似何其乃尔MechanismMechanism病 机null01《黄帝内经·灵枢·本藏第四十七》最早提到肺与本病的特殊关系 古文：肺高则上气肩息咳。 If the lung is in superior position, the patient will gasp and cough with raised shoulder. null02《黄帝内经•素问•至真要大论篇第七十四》提出水饮之内因可上犯于肺引发本病。 古文：饮发于中，咳喘有声。 When the fluid retention occurs inside the body, it will cause cough and wheezing with stridor.null03隋巢元方550-630在《诸病源候论卷十四·咳嗽病诸候》最早指出痰饮与本病的关系。 古文：其胸膈痰饮多者，嗽则气动于痰，上搏喉咽之间，痰气相击，随嗽动息，呼呷有声，谓之呷嗽。 If there is too much phlegm above the diaphragm in the chest, the qi vibrates upward with the phlegm in the throat when the phlegm and qi struggle mutually worsening with the coughing and wheezing, accompanied by the sound, which is called as Xiasou (stridor). null If there is too much phlegm above the diaphragm in the chest, the qi vibrates upward with the phlegm in the throat when the phlegm and qi struggle mutually worsening with the coughing and wheezing, accompanied by the sound, which is called as xia sou (stridor). null04 东汉张仲景在《金匮要略∙痰饮咳嗽病脉证治第十二》中，将哮证归为“伏饮”证。 古文：膈上病痰，满喘咳吐，发则寒热，背痛腰疼，目泣自出，其人振振身膶剧，必有伏饮。 With diseased phlegm above diaphragm, the patient will have heavy panting with cough and vomiting, and then develop fever, lower backache, spontaneous tearing and body shivering during attack, which is rooted in concealed fluid retention inside body.哮病的三饮 水饮-痰饮-伏饮哮病的三饮 水饮-痰饮-伏饮水电解质 失衡 免疫反应null05 明戴思恭1324-1405《秘传证治要诀及类方•哮喘》明确提出本病的“宿根”之说。 古文：喘气之病，哮吼如水鸡之声，牵引胸背，气不得息，坐卧不安。此为嗽而气喘，或宿有此根，遇寒暄则发，一时暴感。 The disease of gasping syndrome is whooping with frog-like sound and raising the chest and shoulders leading to dyspnea and failing to sit and sleep. It is characterized by cough accompanied by gasping or fundamental illness which will recur in case of cold paroxysmally.null06 清李用粹《正治汇补∙哮病》全面阐明哮病病机。 古文：哮即痰喘之久而常发者，因内有壅塞之气，外有非时之感，膈有胶固之痰，三者相合闭拒气道，搏击有声，发为哮病。 It summed up the three links of asthma: “Asthma is long-term wheezing with phlegm having frequent recurrence because there is interior qi obstruction, induction of exogenous factors and tenacious phlegm above the diaphragm, three of which meet together to obstruct airway, fighting mutually with stridor, called as asthma.null太复杂 失去中医特色 nullMechanism Trilogy induced factorsFluid retention Phlegm r.  Root Concealed r. ManifestationManifestation症 候null01巢元芳《诸病源候论•卷之十四•气病诸侯》最早描述“水鸡之鸣”，犹如西医之喉鸣。 古文：肺病令人上气，兼胸膈痰满，气行壅滞, 喘息不调, 致咽喉有声, 如水鸡之鸣也。 Lung disease makes qi ascend with chest full of phlegm and qi stagnation, causing abnormal breathing and noisy sound in the throat like the sound of frog.null02《黄帝内经•素问•逆调论篇第三十四》已经记载本病的端坐呼吸。 古文：不得卧而息有音。 The patient can’t sleep flat and wheezing with stridor.null03《黄帝内经•灵枢•五阅五使第三十七》已经提到呼吸衰竭时出现的鼻翼扇动。 古文：肺病者，喘息鼻张。 A person with the pulmonary disease will wheeze with nasal flaring.null04明李中梓1588-1655在《医宗必读•卷九》(1637成)记载呼气性呼吸困难之表现。 古文：哮者与喘相类，但不似喘开口出气之多，而有呀呷之音。Asthma and wheezing are similar，but asthma does not breathe as much as wheezing，and have it’s sound like “yaxia”nullnullnull古代中医早已完整记载哮喘的临床表现TCM DiagnosisTCM Diagnosis四 诊null（一）望诊 01唐朝王焘670-755在《外台秘要卷九•久咳坐卧不得方》（752年撰成）准确描述哮证大作症候。 古文：久患气嗽，发时奔喘，坐卧不得，并喉里呀声，气欲绝。 It records the paroxysmal manifestations of severe wheezing and dyspnea syndrome: “The patient with long-term coughing and wheezing has heavy wheezing, fails to sit and sleep with stridor in the throat and even and is going to be suffocated due to dyspnea.null02 明王肯堂1549-1613《证治准绳∙喘》描述哮证发作症候，与西医呼衰表现一致。 古文：喘者，促促气急， 喝喝息数，张口抬肩，摇身撷肚。 The patient with asthma is out of breath, wheezing rapidly with stridor, opening mouth and shrugging shoulder, as well as shaking body and abdomen going forward. nullnull03清汪宏在《望诊遵经•卷二诊唇气色条目》(撰于1875年)述及哮喘之望诊。 古文：唇色黑瘀，目睛凸露，呼吸上逆者，哮喘也。 If the patient has black stasis, bulging eyes and upward breathing, asthma would be diagnosed.null03清汪宏在《望诊遵经•卷二诊唇气色条目》(撰于1875年)述及哮喘之望诊。 古文：唇色黑瘀，目睛凸露，呼吸上逆者，哮喘也。 If the patient has bluish color to the lips, bulging eyes and upward breathing, asthma would be diagnosed.风寒犯肺风寒犯肺症状:主证加咳痰稀白,表寒证,口不渴。 舌象:舌淡苔薄白而滑痰热遏肺痰热遏肺症状：主证加咳嗽痰黄稠，咽干，口渴喜冷饮，尿赤，便结或发热。 舌脉：舌红苔黄腻null（二）问诊 03 清何梦瑶在《医碥·喘哮》指出哮与饮食的关系。 古文：得之食味酸咸太过，幼时多食盐醋，往往成此疾，俗谓之盐哮。 Wheezing syndrome is caused by too much acid and salt in the diet during childhood, it is referred to salty wheezing syndrome.null（二）问诊 04 南宋张杲撰在《医说·卷四》(1224刊)记载“鱼腥哮 fish-asthma”。 古文：因食盐虾过多，遂得齁喘之疾。 Taking too much salty fish will lead to asthma due to fish (Houchuan).null（二）问诊 05南宋许叔微1079-1154在《普济本事方•卷一》（撰于1132年）中已经认识到本证具有遗传性。 古文：此病有苦而至终身者，亦有母子相传者。 The patient can suffer from this all his life which can also be inherited from mother to son.null（三）闻诊 06明朝虞抟1438-1517在《医学正传•卷之二•哮喘》（撰于1515年）提出“哮”与“喘”之别 古文：夫喘促喉中如水鸡声者，谓之哮；气促而连属不能以息者，谓之喘。 It is called asthma for the patient is wheezing with frog-like sound in the throat and it is called gasping syndrome for the patient is panting with accelerated and panting respiration.null（四）切诊 07《黄帝内经•素问•通评虚实篇第二十八》中首次提到用脉象判断哮病的预后 古文：乳子中风热，喘鸣肩息者，脉实大也。缓则生，急着死。 The Infantile patient suffering from wheezing syndrome with stridor and raised shoulder has a large and excess pulse. He will live on with relaxed pulse but die with swift pulse.Manifestations Manifestations null（四）切诊 08 唐王焘《外台秘要∙上气喉中水鸡鸣方》记载脉诊诊断本病。 古文：脉浮咳逆，咽喉中水鸡鸣，喘息不通，呼吸欲死。 The patient has floating pulse, bad cough and upwelling qi with frog-like sounds in the throat, gasping because of obstruction of airways and even feeling to die.TCM DifferentiationTCM Differentiation辨 证null01 明虞抟1438-1517《医学正传∙哮喘》(1515年成）提出“哮”与“喘”之别 古文：大抵哮以声响名，喘以气息言。 We diagnose asthma espcially from it’s sound, and diagnose wheesing from it’s breath. null02 元朝朱丹溪1281-1358《丹溪心法·卷二·哮喘十五》提出虚实辨证。 古文：实喘气实肺盛，虚喘由肾虚。 The excessive wheezing syndrome due to excessive lung qi and deficienct wheezing syndrome due to kidney deficiency.肺盛肾虚null03 明张景岳《景岳全·杂证》归纳虚实两证。 古文：实喘者有邪，邪气实也； 虚喘者无邪，元气虚也。 Excessive gasping syndrome has evil qi in which evil qi is excessive and deficient gasping syndrome has no evil in which vital qi is deficient.null05 清林佩琴《类证治裁卷之二∙哮症论治》提出哮喘有冷哮、热哮两大证候。 古文：遇风寒而发者为冷哮为实，伤暑热而哮者为热哮为虚，其盐哮、酒哮、糖哮，皆虚哮也……。 Cold asthma is the excessive one caused by cold wind while the hot asthma is the efficient caused by summer heat and asthma induced by salt, wine and sugar are all deficient one.null06明王肯堂在《证治准绳·第二册·诸气门· ·哮》(撰于1608年)中对寒哮作进一步辨证。 古文：哮喘遇冷则发者有二证∶其一属中外皆寒，……。其二属寒包热，……。 译文：Wheezing syndrome induced by cold has two subtypes: One belongs to cold wheezing syndrome with both interior and exterior cold, the other belongs to the one with exterior cold wrapping heat.null哮病虚实辨证 - 明清佳Treatment PrincipalTreatment Principal治 则null01元朝朱丹溪（1281-1358）在《丹溪心法∙卷二∙哮喘十五》提出治疗“已发”与“未发”之别。 古文：凡久喘之症，未发宜扶正气为主，已发用攻邪为主。 For the patient with long-term disease, vital qi has to be strengthened for pre-paroxysms while evil qi has to be eliminated for paroxysm. null02 明张景岳《景岳全书∙杂证谟∙卷之十九明集•喘促》仔细分析哮证的治疗方法。 古文：扶正气者，须辩阴阳，阴虚者补其阴，阳虚者补其阳。攻邪气者，须分微甚，或散其风，或温其寒，或清其痰火。 The yin-yang differentiation has to be made in the case of strengthening vital Qi, for which yin has to be replenished for the yin-deficient while yang has to be replenished for the yang-deficient. The careful differentiation has to be made in the case of eliminating evil, in which the wind has to be dispelled, the cold be warmed or the fire be cleared. null The yin-yang differentiation has to be made in the case of strengthening vital Qi, for which yin has to be replenished for the yin-deficient while yang has to be replenished for the yang-deficient. The careful differentiation has to be made in the case of eliminating evil, in which the wind has to be dispelled, the cold be warmed or the fire be cleared. null03 元朱丹溪(1281-1358)《丹溪心法·哮喘十四》之治法为后世所宗。 古文：哮喘必用薄滋味，专主于痰，宜大吐。 The plain food must be recommended to the patient with asthma, for whom the emetic agents is used to resolve the phlegm specifically.null04 清林佩琴《类证治裁卷二∙哮症论治》(撰于1773年)提出外感内伤两种治法。 古文：喘由外感者治肺，内伤者治肾。 Gasping syndrome caused by exogenous factor should be treated with focusing on lung, while by internal damage, on kidney.Principle of TreatmentPrinciple of Treatment凡久喘之症, 未发宜扶正气为主, 已发用攻邪为主。 扶正气者, 须辩阴阳, 阴虚者补其阴, 阳虚者补其阳。攻邪气者, 须分微甚, 或散其风, 或温其寒, 或清其痰火。 喘由外感者治肺, 内伤者治肾。 大凡治哮病, 宜忌燥药: 亦不宜纯用凉药。Principle of TreatmentPrinciple of Treatment(背诵) For the patient with long-term disease, vital qi has to be strengthened for pre-paroxysms while evil qi has to be eliminated for paroxysm. 扶正气者, 须辩阴阳, 阴虚者补其阴, 阳虚者补其阳。攻邪气者, 须分微甚, 或散其风, 或温其寒, 或清其痰火。 喘由外感者治肺, 内伤者治肾。 大凡治哮病, 宜忌燥药: 亦不宜纯用凉药。TCM FormulaeTCM Formulae方 药null（一）发作期：治寒哮 01 张仲景《金匮要略·肺痿肺痈咳嗽上气病脉证并治第七》(撰于3世纪初)记载的射干麻黄汤为治疗哮病(寒哮大作)的祖方。 古文：咳而上气，喉中水鸡声，射干麻黄汤主之。 If the patient has cough with upwelling qi and stridor a frog-like sound in throat, Shegan Mahuang decoction should be used as main formula.null（一）发作期：治寒哮 02东汉张仲景在《伤寒论·卷第三·辨太阳病脉证并治中第六》 提出以小青龙汤治喘。 古文：伤寒，心下有水气，咳而微喘，发热不渴。……小青龙汤主之。 If there is pathogenic water fluid below heart, cough and little gasping and fever without thirsty due to damaged cold, Minor Blue Dragon Decoction is used.null（一）发作期：治寒哮 03东汉张仲景在《伤寒论》中记载治喘之方。 古文：喘家作，桂枝加厚朴杏子佳。 When the patient has an attack of wheezing with this previous history, it is better to give him Guizhi plus Houpu and Xingzi. null（二）发作期：治热哮 01明龚廷贤在《寿世保元·卷三·哮吼》用千金定喘汤治热哮。 古文：千金定喘汤 治哮吼如神。 Qianjin Dingchuan decoction is effective in the treatment of wheezing with stirdor.null（二）发作期：治热哮 02清林佩琴在《类证治裁卷二∙哮症论治》(撰于1773)中提出治热哮之方。 古文：热哮当暑月火盛痰喘者，桑白皮汤，或白虎汤加芩、枳、瓜蒌霜。 When wheezing syndrome attacks in summer with exuberant fire and phlegm-gasping, Sangbaipi Decoction or Baihu Decoction plus Powder of Baical Skullcap, Orange Fruit, and Snakegourd Fruit is used.null（二）发作期：治热哮 03 清吴瑭《温病条辨∙寒湿》麻杏石甘汤治疗热饮。 古文：喘咳患促，吐稀涎，脉洪效，右大于左，喉哑，是为热饮，麻杏石甘汤主之 If the patient has cough and wheezing with thin saliva and hoarse voice , whose pulse is rapidly surging with the right bigger than the left, the disease is due to heat fluid which should be treated with Mahuang Xingren Gancao .null（三）缓解期 01张仲景在《金匮要略∙肺痿肺痈咳嗽上气病脉证并治第七》（撰于3世纪初）记载麦门冬汤。 古文：大逆上气，咽喉不利，止逆下气，麦门冬汤主之。 When qi is ascending reversely and the throat is constricted, Maimendong decoction is used to control reverse qi. null（四）喘脱 01 唐王焘670-755在《外台秘要》(撰于752年) 用人参之治喘脱。 古文：“疗咳上气，喘息便欲绝，以人参末之，日五次。 To treat cough and upward qi so as to resolve wheezing and gasping, ginseng powder could be used five times a day.方药小结方药小结Minor Blue Dragon DecoctionAcupuncture & MoxibustionAcupuncture & Moxibustion针 灸null（一）实证：宜针。 01南宋王执中《针灸资生经》(撰于1180-1195) 古文：凡有哮喘者，为按肺俞，无不酸痛，皆为缪刺肺俞，令灸而愈。 Any patient with wheezing syndrome feels ache when pressing acupoint of feishu, which is contray puncture on Feishu and could be cured with moxibustion on it. (Canon of Promoting Health with Acupuncture and Moxibustion).null（一）实证：宜针。 02 明杨继洲1522-1619《针灸大成》(1601) 古文：哮吼嗽喘：俞府、天突、膻中、肺俞、三里、中脘 (主要) Wheezing Syndrome with croup: Shufu, Tiantu, Danzhong, Feishu, Sanli and Zhongwan are used.null（二）虚证：宜灸 01 明朝高武《针灸聚英》（刊于1529年） 古文：喘，灸中府、云门、天府、华盖、肺俞。 Moxibustion is applied in acupoints of zhongfu, yunmen, tianfu, huagai and feishu are selected to treat gasping syndrome. 总 结总 结null了解Diagnostic TermsDiagnostic Terms喘证：gasping syndrome 哮证：wheezing syndrome 哮喘：asthma掌握nullMechanism Trilogy induced factorsFluid retention Phlegm r.  Root Concealed r. Manifestations Manifestations 掌握方药小结方药小结病案分析病案分析 杨某，男，20岁，工人。常发作性喉间哮鸣气急6年，入夏即发。最近哮喘又作，喘息抬肩，喉中痰鸣如锯，不能平卧，痰黄粘稠，咳吐不利，口渴喜冷饮，胸闷、心悸，疲乏无力，舌红，两侧糜烂，舌苔薄白，脉象细数。nullCase Brief Mr. Yang, 20-year-old, worker, has paroxysmal wheezing with stridor and shortness of breath for 6 years, which recur in summer. Recently the patient has recurrence of asthma again, having wheezing with raised shoulder, phlegm rattling in the throat, failure to lie flat and difficulty in coughing with yellow sticky sputum. Other symptoms can be also found: fondness of cold drinks when thirsty, stuffy chest, palpitations, asthenia, red tongue with erosions on both sides, thin white fur and thready-rapid pulse. 诊治程序示范诊治程序示范第一步：明确诊断。 根据“常发作喉间哮鸣气喘, 不能平卧”, 诊断哮病证无疑。 第二步：鉴别缓解期与发作期哮病 根据“喘息抬肩, 喉中痰鸣如锯, 不能平卧, 胸闷,心悸等症”，当属哮喘发作期。 第三步：鉴别寒哮与热哮。 根据“入夏即发，痰黄粘稠，咳吐不利，口渴喜冷饮，舌红，两侧糜烂，舌苔薄白，脉象细数等症”，有热象表现，故属热哮。 第四步：确立治疗。 辨证属热哮，痰热郁肺，治疗应清热化痰，降气平喘。方可定喘汤加减。nullStep1: Diagnosis It can be undoubtedly diagnosed as asthma according to “paroxysmal wheezing with stridor, shortness of breath and failure to lie flat”. Step 2: Differentiate remission stage and stage of attack It can be diagnosed as wheezing syndrome in the stage of attack based on the manifestation: wheezing with raised shoulder, phlegm rattling in the throat in throat, failure to lie flat, stuffy chest and palpitations. nullStep 3: Syndrome differentiations for cold-type or heat-type of wheezing syndrome It can be diagnosed as heat-type of wheezing syndrome according to the manifestation: recurrence in summer, difficulty in coughing yellow sticky sputum, fondness of cold drinks, red tongue with erosions on both sides, thin white fur and thready-rapid pulse, all of which are regarded as heat syndrome. nullStep 4: Treatment principles & Prescriptions Syndrome: heat-type of wheezing syndrome due to phlegm-heat accumulating in lung Therapeutic principles: to clear heat and resolve phlegm, lowering reverse qi to relieve wheezing Prescription: Modified Dingchuan Decoction THANK YOUTHANK YOU