Stratified diagnosis of cough
Cough is both a disease and one of the most common symptoms. In the treatment of cough, there are commonalities – loss of lung circulation and Qi rebellion – but there are also differences in the prescription of medication due to the cause, location and nature of the disease. We advocate the adoption of a “layered diagnosis” approach to the diagnosis and treatment of cough.
For example, cough – lung cancer (Yin deficiency, toxicity and heat). “Cough” is the diagnosis of disease evidence, i.e. the first level of diagnosis, which is the target point for treating different diseases in TCM; “lung cancer” is the diagnosis of disease cause, i.e. the second level of diagnosis, which is the basis for treating different diseases in TCM; “yin deficiency and toxic heat The diagnosis of “yin deficiency, toxin and heat” is the third level of diagnosis, which includes the combination of disease location and disease diagnosis, and is the basis for the specific prescription and medicine selection at the current stage of the disease.
In the above example, “cough” is the patient’s most current concern and the main reason for seeking medical treatment. The patient wants to alleviate or eliminate the cough. In the traditional approach, a distinction is made between external and internal injuries, and then the symptoms and tongue and pulse are used to draw the symptoms and select the medication. The problem follows: Even if the same symptom is identified, rarely do two doctors prescribe the same medicine. The answer is the lack of etiological diagnosis and the grasp of the overall pathological mechanism of the disease. Imagine that even with the “yin deficiency, toxicity and heat” symptoms, the effects of the same prescription for lung cancer and consumption may sometimes be very different.
First, the determination of the “cough” evidence
According to the textbook, cough is a clinical condition characterized by a loss of lung circulation and purification due to external or internal injury, resulting in the rebellion of lung qi upward and impacting the airway, resulting in a coughing sound or sputum production. It is called cough with sound but no phlegm, cough with phlegm but no sound, and cough with phlegm but sound. It can be seen that all illnesses with coughing with sound or coughing up sputum as the main clinical symptom can be classified as “cough”.
I think it is inappropriate for the new version of internal medicine to force the term “cough” to correspond with the Western term “acute bronchitis”, and I reserve my personal opinion.
Second, the etiological diagnosis
In the article “Jin Kui Yao – Pulmonary Impotence, Coughing and Coughing in the Upper Air”, Zhong Jing points out that the number of pulse in the inch mouth, the person coughing, …… is a disease of pulmonary impotence. …… cough that is vague pain in the chest, the pulse counters slippery number, this is lung carbuncle, coughing spit and pus and blood. If the pulse count is deficient, it is lung impotence, and if the pulse count is solid, it is lung carbuncle. He also prescribed different prescriptions for treatment according to different causes and main symptoms, combined with the tongue and pulse. It can be said to be a model of combining disease identification and evidence identification.
1. External cough
Characteristics of the main symptoms: cough with or without coughing sputum. Mostly new (within 3 weeks), with rapid onset and short duration, often accompanied by superficial evidence of lung health. Auscultation: normal pulmonary breath sounds, or dry moist woven Q purple can be heard; weevils are often heard in the x-ray: normal or with thickened lung texture.
External cough that is not cured for a long time can also be transformed into internal cough. However, care should be taken to differentiate it from lung cancer, consumption, Taiyin warm disease, pulmonary carbuncle, drug-derived cough (pharmacogenic cough), cough (cough variant asthma), etc.
2. Internal injury cough
According to Zhang Jinyue’s view, a cough that is not externally induced is a cough of internal injury. However, with the development of medicine and in-depth research, it is no longer possible to meet clinical needs by remaining on Zhang Jinyue’s idea of dividing cough evidence. It is believed that internal injury cough can be defined separately in two senses: broad and narrow. The so-called “cough of internal injury” in the broad sense means “non-external cough”; the cough of internal injury in the narrow sense is defined as a cough with a long history of illness, repeated coughing, a long duration of illness, and a cough that can be accompanied by other organs and can exclude known causes such as consumption, pulmonary carbuncle, lung cancer, medicine cough, and croup cough.
3. Consumption cough
According to the Secrets of Wai Tai, in addition to cough, this disease is characterized by symptoms such as bone vapor, irritability, tasteless food, emaciation, night sweats, and cheeks that look like carmine. However, with the widespread use of modern antibacterial drugs, the clinical symptoms of many diseases, including pulmonary consumption, are becoming more and more atypical, bringing many obstacles to clinical diagnosis. Therefore, the combination of chest radiograph, PPD skin test, blood TB antibodies, and pathogenetic examination is crucial to determine the diagnosis.
4. Cough with pulmonary carbuncle
Most of them have a history of external infection. The onset of the disease is rapid, with sudden chills and high fever, cough, chest pain, and vomiting of large amounts of fishy, foul-smelling sputum or even pus and blood. It is believed that observation with the help of imaging is actually an expanded connotation of TCM diagnosis, which is a direct diagnosis of the lung lesion and is more objective and instructive. Imaging suggests the presence of pale flaky or dense shadows in the lungs, or round, round-like, or spherical lesions with relatively neat margins; symptoms are either seen in coughing or coughing up pus and sputum with or without blood; or chest pain or chest pain is not obvious; or fever or no fever, etc.; or only imaging indicators are present, and the remaining symptoms are not obvious. Sputum bacterial culture and the obvious effect of targeted treatment can help confirm the diagnosis.
For those who do not have obvious clinical symptoms, special attention should be paid to differentiate them from lung malignant tumors!
5.Cough in lung cancer
Lung cancer, according to Chinese medicine, is a malignant tumor of the lung caused by internal deficiency of positive energy, external invasion of evil toxins, loss of lung circulation and descent, internal accumulation of phlegm and turbidity, stagnation of qi and blood stasis, and accumulation of phlegm and stasis in the lung, which forms a lung mass over time and is confirmed by cytology or pathological histology.
Early symptoms include choking cough, persistent dry cough that persists for several weeks, or recurrent hemoptysis, or unexplained persistent chest pain, shortness of breath, fever, or with wasting and fatigue. Men aged 40 years or older with a long history of smoking are at high risk.
Chest X-ray and CT examination are helpful for early diagnosis of lung cancer. Sputum exfoliative cytology examination is a simple and effective method for early diagnosis of lung cancer, with a positive rate of about 80%, and the positive rate can be increased with multiple examinations. Fiberoptic bronchoscopy and percutaneous lung aspiration examination can determine the nature of lesions, and pathological examination is an important method to confirm the diagnosis of lung cancer; PET-CT examination can help to stage lung cancer.
6.Medicinal cough
With the widespread use of Western medicine, many Chinese medicine textbooks do not have corresponding names for the disease, such as “medicine cough (drug-related cough)”, which is mainly seen in ACEI preparations (captopril, benazepril, etc.). Characteristics: Intermittent dry cough with discomfort, itching and dryness in the throat, which can be aggravated at night, and in a few cases, cough variant asthma, which is not treated with cough suppressants and antibiotics and is relieved 1 to 2 weeks after stopping ACEI. If this type of cough is neglected and the ACEI is not stopped, it is difficult to cure it even if the evidence is accurate.
7. Pneumothorax
Chinese medicine does not have the name “pneumothorax”. It was first recorded in Suwen? It is written in “The Theory of Stabbing Prohibition” that if the lung is stabbed, it will die in three days, and its movement is cough. It is clearly pointed out that (needle) stabbing the lung (from the current medical common sense is mostly pneumothorax) mostly manifests as “cough”, there is no good treatment method, and the disease is dangerous. Clinically, it includes two categories: spontaneous and traumatic (including medical origin), mainly manifested as “qi stagnation and blood stasis” and “qi deficiency and blood stasis”. In terms of treatment, closed chest drainage (traffic pneumothorax, tension pneumothorax) or thoracic puncture and aspiration (closed pneumothorax) is recommended for 20% or more of pneumothorax, together with TCM treatment to invigorate blood and benefit qi or invigorate blood and move qi; for less than 20% of closed pneumothorax, bed rest, oxygen absorption + TCM treatment is recommended. In addition, Chinese medicine is also worthy of research and discussion in preventing recurrence.
Diagnosis of disease location
The “internal organs identification” is the main identification method for disease location diagnosis. Su Wen? Cough Theory: “All the five internal organs and six internal organs cause coughing, not only the lungs”. Another cloud: “Each of the five internal organs is affected by the disease at its own time. Not its time. Each of them is transmitted to the other”. And separately listed the symptoms of cough from the five viscera and six bowels.
1, lung cough, positioning symptoms: “cough and wheezing with sound, and even spit blood”, cough phlegm, and even chest pain. That is, coughing with phlegm, shortness of breath, coughing blood, chest pain, mostly caused by lung disorders.
The so-called “heart cough, liver cough, spleen cough, kidney cough” and “six internal organs cough” are distinguished from other organs and lungs and lungs and other organs. They should be carefully distinguished clinically.
2. Other organs and lungs: Heart cough, such as “palpitations, swelling, nocturnal paroxysmal dyspnea and rapid pulse generation”, and stomach cough, such as “stomach regurgitation, vomiting, acidity and burning pain behind the sternum”, can all lead to lung cough. If this type of cough is treated for heart and stomach diseases, the cough will stop and there is no need to treat the lungs.
3. Lung and others: such as heart cough with swollen throat; liver cough with pain under the two hypochondrium, even if it cannot be turned, and when it is turned, the two hypochondrium are full; spleen cough with pain under the right hypochondrium, leading to pain in the back of the shoulder, even if it cannot be moved, and when it is moved, the cough is severe; kidney cough with pain in the back of the shoulder, even if it is coughing and salivating; stomach cough with vomiting, bile cough with vomiting, large intestine cough with loss, small intestine cough with loss of gas, bladder cough with loss of drowning, and triple jiao cough with abdominal fullness and lack of desire to eat and drink, etc., are all caused by cough. It is the result of a severe cough. When the cause of coughing is corrected, it should be treated according to the evidence, “For those who treat the organs, treat their Yu; for those who treat the bowels, treat their Hap.” (Huangdi Neijing – Cough Theory Chapter 38).
Diagnosis of pathology
Pathology means the nature of the pathology. Although “cough” can be distinguished from external sensation, internal injury, or external sensation on the basis of internal injury, and there are also differences between the five dry lungs and the self-inflicted diseases of the lungs, the “eight levels of identification” is the basis. Through the “eight syllogisms”, we can analyze and summarize the types, locations, nature, strengths and weaknesses of various symptoms.