談中醫義診遙距診治新冠肺炎

[MOMO]

摘要： 疫情在緊急的情況下，遙距治療既可預防醫生受到感染，亦可緩解前線醫護人員的工作 量，並可讓患者盡早獲得治療紓緩症狀。在新型冠狀病毒肺炎疫情流行的當下，若中醫可 以義診或贈醫施藥，既可紓緩民眾所受到的各種壓力，又可發揮中醫藥防疫抗疫的優勢。
世界衛生組織（World Health Organization，WHO）將新型冠狀病毒感染的肺炎命名為 COVID-19[1]，疫情至今已肆虐二年多，於 2022 年 3 月香港出現第 5 波疫情，曾每日確診人 數達四位數字。幸在國家的關懷及支持下派出星級醫療團隊協助，並與當地醫護人員共同努 力，又有中醫醫師加入「遙距診治」，義診兼送中藥包，萬衆一心，齊心抗疫，讓患者盡早 獲得治療。
究竟中醫在僅有的條件下如何作出「遙距診治」？在沒有把脈的情況下中醫是如何開出 處方？這類問題經常被問及。在回答前先要指出，中醫治療疫病已有幾千年的歷史，對其病 因、病機、辨證論治等較多醫家均有深入研究，特別是中醫藥在 2003 年我國非典型肺炎的 治療中曾發揮巨大作用，國家衛生健康委員會和國家中醫藥管理局多次聯合發文，提倡中西 醫結合治療，力圖縮短病程，提高臨床療效，減少危重症患者的發生率及病死率 。

1. 明晰民眾對遙距治療的誤解與憂慮
   中醫以「望、聞、問、切」為四大方法去收集診斷依據，可惜坊間對「切」即「切脈」 或「把脈」誤解過深，誤認為中醫單憑「把脈」即可把患者身體狀況瞭如指掌。需要正視臨 床經常會遇到「假脈」，此時則會「捨脈從證」，即脈象與症狀不符合，會選擇不考慮脈診 所獲得的資訊，以觀察到外證來判斷疾病和製定治療方案。明朝李時珍在《瀕湖派學》中就 提到：「世之醫病兩家，咸以脈為首務，不知脈乃四診之末，謂之巧者爾，上士欲會其全， 非備四診不可。」李時珍所言的「四診」，即望、聞、問、切，從四字之順序可分析，脈診 只佔中醫診斷之四分一，而且排於最後。面對疾病，不容小覷，故診斷過程必須通過綜合瞭 解並詳細分析患者症狀、病歷等方可作出判斷。反觀望診排最前，古有扁鵲見蔡桓公，扁鵲 曰：「君有疾在腠理，不治將恐深。」或舉例醫者一見患者是杵狀指，已可建議檢查心肺， 因許多肺部腫瘤會引發杵狀指，當然少部分是例外。還有，古時兒科又被稱為「啞科」，因 嬰幼兒未能通過語言表達不適的症狀，所以望診成為主力，而醫生的「望」便是看孩子的神 態、面色、體形、二便等，其中有一種相對脈診的方法也是通過「望」而達成，即望「指紋」 的氣血，是否到達風關、氣關、命關，以此識別正邪之間的強弱、深淺等。另外，聞診是指 醫者通過聽覺和嗅覺了解病人的聲音和氣味兩方面的變化，如許多幽門螺桿菌感染患者，其 口臭發生率明顯高於未感染者。問診同樣重要，如同福爾摩斯查案，蛛絲馬跡也不可放過， 目的是為患者縮短治療時間，盡早康復，舉例某繼發性不孕患者，每月均通過超聲波檢查監 測排卵，服過促排卵藥、黃體酮等已有年多，可惜罔效。轉試中醫，通過詳細問診後終發現 原因，得知其生第一胎於冬天，當時沒好好坐月，讓寒邪入體，即古人言的「伏寒」，找到 35 【疫病防治 - 新冠肺炎探析】 病因後，針對「伏寒」作出相應治療，翌年誕下麟兒。尤其在「遙距診治」時，問診就更顯 得重要，而且應更詳細。
   當然，可以四診合參一定是最佳選擇，但事有緩急，於疫情緊急的情況下，遙距治療既 可預防醫生受到感染，亦可緩解前線醫護人員的工作量，並可讓患者盡早獲得治療，紓緩症 狀。還記得當學徒的時候，常見吾師們為患者遙距開方，有用視象與患者問診，已昏迷的則 通過家人的描述及相片…。
2. 分享遙距診治新冠肺炎案例
   筆者亦有加入遙距義診，接到的求助個案為 2020 年 10 月 09 日出生的男孩（未足 1 歲 半），自家新冠核酸呈陽性，疑未獲安排現代醫學治療，父母曾私下給予羚羊角粉及退燒栓 劑，但體溫還是波動，因極為擔心而求診筆者，全程以通訊軟件 Whatsapp，通過留言，以 一問一答形式問診，其時症狀如下：高熱（39.5 度～ 40.1 度）、口渴欲飲、聲音沙啞、間 中出現咳嗽及流鼻涕，胃納一般，看舌相其色偏絳紅。因患童為肺陰不足，處以玄麥甘桔湯 加減，處方如下：玄参 3g、麥冬 3g、桔梗 3g、生甘草 3g、枳殼 3g、丹参 3g、蘆根 3g、白 茅根 3g、牛蒡子 3g 及射干 3g，囑其到相熟中藥房免費取中藥，2022 年 3 月 30 號開始服藥， 藥後症狀均有緩和，體溫於 3 月 31 號為 36.7 度，可惜未有大便，當日核酸陽性，其間按其 症狀改變有修改處方內藥物。4 月 1 號體溫為 36.3 度，核酸還是陽性，4 月 4 號核酸還是陽 性，症狀餘下單咳及流涕，囑其堅持服藥，於 4 月 6 號收到其母通知核酸轉陰，為免病情反 覆，囑把已取回家之藥包服完。4 月 29 日隨訪，其母親回道：「挺好的。」
   按：玄麥甘桔湯主治肺陰虛咳嗽、喉癢乾咳無疾或痰少而粘，不易咯出，亦治夜間發熱， 盜汗，口渴咽乾。當中玄參味苦、鹹，性寒，入肺、胃二經，有清熱解毒，滋陰潤燥的功效， 善治結熱毒癰及咽喉疼痛；麥冬味甘、微苦，性寒，入心、肺、胃經以潤肺清心、養胃生津， 專治肺胃陰虛的咳嗽、喉痛；甘草味甘，性平，生用能清熱、瀉火、解毒；桔梗味苦、辛， 性平，入肺經，有宣肺、祛痰及排膿的功用。甘草與桔梗配合名為桔梗湯或甘桔湯，是通治 咽喉病的一張良方。綜合上方有清熱解毒、滋陰潤燥及排膿祛痰等功效。
3. 新型冠狀病毒 Omicron 變異株感染患者的中醫證候特徵
   據專家研究指出 Omicron（奧密克戎）病毒感染的證候學特點[3]是濕毒鬱肺，兼夾風熱。 各期表現：1）初期濕毒挾風，侵襲肺衛，如發熱、咽痛、咳嗽，同時可伴有鼻塞、流涕、 頭痛等上呼吸道感染症狀，而濕毒閉肺不明顯，故憋喘不重。病情輕淺，但寒熱轉化快，多 見舌紅、薄苔黃膩。治療以宣肺清熱、疏風解毒為主。2）中期表邪化熱入里、氣分鬱熱、 濕毒蘊肺，可見咳嗽、咯痰，痰粘色黃 等，消化道症狀不明顯，舌偏紅，苔膩或黃膩。治 療以清熱解毒，止咳化痰為主。3）後期余邪未盡、氣陰兩傷，可見乏力、倦怠、心悸、肌 肉酸痛等，舌紅少津，治療以益氣養陰為主
4. 結語
   中醫自古以有贈醫施藥，在疫情期間民眾可因物價上漲、失業等同題，導致生活壓力， 因此自古至今曾參與義診或贈醫施藥的中醫不計其，目的都是希望疫情盡早完結。另外，民 眾在服藥上必須注意，中醫治病以「辨證論治」為前提，同是新冠陽性，但症狀有異，或年 紀不同，或體質不同，處方的藥物可完全不同，故服用任何中藥，建議必須咨訊專業中醫師， 不可盲目服用任何偏方，必須依據國家衛生健康委和國家中醫藥局新的證候標準《新型冠狀 病毒肺炎診療方案》，更應積極配合政府的指示及安排。
   作者簡介： About the Author : 呂澤康中醫生，澳門人。澳門科技大學中醫學學士，南京中醫藥大學中醫婦科碩士，南京中醫 藥大學中醫內科博士，師承孟河醫派國醫大師朱良春教授、針灸名醫盛燦若教授、婦科名醫趙 可寧教授、風濕免疫科名醫周學平教授及眼科針灸名醫謝奇。著作有《中醫在西方 -中英對照》、 《治不孕錦囊 - 中英對照》及《遠離風濕免疫病》等。醫學文章刊於各醫學期刊、國際著名雜 誌《Marie Claire HK》網站、《力報》及《澳門日報》等
   唐鴿，南京中醫藥大學七年制碩士，腫瘤學專業。柏林洪堡大學認知神經科學碩士，現慕尼黑 大學系統神經學在讀博士
   關鍵詞： 新冠肺炎；中醫藥治療；遙距診治；贈醫施藥

[mina]

宜家疫情係唔係總算冇咁嚴重

[venus]

不嬲都話睇中醫對COVID有幫助,所以蓮花個陣一出就咁多人買話有效

[MOMO]

Abstract: Under the current covid-19 crisis, remote diagnosis and treatment show their advantages. It can protect doctors from exposure to the virus and reduce their working load. The most important is that patients can receive proper treatment in time. As Chinese medicine has already shown an advantage in treating COVID-19, If we can make practising Chinese medicine remotely possible, it would greatly relieve the pressure on our medical system.

It is already 2 years since the world health organization has named this new pandemic as COVID-19[1]. HongKong started the fifth wave at the march 2022, and the number of daily diagnosed people was exceeded ten thousand. With the excellent volunteer doctor teams came through the country and the hardworking of local medical system, in addition the remote diagnosis and treatment from Chinese medicine, the pandemic got under control in the end. For example, regarding the Chinese medicine, we delivered the herbal packages to the patients as soon as possible.
How to practice Chinese medicine remotely under restricted conditions? How to make prescription without feeling the pulse? These are common questions to be asked during remote diagnosis and treatment. Before answering these questions, here are some facts we should know. During the thousand-year history of Chinese medicine, lots of great doctors had a thorough research on the etiology, pathogenesis, diagnosis, and treatment. Chinese medicine already showed its power during the outbreak of SARS in 2003. The national health commission has documented that we should combine the Chinese medicine and western medicine, and shorten the course of the disease, improve the treatment, and reduce the ICU admission and death rate [2]

1. Clarify the misunderstanding and the concern to the remote diagnosis and treatment
   Four diagnoses (inspection, auscultation and olfaction, inquiry and palpation) are the foundation of the Chinese medicine. It is sometimes misleading for the public that feel the pulse can get all the information needed for diagnosis. During practice, the false pulse should take into consideration, under such situation, we should ignore the pulse and make the diagnosis and treatment mainly based on symptoms. Li Shizhen has written in his book ‘Pin Hu Mai Jue’ : one school of bad doctors give too much credits to the feeling pulse, they did not realize that feeling the pulse is one diagnosis method. On the country, a good doctor will integrate these four diagnoses. The ‘Four diagnoses mentioned by Li Shizhen are inspection, auscultation and olfaction, inquiry and palpation. Feeling the pulse is one of them, and it is listed at the end. During the practice, we should be very careful, integrate and analyze all the information, (e.g., the symptoms, medical history and so on) collected from these four methods, then we could make diagnosis. From the order of the four diagnoses, the observe are the first on this list, which emphasize its importance. Bian Que, a famous doctor, came to meet Cai Huan Gong. After a first look, he told Cai, ‘You are not healthy, if you did not treat now, it will develop a severe disease.’ Another example, usually, doctors would suggest the lung and heart examination after observing the clubbing of the fingers or toes. Of course, there are also exceptions. For the pediatricians, they mainly diagnose by observation, since cannot express themselves, which also called ‘deaf department’ in the old time. They will observe the spirit, the color of the face, the shape, the urine and stool, and the index fingerprints. Observing the index fingerprints is a special methods only work for child, it can reveal the Qi Xue of the child. The extension level of this fingerprint, to the Feng Guan, Qi Guan, or Ming Guan, tells the progress of disease, the depth of the Xie Qi and the strength of Zheng Qi. On the other hand, auscultation and olfaction diagnosis means the doctor diagnose the disease by the sound and smell from patients. For example, the probability of bad breath is much higher in patients infected by helicobacter pylori than those not. Similar to the detector Holmes works on a case, to make a correct diagnose, details are as important as inquiry. It is critical for shorten the treatment, and faster recovery. There is one patient with secondary infertility. She had the ultrasonography every month to observe the growth of the follicle and ovulation and take the ovulation stimulation drugs and progesterone for years, while she still cannot have a child. She started to seek treatment from Chinese medicine. After a detailed inquiry, I found that she did not recover well after the first child. It was winter, and she was invaded by the Han Xie, which is called ‘Fu Han’. So, I treated this ‘Fu Han’. The next year, she had a health baby. After all of these examples for the four diagnoses, I would like to strength that during remote diagnosis and treatment, inquiry became extreme important, and we should got more details from patients than usual.
   Of course, the best practice should integrate the four diagnoses, while in current urgent situation, the remote diagnosis and treatment can protect doctors from exposure to the virus and reduce their working 36 【疫病防治 - 新冠肺炎探析】 load. The most important is that patients can receive proper treatment in time. Back to the old days, I was still a student. My supervisors also make prescription after video chats, sometimes they make diagnose through indirect inquiry to the family member.
2. COVID Cases from remote diagnosis and treatment
   I had volunteered the remote diagnosis and treatment. One case is a one and half year-old boy, born on 2020.10.09. He was tested positive for COVID-19. His parents fed him some Lin Yang Jiao powder and antipyretic medicine, but the fever is not getting better. They asked me for help. We communicated by whatsapp. The symptoms were fever (39.5 to 40.1 degree), thirsty, hoarse sound, cough, running nose, normal appetite, and dark red tongue. He had a deficiency in Fei Yin, so I prescribed him with Xuan Mai Gan Jie Tang : Xuan Shen 3 gram, Mai Dong 3 gram, Jie Geng 3 gram, Sheng Gan Cao 3 gram, Zhi Ke 3 gram, Dan Shen 3 37 【疫病防治 - 新冠肺炎探析】 gram, Lu gen 3 gram, Bai Mao Gen 3 gram, Niu Bang Zi 3 gram and She Gan 3 gram. I asked them to get the medicine from my contacted store, and the child started to take medicine on 2020.03.30. All the symptoms were improved, and the fever went down to 36.7 degree, but he did not have the bowl movement. I slightly adjusted the prescription according to his symptoms. On 2022.04.01, his fever is gone. The body temperature is 36.3 degree. On 2022.04.04. he still has some cough, and running nose left, and the COVID test was still positive. I asked them to continue taking the medicine. On 2022.04.06, I got the message from his mother that the test turned to negative. To enhance the treatment, I asked them to finish the medicine. The follow up on 2022.04.29, his mother told me that everything is fine.
   Note: Xuan Mai Gan Jie Tang is effective to cough caused by Fei Yin deficiency, patients will experience dry throat, less and sticky phlegm, difficult to spit. It also works for fever in the midnight, night sweats, thirsty. Ku Shen, taste bitte and salty with cold quality, belongs to the Lung and Stomach. It has the function of clear heat and resolve toxicity, nourishing yin for moistening dryness. It is effective for heat toxicity and sore throat. Mai Dong, taste sweet and slightly bitte with cold quality, belongs to the heart, Lung and Stomach. It has the function of nourishing the lung and clear the heart fire, nourishing stomach and generate the water. It is effective for cough and sore throat due to the Yin deficiency of lung and stomach. Gan Cao, taste sweet with neutral quality. Raw Gan Cao has the function of clear hear, resolve toxicity. Jie Gen, taste bitte and spicy with neutral quality, belongs to lung. It has the function of refresh lung, clear the phlegm, and discharge pus. Gan Cao and Jie Gen can be used for treating throat diseases, it is called Gan Jie Tang. In a word, the prescription for the little boy has the function of clear heat and resolve toxicity, nourishing yin for moistening dryness, expel the pus and phlegm.
3. The syndromes of Omicron infection from Chinese medicine view
   The specialists points out that the typical syndrome is damp toxicity in the Lung, mixed with the wind heat[3]. They have three different stages: at the beginning, the damp toxicity mixed with the wind, which attacks the lung, patients will show fever, sore throat, cough, running nose, headache and so on. since the damp toxicity did not totally disrupt the lung, the patients would not breath heavily. While the cold could turn to heat quickly, patients will show red tongue, thin and greasy coating. The treatment should be dispel wind and unleash the inhibited lung energy, clearing toxicity. At the second stage, the Xie Qi went deeper, the heat stagnation in the Qi, damp toxicity invading the lung, patients have cough, greasy and yellow phlegm, relative normal appetite, dark red tongue, greasy or yellow tongue coating. The treatment should be clear the heat and resolve the toxicity, relieve the cough and reduce the phlegm. At the final stage, there is still remaining Xie Qi, at the same time, patients had deficiency of both Qi and Yin. They will complain fatigue, palpitation, sore muscles, red dry tongue. The treatment should be supplementing Qi and nourishing Yin.

[MOMO]

4. A final word
   It is a tradition that doctors practice Chinese medicine would treat patients for free. Especially since the pandemic, people facing a lot of challenges, the increased living costs, losing jobs and so on. We are all making effort to help ending the pandemic. Be careful, Chinese medicine is still based on syndrome differentiation, the same disease may have different syndromes in different people. You should visit a doctor before taking any medicine. Do not taking the folk prescription. We should follow the guidelines from the diagnosis and treatment protocol for COVID-19, and actively cooperate with governments instructions and arrangements
   About the Author :
   ChakHong Lui ( TCM practitioner), a native of Macau. Bachelor of Traditional Chinese Medicine from Macau University of Science and Technology, Master of Traditional Chinese Medicine and Gynecology from Nanjing University of Chinese Medicine, Doctor of Internal Medicine from Nanjing University of Chinese Medicine, was a disciple of Professor Zhu Liangchun, a master of Chinese medicine from Menghe Medical School, Professor Sheng Canruo, a famous acupuncture doctor, Professor Zhao Kening, a famous gynecology doctor, and a rheumatology and immunology department Professor Zhou Xueping and famous ophthalmologist and acupuncturist Xie Qi. His books include "Traditional Chinese Medicine in the West - A Comparison between Chinese and English", “The Key to Baby Making - A Comparison between Chinese and English" and "Away from Autoimmune Diseases". Medical articles are published in various medical journals, the website of the internationally renowned magazine "Marie Claire HK", "ExMoo" and "Macao Daily", etc

Ge Tang, master of Traditional Chinese Medicine and oncology from Nanjing University of Chinese Medicine. Master of cognitive neuroscience from Humboldt university Berlin, Doctoral candidate for systematic neuroscience at Ludwig-Maximilians-Universität Munich

key words : COVID-19, Chinese medicine, remote diagnosis and treatment, volunteer medical consultant and
providing free medicine