于部徐某，年届四旬，常患咳嗽，入冬辄发。每服开肺化痰之宁嗽露，可以渐安，因而发必服之，已成案头常备之物。咳止后稍感寒邪又必复作。如此经历数个冬天，病终不除。1975年2月间就治于余，询知平素精神不振，胃纳不馨，饱食即胀满不舒、心下塞闷，大便软溏，日行二、三次。脉则细小，两尺软弱，舌质暗淡，苔呈薄白。闻其咳声轻浅无力，痰多而稀薄，断为气虚脾阳不运，兼水寒射肺而咳也。投补中益气汤加干姜、五味子，三剂而安，后亦不发。方为：
党参9g黄芪9g当归9g焦白术9g陈皮4．5g升麻3g柴胡3g炙草3g五味子3g于姜1．5g
按：此为气虚下陷兼有痰饮之证，故以补中益气汤健脾升阳，配入干姜、五味化饮敛肺，双管齐下故收捷效。
(三)气陷腹痛，须仗补中益气
会计王某，年过五旬，素来健康无病。是年于乡下营建房屋，操持过甚。数日后，自觉脐下气海穴内隐隐作痛，时轻时剧。脉弦软，苔薄白。按其腹部绵软，且得按则痛减，故虑其气虚。予六君子汤，不效。更加归、芍以调和肝脾，亦不知。余反复推究病情，思必因负重过度，而致中气下陷。前方有益气之能，而乏升举之力，法当补而兼升。且用力不当每致气滞，气滞则血亦不畅，理宜兼顾。因此给予补中益气丸及三七片同服。丸药每日三次，每次10g。片剂仅服常量之半，日服二次，每次二片。三日后腹痛止。为巩固疗效计，嘱续服补中益气丸250g，三七片二瓶。以后直至退休，未闻腹痛重作也。
(四)子夜晕厥，应用泻火升提
某商店经理甘先生，三十八岁。1978年诊，患者形躯肥胖，素体尚健。然近年余以来，却患一奇症：每晚睡至半夜辄醒。四肢不能动弹，口不能言，但心中了了，外界之声响及家人之活动，悉知悉见。如此经历两小时许，即自行复常，自昼除稍感疲劳外，并无他异。时至夜半，病必复作。循此规律周而复始。虽经中西医药多方治疗，略无征验。嗣后，在某区中医院住院四十天，医家从“怪病皆属于痰”立论，药用二陈汤加味，予以行气化痰，服三十多帖，未见影响。出院后来就余诊。余察其脉象细软，而两手寸脉尤见细弱．左尺搏大鼓指。推详脉证，是“阳气下陷阴中”之见证。夜半虽阴气极盛，而子时为一阳初生之时，阳气来复，阴霾渐退。值此阴阳交替之候，阳当渐壮而胜阴，缘患者阳气下陷，滞于阴中，无力升腾，是故阳气当升而不能升；又因阴中阳气内郁，阻碍阴阳进退之路，故阴气当退而不能退。如此便使阴阳之气不能顺利交替接续。而上述诸证见焉。经二小时许进人丑时，阳气渐旺则阴气渐退，由是正阳升发，则一切复常。既然病机若此，则本病之治疗，当“升提下陷之阳气，清泄下焦之阴火。”用补中益气汤加黄柏治之。方为：
黄芪12g焦白术9g陈皮6g升麻3g柴胡3g党参9g炙甘草3g当归9g黄柏9g
服药首剂，病即未发，连服_J帖，夜夜安然无恙。复诊时左尺之脉已平，原方去黄柏，即单用补中益气汤方，又服一周，病均未发，就此停药。至今近二_卜年，夜夜安然人梦乡。
(五)气虚阳衰地道不通，温润益气清升浊降
革命前辈徐大姐，于古稀高龄苦便秘不通。初服通便药片，尚可勉强通下，久则失灵。余曾为之诊治一、二次，用益气通便之方，略有小效。彼则急于求成，访求专家名医，经友人介绍请一名医诊治，诊后持处方向余咨询，余见方大骇，全方药有十余味，均是养血滋阴之品，如生熟地、天麦冬、川石斛、玉竹、沙参、柏子仁、火麻仁、全瓜蒌等，药之用量每在15～20g之间。虽有甘草、茯苓之类。岂敌大队滋腻之害。余劝勿服，终不听之。服四十剂，复邀余诊。余见其瘫坐椅上，面色黄白相杂，全无血气。语声低微勉强，似难接续。自诉极度倦怠，气短欲喘。大便艰涩，腹笥胀满，五、六日方得便解一次。胃纳甚差，每天仅食一小碗。切其脉大而涩滞不扬，按之软而无力。舌质阔厚而歪向左侧，舌色淡白，苔则白干厚腻。据此脉症，显是阴药过度不仅使中气受戕，脾失健运，痰浊阻滞致上下气机不畅，而且阻遏下焦阳气，阴寒凝滞，遂致地道不通。治法当健脾化痰，温阳通便。投以香砂六君子汤合景岳济川煎，服后仅大便略有好转，胃纳稍开外，并无他效，且觉口中干燥。但白厚腻苔渐变薄白微腻，可以测知痰浊渐化，中焦气机复苏。但疲乏无力不见改善，虑其高年气衰，必有清气虚陷之机。改拟补中益气汤合济川煎，自觉服后极为舒适，大便二、三日一行，量多质软，体力渐复，胃纳亦开。两月后，生活学习，走亲访友均已恢复常态。前方服及一年，大便又渐干结，再合魏龙骧先生之白术通便方，竞得幽通气道，大便一、二日即行一次，自然而舒适。以后每日一一剂，常服不辍，至今已服及四年有余，稍稍停药二、三口即感中气不续，纳差便涩，再进前药，又可复常。闷前仍在服用中。所用方为：
黄芪30g党参15g炒白术30g陈皮6g升麻3g柴胡4．5g炙甘草3g当归9g淮牛膝15g泽泻9g炒枳壳6g苁蓉15g生地15g大枣30g
桂附八味丸方证散议
(一)桂附八味丸，首见于仲景《金匮要略》，但古今方名略有不同。本方于《金匮》书中凡两见：先见于“血痹虚劳病脉证并治第六”篇，名曰“八味肾气丸”。又见于“妇人杂病脉证并治第二十二”篇，删去“八味”二字，仅名“肾气丸”。因此方首出《金匮》，后世称之为“金匮肾气丸”，此名至今尚在沿用。现时之“金匮肾气丸”与仲景原方不尽一致，已略有变动，故有改称“桂附八味丸”者。
《金匮要略》之肾气丸药用：“干地黄八两，山茱萸、薯蓣各四两，泽泻、茯苓、牡丹皮各三两，桂枝、附子(炮)各一两。”其所治证为“虚劳腰痛，少腹拘急，小便不利者”及“转胞”而“不得溺”者，用肾气丸于补益肾气之基础上，“但利小便则愈。”可见桂枝于此方中不仅有协助附子以温肾脏之效，更重要者在于增强膀胱气化，以利小便。但后世之肾气丸，多用以治疗肾阳虚衰之证，常不兼挟水液代谢障碍，故不用桂枝而用肉桂，以增温肾纳气、引火归元之力，更有利于肾衰阳虚内寒或虚阳浮动之证。原方中干地黄改用熟地，则滋肾之功尤胜。古时之干地黄即今时之生地黄，古之生地黄则为今之鲜生地。故仲景之百合地黄汤方可用生地黄捣汁，职是故也。仲景何以于肾气丸中不用熟地，余未加考证，似汉时尚未发明加工熟地之法。
熟地滋补真阴、摄纳肾气之功远胜生地。如清代许松如于《诊余脞谈》中曰：“徐洄溪、陈修园辈，以熟地柔腻滞胃，宜人丸剂而不宜入煎剂，引古以为证，此拘牵之说也。余见肾虚宜填纳而胃气不弱者，服之利益甚大。佐以流动之品，绝不碍胃。且应用熟地之时，即以枸杞、女贞、龟版辈代之，效力亦逊，讵可悬以为禁，没其功用乎?”许氏所说为临证有得之言，皆从经验中来。熟地滋腻碍胃之弊，除“佐以流动之品”而外，尚有重用一法。盖熟地少用则滋腻，多用反不碍胃。所谓多用，即每剂或每次单服用至30g即可。此余临证屡经试验，乃历历不爽者也。世传有用熟地拌砂仁之法，法非不善，而虚损症常多脾肾双亏、胃气伤残者，虽些少砂仁亦难接受，不如上法为妥。但熟地服用不当以致胃气腻滞、经络壅塞者，又非砂仁、沉香不能开。
有肾阴亏极、虚阳上浮者，舍熟地难能滋填摄纳以归窟宅。余曾治一虚损症，真阴虚衰而致倦怠乏力，吸吸少气，上重下轻，头脑昏沉不清，腰酸肢软，遗精频频，纳差神呆，余于其对症方中加熟地30g，首次服药后即觉有气自头中下降入腹，立见头脑清醒、精神倍增，腹笥充实，两足有力。以后续服前方，胸腹经络之间，常有气机走动之感，不用熟地则不见气感，此乃熟地招纳虚阳下归之效。由此可知，真阴虚衰者，要非熟地无以为用。无怪乎景岳好用熟地，致有“张熟地”之美名，不为无因。
熟地之选材加工炮制方法，对于药效至关重要。王汝霖曰：“惟此丸(桂附八味丸)中之熟地，必须用九煮九蒸九晒制极透者，否则无效。有心活人者，须自制为妥。”此说聊备一格，姑且存而勿论。
(二)桂附八味丸之方义解释，多属随文敷衍，未抉精要。如《医方集解》释曰：“熟地滋阴补肾，生血生精；山茱温肝逐风，涩精秘气；牡丹泻君相之伏火，凉血退蒸；山药清虚热于肺脾，补脾固肾；茯苓渗脾中湿热，而通肾交心；泽泻泻膀胱水邪，而聪耳明目。”“惟附子、肉桂，能入肾命之间而补之，故加入六味丸中，为补火之剂。”又如《医贯》曰：“熟地、山萸、丹皮、泽泻、山药、茯苓、皆濡润之品，所以能壮水之主。肉桂、附子，辛润之物，能于水中补火，所以益火之原。水火得其养，则肾气复其天矣。”以上释义，皆就肾脏本身之生理病理及方中诸药之功能而言，固属不谬，然则难免有浅近之嫌。而尤在泾于《医学读书记》中论六味地黄丸则曰：“六味地黄丸多用熟地、萸肉、山药、味厚体重者，补阴益精。而以茯苓、泽泻之甘淡助之下降。……气浮者多热，牡丹之寒所以清浮热。”肾气亏损，阴阳失调之病理中，属肾阴虚耗者，必致阴不恋阳而虚阳上浮，若单以熟地滋填摄纳犹难招浮阳归于窟宅，故佐苓泽以引导下降，直趋命门。尚有散见之浮阳，则以丹皮清之。由是阴阳重归和合，水火继续交媾，而复其生理之常矣。据此，方中茯苓、泽泻，非仅为通利小便而设，仲景制方有出神入化之妙，而钱仲阳将八味丸去桂附而变为六味地黄丸，立滋补真阴之祖方，乃深得个中意趣者。故用方之时，更须斟酌尽善，不宜随便删除泽泻，易以他物。
泽泻除用以利水之外，李时珍谓其还具固精之功，可治遗泄。而肾精为肾中阴阳二气之物质基础，无论肾阴虚症或肾阳虚症，必然波及肾精，因而固护精气实为治疗肾气亏损必不可少之环节，而于全方中虽地、萸、山药皆兼此能，而无突出之效，惟有泽泻独擅其功，是以仲景用泽泻不特治水而已，自有更为重要之作用在。泽泻固精止遗其功独特，单味煎服即可取效，一般每次用10g即可。余曾治一少年，遗精频作，诸药罔效，以致神思恍惚，记忆减退，读书成绩节节下降，其母深以为虑，央余设法治疗。余嘱每日以泽泻30g煎服，连服七天，从此不再遗泄。一周内服用泽泻200余克，未见任何不适。《本草纲目)渭此物宜于湿热遗精，其实用于虚证亦效，第虚证宜辨证选加熟地、山药、枸杞、沙苑之类，则效验更彰。
泽泻具止、通两种功能，除固精止遗之外，还善治前列腺肥大之排尿不畅以至癃闭。是以说明六味地黄丸，桂附八味丸用泽泻，并非仅为利水一端而已。倘仲景肾气丸中用泽泻只为通利小便，则后世之用六味、八味多为单纯肾虚而设，理宜效景岳之左右归，去泽泻而不用之，何以直至今时，六味、八味方中，仍用苓泽哉!钱仲阳将肾气丸方去桂附而成补阴之祖方，而却留利水、伤阴之泽泻，抑何不思之甚也!可见此方(六味丸同)中用泽泻，其意至深，既能降上升之浮阳，又可摄下流之阴精，更能于生殖系统散结、消炎、决癃排尿，不可以其“能泻泽中之水”而浅之乎视之也。然肾虚兼见津液损伤者，则不用苓泽为宜。
Mr. Xu, surnamed Yu, was around forty years old and frequently suffered from coughing, which invariably flared up in winter. Each time he took Ningsu Lu (Cough-Calming Elixir), a formula for diffusing the lungs and resolving phlegm, his symptoms would gradually subside. Consequently, he felt compelled to take it whenever a cough occurred, and it had become a staple on his desk. After the cough subsided, if he caught even a slight chill, the condition would inevitably recur. Having endured this cycle through several winters, the illness remained uncured. In February 1975, he sought my treatment. Upon inquiry, I learned that he generally lacked mental vigor, had poor appetite, and experienced abdominal distension and discomfort, along with a sensation of fullness and oppression in the epigastrium, immediately after eating. His stools were soft and loose, occurring two to three times daily. His pulse was fine and small, with the bilateral Chi positions being weak and feeble. His tongue body was dark and pale, with a thin white coating. Listening to his cough, it sounded light, shallow, and powerless, with copious, thin sputum. I diagnosed this as Qi deficiency leading to failure of Spleen Yang to transport, combined with Cold-Fluid attacking the lungs causing cough. I prescribed Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) with added Ganjiang (Dried Ginger Rhizome) and Wuweizi (Schisandra Fruit). After three doses, he stabilized, and the condition did not recur subsequently. The prescription was:
Codonopsis Radix (Dangshen) 9g, Astragali Radix (Huangqi) 9g, Angelicae Sinensis Radix (Danggui) 9g, Atractylodis Macrocephalae Rhizoma (Jiaobaizhu) 9g, Citri Reticulatae Pericarpium (Chenpi) 4.5g, Cimicifugae Rhizoma (Shengma) 3g, Bupleuri Radix (Chaihu) 3g, Glycyrrhizae Radix et Rhizoma Preparata (Zhigancao) 3g, Schisandrae Fructus (Wuweizi) 3g, Zingiberis Rhizoma Recens (Ganjiang) 1.5g.
Commentary: This is a syndrome of sinking Qi accompanied by Phlegm-Fluid retention. Therefore, Buzhong Yiqi Tang was used to strengthen the Spleen and raise Yang, combined with Ganjiang and Wuweizi to resolve fluids and astringe the lungs. Addressing both aspects simultaneously yielded rapid results.
(III) Abdominal pain due to Qi sinking requires the Tonify the Middle and Augment the Qi method.
Accountant Mr. Wang, over fifty years old, had always been healthy. That year, while managing construction of a house in the countryside, he exerted himself excessively. Several days later, he felt a dull pain in the Qihai (Sea of Qi, CV6) acupoint below the umbilicus, varying in intensity from mild to severe. His pulse was wiry yet soft, and the tongue coating was thin and white. Palpation of the abdomen revealed softness, and pressure alleviated the pain, suggesting Qi deficiency. I prescribed Liujunzi Tang (Six Gentlemen Decoction), but it was ineffective. I then added Danggui (Angelicae Sinensis Radix) and Shaoyao (Paeoniae Radix) to harmonize the Liver and Spleen, but there was no improvement. After repeatedly analyzing the case, I reasoned that the cause must be excessive burden leading to sinking of Middle Qi. The previous prescriptions had the ability to tonify Qi but lacked the power to lift and raise. The treatment principle should be tonification combined with lifting. Furthermore, improper exertion often leads to Qi stagnation; when Qi stagnates, Blood flow also becomes unsmooth, so these factors should be addressed concurrently. Therefore, I administered Buzhong Yiqi Wan (Tonify the Middle and Augment the Qi Pills) together with Sanqi Pian (Notoginseng Tablets). The pills were taken three times daily, 10g each time. The tablets were taken at half the standard dose, twice daily, two tablets each time. After three days, the abdominal pain ceased. To consolidate the curative effect, I advised continuing Buzhong Yiqi Wan (250g total) and two bottles of Sanqi Pian. From then until his retirement, he never reported a recurrence of abdominal pain.
(IV) Midnight syncope requires clearing fire and lifting Yang.
Mr. Gan, manager of a certain store, was thirty-eight years old. He presented in 1978. The patient was obese and generally healthy. However, in recent years, he developed a peculiar symptom: every night upon waking at midnight, he found himself unable to move his limbs or speak, although his mind remained clear. He was fully aware of external sounds and his family's activities. This state lasted for about two hours, after which he spontaneously returned to normal. During the day, aside from slight fatigue, he had no other abnormalities. At midnight, the illness invariably recurred, following this cyclical pattern. Despite various treatments with Chinese and Western medicine, there was no effect. Subsequently, he was hospitalized for forty days at a district Traditional Chinese Medicine hospital. Physicians based their diagnosis on the theory that "strange diseases all belong to Phlegm," prescribing Erchen Tang (Two-Aged Decoction) with modifications to move Qi and resolve Phlegm. After taking more than thirty doses, there was no impact. After discharge, he came to me for consultation. I observed his pulse was fine and soft, with the Cun positions on both hands particularly fine and weak, while the Left Chi position was large, forceful, and striking against the fingers. Analyzing the pulse and symptoms, this manifested as "Yang Qi sinking into Yin." Although Yin Qi is at its peak at midnight, Zi hour (11 PM–1 AM) is when one Yang begins to generate; Yang Qi returns, and Yin pathogens gradually recede. At this juncture of Yin-Yang transition, Yang should gradually strengthen and overcome Yin. However, because the patient's Yang Qi was sunk and stagnant within Yin, lacking the strength to ascend, Yang could not rise when it should. Additionally, internal stagnation of Yang within Yin obstructed the pathway for Yin-Yang progression, so Yin could not retreat when it should. Thus, the Qi of Yin and Yang could not alternate smoothly, resulting in the aforementioned symptoms. After approximately two hours, entering Chou hour (1 AM–3 AM), Yang Qi gradually became robust and Yin Qi receded. Consequently, upright Yang ascended, and everything returned to normal. Given this pathogenesis, the treatment for this disease should be "lifting the sunk Yang Qi and clearing/draining the ministerial fire of the Lower Jiao." I treated him with Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) plus Huangbai (Phellodendri Cortex). The prescription was:
Astragali Radix (Huangqi) 12g, Atractylodis Macrocephalae Rhizoma (Jiaobaizhu) 9g, Citri Reticulatae Pericarpium (Chenpi) 6g, Cimicifugae Rhizoma (Shengma) 3g, Bupleuri Radix (Chaihu) 3g, Codonopsis Radix (Dangshen) 9g, Glycyrrhizae Radix et Rhizoma Preparata (Zhigancao) 3g, Angelicae Sinensis Radix (Danggui) 9g, Phellodendri Cortex (Huangbai) 9g.
After the first dose, the illness did not recur. After continuously taking several doses, he slept peacefully every night. At the follow-up visit, the Left Chi pulse had normalized. Huangbai was removed from the original prescription, leaving only Buzhong Yiqi Tang. After another week of intake, the illness did not recur, and medication was stopped. Nearly twenty years later, he still sleeps peacefully every night.
(V) Constipation due to Qi deficiency and Yang decline involves unblocking the pathways, warming and moistening, tonifying Qi, clearing the upper, and descending the turbid.
Comrade Xu, an elder revolutionary, suffered from severe constipation in her seventies. Initially, laxative tablets allowed for勉强 passage, but they eventually lost efficacy. I treated her once or twice with formulas to tonify Qi and promote bowel movement, achieving slight effects. Impatient for results, she sought expert physicians. Introduced by a friend, she consulted a renowned doctor who prescribed a formula containing over ten herbs, primarily blood-nourishing and Yin-moistening agents such as Shengdihuang (Rehmanniae Radix), Shudihuang (Prepared Rehmanniae Radix), Tiandong (Asparagi Radix), Maidong (Ophiopogonis Radix), Chuanshihu (Dendrobii Caulis), Yuzhu (Polygonati Odorati Rhizoma), Shashen (Glehniae Radix), Baiziren (Biota Seed), Huomaren (Hemp Seed), and Gua Lou (Trichosanthis Fructus). Dosages ranged from 15 to 20g per herb. Although Gancao (Licorice Root) and Fuling (Poria) were included, they could not counteract the detrimental effects of such a large quantity of cloying, moistening herbs. I advised against taking them, but she refused. After forty doses, she invited me again. She was slumped in her chair, her complexion a mix of yellow and pale, devoid of luster. Her voice was low and strained, difficult to sustain. She complained of extreme exhaustion, shortness of breath, and difficulty breathing. Stools were hard and difficult to pass, with abdominal distension; she defecated only once every five to six days. Appetite was very poor, consuming only a small bowl of rice daily. Her pulse was large, choppy, and unyielding, feeling soft and powerless upon deep pressure. Her tongue was broad, thick, deviated to the left, with a pale color and a dry, thick, greasy white coating. Based on these signs and symptoms, it was evident that excessive use of Yin-nourishing herbs had damaged Middle Qi, impaired Spleen transportation, caused Phlegm-Turbidity obstruction leading to poor Qi mechanism between upper and lower Jiao, and blocked Lower Jiao Yang Qi. Yin-Cold stagnation resulted in blocked intestinal pathways. The treatment principle should be strengthening the Spleen, resolving Phlegm, warming Yang, and promoting bowel movement. I prescribed Xiangsha Liujunzi Tang (Costus and Amomum Six Gentlemen Decoction) combined with Jingyue Jichuan Jian (Jingyue’s Decoction for Crossing the River). After ingestion, there was only slight improvement in stool consistency and a minor opening of appetite, with no other effects, and she felt dry mouth. However, the thick white greasy coating gradually thinned to a thin white slightly greasy coating, indicating gradual resolution of Phlegm-Turbidity and recovery of Middle Jiao Qi mechanism. Yet, fatigue and weakness persisted. Considering her advanced age and Qi decline, I suspected sinking of Clear Qi. I modified the prescription to Buzhong Yiqi Tang combined with Jichuan Jian. She felt extremely comfortable after taking it. Bowel movements occurred every two to three days, with increased volume and softer consistency. Physical strength gradually recovered, and appetite improved. Two months later, her daily life, study, and social visits returned to normal. She continued the previous prescription for a year. When her stools became dry and hard again, I combined it with Mr. Wei Longxiang’s Baizhu Tongbian Fang (Baizhu Constipation-Relieving Formula). This successfully unblocked the intestinal pathways, allowing bowel movements every one to two days, naturally and comfortably. Thereafter, she took one dose daily without interruption. For over four years now, stopping the medication for just two or three days causes sensations of insufficient Middle Qi, poor appetite, and difficult stools. Resuming the previous medication restores normalcy. She is currently still taking it. The prescription used was:
Astragali Radix (Huangqi) 30g, Codonopsis Radix (Dangshen) 15g, Atractylodis Macrocephalae Rhizoma Stir-fried (Chaobaizhu) 30g, Citri Reticulatae Pericarpium (Chenpi) 6g, Cimicifugae Rhizoma (Shengma) 3g, Bupleuri Radix (Chaihu) 4.5g, Glycyrrhizae Radix et Rhizoma Preparata (Zhigancao) 3g, Angelicae Sinensis Radix (Danggui) 9g, Achyranthis Bidentatae Radix (Huainiuxi) 15g, Alismatis Rhizoma (Zexie) 9g, Aurantii Fructus Immaturus Stir-fried (Chao Zhike) 6g, Cynomorii Herba (Rongsong) 15g, Rehmanniae Radix (Shengdi) 15g, Jujubae Fructus (Dazao) 30g.
Discussion on Gui Fu Ba Wei Wan (Cinnamon Twig and Aconite Eight-Ingredient Pill) Syndrome and Prescription
(I) Gui Fu Ba Wei Wan first appeared in Zhang Zhongjing’s *Jin Gui Yao Lue* (Essential Prescriptions from the Golden Cabinet), though ancient and modern names differ slightly. This formula appears twice in *Jin Gui*: first in Chapter 6 "Blood Bi and Deficiency Consumption Disease Pulse, Signs, and Treatment," named "Ba Wei Shen Qi Wan" (Eight-Ingredient Kidney Qi Pill). It appears again in Chapter 22 "Women's Miscellaneous Diseases Pulse, Signs, and Treatment," where "Ba Wei" is deleted, naming it simply "Shen Qi Wan" (Kidney Qi Pill). Since it originated in *Jin Gui*, later generations called it "Jin Gui Shen Qi Wan" (Golden Cabinet Kidney Qi Pill), a name still in use today. The current "Jin Gui Shen Qi Wan" is not entirely consistent with Zhang Zhongjing’s original formula and has undergone slight changes, hence some rename it "Gui Fu Ba Wei Wan."
The herbs in the *Jin Gui* Shen Qi Wan are: "Dry Rehmannia Root (Gan Dihuang) 8 liang, Cornus Fruit (Shanzhuyu) and Chinese Yam (Shuyu) each 4 liang, Alisma Rhizome (Zexie), Poria (Fuling), and Moutan Bark (Mudanpi) each 3 liang, Cinnamon Twig (Guizhi) and Prepared Aconite Root (Paofuzi) each 1 liang." The syndromes it treats include "deficiency consumption with lower back pain, urgency and tension in the lower abdomen, and difficulty urinating," as well as "uterine prolapse causing inability to urinate." Using Shen Qi Wan on the basis of tonifying Kidney Qi, "merely promoting urination leads to cure." Thus, Guizhi (Cinnamon Twig) in this formula not only assists Fuzi (Prepared Aconite Root) in warming the Kidneys but, more importantly, enhances Bladder Qi transformation to facilitate urination. However, later Shen Qi Wan formulations were mostly used for Kidney Yang deficiency syndromes, often without accompanying water metabolism disorders. Therefore, Guizhi was replaced by Rougui (Cinnamon Bark) to increase the power of warming the Kidneys, grasping Qi, and guiding fire back to its source, which is more beneficial for renal failure with Yang deficiency, internal cold, or floating deficient Yang. Replacing Gan Dihuang (Dried Rehmannia Root) with Shudihuang (Prepared Rehmannia Root) in the original formula further enhances the function of nourishing the Kidneys. Ancient Gan Dihuang corresponds to modern Shengdihuang (Fresh/Processed Rehmannia Root), and ancient Shengdihuang corresponds to modern fresh Rehmannia. Hence, Zhang Zhongjing’s Baihe Dihuang Tang (Lily and Rehmannia Decoction) could use fresh Shengdihuang crushed for juice, for this reason. Why Zhang Zhongjing did not use Shudihuang in Shen Qi Wan, I have not verified; it seems processing methods for prepared Rehmannia were not yet invented in the Han Dynasty.
Shudihuang’s ability to nourish True Yin and grasp Kidney Qi far surpasses that of Shengdihuang. For instance, Xu Songru stated in Qing Dynasty’s *Zhenyu Suotan* (Casual Talks After Diagnosis): "Xu Huixi and Chen Xiuyuan argued that Shudihuang is soft, cloying, and stagnates the Stomach, suitable for pills but not decoctions, citing ancients as evidence. This is a rigid view. I have seen cases of Kidney deficiency requiring filling and grasping, where patients with strong Stomach Qi benefit greatly from it. Assisted by moving herbs, it does not hinder the Stomach at all. Moreover, when applying Shudihuang, substituting it with Gouqi (Goji Berry), Nvzhenzi (Privet Fruit), or Guiban (Turtle Shell) yields inferior efficacy. How can we ban it and obscure its utility?" Xu’s words reflect clinical experience. Besides "assisting with moving herbs" to mitigate Shudihuang’s cloying nature hindering the Stomach, there is another method: heavy dosage. Using small amounts makes it cloying; using large amounts actually does not hinder the Stomach. "Large amount" means 30g per dose or per single administration. This has been repeatedly tested in my clinical practice with consistent results. The folk method of mixing Shudihuang with Shanren (Amomum Fruit) is not bad, but deficiency syndromes often involve dual Spleen-Kidney deficiency and damaged Stomach Qi, making even small amounts of Shanren difficult to tolerate. The aforementioned method is preferable. However, if improper use of Shudihuang leads to Stomach Qi stagnation and meridian blockage, only Shanren and Chenxiang (Agarwood) can open it.
In cases of extreme Kidney Yin deficiency with floating deficient Yang, only Shudihuang can nourish, fill, and grasp to return the Yang to its residence. I once treated a deficiency syndrome characterized by True Yin depletion causing fatigue, weak breathing, heaviness in the upper body and lightness in the lower, dizziness, sore waist and weak limbs, frequent seminal emission, poor appetite, and dull spirit. I added 30g of Shudihuang to his symptomatic prescription. After the first dose, he felt Qi descending from his head to his abdomen, immediately experiencing clarity of mind, doubled energy, abdominal fullness, and strength in both legs. Continuing the prescription, he often felt Qi moving in the chest, abdomen, and meridians; without Shudihuang, this sensation was absent. This demonstrates Shudihuang’s effect of attracting and returning floating deficient Yang downward. Thus, for True Yin depletion, Shudihuang is indispensable. No wonder Zhang Jingyue favored Shudihuang, earning the nickname "Zhang Shudihuang," which is well-deserved.
The selection, processing, and preparation of Shudihuang are crucial for efficacy. Wang Rulin stated: "For this pill (Gui Fu Ba Wei Wan), the Shudihuang must be processed through nine boils, nine steams, and nine sun-dryings to be thoroughly effective; otherwise, it is useless. Those wishing to save lives should prepare it themselves." This view is noted here for reference but remains debatable.
(II) Explanations of the rationale behind Gui Fu Ba Wei Wan are often superficial and miss the essence. For example, *Yi Fang Ji Jie* (Collection of Formulas Explained) states: "Shudihuang nourishes Yin and tonifies Kidneys, generates Blood and Essence; Shanzhuyu warms the Liver, expels Wind, astrings Essence and secures Qi; Mudanpi clears latent Fire of the Minister and Emperor, cools Blood and reduces steaming bone disorder; Shanyao clears deficient heat in Lungs and Spleen, tonifies Spleen and secures Kidneys; Fuling drains Damp-Heat from Spleen and connects Kidney to Heart; Zexie drains Water Evil from Bladder and improves hearing and vision." "Only Fuzi and Rougui can enter the Kidney and Mingmen to tonify them, thus added to Liuwei Wan, forming a Fire-tonifying agent." Similarly, *Yi Guan* (Guide to Medicine) says: "Shudihuang, Shanzhuyu, Danpi, Zexie, Shanyao, and Fuling are all moistening substances, capable of strengthening the Master of Water. Rougui and Fuzi are pungent and moistening, capable of tonifying Fire within Water, thus benefiting the Source of Fire. When Water and Fire are nurtured, Kidney Qi restores its natural state." These explanations focus on the physiology and pathology of the Kidneys and the functions of the herbs, which are correct but somewhat shallow. You Zaijing, in *Yi Xue Du Shu Ji* (Records of Reading Medical Books), discussing Liuwei Dihuang Wan, said: "Liuwei Dihuang Wan uses large amounts of Shudihuang, Roushen (Cornus), and Shanyao—substances with thick flavors and heavy weights—to tonify Yin and benefit Essence. Fuling and Zexie, with their sweet and bland properties, assist in descending... Qi floating usually indicates Heat; the cold nature of Mudanpi clears floating Heat." In the pathology of Kidney Qi deficiency and Yin-Yang imbalance, if due to Kidney Yin consumption, Yin fails to retain Yang, causing floating deficient Yang. If relying solely on Shudihuang to nourish and grasp, it may still fail to attract floating Yang back to its residence. Therefore, Fuling and Zexie are added to guide descent directly to Mingmen. Any remaining scattered floating Yang is cleared by Danpi. Thus, Yin and Yang return to harmony, Water and Fire continue to interact, restoring physiological normalcy. Accordingly, Fuling and Zexie in the formula are not merely for promoting urination. Zhang Zhongjing’s formulation skills were miraculous. Qian Yi’s removal of Guizhi and Fuzi from Ba Wei Wan to create Liuwei Dihuang Wan, establishing the ancestral formula for tonifying True Yin, deeply understood this intent. Therefore, when using the formula, one must deliberate carefully and not casually delete Zexie or substitute it with other herbs.
Besides promoting urination, Li Shizhen attributed to Zexie the function of securing Essence, treating spermatorrhea and leakage. Kidney Essence is the material basis for Yin and Yang Qi in the Kidneys. Whether Kidney Yin or Yang deficiency, Kidney Essence is inevitably involved. Thus, protecting Essence and Qi is an essential link in treating Kidney Qi deficiency. Although Dihuang, Shanzhuyu, and Shanyao in the formula possess this ability, none stand out. Only Zexie excels in this regard. Hence, Zhang Zhongjing used Zexie not just for treating water, but for a more important role. Zexie’s unique ability to secure Essence and stop leakage can be effective even as a single herb decoction, typically 10g per dose. I once treated a young man with frequent spermatorrhea unresponsive to various medicines, leading to mental confusion, memory loss, and declining academic performance. His mother was deeply worried and asked for help. I instructed him to decoct and drink 30g of Zexie daily for seven consecutive days. From then on, spermatorrhea ceased. He consumed over 200g of Zexie in a week with no adverse effects. *Ben Cao Gang Mu* (Compendium of Materia Medica) states this herb is suitable for damp-heat spermatorrhea, but it is also effective for deficiency syndromes. For deficiency, one should add Shudihuang, Shanyao, Gouqi, and Shayuanzi based on syndrome differentiation to enhance efficacy.
Zexie possesses both astringent and draining functions. Besides securing Essence and stopping leakage, it effectively treats urinary difficulty and retention due to prostatic hypertrophy. This explains why Zexie is used in Liuwei Dihuang Wan and Gui Fu Ba Wei Wan, not merely for diuresis. If Zhang Zhongjing used Zexie in Shen Qi Wan solely for promoting urination, later formulas for simple Kidney deficiency, like Zhang Jingyue’s Zuogui and Yougui, should have removed Zexie. Why do Liuwei and Ba Wei formulas still use Fuling and Zexie today? Qian Yi created the Yin-tonifying ancestral formula by removing Guizhi and Fuzi from Shen Qi Wan but retained Zexie, which drains Water and damages Yin. Is this not thoughtless? Clearly, the use of Zexie in this formula (and Liuwei Wan) has profound meaning: it can descend floating Yang rising upward, grasp Yin Essence flowing downward, and resolve nodules, reduce inflammation, and relieve urinary retention in the reproductive system. One should not underestimate it merely for its ability to "drain water in the marsh." However, for Kidney deficiency accompanied by fluid injury, it is advisable not to use Fuling and Zexie.