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Teachings from a Renowned Master

Professor Xiao Yonglin, Changchun University of Traditional Chinese Medicine

Su Ruijun, Jilin Provincial Academy of Traditional Chinese Medicine and Materia Medica

Male patient, Li XX, 56 years old, consulted in April 1988.

The patient complained of distension and fullness in the epigastrium and hypogastrium, with reduced appetite, persisting for over one year. Initially, he only felt abdominal distension after meals, which relieved slightly after some time. Later, it gradually worsened, resulting in constant distension throughout the day. He had taken Yeast Tablets, Baohe Wan (Prescription to Harmonize the Stomach), Muxiang Shunqi Wan (Prescription to Promote Qi Circulation and Relieve Pain), Ziku Wan, Kuanxiong Shunqi Wan, and several doses of herbal decoctions. Initially, he felt temporarily relieved, but prolonged use yielded no effect. Believing the disease was severe while the medication was too mild, he took two packs of Binglang Sixiao Wan (Areca Nut Pill for Eliminating Accumulation). About two hours after ingestion, borborygmus occurred in his abdomen, followed by cramping pain. After several episodes of diarrhea, the epigastric and abdominal distension felt slightly relieved, but soon the distension became more severe. His abdomen hurt intermittently; when it hurt, he felt the urge to defecate. Although defecation occurred, the abdominal distension did not decrease.

Previously, the patient's health was generally good. One year ago, he suffered from abdominal pain and diarrhea due to excessive consumption of cold foods, which was cured with medication. Subsequently, he gradually developed postprandial distension, a sensation of fullness and discomfort in the epigastrium and hypogastrium, and reduced appetite. Although his food intake decreased, the distension increased progressively. He gradually felt whole-body fatigue, weakness in the four limbs, drowsiness, and frequent loose stools. The distension worsened after consuming raw or cold foods or exposure to cold (especially on the abdomen and feet). Conversely, consuming hot foods, lying prone on a heated kang (brick bed), applying hot compresses to the abdomen, and massaging the area would gradually alleviate the distension, making the abdomen feel particularly warm and comfortable. The patient was emaciated, with a sallow complexion, a pale and swollen tongue with a moist coating, and a fine and weak pulse. Palpation of the epigastrium and hypogastrium revealed a flat and soft abdomen without pain or discomfort.

Careful consideration of the entire disease process reveals that the condition originated from cold and was exacerbated by digestive-promoting and purgative treatments. Although the patient complained of distension, there was no visible abdominal enlargement. Upon detailed inquiry, the patient described a sensation of blockage and lack of smoothness in the epigastrium, along with reduced appetite. Therefore, this condition is actually Pi Man (epigastric stuffiness and fullness). Given the duration of over one year, the aggravation after taking digestive and qi-regulating agents, and the preference for warmth and aversion to cold, the syndrome belongs to Spleen-Stomach Deficiency-Cold, with failure of Middle Jiao Yang to transport and transform. The treatment principle is to Warm the Middle and Tonify the Spleen. A modified Lizhong Tang (Regulate the Middle Decoction) was prescribed: Dangshen 20g, Baizhu 15g, Zhigancao 10g, Ganjiang 15g, Dingxiang 10g, Sharen 10g, Chuanpo 10g. Decocted in water, taken three times daily.

After three doses, the patient reported reduced Pi Man, a warming sensation in the abdomen, and increased flatus. Since efficacy was observed, indicating the prescription matched the syndrome, the formula was maintained without modification. Three additional doses were administered, resulting in significant improvement. Fuzi Lizhong Wan (Aconite Regulate the Middle Pill) was prescribed, 20 pills total, one pill per dose, three times daily. One week later, the sensation of distension disappeared, appetite increased, and bowel movements normalized to once daily. Symptoms such as limb fatigue and drowsiness improved significantly, and the patient felt an increase in physical strength. To consolidate the curative effect, he continued taking Lizhong Wan and Renshen Jianpi Wan until recovery.

Student: Please explain your diagnostic reasoning for this case.

Master: When treating a patient, especially one with a long course of disease who has responded poorly to previous treatments, one must think comprehensively and consider all possibilities. First, one should consider approaches different from previous ones, paying particular attention to the possibility of a Deficiency Syndrome.

This patient has been ill for over a year. Repeated use of formulas to open stagnation and regulate Qi failed, indicating it is not Qi Stagnation. Use of herbs to digest food and guide out stagnation was ineffective, clearly indicating it is not Food Accumulation. Particularly, the sudden worsening of symptoms after taking Binglang Sixiao Wan further elucidates the nature of this syndrome. Binglang Sixiao Wan consists of Dahuang (Rhubarb Rhizome and Radix), Heichou (Morning Glory Seed), Zaojiao (Gleditsia Sinensis Fruit), Xiangfu (Cyperus Rotundus Rhizome), and Wulingzhi (Trogopterus Dung). Areca nut is heavy and hard like iron or stone. Pharmacopoeias state it breaks hardness, eliminates distension, digests food, resolves phlegm, promotes urination, moves Qi, opens bowels, and removes stagnation, demonstrating its potent and harsh nature. Dahuang is bitter and cold, attacking accumulation and guiding out stagnation, scouring the stomach and intestines. Heichou is pungent and acrid, effectively descending Qi and promoting water metabolism, unblocking both urine and feces. Zaojiao is pungent, acrid, and penetrating, opening orifices and facilitating large intestine function. Together, these herbs scour the gastrointestinal tract, digest food, guide out stagnation, promote diuresis, and relieve distension. For distension and anorexia caused by retained food and water, in cases where both form and Qi are Excess, these herbs would undoubtedly have a powerful effect of eliminating pathogens and renewing vitality. However, this patient experienced no benefit and worsening symptoms, confirming that this is not a case of Qi Stagnation or Food Accumulation, but purely a Deficiency Syndrome. Furthermore, the patient's illness originated from cold, and he fears cold while preferring warmth, indicating that the syndrome is not only Deficient but also Cold. The above analysis determines the condition based on medical history and reactions to medications.

Analyzing the patient's symptoms further: although the patient feels distended, the abdomen is not visibly enlarged or protruding, and palpation causes relief rather than pain, confirming it is not Excess Distension. Poor appetite, emaciation, fatigue, drowsiness, frequent loose stools, and a pale, swollen tongue all indicate a picture of insufficient Middle Jiao Yang and Spleen-Stomach Qi Deficiency. Moreover, the condition improves with warmth and worsens with cold, confirming Middle Jiao Deficiency-Cold. Thus, I dared to directly use Lizhong Tang to tonify the Spleen and Stomach and warm the Middle Jiao Yang, achieving satisfactory results.

Student: Distension and fullness caused by Qi Stagnation, Food Accumulation, or internal retention of Fluids are relatively easy to understand. However, why does Distension and Fullness appear in Spleen-Stomach Qi Deficiency or Deficiency-Cold, which are clearly Deficiency Syndromes?

Master: Distension and fullness is a symptom produced by various causes leading to Qi stagnation in the stomach and intestines. It can occur in both Excess and Deficiency syndromes. As you mentioned, viewing distension as an Excess syndrome is easily understood and accepted because internal Qi stagnation, food accumulation, or damp-water can affect the smooth flow of gastrointestinal Qi, causing distension. Clinically, many cases of distension belong to Excess syndromes, and treatments such as regulating Qi and opening depression, digesting food and resolving stagnation, or driving out water and transforming dampness often yield satisfactory results, making people familiar with them. However, clinically, distension due to Qi Deficiency or Deficiency-Cold is also quite common. Why can Middle Jiao Qi Deficiency produce distension? The Middle Jiao Spleen and Stomach govern ascending the clear and descending the turbid. If Spleen Qi is strong and capable of transformation, the clear Qi ascends naturally; if the Stomach is full and capable of passage, the turbid Qi descends naturally. With smooth Qi mechanism and no obstruction in the abdomen, how could there be distension? If Spleen and Stomach Qi are deficient or deficient-cold, Yang Qi cannot warm and transport smoothly, causing blockage of the Middle Jiao Qi mechanism. The clear fails to ascend, the turbid fails to descend, mixing in the middle and generating distension. "Spleen deficiency leads to abdominal fullness" (from *Suwen: Zangqi Fazhi Lun*) and "Cold in the zang organs generates fullness diseases" (from *Yifa Fangyi Lun*) both illustrate this point. Cheng Zhongling explained it even more thoroughly: "The reason Qi stagnates is Qi deficiency; the reason Qi moves is Qi abundance." (*Yixue Xinwu*).

Student: How should one distinguish between Excess and Deficiency in Pi Man?

Master: *Jingui Yaolue* states, "When a patient has abdominal fullness, pressing without pain indicates Deficiency, while pain indicates Excess." Zhang Jingyue said, "In distinguishing Pi Man, the key lies in the characters 'Excess' and 'Deficiency'. Pi caused by pathogens and stagnation is Excess Pi; Pi without objects or stagnation is Deficiency Pi. Fullness accompanied by distension and pain is Excess Fullness; fullness without distension or pain is Deficiency Fullness." He further stated, "Most Yang syndromes involve Heat, and Heat syndromes are mostly Excess; most Yin syndromes involve Cold, and Cold syndromes are mostly Deficiency... Red urine and constipation indicate Excess; clear urine and loose stools indicate Deficiency. Slippery and forceful pulses indicate Excess; floating, faint, and fine pulses indicate Deficiency. Red-yellow complexion and coarse breathing indicate Excess; haggard appearance and short voice indicate Deficiency. Youth and vigor with rebellious Qi stagnation indicate Excess; decline and accumulated labor with mental fatigue and timid Qi indicate Deficiency. The treatments for Excess and Deficiency are as opposite as ice and charcoal; misusing them will certainly cause harm." (*Zhang Jingyue Quanshu*). Zhang Jingyue not only pointed out how to distinguish Excess and Deficiency in distension and fullness but also emphasized that they must not be treated incorrectly. The above mainly distinguishes based on symptoms, combined with the duration of the disease and reactions to medication. Generally, new diseases are mostly Excess, while chronic diseases are mostly Deficiency. Conditions that improve with dispersing, digesting, and purging herbs are Excess; those that worsen with such herbs are mostly Deficiency.

Student: How should Deficiency-type Pi Man be treated?

Master: "Tonify when Deficient" is the general principle for treating all Deficiency syndromes, including Pi Man. Zhang Jingyue said, "Excess Pi and Excess Fullness can be scattered and eliminated; Deficiency Pi and Deficiency Fullness require substantial warming and tonification." (*Zhang Jingyue Quanshu: Za Zheng Mo · Pi Man*). Since Deficiency Pi Man results from Middle Jiao Qi Deficiency or Deficiency-Cold, tonifying the Spleen and Stomach and warming the Middle to assist Yang is the major method for treating Deficiency Pi. If Spleen and Stomach are slightly deficient with mild Pi Man, Si Jun Zi Tang (Four Gentlemen Decoction) or Yigong San may be selected. If Heart and Spleen are insufficient, Guipi Tang can be used. If Middle Jiao Deficiency-Cold exists, Lizhong Tang, Wenwei Yin (Warming Stomach Drink), or Shenjiang Yin may be chosen. If Lower Jiao Yang Deficiency and Mingmen Fire insufficiency are present, Lizhong Tang plus Rougui and Fuzi, or Liyin Jian, or Liuwei Huiyang Yin can be used. It must be known that for Deficiency Pi, Middle Deficiency is the root, and Pi Man is the branch. Do not hesitate to use tonification just because of Pi Man and anorexia. Zhu Danxi said, "There is no tonification method for Qi; this is a vulgar opinion. Because Pi Man and blockage seem difficult to tonify, one does not realize that when Righteous Qi is deficient, Turbid Qi stagnates. When Righteous Qi is tonified and performs its transporting functions, Turbid Qi descends and Pi Man is removed. If Qi Deficiency is not tonified, how will pathogens retreat?"

Student: Since this case is Deficiency-Cold Pi Man, and Lizhong Tang already matches the pathology, why were Dingxiang, Sharen, and Chuanpo added to the formula?

Master: The intent behind adding Dingxiang differs from adding Sharen and Chuanpo. Adding Dingxiang aims to enhance the original formula's ability to warm the Middle and assist Yang. Dingxiang is pungent and hot; it enters the Spleen and Stomach to warm the Middle and enters the Lower Jiao to assist Fire. This patient's illness has lasted a long time, originating from cold and damaging the Middle. Since organ deficiency eventually affects the Kidneys over time, adding Dingxiang allows it to gently descend while warming the Middle and assisting Fire to strengthen Earth. Adding Sharen and Chuanpo is because both are pungent, aromatic, and warm herbs that can move Qi stagnation and warm the Spleen and Stomach. Added to tonifying agents, they prevent stagnation from tonification, revive the Spleen and Stomach, and facilitate Qi mechanism. However, as adjunct herbs, their dosages are small. This method originates from Zhu Danxi, who said, "For Deficiency Pi, the more one disperses, the worse the Pi becomes; slight unblocking should be included in tonifying formulas." Luo Chicheng elaborated specifically on herb application: "Among Ginseng, Atractylodes, Angelica, and Astragalus, add one or two herbs like Chenpi, Houpo, Xiangfu, or Sharen to moderate them. Do not attack alone, do not tonify alone, do not attack then tonify; instead, combine attacking and tonifying." Student: Ancients said "Avoid Licorice for Middle Fullness"; why is Zhigancao still used in this formula?

Master: "Avoid Licorice for Middle Fullness" refers to avoiding Licorice in Excess-type Pi Man, not that all Pi Man syndromes prohibit Licorice. For Excess Pi Man caused by Qi stagnation, food accumulation, damp-turbidity retention, or phlegm-fluid retention, treatment should focus on regulating Qi, opening depression, digesting food, resolving phlegm, driving out fluids, or removing dampness to ensure smooth Qi mechanism and resolve stagnation. Licorice is sweet and緩 (moderating); its nature is cloying and central-staying, hindering the smoothing of Qi mechanism and expulsion of pathogens, hence it is avoided. For example, in treating Damp-Warmth diseases with epigastric and abdominal Pi Man due to damp-turbidity blocking the Middle and Qi stagnation, formulas like Huopo Xueling Tang, Sanren Tang, Lianpo Yin, and Xingren Huashi Tang do not use Licorice for this reason. The Pi Man in this case resulted from Spleen-Stomach Qi Deficiency and insufficient Middle Yang unable to warm and transport. The method should be tonifying the Spleen and Stomach and strengthening Middle Yang; thus, Licorice is not prohibited but indicated. Zhu Danxi said, "The world treats Middle Fullness and Pi Distension, regardless of Excess or Deficiency, all avoiding Licorice." Little do they know that the ancients' saying "avoid sweet foods for Middle Fullness" referred to Excess Fullness. If one feels full externally without abdominal distension, it should be treated with sweet flavors.

Prolonged High Fever, Shortness of Breath, Vertigo, Loose Stools

Professor Xiao Yonglin, Changchun University of Traditional Chinese Medicine

Xia Wenjing, Jilin Provincial People's Hospital

Female patient, 34 years old, worker, first consulted in late March 1983. The patient had fever for over three years. Despite multiple treatments, no definitive diagnosis was made, and efficacy was poor. Inquiry into her condition revealed frequent fever over the past three years: usually between 37-38°C in the morning, 38-39°C in the afternoon, and often above 40°C at night. She felt whole-body fatigue, heaviness in the limbs, shortness of breath with reluctance to speak, poor appetite, loose stools, occasional vertigo, frequent sweating, susceptibility to colds, thirst without desire to drink, pale yellow complexion, pale lips, pale swollen tongue with moist coating, and deep, weak pulse. Symptoms worsened with slight exertion. Previous prescriptions were mostly clearing heat and draining fire, or nourishing Yin and blood. She also took Angong Niuhuang Wan (Calming Palace Bezoar Pill), after which her temperature temporarily dropped but rose again later, accompanied by abdominal pain and loose stools. Comprehensive analysis of pulse, symptoms, medical history, and previous medications led to a diagnosis of Qi Deficiency Fever. Buzhong Yiqi Tang (Tonify the Middle and Augment Qi Decoction) plus Rougui and Sheng Maiya was prescribed. After two doses, fatigue and shortness of breath lightened, appetite slightly increased, and fever decreased. After four doses, body temperature returned to normal, and major symptoms subsided. The previous formula minus Rougui was given for four more doses, followed by Buzhong Yiqi Wan to consolidate the effect.

Physician A: This disease has persisted despite long-term treatment. When encountering such cases clinically, from what aspects should we begin our analysis?

Master: For patients with poor response to long-term treatment, comprehensive analysis should be conducted based on symptoms and previous medications. First, pure Excess syndromes are rare in chronic diseases. Generally, "acute diseases are mostly Excess, chronic diseases are mostly Deficiency," or they are mixed Excess-Deficiency syndromes. Second, carefully analyze the patient's symptoms. Due to prolonged high fever, people often focus solely on this aspect while ignoring others. Aside from high fever, the patient's other symptoms (as described previously) all present a picture of Qi Deficiency, which is not difficult to identify with slight attention. Third, looking at the medications used: ineffectiveness of heat-clearing and fire-draining herbs indicates it is not Excess Heat; ineffectiveness of Yin-nourishing and blood-tonifying herbs indicates it is not Yin Deficiency or Blood Deficiency fever. Therefore, we cannot continue using previous methods. Paths taken by others provide lessons and experience, preventing us from repeating mistakes and encouraging consideration of other approaches. For patients with poor response to long-term treatment, referencing previously used methods is very important.

Physician B: What syndromes are associated with persistent long-term fever? How should they be distinguished from Qi Deficiency Fever?

Master: Clinically, persistent long-term fever, especially unremitting high fever, presents many syndromes, but primarily includes four: Damp-Heat Fever, Blood Stasis Fever, Yin Deficiency Fever, and Qi Deficiency Fever.

Qi Deficiency Fever, besides fever (high or low), must simultaneously present symptoms of Spleen Deficiency and Qi Weakness with failure of Clear Yang to ascend, such as fatigue, weakness, shortness of breath, reluctance to speak, drowsiness, poor appetite, loose stools, spontaneous sweating, and susceptibility to colds. Fever and other symptoms exacerbate after exertion. The tongue is pale and swollen, and the pulse is typically deep, weak, and powerless. Damp-Heat Fever is often caused by internal and external pathogenic factors combining. From the perspective of pathological characteristics, it is dominated by Dampness, often presenting with heavy pain in the head and body, epigastric stuffiness and abdominal distension, pale swollen tongue with teeth marks, and white greasy coating, distinguishing it from Qi Deficiency Fever which is primarily Deficient. With slight attention, differentiation is not difficult. Blood Stasis Fever often presents with fixed-point pain in certain body parts, purple lips and tongue, or ecchymosis, easily distinguishing it from Qi Deficiency Fever. Although both Yin Deficiency Fever and Qi Deficiency Fever are Deficiency syndromes, Yin Deficiency Fever often features heat in the palms and soles, bone-steaming, and malar flush; whereas Qi Deficiency Fever features cool extremities and a pale, lusterless face. Yin Deficiency Fever often involves irritability, insomnia, and night sweats; whereas Qi Deficiency Fever involves calmness, drowsiness, and spontaneous sweating. Yin Deficiency Fever often presents with dry red lips, dry throat, and thirst; whereas Qi Deficiency Fever presents with pale and mild lips, no dryness or thirst. Yin Deficiency Fever often involves dry stools and scanty dark urine; whereas Qi Deficiency Fever involves loose stools and clear, copious urine. Yin Deficiency Fever tongues are often red and dry, possibly with cracks; whereas Qi Deficiency Fever tongues are pale and moist, without cracks. Based on the patient's symptoms and response to medication, diagnosing Qi Deficiency Fever clinically is not difficult.

Physician A: What is the mechanism of Qi Deficiency Fever?

Master: The Qi Deficiency in Qi Deficiency Fever mainly refers to Spleen-Stomach Qi Deficiency. Irregular diet and excessive labor are the main causes of Spleen-Stomach Qi Deficiency. The mechanism by which Spleen-Stomach Qi Deficiency leads to fever is not fully clear, so there is no unified theory. Currently, there are several views: First, Spleen Deficiency with Qi sinking and Middle Jiao Deficiency-Cold causes Deficient Yang to float outward, presenting as Heat. Second, Spleen-Stomach Qi Deficiency causes Grain Qi to flow downward and accumulate as Damp-Heat, prompting Yin Fire from the Lower Jiao to rush upward, causing fever. Third, Qi Deficiency leads to insecure Wei (Defensive) Qi, allowing external pathogens to invade, with Zheng (Righteous) and Pathogenic Qi clashing, causing fever. Fourth, Spleen-Stomach Qi Deficiency impairs transportation and transformation, failing to generate Blood, leading to Blood Deficiency fever. Fifth, insufficient Yang fails to cook and ripen food and water, leading to Yin Deficiency, which generates Heat. Sixth, Spleen-Stomach Qi Deficiency disrupts ascending and descending, causing Qi mechanism stagnation, which transforms into Heat upon stagnation. Among these six views, I believe the last one most accurately explains the mechanism of Qi Deficiency Fever. Li Dongyuan said, "With labor and fatigue, form and Qi decline, Grain Qi is not abundant... [Qi] fails to circulate, the Stomach Qi becomes hot, hot Qi steams the chest, thus internal heat arises." (*Piwei Lun: Yinshi Laojun Suoshang Shi Weirezhong Lun*).