老师：从痹证的原因来看，因风寒湿气侵入，致经络失畅，气血痹阻而成。邪气盛则实，故治疗痹证大抵皆以祛风散寒除湿为主，日久者往往佐以活血通络之法，所谓"治风先治血，血活风自灭"，即寓此义在内。这是痹证的一般情况。由于内在的和外在的各种因素的影响，疾病的证情是不断变化的，实与虚，寒与热，表与里，阴与阳都可在一定的条件下互相转化。就谈此患吧，其病有邪实的一面，但又有虚的一面。严用和在谈到痹证的发病时说，"皆因体虚，腠理空疏，受风寒湿气而成痹也"。((济生方))张介宾更强调"惟气血不足，故风寒得以入之"。((景岳全书))周学海则主要从正气不足的角度讲，"凡人之身，卫气不到则冷，荣气不到则枯，宗气不到则痿痹不用"。((读医随笔))此其一也。第二，"初病多实，久病多虚"，这是许多疾病发生发展的一般规律。痹证也不例外。当初病之时，由于疾病主要表现为邪实的一面，而通过治疗或疾病本身的变化，邪实渐渐减少，而正虚的表现便逐渐突出。此患者之临床表现就是如此。其开始以疼痛为主症，可后来渐致腰膝酸软无力，不耐久立久行，全身虚乏无力，倦怠；动则心悸、汗出；以至后来典型的阴血虚亏，燥热内生之象。第三，药物的作用。"药性皆偏"。每种药物都不例外，既有治病的一面，又有致病的一面。就拿治疗痹证的药物来讲，这类药物大抵以辛温(热)燥烈通窜者为主。它可以通畅经络，宣畅气血以收祛风散寒除湿而止痛之功。但如常服久服，必然会产生耗散气血、灼伤阴液，使气血不足，阴液亏少，肝肾损伤，筋骨痿弱的后果。因而痹证至于后期，其诸多症状，往往已经不是邪气痹阻而致，却多半是自身气血阴阳失调(或因病久之变化，或因药物之作用)而致。这些失调，多以偏虚为主。因而治疗本患所用之方药，是以调补阴阳气血之失调为主的，而未用常用的治疗痹证的药物。
医生乙治疗本患的几张处方，药物的变化有无规律?为何要这样加减?
老师：前面讲过，患者后期之临床症状，主要是气血不足，阴阳两虚。气血不足应重在调补中焦脾胃，使脾胃之气健旺，能纳能化则气血渐生；阴阳两虚当重在滋补下焦肾肝。因肾主骨而肝主筋，患者腰膝酸软无力，不耐久立久行，以及阴部冷湿，性欲减退，阳举不坚，夜尿频多等，皆系肝肾不足，筋骨痿弱，阴阳两虚之证。虚者当补。但当患者尚存有一系列燥热症状的情况下，则应先予滋阴，免使补益阳气之时而火热更盛，更伤阴液。可是此时之热并非实热内炽，而是由于辛热燥烈行散之品过于应用，伤耗阴液而至之燥热，所以不能用苦寒之品，恐苦寒化燥伤钥而败胄，只宜用寒凉柔润之药，使津液生而虚火降，胃阴复而胃用行。于是食欲旺盛而谷气增，精微化而气血之生有本，阴阳之复有望。且胃阴一复则约力也易运化，可免虚不受补之虞。当此目的达到后，则适当地减去一些寒凉降火之品，如玄参、麦冬。加入益养血气之味，如人参、枸杞子、当归、黄芪等。用药之后，见其气血虚衰诸症稍有起色，而虚热之症未生，故又相机加入补肝肾，强筋骨，助阳气之品，如杜仲、狗脊、巴戟天、羊藿叶等药。在用上药后，并未出现燥热津伤之症，而阳阴气血之虚象逐渐好转，才在最后的丸剂中又加入白术、茯苓等燥湿健脾之药，以增五脏六腑，气血津液生化之本。另外，在整个治疗过程中，始终用了寄生、川断、牛膝等。因这3味药，药性平和，既能补肝肾，强筋骨，而又无燥热助火、寒凉伤阳之弊。且寄生又能养血祛风，川断、牛膝又能活血通络，对于由痹症而渐出现肝肾不足、筋骨酸软疼痛者，正合其宜。使补中有通，则补而不滞；通中有补则行而不伤。其他如鸡血藤、巴戟天、羊藿叶等药的选择也注意了其各自的特点。鸡血藤可补血活血而祛风湿、舒筋脉；巴戟天补肾阳而强筋骨，其性温而不燥热；羊藿叶虽性较温热，易于动火，能祛寒湿而宣通不滞，且其用量不大，而又伍以地、芍等凉润之品，则阴阳并补，相得益彰。在应用诸多补药之时，只选用1味理气行滞，辛温健胃兼能活血通痹之姜黄，而未用其他理气之品，恐其化燥伤阴也。
痰多、咳嗽3年余
张X，男，36岁，1982年2月来诊。该患常觉喉中痰涎不绝，必咳之使出而后快。但每次只能咳少量痰涎。咳后稍舒，而稍过片时又觉喉中不畅，仍需再咳。这样就致每日咳声不绝，已经3年多了。询其发病之原因及病程经过，患者言，大约3年前的冬季，因感冒而咳嗽较重，由于治疗不当，一直缠绵二三个月咳嗽不愈。当时的症状是，干咳无痰，有时有少量粘痰，咳声重浊，常觉身上发冷，不热不渴，不烦不躁，大便如常，小便清利而无赤涩热痛之症。咳嗽每于遇风冷及早晚起床睡觉时加重，甚或出现连续性咳嗽。虽服用一些银翘解毒片、桑菊感冒片、甘草片、咳必清、麻杏止咳片、川贝精片、蛇胆陈皮末等药物，效仍不佳。后求治于一位老中医，认为是肺阴不足，燥热咳嗽，服了几剂汤药，又用过5盒百合固金丸。服药月余后，咳嗽未见好转，又觉胸中满闷，脘腹痞胀、大便溏薄，喉中觉得有痰涎，咳之不尽。天长日久，习以为常。3年来，并无宁时。每于阴天寒冷或感冒时，咳嗽更重，如在夏季或处温热之处则减轻。视其口唇淡润，舌质色淡肥大湿润，舌苔白滑，脉象沉弦。据其现有症情及整个病程，考虑此证当为寒饮阻肺，拟先用辛温燥剂以温肺化饮，暂不用止咳之药。为其疏方：桂枝10g，麻黄5g，干姜10g，半夏15g，五味子5g，白芍10g，细辛5g，甘草10g，茯苓15g，陈皮10g。水煎3次，分3次服，日服2次。5剂后，自觉胸闷略轻，喉中痰涎稍少，咳嗽也随之减少。又5剂后，症又见轻。考虑此患病程较长，非旦夕可愈，又将上方略为增减：桂枝10g，干姜10g，半夏15g，五味子5g，白芍10g，甘草10g，细辛5g，茯苓15g，白术15g，陈皮10g，山药25g。上方5剂，干燥后，共为细末，炼蜜为丸，每丸重10g，日服3次。上药大约1个多月服完，喉中痰涎明显减少，咳嗽大减，每日只能咳十几次，每次一二声，胸闷、脘痞腹胀基本消失，大便已正常。又用上方5剂做成丸药，服后诸症基本消失。
医生甲请老师谈一下辨治此证的思路。
老师：此患3年前所患之感冒咳嗽，很可能由风寒犯肺所致。从其发病季节来看，时值冬季气候寒冷之时，东北地区每年冬季此类病证相当多见。从症状来看，患者一直感觉身上发冷，不热不渴，不躁不烦，小便清利，毫无热象可察。其干咳少痰，咳嗽声重，为风寒咳嗽之重要特征。二三个月不见化热之变，遇风冷则咳剧，而居处温暖之处则咳轻，都说明其证为肺寒咳嗽。再从其所服用之药来看，如银翘、桑菊、麻杏甘石片、川贝精、蛇胆陈皮末等，无一不是寒凉之晶。以寒治寒，无怪乎其无效可言。由风寒犯肺所致的肺寒咳嗽，虽然有些患者由于治疗不当，有，迁延于整个冬季之可能，但也有很多随着春季的到来，气温之逐渐转暖，而渐趋减轻，以致痊愈。而如此患者一直3年多不愈，且常喉间痰涎源源而来，必咳之使出而后快，而咳痰之后不久，痰涎又来，可能与曾经误认此证为阴虚肺燥而投以滋阴润肺之药有关。患者虽不曾谈及当时所用汤剂之药物，但据其随后所服之百合固金丸推测，其所用之汤剂，可能为由如二冬、二地、百合、玄参之类的药物组成。当时所以能将此证误认为阴虚燥咳，可能一是由于咳嗽时间较长，二是患者干咳无痰或痰少而致。本为肺寒咳嗽，又投以寒凉滋润之品，何异雪上覆霜?宜其肺阳重被寒凉所遏，而滋润之晶又足以生痰致饮。故其咳终无宁日，虽已3年，仍无化热之象。此证咳是标，痰涎上泛是致咳之因，而脾肺阳气被寒润所伤，气化郁而不宣则又为痰涎之本。故治疗此证，当用辛甘温燥宣通之品，宣畅肺脾之阳气而化饮。应当明确的是，治疗此证时，不应只顾及于肺，而遗忘了中焦脾气。因寒凉滋润之晶不仅困遏了肺阳，而同时也伤害了脾阳。"脾喜暖而恶寒，土恶湿而喜燥"。((景岳全书))中焦阳气被寒湿困阻，阳气升降之机失宜，故出现脘痞腹胀、大便溏薄之症。因而在治疗此证之时，又适当地应用了温运中焦之阳气的药物。第…张处方，为小青龙汤加茯苓、陈皮。第二张处方为前方去麻黄加白术、山药。小青龙汤原为温肺、下气、化饮之方，主治寒饮喘咳。是以方巾以桂枝、麻黄、干姜、细辛、半夏等辛宣温燥，畅达阳气而温化寒饮之药物为主。第二方经过增减，实寓二陈、苓桂术甘、桂苓五味甘草汤、苓甘五味姜辛汤等方。"脾为生痰之源，肺为旷痰之器"。((张氏医通))-七方不仅能温煦上焦之阳气，也能温暖中焦之阳气，使阳气渐充而宣畅，则寒邪自去而痰饮自化。痰饮化而不再上泛，故不?台咳而咳自止。
医生乙书中有言，脾肺二家之痰不可混治，一治以温燥，-治以清润，与此证之治疗是否不符?
老师：书中确有此说，李中梓在(医宗必读)中就明确地说过，"脾肺二家之痰不可混治。脾为湿土，喜温燥而恶寒润，故：二术、星、夏为要药；肺为燥金，喜凉润而恶温燥，故二母、二冬、地黄、桔梗为要药"。此处所言之脾肺二家之痰，治疗用；药之不同，实即为湿痰与燥痰治疗用药不可混同。盖湿痰多缘于脾肾阳气不足。"脾主湿，湿动则为痰；肾主求，水泛亦为痰"。((景岳全书))然湿之所以动，在于脾气虚不能制水；水之所以泛，源于肾阳虚不能主水。痰饮之成，虽有其他各种原因，而关键在于脾肾之阳虚，不能运化水湿，停蓄而成。故有"脾肾为生痰之源"之说。此类痰饮实即为"寒痰"或"湿痰"。燥痰之生，多由于肺肾阴虚，或热灼阴液而成。燥痰与湿痰从成因、辨证与治疗上正好相反。《类证治裁》说，"夫肾阳虚，火不制水，水泛为痰，为饮逆上攻，故清而澈，治宜通阳泄湿，忌用腻晶助阴；肾阴虚，火必烁金，水结为痰，为痰火上升，故稠而浊，治宜滋阴清润，忌用温品助阳"。上面虽只谈到肾阳虚，水泛为痰，与肾阴虚，水结为痰之不同，但其证情与用药宜忌，完全适用于脾家之湿痰与肺家之燥痰。前面所谈到的只是脾家湿痰与肺家燥痰对待而言，并不是说肺家之痰必属燥热而已，而实际上肺家之痰也有属于寒湿者，并且在东北地区还很多见。肺为娇脏，既易伤于寒，也易伤于热。既易阴液耗伤而病阴虚燥热，也易阳气虚衰而致气虚寒湿。肺为水之上源而主津液之施布及水道之通调，若由于"形寒饮冷"或为寒药所伤，则阳气被困而气不敷布，津液凝聚而病寒饮湿痰。若由于热邪壅阻或被燥邪所伤，则热煎津液而为热痰燥痰。若因于肺肾阴虚火旺，也有病燥痰之可能。在肺家痰饮的治疗上，燥痰热痰固可用寒凉清润之品，而寒痰湿痰则非辛温燥烈之药而莫属。能全面地正确地掌握肺脏痰饮的各种不同特点，则在治疗用药时自能应用自如，而不会因囿于一偏之见，束缚自己的手足。
医生丙在治疗咳嗽的方剂中，有很多都应用杏仁；在祛痰时又每多应用桔梗。此患者咳嗽既久，而痰涎又多，为何方中不用此二药。
老师：咳与痰常相因为患，因而疾病中也常同时出现。但在治疗时，应先辨明是因痰而致咳，还是因咳而生痰。若因痰而致咳者，当先治痰，使痰清则咳自愈；若因咳而生痰者，应先察明致痰之因，必伏其所主而先其所因，使肺气清肃，咳止而不再生痰。杏仁苦温而润，善降肺气而止咳平喘，对于肺气壅逆之咳喘较为有效，故很多止咳平喘之方剂常用之。据药理研究，杏仁中含苦杏仁甙和苦杏仁酶。苦杏仁甙可被酶水解产生氢氰酸，少量氢氰酸有镇静呼吸中枢的作用，因而能使呼吸运动趋于安静而奏镇咳乎喘之功。而本证之咳，是因痰涎所致，通过咳嗽，又可排出痰涎。所以对于此种咳不要强于制止。若强止其咳，反不利于痰之排除。况杏仁多脂而柔润，与本方之辛温燥烈而化痰饮者又不相符，故未用杏仁。桔梗苦辛平，善开宣肺气而祛痰。故痰多者常用之。但祛痰与消痰(化痰)不同。祛痰是指祛除已经产生之痰，如桔梗、皂荚、贝母、瓜蒌等；而消痰则是消除生痰之原因，使气机宣畅，津液施布而不再生痰聚饮。欲达此目的，必用"温药和之"。此证即用辛温燥散之晶，宣畅脾肺之气机而使清升浊降，津液敷布，痰饮自无生成之由。此为治痰之本，而桔梗只能治痰之标，故未用之。
盗汗2年
四川省乐山市人民医院中医研究室主任余国俊
张X，女，5岁，1985年9月15日初诊。
Teacher: From the perspective of the etiology of Bi syndrome (a condition caused by invasion of wind, cold, and dampness pathogens into the meridians, leading to stagnation and obstruction of qi and blood), it is formed due to the invasion of wind-cold-dampness pathogens, causing the meridians and collaterals to lose smooth flow, resulting in bi-stagnation of qi and blood. When pathogenic factors are abundant, it manifests as an excess pattern; therefore, the treatment of Bi syndrome generally focuses on dispelling wind, scattering cold, and removing dampness. In cases lasting for a long time, methods to invigorate blood and unblock collaterals are often added as adjuvants. The saying "To treat wind, first treat the blood; when blood moves, wind extinguishes itself" embodies this principle. This is the general situation of Bi syndrome. Due to the influence of various internal and external factors, the clinical manifestations of the disease are constantly changing; excess and deficiency, cold and heat, exterior and interior, yin and yang can all transform into each other under certain conditions. Taking this patient as an example, his illness has both aspects of pathogenic excess and righteous deficiency. Yan Yonghe, when discussing the onset of Bi syndrome, stated, "It is all because of weak constitution, sparse interstices (couli), and contraction of wind-cold-dampness pathogens to form Bi." (from *Jisheng Fang*) Zhang Jiebin further emphasized, "Only because of insufficiency of qi and blood can wind-cold pathogens enter." (from *Jingyue Quanshu*) Zhou Xuehai mainly spoke from the perspective of righteous qi insufficiency, stating, "In the human body, if Wei Qi does not reach, there is cold; if Ying Qi does not reach, there is withering; if Zong Qi does not reach, there is flaccidity and bi-obstruction with loss of function." (from *Du Yi Suibi*) This is the first reason. Second, "early diseases are mostly excess, while chronic diseases are mostly deficiency," which is a general law of the occurrence and development of many diseases. Bi syndrome is no exception. At the beginning of the disease, since the disease mainly manifests as pathogenic excess, and through treatment or changes inherent to the disease, pathogenic excess gradually decreases, while manifestations of righteous deficiency gradually become prominent. The clinical manifestations of this patient are exactly like this. Initially, pain was the main symptom, but later he gradually developed soreness and weakness of the waist and knees, inability to stand or walk for long periods, general physical exhaustion and fatigue; palpitations and sweating upon exertion; until later presenting typical signs of yin-blood deficiency and endogenous dryness-heat. Third, the effect of drugs. "Drug properties all have biases." Every drug is no exception; it has both therapeutic and pathogenic aspects. Taking drugs for treating Bi syndrome, these are mostly acrid-warm (hot), drying, pungent, and penetrating agents. They can unblock meridians and collaterals, promote the free flow of qi and blood, thereby achieving the effects of dispelling wind, scattering cold, removing dampness, and relieving pain. However, frequent and long-term use will inevitably lead to consumption of qi and blood, burning of yin fluids, resulting in insufficiency of qi and blood, scarcity of yin fluids, damage to liver and kidney, and flaccidity and weakness of sinews and bones. Therefore, in the late stage of Bi syndrome, many symptoms are often not caused by pathogenic bi-stagnation, but rather by disharmony of one's own qi, blood, yin, and yang (either due to changes over a long illness or due to drug effects). These disharmonies are mostly characterized by deficiency. Therefore, the prescription used to treat this patient primarily focused on regulating and tonifying the disharmony of yin, yang, qi, and blood, rather than using commonly employed drugs for Bi syndrome.
Doctor Yi: Regarding the several prescriptions used to treat this patient, is there any regularity in the variation of herbs? Why were they modified in this way?
Teacher: As mentioned earlier, the clinical symptoms in the late stage of the patient were mainly insufficiency of qi and blood, and deficiency of both yin and yang. For insufficiency of qi and blood, emphasis should be placed on regulating and tonifying the middle jiao spleen and stomach, so that spleen and stomach qi becomes robust, capable of receiving and transforming, thus gradually generating qi and blood; for deficiency of both yin and yang, emphasis should be placed on nourishing the lower jiao liver and kidney. Since the kidney governs bones and the liver governs sinews, the patient's soreness and weakness of waist and knees, inability to endure prolonged standing and walking, cold and dampness in the genital area, decreased libido, impotence, and frequent nocturia all belong to patterns of liver-kidney insufficiency, flaccidity and weakness of sinews and bones, and deficiency of both yin and yang. Deficient patterns require tonification. However, when the patient still presents with a series of dryness-heat symptoms, nourishment of yin should be given first to prevent fire-heat from becoming more intense during the tonification of yang, which would further injure yin fluids. Yet, the heat at this time is not excessive internal heat, but dryness-heat caused by the overuse of acrid-hot, drying, and dispersing agents that consumed yin fluids. Therefore, bitter-cold agents cannot be used, as they may transform into dryness and damage the stomach; instead, cool and moistening agents should be used to generate fluids, subdue deficient fire, restore stomach yin, and facilitate stomach function. Consequently, appetite increases, grain qi grows, essence and microcosm are transformed, providing a foundation for the generation of qi and blood, offering hope for the restoration of yin and yang. Moreover, once stomach yin is restored, digestion and transportation are easier, avoiding the risk of "deficiency unable to tolerate tonification." After this goal is achieved, some cool agents that descend fire, such as Xuanshen (Scrophulariae Radix) and Maidong (Ophiopogonis Radix), are appropriately reduced. Herbs that benefit blood and nourish qi, such as Renshen (Ginseng Radix), Gouqizi (Lycii Fructus), Danggui (Angelicae Sinensis Radix), and Huangqi (Astragali Radix), are added. After medication, seeing slight improvement in symptoms of qi and blood deficiency without the emergence of deficient heat, herbs that tonify liver and kidney, strengthen sinews and bones, and assist yang qi, such as Duzhong (Eucommiae Cortex), Gouji (Cibotii Rhizoma), Bajitian (Morindae Officinalis Radix), and Yinyangye (Epimedii Folium), are added opportunistically. After using these herbs, no symptoms of dryness-heat and fluid injury appeared, and the deficiency images of yin, yang, qi, and blood gradually improved. Only then were Baizhu (Atractylodis Macrocephalae Rhizoma) and Fuling (Poria) added to the final pills to enhance the root of transformation and production of qi, blood, and fluids in the five zang and six fu organs. Additionally, Sangjisheng (Taxilli Caulis), Chuanxian (Dipsaci Radix), and Niuxi (Achyranthis Bidentatae Radix) were consistently used throughout the treatment process. Because these three herbs have mild properties, they can tonify liver and kidney, strengthen sinews and bones, without the drawbacks of drying-heat aiding fire or cold injuring yang. Furthermore, Sangjisheng can nourish blood and dispel wind; Chuanxian and Niuxi can invigorate blood and unblock collaterals, which is perfectly suitable for cases where Bi syndrome gradually leads to liver-kidney insufficiency and soreness/pain of sinews and bones. This ensures tonification includes unblocking, preventing stagnation; unblocking includes tonification, preventing damage during movement. Other choices like Jixueteng (Spatholobi Caulis), Bajitian, and Yinyangye also considered their respective characteristics. Jixueteng can nourish blood, invigorate blood, dispel wind-dampness, and relax sinews and vessels; Bajitian tonifies kidney yang and strengthens sinews and bones, its nature is warm but not drying-heat; Yinyangye, although relatively warm-hot and prone to stirring fire, can dispel cold-dampness and promote free flow without stagnation. Its dosage was small, and it was combined with cooling-moistening agents like Dihuang (Rehmanniae Radix) and Shaoyao (Paeoniae Radix), allowing yin and yang to tonify each other harmoniously. When applying many tonifying drugs, only one herb, Jianghuang (Curcumae Longae Rhizoma), which regulates qi, moves stagnation, is acrid-warm, strengthens the stomach, and invigorates blood to unblock Bi, was selected, avoiding other qi-regulating herbs to prevent transformation into dryness and injury to yin.
Phlegm and Cough for Over 3 Years
Professor Xiao Yonglin and Chen Fengzhi, Changchun University of Chinese Medicine
Zhang X, male, 36 years old, consulted in February 1982. The patient often felt continuous phlegm-saliva in the throat, feeling relieved only after coughing it out. However, only a small amount could be coughed up each time. He felt slightly relieved after coughing, but after a short while, discomfort returned, requiring further coughing. This resulted in non-stop coughing every day for over 3 years. Upon inquiry about the cause and course of the disease, the patient stated that about 3 years ago in winter, he had a severe cough due to a common cold. Due to improper treatment, the cough persisted for two to three months. The symptoms at that time were: dry cough without sputum, sometimes with a small amount of sticky sputum, heavy cough sound, constant feeling of coldness in the body, no fever, no thirst, no irritability or restlessness, normal bowel movements, clear and profuse urination without redness, turbidity, heat, or painful dysuria. The cough worsened upon exposure to wind-cold and during getting up or going to bed in the morning and evening, even appearing as continuous coughing. Although he took some medicines such as Yinqiao Jiedu Pian, Sangju Ganmao Pian, Gancao Pian, Kebin Qing, Maxing Zhike Pian, Chuanbei Jing Pian, Shedan Chenpi Mo, etc., the efficacy was still poor. Later, he sought treatment from an experienced TCM practitioner who diagnosed lung yin insufficiency and dryness-heat cough. He took several doses of decoction and used 5 boxes of Baihe Gujin Wan. After taking medicine for over a month, the cough did not improve, and he felt chest fullness, epigastric and abdominal distension, loose stools, and sensation of phlegm-saliva in the throat that could not be fully coughed up. Over time, this became habitual. For 3 years, there was no relief. The cough worsened on cloudy, cold days or during colds, and alleviated in summer or in warm places. His lips were pale and moist, tongue body was pale, enlarged, and moist, tongue coating was white and slippery, pulse was deep and wiry. Based on current symptoms and the entire course, this pattern was considered cold-fluid retention obstructing the lungs. It was planned to first use acrid-warm drying agents to warm the lungs and transform fluids, temporarily avoiding antitussives. The prescription was: Guizhi 10g, Mahuang 5g, Ganjiang 10g, Banxia 15g, Wuweizi 5g, Baishao 10g, Xixin 5g, Gancao 10g, Fuling 15g, Chenpi 10g. Decocted in water three times, divided into three doses, taken twice daily. After 5 doses, chest tightness felt slightly lighter, phlegm-saliva in throat slightly decreased, and cough also reduced. After another 5 doses, symptoms lightened further. Considering the long duration of the disease, which cannot be cured overnight, the above formula was slightly modified: Guizhi 10g, Ganjiang 10g, Banxia 15g, Wuweizi 5g, Baishao 10g, Gancao 10g, Xixin 5g, Fuling 15g, Baizhu 15g, Chenpi 10g, Shanyao 25g. Five doses of the above formula were dried, ground into fine powder, and made into honey pills, each weighing 10g, taken 3 times daily. After finishing approximately one month's supply, phlegm-saliva in the throat significantly decreased, cough greatly reduced to about ten times a day, one or two sounds each time, chest tightness and epigastric/abdominal distension basically disappeared, and bowel movements normalized. Another 5 doses were made into pills; after taking them, all symptoms basically disappeared.
Doctor Jia: Please discuss the diagnostic and therapeutic思路 (approach) for this pattern.
Teacher: The cold and cough suffered by this patient 3 years ago was likely caused by wind-cold invading the lungs. From the season of onset, it occurred during the cold winter climate; such patterns are quite common in Northeast China every winter. From the symptoms, the patient always felt coldness in the body, no fever, no thirst, no irritability, clear urination, with no signs of heat observable. His dry cough with little sputum and heavy cough sound are important characteristics of wind-cold cough. The absence of transformation into heat after two to three months, worsening upon exposure to wind-cold, and alleviation in warm environments all indicate lung-cold cough. Looking at the medications he took, such as Yinqiao, Sangju, Maxing Gan Shi Pian, Chuanbei Jing, Shedan Chenpi Mo, etc., none were not cold-cooling agents. Treating cold with cold, it is no wonder it was ineffective. Lung-cold cough caused by wind-cold invading the lungs, although some patients may prolong throughout the winter due to improper treatment, many gradually alleviate and recover as spring arrives and temperatures rise. However, this patient remained untreated for over 3 years, with continuous phlegm-saliva in the throat, needing to cough it out to feel relief, and phlegm returning shortly after coughing. This might be related to the previous misdiagnosis of this pattern as yin-deficiency lung dryness, leading to the administration of yin-nourishing and lung-moistening drugs. Although the patient did not mention the specific herbs in the decoction used at that time, based on the subsequent use of Baihe Gujin Wan, it can be speculated that the decoction might have consisted of herbs like Dongguandong (Asparagi Radix and Ophiopogonis Radix), Erdi (Rehmanniae Radix and Scrophulariae Radix), Baihe (Lilii Bulbus), Xuanshen (Scrophulariae Radix), etc. The reason for misdiagnosing this pattern as yin-deficiency dry cough might be firstly due to the long duration of cough, and secondly due to the patient's dry cough without sputum or with little sputum. Originally a lung-cold cough, administering cold-cooling and moistening agents is like adding frost to snow. It is appropriate that lung yang was heavily suppressed by cold-cooling, and moistening agents generated phlegm and fluids. Thus, his cough never ceased; although it has been 3 years, there are still no signs of transformation into heat. In this pattern, cough is the branch manifestation, upward flooding of phlegm-saliva is the cause of cough, and damage to spleen and lung yang by cold-moistening agents, leading to stagnation and failure of qi transformation to disperse, is the root of phlegm-saliva. Therefore, the treatment of this pattern should use acrid-sweet-warm-drying and dispersing agents to promote the free flow of lung and spleen yang qi and transform fluids. It must be clarified that when treating this pattern, one should not only focus on the lungs but forget the spleen qi of the middle jiao. Because cold-cooling and moistening agents not only suppress lung yang but also injure spleen yang. "The spleen likes warmth and dislikes cold; earth dislikes dampness and likes dryness." (from *Jingyue Quanshu*) Middle jiao yang qi being trapped by cold-dampness, the mechanism of ascending and descending of yang qi becomes inappropriate, hence the symptoms of epigastric distension, abdominal bloating, and loose stools. Therefore, in treating this pattern, drugs that warm and move middle jiao yang qi were appropriately applied. The first prescription was Xiao Qing Long Tang (Minor Green Dragon Decoction) plus Fuling (Poria) and Chenpi (Citri Reticulatae Pericarpium). The second prescription was the former formula minus Mahuang (Ephedrae Herba) plus Baizhu (Atractylodis Macrocephalae Rhizoma) and Shanyao (Dioscoreae Rhizoma). Xiao Qing Long Tang is originally a formula for warming the lungs, directing qi downward, and transforming fluids, indicated for cold-fluid wheezing and cough. It mainly uses acrid-dispersing, warm-drying agents like Guizhi (Cinnamomi Ramulus), Mahuang, Ganjiang (Zingiberis Rhizoma), Xixin (Asari Radix et Rhizoma), Banxia (Pinelliae Rhizoma) to promote yang qi and warm-transform cold-fluid. The second formula, after modification, actually contains elements of Er Chen Tang (Two-Cured Decoction), Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes, and Licorice Decoction), Guiling Wuweizi Gancao Tang (Cinnamon Twig, Poria, Schisandra, and Licorice Decoction), and Linggan Wuweizi Jiangxin Tang (Poria, Licorice, Schisandra, Ginger, and Asari Decoction). "The spleen is the source of phlegm production; the lungs are the vessel for storing phlegm." (from *Zhangshi Yitong*) One formula can not only warm the upper jiao yang qi but also warm the middle jiao yang qi, making yang qi gradually sufficient and free-flowing, so that cold pathogens depart and phlegm-fluids transform spontaneously. Once phlegm-fluids transform and no longer flood upward, cough stops spontaneously without waiting for antitussive action.
Doctor Yi: Books state that phlegm from the spleen and lungs cannot be treated indiscriminately; one is treated with warm-drying, the other with clearing-moistening. Is this inconsistent with the treatment of this case?
Teacher: There is indeed such a statement in books. Li Zhongzi clearly stated in *Yizong Bidu* (Essential Knowledge for Medical Practitioners): "Phlegm from the spleen and lungs cannot be treated indiscriminately. The spleen is wet earth, liking warm-drying and disliking cold-moistening, so Baizhu (Atractylodis Macrocephalae Rhizoma), Cangzhu (Atractylodis Rhizoma), Nanxing (Arisaematis Cum Bile), Banxia (Pinelliae Rhizoma) are essential herbs; the lungs are dry metal, liking cool-moistening and disliking warm-drying, so Zhimu (Anemarrhenae Rhizoma), Beimu (Fritillariae Cirrhosae Bulbus), Dongguandong (Asparagi Radix and Ophiopogonis Radix), Dihuang (Rehmanniae Radix), Jiegeng (Platycodonis Radix) are essential herbs." The difference in treatment drugs for spleen and lung phlegm mentioned here essentially means that wet-phlegm and dry-phlegm treatments cannot be mixed. Wet-phlegm mostly originates from insufficiency of spleen and kidney yang qi. "The spleen governs dampness; when dampness moves, it becomes phlegm; the kidney governs water; when water floods, it also becomes phlegm." (from *Jingyue Quanshu*) However, the reason dampness moves is spleen qi deficiency failing to control water; the reason water floods is kidney yang deficiency failing to master water. The formation of phlegm-fluids, although having other various causes, lies key in spleen-kidney yang deficiency, failing to transport and transform water-dampness, leading to accumulation. Hence the saying "Spleen and kidney are the sources of phlegm production." Such phlegm-fluids are essentially "cold-phlegm" or "wet-phlegm". Dry-phlegm arises mostly from lung-kidney yin deficiency or heat scorching yin fluids. Dry-phlegm and wet-phlegm are exactly opposite in etiology, differentiation, and treatment. *Leizheng Zaican* states: "When kidney yang is deficient, fire fails to control water, water floods to become phlegm, fluid rebels upward attacking, thus clear and transparent; treatment should promote yang and drain dampness, avoiding greasy products that aid yin; when kidney yin is deficient, fire surely scorches metal, water knots to become phlegm, phlegm-fire rises upward, thus thick and turbid; treatment should nourish yin and clear-moisten, avoiding warm products that aid yang." Although only kidney yang deficiency leading to water flooding and kidney yin deficiency leading to water knotting are discussed above, the clinical presentation and contraindications of drugs apply completely to spleen wet-phlegm and lung dry-phlegm. What was discussed earlier is merely contrasting spleen wet-phlegm with lung dry-phlegm, not implying that lung phlegm must be dry-heat. In reality, lung phlegm can also belong to cold-dampness, which is very common in Northeast China. The lungs are delicate organs, easily injured by cold and heat. Yin fluids are easily consumed leading to yin-deficiency dry-heat, or yang qi declines leading to qi-deficiency cold-dampness. The lungs are the upper source of water, governing the distribution of fluids and regulation of water passages. If injured by "external cold and internal cold drinks" or cold drugs, yang qi is trapped, qi fails to distribute, fluids condense, leading to cold-fluid wet-phlegm. If blocked by heat pathogens or injured by dry pathogens, heat fries fluids into heat-phlegm and dry-phlegm. If due to lung-kidney yin deficiency with fire hyperactivity, dry-phlegm is also possible. In the treatment of lung phlegm-fluids, dry-phlegm and heat-phlegm can certainly use cool-clearing-moistening agents, while cold-phlegm and wet-phlegm must rely on acrid-warm-drying agents. Comprehensively and correctly mastering the various characteristics of lung phlegm-fluids allows for flexible application in treatment, avoiding being bound by one-sided views.
Doctor Bing: In formulas for treating cough, Xingren (Prunus Armeniacae Semen) is often used; for resolving phlegm, Jiegeng (Platycodonis Radix) is frequently used. This patient has had cough for a long time and much phlegm-saliva, why were these two herbs not used in the formula?
Teacher: Cough and phlegm often occur together due to mutual causation, appearing simultaneously in diseases. But in treatment, one must first distinguish whether cough is caused by phlegm or phlegm is generated by cough. If cough is caused by phlegm, treat phlegm first; once phlegm clears, cough heals itself. If phlegm is generated by cough, first identify the cause of phlegm, address the primary factor and the initial cause, make lung qi clear and descending, stop cough, and prevent new phlegm generation. Xingren is bitter-warm and moist, good at descending lung qi, stopping cough, and calming wheezing, relatively effective for cough-wheezing due to lung qi congestion and rebellion, so it is commonly used in many antitussive and anti-wheezing formulas. According to pharmacological research, Xingren contains amygdalin and emulsin. Amygdalin can be hydrolyzed by emulsin to produce hydrogen cyanide; small amounts of hydrogen cyanide have a sedative effect on the respiratory center, thus quieting respiratory movement and achieving antitussive and anti-wheezing effects. However, the cough in this case is caused by phlegm-saliva, and coughing helps expel phlegm-saliva. Therefore, this type of cough should not be forcibly stopped. Forcibly stopping cough hinders phlegm expulsion. Moreover, Xingren is oily and moistening, inconsistent with the acrid-warm-drying and phlegm-transforming nature of this formula, so Xingren was not used. Jiegeng is bitter-acrid-neutral, good at opening and diffusing lung qi and resolving phlegm, so it is commonly used for excessive phlegm. But resolving phlegm (qu tan) is different from eliminating phlegm (xiao tan). Resolving phlegm refers to removing already produced phlegm, such as Jiegeng, Zaojiao (Gleditsiae Spina), Beimu, Gualou (Trichosanthis Fructus); whereas eliminating phlegm means removing the cause of phlegm production, promoting free flow of qi mechanism, distributing fluids, and preventing new phlegm and fluid accumulation. To achieve this purpose, "warm drugs must harmonize" must be used. This case uses acrid-warm-drying agents to promote free flow of spleen-lung qi mechanism, making clear ascend and turbid descend, fluids distribute, leaving no cause for phlegm-fluid generation. This is the root of treating phlegm, while Jiegeng only treats the branch of phlegm, so it was not used.
Night Sweats for 2 Years
Yu Guojun, Director of TCM Research Office, People's Hospital of Leshan City, Sichuan Province
Zhang X, female, 5 years old, first consultation on September 15, 1985.