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Teacher: I believe we should shift our focus to clinical practice: Does there actually exist in the clinic a syndrome where both Liver-Kidney Yin Deficiency (Gan Shen Yin Xu, deficiency of Yin fluids in the Liver and Kidney) and Liver Qi Stagnation (Gan Yu Qi Zhi, stagnation of Liver Qi causing obstruction of Qi mechanism) coexist as primary pathogenic mechanisms? Please note, I am not referring to Liver-Kidney Yin Deficiency combined with Liver Qi Stagnation, nor Liver Qi Stagnation combined with Liver-Kidney Yin Deficiency, but rather a situation where the two pathogenic mechanisms coexist side by side, making it impossible to distinguish which is primary and which is secondary. For example, in this patient case, her dull pain in the chest and hypochondrium, burning sensation in the lower abdomen that worsens at night, accompanied by dry eyes, frequent dreams at night, bitter taste in the mouth, and dry mouth, clearly belongs to Liver-Kidney Yin Deficiency; whereas her epigastric fullness and stuffiness, frequent belching, and abdominal distension (Zhen Zhang) belong to Liver Qi Stagnation. The suffering experienced by the patient from these two sets of subjective symptoms is equally unbearable; after repeated inquiries, even the patient herself cannot distinguish which is primary and which is secondary, so it is even more difficult for the physician to forcibly differentiate them. When treating this syndrome, if one simply uses Yi Guan Jian (One-Glue Decoction) (or adds a few herbs to nourish the Kidney and fill the essence), although it can nourish the Liver and Kidney, the formula only contains a small amount of Jin Ling Zi (Black Currant Fruit) to soothe the Liver and move Qi, which is weak and insufficient. Can we expect it to eliminate fullness and abdominal distension?

Student Bing: According to the records in *Liu Zhou Yi Hua* (Medical Conversations from Liu Zhou), the efficacy of Yi Guan Jian is to nourish Yin and soothe the Liver, mainly treating syndromes of Liver-Kidney Yin Deficiency with stagnant Qi movement, such as pain in the chest, epigastrium, and hypochondrium, acid regurgitation, bitter vomiting, hernia, and abdominal masses. It seems this formula excels in both nourishing the Liver and Kidney and soothing the Liver while moving Qi. Combining it with Si Ni San (Frigid Extremities Powder) seems superfluous.

Teacher: Is that really the case? Deeply investigating the mechanism and characteristic manifestations of Yin Deficiency with Qi Stagnation might help answer this doubt. What is meant by "Liver-Kidney Yin Deficiency, Qi Stagnation and Non-movement"? The *Nei Jing* (Inner Canon) states, "Yin Deficiency leads to lack of Qi," meaning that when Yin fluids are deficient, they cannot transform into Qi; when Qi is scarce, it is difficult to promote blood circulation to moisten the Zang-Fu organs and meridians, thereby producing pain in the chest, epigastrium, and hypochondrium. This pain is not severe, merely dull or lingering. Thus, the "Qi Stagnation" mentioned in *Liu Zhou Yi Hua* should actually be attributed to a lack of Qi; and the lack of Qi should be attributed to Liver-Kidney Yin Deficiency. Therefore, to treat this kind of "Qi Stagnation," one must base the treatment on nourishing the Yin fluids of the Liver and Kidney, adding a small amount of Qi-moving herbs that do not damage Yin, so that tonification does not hinder movement. If one only engages in nourishing Yin without adding Qi-moving herbs, it becomes "static tonification" (ineffective tonification). On the other hand, can the set of Qi Stagnation symptoms in this patient be blamed on a lack of Qi? Judging from her epigastric fullness, frequent belching, and severe abdominal distension, it is obviously combined with the pathogenic mechanism of Liver Qi Stagnation. And Liver Qi Stagnation is absolutely not a lack of Qi, but rather an excess and flourishing of Qi. From this, it is not difficult to understand: the previously mentioned lack of Qi refers to physiological insufficiency of Qi; whereas the excess and flourishing of Qi in this case refer to pathological Qi hyperactivity. If this explanation is correct, then combining Si Ni San is not superfluous.

Trainee Jia: I noticed that after the patient took 3 doses of the initial prescription, the dull pain in the hypochondrium, epigastric fullness, and burning abdominal distension all decreased, but the dull chest pain remained unchanged, and the stool was still dry. I originally thought that in the second-visit prescription, the teacher might add Ma Ren Wan (Hemp Seed Pill) and blood-invigorating and collateral-unblocking drugs. Unexpectedly, only Bai He (Lily Bulb), Jue Ming Zi (Cassia Seed), and Rou Cong Rong (Cistanche) were added, and Zhi Ke (Aurantium Fruit) was changed to Zhi Shi (Immature Aurantium Fruit), after which the chest pain eased and bowel movements became smooth. What is the reason for this?

Teacher: Dull chest pain appearing in Liver diseases occurs because the Liver meridian passes through the diaphragm and enters the Lung. However, if treating the Liver is ineffective, one should consider concurrent Lung Metal pathology. In this case, deficiency fire from the Liver and Kidney scorches the Lung, causing Lung Dryness and collateral damage, resulting in dull pain; Lung heat transfers downward to the Large Intestine, causing intestinal dryness and fluid deficiency, hence the dry stool. Therefore, Bai He was added to clear and moisten the Lung collaterals, and Jue Ming Zi and Rou Cong Rong were added along with Zhi Shi to moisten the intestines and unblock bowels. Experience proves that for dull chest pain caused by deficiency fire scorching the Lung and Lung Dryness damaging collaterals, heavy use of Bai He can often relieve pain quickly; and for constipation due to intestinal dryness and fluid deficiency, heavy use of Jue Ming Zi and Rou Cong Rong, with a small amount of Zhi Shi to moisten the intestines and unblock bowels, rarely leads to rebound constipation. This is superior to Ma Zi Ren Wan (Hemp Seed Pill).

Trainee Yi: I have been thinking: Although this case combines the pathogenic mechanism of Liver Qi Stagnation, the signs of Liver-Kidney Yin Deficiency are very prominent. Therefore, combining Si Ni San seems somewhat drying. Could we not change to milder Liver-soothing and Qi-regulating herbs?

Teacher: Si Ni San consists of four herbs: Chai Hu (Bupleurum Root), Bai Shao (White Peony Root), Zhi Shi (Immature Aurantium Fruit), and Gan Cao (Licorice Root). Which one is drying? Even if one worries that Chai Hu "steals Liver Yin," the formula contains Shao Yao Gan Cao Tang (Peony and Licorice Decoction), which generates Yin through Sour-Sweet combination to counteract this. Thus, the claim that this formula is "drying" is a misunderstanding. By the way, Jin Ling Zi in Yi Guan Jian is cold in nature and extremely bitter and unpleasant, making it hard to swallow. It should only be used in small amounts temporarily and never in large amounts for long periods. Although Wei Liu Zhou created this formula, a careful review of his medical cases shows he mostly did not use Jin Ling Zi, but instead substituted Bai Ji Li (Tribulus Fruit), which probably reflects a form of reflection.

Trainee Bing: I heard that the teacher has had many successful treatments using Yi Guan Jian combined with Si Ni San in recent years. What diseases have been treated?

Teacher: We have treated the recovery phase of acute hepatitis, chronic hepatitis, sequelae of hepatitis, menopause syndrome in women and men, chronic adnexitis, neurosis, etc. These are Western medical diagnoses; do not let them bind your mind. In clinical practice, one only needs to observe the pulse and manifestations. If it truly belongs to Liver-Kidney Yin Deficiency combined with Liver Qi Stagnation, using this method can yield sensitive effects.

Long-term Low-grade Fever

Professor Xiao Yonglin, Changchun University of Chinese Medicine

Patient Zhao XX, female, 23 years old. First visit in early December 1976. The patient is a nurse in Ward X of Clinical Hospital XX of XX Medical University, admitted to this ward for treatment of long-term low-grade fever. She had been hospitalized for a long time with no obvious effect. Examination revealed the patient was emaciated, complexion yellowish-white and lusterless, lips pale and moist, presenting a state of fatigue and weakness. She stated she had low-grade fever for a long time, with body temperature usually between 37-37.5°C, rarely rising to 38°C. Various clinical and laboratory examinations failed to find the cause. She felt physically fatigued, reluctant to move or speak, becoming tired and short of breath with excessive activity, sometimes sweating, poor appetite, bloating that does not resolve after forced eating, preferring to lie down and rest, and frequently cold extremities. Tongue inspection showed a pale tongue lacking luster, thin white moist coating, and a weak, powerless pulse. Regarding other symptoms, she reported no headache or body ache. Although having low-grade fever, she did not feel aversion to heat; instead, she felt periodic chills, which resolved with warmth. There were no sensations of vexatious heat in the chest or thirst. Bowel movements were basically normal, occasionally slightly loose. Urination was clear and free. Menstrual cycles were roughly normal, except for fluctuating volume and pale color. It seemed to belong to Qi Deficiency Fever. Thus, Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) was modified: Dang Shen (Codonopsis Root) 15g, Sheng Huang Qi (Raw Astragalus Root) 20g, Bai Zhu (Atractylodes Macrocephala Rhizome) 15g, Fu Ling (Poria) 15g, Dang Gui (Angelica Sinensis Root) 15g, Gan Cao (Licorice Root) 10g, Sheng Ma (Cimicifuga Rhizome) 5g, Chai Hu (Bupleurum Root) 5g, Chen Pi (Citrus Reticulata Peel) 10g, Mai Ya (Hordeum Vulgare Sprout) 15g. Decocted in water three times, filtrates combined and divided into three doses per day. After 3 doses, appetite improved, food intake increased, and other symptoms remained as before. After another 2 doses, besides increased food intake, she felt some strength returning to her body, no longer as exhausted as before. Continuing to take the previous prescription for several more doses, body temperature dropped to 36.5°C, and symptoms like fatigue, weakness, and shortness of breath greatly improved. Based on the current situation, the patient discussed with the ward leadership and decided to be discharged home to take medicine and rest. She was instructed to take Ren Shen Jian Pi Wan (Ginseng Spleen-Strengthening Pill) and Bu Zhong Yi Qi Wan (Tonify the Middle and Augment the Qi Pill) to tonify Spleen Qi and cultivate the root. Continuing to take these two pills until the Spring Festival, her body completely recovered, never fevered again, looking radiant and energetic, completely different from her state one and a half months prior.

Doctor Jia: This patient had long-term low-grade fever. On what basis did the teacher diagnose it as Qi Deficiency low-grade fever?

Teacher: Clinically, there are many patients with long-term low-grade fever, and the causes leading to prolonged fever are numerous, with complex manifestations. The reason this patient's long-term low-grade fever was diagnosed as Qi Deficiency Fever is mainly because she presented with a set of Spleen Deficiency and Qi Weakness signs. First, for long-term fever, one must distinguish whether it is Exogenous Fever or Endogenous Fever. This patient had neither manifestations of Excess Heat nor signs of Damp-Heat, nor any signs of Toxic Heat (such as carbuncles and sores). Therefore, Exogenous Excess Heat can basically be excluded. Thus, the fever in this disease must belong to the category of Endogenous Fever. Second, within Endogenous Fever, there are also Deficiency and Excess categories, which should also be distinguished. This patient had no history of trauma or bleeding, no symptoms of fixed-point stabbing pain, and no cyanosis or ecchymosis on the lips or tongue, indicating her fever was not due to Blood Stasis. The patient had no cause for Qi Stagnation and Liver Depression due to frustration or anger, nor signs of bloating, irritability, or sighing, nor symptoms of dysmenorrhea or breast distension during menstruation, so fever due to Qi Stagnation and Liver Depression transforming into Fire can also be excluded. Only differentiation within Deficiency Syndromes remains. Fevers caused by Deficiency differ between Insufficiency of Yin-Blood and Decline of Yang-Qi, both belonging to Deficient Heat, also called Deficient Fire. The "Deficient Fire" mentioned by Dan Xi—"Excess Fire can be purged with Scutellaria and Phellodendron; Deficient Fire can be tonified with Codonopsis and Astragalus"—belongs to this category. More precisely, the Deficient Fire treated with Codonopsis and Astragalus must undoubtedly be Qi Deficiency. Fevers due to Insufficiency of Yin-Blood occur because Yin Deficiency fails to contain Yang, leading to independent hyperactivity of Yang, thus often presenting with Five-Center Vexatious Heat (heat in palms, soles, and chest), frequent dreams, and insomnia; whereas this patient had no Five-Center Vexatious Heat and preferred lying down and sleeping. Fevers due to Yin Deficiency occur because insufficient Yin fluids fail to moisten, thus often presenting with dry, red lips and throat dryness; whereas this patient had pale, moist lips, not red or dry, and no sensation of throat dryness. Knowing it is not Yin (Blood) Deficiency Fever. This patient clearly manifested physical fatigue, limb lassitude, reluctance to move or speak, worsening with activity, confirming Spleen Qi Decline beyond doubt. Therefore, in treatment, the method of Tonifying the Middle and Augmenting Qi was adopted and achieved success. Looking at the effects after taking the medicine: first, appetite turned good, and food intake increased. This indicates that Middle Qi gradually strengthened, and the functions of Spleen Ascending and Stomach Descending gradually recovered. With increased diet, grain transforms into essence, nourishing the body, so strength gradually returns. Subsequently, body temperature gradually decreased and returned to normal. It can be seen that to treat Qi Deficiency Fever, one must first tonify Middle Qi, restoring Spleen and Stomach Qi, enabling them to accept and transform, replenishing Gu Qi daily, so the fever recedes naturally. If one sees fever and, without distinguishing between Deficiency and Excess, or Qi (Yang) and Blood (Yin), uniformly applies cooling and moisturizing methods, not only is it difficult to achieve success, but it may also exacerbate the disease.

Doctor Yi: Yin-Blood Deficiency leads to Heat, and Yang-Qi Deficiency leads to Cold; this is a general rule. How should we understand that Qi Deficiency can instead lead to Fever?

Teacher: Heat arising internally from Yin-Blood Deficiency and Cold arising from within due to Yang-Qi Deficiency are easy to understand. That Qi Deficiency can instead lead to Fever is indeed difficult to explain mechanistically. However, clinically, fever caused by Qi Deficiency does exist, causing either long-term low-grade fever or long-term high fever. First, it must be clarified that the Qi Deficiency in Qi Deficiency Fever refers to Spleen-Stomach Qi Deficiency. The main causes of Spleen-Stomach Qi Deficiency are irregular diet, excessive labor, sorrow, and overthinking. But why Spleen-Stomach Qi Deficiency leads to fever currently has no unified understanding. Summarizing, there are roughly the following views, to which we offer our opinions: One view holds that Spleen Qi sinking, Middle Jiao Deficiency Cold, and floating of Deficient Yang externally cause fever. But clinically, many patients with Qi Deficiency Fever show no signs of Middle Cold, so the theory that Middle Jiao Deficiency Cold causes floating Deficient Yang seems unfounded. Moreover, in treatment, warming-Middle and dispersing-Cold herbs or herbs guiding fire back to its source are rarely used! Another view holds that Spleen-Stomach Qi Deficiency causes Grain Qi to flow downward, accumulating as Damp-Heat, causing Yin Fire from the Lower Jiao to rush upward, resulting in fever. This view is opposite to the previous one; the former is Deficiency Cold, while this is Damp-Heat. If it were internal accumulation of Damp-Heat, there would surely be signs of Damp-Heat in urine/stool or tongue coating. Treatment would require addressing Damp-Heat first, after which fever symptoms would gradually recede. However, clinically, patients with Qi Deficiency Fever often show no signs of Damp-Heat and do not need Damp-Heat-clearing and draining herbs; only Sweet-Warm lifting agents are suitable, and once Qi Deficiency is tonified, fever retreats naturally. Besides, Damp-Heat clearing and draining products primarily dispel pathogens and are certainly not applicable to Spleen Qi sinking. Thus, this view also seems inconsistent. A third view holds that Qi Deficiency leads to insecure Wei Qi, making one susceptible to external pathogens, and struggle between Righteous Qi and Pathogen causes fever. This view clearly belongs to Exogenous Fever, definitely not Endogenous Fever. Although Bu Zhong Yi Qi Tang can be used for Qi Deficiency with External Contraction, benefiting Qi and releasing the exterior, one cannot therefore confuse Qi Deficiency Fever with fever caused by Qi Deficiency leading to external contraction. Moreover, Qi Deficiency Fever is often long-term, without observable Exterior Signs, clearly different from Qi Deficiency External Contraction where one often catches colds, fevers with external contraction, and does not fever without it. A fourth view holds that Spleen-Stomach Qi Deficiency impairs transportation and transformation, failing to generate Blood, and Blood Deficiency causes fever. This view essentially confuses Qi Deficiency Fever with Blood Deficiency Fever. A fifth view holds that insufficient Yang cannot rot and cook grain and water, leading to Yin Deficiency, and Yin Deficiency causes Heat. The above two views suggest Qi Deficiency leads to Blood Deficiency, and Qi Deficiency leads to Yin Deficiency. Insufficient Yin-Blood cannot coordinate with Yang, leading to Yang hyperactivity and fever. If saying Spleen-Stomach Qi Deficiency fails to digest and transport grain and water, leading to Yin-Blood Deficiency, this is common clinically. Treatment involves either tonifying Qi to generate Blood, like Dang Gui Bu Xue Tang (Angelica Tonifying Blood Decoction); or cultivating Earth to nourish Yin, like Zi Sheng Tang (*Medical Records of Integrating Chinese and Western Medicine*: Bai Zhu, Shan Yao, Nei Jin, Xuan Shen, Niu Bang Zi). Both formulas are based on Spleen-tonifying and Qi-augmenting herbs, adding either Blood-tonifying or Yin-nourishing herbs. This cannot be compared with Bu Zhong Yi Qi Tang, which mainly uses Warm-Tonifying and Lifting herbs, so these two views are seemingly plausible but actually incorrect. A sixth view holds that Spleen-Stomach Qi Deficiency causes abnormal ascending and descending, poor Qi mechanism flow, stagnation, and transformation into Heat. Although this view is not perfect, it can relatively correctly explain the mechanism of Qi Deficiency Fever. The key is that Qi Deficiency leads to Stagnation, and Stagnation transforms into Heat. Among them, Heat transforming from Qi Mechanism Stagnation is easy to understand. So, how can Qi Deficiency lead to Qi Stagnation? This is often difficult to understand. The Qi of the human body is constantly running; only with continuous ascending, descending, entering, and exiting of the Qi Mechanism does vitality continue; if there is stagnation, disease arises, and if it stops, life ends. The ascending, descending, entering, and exiting of Qi in the Zang-Fu organs takes the Qi Mechanism of the Middle Jiao Spleen and Stomach as the pivot. Spleen governs ascending Clear Qi, Stomach governs descending Turbid Qi; the mechanism of ascending, descending, entering, and exiting relies most on the Spleen and Stomach. If diet is irregular, labor excessive, damaging the Spleen and Stomach, leading to Spleen-Stomach Qi Deficiency, impaired transportation and transformation, when things should ascend they do not ascend, when things should descend they do not descend, Qi Mechanism becomes sluggish, stagnates, and generates Heat. Then, Qi Stagnation is Excess, how can Qi Deficiency lead to Qi Stagnation? The Qi and Blood of humans are like river water. When water volume is vast, it rushes forward rapidly, how can there be stagnation? Once water volume decreases, or even dries up, pushing force is weak, flow becomes sluggish, and accumulation occurs everywhere. Hence it is said, "The reason Qi moves is because Qi is vigorous; the reason Qi stagnates is because Qi is deficient." It is also said, "Human Qi and Blood are like water; when abundant, it flows freely; when deficient, stagnation is rare to avoid."

Doctor Bing: Qi Deficiency Fever should be treated with tonifying Qi methods. There are many formulas for tonifying Qi, why is Bu Zhong Yi Qi Tang the main formula?

Teacher: For Qi Deficiency Fever, any formula primarily tonifying Qi can be considered. The reason Bu Zhong Yi Qi Tang is the main formula is, first, because it focuses on lifting and tonifying Spleen Qi; second, because its action includes lifting and dispersing within tonification. Essentially, Qi is tonified by smooth movement. Tonifying deficiency and venting stagnation constitutes good Qi tonification. Moreover, this syndrome is caused by Deficiency leading to Stagnation!

Vomiting for 2 Months

Director Yu Guojun, TCM Research Office, People's Hospital of Leshan City, Sichuan Province