老师：方中所加的葛根、水蛭、川芎、荷叶4味药，对此病起着举足轻重的作用，虽为治标之品，然与补虚固本之剂起着相辅相成的作用。葛根据传统治疗"头项强痛"(张仲景)的经验，现代药理研究证实，葛根具有扩张血管，解除血管痉挛，降低血压，祛除瘀滞，调畅血行的作用。故有人将葛根移作活血药应用于临床疗效卓然。所以凡头、项血运不畅的脑部、颈项、颈椎的病变皆可用之。有人报道葛根30g加入辨证施治方中治疗脑血流图异常，有明显作用。对于脑血栓形成、偏头痛、颈椎骨质增生症等皆有治疗作用。本案中就取用葛根的这种特殊性，而葛根又有升阳上达的功效，能升提中气，有助于补气养血之品上荣脑部。水蛭为笔者常用之晶，该品虽历代中药专著中认作有毒，但据临床实践证明，不但无毒，且有"血肉有情"之功；其活血破瘀之力甚著，能在多种疾病中配伍应用，张锡纯认为"破瘀血而不伤新血"，"纯系水之精华生成，故最宜生用，甚忌火炙"，笔者甚为赞赏；本品除祛瘀外，尚有利水化瘀之功，因此是痰瘀同治之佳品，为高血脂、肺心病、老慢性支气管炎、脑血管病均可配伍应用，丝毫无毒，放胆用之!荷叶升清降浊，古有清震汤，能降脂杜痰，对老年性代谢障碍之心脑血管病可随症加用，此晶最宜用鲜品，有清香悦脾，芳香醒脑之功。川芎，古有"头痛用川芎"之说，能直趋灵虚，王清任之通瘀活血汤也用川芎之趋脑之性，最大剂量可用15～30g，但因此药辛渴偏燥，故量大时需配滋润之品，如制首乌、杞子之属。
学生丙患者经治月余，已见效验，何以老师还要灸百会，请释其义。
老师："病久入络"，"久病致虚"，对于慢性病，必须时时认识这两方面的变化。灸百会通过经络的作用达到升提元气的目的。据报道，灸百会可治各种虚性眩晕。笔者经验，在70年代曾治70岁老妇贫血性眩晕，用单纯灸百会而痊。当时山区缺医少药，经济贫困，对于因气血不足所致眩晕，用补气养血之剂，条件不许可，因此用灸百会收到同样效果。故由鉴于此，配合灸百会以增强疗效，调节自身抗病能力。同时于慢性、久治不愈的痼疾，笔者重视中医的综合性治疗，开拓临床思路，如内病外治，针药配合，食养食疗，气功疗法，心理治疗等，灸百会也是出于此种治疗思路。百会穴除治疗眩晕外，还可治疗小儿脱肛，妇女子宫脱垂，痔疮出血等人体下部病变，即所谓"下病上治"之意；百会有补虚强壮的作用，上述诸症皆因气血不足所致病证；灸百会最有效是用艾绒直接灸，次数越多越有效，但以能忍耐为度。若不耐疼痛，可用穴位药贴方法，取斑蝥1只研细，调敷穴上，同样能发泡刺激穴位。这些方法都是临床用之确凿的疗法，且药简效宏，值得提倡。
湖南中医学院教授熊继柏
患者，女，50岁。1986年5月就诊。患者自诉：1970年间，其家庭生活条件艰苦，饮食生冷饥饱无节，遂患泄泻兼腹痛的病证，持续发作达半年之久，经多方治疗始愈。但不久后或遇天气骤变，或饮食过饱，或食辛辣之物，或进生冷及油腻之晶，则必触发，发则大便泄泻，腹中胀痛。延医用药，多为黄连素、氯霉素之类，服后痛泄即可控止。然仅过旬日又发，如此数年，其发作愈加频繁，每月约发3～4次，春夏秋冬几乎无有间断，不得不经常自备黄连素、香连丸等随身携带服用。并先后5次住院治疗，其间也曾多次请中医治疗，亦未获显效。今年入夏以来，症状明显加重，大便泄泻，每日轻则3～4次，重则7～8次，自觉大腹胀满，隐隐作痛，每于食后胀痛明显，欲其转矢气而胀痛才得以松缓，并且泻而不爽，所下稀便稠粘，每便之后都要刷洗厕池，其粪始去。曾去医院做过数次大便检验，均未发现痢疾杆菌。患者饮食日见减少，精神日见衰弱，口中时苦时腻，脘腹时觉痞满，嗳气、矢气常作。视患者，其大腹较为胀满，按之觉痛，形体颇瘦，舌红苔垢腻而黄滑，脉滑。据脉症分析：病属湿热挟积滞的泄泻腹痛证，治必清其湿热，去其积滞，方可止其泻，除其痛，乃拟木香导滞丸加厚朴，做汤剂服之。处方：广木香6g，槟榔10g，大黄6g，枳实(麸炒)15g，神曲15g，茯苓10g，白术(炒)10g，泽泻6g，黄连5g，黄芩6g，厚朴10g。嘱服5剂。次诊：患者自诉服药后便泻爽快，次数减少，每日2-3次，腹中胀痛明显减轻。察其舌腻苔亦已减退，其脉仍滑。药已对证，施以原法原方，再进5剂。三诊：泄泻基本控制，大便时溏，腹中已不觉胀痛，饮食增进，舌苔转为薄腻，脉滑。取效明显，可望根治，乃拟原方做丸剂，缓缓服之。处方：广木香30g，槟榔60g，枳实60g，大黄30g，茯苓60g，泽泻30g，厚朴60g，白术60g，黄芩40g，黄连30g，神曲60g。合碾细末，和蜜为丸如黄豆大，每服20-30丸，早晚用开水送服。约服月余，其泄泻腹痛基本痊愈。四诊：时过半年，病人复来求诊，谓泄泻腹痛之病并未复发，但逢饮食稍多之后，便觉腹中微微胀闷不舒，大便或时而溏泻1-2次。视其舌红苔薄腻，脉缓。此乃脾气尚虚，滞犹未尽之征，改拟岳氏加减资生丸，仍制丸剂服之。处方：党参50g，炒白术50g，茯苓50g，甘草20g，砂仁30g，陈皮30g，桔梗30g，扁豆50g，怀山药50g，莲子肉30g，薏苡仁50g，芡实50g，炒麦芽50g，神曲50g，炒山楂50g，鸡内金50g，白豆蔻30g，藿香30g，黄连20go又过半年，患者约见，谢曰，"病已痊愈，未见复发"。数年后余复追访，言其病确未再发。其人精神饱满，饮食正常，大便正常。10余年的痼疾得以根治。
医生甲此病属久泻，老师为何不考虑它是虚证，却断定它是实证?
老师："暴泻多实，久泻多虚"，这是指一般情况而言。若患者素体不足，虽非久泻，亦可为虚证；或暴泻过度，造成津脱阳衰，更为虚证。又若久泻患者，虽则体质已虚，但却感受邪气，伤于饮食，邪留不去，则为实证；或虽久泻，而腹中宿有积滞未去，亦为实证。因此泄泻不论新久，皆有虚实之辨，绝不可一概而论。泄泻而兼腹痛，其病位显然在肠胃，(内经)指出"六府者，传化物而不藏"。以肠胃言，则主司食物的传导乃致糟粕的传泄。如果传导失职，不通则病，故凡肠胃间病，诸如呕吐、泄泻、腹痛等疾，即使病程颇久，亦不可忽视实证。奉患者泄泻已达10余年，无疑正气亏虚，故尔形瘦体倦。然其症见腹中胀痛，按之不舒，反欲矢气得缓，且大便泄而不爽，挟带粘液，这些都是实象。尤其是舌苔垢腻而黄滑，更表明腹中定有湿热、积滞。<医门棒喝)所谓"凡苔垢黄滑者，湿热也"。又泄泻脉滑，亦属实象，朱丹溪曾谓，"下利脉反滑，当有所去，下之安"。由于患者表现了这些实证特点，所以尽管他是久泻，也要断定为实证。
医生乙久泻病证，每多缠绵反复而不易治愈，请老师谈谈其辨证要点。
老师：辨治久泻，最要紧的有两点：第一，要审察虚实。一般而言，虚证中常见的有脾虚证、肾虚证及肝郁脾虚证。脾虚证表现大便溏泻，迁延反复，所下食物不化，伴食少体倦，食后脘腹满闷不舒，稍食油腻或稍事劳累则泄泻加重，面黄，舌淡，脉细。治当健脾益气，可用参苓白术散之类(处方略)。肾虚证表现形寒肢冷，腰膝酸软而泄泻多在黎明前后，舌淡苔白，脉沉细，治宜温肾固涩，用四神丸之类(处方略)。肝郁脾虚证表现泄泻而脘胁或胁腹部胀痛，暧气矢气，其泄每随情志郁怒而加重，苔薄，脉弦。治宜抑肝扶脾，用痛泻要方之类(处方略)。久泻中的实证，常见的有湿邪停滞证和宿积不化证。湿邪停滞证又有湿热、寒湿之分：湿热证表现泄下物稠粘如酱、或挟粘液，腹中痞满，小便黄，舌苔黄腻，治以王氏连朴饮之类(处方略)。寒湿证表现泄下物清稀，腹部冷痛，小便清，舌苔白滑厚腻，治以胃苓汤之类。宿积不化证具有泄泻反复迁延，每与饮食相关，腹中胀痛不休，泻下物多腐臭之气，舌苔垢腻，脉滑有力等特点，治宜消积导滞，可用枳实导滞汤合保和丸之类(处方略)。第二，要注意兼挟证。临床所见，凡久泻不愈者，多为兼挟证。如脾虚挟湿证，脾虚挟滞证，脾虚气陷证，脾肾两虚证，湿热兼积滞证等，而此类证侯较之单纯的虚证、实证则尤为多见。脾虚挟湿证：表现大便溏泻，反复不愈，腹胀，食不化，四肢倦怠，舌苔白腻等特点，治宜健脾祛湿，可用四君子汤合平胃散加淮山药、苡米之类(处方略)。脾虚挟滞证：表现便泻时发时止，极易为饮食不节所触发，脘腹胀闷不舒，四肢倦怠，食欲不佳，泄泻时挟有不消化食物，常觉暧腐吞酸以及舌苔腻等特点，治宜健脾化积，可用岳美中加减资生丸之类(党参、白术、茯苓、山药、苡米、莲子、芡实、陈皮、甘草、炒麦芽、神曲、山楂、白蔻、藿香、砂仁、桔梗、扁豆、黄连)。脾虚气陷证：表现大便溏泻，遇劳则甚，食欲不振，一身酸困乏力，甚则肛门坠胀，舌淡，脉虚缓等特点，治宜升阳健脾，可用升阳益胃汤加减(党参、黄芪、白术、陈皮、法夏、茯苓、甘草、黄连、泽泻、防风、葛根、柴胡、薄荷)。脾肾两虚证：久泻不止，反复发作，常见完谷不化，每于五更时脐腹作痛，肠鸣泄泻，伴食少体倦，腹中冷痛，腰膝酸软，畏寒肢冷，舌淡苔白，脉沉细等特点，治宜温补脾肾，可用理中汤合四神丸之类(处方略)。湿热兼积滞证：表现泄泻兼腹痛腹胀，腹部按之不舒，泻而不爽，并挟粘液，舌苔黄厚腻，脉滑等特点，治宜清湿热、导积滞，可用木香导滞丸之类(本病例即属此类)。总之，治疗久泻，必须注意其兼证特点，辨别虚实，分清主次。《谦斋医学讲稿》中说过一段话，"腹泻的原因不一，从本质分析不外二类：虚证属于内伤，浅者在脾，深者及肾；实证属于病邪，以湿为主，结合寒邪和热邪以及食滞等。根据病因病机，分别使用化湿、分利、疏散、泄热、消导、调气等多系泻法；健脾、温肾、益气、升提、固涩等多系补法。泻法中可以兼用补法，补法中也能兼用泻法，同时与其他治法互相结合，均须分清主次"。此话很有道理。此外，久泻之病，还须注意饮食宜忌。若饮食不节，生冷无忌，即使方药对证，亦难奏良效。《难经》所谓"损其脾者，调其饮食，适其寒温"，这一原则，对于久泻尤为重要。
老师：木香导滞丸功在消导积滞，清利湿热。《松崖医经》谓，"木香导滞丸，……用治伤湿热之物，不得消化，痞满闷乱不安者"。《医方集解》又谓，"木香导滞丸，……此足太阴阳明药也。饮食伤滞，作痛作积，非有以推荡之，积滞不尽，病终不除。故以大黄、枳实攻下之，而痛泻反止，经所谓通因通用也。伤由湿热，黄芩黄连佐之以清热；茯苓泽泻佐之以利湿。积由酒食，神曲蒸窨之物，化食解酒，因其同类，温而消之。芩连大黄，苦寒太甚，恐其伤胃，故又以白术之甘温，补土而固中也"。由是可见，木香导滞丸用治泄泻，法在通利去邪，因势利导，故其泄泻不论久暂，一定具有湿热、积滞的证侯特点，一定属于实证。要知湿热挟滞胶着肠道，并非一次性攻下就可以使邪气尽去，故诸承气汤皆非所宜。当以缓缓荡涤之法，持续服药，以俟邪去而正安，方可图其根治。《金匮翼》云，"久泻不止，百药不效，或暂止而复来，此必有陈积在肠胃之间。积一日不去，则泻一日不愈，必先逐去陈积而复补之，庶几获益"。
专方专药治口苦
四川省乐山市人民医院中医研究室主任余国俊
案1周X，男，61岁，1985年10月5日初诊。患者口苦约半年，未尝介意。半月前饮酒过多，口苦加重，夜卧尤甚，而辗转难寐。前医曾予小柴胡汤加焦栀、知母、夏枯草3剂，口苦稍减；又换服龙胆泻肝汤3剂，仍无显效。舌质红苔薄黄，脉弦细略数。此为单纯性口苦，病名曰"胆瘅"。予简裕光老中医自拟"柴胆牡蛎汤"加味：柴胡log，胆草log，生牡蛎30g，葛根30g，生甘草6g。2剂。效果：服头煎后约丑小时，口苦大减；服完1剂，口苦消失，夜寐亦安o1个月后因饮酒啖辛辣，口苦复发，乃取上次所余之药煎服，亦尽剂而口苦消失。几年来口苦偶尔复发，均照服本方1～2剂而安。
Teacher: The four herbs added to the prescription—Puerariae Radix (Gegen, 葛根), Hirudo (Shuizhi, 水蛭), Chuanxiong Rhizome (Chuanxiong, 川芎), and Nelumbinis Folium (Heye, 荷叶)—play a pivotal role in treating this disease. Although they are primarily for treating symptoms (biao, 标), they complement the decoctions that tonify deficiency and consolidate the root (ben, 本). Based on Zhang Zhongjing's experience in treating "stiffness and pain of the head and neck" (Tou Xiang Qiang Tong, 头项强痛), modern pharmacological research confirms that Puerariae Radix has the effects of dilating blood vessels, relieving vascular spasms, lowering blood pressure, removing blood stasis, and promoting smooth blood circulation. Therefore, some clinicians use Puerariae Radix as a blood-invigorating herb with remarkable clinical efficacy. Thus, it can be used for lesions of the brain, neck, and cervical spine caused by poor blood circulation in the head and neck. Reports indicate that adding 30g of Puerariae Radix to a syndrome-differentiated prescription effectively treats abnormal cerebral blood flow graphs. It also has therapeutic effects on cerebral thrombosis, migraine, and cervical spondylosis. In this case, we utilize this specific property of Puerariae Radix. Furthermore, Puerariae Radix has the function of raising yang qi and ascending upwards; it can lift middle qi, thereby assisting blood-tonifying and qi-nourishing herbs to nourish the brain.
Hirudo is a herb commonly used by me. Although traditional Chinese materia medica texts consider it toxic, clinical practice proves it is non-toxic and possesses the merit of being a "flesh-and-blood sentient substance" (Rou Xue You Qing, 血肉有情), meaning animal-derived substances have the ability to replenish human essence and blood. Its power to invigorate blood and break up stasis is significant, allowing its compatibility in various diseases. Zhang Xichun believed it "breaks up blood stasis without damaging new blood," and since it is "purely generated from the essence of water, it is best used raw and strongly advises against roasting." I highly appreciate this view. Besides removing stasis, this herb also promotes diuresis and resolves stasis, making it an excellent choice for simultaneously treating phlegm and stasis. It can be combined in the treatment of hyperlipidemia, cor pulmonale, chronic bronchitis, and cerebrovascular diseases without any toxicity; use it boldly! Nelumbinis Folium raises clear yang and descends turbid yin. The ancient formula Qingzhen Tang uses it to lower lipids and resolve phlegm. It can be added symptomatically for cardiovascular and cerebrovascular diseases caused by metabolic disorders in the elderly. This herb is best used fresh, possessing the properties of refreshing the spleen with its fragrance and awakening the brain. Chuanxiong Rhizome follows the ancient saying "use Chuanxiong for headaches"; it directly targets the brain. Wang Qingren's Tongyu Huoxue Tang also utilizes Chuanxiong's affinity for the brain. The maximum dose can be 15–30g. However, because this herb is acrid, dry, and slightly drying, when used in large doses, it should be combined with moistening herbs such as Prepared Polygoni Multiflori Radix (Zhi Shouwu, 制首乌) and Lycii Fructus (Qizi, 枸杞子).
Student Bing: The patient has shown improvement after more than a month of treatment. Why does the teacher still recommend moxibustion at Baihui (DU20)? Please explain the rationale.
Teacher: "Long-standing diseases enter the collaterals" (Bing Jiu Ru Luo, 病久入络), and "chronic diseases lead to deficiency" (Jiu Bing Zhi Xu, 久病致虚). For chronic diseases, one must constantly recognize these two aspects of change. Moxibustion at Baihui (DU20) achieves the purpose of lifting primordial qi through the meridian system. Reports indicate that moxibustion at Baihui (DU20) can treat various types of vertigo due to deficiency. My experience includes treating a 70-year-old woman with anemia-induced vertigo in the 1970s using only moxibustion at Baihui (DU20), resulting in a cure. At that time, the mountainous area lacked medical resources and was economically impoverished. For vertigo caused by qi and blood deficiency, the conditions did not permit the use of decoctions to tonify qi and blood. Therefore, moxibustion at Baihui (DU20) achieved the same effect. Given this, combining moxibustion at Baihui (DU20) enhances efficacy and regulates the body's own resistance. Additionally, for chronic, stubborn diseases that are difficult to cure, I emphasize comprehensive TCM treatment and broaden clinical approaches, such as treating internal diseases externally, combining acupuncture and herbal medicine, dietary therapy, qigong, and psychotherapy. Moxibustion at Baihui (DU20) stems from this therapeutic philosophy. Besides treating vertigo, Baihui (DU20) can also treat lower-body lesions such as pediatric rectal prolapse, uterine prolapse in women, and hemorrhoidal bleeding, embodying the principle of "treating lower diseases from above" (Xia Bing Shang Zhi, 下病上治). Baihui (DU20) has the effect of tonifying deficiency and strengthening the body; all the aforementioned conditions are caused by qi and blood deficiency. The most effective method for moxibustion at Baihui (DU20) is direct moxibustion with moxa wool; the more sessions, the better, provided the patient can tolerate it. If pain is intolerable, one can use herbal patching on acupoints: grind one Blister Beetle (Banmao, 斑蝥) into fine powder, mix it, and apply it to the acupoint to induce blistering and stimulate the point. These are clinically proven methods with simple prescriptions and potent effects, worthy of promotion.
Diarrhea and abdominal pain recurring for over 10 years
Professor Xiong Jibo, Hunan College of Traditional Chinese Medicine
Patient: Female, 50 years old. Consulted in May 1986. Patient reported: In 1970, due to harsh living conditions and irregular diet involving cold/raw foods and alternating hunger/fullness, she developed diarrhea accompanied by abdominal pain, which persisted for half a year before resolving with various treatments. However, shortly thereafter, exposure to sudden weather changes, overeating, spicy foods, or cold/greasy foods would trigger relapses, characterized by loose stools and distending pain in the abdomen. Medical treatment mostly involved Berberine Hydrochloride or Chloramphenicol, which controlled the pain and diarrhea temporarily. Yet, relapses occurred within ten days. Over several years, the frequency increased to 3–4 times per month, almost continuously throughout the seasons. She had to carry Berberine Hydrochloride and Xianglian Wan (Coptis Pill) with her at all times. She was hospitalized five times and sought TCM treatment multiple times without significant effect. Since early summer this year, symptoms worsened significantly: diarrhea occurring 3–4 times daily on mild days and 7–8 times on severe days. She felt significant abdominal fullness and dull pain, worsening after meals, relieved only by passing flatus. The stool was loose but sticky and difficult to pass completely, requiring scrubbing of the toilet bowl after each bowel movement. Several stool tests at the hospital failed to detect dysentery bacilli. Her appetite decreased, and her spirit waned. Her mouth tasted bitter and greasy intermittently, and she felt epigastric and abdominal stuffiness. Belching and passing flatus were frequent. Examination revealed a distended abdomen tender to palpation, emaciation, red tongue with greasy yellow-slippery coating, and slippery pulse. Analysis of pulse and symptoms indicated diarrhea and abdominal pain due to damp-heat complicated by food stagnation. Treatment required clearing damp-heat and removing stagnation to stop diarrhea and relieve pain. Thus, Muxiang Daoshi Wan (Aucklandia Pill for Guiding Out Stagnation) modified with Magnoliae Officinalis Cortex (Houpo, 厚朴) was prescribed as a decoction. Prescription: Aucklandiae Radix (Guang Muxiang, 广木香) 6g, Arecae Semen (Binglang, 槟榔) 10g, Rhei Radix et Rhizoma (Dahuang, 大黄) 6g, Aurantii Fructus (Zhishi, 枳实) stir-baked with bran 15g, Massae Fermentatae Medicinales (Shenqu, 神曲) 15g, Poria (Fuling, 茯苓) 10g, Atractylodis Macrocephalae Rhizoma (Baizhu, 白术) stir-fried 10g, Alismatis Rhizoma (Zexie, 泽泻) 6g, Coptidis Rhizoma (Huanglian, 黄连) 5g, Scutellariae Radix (Huangqin, 黄芩) 6g, Magnoliae Officinalis Cortex (Houpo, 厚朴) 10g. Instruction: Take 5 doses.
Second Visit: Patient reported that after taking the medicine, bowel movements became smoother, frequency reduced to 2–3 times daily, and abdominal distending pain significantly alleviated. The greasy tongue coating had receded, and the pulse remained slippery. The prescription matched the syndrome. Continue the original method and prescription for another 5 doses.
Third Visit: Diarrhea was basically controlled; stools were occasionally soft, no abdominal pain, appetite improved, tongue coating turned thin-greasy, pulse slippery. Significant effect observed, expecting a radical cure. Prepare the original prescription as pills for slow administration. Prescription: Aucklandiae Radix (Guang Muxiang, 广木香) 30g, Arecae Semen (Binglang, 槟榔) 60g, Aurantii Fructus (Zhishi, 枳实) 60g, Rhei Radix et Rhizoma (Dahuang, 大黄) 30g, Poria (Fuling, 茯苓) 60g, Alismatis Rhizoma (Zexie, 泽泻) 30g, Magnoliae Officinalis Cortex (Houpo, 厚朴) 60g, Atractylodis Macrocephalae Rhizoma (Baizhu, 白术) 60g, Scutellariae Radix (Huangqin, 黄芩) 40g, Coptidis Rhizoma (Huanglian, 黄连) 30g, Massae Fermentatae Medicinales (Shenqu, 神曲) 60g. Grind into fine powder, mix with honey to form pills the size of soybeans. Take 20–30 pills morning and evening with warm water. After about a month, diarrhea and abdominal pain were basically cured.
Fourth Visit: Half a year later, the patient returned, stating that diarrhea and abdominal pain had not recurred. However, after eating slightly too much, she felt slight abdominal bloating and discomfort, with occasional loose stools 1–2 times. Tongue was red with thin-greasy coating, pulse slow. This indicates remaining spleen qi deficiency and incomplete resolution of stagnation. Prescribe Yue's Modified Zisheng Wan (Yue Shi Jiajian Zisheng Wan, 岳氏加减资生丸), prepared as pills. Prescription: Codonopsis Radix (Dangshen, 党参) 50g, Atractylodis Macrocephalae Rhizoma (Baizhu, 白术) stir-fried 50g, Poria (Fuling, 茯苓) 50g, Glycyrrhizae Radix et Rhizoma (Gancao, 甘草) 20g, Amomi Fructus (Sharen, 砂仁) 30g, Citri Reticulatae Pericarpium (Chenpi, 陈皮) 30g, Platycodonis Radix (Jiegeng, 桔梗) 30g, Dolichoris Semen (Biandou, 扁豆) 50g, Dioscoreae Rhizoma (Huai Shanyao, 怀山药) 50g, Lotus Seed (Lianzi Rou, 莲子肉) 30g, Coicis Semen (Yiyiren, 薏苡仁) 50g, Euryales Semen (Qianshi, 芡实) 50g, Malto stir-fried (Chaoyamai, 炒麦芽) 50g, Massae Fermentatae Medicinales (Shenqu, 神曲) 50g, Crataegi Fructus stir-fried (Chao Shanzha, 炒山楂) 50g, Gallus Gigerium Endothelium Corneum (Jineijin, 鸡内金) 50g, Cardamomi Fructus (Baidoukou, 白豆蔻) 30g, Pogostemonis Herba (Huoxiang, 藿香) 30g, Coptidis Rhizoma (Huanglian, 黄连) 20g. Six months later, the patient met again, thanking me, saying, "The disease is cured, no recurrence." Years later, upon follow-up, she confirmed no recurrence. She was energetic, ate normally, and had normal bowel movements. The stubborn disease of over 10 years was radically cured.
Doctor Jia: This disease is chronic diarrhea. Why did the teacher not consider it a deficiency syndrome but diagnosed it as an excess syndrome?
Teacher: "Acute diarrhea is mostly excess, chronic diarrhea is mostly deficiency" refers to general situations. If a patient has inherent constitution weakness, even acute diarrhea can be a deficiency syndrome; or if acute diarrhea is excessive, leading to fluid loss and yang collapse, it is definitely a deficiency syndrome. Conversely, if a chronic diarrhea patient, despite a deficient constitution, contracts pathogenic factors or suffers from dietary injury, and the pathogen remains, it is an excess syndrome; or even with chronic diarrhea, if there is old stagnation in the abdomen, it is also an excess syndrome. Therefore, whether new or old, diarrhea requires differentiation between excess and deficiency; it cannot be generalized. Diarrhea accompanied by abdominal pain clearly indicates the pathology is in the intestines and stomach. The *Neijing* states, "The six fu organs transmit and transform substances without storing them." Regarding the intestines and stomach, their function is to conduct food and excrete waste. If conduction fails, obstruction leads to disease. Thus, for intestinal and gastric diseases such as vomiting, diarrhea, and abdominal pain, even if the course is long, one must not ignore excess syndromes. This patient has suffered from diarrhea for over 10 years, undoubtedly indicating righteous qi deficiency, hence emaciation and fatigue. However, her symptoms include abdominal distending pain, discomfort upon pressure, relief after passing flatus, unsmooth defecation with mucus—all signs of excess. Especially the greasy, yellow-slippery tongue coating further confirms damp-heat and stagnation in the abdomen. As stated in *Yimen Banghe*, "Whenever the tongue coating is greasy, yellow, and slippery, it indicates damp-heat." Furthermore, a slippery pulse in diarrhea also indicates excess. Zhu Danxi once said, "If the pulse is slippery in dysentery/diarrhea, there is something to remove; purging will bring peace." Since the patient exhibited these characteristics of an excess syndrome, despite the chronic nature, it must be diagnosed as an excess syndrome.
Doctor Yi: Chronic diarrhea often lingers and recurs, making it difficult to cure. Please discuss the key points of syndrome differentiation.
Teacher: There are two crucial points in differentiating and treating chronic diarrhea: First, examine excess and deficiency. Generally, common deficiency syndromes include Spleen Qi Deficiency, Kidney Yang Deficiency, and Liver Stagnation with Spleen Deficiency. Spleen Qi Deficiency presents with loose stools, prolonged course, undigested food in stool, poor appetite, fatigue, postprandial abdominal fullness, worsening with greasy food or exertion, sallow complexion, pale tongue, and fine pulse. Treatment should strengthen the spleen and benefit qi, using Shenling Baizhu San (Poria and Atractylodes Macrocephala Powder) etc. Kidney Yang Deficiency presents with aversion to cold, cold limbs, soreness and weakness of waist and knees, diarrhea around dawn, pale tongue with white coating, and deep-fine pulse. Treatment should warm the kidney and secure astringency, using Sishen Wan (Four Spirits Pill) etc. Liver Stagnation with Spleen Deficiency presents with diarrhea accompanied by hypochondriac or abdominal distending pain, belching, and flatus, worsening with emotional depression or anger, thin coating, and wiry pulse. Treatment should soothe the liver and support the spleen, using Tongxie Yaofang (Essential Formula for Painful Diarrhea) etc. Common excess syndromes in chronic diarrhea include Dampness Stagnation and Food Stagnation. Dampness Stagnation divides into Damp-Heat and Cold-Damp. Damp-Heat presents with thick, sticky, sauce-like stool or mucus, abdominal fullness, yellow urine, yellow-greasy tongue coating. Treatment uses Wangshi Lianpo Yin (Wang's Coptis and Magnolia Decoction) etc. Cold-Damp presents with clear, watery stool, cold abdominal pain, clear urine, white-slippy-thick coating. Treatment uses Weiling Tang (Stomach and Poria Decoction) etc. Food Stagnation presents with recurrent diarrhea related to diet, continuous abdominal distending pain, foul-smelling stool, greasy tongue coating, and forceful slippery pulse. Treatment should eliminate stagnation and guide it out, using Zhishi Daoshi Tang combined with Baohe Wan (Preserve Harmony Pill) etc. Second, pay attention to complicated syndromes. Clinically, persistent chronic diarrhea is often a complicated syndrome, such as Spleen Deficiency with Dampness, Spleen Deficiency with Stagnation, Spleen Qi Sinking, Spleen-Kidney Dual Deficiency, and Damp-Heat with Stagnation. These are more common than pure deficiency or excess. Spleen Deficiency with Dampness: loose stools, persistent, abdominal distension, indigestion, limb fatigue, white-greasy coating. Treatment strengthens spleen and dispels dampness, using Sijunzi Tang combined with Pingwei San plus Chinese Yam and Coix Seed etc. Spleen Deficiency with Stagnation: intermittent diarrhea easily triggered by improper diet, epigastric/abdominal fullness, limb fatigue, poor appetite, undigested food in stool, sour belching, greasy coating. Treatment strengthens spleen and transforms accumulation, using Yue Meizhong's Modified Zisheng Wan etc. Spleen Qi Sinking: loose stools worsening with exertion, poor appetite, whole-body soreness and fatigue, anal bearing-down sensation, pale tongue, weak-slow pulse. Treatment raises yang and strengthens spleen, using Shengyang Yiewei Tang modified etc. Spleen-Kidney Dual Deficiency: persistent diarrhea, recurrent, undigested food, umbilical/abdominal pain and borborygmus at dawn, poor appetite, fatigue, cold abdominal pain, sore waist/knees, aversion to cold, pale tongue with white coating, deep-fine pulse. Treatment warms and tonifies spleen and kidney, using Lizhong Tang combined with Sishen Wan etc. Damp-Heat with Stagnation: diarrhea with abdominal pain/distension, discomfort on pressure, unsmooth defecation with mucus, yellow-thick-greasy coating, slippery pulse. Treatment clears damp-heat and guides out stagnation, using Muxiang Daoshi Wan etc. In summary, treating chronic diarrhea requires attention to complicated features, distinguishing excess and deficiency, and prioritizing main and secondary aspects. *Qianzhai Yixue Jiangao* states: "Causes of diarrhea vary, essentially two categories: deficiency belongs to internal injury, shallow in spleen, deep in kidney; excess belongs to pathogenic factors, mainly dampness, combined with cold, heat, and food stagnation. Based on etiology and pathogenesis, use damp-resolving, separating and draining, dispersing, clearing heat, digesting, and regulating qi as purging methods; strengthen spleen, warm kidney, benefit qi, raise, and secure as tonifying methods. Purging methods can combine tonification, and tonification can combine purging, along with other therapies, always distinguishing priority." This is very reasonable. Additionally, for chronic diarrhea, dietary precautions are essential. If diet is irregular or cold/raw foods are consumed indiscriminately, even a correct prescription may fail. As stated in *Nanjing*, "For those who damage the spleen, regulate their diet and adjust to temperature changes." This principle is particularly important for chronic diarrhea.
Doctor Bing: Muxiang Daoshi Wan is a mild purgative. What principles should be mastered when using it clinically for diarrhea?
Teacher: Muxiang Daoshi Wan functions to digest stagnation and clear damp-heat. *Songya Yijing* states, "Muxiang Daoshi Wan... is used for injuries from damp-heat substances that cannot be digested, causing fullness, oppression, and restlessness." *Yifang Jijie* adds, "Muxiang Daoshi Wan... acts on the Foot Taiyin and Yangming meridians. Dietary injury and stagnation cause pain and accumulation; without pushing it out, stagnation remains, and the disease persists. Thus, using Rhei Radix et Rhizoma and Aurantii Fructus to purge stops pain and diarrhea, illustrating the classic principle of 'treating obstruction with draining' (Tong Yin Yong Tong, 通因通用). Injury from damp-heat is assisted by Scutellariae Radix and Coptidis Rhizoma to clear heat; Poria and Alismatis Rhizoma assist in draining dampness. Accumulation from wine and food, Massae Fermentatae Medicinales is fermented, transforming food and resolving wine; using similar substances, it is warmed and digested. Scutellariae, Coptidis, and Rhei are too bitter and cold, fearing stomach damage, so Atractylodis Macrocephalae Rhizoma's sweet and warm nature tonifies earth and secures the center." Thus, Muxiang Daoshi Wan treats diarrhea by promoting drainage and eliminating pathogens, following the trend. Therefore, regardless of duration, diarrhea treated with this formula must exhibit characteristics of damp-heat and stagnation, belonging strictly to excess syndromes. Know that damp-heat and stagnation adhering to the intestines cannot be cleared by a single purgation; thus, Chengqi Decoctions are not suitable. One should use a gradual cleansing method, continuous medication, waiting for pathogens to leave and righteous qi to recover, before aiming for a radical cure. *Jinkui Yi* says, "Persistent diarrhea unresponsive to hundreds of medicines, or stopping temporarily then returning, must have old accumulation in the intestines and stomach. If accumulation remains one day, diarrhea continues one day; first eliminate old accumulation, then tonify, to gain benefit."
Special Formulas and Herbs for Treating Bitter Taste in Mouth
Yu Guojun, Director of TCM Research Office, Leshan People's Hospital, Sichuan Province
Case 1: Zhou X, Male, 61 years old. Initial consultation October 5, 1985. Patient had bitter taste in mouth for about half a year, ignoring it. Half a month ago, excessive drinking worsened the bitter taste, especially at night, causing insomnia. Previous doctor prescribed Xiaochaihu Tang (Minor Bupleurum Decoction) plus scorched Gardenia, Anemarrhenae Rhizoma, and Prunellae Spica for 3 doses; bitter taste slightly reduced. Then switched to Longdan Xiegan Tang (Gentian Liver-Draining Decoction) for 3 doses, still no significant effect. Red tongue body with thin-yellow coating, wiry-fine-slightly-rapid pulse. This is simple bitter taste in mouth, named "Dan Dan" (Gallbladder Heat). Prescribed Old TCM Practitioner Jian Yuguang's self-formulated "Chai Dan Mu Li Tang" (Bupleurum, Gentian, and Oyster Shell Decoction) modified: Bupleuri Radix (Chaihu, 柴胡) 10g, Gentianae Radix (Dan Cao, 胆草) 10g, Ostreae Concha (Sheng Muli, 生牡蛎) 30g, Puerariae Radix (Gegen, 葛根) 30g, Glycyrrhizae Radix et Rhizoma (Sheng Gancao, 生甘草) 6g. 2 doses. Effect: About 12 hours after the first decoction, bitter taste greatly reduced; after finishing 1 dose, bitter taste disappeared, sleep normalized. One month later, due to drinking and eating spicy food, bitter taste recurred. Used remaining medicine from previous prescription, finished the dose, and bitter taste disappeared. In recent years, occasional recurrences of bitter taste were resolved by taking 1–2 doses of this formula.