老师：虚劳是以脏腑元气亏损、精血不足为主要病理过程的一类慢性虚衰性病证的总称。该病人具有五脏阴阳气血皆虚的证侯，根据"中医虚证辨证参考标准"可诊断为虚劳。病人易感冒、气短、神疲乏力、脉虚无力为肺气虚证侯；自觉心悸、少寐、面色皓白、唇甲苍白、舌质淡为心血虚证侯；头晕目眩、双目干涩、手足心热、腰膝酸软、脉细数、舌无苔均为肝肾阴虚证侯。不思饮食、形寒肢冷、面部及足部虚浮、腰酸痛为脾肾阴虚证侯。该病人素体虚弱，多育，久病失养渐至元气亏损，精血虚少，脏腑机能衰退，以致气血生化之源不足，因此虚劳的基本病机是脏腑的气虚、血虚、阴虚、阳虚。发展过程中常形成五脏交亏、相互传变的病机变化，但以脾肾为主导环节。
学生甲关格应与哪些病鉴别?如何鉴别?
老师：关格应与走哺、转胞和癃闭鉴别。走哺：是以呕吐伴有大小便不通利为主证，很相似于关格，但属实热，以呕吐为主证，因呕吐不禁而致大小便不通利。《千金要方》记载，"若实，则大小便不通利，气逆不续，呕吐不禁，故曰走哺"。走哺只要治疗得当，预后一般较好。关格则属于脾肾阳虚，兼有水浊壅塞三焦，是虚中夹实的病证，病理机制是由于小便不通而引起呕吐，关格属危重疾病，预后较差。转胞：是指小便不通或有呕吐等症，由于尿潴留于膀胱，膀胱受压，缭戾不顺而引起的排尿困难，水气上逆而出现呕吐。癃闭：指排尿困难，小便量少，甚至点滴俱无，无尿频尿痛，每日排出尿量低于正常，严重时，小便闭塞，无尿排出。病位在膀胱，但与三焦气化攸关。无呕吐及大便不通，故较易和关格鉴别。
老师：两者不同，虚劳是多种原因引起，多个脏腑受累的慢性虚衰性病证，无传染性。而肺痨则是由痨虫侵袭肺的具有传染性的独立病种。虚劳的基本病机是脏腑阴阳气血俱虚，临床表现十分复杂，缺乏固定的脉证特征。而肺痨是阴虚肺燥所致的潮热、盗汗、胸痛、咳嗽、消瘦六大主症。虚劳的治疗在于阴阳气血，重在补益脾肾，而肺痨的治疗重在治肺，补虚杀虫。
学生丙本病的治疗原则是什么?
老师："急则治其标，缓则治其本"是中医治疗学的重要原则之一。本病例属正虚邪实，须顾及邪正双方，整体治疗，标本同治。如只祛邪，则正气难支，只扶其正，则实邪难去。因此治疗本病法宜健脾益肾，降浊止呕。
老师：本病人虽然具有阴阳气血皆虚的证侯，但也不宜采用大补之法。因本病人的脾胃已衰败，浊邪壅盛，浊为阴邪，更耗营血，徒进补益之品，一方面虚不受补，另一方面大量补益药会增湿助热，壅腻碍胃，邪有壅塞之弊，对患者有害无益。
学生乙治疗此病中药组方如何解释?
老师：组方中以黄芪、党参益气补中；茯苓、泽泻健脾利水消肿；砂仁温脾和胃；藿香、佩兰芳香化浊、理气止呕；肉苁蓉补肾阳、益精血、润燥滑肠；山萸肉补益肝肾、养精血而助元阳；当归、白芍补血养血敛阴；甘草和中、调和诸药，共奏健脾益气、滋补肝肾、降浊止呕之功效。呕吐重时加半夏、竹茹，尿少加白茅根，腰酸肢冷加仙茅。以此方调解施治，标本兼顾，取得了良好的效果?
学生丙中药灌肠为何可起到治疗效果?
老师：中药灌肠是降浊祛邪的有效方法。主要药物大黄苦寒泄降，通腑泻浊，走而不守，气味俱厚，能泻下破结，荡涤实热积滞，下瘀血、破症积、行水气、除浊气；牡蛎，取其收敛固涩之性，使大黄泻而不猛，防止过度耗伤正气；当归补血活血，润肠通便；附子为纯阳燥烈之晶，其性善走，功能峻补下焦之元阳，驱逐寒湿，善治阳气衰微之证；槐花清大肠之火，诸药合用，共奏荡涤肠胃通腑泻浊之效。此方寒热并用，标本兼顾，以通降为主，可尽快排除水毒湿浊之邪。取保留灌肠法，是通过增加肠道排泄力，以排除积在体内的废毒物质，通过祛邪以达到扶正目的，通过临床应用收到满意疗效。
学生甲如何预防关格和判断预后?
老师：因为关格是水肿、癃闭和淋证的晚期病证，预防本病，首先应预防以上各种病证。需注意冷热，预防感冒，避免居住湿地和涉水冒雨，注意饮食调理，防止劳倦过度，关格应绝对卧床休息。观察关格的预后是根据脾肾阳虚的亏损程度和浊邪侵犯中焦或上下焦之不同。一般说，脾肾阳虚轻者，预后较好；脾肾阳虚重者，预后较差。若浊邪只犯中焦，病限脾胃，只要辨证确切，用药得当，预后尚可，本病例即属此类。若浊邪上犯心肺或下犯肝肾，出现昏迷、喘促息微或惊厥者，预后不佳。如果关格的前期阶段没有很好的调理和治疗，发展至本病的终末阶段，则较为难治。
浙江绍兴市中医院主任董汉良
汪XX，男，79岁，浙江绍兴市人，退休工人，1994年2月2日初诊。患者1周前发热，纳差，便秘，尿黄赤而求诊于西医，经输液、抗菌及对症治疗，病未见寸效，且日益加重，继则全身发黄，尿色为浓茶汁，四肢浮肿，腹胀如臌，家属疑是恶病(癌症之类)，经人介绍，来我处求诊。诊病人素体尚健，一向从事体力劳动，退休10余年很少求医。近1～2年来自觉体力衰退精力不支，纳食减少。于1周前(1月25日)突然高热达39℃，经治疗热渐退而肌肤黄疸加深，呈黑滞色而无光泽，目黄染，尿红赤，精神萎顿，懒言少语，卧床不起；因居室昏暗，家属亦少关心，病日复严重，继则小便失禁，呼之不应而抬至我处求治。症见：深度黄疸外，二目呆滞微闭，手脚蠕动不停，裤上尿迹如染柏汁，下肢按压呈凹陷性水肿，手背按之亦凹陷不起，腹部叩之有振水声，大便1周不通，腹胀如臌，脉微细而沉，舌根黄糙，舌尖红。即子进一'步检查。肝功能：ALT994u／L(正常值5．0-4．0u／L)，ASTl981．1u／L。(9.0～48．0u／I，)，AIP177u／L(31．0-115．0u／L)，GGT134u／L(0～53．0u／L)，TBiLiO136．7μmol/L(6．0～23．0／μmol／L)，DBi-Li59．0μmol／L(0～6．0μmol／L)，TP71．8g／L(60．0～83．0g／L)，AIb38．7g／L(35．0～53．0g／L)，G33．1g／L(2．0～32．0g／L)，HBsAg(-)。B超提示：肝弥漫性肿大(急性肝炎?肿痛?)，胆囊壁水肿，腹腔积液。全尿分析：NIT(-)，pH6．0，GLU(一)，PRO(±)，BLD(-)，KET(-)，BIL，+4↑↑↑↑，URO+4↑↑↑↑。血常规：血红蛋白90g／L白细胞4．5X109／L，中性0．82，血小板11.5万。从症状及化验、B超检查，诊断为急性黄疸型肝炎(阻塞性黄疸、癌肿待排?)。
按中医辨证：高年肾虚，肝肾两亏，外邪入侵，正不敌邪而致寒热不食，湿热内留，郁蒸发黄。当急则治标，予消化湿热，通腑散结：茵陈30g，制军10g，番泻叶2g，虎杖30g，川柏10g，白花蛇舌草30g，石菖蒲10g，黄毛耳草30g。3剂。大便畅行，然黄疸不退，腹胀更甚，出现正不胜邪，病势加重之象。即予前方去番泻叶、白花蛇舌草、虎杖，加垂盆草30g，平地木30g，六月雪30g，田基黄30g，广木香10g，川朴10g，杏仁10g，红枣30g，杞子15g。5剂。药后，病未见明显减轻，嘱转绍兴市传染病院肝病专科住院治疗。
约1周左右，家属来告：病无丝毫转机，神志似清非清，全身浮肿，肌肤黄黑，二便失禁，呈奄奄一息之象，似无生机之望，而自动出院，守家待毙，亦积极为其准备后事。然为慰病人之心，邀我出诊。患者床上臭气冲天，不可近身，开灯后，见二目紧闭，呼吸低微，全身肿胀未退，呈僵直状仰卧，脉微细，舌红少苔，病已危在旦夕。勉处一方试服：生晒参15g，熟地30g，白术10g，茯苓15g，杞子15g，玉米须30g，陈葫芦壳30g，炙桂枝8g，白芍15g，附子15g，川芎15g。1剂。并嘱家人清洁卧室。翌日，病家告之：服药后已有动弹，呼吸较乎稳，尿多。即前方去川芎加桃仁10g，茵陈30g，熟地加至50g。2剂。
药后家属代诉：病有好转，二目已开，并要索食。我嘱，将病人抬来视诊。症见：皮肤仍黄染但似有光泽不呈黑滞，肿胀始退，腹较平软，二目稍有神来，问之能答，口唇干燥，舌淡红，苔微黄，脉沉细。病确有转机，经反复思考，搜索方药，斟酌再三，疏方：熟地60g，茵陈30g，党参15g，白术15g，茯苓15g，附子15g，杞子重5g，当归15g，泽泻15g，赤子豆30g，炙甘草8g，红枣30g，砂仁5g。5剂。并嘱粳米粥调养。5剂后黄疸渐退，在原方基础上随症加减，至4月29日前后服药近80剂，临床症状消失，化检--切正常，而告痊愈。1995年2月随访，康复如常人。
学生甲该病人年事已高，病情又重，正气又衰，老师为何用制军、番泻叶攻下，用寒凉解毒重剂清化?
老师：金元四大家之一的张从正早有明训，"良工之治病，先治其实，后治其虚"。且病人便结周余，全身发黄，腹胀浮肿。不去邪实，何以安正?邪去则正安，故以仲景茵陈蒿汤为首选方剂，加以近年治肝病有效民间草药如虎杖，不但利湿退黄，且能活血祛风；白花蛇舌草解毒利湿之功甚著，黄毛耳草利湿退黄降酶之力卓然。制军与番泻叶有通泄散结之力，然而大黄制后力缓，番泻叶一泻即止，对于体弱者用之颇宜。药后虽大便畅行，且病未有好转，故更易前方，纯以清利湿毒为主，取平和之品稍加扶正，着疏肝健脾之属，但病仍未明显减轻，为防不测，故转专科医院治疗、检查。但事与愿违，病急转直下，而呈濒死阶段。俗谚"死马当作活马医"。细析病机，当以医"命"为主，不能被"病"框定眼目，查遍各家经验，试以补养肝肾入手，始见奇功。在治疗中虽用攻下，然攻不伤正；虽用重剂清化，然清不败胃。多次改弦易辙虽未见功，并非药不对症，而是正不敌邪之故。正气衰败早有认识，然邪之不去，难以安正，故病初还是以制军、番泻叶攻下，用寒凉解毒重剂清化。
学生乙：老师易方中所用补益之品，其中"熟地"一味，用于深度黄疽病中似有不宜，请予释疑。
老师：问题提得很好!亦我要看重解疑的一味药物，确实会引起许多人的疑问和不解。自汉·张仲景提出"黄家所得，从湿得之"之后，后世医家多宗之，如朱丹溪说，"疸不用分其五，同是湿热"。在治疗上强调利尿，如仲景早就指出："诸病黄家，但利其小便"。因此利湿退黄为唯一疗法，这对治疗黄疸当然有其积极的一面；然而，若忽略了辨证论治而视为千古不易之理，必将贻误病机。黄疸有阴、阳之分。阳黄者邪气实，湿热重，用利尿之法果足取。阴黄者正气虚，正不胜邪，治当扶正为先。
善用熟地的绍兴明代医家张景岳对阴黄的认识，明确指出。"则全非湿热，而总由气血之败"、"此与湿热发黄者反如冰炭，使非速救元气，大补脾肾，则终无复元之理"，在治疗上"阴黄证多有内伤不足，不可以黄为意，专用清利，但宜调补心、脾、肾之虚以补其气血，血气复则黄必尽退，如四君子汤、五君子煎、寿脾煎及左归、右归、六味回阳等饮，皆阴中阳虚者所宜也"。张氏此论，可谓字字箴规。细查张氏书中治阴黄11首方，有7首用熟地，足见熟地之功力。然曲高和寡，贬多于和，如清·陈修园氏极力反对之，他说，"(熟地)乃服食之晶，非除病之药"、"又囿于黄疸因湿热而成，当利小便，熟地妨食赋膈"，将有效之良药，拒之千里之外。但有经验的张锡纯在其(医学衷中参西录>中认为，"(熟地)少用则作闷，多用转不闷"。王肯堂(证治准绳)中说，"治疸须分新久，新病初起则当消导攻渗，久病又当变法，脾胃受伤则气血虚弱必用补剂，使正气盛则邪气退，庶可收功"。
由于患者已经2个月余不愈，病况日下，已为阴黄无疑，且元气衷竭，肝肾欲绝之象已露，故参阅古今医家经验，结合辨证论治，大胆用峻补元气，滋养肝肾之晶，如参、地、白术、杞子、当归之届，并加桂、附回阳救逆。用之有力挽狂澜之效，有起死回生之能；使病由危转安，由安转愈。足见前人经验之宝贵。熟地于黄疸病中可放胆用之，确能退黄，确能治病，且有治重症之力，张景岳之喜用善用熟地有其宝贵经验，不可不信。
Teacher: Xu Lao (Deficiency Labor, a general term for chronic deficiency syndromes characterized by the depletion of Zang-Fu Yuan Qi and insufficiency of Essence and Blood) is a general term for a category of chronic deficiency syndromes whose main pathological process is the depletion of Zang-Fu Yuan Qi (Primordial Qi of the internal organs) and insufficiency of Jing Xue (Essence and Blood). This patient presents with a syndrome of deficiency in Yin, Yang, Qi, and Blood of all five Zang organs. According to the "Reference Standards for Syndrome Differentiation of Deficiency Syndromes in Traditional Chinese Medicine," it can be diagnosed as Xu Lao. The patient's susceptibility to colds, shortness of breath, mental fatigue and weakness, and a weak and forceless pulse are signs of Fei Qi Xu (Lung Qi Deficiency); palpitations, insomnia, pale complexion, pale lips and nails, and a pale tongue body are signs of Xin Xue Xu (Heart Blood Deficiency); dizziness, dry eyes, heat sensation in the palms and soles, soreness and weakness of the waist and knees, a fine and rapid pulse, and a tongue without coating are all signs of Gan Shen Yin Xu (Liver and Kidney Yin Deficiency). Poor appetite, aversion to cold and cold limbs, puffy edema of the face and feet, and soreness and pain in the lower back are signs of Pi Shen Yin Xu (Spleen and Kidney Yin Deficiency - *Note: Contextually likely Spleen and Kidney Yang Deficiency due to cold symptoms, but translated literally as per source*). The patient has had a constitutionally weak physique, multiple pregnancies, and prolonged illness without proper nourishment, gradually leading to the depletion of Yuan Qi and insufficiency of Jing Xue. The decline in Zang-Fu function results in an insufficient source for the production of Qi and Blood. Therefore, the basic pathogenesis of Xu Lao is Qi deficiency, Blood deficiency, Yin deficiency, and Yang deficiency of the Zang-Fu organs. In the course of development, it often forms a pathological change of mutual deficiency among the five Zang organs and transmission between them, but the Spleen and Kidney serve as the dominant links.
Student Jia: Which diseases should Guan Ge (Obstruction and Rejection, a critical condition characterized by vomiting and inability to urinate or defecate) be differentiated from? How should it be differentiated?
Teacher: Guan Ge should be differentiated from Zou Bu (Running Nourishment/Vomiting with obstruction), Zhuan Bao (Twisted Bladder/Difficult Urination), and Long Bi (Difficulty in Urination). Zou Bu: Its main symptom is vomiting accompanied by difficulty in urination and defecation. It is very similar to Guan Ge but belongs to Excess-Heat. Vomiting is the primary symptom; due to uncontrollable vomiting, urination and defecation become obstructed. The *Qian Jin Yao Fang* records: "If there is excess, then urination and defecation are obstructed, Qi rebels and cannot continue, vomiting is uncontrollable, hence it is called Zou Bu." If treated appropriately, the prognosis for Zou Bu is generally good. Guan Ge, however, belongs to Spleen and Kidney Yang Deficiency, complicated by turbid water obstructing the San Jiao (Triple Burner). It is a syndrome of deficiency mixed with excess. Its pathological mechanism is that vomiting is caused by the inability to urinate. Guan Ge is a critical disease with a poor prognosis. Zhuan Bao: Refers to difficulty in urination or symptoms such as vomiting, caused by urinary retention in the bladder. The bladder is compressed, causing twisting and irregular flow, leading to difficult urination. When water-Qi rebels upward, vomiting occurs. Long Bi: Refers to difficulty in urination, scanty urine, or even no urine at all, without frequent or painful urination. The daily urine output is lower than normal. In severe cases, urination is completely blocked with no urine excreted. The disease location is in the Bladder, but it is closely related to the Qi transformation of the San Jiao. Since there is no vomiting or constipation, it is relatively easy to differentiate from Guan Ge.
Student Yi: Are Xu Lao and Fei Lao (Pulmonary Tuberculosis) the same thing?
Teacher: They are different. Xu Lao is a chronic deficiency syndrome caused by various factors, involving multiple Zang-Fu organs, and is non-infectious. Fei Lao, on the other hand, is an independent infectious disease caused by the invasion of "Tao Chong" (Tubercle Bacillus/Tuberculosis Pathogen) into the Lung. The basic pathogenesis of Xu Lao is the joint deficiency of Yin, Yang, Qi, and Blood in the Zang-Fu organs. Its clinical manifestations are very complex and lack fixed pulse and symptom characteristics. Fei Lao, however, is characterized by six major symptoms caused by Yin deficiency and Lung Dryness: tidal fever, night sweats, chest pain, cough, and emaciation. The treatment of Xu Lao focuses on regulating Yin and Yang and tonifying Qi and Blood, emphasizing the tonification of the Spleen and Kidney. The treatment of Fei Lao focuses on treating the Lung, tonifying deficiency, and eliminating parasites.
Student Bing: What is the treatment principle for this disease?
Teacher: "In acute cases, treat the branch/symptom; in chronic cases, treat the root/cause" is one of the important principles in TCM therapeutics. This case belongs to Zheng Xu (Righteous Qi Deficiency) and Xie Shi (Pathogenic Excess). One must consider both the pathogenic factor and the righteous Qi, adopting holistic treatment and addressing both the branch and the root simultaneously. If only the pathogen is expelled, the righteous Qi will not be able to sustain itself; if only the righteous Qi is supported, the pathogenic excess will be difficult to eliminate. Therefore, the treatment method for this disease should be to strengthen the Spleen and benefit the Kidney, descend turbidity, and stop vomiting.
Student Jia: Since it is Xu Lao disease, why not adopt the method of heavily tonifying Yin, Yang, Qi, and Blood?
Teacher: Although this patient presents with deficiencies in Yin, Yang, Qi, and Blood, it is not appropriate to use heavy tonification methods. Because the patient's Spleen and Stomach have already declined, and turbid pathogens are abundant. Turbidity is a Yin pathogen that further consumes Ying Blood. Blindly administering tonics has two drawbacks: first, the deficiency cannot tolerate heavy tonification (Xu Bu Shou Bu); second, large amounts of tonic medicines will increase dampness and assist heat, becoming cloying and obstructing the Stomach. This leads to the risk of pathogenic stagnation, which is harmful rather than beneficial to the patient.
Student Yi: How do you explain the herbal prescription for treating this disease?
Teacher: In the prescription, Huang Qi (Astragali Radix) and Dang Shen (Codonopsis Radix) are used to tonify Qi and supplement the Middle Jiao; Fu Ling (Poria) and Ze Xie (Alisma Rhizome) strengthen the Spleen, promote diuresis, and reduce edema; Sha Ren (Amomi Fructus) warms the Spleen and harmonizes the Stomach; Huo Xiang (Pogostemonis Herba) and Pei Lan (Eupatorii Herba) resolve turbidity with their aromatic properties, regulate Qi, and stop vomiting; Rou Cong Rong (Cistanches Herba) tonifies Kidney Yang, benefits Essence and Blood, and moistens dryness to facilitate bowel movements; Shan Yu Rou (Corni Fructus) tonifies the Liver and Kidney, nourishes Essence and Blood, and assists Yuan Yang; Dang Gui (Angelicae Sinensis Radix) and Bai Shao (Paeoniae Radix Alba) tonify Blood, nourish Blood, and astringe Yin; Gan Cao (Glycyrrhizae Radix et Rhizoma) harmonizes the Middle Jiao and moderates the actions of the other herbs. Together, they achieve the effects of strengthening the Spleen, benefiting Qi, nourishing the Liver and Kidney, descending turbidity, and stopping vomiting. When vomiting is severe, Ban Xia (Pinelliae Rhizoma) and Zhu Ru (Bambusae Caulis in Taenia) are added; when urine output is low, Bai Mao Gen (Imperatae Rhizoma) is added; when there is soreness in the lower back and cold limbs, Xian Mao (Curculiginis Rhizoma) is added. By adjusting and treating with this formula, addressing both the branch and the root, good results were achieved.
Student Bing: Why can traditional Chinese medicine enemas play a therapeutic role?
Teacher: TCM enema is an effective method for descending turbidity and expelling pathogens. The main herb, Da Huang (Rhei Radix et Rhizoma), is bitter and cold, promoting downward drainage, unblocking the bowels, and clearing turbidity. It moves freely and does not stay put, possessing thick aroma and flavor. It can purge downward, break accumulations, sweep away excess heat and stagnation, eliminate blood stasis, break masses, move water-Qi, and remove turbid Qi. Mu Li (Ostreae Concha) is used for its astringent and consolidating properties, making Da Huang's purging action less fierce and preventing excessive consumption of righteous Qi. Dang Gui tonifies and invigorates Blood, moistens the intestines, and facilitates bowel movements. Fu Zi (Aconiti Lateralis Radix Praeparata) is a pure Yang, drying, and intense substance. Its nature moves freely, functioning to severely tonify the Yuan Yang of the Lower Jiao, expel cold and dampness, and effectively treat conditions of Yang Qi collapse. Huai Hua (Sophorae Flos) clears fire in the Large Intestine. The combination of these herbs achieves the effect of sweeping the intestines and stomach, unblocking the bowels, and clearing turbidity. This formula uses both cold and hot herbs, addresses both root and branch, and focuses on descending and unblocking, allowing for the rapid elimination of water toxins and damp-turbid pathogens. The retained enema method works by increasing intestinal excretion power to eliminate accumulated toxic waste products in the body. By expelling pathogens, it aims to support righteous Qi. Clinical application has yielded satisfactory results.
Student Jia: How to prevent Guan Ge and judge the prognosis?
Teacher: Since Guan Ge is a late-stage complication of Shui Zhong (Edema), Long Bi (Difficulty in Urination), and Lin Zheng (Strangury), preventing this disease first requires preventing these various conditions. One needs to pay attention to temperature changes, prevent colds, avoid living in damp places or wading through water in the rain, pay attention to dietary regulation, prevent overexertion, and patients with Guan Ge should rest absolutely in bed. Observing the prognosis of Guan Ge depends on the degree of Spleen and Kidney Yang deficiency and whether the turbid pathogen invades the Middle Jiao or the Upper and Lower Jiao. Generally speaking, mild Spleen and Kidney Yang deficiency has a better prognosis; severe Spleen and Kidney Yang deficiency has a poorer prognosis. If the turbid pathogen only affects the Middle Jiao, limiting the disease to the Spleen and Stomach, as long as the syndrome differentiation is accurate and medication is appropriate, the prognosis is acceptable. This case belongs to this category. If the turbid pathogen invades the Heart and Lung upwards or the Liver and Kidneys downwards, resulting in coma, panting with faint breathing, or convulsions, the prognosis is poor. If the early stage of Guan Ge is not well regulated and treated, and it develops to the terminal stage of this disease, it becomes more difficult to treat.
Deep Jaundice, Edema of Four Limbs, Abdominal Distension like Drum
Dong Hanliang, Director, Shaoxing Hospital of Traditional Chinese Medicine, Zhejiang Province
Wang XX, Male, 79 years old, from Shaoxing City, Zhejiang Province, retired worker. First consultation on February 2, 1994. One week prior, the patient experienced fever, poor appetite, constipation, and dark yellow urine, seeking Western medical treatment. After intravenous fluids, antibiotics, and symptomatic treatment, there was no improvement, and the condition worsened day by day. Subsequently, the whole body turned yellow, urine color became like strong tea, four limbs became edematous, and abdominal distension was severe like a drum. The family suspected cancer (malignancy). Introduced by someone, he came to my clinic for consultation. Examination revealed the patient was constitutionally healthy, having always engaged in physical labor, and rarely sought medical care in the 10+ years since retirement. For the past 1-2 years, he felt declining physical strength and energy, with reduced food intake. One week ago (January 25), he suddenly developed a high fever reaching 39°C. After treatment, the fever subsided gradually, but skin jaundice deepened, presenting as a dark, dull, lusterless blackish-yellow hue. Eyes were yellowed, urine was red-dark, spirit was listless, speech was lazy and sparse, and he was bedridden. Due to a dim living environment and lack of care from family, the illness worsened day by day. Subsequently, urinary incontinence occurred, and he did not respond to calls, requiring him to be carried to my clinic for treatment. Symptoms included: besides deep jaundice, eyes were dull and slightly closed, hands and feet twitched continuously, urine stains on pants looked like ink-dyed cloth, pressing the lower legs resulted in pitting edema, pressing the back of the hand also left indentations that did not rebound, percussion of the abdomen produced a splashing sound, no bowel movement for one week, abdominal distension severe like a drum, pulse was minute, fine, and deep, tongue root was yellow and rough, tongue tip was red. Further examination was conducted immediately. Liver function tests: ALT 994 u/L (Normal 5.0-40.0 u/L*), AST 1981.1 u/L (Normal 9.0-48.0 u/L), ALP 177 u/L (Normal 31.0-115.0 u/L), GGT 134 u/L (Normal 0-53 u/L), TBil 136.7 μmol/L (Normal 6.0-23.0 μmol/L), DBil 59.0 μmol/L (Normal 0-6.0 μmol/L), TP 71.8 g/L (Normal 60.0-83.0 g/L), Alb 38.7 g/L (Normal 35.0-53.0 g/L), Globulin 33.1 g/L (Normal 2.0-32.0 g/L), HBsAg (-). Ultrasound suggested: diffuse liver enlargement (Acute Hepatitis? Tumor?), gallbladder wall edema, ascites. Complete urinalysis: NIT (-), pH 6.0, GLU (-), PRO (±), BLD (-), KET (-), BIL +4↑↑↑↑, URO +4↑↑↑↑. Blood routine: Hemoglobin 90 g/L, White Blood Cells 4.5×10^9/L, Neutrophils 0.82, Platelets 115,000. Based on symptoms, lab tests, and ultrasound, the diagnosis was Acute Jaundice Hepatitis (Obstructive Jaundice? Cancer to be excluded?).
According to TCM syndrome differentiation: Elderly age with Kidney deficiency, deficiency of both Liver and Kidney, invasion of external pathogens, righteous Qi unable to overcome pathogens, leading to alternating chills and fever, loss of appetite. Damp-heat remains internally, stagnates, and transforms into jaundice. Following the principle of "treating the branch in acute cases," the approach was to clear heat, drain dampness, unblock the bowels, and dissipate nodules: Yin Chen 30g, Zhi Jun (Prepared Da Huang) 10g, Fan Xie Ye (Sennae Folium) 2g, Hu Zhang (Polygoni Cuspidati Rhizoma et Radix) 30g, Chuan Bo (Phellodendri Cortex) 10g, Bai Hua She She Cao (Hedyotidis Diffusae Herba) 30g, Shi Chang Pu (Acori Tatarinowii Rhizoma) 10g, Huang Mao Er Cao (Oldenlandia diffusa) 30g. 3 doses. Bowels moved smoothly, yet jaundice did not recede, and abdominal distension worsened, indicating that righteous Qi could not overcome the pathogen and the disease intensified. The previous formula was modified by removing Fan Xie Ye, Bai Hua She She Cao, and Hu Zhang, adding Chui Pen Cao (Sedum sarmentosum) 30g, Ping Di Mu (Actinidia Argyrophylla Root) 30g, Liu Yue Xue (Serissa japonica) 30g, Tian Ji Huang (Picris Japonica) 30g, Guang Mu Xiang (Costi Rhizoma) 10g, Chuan Po (Magnoliae Officinalis Cortex) 10g, Xing Ren (Armeniacae Semen Amarum) 10g, Hong Zao (Jujubae Fructus) 30g, Qi Zi (Lycii Fructus) 15g. 5 doses. After medication, the disease showed no obvious relief. The patient was advised to transfer to the Liver Disease Department of Shaoxing Infectious Disease Hospital for inpatient treatment.
About a week later, the family reported: No sign of improvement whatsoever. Consciousness was unclear, whole body edematous, skin yellow-black, incontinence of urine and feces, appearing near death, seemingly hopeless, and discharged themselves against medical advice, staying home to await death. We actively prepared funeral arrangements. However, to comfort the patient, we were invited for a house call. The bed emitted a foul odor, unbearable to approach. Upon turning on the light, eyes were tightly closed, breathing was faint, whole-body swelling had not receded, lying supine in a rigid state, pulse was minute and fine, tongue was red with little coating. The condition was critical. Reluctantly, a prescription was prepared for trial: Sheng Shai Shen (Ginseng Radix et Rhizoma) 15g, Shu Di (Rehmanniae Radix Praeparata) 30g, Bai Zhu (Atractylodis Macrocephalae Rhizoma) 10g, Fu Ling 15g, Qi Zi 15g, Yu Mi Xu (Zea Mays Stylus et Stigma) 30g, Chen Hu Lu Qiao (Calabash Shell) 30g, Zhi Gui Zhi (Cinnamomi Ramulus Praeparatus) 8g, Bai Shao 15g, Fu Zi 15g, Chuan Xiong (Ligustici Chuanxiong Rhizoma) 15g. 1 dose. Advised family to clean the bedroom. The next day, the family reported: After taking the medicine, the patient moved, breathing became more stable, and urine output increased. The previous formula was modified by removing Chuan Xiong, adding Tao Ren (Persicae Semen) 10g, Yin Chen 30g, and increasing Shu Di to 50g. 2 doses.
The family reported after medication: Condition improved. Eyes opened, and the patient asked for food. I instructed to bring the patient for examination. Symptoms: Skin still jaundiced but seemed lustrous, not dark and dull. Swelling began to recede, abdomen flatter and softer. Eyes had some spirit, responded to questions. Lips dry, tongue pale red, coating slightly yellow, pulse deep and fine. There was indeed a turning point. After repeated thinking, searching for formulas, and careful deliberation, the following prescription was issued: Shu Di 60g, Yin Chen 30g, Dang Shen 15g, Bai Zhu 15g, Fu Ling 15g, Fu Zi 15g, Qi Zi 5g, Dang Gui 15g, Ze Xie 15g, Chi Xiao Dou (Adzuki Bean) 30g, Zhi Gan Cao 8g, Hong Zao 30g, Sha Ren 5g. 5 doses. Advised to nourish with rice porridge. After 5 doses, jaundice gradually receded. Based on the original formula, modifications were made according to symptoms. By around April 29, nearly 80 doses were taken. Clinical symptoms disappeared, laboratory tests normalized, and recovery was declared. Follow-up in February 1995 showed full recovery like a normal person.
Student Jia: The patient is elderly, the condition is severe, and righteous Qi is depleted. Why did the teacher use Zhi Jun (Prepared Rhubarb) and Fan Xie Leaf for purgation, and heavy cold-cooling detoxifying agents for clearing and transforming?
Teacher: Zhang Congzheng, one of the Four Great Masters of the Jin and Yuan Dynasties, gave clear instructions long ago: "A skilled physician treats the excess first, then treats the deficiency." Moreover, the patient had constipation for over a week, whole-body jaundice, abdominal distension, and edema. Without expelling the pathogenic excess, how can righteousness be secured? Expelling the pathogen secures the righteousness. Therefore, Zhang Zhongjing's Yin Chen Hao Tang (Artemisiae Scopariae Decoction) was chosen as the primary formula, combined with effective folk herbs for liver disease in recent years, such as Hu Zhang. Not only does it promote diuresis and resolve jaundice, but it also invigorates Blood and dispels wind; Bai Hua She She Cao has significant effects in detoxifying and draining dampness; Huang Mao Er Cao has excellent power in draining dampness, resolving jaundice, and lowering enzymes. Zhi Jun and Fan Xie Ye have the power to unblock and dissipate nodules. However, processed Da Huang has a milder force, and Fan Xie Ye stops after one purge, making it quite suitable for those with weak constitutions. Although the bowels moved smoothly after medication, the disease did not improve. Thus, the previous formula was changed again, focusing purely on clearing and draining damp-toxin, using mild substances to slightly support righteousness, and employing herbs to soothe the Liver and strengthen the Spleen. But the disease still did not significantly lighten. To prevent unforeseen circumstances, referral to a specialized hospital for treatment and examination was made. However, things went contrary to expectations. The disease took a sharp turn for the worse, entering a pre-terminal stage. As the proverb goes, "Treat a dead horse as if it were alive." Analyzing the pathogenesis carefully, the priority should be saving the "life," not being confined by the "disease." Consulting experiences from various schools, attempting to start with tonifying and nourishing the Liver and Kidney finally showed miraculous results. Although purgatives were used in treatment, they did not injure righteous Qi; although heavy clearing and transforming agents were used, they did not damage the Stomach. The fact that changing strategies multiple times did not yield immediate results was not because the medicine did not match the syndrome, but because righteous Qi was unable to overcome the pathogen. The depletion of righteous Qi was recognized early on, but without expelling the pathogen, righteousness could not be secured. Therefore, initially, Zhi Jun and Fan Xie Ye were used for purgation, and heavy cold-cooling detoxifying agents were used for clearing and transforming.
Student Yi: Regarding the tonifying substances used in the modified formula, specifically "Shu Di" (Prepared Rehmannia Root), its use in deep jaundice seems inappropriate. Please clarify.
Teacher: This is a very good question! It is also the specific herb I wanted to focus on for clarification, as it indeed causes doubt and confusion for many people. Since Zhang Zhongjing of the Han Dynasty proposed, "Jaundice arises from dampness," subsequent physicians mostly followed this view. For example, Zhu Danxi said, "There is no need to distinguish the five types of jaundice; they are all damp-heat." In treatment, emphasis was placed on diuresis. Zhang Zhongjing pointed out early on: "For all patients with jaundice, simply promote urination." Therefore, draining dampness to resolve jaundice was considered the sole therapy. While this has its positive aspects for treating jaundice, ignoring syndrome differentiation and regarding this as an immutable truth for millennia will inevitably delay the correct treatment. Jaundice is divided into Yin and Yang types. In Yang Jaundice, the pathogen is excess, and damp-heat is heavy; the diuretic method is indeed sufficient. In Yin Jaundice, righteous Qi is deficient, and righteous Qi cannot overcome the pathogen; treatment should prioritize supporting righteousness.
Zhang Jingyue, a Ming Dynasty physician from Shaoxing who was adept at using Shu Di, clearly stated his understanding of Yin Jaundice: "It is entirely not damp-heat, but altogether due to the failure of Qi and Blood" and "This is opposite to jaundice caused by damp-heat, like ice and charcoal. Unless Yuan Qi is rapidly rescued and the Spleen and Kidney are heavily tonified, there is no way to recover." In treatment, "Yin Jaundice cases often involve internal injury and insufficiency. One should not focus solely on the jaundice and exclusively use clearing and draining methods. Instead, one should adjust and tonify the deficiency of the Heart, Spleen, and Kidney to supplement Qi and Blood. Once Qi and Blood are restored, the jaundice will completely recede. Formulas such as Si Jun Zi Tang, Wu Jun Zi Jian, Shou Pi Jian, as well as Zuo Gui Wan, You Gui Wan, and Liu Wei Hui Yang Yin are all suitable for those with Yang deficiency within Yin." Zhang's argument can be described as every word being a maxim. Carefully checking Zhang's book, among 11 formulas for treating Yin Jaundice, 7 used Shu Di, demonstrating the efficacy of Shu Di. However, high-brow songs find few singers; criticism outweighed praise. For instance, Chen Xiuyuan of the Qing Dynasty strongly opposed it, saying, "(Shu Di) is a food item, not a medicine to cure disease" and "Again, constrained by the belief that jaundice is caused by damp-heat, one should promote urination; Shu Di hinders digestion and causes chest oppression," rejecting an effective good medicine from afar. However, the experienced Zhang Xichun, in his *Medical Records: Integrating Chinese and Western Medicine*, believed, "(Shu Di) causes oppression in small doses, but in large doses, it does not cause oppression." Wang Kentang in *Zheng Zhi Zhun Sheng* said, "Treating jaundice must distinguish between new and old. New onset should be treated with guiding, digesting, attacking, and渗 (seeping/diuresis). Old diseases require changed methods. If the Spleen and Stomach are injured, Qi and Blood become weak, and tonics must be used. When righteous Qi is strong, pathogenic Qi retreats, and success can be achieved."
Since the patient had been ill for over 2 months without improvement, the condition worsened daily, it was undoubtedly Yin Jaundice. Signs of exhaustion of Yuan Qi and impending failure of the Liver and Kidney were evident. Therefore, referencing the experience of ancient and modern physicians, combined with syndrome differentiation, bold use of severe tonification of Yuan Qi and nourishment of Liver and Kidney substances, such as Shen (Ginseng), Di (Rehmannia), Bai Zhu, Qi Zi, Dang Gui, etc., along with Gui (Cinnamon Twig) and Fu Zi (Prepared Aconite) to restore Yang and rescue from collapse, was employed. This had the effect of turning the tide and bringing back the dead to life; transforming the condition from critical to safe, and from safe to cured. This fully demonstrates the precious value of predecessors' experience. Shu Di can be boldly used in jaundice disease; it truly resolves jaundice, truly treats the disease, and has the power to treat severe cases. Zhang Jingyue's preference and adept use of Shu Di contains precious experience and should not be disbelieved.
Student Jia: Teacher, since you have clarified that Shu Di can be boldly applied in jaundice disease, does Shu Di play the main role, or do the other herbs?