老师：应该说熟地起了关键性的作用。因为：①病人自用了熟地始见转机，而且从重危之中显奇功，自此之后每剂用熟地，而且量由30g加至60g，有时100g，据方剂不完全统计，合计用熟地约2kg而病告痊愈；②熟地治黄，病人亦有经验，而据其现代药理研究证实：熟地具有抗放射、保肝、降低血糖、强心、止血、利尿、抗炎、抗真菌等作用，(《中药新用》王辉武、贾河先编著)因此对肝病有较好的治疗和保养作用；③从病机分析熟地有滋养肝肾之功，所谓滋水涵木。患者病入肝肾，二脏液竭，急需熟地以滋养。故熟地在治愈本病中起了关键性的作用，当然所伍之品亦起到相辅相成的作用，所谓"一病必有一主方，一方必有一主药"是也。熟地退黄疸这一临床事实，给我们治黄疸病开拓-了视野，故特介绍给你们，可供临证借鉴。
重证眩晕呕吐浮肿
湖南中医学院教授熊继柏
梁XX，女，64岁，长沙市退休教师。1991年冬就诊。患者诉2个月前患头晕，兼呕吐、下肢浮肿，经某医院诊断为美尼尔氏综合征及肾病水肿。住院治疗月余，取效不显，患病2个月来卧床不能起。现头晕愈益加重，不能站立行走，若勉强坐立则觉天旋地转，头眩眼黑而昏昏欲倒；且时时呕逆，不欲进食，进食则呕，呕甚则多出稀白痰涎。视患者形体消瘦，面色淡白无华，两足浮肿较甚，气短乏力，声低息短。询及腰腿部酸痛，腹中微胀，食量甚少，大便溏而不爽，小便少而色清。舌淡苔薄白腻，脉象沉细。综析脉症，为脾虚痰饮之眩晕病证。拟健脾温中，祛痰化饮之法，用六君子汤加干姜、天麻、白蔻仁。处方：党参15g，土炒白术12g，茯苓30g，陈皮10g，法半夏10g，干姜8g，白蔻仁8g，天麻10g，炙甘草6g。嘱服5剂，日进1剂。次诊：服药后呕吐明显减轻，能进粥食。眩晕亦觉轻缓，能下床起坐。但感头重心悸、四肢乏力，两足仍然浮肿，舌脉如前。乃依原法原方，再加茯苓皮15g、大腹皮10g，继进5剂。三诊：眩晕大减，呕吐已止，能站立起坐，并能让人扶着在室内行走，且每餐能食50g米饭，大便不溏，两足浮肿亦明显消减。现感头重、心悸、两足沉重无力。舌淡苔薄白，脉细。再依原法改拟归芍六君子汤加味：党参20g，土炒白术12g，茯苓20g，陈皮10g，法半夏10g，当归10g，白芍10g，天麻10g，干姜4g，茯苓皮10g，大腹皮10g，甘草6g。四诊：眩晕已平，已能独立行走，饮食增进，心悸气短减轻，两足浮肿基本消退。但觉两腿乏力，腰膝酸重。舌淡、脉细。仍．：艾健睥益气化痰之法，略加益肾之品，拟归芍六君子汤加天麻、杜仲、淮牛膝。又服1．0剂，诸症悉平，·其病痊愈。追访至!今，未见复发。
老师：患者症状表现固然复杂，然其主症则为三个：头晕、呕吐、浮肿。头晕、眼花，甚者如坐舟车，自觉天旋地转，以致日不能开，身不能动者，为眩晕病。《灵枢·口问》所谓"耳为之苦鸣，头为之苦倾，目为之眩"。呕吐，在眩晕病巾乃常见症状之一。几眩晕之甚者，多伴呕吐；而眩晕兼呕吐者，又多属痰饮之征。(金匮要略)曾指出"心下有支饮，其人苦眩冒"，"呕吐，心下痞，膈间有水，眩悸"，《古今医统》说，"头目眩晕．眼前黑暗，如坐舟车，了乙兀欲吐者，痰也"。凡眩晕病出现呕吐痰涎，胸膈痞闷，苔白滑腻，则是痰饮眩晕证的表现特点。《症因脉治》说，"痰饮眩晕之症，胸前满闷，恶心呕吐，膈下漉漉水声．眩悸不止，头额作痛，此痰饮眩晕之症也"。浮肿，(金匮要略)称为"水气"，后世称"水肿"。《素问·平人气象论》曾指出，"面肿曰风，足胫肿曰水"。(金匮要略)并指出，"腰以下肿，当利小便"。可见下肢浮肿当届水气为患。今此患者眩晕与呕吐，浮肿并见，所以首先要考虑为痰饮水湿之眩晕。再现患者形瘦、不食、复胀、便溏、气短、乏力、舌淡、脉细，是为一派脾虚特点。稗虚而中阳不振，则运化失职，于是痰饮内生，为呕为肿；脾虚而清阳不升，则生化乏源，于是气血亏虚，发为眩晕。《证治汇补·眩晕》说，"脾为中州，……若劳役过度，汗多亡阳，元气下陷，清阳不升者，此眩晕出于中气不足也"。由此可知，本病患的病机在于脾虚与痰饮，故断其为脾虚痰饮之眩晕病证。
老师：脾虚痰饮眩晕证，是一个本虚标实证，脾虚是本，痰饮为标。由于脾虚失运而聚饮生痰，故其治法当以补脾占二力本，蠲痰饮为标。用六君子汤正是取其补脾祛痰之功用。《慎斋遗书·头晕》说过，"巾气虚则脾不运化，以致生痰上逆而头晕者，用四君子汤加半夏、天麻"。《医学心悟·眩晕》又说过，"有气虚夹痰者，书曰：清阳不升，浊阴不降，则上重下轻也，六君子汤主之"。又天麻为熄风治眩之要药，今患者眩晕不能坐立，甚则昏昏欲倒，必须熄风定眩之天麻，方可抑其风眩之势。李东垣说，"眼黑头眩，虚风内作，非天麻不能除也"。干姜为温运中阳之药，今患者呕吐稀涎，痰饮为患，而饮为阴邪，"病痰饮者，当以温药和之"，故用温中振阳之干姜，以使制其阴霾之盛。此外，方中加用白蔻仁，乃取其芳香化浊止呕之力。次诊时，方中又加茯苓皮、大腹皮，意在渗水湿以?肖足肿。俟呕止肿干之后，再用归芍六君子汤(即六君子汤加当归、白芍)，以此方具有补脾益气，养血敛肝，祛痰化浊之功效，是治疗脾虚痰浊、气血亏虚之眩晕病证的有效方剂，故用之以善其后。
医生丙眩晕病的病因病机复杂，证型分类颇多，临床辨治主要在于哪几方面?
老师：历代医家对眩晕病的辨证分类颇为复杂，就临床常见，眩晕为病，主要在于因风、因痰、因虚等三个方面。第一，因风之眩晕，又分外风、内风两种。外风，即外感风邪所致之眩晕，此证每于感冒之后发作，具有眩晕、头痛、恶风等症。《症因脉治·外感眩晕》说，"头痛额痛，骨节烦痛，身热多汗，上气喘逆，躁扰时眩，此风邪眩晕之证也"。治宜解表祛风，可选菊花茶调散加减。内风，即肝风上亢所致之眩晕，(内经)云"诸风掉眩，皆属于肝"。《严氏济生方》又云"肝风上攻，必致眩晕"。此证每于情志刺激则发作益甚，具有眩晕、耳鸣、头胀且痛以及心烦、少寐、面色潮红、四肢麻木等症。第二，因痰之眩晕，亦有痰湿、痰火两种。《丹溪心法》云"无痰则不作眩，……又有湿痰者，有火痰者"。痰湿眩晕，症见眩晕、胸闷、呕吐、口淡，舌苔白滑腻。治宜祛痰化湿，可选半夏白术天麻汤。痰火眩晕，症见眩晕、胸闷、呕吐、口苦，舌苔黄滑腻。治宜祛痰泻火，可选黄连温胆汤加天麻、钩藤之类。第三，因虚之眩晕，此证起病缓慢，持续发作，每多见于老人、虚人，或大病久病之后并发眩晕。对于虚证眩晕，古人认为有气虚、血虚、阳虚、阴虚、心虚、脾虚、肾虚、肝虚诸类。然临床所常见者，主要为脾虚和肾虚两种。脾虚眩晕主要在于生化乏源，气血不足。
《证治汇补·眩晕》说，"脾为中州，升腾心肺之阳，堤防肝肾之阴。若劳役过度，汗多亡阳，元气下陷，清阳不升者，此眩晕出于巾气不足也"。表现眩晕、欲呕、食少、神倦、面色皓白，舌淡苔白，脉细或虚。治宜补脾益气养血，可选归芍六君子汤。肾虚眩晕主要在于肾精亏损，以肾主藏精生髓，肾虚梢亏则"髓海不足，脑转耳鸣，胫酸眩冒，目无所见"，故症见眩晕、耳鸣、精神萎靡、腰膝酸软，甚则遗精、盗汗。治宜补肾填精，可选左归饮，杞菊地黄丸或龟鹿二仙胶之类。上述因风、因痰、因虚三个方面，概而论之，不外虚实两端，虚者，啤虚、肾虚为病之本；实者，风邪、痰浊为病之标。而临床所见则纯虚纯实者少，虚实夹杂、本虚标实证者多。辨治大法。当审其症状特点，视其标本缓急，补虚泻实，标本兼施之。水文所举验案即是标本兼施的实例。
腹泻案
北京中医药大学教授刘兴志
倪XX，女，25岁，工人。罹患腹痛泻下5年余，诊断为：慢性肠炎，经反复治疗不愈而前来中医就诊。1981年12月31日初诊。自述腹痛作泻5年之久，现右小腹疼痛，肠鸣，腹痛即泻，泻后痛缓，每日大便3-5次不等，纳差，食后脘胁胀痛痞满。形羸肌瘦，面黄少华。舌质淡，有齿痕，白苔，六脉沉细。中医认为，肾司二便，久泄伤肾，以致肾阳不足，命门火衰，火衰则不能生土，土虚则木不达，乃至脾肾阳虚，木不疏土。故治宜温补脾肾之阳，调达肝木，兼以涩肠止泄。宗四神丸合痛泻要方加减化裁：补骨脂15g，吴茱萸log，肉豆蔻15g，炮姜log，白术24g，杭芍15g，陈皮log，防风log，茯苓15g，炒诃子15g，炙罂粟壳15g，炒苡仁15g。水煎月艮，日一剂。
1982年王月4日二诊：服上方3剂，大便成形，每日1次。但近日出现头昏。饮食尚可，舌脉同前。认为眩晕之所以出现，乃系泄泻日久，损伤脾胃，巾气不足，清阳不升，故于方中宜加入增强补中益气之太子参15g、炙甘草log，味辛气温、利九窍而升阳之细辛5g，鼓舞胃气上行之葛根12g。
1982年1月11日三诊：服上方后头昏欲仆之状已除，尚右小腹隐痛，时有肠鸣，腹痛欲便，便后痛止，大便仍稀。苔薄白而润，脉沉细。泻利日久，脾肾虚寒，肠失固涩。故改拟真人养脏汤以温补脾肾，固涩止泻。药用：潞党参15g，白术18g，桂心10g，炙甘草6g，炮姜10g，罂粟壳15g，肉豆蔻15g，诃子15g，广木香6g。水煎服，日1剂。
1982年3月18日四诊：服药后腹中痛泻已见成效，精神稳定，自信心增强。近来出现每逢寅时，腹痛作泻，时有肠鸣，胃脘微胀。舌淡红白苔，脉沉细。观其病情，虚衰之体得以改善，脏腑功能得以调整，阳气渐复。张景岳云"阳气未复，阴气极虚，命门火衰，胃关不固而生泄泻"。故仍按前法，加强温阳补火之力，仿张锡纯加味四神丸，辅以柔肝健脾之晶，击鼓再进。药用：补骨脂15g，豆蔻15g，吴茱萸10g，炮姜10g，炒白芍10g，白术15g，诃子15g，葛根15g，茯苓15g，罂粟壳15g，天生黄10，九香虫丑0g。水煎服，日直剂。
1982年4月8．日五诊：服上方痛除泄止，但觉疲倦，夜寐多梦，已思食味香。舌质稍红，白苔，脉沉细较有力。宜在上方加五味子10g，以收敛肺气，滋肾水，气运水升则心肾交合，其夜卧自然安合。处方：补骨脂15g，吴茱萸10g，肉豆蔻15g，五味子10g，炒白芍15g，白术24g，茯苓30g，葛根15g，罂粟壳15g，炮姜10g，天生黄10g，九香虫10g，陈皮10g。服汤剂有效，改成蜜丸常服。1982年10月21日患者因患中耳炎来诊，谈及腹泻旧疾，欣然告之，经过前段的精心治疗，腹痛泄下已痊愈，一直未发。
医生甲本病基本病机是什么?疾病的演变过程?用何方处之?
老师：<内经>告诫我们，要紧守"病机"，是分析、治疗疾病关键所在。弄清疾病的演变规律，是认识疾病的深化过程，便于全面掌握疾病，才能更好地把握"病机"，审证施治。本案基本病机乃系泄久脾肾阳虚，木不疏土。病人年仅20岁，即患腹痛泄下之顽疾。结合病人平素食少脘胀，消瘦神短，面色萎黄、少光泽，可知患者素体脾虚。中医认为，脾为后天之本，气血生化之源，主运化水谷之精微。脾与胃相为表里脏腑，脾宜升运，胃主纳降，脾升胃降则气机协调；若脾失健运，胃失和降，则气机紊乱，诸病丛生。脾与胃均属中土，土虚则气血生化之源匮乏，肝失所养，疏泄不及，因而形成郁象，临床上称之为"木不疏土"。．
正如(金匮要略)所云"见肝之病，知肝传脾，当先实脾"。所选药物，一方面要健脾，选白术、茯苓；脾与胃相表里，选和胃之陈皮、砂仁。另-方面要补肝柔肝，选当归、白芍；还要疏肝解郁，选柴胡、香附。常用处方逍遥散、痛泄要方。由于患者素体脾虚，运化失司，水湿下注，因而致泄。泄下之初尚属脾气不足，由于治疗不当，泄下不止，脾气虚进一步发展致脾气下陷，进而造成脾阳不振。按五行学说，脾为阴土，肾中命火为火，火能生土，亦属母子关系，子能令母虚，称之为"子盗母气"。因此泄下日久，由脾阳不足而导致肾中命火不足，出现脾肾阳虚。又肾为水，肝为木，肝肾为母子关系，"母病及子"，肾中命门相火衰而导致肝之相火不足，火不足便生寒，此乃阳虚是也。中医所说"肝主疏泄"是其功能，这种功能的发挥是靠阳的作用，因此肝"体阴而用阳"。
Teacher: It should be said that Shu Di (Prepared Rehmannia Root) played a key role. Because: ① The patient began to show signs of improvement after self-administering Shu Di, and it performed remarkably well from a critical condition; thereafter, Shu Di was included in every prescription, with the dosage increased from 30g to 60g, and sometimes up to 100g. According to incomplete statistics of prescriptions, approximately 2kg of Shu Di were used in total until the disease was cured; ② The patient also had experience using Shu Di to treat jaundice, and modern pharmacological research confirms that Shu Di has effects such as anti-radiation, hepatoprotection, blood sugar lowering, cardiotonic, hemostatic, diuretic, anti-inflammatory, and antifungal actions (as described in *New Uses of Chinese Materia Medica* edited by Wang Huiwu and Jia Hexian). Therefore, it has good therapeutic and maintenance effects on liver diseases; ③ From the perspective of pathogenesis analysis, Shu Di has the function of nourishing the Liver and Kidney, known as "nourishing Water to subdue Wood." The disease had penetrated into the Liver and Kidney, exhausting the fluids of these two organs, urgently requiring Shu Di for nourishment. Thus, Shu Di played a key role in curing this disease. Of course, the accompanying herbs also played a complementary role, as the saying goes, "Every disease must have a main formula, and every formula must have a main herb." This clinical fact of Shu Di reducing jaundice has broadened our horizons in treating jaundice, so I specifically introduce it to you for reference in clinical practice.
Severe Vertigo, Vomiting, and Edema
Professor Xiong Jibo, Hunan College of Traditional Chinese Medicine
Liang XX, female, 64 years old, retired teacher from Changsha. Consulted in winter 1991. The patient reported suffering from dizziness starting 2 months ago, accompanied by vomiting and lower limb edema. Diagnosed at a certain hospital as Meniere's syndrome and nephrotic edema. After more than a month of hospitalization, the effect was not obvious, and she had been bedridden for 2 months due to illness. Currently, the dizziness is worsening, unable to stand or walk; if forced to sit or stand, she feels the world spinning around, dizzy with darkening vision, feeling faint; and frequently experiences retching, loss of appetite, vomiting upon eating, and severe vomiting produces large amounts of thin white phlegm-saliva. Observing the patient, her body is emaciated, complexion pale and lusterless, lower limbs significantly edematous, shortness of breath, fatigue, low voice, and short breathing. Inquired about soreness and pain in the waist and legs, slight abdominal distension, very little food intake, loose stools that are unsatisfactory, and scanty clear urine. Tongue is pale with a thin white greasy coating, pulse is deep and fine. Comprehensive analysis of pulse and symptoms indicates a pattern of vertigo due to Spleen deficiency and Phlegm-fluid retention. The treatment principle is to strengthen the Spleen, warm the Middle, dispel Phlegm, and resolve fluid retention. Using Liu Jun Zi Tang (Six Gentlemen Decoction) plus Gan Jiang (Dried Ginger), Tian Ma (Gastrodia Rhizome), and Bai Kou Ren (Amomum Fruit). Prescription: Dang Shen (Codonopsis Root) 15g, Tu Chao Bai Zhu (Earth-fried Atractylodes Macrocephala Rhizome) 12g, Fu Ling (Poria) 30g, Chen Pi (Citrus Reticulata Peel) 10g, Fa Ban Xia (Processed Pinellia Tuber) 10g, Gan Jiang (Dried Ginger) 8g, Bai Kou Ren (Amomum Fruit) 8g, Tian Ma (Gastrodia Rhizome) 10g, Zhi Gan Cao (Honey-fried Licorice Root) 6g. Instructed to take 5 doses, one dose per day. Second visit: Vomiting significantly reduced after taking the medicine, able to consume porridge. Dizziness also felt lighter and slower, able to get out of bed and sit. But felt heavy head, palpitations, fatigue in four limbs, and lower limbs still edematous, tongue and pulse as before. Following the original method and formula, added Fu Ling Pi (Poria Skin) 15g and Da Fu Pi (Areca Peel) 10g, continued for another 5 doses. Third visit: Dizziness greatly reduced, vomiting stopped, able to stand and sit, and could walk indoors with support, able to eat 50g of rice per meal, stools no longer loose, lower limb edema significantly reduced. Now feels heavy head, palpitations, and heaviness/weakness in both feet. Tongue pale with thin white coating, pulse fine. Again following the original method, modified to Gui Sha Liu Jun Zi Tang (Six Gentlemen Decoction with Angelica and White Peony) with additions: Dang Shen (Codonopsis Root) 20g, Tu Chao Bai Zhu (Earth-fried Atractylodes Macrocephala Rhizome) 12g, Fu Ling (Poria) 20g, Chen Pi (Citrus Reticulata Peel) 10g, Fa Ban Xia (Processed Pinellia Tuber) 10g, Dang Gui (Angelica Sinensis Root) 10g, Bai Shao (White Peony Root) 10g, Tian Ma (Gastrodia Rhizome) 10g, Gan Jiang (Dried Ginger) 4g, Fu Ling Pi (Poria Skin) 10g, Da Fu Pi (Areca Peel) 10g, Gan Cao (Licorice Root) 6g. Fourth visit: Dizziness has subsided, able to walk independently, diet improved, palpitations and shortness of breath reduced, lower limb edema basically resolved. But feels weakness in both legs, soreness and heaviness in waist and knees. Tongue pale, pulse fine. Still adhering to the method of strengthening Spleen, benefiting Qi, resolving Phlegm, and transforming fluids, slightly adding Kidney-benefiting herbs, prescribed Gui Sha Liu Jun Zi Tang (Six Gentlemen Decoction with Angelica and White Peony) plus Tian Ma (Gastrodia Rhizome), Du Zhong (Eucommia Bark), and Huai Niu Xi (Achyranthes Bidentata Root). Took another 10 doses, all symptoms completely resolved, disease cured. Follow-up to present, no recurrence.
Doctor A: The patient's symptoms are complex; how do you judge it as a pattern of vertigo due to Spleen deficiency and Phlegm-fluid retention?
Teacher: Although the patient's symptom presentation is indeed complex, the main symptoms are three: dizziness, vomiting, and edema. Dizziness and blurred vision, severely feeling like riding in a boat, with a sensation of the world spinning around, to the extent that eyes cannot open and body cannot move, is defined as vertigo disease. As stated in *Ling Shu: Kou Wen*, "The ears suffer buzzing, the head suffers tilting, the eyes suffer dizziness." Vomiting is one of the common symptoms in vertigo disease. Severe vertigo is often accompanied by vomiting; and vertigo combined with vomiting mostly belongs to the sign of Phlegm-fluid retention. *Jin Gui Yao Lue* once pointed out, "There is retained fluid under the heart, the person suffers from severe dizziness and vertigo," and "Vomiting, epigastric fullness, water between the diaphragm, dizziness and palpitations." *Gu Jin Yi Tong* says, "Head and eye vertigo, darkness before eyes, feeling like riding in a boat, giddiness wanting to vomit, is Phlegm." Whenever vertigo disease presents with vomiting of phlegm-saliva, chest and diaphragm stuffiness, and white slippery greasy tongue coating, it is the characteristic manifestation of Phlegm-fluid vertigo pattern. *Zheng Yin Mai Zhi* says, "Symptoms of Phlegm-fluid vertigo include chest fullness, nausea and vomiting, gurgling water sound below the diaphragm, incessant dizziness and palpitations, headache on forehead, this is the symptom of Phlegm-fluid vertigo." Edema, referred to as "Water Qi" in *Jin Gui Yao Lue*, and later called "Edema" in subsequent generations. *Su Wen: Ping Ren Qi Xiang Lun* once pointed out, "Swelling of the face is Wind, swelling of the calves is Water." *Jin Gui Yao Lue* also pointed out, "Swelling below the waist should be treated by promoting urination." It can be seen that lower limb edema belongs to the harm of Water Qi. Now, this patient presents with vertigo, vomiting, and edema simultaneously, so the first consideration should be vertigo due to Phlegm-fluid and damp-water. Furthermore, the patient's emaciation, anorexia, recurrent bloating, loose stools, shortness of breath, fatigue, pale tongue, and fine pulse constitute a picture of Spleen deficiency. Spleen deficiency leads to failure of Middle Yang to rise, resulting in failure of transportation and transformation, thus generating internal Phlegm-fluid, causing vomiting and edema; Spleen deficiency leads to failure of Clear Yang to ascend, resulting in lack of source for production and transformation, thus causing deficiency of Qi and Blood, leading to vertigo. *Zheng Hui Hui Bu: Xuan Yun* says, "The Spleen is the Central Plain... If overworked, sweating excessively depletes Yang, Yuan Qi sinks, Clear Yang does not ascend, this vertigo arises from insufficiency of Middle Qi." From this, we know that the pathogenesis of this patient lies in Spleen deficiency and Phlegm-fluid, thus judging it as a vertigo pattern due to Spleen deficiency and Phlegm-fluid retention.
Doctor B: Please explain the principles of selecting Liu Jun Zi Tang plus Tian Ma and Gan Jiang for treating this disease.
Teacher: The vertigo pattern due to Spleen deficiency and Phlegm-fluid retention is a pattern of root deficiency and branch excess, where Spleen deficiency is the root and Phlegm-fluid is the branch. Due to Spleen deficiency failing to transport, fluid gathers to generate Phlegm, so the treatment method should be tonifying the Spleen as the root and eliminating Phlegm-fluid as the branch. Using Liu Jun Zi Tang (Six Gentlemen Decoction) precisely takes advantage of its functions of tonifying the Spleen and dispelling Phlegm. *Shen Zhai Yi Shu: Tou Yun* states, "When Middle Qi is deficient, the Spleen fails to transform and transport, leading to generation of Phlegm that rebels upward causing dizziness, use Si Jun Zi Tang (Four Gentlemen Decoction) plus Ban Xia (Pinellia Tuber) and Tian Ma (Gastrodia Rhizome)." *Yi Xue Xin Wu: Xuan Yun* further states, "For those with Qi deficiency complicated by Phlegm, books say: When Clear Yang does not ascend and Turbid Yin does not descend, the upper becomes heavy and the lower becomes light, Liu Jun Zi Tang (Six Gentlemen Decoction) governs it." Additionally, Tian Ma (Gastrodia Rhizome) is an essential herb for extinguishing Wind and treating vertigo. Now, the patient's vertigo prevents sitting or standing, even feeling faint, requiring Tian Ma (Gastrodia Rhizome) to extinguish Wind and stabilize vertigo to suppress the momentum of Wind-vertigo. Li Dongyuan said, "Black eyes and head vertigo, internal movement of Deficient Wind, without Tian Ma (Gastrodia Rhizome) it cannot be removed." Gan Jiang (Dried Ginger) is an herb that warms and moves Middle Yang. Now, the patient vomits thin saliva, suffering from Phlegm-fluid, and Fluid is a Yin pathogen, "For diseases of Phlegm-fluid, one should harmonize with Warm herbs," thus using Gan Jiang (Dried Ginger) to warm the Middle and振奋 Yang to control the prevalence of Yin cold. In addition, Bai Kou Ren (Amomum Fruit) is added to the formula for its ability to aromatic-transform turbidity and stop vomiting. At the second visit, Fu Ling Pi (Poria Skin) and Da Fu Pi (Areca Peel) were added to the formula, intending to leach out damp-water to reduce foot edema. After vomiting stops and edema resolves, Gui Sha Liu Jun Zi Tang (Six Gentlemen Decoction plus Dang Gui (Angelica Sinensis Root) and Bai Shao (White Peony Root)) is used again, because this formula has the efficacy of tonifying Spleen and benefiting Qi, nourishing Blood and astringing Liver, dispelling Phlegm and transforming turbidity, making it an effective formula for treating vertigo due to Spleen deficiency, Phlegm-turbidity, and Qi-Blood deficiency, thus used to conclude the treatment.
Doctor C: The etiology and pathogenesis of vertigo disease are complex, with many syndrome classifications; what are the main aspects of clinical differentiation and treatment?
Teacher: Physicians of past dynasties had complex classifications for vertigo syndrome differentiation. Clinically, vertigo disease mainly lies in three aspects: due to Wind, due to Phlegm, and due to Deficiency. First, vertigo due to Wind is divided into External Wind and Internal Wind. External Wind refers to vertigo caused by exogenous Wind pathogen, which often occurs after a cold, presenting with vertigo, headache, aversion to wind, etc. *Zheng Yin Mai Zhi: Wai Gan Xuan Yun* says, "Headache and forehead pain, bone joint irritability and pain, body heat with much sweating, upper asthma and rebellion, restlessness and occasional vertigo, this is the syndrome of Wind pathogen vertigo." Treatment should prioritize releasing the exterior and dispelling Wind, optionally choosing Ju Hua Cha Tiao San (Chrysanthemum Powder for Regulating the Pulse) with modifications. Internal Wind refers to vertigo caused by hyperactivity of Liver Wind, *Nei Jing* states, "All Wind tremors and vertigo belong to the Liver." *Yan Shi Ji Sheng Fang* further states, "Liver Wind attacking upwards inevitably causes vertigo." This syndrome worsens with emotional stimulation, presenting with vertigo, tinnitus, head distension and pain, irritability, insomnia, flushed complexion, numbness in four limbs, etc. Second, vertigo due to Phlegm is also divided into Phlegm-Dampness and Phlegm-Fire. *Dan Xi Xin Fa* states, "Without Phlegm, there is no vertigo... there are also Wet Phlegm and Fire Phlegm." Phlegm-Dampness vertigo presents with vertigo, chest tightness, vomiting, bland taste, white slippery greasy tongue coating. Treatment should prioritize dispelling Phlegm and transforming dampness, optionally choosing Ban Xia Bai Zhu Tian Ma Tang (Pinellia, Atractylodes, and Gastrodia Decoction). Phlegm-Fire vertigo presents with vertigo, chest tightness, vomiting, bitter taste, yellow slippery greasy tongue coating. Treatment should prioritize dispelling Phlegm and purging Fire, optionally choosing Huang Lian Wen Dan Tang (Coptis Warming Gallbladder Decoction) plus Tian Ma (Gastrodia Rhizome) and Gou Teng (Uncaria Ramulus cum Uncis). Third, vertigo due to Deficiency, this syndrome starts slowly, persists, and often occurs in the elderly, weak individuals, or after serious/prolonged illnesses. For deficiency vertigo, ancients believed there are types of Qi deficiency, Blood deficiency, Yang deficiency, Yin deficiency, Heart deficiency, Spleen deficiency, Kidney deficiency, and Liver deficiency. However, clinically common are mainly Spleen deficiency and Kidney deficiency. Spleen deficiency vertigo mainly lies in lack of source for production and transformation, insufficient Qi and Blood. *Zheng Hui Hui Bu: Xuan Yun* says, "The Spleen is the Central Plain, ascending Yang of Heart and Lung, defending Yin of Liver and Kidney. If overworked, sweating excessively depletes Yang, Yuan Qi sinks, Clear Yang does not ascend, this vertigo arises from insufficiency of Middle Qi." Manifestations include vertigo, desire to vomit, poor appetite, mental fatigue, bright white complexion, pale tongue with white coating, fine or empty pulse. Treatment should prioritize tonifying Spleen, benefiting Qi, and nourishing Blood, optionally choosing Gui Sha Liu Jun Zi Tang (Six Gentlemen Decoction with Angelica and White Peony). Kidney deficiency vertigo mainly lies in depletion of Kidney Essence, as the Kidney stores Essence and generates Marrow, Kidney deficiency and Essence depletion lead to "insufficiency of Sea of Marrow, brain turning and tinnitus, calf soreness and vertigo, eyes seeing nothing," thus presenting with vertigo, tinnitus, mental depression, soreness and weakness of waist and knees, even seminal emission and night sweats. Treatment should prioritize tonifying Kidney and filling Essence, optionally choosing Zuo Gui Yin (Left Restoring Decoction), Qi Ju Di Huang Wan (Lycium, Chrysanthemum, and Rehmannia Pill), or Gui Lu Er Xian Jiao (Tortoise and Deer Two Immortals Gelatin). Summarizing the three aspects of Wind, Phlegm, and Deficiency, they essentially fall into two ends of Excess and Deficiency. Deficiency involves Spleen and Kidney deficiency as the root of disease; Excess involves Wind pathogen and Phlegm-turbidity as the branch of disease. Clinically, pure deficiency or pure excess cases are few, while mixed Excess and Deficiency, root deficiency and branch excess cases are common. The general principle of differentiation and treatment is to examine symptom characteristics, view the urgency of root and branch, tonify deficiency and purge excess, and treat both root and branch simultaneously. The case presented above is an example of simultaneous treatment of root and branch.
Diarrhea Case
Professor Liu Xingzhi, Beijing University of Chinese Medicine
Ni XX, female, 25 years old, worker. Suffering from abdominal pain and diarrhea for over 5 years, diagnosed as chronic enteritis, came to seek TCM treatment after repeated treatments failed. Initial consultation on December 31, 1981. Reported abdominal pain and diarrhea for 5 years, currently right lower abdominal pain, borborygmus, diarrhea immediately after abdominal pain, pain relieved after defecation, bowel movements 3-5 times daily, poor appetite, postprandial epigastric and hypochondriac distension and fullness. Emaciated body and muscles, sallow complexion lacking luster. Tongue pale with teeth marks, white coating, six pulses deep and fine. TCM believes the Kidney controls the two extremities, prolonged diarrhea damages the Kidney, leading to Kidney Yang deficiency and decline of Mingmen Fire, fire decline cannot generate Earth, Earth deficiency means Wood cannot reach, resulting in Spleen-Kidney Yang deficiency and Wood failing to soothe Earth. Thus, treatment should prioritize warming and tonifying Spleen-Kidney Yang, regulating Liver Wood, and astringing intestines to stop diarrhea. Based on Si Shen Wan (Four Spirits Pill) combined with Tong Xie Yao Fang (Essential Formula for Painful Diarrhea) with modifications: Bu Gu Zhi (Psoralea Fruit) 15g, Wu Zhu Yu (Evodia Fruit) 10g, Rou Dou Kou (Nutmeg) 15g, Pao Jiang (Roasted Ginger) 10g, Bai Zhu (Atractylodes Macrocephala Rhizome) 24g, Hang Shao (Hangzhou White Peony Root) 15g, Chen Pi (Citrus Reticulata Peel) 10g, Fang Feng (Saposhnikovia Root) 10g, Fu Ling (Poria) 15g, Chao He Zi (Fried Chebula Fruit) 15g, Zhi Ying Su Ke (Honey-fried Poppy Shell) 15g, Chao Yi Yi Ren (Fried Coix Seed) 15g. Decoct in water, take one dose daily.
Second consultation on January 4, 1982: Took 3 doses of the above prescription, stool formed, once daily. But recently developed dizziness. Diet acceptable, tongue and pulse same as before. Believed the appearance of vertigo was due to prolonged diarrhea damaging Spleen and Stomach, insufficiency of Middle Qi, failure of Clear Yang to ascend, thus added Tai Zi Shen (Pseudostellaria Root) 15g to enhance tonification of Middle and benefit Qi, Zhi Gan Cao (Honey-fried Licorice Root) 10g, Xi Xin (Asarum Root) 5g which is pungent and warm, opens the nine orifices and ascends Yang, and Ge Gen (Kudzu Root) 12g to encourage Stomach Qi to ascend.
Third consultation on January 11, 1982: After taking the above prescription, the state of dizziness and faintness has disappeared, still slight right lower abdominal pain, occasional borborygmus, abdominal pain wanting to defecate, pain stops after defecation, stool still loose. Coating thin white and moist, pulse deep and fine. Prolonged diarrhea, Spleen-Kidney deficiency-cold, intestines losing firmness and astringency. Thus changed to Zhen Ren Yang Zang Tang (True Human Nourishing Viscera Decoction) to warm and tonify Spleen-Kidney, firm and astringe to stop diarrhea. Medicinals: Lu Dang Shen (Lu Codonopsis Root) 15g, Bai Zhu (Atractylodes Macrocephala Rhizome) 18g, Gui Xin (Cinnamon Twig Center) 10g, Zhi Gan Cao (Honey-fried Licorice Root) 6g, Pao Jiang (Roasted Ginger) 10g, Ying Su Ke (Poppy Shell) 15g, Rou Dou Kou (Nutmeg) 15g, He Zi (Chebula Fruit) 15g, Guang Mu Xiang (Costus Root) 6g. Decoct in water, take one dose daily.
Fourth consultation on March 18, 1982: After taking the medicine, abdominal pain and diarrhea showed effectiveness, spirit stable, self-confidence enhanced. Recently appeared every time during Yin hour, abdominal pain and diarrhea, occasional borborygmus, slight epigastric distension. Tongue pale red with white coating, pulse deep and fine. Observing the condition, the deficient and declining body has improved, organ functions adjusted, Yang Qi gradually recovering. Zhang Jingyue said, "Yang Qi not yet recovered, Yin Qi extremely deficient, Mingmen Fire declining, Stomach Gate not firm leading to diarrhea." Thus still following the previous method, strengthening the power of warming Yang and supplementing Fire, imitating Zhang Xichun's Modified Si Shen Wan (Four Spirits Pill), assisted by herbs softening Liver and strengthening Spleen, beating the drum to advance again. Medicinals: Bu Gu Zhi (Psoralea Fruit) 15g, Dou Kou (Cardamom) 15g, Wu Zhu Yu (Evodia Fruit) 10g, Pao Jiang (Roasted Ginger) 10g, Chao Bai Shao (Fried White Peony Root) 10g, Bai Zhu (Atractylodes Macrocephala Rhizome) 15g, He Zi (Chebula Fruit) 15g, Ge Gen (Kudzu Root) 15g, Fu Ling (Poria) 15g, Ying Su Ke (Poppy Shell) 15g, Tian Sheng Huang (Unknown Herb, likely typo for Tian Nan Xing or similar, kept as Tian Sheng Huang) 10g, Jiu Xiang Chong (Cydnus Bug) 10g. Decoct in water, take one dose daily.
Fifth consultation on April 8, 1982: After taking the above prescription, pain removed and diarrhea stopped, but felt tired, dream-disturbed sleep, already desiring fragrant food tastes. Tongue slightly red, white coating, pulse deep and fine but stronger. Should add Wu Wei Zi (Schisandra Berry) 10g to the above prescription to astringe Lung Qi, nourish Kidney Water, when Qi transports and Water ascends, Heart and Kidney intersect, night sleep naturally peaceful. Prescription: Bu Gu Zhi (Psoralea Fruit) 15g, Wu Zhu Yu (Evodia Fruit) 10g, Rou Dou Kou (Nutmeg) 15g, Wu Wei Zi (Schisandra Berry) 10g, Chao Bai Shao (Fried White Peony Root) 15g, Bai Zhu (Atractylodes Macrocephala Rhizome) 24g, Fu Ling (Poria) 30g, Ge Gen (Kudzu Root) 15g, Ying Su Ke (Poppy Shell) 15g, Pao Jiang (Roasted Ginger) 10g, Tian Sheng Huang (Unknown Herb) 10g, Jiu Xiang Chong (Cydnus Bug) 10g, Chen Pi (Citrus Reticulata Peel) 10g. Effective with decoction, changed to honey pills for regular use. On October 21, 1982, the patient consulted for otitis media, mentioned the old ailment of diarrhea, happily reported that after careful treatment in the previous stage, abdominal pain and diarrhea were completely cured, never recurring.
Doctor A: What is the basic pathogenesis of this disease? The evolution process of the disease? Which formula to use?
Teacher: *Nei Jing* warns us to strictly guard "Pathogenesis," which is the key to analyzing and treating diseases. Understanding the evolutionary laws of diseases is the deepening process of recognizing diseases, facilitating comprehensive mastery of diseases, thereby better grasping "Pathogenesis," examining syndromes to administer treatment. The basic pathogenesis of this case is prolonged diarrhea leading to Spleen-Kidney Yang deficiency and Wood failing to soothe Earth. The patient was only 20 years old when suffering from the stubborn disease of abdominal pain and diarrhea. Combining the patient's usual poor appetite and epigastric distension, emaciation and short spirit, sallow complexion lacking luster, it is known that the patient constitutionally has Spleen deficiency. TCM believes the Spleen is the foundation of Post-Heaven, the source of Qi and Blood production, governing the transportation and transformation of essence of grains and water. The Spleen and Stomach are interior-exterior related organs, the Spleen prefers ascending and transporting, the Stomach governs receiving and descending, Spleen ascending and Stomach descending results in coordinated Qi mechanism; if Spleen loses healthy transportation and Stomach loses harmonious descending, the Qi mechanism becomes chaotic, various diseases arise. Both Spleen and Stomach belong to Central Earth, Earth deficiency leads to scarcity of source for Qi and Blood production, Liver loses nourishment, insufficient free flow, thus forming stagnation image, clinically called "Wood failing to soothe Earth." As stated in *Jin Gui Yao Lue*, "Seeing Liver disease, knowing Liver transmits to Spleen, should first solidify Spleen." Selected drugs, on one hand to strengthen Spleen, choose Bai Zhu (Atractylodes Macrocephala Rhizome) and Fu Ling (Poria); Spleen and Stomach are interior-exterior, choose harmonizing Stomach herbs Chen Pi (Citrus Reticulata Peel) and Sha Ren (Amomum Fruit). On the other hand to tonify and soften Liver, choose Dang Gui (Angelica Sinensis Root) and Bai Shao (White Peony Root); also to soothe Liver and relieve depression, choose Chai Hu (Bupleurum Root) and Xiang Fu (Cyperus Rhizome). Commonly used formulas Xiao Yao San (Free Wanderer Powder) and Tong Xie Yao Fang (Essential Formula for Painful Diarrhea). Due to the patient's constitutional Spleen deficiency, failure of transportation and transformation, damp-water flows downward, thus causing diarrhea. Initially diarrhea belonged to Spleen Qi insufficiency, due to improper treatment, diarrhea did not stop, Spleen Qi deficiency further developed to Spleen Qi sinking, subsequently causing Spleen Yang depression. According to Five Elements theory, Spleen is Yin Earth, Ming Fire in Kidney is Fire, Fire generates Earth, also belonging to mother-son relationship, son can make mother deficient, called "Son stealing Mother Qi." Therefore, prolonged diarrhea, from Spleen Yang insufficiency leads to Ming Fire insufficiency in Kidney, appearing Spleen-Kidney Yang deficiency. Also Kidney is Water, Liver is Wood, Liver-Kidney are mother-son relationship, "Mother disease affecting Son," Mingmen Minister Fire decline in Kidney leads to insufficient Minister Fire in Liver, Fire insufficiency generates Cold, this is Yang deficiency. TCM says "Liver governs free flow" is its function, the exertion of this function relies on Yang action, therefore Liver is "Yin in substance and Yang in function."