实证之不寐，为邪气内扰，心神不安所致。热扰心神症见心烦不寐，坐卧不安，发热，或门干口渴，舌苔微黄；重则心中烦热，胸巾如焚，或口舌生疮，齿龈肿痛，咽干唇焦，尿赤便秘，舌红苔黄，脉数有力。此证或由外邪不解，化热入里；或由五志过急化火而致。治宜清宣郁热。可用余氏清心凉膈散(薄荷、连翘、桔梗、甘草、栀子、黄芩、石膏)，重者可用凉瞒散：阳明热炽症见发热或恶热，心中烦热不寐，口渴欲饮，苔黄而燥，或大便秘结。此证多由外邪化热，传入阳明，胃热炽盛，上扰心神而不寐。可用白虎汤加黄连，清阳明之热兼泻心火。
肝胆有热症见胸胁胀闷或热痛，心烦易怒，口干而苦，或头晕耳鸣，舌红苔黄(或干或腻)。此证多由肝郁不疏，或恚怒不解，致肝胆郁热，上扰心神。宜用龙胆泻肝汤或当归龙荟丸，清泻肝胆之热。
痰浊内盛症见失眠而胸脘满闷烦乱不堪，时欲呕恶、头重、目眩、舌淡胖、苔白厚浊腻；也有痰浊日久化热而成痰热内扰者，除上症外，又见心中烦热，口苦，苔黄腻，脉滑数等症。治宜化痰浊而宁心神。前症可用温胆汤加夜交藤；后者可用温胆汤加黄连、栀子。
此外，尚有因食积内停者，可用保和丸等消食导滞；有因气滞气逆者，可用四磨饮子、木香顺气丸等理气降逆；有因水饮内停者，可用五苓散、五皮饮等淡渗分利；有因阴寒之邪者，宜用理中汤等温中散寒。虚证多为阴血不足，或兼有虚热：气血两虚，心脾不足症见多梦易惊，心悸不寐，倦怠神疲，饮食无味，面色少华，舌淡苔薄，脉细弱。此证多由劳倦或思虑过度所致，宜健脾益气，养心生血，可用归脾丸等。
阴血不足，兼有虚热症见心烦失眠，口干咽燥，五心烦热，舌质红、脉细数，或有头晕耳鸣，遗精、腰酸、心悸等症。此证多由思虑过度、耗伤心血，或肾阴虚损而生虚热。治宜天王补心丹、朱砂安神丸等，滋阴养血而清虚热。或用黄连阿胶汤。此外，尚有由劳倦太过，心脾两伤，中气不足，清阳不升，外感不解而寒热不寐者，可用补中益气汤。
食少、纳呆半年
长春中医学院教授肖永林
长春中医学院周丽雅
患者李XX，女，52岁，家住长春市朝阳区清和街。1978年3月初诊。患者食欲不佳、饮食少思已半年余。曾用多种中西药物治疗不效，遂来求治。患者形体消瘦。食欲明显减退，少食不饥，疲乏无力。常口舌干燥而喜凉，但口干而不能多饮，喜凉而少进即止。自觉食道至胃脘部常有灼热感。近半年来，大便经常干燥而涩滞难解。舌质光红无苔，舌面少津有小裂纹。曾屡用香砂养胃丸、人参健脾丸、人参归脾丸、紫蔻丸、保和丸，以及酵母片、胃蛋白酶等。还曾用过几剂汤药，其药大致为砂仁、木香、陈皮、白术、香橼、佛手、党参、内金、三仙、半夏、竹茹、莱菔子、谷芽等。
根据患者之证情及所用之药，尤其是其舌象之特点，综合分析，其证为胃阴不足，胃降不畅所致之食少、纳呆及便秘。拟用叶氏养胃汤加减，以濡胃阳而复胃用。沙参20g，麦冬15g，石斛15g，玉竹15g，生地15g，扁豆10g，甘草10g，桑叶10g。水煎多取汁，每日1剂。
3剂后，自觉食道及胃部之灼热感大减。口唇干燥减轻，食欲有增，大便通润。又服2剂，食欲增加，已知饥饿，每餐可进食100-150g，口干舌燥，胃中灼热感消除。大便每日1行，已不干燥。视其舌上已有津液，舌色已转为淡红，并有一层薄苔。据其证情，病已基本痊愈，嘱其再取3剂，多煎汁，不拘次数，当茶饮(因此药味甘易饮)，以滋补胃肠之津液。
医生甲请老师谈一下诊治此证之思路。
老师：食少纳呆一证，临床较为多见，但治疗有效有不效。盖因此证之原因不一，证情各异，如不仔细查询证情、病史及用药情况，而只是治以健脾理气，开胃进食之晶，则往往会有很大一部分患者疗效不佳。总的来看，食少纳呆之证，大抵不外虚、实两类。所谓实者，是由邪气有余，干犯胃府而致胃气不降。凡证属实者，皆有实证实脉等一派有余之象。去其有余之邪，则胃气复常，而饮食自能如常。所谓虚者，由于正气不足。其中有脾胃自身之虚者，也有由其他脏腑之虚损而累及于脾胃者。
此患者之食少纳呆，既无痞闷胀满之证，也无湿阻、气滞、食积之征，又无热炽、寒凝之象，故其证非实可知。从患者之临床表现看，既无胸满痰咳喘逆等肺脏之病，也无胸胁胀痛，口苦太息等肝病之形，更无腰膝酸痛、烦热形寒等肾虚之证，又无心悸、失眠、痛闷等心病之证。故其食少纳呆非由其他脏腑之影响可知。既与其他脏腑无涉，定是脾胃自身之虚而然。脾胃之虚所致之食少纳呆，一为阳气不足，一为阴液虚少。从患者之症情来看，如为阳气不足，口中应该淡和而不干渴，胃脘和食道不应有灼热感，大便应为溏薄，舌象应为色淡而多津，舌体应正常或胖大而不该舌红少津而干裂。此患者之症情完全与之相反，所以要考虑到本患者应为胃阴虚证。
再从患者所服过的药物看，曾用过香砂养胃丸，人参健脾丸等而不效，说明其病并非脾胃阳气不足。既非阳气不足，则为阴液亏损已明。故采用了甘寒滋润，濡养胃阴的方法，果然收到了满意的疗效，说明辨证是正确的。
医生乙从古书记载与临床来看，治食少纳呆之证，一般多采用健脾益胃，理气消导等法。而如老师前面所分析的那样，确实较为少见，老师能否谈一下这一问题。
老师：这位同学讲得很对，在以前的各种医书中，对食少纳呆一证，大多责之于脾胃气虚或气滞，食滞不化，肝郁乘脾，痰湿困阻或下焦肾阳不足，火不生土等。对于实证，姑且不谈。即使是虚证，也多从阳气不足立论。如陈修园在(医学实在易)中说，"不能食者，胃中元气虚也"。在治疗上，李念莪在(医家必掷中说，"不能食皆属脾虚，四君子汤、补中益气汤。补之不效，当补其母，八味地黄丸、二神丸。挟痰宜化，六君子汤。挟郁宜开，育气汤。仇木宜安，异功散加木香、沉香……"。看来对于食少纳呆之因于脾胃者，多以阳气虚衰论之。治之者，始则补益脾胃之气，继则温煦下焦之阳，或佐陈皮、半夏以化痰湿，或佐木香、砂仁以开胃气，或配香附、青皮以疏肝郁。但其用药皆为辛甘温热疏通之品，性偏刚燥。李东垣为金元四大家之一，以善治脾胃之病见长，被称为补士派。但其(脾胃论)中之论治，以脾气不足，胃阳衰弱为主。
其方如补中益气汤，升阳益胃汤，调中益气汤等，无不以参术芪草等为主，重在升补脾胃阳气，而对胃阴虚者则略而未详。后世治食少纳呆者，亦多以甘温补益、辛香行滞、消导之晶为主，这对胃阴不足之食少纳呆者，不唯无益，而且有害。至清代叶天士，精辟地论述了脾与胃在生理、病理和治疗方法上的不同之处，给后世对胃阴虚证的治疗开创了新的方法。其对医学的贡献不亚于(脾胃论>，实可补东垣之未备，《临证指南医案》曾对他的观点进行了详尽的阐发，"脾胃之论，莫详于东垣。所著补中益气、凋中益气、升阳益胃等汤，诚补前人之未备。察其立方之意，因以内伤劳倦为主；又因脾乃太阴湿土，且胃阳衰者居多，故用参、芪以补中，二术以燥湿，升柴升下陷之清阳，陈皮、木香理中宫之气滞，脾胃合治，用之得宜，效诚桴鼓。盖东垣之法，不过详于治脾，略于治胃耳。后人宗其意，竟将脾胃总论，即以治脾之药优侗治胃。今观叶氏书，始知脾胃当分析而论。盖胃属戊土，脾属己土，戊阳己阴，阴阳之性有别也。脏宜藏，腑宜通，脏腑之体用有殊也。若脾阳不足，胃有寒湿，一脏一腑，皆宜于温燥升运者，自当恪遵东垣之法。若脾阳不亏，胃有燥火，则当遵叶氏养胃阴之法。观其立论云：纳食主胃，运化主脾，脾宜升则健，胃宜降则和。又云：太阴湿土，得阳始运；阳明燥土，得阴自安，以脾喜则燥，胃喜柔润也。仲景急下存津，其治在胃；东垣大升阳气，其治在脾。……故凡遇禀质木火之体，患燥热之证，或病后热伤津液，以致虚痞不食，舌绛咽干，烦渴不寐，肌燥，嫡热，便不通爽，此九窍不和，都属胃病，岂可以芪、术、升、柴治之乎?所谓胃宜降则和者，非辛开苦降，亦非苦寒下夺，以损胃气，不过甘乎，或甘凉濡润，以养胃阴，则津液来复，使之通降而已矣。此义即宗《内经》所谓六腑者，传化物而不藏，以通为用之理也。总之，脾胃之病，虚实寒热，宜燥宜润，固当详判，其于升降二字，尤为紧要。脾气下陷固病，即不下陷，但不健运，已病矣。胃气上逆固病，即不上逆，但不通降，亦病矣"。本患即遵叶氏之旨，以甘寒滋润之法养胃津而复胃用而使病愈。
医生丙请老师谈一下食少纳呆的辨证施治。
老师：食少纳呆，无不关乎脾胃。脾胃之气健旺，升降自如，则能纳能化；脾胃之气虚或气滞，则出现食少纳呆。食少纳呆有虚实之分。其实者，或由气滞、或因湿困、或由食伤、或因热盛，皆可导致脾胃气机不畅而致食少纳呆。其虚者，不外脾胃阳气虚弱与阴血亏少。大抵实证多见于暂病，虚证多见于久病。亦有虚实挟杂者。实证之治以祛邪为主。邪气去则脾胃之气复而自能饮食。
因于气滞者，多由情态不遂、喜怒不解而肝郁不疏，肝气郁结不能疏泄则脾胃之气也因而呆滞。此证之治当分久暂而辨虚实。大抵初病可见胸胁胀满或疼痛者，为肝郁不疏，当以疏肝解郁为主，如用柴胡疏肝汤等。若久病肝郁已解而唯脾胃受损者，宜补益脾胃，可用香砂六君子汤。若肝郁脾虚者，可用逍遥散。
湿困脾胃，也较多见，或由外湿、或因内湿，皆可困阻脾胃气机而致食少纳呆，其症多见脘腹痞闷，身肢困重，舌苔白腻，治宜芳香辛散之剂，如三仁汤、乎胃散等，宣气化湿以甦醒脾胃。食伤脾胃者，在上者以消食和胃为主，宜用保和丸；在下者以导滞通腑为主，可用枳实导滞丸。
若食伤脾胃，吐泻太甚，或攻伐太过，或迁延日久，脾胃受伤而难存虚证者，按虚证治。因于热盛而食少纳呆者，多见门苦苔黄等一派热象，但清其热，热去则胃气复，自能饮食。虚证之治以补益为主，当分阴阳气血。
再辨是因于脾胃自身之虚，还是由他脏之病而累及者。对脾胃阳气虚者，可用甘温补益法，如四君子汤、异功散、六君子汤、补中益气汤等。偏寒者可用理中汤。若由下焦阳虚，火不生土而致者，可用金匮肾气丸、二神丸(补骨脂、肉豆蔻)补命火以生脾上。若脾胃气虚而兼食滞者，可用健脾丸消补兼施。至于胃阴虚者，前面已经谈过。若由肾阴不足或血虚而致者，可用滋阴补血之品。
呕恶、吐涎沫7，头痛
长春中医学院教授 肖永林
长春二道河子区中医院王精兰
周XX，女，43岁，1977年11月来诊。诊患近3年来经常恶心，呕吐涎沫，剧则头痛眩晕，头沉重，手足发凉。曾用过中、西药物治疗，始终未除根。每于饮食寒凉，或气恼忧郁之时，或天气突然寒冷之际，多有发作。
询其病史，患者身体素弱，睥胃虚寒，平素喜温热及熟烂的食物，稍犯生冷硬物则脘腹胀满疼痛，或出现腹泻。于3年前的秋冬之交，天气突然变冷，自觉心窝部不适，扪之发凉。不欲饮食，时时恶心，呕吐涎沫，稀白而发凉。又觉头部眩晕，发沉，难于抬举。吐后身体疲惫之极，卧床不起，令家人熬生姜汤，饮后稍舒。以后经常发作，发则疲乏无力，四肢怠堕，手足发凉，身冷恶寒，又渐出现头痛。得温热则病减，遇寒凉则病增。视其形体衰弱，面色灰白，眼睑发黑，神情憔悴，口唇淡白，舌淡苔薄白而滑润，脉象沉弱，四末欠温。
据其病史，症侯，舌象及脉象分析，其病乃由脾胃虚寒，阳气不足，痰饮内停，以致胃气不降，痰浊上犯，清阳不升而成。治当温补脾胃，化痰蠲饮，药以辛甘温热为主。人参10g，吴茱萸10g，白术25g，白茯苓15g，姜半夏20g，陈皮15g，天麻20g，炙甘草10g，生姜20g，大枣5枚(劈开)。水煎3次，分3次于1日内服完。3剂后，觉腹中温暖，胀满消而疼痛减，恶逆少而眩晕轻，头痛也得以缓解。又3剂，心窝部扪之已无发凉之感，饮食增加，诸症向愈。为巩固疗效，使用上方3剂，共为细末，炼蜜为丸，每丸重15g，每日服3丸(早、午、晚分服)。自药后未再发作。
医生甲请老师谈一下辨认此证之思路。
老师：此患病已3年，且反复发作，并无表证可察，其病不属于外感，已属无疑。那么，就应从内伤的角度来辨识此病：视其以前所用方荮，有单独治恶心、呕吐的，如用过藿香正气汤、小半夏汤；有只治眩晕或头痛的，如川芎茶调散、清眩丸等；又每于头痛之时经常服用去痛片。以上药物虽能临时解决一些痛苦，但皆不能根除。故治疗此患，就要从整体观念出发，看看这些症状有无内在的联系，以求辨明病本之所在。
Insomnia due to excess patterns is caused by internal disturbance of pathogenic factors, leading to unrest of the Shen (Spirit). Symptoms of heat disturbing the Shen include irritability and insomnia, restlessness in sitting or lying, fever, or dry mouth and thirst, with a slightly yellow tongue coating; in severe cases, there is vexing heat in the heart, chest feeling like burning, sores on the mouth and tongue, swelling and pain of the gums, dry throat and scorched lips, dark urine, constipation, red tongue with yellow coating, and rapid and forceful pulse. This pattern may result from unresolved external pathogens transforming into heat and entering the interior, or from excessive emotional activity generating fire. The treatment should focus on clearing and dispersing stagnant heat. Yu Shi Qing Xin Liang Ge San (Yu's Clear Heart and Cool Diaphragm Decoction, containing Bohe/Menthae Haplocalycis Herba, Lianqiao/Forsythiae Fructus, Jiegeng/Platycodonis Radix, Gancao/Glycyrrhizae Radix et Rhizoma, Zhizi/Gardeniae Fructus, Huangqin/Scutellariae Radix, Shigypsum) can be used; for severe cases, Liang Ge San (Cool Diaphragm Powder) may be employed. Symptoms of blazing heat in the Yangming channel include fever or aversion to heat, vexing heat in the heart with insomnia, thirst with desire to drink, yellow and dry tongue coating, or constipation. This pattern often arises when external pathogens transform into heat and transmit to the Yangming channel, where stomach heat blazes and disturbs the Shen, causing insomnia. Bai Hu Tang (White Tiger Decoction) added with Huanglian/Coptidis Rhizoma can be used to clear Yangming heat and drain heart fire.
Heat in the Liver and Gallbladder presents with distension and fullness or hot pain in the chest and hypochondrium, irritability, dry and bitter mouth, dizziness, tinnitus, red tongue with yellow coating (dry or greasy). This pattern is mostly caused by stagnation of Liver Qi or unresolved anger, leading to stagnant heat in the Liver and Gallbladder that disturbs the Shen. Long Dan Xie Gan Tang (Gentian Decoction to Drain the Liver) or Dang Gui Long Hui Wan (Angelica Dragon Bile Pill) should be used to clear and drain Liver and Gallbladder heat.
Excessive turbid phlegm internally manifests as insomnia accompanied by unbearable fullness, oppression, and confusion in the chest and epigastrium, frequent nausea and vomiting, heavy head, vertigo, pale and swollen tongue with thick, white, greasy coating. In some cases, turbid phlegm transforms into heat over time, resulting in internal disturbance by phlegm-heat; besides the above symptoms, there is also vexing heat in the heart, bitter taste, yellow greasy coating, and slippery rapid pulse. Treatment should focus on resolving turbid phlegm and calming the Shen. For the former, Wen Dan Tang (Warm the Gallbladder Decoction) added with Yejiaoteng/Polygoni Multiflori Caulis can be used; for the latter, Wen Dan Tang added with Huanglian/Coptidis Rhizoma and Zhizi/Gardeniae Fructus.
Additionally, there are cases due to food retention, treatable with Bao He Wan (Preserve Harmony Pill) to promote digestion and remove stagnation; cases due to Qi stagnation and rebellion, treatable with Si Mo Yin Zi (Four Fragments Drink) or Mu Xiang Shun Qi Wan (Aucklandia Regulating Qi Pill) to regulate Qi and descend rebellion; cases due to internal retention of fluid retention, treatable with Wu Ling San (Five Ingredient Powder with Poria) or Wu Pi Yin (Five Peel Drink) to promote diuresis and separate turbidity; cases due to Yin-cold pathogens, treatable with Li Zhong Tang (Regulate the Middle Decoction) to warm the middle and dispel cold. Deficiency patterns are mostly due to insufficiency of Yin and Blood, or accompanied by deficient heat: Qi and Blood deficiency with Heart and Spleen insufficiency presents with vivid dreams and easy fright, palpitations and insomnia, fatigue and listlessness, loss of appetite, lackluster complexion, pale tongue with thin coating, and fine weak pulse. This pattern is mostly caused by overwork or excessive mental exertion; treatment should strengthen the Spleen, benefit Qi, nourish the Heart, and generate Blood, using Gui Pi Wan (Restore the Spleen Pill).
Yin and Blood insufficiency with deficient heat presents with irritability and insomnia, dry mouth and throat, five-palm heat, red tongue body, fine and rapid pulse, possibly accompanied by dizziness, tinnitus, spermatorrhea, soreness and weakness of the waist, and palpitations. This pattern is mostly caused by excessive mental exertion consuming Heart Blood, or Kidney Yin damage generating deficient heat. Treatment should use Tian Wang Bu Xin Dan (Emperor of Heaven's Special Pill to Tonify the Heart) or Zhu Sha An Shen Wan (Cinnabar Calming Spirit Pill) to nourish Yin and Blood and clear deficient heat, or use Huanglian Ejiao Tang (Coptis and Ass-Hide Gelatin Decoction). Additionally, there are cases due to excessive overwork damaging both Heart and Spleen, insufficient Central Qi, failure of clear Yang to ascend, and unresolved external pathogens causing alternating chills and fever with insomnia, treatable with Bu Zhong Yi Qi Tang (Supplement the Middle and Augment the Qi Decoction).
Patient Li XX, female, 52 years old, lives at Qinghe Street, Chaoyang District, Changchun City. First consultation in March 1978. The patient had poor appetite and lack of desire for food for over half a year. Various Chinese and Western medicines were ineffective, so she sought treatment. The patient was emaciated. Appetite was significantly reduced, eating little without hunger, with fatigue and weakness. Mouth and tongue were often dry but preferred cool drinks; however, despite dry mouth, she could not drink much, and stopped after taking little cool liquid. She felt a burning sensation from the esophagus to the epigastrium. For the past half year, stool was frequently dry, difficult, and obstructed. Tongue body was bare red without coating, surface lacked fluids, with small cracks. She had repeatedly used Xiang Sha Yang Wei Wan (Amomum and Aucklandia Stomach-Nourishing Pill), Renshen Jian Pi Wan (Ginseng Spleen-Strengthening Pill), Renshen Gui Pi Wan (Ginseng Restore Spleen Pill), Zi Kou Wan (Purple Cardamom Pill), Bao He Wan (Preserve Harmony Pill), as well as yeast tablets and pepsin. She also took several doses of decoctions roughly containing Sharen/Amomi Fructus, Muxiang/Aucklandiae Radix, Chenpi/Pericarpium Citri Reticulatae, Baizhu/Atractylodis Macrocephalae Rhizoma, Xiangyuan/Eriobotryae Folium, Foshou/Citri Sarcodactylis Fructus, Dangshen/Pseudoginseng Radix, Neijin/Galli Gigerii Endothelium Corneum, Sanxian (Shanzha/Hawthorn Fruit, Shenqu/Fermented Medicament, Maiya/Herba Hordei Germinata), Banxia/Pinelliae Rhizoma, Zhuru/Bambusae Caulis in Taeniam, Laifuzi/Raphani Semen, Guya/Oryzae Fructus Germinatus.
Based on the patient's condition and medications used, especially the characteristics of the tongue image, comprehensive analysis indicates the pattern is insufficient Stomach Yin and impaired descending function of the Stomach, causing poor appetite, anorexia, and constipation. Ye Shi Yang Wei Tang (Ye's Nourishing Stomach Decoction) modified was prescribed to moisten Stomach Yin and restore Stomach function. Shashen/Glehniae Radix 20g, Maidong/Ophiopogonis Tuber 15g, Shihu/Dendrobii Caulis 15g, Yuzhu/Polypodi Rhizoma 15g, Shengdi/Rehmanniae Radix 15g, Biandou/Dolichoris Semen 10g, Gancao/Glycyrrhizae Radix et Rhizoma 10g, Sangye/Mori Folium 10g. Decocted in water to extract ample juice, one dose daily.
After three doses, the burning sensation in the esophagus and stomach decreased significantly. Dryness of lips and mouth alleviated, appetite increased, stool became smooth. After two more doses, appetite increased, hunger was felt, intake per meal reached 100-150g, dry mouth and tongue resolved, gastric burning eliminated. Bowel movement once daily, no longer dry. The tongue showed moisture, color turned pale red, with a thin coating. Based on the condition, the illness was basically cured. Prescribed another three doses, decocted with ample juice, taken as tea whenever desired (due to sweet taste and ease of drinking), to nourish fluids of the gastrointestinal tract.
Doctor A asked the teacher to discuss the diagnostic approach for this case.
Teacher: Anorexia and poor appetite are common clinically, but treatment efficacy varies. This is because causes and conditions differ. If one does not carefully inquire about symptoms, medical history, and medication usage, but merely treats with methods to strengthen the Spleen, regulate Qi, and stimulate appetite, many patients will have poor outcomes. Generally, anorexia falls into two categories: deficiency and excess. Excess is caused by surplus pathogenic factors invading the Stomach, preventing Qi descent. Excess patterns present with excess signs and pulses. Removing the surplus pathogens restores normal Stomach Qi and normal diet. Deficiency is due to insufficient healthy Qi. This includes intrinsic Spleen-Stomach deficiency or deficiency of other Zang-Fu organs affecting the Spleen-Stomach.
This patient's anorexia lacks distension and fullness, signs of damp obstruction, Qi stagnation, or food retention, nor does it show blazing heat or cold coagulation, indicating it is not an excess pattern. Clinically, there are no Lung diseases like chest fullness, phlegm, cough, or wheezing; no Liver diseases like hypochondriac distension/pain, bitter taste, or sighing; no Kidney deficiency signs like soreness of waist/knees, vexing heat, or aversion to cold; nor Heart disease signs like palpitations, insomnia, or oppression. Thus, the anorexia is not influenced by other organs. Since it is unrelated to other organs, it must be intrinsic Spleen-Stomach deficiency. Spleen-Stomach deficiency causing anorexia involves either insufficient Yang Qi or scant Yin fluids. If it were Yang insufficiency, the mouth would be bland without thirst, no burning in epigastrium/esophagus, stool would be loose, tongue pale and moist, body normal or swollen, not red, scanty fluids, and cracked. This patient's symptoms are completely opposite, suggesting Stomach Yin deficiency.
Regarding previous medications, Xiang Sha Yang Wei Wan and Renshen Jian Pi Wan were ineffective, indicating the disease is not Spleen-Stomach Yang insufficiency. Since it is not Yang insufficiency, it is clearly Yin fluid depletion. Therefore, sweet-cold moistening methods to nourish Stomach Yin were adopted, yielding satisfactory results, confirming correct differentiation.
Doctor B noted that ancient texts and clinical practice generally treat anorexia with methods to strengthen the Spleen, benefit the Stomach, regulate Qi, and promote digestion. As analyzed by the teacher, this is indeed rare. Could you discuss this?
Teacher: The student speaks correctly. Ancient medical books mostly attribute anorexia to Spleen-Stomach Qi deficiency or stagnation, food retention, Liver depression invading the Spleen, damp-phlegm obstruction, or lower Jiao Kidney Yang insufficiency failing to warm Earth. Regarding excess patterns, let us not discuss them. Even for deficiency patterns, arguments often focus on Yang insufficiency. For example, Chen Xiuyuan in *Yi Xue Shi Zai Yi* (Medical Essentials) stated, "Inability to eat is due to deficiency of Yuan Qi in the Stomach." In treatment, Li Nian'e in *Yi Jia Bi Zheng* (Essentials for Physicians) said, "Inability to eat all belongs to Spleen deficiency; Si Jun Zi Tang (Four Gentlemen Decoction), Bu Zhong Yi Qi Tang (Supplement the Middle and Augment the Qi Decoction). If tonification fails, tonify the mother organ; Ba Wei Di Huang Wan (Eight-Ingredient Rehmannia Pill), Er Shen Wan (Two Divine Pills). With phlegm, resolve it with Liu Jun Zi Tang (Six Gentlemen Decoction). With depression, open it with Yu Qi Tang. With Wood [Liver] conflict, calm it with Yi Gong San (Extraordinary Power Powder) added with Muxiang/Aucklandiae Radix and Chenxiang/Aquilariae Lignum Resinatum..." It appears that anorexia due to Spleen-Stomach issues is mostly discussed as Yang Qi decline. Treatments start by tonifying Spleen-Stomach Qi, then warming Lower Jiao Yang, or assisting with Chenpi/Pericarpium Citri Reticulatae and Banxia/Pinelliae Rhizoma to resolve damp-phlegm, Muxiang/Aucklandiae Radix and Sharen/Amomi Fructus to open Stomach Qi, or Xiangfu/Cyperi Rhizoma and Qingpi/Tangerine Peel (Green) to soothe Liver depression. Medications are pungent, sweet, warm, and unblocking, with rigid-drying properties. Li Dongyuan, one of the Four Masters of Jin-Yuan Dynasties, specialized in Spleen-Stomach diseases and was called the "Tonifying Earth School." His *Pi Wei Lun* (Treatise on the Spleen and Stomach) focused on Spleen Qi insufficiency and Stomach Yang decline.
Formulas like Bu Zhong Yi Qi Tang, Sheng Yang Yi Wei Tang (Raise Yang and Benefit Stomach Decoction), Tiao Zhong Yi Qi Tang (Regulate the Middle and Benefit Qi Decoction) all rely mainly on Renshen/Ginseng Radix, Baizhu/Atractylodis Macrocephalae Rhizoma, Huangqi/Astragali Radix, and Gancao/Glycyrrhizae Radix, focusing on raising and tonifying Spleen-Stomach Yang Qi, while briefly mentioning Stomach Yin deficiency. Later treatments for anorexia mostly used sweet-warm tonification, pungent-aromatic Qi-moving, and digestive methods, which are not only useless but harmful for Stomach Yin deficiency anorexia. In the Qing Dynasty, Ye Tianshi brilliantly discussed the differences between Spleen and Stomach in physiology, pathology, and treatment, pioneering new methods for treating Stomach Yin deficiency. His contribution rivals *Pi Wei Lun*, supplementing Li Dongyuan's omissions. *Lin Zheng Zhi Nan Yi An* (Guide to Clinical Cases) elaborated on his views: "Discussions on Spleen and Stomach are most detailed by Dongyuan. His formulas like Bu Zhong Yi Qi, Tiao Zhong Yi Qi, Sheng Yang Yi Wei truly supplement predecessors' omissions. Observing his formula intent, he focused on internal injury from overwork; since Spleen is Taiyin Damp Earth and most have declining Stomach Yang, he used Renshen/Ginseng Radix and Huangqi/Astragali Radix to tonify the center, Baizhu/Atractylodis Macrocephalae Rhizoma and Cangzhu/Atractylodis Rhizoma to dry dampness, Shengma/Cimicifugae Rhizoma and Chaihu/Bupleuri Radix to raise fallen clear Yang, Chenpi/Pericarpium Citri Reticulatae and Muxiang/Aucklandiae Radix to regulate Qi stagnation in the Middle Palace. Treating Spleen and Stomach together, if applied appropriately, effects are immediate. Dongyuan's method details treating the Spleen but omits the Stomach. Later generations followed his intent, generalizing Spleen and Stomach, using Spleen-tonifying drugs indiscriminately for the Stomach. Now reading Ye's works, we know Spleen and Stomach should be analyzed separately. Stomach belongs to Wu Earth, Spleen to Ji Earth; Wu is Yang, Ji is Yin, their natures differ. Zang organs store, Fu organs transmit; their structure and function differ. If Spleen Yang is insufficient and Stomach has cold-damp, both Zang and Fu suit warm-drying ascending methods, strictly following Dongyuan's method. If Spleen Yang is intact but Stomach has dry-fire, follow Ye's Stomach Yin-nourishing method. His theory states: 'Digestion is governed by the Stomach, transformation by the Spleen; Spleen is healthy when ascending, Stomach is harmonious when descending.' Also: 'Taiyin Damp Earth begins to transform with Yang; Yangming Dry Earth remains peaceful with Yin. Spleen likes dryness, Stomach likes soft-moisture.' Zhang Zhongjing's urgent purging to preserve fluids treats the Stomach; Dongyuan's great raising of Yang Qi treats the Spleen... Thus, for those with Wood-Fire constitution suffering dry-heat, or post-illness heat damaging fluids causing empty fullness, anorexia, crimson tongue, dry throat, vexing thirst, insomnia, dry skin, steaming bone fever, constipation, these nine orifices disharmonies all belong to Stomach disease. How can Huangqi/Astragali Radix, Baizhu/Atractylodis Macrocephalae Rhizoma, Shengma/Cimicifugae Rhizoma, Chaihu/Bupleuri Radix be used? 'Stomach is harmonious when descending' does not mean pungent-opening and bitter-descending, nor bitter-cold purging damaging Stomach Qi, but rather sweet, or sweet-cool moistening to nourish Stomach Yin, restoring fluids and enabling descending. This principle follows *Neijing*'s saying that Fu organs transmit substances without storing, using transmission as function. In short, Spleen-Stomach diseases, whether deficiency/excess or cold/heat, require drying/moistening, must be judged carefully; the characters 'ascending and descending' are particularly crucial. Spleen Qi sinking is disease; even if not sinking, if not transforming healthily, it is disease. Stomach Qi rebelling upward is disease; even if not rebelling, if not descending smoothly, it is disease." This patient followed Ye's principles, using sweet-cold moistening to nourish Stomach fluids and restore Stomach function, curing the illness.
Doctor C asked the teacher to discuss syndrome differentiation and treatment for anorexia.
Teacher: Anorexia always relates to the Spleen and Stomach. When Spleen-Stomach Qi is robust, ascending and descending freely, it can digest and transform; when Spleen-Stomach Qi is deficient or stagnant, anorexia occurs. Anorexia has deficiency and excess aspects. Excess may be due to Qi stagnation, damp obstruction, food injury, or heat flourishing, all causing Spleen-Stomach Qi mechanism dysfunction leading to anorexia. Deficiency involves Spleen-Stomach Yang Qi weakness and Yin-Blood scarcity. Generally, excess patterns appear in acute illnesses, deficiency in chronic ones. Mixed deficiency-excess cases exist. Excess treatment focuses on expelling pathogens; once pathogens are removed, Spleen-Stomach Qi recovers, and appetite returns naturally.
Due to Qi stagnation, mostly caused by emotional frustration, unresolved anger leading to Liver depression, Liver Qi stagnation failing to disperse, causing Stomach Qi stagnation. Treatment depends on duration and differentiates deficiency/excess. Early stage with hypochondriac distension/pain indicates Liver depression, treat primarily by soothing Liver and resolving depression, e.g., Chai Hu Shu Gan Tang (Bupleurum Powder to Soothe the Liver). If chronic Liver depression resolves but Spleen-Stomach is damaged, tonify Spleen-Stomach, e.g., Xiang Sha Liu Jun Zi Tang (Amomum and Aucklandia Six Gentlemen Decoction). If Liver depression and Spleen deficiency coexist, Xiao Yao San (Free Wanderer Powder) can be used.
Dampness encumbering the Spleen-Stomach is also common, from external or internal dampness, obstructing Qi mechanism causing anorexia. Symptoms include epigastric/abdominal fullness, heavy limbs, white greasy coating. Treatment uses aromatic pungent-dispersing agents like San Ren Tang (Three Seeds Decoction) or Ping Wei San (Peace the Stomach Powder) to diffuse Qi and resolve dampness, awakening the Spleen-Stomach. Food injury to Spleen-Stomach: upper part treated by promoting digestion and harmonizing Stomach, using Bao He Wan (Preserve Harmony Pill); lower part treated by guiding stagnation and unblocking bowels, using Zhi Shi Dao Zhi Wan (Immature Bitter Orange Guiding Stagnation Pill).
If food injury causes severe vomiting/diarrhea, excessive purging, or prolonged course damaging Spleen-Stomach leading to deficiency, treat as deficiency. Heat flourishing causing anorexia shows bitter taste, yellow coating, etc.; clearing heat restores Stomach Qi and appetite. Deficiency treatment focuses on tonification, differentiating Yin/Yang/Qi/Blood.
Differentiate whether deficiency is intrinsic to Spleen-Stomach or secondary to other organs. For Spleen-Stomach Yang Qi deficiency, use sweet-warm tonification like Si Jun Zi Tang (Four Gentlemen Decoction), Yi Gong San (Extraordinary Power Powder), Liu Jun Zi Tang (Six Gentlemen Decoction), Bu Zhong Yi Qi Tang (Supplement the Middle and Augment the Qi Decoction). For cold bias, Li Zhong Tang (Regulate the Middle Decoction). If due to Lower Jiao Yang deficiency failing to warm Earth, use Jin Kui Shen Qi Wan (Golden Cabinet Kidney Qi Pill) or Er Shen Wan (Two Divine Pills, containing Buguzhi/Astragalcomembranaceus Fruit and Roudoukou/Myristicae Semen) to tonify Mingmen Fire to generate Spleen Earth. If Spleen-Stomach Qi deficiency with food retention, Jian Pi Wan (Spleen-Strengthening Pill) combines tonification and drainage. Stomach Yin deficiency was discussed earlier. If due to Kidney Yin insufficiency or Blood deficiency, use Yin-nourishing and Blood-tonifying herbs.
Patient Zhou XX, female, 43 years old, consulted in November 1977. For nearly 3 years, suffered frequent nausea, vomiting of saliva/phlegm, severe headache and vertigo, heavy head, cold hands and feet. Treated with Chinese and Western medicines without root cure. Attacks often occurred after eating cold/raw foods, during anger/depression, or sudden cold weather.
History revealed weak constitution, Spleen-Stomach deficiency-cold, preferring warm/cooked foods; slight exposure to cold/raw/hard foods caused epigastric distension/pain or diarrhea. Three years ago, at autumn-winter transition, sudden cold made her feel discomfort in the epigastrium, cold to touch. Loss of appetite, frequent nausea, vomiting of thin white cold saliva. Felt head vertigo, heaviness, difficulty lifting. After vomiting, extreme fatigue, bedridden, asked family to boil Ginger Decoction, drank it for slight relief. Frequent attacks thereafter, with fatigue, limb drooping, cold extremities, body cold with aversion to cold, gradually developing headache. Warmth alleviated symptoms, cold aggravated them. Physical appearance: emaciated, grayish-white complexion, dark eye bags, haggard expression, pale lips, pale tongue with thin white slippery coating, deep weak pulse, cold extremities.
Based on history, symptoms, tongue, and pulse, the disease is caused by Spleen-Stomach deficiency-cold, insufficient Yang Qi, internal retention of phlegm-fluid, leading to Stomach Qi failing to descend, turbid phlegm attacking upward, clear Yang failing to ascend. Treatment should warm and tonify Spleen-Stomach, resolve phlegm and drain fluids, using pungent-sweet-warm herbs. Renshen/Ginseng Radix 10g, Wuzhuyu/Evodiae Fructus 10g, Baizhu/Atractylodis Macrocephalae Rhizoma 25g, Baifuling/Poria 15g, Jiang Banxia/Pinelliae Rhizoma Preparatum 20g, Chenpi/Pericarpium Citri Reticulatae 15g, Tianma/Gastrodiae Rhizoma 20g, Zhi Gancao/Glycyrrhizae Radix et Rhizoma Preparatum 10g, Shengjiang/Zingiberis Rhizoma Recens 20g, Dazao/Jujubae Fructus 5 pieces (split). Decocted in water three times, divided into three doses within one day. After three doses, abdomen felt warm, distension subsided, pain reduced, nausea decreased, vertigo lightened, headache alleviated. After another three doses, epigastrium no longer felt cold, appetite increased, symptoms improved. To consolidate efficacy, used the same formula for three doses, ground into fine powder, refined honey pills, 15g each, three pills daily (morning, noon, evening). No recurrence after medication.
Doctor A asked the teacher to discuss the diagnostic approach for this case.
Teacher: This patient has been ill for 3 years with recurrent episodes, no exterior signs observed, definitely not an external contraction. Thus, identify from the perspective of internal injury: reviewing previous prescriptions, some treated only nausea/vomiting, e.g., Huo Xiang Zheng Qi Tang (Agaricus Rectifying Qi Decoction), Xiao Ban Xia Tang (Minor Pinellia Decoction); some treated only vertigo/headache, e.g., Chuan Xiong Cha Tiao San (Ligusticum Tea-Powder for Headache), Qing Xuan Wan (Clear Vertigo Pill); also frequently took analgesics for headaches. While these drugs temporarily relieve pain, they cannot eradicate the root. Therefore, treating this patient requires a holistic view, examining internal connections among symptoms to identify the disease origin.