案2吴X，女，30岁，1985年6月13日初诊。主诉：胃脘满闷，腹胀口苦1年余。知饥欲食，食后则胃脘满闷，腹部胀满难受，嗳气、矢气多，心慌，夜间肠鸣漉漉，时如雷鸣，进油腻食物后更甚，便溏不爽，口苦无己时。舌淡胖，苔薄白，脉弦沉。已服中药20余剂未效。西医检查：胃下垂6cm，胃肠无器质性病变。拟诊为脾胃虚寒，浊气聚滞。投以理中汤合厚朴生姜半夏甘草人参汤：党参15g，白术12g，干姜12g，炙甘草6g，茯苓15g，厚朴20g，法夏10g，生姜10g。服3剂，胃脘满闷，腹胀大减，肠鸣、心慌止，但口苦如故；又述常常短气、畏寒。乃于上方加黄芪30g，熟附片15g(先熬)，服3剂，诸症基本消失，但口苦更甚。至此方知此证原挟有肝胆郁热，湿热药有裨于脾肾，而不利于肝胆。遂于第一方中加柴胡10g，胆草3g，生牡蛎15g。服2剂，口苦减轻；即撤去第一方，单服所加之3味药，3剂后口苦消失。
学员甲口苦虽系常见之症，但临床上以口苦为主诉而来就诊者却较为少见，所以有的医者不大重视。老师比较重视口苦，且提倡使用专方专药来治疗。如案1口苦为主症，便主用柴胆牡蛎汤；案2口苦为兼症，则合用柴胆牡蛎汤，疗效均佳。
进修生甲：柴胆牡蛎汤的方名就包括了全部药物：柴胡、胆草、生牡蛎。我揣摩
老师使用如此简单的3味药治疗口苦，是由于口苦的病机比较单纯：胆火上炎。是这样的吗?
老师：是这样，但还可以推衍一步。大家知道，口苦是胆病主症之一，照(内经)的说法，口苦作为一种"奇病"，其病机为"胆虚气上溢"或"胆火上炎"。如《素问·奇病论》说，"有病口苦……病名曰胆瘅。夫肝者，中之将也，取决于胆，咽为之使。此人者，数谋虑不决，故胆虚气上溢而口为之苦"。《素问·痿论》又说，"肝气热则胆泄口苦"。可见口苦的继发病位在胆，而原发病位在肝。因肝主谋虑，若"数谋虑不决"，则肝气郁结，郁久则化火，波及于胆，导致胆的功能失调，胆火上炎，或胆气上溢，则发生口苦。
进修生乙：(伤寒论)说，"少阳之为病，口苦、咽干、目眩也"。口苦作为少阳病提纲三症中的第一症，也可理解为"继发病位在胆，原发病位在肝"吗?
老师：可以这样理解，因为张仲景著(伤寒论)时曾"撰用素问九卷……"，其学术思想与(内经)是一脉相承的。而更重要的是，从临床上看，少阳病的患者，多为平素肝郁不舒之人。所以治疗口苦，既要清降胆火，又要疏肝达郁。我的老师简裕光老先生自拟的柴胆牡蛎汤恰合此意：肝喜条达而宜升，柴胡苦平，升发肝气，疏肝达郁；胆喜宁谧而宜降，胆草苦寒，沉阴下达，清降胆火；生牡蛎咸寒，滋水涵木，敛辑胆火，"则肝胆自得其养"(张锡纯语)o临床实践证明，治疗口苦须3味同用(柴胡10g，胆草6～10g，生牡蛎15～30g)，拆散用之，或随意添加之，则效差或无效。若主症为虚寒，或体质属虚寒者，胆草宜减少至3g左右。
实习生甲这首专方治疗单纯性口苦的有效率大约是多少?
老师：十之八九，可惜独用本方的机会不多，因为单纯性口苦毕竟少见。
进修生丙单纯性口苦虽然少见，但临床上口苦却可以出现在多种疾病之中，又该怎样解释呢?
老师：这是由于胆为阳木，胆中相火敷布于周身，十一脏借此而生机勃勃，故(内经)说，"凡十一脏取决于胆也"。反之，十一脏有病，亦可波及于胆，因此胆病主症之一的口苦，便可以出现在多种疾病之中。
进修生这种解释颇有新意，可以说得具体一些吗?
老师：肝胆相连，肝病最易累胆，故肝病中最多口苦。他如脾胃湿热壅遏，心火上炎，肾火上冲，肺热蕴积等，一旦波及于胆，亦可出现口苦。这些都属实热证，比较好理解。但如案2脾肾虚寒，亦出现口苦者，乃因挟有肝胆郁热，就不大好理解，而易被忽视。此外张景岳还说过，"凡思虑劳倦，色欲过度，多有口苦口燥、饮食无味之症，此其咎不在心脾，则在肝肾。心脾虚则肝胆气溢而口苦，肝肾虚则真阴不足而口苦"。((景岳全书·杂证))这实际上就是心脾虚或肝肾虚而波及于胆的复合证候。
实习生乙：老师喜欢用柴胡、胆草、生牡蛎3味药治疗口苦，除此之外，还有哪些药物可以治疗口苦?
老师：从理论上说，大凡清降或辑敛胆火的药物，都可用来治疗口苦，如青蒿、黄芩、竹茹、青黛、茵陈、栀子、胆星、猪胆汁等。但临床中遇口苦时，应仔细推敲，是胆腑自病，还是它脏之病波及于胆?不可泛泛清热。以胃痛伴口苦为例，如胆热犯胃，当用左金丸；如痰湿化热，当用温胆汤为主；如肝肾阴虚，当用高鼓峰滋肾清肝饮为主，如脾胃虚寒兼肝胆郁热，当用温热药治虚寒证，或在方中少佐黄连，如连理汤。总之，要"谨守病机，各司其属"，遣方用药才有准的。如我曾治某妇，年4旬，口苦半年，曾服龙胆泻肝丸10瓶，口苦未减，反增口干、便秘。我察其舌淡红，苔少欠润，脉弦沉细，考虑为阴虚肝郁，用一贯煎合四逆散加草决明、肉苁蓉，服2剂口苦大减。
进修生乙：既然如此，柴胆牡蛎汤还有多少用武之地呢?
老师：柴胆牡蛎汤作为治疗单纯性口苦的专方，颇具"简、便、廉、验"的特色。口苦为兼症时，若将本方合入治疗主症的当用方中，则有信手拈来而独挡一面的妙用。附带披露一下，此方本系简老先生治疗慢性胆囊炎的通治方，而施用于肝胆郁热型者疗效尤佳。若将此方与辨证选方相结合，则可广泛地适用于慢性胆囊炎的各种证型，如痰热型合黄连温胆汤，湿热型合三仁汤，气郁型合柴胡疏肝散，脾胃虚弱型合柴芍六君子汤等。
实习生：老师用过此方治疗慢性胆囊炎吗?
老师：经常使用，且"隔山"使用亦验。如1983年2月山东聊城县赵X(女，45岁)来函称：右上腹胀痛并放射至肩背，反复发作11年，伴口苦、嗳气、嘈杂；，进油腻食物或忧思恼怒后，上述症状必加重。舌质偏红，苔薄黄，脉弦。经X线胆囊造影，确诊为慢性胆囊炎。经用中西药物治疗，疗效不理想。我初步考虑为肝胆郁热，遂寄去柴胆牡蛎汤原方，嘱其试服。服6剂，右上腹胀痛明显减轻，口苦消失；但大便微溏，口淡，纳差，乏力。乃辨证为肝胆郁热，脾胃虚弱。用此方合柴芍六君子汤加黄芪，服30剂(2日1剂)，诸症若失。经B超检查，胆囊未见异常。1986年9月来函称：其病未复发。我在经常使用本方结合辨证分型治疗慢性胆囊炎的过程中，发现最先消失的症状是口苦，于是推广试用于多种疾病之口苦，而有效率颇高，便视之为治疗口苦的专方专药。古人说，"事莫贵乎有验，言莫弃乎无征"。希望大家在临床上继续进行验证。
内伤头痛巧辨证
山东中医学院方剂教研室教授杨雅西
患者，男，50岁。头痛且空，每兼眩晕耳鸣多年。平素症状不明显，常因看书、阅读文件疲劳而加重，甚则不能从事日常工作。曾多次在西医院就诊，心电图、脑电图、颅骨拍片等检查，均无明显异常发现，常服维生素及安眠药之类，效果不佳。本次因连续数日开会而工作劳累，头痛、眩晕症状明显加重，难以坚持工作，故前来求诊。自述平素腰膝酸软无力，夜寐欠佳，且心烦，情绪易激动，食欲、二便尚可。舌质红苔白，脉弦细。血压、心电图检查均在正常范围内。辨证：头痛(肝肾阴虚，心肾不交)。治法：滋养肝肾，养心安神，佐以平肝潜阳。处方：杞菊地黄丸加减。药用：熟地12g，山萸肉12g，枸杞子15g，菊花12g，白芍12g，丹皮9g，天麻12g，生石决明30g，炒枣仁30g，石菖蒲12g，远志12g。水煎服。每日1剂，分2次服。二诊：患者自述，服上方12剂后，头痛、头晕减轻，心烦已除，睡眠情况略有改善。仍用前方，加陈皮12g，继服12剂。三诊：述服上方以后，腰膝酸软无力、情绪易激动等症状明显改善，头痛而晕亦基本消失；唯睡眠虽较用药前好转，但仍有多梦不宁。考虑到病人头痛症状已趋缓解，其他兼症也基本消失或好转，故改汤剂为丸剂，将二诊方中各药扩大10倍，共为细末，加水成丸，每服6g，每日3次。数月后，病人前来告之，自服前方丸荮1粒后，睡眠、饮食正常，头痛、头晕耳鸣等症状均消失，服药期间，曾连夜加班工作，亦无明显异常出现。
学生甲：老师，这例患者您是从"头痛"一病着手治疗的，数年疴疾，霍然而愈，请老师讲讲其要点。
老师：头痛是临床上常见的自觉症状，可以出现于多种急性、慢性疾病的过程中。祖国医学的所谓"头痛"，系指在内科杂病中以头痛为主要症状者，若属某一疾病过程中而出现的兼症，则不应列入头痛一证讨论范围内。头痛一般可分为外感头痛和内伤头痛两大类。本例患者头痛而晕多年，兼有烦躁、失眠等，此属肾水不足而致水亏木旺，故为内伤头痛。患者常年夜寐不佳，腰膝酸软无力，且情绪易激动，提示素体肾阴偏虚，尚有肝阳偏亢之象，又因连日劳累用脑，耗伤阴血，故出现肝肾阴虚，肝阳亢盛之头痛且空，眩晕耳鸣等症状。因此，治以滋养肝肾，交通心肾，兼平肝潜阳之法，方选杞菊地黄丸化裁。方中熟地、山萸肉、枸杞子、白芍以滋补肝肾之阴；天麻、生石决明、丹皮、菊花以平肝潜阳且清热，既可防肝阳化热，又可制肾阴虚生热；炒枣仁、石菖蒲、远志以养血安神，交通心肾，如此肝肾并治，心肾同调而收效。
学生乙：老师，请您谈一下临诊时如何对内伤头痛进行辨证施治。
老师：好吧，对这个问题，我们先复习内伤头痛的病因病理，然后再言及诊断要点和治疗方法。祖国医学认为头为"诸阳之会"，"清阳之府"，乃髓海所在，既有经络与脏腑相连，又有诸窍内外相通，因此，引起头痛的原因诸多，在此，外感风寒、湿、热之邪而致外感头痛不予讨论，我们着重讨论内伤头痛。内伤头痛其发病原因与肝、脾、肾三脏关系密切。因于肝者，或情志不和，肝失疏泄，郁而化火，上扰清空而头痛；或木火伤阴，肝失濡养，肾水不足，水不涵木导致肝肾阴亏，肝阳上亢，上扰清空而头痛。因于脾者，多系劳伤过度，病后产后体虚，脾胃虚弱，生化不足，或失血之后，营血亏虚，不能上荣于脑髓经络而致头痛；或饮食失节，脾失健运，痰湿内生，痰浊上扰，阻遏清阳而头痛。因于肾者，多因禀赋不足，房劳不节，肾精久亏，脑髓空虚而致头痛；或因肾阳衰微，清阳不展而为头痛。祖国医学认为人体正常的生理状态是清升浊降。经云"六腑者，传化物而不藏"。传化的功能正常，则浊降清升，若传化功能失调，而致气机不畅，水湿痰饮内生，大便秘结不通，则浊气不得下降，反而上逆，导致头痛，多属实证范围。经云"五脏者，藏精气而不泄"。五脏精华气血，六腑清阳之气，皆上注于头而荣养之，若劳倦伤气，虚劳损精，产后失血等，致清阳不升，气血不得荣于脑，亦导致头痛，多属虚证范围。不通则痛，凡气血郁滞，阻塞脉络，或久病入络，瘀血内停，致经脉壅滞不通，亦可引起头痛。以上是内伤头痛的主要病因病理，至于内伤头痛的辨证，除了详细询问病史及伴发症外，还应注意以下几个方面，以协助诊断。一是要注意头痛的部位，分清全头痛还是偏头痛，巅顶痛还是头项痛；二是要注意头痛的时间，如清晨、中午或午后疼痛出现或加重等；三是要注意诱因，如因劳累过度，失血过多，情绪激动，房劳或饮食失节导致等。对于内伤头痛的治疗，不宜简单地见痛而止痛，一般常可采用补气升阳，养血疏风，活血化瘀，平肝潜阳，清肝降火，疏肝解郁，利湿化痰，暖肝降逆，滋补肾阴，温肾扶阳十法。
学生丙：老师，能否传授一下您对内伤头痛的治疗经验?
案例2：患者吴X，女性，30岁，于1985年6月13日初次就诊。主诉：胃脘部胀闷不适，腹部胀满伴口苦持续一年有余。自觉饥饿想吃东西，但进食后胃脘胀闷、腹部胀满难受感加重，嗳气（打嗝）和矢气（放屁）频繁，心慌，夜间肠鸣音明显，声音如雷鸣般，进食油腻食物后症状加剧，大便稀溏且排出不畅，口苦无休止。舌质淡而胖大，苔薄白，脉象弦沉。此前已服用中药20余剂，未见疗效。西医检查显示：胃下垂6厘米，胃肠无器质性病变。初步诊断为脾胃虚寒，浊气聚滞。给予理中汤合厚朴生姜半夏甘草人参汤治疗：党参15克，白术12克，干姜12克，炙甘草6克，茯苓15克，厚朴20克，法半夏10克，生姜10克。服用3剂后，胃脘胀闷和腹胀大幅减轻，肠鸣和心慌停止，但口苦依旧；患者又诉说常感短气、畏寒。于是在原方基础上加用黄芪30克，熟附片15克（先煎），再服3剂，诸症基本消失，但口苦反而更严重。至此才明白此证原本兼有肝胆郁热，温热性质的药物虽对脾肾有益，却不利于肝胆。于是回到第一张处方中加入柴胡10克，龙胆草3克，生牡蛎15克。服用2剂后，口苦减轻；随即停用第一张处方，单独服用所加的这3味药，再服3剂后口苦消失。
学员甲：口苦虽是常见症状，但以口苦为主诉前来就诊者却较少见，因此有些医者不太重视。老师比较重视口苦，且提倡使用专方专药来治疗。例如案例1中口苦是主要症状，便主用柴胆牡蛎汤；案例2中口苦是伴随症状，则合用柴胆牡蛎汤，疗效均佳。
进修生甲：柴胆牡蛎汤的方名包含了全部药物：柴胡、龙胆草、生牡蛎。我揣摩老师使用如此简单的3味药治疗口苦，是由于口苦的病机比较单纯：胆火上炎。是这样吗？
老师：是这样，但还可以推衍一步。大家知道，口苦是胆病的主要症状之一，照《内经》的说法，口苦作为一种“奇病”，其病机为“胆虚气上溢”或“胆火上炎”。如《素问·奇病论》说：“有病口苦……病名曰胆瘅。夫肝者，中之将也，取决于胆，咽为之使。此人者，数谋虑不决，故胆虚气上溢而口为之苦。”《素问·痿论》又说：“肝气热则胆泄口苦。”可见口苦的继发病位在胆，而原发病位在肝。因肝主谋虑，若“数谋虑不决”，则肝气郁结，郁久则化火，波及于胆，导致胆的功能失调，胆火上炎，或胆气上溢，则发生口苦。
进修生乙：《伤寒论》说：“少阳之为病，口苦、咽干、目眩也。”口苦作为少阳病提纲三症中的第一症，也可理解为“继发病位在胆，原发病位在肝”吗？
老师：可以这样理解，因为张仲景著《伤寒论》时曾“撰用素问九卷……”，其学术思想与《内经》是一脉相承的。而更重要的是，从临床上看，少阳病的患者，多为平素肝郁不舒之人。所以治疗口苦，既要清降胆火，又要疏肝达郁。我的老师简裕光老先生自拟的柴胆牡蛎汤恰合此意：肝喜条达而宜升，柴胡苦平，升发肝气，疏肝达郁；胆喜宁谧而宜降，龙胆草苦寒，沉阴下达，清降胆火；生牡蛎咸寒，滋水涵木，敛辑胆火，“则肝胆自得其养”（张锡纯语）。临床实践证明，治疗口苦须3味同用（柴胡10克，龙胆草6～10克，生牡蛎15～30克），拆散用之，或随意添加之，则效差或无效。若主症为虚寒，或体质属虚寒者，龙胆草宜减少至3克左右。
实习生甲：这首专方治疗单纯性口苦的有效率大约是多少？
老师：十之八九，可惜独用本方的机会不多，因为单纯性口苦毕竟少见。
进修生丙：单纯性口苦虽然少见，但临床上口苦却可以出现在多种疾病之中，又该怎样解释呢？
老师：这是由于胆为阳木，胆中相火敷布于周身，十一脏借此而生机勃勃，故《内经》说：“凡十一脏取决于胆也。”反之，十一脏有病，亦可波及于胆，因此胆病主症之一的口苦，便可以出现在多种疾病之中。
进修生：这种解释颇有新意，可以说得具体一些吗？
老师：肝胆相连，肝病最易累及胆，故肝病中最多见口苦。他如脾胃湿热壅遏，心火上炎，肾火上冲，肺热蕴积等，一旦波及于胆，亦可出现口苦。这些都属实热证，比较好理解。但如案例2脾肾虚寒，亦出现口苦者，乃因挟有肝胆郁热，就不大好理解，而易被忽视。此外张景岳还说过：“凡思虑劳倦，色欲过度，多有口苦口燥、饮食无味之症，此其咎不在心脾，则在肝肾。心脾虚则肝胆气溢而口苦，肝肾虚则真阴不足而口苦。”（《景岳全书·杂证》）这实际上就是心脾虚或肝肾虚而波及于胆的复合证候。
实习生乙：老师喜欢用柴胡、龙胆草、生牡蛎3味药治疗口苦，除此之外，还有哪些药物可以治疗口苦？
老师：从理论上说，大凡清降或收敛胆火的药物，都可用来治疗口苦，如青蒿、黄芩、竹茹、青黛、茵陈、栀子、胆南星、猪胆汁等。但临床中遇口苦时，应仔细推敲，是胆腑自病，还是它脏之病波及于胆？不可泛泛清热。以胃痛伴口苦为例，如胆热犯胃，当用左金丸；如痰湿化热，当用温胆汤为主；如肝肾阴虚，当用高鼓峰滋肾清肝饮为主；如脾胃虚寒兼肝胆郁热，当用温热药治虚寒证，或在方中少佐黄连，如连理汤。总之，要“谨守病机，各司其属”，遣方用药才有准的。如我曾治某妇，年4旬，口苦半年，曾服龙胆泻肝丸10瓶，口苦未减，反增口干、便秘。我察其舌淡红，苔少欠润，脉弦沉细，考虑为阴虚肝郁，用一贯煎合四逆散加草决明、肉苁蓉，服2剂口苦大减。
进修生乙：既然如此，柴胆牡蛎汤还有多少用武之地呢？
老师：柴胆牡蛎汤作为治疗单纯性口苦的专方，颇具“简、便、廉、验”的特色。口苦为兼症时，若将本方合入治疗主症的当用方中，则有信手拈来而独挡一面的妙用。附带披露一下，此方本系简老先生治疗慢性胆囊炎的通治方，而施用于肝胆郁热型者疗效尤佳。若将此方与辨证选方相结合，则可广泛地适用于慢性胆囊炎的各种证型，如痰热型合黄连温胆汤，湿热型合三仁汤，气郁型合柴胡疏肝散，脾胃虚弱型合柴芍六君子汤等。
实习生：老师用过此方治疗慢性胆囊炎吗？
老师：经常使用，且“隔山”使用亦验。如1983年2月山东聊城县赵X（女，45岁）来函称：右上腹胀痛并放射至肩背，反复发作11年，伴口苦、嗳气、嘈杂；进油腻食物或忧思恼怒后，上述症状必加重。舌质偏红，苔薄黄，脉弦。经X线胆囊造影，确诊为慢性胆囊炎。经用中西药物治疗，疗效不理想。我初步考虑为肝胆郁热，遂寄去柴胆牡蛎汤原方，嘱其试服。服6剂，右上腹胀痛明显减轻，口苦消失；但大便微溏，口淡，纳差，乏力。乃辨证为肝胆郁热，脾胃虚弱。用此方合柴芍六君子汤加黄芪，服30剂（2日1剂），诸症若失。经B超检查，胆囊未见异常。1986年9月来函称：其病未复发。我在经常使用本方结合辨证分型治疗慢性胆囊炎的过程中，发现最先消失的症状是口苦，于是推广试用于多种疾病之口苦，而有效率颇高，便视之为治疗口苦的专方专药。古人说：“事莫贵乎有验，言莫弃乎无征。”希望大家在临床上继续进行验证。
内伤头痛巧辨证
山东中医学院方剂教研室教授杨雅西
患者，男性，50岁。头痛且有空虚感，每兼眩晕耳鸣多年。平素症状不明显，常因看书、阅读文件疲劳而加重，甚则不能从事日常工作。曾多次在西医院就诊，心电图、脑电图、颅骨拍片等检查，均无明显异常发现，常服维生素及安眠药之类，效果不佳。本次因连续数日开会而工作劳累，头痛、眩晕症状明显加重，难以坚持工作，故前来求诊。自述平素腰膝酸软无力，夜寐欠佳，且心烦，情绪易激动，食欲、二便尚可。舌质红苔白，脉弦细。血压、心电图检查均在正常范围内。辨证：头痛（肝肾阴虚，心肾不交）。治法：滋养肝肾，养心安神，佐以平肝潜阳。处方：杞菊地黄丸加减。药用：熟地黄12克，山萸肉12克，枸杞子15克，菊花12克，白芍12克，丹皮9克，天麻12克，生石决明30克，炒枣仁30克，石菖蒲12克，远志12克。水煎服。每日1剂，分2次服。二诊：患者自述，服上方12剂后，头痛、头晕减轻，心烦已除，睡眠情况略有改善。仍用前方，加陈皮12克，继服12剂。三诊：述服上方以后，腰膝酸软无力、情绪易激动等症状明显改善，头痛而晕亦基本消失；唯睡眠虽较用药前好转，但仍有多梦不宁。考虑到病人头痛症状已趋缓解，其他兼症也基本消失或好转，故改汤剂为丸剂，将二诊方中各药扩大10倍，共为细末，加水成丸，每服6克，每日3次。数月后，病人前来告之，自服前方丸药1粒后，睡眠、饮食正常，头痛、头晕耳鸣等症状均消失，服药期间，曾连夜加班工作，亦无明显异常出现。
学生甲：老师，这例患者您是从“头痛”一病着手治疗的，数年疴疾，霍然而愈，请老师讲讲其要点。
老师：头痛是临床上常见的自觉症状，可以出现于多种急性、慢性疾病的过程中。祖国医学的所谓“头痛”，系指在内科杂病中以头痛为主要症状者，若属某一疾病过程中而出现的兼症，则不应列入头痛一证讨论范围内。头痛一般可分为外感头痛和内伤头痛两大类。本例患者头痛而晕多年，兼有烦躁、失眠等，此属肾水不足而致水亏木旺，故为内伤头痛。患者常年夜寐不佳，腰膝酸软无力，且情绪易激动，提示素体肾阴偏虚，尚有肝阳偏亢之象，又因连日劳累用脑，耗伤阴血，故出现肝肾阴虚，肝阳亢盛之头痛且空，眩晕耳鸣等症状。因此，治以滋养肝肾，交通心肾，兼平肝潜阳之法，方选杞菊地黄丸化裁。方中熟地、山萸肉、枸杞子、白芍以滋补肝肾之阴；天麻、生石决明、丹皮、菊花以平肝潜阳且清热，既可防肝阳化热，又可制肾阴虚生热；炒枣仁、石菖蒲、远志以养血安神，交通心肾，如此肝肾并治，心肾同调而收效。
学生乙：老师，请您谈一下临诊时如何对内伤头痛进行辨证施治。
老师：好吧，对这个问题，我们先复习内伤头痛的病因病理，然后再言及诊断要点和治疗方法。祖国医学认为头为“诸阳之会”，“清阳之府”，乃髓海所在，既有经络与脏腑相连，又有诸窍内外相通，因此，引起头痛的原因诸多，在此，外感风寒、湿、热之邪而致外感头痛不予讨论，我们着重讨论内伤头痛。内伤头痛其发病原因与肝、脾、肾三脏关系密切。因于肝者，或情志不和，肝失疏泄，郁而化火，上扰清空而头痛；或木火伤阴，肝失濡养，肾水不足，水不涵木导致肝肾阴亏，肝阳上亢，上扰清空而头痛。因于脾者，多系劳伤过度，病后产后体虚，脾胃虚弱，生化不足，或失血之后，营血亏虚，不能上荣于脑髓经络而致头痛；或饮食失节，脾失健运，痰湿内生，痰浊上扰，阻遏清阳而头痛。因于肾者，多因禀赋不足，房劳不节，肾精久亏，脑髓空虚而致头痛；或因肾阳衰微，清阳不展而为头痛。祖国医学认为人体正常的生理状态是清升浊降。经云“六腑者，传化物而不藏”。传化的功能正常，则浊降清升，若传化功能失调，而致气机不畅，水湿痰饮内生，大便秘结不通，则浊气不得下降，反而上逆，导致头痛，多属实证范围。经云“五脏者，藏精气而不泄”。五脏精华气血，六腑清阳之气，皆上注于头而荣养之，若劳倦伤气，虚劳损精，产后失血等，致清阳不升，气血不得荣于脑，亦导致头痛，多属虚证范围。不通则痛，凡气血郁滞，阻塞脉络，或久病入络，瘀血内停，致经脉壅滞不通，亦可引起头痛。以上是内伤头痛的主要病因病理，至于内伤头痛的辨证，除了详细询问病史及伴发症外，还应注意以下几个方面，以协助诊断。一是要注意头痛的部位，分清全头痛还是偏头痛，巅顶痛还是头项痛；二是要注意头痛的时间，如清晨、中午或午后疼痛出现或加重等；三是要注意诱因，如因劳累过度，失血过多，情绪激动，房劳或饮食失节导致等。对于内伤头痛的治疗，不宜简单地见痛而止痛，一般常可采用补气升阳，养血疏风，活血化瘀，平肝潜阳，清肝降火，疏肝解郁，利湿化痰，暖肝降逆，滋补肾阴，温肾扶阳十法。
学生丙：老师，能否传授一下您对内伤头痛的治疗经验？
Case 2: Patient Wu X, female, 30 years old, first seen on June 13, 1985. Chief complaint: Epigastric fullness and stuffiness, abdominal distension with bitter taste in the mouth for over one year. The patient feels hungry and desires food, but after eating, epigastric fullness and abdominal distension worsen significantly. Frequent belching (Odynophagia/Belching) and flatus (Flatus), palpitations, loud borborygmi at night sounding like thunder, exacerbated by greasy foods. Loose stools that are difficult to pass completely, and persistent bitter taste in the mouth. Tongue is pale and swollen with a thin white coating; pulse is wiry and deep. Previously taken more than 20 doses of Chinese herbal medicine without effect. Western medical examination revealed: Gastric ptosis of 6 cm, no organic lesions in the gastrointestinal tract. Preliminary diagnosis: Spleen-Stomach Deficiency-Cold with stagnation of turbid Qi. Prescribed Lizhong Tang combined with Houpo Shengjiang Banxia Gancao Renshen Tang: Codonopsis Radix (Dangshen) 15g, Atractylodis Macrocephalae Rhizoma (Baizhu) 12g, Zingiberis Rhizoma Recens (Ganjiang) 12g, Glycyrrhizae Radix et Rhizoma Preparata (Zhigancao) 6g, Poria (Fuling) 15g, Magnoliae Officinalis Cortex (Houpo) 20g, Pinelliae Rhizoma Preparatum (Faxia) 10g, Zingiberis Rhizoma Recens (Shengjiang) 10g. After taking 3 doses, epigastric fullness and abdominal distension decreased significantly, borborygmi and palpitations ceased, but the bitter taste remained unchanged. The patient also reported frequent shortness of breath and aversion to cold. Therefore, Astragali Radix (Huangqi) 30g and Prepared Aconiti Lateralis Radix (Shu Fupian) 15g (decocted first) were added to the original formula. After another 3 doses, most symptoms basically disappeared, but the bitter taste became more severe. It was then realized that this syndrome originally involved Liver-Gallbladder Stagnant-Heat. Warming herbs benefited the Spleen-Kidney but were detrimental to the Liver-Gallbladder. Thus, Bupleuri Radix (Chaihu) 10g, Gentianae Radix (Longdancao) 3g, and Ostrea Concha (Sheng Muli) 15g were added to the first prescription. After 2 doses, the bitter taste lessened; the first prescription was then discontinued, and only the added three herbs were taken alone. After 3 more doses, the bitter taste disappeared.
Student Jia: Although bitter taste in the mouth is a common symptom, it is relatively rare for patients to present primarily with this complaint, so some physicians do not pay much attention to it. Teacher places great emphasis on bitter taste in the mouth and advocates using specific formulas and herbs for treatment. For example, in Case 1, where bitter taste was the main symptom, Chai Dan Mu Li Tang was used as the primary formula; in Case 2, where bitter taste was an accompanying symptom, Chai Dan Mu Li Tang was combined with other treatments, both yielding excellent results.
Advanced Student Jia: The name of the formula Chai Dan Mu Li Tang includes all the medicinal ingredients: Bupleuri Radix (Chaihu), Gentianae Radix (Longdancao), and Ostrea Concha (Sheng Muli). I speculate that the teacher uses such a simple three-herb formula to treat bitter taste in the mouth because the pathogenesis is relatively straightforward: Gallbladder Fire flaming upward. Is this correct?
Teacher: Yes, but we can deduce one step further. As everyone knows, bitter taste in the mouth is one of the main symptoms of Gallbladder disease. According to *Nei Jing* (The Inner Canon), regarding bitter taste in the mouth as a "rare disease," its pathogenesis is described as "Deficiency of Gallbladder Qi overflowing upward" or "Gallbladder Fire flaming upward." For instance, *Su Wen: Qi Bing Lun* states: "There is a condition with bitter taste in the mouth... the disease is named Dan Dan (Gallbladder Heat). The Liver is the general within, relying on the Gallbladder for decision-making, and the pharynx serves as its envoy. This person often deliberates but cannot decide, thus causing Gallbladder Qi deficiency and Qi overflowing upward, resulting in a bitter taste in the mouth." *Su Wen: Wei Lun* also states: "When Liver Qi is hot, Gallbladder bile leaks out, causing bitter taste in the mouth." It can be seen that the secondary site of pathology for bitter taste in the mouth is the Gallbladder, while the primary site is the Liver. Since the Liver governs deliberation, if one "often deliberates but cannot decide," Liver Qi becomes stagnant. Over time, stagnation transforms into Fire, affecting the Gallbladder, leading to dysfunction of the Gallbladder. When Gallbladder Fire flames upward or Gallbladder Qi overflows upward, bitter taste in the mouth occurs.
Advanced Student Yi: *Shanghan Lun* states: "For Shaoyang disease, the key symptoms are bitter taste in the mouth, dry throat, and dizziness." Can bitter taste in the mouth, being the first of the three guiding symptoms of Shaoyang disease, also be understood as "secondary pathology in the Gallbladder, primary pathology in the Liver"?
Teacher: It can be understood this way, because when Zhang Zhongjing wrote *Shanghan Lun*, he "utilized nine volumes of Suwen..." His academic thought is consistent with that of *Nei Jing*. More importantly, from a clinical perspective, patients with Shaoyang disease are mostly those who suffer from chronic Liver Qi stagnation. Therefore, treating bitter taste in the mouth requires both clearing and descending Gallbladder Fire and soothing the Liver to relieve stagnation. The self-formulated formula Chai Dan Mu Li Tang by my teacher, Mr. Jian Yuguang, fits this intention perfectly: The Liver likes free flow and prefers ascending; Bupleuri Radix (Chaihu) is bitter and neutral, promoting Liver Qi ascent and relieving Liver stagnation; The Gallbladder likes tranquility and prefers descending; Gentianae Radix (Longdancao) is bitter and cold, sinking downward to clear and descend Gallbladder Fire; Ostrea Concha (Sheng Muli) is salty and cold, nourishing Water to subdue Wood and restraining Gallbladder Fire, so that "the Liver and Gallbladder naturally receive their nourishment" (as stated by Zhang Xichun). Clinical practice has proven that treating bitter taste in the mouth requires the simultaneous use of these three herbs (Bupleuri Radix 10g, Gentianae Radix 6–10g, Ostrea Concha 15–30g). Using them separately or adding arbitrary herbs will result in poor or no efficacy. If the main symptom is Deficiency-Cold, or if the constitution is Deficiency-Cold, the dosage of Gentianae Radix should be reduced to about 3g.
Intern Jia: What is the approximate effective rate of this specific formula for treating simple bitter taste in the mouth?
Teacher: Eight or nine out of ten. Unfortunately, there are few opportunities to use this formula exclusively, because simple bitter taste in the mouth is indeed rare.
Advanced Student Bing: Although simple bitter taste in the mouth is rare, clinically it can appear in various diseases. How should this be explained?
Teacher: This is because the Gallbladder is Yang-Wood. The Ministerial Fire within the Gallbladder spreads throughout the body, giving vitality to the eleven zang-fu organs. Hence, *Nei Jing* states: "All eleven organs depend on the Gallbladder." Conversely, disease in any of the eleven organs can affect the Gallbladder. Therefore, bitter taste in the mouth, as one of the main symptoms of Gallbladder disease, can appear in various diseases.
Advanced Student: This explanation is quite novel. Could you elaborate?
Teacher: The Liver and Gallbladder are closely connected, and Liver disease easily affects the Gallbladder; thus, bitter taste in the mouth is most common in Liver diseases. Other conditions such as Damp-Heat obstruction in the Spleen-Stomach, Heart Fire flaming upward, Kidney Fire rushing upward, and Lung Heat accumulation, once affecting the Gallbladder, can also cause bitter taste in the mouth. These are all Excess-Heat syndromes, which are relatively easy to understand. However, in Case 2, where Spleen-Kidney Deficiency-Cold presented with bitter taste in the mouth, it was due to concurrent Liver-Gallbladder Stagnant-Heat, which is harder to understand and easily overlooked. Additionally, Zhang Jingyue said: "Regarding excessive thinking, fatigue, and sexual excess, many people experience bitter taste in the mouth, dry mouth, and loss of appetite. The fault lies not in the Heart-Spleen, but in the Liver-Kidneys. Heart-Spleen deficiency causes Liver-Gallbladder Qi overflow leading to bitter taste; Liver-Kidney deficiency leads to insufficiency of True Yin, also causing bitter taste." (*Jingyue Quanshu: Miscellaneous Diseases*). This is essentially a complex syndrome where Heart-Spleen deficiency or Liver-Kidney deficiency affects the Gallbladder.
Intern Yi: The teacher likes to use Bupleuri Radix (Chaihu), Gentianae Radix (Longdancao), and Ostrea Concha (Sheng Muli) to treat bitter taste in the mouth. Besides these, what other herbs can be used?
Teacher: Theoretically, any herb that clears/descends or astringes Gallbladder Fire can be used to treat bitter taste in the mouth, such as Artemisiae Annuae Herba (Qinghao), Scutellariae Radix (Huangqin), Bambusae Medulla (Zhuru), Indigo Naturalis (Qingdai), Imperatae Rhizoma (Yinchen), Arisaematis Cum Bile (Danning), and Porci Bile (Zhudan). However, in clinical practice, when encountering bitter taste in the mouth, one must carefully analyze whether it is a primary Gallbladder disorder or a secondary effect from other organs. One should not simply apply heat-clearing methods generally. Taking stomach pain accompanied by bitter taste as an example: if Gallbladder Heat invades the Stomach, Zuojin Wan should be used; if Phlegm-Dampness transforms into Heat, Wendan Tang should be the primary formula; if Liver-Kidney Yin Deficiency exists, Gao Gufeng's Zishen Qinggan Yin should be used; if Spleen-Stomach Deficiency-Cold coexists with Liver-Gallbladder Stagnant-Heat, warming herbs should treat the Deficiency-Cold, or a small amount of Coptidis Rhizoma (Huanglian) can be added, such as in Lianti Tang. In short, one must "strictly adhere to the pathogenesis and assign each to its category" to prescribe accurately. For instance, I once treated a woman in her forties who had bitter taste in the mouth for half a year. She had taken 10 bottles of Longdan Xiegan Wan, but the bitter taste did not decrease; instead, she developed dry mouth and constipation. Observing her pale-red tongue with scanty moist coating and wiry-deep-thready pulse, I considered it Yin Deficiency with Liver Stagnation. I used Yiguan Jian combined with Sini San plus Cassiae Semen (Juemingzi) and Cistanches Herba (Roucongrong). After 2 doses, the bitter taste greatly diminished.
Advanced Student Yi: Given this, how much room is left for the application of Chai Dan Mu Li Tang?
Teacher: As a specific formula for treating simple bitter taste in the mouth, Chai Dan Mu Li Tang features the characteristics of "simplicity, convenience, affordability, and efficacy." When bitter taste is an accompanying symptom, combining this formula into the appropriate formula for the main symptom yields remarkable results effortlessly. Incidentally, this formula was originally a general formula formulated by Mr. Jian for treating chronic cholecystitis, with particularly good efficacy for the Liver-Gallbladder Stagnant-Heat type. By combining this formula with syndrome differentiation and selection, it can be widely applied to various syndromes of chronic cholecystitis, such as combining with Huanglian Wendan Tang for Phlegm-Heat type, Sanren Tang for Damp-Heat type, Chaihu Shugan San for Qi Stagnation type, and Chaishao Liujunzi Tang for Spleen-Stomach Weakness type.
Intern: Has the teacher used this formula to treat chronic cholecystitis?
Teacher: Frequently, and even "remote" prescriptions have been effective. For example, in February 1983, Ms. Zhao X (female, 45 years old) from Liaocheng County, Shandong, wrote to me stating: Right upper quadrant distending pain radiating to the shoulder and back, recurring for 11 years, accompanied by bitter taste in the mouth, belching, and gastric discomfort; symptoms inevitably worsen after consuming greasy food or experiencing worry/anger. Tongue body is slightly red with a thin yellow coating; pulse is wiry. Confirmed as chronic cholecystitis via X-ray cholecystography. Treatment with Chinese and Western medicines yielded unsatisfactory results. I preliminarily considered it Liver-Gallbladder Stagnant-Heat and sent the original Chai Dan Mu Li Tang formula, instructing her to try it. After 6 doses, right upper quadrant distending pain significantly decreased, and bitter taste disappeared; however, stool was slightly loose, taste in mouth was bland, appetite was poor, and she felt fatigued. Syndrome differentiation indicated Liver-Gallbladder Stagnant-Heat and Spleen-Stomach Weakness. This formula was combined with Chaishao Liujunzi Tang plus Astragali Radix (Huangqi). After taking 30 doses (one dose every two days), all symptoms vanished. Ultrasound examination showed no abnormalities in the gallbladder. In September 1986, she wrote again stating the disease had not recurred. During my frequent use of this formula combined with syndrome differentiation for chronic cholecystitis, I found that bitter taste in the mouth was the first symptom to disappear. Thus, I promoted its trial use for bitter taste in the mouth in various diseases, achieving high efficacy, and came to view it as a specific formula and herbs for treating bitter taste in the mouth. The ancients said: "Nothing is more precious than verified efficacy; nothing should be discarded without evidence." I hope everyone continues to verify this in clinical practice.
Skillful Differentiation of Internal Injury Headache
Professor Yang Yaxi, Department of Formulae, Shandong College of Traditional Chinese Medicine
Patient: Male, 50 years old. Headache with a hollow sensation, often accompanied by vertigo and tinnitus for many years. Symptoms are usually mild but worsen with fatigue from reading books or documents, sometimes preventing him from performing daily work. He has visited Western hospitals multiple times; ECG, EEG, and skull X-rays showed no obvious abnormalities. Regular intake of vitamins and sleeping pills yielded poor results. This time, due to continuous meetings and work fatigue over several days, headache and vertigo symptoms significantly worsened, making it difficult to persist in work, so he sought consultation. He reports chronic soreness and weakness in lower back and knees, poor sleep, irritability, and emotional lability. Appetite and bowel/bladder functions are acceptable. Tongue is red with a white coating; pulse is wiry and fine. Blood pressure and ECG are within normal ranges. Syndrome Differentiation: Headache (Liver-Kidney Yin Deficiency, Heart-Kidney Non-interaction). Treatment Method: Nourish Liver and Kidney, calm the Heart and spirit, assist with pacifying Liver and subduing Yang. Prescription: Qiju Dihuang Wan modified. Medicinals: Prepared Rehmanniae Radix (Shudi) 12g, Corni Fructus (Shanzhuyu) 12g, Lycii Fructus (Gouqizi) 15g, Chrysanthemi Flos (Juhua) 12g, Paeoniae Radix Alba (Baishao) 12g, Moutan Cortex (Danpi) 9g, Gastrodiae Rhizoma (Tianma) 12g, Prepared Aragonis Concha (Sheng Shijueming) 30g, Fried Ziziphi Spinosomi Semen (Chao Zaoren) 30g, Acori Tatarinowii Rhizoma (Shichangpu) 12g, Polygalae Radix (Yuanzhi) 12g. Decoct in water and take orally. One dose per day, divided into two servings. Second Visit: Patient reported that after 12 doses of the above formula, headache and dizziness alleviated, irritability disappeared, and sleep improved slightly. Continued with the previous formula, adding Citri Reticulatae Pericarpium (Chenpi) 12g, continued for 12 doses. Third Visit: Reported significant improvement in soreness/weakness of lower back/knees and emotional lability after taking the previous formula; headache and vertigo basically disappeared. However, although sleep improved compared to before medication, dream-disturbed sleep persisted. Considering the headache symptoms were alleviating and other accompanying symptoms had basically disappeared or improved, the decoction was changed to pills. The dosages of all herbs in the second visit formula were increased tenfold, ground into fine powder, mixed with water to form pills. Take 6g per dose, three times daily. Several months later, the patient reported that after taking one pill of the previous formula, sleep and diet normalized, and symptoms of headache, dizziness, and tinnitus disappeared. Even during periods of working overtime overnight while taking the medication, no obvious abnormalities occurred.
Student Jia: Teacher, you treated this patient starting from the disease of "Headache." After years of chronic illness, he recovered suddenly. Please explain the key points.
Teacher: Headache is a common subjective symptom in clinical practice, appearing in the course of various acute and chronic diseases. In Traditional Chinese Medicine (TCM), "Headache" refers to cases where headache is the main symptom in internal medicine miscellaneous diseases. If it appears as an accompanying symptom in the process of a specific disease, it should not be discussed under the category of Headache. Headache is generally divided into two major categories: Exterior-Attack Headache and Internal-Injury Headache. This patient suffered from headache and vertigo for many years, accompanied by irritability and insomnia. This belongs to Kidney Water insufficiency leading to Water Deficiency and Wood Hyperactivity, hence it is Internal-Injury Headache. The patient's chronic poor sleep, soreness/weakness of lower back/knees, and emotional lability indicate a constitutional tendency toward Kidney Yin Deficiency and Liver Yang Hyperactivity. Furthermore, continuous mental fatigue consumed Yin and Blood, resulting in Liver-Kidney Yin Deficiency and Liver Yang Hyperexcitation, manifesting as hollow headache, vertigo, and tinnitus. Therefore, the treatment method is to nourish Liver and Kidney, facilitate Heart-Kidney interaction, and pacify Liver and subdue Yang. The selected formula is Qiju Dihuang Wan modified. In the formula, Prepared Rehmanniae Radix (Shudi), Corni Fructus (Shanzhuyu), Lycii Fructus (Gouqizi), and Paeoniae Radix Alba (Baishao) nourish Liver and Kidney Yin; Gastrodiae Rhizoma (Tianma), Prepared Aragonis Concha (Sheng Shijueming), Moutan Cortex (Danpi), and Chrysanthemi Flos (Juhua) pacify Liver, subdue Yang, and clear Heat, preventing Liver Yang from transforming into Heat and controlling Heat generated by Kidney Yin Deficiency; Fried Ziziphi Spinosomi Semen (Chao Zaoren), Acori Tatarinowii Rhizoma (Shichangpu), and Polygalae Radix (Yuanzhi) nourish Blood, calm the spirit, and facilitate Heart-Kidney interaction. Thus, treating Liver and Kidney simultaneously, and harmonizing Heart and Kidney, achieves efficacy.
Student Yi: Teacher, please discuss how to differentiate and treat Internal-Injury Headache in clinical practice.
Teacher: Alright, regarding this issue, let us first review the etiology and pathogenesis of Internal-Injury Headache, and then discuss diagnostic points and treatment methods. TCM considers the head as the "Assembly of All Yang Meridians" and the "Residence of Clear Yang," where the Sea of Marrow resides. It is connected to meridians and zang-fu organs, and communicates internally and externally through orifices. Therefore, there are many causes of headache. Here, we will not discuss Exterior-Attack Headache caused by Wind-Cold, Dampness, or Heat pathogens, but focus on Internal-Injury Headache. The causes of Internal-Injury Headache are closely related to the Liver, Spleen, and Kidney. Caused by the Liver: either emotional disharmony leading to Liver failing to maintain free flow, stagnation transforming into Fire, disturbing the clear spaces above causing headache; or Wood-Fire damaging Yin, Liver losing nourishment, Kidney Water insufficient, Water failing to nourish Wood, leading to Liver-Kidney Yin Deficiency and Liver Yang Hyperactivity, disturbing the clear spaces above causing headache. Caused by the Spleen: mostly due to excessive labor, post-illness/post-partum weakness, Spleen-Stomach weakness, insufficient production of Qi and Blood, or post-hemorrhage deficiency of Ying-Blood, unable to nourish the brain marrow and meridines, causing headache; or irregular diet, Spleen failing to transport and transform, generating internal Phlegm-Dampness, Turbid Phlegm disturbing upward, obstructing Clear Yang, causing headache. Caused by the Kidney: mostly due to congenital insufficiency, excessive sexual activity, long-term depletion of Kidney Essence, resulting in empty brain marrow causing headache; or due to Kidney Yang decline, Clear Yang failing to ascend, causing headache. TCM believes the normal physiological state of the human body is Clear Ascending and Turbid Descending. The Classics state: "The Six Fu Organs transmit and transform substances without storing." If transmission and transformation function is normal, Turbid descends and Clear ascends. If this function is disordered, causing Qi mechanism stagnation, internal generation of Water-Dampness-Phlegm-Fluid, and constipation, Turbid Qi cannot descend but instead rebels upward, causing headache, mostly belonging to Excess syndromes. The Classics also state: "The Five Zang Organs store Essence-Qi without leaking." The essence, Qi, and Blood of the Five Zang, and the Clear Yang Qi of the Six Fu, all ascend to the head to nourish it. If fatigue damages Qi, consumptive disease damages Essence, or post-partum hemorrhage occurs, leading to failure of Clear Yang to ascend and lack of Qi-Blood nourishment to the brain, headache also occurs, mostly belonging to Deficiency syndromes. Blockage causes pain. Any Qi-Blood stagnation, blocking collaterals, or long-standing disease entering collaterals with internal stasis of Blood, causing meridian congestion and blockage, can also cause headache. The above are the main etiologies and pathogenesis of Internal-Injury Headache. Regarding the differentiation of Internal-Injury Headache, besides detailed inquiry into medical history and accompanying symptoms, the following aspects should be noted to assist diagnosis. First, note the location of the headache, distinguishing between generalized headache and unilateral headache, vertex pain or occipital/cervical pain. Second, note the timing of the headache, such as appearance or worsening in the morning, noon, or afternoon. Third, note triggers, such as excessive fatigue, excessive blood loss, emotional agitation, sexual excess, or dietary irregularities. For the treatment of Internal-Injury Headache, it is inappropriate to simply stop pain upon seeing pain. Generally, ten methods can be adopted: Tonifying Qi and raising Yang, Nourishing Blood and dispersing Wind, Invigorating Blood and resolving Stasis, Pacifying Liver and subduing Yang, Clearing Liver and descending Fire, Soothing Liver and relieving Stagnation, Promoting Diuresis and resolving Phlegm, Warming Liver and descending Rebellious Qi, Nourishing Kidney Yin, and Warming Kidney and supporting Yang.
Student Bing: Teacher, could you share your experience in treating Internal-Injury Headache?