老师：中医治病要抓住辨证论治，要抓住病情的变化，随证治之。本方之所以有效果，可以从上方的组合及作用分析。方中沙参、玉竹、石斛甘凉滋胃阴；白芍、佛手柔肝理气而不伤阴；郁金解郁散结，菖蒲芳香理气，且不致甘凉过盛，二者兼治心疾；鸡内金、炒稻芽助消化开胃；荷叶性平和，升清降浊，益胃而不呆滞。全方共奏滋胃柔肝，理气和胃，消食开胃之功。药证相符，直达病所，故投药3剂而得效。1980年9月24日诊：上方得效，效如桴鼓。食谷味馨，已如常态，心中悦脘中舒，睡眠安稳，口亦不干，舌绛苔见薄白，津液来复，上方加女贞子10g，继服6剂，以资巩固。经随访3个月，一直饮佳调便。案4陈XX，男，61岁，干部。患者因排尿困难而入院，入院后行前列腺切除术，术后14天，患者不思食，遂请中医调理饮食。一诊：患者主要表现食欲不振，食后汗出；小便失禁，余沥不尽。舌红润白苔，脉沉细。宗内经所云"饮食饱甚，汗出于胃"。又肾司二便，肾气不固故小便频，甚则失禁、余沥不尽。故证属脾胃气虚，肾气不固，宜健脾固肾，益气开胃。拟六君子汤健脾益气，加焦四仙、乌梅以助消化；更加益智仁、菟丝子、补骨脂固肾缩尿。二诊：服上方3剂，精神略增，小便稍有控制，但仍不思食，观察舌体胖大，舌根白苔，脉象沉细。思考良久，认为术后伤肾，以致命门火衰，火不生土，脾失健运，胃失受纳故见饮食少进，纳谷不香。改拟"补火生上法"。据《内经》所云"阳之不足，温之以气"，故选用金匮肾气汤加异功散。药用：附子15g(先煮20分钟，不麻为度)，桂枝15g，熟地15g，山茱萸10g，怀山药15g，茯苓15g，泽泻10g，牡丹皮9g，党参15g，白术15g，陈皮6g，炙甘草6g。三诊：仅服药3剂，饮食顿增。据述患者服药当日下午5时即感胃中空虚，有饥饿感。上方加砂仁9g，继服5剂，饮食恢复正常而出院。
学生：老师慧眼，二诊即抓住病本而获捷效，可谓妙矣。请您讲一讲用金匮肾气汤的道理。
老师：本案系术后伤肾，肾司二便故小便失禁而余沥不尽。肾阳虚衰，火不生土，脾失健运，胃失受纳，故不思食。治疗宜用补肾温阳，补阳以配阴为主的方法，明·张景岳指出，"善补阳者，必于阴中求阳，则阳得阴助，而生化无穷"。选"金匮肾气汤"正合此意。不思食案专事补肾而获捷效，进一步证实了许叔微所说"补脾不如补肾"的见解。
"诸风掉眩，皆属于肝"的临床运用
长春中医学院教授段成功
病例1杨XX，男，43岁，干部。患阵发性头痛10余年，近2个月加重，前来就诊。10余年来，每日下午2时左右开始头痛，持续数小时后方可缓解，痛时伴有眩晕、恶心、心烦等。经服中、西药效果不明显。近2个月来逐渐加重，发作时以巅顶、后头部疼痛为主，剧烈难忍，不能正常工作，服用镇痛药后仍不能缓解。观其体态胖大，颜面潮红，查其舌红、体胖大边有齿痕，苔黄厚腻，脉弦数无力。辨证：肝虚生风风热头痛。治法：养阴清热，活血祛风。方药：生地50g，吴萸5g，川芎15g，黄芩15g，羌活15g，龙骨50g，牡蛎50g，夏枯草10g，菊花20g。水煎服，每日l剂。治疗经过：服药3剂后，自觉眩晕、恶心明显好转，头痛亦缓解。8剂后头痛明显减轻。于上方去羌活，加山楂片20g。共服药12剂，基本痊愈。追访5年未复发。
病例2张X，女，52岁。以发作性眩晕3日就诊。该患1年前患突发性眩晕，西医确诊为"美尼尔氏综合征"，经治疗好转。3日前因劳累、动怒复发。现症头晕目眩，头部不敢转动，动则天旋地转，恶心、呕吐，有强烈的恐惧感。经用西药阿托品、安定、培他定等，未见明显好转。查其舌红、苔黄、脉沉细数无力。辨证：肝郁气滞，肝风内动。治则：养阴清热，平肝熄风。方药：镇肝熄风汤加减。天麻15g，钩藤15g，龙骨50g，牡蛎50g，牛膝15g，龟板20g，代赭石20g，天门冬15g，麦门冬15g，茵陈20g，玄参15g，甘草10g，川楝子15g，生地20g，白芍上5g。水煎服。每1．5日1剂。治疗经过：服药1剂即明显缓解，已能坐起进食。2剂后可下地行走，已无恶呕之症，只是不敢突然转头，守方连服5剂，诸症悉解，调养几日后上班工作。
病例3于XX，女，34岁，以3年来经常失眠为主诉就诊。该患3年前因与婆母口角，心情抑郁，后发生失眠、多梦，逐渐加重。现症头晕、乏力、消瘦、纳呆、烦躁易怒，每日睡眠4-5个小时，且多梦，醒来颇觉疲乏。查其舌尖红，苔薄黄，脉细数，左关弦。细观其头部有轻微的不自主颤功，再查其双手也不停颤动，追问其病情，自诉手足经常"抽筋"。辨证：虚风内动，热扰心神。治法：疏肝健脾，安神熄风。方药：党参15g，清半夏15g，天麻15g，钩藤15g，石决明30g，灵磁石30g，柴胡15g，白芍10g，甘草10g，茯苓15g，当归15g，白术15g，丹皮15g。水煎服，每日1剂。以铁锈水浸药后再煎。治疗经过：服药3剂后，自觉诸症见轻，但失眠仍无明显好转。上方去天麻、钩藤，加夜交藤15g，元参15g。继服3剂。自诉睡眠明显好转，头晕、乏力见轻。守原方加减，共服药20余剂，诸症悉解，健康如初。嘱其调节生活节奏，保持心情愉快，遇事不急不躁。患者遵医嘱，至今健康。
学生甲以上所举3例为头痛、眩晕、失眠3种不同病证，为什么都用"熄风"的治法?
老师：问得很好。之所以皆以熄风(或祛风)为治法，就是因为虽为3种不同病证，临床表现也不-样，但都有"风"的证侯。中医诊病的主要方法，就是辨证施治，通过辨证以求其因，并确定治疗法则。中医基础理论中，用取类比象的方法将人体内的病理变化加以归类，认为有一类疾病类似自然界的风，并引伸其义，将其与春、木、肝等联系起来，总结了其常、其变的各种表现。指出风有外风、内风之分。外风是一种外来的邪气。内风是脏腑变化导致的病变，因其特点与风类似，所以称内风，并认为与肝密切相关，乃有肝风之称。《内经·至真要大论》说"诸风掉眩，皆属于肝"，诸风，是指各种风证，掉，张介宾注"掉，摇也"，即抽动，"眩，运也"，即眩晕。意思是说，各种风证，例如抽搐、眩晕等，大都属于肝病范畴。临床上，凡是见到有抽搐、眩晕等表现，皆可以风辨治，并将其与肝联系起来考虑。那么，当然就应以熄风为治疗法则了。
学生乙：请结合3个病例谈一下"风"证的辨治。
老师：所谓"风"证，在临床上表现十分复杂。中医认为，风性"善行而数变"，并可挟湿、挟热、挟寒。另有中风之证，亦是历代医家研究的课题，不在此论之列。(内经)"诸风掉眩皆属于肝"，对风证的辨治具有重要的指导意义。病例1为头痛。古人称头痛亦作"头风"，可见其与风的关系。此例特点为定时发作，并伴有眩晕、脉弦，可以认为是肝虚生风，肝阳上亢，病久虚而生热，热郁脉络，风热相煽而作头痛，故治以养阴清热为法，兼以活血祛风。方中生地、黄芩、夏枯草、菊花养阴清热，龙骨、牡蛎平肝熄风，川芎行血化瘀，羌活祛风以治太阳经之头痛。更用吴茱萸一味，既治厥阴头痛，又佐诸清热药，使之清热而不伤阳。诸药合用，共达祛风止痛之目的。
病例2为眩晕，其特点为发病急骤，症状重。其病因与"怒"有关。因肝主怒，故与肝关系密切，综观其证，乃肝郁生热，热而生风，肝风内动，风热相搏，上犯清窍，因作眩晕。所以治疗从"肝风"着手，以清，张寿甫之镇肝熄风汤为主加减。方中天麻、钩藤为熄风之晶，龙骨、牡蛎、代赭石为镇肝降逆药，龟板、天冬、麦冬、玄参、生地、白芍为养阴柔肝之物，兼以清肝之热，茵陈、川楝子入肝经行气化湿，牛膝引气下行，甘草调和诸药。诸药协同，平肝清热以熄风，故疗效迅捷。
病例3以失眠为主症，西医诊断为"神经官能症"(神经衰弱)。此病临床表现各种各样，虽不算重症，但治疗也不是轻而易举之事。应细心辨证，对证施治，方可收效，此例经细致诊查，发现其头、手震颤，正与"诸风掉眩"之意吻合，故认为属虚风内动之证。乃以治风疏肝为原则组方，果收良效，证明辨证无误。用方以天麻钩藤饮合逍遥散加减，方中石决明、灵磁石、铁锈水镇静安神，党参、清夏升降并用，健脾化痰，逍遥散疏肝达郁，丹皮清阴虚之热。诸药同用，共奏疏肝健脾，安神熄风之功。
综合以上3例，因临床表现都有掉或眩的证侯，所以都从风辨治．并追本溯源求之于肝，取得满意疗效，可见，深刻理解(内经)"诸风掉眩，皆属于肝"的指导意义，颇有临床价值。
呕吐尿少1个月余
吉林省中医中药研究院教授苏瑞君蔡鸿彦
患者，殷X，女，62岁，干部，1994年12月18日就诊。该患自觉腰酸乏力已5年之久，每逢感冒劳累和受寒凉后，腰痛反复发作，并且日益加重。近1个月来出现呕吐恶心、不思饮食、腰部酸痛、形寒肢冷、周身乏力、浮肿尿少，尤其是夜间尿频、尿少，每日尿量仅300ml左右。伴心悸气短、头晕目眩、手足心热、口干不欲饮、双目干涩、皮肤瘙痒、大便干结。遂求中医诊治。诊见形体中等、营养欠佳、眼睑浮肿、面色觥白虚浮、精神疲惫、肌肤欠润、唇甲苍白、下肢浮肿、呕吐频作，舌质淡、少苔，双脉沉细数。
中医诊断：①关格、脾肾阳虚证，浊邪侵犯中焦；②虚劳，气血两虚证。拟以健脾益肾、止呕降浊之法治疗。处方组成：黄芪25g，党参20g，茯苓20g，砂仁20g，仙茅15g，半夏10g，白芍15g，藿香15g，竹茹10g，泽泻15g，甘草10g。水煎服，每日1剂。药进7剂，恶心呕吐减轻，仍然尿少、大便于结，继续内服中药，前方加白茅根20g。同时给予中药水煎剂高位保留灌肠。处方：大黄25g，牡蛎20g，当归20g，槐花20g，附子10g。每日1剂，水煎外用灌肠，保留时间越长越好。以此法治疗1周后，症状明显好转，呕吐消失，浮肿明显减轻，尿量增加，舌脉无明显变化。调整中药处方：黄芪25g，党参20g，茯苓20g，砂仁10g，山萸肉20g，白芍20g，当归15g，佩兰15g，藿香15g，肉苁蓉15g，泽泻15g，甘草15g。水煎服，早晚各服1次，每日l剂。继续前方保留灌肠。以此法坚持治疗1个月，诸症基本消除，恶心、呕吐消失，浮肿消退，精神和体力状态均有所改善，食欲渐增。舌质淡红，舌苔薄白，双脉沉细。精神状态恢复，并能操持家务。随访1年，未再复发。
学生甲何谓关格?诊断此病为关格的根据是什么?
老师："关"是关闭，小便不通名曰关；"格"是格拒，呕吐不止名曰格。所谓关格就是小便不通与呕吐不止并见的病证。正如张仲景在(伤寒论·平脉法第二)中说，"关则不得小便，格则吐逆"。因此关格一病是指-亡吐下闭之证，以尿少、尿闭、恶心呕吐为主要临床表现，属危重病证，多见于水肿、癃闭、淋证等病证的晚期。此病诊断为关格并不难，从临床表现上看，除具有呕吐频作、尿少两大主证外，还有脾肾阳虚和阴血虚衰等证侯。恶心呕吐、不思饮食、腰部酸痛、形寒肢冷均为脾肾阳虚证侯。头晕目眩、口干不欲饮、肌肤欠润、唇甲苍白、舌少苔、脉细数均为阴血虚衰证侯。因此，此病除诊断"关格"外，还可以诊断为"虚劳"。
学生乙关格病的主要病因、病机是什么?
老师：本病的病机，关键在于脾肾同病。病人年迈体虚，由于脾阳亏损，肾气衰惫，气化失权，水不化精，生化无源，三焦之气闭塞，决渎无权，上下升降出入不利，故小便失司而为尿闭；脾失运化，不能升清降浊，失其"为胃行其津液"的功能，邪浊犯胃，胃失和降，故呕吐频作、不思饮食，此乃关格浊邪侵犯中焦之病证。引起脾肾阳虚的原因很多，最常见的有风邪外袭，肺气不宣，不能通调水道，下输膀胱，溢于肌肤，水肿日久不愈，水湿浸渍损伤脾阳造成脾阳虚；或因久居湿地，涉水冒雨，水湿内侵，湿留中集，使脾运失职，湿困脾阳，日久不愈，致使脾阳亏虚；或因饮食不节，饥饱失调，脾气受伤，运化失司，湿浊内生，湿困中焦伤及脾阳，致使脾阳虚衰；或因劳倦过度，生育过多，肾气内伤，肾主水液排泄，脾主运化水湿，如脾肾阳虚，水液运化与排泄功能减弱，则水湿泛滥，溢于肌肤，形成水肿，尿少，重者小便不通，而致关格。由于脾阳不振不能腐热水谷，使气血来源不足，气不足则周身乏力；血不足则面色无华，唇甲苍白，肌肤甲错，舌质淡，脉沉细，此乃阴血亏虚之病证。
学生丙该病人除诊断关格外，为什么还要诊断虚劳?基本病机是什么?
老师：中医治病要抓住辨证论治，要抓住病情的变化，随证治之。本方之所以有效果，可以从上方的组合及作用分析。方中沙参、玉竹、石斛甘凉滋胃阴；白芍、佛手柔肝理气而不伤阴；郁金解郁散结，菖蒲芳香理气，且不致甘凉过盛，二者兼治心疾；鸡内金、炒稻芽助消化开胃；荷叶性平和，升清降浊，益胃而不呆滞。全方共奏滋胃柔肝，理气和胃，消食开胃之功。药证相符，直达病所，故投药3剂而得效。1980年9月24日诊：上方得效，效如桴鼓。食谷味馨，已如常态，心中悦脘中舒，睡眠安稳，口亦不干，舌绛苔见薄白，津液来复，上方加女贞子10g，继服6剂，以资巩固。经随访3个月，一直饮佳调便。
案4陈XX，男，61岁，干部。患者因排尿困难而入院，入院后行前列腺切除术，术后14天，患者不思食，遂请中医调理饮食。一诊：患者主要表现食欲不振，食后汗出；小便失禁，余沥不尽。舌红润白苔，脉沉细。宗内经所云"饮食饱甚，汗出于胃"。又肾司二便，肾气不固故小便频，甚则失禁、余沥不尽。故证属脾胃气虚，肾气不固，宜健脾固肾，益气开胃。拟六君子汤健脾益气，加焦四仙、乌梅以助消化；更加益智仁、菟丝子、补骨脂固肾缩尿。二诊：服上方3剂，精神略增，小便稍有控制，但仍不思食，观察舌体胖大，舌根白苔，脉象沉细。思考良久，认为术后伤肾，以致命门火衰，火不生土，脾失健运，胃失受纳故见饮食少进，纳谷不香。改拟"补火生上法"。据《内经》所云"阳之不足，温之以气"，故选用金匮肾气汤加异功散。药用：附子15g(先煮20分钟，不麻为度)，桂枝15g，熟地15g，山茱萸10g，怀山药15g，茯苓15g，泽泻10g，牡丹皮9g，党参15g，白术15g，陈皮6g，炙甘草6g。三诊：仅服药3剂，饮食顿增。据述患者服药当日下午5时即感胃中空虚，有饥饿感。上方加砂仁9g，继服5剂，饮食恢复正常而出院。
学生：老师慧眼，二诊即抓住病本而获捷效，可谓妙矣。请您讲一讲用金匮肾气汤的道理。
老师：本案系术后伤肾，肾司二便故小便失禁而余沥不尽。肾阳虚衰，火不生土，脾失健运，胃失受纳，故不思食。治疗宜用补肾温阳，补阳以配阴为主的方法，明·张景岳指出，"善补阳者，必于阴中求阳，则阳得阴助，而生化无穷"。选"金匮肾气汤"正合此意。不思食案专事补肾而获捷效，进一步证实了许叔微所说"补脾不如补肾"的见解。
"诸风掉眩，皆属于肝"的临床运用
长春中医学院教授段成功
病例1杨XX，男，43岁，干部。患阵发性头痛10余年，近2个月加重，前来就诊。10余年来，每日下午2时左右开始头痛，持续数小时后方可缓解，痛时伴有眩晕、恶心、心烦等。经服中、西药效果不明显。近2个月来逐渐加重，发作时以巅顶、后头部疼痛为主，剧烈难忍，不能正常工作，服用镇痛药后仍不能缓解。观其体态胖大，颜面潮红，查其舌红、体胖大边有齿痕，苔黄厚腻，脉弦数无力。辨证：肝虚生风风热头痛。治法：养阴清热，活血祛风。方药：生地50g，吴萸5g，川芎15g，黄芩15g，羌活15g，龙骨50g，牡蛎50g，夏枯草10g，菊花20g。水煎服，每日l剂。治疗经过：服药3剂后，自觉眩晕、恶心明显好转，头痛亦缓解。8剂后头痛明显减轻。于上方去羌活，加山楂片20g。共服药12剂，基本痊愈。追访5年未复发。
病例2张X，女，52岁。以发作性眩晕3日就诊。该患1年前患突发性眩晕，西医确诊为"美尼尔氏综合征"，经治疗好转。3日前因劳累、动怒复发。现症头晕目眩，头部不敢转动，动则天旋地转，恶心、呕吐，有强烈的恐惧感。经用西药阿托品、安定、培他定等，未见明显好转。查其舌红、苔黄、脉沉细数无力。辨证：肝郁气滞，肝风内动。治则：养阴清热，平肝熄风。方药：镇肝熄风汤加减。天麻15g，钩藤15g，龙骨50g，牡蛎50g，牛膝15g，龟板20g，代赭石20g，天门冬15g，麦门冬15g，茵陈20g，玄参15g，甘草10g，川楝子15g，生地20g，白芍上5g。水煎服。每1．5日1剂。治疗经过：服药1剂即明显缓解，已能坐起进食。2剂后可下地行走，已无恶呕之症，只是不敢突然转头，守方连服5剂，诸症悉解，调养几日后上班工作。
病例3于XX，女，34岁，以3年来经常失眠为主诉就诊。该患3年前因与婆母口角，心情抑郁，后发生失眠、多梦，逐渐加重。现症头晕、乏力、消瘦、纳呆、烦躁易怒，每日睡眠4-5个小时，且多梦，醒来颇觉疲乏。查其舌尖红，苔薄黄，脉细数，左关弦。细观其头部有轻微的不自主颤功，再查其双手也不停颤动，追问其病情，自诉手足经常"抽筋"。辨证：虚风内动，热扰心神。治法：疏肝健脾，安神熄风。方药：党参15g，清半夏15g，天麻15g，钩藤15g，石决明30g，灵磁石30g，柴胡15g，白芍10g，甘草10g，茯苓15g，当归15g，白术15g，丹皮15g。水煎服，每日1剂。以铁锈水浸药后再煎。治疗经过：服药3剂后，自觉诸症见轻，但失眠仍无明显好转。上方去天麻、钩藤，加夜交藤15g，元参15g。继服3剂。自诉睡眠明显好转，头晕、乏力见轻。守原方加减，共服药20余剂，诸症悉解，健康如初。嘱其调节生活节奏，保持心情愉快，遇事不急不躁。患者遵医嘱，至今健康。
学生甲以上所举3例为头痛、眩晕、失眠3种不同病证，为什么都用"熄风"的治法?
老师：问得很好。之所以皆以熄风(或祛风)为治法，就是因为虽为3种不同病证，临床表现也不-样，但都有"风"的证侯。中医诊病的主要方法，就是辨证施治，通过辨证以求其因，并确定治疗法则。中医基础理论中，用取类比象的方法将人体内的病理变化加以归类，认为有一类疾病类似自然界的风，并引伸其义，将其与春、木、肝等联系起来，总结了其常、其变的各种表现。指出风有外风、内风之分。外风是一种外来的邪气。内风是脏腑变化导致的病变，因其特点与风类似，所以称内风，并认为与肝密切相关，乃有肝风之称。《内经·至真要大论》说"诸风掉眩，皆属于肝"，诸风，是指各种风证，掉，张介宾注"掉，摇也"，即抽动，"眩，运也"，即眩晕。意思是说，各种风证，例如抽搐、眩晕等，大都属于肝病范畴。临床上，凡是见到有抽搐、眩晕等表现，皆可以风辨治，并将其与肝联系起来考虑。那么，当然就应以熄风为治疗法则了。
学生乙：请结合3个病例谈一下"风"证的辨治。
老师：所谓"风"证，在临床上表现十分复杂。中医认为，风性"善行而数变"，并可挟湿、挟热、挟寒。另有中风之证，亦是历代医家研究的课题，不在此论之列。(内经)"诸风掉眩皆属于肝"，对风证的辨治具有重要的指导意义。病例1为头痛。古人称头痛亦作"头风"，可见其与风的关系。此例特点为定时发作，并伴有眩晕、脉弦，可以认为是肝虚生风，肝阳上亢，病久虚而生热，热郁脉络，风热相煽而作头痛，故治以养阴清热为法，兼以活血祛风。方中生地、黄芩、夏枯草、菊花养阴清热，龙骨、牡蛎平肝熄风，川芎行血化瘀，羌活祛风以治太阳经之头痛。更用吴茱萸一味，既治厥阴头痛，又佐诸清热药，使之清热而不伤阳。诸药合用，共达祛风止痛之目的。
病例2为眩晕，其特点为发病急骤，症状重。其病因与"怒"有关。因肝主怒，故与肝关系密切，综观其证，乃肝郁生热，热而生风，肝风内动，风热相搏，上犯清窍，因作眩晕。所以治疗从"肝风"着手，以清，张寿甫之镇肝熄风汤为主加减。方中天麻、钩藤为熄风之晶，龙骨、牡蛎、代赭石为镇肝降逆药，龟板、天冬、麦冬、玄参、生地、白芍为养阴柔肝之物，兼以清肝之热，茵陈、川楝子入肝经行气化湿，牛膝引气下行，甘草调和诸药。诸药协同，平肝清热以熄风，故疗效迅捷。
病例3以失眠为主症，西医诊断为"神经官能症"(神经衰弱)。此病临床表现各种各样，虽不算重症，但治疗也不是轻而易举之事。应细心辨证，对证施治，方可收效，此例经细致诊查，发现其头、手震颤，正与"诸风掉眩"之意吻合，故认为属虚风内动之证。乃以治风疏肝为原则组方，果收良效，证明辨证无误。用方以天麻钩藤饮合逍遥散加减，方中石决明、灵磁石、铁锈水镇静安神，党参、清夏升降并用，健脾化痰，逍遥散疏肝达郁，丹皮清阴虚之热。诸药同用，共奏疏肝健脾，安神熄风之功。
综合以上3例，因临床表现都有掉或眩的证侯，所以都从风辨治．并追本溯源求之于肝，取得满意疗效，可见，深刻理解(内经)"诸风掉眩，皆属于肝"的指导意义，颇有临床价值。
呕吐尿少1个月余
吉林省中医中药研究院教授苏瑞君蔡鸿彦
患者，殷X，女，62岁，干部，1994年12月18日就诊。该患自觉腰酸乏力已5年之久，每逢感冒劳累和受寒凉后，腰痛反复发作，并且日益加重。近1个月来出现呕吐恶心、不思饮食、腰部酸痛、形寒肢冷、周身乏力、浮肿尿少，尤其是夜间尿频、尿少，每日尿量仅300ml左右。伴心悸气短、头晕目眩、手足心热、口干不欲饮、双目干涩、皮肤瘙痒、大便干结。遂求中医诊治。诊见形体中等、营养欠佳、眼睑浮肿、面色觥白虚浮、精神疲惫、肌肤欠润、唇甲苍白、下肢浮肿、呕吐频作，舌质淡、少苔，双脉沉细数。
中医诊断：①关格、脾肾阳虚证，浊邪侵犯中焦；②虚劳，气血两虚证。拟以健脾益肾、止呕降浊之法治疗。处方组成：黄芪25g，党参20g，茯苓20g，砂仁20g，仙茅15g，半夏10g，白芍15g，藿香15g，竹茹10g，泽泻15g，甘草10g。水煎服，每日1剂。药进7剂，恶心呕吐减轻，仍然尿少、大便于结，继续内服中药，前方加白茅根20g。同时给予中药水煎剂高位保留灌肠。处方：大黄25g，牡蛎20g，当归20g，槐花20g，附子10g。每日1剂，水煎外用灌肠，保留时间越长越好。以此法治疗1周后，症状明显好转，呕吐消失，浮肿明显减轻，尿量增加，舌脉无明显变化。调整中药处方：黄芪25g，党参20g，茯苓20g，砂仁10g，山萸肉20g，白芍20g，当归15g，佩兰15g，藿香15g，肉苁蓉15g，泽泻15g，甘草15g。水煎服，早晚各服1次，每日l剂。继续前方保留灌肠。以此法坚持治疗1个月，诸症基本消除，恶心、呕吐消失，浮肿消退，精神和体力状态均有所改善，食欲渐增。舌质淡红，舌苔薄白，双脉沉细。精神状态恢复，并能操持家务。随访1年，未再复发。
学生甲何谓关格?诊断此病为关格的根据是什么?
老师："关"是关闭，小便不通名曰关；"格"是格拒，呕吐不止名曰格。所谓关格就是小便不通与呕吐不止并见的病证。正如张仲景在(伤寒论·平脉法第二)中说，"关则不得小便，格则吐逆"。因此关格一病是指-亡吐下闭之证，以尿少、尿闭、恶心呕吐为主要临床表现，属危重病证，多见于水肿、癃闭、淋证等病证的晚期。此病诊断为关格并不难，从临床表现上看，除具有呕吐频作、尿少两大主证外，还有脾肾阳虚和阴血虚衰等证侯。恶心呕吐、不思饮食、腰部酸痛、形寒肢冷均为脾肾阳虚证侯。头晕目眩、口干不欲饮、肌肤欠润、唇甲苍白、舌少苔、脉细数均为阴血虚衰证侯。因此，此病除诊断"关格"外，还可以诊断为"虚劳"。
学生乙关格病的主要病因、病机是什么?
老师：本病的病机，关键在于脾肾同病。病人年迈体虚，由于脾阳亏损，肾气衰惫，气化失权，水不化精，生化无源，三焦之气闭塞，决渎无权，上下升降出入不利，故小便失司而为尿闭；脾失运化，不能升清降浊，失其"为胃行其津液"的功能，邪浊犯胃，胃失和降，故呕吐频作、不思饮食，此乃关格浊邪侵犯中焦之病证。引起脾肾阳虚的原因很多，最常见的有风邪外袭，肺气不宣，不能通调水道，下输膀胱，溢于肌肤，水肿日久不愈，水湿浸渍损伤脾阳造成脾阳虚；或因久居湿地，涉水冒雨，水湿内侵，湿留中集，使脾运失职，湿困脾阳，日久不愈，致使脾阳亏虚；或因饮食不节，饥饱失调，脾气受伤，运化失司，湿浊内生，湿困中焦伤及脾阳，致使脾阳虚衰；或因劳倦过度，生育过多，肾气内伤，肾主水液排泄，脾主运化水湿，如脾肾阳虚，水液运化与排泄功能减弱，则水湿泛滥，溢于肌肤，形成水肿，尿少，重者小便不通，而致关格。由于脾阳不振不能腐热水谷，使气血来源不足，气不足则周身乏力；血不足则面色无华，唇甲苍白，肌肤甲错，舌质淡，脉沉细，此乃阴血亏虚之病证。
学生丙该病人除诊断关格外，为什么还要诊断虚劳?基本病机是什么?
Teacher: In treating diseases, Traditional Chinese Medicine (TCM) must grasp the principle of syndrome differentiation and treatment (Bian Zheng Lun Zhi), seize the changes in the patient's condition, and treat according to the evolving syndrome. The efficacy of this prescription can be analyzed from the combination and actions of the herbs above. In the formula, Sha Shen (Glehniae Radix), Yu Zhu (Polygonati Odorati Rhizoma), and Shi Hu (Dendrobii Caulis) are sweet and cool, nourishing Stomach Yin (Wei Yin); Bai Shao (Paeoniae Radix Alba) and Fo Shou (Citri Sarcodactylis Fructus) soften the Liver (Gan) and regulate Qi without damaging Yin; Yu Jin (Curcumae Radix) resolves depression and dissipates nodules, while Shi Pu (Acori Tatarinowii Rhizoma) uses its aromatic property to regulate Qi, preventing excessive coolness from the sweet herbs; these two together treat Heart (Xin) disorders; Ji Nei Jin (Galli Gigerii Endothelium Corneum) and Chao Dao Ya (Fried Oryzae Fructus Germinatus) aid digestion and stimulate appetite; He Ye (Nelumbinis Folium) has a neutral nature, ascending clear Yang and descending turbid Yin, benefiting the Stomach without causing stagnation. The entire formula jointly achieves the effects of nourishing Stomach Yin, softening the Liver, regulating Qi and harmonizing the Stomach, promoting digestion and stimulating appetite. Since the herbs match the syndrome precisely, reaching the disease site directly, efficacy was achieved after taking 3 doses. Diagnosis on September 24, 1980: The previous prescription was effective, with results as immediate as a drumstick striking a drum. Food tastes good, returning to normal; the heart feels joyful and the epigastrium is comfortable; sleep is stable; the mouth is not dry; the tongue is crimson with a thin white coating, indicating the return of Body Fluids (Jin Ye). Add Nu Zhen Zi (Ligustri Lucidi Fructus) 10g to the previous prescription, continue taking it for 6 doses to consolidate the effect. Follow-up for 3 months showed good appetite and regular bowel movements.
Case 4: Chen XX, Male, 61 years old, cadre. The patient was admitted due to difficulty urinating and underwent prostatectomy. Fourteen days post-operation, the patient had no desire to eat, so TCM consultation was requested to regulate diet. First visit: The main manifestations were poor appetite and sweating after eating; urinary incontinence with dribbling. The tongue was red with a white coating, and the pulse was deep and fine. According to the *Nei Jing* (Inner Canon): "When food intake is excessive, sweat comes from the Stomach." Furthermore, the Kidney (Shen) controls the two lower orifices (urination and defecation); insecure Kidney Qi leads to frequent urination, and in severe cases, incontinence and dribbling. Thus, the syndrome belongs to Spleen-Stomach Qi Deficiency and insecure Kidney Qi. The treatment should strengthen the Spleen and secure the Kidney, tonify Qi, and stimulate appetite. Prescribe Liu Jun Zi Tang (Six Gentlemen Decoction) to strengthen the Spleen and tonify Qi, add Jiao Si Xian (Charred Four Immortals) and Wu Mei (Mume Fructus) to aid digestion; additionally add Yi Zhi Ren (Alpiniae Oxyphyllae Fructus), Tu Si Zi (Cuscutae Semen), and Bu Gu Zhi (Psoraleae Fructus) to secure the Kidney and reduce urination. Second visit: After taking 3 doses of the previous prescription, spirit slightly increased, and urination was somewhat controlled, but there was still no desire to eat. Observation showed an enlarged tongue body with a white coating at the root, and a deep, fine pulse. After much thought, it was concluded that the surgery damaged the Kidney, leading to decline of Ming Men Fire (Gate of Life Fire), failure of Fire generating Earth, loss of Spleen transportation, and loss of Stomach reception, resulting in reduced food intake and poor taste of food. Changed to the method of "Tonifying Fire to Generate Earth." According to the *Nei Jing*: "For insufficiency of Yang, warm it with Qi," thus selecting Jin Gui Shen Qi Tang (Kidney Qi Pill from the Golden Cabinet) combined with Yi Gong San (Yi Gong Powder). Medicinals: Fu Zi (Prepared Aconiti Lateralis Radix) 15g (boil first for 20 minutes until numbness disappears), Gui Zhi (Cinnamomi Ramulus) 15g, Shu Di Huang (Prepared Rehmanniae Radix) 15g, Shan Zhu Yu (Corni Fructus) 10g, Huai Shan Yao (Dioscoreae Hypoglaucae Rhizoma) 15g, Fu Ling (Poria) 15g, Ze Xie (Alismatis Rhizoma) 10g, Mu Dan Pi (Moutan Cortex) 9g, Dang Shen (Codonopsis Radix) 15g, Bai Zhu (Atractylodis Macrocephalae Rhizoma) 15g, Chen Pi (Citri Reticulatae Pericarpium) 6g, Zhi Gan Cao (Honey-fried Glycyrrhizae Radix et Rhizoma) 6g. Third visit: After only 3 doses, appetite suddenly increased. The patient reported feeling empty in the stomach and hunger at 5 PM on the day of taking the medicine. Add Sha Ren (Amomi Fructus) 9g to the previous prescription, continue for 5 doses. Diet returned to normal, and the patient was discharged.
Student: Teacher, your keen insight allowed you to grasp the root of the disease in the second visit and achieve rapid results; this is truly wonderful. Please explain the rationale behind using Jin Gui Shen Qi Tang.
Teacher: This case involves post-operative Kidney damage. Since the Kidney controls the two lower orifices, urinary incontinence and dribbling occur. Decline of Kidney Yang (Shen Yang Xu Shuai) leads to Fire failing to generate Earth, loss of Spleen transportation, and loss of Stomach reception, resulting in no desire to eat. Treatment should focus on tonifying the Kidney and warming Yang, primarily by tonifying Yang to complement Yin. Zhang Jing Yue of the Ming Dynasty pointed out, "Those skilled in tonifying Yang must seek Yang within Yin, so that Yang receives assistance from Yin, and generation becomes endless." Selecting "Jin Gui Shen Qi Tang" fits this meaning perfectly. The case of no desire to eat achieving rapid results through specific Kidney tonification further confirms Xu Shimie's view that "tonifying the Spleen is inferior to tonifying the Kidney."
Clinical Application of "All Wind Tremors and Dizziness Belong to the Liver"
Professor Duan Chenggong, Changchun College of Traditional Chinese Medicine
Case 1: Yang XX, Male, 43 years old, cadre. Suffered from paroxysmal headache for over 10 years, worsening in the last 2 months. For over 10 years, headaches started around 2 PM daily, lasting several hours before relief, accompanied by dizziness, nausea, and irritability. Effect of Chinese and Western medicines was insignificant. Over the last 2 months, it gradually worsened; attacks were mainly at the vertex and back of the head, severe and unbearable, unable to work normally, and analgesics did not relieve it. The patient was obese, face flushed. Examination showed a red tongue, enlarged body with teeth marks on the sides, thick greasy yellow coating, and a string-taut, rapid, and weak pulse. Syndrome Differentiation: Liver Deficiency generating Wind, Wind-Heat Headache. Treatment Method: Nourish Yin and Clear Heat, Invigorate Blood and Dispel Wind. Prescription: Sheng Di Huang (Rehmanniae Radix) 50g, Wu Zhu Yu (Evodiae Fructus) 5g, Chuan Xiong (Ligustici Chuanxiong Rhizoma) 15g, Huang Qin (Scutellariae Radix) 15g, Qiang Huo (Notopterygii Rhizoma et Radix) 15g, Long Gu (Fossilia Ossis Mastodi) 50g, Mu Li (Ostreae Concha) 50g, Xia Ku Cao (Prunellae Spica) 10g, Ju Hua (Chrysanthemi Flos) 20g. Decoct in water, take once daily. Treatment Course: After 3 doses, dizziness and nausea improved significantly, and headache also relieved. After 8 doses, headache significantly reduced. Remove Qiang Huo from the previous prescription, add Shan Zha Pian (Crataegi Fructus Slice) 20g. Total 12 doses taken, basically cured. Follow-up for 5 years showed no recurrence.
Case 2: Zhang X, Female, 52 years old. Presented with paroxysmal dizziness for 3 days. One year ago, suffered sudden dizziness, diagnosed by Western medicine as "Meniere's Disease," improved after treatment. Recurred 3 days ago due to fatigue and anger. Current symptoms: dizziness and vertigo, inability to turn head, spinning sensation upon movement, nausea, vomiting, strong sense of fear. Western medicines such as Atropine, Diazepam, and Betahistine showed no significant improvement. Examination showed red tongue, yellow coating, and deep, fine, rapid, and weak pulse. Syndrome Differentiation: Liver Qi Stagnation, Internal Movement of Liver Wind. Treatment Principle: Nourish Yin and Clear Heat, Pacify Liver and Extinguish Wind. Prescription: Modified Zhen Gan Xi Feng Tang (Decoction for Subduing Liver and Extinguishing Wind). Tian Ma (Gastrodiae Rhizoma) 15g, Gou Teng (Uncariae Ramulus cum Uncis) 15g, Long Gu 50g, Mu Li 50g, Niu Xi (Achyranthis Bidentatae Radix) 15g, Gui Ban (Testudinis Carapax et Plastrum) 20g, Dai Zhe Shi (Haematitum) 20g, Tian Dong (Asparagi Radix) 15g, Mai Dong (Ophiopogonis Radix) 15g, Yin Chen (Artemisiae Scopariae Herba) 20g, Xuan Shen (Scrophulariae Radix) 15g, Gan Cao (Glycyrrhizae Radix et Rhizoma) 10g, Chuan Lian Zi (Meliae Fructus) 15g, Sheng Di Huang 20g, Bai Shao (Paeoniae Radix Alba) 15g. Decoct in water, one dose every 1.5 days. Treatment Course: Significant relief after 1 dose, able to sit up and eat. After 2 doses, able to walk, no more nausea/vomiting, only afraid to turn head suddenly. Continued same prescription for 5 doses, all symptoms resolved. Rested for a few days then returned to work.
Case 3: Yu XX, Female, 34 years old, chief complaint of frequent insomnia for 3 years. Three years ago, due to argument with mother-in-law, felt depressed, then developed insomnia and vivid dreams, gradually worsening. Current symptoms: dizziness, fatigue, emaciation, poor appetite, irritability, sleeping only 4-5 hours daily with many dreams, waking up very tired. Examination showed red tongue tip, thin yellow coating, fine and rapid pulse, string-taut left Guan position. Careful observation revealed slight involuntary tremors of the head, and continuous trembling of both hands. Inquiry revealed frequent "cramps" in hands and feet. Syndrome Differentiation: Internal Movement of Deficient Wind, Heat Disturbing Heart Spirit. Treatment Method: Soothe Liver and Strengthen Spleen, Calm Spirit and Extinguish Wind. Prescription: Dang Shen 15g, Qing Ban Xia (Processed Pinelliae Rhizoma) 15g, Tian Ma 15g, Gou Teng 15g, Shi Jue Ming (Haliotidis Concha) 30g, Ling Ci Shi (Magnetitum) 30g, Chai Hu (Bupleuri Radix) 15g, Bai Shao 10g, Gan Cao 10g, Fu Ling 15g, Dang Gui (Angelicae Sinensis Radix) 15g, Bai Zhu 15g, Dan Pi (Moutan Cortex) 15g. Decoct in water, once daily. Soak herbs in rusty water before decocting. Treatment Course: After 3 doses, symptoms lightened, but insomnia did not improve significantly. Remove Tian Ma and Gou Teng from previous prescription, add Ye Jiao Teng (Polygoni Multiflori Caulis) 15g, Yuan Shen (Scrophulariae Radix) 15g. Continue for 3 doses. Reported significant improvement in sleep, lightening of dizziness and fatigue. Adjust original prescription, total over 20 doses taken, all symptoms resolved, health restored. Advised to adjust life rhythm, maintain happy mood, not be anxious when facing matters. Patient followed advice, remains healthy to date.
Student A: The three examples cited above are three different syndromes: headache, dizziness, and insomnia. Why is the treatment method of "Extinguishing Wind" used for all of them?
Teacher: Good question. The reason all use Extinguishing Wind (or Dispelling Wind) as the treatment method is that although they are three different syndromes with different clinical manifestations, they all have "Wind" signs. The main method of TCM diagnosis is Syndrome Differentiation and Treatment, seeking the cause through differentiation and determining treatment principles. In TCM basic theory, pathological changes in the human body are classified using the method of analogy, considering a category of diseases similar to natural wind, extending its meaning, linking it with Spring, Wood, Liver, etc., summarizing its constant and variable manifestations. It points out that Wind is divided into External Wind and Internal Wind. External Wind is an external pathogenic factor. Internal Wind is a lesion caused by changes in Zang-Fu organs; because its characteristics are similar to wind, it is called Internal Wind, and is considered closely related to the Liver, hence the term Liver Wind. The *Nei Jing · Zhi Zhen Yao Da Lun* states: "All Wind tremors and dizziness belong to the Liver." "All Wind" refers to various Wind syndromes; "Tremor" (Diao), noted by Zhang Jiebin as "shaking," means convulsion/twitching; "Dizziness" (Xuan) means vertigo. It means that various Wind syndromes, such as convulsions and vertigo, mostly belong to the category of Liver diseases. Clinically, whenever convulsions, vertigo, etc., are seen, they can be treated based on Wind and considered in connection with the Liver. Therefore, naturally, Extinguishing Wind should be the treatment principle.
Student B: Please discuss the differentiation and treatment of "Wind" syndromes combining the three cases.
Teacher: "Wind" syndromes manifest very complexly in clinical practice. TCM believes that Wind nature is "agile and changeable," and can carry Dampness, Heat, or Cold. There is also Stroke (Zhong Feng), which is a topic studied by physicians through generations, not discussed here. The *Nei Jing* statement "All Wind tremors and dizziness belong to the Liver" has important guiding significance for the differentiation and treatment of Wind syndromes. Case 1 is headache. Ancients also called headache "Head Wind," showing its relationship with Wind. This case is characterized by timed onset, accompanied by dizziness and string-taut pulse, which can be considered Liver Deficiency generating Wind, Liver Yang Hyperactivity. Long-standing disease leads to deficiency generating Heat, Heat stagnating in collaterals, Wind-Heat stirring each other causing headache. Thus, treatment uses Nourishing Yin and Clearing Heat, combined with Invigorating Blood and Dispelling Wind. In the formula, Sheng Di Huang, Huang Qin, Xia Ku Cao, and Ju Hua nourish Yin and clear Heat; Long Gu and Mu Li pacify Liver and extinguish Wind; Chuan Xiong moves blood and resolves stasis; Qiang Huo dispels Wind to treat Taiyang Meridian headache. Additionally, Wu Zhu Yu is used to treat Jueyin headache and assist the heat-clearing herbs, making them clear heat without damaging Yang. The combined herbs achieve the purpose of dispelling Wind and relieving pain.
Case 2 is dizziness, characterized by sudden onset and severe symptoms. Its etiology is related to "Anger." Since the Liver governs Anger, it is closely related to the Liver. Overall, the syndrome is Liver Stagnation generating Heat, Heat generating Wind, Internal Movement of Liver Wind, Wind-Heat clashing, attacking the clear orifices, causing dizziness. Therefore, treatment starts from "Liver Wind," using modified Zhen Gan Xi Feng Tang by Zhang Shuhua. In the formula, Tian Ma and Gou Teng are herbs for extinguishing Wind; Long Gu, Mu Li, and Dai Zhe Shi are herbs for subduing Liver and directing rebellious Qi downward; Gui Ban, Tian Dong, Mai Dong, Xuan Shen, Sheng Di Huang, and Bai Shao are substances for nourishing Yin and softening the Liver, simultaneously clearing Liver Heat; Yin Chen and Chuan Lian Zi enter the Liver Meridian to move Qi and resolve Dampness; Niu Xi guides Qi downward; Gan Cao harmonizes the herbs. The herbs work synergistically to pacify Liver, clear Heat, and extinguish Wind, hence rapid efficacy.
Case 3 has insomnia as the main symptom, diagnosed by Western medicine as "Neurosis" (Neurasthenia). This disease has various clinical manifestations. Although not a severe illness, treatment is not easy. Careful differentiation and targeted treatment are required for efficacy. In this case, careful examination found tremors of the head and hands, consistent with the meaning of "All Wind tremors and dizziness," thus considered a syndrome of Internal Movement of Deficient Wind. The prescription was formed based on the principle of treating Wind and soothing the Liver, achieving good results, proving correct differentiation. The formula used modified Tian Ma Gou Teng Yin combined with Xiao Yao San. In the formula, Shi Jue Ming, Ling Ci Shi, and rusty water calm the Spirit; Dang Shen and Qing Ban Xia ascend and descend together, strengthening Spleen and resolving Phlegm; Xiao Yao San soothes Liver and relieves depression; Dan Pi clears deficiency Heat. The herbs jointly achieve the effects of soothing Liver, strengthening Spleen, calming Spirit, and extinguishing Wind.
Synthesizing the above three cases, since the clinical manifestations all included tremors or dizziness, they were all treated based on Wind, tracing back to the source and seeking resolution in the Liver, achieving satisfactory results. This shows that deeply understanding the guiding significance of the *Nei Jing* statement "All Wind tremors and dizziness belong to the Liver" has considerable clinical value.
Vomiting and Scanty Urination for Over 1 Month
Professors Su Ruijun and Cai Hongyan, Jilin Academy of Traditional Chinese Medicine and Materia Medica
Patient: Yin X, Female, 62 years old, cadre, consulted on December 18, 1994. The patient felt waist soreness and fatigue for 5 years. Every time catching cold, overworking, or exposed to cold, lower back pain recurred and worsened. In the last month, appeared vomiting, nausea, no desire to eat, waist soreness, aversion to cold and cold limbs, general fatigue, edema, and scanty urination, especially frequent nocturia and scanty urine, daily volume only about 300ml. Accompanied by palpitations, shortness of breath, dizziness, hot palms and soles, dry mouth without desire to drink, dry eyes, skin itching, and dry stool. Sought TCM treatment. Examination showed medium build, poor nutrition, eyelid edema, pale and puffy complexion, mental fatigue, dry skin, pale lips and nails, lower limb edema, frequent vomiting, pale tongue with little coating, deep, fine, and rapid pulses bilaterally.
TCM Diagnosis: ① Guan Ge (Obstruction and Rejection), Spleen-Kidney Yang Deficiency Syndrome, Turbid Pathogen invading Middle Jiao; ② Xu Lao (Deficiency Consumption), Qi and Blood Dual Deficiency Syndrome. Proposed treatment method: Strengthen Spleen, Benefit Kidney, Stop Vomiting, Descend Turbidity. Prescription Composition: Huang Qi (Astragali Radix) 25g, Dang Shen 20g, Fu Ling 20g, Sha Ren (Amomi Fructus) 20g, Xian Mao (Curculiginis Rhizoma) 15g, Ban Xia (Pinelliae Rhizoma) 10g, Bai Shao 15g, Huo Xiang (Agastaches Herba) 15g, Zhu Ru (Bambusae Caulis in Taenia) 10g, Ze Xie 15g, Gan Cao 10g. Decoct in water, once daily. After 7 doses, nausea and vomiting decreased, but still scanty urine and dry stool. Continued internal Chinese medicine, added Bai Mao Gen (Imperatae Rhizoma) 20g to the previous prescription. Simultaneously gave high-retention enema with Chinese herbal decoction. Prescription: Da Huang (Rhei Radix et Rhizoma) 25g, Mu Li 20g, Dang Gui 20g, Huai Hua (Sophorae Flos) 20g, Fu Zi 10g. Once daily, decoct externally for enema, retention time as long as possible. After 1 week of this treatment, symptoms significantly improved, vomiting disappeared, edema significantly reduced, urine volume increased, tongue and pulse showed no significant change. Adjusted Chinese medicine prescription: Huang Qi 25g, Dang Shen 20g, Fu Ling 20g, Sha Ren 10g, Shan Yu Rou (Corni Fructus) 20g, Bai Shao 20g, Dang Gui 15g, Pei Lan (Eupatorii Herba) 15g, Huo Xiang 15g, Rou Cong Rong (Cistanche Caulis) 15g, Ze Xie 15g, Gan Cao 15g. Decoct in water, take morning and evening, once daily. Continue high-retention enema with previous prescription. Persisting with this method for 1 month, most symptoms basically eliminated, nausea and vomiting disappeared, edema subsided, mental and physical state improved, appetite gradually increased. Tongue pale red, thin white coating, deep and fine pulses bilaterally. Mental state recovered, able to manage household chores. Follow-up for 1 year, no recurrence.
Student A: What is Guan Ge? What is the basis for diagnosing this disease as Guan Ge?
Teacher: "Guan" means closure; inability to urinate is called Guan; "Ge" means rejection; incessant vomiting is called Ge. Guan Ge refers to a syndrome where inability to urinate and incessant vomiting occur simultaneously. As Zhang Zhongjing said in *Shang Han Lun · Ping Mai Fa Chapter 2*: "Guan means inability to urinate, Ge means vomiting and regurgitation." Therefore, Guan Ge refers to a syndrome of vomiting and constipation/closure, with main clinical manifestations of oliguria, anuria, nausea, and vomiting. It is a critical illness, often seen in the late stages of Edema (Shui Zhong), Lin Bi (Difficulty in Urination), and Lin Zheng (Strangury). Diagnosing Guan Ge is not difficult. From clinical manifestations, besides the two main signs of frequent vomiting and scanty urine, there are also Spleen-Kidney Yang Deficiency and Yin-Blood Exhaustion signs. Nausea, vomiting, no desire to eat, waist soreness, aversion to cold, and cold limbs are all Spleen-Kidney Yang Deficiency signs. Dizziness, dry mouth without desire to drink, dry skin, pale lips and nails, little tongue coating, and fine rapid pulse are all Yin-Blood Exhaustion signs. Therefore, besides diagnosing "Guan Ge," this disease can also be diagnosed as "Xu Lao" (Deficiency Consumption).
Student B: What are the main etiology and pathogenesis of Guan Ge disease?
Teacher: The key to the pathogenesis of this disease lies in simultaneous involvement of Spleen and Kidney. The patient is elderly and weak. Due to Spleen Yang depletion and Kidney Qi exhaustion, Qi transformation loses authority, Water does not transform into Essence, generation has no source, Qi of Triple Burner (San Jiao) is blocked, control of water passages is lost, ascent/descent and entry/exit are unfavorable, thus Urinary Bladder fails to govern, leading to anuria; Spleen loses transportation, cannot ascend Clear and descend Turbid, loses its function of "transporting fluids for the Stomach," pathogenic turbidity invades Stomach, Stomach loses harmony and descent, thus frequent vomiting and no desire to eat. This is the pathology of Guan Ge where Turbid Pathogen invades Middle Jiao. There are many causes for Spleen-Kidney Yang Deficiency. The most common include: External invasion of Wind Pathogen, Lung Qi not diffusing, unable to regulate water passages, transport to Bladder, overflow into skin, Edema long-standing not healing, Damp-Water soaking damages Spleen Yang causing Spleen Yang Deficiency; or living long in damp places, wading in water/rain, Damp-Water internally invading, Dampness accumulating in middle, causing Spleen transportation failure, Dampness trapping Spleen Yang, long-standing not healing, resulting in Spleen Yang deficiency; or irregular diet, imbalance of fullness/hunger, injuring Spleen Qi, transportation fails, Damp-Turbidity generated internally, Dampness trapping Middle Jiao damaging Spleen Yang, resulting in Spleen Yang collapse; or excessive labor/fatigue, too many births, injuring Kidney Qi. Kidney governs water excretion, Spleen governs water metabolism. If Spleen-Kidney Yang Deficiency, water metabolism and excretion functions weaken, then Damp-Water floods, overflows into skin, forming Edema, scanty urine, severe cases anuria, leading to Guan Ge. Because Spleen Yang is not vigorous, unable to rot and cook food grains, Qi and Blood sources are insufficient. Qi insufficiency leads to general fatigue; Blood insufficiency leads to lack of luster in complexion, pale lips and nails, rough skin, pale tongue, deep fine pulse. This is a syndrome of Yin-Blood Deficiency.
Student C: Besides diagnosing Guan Ge, why diagnose Xu Lao for this patient? What is the basic pathogenesis?