今肝阳已虚，势必功能减弱，临床上往往出现腹泻，泻前肠鸣、腹胀，腹中一痛即泄，泄后缓解，并不立即消失，是其一大特点。这种表现称之为"木不疏土"。由脾虚发展至肾虚作泄，主要表现为泻下时间在早晨，泄前肠鸣、腹痛，泻后痛除。多选用四神丸，我在临床上多仿张锡纯加味四神丸，效果甚佳。
医生乙痛泻要方如何运用?方中为何选用防风?
老师：痛泻要方主要用于肝脾不凋，中医认为脾与胃属中焦，(内经)云"中焦受气取汁变化为赤，是谓血也"。脾为气血生化之源，若脾虚运化不足，气血亏虚，肝失所养，而致肝不疏泄，因此方中用白术健脾助运，用白芍补肝，柔和肝体，二药合用则养肝健脾，使脾得健运，肝得疏泄。肝能疏泄则脾胃气机升降协调。我在临证时治疗肠鸣腹泄，泄前腹痛，泄后痛缓之肝脾不调泄下证，常以本方合苓桂术甘汤加炮姜，每获良效。至于方中用防风，是根据"气顺则风散"如乌药顺气散；"风散则气顺"，本方中防风能祛风理脾，使气机和调，则肠鸣腹胀自消。
医生丙肝阳虚如何补法?用何药为宜?
老师：肝阳虚乃相火不足。相火是一种能源，脏器功能的原动力。人体在命门、肝脏、胆腑及三焦内均有相火，总根源在命门。入有两肾，左右各1枚，(难经)指出"左为肾，右为命门"。由于命门相火衰，而导致肝之相火不足，当然补命门相火，会有助于肝脏所藏的相火，补肾阳即补肝阳。肝气虚和肝阳虚，表现为懈怠、忧郁、胆怯、头痛麻木、四肢不温、腹痛泄下等症。《圣惠方》上说，"肝虚则生寒"，寒即阳不足的意思。若寒邪伤肝，当用温剂辛散，若肝脏本身阳气不足，宜以温养肝阳以助其生发之性。常用药物如肉桂、桂枝、吴茱萸、细辛、胡椒、菟丝子、艾叶、茴香、骨碎补、肉苁蓉等。
医生丁张锡纯在(医学衷中参西录)中"加味四神丸"用生硫黄，老师在方中用天生黄何意?四神丸为何能治黎明腹痛泄泻?
老师：问题提得好。人之所以黎明作泄，请看张锡纯是怎样论述的："人禀天地之气而生，人身一小天地也。天地之一阳生于子，故人至夜半之时，肾系命门之处，有气息萌动，即人身之阳气也。至黎明寅时，为三阳之候，人身之阳气，亦应候上升，自下焦而将达中焦。当脐之处，或兼有凝寒遮蔽，即互相薄激，致小腹作疼。久之阳气不胜凝寒，上升之机转为下降，大便功工即溏下。此黎明作泻之所由来也"。又云，"夫下焦之阳气少火也，即相火也，其火生于命门，而寄于肝胆。故四神方中，用补骨脂为补命门，吴茱萸以补肝胆，此培火之基地。然泻者关乎下焦，实又关乎中焦，放又用肉蔻之辛温者，以暖补脾胃，且其味辛而涩，协同五味于之酸取者，又能固涩大肠，摄下焦气化。然此药病轻者可愈，病重者服之，间或不愈，以其补火之力犹微也。故又加花椒、硫黄之大补元阳者以助之，而后药力始能胜病也"。
服用生硫黄法，锡纯自认为乃"系愚之创见"也。服法从小量开始，徐徐加多，以服后移时觉微温为度。此正合(伤寒论)服理中丸法之意。考硫黄具有补火壮阳，疏利大肠作用，适用于肾中命门火衰，下元虚冷诸证，临床可治疗虚冷便秘，如半硫丸。硫黄为何有缓泻、软化大便作用，据研究认为，内服后成硫化氢，刺激肠壁而致泻。我在临床上曾在方中用硫黄(市面上药房所用之硫黄)治疗肾虚作泻，并未能止泻，反而泻下更多，恐怕就是上述的原因。我在临证时往往用硫黄的升化物--天生黄，不但能温阳而且能止泻，屡用屡效。寇氏云"治下元虚冷，元气将绝，久患寒泄，脾胃虚弱，垂命欲尽，服之无不效"。多年来我用此药治愈许多沉寒锢冷之病，不胜枚举。用补肾壮阳之方救治了不少沉疴固疾。此案是运用四神丸加味治愈顽固性腹痛泄下之1例，自始至终抓住肾阳不足，命门火衰这个根本，正如张景岳所云，"肾为胃之关，开窍于二阴，所以二便之开闭，皆肾脏之所主，今肾中阳气不足，则命门火衰，而阴寒极盛之时，则令人洞泄不止"。结合脏腑之间关系，全面综合分析，随着疾病的不断变化，紧守病机，锲而不舍，穷追到底。使阴寒散，阳气复，气血平和，痛泄自除。
医生戊：老师治病可谓妙，善于守法变方，抓住根本，而且用药不凡，请指点。
老师：我以为"发展中医学术，临床是基础"。深层次的临床，要靠深层次的理论，只有通过实践，才能深刻地理解与认识高深的理论。譬如《伤寒论》、《金匮要略》是在实践中产生，就必须通过大量的、多层次的临床实践，才能加深对他的理解与认识。大家对肾阳虚、脾阳虚的诊断与处方用药，可以说作为一个临床大夫拈手即来，而对肝阳虚的认识则略显不足。都知道"肝主疏泄"，但肝为什么能主疏泄?则在"体阴而用阳"方面的认识又路显不全面。在用药方面，一般性的方药人人皆用，对冷僻的药、猛烈的药、毒性大的药则望而生畏，或用量极小发挥不了作用。本案只言及硫黄，若用量小不会起作用，用量大会出现燥热反应，因此常不被选用，它的特效之处自然会丢失。这问题应该引起我们的重视。
心悸8年
四川省乐山市人民医院中医研究室主任余国俊
女患，40岁，1987年12月25日初诊。主诉：心悸8年。患者产育后曾人流3次，患过肾盂炎、慢性肠炎，体质渐差。8年来经常感觉心中悸动不安，胸膺窒闷，隐痛，短气，冬春季节及阴雨天诸症明显加重；且每因情怀不畅、受凉、劳累而诱发早搏及心动过速，心跳可达150～180次／分；夜眠或午眠时，于目合而将欲入睡之际，往往突发早搏而难以入眠。经心电图检查，心脏无器质性病变，西医拟诊为"房性早博"、"阵发性心动过速"。长期服安定、心得安、谷维素、维生素、复方丹参片、脑心舒等，中药曾叠用安神定志丸、归脾丸、天王补心丹、复脉汤，疗效乎平。刻诊：症如上述，身形瘦削，面憔悴，眼眶、颧部色稍黯，经期少腹痛，经色偏黑夹血块；舌质红，边尖有瘀点，舌下静脉呈紫暗色，苔黄薄腻，脉细，偶有促象。考虑为心阴亏损，心阳不足，痰瘀阻滞心络之证，治宜滋养心阴，温通心阳，化瘀祛瘀通络。予生脉散合桂枝甘草汤、温胆汤化裁：潞党参15g，麦冬20g，五味子6g，桂枝15g，炙甘草6g，法夏10g，茯苓15g，陈皮10g，枳实10g，竹茹10g，苦参10g，甘松6g，五灵脂15g(包煎)。6剂。二二诊：心中似乎较前平稳-些，余症如前，脉仍偶有促象。上方去陈皮、竹茹，加桑寄生20g，北细辛6g，三-匕粉6g(吞服)，苦参增至20g，甘松增至12g，6剂。三诊：服药期间适逢月经来潮，小腹痛减轻，血块减少，心悸明显缓解。舌质淡红，边尖瘀点已暗淡，舌下静脉色基本复常，脉细已无促象。上方加黄芪30g，石菖蒲10g，炙远志6g，6剂。微火烘脆，轧细，炼蜜为丸，每丸约重10g，每次l丸，日3次，连服40天。效果：1年后因他病来诊，言服完1粒心悸进一步减轻，乃照方炮制续服2粒。数月来虽偶发早搏及心动过速而出现短暂心悸，但无须服西药，稍事休息即安。眠食正常，气色较好。
进修生甲：心悸是心系疾病的主要证侯之一，有虚有实。虚证有心气虚、心阴虚、心脾两虚、肾阴虚、肾阳虚等；实证则有痰饮、瘀血。若为纯虚证或纯实证，治之不难。但临床所见者多为病程较长的虚中夹实或实中夹虚证，治之较为棘手。如本例心悸8年，此前曾人流3次，患过肾盂炎、慢性肠炎，体质渐差而累及于心，虚象昭然。但长期服用镇心安神、补养心脾以及滋养心阴、温通心阳之方药而疗效平平，可见不是纯虚之证，而是虚中夹实之证。
进修生乙：从患者眼眶、颧部色稍黯，经期小腹痛夹血块，舌有瘀点，舌下静脉呈紫暗色等来看，夹有瘀血是很明显的。但老师还考虑到痰的方面，言其"痰瘀阻滞心络"，不知这"痰"从何处辨宋?
老师：从整体上看，患者似无痰可辨。但患者有一个特异症状：睡觉时于目合而将入睡之际，往往突发早搏而难以入眠。这一特异症状便是痰饮停于心下的确征。为什么呢?大家知道，人之所以能入眠，全赖心肾相交，即心阳下降交于肾，肾阴上升交于心，而成"水火既济"之态。今痰饮停于心下，则于心阳下交于肾之道路上成阻，使心阳不能息息下达，必郁结而内陷，且化热化火，火热扰乱心神，则惊悸而不能入眠矣。此乃心脏突发早搏而惊悸不寐之缘由也。况痰饮之与瘀血，总是交互为患，难分难解，是以古贤今贤，咸谓"痰瘀相关"。这就提醒临证者治疗心悸之时，不仅要重视瘀血，而且要在胸巾存一"痰"字。纵无显性之痰可辨，亦当细推是否存在隐性之痰；何况痰饮停于心下而致惊悸不寐，本系显症乎!若此者，则当于补益心脏气血阴阳。
如今肝阳已经虚弱，必然导致功能减弱，临床上常常出现腹泻，泻前肠鸣、腹胀，腹中一痛即泄，泄后缓解，但并不立即消失，这是其一大特点。这种表现称之为“木不疏土”。由脾虚发展至肾虚作泄，主要表现为泻下时间在早晨，泄前肠鸣、腹痛，泻后痛除。多选用四神丸，我在临床上多仿张锡纯加味四神丸，效果甚佳。
医生乙问：痛泻要方如何运用？方中为何选用防风？
老师：痛泻要方主要用于肝脾不调（中医认为脾与胃属中焦，《内经》云“中焦受气取汁变化为赤，是谓血也”）。脾为气血生化之源，若脾虚运化不足，气血亏虚，肝失所养，而致肝不疏泄，因此方中用白术健脾助运，用白芍补肝，柔和肝体，二药合用则养肝健脾，使脾得健运，肝得疏泄。肝能疏泄则脾胃气机升降协调。我在临证时治疗肠鸣腹泄，泄前腹痛，泄后痛缓之肝脾不调泄下证，常以本方合苓桂术甘汤加炮姜，每获良效。至于方中用防风，是根据“气顺则风散”如乌药顺气散；“风散则气顺”，本方中防风能祛风理脾，使气机和调，则肠鸣腹胀自消。
医生丙问：肝阳虚如何补法？用何药为宜？
老师：肝阳虚乃相火不足。相火是一种能源，脏器功能的原动力。人体在命门、肝脏、胆腑及三焦内均有相火，总根源在命门。人有两肾，左右各1枚，《难经》指出“左为肾，右为命门”。由于命门相火衰，而导致肝之相火不足，当然补命门相火，会有助于肝脏所藏的相火，补肾阳即补肝阳。肝气虚和肝阳虚，表现为懈怠、忧郁、胆怯、头痛麻木、四肢不温、腹痛泄下等症。《圣惠方》上说，“肝虚则生寒”，寒即阳不足的意思。若寒邪伤肝，当用温剂辛散，若肝脏本身阳气不足，宜以温养肝阳以助其生发之性。常用药物如肉桂、桂枝、吴茱萸、细辛、胡椒、菟丝子、艾叶、茴香、骨碎补、肉苁蓉等。
医生丁问：张锡纯在《医学衷中参西录》中“加味四神丸”用生硫黄，老师在方中用天生黄何意？四神丸为何能治黎明腹痛泄泻？
老师：问题提得好。人之所以黎明作泄，请看张锡纯是怎样论述的：“人禀天地之气而生，人身一小天地也。天地之一阳生于子，故人至夜半之时，肾系命门之处，有气息萌动，即人身之阳气也。至黎明寅时，为三阳之候，人身之阳气，亦应候上升，自下焦而将达中焦。当脐之处，或兼有凝寒遮蔽，即互相薄激，致小腹作疼。久之阳气不胜凝寒，上升之机转为下降，大便功工即溏下。此黎明作泻之所由来也”。又云，“夫下焦之阳气少火也，即相火也，其火生于命门，而寄于肝胆。故四神方中，用补骨脂为补命门，吴茱萸以补肝胆，此培火之基地。然泻者关乎下焦，实又关乎中焦，放又用肉蔻之辛温者，以暖补脾胃，且其味辛而涩，协同五味于之酸取者，又能固涩大肠，摄下焦气化。然此药病轻者可愈，病重者服之，间或不愈，以其补火之力犹微也。故又加花椒、硫黄之大补元阳者以助之，而后药力始能胜病也”。
服用生硫黄法，锡纯自认为乃“系愚之创见”也。服法从小量开始，徐徐加多，以服后移时觉微温为度。此正合《伤寒论》服理中丸法之意。考硫黄具有补火壮阳，疏利大肠作用，适用于肾中命门火衰，下元虚冷诸证，临床可治疗虚冷便秘，如半硫丸。硫黄为何有缓泻、软化大便作用，据研究认为，内服后成硫化氢，刺激肠壁而致泻。我在临床上曾在方中用硫黄（市面上药房所用之硫黄）治疗肾虚作泻，并未能止泻，反而泻下更多，恐怕就是上述的原因。我在临证时往往用硫黄的升化物--天生黄，不但能温阳而且能止泻，屡用屡效。寇氏云“治下元虚冷，元气将绝，久患寒泄，脾胃虚弱，垂命欲尽，服之无不效”。多年来我用此药治愈许多沉寒锢冷之病，不胜枚举。用补肾壮阳之方救治了不少沉疴固疾。此案是运用四神丸加味治愈顽固性腹痛泄下之1例，自始至终抓住肾阳不足，命门火衰这个根本，正如张景岳所云，“肾为胃之关，开窍于二阴，所以二便之开闭，皆肾脏之所主，今肾中阳气不足，则命门火衰，而阴寒极盛之时，则令人洞泄不止”。结合脏腑之间关系，全面综合分析，随着疾病的不断变化，紧守病机，锲而不舍，穷追到底。使阴寒散，阳气复，气血平和，痛泄自除。
医生戊：老师治病可谓妙，善于守法变方，抓住根本，而且用药不凡，请指点。
老师：我以为“发展中医学术，临床是基础”。深层次的临床，要靠深层次的理论，只有通过实践，才能深刻地理解与认识高深的理论。譬如《伤寒论》、《金匮要略》是在实践中产生，就必须通过大量的、多层次的临床实践，才能加深对他的理解与认识。大家对肾阳虚、脾阳虚的诊断与处方用药，可以说作为一个临床大夫拈手即来，而对肝阳虚的认识则略显不足。都知道“肝主疏泄”，但肝为什么能主疏泄？则在“体阴而用阳”方面的认识又路显不全面。在用药方面，一般性的方药人人皆用，对冷僻的药、猛烈的药、毒性大的药则望而生畏，或用量极小发挥不了作用。本案只言及硫黄，若用量小不会起作用，用量大会出现燥热反应，因此常不被选用，它的特效之处自然会丢失。这问题应该引起我们的重视。
心悸8年
四川省乐山市人民医院中医研究室主任余国俊
女患，40岁，1987年12月25日初诊。主诉：心悸8年。患者产育后曾人流3次，患过肾盂炎、慢性肠炎，体质渐差。8年来经常感觉心中悸动不安，胸膺窒闷，隐痛，短气，冬春季节及阴雨天诸症明显加重；且每因情怀不畅、受凉、劳累而诱发早搏及心动过速，心跳可达150～180次／分；夜眠或午眠时，于目合而将欲入睡之际，往往突发早搏而难以入眠。经心电图检查，心脏无器质性病变，西医拟诊为“房性早博”、“阵发性心动过速”。长期服安定、心得安、谷维素、维生素、复方丹参片、脑心舒等，中药曾叠用安神定志丸、归脾丸、天王补心丹、复脉汤，疗效平平。刻诊：症如上述，身形瘦削，面憔悴，眼眶、颧部色稍黯，经期少腹痛，经色偏黑夹血块；舌质红，边尖有瘀点，舌下静脉呈紫暗色，苔黄薄腻，脉细，偶有促象。考虑为心阴亏损，心阳不足，痰瘀阻滞心络之证，治宜滋养心阴，温通心阳，化瘀祛瘀通络。予生脉散合桂枝甘草汤、温胆汤化裁：潞党参15g，麦冬20g，五味子6g，桂枝15g，炙甘草6g，法夏10g，茯苓15g，陈皮10g，枳实10g，竹茹10g，苦参10g，甘松6g，五灵脂15g(包煎)。6剂。二诊：心中似乎较前平稳一些，余症如前，脉仍偶有促象。上方去陈皮、竹茹，加桑寄生20g，北细辛6g，三七粉6g(吞服)，苦参增至20g，甘松增至12g，6剂。三诊：服药期间适逢月经来潮，小腹痛减轻，血块减少，心悸明显缓解。舌质淡红，边尖瘀点已暗淡，舌下静脉色基本复常，脉细已无促象。上方加黄芪30g，石菖蒲10g，炙远志6g，6剂。微火烘脆，轧细，炼蜜为丸，每丸约重10g，每次l丸，日3次，连服40天。效果：1年后因他病来诊，言服完1粒心悸进一步减轻，乃照方炮制续服2粒。数月来虽偶发早搏及心动过速而出现短暂心悸，但无须服西药，稍事休息即安。眠食正常，气色较好。
进修生甲：心悸是心系疾病的主要证侯之一，有虚有实。虚证有心气虚、心阴虚、心脾两虚、肾阴虚、肾阳虚等；实证则有痰饮、瘀血。若为纯虚证或纯实证，治之不难。但临床所见者多为病程较长的虚中夹实或实中夹虚证，治之较为棘手。如本例心悸8年，此前曾人流3次，患过肾盂炎、慢性肠炎，体质渐差而累及于心，虚象昭然。但长期服用镇心安神、补养心脾以及滋养心阴、温通心阳之方药而疗效平平，可见不是纯虚之证，而是虚中夹实之证。
进修生乙：从患者眼眶、颧部色稍黯，经期小腹痛夹血块，舌有瘀点，舌下静脉呈紫暗色等来看，夹有瘀血是很明显的。但老师还考虑到痰的方面，言其“痰瘀阻滞心络”，不知这“痰”从何处辨宋？
老师：从整体上看，患者似无痰可辨。但患者有一个特异症状：睡觉时于目合而将入睡之际，往往突发早搏而难以入眠。这一特异症状便是痰饮停于心下的确征。为什么呢？大家知道，人之所以能入眠，全赖心肾相交，即心阳下降交于肾，肾阴上升交于心，而成“水火既济”之态。今痰饮停于心下，则于心阳下交于肾之道路上成阻，使心阳不能息息下达，必郁结而内陷，且化热化火，火热扰乱心神，则惊悸而不能入眠矣。此乃心脏突发早搏而惊悸不寐之缘由也。况痰饮之与瘀血，总是交互为患，难分难解，是以古贤今贤，咸谓“痰瘀相关”。这就提醒临证者治疗心悸之时，不仅要重视瘀血，而且要在胸巾存一“痰”字。纵无显性之痰可辨，亦当细推是否存在隐性之痰；何况痰饮停于心下而致惊悸不寐，本系显症乎！若此者，则当于补益心脏气血阴阳。
Now that the Liver Yang (Liver Yang) is deficient, its functions will inevitably weaken. Clinically, diarrhea often occurs, characterized by borborygmus and abdominal distension before defecation, immediate evacuation upon abdominal pain, relief after defecation but not immediate disappearance of symptoms; this is a major characteristic. This manifestation is termed "Wood failing to soothe Earth" (Wood failing to soothe Earth). When Spleen deficiency progresses to Kidney deficiency causing diarrhea, it mainly presents as morning defecation, with borborygmus and abdominal pain before defecation, and pain relief after defecation. Si Shen Wan (Four Spirits Pill) is often selected. In my clinical practice, I frequently use Zhang Xichun's Modified Si Shen Wan (Modified Four Spirits Pill), which yields excellent results.
Doctor Yi asked: How should Tongxie Yaofang (Painful Diarrhea Essential Formula) be applied? Why is Fangfeng (Saposhnikovia Root) selected in this formula?
Teacher: Tongxie Yaofang (Painful Diarrhea Essential Formula) is mainly used for Liver-Spleen disharmony (Liver-Spleen disharmony). Traditional Chinese Medicine believes that the Spleen and Stomach belong to the Middle Jiao (Middle Burner). As stated in *Neijing* (Inner Canon): "The Middle Jiao receives Qi and extracts juices, transforming them into red blood, which is called Blood." The Spleen is the source of Qi and Blood production. If Spleen deficiency leads to insufficient transportation and transformation, resulting in Qi and Blood deficiency, the Liver loses nourishment and fails to ensure smooth flow (Liver failing to ensure smooth flow). Therefore, Baizhu (Atractylodis Rhizoma) is used in the formula to strengthen the Spleen and assist transportation, while Baishao (Paeoniae Radix Alba) nourishes the Liver and softens the Liver body. The combination of these two herbs nourishes the Liver and strengthens the Spleen, enabling the Spleen to transport effectively and the Liver to flow smoothly. When the Liver ensures smooth flow, the ascending and descending mechanisms of the Spleen and Stomach Qi are coordinated. In my clinical practice, when treating diarrhea accompanied by borborygmus, abdominal pain before defecation, and pain relief after defecation due to Liver-Spleen disharmony, I often combine this formula with Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala and Licorice Decoction) plus Paojiang (Prepared Ginger), achieving good results. Regarding the use of Fangfeng (Saposhnikovia Root) in the formula, it is based on the principle that "when Qi flows smoothly, Wind disperses," as seen in Wuyao Shunqi San (Lindera Powder to Smooth Qi); and "when Wind disperses, Qi flows smoothly." Fangfeng (Saposhnikovia Root) in this formula can dispel Wind and regulate the Spleen, harmonizing Qi mechanism, thereby eliminating borborygmus and abdominal distension naturally.
Doctor Bing asked: How should Liver Yang deficiency be tonified? Which herbs are suitable?
Teacher: Liver Yang deficiency is essentially insufficient Xiang Huo (Ministerial Fire). Xiang Huo (Ministerial Fire) is an energy source, the primary driving force of organ functions. Xiang Huo (Ministerial Fire) exists in the Mingmen (Gate of Life), Liver, Gallbladder, and Sanjiao (Triple Burner) in the human body, with its ultimate source in the Mingmen (Gate of Life). Humans have two Kidneys, one on the left and one on the right. *Nanjing* (Classic of Difficult Issues) states: "The left is the Kidney, the right is the Mingmen (Gate of Life)." Due to the decline of Mingmen (Gate of Life) Xiang Huo (Ministerial Fire), the Liver's Xiang Huo (Ministerial Fire) becomes insufficient. Therefore, tonifying Mingmen (Gate of Life) Xiang Huo (Ministerial Fire) will help the Xiang Huo (Ministerial Fire) stored in the Liver; tonifying Kidney Yang is equivalent to tonifying Liver Yang. Liver Qi deficiency and Liver Yang deficiency manifest as lethargy, depression, timidity, headache and numbness, cold limbs, abdominal pain, and diarrhea, etc. *Shenghui Fang* (Prescriptions from the Holy Emporium) states: "When the Liver is deficient, Cold is generated"; Cold means insufficient Yang. If Cold pathogen injures the Liver, warm and acrid-dispersing agents should be used. If the Liver's own Yang is insufficient, it is appropriate to warm and nourish Liver Yang to assist its generating nature. Commonly used herbs include Rougui (Cinnamomi Cortex), Guizhi (Cinnamomi Ramulus), Wuzhuyu (Evodiae Fructus), Xixin (Asari Radix et Rhizoma), Hujiao (Piperis Longi Fructus), Tusizi (Cuscutae Semen), Aiye (Artemisiae Argyi Folium), Huixiang (Foeniculi Fructus), Gusuibu (Drynariae Rhizoma), and Roushouyu (Cibotii Rhizoma), etc.
Doctor Ding asked: Zhang Xichun used raw Sulfur (Sulfur) in his "Modified Si Shen Wan (Four Spirits Pill)" in *Yixue Zhongzhong Canxi Lu* (Records of Traditional Chinese Medicine Integrated with Western Medicine). What is the meaning of your use of Tianshenghuang (Natural Sulfur) in the formula? Why can Si Shen Wan (Four Spirits Pill) treat dawn abdominal pain and diarrhea?
Teacher: Good question. Let us see how Zhang Xichun discussed why people suffer from dawn diarrhea: "Humans are born endowing the Qi of Heaven and Earth; the human body is a small heaven and earth. One Yang of heaven and earth arises at Zi hour (11 PM-1 AM). Thus, at midnight, at the location of the Kidney system and Mingmen (Gate of Life), there is a stirring of breath, which is the Yang Qi of the human body. By dawn at Yin hour (3 AM-5 AM), which is the time of the Three Yangs, the Yang Qi of the human body should also rise according to the season, moving from the Lower Jiao (Lower Burner) towards the Middle Jiao (Middle Burner). At the navel area, if there is coagulated Cold obstructing, they mutually clash, causing lower abdominal pain. Over time, Yang Qi cannot overcome the coagulated Cold; the mechanism of rising turns into descending, and stool becomes loose and watery. This is the origin of dawn diarrhea." He further stated: "The Yang Qi of the Lower Jiao (Lower Burner) is Lesser Fire (Shaohuo), which is Xiang Huo (Ministerial Fire). Its fire originates from the Mingmen (Gate of Life) and resides in the Liver and Gallbladder. Therefore, in Si Shen Wan (Four Spirits Pill), Buguzhi (Psoraleae Fructus) is used to tonify the Mingmen (Gate of Life), and Wuzhuyu (Evodiae Fructus) to tonify the Liver and Gallbladder; this cultivates the foundation of Fire. However, diarrhea concerns the Lower Jiao (Lower Burner) but actually also involves the Middle Jiao (Middle Burner). Thus, Roukou (Myristicae Semen) is used for its acrid-warm nature to warm and tonify the Spleen and Stomach. Moreover, its acrid and astringent flavor, combined with the sour astringency of Wuweizi (Schisandrae Chinensis Fructus), can astringe the Large Intestine and secure Lower Jiao (Lower Burner) Qi transformation. However, this medicine may cure mild cases, but severe cases may occasionally not respond because its power to tonify Fire is still slight. Therefore, Huajiao (Zanthoxyli Pericarpium) and Sulfur (Sulfur), which greatly tonify Original Yang, are added to assist it, so that the medicinal power can overcome the disease."
Regarding the method of taking raw Sulfur (Sulfur), Xichun considered it "my original insight." The dosage starts small and gradually increases, stopping when a slight warmth is felt after some time. This aligns with the method of taking Lizhong Wan (Regulate the Middle Pill) in *Shanghan Lun* (Treatise on Cold Damage). It is recorded that Sulfur (Sulfur) has the effects of tonifying Fire and strengthening Yang, and promoting bowel movement. It is suitable for various conditions of Kidney Mingmen (Gate of Life) Fire decline and Lower Yuan (Lower Origin) deficiency-cold, clinically used for deficiency-cold constipation, such as Banshu Wan (Half Sulfur Pill). Why does Sulfur (Sulfur) have a laxative and stool-softening effect? Research suggests that after internal administration, it forms hydrogen sulfide, stimulating the intestinal wall to cause diarrhea. In my clinical practice, I once used Sulfur (Sulfur) available in pharmacies to treat Kidney deficiency diarrhea, but it failed to stop the diarrhea and instead caused more frequent stools, likely for the reasons mentioned above. In my clinical practice, I often use the refined product of Sulfur (Sulfur)—Tianshenghuang (Natural Sulfur)—which not only warms Yang but also stops diarrhea, yielding consistent success. Kou Shi said: "For treating Lower Yuan (Lower Origin) deficiency-cold, impending exhaustion of Original Qi, chronic cold diarrhea, Spleen-Stomach weakness, and life-threatening conditions, taking this medicine is invariably effective." For many years, I have used this medicine to cure numerous cases of deep-seated cold and entrenched cold diseases, too numerous to list. Using Kidney-tonifying and Yang-strengthening formulas has saved many patients with chronic and stubborn diseases. This case is an example of using Modified Si Shen Wan (Four Spirits Pill) to cure stubborn abdominal pain and diarrhea. From beginning to end, it grasped the root cause: Kidney Yang deficiency and Mingmen (Gate of Life) Fire decline. As Zhang Jingyue stated: "The Kidney is the gate of the Stomach, opening into the two yin orifices. Therefore, the opening and closing of urination and defecation are all governed by the Kidneys. Now, if Kidney Yang is insufficient, Mingmen (Gate of Life) Fire declines, and when Yin-Cold is extremely abundant, it causes relentless profuse diarrhea." Combining the relationships between Zang-Fu organs, comprehensive analysis should be conducted. With the continuous changes of the disease, strictly adhering to the pathogenesis and persevering until the end allows Yin-Cold to dissipate, Yang Qi to recover, Qi and Blood to become peaceful, and painful diarrhea to disappear naturally.
Doctor Wu: Your treatment skills are wonderful, Master. You are good at maintaining principles while modifying formulas, grasping the root cause, and using extraordinary herbs. Please give guidance.
Teacher: I believe that "developing TCM academics relies on clinical practice as the foundation." Deep-level clinical practice requires deep-level theory. Only through practice can one deeply understand and recognize profound theories. For instance, *Shanghan Lun* (Treatise on Cold Damage) and *Jingui Yaolue* (Essential Prescriptions of the Golden Cabinet) were produced in practice. Therefore, extensive and multi-level clinical practice is required to deepen understanding and recognition of them. Regarding the diagnosis and prescription for Kidney Yang deficiency and Spleen Yang deficiency, clinicians can handle them easily. However, the understanding of Liver Yang deficiency is somewhat lacking. Everyone knows that "the Liver governs smooth flow," but the understanding of why the Liver can govern smooth flow, particularly regarding "nourishing the Yin substance to support the Yang function" (Substance is Yin, Function is Yang), is apparently incomplete. In terms of medication, general formulas and herbs are commonly used by everyone, but rare, potent, or highly toxic herbs are often feared, or their dosages are so small that they fail to exert effects. This case only mentions Sulfur (Sulfur). If the dosage is small, it will not work; if large, it will cause dryness and heat reactions. Therefore, it is often not selected, and its special efficacy is lost. This issue deserves our attention.
Palpitations for 8 Years
Yu Guojun, Director of the TCM Research Office, Leshan People's Hospital, Sichuan Province
Female patient, 40 years old, first consultation on December 25, 1987. Chief complaint: Palpitations for 8 years. After childbirth, the patient had three induced abortions and suffered from pyelonephritis and chronic enteritis, leading to gradual deterioration of her constitution. For 8 years, she has frequently felt restless palpitations, chest tightness, dull pain, and shortness of breath. Symptoms worsen significantly in winter/spring seasons and rainy days. Premature beats and tachycardia, with heart rates reaching 150–180 beats/min, are often triggered by emotional distress, exposure to cold, or fatigue. During night or afternoon sleep, just as eyes close and sleep is about to begin, premature beats often occur suddenly, making it difficult to fall asleep. Electrocardiogram examination showed no organic heart lesions. Western medicine diagnosed "atrial premature beats" and "paroxysmal tachycardia." She has long taken Diazepam, Propranolol, Oryzanol, Vitamins, Compound Danshen Tablets, and Naoxintshu. TCM previously used Anshen Dingzhi Wan (Calming Spirit and Stabilizing Will Pill), Guipi Wan (Restore the Spleen Pill), Tianwang Buxin Dan (Emperor of Heaven's Heart-Nourishing Pill), and Fumai Tang (Revive Pulse Decoction), with mediocre efficacy. Current examination: Symptoms as above; emaciated body, haggard face, slightly darkened eye sockets and cheekbones, lower abdominal pain during menstruation, dark menstrual blood with clots; red tongue body with stasis points at the edges and tip, purple-dark sublingual veins, thin yellow greasy coating, fine pulse with occasional irregularity (Cu pulse). Considered as Heart Yin deficiency, Heart Yang insufficiency, and Phlegm-Stasis obstructing Heart collaterals. Treatment should nourish Heart Yin, warm and unblock Heart Yang, and resolve stasis to unblock collaterals. Prescribed Shengmai San (Generate the Pulse Powder) combined with Guizhi Gancao Tang (Cinnamon Twig and Licorice Decoction) and Wendan Tang (Gall-Blandening Decoction) modified: Ludangshen (Codonopsis Radix) 15g, Maidong (Ophiopogonis Radix) 20g, Wuweizi (Schisandrae Chinensis Fructus) 6g, Guizhi (Cinnamomi Ramulus) 15g, Zhigancao (Prepared Licorice Radix et Rhizoma) 6g, Faxia (Pinelliae Rhizoma Preparatum) 10g, Fuling (Poria) 15g, Chenpi (Citri Reticulatae Pericarpium) 10g, Zhishi (Aurantii Fructus Immaturus) 10g, Zhuru (Bambusae Caulis in Taenia) 10g, Kushen (Sophorae Flavescentis Radix) 10g, Gansong (Nardostachyos Radix et Rhizoma) 6g, Wulingzhi (Trogopterori Faeces) 15g (wrapped and decocted). 6 doses. Second visit: Palpitations seemed slightly more stable than before, other symptoms remained, pulse still occasionally showed irregularity (Cu pulse). Remove Chenpi (Citri Reticulatae Pericarpium) and Zhuru (Bambusae Caulis in Taenia) from the previous formula, add Sangjisheng (Taxilli Cacumen) 20g, Beixixin (Asari Radix et Rhizoma) 6g, Sanqi Fen (Notoginseng Radix Powder) 6g (swallowed), increase Kushen (Sophorae Flavescentis Radix) to 20g, increase Gansong (Nardostachyos Radix et Rhizoma) to 12g. 6 doses. Third visit: Menstruation occurred during medication; lower abdominal pain decreased, blood clots reduced, palpitations significantly relieved. Tongue became pale-red, stasis points at edges and tip faded, sublingual veins color basically returned to normal, fine pulse no longer showed irregularity (Cu pulse). Add Huangqi (Astragali Radix) 30g, Shichangpu (Acori Tatarinowii Rhizoma) 10g, Zhi Yuanzhi (Polygalae Radix Preparata) 6g to the previous formula. 6 doses. Dried gently over low fire, ground finely, made into pills with refined honey, each pill weighing about 10g. Take 1 pill per dose, 3 times daily, continuously for 40 days. Outcome: One year later, the patient visited for another illness, stating that after finishing one pill, palpitations further decreased. She continued taking two more pills according to the prescription. Although occasional premature beats and tachycardia causing brief palpitations occurred over several months, no Western medicine was needed; rest brought relief. Sleep and appetite were normal, complexion was good.
Trainee Jia: Palpitations are one of the main syndromes of Heart diseases, presenting as deficiency or excess. Deficiency syndromes include Heart Qi deficiency, Heart Yin deficiency, Heart-Spleen dual deficiency, Kidney Yin deficiency, Kidney Yang deficiency, etc.; Excess syndromes include Phlegm-Fluid retention and Blood Stasis. Treating pure deficiency or pure excess syndromes is not difficult. However, clinically observed cases are mostly chronic deficiency-excess mixed or excess-deficiency mixed syndromes, which are more tricky to treat. For example, this case of 8-year palpitations, preceded by three induced abortions, pyelonephritis, and chronic enteritis, led to gradual constitutional decline affecting the Heart, clearly showing deficiency signs. But long-term use of sedative, Heart-calming, Spleen-nourishing, Heart Yin-nourishing, and Heart Yang-warming formulas yielded mediocre results, indicating it is not a pure deficiency syndrome but a deficiency-excess mixed syndrome.
Trainee Yi: From the patient's slightly darkened eye sockets and cheekbones, lower abdominal pain with blood clots during menstruation, stasis points on the tongue, and purple-dark sublingual veins, it is obvious that Blood Stasis is involved. But the teacher also considered Phlegm, stating "Phlegm-Stasis obstructing Heart collaterals." I wonder where this "Phlegm" is identified?
Teacher: Overall, the patient seems to have no discernible Phlegm. However, the patient has a specific symptom: sleeping, just as eyes close and sleep is about to begin, premature beats often occur suddenly, making it difficult to fall asleep. This specific symptom is a definite sign of Phlegm-Fluid retention in the Heart region (Xin Xia). Why? Everyone knows that sleep depends entirely on the interaction between Heart and Kidney, i.e., Heart Yang descending to interact with Kidney, and Kidney Yin ascending to interact with Heart, forming a state of "Water and Fire both accomplished" (Shuihuo Jiji). Now, Phlegm-Fluid retention in the Heart region obstructs the pathway of Heart Yang descending to the Kidney, preventing Heart Yang from continuously descending. It must stagnate and sink inward, transforming into Heat and Fire. Heat and Fire disturb the Heart Spirit, causing fright, palpitations, and insomnia. This is the reason for sudden cardiac premature beats, fright, palpitations, and insomnia. Moreover, Phlegm-Fluid and Blood Stasis always interact and are inseparable, hence ancient and modern sages all say "Phlegm and Stasis are related." This reminds clinicians treating palpitations to not only pay attention to Blood Stasis but also keep "Phlegm" in mind. Even if no obvious Phlegm is discernible, one should carefully deduce whether hidden Phlegm exists; moreover, Phlegm-Fluid retention in the Heart region causing fright, palpitations, and insomnia is itself an obvious sign! In such cases, one should tonify the Qi, Blood, Yin, and Yang of the Heart.