进修医师甲：老师用方一派温阳止泻，而清利湿热和疏肝药用得很少，药证相符如何理解呢?
老师：此患者以脾肾阳虚为基本病机，其湿邪是因为脾虚失于运化和肾阳亏虚，蒸化开合失司而产生的，故阳虚是本，湿热是标，且从症状表现看，阳虚表现突出，湿热是次要的，故以温补脾肾为主，清利湿热药仅用了黄连、干荷叶、炒薏苡仁3味。只有通过温补脾肾，使脾肾阳气振奋，则运化、蒸化有权，利于水谷的腐熟消化，一旦泄泻改善，水谷就容易化生精微，而不复生水湿了，故温阳利于驱湿。这种理解当然更适于虚寒湿，对湿热则有不同，过用温阳，容易助长热邪，正因考虑到这点，才用了少量黄连，一是清湿热，二是苦燥坚肠，三能清心除烦。不能把湿热看得过重，如果过用苦寒清利，又要进一步损伤阳气，泄泻只会加重。
进修医师乙：此患者五心潮热，盗汗，心烦寐差，苔根微黄腻，我看实证表现也较明显，为什么老师总认为以阳虚为主?
老师：患者每至五更即泻，泻下稀便，且腹有冷感，伴肢倦乏力、头晕、口淡纳差、舌质淡，一派虚寒之象。五更泻伴腹冷是肾阳虚最重要的表现，脾主四肢肌肉，开窍于口，又主运化，肢倦口淡属脾阳虚无疑。慢性久泻绝大多数离不开脾虚，泄泻发展到肾阳虚，一般总是先由脾阳虚开始。因此，我个人认为，阳虚表现明显，而五心潮热、心烦等症系由泄泻损耗水谷精微，加之湿热内郁，天气炎热，哈尔滨人不适宜炎夏气候也是一个原因。
医师甲：我经常看到老师用附子治疗慢性泄泻，有一段时间曾用过15g，每日2剂。炎夏之季用30g附子，不嫌太热吗?
老师：有斯症，用斯药。患者久居东北阴寒之地，沉寒痼冷久积肠胃，非大辛大热之附子不能去其寒、温其脏。事实上这样用后，舌质始终未见变红，心烦未见加重。相反，随着泄泻好转，心烦、五心潮热等自觉症状逐步改善。当然，泄泻使用附子，须碗属虚寒方可。若见肛门滞胀，或有灼热感者，则不适宜，而且附子用量，要视病情轻重掌握。量大时，如无腹痛，无需附子温阳止痛时，可以先煎，尤其老年人心脏功能不正常寸，要防止引起心律失常。我曾遇一位老年患者，因附子量较大，煎者时间过短，引起心律失常，出现唇绀晕厥。虽然抢救过来，但教训不应忘记，既要胆大，又要心细。
老师：请哪位谈谈，该患者使用的是什么方剂?
实习生甲:附子理中汤。
实习生乙:还有真人养脏汤。
老师：还有呢?
老师：还有香连丸。该患者所用的药是由上述3个方化裁组成的。临床有时病情复杂，不是1个方所能适应得了的，有时需几个方融合化裁加减使用，方能适应本病。临床既要法中有方，又要方中有法，要活用古方，不能拘泥。
实习生乙既然是五更泻，为何不用四神丸?据教科书上记裁，四神丸是治疗五更泻的代表方。
老师：我个人体会，四神丸治疗五更泻效果并不理想，不如上述方剂有效。当然各人经验体会不同。另外，教科书只是从历代许多医籍中归纳整理出来的最基本、最常用的方法，不能概括丰富多彩的临床经验。
治疗五更泻古方多得很，要想看好大病、疑难病，仅靠教科书这些知识是不够的。此患者在东北多处求医，所用处方为四神丸、真人养脏汤、参苓白术散、补中益气汤、升阳益胃汤，还有葛根芩连汤等等，可谓应有尽有。用参附术姜粟壳豆蔻者，也不乏其人，粟壳曾用过15g。为什么都未能治愈，而在这里基本治好了?一是在于药物组方和用量要合理，不是越大越好；二是一旦有效，就要守方坚持。
进修医师甲：真人养脏汤，老师常用以治疗慢性久泻，能否请您谈淡使用该方如何掌握宜忌和如何加减?
老师：真人养脏汤具有补虚温中、涩肠固脱的功能，治疗脾肾虚寒所引起的泻利不禁最为适宜。方中党参、白术、甘草健脾助运；合肉桂、肉豆蔻温中止泻；罂粟壳、诃子固肠止泻；当归、白芍以和血止痛；木香调气。本方使用宜忌的要点有：①脾肾(肠)的虚与寒，缺一不可；②泻利次频，便中无脓血，滑脱不禁更宜；③无里急后重，无肛门滞胀或灼热感；④无腹胀；⑤无肠鸣音过弱；⑥无大便秽臭。本方加减使用方法很多，主要有：无腹痛的，可去当归、白芍；苔腻夹湿的，再去党参、甘草，加薏苡仁、茯苓；腹胀甚，大便不爽的，去粟壳、诃子、肉豆蔻，加陈皮、槟榔及砂仁；肠鸣音弱的，亦去以上3味，加焦槟榔；食少的，加焦山楂、神曲、砂仁及山药；苔黄或见心烦或尿微黄的，加川连，或再加车前草；腹中寒甚的，加熟附片、炮姜炭；肠鸣漉漉，泻下稀水较多的，加茯苓、泽泻、羌独活及煨姜；肛门下坠感的，加荷叶梗、炙黄芪及柴胡。此外，虚寒滑脱不禁，张仲景使用的桃花汤、赤豆脂禹余粮丸和灶心土等，也可以考虑参入使用。
医师乙：罂粟壳是鸦片壳，属于麻醉药，我们不敢用，不知应如何掌握适应证和剂量?
老师：简言之，有邪有滞的不宜用，无邪无滞、滑泄不禁者宜用。此药收涩固肠为主，也有些止痛作用，剂量宜掌握在3-5-10g，一般不超过6g。老年人要尽量避免使用，疗程不宜长。
医师甲：老师配用外用药穴位敷贴，也是取其温阳作用吧!
老师：很对。请你们复习一下，天枢、关元、气海、脾俞诸穴所主病证，并和奉病病机联系，就都理解了。丁香、肉桂、麝香性味辛热，外用可以使药性透过皮肤，直达病所。内外合用，以达到温阳祛寒，增强疗效的目的。
进修医师甲：老师用了些涩肠药，当然对大便成形有利，假如停药后，会不会导致泄泻复发?
老师：固涩一法，是治泻九法或治泻个法中的最后一法，上边谈了不少。在无邪滞而又频繁泄泻属虚寒者用之是必要的，但不宜久用，尤其罂粟壳，适可而止。停药后一般不会反复，因为在此同时用了健脾温肾固本之法。本固了，标就不易出现了。
不寐案析
长春中医学院教授肖永林
1977年4月，去吉林省通榆县为西学中班讲课。该县当时的县委罗部长之母，病心中烦不得寐已数月。曾服用中西药物多种，效果不佳。延余为之诊治。该患67岁，体质健壮，形气俱实。数月前因家中琐事，心中郁闷不畅，开始觉脘痞腹胀，胸胁满闷不舒，逐渐心中热而闷乱，夜不能寐。自觉口干而苦，胁胀胸闷，易怒，目红多眵，小便赤涩热痛，舌质红苔黄厚，脉弦数有力。查以前所用之药，皆系镇心安神之品，如朱砂安神丸、琥珀安神丸、天王补心丹、人参归脾丸，以及安定片等。
据其脉证，诊为肝胆热盛，上扰心神，而致心烦不寐。拟以清泻肝胆之热为法，用龙胆泻肝汤加黄连。处方：龙胆草20g，黄芩15g，栀子15g，生地10g，当归10g，柴胡10g，木通10g，车前子10g(包煎)，泽泻10g，甘草10g，黄连10g。水煎服。3剂后，心烦除而夜间能安睡。目红多哆，小便赤涩，口干而苦等症皆好转，舌上黄苔亦退。
其亲家母(即罗部长之岳母)，也患不寐证，见其服药效佳，也照其方抓药2剂。1剂后即觉腹中冷痛，大便泄泻数次。未敢再服上药，遂求余为之诊治。见其形体消瘦，面色黄白，自觉全身疲乏无力，四肢倦怠，食欲不振，大便多溏，心悸易惊，夜难成寐，即或入睡也不实，稍有响动即便惊醒，心中悸动，再难入睡。视其舌质淡，苔薄白，脉沉弱无力。据其脉症，知为心脾两虚，气血不足，神失所养而致之心悸失眠。治以健脾养心，双补气血之法。用归脾汤加山药、干姜，去龙眼肉(因无药)。处方：党参15g，生芪20g，白术15g，茯神15g，山药25g，干姜10g，当归15g，远志10g,酸枣仁10g，木香5g，生姜3片，大枣5枚c)水煎服o2剂，患者腹中冷痛已愈，大便已不泄泻，心悸失眠有所好转，后用人参归脾丸而愈。
学生甲失眠皆由于心神不安，应以镇心安神为主，可是这两个患者为何不用?
老师：不寐证，又称失眠。引起失眠的原因很多。对于因惊恐不安，心常怵惕，神气浮越而致之心悸失眠者，原应治以镇心安神之品，如龙骨、牡蛎、磁石、朱砂、琥珀等药，以收敛心气，镇摄心神。但这两个患者都不属于此范畴，其不寐证皆各有原因。如不除去其病因，而单用镇心安神药，是不会收到理想效果的。从前一个患者的情况可以看出，她虽用了各种安神镇心药，都没有效果，而根据其症情，用了清泻肝胆实热之剂，病即随之而愈。
学生乙这两个患者，都是不寐证，可是一用清肝泻热法，一用补益气血法而皆获愈，我们应从中学习些什么呢?
老师：这两个患者，虽然都是不寐证，但由于证情不同，所以治法各异。第一个患者证属肝胆有热，上扰神志而致失眠，因而用清肝泻热法而愈；后一个患者为气血不足，心脾两虚，神失所养而不寐，故用健脾养心，双补气血法而愈。从中我们可以学习到中医学的特点之所在：整体观念与辨证施治。不寐属于心、神其主也。从表面看，似乎只属于心神之病，单用镇心安神之品即可。同学甲提的问题恐怕就属于这种看法。
人体是一个有机的整体，各脏腑虽各有其特点与功能，但是，互相之间在生理上互相生化，互为制约，在病理状态下又可互相影响。从不寐证来看，虽为阳不入于阴，心神不宁之病，但其原因，却不尽因心病而致，而涉及其他各脏腑。前一个患者，原为肝气不疏，郁而化火。故表现为口干而苦，胸胁胀闷，目红多眵，易于生气上火，脉弦数有力等一派肝经热盛之象。肝胆之火为相火，心火为君火。在病理状态下，君火亢盛每易致相火妄动；相火炽盛，则可引发心火上炎。心火亢盛，阳不入于阴则心烦而失眠。可见此证肝胆火盛是因，心火盛而心烦不寐是果。所以从肝论治。这体现了整体观念和辨证施治、治病求本的原则。
后一个患者，因素体不足，脾虚气弱，饮食少思，则气血生化之源不足。气血两虚，心神失养，而致心悸失眠。欲要心安神静，必须补养气血。而要气血壮旺，又须先益脾胃。可见此证脾胃气虚是病之本(因)，而心神不安则是病之标(果)。如果此患之治疗不是用归脾汤，重用参、术、芪等补脾益气药，而只是养心阴而安神，则很难收到如此疗效。因养心阴之药多偏滋腻，而安神镇静之品又多为金石介类。二者对于脾胃皆无益而有损。如果因用药而使脾胃受伤，先绝气血生化之源，难以收到养心安神之效果。中医治病本着"治病必求其本"，"必伏其所主先其所因"的原则，辨证求因，审因论治。而不是头痛医头，脚痛医脚。
学生丙请老师讲一下，前一患者的方中加黄连，后一患者方中加山药、干姜，原因何在?
老师：前一患者之不寐证，为肝胆之火(相火)炽盛导致心火(君火)亦盛，从而扰神致心烦不寐。故在用龙胆泻肝汤清泄肝胆之火的同时，加入黄连，以清心火。这就体现了标(心火)本(肝胆火)同治，君相兼顾之义，较之单清相火之治法更为全面一些。
后一患者之不寐证，乃由其人素体较弱，脾胃气虚，本应以甘温之剂补中益气而生气血，使气血充沛则心神得以濡养，自然心悸止而夜眠安。但由于患家不明此理，见人用龙胆泻肝汤治愈了不寐证，也盲目地服用。其结果不唯无效，却反使本来已经虚弱的脾胃，更被寒凉(龙胆泻肝汤为寒凉泻火之剂)所伤，从而致腹中冷痛、泄泻等脾胃虚寒之症。此患者之心悸不寐，选用归脾汤治疗，本来是完全符合证情的，但此时患者由于误被凉药所伤，中阳受损而腹部冷痛，脾虚肠滑而大便泄泻，故加卒热中守之千姜，祛寒邪而暖中止痛，甘温补涩之山药，健脾气而涩肠止泻。使寒去而中阳渐复，泄止而脾气渐旺。脾健阳复则能化生气血，气血充沛，心神得养则心悸不寐之证可渐痊愈。加山药、干姜完全是为了纠正前药之误。当腹部冷痛消失，泄泻渐止之后，即去此二药，改用归脾丸而病愈。
学生甲不寐一证，临床较为多见，请老师谈谈具体的证治。
老师：张景岳说过，"不寐证，虽病有不一，然惟知邪正二字则尽之矣。盖寐本乎阴，神其主也。神安则寐，神不安则不寐。其所以不安者，一由邪气之扰，一由营气之不足耳。有邪者盖实证，无邪者皆虚证"。(《景岳全书·杂证谟·不寐》)从上面所言，不难看出，不寐证之原因虽多，但其证不外虚(营虚--阴血不足)、实(邪气之扰)二证。但虚有阴血阳气之异，实有寒热痰食之分，下面略谈其证治。
进修医师甲：老师开方时主要使用温阳止泻的药物，而清利湿热和疏肝理气的药物用得很少，如何理解这种药证相符的情况呢？
老师：这位患者的基本病机是脾肾阳虚。体内的湿邪是因为脾虚导致运化功能失常，以及肾阳亏虚导致蒸腾气化及开合功能失调而产生的。因此，阳虚是本，湿热是标。从症状表现来看，阳虚的表现突出，湿热是次要的，所以治疗以温补脾肾为主，清利湿热的药物仅用了黄连、干荷叶、炒薏苡仁这3味药。只有通过温补脾肾，振奋脾肾阳气，才能使运化和蒸化功能恢复正常，有利于水谷的腐熟和消化。一旦泄泻改善，水谷就容易化生为精微物质，而不再产生水湿，所以温阳有利于驱除湿邪。当然，这种理解更适用于虚寒湿证；对于湿热证则有所不同，过用温阳药物容易助长热邪。正因考虑到这一点，才使用了少量的黄连，一是为了清利湿热，二是利用其苦燥之性坚固肠道，三是能清心除烦。不能把湿热看得过重，如果过用苦寒清利药物，又会进一步损伤阳气，使泄泻加重。
进修医师乙：这位患者有手足心发热（五心潮热）、盗汗、心烦睡眠差的症状，舌根苔微黄腻，我看实证的表现也比较明显，为什么老师总认为以阳虚为主呢？
老师：患者每到五更时分就发生腹泻，泻下稀便，且腹部有冷感，伴有四肢倦怠乏力、头晕、口淡无味、食欲减退、舌质淡等一派虚寒之象。五更泻伴有腹部发冷是肾阳虚最重要的表现。脾主四肢肌肉，开窍于口，又主管运化，四肢倦怠、口淡无味无疑属于脾阳虚。慢性久泻绝大多数离不开脾虚，泄泻发展到肾阳虚，一般总是先由脾阳虚开始。因此，我个人认为，阳虚表现明显，而五心潮热、心烦等症状是由于泄泻损耗了水谷精微，加之湿热内郁，天气炎热，哈尔滨人不适应炎夏气候也是一个原因。
医师甲：我经常看到老师用附子治疗慢性泄泻，有一段时间曾用过15克，每日2剂。在炎夏季节使用30克附子，不觉得太热吗？
老师：有什么样的病症，就用什么样的药物。患者长期居住在东北阴寒之地，沉寒痼冷积聚在肠胃深处，非大辛大热的附子不能去除寒气、温暖脏腑。事实上这样用药后，舌质始终未见变红，心烦也没有加重。相反，随着泄泻的好转，心烦、五心潮热等自觉症状逐步改善。当然，治疗泄泻使用附子，必须确认属于虚寒证方可。如果见到肛门滞胀，或有灼热感者，则不适宜使用。而且附子的用量，要根据病情的轻重来掌握。用量大时，如果没有腹痛，不需要附子温阳止痛时，可以先煎煮。尤其是老年人心脏功能不正常时，要防止引起心律失常。我曾遇到一位老年患者，因附子用量较大，煎煮时间过短，引起了心律失常，出现嘴唇发绀、晕厥。虽然抢救过来了，但教训不应忘记，既要胆大，又要心细。
老师：请哪位谈谈，该患者使用的是什么方剂？
实习生甲：附子理中汤。
实习生乙：还有真人养脏汤。
老师：还有呢？
老师：还有香连丸。该患者所用的药是由上述3个方剂化裁组成的。临床有时病情复杂，不是一个方剂所能适应的，有时需要几个方剂融合化裁加减使用，才能适应本病。临床既要法中有方，又要方中有法，要活用古方，不能拘泥。
实习生乙：既然是五更泻，为何不用四神丸？据教科书记载，四神丸是治疗五更泻的代表方。
老师：我个人体会，四神丸治疗五更泻效果并不理想，不如上述方剂有效。当然各人经验体会不同。另外，教科书只是从历代许多医籍中归纳整理出来的最基本、最常用的方法，不能概括丰富多彩的临床经验。
治疗五更泻的古方多得很，要想看好大病、疑难病，仅靠教科书这些知识是不够的。此患者在东北多处求医，所用处方为四神丸、真人养脏汤、参苓白术散、补中益气汤、升阳益胃汤，还有葛根芩连汤等等，可谓应有尽有。用参附术姜粟壳豆蔻者，也不乏其人，粟壳曾用过15克。为什么都未能治愈，而在这里基本治好了？一是在于药物组方和用量要合理，不是越大越好；二是一旦有效，就要守方坚持。
进修医师甲：真人养脏汤，老师常用以治疗慢性久泻，能否请您谈谈使用该方如何掌握宜忌和如何加减？
老师：真人养脏汤具有补虚温中、涩肠固脱的功能，治疗脾肾虚寒所引起的泻利不禁最为适宜。方中党参、白术、甘草健脾助运；合肉桂、肉豆蔻温中止泻；罂粟壳、诃子固肠止泻；当归、白芍以和血止痛；木香调气。本方使用宜忌的要点有：①脾肾（肠）的虚与寒，缺一不可；②泻利次数频繁，便中无脓血，滑脱不禁更宜；③无里急后重，无肛门滞胀或灼热感；④无腹胀；⑤无肠鸣音过弱；⑥无大便秽臭。本方加减使用方法很多，主要有：无腹痛的，可去当归、白芍；苔腻夹湿的，再去党参、甘草，加薏苡仁、茯苓；腹胀甚，大便不爽的，去粟壳、诃子、肉豆蔻，加陈皮、槟榔及砂仁；肠鸣音弱的，亦去以上3味，加焦槟榔；食少的，加焦山楂、神曲、砂仁及山药；苔黄或见心烦或尿微黄的，加川连，或再加车前草；腹中寒甚的，加熟附片、炮姜炭；肠鸣漉漉，泻下稀水较多的，加茯苓、泽泻、羌独活及煨姜；肛门下坠感的，加荷叶梗、炙黄芪及柴胡。此外，虚寒滑脱不禁，张仲景使用的桃花汤、赤石脂禹余粮丸和灶心土等，也可以考虑参入使用。
医师乙：罂粟壳是鸦片壳，属于麻醉药，我们不敢用，不知应如何掌握适应证和剂量？
老师：简言之，有邪有滞的不宜用，无邪无滞、滑泄不禁者宜用。此药收涩固肠为主，也有些止痛作用，剂量宜掌握在3-5-10克，一般不超过6克。老年人要尽量避免使用，疗程不宜长。
医师甲：老师配用外用药穴位敷贴，也是取其温阳作用吧！
老师：很对。请你们复习一下，天枢、关元、气海、脾俞诸穴所主病证，并和本病病机联系，就都理解了。丁香、肉桂、麝香性味辛热，外用可以使药性透过皮肤，直达病所。内外合用，以达到温阳祛寒，增强疗效的目的。
进修医师甲：老师用了些涩肠药，当然对大便成形有利，假如停药后，会不会导致泄泻复发？
老师：固涩一法，是治泻九法或治泻十法中的最后一法，上面谈了不少。在无邪滞而又频繁泄泻属虚寒者用之是必要的，但不宜久用，尤其罂粟壳，适可而止。停药后一般不会反复，因为在此同时用了健脾温肾固本之法。本固了，标就不易出现了。
不寐案析
长春中医学院教授肖永林
1977年4月，去吉林省通榆县为西学中班讲课。该县当时的县委罗部长之母，病心中烦闷不得睡眠已数月。曾服用中西药物多种，效果不佳。延请我为其诊治。该患67岁，体质健壮，形气俱实。数月前因家中琐事，心中郁闷不畅，开始觉脘痞腹胀，胸胁满闷不舒，逐渐心中热而闷乱，夜不能寐。自觉口干而苦，胁胀胸闷，易怒，目红多眵，小便赤涩热痛，舌质红苔黄厚，脉弦数有力。查以前所用之药，皆系镇心安神之品，如朱砂安神丸、琥珀安神丸、天王补心丹、人参归脾丸，以及安定片等。
据其脉证，诊为肝胆热盛，上扰心神，而致心烦不寐。拟以清泻肝胆之热为法，用龙胆泻肝汤加黄连。处方：龙胆草20克，黄芩15克，栀子15克，生地10克，当归10克，柴胡10克，木通10克，车前子10克（包煎），泽泻10克，甘草10克，黄连10克。水煎服。3剂后，心烦除而夜间能安睡。目红多眵，小便赤涩，口干而苦等症皆好转，舌上黄苔亦退。
其亲家母（即罗部长之岳母），也患不寐证，见其服药效佳，也照其方抓药2剂。1剂后即觉腹中冷痛，大便泄泻数次。未敢再服上药，遂求我为其诊治。见其形体消瘦，面色黄白，自觉全身疲乏无力，四肢倦怠，食欲不振，大便多溏，心悸易惊，夜难成寐，即或入睡也不实，稍有响动即便惊醒，心中悸动，再难入睡。视其舌质淡，苔薄白，脉沉弱无力。据其脉症，知为心脾两虚，气血不足，神失所养而致之心悸失眠。治以健脾养心，双补气血之法。用归脾汤加山药、干姜，去龙眼肉（因无药）。处方：党参15克，生芪20克，白术15克，茯神15克，山药25克，干姜10克，当归15克，远志10克，酸枣仁10克，木香5克，生姜3片，大枣5枚。水煎服。2剂，患者腹中冷痛已愈，大便已不泄泻，心悸失眠有所好转，后用人参归脾丸而愈。
学生甲：失眠皆由于心神不安，应以镇心安神为主，可是这两个患者为何不用？
老师：不寐证，又称失眠。引起失眠的原因很多。对于因惊恐不安，心常怵惕，神气浮越而致之心悸失眠者，原应治以镇心安神之品，如龙骨、牡蛎、磁石、朱砂、琥珀等药，以收敛心气，镇摄心神。但这两个患者都不属于此范畴，其不寐证皆各有原因。如不除去其病因，而单用镇心安神药，是不会收到理想效果的。从前一个患者的情况可以看出，她虽用了各种安神镇心药，都没有效果，而根据其症情，用了清泻肝胆实热之剂，病即随之而愈。
学生乙：这两个患者，都是不寐证，可是一用清肝泻热法，一用补益气血法而皆获愈，我们应从中学习些什么呢？
老师：这两个患者，虽然都是不寐证，但由于证情不同，所以治法各异。第一个患者证属肝胆有热，上扰神志而致失眠，因而用清肝泻热法而愈；后一个患者为气血不足，心脾两虚，神失所养而不寐，故用健脾养心，双补气血法而愈。从中我们可以学习到中医学的特点之所在：整体观念与辨证施治。不寐属于心、神其主也。从表面看，似乎只属于心神之病，单用镇心安神之品即可。同学甲提的问题恐怕就属于这种看法。
人体是一个有机的整体，各脏腑虽各有其特点与功能，但是，互相之间在生理上互相生化，互为制约，在病理状态下又可互相影响。从不寐证来看，虽为阳不入于阴，心神不宁之病，但其原因，却不尽因心病而致，而涉及其他各脏腑。前一个患者，原为肝气不疏，郁而化火。故表现为口干而苦，胸胁胀闷，目红多眵，易于生气上火，脉弦数有力等一派肝经热盛之象。肝胆之火为相火，心火为君火。在病理状态下，君火亢盛每易致相火妄动；相火炽盛，则可引发心火上炎。心火亢盛，阳不入于阴则心烦而失眠。可见此证肝胆火盛是因，心火盛而心烦不寐是果。所以从肝论治。这体现了整体观念和辨证施治、治病求本的原则。
后一个患者，因素体不足，脾虚气弱，饮食少思，则气血生化之源不足。气血两虚，心神失养，而致心悸失眠。欲要心安神静，必须补养气血。而要气血壮旺，又须先益脾胃。可见此证脾胃气虚是病之本（因），而心神不安则是病之标（果）。如果此患之治疗不是用归脾汤，重用参、术、芪等补脾益气药，而只是养心阴而安神，则很难收到如此疗效。因养心阴之药多偏滋腻，而安神镇静之品又多为金石介类。二者对于脾胃皆无益而有损。如果因用药而使脾胃受伤，先绝气血生化之源，难以收到养心安神之效果。中医治病本着“治病必求其本”，“必伏其所主先其所因”的原则，辨证求因，审因论治。而不是头痛医头，脚痛医脚。
学生丙：请老师讲一下，前一患者的方中加黄连，后一患者方中加山药、干姜，原因何在？
老师：前一患者之不寐证，为肝胆之火（相火）炽盛导致心火（君火）亦盛，从而扰神致心烦不寐。故在用龙胆泻肝汤清泄肝胆之火的同时，加入黄连，以清心火。这就体现了标（心火）本（肝胆火）同治，君相兼顾之义，较之单清相火之治法更为全面一些。
后一患者之不寐证，乃由其人素体较弱，脾胃气虚，本应以甘温之剂补中益气而生气血，使气血充沛则心神得以濡养，自然心悸止而夜眠安。但由于患家不明此理，见人用龙胆泻肝汤治愈了不寐证，也盲目地服用。其结果不唯无效，却反使本来已经虚弱的脾胃，更被寒凉（龙胆泻肝汤为寒凉泻火之剂）所伤，从而致腹中冷痛、泄泻等脾胃虚寒之症。此患者之心悸不寐，选用归脾汤治疗，本来是完全符合证情的，但此时患者由于误被凉药所伤，中阳受损而腹部冷痛，脾虚肠滑而大便泄泻，故加辛热中守之干姜，祛寒邪而暖中止痛，甘温补涩之山药，健脾气而涩肠止泻。使寒去而中阳渐复，泄止而脾气渐旺。脾健阳复则能化生气血，气血充沛，心神得养则心悸不寐之证可渐痊愈。加山药、干姜完全是为了纠正前药之误。当腹部冷痛消失，泄泻渐止之后，即去此二药，改用归脾丸而病愈。
学生甲：不寐一证，临床较为多见，请老师谈谈具体的证治。
老师：张景岳说过，“不寐证，虽病有不一，然惟知邪正二字则尽之矣。盖寐本乎阴，神其主也。神安则寐，神不安则不寐。其所以不安者，一由邪气之扰，一由营气之不足耳。有邪者盖实证，无邪者皆虚证”。（《景岳全书·杂证谟·不寐》）从上面所言，不难看出，不寐证之原因虽多，但其证不外虚（营虚——阴血不足）、实（邪气之扰）二证。但虚有阴血阳气之异，实有寒热痰食之分，下面略谈其证治。
Attending Physician A: The teacher primarily prescribes formulas for warming yang and stopping diarrhea, using very few herbs for clearing heat and draining dampness or soothing the liver. How should we understand this compatibility between prescription and syndrome?
Teacher: The fundamental pathogenesis of this patient is Spleen-Kidney Yang Deficiency (Pi Shen Yang Xu). The dampness in the body arises because Spleen deficiency leads to impaired transportation and transformation, and Kidney Yang deficiency results in dysfunction of steaming, vaporization, opening, and closing. Therefore, Yang deficiency is the root (Ben), while damp-heat is the branch (Biao). From the symptom presentation, Yang deficiency manifestations are prominent, and damp-heat is secondary. Thus, treatment focuses on warming and tonifying the Spleen and Kidney, with only three herbs for clearing heat and draining dampness: Huanglian (Coptidis Rhizoma), Gan Lian Ye (Lotus Leaf), and Chao Yi Yi Ren (Fried Coicis Semen). Only by warming and tonifying the Spleen and Kidney can Spleen and Kidney Yang be revitalized, restoring normal transportation and vaporization functions, thereby facilitating the rotting and digestion of food and fluids. Once diarrhea improves, food and fluids will easily transform into essence and nutrients rather than generating water-dampness; thus, warming Yang facilitates the expulsion of dampness. Of course, this understanding applies more suitably to deficiency-cold-damp syndromes; for damp-heat syndromes, it differs. Overuse of warming Yang herbs may exacerbate heat pathogens. Precisely considering this point, a small amount of Huanglian was used: firstly, to clear damp-heat; secondly, to utilize its bitter-dry nature to firm the intestines; thirdly, to clear the Heart and remove irritability. Damp-heat should not be overemphasized. If bitter-cold clearing and draining herbs are overused, they will further damage Yang Qi, worsening the diarrhea.
Attending Physician B: This patient exhibits five-center tidal fever (Wu Xin Chao Re), night sweats, irritability, and poor sleep. The root of the tongue coating is slightly yellow and greasy. I observe that excess syndrome manifestations are also quite obvious. Why does the teacher always consider Yang deficiency as the primary aspect?
Teacher: The patient experiences diarrhea every time at dawn (Wu Geng Xie), passing loose stools, accompanied by a cold sensation in the abdomen, fatigue in the limbs, dizziness, bland taste in the mouth, poor appetite, and a pale tongue body—a picture of deficiency-cold. Dawn diarrhea accompanied by abdominal coldness is the most important manifestation of Kidney Yang Deficiency. The Spleen governs the four limbs and muscles, opens into the mouth, and is responsible for transportation and transformation. Limb fatigue and a bland taste undoubtedly belong to Spleen Yang Deficiency. Chronic prolonged diarrhea almost invariably involves Spleen deficiency. When diarrhea progresses to Kidney Yang Deficiency, it generally begins with Spleen Yang Deficiency. Therefore, I personally believe that Yang deficiency manifestations are prominent. The symptoms of five-center tidal fever and irritability are due to the loss of essence and nutrients from food and fluids caused by chronic diarrhea, compounded by internal stagnation of damp-heat, hot weather, and the fact that Harbin residents are not accustomed to the summer climate.
Physician A: I often see the teacher using Fuzi (Aconiti Lateralis Radix Praeparata) to treat chronic diarrhea. For a period, 15g was used, twice daily. Is it not too heating to use 30g of Fuzi during the peak of summer?
Teacher: Prescribe medicine according to the syndrome. The patient has long resided in the cold Yin region of Northeast China, where deep-seated cold and stubborn cold have accumulated in the intestines and stomach. Only the large acrid-hot herb Fuzi can dispel the cold and warm the viscera. In fact, after such usage, the tongue body never turned red, and irritability did not worsen. Conversely, as diarrhea improved, subjective symptoms like irritability and five-center tidal fever gradually resolved. However, when using Fuzi for diarrhea, it must be confirmed that the syndrome is deficiency-cold. If there is a sensation of fullness or burning in the anus, it is unsuitable. Moreover, the dosage of Fuzi must be controlled based on the severity of the condition. When the dosage is high, if there is no abdominal pain requiring Fuzi to warm Yang and relieve pain, it should be decocted first. Especially in elderly patients with abnormal cardiac function, one must prevent arrhythmias. I once encountered an elderly patient who developed arrhythmia, cyanosis of the lips, and syncope due to a large dose of Fuzi with insufficient decoction time. Although rescued, the lesson should not be forgotten: one must be both bold and meticulous.
Teacher: Who can discuss what formula was used for this patient?
Intern A: Fuzi Lizhong Tang (Aconite Pill to Regulate the Middle).
Intern B: Also Zhenren Yangzang Tang (Real Person’s Nourishing Viscera Decoction).
Teacher: And anything else?
Teacher: Also Xianglian Wan (Costus and Coptis Pill). The medication used for this patient was composed by modifying these three formulas. Clinically, sometimes conditions are complex, and a single formula cannot adapt to them. Sometimes several formulas need to be fused, modified, and added/subtracted to suit the disease. Clinical practice requires methods within formulas and formulas within methods; one must flexibly apply ancient formulas without being rigid.
Intern B: Since it is dawn diarrhea, why not use Sishen Wan (Four Spirits Pill)? According to textbooks, Sishen Wan is the representative formula for treating dawn diarrhea.
Teacher: In my personal experience, the effect of Sishen Wan on dawn diarrhea is not ideal, inferior to the aforementioned formulas. Of course, individual experiences differ. Additionally, textbooks merely summarize the most basic and commonly used methods from many medical texts throughout history and cannot encompass the rich and colorful clinical experience.
There are many ancient formulas for treating dawn diarrhea. To effectively treat major and difficult diseases, relying solely on textbook knowledge is insufficient. This patient sought medical help in various places in Northeast China, receiving prescriptions such as Sishen Wan, Zhenren Yangzang Tang, Shenling Baizhu San (Ginseng, Poria, and Atractylodes Macrocephala Powder), Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction), Shengyang Yiwang Tang (Raise Yang and Benefit the Stomach Decoction), and Gegen Qinlian Tang (Kudzu Root, Scutellaria, and Coptis Decoction), among others, covering everything available. There were also those using Renshen (Ginseng), Fuzi, Baizhu (Atractylodes), Jiang (Ginger), Husuke (Poppy Capsule), and Doukou (Cardamom); some even used 15g of Husuke. Why were they unable to cure him, while he was basically cured here? First, the drug composition and dosage must be reasonable; larger is not always better. Second, once effective, one must adhere to the formula.
Attending Physician A: Zhenren Yangzang Tang is frequently used by the teacher to treat chronic prolonged diarrhea. Could you please discuss how to master its indications, contraindications, and modifications?
Teacher: Zhenren Yangzang Tang has the functions of tonifying deficiency, warming the middle, binding the intestines, and securing leakage. It is most suitable for treating incontinence of stool caused by Spleen-Kidney deficiency-cold. In the formula, Dangshen (Codonopsis), Baizhu (Atractylodes macrocephala), and Gancao (Licorice) strengthen the Spleen and assist transportation; combined with Rougui (Cinnamon Twig) and Roudoukou (Nutmeg) to warm the middle and stop diarrhea; Yingsuke (Poppy Capsule) and Hezi (Chebula Fruit) bind the intestines and stop diarrhea; Danggui (Angelica sinensis) and Baishao (White Peony Root) harmonize blood and relieve pain; Muxiang (Aucklandiae Radix) regulates Qi. Key points for the indications and contraindications of this formula include: ① Both deficiency and cold of the Spleen/Kidney (Intestines) are indispensable; ② Frequent diarrhea without pus or blood in the stool, especially with sliding incontinence, is more suitable; ③ No tenesmus, no anal fullness or burning sensation; ④ No abdominal distension; ⑤ No excessively weak bowel sounds; ⑥ No foul-smelling stool. There are many modification methods for this formula, mainly: if there is no abdominal pain, remove Danggui and Baishao; if the coating is greasy with dampness, additionally remove Dangshen and Gancao, add Yiyiren (Coix Seed) and Fuling (Poria); if abdominal distension is severe and stool is unsatisfactory, remove Husuke, Hezi, and Roudoukou, add Chenpi (Tangerine Peel), Binglang (Areca Seed), and Sharen (Amomum Fruit); if bowel sounds are weak, also remove the above three herbs, add Jiao Binglang (Charred Areca Seed); if appetite is poor, add Jiao Shanzha (Charred Hawthorn Fruit), Shenqu (Medicated Leaven), Sharen, and Shanyao (Dioscorea Rhizome); if the coating is yellow, or there is irritability or slightly yellow urine, add Chuanlian (Coptis), or additionally add Cheqiancao (Plantago Herb); if the abdomen is very cold, add Shu Fupian (Prepared Aconite Slice) and Paojiang Charred Ginger); if bowel sounds are gurgling and watery diarrhea is frequent, add Fuling, Zexie (Alisma), Qianghuo (Notopterygium Rhizome), and Wei Jiang (Roasted Ginger); if there is a sensation of anal prolapse, add Heluogeng (Lotus Stem), Zhi Huangqi (Honey-fried Astragalus), and Chaihu (Bupleurum Root). Furthermore, for deficiency-cold sliding incontinence, formulas and substances used by Zhang Zhongjing such as Taohua Tang (Peach Blossom Decoction), Chishizhi Yuyuliang Wan (Red Stone Lipstick and Metastone Pill), and Zaoxintu (Stove Heart Earth) can also be considered for inclusion.
Physician B: Yingsuke (Poppy Capsule) is the shell of opium, belonging to narcotic drugs. We dare not use it. I do not know how to master its indications and dosage?
Teacher: Briefly speaking, it is unsuitable for cases with pathogens and stagnation, but suitable for cases without pathogens or stagnation, characterized by sliding incontinence. This herb primarily acts to astringe and secure the intestines, with some pain-relieving effects. The dosage should be controlled between 3-5-10g, generally not exceeding 6g. Elderly people should avoid using it as much as possible, and the course of treatment should not be long.
Physician A: The teacher also uses external herbal patches on acupoints, taking advantage of their warming Yang effect, right?
Teacher: Correct. Please review the diseases governed by the acupoints Tianshu (ST25), Guanyuan (CV4), Qihai (CV6), and Pishu (BL20), and relate them to the pathogenesis of this disease, and you will understand. Dingxiang (Caryophylli Flos), Rougui (Cinnamomi Cortex), and Shexiang (Moschus) are acrid and hot in nature. External application allows the medicinal properties to penetrate the skin and reach the disease site directly. Internal and external use combined aims to warm Yang, dispel cold, and enhance therapeutic efficacy.
Attending Physician A: The teacher used some intestinal-binding herbs, which certainly help form the stool. If the medication is stopped, will it lead to a recurrence of diarrhea?
Teacher: The method of astringency is the last of the nine methods for treating diarrhea. We have discussed it extensively above. It is necessary to use it for frequent diarrhea due to deficiency-cold without pathogens or stagnation, but it should not be used for a long time, especially Yingsuke (Poppy Capsule); stop when appropriate. After stopping the medication, recurrence is generally unlikely because methods for strengthening the Spleen, warming the Kidney, and consolidating the root were used simultaneously. Once the root is solidified, the branch symptoms are less likely to appear.
Analysis of Insomnia Case
Professor Xiao Yonglin, Changchun University of Chinese Medicine
In April 1977, I went to Tongyu County, Jilin Province, to lecture for the "Western Medicine Learning Chinese Medicine" class. The mother of Minister Luo of the County Party Committee at that time had suffered from mental restlessness and inability to sleep for several months. She had taken various Chinese and Western medicines with poor results. She invited me to diagnose and treat her. The patient was 67 years old, with a robust constitution and substantial Qi and form. Several months ago, due to trivial family matters, she felt depressed and stifled. Initially, she experienced epigastric fullness and abdominal distension, chest and hypochondriac fullness and discomfort. Gradually, she felt heat and confusion in the heart, unable to sleep at night. She complained of dry mouth and bitter taste, distension in the hypochondrium and chest, irritability, red eyes with excessive discharge, dark and scanty painful urination, red tongue body with thick yellow coating, and wiry, rapid, and forceful pulse. Checking the medications previously used, they were all calming the Heart and anchoring the Spirit preparations, such as Zhusha Anshen Wan (Cinnabar Calming the Heart Pill), Hupo Anshen Wan (Amber Calming the Heart Pill), Tianwang Buxin Dan (Emperor of Heaven’s Tonifying the Heart Pill), Renshen Guipi Wan (Ginseng and Spleen-Nourishing Pill), and Valium tablets, etc.
Based on her pulse and symptoms, she was diagnosed with Exuberant Heat in the Liver and Gallbladder disturbing the Heart Spirit, causing mental restlessness and insomnia. The treatment principle was to clear and drain the heat of the Liver and Gallbladder, using Longdan Xiegan Tang (Gentian Liver-Draining Decoction) plus Huanglian (Coptidis Rhizoma). Prescription: Longdancao (Gentianae Radix) 20g, Huangqin (Scutellariae Radix) 15g, Zhizi (Gardeniae Fructus) 15g, Shengdi (Rehmanniae Radix) 10g, Danggui (Angelicae Sinensis Radix) 10g, Chaihu (Bupleuri Radix) 10g, Mutong (Akebiae Caulis) 10g, Cheqianzi (Plantaginis Semen) 10g (wrapped and decocted), Zexie (Alismatis Rhizoma) 10g, Gancao (Glycyrrhizae Radix et Rhizoma) 10g, Huanglian (Coptidis Rhizoma) 10g. Decoct in water and take orally. After 3 doses, mental restlessness ceased, and she could sleep peacefully at night. Red eyes with excessive discharge, dark and scanty urination, dry mouth and bitter taste, and other symptoms all improved, and the yellow coating on the tongue receded.
Her relative’s mother-in-law (the mother-in-law of Minister Luo’s wife) also suffered from insomnia. Seeing the good effect of the previous patient's medication, she also obtained 2 doses of the same prescription. After just 1 dose, she felt cold pain in the abdomen and had several episodes of diarrhea. Daring not to take the medicine further, she sought my diagnosis and treatment. Her body was emaciated, complexion sallow and white, feeling general fatigue and weakness, limb heaviness, poor appetite, loose stools, palpitations, and easily startled. She found it difficult to fall asleep at night; even if she fell asleep, it was light, and any slight noise would startle her awake, causing heart palpitations and making it hard to sleep again. Her tongue body was pale with thin white coating, and the pulse was deep, weak, and powerless. Based on her pulse and symptoms, it was known that Heart-Spleen Dual Deficiency, insufficiency of Qi and Blood, and lack of nourishment for the Spirit caused palpitations and insomnia. The treatment principle was to strengthen the Spleen and nourish the Heart, doubly tonifying Qi and Blood. Using Guipi Tang (Spleen-Nourishing Decoction) plus Shanyao (Dioscoreae Rhizoma) and Ganjiang (Zingiberis Rhizoma), removing Longyanrou (Longan Aril) due to unavailability. Prescription: Dangshen (Codonopsis Radix) 15g, Shengqi (Astragali Radix) 20g, Baizhu (Atractylodis Macrocephalae Rhizoma) 15g, Fushen (Poria with Hostwood) 15g, Shanyao (Dioscoreae Rhizoma) 25g, Ganjiang (Zingiberis Rhizoma) 10g, Danggui (Angelicae Sinensis Radix) 15g, Yuanzhi (Polygalae Radix) 10g, Suanzaoren (Ziziphi Spinosae Semen) 10g, Muxiang (Aucklandiae Radix) 5g, Shengjiang (Zingiberis Rhizoma Recens) 3 slices, Dazao (Jujubae Fructus) 5 pieces. Decoct in water and take orally. After 2 doses, the patient’s abdominal cold pain had healed, diarrhea had stopped, and palpitations and insomnia had improved. Later, she was cured with Renshen Guipi Wan (Ginseng and Spleen-Nourishing Pill).
Student A: Insomnia is all due to unrest of the Heart Spirit and should primarily be treated with calming the Heart and anchoring the Spirit. Why were these two patients not treated this way?
Teacher: The syndrome of Bu Mei (Insomnia), also known as insomnia, has many causes. For those suffering from palpitations and insomnia due to fright and anxiety, constant fearfulness, and floating of the Spirit Qi, the original treatment should involve calming the Heart and anchoring the Spirit preparations, such as Longgu (Fossilized Bones), Muli (Concha Ostreae), Cishi (Magnetitum), Zhusha (Cinnabaris), and Hupo (Electrum), to converge Heart Qi and anchor the Spirit. However, these two patients do not belong to this category; their insomnia syndromes each have specific causes. If the etiology is not removed and only calming herbs are used alone, ideal effects will not be achieved. From the situation of the first patient, it can be seen that although she used various calming and anchoring medicines without effect, based on her symptoms, a formula to clear and drain excess heat from the Liver and Gallbladder was used, and the disease was subsequently cured.
Student B: These two patients both had insomnia syndromes, yet one was cured by clearing the Liver and draining heat, and the other by tonifying Qi and Blood. What should we learn from this?
Teacher: Although these two patients both had insomnia syndromes, because the syndromes differed, the treatment methods varied. The first patient’s syndrome belonged to Heat in the Liver and Gallbladder disturbing the Mind, causing insomnia, hence cured by clearing the Liver and draining heat. The latter patient suffered from insufficiency of Qi and Blood, dual deficiency of Heart and Spleen, and lack of nourishment for the Spirit, leading to insomnia, hence cured by strengthening the Spleen, nourishing the Heart, and doubly tonifying Qi and Blood. From this, we can learn the characteristics of Traditional Chinese Medicine: Holistic Concept and Syndrome Differentiation and Treatment. Insomnia is primarily governed by the Heart and Spirit. On the surface, it seems to be merely a disease of the Heart Spirit, treatable simply with calming herbs. Student A’s question probably stems from this view.
The human body is an organic whole. Although each Zang-Fu organ has its own characteristics and functions, they mutually generate and constrain each other physiologically, and influence each other pathologically. Looking at the insomnia syndrome, although it is a disease where Yang does not enter Yin and the Heart Spirit is restless, the cause is not entirely due to Heart disease but involves other Zang-Fu organs. The first patient originally had stagnant Liver Qi transforming into Fire. Thus, she manifested dry mouth and bitter taste, chest and hypochondriac distension, red eyes with excessive discharge, tendency to anger and fire, wiry rapid forceful pulse, and other images of exuberant Heat in the Liver Meridian. Liver and Gallbladder Fire is Minister Fire, while Heart Fire is Sovereign Fire. In pathological states, exuberance of Sovereign Fire often leads to reckless movement of Minister Fire; exuberance of Minister Fire can trigger flaming up of Heart Fire. Exuberance of Heart Fire, where Yang does not enter Yin, causes mental restlessness and insomnia. It can be seen that exuberance of Liver-Gallbladder Fire is the cause, and exuberance of Heart Fire with mental restlessness and insomnia is the effect. Therefore, treatment focuses on the Liver. This embodies the principles of holistic concept, syndrome differentiation and treatment, and seeking the root of the disease.
The latter patient, due to congenital insufficiency, Spleen deficiency and weak Qi, and little desire for food, lacked the source for generating Qi and Blood. Dual deficiency of Qi and Blood led to lack of nourishment for the Heart Spirit, causing palpitations and insomnia. To calm the Heart and quiet the Spirit, one must tonify and nourish Qi and Blood. To make Qi and Blood robust, one must first benefit the Spleen and Stomach. It can be seen that Spleen-Stomach Qi deficiency is the root (cause) of this syndrome, while unrest of the Heart Spirit is the branch (effect). If the treatment for this patient had not used Guipi Tang, heavily employing Ginseng, Atractylodes, and Astragalus to tonify Spleen and augment Qi, but instead only nourished Heart Yin and calmed the Spirit, it would be difficult to achieve such efficacy. Because herbs that nourish Heart Yin tend to be cloying and greasy, and herbs that calm and sedate the Spirit are mostly minerals, shells, or fossils. Both are detrimental to the Spleen and Stomach. If medication damages the Spleen and Stomach, cutting off the source of Qi and Blood generation first, it is difficult to achieve the effect of nourishing the Heart and calming the Spirit. TCM treatment adheres to the principles of "treating the disease must seek its root" and "subdue the main factor by addressing its cause," seeking the cause through syndrome differentiation and treating based on the cause. It is not treating the head when the head hurts and the foot when the foot hurts.
Student C: Please explain to us, Teacher, why Huanglian (Coptidis Rhizoma) was added to the formula for the first patient, and why Shanyao (Dioscoreae Rhizoma) and Ganjiang (Zingiberis Rhizoma) were added to the formula for the second patient?
Teacher: The insomnia syndrome of the first patient was caused by exuberant Fire of the Liver and Gallbladder (Minister Fire) leading to exuberance of Heart Fire (Sovereign Fire), thereby disturbing the Spirit and causing mental restlessness and insomnia. Therefore, while using Longdan Xiegan Tang to clear and drain the Fire of the Liver and Gallbladder, Huanglian was added to clear Heart Fire. This embodies the meaning of treating both the branch (Heart Fire) and the root (Liver-Gallbladder Fire) simultaneously, and considering both Sovereign and Minister Fire, which is more comprehensive than the method of clearing only Minister Fire.
The insomnia syndrome of the second patient was due to her naturally weak constitution, Spleen-Stomach Qi deficiency. Originally, sweet-warm formulas should have been used to tonify the Middle and augment Qi to generate Qi and Blood. When Qi and Blood are abundant, the Heart Spirit is nourished, naturally stopping palpitations and ensuring peaceful sleep. However, due to the family's ignorance of this principle, seeing that Longdan Xiegan Tang cured the first patient's insomnia, they blindly took it. The result was not only ineffectiveness but also injury to the already weak Spleen and Stomach by the cold-cooling nature (Longdan Xiegan Tang is a cold-cooling fire-draining formula), leading to symptoms of Spleen-Stomach deficiency-cold such as abdominal cold pain and diarrhea. The selection of Guipi Tang to treat this patient’s palpitations and insomnia was originally completely consistent with the syndrome. However, at this time, the patient, having been injured by the cooling medicine, suffered damage to Middle Yang with abdominal cold pain, and Spleen deficiency with slippery intestines causing diarrhea. Therefore, Ganjiang (Zingiberis Rhizoma), a hot herb that stays in the Middle, was added to dispel cold pathogens, warm the Middle, and relieve pain; Shanyao (Dioscoreae Rhizoma), a sweet-warm astringent herb, was added to strengthen Spleen Qi and bind the intestines to stop diarrhea. This allowed the cold to dissipate and Middle Yang to gradually recover, and diarrhea to stop and Spleen Qi to gradually flourish. With a strong Spleen and recovered Yang, Qi and Blood can be generated; with abundant Qi and Blood, the Heart Spirit is nourished, and the syndrome of palpitations and insomnia can gradually heal. Adding Shanyao and Ganjiang was entirely to correct the error of the previous medication. When abdominal cold pain disappeared and diarrhea gradually stopped, these two herbs were removed, and Guipi Wan was switched to, resulting in recovery.
Student A: The syndrome of insomnia is relatively common clinically. Please discuss the specific syndrome differentiation and treatment.
Teacher: Zhang Jingyue said, "Although the manifestations of insomnia vary, knowing only the characters 'Evil' (Xie) and 'Righteous' (Zheng) covers it all. Sleep is fundamentally based on Yin, and the Spirit is its master. When the Spirit is tranquil, there is sleep; when the Spirit is unsettled, there is insomnia. The reasons for unease are either disturbance by Evil pathogens or insufficiency of Ying Qi. Cases with Evil are essentially excess syndromes; cases without Evil are all deficiency syndromes." (Jingyue Quanshu · Miscellaneous Diseases · Insomnia). From the above statement, it is not difficult to see that although the causes of insomnia are numerous, the syndromes are essentially either deficiency (Ying deficiency—insufficiency of Yin and Blood) or excess (disturbance by Evil pathogens). However, deficiency varies between Yin/Blood and Yang/Qi, and excess varies between Cold, Heat, Phlegm, and Food. Below, I will briefly discuss the syndrome differentiation and treatment.