从患者的主要症状看，一为恶心、呕吐，一为眩晕、头痛。-二者父常同时发生，这就说明二者完全可能是同一原因所产生的不同症状。其呕吐物为稀白之涎沫，并且发凉，知其病为痰浊内盛。在整个病变过程中，无发热、口渴、烦躁、便秘、尿赤及口舌焦燥之热象，且又四末发凉，喜温热而畏寒凉，遇热则病缓解，得寒则病加剧，足以说明此证系纯寒而无热。患者于每次发病后更觉疲惫虚乏，四肢懒堕，明明是脾胃气虚之象。从．卜面的分析中可知，此证有痰浊内盛，又有脾胃虚寒。那么，此二者之间是什么关系呢?古人云，"脾为生瘀之原"，脾所以能生痰，原因在于脾之阳气虚衰。《医林绳墨》说，"行则为液，聚则为痰；流则为滓，止则为涎"。痰涎与津液皆人体水谷之气而生。若脏腑(特别是脾肾)之阳气旺盛而运行不滞，则水谷之精微尽为人体所用，而为津为液为血为精；若脏腑阳气虚衰而运化迟滞，则阴液停聚而为饮为痰为水为涎。此患平素脾胃虚寒，阳气虚弱．或外受寒凉而郁遏阳气，或饮食生冷而阳气更伤，或气恼忧郁而脾气更滞，皆能导致阳气虚衰不能运化水谷之精微而生痰聚饮。痰饮内盛，阻遏中焦之气机，则出现中焦气机逆乱之症。所谓中焦气机逆乱，是指脾气当升而不升，胃气当降而不降。胃气不降则反而逆上，于是则脘腹胀满、恶心、呕吐涎沫之症生；脾气不升则反陷下，于是泄泻之症起。且脾主肌肉，又主四肢，今脾胃虚寒，阳气不足以温煦四肢，则四末发凉，水谷之精微不足以充养肌肉则身肢疲乏而怠堕。痰湿中阻，则清阳之气不能上充于脑，脑失所养，且痰浊挟胃气上犯，则出现眩晕、头痛等证。此种眩晕为痰浊眩晕或痰饮眩晕。此种头痛为痰厥头痛。如头痛之部位以巅顶为主，则称厥阴头痛，也称肝厥头痛，或厥头痛。认为此种头痛产生的机理为平素胃气虚寒，以致肝胃不和，肝气挟胃中寒浊之气上冲厥阴经脉而致。因肝之经脉从少腹上行，挟胃、属肝、络胆，直上至巅。故厥阴头痛出现巅顶疼痛，四肢厥冷，呕吐涎沫之症。
医生乙请老师谈一下此证之治疗。
老师：通过前面的分析，我们知道此证的要点在于虚，在于寒，还应注意痰。因而在治疗时主要解决虚＼寒与痰。而不要只看到症状上主要表现为恶心、呕吐、眩晕与头痛，治疗时见头医头，见脚医脚。"治病必求其本"，"必伏其所主，而先其所因"。本病之虚寒主要在于脾胃，因而在治疗时注重于解决脾胃之虚寒。只要脾胃之虚寒得以解除，则中焦气机恢复正常，胃气得降则呕逆自平，脾气得升则痰饮易化。上面的处方，实际是吴茱萸汤与半夏天麻白术汤的合方。意在温补脾胃与化痰息风同用。此方用人参、白术、茯苓、甘草，功在健脾益气。吴茱萸与生姜皆辛温(热)之品，能温胃散寒，下气降浊。方中之陈皮、半夏、茯苓、甘草、生姜实为二陈汤，功能燥湿化痰，理气和中。用天麻在于息内风而除眩晕。如果我们将处方中的药物仔细地归纳一下，将发现这里面包括几个常用的方剂。其中有健脾益气的主方四君子汤(人参、白术、茯苓、甘草)；有健脾、益气、和胃的异功散(四君加陈皮)；有健脾、益气、止呕、化痰，而善治脾胃气虚兼有痰湿的六君子汤(四君子加陈皮，半夏)。还有善于降胃止呕的小半夏汤(半夏、生姜)，及小半夏加茯苓汤。另外，就是前面说过的燥湿化痰的主方二陈汤；温中补虚，降逆止呕的吴茱萸汤和善于燥湿化痰、乎息内风眩晕的半夏天麻白术汤。这些方剂，总地来看，其功用重在补脾之虚，温中散寒而降逆化痰，与此证之虚、寒、痰三者正相符合，故能收到比较好的效果。
医生丙我仔细地看了上面的处方，发现其中的白术、半夏、生姜和天麻的用量比较多，老师能讲一下其中的原因吗?
老师：看起来这位医生很细心，本处方重用这几味药，是有一定用意的。本方重用白术者，盖以白术味苦甘性温，善能燥湿健脾，利水化痰。黄宫绣称其为"脾脏补气第一要药"((本草求真))。凡补脾益气，消痰逐饮，利水渗湿之剂中，皆以之为主药。其他补脾益气之药如人参、茯苓、甘草等皆可随症增减，而白术则为必用之药。临床中常用的补脾益气之方如四君、六君、补中益气、归脾等无一不用白术，即使(伤寒论)、(金匮要略)中诸健脾温中化痰利水诸方也皆以之为中流砥柱，如理中汤、苓桂术甘汤、五苓散、枳术汤、白术附子汤等。本证既属脾胃虚寒，而又痰浊中阻，当然要重用白术了。半夏辛温而燥，既善燥湿化痰，又长于降胃止呕。况此证痰湿中阻，恶心呕逆，半夏是在所必用。此患之痰厥头痛，半夏又偏具异能。李东垣说，"痰厥头痛，非半夏不能疗"。所以本证重用之。此患者所以重用生姜，因其最善温中止呕。配参、术、草等以治中焦虚寒；配半夏长于祛痰而止呕。(金匮要略)之小半夏汤，治诸呕吐、谷不得下，即半夏与生姜二味组成。二者相辅既可增温中开胃，降逆止呕之功，同时生姜又善解半夏之毒。这样，既可增利，又可除弊。天麻甘辛平，为肝家气分定风药。凡头晕眼黑，语言不利，身肢麻木之属于痰气郁滞经络或肝气疏达不畅者，用此性升属阳之药，正合其宜。李东垣说，"眼黑头旋，风虚内作，非天麻不能除"。即是指的此种情况。但必须明确，若肝之阴血不足，或肝阳偏亢，或阴血亏少不能濡润而致之肝风内动者，则不宜应用天麻。《本草求真》称其为"肝家气分定风药"，意即在此。
便秘、腹满、胸闷、头晕
长春中医学院教授肖永林
吉林省人民医院夏文静
患者丁XX，女，62岁，1983年4月就诊。该患因便秘、腹满、胸闷、头目眩晕，久治疗效欠佳，遂来就诊。患者于2年前开始大便干涩难行，初起二三日l行，渐至五六日1行，并常感脘腹部胀闷不舒。饮食减少，稍微增多则胀满加重，暖气频频，时有恶心、呕逆。之后又觉胸部满闷，两胁胀痛，心中时觉烦热，呼吸气粗而不顺畅。并觉时常有气自小腹上冲于胸脘。近1年来又出现头晕目眩、耳鸣、头脑发胀，面目时潮红，烦躁易怒，口苦，舌胀。每于生气、上火后诸症加重。视其身体发胖，形气俱实，舌红胖苔白黄而厚，面目虚浮状，脉象弦而有力。
询其以往治疗用药情况：因为大便干燥，曾用过清宁丸、番泻叶、果导、蜂蜜等，也曾用过开塞露。以上诸药，用后则大便即通，过后仍然秘结。因胸脘痞满，腹部胀闷，曾服过紫蔻丸、疏肝丸、宽胸顺气丸、木香顺气丸、保和丸等理气开郁之品，服后胸腹暂舒，不用药则胀闷依然。因头目眩晕，上焦有火，曾用过上清丸、清眩丸、龙胆泻肝丸等，药后火热稍清，停药则仍然如前。并用过行气开郁，通便清火之汤药数剂，其作用大抵如前药。据其症情与服药情况，知其病为胃气不降，导致肺气不清，冲气上逆，肝气郁滞化火，而上焦有热。遂用降胃安冲，清金疏肝之法。
其方：生代赭石细粉30g，生山药30g，半夏15g，竹茹10g，玄参20g，白芍20g，寸冬15g，当归15g，牛膝15g，生麦芽15g，茵陈10g。水煎每日1剂，3次服。3剂后，觉上逆之气渐少，大便稍通，胀闷略舒，头目眩晕也轻。又于前方中加柏仁15g，代赭细粉每次冲服5g，其余煎服。3剂后，大便畅通，日行1次，腹满胸闷也大有好转，已不觉呕逆、恶心；头目也觉清爽。又3剂后，诸证皆乎。后用脑立清善后。
医生甲请老师谈谈此证的辨证思路。
老师：在临床中，患者经常出现大便秘结，或三五日1行，或七八日1解，便时干涩困难，同时伴有腹部胀满，胸脘满闷，烦热，经常嗳气，呕逆，饮食减少，或两胁胀痛，或呼吸不顺畅而气粗，渐渐出现头晕目眩、耳鸣，或头部胀痛者，并不少见。高龄者尤多。其大便秘结难行，或用泻下药，或用润肠药，虽可暂通，而过后更甚；其胸腹胀满，饮食少思，嗳气、呕逆，极似气机郁滞，食积不消，但施以行气消导之品，药后稍舒而药停依旧；其头目眩晕耳鸣口苦，似为上焦有热，用清热泻火之品而疗效不能持续者，皆可考虑为本证。因大便秘结，在用泻下药与润肠药后而效果不能持续者，说明其证非为热结或肠燥。若系热结便秘，当用苦寒泻下之晶后，随着大便之通利而热邪自去，热邪去而津液不伤，自无再秘之理。如属肠燥津亏便秘，用滋阴润肠之品而大便滑润后，说明阴液渐复。而此证初用虽通而停后无效，其秘结既非热结，又非肠燥。其胸腹胀满，胁肋不舒、嗳气、呕逆等，用行气开郁消导之剂，疏而又滞者，说明其证非气郁食积可知，且其并无饮食自倍之因，即或少食或不食，而诸症并不减轻。其头目眩晕、耳鸣、口苦等，如为上焦有热，服清热泄火之品当火热渐除，头目自然清爽。而此证则不然，服药则清，药过则否。何处之火热，如此难除?且去而又至，其宋何易?其火伏于何处?凡此种种，皆缘于胃气不降，诸脏腑之气升多降少，渐渐郁滞化火而然。故选用沉重降下之品，使胃气降而胃用复，则诸上逆之气皆得顺降，而脏腑之气机渐可复常，大便自然通润，而胀满、痞闷自除，气降则火也降，眩晕、耳鸣、口苦、胸中烦热等症，不用清凉而自去。
医生乙请老师谈谈胃气下降之机理及所产生的症状。
老师：要谈清这一问题，得先从脾胃谈起。脾胃二者，一脏一腑，一阴-阳，相反相成，共同完成纳受水谷，消导运化，升清降浊之任务，而为人体后天之本，精津气血生化之源。其中脾主升清，以阳气为主，喜燥而恶湿，喜暖而恶寒。故脾之不升，多由阳气不足，而化寒化湿，以致清阳不升，水谷之精气下流，从而出现泄泻或便溏，倦怠，少气，肢体困重无力等症。胃主降浊，以阴液为用，喜润而恶燥，喜凉而恶热。故胃之不降多由阴液不足而化热化燥，以致浊阴不降，糟粕不得下行，出现便秘、胀满、暖气、呕逆、食少等症。造成胃气不降之原因很多：有由于禀赋者，来源于先天，自幼即有便秘习惯；有由于饮食者，或过食辛辣至阴伤多火；或食物过于精细，少食蔬菜、粗糙食物；有由于性情急躁而多怒，肝胆之火偏升，以致胃气不降者；有由于肺气肃降不行而上逆，影响而致胃气不降；有由于年龄偏高，肾阴不足而致者，此类患者较多。
经曰，"年四十而阴气自半也，起居衰矣"。特别是肾阴不足，收敛摄纳之力渐弱。以致冲脉之气上冲，进而导致胃气不降。盖冲脉起于胞中，并足少阴肾经之脉挟脐-亡行。如肾阴虚收摄之力弱，则冲气易于上逆。冲脉之气上逆日久，可引起阳明之气上逆。因冲脉从足阳明经之气街穴出于体表，旁阳明之脉而行。反之胃气不降也可导致冲气上逆。此患者之自觉有气从少腹上冲，即为冲气上逆之象。人身之气机，有升有降。大抵肝脾之气宜升，肺胃之气宜降。升降不息，气机周流则脏腑之气调和而人体康泰无病。若用各种原因造成胃气不降，其初起时有不降，如不愈则经常发作。时间既久，遂成胃气不降之证。胃气不降，则难于传导下行，引起大肠之气也滞而不畅，遂成便秘不通。胃肠之气不通于下，则蓄积于中而现痞闷胀满之症。下既不通，必反上行，因而出现食少、暖气呕逆等症。胃气不降，可影响肺气之下降，于是出现胸中满闷，呼吸不畅，或胸中烦热。肺胃之气不降，则肝之疏泄受阻，从而郁滞不疏。且气有余便是火，故出现头晕胀痛、目眩、耳鸣、口苦等症。也可由于气逆不降，渐致血随气升，气血逆上也可导致吐血衄血等症。可见，胃气不降之原因，非止-端。胃气不降所导致的结果，也并非只是胃肠本身的病变，而是由于胃气不降，导致诸脏腑的气机升降失常，升多降少。
医生甲请老师谈一下此证的治疗原则。
老师：前面讲过，胃气不降由多种因素造成，胃气不降又可导致各脏腑气机失调，升多降少。因而在治疗此证时，既要抓住病证的关键，以降胃气为主，又要适当考虑致病之原因及所导致的后果，辅以相应的治疗。从本患者以前的治疗用药可知，如果
从患者的主要症状来看，一是恶心、呕吐，二是眩晕、头痛。这两者常常同时发生，这说明它们完全可能是由同一原因引起的不同症状。其呕吐物为稀薄的白色涎沫，并且发凉，由此可知病因为痰浊内盛。在整个病变过程中，没有发热、口渴、烦躁、便秘、尿赤及口舌焦燥等热象，反而四肢末端发凉，喜欢温热而畏惧寒凉，遇热则病情缓解，遇寒则病情加剧，这足以说明此证属于纯寒而无热。患者在每次发病后感到更加疲惫虚乏，四肢懒堕无力，这明显是脾胃气虚的表现。从上述分析可知，此证既有痰浊内盛，又有脾胃虚寒。那么，这两者之间是什么关系呢？古人说：“脾为生痰之源”，脾之所以能生痰，原因在于脾的阳气虚衰。《医林绳墨》中说：“流动时为津液，积聚时为痰；流淌时为渣滓，停止时为涎。”痰涎与津液都是由人体水谷之气化生而成。如果脏腑（特别是脾肾）的阳气旺盛且运行通畅，那么水谷的精微物质就会全部被人体利用，转化为津、液、血、精；如果脏腑阳气虚衰且运化迟滞，那么阴液就会停聚而形成饮、痰、水、涎。这位患者平素脾胃虚寒，阳气虚弱，或者外受寒凉而郁遏阳气，或者饮食生冷而进一步损伤阳气，或者因气恼忧郁而导致脾气更加滞涩，这些都能导致阳气虚衰，不能运化水谷精微而生痰聚饮。痰饮内盛，阻遏中焦的气机，就会出现中焦气机逆乱的症状。所谓中焦气机逆乱，是指脾气应当上升而不能上升，胃气应当下降而不能下降。胃气不降反而上逆，于是产生脘腹胀满、恶心、呕吐涎沫等症状；脾气不升反而下陷，于是产生泄泻症状。而且脾主肌肉，又主四肢，现在脾胃虚寒，阳气不足以温煦四肢，所以四肢末端发凉，水谷精微不足以充养肌肉，所以身体四肢疲乏而怠惰无力。痰湿阻滞中焦，清阳之气不能上充于脑，脑失所养，加上痰浊挟带胃气上犯，就出现眩晕、头痛等症状。这种眩晕称为痰浊眩晕或痰饮眩晕。这种头痛称为痰厥头痛。如果头痛的部位主要在巅顶，则称为厥阴头痛，也称肝厥头痛，或厥头痛。认为这种头痛产生的机理是平素胃气虚寒，导致肝胃不和，肝气挟带胃中的寒浊之气上冲厥阴经脉所致。因为肝的经脉从少腹上行，挟胃、属肝、络胆，直上至巅顶。所以厥阴头痛会出现巅顶疼痛、四肢厥冷、呕吐涎沫等症状。
医生乙请老师谈谈此证的治疗方案。
老师：通过前面的分析，我们知道此证的要点在于“虚”和“寒”，还应注意“痰”。因此在治疗时主要解决虚、寒与痰的问题。不要只看到症状上主要表现为恶心、呕吐、眩晕与头痛，治疗时见头医头，见脚医脚。“治病必求其本”，“必须制服其主要矛盾，并先处理其原因”。本病的虚寒主要在于脾胃，因此在治疗时注重解决脾胃的虚寒。只要脾胃的虚寒得以解除，中焦气机就能恢复正常，胃气得降则呕逆自然平息，脾气得升则痰饮容易化解。上面的处方，实际上是吴茱萸汤与半夏天麻白术汤的合方。意在温补脾胃与化痰息风并用。此方用人参、白术、茯苓、甘草，功效在于健脾益气。吴茱萸与生姜都是辛温（热）之品，能温胃散寒，下气降浊。方中的陈皮、半夏、茯苓、甘草、生姜实为二陈汤，功能燥湿化痰，理气和中。用天麻在于平息内风而消除眩晕。如果我们仔细归纳处方中的药物，会发现这里面包括几个常用的方剂。其中有健脾益气的主方四君子汤（人参、白术、茯苓、甘草）；有健脾、益气、和胃的异功散（四君子加陈皮）；有健脾、益气、止呕、化痰，且善于治疗脾胃气虚兼有痰湿的六君子汤（四君子加陈皮、半夏）。还有善于降胃止呕的小半夏汤（半夏、生姜），以及小半夏加茯苓汤。另外，就是前面说过的燥湿化痰的主方二陈汤；温中补虚、降逆止呕的吴茱萸汤，以及善于燥湿化痰、平息内风眩晕的半夏天麻白术汤。这些方剂，总体来看，其功用重在补脾之虚，温中散寒而降逆化痰，与此证的虚、寒、痰三者正相符合，故能收到比较好的效果。
医生丙我仔细地看了上面的处方，发现其中的白术、半夏、生姜和天麻的用量比较多，老师能讲一下其中的原因吗？
老师：看起来这位医生很细心，本处方重用这几味药，是有一定用意的。本方重用白术，是因为白术味苦甘性温，善于燥湿健脾，利水化痰。黄宫绣称其为“脾脏补气第一要药”（《本草求真》）。凡是补脾益气、消痰逐饮、利水渗湿的方剂中，都以它为主药。其他补脾益气的药如人参、茯苓、甘草等皆可随症增减，而白术则是必用的药。临床中常用的补脾益气之方如四君子汤、六君子汤、补中益气汤、归脾汤等无一不用白术，即使《伤寒论》、《金匮要略》中诸健脾温中化痰利水诸方也皆以之为中流砥柱，如理中汤、苓桂术甘汤、五苓散、枳术汤、白术附子汤等。本证既属脾胃虚寒，而又痰浊中阻，当然要重用白术了。半夏辛温而燥，既善于燥湿化痰，又长于降胃止呕。况且此证痰湿中阻，恶心呕逆，半夏是在所必用的。此患的痰厥头痛，半夏又偏具异能。李东垣说：“痰厥头痛，非半夏不能疗。”所以本证重用之。此患者所以重用生姜，是因为生姜最善于温中止呕。配伍人参、白术、甘草等以治中焦虚寒；配伍半夏长于祛痰而止呕。《金匮要略》的小半夏汤，治疗各种呕吐、谷不得下，即由半夏与生姜两味组成。二者相辅相成既可增加温中开胃、降逆止呕的功效，同时生姜又善于解半夏之毒。这样，既可增利，又可除弊。天麻甘辛平，为肝家气分定风药。凡是头晕眼黑、语言不利、身肢麻木属于痰气郁滞经络或肝气疏达不畅者，用此性升属阳的药，正合其宜。李东垣说：“眼黑头旋，风虚内作，非天麻不能除。”即是指的这种情况。但必须明确，若肝之阴血不足，或肝阳偏亢，或阴血亏少不能濡润而致之肝风内动者，则不宜应用天麻。《本草求真》称其为“肝家气分定风药”，意即在此。
便秘、腹满、胸闷、头晕
长春中医学院教授肖永林
吉林省人民医院夏文静
患者丁XX，女，62岁，1983年4月就诊。该患因便秘、腹满、胸闷、头目眩晕，久治疗效欠佳，遂来就诊。患者于2年前开始大便干涩难行，初起二三日一行，渐至五六日一行，并常感脘腹部胀闷不舒。饮食减少，稍微增多则胀满加重，嗳气频频，时有恶心、呕逆。之后又觉胸部满闷，两胁胀痛，心中时觉烦热，呼吸气粗而不顺畅。并觉时常有气自小腹上冲于胸脘。近1年来又出现头晕目眩、耳鸣、头脑发胀，面目时潮红，烦躁易怒，口苦，舌胀。每于生气、上火后诸症加重。视其身体发胖，形气俱实，舌红胖苔白黄而厚，面目虚浮状，脉象弦而有力。
询其以往治疗用药情况：因为大便干燥，曾用过清宁丸、番泻叶、果导、蜂蜜等，也曾用过开塞露。以上诸药，用后则大便即通，过后仍然秘结。因胸脘痞满，腹部胀闷，曾服过紫蔻丸、疏肝丸、宽胸顺气丸、木香顺气丸、保和丸等理气开郁之品，服后胸腹暂舒，不用药则胀闷依然。因头目眩晕，上焦有火，曾用过上清丸、清眩丸、龙胆泻肝丸等，药后火热稍清，停药则仍然如前。并用过行气开郁，通便清火之汤药数剂，其作用大抵如前药。据其症情与服药情况，知其病为胃气不降，导致肺气不清，冲气上逆，肝气郁滞化火，而上焦有热。遂用降胃安冲，清金疏肝之法。
其方：生代赭石细粉30g，生山药30g，半夏15g，竹茹10g，玄参20g，白芍20g，寸冬15g，当归15g，牛膝15g，生麦芽15g，茵陈10g。水煎每日1剂，3次服。3剂后，觉上逆之气渐少，大便稍通，胀闷略舒，头目眩晕也轻。又于前方中加柏仁15g，代赭细粉每次冲服5g，其余煎服。3剂后，大便畅通，日行1次，腹满胸闷也大有好转，已不觉呕逆、恶心；头目也觉清爽。又3剂后，诸证皆平。后用脑立清善后。
医生甲请老师谈谈此证的辨证思路。
老师：在临床中，患者经常出现大便秘结，或三五日一行，或七八日一解，便时干涩困难，同时伴有腹部胀满，胸脘满闷，烦热，经常嗳气，呕逆，饮食减少，或两胁胀痛，或呼吸不顺畅而气粗，渐渐出现头晕目眩、耳鸣，或头部胀痛者，并不少见。高龄者尤多。其大便秘结难行，或用泻下药，或用润肠药，虽可暂通，而过后更甚；其胸腹胀满，饮食少思，嗳气、呕逆，极似气机郁滞，食积不消，但施以行气消导之品，药后稍舒而药停依旧；其头目眩晕耳鸣口苦，似为上焦有热，用清热泻火之品而疗效不能持续者，皆可考虑为本证。因大便秘结，在用泻下药与润肠药后而效果不能持续者，说明其证非为热结或肠燥。若系热结便秘，当用苦寒泻下之品后，随着大便之通利而热邪自去，热邪去而津液不伤，自无再秘之理。如属肠燥津亏便秘，用滋阴润肠之品而大便滑润后，说明阴液渐复。而此证初用虽通而停后无效，其秘结既非热结，又非肠燥。其胸腹胀满，胁肋不舒、嗳气、呕逆等，用行气开郁消导之剂，疏而又滞者，说明其证非气郁食积可知，且其并无饮食自倍之因，即或少食或不食，而诸症并不减轻。其头目眩晕、耳鸣、口苦等，如为上焦有热，服清热泄火之品当火热渐除，头目自然清爽。而此证则不然，服药则清，药过则否。何处之火热，如此难除？且去而又至，其来何易？其火伏于何处？凡此种种，皆缘于胃气不降，诸脏腑之气升多降少，渐渐郁滞化火而然。故选用沉重降下之品，使胃气降而胃用复，则诸上逆之气皆得顺降，而脏腑之气机渐可复常，大便自然通润，而胀满、痞闷自除，气降则火也降，眩晕、耳鸣、口苦、胸中烦热等症，不用清凉而自去。
医生乙请老师谈谈胃气下降之机理及所产生的症状。
老师：要谈清这一问题，得先从脾胃谈起。脾胃二者，一脏一腑，一阴一阳，相反相成，共同完成纳受水谷，消导运化，升清降浊之任务，而为人体后天之本，精津气血生化之源。其中脾主升清，以阳气为主，喜燥而恶湿，喜暖而恶寒。故脾之不升，多由阳气不足，而化寒化湿，以致清阳不升，水谷之精气下流，从而出现泄泻或便溏，倦怠，少气，肢体困重无力等症。胃主降浊，以阴液为用，喜润而恶燥，喜凉而恶热。故胃之不降多由阴液不足而化热化燥，以致浊阴不降，糟粕不得下行，出现便秘、胀满、嗳气、呕逆、食少等症。造成胃气不降之原因很多：有由于禀赋者，来源于先天，自幼即有便秘习惯；有由于饮食者，或过食辛辣至阴伤多火；或食物过于精细，少食蔬菜、粗糙食物；有由于性情急躁而多怒，肝胆之火偏升，以致胃气不降者；有由于肺气肃降不行而上逆，影响而致胃气不降；有由于年龄偏高，肾阴不足而致者，此类患者较多。
经曰：“年四十而阴气自半也，起居衰矣”。特别是肾阴不足，收敛摄纳之力渐弱。以致冲脉之气上冲，进而导致胃气不降。盖冲脉起于胞中，并足少阴肾经之脉挟脐上行。如肾阴虚收摄之力弱，则冲气易于上逆。冲脉之气上逆日久，可引起阳明之气上逆。因冲脉从足阳明经之气街穴出于体表，旁阳明之脉而行。反之胃气不降也可导致冲气上逆。此患者之自觉有气从少腹上冲，即为冲气上逆之象。人身之气机，有升有降。大抵肝脾之气宜升，肺胃之气宜降。升降不息，气机周流则脏腑之气调和而人体康泰无病。若用各种原因造成胃气不降，其初起时有不降，如不愈则经常发作。时间既久，遂成胃气不降之证。胃气不降，则难于传导下行，引起大肠之气也滞而不畅，遂成便秘不通。胃肠之气不通于下，则蓄积于中而现痞闷胀满之症。下既不通，必反上行，因而出现食少、嗳气呕逆等症。胃气不降，可影响肺气之下降，于是出现胸中满闷，呼吸不畅，或胸中烦热。肺胃之气不降，则肝之疏泄受阻，从而郁滞不疏。且气有余便是火，故出现头晕胀痛、目眩、耳鸣、口苦等症。也可由于气逆不降，渐致血随气升，气血逆上也可导致吐血衄血等症。可见，胃气不降之原因，非止一端。胃气不降所导致的结果，也并非只是胃肠本身的病变，而是由于胃气不降，导致诸脏腑的气机升降失常，升多降少。
医生甲请老师谈一下此证的治疗原则。
老师：前面讲过，胃气不降由多种因素造成，胃气不降又可导致各脏腑气机失调，升多降少。因而在治疗此证时，既要抓住病证的关键，以降胃气为主，又要适当考虑致病之原因及所导致的后果，辅以相应的治疗。从本患者以前的治疗用药可知，如果
From the patient's main symptoms, one is nausea and vomiting, and the other is vertigo and headache. These two often occur simultaneously, which indicates that they are likely different symptoms caused by the same etiology. The vomitus consists of thin, white saliva/phlegm fluid (Xianmo) and feels cold, indicating that the pathology is excessive accumulation of turbid phlegm (Tan Zhuo) internally. Throughout the course of the disease, there are no signs of heat such as fever, thirst, restlessness, constipation, dark urine, or scorched tongue and mouth; instead, the four extremities are cold, the patient prefers warmth and fears cold, the condition alleviates with heat, and aggravates with cold. This sufficiently demonstrates that this syndrome is purely cold without heat. After each episode, the patient feels more exhausted and weak, with lazy and drooping limbs, which is clearly a manifestation of Spleen-Stomach Qi deficiency (Pi Wei Qi Xu). From the above analysis, it can be known that this syndrome involves both excessive internal turbid phlegm and deficiency-cold of the Spleen and Stomach. So, what is the relationship between these two? The ancients said, "The Spleen is the source of phlegm production." The reason why the Spleen can generate phlegm lies in the deficiency and decline of Spleen Yang. *Yi Lin Sheng Mo* states, "When flowing, it is body fluid; when accumulating, it is phlegm; when moving, it is dregs; when stopping, it is saliva." Saliva and phlegm fluid are both generated from the Qi of food and water in the human body. If the Yang Qi of the Zang-Fu organs (especially the Spleen and Kidney) is vigorous and circulation is unimpeded, then the essence of food and water will be fully utilized by the body, transforming into Jin-Ye (body fluids), blood, and essence; if the Yang Qi of the Zang-Fu organs is deficient and transformation is sluggish, then Yin fluids will stagnate and accumulate to form Yin (fluid retention), Tan (phlegm), Shui (water), and Xian (saliva). This patient has had chronic Spleen-Stomach deficiency-cold and weak Yang Qi. External exposure to cold may constrain the Yang Qi, consumption of raw/cold foods may further injure the Yang Qi, or emotional anger/depression may cause further stagnation of Spleen Qi. All these can lead to Yang Qi deficiency, failing to transform the essence of food and water, thereby generating phlegm and retaining fluids. Excessive internal phlegm-fluid obstructs the Qi mechanism of the Middle Jiao, resulting in chaotic reversal of Middle Jiao Qi. The so-called chaotic reversal of Middle Jiao Qi refers to the failure of Spleen Qi to ascend when it should, and the failure of Stomach Qi to descend when it should. When Stomach Qi fails to descend and rebels upward, symptoms such as epigastric/abdominal distension/fullness, nausea, and vomiting of saliva/phlegm arise; when Spleen Qi fails to ascend and sinks downward, diarrhea occurs. Moreover, the Spleen governs muscles and the four limbs. Now, due to Spleen-Stomach deficiency-cold, Yang Qi is insufficient to warm the four limbs, hence the coldness of the extremities; the insufficiency of food-water essence to nourish muscles leads to bodily and limb fatigue and lethargy. Phlegm-dampness obstructing the middle prevents Clear Yang Qi from ascending to the brain, causing the brain to lose nourishment. Additionally, turbid phlegm carrying Stomach Qi attacks upward, leading to vertigo and headache. This type of vertigo is called turbid phlegm vertigo or phlegm-fluid vertigo. This type of headache is called Phlegm-Jue Headache. If the headache is mainly located at the vertex, it is called Jueyin Headache, also known as Liver-Jue Headache or Jue Headache. It is believed that the mechanism of this headache arises from chronic Stomach Qi deficiency-cold, leading to Disharmony between Liver and Stomach, where Liver Qi carries cold-turbid Qi from the Stomach to rush up along the Jueyin Meridian. Since the Liver Meridian ascends from the lower abdomen, passes through the Stomach, connects to the Liver, links to the Gallbladder, and goes straight up to the vertex, Jueyin Headache presents with vertex pain, coldness of the four extremities, and vomiting of saliva/phlegm.
Doctor Yi asked the teacher to discuss the treatment for this syndrome.
Teacher: Through the previous analysis, we know that the key points of this syndrome lie in "deficiency" and "cold," and attention must also be paid to "phlegm." Therefore, in treatment, the primary goal is to resolve deficiency, cold, and phlegm. One should not merely see the symptoms manifesting as nausea, vomiting, vertigo, and headache, treating the head when seeing head issues and the feet when seeing foot issues ("Treat the root of the disease," "Subdue the master cause and address the origin first"). The deficiency-cold of this disease primarily resides in the Spleen and Stomach; thus, treatment focuses on resolving Spleen-Stomach deficiency-cold. Once Spleen-Stomach deficiency-cold is resolved, the Middle Jiao Qi mechanism returns to normal; descending Stomach Qi naturally stops rebellion/vomiting, and ascending Spleen Qi facilitates the transformation of phlegm-fluid. The prescription above is actually a combination of Wuzhuyu Tang (Evodia Decoction) and Banxia Tianma Baizhu Tang (Pinellia, Gastrodia, and Atractylodes Macrocephala Decoction). The intent is to combine warming and tonifying the Spleen-Stomach with resolving phlegm and extinguishing wind. This formula uses Renshen (Ginseng Radix), Baizhu (Atractylodis Macrocephalae Rhizoma), Fuling (Poria), and Gancao (Licorice Root) to strengthen the Spleen and benefit Qi. Wuzhuyu (Evodiae Fructus) and Shengjiang (Zingiberis Rhizoma Recens) are acrid-warm (hot) substances capable of warming the Stomach, dispersing cold, directing Qi downward, and descending turbidity. Chenpi (Citri Reticulatae Pericarpium), Banxia (Pinelliae Rhizoma), Fuling, Gancao, and Shengjiang in the formula constitute Erchen Tang (Two-Aged Decoction), which functions to dry dampness and resolve phlegm, regulate Qi and harmonize the Middle. Tianma (Gastrodiae Rhizoma) is used to extinguish internal wind and relieve vertigo. If we carefully categorize the herbs in the prescription, we will find it includes several commonly used formulas. Among them is the main formula for strengthening the Spleen and benefiting Qi, Sijunzi Tang (Four Gentlemen Decoction: Renshen, Baizhu, Fuling, Gancao); Yigong San (Extraordinary Efficacy Powder: Sijunzi Tang plus Chenpi), which strengthens the Spleen, benefits Qi, and harmonizes the Stomach; Liujunzi Tang (Six Gentlemen Decoction: Sijunzi Tang plus Chenpi and Banxia), which strengthens the Spleen, benefits Qi, stops vomiting, resolves phlegm, and is particularly effective for Spleen-Stomach Qi deficiency complicated by phlegm-dampness. There is also Xiaobanxia Tang (Minor Pinellia Decoction: Banxia, Shengjiang), good at descending Stomach Qi and stopping vomiting, and Xiaobanxia Ji Fuling Tang (Minor Pinellia Decoction plus Poria). Additionally, there is Erchen Tang (Two-Aged Decoction), the main formula for drying dampness and resolving phlegm mentioned earlier; Wuzhuyu Tang (Evodia Decoction), which warms the center, tonifies deficiency, directs rebellious Qi downward, and stops vomiting; and Banxia Tianma Baizhu Tang, which is adept at drying dampness, resolving phlegm, and extinguishing internal wind/vertigo. Overall, these formulas focus on tonifying Spleen deficiency, warming the center, dispersing cold, directing rebellious Qi downward, and resolving phlegm, which perfectly matches the deficiency, cold, and phlegm of this syndrome, thus achieving good results.
Doctor Bing carefully examined the prescription above and noticed that the dosages of Baizhu, Banxia, Shengjiang, and Tianma were relatively high. Could the teacher explain the reasons for this?
Teacher: It appears this doctor is very meticulous. The heavy use of these herbs in this prescription is intentional. Baizhu is used in heavy dosage because it is bitter, sweet, and warm, excelling at drying dampness, strengthening the Spleen, promoting diuresis, and resolving phlegm. Huang Gongxiu referred to it as the "number one herb for tonifying Qi in the Spleen organ" (*Bencao Qiuyi*). In all formulas that tonify Spleen Qi, eliminate phlegm and retain fluids, and promote diuresis and leach out dampness, it serves as the principal herb. Other Spleen-tonifying and Qi-benefiting herbs like Renshen, Fuling, and Gancao can be adjusted according to symptoms, but Baizhu is essential. Common clinical formulas for tonifying Spleen and benefiting Qi, such as Sijunzi Tang, Liujunzi Tang, Buzhong Yiqi Tang, and Guipi Tang, all utilize Baizhu. Even in various Spleen-strengthening, center-warming, phlegm-resolving, and diuretic formulas from *Shanghan Lun* and *Jingui Yaolue*, it acts as the pillar, such as Lizhong Tang, Linggui Zhugan Tang, Wuling San, Zhizhu Tang, and Baizhu Fuzi Tang. Since this syndrome belongs to Spleen-Stomach deficiency-cold with turbid phlegm obstruction in the middle, it is necessary to use Baizhu in heavy dosage. Banxia is acrid, warm, and drying; it excels at drying dampness and resolving phlegm, and is particularly skilled at descending Stomach Qi and stopping vomiting. Given the phlegm-dampness obstruction in the middle, nausea, and vomiting in this case, Banxia is indispensable. For this patient's Phlegm-Jue Headache, Banxia possesses special efficacy. Li Dongyuan stated, "For Phlegm-Jue Headache, only Banxia can treat it." Hence, it is used heavily in this syndrome. Shengjiang is used in heavy dosage for this patient because it excels at warming the middle and stopping vomiting. Paired with Renshen, Baizhu, and Gancao, it treats Middle Jiao deficiency-cold; paired with Banxia, it enhances phlegm removal and vomiting cessation. Xiaobanxia Tang in *Jingui Yaolue* treats various vomiting and inability to swallow grain, composed solely of Banxia and Shengjiang. Together, they synergistically increase the effects of warming the middle, opening the appetite, directing rebellious Qi downward, and stopping vomiting, while Shengjiang also effectively mitigates the toxicity of Banxia. Thus, benefits are increased, and drawbacks eliminated. Tianma is sweet, acrid, and neutral, serving as a wind-calming herb for the Qi aspect of the Liver. For dizziness, blurred vision, speech difficulties, and numbness of the body and limbs caused by phlegm-Qi stagnation in meridians or impaired Liver Qi dispersion, using this ascending, Yang-natured herb is appropriate. Li Dongyuan said, "For blackouts and spinning vertigo caused by internal wind deficiency, only Tianma can remove it." This refers to such situations. However, it must be clarified that if Liver Yin-blood is insufficient, Liver Yang is hyperactive, or Yin-blood deficiency fails to moisten leading to internal stirring of Liver Wind, Tianma should not be applied. *Bencao Qiuyi* calls it a "wind-calming herb for the Qi aspect of the Liver," which implies this meaning.
Constipation, abdominal fullness, chest tightness, dizziness
Professor Xiao Yonglin, Changchun University of Chinese Medicine
Xia Wenjing, Jilin Provincial People's Hospital
Patient Ding XX, female, 62 years old, visited in April 1983. The patient presented with constipation, abdominal fullness, chest tightness, and dizziness/blurred vision, with poor efficacy from long-term treatment, prompting her visit. Two years prior, she began experiencing dry and difficult bowel movements, initially occurring every two to three days, gradually progressing to once every five to six days, accompanied by frequent sensations of epigastric and abdominal distension and discomfort. Food intake decreased; slight increases led to worsened fullness, frequent belching, and occasional nausea and vomiting. Subsequently, she felt chest tightness, distending pain in both hypochondria, occasional inner heat/restlessness, and coarse, unsmooth breathing. She also felt gas frequently rushing from the lower abdomen to the chest and epigastrium. Over the past year, she developed dizziness, tinnitus, head distension, occasional facial flushing, irritability, bitter taste, and swollen tongue. Symptoms aggravated after anger or "internal fire." Examination revealed an obese body, robust constitution and Qi, red and enlarged tongue with thick white-yellow coating, puffy face and eyes, and a wiry and forceful pulse.
Inquiry into previous treatments: Due to dry stools, she had used Qingning Wan, Senna Leaf, Dulcolax, honey, etc., and also enemas. These medications induced bowel movements temporarily, but constipation returned afterward. Due to chest/epigastric stuffiness and abdominal bloating, she took Zikou Wan, Shugan Wan, Kuanxiong Shunqi Wan, Muxiang Shunqi Wan, Baohe Wan, etc., Qi-regulating and depression-relieving agents. These provided temporary relief in the chest and abdomen, but blooming persisted without medication. For dizziness and upper Jiao fire, she used Shangqing Wan, Qingxuan Wan, Longdan Xiegan Wan, etc. Fire was slightly cleared after medication, but returned upon cessation. She also took several doses of decoctions for regulating Qi, relieving depression, purging bowels, and clearing fire, with similar effects. Based on symptoms and medication history, the pathology was identified as Stomach Qi failing to descend, leading to unclear Lung Qi, Chong Mai Qi rebelling upward, Liver Qi stagnating and transforming into fire, and heat in the Upper Jiao. The method employed was descending Stomach Qi, calming the Chong Mai, clearing Metal (Lung), and soothing the Liver.
Prescription: Raw Daizheshi (Ostreae Concha) fine powder 30g, Raw Shanyao (Dioscoreae Rhizoma) 30g, Banxia (Pinelliae Rhizoma) 15g, Zhuru (Bambusae Folium) 10g, Xuanshen (Scrophulariae Radix) 20g, Baishao (Paeoniae Radix Alba) 20g, Cundong (Ophiopogonis Radix) 15g, Danggui (Angelicae Sinensis Radix) 15g, Niuxi (Achyranthis Bidentatae Radix) 15g, Sheng Maiya (Hordei Fructus Germinatus) 15g, Yichen (Artemisiae Scopariae Herba) 10g. Decocted in water, one dose daily, taken three times. After three doses, upward-rushing Qi decreased, bowel movements slightly improved, distension eased slightly, and dizziness/lightness of head improved. Added Bai Ren (Pruni Semen) 15g to the previous formula, and Daizheshi fine powder 5g taken orally each time, remaining ingredients decocted. After three more doses, bowel movements became smooth, once daily, abdominal fullness and chest tightness greatly improved, nausea and vomiting ceased, and the head felt clear. After another three doses, all symptoms resolved. Nao Li Qing was subsequently used for convalescence.
Doctor Jia asked the teacher to discuss the differentiation and reasoning for this syndrome.
Teacher: In clinical practice, patients frequently present with severe constipation, occurring every three to five days or seven to eight days, with dry and difficult passage, accompanied by abdominal fullness, chest/epigastric stuffiness, inner heat, frequent belching, vomiting, reduced appetite, distending pain in hypochondria, or coarse/unsmooth breathing, gradually developing dizziness, tinnitus, or head distending pain. This is not uncommon, especially among the elderly. Severe constipation treated with purgatives or moistening laxatives may provide temporary relief but worsens afterward. Chest/abdominal fullness, poor appetite, belching, and vomiting resemble Qi stagnation and food retention, but Qi-regulating and digestion-promoting agents provide only temporary relief, with symptoms returning after stopping medication. Dizziness, tinnitus, and bitter taste suggest Upper Jiao heat, but heat-clearing and fire-purging agents fail to sustain efficacy. Such cases should be considered as this syndrome. Constipation that does not sustain improvement after purgatives and moisteners indicates the pathology is neither Heat-Excess nor Intestinal Dryness. If it were Heat-Excess constipation, bitter-cold purgatives would clear heat as stool moves, preserving fluids and preventing recurrence. If it were Intestinal Dryness due to Yin deficiency, yin-nourishing and moistening agents would restore fluids and lubricate stools. However, in this case, initial improvement followed by ineffectiveness indicates the constipation is neither Heat-Excess nor Intestinal Dryness. Chest/abdominal fullness, hypochondriac discomfort, belching, and vomiting that remain stagnant despite Qi-regulating and digestion-promoting agents indicate the pathology is not Qi stagnation or food retention. Furthermore, there is no history of overeating; whether eating little or nothing, symptoms do not diminish. Dizziness, tinnitus, and bitter taste, if due to Upper Jiao heat, should clear with heat-purging agents, restoring clarity to the head and eyes. In this case, however, symptoms clear with medication but return afterward. Where is this heat so hard to eradicate? Why does it return so easily? Where is the heat hidden? All these stem from Stomach Qi failing to descend, causing excessive rising and insufficient descending of Qi in all Zang-Fu organs, gradually stagnating and transforming into fire. Therefore, heavy, descending substances are selected to descend Stomach Qi and restore its function. Then, all rebellious Qi descends smoothly, Zang-Fu Qi mechanisms gradually normalize, stools become naturally moist, and fullness/stuffiness disappear. As Qi descends, fire descends, and symptoms like dizziness, tinnitus, bitter taste, and chest restlessness resolve without cooling agents.
Doctor Yi asked the teacher to discuss the mechanism of Stomach Qi descending and the resulting symptoms.
Teacher: To clarify this, we must start with the Spleen and Stomach. The Spleen and Stomach are a Zang and Fu organ pair, Yin and Yang, opposing yet complementary, jointly responsible for receiving water and food, digesting and transforming, ascending clear and descending turbid, serving as the foundation of postnatal existence and the source of essence, fluids, Qi, and blood. The Spleen governs ascending clear Qi, primarily relying on Yang Qi; it prefers dryness and dislikes dampness, prefers warmth and dislikes cold. Thus, failure of Spleen Qi to ascend is mostly due to insufficient Yang Qi, leading to cold and dampness formation, preventing Clear Yang from ascending, causing essence of food/water to flow downward, resulting in diarrhea or loose stools, fatigue, shortness of breath, and heavy/weak limbs. The Stomach governs descending turbid Qi, primarily utilizing Yin fluids; it prefers moisture and dislikes dryness, prefers coolness and dislikes heat. Thus, failure of Stomach Qi to descend is mostly due to insufficient Yin fluids leading to heat and dryness formation, preventing turbid Yin from descending, causing waste to fail to move downward, resulting in constipation, fullness, belching, vomiting, and poor appetite. Many factors cause Stomach Qi failure to descend: congenital predisposition, leading to lifelong constipation habits; dietary factors, such as excessive spicy food injuring Yin and generating fire, or overly refined food lacking vegetables and roughage; emotional factors, such as irritability and anger causing Liver/Gallbladder fire to rise excessively, impeding Stomach Qi descent; Lung Qi failing to descend and rebelling upward, affecting Stomach Qi descent; and advanced age with Kidney Yin deficiency, a common scenario.
The Classics state, "At forty, Yin Qi naturally halves, and daily activities decline." Particularly, insufficient Kidney Yin weakens the power of convergence and retention. This causes Qi of the Chong Mai to rush upward, subsequently leading to Stomach Qi failure to descend. The Chong Mai originates in the uterus and runs alongside the Foot-Shaoyin Kidney Meridian, flanking the navel upward. If Kidney Yin deficiency weakens retention power, Chong Qi easily rebels upward. Chronic upward rebellion of Chong Qi can cause Yangming Qi to rebel upward. Because the Chong Mai emerges from the体表 at the Qichuan point of the Foot-Yangming Meridian and runs alongside the Yangming meridian. Conversely, Stomach Qi failure to descend can also cause Chong Qi rebellion. The patient's sensation of gas rushing from the lower abdomen is a sign of Chong Qi rebellion. Human Qi mechanism involves both ascending and descending. Generally, Liver and Spleen Qi should ascend, while Lung and Stomach Qi should descend. Continuous ascending and descending allow Qi to circulate, harmonizing Zang-Fu Qi and ensuring health. If various causes lead to Stomach Qi failure to descend, initial episodes may resolve, but if untreated, they recur frequently. Over time, this becomes a chronic Stomach Qi failure to descend syndrome. Failure of Stomach Qi to descend hinders downward transmission, causing Large Intestine Qi to stagnate, resulting in constipation. Qi stagnation in the intestines and stomach accumulates in the middle, presenting as stuffiness and fullness. Since downward flow is blocked, Qi must reverse upward, causing poor appetite, belching, and vomiting. Stomach Qi failure to descend affects Lung Qi descent, causing chest tightness, breathing difficulty, or chest restlessness. Failure of Lung and Stomach Qi to descend impedes Liver dispersion, causing stagnation. Moreover, excess Qi transforms into fire, leading to dizziness, distending pain, vertigo, tinnitus, and bitter taste. Qi rebellion can also cause blood to follow Qi upward, leading to hematemesis or epistaxis. Thus, the causes of Stomach Qi failure to descend are manifold. The consequences are not limited to gastrointestinal lesions but involve dysfunction of Qi ascending/descending in all Zang-Fu organs, characterized by excessive rising and insufficient descending.
Doctor Jia asked the teacher to discuss the treatment principles for this syndrome.
Teacher: As mentioned earlier, Stomach Qi failure to descend is caused by multiple factors and can lead to Zang-Fu Qi disharmony, with excessive rising and insufficient descending. Therefore, in treating this syndrome, one must grasp the key, focusing on descending Stomach Qi, while appropriately considering the etiology and consequences, supplementing with corresponding treatments. From the patient's previous medication, it can be seen that if...