学员乙但也使我产生了两点疑问：第一，患者以前服的2个复方，颇与证侯相符合，为什么竟无显效?第二，患者明明有--派热象，如门干，连连饮水不能解渴，舌质红边尖密布小红点，苔白微黄厚腻，脉弦滑略数等，为什么还可以使用大辛大热的吴茱萸汤呢?
学员丙吴茱萸汤治愈头痛的报道很多，其头痛的病机是肝胃虚寒，浊阴-匕逆，吴茱萸汤暖肝温胃，升清降浊，准确地针对病机，所以疗效很好。但正如前面所说，本例并不具备肝胃虚寒，浊阴上逆的全身证侯和舌脉--如四肢欠温，脘腹怯寒或冷痛，舌淡苔白滑，脉弦沉或弦迟等；相反，还具有一派明显的热象，老师竟然出吴茱萸汤原方，剂量也不轻，确实不好理解。
老师：我知道大家的疑问不少，现择其要点解答。(伤寒论)378条说，"干呕，吐涎沫，头痛者，吴茱萸汤主之"。因本条出在厥阴篇，头痛的部位当在巅顶(厥阴肝脉与督脉会于巅)；又以方测证，属寒无疑。根据"有诸内必形诸外"的规律，其全身证侯和舌脉，自应出现一派寒象。验之临床，确是一般规律。但值得引起注意的是，这一规律不可能穷尽一切，我近年来治疗过一些头痛伴恶心、呕吐清水或稀涎的患者，并非都具备肝胃虚寒、浊阴上逆的全身证侯和舌脉；更有出现一些热象，头痛部位也不在巅顶者。如被一般规律所拘泥，划地为牢，就不敢独用、重用吴茱萸汤了。这就提醒我们临证时要防止思维定势。
学员乙防止思维定势当然是对的，但总不能不顾虑患者的一派热象呀!难道吴茱萸汤可以用于热证头痛吗?
老师：要是不顾虑那一派热象，我就不会刨根究底地询问患者的生活史了。患者近几年3～10月每天坚持下河游泳，常食水果、冰食，饮浓茶等生活史是颇有启发意义的。根据生活史和药效来推测，大约是寒凝冷结长期留着，体内阳气不能畅舒，转郁而作热，或阴霾寒气迫阳气上浮，所以出现一派浮热上冲之象。本例使用吴茱萸汤的关键，-是抓住了特征性证侯--头痛伴呕吐稀涎；二是结合生活史和治疗史进行综合分析，透过浮热的现象，暴露阴寒的本质。
学员甲看来老师使用的是方证相对的辨证方法。我的理解是：吴茱萸汤的方证相对，指的是凡见到"干呕，吐涎沫，头痛者"，便可首选并独用吴茱萸汤，不必斤斤计较是否具备肝胃虚寒，浊阴上逆的全身证侯和舌脉，也不必论其属外感或内伤，经络或脏腑，以及病程的久暂等等因素，是这样的吗?
老师：是这样的。因为仲景所描述的"干呕，吐涎沫，头痛"这一特征性证侯，已经比较充分地反映了这种疾病的特殊本质。如成无己《注解伤寒论》说，"干呕吐涎沫者，里寒也；头痛者，寒气上攻也。与吴茱萸汤温里散寒"。换句话说，仲景辨析此证，已经准确无误，且已出具了高效方药；临床上只要证侯相符，即可信手拈来，大有执简驭繁，驾轻就熟之妙。本例头痛收速效的主要原因就在于此。值得反思的是，近年来似乎存在着一种倾向：强调辨证论治的灵活性(这是应该的)，忽视方证相对的原则性。这是不利于仲景学说的继承和弘扬的。
学员乙患者服吴茱萸汤原方之前曾服过一个大复方，其中就包含吴茱萸汤，为什么疗效不佳呢?
老师：那个大复方是由苍耳散、升麻葛根汤、小柴胡汤、吴茱萸汤4方合成的，药物多达19味，药量又轻，有可能互相掣肘。大家知道，仲景"勤求古训，博采众方"验证筛选，传之后世者，多系高效经验方。如吴茱萸汤药仅4味，看似平淡无奇，实则底蕴无穷。若嫌药味少，或恐病人不相信而随意添加之，有时反而影响疗效。倘方证相对，用原方便可获佳效时，何必画蛇添足呢?当然，艰据病情适当化裁，亦在所必需。但若加味太多，喧宾夺主；或加减得面目全非，还说是"经方化裁"就不足为训了。近贤陈逊斋说过，"经方以不加减为贵"，是很发人深省的。
学员丁：老师用吴茱萸汤原方治疗头痛时，方中4味药的常规用量是多少?
老师：初服时，吴茱萸、生姜不少于15g，党参、大枣不少于30g，中病可以酌减。
咳喘1个月
四川省乐山市人民医院中医研究室主任余国俊
常X，男，56天，1986年2月6日初诊。患儿系8个月早产儿，出生20天即患肺炎；住院14天，好转出院数日，咳喘复发。曾服麻杏石甘汤数剂病减，但停药复发，且日渐加重，不发烧。叠经打针、服药、输液、输氧，病情不减，且多次出现病危。西医诊断：喘息性肺炎，先天性心脏病(房缺)。不得已，转来中医门诊。诊见：患儿精神萎靡，面色苍白，肌肤瘦瘪；咳喘气紧，喉中痰声漉漉，口唇发绀；啼哭之际，冷汗淋漓；夜寐不安，时而烦躁惊厥，四肢冰冷；拒进乳食，大便挟乳食残渣；舌质淡、苔白，指纹淡红。考虑为体弱患感，正邪相争已久，正不胜邪，致阴阳俱伤，风寒羁肺，肺失宣降；加之心阳衰弱，脾运不昌，正气日衰，故尔缠绵而渐趋危殆。拟化气调阴阳兼降气止喘之桂枝加厚朴杏子汤加味：桂枝3g，白芍6g，甘草3g，大枣10g，生姜2片，厚朴10g，杏仁6g，苏子10g，白芥子5g，炒莱菔子6g，葶苈子6g，黄芪15g，白术6g，茯苓6g。服1剂，当晚汗出溱溱，喘咳、气紧、冷汗大减，安卧。服完2剂，纳开，大便正常；颜面、口唇转淡红。惟仍咳嗽，上方去莱菔子，加旋复花3g(包煎)、桔梗6g、法夏6g。服3剂，诸症痊愈，精神爽慧，面色红润，纳增，眠佳，二便正常。后有微咳，左眼眵多，服金沸草散加菊花、连翘、桑叶2剂，以后咳喘未复发。(本案已载入《桂枝汤类方证应用研究》一书--笔者)
进修生甲：奉例早产儿出生20天即患肺炎，住院14天，好转出院数日，咳喘复发，叠经西医药救治，病情不减，迁延1个月，且多次出现病危。老师接诊时，心中有绝对把握吗?
老师：说实话，的确没有把握，更不要说"绝对"了。虽然开了2剂药，但心中都不踏实，故特向患儿父母约定：服完1剂即来复诊。次日我们在诊室里等候至10时，十分焦急，忽见患儿父母面露喜色而来，急询之，知药已中病，我们才松了一口气，乃嘱其续服第二剂。此后均是坦途，不足道矣。
学员甲本例喘息性肺炎，症状不少，危象毕呈，病机很复杂，稍不谨慎，虑其"动手便错"。
老师是怎样掌握其病机的呢?
老师：使用归纳法，就一目了然：第一，患儿早产，先天不足；咳喘迁延1个月，叠用西药乏效，症见精神萎靡，面色苍白，口唇发绀，冷汗淋漓，烦躁惊厥，四肢冰冷，显系心阳虚惫。第二，肌肤瘦瘪，拒进乳食，大便挟乳食残渣，显系胃虚不纳，脾虚失运。第三，咳喘气紧，痰声漉漉，显系痰气冲逆犯肺。前二条是正虚，第三条是邪盛。
进修生乙：基本病机既然是正虚邪盛，基本治则自然是扶正驱邪。但据此造方用药，如何好下手?
老师：从总体上掌握基本病机及治则，可以避免造方用药时出现原则性的失误，这是值得临证时高度重视的。而在具体施治时，还得依据具体病机，确立具体治则，才能丝丝入扣。本例的具体病机是心阳虚惫，脾胃困顿，痰气上逆；具体治法应是温壮心阳，运脾和胃，祛痰降逆。因心阳虚惫显得急重，故把温壮心阳作为救治的重心。
进修生丙既然以温壮心阳为救治的重心，为什么要选用桂枝加厚朴杏子汤加味呢?本方只能调和营卫，祛痰降气，从未听说过有温壮心阳的功效。
老师：这就要归功于江尔逊导师的熏陶和启迪了。大家知道，江老近年来潜心于《伤寒论》基础方证--桂枝汤方证的理论和临床研究，发表了不少独特的见解。江老确信：古贤关于桂枝汤一方"外证得之解肌和营卫，内证得之化气调阴阳"的理论概括，绝不是一句空话。他认为，桂枝汤一方，系由桂枝甘草汤和芍药甘草汤两方合成，前者辛甘化阳，后者酸甘化阴，合之便能调和外证及内证的阴阳，是实现整体性调节的最佳方药。(伤寒论)中说，"喘家，作桂枝汤，加厚朴杏子佳"，乃言平素阴阳(包括营卫、气血)不足而失调之人，若感外邪而诱发宿喘，宜用桂枝汤调和阴阳，加厚朴、杏仁祛痰降气。仲景言"佳"，是经得起临床验证的。但凭心而论，我当时遵循江老的思路借用本方，只符合了本例的基本病机(正虚邪盛)，尚未切合其具体病机。于是我当场请教江老，江老思索片刻，添上白术、茯苓、黄芪，便成了本方合苓桂术甘汤加黄芪；这一合，便合出温壮心阳的功效了。江老复诊患儿后，又添上苏子、白芥子、莱菔子、葶苈子，即再合三子养亲汤、葶苈大枣泻肺汤；这一合，不仅合出了运脾和胃的功效，祛痰降气的功效也大大增强了。由此可见，本方名曰桂枝加厚朴杏子汤加味，实则是一首复方，内寓桂枝加厚朴杏子汤、苓桂术甘汤、三子养亲汤、葶苈大枣泻肺汤4方，共同发挥温壮心阳、运脾和胃、祛痰降气的功效。
进修生乙：这个复方用得好，收到了高效，值得借鉴。但是否如俗语说的"只此一家，别无分店"了呢?据病历记载，本例曾服麻杏石甘汤数剂病减，但停药复发。
老师为什么不借鉴前医的思路呢，何况患儿咳喘气紧，出冷汗，正是麻杏石甘汤的适应症!
老师：《伤寒论》中说，"发汗后，不可更行桂枝汤，汗出而喘，无大热者，可与麻黄杏仁甘草石膏汤"。以方测证，其喘逆为邪气闭肺，故用麻黄配杏仁宣肺开闭，其汗出为郁热壅肺，故用麻黄配石膏宣肺泄热。全方辛凉宣泄，肃肺平喘，乃为实热喘咳而设。本例喘咳初期服之有效时，必具有此等证侯。但停药复发，且日渐加重；虽仍见咳喘气紧，但已不仅仅是出冷汗，而是冷汗淋漓，且伴见一派心阳虚惫的证侯，说明已由实喘转化为虚喘。若见前方有效而步其后尘，再用麻杏石甘汤，必犯"虚虚"之戒。目前临床上似乎存在着一种倾向，就是"对号入座"，如一见肺炎咳喘，便首先考虑使用麻杏石甘汤，这种省疾识证时懒于细察精详，选方用药时喜用套方套药的倾向，是违背辨证论治原则的。附记：本例患儿愈后曾经华西医科大学附属医院检查，已否定"先天性心脏病"的诊断，现已5岁，身体健康。
胸胁隐痛、胃脘满闷、小腹灼热（月真）胀半年
四川省乐山市人民医院中医研究室主任余国俊
刘XX，女，56岁，1987年3月16日初诊。患者12年前曾患过急性黄疸型肝炎，经治疗已痊愈。嗣后偶尔肝区隐痛，胃脘满闷，服疏肝和胃方药数剂，便可暂安。惟半年前因情怀不畅，加之操劳过度，致胸胁隐痛，胃脘满闷，小腹灼热（月真）胀加重，曾屡用小柴胡汤、丹栀逍遥散、半苓汤、滋水清肝饮等方药加减，服药60余剂，均少效验。患者自忖得了不治之症，终日惶惧。但经B超、X光、胃镜等检查，均未发现病灶。刻诊：午后胸胁隐痛，胃脘满闷，小腹灼热膑胀，嗳气频作，入夜加重；伴双目干涩，夜梦纷纭，口干苦，大便干燥；舌淡红苔薄黄欠润，脉弦细。此乃肝肾阴虚合并肝气郁滞之证，治宜滋养肾，疏肝行气。予一贯煎合四逆散加味：当归10g，生地12g，枸杞丑2g，北沙参12g，麦冬15g，金铃炭6g，柴胡10g，白芍12g，枳壳10g，生甘草5g，炒枣仁10so3剂。并告之以其病可治，亟宜移情易性，乐观开朗。二诊：胁隐痛、胃脘满闷、小腹灼热膑胀减轻；但胸部隐痛未减，大便仍干燥。上方加百合308，草决明20g，肉苁蓉20g，枳实易枳壳，3剂。三诊：胸部隐痛及诸症均明显减轻，大便畅，舌淡红苔薄白，脉弦细，上方去金铃炭，加白蒺藜10g，服至自觉症状消失为止。3个月后患者介绍其亲戚来诊，言上方续服8剂后，一切自觉症状均消失。
学员甲：老师治肝病，凡属肝肾阴虚的，必首选一贯煎，酌加数味滋肾填精药物，常获良效。但近来使用一贯煎合四逆散的治验也不少。
学员乙疗效不可否认，但容易贻人以话柄。因为这2首方子的功效和主治大相径庭，合并用之，在理论上是不大说得通的。简而言之，一贯煎以大队阴柔药物滋养肝肾，少佐一味金铃子疏肝行气，使之补而不滞；四逆散则属阳刚之剂，专司疏肝行气。故而两方合用必有顾忌：若其证是以肝肾阴虚为主，使用一贯煎时合用四逆散，则有损气伤阴之弊；若其证是以肝郁气滞为主，使用四逆散时合用一贯煎，则有滋腻碍气之弊。
学员乙：这也让我产生了两点疑问：第一，患者之前服用的两个复方，与证候颇为相符，为什么竟然没有明显效果？第二，患者明明有一派热象，如口干，连续饮水不能解渴，舌质红，边缘和尖端密布小红点，苔白微黄厚腻，脉弦滑略数等，为什么还可以使用大辛大热的吴茱萸汤呢？
学员丙：用吴茱萸汤治愈头痛的报道很多，其头痛的病机是肝胃虚寒，浊阴上逆，吴茱萸汤暖肝温胃，升清降浊，准确地针对病机，所以疗效很好。但正如前面所说，本例并不具备肝胃虚寒、浊阴上逆的全身证候和舌脉——如四肢欠温，脘腹怯寒或冷痛，舌淡苔白滑，脉弦沉或弦迟等；相反，还具有一派明显的热象，老师竟然出吴茱萸汤原方，剂量也不轻，确实不好理解。
老师：我知道大家的疑问不少，现择其要点解答。(伤寒论)378条说，“干呕，吐涎沫，头痛者，吴茱萸汤主之”。因本条出在厥阴篇，头痛的部位当在巅顶（厥阴肝脉与督脉会于巅）；又以方测证，属寒无疑。根据“有诸内必形诸外”的规律，其全身证候和舌脉，自应出现一派寒象。验之临床，确是一般规律。但值得引起注意的是，这一规律不可能穷尽一切，我近年来治疗过一些头痛伴恶心、呕吐清水或稀涎的患者，并非都具备肝胃虚寒、浊阴上逆的全身证候和舌脉；更有出现一些热象，头痛部位也不在巅顶者。如被一般规律所拘泥，划地为牢，就不敢独用、重用吴茱萸汤了。这就提醒我们临证时要防止思维定势。
学员乙：防止思维定势当然是对的，但总不能不顾虑患者的一派热象呀！难道吴茱萸汤可以用于热证头痛吗？
老师：要是不顾虑那一派热象，我就不会刨根究底地询问患者的生活史了。患者近几年3～10月每天坚持下河游泳，常食水果、冰食，饮浓茶等生活史是颇有启发意义的。根据生活史和药效来推测，大约是寒凝冷结长期留着，体内阳气不能畅舒，转郁而作热，或阴霾寒气迫阳气上浮，所以出现一派浮热上冲之象。本例使用吴茱萸汤的关键，一是抓住了特征性证候——头痛伴呕吐稀涎；二是结合生活史和治疗史进行综合分析，透过浮热的现象，暴露阴寒的本质。
学员甲：看来老师使用的是方证相对的辨证方法。我的理解是：吴茱萸汤的方证相对，指的是凡见到“干呕，吐涎沫，头痛者”，便可首选并独用吴茱萸汤，不必斤斤计较是否具备肝胃虚寒，浊阴上逆的全身证候和舌脉，也不必论其属外感或内伤，经络或脏腑，以及病程的久暂等等因素，是这样的吗？
老师：是这样的。因为仲景所描述的“干呕，吐涎沫，头痛”这一特征性证候，已经比较充分地反映了这种疾病的特殊本质。如成无己《注解伤寒论》说，“干呕吐涎沫者，里寒也；头痛者，寒气上攻也。与吴茱萸汤温里散寒”。换句话说，仲景辨析此证，已经准确无误，且已出具了高效方药；临床上只要证候相符，即可信手拈来，大有执简驭繁，驾轻就熟之妙。本例头痛收速效的主要原因就在于此。值得反思的是，近年来似乎存在着一种倾向：强调辨证论治的灵活性（这是应该的），忽视方证相对的原则性。这是不利于仲景学说的继承和弘扬的。
学员乙：患者服吴茱萸汤原方之前曾服过一个大复方，其中就包含吴茱萸汤，为什么疗效不佳呢？
老师：那个大复方是由苍耳散、升麻葛根汤、小柴胡汤、吴茱萸汤4方合成的，药物多达19味，药量又轻，有可能互相掣肘。大家知道，仲景“勤求古训，博采众方”验证筛选，传之后世者，多系高效经验方。如吴茱萸汤药仅4味，看似平淡无奇，实则底蕴无穷。若嫌药味少，或恐病人不相信而随意添加之，有时反而影响疗效。倘方证相对，用原方便可获佳效时，何必画蛇添足呢？当然，根据病情适当化裁，亦在所必需。但若加味太多，喧宾夺主；或加减得面目全非，还说是“经方化裁”就不足为训了。近贤陈逊斋说过，“经方以不加减为贵”，是很发人深省的。
学员丁：老师用吴茱萸汤原方治疗头痛时，方中4味药的常规用量是多少？
老师：初服时，吴茱萸、生姜不少于15g，党参、大枣不少于30g，中病可以酌减。
咳喘1个月
四川省乐山市人民医院中医研究室主任余国俊
常X，男，56天，1986年2月6日初诊。患儿系8个月早产儿，出生20天即患肺炎；住院14天，好转出院数日，咳喘复发。曾服麻杏石甘汤数剂病减，但停药复发，且日渐加重，不发烧。叠经打针、服药、输液、输氧，病情不减，且多次出现病危。西医诊断：喘息性肺炎，先天性心脏病(房缺)。不得已，转来中医门诊。诊见：患儿精神萎靡，面色苍白，肌肤瘦瘪；咳喘气紧，喉中痰声漉漉，口唇发绀；啼哭之际，冷汗淋漓；夜寐不安，时而烦躁惊厥，四肢冰冷；拒进乳食，大便挟乳食残渣；舌质淡、苔白，指纹淡红。考虑为体弱患感，正邪相争已久，正不胜邪，致阴阳俱伤，风寒羁肺，肺失宣降；加之心阳衰弱，脾运不昌，正气日衰，故尔缠绵而渐趋危殆。拟化气调阴阳兼降气止喘之桂枝加厚朴杏子汤加味：桂枝3g，白芍6g，甘草3g，大枣10g，生姜2片，厚朴10g，杏仁6g，苏子10g，白芥子5g，炒莱菔子6g，葶苈子6g，黄芪15g，白术6g，茯苓6g。服1剂，当晚汗出溱溱，喘咳、气紧、冷汗大减，安卧。服完2剂，纳开，大便正常；颜面、口唇转淡红。惟仍咳嗽，上方去莱菔子，加旋复花3g(包煎)、桔梗6g、法夏6g。服3剂，诸症痊愈，精神爽慧，面色红润，纳增，眠佳，二便正常。后有微咳，左眼眵多，服金沸草散加菊花、连翘、桑叶2剂，以后咳喘未复发。(本案已载入《桂枝汤类方证应用研究》一书--笔者)
进修生甲：奉例早产儿出生20天即患肺炎，住院14天，好转出院数日，咳喘复发，叠经西医药救治，病情不减，迁延1个月，且多次出现病危。老师接诊时，心中有绝对把握吗？
老师：说实话，的确没有把握，更不要说“绝对”了。虽然开了2剂药，但心中都不踏实，故特向患儿父母约定：服完1剂即来复诊。次日我们在诊室里等候至10时，十分焦急，忽见患儿父母面露喜色而来，急询之，知药已中病，我们才松了一口气，乃嘱其续服第二剂。此后均是坦途，不足道矣。
学员甲：本例喘息性肺炎，症状不少，危象毕呈，病机很复杂，稍不谨慎，虑其“动手便错”。老师是怎样掌握其病机的呢？
老师：使用归纳法，就一目了然：第一，患儿早产，先天不足；咳喘迁延1个月，叠用西药乏效，症见精神萎靡，面色苍白，口唇发绀，冷汗淋漓，烦躁惊厥，四肢冰冷，显系心阳虚惫。第二，肌肤瘦瘪，拒进乳食，大便挟乳食残渣，显系胃虚不纳，脾虚失运。第三，咳喘气紧，痰声漉漉，显系痰气冲逆犯肺。前二条是正虚，第三条是邪盛。
进修生乙：基本病机既然是正虚邪盛，基本治则自然是扶正驱邪。但据此造方用药，如何好下手？
老师：从总体上掌握基本病机及治则，可以避免造方用药时出现原则性的失误，这是值得临证时高度重视的。而在具体施治时，还得依据具体病机，确立具体治则，才能丝丝入扣。本例的具体病机是心阳虚惫，脾胃困顿，痰气上逆；具体治法应是温壮心阳，运脾和胃，祛痰降逆。因心阳虚惫显得急重，故把温壮心阳作为救治的重心。
进修生丙：既然以温壮心阳为救治的重心，为什么要选用桂枝加厚朴杏子汤加味呢？本方只能调和营卫，祛痰降气，从未听说过有温壮心阳的功效。
老师：这就要归功于江尔逊导师的熏陶和启迪了。大家知道，江老近年来潜心于《伤寒论》基础方证——桂枝汤方证的理论和临床研究，发表了不少独特的见解。江老确信：古贤关于桂枝汤一方“外证得之解肌和营卫，内证得之化气调阴阳”的理论概括，绝不是一句空话。他认为，桂枝汤一方，系由桂枝甘草汤和芍药甘草汤两方合成，前者辛甘化阳，后者酸甘化阴，合之便能调和外证及内证的阴阳，是实现整体性调节的最佳方药。(伤寒论)中说，“喘家，作桂枝汤，加厚朴杏子佳”，乃言平素阴阳（包括营卫、气血）不足而失调之人，若感外邪而诱发宿喘，宜用桂枝汤调和阴阳，加厚朴、杏仁祛痰降气。仲景言“佳”，是经得起临床验证的。但凭心而论，我当时遵循江老的思路借用本方，只符合了本例的基本病机（正虚邪盛），尚未切合其具体病机。于是我当场请教江老，江老思索片刻，添上白术、茯苓、黄芪，便成了本方合苓桂术甘汤加黄芪；这一合，便合出温壮心阳的功效了。江老复诊患儿后，又添上苏子、白芥子、莱菔子、葶苈子，即再合三子养亲汤、葶苈大枣泻肺汤；这一合，不仅合出了运脾和胃的功效，祛痰降气的功效也大大增强了。由此可见，本方名曰桂枝加厚朴杏子汤加味，实则是一首复方，内寓桂枝加厚朴杏子汤、苓桂术甘汤、三子养亲汤、葶苈大枣泻肺汤4方，共同发挥温壮心阳、运脾和胃、祛痰降气的功效。
进修生乙：这个复方用得好，收到了高效，值得借鉴。但是否如俗语说的“只此一家，别无分店”了呢？据病历记载，本例曾服麻杏石甘汤数剂病减，但停药复发。老师为什么不借鉴前医的思路呢，何况患儿咳喘气紧，出冷汗，正是麻杏石甘汤的适应症！
老师：《伤寒论》中说，“发汗后，不可更行桂枝汤，汗出而喘，无大热者，可与麻黄杏仁甘草石膏汤”。以方测证，其喘逆为邪气闭肺，故用麻黄配杏仁宣肺开闭，其汗出为郁热壅肺，故用麻黄配石膏宣肺泄热。全方辛凉宣泄，肃肺平喘，乃为实热喘咳而设。本例喘咳初期服之有效时，必具有此等证侯。但停药复发，且日渐加重；虽仍见咳喘气紧，但已不仅仅是出冷汗，而是冷汗淋漓，且伴见一派心阳虚惫的证侯，说明已由实喘转化为虚喘。若见前方有效而步其后尘，再用麻杏石甘汤，必犯“虚虚”之戒。目前临床上似乎存在着一种倾向，就是“对号入座”，如一见肺炎咳喘，便首先考虑使用麻杏石甘汤，这种省疾识证时懒于细察精详，选方用药时喜用套方套药的倾向，是违背辨证论治原则的。附记：本例患儿愈后曾经华西医科大学附属医院检查，已否定“先天性心脏病”的诊断，现已5岁，身体健康。
胸胁隐痛、胃脘满闷、小腹灼热（月真）胀半年
四川省乐山市人民医院中医研究室主任余国俊
刘XX，女，56岁，1987年3月16日初诊。患者12年前曾患过急性黄疸型肝炎，经治疗已痊愈。嗣后偶尔肝区隐痛，胃脘满闷，服疏肝和胃方药数剂，便可暂安。惟半年前因情怀不畅，加之操劳过度，致胸胁隐痛，胃脘满闷，小腹灼热（月真）胀加重，曾屡用小柴胡汤、丹栀逍遥散、半苓汤、滋水清肝饮等方药加减，服药60余剂，均少效验。患者自忖得了不治之症，终日惶惧。但经B超、X光、胃镜等检查，均未发现病灶。刻诊：午后胸胁隐痛，胃脘满闷，小腹灼热膑胀，嗳气频作，入夜加重；伴双目干涩，夜梦纷纭，口干苦，大便干燥；舌淡红苔薄黄欠润，脉弦细。此乃肝肾阴虚合并肝气郁滞之证，治宜滋养肾，疏肝行气。予一贯煎合四逆散加味：当归10g，生地12g，枸杞丑2g，北沙参12g，麦冬15g，金铃炭6g，柴胡10g，白芍12g，枳壳10g，生甘草5g，炒枣仁10so3剂。并告之以其病可治，亟宜移情易性，乐观开朗。二诊：胁隐痛、胃脘满闷、小腹灼热膑胀减轻；但胸部隐痛未减，大便仍干燥。上方加百合308，草决明20g，肉苁蓉20g，枳实易枳壳，3剂。三诊：胸部隐痛及诸症均明显减轻，大便畅，舌淡红苔薄白，脉弦细，上方去金铃炭，加白蒺藜10g，服至自觉症状消失为止。3个月后患者介绍其亲戚来诊，言上方续服8剂后，一切自觉症状均消失。
学员甲：老师治肝病，凡属肝肾阴虚的，必首选一贯煎，酌加数味滋肾填精药物，常获良效。但近来使用一贯煎合四逆散的治验也不少。
学员乙：疗效不可否认，但容易贻人以话柄。因为这2首方子的功效和主治大相径庭，合并用之，在理论上是不大说得通的。简而言之，一贯煎以大队阴柔药物滋养肝肾，少佐一味金铃子疏肝行气，使之补而不滞；四逆散则属阳刚之剂，专司疏肝行气。故而两方合用必有顾忌：若其证是以肝肾阴虚为主，使用一贯煎时合用四逆散，则有损气伤阴之弊；若其证是以肝郁气滞为主，使用四逆散时合用一贯煎，则有滋腻碍气之弊。
Student Yi: This also raised two doubts in my mind: First, the two compound prescriptions the patient took previously were quite consistent with the syndrome differentiation, so why did they show no obvious effect? Second, the patient clearly presented a set of heat signs, such as dry mouth, continuous drinking without relief of thirst, red tongue body with densely distributed small red spots on the edges and tip, white coating slightly yellow and thick/greasy, and wiry-slippery pulse slightly rapid. Why could Da Xin Da Re (greatly pungent and greatly hot) Wu Zhu Yu Tang be used?
Student Bing: There are many reports of Wu Zhu Yu Tang curing headaches. The pathogenesis of this headache is Liver-Stomach deficiency-cold with turbid yin counterflow. Wu Zhu Yu Tang warms the Liver and Stomach, raises clear yang and descends turbid yin, accurately targeting the pathogenesis, hence its good efficacy. However, as mentioned earlier, this case does not possess the systemic syndromes and tongue/pulse manifestations of Liver-Stomach deficiency-cold and turbid yin counterflow—such as cold limbs, fear of cold or cold pain in the epigastrium/abdomen, pale tongue with white slippery coating, wiry-deep or wiry-slow pulse. On the contrary, it presents a clear set of heat signs. It is indeed hard to understand why the teacher prescribed the original formula of Wu Zhu Yu Tang with a non-light dosage.
Teacher: I know you have many questions, so I will address the key points. Article 378 of *Shanghan Lun* states: "For dry retching, vomiting of saliva/froth, and headache, Wu Zhu Yu Tang governs." Since this article appears in the Jueyin chapter, the location of the headache should be at the vertex (the Jueyin Liver meridian meets the Du vessel at the vertex); furthermore, inferring the syndrome from the prescription, it undoubtedly belongs to cold. According to the principle that "what exists internally must manifest externally," the systemic syndromes and tongue/pulse should naturally present a set of cold signs. Clinical verification confirms this is a general rule. However, what deserves attention is that this rule cannot exhaust all possibilities. In recent years, I have treated some patients with headaches accompanied by nausea and vomiting of clear water or thin froth who do not necessarily possess the systemic syndromes and tongue/pulse of Liver-Stomach deficiency-cold and turbid yin counterflow; moreover, some present heat signs, and the headache location is not at the vertex. If one is constrained by general rules and limits oneself, one would dare not use Wu Zhu Yu Tang exclusively or heavily. This reminds us to prevent fixed thinking patterns during clinical practice.
Student Yi: Preventing fixed thinking patterns is certainly correct, but one cannot simply disregard the patient's set of heat signs! Can Wu Zhu Yu Tang be used for headache due to heat syndromes?
Teacher: If I disregarded that set of heat signs, I would not have probed into the patient's lifestyle history. The patient's lifestyle history of swimming in the river daily from March to October over the past few years, frequently eating fruits and ice foods, and drinking strong tea is quite enlightening. Based on the lifestyle history and drug efficacy, it is speculated that cold stagnation and cold binding remained for a long time, preventing the smooth distribution of internal Yang qi, which turned stagnant and generated heat, or the dark/cold qi forced Yang qi to float upward, thus presenting a set of floating heat rushing upward. The key to using Wu Zhu Yu Tang in this case lies in: first, grasping the characteristic syndrome—headache accompanied by vomiting of thin froth; second, conducting a comprehensive analysis combining lifestyle history and treatment history, exposing the essence of Yin-cold through the phenomenon of floating heat.
Student Jia: It seems the teacher uses the method of syndrome-prescription correspondence (Fang Zheng Xiang Dui). My understanding is: For the syndrome-prescription correspondence of Wu Zhu Yu Tang, it means that whenever one sees "dry retching, vomiting of saliva/froth, and headache," one can prioritize and use Wu Zhu Yu Tang exclusively, without obsessing over whether the systemic syndromes and tongue/pulse of Liver-Stomach deficiency-cold and turbid yin counterflow are present, nor discussing whether it belongs to external contraction or internal injury, meridians or zang-fu organs, or the duration of the disease. Is this correct?
Teacher: Yes. Because the characteristic syndrome described by Zhongjing—"dry retching, vomiting of saliva/froth, and headache"—has already sufficiently reflected the special essence of this disease. As Cheng Wuji said in *Zhu Jie Shanghan Lun*: "Dry retching and vomiting of saliva/froth indicate interior cold; headache indicates cold qi attacking upward. Give Wu Zhu Yu Tang to warm the interior and dissipate cold." In other words, Zhongjing's analysis of this syndrome was accurate and error-free, and he provided an highly effective prescription. Clinically, as long as the syndrome matches, one can apply it effortlessly, demonstrating the wonder of mastering simplicity to control complexity and handling things with ease. The main reason for the rapid effect in this headache case lies here. What deserves reflection is that there seems to be a tendency in recent years: emphasizing the flexibility of syndrome differentiation and treatment (which is appropriate), while neglecting the principled nature of syndrome-prescription correspondence. This is unfavorable to the inheritance and promotion of Zhongjing's theory.
Student Yi: Before taking the original formula of Wu Zhu Yu Tang, the patient had taken a large compound prescription containing Wu Zhu Yu Tang. Why was the efficacy poor?
Teacher: That large compound prescription was synthesized from four formulas: Cang Er San, Sheng Ma Ge Gen Tang, Xiao Chai Hu Tang, and Wu Zhu Yu Tang. It contained up to 19 herbs, and the dosages were light, which might have interfered with each other. As everyone knows, the prescriptions passed down after Zhongjing's "diligent study of ancient teachings and extensive collection of prescriptions" were mostly high-efficiency empirical formulas. For example, Wu Zhu Yu Tang contains only four herbs; although it seems plain, its depth is infinite. If one dislikes the small number of herbs or fears the patient won't believe it and arbitrarily adds them, it may sometimes affect efficacy. If syndrome-prescription correspondence is achieved and the original formula yields good results, why add superfluous elements? Of course, appropriate modification according to the condition is necessary. But if too many additions are made, overshadowing the main theme; or if modifications make the formula unrecognizable yet still called "modification of Jing Fang," it is not worthy of instruction. The modern sage Chen Xunzai said, "Jing Fang values non-modification," which is very thought-provoking.
Student Ding: When the teacher used the original formula of Wu Zhu Yu Tang to treat headache, what were the routine dosages of the four herbs in the formula?
Teacher: At initial intake, Wu Zhu Yu and Sheng Jiang should not be less than 15g, Dang Shen and Da Zao should not be less than 30g. Dosages can be reduced appropriately once the disease is addressed.
Cough and Asthma for 1 Month
Yu Guojun, Director of TCM Research Office, Leshan People's Hospital, Sichuan Province
Chang X, Male, 56 days old, First visit on Feb 6, 1986. The infant was born prematurely at 8 months gestation and developed pneumonia 20 days after birth; hospitalized for 14 days, improved and discharged, but cough and asthma recurred a few days later. Previously took several doses of Ma Xing Shi Gan Tang, symptoms decreased, but relapsed upon stopping medication, worsening day by day, without fever. After repeated injections, oral medications, IV fluids, and oxygen therapy, the condition did not improve, and critical conditions occurred multiple times. Western medical diagnosis: Wheezing pneumonia, Congenital heart disease (Atrial Septal Defect). Reluctantly transferred to TCM outpatient clinic. Examination revealed: Infant listless, pale complexion, emaciated skin/muscles; cough and asthma with tight breathing, rattling phlegm sound in throat, cyanotic lips; profuse cold sweat when crying; restless sleep at night, occasional irritability and convulsions, cold limbs; refusing milk/food, stool containing undigested milk/food residues; pale tongue body, white coating, pale red fingerprint. Considered as weak constitution contracting pathogen, prolonged struggle between righteous Qi and pathogenic factors, righteous Qi unable to overcome pathogen, resulting in damage to both Yin and Yang, Wind-Cold lingering in Lung, Lung losing diffusion and descending functions; plus Heart Yang weakness, Spleen transport dysfunction, righteous Qi declining daily, thus lingering and gradually becoming critical. Prescribed Gui Zhi Jia Hou Po Xing Zi Tang modified to transform Qi, regulate Yin/Yang, and descend Qi to stop asthma: Gui Zhi 3g, Bai Shao 6g, Gan Cao 3g, Da Zao 10g, Sheng Jiang 2 slices, Hou Po 10g, Xing Ren 6g, Su Zi 10g, Bai Jie Zi 5g, Chao Lai Fu Zi 6g, Ting Li Zi 6g, Huang Qi 15g, Bai Zhu 6g, Fu Ling 6g. After 1 dose, profuse sweating that night, asthma/cough/tight breathing/cold sweat greatly reduced, slept peacefully. After finishing 2 doses, appetite opened, stool normal; face/lips turned pale red. Still coughing, removed Lai Fu Zi from above formula, added Xuan Fu Hua 3g (wrapped decoction), Jie Geng 6g, Fa Xia 6g. After 3 doses, all symptoms cured, spirit bright, ruddy complexion, increased appetite, good sleep, normal urination/defecation. Later slight cough, excessive discharge in left eye, took Jin Fei Cao San plus Ju Hua, Lian Qiao, Sang Ye for 2 doses, thereafter cough/asthma did not recur. (This case has been recorded in the book *Research on Application of Gui Zhi Tang Category Formulas* -- Author)
Trainee Jia: In this case, the premature infant developed pneumonia 20 days after birth, hospitalized for 14 days, improved and discharged, but cough/asthma recurred a few days later. Despite repeated Western medicine rescue, condition did not improve, lingering for 1 month, with multiple critical episodes. Did the teacher have absolute confidence when receiving the patient?
Teacher: To be honest, there was indeed no confidence, let alone "absolute." Although I prescribed 2 doses, I felt uneasy, so I specifically agreed with the parents: come for follow-up after finishing 1 dose. The next day we waited in the clinic until 10 AM, very anxious. Suddenly seeing the parents arrive with joyful expressions, I urgently asked and learned the medicine hit the mark, then we breathed a sigh of relief, and instructed them to continue the second dose. Afterwards, it was smooth sailing, nothing worth mentioning.
Student Jia: This case of wheezing pneumonia has many symptoms, presenting critical signs, complex pathogenesis. A slight lack of caution could lead to errors. How did the teacher grasp the pathogenesis?
Teacher: Using induction, it becomes clear at a glance: First, the infant was premature, congenital insufficiency; cough/asthma lingered for 1 month, repeated Western medicines ineffective, symptoms showed listlessness, pale complexion, cyanotic lips, profuse cold sweat, irritability/convulsions, cold limbs, obviously indicating Heart Yang deficiency/exhaustion. Second, emaciated skin/muscles, refusing food, stool with undigested residues, obviously indicating Stomach deficiency failing to receive, Spleen deficiency failing to transport. Third, cough/asthma with tight breathing, rattling phlegm, obviously indicating Phlegm-Qi rushing upward attacking Lung. The first two points are Righteous Qi deficiency, the third is Pathogenic Excess.
Trainee Yi: Since the basic pathogenesis is Righteous Qi deficiency and Pathogenic excess, the basic treatment principle is naturally supporting Righteous Qi and expelling Pathogen. But based on this to create prescriptions and use drugs, how to proceed?
Teacher: Grasping the basic pathogenesis and treatment principle overall can avoid principled errors in creating prescriptions and using drugs, which is highly valued in clinical practice. However, in specific treatment, one must establish specific treatment principles based on specific pathogenesis to fit precisely. The specific pathogenesis of this case is Heart Yang exhaustion, Spleen/Stomach distress, Phlegm-Qi counterflow; the specific treatment method should be warming/strengthening Heart Yang, moving Spleen/harmonizing Stomach, dispelling Phlegm/descending counterflow. Because Heart Yang exhaustion appears urgent and severe, warming/strengthening Heart Yang is taken as the focus of rescue.
Trainee Bing: Since warming/strengthening Heart Yang is the focus of rescue, why choose Gui Zhi Jia Hou Po Xing Zi Tang modified? This formula only harmonizes Ying/Wei, dispels Phlegm/descends Qi; I've never heard of it having the effect of warming/strengthening Heart Yang.
Teacher: This is thanks to the influence and enlightenment of my mentor Jiang Erxun. Everyone knows, Master Jiang has recently devoted himself to the theoretical and clinical research of the basic syndrome-prescriptions of *Shanghan Lun*—specifically Gui Zhi Tang. He published many unique insights. Master Jiang firmly believes: The ancient sages' theoretical summary regarding Gui Zhi Tang—"for exterior syndromes, it resolves muscle layer and harmonizes Ying/Wei; for interior syndromes, it transforms Qi and regulates Yin/Yang"—is absolutely not empty talk. He considers that Gui Zhi Tang is synthesized from Gui Zhi Gan Cao Tang and Shao Yao Gan Cao Tang; the former is Pungent-Sweet transforming Yang, the latter is Sour-Sweet transforming Yin; combined, they can harmonize Yin/Yang of exterior and interior syndromes, being the best prescription for holistic regulation. *Shanghan Lun* says, "For asthmatics, make Gui Zhi Tang, adding Hou Po and Xing Zi is good." This refers to people whose Yin/Yang (including Ying/Wei, Qi/Blood) are deficient and disordered normally; if contracted by external pathogens triggering chronic asthma, one should use Gui Zhi Tang to harmonize Yin/Yang, adding Hou Po and Xing Ren to dispel Phlegm/descend Qi. Zhongjing's word "good" stands up to clinical verification. But honestly, when I followed Master Jiang's思路 to borrow this formula, it only matched the basic pathogenesis of this case (Righteous Qi deficiency, Pathogenic excess), not yet fitting the specific pathogenesis. So I consulted Master Jiang on the spot. After pondering for a moment, he added Bai Zhu, Fu Ling, Huang Qi, turning it into this formula combined with Ling Gui Zhu Gan Tang plus Huang Qi; this combination yielded the effect of warming/strengthening Heart Yang. After Master Jiang re-examined the infant, he added Su Zi, Bai Jie Zi, Lai Fu Zi, Ting Li Zi, i.e., further combining San Zi Yang Qin Tang and Ting Li Da Zao Xie Fei Tang; this combination not only yielded the effect of moving Spleen/harmonizing Stomach, but also greatly enhanced the effect of dispelling Phlegm/descending Qi. Thus, although this formula is named Gui Zhi Jia Hou Po Xing Zi Tang modified, it is actually a compound formula, containing within it Gui Zhi Jia Hou Po Xing Zi Tang, Ling Gui Zhu Gan Tang, San Zi Yang Qin Tang, and Ting Li Da Zao Xie Fei Tang, jointly exerting effects of warming/strengthening Heart Yang, moving Spleen/harmonizing Stomach, and dispelling Phlegm/descending Qi.
Trainee Yi: This compound formula was used well, achieving high efficiency, worth learning from. But is it like the saying "only this shop, no other branches"? According to medical records, this case took several doses of Ma Xing Shi Gan Tang initially, symptoms decreased, but relapsed upon stopping. Why didn't the teacher learn from the previous doctor's approach, especially since the infant's cough/asthma with tight breathing and cold sweat are indications for Ma Xing Shi Gan Tang!
Teacher: *Shanghan Lun* states, "After sweating, do not use Gui Zhi Tang again; if sweating occurs with asthma and no great heat, Ma Huang Xing Ren Gan Cao Shi Gao Tang can be given." Inferring syndrome from prescription, the asthma/wheezing is due to pathogen closing Lung, so Ma Huang paired with Xing Ren diffuses Lung/opens closure; the sweating is due to stagnant heat congesting Lung, so Ma Huang paired with Shi Gao diffuses Lung/drains heat. The whole formula is Pungent-Cool dispersing/venting,肃肺 (calming Lung) calming asthma, designed for Excess-Heat cough/asthma. When the infant took it effectively in the early stage of cough/asthma, it must have possessed these syndromes. But relapse upon stopping, worsening day by day; although still seeing cough/asthma/tight breathing, it is no longer just sweating cold sweat, but profuse cold sweat, accompanied by a set of Heart Yang exhaustion syndromes, indicating transformation from Excess asthma to Deficiency asthma. If one sees the previous formula effective and follows suit, using Ma Xing Shi Gan Tang again, one will definitely commit the taboo of "making deficiency more deficient." Currently, there seems to be a clinical tendency of "fitting into slots," e.g., seeing pneumonia cough/asthma, immediately considering Ma Xing Shi Gan Tang. This laziness in careful observation/differentiation when identifying diseases/syndromes, and preference for standard formulas/drugs when selecting prescriptions, violates the principle of syndrome differentiation and treatment. Note: After recovery, this infant was examined at Affiliated Hospital of West China University of Medical Sciences, where the diagnosis of "Congenital Heart Disease" was negated. Now 5 years old, healthy.
Hypochondriac Dull Pain, Epigastric Fullness, Lower Abdominal Burning Distension for Half a Year
Yu Guojun, Director of TCM Research Office, Leshan People's Hospital, Sichuan Province
Liu XX, Female, 56 years old, First visit on Mar 16, 1987. The patient suffered from acute icteric hepatitis 12 years ago, cured after treatment. Subsequently occasional dull pain in liver area, epigastric fullness, taking several doses of soothing Liver/harmonizing Stomach prescriptions could temporarily relieve. Only half a year ago, due to emotional depression plus overwork, causing hypochondriac dull pain, epigastric fullness, lower abdominal burning distension to worsen. Previously repeatedly used Xiao Chai Hu Tang, Dan Zhi Xiao Yao San, Ban Ling Tang, Zi Shui Qing Gan Yin etc. modified, taking over 60 doses, all with little effect. Patient assumed she had an incurable disease, living in constant fear. But after B-ultrasound, X-ray, gastroscopy etc., no lesions found. Current examination: Hypochondriac dull pain in afternoon, epigastric fullness, lower abdominal burning distension, frequent belching, worsening at night; accompanied by dry eyes, chaotic dreams at night, dry/bitter mouth, dry stool; pale red tongue, thin yellow coating lacking moisture, wiry-thin pulse. This is Liver-Kidney Yin deficiency combined with Liver Qi stagnation syndrome. Treatment should nourish Kidney, soothe Liver/move Qi. Prescribed Yi Guan Jian combined with Si Ni San modified: Dang Gui 10g, Sheng Di 12g, Gou Qi Zi 12g, Bei Sha Shen 12g, Mai Dong 15g, Jin Ling Zi Tan 6g, Chai Hu 10g, Bai Shao 12g, Zhi Ke 10g, Sheng Gan Cao 5g, Chao Zao Ren 10g, 3 doses. Also informed her the disease is curable, urgently needs to change emotions/nature, be optimistic/open-minded. Second visit: Hypochondriac dull pain, epigastric fullness, lower abdominal burning distension reduced; but chest dull pain unchanged, stool still dry. Added Bai He 30g, Jue Ming Zi 20g, Rou Cong Rong 20g to above formula, changed Zhi Ke to Zhi Shi, 3 doses. Third visit: Chest dull pain and all symptoms significantly reduced, stool smooth, pale red tongue, thin white coating, wiry-thin pulse. Removed Jin Ling Zi Tan from above formula, added Bai Ji Li 10g, continued until subjective symptoms disappeared. 3 months later, patient introduced relatives to consult, stating after continuing 8 doses of above formula, all subjective symptoms disappeared.
Student Jia: When treating Liver diseases belonging to Liver-Kidney Yin deficiency, the teacher always prioritizes Yi Guan Jian, adding several Kidney-nourishing/Essence-filling herbs, often achieving good results. But recently, the therapeutic experience of using Yi Guan Jian combined with Si Ni San is also considerable.
Student Yi: Efficacy is undeniable, but it easily invites criticism. Because the efficacy and indications of these two formulas are vastly different, using them together is theoretically hard to justify. Simply put, Yi Guan Jian uses a large group of Yin-nourishing herbs to nourish Liver/Kidney, with a small amount of Jin Ling Zi to soothe Liver/move Qi, making tonification without stagnation; Si Ni San belongs to Yang-gang agents, specializing in soothing Liver/moving Qi. Therefore, combining the two must have reservations: If the syndrome is mainly Liver-Kidney Yin deficiency, using Yi Guan Jian combined with Si Ni San may damage Qi and injure Yin; if the syndrome is mainly Liver Qi stagnation, using Si Ni San combined with Yi Guan Jian may cause cloying/stagnating Qi.