老师：我认为要把眼光移向临床：临床上到底有没有肝肾阴虚与肝郁气滞两种病机共存，且都是主要病机的病证?请注意，我指的不是肝肾阴虚兼肝郁气滞，也不是肝郁气滞兼肝肾阴虚，而是两种病机共存并列，分不出孰主孰次的情形。如本例患者，其胸胁隐痛、小腹灼热入夜加重，伴双目干涩，夜梦纷纭，口干苦等，显然属于肝肾阴虚；而其胃脘满闷、嗳气频作、小腹（月真）胀等，则又属于肝郁气滞。这两组主观性症状，患者的感受一样地苦不堪言；经反复询问，连她本人都分辨不清楚孰主孰次，医者就更难强为之区分了。治疗此证，若单同一贯煎(或酌加数味滋肾填精之晶)，其滋养肝肾犹可，但方中仅少佐一味金铃子疏肝行气，力薄势单，能希冀其除满闷消膜胀吗?
学员丙据《柳州医话》记载，一贯煎的功效是滋阴疏肝，主治肝肾阴虚，气滞不运，胸脘胁痛，吞酸吐苦，疝气瘕聚等症。看来本方是滋养肝肾与疏肝行气两擅其长的，合用四逆散，似有蛇足之嫌。
老师：果真如此吗?深究一下阴虚气滞的机理和证侯特征，或许有助于回答这一疑问。何谓"肝肾阴虚，气滞不运"?《内经》上说，"阴虚则无气"，就是说阴液亏虚，不能化气；气少，则难以推动血行而濡润脏腑经脉，故而产生胸脘胁痛。这种疼痛并不剧烈，不过为隐痛或绵绵作痛而已。可见(柳州医话)所谓的"气滞"，当责之气少；气少，又当责之肝肾阴虚。因此治疗这种"气滞"，只能在滋养肝肾阴液的基础上，少佐行气而不伤阴之品，俾其补而不碍运。若惟事滋阴，而不少佐行气之晶，便成"呆补"了。话又说回来，本例患者的一派气滞症状，可否归咎于气少呢?从其胃脘满闷，嗳气频作，小腹（月真）胀而极端难受来看，显然是合并有肝郁气滞的病机。而肝郁气滞，绝不是气少，而是气多、气盛。由此还不难理解：前面说的气少，乃是生理之气少；而本例之气多而盛，则是病理之气多而盛。如果这种解释不谬，则合用四逆散就不是蛇足了。
进修生甲：我注意到患者服初诊方3剂后，胁隐痛、胃脘满闷、小腹灼热膑胀等均减轻，但胸部隐痛未减，大便仍干燥。我原以为老师在二诊方中可能要加用麻仁丸及活血通络药物，不意仅加入百合、草决明、肉苁蓉，枳壳改用枳实之后，胸痛即缓，大便亦畅，是何道理?
老师：肝病出现胸部隐痛，乃因肝的经脉上贯膈而注肺。但治肝不效，当考虑肺金同病。本例肝肾虚火灼肺，肺燥络伤而隐痛；肺热下移大肠，肠燥津乏，故大便干燥。乃加百合清润肺络，加草决明、肉苁蓉合枳实润肠通便，经验证明，凡胸部隐痛之属虚火灼肺，肺燥络伤者，重用百合多能很快止痛；而肠燥津乏之便秘，重用草决明、肉苁蓉，少佐枳实以润肠通便，多无通而复秘之虞，这是优于麻子仁丸之处。
进修生乙：我一直在思考：本例虽然合并有肝郁气滞的病机，但肝肾阴虚之象十分显著，因此合用四逆散还是有点偏燥，难道不可以改用较为平和的疏肝气药物吗?
老师：四逆散由柴胡、白芍、枳实、甘草4味药组成，哪一味是偏燥的药物呢?即使担心柴胡"劫肝阴"，但方中寓有芍药甘草汤酸甘化阴以济之。可见本方"偏燥"之说，是一种误解。附带说一下，一贯煎中的金铃子，性寒，味极苦而劣，颇难下咽，只宜少用暂用，切不可多用久用。魏柳州虽创制了本方，但细观其医案，多不用金铃子，而改用白蒺藜，大概也属于一种反思吧。
进修生丙听说老师近年来使用一贯煎合四逆散的治验不少，不知曾治疗过哪些疾病?
老师：治过急性肝炎恢复期，慢性肝炎，肝炎后遗症，妇女及男子更年期综合征，慢性附件炎，神经官能症等等。这些都是西医病名，不要让它们束缚住自己的头脑。临床上只须观其脉证，如确属肝肾阴虚合并肝郁气滞者，用之可以收敏效。
长春中医学院教授肖永林
患者赵XX，女，23岁。1976年12月初诊。该患系XX医科大学XX临床医院X疗区的护士，因长期低烧而住本医院本疗区治疗。已住院很长时间，无明显效果。诊见患者形体消瘦，面色黄白少华，口唇淡润，呈疲惫无力状。自言低烧已很长时间，体温经常在37-37．5℃之间，很少升至38℃。经多种临床及实验室检查，未查出原因，自感身体疲乏，懒动懒言，动甚则疲倦、气短，或有汗出，食欲不振，强食则胀满不消，嗜卧喜静，四末经常清冷。视其舌淡少华，苔白薄而润，脉弱无力。询问其他症情，言无头痛身痛之感。虽有低烧，而不恶热，反有阵阵畏寒之感，得温暖则消除。无心中烦热、口渴等症，大便基本正常，有时稍溏，小便清利，经期大致正常，唯血量时多时少而色淡。似属气虚发热，遂用补中益气汤加减：党参15g，生黄芪20g，白术15g，茯苓15g，当归15g，甘草10g，升麻5g，柴胡5g，陈皮10g，麦芽15g。水煎3次，合并滤液分3次服，为1日量。3剂后，自觉食欲好转，饮食增多，其他症状如前。又2剂后，除饮食增加外，又觉身上有点气力，已不像从前那样疲惫不堪。继续服前方数剂，体温降至36．5℃，疲乏无力、短气等症皆大有好转。根据现在的情况，患者与疗区的领导研究，决定出院回家服药休养。嘱其服用人参健脾丸与补中益气丸，补益脾气，以培根本。继续服上述2种丸药至春节，身体完全复原，从未发热，容光焕发，精力充沛，与1个半月以前完全判若两人。
老师：临床上，长期低热的患者不少，导致长期发热的原因很多，证情也较复杂。此患者之长期低热，所以诊为气虚发热，主要是因为其有一派脾虚气弱之候。首先，对长期发热，应辨明其为外感发热，还是内伤发热。此患者既无实热之表现，也无湿热之征象，更无毒热(如疮痛)之证侯。故基本上可以排除外感之实热。那么，此病之发热只能属于内伤发热之范畴。其次，在内伤发热中，也有虚、实两类，也应辨明。此患者，既无外伤、出血之病史，也无痛有定处与刺痛之症状，口唇舌质又无青紫及瘀斑之现象，则其发热非瘀血发热可知。患者无恚怒不遂而致气滞肝郁之因，也无胀闷易怒、太息之征，又无经期腹痛乳房胀痛之症，则气滞肝郁化火之发热也可排除。剩下的只有在虚证中进行辨别了。因虚而致之发热，有阴血不足与阳气虚衰之不同，皆为虚热之属，也称虚火。丹溪所说的"实火可泻，苓连之属；虚火可补，参芪之属"的"虚火"，即属此类。更确切地讲，参芪之属所治的虚火，必为气虚无疑。阴血不足之发热，由于阴虚不足以涵纳阳气，而阳气独亢，故多出现五心烦热(即手足心发热，心中烦热)，多梦失眠；而此患者五心不烦热，且嗜卧多眠。阴虚之发热，由于阴液不足则欠于濡润，故多口唇焦干而红，咽燥；而此患口唇淡润，不红不干，且无咽燥之感。知其并非阴(血)虚发热。该患者明显地表现出身体疲乏，四肢倦怠，懒动懒言，动则益甚，则其为脾气虚衰已属无疑。故在治疗时，采用补中益气之法而获效。从其服药后的效果看：首先表现出来的是食欲转佳，饮食增多。说明中气渐旺，脾升胃降之功渐复。饮食一增，则谷化精微，机体得养，故逐渐感觉有了力气。以后才逐渐体温下降恢复至正常。可见欲治气虚发热，必先补益中气，使脾胃之气得复，能纳能化，谷气日充，则热可自退。若一见发热，而不辨其属虚属实，在气(阳)在血(阴)，而一概施以寒凉继以滋润，不唯难于收功，恐反益增其疾。
医生乙阴血虚则热，阳气虚则寒，这是一般的规律。而气虚反能发热，应该怎样理解呢?
老师：阴血虚而热自内生，阳气虚而寒从中起，易于为人所理解。气虚反能发热，确实难于说明其机理。但在临床上，由于气虚而导致的发热，确实存在，有致长期低热者，也有长期高热者。首先，应当明确，气虚发热之气虚，是指脾胃气虚而言。造成脾胃气虚之原因，主要为饮食失节，劳役过度，忧伤思虑等。但对脾胃气虚为什么能导致发热，目前尚无统一的认识，归纳起来，大致有以下几种说法，并对这些说法提出我们的看法：一是认为脾气虚陷，中焦虚寒，虚阳外浮而致发热。但从临床来看，很多气虚发热的患者，并无中寒之象，所以说因中焦虚寒而致虚阳外浮之说，似属无据。何况在治疗时，又很少应用温中散寒，引火归原之药!二是认为脾胃气虚，谷气下流而蕴为湿热，使下焦阴火上冲而致发热。此说与上说正属相反，前者为虚寒，而此则为湿热。如若为湿热内蕴，或在便溺时，或在舌苔上必有湿热之象。而治之者，必先治其湿热，而后发热之症方能渐退。可是临床上，气虚发热的患者，往往既无湿热之表现，而又无需使用清利湿热之药，只宜甘温升举之剂而气虚得补则发热自退。况清利湿热之品是以祛邪为主，绝非脾气虚陷之可用。因而此说也似属不符。三是认为气虚而卫气不固，因之易于感受外邪，正邪相搏而致发热。此说显然属于外感而致之发热，绝非内伤发热之属。尽管补中益气汤可用于气虚外感证，有益气解表之功，但不能因此而将气虚发热与因气虚而外感之发热混为一谈。况且气虚发热往往为长期发热，又无表证可察，与气虚外感之时常感冒，有外感则发热，无外感则不发热者显然不同。四是认为脾胃气虚，健运失职，不能生血，血虚而致发热。这种说法实是将气虚发热与血虚发热混为一谈。五是认为阳气不足，不能腐热水谷，而致阴虚，阴虚则热。上两种说法，-为气虚导致血虚，一为气虚导致阴虚。阴血不足不能配阳，阳气偏亢而发热。若说脾胃气虚不能腐熟，运化水谷而致阴血不足，为临床所常见。治之者，或补气而生血，如当归补血汤；或培土而养阴，如资生汤((医学衷中参西录)方：白术、山药、内金、玄参、牛蒡子)。上方皆是在用补脾益气之药的基础上，或加补血之药，或加滋阴之晶。这与以温补升提宜畅之药为主的补中益气汤等，不能同日而语，因而上两种说法也属似是而实非。六是认为脾胃气虚，升降失常，气机不畅，郁滞而化热。这种说法，虽然尚难尽美尽善，但却能够比较正确地说明气虚发热的机理。其关键即是因气虚而致郁，因郁而化热。其中因气机郁滞而化热，易于为人所理解。那么，因为气虚又怎么能致成气郁呢?往往难于理解。盖人身之气，无时无刻不在运行，只有气机之升降出入运行不已，则生机不息，若有郁滞则疾病生，一旦停止则生命息。人身脏腑之气的升降出入，以中焦脾胃的气机为枢。脾主升清，胃主降浊，升降出入之机以脾胃为最。若饮食失节，劳役过度，损伤脾胃，至脾胃气虚，运化失常，当升者不升，当降者不降，气机滞涩，郁而生热。那么，气滞属实，气虚如何能导致气滞呢?盖人之气血，如江河之水。水势浩荡则奔流涌泻，一日千里，何滞之有?一旦水量减少，甚或枯涸，则推动无力，流通滞涩而处处淤积。故有云，"气之所以行者，气旺故也；气之所以滞者，气虚故也"。又有云，"人之气血如水，盛则流行，虚则鲜有不滞者"。
医生丙气虚发热，应以补气为法。而补气之方很多，为何以补中益气汤为主呢?
老师：气虚发热，凡以补气为主的方剂皆可酌用。其所以以补中益气汤为主方者，一因其方重在升补脾气，二因其方之作用补益之中又有升发行散之义。盖气以畅行为补。补其不足，宣其壅滞方为善补气者。况此证又为因虚致郁者乎!
呕吐2个月
四川省乐山市人民医院中医研究室主任余国俊
老师：我认为应该将关注点转向临床实际：临床上究竟是否存在肝肾阴虚与肝郁气滞两种病机同时存在，且两者均为主要病机的证候？请注意，我指的并非肝肾阴虚兼夹肝郁气滞，也非肝郁气滞兼夹肝肾阴虚，而是指两种病机并列共存、难以区分主次轻重的情形。例如本例患者，其胸胁部隐痛、小腹灼热感且在夜间加重，伴有双目干涩、夜间多梦、口苦口干等症状，显然属于肝肾阴虚（指肝肾阴液亏虚）；而其胃脘部胀满闷堵、频繁嗳气、小腹胀满等，则又属于肝郁气滞（指肝气郁结导致气机阻滞）。这两组主观症状，患者的痛苦感受是一样的；经过反复询问，连患者本人都无法分辨孰主孰次，医生就更难强行加以区分了。治疗此证，如果单纯使用一贯煎（或酌情加入几味滋补肾精的药物），虽然滋养肝肾尚可，但方中仅少佐一味金铃子来疏肝行气，力量单薄，能指望它消除胀闷和腹部的胀满感吗？
学员丙根据《柳州医话》的记载，一贯煎的功效是滋阴疏肝，主治肝肾阴虚、气机运行不畅引起的胸脘胁痛、吞酸吐苦、疝气及腹部包块等症状。看来这个方剂在滋养肝肾与疏肝行气两方面都擅长，如果再合用四逆散，似乎有画蛇添足之嫌。
老师：果真如此吗？深入探究阴虚和气滞的机理及证候特征，或许有助于回答这一疑问。什么是“肝肾阴虚，气滞不运”？《内经》上说，“阴虚则无气”，意思是阴液亏虚，不能化生为气；气少了，就难以推动血液运行以濡润脏腑经脉，从而产生胸脘胁痛。这种疼痛并不剧烈，只是隐痛或绵绵作痛而已。可见《柳州医话》所说的“气滞”，实际上应归咎于气少；而气少，又应归咎于肝肾阴虚。因此，治疗这种“气滞”，只能在滋养肝肾阴液的基础上，少量佐以行气而不伤阴的药物，使其补益而不阻碍气机运行。如果只从事滋阴，而不少佐行气的药物，就会变成“呆补”（死板无效的补益）。话又说回来，本例患者的一派气滞症状，是否可以归咎于气少呢？从其胃脘满闷、频繁嗳气、小腹胀满且极度难受来看，显然是合并有肝郁气滞的病机。而肝郁气滞，绝不是气少，而是气多、气盛。由此不难理解：前面所说的气少，是指生理之气不足；而本例的气多而盛，则是病理性的气机壅盛。如果这种解释没有错误，那么合用四逆散就不是画蛇添足了。
进修生甲：我注意到患者服用初诊方3剂后，胁肋隐痛、胃脘满闷、小腹灼热胀满等症状均有所减轻，但胸部隐痛未减，大便仍然干燥。我原以为老师在二诊方中可能会加用麻仁丸及活血通络的药物，没想到仅仅加入了百合、草决明、肉苁蓉，并将枳壳改为枳实之后，胸痛即缓解，大便也通畅了，这是什么道理？
老师：肝病出现胸部隐痛，是因为肝的经脉上贯膈肌并注入肺脏。但如果治肝无效，应当考虑肺金同病。本例因肝肾虚火灼伤肺脏，导致肺燥络脉受损而出现隐痛；肺热下移大肠，导致肠道干燥津液匮乏，所以大便干燥。于是加入百合以清润肺络，加入草决明、肉苁蓉配合枳实以润肠通便。经验证明，凡是胸部隐痛属于虚火灼肺、肺燥络伤者，重用百合大多能很快止痛；而对于肠燥津乏导致的便秘，重用草决明、肉苁蓉，少量佐以枳实以润肠通便，大多没有通便后又秘结的担忧，这是优于麻子仁丸的地方。
进修生乙：我一直在思考：本例虽然合并有肝郁气滞的病机，但肝肾阴虚的迹象十分显著，因此合用四逆散还是有点偏燥，难道不可以改用较为平和的疏肝理气药物吗？
老师：四逆散由柴胡、白芍、枳实、甘草4味药组成，哪一味是偏燥的药物呢？即使担心柴胡“劫肝阴”（耗伤肝阴），但方中寓有芍药甘草汤，通过酸甘化阴来济助制约。可见本方“偏燥”的说法，是一种误解。顺便说一下，一贯煎中的金铃子，性寒，味道极苦且劣，很难咽下，只宜少量暂时使用，切不可多用久用。魏柳州虽然创制了这个方子，但细看他的医案，大多不用金铃子，而改用白蒺藜，大概这也属于一种反思吧。
进修生丙听说老师近年来使用一贯煎合四逆散的治验不少，不知曾治疗过哪些疾病？
老师：治疗过急性肝炎恢复期、慢性肝炎、肝炎后遗症、妇女及男子更年期综合征、慢性附件炎、神经官能症等等。这些都是西医病名，不要让它们束缚住自己的头脑。临床上只需观察脉象和证候，如果确实属于肝肾阴虚合并肝郁气滞者，使用此法可以收到灵敏的疗效。
长春中医学院教授肖永林
患者赵XX，女，23岁。1976年12月初诊。该患系XX医科大学XX临床医院X疗区的护士，因长期低烧而住本医院本疗区治疗。已住院很长时间，无明显效果。诊见患者形体消瘦，面色黄白缺乏光泽，口唇淡润，呈疲惫无力状。自述低烧已很长时间，体温经常在37-37.5℃之间，很少升至38℃。经多种临床及实验室检查，未查出原因，自感身体疲乏，懒动懒言，活动过多则疲倦、气短，或有汗出，食欲不振，勉强进食则胀满不消，嗜卧喜静，四肢经常清冷。视其舌质淡少光泽，苔白薄而润，脉弱无力。询问其他病情，说没有头痛身痛的感觉。虽有低烧，但不恶热，反而阵阵畏寒，得温暖则消除。心中无烦热、口渴等症状，大便基本正常，有时稍溏，小便清利，经期大致正常，唯血量时多时少且色淡。似属气虚发热，遂用补中益气汤加减：党参15g，生黄芪20g，白术15g，茯苓15g，当归15g，甘草10g，升麻5g，柴胡5g，陈皮10g，麦芽15g。水煎3次，合并滤液分3次服，为1日量。3剂后，自觉食欲好转，饮食增多，其他症状如前。又2剂后，除饮食增加外，又觉身上有点气力，已不像从前那样疲惫不堪。继续服前方数剂，体温降至36.5℃，疲乏无力、短气等症状皆大有好转。根据现在的情况，患者与疗区的领导研究，决定出院回家服药休养。嘱其服用人参健脾丸与补中益气丸，补益脾气，以培根本。继续服上述2种丸药至春节，身体完全复原，从未发热，容光焕发，精力充沛，与1个半月以前完全判若两人。
老师：临床上，长期低热的患者不少，导致长期发热的原因很多，证情也较复杂。此患者之长期低热，所以诊为气虚发热，主要是因为其有一派脾虚气弱之候。首先，对长期发热，应辨明其为外感发热，还是内伤发热。此患者既无实热之表现，也无湿热之征象，更无毒热（如疮疡痈痛）之证候。故基本上可以排除外感之实热。那么，此病之发热只能属于内伤发热的范畴。其次，在内伤发热中，也有虚、实两类，也应辨明。此患者，既无外伤、出血之病史，也无痛有定处与刺痛之症状，口唇舌质又无青紫及瘀斑之现象，则其发热非瘀血发热可知。患者无恚怒不遂而致气滞肝郁之因，也无胀闷易怒、太息之征，又无经期腹痛乳房胀痛之症，则气滞肝郁化火之发热也可排除。剩下的只有在虚证中进行辨别了。因虚而致之发热，有阴血不足与阳气虚衰之不同，皆为虚热之属，也称虚火。丹溪所说的“实火可泻，苓连之属；虚火可补，参芪之属”的“虚火”，即属此类。更确切地讲，参芪之属所治的虚火，必为气虚无疑。阴血不足之发热，由于阴虚不足以涵纳阳气，而阳气独亢，故多出现五心烦热（即手足心发热，心中烦热），多梦失眠；而此患者五心不烦热，且嗜卧多眠。阴虚之发热，由于阴液不足则欠于濡润，故多口唇焦干而红，咽燥；而此患口唇淡润，不红不干，且无咽燥之感。知其并非阴（血）虚发热。该患者明显地表现出身体疲乏，四肢倦怠，懒动懒言，动则益甚，则其为脾气虚衰已属无疑。故在治疗时，采用补中益气之法而获效。从其服药后的效果看：首先表现出来的是食欲转佳，饮食增多。说明中气渐旺，脾升胃降之功渐复。饮食一增，则谷化精微，机体得养，故逐渐感觉有了力气。以后才逐渐体温下降恢复至正常。可见欲治气虚发热，必先补益中气，使脾胃之气得复，能纳能化，谷气日充，则热可自退。若一见发热，而不辨其属虚属实，在气（阳）在血（阴），而一概施以寒凉继以滋润，不唯难于收功，恐反益增其疾。
医生乙：阴血虚则热，阳气虚则寒，这是一般的规律。而气虚反能发热，应该怎样理解呢？
老师：阴血虚而热自内生，阳气虚而寒从中起，易于为人所理解。气虚反能发热，确实难于说明其机理。但在临床上，由于气虚而导致的发热，确实存在，有致长期低热者，也有长期高热者。首先，应当明确，气虚发热之气虚，是指脾胃气虚而言。造成脾胃气虚之原因，主要为饮食失节，劳役过度，忧伤思虑等。但对脾胃气虚为什么能导致发热，目前尚无统一的认识，归纳起来，大致有以下几种说法，并对这些说法提出我们的看法：一是认为脾气虚陷，中焦虚寒，虚阳外浮而致发热。但从临床来看，很多气虚发热的患者，并无中寒之象，所以说因中焦虚寒而致虚阳外浮之说，似属无据。何况在治疗时，又很少应用温中散寒，引火归原之药！二是认为脾胃气虚，谷气下流而蕴为湿热，使下焦阴火上冲而致发热。此说与上说正属相反，前者为虚寒，而此则为湿热。如若为湿热内蕴，或在便溺时，或在舌苔上必有湿热之象。而治之者，必先治其湿热，而后发热之症方能渐退。可是临床上，气虚发热的患者，往往既无湿热之表现，而又无需使用清利湿热之药，只宜甘温升举之剂而气虚得补则发热自退。况清利湿热之品是以祛邪为主，绝非脾气虚陷之可用。因而此说也似属不符。三是认为气虚而卫气不固，因之易于感受外邪，正邪相搏而致发热。此说显然属于外感而致之发热，绝非内伤发热之属。尽管补中益气汤可用于气虚外感证，有益气解表之功，但不能因此而将气虚发热与因气虚而外感之发热混为一谈。况且气虚发热往往为长期发热，又无表证可察，与气虚外感之时常感冒，有外感则发热，无外感则不发热者显然不同。四是认为脾胃气虚，健运失职，不能生血，血虚而致发热。这种说法实是将气虚发热与血虚发热混为一谈。五是认为阳气不足，不能腐热水谷，而致阴虚，阴虚则热。上两种说法，一为气虚导致血虚，一为气虚导致阴虚。阴血不足不能配阳，阳气偏亢而发热。若说脾胃气虚不能腐熟，运化水谷而致阴血不足，为临床所常见。治之者，或补气而生血，如当归补血汤；或培土而养阴，如资生汤（《医学衷中参西录》方：白术、山药、内金、玄参、牛蒡子）。上方皆是在用补脾益气之药的基础上，或加补血之药，或加滋阴之品。这与以温补升提宜畅之药为主的补中益气汤等，不能同日而语，因而上两种说法也属似是而实非。六是认为脾胃气虚，升降失常，气机不畅，郁滞而化热。这种说法，虽然尚难尽美尽善，但却能够比较正确地说明气虚发热的机理。其关键即是因气虚而致郁，因郁而化热。其中因气机郁滞而化热，易于为人所理解。那么，因为气虚又怎么能致成气郁呢？往往难于理解。盖人身之气，无时无刻不在运行，只有气机之升降出入运行不已，则生机不息，若有郁滞则疾病生，一旦停止则生命息。人身脏腑之气的升降出入，以中焦脾胃的气机为枢。脾主升清，胃主降浊，升降出入之机以脾胃为最。若饮食失节，劳役过度，损伤脾胃，至脾胃气虚，运化失常，当升者不升，当降者不降，气机滞涩，郁而生热。那么，气滞属实，气虚如何能导致气滞呢？盖人之气血，如江河之水。水势浩荡则奔流涌泻，一日千里，何滞之有？一旦水量减少，甚或枯涸，则推动无力，流通滞涩而处处淤积。故有云，“气之所以行者，气旺故也；气之所以滞者，气虚故也”。又有云，“人之气血如水，盛则流行，虚则鲜有不滞者”。
医生丙：气虚发热，应以补气为法。而补气之方很多，为何以补中益气汤为主呢？
老师：气虚发热，凡以补气为主的方剂皆可酌用。其所以以补中益气汤为主方者，一因其方重在升补脾气，二因其方之作用补益之中又有升发行散之义。盖气以畅行为补。补其不足，宣其壅滞方为善补气者。况此证又为因虚致郁者乎！
呕吐2个月
四川省乐山市人民医院中医研究室主任余国俊
Teacher: I believe we should shift our focus to clinical practice: Does there actually exist in the clinic a syndrome where both Liver-Kidney Yin Deficiency (Gan Shen Yin Xu, deficiency of Yin fluids in the Liver and Kidney) and Liver Qi Stagnation (Gan Yu Qi Zhi, stagnation of Liver Qi causing obstruction of Qi mechanism) coexist as primary pathogenic mechanisms? Please note, I am not referring to Liver-Kidney Yin Deficiency combined with Liver Qi Stagnation, nor Liver Qi Stagnation combined with Liver-Kidney Yin Deficiency, but rather a situation where the two pathogenic mechanisms coexist side by side, making it impossible to distinguish which is primary and which is secondary. For example, in this patient case, her dull pain in the chest and hypochondrium, burning sensation in the lower abdomen that worsens at night, accompanied by dry eyes, frequent dreams at night, bitter taste in the mouth, and dry mouth, clearly belongs to Liver-Kidney Yin Deficiency; whereas her epigastric fullness and stuffiness, frequent belching, and abdominal distension (Zhen Zhang) belong to Liver Qi Stagnation. The suffering experienced by the patient from these two sets of subjective symptoms is equally unbearable; after repeated inquiries, even the patient herself cannot distinguish which is primary and which is secondary, so it is even more difficult for the physician to forcibly differentiate them. When treating this syndrome, if one simply uses Yi Guan Jian (One-Glue Decoction) (or adds a few herbs to nourish the Kidney and fill the essence), although it can nourish the Liver and Kidney, the formula only contains a small amount of Jin Ling Zi (Black Currant Fruit) to soothe the Liver and move Qi, which is weak and insufficient. Can we expect it to eliminate fullness and abdominal distension?
Student Bing: According to the records in *Liu Zhou Yi Hua* (Medical Conversations from Liu Zhou), the efficacy of Yi Guan Jian is to nourish Yin and soothe the Liver, mainly treating syndromes of Liver-Kidney Yin Deficiency with stagnant Qi movement, such as pain in the chest, epigastrium, and hypochondrium, acid regurgitation, bitter vomiting, hernia, and abdominal masses. It seems this formula excels in both nourishing the Liver and Kidney and soothing the Liver while moving Qi. Combining it with Si Ni San (Frigid Extremities Powder) seems superfluous.
Teacher: Is that really the case? Deeply investigating the mechanism and characteristic manifestations of Yin Deficiency with Qi Stagnation might help answer this doubt. What is meant by "Liver-Kidney Yin Deficiency, Qi Stagnation and Non-movement"? The *Nei Jing* (Inner Canon) states, "Yin Deficiency leads to lack of Qi," meaning that when Yin fluids are deficient, they cannot transform into Qi; when Qi is scarce, it is difficult to promote blood circulation to moisten the Zang-Fu organs and meridians, thereby producing pain in the chest, epigastrium, and hypochondrium. This pain is not severe, merely dull or lingering. Thus, the "Qi Stagnation" mentioned in *Liu Zhou Yi Hua* should actually be attributed to a lack of Qi; and the lack of Qi should be attributed to Liver-Kidney Yin Deficiency. Therefore, to treat this kind of "Qi Stagnation," one must base the treatment on nourishing the Yin fluids of the Liver and Kidney, adding a small amount of Qi-moving herbs that do not damage Yin, so that tonification does not hinder movement. If one only engages in nourishing Yin without adding Qi-moving herbs, it becomes "static tonification" (ineffective tonification). On the other hand, can the set of Qi Stagnation symptoms in this patient be blamed on a lack of Qi? Judging from her epigastric fullness, frequent belching, and severe abdominal distension, it is obviously combined with the pathogenic mechanism of Liver Qi Stagnation. And Liver Qi Stagnation is absolutely not a lack of Qi, but rather an excess and flourishing of Qi. From this, it is not difficult to understand: the previously mentioned lack of Qi refers to physiological insufficiency of Qi; whereas the excess and flourishing of Qi in this case refer to pathological Qi hyperactivity. If this explanation is correct, then combining Si Ni San is not superfluous.
Trainee Jia: I noticed that after the patient took 3 doses of the initial prescription, the dull pain in the hypochondrium, epigastric fullness, and burning abdominal distension all decreased, but the dull chest pain remained unchanged, and the stool was still dry. I originally thought that in the second-visit prescription, the teacher might add Ma Ren Wan (Hemp Seed Pill) and blood-invigorating and collateral-unblocking drugs. Unexpectedly, only Bai He (Lily Bulb), Jue Ming Zi (Cassia Seed), and Rou Cong Rong (Cistanche) were added, and Zhi Ke (Aurantium Fruit) was changed to Zhi Shi (Immature Aurantium Fruit), after which the chest pain eased and bowel movements became smooth. What is the reason for this?
Teacher: Dull chest pain appearing in Liver diseases occurs because the Liver meridian passes through the diaphragm and enters the Lung. However, if treating the Liver is ineffective, one should consider concurrent Lung Metal pathology. In this case, deficiency fire from the Liver and Kidney scorches the Lung, causing Lung Dryness and collateral damage, resulting in dull pain; Lung heat transfers downward to the Large Intestine, causing intestinal dryness and fluid deficiency, hence the dry stool. Therefore, Bai He was added to clear and moisten the Lung collaterals, and Jue Ming Zi and Rou Cong Rong were added along with Zhi Shi to moisten the intestines and unblock bowels. Experience proves that for dull chest pain caused by deficiency fire scorching the Lung and Lung Dryness damaging collaterals, heavy use of Bai He can often relieve pain quickly; and for constipation due to intestinal dryness and fluid deficiency, heavy use of Jue Ming Zi and Rou Cong Rong, with a small amount of Zhi Shi to moisten the intestines and unblock bowels, rarely leads to rebound constipation. This is superior to Ma Zi Ren Wan (Hemp Seed Pill).
Trainee Yi: I have been thinking: Although this case combines the pathogenic mechanism of Liver Qi Stagnation, the signs of Liver-Kidney Yin Deficiency are very prominent. Therefore, combining Si Ni San seems somewhat drying. Could we not change to milder Liver-soothing and Qi-regulating herbs?
Teacher: Si Ni San consists of four herbs: Chai Hu (Bupleurum Root), Bai Shao (White Peony Root), Zhi Shi (Immature Aurantium Fruit), and Gan Cao (Licorice Root). Which one is drying? Even if one worries that Chai Hu "steals Liver Yin," the formula contains Shao Yao Gan Cao Tang (Peony and Licorice Decoction), which generates Yin through Sour-Sweet combination to counteract this. Thus, the claim that this formula is "drying" is a misunderstanding. By the way, Jin Ling Zi in Yi Guan Jian is cold in nature and extremely bitter and unpleasant, making it hard to swallow. It should only be used in small amounts temporarily and never in large amounts for long periods. Although Wei Liu Zhou created this formula, a careful review of his medical cases shows he mostly did not use Jin Ling Zi, but instead substituted Bai Ji Li (Tribulus Fruit), which probably reflects a form of reflection.
Trainee Bing: I heard that the teacher has had many successful treatments using Yi Guan Jian combined with Si Ni San in recent years. What diseases have been treated?
Teacher: We have treated the recovery phase of acute hepatitis, chronic hepatitis, sequelae of hepatitis, menopause syndrome in women and men, chronic adnexitis, neurosis, etc. These are Western medical diagnoses; do not let them bind your mind. In clinical practice, one only needs to observe the pulse and manifestations. If it truly belongs to Liver-Kidney Yin Deficiency combined with Liver Qi Stagnation, using this method can yield sensitive effects.
Long-term Low-grade Fever
Professor Xiao Yonglin, Changchun University of Chinese Medicine
Patient Zhao XX, female, 23 years old. First visit in early December 1976. The patient is a nurse in Ward X of Clinical Hospital XX of XX Medical University, admitted to this ward for treatment of long-term low-grade fever. She had been hospitalized for a long time with no obvious effect. Examination revealed the patient was emaciated, complexion yellowish-white and lusterless, lips pale and moist, presenting a state of fatigue and weakness. She stated she had low-grade fever for a long time, with body temperature usually between 37-37.5°C, rarely rising to 38°C. Various clinical and laboratory examinations failed to find the cause. She felt physically fatigued, reluctant to move or speak, becoming tired and short of breath with excessive activity, sometimes sweating, poor appetite, bloating that does not resolve after forced eating, preferring to lie down and rest, and frequently cold extremities. Tongue inspection showed a pale tongue lacking luster, thin white moist coating, and a weak, powerless pulse. Regarding other symptoms, she reported no headache or body ache. Although having low-grade fever, she did not feel aversion to heat; instead, she felt periodic chills, which resolved with warmth. There were no sensations of vexatious heat in the chest or thirst. Bowel movements were basically normal, occasionally slightly loose. Urination was clear and free. Menstrual cycles were roughly normal, except for fluctuating volume and pale color. It seemed to belong to Qi Deficiency Fever. Thus, Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) was modified: Dang Shen (Codonopsis Root) 15g, Sheng Huang Qi (Raw Astragalus Root) 20g, Bai Zhu (Atractylodes Macrocephala Rhizome) 15g, Fu Ling (Poria) 15g, Dang Gui (Angelica Sinensis Root) 15g, Gan Cao (Licorice Root) 10g, Sheng Ma (Cimicifuga Rhizome) 5g, Chai Hu (Bupleurum Root) 5g, Chen Pi (Citrus Reticulata Peel) 10g, Mai Ya (Hordeum Vulgare Sprout) 15g. Decocted in water three times, filtrates combined and divided into three doses per day. After 3 doses, appetite improved, food intake increased, and other symptoms remained as before. After another 2 doses, besides increased food intake, she felt some strength returning to her body, no longer as exhausted as before. Continuing to take the previous prescription for several more doses, body temperature dropped to 36.5°C, and symptoms like fatigue, weakness, and shortness of breath greatly improved. Based on the current situation, the patient discussed with the ward leadership and decided to be discharged home to take medicine and rest. She was instructed to take Ren Shen Jian Pi Wan (Ginseng Spleen-Strengthening Pill) and Bu Zhong Yi Qi Wan (Tonify the Middle and Augment the Qi Pill) to tonify Spleen Qi and cultivate the root. Continuing to take these two pills until the Spring Festival, her body completely recovered, never fevered again, looking radiant and energetic, completely different from her state one and a half months prior.
Doctor Jia: This patient had long-term low-grade fever. On what basis did the teacher diagnose it as Qi Deficiency low-grade fever?
Teacher: Clinically, there are many patients with long-term low-grade fever, and the causes leading to prolonged fever are numerous, with complex manifestations. The reason this patient's long-term low-grade fever was diagnosed as Qi Deficiency Fever is mainly because she presented with a set of Spleen Deficiency and Qi Weakness signs. First, for long-term fever, one must distinguish whether it is Exogenous Fever or Endogenous Fever. This patient had neither manifestations of Excess Heat nor signs of Damp-Heat, nor any signs of Toxic Heat (such as carbuncles and sores). Therefore, Exogenous Excess Heat can basically be excluded. Thus, the fever in this disease must belong to the category of Endogenous Fever. Second, within Endogenous Fever, there are also Deficiency and Excess categories, which should also be distinguished. This patient had no history of trauma or bleeding, no symptoms of fixed-point stabbing pain, and no cyanosis or ecchymosis on the lips or tongue, indicating her fever was not due to Blood Stasis. The patient had no cause for Qi Stagnation and Liver Depression due to frustration or anger, nor signs of bloating, irritability, or sighing, nor symptoms of dysmenorrhea or breast distension during menstruation, so fever due to Qi Stagnation and Liver Depression transforming into Fire can also be excluded. Only differentiation within Deficiency Syndromes remains. Fevers caused by Deficiency differ between Insufficiency of Yin-Blood and Decline of Yang-Qi, both belonging to Deficient Heat, also called Deficient Fire. The "Deficient Fire" mentioned by Dan Xi—"Excess Fire can be purged with Scutellaria and Phellodendron; Deficient Fire can be tonified with Codonopsis and Astragalus"—belongs to this category. More precisely, the Deficient Fire treated with Codonopsis and Astragalus must undoubtedly be Qi Deficiency. Fevers due to Insufficiency of Yin-Blood occur because Yin Deficiency fails to contain Yang, leading to independent hyperactivity of Yang, thus often presenting with Five-Center Vexatious Heat (heat in palms, soles, and chest), frequent dreams, and insomnia; whereas this patient had no Five-Center Vexatious Heat and preferred lying down and sleeping. Fevers due to Yin Deficiency occur because insufficient Yin fluids fail to moisten, thus often presenting with dry, red lips and throat dryness; whereas this patient had pale, moist lips, not red or dry, and no sensation of throat dryness. Knowing it is not Yin (Blood) Deficiency Fever. This patient clearly manifested physical fatigue, limb lassitude, reluctance to move or speak, worsening with activity, confirming Spleen Qi Decline beyond doubt. Therefore, in treatment, the method of Tonifying the Middle and Augmenting Qi was adopted and achieved success. Looking at the effects after taking the medicine: first, appetite turned good, and food intake increased. This indicates that Middle Qi gradually strengthened, and the functions of Spleen Ascending and Stomach Descending gradually recovered. With increased diet, grain transforms into essence, nourishing the body, so strength gradually returns. Subsequently, body temperature gradually decreased and returned to normal. It can be seen that to treat Qi Deficiency Fever, one must first tonify Middle Qi, restoring Spleen and Stomach Qi, enabling them to accept and transform, replenishing Gu Qi daily, so the fever recedes naturally. If one sees fever and, without distinguishing between Deficiency and Excess, or Qi (Yang) and Blood (Yin), uniformly applies cooling and moisturizing methods, not only is it difficult to achieve success, but it may also exacerbate the disease.
Doctor Yi: Yin-Blood Deficiency leads to Heat, and Yang-Qi Deficiency leads to Cold; this is a general rule. How should we understand that Qi Deficiency can instead lead to Fever?
Teacher: Heat arising internally from Yin-Blood Deficiency and Cold arising from within due to Yang-Qi Deficiency are easy to understand. That Qi Deficiency can instead lead to Fever is indeed difficult to explain mechanistically. However, clinically, fever caused by Qi Deficiency does exist, causing either long-term low-grade fever or long-term high fever. First, it must be clarified that the Qi Deficiency in Qi Deficiency Fever refers to Spleen-Stomach Qi Deficiency. The main causes of Spleen-Stomach Qi Deficiency are irregular diet, excessive labor, sorrow, and overthinking. But why Spleen-Stomach Qi Deficiency leads to fever currently has no unified understanding. Summarizing, there are roughly the following views, to which we offer our opinions: One view holds that Spleen Qi sinking, Middle Jiao Deficiency Cold, and floating of Deficient Yang externally cause fever. But clinically, many patients with Qi Deficiency Fever show no signs of Middle Cold, so the theory that Middle Jiao Deficiency Cold causes floating Deficient Yang seems unfounded. Moreover, in treatment, warming-Middle and dispersing-Cold herbs or herbs guiding fire back to its source are rarely used! Another view holds that Spleen-Stomach Qi Deficiency causes Grain Qi to flow downward, accumulating as Damp-Heat, causing Yin Fire from the Lower Jiao to rush upward, resulting in fever. This view is opposite to the previous one; the former is Deficiency Cold, while this is Damp-Heat. If it were internal accumulation of Damp-Heat, there would surely be signs of Damp-Heat in urine/stool or tongue coating. Treatment would require addressing Damp-Heat first, after which fever symptoms would gradually recede. However, clinically, patients with Qi Deficiency Fever often show no signs of Damp-Heat and do not need Damp-Heat-clearing and draining herbs; only Sweet-Warm lifting agents are suitable, and once Qi Deficiency is tonified, fever retreats naturally. Besides, Damp-Heat clearing and draining products primarily dispel pathogens and are certainly not applicable to Spleen Qi sinking. Thus, this view also seems inconsistent. A third view holds that Qi Deficiency leads to insecure Wei Qi, making one susceptible to external pathogens, and struggle between Righteous Qi and Pathogen causes fever. This view clearly belongs to Exogenous Fever, definitely not Endogenous Fever. Although Bu Zhong Yi Qi Tang can be used for Qi Deficiency with External Contraction, benefiting Qi and releasing the exterior, one cannot therefore confuse Qi Deficiency Fever with fever caused by Qi Deficiency leading to external contraction. Moreover, Qi Deficiency Fever is often long-term, without observable Exterior Signs, clearly different from Qi Deficiency External Contraction where one often catches colds, fevers with external contraction, and does not fever without it. A fourth view holds that Spleen-Stomach Qi Deficiency impairs transportation and transformation, failing to generate Blood, and Blood Deficiency causes fever. This view essentially confuses Qi Deficiency Fever with Blood Deficiency Fever. A fifth view holds that insufficient Yang cannot rot and cook grain and water, leading to Yin Deficiency, and Yin Deficiency causes Heat. The above two views suggest Qi Deficiency leads to Blood Deficiency, and Qi Deficiency leads to Yin Deficiency. Insufficient Yin-Blood cannot coordinate with Yang, leading to Yang hyperactivity and fever. If saying Spleen-Stomach Qi Deficiency fails to digest and transport grain and water, leading to Yin-Blood Deficiency, this is common clinically. Treatment involves either tonifying Qi to generate Blood, like Dang Gui Bu Xue Tang (Angelica Tonifying Blood Decoction); or cultivating Earth to nourish Yin, like Zi Sheng Tang (*Medical Records of Integrating Chinese and Western Medicine*: Bai Zhu, Shan Yao, Nei Jin, Xuan Shen, Niu Bang Zi). Both formulas are based on Spleen-tonifying and Qi-augmenting herbs, adding either Blood-tonifying or Yin-nourishing herbs. This cannot be compared with Bu Zhong Yi Qi Tang, which mainly uses Warm-Tonifying and Lifting herbs, so these two views are seemingly plausible but actually incorrect. A sixth view holds that Spleen-Stomach Qi Deficiency causes abnormal ascending and descending, poor Qi mechanism flow, stagnation, and transformation into Heat. Although this view is not perfect, it can relatively correctly explain the mechanism of Qi Deficiency Fever. The key is that Qi Deficiency leads to Stagnation, and Stagnation transforms into Heat. Among them, Heat transforming from Qi Mechanism Stagnation is easy to understand. So, how can Qi Deficiency lead to Qi Stagnation? This is often difficult to understand. The Qi of the human body is constantly running; only with continuous ascending, descending, entering, and exiting of the Qi Mechanism does vitality continue; if there is stagnation, disease arises, and if it stops, life ends. The ascending, descending, entering, and exiting of Qi in the Zang-Fu organs takes the Qi Mechanism of the Middle Jiao Spleen and Stomach as the pivot. Spleen governs ascending Clear Qi, Stomach governs descending Turbid Qi; the mechanism of ascending, descending, entering, and exiting relies most on the Spleen and Stomach. If diet is irregular, labor excessive, damaging the Spleen and Stomach, leading to Spleen-Stomach Qi Deficiency, impaired transportation and transformation, when things should ascend they do not ascend, when things should descend they do not descend, Qi Mechanism becomes sluggish, stagnates, and generates Heat. Then, Qi Stagnation is Excess, how can Qi Deficiency lead to Qi Stagnation? The Qi and Blood of humans are like river water. When water volume is vast, it rushes forward rapidly, how can there be stagnation? Once water volume decreases, or even dries up, pushing force is weak, flow becomes sluggish, and accumulation occurs everywhere. Hence it is said, "The reason Qi moves is because Qi is vigorous; the reason Qi stagnates is because Qi is deficient." It is also said, "Human Qi and Blood are like water; when abundant, it flows freely; when deficient, stagnation is rare to avoid."
Doctor Bing: Qi Deficiency Fever should be treated with tonifying Qi methods. There are many formulas for tonifying Qi, why is Bu Zhong Yi Qi Tang the main formula?
Teacher: For Qi Deficiency Fever, any formula primarily tonifying Qi can be considered. The reason Bu Zhong Yi Qi Tang is the main formula is, first, because it focuses on lifting and tonifying Spleen Qi; second, because its action includes lifting and dispersing within tonification. Essentially, Qi is tonified by smooth movement. Tonifying deficiency and venting stagnation constitutes good Qi tonification. Moreover, this syndrome is caused by Deficiency leading to Stagnation!
Vomiting for 2 Months
Director Yu Guojun, TCM Research Office, People's Hospital of Leshan City, Sichuan Province