刘XX，女，52岁，1988年4月6日初诊。患者5年来胃痛伴呕吐反复发作，曾多次住院治疗。胃镜示：慢性浅表性胃炎。2个月前因受凉，胃痛甚剧，且放射至背部，伴恶心呕吐，自服藿香正气水、胃复安等未能缓解，乃收住病房。经解痉止痛、补液并配服中药后，胃痛渐止，恶心呕吐亦减轻。惟害怕进食，因不食则不吐，而进食后约半小时则呕吐频频。曾选用化肝煎、小半夏加茯苓汤、香砂六君子汤、温胆汤、旋复代赭汤等，服后少顷，往往呕出药液，竟尔害怕服药。经胃镜复查，仍属慢性浅表性胃炎。刻诊：身形瘦削，面色无华，两颧凹陷，神疲乏力，气短声微；每次进食后约半小时，必呕出粘涎及少许食物；口干苦，大便少而不畅，小便黄，舌淡紫，苔微黄薄腻，脉弦细稍数。此乃寒格热扰，土败木乘，难以受药之侯。处方：①干姜黄芩黄连人参汤加生姜汁：干姜3g，黄芩3g，黄连3g，党参5g。制法：冷水浸泡30分钟，煮沸30分钟，滤取药液200mi；另取生姜30g，去皮捣烂，加入冷开水30ml，浸泡30分钟，滤取生姜汁。服法：取温热药液50ml，兑入生姜汁5ml，呷服，2小时服1次。②白蔻仁5g，服汤剂前嚼服2粒(吐出渣滓)。③红参10g，切成薄片，每次口含2-3片，待其变软后嚼月艮。效果：服药1剂，呕吐停止。为巩固疗效，续服1剂。转用柴芍六君子汤加味疏肝运脾，和胃降逆以善后：柴胡10g，白芍10g，党参10g，白术10g，茯苓12g，甘草3g，法夏5g，陈皮5g，千姜3g，生姜3g，黄连3g。此方共服26剂，每日配服红参3g(服法同前)，连服1个月。1年后追访，胃痛、呕吐未复发，身体比较健康。
进修生甲：本例慢性浅表性胃炎，表现为食后不久即呕吐粘涎及少量食物，叠经治疗乏效，身体极度虚弱。老师出一千姜黄芩黄连人参汤原方加生姜汁，药味少，剂量轻，但奏效迅速，且时隔1年未复发，值得借鉴。
进修生乙：老师常说"精方简药亦能起大症"，真是百闻不如一见!不过我想，本例呕吐换了那么多方药都不见效，主要是病机不大好掌握，是这样的吗?
老师：也许是的。但一般地说，呕吐的病机并不难掌握，我们甚至可以把它归结为4个字：胃气上逆。因胃主受纳、腐熟，其气以下行为顺。今受纳食物之后，未即腐熟而吐出，是胃气失却顺降之职，转而上逆。其治疗大法，自然是和胃降逆。临证时辨明引起胃气上逆的病因，便可确立具体治法。如因寒则温而降之，因热则清而降之；因食则消而降之，因虚则补而降之等等。但本例呕吐的病机却没有这样单纯。一是病程较长，二是体质极差，三是寒热虚实杂呈，所以换了那么多和胃降逆的方药都不见显效。
进修生乙：那么本例呕吐的病机到底是什么呢?
进修生乙：可以说得具体一点吗?
老师：寒格是指胃气虚寒，格拒饮食；即使勉强进食，亦因胃寒不能腐熟食物而复吐出。热扰是指胆腑郁热，而胆腑郁热之际，不仅不能助胃磨食，反而进一步扰乱胃腑受纳、腐熟之功能，促其呕吐。而长期呕吐不止，胃腑功能日渐衰惫，胆热犯胃益急，造成恶性循环，故曰"土败木乘"。选用干姜黄芩黄连人参汤，是取干姜温胃祛寒，芩、连清胆撤热，党参(人参)匡扶正气。此为针对病机而出方，不是见呕止呕。
学员甲：老师对本例呕吐病机的分析以及选方用药，一定是借鉴了(伤寒论)厥阴篇第359条，"伤寒本自寒下，医复吐下之，寒格，更逆吐下，若食入口即吐，干姜黄芩黄连人参汤主之"。但教科书及大多数注家皆言本条的病机是上热与下寒互相格拒，
老师：确实是借鉴了这一条，但我的理解有所不同。第一，把本条呕吐的病机归结为"寒热相格"或"上热与下寒互相格拒"，语涉空泛和抽象，落不到实处。第二，本条"伤寒本自寒下，医复吐下之……"是说病人本来就是虚寒下利，而医者还用吐下方药，世上哪有如此昏庸的医者?所以{医宗金鉴)说，"寒下之下字，当是格字，文义始属。注家皆释胃寒下利，不但文字不属，且与芩连之药不合"。第三，古医书上"关"与"格"是对峙文字，关指二便不通，格指格拒不食，或食入即呕。本条"寒格"，义亦取此，不是什么"寒热格拒"。再看本例呕吐患者，口干苦，大便少而不畅，小便黄，色淡紫，苔微黄薄腻，脉弦细稍数，显然是挟有胆腑郁热。我这样说，绝不是想用本例呕吐的治验来解释359条，只不过提供一点临证思路而已。
学员乙干姜黄芩黄连人参汤主治"食入口即吐"，本例则是食后约半小时才吐出，怎能借用本方呢?
老师：我认为，食后约半小时才呕吐，也属于"食入口即吐"的范畴。因为"食入口即吐"是与"朝食暮吐，暮食朝吐"的胃反证相对而言。后者纯属脾胃虚寒，前者则挟有郁热。
进修生丙：老师借用本方，用量极轻，但又重加生姜，不滤其增热吗?
老师：寒格热扰，土败木乘，难以受药的呕吐，最难处方。惟小剂浓煎呷服，可冀其不吐或少吐。生姜是止呕圣药，虽重用30g，但不是同煎，而是捣烂取汁，每次只用5ml生汁兑入药液中，不会增热。陈修园推许本方治疗"诸凡格拒"，可谓独具慧眼。根据他的经验，"若汤水不得入口，去干姜，加生姜汁少许，徐徐呷之，此少变古法，屡验"。但我历来使用本方治疗顽固性呕吐，均加生姜汁而不去干姜，亦屡验。
学员丙：老师曾用旋复代赭汤加生姜汁迅速治愈过几例顽固性呕吐，这次为何不用呢?
老师：本例不仅进食吐食，而且服药吐药。既然前医已经用过旋复代赭汤而乏效，即使加入生姜汁，也难以矫正旋复花的劣味，惟恐重蹈服药吐药的覆辙!
实习生如果陈修园的说法是对的，那么本方可以作为治疗顽固性呕吐的主方了?
老师：不能那样理解，例如呕吐之属胃阴虚而舌红少津者，就不可误用。柯韵伯说过，"凡呕家夹热者，不利于香砂橘半，服此方而晏如"。据《辞海》解释，晏就是"平静；安逸"。请大家仔细玩味柯氏这句话，确有其金针度人之处。
脐痛1个月
四川省乐山市人民医院中医研究室主任余国俊
徐XX，男，58岁，农民，1985年12月15日诊。患者肚脐中隐痛1个月余，虽整天疼痛不止，却不加重，喜温喜按。曾自取陈艾煎汤薰洗，葱白捣烂和盐炒热敷脐上，可取效于一时，但旋又隐痛如故。乃就医，先眼乌梅丸汤剂2帖不效，改服附子理中汤2帖，似觉减轻，但数日后又隐痛如故，迁延至今。此明系寒证，但何以内服、外用温热药物疗效均不佳?细询其得病之由，言平素便畏寒凉，今秋曾守护柑橘园10余日。夜间茅屋透风，又频起巡查，衣履较单薄，颇感凉意。有一夜，因不慎失火，茅屋化为灰烬，惊惧交加，卧床数日，便觉肚脐中隐隐作痛，如此而已。患者面色少华，手足逆冷，肠鸣便溏，舌淡苔白滑，脉沉迟。揆度其脐痛之病机，确系肾阳虚衰，寒凝神阙，乃借鉴陈鼎三--江尔逊经验，用真武汤加胡芦巴治之：熟附片30g(先煎1小时)，白术15g，茯苓15g，白芍12g，生姜15g，胡芦巴30g：服3剂，肚脐中隐痛消失，手足转温，肠鸣、便溏均止。随访1年，脐痛未复发。
学员本例脐中隐痛，病情虽不重，但临床少见，教科书也未写上，而老师出一真武汤取得佳效，更是我始料不及的。
进修生甲：我也有同感。但难以理解的是，本例脐痛，从病因、病性、体质、舌脉等综合分析，应届于脾肾阳虚，何以眼附子理中汤疗效不佳呢?
老师：肚脐是神阙穴所居之地。神阙穴中痛，方书有称为"当脐痛"者，属于少阴腹痛范畴。患者年近花甲，素畏寒凉，其肾阳不足可知；又得之餐风饮露，大惊卒恐之后，且伴手足逆冷，肠鸣便溏，舌淡苔白滑，脉沉迟，确系肾阳虚衰，寒凝神阙。当然，如仅仅根据伴见的一派虚寒症状、舌脉，笼统地辨证为"脾肾阳虚"未尝不可，但本例疼痛的确切部位却不支持这一辨证结论。为什么这样说呢?因为按部位来划分，从胃脘至脐为大腹，属太阴脾；本例痛在脐中，不在大腹部，因而不涉及或主要不涉及太阴脾脏。而附子理中汤温补脾肾，是以温补脾阳为主，兼温肾阳，没有紧扣本例的确切病机，所以疗效不佳。
实习生看来治疗腹痛时要确切地辨明部位，这一点教科书上没有充分强调，请老师再指点一下。
老师：大家知道，中医所称的腹部，指的是胃脘以下，耻骨毛际以上的部位。具体归属是：从胃脘至脐为大腹，属太阴脾；脐中及脐下小腹属少阴肾；脐旁左右属冲脉；脐下小腹两旁为少腹，属肝。治疗腹痛时如不确切地辨别部位，就不知到底病在何脏腑何经脉，遣方选药时就不可能成竹在胸，稳操胜券，而有"虑其动手便错"之虞。
进修生乙：真武汤是温阳利水之方，治疗阳虚水肿。但本例脐痛，并无阳虚水肿症侯，何以要选用此方?
老师：说真武汤可以治疗阳虚水肿是对的，但如把真武汤的主治范围仅仅局限于阳虚水肿，就有"划地为牢"之嫌了。严密地说，真武汤是治疗肾阳虚衰、水气为病之方。水气为病，外溢则为水肿，上冲则为头眩或喘咳，内停则为肠鸣便溏(本例便是)。当然，本例的主症--脐痛，不是水气为病，而是肾阳虚衰，寒凝神阙。为什么要选用真武汤呢?因为真武汤中附子配芍药，不仅能温肾阳、祛寒凝，更能入阴破结，敛阴和阳，完全契合少阴腹痛的基本病机。清·吴仪洛《成方切用》称真武汤为"治少阴伤寒腹痛"之方，是很有见地的。临床实践早已证明，真武汤不仅可以治疗肾阳虚衰，水气为病，还可以扩大运用于肾阳虚衰，寒凝内痛之证。
进修生乙：为什么还要重加胡芦巴30g呢?
老师：这是江老的老师陈鼎三先生的经验，也是有文献记载的。如《本草纲目》谓胡芦巴性味"苦，大温，无毒"，主治"元脏虚冷气"。"元脏"就是肾脏。陈老及江老平生治疗阳虚寒凝的当脐痛，都用真武汤原方重加胡芦巴一味，无不应手取效。
进修生甲：我由此产生两点疑问：第一，既然老师断言真武汤可以扩大运用于阳虚寒凝内痛之证，那么，本例脐痛只用真武汤，而不加胡芦巴，疗效将如何?第二，如果用真武汤疗效不甚佳，又不加胡卢巴，而加用同样可以治疗"元脏虚冷气"的其他大温药物，如肉桂、仙茅、小茴、丁香等，疗效又将如何呢?
老师：据江老临床体验，治疗阳虚寒凝脐痛，用真武汤重加胡芦巴，见效快，且不易复发，其疗效优于单用真武汤。至于不加胡芦巴，而用其他温肾祛寒药物疗效又将如何，请大家今后有机会时进行验证。这里附带说一句：若不是脐中痛，而是脐下小腹痛之属阳虚寒凝者，单用真武汤即可奏佳效。
长春中医学院教授肖永林
长春中医学院附属医院周世民
刘XX，女，52岁，1988年4月6日初诊。患者5年来胃痛伴呕吐反复发作，曾多次住院治疗。胃镜示：慢性浅表性胃炎。2个月前因受凉，胃痛甚剧，且放射至背部，伴恶心呕吐，自服藿香正气水、胃复安等未能缓解，乃收住病房。经解痉止痛、补液并配服中药后，胃痛渐止，恶心呕吐亦减轻。惟害怕进食，因不食则不吐，而进食后约半小时则呕吐频频。曾选用化肝煎、小半夏加茯苓汤、香砂六君子汤、温胆汤、旋复代赭汤等，服后少顷，往往呕出药液，竟尔害怕服药。经胃镜复查，仍属慢性浅表性胃炎。刻诊：身形瘦削，面色无华，两颧凹陷，神疲乏力，气短声微；每次进食后约半小时，必呕出粘涎及少许食物；口干苦，大便少而不畅，小便黄，舌淡紫，苔微黄薄腻，脉弦细稍数。此乃寒格热扰，土败木乘，难以受药之侯。处方：①干姜黄芩黄连人参汤加生姜汁：干姜3g，黄芩3g，黄连3g，党参5g。制法：冷水浸泡30分钟，煮沸30分钟，滤取药液200ml；另取生姜30g，去皮捣烂，加入冷开水30ml，浸泡30分钟，滤取生姜汁。服法：取温热药液50ml，兑入生姜汁5ml，呷服，2小时服1次。②白蔻仁5g，服汤剂前嚼服2粒(吐出渣滓)。③红参10g，切成薄片，每次口含2-3片，待其变软后嚼服。效果：服药1剂，呕吐停止。为巩固疗效，续服1剂。转用柴芍六君子汤加味疏肝运脾，和胃降逆以善后：柴胡10g，白芍10g，党参10g，白术10g，茯苓12g，甘草3g，法夏5g，陈皮5g，千姜3g，生姜3g，黄连3g。此方共服26剂，每日配服红参3g(服法同前)，连服1个月。1年后追访，胃痛、呕吐未复发，身体比较健康。
进修生甲：本例慢性浅表性胃炎，表现为食后不久即呕吐粘涎及少量食物，叠经治疗乏效，身体极度虚弱。老师出一干姜黄芩黄连人参汤原方加生姜汁，药味少，剂量轻，但奏效迅速，且时隔1年未复发，值得借鉴。
进修生乙：老师常说"精方简药亦能起大症"，真是百闻不如一见!不过我想，本例呕吐换了那么多方药都不见效，主要是病机不大好掌握，是这样的吗?
老师：也许是的。但一般地说，呕吐的病机并不难掌握，我们甚至可以把它归结为4个字：胃气上逆。因胃主受纳、腐熟，其气以下行为顺。今受纳食物之后，未即腐熟而吐出，是胃气失却顺降之职，转而上逆。其治疗大法，自然是和胃降逆。临证时辨明引起胃气上逆的病因，便可确立具体治法。如因寒则温而降之，因热则清而降之；因食则消而降之，因虚则补而降之等等。但本例呕吐的病机却没有这样单纯。一是病程较长，二是体质极差，三是寒热虚实杂呈，所以换了那么多和胃降逆的方药都不见显效。
进修生乙：那么本例呕吐的病机到底是什么呢?
进修生乙：可以说得具体一点吗?
老师：寒格是指胃气虚寒，格拒饮食；即使勉强进食，亦因胃寒不能腐熟食物而复吐出。热扰是指胆腑郁热，而胆腑郁热之际，不仅不能助胃磨食，反而进一步扰乱胃腑受纳、腐熟之功能，促其呕吐。而长期呕吐不止，胃腑功能日渐衰惫，胆热犯胃益急，造成恶性循环，故曰"土败木乘"。选用干姜黄芩黄连人参汤，是取干姜温胃祛寒，芩、连清胆撤热，党参(人参)匡扶正气。此为针对病机而出方，不是见呕止呕。
学员甲：老师对本例呕吐病机的分析以及选方用药，一定是借鉴了《伤寒论》厥阴篇第359条，"伤寒本自寒下，医复吐下之，寒格，更逆吐下，若食入口即吐，干姜黄芩黄连人参汤主之"。但教科书及大多数注家皆言本条的病机是上热与下寒互相格拒，老师却言胃寒胆热，有何根据?
老师：确实是借鉴了这一条，但我的理解有所不同。第一，把本条呕吐的病机归结为"寒热相格"或"上热与下寒互相格拒"，语涉空泛和抽象，落不到实处。第二，本条"伤寒本自寒下，医复吐下之……"是说病人本来就是虚寒下利，而医者还用吐下方药，世上哪有如此昏庸的医者?所以《医宗金鉴》说，"寒下之下字，当是格字，文义始属。注家皆释胃寒下利，不但文字不属，且与芩连之药不合"。第三，古医书上"关"与"格"是对峙文字，关指二便不通，格指格拒不食，或食入即呕。本条"寒格"，义亦取此，不是什么"寒热格拒"。再看本例呕吐患者，口干苦，大便少而不畅，小便黄，色淡紫，苔微黄薄腻，脉弦细稍数，显然是挟有胆腑郁热。我这样说，绝不是想用本例呕吐的治验来解释359条，只不过提供一点临证思路而已。
学员乙：干姜黄芩黄连人参汤主治"食入口即吐"，本例则是食后约半小时才吐出，怎能借用本方呢?
老师：我认为，食后约半小时才呕吐，也属于"食入口即吐"的范畴。因为"食入口即吐"是与"朝食暮吐，暮食朝吐"的胃反证相对而言。后者纯属脾胃虚寒，前者则挟有郁热。
进修生丙：老师借用本方，用量极轻，但又重加生姜，不虑其增热吗?
老师：寒格热扰，土败木乘，难以受药的呕吐，最难处方。惟小剂浓煎呷服，可冀其不吐或少吐。生姜是止呕圣药，虽重用30g，但不是同煎，而是捣烂取汁，每次只用5ml生汁兑入药液中，不会增热。陈修园推许本方治疗"诸凡格拒"，可谓独具慧眼。根据他的经验，"若汤水不得入口，去干姜，加生姜汁少许，徐徐呷之，此少变古法，屡验"。但我历来使用本方治疗顽固性呕吐，均加生姜汁而不去干姜，亦屡验。
学员丙：老师曾用旋复代赭汤加生姜汁迅速治愈过几例顽固性呕吐，这次为何不用呢?
老师：本例不仅进食吐食，而且服药吐药。既然前医已经用过旋复代赭汤而乏效，即使加入生姜汁，也难以矫正旋复花的劣味，惟恐重蹈服药吐药的覆辙!
实习生：如果陈修园的说法是对的，那么本方可以作为治疗顽固性呕吐的主方了?
老师：不能那样理解，例如呕吐之属胃阴虚而舌红少津者，就不可误用。柯韵伯说过，"凡呕家夹热者，不利于香砂橘半，服此方而晏如"。据《辞海》解释，晏就是"平静；安逸"。请大家仔细玩味柯氏这句话，确有其金针度人之处。
脐痛1个月
四川省乐山市人民医院中医研究室主任余国俊
徐XX，男，58岁，农民，1985年12月15日诊。患者肚脐中隐痛1个月余，虽整天疼痛不止，却不加重，喜温喜按。曾自取陈艾煎汤薰洗，葱白捣烂和盐炒热敷脐上，可取效于一时，但旋又隐痛如故。乃就医，先服乌梅丸汤剂2帖不效，改服附子理中汤2帖，似觉减轻，但数日后又隐痛如故，迁延至今。此明系寒证，但何以内服、外用温热药物疗效均不佳?细询其得病之由，言平素便畏寒凉，今秋曾守护柑橘园10余日。夜间茅屋透风，又频起巡查，衣履较单薄，颇感凉意。有一夜，因不慎失火，茅屋化为灰烬，惊惧交加，卧床数日，便觉肚脐中隐隐作痛，如此而已。患者面色少华，手足逆冷，肠鸣便溏，舌淡苔白滑，脉沉迟。揆度其脐痛之病机，确系肾阳虚衰，寒凝神阙，乃借鉴陈鼎三--江尔逊经验，用真武汤加胡芦巴治之：熟附片30g(先煎1小时)，白术15g，茯苓15g，白芍12g，生姜15g，胡芦巴30g：服3剂，肚脐中隐痛消失，手足转温，肠鸣、便溏均止。随访1年，脐痛未复发。
学员：本例脐中隐痛，病情虽不重，但临床少见，教科书也未写上，而老师出一真武汤取得佳效，更是我始料不及的。
进修生甲：我也有同感。但难以理解的是，本例脐痛，从病因、病性、体质、舌脉等综合分析，应届于脾肾阳虚，何以服附子理中汤疗效不佳呢?
老师：肚脐是神阙穴所居之地。神阙穴中痛，方书有称为"当脐痛"者，属于少阴腹痛范畴。患者年近花甲，素畏寒凉，其肾阳不足可知；又得之餐风饮露，大惊卒恐之后，且伴手足逆冷，肠鸣便溏，舌淡苔白滑，脉沉迟，确系肾阳虚衰，寒凝神阙。当然，如仅仅根据伴见的一派虚寒症状、舌脉，笼统地辨证为"脾肾阳虚"未尝不可，但本例疼痛的确切部位却不支持这一辨证结论。为什么这样说呢？因为按部位来划分，从胃脘至脐为大腹，属太阴脾；本例痛在脐中，不在大腹部，因而不涉及或主要不涉及太阴脾脏。而附子理中汤温补脾肾，是以温补脾阳为主，兼温肾阳，没有紧扣本例的确切病机，所以疗效不佳。
实习生：看来治疗腹痛时要确切地辨明部位，这一点教科书上没有充分强调，请老师再指点一下。
老师：大家知道，中医所称的腹部，指的是胃脘以下，耻骨毛际以上的部位。具体归属是：从胃脘至脐为大腹，属太阴脾；脐中及脐下小腹属少阴肾；脐旁左右属冲脉；脐下小腹两旁为少腹，属肝。治疗腹痛时如不确切地辨别部位，就不知到底病在何脏腑何经脉，遣方选药时就不可能成竹在胸，稳操胜券，而有"虑其动手便错"之虞。
进修生乙：真武汤是温阳利水之方，治疗阳虚水肿。但本例脐痛，并无阳虚水肿症侯，何以要选用此方?
老师：说真武汤可以治疗阳虚水肿是对的，但如把真武汤的主治范围仅仅局限于阳虚水肿，就有"划地为牢"之嫌了。严密地说，真武汤是治疗肾阳虚衰、水气为病之方。水气为病，外溢则为水肿，上冲则为头眩或喘咳，内停则为肠鸣便溏(本例便是)。当然，本例的主症--脐痛，不是水气为病，而是肾阳虚衰，寒凝神阙。为什么要选用真武汤呢？因为真武汤中附子配芍药，不仅能温肾阳、祛寒凝，更能入阴破结，敛阴和阳，完全契合少阴腹痛的基本病机。清·吴仪洛《成方切用》称真武汤为"治少阴伤寒腹痛"之方，是很有见地的。临床实践早已证明，真武汤不仅可以治疗肾阳虚衰，水气为病，还可以扩大运用于肾阳虚衰，寒凝内痛之证。
进修生乙：为什么还要重加胡芦巴30g呢?
老师：这是江老的老师陈鼎三先生的经验，也是有文献记载的。如《本草纲目》谓胡芦巴性味"苦，大温，无毒"，主治"元脏虚冷气"。"元脏"就是肾脏。陈老及江老平生治疗阳虚寒凝的当脐痛，都用真武汤原方重加胡芦巴一味，无不应手取效。
进修生甲：我由此产生两点疑问：第一，既然老师断言真武汤可以扩大运用于阳虚寒凝内痛之证，那么，本例脐痛只用真武汤，而不加胡芦巴，疗效将如何?第二，如果用真武汤疗效不甚佳，又不加胡卢巴，而加用同样可以治疗"元脏虚冷气"的其他大温药物，如肉桂、仙茅、小茴、丁香等，疗效又将如何呢?
老师：据江老临床体验，治疗阳虚寒凝脐痛，用真武汤重加胡芦巴，见效快，且不易复发，其疗效优于单用真武汤。至于不加胡芦巴，而用其他温肾祛寒药物疗效又将如何，请大家今后有机会时进行验证。这里附带说一句：若不是脐中痛，而是脐下小腹痛之属阳虚寒凝者，单用真武汤即可奏佳效。
长春中医学院教授肖永林
长春中医学院附属医院周世民
Liu XX, female, 52 years old. First consultation on April 6, 1988. For the past five years, the patient has suffered from recurrent stomachache accompanied by vomiting, with multiple hospitalizations. Gastroscopy indicated: chronic superficial gastritis (Chronic Superficial Gastritis). Two months ago, due to exposure to cold, the stomachache became severe and radiated to the back, accompanied by nausea and vomiting. Self-medication with Huoxiang Zhengqi Shui (Agastache Recta Water) and Metoclopramide failed to relieve symptoms, leading to admission. After antispasmodic analgesia, fluid replacement, and adjunctive Chinese herbal medicine, the stomachache gradually ceased, and nausea and vomiting subsided. However, she developed a fear of eating; not eating prevented vomiting, but eating led to frequent vomiting about half an hour later. Previously prescribed formulas including Huaghe Decoction (Liver Dissolving Decoction), Xiao Banxia Jia Fuling Tang (Minor Pinellia plus Poria Decoction), Xiangsha Liujunzi Tang (Aucklandia and Amomum Six Gentlemen Decoction), Wendan Tang (Gallbladder-Warming Decoction), and Xuanshu Daizhe Tang (Inula and Hematite Decoction) were ineffective; shortly after ingestion, the medication was often vomited out, causing a fear of taking medicine. Follow-up gastroscopy still showed chronic superficial gastritis. Current examination: emaciated body, lackluster complexion, sunken malar eminences, mental fatigue, weakness, shortness of breath, and faint voice; approximately half an hour after each meal, sticky saliva and small amounts of food are vomited; dry mouth with bitter taste, scanty and unsmooth bowel movements, yellow urine, pale purple tongue coating, thin yellow greasy moss, wiry, fine, and slightly rapid pulse. This is a pattern of Cold Obstruction and Heat Disturbance, Earth Decline and Wood Overacting, making it difficult to tolerate medication. Prescription: ① Ganjiang Huangqin Huanglian Renshen Tang (Dried Ginger, Scutellaria, Coptis, and Ginseng Decoction) added with fresh ginger juice: Dried Ginger 3g, Scutellaria Root 3g, Coptis Rhizome 3g, Codonopsis Root 5g. Preparation: Soak in cold water for 30 minutes, boil for 30 minutes, filter to obtain 200ml of decoction; separately, take 30g fresh ginger, peel and crush, add 30ml cold boiled water, soak for 30 minutes, filter to obtain ginger juice. Administration: Take 50ml of warm decoction, mix with 5ml ginger juice, sip slowly, once every 2 hours. ② Bai Kou Ren (Cardamom Seed) 5g, chew 2 grains before taking the decoction (spit out dregs). ③ Hong Shen (Red Ginseng) 10g, sliced thinly, hold 2-3 slices in mouth each time, chew and swallow after softening. Effect: Vomiting stopped after one dose. To consolidate efficacy, one more dose was taken. Subsequently switched to Chai Shao Liujunzi Tang (Bupleurum and White Peony Six Gentlemen Decoction) with modifications to soothe Liver, strengthen Spleen, harmonize Stomach, and direct rebellious Qi downward for convalescence: Bupleurum Root 10g, White Peony Root 10g, Codonopsis Root 10g, Atractylodes Macrocephala Rhizome 10g, Poria 12g, Licorice Root 3g, Processed Pinellia Tuber 5g, Tangerine Peel 5g, Dried Ginger 3g, Fresh Ginger 3g, Coptis Rhizome 3g. The patient took this formula for a total of 26 doses, accompanied daily by 3g Red Ginseng (same administration method as above), continuously for one month. One-year follow-up: no recurrence of stomachache or vomiting, relatively healthy condition.
Intern A: This case of chronic superficial gastritis presented with vomiting of sticky saliva and small amounts of food shortly after eating. Despite repeated treatments, there was little effect, and the patient's physical condition was extremely weak. The teacher prescribed the original Ganjiang Huangqin Huanglian Renshen Tang (Dried Ginger, Scutellaria, Coptis, and Ginseng Decoction) with added fresh ginger juice. Although the number of herbs was small and dosages light, the efficacy was rapid, and there was no recurrence after one year, which is worth learning from.
Intern B: The teacher often says, "Precise formulas with simple medicines can also cure serious diseases." It is truly better to see once than to hear a hundred times! However, I think that the reason why so many different prescriptions failed for this case of vomiting is mainly because the pathogenesis was difficult to grasp. Is this correct?
Teacher: Perhaps. Generally speaking, the pathogenesis of vomiting is not difficult to grasp; we can even summarize it in four characters: Rebellious Stomach Qi (Rebellious Qi of the Stomach). Since the Stomach governs reception and decomposition, its Qi should descend smoothly. Now, after receiving food, if it is not decomposed immediately and is vomited out, it means the Stomach Qi has lost its function of smooth descent and turned upward. Its general treatment principle is naturally to harmonize the Stomach and direct rebellious Qi downward. When treating clinically, identifying the cause of rebellious Stomach Qi allows for specific treatment methods. For example, if due to Cold, warm and direct downward; if due to Heat, clear and direct downward; if due to Food stagnation, resolve and direct downward; if due to Deficiency, tonify and direct downward, etc. However, the pathogenesis of vomiting in this case is not so simple. Firstly, the course of disease is long; secondly, the constitution is very poor; thirdly, Cold, Heat, Excess, and Deficiency are mixed. Therefore, many formulas for harmonizing the Stomach and directing rebellious Qi downward did not show obvious effects.
Intern B: Then what exactly is the pathogenesis of vomiting in this case?
Teacher: Cold Obstruction and Heat Disturbance, Earth Decline and Wood Overacting.
Intern B: Can you explain it more specifically?
Teacher: Cold Obstruction refers to deficiency-Cold of Stomach Qi obstructing food intake; even if forced to eat, the food is vomited again because the Cold Stomach cannot decompose it. Heat Disturbance refers to stagnant Heat in the Gallbladder; during this state of Gallbladder Heat, not only does it fail to assist the Stomach in grinding food, but it further disturbs the Stomach's functions of reception and decomposition, promoting vomiting. Long-term continuous vomiting causes the Stomach's function to decline day by day, and Gallbladder Heat invading the Stomach becomes more urgent, creating a vicious cycle, hence called "Earth Decline and Wood Overacting." Selecting Ganjiang Huangqin Huanglian Renshen Tang (Dried Ginger, Scutellaria, Coptis, and Ginseng Decoction) uses Dried Ginger to warm the Stomach and dispel Cold, Scutellaria and Coptis to clear Gallbladder Heat, and Codonopsis (Ginseng) to support upright Qi. This formula is targeted at the pathogenesis, not merely stopping vomiting when seen.
Student A: The teacher's analysis of the pathogenesis of vomiting in this case and the selection of prescription and medicines must have drawn from Article 359 of the Jueyin Chapter in Shanghan Lun (Treatise on Cold Damage): "Shanghan originally had Cold below, the doctor again used vomiting and purging methods, Cold obstruction, further reversing vomiting and purging, if food enters the mouth and is immediately vomited, Ganjiang Huangqin Huanglian Renshen Tang (Dried Ginger, Scutellaria, Coptis, and Ginseng Decoction) governs it." But textbooks and most commentators state that the pathogenesis of this article is mutual obstruction between Upper Heat and Lower Cold. The teacher, however, speaks of Stomach Cold and Gallbladder Heat. What is the basis?
Teacher: Indeed, it drew from this article, but my understanding differs. First, summarizing the pathogenesis of vomiting in this article as "Cold and Heat mutually obstructing" or "mutual obstruction between Upper Heat and Lower Cold" is vague and abstract, lacking concrete grounding. Second, the phrase "Shanghan originally had Cold below, the doctor again used vomiting and purging methods..." implies the patient originally had deficiency-Cold diarrhea, yet the doctor still used vomiting and purging drugs. How could there be such incompetent doctors in the world? Thus, Yizong Jinjian (Golden Mirror of Medicine) states, "The character 'xia' (below/purge) in 'cold xia' should be 'ge' (obstruct); only then does the text make sense. Commentators all interpret it as Stomach Cold diarrhea, which not only contradicts the text but also conflicts with the properties of Scutellaria and Coptis." Third, in ancient medical texts, "Guan" (closure) and "Ge" (obstruction) are contrasting terms. Guan refers to inability to pass urine and stool; Ge refers to obstruction preventing eating, or immediate vomiting upon eating. The "Cold Ge" in this article takes this meaning, not "Cold and Heat mutual obstruction." Looking at this vomiting patient again: dry mouth with bitter taste, scanty and unsmooth bowel movements, yellow urine, pale purple tongue coating, thin yellow greasy moss, wiry, fine, and slightly rapid pulse, clearly indicating accompanying Gallbladder stagnant Heat. I say this not to use this clinical experience to interpret Article 359, but merely to provide some clinical thinking.
Student B: Ganjiang Huangqin Huanglian Renshen Tang (Dried Ginger, Scutellaria, Coptis, and Ginseng Decoction) governs "immediate vomiting upon food entering the mouth," whereas this case vomits about half an hour after eating. How can this formula be borrowed?
Teacher: I believe that vomiting about half an hour after eating also falls under the category of "immediate vomiting upon food entering the mouth." Because "immediate vomiting upon food entering the mouth" is contrasted with "morning food evening vomiting, evening food morning vomiting" (Wei Fan syndrome/Reverse Vomiting). The latter is purely Spleen-Stomach deficiency-Cold, while the former involves stagnant Heat.
Intern C: The teacher borrowed this formula with very light dosages but heavily added Fresh Ginger. Does this not increase Heat?
Teacher: Vomiting due to Cold Obstruction and Heat Disturbance, Earth Decline and Wood Overacting, which is difficult to tolerate medication, is the hardest to prescribe. Only small doses, concentrated decoction, sipped slowly, can hope to prevent vomiting or reduce it. Fresh Ginger is the holy medicine for stopping vomiting. Although 30g is used heavily, it is not decocted together, but crushed to extract juice, using only 5ml of raw juice mixed into the decoction each time, which will not increase Heat. Chen Xiuyuan praised this formula for treating "all kinds of obstructions," showing unique insight. According to his experience, "If soup and water cannot enter the mouth, remove Dried Ginger, add a little Fresh Ginger juice, sip slowly; this slight variation of the ancient method has been repeatedly verified." However, I have always used this formula to treat stubborn vomiting, adding Fresh Ginger juice without removing Dried Ginger, and it has also been repeatedly verified.
Student C: The teacher once quickly cured several cases of stubborn vomiting using Xuanshu Daizhe Tang (Inula and Hematite Decoction) with added Fresh Ginger juice. Why not use it this time?
Teacher: In this case, not only is food vomited after eating, but medication is also vomited after taking it. Since previous doctors already used Xuanshu Daizhe Tang (Inula and Hematite Decoction) with little effect, even adding Fresh Ginger juice would hardly correct the inferior taste of Inula Flower, fearing a repetition of vomiting the medication!
Intern: If Chen Xiuyuan's statement is correct, can this formula be used as the main formula for treating stubborn vomiting?
Teacher: It cannot be understood that way. For example, vomiting belonging to Stomach Yin Deficiency with red tongue and scanty fluids should not be mistakenly used. Ke Yunbo said, "For vomitors with accompanying Heat, fragrant aromatics like Sha Ren and Ju Pi, along with Ban Xia, are unfavorable; taking this formula results in tranquility." According to Ci Hai (Dictionary of All Books), Yan means "calm; peaceful." Please carefully ponder this sentence by Mr. Ke; it indeed has the essence of passing on golden needles (secret techniques).
Abdominal Pain at Umbilicus for 1 Month
Yu Guojun, Director of Traditional Chinese Medicine Research Office, Leshan People's Hospital, Sichuan Province
Xu XX, male, 58 years old, farmer. Consultation on December 15, 1985. The patient had dull pain in the umbilicus for over 1 month. Although the pain lasted all day without worsening, he preferred warmth and pressure. He previously self-prepared decoctions of aged mugwort for fumigation and washing, and applied fried scallion white mixed with salt to the umbilicus, which provided temporary relief, but the dull pain returned soon. Seeking medical help, he first took 2 doses of Wumei Wan (Mume Pill) decoction without effect, then changed to Fuzi Lizhong Tang (Aconite and Magnolia Decoction) for 2 doses, feeling somewhat relieved, but the dull pain returned after a few days, persisting until now. This is clearly a Cold syndrome, but why were internal and external warm medicines ineffective? Detailed inquiry into the cause revealed that he usually feared cold and coolness. This autumn, he guarded an orange garden for over 10 days. At night, the thatched hut was drafty, and he frequently got up to patrol with thin clothing, feeling quite chilly. One night, due to accidental fire, the thatched hut burned to ashes. Adding fear and shock, he lay in bed for several days, then felt dull pain in the umbilicus, nothing more. Patient's complexion was less lustrous, hands and feet were cold, borborygmus and loose stools, pale tongue with white slippery coating, deep and slow pulse. Estimating the pathogenesis of umbilical pain, it is indeed Kidney Yang Deficiency and Decline, Cold condensing at Shenque. Borrowing the experience of Chen Dingsan and Jiang Erxun, Zhenwu Tang (True Warrior Decoction) added with Hulusba (Trigonella Foenum-graecum Seed) was used: Prepared Aconite Side-root 30g (decocted first for 1 hour), Atractylodes Macrocephala Rhizome 15g, Poria 15g, White Peony Root 12g, Fresh Ginger 15g, Trigonella Foenum-graecum Seed 30g. After 3 doses, dull pain in the umbilicus disappeared, hands and feet turned warm, borborygmus and loose stools stopped. One-year follow-up: no recurrence of umbilical pain.
Student: In this case of dull pain in the umbilicus, although the condition is not severe, it is rare in clinical practice and not mentioned in textbooks. The teacher's use of Zhenwu Tang (True Warrior Decoction) achieving good results was beyond my expectations.
Intern A: I feel the same. But what is hard to understand is that, comprehensively analyzing the etiology, nature of disease, constitution, tongue, and pulse of this umbilical pain, it should belong to Spleen-Kidney Yang Deficiency. Why was the efficacy of Fuzi Lizhong Tang (Aconite and Magnolia Decoction) poor?
Teacher: The umbilicus is the location of the Shenque Acupoint (CV-8). Pain in the Shenque Acupoint is called "pain at the umbilicus" in some books, belonging to the category of Shaoyin abdominal pain. The patient is near sixty, usually fears cold and coolness, indicating insufficient Kidney Yang; furthermore, exposed to wind and dew, after great shock and fear, accompanied by cold hands and feet, borborygmus, loose stools, pale tongue with white slippery coating, deep and slow pulse, it is indeed Kidney Yang Deficiency and Decline, Cold condensing at Shenque. Of course, if simply based on the accompanying deficiency-Cold symptoms, tongue, and pulse, broadly diagnosing as "Spleen-Kidney Yang Deficiency" is acceptable, but the exact location of pain in this case does not support this diagnostic conclusion. Why say this? Because dividing by location, from epigastrium to umbilicus is the Greater Abdomen, belonging to Taiyin Spleen; this case's pain is in the umbilicus, not in the Greater Abdomen, thus not involving or mainly not involving the Taiyin Spleen. And Fuzi Lizhong Tang (Aconite and Magnolia Decoction) warms and tonifies Spleen and Kidney, primarily warming Spleen Yang and secondarily warming Kidney Yang, failing to closely target the exact pathogenesis of this case, hence poor efficacy.
Intern: It seems that when treating abdominal pain, accurately distinguishing the location must be emphasized. Textbooks do not emphasize this enough. Please guide us further, Teacher.
Teacher: As everyone knows, the abdomen referred to in TCM refers to the area below the epigastrium and above the pubic hairline. Specific attribution is: from epigastrium to umbilicus is the Greater Abdomen, belonging to Taiyin Spleen; the umbilicus and lower abdomen below the umbilicus belong to Shaoyin Kidney; the sides left and right of the umbilicus belong to the Chong Mai (Penetrating Vessel); the hypogastria on both sides below the umbilicus belong to the Liver. When treating abdominal pain, if the location is not accurately distinguished, one does not know which Zang-Fu organ or meridian is diseased. When prescribing and selecting medicines, one cannot be confident and secure, risking "making mistakes upon acting."
Intern B: Zhenwu Tang (True Warrior Decoction) is a formula for warming Yang and promoting diuresis, treating Yang Deficiency edema. But this case of umbilical pain has no Yang Deficiency edema symptoms. Why select this formula?
Teacher: It is correct to say Zhenwu Tang (True Warrior Decoction) can treat Yang Deficiency edema, but limiting its scope solely to Yang Deficiency edema is like "drawing a prison on the ground." Strictly speaking, Zhenwu Tang (True Warrior Decoction) is a formula for treating Kidney Yang Deficiency and Decline with Water-Qi pathology. Water-Qi pathology, overflowing externally becomes edema, rushing upward becomes vertigo or wheezing/coughing, staying internally becomes borborygmus and loose stools (this case is so). Of course, the main symptom of this case—umbilical pain—is not Water-Qi pathology, but Kidney Yang Deficiency and Decline, Cold condensing at Shenque. Why select Zhenwu Tang (True Warrior Decoction)? Because in Zhenwu Tang (True Warrior Decoction), Aconite paired with White Peony can not only warm Kidney Yang and dispel Cold condensation, but also enter Yin to break knots, gather Yin and harmonize Yang, completely fitting the basic pathogenesis of Shaoyin abdominal pain. Qing Dynasty Wu Yiluo's Chengfang Qieyong (Selected Formulas) calls Zhenwu Tang (True Warrior Decoction) a formula for "treating Shaoyin Cold Damage abdominal pain," which is very insightful. Clinical practice has long proven that Zhenwu Tang (True Warrior Decoction) can not only treat Kidney Yang Deficiency and Decline with Water-Qi pathology, but can also be expanded to treat Kidney Yang Deficiency and Decline with Cold condensation and internal pain.
Intern B: Why add Hulusba (Trigonella Foenum-graecum Seed) 30g heavily?
Teacher: This is the experience of Mr. Chen Dingsan, Jiang Lao's teacher, and is documented in literature. For example, Bencao Gangmu (Compendium of Materia Medica) states Hulusba's nature and flavor as "bitter, greatly warm, non-toxic," governing "deficiency-cold Qi of the Yuan Zang (Primordial Organ)." "Yuan Zang" refers to the Kidneys. Mr. Chen and Mr. Jiang throughout their lives treated umbilical pain due to Yang Deficiency and Cold condensation using the original Zhenwu Tang (True Warrior Decoction) heavily adding Hulusba (Trigonella Foenum-graecum Seed), with no failure to achieve effect promptly.
Intern A: I have two doubts arising from this: First, since the teacher asserts that Zhenwu Tang (True Warrior Decoction) can be expanded to treat Yang Deficiency and Cold condensation internal pain, how would the efficacy be if this case of umbilical pain used only Zhenwu Tang (True Warrior Decoction) without adding Hulusba (Trigonella Foenum-graecum Seed)? Second, if the efficacy of Zhenwu Tang (True Warrior Decoction) is not very good, and instead of adding Hulusba (Trigonella Foenum-graecum Seed), other greatly warm medicines that can also treat "deficiency-cold Qi of the Yuan Zang," such as Cinnamon Bark, Curculigo Rhizome, Fennel, Clove, etc., are added, what would the efficacy be?
Teacher: According to Mr. Jiang's clinical experience, treating umbilical pain due to Yang Deficiency and Cold condensation with Zhenwu Tang (True Warrior Decoction) heavily adding Hulusba (Trigonella Foenum-graecum Seed) acts fast and is not prone to recurrence, with efficacy superior to using Zhenwu Tang (True Warrior Decoction) alone. As for the efficacy of not adding Hulusba (Trigonella Foenum-graecum Seed) but using other warming Kidney and dispelling Cold medicines, please verify this when you have the opportunity in the future. By the way: if it were not pain in the umbilicus, but pain in the lower abdomen below the umbilicus belonging to Yang Deficiency and Cold condensation, using Zhenwu Tang (True Warrior Decoction) alone can achieve good results.
High Fever, Clouded Spirit
Xiao Yonglin, Professor, Changchun University of Chinese Medicine
Zhou Shimin, Affiliated Hospital of Changchun University of Chinese Medicine