老师：患者营养状况差，平时贫血，又加呕恶纳少，所以出现脱水、酸中毒、皮肤弹性差，这时配合纠正水、电解质、酸碱平衡失调是必要的。能改善机体内环境和全身状况，使中药更好地发挥作用。但我们必须看到，仅仅依靠输液等，是起不到这么好的效果的，必须以正确的中医辨证施治为主，输液只是暂时的权宜之计。
医师乙：该患者有肝胆疾病，为何未予治疗?
老师：长期贫血、低蛋白血症、营养不良可以引起肝脏不正常，加之脂肪肝，故出现蛋白电泳异常、A／G倒置、肝大等，随着全身营养状况好转，这些自会改善，无须专门治疗。至于B超所示情况胆囊炎、胆石症，只要没有症状，可以不予治疗，即使治疗，也不易见到效果，反而喧宾夺主，结果什么病也治不好。
北京中医学院一附院内科博士江杨清
患者赵XX，男，4g岁，干部。住院号：49338。1988年8月12日入院。患者1986年8月无明显诱因出现舌面及口腔粘膜多发性紫暗色血疱并有溃疡，尤以齿牙碰撞后明显，全身皮肤见大量点状或斑片状出血，未经系统诊治。1987年查血小板3．5万／mm3，骨髓象正常，未能明确诊断。1987年9月又出现四肢浮肿，形体消瘦，纳差乏力等症状并逐渐加重。当时查尿蛋白++～+++，遂于1988年1月来北京，先后2次住入协和医院，中途曾转入石景山医院，前后共住院半年余。肾活检病理报告为："IgG、IgA、IgM在基底膜呈颗粒状沉积，病变符合系膜增殖性肾炎伴部分灶性硬化"。先后2次行血管造影均提示："左侧桡动脉不显影，右侧桡动脉显影延迟"o结合其他检查诊为：①紫癜性肾炎、肾病综合征；②血管炎。强的松曾用至每日60mg，尿蛋白及浮肿未见好转。遂加用环磷酰胺，总量用至3600rug，并加用雷公藤、潘生丁、安络血等，前后半年余，因疗效不显而出院。出院时尿蛋白+++～++++，24小时尿蛋白总量5～7g％，血浆白蛋白4．5g％。入院时患者精神萎靡，全身倦怠，柯兴氏貌明显。颜面虚浮皓白，口唇青紫明显，前胸后背满布痤疮，颜面、两腋窝、双下肢内侧、双腹股沟、两手腕及后背等处，可见多处大片状紫暗色出血斑点，边界清楚微隆起，大者如盘碟，小者如铜钱，斑疹表面密布出血斑点及红色丘疹，轻度瘙痒。另有许多散在斑片状出血点。口腔粘膜和舌面可见数个血疮和糜烂、溃疡面，颊唇粘膜紫暗硬肿，触之易出血。四肢浮肿，按之凹陷如泥，尿少而黄多泡沫，24小时800-900ml。便溏日2次，便意频有坠感，舌质红绛，苔黄腻，脉几难触及，按之着骨始得小弱不清。实验室检查：血小板直3．5万／mm3，尿蛋白++++，24小时尿蛋白5．4g,胆固醇294mg％，甘油三脂201mg％，p脂蛋白751rng％。血浆总蛋白4．2g％，白蛋白2．7g％，球蛋白1．5g％。肝肾功能未见异常。
治疗经过：入院时老师给予处方：生、熟地各30g，山萸肉log，山药15g，茯苓15g，丹皮15g，泽泻15g，车前草15g，枸杞子12g，旱莲革15g，牛膝炭15g，黑料豆12g，仙鹤草30g，大、小蓟各log，白茅根30g。为了防止激素骤停导致的反应，暂沿用强的松出院时剂量40mg／日。服上方2周后患者四肢浮肿基本消失，全身紫癜明显减少，皮肤红肿瘙痒已除。24小时尿量1500ml左右。便溏日行4次，舌质暗红不绛，苔薄白腻，脉沉细无力。复查尿蛋白++，24小时尿蛋白总量3g，老师看过病人，嘱仍用原方，并加服健脾益气剂：黄芪30g，炒薏仁30g，菟丝子12g，芡实15g，炮姜炭5g，红枣5枚。1个月后全身紫癜、口腔血疱、溃疡及四肢浮肿
基本消除，但双下肢仍偶有紫癜复发，口唇青紫基本消除，大便成形日1-2次，尿量为1200-1500u/日，精神体力明显改善，复查尿蛋白多次稳定在++，24小时尿蛋白2．55g，强的松已减至15mg／日。舌质紫暗转为淡暗，舌苔薄白，脉沉细，清晰可得。老师转用下方：生、熟地各30g，山萸肉10g，山药15g，茯苓10g，丹皮10g，白莲须10g，益智仁10g，菟丝子10g，生黄芪30g，白术log，紫珠草15g，白茅根30g，益母草15g，炒苡仁20g。并参四妙勇安汤意：生黄芪30g，银花15g，玄参15g，当归10g。每日各1剂，药后皮疹未再反复，陈旧性出血斑片逐渐隐退，皮肤逐渐光滑。尿蛋白++，24小时1.75g，血浆总蛋白升至6g％(白蛋白3．1g％)，血清胆固醇368mg％。p脂蛋白707mg％，甘油三脂115mg％。脉来较前有力，强的松已减至2．5mg／日，至11月初强的松全撤，病情稳定无反复。整个治疗中加服人参粉3g，2次／日，云南白药2粒，每日2次。
科内病例讨论
老师：该病属免疫性疾病，西医颇感棘手。三高一低现象加上肾脏活检，肾病综合征可以确诊。动脉造影结合典型皮损，动脉炎也可确诊。我们仅用中药治疗3个月而基本治愈，可见中医药确有其独到之处，因此我们重点从中医角度加以讨论，总结经验教训。
进修医师甲：该病人刚入院时，我有些缺乏信心，认为条件那么好的西医院久治不愈的病，我们能治好吗?事实推翻了我的臆断，我们在不断减少以至停用强的松和停用其他西药的情况下，依靠中医的辨证施治，使患者的血管炎、肾病均得到满意的控制，这是了不起的成绩。过去我总认为西医科学，中医难以捉摸，通过几个月的学习，确实看到老师用中医药治好不少西医已到山穷水尽的疑难杂证，因此对中医发生了兴趣，坚定了我学习中医的信心。但是对取效的缘由和老师辨证用药的思维过程领会不深，能否请老师谈谈入院时辨证立法用药的思路?
老师：患者入院时有以下几个突出表现：①阴虚血热证：舌红绛，斑疹色暗红，口腔粘膜的血疱、糜烂溃疡等，全身血管皮肤的出血系阴虚血热伤络所致。②血瘀证：从皮疹的色泽，尤其是唇颊粘膜紫暗硬肿，一碰即出现血疱等，舌脉象亦支持瘀血证。③气分湿热证：苔黄腻，尿黄少有泡沫，面肢浮肿，皮疹有轻度瘙痒。④脾虚气弱证：神萎体倦，脉沉细难以触及，面肢浮肿以下肢为显，便溏，便意频有坠感，尿蛋白持续，系运化失司，水谷精微下渗之象。总其病机，症属：久病肝肾阴分已伤，正气已虚，营热迫血妄行，瘀血阻络，气分湿热内蕴。方以六味地黄滋补肝肾，兼泻肾水，佐车前子加强清利之功。牛膝炭、仙鹤草、旱莲草、大小蓟、白茅根，并重用丹皮以凉血止血，兼能散瘀，黑料豆补肝肾，利湿热。并加人参粉补气，云南白药散瘀止血。合方共奏滋补肝肾，兼顾正气，凉血散瘀，活血止血，清气化湿之功。
医师乙：强的松对中医药的治疗有何影响?
老师：用大量强的松无效，说明该药非本例适应证，用后反而导致机体阴阳失衡，呈现一派阴虚湿热假象，给中医辨证和治疗带来困难，所以这阶段的治疗，实际上是纠正强的松引起的副
作用。强的松必须停用，但又不能骤停，防止体内激素水平骤降带来不良后果。这时在加强中医治疗措施的同时，逐渐撤减强的松，以致停用，使强的松导致的阴虚湿热之象得以纠正，恢复了疾病的本来面目。为以后进一步治疗，创造了有利条件。
进修医师乙：老师第二次转方时，原方未动，加了健脾益气剂，其意何在?
老师：原方不动，是为了进一步加强和巩固疗效。加健脾剂是因为阴虚湿热渐清，脾虚夹湿之本象显现，如便溏日行2次增至4次，舌由红绛转为淡暗，苔黄腻转为薄白腻。加之久用寒凉
之品，脾阳不胜阴药之消伐，故加用健脾益气剂，以健脾助运，固守元气，以防脾胃一败，药石难施，进一步削弱脾的转输运化功能，加重浮肿和蛋白尿，这就是脾胃为本的具体体现。果然加用以后，使便溏成形，浮肿、蛋白尿逐渐改善，体力恢复较快，为进一步治疗提供了基础。
进修医师甲：为什么在皮疹逐渐隐退、各种情况逐渐改善、仅皮疹偶有反复时，老师不仅不逐渐撤减凉血散瘀药，反而又用了四妙勇安汤?
老师：目的是使皮疹得以彻底控制，死灰难燃。正如徐大椿在(用药如用兵论)-上所说"病方衰，则必穷其所之，更益精锐，所以捣其穴。"
医师甲：中医药对尿蛋白有些什么好的治疗办法?
老师：据我个人体会，对尿蛋白的治疗，既要着眼于"病"，更要着眼于"证"，即在辨证的基础上，结合辨病：如果中药有能消除蛋白尿的药物符合或起码不违背该病辨证原则的话，就可以使用。比如黄芪、山药、薏苡仁、茯苓、菟丝子、益智仁、芡实等均有不同程度消减尿蛋白的作用。这些药物甘平微温，能健脾益肾。因为尿蛋白是由脾虚运化失司，水谷之精不能转输上承，反随下陷之脾气下泄和肾虚不能开合，闭藏失职，精微下趋所引起。本例结合全身症状和舌、脉表现，脾肾亏虚是存在的，比如面色皓白虛浮，大便溏有下坠感，经用养阴偏凉药物后便次增多，乏力神萎，全身水肿，脉虚细沉等等。正是在脾肾亏虚的情况下，精微蛋白才得以下泄。强的松未能控制尿蛋白，反而造成阴阳的新的不平衡。导致肾阴亏虚，虚火挟湿热交织，进一步耗伤真阴，阴虚则阳无以化，而脾气、脾阳不足，气不化水，所以尿蛋白、浮肿反复难愈。这时首先要调整脾肾阴阳的不平衡，而这些调整脾肾阴阳的药物又都具有消除尿蛋白的作用，所以就更适宜使用。药后使浮肿消，大便实，脾肾固而蛋白消减。假如脾虚现象不明显，而湿热表现突出，尿黄多沬，即使尿蛋白再多，也不适宜使用菟丝子、益智仁之类荮物。所以辨证仍是主要着眼点。
医师乙：为什么在皮疹没有完全消除的情况下，血分尚有热，你用辛温大热的炮姜?
老师：炮姜有很好的温中止泻和止血作用，对于虚寒性腹泻便溏很适用。本例便溏显系脾阳虚寒引起，一味炮姜，加入大队凉血止血方中，一可加强止血，二二能防止凉药损伤脾阳，决无动血之虞，故用之。
北京中医学院第一附属医院内科博士江杨清
张X，男，56岁，干部。1987年6月24日入院，住院号：045532。
患者自1982年11月起，因工作紧张，引起便次增多，每日3-6次，最多达)5次。腹泻每于紧张或劳累之后加重，与饮食无明确关系，无腹痛、腹胀和脓血便。曾在黑龙江人民医院住院治疗，服复方苯乙哌啶及中药，症情稍有改善。纤维结肠镜诊为慢性结肠炎、肠息肉。出院后症情时轻时重，又先后服用多种药物，遍访东北名医，中药用过温阳健脾、涩肠止泻、淡渗分利、寒热并用、升阳益胃、燥湿祛痰等法，罂粟壳每剂用过15g，并复方苯乙哌啶每次3片，每日3次，亦未能止泻。刻症：大便日行6-8次，晨起五更即泻，随即连续几次稀水样便，时感腹胀，腹有冷感，肢倦乏力，伴头晕、盗汗、五心潮热、心烦、口淡纳久、晨起泛吐涎沫、夜寐不安，舌淡暗，苔根黄微腻，脉细。老师拟方如下：熟附片10g，肉桂5g，炮姜炭5g，煨肉豆蔻10g，煨诃子肉10g，煨木香10g，砂仁3g(后下)，焦白术10g，炒薏苡仁20g，千荷叶6g，芡实20g，怀山药15g，川连2g，焦山楂12g。2剂。
6月24日：诉昨日解2次稀便，今晨起排便3次，肠中作响，无腹痛腹胀，上身烘热汗出，下肢发凉，余均同前。病属久泻，脾肾阳虚，心火偏旺，兼肠府湿热，前法加减调理：熟附片10g，肉桂3g，炮姜炭5g，煨肉蔻10g，煨诃子log．煨木香6g，砂仁3g，焦白术10g，炒苡仁15g，干荷叶6g，焦山楂12g，川连3g，山药15g，乌梅炭log，莲子肉log。并用丁香粉、肉桂粉、麝香粉以20：20：1，混匀，撤伤湿膏敷贴天枢、关元、气海、脾俞穴，每日一换。
将上方药稍作加减，用至7月8日，病情已趋稳定，日解1-2次，为软便，体力、纳谷增加，呕恶已除。原方加罂粟壳6g，每日2剂。
7月13日查房：病情续有改善，每日解1次已能成堆，心烦及余症消除，舌质淡红，苔根灰腻，上方再服4天，仍每日大便1次，有时能成形。巩固治疗至9月6日出院。住院期间做过钡灌肠、X线检查、大便培养、霉菌培养等多种检查，未发现明显异常。
科内组织多次中医病案讨论，归纳如下：
医师甲：这个患者症状比较复杂，不知在辨证时老师是怎样考虑的?
老师：这个患者既有虚寒的--面，又有湿热的一面，而且还有肝郁证表现。选方用药要依据病机，病机要依据症状和病因。这个患者，我认为病机应当是：久泻脾阳已耗，运化失司，日久损及肾阳，以致脾肾阳衰，蒸化开合失度，水湿内蕴肠府，蕴郁化热，湿热上蒸，脾虚肝木乘侮，木土不和。
【背景信息】
书名：名师垂教 章节：正文(4/27) 类别：综合
【待处理原文】
老师：患者营养状况差，平时贫血，又加呕恶纳少，所以出现脱水、酸中毒、皮肤弹性差，这时配合纠正水、电解质、酸碱平衡失调是必要的。能改善机体内环境和全身状况，使中药更好地发挥作用。但我们必须看到，仅仅依靠输液等，是起不到这么好的效果的，必须以正确的中医辨证施治为主，输液只是暂时的权宜之计。
医师乙：该患者有肝胆疾病，为何未予治疗?
老师：长期贫血、低蛋白血症、营养不良可以引起肝脏不正常，加之脂肪肝，故出现蛋白电泳异常、A／G倒置、肝大等，随着全身营养状况好转，这些自会改善，无须专门治疗。至于B超所示情况胆囊炎、胆石症，只要没有症状，可以不予治疗，即使治疗，也不易见到效果，反而喧宾夺主，结果什么病也治不好。
北京中医学院一附院内科博士江杨清
患者赵XX，男，4g岁，干部。住院号：49338。1988年8月12日入院。患者1986年8月无明显诱因出现舌面及口腔粘膜多发性紫暗色血疱并有溃疡，尤以齿牙碰撞后明显，全身皮肤见大量点状或斑片状出血，未经系统诊治。1987年查血小板3．5万／mm3，骨髓象正常，未能明确诊断。1987年9月又出现四肢浮肿，形体消瘦，纳差乏力等症状并逐渐加重。当时查尿蛋白++～+++，遂于1988年1月来北京，先后2次住入协和医院，中途曾转入石景山医院，前后共住院半年余。肾活检病理报告为："IgG、IgA、IgM在基底膜呈颗粒状沉积，病变符合系膜增殖性肾炎伴部分灶性硬化"。先后2次行血管造影均提示："左侧桡动脉不显影，右侧桡动脉显影延迟"o结合其他检查诊为：①紫癜性肾炎、肾病综合征；②血管炎。强的松曾用至每日60mg，尿蛋白及浮肿未见好转。遂加用环磷酰胺，总量用至3600rug，并加用雷公藤、潘生丁、安络血等，前后半年余，因疗效不显而出院。出院时尿蛋白+++～++++，24小时尿蛋白总量5～7g％，血浆白蛋白4．5g％。入院时患者精神萎靡，全身倦怠，柯兴氏貌明显。颜面虚浮皓白，口唇青紫明显，前胸后背满布痤疮，颜面、两腋窝、双下肢内侧、双腹股沟、两手腕及后背等处，可见多处大片状紫暗色出血斑点，边界清楚微隆起，大者如盘碟，小者如铜钱，斑疹表面密布出血斑点及红色丘疹，轻度瘙痒。另有许多散在斑片状出血点。口腔粘膜和舌面可见数个血疮和糜烂、溃疡面，颊唇粘膜紫暗硬肿，触之易出血。四肢浮肿，按之凹陷如泥，尿少而黄多泡沫，24小时800-900ml。便溏日2次，便意频有坠感，舌质红绛，苔黄腻，脉几难触及，按之着骨始得小弱不清。实验室检查：血小板直3．5万／mm3，尿蛋白++++，24小时尿蛋白5．4g,胆固醇294mg％，甘油三脂201mg％，p脂蛋白751rng％。血浆总蛋白4．2g％，白蛋白2．7g％，球蛋白1．5g％。肝肾功能未见异常。
治疗经过：入院时老师给予处方：生、熟地各30g，山萸肉log，山药15g，茯苓15g，丹皮15g，泽泻15g，车前草15g，枸杞子12g，旱莲革15g，牛膝炭15g，黑料豆12g，仙鹤草30g，大、小蓟各log，白茅根30g。为了防止激素骤停导致的反应，暂沿用强的松出院时剂量40mg／日。服上方2周后患者四肢浮肿基本消失，全身紫癜明显减少，皮肤红肿瘙痒已除。24小时尿量1500ml左右。便溏日行4次，舌质暗红不绛，苔薄白腻，脉沉细无力。复查尿蛋白++，24小时尿蛋白总量3g，老师看过病人，嘱仍用原方，并加服健脾益气剂：黄芪30g，炒薏仁30g，菟丝子12g，芡实15g，炮姜炭5g，红枣5枚。1个月后全身紫癜、口腔血疱、溃疡及四肢浮肿
基本消除，但双下肢仍偶有紫癜复发，口唇青紫基本消除，大便成形日1-2次，尿量为1200-1500u/日，精神体力明显改善，复查尿蛋白多次稳定在++，24小时尿蛋白2．55g，强的松已减至15mg／日。舌质紫暗转为淡暗，舌苔薄白，脉沉细，清晰可得。老师转用下方：生、熟地各30g，山萸肉10g，山药15g，茯苓10g，丹皮10g，白莲须10g，益智仁10g，菟丝子10g，生黄芪30g，白术log，紫珠草15g，白茅根30g，益母草15g，炒苡仁20g。并参四妙勇安汤意：生黄芪30g，银花15g，玄参15g，当归10g。每日各1剂，药后皮疹未再反复，陈旧性出血斑片逐渐隐退，皮肤逐渐光滑。尿蛋白++，24小时1.75g，血浆总蛋白升至6g％(白蛋白3．1g％)，血清胆固醇368mg％。p脂蛋白707mg％，甘油三脂115mg％。脉来较前有力，强的松已减至2．5mg／日，至11月初强的松全撤，病情稳定无反复。整个治疗中加服人参粉3g，2次／日，云南白药2粒，每日2次。
科内病例讨论
老师：该病属免疫性疾病，西医颇感棘手。三高一低现象加上肾脏活检，肾病综合征可以确诊。动脉造影结合典型皮损，动脉炎也可确诊。我们仅用中药治疗3个月而基本治愈，可见中医药确有其独到之处，因此我们重点从中医角度加以讨论，总结经验教训。
进修医师甲：该病人刚入院时，我有些缺乏信心，认为条件那么好的西医院久治不愈的病，我们能治好吗?事实推翻了我的臆断，我们在不断减少以至停用强的松和停用其他西药的情况下，依靠中医的辨证施治，使患者的血管炎、肾病均得到满意的控制，这是了不起的成绩。过去我总认为西医科学，中医难以捉摸，通过几个月的学习，确实看到老师用中医药治好不少西医已到山穷水尽的疑难杂证，因此对中医发生了兴趣，坚定了我学习中医的信心。但是对取效的缘由和老师辨证用药的思维过程领会不深，能否请老师谈谈入院时辨证立法用药的思路?
老师：患者入院时有以下几个突出表现：①阴虚血热证：舌红绛，斑疹色暗红，口腔粘膜的血疱、糜烂溃疡等，全身血管皮肤的出血系阴虚血热伤络所致。②血瘀证：从皮疹的色泽，尤其是唇颊粘膜紫暗硬肿，一碰即出现血疱等，舌脉象亦支持瘀血证。③气分湿热证：苔黄腻，尿黄少有泡沫，面肢浮肿，皮疹有轻度瘙痒。④脾虚气弱证：神萎体倦，脉沉细难以触及，面肢浮肿以下肢为显，便溏，便意频有坠感，尿蛋白持续，系运化失司，水谷精微下渗之象。总其病机，症属：久病肝肾阴分已伤，正气已虚，营热迫血妄行，瘀血阻络，气分湿热内蕴。方以六味地黄滋补肝肾，兼泻肾水，佐车前子加强清利之功。牛膝炭、仙鹤草、旱莲草、大小蓟、白茅根，并重用丹皮以凉血止血，兼能散瘀，黑料豆补肝肾，利湿热。并加人参粉补气，云南白药散瘀止血。合方共奏滋补肝肾，兼顾正气，凉血散瘀，活血止血，清气化湿之功。
医师乙：强的松对中医药的治疗有何影响?
老师：用大量强的松无效，说明该药非本例适应证，用后反而导致机体阴阳失衡，呈现一派阴虚湿热假象，给中医辨证和治疗带来困难，所以这阶段的治疗，实际上是纠正强的松引起的副
作用。强的松必须停用，但又不能骤停，防止体内激素水平骤降带来不良后果。这时在加强中医治疗措施的同时，逐渐撤减强的松，以致停用，使强的松导致的阴虚湿热之象得以纠正，恢复了疾病的本来面目。为以后进一步治疗，创造了有利条件。
进修医师乙：老师第二次转方时，原方未动，加了健脾益气剂，其意何在?
老师：原方不动，是为了进一步加强和巩固疗效。加健脾剂是因为阴虚湿热渐清，脾虚夹湿之本象显现，如便溏日行2次增至4次，舌由红绛转为淡暗，苔黄腻转为薄白腻。加之久用寒凉
之品，脾阳不胜阴药之消伐，故加用健脾益气剂，以健脾助运，固守元气，以防脾胃一败，药石难施，进一步削弱脾的转输运化功能，加重浮肿和蛋白尿，这就是脾胃为本的具体体现。果然加用以后，使便溏成形，浮肿、蛋白尿逐渐改善，体力恢复较快，为进一步治疗提供了基础。
进修医师甲：为什么在皮疹逐渐隐退、各种情况逐渐改善、仅皮疹偶有反复时，老师不仅不逐渐撤减凉血散瘀药，反而又用了四妙勇安汤?
老师：目的是使皮疹得以彻底控制，死灰难燃。正如徐大椿在(用药如用兵论)-上所说"病方衰，则必穷其所之，更益精锐，所以捣其穴。"
医师甲：中医药对尿蛋白有些什么好的治疗办法?
老师：据我个人体会，对尿蛋白的治疗，既要着眼于"病"，更要着眼于"证"，即在辨证的基础上，结合辨病：如果中药有能消除蛋白尿的药物符合或起码不违背该病辨证原则的话，就可以使用。比如黄芪、山药、薏苡仁、茯苓、菟丝子、益智仁、芡实等均有不同程度消减尿蛋白的作用。这些药物甘平微温，能健脾益肾。因为尿蛋白是由脾虚运化失司，水谷之精不能转输上承，反随下陷之脾气下泄和肾虚不能开合，闭藏失职，精微下趋所引起。本例结合全身症状和舌、脉表现，脾肾亏虚是存在的，比如面色皓白虛浮，大便溏有下坠感，经用养阴偏凉药物后便次增多，乏力神萎，全身水肿，脉虚细沉等等。正是在脾肾亏虚的情况下，精微蛋白才得以下泄。强的松未能控制尿蛋白，反而造成阴阳的新的不平衡。导致肾阴亏虚，虚火挟湿热交织，进一步耗伤真阴，阴虚则阳无以化，而脾气、脾阳不足，气不化水，所以尿蛋白、浮肿反复难愈。这时首先要调整脾肾阴阳的不平衡，而这些调整脾肾阴阳的药物又都具有消除尿蛋白的作用，所以就更适宜使用。药后使浮肿消，大便实，脾肾固而蛋白消减。假如脾虚现象不明显，而湿热表现突出，尿黄多沬，即使尿蛋白再多，也不适宜使用菟丝子、益智仁之类荮物。所以辨证仍是主要着眼点。
医师乙：为什么在皮疹没有完全消除的情况下，血分尚有热，你用辛温大热的炮姜?
老师：炮姜有很好的温中止泻和止血作用，对于虚寒性腹泻便溏很适用。本例便溏显系脾阳虚寒引起，一味炮姜，加入大队凉血止血方中，一可加强止血，二二能防止凉药损伤脾阳，决无动血之虞，故用之。
北京中医学院第一附属医院内科博士江杨清
张X，男，56岁，干部。1987年6月24日入院，住院号：045532。
患者自1982年11月起，因工作紧张，引起便次增多，每日3-6次，最多达)5次。腹泻每于紧张或劳累之后加重，与饮食无明确关系，无腹痛、腹胀和脓血便。曾在黑龙江人民医院住院治疗，服复方苯乙哌啶及中药，症情稍有改善。纤维结肠镜诊为慢性结肠炎、肠息肉。出院后症情时轻时重，又先后服用多种药物，遍访东北名医，中药用过温阳健脾、涩肠止泻、淡渗分利、寒热并用、升阳益胃、燥湿祛痰等法，罂粟壳每剂用过15g，并复方苯乙哌啶每次3片，每日3次，亦未能止泻。刻症：大便日行6-8次，晨起五更即泻，随即连续几次稀水样便，时感腹胀，腹有冷感，肢倦乏力，伴头晕、盗汗、五心潮热、心烦、口淡纳久、晨起泛吐涎沫、夜寐不安，舌淡暗，苔根黄微腻，脉细。老师拟方如下：熟附片10g，肉桂5g，炮姜炭5g，煨肉豆蔻10g，煨诃子肉10g，煨木香10g，砂仁3g(后下)，焦白术10g，炒薏苡仁20g，千荷叶6g，芡实20g，怀山药15g，川连2g，焦山楂12g。2剂。
6月24日：诉昨日解2次稀便，今晨起排便3次，肠中作响，无腹痛腹胀，上身烘热汗出，下肢发凉，余均同前。病属久泻，脾肾阳虚，心火偏旺，兼肠府湿热，前法加减调理：熟附片10g，肉桂3g，炮姜炭5g，煨肉蔻10g，煨诃子log．煨木香6g，砂仁3g，焦白术10g，炒苡仁15g，干荷叶6g，焦山楂12g，川连3g，山药15g，乌梅炭log，莲子肉log。并用丁香粉、肉桂粉、麝香粉以20：20：1，混匀，撒伤湿膏敷贴天枢、关元、气海、脾俞穴，每日一换。
将上方药稍作加减，用至7月8日，病情已趋稳定，日解1-2次，为软便，体力、纳谷增加，呕恶已除。原方加罂粟壳6g，每日2剂。
7月13日查房：病情续有改善，每日解1次已能成堆，心烦及余症消除，舌质淡红，苔根灰腻，上方再服4天，仍每日大便1次，有时能成形。巩固治疗至9月6日出院。住院期间做过钡灌肠、X线检查、大便培养、霉菌培养等多种检查，未发现明显异常。
科内组织多次中医病案讨论，归纳如下：
医师甲：这个患者症状比较复杂，不知在辨证时老师是怎样考虑的?
老师：这个患者既有虚寒的--面，又有湿热的一面，而且还有肝郁证表现。选方用药要依据病机，病机要依据症状和病因。这个患者，我认为病机应当是：久泻脾阳已耗，运化失司，日久损及肾阳，以致脾肾阳衰，蒸化开合失度，水湿内蕴肠府，蕴郁化热，湿热上蒸，脾虚肝木乘侮，木土不和。
[Background Information]
Book: Master's Teaching Chapter: Main Text (4/27) Category: Comprehensive
[Original Text]
Teacher: The patient has poor nutritional status, chronic anemia, and is now experiencing vomiting, nausea, and poor appetite. Consequently, dehydration, acidosis, and poor skin turgor have developed. At this stage, it is necessary to correct the imbalance of water, electrolytes, and acid-base balance. This can improve the internal environment of the body and the overall condition, allowing Chinese herbal medicine to play a better role. However, we must recognize that relying solely on intravenous infusion cannot achieve such good results. The primary treatment must be based on correct TCM syndrome differentiation and treatment; intravenous infusion is merely a temporary expedient.
Physician B: The patient has hepatobiliary diseases, why were they not treated?
Teacher: Long-term anemia, hypoproteinemia, and malnutrition can cause liver dysfunction. Coupled with fatty liver, this leads to abnormal protein electrophoresis, an inverted Albumin/Globulin (A/G) ratio, and hepatomegaly. As the overall nutritional status improves, these conditions will naturally improve without requiring specific treatment. Regarding the cholecystitis and cholelithiasis shown in the ultrasound, if there are no symptoms, treatment is unnecessary. Even if treated, it may not yield significant results and could distract from the main issue, resulting in failure to cure any disease.
Generalized Skin and Mucosal Purpura, Severe Edema, Proteinuria Accompanied by Pulselessness
Jiang Yangqing, MD, Department of Internal Medicine, First Affiliated Hospital, Beijing College of Traditional Chinese Medicine
Patient Zhao XX, male, 49 years old [Note: '4g' appears to be a typo for 49], cadre. Hospitalization No.: 49338. Admitted on August 12, 1988. In August 1986, the patient developed multiple purplish-dark blood blisters and ulcers on the tongue surface and oral mucosa without obvious triggers, which were particularly evident after tooth collision. Large amounts of punctate or patchy hemorrhages appeared on the whole body skin, but no systematic diagnosis or treatment was received. In 1987, platelet count was 35,000/mm³, bone marrow morphology was normal, and a clear diagnosis could not be made. In September 1987, edema of the four limbs, emaciation, poor appetite, and fatigue appeared and gradually worsened. Urine protein was ++ to +++ at that time. The patient came to Beijing in January 1988 and was hospitalized twice at Peking Union Medical College Hospital, transferring to Shijingshan Hospital midway, totaling over half a year of hospitalization. Renal biopsy pathology report stated: "Granular deposition of IgG, IgA, and IgM on the basement membrane, lesions consistent with mesangial proliferative nephritis accompanied by partial focal sclerosis." Two angiographies indicated: "Non-filling of the left radial artery, delayed filling of the right radial artery." Combined with other examinations, the diagnoses were: ① Henoch-Schönlein purpura nephritis, Nephrotic Syndrome; ② Vasculitis. Prednisone was used up to 60 mg/day, but urine protein and edema did not improve. Cyclophosphamide was then added, with a total dose of 3600 mg [Note: 'rug' likely typo for mg], along with Tripterygium wilfordii (Leigongteng), Dipyridamole (Persantine), Anluoxue, etc. After more than half a year, due to lack of efficacy, the patient was discharged. At discharge, urine protein was +++ to +++, 24-hour urine protein total was 5–7 g%, plasma albumin was 4.5 g%. Upon admission, the patient showed mental depression, general fatigue, and obvious Cushingoid appearance. The face was puffy and pale white, lips clearly cyanotic, chest and back covered with acne. On the face, both axillae, inner sides of both lower limbs, both groins, both wrists, and back, large patches of purplish-dark hemorrhagic spots were visible, with clear boundaries and slight elevation. Large ones were like plates or saucers, small ones like coins. The surface of the macules and papules was densely dotted with hemorrhagic spots and red papules, with mild itching. Additionally, many scattered patchy hemorrhagic points were present. Several blood blisters, erosions, and ulcerations were seen on the oral mucosa and tongue surface. The buccal and lip mucosa were purplish-dark, hard, and swollen, bleeding easily upon touch. Edema of the four limbs was present, leaving pits when pressed like mud. Urine output was low, yellow, and foamy, 800–900 ml in 24 hours. Stool was loose, twice daily, with frequent urge and a sensation of bearing down. Tongue body was red and crimson, coating yellow and greasy. Pulse was barely palpable, becoming small, weak, and unclear only when pressed deeply to the bone. Laboratory tests: Platelet count 35,000/mm³, urine protein +++++, 24-hour urine protein 5.4 g, cholesterol 294 mg%, triglycerides 201 mg%, beta-lipoprotein 751 mg% [Note: 'rng' likely typo for mg]. Plasma total protein 4.2 g%, albumin 2.7 g%, globulin 1.5 g%. Liver and kidney functions were unremarkable.
Treatment Course: Upon admission, the teacher prescribed: Raw and Prepared Rehmannia Root (Sheng/Di Huang) 30 g each, Cornus Officinalis Fruit (Shan Yu Rou) 10 g [Note: 'log' likely typo for 10g], Dioscorea Rhizome (Shan Yao) 15 g, Poria (Fu Ling) 15 g, Moutan Cortex (Dan Pi) 15 g, Alisma Rhizome (Ze Xie) 15 g, Plantago Seed/Herb (Che Qian Cao) 15 g, Lycium Fruit (Gou Qi Zi) 12 g, Eclipta Herba (Han Lian Cao) 15 g [Note: 'ge' likely typo for 'cao'], Achyranthes Root Charcoal (Niu Xi Tan) 15 g, Black Soybean (Hei Liao Dou) 12 g, Agrimony Herba (Xian He Cao) 30 g, Cirsium Japonicum and Cirsium Setosum (Da/Xiao Ji) 10 g each, Imperata Rhizome (Bai Mao Gen) 30 g. To prevent reactions from sudden withdrawal of hormones, the discharge dose of Prednisone 40 mg/day was temporarily continued. After two weeks of taking the above prescription, the edema of the four limbs basically disappeared, generalized purpura significantly decreased, and skin redness, swelling, and itching were resolved. 24-hour urine volume was around 1500 ml. Loose stools occurred 4 times daily. Tongue body was dark red but not crimson, coating thin white and greasy. Pulse was deep, fine, and weak. Re-examination showed urine protein ++, 24-hour urine protein total 3 g. After seeing the patient, the teacher instructed to continue the original formula and add a Spleen-invigorating and Qi-tonifying agent: Astragalus Root (Huang Qi) 30 g, Fried Coix Seed (Chao Yi Ren) 30 g, Dodder Seed (Tu Si Zi) 12 g, Euryale Seed (Qian Shi) 15 g, Ginger Charcoal (Pao Jiang Tan) 5 g, Red Dates (Hong Zao) 5 pieces. One month later, generalized purpura, oral blood blisters, ulcers, and limb edema were basically eliminated. However, purpura occasionally recurred in both lower limbs. Lip cyanosis was basically gone. Stools formed, 1–2 times daily. Urine volume 1200–1500 ml/day. Mental and physical strength improved significantly. Repeated checks showed urine protein stable at ++, 24-hour urine protein 2.55 g. Prednisone had been reduced to 15 mg/day. Tongue body changed from purplish-dark to pale dark, coating thin white. Pulse was deep and fine, clearly palpable. The teacher switched to the following formula: Raw and Prepared Rehmannia Root (Sheng/Di Huang) 30 g each, Cornus Officinalis Fruit (Shan Yu Rou) 10 g, Dioscorea Rhizome (Shan Yao) 15 g, Poria (Fu Ling) 10 g, Moutan Cortex (Dan Pi) 10 g, Lotus Stamen (Bai Lian Xu) 10 g, Alpinia Oxyphylla Fruit (Yi Zhi Ren) 10 g, Dodder Seed (Tu Si Zi) 10 g, Raw Astragalus Root (Sheng Huang Qi) 30 g, Atractylodes Macrocephala Rhizome (Bai Zhu) 10 g, Callicarpa Herb (Zi Zhu Cao) 15 g, Imperata Rhizome (Bai Mao Gen) 30 g, Motherwort Herba (Yi Mu Cao) 15 g, Fried Coix Seed (Chao Yi Ren) 20 g. Also referencing the intention of Simiao Yong'an Decoction: Raw Astragalus Root (Sheng Huang Qi) 30 g, Lonicera Flower (Yin Hua) 15 g, Scrophularia Root (Xuan Shen) 15 g, Angelica Sinensis Root (Dang Gui) 10 g. One dose of each daily. After medication, the rash did not recur again, old hemorrhagic patches gradually faded, and skin became smooth. Urine protein ++, 24-hour 1.75 g. Plasma total protein rose to 6 g% (albumin 3.1 g%), serum cholesterol 368 mg%. Beta-lipoprotein 707 mg%, triglycerides 115 mg%. Pulse was stronger than before. Prednisone was reduced to 2.5 mg/day. By early November, Prednisone was completely withdrawn, and the condition stabilized without recurrence. Throughout the treatment, Ginseng Powder (Ren Shen Fen) 3 g was taken twice daily, and Yunnan Baiyao 2 capsules twice daily.
Intra-departmental Case Discussion
Teacher: This disease belongs to immune-mediated diseases, which are quite tricky for Western medicine. The phenomenon of "three highs and one low," combined with renal biopsy, confirms Nephrotic Syndrome. Angiography combined with typical skin lesions confirms Arteritis. We achieved basic cure using only Chinese herbal medicine in 3 months, demonstrating the unique advantages of TCM. Therefore, we focus on discussing from a TCM perspective to summarize experiences and lessons.
Trainee Physician A: When the patient was first admitted, I lacked confidence, thinking that diseases untreatable in well-equipped Western hospitals could not be cured by us. Facts overturned my assumptions. Under the continuous reduction and eventual cessation of Prednisone and other Western drugs, relying on TCM syndrome differentiation and treatment, we satisfactorily controlled the patient's vasculitis and nephropathy. This is an remarkable achievement. I previously thought Western medicine was scientific while TCM was elusive. Through several months of study, I indeed saw the teacher cure many difficult cases where Western medicine had reached its limits, sparking my interest in TCM and strengthening my confidence in learning it. However, I do not deeply understand the reasons for efficacy and the teacher's thinking process in syndrome differentiation and medication. Could the teacher please discuss the思路 (approach) to syndrome differentiation, legislation, and medication upon admission?
Teacher: The patient had several prominent manifestations upon admission: ① Yin Deficiency with Blood Heat Syndrome: Red and crimson tongue, dark-red macules and papules, blood blisters, erosions, and ulcers in oral mucosa. Generalized vascular and skin bleeding is caused by Yin deficiency and blood heat damaging collaterals. ② Blood Stasis Syndrome: Based on the color of the rash, especially the purplish-dark, hard, and swollen lip and cheek mucosa, and blood blisters appearing upon slight touch, tongue and pulse signs also support Blood Stasis. ⑤ Damp-Heat in Qi Level Syndrome: Yellow and greasy coating, yellow urine with little foam, facial and limb edema, mild itching of rashes. ④ Spleen Deficiency with Qi Weakness Syndrome: Mental depression and physical fatigue, deep and fine pulse difficult to palpate, facial and limb edema more prominent in lower limbs, loose stools, frequent urge with bearing-down sensation, persistent proteinuria. These indicate failure of transformation and transportation, with essence of food and water seeping downward. Summarizing the pathogenesis, the symptoms belong to: Long-standing illness has damaged Liver and Kidney Yin, Zheng Qi is already deficient, Ying Heat forces blood to move recklessly, Blood Stasis obstructs collaterals, Damp-Heat accumulates internally. The formula uses Liuwei Dihuang Pill to nourish Liver and Kidney, while draining Kidney water, assisted by Plantago Seed to enhance clearing and draining effects. Achyranthes Root Charcoal, Agrimony Herba, Eclipta Herba, Greater and Lesser Cirsium, Imperata Rhizome, and heavy use of Moutan Cortex cool blood and stop bleeding, while also dispersing stasis. Black Soybean tonifies Liver and Kidney and promotes damp-heat drainage. Ginseng Powder is added to tonify Qi, and Yunnan Baiyao disperses stasis and stops bleeding. The combined formula achieves the effects of nourishing Liver and Kidney, attending to Zheng Qi, cooling blood and dispersing stasis, invigorating blood and stopping bleeding, clearing Qi and transforming dampness.
Physician B: What impact does Prednisone have on TCM treatment?
Teacher: The ineffectiveness of large doses of Prednisone indicates that this drug is not indicated for this case. Its use instead led to an imbalance of Yin and Yang in the body, presenting a false image of Yin deficiency and damp-heat, causing difficulties for TCM syndrome differentiation and treatment. Therefore, the treatment during this phase was essentially correcting the side effects caused by Prednisone. Prednisone must be stopped, but not abruptly, to prevent adverse consequences from a sudden drop in internal hormone levels. At this time, while strengthening TCM treatment measures, Prednisone was gradually tapered and eventually discontinued, correcting the Yin deficiency and damp-heat image caused by Prednisone, restoring the true nature of the disease. This created favorable conditions for further treatment.
Trainee Physician B: When the teacher changed the formula for the second time, the original formula remained unchanged, but a Spleen-invigorating and Qi-tonifying agent was added. What was the intention?
Teacher: Keeping the original formula unchanged was to further strengthen and consolidate the curative effect. Adding a Spleen-invigorating agent was because Yin deficiency and damp-heat were gradually cleared, revealing the underlying image of Spleen deficiency with dampness, such as loose stools increasing from 2 to 4 times daily, tongue changing from red-crimson to pale-dark, and coating changing from yellow-greasy to thin-white-greasy. Furthermore, long-term use of cold-natured herbs weakened Spleen Yang, which could not withstand the consumption by Yin-nourishing drugs. Thus, a Spleen-invigorating and Qi-tonifying agent was added to strengthen the Spleen and assist transportation, secure Yuan Qi, and prevent the collapse of Spleen and Stomach, which would make medication ineffective, further weaken the Spleen's transport and transformation function, and exacerbate edema and proteinuria. This embodies the principle that Spleen and Stomach are the foundation. Indeed, after adding it, loose stools formed, edema and proteinuria gradually improved, and physical strength recovered quickly, providing a foundation for further treatment.
Trainee Physician A: Why, when the rash was gradually fading, various conditions improving, and only occasional recurrence of the rash, did the teacher not gradually reduce the blood-cooling and stasis-dispersing herbs, but instead use Simiao Yong'an Decoction again?
Teacher: The purpose was to thoroughly control the rash and prevent it from reigniting ("dead ashes hard to burn"). As Xu Dachun said in "On Medication Like Using Troops": "When the disease is just declining, one must pursue its source, add elite forces, so as to strike its stronghold."
Physician A: What are some good TCM methods for treating proteinuria?
Teacher: Based on my personal experience, treating proteinuria requires focusing on both the "disease" and the "syndrome." That is, based on syndrome differentiation, combined with disease differentiation: If there are Chinese herbs that can eliminate proteinuria and conform to or at least do not violate the syndrome differentiation principles of this disease, they can be used. For example, Astragalus Root, Dioscorea Rhizome, Coix Seed, Poria, Dodder Seed, Alpinia Oxyphylla Fruit, and Euryale Seed all have varying degrees of effect in reducing urine protein. These herbs are sweet, neutral, and slightly warm, capable of invigorating the Spleen and benefiting the Kidney. This is because proteinuria is caused by Spleen deficiency leading to failure of transformation and transportation, where the essence of food and water cannot be transported upward but instead leaks downward with the sinking Spleen Qi, and Kidney deficiency leading to failure of opening and closing, loss of storage function, and descent of essence. In this case, combining systemic symptoms and tongue/pulse manifestations, Spleen and Kidney deficiency exists, such as pale white and puffy complexion, loose stools with bearing-down sensation, increased bowel movements after using Yin-nourishing and cooling drugs, fatigue and mental depression, generalized edema, and empty, fine, deep pulse. It is precisely under the condition of Spleen and Kidney deficiency that essential protein leaks downward. Prednisone failed to control proteinuria and instead caused a new imbalance of Yin and Yang, leading to Kidney Yin deficiency, with deficient fire intertwining with damp-heat, further consuming True Yin. Yin deficiency means Yang has nothing to transform, and Spleen Qi and Yang are insufficient, failing to transform water. Thus, proteinuria and edema persist and are difficult to cure. At this time, the first step is to adjust the imbalance of Yin and Yang in the Spleen and Kidney. Since these herbs that adjust Spleen and Kidney Yin and Yang also have the effect of eliminating proteinuria, they are even more suitable for use. After medication, edema subsided, stools solidified, Spleen and Kidney were secured, and protein decreased. If Spleen deficiency is not obvious, but damp-heat is prominent, with yellow urine and much foam, even if proteinuria is severe, it is not appropriate to use herbs like Dodder Seed or Alpinia Oxyphylla Fruit. Therefore, syndrome differentiation remains the primary focus.
Physician B: Why did you use Pao Jiang (Charred Ginger), which is pungent, warm, and hot, when the rash was not completely eliminated and there was still heat in the Blood level?
Teacher: Pao Jiang has good effects of warming the middle and stopping diarrhea and stopping bleeding, making it very suitable for deficiency-cold diarrhea and loose stools. The loose stools in this case are clearly caused by Spleen Yang deficiency and cold. Adding a single herb of Pao Jiang to a large group of blood-cooling and hemostatic formulas can, on one hand, strengthen hemostasis, and on the other hand, prevent cold herbs from damaging Spleen Yang. There is absolutely no risk of disturbing blood, hence its use.
Wugeng Diarrhea Accompanied by Restlessness and Dizziness for 4.5 Years
Jiang Yangqing, MD, Department of Internal Medicine, First Affiliated Hospital, Beijing College of Traditional Chinese Medicine
Zhang X, male, 56 years old, cadre. Admitted on June 24, 1987, Hospitalization No.: 045532.
Since November 1982, due to work stress, the patient experienced increased bowel frequency, 3–6 times daily, reaching up to 5 times at most. Diarrhea worsened after stress or fatigue, with no clear relationship to diet. No abdominal pain, bloating, or pus-blood in stool. Hospitalized at Heilongjiang Provincial People's Hospital, taking Compound Benzethidine and Chinese herbs, symptoms improved slightly. Fiberoptic colonoscopy diagnosed Chronic Colitis and Intestinal Polyps. After discharge, symptoms fluctuated. Various medications were taken, visiting famous doctors in Northeast China. TCM treatments included warming Yang and invigorating Spleen, astringing intestines and stopping diarrhea, light diuresis and separating turbidity, combining cold and hot, raising Yang and benefiting Stomach, drying dampness and resolving phlegm, etc. Poppy Shell (Yangsuke) 15 g per dose was used, along with Compound Benzethidine 3 tablets three times daily, yet diarrhea could not be stopped. Current symptoms: Bowel movements 6–8 times daily, diarrhea immediately upon waking in the early morning (Wugeng), followed by several consecutive watery stools. Occasional abdominal bloating, cold sensation in abdomen, fatigue in limbs, accompanied by dizziness, night sweats, five-palm tidal fever, restlessness, bland taste with poor appetite, morning regurgitation of saliva, restless sleep. Tongue pale-dark, root coating yellow and slightly greasy, pulse fine. The teacher proposed the following formula: Prepared Aconite Root (Shu Fu Pian) 10 g, Cinnamon Bark (Rou Gui) 5 g, Ginger Charcoal (Pao Jiang Tan) 5 g, Roasted Nutmeg (Wei Rou Dou Kou) 10 g, Roasted Chebulic Myrobalan Fruit (Wei He Zi Rou) 10 g, Roasted Costus Root (Wei Mu Xiang) 10 g, Amomum Fruit (Sha Ren) 3 g (added later), Scorched Atractylodes Macrocephala Rhizome (Jiao Bai Zhu) 10 g, Fried Coix Seed (Chao Yi Yi Ren) 20 g, Dried Lotus Leaf (Qian He Ye) 6 g, Euryale Seed (Qian Shi) 20 g, Huai Dioscorea Rhizome (Huai Shan Yao) 15 g, Sichuan Coptis Rhizome (Chuan Lian) 2 g, Scorched Hawthorn Fruit (Jiao Shan Zha) 12 g. 2 doses.
June 24: Reported passing 2 loose stools yesterday, 3 times this morning. Bowel sounds audible, no abdominal pain or bloating. Upper body felt hot with sweating, lower limbs cold. Others same as before. Disease belongs to chronic diarrhea, Spleen-Kidney Yang Deficiency, Hyperactive Heart Fire, complicated by Intestinal Damp-Heat. Adjust previous method: Prepared Aconite Root (Shu Fu Pian) 10 g, Cinnamon Bark (Rou Gui) 3 g, Ginger Charcoal (Pao Jiang Tan) 5 g, Roasted Nutmeg (Wei Rou Kou) 10 g, Roasted Chebulic Myrobalan Fruit (Wei He Zi) 10 g, Roasted Costus Root (Wei Mu Xiang) 6 g, Amomum Fruit (Sha Ren) 3 g, Scorched Atractylodes Macrocephala Rhizome (Jiao Bai Zhu) 10 g, Fried Coix Seed (Chao Yi Ren) 15 g, Dried Lotus Leaf (Qian He Ye) 6 g, Scorched Hawthorn Fruit (Jiao Shan Zha) 12 g, Sichuan Coptis Rhizome (Chuan Lian) 3 g, Dioscorea Rhizome (Shan Yao) 15 g, Mume Fruit Charcoal (Wu Mei Tan) 10 g, Lotus Seed Flesh (Lian Zi Rou) 10 g. Also used powder of Clove Bud (Ding Xiang), Cinnamon Bark (Rou Gui), and Musk (She Xiang) mixed in ratio 20:20:1, applied to Tian Shu, Guan Yuan, Qi Hai, and Pi Shu acupoints with Shangshi Gao plaster, changed once daily.
Slightly modified the above formula and used until July 8. Condition stabilized, passing 1–2 soft stools daily. Physical strength and appetite increased, vomiting and nausea resolved. Added Poppy Shell (Yangsuke) 6 g to original formula, 2 doses daily.
July 13 Ward Round: Condition continued to improve, passing 1 stool daily, forming a pile. Restlessness and other symptoms resolved. Tongue pale-red, root coating gray-greasy. Continue above formula for 4 more days. Still passing 1 stool daily, sometimes formed. Consolidation treatment until discharge on September 6. During hospitalization, barium enema, X-ray, stool culture, fungal culture, and other examinations were performed, showing no obvious abnormalities.
Multiple TCM case discussions were organized within the department, summarized as follows:
Physician A: The patient's symptoms are complex. How did the teacher consider them during syndrome differentiation?
Teacher: This patient has both deficiency-cold and damp-heat aspects, as well as Liver Qi Stagnation manifestations. Selection of formulas and herbs must be based on pathogenesis, which in turn depends on symptoms and etiology. For this patient, I believe the pathogenesis should be: Chronic diarrhea has consumed Spleen Yang, leading to failure of transformation and transportation. Over time, Kidney Yang is damaged, resulting in decline of Spleen and Kidney Yang. Evaporation, transformation, opening, and closing are out of regulation. Water-dampness accumulates internally in the intestines, stagnates and transforms into heat. Damp-heat steams upward. Spleen deficiency allows Liver Wood to invade, leading to disharmony between Wood and Earth.