老师：临床上遇到咳嗽患者，首先当辨别其为内伤咳嗽还是外感咳嗽。此患者平素既无咳嗽痰饮之宿疾，又无肺气肺阴不足之虚象，只于1个多月前偶感外邪而发病，虽然咳嗽始终不愈，但并无气短乏力，痰多气逆，潮热颧红等症，显非内伤咳嗽。且其初起伴有全身不适、畏寒、无汗、鼻塞等症，则其证实属外感咳嗽无疑。既知其为外感咳嗽，则当辨其为何邪所伤。从发病季节来看，其病开始于11月中旬前后，正值霜降、立冬之交，正是气温逐渐转寒，而又燥气偏盛之时，斯时燥寒之气正盛。燥寒之气伤人，一为寒邪从外而受，束闭皮毛，而邪气内舍于肺；一为燥寒之邪从口鼻而入，直伤于肺。再从其临床表现来看，其症有寒无热，且有口燥咽干而痒、干咳无痰等症，与燥寒之邪所引起的症状正相符合。再结合其曾服用过的药物来看，多系清热化痰药(如川贝精片)及辛凉解表(如银翘片、桑菊感冒片)药，服后无效，说明此证之咳嗽，既非因于痰热郁肺，也非由于风热袭肺。这也为我们的辨证提供了必要的佐证。既为燥寒而致之咳嗽，故采用辛开温润法，以辛温之品开肺而散寒，温润之药温肺而润燥，竟收到了较好的效果。
医生乙：请老师谈一下寒燥咳嗽及其证治。
老师：寒燥咳嗽即凉燥咳嗽之寒证偏重者，一般发生于深秋与初冬之时。从时令与主气来看，秋分至小雪之间燥气当令，其时多晴少雨，燥气偏盛。此段时间内，由于气温有寒(凉)热(温)之别，故燥证有温燥与凉燥之不同。从秋分至霜降之间(大约为9月下旬至10月中旬)，气温尚高(华北及西北地区尤为明显)，此时燥热之气较盛，如感受燥热之邪所引起的疾病，称为温燥；霜降之后，气温急骤下降，气候转冷，此时燥凉之气偏盛，感之者即病凉燥。在东北地区，此时之气温已相当寒冷，如仍称为"凉"，已不足以说明其实际情况，故称之为"寒"。由"燥凉"之邪引起之病称为"凉燥"，故我们因之将"燥寒"之邪引起之咳嗽，称为"寒燥咳嗽"。这种咳嗽在秋末、冬初之际相当多见。有的患者久治不愈，可延及整个冬季。病情轻者，可以渐渐自愈。此证之久治不愈，并非由于其证难治，而是由于治不对证而致。肺为娇脏，既易伤于热，也易伤于寒，更易病于燥。当深秋初冬天气乍寒，气候偏燥之日寸，人们尚难于完全适应。特别是在气温时寒寸热，寒热剧变的情况下，极易感受燥寒之邪而为病。其证既有寒束皮毛之表证，又有燥伤肺津之里证，故往往出现全身不适或疼痛、头痛、畏寒、无汗、鼻塞不通等表证，同时又以咳嗽为主要症状。其咳嗽的特点为颐嗽连声，咳声重浊，干咳无痰。即或有痰也少而成块(如其人痰湿素盛，也可出现痰多清稀之症)，遇寒则咳嗽加剧，故每当到室外或半夜室温最低时，或于晚间睡前脱衣及早晨穿衣时，由于寒凉之气袭于皮肤，内舍于肺，故出现咳嗽连声。遇热则咳嗽减轻或完全不咳。由于燥气伤肺，津液不足，故又表现为干咳无痰，或痰少而粘成块，且有咽干而痒，口唇干燥等症。只是这种表现常不引人注意，如不提示，患者往往不会言及。
从上述分析中可知，此证之关键在于寒、燥二字，而其中以寒为主，燥则次之。所以在治疗此证时，以温、润为法，其中以温为主，而以润辅之。所谓"辛开温润"之法，即以辛温之晶温肺而散寒邪，温润之晶滋阴而润肺燥。但必须注意的是，散寒之晶不可过于温热，恐伤津液而化燥；润燥之药不可偏于寒凉，恐寒凉之荮益增肺寒。故如沙参、麦冬、石斛、天冬、花粉、生地、玄参、玉竹等在温燥时经常应用之药，于此证则大不适宜。此方中重用百部、紫菀、款冬花、杏仁等温润之品，既能温肺而散寒，又能润肺而滋燥。又用荆芥、苏叶、生姜等辛温轻扬之品，轻浮以上达于肺而外达皮毛，使从皮毛而入之寒邪复从皮毛而外散。再加陈皮、桔梗、甘草等调理肺气而祛痰。所用药物正符合上面所谈的治疗原则。过去，治疗寒燥咳嗽皆以杏苏散为主方，其方由二陈汤加杏仁、苏叶、枳壳、前胡、桔梗、甘草、生姜、大枣而成。虽有理气化痰散寒之功，但药物偏燥而少润，故对于肺寒而燥者，似不如本方为佳。近些年来每于秋冬之季的寒燥咳嗽，用他药不愈者，常以此方取效。
医生丙：请老师讲一下此证出现诊治错误的原因可能有哪些。
老师：寒燥咳嗽，尽管各年中的发病情况不尽相同，有些年份多些，有些年份少些，但总地看来，每年的深秋与冬季，还是不少见的。此种咳嗽，多数证情较为轻浅，可以不药自愈。证情较重的，如果辨证不确，治疗不当，往往使病情迁延，久治不愈。造成诊断(主要是辨证)和治疗不当的原因，可能有以下几方面：首先，是理论认识上的问题。前面我们分析过，此证之病机主要为"寒"、"燥"二者。但在中医学的发展过程中，有相当长的时间，对"燥"有所忽略。如《素问·至真要大论》的病机十九条中，有风、有寒、有火、有热、有湿，而唯独无"燥"。又如《素问·阴阳应象大论》中有"冬伤于寒，春必病温；春伤于风，夏生飧泄，夏伤于暑，秋必痃疟；秋伤于湿，冬生咳嗽"。《素问，生气通天论》又说，"秋伤于湿，上逆而咳，发为痿厥"。秋季(特别是秋分之后)应为燥气当令，而"上逆而咳，发为痿厥"，本为燥气伤肺，津枯肺燥之结果，但经文中不言燥而言湿。由于以上原因的影响，以致后世有"燥不为病"之说。所以，在金元以前的医学著述中，对燥病的论述是比较少的。直至金元时期的刘河间，才在《素问玄机原病式》中提出了"诸涩枯涸，干劲皴揭，皆属于燥"一条，以补《内经》病机十九条之不足。清·喻嘉言在《医门法律·秋燥论》中改(内经)"秋伤于湿"为秋伤于燥，并制清燥救肺汤。但其论证及用药仍以燥热为主。其后费伯雄提出"以燥为全体，而以热与凉为之用"之说。至此对燥证的认识才转为全面。由于以上历史原因，致使人们对燥证的认识有所疏漏，是在所难免的。其次，从辨证上来看，也有一定的原因。前面讲过，对于本证在燥方面的症状，如果
医生不予提示，详细询问，患者自己往往不太注意，也不会主动地告诉医生。这样就很难考虑为"燥"证。除了"燥"的表现易被忽略外，"寒"的临床表现，也容易疏漏。从中医外感热病学的发展历史来看，在治疗上曾出现过两种大的差误。在清代温病学派未形成之前，往往以辛温之剂治疗温病初起，邪在卫分。这样势必造成以温助热，伤津化燥之弊。今天的情况恰恰与过去相反，而是多以辛凉(或寒凉)来治疗风寒表证。从现在的实际情况看，感受寒邪所引起的疾病，随处可见。但人们对"寒"的认识却日益淡化。人们往往只看到因寒所致之热症，而忽略了病因之寒。这种情况，不仅外感证中存在，而且在各科疾病中也皆存在。这就难免使轻病变重，甚或长期不愈。再次，与现在市场上中成药的情况有很大关系。从近些年的情况看，以治咳嗽为主要作用的中成药，大抵皆为辛凉解表、清肺泄热、化痰之类，如银翘解毒丸(片)、桑菊感冒片、川贝精片、蛇胆陈皮末、牛黄清肺散、珠黄散等比比皆是。而辛温宣肺或温肺之药少之又少，连前些年尚可见到的参苏理肺丸、橘红丸等也越来越少。这不能不认为是造成以寒治寒的原因之一。
痹证日久，药后渐虚
刘XX，男，53岁，1986年4月来诊。该患于10年前因睡卧潮湿阴冷之处而关节疼痛。其痛先从膝部开始，继则足踝、髋部疼痛，渐至周身关节皆痛。服用抗风湿药而疼痛渐止，遂停药。但其后每因天气寒冷，阴雨之时而又疼痛。于每年春秋两季气候冷暖变化或寒热剧变之时发作较为明显。开始时只觉疼痛，以后逐渐关节活动不灵，两腿发凉，脚部尤甚，腰部转侧重滞，腰膝酸软无力。曾先后服用小活络丹、风湿寒痛片、伸筋活络丸、风络痛、虎骨酒等。自己又用走马芹根(即独活)、老鹳草(贯筋)、钻地风、千年见等药用酒泡，长期饮用。以上药物，在初服用时都有一定效果，感觉疼痛减轻，关节活动轻快。但服稍久，则作用不佳，反而出现身体虚乏倦怠，周身关节有松散无力之感，腰膝酸软，久立久行尤甚。且口唇焦燥，渴欲饮冷，咽中干热如冒火，食欲明显减退，动则心悸、汗出，而下肢仍觉发凉。视其舌质淡红而干，脉象沉数无力。
据其症情，先宜滋养阴血，去燥热而补不足。药用：生地25g，白芍15g，玄参25g，麦冬15g，寄生20g，川断20g，牛膝15g，桑枝15g，甘草10g。水煎3次，每日早晚各服1次。5剂后，觉口唇干燥、渴饮、咽中干而冒火等大有好转，其他症状未见明显改变。于是在前方基础上，又加人参10g杜仲15g、枸杞果15g。又5剂后，口唇咽干、燥渴之症已基本消除，食欲增加，身体渐觉有力，出汗、心悸等症也有好转，但腰膝酸软无力、下肢发凉等症并未见轻。视其舌上已经津回，又为其疏方：生地25g，白芍20g，当归15g，黄芪15g，人参10g，川断20g，杜仲炭20g，寄生20g，狗脊15g，枸杞子25g，巴戟天10g，羊藿叶10g，桂枝10g，牛膝15g，甘草10g。5剂后，自觉身体倦怠无力、腰膝酸软有所好转，活动时心悸、汗出更轻于以前。考虑数年之疾，非急切可以收功。况此证并非纯系外邪为患，而气血不足，阴衰阳弱又占重要地位，故变汤剂为丸剂，以收缓图之功。使正气渐复，则邪气自去。重为疏方：当归25g，生地25g，山药25g，黄芪20g，人参15g，白术20g，茯苓20g，川断20g，杜仲炭20g，寄生20g，枸杞子25g，巴戟天10g，羊藿叶10g，桂枝10g，牛膝15g，鸡血藤20g，姜黄15g，甘草15g，白芍20g。上方5剂，干燥后，共为细末，炼蜜为丸，每丸15g，日月艮2户-3丸。11月中旬，患者来讲，上药共做蜜丸210多丸。服用3个月左右，自觉身体逐渐有力，下体发凉疼痛、酸软也有减轻。另外，从前有阴部冷湿，阳举不坚，性欲减弱，夜尿频多之症(患者认为与本病无关，因而未向医生讲)也有明显好转。所以，患者又按前方配药5剂，最近服完，疼痛及酸软等症皆无，而体力增强较为明显，今秋变冷之时，亦未复发。
医生甲看老师开的第一张处方，除了寄生、川断、桑枝外，皆非治痹证常用荮，其意为何?
老师：很对!这张处方所用之药，确非以寻常治痹证之药为主，而是一张以滋养阴血又清燥热为主要功用的处方。所以这样用药是根据患者当时的具体证情而决定的。因为本患者病痹的时间较久，且在长期服用祛风散寒除湿而通络的药物之后，出现一系列阴血虚少，燥热内生之症。此时若无视患者的这些症状，而只是以为痹痛，继续投以上述药物，必然会火上添油，燥热更甚。何况患者在出现口唇咽部干燥的同时，已经食欲明显减退，说明其胃中燥热，阴液伤耗已经很重。患者的其他症状，如身体虚乏、腰膝酸软、心悸、多汗等，都说明患者当时的证情并非以邪气痹阻为主，而是以正气不足的虚象占主导地位。因而在治疗时，放弃了祛邪通痹止痛的治法，未有再用辛烈燥热通窜之晶，而是以补虚扶正作为本病的主要治则，特别是在补虚中，首先采用了滋阴血、清燥热之法。药用诸如生地、玄参、麦冬、白芍等柔润寒凉之品，意在清燥热，复胃阴以使食欲增加。通过治疗过程说明，也正像所预料的那样，在应用上法后，燥热渐除而胃阴渐复，饮食增而精微化，气血渐充，阴阳渐旺，为以后的治疗打下了良好的基础。
医生乙痹证皆因风寒湿三气侵入人体而致，其证属实，可是老师的几张处方皆似以补为主，是否此患之病是虚证呢?
老师：在临床上遇到咳嗽患者时，首先应当辨别其属于内伤咳嗽还是外感咳嗽。这位患者平时既没有咳嗽、咳痰的旧疾，也没有肺气或肺阴不足的虚象，只是在1个多月前偶然感受了外邪而发病。虽然咳嗽一直未愈，但并没有气短乏力、痰多气逆、潮热颧红等症状，显然不是内伤咳嗽。而且他初起时伴有全身不适、畏寒、无汗、鼻塞等症状，因此可以确定属于外感咳嗽。既然知道是外感咳嗽，就应当辨别是何种邪气所致。从发病季节来看，他的病开始于11月中旬前后，正值霜降和立冬交替之时，气温逐渐转寒，而燥气偏盛，此时正是燥寒之气旺盛的时候。燥寒之气伤人，一是寒邪从外部侵袭，束缚皮毛，邪气内侵于肺；二是燥寒之邪从口鼻进入，直接伤害肺部。再结合临床表现来看，他的症状有寒象而无热象，且有口燥咽干发痒、干咳无痰等表现，这与燥寒之邪引起的症状完全相符。再结合他曾服用过的药物来看，多为清热化痰药（如川贝精片）及辛凉解表药（如银翘片、桑菊感冒片），服用后无效，说明此证咳嗽并非因痰热郁肺，也不是由于风热袭肺。这也为我们的辨证提供了必要的佐证。既然是燥寒所致的咳嗽，故采用辛开温润法，用辛温的药物宣通肺气并散寒，用温润的药物温养肺气并润燥，结果收到了较好的疗效。
医生乙：请老师谈谈寒燥咳嗽及其证治。
老师：寒燥咳嗽即凉燥咳嗽中寒证较重者，一般发生在深秋与初冬时节。从时令与主气来看，秋分至小雪之间燥气当令，此时多晴少雨，燥气偏盛。这段时间内，由于气温有寒（凉）与热（温）的区别，所以燥证有温燥与凉燥的不同。从秋分至霜降之间（大约为9月下旬至10月中旬），气温尚高（华北及西北地区尤为明显），此时燥热之气较盛，若感受燥热之邪所引起的疾病，称为温燥；霜降之后，气温急剧下降，气候转冷，此时燥凉之气偏盛，感受者即患凉燥。在东北地区，此时气温已相当寒冷，如果仍称为“凉”，已不足以说明实际情况，故称之为“寒”。由“燥凉”之邪引起的病称为“凉燥”，所以我们据此将“燥寒”之邪引起的咳嗽，称为“寒燥咳嗽”。这种咳嗽在秋末、冬初之际相当多见。有的患者久治不愈，可延续整个冬季。病情轻者，可以渐渐自愈。此证久治不愈，并非因为难治，而是因为治疗不对证。肺为娇脏，既易受热邪伤害，也易受寒邪伤害，更易受燥邪致病。当深秋初冬天气乍寒、气候偏燥时，人们往往难以完全适应。特别是在气温忽冷忽热、寒热剧烈变化的情况下，极易感受燥寒之邪而生病。其证既有寒束皮毛的表证，又有燥伤肺津的里证，故常出现全身不适或疼痛、头痛、畏寒、无汗、鼻塞不通等表证，同时以咳嗽为主要症状。其咳嗽的特点是连续咳嗽，咳声重浊，干咳无痰。即使有痰也很少且成块（如果其人素来痰湿盛，也可出现痰多清稀的症状），遇寒则咳嗽加剧，所以每当到室外或半夜室温最低时，或在晚间睡前脱衣及早晨穿衣时，由于寒凉之气侵袭皮肤，内舍于肺，故出现连续咳嗽。遇热则咳嗽减轻或完全不咳。由于燥气伤肺，津液不足，故又表现为干咳无痰，或痰少而粘成块，且有咽干发痒、口唇干燥等症状。只是这种表现常不引人注意，如果不提示，患者往往不会主动提及。
从上述分析可知，此证的关键在于“寒”、“燥”二字，其中以寒为主，燥次之。所以在治疗此证时，以温、润为法，其中以温为主，而以润为辅。所谓“辛开温润”之法，即以辛温的药物温肺散寒邪，温润的药物滋阴润肺燥。但必须注意的是，散寒的药物不可过于温热，恐怕损伤津液而化燥；润燥的药物不可偏于寒凉，恐怕寒凉之药增加肺寒。所以像沙参、麦冬、石斛、天冬、花粉、生地、玄参、玉竹等在温燥时经常应用的药物，对此证则非常不适宜。此方中重用百部、紫菀、款冬花、杏仁等温润之品，既能温肺散寒，又能润肺滋燥。又用荆芥、苏叶、生姜等辛温轻扬之品，轻浮而上达于肺并外达皮毛，使从皮毛而入的寒邪又从皮毛向外发散。再加陈皮、桔梗、甘草等调理肺气并祛痰。所用药物正符合上面所谈的治疗原则。过去，治疗寒燥咳嗽多以杏苏散为主方，该方由二陈汤加杏仁、苏叶、枳壳、前胡、桔梗、甘草、生姜、大枣组成。虽有理气化痰散寒之功，但药物偏燥而少润，所以对于肺寒而燥者，似乎不如本方好。近些年来，每逢秋冬季节的寒燥咳嗽，用其他药不愈者，常用此方取效。
医生丙：请老师讲一下此证出现诊治错误的原因可能有哪些。
老师：寒燥咳嗽，尽管每年的发病情况不尽相同，有些年份多些，有些年份少些，但总体看来，每年的深秋与冬季，还是不少见的。此种咳嗽，多数证情较为轻浅，可以不药自愈。证情较重的，如果辨证不确，治疗不当，往往使病情迁延，久治不愈。造成诊断（主要是辨证）和治疗不当的原因，可能有以下几方面：首先，是理论认识上的问题。前面我们分析过，此证的病机主要为“寒”、“燥”二者。但在中医学的发展过程中，有相当长的时间，对“燥”有所忽略。如《素问·至真要大论》的病机十九条中，有风、有寒、有火、有热、有湿，而唯独无“燥”。又如《素问·阴阳应象大论》中有“冬伤于寒，春必病温；春伤于风，夏生飧泄，夏伤于暑，秋必痃疟；秋伤于湿，冬生咳嗽”。《素问·生气通天论》又说，“秋伤于湿，上逆而咳，发为痿厥”。秋季（特别是秋分之后）应为燥气当令，而“上逆而咳，发为痿厥”，本为燥气伤肺，津枯肺燥的结果，但经文中不言燥而言湿。由于以上原因的影响，以致后世有“燥不为病”之说。所以，在金元以前的医学著述中，对燥病的论述是比较少的。直至金元时期的刘河间，才在《素问玄机原病式》中提出了“诸涩枯涸，干劲皴揭，皆属于燥”一条，以补《内经》病机十九条之不足。清代喻嘉言在《医门法律·秋燥论》中将《内经》中的“秋伤于湿”改为“秋伤于燥”，并创制清燥救肺汤。但其论证及用药仍以燥热为主。其后费伯雄提出“以燥为全体，而以热与凉为之用”之说。至此对燥证的认识才转为全面。由于以上历史原因，致使人们对燥证的认识有所疏漏，是在所难免的。其次，从辨证上来看，也有一定的原因。前面讲过，对于本证在燥方面的症状，如果医生不予提示，详细询问，患者自己往往不太注意，也不会主动地告诉医生。这样就很难考虑为“燥”证。除了“燥”的表现易被忽略外，“寒”的临床表现，也容易疏漏。从中医外感热病学的发展历史来看，在治疗上曾出现过两种大的差误。在清代温病学派未形成之前，往往以辛温之剂治疗温病初起，邪在卫分。这样势必造成以温助热，伤津化燥之弊。今天的情况恰恰与过去相反，而是多以辛凉（或寒凉）来治疗风寒表证。从现在的实际情况看，感受寒邪所引起的疾病，随处可见。但人们对“寒”的认识却日益淡化。人们往往只看到因寒所致之热症，而忽略了病因之寒。这种情况，不仅外感证中存在，而且在各科疾病中也皆存在。这就难免使轻病变重，甚或长期不愈。再次，与现在市场上中成药的情况有很大关系。从近些年的情况看，以治咳嗽为主要作用的中成药，大抵皆为辛凉解表、清肺泄热、化痰之类，如银翘解毒丸（片）、桑菊感冒片、川贝精片、蛇胆陈皮末、牛黄清肺散、珠黄散等比比皆是。而辛温宣肺或温肺之药少之又少，连前些年尚可见到的参苏理肺丸、橘红丸等也越来越少。这不能不认为是造成以寒治寒的原因之一。
痹证日久，药后渐虚
刘XX，男，53岁，1986年4月来诊。该患者于10年前因睡卧潮湿阴冷之处而关节疼痛。其痛先从膝部开始，继则足踝、髋部疼痛，渐至周身关节皆痛。服用抗风湿药而疼痛渐止，遂停药。但其后每因天气寒冷，阴雨之时而又疼痛。于每年春秋两季气候冷暖变化或寒热剧变之时发作较为明显。开始时只觉疼痛，以后逐渐关节活动不灵，两腿发凉，脚部尤甚，腰部转侧重滞，腰膝酸软无力。曾先后服用小活络丹、风湿寒痛片、伸筋活络丸、风络痛、虎骨酒等。自己又用走马芹根（即独活）、老鹳草（贯筋）、钻地风、千年见等药用酒泡，长期饮用。以上药物，在初服用时都有一定效果，感觉疼痛减轻，关节活动轻快。但服稍久，则作用不佳，反而出现身体虚乏倦怠，周身关节有松散无力之感，腰膝酸软，久立久行尤甚。且口唇焦燥，渴欲饮冷，咽中干热如冒火，食欲明显减退，动则心悸、汗出，而下肢仍觉发凉。视其舌质淡红而干，脉象沉数无力。
据其症情，先宜滋养阴血，去燥热而补不足。药用：生地25g，白芍15g，玄参25g，麦冬15g，寄生20g，川断20g，牛膝15g，桑枝15g，甘草10g。水煎3次，每日早晚各服1次。5剂后，觉口唇干燥、渴饮、咽中干而冒火等大有好转，其他症状未见明显改变。于是在前方基础上，又加人参10g、杜仲15g、枸杞果15g。又5剂后，口唇咽干、燥渴之症已基本消除，食欲增加，身体渐觉有力，出汗、心悸等症也有好转，但腰膝酸软无力、下肢发凉等症并未见轻。视其舌上已经津回，又为其疏方：生地25g，白芍20g，当归15g，黄芪15g，人参10g，川断20g，杜仲炭20g，寄生20g，狗脊15g，枸杞子25g，巴戟天10g，羊藿叶10g，桂枝10g，牛膝15g，甘草10g。5剂后，自觉身体倦怠无力、腰膝酸软有所好转，活动时心悸、汗出更轻于以前。考虑数年之疾，非急切可以收功。况此证并非纯系外邪为患，而气血不足，阴衰阳弱又占重要地位，故变汤剂为丸剂，以收缓图之功。使正气渐复，则邪气自去。重为疏方：当归25g，生地25g，山药25g，黄芪20g，人参15g，白术20g，茯苓20g，川断20g，杜仲炭20g，寄生20g，枸杞子25g，巴戟天10g，羊藿叶10g，桂枝10g，牛膝15g，鸡血藤20g，姜黄15g，甘草15g，白芍20g。上方5剂，干燥后，共为细末，炼蜜为丸，每丸15g，每日服2-3丸。11月中旬，患者来讲，上药共做蜜丸210多丸。服用3个月左右，自觉身体逐渐有力，下体发凉疼痛、酸软也有减轻。另外，从前有阴部冷湿，阳举不坚，性欲减弱，夜尿频多之症（患者认为与本病无关，因而未向医生讲）也有明显好转。所以，患者又按前方配药5剂，最近服完，疼痛及酸软等症皆无，而体力增强较为明显，今秋变冷之时，亦未复发。
医生甲看老师开的第一张处方，除了寄生、川断、桑枝外，皆非治痹证常用药，其意为何？
老师：很对！这张处方所用之药，确非以寻常治痹证之药为主，而是一张以滋养阴血又清燥热为主要功用的处方。所以这样用药是根据患者当时的具体证情而决定的。因为本患者病痹的时间较久，且在长期服用祛风散寒除湿而通络的药物之后，出现一系列阴血虚少，燥热内生之症。此时若无视患者的这些症状，而只是以为痹痛，继续投以上述药物，必然会火上浇油，燥热更甚。何况患者在出现口唇咽部干燥的同时，已经食欲明显减退，说明其胃中燥热，阴液伤耗已经很重。患者的其他症状，如身体虚乏、腰膝酸软、心悸、多汗等，都说明患者当时的证情并非以邪气痹阻为主，而是以正气不足的虚象占主导地位。因而在治疗时，放弃了祛邪通痹止痛的治法，未有再用辛烈燥热通窜之药，而是以补虚扶正作为本病的主要治则，特别是在补虚中，首先采用了滋阴血、清燥热之法。药用诸如生地、玄参、麦冬、白芍等柔润寒凉之品，意在清燥热，复胃阴以使食欲增加。通过治疗过程说明，也正像所预料的那样，在应用上法后，燥热渐除而胃阴渐复，饮食增而精微化，气血渐充，阴阳渐旺，为以后的治疗打下了良好的基础。
医生乙：痹证皆因风寒湿三气侵入人体而致，其证属实，可是老师的几张处方皆似以补为主，是否此患之病是虚证呢？
Teacher: When encountering patients with cough in clinical practice, one must first distinguish whether it is an internal injury cough (internal injury cough) or an external contraction cough (external contraction cough). This patient has no history of chronic cough or phlegm-fluid retention, nor any deficiency signs of lung Qi or lung Yin. The illness began only about a month ago after accidental exposure to external pathogens. Although the cough has persisted, there are no symptoms such as shortness of breath and fatigue, excessive phlegm with rebellious Qi, tidal fever, or malar flush; thus, it is clearly not an internal injury cough. Moreover, the initial onset was accompanied by systemic discomfort, aversion to cold, absence of sweating, and nasal congestion, confirming that this is undoubtedly an external contraction cough. Knowing it is an external contraction cough, we must further differentiate which pathogen caused it. From the perspective of the season of onset, the illness began around mid-November, at the transition between Frost's Descent and Start of Winter. During this period, temperatures gradually drop while dryness Qi prevails, making dry-cold Qi particularly strong. Dry-cold Qi injures the human body in two ways: first, cold pathogen enters from the exterior, binding the skin and hair, and the pathogen moves inward to lodge in the Lung; second, dry-cold pathogen enters through the mouth and nose, directly injuring the Lung. Combining this with clinical manifestations, the patient presents with cold signs but no heat signs, along with dry mouth and throat with itching, and dry cough without phlegm. These symptoms perfectly match those caused by dry-cold pathogen. Furthermore, considering the medications previously taken—mostly heat-clearing and phlegm-resolving drugs (such as Chuanbei Jing Pian) and acrid-cool exterior-releasing agents (such as Yinqiao Pian and Sangju Ganmao Pian)—which proved ineffective, it indicates that this cough is neither due to phlegm-heat stagnating in the Lung nor wind-heat attacking the Lung. This provides necessary corroboration for our syndrome differentiation. Since the cough is caused by dry-cold, we adopted the method of "acrid-opening and warm-moistening." We used acrid-warm herbs to open the Lung and disperse cold, and warm-moistening herbs to warm the Lung and moisten dryness, achieving good results.
Doctor Yi: Please discuss cold-dry cough and its syndrome differentiation and treatment.
Teacher: Cold-dry cough refers to cases where the cold aspect of cool-dry cough (cool-dry cough) is predominant. It generally occurs in late autumn and early winter. From the perspective of seasonal timing and dominant Qi, between Autumn Equinox and Light Snow, dryness Qi is in command. The weather is mostly sunny with little rain, and dryness Qi is strong. Within this period, due to variations in temperature (cool vs. warm), dryness syndromes differ into warm-dry and cool-dry. Between Autumn Equinox and Frost's Descent (approximately late September to mid-October), temperatures remain relatively high (especially obvious in North China and Northwest China), and dry-heat Qi is strong. Diseases caused by contracting dry-heat pathogen are called warm-dry. After Frost's Descent, temperatures drop sharply, and the climate turns cold. At this time, dry-cool Qi prevails, and contracting it leads to cool-dry disease. In Northeast China, temperatures are already quite cold; referring to it merely as "cool" is insufficient to describe the reality, so it is termed "cold." Diseases caused by "dry-cool" pathogen are called "cool-dry," so we term coughs caused by "dry-cold" pathogen as "cold-dry cough." This type of cough is quite common in late autumn and early winter. Some patients suffer from it for a long time without cure, extending through the entire winter. Mild cases may resolve spontaneously over time. The persistence of this syndrome is not due to difficulty in treatment but rather incorrect treatment. The Lung is a delicate organ, susceptible to heat, cold, and especially dryness. When the weather turns suddenly cold and dry in late autumn and early winter, people often struggle to adapt. Especially under conditions of fluctuating temperatures and drastic changes between cold and heat, one is highly susceptible to dry-cold pathogen. The syndrome involves both exterior signs of cold binding the skin and hair and interior signs of dryness injuring Lung fluids. Thus, exterior signs such as systemic discomfort or pain, headache, aversion to cold, absence of sweating, and nasal congestion often appear, alongside cough as the main symptom. The cough is characterized by continuous bouts, heavy and turbid sound, and dry cough without phlegm. Even if phlegm exists, it is scanty and clumped (if the person has a constitution prone to phlegm-dampness, copious clear phlegm may occur). Cough worsens upon exposure to cold; therefore, when going outdoors, during the coldest hours of the night, or when undressing before sleep and dressing in the morning, the invasion of cold air into the skin and lodging in the Lung triggers continuous coughing. Upon exposure to heat, the cough alleviates or stops completely. Due to dryness injuring the Lung and insufficient fluids, symptoms include dry cough without phlegm, or scanty sticky clumped phlegm, along with dry and itchy throat and dry lips. However, these manifestations are often overlooked; unless prompted, patients rarely volunteer this information.
From the above analysis, the key to this syndrome lies in "cold" and "dryness," with cold being primary and dryness secondary. Therefore, treatment focuses on warming and moistening, prioritizing warming and assisting with moistening. The "acrid-opening and warm-moistening" method uses acrid-warm herbs to warm the Lung and disperse cold pathogen, and warm-moistening herbs to nourish Yin and moisten Lung dryness. Crucially, cold-dispersing herbs must not be too hot, lest they damage fluids and generate dryness; dryness-moistening herbs must not be too cold, lest they increase Lung cold. Thus, herbs commonly used for warm-dry, such as Glehniae Radix (Shashen), Ophiopogonis Radix (Maidong), Dendrobii Caulis (Shihu), Asparagi Radix (Tian Dong), Paeoniae Radix Alba (Huafen - *Note: usually refers to Trichosanthis Radix here*), Rehmanniae Radix (Sheng Di), Scrophulariae Radix (Xuanshen), and Polygonati Odorati Rhizoma (Yuzhu), are highly unsuitable for this syndrome. This prescription heavily employs warm-moistening herbs like Stemona Radix (Baibu), Asteris Radix (Zi Wan), Farfioris Flos (Kua Dong Hua), and Armeniacae Semen Amarum (Xing Ren), which can both warm the Lung to disperse cold and moisten the Lung to nourish dryness. It also uses light and ascending acrid-warm herbs like Schizonepetae Herba (Jing Jie), Perillae Folium (Su Ye), and Zingiberis Rhizoma Recens (Sheng Jiang) to reach the Lung from above and the skin from outside, allowing cold pathogen entering via the skin to dissipate outward. Additionally, Citri Reticulatae Pericarpium (Chen Pi), Platycodonis Radix (Jie Geng), and Glycyrrhizae Radix et Rhizoma (Gan Cao) regulate Lung Qi and resolve phlegm. The herbs used align with the aforementioned treatment principles. Historically, Xing Su San (Apricot and Perilla Powder) was the primary formula for cold-dry cough, composed of Er Chen Tang plus Armeniacae Semen Amarum, Perillae Folium, Aurantii Fructus Immaturus (Zhi Ke), Peucedani Radix (Qian Hu), Platycodonis Radix, Glycyrrhizae Radix et Rhizoma, Zingiberis Rhizoma Recens, and Jujubae Fructus. While it has effects of regulating Qi, resolving phlegm, and dispersing cold, its herbs are predominantly drying with few moistening ones, making it less suitable than this prescription for Lung cold with dryness. In recent years, this prescription has proven effective for cold-dry coughs in autumn and winter that do not respond to other medicines.
Doctor Bing: What might be the reasons for diagnostic and treatment errors in this syndrome?
Teacher: Although the incidence of cold-dry cough varies annually, it remains common in late autumn and winter. Most cases are mild and may resolve spontaneously without medication. Severe cases, if misdiagnosed or improperly treated, often become chronic. Reasons for diagnostic (mainly syndrome differentiation) and treatment errors include: First, theoretical understanding. As analyzed, the pathogenesis involves "cold" and "dryness." However, throughout TCM history, "dryness" was often neglected. For instance, among the Nineteen Pathogenesis Statements in *Su Wen: Zhi Zhen Yao Da Lun*, there are Wind, Cold, Fire, Heat, and Dampness, but no Dryness. Similarly, *Su Wen: Yin Yang Ying Xiang Da Lun* states, "Winter injury by cold leads to warmth diseases in spring; spring injury by wind leads to undigested food diarrhea in summer; summer injury by summer-heat leads to malaria in autumn; autumn injury by dampness leads to cough in winter." *Su Wen: Sheng Qi Tong Tian Lun* says, "Autumn injury by dampness causes rebellious Qi leading to cough and flaccidity/numbness." Autumn (especially after Autumn Equinox) should be dominated by dryness Qi, yet the text mentions dampness causing cough and flaccidity, which are actually results of dryness injuring the Lung and drying up fluids. Due to these influences, later generations held the view that "dryness does not cause disease." Consequently, pre-Jin-Yuan medical texts discussed dryness diseases sparingly. It was not until Liu Hejian in the Jin-Yuan period who, in *Su Wen Xuan Ji Yuan Bing Shi*, proposed "All astringency, withering, drying, stiffness, and cracking belong to dryness," supplementing the *Nei Jing*. Later, Yu Jiayan in Qing Dynasty's *Yi Men Fa Lv: Qiu Zao Lun* changed "autumn injury by dampness" to "autumn injury by dryness" and created Qing Zao Jiu Fei Tang. However, his arguments and prescriptions still focused mainly on dry-heat. Subsequently, Fei Boxiong proposed viewing dryness as the whole, with heat and coolness as its applications. Only then did the understanding of dryness syndromes become comprehensive. Historical reasons inevitably led to omissions in recognizing dryness syndromes. Second, from a differentiation perspective, certain factors contribute. As mentioned, if doctors do not prompt or ask detailed questions regarding dryness symptoms, patients often overlook them and do not volunteer this information, making it difficult to consider a "dryness" syndrome. Besides dryness signs being easily ignored, cold clinical manifestations are also prone to omission. Looking at the history of TCM exogenous febrile diseases, two major therapeutic errors occurred. Before the formation of the Warm Disease School in the Qing Dynasty, acrid-warm formulas were often used for the initial stage of warm diseases (pathogen in the Wei level), inevitably aiding heat with warmth, damaging fluids, and generating dryness. Today, the situation is reversed: acrid-cool (or cold-cool) agents are frequently used to treat wind-cold exterior syndromes. Currently, diseases caused by cold pathogen are ubiquitous, yet the recognition of "cold" is fading. People often see only the heat symptoms resulting from cold, ignoring the cold etiology. This phenomenon exists not only in exogenous syndromes but across all specialties, potentially turning mild diseases severe or chronic. Third, the market availability of Chinese patent medicines plays a significant role. Recently, most cough-patent medicines are acrid-cool exterior-releasers, lung-heat-clearers, or phlegm-resolvers, such as Yinqiao Jiedu Wan/Pian, Sangju Ganmao Pian, Chuanbei Jing Pian, Shedan Chenpi Mo, Niuhuang Qingfei San, and Zhuhuang San. Acrid-warm lung-opening or lung-warming herbs are scarce; even previously common Shen Su Li Fei Wan and Juhong Wan are becoming rare. This contributes significantly to the tendency to treat cold with cold.
Bi Syndrome prolonged, deficiency emerging after medication
Professor Xiao Yonglin and Chen Fengzhi, Changchun University of Traditional Chinese Medicine
Liu XX, male, 53 years old, visited in April 1986. Ten years prior, joint pain began after sleeping in a damp, cold place. Pain started in the knees, then spread to ankles and hips, eventually affecting all joints. Rheumatoid medications temporarily relieved pain, leading to discontinuation. However, pain recurred during cold weather and rainy days, particularly during seasonal transitions in spring and autumn. Initially, only pain was felt; later, joint mobility decreased, legs felt cold (especially feet), waist movement was stiff, and lower back and knees felt sore and weak. Treatments included Xiao Huoluo Dan, Fengshi Han Tong Pian, Shenjin Huoluo Wan, Fengluo Tong, and Tiger Bone Wine. Self-medication involved soaking roots of Heracleum hemsleyanum (Zoumaqin/Du Huo), Old Stork's Bill (Laoguancao/Guanjin), Cissus sicyoides (Zuandifeng), and Panax japonicus (Qiannianjian) in wine for long-term consumption. Initially, these provided relief and improved mobility. However, prolonged use led to poor efficacy, resulting in physical weakness, fatigue, a sensation of looseness and weakness in all joints, sore and weak lower back and knees (worse with standing/walking), scorched lips, thirst for cold drinks, dry and burning throat, reduced appetite, palpitations and sweating upon exertion, while lower limbs remained cold. Tongue was pale red and dry; pulse was deep, rapid, and forceless.
Based on symptoms, the priority was to nourish Yin and Blood, clear dry-heat, and tonify deficiency. Prescription: Sheng Di Huang 25g, Bai Shao 15g, Xuan Shen 25g, Mai Dong 15g, Du Zhong (Du Zhong) 20g, Xu Duan 20g, Niu Xi 15g, Sang Zhi 15g, Gan Cao 10g. Decocted in water three times, taken morning and evening. After 5 doses, lip dryness, thirst, and throat burning improved significantly, though other symptoms remained unchanged. Based on this, Ren Shen 10g, Du Zhong 15g, and Gou Qi Zi 15g were added. After another 5 doses, lip/throat dryness and thirst were basically eliminated, appetite increased, strength returned, and sweating/palpitations improved, but lower back/knee soreness and leg coldness persisted. With fluid returning to the tongue, a new prescription was given: Sheng Di Huang 25g, Bai Shao 20g, Dang Gui 15g, Huang Qi 15g, Ren Shen 10g, Xu Duan 20g, Du Zhong Tan 20g, Du Zhong 20g, Gou Ji 15g, Gou Qi Zi 25g, Ba Ji Tian 10g, Lu Hui Ye 10g, Gui Zhi 10g, Niu Xi 15g, Gan Cao 10g. After 5 doses, fatigue and lower back/knee soreness improved, and palpitations/sweating during activity were lighter. Considering the chronic nature of the disease, immediate cure was unlikely. Since this case was not purely external pathogen but involved significant Qi/Blood deficiency and Yin/Yang weakness, decoction was switched to pills for gradual effect, aiming to restore Zheng Qi so Xie Qi would naturally depart. New prescription: Dang Gui 25g, Sheng Di Huang 25g, Shan Yao 25g, Huang Qi 20g, Ren Shen 15g, Bai Zhu 20g, Fu Ling 20g, Xu Duan 20g, Du Zhong Tan 20g, Du Zhong 20g, Gou Qi Zi 25g, Ba Ji Tian 10g, Lu Hui Ye 10g, Gui Zhi 10g, Niu Xi 15g, Ji Xue Teng 20g, Jiang Huang 15g, Gan Cao 15g, Bai Shao 20g. Five doses were dried, ground into fine powder, and formed into honey pills, each 15g, taken 2-3 times daily. In mid-November, the patient reported making over 210 honey pills. After about 3 months of use, physical strength gradually increased, and lower body coldness, pain, and soreness alleviated. Additionally, previous symptoms of cold/damp genitals, weak erection, reduced libido, and frequent nocturia (previously unreported as unrelated) improved significantly. The patient refilled the prescription for 5 doses. Upon finishing, pain and soreness disappeared, strength noticeably increased, and no recurrence occurred despite the cold autumn weather.
Doctor A asked why the first prescription contained few typical Bi-syndrome herbs besides Du Zhong, Xu Duan, and Sang Zhi.
Teacher: Correct! This prescription primarily aims to nourish Yin/Blood and clear dry-heat, rather than using standard Bi-syndrome herbs. This approach was dictated by the patient's specific condition. Having suffered from Bi syndrome for a long time and taken wind-dispelling, cold-resolving, damp-draining, and channel-unblocking herbs for an extended period, the patient developed signs of Yin/Blood deficiency and internal dry-heat. Ignoring these symptoms and continuing with the same herbs would be adding fuel to the fire, worsening dry-heat. Moreover, concurrent loss of appetite indicated severe stomach dry-heat and Yin depletion. Other symptoms like weakness, sore back/knees, palpitations, and sweating indicated that deficiency of Zheng Qi, rather than pathogen obstruction, was dominant. Thus, the treatment abandoned dispelling pathogens and unblocking channels for pain relief, avoiding harsh, drying, and penetrating herbs. Instead, tonifying deficiency and supporting Zheng Qi became the main principle, specifically starting with nourishing Yin/Blood and clearing dry-heat using soft, moist, cold-cool herbs like Sheng Di Huang, Xuan Shen, Mai Dong, and Bai Shao. The intent was to clear dry-heat and restore Stomach Yin to improve appetite. The treatment outcome confirmed expectations: dry-heat gradually cleared, Stomach Yin restored, diet improved, essence transformed, Qi/Blood filled, and Yin/Yang strengthened, laying a solid foundation for subsequent treatment.
Doctor B: Bi syndrome is caused by invasion of Wind, Cold, and Dampness, presenting as excess. Yet your prescriptions seem primarily tonifying. Is this patient's disease a deficiency syndrome?