Dai, female, 76 years old. First diagnosis on March 20 10 10.

Joint pain and muscle pain all over the body 1 year, which can't be diagnosed clearly after multiple diagnosis and treatment, and the treatment has no curative effect. The symptoms are: finger joint pain, waist, back, hip and knee pain, limb muscles pain from time to time, sometimes jet lag, affecting sleep. Accompanied by dry mouth, four adverse reactions, anorexia, and sometimes trembling. White tongue coating, thin and stringy pulse. Differentiation of six meridians belongs to Taiyin disease, and the syndrome of differentiation is Guizhi Shaoyao Zhimu Decoction, Poria, Chenpi and Ciji. Prescription: 6 g of Herba Ephedrae, 0/0g of Ramulus Cinnamomi/kloc, 0/0g of Rhizoma Anemarrhenae/kloc, 0/0g of Radix Paeoniae Alba, 0/5g of Rhizoma Atractylodis/kloc, 0/2g of Radix Aconiti Lateralis Preparata/kloc, 0/2g of Poria/kloc and 0/2g of Radix Saposhnikoviae. 7 doses, decocted in water.

20 10/March 017th Second visit: The symptoms are the same as before, and the stool is dry. Differentiation of the six meridians belongs to the diseases of Jueyin and Taiyin, and the syndrome of differentiation of prescriptions belongs to Chaihu Guizhi Ganjiang Decoction combined with Danggui Shaoyao Powder. Prescription: Bupleurum12g, Scutellariae Radix10g, Trichosanthes Radix12g, raw Os Draconis and oysters15g, Ramulus Cinnamomi10g, dried ginger 6g, Chinese angelica10g. 7 doses, decocted in water.

20 10/24 March: The patient complained that the first party was invalid, but taking the second party was particularly effective. Dry mouth, body aches, body tremors and joint pains are all obviously relieved. White tongue coating, thin and stringy pulse. The dried ginger above was changed to10g, followed by 7 doses.

20 10/March 3 1 day four consultations: the symptoms continued to improve, the back pain was more obvious, and the hands and feet were milder than before. White tongue coating, thin and stringy pulse. Add 0/5g of Rhizoma Cibotii/KLOC-above, 7 doses, and decoct with water.

20 10: The whole body feels comfortable and relaxed, the joint pain is not obvious, the sleep is obviously improved, the food intake is good, and the urination and defecation are normal. White tongue coating, thin and stringy pulse. Remove Rhizoma Atractylodis from the top, add Rhizoma Atractylodis Macrocephalae15g, Rhizoma Alismatis15g, Rhizoma Cibotii12g, 7 doses, and decoct with water.

20 10/April 014th Six diagnosis: All the symptoms have been cured without discomfort. Tell the superior to continue taking 7 doses and stop taking the medicine.

Sports meeting

Syndrome differentiation is the tip of syndrome differentiation.

Different academic schools of traditional Chinese medicine have different theoretical systems, but it is an indisputable fact that the curative effect of prescription drugs depends on the degree of coincidence between the syndrome treated by prescription and the syndrome suffered by patients. We can use "monarch, minister, assistant and envoy" to decipher the composition of Mahuang decoction and "three supplements and three purges" to decipher the composition of Liuwei Dihuang pill, but we find that not all the doctors who can skillfully interpret and master the prescription are doctors with high clinical efficacy. Why? Perhaps we can make such an analogy: the whole process of syndrome differentiation and treatment includes "strategic deployment" and "hand-to-hand combat". All the theoretical reserves of Chinese medicine we have learned serve the strategic deployment. The real hand-to-hand combat is the correspondence between the prescription and the certificate on the prescription paper, and it is the hand-to-hand combat that finally tells the success or failure. Just as in this case, the initial diagnosis and syndrome differentiation seems to be correct, but the prescription and syndrome are inconsistent, which is invalid. Instead, the combination of two prescriptions and syndromes has obvious effect. The difference between them requires the witness to study hard and think hard, plus "wisdom and understanding alone."

Mr. Hu Xishu has made a very incisive exposition on syndrome differentiation from the clinical point of view: "Although the six meridians and eight outlines are the basis of syndrome differentiation, and on this basis, the criteria for treatment can indeed be formulated, as mentioned above, but if the clinical application is concerned, it is still far from enough. For example, there are many prescriptions for sweating according to law for sun disease. Is it possible to use any sweating medicine effectively? Our answer is no, absolutely not, because TCM syndrome differentiation is not only about differentiating the six meridians and eight classes, but more importantly, it is also necessary to distinguish the indications of prescriptions and syndromes through them. Of course, sunstroke requires sweating, but sweating must be based on the overall situation, such as, more specifically, besides the general characteristics of sunstroke, all other conditions of patients should be carefully examined, so as to choose a fully adapted sweating drug, which can achieve the expected curative effect ... However, the differentiation of prescription and syndrome is not as simple and easy to know as the six classics and eight outlines, and it is necessary to memorize it in detail in the specific treatment of syndrome. "("Hu Xishu talks about typhoid and miscellaneous diseases ")

Syndrome of Chaihu Guizhi Ganjiang Decoction

The prescription of Chaihu Guizhi Ganjiang Decoction can be found in the article 147 of Taiyang in Treatise on Febrile Diseases: "The typhoid fever has returned after five or six days, and the chest and hypochondrium are full of slight knots, and urination is not good, but the head sweats, cold and heat, and upset, which is the main treatment." Traditionally, the interpretation of this prescription is mostly from the perspective of zang-fu organs and meridians, and it is considered that the syndrome belongs to deficiency of spleen and fluid, or to deficiency of yin and cold due to deficiency of yang, or to spleen deficiency and cold due to stagnation of heat in liver and gallbladder, and so on. In the process of inheriting the theory of his teacher, Mr. Hu Xishu, Feng Shilun repeatedly studied articles 147 and 148 of Treatise on Febrile Diseases, and combined with clinical practice, clearly put forward that this prescription belongs to Jue Yin disease rather than Shao Yang disease. Feng Shilun pointed out in the book Interpretation of Zhang Zhongjing's Medicine: "Scholars think that the location of the syndrome of this prescription is the same in half exterior and half interior, but influenced by the interpretation of typhoid fever in Neijing, they always think that half exterior and half interior is shaoyang, Xiaochaihu decoction is the representative of shaoyang disease, and Chaihu Guizhi Ganjiang decoction is modified from Xiaochaihu decoction, so it is still regarded as shaoyang. The reason is that the essence of six meridians is unknown. We should know that the six meridians in Treatise on Febrile Diseases are not the zang-fu organs and meridians in the Neijing, but the six meridians formed by adding the concept of semi-exterior and semi-interior to the eight classes. In the semi-exterior and semi-interior, there are yang syndrome and yin syndrome, and the yang syndrome is shaoyang disease and the yin syndrome is Jueyin disease. "Dried ginger and easy ginger are the big eyes that distinguish Chaihu Guizhi Dried Ginger Decoction from Xiaochaihu Decoction. At the same time, it reminds future generations that Xiaochaihu Decoction focuses on relieving half-exterior and half-interior heat, while Chaihu Guizhi Dried Ginger Decoction tends to dispel half-exterior and half-interior cold. 」

Chaihu Guizhi Ganjiang Decoction is one of Feng Shilun's commonly used prescriptions, and those who suffer from Jue Yin disease with mixed cold and heat have more opportunities to use this prescription. The main points of Feng Shilun's clinical identification of this prescription are that there is dry mouth (or bitter mouth) in the upper part, dry stool in the lower part and four adverse reactions in the outer part. What interests me is that, if interpreted from the perspective of viscera and meridians, this prescription should have spleen deficiency and spleen cold (or too yin deficiency and cold), and one of its important indications is loose stool. However, Feng Shilun interprets the Six Classics according to the Eight Outline, and thinks that the prescription should be done when it is necessary, that is, the "yang micro-knot" mentioned in article 148. Hu Xishu's treatise on typhoid and miscellaneous diseases clearly points out: "If the stool is slightly knotted, you can use this recipe, and if the stool is taken normally, it will cause slight sputum. 」

Sorting out the syndrome differentiation and treatment of this case

The patient is old, chronically ill, weak, with four adverse reactions and poor appetite. It is reasonable to distinguish Taiyin disease as internal deficiency and cold. Combined with arthralgia, it is classified as Guizhi Shaoyao Zhimu decoction, but the medication of 1 week is ineffective, and the syndrome of disproof is wrong. The second diagnosis focused on dry mouth, dry stool and four adverse reactions, and the syndrome of Chaihu Guizhi Ganjiang Decoction combined with Danggui Shaoyao Powder was distinguished as Jueyin and Taiyin, and the prescription and syndrome were opposite, which achieved good results. After 5 consecutive visits, the main symptoms and prescriptions remained unchanged, and only fine-tuned the dosage and medication, and finally got all the work. When Feng Shilun used Chaihu Guizhi Ganjiang Decoction, he often used Danggui Shaoyao Powder. When asked about the reasons, Feng Shilun's answer was: Most of the syndromes in this prescription are blood deficiency and water excess.