ZHAI Jin-hai (翟金海), CHEN Lan (陳 蘭)

1. Medical School, Jiangsu Vocational College of Medicine, Yancheng 224005, China

2. Emergency Department of Internal Medicine, Jiangyin Hospital of Traditional Chinese Medicine, Jiangyin 214400, China

ABSTRACT Chronic diarrhea is one of the most common clinical diseases in the department of spleen and stomach diseases. This paper mainly introduces the key points of Professor YUAN Shi-liang diagnosing and treating chronic diarrhea, methods of dealing with common accompanying symptoms, as well as typical cases, which have certain guiding role in clinical practice.

KEYWORDS Chronic diarrhea; Famous doctor's experience; YUAN Shi-liang

Chronic diarrhea is one of the most common clinical diseases in the department of spleen and stomach diseases. In western medicine, it mainly refers to diarrhea-predominant irritable bowel syndrome (IBS-D) and functional diarrhea,whose diagnostic standard followsRome IV[1]. Its pathogenesis is not clear yet. The main western medicine are antidiarrheal agents, probiotics,antidepressant drugs, antibiotics and spasmolytics,without ideal efficacy, which is easy to relapse[2-4].Traditional Chinese Medicine for the disease is obviously effective, which has certain advantages.Professor YUAN Shi-liang is a nationally renowned grass-roots TCM doctor, one of the representative inherators of Chengjiang medical school. He is flexible in clinical diagnosis and treatment, and likes to use classical prescriptions to treat chronic diarrhea, with good efficacy. This paper mainly introduces the key points and typical cases of Prof.YUAN Shi-liang diagnosing and treating chronic diarrhea was introduced.

KEY POINTS OF DIAGNOSIS AND TREATMENT

Syndrome of Dampness-heat due to Spleen Deficiency is the Most Common Clinical Syndrome in Prof. YUAN Shi-liang's Cases

"The cause of diarrhea is all due to the spleen and stomach."[8]Dampness-heat due to spleen deficiency is the main syndrome of chronic diarrhea. Invigorating spleen and clearing heat,as well as eliminating dampness and relieving diarrhea are basic principles in treating chronic diarrhea. Prof. YUAN Shi-liang often uses modified Zisheng Pills (資生丸) in treatment, with significant efficacy. "No dampness, no diarrhea."[9]If there is severe dampness pathogen, Pingwei Powder (平胃散),Herba Pogostemonis,Herba EupatoriiandRhizoma Alismatiscan be added. If the tongue is coated with thin fur, aromatics lightly should be used. If dampness combines heat, it is necessary to distinguish predominance between the dampness and heat. A redder and drier tongue with yellower fur indicates predominance of heat, in whichRhizoma Coptidis,Herba Patriniae,Radix Scutellariae, etc.are frequently used to clear intestine and eliminate dampness. Dampness-heat with predominant heat is mainly treated by clearing heat which accompanied by eliminating dampness. Dampnessheat with predominant dampness is mainly treated by eliminating dampness which accompanied by clearing heat. If there is no obvious heat manifestations, drugs for clearing heat may not be used or used less as corrigents. If there is a balance between dampness and heat, then a balance between clearing heat and eliminating dampness should be maintained. However, attention should be paid to prevent excessive heat clearing, which is not conducive to the elimination of dampness due to a disadvantage of cold damaging stomach. Therefore,eliminating dampness should be slightly more than heat clearing, because "heat originates from dampness, and if the dampness is not eliminated,the heat will not be cleared"[10]. And "heat becomes weak as long as dampness is eliminated"[11], thus the pathogenic heat is easy to be cleared.

Weighing Treatment for Syndrome of Cold Intermingled with Heat is Prof. YUAN Shiliang's Typical Feature

Intermingled cold and heat is a common syndrome in chronic diarrhea, and medication should be weighed in clinical practice. If upper heat is severe and lower cold is mild, Huanglian Wendan Decoction(黃連溫膽湯) and Shenling Baizhu Powder (參苓白術(shù)散) are used to clear heat and eliminate dampness,as well as invigorate spleen and relieve diarrhea.For patients after gallbladder surgery, Sini Powder(四逆散) can be added to disperse stagnated liver Qi (氣) for promoting bile flow. If upper heat is mild and lower cold is mild, Zisheng Pills (資生丸) is used for invigorating spleen, clearing heat and relieving diarrhea. If there is also severe dampness, modified Pingwei Powder (平胃散) can be added. If upper heat is mild and lower cold is severe, it should be treated with Zisheng Pills plusRhizoma Zingiberis Praeparatum,Fructus Evodiae,Fructus Alpiniae Oxyphyllae,Rhizoma Drynariae,Fructus Psoraleae,Radix Aconiti Lateralis PreparataandFructus Chebulaefor clearing heat, eliminating dampness,as well as warming and tonifying spleen and kidney to relieve diarrhea. If upper heat is severe and lower cold is a bit severe, mimicking the therapeutic intent of Banxia Xiexin Decoction (半夏瀉心湯), Huanglian Wendan Decoction and Shenling Baizhu Powder plusRhizoma Zingiberis Praeparatum,Fructus Evodiae,Fructus Alpiniae Oxyphyllae, etc. are used to clear heat and eliminate dampness, as well as warm and tonify spleen Yang (陽(yáng)) to relieve diarrhea. If upper heat is severe and lower cold is badly severe, it should be treated with Huanglian Wendan Decoction and Shenling Baizhu Powder plusRhizoma Zingiberis Praeparatum,Fructus Evodiae,Fructus Alpiniae Oxyphyllae,Rhizoma Drynariae,Fructus Psoraleae,Radix Aconiti Lateralis PreparataandFructus Chebulaefor clearing heat, eliminating dampness, as well as warming and tonifying spleen and kidney to relieve diarrhea. If upper heat is severe and injures Yin(陰), while lower cold is badly severe, accompanied by obvious abdominal pain, mimicking the therapeutic intent of Wumei Pills (烏梅丸), it should be treated with Zisheng Pills plusRhizoma Zingiberis Praeparatum,Fructus Evodiae,Fructus Alpiniae Oxyphyllae,Rhizoma Drynariae,Fructus Psoraleae,Radix Aconiti Lateralis Preparata,Fructus Chebulae,Fructus Mume,Fructus Chaenomelis,Herba Dendrobii, etc. for clearing heat, eliminating dampness, nourishing Yin,as well as warming and tonifying spleen and kidney to relieve diarrhea. If the lower cold is obvious without heat manifestations, it should be treated with Shenling Baizhu Powder and Fuzi Lizhong Decoction (附子理中湯) for warming and tonifying spleen and kidney to relieve diarrhea, in whichRhizoma Coptidiscan be removed or used less as a corrigent.

Diagnosis and Treatment for Acute Exacerbations of Chronic Diarrhea Based on Qi and Blood

Acute exacerbation of chronic diarrhea,aggravation of diarrhea, and mucous bloody feces,are mostly transformed by heat. When there is a reddish tongue with yellow greasy fur, it indicates a mild disease condition, and it is caused by dampheat, which involves the blood level. So the treatment should put dampness-heat in the Qi level first, and the blood level second, with modified Shaoyao Decoction(芍藥湯) applied. If symptoms of spleen deficiency are severe, Zisheng Pills plusRadix Rubiae,Radix Lithospermi,Herba Patriniae,Caulis Sargentodoxaeand other cooling blood for hemostasis drugs are applied. If the tongue is significantly red with thin yellow greasy fur, or there is less fur, its treatment is mainly cooling blood for hemostasis, accompanied by clearing the Qi level, in which modified Baitouweng Decoction (白頭翁湯) and Huanglian Ejiao Decoction(黃連阿膠湯) are applied.

Combination of Radix Aconiti Lateralis Preparata-Fructus Psoraleae-Fructus Chebulae is Preferred for Syndrome of Yang Deficiency of Spleen and Kidney

Chronic diarrhea of cold syndrome is not uncommon. Patients have obvious aversion to cold,especially for their feet and knees. There are even soreness of waist and weakness of knees, as well as lingering diarrhea. For patients with mild aversion to cold and spleen Yang deficiency (陽(yáng)虛),Radix Puerariae,Herba Agrimoniae,Rhizoma Zingiberis Praeparatum,Fructus EvodiaeandFructus Alpiniae Oxyphyllaecan be added. For patients with severe aversion to cold, soreness of waist and weakness of knees, frequent urination at night and lingering diarrhea,Fructus Psoraleae,Radix Aconiti Lateralis PreparataandFructus Chebulaecan also be added for warming kidney and astringing. For some patients, efficacy of tonifying spleen is not sufficient, so tonifying fire and generating earth must be applied. Only whenRadix Aconiti Lateralis Preparata,Fructus PsoraleaeandFructus Chebulaeare used to warm and tonify kidney Yang, as well as astringe and relieve diarrhea, can it be significantly effective.

Modified Lianmei Decoction (連梅湯) is Preferred for Syndrome of Spleen Yin Deficiency

Long-term diarrhea injures Yin, eroded fur can be seen. For patients with a plump reddish tongue, treatment can focus mainly on invigorating spleen, accompanied by nourishing Yin.Fructus Mume,Fructus Schisandrae Chinensis,Radix Pseudostellariae,Herba Dendrobii, etc. can be added as appropriate. If the tongue is deep red without fur, it indicates endogenous heat due to Yin deficiency (陰虛). So the dosage of pungent and warm natured drugs for dampnesseliminating should be decreased, while the dosage of Yin-nourishing and heat-clearing drugs should be increased. Modified Lianmei Decoction is frequently used, in whichFructus Amomi VillosiandRadix Codonopsisare removed, whileRadix Pseudostellariae,Herba Dendrobii,Radix Puerariae,Radix Adenophorae,Radix Glehniae,Radix Ophiopogonis,Fructus Mume, stir-friedRadix Paeoniae AlbaandRhizoma Coptidisare added to nourish Yin and clear heat, as well as invigorate spleen and relieve diarrhea. For regulating Qi, a small amount of roastingRadix AucklandiaeandPericarpium Citri Reticulataecan be applied. Warm dryness and bitter cold are avoided. The choice of Yin-nourishing drugs should be sweet and cool but not greasy. Medicine that can both nourish Yin and relieve diarrhea are preferred, such asFructus Mume,Herba Dendrobii,Fructus Schisandrae Chinensis,Pericarpium Granati, etc.

Combination of Fructus Chaenomelis-Radix Saposhnikoviae-Rhizoma et Radix Notopterygii is Preferred for Borborygmus and Abdominal Pain

For patients with obvious borborygmus and abdominal pain,Fructus Chaenomelisis used to eliminate dampness, relieve spasm and relieve pain, andRadix Saposhnikoviaeis used to dispell pathogenic wind and eliminate dampness.Rhizoma Corydalisshould be added to regulate Qi and relieve pain for patients with distending pain.Rhizoma et Radix Notopterygiiis added for patients with obvious borborygmus. Prof. YUAN Shi-liang believes thatFructus Chaenomelishas better efficacy thanRadix Paeoniae Albain eliminating dampness and relieving spasm. Some patients' diarrhea is not obvious and they have loose stool, but their borborygmus is obvious. That is, "short of middle Qi leads to borborygmus and change in urination and defection"[12]. The treatment is invigorating spleen and benefiting Qi, combined with medicine for dispelling pathogenic wind such asRadix Saposhnikoviae,Rhizoma et Radix Notopterygii,Periostracum Cicadae, etc., which have good efficacy. Some patients have food allergic enteritis.After eating certain foods, diarrhea occurs.Periostracum CicadaeandRadix Saposhnikoviaecan be added for dispelling pathogenic wind and preventing allergies.Radix Linderaecan be added for patients with deficient cold.

Fructus Crataegi and Massa Medicata Fermentata are Used for Relieving Indigestion

Spleen deficiency and inability to transport and transform can lead to indigestion, which is also very common. The patient does not want to eat, and his tongue is coated with thick greasy fur. It can be treated with scorchFructus CrataegiandMassa Medicata Fermentatafor promoting digestion. For those with severe indigestion, a small amount ofRadix et Rhizoma Rhei Praeparata(1-2 g) can be added to perform symptomatic treatment by eliminating pathogenic factor first.

Light Use of Qi Regulated Drugs for Removing Flatulence

"Zang-viscera Cold leads disease of flatulence."Some patients may suffer from abdominal flatulence. Generally speaking, if the flatulence is not severe, or sometimes mild and sometimes severe, it belongs to pain due to coagulated cold and stagnant Qi, which can be treated withRadix Linderae,Rhizoma Corydalis, roastingRadix AucklandiaeandPericarpium Citri Reticulataefor dispelling cold and regulating Qi. If it belongs to dampness retention and Qi stagnation, manifesting as abdominal distension, and excessive feces with unsmooth defecation, Semen Coicis,Cortex Magnoliae Officinalis,Pericarpium Arecae, stir-friedFructus AurantiiandSemen Raphanican be added to eliminate dampness and regulate Qi. Since this kind of Qi stagnation is based on spleen deficiency,so the use of Qi regulated drugs should not be too much, but should be used rationally on the basis of invigorating spleen. Otherwise, to pursue a quick relief, it will injure spleen Qi and aggravate the disease.

Promoting Blood Circulation for Removing Blood Stasis is a Modified Method for Treating Intractable Diarrhea

Correction on Errors in Medical Classics(《醫(yī)林改錯(cuò)》) records, "Diarrhea for a long time, hundreds of prescriptions are not effective,because there is excessive static blood."[13]Dark tongue with ecchymosis and enlarged dull purple sublingual vessels with branches indicate existence of blood stasis.Rhizoma Corydalis, stir-fried Faeces TogopteriandFlos Carthamiare added to promote blood circulation for removing blood stasis. ZHANG Min-hua et al. reported that they cured a patient with stasis-heat diarrhea after abdominal trauma by applying Xuefu Zhuyu Decoction (血府逐瘀湯) with Danshen Decoction (丹參飲)[14]. There was a chronic diarrhea patient of Prof. YUAN Shi-liang, who had been treated for a long time, but it was not effective.There was nothing wrong according to multiple examinations. His tongue was dull purple with white greasy fur, and he had a thready and hesitant pulse.Prof. YUAN Shi-liang diagnosed him as Yangming(陽(yáng)明) disease with stagnated blood and internal blockade of cold-dampness syndrome. Based on WANG Qing-ren's method, Xuefu Zhuyu Decoction plusRhizoma ZingiberisandRadix Aconiti Lateralis Preparatawere used, which worked well. "There are patients cured by symptomatic treatment and patients cured by radical treatment." If promoting blood circulation for removing blood stasis works well in symptomatic treatment, after the disease condition improves, warming and tonifying spleen and kidney can be used to consolidate the efficacy.

Medical Skill Reflected in Treating Concurrent Syndromes

Patients with chronic diarrhea often suffer from various concurrent syndromes. For example, if intestinal polyps are found by colonoscopy,Fructus Mume,Bombyx Batryticatus,Rhizoma Curcumae,Herba HedyotisandSemen Coiciscan be added. If it is accompanied by hyperlipidemia,Herba Leonuri,rawFructus Crataegi,Radix Salviae MiltiorrhizaeandRhizoma Polygonatican be added. For patients accompanied by fatty liver and abnormal liver function,Herba Abri,Herba Sedi,Herba Artemisiae ScopariaeandHerba Hyperici Japonicican be added. If it is accompanied by dampness-heat symptoms in the stomach like dry mouth, bitter taste in mouth, stomach distension and insomnia,modified Zisheng Pills and Huanglian Wendan Decoction can be applied. For patients with obvious stomach symptoms and mild diarrhea, modified Banxia Xiexin Decoction is used. For patients accompanied by bile reflux, Sini Powder,Herba Lysimachiae,Rhizoma Cyperi,Radix Curcumae,Rhizoma Pinelliae PreparataandHaematitumto disperse stagnated liver Qi and promote bile flow.If belching is obvious,Folium Eriobotryae,Radix Curcumae,Pericarpium Canavaliae,Fructus Citri Sarcodactylis,Lignum Dalbergiae Odoriferae,Flos Caryophylli,Calyx Kaki, etc. can be added to disperse stagnated liver Qi and descend stomach Qi.For patients without belching,Radix Platycodonis,

Fructus Aurantii,Semen Oroxyli,Rhizoma Cyperi,etc. can be added to disperse liver and regulating Qi. Diarrhea complicated with chronic pharyngitis can be treated with Banxia Houpo Decoction (半夏厚樸湯), Xuanmai Ganjie Decoction (玄麥甘桔湯),Semen Oroxyli,Fructus Forsythiae,Rhizoma BelamcandaeandBulbus Fritillariae Thunbergiito clear lung-heat, dissipate phlegm, regulate Qi and relieve throat disorder. If it is accompanied by rhinitis belonging to deficiency of both lung and spleen,Shenling Baizhu Powder, Yupingfeng Powder (玉屏風(fēng)散) and Cang'erzi Powder (蒼耳子散) are used. If dry mouth is obvious and belongs to Yin deficiency, it can be treated with modified Shashen Maidong Decoction (沙參麥冬湯) andHerba Dendrobii. For patients with gastroesophageal reflux, the treatment should be based on weighing severities of the upper and lower syndromes. For patients with obvious diarrhea, invigorating spleen should be given priority, supplemented by purging liver and restricting acid. If acid regurgitation and heart-burn are obvious, the treatment is mainly to purge liver, harmonize stomach and restrict acid,supplemented by invigorating spleen and eliminating dampness. For patients complicated with prostatitis,Herba Epimedii,Radix Morindae OfficinalisandSemen Cuscutaecan be added to tonify kidney and eliminate dampness, benefiting both spleen and kidney.Herba Hedyotis,Semen Vaccariae,Herba Solani Nigri,Radix Achyranthis BidentataeandSemen Plantaginiscan be added to clear heat,promote diuresis and promote blood circulation.If complicated with urinary tract infection, Bixie Fenqing Decoction (萆薢分清飲),Herba Plantaginis,Herba Polygoni Avicularis,Herba Dianthi, etc. can be added to free strangury and promote diuresis.For patients with common cold, relieving superficies syndrome and invigorate spleen can be combined,avoiding too much bitter cold injuring stomach. If the common cold belongs to wind-heat syndrome,modified Sangju Decoction (桑菊飲) and Shenling Baizhu Powder can be used to dispell wind-heat,invigorate spleen and stop diarrhea. If complicated with morbid vaginal discharge, it can be treated with modified Wandai Decoction (完帶湯) and Yihuang Decoction (易黃湯). If combined with alopecia, Shenying Yangzhen Decoction (神應(yīng)養(yǎng)真湯), which consists ofRhizoma Gastrodiae,Semen Cuscutae,Rhizoma et Radix Notopterygii,Fructus Chaenomelis,Radix Angelicae Sinensis,Rhizoma Ligustici ChuanxiongandRadix Rehmanniae Preparata, can be modified and used for tonifying spleen and kidney, eliminating dampness, dispelling pathogenic wind and promoting hair growth. If complicated with itchy eczema, Sanren Decoction(三仁湯), Bixie Fenqing Decoction,FructusKochiae,Fructus Tribuli,Periostracum Cicadae,Radix Saposhnikoviae,Cortex Dictamni,Radix Lithospermi, etc. can be applied for dispelling pathogenic wind and relieving itching. For patients complicated with chronic cheilitis,Periostracum Cicadae,Radix Saposhnikoviae,Rhizoma Ligustici Chuanxiong,Radix Salviae Miltiorrhizaeare added to invigorate spleen, promote blood circulation and dispell pathogenic wind. If complicated with headache due to spleen deficiency and liver hyperactivity,Rhizoma Gastrodiae,Radix PuerariaeandRamulus Uncariae CumUnciscan be added to tonify spleen and suppress hyperactive liver. If it is combined with dysmenorrhea, Shenling Baizhu Powder plus vinegar-processedRhizoma Corydalis,Radix Paeoniae RubraandRadix Angelicae Sinensisare applied to invigorate spleen, regulate Qi and relieve pain.

Personal Care is an Important Measure to Prevent from the Onset of Diseases

Patients with chronic diarrhea must pay attention to personal care. Improper diet and overstrain impair spleen. Diet should be light and easy to digest. Cold food is avoided, especially in summer. Watermelon, ice beer, etc. are avoided.Alcohol is quit, overfatigue is avoided and keeping warm is paid attention to. Otherwise, it is easy to attack. Once a young patient with chronic diarrhea came to visit. He defecated 5-6 times per day. The patient worked on night shift for a long time and had obvious aversion to cold. Fuzi Lizhong Decoction (附子理中湯) and Sishen Pills (四神丸) were modified and applied, and his diarrhea was improved slightly.After the patient adjusted his work, he reported that the diarrhea was improved obviously, which showed that daily life is also very important for the treatment of the disease.

In addition, some patients may have aggravated diarrhea after taking TCM decoction for 1 day. Most of them belong to the record inTreatise on Cold Pathogenic Diseases(《傷寒論》), "When the spleen is tonified, the rot is going to be discharged."[16]If they persist in taking the medicine, the diarrhea will get better. Very few patients may suffer from fever and aggravation of diarrhea, which are allergic to Traditional Chinese medicine. They can no longer be treated with traditional Chinese medicine, but can be treated with western medicine probiotics, etc. "Treatment for chronic diseases should contain both prescriptions and sticking to taking them."[17]After the syndrome is controlled, medication should be continued and the treatment should be maintained for a period of time. The course of treatment generally needs to be maintained for 2-3 months before it becomes stable.After the condition is stable, diet and living are paid attention to. Don't indulge in cold drinks, keep a light diet and keep warm to reduce recurrence.

EXAMPLES OF CURED CASES

(1) Mr. LI was 62 years old, he was obese and had suffered from intermittent diarrhea for 2 years. He defecated 2-3 times a day with loose stool. He had diarrhea whenever the diet was improper. There was dull pain and discomfort in the abdomine, with relatively severe borborygmus but no mucopurulent bloody stool. His appetite was not bad, but he could not sleep well. His tongue was dark red, and the fur was thin, yellow and greasy,whose middle part had peeled off. The pulse was thready, stringy and slippery. There was a medical history of fatty liver. He was diagnosed as spleen deficiency and dampness-heat injuring Yin, which was treated by invigorating spleen and nourishing Yin, as well as clearing and eliminating dampnessheat. The prescription was modified Zisheng Pills,which consists of 15 g stir-friedRadix Codonopsis,10 g stir-friedRhizoma Atractylodis Macrocephalae,15 gPoria, 6 gRadix Glycyrrhizae Praeparata, 10 g stir-friedSemen Dolichoris Album, 20 gRhizoma Dioscoreae, 20 g scorchSemen Coicis, 3 gFructus Amomi Villosi, 3 gRhizoma Coptidis, 10 g Fructus Mume, 10 gHerba Dendrobii, 15 g stir-fried Fructus Crataegi, 15 g scorchMassa Medicata Fermentata,10 gRadix Linderae, 10 gRadix Saposhnikoviae,10 gFructus Chaenomelisand 15 gRadix Puerariae.At the same time, the patient was instructed to eat a light and warm diet. During the second visit, diarrhea was improved, and it recovered after more than a month of consolidation therapy.

Note: This patient, who ate greasy and sweet food for a long time, had phlegm and dampness retention in the body. That is, "overeating does damage to the stomach and intestine". Since the spleen and stomach had been injured for a long time, it induced deficiency of spleen and stomach,and phlegm and dampness were easy to be generated internally. Retention of dampness-heat transformed into heat, which did damage to Yin,thus causing symptoms like diarrhea. It was treated with drugs sweet and light in flavor to consolidate spleen and clear away dampness-heat, combined with drugs sour and sweet in flavor to transform into Yin. The prescription is based on MIAO Xi-yong's Zisheng Pills, removingSemen Dolichoris Album,Fructus Ammomi Rotundus,Radix Platycodonis,Rhizoma Alismatis,Semen Nelumbinis,Semen EuryalesandFructus Hordei Germinatus, and addingRadix Puerariaefor ascending Yang,Radix LinderaeandRadix Saposhnikoviaefor dispelling pathogenic wind and eliminating dampness, andFructus Chaenomelisfor eliminating dampness to stop diarrhea. It corresponds with the intent of a record inInner Canon of Huangdi(《黃帝內(nèi)經(jīng)》), "If dampness is excessive in the internal, drugs bitter and heat in property can be used to treat, while drugs sour and bland in taste can be used as adjuvants."[18]It is clinically used to treat diarrhea with spleen deficiency and dampness-heat syndrome or those combined with deficiency of spleen Yin, with good efficacy. When dampness-heat is clear, spleen Yin is restored, and spleen-stomach function is recovered,the disease is naturally cured.

(2) Mrs. Wang, 42 years old, was first diagnosed on October 20, 2014. The patient had a history of 5 years after cholecystectomy. The patient had burning sensation in the epigastric region, bitter taste in mouth, dry mouth, vexation,loose stool which was easy to discharge, with 3 times a day, diarrhea caused by improper diet, and usual aversion to cold. Gastroscopy showed bile reflux gastritis and colonoscopy showed chronic colitis. She had been diagnosed as cholecystectomy syndrome and bile reflux gastritis. She was given Almagate Suspension, Rabeprazole Tablets,Mosapride Tablets, Peifeikang and other drugs orally, which had little efficacy. She went to Prof.YUAN Shi-liang for treatment and was found to have a plump pale tongue with thin, yellow and greasy fur, and her pulse was thready, stringy and weak.Prof. YUAN Shi-liang diagnosed her as concurrent disease of Shaoyang (少陰) and Taiyin (太陰)Channels. Shaoyang gallbladder fire did not descend and reversed to the upper, and Taiyin deficient cold stayed in the middle. The prescription was modified Chaihu Guizhi Ganjiang Decoction (柴胡桂枝干姜湯), which consisted of 10 g stir-friedRadix Bupleuri,6 gRamulus Cinnamomi, 3 gRhizoma Zingiberis Praeparatum, 20 g rawConcha Ostreae, 10 g stirfriedRadix Scutellariae, 6 gRadix Glycyrrhizae Praeparata, 10 gRadix Ophiopogonis, 15 g stir-friedRadix Codonopsis, 20 gRhizoma Dioscoreaefrom Henan province, 20 gRadix Puerariae powder, 15 gHerba Agrimoniaeand 30 g stir-friedSemen Coicis.She took 7 sets of the prescription and then nursed her health. She was cured after more than 1 month.

Note: This patient had a cholecystectomy,which was easy to cause adverse rising of gallbladder Qi. Gallbladder fire failed to descend and invaded the stomach. Stomach Qi failing to descend manifested as bitter taste in mouth,vomiting and nausea, etc. Gallbladder and stomach failing to descend and liver Qi failing to ascend were easy to cause deficient cold in spleen earth,which manifested as loose stool and diarrhea.The treatment principle was to ascend liver Qi,descend gallbladder fire and warm spleen Yang.The course of the disease was relatively long, and severe spleen deficiency resulted in a plump and teeth-printed tongue. Therefore,Radix Codonopsis,Rhizoma Dioscoreae,Herba AgrimoniaeandRadix Glycyrrhizae Praeparatawere used for tonifying spleen and relieving diarrhea. Stir-friedSemen Coiciswas used for invigorate spleen and eliminating dampness to relieve diarrhea.Radix Puerariaewas used for ascending spleen and relieve diarrhea.Rhizoma Zingiberis PraeparatumandRamulus Cinnamomiwere used for warming spleen Yang.Fried Radix Bupleuriwas used for ascending liver Qi.Radix ScutellariaeandConcha Ostreaewere used for clearing gallbladder fire,descending gallbladder Qi and stomach Qi, andRadix Ophiopogoniswas used for nourishing Yin and stomach fluid which had been consumed by gallbladder fire.

(3) An elderly female patient suffered from abdominal pain and diarrhea for more than 10 years.She defecated 4-5 times a day, with watery stool.There was less efficacy in seeking medical treatment for these 10 years. There were obvious pain at night, soreness of waist, deadly cold of both lower limbs but not upper limbs, dry mouth and excessive drinking, a plump reddish tongue, yellow greasy fur in the middle, with dry fur nature, no fur on the edge,and slippery pulse. She was diagnosed as syndrome of spleen-kidney Yang deficiency, stomach heat injuring Yin, and liver Qi over-restricting spleen. The prescription was based on Wumei Pills, including 15 g stir-friedRadix Codonopsis, 10 g Rhizoma Atractylodis Macrocephalae, 15 gPoria, 5 gRadix Glycyrrhizae, stir-friedSemen Coicis, 15 gRhizoma Dioscoreae, 10 g stir-friedSemen Dolichoris Album, 10 gHerba Pogostemonisfrom Guangdong province, 15 g scorchMassa Medicata Fermentata,15 g scorchFructus Crataegi, 10 gRadix Puerariae powder, 15 gHerba Agrimoniae, 10 gRadix Aucklandiae, 10 gRadix Curcumae, 10 gFructus Mume, 10 gRadix Linderae, 5 gRhizoma Coptidis,10 g vinegar-processedRhizoma Corydalis, 10 gFructus Chaenomelis, 15 g stir-friedRadix Paeoniae Alba, 2 gFructus Evodiae Praeparata, 3 gRhizoma Zingiberis Praeparatumand 10 g stir-friedFructus Psoraleae. During the second visit, her disease was improved significantly.Fructus Psoraleaewas removed in consideration of its hepatotoxicity, which is not suitable for long-term use, and 5 gRadix Aconiti Lateralis Preparatawas added for warming and tonifying kidney Yang during her consolidation therapy.

Note: This patient had a long course of diarrhea. Since "the root of diarrhea is all due to the spleen and stomach", invigorating spleen and eliminating dampness are basic treatment methods.Shenling Baizhu Powder was given to invigorate spleen and relieve diarrhea;Rhizoma Zingiberis PraeparatumandFructus Evodiaewere added to warm and tonify spleen Yang. Since spleen deficiency involving kidney resulted in kidney Yang deficiency,Fructus PsoraleaeandRadix Aconiti Lateralis Preparatawere given to warm and tonify kidney Yang. Due to deficient earth and overrestriction of wood, that is, "the liver is responsible for abdominal pain",Fructus Mume,FructusChaenomelisandRadix Paeoniae Albawere applied to astringe liver and relieve pain.Rhizoma CorydalisandRadix Linderaewere given to regulate Qi and relieve pain.Rhizoma Coptidiswas used for clearing dampness-heat in the stomach.Fructus MumeandRadix Paeoniae Albawere given for nourishing Yin and quenching thirst. Yang deficiency of spleen and kidney was the root cause, while liver wood overrestricting spleen and dampness-heat injuring Yin were manifestations. Wumei Pills was applied in this case, but it was more than Wumei Pills. "We read ZHANG Zhong-jing's book and apply his methods,but we do not alway stick to his prescriptions,because his intent has been understood by us."[19]It is necessary to modify flexibly according to specific circumstances. After this case, it was realized that Wumei Pills (烏梅丸) treats cold limbs syndrome due to ascariasis, and chronic dysentery. When roundworms are disturbing diaphragm, pain is the main symptom. Therefore, Wumei Pills can treat chronic diarrhea accompanied by obvious abdominal pain.

(4) Mr. ZHAO, 49 years old, had a history of chronic rhinitis. He had nasal obstruction and clear nasal discharge after catching cold, a small amount of epistaxis, loose stool with 2-3 times a day, sore pain in the waist, a plump pale tongue and thready weak pulse. The syndrome was lungspleen Qi deficiency and failure of Qi to keep blood. The treatment was invigorating spleen and lung, unblocking stuffy orifice and stopping bleeding. The prescription was Shenling Baizhu Powder with Yupingfeng Powder (玉屏風(fēng)散) plus 15 g scorchFructus Crataegi, 15 g scorchMassa Medicata Fermentata, 10 gFructus Xanthii,10 gFlos Magnoliae, 10 gRadix Rubiae, 15 gRadix Achyranthis Bidentataeand 10 gCortex Eucommiae, with 10 sets. It was taken after mixing it with water, with 1 set per day. During the second visit, there was no bleeding in the nose or nasal obstruction. Clear nasal discharge was improved.Since he had bitter taste in mouth, 10 gRadix Scutellariaeand 10 gHerba Pogostemoniswere added, with 10 sets. It was taken after mixing it with water, with 1 set per day.

Note: Lung Qi deficiency syndrome in rhinitis or allergic rhinitis is commonly seen. The pathogenesis of this case was lung-spleen Qi deficiency and failure of Qi to keep blood. Yupingfeng Powder was used to tonify lung for consolidating superficies.Shenling Baizhu Powder was used to invigorate spleen and relieve diarrhea. Cang'erzi Powder was used to unblock stuffy orifice.Radix Rubiaewas used to stop bleeding.Radix Achyranthis BidentataeandCortex Eucommiaewere used to tonify kidney and strengthen waist.Radix Scutellariaewas used to treat the bitter taste in mouth. AndHerba Pogostemoniswas used to eliminate dampness,relieve diarrhea and unblock stuffy orifice.Radix Achyranthis Bidentataehas the function of conducting fire and blood to descend, and is used for upper hemorrhage. The pathogenesis of epistaxis in this case was deficiency of both lung and spleen, which belongs to deficiency. Heatclearing drugs should not be used excessively.ZHANG Xi-chun's Wenjiang Decoction (溫降湯)"treats hematemesis and epistaxis with weak, soft and slow pulse, as well as food stagnation in the stomach, failing to be digested, which is induced by cool and stomach Qi failing to descend, so drugs of warming, tonifying and promoting digestion should be applied for descending stomach Qi, so as to stopping bleeding". The prescription consists of 10 gRhizoma Atractylodis Macrocephalae, 10 g alumen immersionRhizoma Pinelliae Preparata, 20 g rawRhizoma Dioscoreae, 10 gRhizoma Zingiberis,18 g rawHaematitum, 6 g rawRadix Paeoniae Alba, 5 gCortex Magnoliae Officinalisfrom Sichuan province and 6 gRhizoma Zingiberis Recens. The pathogenesis is deficient cold of spleen-stomach and adverse rising of Jueyin (厥陰), indicating that hemorrhage with deficient cold pathogenesis is also relatively common.

CONCLUSION

TCM treatment based on syndrome differentiation for chronic diarrhea has obvious advantages and remarkable efficacy. After the disease condition is stable, combined with recuperation of daily life, the disease is not easy to attack. It is one of the diseases in which TCM can work quite well. Patients with chronic diarrhea are often complicated with various diseases. By taking regulating spleen and stomach as the center and treating various diseases from the spleen, it has obvious advantages and ideal efficacy. Prof. YUAN Shi-liang's treatment for chronic diarrhea and its concurrent syndromes has remarkable efficacy,which is worthy of further clinical summary and promotion.