Professor Hu Kaiwen’s Experience in Treating Elderly Lung Cancer with the Method of Supporting the Right and Expelling Pathogenic Factors Zhong Ruikang, Yang Lihui, Li Jinghua, Zhou Tian, Hu Kaiwen Beijing University of Chinese Medicine, Beijing University of Chinese Medicine Dongfang Hospital
Abstract: Professor Hu Kaiwen has been engaged in clinical work in Traditional Chinese Medicine (TCM) for nearly 40 years, focusing on the prevention and treatment of tumors. He believes that the etiology and pathogenesis of elderly lung cancer mainly stem from deficiency of the spleen and kidney, and imbalance of yin and yang, with qi, dampness, phlegm, stasis, and cancer toxins as secondary factors. He effectively utilizes medicinal pairs in treatment, among which the common supportive pairs include Huang Qi (Astragalus) – Rou Gui (Cinnamon), Gan Jiang (Dried Ginger) – Fu Zi (Aconite), Shu Di Huang (Rehmannia) – Dang Gui (Angelica), Mai Dong (Ophiopogon) – Wu Wei Zi (Schisandra), while the common expelling pairs include Fu Ling (Poria) – Yi Yi Ren (Job’s Tears), Zhu Ru (Bamboo Shavings) – Zhi Shi (Bitter Orange), Qing Ban Xia (Pinellia) – Chen Pi (Tangerine Peel), and Feng Fang (Beehive) – Wu Gong (Centipede). This article introduces Professor Hu’s experience in treating elderly lung cancer based on the method of supporting the right and expelling pathogenic factors, combined with case studies.
Keywords: Elderly lung cancer; medicinal pairs; supporting the right and expelling pathogenic factors; expert experience; Hu Kaiwen;
Lung cancer is one of the most burdensome malignant tumors globally [1]. In China, lung cancer has the highest incidence and mortality rate among all malignant tumors [2], and its occurrence is positively correlated with age [3,4]. With the increasing trend of population aging in China, the number of elderly lung cancer patients is also on the rise. TCM has shown advantages in treating elderly lung cancer, effectively improving clinical symptoms, reducing toxic side effects, enhancing quality of life, stabilizing tumors, and adjusting immune function [5,6]. Professor Hu Kaiwen is a chief physician at Beijing University of Chinese Medicine Dongfang Hospital, a renowned TCM expert, and a guiding teacher for the seventh batch of national TCM expert academic experience inheritance. He has been engaged in clinical work in TCM for nearly 40 years and pioneered the “Green Treatment of Tumors” [7,8]. He believes that the fundamental issue in elderly lung cancer is deficiency of the right qi. Although the disease is located in the lungs, its essence is due to deficiency of the spleen and kidney, leading to yang deficiency and essence depletion, and imbalance of yin and yang, which causes obstruction of qi flow, accumulation of phlegm, dampness, stasis, and toxins in the lungs, and even throughout the body. Treatment principles focus on supporting the right and expelling pathogenic factors, effectively utilizing medicinal pairs that complement and assist each other, resulting in simple yet effective formulas. This article summarizes and analyzes Professor Hu’s commonly used medicinal pairs for treating elderly lung cancer from the perspectives of supporting the right and expelling pathogenic factors. 1 Etiology and Pathogenesis of Elderly Lung Cancer1.1 Deficiency of Spleen and Kidney, Imbalance of Yin and Yang as the Root Cause There is no specific term for “lung cancer” in ancient TCM texts; based on its main clinical manifestations, it generally falls under categories such as “lung accumulation,” “mass,” and “xibin.” The “Medical Essentials of the Medical School” [9] states: “The formation of accumulation is due to insufficient right qi, allowing evil qi to take hold.” This indicates that deficiency of the right qi is an internal condition for the formation of tumors such as lung cancer. Professor Hu believes that the fundamental influence on the right qi lies in the spleen and kidney. Elderly patients experience gradual depletion of essence and qi, with weakened functions of various organs, particularly the spleen and kidney. As stated in the “Complete Book of Jingyue” [10]: “Those with deficiency of spleen and kidney often suffer from accumulation diseases.” The spleen is the mother of the lungs, and the kidney is the child of the lungs; the lungs and kidneys are the upper and lower sources of water, respectively. Kidney yang promotes the transformation and dispersal of qi to assist the lungs in their functions of dispersing and descending. If the spleen and kidney are deficient, the mother is weak and the child is constrained, leading to loss of right qi in the lungs, obstruction of qi flow, and accumulation of phlegm and dampness in the lungs, which can eventually lead to stasis and accumulation, thus the deficiency of the right qi in lung cancer should be attributed to the spleen and kidney. The “Suwen: On the Vital Qi” states: “Yang qi is like the heavens and the sun; if it loses its place, it shortens life and does not shine.” This highlights the importance of yang qi in maintaining life activities and prolonging life. The kidney governs the body’s yang, and the yang qi of the five organs and six bowels originates from the kidney’s original yang, relying on the warming and transforming function of kidney qi. The spleen’s ability to transform and transport also depends on spleen yang. Deficiency of spleen and kidney, and deficiency of yang qi lead to a loss of warmth and transformation in the body, resulting in insufficient “yang transformation of qi,” causing substances that should be transformed to accumulate as phlegm, stasis, and dampness, leading to tumors. Professor Hu believes that elderly lung cancer patients often exhibit a pattern of yang deficiency and excess yin, characterized by systemic deficiency and coldness, while the tumor site is often solid and hot. Yang damage affects yin; if treatment is delayed or aggressive treatments further damage the right qi, it will ultimately lead to deficiency of both yin and yang. Therefore, Professor Hu emphasizes the importance of warming and tonifying the spleen and kidney, and harmonizing yin and yang in the treatment of elderly lung cancer.1.2 Qi, Dampness, Phlegm, Stasis, and Cancer Toxins as the Manifestation Deficiency of the lungs, spleen, and kidneys leads to abnormal qi flow and water metabolism throughout the body. Additionally, elderly lung cancer patients often suffer from prolonged pain and emotional distress, leading to qi stagnation, accumulation of dampness and phlegm, and coldness due to yang deficiency, which can eventually lead to stasis. Cancer toxins are a specific pathological factor generated on the basis of organ dysfunction and qi and blood stagnation, and are also a key factor in tumor formation [11]. Elderly lung cancer patients are often in advanced stages, and cancer toxins are no longer confined to the lung mass but spread throughout the lungs and even the body, making distant metastasis more likely. Therefore, Professor Hu often addresses the expulsion of pathogenic factors through multiple approaches, including regulating qi, promoting dampness, transforming phlegm, resolving stasis, and detoxifying.2 Common Medicinal Pairs for Supporting the Right
2.1 Huang Qi (Astragalus) – Rou Gui (Cinnamon) to Raise Yang, Strengthen the Spleen, and Guide Fire Back to the Source Huang Qi is sweet, slightly warm, and enters the lung and spleen meridians, excelling in tonifying qi, raising yang, strengthening the spleen, and benefiting the lungs, as well as detoxifying and promoting tissue regeneration. Rou Gui is pungent and sweet, very warm, and enters the kidney, spleen, heart, and liver meridians, excelling in tonifying fire, assisting yang, guiding fire back to the source, and dispelling cold to relieve pain. Modern pharmacological studies show that Huang Qi has immune-regulating, anti-tumor, lung function-protecting, and anti-aging effects [12], and Rou Gui also has good anti-tumor effects [13,14]. Professor Hu believes that the disease location of elderly lung cancer is in the lungs, closely related to the spleen and kidney. The combination of Huang Qi and Rou Gui raises clear yang into the lungs and tonifies the qi of the spleen and lungs, while guiding the fire back to the kidneys and assisting the fire of life gate, thus treating the lungs, spleen, and kidneys together and stimulating yang qi. Additionally, raw Huang Qi tonifies qi more quickly than roasted Huang Qi, and can detoxify, promote water metabolism, and is warm without being drying, making it more suitable for tumor patients, with clinical dosages often reaching 90 g. Rou Gui, being very warm, has a strong tonifying effect, and to prevent the tumor from absorbing its yang heat, clinical practice follows the principle of gentle tonification, with dosages typically around 3 g.2.2 Gan Jiang (Dried Ginger) – Fu Zi (Aconite) to Warm the Middle, Nourish the Kidney, and Restore Yang to Open the Meridians Gan Jiang is pungent and warm, entering the spleen, stomach, kidney, heart, and lung meridians, capable of warming the middle, dispelling cold, restoring yang, and warming the lungs to transform fluids. Fu Zi is pungent and sweet, very warm, and has great toxicity, entering the heart, kidney, and spleen meridians, capable of restoring yang, rescuing from reversal, tonifying fire, assisting yang, and dispelling cold to relieve pain. Modern pharmacological studies show that both have effects on improving circulation, regulating immunity, and anti-tumor effects [15]. Elderly lung cancer patients often delay treatment due to neglect of their condition, leading to accelerated tumor spread and consumption; or they may be intolerant to aggressive treatments such as surgery and chemotherapy, further damaging the right qi, clinically presenting as fatigue, cold intolerance, cold limbs, weakness in the lower back and knees, and poor appetite, with cancer pain becoming more pronounced. For patients with severe conditions and significant signs of deficiency and cold, Professor Hu believes this indicates a long-standing illness, with severe deficiency of spleen and kidney yang and internal cold accumulation. Therefore, he emphasizes increasing the warming and tonifying power of the spleen and kidney and restoring yang to open the meridians. Fu Zi primarily tonifies kidney yang, while Gan Jiang primarily warms spleen yang. The combination of these two herbs can both move and hold, passing through the twelve meridians, restoring yang, warming the meridians, resolving cold, and dispelling dampness. Additionally, Gan Jiang can also mitigate the toxicity of Fu Zi, nurturing the earth to generate metal, thus reducing toxicity and enhancing efficacy, with clinical dosages commonly being 9 g of Gan Jiang and 3 g of Fu Zi.2.3 Shu Di Huang (Rehmannia) – Dang Gui (Angelica) to Tonify the Kidney, Fill Essence, Nourish Yin, and Enrich Blood Shu Di Huang is sweet, slightly warm, and enters the liver and kidney meridians, primarily nourishing kidney water, filling essence, and enriching blood, serving as a principal herb for strengthening water. Dang Gui is sweet and pungent, warm, and enters the liver, heart, and spleen meridians, primarily nourishing liver blood and also invigorating blood, known as the “holy medicine for blood.” Modern pharmacological studies show that Shu Di Huang has anti-aging, immune-enhancing, anti-mutation, and anti-tumor effects [16], while Dang Gui has anti-aging, anti-tumor, immune-enhancing, and analgesic effects [17]. Professor Hu believes that aging is a major inducement for the occurrence and development of tumors. The “Suwen: On Yin and Yang” states: “At the age of forty, the yin qi is already half, and vitality declines.” The life stages of growth, development, maturity, and aging are all governed by the essence and qi in the kidneys. Elderly patients often have insufficient kidney essence, accompanied by declining organ function and deficiency of right qi, leading to the accumulation of pathological products in the body and the formation of cancer. Shu Di Huang is good at tonifying kidney essence and yin, while also having the meaning of “seeking yang within yin.” Clinical dosages can often reach 60 g. Additionally, the liver stores blood, and the kidney stores essence; essence and blood share the same source. Kidney essence relies on liver blood for nourishment, and Dang Gui tonifies liver blood while also invigorating blood. Its nature is good at movement, which can prevent excessive richness from large doses of Shu Di Huang. Clinical dosages are commonly 15 g for Dang Gui.2.4 Mai Dong (Ophiopogon) – Wu Wei Zi (Schisandra) to Astringe Yin and Harmonize Yang, Generating Metal and Water. Mai Dong is sweet, slightly bitter, and slightly cold, entering the heart, lung, and stomach meridians, primarily nourishing yin, generating fluids, moistening the lungs, and stopping cough, effectively clearing lung fire. Wu Wei Zi is sour and sweet, warm, both astringing lung qi and nourishing the kidney, strengthening yin, and generating fluids, suitable for chronic cough, weakness, and thirst. Modern pharmacological studies show that both have immune-enhancing and anti-tumor effects [18,19]. Elderly lung cancer patients in the later stages often suffer from prolonged illness, leading to damage to yang and excess yin. Common chemotherapy and targeted drugs are often heat-inducing [20], which can damage yin fluids, resulting in lung yin deficiency, and virtual fire scorching the lungs, clinically presenting as dry cough with little phlegm, dry mouth, and thirst. Insufficient kidney essence leads to the kidney’s inability to receive qi, causing lung qi to not be restrained and to rise, resulting in virtual wheezing and chronic cough. Professor Hu believes that Mai Dong primarily clears virtual fire from the lungs, while Wu Wei Zi primarily astringes and descends lung qi into the kidneys. The combination of the two can achieve a clearing and tonifying effect, both clearing and moistening the lungs to nourish the kidneys, allowing metal and water to generate each other, while also benefiting qi and nourishing yin to harmonize yang, with clinical dosages commonly being 15 g of Mai Dong and 3 g of Wu Wei Zi.3 Common Medicinal Pairs for Expelling Pathogenic Factors
3.1 Fu Ling (Poria) – Yi Yi Ren (Job’s Tears) to Promote Water and Drain Dampness, While Also Opening Yang Fu Ling is sweet and bland, neutral in nature, entering the heart, lung, spleen, and kidney meridians, primarily promoting water metabolism, draining dampness, and calming the heart. The “Compendium of Materia Medica” [21] states: “Fu Ling… ascends to drain dampness from the spleen and lungs, and descends to attack the evil from the liver and kidneys, its qi first ascends (clearing the lungs and transforming sources) and then descends (promoting water).” The “Compendium of Materia Medica” mentions its “floating and ascending nature” [22]. Yi Yi Ren is sweet and bland, cool in nature, entering the spleen, stomach, and lung meridians, promoting water metabolism, draining dampness, and also detoxifying and dispersing masses. The “Compendium of Materia Medica” states: “It ascends slightly and descends more” [21]198. Modern pharmacological studies have confirmed that both have anti-cancer, immune-regulating, and anti-aging effects [23,24]. The lungs govern the regulation of water pathways, the spleen governs the transformation of water and fluids, and the kidneys govern the qi transformation and movement of water. If the lungs, spleen, and kidneys are all deficient, water metabolism becomes disordered, leading to accumulation of dampness and heat, which can generate phlegm. Therefore, the first step in expelling pathogenic factors is to promote dampness. Professor Hu believes that Fu Ling tends to ascend, while Yi Yi Ren tends to descend. The combination of these two herbs harmonizes the ascending and descending, allowing the water pathways to be smooth, and the water and fluids to flow freely. Both herbs enter the lung and spleen meridians, tonifying the spleen and clearing the lungs, and their neutral nature promotes water without harming the right qi, making them suitable for elderly patients with a relatively weak constitution. Additionally, elderly lung cancer patients often experience frequent urination, urinary hesitancy, and nocturia, which are due to deficiency of spleen and kidney yang leading to failure in the transformation of water and dampness, causing water to accumulate in the lungs and obstructing yang qi. Therefore, Professor Hu clinically follows the principle of “opening yang is not about warming, but about promoting urination,” using Fu Ling and Yi Yi Ren to gently drain dampness and promote urination, achieving a balance of tonification and drainage, with clinical dosages commonly being 15 g each of Fu Ling and Yi Yi Ren.3.2 Zhu Ru (Bamboo Shavings) – Zhi Shi (Bitter Orange) and Qing Ban Xia (Pinellia) – Chen Pi (Tangerine Peel) to Regulate Qi, Resolve Stagnation, and Transform Phlegm Zhu Ru is sweet, slightly cold, entering the lung, stomach, heart, and gallbladder meridians, capable of clearing heat, transforming phlegm, and relieving nausea. Zhi Shi is bitter, pungent, and sour, slightly cold, entering the spleen and stomach meridians, capable of breaking qi stagnation, resolving accumulation, and transforming phlegm. Research shows that Zhu Ru polysaccharides have significant immune-regulating effects on both immunocompromised and normal mice [25], and the hesperidin contained in Zhi Shi has strong anti-cancer activity [26,27]. Qing Ban Xia is pungent and warm, entering the spleen and stomach meridians, capable of drying dampness, transforming phlegm, descending counterflow, and relieving nausea. After processing, it can reduce the toxicity and irritation of raw Ban Xia and enhance its ability to dry dampness and transform phlegm; Chen Pi is bitter and pungent, warm, entering the lung and spleen meridians, capable of regulating qi, strengthening the spleen, and drying dampness. Both have good anti-tumor and antioxidant effects [28,29]. Elderly lung cancer patients often have deficient yang qi, and due to the inability to bear the impact of cancer and the torment of illness, they may experience prolonged depression and worry. The “Lingshu: On the Origin of All Diseases” states: “If suddenly exposed to cold from the outside, or if internally injured by worry, qi will reverse… and qi will congeal and accumulate, leading to stagnation of fluids and accumulation of masses.” Qi stagnation can easily lead to the accumulation of dampness and phlegm, and phlegm can become sticky and adhesive, marking the turning point for pathogenic factors to become tangible accumulations, which can easily generate heat and lead to stasis in the later stages. Therefore, Professor Hu believes that regulating qi, resolving stagnation, and transforming phlegm is a key aspect of treating elderly tumors. The above two pairs of herbs are derived from the classic formula “Wen Dan Tang” and can regulate the central qi mechanism, also entering the lung meridian, with a pungent flavor to soothe the liver, primarily focusing on unblocking the middle while also considering the upward and downward flow, promoting qi circulation throughout the body [30]. They can also clear the gallbladder and stomach, relieve nausea, and alleviate adverse reactions from chemotherapy in elderly lung cancer patients [31], making them commonly used expelling pairs by Professor Hu. Among them, Zhu Ru – Zhi Shi is slightly cold, focusing on clearing and transforming heat phlegm, while Qing Ban Xia – Chen Pi is warm, focusing on drying and transforming cold phlegm. In clinical practice, they can be used separately or in combination, with common dosages being 18 g of Zhu Ru, 15 g of Zhi Shi, 15 g of Qing Ban Xia, and 18 g of Chen Pi.3.3 Feng Fang (Beehive) – Wu Gong (Centipede) to Open Meridians, Disperse Masses, and Attack Toxins Feng Fang is sweet, neutral, capable of clearing heat, detoxifying, and opening meridians, commonly used to treat abscesses and sores. Wu Gong is pungent, warm, capable of opening meridians, relieving pain, and attacking toxins. Modern pharmacological studies show that Feng Fang not only has anti-tumor and analgesic effects but also tonifies the kidney and strengthens yang [32], while Wu Gong has good anti-lung cancer activity [33]. Elderly patients experience declining organ function and deficiency of qi and blood, leading to increasingly sluggish blood circulation, compounded by the accumulation of phlegm and pathogenic factors. If not controlled in time, tumors will continue to grow and carry cancer toxins to various parts of the body. Professor Hu has clinically observed that elderly lung cancer patients are often diagnosed at advanced stages, with lung metastasis or even distant metastasis, and their tongues often appear dark, indicating the accumulation of phlegm, qi, stasis, and toxins, with insufficient right qi to restrain cancer toxins, allowing them to run rampant. Feng Fang is light and clear, resembling the lungs in its hollow shape, capable of unblocking lung meridians and detoxifying. Wu Gong has strong mobility, capable of searching for wind and unblocking meridians, attacking scattered cancer toxins. The combination of the two promotes blood circulation and resolves stasis, attacking toxins with toxins, and can restrain both cold and heat pathogenic factors. Clinical dosages are commonly 15 g of Feng Fang and 3 g of Wu Gong.4 Case Study Patient: Male, 74 years old. The main complaint is right upper lobe adenocarcinoma resection surgery performed over a month ago. On January 26, 2021, he visited the oncology department of Beijing University of Chinese Medicine Dongfang Hospital. The patient was diagnosed with a right upper lung mass approximately 2.8 cm in diameter during a physical examination on November 22, 2020, suspected to be malignant; multiple ground-glass nodules in both lungs. On December 25, 2020, he underwent thoracoscopic right upper lobe cancer resection at a tertiary hospital in Beijing, with postoperative pathology indicating infiltrative lung adenocarcinoma, measuring 2.5 cm × 1.7 cm × 1.5 cm, with lymph node metastasis around the bronchus. No further treatment was performed postoperatively, and he came for further treatment. Current symptoms include occasional cough with phlegm, phlegm is mostly white and can be coughed out, sighing frequently, prefers fatty and sweet foods, sleeps well, and has normal bowel movements. The body is slightly overweight, with a dark complexion, pale red tongue, white greasy coating, and a deep pulse. TCM diagnosis: lung accumulation, pattern differentiation as qi stagnation and phlegm obstruction. Western diagnosis: postoperative right lung adenocarcinoma. Treatment principle: regulate qi, resolve stagnation, and expel dampness and transform phlegm. Prescribed Wen Dan Tang with modifications, the prescription is as follows: Zhu Ru 18 g, Zhi Shi 15 g, Sheng Jiang (Fresh Ginger) 18 g, Qing Ban Xia 15 g, Chen Pi 18 g, Fu Ling 30 g, Yi Yi Ren 15 g, Sheng Gan Cao (Raw Licorice) 6 g, Zhi Zi (Gardenia) 9 g, Xiang Fu (Cyperus) 15 g, Yu Jin (Curcuma) 6 g. 14 doses, decocted in water, 1 dose per day, taken warm in the morning and evening. The patient was advised to maintain emotional balance and eat until 80% full. On March 9, 2021, during the second visit. After taking the medicine, the patient reported reduced cough and phlegm, but experienced chest tightness and shortness of breath after activity, fatigue, prefers warm water, and loose stools. The complexion is yellow, tongue is red, thin coating, and pulse is deep and thin. Pattern differentiation indicates deficiency of spleen and kidney, and deficiency of both qi and yin. Prescribed Jin Gui Shen Qi Wan with modifications, the prescription is as follows: Shu Di Huang 60 g, Shan Zhu Yu (Cornus) 24 g, Shan Yao (Chinese Yam) 18 g, Dan Pi (Moutan) 9 g, Fu Ling 15 g, Ze Xie (Alisma) 9 g, Mai Dong 15 g, Wu Wei Zi 3 g, Sheng Huang Qi 90 g, Dang Gui 15 g, Rou Gui 3 g, Dang Shen (Codonopsis) 9 g, Feng Fang 15 g, Wu Gong 3 g. 14 doses, decocted in water, 1 dose per day, taken warm in the morning and evening. On March 23, 2021, during the third visit. The patient reported relief of chest tightness and shortness of breath after activity, occasional cough with little phlegm, still experiencing fatigue, cold intolerance, bitter mouth, heat intolerance, vivid dreams, and slightly loose stools, with bowel movements every 1-3 days. The complexion is yellow, tongue is pale red, white coating, and pulse is deep and thin. The second visit prescription was modified by removing Shan Zhu Yu, Shan Yao, Dan Pi, Ze Xie, Mai Dong, and Wu Wei Zi, adding Zhu Ru 18 g, Zhi Shi 15 g, Sheng Jiang 18 g, Qing Ban Xia 15 g, Chen Pi 18 g, Sheng Gan Cao 6 g, Huang Lian (Coptis) 3 g, and Chao Jiao Ren (Fried Ziziphus) 15 g. 14 doses, decocted in water, 1 dose per day, taken warm in the morning and evening. On April 6, 2021, during the fourth visit. The patient reported improvement in all symptoms, with tongue and pulse similar to previous visits. Prescribed the third visit formula for an additional 30 doses, decoction method as before. Subsequently, the patient regularly returned for follow-up visits, reporting no significant discomfort. On December 31, 2021, a follow-up chest CT showed postoperative changes in the right lung, with no enlarged lymph nodes in the mediastinum, and the small nodules in both lungs remained stable compared to the previous examination on November 22, 2020, with a trend of reduction and fading in the left lung nodules. Conclusion: This case involves an elderly male patient with deficiency of spleen and kidney, who enjoys fatty and sweet foods, leading to phlegm and dampness accumulation in the lung meridians, which developed into masses over time. At the initial visit, the patient was recently diagnosed post-surgery and was in poor spirits, with symptoms primarily of cough with excessive phlegm, frequent sighing, dark complexion, and white greasy tongue, indicating a focus on treating the symptoms. The treatment primarily focused on expelling the accumulation. The medicinal pairs Zhu Ru – Zhi Shi and Qing Ban Xia – Chen Pi were used to regulate qi and transform phlegm, while Fu Ling – Yi Yi Ren were used to strengthen the spleen and promote dampness, addressing the source of phlegm. Fresh ginger was added to harmonize the spleen and stomach, while Xiang Fu, Yu Jin, and Zhi Zi were included to enhance the function of soothing the liver, resolving stagnation, and relieving anxiety. Licorice was used to harmonize the various herbs. During the second visit, the patient reported reduced cough and phlegm, with a change in complexion from dark to yellow, indicating a reduction in phlegm and qi obstruction. Symptoms shifted to shortness of breath, fatigue, preference for warmth, and loose stools, indicating a predominance of yang deficiency. The tongue and pulse also showed signs of yin deficiency, suggesting that the initial treatment for symptoms had stabilized, revealing underlying deficiency. Therefore, the treatment should focus on supporting the right qi, warming and tonifying the spleen and kidney, and nourishing qi and yin. The medicinal pairs Huang Qi – Rou Gui were used to tonify qi and assist yang, while Shu Di Huang – Dang Gui were used to nourish the kidney and fill essence, serving as the main medicinal pairs. Mai Dong – Wu Wei Zi were used to nourish yin and harmonize yang, serving as the ministerial pairs. Additionally, Dang Shen was added to strengthen the spleen and tonify qi, while Shan Zhu Yu and Shan Yao were used to nourish the liver and spleen to assist in seeking yang within yin. Feng Fang – Wu Gong were used to attack toxins and disperse masses, while Fu Ling and Ze Xie were used to promote water and drain dampness, and Dan Pi was used to invigorate blood and resolve stasis to complement the expulsion of accumulation. During the third visit, the right qi had improved, allowing it to counteract the toxins. Symptoms included fatigue, cold intolerance, and loose stools, indicating deficiency and cold, while heat intolerance, bitter mouth, and vivid dreams indicated heat in the gallbladder. At this point, it was appropriate to support the right and expel pathogenic factors simultaneously. The main medicinal pairs from the second visit were retained to continue supporting the right qi, and the patient’s signs of yin deficiency improved. Therefore, Shan Zhu Yu, Shan Yao, Mai Dong, and Wu Wei Zi were removed, and the Wen Dan Tang was added to clear the gallbladder and stomach, transform phlegm, and include Huang Lian and Chao Jiao Ren to clear heat and calm the spirit. Subsequent treatment was adjusted based on pattern differentiation, flexibly applying the principles of supporting the right and expelling pathogenic factors. 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