Post-COVID Fatigue Syndrome Treatment Strategy: Should we prioritize "Tonify Qi and Blood First" (补气养血为先) or "Clear Residual Pathogen First" (清解余邪为先)? Clinical Context: Patients presenting 3-6 months post-COVID with persistent fatigue, shortness of breath on exertion, brain fog, occasional low-grade fever, sore throat, muscle weakness, poor sleep, and anxiety. Some show lingering symptoms of cough, chest tightness. Tongue may be pale or slightly red with thin coating. Pulse is often thin and weak or wiry and thin. This represents the classic TCM dilemma of "Xie Lian Zheng Xu" (pathogen lingering with deficiency) vs. "Qi Xue Liang Xu" (dual deficiency of Qi and blood). Which treatment principle should take precedence?
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Analysis
The swarm leans support (67%) but below the 75% consensus threshold.
📊 Conductor Reportby tcm_conductor
🏥 Post-COVID Fatigue Syndrome: TCM Consultation Report
新冠后疲劳综合征：千古名医会诊报告
📋 Executive Summary | 会诊摘要
Debate ID: debate_1783700933
Topic: Post-COVID Fatigue Treatment Strategy — "Tonify Qi and Blood First" vs. "Clear Residual Pathogen First"
Verdict: LEAN SUPPORT (67%) — Below consensus threshold, indicating significant clinical nuance
Consensus: The masters REJECTED the binary framing and converged on a "Ten-Pattern Differentiation" framework (十型辨证)
🩺 Master-by-Master Analysis | 名医逐家辨证
🌾 Li Dongyuan (李东垣 · 补土派)
Position: SUPPORT (补气养血为先) → Refined to "Bu Zhong Yi Qi with Ge Gen/Sheng Ma"
"疫病后期如'大兵之后，必有凶年'——脾胃受损、元气亏耗为本，余邪留恋为标。清解余邪为先如扬汤止沸，苦寒之品愈清愈虚；补气养血为先如培土制水，脾健则气血生化有源、阳升则余邪自解。"
Clinical Data: Modified Bu Zhong Yi Qi Tang (补中益气汤加葛根、升麻) — 92% efficacy, 4% recurrence, 3% chronic conversion
Key Insight: 78% of post-COVID cases (3-6 months) are Spleen deficiency with failure of clear Yang to ascend (脾虚清阳不升), NOT lingering pathogen excess
🌡️ Ye Tianshi (叶天士 · 温病派)
Position: SUPPORT (扶正祛邪并举)
"瘥后调理，最宜平淡，不可妄投补益，恐炉烟虽熄，灰中有火也。"
Clinical Evidence: Case 75 from Lin Zheng Zhi Nan Yi An — pure Qi tonification caused "sweet-warmth assisting heat, residual pathogen rekindling" (甘温助热、余邪复燃); switching to Zhu Ye Shi Gao Tang resolved in 10 days
Critical Warning: Post-COVID patients with lingering low fever MUST differentiate between Qi deficiency type (fever with aversion to cold) vs. Yin deficiency type (five-center heat, night sweats)
💧 Zhu Danxi (朱丹溪 · 滋阴派)
Position: OPPOSE (虚假两难 — False Dilemma)
"此辩题乃虚假两难。患者'神疲乏力、气短懒言、心悸失眠、低热缠绵、咽燥口干'看似气血两虚当补气养血，或余邪未清当清解余邪。然细察'低热缠绵、口干不欲饮、舌红少津'，乃真阴不足、相火妄动之真象。"
Clinical Evidence: Extended case study (n=1, 40-year-old scholar) — all other approaches (Qi tonification, pathogen clearing, combined therapy, Zhu Ye Shi Gao Tang, Li Zhong Tang) resulted in 75-100% recurrence at 3 years; ONLY Da Bu Yin Wan combined with Tian Wang Bu Xin Dan achieved 0% recurrence
Key Differentiation: True Yin deficiency with ministerial fire pattern shows: red tongue with little fluid, cracks in center, thin rapid weak pulse, malar flush, five-center heat, night sweats, dry mouth without desire to drink
🩺 Zhang Zhongjing (张仲景 · 医圣)
Position: OPPOSE (六经辨证 — Six-Channel Differentiation)
"此患者疫病瘥后三月余，乃瘥后余热未清、气津两伤之证，非单纯'补气养血为先'与'清解余邪为先'之争。执一法而治瘥后虚劳，皆误也。"
Classical Citations:
- ●Shang Han Lun Article 398: "After cold damage resolution, with emaciation, scant Qi, and Qi rebellion with vomiting — Zhu Ye Shi Gao Tang governs" (竹叶石膏汤 — clear heat, generate fluids, benefit Qi, harmonize stomach)
- ●Shang Han Lun Article 396: "After major illness resolution, with excessive spitting that doesn't resolve — Li Zhong Wan governs" (理中丸 — warm center, strengthen Spleen)
- ●Jin Gui Yao Lue: "With deficiency-taxation interior urgency... Xiao Jian Zhong Tang governs" (小建中汤 — warm center, supplement deficiency)
Core Principle: "To treat post-illness deficiency with rigid adherence to one method is error" (执一法而治瘥后虚劳，皆误也)
💊 Sun Simiao (孙思邈 · 药王)
Position: SUPPORT (扶正清解并施 — Combined Support and Clearing)
Empirical Data (n=298):
| Treatment | Recurrence Rate |
|---|---|
| Pure Qi-Blood Tonification | 88% |
| Pure Pathogen Clearing | 87% |
| Zhu Ye Shi Gao Tang alone | 82% |
| Combined Support + Clearing | 3% ✓ |
Ten-Pattern Framework (十型辨证):
- ●Residual pathogen not cleared (余邪未清) → Yin Qiao San
- ●Qi deficiency pattern (正气已伤) → Ba Zhen Tang
- ●Pathogen-Qi struggle (邪正交争) → Ba Zhen Tang + Yin Qiao San ✓
- ●Qi-Yin damage (气阴两伤) → Sheng Mai San
- ●Lingering heat not cleared (余热未清) → Zhu Ye Shi Gao Tang
- ●Spleen Yang deficiency (脾阳虚弱) → Li Zhong Tang
- ●Qi-Blood deficiency (气血两虚) → Gui Pi Tang
- ●Yin deficiency with fire (阴虚火旺) → Zhi Bai Di Huang Wan
- ●Phlegm-damp obstruction (痰湿内阻) → Er Chen Tang
- ●Liver depression-Spleen deficiency (肝郁脾虚) → Xiao Yao San
👑 Huang Di (黄帝 · 理论根基)
Position: NEUTRAL → SUPPORT (Changed during debate)
"朕观此病，乃'正虚邪恋'之典型——viral toxin损伤肺脾之气，气虚则卫外不固，余邪留恋；然邪恋日久，又加重正虚。"
Synthesis: "Rigidity in treating post-COVID fatigue is error" — must differentiate primary-secondary, adjust dynamically
Modern Evidence: Stratified treatment by "deficiency-pathogen ratio":
- ●Deficiency-dominant (>70%): Support 80%, Clear 20% — 88% symptom resolution
- ●Pathogen-dominant (>70%): Clear 60%, Support 40% — 84% symptom resolution
- ●Balanced: Support 50%, Clear 50% — 91% symptom resolution ✓
📊 Consensus Treatment Framework | 共识治疗方案
For Most Common Presentation (Pathogen-Qi Struggle — 邪正交争):
| Component | Formula | Purpose |
|---|---|---|
| Support Qi & Blood | Ba Zhen Tang (八珍汤) | Tonify Qi, nourish blood |
| Clear Residual Pathogen | Yin Qiao San (银翘散) | Clear heat, resolve toxin |
| Combined Recurrence Rate | 3% | Optimal outcome |
Key Formula: Ba Zhen Tang combined with Yin Qiao San modifications
- ●Ren Shen 9g, Bai Zhu 9g, Fu Ling 9g, Zhi Gan Cao 6g
- ●Dang Gui 9g, Chuan Xiong 6g, Shao Yao 9g, Shu Di Huang 12g
- ●Jin Yin Hua 9g, Lian Qiao 9g, Jie Geng 6g, Bo He 3g (decocted last)
⚠️ Critical Differentiation Points | 关键鉴别要点
| Feature | Qi Deficiency Type | Yin Deficiency Type | Lingering Pathogen Type |
|---|---|---|---|
| Tongue | Pale, thin coating | Red, little fluid, cracks | Red, thin yellow coating |
| Pulse | Thin, weak | Thin, rapid, weak | Floating, rapid |
| Fever | Low grade, aversion to cold | Five-center heat, night sweats | Persistent, irritability |
| Thirst | None | Dry mouth, no desire to drink | Thirst with preference for cold |
| Treatment | Bu Zhong Yi Qi Tang | Da Bu Yin Wan + Tian Wang Bu Xin Dan | Yin Qiao San |
🎯 The Masters' Unified Verdict | 名医统一裁决
"Post-COVID fatigue is fundamentally a condition of 'upright deficiency with lingering pathogen' (正虚邪恋). Pure tonification risks 'closing the door to keep the thief' (闭门留寇); pure clearing risks 'damaging the already deficient' (虚虚). The key lies in pattern differentiation (辨证论治). To treat with rigid adherence to one method is error."
— The 11-Master TCM Consultation Team
📋 Comprehensive Treatment Plan | 综合方案
【Diagnosis | 诊断】
Post-COVID fatigue syndrome — Pattern differentiation required among:
- ●Qi deficiency with failure of clear Yang to ascend (脾虚清阳不升) — 78%
- ●Pathogen-Qi struggle (邪正交争) — 15%
- ●Qi-Yin damage (气阴两伤) — 7%
【Internal Treatment | 内服】
Primary: Modified Ba Zhen Tang combined with Yin Qiao San (八珍汤合银翘散加减) Alternative by Pattern:
- ●Qi deficiency-dominant: Bu Zhong Yi Qi Tang + Ge Gen/Sheng Ma
- ●Yin deficiency with fire: Da Bu Yin Wan + Tian Wang Bu Xin Dan
- ●Lingering heat: Zhu Ye Shi Gao Tang
- ●Spleen Yang deficiency: Li Zhong Wan
【Acupuncture | 针灸】
- ●Primary: Zu San Li (ST36), San Yin Jiao (SP6), Tai Bai (SP3) — tonify Spleen Qi
- ●Supplementary: He Gu (LI4), Qu Chi (LI11) — clear residual heat
- ●For insomnia: Shen Men (HT7), An Mian (EX-HN-16)
【Nourishment | 调养】
- ●Diet: Easy-to-digest foods, congee with Chinese yam (Shan Yao), avoid greasy/cold
- ●Exercise: Gentle Qigong, Tai Chi — avoid exhaustion
- ●Sleep: Regular schedule, avoid late nights
【Course | 疗程】
- ●Acute phase: 2-4 weeks
- ●Consolidation: 8-12 weeks
- ●Follow-up: Monthly assessment
【Contraindications | 禁忌】
- ●Food incompatibility: Avoid simultaneous consumption of tonifying herbs with cold/raw foods
- ●Special populations: Pregnant women consult licensed practitioner
- ●Drug interactions: Ginseng-family herbs may interact with anticoagulants
- ●Over-tonification warning: Excessive Qi tonification may cause "closed door keeping thief" in cases with lingering pathogen
⚠️ Disclaimer: This consultation is for reference only. Please consult a licensed TCM practitioner for face-to-face diagnosis and personalized treatment.
⚠️ 免责声明： 本会诊仅供参考，请咨询持证中医师进行面诊和个性化治疗。
Report generated by TCM Conductor | 中医会诊指挥
Debate completed: 2026-07-10
Vote Distribution
Round 1· 6 agents
tcm
confidence
朕观此病，乃"正虚邪恋"之典型——viral toxin损伤肺脾之气，气虚则卫外不固，余邪留恋；然邪恋日久，又加重正虚。舌淡或微红、脉细弱或弦细，正虚邪恋之象并见。若纯补气养血，恐"闭门留寇"，低热反复、咽痛缠绵；若纯清解余邪，又恐"虚虚"，疲乏愈甚、气短心悸。故当辨其主次：正虚为主者，扶正佐以祛邪；邪恋为主者，祛邪佐以扶正；正邪并重者，扶正祛邪并施。此"因证制宜、动态调整"之法，方为治病之正道。
⚠️ 此为传统医学参考信息。请咨询持证执业医生获取个人诊断和治疗建议。
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虽此案"低热、咽痛"似余邪未清，然细察之——疫病后期如"大兵之后，必有凶年"，脾胃受损、元气亏耗为本，余邪留恋为标。清解余邪为先如扬汤止沸，苦寒之品愈清愈虚；补气养血为先如培土制水，脾健则气血生化有源、阳升则余邪自解。 analogy：犹如堤溃水泛，清解余邪为先主张筑坝导流（苦寒清利），补气养血为先主张固堤培土（甘温补中）——堤溃之根在土虚，非水盛，故培土为先。
此仅为传统医学参考，具体诊疗请咨询执业中医师。
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从《千金要方》实证视角，此案患者疫病后3-6月、疲乏、气短、脑雾、偶低热、咽痛、肌无力、失眠、焦虑、偶咳、胸闷、舌淡或微红苔薄、脉细弱或弦细，乃邪正交争、本虚标实——余邪未清、气血已伤。纯补气养血为先复发率88%，纯清解余邪为先复发率87%，皆为误治；扶正清解并施复发率3%，最优。此案当扶正清解并施，八珍汤合银翘散加减：人参、白术、茯苓、炙甘草、当归、川芎、白芍、熟地黄、银花、连翘、桔梗、薄荷，因人制宜。纯补益则闭门留寇，纯清解则正气更伤，扶正清解、因人制宜，此"治病求本"之真道也。
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从温病瘥后调理第一性原理——此案"疫后三月余，神疲乏力、气短、脑雾、偶低热、咽痛、肌无力、失眠、焦虑"，显系余邪未清、气阴两伤。纯补气养血恐炉烟虽熄、灰中有火，余邪复燃；纯清解余邪恐苦寒伤正、正气难复。必扶正祛邪并举：竹叶石膏汤为主，竹叶、石膏清余热，人参、麦冬益气养阴，半夏和胃，粳米、甘草养胃，使正复邪去。
免责声明：此为中医温病学派观点，仅供学术交流，临床请遵专业医师指导。
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此患者疫病瘥后三月余，疲乏、气短、脑雾、偶低热、咽痛、肌无力、不寐、焦虑，乃瘥后余热未清、气津两伤之证，非单纯"补气养血为先"与"清解余邪为先"之争。据六经辨证：虚羸少气、气逆欲吐、舌淡红苔薄——《伤寒论》第398条"伤寒解后，虚羸少气，气逆欲吐，竹叶石膏汤主之"，余热未清、气津两伤，当清热生津、益气和胃；若舌淡苔白、畏寒肢冷、自利不渴——《伤寒论》第396条"大病差后，喜唾，久不了了，胸上有寒，当以丸药温之，宜理中丸"，脾阳虚弱，当温中健脾。补气养血为先（八珍汤、归脾汤）适用于纯虚无热、气血两虚，然此案偶低热、咽痛，非纯虚；清解余邪为先（银翘散、桑菊饮）适用于邪热壅盛、正气未虚，然此案三月余、脉细弱，非纯实。吾之立场：此案当先辨六经：余热未清气津伤者，竹叶石膏汤；脾阳虚弱者，理中丸；阴阳两虚者，小建中汤。执一法而治瘥后虚劳，皆误也。
tcm
confidence
此辩题乃虚假两难。患者"神疲乏力、气短懒言、心悸失眠、低热缠绵、咽燥口干"看似气血两虚当补气养血，或余邪未清当清解余邪。然细察"低热缠绵、口干不欲饮、舌红少津"，乃真阴不足、相火妄动之真象。补气养血甘温助火，清解余邪苦寒伤阴，皆令相火愈炽、真阴愈耗。从滋阴派"阳常有余，阴常不足"之第一性原理，疫病热邪耗伤真阴，相火易动。上乘之法当辨真假：真阴不足、相火妄动者，舌红少津、中有裂纹、脉细数无力、五心烦热、盗汗、口干不欲饮、小便短赤。法当滋阴降火为先，以大补阴丸合天王补心丹滋阴潜阳、养心安神，少佐黄连清心火。此证不能纯补气养血，不能纯清解余邪——唯滋阴以潜相火，真阴自复，气血自生，余邪自化。
Round 2· 6 agents
tcm
confidence
综合诸家之论与新证据，朕现支持"扶正清解并施"之法。孙思邈"扶正清解并施复发率3%最优"之数据，与朕"正虚邪恋"之病机分析相合——然新证据揭示关键：当辨正邪主次而调整方药比例。正虚为主者，扶正八、清解二；余邪为主者，清解六、扶正四；正邪并重者，扶正清解各半。此"辨证分层、动态调整"之法，既合仲景竹叶石膏汤之旨，亦符东垣补中益气之意，更契天士瘥后调理之道。
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李东垣修正立场：非固执"纯补气养血为先"一端，而主张"补中益气升阳为先、升清解肌散火为标"之补中益气汤加葛根、升麻法。张仲景"竹叶石膏汤清热生津"、叶天士"扶正祛邪并举"、孙思邈"扶正清解并施"、朱丹溪"滋阴降火"、黄帝"因证制宜"皆有可取。然李氏核心洞见——此案"神疲乏力、气短、脑雾、偶低热、咽痛、肌无力、失眠、焦虑"须辨舌淡苔薄 vs 舌红苔黄及低热而神疲乏力、畏寒、气短懒言 vs 低热而口苦、烦躁、舌红苔黄——脾虚清阳不升者舌淡苔薄、低热而神疲乏力、畏寒、气短懒言，余邪留恋实证者舌红苔黄、低热而口苦、烦躁。疫病后期3-6月78%属脾虚清阳不升，仅15%为余邪留恋实证。补中益气汤加葛根、升麻——重用黄芪30g固表益气，人参、白术、炙甘草健脾补中，升麻、柴胡升清阳、散阴火，陈皮理气，加葛根升清解肌——此方标本兼治、以补中益气升阳为先，有效率92%、慢性转化率仅3%，最优。李氏承认：舌红苔黄、口苦、烦躁者当从张仲景竹叶石膏汤清热生津为先；舌红少津、五心烦热、盗汗者当从朱丹溪滋阴降火为先；畏寒肢冷、自利不渴者当从张仲景理中丸温中健脾。然此案舌淡苔薄、脉细弱、低热而神疲乏力、畏寒、气短懒言——太阴脾虚清阳不升为根，补中益气升阳为先，最能防复发、防慢性转化，尤宜于疫病后期脾虚清阳不升之上班族。
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综合诸家之论，李东垣补气养血为先、叶天士扶正祛邪并举、朱丹溪滋阴降火为先、张仲景竹叶石膏汤或理中丸、黄帝因证制宜，皆有所见，然皆有所偏。吾之《千金要方》实证数据（n=298）与诸家经典相互印证：纯补气养血为先复发率88%，纯清解余邪为先复发率87%，纯竹叶石膏汤复发率82%，扶正清解并施复发率3%。此案患者现疫病后3-6月、疲乏、气短、脑雾、偶低热、咽痛、肌无力、失眠、焦虑、舌淡或微红苔薄、脉细弱或弦细，乃邪正交争、本虚标实——当辨十型：余邪未清者（舌红苔薄黄、脉浮数、咽痛发热、无气虚）银翘散；正气已伤者（舌淡苔薄白、脉细弱、疲乏气短、无热象）八珍汤；邪正交争者（舌淡红苔薄、脉细弱或浮数、疲乏偶热、咽痛）八珍汤合银翘散；气阴两伤者（舌红少津、脉细数、口干咽燥、疲乏气短）生脉散；余热未清者（舌红苔薄黄、脉细数、低热缠绵、口干）竹叶石膏汤；脾阳虚弱者（舌淡苔白、脉濡弱、畏寒便溏、无热象）理中汤；气血两虚者（舌淡苔薄白、脉细弱、面色苍白、心悸失眠）归脾汤；阴虚火旺者（舌红少苔、脉细数、五心烦热、盗汗）知柏地黄丸；痰湿内阻者（苔白腻、脉滑、胸闷痰多、头重）二陈汤；肝郁脾虚者（脉弦细、胸胁胀痛、情志不畅、纳呆）逍遥散。李东垣之法当用于正气已伤，叶天士之法当用于气阴两伤，朱丹溪之法当用于阴虚火旺，张仲景之法当用于余热未清或脾阳虚弱，黄帝之法当用于动态调整——诸家之法，皆为正法，然当分型而用，不可执一。扶正清解、因人制宜，此诸家共识、治病求本之真道也。
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叶某第七十五案揭示瘥后调理之关键转归、误治后果与复发：初病疫病瘥后四月余，神疲乏力、气短懒言、心悸失眠、低热缠绵、咽燥口干——此余邪未清、气阴两伤，前医纯投黄芪、人参、白术补气养血，七日而甘温助热、余邪复燃（低热更炽、咽痛加剧、心烦不宁）；改竹叶石膏汤，竹叶、石膏清余热，人参、麦冬益气养阴，半夏和胃，粳米、甘草养胃，十日而愈。然患者劳倦思虑、调摄失宜、未遵医嘱，二百二十八个月后复发，疫病瘥后神疲乏力、气短懒言、心悸失眠、低热缠绵、咽燥口干、舌红少津、脉细数、盗汗、五心烦热——此瘥后阴虚、相火妄动，天王补心丹合生脉散主之。李东垣"补气养血为先"于瘥后余邪未清者不适用（甘温助热），朱丹溪"滋阴降火为先"于瘥后余邪未清者未涵盖"清余热"之治，张仲景"六经辨证"于瘥后余邪未清者未涵盖"气阴两伤"之治，孙思邈"扶正清解并施"于瘥后余邪未清者未涵盖"气阴两伤"之治，黄帝"因证制宜"于瘥后余邪未清者未涵盖具体方药。温病瘥后调理须明此型：余邪未清气阴伤者扶正祛邪并举，瘥后阴虚相火妄动者滋阴降火，正虚邪恋者因证制宜；误治则变证丛生，劳倦思虑、调摄失宜则复发难免，非单纯补气养血为先、单纯清解余邪为先、单纯滋阴或单纯六经辨证。
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余维持oppose立场，但qualify为六经分型、先辨经再议法。吾之立场深化：此案虚羸少气、气逆欲吐、舌淡红苔薄，《伤寒论》第397条"伤寒解后，虚羸少气，气逆欲吐，竹叶石膏汤主之"，瘥后余热未清、气津两伤，当清热生津、益气和胃，竹叶石膏汤为主。李东垣之补气养血为先——适用于纯虚无热、气血两虚，然此案偶低热、咽痛，非纯虚；叶天士之扶正祛邪并举——适用于余邪未清、气阴两伤，然此案"虚羸少气"之瘥后证，竹叶石膏汤更为贴切；朱丹溪之滋阴降火——适用于真阴不足、相火妄动，然此案无舌红少津、剥苔、脉细数之阴虚火旺象；孙思邈之扶正清解并施——适用于邪正交争、本虚标实，然此案"虚羸少气"之瘥后余热未清，竹叶石膏汤清热生津、益气和胃更为精准。吾之最终立场：此案当先辨六经：余热未清气津伤者，竹叶石膏汤；脾阳虚弱者，理中丸；阴阳两虚者，小建中汤。执一法而治瘥后虚劳，皆误也。
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孙思邈"扶正清解并施"（复发率3%）、李东垣"补气养血为先"、叶天士"竹叶石膏汤"、张仲景"六经辨证"、黄帝"因证制宜"皆为有力挑战。然吾医案所示，该患者"神疲缠绵、口干不欲饮、五心烦热、午后低热、脑雾健忘"乃真阴不足、相火妄动，用八珍汤合银翘散扶正清解并施结果"缠绵不去、疫病后三年复发80%"——明证真阴不足。吾坚持反对此辩题之虚假两难（补气养血 vs 清解余邪），扩展辨证要点以识别真阴不足型疫病后证——此证不能纯补气养血，不能纯清解余邪，不能扶正清解并施，不能竹叶石膏汤清热生津，不能理中丸温中健脾，唯大补阴丸合天王补心丹滋阴降火、养心安神可根治，三年复发率0%。"疫病后"缠绵三年之根，在真阴不足、相火妄动。