Late last year, a young man came to see me, presenting with spermatorrhea. He reported having suffered from nocturnal emissions for several years. Despite multiple treatments, his condition fluctuated — sometimes improving, sometimes worsening. Recently, it had deteriorated for no clear reason; at its worst, he experienced emissions twice in a single night. After each episode, his entire body ached with weakness, his spirit was low, and he was in considerable distress.
Reviewing the prescriptions from previous practitioners, most had adopted a kidney-tonifying approach. Some had used formulas to clear the mind and strengthen the spleen, and others had employed dampness-draining and phlegm-resolving agents. The results were inconsistent — sometimes effective, sometimes exacerbating the condition. At his best, he could go a month between episodes.
On pattern differentiation, I clearly perceived signs of the kidney failing to receive qi, along with disharmony between the nutritive and defensive qi. Guizhi plus Longgu Muli Tang (Cinnamon Twig plus Dragon Bone and Oyster Shell Decoction) immediately came to mind. I prescribed this formula with a few additions to clear the minister fire and subdue yang, and instructed him to relax his mind and take it calmly to observe the results. After taking this formula, the effect was quite good. Several follow-up adjustments later, the best results reached one episode every fifteen days.
However, he had many other complaints — diarrhea, palpitations, a feeling of blockage in the stomach, and poor appetite. What left the deepest impression on me was his tasteless mouth. These problems were undoubtedly and directly related to kidney deficiency, yet simply tonifying the kidney was not an expedient solution at this stage.
For this reason, I re-examined how the ancient physicians understood this condition.
The ancients’ understanding was actually quite straightforward. First, the very fact of nocturnal emission proves that the kidney’s vaporization function is still operative and that kidney essence remains. As the ancients held,
“When the five viscera are full and flourishing, only then can there be discharge.”
The functions of the organs are intact — they simply cannot retain what they should, which readily leads to deficiency and damage.
Second, the ancients generally believed that the root cause of spermatorrhea lies primarily in the Heart. As the old saying goes,
“When the Heart stirs, the Kidney must respond.”
This is why so much online advice for this problem insists on abstaining from sexual thoughts — something I find rather difficult to achieve in practice. Nonetheless, a calm mind is undoubtedly beneficial for this condition.
The remaining patterns are simply deficiency of both Heart and Spleen, downward pouring of damp-heat, depletion of the lower yuan, and so on. Overall, excess patterns outnumber deficiency patterns — particularly when dampness stagnates in the Spleen and Stomach, which easily transforms into heat and disturbs the kidney qi. I have always maintained that tonifying methods should be used with great caution; only when nocturnal emissions progress to outright spermatorrhea without dreams (sliding essence) should one consider nourishing kidney yin.
The ancients’ approach was simple: when Heart fire is vigorous, clear the Heart and extinguish fire; when Heart fire is deficiently hyperactive, nourish the Heart and calm the spirit; when minister fire is vigorous, soothe the Liver, clear fire, and nourish yin; when minister fire is deficiently hyperactive, tonify the Heart and Spleen. Only when kidney yuan is profoundly depleted did they resort to Zuogui Wan (Left-Restoring Pill) or Yougui Wan (Right-Restoring Pill).
The ancients were also cautious with cold-cooling herbs. The strongest they typically used were Coptis (Huanglian) and Phellodendron (Huangbo); they rarely employed mineral medicines for clearing heat, and frequently used Cinnamon Bark (Rougui) as a corrective assistant. This tells us a great deal.
My conclusion is that for conditions such as this — lingering for years — one must peel away the layers like unraveling silk, resolving each level in turn. One cannot be greedy for dramatic results, still less be tempted by short-term gains. My teacher has always taught us to seek the root when treating disease. One should start from the deepest layer of pathogenesis, firmly grasp the principal contradiction, and dismantle the secondary contradictions one by one — only then can the outcome be truly satisfactory.
中文原文 / Chinese Original
去年年底，有位青年男士前来求诊，主诉遗精，据闻已梦遗数年，历经多方治疗，病情时好时坏，近期不明原因加重，严重时一夜两次，遗精后浑身酸软无力，精神不佳，痛苦至极。
观前医之方，多以补肾论治，亦有清新健脾之剂，也有利湿祛痰之品，有时收效，有时加重，好的时候能够坚持到一个月一次。我当时辨证明显感觉到有肾不纳气，营卫不和之象，桂枝加龙骨牡蛎汤马上进入脑海中，于是用了此方加了几位清相潜阳之物，嘱其放松心态，淡然从之，以观后效。此方服用后，效果不错，后续调理了几次，最好的时候达到15天一次。
但是，他还有许多别的问题，腹泻、心悸、胃堵、纳差，给我留下深刻印象的是口中淡而无味。这些问题毫无疑问跟肾虚有直接的关系，但是，补肾在此时并非权宜之计。
为此我又重新审视了古人对此病的认识。
古人的认识其实还是很简单的，首先，遗精证明肾的气化功能还正常，肾精还有所保留，古人认为”五脏盛，乃能泻”，脏腑的功能是好的，只不过留不住货，容易造成虚损。
其次，古人基本上都认为，遗精的病因主要在心，正所谓”心有所动，肾必应之”，所以现在网络上对该问题都要求戒色，我看是很难的，但是心静对此病绝对有好处。
剩下的情况，无非就是心脾两虚，湿热下注，下元虚损等等了，总的来说，实证多于虚证，特别是有湿郁于脾胃，很容易化热扰动肾气，所以我始终认为慎用补法，只有合并出现滑精的情况，才应该考虑滋补肾阴。
古人的方法很简单，心火旺的清心去火，心火虚旺的养心安神，相火旺的要疏肝清火养阴，相火虚旺的要补心脾，唯肾元极亏时才用左归或右归。
古人对寒凉药的运用也比较谨慎，最重的也就是用黄连黄柏之类，很少用到矿物药清热，且多用肉桂反佐，如此可见一斑。
我思考，对于这类缠绵多年的疾病应该抽丝剥茧，逐层解决，不能好大喜功，更不能贪图短效，老师一直教育我们要治病求本，还是应该从病机的最深处入手，抓住主要矛盾不放，次要矛盾逐个击破，方能圆满。
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