Huáng Huáng – A Bàn Xià Hòu Pò Tāng Case

Huang, 65-year-old male, 171cm/75kg. 

Initial consultation on January 29, 2019.

History: Superficial gastritis with ulceration for over 10 years. Patient reported that he often experienced abdominal pain after taking western medications as well as abdominal discomfort after eating fruit. He felt a sticky sensation in his umbilicus, and also experienced abdominal distention, belching, poor appetite, difficulty falling asleep, and had no issues with his bowel movements. He was worried that his digestive disease will develop into cancer, and therefore, his mood was quite poor. 

Signs: Robust build, double eyelids, frowning eyebrows, lively facial expressions, a red face, and dusky red lips. In addition, he procrastinated when he spoke. His abdomen was soft, there were purple stasis marks below his tongue, his throat was red, tongue coating slightly greasy, and his pulse was slippery. 

Prescription: jiangbanxia 15g, houpo 15g, fuling 15g, sugeng 15g, zhike 15g, zhizi 15g, lianqiao 30g, huangqin 10g; 9 packets; 3 days on, 2 days off. 

Second consultation on February 26, 2019: After taking the formula, his symptoms had improved. However, once stopping them, the symptoms returned, yet this time there was no abdominal pain, and only a feeling of discomfort, plus the location of the pain had now changed. He was also belching, had subcostal distention, and his sleep was reduced. 9 packets of the same formula with chenpi 20g was given; 3 days on, 2 days off. 

Selected Clinical Case Histories of Liú Dù-Zhōu – Gé Gēn Tāng

 

Li X, a 38-year-old male. He had suffered with stubborn migraines for 2 years, which had not resolved despite being treated for a long time. He was introduced to Doctor Liu by a good friend and brought in for a consultation. 

Chief complaint: right sided headaches, which commonly extended to the forehead and supraorbital ridge. This was accompanied by an absence of sweating, chills, a runny nose with clear mucus, irritability, a red complexion, dizziness, and poor sleep. During examination, the patients’ range of motion in his back was inhibited, and on inquiry, the patient reported that his neck and occiput usually felt tight, more severely so during his headaches. His tongue was pale with a white coat, and his pulse was floating and slightly rapid. 

This was differentiated as cold pathogens being lodged in the taiyang channels, resulting in symptoms of inhibited flow of channel qi. 

Treatment required the promotion of sweat to expel pathogens, and unblock taiyang qi, so Kudzu Decoction (gé gēn tāng) was given: 

Ephedrae Herba (má huáng) 4g
Puerariae Radix (gé gēn) 18g
Cinnamomi Ramulus (guì zhī) 12g
Paeoniae Radix alba (bái sháo) 12g
Glycyrrhizae Radix praeparata (zhì gān cǎo) 6g
Zingiberis Rhizoma recens (shēng jiāng) 12g
Jujubae Fructus (dà zǎo) 12 pieces

Ephedrae Herba (má huáng) and Puerariae Radix (gé gēn) were to be decocted first with the froth removed before adding the other ingredients. 

After taking the decoction, the patient was covered up so a slight sweat could be obtained. He was instructed to avoid cold drafts. 

After taking 3 packets, his back felt warm, which was followed by a mild sweat throughout the body, and a reduction in his headache and neck tension. 15 packets of the same formula was
prescribed again, which completely resolved his headaches and neck tension. 

Selected Clinical Case Histories of Liu Du-Zhou (Liú Dù-Zhōu lín zhèng yàn àn jīng xuǎn)

The Wandering Kidney – A Discussion on Shèn Qí Wán by Keisetsu Ōtsuka

 The Wandering Kidney
– Keisetsu Ōtsuka (大塚敬節)
A while back, a male presented at the clinic looking to improve his overall health.  He complained that he would be easily fatigued following exercise, and afterwards would experience lower back and abdominal pain. He had been diagnosed with various conditions such as gallstones, kidney stones, and chronic appendicitis. Most recently following thorough examination, he was diagnosed with a wandering or floating kidney[1]on the right side. During abdominal diagnosis his kidney was easily palpated below his ribs on the right side when sitting up, however, when laying down the kidney was difficult to palpate. His appetite was normal as were his bowel movements and urination.
Shèn Qì Wán was administered, in accordance with the Jīn Guì Yào Lüè line that states,
“For deficiency taxation manifesting with lumbar pain, lesser abdominal hypertonicity, and inhibited urination, Bā Wèi Shèn Qì Wán (Eight-Ingredient Kidney Qi Pill) is indicated”.
After one month his fatigue had markedly improved and he no longer felt the lower back and abdominal pain.
Not long after this case, I saw a woman with a floating kidney, for which I reluctantly administered Shèn Qì Wán. Although the previous patient had excellent results with the formula, after giving this patient Shèn Qì Wán, she suffered from vomiting and poor appetite. The formula was discontinued after two days. This patients’ entire abdomen was soft and weak, with water sounds in the abdomen on percussion. In addition, her pulse was weak, appetite poor, and she experienced abdominal, back and lumbar pain, which were affecting her work. If Shèn Qì Wán is used in gastroptosia[2] or in patterns associated with sluggish stomach function manifesting with poor appetite, diarrhea, or vomiting there will frequently be side effects and great difficulty in resolution of the patients’ condition. There is also a line related to the formula in the Jīn Guì Yào Lüè, which states, “Eating and drinking as normal”, which clearly specifies that Shèn Qì Wán is not indicated in cases involving obstruction of the gastrointestinal tract. Although the line is very clear, I still administered the formula, ignoring the pattern identification and therefore failed to control the disease. I changed the formula to Liáng Zhǐ Tāng, which was able to control the symptoms, and reduce the abdominal, back and lumbar pain. In addition, this patient also had obvious umbilical pulsations.
The famous Japanese doctor Wada Tōkaku (和田東郭– 1744-1803), said that umbilical pulsations are a typical Dì Huáng formula sign, but should be combined with lóng gǔ (Fossilia Ossis Mastodi), mǔ lì (Ostreae Concha), guì zhī (Cinnamomi Ramulus) and gān cǎo (Glycyrrhizae Radix) formulas, which also present with umbilical pulsations. Therefore one must be cautious in using Shèn Qì Wán based on umbilical pulsations alone.
Liáng Zhǐ Tāng is líng guì cǎo zǎo tāng (Poria, Cinnamon Twig, Licorice, and Jujube Decoction) with the addition of zhǐ shí (Aurantii Fructus immaturus), bàn xià (Pinelliae Rhizoma preparatum), and liáng jiāng (Alpiniae Officinarum Rhizoma). When I find umbilical pulsations with hardness in the abdomen, I will typically use this formula to attack and move the pain.

[1] Floating kidney is a condition that is also termed as hypermobile kidney or the wandering kidney. The medical name of such a condition is nephroptosis. In such a condition the kidney is seen to drop downwards when a person stands up or is transiting from a lying down to an upright position. It is also known as the kidney prolapse condition. The kidney moving downward suggests that it is not fixed fully by the tissues that surround it. Such a condition is not uncommon and has been noted over a century by physicians in many cases.
[2] Downward displacement of the stomach.

A case of Xiǎo Jiàn Zhōng Tāng (minor construct the middle decoction)


Fàn Zhōng-Lín

A 22-year-old female factory manager from Chóng Qìng city presented at the clinic.

In July 1959 the patient had developed a high fever and lost consciousness. She was immediately taken into a local hospitals emergency department for investigation. She was administered an anti-pyretic medication, however her fever would not reduce. She was also given various medications to manage and reduce her heat all to no avail. Her diagnosis was inconclusive. At this point she was discharged from the hospital after requesting Chinese medical treatment. After taking two packages of a heat reducing formula, she had gradually regained consciousness. However, in the evening the following day she once again lost consciousness. Again, she was sent to the hospital for treatment, but as she had once again come down with a critical condition as before, they were still unable to make a clear diagnosis. The old Chinese medical doctor[1] was once again consulted who said he was able to diagnose her. After taking Chinese medicinals, her condition gradually improved.

The old Chinese medical doctor believed her condition was due to cerebral stagnation. She was sent for examination and film of her head, which clearly showed blood stagnation in her cranium, and was thus immediately sent to surgery in order to escape any form of danger.

A month following the surgery she was experiencing twitching in her extremities and coldness in the lower half of her body. She was discharged from hospital and continued using herbal medicines for the next five or six years, with very little clear improvement. In 1965 she travelled here to Róng[2] for a consultation.

Her current symptoms were, twitching in her extremities on the right side, occasional deviation of her mouth and eyes, which occurred five or six times per month and would precede the twitching. Afterwards she would feel numbness on her right side. Over the last few years she was especially fearful of cold, and even during the intense heat of June she would wear a sweater, and her extremities still experienced coldness. Her menstrual cycle was irregular with a pale dark color. Her vision had been receding becoming dim and unclear, and her memory and reaction time were remarkably decreased and slow. She was fatigued and had a poor appetite. Her tongue was pale with a scant amount of grey coating. Pulse was deep and thin.

Symptoms and Disease Mechanisms

  • Deep thin pulse, pale tongue, fear of cold, cold extremities, fatigue, twitching in half the body and extremities: symptoms belongs to a Tài Yīn and Shào Yīn spleen and kidney yáng deficiency pattern.
  • Twitching of the extremities, deviation of the mouth and eyes: This pattern belongs to tetany disease[3].

After suffering from such a major illness, both qì and blood are damaged, and thus tetany may form. When qì and blood are both deficient, the sinews and vessels will jerk and become hypertonic. For example, Sù Wèn chapter 74 ‘The Great Treatise on the Utmost Truth’ says,

“All Cold, with contraction and tautness belongs to the kidneys”. 

The Channels and Sinews chapter (ch.13) of the Líng Shū says,

“[When] the sinews of the Foot Shào Yīn [are diseased], [they manifest with] epilepsy, tugging and tetany”.

Analysis

Tài Yīn, Shào Yīn; qì and blood deficiency.
Among these the qì and blood deficiency are primary.

Treatment Strategy

Here it is appropriate to first warm the center, strengthen the spleen, and harmonize qì and blood.
For this xiǎo jiàn zhōng tāng (minor construct the middle decoction) masters.

Formula:

guì zhī (Cinnamomi Ramulus) 12g
zhì gān cǎo (Glycyrrhizae Radix preparata) 6g
bái sháo (Paeoniae Radix alba) 15g
shēng jiāng (Zingiberis Rhizoma recens) 30g
hóng zǎo (Jujubae Fructus) 15g
yí tang (Maltosum) 60g (dissolved in decoction)

6 packages were given.

She took the six packages above, and followed up ten days later, at which point the twitching in the extremities only occurred once, and the numbness in the body was reduced. In addition, both her spirit and appetite were harmonized, and she was overall making a great recovery.

[1] A Lǎo Zhōng Yī (老中医 ) refers to an older, highly experienced Chinese medical physician, typically held in very high regard throughout the country.
[2] Róng is another name for Chéng Dū.
[3] Refer to chapter 2 in the Jīn Guì Yào Lüè.

Headache: Two cases by Liu Duzhou 劉渡舟

Headache: Two cases by Liu Duzhou 劉渡舟

Translated by Daniel Eng, L.Ac.

Case 1: Zhenwu tang + Ling gui zhu gan tang

Liu Duzhou
Mr. Li, male, 32 years old. The patient was a driver. When he drove in the summer, the weather was hot and he would freely drink ice-cold beer or soda, daily and without restraint. When autumn came he started experiencing headaches every night. The pain was severe, and he had to knock his fists against his head or take analgesic pills in order to obtain relief; it was also accompanied by blurred vision. The condition had persisted for over a month.
On visual inspection, the patient’s facial complexion was dark and sallow, his tongue was pale and tender with a wet, slippery coating, and his pulse was deep, wiry and moderate. This was a case of yang deficiency with water overflowing, turbid yin escaping upward, and clear yang being stifled.
Fuzi 12g, fuling 18g, baizhu 9g, shengjiang12g, baishao 9g, guizhi 6g, zhi gancao 6g
After taking six packets of the medicine, the headaches had lessened significantly. His formula was changed to Ling gui zhu gan tang, and after four packets he was cured.
Commentary by Dr. Liu: Zhenwu tangis also known as Xuanwu tang.Xuanwu is the spirit that controls water in the north. Because this formula has the function of supporting yang and controlling water, it is therefore named Zhenwu tang; it is used for patterns such as Shaoyin yang deficiency with cold, and water qi failing to transform. The Shanghan lun says: “Abdominal pain and inhibited urination . . . means there is water qi.” This indicates the key pathomechanism of this pattern. Yin deficiency with hyperactive yang often stirs wind, while yang decline with exuberant yin often stirs water—this is a basic rule of the occurrence and development of disease. Yang deficiency stirring water is normally treated with the Ling gui formulas; if the disease has reached the kidneys, with yang qi deficiency and decline, palpitations, dizziness, instability when standing, and swaying as if about to fall to the ground, then we must treat using Zhenwu tang.If one takes Zhenwu tang,and the kidney yang is warmed yet the water qi is still unable to transform completely, then we can further use the warming herbs of the Ling gui formulas to harmonize.

Case 2: Guizhi qu gui jia fuling baizhu tang

Ms. Jin, female, 42 years old. The patient had been suffering from left-sided migraines for over three years. She had tried many treatments without effect. Accompanying symptoms included stiff nape; distention, fullness and discomfort of the chest and epigastrium; and frequent, scanty urination. Bowel movements were normal. The pulse was wiry and tight, and the tongue fur was wet and slippery almost to the point of dripping.
Fuling 30g, baishao 30g, baizhu 10g, zhi gancao 10g, dazao 12 pieces, shengjiang10g.
After taking six packets, she was cured.
Commentary by Dr. Liu: Line 28 of the Shanghan lunsays: “When Guizhi tangis taken, or down-purging is used, and there is still pain and stiffness of the head and nape, feathery-warm heat effusion, no sweating, fullness and slight pain beneath the heart, and inhibited urination, Guizhi qu gui jia fuling baizhu tang masters.” Physicians throughout the ages have had quite different understandings of this line from the original text. For example, Xu Dachun of the Qing dynasty said: “Whenever formulas are modified, it is always the assistant or envoy herb [that is removed]. If the chief herb is removed, a new formula name is given. Here guizhiis removed, yet [the formula] is still named after guizhi;this cannot be explained.” Qian Tianlai also said: “The significance of treatment with Guizhi qu gui jia fuling baizhu tang is unclear. I am afraid that this was the error of a later copyist—it is impossible to know. Even if one uses it, I am afraid that it will not necessarily be effective.” And Wu Qian, the author of the Yizong jinjian, asserted even more directly that “remove guizhi” was erroneously written instead of “remove shaoyao.
So, how should we understand this issue? First, we should remember the features of Guizhi tang and its modifications and transformations. The biggest feature of Guizhi tang is that it moistens yin and harmonizes yang, and the herbal combination that achieves this feature is guizhi combined with shaoyao. Guizhiand shaoyao,one yang and one yin, clinically can be taken to form a dichotomy. For example, there is a Guizhi jia gui tang,so there is also a Guizhi jia shaoyao tang;therefore, since there is a Guizhi qu shaoyao tang,there should also be a Guizhi qu gui tang. This way, yin and yang are counterparts, and this fits the objective rules of disease transformations and their treatments. If we analyze along these lines, Guizhi tang with the removal of guiis actually a real phenomenon.
Furthermore, from the perspective of the herbal composition of Guizhi qu gui jia fuling baizhu tang, it wouldn’t hurt to compare it to Ling gui zhu gan tang,in order to understand more clearly the significance of removing gui.In the Shanghan lun, Zhongjing used Zhenwu tang to support yang and disinhibit water, so he also had Zhuling tang to supplement yin and disinhibit water as its counterpart. This is because fluid metabolism dysfunction in the human body is related to the two aspects of yin and yang. Therefore, since Zhongjing offered Ling gui zhu gan tang to unblock the yang and disinhibit water, he should have a formula to harmonize yin and disinhibit water as its counterpart. The answer to this question lies precisely in Qu gui jia fuling baizhu tang.
This formula’s herbal composition is as follows: fuling, shaoyao, baizhu, zhi gancao, shengjiang and dazao.If we look at these ingredients, it is not difficult to discover that the four ingredients fuling, shaoyao, baizhuand zhi gancao are exactly analagous to the four ingredients of Ling gui zhu gan tang, with guizhiand shaoyao as yin-yang counterparts. For this reason, it wouldn’t hurt to call this “Ling shao zhu gan tang”for the moment. “Ling shao zhu gan tang” uses shaoyaoon one hand to moisten the ying and harmonize yin, and on the other hand in combination with fuling, so it also has the function of removing water qi and disinhibiting urination. So the ability of Ling shao zhu gan tang” to harmonize yin and disinhibit water is in exact yin-yang relationship with the ability of Ling gui zhu gan tang to unblock yang and disinhibit water. And the fact that shengjiang and dazao are further included is just like how Ling gui zhu gan tang also has the adaptations known as Ling gui zao gan tang and Ling gui jiang gan tang.
Even if this is so, why didn’t Zhongjing simply name it “Ling shao zhu gan tang,” instead of naming it Guizhi qu gui jia fuling baizhu tang? There may be two reasons for this. The first is that in Zhongjing’s writings, there is often a paired relationship between lines that appear before and after each other. After all, Line 21 lists Guizhi qu shaoyao tang, so Line 28 goes on to mention Guizhi tang and the method of removing gui. This causes a person to compare, so that they see the difference between “chest fullness” in the line above, and “fullness and slight pain beneath the heart” in the line below.
Secondly, Zhongjing was afraid that later generations, upon seeing “pain and stiffness of the head and nape” and “feathery-warm heat effusion,” would grasp onto guizhi and not let it go, overly insistent on the exterior-releasing function of guizhi; so he emphasized that for this formula we must remove guizhiand keep shaoyao. Therefore, when reading Zhongjing’s books we must search in hidden places to tease out deeper meanings.
In the clinical use of Guizhi qu gui jia fuling baizhu tang, the key to pattern differentiation lies in “inhibited urination.” Inhibited urination is a manifestation of bladder qi transformation dysfunction, leading to water evil stagnating internally. Water evil stagnating internally in the bladder can obstruct the flow of yang qi in its channel. When yang qi is blocked and the channel is inhibited, there may be external signs such as feathery-warm heat effusion and pain and stiffness of the head and nape, so it looks like an exterior pattern but really is not an exterior pattern. When the water evil congeals and binds, blocking the qi mechanism and causing interior qi disharmony, there may be interior signs such as fullness and slight pain beneath the heart, so it looks like an interior excess pattern but really is not an interior excess pattern. Therefore the methods of promoting sweating and down-purging are both inappropriate. The pathomechanism of this pattern is as follows: inhibited urination → water blocking the bladder → external qi obstruction and internal qi binding.
If the key to pattern differentiation is inhibited urination, why don’t we use Wuling san to disinhibit urination? This issue has already been clearly explained by Tang Rongchuan of the Qing dynasty. He said: “Wuling sanis for the qi of Taiyang failing to reach the exterior, so guizhiis used to diffuse the qi of Taiyang; when the qi reaches the exterior, water will descend on its own, and urination will be disinhibited. This formula [Guizhi qi gui jia fuling baizhu tang]is for the water of Taiyang failing to descend, and therefore guizhi is removed, and fulingand baizhu are further added to move the water of Taiyang; when the water descends, the qi will reach the exterior on its own, and signs such as headache and heat effusion will naturally be resolved. Those without sweating can be cured with slight sweating, and therefore Wuling sanmakes special use of guizhito promote sweating; sweating is what disinhibits water. This formula makes special use of fulingand baizhu to disinhibit water; disinhibiting water is what promotes sweating. Actually this is due to the knowledge that water can transform qi, and qi can move water.”
Source: Liu Duzhou, ed., Jingfang linzheng zhinan (Beijing: People’s Medical Publishing House, 2013), pp. 50–53, 126–128.

A Concretions and Conglomerations Case- Féng Shì-Lún (冯世纶)

%E5%86%AF%E4%B8%96%E7%BA%B6.jpgA seventy-two year old retired gentleman presented on September 14, 2004 with a three- year history of liver and spleen hypertrophy.

At sixty years of age he had contracted and suffered from gallbladder inflammation and onychomycosis (ringworm of the nails). At sixty-nine he was given griseofulin to treat the ringworm, which consequently damaged his liver function.  In 2001 his ringworm had gotten much worse and so he was administered Itraconazole for several months. Although the ringworm did improve, his liver function was now abnormal, and his blood platelets had decreased.  His diagnosis was drug-induced hepatitis with splenic-liver syndrome. Western medications were ineffective. The results of his medical exams were as follows:

Blood panels: WBC 4.6 x 1012/L, RBC 3.93 x 1012/L, Platelets 59 x 109/L.

Ultrasound showed a fatty liver, liver enlargement (hepatomegaly), spleen enlargement (splenomegaly), with the thickness of the liver being 156mm and the thickness of the spleen being 70mm.

Liver function tests: AST 45IU/L, TP 8.4g/DL, GGT 76IU/L, TBA 37umol/L.

Current symptoms: Lack of strength, dryness of the mouth in the morning, frequent chest fullness, and frequent passing of flatus. He had a white tongue coat, which was greasy at the root, and his pulse was wiry and thin.

Pattern identification and basis of treatment:

Chest fullness belongs to Shào Yáng

Mouth dryness belongs to Yáng Míng

Lack of strength is associated with Tài Yīn

He was administered a modified version of xiǎo chái hú jiā shí gāo tāng (Minor Bupleurum Decoction with Gypsum)

chái hú (Bupleuri Radix) 12g

huáng qín (Scutellariae Radix) 10g

bàn xià (Pinelliae Rhizoma preparatum) 15g

dǎng shēn (Codonopsis Radix) 10g

zhǐ shí (Aurantii Fructus immaturus) 10g

chén pí (Citri reticulatae Pericarpium) 30g

shēng jiāng (Zingiberis Rhizoma recens) 12g

dà zǎo (Jujubae Fructus) 4 pieces

zhì gān cǎo (Glycyrrhizae Radix preparata) 6g

yīn chén hāo (Virgate Wormwood herba) 15g

dān shēn (Salvia Militiorrhiza) 15g

tiān huā fěn (Trichosanthis Radix 12g

biē jiǎ (Trionycis Carapax) 10g

wǔ wèi zǐ (Schisandrae Fructus) 10g

shēng shí gāo (Gypsum fibrosum) 45g

Seven packages were given.

Question: Is the ancient rén shēn actually dǎng shēn, bái shài shēn or gāo lí shēn?

Answer: If we look, we see that rén shēn’s applications in Zhòng Jǐng’s formulas are quite numerous, and dǎng shēn is capable of meeting these major requirements.

Question: In this treatment xiǎo chái hú tāng (Minor Bupleurum Decoction) was used, and in Japan it is also frequently used for hepatitis. Is this formula especially efficacious at treating hepatitis?

Answer: Not necessarily. Chinese medicine looks at the individual systems when treating and is not influenced by western medical diagnosis.  Japan’s misuse of this formula for treating hepatitis has created lots of disputes around the use of this formula, mainly because they are not relying on pattern (identification) for herb usage and strictly use western medical diagnosis to determine its use. From the perspective of orthodox Chinese medicine this use is incorrect, erroneous and can bring about side effects from the formula.  In this case xiǎo chái hú tāng (Minor Bupleurum Decoction) was used for an extended period of time, yet none of these so-called side effects were observed. These are the lessons the Chinese western integrative doctors should be drawing from.

Second consultation on September 21, 2004:  The chest fullness was not as pronounced, yet he was still lacking strength and was frequently passing gas. Shēng shí gāo (Gypsum fibrosum) was removed from the previous formula and 30g of chén pí (Citri reticulatae Pericarpium) was added. Seven packages were administered and he was also given dà huáng zhè chóng wán (Rhubarb and Ground Beetle Pill) and was instructed to take three grams once daily.

Third consultation on October 8, 2004:  Gas was reduced and bowel movements were normalized. The chén pí (Citri reticulatae Pericarpium) was kept at 30g and 15g of cāng zhú (Atractylodis Rhizoma) was added. Fourteen packs were given.

Fourth consultation on October 22, 2004: Chest fullness was still not pronounced, he experienced itchiness of his abdomen and back, he was only tired after walking and his mouth was no longer dry in the morning. Here we see the lack of strength and harmony of the mouth (no abnormal taste or sensation in the mouth) as the key signs of a Tài Yīn vacuity pattern. Therefore fú líng yǐn (Poria Beverage) is used combined with medicinals to nourish the blood, eliminate stasis, and soften hardness.

bàn xià (Pinelliae Rhizoma preparatum) 10g

dǎng shēn (Codonopsis Radix) 10g

zhǐ qiào (Aurantii Fructus immaturus) 10g

chén pí (Citri reticulatae Pericarpium) 30g

cāng zhú (Atractylodis Rhizoma) 10g

fú líng (Poria) 12g

bái sháo (Paeoniae Radix alba) 10g

táo rén (Juglandis Semen) 10g

dāng guī (Angelicae sinensis Radix) 10g

chuān xiōng (Chuanxiong Rhizoma) 6g

yīn chén hāo (Virgate Wormwood herba) 15g

dān shēn (Salvia Militiorrhiza) 15g

biē jiǎ (Trionycis Carapax) 10g

wǔ wèi zǐ (Schisandrae Fructus) 10g

After taking seven packages he occasionally had a dry mouth with a bitter taste and his GPT levels had increased. He was given a modified version of the formula from the first consultation. Afterwards he had abdominal distention, a lack of strength, and an absence of dryness or bitterness in the mouth. He was then given a modified version of the formula from his fourth consultation.

He was seen again in April of 2005 where he was commonly experiencing a dry mouth with a bitter taste, and a lack of strength in the lower limbs. His tongue coating was white and greasy and his pulse was wiry and thin.  This was a Jué Yīn pattern of blood vacuity with water exuberance and cold-heat complex for which he was given a combination of chái hú guì zhī gān jiāng tāng (Bupleurum, Cinnamon Twig, and Ginger Decoction) and dāng guī sháo yào sǎn (Tangkuei and Peony Powder) to treat it. This formula was taken for roughly one year after which his abdominal distention, poor appetite, and lack of strength were resolved, and his overall spirit had improved. In July of 2005 he returned for a follow-up ultrasound. The results were as follows:

1.     Hepatic diffused lesion

2.     Spleen enlargement, increase of the Spleen’s portal vein (thickness of liver was 110mm, and the thickness of the spleen was 50mm)

Overall, his symptoms were improved, and his liver and spleen had reduced in size. He was advised to stop his formula and keep a close watch (on his symptoms).

Question: In the first consultation this man was given a modified version of xiǎo chái hú tāng (Minor Bupleurum Decoction), in the fourth consult he was given wài tái fú líng yǐn (Poria Beverage from the Wài Tái), and afterwards he was given a combination of chái hú guì zhī gān jiāng tāng (Bupleurum, Cinnamon Twig, and Ginger Decoction) with dāng guī sháo yào sǎn (Tangkuei and Peony Powder). Can you please elucidate as to whether a half interior half exterior pattern can shift into the interior, and also if an interior condition can shift into the half interior half exterior?

Answer:  It’s not exactly like that. Generally, a disease shifts due to the diminishing of fluids and can pass through the exterior, half exterior half interior, and interior. In disease, Shào Yáng can pass through to Yáng Míng, but Yáng Míng can absolutely not pass to Shào Yáng. This is the reason it is said that in Yáng Míng disease “there is nothing to return to”.  So when a disease presents as a combination of half exterior half interior with an interior (condition), one must use medicinals on the basis of the aspect that is stressed more.

Question: It is said the Dr. Hú was greatly influenced by the great Kampo doctors.  What are the differences and similarities between his research on the works of Zhòng Jǐng’s to those done by Japanese physicians?

Answer: Both sides attached great importance to the work of Zhòng Jǐng and the reasoning, thought process, and identification of the cause of diseases. They both used the perspective of the eight principles pattern identification in order to research and study classic formulas, and paid particular attention to formula pattern correspondences. They felt the six channels were established rules (suitable) for (diagnosing) hundreds of diseases.

Rén Yīng Qiū- A Zhēn Wǔ Tāng (True Warrior Decoction) Case

Dr. Hú Xī-Shù (胡希恕) -Chest Pain

On May 28th, 1965, a 67 year-old male presented at the clinic suffering from shortness of breath, chest pain, and hu xi shu 2.jpgchest oppression for over a month. On April 23rd he was diagnosed with a myocardial infarction, and was administered both nitroglycerine and aminophylline, which were ineffective. He also sought out Chinese medical treatments and was given various qi boosting, blood invigorating, phlegm transforming, and collateral freeing medicinals (such as rén shēn, huáng qí, mù guā, chì sháo, jiàng xiāng, táo rén, xiè bái, and yù jīn), which he had been taking for the last month but no obvious improvement was observed.  Currently he was experiencing a burning hot pain in the left side of his chest, shortness of breath, which was exacerbated with movement, he was occasionally cold and hot, had a stifling sensation below his heart, a bitter taste in the mouth, occasional head distention, insomnia, and dry stools. He had a yellow tongue coating, and a wiry, slippery pulse.  

Dr. Hú administered a modified version of dà chái hú tāng (Major Bupleurum Decoction) combined with guì zhī fú líng wán (Cinnamon and Poria Pill).

chái hú (Bupleuri Radix) 4 qián

bàn xià (Pinelliae Rhizoma preparatum) 3 qián

huáng qín (Scutellariae Radix) 3 qián

bái sháo (Paeoniae Radix alba) 3 qián

zhǐ shí (Aurantii Fructus immaturus) 3 qián

shēng jiāng (Zingiberis Rhizoma recens) 3 qián

dà zǎo (Jujubae Fructus) 4 pieces

guì zhī (Cinnamomi Ramulus) 3 qián

fú líng (Poria) 4 qián

táo rén (Juglandis Semen) 3 qián

dà huáng (Rhei Radix et Rhizoma) 2 qián

shí gāo (Gypsum fibrosum) 1 liǎng

zhì gān cǎo (Glycyrrhizae Radix preparata) 1 qián

Second consultation (June, 1st): After taking three packages of the formula most of his symptoms had improved, but he was still feeling suffocated in the evenings, had heartburn after meals, and his stools were still dry. His tongue coat was still yellow, and his pulse was wiry, slippery, and slightly rapid.  The same formula was administered but the dà huáng was increased to 3 qián.

Third consultation (December 23rd): After taking two packages of the formula, the suffocating feeling in the evenings disappeared, and while he still experienced some shortness of breath on exertion, it would gradually resolve after a little bit of rest. Afterwards he did not return for a follow up.  He was currently being treated for a weeklong cough with a modified version of bàn xià hòu pò tāng (Pinellia and Magnolia Bark Decoction).

Commentary:  In regards to the treatment of this case, the previous physicians had used blood invigorating, qi regulating medicinals, however they all failed to provide any relief for the patient, while Dr. Hú was able to offer a good effect by grasping the crucial aspect of the condition.  The previous physician paid little attention to whether the condition involved heat, cold, repletion, or vacuity, while Dr. Hú recognized this to be a repletion heat pattern stuck in the half exterior half interior portion of the body.  In addition, he recognized this as a dà chái hú tāng and guì zhī fú líng wán formula presentation, which is the reason why his treatment worked so well.

A Mismanaged Case Corrected By Zhāng Jī

Introduction:

ZZJ.jpgThe following is a case presentation for a woman that was treated at my clinic in the spring of 2009.  It starts as what seems like a simple case but proves to be quite the challenge until I delved a little deeper into the classics, specifically the seminal and possibly the oldest medical text Treatise on Cold Damage (Shāng Hán Lùn), with further elucidations by the late great Běijīng physician Hú Xī-Shù (胡希恕,1898-1984).

  

Case:

A 29-year-old female presented at my clinic with abdominal pain she had been suffering with for four years.  Most of her pain was felt in the lower abdomen and occasionally in the peri-umbillical area.  Pain was occasionally alleviated with warm compresses and with mild abdominal massage.  When asked, she was not sure whether warm or cool drinks affected the pain but was sure to be more mindful after our first meeting. The pain was very unpredictable, appearing one day before meals, the next after without one distinct pattern.   She mentioned that she first remembers her pain starting a couple months after a difficult break up from her fiancé and several months of instability at her job.  This initial stress had first affected her sleep, which is basically now under control with the occasional use of sleep medication.  Her appetite fluctuated with her moods, as did her overall energy levels.  Bowel movements were not too affected but had a tendency to be soft.   Urination was unaffected.  Mild nausea was noted but she felt it was insignificant since she has always felt slightly nauseous since her break-up.   Her tongue was slightly pale with a thin coating and her pulse was slightly wiry on deep palpation, otherwise they were both unremarkable.  Aside from the above the symptoms, she was a healthy, active woman, who was at her wits end with this nagging pain.  Various western medications were tried all to no avail. 

I had diagnosed the pattern as a simple Liver-Spleen disharmony and assumed I could treat this with a basic Qì moving, Spleen boosting formula such as the Free and Easy Wanderer powder (Xiāo Yáo Sǎn) from the Imperial Grace Formulary of the Tai Ping Era (He Ji Ju Fang), with the addition of Fructus Amomi (Shā Rén) and Radix Aucklandiae (Mù Xiāng).  I prescribed one weeks worth of 5:1 concentrated powders.

The following week she returned to the clinic and reported that after taking the first dose of herbs there was some rumbling in her abdomen and within an hour the pain returned slightly worse than before she came to see me.  For the next couple of days after taking the herbs she felt tired and her abdominal pain was slightly more pronounced.  All other symptoms remained the same including her tongue and pulse presentations.  

In the past when presented with similar cases of digestive problems due to a Liver-Spleen disharmony when herbal formulas were prescribed correctly, at least some alleviation of symptoms would be noted after a few days.  Now in this particular case, with the slight exacerbation of her symptoms and the fact that she felt weaker, it was clear that I was missing something.  Scouring through the pages of the ‘Treatise on Cold Damage’ I came upon clause 100 where it states;

“In Cold damage, when the Yáng pulse is choppy and the Yīn pulse is wiry, there should be acute abdominal pain.  First administer Xiǎo jiàn zhōng tāng.  If there is no reduction (of symptoms), Xiǎo chái hú tāng governs”.

The use of Minor centre fortifying decoction (Xiǎo jiàn zhōng tāng) was definitely justifiable, as her abdominal pain liked the occasional use of warm compresses and abdominal massage.  These two symptoms will usually warrant a diagnosis of deficiency cold and this is what the above formula treats.  With my initial diagnosis, too much stock was put into her  stagnation and the other symptoms were overlooked.  In addition she had a deep wiry pulse, which is included in the above clause (‘Yīn pulse is wiry’).  In the original clause it states that patients experiencing nausea or vomiting should not take this formula and although she did experience some nausea, I felt it was fine and was merely a manifestation of the Qì depression more than anything else.  A weeks’ worth of Minor centre fortifying decoction granules were prescribed with no additions.

A week later she returned to report that there had been a significant reduction of pain and there were even a couple days where she would forget about her stomach and go about her day pain-free. Her energy was slightly improved but she still felt quite tired most days.  Another two weeks of the same formula were prescribed. 

Two weeks later she returned feeling great.  There was an even greater reduction in the pain (about 80%) and her energy levels were “not a hundred percent, but getting better”.  Another two weeks worth of formula with the addition of Radix Astragali (Huáng Qí) were prescribed in hopes that the condition would resolve. 

Another two weeks past and she returned feeling essentially the same as before.  Most of the abdominal pain was alleviated except for a few occasions and her energy levels were slowly improving.

xiǎo chái hú tāng was prescribed for ten days according to the rule of Clause 100, in the Treatise on Cold Damage where it states;

“If there is no reduction in symptoms, xiǎo chái hú tāng governs”.

Hú Xī-Shù offers his interpretation of this passage in his ‘Discussion and Elucidation on Cold Damage’ (越辩越明释伤寒)[1];

“No reduction of symptoms namely means that after taking xiǎo jiàn zhōng tāng the abdominal pain is not completely resolved.  Now because both xiǎo jiàn zhōng tāng and xiǎo chái hú tāng symptoms exist, we must first treat the interior and afterwards the exterior.  Since xiǎo jiàn zhōng tāng only treated half the condition, we must follow up with xiǎo chái hú tāng to affect a complete resolution of symptoms”

Ten days later my patient returned pain free. She had not had any abdominal discomfort in over eight days.  Her energy has improved and she reported an overall greater sense of wellbeing.  This was followed with another two weeks of Minor Buplureum decoction (xiǎo chái hú tāng) to consolidate her condition by resolving Qi stagnation and further supplementing her Spleen and she was discharged.  On follow up almost one year later, she has not had any major problems with her stomach and the only time she has any discomfort is following days of overindulgence in foods that are known triggers for her. 

Afterthoughts:

In retrospect I believe that my initial diagnosis of a Liver-Spleen disharmony was correct, it was my focus and choice of medicinals that failed to offer a quick resolution of symptoms. As we can see from clause 100 and from the perspective of Hú Xī-Shù, it is clear that the deficiency (of the central burner) must be addressed first and afterwards the stagnation.  As Xú Líng-Tāi says in his Categorization of Formulas from the Discussion of Cold Damage (伤寒论类方) regarding Minor Centre Fortifying Decoction[2];

“The Yáng Qì of the office of the centre (burner) is deficient, thereby allowing wood to overwhelm earth”

What this means to me is that Minor Centre Fortifying Decoction would in fact address a Liver-Spleen disharmony with emphasis on supplementation. Once we are able to bank up and entrench earth, wood would no longer be able to exploit, and as per the original clause, we follow up with a formula to harmonize Liver and Spleen, resolve Qi stagnation and supplement the Spleen such as Minor Buplureum decoction (Xiǎo chái hú tāng).

According to Kē Qín (a Qing dynasty Shang Han expert), Minor Centre Fortifying decoction is a great centre harmonizing pain-relieving formula[3] and proved to be just that in this case.

I believe this case to be a bit of an anomaly as it fit almost too perfect with Zhāng Zhòng Jǐng’s original line and even responded to his predictions.  I used to believe that practicing the classics in this day and age was far too difficult and that pre-modern conditions had nothing to do with the complex, modern maladies our patients present with today.  As I continue to study the classics and apply them in my day to day practice, I find that when we truly begin to look at our cases from a different lens we find these patterns that Zhāng Jī and the great physicians after his time spoke about and are offered numerous opportunities to utilize them and bring them to life. 

[1]胡希恕越辩越明释伤寒, 冯世纶, 中国中医药出版社, 2009.

 [2]伤寒论类方 , 徐灵胎公元1759.

[3]伤寒论翼柯琴

Yáng Vacuity Insomnia

Dr. Féng Xué-Gōng

Case taken from ‘Forum on Classical Formulas from Throughout the Country’ (全国经方论坛)

A seventy-one year old female was first seen on June 24, 2010 suffering with insomnia for over forty years, which has been quite severe over the last 3 years. When the condition had first started many years ago, she never paid much attention to it or received any kind of treatments. Over the last three years the insomnia has gotten quite bad.  She has great difficulty falling asleep, and although she typically goes to bed around nine o’clock every night, she doesn’t actually fall asleep until at least midnight or one o’clock.  Her sleep is very short, and she wakes very easily. If she takes a sleeping pill, she is able to sleep up to three or four hours. In addition, she experiences heart vexation, and has two to three dry bowel movements per day.  Her appetite is good and urination is normal.  Tongue is pale red with a white coat, and pulse is wiry.

In my experience, cases of insomnia accompanied by heart vexation are typically due to Shào Yáng depressed heat, and are treated as such. 

Formula:

A modified version of Chái Hú Jiā Lóng Gǔ Mǔ Lì Tāng (Bupleurum plus Dragon Bone and Oyster Shell Decoction)

chái hú (Bupleuri Radix) 12g

guì zhī (Cinnamomi Ramulus) 10g

huáng qín (Scutellariae Radix) 10g

dǎng shēn (Codonopsis Radix) 10g

bàn xià (Pinelliae Rhizoma preparatum) 12g

fú líng (Poria) 30g

dà huáng (Rhei Radix et Rhizoma) 10g

shēng lóng gǔ (Fossilia Ossis Mastodi) 30g

shēng mǔ lì (Ostreae Concha) 30g

hé huān pí (Albizziae Cortex) 30g

zhì gān cǎo (Glycyrrhizae Radix preparata) 6g

shēng jiāng (Zingiberis Rhizoma recens) 10g

dà zǎo (Jujubae Fructus) 10g

Seven packages were administered, and to be cooked as a water decoction, taking one pack per day. 

Follow up on July 1, 2010:  After taking the seven packages, none of her symptoms improved and she was still experiencing insomnia. Her tongue was pale red with a white coat, and the pulse was (still) wiry.

Since this woman was older, and had been suffering from insomnia for many years, I tried treating her from the perspective of a kidney yáng insufficiency with ministerial fire being unable to return to its residence.

Formula:

A modified version of Qián Yáng Fēng Suǐ Dān (Yáng Descending Marrow Sealing Elixir)

páo fù zǐ (Aconiti Radix lateralis tosta) 10g

shā rén (Amomi fructus) 15g

guī bǎn (Tortoise plastron) 10g

huáng bǎi (Phellodendri Cortex) 10g

ròu guì (Cinnamomi Cortex) 6g

shēng lóng gǔ (Fossilia Ossis Mastodi) 30g

shēng mǔ lì (Ostreae Concha) 30g

fú líng (Poria) 30g

zhì gān cǎo (Glycyrrhizae Radix preparata) 6g

Seven packages were administered, and to be cooked as a water decoction, taking one pack per day. 

Third consultation on July 8, 2010: Her insomnia was definitely improving, as she was now able to fall asleep easier, wasn’t waking up easily, and was also able to avoid taking any sleeping pills. Tongue was pale red with a white coat, and pulse was wiry.

The strategy of warming the yáng was effective so this is where the emphasis would remain.  To the previous formula (July 1st), ròu guì was increased to 10g, and 30g of cí shí was added. She was given fourteen more packages, to be cooked as a water decoction, taking one pack per day. 

Fourth consultation on July 22, 2010: The insomnia had now clearly improved, and she completely stopped taking any kind of sleeping pills. It now took her only ten minutes to fall asleep; she was not waking easily, and slept for five hour stretches at a time. Her bowel movements were now much easier occurring once per day. Her tongue was pale red, and her pulse was wiry. To her previous formula páo fù zǐ was increased to 15g and the other medicinals were left as is. She was given another fourteen packages. 

Commentary:  In clinical practice, insomnia is typically diagnosed and treated as either a yīn-blood insufficiency, heart spirit deprived of nourishment, internal brewing of fire, or hyperactivity of the heart spirit, and is rarely identified and treated as yáng vacuity. In actual fact, yáng vacuity insomnia is very common, and many cases are due to yáng vacuity insecurity with ministerial fire being unable to return to its residence and producing false heat, which can be erroneously regarded as true heat. This case clearly exemplifies this concept.

Qián Yáng Dān (Yáng Descending Elixir) is a fire spirit school formula created by Zhèng Qīn-Ān. It contains shā rén (Amomi fructus), páo fù zǐ (Aconiti Radix lateralis tosta), guī bǎn (Tortoise plastron), and gān cǎo (Glycyrrhizae Radix). Fēng Suǐ Dān (Marrow Sealing Elixir) is a formula from the Golden Mirror of Medicine (医宗金鉴), which contains huáng bǎi (Phellodendri Cortex), shā rén (Amomi fructus), and gān cǎo (Glycyrrhizae Radix). In clinical practice when treating floating and ascending vacuous yáng, master Zhèng would commonly combine these two formulas, achieving miraculous results. Later generations of physicians commonly utilized master Zhèngs methods, including Wú Péi-Héng (吴佩衡) from Yúnnán province, who renamed the combination of these two formulas Qián Yáng Fēng Suǐ Dān (Yáng Descending Marrow Sealing Elixir). Within the formula Zhèng Qīn-Ān believed that guī bǎn was able to generate the essence within water, not for the purpose of nourishing yīn, but for freeing yīn in order to assist yáng. Shā rén is generally thought of as a medicinal, that moves qì, transforms turbidity, and harmonizes the stomach.  However, in the Běn Cǎo it is said to be able to absorb qì and return it to the kidneys thereby treating and guiding qì, which is unable to return to its source.

This patients’ insomnia had lasted for many years, and was first treated as a pattern of Shào Yáng depressed heat but with no effect. After some contemplation, I figured due to the patients’ age, and the fact that this was an enduring disease, there (must have) initially (been) a yīn vacuity, which eventually affected the yáng.  Moreover, all enduring conditions (eventually) reach the kidneys. With kidney yáng insufficiency, (the kidneys) lose their ability to secure and contain, which then leaves the ministerial fire unable to return to its residence; floating yáng will then ascend disturbing the heart spirit resulting in insomnia. Therefore, the root of the insomnia here lies in yáng vacuity. After using Qián Yáng Fēng Suǐ Dān (Yáng Descending Marrow Sealing Elixir), vacuous fire is able to descend, ministerial fire will return to its residence, and the heart spirit will be tranquil, thereby eliminating insomnia. This case illustrates the importance of paying close attention to recognizing yáng vacuity insomnia and serves to increase and improve our overall clinical efficacy.