Gé Gēn Tāng Case – Liú Dùzhōu

Selected Clinical Case Histories of Liu Duzhou《刘渡舟临证验案精选》

Li X, a 38-year-old male.

He had suffered with persistent migraines for 2 years that remained unresolved despite long periods of treatment. 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. The range of motion in his back was limited and he reported tightness in his neck and occipital area that became more severe during his headaches. His tongue was pale with a white coat, and his pulse was floating and slightly rapid.

This was differentiated as being cold pathogen 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 to avoid drafts and cold.

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 were prescribed again, which completely resolved his headaches and neck tension.

Cáo Yǐngfǔ on the Use of Xiǎo Jiàn Zhōng Tāng 

Master Cao was a pivotal force in the classical formulas school (经方派) and was a true master in using the underlying principles and formulas found in the Shang Han Lun and Jin Gui Yao Lue. Master Cao felt that the medical texts, which followed were too insignificant to study and discuss, and therefore he attached great importance to the thorough study of these texts to his students, and felt that Zhang Zhongjing’s theories and formulas were the perfect framework for successful medical practice. In addition to being skillfully versed in these medical canons, Cao Yingfu was also an accomplished poet, often interweaving the two when attempting to convey his thought process in clinic, often instructing his students to compose a poem and matching it with a relevant line from the classics. This kind of inquiry and thought process truly shows the breadth of his skill and how his mind rarely waivered from the classical Chinese medicine concept of the human body being a reflection of his environment, the microcosm of the macrocosm.
However, master Cao was not completely strict in his formula choices and would often use formulas like Bu Zhong Yi Qi Tang, Xiao Yao San, and Liu Wei Di Huang Wan, in addition to herbs such as niu bang zi, qian hu and various others. This shows that he was obviously well read and did not quickly write off more modern formulas. His use of these non Zhang Zhongjing formulas displayed his deep understanding in the formula constructions and where they were applicable. He advocated that students must understand and study the root of the medical philosophies and not just pick the flowers, and it’s from this same feeling that he encouraged his students to read the Yue Fu (乐府诗集) poetry of the Han and Wei dynasties and specifically the poet Wang Yuyang (王漁洋).

When the Japanese invaded the south, his hometown of Jiangyin, Jiangsu province fell into enemy hands and on December 7th, 1937, he died heroically resisting the invaders. While master Cao died a hero, the world lost a great Chinese medicine master. We are very fortunate to have several of his books available in order for subsequent generations to learn from not just in China, but also around the world. It is my hope in translating some of his cases that this knowledge can spread. We are also very fortunate to have scholar-physicians like my teacher Dr. Huang Huang uphold this love and dedication to master Cao’s work and to classical literature.

Case 1
Female. Since delivering a child her cycles come every forty days, which are accompanied by distending pain in the epigastrium following meals. When the cycle arrives, there is pain extending from the stomach to the lower abdomen. During the pain she experiences a strong desire to have a bowel movement. After the bowel movement the pain would typically stop. Pain would return the following afternoon and stop during the menstrual flow, and once again come and go the following day. Both pulses were wiry.
This is liver and gall-bladder exploiting deficiency of the spleen viscera. In this case Xiao Jian Zhong Tang with Chai hu and Huang Qin is appropriate.


Gui Zhi 3 qian
Sheng Bai Shao 5 qian
Zhi (Gan) Cao 2 qian
Sheng Jiang 5 pcs
Hong Zao 12 pieces
Yi Tang 2 liang
Chai Hu 3 qian
Jiu (Huang) Qin 1 qian
Tai Wu Yao 1.5 qian

After one package, her pain stopped and the menses ceased. Patient continued with two more packages, after which the condition resolved.
The master (Zhang Zhongjing) in his great classic said:


“In cold damage, (when) the yang pulse is choppy and the yin pulse is wiry, as a rule there should be urgent pain in the abdomen. First give Xiao Jian Zhong Tang; if it does not reduce, Xiao Chai Hu Tang governs.”
“伤寒,阳脉涩,阴脉弦,法当腹中急痛,先与小建中汤,不差者,小柴胡汤主之”.

Cao Yingfu (曹颖甫): Now here (in this case) I feel it goes without saying that there had not been a reduction and I immediately added Chai Hu and Huang Qin to treat her, why not? This woman’s situation was a menstrual disease and many belong to Chai Hu patterns, and so it was clearly obvious (to add it). The following day it was reported that the disease had resolved.

Case 2
Abdominal pain which liked pressure. During episodes of pain a distressing sensation of cold air was felt moving up and down (the body). Pulse was wiry-deficient. In addition there was an aversion to cold.
This is due to the liver exploiting the spleen and Xiao Jian Zhong Tang governs.
Gui Zhi 9g
Bai Shao 18g
Sheng Jiang 9g
Zhi Gan Cao 6g
Da Zao 6g
Yi Tang 30g

Liáo Shēng annotation: “This case is a pattern of abdominal pain (due to) central yang insufficiency with interior deficiency. The patient experienced abdominal pain, which liked pressure, the pulse was wiry-deficient and an aversion to cold was present. This signifies the overabundance of yin cold-qi, central yang insufficiency, and liver wood exploiting spleen (earth). Therefore Xiao Jian Zhong Tang was used to treat and resolve the condition.
The function of this formula is to supplement deficiency, quiet the center, moderate urgency and stop pain. The name of this formula is center fortifying (decoction). Fortify means to establish or set up, and because central qi is insufficient, it is very important to ‘establish’ or ‘set it up’. The formula contains sweat inducing (herbs) and not central effusing (herbs). It is referred to as a ‘minor’ (decoction) and only half (of the formula) resolves the exterior, so it does not completely secure the center. Xiao Jian Zhong Tang uses a heavy dose of Yi Tang, which is sweet, warm and serves as the sovereign to supplement the center. Bai Shao is the minister, which is sour and sweet to tonify yin. The assistant Gui Zhi is acrid-warm, which effuses and scatters. Combined with Bai Shao it regulates the nutritive and defense. In addition, Gan Cao, Da Zao and Sheng Jiang, which are sweet moderating and acrid warm, nourish the stomach and harmonize the center. Therefore (this formula) is able to warm and nourish central qi, calm and supplement yin and yang and regulate the nutritive and defense.”

*Xióng Liáo-Shēng (熊廖笙) style name Yǐ Xíng (以行) was born in 1905 in Ba County in Chongqing, Sichuan Province. Master Xióng was well versed in the classics, primarily the Nei Jing, Nan Jing, Shang Han Lun, and Jin Gui Yao Lue. The author of several books, Dr. Xióng possessed a deep and profound scholarship of the Shang Han Lun and was highly skilled in distilling the essence and precise details of various ancient doctors cases, which were found in his various annotations.

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Huáng Yuányù discusses Bǎi Hé

With today being the arrival of ‘Major Cold ‘(大寒 – the 24th solar term in the Chinese calendar lasting until Feb 3), what better day than today, to sit down with a cup of warm Wulong or Hongcha to translate passages from some of my favourite books.
The following is a direct translation from the Bǎi Hé section of Huáng Yuányù’s (1705-1758) excellent ‘Interpretation of Medicinals’ (黃元御藥解).

Huáng Yuányù discusses Bǎi Hé

– Translated from Huáng’s Interpretation of Medicinals (黃元御藥解)

百合 味甘、微苦,微寒,入手太陰肺經。涼金瀉熱,清肺除煩。

Bǎi Hé – Sweet flavour, slightly bitter and slightly cold. Enters the hand Taiyin lung channel. Cools metal, drains heat, clears the lungs and eliminates vexation.

金匱百合知母湯,百合七枚,知母二兩。治百合病,發汗後者。傷寒之後,邪氣傳變,百脈皆病,是為百合。其證眠食俱廢,吐利皆作,寒熱難分,坐臥不安,口苦便赤,心煩意亂,不能指其為何經何臟之病也。然百脈之氣,受之於肺,肺者,百脈之宗也,是宜清肺。其在發汗之後者,津枯而金燔。百合清肺而生津,知母涼金而瀉熱也。

The Jīn Guì’s Bǎi Hé Zhī Mǔ Tāng

Bǎi Hé 7 pieces
Zhī Mǔ 2 liǎng [listed as 3 liǎng in the Jīn Guì Yào Lüè]

Treats Bǎi Hé disease following the induction of sweat. Following cold damage, pathogenic qi shifts, and the hundred vessels are diseased. This is Bǎi Hé [disease]. Its symptoms present with disturbance to sleep and appetite, the occurrence of diarrhea and vomiting, difficulty differentiating between cold and heat, disquietude whether sitting or laying down, a bitter taste in the mouth, red urination, heart vexation, and a confused state of mind, with an inability to point to any specific channel or visceral disease. Now, the qi of the hundred vessels is received in the lungs, as the lungs are the ancestor of the hundred vessels. Thus, it is appropriate for the lungs to be clear. Following the promotion of sweat, the fluids [may be] desiccated and metal burned. Bǎi Hé clears the lungs and generates fluids. Zhī Mǔ cools metal and drains heat.

滑石代赭湯,百合七枚,滑石三兩,碎,代赭石如雞子大。治百合病,下之後者。下敗中脘之陽,土濕胃逆,肺熱鬱蒸。百合清肺而瀉熱,滑石、代赭,滲濕而降逆也。

Huá Shí Dài Zhě Tāng

Bǎi Hé 7 pieces
Huá Shí 3 liǎng (broken)
Dài Zhě Shí (a pellet sized piece)

Treats Bǎi Hé disease following purgation. Purgation damages the yang of the central stomach duct, [resulting in] earth-damp counterflow [of the] stomach and depressed steaming lung heat. Bǎi Hé clears the lungs and drains heat; Huá Shí and Dài Zhě percolate dampness and downbear counterflow.

百合雞子湯,百合七枚,煎湯,入雞子黃一枚,攪勻,煎。治百合病,吐之後者。吐傷肺胃之津,金土俱燥。百合清肺熱而生津,雞子黃補脾精而潤燥也。

Bǎi Hé Jī Zǐ Tāng

Bǎi Hé 7 pieces
Boil the decoction and add one egg yolk, blend until smooth, and boil. Treats Bǎi Hé disease following vomiting. Vomiting damages the fluids of the lungs and stomach, resulting in the dryness of both metal and earth. Bǎi Hé clears the lungs and generates fluids. Jī Zǐ Huáng [egg yolk] supplements spleen essence and moistens dryness.

百合地黃湯,百合七枚,生地黃汁一斤。入百合湯,煎服。大便當如漆。治百合病,不經發汗吐下,病形如初者。不經發汗吐下,而瘀熱淫蒸,敗濁未泄。百合清肺而瀉熱c生地黃汁涼瀉腸胃而下垢濁也。

Bǎi Hé Dì Huáng Tāng

Bǎi Hé 7 pieces
Shēng Dì Huáng juice 1 jīn [listed as 1 shēng in the Jīn Guì Yào Lüè]
Add to Bǎi Hé decoction, boil and take. The stools should be like lacquer. Treats Bǎi Hé disease when neither sweating, vomiting or purgation have been used, and the disease appears as in the beginning. [Here] sweating, vomiting or purging have not been used and there is excess steaming of stasis heat [as well as] turbidity [which] has not been drained. Bǎi Hé clears the lungs and drains heat, while the juice of Shēng Dì cools and drains the stomach-intestines, and purges foul turbidity.

百合洗方,百合一斤。水一斗,漬一宿,洗身。洗後食煮餅,勿以鹽。治百合病,一月不解,變成渴者。火炎金燥,則肺熱不解,變而為渴。肺主皮毛,百合洗皮毛,以清肺熱也。

Bǎi Hé Xǐ Fāng [Lily bulb wash]

Bǎi Hé 1 jīn [listed as 1 shēng in the Jīn Guì Yào Lüè]
Use 1 dǒu of water and soak overnight. Use [the liquid] to bathe the body. After bathing, eat boiled cake, and avoid salt. Treats Bǎi Hé disease, which has not resolved within a month, and has resulted in thirst. [Here] fire flares and dries metal, resulting in lung heat which fails to resolve, leading to thirst. The lungs govern the skin and hair, and the Bǎi Hé is used to wash the skin and hair, thereby clearing lung heat.

百合滑石散,百合一兩,滑石二兩。為散,飲服方寸匕,日三服。微利,止服,熱則除。治百合病,變發熱者。濕動胃逆,肺郁生熱。百合清金而瀉熱,滑石利水而除濕也。

Bǎi Hé Huá Shí Sǎn

Bǎi Hé 1 liǎng
Huá Shí 2 liǎng [listed as 3 liǎng in the Jīn Guì Yào Lüè]
Powder [the ingredients], and take a square-inch spoonful in liquid, three times per day. When there is slight diarrhea, stop taking, as [this indicates that] heat has been eliminated. Treats Bǎi Hé disease, which has transmitted into heat effusion. [When] dampness is stirred, the stomach runs counterflow, resulting in lung depression that generates heat. Bǎi Hé clears metal and drains heat; Huá Shí disinhibits water and eliminates dampness.

百合涼金潤燥,瀉熱消郁,清肅氣分之上品。其諸主治,收涕淚,止悲傷,開喉痹,通肺癰,清肺熱,療吐血,利小便,滑大腸,調耳聾耳痛,理脅癰乳癰、發背諸瘡。
水漬一宿,白沫出,去其水,更以泉水煎湯用。

Bǎi Hé is a superior medicinal, which cools metal, moistens dryness, drains heat, disperses depression, and depurates the qi layer. It’s various treatments include stopping tearing, stopping sadness, opening throat impediment, disinhibiting welling-abscess of the lung, clearing lung heat, treating vomiting of blood, disinhibiting urination, lubricating the large intestine, controlling deafness and ear pain, rectifying subcostal and breast welling-abscesses, and effusing the back of various sores. Steep Bǎi Hé in water overnight. [When] white foam appears, discard the water, and then decoct with spring water and use.

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Huáng Huáng’s Use of Guì Zhī Fú Líng Wán in Respiratory Conditions

Cinnamon Twig and Poria Pill (guì zhī fú líng wán)

Indications: Bronchial asthma, chronic obstructive pulmonary disease (COPD), pulmonary arterial hypertension, pleurisy, pleural effusion, interstitial pneumonia, pulmonary fibrosis, and recurrent pulmonary infections typically manifesting with a dark-red complexion, a stifling sensation and pain in the chest, purple lips and a dark tongue. This formula has a blood invigorating, stasis transforming effect, which can improve the blood supply of the heart and lungs.

Usage & Modifications:

1. Patients for whom this formula is suitable tend to have a red or purple-red complexion, abdominal fullness, resistance to pressure in the lower left abdomen with possible tenderness, headaches, dizziness, insomnia, irritability, restlessness, stirring palpitations, and a dark tongue body with possible purple spots.

2. For patients that experience diarrhea after taking the formula, have them take in after meals or decrease the dosage.

3. Use with caution in pregnancy.

4. Modifications:

  • If there is a stifling sensation and pain in the chest, a chronic cough, and a wan and sallow complexion, add Angelicae sinensis Radix (dāng guī) 15g, Chuanxiong Rhizoma (chuān xiōng) 15g, and Salviae miltiorrhizae Radix (dān shēn) 15g
  • If there is a stifling sensation in the chest, abdominal distention, and an oily complexion, add Citri reticulatae Pericarpium (chén pí) 20g, Aurantii Fructus (zhǐ ké) 20g, and Zingiberis Rhizoma recens (shēng jiāng) 20g
  • If there is a stifling sensation in the chest  and constipation, add Aurantii Fructus (zhǐ ké) 20g, Allii macrostemi Bulbus (xiè bái) 20g, and Trichosanthis Fructus (quán guā lóu) 30g.

Representative Case History:

Yu, 74-year-old male, 160cm/70kg.

Initial consultation on June 5, 2018

Chief complaint: Recurrent cough and wheezing for 9 years, with dyspnea, an inability to climb stairs quickly, and abdominal distention following meals.

History: In April 2018 during a hospital visit, he was diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD), arrhythmia, atrial fibrillation, cardiac insufficiency, heart valve disease, and a fatty liver.

Signs: average build, dark, red and oily complexion, obvious bags under the eyes, purple-dark lips and tongue, stasis marks under the tongue, abdominal fullness, and resistance to pressure in the lower costal arch (flanks).

Prescription: Cinnamomi Ramulus (guì zhī) 10g, Cinnamomi Cortex (ròu guì) 10g, Poria (fú líng) 20g, Paeoniae Radix rubra (chì sháo) 20g, Moutan Cortex (mǔ dān pí) 15g, Persicae Semen (táo rén) 15g, Angelicae sinensis Radix (dāng guī) 15g, Chuanxiong Rhizoma (chuān xiōng) 15g, Salviae miltiorrhizae Radix (dān shēn) 15g, Aurantii Fructus (zhǐ ké) 30g, Citri reticulatae Pericarpium (chén pí) 30g, Zingiberis Rhizoma (gān jiāng) 10g; 15 packets.

Second consultation on June 25, 2018: After taking the herbs, his breathing was smooth and easy, however cough and wheezing were still present, but he was still able to play mah-jong. The same formula was continued.

Third consultation on August 20, 2018: No labored breathing when walking and he was able to climb 3 floors. The stasis marks under his tongue had improved.

Musings on Bēn Tún Tāng

A formula I’ve been quite intrigued with for many years, and use quite often in clinic, is Bēn Tún Tāng from the Jīn Guì Yào Lüè. The following is a short translation from one of my favourite Qīng dynasty scholar/physicians Huáng Yuán-Yù, followed by some brief clinical musings written by myself. 

Huáng Yuán-Yù on Bēn Tún Tāng

Translated from the Cháng Shā Yào Jiě (长沙药解)

The Golden Cabinet’s Bēn Tún Tāng

Gān Cǎo  2 liǎng

Bàn Xià 4 liǎng

Shēng Jiāng 4 liǎng

Shēng Gé (Gēn) 5 liǎng

Huáng Qín 2 liǎng

Xiōng Qióng 2 liǎng

Dāng Guī 2 liǎng

Sháo Yào 2 liǎng

Gān Lǐ Gēn Bái Pí 1 jīn 

This formula treats Bēn Tún qi, with surging into the chest, abdominal pain, and alternating heat and cold. When yang collapses, and the spleen is vanquished, (this causes) sinking and obstruction in Liver-wood, wood qi depressed effusion, and surging from the umbilicus, abdomen, chest and diaphragm, (resulting in) pain and concurrent heat and cold. Because Liver-wood surges upwards, both the stomach and gall-bladder run counterflow, and the Shaoyang is depressed and distressed, this results in a struggle between the interior and the yin, and this ongoing battle manifests with alternating cold and heat. The qi of Jué Yīn is wind-wood. When wind stirs it consumes the blood, and when warmth is depressed, it results in heat. Gān Cǎo supplements the earth and moderates the center; Shēng Jiāng and Bàn Xià descend stomach and gall-bladder counterflow; Huáng Qín and Shēng Gé (Gēn) clear depressed heat in the stomach and gall-bladder; Xiōng Qióng and Sháo Yào course wood and moisten wood dryness; Gān Lǐ Gēn Bái Pí clears the liver and descends surging qi. 

Gān Lǐ Gēn Bái Pí is sweet, cold, collecting and astringent. It is excellent at descending the surging qi of Jué Yīn, which can therefore treat bēn tùn. It is mainly indicated for alleviating thirst, eliminating vexing counterflow, arresting dysentery, and stopping vaginal discharge. 

Notes:

In my experience, Bēn Tùn (running piglet) can be both objective and subjective. Subjective in that the patient will feel some sort of rush that starts in the lower body, and rises either to the chest, throat, or face. It’s pretty hard to get a patient to tell you that they feel a surging sensation from their lower abdomen to their chest. Some do, but it’s not something I hear very often. Anxiety can manifest this way for some people, while some will tell you that they get facial redness, slightly dizzy or a bit of a rush when they are nervous. Another possibility for some is that this sensation, or ‘rush’ can cause patients to become anxious. I would interpret these manifestations as a form of running piglet. 

However, running piglet is also objective, manifesting in several ways such as; sudden sweating, facial redness, epigastric pain, chest tightness, shortness of breath, dizziness, headaches/migraines, premenstrual acne, etc.

This is due to a wood-earth pathology, where wood is abundant, which damages the earth, hence we see the abdominal pain. Since we have a Shào Yáng element here, there is alternating heat and cold (往来寒热), which can be interpreted the way Huáng Huáng (黄煌) does in that this alternating heat and cold can refer to anything that alternates, or occurs cyclically. This is a major feature of the Shào Yáng, and so having someone that breaks out into sweats, gets cyclical acne, cyclical migraines, anxiety attacks, etc., that is due to a wood-earth pathology, Bēn Tùn Tāng is a great choice. 

In addition, we have an element of a Jué Yīn pathology as well just to complicate things. Here, blood was affected which left a slight blood deficiency and when there is not enough blood and wood-qi tries to move, this can get stuck and lead to heat (which is the flaring of ministerial fire). 

Sāng Bái Pí is the most common substitute for the Gān Lǐ Gēn Bái Pí. Some doctors like Hu Xi-Shu used Chái Hú as they saw this pattern as a Shào Yáng-Tài Yīn concurrent pattern, and added Chái Hú to clear Shào Yáng heat from the chest. I personally use Sāng Bái Pí, as I feel that due to the flaring of ministerial fire, there is a bit of heat in the lungs and adding Sāng Bái Pí ensures that it gets cleared but also that metal descends. With the Spleen-earth affected, ascent and descent in the entire body is affected and we always need to make sure that the proper physiological wheel keeps turning. 

Huáng Yuán-Yù on Wú Zhū Yú Tāng

Wú Zhū Yú (吳茱萸): Acrid and bitter flavor, warm nature; enters the foot Yángmíng stomach, foot Tàiyīn spleen, and foot Juéyīn liver channels. Warms the centre, drains dampness, opens depression, breaks congealment, descends turbid yin to stop vomiting, and ascends clear yang to stop diarrhea. 

Cold Damage’s Wú Zhū Yú Tāng

Wú Zhū Yú (吳茱萸) 1 shēng

Rén Shēn (人蔘) 3 liǎng

Shēng Jiāng (生薑) 6 liǎng

Dà Zǎo (大棗) 12 pieces

Treats Yángmíng cold damage with a desire to vomit after eating. Normally, stomach qi descends, [which results] in the absence of vomiting on the intake [of food]. [When] stomach qi adversely ascends, this results in vomiting and reduced [food] intake. Rén Shēn and Dà Zǎo bank the earth and supplement the center; Wú Zhū Yú and Shēng Jiāng warm the stomach and descend counterflow. [This] treats Juéyīn disease with dry retching, vomiting of foamy drool, and headaches. 

Due to deficiency of the earth, wood becomes stagnant, centre qi is harmed, the stomach ascends as opposed to descending, and turbid qi is upthrusted, resulting in headaches and dry retching. 

When damp qi is congealed and stagnant, this results in vomiting of foamy drool. Rén Shēn and Dà Zǎo bank the earth and supplement the center; Wú Zhū Yú and Shēng Jiāng descend counterflow and course wood. [This] treats Shàoyīn disease with vomiting, diarrhea, reversal cold of the extremities, vexation, agitation and a desire to die. 

When cold water rebels against the earth, the spleen sinks and the stomach [runs] counterflow, which leads to both vomiting and diarrhea. [When] center qi is depleted, the four limbs lack warmth, resulting in reversal cold of the extremities. [When] yang departs from its root, it disperses and strays without returning, resulting in vexation, agitation and a desire to die. Rén Shēn and Dà Zǎo bank the earth and supplement the center; Wú Zhū Yú and Shēng Jiāng descend counterflow and ascend that which is sinking. 

In the Jīn Guì [this formula] treats vomiting and chest fullness. [When] the center is deficient and the stomach runs counterflow, turbid qi becomes congested in the chōng vessel, resulting in vomiting and chest fullness. Rén Shēn and Dà Zǎo bank the earth and supplement the center; Wú Zhū Yú and Shēng Jiāng descend counterflow and drain fullness. 

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. 

Kē Qín on Xuán Fù Dài Zhě Shí Tāng from the Collected Writings on Renewal of the Discussion of Cold Damage (伤寒来苏集)

 

“In Cold Damage which has resolved following sweating, purging or vomiting, [but there is now] a hard glomus below the heart and belching which will not resolve, Xuán Fù Dài Zhě Shí Tāng (Inula and Hematite Decoction) governs.”

(Shāng Hán Lùn clause 161) 

 

 

In cold damage, cold damages the heart. Now if sweat is effused, or one is purged or made to vomit, heart qi will become majorly deficient, and exterior cold will exploit this deficiency and bind below the heart. Heart qi will be unable to descend and instead ascend upwards resulting in noise [belching]. The sovereign [medicinal] governs the manifestation of this fleeing. Belching is the sound of pain. It cannot be referred to as sound, but should be named qi. Qi follows the sound and is seen on the outside.  

Xuán Fù Huā 3 liǎng

Gān Cǎo 3 liǎng

Rén Shēn 2 liǎng

Bàn Xià half a shēng

Dài Zhě Shí 1 liǎng

Shēng Jiāng 5 liǎng

Dà Zǎo 12 pieces

Use one dou of water for the above 7 ingredients, and boil until 6 shēng remain. Remove the dregs, and simmer again until 3 shēng remain. Take 1 shēng warm, three times daily.

This formula is shēng jiāng xiè xīn tang with huáng qín, huáng lián, and gān jiāng removed, and xuán fù huā and dài zhě shí added. In a heart qi deficiency a xiè xīn tang [formula] should not be taken, and can therefore be controlled with this formula. The heart governs the summer, and xuán fù huā reaches its end stage in the summer. Its salty flavor can supplement the heart, soften hardness, and disperse bound qi. Bàn xià grows at the beginning of summer, and its acrid flavor can scatter pathogens, disperse glomus, and move bound qi. Dài zhě shí is endowed with the fire of the south, which enters and frees the heart, scatters hard glomus, and settles the deficient counterflow. The sweetness of rén shēn, gān cǎo, and dà zǎo assist xuán fù huā in draining deficient fire, while acrid shēng jiāng assists bàn xià in scattering bound water. This will result in the dispersal of the hard glomus, and the elimination of belching. If huáng qín and huáng lián are used to drain the heart, how can one protect subtle yang from not being extinguished?

Kē Qín (柯琴), courtesy name Yùn Bó (韵伯) (1662 – 1735) was a Qīng Dynasty Shāng Hán Lùn (傷寒論 Discussion of Cold Damage) scholar, from Cí Xī county in Zhè Jiāng province. A prolific writer, Kē authored several books in his time and was a large proponent of the ‘school of formula types’ (方类证派), famously saying,  “Patterns are differentiated from the conformations, therefore the pattern is named after the formula (证从经分,以方名证).”

Zé Xiè Tāng from the Jīn Guì Fāng Gē Kuò

澤瀉湯
Zé Xiè Tāng
Alisma Decoction

治心下有支飲, 其人苦冒眩者, 主之。
 
A treatment for propping rheum below the heart, where the person suffers from veiling dizziness, (this formula) rules it.  

澤瀉五兩            白朮二兩
zé xiè
澤瀉
15g
bái zhú
6g
上二味, 以水二升, 煮取一升, 分溫再服。
Simmer the two ingredients above in 400 ml, until reduced to 200 ml.  Divide and take heated in two doses.   

Song 歌曰:

清陽之位飲邪乘, 眩冒頻頻苦不勝; 澤五為君朮二兩, 補脾制水有奇能。

The location of clear yáng has been overwhelmed by the presence of pathogenic rheum, causing (one to) suffer from frequent veiling dizziness which is difficult to endure; fifteen grams of the sovereign zé xiè and six of bái zhú, have the special ability of supplementing the spleen and controlling water.

Commentary by Lín Lǐfēng[1] 受業林禮豐按

心者, 陽中之陽。  頭者, 諸陽之會。  人之有陽氣, 猶天之有日也。  天以日而光明, 猶人之陽氣會於頭而目能明視也。  夫心下有支飲, 則飲邪上蒙於心, 心陽被遏不能上會於巔, 故有頭冒目眩之病。  仲師特下一“苦”字, 是水陰之氣\\盪漾於內, 而冒眩之苦有莫可言傳者, 故主澤瀉陽。  蓋澤瀉氣味甘寒, 生於水中, 得水陰之氣而能利水, 一莖直上, 能從下而上, 同氣相求, 領水陰之氣以下走, 然猶恐水氣下而復上, 故用白朮之甘溫土制水者以諸之, 猶治水者之必筑堤防也。  古聖用方之妙, 有如此者; 今人反以澤瀉利水伐腎, 多服傷目之說疑之。  其說創於宋元諸醫, 而李時珍、 張景岳、 李士材、 汪讱庵輩和之, 貽害至今弗熄。  然天下人信李時珍之《本草》者, 殆未讀《神農本草經》耶? 余先業師《神農本經小注》最詳, 願業斯道者, 三復之而後可。

The heart is yáng within yáng; the head is the gathering place of all yáng.  Humans have yáng qì, as heaven has the sun.  Heaven, by means of the sun is bright, as such human\’s yang qì gathers in the head and eyes providing bright vision.  When there is propping rheum below the heart, water rheum will ascend and cloud the heart obstructing heart yáng, which is (then) unable to gather at the top of the head, causing dizziness and dizzy vision.  Master Zhòng used the following character “” () to convey the suffering of dizziness, (resulting from) the qì of water yīn agitating and flowing into the interior. This is ruled by zé xiè tāng.  The qì and flavor of zé xiè tāng is sweet and cold, and since it grows in water, where it obtains the qi (of water yīn), it is able to disinhibit water.  (Similar to the way) the stalk ascends vertically it can (help) bring the qì together from the bottom to the top and guide the qì of water yīn in its downward movement.  However (with) fear of water rising again after it has descended, sweet and warm bái zhú is used so earth can restrain the various forms of water so while still treating water, an embankment is built.  The ancient sages were very clever in using formulas like these.  
People nowadays, are administering copious amounts of zé xièto disinhibit water and quell the kidneys, which damages the objective (of this) doctrine and (creates) doubt (of its effectiveness).  This doctrine began with the physicians of the Sóng[2]and Yuàn[3]dynasties, as well as contemporaries such as Lǐ Shízhēn[4], Zhāng Jǐngyuè[5], Lǐ Shìcái[6], and Wāng Rènān[7], who have left a legacy, which has yet to die even to the present day.  Even though people of the world trust the words of Lǐ Shízhēn’s Běn Cǎo, why have almost (none of them) read the Shén Nóng Běn Cǎo Jīng?  My passed masters’ copy of the classic was annotated with extreme detail, and it is my hope that one follows this way in their course of study, repeatedly returning to (the classic).

[1] Lín Lǐfēng was believed to be a student of Chén Xiūyuán. The characters 受業can be translated as ‘to receive instructions’, ‘to study’, ‘to learn from a master’, or as a first pronoun as ‘I’, or ‘your student’, often used as a title by a teachers’ disciple. I have opted to translate this as the latter, but in the interest of keeping the translation clean, have left is as commentary by Lín Lǐfēng, as opposed to ‘Commentary by I (your student) Lín Lǐfēng’.
[2] Sòng Dynasty (960–1179 A.D.)
[3] Yuán (Mongol) Dynasty (1260–1368 A.D.)
[4] Lǐ Shízhēn (1518-1593), Míng botanist and pharmacologist, as well as the author of the Compendium of medical herbs 本草綱目
[5]Late Míng dynasty physician who wrote several books including the ‘Rectification of the Materia Medica’本草正
[6] Míng dynasty phyisician who wrote several books including the ‘Essential Knowledge from the Inner Classic’經知要
[7] Wāng Áng (1615-1694), Late Míng and early Qīng dynasty physician who wrote the ‘Essentials of the Materia Medica’ 本草備要

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.