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.

Má Xìng Gān Shí Tāng from the Zhù Jiě Shāng Hán Lùn

Chéng Wú-Jǐ (1050-1144) images.jpg

A scholar/physician from the Northern Sōng dynasty who compiled the Annotations to the Shāng Hán Lùn (注解伤寒论), which became what’s known as the Sōng version of the Shāng Hán Lùn used to the present day.  Chéng devoted over forty years of his life to compiling his seminal work, which he completed in 1140. However, Chéng never saw it published, which occurred in 1172, close to thirty years after his death. Chéngs’ annotation was extremely comprehensive and detailed, citing numerous sources and references in his attempt to repair and resolve the various inconsistencies that existed amongst the numerous surviving versions of the text.

The following is taken from Chéngs Annotations to the Shāng Hán Lùn

Line 63:

“Following the promotion of sweat, Guì Zhī Tāng should not be given again; (if) there is sweating with panting and the absence of great heat, one can use má xìng gān shí tāng (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction)”. 1

 

With panting after the promotion of sweat, one can typically use guì zhī jiā hòu pò xìng zǐ tāng (Cinnamon Twig Decoction Plus Magnolia Bark and Apricot Kernel), as once sweat (further) effuses, the condition will resolve.  (However) here there is sweating with panting signifying that evil qì is quite severe, therefore guì zhī tāng (Cinnamon Twig Decoction) would be unable to effuse and dissipate (evils), and so this is the reason, the guì zhī tāng should not be given again. Sweating and panting with great heat, indicates the presence of severe hot qì in the interior. The absence of great heat signifies that exterior evils must be severe. In this case it is suitable to give má xìng gān shí tāng in order to dissipate the evils. 

Má Xìng Gān Shí Tāng (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction)

má huáng (Ephedrae Herba) 4 liǎng (remove nodes)- flavor is sweet and warm

xìng rén (Armeniacae Semen amarum) 50 pieces (remove skin and tips)- flavor is sweet and warm

zhì gān cǎo (Glycyrrhizae Radix preparata) 2 liǎng- flavor is sweet and neutral

shí gāo (Gypsum fibrosum) ½ jīn (crushed and cotton wrapped)- flavor is sweet and cold

The Huáng Dì Nèi Jīng says “When the liver suffers from urgency, swiftly eat sweet (flavors) in order to moderate it”. (Here) wind qì passes through the liver and wind evils are severe in the exterior, therefore a purely sweet formula is given to effuse it.

For the four ingredients above use seven shēng of water.  First boil the má huáng and reduce (the water) by two shēng and remove the foam collecting on top. Add the remaining ingredients and boil until reduced to two shēng, remove the dregs and take one shēng warm.  The original text says that the formula should be put into a yellow-eared cup (a Hàn dynasty drinking vessel). 

1. It should be noted here that line 162 is almost identical to this one with the only difference being that the line starts off by saying “following precipitation”.

Guì Zhī Jiù Nì Tāng (Cinnamon Counterflow-Stemming Decoction)

Case of Dr. Hú Xī-Shù (胡希恕)

A twenty-six year old air force translator came in for an initial consultation. Recently while observing the repair of some electric wiring, he (suddenly) became very frightened, which manifested with fright palpitations, flusteredness, insomnia, headaches, poor appetite, nausea, and the occasional sound of phlegm in the back of his throat, which caused him to become uncontrollably angry, restless, and vexed every time he would hear this sound, but over some time (his emotions) would gradually recede slightly. Nonetheless two people assisted him when he had come in for a consultation. 

(Aside from the symptoms above) he had a thick white tongue coat, and his pulse was wiry, slippery and the cùn (inch) position was floating. This pattern is due to the upward harassment of enduring cold rheum, and treatment should involve warming, transforming, and downbearing counterflow. He was given a modified version of (guì zhī) jiù nì tāng (Cinnamon Twig Counterflow-Stemming Decoction). 

guì zhī (Cinnamomi Ramulus) 10g

shēng jiāng (Zingiberis Rhizoma recens) 10g

zhì gān cǎo (Glycyrrhizae Radix preparata) 6g

dà zǎo (Jujubae Fructus) 4 pieces

bàn xià (Pinelliae Rhizoma preparatum) 12g

fú líng (Poria) 12g

shēng mǔ lì (Ostreae Concha) 15g

shēng lóng gǔ (Fossilia Ossis Mastodi) 15g

Results: After taking three packages of the above formula his flusteredness and phlegm sound in the back of his throat were reduced. After six packages, his appetite increased, and his sleep had improved. He continued on the formula and after ten packages all of his symptoms disappeared. 

Line 112 in the Shāng hán lùn (傷寒論 Discussion of Cold Damage) says:

“(When) in cold damage the pulse is floating, and a fire (method) is used to force (sweating), as a result yáng collapses and there will be fright mania, and fidgetiness whether lying or sitting; guì zhī qù sháo yào jiā shǔ qī mǔ lì long gǔ jiù nì tāng governs”.

Analysis: When there is cold damage with a floating pulse, one should consider treating it with má huáng tāng to promote sweating, however, if it is treated with a fire method, which could include moxibustion, fire needling, fire fuming, and other similar methods, to force sweating, it can result in major sweating, and this is an erroneous treatment. When there is major sweating, this will result in the collapse of liquids and humors. Not only will this fail to meet the objective of resolving the exterior, but major sweating, will result in upper vacuity, causing qì to overwhelm the vacuity and surge upwards. This will also stimulate the interior causing the ascent of rheum, which will cloud the clear orifices resulting in symptoms of fright mania, and fidgetiness whether lying or sitting. The suitable treatment here is with guì zhī qù sháo yào jiā shǔ qī mǔ lì long gǔ jiù nì tāng.

A Breakdown of thirst in the Shāng hán lùn (傷寒論) by Liú Dù-Zhōu (刘渡舟)

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.

Dr. Hú Xī-Shù- A Case of a Gastrointestinal Common Cold

On July 6, 1967 a thirty-six-year old female presented at the clinic complaining of a cough and diarrhea, which has hu xi-shu.jpglasted for over twenty days after contracting a common cold. She has undergone IV injections of streptomycin, and taken various western medications all to no avail. 

Current signs and symptoms: cough with shortness of breath, an aversion to wind and cold, dry mouth with no desire to drink, no desire to eat, loose bowel movements occurring three to four times a day, a white tongue coating, and a thin-wiry and rapid pulse. 

She was administered gé gēn tāng (Kudzu Decoction) with shí gāo (Gypsum fibrosum)

gé gēn (Kudzu Radix) 3 qián

guì zhī (Cinnamomi Ramulus) 3 qián

bái sháo (Paeoniae Radix alba) 3 qián

zhì gān cǎo (Glycyrrhizae Radix preparata) 2 qián

dà zǎo (Jujubae Fructus) 4 pieces

má huáng (Ephedrae Herba) 2 qián

shēng jiāng (Zingiberis Rhizoma recens) 3 qián

shēng shí gāo (Gypsum fibrosum) 1 ½ liǎng

Results: After taking two packages of the above formula, all her symptoms were immediately resolved.

Commentary:  This is diarrhea due to a Tài Yáng Yáng Míng combination disease, for which Dr. Hú commonly used gé gēn tāng (Kudzu Decoction) with shí gāo (Gypsum fibrosum) to treat it. Can shí gāo be used in cases presenting with diarrhea?  This fact is usually faced with skepticism.

In clause 4 of the Shāng hán lùn (傷寒論 Discussion of Cold Damage) it says;

“On the first day of cold damage, Tài Yáng has contracted the disease, (and if) the pulse is tranquil, (this means) there has been no passage. (With) a strong desire to vomit, agitation, vexation, and a rapid and urgent pulse, (this) means passage (has occurred)”.

Here the patient had a cough, aversion to wind and cold, a dry mouth, and a rapid pulse, which suggests a passage from Tài Yáng to Yáng Míng. The major cause of diarrhea is Yáng Míng heat, therefore, gé gēn tāng (Kudzu Decoction) with shēng shí gāo (Gypsum fibrosum) is used to resolve the exterior and clear Yáng Míng heat. Once the exterior is resolved, the diarrhea will cease. In cases like this, one’s who are unfamiliar with classical formulas, will tend to use modified versions of huò xiāng zhèng qì tāng (Patchouli Qì-Regulating Decoction), however, clinically their results are very often never as quick as with this case, so therefore, cases such as these are provided to offer opportunity for further study and contemplation.

A Shào Yáng-Yáng Míng Common Cold- Dr. Féng Shì-Lún (冯世纶)

Common cold

External contraction heat effusion

52 year-old female presented on November 6, 2006 with a fever, which has lasted for seven days. Seven days prior, the patient contracted an external invasion, which manifested with a fever of 38.7°C, and because of her age, she was admitted to hospital for treatment. White blood cell count was 1.35×109/L, neutrophil count was 0.83, and a chest x-ray revealed slight shadowing over the upper portion of the left lung. She was diagnosed with a lung infection.  She felt happy after entering the hospital, and while waiting for treatment to fight the infection was given an infusion of chái hú specifically for the fever. The fever would recede but would again rise, repeatedly remaining abnormal.  The physician administered qi boosting, yin nourishing medicinals all to no avail, and at that point Dr. Féng was asked to consult with the patient.

At the time of the consult the patients temperature was 38.9°C, she had a dry mouth with a bitter taste, dry throat, thirst with a desire to drink water, chest and sub-costal distention and fullness, vexation and agitation with a desire to sleep, right sub-costal pain, no cough but a phlegmy sound (in her chest), no aversion to cold, nor generalized body pain, sweating, which would not lower her temperature, dry stools occurring every three days, regular urination, reduced sleep, a red tongue body with a thin yellow slippery coat, and a wiry slippery pulse.

This woman’s age was already considered high, and moreover suffered from a fever with a lung infection, so western medications were used, but with no effect. Her physician felt that because of her age, the patho-mechanism involved must be due to qi and yin vacuity, and so used qi boosting, toxin resolving, and heat abating methods also with no effect.

Dr, Féng advocated in clinic, that the pattern identification should be based on the characteristics of the symptoms.

This patient suffered from a fever, dry throat, dry mouth with a bitter taste, subcostal distention and pain, which according to six channel pattern identification belongs to a shào yáng disease.

In addition, she also had thirst with a desire to drink, dry stools, a red tongue body with a thin yellow slippery coat, and a wiry-slippery pulse, which according to pattern identification belongs to the interior heat exuberance of a yáng míng disease.

There was no aversion to cold or generalized body pain so we can rule out a tài yáng disease.

In summing up the above signs and symptoms, the pattern is a shào yáng-yáng míng combination disease.

Dà Chái Hú Tāng with the addition of shí gāo can be used to harmonize and resolve the shào yáng, while simultaneously clearing yáng míng interior heat.

Formula: Dà Chái Hú Tāng Jiā Shēng Shí Gāo (Major Bupleurum Decoction plus Gypsum)

chái hú (Bupleuri Radix) 24g

huáng qín (Scutellariae Radix) 10g

dà huáng (Rhei Radix et Rhizoma) 6g

zhǐ shí (Aurantii Fructus immaturus) 10g

sháo yào (Paeoniae Radix alba) 10g

bàn xià (Pinelliae Rhizoma preparatum) 12g

shēng shí gāo (Gypsum fibrosum) 45g (cooked with the decoction)

shēng jiāng (Zingiberis Rhizoma recens) 15g

dà zǎo (Jujubae Fructus) 4 pieces

1 package cooked as a decoction

Results: After taking the one package, the patients fever went down from 39°C to 37.2°C. Her dry mouth with a bitter taste, thirst with a desire to drink, and sub-costal distention and fullness had resolved. Her bowel movements had also freed up. She continued taking another package of the formula, whereby her temperature had normalized and nothing else was troubling her. She underwent another chest x-ray, which now showed nothing abnormal in both lungs. She was observed for another two days in hospital after which she had completely recovered and was discharged.