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Case by: Jason Blalack

A 35 year-old female on Wednesday, March 31, 2010 presented with a chief complaint of cough and a hot tongue.

The previous day she had a runny nose and felt like she was getting a cold. She also reported that both of her kids had strep throat, which in the past she would get a couple times a year.

Currently she had a dull and achy sore throat. Her cough was mildly productive with congealed thick discolored phlegm. She felt like she was breathing fire, felt hot, irritable, had a dry mouth, no sweat, no chills, and had some eyelid twitching. Her bowels were not moving and when they did they were black and hard. She had a sensation of abdominal bloating and had no appetite.

Upon further inquiry she reported having some dental work on 3/24/10 where she was given a course of Clindamycin 300mg TID, Flagyl 500mg q 6 hours taken with Phenergan, and Diflucan due to some infectious complications. She noticed a red dry rash appear on the dorsal part of her hands after taking these meds.

Tongue: very red body with no coat

Pulse: Slippery and rapid

Diagnosis: Heat in the qi and nutritive level, clumping of the stools.

Treatment principles: Open the bowels, facilitate resolution of heat via the urine, vent the pathogen from the nutritive aspect, and enrich the fluids.

Prescription:

  • dà huáng (Rhei Radix et Rhizoma) (add)9g
  • máng xiäo (Natrii Sulfas) (add)6g
  • chì sháo (Paeoniae Radix rubra)6g
  • mǔ dān pí (Moutan Cortex)6g
  • shuǐ niú jiǎo (water buffalo horn)15g
  • shēng dì huáng (Rehmannia root, Chinese foxglove root)15g
  • dàn zhú yè (Lophateri Herba)6g
  • lián qiào (Forsythiae Fructus)15g
  • dēng xīn cǎo (Junci Medulla)1g
  • huáng lián (Coptidis Rhizoma)2g

Cooking Instructions: 1 bag=2 days. Cook time =45 minutes. Taken between meals 2-3 times a day.

Outcome: After taking two bags of herbs all of her symptoms were resolved except for a slightly warm feeling on the tongue and slight thirst. We then switched to a constitutional formula. Note: she stopped all pharmaceuticals after initial consultation.

Commentary: Although many consider antibiotics and other similar pharmaceuticals as cold one must always observe what is happening in the body and treat what they see. In this situation the multiple pharmaceuticals seemed to have pushed the heat pathogen deep into the qi and nutritive level. One clue was the rash on the hands, even though this was “caused by the pharmaceuticals.” An aggressive approach was needed to evict the pathogen and prevent damage to the yin and possibly entering the pericardium. Of note, there were no herbs in the formula to directly treat the chief complaint of the cough. Although this seemed to be the most pressing sign to the patient, there was clearly a bigger fish to fry.

Questions or comments?

Location: Boulder, Colorado

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Showing 7 comments
  • Tim Sharpe
    Reply

    Thanks Jason, this case helped a lot with a hot tongue patient I have right now. I never would have thought of dēng xīn cǎo at such a low dose (1g). I’ll need to get some shui niu jiao from Kamwo – Mayway is out.

    For your cook time do you do two ~ 20 minute cooks, or just one 45 min?
    Da Huang in last 10 min (of the final if boiled twice) and mang xiao melted in at end (again of final boil if two)?

    • Jason Blalack
      Reply

      Hi Tim,

      I am glad this case was able to help you. I normally have my patients do only one 45 minute cook. In this case, I had her add the da huang for the last 8-10 minutes. If boiled twice, I would have had her add the da huang for the last 8-10 minutes. Mang xiao should normally be dissolved into a strained decoction, but in this case I had her *add* it with the da huang to lessen the purgative effect. I’m not sure if this method is common or even correct, but at least in this case, according to her, it moved the bowels perfectly and her symptoms resolved.
      This deng xin cao dosage idea is from Qin Bo-Wei.
      Hope that helps…

  • Ariel Jodorkovsky
    Reply

    Hi Jason,
    First of all I would like to compliment you on your excellent web site. Thank you for sharing your knowledge.
    Regarding the cooking time….
    From your experience, what are the advantages of one long cook (45 min) compared to two short one’s (20-25 min)?
    I’m sure It’s more comfortable for the patient, but don’t you think that it extracts less ingredients then 2 short cooks with two boil’s?

    Thank you in advance,
    Ariel Jodorkovsky (ISRAEL)

    • Jason Blalack
      Reply

      Hi Ariel,
      I agree with you. The most optimal method is as you describe two decoctions, cooked for 20-30 minutes each (I prefer 30), and then mixed. About 6 years ago I switched to the more convenient one 45 minute cook. This dramatically improved patient compliance.
      Even though this approach is slightly inferior, if one learns how formulas/ herbs work with this method then one can achieve results. That is, I do not have problems getting results with this method, but admit maybe they could be better with a more accurate cooking method. But the perfect method is useless if the patient does not take the herbs. For more serious patients I do instruct them how to the double cook method.
      Glad you like the website. Best,

  • Sharon Weizenbaum
    Reply

    Hi Jason,

    Maybe this is a question that has an answer that should be obvious to me but – what told you that the urination was a good avenue from which to clear the heat? When the heat is in the nutritive level, do you automatically think of clearing it through urination or were there signs that told you that this would be good?

    Thanks

    Sharon

    • Jason Blalack
      Reply

      Reply to Sharon:

      Good question. First, the treatment principle, “facilitate resolution of heat via the urine,” probably should have been at the end of the list. It is only a minor treatment principle. Only two herbs are used for this purpose. But nonetheless this strategy is utilized.

      Both Lophatheri Herba (dàn zhú yè) and Junci Medulla (dëng xïn câo) are sweet, bland, and cold. They clear the Heart, eliminate irritability, and guide heat downward, eliminating it through the urine. These two are often used together for Heart fire conditions, with key symptoms of irritability, restlessness, and red / crimson tongue. This is a key combo from Qin Bo-wei’s treatment of such disorders. Hence, even with no urinary symptoms, one can use this method to eliminate heat (Heart -> SI -> Bladder). This pattern often overlaps with warm disease nutritive and blood level disorder patterns.

      In addition, Lophatheri Herba (dàn zhú yè) is found in Clear the Nutritive-Level Decoction (qing ying tang) the flagship formula for heat entering the nutritive level.
      Actually if you check out other formulas designed for nutritive level heat, such as Rhinoceros Horn and Rhemannia Decoction for Venting the Nutritive Level (xi di tou ying tang) you find lu gen and deng xin cao, both of which drain heat via the urine.

      Granted such a strategy is not discussed often for nutritive level patterns, but certain physicians, including myself, find it useful. Hope this helps and thanks for giving me a chance to clarify this. Does this make sense to you?

  • Marybeth
    Reply

    Interesting, this article is completly non related to what I was asking for on google, however it is listed on the first page! I guess that your doing something right if Google loves this page enough to put you on the first page of a non related search. 🙂

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