In

Original Case by: Ye Tian-Shi (叶天士)

[Patient] Zhu (32) [suffered from] depression, weeping, and grief that caused an internal stirring of Liver yang.  The yang qi transformed into fire wind. The [disease] had form and had sound, which [could be heard] passing through the diaphragm and gushing to the throat. There was a feeling of cold, but this was not true cold. The Inner Classic says that an excess of any of the five emotions leads to fire. [This condition] however, had not arisen from [an invasion] of external six qi.

Medicinals such as  huang qin (Scutellariae Radix) and huang lian (Coptidis Rhizoma) are unable to subdue the problem. To stabilize [the situation] one must use a soft and moderate [approach] by means of  moistening. This conforms with [the idea that] the Liver is an unyielding viscera and to help it one should use a softening method, while also using a harmonizing method. (Liver constraint wind fire ascending)

sheng di huang (Rehmanniae Radix)
tian men dong (Asparagi Radix )
e jiao (Asini Corii Colla)
fu shen
(Poriae Sclerotium pararadicis)
shi hu (Dendrobii Herba)
mu li (Ostreae Concha)
fu xiao mai (Tritici Fructus levis)
ren zhong bai (urine sediment; Hominis Urinae Sedimentum) boiled into a paste.

(Liver constraint with ascending wind and fire )

Commentary: I find this case especially interesting, primarily because the depression (and other emotions) are treated essentially with a softening/nourishing yin and directing fire downwards method. Ye does not use a moving (Liver) qi method, which seems to be a default treatment for many for such conditions. It should be noted that some people attribute a slightly moving/dispersing quality to fu xiao mai (Tritici Fructus levis). However, this is usually in relation to the Spleen or exterior of the body (e.g. skin and interstices). Here, it is chosen for its ability to augment the Heart qi, calm the spirit, and quiet the heart. It appears in one other constraint case by Ye, Constraint – Heart, Spleen, Wood Fire, in which it appears also with fu shen (Poriae Sclerotium pararadicis).

If anyone has any further ideas (or alternative interpretations) about the phrase, “有形有声。贯膈冲咽” , please let me know. Although phlegm is what is usually heard in the throat, I think this is referring to sounds that are produced by fire / heat. I just do not know what this “sound” here is referring to and what symptoms go along with it. Ideas? There is though for example, a similar idea discussed in the Inner Classic. One of the 19 pathomechanisms is;

“All diseases with [abdominal] sounds, where tapping makes a drum-like sound, are ascribed to heat”

I am not sure if this is exactly what he is talking about, but it doesn’t seem too far off here.

Even though this condition is said to have form, which is a phrase commonly attributed to phlegm,  I see little evidence that phlegm is involved  due to the herbs. However, clearly fire is the cause, and fire can lead to phlegm. But  the fact remains, Ye treats the underlying mechanism and not phlegm, except possibly with Ren zhong bai (Hominis Urinae Sedimentum).

Ren zhong bai (Hominis Urinae Sedimentum) is salty, cold, and enters the Lungs, Heart, and Bladder. It clears heat, directs fire downwards, stops bleeding, and transforms phlegm.

Thoughts?

Translated by: Jason Blalack

Original Chinese: 朱(三二) 因抑郁悲泣。致肝阳内动。阳气变化火风。有形有声。贯膈冲咽。自觉冷者。非真寒也。内经以五志过极皆火。但非六气外来。芩连之属。不能制伏。固当柔缓以濡之。合乎肝为刚脏。济之以柔。亦和法也。(肝郁风火升)生地 天冬 阿胶 茯神 川斛 牡蛎 小麦 人中白 熬膏

Source: From the Constraint Chapter of Case Records as a Guide to Clinical Practice (Lín zhèng zhî nán yï àn) 《临证指南医案》

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