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I thought that this case might be a nice follow-up to the question that was asked about why Ye Tian-Shi chose this or that medicinal for the Liver.

Original Case by: Ye Tian-Shi

Ye was melancholic, which agitated the Liver, causing disease. After persisting for a long time [the disease process] began to involve the Spleen and Stomach. Hence, the center became damaged and he was unable to take in food and had an inability to taste flavors. There was fire and wind that transformed and moved. There was also horizontal movement of qi leading to pain and then distention. This was a failure in free-coursing. There was also constipation then sudden diarrhea [when there was] constraint of the emotions.

It is difficult for medicine to immediately work because the disease had endured for many years. Furthermore, the patient’s body was thin and had his liquids were desiccated. If one continually gave fragrant dry medicinals this would plunder [the yin and fluids], even though it would certainly have make the abdominal fullness better. In contrast, one should give a few acrid moist medicinals to assist in harmonizing the yang.

Prescription:

  • bâi zî rén (Platycladi Semen)6g
  • däng guï (Angelicae sinensis Radix)6g
  • táo rén (Persicae Semen)9g
  • bái sháo (Paeoniae Radix alba)3g
  • huáng lián (Coptidis Rhizoma)0.9g
  • chuän liàn zî (Toosendan Fructus)3g
Original Chinese: 叶(氏) 悒郁动肝致病。久则延及脾胃。中伤不纳。不知味。火风变动。气横为痛为胀。疏泄失职。便秘忽泻。情志之郁。药难霍然。数年久病。而兼形瘦液枯。若再香燥劫 夺。必变格拒中满。与辛润少佐和阳。柏子仁(二钱) 归须(二钱) 桃仁(三钱) 生白芍(一钱) 小川连(三分) 川楝子(一钱)

Translated by: Jason Blalack

Jason’s commentary:

Within the formula, bâi zî rén (Platycladi Semen) and bái sháo (Paeoniae Radix alba) enter the Liver and enrich and nourish the yin and blood. Däng guï (Angelicae sinensis Radix) and táo rén (peach kernel, persica) invigorate the blood and open the collaterals. Huáng lián (Coptidis Rhizoma) and chuän liàn zî (Toosendan Fructus) clear the Liver and regulate the qi. The whole formula is acrid and moist to assist harmonizing the yang. It also has the function of enriching the yin, opening the collaterals, and clearing constraint. It treats constraint damaging the yin collaterals.

From this case, we notice that when the Liver affects the middle we see the key signs of unable to eat, lack of taste, pain and distention, and alternating bowels. There is underlying liquid deficiency. Hence, this patient’s chronic disease has its root in deficiency. Notice that the first four medicinals are all moistening.

Many people believe chuän liàn zî (Toosendan Fructus) is harsh and not suitable for sensitive patients. It is considered toxic and used for killing parasites. However, we can see that in this case Dr. Ye favors it over typical Liver moving medicinals such as xiäng fù (cyperus, nut-grass rhizome) and chái hú (Bupleuri Radix). Since he specifically warns against using fragrant and drying medicinals (so as not to damage the yin) his inclusion demonstrates how mild he believes this herb actually is.

Another reason for its inclusion is because there is pain. In all of Dr. Ye’s constraint case studies chuän liàn zî (Toosendan Fructus) is only chosen when there is pain. Nonetheless this herb is suitable for yin and blood deficient patients with Liver qi constraint invading the Stomach/Spleen, especially when there is pain.

Note on dosage: the original dosages were in qian (钱) not grams. The conversion to grams was made using a modern rounded system, 1 qian = 3g. However more accurately, 1 qian at this time was probably equal to 3.73 grams. Making, for example, bâi zî rén (Platycladi Semen) equal to 7.46g.)

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Showing 4 comments
  • Jason Blalack
    Reply

    First thanks for your thoughts Barry. Here are some quick thoughts:

    1. In regard to outcome etc. you may want to check out, Further thoughts on understanding Ye Tian-Shi’s case records. But I agree it would be nice to know this sort of thing.

    2. There was not just diarrhea but “alternating constipation and sudden diarrhea”, a typical sign we see in the clinic. However Ye looks at the underlying physiological disharmony / pathodynamic and treats this. Hence there is not much worry about moistening herbs creating diarrhea. These moistening herbs treat the underlying cause by softening the Liver, preventing the Liver from attacking the Spleen. When the Spleen is in balance then the bowels will regulate.

    You can compare this formula to Yi Guan Jian (Linking Decoction):

    sheng di huang (Rehmanniae Radix)
    gou qi zi (Lycii Fructus)
    sha shen (Glehniae/Adenophorae Radix)
    mai men dong (Ophiopogonis Radix)
    dang gui (Angelicae sinensis Radix)
    chuan lian zi (Toosendan Fructus)

  • Barry Levine
    Reply

    What would be nice to know in a case like this is what the response was, how long the course of treatment and what the followup treatment was, since he states, “It is difficult for medicine to immediately work because the disease had endured for many years.”
    Worth pointing out that Bai Zi Ren is a spirit calming herb, as well as being an oily seed that moistes the bowels. It seems that diarrhea was only occasional, as the laxative Tao Ren is also included, another oily seed. These are both herbs that can prompt loose stool in a patient with deficient Spleen Qi.

    To me the first four herbs are a laxative formula with spirit calming and lower-warmer blood invigorating properties, as well liver-smoothing (Bai Shao, which relieves smooth muscle spasm/visceral pain.) I think the interesting part is the inclusion of Huang Lian and Chuan Lian Zi, especially the latter, which I have not used much at all, and will now consider more closely in similar cases.

  • Barry Levine
    Reply

    The two formulae are an interesting comparison. It seems that Ye Tian Shi took the idea of Yi Guan Jian, but avoided the cloying hard-to-digest Sheng Di & Mai Men Dong.

    BTW, what do you think he means by “horizontal movement of Qi”. I get that there’s stagnation, lack of descending (or too much, suddenly), but I don’t recall seeing this kind of description and wonder if there’s something specific meant here.

  • Jason Blalack
    Reply

    1 .Yes you are right. This demonstrates how master physicians take the idea of a formula and tweak it for the individual presentation.

    2. “horizontal movement of Qi” refers to Wood invading Earth. It is also referred to a horizontal counterflow pattern or wood not dredging earth (木不疏土 mu bu shu tu). The sentence following it helps understand it further, “This was a failure in free-coursing.” – This pathodynamic can easily lead to pain and alternating constipation and diarrhea. I am not sure that there is a lack of (or too much) descending of qi, to a degree that this must be directly addressed. But there is surely stagnation which has impaired the qi dynamic. The interesting issue is how does one restore it. Ye teaches us a interesting lesson.

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