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(Thanks Steve for this case and the one’s that follow. Please check out his journal, The Lantern)

Insomnia: Case number 12, by Xu Shu-Wei

By: Steven Clavey

A local notable named Chen, when he first became sick, had fever, floating pulse and spontaneous perspiration. The doctor used Ma Huang Tang to cause sweating, but the fever became severe, Chen could not get to sleep, his head was heavy, there were palpitations and he complained of a restless cooped-up feeling. The mistake was insisting on a strong diaphoretic formula when the condition was [not cold invasion but rather] a wind invasion — zhong feng. Zhong-Jing says:

Tai Yang illness: after using diaphoresis the sweat is heavy, there is parched dryness in the Stomach and insomnia. The patient desires to drink water — give him a little at a time: this will cause the Stomach qi to harmonise and he will be cured. [Clause 71]”

I first used Zhu Ling Tang (Polyporus Decoction) followed by herbs like Dang Gui (Angelica Polymorpha, Radix), Shou Di (Rehmanniae Glutinosae Conquitae, Radix), Mai Men Dong (Ophiopogonis Japonici, Tuber), Bai Shao (Paeoniae Lactiflora, Radix) and Wu Mei (Pruni Mume, Fructus) as a soup to sip.

The sweat stopped and he recovered.

Xu’s Discussion:
The Huang Di Zhen Jing (The Yellow Emperor’s Classic of Needling — ie the Ling Shu) says:

Protective wei qi travels the surface yang during the day, but at night it moves to the internal yin. If it cannot move into the yin internally it will wander ceaselessly outside. This external movement makes the yang full, and this fullness makes the Yang Qiao channel surfeited and unable to transfer into yin. Weakened yin means inability to get to sleep [because the quiet settling of yin is reduced] (Ling Shu Chapter 80).”

In this case the jin and ye fluids are exhausted internally [because of the over-sweating of the treatment], the fluids of the Stomach are parched dry [because the sweating drained the Earth flesh]; the malady concentrated in yang, with no refuge for yin — the symptoms are as we have seen.
Thus Dang Gui and Shou Di are used to tonify blood, while [the sourness of Bai Shao and] Wu Mei are used to contract yin. This stopped the sweating and the patient naturally recovered.

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Showing 10 comments
  • Sharon Weizenbaum
    Reply

    This is an interesting case. It is easy to understand the Yin enriching medicinals but what about Zhu Ling Tang? Any thoughts on the use of this? I know this formula is used for Shao Yin presentations with vexation and insomnia but that is usually presenting with cough or vomit or thirst and most probably with inhibited urination. Why not Huang Lian E Jiao Tang instead? I suppose one explanation is that some signs and symptoms left out such as inhibited urination or thirst. Another explanation might be that the heavy head was an indication of dampness above. Zhu Ling Tang is for heat and water binding so perhaps he saw this as dampness binding with the heat he sees caught on the surface. Or perhaps, since he wants to descend the Yang, he sees Zhu Ling Tang as a directional formula to bring it down while enriching Yin. Or maybe there are other interesting and unique ways to think of this formula. I wonder if other cases in which Dr. Xu uses Zhu Ling Tang would be instructional….

  • Jason Blalack
    Reply

    Sharon, I think your questions are good and let me try to answer them as best as possible. First, I do not consider cough, vomiting, or even thirst is a key indicator for zhu ling tang. Cough and vomiting are just manifestations of a disturbance in the water pathways. Another disturbance here would be the heaviness in the head. For example, as you state, this may be dampness in the head. This may also be a sign that there is dampness in the middle obstructing the clear yang from rising, helping point to some water/damp amassment which would lead to zhu ling tang.

    I do not think Xu Shu-Wei is envisioning dampness and heat “caught on the surface.” This is an internal problem, of fluid deficiency leading to yang being unable to enter yin. Understanding the history/etiology is the key to the diagnosis, hence the point of the first quote. Ma huang tang clearly lead to dryness in the Stomach. However, his treatment has two steps. 1) the elimination of a pathogen, 2) tonification of fluids. The wind pathogen is no longer the issue but a second a pathogen that came about from improper treatment. For this formula to work in my mind there is not JUST a fluid deficiency leading to heat. Also, the pathogen must be internal (not on the surface), due to the formula and there must be some element of dampness/water due to the formula.

    Could there be thirst? Of course this is possible but I do not think it is necessary. But with fluid deficiency and the heavy use of yin and blood tonics thirst definitely makes sense. However, let’s entertain the idea that what is not mentioned is important. The fact that there is no thirst mentioned could also point to some dampness or since zhu ling tang is contraindicated for yang ming disease where there is profuse sweating and thirst due to stomach dryness because it promotes urination (line 224). Also the lack of thirst may actually indicate that there is no internal heat.

    If there was thirst with difficult urination then this case would make perfect sense. But on the flipside, it would not be that interesting. So we have to ask, what is he trying to teach us? So at the beginning I really like to try to envision the case without adding on any additional “obvious” symptoms. Therefore, I think Sharon’s idea about using the formula in a unique way may be correct.

    This is where the second nei jing quote comes in. He is pointing out that the problem is coming about from the yang not able to enter the yin. This is because the yin (fluids) is weak (root) which leads to a fullness of yang (symptoms). This is a bit different from a typical zhu ling tang pattern of actual heat.

    Therefore, we have obvious signs of fluid depletion and one sign indicating that there is some type of dampness. This may be enough.
    I do think that the formula will indirectly “descend” yang, but not directly. Meaning, I think it is only through correcting the problem that the yang is able to descend.

    Why not huang lian e jiao tang? this is a good question, especially since it is indicated for yang hyperactivity due to yin deficiency. However, I assume that the problem (due to the etiology/history/ and SHL quote) is not a very severe problem, hence not warranting huang lian e jiao tang. For example, “…huáng lián ë jiä täng focuses on patterns where both the pathogenic heat and the yin deficiency are relatively pronounced with such symp¬toms as focal distention in the epigastrium, abdominal pain, irritability and thirst, and palpitations.” And the sign of ‘dampness’ does not fit.

    Could there be more signs of dampness present? Possibly. Could there be lower abdominal discomfort and fullness, possibly. Or as Sharon suggests, does the mere fact that he is using zhu ling tang automatically include some urinary symptoms. Possibly. At this moment, I am going to hold out and try to envision this case without such additional symptoms, because if the symptoms were there, then the case is not that interesting to me.
    But I do agree with Sharon that this case does bring up quite a few questions that do not have clear answers. However, just thinking through these issues, reviewing basic ideas helps us learn. For example, just yesterday in the clinic I had an opportunity to use zhu ling tang because of my contemplation of this case.

    What do others think?

  • Sharon Weizenbaum
    Reply

    Hi Jason,

    You write “So we have to ask, what is he trying to teach us?” which is such a good question and way to approach a case study. Why would he have written it if he was not trying to illustrate something that was important to him?

    Your thoughts inspired me to read the case a bit more carefully. If we see that this was Zhong Feng then we can say that the correct treatment initially would have been a form of Gui Zhi Tang. Certainly the sweating symptom made Ma Huang Tang the exact wrong formula. So the Ying and Wei needed harmonizing which means that the pores were already too open and Yang was already escaping out them with the Yin. If we think of it directionally, the Yang should have been warmed with sweet Gui Zhi and at the same time the Yin should have been enriched and held in with sour sweet Bai Shao. Instead, The Yin was pushed up and out even further with Ma Huang Tang. Now the Yin is weak and the Yang is way up and out on the surface and effecting the Heart/spirit.

    So, how is it that this diminished Yin makes it so that the Yang cannot enter? This is interesting to me. One explanation that makes sense to me is that Yin deficiency is not just lack of fluid but can be the creation of a body terrain similar to a desert – i.e. non- absorptive of fluids or Yang. Everything sits on and cooks on the surface. Yang cannot descend into Yin. In this case, if we look at it this way, what needs to happen is that the Yin not only needs to be enriched (therefore the E Jiao in Zhu Ling Tang), but it’s absorptive capacity must be renewed.

    It is interesting that he mentions the Yang Qiao vessels since this vessel is related to day and night cycles. Yang is stuck in the Yang Qiao and cannot enter the Yin Qiao to induce sleep and root the Shen.

    I think of all the remaining herbs in Zhu Ling Tang (Zhu Ling, Fu Ling, Ze Xie and Hua Shi) as, not simply damp disinhibiting herbs but as chalky type herbs that increase the absorptive capacity of the Yin. They are not the bitter cold damp disinhibiting herbs but are the bland spongy or chalky looking ones. Did Xu Shu-wei think this way? Who knows. Maybe! In general, with a Yin deficient scenario like this one would not want to promote urination. I think the chalky herbs actually don’t promote urine like diuretics but rather help the Qi hold and absorb physiological fluids and release pathological fluids. This formula then would enrich Yin and increase it’s absorptive capacity of both fluids and Yang and at the same time it would direct the Yang downward and into the absorptive Yin. I don’t know if it “directly” or “indirectly” would do this but it does seem to be a downward and inward formula…?

    This reminds me of the Qin Bo Wei case I wrote about in which there was extreme edema in a very Yin deficient person. He used chalky herbs in that case as here. I’ll send it along and if you would like, you could post it.

    When I think of it this way it certainly makes a lot of sense to me and also relieves the seeming necessity of adding on more than what Dr. Xu wrote. We can also see why he would not have used Huang Lian E Jiao Tang.

    Thanks for taking the time to answer my comment so thoroughly.

    Sharon

    • Jason Blalack
      Reply

      Sharon,
      Thanks for the commentary and case submission. Here are some additional thoughts.

      1. We should not forget that Zhu Ling, Fu Ling, Ze Xie and Hua Shi are key herbs from the SHL that promote urination / leach out dampness. This cannot be denied. Consequently they will damage the yin without the addition of an herb like e jiao. Hence I do not think that they really “increase the absorptive capacity of the yin.” For these herbs to be used, there must be some damp present.

      2. Something that should not be forgotten is the original line order of the Shang Han Lun. Line 221,222, & 223 in Wiseman’s version is broken up, however they should be read together. This gives a little more continuity with zhi zi chi tang. Hence one might just think of this as a further continuation of the zhi zi chi tang pattern. However the above questions that we all bring up still remain.

      3. I also like the Qin Bo-Wei case that you mentioned, and translated it some time ago. Since my version presents a slightly different rendition and commentary. I posted it here.

  • Sharon Weizenbaum
    Reply

    Hi Jason,

    I understand your point. I’m still perplexed a bit though. If Zhu Ling, Fu Ling, Ze Xie and Hua Shi are used in this case, as they are often thought of to be used, to promote urination and leach out dampness, what is the connection between this and the presentation Dr. Xu presents. Why would he want to use these treatment principles here in this case?

    I think you answered in your first commentary above “the pathogen must be internal (not on the surface), due to the formula and there must be some element of dampness/water due to the formula”. So, I think what you are saying is that we can add our own assumptions regarding pathology to a case if the signs and symptoms the doctor mentions don’t add up to the use of the formula without those additions. Here, Dr. Xu did not mention dampness or damp signs or symptoms.

    This brings up another question. It seems that this comes down to how we read, understand and make relevant – case studies. If our basic knowledge of medicine is not enough to fully understand the choices a doctor makes, how do we stretch it so that it makes sense? Do we add symptoms or pathology the doctor didn’t mention or do we expand our possible understanding of the way herbs or formulas work. Either way we are taking a certain license. Right? Can we simply hold the discomfort of being perplexed while we continue study, and consider and work with different ways of understanding?

    Perhaps another piece of the answer, which I think you touched on before, is that we need to study more of Dr. Xu’s cases and more Zhu Ling Tang cases so that an understanding slowly develops over time. And finally, we bring it, as you did, to the clinic which will always test the depth of our understanding.

    As a lover of case studies, I think this blog is so useful. The cases have so much to teach in and of themselves but they also shed light onto the reader. What does a reader bring to the case? What should we bring to the case? A case may seem as if it is teaching one thing at one point in our clinical life and then when it is read years later, its meaning for us may be completely different. In other words, how does our clinical and scholarly experience influence how we read a case. So its interesting to have these discussions to see how there can be more than one approach to understanding.

    Sharon

  • Arnaud Versluys
    Reply

    Hi all,

    Thanks Jason for the opportunity to discuss cases.

    My two cents would be the following. Under normal conditions two things can happen in the scenario that Xu mentions. One is line 26 where sweating exacerbates and causes a Baihu Jia Renshen Tang pattern, or when where the sweating dislodges yang and causes running piglet, palpitations and insomnia. The case Xu mentions is actually the second scenario.

    As such, there are two ways to treat, both effective, but one with less collateral damage: way one is Xu’s way, where he rebalances yin and yang by getting rid of yin (water). Because yang was dislodged and moved up and outward, causing excessive sweating and the imbalance of shen (insomnia), the interior of the body is rendered wet (preventing yang from ever re-internalizing). He eliminated the wetness by promoting urination, thus rebalancing yin and yang (Nutritive and protective). The collateral damage is of course the loss of fluids, which he then wisely replenished with Danggui etc.

    The best way however to treat this case would have been to re-anchor yang directly, and communicate heart and kidneys. This would have been achieved with either a Guizhi Gancao Tang modification called Guizhi Gancao Longgu Muli Tang. There would have been no collateral damage, yang would have descended into the water which would have metabolized by itself.

    Sweating causes the demise of yang, urination causes the demise of yin, is the main principle this case illustrates.

    Thank you for your feedback.

    Arnaud

    • Jason Blalack
      Reply

      Thanks Arnaud for the post, I think re-anchoring the yang is an interesting idea and something we often forget about for the treatment of dampness. I also think your idea about minimizing collateral damage is important. However, I’m not sure how much it applies to this case specifically.

      From my reading (of the case), the fluid deficiency did not come about from giving zhu ling tang. It came about from the ma huang tang (from excessive sweating). Hence, although sweating may deplete the yang it also depletes the yin. I think we know this because of Xu’s quote from clause 71 (discussing dryness in the stomach and insomnia), and Xu’s commentary “jin and ye fluids are exhausted internally.” All of these thoughts preceded his decision to prescribe zhu ling tang. The fact that he choose a formula that specifically addresses yin depletion (ZLT contains e jiao to protect the yin), reinforces the fact that the patient already had fluid damage and Xu was aware of this.

      Therefore I would have a hard time saying that zhu ling tang was incorrect and caused collateral damage. To say such a thing, we essentially have to assume that Xu just missed the idea of anchoring yang and there was fluid depletion that occurred after giving zhu ling tang (not before). Although this is possible, I do not see this from the case record. More importantly, it takes away an important element of reading and analyzing case records, trying to figure out the thinking of the doctor and learn from them.

      However, I appreciate Arnaud mentioning this alternate idea because it gives us another way to think about such situations. Thanks for sharing.

  • Arnaud Versluys
    Reply

    Hi Jason,

    I did not say that the diuresis caused the perceived fluid deficiency. I just wanted to illustrate that yang gets lost from the top and yin from the bottom.

    My question to you is: where do you see signs of fluid deficiency? There is no thirst or no dry stool mentioned. I do not see the yangming dryness arise in this case. The case does not display a single exclusive yangming symptom.

    Second, line 71 that Xu quotes mentions a clear stomach dryness. But line 71 is milder than Baihu Jia Renshen Tang, or Tiaowei Chengqi Tang lines where one actually needs to intervene. The line only calls for the slow and moderate administration of fluids so the body can recuperate on its own.

    If there were a fluid metabolism problem as Xu suggests by the use of Zhuling Tang, then there again would be the presence of thirst. And actually, the treatment of choice would then be Wuling San and not Zhuling Tang. See the rest of line 71 and also line 72 for this.

    If there truly was a yin deficiency due to the sweating, then why didn’t Xu directly give his Shudi, Maidong, etc formula to replenish fluids and calm the mind at the start?

    In Xu’s case, if the patient had such severe sweating and fever that it would damage fluids, then this patient would no longer be a taiyang disease. As such, it would have been shoved into yangming by the doctor’s erroneous treatment. But in such case, line 224 clearly states that in yangming disease, which is stomach dryness, one should not re-introduce a diuretic, such as Zhuling Tang.

    There was no thirst mentioned in the case. Taiyang thirst can only be failure of water metabolism, which is treated with Wuling San. If the sweating was so big that it caused vexing thirst, which belongs to yangming, then it should have been treated with Baihu Jia Renshen Tang (e.g. line 26). But none of these apply, since thirst and inhibited urination were not mentioned as symptoms.

    So what are the main symptoms: lack of resolution of the taiyang disease (floating pulse, fever, sweating, i.e. Guizhi Tang pattern) and restlessness and insomnia.

    To address the exacerbation of the heat/fever, I admit, maybe the Guizhi Gancao Longgu Muli Tang would not be sufficient. If there were thirst, then the fever would have to be treated with a diuretic of which Zhuling would be the prime indicated herb. But there is no thirst.

    As far as the restlessness is concerned, I believe that the dislodging of yang is the cause of the problem. The inappropriate use of Mahuang Tang in a Wind Strike scenario is very much in line with the inappropriate use of the Fire Needle. For example line 112 talks about the fire needle being used in taiyang situations, leading to severe loss of yang (“death of yang”). If sweating was this detrimental to yin, then why in severe sweating it is only detrimental to yang? The formula used here is a modification of Guizhi Gancao Longgu Muli Tang, i.e. Guizhi Qu Shao Jia Shuqi Longgu Muli Jiuni Tang. (not that I recommend it for this case, but just as an illustration)

    The palpitations in taiyang can have two etiologies: one, is lack of yang with floating yang; two, water invading fire. Either are treated with pungent Guizhi, plus either sweet Gancao (Guizhi Gancao Tang, line 64) or plus bland Fuling (Fuling Gancao Tang, Ling Gui Cao Zao Tang, etc). In severe dislodging of yang, the intense sweating can cause running piglet, which it didn’t do in Xu’s case, but still it would be treated with Ling Gui Cao Zao Tang (line 65)

    As far as the heaviness in the head, my reading is that it is the result of floating yang. This is illustrated in line 366 where there is yin yang separation with the “wearing of yang” on the head (dai yang). The line describes severe loss of fluids due to severe diarrhea (fluids demise from below), which leads to unanchoring of yang with the head feeling “oppression and muddledness” (yumao) and “incessant sweating”.

    Lastly, one more possibility is when the yang is lost to the point of taiyang becoming shaoyin disease, then line 82 applies and the treatment should be Zhenwu Tang. Also here we see the incessant sweating, and continuous fever, along with the palpitations, and the heavy head. In this case, with combined insomnia, our lineage would add high dose of Muli to Zhenwu Tang, to anchor yang and lift water. But before I try this approach for such case, I would likely first try to work with a Guizhi-based formula and if that doesn’t work, go to a Fuzi-based one. Also, line 82 perfectly illustrates the point I was trying to make that when yang is moving out, yin accumulates inside as water.

    In short, my money is on Guizhi Gancao Longgu Muli Tang plus Fuling, and maybe Dazao, to be precise. (GZGCLGMLT + LGCZT) If that doesn’t work, then go to the Zhenwu Tang plus Muli approach.

    Cheers,
    Arnaud

  • Jason Blalack
    Reply

    Arnaud asks, “where do you see signs of fluid deficiency.” The dryness is implied from the herbs used. But more importantly Xu tells us there is fluid exhaustion. How can we argue with this?
    More important than second-guessing Xu, is trying to understand his thinking. We can always pontificate about different ways we think are better, but a) we were not there b) anything we come up with is purely theoretical. I do get Arnaud’s point of analysis, but IMO, reading case studies in this manner, is not that exciting. Furthermore, it gives little credit to a master such as Xu – remember his formula worked.
    Second, just as in the SHL, with case studies things are often implied. We must read between the lines to understand the thinking.
    I do though appreciate the involved analysis presented. Thanks Arnaud!

  • Jason Blalack
    Reply

    Original Chinese was found: 夜间不眠证(十二)

    陈姓士人。初得病。身热。脉浮。自汗。医者麻黄汤汗之。发热愈甚。夜间不得眠。头重。

    烦闷。悸悸然。中风证强责汗之过也。仲景云太阳病。发汗后。大汗出。胃中干燥。不得眠。其人欲得饮水者。少少与之。令胃气和则愈。予先与猪苓汤。次投之以当归。地黄。麦门冬。芍药。乌梅之类为汤。饮之。不汗而愈。

    论曰。黄帝针经曰。卫气者昼行阳。夜行阴。卫气不得入于阴。常行于外。行于外则阳满。

    满则阳跷盛而不得入于阴。阴虚则夜不得眠也。今津液内竭。胃中干燥。独恶于阳。阴无所归。

    其候如此。故以当归。地黄补血。用乌梅以收之。故不汗自愈。

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