When I arrived, I saw that the patient was experiencing hasty wheezing and shoulder breathing and spontaneous sweating from his head. This was heat in both the exterior and interior. His tongue coat was dark grey and his tongue was so contracted that he was unable to speak. I immediately took his pulse and found it floating, rapid, and strong, yet extremely empty upon stronger pressure. Because of this I thought that this was a pattern of extreme yang ming heat where the yin aspect was about to be exhausted. It actually was a worsening pattern from incorrect administration of  (gui zhi tang) and Minor Bupleurum Decoction (xiao chai hu tang).

I immediately gave her White Tiger and Ginseng Decoction (bai hu jia ren shen tang), substituting Dioscorea Radix (shan yao) for the nonglutinous rice (jing mi) [1]. In addition, I substituted Scrophulariae Radix (xuan shen) for Anemarrhenae Rhizoma (zhi mu). She took two packets of the formula in succession and her thirst was relieved, and her wheezing stopped. Her pulse was no longer floating and rapid although it was still strong. Her tongue stretched out and she was able to speak. Her phlegmatic cough was no longer intense and appeared to be milder. He then continued with a modification of Follow the Dragon Decoction (cong long tang), omitting the Perillae Fructus (su zi) and adding 4 qian of Ginseng Radix (ren shen) and 8 qian of Ophiopogonis Radix (mai men dong).

After taking 7 packets she was completely cured.

赵××，患温病。医者投以桂枝汤，觉热渴气促。又与柴胡汤，热尤甚，且增喘嗽，频吐痰涎，不得卧者六七日。医者谓病甚重，不能为矣。举家闻之，惶恐无措。伊芳弟××延为延医。急投以白虎加人参以山药代粳米汤，更以玄参代知母。连服两剂，渴愈喘止，脉不浮数，仍然有力，舌伸能言，而痰嗽不甚见轻。继投以从龙汤，去苏子，加人参四钱，天冬八钱，服七剂全愈

—

Follow the Dragon Decoction (cong long tang) contains:

Fossilia Ossis Mastodi (long gu) (not calcined, crushed) 30 grams
Ostreae Concha (mu li) (not calcined, crushed) 30 grams
Paeoniae Radix alba (bai shao) 15 grams
purified Pinelliae Rhizoma (qing ban xia) 12 grams
Dry-fried Perillae Fructus (chao su zi) (crushed) 12 grams
Dry-fried Arctii Fructus (chao niu bang zi) 9 grams

Charles Chace and I provided  commentary to the case in the article Tracing The Dragon, published in the RCHM Journal Autumn 2011, Vol. 8, No. 2.

Please feel free to leave any comments, questions, or criticisms here.

Original Case by:

[Patient] Gu (age 44) had already greying whiskers and hair on the temples. His facial complexion though was bright. He was emotionally worried and irritable. [There was] yang ascending and agitating [the spirit] with phlegm and thin mucus also ascending and overflowing.  The divine pivot says, when yang qi descends, joins and enter the yin, then the yang qiao vessel is full and one is able to sleep. [At this moment though] qi was disseminating and discharging outward and yang was not entering yin. He would drink alcohol in hopes of muddling his consciousness enough so he could sleep. This was not a good method for managing this disease. In middle age and afterwards, men’s lower base is the first to become depleted. [The treatment] was to use Eight-Ingredient Pill (ba wei wan) in the morning and Pinellia and Millet Decoction (ban xia shu mi tang) in the evening. (yang qiao vessel deficiency).

Translated by: Jason Blalack

Original Chinese: 顾（四四） 须鬓已苍。面色光亮。操心烦劳。阳上升动。痰饮亦得上溢。灵枢云。阳气下交入阴。阳跷脉满。令人得寐。今气越外泄。阳不入阴。勉饮酒醴。欲其神昏假寐。非调病之法程。凡中年已后。男子下元先损。早上宜用八味丸。晚时用半夏秫米汤。（阳跷脉虚）

Source: Case from the Insomnia chapter of Case Records as a Guide to Clinical Practice (临证指南医案 lin zheng zhi nan yi an).

Commentary: This case shows one approach to dealing with complex patterns of excess and deficiency, giving separate formulas at different times of day.  Ye uses his typical style of focusing on the pathodynamics and uses little in the way symptomatic “sleep” herbs. Brilliant! Eight-Ingredient Pill (ba wei wan) is another name for Kidney Qi Pill (shen qi wan). Pinellia and Millet Decoction (ban xia shu mi tang) is from the Divine Pivot and contains Pinelliae Rhizoma preparatum (zhi ban xia) and  Setariae Fructus (shu mi).

Comments? Questions? Mistakes?

** This is a work in progress and currently only intended for review by the CHA (Chinese Herb Academy) and The Traditional Chinese Medicine Yahoo Groups :

Working Introduction:

Below is a case record from my clinical practice in Boulder, Colorado that highlights the strength of Chinese medicine’s treatment for common colds and flu. It also illustrates a problem with the health-care system in the U.S. and hopefully will spark a deeper much needed dialogue between Western and Chinese medicine.

Case record (2011): [Patient] X, a male in his mid-30s, came in with a chief complaint of fevers of unknown origin that had persisted for six weeks. The fevers were severe in the afternoons and would also wake him around 3-4 am, when his Advil “wore-off”.

He recently was hospitalized for eight days, when his fevers started reaching 104°F. They were characterized by a strong sensation of shivering cold (rigors). After multiple courses of antibiotics, a loss of 25 lbs. (he was not overweight), and $72,000 in hospital bills, he was discharged. Although his fevers had finally decreased he had no diagnosis, and within days of being discharged his fevers started to return. After a couple days of worsening symptoms he came in to see me for a Chinese medicine consult.

History: Prior to the fevers he was overworked and was not sleeping much. For the last few years he had been taking Metformin for diabetes and Pepcid for acid reflux.

Six weeks prior, he went to urgent care complaining of elevated temperature (102°) and chills, severe headache at the temples and occiput that was worse lying down, sore throat, and a “sinus infection” with nasal congestion. He was given Augmentin, which caused him to vomit. After four days of vomiting and feeling generally worse he was told to stop the Augmentin and given a second antibiotic, Azithromycin. Two days later his condition worsened and his fevers climbed to 104°F. He ended up in the emergency room where he had elevated liver enzymes (possibly from the Augmentin), normal CBC (including WBC), and was suspected to have left lobe pneumonia. He was given IV antibiotics and fluids and remained in the hospital for 8 days while they ran a battery of tests. Nothing conclusive was found.

In my office: The patient reported severe fatigue (unable to work), fever and chills, no sensation of heaviness, no thirst, no dryness of the lips or mouth, and the stools had recently become drier. Previous to the last few days he generally felt cold with the fevers, but now he had started to feel hot with the fevers. He was taking eight Advil a day to control the fevers (4 every 12 hours). When the Advil would wear off the fever would spike and he would start to sweat. His pulse was slippery, floating, and rapid. His tongue had cracks, no coat, was slightly red with small purple spots on the underside of the tongue.

Diagnosis & pathodynamic: Wind-cold pathogen constrained in the muscle layer transforming to heat in the protective level.

Treatment Principles: Use acrid cool medicinals to clear and resolve (disperse and vent out heat in the exterior).

Formula: Two packets of Honeysuckle and Forsythia Powder (yin qiao san) were given (bulk herbs). Cook time was 15 minutes. One packet was consumed over two days, taken between meals three times a day.

Prescription:

jing jie (Schizonepetae Herba) 6g (add)
jin yin hua (Lonicerae Flos) 15g
lian qiao (Forsythiae Fructus) 15g
dan zhu ye (Lophatheri Herba) 6g
niu bang zi (Arctii Fructus) 9g
jie geng (Platycodi Radix) 6g
bo he (Menthae haplocalycis Herba) 3g (add)
dan dou chi (Sojae Semen preparatum) 12g (add)
lu gen (Phragmitis Rhizoma recens) 18g
gan cao (Glycyrrhizae Radix) 3g

Result: After one packet the patient was back at work and although his muscles were achy, they felt stronger. After finishing two packets, he requested a two-bag refill from the pharmacy. He worked five continuous full days and at the next appointment (one week later) he was having no fevers, taking no Advil, and felt almost 100%. At this point I gave him a constitutional formula based on ban xia xie xin tang (Pinellia Decoction to Drain the Epigastrium). He had no recurrence of the fevers.

Commentary:

Although this case had a fortunate outcome with a straightforward treatment, I think it highlights some important issues in regard to Chinese medicine theory as well as Western and Chinese medicine’s roles in treating disease.

Chinese medicine commentary

This case started with a fairly typical flu, most likely caused by a wind-cold pathogen. The prescribed antibiotics constrained the pathogen in the muscle layer. Antibiotics, usually considered cold and bitter, are not appropriate in such situations, which require an acrid warm approach to disperse and release the exterior cold.

The patient had a fairly robust constitution, which helped prevent the pathogen from sinking into the interior. Over time though, the pathogen transformed to heat. The fluids were only starting to become affected as evidenced by the dry stools, yet the lips and mouth were not dry. This was not a pathogen that had entered the Large Intestine or yang ming. The presentation was fairly straightforward from a Chinese medicine diagnostic perspective. We had a lingering pathogen in the superficial aspects of the body and a clear heat and resolving the exterior method was appropriate.

Some points to keep in mind:

1. High fever can still be an exterior problem
2. An ongoing fever for 6 weeks to 6 months can still be an exterior problem
3. The lack of dryness and internal organ symptoms gives evidence that the pathogen was still on the exterior.

It should be noted that the treatment, although fairly basic, was not a mechanical, reflexive action. In my practice I rarely give an unmodified formula, let alone Honeysuckle and Forsythia Powder (yin qiao san). I was a little embarrassed when writing this case up, having published material discussing how this specific formula (and formulas in general) are best thought of as ideas and should not be given as presented in our textbooks. Although formulas are best constructed for each individual presentation, in this case, the stock formula seemed to be spot on.

Furthermore I do not want to suggest that Honeysuckle and Forsythia Powder (yin qiao san) should be given indiscriminately in other cases of fever of unknown origin. One still should perform an appropriate differential diagnosis.

I think though that the nature of the condition, being an uncomplicated pattern, and the simplicity of the treatment really speaks to the strength of the Chinese medicine model compared to Western medicine’s approach to diagnosis and treatment.

The integration of Western and Chinese medicine

Although this is only a single case it does represent a common clinical occurrence and is also emblematic of a greater problem in health care. Cold and flu are treated very successfully with Chinese medicine, even ones that seem fairly urgent. Chinese medicine has quite an arsenal of options that have actively been developed over 2000+ years of clinical practice. There is case study after case study in Chinese and English that demonstrate the effectiveness of the Chinese medicine approach for these conditions.

Western medicine has little to offer since most colds and flu are viral. However, antibiotics are often given because the patient requests “something” or there is a suspected (usually secondary) bacterial infection. Although antibiotics can have their place, the majority of the time Chinese medicine can resolve the problem without their use, hence avoiding the multiple issues that come along with antibiotic treatment.

All health care providers are trying to come up with the best care possible for our patients. Hence it would be worthwhile if we could respect each other’s strengths while acknowledging our own weaknesses. Chinese medicine doctors all too often write off Western medicine because it is not “natural,” or supposedly just treats the “symptoms.” Western medicine writes off “alternative” medicine due to lack of rigorous research.

Is it unreasonable for practitioners to refer to other modalities that have a better handle on a given illness? Ultimately we should all be working together, creating a team that centers on the patient’s best interest.

I often have patients ask me to converse with their Western doctors about collaborative treatments. Some MDs that are open-minded enough to engage in such discussions. Quite simply though, most medical doctors make little effort to understand Chinese medicine. Hence one is unable to discuss Chinese medicine on its own terms (its theory and terminology) and is forced to artificially describe its actions and methods in pseudo-Western medicine lingo.

In contrast, Chinese medicine physicians not only are required to take Western medical courses in their curriculum, ranging from Western physical exam to pharmacology and pathophysiology, but often actively seek out ways to integrate the knowledge into Chinese medicine.

Chinese medicine in 2006 treated more than 3.1 million U.S. adults with acupuncture[1]. Major insurance companies, such as Kaiser, not only cover Chinese medicinal services but are starting to discuss Chinese medicine on its own terms.[2] Is it not reasonable for Western doctors to have at least one course in their training centered on Chinese medicine? Is it not reasonable for them to strive for at least a basic understanding of a medicine that has been around for over 3000+ years?

In conclusion, Chinese medicine is more appropriate than Western medicine for many conditions. However discovering what these may be is a bit difficult if the two cannot openly work together. Quite simply, Chinese medicine must first be understood on its own terms (within its own system). For example, WebMD states,

“Research in China and worldwide has shown Chinese medicine to be helpful for many types of illness. Because Chinese medicine differs from Western medical practice in diagnosis and treatment methods, it is difficult to apply Western scientific standards to it.[3]”

That is, Chinese medicine most often gives individualized treatments based on constitution and whole-body presentation, not a Western disease or a mere symptom. Hence typical research models do not accurately reflect Chinese medicine’s abilities.

However, we can learn from case studies and individual doctor’s experience and see how Chinese medicine thinks about disease as well as what can be successfully treated. What will it take for Western medicine to acknowledge Chinese medicine and start to work together?

Please feel free to post any comments.

[1] http://nccam.nih.gov/health/whatiscam/chinesemed.htm

[2] https://members.kaiserpermanente.org/kpweb/healthency.do?hwid=aa140227spec

[3] http://www.webmd.com/balance/tc/chinese-medicine-topic-overview

The object was removed from the chamber pot with fire tongs, washed off with water, and then carefully examined. It was a “duck butt.” The patient had attended a banquet about 10 days previously where he ate a piece of under cooked duck meat. Because of the circumstances he was too embarrassed to spit it out and reluctantly swallowed it resulting in the illness described above.

又如一76歲老人陳某，15年前患結腸癌，曾手術切除，自後身體一直健康。近1周來，大便不通，少腹手術一側又捫及一塊狀物，幾個醫院均要患者入院作進一步檢查，并認為手術也無希望。要求中醫服些中藥，也覺無能為力而未給處方。後病人竟排出一粒硬屎，頓覺少腹輕鬆。用火鉗從便桶中鉗出硬物，用水沖洗之後仔細辨認，原來是一個“”，是十幾天前赴宴，揀得一塊鴨肉，覺得未燒酥，礙於親朋面前不便吐掉而囫圇吞下，於是發生前述的病證。

Original case by: Liu Bao-Yi (Liu Baoyi) (柳宝诒)

Patient [Zhang] presented with physical cold and fever, no sweat, a wiry and thin pulse, and a yellow tongue [coat]. This was an exterior pathogen with food accumulation knotted up and not transforming. It was suitable to resolve both the exterior and interior.

dan dou chi (Sojae Semen preparatum)
da dou juan (Sojae Semen germinatum)
zi su ye (perilla leaf)
jing jie (Schizonepetae Herba)
xing ren (Armeniacae Semen)
zhi ke (Aurantii Fructus)
gua lou pi (Trichosanthis Pericarpium)
hui xiang tan (charred Foeniculi Fructus)
jiao shen qu (Scorched  Massa medicata fermentata)
jiu chao huang qin (Wine-fried Scutellaria)
lian qiao (Forsythiae Fructus)
qing hao (Artemisiae annuae Herba)
bai mao gen (Imperatae Rhizoma)
sheng jiang pi (Zingiberis Rhizomatis Cortex)

Source: 柳宝诒医案 (伏温篇)

Questions, comments, or thoughts?

[Patient] Zhao (44) [suffered from] chronic constraint and clumping. The five emotions had lead to ascending qi fire. There was Stomach qi counterflow resulting in a stifling sensation of the gastric cavity and no appetite. [This was a pattern of] excessive ascendant Liver yang and wind fire intimidating the orifices. Inevitably there was dizziness and painful obstruction of the throat. There was a feeling of cold, but this was not true cold. All of these signs are due to qi painful obstruction and lack of free flow. This disease [can be understood] from [the classic] phrase, “All clenching, shuddering, and chattering [of the jaws] belongs to fire.” [In addition] Dan Xi said, qi that ascends is from Liver and Gallbladder ministerial fire that does not have a place to reside.

sheng di huang (Rehmanniae Radix)
e jiao (Asini Corii Colla)
xuan shen (Scrophulariae Radix)
mu dan pi (Moutan Cortex)
shi hu (Dendrobii Herba)
hei dou pi (black bean skin)

Translated by: Jason Blalack

Original Chinese: 赵（四四） 郁勃日久。五志气火上升。胃气逆则脘闷不饥。肝阳上僭。风火凌窍。必旋晕咽痹。自觉冷者。非真寒也。皆气痹不通之象。病能篇以诸禁鼓栗属火。丹溪谓上升之气。从肝胆相火。非无据矣。 生地 阿胶 玄参 丹参 川斛 黑 豆皮

Source: Case 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》.

Commentary: I found this case quite instructive. This is a classic Ye Tian-Shi case in that there are multiple symptoms that can be viewed in many ways (secondary patterns) yet Ye focuses on the underlying pathodynamic, addressing all of them in a simple elegant formula.

The way I like to read such cases is to examine how these “other” symptoms can be caused from the pathodynamic that is addressed. That is,we know that such a patient could have red eyes, dry mouth, thirst, a rapid and thin pulse, etc. These are not mentioned because they are obvious. However, the key unusual symptoms are mentioned and this is what we focus our learning on. For example, a question to ask is, why is there low appetite, painful obstruction of the throat, stifling sensation in the gastric cavity, a sensation of cold and how is it related to the diagnosis, the pathodynamic, and addressed in this formula? One can assume that Ye believes that these symptoms will be eliminated with the above formula, which is addressing the root.

Hence from such cases, we can learn that we need not load our formulas with unnecessary symptomatic herbs (that may even be counterproductive) if we properly address the underlying pathodynamic, consequently, teaching us how to keep our formulas small and compact.

Therefore we see a focus on yin and blood deficiency with heat even though there is ascending wind, yang, and fire.  Ye only uses the mild hei dou pi (black bean skin) to calm and descend the Liver yang, which also nourishes yin and blood (and enriches the Kidney yin). {BTW, this is also called 穭豆衣 (lu dou yi) and I have used this herb and idea successfully often in the clinic.}

We also learn that a fire condition can produce a sensation of cold and one does not need to warm the patient. This is often occurs  from constraint. I also find it interesting that there are clear signs of stomach involvement (low appetite, stifling sensation) and Ye does not move qi (which would damage to yin). The only moving herb is mu dan pi. He also does not try to tonify qi (with warm medicinals) just because there is a low appetite. Hence we learn that the Stomach involvement (even the stifling sensation) can arise from yin deficiency. If one addresses the root and the symptoms improve. Clearly, there was not enough evidence to lead Ye to believe that there was a true underlying Spleen and Stomach deficiency which might make the digestion of yin tonic herbs difficult. This is of course inferred.

The phrase “qi that ascends is from Liver and Gallbladder ministerial fire that does not have a place to reside” simply illustrates the need to build yin (place to reside) to control yang. Also “painful obstruction of the throat” is not only painful but often red and swollen.

I would love to hear what others see in this case…

[Patient] Ni had lots of pain and ascending yang. The yin fluids were endlessly pouring out from the upper part of the body. The tongue was dried-up and red-crimson colored. There was irritability and inability to sleep. It was suitable to augment the Kidney water in order to control Heart fire.

xian sheng di (fresh Rehmanniae Radix)
xuan shen (scrophularia, ningpo figwort root)
mai men dong (Ophiopogonis Radix)
lu dou pi (Phaseoli Radiati Testa)
jin yin hua (Lonicerae Flos)
zhu ye xin (Lophatheri Folium Immaturum)

Translated by: Jason Blalack

Original Chinese: 倪 多痛阳升。阴液无以上注。舌涸赤绛。烦不成寐。当益肾水以制心火。（心火）鲜生地 元参 麦冬 绿豆皮 银花 竹叶心

Source: Case from the Insomnia chapter of Case Records as a Guide to Clinical Practice (Lín zhèng zhî nán yï àn) 《临证指南医案》.

Commentary:

lu dou pi (Phaseoli Radiati Testa) is cold and sweet. It resolves heat toxin, clears wind-heat, eliminates eye screen (目翳), transforms maculopapular eruption, and disperses swelling and distention. From: 《纲目》& 《随息居饮食谱》

Comments?

Original Case by:

[Patient] Gu (age 44) had already greying whiskers and hair on the temples. His facial complexion though was bright. He was emotionally worried and irritable. [There was] yang ascending and agitating [the spirit] with phlegm and thin mucus also ascending and overflowing.  The divine pivot says, when yang qi descends, joins and enter the yin, then the yang qiao vessel is full and one is able to sleep. [At this moment though] qi was disseminating and discharging outward and yang was not entering yin. He would drink alcohol in hopes of muddling his consciousness enough so he could sleep. This was not a good method for managing this disease. In middle age and afterwards, men’s lower base is the first to become depleted. [The treatment] was to use Eight-Ingredient Pill (ba wei wan) in the morning and Pinellia and Millet Decoction (ban xia shu mi tang) in the evening. (yang qiao vessel deficiency).

Translated by: Jason Blalack

Original Chinese: 顾（四四） 须鬓已苍。面色光亮。操心烦劳。阳上升动。痰饮亦得上溢。灵枢云。阳气下交入阴。阳跷脉满。令人得寐。今气越外泄。阳不入阴。勉饮酒醴。欲其神昏假寐。非调病之法程。凡中年已后。男子下元先损。早上宜用八味丸。晚时用半夏秫米汤。（阳跷脉虚）

Source: Case from the Insomnia chapter of Case Records as a Guide to Clinical Practice (临证指南医案 lin zheng zhi nan yi an).

Commentary: This case shows one approach to dealing with complex patterns of excess and deficiency, giving separate formulas at different times of day. I often give a daytime and nighttime formula for insomnia. Ye uses his typical style of focusing on the pathodynamics and uses little in the way symptomatic “sleep” herbs. Brilliant! Eight-Ingredient Pill (ba wei wan) is another name for Kidney Qi Pill (shen qi wan). Pinellia and Millet Decoction (ban xia shu mi tang) is from the Divine Pivot and contains Pinelliae Rhizoma preparatum (zhi ban xia) and  Setariae Fructus (shu mi).

(Case 6) – from Understanding Case Records Pt. 2

A 10 year-old presented with a mild cough and tidal fever. This was caused by childhood yin exhaustion and qi aspect heat.

Di Gu Pi 3 qian (Lycii Cortex)
Qing Hao 1 qian (Artemisiae Annuae Herba)
Zhi Mu 1 qian (Anemarrhenae Rhizoma)
Gan Cao 3 fen (Glycyrrhizae Radix)
Nan Sha Shen 1 qian (Adenophorae Radix)
Shi Hu 3 qian (Dendrobii Herba)

Qin Bo-Wei’s Commentary:

This case is also a cough with Lung heat and yin exhaustion, but there is a tidal fever which in general shows that the yin exhaustion has progressed. There is incessant heat that is certainly resulting in more and more consumption of the qi and yin. This is important to consider. Nan Sha Shen (Adenophorae Radix), Gan Cao (Glycyrrhizae Radix) and Shi Hu (Dendrobii Herba) not only moisten the Lungs, but with Di Gu Pi (Lycii Cortex), Qing Hao (Artemisiae Annuae Herba) and Zhi Mu (Anemarrhenae Rhizoma) also clear heat and reduce steaming. The “mild” in “mild cough” illustrates that this is a chronic disease with an infrequent cough. Therefore he did not use Xing Ren (Armeniacae Semen) or Chuan Bei Mu (Fritillariae cirrhosae Bulbus).

Translated by: Jason Blalack

Original Chinese: 十岁，嗽缓，潮热，稚年阴亏，气热所致。地骨皮(三钱)、青蒿(一钱)、知母(一钱)、生甘草(三分)、南沙叁(一 钱)、川斛(三钱)。

按:此案亦咳嗽肺热阴亏，但有潮热则比一般阴亏更进一步，热不止，势必气阴愈受消耗，所以特别提出。并用沙参、甘草、石斜润肺外，加入地骨皮、青莆、知母清热退蒸。咳缓的缓字，说明病已经久，咳己不繁，故不用杏仁、川贝之属。

Source: Case from the Cough chapter of Case Records as a Guide to Clinical Practice (lín zhèng zhî nán yï àn) 《临证指南医案》. Commentary from Complete Famous Medical Works of Qin Bo-Wei.

Comments?