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?

(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?

(Case 5) – from Understanding Case Records Pt. 2

There was exhausted yin existing in conjunction with contraction of a warm pathogen. There was a cough and head distention. It is suitable to use a light formula.

sang ye (Mori Folium)
xing ren (Armeniacae Semen)
chuan bei mu (Fritillariae cirrhosae Bulbus)
bei sha shen (Glehniae Radix)
sheng gan cao (Glycyrrhizae Radix)
tian shui li pi (Pyri Exocarpium) (pear peel)

Qin Bo-Wei’s Commentary:

This and the previous case’s symptoms and cause of disease are identical. In this case there was constitutional yin exhaustion, and moreover the condition is not occurring in conjunction with wind or damp. Therefore Ye used Sang Ye (Mori Folium), Xing Ren (Armeniacae Semen), and Chuan Bei Mu (Fritillariae Cirrhosae Bulbus) to clear and transform the upper burner phlegm heat while simultaneously using Bei Sha Shen (Glehniae Radix), Gan Cao (Glycyrrhizae Radix), and Li Pi (Pyri Exocarpium) to clear and moisten. This “light formula” refers to the idea that “when the condition is located in the upper burner treat like a feather; unless one’s touch is light, one will be unable to grasp it.” It does not refer to dosages.

Translated by: Jason Blalack

Original Chinese: 阴亏挟受温邪，咳嗽、头胀，当以轻药。桑叶 杏仁 川贝 白沙参 生甘草 甜水梨皮

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?

A warm pathogen assaulted the outer body. There was a cough and head distention. It is appropriate to clear the upper burner. [The prescription given was]

Xing Ren (Armeniacae Semen)
Sang Bai Pi (Mori Cortex)
Jie Geng (Platycodi Radix)
Zhe Bei Mu (Fritillariae Thunbergii Bulbus)
Tong Cao (Tetrapanacis Medulla)
Lu Gen (Phragmitis Rhizoma)

Qin Bo-Wei’s Commentary: This case’s only presenting symptoms are cough and head distention, making it difficult to come up with a clear diagnosis. However since we are given the diagnosis of “warm pathogen assaulting the outer body” we can deduce additional symptoms that are related to wind warmth. From the section of Ye Tian-Shi’s text entitled “Externally-contracted Warm Heat” we get a better idea of what this means. For example,

When a warm pathogen assaults the outer body, it first accosts the Lungs.”

Also there is,

The Lungs govern the qi and connect with the skin and body hair. Therefore [the Lungs] reside in the exterior. When the pathogen is in the exterior one should first use an acrid, cool, and light prescription. If occurring in conjunction with wind then one should add Bo He (Menthae haplocalycis Herba) and Niu Bang Zi (Arctii Fructus). If occurring in conjunction with damp one should add Lu Gen (Phragmitis Rhizoma) and Hua Shi (Talcum). This will, respectively, vent the wind to the outside of the heat, or leach the damp away from under the heat, so that [neither of these pathogens] interacts with the heat, and it will be isolated.”

It can be seen that in this case that the cough is the chief patho-condition, but there also should be concurrent symptoms such as headache, phlegm that is difficult to cough up, dry mouth, scanty yellow urination etc. The pulse and tongue was not given, but it ought to be something along the lines of a slippery and rapid pulse with a yellow greasy coat. Therefore the formula uses Xing Ren (Armeniacae Semen), Zhe Bei Mu (Fritillariae Thunbergii Bulbus), and Jie Geng (Platycodi Radix) to dispel wind [by diffusing the Lungs and transforming] phlegm. Sang Bai Pi (Mori Cortex) was used to clear heat. All of these focus on the Lungs. In addition Tong Cao (Tetrapanacis Medulla) and Lu Gen (Phragmitis Rhizoma) were added to clear heat and leach out dampness through their bland flavor.

Translated by: Jason Blalack

Original Chinese: 案四:温邪外袭，咳嗽、头胀，当清上焦。杏仁、桑皮、桔梗、象贝、通草、芦根.

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.

[The patient’s] pulse was thin and rapid. The thin [pulse] indicates visceral yin exhaustion and the rapid [pulse] indicates nutritive yin-fluid depletion. The previous summer and fall the patient was ill. Following this, there was a contraction of winter warmth leading to failure to store. In the spring when the earth’s qi started to ascend, there was Liver wood stirring wind, resulting in right-sided atrophy. The collaterals at the root of the tongue were stiff leading to difficult speech. All of this was caused by a root base exhaustion pattern. The common treatment to drain qi, descend phlegm, and discharge, disperse, and attack wind [was given], which removed the true yin by force and the spirit gradually became muddled as if asleep. If it had worsened, there would have been clouding inversion and then how can one treat this? Zhang Zhong-Jing’s Fu Mai Tang (Restore the Pulse Decoction) method was used. [This was a pattern of] yin fluid deficiency with stirring wind.

On follow up: [It was appropriate] to deal with the channels and nutritive level, the spirit depletion, the harm to the essence, the yin being unable to maintain a grasp [of the yang], and the stirring and jumping of internal wind were all signs of disability attack (fei zhong 痱中). The [previous] treatment of phlegm damaged [the body's] warming tonification [ability], further damaging the yin and leading to withering that progressively became more severe.

It would have been fortunate to be able to foster yin and extinguish wind thereby slightly calming the situation. However, at that time the summer’s heat was increasingly rising and the true qi was even more deficient. Therefore, every day it was important to actively generate fluids and boost qi, because it was the hot part of the summer. [It was voiced that] if the summer’s heat did not change, they would then discuss adjusting the treatment approach. Gu ben wan (Secure the root pill) minus Shu Di Huang (cooked rehmannia root), plus Wu Wei Zi (schisandra fruit) [was given].

[The prescription was]

Tian Men Dong (Asparagi Radix)
Sheng Di Huang (Rehmanniae Radix)
Ren Shen (Ginseng Radix)
Mai Men Dong (Ophiopogonis Radix)
Wu Wei Zi (Schisandrae Fructus)

Qin Bo-Wei’s Commentary [for the first visit]: This was also a case of wind-stroke. There was a connection between the manifestation and aetiology and qi and blood deficiency. However, as a result of an inappropriate treatment, the true yin was further removed by force. The particular manifestation was the muddled spirit as if asleep and a thin and rapid pulse, which illustrated that the Heart was extremely deficient. The Heart generates blood, stores the spirit and governs the vessels. The flow of the channel vessels was hindered, which is bound to lead to one-sided worsening atrophy. One should surely guard against clouding reversal. Therefore Ye gave Fu Mai Tang (Restore the Pulse Decoction) to first treat the Heart. Fu Mai Tang (Restore the Pulse Decoction) fundamentally nourishes Heart fluids, augments the Heart qi and unblocks the Heart yang. Since the pulse was thin and rapid he did not use the acrid and hot Sheng Jiang (Zingiberis Rhizoma recens) and Gui Zhi (Cinnamomi Ramulus), which changed the formula into a softening and moistening one. Actually, years later Wu Ju-Tong in the Wen Bing Tiao Bian (Systematic Differentiation of Warm Pathogen Diseases) (1798), according to this method, designed Jia Jian Fu Mai Tang (Modified Restore the Pulse Decoction), which rescues the yin and fluids for a warm pathogen that spreads into the lower burner. Although our predecessors have used both this formula and the previous Di Huang Yin Zi (Rehmannia Drink) in ways that are different than the original set prescription’s usage, the methods are intelligent and should be studied.

Translated by: Jason Blalack

Original Chinese: 脉细而数，细为脏阴之亏，数为营液之耗，上年夏秋病伤，更因冬暖失藏，入春地气升，肝木风动，遂令右肢偏痿，舌本络强，言蹇，都因根蒂有亏之症，庸俗泄气降痰，发散攻风，再劫真阴，渐神愦如寐，倘加昏厥，将何疗治，议用仲景复脉法，(液虚风动)。复脉汤去姜桂，又 操持经营，神耗精损，遂令阴不上朝，内风动跃，为痱中之象，治痰攻劫温补，阴愈损伤，枯槁日甚，幸以育阴熄风小安，今夏热益加发泄，真气更虚，日饵生津益气勿怠，大暑不加变动再商调理，固本丸去熟地加北味。天冬、生地、人叁、麦冬、五味

Source: Case from the Wind Stroke 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.

[The patient] had blood loss for many years with chronic damage to the yin qi. There was a relapse due to worry, sadness, and melancholy, where yang linked with internal wind which led to a great uprushing to the head (da mao 大冒). The blood residence became empty and qi overwhelmed the left side of the body, producing a deviated mouth, numbness and tingling in the limbs, dark tongue, inability to speak, and foot atrophy with an inability to walk. Obviously the Liver and Kidneys were deficient and famished, the yin qi was unable to govern the bearing upwards. It was important to nurture the lower to extinguish wind. A method [designed by] Liu He-Jian was used.

Make into honey pills and take four qian a day.

Qin Bo-Wei’s Commentary: This is also a wind-stroke pattern from a blood deficiency not nourishing the sinews and bones, with internal wind assaulting the collaterals. However, there was left-sided numbness and tingling in the limbs that had not yet reached the degree of hemilateral withering.

The chief manifestation was wind harassing the upper burner leading to a deviated mouth and dark tongue. There was also lower burner yin exhaustion which resulted in foot atrophy and lack of strength. The origin of the onset of disease was a loss of blood and melancholy. The diagnosis is Liver and Kidney yin deficiency unable to govern the bearing upwards, which warranted an emphasis on nurturing the lower burner in order to extinguish wind.

The pattern belonged to silent collapse^（1） wind-stroke disability⁽²⁾. He adapted Liu He-Jian’s Di Huang Yin Zi (Rehmannia Drink). Since there were no yang deficiency signs he did not use Zhi Fu Zi (Aconiti Radix Lateralis Preparata), Rou Gui (Cinnamomi Cortex) or Ba Ji Tian (Morindae Officinalis Radix). In addition because there was yin deficiency stirring wind heat, he removed the fragrant penetrating Shi Chang Pu (Acori Tatarinowii Rhizoma) and added Gou Qi Zi (Lycii Fructus) and Ju Hua (Chrysanthemi Flos) in order to nourish the blood and extinguish wind. He used Niu Xi (Achyranthis Bidentatae Radix) in order to descend, treating the foot atrophy.

Notes:

(1) Yin jue (喑厥) . This is an inability to talk due to a stiff tongue with reversal cold in the limbs.
(2) Feng fei (风痱) . This refers to atrophy of the limbs with an inability to move, or a paralysis after wind-stroke.

Translated by: Jason Blalack

Original Chinese:

案二:失血有年，阴 气久伤。复遭忧悲悒郁。阳挟内风大冒。血舍自空。气乘于左。口肢麻。舌喑 无声。足痿不耐行走。明明肝肾虚馁。阴气不主上承。重培其下。冀得风熄。议以河间法。熟地四两，牛膝-两半，莫肉二两，炒黑远志一两半，柜子二两，炒菊花二两，五味子-两半，川斜二两四钱，获神二两，淡灰蓉-两二钱，加蜜丸，服四钱。(中风门)

按:此亦血虚不荣筋骨，内风袭络的中风证，但偏左肢麻，末至偏枯程度。其主证为风扰于上而口喝舌暗，阴亏于下而足痞无力。故从发病的根源失血和僵郁等，诊断为 肝肾阴虚不主上承，主张重培其下以冀风熄。证属啃撅风痒，采取了刘河间的地黄饮子，因没有阳虚现象，除附子、肉桂、巴哉，并因阴虚风动，去莒蒲的香窜，加柏菊以养血熄风，牛膝下行以治足屡。

Source: Case from the Wind Stroke 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.

[The patient] had hemilateral withering on the left side of the body. [There was] blood deficiency not nourishing the sinews and bones, [leading to] internal wind assaulting the collaterals. The left pulse was moderate and large.

Zhi Shou Wu (Polygoni Multiflori Radix Preparata) (baked) 4 liang
Gou Qi Zi (Lycii Fructus) (stems removed) 2 liang
Dang Gui Shen (Angelicae Sinensis Radix) (use that with a single stalk, remove the tips) 2 liang
Huai Niu Xi (Achyranthis Bidentatae Radix) (steamed) 2 liang
Tian Ma (Gastrodiae Rhizoma) (roasted) 2 liang
Chong Wei Zi (Leonuri Fructus) (crushed, water rinsed ten times, then baked) 2 liang

These were ground into a powder.

Then Gan Ju Hua (sweet chrysanthemum flower) 3 liang, Shi Hu (Dendrobii Herba) 4 liang and Xiao Hei Dou Pi (small black bean skin) 4 liang were decocted down into a syrup.  A paste [was then made] by adding honey [and the powder from the other herbs]. This was made into extremely fine pills. Every morning [the patient was instructed to] take four qian [of pills] with recently boiled water.

Commentary by Qin Bo-Wei: This case only mentions the one manifestation, “hemilateral withering on the left side”. Hemilateral withering is simply paralysis in half of the body. However since the body can be differentiated by the left side, corresponding to blood, and right the side, corresponding to qi, then this emphasis on the left relates to blood. Paralysis in half of the body is in the category of wind-stroke and can have symptoms such as impaired consciousness or coma, deviated eyes and mouth and so on. These however are not described in the case history, showing that this is the sequela of a wind-stroke, and other such symptoms no longer exist for this patient.

Therefore starting from the “hemilateral withering on the left side” and a moderate and large left pulse, we can say that this relates to the Liver. There is also Kidney yin and blood insufficiency with disquieted internal wind, which can be diagnosed from “blood deficiency not nourishing the sinews and bones, [leading to] internal wind assaulting the collaterals.”

Although there is no treatment method mentioned, a method to nourish blood and extinguish wind is implied. In addition, since the Liver governs the sinews and the Kidneys governs the bones, this is emphasizing the method of enriching and nourishing the lower burner. Therefore, the formula used He Shou Wu (Polygoni Multiflori Radix Preparata), Gou Qi Zi (Lycii Fructus), Dang Gui (Angelicae Sinensis Radix), Tian Ma (Gastrodiae Rhizoma), and Hei Dou (Glycinis Semen) to tonify both the Liver and Kidneys while also paying particular attention to nourishing the blood. Shi Hu (Dendrobii Herba) enriches the Kidneys and eliminates deficiency heat. So it is said, to treat wind one must first treat the blood. When blood moves then wind disappears on its own.

These medicinals were assisted by Tian Ma (Gastrodiae Rhizoma) and Ju Hua (Chrysanthemi Flos) which extinguish wind and Niu Xi (Achyranthis Bidentatae Radix) which fortifies the sinews and bones. Also, Chong Wei Zi (Leonuri Fructus) and Shi Hu (Dendrobii Herba) are able to treat wind painful obstruction and weak legs. Therefore this formula deals with both the root and branch and is regulating and nourishing. Xu Ling-Tai, in analyzing this formula, said “this formula neutrally tonifies, and does not have the drawback of supplementation that generates heat.”

Translated by: Jason Blalack

Original Chinese:

案-:偏枯在左，血虚不荣筋骨，内风袭络，脉左缓大。

制首乌四两，构把子二两，归身二两，淮牛膝蒸二两，炬天麻二两，三角胡麻二两，研末，用黄甘菊三两，川石斜四两，小黑豆皮四两煎汁，加蜜，丸极细，早服四钱，滚水送。(中风门)

按:此案在症状方面只提”偏枯在左”。偏枯即半身不遂，因半身有左血右气之分，故特别指出在左。半身不遂，属于中风病，可以伴见昏撅和口眼喝斜等，案中并不叙列，说明是中风的后遗证，其他症状已不存在。所以单从偏枯在左考虑，结合脉象缓大，系肝。肾阴血不足，内风不静，诊为”血虚不荣筋骨，内风袭络”。虽末指出治法，而养血熄风已在言外，并因肝主筋，肾主骨，应着重在滋养下焦。为此，方用首乌、柜子、归身、胡麻、黑豆并补肝肾而侧重养血，石斜亦能滋肾除虚热，所谓治风先治血，血行风自灭。佐以天麻、菊花熄风，牛膝壮筋骨，而胡麻、石斜也能疗风痹脚弱，合成标本兼顾调养方剂。故徐灵胎分析此方的血药和风药，评为”此方平补，并无用补生热之弊”。

Source: Case from the Wind Stroke 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.

[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》.