[Patient] Wu, age 41, [after] undergoing excessive agitation, had Liver and Gallbladder ascendant yang. The Stomach qi was getting worse and worse. The pulse should be pulsing on the left. The treatment was through [addressing] the constrained heat.

mu dan pi (Moutan Cortex)
hei shan zhi zi (black gardenia)
bo he geng (Menthae haplocalycis Stem)
gou teng (Uncariae Ramulus cum Uncis)
chen pi (Citri reticulatae Pericarpium)
bai shao (Paeoniae Radix alba)
fu ling (Poria)
shen qu (medicated leaven)

Translated by: Jason Blalack

Original Chinese: 吴（四一） 操持过动。肝胆阳升。胃气日减。脉应左搏。从郁热治。（肝胆郁热）丹皮 黑山栀 薄荷梗 钩藤 广皮 白芍 茯苓 神曲

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》.

Commentary: Although the main issue is ascendant yang, Ye treats the root and focuses on the heat from constraint. Although gou teng (Uncariae Ramulus cum Uncis) has an ability to descend yang and bai shao can curb the Liver yang, his approach is mild. Compare to formulas such as tian ma gou teng yin (Gastrodia and Uncaria Drink) where there is tian ma, gou teng, shi jue ming and niu xi to descend or zhen gan xi feng tang which uses niu xi, dai zhe shi, long gu, mu li, and gui ban. His choose is one of style as well as to a certain extant a reflection of the severity of the condition.

Qì and Blood Depletion – Liver and Kidney insufficiency mistaken for wind-cold-damp painful obstruction.

Misuse of the Fire Spirit Current.

[Patient] Xu was a 59 year old woman who is chronically exposed to water- damp while working. After many years she developed joint-bone limp aching pain that sometimes was mild and sometimes was serious. After retirement it progressively worsened year after year. She sought out many treatments from the hospital, but with no results. Someone recommended her an empirical formula of chuan cao wu (Aconiti et Aconiti Kusnezoffii Radix Lateralis) 50g, zhi fu zi (Aconiti Radix Lateralis Praeparata) 50g, gui zhi (Cinnamomi Ramulus 30g, qiang huo Notopterygii Rhizoma seu Radix) 30g, chuan xiong (Chuanxiong Rhizoma) 30g, ma huang (Ephedrae Herba) 15g, xi xin  (Asari Herba) 15g, gan song (Nardostachydis Radix seu Rhizoma) 30g, tao ren (Persicae Semen) 15g, hong hua (Carthami Flos) 15g, chi shao (Paeoniae Radix rubra) 15g, ru xiang (Olibanum) 15g, mo yao (Myrrha) 15g, and qian nian jian (Homalomenae Rhizoma) 30g.

One packet of this formula was taken and the pain did not decrease but instead there was incessant great sweating, flusterdness, and palpitations. At nightfall her extremities would alternately stretch out and contract, quiver, shake, tremor, and when serious they would jerk, cramp and produce pain that was difficult to endure. Although she went through emergency western medicine treatment to resolve the spasms and stop the pain, there still was no long-term relief. She therefore sought out Chinese medicine.

Upon examination, she had a bright white facial complexion and the tip of her nose, lips, mouth, and yin tang [area] all were green-blue purplish. [In general] her extremities would spasm and at times her muscles were stiff and rigid.  Massage felt good, although she incessantly moaned. In her retelling of the past, she reported that after taking the medicine, mentioned above, she had shortness of breath, lack of strength, incessant sweating, aversion to wind, fear of cold, whole body stiffness, and increasing pain. Her tongue body was dark and crimson, the fur was thin with little fluid, and the centre of the tongue had fissures. Her pulse was thin, weak, and slightly rapid.

Differential Diagnosis: This was a deficiency painful obstruction with a misuse of a big formula that effused, dissipated, and attacked the painful obstruction [disease] which further damaged the qi, blood, and fluids,  loss of nourishment of her sinews (and vessels), which lead to convulsions.

 The treatment method was to augment qi and nourish blood, tonify and augment the Liver and Kidneys in order to treat the root, as well as to dispel wind, eliminate dampness, and stop painful obstruction pain, simultaneously treating the tip. The formula given was a modified ba zhen juan bi tang jia jian (Eight Treasure Remove Painful Obstruction Decoction). After 2 packets the convulsions were reduced, pain was clearly relieved, and afterwards the method of supporting the right and dispelling pathogen was applied to bring about recuperative care and healing.

Commentary: This is a pattern of deficiency painful obstruction. The patient was close to 60 years old, and had chronic painful obstruction disease. Qì, blood, yīn and yàng all were deficient and  normal [qì] deficiency was at the root. A lodged pathogen was the tip. The treatment method should support the normal as well as eliminate the pathogen. However, the first doctor thought the disease was an excess painful obstruction [disease], and stubbornly dispelled wind and eliminated dampness. Furthermore he used a large formula with chuan cao wu (Aconiti et Aconiti Kusnezoffii Radix Lateralis), zhi fu zi (Aconiti Radix Lateralis Praeparata), ma huang (Ephedrae Herba), xì xīn (Asari Herba), gui zhi (Cinnamomi Ramulus, and qiang huo (Notopterygii Rhizoma seu Radix) to effuse, dissipate, and attack the painful obstruction which consumed and damaged the qi, blood and fluids. This resulted in the channels [and vessels] losing nourishment and leading to convulsion. From the second examination the patient was seen to have flusteredness and palpations at night fall, her extremities alternately expanded and contracted, quivered and had tremors, bright white facial complexion, shortness of breath, lack of strength, dark crimson and red tongue with fissures and fur that was shiny with little fluids, and a weak slightly rapid pulse. This was a pattern of qi and blood deficiency and Liver and Kidney insufficiency.

Source:  [缪以星•临证随笔2 则•湖南中医学院学报，1986,(1):33]

Translated by: Jason Blalack

Commentary: I found this case interesting because it demonstrated how quickly and severely an incorrect formula can cause problems. The original formula was a fire spirit current approach. At first sight, it looks incredibly odd and somewhat incomprehensible as to why one would would give such high dosages of such medicinals. However, this type of formula (and dosages) is not uncommon in the fire spirit current. Such dramatic formulas, can have incredibly fast results, however they can also be extremely damaging. Obviously, correct diagnosis is important.

[Patient] Wu [suffered from] a warm disease for 70 days. The right pulse was long and left was deep. The tongue was limp with [a desire] to drink cold beverages. There was heart irritability-heat. The spirit qi was sometimes clear yet sometimes deranged. On the third day of menstrual bleeding the disease started. Hot qi settled internally in the blood, overwhelming the emptiness leading to inward fall. This disease should be considered stasis heat in the interior. However it had already become dangerous, and [must be approached] from a condition of buildup of blood with mania.

sheng di huang (Rehmanniae Radix),
mu dan pi (Moutan Cortex)
zhi da huang (prepared Rhei Radix et Rhizoma)
chao tao ren (dry-fried Persicae Semen)
ze lan (lycopos, bugleweed)
ren zhong bai (Hominis Urinae Sedimentum)

Translated by: Jason Blalack

Original Chinese: 吴（氏） 热病十七日，脉右长左沉，舌痿饮冷，心烦热，神气忽清忽乱，经来三日患病，血舍内之热气，乘空内陷，当以瘀热在里论病，但病已至危，从蓄血如狂例。（蓄 血）细生地 丹皮 制大黄 炒桃仁 泽兰 人中白

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

Commentary: Just as we often hear of cold entering the uterus during menstruation, Ye, in this case, makes the connection of warm disease entering the blood during menstruation. The “limp” in limp tongue also has the meaning of atrophy. This corresponds to yin deficiency. 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. It treats taxation heat, Lung atrophy, nosebleeds, spitting up blood, throat impediment, gan of the teeth and gums, and sores in the mouth and tongue. Therefore the formula clears heat from the blood while also promoting the movement of blood.

[Patient] Hu, a 46 year old female, had [suffered from] cough and wheezing for seven years. She recently contracted a wind-cold invasion which manifested as a blockage and stifling sensation in the chest, hindered breathing, cough and wheezing with profuse phlegm, and water sounds in the throat. The tongue coat was white and the pulse was floating.  Two packets of a modified ma huang tang (Ephedra Decotion) prescription was given:

ma huang (Ephedrae Herba) 6g
gui zhi (Cinnamomi Ramulus) 9g
hou po (Magnoliae officinalis Cortex) 9g
zhi shi (Aurantii Fructus immaturus) 9g
xing ren (apricot seed or kernel) 9g
gan cao (Glycyrrhizae Radix) 6g

After taking the herbs, the cough and wheezing was reduced. Two packets of the above formula was given minus hou po (Magnoliae officinalis Cortex) with the addition of  chen pi (Citri reticulatae Pericarpium) 3g. [Following this] the cough stopped, wheezing was pacified, and the breathing was easy and smooth.

Transalted by: Jason Blalack

Source: 陕西中医学院学报1990;<l>:3

Original Chinese: 姜春华医案:胡某某，女，46岁。咳喘已七年，近受风寒侵袭，胸闷窒塞，呼吸不利，咳喘多痰，喉间作水鸣声，苔白，脉软。以麻黄汤加味，处方:麻黄6克，桂枝9克，川朴9克，棋实9克，杏仁9克，甘草6克，2剂。药后咳喘减轻，上方去川朴，加陈皮3克，又服2剂，咳止喘平，呼吸通畅。

Commentary: This is a practical and fairly straightforward use of ma huang tang (Ephedra Decotion). In this case the patient had a constitutional condition of phlegm and thin mucus internally lurking in the Lungs. She contracted a wind cold pathogen which triggered an exacerbation of her cough and wheezing. Ma huang tang (Ephedra Decotion) not only externally resolves to wind cold but also internally diffuses the Lung qi. zhi shi (Aurantii Fructus immaturus) and hou po (Magnoliae officinalis Cortex) were added in order to clarify the Lungs and direct qi downwards.

Jason is a sensitive, caring healer, who always listens to me. He has a vast wealth of knowledge of Chinese, as well as other types of alternative and mainstream medical information. He is professional in every sense of the word, and dedicated to continuing his own education to help his patients in every way possible.” – Terry

Jason is a sensitive, caring healer, who always listens to me. He has a vast wealth of knowledge of Chinese, as well as other types of alternative and mainstream medical information. He is professional in every sense of the word, and dedicated to continuing his own education to help his patients in every way possible.- Deborah

[Patient] Dai [habitually] held in his/her feelings with no desire to speak up. This was a Heart disease and herb medicine is difficult to treat such an illness disease. This is damage caused by constraint of the seven emotions. [Zhu] Dan Xi’s yue ju wan (Escape Restraint Pill) method was used.

xiang fu (Cyperi Rhizoma)
chuan xiong (Chuanxiong Rhizoma)
huang lian (Coptidis Rhizoma)
fu ling (Poria)
zhi ban xia (Pinelliae Rhizoma preparatum)
ju hong (Citri reticulatae Exocarpium rubrum)
chao shan zha (dry-fried Crataegi Fructus)
shen qu (medicated leaven)

Made into pasty pills.

Translated by: Jason Blalack

Original Chinese: 戴（氏） 隐情曲意不伸。是为心疾。此草木攻病。难以见长。乃七情之郁损。以丹溪越鞠方法. 香附 川芎 小川连 茯苓 半夏 橘红 炒楂肉 神曲浆丸

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》.

Commentary: This is a modified yue ju wan (Escape Restraint Pill). Ye chooses not to prescribe cang zhu , but instead uses ban xia, fu ling, and ju hong, er chen tang (Two-Aged [Herb] Decoction) . He also uses huang lian instead of zhi zi. One might assume that there are symptoms such as focal distention and a stifling sensation in the chest and abdomen.

This is a great example of how a master herbalist modifies a stock formula to fit the individual’s presentation.

Spleen and Stomach Yang Deficiency
(Chronic Hepatitis)

(Thanks Greg for this instructive case!)

Bai, male, 39. January 24, 1964, initial consultation, in-patient department. Patient had suffered from chronic hepatitis for six years with intermittent bilateral flank pain, abdominal distention and bloating, anorexia, frequent belching, borborygmus, flatulence, and loose stools one to two times per day or once every-other day. Previously, he had been admitted to the hospital five successive times and undergone hepato-protective therapies, testosterone propionate therapy, etc., all with only temporary effects. When his job was stressful the condition would flare. Formulas such as Chai Hu Shu Gan San (Bupleurum Liver-Coursing Powder) had been applied in the past without obvious benefit. Upon examination, all six pulses were deficient, slow, and weak, and the tongue was swollen and large with a greasy, floating coat. Origin of the disease occurred in his early years when famine and forced labor led to dysfunction of Spleen and Stomach ascension, descension, and transportation. His presentation closely resembled a syndrome from Essential Prescriptions of the Golden Coffer (Jin Gui Yao Lue) “nausea and borborygmus, epigastric distention, Ban Xia Xie Xin Tang (Pinellia Heart-Draining Decoction) commands.” The prescription followed:

法半夏 fa ban xia (Pinelliae Ternatae, Rhizoma Praeparata) 9g
萸炒连 huang lian fried with wu zhu yu (Coptidis Chinensis, Rhizoma fried with Evodiae Rutecarpae, Fructus) 3g
黄芩 huang qin (Scutellariae Baicalensis, Radix) 9g
干姜片 gan jiang (Zingiberis, Rhizoma) 6g
炙甘草 zhi gan cao (Glycyrrhizae Melle Tosta, Radix) 6g
潞党参 dang shen (Codonopsitis Pilosulae, Radix) 9g
大枣 da zao (Zizyphi Jujubae, Fructus ) 4 pieces

2^nd consultation: February 29, 1964. One package of the previous prescription was taken each day, and one month later the poor appetite, borborygmus, flatulence, and other symptoms had decreased significantly. However, there was still abdominal distention and flank pain, and the tongue and pulse were same as before. It was suitable to use Hou Po Sheng Jiang Ban Xia Gan Cao Ren Shen Tang (Magnolia Bark, Fresh Ginger, Pinellia, Licorice, and Ginseng Decoction) from On Cold Damage (Shang Han Lun):

厚朴 hou po (Magnoliae Officinalis, Cortex) 9g
生姜 sheng jiang (Zingiberis Rhizoma Recens) 6g
半夏 ban xia (Pinelliae Ternatae, Rhizoma Praeparata) 6g
党参 dang shen (Codonopsitis Pilosulae, Radix) 9g
炙甘草 zhi gan cao (Glycyrrhizae Melle Tosta, Radix) 6g

3^rd consultation: 20 bags of the above prescription were taken, the abdominal distention was essentially resolved, and aside from some lurking flank pain, all other symptoms were gone. The pulse had more strength than before, energy was abundant, and the patient was discharged from the hospital and returned to his job in Sichuan province. He was advised to continue taking Ban Xia Xie Xin Tang and Bu Zhong Yi Qi Wan for a short period of time to assist with his recuperation.

Commentary: The treatment in this case of chronic hepatitis differed from most common methods. The patient had been ill for six years, with symptoms of abdominal distention, anorexia, borborygmus, diarrhea, deficient, slow, and weak pulses, enlarged tongue, etc. Even though flank pain was present, use of  “soothing the Liver and rectifying the qi” method, as in Chai Hu Shu Gan San (Bupleurum Liver-Coursing Powder), was ineffective. This shows that it was not a case of Liver and Stomach disharmony, but rather of Spleen and Stomach Yang Deficiency. Initially, Ban Xia Xie Xin Tang, “pungent opening, bitter downbearing”, was used, and after one month the anorexia, belching, borborygmus, and other symptoms were greatly reduced. However, the abdominal distention remained, and the six pulses were as before, showing that the Spleen yang was severely debilitated. Shang Han Lun states, “After sweating, abdominal distention and bloating, Hou Po Sheng Jiang Ban Xia Gan Cao Ren Shen Tang commands.” “After sweating” refers to an etiology whereby sweating results in damage to the Spleen yang. Even though this case was not the result of [improper] sweating, because the condition had existed for six years there was significant debilitation of Spleen yang, with stubborn abdominal distention, and deficient, slow, and weak pulses. Although the etiology is different, the syndrome is similar. Therefore, after switching to Hou Po Sheng Jiang Ban Xia Gan Cao Ren Shen Tang (Magnolia Bark, Fresh Ginger, Pinellia, Licorice, and Ginseng Decoction) for 20-plus bags, significant results were obtained.

Source: From Yue Mei-Zhong’s Case Record Collection (Yue Mei Zhong Yi An Ji) 《岳美中医案集》, People’s Medical Publishing House, 1978.

Commentary by Dr. Huang Huang:

This case began with the use of Ban Xia Xie Xin Tang (Pinellia Heart-Draining Decoction), bitter and pungent to free and descend and eliminate glomus, followed by Hou Po Sheng Jiang Ban Xia Gan Cao Ren Shen Tang (Magnolia Bark, Fresh Ginger, Pinellia, Licorice, and Ginseng Decoction) to warm the Stomach yang and eliminate fullness. The treatment followed an orderly progression, and its effectiveness is quite believable. Ban Xia Xie Xin Tang traditionally treats nausea, diarrhea, and glomus, with most patients presenting with epigastric glomus oppression and distending pain that feels worse with palpation, as well as nausea and vomiting, borborygmus and diarrhea, anorexia, vexation heat, insomnia, and often a yellow and greasy tongue coating. Hou po traditionally eliminates distention and fullness, and Hou Po Sheng Jiang Ban Xia Gan Cao Ren Shen Tang is composed of Ban Xia Xie Xin Tang with the omission of huang lian, huang qin, and da zao, and the addition of hou po. Both formulas contain ginseng, pinellia, ginger, and licorice, and in this case while dispersion of glomus and elimination of fullness followed a specific order, warming the middle and harmonizing the stomach was present from beginning to end. (From Yi An Zhu Du 《医案助读》 2001: 314)

Translated by: Greg Livingston

Original Case by: Ye Tian-Shi (叶天士)

[Patient] Wang (63) was overworked and had anger, which damaged the yang. There was qi counterflow and blood constraint leading to pain. There was focal distention and sloppy stools. This was wind and wood rebelling against earth. Previous formulas were ineffective.  A formula that unblocks and boosts the yang ming and jue yin was given.

Prescription: dà bàn xià tang (Major Pinellia Decoction) plus

táo rén (peach kernel, persica)
bǎi zǐ rén (Platycladi Semen)
dāng guī (Angelicae sinensis Radix)
shēng jiāng (fresh ginger rhizome)
dà zǎo (Jujubae Fructus)

Commentary: dà bàn xià tang (Major Pinellia Decoction) contains zhì bàn xià (Pinelliae Rhizoma preparatum), rén shēn (Ginseng Radix), and honey 9-15g.

Translated by: Jason Blalack

Original Chinese: 王（六三） 劳怒伤阳。气逆血郁致痛。痞胀便溏。风木侮土。前方既效。与通补阳明厥阴。（肝犯胃气逆血郁） 大半夏汤加桃仁柏仁当归姜枣汤法。

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》.

[Patient] Lu (24) [had suffered] damage from constraint. The sinews were distended and there was heart (epigastric) pain.

gōu téng (Uncariae Ramulus cum Uncis)
xiāng fù (Cyperi Rhizoma)
yù jīn (Curcuma tuber)
cì jí lí (Tribuli Fructus)
mǔ dān pí (Moutan Cortex)
bò hé (Menthae haplocalycis Herba)
chén pí (Citri reticulatae Pericarpium)
fú líng (Poria)

Translated by: Jason Blalack

Original Chinese: 陆（二四） 郁伤。筋胀心痛。钩藤 生香附 郁金 白蒺藜 丹皮 薄荷 广皮 茯苓

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》.