[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] 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》.

[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.

[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.

[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》.

The patient presented with a chief complaint of chronic migraines, which were preceded by a sensation of heat rising to the head. She also felt warm overall, had red eyes that could easily become swollen with yellow discharge, painful and bleeding gums, difficulty falling asleep and would wake up with her mind racing, a long history of menstrual cramps and pain with clots, alternating bowels (constipation and loose) that had a tendency towards a strong smell that were occasionally sticky. Her abdomen was sore to the touch, her pulse was deep, wiry, and jumpy, and her tongue had a yellow coat.

She had tried many formulas in the past including tian ma gou teng yin as well as bitter, cold, descending and purging methods with no success. This is a pattern of fire due to Liver constraint. The treatment method was to follow the Inner Classic’s “when there is fire from constraint discharge it (火郁发之)”

mǔ dān pí (Moutan Cortex)        9
gōu téng (Uncariae Ramulus cum Uncis)               12
sāng yè (Mori Folium)                    6
lu dòu yī (Glycinis Testa)                               6
bò hé (Menthae haplocalycis Herba)       6
màn jīng zǐ (Viticis Fructus)          12
jú huā (Chrysanthemi Flos)         9
zhī zǐ (Gardeniae Fructus)             9
gǎo běn (Ligustici Rhizoma)         6
cì jí lí (Tribuli Fructus)     9

1 bag=2days.

Location: Boulder, Colorado

Commentary: This formula eliminated all migraines, which was the first time this had occurred. Also her sleep and many other heat related symptoms improved. After stopping the herbs a sense of a migraine would occasionally arise that could be headed off quickly after taking the herbs.

Although I like this formula for the headaches and addressing the basic pathodynamic, I do think there is a deeper level to treat to attempt to “cure” the problem. The patient has expressed interest in pursuing a deeper treatment, and if anything interesting arises I will post the progress.

Constraint damaging the Heart and Spleen nutritive aspect with internal heat

Ji was a 69-year-old elderly person whose emotions were unwell (felt down). When there is constraint then lesser fire transforms into vigorous fire. The appetite was intact but the gastric cavity was uncomfortable. The mouth and tongue were eroded and putrid.

Diagnosis: This was damage to the Heart and Spleen nutritive aspect with wood fire scorching and removing the essence by force.

The muscles were becoming smaller day by day. Only when the patient became joyous would the overall condition begin to lighten, indicating that the internal arising of heat from constraint  could potentially be balanced. However implementing a method of clearing fire with bitter cold medicinals is wrong for regulating the emotions that are  internally causing heat from constraint.

Prescription:

jīn chāi shí hú (Dendrobium nobile)
lián qiáo xīn (Forsythiae Semen)
chǎo mǔ dān pí (dry-fried Moutan Cortex)
shuāng sāng yè (frost mulberry leaves)
chuān bèi mǔ (Fritillariae cirrhosae Bulbus)
fú líng (Poria)

Following this, Ye used the method of nourishing the nutritive aspect of the Heart and Spleen, while slightly assisted by a bitter and descending method.

rén shēn (Ginseng Radix)
huáng lián (Coptidis Rhizoma)
chǎo mǔ dān pí (dry-fried Moutan Cortex)
bái sháo (Paeoniae Radix alba)
fu xiao mai (Tritici Fructus levis)
fú shén (Poriae Sclerotium pararadicis)

Translated by: Jason Blalack

Original Chinese: 季（六九） 老年情志不适。郁则少火变壮火。知饥。脘中不爽。口舌糜腐。心脾营损。木火劫烁精华。肌肉日消。惟怡悦开爽。内起郁热可平。但执清火苦寒。非调情志内因郁 热矣。（郁损心脾营内热）金石斛 连翘心 炒丹皮 经霜桑叶 川贝 茯苓 – 接服养心脾之营。少佐苦降法。 人参 川连 炒丹皮 生白芍 小麦 茯神

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》.

Wu (40 years old) was exhausted and angry which led to damage. The disease was located in the Liver and Spleen. There was chronic brain leakage  and the bone marrow has been secretly damaged. The patient was to take [the below prescription] that resolves constraint for a short time, and then continue with a diffusing and tonifying one.

gōu téng (Uncariae Ramulus cum Uncis)
shēng xiāng fù (unprepared cyperus)
mǔ dān pí (Moutan Cortex)
sāng yè (white mulberry leaf)
shén qū (medicated leaven)
bái sháo (Paeoniae Radix alba)
fú líng (Poria)
chén pí (Citri reticulatae Pericarpium)

Translated by: Jason Blalack

Original Chinese: 吴（四十） 劳倦嗔怒致伤。病在肝脾。久有脑泄。髓脂暗损。暂以解郁。继当宣补。钩藤 生香附 丹皮 桑叶 神曲 白芍 茯苓 广皮

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: Here is chronic condition with deep deficiency which resolves constraint before tonifying.

** Brain leakage (above) refers to deep source nasal congestion. Notice that the prescription does not contain any medicinals to directly address this symptom. Ye resolves the problem by focusing on the core underlying mechanism.

Hu, 46 years of age, had been weeping due to grief. The disease arose from internally generated emotions, which led to constraint. There was a physical manifestation in the area below the heart  that was gradually getting larger with a hardness upon palpation.

Treatment principle: A bitter-acrid and downward-draining method was used. First must treat the qi clumping.

Diagnosis:  (Focal distention and clumping below the heart).

Coptidis Rhizoma (huáng lián)
Zingiberis Rhizoma (gān jiäng)
Pinelliae Rhizoma preparatum (zhì bàn xià)
Zingiberis Rhizomatis Succus (jiāng zhī) (ginger juice)
Poria (fú líng)
poria with cutis (lián pí fú líng)
Trichosanthis Fructus (guā lóu)

Commentary: poria with cutis (lián pí fú líng)  “While it still strengthens the Spleen, its ability to leach out dampness and facilitate water is enhanced, which makes it especially suitable for water-damp edema due to weakness in the transportive function of the Spleen (Clavey and Bensky, p.270).”

Translated by: Jason Blalack

Original Chinese: 胡（四六） 悲泣。乃情怀内起之病。病生于郁。形象渐大。按之坚硬。正在心下。用苦辛泄降。先从气结治。（心下痞结）川连 干姜 半夏 姜汁 茯苓 连皮栝蒌

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》.

There was gastric cavity pain that had already ceased. Currently there was a sour taste in the mouth.  Actually this is Liver constraint.

Gold Dendrobium (jïn shí hú)
Black gardenia (hëi shän zhï zî)
Moutan Cortex (mû dän pí)
Pinelliae massa fermentata (bàn xià qü)
Citri reticulatae Exocarpium rubrum (jú hóng)
Eriobotryae Folium (pí pa yè)

Original Chinese: 某 脘痛已止。味酸。乃肝郁也。（肝郁）金石斛 黑山栀 丹皮 半夏曲 橘红 枇杷叶

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》.

Translated by: Jason Blalack