(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.

[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.

Case By: Fei Sheng-Fu (费绳甫)

Mr Xu Zhongxiu from Zhenjiang [suffered] from swelling of the feet and legs as well as of the testicles, abdominal distension, coughing, facial edema, and reduced urination. He came to me for examination and treatment because treatment so far had not worked. His pulse was floating and wiry in the right cun position indicating water swelling. The Lungs were unable to afford regular passage through the water ways towards the Bladder so that water qi flowed over transversely into the spaces between the skin and flesh. I considered Yu’s treatment [strategy] for flooding, which relies on first dredging [the water pathways] so that [water qi] can flow downward. Once the water has a way to exit [the body] it will no longer have cause to flow over [into the body].

mole cricket (lóu gū) 9g
Tetrapanacis Medulla (töng câo) 9g
Kochiae Fructus (dì fü zî) 9g
Acanthopanacis Cortex (wû jiä pí) 6g
Poriae Cutis (fú líng pí) 12g
Benincasae Exocarpium (döng guä pí)  12g
Armeniacae Semen (xìng rén) 9g
Fritillariae cirrhosae Bulbus (chuän bèi mû) 9g
Citri reticulatae Exocarpium rubrum (jú hóng) 3g
Junci Medulla (dëng xïn câo) 3 chi

Commentary: Whereas in the previous two cases (#6 and #5) obstruction of Lung qi was due to Liver yang or fire, here it is due to obstruction of Lung qi by dampness. No longer moving downward it spills into the body, including the Liver channel (the testes). The treatment strategy relies of draining dampness from the Lungs via the Three Heater with a combination of Three-Seed Decoction (sän rén täng) and Five-Peel Drink (wû pí yîn).

Translated by: Volker Scheid

For more reading on Fei Bo-Xiong, please look for Volker’s upcoming book from Eastland Press. Its working title is, “Menge Medicine,  Vol. 1, Fei Boxiong’s Refined Medicine Remembered with Commentaries and Fei Family Case Histories”

A 35 year-old female on Wednesday, March 31, 2010 presented with a chief complaint of cough and a hot tongue.

The previous day she had a runny nose and felt like she was getting a cold. She also reported that both of her kids had strep throat, which in the past she would get a couple times a year.

Currently she had a dull and achy sore throat. Her cough was mildly productive with congealed thick discolored phlegm. She felt like she was breathing fire, felt hot, irritable, had a dry mouth, no sweat, no chills, and had some eyelid twitching. Her bowels were not moving and when they did they were black and hard. She had a sensation of abdominal bloating and had no appetite.

Upon further inquiry she reported having some dental work on 3/24/10 where she was given a course of Clindamycin 300mg TID, Flagyl 500mg q 6 hours taken with Phenergan, and Diflucan due to some infectious complications. She noticed a red dry rash appear on the dorsal part of her hands after taking these meds.

Tongue: very red body with no coat

Pulse: Slippery and rapid

Diagnosis: Heat in the qi and nutritive level, clumping of the stools.

Treatment principles: Open the bowels, facilitate resolution of heat via the urine, vent the pathogen from the nutritive aspect, and enrich the fluids.

Prescription:

dà huáng (Rhei Radix et Rhizoma) (add) 9g  
máng xiäo (Natrii Sulfas) (add)  6g    
chì sháo (Paeoniae Radix rubra) 6g                             
mǔ dān pí (Moutan Cortex) 6g    
shuǐ niú jiǎo (water buffalo horn) 15g                          
shēng dì huáng (Rehmannia root, Chinese foxglove root) 15g    
dàn zhú yè (Lophateri Herba) 6g   
lián qiào (Forsythiae Fructus) 15g    
dēng xīn cǎo (Junci Medulla) 1g    
huáng lián (Coptidis Rhizoma) 2g

Cooking Instructions: 1 bag=2 days. Cook time =45 minutes. Taken between  meals 2-3 times a day.

Outcome: After taking two bags of herbs all of her symptoms were resolved except for a slightly warm feeling on the tongue and slight thirst. We then switched to a constitutional formula. Note: she stopped all pharmaceuticals after initial consultation.

Commentary: Although many consider antibiotics and other similar pharmaceuticals as cold one must always observe what is happening in the body and treat what they see. In this situation the multiple pharmaceuticals seemed to have pushed the heat pathogen deep into the qi and nutritive level. One clue was the rash on the hands, even though this was “caused by the pharmaceuticals.” An aggressive approach was needed to evict the pathogen and prevent damage to the yin and possibly entering the pericardium. Of note, there were no herbs in the formula to directly treat the chief complaint of the cough. Although this seemed to be the most pressing sign to the patient, there was clearly a bigger fish to fry.

Questions or comments?

Location: Boulder, Colorado

Yang, a two and five month-year-old girl, presented with the chief complaint of cough, that  had been going on for one month. There was sometimes white and sometimes yellow phlegm, nasal congestion, profuse sweating, fear of wind, reduced food intake, no thirst, and her bowels were not dry. She tried many Chinese and Western treatments without success. Her tongue body was normal and there was a white coat. Her pulse was deep and rapid.

Diagnosis: cough (wind pathogen invading the Lungs, which has started to slightly transform to heat).

Prescription: modified guì zhī tāng (Cinnamon Twig Decoction)

guì zhī (Cinnamomi Ramulus) 20g
chì sháo (Paeoniae Radix rubra) 15g
shēng jiāng (fresh ginger rhizome) 20g
dà zǎo (Jujubae Fructus) 15g
zhì gān cǎo (prepared licorice root) 15g
zǐ sū gěng (Perillae Caulis) 15g
qián hú (Peucedani Radix) 10g
fáng fēng (Saposhnikoviae Radix) 10
xì xīn (asarum, Chinese wild ginger) 10g
cāng ěr zǐ (Xanthii Fructus) 8g
sāng yè (Mori Folium) 15g
shén qū (medicated leaven) 20g

She was given three packets to take over three days.

Follow-up visit: the cough had greatly reduced, the sweat was lessened, and appetite was back to normal, but there was still some nasal congestion with clear runny mucus. The tongue coat was white, and the pulse was deep and not rapid. The previous formula, minus sāng yè (white mulberry leaf) and shén qū (medicated leaven), was given.

Prescription:

guì zhī (Cinnamomi Ramulus) 20g
chì sháo (Paeoniae Radix rubra) 20g
shēng jiāng (fresh ginger rhizome) 30g
dà zǎo (Jujubae Fructus) 15g
zhì gān cǎo (prepared licorice root) 15g
zǐ sū gěng (Perillae Caulis) 15g
qián hú (Peucedani Radix) 15g
fáng fēng (Saposhnikoviae Radix) 10
xì xīn (asarum, Chinese wild ginger) 10g
cāng ěr zǐ (Xanthii Fructus) 8g

She was given two packets to take over three days and she completely covered.

Commentary: guì zhï täng (Cinnamon Twig Decoction) is a formula that treats taiyang wind strike and is Zhang Zhong-Jing’s foremost harmonizing formula. It is able to dispel wind and resolve the exterior, harmonize the nutritive and protective, harmonize the yin and yang, and harmonize the exterior and interior.

This is a case of wind cough, but the pulse was deep and rapid and the cough’s mucus was yellow. The dynamic had already moved to the interior and transformed to heat. Therefore a modified guì zhï täng (Cinnamon Twig Decoction) was given. zǐ sū gěng (Perillae Caulis), qián hú (Peucedani Radix), and fáng fēng (Saposhnikoviae Radix) were added to dispel wind, resolve the exterior, diffuse the Lungs, and stop cough. Xì xīn (asarum, Chinese wild ginger) esters the interior to track down the pathogen as well as diffuse the nasal orifices providing assistance to cāng ěr zǐ (Xanthii Fructus). Sāng yè (Mori Folium) was added to clear the Lungs and release heat. Shén qū (medicated leaven) opens the stomach and increases food intake.

Source: <经方医案系列>

Translated by: Jason Blalack

Case by Fei Sheng-Fu (费绳甫）

The wife of Mr. Zhu Zhushi from Zhejiang was ill with cough and panting so that it was difficult for her to lie down at night. Her heart was irritable and vexed, she had a stifling sensation in the upper abdomen, and the mouth was greasy with little intake of either food or drink. The face was puffy and the legs swollen, and at night she could not sleep. The momentum [of this disorders] was extremely serious. When I examined her the pulse came overflowing, big, wiry and rapid.

[Diagnosis & Pathodynamic]: Both qi and yin fluids were deficient so that Liver yang ascended excessively. This combined with habitually steaming phlegm dampness blocking Lungs and Stomach so that clarifying and directing downward had no force.

[Treatment Principle]: The [appropriate] strategy was to build and nourish qi and yin fluids, clear the Liver and transform phlegm.

[Prescription]:

Ginseng Radix (rén shën) 3g
Panacis quinquefolii Radix (xï yáng shën) 4.5g
Eucommiae Cortex (dù zhòng) 9g
Poriae Sclerotium pararadicis (fú shén) 6g
Fritillariae cirrhosae Bulbus (chuän bèi mû) 9g
Aurantii Fructus (zhî ké) 3g
Trichosanthis Pericarpium (guä lóu pí) 9g
Ligustri lucidi Fructus (nu zhën zî) 9g
Armeniacae Semen (xìng rén) 9g
Paeoniae Radix alba (bái sháo) 4.5g
Ostreae Concha (mû lì) 12g
Fossilia Dentis Mastodi (lóng chî) 6g
Benincasae Semen (döng guä zî) 12g
Bambusae Caulis in taeniam (zhú rú) 3g

After two prescriptions the momentum of the excessively ascending Liver yang was gradually being pacified, the heart irritability and vexation had stopped, and she was able to sleep at night. I continued the previous formula with the addition of Dendrobii Herba (shí hú) 9g, five slices of pear, and five pieces of Eleocharitis Rhizoma (bí qì). As the bowel moved [regularly] phlegm was being drained from below so that Stomach and Lungs clarified and directed downward [once more], and wheezing and coughing were pacified, and she could lie down at night. The appetite gradually returned and the facial swelling and swelling of the legs subsided. I continued the formula with the addition of mao yan (毛燕), regulating [the condition] for half a month until she was cured.

** Translated by: Volker Scheid

Volker’s Commentary: This case by FSF does not correspond to any of his own or FBX’s manifestation patterns for swelling and edema. It thereby demonstrates that these patterns, where they are made explicit, constitute a general assessment of the terrain from which pathological processes can be deduced and not an attempt to provide prescriptive protocols. Here, the overflowing rapid pulse when related to the symptom pattern indicates the pathological process described by FSF. Hence, while facilitating the clearing and downward directing functions of Lungs and Stomach is necessary to treat the manifestations, root treatment focuses on pacifying hyperactive Liver yang. 

Jason’s Commentary: This 毛燕 (mao yan) is a type of bird’s nest (燕窝, yan wo) that is of a relatively inferior quality. It is grey colored and contains many feathers.