[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…

[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.

[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.

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》.

The patient had anger with Liver constraint. [In addition,] thought and preoccupation had damaged the Spleen. There was a yellow complexion, choppy pulse, and (s)he was [often] awake with an inability to go to sleep. Ancestor Xue’s method of treatment was used.

rén shēn (Ginseng Radix)
huáng qí (Astragali Radix),
shú bái zhú (steamed?? Atractylodis macrocephalae Rhizoma)
fú shén (Poriae Sclerotium pararadicis)
dà zǎo (Jujubae Fructus)
lóng yǎn ròu (Longan Arillus)
dāng guī (Angelicae sinensis Radix)
zhì gān cǎo (prepared licorice root)
hēi shān zhī zǐ (black gardenia)
mǔ dān pí (Moutan Cortex)
yuǎn zhì (Polygalae Radix)

Translated by: Jason Blalack

Original Chinese: 某 恼怒肝郁。思虑脾伤。面黄脉涩。寤不成寐。宗薛氏法治之。人参 黄 熟于术 茯神 枣仁 桂圆肉 当归 炙草 黑山栀 丹皮 远志

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: Ancestor Xue refers to Xue Ji (薛己) and this formula is based on gui pi tang (Restore the Spleen Decoction) from Categorized Essentials for Normalizing the Structure (Zhèng tǐ lèi yào). This case is interesting because this is a tonifying and fairly cloying formula with very little moving medicinals that treats a pattern that started with Liver constraint. Ye decides to treat the result of the constraint (damage to the Spleen) first and foremost. I think this demonstrates Ye’s desire for getting the patient to sleep and treating the key mechanism causing the insomnia, the Spleen. Although Ye is known for focusing in on the underlying mechanism, even at times completely ignoring branch herbs in favor of addressing the core pattern, this shows that he is flexible, not always treating the initial “cause”. Comments?

* Anyone have any further insight on translating this, 寤不成寐.

** Anyone have any further insight on this medicinal name, 熟于术.

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》.

Shen was 43 years old with a deficient and choppy pulse. The emotions had become unsmooth and the Liver and Spleen qi and blood were excessively constrained. This had persisted without relief for half a year. Giving a drastic formula was difficult [not appropriate]. Therefore giving the official prescription, Rambling Powder (xiäo yáo sân) with Tonify the Middle to Augment the Qi Decoction (bû zhöng yì qì täng) was decided upon.

Original Chinese: 沈（四三） 脉虚涩。情怀失畅。肝脾气血多郁。半载不愈。难任峻剂。议以局方逍遥散。兼服补中益气。

** Other Rambling Powder (xiäo yáo sân) Ye Tian-Shi constraint case studies .