[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.

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》.

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 not smooth (?). 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)
mài yá (Hordei Fructus germinatus)
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 depression 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.

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”

The wife of minister Jin Junhui from Anhui [suffered] from severe distension of the chest and abdomen, which caused painful knotting and lumps. The legs and feet were distended and swollen, there was internal heat with dryness of the mouth, and she was mentally tired and lacked strength. The momentum of this disorder was towards the development of drum-like abdominal distension and previous treatment had been unsuccessful. I examined her pulse, which was deep, thin and slippery. Both qi and yin fluids were deficient. Liver yang ascended carrying damp-heat [with it] to obstruct the qi dynamic and scorch the yin fluids so that their irrigating [function] had been lost. The necessary treatment [strategy] is to build up and nourish qi and yin fluids, combined with clearing the Liver and transforming dampness. Such a strategy is bound to yield results.

Ginseng Radix (rén shën) 2.4g
Panacis quinquefolii Radix (xï yáng shën) 4.5g
Ophiopogonis Radix (mài mén döng) 9g
Poria (fú líng) 12g
Benincasae Semen (döng guä zî) 9g
Benincasae Exocarpium (döng guä pí) 9g
Kochiae Fructus (dì fü zî) 9g
Coptidis Rhizoma (huáng lián) 0.3g
Evodiae Fructus (wú zhü yú) 0.3g
Dendrobii Herba (shí hú) 9g
Gigeriae galli Endothelium corneum (jï nèi jïn) 9g
fresh Bambusae Caulis in taeniam (zhú rú) 3g
Citri reticulatae Exocarpium rubrum (jú hóng) 3g
fresh and prepared Setariae (Oryzae)Fructus germinatus (gû yá) 12g each
Paeoniae Radix alba (bái sháo) 4.5g
Toosendan Fructus (chuän liàn zî) 4.5g

After 12 prescriptions of the above formula the condition was cured.

Commentary: This case byFei Sheng-Fu matches the pathology of case 5 (cough & panting), with the exception that here the hyperactivity of Liver yang is due to Liver fire resultant from constraint rather than Liver yang. Hence, the strategy requires regulating Liver qi as well as clearing Liver fire. 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.

** Translated by: Volker Scheid

At the onset of the illness there was numbness and tingling, the tongue was stiff, the sinews were hoisted (tight?) and back of the head was painful. There was also phlegm obstruction in the throat. This is Liver wind ascending and guiding. This certainly is caused from constraint and clumping of the  emotions.

Saigae tataricae Cornu (líng yáng jiâo)
Forsythiae Semen (lián qiáo xïn)
Fresh Rehmanniae Radix (xiān shëng dì huáng)
Scrophulariae Radix (xuán shën)
Acori tatarinowii Rhizoma (shí chäng pû)
Curcumae Radix juice (yù jïn zhī)

Original Chinese: 某 初起左边麻木。舌强。筋吊脑后痛。痰阻咽喉。此系肝风上引。必由情怀郁勃所致。羚羊角 连翘心 鲜生地 元参 石菖蒲 郁金汁

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

Translation Discussion:

1) 郁勃 (yu bo) – 勃 (bo) - by itself  means vigorous, flourishing, thriving, or abrupt or sudden. I originally thought this sudden/abrupt meaning was important due to the nature of the case. However, I am not sure it is likely that there was a sudden constraint of emotions that caused this problem. It should be noted that historically (non-medical) it (勃) has been used as a compound (郁勃) with various meanings, one of them being, “constraint, clumping, and congestion (郁结壅塞).” Interestingly,  in this usage (this constraint and clumping of the emotions) is compared to a wild animal trapped in a house grabbing, scratching, colliding into the walls, unable to find its way out. Other thoughts?

2) I think that this “guiding (引)”, has the meaning of taking phlegm, fire etc. upward with the ascending Liver wind. Do others have a different opinion?

3) 筋吊 – This 吊 (diao) means to hang, hoisten, lift up, or even to drop, fall, fall down or descend. Therefore here, the sinews may be considered slackened, however due to the pain, the stiff tongue, and nature of many strokes I went with a idea of tenseness. What do others think?

Case from Fei Sheng-Fu (费绳甫）

Mr. Wu from northern Jiangsu [suffered] from Liver wood encroaching the Spleen until only it’s [qi] was present in the abdomen  致成單腹. The abdomen was distended like a drum, the umbilicus protruded outward, the tendons were blue. The back was normal but the waist full. This constituted a dangerous pattern. In this situation [the appropriate strategy] is to curb wood and support earth, unblock with warming [medicinals], and leach out dampness. Prescription was:

** Translated by: Volker Scheid

Volker’s Commentary: Read together with the previous case, this record from FSF’s case histories further illustrates the importance of the middle burner at the centre of the qi dynamic and of fluid metabolism. The situation is described as dangerous because both the qi and yang of the middle burner have collapsed. Movement and transformation have come to a standstill, hence the position of earth is seized by wood. This is visibly manifest in the protruding umbilicus, representing Spleen earth, which is pushed upwards by Liver qi. The treatment therefore is aimed directly and only at the middle burner employing a combined strategy of warming in order to reignite transformative process, acrid downward moving in order to break up stasis, and leaching out of excess dampness from the middle burner. The core formula used for this purpose is modified Bolster the Spleen Drink (shí pí yîn), which in turn builds on True Warrior Decoction (zhën wû täng) and Three-Substance Decoction with Magnolia Bark (hòu pò sän wù täng). Even here, however, FSF takes account of the role and relation between Liver and Lungs, qi and blood. This explains his use of Angelicae sinensis Radix (däng guï), on the one hand, and of Benincasae Semen (döng guä zî) and Coicis Semen (yì yî rén) on the other, which together with Amomi Fructus rotundus (bái dòu kòu) and Magnoliae officinalis Cortex (hòu pò) suggest the intention of Three-Seed Decoction (sän rén täng).

Thus, like his grandfather, FSF skillfully interweaves cold damage and warm pathogen strategies to realize the principles of harmonization and moderation even in a strongly warming and draining prescription.”