by: Jason Blalack

In Chinese medicine, our understanding of technical terms shapes our clinical picture and ultimately how we treat. One such term that recently peaked my interest was the term 烦 (fan), translated as vexation (Wiseman) or irritability (Eastland Press). These translations seem reasonable since modern dictionaries define it as:

1. vexed, irritated; annoyed, terribly upset, worried mood, or
2. to trouble

However sometimes our assumed meaning, based on a translation or modern understanding, is different than how it is used in various Chinese medicine contexts, especially historically.

Thus 烦 (fan), can have very different meanings depending on the context it is used. I would like to present a brief analysis of how it is used in the Discussion of Cold Damage (Shang Han Lun), in which it occurs around 90 times. It is found in numerous compounds, which help define it, such as Heart irritability (心烦 xin fan), internal irritability (内烦 nei fan), irritability and restlessness (烦躁 fan zao), irritability thirst (烦渴 fan ke), restlessness and irritability (躁烦 zao fan), vexing pain (疼烦teng fang), among many others.[i] Understanding how it was classically used helps us understand its meaning today.

Hence, the understanding of these terms, and the passages that they are contained in, have direct clinical relevance today because they make up our core understanding of key symptomatology for patterns such as shao yin with Kidney yang deficiency and formulas such as xiao chai hu tang (Minor Bupleurum Decoction).

Understanding these terms does not come without complication. As with many classical texts there is controversy. Some choose to understand the term more literally, some with a more modern slant, others strive to look at the time period’s understanding and pick apart the context. Let us look at a few perspectives from the Discussion of Cold Damage, which should be noted, is just one of many.

In general, Zhang used irritability (烦 fan) to mean:

1. Heart irritability (心烦 xin fan) or irritability and restlessness (烦躁 fan zao)
2. To show that a symptom was of a serious nature
3. Nausea

1. Heart irritability (心烦 xin fan) or irritability and restlessness (烦躁 fan zao) in the Heart is the most general type of usage for 烦 (fan) . According to mainstream view this relates to symptoms related to the essence-spirit, not unlike how we understand the terms in English. Consider the line 24:

When in Greater yang disease, the patient initially had taken gui zhi tang, but instead [becomes] fan (烦) and [the condition] is unresolved…”

Looking at how fan (烦) was used in Han dynasty gives an added perspective of the term. For example in the shuo wen jie zi (the first Chinese dictionary, complied by Xu Shen, 121 A.D.) it defines 烦 (fan) as a “heat headache.” Discussion of Cold Damage commentators such as Hao Wan-Shan’s[ii] emphasize the importance of this symptom. It is a “hot type headache, where there is heat and also pain.” Hence this 烦 (fan) here has the additional meaning of heat irritability (烦热 fan re) or even just feverishness (发热 fa re). Actually one may interpret this above passage (line 24) as just having an increased fever. Other lines with a similar usage include: 38, 46, 102, 107, 118, and 264.

Consequently, many believe that this aspect of heat is an important component of understanding the term irritability (烦 fan) in a medical context and if we do not see heat, then it is not irritability. In addition irritability in the heart (心烦 xin fan) will also need to have this heat sensation which is especially present in the chest. This may be an objective or subjective feeling.

2. 烦 (fan) used to express the seriousness of a symptom. For example, in line 156, it says “…give xie xin tang. If the focal distention is unresolved and the person is thirsty, has a severe dry mouth (口燥烦 kou zao fan)…”. Some textbooks tend to interpret this as “… and the person is thirsty, has a dry mouth, has vexation….”

Line 240 begins with “病人烦热 (bing ren fan ren) …” Although some textbooks understand this as “When the patient has heat vexation” others interpret this as “When the patient has severe heat…”

Other instances of this type of usage are lines 174, 175, and various passages in the Essentials from the Golden Cabinet (see endnote[iii]). Hence we get dramatically different interpretations depending on how one understands this 烦 (fan).

3. Nausea: Modern day Chinese medicine uses 恶心 (e xin) for nausea, however this technical term was not used in the Discussion of Cold Damage, or the Inner Classic. Zhang Zhong-Jing instead used phrases such as 欲吐不吐 (yu tu bu tu) line 282 or 温温欲吐 (wen wen yu tu) line 324 among others, to express nausea.

Commenters such as Li Xinji believe that 心烦 (xin fan) refers to nausea in some instances. His argument is that 烦 (fan) according to historical record has this meaning of  “entangled disturbance (搅扰纠结 jiao rao jiu jie)”, with commentary explaining this as being  a “frequent disturbance”. Heart (心 xin) in Chinese medicine often refers to the location below the heart or stomach duct.  Hence this is a “churning disturbance in the stomach duct region”, hence nausea.

For example, in Line 96, which is a key passage for xiao chai hu tang (Minor Bupleurum Decoction) says,

When in cold damage [that has lasted for] five or six days [or] wind strike, [there is] alternating chills and fever, and [the patient] has a sense of discomfort and fullness in the chest and ribs, being dejected with no desire to eat, 烦心喜呕 (fan xin xi ou) 胸中烦而不呕 (xiong zhong fan er bu ou).”

Here 心烦 (xin fan) is often interpreted as irritability and restless within the Heart. However Li Xinji points out that if we look at what comes before and after this term, “no desire to eat”, 心烦 (xin fan), “likes to vomit” it makes sense that this actually refers to nausea. He further says, this 心烦 (xin fan) has nothing to do with spirit-light symptoms of the Heart (神明之心 shen ming zhi xin).

Also notice line 326, “…pain and heat in the HEART (心中疼热 xin zhong teng re), hunger with no desire to eat…” – This “heart” here also refers to the stomach.

Hence looking back at line 96, the next series of characters are “irritability in the chest without vomiting (胸中烦而不呕 xiong zhong fan er bu ou).” This 胸中烦 (xiong zhong fan) has the meaning of irritability and restless within the heart (chest). So the whole passage is:

When in cold damage [that has lasted for] five or six days [or] wind strike, [there is] alternating chills and fever, and [the patient] has a sense of discomfort and fullness in the chest and ribs, being dejected with no desire to eat, nausea (心烦 xin fan) with a tendency to vomit, or [there is] irritability and restless within the heart without vomiting, or thirst…”

There are other instances where 烦 (fan) and 心烦 (xin fan) refer to nausea, such as in lines 282, 315, and 355. Notice how the surrounding symptoms are specifically gastrointestinal symptoms such as desire to vomit, dry retching etc.. Understanding things in this manner explains many contradictions in passages such as in line 282.

For example line 282 discusses a shao yin disease with Kidney yang deficiency. One of the symptoms mentioned is 心烦 (xin fan) which is often understood as irritability and restless in the heart. However if one looks at the surrounding symptoms, as we did above, we see;

In shao yin disease, [there is] a desire to vomit, but no vomiting ( or: with an inability to vomit), nausea (心烦 xin fan), and a desire to sleep…”

Does “irritability in the heart (心烦 xin fan)” a heat symptom, make sense when there is lower burner deficiency and cold? Some commentators justify this by explaining the irritability in the heart  as a “contradictory” symptom caused by the “lower burner struggling with exuberant yin cold which is pushed upward, where it harasses the Heart.” In my opinion, a more likely explanation is the same pathodynamic proposed for the “desire to vomit”, which is, turbid yin counterflowing upward, causing disharmony of the Stomach qi that disturbs the normal downbearing.

In summary, the ideas presented above are just one opinion, as there are many valid interpretations. They are presented to hopefully widen one’s clinical gaze. No one knows for sure of Zhang Zhong-Jing exact intentions but we can try these ideas out in the clinic and see what makes the most sense.

As a comparison it is interesting to look at a modern Chinese medicine Chinese language dictionary’s definitions for 烦 (fan):

1. Heat (热 re)
2. Irritability and restlessness (烦躁 fan zao)
3. Internal heat irritability in the Heart (内热心烦 nei re xin fan)

It further defines 心烦 (xin fan) as “irritability heat and oppression in the Heart (心中烦热郁闷 xin zhong fan re yu men).”

These entries in and of themselves are a bit circular in definition and hard to grasp, which is what led me on this quest to begin with. As we have seen above, these terms have a large variety of meanings that are not as straight forward as some may like.

Throughout history people use terms in different ways, figuring out the true meaning is never easy. Therefore this essay probably brings up more questions than gives answers, but that is the nature of Chinese medicine. Becoming comfortable with contradictions and varying interpretations and how to make use of them is a useful clinical skill.

For further reference, here are 11 translations for the term 心烦 (xin fan):

• Restless feelings and agitation in the chest
• Anxious feeling or restlessness in the chest
• Anxious restlessness
• Heat in the chest and suffocation (usually translated as ‘anxious agitation’)
• Mental restlessness
• A restless feeling in the chest
• Heart vexation
• Cardiac vexation
• Vexation
• Irritability of the heart
• A feeling of restlessness, heat, and oppression in the region of the heart

English translations have an even more difficult task, because readers often assume they understand the meaning of a technical term based on a seemingly transparent phrase, e.g. “mental restlessness.” Each translation evokes a bit of a different meaning.

However instead of being limited to a single author’s translation of a phrase we can begin to make use of the large breadth of possibilities and usages. Hence none the above are necessarily wrong, if matched to the correct context. However most likely they are going to fall short in certain instances or other people will simply have a different opinion on the meaning. However if we can keep in mind open I think it can help us find some truth in our own clinical experience.

Thank you for reading this essay. Feel free to leave any comments, corrections, or questions?

[i] I purposely chose to use very literal translations, because as we will see, the meaning of these terms can be very different based on the context of a given passage. Also for convenience I chose to mostly use irritability for 烦 (fan), but this, as well as vexation, is an incorrect portrayal in some instances.

[ii] 郝万山强伤寒论

[iii]《金匮要略·痉湿暍病脉证治》：“湿家身烦疼，可与麻黄加术汤发其汗为宜……”；《金匮要略·妇人杂病脉证并治》

New Post / article + Recent Posts: For those that might have missed some recent posts:

1. Some issues in warm disease Three essays from Qin Bo-Wei (秦伯未). Originally published in The Lantern, Volume VIII, Issue: 2 — (Australia) (May 2011). The three essays are spereated below, so that if one desires they may post comments on them.
   1. A restructuring of Warm Disease names by Qin Bo-Wei
   2. The issue of newly contracted pathogens and lurking pathogens by Qin Bo-Wei
   3. The relationship between warm disease (温病, wen bing) and cold damage (伤寒, shang han) by Qin-Wei
2. Case studies:
   1. Duck Butt
   2. Lurking-warmth case study by Liu Bao-Yi (Liu Baoyi) (柳宝诒)

By Qin Bo-Wei (秦伯未)

This small essay in taken from Qin Bo-Wei’s larger Warm Disease thesis that was written in 1963. This essay was published in The Lantern Volume 8 No.2, May 2011, as part of a larger three-part essay entitled Some Issues in Warm Disease by Qin Bo-Wei.

Warm disease (温病 wen bing) is a type of illness¹. Warm disease theory, though, is also a current of thought. This current of thought has been very influential, and when set up in opposition to the cold damage (shang han) current, there have been many debates among our predecessors, some of which remain unresolved.

However, I believe that warm disease theory is a development of cold damage theory. Consequently, if we make an extra effort to dispel the differences between them, we can greatly improve the clinical application of Chinese medicine’s externally contracted disease studies.

To properly discuss this issue, it is fundamental that one has basic knowledge of the topic coupled with clinical experience. Then it is important to ask, what is the origin of the disagreements between the warm disease and cold damage currents? What are the clinical differences? Do they have commonalities? If these issues can be clarified then we will be able to correctly approach these schools of thought, thereby integrating them.

The way I see it, cold damage is the contraction of a cold pathogen, and warm disease is the contraction of a warm pathogen. Hence each has a different cause for the onset of disease. Cold damage considers the six channels as their guiding principle, and generally views things as moving from exterior to the interior. On the other hand, warm disease considers the three burners as their guiding principle, and generally views things as moving from upper to lower². They also have differing methods of pattern differentiation.

Furthermore, cold damage conditions use a warming method, and in the beginning stages use an acrid and warm strategy. Ultimately the method of returning yang is used. On the other hand, warm disease conditions use a cooling method, and in the beginning stages use an acrid and cool strategy. Ultimately the method of rescuing yin is used. Therefore, the treatment principles are also different.

[As fundamental as these may sound], in the clinic all of these points are actually a source of disagreement, and have been the basis for long-term debate. Hence, this issue is by no means so simple.

Although the causes of cold damage and warm disease are different, they similarly come about from external pathogens, and the beginning stages are both exterior patterns.Consequently, they similarly use resolve exterior methods. In addition, if the exterior pathogen does not resolve, it similarly will transfer into the interior, and then transform into heat. Consequently they both will then require a clear heat and open the bowels method. It should be noted that cold damage theory similarly has damage to yin, and warm disease similarly has damage to yang. Hence looking at the onset and course of disease of both, we have to acknowledge that although there are differences they have common ground.

From a pattern differentiation perspective, although the six stages of cold damage emphasises transmission from exterior to interior, it also can be divided into the upper and lower. Although the three burners of warm disease emphasise transmission from upper to lower, it also can be differentiated into the exterior and interior. Furthermore, the fundamental theory of Chinese medicine has its core in zang-fu organs, and this has a relationship with the exterior, interior, upper, and lower aspects [of the body].

Moreover, Chinese medicine is unable to deviate from channel and collateral theory. Hence in pattern differentiation of the six stages and three burners it is fundamental to understand the horizontal and vertical aspects. For example, clinically we see the taiyang pattern of six stages as an upper burner disease. Yangming, shaoyang and tai yin patterns are middle burner diseases. Shao yin and jue yin patterns are lower burner diseases. The relationship of the internal organs is also identical. The diagrams will help illustrate this point.

To go a step further, we can look at the herbal prescriptions used for cold damage and warm disease. For example, cold damage essentially uses acrid warm resolve the exterior formulas such as Ma Huang Tang (Ephedra Decoction). Warm disease uses acrid cold resolve the  exterior formulas such as Sang Ju Yin (Mulberry Leaf and Chrysanthemum Drink) and Yin Qiao San (Honeysuckle and Forsythia Powder). Of course there are differences, but cold damage also has the acrid cold formula Ma Xing Shi Gan Tang (Ephedra, Apricot Kernel, Gypsum, and Licorice Decoction). If you use Ma Xing Shi Gan Tang, is it true that you don’t need Sang Ju Yin and Yin Qiao San? Or if you use the newer  Sang Ju Yin and Yin Qiao San, do you not need the older Ma Xing Shi Gan Tang? I think that these all can co-exist.

In addition, cold damage unblocks the bowels using the purging of the Cheng Qi Tang (Order the Qi Decoction) family of formulas and the  moist purging of Ma Zi Ren Wan (Hemp Seed Pill). Warm disease also uses the Cheng Qi Tang (Order the Qi Decoction) family of formulas  and equally puts forward the nourish yin, moist-purging formula, Zeng Ye Tang (Increase the Fluids Decoction). In addition the warm disease current puts forward the method of combining both Cheng Qi Tang (Order the Qi Decoction) and Zeng Ye Tang (Increase the Fluids Decoction).

In regard to impaired consciousness, delirious speech, and damage of yin patterns, cold damage uses only the purging drain fire of the Cheng Qi Tang (Order the Qi Decoction) family of formulas. In comparison, warm disease uses Zi Xue Dan (Purple Snow Special Pill) and Zhi Bao Dan (Greatest Treasure Special Pill) to open the orifices and clear the Heart which appropriately combines the ideas of nourishing yin and moist purging. However, I consider all of these ideas not only to be essentially the same, but step-by-step developments based on our predecessor’s ideas which consequently have increased our clinical effectiveness.

In fact, warm disease makes use of many cold damage formulas by flexibly applying the concepts to the clinic, such as with modifications of Fu Mai Tang (Restore the Pulse Decoction). Cold damage’s Fu Mai Tang (Restore the Pulse Decoction) fundamentally treats Heart yang insufficiency with simultaneous Heart blood deficiency. Warm disease modifies this formula by subtracting the support yang medicinals, Ren Shen (Ginseng Radix), Gui Zhi (Cinnamomi Ramulus), Sheng Jiang (Zingiberis Rhizoma recens) and Da Zao (Jujubae Fructus) and adding Bai Shao (Paeoniae Radix alba) to safeguard the yin. This turns it into a key formula that nourishes the Liver and Kidney. This kind of skill at using ancient formulas even further illustrates how the warm disease current is a development out of the foundation of cold damage.

Among the warm disease books, Systematic Differentiation of Warm Pathogen Diseases (Wen Bing Tiao Bian, 1798) is one of the most  complete. In its first clause it says, “This book follows the method of Zhong Jing’s Discussion of Cold Damage.” In the second clause it says,  “Although this book was written for warm disease, it actually can be helpful in understanding cold damage.”

It can be seen that the [ancient] warm disease scholars had no disagreement with the cold damage scholars; hence to put these two currents  against each other makes no sense.

Furthermore, since cold damage and warm damage currents already exist, the proponents of each should mutually respect and value each other, eliminating their prejudices. There is a responsibility to unify these two currents, turning it into a completely integrated Chinese medicine externally contracted disease theory.

Translated by: Jason Blalack

Original Essay from: Some Ideas I Have Learned About Warm Disease published in 1963.

End-notes:

1. First mentioned in Chapter 4 of Basic Questions (素问 Su Wen).
2. Actually Zhang Ji (张机) in the Essentials of the Golden Cabinet (Jin Gui Yao Lue) first introduced treating internal disharmonies via differentiation of the three burners.

Please feel free to make any comments…

[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.

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

A 52 year old male came in for a diagnosis on July 18, 1994. He had diarrhea that had been going on for more than one year and had used many kinds of antibiotics with no avail. Every day he had diarrhea 3 to 6 times, and at the time of the intake it was a watery type with small amount of pus and blood. There was also tenesmus, abdominal tenderness, which was especially severe on the lower left quadrant. There was also a fear of cold and a fever (approx 37.5C / 99.5F).

Tongue: red with a white coat
Pulse: submerged and wiry

Western Exam: Microscopic examination of stool revealed leukocytes and a small amount of phagocytes. Western medicine had diagnosed “chronic bacterial dysentery.“

Differential diagnosis: qi and blood congealing in the Spleen, wood constraining the earth center.

Treatment method: regulate the yin and yang of the Spleen, free the qi and blood, while simultaneously curtailing wood, preventing it from attacking the earth center.

Presciption:

guì zhī (Cinnamomi Ramulus) 10g
bái sháo (Paeoniae Radix alba) 30g
zhì gān cǎo (prepared licorice root) 10g
shēng jiāng (fresh ginger rhizome) 10g
dà zǎo (Jujubae Fructus) 12 pieces

After 2 packets the frequency of the diarrhea was remarkably decreased and the abdomen was more relaxed. After 3 more packets the stool was basically formed, abdominal urgency of the lesser abdomen was gone. After 4 more packets of herbs his pattern was resolved.

Source: 《刘渡舟临证验案精选》1996:105一106

Commentary: The patient suffered from chronic dysentery due to a  disharmony of the Spleen and Stomach and disharmony of the qi and blood. There was diarrhea, pain, and tenesmus. If there is pain there is no free flow. These signs belong to qi stagnation and blood stasis of the Spleen. The Spleen belongs to earth and Liver belongs to wood. When the Spleen’s qi and blood is inhibited this causes the qi of Liver / wood to not outthrust. Therefore the pulse was deep and wiry. Furthermore, because of the ongoing diarrhea there was damage to the yin, qi and blood stagnation, and Spleen yin disharmony. Therefore we see a red tongue.

The treatment was to use guì zhï jiä sháo yào täng (Cinnamon Twig Decoction plus Peony) in order to regulate and harmonize the Spleen and Stomach, free the qi and blood, boost the Spleen yin, calm the Liver’s urgency (tension). This is a unique usage of this formula for diarrhea and abdominal pain in tai yin disease. It is exactly like what li dong-yuan said, “If there is abdominal pain one should use gān cǎo (Glycyrrhizae Radix) and bái sháo (Paeoniae Radix alba). Ssowing and reaping is regarded as [the flavor] sweet, and sweet is the 6th heavenly stem (earth). Bending and straightening is regarded as [the flavor] sour, and sour is 1st  heavenly stem (wood). [Using the] 1st and 6th heavenly stems transforms earth, this is the marvelous (mistaken character: 炒=妙？) method of Zhong-Jing. ” *** (I am not sure how to interpret and translate this quote, does someone have any better  insights?)

This formula can be used in the clinic if one sees the three issues of disharmony of the Spleen and stomach, inhibited qi and blood, and Liver / wood overwhelming earth. Then this formula can be used without danger and obtain good results.

Translated by: Jason Blalack

Original Chinese: 一、下利(慢性菌痢)

刘渡舟医案：林某某，男，52岁，1994年4月18日就诊。大便下利达一年之久，先后用多种抗菌素，收效不大。每日腹泻3～6次，呈水样便，并挟有少量脓血，伴有里急后重，腹部有压痛，以左下腹为甚，畏寒，发热(37．5℃左右)舌红，苔白，脉沉弦。粪便镜检有红、白细胞及少量吞噬细胞。西医诊为“慢性菌痢’’。
辨证：脾脏气血凝滞，木郁土中所致。
治法：调脾家阴阳，疏通气血，并于土中伐木。桂枝1O克，白芍30克，炙甘草1O克，生姜1O克，大枣12枚。服汤2剂，下利次数显著减少，腹中颇觉轻松。3剂后则大便基本成形，少腹之里急消失，服至4剂则诸症霍然而瘳。

按语：患痢日久，致脾胃不和，气血不调。腹泻而痛，里急后重，痛则不通，为脾家气滞血瘀之象。脾为土，肝属木，脾家气血不利，而使肝木之气不达，故其脉见沉弦。又因久利伤阴，气血郁滞，脾阴不和，故见舌红。治用桂枝加芍药汤以调和脾胃，疏通气血，益脾阴，平肝急，兼能疏泄肝木。本方用于太阴病之下利、腹痛，别具一格，正如李东垣所说：“腹中痛者加甘草、白芍药，稼穑作甘，甘者己也；曲直作酸，酸者甲也。甲己化土，此仲景之炒法也。”临床运用本方时，如能抓住脾胃不和，气血不利和肝木乘土三个环节，则用之不殆，历验不爽。

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

Shang Han Case

There was external cold assaulting the tai yang with damp stagnation internally blocking the middle burner. This pattern presented with sweat and chills that failed to resolve the condition. There was also full body aching pain, stifling sensation in the chest, upflow nausea, and abdominal distention. It was suitable to disperse the pathogen, release the muscle layer, transform stagnation, and open the middle burner.

Prescription:

Cinnamomi Ramulus (guì zhï) 8 fen
Pinelliae Rhizoma preparatum (zhì bàn xià) 2 qian
dry-fried Aurantii Fructus (châo zhî ké) 1 qian
Amomi Fructus rotundus (bái dòu kòu) 8 fen
dry-fried Paeoniae Radix rubra (châo chì sháo) 1 qian 5 fen
Citri reticulatae Pericarpium (chén pí) 1 qian
Arecae Pericarpium (dà fù pí) 2 qian
Massa medicata fermentata (shén qü) 3 qian
Perillae Caulis (zî sü gêng) 1 qian 5 fen
Zingiberis Rhizoma recens (shëng jiäng) 2 slices.

Commentary: This is a case that uses Cinnamon Twig Decoction (guì zhï täng) to resolve the exterior of the tai yang, Two-Aged [Herb] Decoction (èr chén täng) to harmonize the stomach, descend counterflow, and transform damp in the middle burner.  Magnoliae officinalis Cortex (hòu pò) and Arecae Pericarpium (dà fù pí) was used in order to eliminate distention. Aurantii Fructus (zhî ké) and Massa medicata fermentata (shén qü) was used in order to guide out stagnation.

Translated by: Jason Blalack

Case from: Dr. Liu Du Zhou

This patient was a 10-year-old girl who received a cold Qi in late autumn.  She developed fever and an aversion to cold and had episodes of this many times a day.  This went on for several months.  Her pulse was floating and without strength.  Her tongue body was red and the moss was thin and white.  Her food and drink intake and excretions were normal.  This was a case of wind cold stagnating on the outside chronically without resolution.  The cold had transformed to heat but was a light case.  I gave her two packages of Gui Zhi Er Yue Bi Yi Tang (modified).

Gui Zhi 5g
Bai Shao 5g
Chao Xing Ren 3g
Zhi Gan Cao 3g
Sheng Jiang 3g
Ma Huang 3g
Da Zao 4g
Zhu Ru 3g

There was slight sweating and this brought resolution.

Discussion:

In this case there was fever and an aversion to cold that came in frequent episodes every day.  This indicated unresolved Tai Yang evil.  These external evils have a tendency to enter the interior and transform into heat.  The pulse was floating but without strength.  This is an indication that the cold evil is wanting to journey out to the fleshy exterior.  The original text says, “The pulse is slightly weak and this means an absence of Yang”.  So treatment should not rashly use pungent and warm Ma Huang and Gui Zhi.  One should treat this patient by using Gui Zhi Er Yue Bi Yi Tang with the addition of Zhu Ru to resolve the exterior and clear the interior, generate fluids and nourish moisture.

Commentary:

In regard to the sentence “The pulse is slightly weak and this indicates an absence of Yang”, many scholars think that this means there is Yang depletion.  Because the clause has two parts, they connect the use of Gui Zhi Er Yue Bi Yi Tang to the part that says “fever is greater than cold”.  I do not agree with this.  In this case, the pulse being slightly weak is the opposite of being floating and tight.  This is a pulse that was floating and tight and it changed to be scattered and weak.  The exterior evil, though wanting to leave then has a tendency to enter the interior and transform into heat. This is not the expiring pulse of Yang depletion.  This “absence of Yang” is speaking about the evil wanting to leave the exterior.  This is exactly like that impartial saying “The absence of Yang that stagnates the exterior pattern”.  The evil qi moves into the interior from the exterior and therefore one should not use Ma Huang and Gui Zhi to promote sweating.  One should use Gui Zhi Er Yue Bi Yi Tang to resolve the exterior and clear the interior.

Gui Zhi Er Yue Bi Yi Tang

Gui Zhiu 4g
Sheng Jiang 3g
Bai Shao 3g
Zhi Gan Cao 3g
Ma Huang 3g
Da Zao 4pieces
Shi Gao 3g

This formula is indicated when there is external wind cold and internal stagnant heat.  This formula is differentiated from Xiao Qing Long Tang by the degree of seriousness.  In the Xiao Qing Long Tang pattern, in addition to the cold and heat with fever predominant, there is also lack of sweating, headache, mouth thirst and agitation.  This formula is used when one wants to create a mild sweat while clearing inner heat.

** Translated by: Sharon Weizenbaum

From doctor Huang Dao-fu[1], September 14, 1984:
Ms. Chen was age 17.  Seven days previously she had developed a cold with fever and fear of cold.  The heat was more than the cold.  Everyday she had fever 2-3 times.    Though she had dizziness, there was no vomiting and her two excretions were normal.  She did not sweat easily.  She had itching and an unpleasant body odor that did not go away with bathing.  The school doctor suspected malaria but blood tests were negative for the malaria organism.  She was then diagnosed with an endocrine disorder and treated with oryzanol but there was no improvement.  She then came to see me.  I saw that her tongue was pale with thin white moss and her pulse was minute and weak.  This was a case of long term wind cold damp and Ying and Wei disharmony.  It was appropriate to dispel wind and scatter cold while harmonizing the Ying and the Wei.  I thought to try Zhang Zhong-jing’s method and gave her two packages of Gui Zhi Ma Huang Ge Ban Tang with added flavors. 

Gui Zhi 5g
Bai Shao 3g
Chao Xing Ren 3g
Zhi Gan Cao 3g
Sheng Jiang 2 Slices
Ma Huang 3g
Da Zao 4g
Yi Yi Ren 15g

After one package the patient experienced a physiological sweat and the body itching stopped.  After 2 packages, she noticed that her body felt light and relaxed after bathing and that the unpleasant odor had gone.  After several days there was no recurrence.

Discussion: In terms of unpleasant body odor, Chao Yuan-fang says in the Zhu Bing Yuan Hou Lun (诸病源侯论),

That when the Qi is not harmonized, the fluids become mixed with dirtiness.  This causes unpleasant body odor.” 

In this case, the symptom followed the contraction of a cold.  This was Qi closure in which the remaining evil had not completely left and it mixed with damp turbidity.  This was contained and flowed out the surface with a bad odor.  It is said that,

When the body cannot slightly sweat, there will be body itching”

and therefore one should use pungent warm to resolve the exterior in order to induce a slight sweat with Gui Zhi Ma Huang Ge Ban Tang.  The added Yi Yi Ren increases the formula’s ability to transform and induce the dampness to seep out and makes the formula’s action very quick. 

Translated by: Sharon Weizenbaum

NOTE: For further reading on this case and formula, please see Sharon’s introduction, Guizhi mahuang ge ban tang & guizhi er mahuang yi tang

[1] From the Hu Nan Journal of Traditional Chinese Medicine, 1990 (5) :29

Original Chinese:  体臭 – 黄道富医案；陈某，女，17岁，1989年9月14日初诊。自述7天前曾患“感冒”，发热恶寒．热多寒少，一日二三发，头晕不呕，二便正常；汗出不畅，身痒体臭，浴后不减，校医疑为“疟疾”，建议至某院诊治。血液检验未找到疟原虫，诊断为内分泌功能紊乱．予谷维素等药治疗，症情依然，遂求治于余。证见舌质淡、苔薄白，脉微弱。此届风寒湿久稽，营卫不和。宜祛风散寒，调和营卫。仿张仲景小发汗例，试投桂麻各半汤加味：桂枝5克，白芍3克，麻黄(先煎)3克，杏仁3克，炙甘草3克，生姜2片，薏苡仁15克，2剂，水煎服。
服药1剂，汗出、身痒即止；2剂后自觉身如浴后轻松舒畅，体臭等症随之消失，至今未复发。
(湖南中医杂志1990，(5)：29)
按语：体臭一症，隋·巢元方《谙病源侯论》云：“体气不和，使津液杂秽，故令体臭。”本例发于感冒之后，当为余邪未尽与湿浊之气相搏，蕴蒸外溢作臭。所谓“以其不得小汗出，身必痒。”故采用辛温解表，小发其汗的桂枝麻黄各半汤，更加薏苡仁一味以增强其宣化渗湿之功，故取效甚捷。