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》.

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.

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。

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.”

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 .

Original case by: Fei Bo-Xiong (费伯雄)

When the Spleen is deficient and dampness wins out [over physiological transformation], the momentum [of the disorder] is towards Wood seizing the position of earth. Employing [a strategy] of relaxing the movement [of the qi dynamic] while separately eliminating [the various pathogenic qi] yielded results [quickly] after [the prescriptions] was taken. However, dampness is still soaking Spleen yang disabling movement and transformation. [Therefore, I once again] employ the previous strategy in order to promote a resolution [of the disorder].

Magnoliae officinalis Cortex (hòu pò) 3g
Perillae Caulis (zî sü gêng) 6g
Pogostemonis/Agastaches Caulis (huò xiäng gêng) 6g
Artemisiae scopariae Herba (yïn chén häo) 3g
fried Atractylodis macrocephalae Rhizoma (bái zhú) 6g
Amomi Fructus (shä rén) 1.5g
Narcissus Semen (shuǐ xiān zî) (水仙子) 9g
Aurantii Fructus immaturus (zhî shí) 3g
Aucklandiae Radix (mù xiäng) 1.5g
Pinelliae Rhizoma preparatum (zhì bàn xià) 6g
Citri reticulatae viride Pericarpium (qïng pí) 3g
Citri reticulatae Pericarpium (chén pí) 3g
Poria rubra (chì fú líng) 6g
Massa medicata fermentata (shén qü) 9g
Eupatorii Herba (pèi lán) 3g
Zingiberis Rhizomatis Cortex (shëng jiäng pí) 1g

Comment: This case record is listed immediately after the preceding one and thus may well be a description of a follow-up treatment. If not, it describes a case of distension where the strategy focuses almost exclusively on promoting the movement of middle burner yang qi in order to eliminate Spleen dampness.

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”

Original case by:

Wood seizes the position of earth, hence only the abdomen is distended. [The appropriate strategy] is to curtail wood and support earth.

calcined Arcae Concha (wâ léng zî)
Corydalis Rhizoma (yán hú suô)
Benincasae Exocarpium (döng guä pí)
Benincasae Semen (döng guä zî)
Magnoliae officinalis Cortex (hòu pò)
Paeoniae Radix alba (bái sháo)
Codonopsis Radix (dâng shën)
Poriae Cutis (fú líng pí)
Atractylodis macrocephalae Rhizoma (bái zhú)
Aurantii Fructus immaturus (zhî shí)
Gigeriae galli Endothelium corneum (jï nèi jïn)
Aucklandiae Radix (mù xiäng)
Zingiberis Rhizoma preparata (páo jiäng)
Angelicae sinensis Radix (däng guï)
Cinnamomi Cortex (ròu guì)

Comment: This is a simple diagnosis of Spleen deficiency allowing Liver to encroach on earth causing stagnation of the qi dynamic and hence distension. The formula directly addresses this patho-dynamic by tonifying the Spleen, harmonizing the Stomach, and regulating the Liver. Yet, it also brings into play a complex of five-phases relationships attesting to the importance of five-phases doctrine in Fei Bo-Xiong’s thinking.

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”

Zhou was a 17-year-old unmarried girl with menstrual irregularities. Her menses were sometimes early and sometimes late. Prior to her menses she had abdominal pain that was worse than normal, and her intake of food and drink was greatly reduced. This problem started at the beginning of summer, and going into autumn her lower burner was often cold. There were abdominal sounds, and alternating diarrhea and constipation. The examination revealed that she easily had depressed anger without any real reason. This was Liver qi tending towards horizontal [attack], in which the Stomach first was harmed. The chong, ren, qiao, and wei channels all belong to the Liver and Kidney. The channels were not circulating properly, and the qi and blood was gradually becoming blocked, leading to obstruction. If there is a lack of flow there must be clumping with mobile abdominal masses, accumulations of strings and aggregations (a kind of abdominal masses).

Prescription:

Crataegi Fructus (shan zha)
unprocessed Cyperi Rhizoma (sheng xiang fu)
Corydalis Rhizoma (yan hu suo)
Angelicae sinensis Radix (dang gui)
Citri reticulatae viride Pericarpium (qing pi)
Sparganii Rhizoma (san leng)
Atractylodis macrocephalae Rhizoma (bai zhu)
Achyranthis bidentatae Radix (niu xi)
Toosendan Fructus (chuan lian zi)
Lycopi Herba (ze lan)
Cinnamomi Cortex (rou gui)
Foeniculi Fructus (xiao hui xiang)
made into pills with the juice of Allii fistulosi Bulbus (cong bai)

Commentary: Ye Tian-Shi said,

the 12 channels travel through the body like ditches with circular flow and without limit, only the eight extraordinary channels are like canals, if they are overflowing they become like deep rivers, which is not the same as how the 12 normal channels flow.”

To briefly elaborate “the eight extraordinary channels are not limited like the normal 12 channels.” Concerning the physiology of the eight extraordinary channels Mr. Ye thought that they gather and contain essence qi, regulate the normal channel’s qi and blood, connect and join, protect, and the function of lifting up the body and bones. The disease is due to a disturbance in the chong and ren disrupting the Liver and Stomach, leading to chaotic qi counterflow of the Liver and Stomach and Liver and Stomach disharmony. If the menses are unable to come on time, and conversely remaining internally and following the movement of the uterine vessels, this will often lead to mobile abdominal masses.

When this is happens one must attack the accumulation, expelling and driving out stasis. This not only causes the eight extraordinary channels to flow smoothly, but also can flush away lodged stasis, preventing mobile abdominal masses. The principal method was to disperse, descend, warm, and unblock, when using an attacking method it is most suitable to use a moderate and roundabout method. Therefore Mr. Ye used the school of thought of using medicinals to promoting the movement of qi, attacking accumulation and driving out stasis. This was used to prevent further complications by reducing accumulation in the early stages.

For further reading on understanding Ye Tian-Shi’s eight extraordinary channel application, check out: Ye Tian-Shi’s Pattern Differentiation and Treatment of the Eight Extraordinary Channels.

Translated by: Jason Blalack