Constraint Harming the Heart yang (YTS)
Case by: Ye Tian-Shi (叶天士)
Yu, 55 years old, suffered from constraint that harmed the Heart yang. The yang sunk into the yin leading to a turbid painful urinary dribbling disorder. This was internal damage from the emotions leading to a yin [area?] deficiency resulting in disease. Merely seeing the symptoms will bring about a disordered (incorrect) treatment and is most inferior.
The Heart stores the Spirit. The spirit was damaged with symptoms such as muddle-headedness; all the orifices were disturbed. The herb treatment should not emphasize cold or hot medicinals. It must be opening and bright, striving for tranquility. If one only uses botanicals (e.g. no animal products) then I am afraid the results will be unsatisfactory. This is constraint harming the Heart yang and the prescription was Marvelously Fragrant Powder (miao xiang san).
Translated by: Jason Blalack
Jason’s Commentary: This is a brilliant case where Mr. Ye sees beyond the chief complaint and addresses the underlying mechanism for the turbid painful urinary dribbling disorder, constraint harming the Heart yang. Of note, Ye differentiates elsewhere between painful urinary dribbling (淋 lín) and turbid urine (濁 zhuó). He states,
Painful urinary dribbling is attributed to the Liver and Gallbladder. Turbidity is attributed to the Heart and Kidneys.
Yang deficiency can easily lead to turbidity. Turbidity is heavy and sinks causing the urinary disorder. I can’t say that I truly understand his point of “yin deficiency causing disease.” This formula does not address this. Maybe the yin was addressed after this formula. Does anyone have any additional ideas?
Marvelously Fragrant Powder (妙香散, miao xiang san)
Source: Formulary of the Pharmacy Service for Benefiting the People in the Taiping Era (1148)
- Ginseng Radix (rén shën)15g
- Dioscoreae Rhizoma (shän yào)30g
- Astragali Radix (huáng qí)30g
- is Poria (fú líng)30g
- Poriae Sclerotium pararadicis (fú shén)30g
- Polygalae Radix (yuân zhì)30g
- Cinnabaris (zhü shä)9g
- Aucklandiae Radix (mù xiäng)75g
- Moschus (shè xiäng)3g
- Platycodi Radix (jié gêng)15g
- Glycyrrhizae Radix preparata (zhì gän câo)15g
Original Chinese: 于（五五） 郁损心阳。阳坠入阴为淋浊。由情志内伤。即为阴虚致病。见症乱治。最为庸劣。心藏神。神耗如愦。诸窍失司。非偏寒偏热药治。必得开爽。冀有向安。服药以草木功能。恐不能令其欢悦。（郁损心阳） 妙香散。
即为阴虚致病 is indeed opaque.
My tentative parsing is this.
Idea 1 郁损心阳。阳坠入阴为淋浊。
The constraint damages the heart yang, which weakened, collapses into the yin (as in lower yin) causing urinary turbidty
The emphasis here is specifically on the emotional aspect of the constraint that causes internal damage. It causes a deficiency in the “yin” by both virtue of its damaging the heart, and/or more likely, the urogenital system. Its not that the collapse of heart yang causes a major obstruction below, it causes a weakness leading to a seconday obstruction. The herbs in the rx make that clear. Yet, Ye emphasises the heart, not the kidney.
Does that make sense?
Pardon my thought experiment here – I am a casual western doctor with a keen interest only.
My view of this disorder, and its treatment might best be explained by his comment ‘ The herb treatment should not emphasize cold or hot medicinals. It must be opening and bright, striving for tranquility.’.
I think this disorder goes back to addressing first principals of Yin and Yang, fire and water. His main symptoms related to the excess symptoms of blocked orifices, such as muddled thinking and turbid dripping urination. He goes on to describe these symptoms of turbidity blocking the very fundamental interaction between fire and water (?Via the San Jiao or possibly some divergent channel pathology). His description squarely states ‘ The yang sunk into the yin’ as a pathological state – a lack of tranquility. He suggest that the initiation the pathology, whilst not explicitly described, was a yin draining mental state – be that shock draining heart yin or chronic worry/obsession draining kidney yin, etc which lead to this deeper separation of Yin and Yang.
The Yuan qi is constrained yet scattered; San Jiao is closed; the system is ‘constrained’ and ‘blocked.’ He talks of constraint of heart yang – an excess condition in which yuan qi cannot drive the San Jiao: there an exuberance of fire further damaging water, ultimately producing misting turbidity. Yuan Qi is damaged: being the functional/yang aspect of Jing, yin-essence is also deficiency.
He identifies that the first principal of therapy here is to reconnect fire and water, but implicitly cautions against formulas such as jiao tai wan, which won’t address the turbidity or open the orifices, and would further damage yin and worsen the “constraint’ of ‘heart yang’.
Thus the principals of therapy, at this stage, is to clear the turbidity within the San Jiao and open the orifices, stabilise Shen and re-establish communication between kidney and heart by tonifying Yuan Qi.
She Xiang, Jie Geng and Mu Xiang (high dose) – Fragrant medicines with penetrating pungent and lifting flavours (ie., not reliably achieved with botanical agents alone) to open the orifices and promote flow of Yuan Qi within the San Jiao.
Fu ling/Fu Shen/Shan Yao/Gan Cao/Ren Shen. – neutral or slightly warm sweet herbs which stabilise and tonify yuan Qi’s function within the San Jiao
Fu Shen/Zhu Sha/Ren Shen/Yuan Zhi/Gan cao – specifically stabilise the heart at the qi and Spirit levels.
Yuan Zhi/Fu Shen /Ling and zhu Sha – Specifically re-establish communication between kidney and heart.
I think his diagnosis, and the formula really are beautiful. It is a very interesting thought experiment to think what he may have used subsequently, as Jason suggested. One would imagine that he might move on, after addressing the excess turbidity, to consolidate Yuan qi, yin and essence and any remaining floating fire.