Gui zhi ma huang ge ban tang #2

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4. Unpleasant Body Oder

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 Zhi5g
  • Bai Shao3g
  • Chao Xing Ren3g
  • Zhi Gan Cao3g
  • Sheng Jiang2 Slices
  • Ma Huang3g
  • Da Zao4g
  • Yi Yi Ren15g

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。

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  • Jason Blalack

    Some brief thoughts:
    1) Note there is an unpleasant odor due to dampness/cold and not heat. Some might assume that because there was more heat than cold in the initial condition and it was lingering for over a week, that there must be some heat transformation. This seems to be not the case.
    2) The fact that there was no vomiting and excretions were normal demonstrate that the condition is still on the surface and did not reach the interior. The dizziness is merely from the dampness.
    3) I think this quote about the itching when the body cannot produce much of a sweat is interesting. This idea is used in some dermatology formulas (for eczema etc.) where there is itching and the patient can’t sweat, hence the doctor adds medicinals such as ma huang.

  • alon marcus

    I have to wander about the choice of yi yi ren at 15g. If he did not think of the possibility of some heat why choose yi yi ren

  • Jason Blalack

    Here is how I think of this issue. We have to respect Huang’s analysis describing the case study. He specifically tells us this is a “long term wind cold damp and Ying and Wei disharmony.” So I like to ask, why would he is Coicis Semen (yi yi ren) in this context.

    You are right that Coicis Semen (yi yi ren ) is considered slightly cold, but it is also one of the few drain dampness / transform damp-turbidity medicinals that also unblock the channels and collaterals. Most drain damp medicinals only work on the interior, Coicis Semen (yi yi ren) works on both. He might ask, why did he not use a warm herbal like Notopterygii Rhizoma seu Radix (qiang huo). This is because it is too superficial. The language that Huang uses points to some internal involvement, for example, “damp-turbidity (湿浊)” that “collects (蕴)”. Which herb would you have picked?

    Furthermore, if he did want to just clear heat, there are so many other herbs that really clear heat. BTW, I do not consider 15g that high of dose.

    Do you or others have some different ideas?

  • alon marcus

    Hi Jason
    I am just thinking about YYR in terms of the way ZZJ uses it. You are right we have to respect what the author says in the article. Its just that lately i am trying to shift my thinking understanding herb usage in terms of a more classical context. As far as dosage, 15g is not high but in comparison to other doses in this rx its the highest by far. Having a minute and weak pulse is not what i would associate this Rx with, if memory serves me right. Dampness can prevent the pulse from rising and purhaps that is a clue. The itching does bring me to this rx but having heat more than cold also makes we wander. Cold and damp both tend dampen fever/heat and she had more fever than cold.
    But one cannot argue with results so any more thoughts would be welcomed

    • Jason Blalack

      Thanks for the response; I definitely would like to hear more about what you are thinking. Here are some quick thoughts:

      1. I do agree that looking at herbs through a classical lens can be helpful. However, I am not sure that I understand how looking at yi yi ren through a classical perspective changes anything. Can you explain? Did ZZJ use yiyiren? If so, in what way that helps us understand this better.

      2. Also, it is not uncommon to have a high fever in cases of cold and damp, many times such fevers are more severe than in straight heat patterns. Once damp is in the picture, the chance of heat increases. Check out Ginseng Powder to Overcome Pathogenic Influences (ren shen bai du san). Even ma huang tang can have a very high fever. One problem might be the term fa re (发热) (used above) which can mean actual “high temperature” or just a “sensation of heat.”
      Although, I agree that the fact that it was mentioned that there was more heat than cold is interesting. I just took this as the doctor pointing out that one can have a wind cold pathogen pattern with more heat than cold. Maybe I am incorrect, however it seems that I do see this clinically, do others?

  • Steve Bonzak

    Hi Jason and Alon-

    I noticed a couple of things. First, with the inclusion of yiyiren in the formula, Huang incorporates the formula Ma Xing Yi Gan Tang into the prescription. MXYGT is a formula that ZZJ prescribes for Dampness Disease. The translation of the line from the JGYL reads:

    “If the patient has full body ache, with fever, which is worse in the afternoon, then this is Wind Dampness. This disease is due to damage by wind after sweating, or longterm damage by raw and cold [foods]. One can give Mahuang Xingren Yiyi Gancao Tang.”

    In Dampness Disease there is always the possibility of heat developing due to the stagnation at the surface. This chapter of the JGYL is related to the chapters on Yellow Sweating and Joint Disease. We see this clearly with the line from the Dampness Disease chapter where ZZJ says:

    “The disease of dampness patients, shows full body ache (vexing ache), fever, and smoky yellow skin color.”

    The development of the “smoky yellow color” is an indication that the dampness has started to develop some heat.

    This brings me back to the case above. While Huang states that “This was a case of long term wind cold damp and Ying and Wei disharmony,” I do not think that it rules out the development of heat. When he says “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,” I really think he is talking about the formation of heat from stuck damp at the surface that we see in the Dampness Disease chapter of the JGYL. If left untreated, it is possible that the next step of transformation of the damp turbidity and bad odor could be yellow sweating or a yellowing of the skin.

    Finally, it seems safe to assume that Huang was a ZZJ scholar, so I think that it follows that the addition of yiyiren to this formula, thus incorporating MXYGT into his prescription, would not have been unintentional. If not unintentional, then he must have felt that there was some heat starting due to the dampness as described in the JGYL. If he felt that there was really no heat starting to form, wouldn’t he have chosen an addition like baizhu to incorporate Mahuang Jia Zhu Tang into his prescription?


    • Jason Blalack

      Thanks for pointing out, Ma Xing Yi Gan Tang (or Ephedra, Apricot Kernel, Coicis, and Licorice Decoction
      má huáng xìng rén yì yî gän câo tang) , nice find!
      A couple things to notice about the dampness discussion in the JGYL.
      1. Symptoms such as fever and irritability do not always equate to a heat pattern. For example, as in a exterior cold damp. Or more importantly, one does not use a cooling method for such symptoms.
      2. Steve points out the above passage discussing “Smokey yellow skin color”. It should be made clear that this quote is one of many discussing dampness and is not directly associated with ma xing yi gan tang (not that he is saying this). For example, the following are some of the line numbers with a brief description and what that line discusses.
      (15) Damp pathogens transforms to heat pattern (Steve’s quote above)
      (16) mistakenly treated chronic damp person
      (17) dampness in the lower burner
      (18) wind damp
      (19) cold damp in the head
      (20) cold damp exterior excess (ma huang jia zhu tang)
      (21) wind damp exterior excess (ma huang xing ren yi yi gan cao tang)
      3. However after reviewing the chapter in the JGYL I change my stance. There may be some transformation to heat. However, MXYGT’s fundamental pattern in the JGYL is wind dampness in the exterior and fundamentally this is a warm formula and the diagnosis is wind cold and damp.
      4. As for, ma huang jia zhu tang, this is indicated for cold dampness in the exterior. Therefore Steve’s question is valid. The only other idea would be that because he is incorporating gui zhi tang (warm formula) therefore he chooses yi yi ren instead of bai zhu. I find no insight from the JGYL that sugests why he did not use bai zhu, esp with his dx, except the possible difference of having wind. Maybe he considered yi yi ren better for wind.
      5. The JGYL commentary supports the idea that fever in cold dampness often is a high and one in wind dampness pattern is often low.

  • alon marcus

    The only other point is according to arnaud wind tends to lead to heat.
    I think ZZJ also uses yyr for chest obstruction i wander why?

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