Insomnia – yang qiao deficiency (YTS)

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Original Case by: Ye Tian-Shi (叶天士)

[Patient] Gu (age 44) had already greying whiskers and hair on the temples. His facial complexion though was bright. He was emotionally worried and irritable. [There was] yang ascending and agitating [the spirit] with phlegm and thin mucus also ascending and overflowing. The divine pivot says, when yang qi descends, joins and enter the yin, then the yang qiao vessel is full and one is able to sleep. [At this moment though] qi was disseminating and discharging outward and yang was not entering yin. He would drink alcohol in hopes of muddling his consciousness enough so he could sleep. This was not a good method for managing this disease. In middle age and afterwards, men’s lower base is the first to become depleted. [The treatment] was to use Eight-Ingredient Pill (ba wei wan) in the morning and Pinellia and Millet Decoction (ban xia shu mi tang) in the evening. (yang qiao vessel deficiency).

Translated by: Jason Blalack

Original Chinese: 顾(四四) 须鬓已苍。面色光亮。操心烦劳。阳上升动。痰饮亦得上溢。灵枢云。阳气下交入阴。阳跷脉满。令人得寐。今气越外泄。阳不入阴。勉饮酒醴。欲其神昏假寐。非调病之法程。凡中年已后。男子下元先损。早上宜用八味丸。晚时用半夏秫米汤。(阳跷脉虚)

Source: Case from the Insomnia chapter of Case Records as a Guide to Clinical Practice (临证指南医案  lin zheng zhi nan yi an).

Commentary: This case shows one approach to dealing with complex patterns of excess and deficiency, giving separate formulas at different times of day.  Ye uses his typical style of focusing on the pathodynamics and uses little in the way symptomatic “sleep” herbs. Brilliant! Eight-Ingredient Pill (ba wei wan) is another name for Kidney Qi Pill (shen qi wan). Pinellia and Millet Decoction (ban xia shu mi tang) is from the Divine Pivot and contains Pinelliae Rhizoma preparatum (zhi ban xia) and  Setariae Fructus (shu mi).

Comments? Questions? Mistakes?

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  • ryan

    I missed something I think. Did he prescribe BA Wei based solely on the patients age and grey whiskers?

  • Jason Blalack

    I think it is more than just the grey whiskers. For example, when you have Phlegm and thin mucus (tan yin) there usually is an underlying yang deficiency of either the Spleen (less serious) or Kidney (usually more long-term and serious). In addition he mentions the age. There where also probably other ‘obvious’ symptoms’ that Ye did not feel where necessary to write in the case and this is common for many pre-modern case records. One has to somewhat backwards engineer what the ‘other’ symptoms might have been based on the diagnosis and herbal prescription. Using Ba Wei, though, is a reflection of Ye’s deep understanding of the pathodynamic. Yang is rising, why? Ruling out other options and having a couple clues that the lower base is deficient, is also enough to use ba wei to strengthen the base and pull down the yang. Does this make sense?

  • ryan

    Yes. That makes sense. I could see the phlegm/yang vacuity, that seems straightforward. I always thought, though, that if yang was so vacuous as to rise, or ‘float up’, that it only occurs in very serious/grave cases, like where a patient is gravely ill, e.g i think the Chinese term is ‘capping yang’ maybe the Chinese was ‘dai yang’. But Dr Ye didn’t make note of anything like that. Any thoughts, insights?

  • Jason Blalack

    I think that when we see case studies such as this we can use them precisely to challenge our belief system on what we think must or must not be seen to diagnose / treat a specific pattern. Thus we quite simply see that we don’t have to have a serious condition for floating yang due to deficiency of yang. I often use case studies in this way, especially when they are from one of the most important clinicians in CM history.

  • ryan

    Well said!! One of the things I’ve often felt is that I should seek to understand the idea behind the pattern, so i can recognize it even when I don’t see cardinal signs and symptoms. Its good to hear your comment.

  • PeterGalle

    I love these translations of Ye’s case studies and your commentary. They really elucidate precise diagnosis to treat the root cause of symptoms, as you say. Thank you for them!

    I have a question on the Shu mi. I’ve read 3 different explanations of what this herb is: Husked Sorghum, Millet (Su mi) and Setariae Fructus, (which when googled shows confusing results as being Gu Ya or Su Ya, either rice or millet sprouts). Is it supposed to be Su Mi (millet) thereby validating its translated name (Pinella and Millet Decotion), and Maciocia is incorrect in his gyno book when he says Shu Mi is husked sorghum? Then perhaps the above is a typo (from that particular translation from the Divine Pivot)? For TCM wiki has Sorghum seed as Gao Ling (which might be different than husked sorghum, but looks the same), yet has it as Shu Mi, as in Maciocia.

    Even though they have varying functions, is the point to just make a porridge using a harmonizing grain with Ban Xia? Does it even matter!? Or is it simply millet (perhaps sprouted), as the translation says, and the pinyin has been mistaken?

    Lastly, I am reminded of Kurosawa’s Seven Samurai eating rice as a prize instead of millet, and wonder if the two have been used interchangeably based on cost (as other herb books sometimes identify gu ya as sprouted millet), and Sorghum is just an incorrect translation? Thank you for any clarity on this subject!

  • Huang Qi

    This is a good question which I do not have a definitive answer. I personally have used straight millet in my clinic and this seems to be effective. For reference:

    秫米 shu2 mi3 (shu mi), 中药异名 broomcorn millet (Panici Miliacei Semen)
    北秫米 bei3 shu2 mi3 (bei shu mi), sorghum (Sorghi Semen)

    This is from F&S II in reference to ban xia shu mi tang:

    “This decoction is one of the few formulas mentioned in the Inner Classic, as it is noted in Chapter 71 of Divine Pivot. It dispels phlegm and clears away filth and establishes communication between the yin and yang. It is used to treat insomnia due to phlegm and dampness obstructing the middle burner, which obstructs the qi dynamic and results in the yang being unable to enter the yin. The sweet, cool nature of Setariae Fructus (shú mî) balances the acrid, warm nature of Pinelliae Rhizoma preparatum (zhì bàn xià) and harmonizes the middle burner, with an emphasis on directing downward. This allows the yang to enter the yin at night and therefore resolves insomnia. Note that some commentators follow Li Shi-Zhen who identified 秫米 shú mî as sorghum (Sorghum Fructus). In present-day China, both types of grain are commonly used. While it can be used by itself, it is commonly combined with other medicinals or with Grand Communication Pill (jiäo tài wán) for a more complete effect on both the Triple Burner and the Heart-Kidney axis.
    Note that Setariae Fructus (shú mî) is sweet and slightly cold and enters the Lung, Stomach, and Large Intestine channels. It harmonizes the Stomach and calms the spirit, dispels wind and eliminates dampness, while also resolving toxicity and helping sores close. The normal dosage is 9-15g, either in a decoction or as a porridge.”

    Thanks for the question and comments, I enjoy hearing Kurosawa’s words 🙂
    – Jason Blalack

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