March 28, 2011

Hu Xi-Shus’ unique approach and commonly used formulas for treating wheezing and panting

Patterns where phlegm –rheum is the primary cause of wheezing and panting

A commonly seen presentation in wheezing and panting is the contraction of an external pathogenic factor with simultaneous retention of phlegm-rheum.  In patients who are constitutionally predisposed to phlegm-damp retention, usually the initial attack by an external factor will stir the interior phlegm which will counterflow into the lung, invariably causing the wheezing and panting.  This pattern is mentioned in the Shang Han Lun, where it states:
“In cold damage where the exterior is unresolved, (and) there is water qi below the heart….”

In these cases treatment generally involves, effusion to resolve the exterior, with simultaneous warm transformation of fluids.  The various manifestations of this condition can be treated with the following prescriptions:

She Gan Ma Huang Tang: (Belamcanda and Ephedra Decoction)
Main signs:  Aversion to cold, generalized body pain, copious phlegm, and the sound of phlegm in the back of the throat.  If this pattern is accompanied by signs such as a dry mouth, dry tongue, and heart vexation, Sheng Shi Gao may be added.

Xiao Qing Long Tang: (Minor Blue-Green Dragon Decoction)
Main signs:  Aversion to cold, generalized body pain, an absence of sweating, coughing with a need to rest and lean up against something, yet unable to lie down.  (This is normally due to the presence of copious phlegm), severe coughing with frothy phlegm.  If this is accompanied by signs such as a dry throat, vexation and agitation, Sheng Shi Gao may be added.  

Ge Gen He Xiao Xian Xiong Tang: (Minor Sinking into the Chest Decoction with Pueraria)
Main signs:  Hypertonic back and nape, chest fullness, oppression or pain, heat effusion, aversion to cold and panting.  If heart vexation is quite obvious, then Sheng Shi Gao may be added.

Ling Gan Wu Wei Jiang Xin Xia Xing Tang: (Poria, Licorice, Schisandra, Ginger, Asarum, Pinellia and Apricot Seed Decoction)
Main signs:  Coughing, panting with chest fullness, spitting up of frothy phlegm and a normal taste in the mouth. 

Ma Huang Fu Zi Xi Xin Tang: (Ephedra, Asarum and Prepared Aconite Decoction)
Main signs:  Aversion to cold, absence of sweating, perhaps an aversion to cold felt in the back, counterflow cold of the extremities, a fatigued spirit, and a deep-thin pulse.

Patterns where blood stasis is the primary cause of wheezing and panting.

Originally when blood stasis is laying dormant in the interior, any changes caused by external contraction, food damage or damage from the seven affects will induce and entice the movement of blood stasis which will eventually invade the liver and lungs and cause wheezing and panting.  If this stasis is not eliminated than the wheezing and panting will endure and recovery would be difficult to achieve.  Therefore many cases of wheezing and panting due to cold, or summer-heat that fail to resolve, usually contain elements of static blood.  The following are a couple formulas that can effectively treat these presentations.

Da Chai Hu Tang He Gui Zhi Fu Ling Wan (Major Bupleurum Decoction combined with Cinnamon Twig and Poria Pill)
Main signs:  Chest and rib-side bitter fullness, difficulty breathing, hypertonic epigastrium, bitter taste in the mouth, dry throat, and dry bowel movements.

Da Chai Hu Tang He Tao He Cheng Qi Tang (Major Bupleurum Decoction combined with Peach Pit Decoction to Order the Qi)
Main signs:  Similar symptoms to the above, with the addition of abdominal distension and fullness, and difficult bowel movements.

Modifications to the above formulas: 
With signs of dry mouth, throat or tongue, vexation, agitation and/or vexation thirst, add Sheng Shi Gao
With signs of external contraction with symptoms of heat effusion, aversion to cold and an absence of sweating, combine with Ge Gen Tang.
With signs of sweating and significant wheezing, combine with Ma Xing Shi Gan Tang

Patterns where both phlegm-rheum and blood stasis are the primary cause

  If for example our patient presents with a Xiao Qing Long Tang presentation with elements and signs of Da Chai Hu Tang He Gui Zhi Fu Ling Wan, then these three formulas may be combined.  
With difficult bowel movements it is easy to see signs of either Gui Zhi Fu Ling Wan or Tao He Cheng Qi Tang.  If in this case a She Gan Ma Huang Tang presentation exists, then the combination of these formulas would be applicable. 
If signs of mouth or tongue dryness, or vexation and agitation are seen with the above formulas, then Sheng Shi Gao may be added. 

Why Da Chai Hu Tang?

Dr Hu explained that many patients presenting with wheezing and/or panting manifest a Shao-Yang, Yang-Ming combination disease. Therefore, the cardinal Shang Han Lun formula Da Chai Hu Tang (Major Buplureum Decoction) may be used with quite astonishing results. Many of Dr. Hu’s students would often ask him why when treating wheezing he wouldn’t just use Ma Huang (Radix Ephedra)? He would simply state that unless the case presenting was a Ma Huang pattern, its use was not warranted. In the Shang Han Lun (On Cold damage) it states that “In wheezing with chest fullness, Ma Huang is appropriate, but in wheezing with abdominal fullness, Ma Huang should not be used”.

Dr. Hu would explain that in order to diagnose a Shao-Yang Yang-Ming case of wheezing and panting, we need to look for symptoms such as; wheezing and panting with occasional chest fullness, rib-side pain, sweating, dry throat, dry bowel movements, etc.

March 2, 2011

Two Cases on the use of Si Ni San

A Collection of the Clinical Experience of He Ren

Case #1
On April 8 1983, a 48 year old female presented with irregular menstruation.  She was a very sceptical woman and was easily angered.  Her sleep was poor with copious dreaming, she experienced rib side pain, abdominal distension, her bowel movements alternated between hard and loose, her tongue had a thin white coat and her pulse was wiry.  In this case it is appropriate to harmonize and scatter the depression, course the liver, and regulate qi.  The following formula was prescribed;

Zhi Shi 9g
Chai Hu 9g
Sheng Gan Cao 9g
Dang Gui 9g
Bai Shao 15g
Huai Xiao Mai 30g
Zhi Xiang Fu 9g
Da Zao 7 pieces

5 packages were administered.

Follow up consultation on April 15 1983:  After taking the above formula, her sleep had improved and she felt calmer.  The abdominal distension had decreased, her bowel movements were regular, but the rib side pain was still occasionally present.  Tongue coating was still thin and the pulse was wiry.  A modified version of the original formula was prescribed.

Zhi Shi 9g
Chai Hu 9g
Sheng Gan Cao 9g
Yu Jin 9g
Bai Shao 15g
Zhi Xiang Fu 9g
Huai Xiao Mai 30g
Da Zao 7 pieces

5 packages were administered.

Commentary:  The patient in this case originally suffered from neurosis occurring alongside menopause.  Therefore we have a pattern of qi and blood disharmony with liver depression, causing rib side pain and abdominal distension.  This pattern is effectively treated with a combination of Si Ni San and Gan Mai Da Zao Tang.  On follow up after finishing the formula, the patient reported a full resolution of symptoms.

Case #2
A 41 year old male presented on August 17, 1981 with a depressed spirit, irritability and anger.  In addition he had epigastric pain, an increase in bowel movements, with occasional diarrhea, cold fingers and toes, slight sweating, fatigue, a wiry-rapid pulse, and a thin yellow tongue coat.  In this case it is appropriate to course the liver, regulate qi and resolve depression.  The following formula was prescribed;

Chai Hu 9g
Bai Shao 9g
Sheng Gan Cao 9g
Zhi Shi 9g
Chun Yang Zheng Qi Wan 3g* (separated into two doses and taken with decoction)
*Pure Yang to Rectify the Qi pills is a patent formula containing Chen Pi, Cang Zhu, Rou Gui, Ding Xiang, Huo Xiang, Bai Zhu, Fu Ling, Zhi Ban Xia, and Qing Mu Xiang.

Four packages were administered.

Commentary:  The patient in this case suffered from a depressed spirit.  He tended to think excessively and was easily angered.  This patient was initially diagnosed during the summer, and was manifesting a Si Ni San presentation.  Taking the season into consideration and the conditions of his diet with the mild reversal symptoms, we are unable to say that this is a pure case of binding depression of liver qi.  Due to these factors, Chun Yang Zheng Qi Wan was added to clear the stomach and intestines and eliminate seasonal pathogenic factors.  After taking two packages of the formula his (epigastric) pain and diarrhea had completely resolved, and he felt much calmer.

The clinical scope of Si Ni San is quite vast.  In all cases of qi stagnation, qi depression, and qi reversal the pattern and presentation of Si Ni San is often present with several opportunities for use.  The formula is applicable in cases of cholelithiasis, cholecystitis, intercostal neuralgia, weak digestive system functioning, stomatitis, panting, palpitations, colitis, neurological disorders, menopause, and several other conditions.  Generally when the pattern is correctly identified and the herbs and/or formula are matched to the presentation, our results can be 100% effective.