May 15, 2013

Yáng Vacuity Insomnia


Dr. Féng Xué-Gōng
Case taken from ‘Forum on Classical Formulas from Throughout the Country’ (全国经方论坛)


A seventy-one year old female was first seen on June 24, 2010 suffering with insomnia for over forty years, which has been quite severe over the last 3 years. When the condition had first started many years ago, she never paid much attention to it or received any kind of treatments. Over the last three years the insomnia has gotten quite bad.  She has great difficulty falling asleep, and although she typically goes to bed around nine o’clock every night, she doesn’t actually fall asleep until at least midnight or one o’clock.  Her sleep is very short, and she wakes very easily. If she takes a sleeping pill, she is able to sleep up to three or four hours. In addition, she experiences heart vexation, and has two to three dry bowel movements per day.  Her appetite is good and urination is normal.  Tongue is pale red with a white coat, and pulse is wiry.
In my experience, cases of insomnia accompanied by heart vexation are typically due to Shào Yáng depressed heat, and are treated as such. 

Formula:

A modified version of Chái Hú Jiā Lóng Gǔ Mǔ Lì Tāng (Bupleurum plus Dragon Bone and Oyster Shell Decoction)

chái hú (Bupleuri Radix) 12g
guì zhī (Cinnamomi Ramulus) 10g
huáng qín (Scutellariae Radix) 10g
dǎng shēn (Codonopsis Radix) 10g
bàn xià (Pinelliae Rhizoma preparatum) 12g
fú líng (Poria) 30g
dà huáng (Rhei Radix et Rhizoma) 10g
shēng lóng gǔ (Fossilia Ossis Mastodi) 30g
shēng mǔ lì (Ostreae Concha) 30g
hé huān pí (Albizziae Cortex) 30g
zhì gān cǎo (Glycyrrhizae Radix preparata) 6g
shēng jiāng (Zingiberis Rhizoma recens) 10g
dà zǎo (Jujubae Fructus) 10g
Seven packages were administered, and to be cooked as a water decoction, taking one pack per day. 


Follow up on July 1, 2010:  After taking the seven packages, none of her symptoms improved and she was still experiencing insomnia. Her tongue was pale red with a white coat, and the pulse was (still) wiry.
Since this woman was older, and had been suffering from insomnia for many years, I tried treating her from the perspective of a kidney yáng insufficiency with ministerial fire being unable to return to its residence.

Formula:

A modified version of Qián Yáng Fēng Suǐ Dān (Yáng Descending Marrow Sealing Elixir)

páo fù zǐ (Aconiti Radix lateralis tosta) 10g
shā rén (Amomi fructus) 15g
guī bǎn (Tortoise plastron) 10g
huáng bǎi (Phellodendri Cortex) 10g
ròu guì (Cinnamomi Cortex) 6g
shēng lóng gǔ (Fossilia Ossis Mastodi) 30g
shēng mǔ lì (Ostreae Concha) 30g
fú líng (Poria) 30g
zhì gān cǎo (Glycyrrhizae Radix preparata) 6g

Seven packages were administered, and to be cooked as a water decoction, taking one pack per day. 


Third consultation on July 8, 2010: Her insomnia was definitely improving, as she was now able to fall asleep easier, wasn’t waking up easily, and was also able to avoid taking any sleeping pills. Tongue was pale red with a white coat, and pulse was wiry.
The strategy of warming the yáng was effective so this is where the emphasis would remain.  To the previous formula (July 1st), ròu guì was increased to 10g, and 30g of cí shí was added. She was given fourteen more packages, to be cooked as a water decoction, taking one pack per day. 


Fourth consultation on July 22, 2010: The insomnia had now clearly improved, and she completely stopped taking any kind of sleeping pills. It now took her only ten minutes to fall asleep; she was not waking easily, and slept for five hour stretches at a time. Her bowel movements were now much easier occurring once per day. Her tongue was pale red, and her pulse was wiry. To her previous formula páo fù zǐ was increased to 15g and the other medicinals were left as is. She was given another fourteen packages. 


Commentary:  In clinical practice, insomnia is typically diagnosed and treated as either a yīn-blood insufficiency, heart spirit deprived of nourishment, internal brewing of fire, or hyperactivity of the heart spirit, and is rarely identified and treated as yáng vacuity. In actual fact, yáng vacuity insomnia is very common, and many cases are due to yáng vacuity insecurity with ministerial fire being unable to return to its residence and producing false heat, which can be erroneously regarded as true heat. This case clearly exemplifies this concept.

Qián Yáng Dān (Yáng Descending Elixir) is a fire spirit school formula created by Zhèng Qīn-Ān. It contains shā rén (Amomi fructus), páo fù zǐ (Aconiti Radix lateralis tosta), guī bǎn (Tortoise plastron), and gān cǎo (Glycyrrhizae Radix). Fēng Suǐ Dān (Marrow Sealing Elixir) is a formula from the Golden Mirror of Medicine (医宗金鉴), which contains huáng bǎi (Phellodendri Cortex), shā rén (Amomi fructus), and gān cǎo (Glycyrrhizae Radix). In clinical practice when treating floating and ascending vacuous yáng, master Zhèng would commonly combine these two formulas, achieving miraculous results. Later generations of physicians commonly utilized master Zhèngs methods, including Wú Péi-Héng (吴佩) from Yúnnán province, who renamed the combination of these two formulas Qián Yáng Fēng Suǐ Dān (Yáng Descending Marrow Sealing Elixir). Within the formula Zhèng Qīn-Ān believed that guī bǎn was able to generate the essence within water, not for the purpose of nourishing yīn, but for freeing yīn in order to assist yáng. Shā rén is generally thought of as a medicinal, that moves qì, transforms turbidity, and harmonizes the stomach.  However, in the Běn Cǎo it is said to be able to absorb qì and return it to the kidneys thereby treating and guiding qì, which is unable to return to its source.
This patients’ insomnia had lasted for many years, and was first treated as a pattern of Shào Yáng depressed heat but with no effect. After some contemplation, I figured due to the patients’ age, and the fact that this was an enduring disease, there (must have) initially (been) a yīn vacuity, which eventually affected the yáng.  Moreover, all enduring conditions (eventually) reach the kidneys. With kidney yáng insufficiency, (the kidneys) lose their ability to secure and contain, which then leaves the ministerial fire unable to return to its residence; floating yáng will then ascend disturbing the heart spirit resulting in insomnia. Therefore, the root of the insomnia here lies in yáng vacuity. After using Qián Yáng Fēng Suǐ Dān (Yáng Descending Marrow Sealing Elixir), vacuous fire is able to descend, ministerial fire will return to its residence, and the heart spirit will be tranquil, thereby eliminating insomnia. This case illustrates the importance of paying close attention to recognizing yáng vacuity insomnia and serves to increase and improve our overall clinical efficacy.

5 comments:

Jason said...

Thanks for an interesting case. As it's written, Dr. Feng's method seems to be, try this then try that. He also makes an assumption (that turns out to be correct) that if her 40 years of insomnia doesn't improve the first week, the treatment is wrong. Maybe that's the key?

Eran Even said...

Hey Jason,

It does kinda seem like that, and from reading a few of his other cases, he would do this often, expecting dramatic results within the first week. This time his assumption was right on, but I wonder how many times this has not worked for him (which he would obviously not publish). Maybe he felt the need to make the change because after a week, none of her symptoms improved, but sometimes I feel that these 'so called' fire spirit practitioners, try to find any reason to justify supplementing yang. Nonetheless, I found this to be an interesting case worthy of translation.

Stephen Bonzak, L.Ac., Dipl. OM said...

Hi Eran-

While it may be the case that he was looking for an excuse to use fuzi, I think it is reasonable to change a formula strategy completely if there was little improvement. In my experience, because the formulas in the SHL and JGYL are quite focused and strong (high dosages of chaihu, baishao, or fuzi for example), when the patient reports no change, it means the focus should be changed as well. Unless I am convinced of my diagnosis and I just need to increase dosages of herbs, I will change the formula.

Best
-Steve

Eran Even said...

Hey Steve, Yes, I totally agree, and do think that he changed the formula because she had absolutely no change whatsoever. I was just being silly and taking a jab at the 'Huo Shen Pai'. :)

In actual fact, in my own clinic I too dose quite high and always expect to see some sort of change within the week, and if nothing happens, I would typically alter the formula, unless of course as you mentioned, I am completely sure of my diagnosis, and the pulse/presentation fits the original formula.

Thanks Steve!

Eran

Jason said...

This makes me realize that I've been operating from the idea that if the formula doesn't cause side-effects, it must be in the ballpark. Obviously, that's a low bar. Thanks Steve and Eran.

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