Headache: Two cases by Liu Duzhou 劉渡舟
Translated by Daniel Eng, L.Ac.
Case 1: Zhenwu tang + Ling gui zhu gan tang
Mr. Li, male, 32
years old. The patient was a driver. When he drove in the summer, the
weather was hot and he would freely drink ice-cold beer or soda,
daily and without restraint. When autumn came he started experiencing
headaches every night. The pain was severe, and he had to knock his
fists against his head or take analgesic pills in order to obtain
relief; it was also accompanied by blurred vision. The condition had
persisted for over a month.
On visual
inspection, the patient’s facial complexion was dark and sallow,
his tongue was pale and tender with a wet, slippery coating, and his
pulse was deep, wiry and moderate. This was a case of yang deficiency
with water overflowing, turbid yin escaping upward, and clear yang
being stifled.
Fuzi 12g,
fuling 18g, baizhu 9g, shengjiang
12g, baishao 9g, guizhi 6g, zhi
gancao 6g
After taking six
packets of the medicine, the headaches had lessened significantly.
His formula was changed to Ling gui zhu gan tang, and after
four packets he was cured.
Commentary by
Dr. Liu: Zhenwu tang
is also known as Xuanwu tang.
Xuanwu is the spirit that
controls water in the north.
Because this formula has the
function of supporting yang and controlling water, it is therefore
named Zhenwu tang; it
is used for patterns such as Shaoyin yang deficiency with cold, and
water qi failing to transform. The
Shanghan lun says:
“Abdominal pain and inhibited urination . . . means there is water
qi.” This indicates the key
pathomechanism of this pattern. Yin deficiency with hyperactive yang
often stirs wind, while yang
decline with exuberant yin often
stirs water—this is a basic rule of the occurrence and development
of disease. Yang deficiency stirring water is normally treated with
the Ling gui formulas;
if the disease has reached the kidneys, with yang qi deficiency and
decline, palpitations, dizziness, instability when
standing, and swaying
as if about to fall to the ground, then
we must treat using Zhenwu tang.
If one takes Zhenwu tang,
and the kidney yang is warmed yet the water qi is still unable to
transform completely, then we can further use the warming herbs of
the Ling gui formulas
to harmonize.
Case 2: Guizhi qu gui jia fuling baizhu tang
Ms. Jin, female, 42
years old. The patient had been suffering from left-sided migraines
for over three years. She had tried many treatments without effect.
Accompanying symptoms included stiff nape; distention, fullness and
discomfort of the chest and epigastrium; and frequent, scanty
urination. Bowel movements were normal. The pulse was wiry and tight,
and the tongue fur was wet and slippery almost to the point of
dripping.
Fuling 30g,
baishao 30g, baizhu 10g, zhi
gancao 10g, dazao 12 pieces, shengjiang
10g.
After taking six
packets, she was cured.
Commentary by
Dr. Liu: Line 28 of the Shanghan lun
says: “When Guizhi tang
is taken, or down-purging is used, and there is still pain and
stiffness of the head and nape, feathery-warm heat effusion, no
sweating, fullness and slight pain beneath the heart, and inhibited
urination, Guizhi qu gui jia fuling baizhu
tang masters.” Physicians
throughout the ages have had quite different understandings of this
line from the original text. For example, Xu Dachun of the Qing
dynasty said: “Whenever formulas are modified, it is always the
assistant or envoy herb [that is removed]. If the chief herb is
removed, a new formula name is given. Here guizhi
is removed, yet [the formula] is still named after guizhi;
this cannot be explained.” Qian Tianlai also said: “The
significance of treatment
with Guizhi qu gui
jia fuling baizhu tang is
unclear. I am afraid that this was the error of a later copyist—it
is impossible to know. Even
if one uses it, I am afraid that it will not necessarily be
effective.” And Wu Qian,
the author of the
Yizong jinjian, asserted
even more directly that
“remove
guizhi” was
erroneously written instead of “remove shaoyao.”
So,
how should we understand this issue? First, we should remember
the features of
Guizhi tang and its
modifications and transformations. The biggest
feature of Guizhi tang is
that it moistens yin and harmonizes yang, and the herbal combination
that achieves this feature is guizhi combined
with shaoyao. Guizhi
and shaoyao,
one yang and one yin, clinically can be taken to form a dichotomy.
For example, there is a
Guizhi jia gui tang,
so there is also a
Guizhi jia shaoyao tang;
therefore, since there is a Guizhi qu shaoyao tang,
there should also be a Guizhi qu gui tang. This
way, yin and yang are counterparts,
and this
fits the objective rules of disease
transformations and their treatments. If we analyze along these
lines, Guizhi tang with
the removal of gui
is actually a real phenomenon.
Furthermore,
from the perspective of the herbal composition of Guizhi qu
gui jia fuling baizhu tang, it
wouldn’t
hurt to
compare it to Ling gui zhu gan tang,
in order to understand more clearly the significance of removing gui.
In the Shanghan lun, Zhongjing
used Zhenwu tang to
support yang and disinhibit
water, so he also had Zhuling tang to
supplement yin and disinhibit
water as its counterpart. This is because fluid metabolism
dysfunction in the human body is related to the two aspects of yin
and yang. Therefore, since Zhongjing offered Ling gui zhu
gan tang to unblock the yang and
disinhibit
water, he should have a formula to harmonize yin and disinhibit
water as its counterpart. The
answer to this question lies precisely in Qu gui jia fuling
baizhu tang.
This
formula’s herbal composition is as follows: fuling,
shaoyao, baizhu, zhi
gancao, shengjiang and dazao.
If we look at these ingredients, it is not difficult to discover that
the four ingredients fuling, shaoyao, baizhu
and zhi gancao are exactly analagous to the four
ingredients of Ling gui zhu gan tang, with guizhi
and shaoyao as yin-yang counterparts. For this reason,
it wouldn’t hurt to call this “Ling shao zhu gan tang”
for the moment. “Ling shao zhu gan tang” uses shaoyao
on one hand to moisten the ying and harmonize yin, and on the other
hand in combination with fuling, so it also has the
function of removing water qi and disinhibiting urination. So the
ability of “Ling shao zhu gan tang” to
harmonize yin and disinhibit water is in exact yin-yang relationship
with the ability of Ling gui zhu gan tang to unblock yang and
disinhibit water. And the fact that shengjiang and
dazao are further included is just like how Ling gui
zhu gan tang also has the adaptations known as Ling gui zao
gan tang and Ling gui jiang gan tang.
Even
if this is so, why didn’t Zhongjing simply name it “Ling shao
zhu gan tang,” instead of naming it Guizhi qu gui jia fuling
baizhu tang? There may be two reasons for this. The first is that
in Zhongjing’s writings, there is often a paired relationship
between lines that appear before and after each other. After all,
Line 21 lists Guizhi qu shaoyao tang, so Line 28 goes on to
mention Guizhi tang and the method of removing gui.
This causes a person to compare, so that they see the difference
between “chest fullness” in the line above, and “fullness and
slight pain beneath the heart” in the line below.
Secondly,
Zhongjing was afraid that later generations, upon seeing “pain and
stiffness of the head and nape” and “feathery-warm heat
effusion,” would grasp onto guizhi and not let it go,
overly insistent on the exterior-releasing function of guizhi;
so he emphasized that for this formula we must remove guizhi
and keep shaoyao. Therefore, when reading Zhongjing’s
books we must search in hidden places to tease out deeper meanings.
In
the clinical use of Guizhi qu gui jia fuling baizhu tang, the
key to pattern differentiation lies in “inhibited urination.”
Inhibited urination is a manifestation of bladder qi transformation
dysfunction, leading to water evil stagnating internally. Water evil
stagnating internally in the bladder can obstruct the flow of yang qi
in its channel. When yang qi is blocked and the channel is inhibited,
there may be external signs such as feathery-warm heat effusion and
pain and stiffness of the head and nape, so it looks like an exterior
pattern but really is not an exterior pattern. When the water evil
congeals and binds, blocking the qi mechanism and causing interior qi
disharmony, there may be interior signs such as fullness and slight
pain beneath the heart, so it looks like an interior excess pattern
but really is not an interior excess pattern. Therefore the methods
of promoting sweating and down-purging are both inappropriate. The
pathomechanism of this pattern is as follows: inhibited urination →
water blocking the bladder → external qi obstruction and internal
qi binding.
If the key to
pattern differentiation is inhibited urination, why don’t we use
Wuling san to disinhibit
urination? This issue has already been clearly explained by Tang
Rongchuan of the Qing dynasty. He said: “Wuling san
is for the qi of Taiyang failing to reach the exterior, so guizhi
is used to diffuse the qi of Taiyang; when the qi reaches the
exterior, water will descend on its own, and urination will be
disinhibited.
This formula [Guizhi qi gui jia fuling baizhu tang]
is for the water of Taiyang failing to descend, and therefore guizhi
is removed, and fuling
and baizhu are further
added to move the water of Taiyang; when the water descends, the
qi will reach the exterior on
its own, and signs such as headache and heat effusion will naturally
be resolved. Those without sweating can be cured with slight
sweating, and therefore Wuling san
makes special use of guizhi
to promote sweating; sweating is what disinhibits
water. This formula makes special use of fuling
and baizhu to
disinhibit
water; disinhibiting
water is what promotes sweating. Actually this is due to the
knowledge that water can transform qi, and qi can move water.”
Source: Liu Duzhou,
ed., Jingfang linzheng zhinan (Beijing:
People’s Medical Publishing House, 2013), pp.
50–53, 126–128.