Chinese Medicine Traveller

Being a classical Chinese physician and treating diseases according to the classical thinking, we must first identify the type of disease through the “eight principles”.  We must determine if it is a hot or a cold disease, or a mixture of hot and cold disease.  We must identify if it is an internal or an external disease or a half internal and half external disease.  We must identify if it is an excessive or a deficient pattern or if it is a simultaneous excess and deficient pattern.  Secondly, we must identify which syndrome or syndromes have been affected according to the “six-syndrome identification system”. This will lead us directly to the “formula pattern” and guide us to the appropriate formula. Finally we will be able to make modifications to the ingredients and dosages according to the symptoms.

       

Previously, in earlier articles, we have described the main symptoms related to the six syndromes so we will not go over them completely again. However, we will review them in relation to the symptoms of “fever”, or “hot sensation of the body”. It is commonly said in China that if a doctor is to be a good practitioner, they must be able to treat “fever” correctly. The symptoms of “fever” (fa shao - 发烧)or of “hot sensation of the body” (fa re - 发热) as it is mentioned in the Shang Han Lun can be classified within the following syndromes: the external yang -tai yang syndrome, the internal yang – Yang ming syndrome, and the half-exterior half interior yang or yin syndrome.  One can not completely identify a syndrome by having only one symptom but it is the combination of symptoms that will demonstrate the full syndrome and show us the effect of the pathogen on the body. It is very important to realize which of the “six syndrome identification” is affected to identify the correct formula pattern.  Here is a list of accompanied symptoms that are associated in each separate syndromes.

   

• In the Tai Yang (exterior yang) syndrome: chills, fever, aversion to cold or wind, body heaviness or stiffness, pain the joints, skin diseases, headache and a floating pulse.
 
• In the Shao Yin (exterior yin) syndrome: drowsiness, chills, cold extremities, aversion to cold, joint and body pain with a deep and constrained pulse.
 
• In the Yang Ming (interior yang) syndrome: the disease characterized by internal excess heat condition with fever without chills, distended abdomen, irritability, easily emotional, constipation and a rapid pulse.
 
• In the Tai Yin (interior yin) syndrome: the symptoms include feeling of severe internal cold, chills, with a distended abdomen with occasional pain, diarrhea or loose stools.
 
• In the Shao Yang (half-exterior half-interior yang) syndrome: the symptoms are located in the chest or abdominal areas and can affect any organ or organs, with chest discomfort, pain or stiffness in the rib side, dry mouth, alternating chills and fever with a bitter taste in the mouth.
 
• In the Jue Yin (half-exterior half-interior yin) syndrome: the symptoms are located in the chest or abdominal areas and can affect any organ or organs, they are the counterpart of the Shao yang syndrome with an increase on the symptoms of heat in the upper area and severe cold in the lower limbs or the lower abdomen, thirst, difficult urination, physical weakness, lethargy with a deep and weak pulse.

     

It is important to always remember which syndrome or syndromes is affected by the pathogen which tell us where the pathogen will be located in the body. Knowing where the pathogen is located will tell us how to treat it. If the pathogen is located in the Tai yang syndrome it is on the external yang layer so we will need to promote sweating with formula patterns such as Ma Huang Tang, Da Qing Long Tang and Gui Zhi Tang. However if the fever is caused by a pathogen located in the Yang Ming syndrome, it is due to an internal yang pattern and we will need to dredge, clear internal heat or promote vomiting, depending if the pathogen is located in the lower, middle or upper Yang ming syndrome. To treat these syndromes, we will be using formulas such as Da Cheng Qi Tang, Bai Hu Tang, and Gua Di San. On the other hand, if we evaluate that the fever is related to a pathogen located in the half exterior half-interior yang layer of the Shao yang syndrome, then we will need to harmonize and clear the upper as well and warm the middle with formula patterns such as Xiao Chai Hu Tang, Huang Qin Tang, and Jie Geng Tang. Lastly, if we have some heat sensation of the body in the upper with vertigo, hot flashes, dryness of the eyes and mouth accompanied with severe cold sensation in the lower limbs and lower abdomen, this is related to the half-exterior half- interior layer of the Jue yin syndrome. Formula pattern to treat the Jue yin syndrome include Wu Mei wan, Gan Cao Xie Xin tang, Chai Hu Gui Zhi Gan Jiang Tang.

     

Formula patterns are the key in achieving clinical success with Jing Fang.  Each of the formula patterns have been identified to treat a syndrome or multiple affected syndromes at once. However, these formula patterns have a very sensitive symbiosis and balance between the ingredients and their ratio and any addition or subtraction results in a completely different formula pattern. In this sense, finding the exact formula pattern for the presenting syndrome is the key and any changes to the formula deserve serious consideration.

     

For example, if your patient presents with fever, chills, an aversion to cold with sweating and a floating pulse.  Clause 12 of the Shang Han Lun tells you that the formula Gui Zhi Tang is appropriate. However, if the patient has the same symptoms with an addition of painful joints with a deep pulse, which herbs will you add in this case? Will you go back to the zang fu theory and add blood moving or pain relieving herbs such as San Qi Fen or Hong Hua? This would not be suitable in the Jing Fang approach to medicine. Hence, we notice that the full symptoms presentation demonstrate an external yin pattern of Shao yin Syndrome and use one of the Shao yin syndrome Formulas. In this case Zhang Zhong jing has already recorded in Clause 20 if the Gui Zhi Tang pattern presents with an addition of joint pain and a deep pulse, the formula pattern is Gui Zhi Jia Fu Zi Tang. By adding Fu Zi to the original Gui Zhi Tang Pattern, we are still able to promote sweating to clear the external layer but we also support the internal to promote fluids. Only when the syndrome is addressed fully with the appropriate formula pattern will the disease be resolved.

     

Clinical Case #1: Ms. Dong, 51 years old. 1st consultation: March 23th 2013. Her main symptoms were sweating with hot sensation of the body for over 1 week without knowing the cause of the disease. The sweating was excessive only at the head with a cold sensation of the lower limbs, no dryness of the mouth, but there was dryness of the lips. The patient suffered from fever with aversion to cold between 3 to 5pm every afternoon. The tongue was pale with a white coating. The pulse was deep and thready.

     

Six Syndrome Differentiation: Tai yang syndrome

     

Formula pattern Identification: Gui Zhi Formula pattern

     

Ingredients:

Gui Zhi	10g	Bai Shao	10g	Zhi Gan Cao	6g
Sheng Jiang	15g	Da Zao	4pcs

     

Results: After taking 1 day of decoction the heat sensation and fever subsided. However, since the cold sensation of the lower limbs increased, 10g of Chuan Fu Zi were added to the decoction and taken for 3 days. After the 3rd day all symptoms subsided.

   

Analysis: In this case, the patient had unexplained fever with chills and aversion to cold reoccurring regularly demonstrating a Gui Zhi pattern. However, the pulse was a deep and not floating. Since the symptoms of fever were very severe, we treated it successfully as an externally yang - Tai yang syndrome. However after one dose of medication, the symptoms changed and the fever subsided as well as the cold symptoms increased demonstrating an external cold / Shao yin syndrome. In that case changing the formula pattern to Gui Zhi Jia Fu Zi Tang was appropriate as it treated the pattern successfully.

   

Clinical Case #2: Mr. Feng, 10 years old. 1st consultation: September 24th 2009. This was a very important season for influenza in Beijing and less than half of his classmates came to class that day. The boy had no symptoms that afternoon; but he suffered from a fever and dry throat that night and was administered Lian Hua Qing Du Capsule with no results. He later took a capsule of Bai Jia Hei to lower the fever and experienced excessive sweating but the fever did not decrease. The fever remained between 39- 39.5 ℃ with sweating, low consciousness, dry mouth, a desire to drink and only ate watermelon. His temperature that night at 7pm was 39.4℃ with a greasy white tongue coating and a wiry and slippery pulse.

   

Six Syndrome Differentiation: Yang ming syndrome

   

Formula pattern: Bai Hu Jia Ren Shen Cang Zhu Formula pattern

   

Ingredients:

Sheng Shi Gao	100g	Zhi Mu	15g	Zhi Gan Cao	6g
Cang Zhu	10g	Ren Shen (xing kai he)	10g	a pinch of rice

   

Results: The 1st dose was given at 8pm and the fever decreased to 38.8℃ after one hour. The patient had no fever the next morning. Since there was a cough with scanty phlegm, Ban Xia Hou Po Tang Modified was given for 2 days and all symptoms resolved.

   

Analysis: The patient was administered Bai Hu Tang since he suffered from the 4 bigs heat, fever, large pulse, thirst and sweating. In this case Ren shen was added to support the function of the body in creating body fluid. After such excessive sweating the patient had a severe fluid deficiency which needed to be addressed. On the other hand, Cang Zhu was also added because of the greasy tongue coating and the inability to process fluids anymore.

   

Note: the 10 year old patient was administered 100g of Sheng Shi Gao which is well beyond the recommended dosage of 15g. The temperature of Sheng Shi Gao is extremely cold and can affect the functions of the stomach. However, in this case, the boy was given one dose before he had a reaction and started sweating. One hour later the fever was already starting to decrease so the other dose was not administered. In this sense we can observe that the boy did not ingest the full dosage of 100g before he felt the relief of his fever.

   

In treating children under the age of 10 we need to remain aware of the quantity of the medicinals. When treating children with Jing fang, Dr. Feng usually prescribes one day’s worth of decoction to be taken over the course of two days while being under the observation of the parents which can stop administration of the decoction as soon as the child’s fever begins to drop.

   

Clinical Case #3: Mr. Sun, 2 years old. 1st consultation: November 24th 2013. The boy caught a cold and suffered from a fever for 10 days. He had taken antibiotics with no results. He now presented with symptoms of cough, sticky phlegm, wheezing, shortness of breath, abdominal fullness, loose stools, hot sensation of the hands and feet, white and greasy tongue coating and a wiry and rapid pulse.

   

Six Syndrome Differentiation: Three Yang syndrome with internal phlegm dampness retention.

   

Formula pattern: Xiao Chai Hu Jia Sheng Shi Gao He Ban Xia Hou Po Tang Formula pattern

   

Ingredients:

Chai Hu	24g	Ban Xia	12g	Dang Shen	10g
Huang Qin	10g	Da Zao	4pcs	Sheng Shi Gao	45g
Zhi Gan Cao	6g	Hou Po	10g	Su Zi	10g
Fu Ling	12g	Sheng Jiang	10g

   

Results: The decoction was prepared once and separated in two portions. After taking the 1st portion, the patient experienced some sweating and the fever decreased. The cough reduced and the shortness of breath and the abdominal fullness was also resolved. Since the patient had a cough with scanty phlegm, Ban Xia Hou Po Tang Modified was given for 2 days and all symptoms resolved.

   

Analysis: In this case we notice that the amount of Chai Hu is double the traditional amount due to the high fever. Giving the lower dosage would not have the desired effect in cases of high fever.

   

When it comes to treating children, the syndromes are usually acute and their symptoms change very quickly so giving one one day of decoction taken over the course of two days while paying close attention to the changes in the symptoms is appropriate. Once the symptoms change we also need to change the formula.

   

If you want to know more you can join our Jing Fang Community on our Jing Fang Forum on Facebook.