Clinical case reviewed in 2015 SHL webinar 2 with Dr. Feng

Ms. Zhang, 51 years old
1st consultation on December 28th, 2010
The patient suffered from insomnia with profuse dreaming for over 2 years, accompanied by vexation, palpitations, fatigue upon exertion, no desire to move, occasional hot sweating, poor appetite and thirst, slightly dry stools, cold limbs, amenorrhea for 1 year. Her tongue was pale red with a white coating, the pulse was thready and wiry.

Symptom analysis: In this case, the patient has many symptoms of heat above and cold below pointing to a Half and half syndrome. The heat above is seen as dreamful sleep, thirst and vexation; while the cold or depletion below is seen in the lack of appetite, slightly dry stools. If the heat symptoms were stronger with excessive sweating we could consider this case to be a Shao yang syndrome. However, there is a severe blood and body fluid depletion seen in the fatigue upon exertion, palpitation, dry stools, cold limbs, amenorrhea (menopause), and thready pulse. A half and half syndrome with blood and body fluid depletion is a Jue yin syndrome. In this case there was severe cold limbs and fatigue as well as low appetite and so the internal depletion was more severe than a singular Jue yin syndrome and we also addressed the Tai yin syndrome.

Six syndrome: Jue Yin Tai Yin concurrent syndrome
Formula pattern: Chai Hu Gui Zhi Gan Jiang jia Fu Ling Ban Xia Tang pattern

Result: After taking the formula, all of the symptoms showed gradual improvement for a month after slightly modifying the formula according to the corresponding changes in her symptoms. The sleep became deep and rejuvenating, and all other symptoms subsided.

Formula Analysis: The Chai hu Gui zhi Gan Jiang Tang addresses the Jue yin syndrome by clearing the heat above and the Fu Ling Ban Xia Tang address the Tai yin excess and depletion by activating the function of the digestion and expelling internal rheum. Ban xia is added to further expel rheum from the upper, which is one of the reasons for the severe insomnia.

Note: In order to understand why Chai Hu Gui Zhi Gan Jiang Tang was used in this case it is crucial to review clause 147

Clause 147: “Shang Han for 5-6 days, sweat promotion and purging methods were already applied, if there is chest and ribs fullness, there is a slight yang constriction, inhibited urination, thirst without vomiting, however there is sweating from the head, alternating cold and heat with vexation, it is due to an unresolved syndrome, Chai Hu Gui Zhi Gan Jiang Tang governs”

第147条：伤寒五六日，已发汗而复下之，胸胁满，(阳)微结、小便不利、渴而不呕、但头汗出、往来寒热、心烦者，此为未解也，柴胡桂枝干姜汤主之。

Explanation: During a shang han for 5-6 days, if sweating and purgation therapies were applied it would have severely damaged body fluids, causing the syndrome to progress from the exterior to the half-exterior half-interior, as evident by the chest and rib-side fullness and alternating fever and chills. The fluid damage is seen in the slight yang binding (presenting as hard stools) and thirst without vomiting.

We can notice heat in the upper marked by sweating from the head and vexation. All of these symptoms indicate an unresolved half-exterior half-interior yin syndrome, fitting a Chai Hu Gui Zhi Gan Jiang Tang pattern.

Original Formula

Explanation: This formula stems from Xiao Chai Hu Tang by removing Ban Xia and adding Tian Hua Fen. Huang Qin has bitter and cold properties and so when coupled with Chai Hu which is bitter and neutral they clear heat from the half-exterior half-interior layers seen in symptoms of the upper body.

• Gan Cao and Gan Jiang are warm and can warm the cold presenting in the middle in a half exterior and half interior syndrome while nourishing fluids and releasing the slight yang binding (constipation).
• Gua Lou Gen (Tian Hua Fen) moistens which supports Mu Li in clearing heat in the upper and relieving thirst.
• Gui Zhi and Gan Cao have the dual effect of descending up surging of qi and harmonizing the exterior.
• Da Zao can cause fullness and accumulation therefore even in cases of mild binding it is removed.