Bi Syndrome is associated with Jue Yin and Tai Yin Feng Shi Lun Case Study
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August 21, 2013 at 8:49 am #848
Dr Greta Young Jie DeKeymaster
Dai x, female 76 years old
First consultation: 10th March 2010
History: The patient suffered from joint pain and muscle ache for more than one year and had been treated with different mode of medicine but was not effective.
Current S/S: Finger joints pain, lumbar, back, pelvic and knee pain, intermittent generalized aching muscle in the four limbs which affected her sleep. Other symptoms: Thirst, reversal four limbs, poor appetite, occasional body tremor, white tongue coat and a thready and wiry pulse.
Six Channel Pattern identification: Tai Yin disease
Formula pattern: Gui Zhi Shao Yao Zhi Mu Tang + Fu Ling, Chen Pi and Gou Ji.
Prescription: Ma Huang 6g; Gui Zhi 10g; Zhi Mu 10g; Bai Shao 10g; Cang Zhu 15g; Zhi Fu Zi 12g; Fu Ling 12g; Fang Feng 10g; Zhi Gan Cao 6g; Gou Ji 15g; Chen Pi 30g; Sheng Jiang 15g. Seven packs decoct in water.
Second consultation: 17th March 2010
There was no significant changes and her bowel movement was dry.
Six Channel Pattern Identification: Jue Yin and Tai Yin concurrent pattern
Formula pattern: Chai Hu Gui Zhi Gan Jiang Tang + Dang Gui Shao Yao San
Prescription: Chai Hu 12g; Huang Qin 10g; Tian Hua Fen 12g; Sheng Long Gu Mu Li 15g each; Gui Zhi 10g; Gan Jiang 6g; Dang Gui 10g; Bai Shao 10g; Chuan Xiong 6g; Cang Zhu 15g; Ze Xie 12g; Fu Ling 12g; Zhi Gan Cao 6g. Seven packs decocted in water.
Third consultation: 24th March 2010
The patient said that the first prescription was not effective but the second prescription was good. There was improvement of parched mouth, generalized ache, body tremor and joint pain. Her tongue coat was white and her pulse was thready and wiry. Change the dosage of Gan Jiang to 10g and continued for another seven packs.
Fourth consultation: 31st March 2010
There was continuous improvement of her symptoms, but there was more significant lumbar and back pain and her four limbs were comparatively warmer. Her tongue coat was white and her pulse was wiry. Add Gou Ji 15g to the previous prescription for another seven packs.
Fifth consultation: 7th April 2010
The patient felt comfortable overall and there was no apparent joint pain, absence of cold extremities, improved sleep, good appetite and normal bowel and urination. Her tongue coat was white and her pulse was thready and wiry. Omit Cang Zhu from the previous formula, add Sheng Bai Zhu 15g; change Ze Xie’s dosage to 15g; Gou Ji’s dosage to 12g. Seven packs decocted in water.
Six Consultation: 14th April 2010
Continuous improvement and there was no further discomfort. She was told to take another seven packs and then stopped the medication.
Formula identification is the pinnacle of pattern identification
There are different schools of thought in Chinese medicine with different theory. From the clinical perspective, the overall efficacy hinges on the prescription formula and the degree of accuracy in matching the patient’s pattern. We can adopt the method of using the formula construction theory of Sovereign, Minister, Assistant and courier to decipher Ma Huang Tang; to use the method of three tonifying and three purging herbs to comprehend the construction of Liu Wei Di Huang Wan. However it has been found that practitioners who are fully conversant with this method does not translate directly into a clinically effective practitioners and why? Perhaps we can draw an analogy of dispensing herbs to arranging soldiers in battle as the course of pattern identification incorporates strategy of hand to hand fighting. The objective of Chinese medicine theory is in reality a strategy of hand to hand fighting which is reflected in the prescription and failure or success entirely depends on the correct strategy. The above case study, diagnosis at the first consultation seems correct but the formula pattern is not appropriate. The second consultation is correct with good treatment effect. It requires hard work on the practitioners to prescribe the optimum treatment coupled with special comprehension skill.
Formula Pattern Identification:
Professor Hu Xi Shu has detailed discussion regarding formula pattern identification, he said: “In spite of the Six Channels and Eight Guiding principle being the core fundamental of pattern identification, however from the practical perspective, it is not sufficient. For example Tai Yang disease according to the six channels theories the correct treatment is sweat promotion but there are many sweat promotion formulas, whether any kind of sweat promotion herbs are all effective. Our reply is no, as one needs to further discern the indications. Thus apart from sweat promotion for Tai Yang disease, more importantly one must identify the patient’s generalized condition in order to select the optimum sweat promotion formula. Formula pattern identification is a follow up procedure after the Six Channels and Eight Guiding Principles identifications which in reality constitute the pinnacle of pattern identification. The efficacy of Chinese medicine treatment hinges on the correct formula pattern identification which is a little harder than the former. (Ref: Hu Xi Shu Jiang Shang Han Za Bing Lun).
Chai Hu Gui Zhi Gan Jiang Tang formula pattern:
This was discussed in Shang Han Lun [Clause 147]: Shang han for five or six days, following the promotion of sweat, there has then been purgation, if the chest and ribs are full with a slight bind, urination is not free, there is thirst but no vomiting, sweating only from the head, alternating chills and fever, and vexation, this means there is no resolution, Chai Hu Gui Zhi Gan Jiang Tang governs. As for the interpretation of this formula, the traditional explanation from the zang fu’s perspective, this is a Shao Yang pattern characterized by Tai Yin deficient cold or the pattern is associated with the liver and gallbladder constrained heat with spleen deficiency and spleen coldness etc. Professor Feng Shi Lun based on the legacy of Hu Xi Shu had done extensive research on clause 147 and 148, suggested that this formula is a Jue Yin disease instead of Shao Yang disease.
Professor Feng Shi Lun in his book “Jie Du Zhang Zhong Jing Yi Xue” said “many specialists unanimously suggest that this is a half exterior and half interior pattern but in reality historically the general practice is to interpret Shang Han Lun with the theory in Nei Jing which regards half exterior and half interior pattern is associated with Shao Yang.
Xiao Chai Hu Tang is the representative formula for Shao Yang while Chai Hu Gui Zhi Gan Jiang Tang is a modified version of Xiao Chai Hu Tang therefore it is still associated with Shao Yang. The reason can be attributed to a lack of understanding of the essence of the Six Channels. The comprehension that the six channels described in Shang Han Lun is not the same as that discussed in Nei Jing which is associated with the zang fu and the network vessels; instead it is the theory of the eight guiding principles with the connotation of the half exterior and half interior to be part and parcel of the six channels theory. The half exterior and half interior disease location encompasses a yang and yin pattern with the yang pattern being Shao Yang disease and the yin pattern being the Jue Yin disease. The substitution of Sheng Jiang with Gan Jiang is the difference of Chai Hu Gui Zhi Gan Jiang Tang and Xiao Chai Hu Tang while at the same time implying that the function of Xiao Chai Hu Tang is focused on releasing the heat in the half exterior and half interior while Chai Hu Gui Zhi Gan Jiang Tang is focused on the elimination of cold located at the half exterior and half interior.
Chai Hu Gui Zhi Gan Jiang Tang is a frequently used formula by Professor Feng with manifestation of complex heat and cold Jue Yin disease. Clinically Professor Feng is targeting parched mouth or bitter taste in the mouth in the upper jiao and dry bowel movement in the lower jiao with cold extremities.. What is interesting to the writer is that if you interpret this from the zang fu and network vessels perspective, the above formula is characterized by spleen deficiency, spleen cold or Tai Yin deficient cold with the focus on sloppy stool. Professor Feng based on the eight guiding principles and the six channels theory regards this formula should be characterized by dry bowel movement which is described in Clause 148 as “Slight yang bind”. Professor Hu Xi Shu in this book “Hu Xi Shu “Jiang Jie Shang Han Za Bing Lun” suggested that the formula is indicated for patient with slight bowel dryness and if the person has normal bowel movement will have sloppy stool after taking this formula.
Case Study Analysis:
The patient is an aging person with chronic problem, weak constitution, cold extremities, poor appetite and the diagnosis is interior deficient cold Tai Yin disease compounded with Bi syndrome and pain and was diagnosed as Gui Zhi Shao Yao Shi Mu Tang pattern. But was not effective after one week of medication . During the second consultation, the focus is on parched mouth, dry bowel movement and cold extremities and the diagnosis was Jue Yin and Tai Yin concurrent pattern with Chai Hu Gui Zhi Gan Jiang Tang + Dang Gui Shao Yao San. The formula pattern was correct and treatment was effective. After a series of five consultations, there was no change in the core formula with slight change in the dosage and the result was good. Professor Feng when using Chai Hu Gui Zhi Gan Jiang Tang often combined with Dang Gui Shao Yao San and when asked about the reason, his reply was the formula patient often suffers from blood deficiency and exuberant water presentations.
Posted by Dr. Greta Young Jie DeFebruary 20, 2015 at 8:28 pm #1880
I will like to hear more abuat the difference between the thorey of the nei jing and shang han lun, abut the six channels
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