Module Title: Chinese Herbal Medicine Clinical Practice
Module Code: 3TCM7A3
Module Leader: Alan Treharne
Assignment: Self Directed Research
Treatment of disorders caused by phlegm: the use of Wen dan tang and its
variations
An investigation of the conditions treated with these formulas in the University of
Westminster Polyclinic compared with the ones in Chinese Medicine literature
July 2015
Total number of pages: 44
Word Count: 6937
This report is submitted in partial fulfillment of the requirements of the
University of Westminster for the award of Master of Science in Chinese
Herbal Medicine
Acknowledgements
1
I would like to thank my supervisor Alan Treharne for his guidance and
practical advice, the Polyclinic staff particularly the manager Hal Andrews for
his help and assistance in the moments of need.
I am grateful to the Polyclinic patients for letting students use their cases for
research purposes.
I express my gratitude to all my teachers for inspiring me with their ideas and
enthusiasm.
I am extremely grateful to all the great scholar physicians who have taught me
to think and learn.
Abstract
2
This study aims to discuss several topics that are intrinsically connected with
each other: the clinical uses of a formula, Wen dan tang (WDT), Warm the
Gallbladder decoction and its variations, which treat phlegm-heat conditions;
the historical perceptions of phlegm in Chinese medicine (CM); a discussion
of the different interpretations of the formula’s name, which influence its
clinical applications; the conditions are treated by this formula in the University
of Westminster (UoW) Polyclinic; and a comparison of these findings with the
wider literature in the English language. An in-depth study that closely
examines the formula and its origins will hopefully deepen the understanding
of its use and its clinical relevance in contemporary practice.
Methodology
The study employs a mixed methodology approach to compare the use of
WDT in classical and contemporary texts written in English with its application
in the UoW Polyclinic. To this end, it employs an in-depth literature review
with the examination of records of patients treated with WDT at the University
of Westminster Polyclinic between 2012 and 2015 were chosen for the
purpose of the study.
Results
The study demonstrates congruence between the conditions treated with
WDT in the UoW Polyclinic and those in the literature examined. A range of
diagnostic indicators for the use of WDT were identified in both the case
records and the literature: presence of phlegm (with form or without form) as
main pathology, greasy dirty tongue coating, and a slippery and wiry pulse.
Clinical studies will be necessary to evaluate the effectiveness of these
formulas for the wide variety of conditions presenting with these
manifestations that are commonly encountered in clinical practice.
Index
3
1. Introduction
5
2. Literature Review
5
2.1 History of the Formula
5
2.2 Historical overview of the meaning of 痰 tan, phlegm, in CM
8
2.3 Contemporary overview of 痰 tan, phlegm in CM
10
2.4 Present Research on WDT
12
3. Methodology
13
3.1 Method Description
13
3.2 Location and context
16
3.3 Data Collection
16
4. Data Analysis and Results
17
5. Discussion
20
5,1 Comparison of patients conditions with the ones in the literature
20
5.2 Contemporary understanding of phlegm
24
6. Conclusions and Recommendations
24
Reference
27
Appendix 1: Wen dan tang Formula
34
Appendix 2: Versions of WDT
35
Appendix 3: The Tridosha
36
Appendix 4: Patients Case Histories Table
37
1. Introduction
4
In our modern world many ailments are caused by a lifestyle that predisposes
people – in Chinese medical terms – to accumulate phlegm and heat due to
the consumption of a rich diet, junk food, lack of exercise, overwork, lack of
proper rest, stress, worrying and anxiety that cause more serious psychoemotional illnesses (Guo et al, 2014; Maciocia, 2009; Luria and Zelicka,
2009). Frequently encountered conditions in contemporary practice such as
hypertension, high cholesterol, diabetes, obesity, anxiety, insomnia, weight
gain as well as certain types of pain, to give just a few common examples,
may be diagnosed as ‘phlegm disorders’.
Wen dan tang (WDT), Warm the Gallbladder Decoction and its variations, is
one of the most commonly employed formulas that addresses conditions
associated with the aetiologies mentioned above. Its popularity in clinical
practice arises from the fact that WDT treats phlegm as well as the heat that
often accompanies conditions of chronic stagnation. Common clinical
indications thus include conditions such as cardio-vascular, digestive, mental
and gynaecological disorders whose incidence has considerably increased in
the industrialised world affecting not only populations of affluent nations, but
also the underprivileged social classes in developing countries (Caballero et
al, 2002; Yusuf et al, 2001). This makes WDT an appropriate focus for the
purposes of this study.
The specific aims of this study are: i) to deepen the understanding of the
formula WDT from both historical and clinical perspectives; ii) to examine
historically and theoretically the concept of phlegm; iii) to investigate which
conditions are treated with this formula and its variations in the University of
Westminster (UoW) Polyclinic; iv) to compare the findings with the wider
literature available in English language, which discusses the clinical
application of these formulas.
2. Literature Review
2.1 History of the Formula
Examining the history of WDT is important because over the centuries it
underwent changes both in medicinal constituents and indications (Scheid et
5
al, 2009). The antecedent of WDT is Er chen tang, Two Aged (Ingredients)
Decoction, which treats dampness and phlegm, descends qi counter flow and
harmonises stomach qi (Scheid et al., 2009). The two formulas have similar
constituents: zhi ban xia, chen pi, fu ling, zhi gan cao and sheng jiang; the
only difference is that WDT in addition also contains zhu ru, zhi shi and da
zao (see Appendix 1 for a full description of WDT).
The first logical question that the researcher needs to answer is why this
formula is called Wen Dan Tang (WDT), Warm the Gallbladder Decoction,
when it deals with phlegm-heat and not cold. The paradoxical name of this
formula has intrigued scholar-physicians and commentators over a long
period of time (Scheid et al, 2009).
Firstly, it is important to consider that there are two versions of the formula
(see Appendix 2): one written in the 6th century AD during the Northern Zhou
(557-581 AD) and Sui dynasties (581-618 AD) by Yao Seng-Yuan, in Ji Yan
Fang, Collection of Effective Formulas, a text that unfortunately has been lost
(Scheid et al, 2009; Wang et al, 2014). The same formula is included in Wang
Tao’s Wai Tai Bi Yao, The Arcane Essentials from the Imperial Library, for the
following condition: ‘After a severe illness [when the patient suffers from]
irritability and insomnia, it is because of Gallbladder cold (dan han)’ (Scheid et
al, 2009). The formula mentioned in this text contains more sheng jiang (12g
instead of 3-6g) and no fu ling and da zao. This version of WDT is also found
in the Qian Jin Yao Fang, Formulas Worth a Thousand, compiled by Sun SiMiao and published in 652 AD (Scheid et al, 2009; Liu, 2001).
The contemporary WDT is a modified version of the Song dynasty (960-1279)
formula, which is listed in the San yin ji yi bing zheng fang lun, Discussion of
Illnesses, Patterns and Formulas Related to the Unification of the Three
Aetiologies, written by Chen Yan (Liu, 2001), where it is indicated for
deficiency irritability patterns due to internal heat caused by constraint, with
symptoms such as headache or light headedness, sleeping problems, dry
mouth with no thirst (Scheid et al, 2009; Huang, 2009).
Deficiency in this case means that qi constraint has produced an
accumulation of heat in the chest and epigastrium, but these areas remain
6
soft on palpation (Ikeda, 2005), because in case of fullness there would be
hardness and resistance (Ikeda, 2005). WDT treats the disharmony between
the gallbladder and the stomach with phlegm-heat obstructing the qi dynamic
because by transforming phlegm and clearing heat the correct physiological qi
function and movement is restored, and the shao yang resumes the
distribution of the ministerial fire (Scheid et al, 2009). Therefore, the term
‘warm’ in the name of the formula does not mean literally supplementing the
yang qi, but rather unblocking the ministerial fire obstructed by phlegm and
heat in order to restore the expansion of physiological gallbladder qi.
‘Warming’ in this case means harmonising, which is obtained by resolving
phlegm and clearing heat, moving constraint and regulating stomach and
gallbladder qi (Scheid et al, 2009). Huang (2009) supports this view by stating
that the medicinals of WDT are not warm by nature, but they have a rather
calming effect specific for conditions where anxiety and agitation caused by
internal heat are present. Furthermore, he explains that WDT could be
thought of also as a formula that strengthens the ‘gallbladder type’, namely
people who are timid and afraid, hence ‘warming’ could mean supplementing
gallbladder qi deficiency (Huang, 2009).
According to Scheid et al (2009), modern textbooks explain that the original
formula from the 6th century AD had a warming action because it contained a
larger dosage of sheng jang, thus justifying the name of the formula. This
explanation is not convincing for the authors because the presence of zhu ru
in the formula, a herb that cools, moves downwards and opens constraint.
Rather, it supports the view that WDT unblocks the movement of qi (Ping,
2011; Huang, 2008; Bensky et al, 2004). Therefore, ‘warming’ in this case
means freeing stagnation (Scheid et al, 2009). In fact, the main action of this
formula is not to drain heat or warm cold, but to move qi and body fluids within
the shao yang in order to regulate the qi dynamic (Huang, 2009; Scheid et al,
2009). This interpretation is supported by the Qing dynasty physician Zhang
Lu (1617-1700), who stated that the gallbladder being the decision maker in
the body, directs the qi of all the other zangfu and therefore needs to be calm
and efficient, and its movement unobstructed in order to perform this task
(Scheid et al., 2009). Furthermore, the physician Chen Nian-zu (1753-1823)
7
explained that ‘warming’ the gallbladder means calming by clearing heat, and
harmonising by unclogging, thus, paradoxically, ‘cooling’ (Schied et al, 2009).
Liu (2001) includes WDT to treat attacks of damp-heat where dampness
predominates, where the san jiao’s physiological function in fluid metabolism
has been impaired. It causes abdominal distension, dark and scanty urine,
accompanied by a greasy and yellow tongue fur (Liu, 2001). In this case the
formula is indicated to treat spleen, stomach and san jiao.
In Japanese kampo WDT is used to dispel stagnant water in the stomach,
which causes obstruction and accumulation of heat, for conditions such as
gastric malfunction, palpitations and insomnia due to a weak constitution
and/or prolonged illness (Hsu and Hsu, 2006). Ikeda (2005) states that this
formula treats phlegm and thin mucus (痰飲 tan yin) in the stomach, spleen
deficiency and heat patterns. He explains that the pathological water in the
stomach, the yang qi of the gallbladder get stuck and the stagnation causes
heat rising to the chest and disturbing the heart (Ikeda, 2005).
It is interesting to notice that in Japanese herbal medicine, kampo, this
formula is prescribed to treat stagnant water and not phlegm. Therefore, the
researcher considers necessary to examine the concept of phlegm in CM in
order to fully understand and appreciate the use of this formula in clinical
practice.
2.2 Historical overview of the meaning of 痰 tan, phlegm, in CM
Buddhism entered China in the second century BC and by the first century AD
the Buddhist canon was translated in Chinese and taught widely by Buddhist
monks (Long, 2007; Kovacs and Unschuld, 1999). Buddhism had a deep
influence not only in religion, but also in Chinese political, social and
philosophical notions, which included medical knowledge (Salguero, 2014;
Deshpande, 2008). A vast cultural exchange of art and science took place
between India and China, involving also scholarly activities and thought,
science and technology (Deshpande, 2008). Particularly relevant was the
Buddhist influence in medicine because Buddhist medical ethics was
8
concerned with showing compassion and rescuing humanity from suffering;
therefore, a large part of monks’ education included medical knowledge
(Deshpande, 2008; Long, 2007). The medical exchange between India and
China reached its peak between the first and fifth century AD and went on
during the Tang dynasty (618-907). In the 8th and 9th centuries AD, Chinese
monks went to India looking for scriptures, which were then imported and
translated, thus, several Indian medical texts appeared in Chinese editions
(Long, 2007). One of the first works was a treatise on eye diseases in which
the aetiology of eye conditions was discussed and connected with Ayurveda.
It mentioned the three conventional Ayurvedic aetiological factors: wind-vata,
bile-pitta and phlegm-kapha (Deshpande, 2008), (See Appendix 3).
Several ideas introduced by the translation of these Indian texts were
integrated into the existing medical knowledge, as part of CM tradition (Long,
2007). However, the German historian Unschuld (1985) argues that the
concepts underpinning Indian medicine were incompatible with Chinese
ideas, therefore Buddhist influence was solely religious. His ideas are
contradicted by the fact that a large variety of medicinal herbs were imported
to China via the Silk route and the number of therapeutic prescriptions
increased dramatically due to the import of the new Indian pharmaceutical
ingredients; in addition, cataract surgery was introduced and thought of as
miraculous, to a point that poets wrote verses about it (Long, 2007). In fact,
the success of restoring vision to people who were almost blind was one of
the major contributing factors that facilitated the acceptance and integration of
Ayurvedic principles in CM (Long, 2007).
Furthermore, recent studies have shown that the concept of phlegm changed
when Buddhist medical texts were introduced in medieval China from India
(Nakamura et al, 1993a; Nakamura et al, 1993b). Originally 痰 tan, according
to the Shang han za bing lun, Treatise on Cold Damage and Miscellaneous
Diseases, referred to a condition of thin cold fluids, 飲 yin, in the body;
afterwards it indicated thick viscous fluid, which is more similar to what is
commonly understood by the term phlegm in the present (Nakamura et al,
1993a; Nakamura et al, 1993b).
9
These views are based on close examination of the main classical texts
predating the Tang dynasty:
a) Huangdi Neijing Suwen (Unschuld, 2011) talks about 飲 yin, mucus, in the
chapter discussing Taiyin.
b) Jin gui yao lue, Essential from the Golden Cabinet, Chapter 12 (Chang,
1983) contains a discussion on 痰飲 tan yin, stagnant water or phlegmy thin
mucus located in the five zang, stomach and intestines.
c) Bei Ji Qian Jin Yao Fang, Emergency Appendices to Prescriptions worth a
Thousand Gold, written by Sun Simiao the 6th century AD, agrees with the Jin
gui yao lue about 痰飲 tan yin (see above) and includes cough as an
additional sign (Huang and Wang, 1993).
The earliest physician who differentiated between 痰 tan, phlegm and 飲 yin,
mucus was Chao Yuanfang in the Zhubing yuan hou lun, On the Origin and
Signs of all Illnesses, which was written in 610 AD (Kovacs and Unschuld,
1999). In the chapter on external and internal causes of eye disease, Chao
states that among the latter there is so called phlegm and liquid (retention
syndrome) and adds: ‘If the pulse is more wiry, it is 痰 tan [phlegm]; if [the
pulse is] floating and thin, it means 飲 yin [mucus].’ (Kovacs and Unschuld,
1999). Chao’s work came out when the influence of Indian medicine was very
strong and many texts were translated into Chinese as already mentioned
before. This supports the argument that until the Tang dynasty CM had
discussed fluids pathology, and not phlegm pathology.
2.3 Contemporary overview of 痰 tan, phlegm in CM
Scheid et al (2009) define phlegm as ‘a disorder of the body fluids that have
become thick dense and turbid, and interfere with the proper flow of qi in the
channels, collaterals, Triple Burner, and organ system.’ The authors continue
stating that phlegm may exist in the human body without necessarily causing
illness; it is only when the body cannot transform it or get rid of it that the
problems arise; hence the strategies to address phlegm pathology is to
10
regulate the qi dynamic and strengthen the root, namely the middle jiao and
the mingmen fire (Scheid et al, 2009).
It is essential to define the difference between phlegm and dampness. The
canonical text Huangdi Neijing Suwen 5,The Yellow Emperor Internal Canon:
Simple Questions, describes dampness as one of the climatic pathogenic
factors (Unschuld, 2011). But it is also the transformative product of the
spleen and stomach (Larre and Rochat de la Vallee, 2004). Bensky et al
(2004) add that dampness is the accumulation of pathological water in the
body, such as oedema and thin mucus, which obstructs the physiological fluid
metabolism; however, this term refers mainly to the digestive and respiratory
systems. Furthermore, the authors state that herbs that resolve dampness
treat also phlegm pathologies (Bensky et al, 2004).
Most contemporary texts understand dampness as fluids that are not
metabolised nor excreted, thus, get stuck in the body. Instead, they define
phlegm as a sub-product of non-transformed fluids/dampness by the middle
jiao, which condenses and stagnates either because of qi stagnation, yang qi
deficiency or other causes (Clavey, 1995). In other words, first we have the
formation and accumulation of dampness, which then, when not drained from
the body, turns into phlegm.
Clavey (1995) and Maciocia (1989) divide phlegm into two types: ‘external’ or
substantial phlegm, which is visible and it is contained in the respiratory tract
and the lungs, and ‘internal’ phlegm (Clavey, 1995), which is not perceptible
to the eyes, hence in Maciocia’s definition ‘unsubstantial’ (1989). Howerver,
phlegm with and without form is probably a better translation of the original
Chinese terms.
In CM, ‘internal’ phlegm causes a large variety of symptoms, such as
dizziness, palpitations, insomnia, cough, diarrhoea, leucorrhoea, nodules, and
so on, affecting various body systems and areas, causing very complex
conditions, and it is usually difficult to treat (Scheid et al, 2009); phlegm, in
fact, can be found anywhere in the body (Clavey, 1995). However, the
distinction of the two types of phlegm has further understanding: for example,
11
Qin Bo Wei defines visible phlegm the one produced by cough and invisible
phlegm the thin mucus that leads to asthma (Ping, 2011).
In Ayurveda phlegm is considered one of the three humours contained in the
body, it is not a sub-product that the organism failed to eliminate, but a vital
bodily constituent that can get corrupted by all sort of factors, including diet,
lifestyle, and emotions, thus, causing illnesses (Silvestri, 2014). In other words,
it is not the result of malfunction, but it is a vital body substance that can get
damaged, and this can lead to illness (See Appendix 3).
It is very important to understand how CM combines the new concepts and
practices from Indian medicine, which include the notion of phlegm, into its
traditional knowledge. Historically CM has always integrated past ad present
traditions, it has never replaced old knowledge with new one (Unschuld, 1985;
Scheid, 2002). According to CM theory, phlegm was not part of the
physiological fluids of the body like the 津液 jin ye fluids, discussed in Suwen
23 (Unschuld, 2011), hence it had to be thought of something corrupted and
pathological that led to illness, a constituent that the body had failed to
assimilate and, instead of being excreted, had accumulated inside in
organism (Clavey,1995).
2.4 Present Research on WDT
Very few clinical studies have been conducted on WDT, mainly in China,
Taiwan and South Korea, and, unfortunately, most of them using cellular
models and animals, of which several were in Chinese language.
Xu et al’s review (2015) evaluated the efficacy of WDT in ischaemic and
haemorrhagic strokes in 26 Randomised Controlled Clinical Trials (RCTs)
conducted in China involving 1167 patients (out of 2214) taking WDT. The
conclusion of this meta-analysis was that WDT was therapeutically effective in
both types of strokes.
Gao (2000) in his article cites a few clinical examples when WDT was given to
patients suffering from diabetes micro-vascular complications, such as
diabetic nephropathy, failing vision due to diabetic retinopathy, and diabetic
12
gangrene with very positive results in patients suffering from phlegm
obstruction and stagnant qi.
In an epidemiologic study conducted in Taiwan on CHM prescriptions for
insomnia in 2002, in outpatient national care for National Health Insurance
claim, it was found that WDT was the fifth mostly prescribed formula for this
condition (Chen et al, 2011).
3. Methodology
3.1 Method Description
As stated in the Introduction, the main aim of the study is to compare the
clinical uses of WDT in the English language literature review with data from
clinical usage of WDT in the University of Westminster Polyclinic patients’ file.
The methodology used by the researcher for this part of this project focussed
primarily on qualitative data collected and analysed at the same time (Prior,
2003). The process involved several steps:
1.
Two searches on E-resources of classical and contemporary literature
in English:
a) On WDT and modifications of the formula, using various scholarly research
databases, namely PubMed, Medline, Sciencedirect, Embase, AMED and
Google scholar to find clinical applications in biomedical conditions of the
formula. The terms used were: WDT, WDT and formula modifications,
indications and use of WDT, clinical studies on WDT. Chinese medicine
journals peer reviewed were chosen, but the researcher had to rely also on
non-peer reviewed because relevant to the research question (i.e. Journal of
Chinese Medicine, The Lantern, etc.).
b) On the history of the formula and the wider concept of phlegm in CM, the
words used were: phlegm, phlegm and fluids, phlegm concept in CM,
Ayurveda, influence of Ayurveda in CM. Peer reviewed journal articles were
13
chosen by the researcher on the relevant topics. Only studies on humans
were selected for this study.
2.
Search textbooks and scholarly written books and essays in various
libraries, written by specialists in the field of East Asian (EA) studies, EA
medicine and its history, Ayurveda, CM, CHM and kampo.
3.
A search in the Polyclinic prescription file database of patients treated
between November 2011 (when these files started to be recorded in the
Polyclinic computer database) and end of April 2015, who had prescriptions
with zhu ru, one of the main medicinals of the chosen formula. This method
was suggested to the researcher by the supervisor and it was very effective in
finding all the patients who had taken WDT. It is a replicable method, because
the researcher used it for a different formula and achieved similar results.
Replicability is essential in research methods (Silverman, 2006). The patients
who attended the polyclinic for at least three consecutive visits and took WDT
or a variation of WDT for a minimum of six-eight consecutive weeks period
were selected (see Table 1: Patients’ Files Inclusion/exclusion criteria). For
convenience the maximum number of visits was limited to six. Patient data
was then saved and analysed.
4.
Patients’ files were scrutinised using a qualitative method, conditions
and main symptoms were summarised in a table in order to find similarities
and differences between the various case records (Siverman, 2006) and
group them in themes for comparison.
5.
The findings in the literature were then analysed and compared with
the ones obtained from the Polyclinic patients’ files. The aim was to compare
two different categories in order to find affinities and divergences, not to
evaluate which one was the ‘true’ representative of the conditions treated by
WDT and which was not (Siverman, 2006).
14
Table 1: Patients’ files inclusion/exclusion criteria
INCLUSION
EXCLUSION
Patients’ files stored in the Polyclinic
computer database between
15/9/2011 and 31/4/2015
Patients’ files not stored in the
Polyclinic computer database
Patient age over 18 years
Patients age under 18
Patients’ condition was chronic
Patients’ condition was acute
Minimum of three consecutive visits
over a six or more weeks period
Less than three consecutive visits
Administration of the same formula
WDT or a modification of WDT for at
least three consecutive visits
Different formulas were prescribed on
each visit
Patients took the prescribed formula
as advised
Patients stopped taking the
prescribed formula
The researcher original plan was to find patients who attended a minimum of
six consecutive visits. Unfortunately, there were not enough patients who took
WDT and/or modification of WDT for that length of time. Therefore, it was
agreed with the supervisor that the number of consultation had to be reduced.
In total seven patients, who attended the Polyclinic for three and more
sessions were found. However, the number of visits was not so important
irrelevant for the scope of this study, as it was not focussed on the effect of
the formulas but on which conditions were treated by these medicinals. The
minimum of three successive visits ensured that the patients took the
medication regularly as prescribed by the practitioners.
The rationale for selecting patients who took WDT or modified WDT for a
minimum of three consecutive treatment sessions is that conditions caused by
phlegm are chronic, difficult to treat and take a long time to improve;
therefore, the formula needs to be repeated for a prolonged period of time
(Flaws and Sionneau, 2001).
15
The researcher has chosen to examine case histories because it is a method
that has belonged to CM epistemology for centuries and it is still used
routinely in contemporary China to teach CM students how to apply the
ancient doctrines in clinical practice (Furth et al, 2007). Case records have
been a really important component in the legal and medical scholarly tradition
(Furth et al, 2007). As a genre, physicians started to include their personal
patients’ case histories in their books during the Jin and Yuan dynasties
(1115-1368 AD) in order to supply evidence of their diagnoses, treatment
strategies and methods; in other words, they were a mean to transmit medical
knowledge (Furth et al, 2007). Grant (2003) agrees with Furth et al, about
case records being a valid educational tool, and she adds that case histories
served the purposes of putting in paper clinical experience, self-promoting the
author and recording what was unusual (Grant, 2003). The cases provide an
account of the clinical encounter in all its aspects - diagnoses, treatments
employed, interactions between patients and physicians, etc. - and they give
an insight to medical practice as it happened in specific clinical contexts
(Grant, 2003).
3.2 Location and context
The location of the study was limited to London, during a definite period of
time (2011-2015) and a very small number of patients’ files were examined;
therefore, it cannot be considered representative of a significant sample of
population and used for generalization (Siegel and Castellan, 1988).
However, even a small sample can ‘tease out some generalities’, therefore, it
is important to find cases that are representative of the ‘greater phenomenon’
that the researcher is examining (Luker, 2008). This is consistent with
qualitative research method on retrospective case data, which evaluates case
histories, looking at the individual characteristics of each patient rather than
focusing on a large population sample and focus on generalities (Kane, 2004).
3.3 Data Collection
16
The patients’ data was gathered at the University of Westminster Polyclinic,
after the Polyclinic director gave permission to the researcher to access
patients’ files, which were kept in the premises during the whole investigation.
Patients’ data was saved under a patient identifier number to protect their
identity. There is an agreement signed by patients that their personal data
could be used for research purposes, providing confidentiality is maintained,
thus satisfying ethical issues.
The researcher recognised key categories to group conditions based on
patients’ signs and symptoms (including pulse and tongue), diagnoses (both
according to CM and biomedicine), treatment principles and prescribed
formulas (See Table 2: Patients’ Case Histories 1st WDT Prescription and
Appendix 4: Patients Case Histories Table). The findings were linked in order
to find common terrain giving possible themes for analysis and comparison
with the literature.
4. Data Analysis and Results
In total the researcher analysed fifty-six prescriptions, but twenty-seven were
discarded, for various reasons:
•
They were not WDT or a WDT modification
•
The information on patient’s files were not completed, hence difficult to
analyse
•
Visits intervals were too long
•
Patients had several prescriptions of which WDT was prescribed only once
•
Day sheet were missing from two patients’ file, only the administered
prescription was present
The selected files belonged to seven patients who satisfied the inclusion
criteria and were coded with alphabetical letters from A to G.
No patient had the original WDT formula; in fact, they all took a modified
version where a minimum of two and a maximum of nine herbs were added to
17
the main components. (See Table 2. Patients’ Case Histories: 1st WDT
Prescription and, for more details, Appendix 4: Patients Case Histories Table).
Table 2. Patients Case Histories: 1st WDT Prescription
Signs and
Symptoms
CM
Diagnosis
Formula
Anxiety and
sleeping
problems
Palpitations,
memory loss, hot
flushes at night,
sleeping difficulties;
thick yellow tongue
fur with middle
crack; deep and thin
pulse
Liver qi
stagnation;
spleen qi xu
with phlegmdamp; heart
blood xu
WDT + yuan
zhi, suan zao
ren, huang lian,
shan zha, chuan
xiong
10552
Insomnia
and anxiety,
pancreatic
insufficiency
Irregular sleeping
(wake up very early
and cannot fall
asleep again),
anxiety; Thick
creamy tongue
coating; slippery and
wiry pulse
Spleen and
heart qi xu
with phlegm
WDT + yuan
zhi, xia ku cao,
cang zhu
10681
Depression
and anxiety,
arthritis,
gastric
reflux, mild
hypertensio
n
Low mood, anxious,
tiredness; painful
joints back, neck
stiffness, heartburn,
constipation;
swollen, flabby
tongue body with
frontal cracks and a
dirty thick coating;
pulse rapid and full,
deficient In both chi
positions
Phlegm
accumulation
in the idle
jiao, misting
the mind and
obstructing
the joints
WDT + dang
shen, shi chang
pi, ge gen, gua
lou ren, chuan
niu xi
11450
Hypertensio
nhyperchole
sterolemia;
sleeping
problems
Heavy headedness,
hypertension; high
cholesterol; cannot
fall asleep; poor
memory and
concentration; tired,
breathlessness after
bronchitis; arthritis in
both knees; feeling
stressed and
anxious; pain on left
side of the chest,
Phlegm
stagnation in
the middle
jiao, shen
disturbance
WDT + shan
zha, suan zao
ren, he huan pi
Patient
Biomedical
ID
Condition
9696
18
two adrenal cysts;
heartburn. Flabby
and swollen tongue
body, white coating;
slippery and wiry
pulse
11065
Cholecystiti
s,
Gallbladder
stones
Epigastric and
hypochondriac pain,
yellow eyes,
bloating, flatulence,
yellow stools,
headaches; feel
stressed; slippery
pulse; swollen
tongue body,
toothmarks and thin
white fur
Damp-heat
accumulation
in liver and
gallbladder
WDT + yu jin
Blood stasis
10481
Cystic acne
and PCOS;
migraines
Acne with sore and
painful large lumps;
irregular
menstruations (2834 cycle); dizziness,
sweating (day and
night); sharp pain
under ribcage on the
right side; swollen
and wet tongue;
wiry, slippery,
deficient pulse
Dampphlegm in the
lower jiao,
blood and qi
stagnation,
stomach heat
WDT + cang
zhu. chuan
xiong, xiang fu,
xia ku cao
10700
Acne,
sleeping
problems
and anxiety
Sleeping problems,
restless legs, feeling
stressed and
anxious; acne with
spots on the back
and buttocks;
quivering tongue,
with red tip and dark
red in the middle;
wiry pulse
Phlegm-heat
with toxic
heat; shen
disturbance
WDT + suan
zao ren, xuan
shen, pu gong
yin
The most common conditions treated were: anxiety (71%), sleeping problems
(57%), hypertension (28%), loose stools (28%), poor memory (28%), acne
(28%), headache/migraine (28%), joint ache/stiffness (28%), gallstones
(14%). (See Table 3: Patients Conditions Chart).
19
Table 3: Patients Conditions Chart
According to CM pattern differentiation, all patients were diagnosed with
phlegm accumulation. The difference was in the accompanying patterns,
which caused or contribute to the formation and piling up of phlegm: spleen qi
deficiency with dampness, heart blood and qi deficiency, liver qi stagnation,
liver yang rising, heat or fire.
The same main formulas were administered to all patients during the visits
analysed by the researcher, with minor variations according to the patient’s
feedback after taking the herbal prescription and presenting signs and
symptoms occurring at the time of the treatment session (See Appendix 4).
5. Discussion
5.1 Comparison of patients conditions with the ones in the literature
WDT and variations of this formula are used for a wide range of conditions
caused by phlegm, damp-phlegm, phlegm-heat, damp-heat and phlegm-fire
(Scheid et al, 2009; Huang, 2009; Flaws and Sionneau, 2001; Maciocia,
20
1989). In psycho-emotional conditions, WDT and modifications is mostly used
for sleeping disorders and insomnia (Maciocia 2009; Jiao, 2003; Flaws and
Lake, 2001). Maciocia (2009) recommends WDT also for manic depression
accompanied by anxiety and worrying due to phlegm-heat or fire obstructing
the heart orifice with mental confusion and Shi wei WDT for qi deficiency with
phlegm. Lin and Hua (2005) recommend Huang lian WDT for irrational and
manic behaviour, while Flaws and Lake (2001) indicate both WDT and Huan
lian WDT for depression. In an interview for an Australian CM journal, Dr
Xuejian Liu said that WDT is one of the most common formulas he prescribed
for depression because it is very effective and has no side effects (Lam and
Lam, 2009). Huang (2009) states that presently this formula is clinically used
for mental illnesses and specifically for neuroses and psychoses. Frueauf
(1995) considers WDT a very effective formula to treat phlegm-heat, with
symptoms such as chronic insomnia, dreaming, restlessness, palpitation,
fullness and stuffiness in the chest, dizziness, bitter taste in the mouth, a
yellow thick tongue fur and a slippery pulse.
The most common condition treated in the Polyclinic patients was anxiety and
the second one was sleeping problems, which shows that the finding are in
agreement with the literature.
In cardio-vascular conditions, Becker et al (2005) discuss the efficacy of WDT
in myocarditis caused by phlegm-fire patterns, backed up by Chinese clinical
cases where 90% patients were cured after 1-3 months of taking Huang lian
WDT. Shi wei WDT is often prescribed for hypercholesterolemia (Becker et al,
2005). In addition, Becker et al (2005) recommend Huang lian WDT for
cardiac neurosis with palpitation and feeling of oppression in the chest.
Huang (2009) uses WDT to treat coronary heart diseases and angina pectoris
and, with Sheng mai san, for preventricular contractions. In addition, he
combines it with ren shen and huang qi for atrial fibrillation (Huang, 2009).
When there are strong manifestations of heat, such as agitation, restlessness,
irritability, sleeping problems, focal distension, red complexion, red tongue
body with a yellow coating, often causing hypertension, high cholesterol,
dizziness, chronic gastritis, etc, Huang lian WDT is a suitable formula (Huang,
21
2009). However, the author states that the key for successfully using WDT in
clinical practice is to identify correctly the presentation of this formula,
characterised by a set of specific signs and symptoms: nausea/vomiting, bitter
taste/sticky feeling in the mouth, sleeping problems, emotional instability,
greasy tongue fur (Huang, 2009).
Only two of the Polyclinic patients suffered from hypertension and one from
palpitations. The first patient, who suffered from high cholesterol and
hypertension, was taking biomedical medication, but the drugs were not
controlling effectively the blood pressure (BP). After two weeks on modified
WDT, the BP was lower. Unfortunately it was not possible to check the
cholesterol level at the time. The second patient eventually had to take the
drugs prescribed by her doctor because the BP did not decrease after more
than three months on a few modified WDT formulas. The third patient, who
took Huan lian WDT with added herbs, continued to suffer from palpitations
throughout the whole length of her treatment. However, she did not suffer
from a cardiovascular condition because her palpitations were more
pronounced whenever she felt more stressed.
In gynaecology Flaws (2005) uses Huang lian WDT for early menstruation
caused by phlegm heat. While Flaws (2006) recommends Shi yi wei WDT jia
jian for menopausal women, who have a strong constitution and are
overweight, with symptoms such as palpitations, agitation, insomnia or
sleeping problems, and plum stone qi.
In gastro-intestinal conditions, Jiao (2003) recommends to use WDT for
feeling of vexation in the chest with nausea and vomiting. It can also be used
for patients who suffered from a serious illness and are cold and have
gallbladder qi deficiency, with poor appetite and bloating, greasy tongue
coating and feeling of oppression in the stomach area (Jiao, 2003).
WDT and its modifications are often used for peptic ulcer, gastritis, biliary
disease, including cholecystitis and gallbladder stones (Huang, 2009).
22
One Polyclinic patient suffered from gallstones with epigastric and
hypochondriac pain and bloating. After nearly three months on modified WDT
the pain had gone as well as the bloating.
Other indications for WDT and its modifications comprise Meniere’s disease
(Chen and Chen, 2008), dizziness, autonomic dystonia, and epilepsy (Huang,
2009; Chen and Chen, 2008). Flaws et al (2002) indicate the use of WDT and
its modifications for diabetes mellitus due to spleen and kidney deficiency with
phlegm, damp-heat and phlegm-heat.
Liu (2007) and Dr Shen (Hammer and Rotte, 2013) advise this formula and
modifications for frequently encountered pregnancy conditions, such as
nausea and morning sickness.
Shi wei WDT, where ren shen, shu di huang, suan zao ren, and yuan shi are
added could be very effective for patients who are very thin, who might have
suffered from a prolonged serious condition, exhaustion with a thin tongue,
suffering from palpitations, forgetfulness and insomnia with a WDT
presentation (Huang 2009).
In the literature there was no mention of WDT and its variations for the
treatment of acne, joint conditions and migraine. One of the patients who
suffered from migraine found that modified WDT was helpful in lessening the
intensity of the attacks and the patient who had headaches noticed that that
they were milder. One patient who complained of heavy headiness was
completely cured of this symptom after three weeks.
The two patients with acne, reported that there was a slight improvement: in
one case the spots were less and smaller and the other had flare up only at
ovulation time.
It is interesting to note that according to tongue diagnosis, most patients
(71%) presented with a thick dirty tongue coating, either white or creamy or
yellow. The pulses were found slippery and wiry (85%) in most patients, too,
regardless whether they were full or empty. In the literature most CM authors
state that the tongue coating is usually thick, dirty, greasy, slimy (Scheid et al,
23
2009; Huang, 2009; Jiao, 2003; Flaws and Sionneau, 2001; Clavey, 1995;
Maciocia, 1989). The Japanese authors instead prefer to emphasize
abdominal diagnosis (Hsu and Hsu, 2006; Ikeda, 2005), and the presentation
that the authors give for WDT is: the abdomen feels soft and weak, and there
is focal distension and tightness under the ribcage.
Unfortunately, there was no record of abdominal diagnosis in the Polyclinic
patients file.
Finally, none of the patients reported any side effect after taking the formulas,
which is in agreement with Dr Liu (Lam and Lam, 2009), who said in the
interview that WDT is a very safe formula.
5.2. Contemporary understanding of phlegm
The other important point of the discussion is the understanding of phlegm in
contemporary CM (see above Sections 2.2 and 2.3). The questions that the
researcher asked were why it is so important to understand what is the
meaning of phlegm at different points in time and what is phlegm in modern
clinical practice. A possible answer is that it is relevant because prescriptions
compiled before the encounter with Indian medicine were addressing different
problems from those attributed to those formulas. In other words, when the Jin
gui yao lue, Essential Prescriptions from the Golden Cabinet (Wiseman and
Wilms, 2013) discusses 痰飲 tanyin, phlegm pathology, it means looking at
long term retention of fluids (Endo et al, 1994) or ‘sputum stagnancy’, which is
defined either as ‘water running in the intestines’ if located below the
diaphragm, or expectorated, if located above, in the chest (Zhang,1983). This
pathological ‘water’ refers to something different from what is meant
nowadays with 痰 tan, phlegm, namely, the pathological viscous matter
accumulated in the body because of various zangfu malfunctions and
disharmonies in the qi dynamic (Bensky et al, 2004; Clavey,1995).
Furthermore, the Jin gui yao lue recommends to treat tan yin, water
stagnancy, with warming formula, such as Ling gui zhu gan tang (Zhang,
1983), which is in the category of ‘Formulas that warm and transform water
24
and dampness’ and not in the ‘Formulas that dispel phlegm’ (Scheid et al,
2009) pointing to a totally different treatment strategy than the one associated
with WDT which is a harmonizing formula. The profound understanding of
treatment strategies a well as formulating the correct diagnoses is paramount
in CM for achieving clinical results (Ping, 2011).
6. Conclusion and Recommendations
The case histories provide an account of the clinical encounter in all its
aspects - diagnoses, treatments employed, interactions between patients and
physicians, etc. - and they give an insight to medical practice as it happened
in specific clinical contexts (Grant, 2003). They do not necessarily reflect
textbooks or journal articles because CM treats patients in a unique manner
according to their individual presentations. This explains why all the examined
patients received a modified version of WDT, with added medicinals
according to the specific signs and symptoms that they presented at each
treatment episode.
However the files were not recorded in a very precise and understandable
manner, making the clinical reasoning difficult to understand. In fact diagnosis
and treatment principle were often missing leaving the researcher to fill the
blanks from reading between the lines of the scanty information recorded on
the day sheets and prescribed formulas.
This project has explored the different conditions that WDT and its variations
treats and has treated in modern as well as classical literature. It has
compared the finding with patients’ case records retrieved from the UoW
Polyclinic to find similarities and differences. The finding showed an overall
consistency between the conditions discussed in the literature and the ones
from the Policlinic case histories treated with these formulas.
This research project has also begun to discuss the perception of phlegm in
CM. This debate is very important because the researcher has found that the
notion of phlegm has not been explained clearly in the textbooks available in
English, which are used in contemporary teaching of CM worldwide. Further
research is necessary to deepen this understanding in order to be clearer in
25
clinical practice about treatment principle and strategies when treating phlegm
disorders. In addition, further studies on the influence of Indian medicine on
CM are necessary because there is very little literature on the topic.
Finally, clinical research on patients would be very useful to evaluate the
effectiveness of WDT and its variations on the most commonly encountered
conditions that it treats, such as sleeping problems, anxiety, high cholesterol,
and hypertension.
26
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APPENDIX 1: WEN DAN TANG FORMULA (Scheid et al, 2009).
Zhu ru 6g
Zhi shi 6g
Zhi ban xia 6g
Chen pi 9g
Fu ling 4.5g
Zhi gan cao 3
Grind herbs in a powder and prepare as a draft by decocting 12g in a cup of
water with 5 slices of sheng jiang and a piece of da zao.
The chief herb is zhi ban xia, opens obstruction, dries dampness, descends
qi counter flow, transforms phlegm and regulates stomach qi. The deputy
ingredient is zhu ru, which enters the stomach and clears heat, moves
stagnation, calms irritability and pacifies the shen.
The first group of assistants comprises bitter cooling herbs: zhi shi, which
down bears qi counter flow (treats focal distension); chen pi, dries dampness
and resolves phlegm. Together with zhi ban xia and zhu ru they treat phlegmheat patterns which have caused obstruction of stomach qi and gallbladder qi
in the epigastrium and chest, producing palpitations, sleeping problems,
irritability and emotional instability.
The second group of assistants includes: fu ling neutral bland herb and zhi
gan cao, sweet and warming herb. Together they fortify the spleen, eliminate
dampness and calm the shen.
The envoy, sheng jiang regulates the stomach and gallbladder and stops
nausea and vomiting.
This formula is indicated for a wide variety of symptoms: dizziness, vertigo,
nausea, vomiting, insomnia, dream-disturbed sleep, palpitations, anxiety,
34
indeterminate gnawing hunger, seizures with sputum, focal distension, bitter
taste in the mouth, slight thirst, a greasy, yellow tongue coating, rapid pulse
either slippery or wiry.
Scheid et al (2009) explain the above symptoms as a manifestation of a
disharmony between the gallbladder and the stomach, which creates phlegmheat and obstructs the qi flow, forms constraint, thus, on one hand impeding
the rising upwards of clear yang (dizziness and vertigo), and on the other,
allowing turbid yin to ascend (nausea and vomiting); phlegm-heat stuck in the
chest disturbs the heart-zang and heart-shen (palpitations, sleeping problems,
anxiety, seizures, etc.). The authors add that phlegm in the stomach causes
the greasy tongue fur, focal distension, abundant mucus, wiry pulse, while
heat in the gallbladder produces a bitter taste in the mouth and a fast pulse.
APPENDIX 2: VERSIONS OF WEN DAN TANG
1. Wang Tao, The Arcane Essentials from the Imperial Library (6th century
AD) and Sun Simiao, Important Formulas Worth a Thousand Gold Pieces
(652 AD)
Ban xia 6g
Zhu ru 6g
Zhi shi 6g
Chen pi 9g
Sheng jiang 12g
Gan cao 3g
35
2. Chen Yan, Discussion of Illnesses, Patterns, and Formulas Related to the
Unification of the three Aetiologies (1174)
Zhu ru 6g
Ban xia 6g
Zhi shi 6g
Chen pi 9g
Fu ling 4.5g
Zhi gan cao 3g
Sheng jiang 5 pieces
Da zao 1 piece
APPENDIX 3: The Tridosha (Surendra and Prasad, 2013; Shilpa, S. and
Venkatesha Murthy, C.G., 2011)
Ayurveda doctrine of health and disease in the human body is underpinned by
the tridoshas, universal principles that govern the universe, which includes
earth, its cycles and environment. The five elements, akasa-ether, vayu-air,
tejas-fire, ap-water and prithvi-earth make all the earth creation and beings
and they combine with each other to form the three humors or three doshas,
namely wind-Vata, which is the outcome of ether and air, bile-Pitta the result
of fire and phlegm-Kapha, made of water and earth elements.
36
APPENDIX 4: Patients Case Histories Table
Patient A: ID 9696
Date of
visit
Biomedical
Signs and
Symptoms
CM Diagnosis
Formula
20/2/13
Anxiety and
sleeping
problems
Palpitations, memory
loss, hot flushes at
night, sleeping
difficulties; thick
yellow tongue fur
with middle crack;
deep and thin pulse
Liver qi
stagnation; spleen
qi xu with phlegmdamp; heart blood
xu
WDT + yuan zhi,
suan zao ren,
huang lian, shan
zha, chuan xiong
6/3/13
Anxiety and
sleeping
problems
Palpitations,
sleeping difficulties,
loose stools,
frequent urination;
thick yellow tongue
fur with middle crack
and swollen body;
slippery and wiry
pulse
Liver qi
stagnation; spleen
qi xu with phlegmdamp; heart blood
xu and heat in the
heart
Huang lian WDT +
chai hu, yuan zhi,
suan zao ren,
chuan xiong
20/3/13
Anxiety and
sleeping
problems
Sleeping difficulties,
Palpitations, feeling
panicky, loose
stools; thick yellow
tongue fur with
middle crack, but
less swollen; pulse
slippery on the right
side and weak on left
Phlegm-dampheat constraining
qi, spleen qi xu,
heart blood xu
Huang lian WDT +
chai hu, suan zao
ren,yuan zhi, chuan
xiong
22/5/13
Anxiety and
sleeping
problems
Palpitations, feeling
stress, dizziness,
twitching eyelids, hot
flushes, loose,
smelly stools with
flatulence, burping;
Thick yellow tongue
coating with middle
crack and red tip;
slippery pulse
Internal windphlegm-heat; liver
qi stagnation
WDT + bai zhu znd
tian ma
Condition
Patient B: ID 10552
Date of visit
Biomedical
Signs and Symptoms
CM Diagnosis
Formula
Irregular sleeping
(wake up very early
Spleen and
heart qi xu with
WDT + yuan zhi,
xia ku cao, cang
Condition
23/4/14
Insomnia and
anxiety,
37
pancreatic
insufficiency
and cannot fall asleep
again), anxiety; Thick
creamy tongue coating;
slippery and wiry pulse
phlegm
zhu
21/5/14
Anxiety and
insomnia;
pancreatic
insufficiency
Sleep improved, but
still problematic at
times; anxiety much
reduced, slimy stools
with difficult
evacuation; less thick
tongue coating; middle
crack; wiry pulse
Spleen and
heart qi xu with
phlegm
WDT + xia ku
cao, cang zhu
25/6/14
Anxiety and
insomnia;
pancreatic
insufficiency
Sleep non consistent,
but generally improved;
less thick tongue
coating; middle crack;
soft pulse
Spleen and
heart qi xu with
phlegm
WDT + fu shen,
xia ku cao, cang
zhu, huang bai,
ye jiao teng, zhi
zi
8/7/14
Anxiety and
insomnia;
pancreatic
insufficiency
Sleep wakeful, but can
fall asleep again;
dizziness
Spleen and
heart qi xu with
phlegm-wind
WDT + fu shen.
xia ku cao, cang
zhu, huang lian,
ye jiao teng,
xiang fu
24/9/14
Anxiety and
insomnia;
pancreatic
insufficiency
Restless sleep, with a
lot of dreams; burning
pain in the stomach;
thick creamy tongue
coating, pale and
swollen body; slippery
pulse, thin in both chi
positions
Liver qi
stagnation, liver
and gallbladder
fire, stomach
and spleen qi
xu; blood xu
WDT + fu shen.
xia ku cao, cang
zhu, huang lian,
ye jiao teng,
xiang fu
22/10/14
Anxiety and
insomnia;
pancreatic
insufficiency
Sleep improved, but
anxiety has mildly
increased; creamy
tongue coating, pale
and swollen body;
slippery pulse
WDT + fu shen,
xia ku cao, cang
zhu, huang lian,
ye jiao teng,
suan zao ren
Patient C: ID 10681
Date of
visit
Biomedical
28/5/14
Depression and
anxiety, arthritis,
gastric reflux,
mild
hypertension
Signs and Symptoms
CM Diagnosis
Formula
Low mood, anxious,
tiredness; painful joints
back, neck stiffness,
heartburn, constipation;
swollen, flabby tongue
body with frontal cracks
and a dirty thick
coating; pulse rapid
Phlegm
accumulation in
the idle jiao,
misting the
mind and
obstructing the
joints
WDT + dang
shen, shi chang
pi, ge gen, gua
lou ren, chuan
niu xi
Condition
38
and full, deficient In
both chi positions
18/6/14
Depression and
anxiety, arthritis,
gastric reflux
Anxiety and low mood
improved; pain in upper
back, neck and hands;
restless legs;
heartburn; flabby
tongue body with
frontal cracks, dry dirty
coating; pulse full in
both cun and right guan
positions, deficient In
both chi positions
Phlegm
accumulation in
the idle jiao,
misting the
mind and
obstructing the
joints
WDT + dang
shen, shi chang
pi, ge gen, gua
lou ren, chuan
niu xi, yan hu
suo
23/7/14
Depression and
anxiety, arthritis,
gastric reflux
Arthritis pains worse,
restless legs, tiredness,
heartburn, constipation
has returned; flabby
tongue body with a thin
dry coating; deficient
rapid pulse
Phlegm
accumulation in
the idle jiao,
misting the
mind and
obstructing the
joints
WDT + dang
shen, shi chang
pi, ge gen, gua
lou ren, chuan
niu xi, yan hu
suo, sang ji
sheng
10/9/14
Depression and
anxiety, arthritis,
hyperthyroidism,
hypertension,
gastric reflux
Taking thyroxine and
hypertension
medication; feels
mentally confused;
achy joints
Accumulation of
phlegm in the
interior, liver
yang rising
WDT +, dang
shen, shi chang
pi, ge gen, gua
lou ren, chuan
niu xi, yan hu
suo, sang ji
sheng, huang
qin
Patient D: ID 11450
Date of
visit
Biomedical
28/1/2015
Hypertension,
hypercholester
olemia;
sleeping
problems
Condition
Signs and
Symptoms
CM Diagnosis
Formula
Heavy headedness,
hypertension; high
cholesterol; cannot
fall asleep; poor
memory and
concentration; tired,
breathlessness after
bronchitis; arthritis in
both knees; feeling
stressed and
anxious; pain on left
side of the chest, two
adrenal cysts;
heartburn. Flabby
and swollen tongue
body, white coating;
slippery and wiry
pulse
Phlegm
stagnation in the
middle jiao,
shen
disturbance
WDT + shan zha,
suan zao ren, he
huan pi
39
4/2/15
Hypertension,
hypercholester
olemia;
sleeping
problems
BP has lowered
(140/90mmHg); less
tired and heavy
headed, but still
having sleeping
problems; phlegmy
throat; no heartburn;
emotionally up and
down; pain on left
side of chest quite
severe, waiting for a
scan. Flabby tongue
body, less swollen;
pulse deficient, both
guan positions
slippery
Phlegm
stagnation in the
middle jiao,
shen
disturbance
WDT + shan zha,
suan zao ren, he
huan pi
18/2/15
Hypertension,
hypercholester
olemia;
sleeping
problems
Heavy head gone for
the past week;
occasional
drowsiness; moods
lifted; have a nap in
the afternoon and
feel better for it;
sleep quality
improved, still
wakeful; slippery
pulse, but deficient;
less thick tongue fur
with red spots
Phlegm
stagnation in the
middle jiao,
shen
disturbance
WDT + shan zha,
suan zao ren, he
huan pi, huang qin
Signs and
Symptoms
CM Diagnosis
Formula
Epigastric and
hypochondriac pain,
yellow eyes, bloating,
flatulence, yellow
stools, headaches;
feel stressed;
slippery pulse;
swollen tongue body,
toothmarks and thin
white fur
Damp-heat
accumulation in
liver and
gallbladder
WDT + yu jin
Epigastric and
hypochondriac pain
less severe, normal
stools, headaches;
swollen tongue body,
wet white fur; wiry
pulse
Damp-heat
accumulation in
liver and
gallbladder
Patient E: ID 11065
Date of
visit
Biomedical
26/2/14
Cholecystitis,
Gallbladder
stones
1/4/14
Condition
Cholecystitis,
Gallbladder
stones
Blood stasis
WDT + yu jin and
xiang fu
40
28/5/14
Cholecystitis,
Gallbladder
stones
No pain, very mild
abdominal
discomfort, no
bloating; milder
headaches affecting
left eye; swollen
tongue body with wet
coating; fast, but
weak pulse
Damp-heat
accumulation in
liver and
gallbladder
WDT + yu jin and
xiang fu
Signs and
Symptoms
CM Diagnosis
Formula
Patient F: ID 10481
Date of
visit
Biomedical
10/9/12
Cystic acne
and PCOS;
migraines
Acne with sore and
painful large lumps;
irregular
menstruations (28-34
cycle); dizziness,
sweating (day and
night); sharp pain
under ribcage on the
right side; swollen
and wet tongue; wiry,
slippery, deficient
pulse
Damp-phlegm in
the lower jiao,
blood and qi
stagnation,
stomach heat
WDT + cang zhu.
chuan xiong, xiang
fu, xia ku cao
26/9/12
Cystic acne
and PCOS;
migraines
Acne, slight
improvement, no
new spot; no
dizziness, no pain
under rib cage; pulse
less wiry, slippery,
wiry and weak
Damp-phlegm in
the lower jiao,
blood and qi
stagnation,
stomach heat
WDT + cang zhu.
chuan xiong, xiang
fu, xia ku cao
10/10/12
Cystic acne
and PCOS;
migraines
Migraine during
period (first day and
at the end), but less
severe; period 29
days cycle; acne
worse before period,
but improved after,
skin looks clearer;
loose stools; swollen
tongue body with
toothmarks, normal
fur; pulse less wiry
Damp-phlegm in
the lower jiao,
blood and qi
stagnation
WDT + cang zhu.
chuan xiong, xiang
fu, xia ku cao
24/10/12
Cystic acne
and PCOS;
migraines
Acne improved,
flared up during
ovulation; migraine
on day 24 of the
cycle; slightly
bloated; normal
Damp-phlegm in
the lower jiao,
blood and qi
stagnation
WDT + cang zhu.
chuan xiong, xiang
fu, xia ku cao, pu
gong yin
Condition
41
stools; swollen
tongue body with
toothmarks, normal
fur; pulse less wiry
Patient G: ID 10700
Date of
visit
Biomedical
Signs and
Symptoms
CM Diagnosis
Formula
2/10/13
Acne, sleeping
problems and
anxiety
Sleeping problems,
restless legs, feeling
stressed and
anxious; acne with
spots on the back
and buttocks;
quivering tongue,
with red tip and dark
red in the middle;
wiry pulse
Phlegm-heat
with toxic heat;
shen
disturbance
WDT + suan zao
ren, xuan shen, pu
gong yin
16/10/13
Acne, sleeping
problems and
anxiety
Anxiety is less, sleep
improved; greasy
skin with red spots;
tongue quivering,
sublingual veins dark
and distended; wiry
pulse
Phlegm-heat
with toxic heat;
shen
disturbance
WDT + huang qin,
suan zao ren, xuan
shen, pu gong yin,
yuan zhi
6/11/13
Acne, sleeping
problems and
anxiety
Up and down,
anxiety with vexation
in the chest; feeling
hot in the upper
body, sweating;
sleep good; skin the
same; quivering, wet
tongue; wiry pulse,
thin and weak in the
kidneys
Phlegm-heat
with toxic heat;
shen
disturbance
WDT + huang qin,
suan zao ren, xuan
shen, pu gong yin,
yuan zhi, mu dan
pi, chi shao yao, zhi
zi
27/11/13
Acne, sleeping
problems and
anxiety
Decreased anxiety,
discovered that
suffer from OCD,
doing psychotherapy;
still get acne spots,
red with yellow pus;
loose bowels
movements; muscle
tension; feel angry;
wiry, slippery pulse;
swollen tongue body
with toothmarks and
red tip
Wind-damp-heat
in liver,
gallbladder and
stomach
WDT + huang qin,
suan zao ren, xuan
shen, pu gong yin,
yuan zhi, mu dan
pi, chi shao yao, zhi
zi, tian ma
11/12/13
Acne, sleeping
Still anxious, but less
Spleen qi xu
WDT + huang qin,
Condition
42
problems and
anxiety
obsessive about
things; hair dandruff;
acne with smaller red
spots, slight
improvement; wiry
and slippery-soft
pulse; quivering
tongue, toothmarks,
yellowish dirty fur
Damp-heat
Heart yin xu
xuan shen, pu gong
yin, yuan zhi, mu
dan pi, chi shao
yao, zhi zi, tian ma,
shi chang pu
43