Guest guest Report post Posted March 12, 2010 Hello Academy, I am new to the group so hopeful I will post this case with the needed info. Thank you in advance for the advice. 32-year-old women Main symptom: insomnia sleeps only 4-6 hours a night. Started after her gall bladder was removed a few years ago. Has trouble falling asleep and staying asleep. Tosses and turns and feels irritated by not being able to sleep. Has dream disturbed sleep and nightmares. Other symptoms: Severe allergies- both food and environmental. Manifest as congestion and runny nose with clear discharge, sore throat that is itchy, and left ear pain that also keeps her up at night, and sneezing. Overweight: has been trying to lose weight but it is not coming off. Digestion: bloated, has a bowel that does not feel complete. BM dry and small. Menses: heavy, blood clots, pain before and first few days. Acne: Many small raised bumps all over face skin colored. Tongue: red tip with stasis dots back slightly thick white fur. Pulse: slippery rapid Diagnosis: damp-heat, wind-damp heat and blood stagnation Chai Hu Jia Long Gu Mu Li Tang was given for one week. No effect on the insomnia. Digestion seemed more complete though. This week gave Fang Feng Tong Sheng San so no report on this Rx yet. What are your thoughts on this case if you could please recommend a formula. Thanks so much excited to hear comments. ~Suzanne Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 12, 2010 What about Ding zhi san? Less intense than Chai hu jia long gu mu li tang: Ingredients: Poria cocos fungus-spirit, Dens draconis mineral, Polygala tenuifolia root, Poria cocos fungus, Panax ginseng root, Pseudostellaria heterophylla root, Acorus tatarinowii rhizome. - Fu shen, Long chi, Yuan zhi, Fu ling, Ren shen, Tai zi shen, Shi chang pu and then you can add Suan zao ren or based on gall bladder removed, sore throat, left ear pain...a Xiao chai hu tang modification? Chai hu, Huang qin, Ban xia, Ren shen, Sheng jiang, Gan cao, Da zao, Fu shen, Long chi, Yuan zhi, Shi chang pu, Suan zao ren (12 herbs total) K On Fri, Mar 12, 2010 at 7:38 AM, suz <suzstricker wrote: > > > Hello Academy, > I am new to the group so hopeful I will post this case with the needed > info. Thank you in advance for the advice. > 32-year-old women > Main symptom: insomnia sleeps only 4-6 hours a night. Started after her > gall bladder was removed a few years ago. Has trouble falling asleep and > staying asleep. Tosses and turns and feels irritated by not being able to > sleep. Has dream disturbed sleep and nightmares. > Other symptoms: > Severe allergies- both food and environmental. Manifest as congestion and > runny nose with clear discharge, sore throat that is itchy, and left ear > pain that also keeps her up at night, and sneezing. > Overweight: has been trying to lose weight but it is not coming off. > Digestion: bloated, has a bowel that does not feel complete. BM dry and > small. > Menses: heavy, blood clots, pain before and first few days. > Acne: Many small raised bumps all over face skin colored. > Tongue: red tip with stasis dots back slightly thick white fur. > Pulse: slippery rapid > Diagnosis: damp-heat, wind-damp heat and blood stagnation > Chai Hu Jia Long Gu Mu Li Tang was given for one week. No effect on the > insomnia. Digestion seemed more complete though. > This week gave Fang Feng Tong Sheng San so no report on this Rx yet. > What are your thoughts on this case if you could please recommend a > formula. Thanks so much excited to hear comments. > ~Suzanne > > > -- "" www.tcmreview.com Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 12, 2010 Hi Suzanne, Your case looks to me like post-operative blood stagnation turning into heat which is causing the insomnia. I suggest a cold-natured blood activating formula along with a cooling shen calming formula. Gui Zhi Fu Ling Wan is cool and activating for the blood. Tian Wang Bu Xin Dan is cooling and calming to the shen. If you're in a position to add a few single herbs, consider adding a dash of huang lian and lian qiao which both remove heat from the Yang Ming but also calm the shen by clearing heat from the Heart. -al. On Fri, Mar 12, 2010 at 7:38 AM, suz <suzstricker wrote: > > > Hello Academy, > I am new to the group so hopeful I will post this case with the needed > info. Thank you in advance for the advice. > 32-year-old women > Main symptom: insomnia sleeps only 4-6 hours a night. Started after her > gall bladder was removed a few years ago. Has trouble falling asleep and > staying asleep. Tosses and turns and feels irritated by not being able to > sleep. Has dream disturbed sleep and nightmares. > Other symptoms: > Severe allergies- both food and environmental. Manifest as congestion and > runny nose with clear discharge, sore throat that is itchy, and left ear > pain that also keeps her up at night, and sneezing. > Overweight: has been trying to lose weight but it is not coming off. > Digestion: bloated, has a bowel that does not feel complete. BM dry and > small. > Menses: heavy, blood clots, pain before and first few days. > Acne: Many small raised bumps all over face skin colored. > Tongue: red tip with stasis dots back slightly thick white fur. > Pulse: slippery rapid > Diagnosis: damp-heat, wind-damp heat and blood stagnation > Chai Hu Jia Long Gu Mu Li Tang was given for one week. No effect on the > insomnia. Digestion seemed more complete though. > This week gave Fang Feng Tong Sheng San so no report on this Rx yet. > What are your thoughts on this case if you could please recommend a > formula. Thanks so much excited to hear comments. > ~Suzanne > > > -- , DAOM Pain is inevitable, suffering is optional. http://twitter.com/algancao Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 13, 2010 Hi Al, I was a little surprised to see your description of gui zhi fu ling wan as 'cool', would you mind explaining that? Have you seen/heard of it being used to treat heat syndromes? Regards, Henry Al Stone wrote: > I suggest a cold-natured blood activating formula along with a cooling shen > calming formula. > > Gui Zhi Fu Ling Wan is cool and activating for the blood. > Tian Wang Bu Xin Dan is cooling and calming to the shen. > Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 13, 2010 Hi Al, Gui zhi fu ling san looks good, but do you think that Tian wang bu xin dan might be a little too sticky? She has phlegm, mucus, is overweight... slightly thick fur and slippery, rapid pulse... K On Fri, Mar 12, 2010 at 10:59 PM, Al Stone <al wrote: > Hi Suzanne, > > Your case looks to me like post-operative blood stagnation turning into > heat > which is causing the insomnia. > > I suggest a cold-natured blood activating formula along with a cooling shen > calming formula. > > Gui Zhi Fu Ling Wan is cool and activating for the blood. > Tian Wang Bu Xin Dan is cooling and calming to the shen. > > If you're in a position to add a few single herbs, consider adding a dash > of > huang lian and lian qiao which both remove heat from the Yang Ming but also > calm the shen by clearing heat from the Heart. > > -al. > > On Fri, Mar 12, 2010 at 7:38 AM, suz <suzstricker wrote: > > > > > > > Hello Academy, > > I am new to the group so hopeful I will post this case with the needed > > info. Thank you in advance for the advice. > > 32-year-old women > > Main symptom: insomnia sleeps only 4-6 hours a night. Started after her > > gall bladder was removed a few years ago. Has trouble falling asleep and > > staying asleep. Tosses and turns and feels irritated by not being able to > > sleep. Has dream disturbed sleep and nightmares. > > Other symptoms: > > Severe allergies- both food and environmental. Manifest as congestion and > > runny nose with clear discharge, sore throat that is itchy, and left ear > > pain that also keeps her up at night, and sneezing. > > Overweight: has been trying to lose weight but it is not coming off. > > Digestion: bloated, has a bowel that does not feel complete. BM dry and > > small. > > Menses: heavy, blood clots, pain before and first few days. > > Acne: Many small raised bumps all over face skin colored. > > Tongue: red tip with stasis dots back slightly thick white fur. > > Pulse: slippery rapid > > Diagnosis: damp-heat, wind-damp heat and blood stagnation > > Chai Hu Jia Long Gu Mu Li Tang was given for one week. No effect on the > > insomnia. Digestion seemed more complete though. > > This week gave Fang Feng Tong Sheng San so no report on this Rx yet. > > What are your thoughts on this case if you could please recommend a > > formula. Thanks so much excited to hear comments. > > ~Suzanne > > > > > > > > > > -- > , DAOM > Pain is inevitable, suffering is optional. > http://twitter.com/algancao > > > Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 13, 2010 I was actually looking for a blood moving formula that had dan shen (Rx. Savliae) and chi shao (Rx. Peonae Rubra) in it. Those were really the goal. But seeing the fu ling (Poria) and tao ren (Sm. Persica), both of which are neutral works for me too. The fu ling is good for her phlegm/dampness too. To address the heat, it may be prudent to lower the dosage of the gui zhi in there, otherwise if you look at the formula all at once, it seems to me that it is on the cool side on balance. -al. On Sat, Mar 13, 2010 at 7:10 AM, henry_buchtel <henry.buchtelwrote: > > > Hi Al, I was a little surprised to see your description of gui zhi fu ling > wan as 'cool', would you mind explaining that? > > Have you seen/heard of it being used to treat heat syndromes? > > Regards, Henry > > Al Stone wrote: > > > I suggest a cold-natured blood activating formula along with a cooling > shen > > calming formula. > > > > Gui Zhi Fu Ling Wan is cool and activating for the blood. > > Tian Wang Bu Xin Dan is cooling and calming to the shen. > > > > > -- , DAOM Pain is inevitable, suffering is optional. http://twitter.com/algancao Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 13, 2010 Yeah, I hear ya, John, but based on the patient's chief complaint of insomnia, I gave the heat and stagnation more weight and other things less weight. My goal with Tian Wang Bu Xin Dan was to cool the heart and its blood. But I recognize that might aggravate the middle jiao stuff. That's one reason I would encourage the addition of huang lian and lian qiao to cool and dry the yang ming. And this is really about case management too, Heart problems get in the way of compliance. If she's feeling more calm and sleeping better, she'll be back, and then you can start to focus on the dampness. I don't even know where that's coming from right now. Could be the backup of fluids that are addressed by the fu ling in the stagnation of qi, blood, and fluids in gui zhi fu ling wan. If she gets indigestion on the TWBXD, then we'd want to add something for that, maybe some cang zhu, shan zha and mai ya. Something like that. -al. On Sat, Mar 13, 2010 at 8:02 AM, <johnkokko wrote: > > > Hi Al, > Gui zhi fu ling san looks good, but do you think that Tian wang bu xin dan > might be a little too sticky? > She has phlegm, mucus, is overweight... slightly thick fur and slippery, > rapid pulse... > > K > > On Fri, Mar 12, 2010 at 10:59 PM, Al Stone <al<al%40gancao.net>> > wrote: > > > Hi Suzanne, > > > > Your case looks to me like post-operative blood stagnation turning into > > heat > > which is causing the insomnia. > > > > > I suggest a cold-natured blood activating formula along with a cooling > shen > > calming formula. > > > > Gui Zhi Fu Ling Wan is cool and activating for the blood. > > Tian Wang Bu Xin Dan is cooling and calming to the shen. > > > > If you're in a position to add a few single herbs, consider adding a dash > > of > > huang lian and lian qiao which both remove heat from the Yang Ming but > also > > calm the shen by clearing heat from the Heart. > > > > -al. > > > > On Fri, Mar 12, 2010 at 7:38 AM, suz <suzstricker<suzstricker%40>> > wrote: > > > > > > > > > > > Hello Academy, > > > I am new to the group so hopeful I will post this case with the needed > > > info. Thank you in advance for the advice. > > > 32-year-old women > > > Main symptom: insomnia sleeps only 4-6 hours a night. Started after her > > > gall bladder was removed a few years ago. Has trouble falling asleep > and > > > staying asleep. Tosses and turns and feels irritated by not being able > to > > > sleep. Has dream disturbed sleep and nightmares. > > > Other symptoms: > > > Severe allergies- both food and environmental. Manifest as congestion > and > > > runny nose with clear discharge, sore throat that is itchy, and left > ear > > > pain that also keeps her up at night, and sneezing. > > > Overweight: has been trying to lose weight but it is not coming off. > > > Digestion: bloated, has a bowel that does not feel complete. BM dry and > > > small. > > > Menses: heavy, blood clots, pain before and first few days. > > > Acne: Many small raised bumps all over face skin colored. > > > Tongue: red tip with stasis dots back slightly thick white fur. > > > Pulse: slippery rapid > > > Diagnosis: damp-heat, wind-damp heat and blood stagnation > > > Chai Hu Jia Long Gu Mu Li Tang was given for one week. No effect on the > > > insomnia. Digestion seemed more complete though. > > > This week gave Fang Feng Tong Sheng San so no report on this Rx yet. > > > What are your thoughts on this case if you could please recommend a > > > formula. Thanks so much excited to hear comments. > > > ~Suzanne > > > > > > > > > > > > > > > > > -- > > , DAOM > > Pain is inevitable, suffering is optional. > > http://twitter.com/algancao > > > > > > Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 13, 2010 The chi shao and mu dan pi in GZFLW would be helpful for that clotting in the blood in the lower jiao and cool the blood. Gui zhi, fu ling, chi shao, mu dan pi, tao ren.... great idea and then add something for the insomnia, like suan zao ren and ye jiao teng (moves blood as well) for the damp/phlegm... yuan zhi as in An mien pian... a modification of Suan zao ren tang with yuan zhi in it. K On Sat, Mar 13, 2010 at 11:36 AM, Al Stone <al wrote: > I was actually looking for a blood moving formula that had dan shen (Rx. > Savliae) and chi shao (Rx. Peonae Rubra) in it. Those were really the goal. > But seeing the fu ling (Poria) and tao ren (Sm. Persica), both of which are > neutral works for me too. The fu ling is good for her phlegm/dampness too. > > To address the heat, it may be prudent to lower the dosage of the gui zhi > in > there, otherwise if you look at the formula all at once, it seems to me > that > it is on the cool side on balance. > > -al. > > On Sat, Mar 13, 2010 at 7:10 AM, henry_buchtel <henry.buchtel > >wrote: > > > > > > > Hi Al, I was a little surprised to see your description of gui zhi fu > ling > > wan as 'cool', would you mind explaining that? > > > > Have you seen/heard of it being used to treat heat syndromes? > > > > Regards, Henry > > > > Al Stone wrote: > > > > > I suggest a cold-natured blood activating formula along with a cooling > > shen > > > calming formula. > > > > > > Gui Zhi Fu Ling Wan is cool and activating for the blood. > > > Tian Wang Bu Xin Dan is cooling and calming to the shen. > > > > > > > > > > > > > -- > , DAOM > Pain is inevitable, suffering is optional. > http://twitter.com/algancao > > > Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 13, 2010 Thanks for the comments! I agree Tian Wang Bu Xin Dan seems to be too sticky/moistening right now. Although calming/cooling to the heart the dampness will also be nourished. I think the damp-heat needs to be cleared first. ~Suzanne , Al Stone <al wrote: > > Yeah, I hear ya, John, but based on the patient's chief complaint of > insomnia, I gave the heat and stagnation more weight and other things less > weight. My goal with Tian Wang Bu Xin Dan was to cool the heart and its > blood. But I recognize that might aggravate the middle jiao stuff. That's > one reason I would encourage the addition of huang lian and lian qiao to > cool and dry the yang ming. > > And this is really about case management too, Heart problems get in the way > of compliance. If she's feeling more calm and sleeping better, she'll be > back, and then you can start to focus on the dampness. I don't even know > where that's coming from right now. Could be the backup of fluids that are > addressed by the fu ling in the stagnation of qi, blood, and fluids in gui > zhi fu ling wan. > > If she gets indigestion on the TWBXD, then we'd want to add something for > that, maybe some cang zhu, shan zha and mai ya. Something like that. > > -al. > > Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 13, 2010 Insomnia is a very common symptom that can be caused by at least four different patterns with differnet pathomechanism respectively. By seeing which base formula you choose, we can deduct what pathomechanisms you deem. In your case, you use Chai Hu Jia Long Gu Mu Li Tang. It is a formula from Shang Han Lun and the pathomechanism should be qi stagnation in the liver and gall bladder, fluid and blood stagnation. The treatment methods are blood-invigorating, phlegm-promoting, qi-moving, and calming. It best addresses to phlegm-heat clouding the brain. In accordance with the principle of pattern differenitation of visceral and bowel established in Jin Gui Yao Lue (The Essential of Golden Cabinet), the related viscera should be heart and spleen. I guess this may explain why Chai Hu Jia Long Gu Mu Li Tang did not work as it did not address the heart and spleen issue. Fang Feng Tong Sheng San is a formula that addresses wind heat in dual exterior and interior. Signs should include heat in the exterior marked exuberant heat, chills etc. Internally there are thirst, bitterness in the mouth, fright, dizzness, conspitation, sores,reddish urines, etc. It will increase more heat signs and damage to yin as there are quite a few purgative medicinals. I wish i could contribute more but there are no sufficient data for me to come up with a proper diagnosis, things that you have not included in your description such as ---how long the insomnia (better use sleeplessness as insomnia is a western medicine term, we have to use our symptom) has been ---color of urine ---mense duration, color, punctuality, etc. By firming identifying the pathomechanisms, especially the teachings of Jin Gui Yao Lue, which is first and ultimate the book of internal medicine, our diagnosis is as evidence-based as any other medical modalities, if not more. My 2 cents, Sung, Yuk-ming Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 13, 2010 Al, Rather than going all over the map (two formulas, adding ingredients for this and that), one can work with a good base formula such as, perhaps, huang lian tang. One cannot treat a 'chief complaint' and ignore other aspects of a case, especially contradictory ones, as they may provide the key to resolving it. If dampness is a major issue, it may be interfering with sleep. Not only that, by exacerbating dampness, you will just worsen the case, it can't just be pushed aside. It was the gall bladder that was removed before the problem began, therefore it may be possible that we have an issue of qi transformation involving gall bladder, spleen and stomach, especially with the bloating. The fact that the chai hu jia long gu mu li tang helped her digestion is a sign that you may want to continue in this direction with a similar formula. The 'ban xia xie xin tang' family is closely related to the 'xiao chai hu tang' family, and many cases of insomnia are resolved by rectifying qi transformation. Sharon Weizenbaum published a similar case of insomnia to this one in a recent issue of " The Lantern " which used a modification of ban xia xie xin tang to great effect. Evil heat often collects in the chest when qi transformation is obstructed, by opening up ascending clear yang and descending turbid yin, the evil heat will be relieved, the bloating will be reduced, and perhaps the runny nose will improve as well. . I'd be curious about two things: 1) when did she develop menstrual problems 2) is she on any medications. . On Mar 13, 2010, at 11:46 AM, Al Stone wrote: > Yeah, I hear ya, John, but based on the patient's chief complaint of > insomnia, I gave the heat and stagnation more weight and other things less > weight. My goal with Tian Wang Bu Xin Dan was to cool the heart and its > blood. But I recognize that might aggravate the middle jiao stuff. That's > one reason I would encourage the addition of huang lian and lian qiao to > cool and dry the yang ming. > > And this is really about case management too, Heart problems get in the way > of compliance. If she's feeling more calm and sleeping better, she'll be > back, and then you can start to focus on the dampness. I don't even know > where that's coming from right now. Could be the backup of fluids that are > addressed by the fu ling in the stagnation of qi, blood, and fluids in gui > zhi fu ling wan. > > If she gets indigestion on the TWBXD, then we'd want to add something for > that, maybe some cang zhu, shan zha and mai ya. Something like that. > > -al. > > > On Sat, Mar 13, 2010 at 8:02 AM, <johnkokko wrote: > >> >> >> Hi Al, >> Gui zhi fu ling san looks good, but do you think that Tian wang bu xin dan >> might be a little too sticky? >> She has phlegm, mucus, is overweight... slightly thick fur and slippery, >> rapid pulse... >> >> K >> >> On Fri, Mar 12, 2010 at 10:59 PM, Al Stone <al<al%40gancao.net>> >> wrote: >> >>> Hi Suzanne, >>> >>> Your case looks to me like post-operative blood stagnation turning into >>> heat >>> which is causing the insomnia. >> >>> >>> I suggest a cold-natured blood activating formula along with a cooling >> shen >>> calming formula. >>> >>> Gui Zhi Fu Ling Wan is cool and activating for the blood. >>> Tian Wang Bu Xin Dan is cooling and calming to the shen. >>> >>> If you're in a position to add a few single herbs, consider adding a dash >>> of >>> huang lian and lian qiao which both remove heat from the Yang Ming but >> also >>> calm the shen by clearing heat from the Heart. >>> >>> -al. >>> >>> On Fri, Mar 12, 2010 at 7:38 AM, suz <suzstricker<suzstricker%40>> >> wrote: >>> >>>> >>>> >>>> Hello Academy, >>>> I am new to the group so hopeful I will post this case with the needed >>>> info. Thank you in advance for the advice. >>>> 32-year-old women >>>> Main symptom: insomnia sleeps only 4-6 hours a night. Started after her >>>> gall bladder was removed a few years ago. Has trouble falling asleep >> and >>>> staying asleep. Tosses and turns and feels irritated by not being able >> to >>>> sleep. Has dream disturbed sleep and nightmares. >>>> Other symptoms: >>>> Severe allergies- both food and environmental. Manifest as congestion >> and >>>> runny nose with clear discharge, sore throat that is itchy, and left >> ear >>>> pain that also keeps her up at night, and sneezing. >>>> Overweight: has been trying to lose weight but it is not coming off. >>>> Digestion: bloated, has a bowel that does not feel complete. BM dry and >>>> small. >>>> Menses: heavy, blood clots, pain before and first few days. >>>> Acne: Many small raised bumps all over face skin colored. >>>> Tongue: red tip with stasis dots back slightly thick white fur. >>>> Pulse: slippery rapid >>>> Diagnosis: damp-heat, wind-damp heat and blood stagnation >>>> Chai Hu Jia Long Gu Mu Li Tang was given for one week. No effect on the >>>> insomnia. Digestion seemed more complete though. >>>> This week gave Fang Feng Tong Sheng San so no report on this Rx yet. >>>> What are your thoughts on this case if you could please recommend a >>>> formula. Thanks so much excited to hear comments. >>>> ~Suzanne >>>> >>>> >>>> >>> >>> >>> >>> -- >>> , DAOM >>> Pain is inevitable, suffering is optional. >>> http://twitter.com/algancao >>> >>> >>> Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 14, 2010 Hi all, Z'ev is on the right track in my opinion, and brings to mind the formula Gan Cao Xie Xin Tang, which includes the " vexation " angle. Brandt Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 14, 2010 Since Suzanne is a friend of mine and I recommended that she post her case, I thought I should chime in. I think Z'ev's analysis, so far, makes the most sense. First let's look at the diagnosis. I think it out is that there is heat. There is also strong evidence for some damn/phlegm. I do not think the blood clots alone are enough to implicate blood stagnation and the gallbladder surgery can mean many things (one must look at the presentation). I am curious why people see so much blood stasis here? As Z'ev pointed out this may manifest as a chief transformation issue. Let's look at other ideas people suggested. 1. Ding zhi wan, fang feng tang sheng san, & xiao chao hu tang does not fit the diagnosis. 2. TWBXD + GZFLW - is too cloying and misses the damp/phlegm component - But Al's point about getting the person to sleep is important, but should be at the expense of missing the core dynamic. But my opinion, the best sleep/Shen calming formula in the world is useless if it does not fit the pattern. Furthermore, GZFLW + " suan zao ren and ye jiao teng yuan " -- again looks like a great insomnia formula but does not really fit the pattern. I know everyone has their style, but I always try to understand the underlying mechanism and treat the pattern and not focus on the " chief complaint " . There is clearly some middle burner involvement, hence why Z'ev is on the right track. This must be addressed. I suggest a classical formula idea from the Ling Shu, such as a ban xia shu mi method. Treatment Principle: improve the qi dynamic, transform damp and phlegm, clear heat, and calm the spirit. Consider something along these lines: Jiang ban xia 6 Shu mi 12 Shi chang pu 6 Chao huang lian 3 Chao zhu ru 9 Fu shen 12 Yuan zhi 9 Yu jin 6 Da huang tan 6 Chao bing lang 6 Guang mu xiang 6 Also for a more straight forward approach consider modified versions of wen dan tang, san ren tang, or ban xia xie xin tang family. - Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 14, 2010 Sorry, my previous post was sent by mistake- it was not edited. Here is a corrected first paragraph. " Since Suzanne is a friend of mine and I recommended that she post her case, I thought I should chime in. I think Z'ev's analysis, so far, makes the most sense. First let's look at the diagnosis. I think it is clear that there is heat. There is also strong evidence for some damn/phlegm. I do not think the blood clots alone are enough to implicate blood stasis (or at least a primary cause of the insomnia) and the gallbladder surgery can mean many things (one must look at the presentation). I am curious why people see so much blood stasis here? As Z'ev pointed out this may be as a qi transformation issue - this makes sense. So first let's look at other ideas people suggested. " -Jason On Behalf Of Sunday, March 14, 2010 9:30 AM RE: Insomnia Since Suzanne is a friend of mine and I recommended that she post her case, I thought I should chime in. I think Z'ev's analysis, so far, makes the most sense. First let's look at the diagnosis. I think it out is that there is heat. There is also strong evidence for some damn/phlegm. I do not think the blood clots alone are enough to implicate blood stagnation and the gallbladder surgery can mean many things (one must look at the presentation). I am curious why people see so much blood stasis here? As Z'ev pointed out this may manifest as a chief transformation issue. Let's look at other ideas people suggested. 1. Ding zhi wan, fang feng tang sheng san, & xiao chao hu tang does not fit the diagnosis. 2. TWBXD + GZFLW - is too cloying and misses the damp/phlegm component - But Al's point about getting the person to sleep is important, but should be at the expense of missing the core dynamic. But my opinion, the best sleep/Shen calming formula in the world is useless if it does not fit the pattern. Furthermore, GZFLW + " suan zao ren and ye jiao teng yuan " -- again looks like a great insomnia formula but does not really fit the pattern. I know everyone has their style, but I always try to understand the underlying mechanism and treat the pattern and not focus on the " chief complaint " . There is clearly some middle burner involvement, hence why Z'ev is on the right track. This must be addressed. I suggest a classical formula idea from the Ling Shu, such as a ban xia shu mi method. Treatment Principle: improve the qi dynamic, transform damp and phlegm, clear heat, and calm the spirit. Consider something along these lines: Jiang ban xia 6 Shu mi 12 Shi chang pu 6 Chao huang lian 3 Chao zhu ru 9 Fu shen 12 Yuan zhi 9 Yu jin 6 Da huang tan 6 Chao bing lang 6 Guang mu xiang 6 Also for a more straight forward approach consider modified versions of wen dan tang, san ren tang, or ban xia xie xin tang family. - Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 14, 2010 Thank you for all of your thoughtful comments!!! I will try to answer the questions you have. " Sleeplessness " for about 2 years since her gallbladder was removed. Urine color dark yellow 2-3 times a week otherwise normal. Menses: has had menstrual issues all her life. 5 days long, 28 day cycle regular, bright red in color. Medications: Claritin during day, other antihistamines, allergy shots. ~Thanks Suzanne , " Yuk Ming " <sxm2649 wrote: > > Insomnia is a very common symptom that can be caused by at least four different patterns with differnet pathomechanism respectively. By seeing which base formula you choose, we can deduct what pathomechanisms you deem. > > In your case, you use Chai Hu Jia Long Gu Mu Li Tang. It is a formula from Shang Han Lun and the pathomechanism should be qi stagnation in the liver and gall bladder, fluid and blood stagnation. The treatment methods are blood-invigorating, phlegm-promoting, qi-moving, and calming. It best addresses to phlegm-heat clouding the brain. > > In accordance with the principle of pattern differenitation of visceral and bowel established in Jin Gui Yao Lue (The Essential of Golden Cabinet), the related viscera should be heart and spleen. I guess this may explain why Chai Hu Jia Long Gu Mu Li Tang did not work as it did not address the heart and spleen issue. > > Fang Feng Tong Sheng San is a formula that addresses wind heat in dual exterior and interior. Signs should include heat in the exterior marked exuberant heat, chills etc. Internally there are thirst, bitterness in the mouth, fright, dizzness, conspitation, sores,reddish urines, etc. It will increase more heat signs and damage to yin as there are quite a few purgative medicinals. > > I wish i could contribute more but there are no sufficient data for me to come up with a proper diagnosis, things that you have not included in your description such as > > ---how long the insomnia (better use sleeplessness as insomnia is a western medicine term, we have to use our symptom) has been > > ---color of urine > > ---mense duration, color, punctuality, etc. > > By firming identifying the pathomechanisms, especially the teachings of Jin Gui Yao Lue, which is first and ultimate the book of internal medicine, our diagnosis is as evidence-based as any other medical modalities, if not more. > > My 2 cents, > > Sung, Yuk-ming > Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 14, 2010 Jason, There are many paths up a mountain... If we're going to use a Xie xin tang family formula it should be Gan cao xie xin tang, which Arnaud Versluys uses to good effect for these kinds of sleep issues. In Formulas and Strategies 2nd ed.. pg. 130 " This formula is used at present, particularly in Japan, for sleep disorders including difficulty in falling asleep, frequent waking, unrefreshed sleep, dream-disturbed sleep, talking in one's sleep and somnambulism...(from the Jin gui yao lue): The patient is silent and desires to sleep (but) the eyes cannot be closed (and when) they get up they are restless. " However, I'm going to defend Al's recommendation of Gui zhi fu ling wan, but not TWBXD, because her primary complaint started after surgery (blood stasis).. the removal of her Gall Bladder. She has heavy periods with blood clots and pain. I agree with your friend Suzanne's diagnosis that there is blood stasis and damp/phlegm heat. So modifying Gui zhi fu ling wan to address the damp/phlegm heat, such as adding Huang qin and Ban xia would be just fine. Gui zhi fu ling wan consists of five herbs: Gui zhi, Fu ling, Chi shao, Mu dan pi, Tao ren Fu ling is a damp-clearing medicinal, Chi shao and Mu dan pi move and cool blood and Tao ren moves blood, especially in the lower jiao. Suzanne's patient also has dry and small stools, which would be addressed with Tao ren. Also, I'm curious why a Xiao chai hu tang modification wouldn't " fit the pattern " here? The three major Xie xin tangs are modifications of the root formula: Xiao chai hu tang, with only a change in Chai hu vs Huang lian and Sheng jiang vs Gan jiang. This patient has clearly a GB related issue (shao yang), has a itchy (wind) sore throat and left ear pain (sides = shao yang). XCHT fits her pattern of damp-heat in the MJ (shao yang specifically) and addresses the branches, as well. The patient has sneezing and a runny nose (wind) and Chai hu vents wind and heat. Xiao chai hu tang: Chai hu, Huang qin, Ban xia, Ren shen, Sheng jiang, Gan cao, Hong zao This formula addresses the damp/phlegm heat in the MJ/UJ and harmonizes the internal with the external. Also, the blood stasis in the lower jiao could be seen as a transmission of Shao yang into Jue yin (uterus), where Xiao chai hu tang would be the formula to vent out the heat and wind. As far as Wen dan tang, I like this formula a lot... Zhu ru and Zhi shi are an amazing combination to harmonize the GB/ST and the rest is basically Er chen tang, except classically Er chen tang has Ju hong and Wu mei, while Wen dan tang has Chen pi and Hong zao. Can you explain more about the Ban xia / Shu mi method from the " Ling shu " ? Is that from the Ling shu? This is a great discussion... K On Sun, Mar 14, 2010 at 8:30 AM, < > wrote: > > > Since Suzanne is a friend of mine and I recommended that she post her case, > I thought I should chime in. I think Z'ev's analysis, so far, makes the > most > sense. First let's look at the diagnosis. I think it out is that there is > heat. There is also strong evidence for some damn/phlegm. I do not think > the > blood clots alone are enough to implicate blood stagnation and the > gallbladder surgery can mean many things (one must look at the > presentation). I am curious why people see so much blood stasis here? As > Z'ev pointed out this may manifest as a chief transformation issue. Let's > look at other ideas people suggested. > > 1. Ding zhi wan, fang feng tang sheng san, & xiao chao hu tang does not > fit the diagnosis. > > 2. TWBXD + GZFLW - is too cloying and misses the damp/phlegm component > - But Al's point about getting the person to sleep is important, but should > be at the expense of missing the core dynamic. > > But my opinion, the best sleep/Shen calming formula in the world is useless > if it does not fit the pattern. > > Furthermore, GZFLW + " suan zao ren and ye jiao teng yuan " -- again looks > like a great insomnia formula but does not really fit the pattern. I know > everyone has their style, but I always try to understand the underlying > mechanism and treat the pattern and not focus on the " chief complaint " . > > There is clearly some middle burner involvement, hence why Z'ev is on the > right track. This must be addressed. I suggest a classical formula idea > from > the Ling Shu, such as a ban xia shu mi method. > > Treatment Principle: improve the qi dynamic, transform damp and phlegm, > clear heat, and calm the spirit. > > Consider something along these lines: > > Jiang ban xia 6 > > Shu mi 12 > > Shi chang pu 6 > > Chao huang lian 3 > > Chao zhu ru 9 > > Fu shen 12 > > Yuan zhi 9 > > Yu jin 6 > > Da huang tan 6 > > Chao bing lang 6 > > Guang mu xiang 6 > > Also for a more straight forward approach consider modified versions of wen > dan tang, san ren tang, or ban xia xie xin tang family. > > - > > > > > Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 14, 2010 Yes John, there are many paths, never stated otherwise. What I present is just my opinion. For the record Al was using GZFLW *together with* TWBXD - and I still think this is incorrect. Yes ban xia shu mi tang is from the Ling Shu. -Jason On Behalf Of Sunday, March 14, 2010 10:43 AM Re: Insomnia Jason, There are many paths up a mountain... If we're going to use a Xie xin tang family formula it should be Gan cao xie xin tang, which Arnaud Versluys uses to good effect for these kinds of sleep issues. Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 14, 2010 Jason, I'd like to read up on Ban xia shu mi... can you quote the chapter/verse? Thanks... Btw.. I also think that phlegm is kind of a dam/n thing.... J wrote: " There is also strong evidence for some damn/phlegm " . I know this was just a typo, but it was kind of funny. Also, just curious for those on the list, 1. What do you think happens with the Hun when the GB is removed from the body? I've heard that Long gu ( " dragon bone " ) can root the Hun, anyone else heard of this kind of thing or seen it in any literature? 2. According to the Five Flavors lecture from Arnaud Versluys, the sour flavor medicinals astringe the Heart (fire phase)... Wu wei zi and Suan zao ren. Do you think these should be added to the formula now or later? Cheers, K On Sun, Mar 14, 2010 at 11:56 AM, < > wrote: > > > Yes John, there are many paths, never stated otherwise. What I present is > just my opinion. For the record Al was using GZFLW *together with* TWBXD - > and I still think this is incorrect. > > Yes ban xia shu mi tang is from the Ling Shu. > > -Jason > > <%40> > [ <%40>\ ] > On Behalf Of > Sunday, March 14, 2010 10:43 AM > <%40> > Re: Insomnia > > > Jason, > There are many paths up a mountain... > If we're going to use a Xie xin tang family formula it should be Gan cao > xie > xin tang, > which Arnaud Versluys uses to good effect for these kinds of sleep issues. > > Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 14, 2010 I am pretty sure it is from Chapter 71, but I am sure you can find info about if you look. -Jason On Behalf Of Sunday, March 14, 2010 1:28 PM Re: Insomnia Jason, I'd like to read up on Ban xia shu mi... can you quote the chapter/verse? Thanks... Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 14, 2010 Geoff wrote: " Lastly - make her do some cardio between dinner and bedtime. Not 2 hours of a spin class, but even 15 minutes of some 80% max HR (220 - age) kind of something to blow some steam off before calming down for the evening. " Can you explain more about how this is effective for insomniacs? I thought that a quiet walk around the block after dinner and then resting for the night, without stimulating the brain was a good idea. Doing cardio in the morning increases metabolism and Sympathetic NS firing. How does doing cardio at night help with sleep.... Thanks, K On Sun, Mar 14, 2010 at 12:53 PM, yingsuke2002 <ozark.canuckwrote: > > > Hi Suz - > The few symptoms that jumped out at me were: > > > --- In <%40>, > " suz " <suzstricker wrote: > >Tosses and turns and feels irritated by not being able to sleep. Has dream > disturbed sleep and nightmares. > > Overweight: has been trying to lose weight but it is not coming off. > > Digestion: bloated, has a bowel that does not feel complete. BM dry and > small. > > Menses: heavy, blood clots, pain before and first few days. > > Acne: Many small raised bumps all over face skin colored. > > Tongue: red tip with stasis dots back slightly thick white fur. > > Pulse: slippery rapid > > Diagnosis: damp-heat, wind-damp heat and blood stagnation > > My first thoughts are to run to Long Dan Xie Gan Wan as it sounds like a > lot of Liver symptoms. 'Feels irritated' 'tossing and turning' 'nightmares' > 'trying to lose weight (I immediately think of stress eating)' 'bloated' > 'dry small stool' > > Is the dream disturbed sleep related to wacky dreams or the nightmares? I > think of nightmares more related to Liver and weird dreams related to the > Heart. > > It's quick and easy to cool fire - acupuncture can do a good number on heat > too - then you can think about more long term strategies that others have > also suggested with phelgm etc. > > Lastly - make her do some cardio between dinner and bedtime. Not 2 hours of > a spin class, but even 15 minutes of some 80% max HR (220 - age) kind of > something to blow some steam off before calming down for the evening. > > What dosage of herbs are you giving? > Geoff > > > -- "" www.tcmreview.com Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 14, 2010 Jason, Thanks. This is very interesting... goes together with that thread of Nei jing channels/ herbalism. This connects the yang qiao/ yin qiao treatment for insomnia/somnolence = UB 62/ KD 6 along with a 2 herb formula: Ban xia tang formula: L 71-4 " Bo-Gao replied: Fill eight shengs (1 sheng = 1 liter) of water that runs from one thousand miles away, and shake it for ten thousand times to strike a balance between yin and yang. And then take 5 shengs of water to boil over fire of reed, because reed burns fast after the water has settled down. After water is boiling, place 1 sheng of husked sorghum (Shu mi), five ges (1 ge= 1 deciliter or one tenth of a liter) of processed ban-xia in the boiling water and continue to boil over low heat until water is reduced to one and half shengs. And then, remove dregs from the utensil. Drink a small cup of decoction each time, three times a day, or according to the conditions of the individual patient until it takes effect. A new patient may go to bed right after drinking the decoction and it takes effect as soon as perspiration starts. As to an old patient, it may take three doses to take effect. " (Henry Lu's 2nd ed. translation) I asked you to " Shu mi the money " . That's a very cool passage. Now, just got to get some sorghum somewhere. where? K On Sun, Mar 14, 2010 at 12:53 PM, < > wrote: > > > I am pretty sure it is from Chapter 71, but I am sure you can find info > about if you look. > > > -Jason > > <%40> > [ <%40>\ ] > On Behalf Of > Sunday, March 14, 2010 1:28 PM > > <%40> > Re: Insomnia > > Jason, > I'd like to read up on Ban xia shu mi... can you quote the chapter/verse? > Thanks... > > Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 14, 2010 Kokko: Gui zhi fu ling wan consists of five herbs: Gui zhi, Fu ling, Chi shao, Mudan pi, Tao ren Stephen Not sure why you keep citing Chi Shao considering the prominent position of Bai Shao in the Tang Ye Jing and the consistent " fit " of Bai shao in formulas of Shanghan Zabing Lun tradition - I believe that this too is Baishao Guizhi + Baishao is an extremely important pairing it would be consistent with SHL formula architecture and makes more sense functionally than chishao Also, from reading the signs and symptoms - it seems that Z'ev's approach should be looked into Suzanne, you posted that the pulse was slippery rapid may I ask at which position you observed the slippery image? if it was right hand 2nd position, it would strongly support the use of dahuang or huanglian + ganjiang can you give us more pulse info? Stephen Woodley LAc www.shanghanlunseminars.com -- http://www.fastmail.fm - Does exactly what it says on the tin Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 14, 2010 Stephen, In the earliest materia medicas and in the Shang han za bing lun, Bai shao and Chi shao were not differentiated, but named " Shao yao " . The species for both is Paeonia lactiflora. The difference today is that Bai shao is cultivated Paeonia lactiflora with the bark removed, while Chi shao is the wild-crafted and the bark is retained (Bensky,Clavey,Stoger MM 3rd ed) So, by going with the rules of the formula, we can choose either herb to use. In this particular patient's case, we can choose either one.. but Chi shao works better for her case with the blood stasis and heat. I've already stated that Gan cao xie xin tang would be an ideal choice, according to the Shang han za bing lun method, but we should also be open to other ways of treating a patient, especially when we don't have the fukushin reflexes and specific pulse-position picture. If the pulse is slippery, wiry and rapid in the left guan position.... Huang qin slippery, rapid in the right guan position...da huang/ huang lian If both positions, then a Xie xin tang would cover both. Without actually being there, I stand on the potential effectiveness of another formula helping the patient as well, either a modified Xiao chai hu tang (my rx), modified Gui zhi fu ling tang (wan would be too sticky- honey pill) (Al's rx) or Ban xia shu mi tang modification (Jason's rx). Great discussion. K On Sun, Mar 14, 2010 at 5:50 PM, stephen woodley <learntcmwrote: > > > Kokko: > > Gui zhi fu ling wan consists of five herbs: Gui zhi, Fu ling, Chi > shao, Mudan pi, Tao ren > > Stephen > Not sure why you keep citing Chi Shao > considering the prominent position of Bai Shao in the Tang Ye > Jing and the consistent " fit " of Bai shao in formulas of Shanghan > Zabing Lun tradition - I believe that this too is Baishao > Guizhi + Baishao is an extremely important pairing > it would be consistent with SHL formula architecture and makes > more sense functionally than chishao > > Also, from reading the signs and symptoms - it seems that Z'ev's > approach should be looked into > > Suzanne, > you posted that the pulse was slippery rapid > may I ask at which position you observed the slippery image? > if it was right hand 2nd position, it would strongly support the > use of dahuang or huanglian + ganjiang > > can you give us more pulse info? > > Stephen Woodley LAc > www.shanghanlunseminars.com > > -- > http://www.fastmail.fm - Does exactly what it says on the tin > > > Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 15, 2010 would a modified wen dan tang be an appropriate direction? Quote Share this post Link to post Share on other sites
Guest guest Report post Posted March 15, 2010 Kokko In the earliest materia medicas and in the Shang han za bing lun, Bai shao and Chi shao were not differentiated... Stephen Sure, we've all heard this...but with your studies of the Tangye jing you know that Baishao is the Earth herb of the metal class and Chishao can't fulfill this positioning. So, I had to poke you Kokko So, by going with the rules of the formula, we can choose either herb to use. In this particular patient's case, we can choose either one. but Chi shao works better for her case with the blood stasis and heat. Stephen: Don't think I can agree with this...the relationship of Guizhi + Baishao is one of outside and inside the vessels and can't be improved upon. IMO, Chishao doesn't represent an improvement, only straying from a perfectly balanced formula. I do agree that we could use more info on the patient, that's why I asked for more pulse info from Suzanne. It is interesting and yeah, without actually seeing the patient it is mostly an exercise in conjecture. see you this weekend Stephen Woodley LAc www.shanghanlunseminars.com -- http://www.fastmail.fm - A fast, anti-spam email service. Quote Share this post Link to post Share on other sites
