Feng Shi-Lun: Reeling the Silk and Unraveling the Cocoon

The 10-month course with professor Feng Shi-Lun is up and running.  I’m relieved that it all seems to be going well.  The course is designed in a rather unprecedented way in which students view course video, read specially translated course material and send any questions to professor Feng in China.  Well, it’s all been working smoothly!  We have a wonderful group of students and a great team of translators including Greta Young, author of The Shang Han Lun Explained.  Greta translates the students questions for Dr. Feng and then translates his answers back.  Thanks to Greta and Dr. Feng, the turn around time for questions has been very fast.

The video presentations are posted each month.  These presentations will stay up and available for the entire 10 months.  There will be a total of about 60 hours of course material.

The fact that the video stays available to students means that it’s not to late to join the course!

Click here if you are interested in this course.

Dr. Feng’s approach to the Shang Han Lun is very practical and systematic.  The course is organized to go through each of the 6 levels in depth and the material is replete with case studies from Dr. Feng and Dr. Hu Xi-Shu, complete with discussions and explanations.

The second 5 hours of video and the new supplemental material is going up in 2 weeks.  This material will go in depth into the Tai Yang and Yang Ming level pathology.  Students will see the classic formulas used for both chronic and acute disorders.

I am posting two case studies, one in which he uses the method of Reeling the Silk and Unraveling the Cocoon, with discussion by Professor Feng Shi-Lun below to give you all  more of an idea about Dr. Feng’s work:

Case Study one:

Li x  male  4 years old

First consultation: 6th March 2010

History: The patient since the age of 10 months suffered from recurrent fever and had been treated by Chinese and Western medicine which was not effective to resolve his fever. His family moved to Beijing to seek treatment for him. The patient suffered from idiopathic vigorous fever every three to five days. He was diagnosed by the outpatient clinic at the San Jia Hospital in Beijing as suffering from upper respiratory infection. At the time of consultation, his body temperature was 38.6o C and was given antipyretic medication. He fever receded after sweating but this morning his body temperature was 39.6o C. The family then consulted Professor Feng Shi Lun.

S/S: Fever, nasal blockage and discharge, cold extremities; red tongue tip, white tongue coat; floating, tight and rapid pulse.

Six Channel Identification:  Tai Yang, Yang Ming concurrent pattern

Formula diagnosis: Da Qing Long + Yi Ren Bai Jiang Jie Geng Tang pattern.

Prescription: Sheng Ma Huang 18g; Gui Zhi 10g; Chao Xing Ren 10g; Zhi Gan Cao 6g; Jie Geng 10g; Sheng Yi Yi Ren 18g; Bai Jiang Cao 18g; Sheng Shi Gao 45g; Sheng Jiang 15g; Da Zao 4 pieces. 1 pack. He was instructed to take ¼ dose and covered with blanket after medication to effect slight sweating. The medication was to be continued to promote slight sweating by following the method of ¼ dose each time. All other medication should be stopped.

Second consultation: 8th March 2010

After taking 1/4 dose of the above medication, there was no sweating but his urination output increased and his body temperature was reduced (39.4o C). Continue with the second and third ¼ dose and still there was no sweating and after taking the last of the ¼ dose, there was sweating at mid-night and his body temperature was back to normal. However the following night his body temperature was again elevated to 38.8o . He did not take any anti-pyretic medication.

Current S/S: Fever, parched throat, thirst for drinks; reduced appetite; normal bowel, nasal discharge; lethargic; red tongue, bright red lips; white tongue coat and a thready, slippery and rapid pulse.

Six Channel Identification: Shao Yang, Yang Ming concurrent pattern.

Formula pattern: Xiao Chai Hu + Shi Gao

Formula: Chai Hu 24g; Huang Qin 10g; Qing Ban Xia 15g; Dang Shen 10g; Jie Geng 10g; Zhi Gan Cao 6g; Sheng Shi Gao 60g; Sheng Jiang 15g; Da Zao 4 pieces. 1 Pack with the same method of medication.

Third consultation: 10th March 2010

After the medication the fever was not resolved. Prior to the onset of fever, there was aversion to cold but his energy level improved and his appetite was normal, there was nasal discharge, his tongue coat turned yellow and his pulse was floating, wiry and rapid.

Six Channel identification: Three yang concurrent pattern.

Formula pattern: Chai Hu Gui Zhi Tang + Bai Hu Tang

Formula: Chai Hu 24g; Huang Qin 12g; Qing Ban Xia 15g; Zhi Gan Cao 6g; Gui Zhi 10g; Sheng Bai Shao 10g; Sheng Shi Gao 100g; Zhi Mu 12g; Sheng Shan Yao 10g; Dang Shen 10g; Jie Geng 10g. 1 pack.

Fourth consultation: 11th March 2010

After taking the medication last night, there was sweating and his fever was resolved. His overall energy was good, appetite was normal and bowel movement was normal. There was still nasal blockage, thirst, his tongue coat was white and the pulse was floating, tight and rapid.

Six Channel identification: Tai Yang Yang Ming concurrent pattern.

Formula pattern: Ma Huang Xing Ren Yi Yi Ren Gan Cao Tang

Presciption: Sheng Ma Huang 10g; Sheng Yi Yi Ren 30g; Chao Xing Ren 10g; Zhi Gan Cao 6g; Bai Jiang Cao 30g. 1 pack. He fully recovered.

 

Overview:

It is rarely seem that a patient should suffer from recurrent high fever for four years.

The above patient was being treated effectively with Jing Fang by employing the Six Channel pattern identification and formula pattern method. It goes without saying that the use of Six Channel identification method is very scientific.

Effective treatment strategy is to diagnose the six channel pattern with follow up diagnosis of  the correct formula pattern. Fever is a frequently encountered disease and treatment by Chinese medicine is very effective but clinically this can be difficult to resolve. The above case study can be regarded as a difficult-to-treat case. This case is basically a Yang Ming pattern right from the start with an external pattern involving Tai Yang and Shao Yang. From Professor Feng’s Six Channel identification perspective it is a Da Qing Long pattern, Ma Huang Xing Ren Yi Yi Ren Gan Cao Tang associated with Tai Yang Yang Ming formula pattern. The Yi Yi Fu Zi Bai Jiang San and Bai Hu Tang are associated with “Zheng Yang Yang Ming formula pattern”. Initially Da Qing Long Tang was use to release Tai Yang exterior and to clear Yang Ming interior heat with simultaneous elimination of exterior water damp. When combined with Yi Yi Fu Zi Bai Jiang San by omitting Fu Zi is to clear heat, expel pus, eliminate swelling ( for nasal discharge).  Xiao Chai Hu Tang + Jie Geng was used for the second consultation. According to the clinical experience of Professor Feng, if there the exterior pattern is released with residual unresolved fever, this is more to do with Xiao Chai Hu Tang + Sheng Shi Gao pattern. Bai Hu Tang + Xiao Chai Hu Tang and Gui Zhi Tang was used for the third consultation. On account of the interior heat, a large dosage of Sheng Shi Gao was used hence the dosage was up to 100g. Gui Zhi Tang is a sweat promotion and  relieving fever formula with simultaneous effect of calming the middle and regulating ying and wei. The above formula is a balanced formula as it is neither a severe antipyretic nor sweat promoting formula. In reality Gui Zhi Tang is a stomach nourishing  and augmenting fluid formula with a dual function of sweat promotion or stopping the sweat formula , a strategy of  dispelling the pathogen without untold damage to zheng qi . It can be cited as a valuable example of sweat promotion formula. Ma Huang Xing Ren Yi Yi Gan Cao Tang + Bai Jiang Cao was used at the fourth consultation to outthrust the damp qi and clearing Yang Ming heat.

Emphasis on the method of decoction for the prescription of corresponding formula pattern

The recurrent fever for the above patient can be attributed to incorrect treatment or the abuse of antibiotics. As for the incorrect treatment of Chinese medicine, this can be mainly attributed to the excessive use of heat clearing and toxin relieving herbs to resolve the fever. Professor Feng places strong emphasis on the correct use of formula to address the corresponding pattern and the stress of apart from the full comprehension of the original clause in Shang Han Lun it is vital as an ongoing exercise to summarize past clinical experience. In Shang Han Lun it states: “Treat according to the pattern [Clause 16] “ is tantamount to prescribe formula based on the pattern , a practice of using the right herbs for the pattern. The above patient’s prescription of Da Qing Long Tang with 18g of Ma Huang is an adult’s dosage hence the instruction of taking ¼ dosage each time and once sweating starts, the medication should stop. In this instance the patient after taking ¾ dose there is no sweating and sweating only occurred after the full pack was taken. This means 18g of Ma Huang is indicated for this patient to achieve the desired effect. The law dictating the correct herbal dosage is found in the text in Shang Han Lun with particular detailed description of decoction method for each formula. This patient may have consulted other Chinese medicine practitioners in Beijing and he may have responded to the initial prescription but as general rule of thumb the normal practice  at the outpatient department is to prescribe seven packs for each consultation. After the first medication, there can be changes and follow up medication may no longer be appropriate. Therefore the key factor is “Treat according to the pattern” and after one pack of medication resulting in any pattern changes, the prescription should change accordingly. Professor Feng follows the principle of jing fang and in this instance only one pack was prescribed. It must be pointed out that the patient is only four years of age and after subjecting to large dosage of sweat promoting and heat clearing formula, there was no abnormal or adverse response and once the fever is resolved, recovery ensued. This can be mainly due to the correct use of formula to address the relevant pattern. The write would like to emphasize that the six channel identification is Tai Yang and Yang Ming concurrent pattern and the formula pattern is Da Qing Long + Yi Yi Bai Jiang Jie Geng Tang.

Case Study 2

Pattern Identification by adopting the method of “ reeling the silk and unraveling the cocoon”

Chen x  male 76 years old

First consultation: 10th March 2010

The patient suffered from insomnia for many years characterized by abdominal distention, poor appetite, occasional heart fright or heart fluster, hairline sores (eczema), bitter taste in the mouth, absence of dry mouth; dry bowel movement. His tongue coat was yellow and greasy and his pulse was big.

Six Channel Identification:   Tai Yin Yang Ming concurrent pattern

Formula pattern: Huang Lian e Jiao Tang + Fu Ling Yin

Prescription: Huang Lian 6g; E Jiao Zhu 10g; Qing Ban Xia 15g; Dang Shen 10g; Chen Pi 30g; Zhi Shi 10g; Fu Ling 12g; Jiao Bai Zhu 10g; Huang Qin 6g; Pao Jing 6g; San Qi fen 2g (to be added to decoction). Seven packs.

Second consultation: 17th March 2010

After the medication, there was improvement of his appetite and sleep; reduced abdominal distention; there was persistent  heart palpitations and heart fright. His tongue coat was white and greasy and his pulse was  thready and intermittent.

Six Channel identification: Jue Yin

Formula pattern: Zhi Gan Cao Tang

Prescription: Zhi Gan Cao 10g; Dang Shen 12g; Mai Dong 15g; Sheng Di 15g; Ma Zi Ren 10g; Gui Zhi 15g; E Jiao Zhu 10g; Fu Ling 15g; Sheng Jiang 15g; Da Zao 4 pieces. Seven packs.

Third consultation: 24th March 2010

There was reduction of heart palpitations; his appetite was normal; no apparent abdominal distention; sloppy stool; slight parched mouth; no bitterness; persistent hairline sores. His tongue coat was white and greasy and his pulse was thready and intermittent.

Six Channel identification: Tai Yang;   Yang Ming Tai Yin concurrent pattern.

Formula pattern: Gui Zhi Gan Cao Long Gu Mu Li Tang + Huang Lian E Jiao Tang + Yi Yi Fu Zi Bai Jiang San + Chi Xiao Dou San.

Prescription: Huang Lian 6g; E Jiao Zhu 10g; Lian Zi Xin 3g; Sheng Yi Ren 18g; Bai Jiang Cao 18g; Gui Zhi 15g; Zhi Gan Cao 6g; Sheng Long Gu Mu Li 15g each; Lian Qian 12g; Chi Xiao Dou 15g; Dang Gui 10g; Fu Ling 12g. Seven packs.

Fourth consultation: 31 March 2010

There was substantial reduction of the hairline sores and also further improvement of his sleep, his bowel movement was sloppy. The objective of the prescription is to augment the treatment of warming and tonifying Tai Yin by omitting Fu Ling and add Pao Jiang 6g; Dang Shen 10g. Seven packs.

Fifth consultation: 7th April 2010

The patient recounted that he had a feeling of wellness during the past few days over the span of the past two years. His hairline sores was basically resolved, improved appetite , no apparent discomfort with his abdomen; energetic; but his sleep was not good with difficult bowel movement and a slight thirst. His tongue coat was white with submerged, wiry and slippery pulse.

Six Channel identification:     Tai Yang, Yang Ming, Tai Yin concurrent pattern.

Formula pattern: Gui Zhi Gan Cao Long Gu Mu Li Tang + Huang Lian E Jiao Tang + Fu Ling Yin.

Prescription: Gui Zhi 10g; Zhi Gan Cao 6g; Sheng Long Mu 15g each; Huang Lian 6g; Huang Qin 6g; E Jiao Zhu 10g; Lian Zi Xin 3g; Dang Shen 10g; Chen Pi 30g; Pao Jiang 6g; Qing Ban Xia 15g; Sheng Jiang 15g; Da Zao 4 pieces. Seven packs.

Sixth consultation: 14th April 2010

There was gradual improvement of his sleep and there was no other discomfort. His tongue coat was white and his pulse was submerged, wiry and slippery.

Six Channel identification:  Tai Yang, Yang Ming, Tai Yin concurrent pattern

Formula pattern: Gui Zhi Gan Cao Long Gu Muli Tang + Huang Lian E Jiao Tang.

Prescription: Huang Lian 3g; Huang Qin 6g; E Jiao Zhu 10g; Gui Zhi 15g; Zhi Gan Cao 6g; Sheng Long Mu 15g each; Yuan Zhi 10g; Shi Chang Pu 10g; Fu Ling 15g; Lian Zi Xin 3g; Chen Pi 30g. Seven Packs.

He was instructed that after the above medication, if there was no further discomfort, the medication should be stopped. Measures can be taken to preserve his health.

 

Overview:

The above patient on account of his age suffered from chronic illness with complications. A total of six consultations with 42 packs of medication was prescribed. Treatment effect was satisfactory due to patient’s compliance.
Six Channel disease transmission: Traditional interpretation of channel transmission is referring to pathogenic qi transmits from one channel to the next. This constitutes an important concept in Shang Han Lun. Discussion of Xun Jing Chuan (Transmission in the sequence of channels); Yue Jing Chuan (Transmission by skipping channels); transmission of exterior to interior etc are well documented in Shang Han Lun. This concept albeit is inkeeping with clinical practice. If one sticks to this theory, clinically may not always be efficacious. For example, diagnosis for the initial consultation was Tai Yin, Yang Ming concurrent pattern; second consultation was Jue Yin; third consultation was Tai Yang, Yang Ming Tai Yin concurrent pattern etc. This makes it difficult to explain the scenario with the theory of the six channel disease transmission pattern. Professor Feng explains that the concept of the six channel is not referring to the channel and its associated network vessels nor is it referring to the concept of zang fu hence it cannot be explained from the perspective of the six channel disease transmission. In reality the disease pattern can be Tai Yang followed by Tai Yin the next day and then back to Tai Yang. Therefore the key issue is to identify the correct channel pattern and treat accordingly. This is basically the “Essence of the Six Channel” and Professor Feng Shi Lun in his book “Jie Du Zhang Zhong Jing Yi Xue” quoted Hu Xi Shu’s philosophy on the essence of the six channel said: “In accordance with the eight guiding principles ie exterior, interior and half exterior and half interior, all of which reflects the disease location; as for the yin, yang, cold, heat, deficiency and excess are associated with disease conditions. Clinically the disease condition must be reflected on the disease location; likewise the disease location also reflects the disease condition. Thus, any absence of disease location, there should not be any disease condition and vice versa. On account of the cold, heat, deficiency and excess are under the scope of yin and yang, therefore irrespective of exterior, interior or half exterior and half interior, all of which can be differentiated into yin and yang. Thus the three disease locations and the two types of disease conditions can be summarized into six different categories known as the six channels.

 Pattern Differentiation of complex syndrome:

Given the three disease locations (exterior, interior and half exterior half interior)  coupled with yin, yang, cold, heat, deficiency and excess, one can proceed to identify the six channels with a follow up diagnosis of the formula pattern which basically constitutes the Chinese medicine pattern identification and treatment. Hu Xi Shu in his book “Hu Xi Shu Jiang Shang Han Za Bing Lun” pointed out that the effectiveness of Chinese medicine treatment hinges on the correct formula pattern and treatment. He also pointed out that it is more difficult to identify the correct formula pattern compared with the identification of the six channel and eight guiding principles. It can be seen that the identification of formula pattern to treat prolonged and chronic illness can be complicated.

By using the outline of the six channel as basis coupled with the symptoms and signs of the patient, identify the correct channel followed by the formula pattern formulates  the normal procedure of diagnosis. However when encountered complex syndrome, apart from knowing the normal procedure, one must be familiar with possible changes which  may present a pattern totally  not inkeeping with the normal condition, similarly factors causing the disease may affect the normal manifestations of formula pattern. Professor Feng Shi Lun in his book “Jie Du Zhang Zhong Jing Yi Xue” pointed out that the treatment strategy of Zhang Zhong Jing albeit focused  on the eight guiding principles and the six channels, in reality there can be many other pathogenic factors such as qi and blood, dietary; blood stasis; phlegm and water rheum and dampness etc. Therefore apart from the basic diagnosis, one must factor in identification of qi and blood, blood stasis; phlegm and water rheum and dampness which is strongly reflected in the diagnosis of formula pattern.

The above case study cannot be classified as a typical example of the six channel disease. Basically each and every formula pattern identification can be regarded as hearsay evidence. The reason being there can be many factors affecting the six channel concurrent disease patterns well as well as the modified formula patterns. In practical terms this is often the case.

An Analysis of the case study:

The patient initially suffered from insomnia and abdominal distention, poor appetite, a pulse which is neither floating nor wiry, greasy tongue coat implying the disease location is in the interior. When coupled with symptoms such as dry bowel movement, bitter taste in the mouth which  can be diagnosed as a Yang Ming pattern, there was absence of thirst and the pulse was not excess indicating the abdominal distention is associated with Tai Yin. The “Wai Tai Mi Yao” Fu Ling Yin pattern seems to be the appropriate formula. Professor Feng Shi Lun in his book “Zhong Guo Tang Ye Jing Fang” points out that Fu Ling Yin is effective in the treatment of  “hard glomus below the heart, reversal fullness and loss of appetite with additional Ban Xia and larger dosage of Chen Pi to achieve optimum results. Insomnia, heart fright, bitter taste in the mouth, dry bowel movement, yellow tongue coat seem to be associated with Shao Yang half exterior and half interior; however the pulse is not wiry with accompanied abdominal distention can be Yang Ming interior pattern with formula such as  Huang Lian E Jiao Tang pattern for deficient vexation and insomnia. At the second consultation, heart palpitations is a key symptom and this coupled with thready and intermittent pulse and the patient’s age, Jue Yin disease and Zhi Gan Cao Tang pattern can be a consideration.  Professor Feng categorized Zhi Gan Cao Tang as a Tai Yin disease during his earlier clinical years and overtime with accumulated clinical experience , he considered Zhi Gan Cao Tang is associated with Jue Yin disease.  During the third consultation, the key symptom was hairline sores which can be regarded as Tai Yang and with the combined insomnia, abdominal distention, the diagnosis was exterior cold with interior water rheum and the formula is Gui Zhi Gan Cao Long Gu Muli Tang pattern with simultaneous Tai Yin formula Chi Xiao Dou Dang Gui San + Yang Ming Fu Zi Yi Yi Bai Jiang San for treatment of sores. It is a difficult to treat pattern with many complications hence there are changes in the formula to address the change.

To summarize the above case study characterized with multi-channel diseases and complications, most of which are all reflected during the course of the treatment.

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