Third Installment: Thirst due to cold?

Today we look at the third formula in this family of formulas.  This rendition is the same as the last with the addition of Pinelliae Rhizoma preparatum (zhì bàn xià).  This creates the formula Cinnamon Twig, Poria, Schisandra, and Licorice Decoction, remove cinnamon, add Ginger, Asari, and Pinellia (guì líng wǔ wèi gān cǎo qu gui jia jiang xin xia tāng)

Taking a quick look at Giovanni Maciocia’s book entitled Diagnosis in Chinese Medicine, he gives 15 possible patterns that can cause thirst and 3 that can cause dry mouth.  Without exception all of these patterns are related to heat, either excess or deficient.  We see here in the first case, that thirst can be caused from cold as well.  In fact, thirst was the main complaint for the patient below.  This case illustrates a point that is the core emphasis in the diagnostic training that is part of the Graduate Mentorship Program: that symptoms need to be explained by the diagnosis and that most symptoms, by themselves, will not reveal the truth about what is going on with a patient.  Dr. Cao Ying-Fu held himself back from jumping to conclusions about the thirst, unlike the doctors the patient had seen previously.  He saw the cold fluids and understood physiology enough to know that ice traps fluids and makes them unavailable for moistening.  Melting and steaming the frozen water allowed the moisture to once again become physiological.  In the Graduate Mentorship Program we call this Explaining the Symptom with What We Know for Sure.  One must have a good understanding of physiology in order to do this well.  Hence, we see thirst as simply the subjective sensation of wanting fluids in the mouth and then let the rest of the diagnosis explain why this is happening.  

In the current White Pine Institute Classic Formula course with Professor Feng Shi-Lun we have seen him use Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) , which is included within the Cinnamon Twig, Poria, Schisandra, and Licorice Decoction, remove cinnamon, add Ginger, Asari, and Pinellia (guì líng wǔ wèi gān cǎo qu gui jia jiang xin xia tāng) quite a number of times for thirst and he explains this in a similar way.  The use of Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) for thirst is based on Clause 29 of the Shang Han Lun.

“When there is Shang Han the pulse is floating, there is spontaneous sweating, frequent urination, there will be heart vexation, a slight aversion to cold, and cramps in the feet, but Gui Zhi Tang is given to attack the exterior, this is a mistake.  Having given it, there is jue, the throat is dry, and if there is vexation and agitation with vomiting due to reversal, administer Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) to restore the Yang.”

I added an interesting case at the end of this post to illustrate the use of Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) for thirst below.  Notice in this case that the previous doctor treated cold but was unsuccessful due to warming the wrong location.

3. Cinnamon Twig, Poria, Schisandra, and Licorice Decoction, remove cinnamon, add Ginger, Asari, and Pinellia (guì líng wǔ wèi gān cǎo qu gui jia jiang xin xia tāng)

Poria (fú líng) 
4 liang – 12 gm
Zingiberis Rhizoma (gān jiāng) 
2 liang – 6 gm
Glycyrrhizae Radix (gān cǎo) 
2 liang – 6 gm
Schisandrae Fructus (wǔ wèi zǐ) 
1/2 sheng – 6 gm
Asari Radix et Rhizoma (xì xīn) 
2 liang – 6 gm
Pinelliae Rhizoma preparatum (zhì bàn xià) 
1/2 sheng – 6 gm

Cooking: Boil the above 6 ingredients in eight sheng of water to get three sheng.  Remove the dregs.  Take half a sheng warm, 3 times each day.

Original text [Chapter 12.38]: After you have stopped the cough and fullness, if the thirst and surging Qi arise again, this due to the hot nature of Asari Radix et Rhizoma (xì xīn) and Zingiberis Rhizoma (gān jiāng).  It is normal for there to be thirst when taking them.  However, if the thirst stops, this means [the thirst was due to] propping rheum.  Where there is propping rheum there is also dizziness and the dizziness is invariably accompanied by retching.  When there is retching, add Pinelliae Rhizoma preparatum (zhì bàn xià) to eliminate water.

(From chapter 12 of the Jin Gui Yao Lue chapter on the pulse, pattern and treatment of phlegm fluid coughing).

Case Study 1: Phlegm Rheum

Dr. Cao Ying-Fu 曹颖甫

When I lived by the North Gate, I saw a married woman named Song.  This patient suffered from a rather persistent dry mouth.  She took herbs, however they were generally not outside the realm of Rehmanniae Radix (shēng dì huáng), Dendrobii Herba (shí hú), Ophiopogonis Radix (mài mén dōng), Bambusae Caulis in taeniam (zhú rú), Anemarrhenae Rhizoma (zhī mǔ), Trichosanthis Radix (tiān huā fěn) and Panacis quinquefolii Radix (xī yáng shēn) type of medicinals.  I saw that she had a cough with runny clear spittle, a wiry pulse and a plump body.  This was a case of phlegm rheum so I gave her Cinnamon Twig, Poria, Schisandra, and Licorice Decoction, remove cinnamon, add Ginger, Asari, and Pinellia (guì líng wǔ wèi gān cǎo qu gui jia jiang xin xia tāng).  After these herbs she did not drink water all day.  The suffering had decreased.  Only then did I see Master Zhong’s words born out by the evidence:  When instead of being thirsty, the thirst stopped, this was because there was propping rheum.

From Cao Ying-Fu’s Jin Gui Fa Wei

Case Study 2, Panting pattern:

Ou Yang Lu-Qin 欧阳履钦

Mr. Song generally suffered from a panting pattern.  Because he lay down in some cold dew, the cough returned.  He felt anxious and unstable with chest obstruction and poor appetite.  Occasionally he felt like vomiting.  Because this had begun with an exposure to cold, he was given Minor Bluegreen Dragon Decoction (xiǎo qīng lóng tāng)  Although the cough was mostly gone, the excessive sweating had left his interstices open.  Putting on clothing bothered him.  Dispelling the exterior caused him to shiver with cold and receiving wind caused his cough to return even more strongly.  Dr. Ou Yang said “Although this pattern was caused by cold, it is not a Shang Han exterior pattern.  The flavors of Zingiberis Rhizoma (gān jiāng) and Cinnamomi Ramulus (guì zhī)   will warm the lung and can be used.  Ephedrae Herba (má huáng) with Cinnamomi Ramulus (guì zhī) will inevitable lead to lung deficiency.  When one sees fluid evils in the chest area with deficiency, one should use Cinnamon Twig, Poria, Schisandra, and Licorice Decoction, remove cinnamon, add Ginger, Asari, and Pinellia (guì líng wǔ wèi gān cǎo qu gui jia jiang xin xia tāng) with Huang Qi to consolidate the exterior.  I gave 5 packages and the coughing leveled but the water still overflowed upward and so there was the desire to vomit.  I continued by using the Wai Tai formula Poria Drink (fu ling yin) and there was a cure.

From Ou Yang Lu-Qin’s Case Studies 欧阳履钦医案

Discussion

It is generally understood that the hot herbs, Zingiberis Rhizoma (gān jiāng) and Asari Radix et Rhizoma (xì xīn) will damage the fluids and can cause mouth thirst.  However, this thirst was stopped when taking Zingiberis Rhizoma (gān jiāng) and Asari Radix et Rhizoma (xì xīn) and so it was due to propping fluids.  When fluids cover above it causes dizziness.  When the fluids reverse into the stomach, this causes vomiting.  There is no thirst but there is dizziness and vomiting.  One only needs to treat fluids and so one uses Poria, Licorice, Schisandra, Ginger, and Asarum Decoction (líng gān wǔ wèi jiāng xīn tāng).  Fresh Pinelliae Rhizoma preparatum (zhì bàn xià) is added to dispel water, stop vomiting and down bear rebellion.  It should be pointed out that both propping fluids and surging Qi can cause dizziness, however, when there is propping fluids, the dizziness will always be accompanied by vomiting.  There is no vomiting when the dizziness is due to surging Qi.   Surging and propping fluids are differentiated this way.

In the first case, this woman had chronic thirst.  This was due to obstruction of fluid evils in which the fluids could not be carried upward.  So, this is not true thirst.  This is why using herbs to clear heat and generate moisture did not work.  Dr. Cao used Poria, Licorice, Schisandra, Ginger, Pinellia and Asarum Decoction (líng gān wǔ wèi jiāng xīn xia tāng) and she did not drink all day and her other symptoms felt better.  This illustrates that the Yang deficiency and propping fluids were the culprits.  This verified the use of warm herbs.

In the second case, there was a panting pattern.  Although this was caused by receiving cold, there was no evidence of a damage from cold exterior pattern.  Because of this, when Minor Bluegreen Dragon Decoction (xiǎo qīng lóng tāng) was used this caused unnecessary and excessive sweating and hence the exterior became deficient.  This mistreatment lead to cough and heart palpitations along with chest fullness and poor appetite.  At times she also felt like vomiting.  This was retention of water fluids in the stomach.  Above this encroached on the heart. Poria, Licorice, Schisandra, Ginger, Pinellia and Asarum Decoction (líng gān wǔ wèi jiāng xīn xia tāng) was then used to dispel water and down bear rebellion.  I added Astragali Radix (huáng qí) to consolidate the exterior and stop sweating.  How can there be rebellion when one knows how to treat according to the pattern?  Dr. Ou Yang Lu-Qin was truly good at applying the classic formulas.

Ginger and Licorice Decoction (gān jiāng gān cǎo tāng): Dispersion Thirst

Dr. Tao Zheng-Zhui 陶政锥
The patient was a man age 43.   He was suffered from dispersion thirst and a previous doctor had diagnosed him with lack of movement of the middle Yang and lower warmer Yang deficiency.  He used the method of supplementing and warming the spleen and kidneys.  He used Regulate the Middle Pill (lǐ zhōng wán) and Kidney Qi Pill from the Golden Cabinet (jīn guì shèn qì wán) with no effect.  It was then decided that he had middle fullness with indigestion.  Then he came to see me for a diagnosis.  He had mouth thirst.  He would drink and drink but the thirst was difficult to bear.  His nose was dry without mucous.  His breath felt cold.  His tongue was pale with scanty fluids.  His pulse was slightly floating, hesitant and thin.  This was a case of lung cold with dispirited Qi. The fluids had become cold and congealed.

Ginger and Licorice Decoction (gān jiāng gān cǎo tāng) 
Glycyrrhizae Radix (gān cǎo)
10 gm
Zingiberis Rhizoma (gān jiāng) 
10 gm

I asked him to drink it like his usual tea.  He had his second visit after 10 days.  The thirst had diminished and the amount he drank decreased.  His nose was moist with mucous and his breath was warm.  I advised him to continue the formula until the end of the month and he recovered.

From: Julin Zhong Yi Yao 1986; (3) :28

Discussion:  This illness was in the upper warmer but the treatment focused on the middle and lower and therefore it was ineffective.  We did use a warming method but applied a Zang Fu diagnosis as well.  This shows that Licorice and Ginger Decoction (gān cǎo gān jiāng tāng) treats lung cold with cold qi patterns.  For this it is truly effective.

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