Golden Mirror of Clinical Practice from Famous Doctors of Ancient and Modern Times:  Mania

  Withdrawal and Epilepsy Book  (Beijing, 1999)

 

 

Case 1: Mania Pathocondition

 

36-year-old female, Gao X was seen for the first time on March 31, 1962.  In October of 1961, the patient suffered an upset at work and her spirit then became abnormal.  On February 2, 1962 she was treated at a hospital in Tianjin.  At that time she presented with slow speech, an apathetic expression, and lusterless nails. Her pulse was deep, fine and weak.  Her tongue was enlarged and crimson with deep cracks and a white coat at the base.  The diagnosis given at the hospital was dual yin and yang vacuity.  She was treated with herbs such as dang gui, shu di huang, bai shao, zhi mu, huang bai, mai men dong, shan zhu yu, mu xiang, dang shen, and e jiao.  Over the following days her condition worsened, she experienced manic agitation, a sense of dread, and at times her consciousness was unclear.  She was also not eating and thus required the use of a nasogastric feeding tube. Observation of the patient during a group consultation revealed a withered-yellow complexion with a slight redness coming through.  Her eyes were closed, she did not want to see people, did not speak,  refused to eat or drink, and had a tongue with a red tip, thin white coat, and a quiver.  The pulse overall was deep, thin, and soft, and there was constant manic agitation.  During times of manic agitation she expressed extraordinary strength, more than ten people could not restrain her, she sweated profusely to the point of dripping, which soaked her clothing and sheets, and she involuntarily urinated and defecated in bed.  In times of restlessness, a settling and tranquil formula was used and the manic agitation became even more extreme, at that point injections of glucose were used in order to restrain her.

            When discussing this disease on the basis of the pulse and symptoms, a diagnosis of dual yin and yang vacuity, and treatment using enriching and supplementing herbs would not appear to be a mistake.  However, during times of manic agitation she expressed extraordinary strength and more than ten people were still not able to control her.  If yin and yang were both vacuous, how then was it possible for her to have this extraordinary strength?  At that point, the extraordinary strength was just mania. According to the Nan Jing, the ancients say, “overabundance of yin is withdrawal, overabundance of yang is mania”.    Her complexion had redness coming through, her sweat was dripping like rain, and she displayed signs related to exuberant yang.  The initial cause of her condition was underlying depression and anger.  The depression then engendered heat, and the heat then engendered phlegm.  Worry and deliberation damaged the heart, and the depression and anger went undiffused and damaged the liver.  There was binding depression of phlegm and qi, which overwhelmed the heart qi vacuity and harassed it, this caused the spirit-mind to become abnormal, and because the phlegm was obstructing the vessel pathways, it caused the pulse to become deep, fine and without strength.  This was caused by constraint and blockage, therefore you can not diagnose this as dual yin and yang vacuity.  The tongue is the sprout of the heart, when phlegm heat harasses and stirs the pericardium the heart spirit is not quiet, causing the tongue to quiver.  The symptoms of closing her eyes and not wanting to see people, not speaking and not eating were similar to yin and vacuity patterns, but actually her symptoms were all caused by phlegm clouding the heart orifices.  To understand why treatment with a settling and tranquil formula made her manic agitation even more extreme, use the explanation that the liver thrives by orderly reaching and is ailed by restraint.  To understand why the use of glucose was able to moderate her manic agitation, use the explanation that when the liver suffers tension, promptly eat sweet in order to moderate it.  Therefore, this pattern is true excess and false vacuity.  The treatment is to sweep phlegm and offensively precipitate in order to drain excess fire. 

            Formula:

            jin meng shi  30g,  chen xiang  6g,  huang qin  9g,  qing ban xia  12g,  chen pi  9g,  yu jin  9g,  sheng bai fan  1g,   da huang  9g,  tian zhu huang  9g,  dan nan xing  9g,  xuan fu hua  9g,  dai zhe shi  15g. Decoct the formula twice. 

Using the first decoction, take one Shi Xiang Dan (Ten Fragrances Special Pill), before bed.  In the morning on an empty stomach take one dose of the following powder with the second decoction.  Separate Formula:  gan sui  4.5g,  zhu sha  1.5g, together grind into a fine powder.

 

            The patient was seen for the second visit on April 5.  After taking the gan sui she experienced relatively severe vomiting and diarrhea, therefore she only took the powder once.  She did however take the decoction continuously for 5 packs, this caused her spirit to improve and her pulse to become slippery and rapid with strength.  This was a true manifestation of phlegm heat obstruction.  The treatment was changed and herbs were used to clear heat, settle the liver, sweep phlegm, and open the orifices. 

            Formula:

            sheng shi gao  30g,  sheng shi jue ming  30g,  jin meng shi  30g,  chen xiang  6g,  huang qin  9g,  da huang  9g,  shi chang pu  9g,  zhi mu  9g,  zhu ru  12g,  long dan cao  9g,  and An Gong Niu Huang Wan (Calm the Palace with Cattle Gallstone) 1 pill dissolved into the decoction.  Every evening take one pack.

              Separate Formula:  gan sui  1.5g,  zhu sha  1.5g,  together grind into a find powder, take once each morning on an empty stomach with water.

               The patient was seen for the third visit on April 17.  The previous formula was taken until April 14, her spirit and mind were now clear, she was able to sit up and eat, she also faced the doctors and nurses and expressed regret.  Furthermore, a couple of days previous, the patient felt an upward rushing from the heart and then had to make noise and jump around, all of which she was unable to control.  The following were removed from the original formula:  shi gao,  gan sui,  and zhu sha.  Again, she took a few packs of the formula and was completely healed and discharged from the hospital.

            It is most likely that during the time of the initial visit the patient’s pulse was a manifestation of a true vacuity pattern.  It was only during times of vexation and agitation that she had unlimited extraordinary strength, at which times her actual diagnosis was false vacuity with true excess.  Herbs were used for fierce and offensive precipitation, therefore the disease healed extremely rapidly, but during the time of the initial visit the amount of gan sui used was relatively extreme, causing severe vomiting and diarrhea.  If at that time enriching and supplementing herbs were continued, the phlegm heat would have been nourished and become more extreme. I fear she would not have healed for sometime!