Seattle Institute of Oriental Medicine

A Cold With Complications - 2nd Year Student Translation

A Cold with Complications:  
A Case Report Using a Combination Formula of
Sang Ju [Yin]-Yin Qiao [San] (桑菊飲-銀翹散) with
Fu Zi Xi Xin [Tang] (附子細辛湯) to Treat a Cold

Translated from A Half Day in Clinic; A Half Day of Reading (半日臨証半日讀書) by Xing, Bin (刑斌)

Translators: SIOM Class of 2016
Samantha Chin, Ellaina Lewis, Pei-Hwa Lin, Lee Mahoney, Isaac Mann-Silverman, Gabi Masek, Michele O’Connell-Fujii, Corey Ojima
Instructor: Daniel L Altschuler, EAMP, PhD

Ms. Shi, female, 42 years old.  First office visit: December 4, 2003.

Main Complaints:  Nasal congestion for two weeks; center of her upper back has had a sensation of cold for ten days; her right eye has been bloodshot, distended and painful for one week

Medical History:  Two weeks ago [she] developed a sore throat, followed by nasal congestion and discharge as well as a cough.  Several days later she experienced a cold sensation in the center of her upper back; she also had a loss of appetite.  One week later her right eye became bloodshot, distended, and painful.  She went to a hospital in Jia Ding, Shanghai, for a diagnosis. [They noted that] her right eye conjunctiva was severely bloodshot (+++), her cornea was normal (-) and the pupil was normal (-). She was diagnosed with right eye conjunctivitis. They prescribed Ribavirin, as well as both antibacterial eye drops and Aureomycin ointment to apply on the eye.  Because these medications proved ineffective she came to my clinic for treatment.

Current Presentation:  Itchy throat; a cough with a little phlegm; nasal congestion; dry mouth; pain in the occipital region; sensation of cold in the center of her upper back; loss of appetite; stools moved daily yet were dry; right eye was bloodshot and distended

The patient denied having a fever or aversion to cold [chills] at the onset of the illness. She reported that she typically feels colder during winters however this sensation of cold in the upper back is unusual.  Further she would not normally have a dry mouth.  Her bowel movements were daily and smooth.  

Examination:  Her right eye conjunctiva was clearly bloodshot. Her throat was swollen and the respiratory sounds in both lungs were normal.  Her tongue was light red and fat.  Her [tongue] coating was thin and white, yet light yellow and greasy at the tongue base.  Her pulse was thin.

My diagnosis was Yang deficiency as the root with a contracted wind-heat [pathogen].

    1.    Sang ye     桑葉        30g
    2.    Ju hua        菊花        30g
    3.    Jin yin hua     金銀花    15g
    4.    Lian qiao    連翹        15g
    5.    Zhi fu zi    制附子    9g
    6.    Xi xin        細辛        2.4g
    7.    Pu gong ying    蒲公英    30g
    8.    Qiang huo    羌活        9g
    9.    Ban lan gen    板藍根    30g
    10.    Jie geng    桔梗        9g
    11.    Sheng gan cao     生甘草    12g
    12.    Ting li zi    葶藶子    18g
    13.    Xing ren    杏仁        9g
    14.    Ma bo        馬勃(包)    4.5g        bagged
    15.    Tian zhu zi    天竺子    9g        bagged
    16.    Tian jiang ke    天漿殼    7g
    17.    Zhi bai bu    炙百部    15g

5 bags.  
This formula was boiled 3 times, each time for 15 minutes.  The first two decoctings were taken orally; to the third decocting, an additional 30g of pu gong ying was added, [and the patient was instructed to] use it to steam her head and eyes.  

December 9, 2003:  second visit
After [finishing] the first bag, the cold sensation in her upper back and occipital pain disappeared.  Her nose also unblocked.  [After] 3 bags, her itchy throat, cough and bloodshot right eye were significantly alleviated.  Only a slightly uncomfortable sensation in her throat and an occasional cough in the mornings remained.  

A modified Zhi Ke San (止咳散) was prescribed to consolidate the treatment. She recovered fully after 2 bags.

Commentary:  The present case is an example of a cold with a rather long disease progression that comprised quite a few symptoms.  Of note is that some symptoms presented as heat while other symptoms presented as cold.  This made the differential diagnosis particularly challenging.  This is a difficult case with respect to other [typical] cold presentations.

I will now analyze this from three aspects.

1.  The sensation of cold in the upper back

Both a wind and cold attack from the exterior and  a deficiency of Yang Qi can result in the upper mid-back feeling cold.  At the onset of this illness, the patient neither had an aversion to cold nor did she experience this cold sensation in the upper back. This [symptom] appeared only after four to five days.  This is unlike the [typical presentation of an] external cold pathogen.  Instead, it resembles a presentation subsequent to damage of the Zheng Qi by pathogenic Qi.  Because the patient was [typically] colder in the winter than an average person, and her tongue was light red and fat, I determined the cause to be Yang deficiency.

This case reminds the reader to pay attention and take note of the clinical interview. Not only should one ask about present circumstances [but it is also] necessary to inquire about past history so as to understand the illness’ cause and development. This helps to accurately analyze the patient’s illness.

2.  There is a cold sensation in the upper back and the tongue is light red and fat. There is thirst, bound stool, and the right eye is bloodshot. The tongue coating is thin, white, and the root is light yellow and greasy.

These symptoms must all be taken into consideration together to make a proper differential diagnosis.

The patient already has cold [symptoms] manifesting yet there are [also] heat signs [present].  It is inappropriate to group them together into a single disease mechanism.  Through inquiry I learned that 1. she normally did not have thirst; 2. she had daily bowel movements; and 3. she typically felt colder than the average person during winters.  [From this I] determined her body had Yang deficiency that subsequently received a wind-heat [pathogen].

Wind-heat attacked the exterior of the lung causing nasal congestion, sore throat and a cough.  Wind-heat upwardly attacked causing the right eye to be bloodshot.  Wind-heat has the ability to gradually enter the interior therefore she had a dry mouth and bound stools.  The tongue coat was thin and white and the root appeared thin, yellow and greasy.  Because of her pre-existing Yang deficiency, her tongue was light red and fat and the pulse was thin.  Because the wind-heat external pathogen damaged  Zheng Qi, her Yang Qi could not warm the spaces between the flesh, and therefore her upper back felt cold.  These particular symptoms do not appear to match the symptoms of previous common colds that she had experienced.
It is a common belief that Yang deficiency leads to contracting wind-cold and Yin deficiency leads to contracting wind-heat.  How is it that here there is [fundamental] Yang deficiency with contracted wind-heat?  One must correctly understand the internal and external causes of the disease’s development.  The process of the development of this disease lies between the patient’s constitution and the [externally acquired] pathogen. The constitution functions as the internal cause and the pathogen functions as the external cause.  Yang deficiency is easily affected by wind-cold, Yin deficiency is easily affected by wind-heat.  In fact, this illustrates that different constitutions are susceptible to different natured [pathogens].  Furthermore, there are also differing tendencies in the course of disease development.  On the other hand, the pathogen, functioning as an external cause also brings into play a definite action particularly at the time when the pathogen is relatively strong when it can become the dominate factor.  In the present case the body was Yang deficient and affected by a rather vigorous wind-heat.  Even while there was severe injury to her Yang Qi, there was also damage to her Yin Qi.  
3. Formula analysis

I understand the mechanism of this case, however there lacked an established formula [that I could draw from].  I could only borrow the principles of the classic formulas and devise my own.  The formula in this particular case was based on changing the principles of the established formulas that support Zheng Qi and resolve the exterior such as Ma huang Fu zi Xi xin Tang.  I constructed a combined formula by selecting the two methods of dispersing wind-heat and warming Yang to expel cold.  [This formula] heavily used sang ye and ju hua at 30 grams to scatter wind, clear heat, and clear the eyes.  Jin yin hua, lian qiao and pu gong ying help resolve the exterior and clear heat.  Ting li zi and xing ren benefit the lung Qi.  Jie geng, sheng gan cao and ban lan gen clear the throat.  Tian zhu zi, tian jian ke, zhi bai bu stop the coughing.  On the other side, fu zi and xi xin warm Yang and dispel cold.  Furthermore, qiang huo acts as a guiding herb to the foot Taiyang channel.  It guides Yang Qi to reach the back of the head and along the entire spine. When all these herbs are combined, the exterior and interior are simultaneously treated and act together without conflict. An external treatment method was also used by adding [more] pu gong ying on the third cook and taking advantage of the heat and steam.  That way the medicine’s efficacy would go straight into the mouth and nose and ascend to the upper respiratory tract.  It also caused the medicine to direct its function toward the eyes.  Since the interior and exterior were both restored, it was a quick and effective [treatment].