A Cold with Complications
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
Case:
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].
Prescription:
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].
感冒也有疑難證
——桑菊銀翹與附子細辛同劑治療感冒醫案
施某，女，42歲。
2003年12月4日初診。
主訴：鼻塞兩周，背心發冷十天，右眼充血脹痛一周。
病史：兩周前出現咽痛，繼之鼻塞流涕，咳嗽。幾天後又出現背心發冷，納呆。一周後右眼充血脹痛，在上海嘉定某醫院就診，見右結膜充血（+++），角膜（-），瞳孔（-），診斷為右眼結膜炎。給予病毒唑液(antiviral)、信利妥液(Ofloxacin)滴眼，金霉素眼膏塗眼，抗病毒口服液口服，用後無效故來就診。刻下：咽癢而咳，痰少，鼻塞，口乾，後腦不利，背心發冷，納呆，大便日行而乾，右眼充血腫脹。病程中無發熱，病初無惡寒。平素在冬天較常人為怕冷，但無背心發冷現象。平素也不口乾，大便日行而通暢。檢查：右眼結膜充血明顯，咽部充血，兩肺呼吸音正常。舌淡紅而胖，苔薄白，根部淡黃膩，脈細。辨證為陽虛為本，感受風熱。
處方：桑葉30g，菊花30g，銀花15g，連翹15g，制附子9g，細辛2.5g，蒲公英30g，羌活9g，板藍根30g，桔梗9g，生甘草12g，葶藶子（包）18g，杏仁9g，馬勃（包）4.5g，天竺子9g，天漿殼7g，炙百部15g，5劑。
上方煎3次，每次煎15分鐘。前2煎內服，第三煎再加蒲公英30g，用藥汁熏蒸頭目。
2003年12月9日二診：用藥1劑，背心發冷、後腦不利消失，自覺鼻子暢通。3劑，咽癢咳嗽、右眼充血明顯減輕。現唯稍感咽部不適，早上偶有咳嗽。
處方以止咳散加味善後，2劑痊癒。
按語：本例感冒病程較長，症狀較多，特別是一些症狀或表現為熱象，或表現為寒象，辨證頗有難度，治療更屬不易。可以說是感冒中的一例疑難證。現從三方面做一分析。
第一，背心發冷的辨析。風寒襲表和陽氣虧虛均可導致背心發冷。但患者發病之初並無惡寒，亦無背心發冷，而是四五天後才出現的，不像是感受表邪，而像是邪氣傷正之後引起的。聯系患者在冬天較常人怕冷，舌淡紅而胖，故判斷是陽虛所致。這裡提醒讀者注意，臨床問診，不僅要問現在的情況，必要時還要詢問患者過去的情況，以了解病情的來龍去脈，從而有助於正確地分析病情。
第二，背心發冷、舌淡紅而胖，與口乾、便結、右眼充血、舌苔薄白而根部見淡黃膩並見的辨析。患者既有寒象又有熱象，而套用常見的感冒病機均不適用。經再三詢問，得知其平素不口乾，大便日行而通暢，在冬天較常人為怕冷，而判斷為陽虛之體，感受風熱。風熱侵襲肺表，故鼻塞、咽痛、咳嗽；風熱上攻，故右眼充血；風熱漸有入裡之勢，故口乾、便結，舌苔薄白而根部見淡黃膩。因其素體陽虛，故舌淡紅而胖、脈細；風熱外邪損傷正氣，則陽氣不能溫分肉，故背心發冷。患者的這一病機似乎與以往常規的感冒病機不符合。人們印象中陽虛者感風寒，陰虛者感風熱，怎麼這裡是陽虛感風熱？這裡牽涉到對發病的內外因的正確理解。機體發病過程中，體質與病邪之間，體質發揮的是內因的作用，病邪發揮的是外因的作用。陽虛者易感風寒，陰虛者易感風熱，實際上說明的是不同的體質對不同的病邪具有不同的易感性，而在發病的過程中也具有不同的傾向性。但另一方面，病邪做為外因也發揮了一定作用，特別當病邪較為強大時，也可起到主導作用。本案就是陽虛之體，感受風熱較盛，既重傷其陽氣，又損其陰津。
第三，處方分析。明曉本案病機，卻無成方可用，唯有借鑑古方制方之理而自擬之。本案的處方，就是根據麻黃附子細辛湯等扶正解表方劑制方之理變化而來，取疏散風熱與溫陽祛寒兩法合于一劑。重用桑葉、菊花各30g疏風清熱明目，銀花、連翹、蒲公英助其解表清熱，葶藶子、杏仁利肺氣，桔梗、生甘草、板藍根、馬勃清咽喉，天竺子、天漿殼、炙百部止咳嗽；另一方面，附子、細辛溫陽散寒，而羌活為足太陽引經藥，導陽氣通達後腦、背脊。諸藥合用，表裡兼治而並行不悖。同時應用外治之法，以方劑第三煎加蒲公英乘熱熏蒸，既使藥力從口鼻直達上呼吸道，又使藥物直接作用於眼部，內外同修，故奏效頗捷。
點睛：問診技巧。體質與病邪。陽虛感受風熱。借鑑古方。桑菊銀翹與附子細辛同劑