Fibromyalgia; Could Chinese Medicine Help You?


Fibromyalgia, also called fibromyalgia syndrome or FMS, is a condition mostly affecting women between 20-50 years of age. It is characterized by chronic, widespread, severe muscular aching, pain, and stiffness accompanied by insomnia, fatigue, and depression. Unlike osteoarthritis, rheumatoid arthritis, and lupus erythmatosus, it is neither a rheumatic, inflammatory, progressive, or degenerative disorder. However, it is also not solely a psychosomatic or psychiatric disorder. In other words, it is not all in the patient’s head. What it is, is a chronic, debilitating condition of unknown etiology or cause which is probably caused by a number of different factors involving a complex relationship between the psyche (the mind) and the soma (the body). In 1987, the American Medical Association (AMA) recognized FMS as a true illness and major cause of disability.1

Because this condition does not result in any physical damage to the body or its tissues, there is no one laboratory test or x-ray which can confirm this diagnosis. Because this condition is so commonly associated with chronic, enduring fatigue, it is often confused with chronic fatigue syndrome (CFS) or what is also known as chronic fatigue immune deficiency syndrome (CFIDS) in the U.S. However, unlike CFS, fibromyalgia sufferers usually experience much more significant muscle-joint aching and pain. It is estimated that as much as 75% of CFS-diagnosed patients actually fit the criteria for FMS.2 Fibromyalgia can also be differentiated from other chronic muscle-joint pain by the presence of pain or tenderness upon pressure in at least 11 out of 18 specific points on the body.

In addition to the above characteristics, FMS sufferers are also typically hypersensitive to odors, bright lights, and loud noises. Headaches and jaw pain, also known as temporomandibular joint (TMJ) pain, are common.

The word syndrome in fibromyalgia syndrome means that this condition presents with a varying range of accompanying signs and symptoms besides just muscle and joint aching and pain. Although Western medicine cannot explain why these symptoms occur together as they do, Western doctors do recognize this constellation of symptoms as a clinical entity or disease. Some of these are listed below along with the rates of their occurrence.

Ninety to 100% of FMS sufferers have generalized body pain effecting all four quadrants of the body, fatigue, and muscular stiffness. These three symptoms are all typically worse in the morning. FMS patients often say their arms and legs feel “like tied to concrete blocks.” The muscular pain associated with FMS is described as deep, burning, throbbing, shooting, and/or stabbing. And the fatigue may range from simple, random exhaustion to being unable to get out of bed.

Seventy to 90% of FMS sufferers will also have one or more of the following: post-exertional malaise, sleep disturbances, headaches, either migraine or tension, tenderness to pressure at certain, specific spots on the body, swollen feet, numbness and/or tingling, difficulty thinking and concentrating, also called “brain fog,” dizziness, sensitivity to light, noise, and/or smells, hypersensitivity to stress, dysmenorrhea, or dry mouth. In terms of sleep disturbances, FMS sufferers are usually able to fall asleep but then are not able to sleep soundly or wake up too early in the morning.

In terms of the swollen feet, the feet may actually be swollen or they may only feel swollen to the patient. The dizziness of FMS is often orthostatic hypotension, meaning dizziness when standing up. Dysmenorrhea may also be diagnosed as endometriosis.

Fifty to 70% of FMS sufferers will also have one or more of the following: irritable bowel syndrome (IBS), blurred vision, mood swings, heart palpitations, cold extremities, feverish feelings, or allergies. Irritable bowel syndrome refers to a constellation of symptoms including lower abdominal bloating, cramping, and pain, typically after eating, diarrhea and/or constipation, and mucus in the stools. It is sometimes also referred to as mucus colitis or allergic colitis.

Based on our own clinical experience, we would add the words “night blindness” after blurred vision. Many women with this condition have decreased visual acuity at night which makes them reluctant or uncomfortable to drive at night even if, strictly speaking, they do not have the Western medical disease of nictolopia or night blindness.

Fifteen to 50% of FMS sufferers will also have one or more of the following: restless leg syndrome, muscle twitches, itchy skin, hearing disturbances, night sweats, breathing problems, proneness to infections, skin rashes, interstitial cystitis, TMJ pain, or multiple chemical sensitivities.

Restless leg syndrome refers to a vague, hard to describe feeling of discomfort experienced in the legs, usually at night, characterized by the need to constantly move the legs in order to try and relieve this discomfort. Breathing problems include allergic rhinitis and allergic asthma. Interstitial cystitis is characterized by decreased urinary capacity and, therefore, frequent, painful urination and hematuria.

Typically, this condition effects middle-aged women and may be either an allergic or autoimmune disease. Multiple chemical sensitivities are also referred to as environmental illness.

Less than 15% of FMS sufferers also display major depression. However, most FMS sufferers are mildly depressed. Other symptoms or conditions also reported in the FMS literature and which we have seen in a number of patients in our own practice are new or worsening PMS, fibrocystic breast disease (FBD), and mouth sores.

In order to qualify for a diagnosis of fibromyalgia, the above generalized muscle pain, stiffness, and fatigue have to have lasted for not less than three months. In addition, as stated above, at least 11 out of 18 specific tender points on the body should be painful to palpation. Because fibromyalgia involves a number of different symptoms, Western physicians try to treat this disorder by prescribing various medications and treatments for each of these different symptoms.

In other words, because it has not yet identified the underlying cause of FMS, Western medicine has no single treatment for FMS per se. This means that antidepressants, such as Prozac, Elavil, Paxil, and Xanax, are commonly prescribed to treat the sleep and mood, while non-steroidal anti-inflammatories (NSAIDs), such as Ibuprofen, are prescribed for the pain. In addition, trigger points, i.e., points that are hypersensitive to pressure, may be injected with lidocaine, a local anesthetic. Many FMS patients benefit from regular weekly massages, but few insurance companies will pay for this even when prescribed by an MD.

Unfortunately, not all patients tolerate antidepressants such as Prozac, Elavil, and Paxil without side effects. For instance, the side effects of Prozac include skin rashes, hives, and itching, headache, nervousness, insomnia, drowsiness and fatigue, tremors, dizziness, and impaired concentration.4 In addition, many other patients simply do not want to take such Western psychotropic pharmaceuticals. NSAIDs can be very effective for acute pain relief, but they also have their own potential side effects, such as skin rashes, hives, and itching, headache, dizziness, blurred vision, ringing in the ears, depression, mouth sores, and gastrointestinal upset.5 Ironically, some of these side effects include many of the symptoms of FMS. There are also some concerns about NSAIDs’ effect on the kidneys when taken over a prolonged period of time.6 Unfortunately, when used in the treatment of fibromyalgia, NSAIDs usually do have to be taken for such a prolonged time.

Chinese disease categorization: Fibromylagia is categorized as ji bi, muscle impediment in Chinese medicine. Most of the complaints associated with fibromylagia syndrome are disease categories in Chinese medicine in their own right. Therefore, when treating FMS, one should consider the patterns and treatments listed in this and other such books for these other Chinese disease categories. FMS’s three main associated disease conditions besides fibromylagia per se are xu lao, vacuity taxation, yu zheng, depressive condition, and shi mian, insomnia.

Disease causes: External contraction of the six environmental excesses, internal damage by the seven affects, unregulated eating and drinking, iatrogenesis, and aging

Disease mechanisms: In our experience, the core disease mechanisms at work in fibromylagia syndrome are a liver-spleen disharmony. Liver depression qi stagnation may be due to unfulfilled desires or anger damaging the liver. However, it may also be due to insufficient blood nourishing the liver or insufficient yang warming and steaming the liver. Spleen vacuity is due to either faulty diet, excessive taxation, excessive thinking and especially worry and anxiety, too little physical exercise, over-use of bitter, cold medicinals, including Western antibiotics, living in a damp, hot environment, and liver wood assailing spleen earth. If the liver becomes depressed, the qi and, therefore, blood and body fluids all will not flow smoothly and easily as they should. Liver qi symptoms include chest, breast, rib-side, and abdominal oppression, distention, fullness, and pain, emotional depression, irritability, headaches, PMS, and dysmenorrhea. Spleen qi vacuity symptoms include fatigue, lack of strength and/or warmth in the extremities, poor appetite, and loose stools. Damp accumulation symptoms include edema, abnormal vaginal discharge, damp skin lesions, and damp impediment. If dampness congeals into phlegm, there may be phlegm nodulation, phlegm in the lungs, or phlegm harassing and disquieting the heart spirit. Blood stasis may result in painful menstruation or any fixed location pain in the body.

Based on this core disease mechanism of liver-spleen disharmony, numerous other disease mechanisms may also be engendered. Since the defensive qi issues from the middle burner, spleen qi vacuity leads to defensive qi not securing with easy invasion of external evils. If spleen vacuity fails to transform and engender sufficient new blood, there will be heart and/or liver blood vacuity. If blood vacuity endures, it may give rise to yin vacuity, internal stirring of wind, worsening of liver depression, or blood stasis. If spleen vacuity endures, it may eventually reach the kidneys, damaging yang. In that case, there will be a spleen-kidney yang vacuity and vacuity cold which may constrict and congeal the blood, hence also causing blood stasis. In addition, if both the spleen and kidney yang are vacuous and weak, water metabolism must be even more negatively affected. If liver depression worsens or endures, qi depression may transform heat. This may give rise to liver fire flaming upward or ascendant liver yang hyperactivity. Heat in the liver may mutually engender heat in the stomach, spleen, heart, lungs, bladder, and/or blood. If heat endures it will damage and consume yin fluids. Further, when heat flares upward, it harasses the spirit and the clear orifices above. According to Li Dong-yuan, when heat flares upward from the lower and middle burners, it also consumes and damages the spleen qi. If dampness due to spleen vacuity and faulty diet unites with or engenders depressive heat, damp heat may pour downward, to the bladder, uterus, and lower limbs. It may also spill over into the space between the muscles and the skin. Damp heat pouring downward may damage liver and kidney yin at the same time as it stirs ministerial fire to flare upward. All of the signs and symptoms of FMS are due to some combination of these inter-related disease mechanisms.

Treatment based on pattern
discrimination:

1. Liver-spleen disharmony pattern

Main symptoms: Irritability, mental-emotional depression, constipation with thin, ribbon-like or small round stools or diarrhea alternating with constipation, burping and belching, chest, rib-side and abdominal distention or pain, premenstrual breast distention and pain, painful menstruation, fatigue, loss of strength in the extremities, reduced food intake, stomach and epigastric distention and fullness after eating, superficial edema, cold hands and feet, easy bruising, profuse menstruation or abnormal uterine bleeding, dizziness upon standing up, a pale facial complexion, a fat, pale yet dark tongue with thin, white fur, and a bowstring, fine pulse which is often soggy in the right bar position

Note: Although this pattern is the core of FMS, there usually must be at least one other disease mechanism before a patient exhibits FMS. By itself, this pattern does not correspond to FMS. However, we have presented it here to emphasize that this disease mechanism sits squarely in the center of all the other patterns which do describe various clinical aspects of FMS.

Treatment principles: Course the liver and rectify the qi, fortify the spleen and boost the qi

Rx: Xiao Yao San (Rambling Powder)

Ingredients: Radix Albus Paeoniae Lactiflorae (Bai Shao), 18g, Radix Bupleuri (Chai Hu), Rhizoma Atractylodis Macrocephalae (Bai Zhu), Sclerotium Poriae Cocos (Fu Ling), Radix Angelicae Sinensis (Dang Gui), 9g each, Herba Menthae Haplocalycis (Bo He) and mix-fried Radix Glycyrrhizae (Gan Cao), 6g each, and uncooked Rhizoma Zingiberis (Sheng Jiang), 2 slices

Analysis of formula: Bai Shao and Dang Gui harmonize and emolliate the liver, while Chai Hu and Bo He course the liver and resolve depression. Bai Zhu, Sheng Jiang, Fu Ling, and mix-fried Gan Cao fortify the spleen, supplement the qi, and dry and transform dampness.

Additions & subtractions: If spleen vacuity is marked with fatigue and lack of strength or if the defensive qi is not securing, add 15 grams of Radix Astragali Membranacei (Huang Qi) and nine grams of Radix Codonopsitis Pilosulae (Dang Shen). If there is more pronounced dampness in the middle burner, add nine grams of Herba Agastachis Seu Pogostemi (Huo Xiang) and Fructus Amomi (Sha Ren). If dampness is spilling over into the extremities with puffy swelling, add nine grams each of Semen Plantaginis (Che Qian Zi) and Rhizoma Alismatis (Ze Xie). If there is phlegm dampness, add nine grams each of Rhizoma Pinelliae Ternatae (Ban Xia) and Pericarpium Citri Reticulatae (Chen Pi). If generalized blood vacuity is pronounced and there is malnourishment of the sinews, add 15 grams of Caulis Milletiae Seu Spatholobi (Ji Xue Teng) and 12 grams of cooked Radix Rehmanniae (Shu Di). If there is more serious liver blood vacuity, add nine grams of Fructus Lycii Chinensis (Gou Qi Zi) and 12 grams of Radix Polygoni Multiflori (He Shou Wu). If heart blood is vacuous and the spirit is disquieted, add 12 grams each of Semen Zizyphi Spinosae (Suan Zao Ren) and Semen Biotae Orientalis (Bai Zi Ren). If liver depression has transformed heat and that heat has entered the blood division, add nine grams each of Fructus Gardeniae Jasminoidis (Zhi Zi) and Cortex Radicis Moutan (Dan Pi). If there is heat specifically in the liver-gallbladder, lungs, stomach, and intestines, add nine grams of Radix Scutellariae Baicalensis (Huang Qin). If there is heat specifically in the liver-gallbladder, heart, stomach, and intestines, add 3-9 grams of Rhizoma Coptidis Chinensis (Huang Lian). If enduring heat has damaged stomach and/or lung fluids, add 12 grams of Tuber Ophiopogonis Japonici (Mai Men Dong). For more serious qi stagnation, add nine grams each of one or more of the following depending on the location, severity, and symptoms of qi stagnation: Rhizoma Cyperi Rotundi (Xiang Fu), Radix Auklandiae Lappae (Mu Xiang), Radix Linderae Strychnifoliae (Wu Yao), Fructus Citri Aurantii (Zhi Ke), Fructus Immaturus Citri Aurantii (Zhi Shi), Pericarpium Citri Reticulatae (Chen Pi), Pericarpium Citri Reticulatae Viride (Qing Pi), Semen Citri Reticulatae (Ju He), and Folium Citri Reticulatae (Ju Ye). If there is blood stasis, add nine grams each of Semen Pruni Persicae (Tao Ren) and Flos Carthami Tinctorii (Hong Hua). If there is painful diarrhea, add nine grams of Radix Ledebouriellae Divaricatae (Fang Feng) and six grams of Pericarpium Citri Reticulatae (Chen Pi).

Acupuncture & moxibustion: Nei Guan (Per 6), Wai Guan (TB 5), Tai Chong (Liv 3), Zu San Li (St 36), Da Bao (Sp 21)

Analysis of formula: According to the ancients, the triple burner is the father of yang qi, while the pericardium is the mother of yin blood. Therefore, together, these two channels help smooth the flow of qi and blood in the whole body. Wai Guan is the network point of the triple burner channel and Nei Guan is the network point of the pericardium channel. Needling these two points harmonizes the qi and blood in the whole body. In addition, Wai Guan is the meeting point of the yang wei mai, while Nei Guan is the meeting point of the yin wei mai, two vessels which regulate the balance between yin and yang and the interior and exterior. Tai Chong is the source point of the liver channel. It courses the liver and rectifies the qi. Zu San Li, the uniting and earth point of the stomach channel, fortifies the spleen and boosts the qi. All these points should be drained, except Zu San Li which should be needled with the supplementing method. Da Bao is the great network point. According to the Nei Jing (Inner Classic), it treats generalized body pain.

Note: In a few rare cases, acupuncture and massage can temporarily worsen the symptoms of fibromyalgia when pain is primarily due to malnourishment as opposed to stasis and stagnation.

Additions & subtractions: If spleen vacuity is marked with fatigue and lack of strength or if the defensive qi is not secure, add Tai Bai (Sp 3) and He Gu (LI 4). If there is more pronounced dampness in the middle burner, add Yin Ling Quan (Sp 9). If dampness is spilling over into the extremities with puffy swelling, also add Yin Ling Quan (Sp 9). If there is phlegm dampness, add Feng Long (St 40). If generalized blood vacuity is pronounced with malnourishment of the sinew vessels, add San Yin Jiao (Sp 6). If there is more serious liver blood vacuity, add Ge Shu (Bl 17) and Gan Shu (Bl 18). If heart blood is vacuous and the spirit is disquieted, add Shen Men (Ht 7) and San Yin Jiao (Sp 6). If liver depression has transformed heat and that heat has entered the blood division, add Xue Hai (Sp 10) and replace Tai Chong with Xing Jian (Liv 2). If there is heat specifically in the liver-gallbladder, lungs, stomach, and intestines, add Yang Ling Quan (GB 34) and He Gu (LI 4). If there is heat specifically in the liver-gallbladder, heart, stomach, and intestines, add Yang Ling Quan (GB 34), Tong Li (Ht 5), and He Gu (LI 4). If enduring heat has damaged stomach and/or lung fluids, add Fu Liu (Ki 7). If there is blood stasis, add He Gu (LI 4) and San Yin Jiao (Sp 6). If there is painful diarrhea, add Tian Shu (St 25). For pain or weakness in the lower limbs, add Cheng Shan (Bl 57). For pain in the upper limbs, add Qu Chi (LI 11).

For pain on palpation near Feng Chi (GB 20), needle Feng Chi (GB 20) or the a shi point. For pain on palpation near Bai Lao (M-HN-30), needle Bai Lao (M-HN-30) or the a shi point. For pain on palpation near Tian Jing (GB 21), needle Tian Jing (GB 21) or the a shi point. For pain on palpation near Qu Yuan (SI 13) or Bing Feng (SI 12), needle these points or the a shi point. For pain on palpation near Yu Zhong (Ki 26), needle Yu Zhong (Ki 26) or the a shi point. For pain on palpation near Shou San Li (LI 10), needle Shou San Li (LI 10) or the a shi point. For pain on palpation near Bao Huang (Bl 53), needle Bao Huang (Bl 53) or the a shi point. For pain on palpation on the greater trochanter posterior to the trochanteric prominence, needle the a shi point or eventually Huan Tiao (GB 30) or Ju Liao (GB 29). For pain on palpation near Xue Hai (Sp 10), needle Xue Hai (Sp 10) or the a shi point. However, usually Da Bao is sufficient to stop pain throughout the body.

2. Damp heat pattern

Main symptoms: Loose stools or diarrhea, possibly dark, green-colored stools or light yellow, mustard-colored stools, a burning or acid feeling around the anus with or after defecation, foul-smelling stools, hot, possibly red, possibly swollen, painful limbs, red, hot, swollen, wet, or weeping skin lesions, hot, frequent, burning, and/or painful urination, red, hot swollen, wet or weeping external genitalia, thick white, curdy or creamy, yellow vaginal discharge, yellow-green nasal mucus, slimy, yellow tongue fur, and a slippery, rapid pulse

Note: Damp heat complicates most if not all cases of FMS. However, it is usually not the main pattern but rather complicates other patterns such as liver-spleen disharmony, qi and yin vacuity, and yin and yang vacuity. Damp heat manifests somewhat differently depending in which part of the body it is lodged. Areas of the body commonly effected by damp heat include the reproductive tract and external genitalia, the urinary tract, the digestive tract, the lower limbs, and the skin. Patients with damp heat typically exhibit that damp heat in two or more of these areas but rarely in all of them at the same time. It is common for damp heat to migrate from system to system within the body, sometimes manifesting as urinary tract damp heat, other times as gastrointestinal damp heat, and yet other times as dermatological damp heat. When damp heat causes impediment pain, this is also often called wind damp heat impediment. Because the heat of damp heat tends to waft upwards, damp heat below can also give rise to signs and symptoms of dry heat above, such as heat in the heart or dry mouth and throat and chapped lips.

Treatment principles: Clear heat and eliminate dampness

Rx: For damp heat in the stomach and intestines, Ban Xia Xie Xin Tang (Pinelliae Drain the Heart Decoction)

Ingredients: Rhizoma Pinelliae Ternatae (Ban Xia), 12g, Radix Codonopsitis Pilosulae (Dang Shen) and Radix Scutellariae Baicalensis (Huang Qin), 9g each, dry Rhizoma Zingiberis (Gan Jiang) and mix-fried Radix Glycyrrhizae (Gan Cao), 6g each Rhizoma Coptidis Chinensis (Huang Lian), 3g, and Fructus Zizyphi Jujubae (Da Zao), 3 pieces

Analysis of formula: Huang Qin and Huang Lian clear heat, eliminate dampness, and resolve toxins. Ban Xia dries dampness and harmonizes the stomach and intestines. Dang Shen, Gan Jiang, Da Zao, and mix-fried Gan Cao fortify the spleen and prevent further damp accumulation which tends to transform into heat.

Additions & subtractions: For marked fatigue, add 18 grams of Radix Astragali Membranacei (Huang Qi). For diarrhea, add 18 grams of Radix Puerariae (Ge Gen).

Acupuncture & moxibustion: Zhong Wan (CV 12), Tian Shu (St 25), Yin Ling Quan (Sp 9), Nei Ting (St 44), Da Bao (Sp 21)

Analysis of formula: Draining Zhong Wan, Tian Shu, Shang Ju Xu, and Nei Ting clears the stomach and intestines, clears and disinhibits dampness and heat. Draining Da Bao treats generalized body pain.

Additions & subtractions: Please see pattern #1 above.

For damp heat impediment, Si Miao San Jia Wei (Four Wonders Powder with Added Flavors)

Ingredients: Uncooked Semen Coicis Lachryma-jobi (Yi Yi Ren), 21g, Radix Achyranthis Bidentatae (Niu Xi), 15g, and Rhizoma Atractylodis (Can Zhu), Cortex Phellodendri (Huang Bai), and Fructus Chaenomelis Lagenariae (Mu Gua), 9g each

Analysis of formula: Yi Yi Ren, Cang Zhu, Huang Bai, and Mu Gua together clear heat and disinhibit dampness. Yi Yi Ren and Mu Gua eliminate dampness and free the flow of impediment, while Cang Zhu dispels wind dampness. Niu Xi supplements liver and kidneys and reinforces sinews and bones. In addition, it guides the other medicinals to move downward to the lower half of the body.

Additions & subtractions: For predominant dampness, add nine grams each of Scerotium Poriae Cocos (Fu Ling) and Rhizoma Alismatis (Ze Xie).

Acupuncture & moxibustion: Yin Ling Quan (Sp 9), Qu Chi (LI 11), a shi points, Da Bao (Sp 21)

Analysis of formula: Draining Yin Ling Quan and Qu Chi clears and disinhibits dampness and heat, dispels wind dampness and frees the flow of impediment. Draining a shi points selected according to the location of pain frees the flow of the network vessels and disinhibits impediment. Da Bao treats generalized body pain.

Additions & subtractions: Please see pattern #1 above.

For damp heat in the bladder, Ba Zheng San (Eight Correcting [Ingredients] Powder) plus Xiao Chai Hu Tang (Minor Bupleurum Decoction) with additions & subtractions

Ingredients: Talcum (Hua Shi), 18g, Sclerotium Poriae Cocos (Fu Ling) and Semen Plantaginis (Che Qian Zi) 12g each, Herba Dianthi (Qu Mai), Fructus Gardeniae Jasminoidis (Zhi Zi), Herba Polygoni Avicularis (Bian Xu), Radix Bupleuri (Chai Hu), Radix Scutellariae Baicalensis (Huang Qin), ginger stir-fried Rhizoma Pinelliae Ternatae (Ban Xia), and Radix Codonopsitis Pilosulae (Dang Shen), 9g each, and mix-fried Radix Glycyrrhizae (Gan Cao), 6g

Analysis of formula: Hua Shi, Che Qian Zi, Qu Mai, and Bian Xu clear heat and eliminate dampness in the bladder and free the flow of urination. Zhi Shi and Huang Qin clear heat and dry dampness. Fu Ling seeps dampness and fortifies the spleen, while Dang Shen and mix-fried Gan Cao fortify the spleen and supplement the qi. Ban Xia transforms dampness and, therefore, helps fortify the spleen. Chai Hu courses the liver and rectifies the qi. It also clears depressive heat via out-thrusting.

Acupuncture & moxibustion: Yin Ling Quan (Sp 9), Zhong Ji (CV 3), Xing Jian (Liv 2), Zu San Li (St 36), Da Bao (Sp 21)

Analysis of formula: Draining Yin Ling Quan and Zhong Ji clears and disinhibits dampness and heat in the bladder. Draining Xing Jian clears and eliminates damp heat from the liver channel, especially in the lower burner. Supplementing Zu San Li fortifies the spleen to prevent further damp accumulation which tends to transform into heat. Da Bao treats generalized body pain.

Additions & subtractions: Please see pattern #1 above.

For damp heat in the uterus with abnormal vaginal discharge, Er Huang San Bai Wan Jia Jian (Two Yellows & Three Whites Pills with Additions & Subtractions)

Ingredients: Rhizoma Atractylodis Macrocephalae (Bai Zhu), Radix Albus Paeoniae Lactiflorae (Bai Shao), Hallyositum Rubrum (Chi Shi Zhi), Radix Astragali Membranacei (Huang Qi), and Radix Angelicae Sinensis (Dang Gui), 9g each, Cortex Phellodendri (Huang Bai), Rhizoma Atractylodis (Cang Zhu), Radix Bupleuri (Chai Hu), and Cortex Toonae Sinensis (Chun Gen Pi), 6g each, and Rhizoma Coptidis Chinensis (Huang Lian) and Rhizoma Cimicifugae (Sheng Ma), 3g each

Analysis of formula: Huang Bai, Huang Lian, Sheng Ma, Cang Zhu, and Bai Zhu together clear and dry damp heat. Bai Shao and Chai Hu course and harmonize the liver to prevent liver depression from transforming into heat. Dang Gui nourishes and quickens the blood. Bai Zhu and Huang Qi fortify the spleen and thus also prevent further damp accumulation from transforming into heat. Chun Gen Pi and Chi Shi Zhi astringe, secure, and stop abnormal vaginal discharge.

Acupuncture & moxibustion: Qu Gu (CV 2), Yin Ling Quan (Sp 9), Dai Mai (GB 26), Xing Jian (Liv 2), Zu San Li (St 36), Da Bao (Sp 21)

Analysis of formula: Draining Qu Gu and Yin Ling Quan clears and disinhibits damp heat from the uterus. Dai Mai is an empirical point for the treatment of abnormal vaginal discharge. Draining Xing Jian clears and eliminates damp heat from the liver channel, especially in the lower burner. Supplementing Zu San Li fortifies the spleen to prevent further damp accumulation from transforming into heat. Draining Da Bao treats generalized body pain.

Additions & subtractions: Please see pattern #1 above.

For damp heat in the external genitalia with itching, Yi Huang Tang Jia Jian (Change the Yellow Decoction with Additions & Subtractions)

Ingredients: Cortex Phellodendri (Huang Bai), Radix Sophorae Flavescentis (Ku Shen), Semen Plantaginis (Che Qian Zi), Radix Dioscoreae Oppositae (Shan Yao), Semen Euryalis Ferocis (Qian Shi), Semen Coicis Lachryma-jobi (Yi Yi Ren), Sclerotium Poriae Cocos (Fu Ling), Cortex Radicis Dictamni Dasycarpi (Bai Xian Pi), Radix Bupleuri (Chai Hu), Flos Lonicerae Japonicae (Jin Yin Hua), and Radix Codonopsitis Pilosulae (Dang Shen), 9g each, and mix-fried Radix Glycyrrhizae (Gan Cao), 3g

Analysis of formula: Huang Bai, Ku Shen, Che Qian Zi, Yi Yi Ren, Bai Xian Pi, and Jin Yin Hua together clear and disinhibit dampness and heat in the lower burner, resolve toxins, dispel wind, and stop itching. Shan Yao, Dang Shen, Qian Shi, and mix-fried Gan Cao fortify the spleen to prevent damp accumulation from pouring downward. Chai Hu courses the liver and rectifies the qi as well as leads the other medicinals toward the liver channel in the external genital area.

Acupuncture & moxibustion: Qu Gu (CV 2), Yin Ling Quan (Sp 9), Li Gou (Liv 5), Zu San Li (St 36), Da Bao (Sp 21)

Analysis of formula: Draining Qu Gu and Yin Ling Quan clears and disinhibits damp heat in the lower burner. Li Gou clears and disinhibits damp heat in the liver channel. It is also an empirical point for treating external genital itching. Supplementing Zu San Li fortifies the spleen to prevent further damp accumulation from transforming into heat. Draining Da Bao treats generalized body pain.

Additions & subtractions: Please see pattern #1 above.

For damp heat in the yang ming causing acne, Yin Chen Hao Tang (Artemisia Decoction) plus Ban Xia Xie Xin Tang (Pinelliae Drain the Heart Decoction) plus Xiao Chai Hu Tang (Minor Bupleurum Decoction) with additions & subtractions

Ingredients: Herba Artemisiae Capillaris (Yin Chen Hao) and Flos Lonicerae Japonicae (Jin Yin Hua), 18g each, Flos Chrysanthemi Indici (Ye Ju Hua), Fructus Gardeniae Jasminoidis (Zhi Zi), Radix Scutellariae Baicalensis (Huang Qin), and Radix Rubrus Paeoniae Lactiflorae (Chi Shao), 9g each, Rhizoma Pinelliae Ternatae (Ban Xia), Radix Bupleuri (Chai Hu), Radix Codonopsitis Pilosulae (Dang Shen), and mix-fried Radix Glycyrrhizae (Gan Cao), 6g each, and Rhizoma Coptidis Chinensis (Huang Lian), 3g

Analysis of formula: Yin Chen Hao, Jin Yin Hua, Ye Ju Hua, Zhi Zi, Huang Qin, and Huang Lian together clear heat in the stomach and intestines, dry dampness and resolve toxins. Ban Xia dries dampness and harmonizes the stomach and intestines. Chi Shao cools the blood and clears the liver. Chai Hu courses the liver and rectifies the qi. Dang Shen and mix-fried Gan Cao fortify the spleen to prevent further damp accumulation from transforming into heat.

Acupuncture & moxibustion: Ling Tai (GV 10), Wei Zhong (Bl 40), Yin Ling Quan (Sp 9), He Gu (LI 4), Nei Ting (St 44), Da Bao (Sp 21)
Analysis of formula: Draining Ling Tai and Wei Zhong cools the blood and clears heat, especially in the skin. Draining Yin Ling Quan, He Gu, and Nei Ting clears and eliminates damp heat in the stomach and intestines. In addition, He Gu is the master point of the face where acne mainly occurs. Draining Da Bao treats generalized body pain.

Additions & subtractions: Please see pattern #1 above.

3. Qi & yin vacuity with liver depression & fire effulgence pattern

Main symptoms: Fatigue, lack of strength, scanty qi, disinclination to speak, low back pain and knee soreness, night-time urination, frequent but scanty, darkish urination, loose stools, dizziness, tinnitus, matitudinal insomnia, night sweats, tidal heat, a pale face but malar flushing, cold hands and feet alternating with vexatious heat in the five hearts, a fat, pale tongue with red tip and scanty, possibly dry and/or yellowish fur, and a fine, rapid, or floating, surging, rapid pulse

Treatment principles: Fortify the spleen and boost the qi, supplement the kidneys and enrich yin, clear heat and drain fire

Rx: Tian Wang Bu Xin Dan Jia Jian (Heavenly Emperor Supplement the Heart Elixir with Additions & Subtractions)

Ingredients: Uncooked Radix Rehmanniae (Sheng Di) and Radix Astragali Membranacei (Huang Qi), 15g each, Radix Codonopsitis Pilosulae (Dang Shen), Radix Scrophulariae Ningpoensis (Xuan Shen), Tuber Ophiopogonis Japonici (Mai Dong), and Tuber Asparagi Cochinensis (Tian Men Dong), 12g each, Fructus Schisandrae Chinensis (Wu Wei Zi), Radix Salviae Miltiorrhizae (Dan Shen), Radix Angelicae Sinensis (Dang Gui), Sclerotium Poriae Cocos (Fu Ling), Radix Dioscoreae Oppositae (Shan Yao), Radix Polygalae Tenuifoliae (Yuan Zhi), Radix Albus Paeoniae Lactiflorae (Bai Shao), Semen Zizyphi Spinosae (Suan Zao Ren), and Fructus Meliae Toosendan (Chuan Lian Zi), 9g each, Radix Platycodi Grandiflori (Jie Geng) and mix-fried Radix Glycyrrhizae (Gan Cao), 6g each, and Rhizoma Coptidis Chinensis (Huang Lian), 3g