The following cases present variations of this condition. After familiarizing yourself with the possible common patern presentations and appropriate formulas for treatment, use the following exercises to test your overall understanding of the condition.

1. Male, age 56. Presenting with dryness and pain in the lef eye, photophobia and an inability to open the eye, constant hot tearing, hard stools and yellow urine. The patient came to the clinic fve days afer the symptoms presented. An eye examination revealed mixed conjunctival congestion, corneal ulceration with raised borders and a hollow center. The tongue was red with a yellow coating and the pulse was wiry and rapid.

Select the most appropriate formula:

A . Bái Wēi Wán (Black Sallowwort Pill)

B . Xiè Gān Săn (Liver-Draining Powder)

C . Qīng Wèi Tāng (Stomach-Clearing Decoction)

D . Dăo Chì Săn (Red-Abducting Powder)

2. Male, age 49. Presenting with a stinging pain in the right eye with a burning sensation, photophobia, and decreased visual acuity for a week prior to seeking treatment. An eye examination revealed mixed conjunctival congestion, corneal ulceration with raised borders and a hollow center. There was also a biter taste in the mouth and a dry throat, dry stools and yellow urine. The tongue was red with yellow coating and the pulse was slippery and rapid.

Select the most appropriate diagnosis:

A. Wind-heat in the lung and liver

B. Liver fre faming upwards

C. Intense heat and bowel excess

D. Damp-heat brewing and steaming

3. Female, age 53. Presenting with dryness and pain in the right eye for three months prior to treatment. The symptoms were alternating, at times improving and at times geting worse, however, the condition became aggravated for two days prior to treatment. This time the patient complained about slight photophobia in the afected eye and cold extremities. An eye examination revealed ciliary congestion with a dusky color in the right eye and corneal ulceration. The tongue was pale with a white coating and the pulse was deep and thready.

Select the most appropriate formula:

A . Jiā Wèi Xiū Gān Săn (Supplemented Liver-Repairing Powder)

B . Xiān Fāng Huó Mìng Yĭn (Immortal Formula Life-Giving Beverage)

C . Xiōng Guī Bŭ Xuè Tāng (Chuanxiong and Chinese Angelica Blood-Supplementing Decoction)

D . Dāng Guī Sì Nì Tāng (Chinese Angelica Frigid Extremities Decoction)

1. B

2. C

3. D

The first two case histories have similar presentations. Both depict scenarios of intense heat, along with constipation and red tongues with yellow coating. The first patient is treated with Xiè Gān Săn (Liver-Draining Powder) which was recorded in the 34 ^rd nosography of the Essentials from the Silver Sea ( Yín Hăi Jīng Wēi, 银海精微): “Patterned Shade with White Dimple”. ¹ It treats “a shade growing in the eye that resembles a turnip flower or fish scales.” This disease is similar to the 33 ^rd nosography where there is a “white dimple (that has been compared with a) date flower.” The passage goes on to describe an extreme condition of wind and heat penetrating the eye and the brain. The author recommends using Xiè Gān Săn combined with Jiā WèiXiū Gān Săn, also from the same text.

Formula: Xiè Gān Săn (Liver-Draining Powder)

[Prescription]

[Actions] Clear the liver, drain fre, and unblocks the bowels.

[Indications] It is indicated for huā yì bái xiàn (花翳白陷, petaloid nebula with a sunken center), or corneal ulcer.

The formula can be deconstructed in a number of ways: The most obvious is that is appears to be a combination of Dà Chéng Qì Tāng (Major Purgative Decoction) and Lóng Dăn Xiè Gān Tāng (Gentian Liver-Draining Decoction). Dà huáng and máng xiāo form the core of Dà Chéng Qì Tāng, while lóng dăn căo, huáng qín, chē qián zĭ and dāngguī are from Lóng Dăn Xiè Gān Tāng. Now it is easy to understand how the formula robustly drains heat and clears liver fire. Xuán shēn moistens dryness and clears heat, jié gĕng clears infection and guides the formula to the upper body. Qiāng huó dispels wind and alleviates pain. Thus, the formula is appropriate for cases 1 and 2.

The diagnosis for the second case scenario is intense heat and bowel excess. Using the guidelines in the introduction, we would select Yín Huā Fù Míng Tāng (Lonicera Light-Restoring Decoction, 银花复明汤) to treat this patern. This is a modern formula from the Clinical Practice in TCM Ophthalmology ( Zhōng Yī Yăn Kē Lín Chuáng Shí Jiàn,中医眼科临床实践) by Pang Zan-xiang.

Formula: Yín Huā Fù Míng Tāng (Lonicera Light-Restoring Decoction)

[Prescription]

[Indications] It is indicated for congealed-fat nebula (purulent keratitis)

The formula clearly references the architecture of many classic formulas: jīn yínhuā and pú gōng yīng are from the toxin-clearing, abscess-reducing Wŭ Wèi Xiāo Dú Yĭn (Five Ingredients Toxin-Removing Beverage). Huáng lián, huáng qín and dà huáng form the classic formula Xiè Xīn Tāng (Heart-Draining Decoction) which drains fre, dries dampness and resolves toxicity. Dà huáng and xuán míng fĕn form Dà Chéng Qì Tāng. As in the above formula, it is included to drain heat through the stool. Components of Lóng Dăn Xiè Gān Tāng are also featured here with lóng dăn căo, huáng lián, shēng dì and gān căo. Zhī mŭ, shēng dì and tiān huā fĕn are heat clearing and moistening. Màn jīng zĭ is specifc for abating nebula and gān căo serves a dual role to assist in healing ulcers and also to harmonize the formula.

In the third case scenario, the diagnosis is implied by the formula selection. DāngGuī Sì Nì Tāng warms the channels, dispels cold, nourishes the blood and unblocks the vessels. The patients’ symptoms of lower level pain, along with the cold extremities, ciliary congestion with a dusky color, the pale tongue and deep thready pulse support this. Working backwards through the case, the formula selection combined with the patient’s symptoms can only mean that the diagnosis is cold blocking the channels and collaterals. For this case, the channel blockage is extended to include the collaterals of the eyes, preventing them from receiving nourishment, leading to the nebula.

The contrast with the first 2 case histories is vivid. Not only is do they have opposite symptoms, in comparison to the frst two cases, which presented a patern, or zhèng of liver fire attacking the lungs, which was treated with Xiè Gān Săn, this woman is treated constitutionally.

Dāng Guī Sì Nì Tāng was written by Zhang Zhong-jing in the Essentials from theGolden Cabinet ( Jīn Guì Yào Lüè, 金匮要略). Zhang’s formulas were based on treating a Bìng: a disease or syndrome or patern. In this case, the patient is presenting with a Dāng Guī Sì Nì Tāng bìng, which describes a scenario of long standing cold hands and feet, a pale tongue and a barely perceivable pulse. This type of person has chronic poor circulation, possibly dry skin. In contrast to the frst two cases in which the onset was acute, she had been living with the condition for 3 months, and only sought treatment afer a recent fare up.

Formula: Dāng Guī Sì Nì Tāng (Chinese Angelica Frigid Extremities Decoction)