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. Female, 46 years old. Persistent tearing in the left eye, pain, redness and swelling around the inner canthus with induration below for two days. There was a nodule upon palpation, with an aversion to palpation due to pain. The tongue body was red with a thin yellow coating, and the pulse was floating and rapid.

Choose the best formula below:

A. Modified Qū Fēng Sàn Rè Yĭn Zĭ (Wind-Expelling and Heat-Dissipating Drink)

B. Modified Huáng Lián Jiĕ Dú Tāng (Coptis Toxin-Resolving Decoction)

C. Modified Zhú Yè Xiè Jīng Tāng (Lophatherum Channel-Draining Decoction)

D. Modified Qū Fēng Yī Zì Săn (Wind-Expelling One Word Powder)

E. Tuō Lĭ Xiāo Dú Săn (Internal Expulsion Toxin-Dispersing Powder)

2. Female, 59 years old. Persistent tearing in the right eye three weeks prior to treatment; pain and redness in the inner canthus with an induration appearing below. The nodule broke apart a week prior to treatment. Since then, the redness subsided and the pus drained persistently. Her face was pale; she was fatigued and had a poor appetite. The tongue was pale with a thin coating, and the pulse was thin and weak.

Choose the most appropriate formula:

A. Modified Qū Fēng Sàn Rè Yĭn Zĭ (Wind-Expelling and Heat-Dissipating Drink)

B. Modified Huáng Lián Jiĕ Dú Tāng (Coptis Toxin-Resolving Decoction)

C. Modified Zhú Yè Xiè Jīng Tāng (Lophatherum Channel-Draining Decoction)

D. Modified Qū Fēng Yī Zì Săn (Wind-Expelling One Word Powder)

E. Tuō Lĭ Xiāo Dú Săn (Internal Expulsion Toxin-Dispersing Powder)

1. A

2. E

The first case scenario is a short depiction of two patterns: wind heat attacking upward and toxic heat congestion. This is determined by the acute onset of the nodule, tearing and the foating, rapid pulse, signs of wind, along with pain swelling and redness, signs of heat and blood stasis. The actions of the formula Qū FēngSàn Rè Yĭn Zĭ (Wind-Expelling and Heat-Dissipating Drink) are divided between expelling wind, clearing heat and cooling the blood, which matches the presentation perfectly.

In TCM, there are two main strategies for eliminating heat from the body. The frst, if the heat afects the superfcial aspects of the body, is to use surface relieving diaphoretics. The second, if the heat has penetrated internally, is to purge it through the stool or urine. A third variation is the combined patern of internal and external excess. In such a case, there will be simultaneous symptoms of chills fever along with constipation, scanty urine and a biter taste in the mouth. This strategy is used for this case:

Formula: Qū Fēng Sàn Rè Yĭn Zĭ (Wind-Expelling and Heat-Dissipating Drink)

[驱风散热饮子]

[Method]

Use equal parts of all the medicinals and only a litle gān căo.

[Modifications]

If the shaoyang channels are afected, add chái hú (Radix Bupleuri). If the shaoyin channels are afected, add huáng lián.

Within the formula, lián qiào, niú bàng zĭ and bò he are used together in Yín Qiào Săn (Lonicera and Forsythia Powder). They clear wind, expel heat and reduce swelling. Qiāng huó and fáng fēng release exterior wind-cold and stop pain. Dà huáng (winesteeped) and shān zhī zĭ purge heat through stool and urination, respectively. Soaking the dà huáng in wine reduces the purgative action and guides the formula to the blood level. This pair is used together in many formulas that clear internal heat. The majority of the medicinals are acrid and/or aromatic, underscoring the qi-moving and heat-dispersing dynamic of the formula.

The formula is structurally similar to another, more commonly used formula that releases the exterior and purges the interior: Fáng Fēng Tōng Shèng Săn (Ledebouriella Sage-Inspired Powder). Both are large, complex formulas. Both include the medicinals fáng fēng, bò he, dà huáng (wine steeped) , zhī zĭ, lián qiào, dāng guī (Radix Angelicae Sinensis) , chuān xiōng and gān căo. The indications for Fáng Fēng Tōng Shèng Săn are strong fever and chills (which are symptoms of exterior pathogens), and bitter taste, constipation and rough scanty urination (which are symptoms of internal heat accumulation). In contrast, Qū Fēng Sàn Rè Yĭn Zĭ clears wind and dissipates heat, cools the blood, relieves nodulation and stops pain.

The modifcations of Qū Fēng Sàn Rè Yĭn Zĭ also deserve comment. If the shaoyang channels are affected, then the nodules will appear closer to the outer canthus, towards the gallbladder channel. Thus, chái hú is selected both for its wind expelling actions and because it acts as an envoy, guiding the formula to the outer corner of the eye. In contrast, if the shaoyin channels are affected, then the nodules and inflammation will present towards the inner canthus, which is associated with the heart channel. Thus, huáng lián is added to clear heart heat and to focus the actions of the medicinals in the formula on the inner canthus.

The second case scenario provides a useful contrast to the primary case history. The physician presents a case with mixed paterns of qi defciency, blood defciency and toxic heat. The formula Tuō Lĭ Xiāo Dú Săn (Internal Expulsion Toxin-Dispersing Powder) would address the entire constellation of signs and symptoms.

Formula: Tuō Lĭ Xiāo Dú Săn (Internal Expulsion Toxin-Dispersing Powder)

[托里消毒散]

This formula can be considered a modification of Bā Zhēn Tāng (Eight-Gem Decoction) minus shú dì huáng (Radix Rehmanniae Praeparata) and with zào jiăocì, jié gĕng, bái zhĭ and huáng qí added. The first three medicinals are used to burst abscesses and expel pus. Bear in mind that in addition to supplementing the qi and blood, huáng qí promotes the discharge of pus. Another way to reframe Tuō Lĭ Xiāo DúSăn is to view it as a variation of Tòu Nóng Săn (Pus-Expelling Powder), which also features huáng qí, dāng guī and zào jiăo cì. Since the patient has a poor appetite, Tuō LĭXiāo Dú Săn is a beter choice as it includes bái zhú. Huáng qí and bái zhú are both qi supplementing medicinals, however, a key diference is that the former is beter for raising the yang and consolidating the exterior, while the later is more efective for increasing the appetite and improving digestion.