By Suzanne Robidoux, PhD, CM, DOM, LAc
As practitioners, we always want to bring the quickest, most effective treatment at the lowest price possible. In TCM, sexual disorders are mainly due to either liver qi stagnation, liver and kidney depletion, or the kidney and heart not communicating. What can we offer our patients, however, once we have used all the resources TCM has without any success?
In the Han Dynasty, Zhang Zhong Jing had already recorded effective formula patterns for male and female sexual disorders in the Lun Guang Tang Ye Jing, later renamed and compiled by Wang Shu He as the Shang Han Za Bing Lun.
Like every classical school of thought, understanding the medical system within the Shang Han Za Bing Lun is essential to applying it correctly in clinic. It is important to clarify that this system is unrelated to the constitution of the patient; whether they are young or old, thin or heavyset, has no correlation to the acupuncture channels or their pathways–it does not integrate with the zang fu TCM diagnosis. Furthermore, it does not depend on the season or the weather. This system is based entirely on the full spectrum of symptoms presentation, including the tongue and pulse. Analysing these symptoms will tell us if the pathogens are lodged within the external layers, internal layers, or the half exterior-half interior layers of the body. According to the symptoms presentation, we will also be able to diagnose if the syndrome are of a yang and/or yin nature in each layer.
When we are treating acute or chronic cases of impotence, spermattorhea, premature ejaculation, lack of libido, or any other male sexual disorders, we must again record all of the presenting symptoms, diagnose which of the syndromes are affected, and eventually target a treatment formula and its modifications. The symptoms analysis according to syndromes has been listed in this newspaper in a previous article, but since they are the basis of this system, I will review them briefly. As Dr. Feng Shi Lun often says: “Being a true classical practitioner is not only using classical formulas, but also fully understanding the six syndrome system and formula and medicinal patterns.”
The key characteristics of the Six Syndrome System are:
- Tai Yang Syndrome (external yang pattern): Fever, sweating or no sweating; aversion to cold and wind; pain and stiffness of the neck; severe pain of the joints and muscles; itchy skin disorders; floating pulse.
- Shao Yin Syndrome (external yin pattern): Sweating (spontaneous deficient); aversion to wind and cold; joint and body pain; skin disorders; floating or deep pulse. Notice the lack of heat sensation and fever.
- Yang Ming Syndrome (internal yang pattern): Fever; heat sensation; day or night sweating; aversion to heat; vexation; insomnia; depression; restlessness (excessive and deficient type); fullness in the epigastrium; chest oppression; diarrhea or constipation; swollen red and painful joints; rapid and slippery pulse.
- Tai Yin Syndrome (internal yin pattern): Cold sensation; fatigue; bloating or vomiting after eating or drinking; diarrhea or constipation; with internal rheum, there will be insomnia; restlessness; joint and body pain; deep and slow pulse. (lack of heat sensation).
It is also important to note that the symptoms of external internal Tai Yin Syndrome are often seen in the symptom of upsurging qi, with internal rheum retention bringing the pathogens upward, along with symptoms of dizziness, vertigo, vomiting and heaviness of the head.
The syndromes of the half exterior-half interior layers are mainly seen as heat in the upper with cold in the middle or the lower, bitter taste, and pain in the rib sides:
- Shao Yang Syndrome: Fever; heat sensation; sore throat; restlessness; irritability; introverted; tensed; glomus & tension under the heart; wiry pulse.
- Jue Yin Syndrome: Acne; hot flushes; cold sores; cold sensation in the lower; fatigue; weakness; bloating after eating or drinking; diarrhea or constipation; restlessness; joint and body pain; deep and slow pulse demonstrating a depletion of body fluid and blood.
Furthermore, to deepen our review of this system, I have collected a few meaningful clinical cases from Dr. Feng Shi Lun and Professor Hu Xi Shu and have added in depth analysis according to this system to shed some light on the medical legacy given to us by Zhang Zhong Jing.
Case Studies and Formula Patterns
Case 1: Chronic Prostatitis with Urgent Urination
Mr. Yu, 25 years old
1st consultation on March 3rd, 2011
The patient was suffering from prostatitis for about 8 months before being treated with IV infusions for half a year, followed by micro-wave therapy and self-administration of the Chinese patent medicine Ba Zheng San, all of which proved to be ineffective.
The presenting symptoms were: severe frequent urination, roughly once every hour; a damp sensation in the scrotal area; a pulling sensation in the lower abdomen and perineum; night urination, 2-3 times a night; passing formed stools once every 2-3 days; a neutral taste in the mouth; normal appetite; occasional night sweats; a pale tongue with white and greasy coating; and a wiry rapid pulse—his left cun pulse was slightly floating and thin.
Analysis: The symptoms of severe frequent urination, pulling sensation in the lower abdomen and scrotum, and frequent bowel movement all belong to the Tai Yin internal depletion syndrome. This internal depletion has created internal rheum seen in the symptoms of dampness in the scrotum area, night urination and greasy tongue coating. In addition, this patient has the symptoms of occasional night sweats and a rapid pulse, demonstrating that the internal rheum has slightly transformed into heat, giving us a slight Yang Ming syndrome. The full differentiation is a Tai Yin Yang Ming Syndrome.
Prescription given was Shen Zhuo Tang plus Chi Xiao Dou Dang Gui San plus Sheng Yi Ren for seven days.
|Cang Zhu||15g||Gan Jiang||15g||Fu Ling||15g|
|Zhi Gan Cao||6g||Chi Xiao Dou||15g||Dang Gui||10g|
|Sheng Yi Ren||18g|
Shen Zhuo Tang (also commonly referred to as Gan Jiang Ling Zhu Tang) was recorded on line 16 in the Jin Gui Yao Lue· On Visceral Wind and Cold, Accumulation and Gathering Disorders: “Patients with kidney disease will feel diffused body heaviness and coldness in the lower back, as if sitting in water, presenting with symptoms similar to rheumatic conditions, but without thirst or inhibited urination, thirst and hunger will be normal. This disease belongs to the lower jiao, sweating with exertion and damp-coldness inside the clothes. Over time, there will be cold soreness below the waist and abdominal heaviness which will feel as if one is carrying five thousand coins; Gan Jiang Ling Zhu Tang governs”.
Shen Zhuo Tang includes Gan Cao, Gan Jiang, Fu Ling, and Bai Zhu, which fortify and warm the middle to treat the Tai Yin Syndrome and promote urination to drain the stagnation of the internal rheum. In this case, the chronic retention of internal rheum intermingles with blood and creates blood stasis. Chi Xiao Dou Dang Gui San was added to move stasis and drain internal rheum. Sheng Yi Ren is also added in this case to treat the slight Yang Ming Syndrome and expel dampness, since it is cool in nature and drains dampness by promoting urination.
2nd consultation on March 10th, 2011
After a week of this formula, the urinary frequency and scrotal dampness reduced, the pulling pain in the scrotum also resolved, the nocturia reduced to once a night, he passed formed stools 1-2 times a day, had occasional borborygmus, normal appetite, normal taste in the mouth, his tongue was pale with white and slightly greasy coating, right pulse was wiry, rapid, and forceful, the left guan pulse was slightly slippery, and both cun positions were floating.
At this time the symptoms improved, but the syndrome remained the same except for the resolution of the internal heat symptoms of night sweating, so the same prescription was given by removing Sheng Yi Ren. However, there was still a slight urine frequency and slight night urination, so the medicinals Sang Piao Xiao 10g and Yi Zhi Ren 10g were used to astringe fluid and consolidate essence.
Results: After taking this formula for 7 more days, the urinary frequency and scrotal dampness were no longer evident and his borborygmus resolved.
Chronic prostatitis can be the cause of many sexual disorders in men, such as spermatorrhea, impotence, and premature ejaculation. By treating the prostatitis, we can also treat the secondary symptoms successfully. This case is also a clear example of how 6 months of TCM costly treatment brought no relief and instead aggravated the symptoms. However, only two simple classical formulas, applied according to the Six Syndrome system, were able to bring relief within 2 weeks. The focus of the treatment was to fortify the middle, treating the Tai Yin Syndrome and promoting the body’s natural function of expelling internal rheum by urination.
Case 2: Premature Ejaculation
Mr. Yang, 31 years old
1st consultation on July 12th, 2011
The patient suffered from premature ejaculation for over half a year, accompanied by depression, anxiety disorders, and cold limbs. He took antidepressants and TCM patent medicine to tonify kidney yang and sooth liver qi for 6 months with no obvious curative effect.
The patient experienced ejaculation with intercourse lasting less than 1 minute, followed by local spasmodic twitches, nervousness, anxiety attacks, cold sensation in the lower limb, deep sighing, irritability, dry mouth, profuse sweating, sloppy stools once a day, dark tongue with a white coating, and a wiry and rapid pulse.
If we analyze the symptom presentation according to the Six Syndrome System: the cold limbs and sloppy stools belong to a Tai Yin Syndrome, the spontaneous sweating and the qi rushing upward symptom, causing the anxiety attack and nervousness, point to an unresolved exterior depletion Shao Yin Syndrome; the dry mouth, restlessness, depression, deep sighing, irritability, excessive sweating, and rapid pulse fit a Yang Ming Syndrome. Hence, the complete differentiation in this case is a Shao Yin Tai Yin Yang Ming concurrent syndrome.
Prescription given was Er Jia Long Gu Mu Li Tang plus Cang Zhu, Fu Ling, Sheng Yi Ren.
|Gui Zhi||10g||Bai Shao||10g||Bai Wei||10g|
|Long Gu||15g||Mu Li||15g||Cang Zhu||15g|
|Chuan Fu Pian||15g||Sheng Jiang||15g||Da Zao||20g|
|Zhi Gan Cao||6g||Fu Ling||12g||Sheng Mi Ren||18g|
Since he also suffered from spontaneous sweating, the ying-wei were not consolidated, which leaves an opening for external pathogens to invade. If not treated properly, this depletion of body fluid leads to a yang deficiency in the lower, causing yang hyperactivity in the upper. Therefore, the treatment must include harmonizing ying-wei and expelling external pathogens while using Fu Zi to warm and tonify the deficient cold in the lower, and using Bai Wei, Sheng Long Gu and Sheng Mu Li to astringe the floating yang.
Er Jia Long Gu Mu Li Tang comes from the formula Gui Zhi Long Gu Mu Li Tang was recorded in the Jin Gui Yao Lue· On Blood Impediment and Taxation Disorders, line 8: “If a man loses his essence, his lower abdomen will be urgently tense, his glans penis will be cold, his vision will be blurry and he will lose his hair, and his pulse will be extremely deficient, hollow and slow, indicating clear food [diarrhea], causing blood collapse and seminal loss. Hollow, stirred, faint, or tight pulses indicate seminal essence loss in men and dreaming of intercourse in women; Gui Zhi Long Gu Mu Li Tang governs.”
Seminal loss and dreaming of intercourse are both lustful in nature and have a tendency to occupy the mind incessantly. This disorder also stems from body fluid damage due to sweating, leading to ying-wei disharmony. Long Gu and Mu Li not only astringe the essence, they also calm the mind and focus on clearing internal Yang Ming heat, restraining the spirit and checking nervousness. When combined with Gui Zhi Tang, which harmonizes ying-wei, this formula targets the pattern entirely. In the Xiao Pin Essay Quotations, it was recorded: “In case of weakness, floating heat and sweating, remove Gui Zhi and add Bai Wei and Fu Zi, otherwise known as Er Jia Long Gu Tang”. In clinic, however, Prof. Hu Xi Shu and Dr. Feng Shi Lun often add Gui Zhi to this formula to fortify the effect of harmonizing the ying-wei.
After taking this formula for one week, the patient reported on the second consultation that his sexual endurance improved and he could remain erect for 2-3 minutes during intercourse, that his nervousness had reduced, and that he had not experienced any anxiety attack that week. However, the patient experienced spermatorrhea twice, profuse sweating—especially at night—epigastric fullness, aversion to cold, and a neutral taste in the mouth. The symptoms of spermatorrhea, aversion to cold, and profuse sweating demonstrated that the exterior Shao Yin Syndrome was still present. The dosage of Chuan Fu Zi was increased to 20g and 10g of Jin Ying Zi was added to consolidate the exterior and astringe the body fluids.
As Chinese medicine practitioners, we see the conventional TCM treatments were ineffective since they were not aiming at the full syndrome. If there is a pathogen remaining on the exterior layer of either Tai Yang or Shao Yin Syndromes, as well as symptoms of these syndromes’ interior layers, we need to slightly promote sweating to resolve the pathogen on the exterior layer while simultaneously clearing the internal Yang Ming heat, addressing the internal deficiency of Tai Yin syndrome and harmonizing the interior and exterior ying-wei. The medicinal Fu Ling and Cang Zhu were effective to further drain the internal retention of rheum by warming the middle.
Case 3: Impotence
Mr. Cang, 30 years old
1st consultation on February 28th, 1963 (treated by Professor Hu Xi Shu and recorded by Dr. Feng Shi Lun)
The patient suffered from impotence and premature ejaculation for 4 years. During this time he had taken both TCM and Western medicines, which had had no effect. An examination revealed that he was suffering from chronic prostatitis, for which he was prescribed Gui Fu Di Huang Wan, but had no curative effect.
Symptoms: inability to maintain a full erection, premature ejaculation, excretion of urethral white mucus-like substance before and after defecation, lower back pain, tinnitus, white tongue coating, wiry and thin pulse.
If we analyze the symptoms, the impotence and premature ejaculation, inability to maintain a full erection, white tongue coating, lower back pain, wiry and thin pulse point to a external and internal concurrent syndrome of Shao Yin Tai Yin Syndrome. The excretion of urethral white mucus-like substance before and after defecation and tinnitus show internal rheum retention turning into heat, creating a Yang Ming Syndrome. The full Six Syndrome diagnosis is Shao Yin Tai Yin Yang Ming concurrent syndrome.
Formula pattern: Er Jia Long Gu Mu Li Tang pattern
|Gui Zhi||3qian – 9g||Bai Shao||3qian – 9g||Bai Wei||3qian – 10g|
|Long Gu||8qian – 24g||Mu Li||8qian – 24g||Zhi Gan Cao||2qian – 6g|
|Chuan Fu Pian||3qian – 9g||Sheng Jiang||3qian – 9g||Da Zao||4pcs – 20g|
*1 qian is equal to 3g.
Result: After taking 3 packs, his tinnitus reduced and the amount of urethral fluid-excretion after defecation was markedly less severe. However, he would still occasionally suffer from tinnitus and lower back pain so he was given Si Ni San to target the slight Shao Yang syndrome causing the tinnitus and Dang Gui Shao Yao San was added to the original prescription to further treat the Tai Yin syndrome with blood depletion. After 6 further packs of this formula, all symptoms improved greatly and his impotence resolved.
The key to successfully using classical formulas in clinic and reaching results worth noting is to fully understand the classical system from which they stem. Every modification of the formula is able to reach a different syndrome combination. Particular care needs to be brought when adding or removing a medicinal, since every formula pattern is a key to unlocking a specific syndrome. Every change of symptoms might indicate an additional syndrome, at which time a new formula pattern or medicinal will be needed. Chinese medicine treatment is not a rigid system of prescriptions given for specific diseases as it is commonly seen in TCM and Western medicine. The essence of Chinese medicine resembles nature, with its multiple changes according to changes in the symptoms. Constant change and appropriate adaptation of the treatment are integral parts of the true nature of health and healing in classical Chinese medicine.
By reviewing these cases, we see that the commonly known treatment in both western medicine and TCM did not relieve the symptoms of these patients, and in some cases worsened their condition, whereas the correct syndrome diagnosis with the appropriate formula pattern brought about satisfactory results in a timely and cost-effective manner. As Dr. Feng often repeats: “有是诊，有是方：有是诊，有是药”. This quote translates to: “For each syndrome, there is a formula; for each syndrome, there are medicinals”. This lineage of the understanding of the works of Zhang Zhong Jing does not link the classical formulas to any of the acupuncture channels, zang fu diagnosis, body constitutions, or the changing seasons. Instead, each prescription is based solely upon syndrome diagnosis according to the symptom presentations.
Hopefully, this long standing lineage and understanding of the classical text from the Han Dynasty, handed down to us by the empirical doctors and dedicated teachers like Professor Hu Xi Shu and Dr. Feng Shi Lun, will survive the test of time and we will continue to keep the system pure and effective.
Dr. Suzanne Robidoux is a renowned international teacher and author of Chinese medicine in Europe, Asia and North America. She has learned and practiced in China for the last 15 years. She teaches one of the 3 classical acupuncture techniques from Taiwan effective for rapid pain management, three different scalp acupuncture techniques from Bei Jing, Shang Hai and Nan Jing, traditional and modern moxa techniques, and classical medicine. Dr. Robidoux completed her doctorates education in Nanjing with a clinical research on treating neurological pain. She is currently completing her postdoctoral clinical research on the classical system of the Shang Han Za Bing Lun at the Beijing University of Chinese Medicine and has also founded an international online teaching portal online.