Case Study: Halitosis and Anxiety (Stank breath and worry)
By Jin Zhao DTCM
Recorded by Inbar Cohen Licensed Acupuncturist
Explanation part 1
Explanation pt 2
The Patient:
36-year-old female suffering from persistent halitosis (bad breath) for about two years. Previous treatments with herbs and probiotics were ineffective. Also experiences anxiety (no specific symptoms reported).
Additional Symptoms:
Loose stools
Yellow urine
Poor sleep quality
Bland diet
Gynecological History:
Miscarriage approximately two months ago
Menstruation one month post-miscarriage - heavy flow, red color, mild dysmenorrhea
Medical History:
Chronic throat infections
Chronic superficial gastritis
Stomach polyps
Pulse: Rapid, deep. Thin in yang positions, full in yin positions. Rolling on the left hand.
Tongue and Appearance: Slightly dark/purple lips. Swollen tongue but not soft, red, with red dots, thick and greasy white coating. Slight teeth marks.
Prescription:
Chao Cang Zhu 15g
Chao Bai Zhu 15g
Fa Ban Xia 5g
Chen Pi 5g
Fu Ling 20g
Xing Ren 5g
Bai Dou Kou 5g
Dong Gua Zi (Ren) 15g
Huo Xiang 20g
Zhu Ye Chai Hu 10g
Pu Gong Ying 5g
Xu Duan 15g
Sha Ren 5g
Jin Qian Cao 5g
Jian Qu 10g
Shan Zha 10g
Sheng Jiang 5g
Analysis and Explanation:
Based on the Eight Principles perspective, the patient presents a condition of internal excess (dominant) with deficiency (less dominant) and heat. The deep pulse indicates an internal condition but also reveals weakness in Qi and Yang. This weakness generates dampness and phlegm, which is why the Yin pulse feels full and slippery the left hand.
Additional signs of dampness and phlegm include a swollen tongue - not a "soft" swelling indicative of Qi and fluid deficiency (marshmallow-like texture), but rather a thick swelling (rubber-like texture), indicating an excess of turbid and viscous fluids.
The tongue coating is thick and greasy, resembling a greasy spread applied to the tongue, along with the accumulated viscous saliva, indicating sticky fluids in the body.
The polyps in the stomach represent an accumulation of phlegm.
We also observe deficiency—there are toothmarks on the edges of the tongue, and a thin, weak pulse at the Yang position with soft stool (a symptom that can be associated with either excess or deficiency).
At the level of excess, there is a significant visible excess heat: yellow urine, rapid pulse, poor sleep, red tongue, and red spots on the tangue all indicate excess heat in the body. The patient's two main complaints—anxiety and bad breath—both are a result of excess heat (and dampness) in the stomach.
When we observe such excess heat in the body, we would expect to see a patient suffering from heat, with a yellow and dry coating on the tongue. However, despite the evident heat in all symptoms, the patient does suffer from heat, and the tongue coating is thick, white, not yellow or dry.
This suggests that the heat is not the root of the problem but rather results from an excess of phlegm and dampness in the body, primarily stagnating in the middle burner and blocking the natural movement of Qi and Yang Qi, leading to overheating.
The patient's bad breath arises not only from the heat but also from long-term stagnation of phlegm in the stomach, which "rots" there and creates a lack of movement in a place that should be in constant motion. The heat is merely a byproduct of this stagnation.
Therefore, in the prescription that Dr. Jin wrote for the patient, we see a primary focus on phlegm and dampness in the body, with minimal reference to heat. The main formula chosen for her is Er Zhu Er Chen Tang, accompanied by the emperors of San Ren Tang. Additionally, we see inspiration from Ping Wei San, which will be elaborated on later.
Analysis of Herbs and Formulas:
Er Zhu Er Chen Tang:
Chao Cang Zhu - fried in wheat bran. Moderates its action, reduces aromatics and warms the herb's temperature.
Chao Bai Zhu - fried in wheat bran. Slightly reduces aromatics and warms the herb's temperature.
Fa Ban Xia - processed with Gan Cao.
Chen Pi
Fu Ling
This is the main formula addressing the patient's primary syndrome - excess phlegm and dampness in the stomach. Gan Cao was omitted as it is too sweet and therefore promotes dampness formation in the body. However, it is present in the processing of Ban Xia.
San Ren Tang
Xing Ren
Bai Dou Kou
Dong Gua Zi (Ren)
The Three-Seed Formula is used to eliminate damp-heat from the three burners. In this patient, the dampness is not hot, and cold herbs would only weaken the patient's Qi and contribute to additional dampness and phlegm formation. Therefore, Dr. Jin only uses the chief herbs of the formula, preserving the treatment principle.
Dr. Jin substitutes Yi Yi Ren with Dong Gua Zi, which has similar properties - it is also cooling, drains dampness from the lower burner, and is a food, indicating its gentle action.
Interestingly, Dr. Jin chooses to use low dosages of this formula. Typically, he would use 10-15g of Xing Ren and 20-30g of Dong Gua Zi. This time he chose significantly reduced dosages, showing that the main issue for the patient is phlegm in the middle burner, not dampness.
Herbs for Regulating the Qi and Blood, Addressing Food Stagnation:
Chen Pi - as part of the patient's main formula
Zhu Ye Chai Hu - slightly cooler than the familiar herb
Jian Qu - similar to Shen Qu, treats more dampness along with food stagnation
Shan Zha - in its fresh form (sheng), addresses both Qi movement and gentle blood movement according to Dr. Jin
We can see that Dr. Jin maintains the therapeutic principle of Er Chen Tang and expands it - drying dampness (Ban Xia), moving Qi in the middle burner and body (Chen Pi), draining dampness (additional herbs we'll see later) and supporting Qi (Bai Zhu).
In this part of the modifications, we see herbs that help move the middle Qi.
First, Chen Pi of course. Along with it appears Zhu Ye Chai Hu which moves Liver Qi and helps move phlegm and dampness throughout the body and address the resulting stagnation.
The herbs Jian Qu and Shan Zha are both classified as food stagnation eliminators. This means they can assist with significant and long-term stagnation in the center while also promoting the movement of Qi. Given that the patient has suffered from bad breath for two years without improvement, even with herbs and probiotics, we understand that there is chronic, significant food stagnation present, and these herbs support this issue.
Shan Zha specifically appears in its fresh form and also addresses Liver Qi movement, thus working in cooperation with Zhu Ye Chai Hu.
An interesting point is that there is inspiration from the formula Zha Qu Ping Wei San, which combines the Ping Wei San formula with Shan Zha and Shen Qu (which in this case has been replaced by Jian Qu).
All the main herbs of the formula are present except for Hou Po, which is a primary Qi mover but too strong for this patient, along with the supporting herbs Gan Cao and Da Zao, which are unsuitable due to their sweetness. (Cang Zhu, Chen Pi, Sheng Jiang).
This further indicates that Dr. Jin sees a certain degree of phlegm stagnation in the patient—evidenced by her purplish lips, red spots on the tongue, and her mental state. He uses herbs that move Qi in the middle burner (including herbs for food stagnation) to address this issue.
Aromatic Herbs for Spleen Arousal and Aromatic Drying of Dampness:
Huo Xiang
Sha Ren
Bai Dou Kou
Sheng Jiang
Another strategy for treating dampness is using aromatic herbs that stimulate the Spleen.
These herbs, together with the other herbs in the formula, help open the Xuan Fu throughout the body.
Briefly, the Xuan Fu theory states that just as the skin is full of pores that help the body communicate between interior and exterior, so too is the body's interior full of pores - the muscles, bones, marrow, and internal organs. These pores are called Xuan Fu and through them flow Qi, blood, yin, yang, fluids, and Shen. Their role is to create smooth passage for materials and Qi, and enable continuous and proper communication between all parts of the body.
The Xuan Fu pores, like skin pores, can become blocked due to excess or deficiency. When these pores are blocked, the body cannot work toward its complete healing because there is no smooth passage for materials and Qi, and no good communication between different parts of the body.
Therefore, one of the main strategies in Dr. Jin's prescriptions is to open and ventilate the Xuan Fu pores to correct and renew the body's natural Qi mechanism, so the body can heal itself.
Here Dr. Jin uses aromatic herbs that stimulate the Spleen, as well as Sheng Jiang which is from the exterior-releasing group and helps support the Stomach.
All these herbs are pungent, thus their Qi direction is outward, a function that helps open the Xuan Fu. They are also warm, which supports gentle warming of the Spleen to help it properly perform its fluid transformation function.
Clearing Damp-Heat
Pu Gong Ying
This herb from the fire and toxicity-clearing group and clears damp-heat. This herb is unique in the group because despite its cold temperature and bitterness, it doesn't significantly damage Spleen Qi like other herbs in the group.
In fact, this is the only herb that predominantly addresses heat in the patient's prescription, along with Zhu Ye Chai Hu and slightly with Dong Gua Zi supporting cooling.
Draining
Jin Qian Cao
Dong Gua Zi
Fu Ling
A third (or fourth, depending on how you count) strategy for clearing dampness and phlegm that Dr. Jin uses here is draining.
Along with Fu Ling from Er Chen Tang, Dr. Jin uses Jin Qian Cao which is neutral, sweet, and bland.
The herb helps drain and dissolve nodules, and therefore together with Pu Gong Ying both herbs treat the stomach polyps.
Kidney Support
Xu Duan
The main strengthening herb of the formula. Dr. Jin chooses to include it due to the patient's recent miscarriage and heavy menstrual bleeding.
The patient shows deficiency in additional symptoms (weak and thin pulse in yang positions, teeth marks and swelling on tongue), and together with Bai Zhu, Dr. Jin supports the Spleen and Kidney Qi.
The herb Xu Duan strengthens Kidney Qi and has a "gathering" quality - it can stop bleeding due to Kidney deficiency and prevent miscarriage due to its holding quality.