Case Study: Rhinitis
By Jin Zhao DTCM
Recorded by Inbar Cohen Licensed Acupuncturist
Rhinitis Part 1
The Patient: A 12-year-old girl.
Suffering from rhinitis with itching in the throat, nose, and eyes.
Additional symptoms:
- Fatigue
- Frequent abdominal pain after meals
- Has not yet started menstruating
Pulse: Slippery
Tongue: Thin, with a red tip and red points, a thin white greasy coating, dry in the center.
The Prescription:
Dang Shen 5
Gan Jiang 3
Jiao Shan Zha 5
Chao Shen Qu 10
Dong Gua Zi (Ren) 15
Lu Gen 15
Bai Dou Kou 5
Sha Ren 3
Xin Yi Hua 10
Bai Zhi 5
Zi Su Ye 10
Fang Feng 10
Jie Geng 10
Tian Ye Ju 1
Explanation and Analysis:
This case is particularly interesting because it represents a very common issue with only a few symptoms. At first glance, the formula seems not to be based on any classic formula. However, upon closer examination, one can see that the prescription draws inspiration from several classic formulas and various treatment strategies.
In this patient, we see itching in the throat, eyes, and nose - suggesting a possible allergy and indicating allergic rhinitis rather than "just" rhinitis. Additionally, the itching indicates the presence of wind.
When discussing allergies, it often relates to a deficiency of zheng qi. In cases of zheng qi deficiency in children, Dr. Jin strengthens the spleen and stomach.
The tongue shows a red tip with red spots, but the coating is white and greasy; the pulse is not rapid but slippery, and the patient does not exhibit symptoms of heat.
Fatigue indicates Qi deficiency, and abdominal pain after meals suggests that the stomach and spleen struggle to digest food properly—also indicating Qi deficiency. However, since the abdominal pain occurs after eating, it implies some degree of excess as well. The slippery pulse and greasy coating on the tongue lead us to understand that there is excess dampness in the middle burner.
So, where does the heat come from?
If we look at the prescription she received, we can see an "inspiration" from the formula Li Zhong Wan—the prescription contains Gan Jiang and Dang Shen, which replaces Ren Shen. This suggests that the patient suffers from cold due to deficiency in the middle burner.
Dr. Jin substitutes Ren Shen with Dang Shen due to her young age—based on his clinical experience, Ren Shen tends to encourage early sexual development. The patient has not yet started her menstrual cycle, and her age is appropriate for this, so we do not want to promote this before her body is ready.
Other noteworthy herbs are Jiao Shan Zha and Chao Shen Qu, both processed (cooked or fried) to warm them a little, making them easier to digest and warmer in nature. These herbs address food stagnation, a form of dampness stuck in the middle burner that hinders digestion. This explains the greasy white tongue coating.
From this, we can understand that cold and dampness are stuck in the middle burner, combined with qi deficiency. Qi deficiency weakens the yang qi, and together with cold and dampness in the middle burner, it disrupts its movement, creating yang qi stagnation.
Stagnation, by nature, tends to generate heat and dryness, which is reflected as heat on the tongue. Thus, paradoxically, this is heat arising from cold and damp stagnation combined with yang qi deficiency.
Dr. Jin uses Lu Gen to slightly alleviate the heat and restore the depleted fluids, along with Dong Gua Zi (Ren), which promotes urination to remove dampness and has a mild cooling effect.
Additionally, the herb Dong Gua Zi is diuretic and suitable for fluid accumulation, and together with Lu Gen, it can drain phlegm from the lungs—especially if it is warm. Here, we can see inspiration from the formula Qing Jin Wei Jing Tang, without the herb Tao Ren due to the absence of severe stagnation and without Yi Yi Ren, which is too cold for her.
Bai Dou Kou and Sha Ren are included to warm and awaken the spleen, aiding it in expelling dampness. Sha Ren slightly warms the lower burner as well, making it relevant for yang qi deficiency.
The next group of herbs is the obvious: Xin Yi Hua combined with Bai Zhi to open the nasal passages and address the main complaint—rhinitis, which we now understand stems from yang qi deficiency and cold stagnation with dampness creating heat.
Bai Zhi also has other roles: along with Zi Su Ye and Fang Feng, it releases the exterior, supporting the weakened yang qi that is now making the body more vulnerable to external wind (a contributing factor to the rhinitis).
When combining these three herbs with Sha Ren and Dou Kou, we see an approach that considers the Xuan Fu in the body.
Briefly, this theory posits that the body is filled with internal "pores" akin to those on the skin. These pores exist in internal organs, muscles, bones, tendons, marrow, and more. Just as skin pores facilitate interaction between the body and the environment, internal pores enable the continuous flow of substances (qi, blood, fluids, shen, jing) and seamless internal communication. When the Xuan Fu is blocked for any reason, the body’s self-healing capacity is impaired.
These five herbs are part of a group called Wind Herbs, which are pungent, therefore their natural direction is upward and outward, helping to open the Xuan Fu within the body. By choosing these herbs, Dr. Jin not only addresses the branch (the symptoms) but also the root cause of the patient’s issue, enabling the body to restore its healing capabilities.
Now, let's discuss Jie Geng. Though commonly used for phlegm in the lungs and coughing, Dr. Jin applies it differently here. The patient’s qi deficiency with dampness leads to yang qi stagnation, which suppresses qi movement throughout the body. This stagnation disrupts the overall qi mechanism. The lungs, as the body’s Prime Minister, initiate qi circulation throughout the body. Through respiration, they provide the initial "kick" that propels qi movement. Jie Geng enhances the dispersing and descending functions of the lungs, essentially serving as a "starter" for qi movement. Paired with the warming, strengthening, dampness-expelling, and Xuan Fu-opening herbs, it helps restore smooth qi flow throughout the body.
Lastly, Tian Ye Ju (stevia) is included. Though it is cooling, its dose here is only 1 gram. Dr. Jin adds it to formulas for children or adults who struggle to drink herbal decoctions, using it to sweeten and make them more palatable. If its cooling property were to be utilized, the dose would be 2 grams.