By Jin Zhao DTCM

Recorded by Inbar Cohen Licensed Acupuncturist

Explanation part 1

Explanation part 2

 Case Study: Chronic Atrophic Gastritis

The Patient:
A 58-year-old woman suffering from chronic atrophic gastritis, presenting with abdominal pain and discomfort, heartburn, acrid oral pain with unusual sensations, and recurring mouth ulcers.

Additional Symptoms:
- Hot flashes and sweating causing irritability or heart stress
- Tightness in the chest
- Anxiety and depression
- Yellow urine
- Shapeless stools
- Loss of appetite
- Difficulty falling asleep, waking up at night difficulty falling asleep again

Medical History:
- Menopause at age 52
- Liver cyst
- Lung nodules (GGN)

Pulse: Deep, moderate, slightly slow, and slightly slippery
Tongue: Dark, with thin and greasy coating, toothmarks, a midline crack, deep in the lung area, and slightly swollen edges.

The prescription:
- Gan Jiang 5g
- Ren Shen 5g
- Bai Zhu 15g
- Fu Ling 15g
- Bai Bian Dou 15g
- Sha Ren 5g
- Bai He 5g
- Dao Ya 20g
- Jian Qu 10g
- Zi Su Ye 10g
- Fo Shou 5g
- Chuan Xiong 5g
- Liu Ji Nu 5g
- Wei Ling Xian 5g
- Huo Xiang 15g

 Explanation and Analysis:

 Dr. Jin initially prescribed Li Zhong Wan. At first glance, this might seem paradoxical given the patient’s symptoms indicating heat, such as heartburn, acrid oral pain, ulcers, hot flashes, and yellow urine. However, examining the pulse and tongue reveals cold signs: a dark tongue, deep and moderate, slightly slow pulse. So where does the heat come from?
This is a patient with Qi deficiency that has led to Yang Qi stagnation.

The stagnation, as is typical of stagnation, generated heat in various parts of the body. However, its root cause is cold. In this patient, there is a fundamental deficiency in the spleen's function. We might refer to this as a deficiency in the spleen’s essence; Dr. Jin uses the term "spleen Yin deficiency," which reflects the most basic level of dysfunction.

For the spleen, as a primary organ in the process of Qi production, Yin deficiency is always accompanied by Qi deficiency. In this case, the patient exhibits both spleen Yin and Qi deficiency, alongside cold in the center.

Key indicators include abdominal pain and discomfort, unusual oral sensations, shapeless stools, loss of appetite, and difficulty sleeping—all associated with spleen dysfunction. 

As part of the spleen's Yin and Qi deficiency, this patient exhibits disruptions in the natural movement of the Qi mechanism, where the spleen raises the pure, and the stomach descends the turbid. This is reflected in heartburn and ulcers (the stomach raising the turbid), as well as anxiety and depression (a manifestation of the pure not ascending, combined with heat, stagnation, and spleen Qi deficiency).

Additionally, there is evidence of deep, sticky phlegm accumulation, as seen in the liver cyst, lung nodules, and chest pressure. This sticky accumulation stems from the heat generated—cold causes stagnation, which leads to heat. This process explains the symptoms observed: heartburn, acrid oral pain, mouth ulcers, hot flashes and sweating due to Yang Qi deficiency or stagnation, anxiety and depression, chest tightness, and frequent awakenings.

Therefore, the primary formula for this patient addresses the root of the problem—cold stagnation in the middle warmer—and that is why the classical Li Zhong Wan was chosen.

The second formula in the prescription is a modification of Shen Ling Bai Zhu San. According to Dr. Jin, this is the primary formula for treating spleen Qi and Yin deficiency.

The formula includes Si Jun Zi Tang, along with herbs that are both highly nourishing and easy to digest (in the original formula: Shan Yao and Bai Bian Dou. In this modification: Bai Bian Dou and Dao Ya).

In addition, there are herbs that help warm and stimulate the spleen, "resetting" the basic ascending and descending mechanism of the spleen and stomach.

The prescription also includes modifications aimed at addressing stagnation, with Qi- and blood-regulating and invigorating herbs to resolve deep stagnation (cold and phlegm).

Finally, warm, aromatic, spleen-stimulating herbs are included to recruit the body’s natural healing abilities by aiding in the renewal of its Qi mechanism.

 Herb and Formula Analysis:

Li Zhong Wan:
- Gan Jiang
- Ren Shen
- Bai Zhu
Zhi Gan Cao was excluded due to its sweet-cloying nature, which can exacerbate dampness in cases of cold and Qi deficiency.

Shen Ling Bai Zhu San:
- Ren Shen
- Fu Ling
- Bai Zhu
- Bai Bian Dou
- Sha Ren
Modifications:

 - Dao Ya

Replaces Shan Yao as it is sweet, neutral, enters the SP and ST. This herb is very nourishing, and easier to digest than Shan Yao, which can be too sticky.
- Bai He 

Replaces Lian Zi. Both herbs have calming-the-spirit properties, but Bai He nourishes the Yin of the lungs and heart, helps to moisten the lungs (addressing the sticky phlegm and nodules), and is slightly cooler in nature. Although the heat originates from an internal cold source (hence the use of Li Zhong Wan), it is still necessary to address the heat directly.

The herb helps to cope with heat waves, insomnia, and mental state. 

Another point is that Lian Zi is a seed—it is solid and dense and may be too nourishing for the patient. It has an absorptive quality, which can increase stagnation. In contrast, Bai He is sweet and refreshing, and it is digested more easily.

 Omitted herbs: yi yi ren, jie geng, zhi gan cao (shan yao, lian zi)

Herbs addressing the stomach and Qi mechanism:

• jian qu

• zi su ye

The herb Jian Qu is a variant of Shen Qu that specifically addresses cold (usually external) and dampness. It helps resolve accumulations and stagnation in the middle burner, naturally aiding in the restoration of the Qi mechanism—allowing the pure to ascend and the turbid to descend.

The herb Zi Su Ye, from the category of exterior-releasing herbs, is pungent, which means its movement is upward and outward. It assists the spleen in raising the pure and is highly effective for rebellious stomach Qi, making it particularly relevant here.

Another important function of Zi Su Ye is its ability to open the Xuan Fu throughout the body. The Xuan Fu theory describes the body as being filled with micro-pores, much like the skin. These pores exist in the muscles, bones, tendons, marrow, and organs. Their role is to facilitate the movement of substances and Qi (including Qi, blood, Shen, Jing, and fluids) and to maintain continuous communication between different parts and organs of the body.

When the Xuan Fu are blocked, the body’s healing ability is significantly impaired. Zi Su Ye, with its upward and outward movement (pungency), helps open these internal pores, enabling the body to renew its natural healing abilities.

 Herbs for stagnation:
- Wei Ling Xian
- Fo Shou
- Chuan Xiong
- Liu Ji Nu

The patient exhibits deep stagnation, involving both cold and sticky phlegm. To address this, herbs capable of entering the channels are required to disperse the stagnation and support the natural movement of Qi.

Wei Ling Xian, from the category of wind-damp dispelling herbs, has the ability to penetrate the channels, alleviate stagnation in the middle burner, and soften hard accumulations due to its salty taste. It is highly relevant for cases of lung nodules.

Fo Shou is a Qi-regulating herb, prescribed mainly for the patient's emotional state (anxiety and depression). This reflects Qi stagnation due to Qi deficiency. Together with Shen Ling Bai Zhu San, and specifically with Bai He, this herb performs exceptionally well.

Chuan Xiong moves Qi in the chest and enters the channels due to its blood-invigorating properties, making it relevant for nodules and cysts. Additionally, it helps resolve cold stagnation, which is a deeper form of stagnation than Qi stagnation. Dr. Jin frequently uses it for cold-induced stagnation.

Liu Ji Nu, from the blood-invigorating category, is bitter and warm, entering the heart and spleen. Beyond resolving blood stasis, it lowers rebellious stomach Qi, resolves food stagnation, dissolves masses, and aids in diarrhea. Combined with the rest of the formula, it effectively addresses all these issues.

Dr. Jin often uses the combination of Wei Ling Xian and Liu Ji Nu in cases of stagnation and abdominal pain due to Qi and blood stagnation.

Warm, aromatic herbs for the spleen:
- Huo Xiang
- Sha Ren
The herbs from the aromatic damp-transforming category are key components in Dr. Jin's formulas. These herbs are pungent, warm, and sometimes sweet, helping to restore the natural movement of Qi.

Their pungent flavor directs movement upward and outward, and together with Zi Su Ye, they help to open the Xuan Fu throughout the body.

Their warmth enables the spleen to recover and resume its proper transformation and transportation (T&T) functions. Along with Dao Ya and Jian Qu, they also assist in resolving central stagnation and supporting the patient.