Traditional Chinese Medicine Case Study / Clinical Reference Article
For patients with recurrent oral ulcers due to Yin deficiency and damp-heat accumulation, the treatment should nourish Yin fluids, clear damp-heat, and supplement the earth to subdue fire, using Ganlu Decoction (甘露饮) combined with Fengsui Pill (封髓丹).Ganlu DecoctionIngredients: 20g Sheng Di Huang (Rehmannia Root), 20g Shu Di Huang (Prepared Rehmannia Root), 20g Tian Dong (Asparagus Tuber), 20g Mai Dong (Ophiopogon Tuber), 15g Shi Hu (Dendrobium), 10g Chao Zhi Qiao (Stir-fried Bitter Orange Peel), 10g Huang Qin (Scutellaria), 10g Yin Chen (Virgate Wormwood), 15g Pi Pa Ye (Loquat Leaf), 6g Sha Ren (Amomum Fruit), 10g Jiao Huang Bai (Fried Phellodendron), 10g Sheng Gan Cao (Raw Licorice)1. Brief Understanding of the FormulaRecurrent oral ulcers (known as recurrent aphthous stomatitis in Western medicine) are often due to Yin deficiency and damp-heat accumulation. The treatment should nourish Yin fluids and clear damp-heat.The Ganlu Decoction from the Taiping Huimin Heji Ju Fang uses two types of Rehmannia (Sheng Di Huang and Shu Di Huang) and two types of Dong (Tian Dong and Mai Dong) to nourish Yin fluids; Huang Qin and Yin Chen to clear damp-heat; Zhi Qiao to regulate Qi; and particularly, Pi Pa Ye to clear and regulate lung Qi (the lungs govern Qi, and when Qi is transformed, dampness is also transformed).This formula nourishes Yin fluids without hindering damp-heat, and clears damp-heat without harming Yin fluids; combined with the Fengsui Pill from the Qixiao Liangfang to supplement the earth and subdue fire, it is indeed an effective specialized formula for treating Yin deficiency and damp-heat type oral ulcers.2. Origin of the FormulaIn my early years of treating recurrent oral ulcers, I was hesitant to use Ganlu Decoction for patients with a red tongue and yellow greasy coating, fearing the richness of the two types of Rehmannia and two types of Dong.Once, I casually mentioned this to my friend Chen Siyi, who said he had treated a stubborn cough and asthma in a patient with a thick yellow greasy tongue coating that covered the entire tongue surface. After repeatedly using heat-clearing and phlegm-resolving formulas without effect, the thick yellow coating did not recede. The patient consulted a 70-year-old TCM doctor, who prescribed Ganlu Decoction for three doses, resulting in a significant reduction in cough and asthma, and the thick yellow greasy coating receded by half; later, the patient combined this with Jinshui Liu Jun Decoction for a complete recovery.Upon hearing this, Chen was astonished and regretted his previous lack of insight, and from then on, he viewed this formula with new respect. I, on the other hand, was awakened by this revelation. Since then, I have tried using this formula, and the results have indeed been reliable.Later, I browsed through formula books and found a case recorded by Wang Kentang in the Ming Dynasty in the book Linglan Yaolan, stating: “Mr. Yan Wenjing from Changshu, over seventy years old, had not ceased sexual activity, took countless warming and tonifying medicines daily, and also cooked porridge with ginseng and made soup with Cistanche, which led to stomach heat, mouth ulcers, loose teeth, and foul breath, making it unbearable to approach. He repeatedly took cold and cooling medicines to clear the stomach without effect. When he wanted to use ginger and cinnamon as an adjunct, I advised against it, saying, ‘Using it will definitely worsen the condition.’ Instead, I prescribed a modified Ganlu Decoction, and after eight doses, he was cured.”Even doctors like Chen Xiuyuan, who respected ancient texts and dismissed contemporary formulas, acknowledged that Ganlu Decoction excels in nourishing Yin and benefiting dampness.Chen believes that the two types of Dong and two types of Rehmannia in Ganlu Decoction are meant to nourish Yin like the Ejiao in the Zhu Ling Decoction from the Shang Han Lun; while Huang Qin, Yin Chen, and Zhi Qiao are meant to clear dampness and eliminate turbidity like the herbs in Zhu Ling Decoction with Shi Gao and Ze Xie.In my early years of treating recurrent oral ulcers, I often diagnosed patients with a pale tongue lacking moisture or with a thin yellow coating, dry lips, as having insufficient spleen Yin, with deficient fire rising and dampness stagnating.I had previously used Shenrou Yangzhen Decoction and Shenling Baizhu Powder with little success.Later, drawing on the experience of Elder TCM doctor Pu Fuzhou, I used a modified Fengsui Pill, which yielded better results.The Fengsui Pill (Sha Ren, Huang Bai, Gan Cao) was originally a formula for lowering heart fire and benefiting kidney water to treat nocturnal emissions and dreams, but Elder Pu uniquely recognized that Fengsui Pill could supplement the earth and subdue fire, making it applicable for treating recurrent oral ulcers due to earth deficiency and floating fire, which is truly remarkable.After middle age, I began to combine Ganlu Decoction with Fengsui Pill as a specialized formula for treating Yin deficiency and damp-heat type oral ulcers.3. Clinical Case ExamplesA 52-year-old male patient was diagnosed on September 25, 2002. He had recurrent oral ulcers for nearly ten years, with episodes alternating; Western medicine diagnosed it as recurrent aphthous stomatitis. During episodes, he took a mix of Western and Chinese medicines, with uncertain effects. Five years ago, an elderly TCM doctor prescribed over 30 doses, and the oral ulcers did not recur for half a year, leading him to believe he was cured, which brought him great relief. However, after a recurrence, he sought treatment again, but the elderly TCM doctor had passed away. He then followed the original prescription from the elderly doctor, but it was not as effective as before. He consulted over ten other doctors, with over 40 different prescriptions, including names like Wuwei Xiaodu Decoction, Shengjiang San, Dan Zhi Xiao Yao San, Xie Huang San, and Zhi Bai Di Huang Decoction. The prescription from the deceased elderly TCM doctor contained over 30 ingredients, including Ganlu Decoction.Upon examination, the patient had a sallow complexion, foul breath, dry stools, and yellow urine; his tongue was red with a thick yellow greasy coating in the middle and back, and his pulse was wiry and weak. In the oral cavity, there were five oral ulcers, round and slightly larger than soybeans, yellow in color, with depressed surfaces and red surrounding mucosa. He reported a fondness for alcohol and mental strain. The diagnosis was Yin deficiency and damp-heat accumulation, and the treatment should nourish Yin fluids, clear damp-heat, and supplement the earth to subdue fire. I prescribed Ganlu Decoction combined with Fengsui Pill for six doses, advising him to abstain from alcohol, avoid spicy foods, and maintain a balanced lifestyle.In the second consultation, all oral ulcers had disappeared. The tongue was slightly red, and the thick yellow greasy coating had receded significantly. The treatment continued with 24 doses without changing the formula.In the third consultation, the patient had taken a total of 30 doses, and the oral ulcers had not recurred. He was advised to stop the medication and observe, with instructions to keep the original prescription in case of recurrence, in which case he could take six doses. In October 2010, the patient returned for another illness, stating that in the past four years, he had experienced three recurrences of oral ulcers, all mild, and that taking this formula for three or four doses resolved them without issue.4. Considerations for the Formula1. Although there are many types of recurrent oral ulcer syndromes, the Yin deficiency and damp-heat type accounts for the majority. If Ganlu Decoction combined with Fengsui Pill is used properly, half the battle is won. It is advisable to use the original formula directly, adjusting the dosage as needed, but not altering the ingredients.2. Occasionally, I encounter cold-type oral ulcers, where the ulcer surface and surrounding mucosa appear pale or grayish-white; taking cooling medicines may worsen the condition.If accompanied by symptoms of fatigue, spontaneous sweating, lethargy, and poor appetite with loose stools, it indicates spleen deficiency with Qi sinking and fire not being anchored, and treatment should focus on tonifying the spleen, raising the sinking Qi, and draining Yin fire, which can be achieved with Buzhong Yiqi Decoction combined with Fengsui Pill (using only 3g of Jiao Huang Bai).If accompanied by cold limbs, abdominal pain, and loose stools, it indicates spleen and kidney Yang deficiency, with internal cold and Yang being forced upward, and treatment should focus on warming and tonifying the spleen and kidney, breaking Yin and returning Yang, using Guizhi Fuling Decoction for mild cases and Tongmai Sini Decoction for severe cases.The formula of Ganlu Decoction combined with Fengsui Pill raises many questions worth exploring, and here I will add three points.First, Differentiation of Syndromes.How to differentiate oral ulcers?Based on clinical observations, patients rarely exhibit systemic symptoms, and the pulse does not show any special characteristics, but the tongue presentation is unmistakable. Generally, the tongue is red with a yellow greasy coating; or the tongue is slightly red with a white and slightly yellow, thin greasy or thick greasy coating. This is the tongue presentation of Yin deficiency with damp-heat, without a doubt.Some say this syndrome accounts for over 60%, while my experience suggests it is over 80%, making the opportunity to use Ganlu Decoction combined with Fengsui Pill very high.Other syndromes, due to my limited experience, I have rarely encountered.I have never encountered excess fire, and occasionally seen cold-type cases. As mentioned in the text, these have systemic symptoms such as fatigue, lethargy, poor appetite, and loose stools, indicating spleen deficiency with Qi sinking and fire not being anchored, and treatment should focus on tonifying the spleen, raising the sinking Qi, and draining Yin fire, which can be achieved with Buzhong Yiqi Decoction combined with Fengsui Pill.I have treated two cases, but only the symptoms were alleviated, and they were not cured. I also introduced them to a doctor from the Huoshen school, but they were not cured either.Therefore, what I fear most now is the occasional cold-type oral ulcers; if encountered, I can only honestly inform the patient that if after three treatments, each with six doses of Chinese medicine, there is still no significant effect, they should consult another doctor.Second, Selection of Formulas.For oral ulcers with Yin deficiency and damp-heat, it is essential to select Ganlu Decoction combined with Fengsui Pill, and to use it consistently without changing formulas. Generally, effects are seen after three doses, and recent cures occur after nine doses. In the case mentioned in the text, 30 doses were taken, which is the maximum. One must not be creative and select other prescriptions or create their own formulas.As mentioned earlier, in the summer of 2010, a previous doctor used Sanren Decoction with modifications, which seemed to be on the right track, and the oral ulcers occasionally disappeared, but the tongue presentation did not change, indicating that the internal environment causing the disease had not changed. However, using Ganlu Decoction combined with Fengsui Pill made a significant difference, with the tongue returning to a light red color and the thick greasy coating receding, indicating a change in the internal environment.When treating oral ulcers, I initially learned from Elder TCM doctor Pu Fuzhou’s unique experience, using Fengsui Pill combined with Shaoyao and Gan Cao Decoction, adding Shi Hu, Lu Gen, and Amber powder (taken in water). The tongue presentation generally shows no obvious abnormalities.If the tongue is red, the tongue tip is dry, or the tongue tip has a peeled coating, with the surrounding coating being yellow greasy or grayish-yellow greasy, it indicates stomach Yin deficiency and damp-heat accumulation, and I temporarily use Ganlu Decoction combined with Fengsui Pill with modifications. This realization, which I shared in the 1980s in the Journal of Traditional Chinese Medicine, was a result of deep reflection.Coincidentally, a disciple of my enlightening teacher, Mr. Jian Yuguang, visited and candidly told me, “Your formula for treating oral ulcers was ineffective for me.” This was a wake-up call! I then devoted myself to deep thinking and repeated verification, and it took another ten years to confirm the formula of Ganlu Decoction combined with Fengsui Pill. This is not just a minor difference; I love to quote Columbus’s famous saying, “The difference is just a little bit.”When encountering oral ulcers, the first consideration is the formula of Fengsui Pill; secondly, for those with Yin deficiency and damp-heat, I use Ganlu Decoction with modifications, including Nansha Ren, Beisha Ren, Tian Dong, Mai Dong, Sheng Di Huang, Yin Chen, Huashi, Zexie each 15g, Huang Qin 6g, Amber powder 6g (taken in water), and Sheng Gan Cao 3g. This is no longer the original Ganlu Decoction. Now, I use the original Ganlu Decoction combined with the original Fengsui Pill, with 10g of Sheng Gan Cao, and the effects are significantly different.I hope that practitioners encountering oral ulcers will first keep the formula of Ganlu Decoction combined with Fengsui Pill in mind. This is the rule; without rules, one cannot form a circle.Third, Prevention of Recurrence.This is the real challenge. In the case mentioned, “At 52 years old, he was cured after taking 30 doses of Ganlu Decoction combined with Fengsui Pill; eight years later, he came for another illness, stating that in the past four years, he had experienced three recurrences of oral ulcers, all mild, and taking this formula for three or four doses resolved them without issue.” However, I heard last year that this person developed oral cancer. According to those in the know, after recovery, due to some grievances, he became depressed and resumed drinking.I often tell patients with oral ulcers that even minor issues should be taken seriously.In the past, Western medicine attributed it to a lack of vitamins, recommending more fruits and vegetables.In recent years, Western medical researchers have confirmed that recurrent oral ulcers are caused by poor immune function and a deficiency of T cells.This is worth noting for TCM.How to improve immune function?It requires comprehensive management, as the effects of medication are limited.This article is excerpted from the “Lectures on the Inheritance of Traditional Chinese Medicine by Yu Guojun”Author: Yu Guojun;You May Also Like, click to read the original text:Huang Huang: Three Key Elements and Classic Dosage of Using “Huang Qi”Liu Boiling: Clinical Experience in Treating Bone Hyperplasia, Regarding the Preparation and Administration of Bone Hyperplasia Pills//////////
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