Traditional Chinese Medicine Case Studies / Clinical References for Learning TCM
Yin fluid deficiency with damp-heat accumulation leading to oral ulcers is treated with Ganlu Decoction combined with Fengsui Pill.Ganlu Decoction combined with Fengsui PillSheng Di Huang (Rehmannia Root) 20g, Shu Di Huang (Prepared Rehmannia Root) 20g, Tian Dong (Asparagus Tuber) 20g, Mai Dong (Ophiopogon Tuber) 20g, Shi Hu (Dendrobium) 15g, Chao Zhi Ke (Stir-fried Bitter Orange Peel) 10g, Huang Qin (Scutellaria) 10g, Yin Chen (Virgate Wormwood) 10g, Pi Pa Ye (Loquat Leaf) 15g, Sha Ren (Amomum Fruit) 6g, Jiao Huang Bai (Burnt Phellodendron) 10g, Sheng Gan Cao (Raw Licorice) 10g1. Brief Understanding of the FormulaRecurrent oral ulcers (known as recurrent aphthous stomatitis in Western medicine) are often due to yin fluid 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 Ke to regulate qi; and particularly uses Pi Pa Ye to clear 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 Fengsui Pill from the Qixiao Liangfang to tonify the earth and subdue fire, it is an effective specialized formula for treating yin deficiency with 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 case where the patient had a thick yellow greasy coating all over the tongue, and repeated use of heat-clearing and phlegm-resolving herbs was ineffective, with the yellow greasy coating not receding. The patient was referred to a septuagenarian 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 more than half; later, the patient was treated with this formula combined with Jinshui Liu Jun Decoction to complete the treatment. Upon hearing this, Chen stomped his foot and sighed, deeply regretting his lack of insight, and from then on, he viewed this formula with new respect. I, on the other hand, was awakened by this remark. From then on, I tried using this formula, and the efficacy was indeed reliable.Later, I browsed through formula books and found a case recorded by Ming Dynasty Wang Kentang in the Linglan Yaolan, stating: “The elderly Yan Wenjing from Changshu, over seventy years old, had not ceased sexual activity, taking countless warming and tonifying medicines daily, along with ginseng porridge and cistanche soup, which led to stomach heat, resulting in severe oral ulceration, loose teeth, and foul breath, almost unbearable. Repeated administration of cold and cooling stomach medicines was ineffective. When asked about using ginger and cinnamon as a countermeasure, I advised against it, saying, ‘Using it would definitely cause great harm.’ Instead, I prescribed a modified Ganlu Decoction, and after eight doses, the condition stabilized.”Even physicians like Chen Xiuyuan, who respected ancient texts and dismissed contemporary formulas, acknowledged that Ganlu Decoction excels in nourishing yin and benefiting dampness.Chen believed that the two types of Dong and two types of Rehmannia in Ganlu Decoction are akin to the use of Ejiao (Donkey-hide Gelatin) in Zhu Ling Decoction for nourishing yin; while Huang Qin, Yin Chen, and Zhi Ke are similar to the use of talc and Ze Xie in Zhu Ling Decoction for benefiting dampness and removing turbidity.In my early years of treating recurrent oral ulcers, patients with a pale tongue lacking moisture or with a thin yellow coating and dry lips were often diagnosed with spleen yin deficiency and upward flaming of empty fire, with damp-heat retention. I had previously used Shenrou Yangzhen Decoction and Shenling Baizhu San with modifications, but the results were not ideal. Later, drawing on the experience of old TCM doctor Pu Fuzhou, I used Fengsui Pill with modifications, which yielded better results. The Fengsui Pill (Sha Ren, Huang Bai, Gan Cao) was originally for lowering heart fire and benefiting kidney water to treat nocturnal emissions and dream-related issues, but Pu had the insight to believe that Fengsui Pill could tonify the earth and subdue fire, making it applicable for treating recurrent oral ulcers caused by 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 with damp-heat type oral ulcers.3. Clinical EvidenceA 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 Chinese and Western medicines, with varying effects. Five years prior, an old TCM doctor had prescribed over 30 doses, and the oral ulcers did not recur for six months, leading him to believe he was cured, which brought him great relief. However, after recurrence, when he sought treatment again, the old TCM doctor had passed away.He then followed the original prescription from the old TCM doctor, but it was not as effective as before. He consulted over ten other doctors, with prescriptions exceeding forty, including Wuwei Xiaodu Decoction, Shengjiang San, Dan Zhi Xiao Yao San, Xie Huang San, Zhi Bai Di Huang Decoction, etc. The prescription from the deceased old TCM doctor contained over thirty herbs, including Ganlu Decoction.Current Diagnosis:Patient’s complexion was pale yellow, foul breath, dry stools, yellow urine; tongue was red with a thick yellow greasy coating in the middle and back, pulse was wiry and weak. Upon examination, there were five oral ulcers in the mouth, round, slightly larger than soybeans, yellow in color, with depressed surfaces and red surrounding mucosa. The patient reported a fondness for alcohol and mental strain. The diagnosis was yin fluid deficiency with damp-heat accumulation, and the treatment should nourish yin fluids, clear damp-heat, and tonify the earth while subduing 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.Second Diagnosis:All oral ulcers had disappeared. The tongue was slightly red, and the thick yellow greasy coating had receded by more than half. No changes were made to the prescription, and he continued with 24 doses.Third Diagnosis:The patient had taken a total of 30 doses, and the oral ulcers did not recur. He stopped the medication for observation, and I advised him to keep the original prescription, to take six doses if the oral ulcers recurred. 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 with damp-heat type is indeed the most common; 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, and taking cooling medicines worsens the condition. If accompanied by fatigue, spontaneous sweating, lethargy, poor appetite, and loose stools, it indicates spleen deficiency with qi sinking and fire not being properly anchored, and treatment should focus on tonifying the spleen, raising the sinking qi, and draining the yin fire, which can be done using 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 the yin and returning the yang, using Gui Fu Li Zhong Decoction for mild cases, and Tong Mai Si Ni Decoction for severe cases.There are many issues worth exploring regarding the formula of Ganlu Decoction combined with Fengsui Pill; here I will only add three points.First, syndrome differentiation.How to differentiate oral ulcers? According to clinical observations, patients rarely exhibit systemic symptoms, and the pulse is also unremarkable, 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 type accounts for over 60%, while I have experienced it being over 80%, making the use of Ganlu Decoction combined with Fengsui Pill very likely.Other syndrome types, due to my limited experience, I have rarely encountered. I have never encountered true fire, and have only occasionally seen cold-type cases.As mentioned in the text, there are systemic symptoms such as fatigue, lethargy, poor appetite, and loose stools, indicating spleen deficiency with qi sinking and fire not being properly anchored, and treatment should focus on tonifying the spleen, raising the sinking qi, and draining the yin fire, which can be done using Buzhong Yiqi Decoction combined with Fengsui Pill.I have treated two such cases, but only the symptoms were alleviated, and they were not cured. For those with spleen and kidney yang deficiency, I have used Gui Fu Li Zhong Decoction, and the symptoms slightly improved; adding a small amount of deer antler yielded similar results, but did not cure them. I have also referred them to doctors from the Huoshen school, but they did not achieve a cure.Thus, I am now most apprehensive about the occasionally seen 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 seek another doctor.Second, formula selection.For oral ulcers with yin deficiency and damp-heat, one must select Ganlu Decoction combined with Fengsui Pill, and it should be used consistently without changing formulas. Generally, it takes three doses to see results, and nine doses for recent cures. In the case mentioned in the text, 30 doses were the maximum. One must not be creative and select other prescriptions or create their own formulas.As mentioned earlier, in a summer case from 2010, the previous physician used San Ren Decoction with modifications, which seemed to be on the right track, and although the oral ulcers occasionally disappeared, 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 quality returning to pale red, and the thick greasy coating receding, indicating a change in the internal environment.In treating oral ulcers, I initially learned from the unique experience of old TCM doctor Pu Fuzhou, using Fengsui Pill combined with Shaoyao Gan Cao Decoction, adding Shi Hu, Lu Gen, and Amber powder (taken in water). The tongue quality generally shows no obvious abnormalities, and this is how I usually use it. If the tongue is red, the tongue tip is dry, or the tongue coating is peeling off, with the surrounding coating being yellow greasy or grayish-yellow, indicating a diagnosis of stomach yin deficiency and damp-heat accumulation, I temporarily use Ganlu Decoction combined with Fengsui Pill with modifications. This humble understanding was published in the Journal of Traditional Chinese Medicine in the 1980s.Coincidentally, a disciple of my mentor Jian Yuguang visited and candidly told me, “The formula you use for oral ulcers is ineffective for me.” This was a wake-up call! Thus, I pondered deeply and repeatedly verified, and it took another ten years to confirm the formula of Ganlu Decoction combined with Fengsui Pill. This is not just a matter of being close; I love to quote Columbus’s famous saying, “The difference is just a little bit.”When encountering oral ulcers, the first consideration is the Fengsui Pill formula; 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, Ze Xie each 15g, Huang Qin 6g, Amber powder 6g (taken in water), 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 effect is 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 example 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 alcohol.I often tell patients with oral ulcers that even small issues should be taken seriously. In the past, Western medicine attributed it to vitamin deficiency, recommending increased fruit and vegetable intake. In recent years, Western medical researchers have confirmed that recurrent oral ulcers are caused by poor immune function and T-cell deficiency. 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 TCM by Yu Guojun”Author: Yu Guojun; Edited and compiled by Liu Jifang
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