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Zhang's elderly lady from Tianjin, aged 92, suffered from a disease characterized by vexation and heat in the Upper Jiao (Upper Burner).

Etiology: She was generally robust in health, possessing an exceptionally vigorous Yuan Yang (Primordial Yang), which enabled her to enjoy longevity. After reaching eighty years of age, her Yin aspect gradually declined while the Yang aspect became relatively excessive, causing constant sensations of vexation and heat in the chest. Medical treatment required the use of mostly Yin-nourishing herbs for recovery. Upon passing ninety years of age, with Yin further declining and Yang becoming more hyperactive, the emergence of Yang Qi in mid-spring triggered a severe recurrence of this old ailment.

Symptoms: There was extreme vexation and heat in the chest; during severe episodes, it felt as if she could not remain in the room, so she would often sit for long periods facing the door in the hall to inhale the air from the courtyard. Occasionally, she felt her heart being pressed by heat, leading to palpitations and restlessness. Her stool was dry, passed only once every four or five days, and sometimes required medication to facilitate passage. Her pulse was wiry and hard on both left and right sides, occasionally presenting as a Knotted Pulse (a pulse with irregular pauses), with a normal rate.

Diagnosis: A detailed examination of symptoms and pulse indicates a pure pattern of Excess in the Yang aspect and Deficiency in the Yin aspect. However, her longevity is indeed due to sufficient Yuan Yang. Although Yang is currently excessive, the treatment should focus on heavily nourishing True Yin to subdue the floating Yang, rather than using Bitter-Cold herbs to drain fire. Regarding the Knotted Pulse, although not strictly contraindicated in the elderly, it ultimately signifies a deficiency in Qi. Therefore, the prescription should primarily consist of herbs that heavily nourish True Yin, supplemented with a small amount of Qi-tonifying herbs to regulate the pulse.

Prescription: Raw Huai Shan Yao (Dioscoreae Hypoglaucae Rhizoma) (1 liang), Xuan Shen (Scrophulariae Radix) (1 liang), Prepared Huai Di Huang (Rehmanniae Radix Preparata) (1 liang), Raw Huai Di Huang (Rehmanniae Radix) (8 qian), Tian Dong (Asparagi Radix) (8 qian), Gan Cao (Glycyrrhizae Radix et Rhizoma) (2 qian), Da Gan Gou Qi Zi (Lycii Fructus) (8 qian), Raw Hang Shao Yao (Paeoniae Radix Alba) (5 qian), Ye Tai Shen (Codonopsis Radix) (3 qian), Zhe Shi (Hematitum) (6 qian, finely crushed), Raw Ji Nei Jin (Galli Gigerii Endothelium Corneum) (2 qian, yellow variety, pounded).

Decoct together in three large bowls to yield one day's dosage, taken slowly in multiple warm doses.

Formula Analysis: The principle of this formula relies on heavily using Cool-Moistening herbs to nourish True Yin, with a small amount (3 qian) of Ye Tai Shen to regulate the pulse. Fearing that the warming and ascending nature of Ginseng might be unsuitable for the vexation and heat in the Upper Jiao, the dose of Raw Zhe Shi is doubled to guide the action downward. Furthermore, since this condition involves difficulty in bowel movement, Zhe Shi also descends Stomach Qi to facilitate bowel movements. Ji Nei Jin is used to assist Stomach Qi in transforming and transporting the medicinal efficacy. Gan Cao is used because it can soften the wiry-hard quality of the pulse and harmonize the properties of the various cooling herbs.

Outcome: After taking one decoction per day for up to three days, the vexation and heat were significantly reduced, the pulse no longer showed knotted characteristics, and it became softer than before. Consequently, the dosages of Xuan Shen and Raw Di Huang in the formula were reduced to 6 qian each, and Long Yan Rou (Longan Aril) 5 qian was added. After continuing this modified prescription for five days, all ailments were cured.