It is notable because of the successful use of warming herbs, in a condition where they are usually contradicted. This case study is posted as an example of the treatment of a chronic inflammatory condition with herbal medicine, and is not intended to provide diagnostic or treatment advice. Enjoy!
First Visit: October 6, 2012
For more than ten years this patient had recurrent ulcers erupting unceasingly on his tongue and throughout his mouth, which only healed up for four or five days in each month. Over the years he had seen various ENT specialists in Changsha, Wuhan, and Beijing without obtaining relief. I could also see from his medical history that he had visited many of the better-known Chinese medicine physicians in the area, and had been prescribed modifications of the formulas daochisan, xiehuangsan, and shengmaisan, as well as precious medicinals and patent formulas such as xiongdan, niuhuang, zhongtongan, zhenhuangpian, etc. At various points he had been instructed to eat simple and mild-tasting foods, and to scrupulously avoid spicy or stimulating dishes. Although he followed these recommendations to the letter, the sores would still erupt, and the pain and discomfort never ceased.
With the exception of this issue he was generally healthy and active and his bowel movements were regular. Besides having urine that was more yellow than normal, he reported no other symptoms. His tongue was pale, and his pulse was small and wiry. I prescribed a modified ganluyin:
shenghuangdi (dosages deleted)
Second Visit: October 13
After finishing seven doses of the prescription the patient’s sores had not healed and were still painful, and the patient had a sense that they were actually getting worse. I looked carefully at his tongue and noted three or four small ulcers distributed over both sides of the tongue. His tongue was fat (swollen) and pale, with tooth marks and a thin white coating. His pulse was small and wiry.
I changed the prescription to a modified mahuangfuzixixintang:
mahuang (dosages deleted)
Third Visit: October 18
The patient had come early as he was about to leave on a business trip, and at the time of the visit he had not yet finished all seven doses of the prescription. He told me that by the time he had finished the second dose the pain had already gone, and by the fifth dose, which he had just taken, the ulcers had already healed.
I observed that his tongue was much thinner (less swollen) than before, and it was still pale with a thin white coating. His pulse was thin and wiry. The patient also mentioned that every since he started getting oral ulcers he had also developed small lumps on his scalp, which were reddish and sensitive to pressure. This was in spite of having taken so many cold and cooling herbal prescriptions in the past.
I re-prescribed seven doses of the decoction, and additionally prescribed the same formula in pill form for him to take on his trip:
mahuang (dosages deleted)
(the pill prescription was to be taken twice a day, 6g each time)
Fourth Visit: November 22
The previous prescription had lasted about a month, and the patient came back in as he was running low. He said that in the last month he had not had a single ulcer appear, and in addition the lumps on his scalp had gotten much smaller.
There was no need to change an effective formula like this, so I prescribed another month’s worth of pills to consolidate the treatment.
Fifth Visit: March 11, 2013
After finishing the previous prescription the patient had not had any more oral ulcers, and the lumps on his scalp had disappeared. I observed that his tongue was still pale and had tooth marks. I added 30 grams of xianlingpi to the formula, and re-prescribed another month’s worth of pills.
Lessons learned from this case
Generally speaking, oral ulcers are usually associated with a pattern of yin deficiency with damp heat. It is extremely rare to see them occur in a pattern of yang deficiency with cold damp. This was one of those rare cases.
In the initial visit, although I noted that the patient’s tongue was pale with a thin white coat (in contrast to the usual red tongue with yellow coating of most oral ulcer sufferers), I still did not feel confident about using warm medicinals. It was quite possible that these signs of cold resulted from taking so many cold and cooling medicinals, rather than being a true sign of internal cold, so I was concerned about the possibility of adding fuel to a fire. The initial use of ganluyin was a way of testing the waters, and when it became obvious in the second visit that not only had the patient not improved, but even seemed to be getting worse, and now had a fat (swollen) tongue, I felt more confident about turning to warming methods, and prescribed mahuangfuzixixintang to warm the channels and disperse cold. Added to the formula were banxia to transform phlegm, fuling to leach out dampness, and ganjiang to warm the center. I was still concerned that this sudden change to warm herbs might cause lurking fire to float upwards, so I also added erhuanshihu to nourish stomach yin, and renzhongbai to clear deficiency fire from the middle burner. This approach turned out to be the right one.
One of the factors that prompted me to re-write the formula from scratch was an offhand comment by the patient: “As soon as I see my tongue getting fat, and as soon as those tooth marks appear, I know things are going to get worse.” As the old saying goes, “Patients are our teachers”! If he hadn’t mentioned this information I might not have had the temerity to use such warm and hot medicinals!