Appreciation of Two Medical Cases of Mania (Manic Episode) Treated by Gao Yimin

Gao Yimin was a native of Shenyang, Liaoning Province, born in 1920; he was a chief physician trained through the traditional apprenticeship (shicheng) system in Chinese medicine. From childhood he studied under the renowned Shenyang physician Zhang Zizhou. After liberation he served as honorary chairman of the Hunjiang (Jilin) Association of Chinese Medicine and honorary president of the Hunjiang Chinese Medicine Hospital, and his clinical skill was of a high order.

Gao once treated two patients with dian-kuang (mania, corresponding to modern manic episode). His therapeutic reasoning was distinctive and of considerable reference value. Below I reprint his cases and add a brief commentary on his methods.

Case 1: Zhang, male, 55 years old. First visit January 29, 1977.

The patient had always been an honest, reserved man of few words. After an argument with others he harbored a bellyful of resentment, feeling wronged and unable to let it go, and suddenly fell ill. For more than ten days he had been mentally deranged, speaking incoherently, alternating between crying and laughing, tense, fearful and uneasy, with tremulous muscles, a restless heart, inability to sleep at night, and an urge to run about. Appetite was poor and the stool was dry and bound. The pulse was deep, wiry, and forceful; the tongue coating was yellow and greasy.

Old Master Gao's pattern differentiation: this patient's condition arose from emotional constraint, failure of the liver to freely spread and courser, constraint transforming to fire and engendering phlegm that blocked the clear orifices. The treatment principle was to soothe the liver and resolve constraint, calm the spirit and settle the will, and flush phlegm to open the orifices.

Prescription: Shengtieluo (crude iron slag) 50 g (decoct first for half an hour), Dahuang (Rhei Radix et Rhizoma, rhubarb) 15 g, Yujin (Curcumae Radix) 25 g, Xiangfu (Cyperi Rhizoma) 25 g, Muxiang (Aucklandiae Radix) 15 g, Fuling (Poria) 50 g, Banxia (Pinelliae Rhizoma) 15 g, Chao Suanzaoren (fried Ziziphi Spinosae Semen) 35 g, Yuanzhi (Polygalae Radix) 25 g, Yejiaoteng (Polygoni Multiflori Caulis) 50 g, Shichangpu (Acori Tatarinowii Rhizoma) 15 g, Longchi (Dentis Draconis) 50 g (decoct first together), Hehuanhua (Albiziae Flos) 20 g. Three doses, decocted in water.

After taking the medicine the patient's mentality returned to normal, sleep became peaceful, and appetite returned to normal. To consolidate the effect, he continued taking medicine along the same lines.

Second visit prescription: Yuanzhi 25 g, Chao Suanzaoren 25 g, Baiziren (Platycladi Semen) 15 g, Danshen (Salviae Miltiorrhizae Radix) 15 g, Yujin 20 g, Xiangfu 20 g, Muxiang 15 g, Zhiqiao (Aurantii Fructus) 15 g, Hehuanhua 20 g, Banxia 15 g, Fuling 25 g, Maidong (Ophiopogonis Radix) 15 g. Three doses, decocted in water.

After another three doses the patient had fully recovered with no relapse.

Case 2: Zhang, male, 19 years old. First visit June 1, 1983.

After failing his school entrance examination, the patient suffered an intense emotional shock and became delirious. At times he appeared demented, staring fixedly with wide unblinking eyes, neither eating nor sleeping, timid and fearful, silent, giving no answer to any question, with trembling limbs. At other times he was wild and irascible, claiming that someone meant to harm him and wanting to arm himself in self-defense, with phlegm drooling from his mouth. He had been ill for over a month, and neither Chinese nor Western medicine had helped. The pulse was deep, wiry, and fine; the tip of the tongue was red and the coating thick, sticky, and greasy.

Old Master Gao differentiated this as a pattern of Yangming bowel repletion combined with liver qi stagnation, and treated it by freeing the bowels and soothing the liver, calming the spirit and aiding sleep.

First-visit prescription: Dahuang 15 g, Houpo (Magnoliae Cortex) 20 g, Zhishi (Aurantii Fructus Immaturus) 20 g, Binglang (Arecae Semen) 20 g, Qing Banxia (cleansed Pinellia) 15 g, Yujin 20 g, Yuanzhi 20 g, Suanzaoren (Ziziphi Spinosae Semen) 20 g, Hehuanhua 40 g, Yejiaoteng 50 g, Shichangpu 20 g, Chenxiang (Aquilariae Lignum) 10 g. Two doses, decocted in water.

On returning after the two doses, his mental state had improved slightly; he was somewhat clearer, could sleep a little and eat a little. He could answer questions but not accurately, as if talking in his sleep; his spirit had not yet settled in its abode. Since the formula was effective, the principle of treatment should not change; it was only slightly adjusted.

Second-visit prescription: Yujin 20 g, Shichangpu 20 g, Yuanzhi 20 g, Suanzaoren 30 g, Hehuanhua 30 g, Yejiaoteng 50 g, Houpo 20 g, Zhishi 20 g, Binglang 20 g, Juhua (Chrysanthemi Flos) 20 g, Danshen 25 g, Dahuang 10 g, Banxia 15 g. Two doses, decocted in water.

After two doses the patient's consciousness was clear; he ate little, and the previous day he had had one brief episode of confusion. He was told to continue the second-visit formula for five doses. After another five doses his consciousness was completely normal, memory was gradually improving, and all symptoms had resolved. To consolidate, the formula was slightly adjusted for follow-up.

Fourth-visit prescription: Yuanzhi 20 g, Suanzaoren 25 g, Shichangpu 20 g, Yujin 20 g, Hehuanhua 25 g, Juhua 20 g, Danggui (Angelicae Sinensis Radix) 20 g, Nüzhenzi (Ligustri Lucidi Fructus) 20 g, Gouteng (Uncariae Ramulus cum Uncis) 20 g, Xiangyuan (Citri Fructus) 20 g, Xiangfu 20 g, Jiangcan (Bombyx Batryticatus) 15 g. Three doses, decocted in water.

This patient later returned to Old Master Gao for another illness; on inquiry, he learned that after taking some 20-odd doses the patient had gradually become calm in spirit, clear-minded, and fully recovered, with no relapse.

Both patients in these two cases suddenly erupted into manic episodes after stressful life events; in modern psychiatry they would both be regarded as patients with mental disorders. Gao Yimin's treatment of the two was broadly similar, essentially following the treatment principles in the Shanghan Lun for Taiyang disease with heat entering the bladder and for Yangming disease with bowel repletion.

Why do I say this? We can find passages in the Shanghan Lun in which Zhang Zhongjing discusses mania-type disorders.

Shanghan Lun, Article 106: "When a Taiyang disease does not resolve and heat binds in the bladder, the person may appear manic; if the blood is discharged naturally, recovery follows. If the exterior has not resolved, one may not attack; first resolve the exterior. Once the exterior is resolved and only acute binding in the lower abdomen remains, then one may attack it, appropriately with Taoren Chengqi Tang (Peach Pit Order the Qi Decoction). Taoren Chengqi Tang: Taoren (Persicae Semen) 50 pits, Dahuang 4 liang, Guizhi (Cinnamomi Ramulus) 2 liang, Gancao (Glycyrrhizae Radix) 2 liang, Mangxiao (Natrii Sulfas) 2 liang."

Article 212: "After cold damage, if vomiting or purgation has not resolved the condition, with no bowel movement for five or six days, even ten-plus days, with tidal fever in the late afternoon, no aversion to cold, and solitary speech as if seeing ghosts— in severe cases, when the attack comes the patient does not recognize people, pulls at clothing and feels the bed rails, is apprehensive and uneasy, slightly panting with fixed staring eyes; a wiry pulse indicates survival, a rough pulse indicates death. In mild cases, where there is only fever and delirious speech, treat with Dachengqi Tang (Major Order the Qi Decoction). If one dose produces purgation, stop further dosing."

Article 217: "Sweating with delirious speech indicates dry bound stool in the stomach; this is wind and must be purged, but only after the channel has passed. Purging too early causes confused speech, because the exterior is deficient and the interior replete."

Article 220: "When two yang diseases combine, the Taiyang pattern has resolved and only tidal fever remains, with continuous dripping sweating on the hands and feet, difficult bowel movement, and delirious speech, purging will effect recovery; appropriately use Dachengqi Tang."

From these passages of the Shanghan Lun we can see that in the Han dynasty Zhang Zhongjing likewise encountered patients with manic agitation, and the symptoms he recorded share many similarities with those of modern manic patients. Most manic patients I have encountered, in addition to manic agitation and incoherence, also suffer from constipation.

Zhang Zhongjing treated such disorders essentially with the Chengqi series of formulas, which drain heat and free the bowels, addressing Yangming bowel repletion. Dachengqi Tang is composed of Dahuang, Houpo, Zhishi, and Mangxiao and is strongly purgative. Taoren Chengqi Tang contains the purgative Dahuang and Mangxiao along with Taoren, which activates blood and resolves stasis, and Guizhi, which releases the exterior and quickens blood. Zhang Zhongjing also records using Tiaowei Chengqi Tang for such cases; that formula is considerably milder. When the presentation involves vexation, fear, remorse, and insomnia without Yangming bowel repletion, he instead used Zhizi Douchi Tang (Gardenia and Fermented Soybean Decoction; see Shanghan Lun Article 221).

Reading these Shanghan Lun passages alongside Old Master Gao's two cases, it is not hard to see that his basic therapeutic idea derives from Zhang Zhongjing's Chengqi series. Both formulas heavily use Dahuang, the core herb of the Chengqi decoctions, and also heavily use qi-moving herbs such as Zhishi, Houpo, Muxiang, and Xiangfu, which are the chief assistants in the Chengqi formulas.

In Zhang Zhongjing's era there were not yet many herbs for calming the spirit and aiding sleep. Over the course of history, later generations of Chinese medicine gradually discovered more such herbs—Hehuanhua, Hehuanpi (Albiziae Cortex), Yejiaoteng (Polygoni Multiflori Caulis, fleeceflower vine), Yuanzhi, Shichangpu, and others. In both cases, while following Zhang Zhongjing's main line of reasoning, Old Master Gao incorporated later-generation herbs proven effective for nervous system disorders. This approach to medication is safer and more effective, and more scientific; that is why both patients achieved good results.

Some mental disorders are transient, while others are stubborn and lifelong. Both patients here were, overall, predisposed individuals—honest, reserved, quiet people who did not know how to discharge their inner negative emotions but were sensitive to external stimuli; thus after an emotional blow they suddenly became manic and agitated.

Traditional Chinese medicine views this as heat entering Yangming or heat entering the Taiyang bladder channel, with interior heat producing bowel repletion so that the spirit does not return to its place. Treatment should promptly use formulas that drain heat and free the bowels, while soothing the liver and moving qi, calming the spirit and aiding sleep, so that the patient can sleep well; once sleep improves, the manic agitation is bound to lessen.