Experience in Treating Insomnia with Guizhi Jia Gui Tang from the Shanghan Lun
The patient was a female eighth-grader. Because her maternal grandfather had osteosarcoma, her parents had been in frequent contact with me. One day the girl's father asked me to see the patient via video. The patient had suffered from intractable insomnia since fifth grade, and also frequently belched and had stomach pain. Because she was too young, she had not been tested for Helicobacter pylori. The family reported that her post-meal belching was very loud, with hair loss and bodily fatigue. She had taken various medicines for insomnia and stomach problems, all ineffective. Her insomnia had lasted over three years and was very distressing.
Because of the pandemic, the consultation could only be done by remote video. When I questioned the patient, I learned that her hands and sweated easily, she averted cold, her urine was clear, her stools were acceptable (twice daily), and her appetite was fine. The problem that bothered her most was insomnia: starting in fifth grade, she had difficulty falling asleep, slept lightly, woke easily, and after waking found it very hard to fall asleep again. She also had long-standing stomach discomfort, always feeling qi pushing upward; taking pill-form medicines caused vomiting, so she was unwilling to use patent medicines and asked to be treated with a decoction.
Based on her account, I considered the patient an indication for Guizhi Jia Gui Tang. There was no obvious trigger before these symptoms appeared; I suspected it might be due to eating raw and cold foods, or an earlier unaddressed contraction of wind-cold.
Among the Guizhi series formulas, Guizhi Jia Gui Tang treats “qi rising from the lower abdomen to the heart”; it is Guizhi Tang with an increased dose of cinnamon twig, because cinnamon twig pacifies rebellion and downbears counterflow. This patient averted cold and sweated easily on her hands and feet, which is an indication for Guizhi Tang. The qi pushing upward and belching belong to “qi rising from the lower abdomen to the heart,” so I considered Guizhi Jia Gui Tang fairly well matched.
Although Guizhi Tang is not a formula for treating insomnia, TCM emphasizes pattern differentiation and treatment; as long as one grasps the principal contradiction and matches the medicine to the pattern, accompanying symptoms often resolve without treatment. Moreover, according to Professor Liu Duzhou's experience, Guizhi Tang is also an excellent formula for spleen-stomach disease. TCM holds that when the stomach is not at harmony, sleep is uneasy; once the stomach problem is resolved, the insomnia can also be resolved.
So after consideration, I decided to prescribe modified Guizhi Jia Gui Tang for the patient. The prescription: Guizhi (Cinnamomi Ramus) 15 g, Bai Shao (Paeoniae Alba Radix) 10 g, Zhi Gan Cao (honey-fried Glycyrrhizae Radix) 10 g, fresh Sheng Jiang (Zingiberis Rhizoma) 7 slices, Da Zao (Jujubae Fructus) 7 pieces, Fu Xiao Mai (leaveted Tritici Fructus) 30 g. This is Guizhi Jia Gui Tang plus some Fu Xiao Mai, with the dose of licorice also slightly larger. Why use Fu Xiao Mai? First, because it stops sweating; second, with the intention of combining Gan Mai Da Zao Tang to calm the spirit and aid sleep.
After the patient took five doses, her father reported marked improvement in sleep; her belching was also much better, and her condition improved greatly. There remained only a little belching, but it was much milder than before. So on the basis of the original formula I added Xuan Fu Hua (Inulae Flos) 6 g and Dai Zhe Shi (Hematitum) 6 g, and prescribed three more doses to consolidate.
This is an atypical approach to treating insomnia, relying mainly on TCM pattern differentiation to solve the patient's problem. The patient's insomnia had long been attributed to study pressure, and its true cause was overlooked; hence for over three years it not only failed to resolve but worsened. Following TCM pattern differentiation, grasping the formula-pattern and herb-pattern and composing flexibly, treatment achieved results. This shows that pattern differentiation remains very meaningful in TCM clinical practice.