Heart Disease and Water Pathologies

I love Professor Liu Du-Zhou.  Really, his teachings have and continue to have such an impact on my practice of Chinese medicine and my understanding and use of Classic Formulas.  Professor Liu was not only a busy Classic Formula doctor with a long long career, he was luckily also a prolific writer.  Below I have a short passage from one of his books on the essence of his own clinical experience, 刘渡舟验案精选.

This text is rich with case studies that are organized around theoretical discussion.

I translated the passages below in preparation for the last 3-day weekend of the 2012 Graduate Mentorship Program.  During this weekend we cover illnesses of aging, a broad concept that I use to lead us into topics such as heart diseases, hypertension, cancer, menopausal issues, obesity and metabolic illness (diabetes, syndrome x etc).  Of course we use a very classical approach in our understanding and treatment of these illnesses our patients are often diagnosed with.

Just to mention that this particular graduating class has been incredibly wonderful to work with.  A new group of students will be starting the 2014 Graduate Mentorship Program this May.

I hope you find this passage instructive.  Personally I have treated many patients diagnosed with various types of heart disease as Water Qi patterns and have found it very effective.

 Water Heart Disease (Coronary Heart Disease)

Liu Du-Zhou

The patient was male; age 42 had a full body.  He had coronary heart disease and had suffered from a heart attack. He received western medical treatment for more than two months with no results.  He suffered from heart and chest pain with palpitations, shortness of breath.  This would occur mostly at night and each time it happened he would feel Qi rushing up into his throat, blocking his breath.    At times he felt suffocated and his whole body would break out in a sweat as if death had arrived.  The blood vessels on the side of his neck also followed the upward surging Qi and they pulsated ceaselessly with distention and pain.  Observation showed his tongue to be dripping wet.  Touching revealed his pulse to be deep and wiry and occasionally knotted.  Dr. Liu differentiated this as water Qi encroaching on the heart and blocking the heart Yang.  The water heart illness inhibited the blood vessels of the heart.

After three packages of the above formula, the surging Qi leveled and the heart spirit calmed.  The chest pain and the distending pain of the vessels on the neck clearly diminished.  However, the pulse was still knotted and there was an aversion to cold with cold limbs.  This was a Yang deficiency patter.  I gave the same formula with 9 gm of Fu Zi and 6 gm of Rou Gui in order to restore the Yang of the heart and kidney.  After 3 packages, his feet became warm and there was no aversion to cold.  The patient still suffered from heart palpitations and shortness of breath so I again gave this formula with 10 gm of Dang Shen and Wu Wei Zi so as to supplement the Qi of the heart and lung vessels and collaterals.

After 6 more packages, the symptoms were all gone.

Discussion: This case of coronary heart disease was due to water Qi surging upward.  Dr. Liu is famous for coining the term “water heart disease.”  This illness is invariable due to heart, spleen or kidney Yang deficiency in which the water is not transformed and instead stops internally.  It becomes phlegm and it becomes fluid.  It causes damage by upwardly encroaching.  When the heart Yang is deficient and damaged, there is no command central and so the water Qi can encroach, surging upward.  This causes chest pain, heart palpitations and shortness of breath, which is the heart disease syndrome.  In the clinic, when one is differentiating and identifying this illness, one should pay attention to the color, the tongue, the pulse and the pattern as below:

1. Diagnosing by appearance – For the most part the complexion will be dark.  This is the so-called “water color.”  When the illness is serious, this coloring will show on the cheeks, forehead, lips, nose and below the chin.  Inside the skin but outside of the flesh, there can be dark pigmentation spots and these are called “water spots.”
2. Observing the tongue – The tongue body will be pale and tender and the moss will be watery and dripping.
3. Palpating the pulse – The pulse may be wiry or deep or deep and wiry.  When the illness is serious the pulse may be knotted, hesitant or deep and hidden without rising up.

Differentiating the pattern:

1. When water qi is surging upward, the patient will generally feel that there is Qi surging up from the epigastric area into the chest and throat.
2. There is chest fullness that becomes more extreme at night and worse when encountering cold; this will mostly be accompanied by an inhibition of the throat as if there is something blocking it.
3. There are palpitations that often manifest in the morning when getting out of bed or after eating.  This is often accompanied by distention and pain of the artery on the left side of the neck.
4. There is shortness of breath that manifests when the patient moves with chest oppression and a suffocating feeling and inhibited breathing.  When this is extreme there is a cold spontaneous sweat.

When treating “water Qi disease” with water Qi surging upward, the first choice is Ling Gu Zhu Gan Tang.  The Shang Han Lun recommends using this formula to treat “epigastric reversal fullness with Qi surging upward into the chest giving rise to head dizziness with a deep tight pulse.”  The Jin Gui Yao Lue recommends it to treat “phlegm fluid in the epigastric area with propping fullness in the chest and rib-side and eye dizziness.”  This is an illness pattern in which water Qi encroaches into the heart and extends to the lungs.

Ling Gui Zhu Gan Tang has two main applications.  The first is that it warms the Yang and down bears Qi to treat heart palpitations and chest fullness.  The second is that it treats inhibited urination by dispersing water Yin and phlegm fluid cough rebellion.

Ling Gui Zhu Gan Tang includes Fu Ling, which is the principle herb.  It has 4 applications:

1. Its sweet bland nature disinhibits the urination
2. It nourishes the heart and calms the shen
3. It benefits the lung’s restraining function
4. Supplements the spleen and thickens earth

This formula also includes Gui Zhi and this is also a principle herb.  It has 3 functions:

1. It warms and restores the heart Yang
2. It down bears Qi and descends surging
3. It opens through the Yang and disperses Yin

When Gui Zhi and Fu Ling are combined, they warm the middle Yang in order to control water.  They disinhibit the middle water in order to restore the heart Yang.  Each of them shine more brightly in the company of the other and neither is dispensable.

Bai Zhu supplements the spleen and helps Fu Ling control water.

Zhi Gan Cao warms the middle and helps Gui Zhi support the heart Yang.

Ling Gui Zhu Gan Tang has only 4 herbs but they are combined precisely.  Their power is mighty and the clinical results can be astonishing, especially for “water heart disease” patterns.

Water Qi encroaching onto the heart (Rheumatic heart disease, weak heart)

Mr. Sun was 53 years old and came for a consultation on May 25, 1991.

He had a history of rheumatic heart disease and due to a recent exterior wind cold, his illness became worse.  He had throbbing heart palpitations, chest oppression with a suffocating feeling and urgent panting.  When he coughed he had abundant clear white frothy phlegm.  During the day and night he could not lay flat and when he got up he felt dizzy.  His four limbs had slight reversal cold and he also had abdominal distention, short scanty urination and pitting edema in his legs.  His appetite was poor with nausea and his stool was dry and knotted.  Observation revealed that his lips were cyanotic and his complexion was dark. His tongue was white and slippery.  His pulse was knotted.  His western diagnosis was “rheumatic heart disease, congestive heart failure, cardiac function level 4.” Dr. Liu differentiated the pattern as heart, spleen and kidney triple organ Yang deficiency with Yin accumulation and cold water not transforming.  The treatment had to warm the Yang and disinhibit water and so Zhen Wu Tang was used with added flavors.

After 3 packages his urination increased and the cough was reduced dramatically.   The palpitations and swelling in his legs appeared to be less.  I continued by using Zhen Wu Tang combined with Ling Gui Zhu Gan Tang in order to warm and supplement the heart, spleen and kidneys, restore the Yang and disinhibit urination.

After 10 packages of this formula, the urination was uninhibited and the swelling was gone.  In addition, the palpitations and chest oppression were gone.  At night he was able to lie down.  The only symptom that remained was thirst.  I changed his formula to “Chun Xie Tang.”

After this there was a cure.

Discussion:   Water is Yin.  When it overflows, it must overflow into the Qi transformation function of the lungs, spleen and kidneys. Of these 3 zang, the kidneys are the key.  If the lung cannot down bear and disseminate it will be unable to open and regulate the water pathways.  If the spleen is without fortification and movement, it will be unable to transform water damp.  If the kidney cannot open and close, they will be unable to transform Qi and move water.  This can cause the water Qi to stop internally and give rise to water Qi illness.  Within the category of the 3 Zang, the “kidney is the principle” and it has a “relationship with the stomach.”  If the gate to this connection is closed, the water will gather and cause illness.  In this case the spleen and kidney Yang was weak with Yin abundance.  The water Qi did not transform and there was cold water evils above and below, from the inside to the outside, from the interior to the exterior.  Whether above or below, it was flooding disastrously.  The water Qi above encroached on the heart and caused throbbing and palpitations and a suffocated oppressed feeling in the chest.  The water followed the Shao Yin channel upward and spread out into the lungs causing cough with abundant phlegm to the point that the patient was unable to lay down.  The water Qi went up to attack the stomach causing nausea and poor appetite.  The water Qi rose to harass the clear orifices causing heat and eye dizziness.  The bladder Qi transformation was inhibited so the urination did not flow.  As for the treatment method, the first method needed was to warm and supplement the kidney Yang.  Secondarily one must disinhibit the water Qi.  The special achievement of Zhen Wu Tang is to restore the Yang to disperse Yin, dispel cold and descend water.  The formula uses the pungent heat of Fu Zi to go down and warm the kidney Yang.  It assists in the governing of water.  Bai Zhu dries, warms and fortifies the spleen and assists in controlling water.  Sheng Jiang disseminates and scatters and it assist Fu Zi in benefitting the Yang.  It scatters cold while governing water.  Fu Ling is bland and seeping.  It assists Bai Zhu by fortifying the spleen.  It has the function of leading water out while governing water.  Then there is the wonderful Shao Yao.  It has many uses in one fell swoop.  Firstly it can restrain the Yin and harmonize the Ying.  Secondly it controls the strong drying of Fu Zi.  Thirdly it disinhibits water and dispels water.  The Shen Nong Ben Cao Jing says, “Shao Yao is able to disinhibit the urination.”  It has the function to move the Yin and disinhibit water.

This formula is very effective for pulmonary heart disease, rheumatic heart disease when there is weakness of the heart with water swelling in the limbs, heart palpitations and abdominal distention.

Heart palpitations 1 (Premature Ventricular Contraction)

Mr. Yang was a 33 year-old worker.  He came for his first visit on September 15, 1993.  A year previously, because of overwork, he became exhausted.  He suddenly had heart palpitations and restlessness, insomnia and weakness of his whole body.  The electrocardiogram showed “repeated premature ventricular contractions.”  He took beta-blockers and inosine and the palpitations decreased.  However, when he stopped the medicines the pathology returned.  He had frequent heart palpitations, emptiness in the chest, non-continutous shortness of breath, sweating with movement and weakness.  His sleep was poor and his tongue body was pale and tender.  His pulse was wiry and thin, hesitant and knotted.  Dr. Liu differentiated this as heart and chest Yang Qi insufficiency that lead to water Qi surging upward.  This was a “water heart illness” pattern.  The treatment method was to warm and open through the Yang and transform fluids, supplement and boost the heart Qi.  He used Ling Gui Zhu Gan Tang.

After 7 packages the heart palpitations had greatly decreased and there was no longer emptiness in the chest.  After more than 10 packages, there was a cure.

Discussion:   Regarding Dr. Liu’s “water heart disease”, we have already looked at the syndrome and contributing factors.  In this case, the meaning behind adding the “3 Shen” is that there was simultaneous deficiency and weakness of the ancestral Qi.  The Ling Shu: Guest Evils Chapter says, “The Zong Qi accumulates in the chest and emits from the throat and links with the heart vessels and thereupon moves the breathing.  If the Zong Qi is weak it does not have the strength to motivate the movement of the blood vessels and so the heart vessels become slow and hesitant.  This will inevitably lead to a more serious condition of “water heart disease.” This is when one uses Ling Gui Zhu Gan Tang along with the 3 Shen, Dang Shen, Sha Shen and Dan Shen.  These 3 additions will boost the heart Zang Qi, while opening through the vessels of the heart Zang.  This formula is called the 3 Shen Ling Gui Zhu Gan Tang.  Clinically it is very effective.