JOURNAL OF CHINESE MEDICINE NUMBER 70 OCTOBER 2002

A CASE HISTORY

EXCESS AND DEFICIENCY IN THRUSH

by Cheng Hao Zhou
This is a case analysis in which both excess and deficiency patterns are present. A female patient aged 25 had suffered abnormal vaginal discharge accompanied by itching for more than 2 years; her symptoms had been severe for the last 6 months. The abnormal discharge and vaginal itching began more than 2 years ago with no obvious cause. The discharge was sticky with a sour and foul odour. A candida infection was diagnosed, and anti-fungal antibiotics (nystatin) and a low sugar diet improved the symptoms. During the last 2 years however, the symptoms had been recurring frequently. Sweet food, warm and damp surroundings and stress could worsen or trigger the problem. There was no obvious relationship between the discharge and itching and her menstrual cycle. The frequency and degree of thrush had been getting worse because of stress at work over the last 6 months. There was now a large amount of yellow and sticky discharge, with a strong odour, accompanied by a slightly dull dragging pain in the lower abdomen and lower back. The patient felt thirsty a lot and preferred cold drinks, she had a bitter and metallic taste in her mouth, excessive appetite especially at night, unsettled sleep, and tiredness during the daytime. Her defecation and urination were normal. On the contraceptive pill she had a regular 30 day menstrual cycle and her menstrual period lasted 5 days, with a medium flow of a normal red colour, without severe pain or clots. She had a calm personality and was otherwise healthy. Her mother and one sister also suffered from chronic candida infection; there was no history of diabetes in the family. Tongue: white and slightly thin coating on a red tongue body. Pulse: generally thin, wiry and slippery at the Liver position, hidden at the Kidney position. Diagnosis: heat and damp retained in the Liver channel, with slight weakness of Kidney essence. Treatment principle: clear Liver heat and damp, drain damp from the lower jiao, gently strengthen Kidney essence. Formula: based on Long Dan Xie Gan Tang (Gentiana Longdancao Decoction to Drain the Liver) and San Miao Wan (Three Marvel Pill): Long Dan Cao (Radix Gentianae Scabrae) 5g Zhi Zi (Fructus Gardeniae Jasminoidis) 9g Huang Qin (Radix Scutellariae Baicalensis) 6g Huang Bai (Cortex Phellodendri) 9g Chuan Niu Xi (Radix Cyathulae) 6g Cang Zhu (Rhizoma Atractylodis) 9g Che Qian Zi (Semen Plantaginis) 6g Chai Hu (Radix Bupleuri) 3g Dang Gui (Radix Angelicae Sinensis) 9g Sheng Di Huang (Radix Rehmanniae Glutinosae) 6g Du Zhong (Cortex Eucommiae Ulmoidis) 6g Chen Pi (Pericarpium Citri Reticulatae) 6g Tai Zi Shen (Radix Pseudostellariae Heterophyllae) 6g She Chuang Zi (Fructus Cnidii Monnieri) 6g One bag each day, decocted, divided into two portions and drunk warm, twice a day. The lower back pain and vaginal itching were totally cleared up after 5 days. As the period had started, the patient could not tell if there was any change in the discharge. The quality of the period was unchanged. She felt more energetic and her sleep was improved, but she still felt stress at work. The thirst and excessive appetite were reduced. Her urine seemed dark. I kept the same formula with the addition of Xia Ku Cao (Spica Prunellae Vulgaris) 6g. Each bag decocted, divided into two portions and drunk warm, over two days. After two weeks the discharge was completely normal without any vaginal itching, and with no pain in the back or abdomen. She still felt thirsty and had a bitter taste in her mouth, her stools were slightly loose after taking the herbal decoction (but were still once a day), her tongue was pinkred with a normal coating, and her pulse was wiry on the left. I kept to the main treatment principle, modified with herbs to protect Stomach qi and yin: Long Dan Cao (Radix Gentianae Scabrae) 5g Zhi Zi (Fructus Gardeniae Jasminoidis) 6g Huang Bai (Cortex Phellodendri) 9g Cang Zhu (Rhizoma Atractylodis) 9g Chuan Niu Xi (Radix Cyathulae) 9g Che Qian Zi (Semen Plantaginis) 6g She Chuang Zi (Fructus Cnidii Monnieri) 6g

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JOURNAL OF CHINESE MEDICINE NUMBER 70 OCTOBER 2002

Du Zhong (Cortex Eucommiae Ulmoidis) 6g Zhi Mu (Radix Anemarrhenae Asphodeloidis) 6g Lu Gen (Rhizoma Phragmitis Communis) 6g Tai Zi Shen (Radix Pseudostellariae Heterophyllae) 6g Each bag decocted, divided into two portions and drunk warm, over two days, for two weeks. After taking this prescription the symptoms resolved completely and have not recurred for more than a year.

Discussion
It is not difficult to diagnose heat and damp in the Liver channel in this case. Underneath all the long-term excessive heat symptoms however, a possible deficiency is presenting, because the excess factors consume the normal qi, blood and essence. That is why the symptoms recurred frequently, and also why the patient started to complain of the dragging pain in the lower abdomen and lower back. It is also possible that the dragging pain indicates a further pathological development of qi or blood stagnation. The tongue did not present a thick yellow greasy coating as we would expect in a damp-heat pattern. Comparing the tongue with the manifestations, the white and thin coating on the red tongue body indicated deficiency more than damp-heat and alerted me to the possibilityof underlying deficiency, and the generally thin pulse confirmed the diagnosis. Again, the combination of manifestations and physical signs help our judgement of how to balance a formula for each individual. The main initial prescription is cooling and draining and it looks unreasonable to put Du Zhong (Cortex Eucommiae Ulmoidis), a warming yang herb, in this group of damp and heat clearing herbs, in case it worsens the heat symptoms. In fact, Du Zhong plays a promoting role in the whole formula, tonifies the consumed Kidney essence, and also helps diffuse the turbidity and warm the cold quality of the damp, as filthy dampness has cold, turbid and descending properties. The conclusion is that excess and deficiency patterns, and warm and cool herbs, are not distinctly separable and in practice we can see many combinations of them. One should pay attention to the long-term deficiency factor within an excess pattern. The deficiency pattern underlying the excess pattern is the root and source of the diseases development and change. The tonifying herbs do not only treat the deficiency to reduce the tendency of disease development and recurrence, but also reduce the purging effect of the clearing herbs. This brings us back to the theory that yin and yang root each other and cannot be separated. Even when we see a lot of damp and heat, bitter and cold herbs should be used carefully, as they may harm the Stomach qi, whilst draining herbs such as Cang Zhu (Rhizoma Atractylodis) may harm Stomach yin. That is the reason for the addition of Tai Zi Shen (Radix Pseudostellariae Heterophyllae) which tonifies qi and fluid, Zhi Mu (Radix Anemarrhenae Asphodeloidis) which clears Stomach heat but also tonifies Stomach yin, and Lu Gen (Rhizoma Phragmitis Communis) which gently clears heat from the

Lung and Stomach and also nourishes yin and fluid. Since the patient complained about stress again at the second session, Xia Ku Cao (Spica Prunellae Vulgaris) was added, as its heat clearing action is similar to Long Dan Cao (Radix Gentianae Scabrae), and it can further relieve Liver fire caused by emotional tension. This is a case that responded wonderfully; usually candida infection is fairly stubborn. I would suggest patients take the patent pill Yu Dai Wan (Cure Discharge Pill) for a while as prevention when the treatment with decoctions is finished.

Acknowledgements
Thanks to Richard Blackwell, Principal of the Northern College of Acupuncture, for his help with this article.

References
Yin Hui-He (1985). Chinese Medicine Basic Theory. Shanghai Science and Technology Publishing House. Li Zhao-Guo (1997). A Comprehensive Chinese-English Dictionary of TCM. The World Book Press. Cheng Hao Zhou is clinical supervisor of the herbal medicine teaching clinic at the Northern College of Acupuncture. The College runs a three year course for acupuncturists leading to a Diploma in Chinese Herbal Medicine and to membership of the RCHM.

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