VITILIGO, or leukoderma, is a chronic skin condition that causes loss of pigment which results in irregular pale patches of skin. The precise cause of vitiligo is not fully understood. There is some evidence suggesting it is caused by a combination of auto-immune, genetic, and environmental factors. The population incidence worldwide is considered to be between 1% and 2%.

PATTERNS AND HERBAL FORMULAS

1. Wind-Damp + Qi and Blood disharmony: localized white discolorations on the face, neck, and back of the hand; round, oval, or irregular shape discolorations with a smooth suface
Tu Fu Ling  30-60g
Jin Yin Hua  12g
Wei Ling Xian  9g
Sheng Gan Cao  6g
Cang Er Zi  15g
Fu Ping  6g
Xi Xian Cao  6g
Bai Ji Li  6g
Wu Shao She  6g (Zaocys)

2. Wind pathogen: Wind attacks the pores and causes Qi & Blood stagnation, which closes the pores and prevent Blood from nourishing the skin
Han Lian Cao  9g
Bai Zhi  6g
He Shou Wu  6g
Bai Ji Li (fried)  6g
Bai Ji Li  6g
Zi Cao  4.5g
Zao Xiu  3g (Rhizoma Paridis)
Dan Shen  3g
Ku Shen  3g
Cang Zhu  2.5g


EMPIRICAL FORMULAS

Formula 1: Activate Blood, expel Wind, harmonize Qi & Blood
He Shou Wu  30g
Sang Shen  30g
Bai Ji Li  18g
Bai Jiang Chan  12g
Chi Shao  12g
Chuan Xiong  12g
San Leng  15g
E Zhu  15g
Fang Feng  15g

Formula 2: Harmonize Qi & Blood
Sheng Di  12g
Dan Shen  12g
Gou Teng  12g
Bai Ji Li  12g
Dang Gui  6g
Fu Ping  6g
Ji Xue Teng  3g
Ye Jiao Teng  9g


EXTERNAL FORMULAS:
Actions: Harmonize Qi & Blood, activate Blood, open the collaterals
Method: Soak the herbs in 600ml of 70% alcohol for 7 days before applying to the skin

External 1
Bai Fan  80g
Wu Bei Zi  80g
Fu Zi  80g
Bu Gu Zhi  80g

External 2
Bai Fan  80g
Bai Bu  80g
Fu Zi  80g
Bu Gu Zhi  80g

External 3
Bu Gu Zhi  300g


ACUPUNCTURE

TCM STYLE
1. By Patterns
Qi/Blood disharmony: SP10, SP6, ST36, LI11
LV/KD deficiency: UB18, UB23, DU4, LV3, KD3, SP6
Blood stasis: SP6, SP10, LV2, GB31, UB17
2. By Locations
Head/face: LI4, GB20
Abdomen: RN12
Chest: RN17
Upper limb: LI11
Lower limb: SP10, SP6

KOREAN STYLE (4 needle technique)
RIGHT SIDE: TONIFY LV (Tonify KD10, LV8 & Sedate LU8, LV4)
LEFT SIDE: SEDATE LU (Tonify HT8, LU10 & Sedate KD10, LU5)

TCM PATTERNS

1. Damp-Heat: diarrhea, abdominal distention, fatigue, weakness, lack of appetite, slight fever, white greasy coating, soggy rapid pulse
9.0g   Hua Shi 
6.0g   Huang Qin
6.6g   Yin Chen
2.4g   Huo Xiang
2.4g   Lian Qiao
3.6g   Shi Chang Pu
2.4g   Bai Dou Kou
2.4g   Bo He
3.0g   Mu Tong
2.4g   She Gan
3.0g   Chuan Bei Mu
3.0g   Bai Hua She She Cao
3.0g   Mu Dan Pi
3.0g   Ban Lan Gen
3.0g   Jin Yin Hua

2. Heat enters Ying-Blood level: fever, vomiting blood, delirious speech, dry mouth, thirst, red tongue with yellow coat, thready rapid pulse
60g    Shi Gao
6.0g   Sheng Di 
6.0g   Shui Niu Jiao
4.0g   Huang Lian 
4.0g   Zhi Zi
4.0g   Jie Geng
4.0g   Huang Qin
4.0g   Zhi Mu
4.0g   Chi Shao
4.0g   Xuan Shen
4.0g   Lian Qiao
4.0g   Dan Zhu Ye
4.0g   Gan Cao
4.0g   Mu Dan Pi
4.0g   Bai Hua She She Cao

3. HT and SP deficiency: fatigue, emaciation, palpitations, lack of appetite, loose stool, white tongue coat, thready and weak pulse
15g   Bai Zhu
15g   Fu Shen 
15g   Huang Qi 
15g   Long Yan Rou 
15g   Suan Zao Ren (fried)
7.5g  Ren Shen 
7.5g  Mu Xiang
3.7g  Zhi Gan Cao
3.7g  Ji Xue Teng 
3.7g  Tu Si Zi   

4. Qi and Yin deficiency: slight fever, cough, dry mouth and throat, decreased appetite, fatigue, weakness, slight pale tongue, no coating, thready rapid pulse
9.0g  Mai Men dong 
3.0g  Wu Wei Zi
9.0g  Ren Shen
6.0g  Nu Zhen Zi
6.0g  Han Lian Cao
6.0g  Ji Xue Teng

5. Yin deficiency + Phlegm: slight fever, emaciation, phlegm nodules under the skin, cough, red tongue, white coating, thready and slippery pulse
6.0g  Zhi Mu
6.0g  Huang Bai
24g   Shu Di
12g   Shan Zhu Yu
9.0g  Mu Dan Pi
12g   Shan Yao
7.0g  Fu Ling
7.0g  Ze Xie
6.0g  Bei Mu
6.0g  Zhu Ru
6.0g  Mu Li
6.0g  Hai Zao

6. SP and KD deficiency: fatigue, weakness, decreased appetite, loose stool, pain in lower back and knees, white coating, thready and weak pulse
8.0g  Ren Shen
8.0g  Huang Qi
8.0g  Shu Di
8.0g  Shan Yao
8.0g  Shan Zhu Yu
8.0g  Mu Dan Pi
8.0g  Fu Ling
8.0g  Ze Xie
8.0g  Tu Si Zi

7. KD Yang deficiency: fatigue, weakness, low back and knee pain, cold body and limbs, white coating, deep and thready pulse
16g   Shu Di Huang
8.0g  Shan Yao
8.0g  Shan Zhu Yu
6.0g  Fu Ling
6.0g  Ze Xie
6.0g  Mu Dan Pi
2.0g  Rou Gui
2.0g  Fu Zi
4.0g  Yin Yang Huo
4.0g  Tu Si Zi
4.0g  Ba Ji Tian


EMPIRICAL FORMULAS

Formula 1: latent HIV, without any apparent symptoms
8.0g  Dang Shen
8.0g  Huang Qi
8.0g  Bai Zhu
8.0g  Fu Ling
8.0g  Ku Shen
8.0g  Tu Fu Ling
8.0g  Da Qing Ye
8.0g  Bai Hua She She Cao
8.0g  Lian Qiao
8.0g  Huang Lian
8.0g  Zhi Gan Cao

Formula 2: Kaposi's Sarcoma, Turbid-Phlegm on channels
6.0g  Xuan Shen
6.0g  Mu Li
6.0g  Bei Mu
6.0g  Shan Ci Gu
6.0g  Ban Xia
6.0g  Jiang Chan
6.0g  Xia Ku Cao
6.0g  Hai Zao
6.0g  Dan Nang Xing
6.0g  Bai Jie Zi
6.0g  Bai Hua She She Cao
6.0g  Huang Yao Zi

Formula 3: AIDS symptoms of Yin deficiency + Exterior pathogen and fever
6.0g  Yu Zhu
6.0g  Bai Wei
6.0g  Jie Geng
6.0g  Bo He
6.0g  Dan Dou Chi
6.0g  Sheng Di Huang
6.0g  Mai Men Dong
6.0g  Bei Mu
6.0g  Ban Lan Gen
6.0g  Da Qing Ye
6.0g  Jin Yin Hua
6.0g  Tian Zhu Huang
6.0g  Gan Cao

WESTERN REVIEW

DESCRIPTION: TB is an infectious bacterial disease transmitted primarily by air that commonly affects the lungs but also can involve almost any organ of the body.  The kidneys, bone, and meninges are the most common sites where TB spreads.  AGE: most common in children and in adults over age 60; LIFESTYLE: overcrowded conditions and malnutrition are risk factors; GENDER, GENETIC: not significant factors

CAUSE: The bacterium Mycobacterium tuberculosis causes most cases of TB and is usually transmitted in airborne droplets that are produced when an infected person coughs.  Although many people are infected with the bacterium at some point in their lives, only a small proportion of these people develop TB.  People with reduced immunity are more likely to develop TB.  This includes people who are infected with HIV, those who have diabetes mellitus, and those who are taking immunosuppressant drugs.

SYMPTOMS: Initial Stage: Cough, which may be dry, and generally feeling unwell; Later Stage: Persistent cough, greenish or yellowish sputum, chest pain when inhaling deeply, shortness of breath, fever, poor appetite and weight loss, excessive sweating at night, fatigue

DIAGNOSIS: Chest X-rays, CT scanning, analysis of sputum, TB skin test, bronchoscopy, exam samples of tissues from other than the lungs

TREATMENT: Antibiotics are generally effective, but should be taken for at least 6 months. Without treatment, tuberculosis can be a lethal infection. Therefore, early diagnosis is important. Those individuals who have been exposed to a person with TB, or suspect that they have been, should be examined by a doctor for signs of TB and screened with a TB skin test.

PREVALENCE: In the United States, it is estimated that 10-15 million people are infected with the TB bacteria and 22,000 new cases of TB occur each year.


EASTERN PATTERNS

1. LU Yin deficiency: Dry cough, scanty sputum, hemoptysis, blood-streaked sputum, tidal fever, fatigue, red tongue especially anterior third, no tongue coating, thready and rapid pulse
9.0g  Shu Di
9.0g  Sheng Di
9.0g  Dang Gui
3.0g  Bai Shao
3.0g  Gan Cao
2.4g  Jie Geng
2.4g  Xuan Shen
4.5g  Chuan Bei Mu
4.5g  Mai Men Dong
4.5g  Bai He
4.5g  Bai Ji
4.5g  Ce Bai Ye
4.5g  Xian He Cao

2. Yin deficient Fire: Steaming bone fever, afternoon fever, night sweating, cough, scanty sputum, possibly greenish sputum, hemoptysis, emaciation, irritability, thin white and dry tongue coating, thready and rapid pulse
9.0g  Chai Hu
9.0g  Bie Jia
9.0g  Di Gu Pi
4.5g  Qin Jiao
4.5g  Dang Gui
4.5g  Zhi Mu
4.5g  Bai Bu
4.5g  Bai Ji

3. Qi and Yin deficiency: steaming bone fever, afternoon fever, night sweating, cough, shortness of breath, dull chest pain, heat sensation in the palms and soles, insomnia, dreaming, irritability, easily angered, emaciation, spermatorrhea or irregular menstruation, dark red tongue, thready and rapid pulse
9.0g  Tian Men Dong
9.0g  Sheng Di
9.0g  Mai Men Dong
9.0g  Shu Di
9.0g  Shan Yao
9.0g  Bai Bu
9.0g  Sha Shen
9.0g  Chuan Bei Mu
9.0g  E Jiao
9.0g  Fu Ling
9.0g  San Qi

4. SP and KD Yang deficiency: Cough and asthma, shortness of breath, spontaneous sweating, pallor, cold hands, feet, and body, aversion to cold food, reduced appetite, indigestion, emaciation, pale tongue with white coating, thready and rapid pulse
9.0g  Dang Gui
9.0g  Ren Shen
9.0g  Sheng Di
9.0g  Shu Di
9.0g  Bai Zhu
9.0g  Huang Qi
4.5g  Chi Fu Ling
4.5g  Bai Fu Ling
6.0g  Tian Men Dong
6.0g  Mai Men Dong
6.0g  Chi Shao
6.0g  Bai Shao
6.0g  Zhi Mu
6.0g  Huang Bai
6.0g  Wu Wei Zi
6.0g  Chai Hu
6.0g  Di Gu Pi
4.5g  Gan Cao
4.5g  Chen Pi
4.5g  Hou Po


EMPIRICAL FORMULAS

Formula 1: Tonify deficiency and expel germs
Bai Ji  18g
Bai Gu  18g
Mu Li  15g
Zhen Zhu Mu 15g
Chuen Bei Mu  12g
E Jiao 6g
Hu Huang Lian  3g

Formula 2: Open LU, expel pathogens, nourish dryness and dissolve phlegm
Ma Huang (honey fried)  5g
Ma Huang Gen  5g
Ku Xing Ren  9g
Bai Zi Ren  9g
Tao Ren  9g
Yu Li Ren  9g


ACUPUNCTURE
Right side: LU7, KD6
Left side: Tonify SP3 & LU9; Sedate HT8 & LU10

WESTERN REVIEW
Definition: Spinal stenosis is narrowing of the vertebral openings which can cause pressure on the spinal cord or spinal nerves. 
Signs and symptoms: Symptoms include pain in the neck or back, and numbness, weakness, or pain in the arms, legs, or feet.  Symptoms often occur gradually.  Some people may not experience any symptoms.
Causes: Diseases such as arthritis or scoliosis can cause spinal stenosis; it occurs more often in people over 50 years old.  Traumatic injury is another cause of spinal stenosis.
Western treatment: Medications, physical therapy, braces, surgery


TCM PATTERNS
Spinal stenosis belongs to "Muscle-Bone Bi syndrome" or "Back/Leg Pain" according to TCM disease differentiation.

1. Wind-Cold-Damp: Spinal stenosis with symptoms worsened by windy and damp weather, pain alleviated by warmth, difficult to turn body, pain does not subside even when lying down, thin and white tongue coating, deep pulse

Treatment principle: Expel pathogen, open collaterals, tonify Kidney, nourish Blood
9g  Du Huo
6g  Sang Ji Sheng
6g  Du Zhong
6g  Huai Niu Xi
6g  Xi Xin
6g  Qin Jiao
6g  Fu Ling
6g  Rou Gui
6g  Fang Feng
6g  Chuan Xiong
6g  Ren Shen
6g  Gan Cao
6g  Dang Gui
6g  Bai Shao
6g  Shu Di Huang


2. Blood Stasis: Spinal stenosis caused by trauma, severe low back pain, aversion to touch, inability to turn body, difficulty walking or moving, purple tongue, hesitant and wiry pulse

Treatment principle: Move qi and blood, remove blood stasis, stop pain
3.0g  Tu  Bie Chong
6.0g  Dang Gui
1.2g  Ru Xiang
1.8g  Zi Ran Dong (duan)
1.2g  San Qi


3. KD Yang deficiency: Spinal stenosis, dull lower back pain, prefers massage or touch, low back and knee weakness, cold body and limbs, pale and abundant urination, thin and white tongue coat, deep and weak pulse

Treatment principle: Tonify and warm Kidney Yang
13g   Shu Di Huang
6.0g  Shan Yao (fried)
4.5g  Shan Zhu Yu
6.0g  Gou Qi Zi
6.0g  Lu Jiao Jiao (fried)
6.0g  Tu Si Zi
6.0g  Du Zhong (fried with ginger juice)
4.5g  Dang Gui
3.0g  Rou Gui
3.0g  Fu Zi


4. KD Yin deficiency: Spinal stenosis with dull lower back pain, irritability, insomnia, dry mouth and throat, heat sensation in 'five palms,' red tongue, scanty or no coating, thready and rapid pulse

Treatment principle: Tonify Kidney Yin
13g   Shu Di Huang
6.0g  Shan Yao (fried)
6.0g  Gou Qi Zi
6.0g  Shan Zhu Yu
4.5g  Chuan Niu Xi
6.0g  Tu Si Zi
6.0g  Lu Jiao Jiao
6.0g  Gui Ban Jiao


5. Under-nourished Bones and Sinews: Spinal stenosis with Cauda Equina Syndrome, difficulty controlling bowel and bladder, frequent urination, incontinence, constipation, numbness around the genitals, impotence, progressive numbness or weakness of the legs

Treatment principle: Tonify Liver and Kidney, nourish muscle and bones
30g   Shu Di Huang
1.5g  Ma Huang
9.0g  Lu Jiao Jiao
6.0g  Bai Jie Zi (fried)
3.0g  Rou Gui
3.0g  Gan Cao
1.5g  Pao Jiang

LONG YAN ROU (Arillus Longan)
If a patient comes in and you notice that they look anxious or restless, or if they have neurosis due to chronic stress, then Long Yan Rou is definitely a good herb to incorporate into their formula.  Long Yan Rou is good for the chronic stress of modern life.  Chronic stress is taxing on the Heart blood.  Long Yan Rou both tonifies the Heart blood and calms the Shen.  The fruit itself is soft and sweet, and it can be compared to chocolate because eating just makes people feel better.  HT7 is the acupuncture point that has the same actions as Long Yan Rou, to tonify Heart blood and calm the Shen.  This is an essential herb for psychological disorders including symptoms of neurosis and palpitations. 


1.  PALPITATION
If a patient body condition is such that just a little tension causes palpitation, increased breathing rate, or panic, Long Yan Rou has to be given in a dose of 12-20 grams.  Below is an example formula for this type of case:
Long Yan Rou 12-16g
Suan Zao Ren 6-8g
Fu Shen 6-8g
Zhu Ru 4-6g
Zhi Shi 3-4g

CASE. A high-school senior has a lot of anxiety and tension, is not sleeping well, and has a foggy feeling in her head.  She studies a lot; her family is very strict and has expectations for her to enter an ivy-league university.
Dang Gui 8g
Long Yan Rou 8g
Suan Zao Ren 6g
Fu Shen 6g
Shan Zhu Yu 6g
Yuan Zhi 4g
Shi Chang Pu 3g


2.  INSOMNIA
If insomnia is a result of over thinking, with thoughts running through the mind unstoppably, the pattern is Heart blood deficiency.  Insomnia can occur in many patterns, but there are two basic types: excess and deficiency.  Excess fire can blaze up to cause insomnia, or deficiency fire can result from Heart blood deficiency.  The most important aspect of the differential diagnosis is to determine whether the case is excess or deficient.  For Heart blood deficiency pattern insomnia, use this combination: 
Suan Zao Ren (fried) 16-20g
Long Yan Rou 8-12g
Ye Jiao Teng 4-6g
Yuan Zhi 3-4g

CASE. A 36 year old teacher has the main complaint of insomnia.  About five months ago she experienced a lot of stress at work with a particular student and with issues among the faculty.  The work issues have resolved since then, but she still has very disturbed sleep with thoughts just running through her head all night.  She wakes easily, and even though she is very tired she can't sleep.  Now her body is starting to feel very heavy all the time and she is becoming very sensitive emotionally.  Last month her MD prescribed some insomnia medication for her.  It works when she takes it, but now she can't sleep at all if she doesn't take it.  She doesn't want to be addicted to sleeping pills so she didn't take the medication for the last couple of nights.  Her head feels so heavy and she just wants to lie down even though she can't sleep. 
Suan Zao Ren (fried) 20g
Long Yan Rou 12g
Ye Jiao Teng 6g
Yuan Zhi 4g
Ling Zhi 3g (Reishi mushroom)
Da Zao 5pcs


3. ANXIETY/NEUROSIS/PHOBIA/Side effect of Xanax
Long Yan Rou can be used for anxiety, which in severe cases may result is shaking tremors of the hands or body. The Heart is the king organ.  If the king has anxiety, then all his citizens will also lose their confidence.  In the case of the body, the limbs are the citizens and the trembling reflects the imbalanced energy of the Heart. 

Xanax is a benzodiapene frequently prescribed for anxiety and panic disorder.  If taken for an extended period of time, side effects manifest as Heart blood deficiency, or in a more progressed case as Heart and Gall Bladder deficiency.  The symptoms escalate from the realm of anxiety into the realm of phobia, as the patient's tolerance for the drug increases and higher dosages are required.  Of course these symptoms also occur when the patient tries to reduce the dosage or quit the drug.  The concurrent use of an herbal formula which includes Long Yan Rou can greatly help to reduce the symptoms of panic and anxiety associated with decreased dosage or cessation of Xanax.  First try Wen Dan Tang or a modified version of Wen Dan Tang.  If that doesn't work well, then the Heart blood deficiency must be targeted first.  Wood is the mother of fire, so if the Heart blood is deficient then the Liver blood will be strained too.  Shu Di Huang and Dang Gui can help to rectify the Heart and Liver blood deficiency.  This is an example formula:   
Shu Di 12g
Dang Gui 8g
Long Yan Rou 8g
Suan Zao Ren 8g
Fu Shen 6g
Bai Zi Ren 6g
Da Zao 6pcs

CASE.  A 39 year old woman of thin body type has the chief complaint of insomnia and phobia.  She has lived alone since she got divorced five years ago.  Her MD diagnosed anxiety and neurosis and prescribed Xanax.  She took the medication for some time, but then decided that she didn't want to be dependent on a drug so she just quit the medication by herself without any supervision from her MD.  She is now also experiencing tinnitus and aural hallucinations.
Shu Di 12g
Dang Gui 8g
Long Yan Rou 8g
Suan Zao Ren 8g
Gou Qi Zi 6g
Shan Zhu Yu 6g
Fu Shen 6g
Ling Zhi 3g (Reishi mushroom)
Sheng Jiang 3pcs
Da Zao 5pcs


TIP: GUI PI TANG  vs.  WEN DAN TANG  vs.  GUI PI WEN DAN TANG
(1) Gui Pi Tang: A patient presents with a thin body constitution, a thin tongue body or with the normal thin white coating, pale skin, palpitations, other blood deficiency symptoms, and sweaty hands and feet.  Choose herbs in the Gui Pi Tang family (Long Yan Rou, Suan Zao Ren, Dang Gui, Yuan Zhi).
(2) Wen Dan Tang: A patient presents with a thick tongue coating, phlegm symptoms or is overweight, and there is evidence of weak Stomach function, also nausea and a stifling sensation in the chest, and the face is dark or there is darkness below the eyes.  Choose herbs in the Wen Dang Tang family (Ban Xia, Fu Shen, Zhu Ru, Zhi Shi, Shi Chang Pu).
(3) Gui Pi Wen Dan Tang: Occasionally in a complicated case, a patient may have both phlegm and blood deficiency symptoms concurrently.  Then combine both formulas together to make Gui Pi Wen Dan Tang.

TCM PATTERNS
It's hard to find Sleep Apnea topics in the Chinese Medicine textbooks. However, since the 1990s, there have been many articles published in various Chinese medical journals on this condition.  Let me introduce some TCM patterns according to the articles:

1. External Wind-Heat: Wind-Heat pathogen may congest and obstruct the Qi mechanism and the orifices.  Therefore, there is a failure in the transportation of Yin fluid which collects and inhibits the free flow of the throat.

2. Internal LV & LU Heat + External Wind Cold: LV/LU Fire is blocked by Wind-Cold, then internal and external pathogens may join together to block the throat and nose.

3. Yang deficiency: Internal damage due to medication, diet, or overwork may lead to Yang deficiency which may also lead to failure to move and transform Yin fluids.  These fluids can be transformed into Phlegm, and lodged in the throat and block its free flow.

4. Deficiency (SP Qi) + Excess (Phlegm, Stasis):  SP Qi deficiency leads to lack of transformation and transportation.  This leads to phlegm, stasis, and inhibition of the Qi mechanism.  So the root is deficiency and the branch is excess.  In its early stage, there is a SP/LU Qi deficiency or LU/KD Qi deficiency, while in the later stage, LU, SP, KD are all deficient.

5. Dampness: Being overweight, smoking, and drinking as a lifestyle can cause Phlegm Dampness, Qi stagnation, and Blood stasis.

6. Phlegm and Heat: These two pathogens mutually binding and causing depression and obstruction of the Qi passageways.


HERBAL FORMULA
Basically, you can choose formulas according to the patterns of TCM.  I want to introduce one of my favorite formulas from the articles. 

8g  Ma Huang
9g  Yi Mu Cao
6g  Jie Geng 
6g  Gan Cao

1. Ma Huang (Hb. Ephedra)
TCM: Disperses the LU Qi, like its shape of a tube, it opens the airway
BIO: Soothes and opens the bronchi, relaxes the smooth muscles, and harmonizes the respiratory center

2. Yi Mu Cao (Hb. Leonuri Hterophylli)
TCM: Activates the blood and transforms stasis
BIO: Excites the respiratory center and improves microcirculation

3. Jie Geng (Rx. Platycodi Grandiflori)
TCM: Diffuses the LU and disinhibits the throat, dissolves phlegm
BIO: Mucolytic effects, anti-inflammatory, antitussive

4. Gan Cao (Rx. Glycyrrhizae)
TCM: With Jie Geng, disinhibits the throat, resolves toxins
BIO: Mucolytic, anti-inflammatory, antitussive

In Oriental Medicine, no matter what is the cause, Sleep Apnea is due to inhibition of the Qi mechanism of the throat and non-diffusion of the Lung Qi.  This formula focuses on the symptoms (Qi, Blood, Phlegm accumulation in the airway).  If you know the root problem, modify this formula accordingly.


ACUPUNCTURE
I would personally use Korean Yin-Yang Balancing and Five Element Haromnizing treatments for this case.  Most Sleep Apnea is the obstructive type, not central type, and the problem is in the Lung channel.  You can press both LU1 points (front-mu of Lung) and find the more painful side.

1. Yin-Yang balancing: Tonify LU10(fire) and LU5(water) on the more painful side, and sedate LU10(fire) and tonify LU5(water) on the opposite side.  This is Korean Yin-Yang balancing theory. 

2. Five-element harmonizing: For Five Element treatment, there is a very special and intricate pulse reading technique so I can't explain it here, but you can use the Four Needle Technique of Tonification of LU (tonify SP3, LU9, sedate HT8, LU10) by using the five-element points.  When you do this treatment, apply it on opposite side from the more painful LU1.


WESTERN MEDICINE REVIEW
DEFINITION: Repeated temporary interruption of breathing during sleep, which occurs 10 seconds at least 5 times/hour. This condition may be life-threatening if low oxygen level reaches a critical point.
● Age: 30-50 years; also in children
● Gender: More common in males
● Lifestyle: Being overweight, drinking, alcohol, and smoking are risk factors
● Genetics: Not a significant factor

TWO TYPES: OSA & CSA
(1) OSA (Obstructive Sleep Apnea)
● OSA occurs when the air passages in the upper respiratory tract become obstructed during sleep; the most common culprit is the soft tissue of the pharynx.
● Obstructed breathing leads to low levels of oxygen in the blood, causing a person to respond by waking up and taking a deep, snorting breath.
● Being overweight (particularly around the neck area) or having a large tongue or a small mouth can also cause or contribute to the obstruction.
● In children, enlarged tonsils or enlarged adenoids are the most common causes leading to OSA.
(2) CSA (Central Sleep Apnea)
● If the region of the brain and the nerves that regulate breathing do not function normally this causes breathing to be impaired.
● Causes of central sleep apnea include brain damage as in head injury or a stroke.

SYMPTOMS: The symptoms of OSA develop gradually.  CSA may develop suddenly, depending on the cause.  Often another family members notices the problem before the patient does.
● Symptoms of both types can include: restless, unrefreshing sleep, daytime sleepiness, poor memory and concentration, headache in the morning, loud snoring, change in personality, impotence , frequent night time urination
● Severe cases, can cause daytime sleepiness enough to cause accidents when driving.  Taking sleeping drugs or drinking alcohol may aggravate the symptoms.
● Left untreated, complications such as an irregular heartbeat, high blood pressure, and pulmonary hypertension can occur. 

DIAGNOSIS: Endoscopy of the nose and throat, X-ray or CT scanning of the head and neck, Sleep studies, Oxygen levels in the blood, Heart rate

TREATMENT
● Mild OSA: avoid sleeping drugs and alcohol
● Overweight: losing weight may help, try to sleep on the side, which may relive the symptoms
● Caused by high altitude: SA should disappear when you acclimatize or return to lower altitudes
● Caused by enlarged tonsils or adenoids: surgery may be necessary to remove them. In some cases, OSA is treated by surgically reconstructing the soft palate.
● If the cause is not treatable, or if you do not wish to have surgery: CPAP (Postive Airway Pressure Device = Positive Pressure Ventilation) may help and is often the first treatment offered.  Dental appliances are another option.
● CSA: drugs that stimulate breathing may help
● TCM: CSA is difficult to treat with western medicine, but is a better candidate for treatment by TCM than OSA.  For Central Sleep Apnea, studies have shown that sleeping in the lateral position can be helpful.  More research must be done.

CLINICAL INDICATION OF HUANG LIAN (Coptidis Rhizoma)

These days, our modern lifestyle tends to create a lot of stress and psychological disorders; in other words a lot of fire.  Many patients turn to acupuncture for help with disorders that have been caused by the seven emotions, the internal cause of disease.  In order to achieve internal harmony, water must rise and fire must descend.  If the fire is not descending, use Huang Lian.  Huang Lian is well known for clearing heat; it actually draws down stagnated heat in the upper jiao through the lower jiao.   


1. Stress
Symptoms including pain in the area of RN17, chest oppression, irritation, red eyes, indigestion, and sensations of heat in the head but cold hands and feet indicate imbalance of the Autonomic Nervous System.  For acute stress Xiang Fu, Chai Hu, Chen Pi, and Qing Pi are important herbs.

Substantial stress lasting for five to ten years can be classified as chronic stress.  This often occurs in people in their 40's and 50's experiencing more responsibilities at work and in the family.  For stress which stagnates qi causing heat in the chest, 4.5-6g of Huang Lian can open the chest. 

Case:
A 40 year old woman has been having marriage difficulties and financial stress for seven years.  She began to experience stifling sensations in the chest and chest pain.  Her cardiologist could find no evidence of any heart problem.  She complains of a stuffy feeling in the center of her chest (RN17 area), and says that when this sensation is severe even breathing is difficult.  Sometimes when she lies down she feels like there is something on her chest, so she doesn't sleep well.  She has a bitter taste in the mouth and cold hands and feet.  A good formula for her is:
Long Yan Rou 12g
Suan Zao Ren 8g
Huang Lian 4g
Zhi Zi 3g
Zhu Ru 3g


2. Gastritis
Some people are sensitive and get stressed easily, and tend to over think things and worry too much.  As a result they have indigestion, nausea, and pain or discomfort in the epigastric area, especially around RN14 and RN15.  Even though this is a middle jiao problem, the treatment principle must focus more on clearing heat from the Heart than on strengthening the Spleen.


3. Cold Hands and Feet
This is not the case of true cold.  In this case, there is heat in the chest but the abdomen, hands and feet feel cold.  Other symptoms probably include chest discomfort, bitter taste in the mouth, or dry mouth.  In this situation, the heat is stuck in the chest instead of being distributed evenly throughout the body.  Even though Huang Lian is a cold herb, using it in this case will warm up the abdomen, hands and feet.
Huang Lian (wine-fried) 8g
Chi Shao 6g
Dang Gui 6g
Mu Dan Pi 4g
Chai Hu 4g
Chen Pi 4g
Gui Zhi 2g


4. Thyroid
People with hyperactive thyroid glands can suffer tachycardia, palpitations, diarrhea, frequent urination, fatigue of the whole body and irregular menstruation.  An unstable emotional state often accompanies this condition, causing the patient to be easily angered, irritable, and full of anxiety and worry.  In addition they often are very sensitive to hot weather and constantly have hot and sweaty palms.  The right combination of herbs including Huang Lian can help to reduce the symptoms.
Long Yan Rou 12g
Huang Lian (fried) 6g
Mai Men Dong 4g
Wu Wei Zi 4g
Sha Shen 4g
Xia Ku Cao 3g
Zhi Zi (fried) 3g


5. Hair Loss
Modern life is a stressful paradigm.  It's easy to picture a business man with a red face and hair that's thin and brittle with hair loss occurring in a circular pattern at the top of the head.  This condition is based on Kidney yin deficiency; the Kidney yin cannot grasp the Heart fire.  In a state of harmony, the Kidney water rises up and the Heart fire descends.  But when Kidney yin is deficient, the Heart fire may flare up and dry the blood in the head, preventing the hair from receiving nourishment.  Someone in this condition may also suffer from insomnia, or heat in the upper body and cold in the lower body.  The treatment principle is to bring the fire down from the head, and also to tonify blood since hair is the surplus of blood.     
Bai He Shou Wu 12g
Shu Di Huang 12g
Dang Gui Body 4g
Dang Gui Tail 4g
Huang Lian 4g
Chuan Xiong 3g
Wu Yao 3g
Hong Hua 2g

CLINICAL INDICATIONS OF HUANG QI (Astragali Radix)
The most common Huang Qi cases you will see in the clinic include skin and membrane disorders, spontaneous sweating, edema, and somnolence.


1. SKIN DISORDERS

a. Chronic Ulcers, Behcet's syndrome: The Lung governs the qi and the skin, and Huang Qi tonifies the Lung very well.  Huang Qi is effective in treating continuous, chronic, inflammatory ulcers, including mouth ulcers which occur with fatigue as in Behcet's syndrome.  Huang Qi's ability to treat mouth ulcers is limited to the etiology of qi deficiency, and does not include mouth ulcers caused by excess heat.  Huang Qi has the action of generating flesh and discharging pus.  So Huang Qi + Ren Shen can tonify the qi, while Huang Qi + Gan Cao can expel the pus.  The result is healing chronic ulcers resulting from fatigue.  The following formula may be used for Behchet's syndrome:

Huang Qi, 20-30g
Ren Shen, 8-10g
Gan Cao, 4g
Jin Yin Hua, 8g
Lian Qiao, 6g

b. Post-surgical tonic: For surgical wounds that aren't healing fast enough, use Huang Qi. Again, Huang Qi has the action of generating flesh and discharging pus.  Huang Qi + Dang Gui can tonify the qi and blood to generate flesh and promote the healing process.  This is the perfect tonic to aid in recovery after surgery: 

Huang Qi, 12-20g
Dang Gui, 8-12g
Ren Shen, 4g
Gan Cao, 2g


2. SWEATING
Huang Qi tonifies the Lung.  The Lung governs Wei qi, which controls the pores, so Huang Qi can treat Spontaneous sweating disorders.  Huang Qi sweating will occur all over the whole body, often excessively, and worse after activity.  A thin, emaciated person with pale and thin skin is a good candidate for a Huang Qi patient.

CASE: A patient comes to the clinic complaining of severe fatigue and excessive sweating.  Even very simple activities like hammering a single nail cause fatigue and sweating.

Huang Qi, 12-20g
Shan Yao, 8-12g
Ren Shen, 4g
Gan Cao, 2g     


3. EDEMA
According to TCM, there are three organs involved with edema: Lung, Spleen, and Kidney.  Huang Qi edema is related to the Lung, and will occur with fatigue or be exasperated by fatigue.  This edema may manifest upon waking as swollen tongue with teeth marks and edema of the eyes or anywhere.  It also may occur after work or tiring activities as the shoes don't fit on the feet or the rings don't fit on the swollen fingers.  We call this Pi Shui ("skin water"), and in this situation Huang Qi may be selected as the king herb.

Huang Qi is effective especially when the patient's MD has ruled out kidney problems, and the use of diuretics didn't help or maybe even caused greater fatigue.  We can refer to this condition as “Functional Edema" since there are no detectible physical problems.  The condition of qi deficiency, especially when the patient is tired also, diminishes the body's ability to regulate water metabolism.  This can also occur as a result of indigestion. 

CASE: A patient complains of edema around the eyes and on arms upon waking every morning.  After the day's activities, the edema in her upper body disappears, but her legs are swollen every night.  This has been going on for quite some time.  The patient's MD could not find any kidney disorders upon testing.  She has already been to an acupuncturist for this problem, and was prescribed an herbal formula which only made her more tired.  You identify her pattern as qi deficiency and assume the previous acupuncturist gave her diuretics.  The best formula for this patient will be:

Huang Qi, 12-20g
Ren Shen, 4g
Gui Zhi, 3g
Chen Pi, 3g
With Stomach disorder:  + Bai Zhu 6g, Fu Ling 6g


4. SOMNOLENCE
Constant sleepiness or drowsiness can be caused by qi deficiency, or chronic qi stagnation as a result of chronic qi deficiency.  This patient always wants to lie down to rest.

CASE: A patient complains of fatigue.  He sleeps regularly at night, but he is sleepy all day long, and he even stays in bed all day every Sunday.  He never feels rested and refreshed, and mentions a heavy feeling in his head.

Huang Qi, 12-20g
Sheng Ma, 4g
Shi Chang Pu, 3-4g
Bo He, 3-4g


5. TONGUE, PULSE, AND DOSAGE

TONGUE:  The Huang Qi tongue will have teeth marks and a thin, white coating.  Qi deficiency alone will create a pale or slightly pale tongue with teeth marks, but qi deficiency with damp-phlegm can cause a white coating.  So the signs of teeth marks plus white coating signify qi deficiency with damp-phlegm, which  Huang Qi + Bai Zhu + Fu Ling can treat.   

PULSE: The Huang Qi pulse is weak, of course, because of qi deficiency.  It may be forceless, thready, deep, or even scarcely perceptible.

DOSAGE: When used as the king herb, the dosage of Huang Qi is 12-20 grams.  The dosage should be adjusted to reflect the degree of qi deficiency.  For Behchet's syndrome, up to 30 grams may be used.

DEFINITION

1. Melasma is also known as chloasma or the mask of pregnancy when present in pregnant women. 
2. Melasma is yellow or brown pigmentary discoloration of the skin, manifesting as macules on the face.  The symptoms of melasma are dark, irregular patches commonly found on the upper cheek, nose, lips, upper lip, and forehead. These patches often develop gradually over time.  Melasma does not cause any other symptoms beyond the cosmetic discoloration.
3. Although it can affect anyone, melasma is particularly common in women, especially pregnant women and those who are taking oral contraceptives or hormone replacement therapy (HRT) medications. 
4. It is also prevalent in men and women of Native American descent (on the forearms) and in men and women of German/Russian Jewish descent (on the face). 
5. In TCM, Melasma is known as mian chen (dusty complexion).


DIFFERENTIATION AND FORMULAS

1. LV Qi stagnation
Chai Hu  10g
Qing Pi  10g
Chen Pi  10g
Chuan Lian Zi  10g
Dang Gui  10g
Fu Ling  12g
Bai Shao (fried)  12g
Bai Zhu  12g
Hong Hua  6g
Ling Xiao Hua (Flos Campsitis)  6g
Sheng Di Huang  15g

2. LV Fire
Qing Pi  10g
Chen Pi  10g 
Mu Dan Pi (fried)  10g
Zhi Zi (charred)  10g
Ze Xie  15g
Bai Shao  10g
Tu Bei Mu (Tuber Bolbostemmatis)  15g
Ling Xiao Hua (Flos Campsistis)  10g
Ji Guan Hua (Flos Celosiae Cristatae)  10g
Mei Gui Hua (Flos Rosae Regosae)  10g

3. SP Damp
Huang Qi (fried with honey)  12g
Dang Shen  12g
Bai Zhu  12g
Fu Ling  12g
Dang Gui  12g
Hong Hua  6g
Ling Xiao Hua (Flos Campsitis)  6g
Sha Ren  6g
Bai Fu Zi  6g
Sheng Ma  6g
Shan Yao  30g
Dong Gua Pi  30g
Zhi Gan Cao  10g

4. SP Damp-Heat
Lian Zi  6g
Yi Yi Ren  6g
Sha Ren  6g
Jie Geng  6g
Bai Bian Dou  6g
Fu Ling  6g
Ren Shen 12g
Gan Cao  3g
Bai Zhu  12g
Shan Yao  12g
Hua Shi  18g
Huang Bai  6g
Huanb Qin  6g
Ze Xie  6g

5. KD Yin Deficiency
Zhi Mu  10g
Huang Bai  10g
Sheng Di Huang  15g
Shan Yao  15g
Shan Zhu Yu  10g
Fu Ling  10g
Mu Dan Pi  10g
Ling Xiao Hua (Flos Campsitis)  10g
Ji Guan Hua (Flos Celosiae Cristatae)  10g
Chai Hu  6g

6. HT Yin Deficiency
Huang Lian  10g
Huang Qin  10g
E Jiao  10g
Sheng Di Huang  15g
Tong Cao  6g
Mai Men Dong  15g
Ji Guan Hua (Flos Celosiae Cristatae)  10g
Ling Xiao Hua  10g


EMPIRICAL FORMULAS

Formula 1: Activate Blood, Cool Blood
Dang Gui  10g
Chuan Xiong  10g
Chi Shao  10g
Shu Di Huang  15g
Sheng Di Huang  15g
Bai Zhi  10g
Nu Zhen Zi  15g
Zi Cao  10g

Formula 2: Move Qi, Activate Blood
Zi Cao  15g
Qian Cao Gen  7.5g
Bai Zhi  7.5g
Chi Shao  7.5g
Su Mu  7.5g
Hong Hua  7.5g
Hou Po  7.5g
Si Gua Luo  7.5g
Mu Tong  7.5g

Formula 3: Regulate Qi and Blood
Chai Hu  6g
Dang Gui  9g
Chi Shao  9g
Bai Shao  9g
Sheng Di Huang  15g
Mu Xiang  6g
Zhi Ke  9g
Dan Shen  9g
Chuan Xiong  6g
Yi Mu Cao  15g
Ze Lan  9g
Niu Xi  15g
Zhi Gan Cao  6g

EXTERNAL USE: Grind into fine powder and mix with water to form a thin paste. Use instead of soap; massage into face for 10 minutes 2 times per day.
Mung Bean powder  90g
Bai Ju Hua  30g
Bai Fu Zi  30g
Bai Zhi  30g
Salt  15g
Bing Pian  1.5g


ACUPUNCTURE TREATMENT

TCM Acupuncture: Main points + Secondary Points
1. LV Qi stagnation: ST36, SP6, LV3 + SP9, LV2, UB18, UB20
2. SP Damp: RN12, ST36, SP6 + UB20, RN13, RN10
3. KD Yin Deficiency: KD3, SP6 + UB23, SP9
4. Local Points: Yuyao, Taiyang, SI18
5. Channels: DU14, LI11, SP10, ST36, SP6, GB20 + KD3, DU4, HT7, PC6, ST18, RN3

Auricular Points
1. Main: LV, KD, SP, Face, Endocrine
2. Empirical: Adrenal gland, Endocrine, Uterus, SP, LU

There are various methods for stroke prevention.  Of course, lifestyle factors such as diet, exercise, and stress reduction can not be emphasized enough.  As an acupuncturist, you can offer important acupuncture and moxa treatments.


OVERVIEW OF MOXA & ACUPUNCTURE FOR STROKE PREVENTION

Moxa can be used to prevent stroke by applying moxa to ST36 + GB39 and ST36 + LI11 alternatively.  When you apply moxa to ST36, apply a little more moxa to one side for each treatment, and alternate between the left side and right side receiving more.  The rhythm and movement of life is balanced overall, but the balance is dynamic.  When we dance or walk, we shift from left leg to right leg, back and forth.  To direct the same amount of energy into both sides at the same time wouldn't be natural.

Acupuncture can be used to prevent stroke by needling DU9, SI12, UB12, GB20, and DU16.  Note that most of these points have the word "wind" in the name.  If atrophy has occurred in the trapezius muscle on one side, then also needle UB10 on the “sunken" side.


DISCUSSION OF SPECIFIC POINTS

1. ST36 (Leg Three Mile)
In modern acupuncture, ST36 may be broadly applied to treat almost any condition, including the prevention of disease.  ST36 in combination with GB39 or LI11 can prevent stroke.  For stroke prevention, I recommend alternating treatments of ST36 + GB39 and ST36 + LI11.

2. GB39 (Suspended Bell)
GB39 is the “boss point" of its area.  It is the Influential Point of Marrow, and as such can benefit the brain and head.  It can be used for headache, especially headache related to hunger or food retention.  Moxa at GB39 can help to prevent stroke, and additionally has the effect of boosting T-cell counts and strengthening the immune system.  It is a good point to help people cope with the side effects of chemotherapy. 

The location of GB39 is different according to the text; it is 3 cun above the external malleolus, but some say posterior to the fibula while others say anterior to the fibula.  Actually, they are both correct.  The posterior location should be used for needles, while the anterior location should be used with moxa.   

3. LI11 (Crooked Pond)
Academically, LI11 is indicated for clearing heat.  Clinically, LI11 is one of the 8 best points for stroke, and one of the 10 best points for hemiplegia.  Moxa can be used to prevent stroke by applying moxa to ST36 + GB39 and ST36 + LI11 alternatively.

4. DU9 (Reaching Yang)
DU9 is used to help prevent stroke.  Heat which rises up becomes wind.  DU9 is the so-called "first gate" or "windscreen" for blocking the Lower Dantian from rising up.  To prevent stroke, one method is to reinforce the "windscreen gates."  Needle these points from lowest to highest: DU9, SI11, GB20, DU16, and DU17.

5. SI12 (Grasping Wind)
SI12 is called "Prevent Wind," and it is indeed used for stroke prevention.  As with all points with "wind" in the name, it is located in the upper back/neck region (except GB31).  Heat is the pathological derivative of qi, and when heat intensifies enough to rise to the head, it is called wind.  We can consider the imaginary line created by the scapular spines across the upper back as the borderline between heat and wind.  SI12, then, stands at a critical point in the body's defense against wind, and can be thought of as "border patrol."  Since SI12 is the crossing point of four channels (LI, SI, SJ, GB), this reinforces its ability to relax the upper back and neck area.  People who hold a lot of tension in that area are at a higher risk for stroke.  SI12 is also effective in treating "stomach wind," the occurrence of heat and fever after eating.

6. UB12 (Wind Gate)
UB12, "Wind Gate," is where exterior wind enters the body.  It is better for exterior wind than GB20 "Wind Pool" or DU16 "Wind Mansion."  They all can treat interior or exterior wind, but UB12 is mainly for exterior wind, as the name tells us.

7. GB20 (Wind Pool)
GB20, "Wind Pool," is the most significant point in the back of the head and neck area.  We can call this point the "boss point" or "king point" of that area.  Whenever there is a king, there are always some supporting ministers.  If GB20 is the king, then UB10 is the minister; if DU20 is the king, UB7 is the minister.  Because of its ability to treat wind, GB20 is a great point for Bell's palsy, stroke, hemiplegia, chronic headache, stiff neck, cervical disc problems, and even high blood pressure.

8. DU16 (Wind Mansion)
Named "Wind Mansion," DU16 can treat either exterior or interior wind.  Actually, DU16, GB20, and LI4 can all treat either internal or external wind.  There are four points in the head and neck area with "wind" in the name: DU16, GB20, SI12, and UB12.  UB12, "Wind Gate," is geared more to treating exterior wind.

9. UB10 (Celestial Pillar)
In cases of stroke, innervation to the left and right sides may become unbalanced.  If the trapezius muscle appears atrophic on only one side, needle UB10 on the sunken side, plus DU14 to balance both sides of the trapezius.