Scanty Blood and Darkened Vision
On Jiā Wèi Xiāo Yáo Sǎn
Last time we looked at some late imperial perspectives on Xiāo Yáo Sǎn (Free Wanderer Powder). This time around, I wanted to do a brief discussion of Jiā Wèi Xiāo Yáo Sǎn (Supplemented Free Wanderer powder, JWXYS), which was mentioned in last week’s post. I personally use JWXYS far more often than the original formula, so I will give an example from my own practice at the end. But first, let’s have a look at the original reference in the literature.
Origin of the Formula
JWXYS first appeared in Nèi Kē Zhāi Yào (Summary of Internal Medicine, 內科摘要, 1529) by Xuē Jǐ 薛己 :
加味逍遙散 治肝脾血虛發熱，或潮熱，晡熱，或自汗盜汗，或頭痛，目澀，或怔忡不寧，或頰赤口乾，或月經不調，肚腹作痛，或小腹重墜，水道澀痛，或腫痛出膿，內熱作渴等症。
當歸 芍藥 茯苓 白朮（炒） 柴胡（各一錢） 牡丹皮 山梔（炒） 甘草（炙，各五分）
上水煎服。
Jiā Wèi Xiāo Yáo Sǎn: Treats liver-spleen blood vacuity heat effusion; or tidal or afternoon heat effusion; or spontaneous or night sweats; or headache and dry eyes; or fearful throbbing and disquiet; or flushed cheeks and dry mouth; or unregulated menstruation and abdominal aching and pain; or lower abdominal sagging and heaviness, and waterways rough and painful; or painful swellings that exude pus, interior heat causing thirst, and diseases such as that.
Dāng Guī [Rx Angelicae Sinensis], Sháo Yào [Rx Paeoniae Alba], Fú Líng [Poria], Bái Zhú [Rz Atractylodis Macrocephalae] (fried), Chái Hú [Rx Bupleuri] (each 1 qián); Mǔ Dān Pí [Cx Moutan], Shān Zhī [Fr Gardeniae] (fried), Gān Cǎo (fried) [Rx Glycyrrhizae Praeparata], (each 5 fēn). Take the above decocted in water.
Wài Kē Shū Yào (Vital Pivot of External Medicine外科樞要, 1545), a later book by the same author, adds the indications of whole-body itching and sensations of cold and heat (遍身瘙癢寒熱); aching of the limbs and trunk and clouding and heaviness of the head and eyes (肢體作痛, 頭目昏重); reduced eating and sleeplessness (食少不寐); mouth and tongue sores, and pain inside the ears (口舌生瘡，耳內作痛).
This modification to Free Wanderer Powder appears to have been in wider circulation soon after; one example comes from Yī Fāng Kǎo [Investigation of Medical Prescriptions, 醫方考, 1584] by Wú Kūn 吳昆:
加味逍遙散
當歸 白芍藥 白朮 柴胡 茯神 甘草（各一錢） 丹皮 山梔（各七分）
六極之外，又有七傷。一曰大怒逆氣傷肝。肝傷則少血目暗，宜此方主之。
經曰：肝者，將軍之官，故主怒。怒則氣逆，氣逆則血亦逆，故少血。眼者，肝之竅。又曰：目得血而能視。今肝傷少血，故令目暗。越人云：東方常實，故肝臟有瀉而無補，即使逆氣自傷，疏之即所以補之也。此方名曰逍遙，亦是疏散之意。柴胡能升，所以達其逆也。芍藥能收，所以損其過也。丹、梔能瀉，所以伐其實也。木盛則土衰，白朮、甘草，扶其所不勝也。肝傷則血病，當歸所以養其血也。木實則火燥，茯神所以寧其心也。
Jiā Wèi Xiāo Yáo Sǎn
Dāng Guī, Bái Sháo Yào, Bái Zhú, Chái Hú, Fú Shén [Poria Pararadicis], Gān Cǎo (each 1 qián); Dān Pí, Shān Zhī (each 7 fēn).
[There are the] six exterior extremes and there are the seven [interior] damages. It is said that rage causes counterflow qì and damages the liver. Liver damage results in scanty blood and darkened vision, and accordingly this formula masters it. The classic says: The liver has the office of general, and thus governs anger. Anger results in counterflow qì; qì counterflow results in blood likewise counterflowing, and therefore scanty blood. The eye is the orifice of the liver. It also says: The eye receives blood and so it is able to see. Now if the liver is damaged and blood is scanty, this therefore causes the eyesight to darken. Yuèrén* said: The eastern direction is generally replete, therefore the liver viscera has to be drained and not [directly] supplemented; even if counterflow qì causes it damage, coursing [the liver qì] will result in its supplementation. This formula is called Xiāo Yáo, this too has the meaning of coursing and scattering. Chái Hú can ascend, and therefore reach the counterflow. Sháo Yào can gather, and therefore diminishes the excess. Dān [Pí] and [Shān] Zhī can drain, and therefore attack the repletion. Wood’s exuberance results in earth’s debility, Bái Zhú and Gān Cǎo hold up that which [the spleen] cannot bear. Liver damage results in disease of the blood, Dāng Guī nourishes the blood. Wood repletion results in fire and agitation [lit. dryness], Fú Shén is preferred because it quiets the heart.
*Qín Yuèrén 秦越人, 407 – 310 BC, is a Warring States era physician sometimes identified as the legendary healer Biǎn Què 扁鵲. The sense that I get from the passage about supplementing and draining the liver is that in coursing the liver (i.e. moving the liver qì), one is actually “supplementing” it, rather than using heavy cloying tonics which will further inhibit its spreading, coursing and discharging functions.
JWXYS and Kampo
In Japanese herbal medicine, or kampo, JWXYS is more commonly used than the original Xiāo Yáo Sǎn. Shibata & Wu (1997) include a monograph on it in their book Kampo Treatment for Climacteric Disorders, where they state the formula is “widely prescribed for problems in the perimenopause,” especially suited to “various nonspecific somatic and psychological symptoms (often multiple fluctuating complaints).”
The applications of the prescription are broad, including vasomotor phenomena like hot flashes; sleep disruption; emotional distress including that occurring after gynecological surgery; headaches and body pain; menstrual and urinary problems; IBS; and “psychosomatic cardiovascular disease.”
Case report
In my practice, the majority of cases are treated with acupuncture and the herbal medicine is used in combination with the needling. Here is a recent case involving JWXYS:
A patient of early middle age presented with a chief complaint of stabbing pain, stinging, and sensations of pressure in the eyes for about 8 months, along with deteriorating night vision. The medical diagnosis was optic neuropathy. The suspected cause was a side effect of medication that had been prescribed to treat an internal stye. Additional symptoms included katakori (stiffening of the muscles in the shoulder and upper back), fatigue, hot flashes, night sweats, aversion to warmth, interrupted sleep, rosacea, burning in the epigastrium, reflux, and IBS (irritable bowel). Significant medical history included uterine myoma and subsequent hysterectomy years earlier.
The abdomen had mild subumbilical weakness, and tightness substernal. Pulse was thin and wiry, with hand and foot juéyīn channels indicated. The tongue had swollen sides, and was purplish, with distended sublingual veins.
Pattern: Depressive heat in the liver-gallbladder channels with underlying liver yīn deficiency and blood stasis. Treat as pericardium pattern (PC-LR).
Tx principles:
· Clear heat from juéyīn and shàoyáng channels
· Free the network vessels
· Enrich water to moisten wood
Treatment:
1. LR2, LR8, PC3; PC6 (contact needling); GB37, TB5, LI11; Yìn Táng, TB23, ST2
2. GB20, SI11, SI14, UB43, UB44, UB17, UB18
LR2 clears heat and quickens network vessels, LR8 nourishes yīn-blood. PC3 clears yíng-aspect heat and PC6 rectifies qì; GB37 brightens the eyes, TB5 quickens network vessels and clears the shàoyáng and upper burner, and LI11 clears heat (especially from the liver as it has a 10-stem relationship). Yìn Táng, TB23, ST2 are used as local points for the eyes. GB20 eliminates wind and heat. SI11, SI14, UB43, UB44 all unbind the shoulders and help the turbid yīn to descend from the head. UB17 quickens blood, and UB18 supplements liver yīn-blood.
After 4 weekly treatments, the pain had significantly diminished. After 6 treatments it was agreed to cut back to 10-14 days between sessions, and the patient was instructed to take JWXYS daily, 3 pills TID. By the 8th treatment her eye pain had largely resolved and we decided to work on supplementing liver yīn and thus discontinued the formula.
Various aspects of the case indicate the use of JWXYS as discussed in the preceding sections: eye pain and darkening vision, hot flashes and flushed cheeks, IBS and history of gynecologic surgery. The acupuncture was effective in this case but the use of JWXYS to maintain the effects of the needle therapy after the treatment frequency was reduced was an important factor as well.
A note about the composition of the pills: I frequently use the Herbal Times brand, and in particular their JWXYS formulation increases the proportion of the Dān Pí and Shān Zhī to 16.67% each – one-third of the total formula. As one can imagine, this increases the heat-clearing and blood-moving functions significantly. I have treated cases of stress-mediated skin eruptions, severe hot flashes, and other depressive heat conditions which responded quite well to this specific formulation, and less well to the standard proportions found in granule extract formulas. In a case that might involve less heat and more spleen vacuity, though, this might not be an optimal choice. Always check the label (or, if available, the practitioner’s guide) of any brand you are considering using; it can make a very noticeable difference.
That’s all I’ve got for now, thanks for reading.
Note: this publication is for information purposes only and is not intended as medical advice. Please seek the opinion of a health care professional for any specific medical issues you may have.
References
Shibata, Y., & Wu, J. (1997). Kampo treatment for climacteric disorders. Paradigm Publications.
Wú, K. (1584). Yī fāng kǎo. https://jicheng.tw/tcm/book/%E9%86%AB%E6%96%B9%E8%80%83/index.html
Xuē, J. (1529). Nèi kē zhāi yào. https://jicheng.tw/tcm/book/%E5%85%A7%E7%A7%91%E6%91%98%E8%A6%81/index.html
Xuē, J. (1545). Wài kē shū yào. https://jicheng.tw/tcm/book/%E5%A4%96%E7%A7%91%E6%A8%9E%E8%A6%81/index.html