Crohn's Disease: Western and Oriental Perspectives, Part II

CROHN’S DISEASE

I. Western Medical Designations and Treatment

I.A. Nosology

Crohn’s disease (also called Crohn syndrome and regional enteritis) is a type of inflammatory bowel disease (I.B.D.) that can affect any aspect of the gastrointestinal (G.I) tract, from mouth to anus. Diagnosis depends on differentiation from other types of I.B.D., including ulcerative colitis (U.C., which pairs with Crohn’s to represent the principle types), collagenous colitis, lymphocytic colitis, diversion colitis, Behcet’s disease, and indeterminate colitis.

Crohn’s disease itself can be differentiated into sub-types, either based on the specific tract region affected, or based on the behavior of the disease as it progresses. In terms of regions affected, ileocolitis is a disease of both the ileum (the terminal end of the small intestine) and the large intestine; meanwhile, ileitis manifests in the ileum only; and Crohn’s colitis occurs in the large intestine only. In rare cases, Crohn’s affects only the upper small intestine and the stomach: gastroduodenal Crohn’s affects the stomach and duodenum (the proximal end of the small intestine), and jejunoileitis affects the jejunum (the region between the duodenum and ileum).

Three categories of disease presentation in the progression of Crohn’s are as follows: stricturing, penetrating, and inflammatory. “Stricturing” refers to the narrowing of the bowel, which can lead to obstruction. “Penetrating” refers to the creation of abnormal passageways (fistulae) between the bowel and other structures, like the skin. “Inflammatory” indicates inflammation in the absence of strictures or fistulae.

I.B. Epidemiology

Studies have shown Crohn’s disease to affect about 3 out of every 1,000 people in Europe and North America. There are estimates of 780,000 Americans currently living with Crohn’s, and an additional 33,000 cases are diagnosed yearly. Rates have been increasing in recent decades, especially in the developed world. The disease is thought to be more prevalent in northern countries, especially those of Europe and North America.

Rarely diagnosed in childhood, Crohn’s disease, like U.C., begins most commonly between the ages of 15-35. The disease is only slightly more prevalent in women than in men. There is a clear genetic predisposition to Crohn’s: parents, siblings, or children of people with the disease are 3 to 20 times more likely to also have the disease. Crohn’s sufferers have a slightly reduced life expectancy.

Within the community of Crohn’s patients, about half suffer from the ileocolic sub-type, while 30% are affected by ileitis, and 20% by colitis. Though the disease can attack any part of the digestive tract, regions above the lower small intestine are almost always affected in conjunction with the ileum and/or colon.

I.C. Definition

Crohn’s disease is a type of I.B.D. that can affect any part of the G.I. tract, from mouth to anus. Signs and symptoms include abdominal pain, diarrhea (potentially with blood), fever, weight loss, anemia, skin rashes, arthritis, eye inflammation, and fatigue.

The disease is named after gastroenterologist Burrill Bernard Crohn, of New York’s Mt. Sinai Hospital, who outlined the nature of the disease in 1932. Crohn, along with two colleagues, published a case series called “Regional ileitis: a pathologic and clinical entity.”

I.D. Etiology & Pathophysiology

Crohn’s disease is immune-related: the body’s immune system is attacking the G.I. tract. The exact nature of the immune problem is unclear, but the latest research suggests that this does not seem to be a classic autoimmune condition (where the immune system is being triggered by the body itself); rather, environmental and bacterial factors are considered the primary triggers for the inflammatory response, and immunodeficiency seems to add to the gastrointestinal chaos. In other words, gut immunity is having difficulty differentiating self from other, and external pathogens are taking up residence, further inflaming the situation. Over time, structural damage occurs to tissues of the G.I.

Crohn’s often features a transmural pattern of inflammation of the colon; this means the inflammation can span the entire depth of the intestinal wall. Ulceration is found in highly active forms of the disease. Patterns known as “skip lesions” are characteristic of Crohn’s; these patterns feature abrupt transitions between unaffected tissue and ulcerated tissue. Other characteristic pathophysiological features of Crohn’s are: a cytokine response associated with T-helper cell 17 (as opposed to the response of T-helper cell 2 in ulcerative colitis); granulomas (aggregates of macrophage derivatives known as giant cells); and chronic mucosal damage, which can manifest as blunting of the intestinal villi, atypical branching of the crypts, or change in tissue type (metaplasia).

There’s some speculation that Crohn’s is not one disease, but an umbrella of diseases related to different pathogens (both microbial and environmental). This line of thinking is mainly bolstered by the discoveries of many different types of bacteria that have been linked to the disease. At the same time, underlying weakness is essential to this theory: the host’s mucosal layer is compromised and the immune system is unable to clear bacteria and pathogens from the intestinal walls.

I.E. Risk Factors

About half of the risk of developing Crohn’s disease is related to genetics, with more than 70 genes found to be involved. The increased incidence of Crohn’s disease in the developed world suggests an environmental component. The disease has been associated with increased intake of animal and milk proteins (while those who consume more vegetable proteins have been shown to have less tendency toward developing the disease). Tobacco smokers are twice as likely as non-smokers to develop Crohn’s. The disease often begins after gastroenteritis. Lastly, there is some concern that the uptick in Crohn’s cases, beginning in the 1960s, has meaningfully correlated with the introduction and growth of hormonal contraception.

I.F. Symptomatology

Abdominal pain and diarrhea are the two most common features of Crohn’s. The nature of the diarrhea hinges on the affected intestinal region: ileitis tends to result in copious, watery stool; colitis tends to feature a smaller volume but a higher frequency. Blood in the stool is less common than in U.C., but may be seen in colitis.

Other GI-related symptoms include: flatulence and bloating; itchiness or pain around the anus; perianal skin tags; fecal incontinence; and non-healing sores of the mouth. In rare cases, the throat and stomach are affected in Crohn’s; such cases might feature dysphagia, epigastric pain, and vomiting.

Systemic symptoms include fever; weight loss (due either to loss of appetite or malabsorption of carbohydrates and/or lipids); and retardation of growth in children. Other organs can also be affected by Crohn’s, including the eye (blurred vision, pain, and loss of vision); the gallbladder (gallstones); the joints (arthritis); and the skin (raised nodules or ulcerating lesions). Crohn’s also increases the risk of blood clots (as in deep venous thrombosis or a pulmonary embolism) and anemia. Furthermore, Crohn’s can cause neurological complications, such as seizures, stroke, myopathy, peripheral neuropathy, headache, and depression.

I.G. Differential Diagnosis

One must differentiate Crohn’s disease from the following: ulcerative colitis; collagenous colitis; lymphocytic colitis; diversion colitis; Behcet’s disease; indeterminate colitis; amebiasis; appendicitis; intestinal carcinoid tumor; celiac disease; diverticulitis; gastroenteritis; giardiasis; intestinal tuberculosis; ischemia; tuberculosis; yersiniosis; lymphoma; amyloidosis; actinomycosis; histoplasmosis; and carcinoma of the cecum.

I.H. Diagnosis

Colonoscopies are roughly 70% effective in diagnosing Crohn’s disease; diagnosis becomes more difficult the more proximal the affected region is, since colonoscopy allows access only to the colon and the lower portions of the small intestine. Patchy distribution of the disease (“skip lesions”) over the colon or ileum, but not the rectum, suggests a positive Crohn’s finding.

X-rays can be useful when the disease solely involves the small intestine. Barium enema can be effective in identifying anatomical abnormalities (strictures and fistulae). CT and MRI scans can also add information to the diagnostic process. Lastly, blood tests can reveal anemia; assess the degree of inflammation; and isolate the presence of antibodies that serves to differentiate Crohn’s from U.C.

I.J. Prognosis & Complications

Crohn’s is a chronic condition without a cure. It is characterized by periods of remission and flare-ups. The disease can vary from benign to severe, and many sufferers can remain disease-free for years or decades; most with Crohn’s live a normal lifespan. In cases where remission is possible, western biomedicine recommends using medication, as well as lifestyle and dietary changes (including eating a balanced diet; eliminating trigger foods; eating small meals frequently; avoiding smoking; and practicing healthy sleep hygiene and regular exercise) to heal and prevent relapse.

Long-term antibiotics are generally considered effective in Crohn’s (while not in U.C.). Anti-inflammatories like aminosalicylates and corticosteroids are used to reduce inflammation. Iron is administered in cases of anemia.

A core complication of Crohn’s is structural abnormality (such as strictures, fistulae, and abscesses). In cases of partial or full blockage of the intestine, surgery is required. However, the disease often recurs at the site of the resection; also, scar tissue usually builds up at the resection site, which can cause strictures and thus blockage. Other potential complications of surgery include short bowel syndrome (SBS) and bile acid diarrhea.

Crohn’s disease also increases the risk of cancer in the inflamed regions. Lastly, it can cause complications in pregnancy for both fetus and mother.

II. Chinese Medical Differentiation and Treatment

Intoduction: Chinese Medical Treatment vs. Western Medical Treatment

Western medical treatment for Crohn’s—and, in fact, for many modern G.I. diseases, from Crohn’s and U.C. to Small Intestinal Bacterial Overgrowth disease to Celiac disease—is lacking. Biomedical doctors will typically seek to suppress Crohn’s symptoms with antibiotics and anti-inflammatories, and will offer diet and lifestyle advice so as to not exacerbate the disease; surgery is waiting in the wings for cases that have progressed to structural damage. Therapy is largely centered around avoidance and suppression, without much emphasis on getting to the root of the matter.

Chinese medicine offers a promising system of theory and therapy for sufferers of Crohn’s disease. It is able to address the root-cause and branch-symptoms with a multi- pronged approach featuring herbs, acupuncture, and moxibustion, and it lends itself to other alternative modalities, such as essential oils, tuning forks, and gem-stones. Part of the problem with the western approach is that it views Crohn’s as one “thing.” In fact, studies are showing that there are many different factors involved from case to case, whether exogenous (including a whole spectrum of microbes, as well as environmental and dietary substances) or endogenous (including a variety of cytokines and even genes). One of the great virtues of Chinese medicine is its ability to adapt treatment to the particular disease process revealing itself at a given moment. It can offer individualized treatments that take into account the whole of the person, without getting caught in the trap of treating a disease. What does the pulse say? The tongue? The abdomen, the face, the skin? The patient herself—what is the gesture of her disease? By listening to the body, the Chinese medicine practitioner is able to create a coherent treatment plan that seeks not only to ameliorate the disease’s uncomfortable expressions (pain, diarrhea, fever, etc.), but to make contact with the core imbalance, the root process that has gone awry, and to invite the person back to health.

II.A. Chinese Disease: Etiology/Pathology and Diagnosis

We have established that, from a western biomedical perspective, the cause of Crohn’s disease is murky. It seems to result from some combination of immunodeficiency and pathogenic invasion (whether bacteria or environmental toxins). Correspondingly, we can say that the etiology of the disease from a Chinese medical perspective could involve any of the three causes: external, internal, or other. “External” would include any pathogenic invasion (bacterial or environmental); “internal” would pertain to any harmful emotions compromising the immune system; and “other” could encompass any lifestyle factors that have played a role (such as poor diet, drug use, stress, and overwork).

In terms of diagnosing, one employs the four methods (looking, listening, asking, and palpating), as with any disease. Abdominal findings can help guide us: Is there tenderness? Where? Is it consistent or transitory? Deficient or excess? In terms of

© Ryan Gallagher, L.Ac. 2015 questioning the patient, we might ask questions like: Do you have diarrhea? How often? What is it like (color, volume, smell)? Is it painful? We might similarly probe a complaint of abdominal pain or mouth ulcers or weight loss, or any other relevant symptom. It’s important to keep in mind that Crohn’s is often preceded by gastric ulcers; thus, such a finding should be taken seriously and treated in order to stave off the progression.

Crohn’s involves inflammation, and so etiology necessarily involves a heat component; this heat can be excess, or it can result from underlying deficiency. An intriguing Crohn’s etiology, from a classical Chinese point of view, is that of a disturbance in the Taiyang. This line of thinking is not found in popular differentiations or treatments of the disease (and thus is not included below in the chart of differentiations), but might be a worthwhile exploration for the practitioner who treats Crohn’s; I’ll mention it briefly here.

The Taiyang Bladder and Small Intestine govern the body’s boundaries (the skin and G.I. lining, in particular). Taiyang’s physiology is Hanshui (“cold water”)—its role is akin to what one experiences when doused with frigid water: contraction. The Bladder and Small Intestine form a tight seal from the outside world, keeping pathogens out. As the body layer that contacts the outer environment, the Taiyang performs immune and neurological functions. The immune weakness, hyper-sensitivity, and structural damage of the G.I. tract that is found in Crohn’s thus point to Taiyang involvement.

Heiner Fruehauf, PhD, LAc, tends to view Crohn’s and similar autoimmune (or at least “autoimmune-like”) diseases, such as interstitial cystitis and Lyme, through the lens of the Taiyang. From a Taiyang perspective, herbs like Guizhi and points like Wangu (SI-4) are essential. Relatedly, Dr. Fruehauf has discovered that the emotional “toxin” of blame, which he associates with the Small Intestine organ network (and especially with Wangu, which he translates as “Bone of Blame”), is a common finding in such diseases. The Heart organ network, Fruehauf contends, connects us to Source more than any other organ network; the Small Intestine, as the ritual officiant and fu-executor of the Heart, makes sure the mandate of the Emperor is being fulfilled. And what obstructs fulfillment of that mandate? Unwillingness to let go, unwillingness to take responsibility. The human being—especially the sufferer of chronic illness—must be able to accept responsibility for his or her mental-emotional habituation, and for his or her current station in life, and not place blame elsewhere. An inability or unwillingness to face and transform such harmful mental-emotional patterns can both create inflammation and severely hamper one’s prospects of healing from diseases like Crohn’s. As practitioners, we can assist in the healing process by, calming Taiyang’s hyper-response to stimuli, cooling and nourishing the G.I. boundary, through herbs and acupuncture, while also exploring with the patient the role he or she might be playing in the disease process. This is a delicate and intricate process, but one that Dr. Fruehauf has found essential in the healing of such modern, inflammatory diseases.

II.B. Chinese Disease Differentiation

Historically, one might find Crohn’s under any of the following disease names (but especially the first three):

• 洩瀉 Xiexie • Diarrhea • 腹痛 Futong • Abdominal Pain • 下痢 Xiali • Dysentery • 滿脹 Fuman • [Abdominal] Distention & Fullness • 發熱 Fare • Fever • 血瘀 Xueyu • Blood Stasis • 皮肤病 Pifu bing • Skin Diseases • 胃疼 Weiteng • Stomachache • 呕吐气呃 Outu Qie • Vomiting and Hiccup • 消瘦 Xiaoshou • Emaciation • 便秘 Bianbi • Constipation • 痹证 Bizheng • Bi Syndrome [Arthritis] • 眼花 Yanhua • Diminished Vision • 膽石 Danshi • Gallstones • 狐惑 Huhuo • Fox Confusion (see the case history section below for more on this disease)

II.C. Chinese Syndrome Differentiation & Treatment

Note that despite the inflammatory nature of the disease, three of the differentiations below are rooted in cold: Spleen Qi/Yang Xu; Kidney Yang Xu; and Cold-Damp Invasion. These are considered root-causes; for the heat component that is characteristic of Crohn’s, we should incorporate treatment strategies from the LI Damp-Heat, Liver Attacking Spleen, and Blood Stasis patterns. On the other hand, chronic heat scorching the intestines can lead to malabsorption of nutrients, causing deficiency; so we should consider tonifying the Spleen in most cases. Lastly, we should remember that genetics plays a significant role in this disease; thus, it could be useful to consider the Kidney/Bladder, Jing, and the Small Intestine (lineage) as themes in treatment.

Pattern Signs/Symptoms include pulse, Treatment Points Formulas** tongue, palpation Strategy

LI Damp- Acute, urgent, frequent diarrhea Regulate and REN12, ST25, Gegen Qin Lian Heat with smelly, yellow/brown stool; cool the Stomach ST36, SP9, Tang; Baitouweng (whether abdominal pain; burning anus, family to stop ST37, LI4, Tang; Shaoyao due to scanty urine; possibly fever & diarrhea and ST44, LI11 Tang external or thirst. alleviate pain. internal Tongue coat: yellow & greasy. causes) Pulse: slippery & rapid.

Liver Recurrent, explosive diarrhea Smoothen Liver REN12, ST25, Tong Xie Yao Fang Attacking with urgency; abdominal pain & Qi and ST36, LR3, if chronic Xiao Yao Spleen distention; gas & belching; Strengthen the BL18, GB34 San mental/emotional issues; possibly Spleen. With eye issues. hypochodriac Tongue: slightly pale with a thin pain: + LR14 white coat. With Pulse: wiry. periumbilical pain: +REN10, REN6

SP Prolonged loose stools; poor Tonify & REN6, REN9, Shen Ling Baizhu Qi/Yang appetite; heaviness; fatigue; Regulate the REN12, SP3, San Xu sallow complexion; possibly Spleen. BL20, BL25, yang xu: Li Zhong blood in stool. Tongue: pale & ST25, ST36, Tang scalloped, with a thin white coat. LR13 collapse: Bu Zhong Pulse: weak. With severe Yi Qi Tang pain: + REN8 also: Crohn’s formula*

KD Yang Prolonged loose stools that are Tonify & BL23, GV4, Si Shen Wan Xu watery & clear; subjective cold; Regulate the REN4, REN12, Sp and Kd: Gui Fu lower back & knee soreness; Kidney. KD3, ST25, Li Zhong Tang frequent urination; diarrhea ST36, LR13 occurs before dawn with With SP xu: borborygmus & pain. + BL20, BL25, Tongue: pale. REN6, REN9, Pulse: weak (esp. chi). SP3

Pattern Signs/Symptoms include pulse, Treatment Points Formulas** tongue, palpation Strategy

Blood Fixed & sharp abdominal pain, Break up and BL17, SP10, Depends on how Stasis worse at night; hard & full lower Flush Blood LI4, SP6, PC6 Blood Stasis is abdomen; dark stool; possibly Stasis. manifesting constipation; dry signs; easy bruising; varicose veins; loss of vision; mental/emotional issues. Tongue: purplish. Pulse: choppy or rough.

External Acute diarrhea; abdominal pain; Regulate and REN6, REN8, Huoxiang Zheng Qi Pathogenic frequent bowel movements; warm the REN9, REN12, San Invasion of watery stool; borborygmus; loss Stomach family ST25, ST36, Damp-Cold of appetite. to stop diarrhea ST37, SP9, LI4 Tongue coat: white & greasy. and alleviate With severe Pulse: soft, moderate, sluggish. pain. pain: + SP6

*Crohn’s Formula (Yan Fan) is a modern formula designed specifically for treating Crohn’s disease that is manifesting with deficiencies of qi and blood. Ingredients and dosage are as follows: salvia (Danshen), 15g; red peony (Chishao), 12g; white peony (Baishao), 12g; white atractylodes (Baizhu), 9g; angelica sinensis (Danggui), 12g; carthamus (Honghua), 9g; cnidium (Chuanxiong), 9g; codonopsis (Dangshen), 12g; aurantium fruit (Zhike), 9g; saussurea (Muxiang), 9g; citrus peel (Chenpi), 9g; pinellia (Banxia), 9g; and licorice (Gancao), 4g.

**A note on formulas: The formulas mentioned in the chart are mainly from Dr. Long’s notes. I’d like to also list the following Shanghan Zabing Lun formulas focusing on diarrhea (with very brief notes attached to each):

• Guizhi Tang: diarrhea with Zhongfeng exterior pattern. • Guizhi jia Shaoyao Tang: diarrhea with abdominal pain, fullness and distention. • Guizhi jia Dahuang Tang: above, plus accumulated stagnation in the GI tract. • Guizhi Xinjia Tang: diarrhea, plus pain, especially in the limbs. • Guizhi jia Longgu Muli Tang: diarrhea from Kidney Yang Xu. • Guizhi jia Fuzi Tang: diarrhea with cold abdominal pain. • Wutou Guizhi Tang: diarrhea with severe, cold abdominal pain and numbness and cold of the limbs. • Lizhong Wan (mentioned in the chart): diarrhea from Spleen Yang Xu. • Guizhi Renshen Tang: above, plus a Guizhi pattern. • Wuling San: diarrhea with thirst and unsmooth urination. • Zhuling Tang: diarrhea with thirst and inhibited urination due to water and heat binding.

• Gegen Tang: diarrhea with a closed surface. • Gegen Huangqin Huanglian Tang (mentioned in the chart): heat-diarrhea, with a thicker body type, a hasty pulse, and panting and sweating. • Xiao Chaihu Tang: diarrhea in Shaoyang Disease. • Sini San: diarrhea with tenesmus; abdominal hypertonicity and knots. • Xiao Chengqi Tang: diarrhea with delirious speech, suggesting hard stool. • Da Chengqi Tang: diarrhea with stagnation and heat signs; clear-water diarrhea can occur when feces sticks to the intestinal wall; the formula purges the dried feces. • Xiexin Tang & Dahuang Huanglian Xiexin Tang: diarrhea with glomus, heat and stagnation. • Fuzi Xiexin Tang: diarrhea with glomus; cold below and heat above. • Gansui Banxia Tang: diarrhea due to lodged rheum, with hardness and fullness below the heart and a Shaoyao Gancao tang pattern. • Sini Tang family: Sini Tang, Ganjiang Fuzi Tang, Baitong Tang, Tongmai Sini Tang, Sini jia Renshen Tang, Fuling Sini Tang; clear-food diarrhea from Kidney Yang Xu, with various permutations. • Zhenwu Tang: diarrhea due to cold-water excess and Kidney Yang Xu. • Tianxiong San: clear-food diarrhea due to Kidney Yang Xu. • Dahuang Mudanpi Tang & Yiyi Fuzi Baijiang San: diarrhea with intestinal abscess. • Da Wutou Jian: diarrhea with extreme cold-pain in the abdomen. • Taohua Tang: diarrhea with pus and blood in the stool. • Chishizhi Yuyuliang Tang: astringing diarrhea with minerals. • Zhizi Chi Tang: diarrhea with deficiency-vexation. • Shizao Tang: diarrhea with pulling pain in the chest/abdomen. • Banxia Xiexin Tang family of formulas: Banxia Xiexin Tang, Gancao Xiexin Tang, Shengjiang Xiexin Tang, Xuanfu Daizhe Tang, Huanglian Tang; glomus, with nausea- reversal and mixed stool patterns, with various permutations. • Ganjiang Huangqin Huanglian Renshen Tang: diarrhea with vomiting, glomus, and heart-vexation. • Huangqin Tang: diarrhea in Taiyang-Shaoyang Combination Disease (add Shengjiang & Banxia for nausea). • Baitouweng Tang (mentioned in the chart): dysentery-like heat-diarrhea with tenesmus (add Gancao & Ejiao for deficiency). • Wuzhuyu Tang: diarrhea with vomiting, headache, and vexation. • Wumei Wan: diarrhea with “roundworm reversal.” • Zishen Tang: “diarrhea with lung-pain.” • Helile San: “qi-diarrhea.” • Mahuang Shengma Tang: diarrhea with Metal heat and Earth cold. [Could be very interesting choice for a Crohn’s case featuring throat/mouth symptoms.]

II.C.i. An Etiology for One of the Differentiations

We’ve seen that Crohn’s is caused by some combination of external, internal, and “other” factors. The pattern of “Liver Attacking Spleen” suggests a process that is less about external invasion, and more about a weakness of the Earth-center that triggers a Wood/Fire inflammation process. The Spleen is deficient—whether due to genetics, chronic illness, or lifestyle/diet—so we know the transportation and transformation mechanism is not at full capacity. The patient is not receiving the post-natal nourishment she needs; as a result, her immune strength is compromised, her energy depleted. Thus, the motive energies of Wood as it tries to stimulate Earth prove to be more aggravating than productive. Wood is poking, but Earth is stuck; the process causes friction and ultimately heat. And so, we have a combination of dampness, due to the lack of transformation in the Earth-center, and heat, leading to volatility in the digestive and emotional realms: hot loose stool, abdominal pain, gas, counterflow-nausea, and emotional outbursts. Over time, the heat begins to mar the intestinal tissue; diarrhea continues as ulcerations grow. At this point, the disease process can go in several different directions: perhaps the immune deficiency combined with the putrefying intestinal tissue combine to create an environment hospitable to new pathogens (bacteria) that colonize and worsen the condition; perhaps the heat ascends the Liver channel to the eye, causing vision problems; perhaps the toxicity seeps through the intestinal lining to the skin, causing rashes, or to the joints, causing arthritis. All these are potential occurrences in Crohn’s. At this point, with the disease process spreading throughout the body, it’s incumbent upon the practitioner to treat both root and branch: tonify Spleen and calm the Liver, for sure, but also be sure to ameliorate the cascade of symptoms now arising.

II.C.ii. Expanding on a Formula (or Two…)

Gegen Huangqin Huanglian Tang is an effective formula for diarrhea due to LI damp- heat. Line 34 of the Shanghan Lun offers the following:

太陽病，桂枝證，醫反下之，利遂不止, 脈促者，表未解也；喘而汗出者，葛根黃芩黃連湯主之。 In Taiyang disease, there is a Guizhi pattern, but the physician purges, [causing] incessant diarrhea and a hasty pulse: [this means] the exterior has not yet resolved. When there is panting with sweating: Gegen Huangqin Huanglian Tang governs.

This formula features an abundance of Gegen, and a relatively large amount of Huanglian. There should be signs of inflammation: hot diarrhea, acid reflux, vexation. We can look for a thicker body type, with a red face and high blood pressure. There tends to be an epigastric glomus and neck stiffness.

The formula combines bitter and sweet tastes, along with cold qi, to address fire in the intestines. Gegen, sweet and cool and prescribed at a half-jin, provides the dominant action of the formula: cooling and softening Imperial Fire (the Suwen says to use sweet

© Ryan Gallagher, L.Ac. 2015 to reduce fire) and moistening dryness in the intestinal tissue. Zhi Gancao enhances this sweet action. Meanwhile, bitter is the flavor of descending and drying; Huanglian and Huangqin, both bitter and cold, purge fire down and out, and dry dampness accumulating in the bowel.

This formula is treating a pathology between Fire and Metal. Fire should control Metal, but here there is over-controlling: Fire is scorching the intestines, drying them out so that they cannot absorb fluids. Digestive water floods through the desiccated intestines and heats up on its way out. The patient has a hasty pulse (suggesting dry heat) and panting (because the LI’s Metal partner, the Lung, is similarly being harassed by Fire).

We should compare this formula with another damp-heat diarrhea formula: Baitouweng Tang. Baitouweng Tang is a Jueyin formula that is more active in astringing diarrhea. This is a more severe case, at a deeper level in the body, and often features bleeding. Blood is being stirred by heat, and the heat is causing congestion in the lower jiao. The Jueyin should lift upward (into the Shaoyang), but there is weakness or blockage, causing congestion that heats up, manifesting as heat-diarrhea, tenesmus, and pain. The formula is bitter and astringent, kind of a cold version of Wumei Wan. Adding Gancao and Ejiao supplements deficiency and can stop bleeding. One should not be surprised to find the eye issues of Crohn’s within the context of this pattern (due to the Liver involvement).

Thus, these two formula treat heat-diarrhea, but in very different cases. In Gegen Huangqin Huanglian Tang’s pattern, heat scorching the Metal is the key pathomechanism. In Baitouweng Tang, we must see heat striking the Jueyin, stirring the blood, trapping the Jueyin down below, its attempts to rise into the Yang realm only causing more friction, heat, and congestion. A third formula to add to this group would be Huangqin Tang, which would treat a milder case of heat-diarrhea that is part of a Shaoyang pattern; unlike the other two formulas, it does not contain Huanglian, so there is no Imperial Fire component.

II.C.iii. Expanding on One of the Point Prescriptions

Given the inflammatory nature of Crohn’s, pathogenic damp-cold tends to be left out of the etiological reasoning. An Acupuncture Today article on Crohn’s differentiation and treatment, for instance, omits it from its list of Crohn’s patterns altogether. However, I think it’s important to remember two things: first, that damp-cold, like deficiency of the Qi or Yang of the Spleen or Kidney, can create an environment that is hospitable to pathogens (which then might create the inflammation found in Crohn’s); and second, that cold-damp itself can create heat by virtue of it’s constricting and congesting nature—yin (cold-damp) becomes yang (heat). With this in mind, let’s examine the reasoning behind the point prescription for External Pathogenic Invasion of Damp-Cold:

• REN6 Qihai: to generate qi and yang (to warm the center). • REN8 Shenque: to warm and harmonize the intestines in cases of ceaseless diarrhea and abdominal pain.

• REN9 Shuifen: to regulate water metabolism and harmonize the intestines. • REN12 Zhongwan (Front-Mu of the Stomach): to harmonize the middle, descend rebellion; tonify the Stomach and fortify the Spleen; regulate qi and alleviate pain. • ST25 Tianshu (Front-Mu of the LI): to regulate the Spleen and transform dampness. • ST36 Zusanli (Lower He-Sea of the Stomach): to tonify qi, harmonize the center, and transform dampness. • ST37 Shangjuxu (Lower He-Sea of the LI): to regulate the intestines. • SP9 Yinlingquan (Spleen He-Sea): to regulate the Spleen and resolve lower-jiao dampness. • LI4 Hegu (LI Yuan-Source): to move the invading pathogen outward. With severe pain: • SP6 Sanyinjiao: to activate the channel, invigorate blood, and alleviate pain. Notes: • Use moxa on REN8. It might also be helpful to use moxa on ST25 (bilateral), REN6, and REN9 or REN12 (“diamond treatment”). • Altogether, we are warming and harmonizing the Earth-center and the intestines, regulating water metabolism, and out-thrusting the pathogen. This should quell diarrhea, alleviate pain, and restore appetite. If there is a heat component branching out from the root of Damp-Cold Invasion, we should either deal with the heat first or, if the heat is not egregious, tonify the center and clear heat simultaneously.

II.D. Case Histories

The following cases are from Keisetsu Otsuka’s Thirty Years of Kampo: Selected Case Studies of an Herbal Doctor. The differentiation of western diseases like Crohn’s and ulcerative colitis has largely taken place since the time Otsuka practiced, so there is no mention of such diseases among his cases histories; furthermore, any mention of the general term “colitis” seems to apply more to ulcerative colitis or infectious colitis (since the instances feature heavy bleeding) than to Crohn’s. Thus, I focused more on cases simply centered around diarrhea and/or abdominal pain—cases that could have, potentially, been Crohn’s.

Below are four such cases. I’ve used bold type to emphasize aspects of the potential Crohn’s pattern, as well as the relevant formulas. Two of the cases reveal cold at the core of the pattern, and require heat and pungency, in the form of such herbs as aconite and ginger. The two other cases feature obstruction in the center causing three-jiao disharmony; they require Gancao Xiexin Tang, a very important formula to consider in the context of Crohn’s. Let’s look at it briefly:

Gancao Xiexin Tang’s Shanghan Lun and Jingui Yaolue lines indicate it for incessant diarrhea, borborygmus, nausea, loss of appetite, and anxiety, as well as for sores on the throat and genitalia. The disease it’s indicated for—Huhuo, or “Fox Confusion,” from chapter three of the Jingui—could give us important insights into the treatment of Crohn’s. Huhuo is caused by toxic damp-heat that results in ulcerations, especially of the throat, anus, and genitalia (the first two pertaining to Crohn’s). Jingui recommends four

© Ryan Gallagher, L.Ac. 2015 formulas to treat the disease: Gancao Xiexin Tang, Kushen Tang, Chixiaodou Danggui San and Xionghuang Xun. Kushen Tang is indicated for a case featuring “lower erosion” (which could be referring to either the anus or genitalia) with dry throat; it is prescribed as a bath. Chixiaodou Dangggui San’s indications include eye symptoms and rectal bleeding (both of which are found in Crohn’s). And Xionghuang Xun is a fumigant whose main indication is anal ulceration. Huhuo’s resemblance to Crohn’s is clear, and we should consider the text lines and the recommended formulas as another way of healing the disease.

***

A moderately sized man of fifty-seven had had an operation for gastric ulcers two years before. Since then he had suffered at times from a stabbing pain in the hypogastrium. When fatigued, he developed diarrhea. During the winter the pain worsened, especially at night, preventing sleep. The pain extended from either side of the navel, along the outside of the abdominal straight muscle, down to the inguinal region. Abdominal examination revealed straight muscle convulsions, a succession sound above the navel, softness, and a splashing sound when pressed. His appetite was moderate and bowel movements occurred daily. His legs and feet frequently felt cold. His pulse was slow and weak; his blood pressure, 102/64. I prescribed Guizhi jia Fuzi Tang. The abdominal pain stopped the next day and he started to sleep well again, but the pain returned if he stopped taking the medicine. After about three months, however, it disappeared completely. In January of the following year he came back to the hospital with the same problem. This time he took the combination for only three weeks before the pain disappeared. I also gave him Zhenwu Tang for his frequent diarrhea, which then stopped. The next winter, no abdominal pain developed. (Case 40, p. 35)

***

A woman I have been on familiar terms with for twenty years suffered from diarrhea that stopped only when she took Gancao Xiexin Tang. Endowed with a good physique, she had a forceful epigastrium and never weakened despite chronic diarrhea occurring once or twice daily for almost a year. Since borborygmus occurred with the diarrhea, I prescribed Gancao Xiexin Tang aiming at the distention and hardness beneath the heart, borborygmus, and diarrhea. Her troublesome diarrhea shortly disappeared. (Case 136, p. 118)

***

A single, twenty-seven year old woman had developed chronic diarrhea ten years earlier. The diarrhea occurred two to three times a day accompanied with abdominal pain. It worsened during menstruation. She woke every morning feeling abdominal pain and gas accumulated in her abdomen. Despite the diarrhea, however, she never felt thirsty. The quality of her urine was scarce. Her complexion looked good. Her nutritional condition was good and her abdomen flexible, but the rectus abdominis muscle on the right side seemed somewhat convulsive. I prescribed Shen Ling Baizhu San for two weeks. Nothing happened. I changed the prescription to Zhenwu Tang for two weeks. Again nothing happened. Next I prescribed Weifeng Tang. Not only was it ineffective, it exacerbated the diarrhea to four times daily and induced fatigue. Therefore, I once again gave her Shen Ling Baizhu San. This time the gastric pain and discomfort worsened, distention appeared beneath the heart, and she lost her appetite. Finally I thought to try Gancao Xiexin Tang. It proved its effectiveness immediately… Gancao Xiexin Tang targets distention and hardening beneath the heart, borborygmus, and diarrhea sometimes with nausea and vomiting. Diarrhea often induces thirst but this patient had neither thirst nor borborygmus. (Case 137, p. 119)

***

[A] forty-one year old woman who had been obese since her youth first visited me on October 6, 1937. One year before she had begun to lose weight for no obvious reason. She felt no pain but on August 20 she began to have diarrhea three or four times a day. None of the many treatments she took resulted in recovery. The diarrhea stopped temporarily after taking each medicine but fullness in the chest, loss of appetite, and black stools invariably ensued. When she stopped taking medicine, the diarrhea began again. This pattern recurred repeatedly. When I saw her, bowel movements occurred two to three times a day with loose stools. She also had borborygmus, distention over the entire abdomen, distention and hardening at the epigastrium, and slight abdominal pain. Her tongue looked wet and was free of tongue fur. She ate only congee every day. I gave her Gancao Xiexin Tang, aiming at the distention and hardening beneath the heart, borborygmus, and diarrhea, but the diarrhea worsened. I switched the prescription to Renshen Tang and the diarrhea stopped. One month later, her complexion and nutritional condition continued to improve. (Case 180, p. 161)

Works Cited and/or Consulted

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