June 5, 2011

Case study of Zhang Xiang-Fu (张祥福)

One of the great things about reading and studying case study literature is that we are able to learn from experienced practitioners, new and unique ways of using classical formulas we may never had thought of. When first seeing this case written up under the Wu Ling San heading, I was surprised, as treating uterine bleeding with this formula would never have existed within my thought process. Initially I thought I stumbled upon a true goldmine, but after reading the case it was clear that the practitioner was merely putting more stock into the presentation, rather than the actual disease. This is essentially the bread and butter of Chinese medicine, yet so easily disregarded these days. So nothing too dramatic nor enlightening here but still an interesting case.

***A 35 year old female presented at the clinic on May 12, 1978. The patient has always been overweight and suffered with excessive menstrual bleeding. The timing of her period has always been indeterminate, with flows usually lasting longer than seven days. This afternoon she suddenly experienced acute lower abdominal pain, and violent, heavy menstrual flooding. A local hospital treated her in the emergency department and administered medicinals to stop bleeding, along with intravenous fluid injections, all to no avail. At this point she was referred to me for treatment.  

Current signs and symptoms: Sallow white facial complexion, icy cold extremities, beads of sweat emanating from the head, spitting up of turbid frothy phlegm, acute lower abdominal pain, which favours palpation, a pale, tender, enlarged tongue body, with stasis macules on the edges, a white slightly greasy tongue coat, and a choppy pulse. Laboratory results were as follows: Hemoglobin 6.5g, white blood cells 5200 m3, neutrophils 65%, lymphocytes 30%, monocytes 2%. 

Diagnosis: Fulminant flooding (functional uterine bleeding)

Pattern:  Damp-phlegm obstructing the uterus

Treatment Principle:  Boost qi, stop bleeding, free the yang, and disinhibit dampness.

Formula:  The formula used was Wu Ling San (Five ingredient powder with poria), with the addition of Shai Shen 10g (Sun-dried ginseng), E Jiao 10g (melted and added to decoction), San Qi 10g (powdered and infused). 2 packages were administered.

Follow up consultation on May 14:  She reported that her spirit felt awakened, her limbs now felt warm, and the bleeding had ceased. The original formula was continued for another five packages which were enough to completely resolve the bleeding and bring about a resolution to her condition.

Commentary:  Along with her main symptoms, this patient was also presenting with spitting up of turbid, frothy phlegm, an enlarged tongue body, with a greasy coat, and had always been overweight, which signify the presence of damp-phlegm retention. This damp-phlegm was obstructing the uterus, and causing insecurity of the ren and chong channels, causing menstrual flooding. Wu Ling San was chosen to free the yang, and disinhibit dampness. Shai Shen, E Jiao, and San Qi were added to boost qi, nourish the blood, and stop bleeding. Therefore by simultaneously treating the root and branch of the syndrome, we are able to achieve excellent results.

(This case was translated from 'Selected Cold Damage cases from the Clinical Experience of Famous Physicians'. Originally found in the ‘Chao Nan Journal of Traditional Chinese Medicine, 1989; (6): 19)’


Z'ev Rosenberg said...

The key to the grand chessboard of Chinese medicine is, of course, to treat the pattern/presentation, and not be pressured to symptomatically resolve a disease/pathocondition. Of course, this is just what students and recent graduates feel pressured to do, treat Western disease names, and as a result the presenting pattern(s) is ignored largely. Case histories such as these are brilliant in their zen-like simplicity, and is a great illustration of how Shang Han Lun-style medicine works, by restoring normal function to the body/mind, then the symptoms or disease resolve. . .

Eran Even said...

Well said Z'ev.
I think that feeling pressured to treat according to disease name as opposed to pattern/presentation goes against everything that Chinese medicine is, which kind of scares me, as this does seem to be the way it is being taught and practiced these days by so many. As long as we have teachers like you, Sharon, Arnaud, etc, we stand a chance at preserving classic thought and practice.
The reason I feel so compelled to post these 'zen-like simple' cases, is to preserve this thought methodology and expose more readers to the old 'Chinese-style' cases that don't get too boggled down by the 'disease' at hand, and only care about the patient's presentation.

Jason Blalack said...


Nice case, I can't say I would have come up with that one on my own. So I personally find it quite enlightening thanks! However, maybe you could explain how you see that he came to this formula. I see no urinary symptoms, no mention of thirst despite fluid intake, floating pulse, edema, A sensation of heaviness or fuzziness in the head, Up-flushing of heat into the face and upper body or other signs that we often see associated with this formula. The only real clincher is spitting up of frothy saliva. How do you make sense for example, of "beads of sweat emanating from the head"?

Eran Even said...


The bizarre use of Wu Ling San is what drew me to this case in the first place. I wasn't too sure initially why he would use it, and really my only assumptions are that maybe the fact that she was overweight, had an enlarged tongue with a greasy coat, and spat up frothy phlegm were enough for Dr. Zhang to justify the use of WLS?
Maybe the beads of sweat on the forehead are another clue to the presence of damp-phlegm. Or, maybe he just loves Wu Ling San and used it whenever he could :)
I know it most certainly is not a typical case for using WLS, but this is exactly why I (and I'm sure you as well)love learning from case studies.

Jason Blalack said...

I agree, however it is hard to learn sometimes if you cannot figure out the why... :) - I will have to contemplate this one for some time...

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