June 10, 2013

A Mismanaged Case Corrected By Zhāng Jī


Introduction:
The following is a case presentation for a woman that was treated at my clinic in the spring of 2009.  It starts as what seems like a simple case but proves to be quite the challenge until I delved a little deeper into the classics, specifically the seminal and possibly the oldest medical text Treatise on Cold Damage (Shāng Hán Lùn), with further elucidations by the late great Běijīng physician Hú Xī-Shù (胡希恕,1898-1984).
 
Case:

A 29-year-old female presented at my clinic with abdominal pain she had been suffering with for four years.  Most of her pain was felt in the lower abdomen and occasionally in the peri-umbillical area.  Pain was occasionally alleviated with warm compresses and with mild abdominal massage.  When asked, she was not sure whether warm or cool drinks affected the pain but was sure to be more mindful after our first meeting. The pain was very unpredictable, appearing one day before meals, the next after without one distinct pattern.   She mentioned that she first remembers her pain starting a couple months after a difficult break up from her fiancé and several months of instability at her job.  This initial stress had first affected her sleep, which is basically now under control with the occasional use of sleep medication.  Her appetite fluctuated with her moods, as did her overall energy levels.  Bowel movements were not too affected but had a tendency to be soft.   Urination was unaffected.  Mild nausea was noted but she felt it was insignificant since she has always felt slightly nauseous since her break-up.   Her tongue was slightly pale with a thin coating and her pulse was slightly wiry on deep palpation, otherwise they were both unremarkable.  Aside from the above the symptoms, she was a healthy, active woman, who was at her wits end with this nagging pain.  Various western medications were tried all to no avail. 
I had diagnosed the pattern as a simple Liver-Spleen disharmony and assumed I could treat this with a basic Qì moving, Spleen boosting formula such as the Free and Easy Wanderer powder (Xiāo Yáo Sǎn) from the Imperial Grace Formulary of the Tai Ping Era (He Ji Ju Fang), with the addition of Fructus Amomi (Shā Rén) and Radix Aucklandiae (Mù Xiāng).  I prescribed one weeks worth of 5:1 concentrated powders.
The following week she returned to the clinic and reported that after taking the first dose of herbs there was some rumbling in her abdomen and within an hour the pain returned slightly worse than before she came to see me.  For the next couple of days after taking the herbs she felt tired and her abdominal pain was slightly more pronounced.  All other symptoms remained the same including her tongue and pulse presentations.  
In the past when presented with similar cases of digestive problems due to a Liver-Spleen disharmony when herbal formulas were prescribed correctly, at least some alleviation of symptoms would be noted after a few days.  Now in this particular case, with the slight exacerbation of her symptoms and the fact that she felt weaker, it was clear that I was missing something.  Scouring through the pages of the ‘Treatise on Cold Damage’ I came upon clause 100 where it states;

“In Cold damage, when the Yáng pulse is choppy and the Yīn pulse is wiry, there should be acute abdominal pain.  First administer Xiǎo jiàn zhōng tāng.  If there is no reduction (of symptoms), Xiǎo chái hú tāng governs”.

The use of Minor centre fortifying decoction (Xiǎo jiàn zhōng tāng) was definitely justifiable, as her abdominal pain liked the occasional use of warm compresses and abdominal massage.  These two symptoms will usually warrant a diagnosis of deficiency cold and this is what the above formula treats.  With my initial diagnosis, too much stock was put into her stagnation and the other symptoms were overlooked.  In addition she had a deep wiry pulse, which is included in the above clause (‘Yīn pulse is wiry’).  In the original clause it states that patients experiencing nausea or vomiting should not take this formula and although she did experience some nausea, I felt it was fine and was merely a manifestation of the Qì depression more than anything else.  A weeks’ worth of Minor centre fortifying decoction granules were prescribed with no additions.
A week later she returned to report that there had been a significant reduction of pain and there were even a couple days where she would forget about her stomach and go about her day pain-free. Her energy was slightly improved but she still felt quite tired most days.  Another two weeks of the same formula were prescribed. 
Two weeks later she returned feeling great.  There was an even greater reduction in the pain (about 80%) and her energy levels were “not a hundred percent, but getting better”.  Another two weeks worth of formula with the addition of Radix Astragali (Huáng Qí) were prescribed in hopes that the condition would resolve. 
Another two weeks past and she returned feeling essentially the same as before.  Most of the abdominal pain was alleviated except for a few occasions and her energy levels were slowly improving.
xiǎo chái hú tāng was prescribed for ten days according to the rule of Clause 100, in the Treatise on Cold Damage where it states;
“If there is no reduction in symptoms, xiǎo chái hú tāng governs”.
Hú Xī-Shù offers his interpretation of this passage in his ‘Discussion and Elucidation on Cold Damage’ (越辩越明释伤寒)[1];

“No reduction of symptoms namely means that after taking xiǎo jiàn zhōng tāng the abdominal pain is not completely resolved.  Now because both xiǎo jiàn zhōng tāng and xiǎo chái hú tāng symptoms exist, we must first treat the interior and afterwards the exterior.  Since xiǎo jiàn zhōng tāng only treated half the condition, we must follow up with xiǎo chái hú tāng to affect a complete resolution of symptoms”

Ten days later my patient returned pain free. She had not had any abdominal discomfort in over eight days.  Her energy has improved and she reported an overall greater sense of wellbeing.  This was followed with another two weeks of Minor Buplureum decoction (xiǎo chái hú tāng) to consolidate her condition by resolving Qi stagnation and further supplementing her Spleen and she was discharged.  On follow up almost one year later, she has not had any major problems with her stomach and the only time she has any discomfort is following days of overindulgence in foods that are known triggers for her. 

Afterthoughts:
In retrospect I believe that my initial diagnosis of a Liver-Spleen disharmony was correct, it was my focus and choice of medicinals that failed to offer a quick resolution of symptoms. As we can see from clause 100 and from the perspective of Hú Xī-Shù, it is clear that the deficiency (of the central burner) must be addressed first and afterwards the stagnation.  As Xú Líng-Tāi says in his Categorization of Formulas from the Discussion of Cold Damage (伤寒论类方) regarding Minor Centre Fortifying Decoction[2];

“The Yáng Qì of the office of the centre (burner) is deficient, thereby allowing wood to overwhelm earth”

What this means to me is that Minor Centre Fortifying Decoction would in fact address a Liver-Spleen disharmony with emphasis on supplementation. Once we are able to bank up and entrench earth, wood would no longer be able to exploit, and as per the original clause, we follow up with a formula to harmonize Liver and Spleen, resolve Qi stagnation and supplement the Spleen such as Minor Buplureum decoction (Xiǎo chái hú tāng).

According to Kē Qín (a Qing dynasty Shang Han expert), Minor Centre Fortifying decoction is a great centre harmonizing pain-relieving formula[3] and proved to be just that in this case.

I believe this case to be a bit of an anomaly as it fit almost too perfect with Zhāng Zhòng Jǐng’s original line and even responded to his predictions.  I used to believe that practicing the classics in this day and age was far too difficult and that pre-modern conditions had nothing to do with the complex, modern maladies our patients present with today.  As I continue to study the classics and apply them in my day to day practice, I find that when we truly begin to look at our cases from a different lens we find these patterns that Zhāng Jī and the great physicians after his time spoke about and are offered numerous opportunities to utilize them and bring them to life. 



[1]胡希恕越辩越明释伤寒, 冯世纶, 中国中医药出版社, 2009.
 
[2]伤寒论类方 , 徐灵胎, , 公元1759.

[3]伤寒论翼, 柯琴,